MunicipalFormNo.

103(Tobeaccomplishedinquadruplicate) REMARKS/ANNOTATION
(revisedJanuary1993)

RepublicofthePhilippines

OFFICEOFTHECIVILREGISTERGENERAL

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

Province_________________________________________________________ Registryno. FOROCRGUSEONLY:

PopulationReferenceNo.
City/Municipality______________________________________________

1.NAME(First)(middle)(last)

a.1YEARORABOVE b.UNDER1YEAR c.UNDER1DAY

TOBEFILLEDUPATTHE
2.SEX 3.RELIGION 4.A
OFFICEOFTHECIVIL
____1Male G Completedyears MonthsDays Hrs/Min/Sec
REGISTRAR
E
____2Female 2 1 0

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


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
TitleorPosition____________________________________ ofHealthCenter
Address_________________________________________
_________________________________________ ______________________

Date
Date___________________________________________ 83

21.CORPPEDISPOSAL 22.BURIAL/CREMATIONPERMIT 23.AUTOPSY

_____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______________________________________


FORAGES0to7DAYS
11.DATEOFBIRTH 12.AGEOFTHEMOTHER 13.METHODOFDELIVERY
(day)(month)(year) ______1Normal;spontaneousvertex
______2Others(Specify)__________
14.LENGTHOFPREGNANCY______________completedweeks
15.TYPEOFBIRTH 16.IFMULTIPLEBIRTH,CHILDWAS
_____1Single____2Twin_____3Triplet,etc. _____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. That___________________________________________________________________diedon_______________________________in
____________________________________________________________________________andwasburied/crematedin
_________________________________________________________________________________on______________________.
2. Thatthedeceasedwas/wasnotattendedtoatthetimeofhisdeath.
3. Thatthereasonforthedelayinregisteringthisdeathwasdueto__________________________________________________________
__________________________________________________________________________________________________________.

___________________________________________________
(Signatureofaffiant)

CommunityTaxNo.__________________________________
DateIssued________________________________________
PlaceIssued_________________________________________

SUBSCRIBEDANDSWORNtobeforemethis_____________dayof______________________________,__________________________at
__________________________________________________________________________________________________,Philippines.

___________________________________________ _____________________________________________
(SignatureofAdministeringOfficer) (Title/Designation)


___________________________________________ _____________________________________________
(NameinPrint) (Address)