KLINIK AMALIA SEHAT

Ds. Sidorejo Rt 01/ Rw 02 Kec. Sedan Kab. Rembang, 59264

Email : amaliasehat1234@gmail.com
Telp. 081339240359

SURAT KETERANGAN LAHIR

Menerangkan bahwa pada:

Hari :...............................................................
Tanggal :...............................................................
Jam :...............................................................

Telah lahir seorang bayi laki-laki/ perempuan di Klinik Amalia Sehat dalam keadaan Hidup/
Mati.

Dengan berat :.............gram

Panjang badan :.............cm
Nama Ibu :...................................................................Umur:........................Tahun
Nama Ayah :...................................................................Umur:........................Tahun
Alamat :................................................................................................................
Kecamatan :................................................................................................................
Kabupaten :................................................................................................................

Sedan, ...........................................

Mengetahui,
Dokter Penanggungjawab Penolong Persalinan

dr Wiwik Susanti, SpOG dr Wiwik Susanti, SpOG