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    Form Surat Keterangan Kawin

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    arfian pw
    This document is a health certificate from the Puskesmas Bojong in Purbalingga Regency for marriage. It states that a medical examination was conducted on a marriage candidate and the results found them to be healthy/unhealthy, with notes. The certificate was issued to obtain documentation for marriage under Regional Regulation Number 6 of 2008.

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    Form Surat Keterangan Kawin

    Uploaded by

    arfian pw
    11 views1 page
    This document is a health certificate from the Puskesmas Bojong in Purbalingga Regency for marriage. It states that a medical examination was conducted on a marriage candidate and the results found them to be healthy/unhealthy, with notes. The certificate was issued to obtain documentation for marriage under Regional Regulation Number 6 of 2008.

    Original Description:

    KIR NIKAH

    Original Title

    Form Surat Keterangan Kawin - Copy

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    This document is a health certificate from the Puskesmas Bojong in Purbalingga Regency for marriage. It states that a medical examination was conducted on a marriage candidate and the results found them to be healthy/unhealthy, with notes. The certificate was issued to obtain documentation for marriage under Regional Regulation Number 6 of 2008.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    11 views1 page

    Form Surat Keterangan Kawin

    Uploaded by

    arfian pw
    This document is a health certificate from the Puskesmas Bojong in Purbalingga Regency for marriage. It states that a medical examination was conducted on a marriage candidate and the results found them to be healthy/unhealthy, with notes. The certificate was issued to obtain documentation for marriage under Regional Regulation Number 6 of 2008.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    PEMERINTAH KABUPATEN PURBALINGGA PEMERINTAH KABUPATEN PURBALINGGA

    SERI : A SERI : A

    SURAT KETERANGAN SEHAT UNTUK KAWIN / SURAT KETERANGAN SEHAT UNTUK KAWIN /
    SURAT KETERANGAN PEMERIKSAAN SURAT KETERANGAN PEMERIKSAAN
    PERDA NOMOR 6 TH 2008 PERDA NOMOR 6 TH 2008

    Yang bertanda tangan di bawah ini : Yang bertanda tangan di bawah ini :
    Nama : NIP. Nama : NIP.
    Jabatan : . Jabatan : BIDAN PUSKESMAS

    Instansi : PUSKESMAS BOJONG Instansi : PUSKESMAS BOJONG


    Sesuai sumpah jabatan,saya telah melakukan pemeriksaan kesehatan bagi calon mempelai: Sesuai sumpah jabatan,saya telah melakukan pemeriksaan kesehatan bagi calon mempelai:

    Nama : ........................................................................................ Nama : ...........................................................................................

    Tgl. Lahir/Umur : ....................................................................................... Tgl. Lahir/Umur : .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Agama : .............................................................................................. Agama : .............................................................................................

    Alamat : ...................................................................................................... Alamat : ..................................................................................

    Menurut hasil pemeriksaan medis yang bersangkutan dinyatakan SEHAT / TIDAK SEHAT *), Menurut hasil pemeriksaan medis yang bersangkutan dinyatakan SEHAT / TIDAK SEHAT *),
    dengan catatan : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . dengan catatan : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
    .............................................................................................................................................. ..............................................................................................................................................

    Demikian surat keterangan ini dibuat guna memperoleh surat keterangan untuk kawin. Demikian surat keterangan ini dibuat guna memperoleh surat keterangan untuk kawin.

    BOJONG . . ,. . 2017 BOJONG . ,. 2017


    Yang memeriksa, Yang memeriksa,

    NIP. NIP.

    *) coret yang tidak perlu *) coret yang tidak perlu

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