N o . S E P :

T g l . S E P :

N o . K a r t u : P e s e r t a : P N S

N a m a P e s e r t a :

T g l . L a h i r : C O B :

J n s . K e l a m i n : L J n s . R a w a t : R J T L

P o l i T u j u a n : K l s . R a w a t :

A s a l F a s k e s T k . I : P E R U M N A S P a s i e n / P e t u g a s

D i a g n o s a A w a l : D M K e l u a r g a P a s i e n B P J S K e s e h a t a n

C a t a t a n :

* S a y a M e n y e t u j u i B P J S K e s e h a t a n m e n g g u n a k a n i n f o r m a s i M e d i s P a s i e n j i k a d i p e r l u k a n .

* S E P b u k a n s e b a g a i b u k t i p e n j a m i n a n p e s e r t a _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

I N T P O L I D A L A M

S U R A T E L E G I B I L I T A S P E S E R T A

M A R S I D I J A Y A , S O S

0 0 0 0 1 5 9 4 9 7 6 0 5

0 5 / 1 2 / 2 0 1 5

2 3 / 0 9 / 1 9 5 8