NTAILKOTA BANJARMASIN
PEMERI y
PNAS KESEHATAN KOTA BANJARMASIN
PUSKESMAS KUIN RAYA
im Ske Neti ta Manor Kee Pon 70116
ee arma pang
ERBADAN SELAT
MAST gu T2027
SURAT KETERANGAN B
Nomwor 8137 676, /PUSRI
ini:
rdrgRONY SIM
£197 10910 200501 1 005
105 / Pelvin / MI /1PD.G / 2002
sip
Pangkat / Gol. Pembina / TV
Jabaran Kepila Puskesmas Kun Raat
YFelaly memberikan tugs kepada :
Nama Lengkap dr, Nurul Huda
NIP +: 19870307 201502 2 001
sip 1508/348/P.[7in/TPD.UL LY Diskes
Pangkat | Gol. : Penata Ie
Jabatan Dokter Muda
‘untuk memeriksa Kesehatan dengan telifi dan menerangkan baba :
‘Nama Lengkap Nuria Ava
‘Tempat & Tanggal Lahir : Ban darbar . 27 deni (393
Jenis Kelammin + Rerengvan
Pekerjaan pas
Alamat Frome: Gaunteng 410.222 AF 35 RW I} Het. Feraton
Fee. Macknguea,
alas permintaan sendiri dengan berpendapat bahiva yang diperiksa tersebut pada pemeriksaan
dinyatakan :
[i SEHAT
[_] TIDAK SEHAT
Surat Keterangan ini diperlukan untuk :melengrags berkas Peepasseagan STE
dan hanya berlaku (1.4) empatbelas hari sejak tanggal surat dikeluarkan
Dikeluarkan di; Banjarmasin
Keterangan hiin-ain : Hula Tugel: ge 2001
ral a ny Dette Famertien
‘Tinggi Badan: Ge cn ie
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