ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAE
1
2
Provinsi
:
BALI
F-2.01
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Kabupaten/Kota
:
BULELENG
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Kecamatan
:
5
Desa/Kelurahan
:
6
Kode Wilayah
:
7
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FORMULIR PELAPORAN PENCATATAN SIPIL DIDALAM WILAYAH NKRI
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Jenis Pelaporan Pencatatan Sipil
:
KEMATIAN
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11
DATA PELAPOR
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Nama
:
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NIK:
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Nomor Dokumen Perjalanan *
:
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Nomor Kartu Keluarga
:
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Kewarganegaraan
:
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DATA SAKSI I
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Nama
:
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20
NIK:
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Nomor Kartu Keluarga
:
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22
Kewarganegaraan
:
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DATA SAKSI II
24
Nama
:
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NIK:
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Nomor Kartu Keluarga
:
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27
Kewarganegaraan
:
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29
DATA ORANGTUA ** (hanya diisi untuk keperluan pencatatan kelahiran, lahir mati dan Kematian)
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Nama Ayah
:
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NIK Ayah
:
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Tempat Lahir Ayah
:
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Tanggal Lahir Ayah
:Tgl :Bln :Thn :
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Kewaganegaraan
:
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Nama Ibu
:
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NIK Ibu
:
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Tempat Lahir Ibu
:
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38
Tanggal Lahir Ibu
:Tgl :Bln :Thn :
39
Kewaganegaraan
:
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41
KEMATIAN
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1.NIK:
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43
2.Nama lengkap:
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44
3.Tanggal kematian:Tgl :Bln :Thn :
45
4.Pukul:
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46
5.Sebab Kematian:
1. Sakit biasa/tua
2. Wabah Penyakit
3. Kecelakaan
47
4. Kriminalitas
5. Bunuh diri
6. Lainnya
48
6.Tempat kematian:
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49
7.Yang menerangkan:
1. Dokter
2. Tenaga kesehatan
3. Kepolisian
4. Lainnya
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51
52
…...................., …...................20...…..
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Mengetahui ;Pelapor,
54
Kepala Desa/Lurah,
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57
58
59
(…...............................................)(…...............................................)
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