PEMERINTAH KABUPATEN TANJUNG JABUNG BARAT

DINAS KESEHATAN
PUSKESMAS RAWAT INAP TUNGKAL V
JL.Lintas SD Kel.Tungkal V Kec. Seberang Kota No Tel.0852-8345-8660 KodePos 36551

SURAT KETERANGAN LAHIR

Nomor : 440/ /PKM.TKL-V/2022

Yang bertandatangan dibawah ini, menerangkan bahwa:

Nama : ..............................................................................

NIK : ..............................................................................

Umur : ..............................................................................

Pekerjaan : ..............................................................................

Nama Suami : ..............................................................................

NIK Suami : ..............................................................................

Umur Suami : ..............................................................................

Pekerjaan Suami : ..............................................................................

Alamat : ..............................................................................

Telah melahirkan seorang anak pada :

Hari / Tanggal : ..............................................................................

Jam : ..............................................................................

Nama : ..............................................................................

Jenis Kelamin : ..............................................................................

Berat Badan : ..............................................................................

Panjang Badan : ..............................................................................

Tempat Lahiran : ..............................................................................

Anak Ke - : ..............................................................................

Agama : ..............................................................................

Demikian surat keterangan ini diberikan agar dapat dipergunakan sebagaimana

mestinya.
......................., ....... /........../20.........
Saksi I Saksi II Penolong Persalinan

(............................................) (............................................) (............................................)