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

Komisarchuk Aleksandr Vladimirovich

Date of birth Sex
22.06.1989 Male

Personal identity document International identity document

4521 288157 -

Personal insurance policy number Policy of obligatory medical insurance

185-734-712 04 7753010827003586

№ 1000 4978 6401 5461

Information about immunization against the novel coronavirus infection COVID-19

Record number Information about the medicinal product (name, Name of the medical institution
manufacturer, batch and date of vactination)

770000077412969 Gam-COVID-Vac (“Sputnik V”), combined heterologous GBUZ "GP N 64 DZM"

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 I-
370721
November 30, 2021

Gam-COVID-Vac (“Sputnik V”), combined heterologous GBUZ "GP N 64 DZM"

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-450721
December 24, 2021

Page 1
Information on medical contraindications to vaccination

Not specified

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

Not specified

Information on positive results of tests on antibodies against the pathogen

of the novel coronavirus infection (COVID-19)

Not specified

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 Page 2