MD/SKI/ MD/SKI/17.07.03 Halaman 1 Dari 2 halaman
PUSAT PENDIDIKAN SHABARA POLRI RUMAH SAKIT BHAYANGKARA PORONG
Jalan Raya Porong no. 1 Sidoarjo 61274 Porong,
Nomor Lampiran P"rihal
Juli 2017
: MD/SKI/17.07.03 : 2 Dua! halaman : #i$um "% &"p"r%um Ha$il P"m"ri'$aan Luar J"na(ah J"na(ah a. n.
Sa)a )ang -"r%ana %angan i -aah ini r. li Mga S,K.,P.N, Do'%"r paa &umah Sa'i% ha)ang'ara Pu$i' Sa-hara m"n"rang'an -aha a%a$ p"rmin%aan %"r%uli$ ari Polr"$%a pa$uruan S"'%or "4i "ngan nomor poli$i / / /2017/Pol$"' /2017/Pol$"' p"rihal P"rmin%aan #i$um +% &"p"r%um Kor-an Kor-an K"5"la'aan Lalu Lin%a$ 6ang M"ninggal a%a$ nama &6N P&N8, ma'a paa %anggal $"m-ilan -"la$ -ulan Juli %ahun ua ri-u %u4uh -"la$, pu'ul "nam -"la$ l"-ih "mpa% puluh lima m"ni% 8a'%u Inon"$ia -agian ara%, -"r%"mpa% i in$%ala$i or"n$i' &umah Sa'i% ha)ang'ara Pu$i' Sa-hara, %"lah m"la'u'an p"m"ri'$aan luar )ang m"nuru% '"%"rangan '"%"rangan $ura% %"r$"-u% aalah $"-agai -"ri'u% -"ri'u% :99999999999999999999999999999999 : 9999999999999999999999999999999999 Nama : &)an Pranoo99999999999999999999999999999999999999999999999999999999999999999999999999999999999999 999999 999 *mur : 2 %ahun9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 %ahun9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 J"ni J"ni$$ K"lam K"lamin in : La'i La'i9L 9La' a'i9 i999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 99999 999999 999999 999999 999999 999999 999999 999999 999999 999 P"'" P"'"r4 r4aa aann : PL& PL&I9 I999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 9999 99 K"arg K"argan" an"gar garaan aan : Inon" Inon"$i $ia/J a/Jaa aa999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 999999 99999 lama% : Jln. aLi ;g II No < & 03 &8 03 D$ Karang "ngah K"5 Sanan8"%an. K LI&.
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ML/SK #I/17.0>.03 Halaman 2 Dari 2 halaman
. "na i $amping ma)a% :9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 Sa%u -uah po"r-an' "ngan 'a-"l u$- i $a'u 'anan -aah, $a%u -uah ro'o' m"r' Mal-oro i $a'u 'anan -aah, Sa%u -uah 'or"' api -"rarna -iru i $a'u 'anan -aah99999999999999999999999999999999999999999 >. L"-am ma)a% -"rarna '"hi%aman i%"mu'an paa punggung an %ia' hilang "ngan p"n"'anan. Ka'u ma)a% %ia' i%"mu'an 9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 7. Ma)a% -"r4"ni$ '"lamin la'i9la'i, ra$ Mongoloi, -"rumur ua puluh $a%u %ahun, pan4ang -aan $"ra%u$ %u4uh puluh $"n%im"%"r, 'uli% $ao ma%ang. 9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 <. I"n%i%a$ 'hu$u$: %ia' aa.999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 ?. &am-u% '"pala : hi%am, luru$, l"-a%, pan4ang "nam $"n%im"%"r. K"ua ali$ ma%a : arna hi%am , luru$,l"-a%. K"ua -ulu ma%a hi%am,luru$,l"-a% 9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 10.Ma%a 'anan: '"lopa' ma%a 'anan -"ng'a' , -"rarna '"-iruan, an %"r%u%up. S"lapu% ma%a pu5a% %"rapa% -"'uan arah. "l"ng ma%a "ngan iam"%"r nol 'oma lima $"n%im"%"r. 8arna %irai ma%a 5o'la%. S"lapu% -ola ma%a %"rapa% -"'uan arah i $uu% 'anan. S"lapu% '"lopa' ma%a pu5a%. 9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 Ma%a 'iri: '"lopa' ma%a 'iri %"r%u%up. S"lapu% ma%a pu5a% %"rapa% lu'a an -"r5a' arah. "l"ng ma%a "ngan iam"%"r nol 'oma lima $"n%im"%"r. 8arna %irai ma%a 5o'la%. S"lapu% -ola ma%a 4"rnih. S"lapu% '"lopa' ma%a pu5a% 9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 11.Hiung: $im"%ri$. "linga: $im"%ri$. Mulu%: %"r-u'a -"ru'uran $a%u $"%"ngah $"n%im"%"r liah %ia' %"r4ulur 9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 12.;igi9g"ligi:999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 &ahang 'anan a%a$ -"r4umlah %u4uh -uah.999999999999999999999999999999999999999999999999999999999999999999999999999 &ahang 'iri a%a$ -"r4umlah %u4uh -uah.99999999999999999999999999999999999999999999999999999999999999999999999999999999 &ahang 'anan -aah, -"r4umlah "lapan -uah.9999999999999999999999999999999999999999999999999999999999999999999 &ahang 'iri -aah, -"r4umlah "lapan -uah.999999999999999999999999999999999999999999999999999999999999999999999999 Jumlah gigi '"$"luruhan %iga puluh -uah. 9999999999999999999999999999999999999999999999999999999999999999999999999999 13.Dari lu-ang mulu% %ia' '"luar apa9apa, ari '"ua lu-ang hiung '"luar arah, ari lu-ang %"linga 'anan %ia' '"luar apa9apa, ari lu-ang %"linga 'iri %ia' '"luar apa9apa. Dari lu-ang '"maluan %ia' '"luar apa9apa. Dari lu-ang p"l"pa$an %ia' '"luar apa9apa. 9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 1=.Lu'a @ lu'a : a. Paa $"%"ngah $"n%im"%"r i-aah ali$ ma%a 'anan iapa%'an lu'a %"r-u'a )ang %"lah i4ahi% "ngan -"nang -"rarna hi%am -"r4umlah %iga 4ahi%an,%"pi %ia' ra%a u'uran %iga 'ali $a%u $"n%im"%"r. -. Paa '"lopa' ma%a -aah 'anan iapa%'an lu'a %"r-u'a )ang %"lah i4ahi% "ngan -"nang -"rarna hi%am -"r4umlah ua 4ahi%an, %"pi %ia' ra%a u'uran %iga 'ali $a%u $"n%im"%"r 5. Paa $uu% -i-ir 'anan iapa%'an lu'a %"r-u'a )ang %"lah i4ahi% "ngan -"nang -"rarna hi%am -"r4umlah $a%u 4ahi%an "ngan %"pi %ia' ra%a l"-ar ua 'ali $a%u $"n%im"%"r . Paa agu 'anan iapa%'an lu'a %"r-u'a )ang %"lah i4ahi% "ngan -"nang -"rarna hi%am -"r4umlah %iga 4ahi%an, %"pi %ia' ra%a l"-ar u'uran ua 'ali $a%u $"n%im"%"r ". Paa aun %"linga 'iri -agian "pan iapa%'an lu'a %"r-u'a )ang %"lah i4ahi% "ngan -"nang -"rarna hi%am -"r4umlah ua 4ahi%an "ngan %"pi %ia' ra%a l"-ar ua 'al $a%u $"n%im"%"r
MD/SKI/17.07.03 Halaman 1 Dari 2 halaman
.9 Paa p"r%"ngahan -ahu 'iri, i%"mu'an lu'a l"5"% -"rarna m"rah "ngan %"pi '"hi%aman, -"n%u' m"man4ang, %"pi %ia' -"ra%uran, "ngan a$ar 'uli%, u'uran %iga 'oma lima 'ali $a%u $"%"ngah $"n%im"%"r. g. Paa 4ari '" lima -agian -"la'ang, nol 'oma "lapan $"n%im"%"r ari -a%a$ 'u'u -agian a%a$, iapa%'an lu'a l"5"% -"rarna m"rah, -"n%u' m"man4ang %ia' -"ra%uran, a$ar 'uli%, "ngan u'uran ua 'ali nol 'oma "nam $"n%im"%"r h. Paa %angan 'iri -agian -"la'ang, iapa%'an %iga lu'a l"5"% -"rarna m"rah "ngan %"pi '"hi%aman, -"raa paa $a%u $"n%im"%"r ari -a%a$ a%a$ 4ari ua, %iga an "mpa%, -"r4ara' $a%u 'oma lima $"n%im"%"r $"%iap lu'a, a$ar 'uli%, ma$ing9ma$ing lu'a -"ru'uran $a%u 'ali nol 'oma %u4uh $"n%im"%"r i.9 Paa %angan $i$i -"la'ang, $a%u $"n%i m"%"r ari p"rg"langan %angan, iapa%'an lu'a l"5"% -"rarna m"rah "ngan %"pi '"5o'la%an, -"n%u' %ia' -"ra%uran, a$ar 'uli%, u'uran ua 'ali $a%u $"n%im"%"r 4.9 Paa %angan $i$i -"la'ang, %iga $"n%im"%"r ari p"rg"langan %angan, iapa%'an lu'a l"5"% -"rarna m"rah mua "ngan %"pi '"5o'la%an, -"n%u' %ia' -"ra%uran, a$ar 'uli%, u'uran ua 'ali %iga $"n%im"%"r '. Paa l"ngan -aah 'iri -agian -"la'ang, nol 'oma lima $"n%im"%"r ari $i$i luar, iapa%'an lu'a l"5"% -"rarna m"rah, -"n%u' m"man4ang %ia' -"ra%uran, a$ar o%o%, u'uran %iga 'ali $a%u $"n%im"%"r l. Paa l"ngan a%a$ 'iri i $i$i alam, %iga -"la$ $"n%im"%"r ari $i'u, iapa%'an lu'a l"5"% -"rarna m"rah '"hi%aman, -"n%u' %ia' -"ra%uran, a$ar 'uli%, u'uran ua 'alo $a%u $"n%im"%"r m. Paa %ung'ai -aah 'anan -agian "pan, ua -"la$ $"n%im"%"r ari lu%u%, iapa%'an lu'a l"5"% arna m"rah "ngan %"pi -"rarna m"rah '"hi%aman, -"n%u' m"man4ang, %ia' -"ra%uran, a$ar 'uli%, u'uran %u4uh 'ali $a%u $"n%im"%"r 1.Pa%ah %ulang: ia' aa.9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999 1>.Lain @ lain: ia' aa 9999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999999
Paa p"m"ri'$aan ma)a% $"orang la'i9la'i )ang -"ru$ia ua puluh lima %ahun paa p"m"ri'$aan luar i%"mu'an lu'am"mar paa'"pala'iri-agian"panan lu'a l"5"% paa l"ngan -aah 'anan $i$i -"la'ang a'i-a% '"'"ra$an %umpul. S"-a- '"ma%ian %ia' apa% i%"n%u'an 'ar"na %ia' ila'u'an p"m"ri'$aan -"ah 4"na(ah D"mi'ianlah %"lah 'ami urai'an "ngan $"4u4ur94u4urn)a an m"ngguna'an '"ilmuan )ang $"-ai'9 -ai'n)a, m"nginga% $umpah $"$uai "ngan Ki%a- *nang9*nang Hu'um 5ara Piana.999999999999999999999999
r. li Mga S,K.,P.N no. &"g S&. 3.1.1.100.1.12.13>>1>
