MunicipalFormNo.

103(Tobeaccomplishedinquadruplicate)
(revisedJanuary1993)

RepublicofthePhilippines
OFFICEOFTHECIVILREGISTERGENERAL
CERTIFICATEOFDEATH
(Filloutcompletely,accuratelyandlegibly,UseInkorTypewriter.
PlaceXbeforetheappropriateanswerinItems2,9,13,15,16,18,19,21AND23)

Davao del Sur

Province_________________________________________________________

Registryno.

Digos City
City/Municipality______________________________________________
1.NAME(First)(middle)(last)

DEADO
TSUGI
NA

a.1YEARORABOVE b.UNDER1YEAR
2.SEX
3.RELIGION
4.A
____1Male

X
Completedyears
MonthsDays
G
Roman

E
____2Female
Catholic
1 0
60 2

c.UNDER1DAY
Hrs/Min/Sec

REMARKS/ANNOTATION

FOROCRGUSEONLY:
PopulationReferenceNo.

TOBEFILLEDUPATTHE
OFFICEOFTHECIVIL
REGISTRAR

5.PLACEOF(NameofHospital/clinic/institution/(city/municipality)(province)
41
DEATHHouseNo.,Street,Barangay)

Brgy. Zone 2, Estrada 5th,

Digos City, Davao del Sur

7.CITIZENSHIP

6.DATEOFDEATH(day)(month)(year)

Filipino
24 DECEMBER 2015

48

8.RESIDENCEHouseno.,Street,Barangay(City/Municipality)(Province)

Brgy. Zone 2, Estrada 5th, Digos City, Davao del Sur

9.CIVILSTATUS
10.OCCUPATION

____1Single_____3Widowed_____Unknown

X
____2Married_____4Others
Martial Artist
495051

MEDICALCERTIFICATE

(Forages0to7days,accomplishitems1117attheback)

17.CAUSESOFDEATHIntervalBetweenOnsetandDeath
54
Cardiac arrest secondary to
I.Immediatecause:a.____________________________________

_______________________________________________________________________________________
hypovolemic shock

secondary to severe bleeding

Antecedentcause:b._____________________________________

secondary to penetrating abdominal trauma

_______________________________________________________________________________________
5965
secondary to stabbing
Underlyingcause:c._____________________________________

_______________________________________________________________________________________
II.Othersignificantconditions_____________________________________________________________________
contributingtodeath:_____________________________________________________________________

66
18.DEATHBYNONNATURALCAUSES

a.MannerofDeath

_____1Homicide_____2Suicide______3Accident______4Other(Specify)
__________________
X

Home
b.Placeofoccurrence(e.g.home,farm,factory,street,sea,etc.______________________________________________
71 72
19.ATTENDANTIfattended,stateduration:

6:30 pm

X PrivatePhysician_____4NoneFrom________________,______________
_____1
Dec. 24, 2015

7:00 pm
________________,______________
_____2PublicHeathOfficer_____5Others(Specify)ToDec.
24, 2015

_____3HospitalAuthority____________________

20.CERTIFICATIONOFDEATH
75
IherebycertifythattheforegoingparticularsarecorrectasnearassamecanbeascertainedandIfurthercertifythatI

Havenotattendedthedeceased

7:00 pm am/pmonthedateindicatedabove.

______________
Haveattendedthedeceasedandthatdeathoccurredat
x
79

REVIEWEDBY:

Signature________________________________________
Gon Freecs
______________________________

Black
Jack
NameinPrint_____________________________________
Signatureoverprintedname
8082

Resident Physician
ofHealthCenter

TitleorPosition____________________________________

Digos Doctors Hospital

Address_________________________________________

_________________________________________
December 24, 2015
______________________

Date
December 24, 2015
83
Date___________________________________________

22.BURIAL/CREMATIONPERMIT
23.AUTOPSY
21.CORPPEDISPOSAL

x
x
123456
_____1Burial_____3Others(Specify)
Number__________________________
_____1
Yes

_____2Cremation__________________
DateIssuedDecember
_______________________
25, 2015 _____2No

25.INFORMATION
85

Brgy. Zone 2, Estrada 5th,

Signature_______________________________________Address__________________________________________

NameinPrint_____________________________________________________________________________
HARVAE NA
Digos City, Davao del Sur

Relationshiptothedeceased_________________________
Date__________________________________________
Spouse
December 24, 2015

86
26.PREPAREDBY:27.RECEIVEDATTHEOFFICEOF

THECIVILREGISTRAR

Signature______________________________________Signature_____________________________________

Killua Zoldyck
NameinPrint___________________________________NameInPrint_________________________________
90
Hospital Secretary
TitleorPosition__________________________________TitleorPosition_______________________________

December 25, 2015

Date__________________________________________Date______________________________________

11.DATEOFBIRTH

12.AGEOFTHEMOTHER

FORAGES0to7DAYS
13.METHODOFDELIVERY
______1Normal;spontaneousvertex
______2Others(Specify)__________

(day)(month)(year)

14.LENGTHOFPREGNANCY______________completedweeks
15.TYPEOFBIRTH
_____1Single____2Twin_____3Triplet,etc.

16.IFMULTIPLEBIRTH,CHILDWAS
_____1First_____2Second______3Other(specify)___________________

MEDICALCERTIFICATE
11.CAUSESOFDEATH
a.Maindisease/conditionofinfant______________________________________________________________________________________________
b.Otherdiseases/conditionsofinfant____________________________________________________________________________________________
c.Mainmaterialdisease/conditionaffectinginfant__________________________________________________________________________________
d.Othermaterialdisease/conditionaffectinginfant_________________________________________________________________________________
e.Otherrelevantcircumstances_________________________________________________________________________________________________

CONTINUETOFILLUPITEM18

POSTMORTEMCERTIFICATEOFDEATH

25th
December
2015
IHEREBYCERTIFYthatIhavethis_____________dayof__________________,________________performedanautopsyuponthebodyofthedeceased
Cardiac
arrest
secondary to hypovolemic shock secondary to severe bleeding

andthatcauseofdeathwasasfollows_____________________________________________________________________________________
_____________________________________________________________________________________________________________________________
secondary to penetrating abdominal trauma secondary to stabbing

Medico Legal
Signature_____________________________________

Title/Designation____________________________________
Digos Doctors Hospital
NameinPrint__________________________________

Address___________________________________________
Grimm Reaper

___________________________________________

CERTIFICATIONOFEMBALMER
IHEREBYCERTIFYthatIhaveembalmed_______________________________________________________________________________afterhaving
followedalltheregulationsprescribedbytheDepartmentofHealth.

Signature____________________________________________

Title/Designation_____________________________________
NameinPrint_________________________________________

LicenseNo.__________________________________________
Address______________________________________________

Issuedon_________at________________________________
____________________________________________________

ExpiryDate__________________________________________

RepublicofthePhilippines________________________________________)
Provinceof____________________________________________________)S.S.
City/Municipality_______________________________________________)

AFFIDAVITFORDELAYEDREGISTRATIONOFDEATH

I,_________________________________________________________________________________,oflegalare,single/married,afterbeing
Dulysworntoinaccordancewithlaw,doherebydeposeandsay:

1.

2.
3.

That___________________________________________________________________diedon_______________________________in
____________________________________________________________________________andwasburied/crematedin
_________________________________________________________________________________on______________________.
Thatthedeceasedwas/wasnotattendedtoatthetimeofhisdeath.
Thatthereasonforthedelayinregisteringthisdeathwasdueto__________________________________________________________
__________________________________________________________________________________________________________.

___________________________________________________

(Signatureofaffiant)

CommunityTaxNo.__________________________________

DateIssued________________________________________

PlaceIssued_________________________________________

SUBSCRIBEDANDSWORNtobeforemethis_____________dayof______________________________,__________________________at
__________________________________________________________________________________________________,Philippines.

___________________________________________

_____________________________________________
(SignatureofAdministeringOfficer)

(Title/Designation)

___________________________________________

_____________________________________________

(NameinPrint)

(Address)