FOR CHILDREN AGED 0 TO 7 DAYS

14. AGE OF MOTHER 15. METHOD OF DELIVERY(Nommatqontawon16.LENGTH OF PREGNANCY

voitex ollea, Nocity) ( ed wooke)

m
it
17. TYPEOF BIRTH 18. IF MULTIPLE BIRTH, CHILD WAS
(Snoke Iwio uet,eto)

MEDICAL CERTIFICATE

19a. CAUSES OF DEATH

a Maln diseaselconditlon of intant

b. Other diseaseslconditions of infant

c Maln maternal diseaselconditlion affecting infant

d Other matermaldiseaselcondition affecting intant

e. Other relevant cireumstances

CONTINUE TO FILL UP ITEM 20

POSTMORTEMCERTIFICATE OF DEATH
I HEREBY CERTIFY that |have perfomed an autopsy upon the body of the decoased and that the cause of doath was

Signature Title/Designation
Name in Print Address

Date

OFEMALMER
B. D\m
CERTIFICATION
IHEREBY CERTIFY that I have ombalmod DLmnio following
all the regulations prescibed by the Department of Health.

Signature Tillo/Dosignatlon lcensedbclöer

Name in Print NAZAnI
CHISTINEle, License No. 09-0--3315
Address
VIlLA FUNE RAL MOMES Issued on 09- 3 -2004
July 2020
PANABO CIY Expiry Date

AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH

of logal age, single/married/divorcod/widow/widower,

with residence and postal address

,after being duly sworn in accordance with law, do hereby depose and say:

1. That died on in

and was buried/crematod in

on

2. That the deceased at the time of his/her death:

was attended by

was not attended.

3. That the cause of death of the deceased was

4. That the reason for the delay in registering this death was due to

5. That am executing this alfidavit to attest to the truthfuiness of the foregoing statenments for all logal intonts and purpos0s.
I
In truth whereof, I have affixed my signature below this day of

Philippines.

(Signature Over Printed Name of Affiant)

SUBSCRIBED AND SWORN to before me this day of at

Philippines, affiant who exhibited to me his/her CTClvalid ID

issued on at

Signature of the Administering Officer Position / Title / Designation

Name in Print