Jl. Sirsak No.

21 Jagakarsa, Jakarta Selatan 12620

Telp : (021) 7872210, 78888723, Fax : (021) 7270013

FORMULIR KEMATIAN
No : ...................................

Bagian / Divisi

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

Ruangan

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

No. Rekam Medis

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

Dokter .................................................................. NIP / ID ..............................................................

Pada Tanggal ....................................................... menerangkan bahwa :
Nama

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

Jenis kelamin

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

Umur

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

Agama

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

Alamat

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

Tanggal masuk

: ................................................. Jam ................................................

Tanggal meninggal

: ................................................. Jam ................................................

Diagnosa

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

DOKTER YANG MEMERIKSA

(...........................................)
Nama dan Tanda Tangan