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DINAS KESEHATAN KABUPATEN TASIKMALAYA UPTD PUSKESMAS DTP KARANGNUNGGAL Jl. Raya Karangnunggal No. 13 Tlp. (0265) 580 113
SURAT KETERANGAN SAKIT No : .......... / .......... / PKM / 2016 Yang bertanda tangan dibawah ini menerangkan : Nama
: ................................................................................................................................................... L / P
Umur
: ............................................................................................................................................................
Pekerjaan
: ............................................................................................................................................................
Alamat
: ............................................................................................................................................................ ............................................................................................................................................................
Berhubung yang bersangkutan sedang sakit, maka memerlukan istirahat selama : ....................................................... ( ....................... ) hari dari tanggal : ................................................... s / d tanggal : ...................................................... Demikian agar menjadi maklum. Karangnunggal, ................................................................. 2016 Dokter Pemeriksa
Dr. H. Lutfi Nurzaman, M.Kes 19630522 199103 1 008
DINAS KESEHATAN KABUPATEN TASIKMALAYA UPTD PUSKESMAS DTP KARANGNUNGGAL Jl. Raya Karangnunggal No. 13 Tlp. (0265) 580 113
SURAT KETERANGAN SAKIT No : .......... / .......... / PKM / 2016 Yang bertanda tangan dibawah ini menerangkan : Nama
: ................................................................................................................................................... L / P
Umur
: ............................................................................................................................................................
Pekerjaan
: ............................................................................................................................................................
Alamat
: ............................................................................................................................................................ ............................................................................................................................................................
Berhubung yang bersangkutan sedang sakit, maka memerlukan istirahat selama : ....................................................... ( ....................... ) hari dari tanggal : ................................................... s / d tanggal : ...................................................... Demikian agar menjadi maklum. Karangnunggal, ................................................................. 2016 Dokter Pemeriksa
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DINAS KESEHATAN KABUPATEN TASIKMALAYA UPTD PUSKESMAS DTP KARANGNUNGGAL Jl. Raya Karangnunggal No. 13 Tlp. (0265) 580 113
SURAT KETERANGAN SAKIT No : .......... / .......... / PKM / 2016 Yang bertanda tangan dibawah ini menerangkan : Nama
: ................................................................................................................................................... L / P
Umur
: ............................................................................................................................................................
Pekerjaan
: ............................................................................................................................................................
Alamat
: ............................................................................................................................................................ ............................................................................................................................................................
Berhubung yang bersangkutan sedang sakit, maka memerlukan istirahat selama : ....................................................... ( ....................... ) hari dari tanggal : ................................................... s / d tanggal : ...................................................... Demikian agar menjadi maklum. Karangnunggal, ................................................................. 2016 Dokter Pemeriksa
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