Name : OLENSIA ARNI BINTI

Date Of Birth : : 04 Apr 1965

Sex: : FEMALE
Nationality : : INDONESIA
Vaccine of prophylaxis Meningitis Meningococcus ACYW135
Date : -
Signature and professional status of
supervising clinician

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Manufacture and batch no of vaccine
-

Certificate valid
OLENSIA ARNI BINTI From :
KAB. SAWAH LUNTO SIJUNJUNG Until :
Official stamp of the
300064280 administering center