Lampiran VI

Keputusan Dirjen Bimas Islam No 713 Tahun 2018

FORMULIR SURAT KETERANGAN KEMATIAN SUAMI/ISTERI

Model N6
KANTOR DESA/KELURAHAN : SIDOMULYO
KECAMATAN : BATU
KABUPATEN/KOTA : BATU

SURAT KETERANGAN KEMATIAN SUAMI/ISTERI

Nomor: 474.2 / / 422.310.006

Yang bertanda tangan di bawah ini menerangkan dengan sesungguhnya bahwa:

A. 1. Nama lengkap dan alias : SURYANI ...........................................................................................................................................................................................................................

2. Bin/Binti*) : MUALAM............................................................................................................................................................................................................................
3. Nomor Induk Kependudukan : .............................................................................................................................................................................................................................................................
4. Tempat dan tanggal lahir : Malang 25 Oktober 1968.....................................................................................................................................................................
5. Warga negara : Indonesia...........................................................................................................................................................................................................................
6. Agama : Islam..........................................................................................................................................................................................................................................
7. Pekerjaan : Swasta.....................................................................................................................................................................................................................................
8. Alamat : RT 06 RW 08 Ds.Junrejo Kec.Junrejo................................................................................................................................
telah meninggal dunia pada tanggal : 02 Nopember 2019.......................................................................................................................................................................................
di : Junrejo....................................................................................................................................................................................................................................
yang bersangkutan adalah suami/istri*) dari:
B. 1. Nama lengkap dan alias : SULIATI.................................................................................................................................................................................................................................
2. Bin/Binti*) : TARTO....................................................................................................................................................................................................................................
3. Nomor Induk Kependudukan : 3579036408720002......................................................................................................................................................................................
4. Tempat dan tanggal lahir : Malang . 24 Agustus 1972.....................................................................................................................................................................
5. Warga negara : Indonesia...........................................................................................................................................................................................................................
6. Agama : Islam..........................................................................................................................................................................................................................................
7. Pekerjaan : Mengurus Rumah Tangga......................................................................................................................................................................
8. Alamat : RT 06 RW 08 Ds.Junrejo Kec.Junrejo................................................................................................................................

Demikianlah surat keterangan ini dibuat dengan mengingat sumpah jabatan dan untuk digunakan seperlunya.

Junrejo, 06 Maret 2020 ….………………………….

……………………………………………
Kepala Desa/Lurah JUNREJO

ANDI FAIZAL HASAN