Medical certificate of immunization against the novel coronavirus infection COVID-19 or medical

contraindications to vaccination and (or) recovery from a disease caused by the novel coronavirus
infection COVID-19

Protopopov Vladislav Ivanovich

Date of birth Sex
19.09.2003 Male

Personal identity document International identity document

3217 865831 -

Personal insurance policy number

191-206-108 34

Policy of obligatory medical insurance

4290699730000205
№ 1000 5446 5923 2193

Information about immunization against the novel coronavirus

infection COVID-19
Vaccination record Information about the medicinal product (name,
Name of the medical institution
number manufacturer, batch and date of vactination)

420000085309895 Gam-COVID-Vac (“Sputnik V”), combined heterologous GAUZ KKRB

recombinant adenovirus (rAd)-based vaccine for
prophylaxis of coronavirus infectious diseases caused by s. Andreevka, per. Sovetskii, d. 1
SARS-CoV-2 pom.2

The Federal Government Budgetary Institution “National

Research Center for Epidemiology and Microbiology
named after Honorary Academician N.F. Gamaleya” of the
Ministry of Health of the Russian Federation, series
I650821

December 24, 2021

Gam-COVID-Vac (“Sputnik V”), combined heterologous GAUZ KKRB

recombinant adenovirus (rAd)-based vaccine for
prophylaxis of coronavirus infectious diseases caused by s. Andreevka, per. Sovetskii, d. 1
SARS-CoV-2 pom.2

The Federal Government Budgetary Institution “National

Research Center for Epidemiology and Microbiology
named after Honorary Academician N.F. Gamaleya” of the
Ministry of Health of the Russian Federation, series
II410721

January 14, 2022

Information about recovery from a disease caused by the novel
coronavirus infection COVID-19 (if any)

There is no data