REPUBLIC OF THE PHILIPPINES )

CITY OF ) S.S.
PROVINCE OF )

AFFIDAVIT OF LATE REGISTRATION OF DEATH

I, ------ Filipino, of legal age, and a resident of --------------, hereby under oath state that:

1. I am the daughter of ------, a Filipino, the husband of ------, and was a resident of -----;

2. My father died on ------ at his residence due to cardio-respiratory arrest, as attested by

------ in the Certificate of Death he furnished and executed on --------. Attached is the
Original unfiled Certificate of Death of ------, and is made part hereof;

3. The said Certificate of Death was not filed with the Local City Registrar of then-
Municipality of Meycauayan, as there was a miscommunication between the
undersigned and the management of Funeraria XXX. The undersigned was not
informed that she should file the same personally with the Local Civil Registrar of
------, and has expected that the funeral parlor will do the filing;

4. I am executing this Affidavit to attest to the truthfulness of the foregoing facts and to
legally register the death of my father, attesting that the same has never been
registered previously with any other local government unit;

IN WITNESS WHEREOF, I have hereunto set my hand this -----------, in the ---------

__________________________________
Affiant

SUBSCRIBED AND SWORN to before me this -----, affiant exhibiting to me her

-------------

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