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				<td><strong style="font-size: 10pt;">F-2.30</strong></td>
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	<p style="margin-top: 40px; margin-bottom: 20px; text-align: left;">Pemerintah Kabupaten/Kota : [SeButan_kabupaten] [NaMa_kabupaten]</p>

	<div style="border: solid 2px black; border-style: solid; padding-left: 5px;">
	<p style="text-align: center; margin-top: 20px; margin-bottom: 20px;"><strong style="font-size: 10pt;">FORMULIR PELAPORAN KEMATIAN</strong></p>
	<p style="text-indent: 40px;">Yang bertanda tangan di bawah ini :</p>

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				<td class="left" style="height: 22.3906px;"><strong>Nama lengkap</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[NAma_pelapor]</td>
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				<td class="left" style="height: 22.3906px;"><strong>NIK</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[Nik_pelapoR]</td>
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				<td class=" left" style="height: 22.3906px;"><strong>Umur</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[Usia_pelapoR]</td>
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				<td class="left" style="height: 22.3906px;"><strong>Pekerjaan</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[Pekerjaan_pelapoR]</td>
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			<tr style="height: 22.3906px;">
				<td style="height: 22.3906px;"><strong>Alamat</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td style="height: 22.3906px;">[Alamat_pelapoR]</td>
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				<td><strong>Hubungan dengan yang mati</strong></td>
				<td>:</td>
				<td>[Form_hubungan_pelapor_dengan_yang_matI]</td>
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	<p style="text-indent: 40px;">Melaporkan Bahwa : </p>
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				<td style="height: 22.3906px;"><strong>Nama lengkap</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td style="height: 22.3906px;">[NamA]</td>
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			<tr style="height: 22.3906px;">
				<td class="left" style="height: 22.3906px;"><strong>NIK</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[NiK]</td>
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				<td style="height: 22.3906px;"><strong>Jenis Kelamin</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td style="height: 22.3906px;">[Jenis_kelamiN]</td>
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				<td class=" left" style="height: 22.3906px;"><strong>Tanggal Lahir/Umur</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[TtL]</td>
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				<td class="left" style="height: 22.3906px;"><strong>Anak ke</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[Anakke_kematiaN] Dari [Jumlah_saudara_kematiaN] Bersaudara</td>
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				<td style="height: 22.3906px;"><strong>Agama</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td style="height: 22.3906px;">[AgamA]</td>
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				<td style="height: 22.3906px;"><strong>Alamat</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td style="height: 22.3906px;">[AlamaT]</td>
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				<td style="height: 22.3906px;"><strong>Kewarganegaraan</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td style="height: 22.3906px;">[Warga_negarA]</td>
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	<p style="text-indent: 40px;">Telah meninggal dunia pada :</p>
	<table style="border-collapse: collapse; width: 100%; height: 111.953px;"><colgroup><col style="width: 30.6802%;"><col style="width: 3.76371%;"><col style="width: 65.5561%;"></colgroup>
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				<td class="left" style="height: 22.3906px;"><strong>Hari</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[Hari_kematiaN]</td>
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				<td class=" left" style="height: 22.3906px;"><strong>Tanggal kematian</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[Tanggal_kematiaN]</td>
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				<td class="left" style="height: 22.3906px;"><strong>Pukul</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td class="kotak padat tengah" style="height: 22.3906px;">[Jam_kematiaN]</td>
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				<td style="height: 22.3906px;"><strong>Bertempat di</strong></td>
				<td style="height: 22.3906px;">:</td>
				<td style="height: 22.3906px;">[Tempat_kematiaN]</td>
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				<td><strong>Penyebab kematian</strong></td>
				<td>:</td>
				<td>[Penyebab_kematiaN]</td>
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				<td><strong>Bukti kematian</strong></td>
				<td>:</td>
				<td>[Bukti_kematiaN]</td>
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	<br>
	<table style="border-collapse: collapse; width: 100%; height: 149.547px;"><colgroup><col style="width: 31.9826%;"><col style="width: 31.9826%;"><col style="width: 35.89%;"></colgroup>
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				<td class="kotak padat tengah" style="height: 22.3906px; text-align: center;">[Sebutan_desa] [NaMa_desa], [TgL_surat]</td>
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				<td class="kotak padat tengah" style="height: 22.3906px; text-align: center;">Pelapor</td>
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				<td class="left" style="height: 52.375px; text-align: center;"></td>
				<td style="height: 52.375px;"></td>
				<td class="kotak padat tengah" style="height: 52.375px; text-align: center;"></td>
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				<td style="height: 22.3906px;"></td>
				<td style="height: 22.3906px; text-align: center;">[NAma_pelapor]</td>
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