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

Petrasheva Viktoriya Ivanovna

Date of birth Sex
31.05.1983 Female

Personal identity document International identity document

1007 050371 -

Personal insurance policy number

145-988-716 29

Policy of obligatory medical insurance

01098660392
№ 1000 3953 4055 2489

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)

410000068758551 Gam-COVID-Vac (“Sputnik V”), combined heterologous Gosudarstvennoe biudzhetnoe

recombinant adenovirus (rAd)-based vaccine for uchrezhdenie zdravookhraneniia
prophylaxis of coronavirus infectious diseases caused by Kamchatskogo kraia
SARS-CoV-2 "Petropavlovsk-Kamchatskaia
gorodskaia bolnitsa N2" (GBUZ
The Federal Government Budgetary Institution “National KK "Petropavlovsk-Kamchatskaia
Research Center for Epidemiology and Microbiology gorbolnitsa N2")
named after Honorary Academician N.F. Gamaleya” of the
Ministry of Health of the Russian Federation, series I- -
290721

November 11, 2021

Gam-COVID-Vac (“Sputnik V”), combined heterologous Gosudarstvennoe biudzhetnoe

recombinant adenovirus (rAd)-based vaccine for uchrezhdenie zdravookhraneniia
prophylaxis of coronavirus infectious diseases caused by Kamchatskogo kraia
SARS-CoV-2 "Petropavlovsk-Kamchatskaia
gorodskaia bolnitsa N2" (GBUZ
The Federal Government Budgetary Institution “National KK "Petropavlovsk-Kamchatskaia
Research Center for Epidemiology and Microbiology gorbolnitsa N2")
named after Honorary Academician N.F. Gamaleya” of the
Ministry of Health of the Russian Federation, series II- -
360721

December 2, 2021
Information about recovery from a disease caused by the novel
coronavirus infection COVID-19 (if any)

There is no data