AFFIDAVIT OF NO MEDICAL RECORD

KNOW ALL MEN BY THESE PRESENTS:

I, ________________, of legal age, married, Filipino, and a

resident of______________, Bacolod City, after having been duly sworn in
accordance with law, hereby depose and say:
1. THAT I am the son of _____________________________
2. THAT my mother died in her sleep on ________________ in her
residence at ____________________ Bacolod City;
3. THAT I cannot obtain a medical record in relation to her
health/death since there was no treating physician at the time of her
demise.
4. THAT I execute this affidavit to attest to the truth of the foregoing.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day

of ____________ 20___ at Bacolod City, Philippines.

________________
__
Affiant

SUBSCRIBED AND SWORN TO before me, a notary public in and for

_____________________ this ____ day of ____________ 20___. The
affiant, whom I identified through the following competent evidence of
identity: _____________, valid from______ to______ issued
by_______________, personally signed the foregoing instrument before
me and avowed under penalty of law to the whole truth of the contents of
said instrument

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