Municipal Form No.

103
quadruplicate)
(revised January 1993)

(To be accomplished in

REMARKS/ANNOTATIO
N

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

Registry
no.

FOR OCRG USE ONLY:

Population Reference No.

City/Municipality
1. NAME

(First)

(middle)

3.RELIGION
A

2. SE

4.

1 Male

a. 1 YEAR OR ABOVE
YEAR
c. UNDER 1 DAY

G
E

_2
Female
5. PLACE OF
DEATH

(day)

TO BE FILLED UP AT THE
OFFICE OF THE CIVIL
REGISTRAR

Hrs/Min/S
ec

(month)

Days 0
(city/municipality)
(province)

41

7. CITIZENSHIP

(year)

48

8. RESIDENCE House no., Street, Barangay

( City/ Municipality)

9.CIVIL STATUS
1 Single
Unknown
2 Married

b. UNDER 1

Months

Completed years

( Name of
1
Hospital/clinic/institution/
House No., Street, Barangay)

6. DATE OF DEATH

(last)

( Province )

10. OCCUPA
TION

3 Widowed

49

50

51

4 Others

MEDICAL CERTIFICATE
( For ages 0 to 7 days, accomplish items 1117 at the back)
17. CAUSES OF DEATH
Interval Between Onset and

54

Death
I. Immediate cause : a.
Antecedent cause : b.

59

Underlying cause : c.

65

II.
Other significant conditions
contributing to death:

18.

66

DEATH BY NONNATURAL CAUSES

a.Manner of Death
1 Homicide

2 Suicide

3 Accident

Other

( Specify)

b. Place of occurrence ( e.g. home, farm, factory, street, sea, etc.

71

19.

72

ATTENDANTIf attended, state

duration:
1 Private Physician
2 Public Heath Officer

4 None
5 Others ( Specify)

,
,

From
To

75

3 Hospital Authority

20. 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 not attended the deceased
Have attended the deceased and that death occurred at

79

am/pm on the date indicated above.

REVIEWED BY:

Signature
Name in Print
Title or Position
Address

80

Signature over printed

name of Health
Center

83

Date
Date

21. CORPPE DISPOSAL

1 Burial
Specify)
2 Cremation

3 Others (

22.

BURIAL / CREMATION PERMIT

Number
Date Issued

25. INFORMATION
Signature
Name in Print
Relationship to the deceased

23.

AUTOPSY
1 Yes
2 No
85

Address
Date

82

26. PREPARED BY:

Signature
Name
Print
Title
Position
Date

in
or

27. RECEIVED AT THE OFFICE OF

THE CIVIL REGISTRAR
Signature
Name In Print
Title or Position
Date

86

90

FOR AGES 0 to 7 DAYS

11. DATE OF BIRTH
(day)

12. AGE OF THE MOTHER

(month)

(year)

14. LENGTH OF PREGNANCY

15. TYPE OF BIRTH
1 Single

completed weeks

2 Twin

3 Triplet,

16. IF MULTIPLE BIRTH, CHILD WAS

1 First
2 Second

MEDICAL CERTIFICATE
11.
CAUSES OF DEATH
a. Main disease/condition of infant
b. Other diseases/conditions of infant
c. Main material disease/condition affecting infant
d. Other material disease /condition affecting infant
e. Other relevant circumstances

CONTINUE TO FILL UP ITEM 18

POSTMORTEM CERTIFICATE OF DEATH

I HEREBY CERTIFY that I have this

_day of
,
performed an autopsy upon the body of the
deceased and that cause of death was as follows

Signature
Name in Print

Title/Designation
Address

CERTIFICATION OF EMBALMER
I HEREBY CERTIFY that I have embalmed
after having followed all the regulations prescribed by the Department of Health.
Signature
Name
Print
Address

Republic
the
of
City/Municipality

Title/Designation
License No.
Issued on
at
Expiry Date

in

Philippines

13. METHOD OF DELIVERY

1 Normal; spontaneou
2 Others (Specify)

of )
) S. S.
Province )

3 Other (specify)

AFFIDAVIT FOR DELAYED REGISTRATION

OF DEATH
I,
_, of legal are, single/married, after being Duly sworn to in accordance with law, do
hereby depose and say:
1.

That

died on
in
and was buried/cremated in
on

2.
3.

_.
That the deceased was/was not attended to at the time of his death.
That the reason for the delay in registering this death was due to
.

(Signature of affiant)

Community Tax
No.
Date Issued
Place Issued

SUBSCRIBED AND SWORN to before me this

, Philippines.
(Signature of Administering Officer)
(Title/Designation)

(Name in Print)
(Address)

_day of
,
at