PEMERINTAH KABUPATEN NGANJUK

DINAS KESEHATAN DAERAH

PUSKESMAS PACE
Jl. Nglirang-Berbek No. 2 KodePos 64472
Email: puskesmaspace@gmail.comTelp& Fax. (0358) 322406

KEPUTUSAN KEPALA PUSKESMAS PACE

NOMOR :............................................................

TENTANG
...............................................

DENGAN RAHMAT TUHAN YANG MAHA ESA

KEPALA PUSKESMAS PACE,

Menimbang : a. bahwa.....................................................................................
..............................................................................................;
b. bahwa.....................................................................................
..............................................................................................;
c. dan seterusnya;
Mengingat : 1. Undang-Undang.....................................................................
..............................................................................................;
2. Peraturan Pemerintah............................................................
...............................................................................................
3. dan seterusnya;

MEMUTUSKAN :
Menetapkan : Keputusan Kepala Puskesmas Tentang ........................................
KESATU : .......................................................................................................
KEDUA : .......................................................................................................
KETIGA : .......................................................................................................
KEEMPAT : .......................................................................................................

Ditetapkan di :............................
Pada tanggal :............................
Kepala Puskesmas Pace,

dr. Hendriyanto
NIP. 19691108 200312 1 004