BLOTTER ENTRY NUMBER

Philippine National Police

INCIDENT RECORD FORM

2024-0034 and 2024-0035
TYPE OF INCIDENT
POISONING INCIDENT

DATE AND TIME REPORTED: DATE AND TIME OF INCIDENT:

February 6,2024 at about 11:30 February 5, 2024 at about
AM 11:30AM ITEM “A” - REPORTING PERSON
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME
AGCARACAR LOKADIA N/A N/A KAJA

CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE
FILIPINO FEMALE MARRIED 19/01/1989 35 BACARRA N/A 09786543216

CURRENT ADDRESS (HOUSE NUMBER STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

PUROK 5 REGTA / BUGAS 20 PULANGI BACARRA ILOCOS NORTE

OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAIN MENT OCCUPATION ID CARD PRESENTED EMAIL ADDRESS (If Any)
HIGH SCHOOL LEVEL HOUSEKEEPER PHILIPPINE ID N/A

ITEM “B” - SUSPECT DATA

 CHECK HERE IF THERE IS NO SUSPECT INVOLVED AND THEREAFTER PROCEED TO ITEM “C”.
 CHECK HERE IF THERE ARE TW O OR MORE SUSPECTS. THEREAFTER, USE ADDITIONAL INCIDENT REPORT FORM SHEETS FOR EACH OF THE SUSPECTS.
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME
GALANZA JONEL RABLADOR N/A JON
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE
FILIPINO MALE MARRIED 19/02/1962 62 BACARRA N/A 09384569908

CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

PUROK 5 REGTA BUGAS 20 PULANGI BACARRA ILOCOS NORTE

OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS RELATION TO VICTIM EMAIL ADDRESS (If Any)
ELEMENTARY LEVEL FISHERMAN BRGY.20 PULANGI, BACARRA, SON N/A
ILOCOS NORTE
IF AFP/PNP PERSONNEL: RANK UNIT ASSIGNMENT GROUP AFFILIATION WITH PREVIOUS CRIMINAL RECORD? [ ] Yes [ /] No STATUS OF PREVIOUS CASE
(If Yes, Pls. Specify)
POLICE MAJOR JIAN BONOAN
BUMAGAT
HEIGHT WEIGHT COLOR OF EYES DESCRIPTION OF EYES COLOR OF HAIR DESCRIPTION OF HAIR UNDER THE INFLUENCE?
5’6 FT 72KG BROWN DYING EYES BLACK SLIGHTLY SHORT (/) NO  DRUGS  LIQUOR
 OTHERS ________________________

FOR CHILDREN IN CONFLICT WITH THE LAW

NAME OF GUARDIAN GUARDIAN ADDRESS HOME PHONE MOBILE PHONE

DIVERSION MECHANISM

OTHER DISTINGUISHING FEATURES (DESCRIBE IN DETAIL CLOTHES, VEHICLE, SUNGLASSES, WEAPON/S, SCARS, AND OTHER DATA OR ACTIVITY OF THE SUSPECT/S WHICH WERE OBSERVED BY THE
REPORTING PERSON AND/OR WITNESS/ES TO IDENTIFY THE SUSPECT/S. THESE ARE IMPORTANT AND MAY BECOME EVIDENCE TO IDENTIFY, AND LINK TO THE CRIME, THE SUSPECT/S. USE ADDITIONAL
SHEET/S IF NECESSARY)

--------------------------------------CUT HERE. ISSUE THIS RECEIPT TO THE REPORTING PERSON-------------------------------------------

BLOTTER ENTRY NUMBER
2024-0034 and 2024-0035 INCIDENT RECORD TRANSACTION RECEIPT
 NAME OF REPORTING PERSON: ADDRESS OF REPORTING PERSON:
THIS CERTIFIES THAT LOKADIA AGCARACAR PUROK 5, REGTA BRGY. 20 PULANGI, BACARRA,
ILOCOS NORTE.
REPORTED AN INCIDENT TO BE TYPE OF INCIDENT:
RECORDED IN THE POLICE BLOTTER POISONING INCIDENT
WHICH INVOLVES AND
DATE/TIME OF REPORT: DATE/TIME OF INCIDENT: PLACE OF INCIDENT: RECORDED BY:

FEBRUARY 6,2024 at about FEBRUARY 5,2024 at about 11:30 PUROK 5 REGTA,BRGY. 20

AM
11:30 AM PULANGI, BACARRA, ILOCOS
NORTE. PSSG: ALBERT RAMIRO
Name of Police Station BACARRA MUNICIPAL POLICE STATION Telephone 077-649-765

Investigator-on-Case PEMS: JOMARWIN L. ACERET Mobile Phone 09876543890

Name of Chief/Head of
POLICE MAJOR JIAN BONOAN BUMAGAT Mobile Phone 09120974737
Office

ITEM “C” – VICTIM DATA

(/) CHECK HERE IF THE REPORTING PERSON (ITEM “A”) IS THE VICTIM. PROCEED TO ITEM “D”.
 CHECK HERE IF THERE ARE TWO OR MORE VICTIMS. USE ADDITIONAL INCIDENT REPORT FORM SHEETS FOR THE DATA OF THE ADDITIONAL VICTIMS.
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME

CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE

CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS EMAIL ADDRESS (If Any)

ITEM “D” - NARRATIVE OF INCIDENT

BLOTTER ENTRY NUMBER TYPE OF INCIDENT TIME DATE PLACE OF INCIDENT
2024-0034 and 2024-0035 POISONING INCIDENT 11:30 AM FEBRUARY PUROK 5 REGTA, BRGY. 20
5,2024 PULANGI, BACARRA, ILOCOS
NORTE.

ENTER IN DETAIL THE NARRATIVE OF THE INCIDENT OR EVENT, ANSWERING THE WHO, WHAT, WHEN, WHERE, WHY AND HOW OF REPORTING. (USE ADDITIONAL SHEET/S IF NECESSARY)

A poisoning incident occurred on February 5, 2024, around 11:30 A.M. in Brgy. 20 Pulangi, Bacarra,
Ilocos Norte. Lokadia Agcaracar reported the incident to the police station. Initial investigation
revealed that the victim was eating, when Jonel Rablador Galanza put a toxic beverage in the water
of his son Michael Capalungan Galanza, causing him to poisoned due to an intended putting of
toxic beverage. Michael Capalungan Galanza sustained a symptom which include changes in
consciousness, body temperature, heart rate, and breathing that cause him instantaneous death
(DOS). Jonel Rablador Galanza was arrested and confessed to the incident, expressing remorse for
his actions.
 (DETAILS OF THIS NARRATIVE SHALL BE THE BASIS IN THE ENTRY OF RECORD IN THE POLICE BLOTTER)

AUTHENTICATION
I HEREBY CERTIFY TO THE CORRECTNESS OF THE NAME/SIGNATURE OF REPORTING PERSON NAME/SIGNATURE OF DESK OFFICER
FOREGOING TO THE BEST OF MY KNOWLEDGE AND
BELIEF.

CASE DISPOSITION (For Chief/Head of Office Use Only)

CHIEF Of STATION/OFFICE INSTRUCTIONS NAME OF DESIGNATED INVESTIGATOR-ON-CASE NAME OF CHIEF OF STATION/OFFICE

-----------------------------CUT HERE--------------------------------------------------------------------------------------CUT HERE------------------------------------------------------

INSTRUCTIONS TO REPORTING PERSON
Keep this Incident Record Transaction Receipt (IRTR). An update of the progress of the investigation of the crime or incident that you reported
will be given to you upon presentation of this IRTR. For your reference, the data below is the contact details of this police station.