Republic of the Philippines)

Victoria, Tarlac ) S.C.

AFFIDAVIT

I, JOSEFINA M. BUCAO, Filipino, of legal age, widow and a resident of Sto. Rosario Baculong
Victoria,Tarlac, after having been duly sworn to in accordance with law, do hereby depose and say:

1. That I am the widow of the deceased, ELISEO DUNGCA BUCAO, who died on 15
October 2020;

2. That based on the Death Certificate, he died due to Cardio Respiratory Arrest;

3. That he died at his residence between 1 O’clock to 3 O’clock in the morning;

4. That at the time of his death, he was alone and conscious of his actuations;

5. That he was found dead hanging on their living room and he was not brought to the
hospital to save or revive him;

6. That he has no medical consultations on other illness;

7. That I am executing this affidavit to attest to the truth of the foregoing statements and
inform the proper authority concerned about the said facts of death and for whatever legal
purpose this affidavit may duly serve.

IN WITNESS whereof, I have hereunto set my hand this 27 th day of October 2020 in the
Province of Tarlac.

JOSEFINA M. BUCAO
Affiant
VIN: 6917-0012A-C1273JMB20000

SUBSCRIBED AND SWORN to before me this 27th day of October 2020 in the Victoria,
Tarlac, who exhibited to me his Competent Evidence of Identity.

Doc. No.______
Page No._____
Book No._____
Series of 2020.