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DINAS KESEHATAN KABUPATEN TASIKMALAYA UPTD PUSKESMAS DTP KARANGNUNGGAL Jl. Raya Karangnunggal No. 13 Tlp. (0265) 580 113

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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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