Certificate Of Death
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1
2Municipal Form No. 103 (To be accomplished in quadruplicate)
REMARKS/ANNOTATION
(revised January 1993)
Republic of the Philippines
OFFICE OF THE CIVIL REGISTER GENERAL
CERTIFICATE OF DEATH
( Fill out completely, accurately and legibly, Use Ink or Typewriter.
Place X before the appropriate answer in Items 2,9,13,15,16,18,19,21 AND 23)
Province _________________________________________________________
.
FOR OCRG USE ONLY:
Registry no
Population Reference No.
______________________________________________
City/Municipality
NAME
1.
(First) (middle) (last)
TO BE FILLED UP AT THE
a. 1 YEAR OR ABOVE
b. UNDER 1 YEAR
c. UNDER 1 DAY
SEX
3. RELIGION
4. A
2.
OFFICE OF THE CIVIL
____ 1 Male
G
Completed years
Days
Hrs/Min/Sec
Months
REGISTRAR
E
____2 Female
2
1
0
PLACE OF
5.
( Name of Hospital/clinic/institution/ (city/municipality) (province)
41
DEATH
House No., Street, Barangay)
7. CITIZENSHIP
6. DATE OF DEATH
(day) (month) (year)
48
8. RESIDENCE
House no., Street, Barangay ( City/ Municipality) ( Province )
9. CIVIL STATUS
10. OCCUPATION
____ 1 Single _____ 3 Widowed _____ Unknown
____ 2 Married _____ 4 Others
49 50 51
MEDICAL CERTIFICATE
( For ages 0 to 7 days, accomplish items 11‐17 at the back)
17. CAUSES OF DEATH
Interval Between Onset and Death
54
____________________________________
I. Immediate cause : a.
_____________________________________________________ __________________________________
_____________________________________
Antecedent cause : b.
_____________________________________________________ __________________________________
59 65
_____________________________________
Underlying cause : c.
_____________________________________________________ __________________________________
_____________________________________________________________________
II. Other significant conditions
_____________________________________________________________________
contributing to death:
66
18. DEATH BY NON‐NATURAL CAUSES
a. Manner of Death
__________________
_____ 1 Homicide _____ 2 Suicide ______ 3 Accident ______ 4 Other ( Specify)
______________________________________________
b. Place of occurrence ( e.g. home, farm, factory, street, sea, etc.
71 72
19.
ATTENDANT
If attended, state duration:
_____ 1
_____
________________ , ______________
Private Physician
4 None From
_____ 2
_____
________________ , ______________
Public Heath Officer
5 Others ( Specify) To
_____ 3
____________________
Hospital Authority
20.
CERTIFICATION OF DEATH
75
I hereby certify that the foregoing particulars are correct as near as same can be ascertained and I further certify that I
Have not attended the deceased
______________
Have attended the deceased and that death occurred at
am/pm on the date indicated above.
79
REVIEWED BY:
Signature ________________________________________
______________________________
Name in Print_____________________________________
Signature over printed name
80 82
Title or Position____________________________________
of Health Center
Address _________________________________________
______________________
_________________________________________
Date
Date ___________________________________________
83
22. BURIAL / CREMATION PERMIT
23. AUTOPSY
21. CORPPE DISPOSAL
_____ 1 Burial _____ 3 Others ( Specify)
__________________________
_____ 1
Number
Yes
__________________
_______________________
_____ 2
_____ 2 Cremation
Date Issued
No
25. INFORMATION
85
_______________________________________
__________________________________________
Signature
Address
___________________________________ __________________________________________
Name in Print
_________________________
__________________________________________
Relationship to the deceased
Date
86
26. PREPARED BY: 27. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
Signature ______________________________________ Signature _____________________________________
Name in Print___________________________________ Name In Print _________________________________
90
Title or Position__________________________________ Title or Position _______________________________
Date __________________________________________ Date ______________________________________
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