Republic of the Philippines)

City of Butuan ) S.S.

Affidavit Attesting to the Death of a Person

I am _______, of legal ages, Filipinos, and resident of __________, after having been
duly sworn to in accordance with law, do hereby depose and state the following:

That I am the mother of the deceased, __________;

That last December 20, 2017, my son died due to Cardiopulmonary Arrest sec. to
multiple Gun Shot Wound in the Head, Chest, Abdominal & (L) leg, Hypoalbumenemia,
Multiple Electrolyt Imbalance;

Copy of his Death Certificate is herein attached as Annex “A”;

To further prove his death, I am also attaching pictures of his casket as well as gravestone
as Annexes “B” and “C”;

That the cause of the delay of the registration of his death was because, the hospital (MJ
Santos) refused to issue and release to us his Death Certificate until we fully paid the billing
expenses;

That we are executing this affidavit to attest to the truthfulness of the fact of death of the
person of my son __________ and for whatever legal purposes that this statement may serve.

IN WITNESS WHEREOF, we have hereunto set my hands this October 12, 2018 in the
City of Butuan, Philippines.

___________
Affiant

          SUBSCRIBED AND SWORN TO before me this 12th day of October day of 2018
in Butuan City, affiant personally known to the undersigned notary public.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2018.