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HEAD QUARTER
STATE POLICE OF THE REPUBLIC OF INDONESIA
SECURITY INTELLIGENCE AGENCY
Jalan Trunojoyo 3, Kebayoran Baru, Jakarta 12110
Number
Classification
Attachment
Subject

Jakarta, July 22 2016

:B/650/ VII/2016/Baintelkam
:ORDINARY
::Application for issuance of Police Record Certificate.

Attention To:
Ms.NATASHA

1. Referred to Your application of the issuance of Police Record Certificate (SKCK) by Security
Intelligence Agency of Republic of Indonesia (Baintelkam Polri).
2. Related to the matter, hereby the requirement for the issuance of SKCK for Foreign Nationalities
which is issued by Security Intelligence Agency of Republic of Indonesia including the following
items:
a. Application letter from the sponsor;
b. Copy of passport;
c. Copy of Kitas/Kitap (Temporary/Permanent Resident Visa) and/or Official Visa from the
Embassy.
d. IMTA (Expatriate Employment Permit) from Ministry of Manpower and Transmigration.
e. Personal Report Letter (STM) from local Police office; and
f. Passport photograph with yellow color background, size 4X6 = 4 pcs.
3. Regarding the document that You have submitted i.e. application letter, copy of passport from
Canadian Authorities Number: HD829152 under the name of NATASHA, copy of Birth Certificate
and passport photograph size 4X6 = 2 pcs, Baintelkam Polri does not issue SKCK for Foreign
Nationalities who does not qualify abovementioned requirement (point a to f), therefore we
would like to inform that Your SKCK (Police Record Certificate) application cannot be issued.
4. Accordingly this is for your reference.

On Behalf THE CHIEF OF SECURITY INTELLIGENCE


KABID YANMAS
U.B.
KASUBBID GIATMAS
(Stamped&Authorized Signed)
ADRI IRNIADI, S.IK.,M.H.
ADJUNT COMMISSIONER POLICE NRP 72080790

---------------------------------------------------This Document has been translated from Indonesian to English by


Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981

AUTHORIZED TRANSLATION

---------------------------------------------------This Document has been translated from Indonesian to English by


Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981

AUTHORIZED TRANSLATION

EAST KALIMANTAN PROVINCE AUTHORITIES

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RSUD (General Hospital) A. WAHAB SJAHRANIE


Jl.Palang Merah Indonesia Phone (0541) 738118 (Hunting system 7 lines) Fax(0541)741793

SAMARINDA 75123
FORM A
DEATH EXAMINATION CERTIFICATE
No.: 1938 / SK / RSAWS / IX / 2015
The undersigned below, Daniel Umar, SH, SpF, as the doctor who is working for Abdul Wahab
Sjahranie Hospital in Samarinda, hereby stated that on Wednesday, the 16th of September 2015, at . . .
. . wita, has performed corpse examination of the following identity:
Name

: CHUPRINA SERGII

No.Reg.RM

:-

Age

: 59 Years

Sex

: Male / Female

Religion

: Christian

Address

: Ukraine

Died at

: Forensic Room of RSUD.A.Wahab Sjahranie

Accordingly this Certificate is made as referred to doctor oath to work as physician.

Samarinda, 16 09 2015
Doctor Examiner,
(Stamped & Authorized Signed)
Dr.Daniel Umar, SH, SpF

---------------------------------------------------This Document has been translated from Indonesian to English by


Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981

AUTHORIZED TRANSLATION

EAST KALIMANTAN PROVINCE AUTHORITIES

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RSUD (General Hospital) A. WAHAB SJAHRANIE


Jl.Palang Merah Indonesia Phone (0541) 738118 (Hunting system 7 lines) Fax(0541)741793

SAMARINDA 75123
FORM M
CONTAGIOUS / NON CONTAGIOUS DISEASE CERTIFICATE
No.: 1938 / SK / RSAWS / IX / 2015
The undersigned below, Daniel Umar, SH, SpF, as the doctor who is working for Abdul Wahab
Sjahranie Hospital in Samarinda, hereby stated that a patient with the following identity:
Name

: CHUPRINA SERGII

No.Reg.RM

:-

Age

: 59 Years

Sex

: Male / Female

Address

: Ukraine

Has died due to CONTAGIOUS / NON CONTAGIOUS DISEASE, as referred to Law of Republic of
Indonesia Number 4 of 1984 in regard of contagious disease and the Decree of Minister of Health
Republic of Indonesia Number 560/Menkes/PER/VIII/1989 in regard of Special Disease that may give
rise to epidemic.

Samarinda, September 16 2015


Doctor Examiner,
(Stamped & Authorized Signed)
Dr.Daniel Umar, SH, SpF

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AUTHORIZED TRANSLATION
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SAMARINDA CITY AUTHORITIES


PUBLIC HEALTH OFFICE
Jalan Milono PHONE. (0541) 735660, 743822, FAX. (0541) 737606

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PERMIT CERTIFICATE ON CARRYING CORPSE


No. 443.01 / 9074/PMK-03/ IX / 2015
The undersigned below :
Name

: Murjani.SKM

Position

: Staff of P2P Section Health Issues Control Department in Public Health Office
Samarinda

Hereby stated that pursuant to the letter of enquiry from:


Name

: Fachrudin

Sex

: Male

Occupation

: Employee

Address

: Perum Pondok Maritim Indah bl.AL no.12 Surabaya, East Java

Referred to the letter dated September 16 2015 for the purpose to carry corpse of:
Name

: Chuprina Sergii

Age

: 59 Years

Sex

: Male

Address

: Ukraine

Carry to

: Jakarta, and country of destination.

AFTER CONSIDERING:
1. Death Certificate issued by RSU Aw. Sjahranie (General Hospital), dated September 16 2014
stating that the death due to non contagious disease, as referred to Law Number 2 of 1962
regarding Air Quarantine and Law Number 6 of 1962 regarding epidemic.
2. Minutes of Corpse Examination and put into coffin.
3. Has been given injection by formaline 10% as much as four (4) liters as preservation material.
4. Our investigation from the aspect of prevention and eradication on contagious disease, that the
corpse was not constituting source of contagion of any quarantine disease and epidemic
disease as referred to the prevailing health regulation.
Therefore we have no objection and give consent on the corpse to be carried to country of origin.
Accordingly this Permit Certificate is granted for the purpose to whom it may concerned.
Samarinda, September 28 2015
On behalf the Head of Public Health Office
Samarinda City
(Stamped & Authorized Signed)

---------------------------------------------------This Document has been translated from Indonesian to English by


Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981

AUTHORIZED TRANSLATION

Murjani, SKM
NIP.197503031998031005

---------------------------------------------------This Document has been translated from Indonesian to English by


Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981

AUTHORIZED TRANSLATION
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(Log
SAMARINDA CITY AUTHORITIES
o)
PUBLIC HEALTH OFFICE
Jalan Milono PHONE. (0541) 735660, 743822, FAX. (0541) 737606
==================================================================

MINUTES OF EXAMINATION
Under the Name of : Chuprina Sergii (RIP)
Today, on Wednesday, the sixteenth of September Two thousand and fifteen, at 16.52 Wita (Central
Indonesian Times), I, who undersigned below:
Name
Occupation

: Murjani SKM
: Staff in PMK Department (Health Issues Control)
Public Health Office in Samarinda city

Has witnessed/examined the corpse of Chuprina Sergii (RIP) which is put into coffin qualified the
requirement as referred to Circular of Ministry of Health Republic of Indonesia, dated April 8 1961,
Number:FK 372/3 as follow:
1. The corpse is wrapped by white cloth, then wrapped again by yellow plastic.
2. Furthermore the corpse is put into coffin which is coated by metal with size length 195 cm, width
(head area) 60 cm, width (foot area) 50 cm, board thickness 3 com and height 50 cm
3. Upper side of corpse is poured by sawdust for absorbtion as thick as 10 cm.
4. Coffin is closed and nailed and screwed with distant as long as 20 cm, then strengthened by
metal/zinc material.
5. The corpse has been injected by formaline 10% as much as four liters as preservation material.
6. Corpse examination has been witnessed by:
a. Fachrudin.
Accordingly this Minutes of Corpse Examination is made for the purpose to whom it may concerned.
Witnessess,

Examiner Officer,

1. Fachrudin

(Authorized Signed)
Murjani, SKM
NIP.19750303.199803.1.005
Samarinda, September 28 2015
On behalf The Chief of Public Health Office
Samarinda City
(Stamped & Authorized Signed)
Murjani, SKM
NIP. 19750303.199803.1.005

---------------------------------------------------This Document has been translated from Indonesian to English by


Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981

AUTHORIZED TRANSLATION

EAST KALIMANTAN PROVINCE AUTHORITIES

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RSUD (General Hospital) A. WAHAB SJAHRANIE


FORENSIC MEDICINE & MEDICAL LEGAL INSTALLATION
Jl.Dr.Soetomo Phone(0541)742055/56 (Hunting System), Fax.(0541)741793

SAMARINDA 75123
================================================================
Samarinda, September 29 2015
No.:040/SK-IV/KF-TU/IX/2015
AUTOPSY (POST MORTEM) REPORT
By-Law
Related to letter of Request for Autopsy (Post Mortem) to Resort Police of Samarinda City in Port Area
entered into by:
Name

: Tamsil

Rank/Nrp

: AIPTU / 64120848

Occupation

: On behalf Chief of Police Sector Port Area of Samarinda

Police Number: B/18/ IX/2015/Sek KP Smd, dated September 16 2015


That we received on September 16 2015, therefore, I, dr.Daniel Umar SH, SpF, a Forensic Specialist in
RSUD (General Hospital) A.Wahab Sjahranie Samarinda, hereby performed an external examination on
September 27 2015, at 15.15 wita (Indonesian Central Times), in the General Hospital mentioned
above, to the corpse with the following identity:
Name

:CHUPINA SERGIY

Place/Date of Birth

:Ukraine, March 19 1956 (56 Years)

Sex

:Male

Religion

:Christian

Nationality

:Ukraine

Occupation

:ABK (Sail Crew) of Vessel

Address

:Ukraine

The abovementioned person has been found on the vessel MV.CRESTED EAGLE, during achored in
muara berau, Kutai Kartanegara Regency City.

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AUTHORIZED TRANSLATION

EXAMINATION RESULT
EXTERNAL EXAMINATION
1. The deceased person is male, fifty nine (59) years age, white color, and good nutrition.
2. The corpse does not have label.
3. Dress wear: the deceased wore working uniform, white color, wearing blue undershirt , and grey
underpants. Brown leather shoes.
4. Corpse bruise on back area, rigor mortis on entire body.
5. The Head:
a.

Oval and round shape, white hair, straight shape, the average length of two centimeters.

b.

At the back of head, on left side there are bruises, size 12.5 x 8 cm (twelve point five times
eight centimeters). At the back of head, on right side there is open wound, oblique direction
from top left to bottom right, size of 8 x 1 cm (eight times one centimeter), uneven edges,
there are bridge tissues, based wound to the skull and palpable skull cracked.

c. Right eye: on the inside corner of the eye there are bruised, size 1.5 x 1 cm (one point five
half times one centimeter), the mucous membranes of the eyelids and eyeballs looks pale,
the eyes look of clear cornea, pupil diameter is half centimeter.
d. Left eye: mucous membranes of the eyelids and eyeballs looks pale, the eyes look of clear
cornea, eye pupil diameter of half a centimeter.
e. Nose: sharp shape, in nose nozzle there is a blood clot.
f.

Mouth: mucous membrane is pale. No abnormalities detected.

g. Teeth: number of teeth twenty-nine, the third rear molars top right, the third molar teeth
behind the lower right, and a rear molar tooth, the third bottom left is not foun. There are
dental fillings on front teeth on the second upper left, upper right second incisors, molars
second front right,
rear molar teeth and both right above. There are teeth coated silver metal in front of the first
molars top left, front first molars top right, front left first molar tooth bottom, back second
molars bottom left, front right first molar tooth bottom, and rear molars the second lower
right.

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Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981

AUTHORIZED TRANSLATION

h. Ear: normal shape, not found any abnormality nor sign of violence.
i.

Forehead: On the right side there is a bruise, size 6 x 6.5 cm (six times six point five

centimeters).
j. Cheeks and chin: not found any lesion nor sign of violence.
6.

Neck: not found any abnormality or sign of violence.

7.

Chest: symmetric shape, on the left side there are bruises, size 3 x 2.5 cm (three times two point
five centimeters), located three centimeters from the midline of the body and seven centimeters
below the horizontal line through nipples. On surface of the bruises there are scuffed, the size of
one and a half centimeters in diameter.

8.

Stomach: flat shape, not found any sign of violence.

9.

Backs: on the left of his back there is bruise, diameter 6.5 cm (six point Iima centimeters). In the
lower right upper surface backbone there are four bruises, each size 4 x 3 cm (four times three
centimeters), 1 x 0.5 cm (zero point five centimeters), 1.5 x 1 cm (one point five times one
centimeter), and 3 x 2 cm (three times two centimeters).

10.

Waist: On the left side there is bruise, size 3 x 2.5 cm (three times two Iima point five
centimeters), located two and half centimeters from the midline back and three centimeters
above the pelvis line.

11.

Upper body movement:


a.

Right arm: in the thumb area of the second segment are open wound, size two

centimeters, uneven edges, the base of wound up to bone, and looked the second finger joint is
broken.
b.
12.

Left arm: not found any sign of violence.

Lower body movement:


a.

Right leg: not found any sign of violence.

b.

Left leg: not found any sign of violence.

13.

Genitals outside: male, no abnormalities found.

14.

Rectal: no abnormalities found.

CONCLUSION:

---------------------------------------------------This Document has been translated from Indonesian to English by


Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981

AUTHORIZED TRANSLATION

1.

Having examined the body of a man, aged fifty-seven (57) years, with body length of one
hundred and sixty-seven centimeters.

2.

On examination finding:
a.

Lacerations on the back of the head, and on the thumb of his right hand.

b.

bruises injuries on the back of the head, forehead, right eyes corner area, chest, back,
and waist.

3.

c.

Bleeding from the nose.

d.

The signs of skull fracture and fracture right thumb.

e.

Abovementioned abnormalities caused by exposure to blunt objects.

Cause of death of the victim cannot be determined with certainty due to does not performed
corpse surgical examination. However it was found any signs of severe head injury.

Accordingly this Autopsy (Post Mortem) Report is made according by the truth and to the best of our
knowledge referred to the oath taken as a doctor.

Physician Examiner,
(Authorized Signed)
Dr. Daniel Umar SH, SpF
NIP. 19591028 198903 1 010

---------------------------------------------------This Document has been translated from Indonesian to English by


Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981

AUTHORIZED TRANSLATION

---------------------------------------------------This Document has been translated from Indonesian to English by


Certified Translator duly authorized by the Governors Decree of Jakarta Capital City Province No.269/1981