REPUBLIC OF THE PHILIPPINES )

PROVINCE OF QUEZON ) S.S.

AFFIDAVIT OF LOSS

I, PAMELA RUBIO NOLASCO, of legal age, Filipino citizen and with residential
address at Barangay Bantilan, Municipality of Infanta, Province of Quezon, after having
been sworn to in accordance with law, hereby depose and state;

That I am one among the eight children of deceased, Leanita Rubio Nolasco who
died on October 11, 2023 at Quezon Medical Center, Lucena City, Quezon;

That when my late mother died, her sister Nerry Rubio Pumarejos went to the
Quezon Medical Center to process her Certificate of Death and the Hospital issued her
the Municipal Form No. 103;

That on October 15, 2023, my aunt, Nerry Rubio Pumarejos handed me the said
Municipal Form No. 103 at Infanta, Quezon. However, I did not check on how many
copies of the same was given to me by my aunt;

That when I proceeded at the Local Civil Registrar of Lucena City, the place
where my mother died, I was informed by an employee thereat that Municipal Form No.
103, should be filed in triplicate copy and I only have two copies of the same;

That I immediately went to the Records Section of Quezon Medical Center to

secure another copy of said Municipal Form No. 103, but they told me to execute first
an Affidavit of Loss;

That I am executing this affidavit in order to attest to the truth of the foregoing
facts and circumstances and for whatever legal purpose this may serve.

Done this 23rd day of October, 2023 at Lucena Citty, Philippines.

PAMELA RUBIO NOLASCO

Affiant

SUBSCRIBED AND SWORN to before a Notary Public for and in the Province of
Quezon, this 23rd day of October 2023, affiant exhibited to me her government issued
identification card with ID with No. 07-025960991 as competent proof of her identity.

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Series of 2023