Ati Binti Samin Binti: Name: Date of Birth: Sex: Nationality

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Name : ATI BINTI SAMIN BINTI

Date Of Birth : : 03 Nov 1981


Sex: : FEMALE
Nationality : : INDONESIA
Vaccine of prophylaxis Meningitis Meningococcus ACYW135
Date : 18 Jun 2019
Signature and professional status of
supervising clinician

..................................................
Manufacture and batch no of vaccine
201803003

Certificate valid
ATI BINTI SAMIN BINTI From : 18 Jun 2019
KAB. TANGERANG Until : 02 Jun 2022
Official stamp of the
2800151194 administering center

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