(reed anuay 1983) Republic of the Philippines OFFICE OF THE CIVIL REGISTER GENERAL CERTIFICATE OF DEATH (Fito completely, accurately and ely, Use tk or Types Pace Xbeore the appropriate ansvt in ems 2,1336,6,18,10,21 ANO 23) RENIAKKS/ANNULAHION 3 Hospital Autocity 20. CERTIFICATION OF DEATH ‘hereby cera tot te foregoing porta re correct os aero tm con be ecetined ond further ety that [Zhvove noratendes ne cececsed [Dope ottenaea te decsszed ond that death oceused a, ‘am/pm onthe dete indeoted above. *” | REVIEWED BY: Signture Nome in Print ARYA. RUIZ ‘Sgnatare over printedname Title 0 Postion MEDICO-LEGAL OFFICER ear Address MANILA ote 1SJ0NE ZOO — Pe 24, CORPPE OISPOSAL 22. BURIAL / CREMATION PERMIT 23. AUTOPSY XO al 5 omnes (Speci) Number _ 01234567, X ives = dceamation oeteiswes ASJUNEZOIG | 2 no 5. INFORMATION Senate Address 124 BAGONG BATO ST. TONDO, MANILA, | name in rine ANNA A. SANTOS, UI Feleuentip tote dacested NIECE ose TEWONEDOS 35. PREPARED BY: 17, RECEIVED AT THE OFFICE OF Fes ‘THE CIVIL REGISTRAR Signature Signature Neme in Print__BELLAR. ORTIZ Name in Prot GERSEIB LARGO. Tite or Poston CLERK Tile or Postion REGISTRATION OFFICERTT 0 Date _1§ JUNE 2019 Date 18 JUNE 3019 or City/Municipality_MANILA 2019 01010 Be ae 2 ie | aA OR ABOVE |b UNDER IVEAR © UNDER 1 DAY ‘FORE FRLED UP AT THE a ROMAN CATHOLIC| REGISTRAR, Xa Female a 40 1 lo a : 6, DATE OF DEATH (aay) (month) (yest) Te cachet ypctia JEWELRY SHOPOWNER (BUY AND SELL) i “3 30 st | ‘Underlying cause : ¢. STAB INJURIES. o 2 6 ie 15 MINUTES a | 18. DEATH BY NON-NATURAL CAUSES a X_rHomicide 2 Suicide: 3 Accident 4 Other (Specify) I 19, ATTENDANT. MFattended, state duration: z igFOR AGES 0 to 7 DAYS TL OATEOF TH 12, AGE OF THE MOTHER 13. METHOD OF DELIVERY a 1 Normal: spontaneous vertex 2 Others Specify) 18, LENGTH OF PREGHANCT completed weeks ISTE OF BIRTH 16 F MULTIPLE BIRTH, CHILD WAS 2 Single 2 Twin 3 Triplet, ete 1 Fist 2 Second 3 Other (specify) MEDICAL CERTIFICATE {CAUSES OF BEATE {2. Main dseose/condition of infent Other dseases/eonditions of infant Main material disease/condition affecting Infant 4. Other material elisease /condtion affecting infant Other relevant circumstances CONTINUE TO FILL UP ITEM 18 POSTMORTEM CERTIFICATE OF DEATH ‘HEREBY CERTIFY that have this doy of. performed on outopsy upon the body ofthe deceosed ond thet couse of decth was a follows Siensture Tie/Designation, Name la Print adress CERTIFICATION OF EMBALMER HEREBY CERTIFY that | have embolined TEODORA ANGELES SANTOS after hoving followed all the regulations prescribed by the Department of Heath Signature Title/Designation_EMBALMER Name a Prat JOFFREY 6. LANNIS LUcense No, 34567 cess MANILA. ‘esued on G4/17/2016 oe MANILA Expiry Date 08/76/2020) Republic ofthe Pilippines ) Province f ss. lv/ktuneipaly. ) AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH. 4 b of legal re, single morse, oft bn Duly sworn to in accordance with low, do hereby depose and say: ° * ° 2 Thactive deceased was/was not attended to at he tne of is death, 3. Thatthe reason fr the delay in registering this death was du to (Sonate of ttart) Community Tax No, Date issued Place tssued ‘SUBSCRIBED AND SW/ORH to before me this. day of. o Philippines (Ggnaure of mniterng Feet Fie/bengration) emer Pom) a rome