Municipal Form No 103 – Fill Out and Use This PDF

The Municipal Form No. 103 is an official document used in the Philippines, specifically designed for the registration of death within the Office of the Civil Registrar General. It requires detailed information to be filled out thoroughly, accurately, and legibly, ensuring that all relevant aspects surrounding an individual's passing, such as cause of death, civil status, and details about the informant, are officially documented. If you need to make a declaration of a death, ensure you complete this form with all the necessary precision. Click this button to start the process of filling out the form.

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Municipal Form No 103 PDF Details

Navigating the intricacies of dealing with a loved one's passing involves several bureaucratic steps, one of which is completing the Municipal Form No. 103. Required to be filled out in quadruplicate and revised as of January 1993, this form serves as a pivotal document within the Republic of the Philippines for officially recording deaths. It demands a meticulous level of detail concerning the deceased, including basic identification, the circumstances of death, and specific choices regarding the disposition of the body. Enumerated sections require information on the deceased's sex, age, citizenship, civil status, and medical causes of death, alongside indications for autopsy and burial or cremation preferences. Additionally, the form addresses whether the death resulted from natural or non-natural causes and includes a separate medical certificate for infants who pass away between 0 to 7 days old. Certifications by health officials and embalmers are also integral parts of the form, ensuring that all facts surrounding the death are accurately and officially recorded. The document is further comprised of affidavits for delayed registrations, making the Municipal Form No. 103 a comprehensive record that facilitates the legal and procedural acknowledgment of death within the jurisdiction of the Philippine civil registry system.

Question	Answer
Form Name	Municipal Form No 103
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	death certificate form philippines, sample death certificate philippines, death certificate form download, sample of death certificate in philippines

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Municipal Form No. 103	(To be accomplished in quadruplicate)	REMARKS/ANNOTATION
(Revised January 1993)

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)

FOR OCRG USE ONLY

Population Reference No.

2. SEX

4. A

a. 1 YEAR OR ABOVE

b. UNDER 1 YEAR

c. UNDER 1 DAY

_____1 MALE

RELIGION

Completed

Months

Days

Hrs/Min/Sec

Years

_____2 FEMALE

TO BE FILLED UP AT THE

5. PLACE OF

(Name of Hospital/Clinic/Institution/

(City/Municipality)

(Province)

OFFICE OF THE CIVIL

DEATH

House No., Street, Barangay)

REGISTRAR

6. DATE OF DEATH (day)

(month)

(year)

7. CITIZENSHIP

8. RESIDENCE House No., Street, Barangay

(City/Municipality)

(Province)

9. CIVIL STATUS

10. OCCUPATION

____ 1 Single

____ 3 Widowed

_____5

Unknown

____ 2 Married

____ 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

If attended, state duration:

______ 1 Private Physician

______ 4 None

From _________,

__________

______ 2 Public Health Officer

______ 5 Others (specify)

______ 3 Hospital Authority

_____________________

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

have not attended the deceased

have attended the deceased and that occurred at __________ am/pm on the date indicated above.

REVIEWED BY:

Signature _______________________________

_____________________________

Signature over printed name

Name in Print ____________________________

Of Health Officer

Title or Position __________________________

_________________________________

Address ________________________________

Date

________________________________

Date ___________________________________

21. CORPSE DISPOSAL

22. BURIAL/CREAMTION PERMIT

23. AUTOPSY

____ Burial _____ 3 Others (Specify)

Number ____________________

_____ 1 Yes

____ Cremation _________________

Date Issued _________________

_____ 2 No

24. NAME AND ADDRESS OF CEMETERY OR CREMATORY

25. INFORMANT

Signature _______________________________

Address _______________________________

Name in Print ____________________________

_______________________________

Relationship to the deceased ________________

Date

_______________________________

26. PREPARED BY

27. RECEIVED AT THE OFFICE

OF THE CIVIL REGISTRAR

Signature ___________________________________

Signature __________________________

Name in Print ________________________________

Name in Print ______________________

Title or Position

______________________________

Title or Position _____________________

Date _______________________________________

Date _____________________________

		FOR AGES 0 TO 7 DAYS

11. DATE OF BIRTH		12. AGE OF THE MOTHER	13.METHOD OF DELIVERY
(day)	(month) (year)		___ 1 Normal; Spontaneous vertex
			___ 2 Other (Specify)
			______________________
14. LENGTH OF PREGNANCY:		____________ competed weeks

15. TYPE OF BIRTH	16. IF MULTIPLE BIRTH, CHILD WAS
__ 1 Single ___ 2 Twin ___ 3 Triplet, etc.	___ 1 First	___ 2 Second	___ 3 Others (Specify)

MEDICAL CERTIFICATE

11. CAUSES OF DEATH

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: _______________________________________

____________________________________________________________________________________________________

Signature __________________________	Title/Designation ______________________
Name in Print _______________________	Address ____________________________
	___________________________________


CERTIFICATION OF EMBALMER
I HEREBY CERTIFY that I have embalmed ________________________________________________ after having
followed all the regulations prescribed by the Department of Health.
Signature __________________________	Title/Designation _____________________
Name in Print _______________________	License No. _________________________
Address ___________________________	Issued on __________ at ______________
__________________________________	Expiry Date _________________________

Republic of the Philippines _________________________________	)
Province of _____________________________________________	)S.S.
City / Municipality of ______________________________________	)

AFFIDAVIT FOR DELAYED REGISTRATION OF DEATH

I, ________________________________________________, of legal age, single/married, after

being duly sworn to in accordance with law, do hereby depose and say:

1.That ____________________________________ died on ___________________________ in

_____________________________________________________ and was burried/cremated in

_________________________________________________________ on ________________.

2.That the deceased was/was not attended to at the time of his death.

3.That the reason for the delay in registering this death was due to ________________________

____________________________________________________.

______________________________________

(Signature of Affiant)

Community Tax No. ____________________

Date Issued __________________________

Place Issued __________________________

SUBSCRIBED AND SWORN to before me this _________ day of ________________, ________________

at ___________________________________________________________________________________, Philippines.

___________________________________

_____________________________________

(Signature of Administering Officer)	(Title/Designation)
_______________________________________	___________________________________
(Name in Print)	(Address)

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Writing section 1 of death certificate form download

2. Soon after performing the previous section, head on to the subsequent part and complete all required details in all these blanks - CAUSES OF DEATH Interval Between, DEATH BY NONNATURAL CAUSES a, and ATTENDANT If attended state.

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Concerning CAUSES OF DEATH Interval Between and DEATH BY NONNATURAL CAUSES a, make sure you do everything right in this section. Both these are considered the most important fields in the PDF.

3. In this step, check out ATTENDANT If attended state, BURIALCREAMTION PERMIT Number, REVIEWED BY, AUTOPSY Yes No, Signature over printed name, Of Health Officer, Date, and INFORMANT Signature Address. These should be taken care of with greatest accuracy.

Completing segment 3 of death certificate form download

4. Your next section needs your details in the subsequent areas: DATE OF BIRTH day month year, AGE OF THE MOTHER METHOD OF, LENGTH OF PREGNANCY competed, TYPE OF BIRTH Single Twin, IF MULTIPLE BIRTH CHILD WAS, MEDICAL CERTIFICATE, CAUSES OF DEATH a Main, CONTINUE FILL UP ITEM, POSTMORTEM CERTIFICATE OF DEATH, and I HEREBY CERTIFY that I have this. Always give all needed info to move further.

Writing part 4 in death certificate form download

5. To finish your form, the final subsection involves a few additional fields. Completing I HEREBY CERTIFY that I have this, CERTIFICATION OF EMBALMER, I HEREBY CERTIFY that I have, and Republic of the Philippines should finalize the process and you'll be done very fast!

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Municipal Form No 103 – Fill Out and Use This PDF

Municipal Form No 103 PDF Details

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