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Municipal Form No 103 Revised January to Be 2016-2026

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Municipal Form No. 103 Revised January 1993 To be accomplished in quadruplicate REMARKS/ANNOTATION Republic of the Philippines OFFICE OF THE CIVIL REGISTAR GENERAL CERTIFICATE OF DEATH Fill out completely accurately and legibly. Use ink or typewriter. Place X before the appropriate answer in items 2 9 13 15 16 18 19 21 and 23. Province Registry No* City/Municipality 1. NAME First Middle Last 4. A 2. SEX 1 MALE RELIGION 5. PLACE OF DEATH G E a* 1 YEAR OR ABOVE Completed 2 Years Name of Hospital/Clinic/Institution/ House No* Street Barangay 6. DATE OF DEATH day month year 8. RESIDENCE House No* Street Barangay 1 Single Unknown 2 Married b. UNDER 1 YEAR Months Days c* UNDER 1 DAY Hrs/Min/Sec Province TO BE FILLED UP AT THE REGISTRAR 7. CITIZENSHIP 9. CIVIL STATUS FOR OCRG USE ONLY Population Reference No* 10. OCCUPATION 3 Widowed 5 4 Others MEDICAL CERTIFICATE For Ages 0 to 7 days accomplish items 11-17 at the back 17. CAUSES OF DEATH Interval Between Onset and Death I. Immediate cause a* Antecedent cause b. Underlying cause c* II. Other significant conditions Contributing to death 18. 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 seam etc* 19. ATTENDANT 1 Private Physician 2 Public Health Officer 3 Hospital Authority If attended state duration 4 None From 5 Others specify 20. CERTIFICATION OF DEATH I hereby certify that the foregoing particulars are correct as near as same can be ascertain and I further certify that I have not attended the deceased have attended the deceased and that occurred at am/pm on the date indicated above. REVIEWED BY Signature Name in Print Title or Position Address Date 21. CORPSE DISPOSAL Signature over printed name Of Health Officer Date 22. BURIAL/CREAMTION PERMIT Burial 3 Others Specify Cremation Number Date Issued 23. AUTOPSY 1 Yes 2 No 24. NAME AND ADDRESS OF CEMETERY OR CREMATORY 25. INFORMANT Relationship to the deceased 26. PREPARED BY 27. RECEIVED AT THE OFFICE OF THE CIVIL REGISTRAR FOR AGES 0 TO 7 DAYS 11. DATE OF BIRTH day 12. AGE OF THE MOTHER 14. LENGTH OF PREGNANCY 13. METHOD OF DELIVERY 1 Normal Spontaneous vertex 2 Other Specify competed weeks 15. TYPE OF BIRTH 16. IF MULTIPLE BIRTH CHILD WAS 1 Single 2 Twin 3 Triplet etc* 1 First 2 Second a* Main disease/condition of infant b. Other diseases/conditions of infant c* Main maternal disease/condition affecting infant d. Other maternal disease/condition affecting infant e. Other relevant circumstances CONTINUE FILL UP ITEM 18 POSTMORTEM CERTIFICATE OF DEATH I HEREBY CERTIFY that I have this day of performed an autopsy upon the body of the deceased and that the cause of death was as follows Title/Designation CERTIFICATION OF EMBALMER followed all the regulations prescribed by the Department of Health. License No* Issued on at Expiry Date S*S* AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH being duly sworn to in accordance with law do hereby depose and say That the deceased was/was not attended to at the time of his death.

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What is the Municipal Form No 103 Revised January To Be

The Municipal Form No 103 Revised January To Be is a specific document utilized within municipal operations in the United States. This form is typically required for various administrative purposes, such as reporting or compliance with local regulations. It is essential for ensuring that municipalities maintain accurate records and adhere to legal standards. Understanding the purpose and requirements of this form is crucial for both individuals and businesses interacting with local government entities.

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Using the Municipal Form No 103 Revised January To Be involves several steps to ensure accurate completion and submission. First, gather all necessary information, including personal or business details relevant to the form's purpose. Next, carefully fill out each section of the form, ensuring that all data is accurate and complete. Once the form is filled, review it for any errors or omissions. Finally, submit the form according to the instructions provided, which may include online submission, mailing, or in-person delivery to the appropriate municipal office.

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The Municipal Form No 103 Revised January To Be is legally binding once completed and submitted. It serves as an official record for municipal authorities and may be used in legal proceedings if necessary. Compliance with the requirements outlined in the form is essential to avoid potential penalties or legal issues. Understanding the legal implications of this form ensures that individuals and businesses can navigate municipal regulations effectively.

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*1993 PH Municipal Form No. 103 [1993-01] 20164.8 Satisfied (26 Votes)
*1993 PH Municipal Form No. 103 [1993-01] 19934.8 Satisfied (19481 Votes)
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