Republic of the Philippines )

Province of Southern Leyte )s.s.

Municipality of MACROHON )
x- - - - - - - - - - - - - - - - - - x

JOINT-AFFIDAVIT OF LATE REGISTRATION OF DEATH

We, NORMA R. VALLES and DOLORES P. PEREZ, both of legal age, Filipino,
married and residents of Sta Sofia, Padre Burgos, Southern Leyte, after having
been duly sworn to in accordance with law, do hereby depose and state;

1. That we personally know the person of NAZARIO BARCELON ACLAO of

Padre Burgos, Southern Leyte;

2. That he was born on October 11, 1945 at Sta Sofia, Padre Burgos
Southern Leyte;

3. That on January 15, 1967, he died due to an illnes at Padre Burgos,

Southern Leyte;

4. That upon verification at the Local Civil Registrar of Padre Burgos,

Southern Leyte & at the Philippine Statistics Authority (PSA), we
discovered that the fact of his death was not yet registered;

5. That we know the fact of the above-named person because we live in

the same barangay and close friends of the family;

6. That we are not related to them within the fourth civil degree, either by
affinity or consanguinity;

7. That we executed this affidavit freely and voluntarily in order to attest to

the truth and veracity of the foregoing in order to support for the late
registration of NAZARIO BARCELON ACLAO whatever legal intents and
purposes this may serve.

IN WITNESS WHEREOF, we have hereunto set our hand this

____________________ in the Municipality of Macrohon, Southern Leyte,
Philippines.

NORMA R. VALLES DOLORES P. PEREZ

Affiant Affiant
Senior Citizen(Padre Burgos) ID No. 1150 Senior Citizen (Padre Burgos) ID No. 1126
Issued on July 14, 2015 issued on May 26, 2015

SUBSCRIBED AND SWORN TO BEFORE ME, this

___________________at Macrohon, Southern Leyte affiant exhibiting to me their
ID as proof of their identity.

ATTY. MENCHIE ANN S. SALINAS

Notary Public
Com. No. 2017-10 UNTIL Dec. 31, 2018
Roll of Attorneys No. 66790
Doc. No. ____ IBP No. 021495; 1/05/18; Pasig City
Page No. ____ PTR No. 6073809; 1/04/18; Maasin City
Book No. ____ Series of 2018 Macrohon, Southern Leyte