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PEMERINTAH KABUPATEN BERAU

DINAS KESEHATANPUSKESMAS TUBAAN KECAMATAN TABALAR

Tubaan 26 Mei 2012

Nomor : / PKM-TBN/VER/ / 2012..................................................................

Lampiran : -..........................................................................................................................

Perihal : a!il Pemeri"!aan a#a! "orban bernama Nel$ %uliana......................................

PRO JUSTITIA

..........................................................Visum Et Repertum..........................................................

%an& ber#an'a #an&an 'iba(ah ini) *hairun Ni!a) +o"#er ,mum Pu!"e!ma! Tubaan)

Keama#an Tabalar) Kabupa#en Berau) Meneran&"an bah(a a#a! permin#aan #er#uli! 'ari

Kepoli!ian Re!or Berau e"#or Tubaan No Pol : B / 0 / V / 2012 / e"-Tbn) #er#an&&al 26

Mei 2012) ma"a pa'a #an&&al +ua Puluh Enam Mei +ua Ribu +ua Bela! pu"ul Tuuh Bela!

le(a# Lima Bela! Meni# (a"#u n'one!ia ba&ian Ten&ah) ber#empa# 'iruan& Balai

Pen&oba#an Pu!"e!ma! Tubaan #elah 'ila"u"an pemeri"!aan #erha'ap "orban $an& menuru#

!ura# #er!ebu# a'alah :...................................................................................................................

Nama : Nel$ %uliana..........................................................................................

,mur : 2 #ahun..................................................................................................

3eni! Kelamin : Perempuan.............................................................................................

4&ama : !lam.......................................................................................................

u"u : n'one!ia/Bu&i!.....................................................................................

Pe"eraan : PN........................................................................................................

4lama# : Pi!an&-pi!an&an Kp. emuru# Ke. Tabalar Kab. Berau.......................Ke#eran&an "ea'ian menuru# "orban

.........................................................HASIL PEMERIKSAAN..................................................

1. Korban 'a#an& 'alam "ea'aan !a'ar 'an "ea'aan umum bai"........................................

2. Pa'a "orban 'i#emu"an lu"a-lu"a :..................................................................................

a. Lu"a ba"ar 'eraa# !a#u 'i !eluruh 'ahi) pipi "iri) 'an pipi "anan.............................

5. Pa'a "orban 'iberi"an pen&oba#an !eu"upn$a...............................................................

. Pa'a "orban #i'a" 'ila"u"an pemeri"!aan penunan&.....................................................

. Korban 'ipulan&"an 'alam "ea'aan bai"........................................................................

...........................................................KESIMPULAN..........................................................

Telah 'iperi"!a "orban perempuan bernama Nel$ %uliana berumur +ua Puluh Empa#

#ahun) pa'a pemeri"!aan #i'a" 'i#emu"an lu"a-lu"a a"iba# "e"era!an.................................+emi"ian !a$a urai"an 'en&an !euur-uurn$a 'an men&&una"an "eilmuan $an& !ebai"-

bai"n$a...................................................................................................................................

+o"#er #er!ebu# 'ia#a!

'r. *hairun Ni!a

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