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VISUM ET REPERTUM: VER/ 1 / XI /2015/ RS. Bhay

SURAT KETERANGAN VISUM ET REPERTUM

KORBAN HIDUP

Bagian Ilmu Kedokteran oren!ik " Medikolegal #IKM$

RS B%a&angkara

'l( Dr( Su%ar!o )rg( III No( * Palu + Indone!ia

PRO 'USTITIA

Nomor Surat Keteranan VeR : VER/ 1 / XI /2015/ RS. Bhay

I( Surat Permintaan VeR #SPV$

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

a! Nomor Surat Keteranan VeR / 2"5 / XI / 2015 / SPKT / Re#or Pa$u%%%%%%%

&! 'ar() Tana$ *an +a,tu SPV *(ter(ma: 'ar( Se$a#a) Tana$ T(a Bu$anSe&e$a# Tahun -ua R(&u (ma Be$a# %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

! P(ha, yan mem&uat SPV eny(*(,! : IPTU Suhen*ar. K SPKT U&

KNIT 3 SPKT) NRP "40500"") 'ar( Se$a#a) Tana$ T(a Bu$an

Se&e$a# Tahun -ua R(&u (ma Be$a#. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

II( )a,oran Vi!um et Re,ertum

#VeR$++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

a! 'ar() Tana$) +a,tu *an Temat Pemer(,#aan VeR : 'ar( Se$a#a) Tana$

T(a Bu$an Se&e$a# Tahun -ua r(&u (ma Be$a# u,u$ #atu $eat emat

$(ma *( (n#ta$a#( aat *arurat rumah #a,(t &ayan,ara%%%%%%%%%%%%%%%%&! Pemer(,#a: *r. Nurmaya#ar( Rau6 *an *o,ter mu*a Rana -uo Rama*an

! I*ent(ta# Pa#(en/Kor&an : Menurut ,or&an ) KTP/ SPV) Pa##ort!%%%%%%%%

1. Nama Kor&an : 'er$(#a%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

2. 7en(# Ke$am(n : +an(ta%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

4. ama : I#$am%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

8. Tana$ ah(r/Umur : T(a u$uh enam tahun%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

5. $amat : 7a$an tan9un ,aran nomor *ua u$uh t(a

Keamatan Pa$u Se$atan Kota Pa$u%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

. Bu,t( I*ent(ta# : T(*a, *(antum,an%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

". No Bu,t( I*ent(ta# : T(*a, *(antum,an%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

*! 'a#($ Pemer(,#aan %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

1. namne#(# :

Seoran ,or&an eremuan u#(a t(a u$uh enam tahun *(antar o$eh

eny(*(, *enan mem&aa SPV *enan nomor:

VER/2"5/XI/2015/SPKT/Re#or Pa$u ata# t(n*a, (*ana ,e,era#an

*a$am rumah tana) er(ha$ erm(ntaan V(#um et Reertum. Ke9a*(an

ter9a*( *( 7a$an Tan9un Sant(( #am(n 'ote$ Rama Keamatan Pa$u

Se$atan ,ota Pa$u u,u$ *e$aan ma$am enam 9am #e&e$um

emer(,#aan!. Kor&an mena,u *(an(aya o$eh #atu oran yan

*(,ena$nya. ;ran ter#e&ut menar(, ram&ut ,or&an ,emu*(anmena,ar mata ,anan ,or&an. Kor&an $a$u *(u,u$ menuna,an

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,ea$an tanan ,anan ,e arah h(*un #e&anya, #atu ,a$( #eh(na

mene$uar,an *arah. Ke9a*(an (n( #e&e$umnya te$ah ter9a*( &eru$an

,a$( *an *((u o$eh ma#a$ah e,onom(. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

2. Pemer(,#aan


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III( Ke!im,ulan+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

++++

'a#($ emer(,#aan $uar a*a ,or&an eremuan umur t(a u$uh enam tahun

*enan nomor SPV : VER / 2"5 / XI /2015 / SPKT / Re#or Pa$u) *enan

,e#(mu$an *(temu,an $u,a $eet ore# *( ,e$oa, mata ,anan ata# *an $u,a

memar *( h(*un a,(&at trauma tumu$. u,a (n( *aat #em&uh #emurna *an

t(*a, memer$u,an enananan ,hu#u#. T(*a, *(temu,an $u,a tan,(#.

Ber*a#ar,an arna $u,a) $u,a (n( ter9a*( a*a a,tu ,uran *ar( *ua u$uh emat

9am #e&e$um emer(,#aan%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

IV( Penutu,

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++Demi

kian Surat keterangan ini di-uat -erda!arkan dengan ,enguraian &ang

!e.u.ur/.u.urn&a dan menggunakan ,engeta%uan &ang !e-aik/-aikn&a !erta

mengingat !um,a% ,ada !aat menerima .a-atan(++++++++++++++++++++++++++++++++++++

a. Temat) har( *an tana$ *(,e$uar,an #urat VeR : Pa$u) 'ar( Se$a#a) Tana$t(a) &u$an #e&e$a#) tahun *ua r(&u $(ma &e$a# %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

&. Nama $en,a Koa## 9aa *( RS. Bhayan,ara : Rana -uo Rama*an S.Ke*

. 7a&atan *an ,ometen#( *ar( &! : Koa## 9aa *( RS. Bhayan,ara Pa$u%%%%%%%%

Koa## 7aa -o,ter 7aa

Rana -uo Rama*an S.Ke* *r. Nurmaya#ar( Rau6

V( )am,iran Pemerik!aan++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++a. am(ran 6oto : -($am(r,an #e&anya, 5 6oto &erarna) *aerah mata) a9ah)

#e$uruh tu&uh) *an SPV %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

&. am(ran ?(*eo : % %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

. am(ran $a(n@$a(n : % %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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VeR 1 Rangga Duo Ramadan

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