REPUBLIC OF IilDOHESIA rt.-:J .ri ir *lt ?

*r*Jt
]IIINISTRY OF HEALTH r - -ll Ltr.,J
Regency/Municipal Health $ervice
of i,.*r*.J' *rr.J Jr*t rrl .rll

TO tIVHOttil IT MAT CONCERN

,F rt tr .{-J
Herawt[r the undarsigned rt*-ltf p-r.;-lr
Narp l* ll
Oocupa$on f---{,t"'
Addrsss trl f""^I
.
NOTIFIES THAT : ol.
l.lame ,-- lt
Passport Number rt,+Jr it
Fllsht iir.t-rt- lJr,,
L.ilf L1.; o lt t+-. I *.1.r. .rt pt* ,rl* v.dJ .,!
fur hlslher oiln nee& has to bring the followlng medlclnes

C{t . l rr-ll tl-{- ; trt* . .r-rJ 1r$

No, Itsrnafidnd of medldnes Unit Amount
t. ftara ttarrattrrttattr*rarrrr rrarr aar.a l.aa rt aa'.

2.
3.
ril.
5. ,..tt.I ral tr. a. atlaa..t...... r r.

6. rtaaatSrtataa.tra.ta.ar.a...r.tttaattaatr.t. a ra..

7. aatt ataaatra. tatt.atr.araa aatrtltra.aa laa aa. a.. f,

8.
g, atartlrttlaeaaaraala r tra ttt a a laattt' r"t'ti a tttsa

10. rt ta atr.aa aaraaarataa acl aa.a r a tl.aatltatlla a ta.!.

rlt-; r.*..1. [rJ r...*rlr Lt..,

ULs,rl.ll..bl*Iilr.r**Ir L hJ ta; - tf-' )Lre r]r lry'.:..I
,J.f $t-JJ
t-;.r ,t ut
blJ.-rt*,#r:-.Jf pt.'rlfuI, *' , Jr.r'.[ r ;. .,* Jp;l r.rt+.Jrrrr r--tr r j
. A.a t Jt r--J r-FJJra-- -I' r -rirJt
Based on madical rcasohs, ths above medicines are $tric{ly propared for daily per-
soilalus6 bythe bearer, ?nd ftls nofrficaton Is prcvided tq be sho*rrfproduced to the
Ssudi Arsbfin e#toriry Whennecessary upon anival for dearance
.,.!...r.*..... ,,,24..,..,
Physician,
"' f*ama
Regietarcd number

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