Republic of the Philippines )

Camiling, Tarlac ) S.S.

AFFIDAVIT

I, BELINDA AGUSTIN GUTIERREZ, 37 years old, single,

Filipino citizen, and a resident of Barangay Sta. Maria, Camiling,
Tarlac, under oath, do hereby depose and state THAT:

1. My father EDUARDO D. GUTIERREZ passed away on March

22, 1991 at Barangay Sta. Maria, Camiling, Tarlac. He was
buried at the Camiling North Cemetery, Camiling, Tarlac;

2. When I went to the Local Civil Registrar of Camiling, Tarlac to

secure a copy of my father’s Certificate of Death, I was
informed that the fact of death of my father was not recorded
or registered in the said office. Also, the Philippine Statistics
Authority (PSA) has no record of his death; hence, a Negative
Certification of Death was issued;

3. The non-registration of the fact of the death of my father may

have been by reason of lack of knowledge of such requirement
and it was only lately that I learned of the same; hence, I am
requesting for the delayed registration of his death;

4. I am executing this Affidavit to attest to the truth of the

foregoing statements and for all legal intents and purposes
this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature

th
this 4 day of December 27, 2017 at Camiling, Tarlac, Philippines.

BELINDA A. GUTIERREZ
Affiant

SUBSCRIBED AND SWORN to before me on the date and place

indicated above. Affiant exhibited before me her Postal Identity Card
with PRN: C86170373322 P issued by the Philippine Postal
Corporation, valid until June 5, 2020.

Doc. No.:______;
Page No.:______;
Book No.:______;
Series of 2017.