dr. I Putu Mega Sidhiarta, S.

Ked
Apotek Halo 7, Jl Gelogor Carik No. 153 A, Pemogan, Denpasar

SURAT KETERANGAN KEMATIAN

Nomor: /HALOTUJUH/ /2019

Yang bertandatangan di bawah ini menerangkan:

Nama : ............................................................................................................
SIP : ............................................................................................................
Jabatan : ............................................................................................................
Alamat : ............................................................................................................

Menerangkan dengan sebenarnya bahwa, telah MENINGGAL:

Nama : ............................................................................................................
Tempat/Tanggal Lahir : ............................................................................................................
Agama : ............................................................................................................
Alamat : ............................................................................................................
No. KTP : ............................................................................................................
Tanggal Kematian : ............................................................................................................
Jam : ............................................................................................................
Tempat Kematian : ............................................................................................................
Penyebab Kematian : ............................................................................................................

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Dokter pemeriksa,

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