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IMMACULATE HEART OF MARY PARISH

KITCHARAO, AGUSAN DEL NORTE

DIOCESE OF BUTUAN

DEATH CERTIFICATION

TO WHOM IT MAY CONCERN:

This may certify that ____________________________ a resident, of Barangay ______________

Kitcharao, Agusan del Norte, a parishioner of the Immaculate Heart of Mary Parish, had been an active
member of the GKK / Chapel where he / she belongs.

She / He died on _______________________ at the age ____ and was buried on ____________

at ________________________ cemetery.

This Certification is being issued upon the request of the interested party in whatever legal
purpose it may serve him / her best.

Given this ______ day of _________________________ 2011 at Parish Rectory office, office,
Kitcharao, Agusan del Norte.

In Mary,

______________________________________

Parish Priest

Parish Seal

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