RUMAH SAKIT KH.

ABDURRAHMAN SYAMSURI
AL MA’HAD AL ISLAMY KARANGASEM
Jl. Raya Deandles KM. 70 Paciran Lamongan 62264
Telp. (0322) 662637, (Hunting) 081232870229 / 085730845336, Fax. (0322) 666626
Email : rs_arsy@yahoo.com

SURAT KETERANGAN KEMATIAN

No. /SKK/III-F/ /20

Yang bertanda tangan dibawah ini, menerangkan dengan sebenarnya bahwa:

Nama : .....................................................................................................
Umur : .....................................................................................................
Jenis Kelamin : Laki-laki / Perempuan *
Pekerjaan : .....................................................................................................
Alamat : .....................................................................................................
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Telah meninggal dunia pada:

Hari : .....................................................................................................
Tanggal : .....................................................................................................
Jam : .....................................................................................................
Di : .....................................................................................................

Demikian Surat Keterangan Kematian ini dibuat dengan sebenar- benarnya.

Lamongan, .............................................

Dokter

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