Republic of the Philippines )

CITY OF CAGAYAN DE ORO ) S.S.

AFFIDAVIT OF DEATH

I, KATRINA R. CALME, of legal age, single, Filipino, and a resident

of Palawan, Camaman-an, Cagayan de Oro City, after having been duly
sworn to in accordance with law, hereby depose and say:

1. That on January 5, 2020, at around 1:00 in the afternoon, I was in

our house in Palawan, Camaman-an, together with my siblings
namely: Darren R. Calme and Denver R. Calme, 12 and 11 years
old, respectively;

2. That we were with our ailing mother, MONALIZA R. CALME,

who have been ill for the past five (5) years or so due to breathing
problems which my father suspects as asthma or perhaps blood
pressure problem. My father also once told us that when they
were still sweethearts, my mother had some several episodes
where she was having problem breathing;

3. That on the said date and time, I noticed that my mother was
heavily breathing. She also lost her appetite and had noticeably
lost weight;

4. That at around 1:30 in the afternoon of the same day, I could

vividly recall my mother told me: “Day, atimana imo mga
manghud” which I replied no problem as my sibling are already
relatively old. I then went to the laundry area to some laundry
things;

5. That a few moments thereafter, I was bewildered when my

attention was called by my 2 younger siblings. When I went up, I
saw my mother already heavily breathing and not long thereafter,
she stopped breathing and was already lifeless;

6. That upon confirmation of my mother’s death, I called my father

who arrived minutes thereafter. We family then decided to no
longer bring my mother to the hospital and instead we brought
her to Everlasting Funeral Homes in Bolonsori, Camamnan-an;

7. That I execute this affidavit for the purpose of attesting as to the

truth of the foregoing facts for the purpose of requesting City
Health of Cagayan de Oro for the issuance of a Death Certificate
and for other legal purpose/s this may serve.
 IN WITNESS WHEREOF, I have hereunto affixed my signature
this 9 day of January 2020 in the City of Cagayan de Oro, Philippines.
th

KATRINA R. CALME
Affiant

SUBSCRIBED AND SWORN TO before me this day of 9th day of

January 2020 in the City of Cagayan de Oro, Philippines.

Doc. No. 89;

Page No.19;
Book No.11;
Series of 2020.