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Republic of the Philippines )

________________ ) S.S.
x- - - - - - - - - - - - - - - - - - - - - - - - //

WAIVER TO UNDERTAKE AUTOPSY

I___________, of legal age, Filipino, single, and residing at ____________________, after


being duty sworn to in accordance with law, hereby, depose and say:

1. That I am the sister of the late _________________ and represents the family;
2. That my brother died on ________ at around ______ due to _____________;
3. That he was rushed to the hospital in ____________ but was declared dead on
arrival;
4. That upon the consensus of the family members, we decided to forego the autopsy
of his body and release ______________ from whatever liability, if there is any, as a
result of this decision not to perform an autopsy of my brothers remains;
5. As such, I am executing this Waiver to attest to the truth of the foregoing and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at


______________, Philippines.

________________

Signed in the presence of :

________________________________________________ _________ __________________________________________

Republic of the Philippines)


___________________ ) S.S.
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ACKNOWLEDGMENT

BEFORE ME, a Notary Public, personally appeared above-named


________________________, with her competent identification, known to me to be the same
person and acknowledge to me that the same is of her own free and voluntary act and deed.

WITNESS MY HAND AND SEAL this _____________ in the _________________,


Philippines.

Doc. No. ______;


Page No. ______;
Book No.______;
Series of 2016.