Name : ARYATI BINTI WARWIN R

Date Of Birth : : 07 Dec 1943

Sex: : FEMALE
Nationality : : INDONESIA
Vaccine of prophylaxis Meningitis Meningococcus ACYW135
Date : 23 Apr 2019
Signature and professional status of
supervising clinician

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Manufacture and batch no of vaccine
201803004

Certificate valid
ARYATI BINTI WARWIN R From : 23 Apr 2019
KAB. BANYUMAS Until : 07 Apr 2022
Official stamp of the
1100418240 administering center