F-2.

01 PERMENDAGRI 109 TAHUN 2019

Provinsi : SULAWESI SELATAN
Kabupaten/Kota : MAKASSAR
Kecamatan : .................................................................................................................
Desa/Kelurahan : .................................................................................................................
Kode Wilayah : 7371……………….
FORMULIR PELAPORAN PENCATATAN SIPIL DI DALAM WILAYAH NKRI
AKTA KEMATIAN

Data Pelapor
1. Nomor Induk Kependudukan (NIK) : ...................................................................................................................................................................................
2. Nama Lengkap : ...................................................................................................................................................................................
3. Tempat, Tanggal Lahir : ...................................................................................................................................................................................
4. Pekerjaan : ...................................................................................................................................................................................
5. Nomor Telp. / HP : ...................................................................................................................................................................................
6. Alamat : ...................................................................................................................................................................................
Kecamatan : ………………………………………………… Kab/Kota : …………………………………………………
Kelurahan : ………………………………………………… Provinsi : …………………………………………………

Data Kematian
1. Nomor Induk Kependudukan (NIK) : ...................................................................................................................................................................................
2. Nama Lengkap : ...................................................................................................................................................................................
3. Tempat, Tanggal Lahir : ...................................................................................................................................................................................
4. Tanggal Kematian : ...................................................................................................................................................................................
5. Pukul : ...................................................................................................................................................................................
6. Sebab Kematian : 1. Sakit Biasa / Tua 2. Wabah Penyakit 3. Kecelakaan
4. Kriminalitas 5. Bunuh Diri 6. Lainnya
7. Tempat Kematian : ...................................................................................................................................................................................
8. Yang Menerangkan : 1. Dokter 2. Tenaga Kesehatan 3. Kepolisian 4. Lainnya
9. Nomor Telp. / HP / WA (*) : ...................................................................................................................................................................................
Salah Satu Anggota Keluarga
10. Email Yang Masih Aktif (*) : ...................................................................................................................................................................................

Data Orangtua
Ayah
1. Nomor Induk Kependudukan (NIK) : ...................................................................................................................................................................................
2. Nama Lengkap : ...................................................................................................................................................................................
3. Tempat, Tanggal Lahir : ...................................................................................................................................................................................
4. Agama : ...................................................................................................................................................................................
5. Pekerjaan : ...................................................................................................................................................................................
6. Alamat : ...................................................................................................................................................................................
Kecamatan : ………………………………………………… Kab/Kota : …………………………………………………
Kelurahan : ………………………………………………… Provinsi : …………………………………………………
7. Warga Negara : ...................................................................................................................................................................................

Ibu
8. Nomor Induk Kependudukan (NIK) : ...................................................................................................................................................................................
9. Nama Lengkap : ...................................................................................................................................................................................
10. Tempat, Tanggal Lahir : ...................................................................................................................................................................................
11. Agama : ...................................................................................................................................................................................
12. Pekerjaan : ...................................................................................................................................................................................
13. Alamat : ...................................................................................................................................................................................
Kecamatan : ………………………………………………… Kab/Kota : …………………………………………………
Kelurahan : ………………………………………………… Provinsi : …………………………………………………
14. Warga Negara : ...................................................................................................................................................................................
Makassar, …………………………………….20…….

Mengetahui : Pelapor
Pejabat Dukcapil Yang Membidangi

…………………………………………………. ………………………………………………….

Nb. Tanda (*) Wajib Isi