Manipal Form No 108 To be accorplaned in quadruples) (Pooveod January 1983) REMARKS/ANNOTATION Republic of the Phiippines CERTIFICATE OF DEATH Ua eng ert a ey. oe 9 oem (cayiMuicipalty Tex S-REUGION a A= EON [OER THOR Te BEET OT red 8] emiens ye | [toon] Town] — metansee a erate E |b 5 PLAGE OF fare agpaitincnetcy (Ci even TSE OF fee aren tome 7 ZENSHIP SORE OF DEATH on wens ‘ERESIDENCE Gomera, teeters TEDICAL CERTIFICATE (Forages to 7 ay eccomph hms 111 7. CAUSES OF DEATH 7B, DEATH BY NON-NATURAL CAUSES a Vente __2 sate 2 ecto _4 or un 35, ATTENDANT Talend, sate duration: 1 Pras mn A he Fan 2 Puen Oe ones spety) To 235, CERTIFICATION OF DEATH ‘heyy ht herein care coe naa ume an be acd fart ctf hat 1 De nat sede he dec eet he ned and et eat cared a Sinan Name in Po Tie or Poon | 21, CORPSE DISPOSAL 2, BURIALCREMATION PERMIT] 28, AUTOPSY peak e here oe) ae 2A NAME AND ADDRESS OF CEMETERY OR CREMATORY 25 INFORMANT Sram 7 REGEIVED AT THE OFFICE OF "THE CIVIL REGISTRARFOR AGES 0 TO 7 DAYS. ‘ATE OF BIRTH 72. AGE OF THE MOTHER | 13. METHOD OF DELIVERY. Ta: LENGTH OF PREGNANGY: coaied wos 16. TYPE OF BIRTH pale a) Tn as Toon | OT ee 78. IF MULTIPLE BIRTH, CHILD WAS 2 Saco _3_ Onn pn, MEDIGAL CERTIFICATE GAUSES OF DEATH Freofernepoeniahnplererny She nar Coon we ot (CONTINUE TO FILL UP ITEM 18 HEREBY CERTIFY thatthe his Aayof ebodyofthedecesed and tha theceuceof deaths asics: POSTMORTEM CERTIFICATE OF DEATH — Peformet an autopsy upon Signature [Name in Print Tule/Designation Address THEREBY CERTIFY that have embalmed {followed al the regulations prescribed by the Departnent of Ha Sigraturo_ Nemein Print Address ‘CERTIFICATION OF EMBALMER Tie/Designation oense Ne Issued on, Expiry Date sjterhacing Republic ofthe Philipines Province of City/ Municipality of se ewe uly sora on accordance with Uo, do herby depose and say 1. That = SUBSCRIBED AND SWORN to bore me this AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH. died on 2. That the deceased was/was not aiended 0 atthe Une of his death 3. That the reason forthe delay in ropistering this death was due to of legal age, singlelmarred, afte being "and was buried/eremated in Sapa of ng ice Su Tile Bosgaand aay