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<html> <head> <link href="../../java/cetak/css/style.css" rel="stylesheet" type="text/css"/> <style type="text/css" media="print,screen"> @page{ size:legal; } table.renggang tr{ line-height: 0.3cm; } tr.renggang{ line-height: 0.3cm; } </style> </head> <body> <table width="93%"> <tr> <td width="27%">Pemerintah Desa/Kelurahan</td> <td width="1%">:</td> <td width="27%"></td> <td width="2%">Ket</td> <td width="1%">:</td> <td width="19%">Lembar 1 Warna Putih</td> <td width="1%">:</td> <td width="22%">UPTD/Instansi Pelaksana</td> </tr> <tr> <td>Provinsi</td> <td>:</td> <td></td> <td colspan="2"></td> <td>Lembar 2 Warna Merah</td> <td>:</td> <td>Untuk Yang Bersangkutan</td> </tr> <tr> <td>Kode Wilayah</td> <td>:</td> <td></td> <td colspan="2"></td> <td></td> <td></td> <td></td> </tr> </table> <table width="100%" class="tengah"> <tr> <td height="5"></td> </tr> <tr> <td class="font17"><b>SURAT KETERANGAN KELAHIRAN</b></td> </tr> <tr> <td class="font15"><b>(ANAK YANG TIDAK DIKETAHUI ASAL-USULNYA)</b></td> </tr> <tr> <td height="10"></td> </tr> </table> <table width="93%" class="font11 renggang" style="border:1px #000000 solid;"> <tr> <td colspan="4"><b>BAYI / ANAK</b></td> </tr> <tr> <td width="3%">1.</td> <td width="17%">Nama</td> <td width="1%">:</td> <td width="79%"></td> </tr> <tr> <td>2.</td> <td>Jenis Kelamin</td> <td>:</td> <td></td> </tr> <tr> <td>3.</td> <td>Tempat Kelahiran</td> <td>:</td> <td></td> </tr> <tr> <td>4.</td> <td>Hari dan Tanggal Lahir</td> <td>:</td> <td></td> </tr> <tr> <td>5.</td> <td>Pukul</td> <td>:</td> <td></td> </tr> <tr> <td>6.</td> <td>Berat Bayi</td> <td>:</td> <td></td> </tr> <tr> <td>7.</td> <td>Panjang Bayi</td> <td>:</td> <td></td> </tr> <tr> <td height="8" colspan="4"></td> </tr> </table> <table width="93%" class="font11 renggang" style="border:1px #000000 solid;"> <tr> <td colspan="11"><b>PELAPOR</b></td> </tr> <tr> <td width="3%">1.</td> <td width="17%">NIK</td> <td width="1%">:</td> <td colspan="8"></td> </tr> <tr> <td>2.</td> <td>Nama Lengkap</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>3.</td> <td>Umur</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>4.</td> <td>Jenis Kelamin</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>5.</td> <td>Pekerjaan</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>6.</td> <td>Alamat</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td></td> <td></td> <td></td> <td width="2%">a.</td> <td width="10%">Desa/Kelurahan</td> <td width="1%">:</td> <td width="27%"></td> <td width="1%">c.</td> <td width="10%">Kab/Kota</td> <td width="1%">:</td> <td width="27%"></td> </tr> <tr> <td></td> <td></td> <td></td> <td>b.</td> <td>Kecamatan</td> <td>:</td> <td></td> <td>d.</td> <td>Provinsi</td> <td>:</td> <td></td> </tr> <tr> <td height="8" colspan="11"></td> </tr> </table> <table width="93%" class="font11 renggang" style="border:1px #000000 solid;"> <tr> <td colspan="11"><b>SAKSI I </b></td> </tr> <tr> <td width="3%">1.</td> <td width="17%">NIK</td> <td width="1%">:</td> <td colspan="8"></td> </tr> <tr> <td>2.</td> <td>Nama Lengkap</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>3.</td> <td>Umur</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>4.</td> <td>Pekerjaan</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>5.</td> <td>Alamat</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td></td> <td></td> <td></td> <td width="2%">a.</td> <td width="10%">Desa/Kelurahan</td> <td width="1%">:</td> <td width="27%"></td> <td width="1%">c.</td> <td width="10%">Kab/Kota</td> <td width="1%">:</td> <td width="27%"></td> </tr> <tr> <td></td> <td></td> <td></td> <td>b.</td> <td>Kecamatan</td> <td>:</td> <td></td> <td>d.</td> <td>Provinsi</td> <td>:</td> <td></td> </tr> <tr> <td height="8" colspan="11"></td> </tr> </table> <table width="93%" class="font11 renggang" style="border:1px #000000 solid;"> <tr> <td colspan="11"><b>SAKSI II </b></td> </tr> <tr> <td width="3%">1.</td> <td width="17%">NIK</td> <td width="1%">:</td> <td colspan="8"></td> </tr> <tr> <td>2.</td> <td>Nama Lengkap</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>3.</td> <td>Umur</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>4.</td> <td>Pekerjaan</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td>5.</td> <td>Alamat</td> <td>:</td> <td colspan="8"></td> </tr> <tr> <td></td> <td></td> <td></td> <td width="2%">a.</td> <td width="10%">Desa/Kelurahan</td> <td width="1%">:</td> <td width="27%"></td> <td width="1%">c.</td> <td width="10%">Kab/Kota</td> <td width="1%">:</td> <td width="27%"></td> </tr> <tr> <td></td> <td></td> <td></td> <td>b.</td> <td>Kecamatan</td> <td>:</td> <td></td> <td>d.</td> <td>Provinsi</td> <td>:</td> <td></td> </tr> <tr> <td height="8" colspan="11"></td> </tr> </table> <table width="93%" class="tengah atas"> <tr> <td width="26%" height="30"></td> <td width="45%"></td> <td width="29%"></td> </tr> <tr> <td>Mengetahui :</td> <td></td> <td>KOTA BLITAR, 11 SEPTEMBER 2013</td> </tr> <tr> <td rowspan="2">Kepala Dinas Kependudukan dan Pencatatan Sipil Kab/Kota </td> <td></td> <td>Pelapor :</td> </tr> <tr> <td></td> </tr> <tr> <td height="60" colspan="3"></td> </tr> <tr> <td>( ...................... )</td> <td></td> <td>(nama pelapor)</td> </tr> </table> </body> </html>
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