Certificate Of Death Page 2
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1
2FOR AGES 0 to 7 DAYS
11. DATE OF BIRTH
12. AGE OF THE MOTHER
13. METHOD OF DELIVERY
(day) (month) (year)
______1 Normal; spontaneous vertex
______2 Others (Specify) __________
14. LENGTH OF PREGNANCY ______________ completed weeks
15. TYPE OF BIRTH
16. IF MULTIPLE BIRTH, CHILD WAS
_____ 1 Single ____ 2 Twin _____ 3 Triplet, etc.
_____ 1 First _____ 2 Second ______ 3 Other (specify) ___________________
MEDICAL CERTIFICATE
11. CAUSES OF DEATH
a. Main disease/condition of infant ______________________________________________________________________________________________
b. Other diseases/conditions of infant ____________________________________________________________________________________________
c. Main material disease/condition affecting infant __________________________________________________________________________________
d. Other material disease /condition affecting infant _________________________________________________________________________________
e. Other relevant circumstances _________________________________________________________________________________________________
CONTINUE TO FILL UP ITEM 18
POSTMORTEM CERTIFICATE OF DEATH
I HEREBY CERTIFY that I have this _____________day of __________________, ________________performed an autopsy upon the body of the deceased
and that cause of death was as follows _____________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Signature _____________________________________
Title/Designation____________________________________
Name in Print __________________________________
Address ___________________________________________
___________________________________________
CERTIFICATION OF EMBALMER
I HEREBY CERTIFY that I have embalmed _______________________________________________________________________________ after having
followed all the regulations prescribed by the Department of Health.
Signature ____________________________________________
Title/Designation_____________________________________
Name in Print _________________________________________
License No. __________________________________________
Address ______________________________________________
Issued on _________ at ________________________________
____________________________________________________
Expiry Date __________________________________________
Republic of the Philippines ________________________________________ )
Province of ____________________________________________________ ) S. S.
City/Municipality _______________________________________________ )
AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH
I, _________________________________________________________________________________, of legal are, single/married, after being
Duly sworn to in accordance with law, do hereby depose and say:
1.
That ___________________________________________________________________died on _______________________________in
____________________________________________________________________________ and was buried/cremated in
_________________________________________________________________________________on ______________________.
2.
That the deceased was/was not attended to at the time of his death.
3.
That the reason for the delay in registering this death was due to __________________________________________________________
__________________________________________________________________________________________________________.
___________________________________________________
)
(Signature of affiant
Community Tax No. __________________________________
Date Issued ________________________________________
Place Issued _________________________________________
SUBSCRIBED AND SWORN to before me this _____________day of ______________________________, __________________________ at
__________________________________________________________________________________________________ , Philippines.
___________________________________________
_____________________________________________
(Signature of Administering Officer)
(Title/Designation)
___________________________________________
_____________________________________________
(Name in Print)
(Address)
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