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003425-81 6JX04-9
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Munic,pal Fom No. [To .mmplishd io quadrup]icate using blac* ink)
{Revised January 2007} Rapublic of tha Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL

CERTIFICATE OF LIVE BIRTH

Province.*-LAG,U.N '
Reoistrv No.
20 1 6t 179il
City/Municipality CITY 0F S AN PEDRO
1. NAME {Fict} (Mlddre) (Last)

DANIEL COLLADO DE BORJA

DATE OF (o"v) (Month) (Year)
L EIRTH 31 MAY 20 16
H (llam of ho60ital/CInidlnslitutiorv (Cily/Municlpslity) (Provio$)
l.lo., g, Bsrangay)
4, PTACE OF
I BlRTH
Itous
L c pFnpn rnqp L- AMANTE EMERGEI{CY H0SPITAL CITY OF SAN PEDRO LAGUNA
5a. TYPE OF BIRTH 5b. IF MULTIPLE BIRTH, CHILD WAS 5c. BIRTHORDER tmroftuilo b 6, WEIGHTAT BIRTH
D (Singh,Twi^,ldplst, eli.) (FlBl, Sond, Third. €lc.) @iffitkdelMryM@)
(First, S6@nd, Thtrd, olc )

SINGLE N/A TI.I T P I} -2-3Li1s- grms

7, MAIDEN (FiGit) (Middr€) {Last)
NAME COLLADO
ROXANNE SARAH MORENO
M
9, REUGION]REUGiOUS SECT
o S,CTTIZENSHIP
FILlPlNO
I
CATHOLIC
,0e. Tobl nutur ol l{o. o, c}ilden born 1 2. l'ee at Oe lry cf U,is
H chlldra bom alM aliie bn &s nd dBad bili' ((mphbd yoffi)
E 3 0 33
R .I3.
RESIDENCE (Prcvin€) {Centry)
* 12 ALVAREZ APT. A.I{ABINI ST.BNGY.POBLACION CITY OF SAN PEDRO LAGUNA
(Ftrs0 (Middre) (Lasl)
14, NAME
F ELIEIO LATINAZO DE BORJA
A lS.CITIZENSHIP 16. RELIGION/RELIGIOUS SECT ,OCCUPATION 1 8. AGE d dE |,re d lhis
T bidl (mpl6led yeaB)
H FlLIPINO CATHOLIC HELPER 36
E 1S. RESTDENCE (City/Muf,icipality) (Provin6i
(Ha$ No., St., Barangay) (Country)
R
SITIO PAGKAKAISA BRGY.CAI,ICAM CANLALAY CITY OT BINAN LAGUNA PHILIPPIJIIEI

DATE Zot - PLACE (City / Municipalily) (Provin6) (Couotry)

NOT TUARRfED

Nffi Midwile ---,-,4 Hilol 8i.dr 5 Cd'e.s{Specry)

CERTtFICATION OFATTENOANTAT BIRTH €hyslcian. N!trr, Midul6, T6dhlon.l BldhAttendant/Hild. etc.)
-2 -3 -
I hereby @nlty that.l atendod lhs birth of the child who ms born ative at .9j-5.33.!B-- atry'pm s ihe date of birth 3p6ifi6d
- above.

Signatu16 Addr6sg SA'i' PEDRO .IOSE T i MA NT!

Nam in EMERGENCY I.IOSPTTAT.

Date

CERTIRCANON OF INFORIIiANT 23, PREPARED BY

I hereby-€rtify that all irfomation suppiied are t ue and
@radto mYlm
Signature Signature
Name in Nare in Print
Rolationship to lhe Child I'!0.TH ER
ritre or Posiiitr
--ilXfN.5-I{lL--
nooTesBRGY . POBLACION SA N P
oare

RECEIVEDBY ---JU-U-{--23--2O1-6-
BY CIVIL

Signatu.e

Name in Print
rE$66rEEt,
Title or Position

REMARKSIANNOTATIONS (For LGRO/OCRG Use

OEJYEO RECISTNAIIO(
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BE FILLED.T'PAT THE OFFICE OFTHE CIVIL REGISIRAR
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15 16 1f 19
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08857-7E-028C LY-00 1 83-B 100 1

POSSIBLE IMAGE CLAiRT DENNIS 5. MAPA, Ph. t}.

National Slatislician anij Civil Registrar General
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