AFFIDAVIT

I, JOSE P. CARISOLA of legal age, Filipino, single and resident of Sagrada,

Iriga City after having been duly sworn to in accordance with law, depose and state
THAT:

1. I and Ruby P. Luzaran (Ruby) have been living together as husband and wife under
the same roof, since 2011 or a period of twelve (12) years;

3. We were blessed with four (4) children during our cohabitation as husband and wife;

4. However, Ruby died on November 8, 2023 due to heart attack;

5. Ruby’s relatives (nearest of kin) are nowhere to be found, that is why I am executing
this Affidavit in order for me to be the one responsible in preparing and executing
her Certificate of Death.

6. As such, I execute this Affidavit to certify or attest to the truth of the foregoing facts
and for whatever legal purpose that this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 10 th day of

November 2023 in Iriga City, Philippines.

JOSE P. CARISOLA
Affiant
National I.D. No. 2796-8156-9763-0148
July 18, 2022
Iriga City

SUBCRIBED AND SWORN TO before me this 10th day of November 2023 in

Iriga City, Philippines, affiant exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2023.