NOT OFFICIAL COPY

Municipal Form 103 (To be accomplished in quadruplicate using black ink)

(Revised January 2007) Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL
CERTIFICATE OF DEATH
Province Registry No.
City/Municipality
1. NAME (First) (Middle) (Last) 2. SEX (Male, Female)

3. DATE OF DEATH (Day, Month, Year) 4. DATE OF BIRTH (Day) (Month) (Year) 5. AGE AT THE TIME OF DEATH (Fill in below accdg to age category)
a. IF 1 YEAR OR ABOVE b. IF UNDER 1 YEAR c. IF UNDER 24 HOURS
[2] Completed years [1] Months [0] Days

6. PLACE OF DEATH (Name of Hospital/Clinic/Institution/House No., St., Barangay, City/Municipality, Province) 7. CIVIL STATUS (Single/Married/Widow/
Widower/Annulled/Divorced)

8. RELIGION/RELIGIOUS SECT 9. CITIZENSHIP 10. RESIDENCE (House No., St., Barangay, City/Municipality, Province, Country)

11. OCCUPATION 12. NAME OF FATHER (First, Middle, Last) 13. MAIDEN NAME OF MOTHER (First, Middle, Last)

MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back)
19b. CAUSES OF DEATH (if the deceased is aged 8 days and over) Interval Between Onset and Death
I. Immediate cause : a.
Antecedent cause : b.
Underlying cause : c.
II. Other significant conditions contributing to death:
19c. MATERNAL CONDITION (If the deceased is female aged 15-49 years old)
a. pregnant b. pregnant, in c. less than 42 days after d. 42 days to 1 year after e. None of the
not in labour labour delivery delivery choices
19d. DEATH BY EXTERNAL CAUSES 20. AUTOPSY
a. Manner of Death (Homicide, Suicide, Accident, Legal intervention, etc.) (Yes, No)

b. Place of Occurrence of External Cause (e.g. home, farm, factory, street, sea, etc.)
21a. ATTENDANT 21b. If attended, state duration (mm/dd/yy)
2 Public
1 Private Health 3 Hospital 5 Others
Physician Officer Authority 4 None (Specify) From To
22. CERTIFICATION OF DEATH
I hereby certify that the foregoing particulars are correct as near as same can be ascertained and I further certify that I have attended/
have not attended the deceased and the death occurred at ________________________ am/pm on the date of death specified above.
REVIEWED BY:
Signature
Name in Print
Title or Position Signature Over Printed Name of Health Officer
Address
Date Date
23. CORPSE DISPOSAL 24a. BURIAL/CREMATION PERMIT 24.b TRANSFER PERMIT
(Burial, Cremation, if others, specify) Number Number
Date Issued Date Issued
25. NAME AND ADDRESSES OF CEMETERY OR CREMATORY

26. CERTIFICATION OF INFORMANT 27. PREPARED BY:

I hereby certify that all information supplied are true and correct
to my own knowledge and belief.
Signature Signature
Name in Print Name in Print
Relationship to the Deceased Address
Address Date
Date__________________________________________________
REMARKS/ANNOTATIONS (For LCRO/OCRG Use only)

TO BE FILLED-UP AT THE OFFICE OF THE CIVIL REGISTRAR

5 8 9 10 11 19(a)/19(b) 19(c )
 NOT OFFICIAL COPY FOR CHILDREN AGED 0 TO 7 DAYS
14. AGE OF MOTHER 15. METHOD OF DELIVERY (Normal spontaneous, 16. LENGTH OF PREGNANCY:
vertex, if others, specify (in completed weeks)

17. TYPE OF BIRTH 18. IF MULTIPLE BIRTH, CHILD WAS

(Single, Twin, Triplet, etc.) (First, Second, Third, etc.)

MEDICAL CERTIFICATE
19a. CAUSES OF DEATH
a. Main diease/condition of infant
b. Other diseases/conditions of infant
c. Main maternal disease/condition affecting infant
d. Other maternal disease/condition affecting infant
e. Other relevant circumstances
CONTINUE TO FILL UP ITEM 20
POSTMORTEM CERTIFICATE OF DEATH
I HEREBY CERTIFY that I have performed an autopsy upon the body of the deceased and that the cause of death was

Signature Title/Designation
Name in Print Address
Date

CERTIFICATION OF EMBALMER
I HEREBY CERTIFY that I have embalmed ______________________________________________________ following
all the regulations prescribed by the Department of Health.

Signature Title/Designation
Name in Print License No.
Address Issued on at
Expiry Date

AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH

I, , of legal age, single/married/divorced/widow/widower,

with residence and postal address
, after being duly sworn in accordance with law, do hereby depose and say:

1. That died on in
and was buried/cremated in
on .
2. That the deceased at the time of his/her death:
was attended by :

was not attended.

3. That the cause of death of the deceased was .
4. That the reason for the delay in registering his death was due to

5. That I am executing this affidavit to attest to the truthfulness of the foregoing statements for legal intents and purposes.
In truth whereof, I have affixed my signature below this day of ,
at , Philippines.

(Signature Over Printed Name of Affiant)

SUBSCRIBED AND SWORN to before me this day of , at

, Philippines, affiant who exhibited to me his Community Tax Cert.
issued on at .