REPUBLIC OF THE PHILIPPINES)

CITY OF ___________________ ) S.S.

x--------------------------------------x

AFFIDAVIT OF DEATH

I, ____________________________, of legal age, Filipino citizen, married and

with residence address at
____________________________________________________________, after having
been duly sworn in accordance with law, do hereby depose and state that:

1. I personally know ______________________________ being his neighbour

for __________ years;

2. On the ____ day of ________________, I was present when said

____________ _______________ died at
___________________________________;

3. On the ____ day of _____________, I attended the burial of said

___________ ___________________ at
________________________________.

4. I am executing this affidavit to attest to the truth of all the foregoing and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of

______________, 202__ in ________________, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN TO before me, this ____ day of

______________, 202__ in the City of _______________, affiant
___________________ exhibiting to me his/her Passport No. ____________ issued on
_____________ at ________________.

WITNESS MY HAND AND NOTARIAL SEAL on the date and place first
above-written.

ATTY. _______________________
NOTARY PUBLIC for the City of ______________
Commission Serial No. _______________
Until December 31, 2024
(address)
Roll of Attorney No. ________
Doc. No. ____; IBP No. _____/Date/Place of Issue
Page No. ____; PTR No. _____/Date/Place of Issue
Book No. ____; MCLE Compliance No. VII – ______________
Series of ____; Valid until April 14, 2025