Republic of the Philippines)

City of Sorsogon ) Sc.

 AFFIDAVIT

I, _________________, of legal age, Filipino, widow and a resident of 065 OLV Pangpang,
Sorsogon City, after being sworn in accordance with law, do hereby depose and state:

1. That I am the surviving spouse of ________________-us having contracted marriage on

July 9,1968 at __________________________-;

2. That the late ___________________ was born on March 14, 1935;

3. That the late ________________________ was a bonafide member of Social Security

System during his lifetime;

4. That the late _____________________ died on September 29, 2016 at SMMGHHSC,

Sorsogon City;

5. That unfortunately it was recently discovered that in Death Certificate his Date of Birth
was erroneously entered as “March 5, 1935 when it should be March 14, 1935”;

6. That I hereby attest that _____________________ correct Date of Birth was on March 15,
1935”;

7. That I have freely executed this affidavit to attest to the foregoing facts and for any legal
purposes this may serve.

In witness whereof, I have hereunto affixed my signature this 15 th day of November 2016 at
Sorsogon City.

____________________________________
Affiant

SUBSCRIBED AND SWORN TO before me this 15 th day of November 2016 at Sorsogon

City, both affiant having exhibited to me her __________________.

Doc. No.__________
Page No. _________
Book No._________
Series of 2016.