Republic of the Philippines)

Quezon City, Metro Manila) S.S.

AFFIDAVIT OF CIRCUMSTANCES OF DEATH

I, MA. VIRGINIA A. LIM, of legal age, married, Filipino and resident of 152G
Tendido St., Bgy. San Jose, Quezon City after having been duly sworn to in accordance
with law, depose and say:

1. That I am the mother of deceased Francis Louie Lim Ferrer who died on August
21, 2019 in Quezon City for probable Acute Myocardial Infection;

2. That before the time of his death we rushed him to the nearest hospital but
expired we reached the same hence was declared, Dead on Arrival (DOA);

3. That I am executing this affidavit for purposes of registering the death of the
above-named deceased with the Local Civil Registry of Quezon City;

AFFIANT FURTHER SAYETH NONE.

MA. VIRGINIA A. LIM

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of August 2019 in

Quezon City affiant with competent proof of identity as ___________________ issued on
_______________________.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2019.