Formulir Daftar Kematian Perinatal.doc

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KEMENTERIAN KESEHATAN FORMULIR DAFTAR KEMATIAN PERI-NEONATAL (DKP) Bulan: …………. Tahun............. Fasilitas Kesehatan:......................

No

Nama neonatus*

Umur (jam atau hari)

Nama ibu/bapak

Alamat

1 2 3 4 5 6 7 8 9 10

* Jika lahir hidup dan sudah diberi nama DKP April 2010

Lahir hidup /lahir mati

Dugaan Sebab kematian

Tanggal meninggal

Tempat meninggal

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