CERTIFICATE Death

Number: / / / 2016

I The undersigned below:

Name: Dr. Widya Ningrum

Position: Head of Hospital

stated,

Died HAS THE WORLD, sister:

Full name :
ID card number :
Gender :
Date of birth :
ON Age:
Status:
Address:

ON Date March 24, 2016 at 6:25 o'clock pm The diabetic complications due to disease
caused by the disease.

Death Certificate so we created to be used as appropriate.

Jakarta, March 24, 2016

Knowing,
Head Hospital

Dr. Widya Ningrum

 SURAT KETERANGAN KEMATIAN
Nomor: / / / 2016

Saya yang bertanda dibawah ini:

Dokter : dr. Sumarwanto, Sp. PD

Jabatan : Dokter Penanggungjawab Pasien

Menyatakan dengan sesungguhnya bahwa:

Nama Lengkap : Tn. Tolib Ali Babsel

Jenis Kelamin : Laki-laki
Tempat, Tanggal Lahir : Pekalongan, 31 Desember 1949
Pada Umur : 67 Tahun
Alamat : Jl. Melati No. 22 Poncol Pekalongan

Telah meninggal dunia pada tanggal 24 Maret 2017 pada Pukul 17:00 WIB dikarenakan
penyakit Sepsis dengan komplikasi Cholecystitis dan penyakit CHF dengan IHD

Demikian Surat Keterangan Kematian kami buat untuk digunakan sebagaimana semestinya.
Pekalongan, 30 Maret 2017
Mengetahui,
Kepala Rumah Sakit

dr. Sumarwanto, Sp. PD

CERTIFICATE OF DEATH
Number: / / / 2016

I, the undersigned below :

Doctors: dr. Sumarwanto, Sp. PD

Occupation: Responsible for the patient's doctor

State that:

Full Name: Mr. Tolib Ali Babsel

Gender : Male
Points, Date of Birth: Pekalongan, December 31th, 1949
At Age: 67 Years
Address: Jasmine street Number 22 Poncol Pekalongan

Have died on March 24th, 2017 at 17:00 o'clock pm because Sepsis disease with
complications Cholecystitis and CHF disease with IHD

Death Certificate so we created to be used as appropriate.

Pekalongan, March 30th, 2017
Knowing,
Responsible for the patient's doctor

dr. Sumarwanto, Sp. PD