Full Name of Baby: Sex: Nationality:
Date of Birth:
Place of Birth:
Gestation (week): ___ weeks Number of Fetus: Fetal Sequence: Number of Delivery:
Delivery Mode: natural labor√, vacuum extractor, obstetric forceps, Caesarean birth, other ()
5-minute Apgar score:
Father: Age: Workplace:
Mother: Age: Workplace:
Issued by: Seal of Facility:
Genuine name of baby:
BIRTH – (RCA)-No. XXX– XXX–
*** In MM/DD/YY, at XX, was born, at XX from the Route de la Madelaine: , of sex masculine, the father of which is XXX, born in MM/DD/YY in Zhongshan, Guangdong (China), cook, the mother of which is XXX, born in MM/DD/YY in Guangdong (China), living in Cayenne (Guyana), 8, rue des Prunes de Cythère Cité Capulo.
*** Made in MM/DD/YY at XX, on declaration of the father, who, the reading made and invited to read the certificate, has signed with Us, XX, 2nd assistant, Civil State officer of Cayenne city.
For conforming photocopies
Civil State Officer