<h4 style="margin: 0; text-align: center;"><span style="text-decoration: underline;">[JUdul_surat]</span></h4>
<p style="margin: 0; text-align: center;">Nomor : [Format_nomor_suraT]<br><br></p>
<p style="text-align: justify; text-indent: 30px;">Yang bertanda tangan di bawah ini [JaBatan] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten], Provinsi [NaMa_provinsi] menerangkan dengan sebenarnya bahwa :</p>
<table style="border-collapse: collapse; width: 100%; height: 118px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left;">1.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">Nama</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;"><strong>[NAma]</strong></td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; text-align: left; height: 18px;">2.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">NIK / No. KTP</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 18px;">[Nik]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left;">3.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">Jenis Kelamin</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[Jenis_kelamin]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left;">4.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[TtL]</td>
</tr>
<tr style="height: 10px;">
<td style="width: 4.31655%; text-align: center; height: 10px;"> </td>
<td style="width: 3.90545%; text-align: left; height: 10px;">5.</td>
<td style="width: 30.5242%; text-align: left; height: 10px;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 10px;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 10px;">[Pekerjaan]</td>
</tr>
<tr style="height: 36px;">
<td style="width: 4.31655%; text-align: center; height: 36px;"> </td>
<td style="width: 3.90545%; height: 36px; text-align: left;">6.<br><br></td>
<td style="width: 30.5242%; text-align: left; height: 36px;">Alamat / Tempat Tinggal<br><br></td>
<td style="width: 1.2333%; text-align: center; height: 36px;">:<br><br></td>
<td style="width: 60.0206%; height: 36px; text-align: justify;">[AlamaT] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Telah meninggal dunia pada:</p>
<table style="border-collapse: collapse; width: 100%; height: 63px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 22px;">
<td style="width: 4.3222%; text-align: center; height: 22px;"> </td>
<td style="width: 3.92927%; height: 22px; text-align: left;">7.</td>
<td style="width: 30.5174%; text-align: left; height: 22px;">Hari / Tanggal / Jam</td>
<td style="width: 1.24427%; text-align: center; height: 22px;">:</td>
<td style="width: 60.0524%; height: 22px; text-align: justify;">[Hari_kematiaN], [Tanggal_kematiaN], [Jam_kematiaN]</td>
</tr>
<tr style="height: 19px;">
<td style="width: 4.3222%; text-align: center; height: 19px;"> </td>
<td style="width: 3.92927%; text-align: left; height: 19px;">8.</td>
<td style="width: 30.5174%; text-align: left; height: 19px;">Bertempat di</td>
<td style="width: 1.24427%; text-align: center; height: 19px;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 19px;">[Tempat_kematiaN]</td>
</tr>
<tr style="height: 22px;">
<td style="width: 4.3222%; text-align: center; height: 22px;"> </td>
<td style="width: 3.92927%; height: 22px; text-align: left;">9.</td>
<td style="width: 30.5174%; text-align: left; height: 22px;">Penyebab Kematian</td>
<td style="width: 1.24427%; text-align: center; height: 22px;">:</td>
<td style="width: 60.0524%; height: 22px; text-align: justify;">[Penyebab_kematiaN]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Surat keterangan ini dibuat berdasarkan keterangan pelapor:</p>
<table style="border-collapse: collapse; width: 100%; height: 109.688px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18.6719px;">
<td style="width: 4.31655%; text-align: center; height: 18.6719px;"> </td>
<td style="width: 3.90545%; height: 18.6719px; text-align: left;">10.</td>
<td style="width: 30.5242%; text-align: left; height: 18.6719px;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 18.6719px;">:</td>
<td style="width: 60.0206%; height: 18.6719px; text-align: justify;">[NAma_pelapor]</td>
</tr>
<tr style="height: 18.6719px;">
<td style="width: 4.31655%; text-align: center; height: 18.6719px;"> </td>
<td style="width: 3.90545%; text-align: left; height: 18.6719px;">11.</td>
<td style="width: 30.5242%; text-align: left; height: 18.6719px;">NIK / No. KTP</td>
<td style="width: 1.2333%; text-align: center; height: 18.6719px;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 18.6719px;">[Nik_pelapoR]</td>
</tr>
<tr style="height: 18.6719px;">
<td style="width: 4.31655%; text-align: center; height: 18.6719px;"> </td>
<td style="width: 3.90545%; height: 18.6719px; text-align: left;">12.</td>
<td style="width: 30.5242%; text-align: left; height: 18.6719px;">Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 18.6719px;">:</td>
<td style="width: 60.0206%; height: 18.6719px; text-align: justify;">[Tanggallahir_pelapoR]</td>
</tr>
<tr style="height: 18.6719px;">
<td style="width: 4.31655%; text-align: center; height: 18.6719px;"> </td>
<td style="width: 3.90545%; text-align: left; height: 18.6719px;">13.</td>
<td style="width: 30.5242%; text-align: left; height: 18.6719px;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 18.6719px;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 18.6719px;">[Pekerjaan]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center;"> </td>
<td style="width: 3.90545%; text-align: left;">14.</td>
<td style="width: 30.5242%; text-align: left;">Alamat / Tempat Tinggal</td>
<td style="width: 1.2333%; text-align: center;">:</td>
<td style="width: 60.0206%; text-align: justify;">[Alamat_pelapoR]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; text-align: left; height: 18px;">15.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">Hubungan dengan yang mati</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 18px;">[Form_hubungan_pelapor_dengan_yang_matI]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Demikian surat keterangan ini dibuat dengan sebenarnya agar dapat dipergunakan sebagaimana mestinya.<br><br></p>
<table style="border-collapse: collapse; width: 100%;" border="0">
<tbody>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[NaMa_desa], [TgL_surat]</td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[Atas_namA]</td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"><br><br><br><br></td>
<td style="width: 35%;"> </td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[Nama_pamonG]</td>
</tr>
<tr>
<td style="width: 35%;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[SEbutan_nip_desa] : [nip_pamong]</td>
</tr>
</tbody>
</table>
<div style="text-align: center;"><br>[qr_code]</div>