Republic of the Philippines )

Province of Leyte )
Municipality of Villaba ) S.S.
x-----------------------------------x

AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH

I, MA. LOURDES M. GONZALES, of legal age, married, Filipino and a resident of
Sitio Si-ong, Brgy. Crossing, San Isidro, Leyte, after having been duly sworn to in
accordance with law, do hereby depose and state:

1. That DIONESIO BRONIOLA ARROFO, died on November 14, 2017 at Sitio Si-
ong, Brgy. Crossing, San Isidro, Leyte, Philippines;

2. That the deceased at the time of his death was NOT attended by a physician.

3. That the cause of death of the deceased was Cardiac Arrest.

4. That the reason for the delay in registering this death was due to inexcusable
neglect and lack of knowledge of the requirements of registration with the Office
of the Civil Registrar.

5. That I am executing this affidavit to attest to the truthfulness of the foregoing

statements for all legal intents and purposes.

IN WITNESS WHEREOF, I have affixed my signature below this 5th day of January,
2018 at Villaba, Leyte, Philippines.

MA. LOURDES M. GONZALES

Affiant

SUBSCRIBED AND SWORN to before this 5th day of January, 2018 at Villaba, Leyte,
Philippines, by Affiant who is personally known to me and who exhibited her competent
evidence of identity issued on _____________________ at ___________________________, Philippines.

NOTARY PUBLIC

Doc. No. 320;

Page No. 65;
Book No. V;
Series of 2018.