Republic of the Philippines)

City of Butuan ...............) S.S.

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

AFFIDAVIT OF ATTENDANT AT DEATH

I, JOVITA MUTIA DALAGAN, of legal age, Filipino, married and a resident of P-4, Brgy. Sangay,
Buenavista, Agusan del Norte, Philippines, after having been duly sworn to in accordance with law, do
hereby depose and state:

1. That I am the natural and legitimate daughter of the late CATALINO BALDE MUTIA who died
on 12 December 2013 at Manuel J. Santos Hospital, Montilla Boulevard, Butuan City;

2. That the immediate, antecedent and underlying causes of his sudden death were from Intestinal
Obstruction secondary to Distal Colonic Mass, Prob. Colonic Ca with Peritoneal Seedings S/P and
Coronary Heart Disease, Hypovolemic Shock, Cardiorespiratory Arrest, correspondingly;

3. That his body was embalmed by a duly licensed embalmer named ROMEL B. BENIG of St.
Peter Memorial Chapel, Butuan City, with license # 09-13-5200 issued on 09-19-2013 at the City of
Manila valid until 01-26-2016;

4. That he was buried four (4) days after his death on 16 December 2013 at the Public Cemetery
of Barangay Sangay, Buenavista, Agusan del Norte;

5. That his death certificate was not immediately registered with the Office of the City Civil
Registrar, Butuan City, because of some unavoidable circumstances and financial constraints; And,

6. That I am executing this Affidavit to attest the truthfulness of the aforementioned statements
and to support my application for the delayed death registration of my father, CATALINO BALDE MUTIA
with the Office of the City Civil Registrar, Butuan City.
 IN WITNESS WHEREOF, I have hereunto set my hand this 13th day of January 2014 in Butuan
City, Philippines.

JOVITA MUTIA DALAGAN

Affiant

SUBSCRIBED AND SWORN to before me this 13th day of January 2014 in Butuan City,
Philippines. Affiant exhibited to me her Unified Multipurpose Identification (UMID) Card No. 006-0098-
1240-0 and Employee Identification Card No. P 070106-026 issued by the Municipal Government of
Buenavista, Agusan del Norte.