Olensia Arni Binti.pdf

Name :

OLENSIA ARNI BINTI

Date Of Birth : : 04 Apr 1965 Sex:

: FEMALE

Nationality :

: INDONESIA

Vaccine of prophylaxis Meningitis Meningococcus ACYW135

Date :

Signature and professional status of supervising clinician .................................................. Manufacture and batch no of vaccine Certificate valid

OLENSIA ARNI BINTI

From :

KAB. SAWAH LUNTO SIJUNJUNG

Until : Official stamp of the

300064280

administering center