PDK3MI | Perhimpunan Dokter Kedokteran Komunitas dan Kesehatan Masyarakat Indonesia

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NOTARIS DI SURABAYA

I{YOMAI{

AYU

RENI

}'UIIAEI{Y

RATIH

S.H.

Berdasarkan Surat Keputusan Menteri _{Hukum dan Hak Asasi Manusia Republik}_lndonesia

Tanggal 16 Desember 2004. Nomor : C-407.HT.03.01_TH.2004

PEJABAT PEMBUAT

AKTA TANAH

WILAYAH

KOTA SURABAYA

II

Berdasarkan _{surat Keputusan}_Kepala_Badanpertanahan _Nasional_Rl

Nomor : 1 26-XVlt-ppAT-2007, Tanggat 04 Oktober 2007

Jo surat Keputusan Kepara Badan pertanahan Nasionar Rl

Nomor : 168/KEp-17.3/tVt2O12, _Tr,rggat_{24 Aprit}₂₀₁₂

Kantor : Jl. Pucang Adi No. 32 Surabaya

Telp. _{(031) 5012537}_{- 5012538}_Fax.₍₀₃₁₎_sO12598

AKTA TANGGAL :

a / )

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ilYOMAN .A.YU RE:JIYLIiiATIiY AATIH, S H.

I r 0 I A h l s S U I t A E A Y A

P E R U B A H A N

N o m o r : - 0 3

P a d a h a r i i n i , S e l a s d ,

f r n n n : 1 I ) ) - n l a n 1 / 1 \ - l ' . ^ ^ " 1 r r h r l r r = A n r i I L a l l 9 9 o a \ - L w ' l - Z - V L a I L r L l a _{P u r u I I} u u q n y r r r r l r r : r i h r r o m n : t v r L r v q e v v h o l : cL s e

f

j a m ( 1 3 . 0 0 W I B ) t . i g a b e l a s

W a k t u I n d o n e s i a B a g i a n B a r a t ,

m e n g h a d a p k e p a d a s a y a , N Y O M A N A Y U R E N I Y U N A E N Y

a A ' l ' T t l ( a r i r n a L l r i k r r m N I o i _ : r i q . l i S n r : k r a r z a

l . n t f l l f A a L _Jq l l q I I q r \ u r r l t r I v u q ! I r v s L s v s f q

I

d e n g a n d i h a d i r i o l e h s a k s i - s a k s i y a n g a k a n

d i s e b u t p a d a b a g i a n a k h i r a k t a i n i d a n y a n g

t e l a h d i k e n a l o l e h s a y a , n o t a r i s .

T u a n S U B U R P

T ^ - l - - - ^ | r * \ J \ r r r r t _{d r 1 9 ,} L a L l

s e r i b u s e m b i

t \ u 9 o r o r l l u v r l Q r r r : h : r r : i :

e q L q v s f s l

K e l u r a h a n K a

n A m a d i n n K a r

N . r . K . 3 5 1 8 2

m e n u r u t k e t e

b e r t i n d a k :

R A J I T N O B U D I I R A W A N , l a h i r d i

-g -g a l ( 0 9 - 1 0 - 1 9 5 6 ) s e m b i l a n O k t o b e r

I a n r a t u s l i m a p u l u h e n a m , W a r g a

^ - i r h a r J - a m ^ a ] . f i n n a r l . l ' i -U J f O , U g ! L s l t l P q u L r r r Y V a ! v I

l a n M r r l r z o s a r i M : r r : n R l n l r n C - 3 / 3 0 ;

I i s a r i - K e c a m a t a n M u l y o r e j o ,

t u T a n d a P e n d u d u k

6 0 9 L 0 5 6 0 0 0 2 ;

r a n o a n n v a d a l a m h a l i n i

a . u n t u k d i r i s e n d i r i ;

b e r d a s a r k a n s u r a t k u a s a d i b a w a h t a n g a n ,

b e r m e t e r a i c u k u p , t a n g g a L ( 2 1 - 0 4 - 2 0 7 4 )

J . , ^ - . . r , , 1 ^ - ^ + , r _{A n r i l r . l}_{r r a r i t ^}

-o u a p u I u r l s d L L - - r - - - - l J u e l t t P d L

-b e l a s , d i L e k a t k a n p a d a a s e l i s a h i h

a k t a i n i , m e w a k i l i u n t u k d a n a t a s n a m a :

T u a n P r o f e s o r D o k t e r M U H A M M A D A R I F ,

M a s t e r o f P u b l i c H e a l t h ,

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I i m a D e s e m b e r s e r i b u S e m b i l a n : =

p u l u h t i g a , W a r g a N e g a r a I n d o n e s

- - - tra

b e r t e m p a t t i n g g a l d i M a l a n g '

j a l a n C i b o g o n o m o r 2 ;

K e l u r a h a n P e n a n g g u n g a n

K e c a m a t a n K I o l e n ;

b e r d a s a r k a n s u r a t k u a s a d i b a w a h t a r : a

b e r m e t e r a i c u k u p , t a n g g a : _ ( 2 1 - 0 4 - 2 C ' - =

d u a p u l u h s a t u A P r i I d u a r i b u e m p a :

b e l a s , d i l e k a t k a n P a d a a s e l i s a r i n

T u a n D o k t e r R a d e n M a s M A R I A S . r ' ' ' ; S T E R

-H A R I P U R N O M O K U S H A D I W I J A Y A , i ' l a s : : : - l

P u b l i c H e a l t h , D o c t o r o f P u b l i c i 3 a - * ' n ,

l a h i r d i J a k a r t a , t a n q g a L ( 2 4 0 2 1 9 = '

-d u a p u l u h e m p a t P e b r u a r i s e r i b u s e m b i '

r a t u s l i m a P u l u h s a t u , W a r g a N e g a r a

I n d o n e s i a , b e r t e m p a t t i n g g a l d i B a n i - - ,

S o r o w a j a n B a r u G a n g S i n d o r o n o r : - : ' i

K e l u r a h a n B a n g u n t a P a n

K e c a m a t a n B a n g u n t a p a n ;

d u a p u l u h d e l a P a n A g u s t u s d u a r i b u

t i g a b e l a s , d i l e k a t k a n p a d a a s e l i s a h i h

T u a n D o k t e r S I S W A N T O A G U S W I L O P O ,

M a s t e r o f S c i e n c e , S c D , l a h i r d i B o y o l a l r ,

t a n g g a l ( 1 5 - 0 3 - 1 9 5 3 ) l i m a b e l a s M a r e t

s e r i b u s e m b i l a n r a t u s l i m a p u l u h t i g a ,

t ^ l ( ,

l d

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-iIYt)MAN AYU FTIJI YUIJAEHY BATIH, S.H.

i l U l A h i S S i ; B H i r A y A

d i B a n t u l , p e r u m T a m b a k M a s n o m o r B 3 / D K fI,

D e s a N g e s t i h a r j o - K e c a m a t a n Kasihan,

p e m e g a n g K a r t u T a n d a p e n d u d u k

N . r . K 3 4 0 2 1 6 . 1 5 0 3 5 3 . 0 0 0 2 ;

b e r m e t e r a i c u k u p , t a n g g a l ( Z B - 0 8 - 2 0 1 3 )

d u a p u l u h d e l a p a n Agustus dua ribu

t i g a b e l _ a s , d i l e k a t k a n _{p a d a a s e l i} _{s a h i h}

a k t a i - n i , m e w a k i l i _{u n t u k d a n a t a s n a m a :}

Tuan Dokter _{BAMBANG GfATNO RAHARDJO,}

M a s t e r o f P u b l l c H e a l t h , l a h i r d i

-S l d o a r j o , _{t a n g g a l ( 0 1 - 0 5 - 1 9 5 2 ) s a t u M e l}

s e r i b u s e m b i l a n r a t u s l i m a p u l u h d u a ,

W a r g a N e g a r a I n d o n e s i a , b e r t e m p a t tinggal ___ d i S u r a b a y a , j a l a n G a y u n g s a r i B a r a t

n o m o r I V - B / A ,

-K e l u r a h a n P a g e s a n g a n - -Kecamatan Jambangan;

p e m e g a n g K a r t u T a n d a p e n d u d u k

N . r . K . 3 5 7 8 2 6 0 1 0 5 5 2 0 0 0 1 ;

b e r d a s a r k a n s u r a t _{k u a s a d i b a w a h t a n g a n ,}

b e r m e t e r a i _{c u k u p , t a n g g a l} ( Z B - 0 8 - 2 0 1 3 )

d u a p u l u h d e l a p a n A g u s t u s d u a r i b u

a k t a i n i , m e w a k i l i _{u n t u k d a n a t a s n a m a :}

N y o n y a D o k t e r H A R I p E N I J U L I A N T f ,

M a g i s t e r K e s e h a t a n , S p e s i a l i s K e d o k t e r a n

t r i s i k d a n R e h a b i l i t a s i , l a h i r d i p u r w o r e j o ,

t a n g g a l ( 0 4 - 0 1 - f 9 1 0 ) _{e m p a t J u l i} _{s e r i b u}

s e m b i l a n r a t u s t _ u j u h p u l u h , W a r g a N e g a r a

f n d o n e s i a , b e r t e m p a t t i n g g a l d i S e m a r a n g ,

l o I

l +

t ! I

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l q

I t r

K e l - u r a h a n P e t o m p o n

l / ^ ^ ^ 6 r f - n a - - i i h M r r n n l z t t r ._{r r u r r Y r ! q !} t

n e m e c r a n c r K a r t r r T a n d a P e n d u d u k

N . r . K . 3 3 . 7 4 0 9 . 4 4 0 1 1 0 . 0 0 0 2 ;

b e r m e t e r a j - c u k u p , t a n g g a L ( 2 8 - 0 8 - 2 0 7 3 )

d r r a n r r l r i h c i e l a n a n A o t t s t t t s c l . u a r i b u

v u u y u t s r a

i i r l a L J 9 o v E r q J h c l e s _ I ( . l U I I E r \ ! c l . i r ^ r . - + r . - ^ L N d . l l ^ ^ . : - y a u a a S e I i S a h i h

T u a n E D I S O N , l a h i r d i B a t u s a n g k a r ,

t a n g g a l ( 2 0 - I I - 7 9 4 9 ) d u a p u l u h N o v e m b e r

s e r i b u s e m b i l a n r a t u s e m p a t p u l u h

^ ^ - l - - : I - - - t ^ I - r ^ - t r ] a a r r r T h ^ ^ h ^ - i

-5 e l t u J I - L c 1 1 I r V V c t _{I 9 c l} I \ 9 9 d r d - L ll \ . 1 \ J l l s J r o /

h a r l . a m n : t i i n r r r r r I r l i P : r l : n r r

v u ! L u l l r l / q u u r r r Y Y q L q v u r r : r t

J a f a n B e l a n t i R a y a n o m o r I 0 4 ,

K e l u r a h a n L o l o n g B e l a n t i

K e c a m a t a n P a d a n g U t a r a , '

n e m e o a n c r K a r f r r T a n d a P e n d u d u k

N . r . K . 1 3 7 r0 4 2 0 1 1 4

9 0 0 0 3 ;

b e r d a s a r k a n s u r a t k u a s a d i b a w a h l a n g a n ,

b e r m e t e r a i c u k u p , t a n g g a l ( 2 8 - 0 8 - 2 0 1 3 )

T u a n D o k t o r R M S U R Y A D I T J E K Y A N , l a h i r d i

-P a l e m b a n g , t a n g g a l ( 1 7 - 0 6 - \ 9 4 9 ) t u ; u h

b e l a s J u n i s e r i b u s e m b i l a n r a t u s e m p a t

n r r I r r h e o m l ^ r i I e n [ d : r r r : N e o : r a T n r l o n e s i a .

I r u l u r t J L r L l v r f u r r /

b e r t e m p a t t i n g g a l d i P a l e m b a n g ,

J a f a n D R M i s a L R G T i m u r n o m o r 9 8

K e l u r a h a n D u k u - K e c a m a t a n I l i r

f C ,

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-ilY0MAN AYU FEl.jl YUltAEtiY RATIH,S,H. t $ 0 1 A f i l S li r , R n i t A Y A

f r l r .

l j .

p e m e g a n q K a r t u T a n d a P e n d u d u k

N . r . K . 7 6 1 1 0 6 1 1 0 6 4 9 0 0 0 2 ;

a k t a i n i , m e w a k i l i u n t u k d a n a c a s n a m a :

T u a n D o k t e r A D I K H U N T O R O , l a h i r d i

-S e m a r a n g , t a n g q a l ( 1 0 - 0 8 - 1 9 5 9 ) s e p u l u h

A g u s t u s s e r i b u s e m b l l a n r a t u s l i m a p u l u h

s e m b i l a n , W a r g a N e g a r a I n d o n e s i a ,

b e r t e m p a t t i n g g a l d i S e m a r a n g ,

J a l a n A n g g r e k X I n o m o r l ;

K e l u r a h a n P e k u n d e n

K e c a m a t a n S e m a r a n g T e n g a h ,

-p e m e g a n g K a r t u T a n d a P e n d u d u

N . r . K . 3 3 . 1 4 0 6 . I 0 0 8 5 9 . 0 0 0 4 ;

b e r d a s a r k a n s u r a t k u a s a d i b a w a h t a n q a n ,

T u a n D o k t e r B U D T P A L A R T O , S p e s i a l i s

-O b s t e t r i G i n e k o l o g i , l a h i r d i S e m a r a n g ,

t a n g g a l ( 2 2 - 7 1 - 1 9 5 3 ) _{d u a p u l u h d u a}

N o p e m b e r s e r i b u s e m b i l a n r a t u s l i m a

p u l u h t r g a , W a r g a N e g a r a I n d o n e s i a ,

b e r t e m p a t t i n g q a l d i S e m a r a n g ,

J a l a n K l e n t e n g s a r i I A n o m o r 0 9 ;

T 1 ^ 1 , , - - t - - ^ n ^ . - J - l r . s l u r o - i o i t r - J a _ L o l l g d l t

(7)

L

l K .

1 1 .

1 5 3 0 0 0 4 ;

b e r m e t e r a i c u k u p

r ' l r r : n r r ' l r r h r l a l ;_{- - r 3 p a}

j - i r - r : l - r o l : s - v v l s u t c J i - I ev

-^ 1 - ! -^ . : - - : - ^ , , a k i

d J < ! L d L I I L t l t t g W C

T u a n D o k t e r D J O H

t k u a s a d i b a w a h t a n g a n ,

, t a n g g a l ( 2 8 - 0 8 - 2 0 7 3 )

AR NUSWANTORO,

l a h i r d i S u r a b a y a , t a n g g a l ( 2 6 - 0 2 - 1 9 5 5 )

d u a p u l u h e n a m F e b r u a r i s e r i b u s e m b i l a n

n e m e r - r a n c r K a r t t r T

N . r . K . 3 3 - 1 4 0 6 2 2 L

b e r d a s a r k a n s u r a

- - + , . ^ ' l . : * ^ ^ , , ] _ U h I d L L I J r r r L t o _{l / u f}

T - - l ^ ^ ^ ^ . : ^ l , - ^ - f ^ _ L l t L l ( J l l E D r d ' r U E ! L s

J a l - a n S e m o l o w a r u

K e l u r a h a n S e m o l o

p e m e g a n g K a r t . u T

N . r . K . 3 5 7 8 0 9 2 6 0

. - J , , - * , . 1 , , 1 - , J ^ l

-o u a p u r u n u e r d p a

! r - ^ L ^ ' r ^ ^ J r _ I e L _ L 9 d J J C T C I J r U l

a k t a i n i , m e w a k i

d i K e d i r i , t a n q g

M e i s e r i b u s e m b i

t i g a , W a r g a N e g a

t i n g g a l d i S u r a b

S i d o r e s m o 6 / 3 0 ;

a n d a P e n d u d u k

n A g u s t u s d u a r l b u

r - - ! r - ^ - * - r ^ ^ s e I i _{s a h i h} J L d L J < ! d . 1 1 P d U d c l i

t i u n t u k d a n a t a s n a m a :

I i m r f a J = r n = \ J o r r : r a I J l t t o ' I v v a L Y a ! r v y q ! u

m n r 1 _ t i n r r n : I r l i Q r r r : h a r z :

r l t y q u u r r r Y Y u r u v L q p v l s l

a n d a P e n d u d u k

n A o r r s f r r s c l r r , a r i b u

k : f k a n n a c l a a s e l i s a h i h

-l i u n t u k d a n a t a s n a m a :

a I ( 0 7 - 0 5 - 1 9 5 3 ) t u j u h

f a n r a t u s l i m a p u l u h

r a T n d o n e s i a , b e r t e m p a t

-d y -d , J a l a n J a g i r

E l o k B l - o k G / 2 4 ;

w a r u K e c a m a t a n S u k o l i l o ;

-2 5 5 0 0 0 1 ;

N v o n v a D o k t e r F L O R E N T I N A S U S T I N I , l a h i r

l m

K e l u r a h a n J a g i r K e c a m a t a n W o n o k r o m o , '

n a m A / - r : n . r K a r f r r T a n C i a P e n d u c r u k v u r r r v

N . r . K . 3 5 7 8 0 4 4 7 0 5 s 3 0 0 0 2 ;

b e r d a s a r k a n s u r a t k u a s a l . . i f - - , , - ] - + - ^ ^ - r

(8)

IIY(IMAN AYU BEI';I_YUi$AEIiY_RATIH,_S.H.

f r 0 I A l i / sS U I T A E A Y A b e r m e t e r a i c u k u p , t a n g g a l ( Z B - 0 8 - 2 0 7 3 )

t i g a b e L a s , d i l e k a t k a n p a d a a s e l i s a h i h

a k t a i n i , m e w a k i l l u n t u k d a n a t a s n a m a :

t \ l \ / ^ n \ 7 i t t ^ v T a r u

-r \ J v l -r y q u v ^ L E ! t l q J _{J c r l t} v v I l J f 1 - L J -

-F A T M A N T N I C R I I M - r r r r r r U ! \ v ! ' 1 , M : n i L J s ) j r J U 9 r q j _ o r K o q a h = F : nr \ U J V I t O L G I I ,

l - a h i r d i P o n o r o g o , t a n g g a f ( 0 8 - 0 1 - 1 9 6 6 )

d e l a p a n J a n u a r i s e r i b u s e r i b u s e m b i l a n

f a t t t q F n a m 6 1 1 1 r r h 6 h : m I i l : r n p N ] o r 1 : r : ! q L u o s r l q r L L y u r u r r g t t o l t t , v v a l g q r ! u y a ! q

T n c l o n e s i : - h e r f e m n ^ J - f i n r - r r r : l r ] i r v f Q r r r : l - r : r r :a v L q v a y a ,

J a l a n D u k u h S e t r o 3 / L ;

K e l u r a h a n G a d i n q

K e c a m a t a n T a m b a k S a r i ;

p e m e g a n g K a r t u T a n d a P e n d u d u k

N . T . K . 3 5 7 8 1 0 4 8 0 1 6 6 0 0 0 2 ;

-b e r d a s a r k a n s u r a t k u a s a d i -b a w a h t a n q a n t

l n

I

l - ' ^ - - ^ + ^ - - . 1

v g ! l L t g L E ! o t

r l r r : n r r l r r h r l | . i ^ - 1 ^ ^ l - ^

L 1 9 A J . . C r C l J / - l - + - - , ' ^ . ;

o N L d I 1 1 I / . l L l

N y o n y a N A N I

c , , - - l ^ - . , - +

J q L A p A Y A _t L

A n r i I q a r i l - r

r a l r t G , v \ a L v o

f i ^ ^ ^ - l . J . ; u r 1 r 9 9 o t u r

n o m o r 1 0 3 ;

c u k u p , t a n g g a l ( Z B - 0 8 - 2 0 7 3 )

e l a n a n A o r r s f r r g d u a r i b u

d i l e k a t k a n p a d a a s e l i s a h i h

e w a k i l i u n t u k d a n a t a s n a m a :

K S E T I J O W A T I , l a h i r d i

-a n g g -a l ( 7 2 - 0 4 - L 9 6 5 ) d u a b e l a s

u s e m b i f a n r a t u s e n a m p u l u h

N e o a r a T n c l o n c s i a - h e - f e m n a L

M a l a n g , J a l a n K a l i u r a n g B a r a t

K e l u r a h a n S a m a a n K e c a m a t a n K l o j e n ;

n a m o n : n - K a r r , t _{T a n d a} _{P e n d U d U k}

N . r . K . 3 5 7 3 4 2 5 2 0 4 6 5 0 0 0 5 ;

b e r d a s a r k a n s u r a t k u a s a d i b a w a h t a n g a n /

b e r m e t e r a i c u k u p , t a n g g a l ( 2 8 - 0 8 - 2 0 f 3 )

l o .

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t ^ t v

I t d

l Y

t i g a b e 1 a s , d i l e k a t k a n p a d a a s e l i s a h i - h

N y o n y a D o k t e r P U D J I L E S T A R I , l a h i r d i

-S u r a b a y a , t a n g q a l ( 2 9 - 0 1 - 1 9 7 0 ) d u a p u l u h

s e m b i l a n J a n u a r i s e r i b u s e m b i l a n r a L u s

. t _

" r r r h n r r l r r h I n l : r c : N J o r r a r : T n r l n n e s i a -L -L . l J ( - l I I y -L r I U l r r v t q r V q r \ v Y q r s ! r r v v a r v v ! s ,

b e r t e m p a t t i n g g a f d i S u r a b a Y a ,

J a l a n K e r t a j a y a 5 R a Y a n o 3 0 ;

K e l u r a h a n K e r t a j a y a K e c a m a t a n G u b e n g ;

n o m o . r A n c r K a r f r t T a n d a P e n d u d u k

N . r . K . 3 5 7 8 0 8 6 9 0 L 7 0 0 0 0 2 ;

b e r m e t e r a i c u k u p , t a n g g a J - ( 2 8 - 0 8 - 2 0 1 3 )

t i g a b e I a s , d i l e k a t k a n p a d a a s e l i s a h i h

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-S u r a b a y a , t a n g g a L ( 2 1 - 1 2 - 7 9 6 1 ) d u a p u J - u h

t u j u h D e s e m b e r s e r i b u s e m b i l a n r a t u s

e n a m p u l u h t u j u h , W a r g a N e g a r a I n d o n e s i a ,

b e r t e m p a t t i n g g a f d i S u r a b a Y a ,

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t i g a b e l a s , d i l e k a t k a n _{P a d a a s e l i}

a k t a i n i , m e w a k i l i u n t u k d a n a t a s

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TYOMAN AYU FETlI YUTSAENY FAT]H, S,H.

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v s l u v q l u r t \ 4 / v u q _{l r u r u l l}

d e l a p a n P e b r u a r i s e r i b u s e m b i l a n r a t u s

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-h o r l _ A m n ^ f j _ in n r r a l d i _{a v L s v s l u l}Q r r r : h : r r :

J a l a n C a r i k a n l V / 4 ;

n o m A ^ r n n K a r r l - t _{T a n d a} _{P e n d U d U k}

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r l r r : r r r r l r r h r l a l ;_{- - * l p a n}

f i o a h e l a s - c l i l e k a

k u a s a d i b a w a h t a n g a n ,

t a n g g a f ( 2 8 - 0 8 - 2 0 7 3 )

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+ 1 . - ^ ^ - J - - ^ ^ r _ i _{s a h i h} L N O . 1 r _{P a . \ - r o .} d J g r

i u n t u k d a n a t a s n a m a

r A N D I A R M Y N N U R D I N ,

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d r r : n t l ' t l - r j o l ; ^ - ^ n ^ " - - " - r U a f i b U

u u o _{I J J f} u i - u L , o P O r r n 9 u J L u D u

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l - r a r l _ a m n 2 t l _ i n n n : l r l i Q r r r : h :- * - - - - y a , J a l a n L e b a k R e i o n o m o r 5 9 ;

K e i u r a h a n G a c i i n g

K e c a m a t a n T a m b a k S a r i ;

n c m e . r e n d K a r f r t T a n d a P e n d u d u k

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b e r m e t e r a i c u k u p , t a n g g a : - . ( 2 8 - 0 8 - 2 0 1 3 )

d r r : n r r l r r h c j e ' l e * - - ^ ^ - " ^ r " ^ - i u a r i b u u u o _{I J u r} u r r u e r d P c l I I f 1 9 L t D L L r J \ J

+ . r - ^ 1 - - ^ r - ^ ^ - : ' r ^ r . - r r . - - * - r ^ _{a S e l i} _{S a h i h}

L I 9 c t I J e j a d > l U r I s r ! d . L N a r l _{P o u o}

a k f a ' i n i - m e w a k i l i L z t L f u n t u k d a n a t a s n a m a :

-N y o n y a D o k t e r W I E -N T A D I A R S V I T R I , M a s t e r

o f S c i e n c e , D o c t o r o f P h i l o s o p h y , I a h i r

-. { i v I M a l e n n l r u r q l l Y J - : n r r r r : l / 1 n - O ' 1 - 1 q 6 g ) \ f v L J v J I q o n r r ' l t t h

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q a m h i l : n [ n J a r r ' . l r l a n : r : T n r ' { n ^ r . , - - J d r \ c 9 d r d - L l I r J ( J t I E ) r o 7

h a r f a m n : i _ t i n r r c r a I r l i S i d o e r a Y - - - , * - - - ] o ,

J a l - a n R a y a S e k a r d a n g a n I n d a h n o m o r B ;

D e s a S e k a r d a n g a n K e c a m a t a n S i d o a r j o ;

n o m e . r a n c r K a r f r t T a n d a P e n d u d u k

N . r . K . 3 5 1 5 0 8 5 0 0 7 6 9 0 0 7 4 ;

b e r d a s a r k a n s u r a t k u a s a d l b a w a h t a n g a n ,

b e r m e t e r a i c u k u p , t a n g q a L ( 2 8 - 0 8 - 2 0 L 3 )

t i g a b e l a s , d i l e k a t k a n p a d a a s e l i

a k t a i n i , m e w a k i l i u n t u k d a n a t a s

N y o n y a D o k t e r N Y I L O P U R N A M I , l a h i r

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(12)

IIYI)MAN AYU NEIJIYUICAENY RATIH, $,I{.

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P L ] r L r l l E 1 r L I J O . L U L

e n a m p u l u h e m p a t , W a r g a N e g a r a I n d o n e s i a ,

k r a r J - a m n a 1 - | i n r r n : I r l i Q r t r a h : " - T ^ I ^ * v v ! u e r r r } J o L L r r r 9 9 a r u r J u ! a v o y d t \ J d . f d l l

-P a n d u g o 2 B I o k -P / 6 ;

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K e c a m a t a n R u n g k u t r

n A m A d : n n K a r | ' ' f _{T a n d a} _{P e n d U d U k}

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0 1 6 4 0 0 0 1 ;

l v . b e r d a s a r k a n s u r a t k u a s a d i b a w a h t a n g a n ,

b e r m e t e r a i c u k u p , t a n g g a L ( 2 8 - 0 8 - 2 0 L 3 )

r ^ l r r : n r r ' l r r h d e l a n a n A o r r s t r r s c l u a r i b u

v u q I r u r u l ]

r . . : - - _{L _ L 9 d} 1 ^ ^ r ^ ^ _{l J U r d} ^ . : r ^ r - ^ ! r - - " . . ^ ^ r - _{a S e l i} _{S a h i h}

> I U r r E J \ d L r . . c l r l _{P a \ . r d}

a k t a i n i , m e w a k i - l i u n t u k d a n a t a s n a m a :

T u a n D o k t e r I V A N R A H M A T U L L A H , M a s t e r o f

P u b l i c H e a l t h _{, l a h i r} d i J e m b e r , t a n g g a l

1 1 ? _ n q _ 1 a Q ' t \ + - . . i - ^ L ^ 1 ^ ^ n ' ^ . _{s e r i b u}

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s e m b i l a n r a t u s d e l a p a n p u l u h s a t u ,

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, l i S r r r a h a r z a - , T a la n K e r f a i a v a 1 7 - B / 6 ;

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L u s e m p a t p u l u h t u j u h , W a r g a N e g a r a

d o n e s i a , b e r t e m p a u L i n g g a l d i J a k a r t a

l : f a n - K o m n l e k P o n d o k L a b u I n d a h n o m o r 5 E ;

l u r a h a n P o n d o k L a b u K e c a m a t a n C i l a n d a k ,

(13)

N . r . K . 3 r 1 4 0 6 4 6 0 5 4 7 0 0 0 3 ;

s e m e n t a r a i n i s e d a n g b e r a d a d i S u r a b a y a ;

l : . T u a n D o k t e r H A R U N A L R A S Y I D , M a s t e r o f

P u b I i c H e a l t h , l a h i r d i M a l a n g , t a n g g a l

-( 1 6 - 0 8 - 1 9 7 8 ) e n a m b e l a s A g u s t u s s e r i b u

s e m b i l a n r a t u s t u j u h p u l u h d e l a p a n ,

W a r g a N e g a r a f n d o n e s i a , b e r t e m p a t t i n g g a l

d i M a l a n g , i a l a n W a t u m u j u r I / 2 5 ,

K e l u r a h a n K e t a w a n g g e d e K e c a m a t a n L o w o k w a r u ;

n a m o n e n c r K a r l r r T a n d a P e n d u d u k

N . r . K . 3 5 7 3 0 5 1 6 0 8 7 8 0 0 0 2 ;

I A _{N y o n y a D o k t e r G R A C E D E B B I E K A N D O U '}

l a h i r d i U j u n g P a n d a n g , t a n g g a l ( 2 6 - 0 9 - 1 9 6 1 )

d u a p u l u h e n a m S e p t e m b e r s e r i b u S e m b i l a n

r a t u s e n a m p u l u h t u j u h , W a r g a N e g a r a

I n d o n e s i a , b e r t e m p a t t i n g g a l d i J a k a r t a

P u s a t , J a l a n K R J a Y a B a r u H - 2 / 4 2 3 ,

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N . r . K . 3 r 1 7 0 8 6 6 0 9 5 7 0 0 0 1 ;

| 5 . T u a n M O H A M M A D Z U L K A R N A I N , l a h i r d i

-P a l e m b a n g , t a n g g a l ( 0 3 - 0 9 - I 9 6 7 ) t i g a ( o n f e m b e r s e r i - b u s e m b i l a n r a t u s e n a m

J U t / L U r L L v u

p u l u h s a t u , W a r g a N e g a r a I n d o n e s i a ,

b e r t e m p a t t i n g g a l d i P a l e m b a n g , K o m p l e k

P H D M X I T n o m o r I 2 4 A ;

K e l u r a h a n K a l i d o n i - K e c a m a t a n K a l i d o n i ,

D e m e o a n q K a r t u T a n d a P e n d u d u k

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s e m b i f a n r a t u s e n a m p u l u h e n a m , W a r g a

N o r r : r a T n d n n a q i - e h o r l _ a m n r l . 1 _ i n n n = l r l i , v v ! u g t r l y q L u r l l Y g e I u I

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U O l L I L ' - L f

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K e c a m a t a n T e l a n a i p u r a ;

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N . r . K . 1 5 7 1 0 1 1 4 0 5 6 5 0 0 0 1 ;

s e m e n t a r a i n i s e d a n g b e r a d a d i S u r a b a y a

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n c r - , l e I : n R r i r r i o n F . l h : q : n " Y '

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s e m e n L a r a i n i s e d a n g b e r a d a d i S u r a b a y a ,

-I S . T u a n K U S B A R Y A N T O , l a h i r d i S l e m a n , t a n g g a l

-( 0 7 - 0 8 - 1 9 5 5 ) t u j u h A g u s t u s s e r i b u s e m b i f a n

r d t u s e n a m p u L u h I i m a , W a r g a N e g a r a f n d o n e s i a ,

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s e m e n t a r a i n i s e d a n g b e r a d a d i S u r a b a y a , '

T u a n I K O M A N G G E R U D U G , l a h i r d i M a t a r a m ,

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G r i v a S h a n f a H / 2 4 0 ;

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n o m o c r A n c r K a r t i r T a n d a P e n d u d u k

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d i S u r a b a y a , t a n g g a f ( 0 3 - 1 0 - 7 9 1 I ) t i g a

a r a I n d o n e s i a ,

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d i S u r a b a y a , J a l a n M u l y o s a r i M a p a n D C - I I ,

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