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CSL

DP.3.392-99/00.H.

PENCATATAN

~??? ~ 2 2

SIPIL

WARGA N:GARA INDONESIA

KUTIPAN
AKTA

KELAHIRAN
4.001/1999

No

Darl. daftar

================

kelahiran menu rut Stbld.


temyata, bahwa di ...

================

U MUM

tentang

~.?~.~~.?:.?. ?~ ~~ ~.~.~:?
~~.?.:
..~.?.~di ..~~.~~.~~~...~.

~~~~?.~~~:
~~.~.
~ ~.~
.~.~
~.~.! ?~.~.~~
...~.~.:.
~.?..~.~~.=.=.~~.~~.

pada tanggal ...~.~~.~.~


..~~~.~~ ...~~.~.~.~.~~.~.~~.~~.~.~~.~~.=.=.
~~.=.=.
~.=.=.~
~.=.=.
~.=.=.~
~.=.=.~~.~~.
sen'bu sem b'I
I an ratus
anak

laki-:a-i

yang di

IZ
anak ke dua

======== te 1ah Iah'Ir:


beri nama:
=====================
Y
DIKA PUTRA ==================
istri : =~===---=================

sembilanpuluh

ari suami

===================

sembilan

H A R

N T 0

================

~=================

PRILIANI

===============

Kutipan ini sesuai dengan keadaan hari ini .

.~.?~~~.~
.., tanggal ..:.~~~.~.~..!~~.~

seribu sembilan ratus .. ~.~.~I!?~~.~.~p..i?:~:t:i.~


~.~~~~.~.~?

Kepala Dinas Kependudukan dan Catatan Sipil

'AB. DATI II BANDUf'G

o
:;/

~v.

NANA SUPE 'A, 3H.

---------

IP. 480 053 ~78.

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