KRONOLOGIS KEMATIAN BAYI DAN BALITA

DI WILAYAH KABUPATEN MAGELANG

BIODATA
Nama Anak : ......................................................................
Nama orang Tua : ................................./....................................
Umur anak : ............jam/hr/bln/th*)
Jenis kematian : Lahir Mati/Peri/Neo/Bayi/Balita*)
Alamat lengkap : ......................................................................
Wilayah Puskesmas : ......................................................................
Tanggal Meninggal : ......................................................................

*) lingkari yg sesuai

DATA RIWAYAT PENYAKIT/KEJADIAN SEBELUM KEMATIAN

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KRONOLOGIS KEMATIAN
N
TGL/JAM URAIAN
O
 Mengetahui Bidan / Perawat
Kepala Puskesmas Pakis

drg. Dyah Puspitasari

NIP. 19791227 200604 2 007

KRONOLOGIS KEMATIAN
N
TGL/JAM URAIAN
O
 Mengetahui Bidan / Perawat
Kepala Puskesmas Pakis

drg. Dyah Puspitasari

NIP. 19791227 200604 2 007