SURAT KETERANGAN KEMATIAN

BIDAN AMILIA, Am.Keb.

Komplek Taman Permata Blok J No.9 RT.003/07

Cipondoh – Tangerang

Tel. 0813-1028-2704

SURAT KETERANGAN KEMATIAN

No. : ............./ 20......

Yang bertanda tangan dibawah ini Bidan Amilia, Am.Keb. menerangkan dengan sesungguhnya bahwa telah meninggal bayi :

Nama Bayi                                           : ...................................................................................................................

Jenia Kelamin                                      : ...................................................................................................................

Anak dari             :

Nama Ibu                                             : ..................................................................................................................

No. KTP                                                : ..................................................................................................................

Pekerjaan                                              : ..................................................................................................................

Nama Ayah                                          : ..................................................................................................................

Pekerjaan                                              : ..................................................................................................................

No. KTP                                                : ..................................................................................................................

Alamat                                                  : ..................................................................................................................

Telah Meninggal dunia  :

Hari                                                        : ..................................................................................................................

Tanggal                                                 : ..................................................................................................................

Pukul                                                      : ..................................................................................................................

Dengan data- data  :

Panjang Badan                                    : .................................................................................................................

Berat Badan                                         : .................................................................................................................

Anak Ke                                                                : .................................................................................................................

Tangerang, ........................................

                Yang  menolong

(Bidan Amilia, Am.Keb.)