Name : ANDI MUPIDAH HANAPI

Date Of Birth : : 10 Apr 1980

Sex: : FEMALE
Nationality : : INDONESIA
Vaccine of prophylaxis Meningitis Meningococcus ACYW135
Date : -
Signature and
professional status of
supervising clinician

..................................................
Manufacture and batch no of vaccine
-

Certificate valid
ANDI MUPIDAH HANAPI From : Official stamp of the
administering center
Until :
KOTA MAKASSAR
2300139513