REPUBLIC OF THE PHILIPPINES)

PROVINCE OF C A V I T E ) S.S.
TRECE MARTIRES CITY )

AFFIDAVIT

I, NOIME CRUZ LOZANO, of legal age, single, Filipino Citizen,

with resident address 288 Purok 3 Langkaan 1, Dasmariñas City,
Cavite, after having been duly sworn to in accordance with law do
hereby deposes and states:

That I am the common-law wife of the late RUEL B. BECINA who

died on July 06, 2019 at City General Trias Doctors Hospital;

That the said decedent died without marrying me or entered into

any legal impediment but we’re living together as husband and wife,
for the reason that we are not yet ready to entered into matrimony of
marriage;

That during our cohabitation we blessed one (1) child;

That further, I am attesting that RUEL B. BECINA died being

single;

That I am executing this statement to attest to all the above

facts, and to whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____

day of ___________________ 2019 at Trece Martires City, Cavite,
Philippines.

NOIME CRUZ
LOZANO
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ____________

day of _____________ 2019 at Trece Martires City, Cavite, Philippines.

DOC. NO. ______ NOTARY PUBLIC

PAGE NO.______
BOOK NO._______
SERIES OF 2019