Surat Keterangan Lahir

KETERANGAN LAHIR
No : .........................................

Yang bertanda tangan di bawah ini, menerangkan bahwa

Pada hari ini .................................... , tanggal......................................., pukul................................telah lahir seorang bayi

Jenis Kelamin    : Laki-laki/Perempuan *

Jenis Kelahiran  : Tunggal/kembar 2/kembar 3/lainnya*

Kelahiran ke     :................................................

Berat lahir         :.........................................gram

Di rumah/rumah bidan/polindes/rumah bersalin/puskesmas/rumah sakit*............................................................................................................................................... alamat : ....................................................................................................................................................

Diberi nama :

.................................................................................................................................................................

 

Dari orang tua :

Nama ibu          :.............................................................................................Umur:......................tahun

Pekerjaan         :.......................................................................................................................................

KTP no.           : .....................................................................................................................................

Alamat             :.......................................................................................................................................

Kecamatan       : ......................................................................................................................................

Kab/kota           : ......................................................................................................................................

..................................tgl..............................

Penolong persalinan

**

............................................................

*lingkari yang sesuai

**Tanda tangan,nama lengkap,no induk pegawai,nama instansi