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PEMERINTAH KOTA PASURUAN

DINAS KESEHATAN
UPT PUSKESMAS BUGUL KIDUL
Jl.Trunojoyo No.203 Telp.(0343) 423 014
PASURUAN
SURAT KETERANGAN KELAHIRAN
Nomor :
Yang bertanda tangan dibawah ini
Nama
Pekerjaan

: ..............................................................................................................................................................................
: ..............................................................................................................................................................................

Dengan ini menerangkan dengan sebenarnya bahwa :


Nama Ibu

: ..............................................................................................................................................................................

Nama Ayah

: ..............................................................................................................................................................................

Alamat

: .............................................................................................................................................................................
.............................................................................................................................................................................

Telah Melahirkan seorang bayi /anak :


Jenis Kelamin

: ...........................................................................................................................................................................

Hari

: ...........................................................................................................................................................................

Tanggal

: ...........................................................................................................................................................................

Pukul

: ...........................................................................................................................................................................

Jenis Kelahiran

: Tunggal/Kembar ....................................................................................................................................

Kelahiran Ke-

: ..........................................................................................................................................................................

Berat Bayi

: .............................

Panjang Bayi

: .......................... cm

Nama Bayi

: ..........................................................................................................................................................................

Kg

Pasuruan,
Bidan

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