Sistem Informasi Kesehatan Pelabuhan

Balai Kekarantinaan Kesehatan/Rumah Sakit

Klinik Medilab

No. Dokumen

M00-0400146

Barcode Number

M00-0400146

This is to certify that [Name]

MUHAMMAD ALI HASAN KHATAMI SINAGA

Date Of Birth

21st November 1998

Sex

Male

Nationality

INDONESIA

National Identification Documents, If Applicable

X1065774

Whose Signature Follows

MUHAMMAD ALI HASAN KHATAMI SINAGA

Has on the date indicated been vaccinated or received prophylaxis againts: (name of disease or condition)

YELLOW FEVER

Vaccine or Prophy	Date	Signature and profesional status of supervising clinican	Manufacture and batch no. of vaccine or prophylaxis	Certificate valid until	Official stamp of the administering centre	Disease targeted	Date	Manufacture, brand name and batch no. of vaccine	Next Booster (date)	Official stamp and signature
YELLOW FEVER	2nd December 2023	DR. EBIET YUDI SANTOKO	28112022 & W3J433V	-	KLINIK MEDILAB	-	-	-	-	-

International Certificate Vaccination Or Prophylaxis