MunicipalFormNo.

103(Tobeaccomplishedinquadruplicate)
(revisedJanuary1993)

RepublicofthePhilippines
OFFICEOFTHECIVILREGISTERGENERAL
CERTIFICATEOFDEATH
(Filloutcompletely,accuratelyandlegibly,UseInkorTypewriter.
PlaceXbeforetheappropriateanswerinItems2,9,13,15,16,18,19,21AND23)

Province_________________________________________________________

Registryno.

City/Municipality______________________________________________
1.NAME(First)(middle)(last)

a.1YEARORABOVE b.UNDER1YEAR
2.SEX
3.RELIGION
4.A
____1Male

Completedyears
MonthsDays
G

E
____2Female

2
1 0

c.UNDER1DAY
Hrs/Min/Sec

REMARKS/ANNOTATION

FOROCRGUSEONLY:
PopulationReferenceNo.

TOBEFILLEDUPATTHE
OFFICEOFTHECIVIL
REGISTRAR

5.PLACEOF(NameofHospital/clinic/institution/(city/municipality)(province)
41
DEATHHouseNo.,Street,Barangay)

7.CITIZENSHIP

6.DATEOFDEATH(day)(month)(year)

48

8.RESIDENCEHouseno.,Street,Barangay(City/Municipality)(Province)

9.CIVILSTATUS
10.OCCUPATION

____1Single_____3Widowed_____Unknown

____2Married_____4Others

495051

MEDICALCERTIFICATE

(Forages0to7days,accomplishitems1117attheback)

17.CAUSESOFDEATHIntervalBetweenOnsetandDeath
54
I.Immediatecause:a.____________________________________

_______________________________________________________________________________________

Antecedentcause:b._____________________________________
_______________________________________________________________________________________
5965
Underlyingcause:c._____________________________________

_______________________________________________________________________________________
II.Othersignificantconditions_____________________________________________________________________
contributingtodeath:_____________________________________________________________________

66
18.DEATHBYNONNATURALCAUSES

a.MannerofDeath

_____1Homicide_____2Suicide______3Accident______4Other(Specify)__________________
b.Placeofoccurrence(e.g.home,farm,factory,street,sea,etc.______________________________________________
71 72
19.ATTENDANTIfattended,stateduration:

_____1PrivatePhysician_____4NoneFrom________________,______________
_____2PublicHeathOfficer_____5Others(Specify)To________________,______________

_____3HospitalAuthority____________________

20.CERTIFICATIONOFDEATH
75
IherebycertifythattheforegoingparticularsarecorrectasnearassamecanbeascertainedandIfurthercertifythatI

Havenotattendedthedeceased

Haveattendedthedeceasedandthatdeathoccurredat______________am/pmonthedateindicatedabove.
79

REVIEWEDBY:

Signature________________________________________
______________________________

NameinPrint_____________________________________
Signatureoverprintedname
8082

ofHealthCenter

TitleorPosition____________________________________

Address_________________________________________

_________________________________________
______________________

Date
83
Date___________________________________________

22.BURIAL/CREMATIONPERMIT
23.AUTOPSY
21.CORPPEDISPOSAL

_____1Burial_____3Others(Specify)
Number__________________________ _____1Yes

_____2Cremation__________________
DateIssued_______________________ _____2No

25.INFORMATION
85

Signature_______________________________________Address__________________________________________

NameinPrint_____________________________________________________________________________

Relationshiptothedeceased_________________________Date__________________________________________

86
26.PREPAREDBY:27.RECEIVEDATTHEOFFICEOF

THECIVILREGISTRAR

Signature______________________________________Signature_____________________________________
NameinPrint___________________________________NameInPrint_________________________________
TitleorPosition__________________________________TitleorPosition_______________________________ 90

Date__________________________________________Date______________________________________

11.DATEOFBIRTH

12.AGEOFTHEMOTHER

FORAGES0to7DAYS
13.METHODOFDELIVERY
______1Normal;spontaneousvertex
______2Others(Specify)__________

(day)(month)(year)

14.LENGTHOFPREGNANCY______________completedweeks
15.TYPEOFBIRTH
_____1Single____2Twin_____3Triplet,etc.

16.IFMULTIPLEBIRTH,CHILDWAS
_____1First_____2Second______3Other(specify)___________________

MEDICALCERTIFICATE
11.CAUSESOFDEATH
a.Maindisease/conditionofinfant______________________________________________________________________________________________
b.Otherdiseases/conditionsofinfant____________________________________________________________________________________________
c.Mainmaterialdisease/conditionaffectinginfant__________________________________________________________________________________
d.Othermaterialdisease/conditionaffectinginfant_________________________________________________________________________________
e.Otherrelevantcircumstances_________________________________________________________________________________________________

CONTINUETOFILLUPITEM18

POSTMORTEMCERTIFICATEOFDEATH

IHEREBYCERTIFYthatIhavethis_____________dayof__________________,________________performedanautopsyuponthebodyofthedeceased

andthatcauseofdeathwasasfollows_____________________________________________________________________________________
_____________________________________________________________________________________________________________________________

Signature_____________________________________

Title/Designation____________________________________
NameinPrint__________________________________

Address___________________________________________

___________________________________________

CERTIFICATIONOFEMBALMER
IHEREBYCERTIFYthatIhaveembalmed_______________________________________________________________________________afterhaving
followedalltheregulationsprescribedbytheDepartmentofHealth.

Signature____________________________________________

Title/Designation_____________________________________
NameinPrint_________________________________________

LicenseNo.__________________________________________
Address______________________________________________

Issuedon_________at________________________________
____________________________________________________

ExpiryDate__________________________________________

RepublicofthePhilippines________________________________________)
Provinceof____________________________________________________)S.S.
City/Municipality_______________________________________________)

AFFIDAVITFORDELAYEDREGISTRATIONOFDEATH

I,_________________________________________________________________________________,oflegalare,single/married,afterbeing
Dulysworntoinaccordancewithlaw,doherebydeposeandsay:

1.

2.
3.

That___________________________________________________________________diedon_______________________________in
____________________________________________________________________________andwasburied/crematedin
_________________________________________________________________________________on______________________.
Thatthedeceasedwas/wasnotattendedtoatthetimeofhisdeath.
Thatthereasonforthedelayinregisteringthisdeathwasdueto__________________________________________________________
__________________________________________________________________________________________________________.

___________________________________________________

(Signatureofaffiant)

CommunityTaxNo.__________________________________

DateIssued________________________________________

PlaceIssued_________________________________________

SUBSCRIBEDANDSWORNtobeforemethis_____________dayof______________________________,__________________________at
__________________________________________________________________________________________________,Philippines.

___________________________________________

_____________________________________________
(SignatureofAdministeringOfficer)

(Title/Designation)

___________________________________________

_____________________________________________

(NameinPrint)

(Address)