REPUBLIC OF THE PHILIPPINES)

PROVINCE OF EASTERN SAMAR) S.S

MUNICIPALITY OF LAWAAN)

AFFIDAVIT OF LATE REGISTRATION OF DEATH

I, MIRANDA ALGARIO ECALDRE, of legal age, married, a Filipino citizen,

and is a resident of, Brgy. 05, Lawaan, Eastern Samar, after having been sworn in accordance with
law hereby depose and state that;

1. That I am the daughter of the late DOMINGA GACITA ALGARIO.

2. That my mother the late DOMINGA GACITA ALGARIO, daughter of

Diosdado Gacita and Eugenia Abe, died on March 04, 2008 at Lawaan, Eastern
Samar.

3. That upon the verifications I made, I discovered that her death and the facts
surrounding thereof, are not yet reported at the LOCAL CIVIL REGISTRY of
Lawaan, Eastern Samar.

4. That I am requesting the proper authorities to register the death of my mother

DOMINGA GACITA ALGARIO.

5. That I am executing this affidavit to attest the truth and veracity of the foregoing
statements and for all legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have affixed my signature this 2nd day of February 2018 at
Lawaan, Eastern Samar.

MIRANDA ALGARIO ECALDRE

Affiant

SUBSCRIBED AND SWORN to before me, this 2nd day of February 2018 in Lawaan,
Eastern Samar, with affiant who personally appeared and presented her Community Tax
Certificate with No. ___________________.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2018.