‘uneipal Form No. 105 (To be accompiched in quadruplate using Black nk) (Revised August 20¢5) Republic of the Philippines OFFICE OF THE CIVIL REGISTRAR GENERAL CERTIFICATE OF DEATH ‘LoILo Regisity No Province__ ity/Municipality GUIMBAL City/Municipatity — | 2024- 63 1 NANE Fo) wa) roy 2 SEX Wawona) ANA MONDIDO TUVALLES. FEMALE | |G GATE OEDEATH (bay wow, Wear & DATEOFBIRTH Gay bony) oop |S AGEATTHE TME OF DEATH (3-9 voy occa ope caps SL DATE OF DEATH (Gay. Monn, Yeu [DATE OF BIRTH (Oey) Qlonn) Cem [S-APSEU naaine Sr BER SES ne CABR Ser 11 FEBRUARY 2024 18 FEBRUARY 1946 erento gene mee | 6, PLAGE OF DEATHA (Name a osprsiCincinaitisonNause No. SL, Serengny. Ceymuncpalty Povnee) TCL STATUS (ShgatiaredWicow | REP PEDROG TRONO MEMORIAL HOSPITAL” GIMBAL ivoLo erat SREUGIONRELIGIOUSSECT | S.CMZENSHP TIO, RESIDENCE foe 3 Sear una Er Car Ronan Canon cen ‘BRGY. BUGTONG LUMANGAN, MIAGAO, ILOILO, PHILI 17 OCCUPATION 12, NAME OF FATHER Feet wisi Las 1S. NADENNAMECENOTHER (Fst ida Las) NOT STATED ‘ADRIANO MONDIDO (DECEASED) ANGELES FAISAN (DECEASED) MEDICAL CERTIFICATE (For ages 0 to 7 days, accomplish tems 14-19a atthe back) | 195. CAUSES OF DEATH (ifthe deceased is aged 8 days and over) Interval Between Onset and Death | ‘Immediate couse ‘a ACUTE RESPIRATORY FAILURE 12.28 HOURS ‘Antecedent cause: b, CVD PROBABLY BLEED 1 WEEK Undenying couse; o, RYPERTENEVE cAROIOWSCULAR DSEAS 2 YEARS pregnant. ».pragot, in 4.42 days to ty 1 None of tne fot sbour Feoour es salve choices ‘i DEATHBY EXTERNAL CAUSES TOPS ‘8. Manner of death (Homicide, Suicide, Accident, Legal intervention, ate a Place of Occurence of Extomal Cause (e.¢. home, frm. factory, sect, sea, eto) 21a, ATTENOANT 00 se drain (nis) 2 Fite 1 pwwte "Fat 3 Hemp 5 ones a ee - eee ron 2792004 git onze 22. CERTIFICATION OF DEATH Tiere cel that the foregoing parculars are coract a8 near as same canbe ascetine have not atended the nd Murer cot that! X' nave atondes! eased and that death occured at 08.36 PM _amipm onthe dato of death spoctieg above REVIEWED BY: sinoue fame in Pont APRIEROSE RECODO, MD iN, MD ‘we or Poston _ MEDICAL OFFICER II — sia Ofer Pred Name ot Heat Or hodessRPGTMH, GUIMBAL, ILOILO ORUARY 15, 2024 Oat _ =a | i coneseorosaL 3, QURIALCRENATIONPERMT Se TRONSEER PERT ‘Bat corso Hobe scm) | perp pal BURIAL Oat esa Oe teed 7 25 NAME ANDADDRESS OF CEMETERY OR CREMATORY CUBAY CEMETERY MIAGAO, ILOILO 28 CERTIGATIONOF AFORMANT 27 PREPAREDEY herby coy Bat at ematnsuppled re ree covet ‘omy om ronadbe ape Signature Signatre PCA - Name in Pint JOLLY T. MONTEVIRGEN | name in Pant SYLVIA LEE T. TORRES, RN _ Rettonstipo he Deceased DAUGHTER | Tl ce Postion NURSE tI ‘adress BRGY. BUGTONG LUMANGAN, MAGAO,LOLO FEBRUARY 11, 2024 Date FEBRUARY 11, 2024 | 20 RECEWED BY ‘7 REGISTERED AT THE OFEICE OF THE CNL REGISTRAR Signature ¢ at Signature Name in Pint GRACE'P.GENOVATIN, PERCYLEJFE G. QUIDATO Name Prt ‘ive or Postion REGISTRATION OFFICER I Tie or Postion MUNICIPAL CIVIL REGISTRAR mae FEB 16 2024 meals FEB 16 204 | REMARKSIANNOTATIONS (For LCROIOCRG Use Only) Vo WHOM IT MAY CONCERN THIS IS TO CERTIFY THAT THE CADAVER GAN BE TRANGFERED JQ OTHER MUNICIPALITY W/O PREJUDICE TO PUBLIC HEALTH & SAFETY "TO BE FILLED-UP AT THE OFFICE OF THE CIVIL REGISTRAR 5 8 9 10 " 189(6y190 19a(0) 277 08 01 60803030 *FOR CHILDREN AGED 0107 DAYS 14, AGE OF MOTHER, vertex, others, spect) 15. METHOD OF DELIVERY owns soonianoos 16. LENGTH OF PREGNANCY” (ir competed weeks) 17, TYPE OF BIRTH (Single, Twin, Tp, ete) 16. IF MULTIPLE BIRTH, CHILD WAS. Second, Thr, tc) MEDICAL CERTIFICATE 198, CAUSES OF DEATH 28, Main diseaselcondiion of tant », Other diseasesiconditonsofnfant Main matamal diseaselconltion affecting infant 6. Other maternal éseassleerstion affecting infant «Other elevantcrcumstances, CONTINUE TO FILL UP ITEM20 POSTMORTEM CERTIFICATE OF DEATH I HEREBY CERTIFY that | have performed an autopsy upon the body of the deceased and that the cause of death was Signature - Title/Designation se Name in Print Address = Date CERTIFICATION OF EM! | HEREBY CERTIFY that | have embalmed ia fl T WALES __ following all the regulations prescribed by the Department of Health. Signature Spe > “TaeiDesignation oo eysiimen - vane ns CELA BARE WAS License No. gg.9p 2159 = address OP Issues on at OOH MANILA a _ Expiry Date AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH 1 with residence and postal address of legal age, singlelmarriedidivorcedwidowiwidower, after being duly sworn in accordance with law, do hereby depose and say: 4. That died on in ‘and was buriedleremated in 2. That the deceased at the time of his/her death: was attended by was not attended. 3, That the cause of death of the deceased was 4. That the reason forthe dolay in registering this death was due to, 5, That | am executing this affidavit to atest tothe truthfulness ofthe foregoing statements forall legal intents and purposes. Intruth whereof, | have affixed my signature below this day of. at Philippines. (Signature Over Printed Name of Afiant) SUBSCRIBED AND SWORN to before me this __dayof_— lt i . Philippines, affiant who exhibited to me his/her CTC/vali ID issued on at ‘Sonature of the Administonng Oticer Postion Tie Designation ‘arose Name in Print