24. Format Visum Korban Mati (pl Dan Pd).docx

PEMERINTAH KABUPATEN LAMPUNG UTARA RUMAH SAKIT DAERAH MAYJEND. HM. RYACUDU KOTABUMI INSTALASI P.J / KEDOKTERAN FORENSIK DAN MEDIKOLEGAL Jl. Jenderal Sudirman No. 02 Telp. 0724-22095 KOTABUMI 34511

Kotabumi, _________________ Nomor Lampiran Ikhwal

: / / KFM/ / 2015 : : Pemeriksaan bedah mayat (autopsy) An. _______________________ VISUM ET REPERTUM

PRO JUSTITIA Permintaan----------------------------------------------------------------------------------------Tanggal permintaan;________________, No Polisi;_____________________, Perihal; Permintaan Visum et Repertum pemeriksaan bedah mayat (autopsy) An. ____________________________, Penyidik;___________________, Pangkat;___________________, NRP;_______________, Jabatan;________________________, Instansi;____________________________, Penjelasan;_________________________________________________, pada hari_________, tanggal;_______________, sekitar jam;_______ wib, dengan kondisi korban;_______________________________________________________ ____________________________________________________________________ _______________________________-----------------------------------------------------Pemeriksa:---------------------------------------------------------------------------------------Nama;_____________________________, NIP;______________________, Instalasi;____________________________ RSUD Mayjed. HM Ryacudu kotabumi, Tanggal pemeriksaan;__________________, Jam pemeriksaan;_______ wib, Korban diantar oleh;_______________, Jenis pemeriksaan; Pemeriksaan ____________________________-----------------------------------------------------------Identitas Korban: ---------------------------------------------------------------------------------Nama;________________________, Jenis kelamin;_____________________, Umur;______ tahun, Agama; ____________, Pekerjaan;_____________, Status perkawinan; _________________, Alamat; Jln. ___________________________________________________-------------------------PEMBERITAAN Benda-benda--------------------------------------------------------------------------------------1 Label mayat; ________________________--------------------------------------------2 Pembungkus mayat; ____________________________----------------------------3 Penutup mayat; _____________________________----------------------------------4 Pakaian mayat; _________________________________________________----5 Benda di tubuh mayat ;_______________________________---------------------6 Perhiasan mayat;________________________________----------------------------7 Benda di sekitar mayat; …………---------------------------------------------------------

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Tanda-tanda kematian-------------------------------------------------------------------------8 Lebam mayat; ______________________________--------------------------------9 Kaku mayat; _________________________________________-------------------10 Pembusukan:__________________________________-----------------------------Identifikasi---------------------------------------------------------------------------------------11 Identifikasi umum ; Dijumpai sesosok mayat dikenal, jenis kelamin _______________, umur ___________, warna kulit _______________, panjang badan _______________________, perawakan _______________, rambut sepanjang ______________, bentuk ____________, warna ______________----12 Identifikasi khusus;__________________________________----------------------Pemeriksaan luar--------------------------------------------------------------------------------13 Kepala;_____________________________________________-------------------14 Dahi;_________________________________________________-----------------15 Mata;_____________________________----------------------------------------------16 Hidung;_______________________________________----------------------------17 Pipi;________________________________-------------------------------------------18 Telinga;________________________________---------------------------------------19 Mulut;___________________________________------------------------------------20 Gigi;______________________________________________----------------------21 Rahang;________________________________---------------------------------------22 Leher;_______________________________________________------------------23 Dada;_______________________________________________________-------24 Perut;_____________________________________________________----------25 Alat kelamin;_________________________________-------------------------------26 Punggung;________________________________------------------------------------27 Pinggang;______________________________________----------------------------28 Bokong;_________________________________-------------------------------------29 Dubur;________________________________----------------------------------------30 Anggota gerak atas;_______________________--------------------------------------31 Anggota gerak bawah;__________________________-------------------------------Pemeriksaan dalam------------------------------------------------------------------------------32 Kepala;_____________________________________________-------------------33 Otak;_________________________________---------------------------------------34 Leher;_______________________________________________------------------35 Saluran nafas atas;_____________________________-----------------------------36 Saluran makan atas;________________________________----------------------37 Dada;_______________________________________________________-------38 Jantung;_________________________________------------------------------------39 Paru-paru;________________________________----------------------------------40 Perut;_____________________________________________________----------41 Lambung;___________________________________--------------------------------42 Hati;______________________________________---------------------------------43 Kantong empedu;______________________________------------------------------44 Limpa;_________________________________-------------------------------------45 Pangkreas;____________________________________-----------------------------46 Ginjal;__________________________________________-------------------------47 Kandung rahim;________________________---------------------------------------48 Kantong pelir;________________________________-------------------------------49 Kelenjar;__________________________________-----------------------------------2

KESIMPULAN Telah diperiksa sesosok mayat dikenal, jenis kelamin_________________, umur__________tahun, warna kulit_______________, panjang badan__________________________, perawakan________________, rambut sepanjang_______________, bentuk_____________, warna_________________---Dari hasil pemeriksan luar dijumpai tanda-tanda kekerasan berupa________________________, pada________________________________, akibat kekerasan_________________________________________. Penyebab kematian korban adalah________________________________________ oleh karena________________________________ akibat__________________----------Demikianlah visum et repertum ini dibuat dengan sejujur-jujurnya berdasarkan sumpah jabatan dan keilmuan menurut Kitab Undang-undang Hukum Acara Pidana (KUHAP) untuk dipergunakan bilamana perlu--------------------------------------------

Dokter yang memeriksa,

Dr. ……………………………… Nip. ………………………………

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