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‘Manipal Form No, 103) Rapubts f the Phimppines voce amomaaned w asaplsi wg Meck
(ied lattes) OFFICE OF THE CIVIL REGISTRAR GENERAL
CERTIFICATE OF DEATH
rove. aa a aa No. a bet
Cityitunicipality a
4, NAME (Fr ‘widdle) ood F ‘SEX WMallFemaie) ~|
ADELAIDA BAYLON ENIPTO | Female
SDATEOF DEATH bor mancYooy [DATE OFBIRTH (On) Woh) ow) |S. AGE ATTHE TIME OF DEATH riieboion soi bape
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nap. yan, roan) 7. CIVIL STATUS. Grgaiaricaidow!
| 6: PLAGE OF DEATH (ans of HessiavCinaineitonoe No.3
WiomonAnoDivercad)
Cagayan Valley Medical Center, Tuguegarao City,
ie Cagayan _ __Married_
E.REUIGIONRELIGIOUS SECT | 9. CITIZENSHIP “770, RESIDENCE (auto Wo, Si Barangay OhyMuncpaty,Provins, Gouri)
Roman Catholie | Filipino |___Purok o7 Aggasian, City of Magan, Tsubela
FF OCUPATION SE NINEGE FATHER Toa Saas EDEN RAE OF MOTHER ti a
None NEMECIO BAYLON. ___wenrra.n.panicanta
MEDICAL CERTIFICATE
| : or ages 0 to 7 days. accomplish Kems 14-19a at the back)
7b. CAUSES OF DEATH (tthe daceasod is aged 8 days anc over) Interval Between Onset end Death
1 Immediatecause =: 8. Septie Shock
Antecedent cause b, Sepele
Underlying cause o, Ascending Cholangitis _
| 1. omerstgniioant condions contbuing to deat: _
“8, MATERNAL CONDITION (ifthe deceased is female aged 16-49 yeas od)
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“a. pregnant y pega ine.lesoman42daysater 4 424aysto1 yearater__o, Noneafthe
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7d, DEATHBY EXTERNAL CAUSES 7 ]ab. AUTOPSY
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22. CERTIFICATION OF DEATH
hereby certify that the foregoing an a ‘same canbe ascertai
il Gath occurred a7807AM__amipm on the date of death spect
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‘Name in Print. ‘0. COSIDON, MD_
se eg Medical Officer II
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Burial emtanad a sept 3 2
2, NAME AND ADDRESS OF CEMETERY OR CREMATORY
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"26. CERTIFICATION OF INFORMANT 27. PREPAREDEY
hereby certify that al Information supplied are true and eoract
tomy own knowledge an bei
Sige ee some
Name in Print| DELSON UBAR Name in Print| ELSAC. LIBAN,
Relationship tothe DodAahorized Representative “The orPosiion _ Administrative Assistant IL
‘Address. City of Hagan, Isabela | cow __ September 09, 2022
Date September 09, 2022
28. RECEIVED BY "| 29, REGISTERED BY THE CIVIL)
sinatwe signature
‘Name in Print __ | Name in Print
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