Republic of the Philippines)

City of __________________) S.S.

Affidavit of Funeral Expense

I, MINDA C. DELA Rosa, of legal age, Filipina, single and a resident of 9 Gozales St., Nagbalon
Marilao Bulacan after having duly sworn to in accordance with law, do herby depose and states THAT:

1. I am the daughter of the late MERCEDES D. DELA ROSA;

2. Died on June 3, 2024 at 9 Gonzales St. Nagbalon Marilao Bulacan;
3. That the following are list of the funeral expenses of the burial of my mother;

Funeral Service P 30,000.00

(Funeral Parlor)
Mass for Burial Ceremony 700.00
(St. Michael Parish church)
Inurnment-Cemetery 1,500.00
Total P 32,200.00

4. That I am executing this affidavit for the purpose of attesting to the truth of the foregoing funeral
expenses and for whatever legal purposes it may serve.

IN TRUTH WHEREOF, I have here unto signed my name below, this __________________, 2024 at
__________________________.

__________________________________
MINDA DELA CRUZ DELA ROSA
Affiant

SUBSCRIVED AND SWORN to before me this ___________ of ________, 2024. Affiant exhibited to me
her PHILIPPINE ID 3027-1378-5973-6089 issued at ________________.

Notary Public

Reg. No.________
Page No.________
Book No.________
Series of_________