Republic of the Philippines )

Province of Davao del Norte) Sc.

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AFFIDAVIT OF LATE REGISTRATION

I, EMMA P. CAMPOMANES, of legal age, Filipino, widow and a resident of Concepcion,

Asuncion, Davao del Norte, Philippines, after having been duly sworn to in accordance with law, do
hereby depose and say:

That I am the same person who applied for the Delayed Registration of my husband’s death,
ELIAS MASUCOL CAMPOMANES, who died on February 25, 2003 due to cancer of the liver;

That he died at our residence at more or less 2 o’clock in the afternoon on the said date;

That I know for a fact that my husband’s death was not registered with the Office of the Local Civil
Registrar of Asuncion, Davao del Norte;

That I am executing this affidavit to inform the authorities concerned about the true facts narrated
above and may my husband’s death be registered with the Office of the Local Civil Registrar of Asuncion,
Davao del Norte.

IN WITNESS WHEREOF, I have hereunto set my hand this 25th day of April 2018 at Asuncion,
Davao del Norte, Philippines.

EMMA P. CAMPOMANES
Affiant
_____________________
_____________________
_____________________

CORROBORATION

WE, EDNA E. MARQUIZO and JERRY PILONGO, both married, of legal age, Filipino, and
residents of Purok 3, Concepcion, Asuncion and Purok 4, Concepcion, Asuncion, Davao del Norte,
respectively, after having been duly sworn to in accordance with law, do hereby depose and say:

That we personally know ELIAS MASUCOL CAMPOMANES who died on February 25, 2003 in
Asuncion, Davao del Norte at his residence at Purok 4, Concepcion, Asuncion, Davao del Norte;

That we are executing this affidavit to attest to the truth of the foregoing facts and to support the
statements made by the above-mentioned affiant for whatever legal purpose this may serve.

IN WITNESS WHEREOF, we have hereunto set our hands this 25th day of April 2018 at
Asuncion, Davao del Norte, Philippines.

EDNA E. MARQUIZO JERRY PILONGO

Affiant Affiant

SUBSCRIBED AND SWORN to before me this 25th day of April 2018 at Asuncion, Davao del
Norte, Philippines. Affiants exhibited to me their identification cards: _____________________________
and _______________________________, respectively, issued at _____________________________,
Philippines.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.