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

Timofeev Timofej Alekseevich

Date of birth Sex
15.05.2002 Male

Personal identity document International identity document

8715 713138 -

Personal insurance policy number

148-802-704 77

Policy of obligatory medical insurance

01042427825
№ 1000 5303 5658 4285

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)

110000076843922 Gam-COVID-Vac (“Sputnik V”), combined heterologous GBUZRK"Usinskaia TSRB"

recombinant adenovirus (rAd)-based vaccine for
prophylaxis of coronavirus infectious diseases caused by g. Usinsk, ul. Neftianikov, d. 34
SARS-CoV-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 l-
530821

November 27, 2021

Gam-COVID-Vac (“Sputnik V”), combined heterologous OOO "LAKHTA KLINIKA"

recombinant adenovirus (rAd)-based vaccine for
prophylaxis of coronavirus infectious diseases caused by -
SARS-CoV-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 II-
710821

December 18, 2021

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

There is no data