Name : SRI SUHARTI BINTI

Date Of Birth : : 18 Oct 1968

Sex: : FEMALE
Nationality : : INDONESIA
Vaccine of prophylaxis Meningitis Meningococcus ACYW135
Date : 26 Mar 2019
Signature and professional status of
supervising clinician

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Manufacture and batch no of vaccine
J201705002

Certificate valid
SRI SUHARTI BINTI From : 26 Mar 2019
KAB. SIDOARJO Until : 10 Mar 2022
Official stamp of the
1300497878 administering center