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Nama Bayi : Nama Bayi : Nama Bayi :

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Jam Lahir : Jam Lahir : Jam Lahir :

Jenis Kelamin : Jenis Kelamin : Jenis Kelamin :

No. RM : No. RM : No. RM :

BBL : BBL : BBL :

Nama Bayi : Nama Bayi : Nama Bayi :

Tanggal Lahir : Tanggal Lahir : Tanggal Lahir :

Jam Lahir : Jam Lahir : Jam Lahir :

Jenis Kelamin : Jenis Kelamin : Jenis Kelamin :

No. RM : No. RM : No. RM :

BBL : BBL : BBL :

Nama Bayi : Nama Bayi : Nama Bayi :

Tanggal Lahir : Tanggal Lahir : Tanggal Lahir :

Jam Lahir : Jam Lahir : Jam Lahir :

Jenis Kelamin : Jenis Kelamin : Jenis Kelamin :

No. RM : No. RM : No. RM :

BBL : BBL : BBL :

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