eee Sb SME Rend, CERTIFICATE OF DEATH ° (Fil out completely. accustay ard gy. Usa ink or ypowier. Place X belere the anpropaie answer inte 2,2, 18, 18, 16, 18, 1, 21 and 23) Province Laguna —— City/Municipalty Bian 1. NAME ve ‘iso Quirico Vergara De Los Santos 2 Sex @. RELIGION] 4 A]= VEARORADOVE | b. UNOER 1 YEAR [= UNDER TOAY Sy wae GI] Compieed years | [Moshe] | Daye] —Hrehtinec ay E 2 Female RC, fa sje 1 | ‘ 5 PLAGE OF [Name of Hospialtiaernstiaion ‘Ginnricbainy Provan) DEATH Hovte Ne,, Srect, Barangay) Univers ity Of Perpetual Help Medical Gtr. Bifian,laguna SODATE OF DEATH a tmomny yaa 7. CITIZENSHIP z 29 Sept. 2002 Pilipino 8. RESIDENCE (HouseNs, sveci, Bano) (yiuhepaiyy (rovines) Blk,5 Lot12 Adelina 1,San Amtonio,San Pedro Laguna 8. CIVIL STATUS 40. OCCUPATION 3 Sigie 8 Widowed __5 Urkroun " 2 Nariea ___4 Owe Driver MEDICAL CERTIFICATE (For ages 0 to 7 days, accomplish items 1117; 17. CAUSES OF DEATH Loess cause: a Interval Beteen Onset and Deh jee Back Page Invwoosert cause 18. DEATH BY NON-NATURAL CAUSES a. Manaaref Death 1 Homicie —_2 Suicide 3 Accident 4 Others Speciyy Plane of Occurrence eg, hors sac ss ss) 49. ATTENDANT attended, state duration: 4 Private Pysian 4 Nore From __ 2 PubicHeath Otteer 5 Oters (Speci) To annoy 20. CERTIFICATION OF DEATH Thar riya he freging reer coc 0s Sane an erie ad ately at (Toast ted te det : Dice ent te dad an hb elt ied ni on he te ue Signature Name in Print Tite or Posiion Address _S Dae October O71, 002 —_ 24. CORPSE DISPOSAL 1 Burst __ 3. othore (Speci Erwin W 28. AUTOPSY 1 Yes paz Nn 2 Cremation 24. NAME AND ADDRESS OF CEMETERY OR CREMATORY 25, eee Signature Ades: Adeline 1, Sen Antonio ,cen Nene n Pin Maria jaxis Winter Mae los Santos: Relationship te the ms a Wize Dae __ Ge 26. PREPARED BY Sionaure Name in Sine