BIDAN PRAKTEK ( ............................................... ) SITI MUSHOFFAH.

SST
MANDIRI
BIDAN PRAKTEK MANDIRI
SITI MUSHOFFAH, SST
SITI MUSHOFFAH, SST
Jln, Masjid Rahmad RT 11.RW 06 Manyar Gresik
Jln, Masjid Rahmad RT 11.RW 06 Manyar Gresik

SURAT KETERANGAN LAHIR

SURAT KETERANGAN LAHIR
NO:......../.........../ SKL / 20...........
NO:......../.........../ SKL / 20............
Yang bertanda tangan di bawah ini, menerangkan bahwa:
Yang bertanda tangan di bawah ini, menerangkan bahwa:
Pada hari ini ........................Tanggal ....................................... Pukul.................
Pada hari ini ........................Tanggal ....................................... Pukul.................
Telah lahir seorang bayi
Telah lahir seorang bayi
Jenis kelamin :.............................. Kelahiran ke ..................................
Jenis kelamin :.............................. Kelahiran ke ..................................
Berat Badan :................................ Panjang Badan ..............................
Berat Badan :................................ Panjang Badan ..............................
Di Rumah Bidan SITI MUSHOFFAH. SST.
Di Rumah Bidan SITI MUSHOFFAH. SST.
Alamat Jln, Masjid Rahmad RT 11.RW 06 Manyar Gresik
Alamat Jln, Masjid Rahmad RT 11.RW 06 Manyar Gresik
Diberi Nama...........................................................................................................
Diberi Nama...........................................................................................................
Dari orang Tua:
Dari orang Tua:
Nama Ibu :.................................................................... Umur .............. Th.
Nama Ibu :.................................................................... Umur .............. Th.
Pekerjaan :....................................................................................................
Pekerjaan :....................................................................................................
Nama Ayah :.................................................................... Umur...............Th.
Nama Ayah :.................................................................... Umur...............Th.
Pekerjaan :....................................................................................................
Pekerjaan :....................................................................................................
Alamat :....................................................................................................
Alamat :....................................................................................................
.....................................................................................................
.....................................................................................................
Gresik , Tanggal ..................................
Gresik , Tanggal ..................................
Saksi Penolong Persalinan
Saksi Penolong Persalinan
( ............................................... ) SITI MUSHOFFAH . SST BIDAN PRAKTEK MANDIRI
BIDAN PRAKTEK SITI MUSHOFFAH, SST
MANDIRI
Jln, Masjid Rahmad RT 11.RW 06 Manyar Gresik
SITI MUSHOFFAH, SST
Jln, Masjid Rahmad RT 11.RW 06 Manyar Gresik
SURAT KETERANGAN PERIKSA
NO:......../.........../ SKS / 20............
SURAT KETERANGAN PERIKSA
Yang bertanda tangan di bawah ini, menerangkan bahwa:
NO:......../.........../ SKS / 20...........
Nama :.................................................................................. ...............
Yang bertanda tangan di bawah ini, menerangkan bahwa:
Umur :....................................................................................................
Nama :..................................................................................................
Pekerjaan :....................................................................................................
Umur :....................................................................................................
Alamat :....................................................................................................
Pekerjaan :....................................................................................................
.....................................................................................................
Alamat :....................................................................................................
Pada hari / Tgl :.............................................................................................
.....................................................................................................
Telah memeriksakan kesehatannya dengan
Pada hari / Tgl :............................................................................................. keluhan ....................................................................................................................
............
Telah memeriksakan kesehatannya dengan
keluhan .................................................................................................................... ................................................................................................................................
............
Dan membutuhkan istirahat .............................hari, tgl .................................
................................................................................................................................
Sampai Tgl...........................................................................................................
Dan membutuhkan istirahat ............................ hari, tgl .................................
Sampai Tgl...........................................................................................................

Gresik , Tanggal ..................................

Gresik , Tanggal ..................................
TTD
TTD

( ............................................... ) SITI MUSHOFFAH . SST

( ............................................... ) SITI MUSHOFFAH. SST