REPUBLIC OF THE PHILIPPINES)

CITY OF CAGAYAN DE ORO ) S.S.

X--------------------------------------X

AFFIDAVIT

I, NAISAH ISMAEL DIDAAGUN, of legal age, Filipino, married, and a resident of

BRGY. MAHAYAHAY, ILIGAN CITY, after having duly sworn in accordance with law, do
hereby depose and state that:

1. I was admitted to and confined at St. Mary’s Maternity and Children’s Hospital
located in Brgy. Palao, Iligan City from 15 September to 16 September 2023 because of a
Stillborn Delivery. My corresponding MEDICAL CERTIFICATE issued by the aforesaid
hospital shall be attached herein as “ANNEX A”;

That I hereby agree to be liable and irrevocable and answerable to perjury and/or
falsification of public Documents in the event that the documents is/are found not in
order;

IN WITNESS WHEREOF, I have hereunto set my hand this 25th day of September
2023, at Cagayan de Oro City, Philippines.

NAISAH ISMAEL DIDAAGUN

Affiant
Passport No. P5452089B
Valid Until 27 Aug 2030

SUBSCRIBED AND SWORN to before me this 25th day of September 2023, at Cagayan de
Oro City, Philippines.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2023 ATTY. NEHEMIAH DAVID ENGBINO KOTICO
Notary Public
Until December 31, 2024
Per Notarial Commission No. NC-2023-206
Roll No. 86122
IBP OR No. 204615, 05-22-2023
PTR No. 5668455 A, 06-01-2023
MCLE No. (Newly Admitted to the Bar on May 02, 2023)
For Cagayan de Oro City and Misamis Oriental