CERTIFIED TRANSLATION OF INDONESIAN LANGUAGE DOCUMENT

[Ministry of Health [Health and Social Security [People’s Movement for

of the Republic of Agency – Health Insurance Healthy Living (GERMAS)]
Indonesia] (BPJS Kesehatan)]

COVID-19 VACCINATION RECORD

Manual Ticket No. Single Identity No. (NIK): LM323119

Full Name : CELESTE LUCIA TATUM OGLE
Date of Birth : 21-03-1989
Mobile No. : 081239205654
Address : CEMPAKA PUTIH NO.26 SAYAN UBUD
Location of Vaccination : III DENPASAR UTARA COMMUNITY HEALTH CENTRE (PUSKESMAS III
DENPASAR UTARA) - 22090203

COVID-19 Vaccination History

Vaccination Vaccine Name Batch Vaccination Notes

Date No. Location
2021-08-06 AZTRA 210046 WANGAYA PUBLIC 1st AZ VACCINE. 2nd VACCINE
ZENECA HOSPITAL (RSUD SCHEDULED FOR 29th OCTOBER
WANGAYA)- 2021. IF COMPLAINTS PERSIST,
2209R002 CONTACT THE CONTACT PERSON
2021-10-29 AZTRA A1051 PUSKESMAS III FULLY VACCINATED
ZENECA DENPASAR
UTARA)- 22090203

Note:
If any symptoms occur following vaccination, please contact:
Name : Dr I Wayan Edi Wirawan
Telephone No. : 082145212505

CERTIFICATION
This is to certify that this translation from the Indonesian text is a true and accurate translation of the COVID-19
Vaccination Record of CELESTE LUCIA TATUM OGLE (source document: electronic copy). This translation has been
prepared by Amelia Lemondhi, NAATI Certified Professional Translator (Indonesian > English), NAATI CPN3KD93E, to her
best skills and knowledge. The translator, in providing this certification, gives no warrant as to the authenticity of the
source document. Any unauthorised change to the translation renders this certification invalid. On 3rd November 2021.

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 SOURCE DOCUMENT:

South Quarter Tower A, 18th floor, t +6221 8066-9612 info@indospeak.com

Unit D-G, Jl R.A. Kartini Kav 8, m +62 812 1426 2710
Cilandak Barat, Jakarta Selatan, 12430 www.indospeak.com