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RS ABDI WALUYO

Jl. KH Wahid Hasyim No. 54 Kudus 59345

Telp/fax 0291-444555

Kudus 15 !esem"e# 2014

PRO JUSTITIA

VISUM ET REPERTUM

No. 05/TU.RSAW/I/2014

$a%& "e#'a%da'a%&a% di "a(ah i%i d#. )ale%'i%e *ef'ia%a *oesa%'o *p+ do,'e# pada umah

*a,i' "di Waluyo a'as pe#mi%'aa% da#i ,epolisia% *e,'o# Kudus de%&a% su#a'%ya "e#%omo# 

)/115///2014/*e,. Kudus 'e#'a%&&al 'uuh "elas !esem"e# 2014 ma,a de%&a% i%i

me%e#a%&,a% "ah(a pada 'a%&&al 'i&a "elas !esem"e# 'ahu% dua #i"u empa' "elas pu,ul lima

 "elas le(a' lima "elas me%i' Wa,'u %do%esia "a&ia% a#a' "e#'empa' di !epa#'eme%

+o#e%si, umah *a,i' "di Waluyo 'elah mela,u,a% peme#i,saa% ,o#"a% de%&a% %omo# 

#e&is'#asi 15032921 ya%& me%u#u' su#a' 'e#se"u' adalah----------------------------------------------

 Nama #.----------------------------------------------------------------------------------

6mu# -----------------------------------------------------------------------------------------

Je%is Kelami% la,i-la,i-------------------------------------------------------------------------------

Wa#&a Ne&a#a -----------------------------------------------------------------------------------------

7e,e#aa% -----------------------------------------------------------------------------------------

lama' -----------------------------------------------------------------------------------------

HASIL PEMERIKSAAN :-----------------------------------------------------------------------------

. 7K*N 86 ----------------------------------------------------------------------------

1. Tida, 'e#dapa' la"el maya'.----------------------------------------------------------------------

2. aya' 'ida, 'e#"u%&,us.-------------------------------------------------------------------------

3. 7e#hiasa% maya' 'ida, di'emu,a%.--------------------------------------------------------------

4. 7a,aia% ya%& di,e%a,a% maya' adalah--------------------------------------------------------

a. ,aos dalam o"lo%&:;;

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a. ,aos dalam o"lo%&: "e#(a#%a pu'ih 'a%pa me#e, u,u#a% 8 ya%& "e#lumu#a% da#ah

di "a&ia% dada da% pe#u' ,i#i 'u"uh ,o#"a%------------------------------------------------

 ". <ela%a pa%a%& ,ai% "e#(a#%a hi'am 'ida, "e#me#e, de%&a% dua "uah sa,u di

 "a&ia% "ela,a%& da% sa'u "uah sa,u masi%&-masi%& pada "a&ia% ,a%a% da% ,i#i

ya%& di"a&ia% "a(ah%ya di&ulu%& hi%&&a se'e%&ah 'u%&,ai "a(ah%ya. 7ada sa,u

,i#i "ela,a%& 'e#dapa' sehelai sapu 'a%&a% "e#(a#%a a"u-a"u "e#&a#is hi'am. 7ada

 "a&ia% depa% a'as <ela%a 'e#dapa' "e#<a, da#ah-------------------------------------------

<. <ela%a dalam "e#(a#%a pu'ih de%&a% ,a#e' "e#(a#%a a"u-a"u pada pi%&&a%& de%&a%

'ulisa% ide# "e#(a#%a hi'am. =ela%a dalam i%i sedi,i' "e#lumu#a% da#ah pada

 "a&ia% depa% a'as se"elah ,i#i---------------------------------------------------------------

5. Tida, 'e#dapa' "e%da disampi%& maya'.-------------------------------------------------------

>. Te#dapa' ,a,u maya' di selu#uh 'u"uh ya%& su,a# dila(a%. Te#dapa' le"am maya' pada

 pe#u' da% dada ,o#"a% ya%& "e#(a#%a me#ah ,e"i#ua% da% hila%& pada pe%e,a%a%.

aya' dalam ,o%disi 'elah mem"usu,.--------------------------------------------------------?. aya' adalah seo#a%& la,i-la,i #as mo%&oloid umu# ,u#a%& le"ih empa' puluh dua

'ahu% (a#%a ,uli' sa(o ma'a%& &i@i "ai, memili,i pa%a%& 'u"uh se#a'us 'uuh puluh

dua se%'ime'e# de%&a% "e#a' 'u"uh delapa% puluh ,ilo&#am da% @a,a# disu%a'.---------

A. Tida, di'emu,a% ide%'i'as ,husus pada pasie% i%i.-------------------------------------------

9. am"u' "e#(a#%a hi'am 'um"uh lu#us de%&a% pa%a%& 'uuh se%'ime'e#. lis ma'a

 "e#(a#%a hi'am 'um"uh a#a%& de%&a% pa%a%& sa'u se%'ime'e#. ulu ma'a "e#(a#%a

hi'am 'um"uh lu#us de%&a% pa%a%& e%am millime'e#. Je%&&o' "e#(a#%a hi'am

'um"uh le"a' de%&a% pa%a%& dua "elas millime'e#.-----------------------------------------

10. Kedua ma'a 'e#'u'up 'ida, ada &am"a#a% pe#"e%du%&a% ma'a da% 'ida, ada "i%'i,-

 "i%'i, pe#da#aha% pada ,omu%&'iBa "ul"i da% palpe"#a------------------------------------

11. Hidu%& "e#"e%'u, ma%<u%&. Teli%&a "e#"e%'u, oBal. ulu' 'e#'u'up.--------------------12. Ci&i &eli&i "e#umlah 'i&a puluh sa'u "uah. Ci&i-&i&i #aha%& ,i#i a'as le%&,ap. Tida, 

'e#dapa' &i&i ,e delapa% pada #aha%& ,i#i "a(ah. Ci&i-&i&i pada #aha%& ,a%a% a'as

le%&,ap. Ci&i-&i&i pada #aha%& ,i#i "a(ah le%&,ap.-----------------------------------------

13. !a#i lu"a%& hidu%& 'eli%&a mulu' da% lu"a%& 'u"uh lai%%ya 'ida, ,elua# apa-apa.-- --

14. 7ada maya' di'emu,a% lu,a-lu,a se"a&ai "e#i,u'-------------------------------------------

a. 7ada dae#ah ,e'ia, ,i#i 'e#dapa' lu,a 'e#"u,a meli%'a%& "e#u,u#a% ,u#a%& le"ih

sepuluh se%'ime'e# de%&a% 'epi #a'a da% 'e#a'u# se#'a sudu' lu,a la%<ip dalam lu,a

'ida, mele"ihi pa%a%& lu,a. 7em"uluh da#ah ,e'ia, 'ampa, pu'us.-------------------

 ". 7ada dae#ah 'u%&,ai "a(ah ,a%a% lima "elas se%'ime'e# da#i ma'a ,a,i dua puluh

se%'ime'e# da#i &a#is "a(ah lu'u' 'e#dapa' "e"e#apa lu,a 'e#"u,a meli%'a%&

 "e#u,u#a% ,u#a%& le"ih lima se%'ime'e# de%&a% 'epi "e#a'u#a%.------------------------<. 7ada dae#ah 'u%&,ai "a(ah ,i#i delapa% se%'ime'e# da#i ma'a ,a,i dua puluh

delapa% se%'ime'e# da#i &a#is "a(ah lu'u' 'e#dapa' lu,a 'e#"u,a meli%'a%&

 "e#u,u#a% ,u#a%& le"ih 'uuh se%'ime'e# de%&a% 'epi "e#a'u#a%.-----------------------

. 7K*N !8 'ida, dila,u,a%.------------------------------------------------

. 7K*N 7N6NJNC 'ida, dila,u,a%.------------------------------------------

KESIMPULAN:------------------------------------------------------------------------------------------

8a%u'a% )e No No. 05/T6.*W//2014

Halama% ,e 2 da#i 3 halama%

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