PEMERINTAH KABUPATEN TANGGAMUS

DINAS KESEHATAN
UPTD PUSKESMAS KELUMBAYAN BARAT
Jln. Raya Lintas No.1 Pekon Lengkukai Kec. Kelumbayan Barat Kab. Tanggamus
No. HP. 0822 7889 6488 email : puskesmaskelumbayanbarat@gmail.com

SURAT KETERANGAN PEMERIKSAAN KESEHATAN CALON MEMPELAI

Nomor : /25/ 2020

Yang bertanda tangan di bawah ini :

Nama : ............................................................................
NIP / NRPTT : ............................................................................
Berdasarkan Peeraturan Daerah Nomor 08 Tahun 2000 Tanggal 22 Juni 2000 tentang retribusi
Pemeriksaan Kesehatan Calon Mempelai Lembaran Daerah Tahun 2000 Nomor 74 seri B 68,
menyatakan :

Nama : .......................................................................................................
TTL / Umur : .......................................................................................................
Jenis Kelamin : .......................................................................................................
Agama : .......................................................................................................
Pekerjaan : .......................................................................................................
Alamat : .......................................................................................................
.......................................................................................................
Calon Suami / Istri dari :

Nama : .......................................................................................................
TTL / Umur : .......................................................................................................
Jenis Kelamin : .......................................................................................................
Agama : .......................................................................................................
Pekerjaan : .......................................................................................................
Alamat : .......................................................................................................
.......................................................................................................

Demikian surat keterangan sehat ini dipergunakan sebagaimana mestinya.

Kelumbayan, ........................................... 2020

Dokter / Pemeriksa

dr. Reni Friska.M.U Sagala, MM

NRPTT. 1982017.1.004
 PEMERINTAH KABUPATEN TANGGAMUS
DINAS KESEHATAN
UPTD PUSKESMAS KELUMBAYAN BARAT
Jln. Raya Lintas No.1 Pekon Lengkukai Kec. Kelumbayan Barat Kab. Tanggamus
No. HP. 0822 7889 6488 email : puskesmaskelumbayanbarat@gmail.com

SURAT KETERANGAN PEMERIKSAAN KESEHATAN CALON MEMPELAI

Nomor : /25/ 2020

Yang bertanda tangan di bawah ini :

Nama : ............................................................................
NIP / NRPTT : ............................................................................
Berdasarkan Peeraturan Daerah Nomor 08 Tahun 2000 Tanggal 22 Juni 2000 tentang retribusi
Pemeriksaan Kesehatan Calon Mempelai Lembaran Daerah Tahun 2000 Nomor 74 seri B 68,
menyatakan :

Nama : .......................................................................................................
TTL / Umur : .......................................................................................................
Jenis Kelamin : .......................................................................................................
Agama : .......................................................................................................
Pekerjaan : .......................................................................................................
Alamat : .......................................................................................................
.......................................................................................................
Calon Suami / Istri dari :

Nama : .......................................................................................................
TTL / Umur : .......................................................................................................
Jenis Kelamin : .......................................................................................................
Agama : .......................................................................................................
Pekerjaan : .......................................................................................................
Alamat : .......................................................................................................
.......................................................................................................

Demikian surat keterangan sehat ini dipergunakan sebagaimana mestinya.

Kelumbayan, ........................................... 2020

Dokter / Pemeriksa

dr. Eka Sandra Amelia

NRPTT. 19800802 201