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Sample Affidavit of Death for
Insurance Claim
Republic of the Philippines )
City of Makati
) S.S.
x--------------------------x

AFFIDAVIT
I, LIZA S. DELA CRUZ of legal age, Filipino citizen, widow
and presently residing at 3333 M. Ocampo Street, Pio del Pilar,
Makati City, after having been duly sworn to in accordance with law,
do hereby depose and say:
1. That I am the widow of BENITO D. DELA CRUZ who died on
July 30, 2013 in Quezon City because of head injuries
sustained in a vehicular accident as per autopsy result
conducted by Dr. Lito R. Santos;
2. That per investigation of the Quezon City Police Station, my
husband was driving along the northbound lane of EDSA in
front of Camp Aguinaldo in Quezon City when he was
hit/bumped by a truck coming from the opposite direction;
copy of the Traffic Investigation Report is hereto attached
as Annex "A";
3. That at the time of the incident, my husband was a duly
licensed driver carrying Driver's License No. 123456 and was
riding on a Toyota