Municipal Form No 103 PDF Details

Understanding the ins and outs of local government is a tricky business. Knowing which forms to fill out, who to submit applications to, and what regulations you must adhere to when making changes or requesting information can be overwhelming. For those in municipalities – whether they are citizens, managers, or elected officials — understanding Municipal Form No 103 is essential for engaging in many actions related to their city’s infrastructure. In this post, we will explore exactly what Municipal Form No 103 does and how it can be used for different tasks regarding cities as well as other useful information about it that you should know.

QuestionAnswer
Form NameMunicipal Form No 103
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdeath certificate form philippines, sample death certificate philippines, death certificate form download, sample of death certificate in philippines

Form Preview Example

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

3.

 

 

4. A

a. 1 YEAR OR ABOVE

 

 

 

 

b. UNDER 1 YEAR

 

 

c. UNDER 1 DAY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____1 MALE

RELIGION

 

G

 

 

Completed

 

 

 

 

Months

 

 

Days

 

 

Hrs/Min/Sec

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

Years

 

 

 

 

 

1

 

 

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____2 FEMALE

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

41

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. RESIDENCE House No., Street, Barangay

(City/Municipality)

 

(Province)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. CIVIL STATUS

 

 

 

 

 

 

 

 

 

 

 

 

10. OCCUPATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____ 1 Single

 

____ 3 Widowed

_____5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

48

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____ 2 Married

____ 4 Others

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL CERTIFICATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(For Ages 0 to 7 days accomplish items 11-17 at the back)

49

50

 

 

51

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. CAUSES OF DEATH

 

 

 

 

 

 

 

 

 

 

 

Interval Between Onset and Death

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I. Immediate cause : a. _____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________________

____________________________

 

 

54

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Antecedent cause : b. _____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________________

____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Underlying cause : c. _____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________________

____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II. Other significant conditions ________________________________________________________

59

 

 

 

 

 

65

 

 

 

Contributing to death: ______________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. DEATH BY NON-NATURAL CAUSES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Manner of Death

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

66

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____ 1 Homicide

_____ 2 Suicide

 

_____ 3 Accident

_____4 Others (Specify) ____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

71

72

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

75

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

79

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REVIEWED BY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature _______________________________

 

 

_____________________________

 

 

80

 

 

 

 

 

82

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature over printed name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name in Print ____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Of Health Officer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title or Position __________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address ________________________________

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

83

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date ___________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. CORPSE DISPOSAL

 

 

22. BURIAL/CREAMTION PERMIT

 

 

23. AUTOPSY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____ Burial _____ 3 Others (Specify)

 

 

Number ____________________

 

 

_____ 1 Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____ Cremation _________________

 

 

Date Issued _________________

 

 

_____ 2 No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

85

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24. NAME AND ADDRESS OF CEMETERY OR CREMATORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. INFORMANT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature _______________________________

Address _______________________________

86

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name in Print ____________________________

 

 

 

 

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to the deceased ________________

Date

 

 

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26. PREPARED BY

 

 

 

 

 

 

 

27. RECEIVED AT THE OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OF THE CIVIL REGISTRAR

90

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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!

Filling in section 5 in death certificate form download

Step 3: Immediately after rereading the fields you've filled in, hit "Done" and you are good to go! Try a free trial plan with us and gain instant access to death certificate form pdf - download or edit from your FormsPal cabinet. With FormsPal, you can fill out forms without needing to get worried about personal data incidents or records being shared. Our secure platform makes sure that your private details are kept safely.