REPUBLIC OF THE PHILIPPINES}

______________________ } S.S

AFFIDAVIT OF NO EMBALMING

I, _______________________, of legal age, married, Filipino and a resident of

____________________________ after having been duly sworn to in accordance with law
hereby depose and state that:

1. I am the brother of deceased ______________________ of

__________________________;

2. On _____________________, deceased _____________________________, who

was previously diagnosed with _________________, fell ill, reason for which,
__________________________ for her immediate medical intervention;

3. Pursuant to existing health protocols, deceased

___________________________________ was subjected to nasopharyngeal test
(SWAB Test), which later yielded a positive result;

4. However, deceased __________________________ was not admitted at the said

medical institution.
5.
Subsequently, she had a sudden cardiac arrest and died on
______________________;

6. Considering the above-stated circumstances and pursuant to

_______________________ specifically under the ____________________, the
cadaver of my deceased sister will no longer be subjected to embalming and autopsy;
and

7. I am executing this affidavit to attest to the truthfulness of the foregoing

circumstances and for whatever legal purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________________________

______________________
Affiant

SUBSCRIBED AND SWORN to before me this

______________________________________________________ as his competent evidence of
identity.

Doc. No.______;
Page No. _____;
Book No. _____;
Series of 2021.