F-2.

01
Provinsi : _____________________________________________
Kabupaten : _____________________________________________
Kecamatan : _____________________________________________
Desa / Kelurahan : _____________________________________________

FORMULIR PELAPORAN PENCATATAN SIPIL

KEMATIAN

DATA PELAPOR
1. Nama Lengkap : ___________________________________________________________________
2. NIK : ___________________________________________________________________
3. No. Dok. Perjalanan :___________________________________________________________________
4. No. KK : ___________________________________________________________________
5. Kewarganegaraan : ___________________________________________________________________

SAKSI I
1. NIK : _________________________________________________________________
2. Nama lengkap : _________________________________________________________________
3. Tgl Lahir / umur : Tgl. Lahir _____________________________________ Umur ______________
4. Pekerjaan : _________________________________________________________________
5. Alamat : _________________________________________________________________

SAKSI II
1. NIK : _________________________________________________________________
2. Nama lengkap : _________________________________________________________________
3. Tgl Lahir / umur : Tgl. Lahir _____________________________________ Umur ______________
4. Pekerjaan : _________________________________________________________________
5. Alamat : _________________________________________________________________

DATA ORANG TUA

AYAH
1. Nama Lengkap : ___________________________________________________________________
2. NIK : ___________________________________________________________________
3. Tempat Lahir : ___________________________________________________________________
4. Tgl Lahir : ___________________________________________________________________
5. Kewarganegaraan : ___________________________________________________________________

IBU
1. Nama Lengkap : ___________________________________________________________________
2. NIK : ___________________________________________________________________
3. Tempat Lahir : ___________________________________________________________________
4. Tgl Lahir : ___________________________________________________________________
5. Kewarganegaraan : ___________________________________________________________________

KEMATIAN
1. NIK : ___________________________________________________________________
2. Nama Lengkap : ___________________________________________________________________
3. Tgl Kematian : ___________________________________________________________________
4. Pukul / Jam : ___________________________________________________________________
5. Sebab Kematian : a. Sakit Biasa b. Wabah Penyakit c. Kecelakaan
d. Kriminalitas e. Bunuh Diri f. Lainnya
6. Tempat Kematian : ___________________________________________________________________
7. Yang Menerangan : a. Dokter b. Tenaga Kesehatan c. Kepolisian d. Lainnya

Sragen, _____ __________________ 20

Pelapor,

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