CLAIMANT’S STATEMENT

I, Vertine Paul Beler, of legal age, residing at Blk8 lot 47 Dalingdingan st. Villa Luisa Homes 1,
Brgy. San agustin 3, Dasmarinas Cavite, do interpose that;

1.) I am the beneficiary of the deceased, Cristina F. Beler, who passed away on March 30,
2021 at De La Salle University Medical Center, and the cause of death is Pneumonia and
suspected Covid-19 patient.

2.) I am one of the legal heir of the deceased, Cristina F. Beler, and reserves the right to
receive any awards, gratuities and benefits arising from any insurance, contract,
agreement that the deceased is entitled to receive.

Vertine Paul F. Beler