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  • Form Surat Keterangan Kawin

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    arfian pw
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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.

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    KIR NIKAH

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    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
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    Download as doc, pdf, or txt
    9 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
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    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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