Dying Declaration

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Republic of the Philippines

NATIONAL POLICE COMMISSION


PHILIPPINE NATIONAL POLICE
ANGELES CITY POLICE OFFICE
POLICE STATION 5
Friendship Highway, Barangay Cuayan, Angeles City
SUBJECT

DATE

First Progress Report - Re Shooting Incident

=============================================
Dying declaration of (NAME)

given to (INVESTIGATOR) at Angeles Medical Center on

(DATE) at around (TIME) in the presence of (WITNESS) and (WITNESS)

Question 1: Why are you here at Angeles Medical Center?


Answer ->
Question 2: Who shot you?
Answer ->
Question 3:
Answer ->
Question 4:
Answer ->
Question 5:
Answer ->
-End of Dying DeclarationNote: At this juncture (TIME), (NAME) died as pronounced by (DOCTOR)

( NAME)
Investigator

(NAME)
Victim
Witnesses:

(NAME)
Nurse
(NAME)
Attending Physician

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