MunicipalFormNo.

103 (Tobeaccomplishedinquadruplicateusingblackink)
(Revised January 2007) RepublicofthePhilippines
OFFICEOFTHECIVILREGISTRARGENERAL
CERTIFICATEOFDEATH
RegistryNo.
Province c
City/Municipality

1. NAME (First) {Middle} (Last)

2. SEX(Male/Female)

3. DATEOFDEATH(Day.Month.Year)4.DATEOFBIRTH(Day) (Month)(Year) 5. AGEATTHETIMEOFDEATH(Fill-inbelowaccda.toaaecateaorv

I
"IF1Y R h.It-:-IN1JJ-H1YEAR rIF'" ;;0'}4uos

12]Completedyears f1]Months Hours Min/Sec

fOJDays

6. PLACEOFDEATH(NameofHospital/Clinic/Institution/HouseNo.,St.,Barangay,City/Municipality.Province) 7. CIVILSTATUS(Single/Married/
Widow/Widower/Annulled/Divorced}

8. RELIGION/RELIGIOUSSECT 9.CITIZENSHIP 10.RESIDENCE(HouseNo.,st.,Barangay,City/Municipality,Province,Country)

11.0CCUPATION 12.NAMEOFFATHER(First.Middle,Last) 13.MAIDENNAMEOFMOTHER(First,Middle,Last)

MEDICALCERTIFICATE
(ForagesOto7days,accomplishitems14-19aattheback)

19b.CAUSESOFDEATH(Ifthedeceasedisaged8daysandover) IntervalBetweenOnsetandDeath
I. Immediatecause a.

Antecedent cause
b.

Underlyingcause C.
II. Othersignificantconditionscontributingtodeath:
19c.MATERNALCONDITION(Ifthedeceasedisfemaleaged15-49yearsold)

a. pregnant, b. pregnant, in c. less than 42 days after ct. 42days to 1 year after e.Noneofthe
not in labour labour
-- delivery delivery choices
19d.DEATHBYEXTERNALCAUSES 20.AUTOPSY
(Yes/No)
a. Mannerofdeath(Homicide,Suicide,Accident,Legalintervention,etc.)

b. PlaceofOccurrenceofExternalCause(e.g.home,farm, factory,street.sea,etc.)
21a.ATTENDANT 21b.Ifattended,stateduration(mm/dd/yy)
2Public
1Private Health 3Hospital 5Others
-- Physician-- Officer-- Authority --4None-- (Specify From To

22.CERTIFICATIONOFDEATH
IherebycertifythattheforegoingparticularsarecorrectasnearassamecanbeascertainedandIfurthercertifythatI have not p
D attended the deceased and that death occurred at am/pmon the dateofdeathspecifiedabov.
REVIEWEDBY:
haveattended/

Signature
Name in Print
Title orPosition SignatureOverPrintedNameofHealthOfficer

Address
Date ua1e
23.CORPSEDISPOSAL 24a.BURIAVCREMATIONPERMIT 24b.TRANSFERPERMIT
(Burial,Cremation,ifothers,specify)
Number Number
DateIssued• DateIssued
25.NAMEANDADDRESSOFCEMETERYORCREMATORY

26.CERTIFICATIONOFINFORMANT 27.PREPAREDBY
I hereby certify thatallinformation suppliedaretrueandcorrect to
my ownknowledge andbelief.
Signature SignatureName
Namein Print in Print
RelationshiptotheDeceased
TitleorPosition
Address
Date
Date
28.RECEIVEDBY 29. REGISTEREDBYTHECIVILREGISTRAR
Signature SignatureName
Name in Print in Print
TitleorPosition TitleorPosition
Date Date
REMARKS/ANNOTATIONS(ForLCRO/OCRGUseOnly)

TOBEFILLED-UPATTHEOFFICEOFTHECIVILREGISTRAR
5 8 9 10 11 19a(a)/19b 19a(c_)

I
I
 FORCHILDRENAGEDOTO7DAYS
14.AGEOFMOTHER 15.METHODOFDELIVERY(Normalspontaneous 16. LENGTHOFPREGNANCY:
vertex, if others, specify) (incompletedweeks)

17.TYPEOFBIRTH 18.IFMULTIPLEBIRTH,CHILDWAS
(Single,Twin,Triplet,etc) (First,Second,Third,etc)

MEDICALCERTIFICATE
19a.CAUSESOFDEATH
a. Maindisease/conditionofinfant

b. Otherdiseases/conditionsof infant
c. Mainmaternaldisease/conditionaffectinginfant

d. Othermaternaldisease/conditionaffectinginfant
e. Otherrelevantcircumstances
CONTINUETOFILLUPITEM20

POSTMORTEMCERTIFICATEOFDEATH
IHEREBYCERTIFYthatIhaveperformedanautopsyuponthebodyofthedeceasedandthatthecause ofdeathwas

Signature _Title/Designation
Name in Print
Address
Date
CERTIFICATIONOFEMBALMER
IHEREBYCERTIFY that Ihave embalmed following
all the regulations prescribedbytheDepartment of Health.

Signature Title/Designation
NameinPrint LicenseNo.
Address _ Issuedon at
------- ----------
Expiry Date

AFFIDAVIT FORDELAYEDREGISTRATIONOFDEATH

I, .of legal age, single/married/divorced/widow/widower,

withresidenceandpostaladdress _
,afterbeingdulysworninaccordancewithlaw,doherebydeposeandsay:

1. That died on in
andwasburied/crematedin
on

D
2. Thatthedeceasedatthetimeofhis/herdeath:
wasattendedby _

D wasnotattended.

3. That thecauseofdeath ofthedeceasedwas _

4. Thatthereasonforthedelayinregisteringthisdeathwasdueto _

5. ThatIamexecutingthisaffidavittoattesttothetruthfulnessoftheforegoingstatementsforalllegalintentsandpurposes.

In truth whereof, I have affixed my signaturebelow this day of _

at ,Philippines.

(SignatureOverPrintedNameofAffiant)

SUBSCRIBEDANDSWORNto beforemethis day of at

--------------------- ,Philippines,affiantwhoexhibitedtomehisCommunityTaxCert.
--------issuedon at _

Signature of the Administering Officer Position/Title/Designation

Namein Print Address