REPUBLIC OF THE PHILIPPINES)

Province of _________________________) S.S.

City/Municipality of ______________)
x - - - - - - - - - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF DEATH DUE TO VEHICULAR ACCIDENT

I, , legal age, widow and a

resident of
, Philippines, after having been duly sworn to in accordance with law, do hereby
depose and state the following:

1. That I am the widow of ;

2. That my husband died on

because of
injuries sustained in a vehicular accident as per the results of the autopsy
conducted by Dr. ;

3. That per investigation of the Police Station, my

husband died as a result of a vehicular accident at when while
he was , he was bumped / hit by a truck
coming from the opposite direction;

4. That my husband was a duly licensed driver at the time of the incident and was
carrying Driver's License No. and was
riding on a , in color and with
Plate No. owned by
with Certificate of Registration No.
;

5. That I am executing this affidavit to attest to the truth of the foregoing and for
whatever legal purposes that this statement may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this _____________, in the City
of _____________, Philippines.

AFFIANT

SUBSCRIBED AND SWORN to before me, this , by the

Affiant whom I have identified through competent evidence of identity and who exhibited
her issued at on ____
_________.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.