Name : ACH WAHYUDI BIN

Date Of Birth : : 07 Jun 1958

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

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Manufacture and batch no of vaccine
201803004

Certificate valid
ACH WAHYUDI BIN From : 26 Apr 2019
KAB. BANYUMAS Until : 10 Apr 2022
Official stamp of the
1100384351 administering center