PEMERINTAH KABUPATEN LAMPUNG UTARA

INSTALASI P.J / KEDOKTERAN FORENSIK DAN MEDIKOLEGAL

RUMAH SAKIT UMUM DAERAH MAYJEND. HM. RYACUDU KOTABUMI
Jl. Jenderal Sudirman No. 02 Telp. 0724-22095
K O TAB U M I 3 4 5 1 1

Kotabumi, _________________
Nomor
Lampiran
Ikhwal

:
/
/ KFM/ / 2015
:
: Pemeriksaan bedah mayat (autopsy)
An. _______________________
VISUM ET REPERTUM

PRO JUSTITIA
Permintaan----------------------------------------------------------------------------------------Tanggal permintaan;________________, No Polisi;_____________________,
Perihal; Permintaan Visum et Repertum pemeriksaan bedah mayat (autopsy)
An. ____________________________, Penyidik;___________________,
Pangkat;___________________, NRP;_______________,
Jabatan;________________________, Instansi;____________________________,
Penjelasan;_________________________________________________, pada
hari_________, tanggal;_______________, sekitar jam;_______ wib, dengan
kondisi korban;_______________________________________________________
____________________________________________________________________
_______________________________-----------------------------------------------------Pemeriksa:---------------------------------------------------------------------------------------Nama;_____________________________, NIP;______________________,
Instalasi;____________________________ RSUD Mayjed. HM Ryacudu kotabumi,
Tanggal pemeriksaan;__________________, Jam pemeriksaan;_______ wib, Korban
diantar oleh;_______________, Jenis pemeriksaan; Pemeriksaan
____________________________-----------------------------------------------------------Identitas Korban:--------------------------------------------------------------------------------Nama;________________________, Jenis kelamin;_____________________,
Umur;______ tahun, Agama; ____________, Pekerjaan;_____________, Status
perkawinan; _________________, Alamat; Jln.
___________________________________________________-------------------------PEMBERITAAN
Benda-benda--------------------------------------------------------------------------------------1 Label mayat; ________________________--------------------------------------------2 Pembungkus mayat; ____________________________----------------------------3 Penutup mayat; _____________________________----------------------------------4 Pakaian mayat; _________________________________________________----5 Benda di tubuh mayat ;_______________________________---------------------6 Perhiasan mayat;________________________________----------------------------7 Benda di sekitar mayat; ---------------------------------------------------------

Tanda-tanda kematian-------------------------------------------------------------------------1

8 Lebam mayat; ______________________________--------------------------------9 Kaku mayat; _________________________________________-------------------10 Pembusukan:__________________________________-----------------------------Identifikasi---------------------------------------------------------------------------------------11 Identifikasi umum ; Dijumpai sesosok mayat dikenal, jenis kelamin
_______________, umur ___________, warna kulit _______________, panjang
badan _______________________, perawakan _______________, rambut
sepanjang ______________, bentuk ____________, warna ______________----12 Identifikasi khusus;__________________________________----------------------Pemeriksaan luar--------------------------------------------------------------------------------13 Kepala;_____________________________________________-------------------14 Dahi;_________________________________________________-----------------15 Mata;_____________________________----------------------------------------------16 Hidung;_______________________________________----------------------------17 Pipi;________________________________-------------------------------------------18 Telinga;________________________________---------------------------------------19 Mulut;___________________________________------------------------------------20 Gigi;______________________________________________----------------------21 Rahang;________________________________---------------------------------------22 Leher;_______________________________________________------------------23 Dada;_______________________________________________________-------24 Perut;_____________________________________________________----------25 Alat kelamin;_________________________________-------------------------------26 Punggung;________________________________------------------------------------27 Pinggang;______________________________________----------------------------28 Bokong;_________________________________-------------------------------------29 Dubur;________________________________----------------------------------------30 Anggota gerak atas;_______________________--------------------------------------31 Anggota gerak bawah;__________________________-------------------------------Pemeriksaan dalam------------------------------------------------------------------------------32 Kepala;_____________________________________________-------------------33 Otak;_________________________________---------------------------------------34 Leher;_______________________________________________------------------35 Saluran nafas atas;_____________________________-----------------------------36 Saluran makan atas;________________________________----------------------37 Dada;_______________________________________________________-------38 Jantung;_________________________________------------------------------------39 Paru-paru;________________________________----------------------------------40 Perut;_____________________________________________________----------41 Lambung;___________________________________--------------------------------42 Hati;______________________________________---------------------------------43 Kantong empedu;______________________________------------------------------44 Limpa;_________________________________-------------------------------------45 Pangkreas;____________________________________-----------------------------46 Ginjal;__________________________________________-------------------------47 Kandung rahim (wanita);________________________------------------------------48 Kantong pelir (pria);________________________________------------------------49 Kelenjar;__________________________________-----------------------------------50 Lain-lain;__________________________________----------------------------------51 Hasil Pameriksaan Tambahan;______________________--------------------------

KESIMPULAN
Telah diperiksa sesosok mayat dikenal, jenis kelamin_________________,
umur__________tahun, warna kulit_______________, panjang
badan__________________________, perawakan________________, rambut
sepanjang_______________, bentuk_____________, warna_________________---Dari hasil pemeriksan luar dan dalam (serta pemeriksaan tambahan) dijumpai tandatanda kekerasan berupa________________________,
pada________________________________, akibat
kekerasan_________________________________________. Penyebab kematian
korban adalah________________________________________ oleh
karena________________________________ akibat__________________----------Demikianlah visum et repertum ini dibuat dengan sejujur-jujurnya berdasarkan
sumpah jabatan dan keilmuan menurut Kitab Undang-undang Hukum Acara Pidana
(KUHAP) untuk dipergunakan bilamana perlu--------------------------------------------

Dokter yang memeriksa,

Dr.
Nip.