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Report Of Death Form

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NOT FOR SALE

REPUBLIC OF THE PHILIPPINES

FA FORM NO.39

DEPARTMENT OF FOREIGN AFFAIRS

(REVISED MARCH 2013)

REPORT OF DEATH

DATE OF REPORT

(day-month-year)

FOR FILIPINOS WHO DIED ABROAD

THIS FORM IS NOT FOR SALE. DO NOT LEAVE ANY SPACES BLANK. INDICATE N/A IF NOT APPLICABLE.

ID#

Foreign Service Post:

PARTICULARS OF THE DECEASED

6. DATE OF BIRTH

1. LAST NAME

(day-month-year)

2. FIRST NAME

7. PLACE OF BIRTH

3. MIDDLE NAME

8. SEX

FEMALE

MALE

4. OCCUPATION

SINGLE

MARRIED

9. CIVIL STATUS

WIDOW/ER

DIVORCED/ ANNULLED

5. CITIZENSHIP

10. EVIDENCE OF CITIZENSHIP

11. PASSPORT NO.

12. NAME OF SURVIVING SPOUSE/ RELATIVE

13. ADDRESS OF SURVIVING SPOUSE/ RELATIVE

CIRCUMSTANCES OF DEATH:

PARTICULARS OF DEATH

14. DATE OF BIRTH

17. TIME OF DEATH

(day-month-year)

15. PLACE OF DEATH

(include hospital or institution's name, city,

state or province, country)

16. IMMEDIATE CAUSE OF DEATH

(technical statement as cause

of death, as given by competent authority or probable cause of death)

22. RELATIONSHIP TO DECEASED

18. INFORMANT'S NAME

19. INFORMANT'S ADDRESS

23. INFORMANT'S SIGNATURE

20. DISPOSITION OF REMAINS

21. DISPOSITION OF EFFECTS

24. PLACE OF BURIAL

25. SUPPORTING DOCUMENTS SUBMITTED

REMAINS IN COFFIN

ASHES IN URN

26. IF SHIPPED TO THE PHILIPPINES:

Death Certificate

28. DATE OF SHIPMENT

27. FLIGHT NO.

(day-month-year)

Transit Certificate

29. NAME OF CONSIGNEE

Notarized Mortuary Certificate

30. ADDRESS OF CONSIGNEE

Embalmer's/ Cremation Certificate

31. NAME OF MORTUARY/ CREMATOR

Non Contagious Disease Certificate

32. ADDRESS OF MORTUARY/ CREMATOR

Others (specify)

EMBASSY/ CONSULATE OF THE REPUBLIC OF THE PHILIPPINES

THE INFORMATION AND DATA CONCERNING AN INVENTORY OF THE EFFECTS, ACCOUNTS, ETC., HAVE BEEN PLACED UNDER FILE IN THE CORRESPONDENCE OF THIS OFFICE.

(To be sent in triplicate to the Department of Foreign Affairs; or to be forwarded in quadruplicate when decedent is Philippine citizen seafarer, a beneficiary of the Veterans

Administration or an officer or employee of the Philippine Government.)

Remarks: _____________________________________________________________

Date: __________________________

Service No.: _____________________

O.R. No.:________________________

Fee Paid: _______________________

SEAL

REPUBLIC OF THE PHILIPPINES