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PEMERINTAH KABUPATEN PRINGSEWU

DINAS KESEHATAN
UPT PUSKESMAS AMBARAWA
Alamat : Jl. H.M. Ghardi No.1 RT 03 RW 01 Ambarawa Kec.Ambarawa
Kode Pos 35376

KEPUTUSAN KEPALA PUSKESMAS AMBARAWA


NOMOR : 440 / ...... / 33 / 2019

TENTANG
.............................

Menimbang : a. bahwa .....................................................................................;


b. bahwa .....................................................................................;
c. ............................................................................................dst

Mengingat : 1. .................................................................................................;

2. .................................................................................................;

3. .................................................................................................;
4. ............................................................................................dst

MEMUTUSKAN

Menetapkan : ........................................................

KESATU : .............................................
KEDUA : .............................................
KETIGA : ............................................. dst;

DITETAPKAN DI...................
PADA TANGGAL : ....................
KEPALA UPT PUSKESMAS AMBARAWA,

Agung Wicaksono

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