Republic of the Philippines )

CITY OF SAN PEDRO S.S

Province of Laguna
x-------------------------------------------x

WAIVER OF AUTOPSY

That I, ________________________________________of legal age, Filipino and residing

at________________________________________________________________________, after being
sworn in accordance with law thereby depose and state:

1. That I am the ________________of the deceased _________________________________ who

died last _________________ at _____________________________________________.

2. That as being ____________ of the deceased I hereby WAIVED an autopsy needed or to be

conducted on the body of the deceased.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of

___________, 20__ at the City of San Pedro Laguna.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______ day of ____________, 20__ in

City of San Pedro Laguna Affiant having exhibited to me her/his proof of Identity in the form of
________________________________.

Doc. No: ________

Page No.:________
Book No.:________
Series of 201_