‘Municipal Form No. 103 epubli ilippines T° DF Bccomplished in quadruplicate using Diack 1nk)) - (Revised August 2016) Fapieto of Sieur OFFICE OF THE CIVIL REGISTRAR GENERAL CERTIFICATE OF DEATH wee ABBA RYN ey pcnicisiy COMCSee ec 2023-45 1, NAME: fy ‘ide (ast) [2 SEX (MateFemaie) REGAN GRAJO SAN PABLO MALE {3 DATE OF DEATH (ay Mowh, Yoo) 4, DATE OF BIRTH (Oxy) (ont) (es) |S. AGE AT THE TIME OF DEATH (linosiow 48 JANUARY 2023- AO SEPTEMBER 1974 csomgg | om = re a PLAGE OF DEATH (ine Feasting i Bosman Clancy Proves) 1 CVIL STATUS Gnginioradvin! ‘IRA . Roxas ISABELA Weonsiamuezdvorxe) SiNGLE © RELIGIONRELIGIOUSSECT |, OTIZENSHIP 10; RESIDENCE (owe No Si. Baroy. Caynicaliy, Proves Cun) ROMAN CATHOLIC FILIPINO ‘SAN AGUSTIN, LIBON, ALBAY, PHILIPPINES 7 OCCUPATION 72, NAME OF FATHER Fst mil Last 13: MAIDEN NANE OF MOTHER (Frat wade. tast) | VISUAL ARTIST ELISEO SAN PABLO MERCEDES GRAJO MEDICAL CERTIFICATE | (For ages 0 to 7 days, accomplish items 14-19a at the back) 190, CAUSES OF DEATH Ifthe de 1. Immediate cause a Interval Between Onset and Death Antecedentcause = b. Underying cause CoN Vit Ua UE I Other significant conditions contributing to death 186, MATERNAL CONDITION (ifthe deceased is female aged 15-49 years old) ‘pregnant pregnant, in . lessthan 42 days ater 4, 42daysto1 yearafter __e. None ofthe oti labour labour elven delivery —* choices 496, DEATH BY EXTERNAL CAUSES 20. AUTOPSY ‘2, Manner of death (Homicide, Suicide, Acide Logainteventon etc) (ean) ». Place of Occurrenea of External Cause (2.9, hom farm, factory, sree, ec) — : 21a. ATTENDANT 2 Public. 2b, attended, sale duration (ones) 1 Private Heath 9 Hospital 5 Others Physician Officer Authority 4 None Specity From, To 22. GPRTIFICAJON OF DEATH, ‘hereby cortythat ng particulars are corrects near as same canbe ascertained and futhg certty thal [have attended! Z rave not attene Signature Name in Print Te of Poston \L HEALTH PHYSICIAN Address Re ee |“ ae JANUARY 19, 2023 7 CORPSE DGPOSAL 2, BURIALCRENATION PERMIT Dab TRANSFERPERNIT Gece tase | row owe BURIAL bata and EBON MOATEIBRE CEMETERY ® "TFB 4 DEL ROSARIO LIBON, ALBAY ‘26. CERTIFICATION OF INFORMANT ‘27. PREPARED BY I howby cay ala omaton spp arte and coed Lemyom vec abel Sioraie feet Sonate fh anal oe. ‘SON GRAJO SAN PABLO naneinpin __ ROJES$ T. LIPAOPAO Felson te Deasns BROTHER ‘ior Poston REGISTRATION OFFICER cat » SAN AGUSTIN, LIBON, ALBON ote JANUARY 19, 2023 Date JANUARY 19, 2023 :. ai; 2. REGENED BY 26 RESISTERERAT THEO ara Soraize 4 Senate NameinPint __ ROJEGS T. LIPAOPAO samen int TecrPoston _ REGISTRATION OFFICER TilocrPosion —_ MUNIQUML CIVIL REGISTRAR ane JANUARY 19, 2023 Date JANUARY 19, 2023 e IREMARKSIANNOTATIONS (For LCROIOCRG Use Only)