AFFIDAVIT OF CIRCUMSTANCE OF DEATH

I, __________________ of legal age, with residence address at ______________________,

after having sworn to in accordance with law do hereby state, that
1. I am the daughter of the late _____________________ who died inside our house at 9-
KL Pasco St., Litis, Quezon City on 11 April 2021, at 2:55 pm.

2. Prior to her death, she had been suffering from Alzheimer's disease, and two days ago,
the slipped inside our bathroom where she complained her buttocks was hit on the floor
from then on, she became weak and always laid in her bed was not waking up.

3. Hence earlier that day of 11 April 2021, we decided to bring my mother to

hospital but no hospital was available, thus, we brought her home, and instead
sought the assistance of the medical volunteer in our barangay, and despite an
oxygen was attached to my mother she slowly stops breathing and exactly 2:55
pm that day, she was declared dead upon checking her pulse by said medical
volunteer.

4. Considering the above factual circumstances, no licensed physician that attended to my

mother to give an expert opinion as to the cause of my mother's death

5. I am executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _______________ at

_______________ Zamboanga Del Sur Philippines
.

FRANZ JOY OFLEAR OBOSA

Affiant

SUBSCRIBED AND SWORN, to before me this _____________ at ________________ ,

Zamboanga Del Sur. Affiant exhibiting to me her government issued ID as indicated above.

Doc No.______
Page No._____
Book No. _____
Series of: _____