Republic of the Philippines )

Province of Palawan )S.S.

City of Puerto Princesa )

AFFIDAVIT OF DEATH
_____________________________, being first duly sworn, deposes and says:
That he personally knows ___________________________ being his (relationship) for
_______________________ years.
That on ______________________ he was present when said
_______________________ died at ______________________.
That on ______________________ he attended the burial of said
___________________________________ at _____________________.

IN WITNESS WHEREOF I have hereunto set my hand on this __th day of ____________,
2022 at Puerto Princesa City, Philippines

____________________
Affiant
SSS ID No. _____________

SUBCRIBED AND SWORN TO to before me on this __th day of _____, 2022, in the City of
Puerto Princesa, Philippines, Affiant exhibited to me her ID No.____________ issued on
___________ at Puerto Princesa City.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2022.