REPUBLIC OF THE PHILIPPINES)

CITY OF TARLAC ) S.S

AFFIDAVIT
I, CECILIA A. LUCIANO, of legal age, widow, Filipino citizen and a
resident of 85 Don Bartolome St., Poblacion 1, Gerona, Tarlac, after having been
duly sworn to in accordance with law, do hereby depose and state – THAT.
1. That I am the mother of the late JERIC A. LUCIANO, who died on
January 26, 2013, a copy of his Certificate of Death is hereto-attached
for reference;
2. That my son is a bona fide resident of 85 Don Bartolome St.,
Poblacion 1, Gerona, Tarlac;
3. That my late son and her wife are renting a house for their dwelling;
4. That when he brought him in hospital at Quezon City he already died
upon arrival;
5. That my son buried at Gerona, Tarlac, Cemetery;
6. I am executing this affidavit to attest to the truth of the foregoing
declarations.

IN WITNESS WHEREOF, I have hereunto set my hand this

_______________, at Tarlac City, Philippines.

CECILIA A. LUCIANO
Affiant

SUBSCRIBED AND SWORN to before me this _____________, at Tarlac

City, Philippines.

Doc. No. _________ ;

Page No. _________ ;
Book No. _________;
Series of 2019