Name : KARTINI BINTI AMAQ

Date Of Birth : : 01 Jul 1976

Sex: : FEMALE
Nationality : : INDONESIA
Vaccine of prophylaxis Meningitis Meningococcus ACYW135
Date : 24 Apr 2019
Signature and professional status of
supervising clinician

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Manufacture and batch no of vaccine
201803004

Certificate valid
KARTINI BINTI AMAQ From : 24 Apr 2019
KAB. LOMBOK TIMUR Until : 08 Apr 2022
Official stamp of the
1500065708 administering center