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ATISTICS
ST Municipal Form No. 103 (To be accomplished in REMARKS/ANNOTATION
AU
ILIPPINE
(revised January 1993) quadruplicate)
THORITY
Republic of the Philippines
OFFICE OF THE CIVIL REGISTER GENERAL
CERTIFICATE OF DEATH
PH
(Fill out completely, accurately and legibly, Use Ink or Typewriter.
Place X beforethe appropriate answer in Items 2,9,13,15,16,18,19,21 AND 23)
Province BATANGAS Registry no. FOR OCRG USE ONLY:
Population Reference No.
City/Municipality LIPA CITY 2025-8459
1. NAME (First) (middle) (last)
NIEMENSIO TOLENTINO MERCADO JR
TO BE FILLED UP AT THE
2. SEX 3. RELIGION 4.A a. 1 YEAR OR ABOVE c. UNDER 1 YEAR c. UNDER 1 DAY
OFFICE OF THE CIVIL
X
_____ 1 Male ROMAN G
Completed years Months Days Hrs/Min/Sec REGISTRAR
E
_____ 2 Female CATHOLIC 2 56 1 0
5. PLACE OF ( Name of Hospital/clinic/institution/ (city/municipality) (province)
41
DEATH House No., Street, Barangay)
KAYBAGAL TAGAYTAY
6. DATE OF DEATH (day) (month) (year) 7. CITIZENSHIP
04 MAY 2025 FILIPINO
8. RESIDENCE House no., Street, Barangay ( City/ Municipality) ( Province ) 48
LIPA CITY, BATANGAS
9. CIVIL STATUS 10. OCCUPATION
____ 1 Single _____ 3 Widowed _____ Unknown
X
____ 2 Married _____ 4 Others UNEMPLOYED
49 50 51
MEDICAL CERTIFICATE
( For ages 0 to 7 days, accomplish items 11‐17 at the back)
17. CAUSES OF DEATH Interval Between Onset and Death 54
I. Immediate cause : a. CHRONIC KIDNEY DISEASE,
CARDIAC ARREST
Antecedent cause : b.
59 65
Underlying cause : c.
II. Other significant conditions
66
18. DEATH BY NON‐NATURAL CAUSES
a. Manner of Death
_____ 1 Homicide _____ 2 Suicide ______ 3 Accident ______ 4 Other ( Specify) ________________________
b. Place of occurrence ( e.g. home, farm, factory, street, sea, etc. _______________________________________
19. ATTENDANT If attended, state duration: 71 72
X
_____ 1 Private Physician _____ 4 None 09:25 A.M. 02:15 P.M.
From ________________ , ______________
20. CERTIFICATION OF DEATH 75
I hereby certify that the foregoing particulars are correct as near as same can be ascertained and I further certify that I
Have not attended the deceased
X 02:28 P.M.
Have attended the deceased and that death occurred at ______________ am/pm on the date indicated above.
79
REVIEWED BY:
Signature JOSEPHINE D. SUAREZ
Name in Print FEDERICO QUINTAS D. Signature over printed name 80 82
Title or position LOCAL HEALTH OFFICER of Health Center
Address LIPA CITY, BATANGAS
MAY 04, 2025
Date
Date MAY 04, 2025
83
21. CORP DISPOSAL 22. BURIAL / CREMATION PERMIT 23. AUTOPSY
_____ 1 Burial _____ 3 Others ( Specify) Number _____ 1 Yes
_____ 2 Cremation __________________ Date Issued _____ 2 No
24. NAME AND ADDRESS OF CEMETERY OR CREMATORY
85
25. INFORMTION
Signature Address LIPA CITY, BATANGAS
Name in Print GREG R. MERCADO
Relationship to the deceased DAUGHTER Date MAY 04, 2025
86
26. PREPARED BY: 27. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
Signature Signature
Name in Print FAITH O. CRUZ Name in Print JOHNMARK A. DE LEON
Title or position REGISTRAR CLERK BLDS Title or position MUNICIPAL CIVIL REGISTRAR 90
Date MAY 04, 2025 Date MAY 04, 2025
06481-H6-015FSA-00236-B|002
CLAIRE DENNIS S. MAPA, Ph. D.
National Statistician and Civil Registrar General
Philippine Statistics Authority
T0050848100500236092920017012
NL7D00589445
