REPUBLIC OF THE PHILIPPINES }

CITY OF TARLAC }S.S.

AFFIDAVIT OF FACTS OF DEATH

I, ALANDY N. BUAN, of legal age, Filipino citizen, widower, and a resident of

Motrico, La Paz, Tarlac, after having been sworn to in accordance with law, do hereby
depose and state THAT:
1. I am the spouse of the late BESSY CANLAS BUAN who died on 29 September
2021 at around 7 o’clock in the evening (7:00 P.M.);

2. The late BESSY CANLAS BUAN died on said date at our matrimonial home at
Barangay Motrico, La Paz, Tarlac;

3. During her last moments, she was accompanied by my eldest son, Bryant Andrew
C. Buan and my mother-in-law, Remedios N. Canlas;

4. Prior to her expiration, I had my wife undergo online check-ups with Dr. Canlos at
the Ramos General Hospital;

5. Her cause of death is due to Acute Respiratory Failure due to Covid-19

Pneumonia;

6. I am executing this affidavit to attest to the truth of the foregoing facts and for
whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this 2 nd day of November

2021 at Tarlac City, Province of Tarlac, Philippines.

ALANDY N. BUAN
Affiant
SSS ID No. 02-1855926-2

SUBSCRIBED AND SWORN to before me this 2 nd day of November 2021 at Tarlac

City, affiant Alandy N. Buan personally known to me to be the same person executing
the foregoing Affidavit of Facts of Death and acknowledged that he executed the same.

NOTARY PUBLIC

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Page No. ____;
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Series of 2021