Republic of the Philippines)

QUEZON CITY, M. M. )S.s.

x------------------------------x

AFFIDAVIT
I, _________________________, of legal age, widow,
Filipino citizen, and permanent resident of
_________________________________, after being duly sworn to,
in accordance with law, do hereby depose and state:

1. That I am ______________ of the late

_______________________ who died of
__________________ at the
_______________________, on _____________ at
_____________;

2. That __________________________ was brought to the

_______________________ and was pronounced DEAD
ON ARRIVAL by the doctors of the said hospital;

3. That I am executing this Affidavit to vouch for the

veracity of all the foregoing narration of facts and for all-
legal intents and purposes it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this _________ day of ______________, in Quezon City, Philippines.

___________________________
Affiant

SUBSCRIBED AND SWORN TO, before me this _______ day of

________________, in Quezon City, Philippines, affiant exhibiting to
me her _____________________________ issued on
______________ in ______________________.
 WITNESS MY HAND and NOTARIAL SEAL on the date and place
above-written.

Notary Public
DOC. NO.
PAGE NO.
BOOK NO.
SERIES OF 2019.