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WITNESSETH
That the undersigned surviving heir hereby affirm that she has
executed the foregoing instrument out of her own voluntary free will
without force, intimidation or violence upon her person;
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___________________________________
vendor
Passport No: _______
Issued On: ____________
Date of Expiration: ______________
ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES} s.s.
IN THE CITY OF ___________ }
WITNESS MY HAND AND SEAL, the day, place and year above-
written.
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