Name : SITI SUMARTI BINTI

Date Of Birth : : 17 Jun 1938

Sex: : FEMALE
Nationality : : INDONESIA
Vaccine of prophylaxis Meningitis ACWY
Date : -
Signature and professional status of
supervising clinician

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Manufacture and batch no of vaccine
-

Certificate valid
SITI SUMARTI BINTI From :
KAB. DHARMASRAYA Until :
Official stamp of the
300082677 administering center