Municipal

Form No.
103
(Revis6d
August
2016) Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR G
CERTIFICATE OF

Province DAVAO DE ORO

City/Municipality MONTEVISTA

1. NAME
AZUCENA (First)
3. DATE OF DEATH (Day, Month, Year) 4. DATE OF

25-Oct-23 4-Nov-53

6. PLACE OF DEATH PRK. 7 CAMANSI (Name of Hospital/Clinic/Institution/House ,NO., St., Barb

MONTEVISTA

8.
RELIGION
RELIGIOUS 9.
SECT CITIZENSH
ROMAN IP
CATHOLiC FILIPINO
 12. NAME
11. OF
OCCUPATI FATHER
ON (First,
HOUSEKE Middle,
EPER, OWN Last)
HOME AGUSTIN
CASTITE
MEDICAL
CERTIFICA
TE
(For ages
0 to 7
days,
accomplis
h items 14-
19a at the
19b. CAUSES OF DEATH (If the deceased is aged 8 days and over) back)
a. 1. Immediate cause

b.
Antecedent cause Underlying cause c. C'fWW0(Z

11. Other significant conditions contributing to death:

19c. MATERNAL CONDITION (If the deceased is female aged 15-49 years old)
a. pregnant, b. pregnant, in labour
not in labour

19d. DEATH BY EXTERNAL CAUSES

a. Manner of death (Homicide, Suicide, Accident, Legal intervention, etc.)
b. Place of Occurrence of External Cause (e.g. home, farm, factory, street, sea, etc.)
21a.ATTE
NDANT
2 Public

1 Private Health 3 Hospital

Physician Officer Authority
22. CERTIFICATION OF DEATH
 1 hereby
certify
that the
foregoing
have not
attended
the
deceased
an
Signature

Name in Print (44 hv'lL/1F

Title or Position u i'
Address

23. CORPSE
DISPOSAL
(Burial,
Crernatjo n,
if others,
specify)
BURIAL

25. NAMEAND ADDRESS OF CÉMETERY OR CREMATORY

PUBLIC CEMETERY
CAMANSI
 26.
CERTIFICA
TION OF
INFORMA
NT hereby
certify
that all
informatio
n supplied
are true
and
correct to
my own
knowledg
e and
belief.
Signature
///
(JAS
Name in Print REYNAL
S Relationship to the Deceased N
7 CAMAN!SI, MONTFVISTA, DAVAO DE 0'?0
Date 29-Oct-23

28.
RECEIVED
gy
Signature AYECTIN
Name in Print

Title or Position REGISTRY CLERK

Date 29-Oct-23
REMARKS/ANNOTATIONS (For LCRO/OCRG Use only)

TO BE FILLED-UP AT THE OFFICE OF THE CIVIL REGISTRAR

A 02.22.26020 51 81
 ENERAL

(Middle)
CASTITE BIRTH TUAS
(Day) (Month)

ngay. City/Municipality, Province)

DAVAO DE ORO

10. RESIDE
PRK. 7 CAM
lé11/2YyC5_g-yI,9tcv7

c. less than 42 days after

delivery

5 Others (Soecifv)
x 4 Hone
p iculars are correct as near as same can be ascertained and further certifr [hat
hat death occurred at

M )V(4QF

Date 25/ 23

2%. BURIAL/CREMATION PERMIT

Number
Date
Issued NOT APPLICABLEI+
 27.
PREPARED
BY
Signature
Name in Print

Title or Position

Date

29,
REGISTER
EDAI THE
OFFICE OF
THE
t/"
Signature
Name in Print
Title
Date

r R TIFIE

VIJAI, 14 RFG'8ff1
1.9 0 01 21 11
 (To be accomplished in quadruplic

DEATH
Registry No

2023-857

(Last)
(Year) 5. AGE AT THE TIME OF DEATH (Fill-tn below accd9 to age
ARöß+80Y

(21 Completed years

69

NCE (House No . St Barangay City/tvlton.c,oal,ty

ANSI, MONTEVISTA, DAVAO DE ORO, PHILIPPINES
13.
MAIDEN
NAME OF
MOTHER
(First.
Middle,
Last)
ANA
SUMAGAY
SAY

Interval Be

d. 42 days t

delivery
am/pm on the date of death specifi
REVIEWED BY:

ignatu e Over Printed Name of He

ae

24b. TRANS
Number
Date
Issued

MONTEVISTA, DAVAO DE ORO

 MERAS

REGIST Y CLERK
29-Oct-23

ERESIT

Position REGISTRA I
29-Oct-23
COPY
7 61

p
 2 SEX
(Male/Fe
male)
FEMALE

01 vnooÉ770rre—-

(1 J Months (071 Days

7 CIVIL
STATUS
(3jnr/e/M
arneeJ/Wl
do•,Y/
Widower/
Annul'eO/
Drvorced)
WIDOW
 een Onset and Death

2 Yet-pd

o 1 year after e None of t

choices
20
AUTOPSY
(Yes No'
NO

21b. If attended, state duration (mm/dd/yy)

From To
 have atten
bov
hk

NOT APPLICABLEI+
 L M. CADINAS

IV REGISTRAR
P. PILONES

ON OFFICER 1

19a(c)
 24739

Hours M16/Sec

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