PEMERINTAH KABUPATEN LAMPUNG UTARA

INSTALASI P.J / KEDOKTERAN FORENSIK DAN MEDIKOLEGAL

RUMAH SAKIT UMUM DAERAH MAYJEND. HM. RYACUDU KOTABUMI
Jl. Jenderal Sudirman No. 02 Telp. 0724-22095
KOTABUMI 34511

Kotabumi, _________________
Nomor : / / KFM/ / 2015
Lampiran : -
Ikhwal : Pemeriksaan bedah mayat (autopsy)
An. _______________________

VISUM ET REPERTUM

PRO JUSTITIA

Permintaan-----------------------------------------------------------------------------------------
Tanggal permintaan;________________, No Polisi;_____________________,
Perihal; Permintaan Visum et Repertum pemeriksaan bedah mayat (autopsy)
An. ____________________________, Penyidik;___________________,
Pangkat;___________________, NRP;_______________,
Jabatan;________________________, Instansi;____________________________,
Penjelasan;_________________________________________________, pada
hari_________, tanggal;_______________, sekitar jam;_______ wib, dengan
kondisi korban;_______________________________________________________
____________________________________________________________________
_______________________________------------------------------------------------------

Pemeriksa:----------------------------------------------------------------------------------------
Nama;_____________________________, NIP;______________________,
Instalasi;____________________________ RSUD Mayjed. HM Ryacudu kotabumi,
Tanggal pemeriksaan;__________________, Jam pemeriksaan;_______ wib,
Korban diantar oleh;_______________, Jenis pemeriksaan; Pemeriksaan
____________________________------------------------------------------------------------

Identitas Korban: ----------------------------------------------------------------------------------

Nama;________________________, Jenis kelamin;_____________________,
Umur;______ tahun, Agama; ____________, Pekerjaan;_____________, Status
perkawinan; _________________, Alamat; Jln.
___________________________________________________--------------------------

PEMBERITAAN
Benda-benda---------------------------------------------------------------------------------------
1 Label mayat; ________________________---------------------------------------------
2 Pembungkus mayat; ____________________________-----------------------------
3 Penutup mayat; _____________________________-----------------------------------
4 Pakaian mayat; _________________________________________________-----
5 Benda di tubuh mayat ;_______________________________----------------------
6 Perhiasan mayat;________________________________-----------------------------
7 Benda di sekitar mayat; ---------------------------------------------------------

1
Tanda-tanda kematian--------------------------------------------------------------------------
8 Lebam mayat; ______________________________---------------------------------
9 Kaku mayat; _________________________________________--------------------
10 Pembusukan:__________________________________------------------------------

Identifikasi----------------------------------------------------------------------------------------
11 Identifikasi umum ; Dijumpai sesosok mayat dikenal, jenis kelamin
_______________, umur ___________, warna kulit _______________, panjang
badan _______________________, perawakan _______________, rambut
sepanjang ______________, bentuk ____________, warna ______________-----
12 Identifikasi khusus;__________________________________-----------------------

Pemeriksaan luar---------------------------------------------------------------------------------
13 Kepala;_____________________________________________--------------------
14 Dahi;_________________________________________________------------------
15 Mata;_____________________________-----------------------------------------------
16 Hidung;_______________________________________-----------------------------
17 Pipi;________________________________--------------------------------------------
18 Telinga;________________________________----------------------------------------
19 Mulut;___________________________________-------------------------------------
20 Gigi;______________________________________________-----------------------
21 Rahang;________________________________----------------------------------------
22 Leher;_______________________________________________-------------------
23 Dada;_______________________________________________________--------
24 Perut;_____________________________________________________-----------
25 Alat kelamin;_________________________________--------------------------------
26 Punggung;________________________________-------------------------------------
27 Pinggang;______________________________________-----------------------------
28 Bokong;_________________________________--------------------------------------
29 Dubur;________________________________-----------------------------------------
30 Anggota gerak atas;_______________________---------------------------------------
31 Anggota gerak bawah;__________________________--------------------------------

Pemeriksaan dalam-------------------------------------------------------------------------------
32 Kepala;_____________________________________________--------------------
33 Otak;_________________________________----------------------------------------
34 Leher;_______________________________________________-------------------
35 Saluran nafas atas;_____________________________------------------------------
36 Saluran makan atas;________________________________-----------------------
37 Dada;_______________________________________________________--------
38 Jantung;_________________________________-------------------------------------
39 Paru-paru;________________________________-----------------------------------
40 Perut;_____________________________________________________-----------
41 Lambung;___________________________________---------------------------------
42 Hati;______________________________________----------------------------------
43 Kantong empedu;______________________________-------------------------------
44 Limpa;_________________________________--------------------------------------
45 Pangkreas;____________________________________------------------------------

2
46 Ginjal;__________________________________________--------------------------
47 Kandung rahim (wanita);________________________-------------------------------
48 Kantong pelir (pria);________________________________-------------------------
49 Kelenjar;__________________________________------------------------------------
50 Lain-lain;__________________________________-----------------------------------
51 Hasil Pameriksaan Tambahan;______________________--------------------------

KESIMPULAN
Telah diperiksa sesosok mayat dikenal, jenis kelamin_________________,
umur__________tahun, warna kulit_______________, panjang
badan__________________________, perawakan________________, rambut
sepanjang_______________, bentuk_____________, warna_________________----

Dari hasil pemeriksan luar dan dalam (serta pemeriksaan tambahan) dijumpai tanda-
tanda kekerasan berupa________________________,
pada________________________________, akibat
kekerasan_________________________________________. Penyebab kematian
korban adalah________________________________________ oleh
karena________________________________ akibat__________________-----------

Demikianlah visum et repertum ini dibuat dengan sejujur-jujurnya berdasarkan

sumpah jabatan dan keilmuan menurut Kitab Undang-undang Hukum Acara Pidana
(KUHAP) untuk dipergunakan bilamana perlu--------------------------------------------

Dokter yang memeriksa,

Dr.
Nip.