Surat Ket Kelhiran Persalinan
Surat Ket Kelhiran Persalinan
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
: ..............................................................................................................................................................................
: ..............................................................................................................................................................................
: ..............................................................................................................................................................................
Nama Ayah
: ..............................................................................................................................................................................
Alamat
: .............................................................................................................................................................................
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: ...........................................................................................................................................................................
Hari
: ...........................................................................................................................................................................
Tanggal
: ...........................................................................................................................................................................
Pukul
: ...........................................................................................................................................................................
Jenis Kelahiran
: Tunggal/Kembar ....................................................................................................................................
Kelahiran Ke-
: ..........................................................................................................................................................................
Berat Bayi
: .............................
Panjang Bayi
: .......................... cm
Nama Bayi
: ..........................................................................................................................................................................
Kg
Pasuruan,
Bidan