Professional Documents
Culture Documents
Kotabumi, _________________
Nomor :/ / KFM/ / 2015
Lampiran : -
Ikhwal : Pemeriksaan luar korban mati (jenazah)
An. _______________________
VISUM ET REPERTUM
PRO JUSTITIA
Permintaan-----------------------------------------------------------------------------------------
Tanggal permintaan;________________, No Polisi;_____________________,
Perihal; Permintaan Visum et Repertum pemeriksaan luar korban mati jenazah An.
____________________________, Penyidik;___________________,
Pangkat;___________________, NRP;_______________,
Jabatan;________________________, Instansi;____________________________,
Penjelasan;_________________________________________________,
padahari_________, 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____________________________---------------------------------------------
---------------
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 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;__________________________--------------------------------
32 Hasil Pemeriksaan Tambahan;______________________--------------------------
KESIMPULAN
Telah diperiksa sesosok mayat dikenal, jenis kelamin_________________,
umur__________tahun, warna kulit_______________, panjang
badan__________________________, perawakan________________, rambut
sepanjang_______________, bentuk_____________, warna_________________----
2
Demikianlah visum et repertum ini dibuat dengan sejujur-jujurnya berdasarkan
sumpah jabatan dan keilmuan menurut Kitab Undang-undang Hukum Acara Pidana
(KUHAP) untuk di pergunakan bila mana perlu--------------------------------------------
Dr.
Nip.