Statement of Live Birth Form
A statement of live birth form is meant for the birth registration of a new born baby. This statement form is consisting of birth information, mother’s details and father’s necessary information to complete the registration.
Sample Statement of Live Birth Form:
Section A:
Child’s Information:
Surname: _______________
Sex of Child: _____________
First Name: _____________
Middle Name: _____________
Date of Birth (MM/ DD/YY): ________________________
Name of the Hospital: ______________________________
Place of Birth (City, town, village by name): ____________
ZIP: ____________________________________________
Section- B:
Mother’s Information: _____________________________
Current Legal Surname: ____________________________
Legal Surname at the time of Birth: __________________
First & Middle Names: ____________________________
Birthplace: ______________________________________
Date of Birth (MM/ DD/ YY): _______________________
Age: ___________________________________________
Mother’s Occupation: _____________________________
Marital Status of mother:
- Married:
- Widow:
- Divorced:
Section C:
Father’s Information:
Current Legal Surname: _____________________
First Name: _______________________________
Any other legal surname: ____________________
Birth Place: ______________________________
Date of Birth (MM/ DD/ YY): ________________
Age: ____________________________________
Father’s Occupation: _______________________
Section D:
Birth Information: _________________________
Mother’s Mailing Address: _________________
Duration of pregnancy in weeks: ____________
Kind of Birth:
- Single
- Twins
- Triplet:
- Others:
Wight of Child at Birth: ___________________
Name of Attendant at Birth:
- Physician
- Midwife
- Other, Specify:
Number of or official kids Alive: _____________
Section- E:
For official use only: _______________________
Code Number: ____________________________
Registration Number: ______________________
Signature of Division Registrar: ____________
Category: Statement Forms
