43 Rev 5
No. RM :...................................................
PEMERINTAH KABUPATEN BLITAR
RSUD Nama
“ Ngudi:...................................................
Waluyo “ Wlingi
Jalan. Dr. Soecipto No. 5 Wlingi
Telp. (0342) 691006 Fax. (0342) 691040
Tgl Lahir :...................................................