Municipal 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 NCR Registry no. FOR OCRG USE ONLY:

Population Reference No.
City/Municipality PASIG CITY
1. NAME (First)
REX II
(middle)
CRUZ
(last)
ALVARADO
I I
TO BE FILLED UP AT THE
2. SEX 3. RELIGION 4.A a. 1 YEAR OR ABOVE b. UNDER 1 YEAR c. UNDER 1 DAY
_K_l Male OFFICE OF THE CIVIL
G Completed years Months Days Hrs/Min/Sec
REGISTRAR
CHRISTIAN
-2
E 10
Female 2 1 0

5. PLACE OF ( Name of Hospital/clinic/institution/ (city/municipality) (province)

41

I I I I I I I I
DEATH House No., Street, Barangay)
Lot 5 Block 6, Camella Homes, Mercedes Ave., Pasig City
7. CITIZENSHIP
6. DATE OF DEATH (day) (month) (year)
15 DEC 2017 FILIPINO

_o
48
8. RESIDENCE House no., Street, Barangay (City/ Municipality) (Province )
Lot 5 Block 6, Camella Homes, Mercedes Ave., Pasig City
9. CIVIL STATUS 10. OCCUPATION
_x_1 Single --3Widowed -- Unknown
--2 Married __40thers
49 50 51

MEDICAL CERTIFICATE
(For ages Oto 7 days, accomplish items 11-17 at the back)
D [I] I I I I
17. CAUSES OF DEATH Interval Between Onset and Death
(FOR AUTOPSY) 54
I. Immediate cause : a.

Antecedent cause : b.
see at tfie 6acl< I I I I I I
Underlying cause : c. 59 65

II. Other significant conditions

I I I I I I D
contributing to death:
66
18. DEATH BY NON-NATURAL CAUSES
a. Manner of Death
--
X 1 Homicide -- 2 Suicide --
3 Accident __ 4 Other ( Specify) I II I I I
b. Place of occurrence ( e.g. home, farm, factory, street, sea, etc.
71 72
19. ATTENDANT If attended, state duration:
__ 1 Private Physician
X 2 Public Heath Officer
--
__ 4 None
__ 5 Others ( Specify)
From
To D I I I I
3 Hospital Authority
20. CERTIFICATION OF DEATH 75

I I I I
I hereby certify that the foregoing particulars are correct as near as same can be ascertained and I further certify that I

D Have not attended the deceased 7:00-9:00

1:00 __ an the dote indicated above.
x Have attended the deceased and that death occurred at
O am/pm
79

Signature
REVIEWED BY: I I I I I
Name in Print Dr. Becky B. Belo Signature over printed name
80 82

D
Title or Position City Health Officer of HealthCenter
Address Pasig City General Hospital Pasig [I]
City
Date December 18, 2017 Date
83
21. CORPPE DISPOSAL
_.X_l Burial __3 Others ( Specify)
22. BURIAL/ CREMATION PERMIT
Number
23. AUTOPSY
_2(_1Yes
[I]
2Cremation Date Issued 2 No
24. NAME AND ADDRESS OF CEMETERY OR CREMATORY
PASIG CEMETERY MERCEDEZ AVE PASIG CITY 85
25. INFORMATION
Signature Address c/o Homicide Section D
Name in Print SPOI Kaiser Mijares
86
Relationship to the deceased inv. on case Date December 18, 2017

26. PREPARED BY: 27. RECEIVED AT THE OFFICE OF I I I I I

THE CIVIL REGISTRAR
Signature Signature 90
Kenneth Landicho
I I I I I
Name in Print Name in Print
Title or Position Secretary Title or Position
Date December 18 2017 Date