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Judeul _____________________

Localitatea __________________
Unitatea sanitar _____________

Nr. fi /carnet de sntate


_____________________

ADEVERIN MEDICAL
Se adeverete c: ____________________________________________________________ Sex
- numele - prenumele Nascut(): anul ________ luna _____________________________ ziua ________ cu domiciliul in:
Judeul _____________________________ localitatea ____________________________________
strada _______________________________________________________________ nr. _________
Avnd ocupatia de: _____________________________________ la _________________________
Este suferind() de: ________________________________________________________________
Se recomand _____________________________________________________________________
S-a eliberat prezena spre a-i servi la: __________________________________________________
Semntura i paraf medic,
Data eliberarii:
20 ______ luna ______________ ziua _____

L.S. ______________________