Name : HAMSIN

Date Of Birth : : 01 Jul 1949

Sex: : MALE
Nationality : : INDONESIA
Vaccine of prophylaxis Meningitis Meningococcus ACYW135
Date : 04 May 2019
Signature and professional status of
supervising clinician

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Manufacture and batch no of vaccine
201706037

Certificate valid
HAMSIN From : 04 May 2019
KAB. PROBOLINGGO Until : 18 Apr 2022
Official stamp of the
1300510600 administering center