Cert. No.

BIRTH CERTIFICATE

Full Name ：
Date of Birth ：
Place of Birth ：
Domicile ：

Father ：
Mother ：
Relationship ：

Certified as above.

Embassy of Japan in Indonesia

Jakarta, , 20 　

This certificate is based on a certified copy of the Official

Family Register issued by the Mayor of City,
Prefecture, on , 20 　 .

（ Fee Rp.