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Republic of the Philippines

City of Manila
C I T Y C I V I L R E G I S T R Y

December 17, 2012

J/CINSP MA. LORAINTINA M. MANENGYAO

Officer-in-charge
Bureau of Jail Management and Penology
National Capital Region
Manila City Jail – Female Dormitory
Quezon Blvd., Sta. Cruz, Manila

Dear Sir:

As per request, we are furnishing you herewith, a certified true copy of the death
certificate of one ROWENA SALDI UMALI died November 29, 2012 in Manila
under Reg. No. 2012-18989.

Thank you for your coordination with our office We assure you of our continued
cooperation and assistance.

Very truly ours,

MARIA JOSEFA ENCARNACION A. OCAMPO

City Civil Registrar

TN067109
 OFFICE OF THE CIVIL REGISTRAR GENERAL FOR OCRG USE ONLY:
Population Reference No.
CERTIFICATE OF DEATH
Province: NCR Registry No.
City/Municipality: Manila 2012-018989
1 NAME (First) (Middle) (Last)
Rowena Saldi Umali

2 SEX 3 RELIGION 4 A a. 1 YEAR OR ABOVE b. UNDER 1 YEAR c. UNDER 1 DAY

1 MALE Roman G COMPLETED YEARS 1 MON 0 DAYS
X 2 FEMALE
Catholic E 2 33 THS

5 PLACE OF (name of Hospital/Clinic/Institution/House No. Street, Barangay) (City/Municipality) (Province)

DEATH 2641 Int. 52 Pasigline St., Brgy. 778 Sta. Ana, Mla.
6 DATE OF DEATH (day) (month) (year) 7 CITIZENSHIP
29, November 2012 Filipino
RESIDENCE (name of Hospital/Clinic/Institution/House No. Street, Barangay) (City/Municipality) (Province)

2641 Int. 52 Pasigline St., Brgy. 778 Sta. Ana, Mla.

CIVIL STATUS OCCUPATION
x 1 Single 3 Widowed 5 Unknown N/A
2 Married 4 Others
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 11-17 at the back)
CAUSES OF DEATH
I Immediate cause a. ___Acute Respiratory Failure_________________________________________
______________________________________________________________________________________
Antecedent cause b. _________________________________________________________________
______________________________________________________________________________________
Underlying cause c. _________________________________________________________________
______________________________________________________________________________________
II Other significant conditions
Contributing to death ___________________________________________________________________

DEATH BY NON-NATURAL CAUSES

a Manner of Death
____1 Homicide ____2 Suicide _____3 Accident _____ 4 Others (Specify) ____________________

b Place of Occurrence (e.g. home, farm, factory, street, sea, etc.) _____________________________________________

ATTENDANT If attended state duration:

____ 1 Private Physician ____ 4 None From: _____________________
____ 2 Public Health Officer ____ 5 Others (Specify) To. _____________________
____ 3 Hospital Authority

CERTIFICATION OF DEATH
I hereby certify that the foregoing particulars are correct as near same can be ascertained and I further certify that I
x have not attended the deceased.
have attended the deceased and that death occurred at am/pm on the date indicated above.

REVIEWED BY:
Signature ________________________________
Name in Print _____CESAR L. DE LEON, MD______ RENATO A. SOLIVEN, MD
Title or Position ______PRC #. 0059143_____________ MEDICAL OFFICER V
Address __MANILA HEALTH DEPARTMENT___ MANILA HEALTH DEPARTMENT
_OFFICE OF PUBLIC CEMETERIES__
CHIEF, OFFICE OF PUBLIC CEMETERIES
03 DEC 2012 Date 03 DEC 2012
21. CORPSE DISPOSAL 22. BURIAL/CREMATION PERMIT 23. AUTOPSY
____1 Burial ____ 3 Others (specify) Number _____1369604________________ ____1 Yes
____2 Cremation Date Issued ______12/03/12_______________ ____ 2 No
NAME AND ADDRESS OF CEMETERY OR CREMATORY
Manila South Cemetery
INFORMANT
Signature _______________________________ Address Same As Above
Name in Print Joanna S. Umali_ ________________
Relationship to the deceased Sister Date 29 November 2012
PREPARED BY RECEIVED AT THE OFFICE OF