INSTALASI KEDOKTERAN FORENSIK

DAN PEMULASARAN JENAZAH

RUMAH SAKIT DR. KARIADI
Jl. Dr. Sutomo No. 16, Semarang. Telp. (024) 8413993

RMI 00118 (CM-VR) 108.0.23

PRO JUSTITIA
VISUM et REPERTUM
NO :
Atas permintaan tertulis dari KEPOLISIAN, melalui suratnya tanggal , No. yang ditandatangani
oleh ,Nrp. , pangkat dan diterima tanggal , jam WIB maka dengan ini saya, Dr. , sebagai dokter
yang bekerja pada Rumah Sakit Dr.Kariadi Semarang menerangkan bahwa pada tanggal , Jam
WIB, telah menerima jenazah, yang berdasarkan surat permintaan tersebut diatas bernama, umur
tahun, jenis kelamin pekerjaan sebelum meninggal dunia , alamat , ditemukan di , dan diduga
meninggal dunia karena .
HASIL PEMERIKSAAN
Dari pemeriksaan luar atas tubuh jenazah tersebut diatas ditemukan fakta-fakta sebagai
berikut :
A. FAKTA YANG BERKAITAN DENGAN IDENTITAS JENAZAH
1. Identitas Umum Jenazah :
a. Jenis kelamin :................................................................................................................
b. Umur :............................................................................................................................
c. Panjang badan : , berat badan :.......................................................................................
d. Warna kulit : , warna pelangi mata : .............................................................................
e. Ciri rambut : , warna : ...................................................................................................
f. Golongan darah : ...........................................................................................................
g. Keadaan gizi : ................................................................................................................
h. Ciri-ciri lain : .................................................................................................................
2. Identitas Khusus Jenazah :
a. Tatoase : ........................................................................................................................
b. Jaringan parut : ..............................................................................................................
c. Cacat fisik : ...................................................................................................................
d. Pakaian : ........................................................................................................................
e. Perhiasan : .....................................................................................................................
f. Ciri-ciri lain : .................................................................................................................
B. FAKTA YANG BERKAITAN DENGAN WAKTU TERJADINYA KEMATIAN
1. Suhu rectal mayat : ..............................................................................................................
2. Lebam mayat : .....................................................................................................................
3. Kaku mayat : .......................................................................................................................
4. Pembusukan : ......................................................................................................................
5. Lain-lain : ............................................................................................................................
C. FAKTA DARI PEMERIKSAAN TUBUH BAGIAN LUAR
1. Permukaan Kulit Tubuh : (memar, lecet, luka, eritema, vesikel, bulla, kelainan lain).
a. Kepala : .........................................................................................................................
o Daerah berambut : ...................................................................................................
o Wajah : ....................................................................................................................
b. Leher : ...........................................................................................................................
c. Bahu : ............................................................................................................................
o Bahu kanan : ............................................................................................................
o Bahu kiri : ................................................................................................................
d. Dada : ............................................................................................................................
e. Punggung : ....................................................................................................................
f. Perut : ............................................................................................................................
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g. Bokong : ........................................................................................................................
o Bokong kanan : .......................................................................................................
o Bokong kiri : ...........................................................................................................
h. Dubur : ..........................................................................................................................
o Lingkaran dubur : ....................................................................................................
o Liang dubur : ...........................................................................................................
i. Anggota gerak : .............................................................................................................
o Anggota gerak atas : ................................................................................................
kanan : ...............................................................................................................
kiri : ...................................................................................................................
o Anggota gerak bawah : ...........................................................................................
kanan : ...............................................................................................................
kiri : ...................................................................................................................
2. Bagian Tubuh Tertentu :
a. Mata :
o Alis mata : ...............................................................................................................
o Bulu mata : ..............................................................................................................
o Kelopak mata : ........................................................................................................
o Selaput kelopak mata : ............................................................................................
o Selaput biji mata : ...................................................................................................
o Selaput bening mata : ..............................................................................................
o Pupil mata : .............................................................................................................
o Pelangi mata : ..........................................................................................................
o Lain-lain : ................................................................................................................
b. Hidung :
o Bentuk hidung : .......................................................................................................
o Permukaan kulit hidung : ........................................................................................
o Lubang hidung : ......................................................................................................
c. Telinga :
o Bentuk telinga : .......................................................................................................
o Permukaan daun telinga : ........................................................................................
o Lubang telinga : ......................................................................................................
d. Mulut :
o Bibir atas : ...............................................................................................................
o Bibir bawah : ...........................................................................................................
o Selaput lendir mulut : ..............................................................................................
o Lidah : .....................................................................................................................
o Gigi geligi : .............................................................................................................
Gigi rahang atas : ..............................................................................................
Gigi rahang bawah : ..........................................................................................
Langit langit mulut : ..........................................................................................
Lain-lain : ..........................................................................................................
e. Alat kelamin :
o Alat kelamin Laki-laki : ..........................................................................................
Pelir : .................................................................................................................
Kantong buah pelir : ..........................................................................................
Lain lain : .......................................................................................................
o Alat kelamin wanita : ..............................................................................................
Bibir besar : .......................................................................................................
Bibir kecil : ........................................................................................................
Kelentit :
Selaput dara : .....................................................................................................
Dinding vagina : ................................................................................................
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 Lain lain : .......................................................................................................

3. Tulang-tulang : ( retak, patah tulang, kelainan lain )
a. Tulang tengkorak :
b. Tulang-tulang belakang : ...............................................................................................
c. Tulang-tulang dada :
d. Tulang-tulang punggung : .............................................................................................
e. Tulang-tulang panggul :
f. Tulang anggota gerak :

KESIMPULAN
Dari fakta fakta yang kami temukan sendiri dari pemeriksaan atas jenazah tersebut maka kami
simpulkan bahwa..............................................................................................................................
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PENUTUP
Demikianlah keterangan tertulis ini saya buat dengan sesungguhnya, dengan mengingat sumpah
pada waktu menerima jabatan sebagai dokter.
Semarang,
Dokter Pemeriksa

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