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F2.01-Kematian

jaOjaa
May 26th, 2023
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  1. <?php defined('BASEPATH') || exit('No direct script access allowed'); ?>
  2.  
  3. <style type="text/css">
  4. <?php include(FCPATH . "/assets/css/lampiran-surat.css"); ?>
  5. </style>
  6.  
  7. <page orientation="portrait" format="215x330" style="font-size: 7pt">
  8. <table id="kode" align="right">
  9. <tr><td><strong>F2.01</strong></td></tr>
  10. </table>
  11.  
  12. <table id="kop" class="disdukcapil">
  13. <col span="48" style="width: 2.0833%;">
  14. <tr><td colspan=48>&nbsp;</td></tr>
  15. <tr>
  16. <td colspan="10">Provinsi</td>
  17. <td>: </td>
  18. <td colspan="7"><?= $config['nama_desa'];?></td>
  19. <td colspan="13">&nbsp;</td>
  20. </tr>
  21. <tr>
  22. <td colspan="10">Kabupaten/Kota</td>
  23. <td>:</td>
  24. <td colspan="7"><?= $config['nama_kabupaten'];?></td>
  25. <td colspan="16">&nbsp;</td>
  26. </tr>
  27. <tr>
  28. <td colspan="10">Kecamatan</td>
  29. <td>: </td>
  30. <td colspan="7"><?= $config['nama_kecamatan'];?></td>
  31. <td colspan="16">&nbsp;</td>
  32. </tr>
  33. <tr>
  34. <td colspan="10">Desa/Kelurahan</td>
  35. <td>: </td>
  36. <td colspan="7"><?= $config['nama_kecamatan'];?></td>
  37. <td colspan="16">&nbsp;</td>
  38. </tr>
  39. <tr>
  40. <td colspan="10">Kode Wilayah</td>
  41. <td>:</td>
  42. <?php for ($i=0; $i<10; $i++): ?>
  43. <td class="kotak padat tengah">
  44. <?php if (isset($config['kode_desa'][$i])): ?>
  45. <?= $config['kode_desa'][$i];?>
  46. <?php else: ?>
  47. &nbsp;
  48. <?php endif; ?>
  49. </td>
  50. <?php endfor; ?>
  51. <td colspan="27">&nbsp;</td>
  52. </tr>
  53. <tr>
  54. <?php for ($i=0; $i<48; $i++): ?>
  55. <td>&nbsp;</td>
  56. <?php endfor; ?>
  57. </tr>
  58. </table>
  59.  
  60. <!-- START OF HEADER -->
  61. <table class="disdukcapil data-subjek-akta-kesatu" style="margin-top: 0px;">
  62. <col span="48" style="width: 2.0833%;">
  63. <tr>
  64. <td colspan=48 align=center style="font-size: 9pt"><strong>FORMULIR PELAPORAN PENCATATAN SIPIL DI DALAM WILAYAH NKRI</strong></td>
  65. </tr>
  66. <tr>
  67. <td colspan=48><strong>Jenis Pelaporan Pencatatan Sipil</strong></td>
  68. </tr>
  69. <tr>
  70. <?php for ($i=0; $i<1; $i++): ?>
  71. <td class="kotak padat tengah">
  72. &nbsp;
  73. </td>
  74. <?php endfor; ?>
  75. <td colspan=15>Kelahiran</td>
  76. <?php for ($i=0; $i<1; $i++): ?>
  77. <td class="kotak padat tengah">
  78. &nbsp;
  79. </td>
  80. <?php endfor; ?>
  81. <td colspan=15>Pengakuan Anak</td>
  82. </tr>
  83. <tr>
  84. <?php for ($i=0; $i<1; $i++): ?>
  85. <td class="kotak padat tengah">
  86. &nbsp;
  87. </td>
  88. <?php endfor; ?>
  89. <td colspan=15>Lahir Mati</td>
  90. <?php for ($i=0; $i<1; $i++): ?>
  91. <td class="kotak padat tengah">
  92. &nbsp;
  93. </td>
  94. <?php endfor; ?>
  95. <td colspan=15>Pengesahan Anak</td>
  96. </tr>
  97. <tr>
  98. <?php for ($i=0; $i<1; $i++): ?>
  99. <td class="kotak padat tengah">
  100. &nbsp;
  101. </td>
  102. <?php endfor; ?>
  103. <td colspan=15>Perkawinan</td>
  104. <?php for ($i=0; $i<1; $i++): ?>
  105. <td class="kotak padat tengah">
  106. &nbsp;
  107. </td>
  108. <?php endfor; ?>
  109. <td colspan=15>Perubahan Nama</td>
  110. </tr>
  111. <tr>
  112. <?php for ($i=0; $i<1; $i++): ?>
  113. <td class="kotak padat tengah">
  114. &nbsp;
  115. </td>
  116. <?php endfor; ?>
  117. <td colspan=15>Pembatalan Perkawinan</td>
  118. <?php for ($i=0; $i<1; $i++): ?>
  119. <td class="kotak padat tengah">
  120. &nbsp;
  121. </td>
  122. <?php endfor; ?>
  123. <td colspan=15>Perubahan Status Kewarganegaraan</td>
  124. </tr>
  125. <tr>
  126. <?php for ($i=0; $i<1; $i++): ?>
  127. <td class="kotak padat tengah">
  128. &nbsp;
  129. </td>
  130. <?php endfor; ?>
  131. <td colspan=15>Perceraian</td>
  132. <?php for ($i=0; $i<1; $i++): ?>
  133. <td class="kotak padat tengah">
  134. &nbsp;
  135. </td>
  136. <?php endfor; ?>
  137. <td colspan=15>Pencatatan Peristiwa Penting Lainnya</td>
  138. </tr>
  139. <tr>
  140. <?php for ($i=0; $i<1; $i++): ?>
  141. <td class="kotak padat tengah">
  142. &nbsp;
  143. </td>
  144. <?php endfor; ?>
  145. <td colspan=15>Pembatalan Perceraian</td>
  146. <?php for ($i=0; $i<1; $i++): ?>
  147. <td class="kotak padat tengah">
  148. &nbsp;
  149. </td>
  150. <?php endfor; ?>
  151. <td colspan=15>Pembetulan Akta</td>
  152. </tr>
  153. <tr>
  154. <?php for ($i=0; $i<1; $i++): ?>
  155. <td class="kotak padat tengah">
  156. X
  157. </td>
  158. <?php endfor; ?>
  159. <td colspan=15>Kematian</td>
  160. <?php for ($i=0; $i<1; $i++): ?>
  161. <td class="kotak padat tengah">
  162. &nbsp;
  163. </td>
  164. <?php endfor; ?>
  165. <td colspan=15>Pembatalan Akta</td>
  166. </tr>
  167. <tr>
  168. <?php for ($i=0; $i<1; $i++): ?>
  169. <td class="kotak padat tengah">
  170. &nbsp;
  171. </td>
  172. <?php endfor; ?>
  173. <td colspan=15>Pengangkatan Anak</td>
  174. <?php for ($i=0; $i<1; $i++): ?>
  175. <td class="kotak padat tengah">
  176. &nbsp;
  177. </td>
  178. <?php endfor; ?>
  179. <td colspan=15>Pelaporan Pencatatan Sipil dari Luar Wilayah</td>
  180. </tr>
  181. </table>
  182.  
  183. <table class="disdukcapil data-pelapor" style="margin-top: 0px;">
  184. <col span="48" style="width: 2.0833%;">
  185. <tr>
  186. <td colspan=48><strong>DATA PELAPOR</strong></td>
  187. </tr>
  188. <tr>
  189. <td colspan="16">Nama</td>
  190. <td>:</td>
  191. <?php for ($i=0; $i<26; $i++): ?>
  192. <td class="kotak padat tengah">
  193. <?php if (isset($input['nama_pelapor'][$i])): ?>
  194. <?= $input['nama_pelapor'][$i];?>
  195. <?php else: ?>
  196. &nbsp;
  197. <?php endif; ?>
  198. </td>
  199. <?php endfor; ?>
  200. <td colspan=21>&nbsp;</td>
  201. </tr>
  202. <tr>
  203. <td colspan="16">NIK</td>
  204. <td>:</td>
  205. <?php for ($i=0; $i<16; $i++): ?>
  206. <td class="kotak padat tengah">
  207. <?php if (isset($input['nik_pelapor'][$i])): ?>
  208. <?= $input['nik_pelapor'][$i];?>
  209. <?php else: ?>
  210. &nbsp;
  211. <?php endif; ?>
  212. </td>
  213. <?php endfor; ?>
  214. <td colspan="4">&nbsp;</td>
  215. </tr>
  216. <tr>
  217. <td colspan="16">Nomor Dokumen Perjalanan</td>
  218. <td>:</td>
  219. <?php for ($i=0; $i<16; $i++): ?>
  220. <td class="kotak padat tengah">
  221. &nbsp;
  222. </td>
  223. <?php endfor; ?>
  224. <td colspan="4">&nbsp;</td>
  225. </tr>
  226. <tr>
  227. <td colspan="16">Nomor Kartu Keluarga</td>
  228. <td>:</td>
  229. <?php for ($i=0; $i<16; $i++): ?>
  230. <td class="kotak padat tengah">
  231. &nbsp;
  232. </td>
  233. <?php endfor; ?>
  234. <td colspan="21">&nbsp;</td>
  235. </tr>
  236. <tr>
  237. <td colspan="16">Kewarganegaraan</td>
  238. <td>:</td>
  239. <?php for ($i=0; $i<16; $i++): ?>
  240. <td class="kotak padat tengah">
  241. <?php if (isset($input['warganegara_pelapor'][$i])): ?>
  242. <?= $input['warganegara_pelapor'][$i];?>
  243. <?php else: ?>
  244. &nbsp;
  245. <?php endif; ?>
  246. </td>
  247. <?php endfor; ?>
  248. <td colspan="21">&nbsp;</td>
  249. </tr>
  250. </table>
  251.  
  252. <table class="disdukcapil data-subjek-akta-kesatu" style="margin-top: 0px;">
  253. <col span="48" style="width: 2.0833%;">
  254. <tr>
  255. <td colspan=48><strong>DATA SUBJEK AKTA KESATU</strong></td>
  256. </tr>
  257. <tr>
  258. <td colspan="16">Nama</td>
  259. <td>:</td>
  260. <?php for ($i=0; $i<26; $i++): ?>
  261. <td class="kotak padat tengah">
  262. &nbsp;
  263. </td>
  264. <?php endfor; ?>
  265. <td colspan=21>&nbsp;</td>
  266. </tr>
  267. <tr>
  268. <td colspan="16">NIK</td>
  269. <td>:</td>
  270. <?php for ($i=0; $i<16; $i++): ?>
  271. <td class="kotak padat tengah">
  272. &nbsp;
  273. </td>
  274. <?php endfor; ?>
  275. <td colspan="4">&nbsp;</td>
  276. </tr>
  277. <tr>
  278. <td colspan="16">Nomor Dokumen Perjalanan</td>
  279. <td>:</td>
  280. <?php for ($i=0; $i<16; $i++): ?>
  281. <td class="kotak padat tengah">
  282. &nbsp;
  283. </td>
  284. <?php endfor; ?>
  285. <td colspan="4">&nbsp;</td>
  286. </tr>
  287. <tr>
  288. <td colspan="16">Nomor Kartu Keluarga</td>
  289. <td>:</td>
  290. <?php for ($i=0; $i<16; $i++): ?>
  291. <td class="kotak padat tengah">
  292. &nbsp;
  293. </td>
  294. <?php endfor; ?>
  295. <td colspan="21">&nbsp;</td>
  296. </tr>
  297. <tr>
  298. <td colspan="16">Kewarganegaraan</td>
  299. <td>:</td>
  300. <?php for ($i=0; $i<16; $i++): ?>
  301. <td class="kotak padat tengah">
  302. &nbsp;
  303. </td>
  304. <?php endfor; ?>
  305. <td colspan="21">&nbsp;</td>
  306. </tr>
  307. </table>
  308.  
  309. <table class="disdukcapil data-subjek-akta-kedua" style="margin-top: 0px;">
  310. <col span="48" style="width: 2.0833%;">
  311. <tr>
  312. <td colspan=48><strong>DATA SUBJEK AKTA KEDUA (Jika ADA)</strong></td>
  313. </tr>
  314. <tr>
  315. <td colspan="16">Nama</td>
  316. <td>:</td>
  317. <?php for ($i=0; $i<26; $i++): ?>
  318. <td class="kotak padat tengah">
  319. &nbsp;
  320. </td>
  321. <?php endfor; ?>
  322. <td colspan=21>&nbsp;</td>
  323. </tr>
  324. <tr>
  325. <td colspan="16">NIK</td>
  326. <td>:</td>
  327. <?php for ($i=0; $i<16; $i++): ?>
  328. <td class="kotak padat tengah">
  329. &nbsp;
  330. </td>
  331. <?php endfor; ?>
  332. <td colspan="4">&nbsp;</td>
  333. </tr>
  334. <tr>
  335. <td colspan="16">Nomor Dokumen Perjalanan</td>
  336. <td>:</td>
  337. <?php for ($i=0; $i<16; $i++): ?>
  338. <td class="kotak padat tengah">
  339. &nbsp;
  340. </td>
  341. <?php endfor; ?>
  342. <td colspan="4">&nbsp;</td>
  343. </tr>
  344. <tr>
  345. <td colspan="16">Nomor Kartu Keluarga</td>
  346. <td>:</td>
  347. <?php for ($i=0; $i<16; $i++): ?>
  348. <td class="kotak padat tengah">
  349. &nbsp;
  350. </td>
  351. <?php endfor; ?>
  352. <td colspan="21">&nbsp;</td>
  353. </tr>
  354. <tr>
  355. <td colspan="16">Kewarganegaraan</td>
  356. <td>:</td>
  357. <?php for ($i=0; $i<16; $i++): ?>
  358. <td class="kotak padat tengah">
  359. &nbsp;
  360. </td>
  361. <?php endfor; ?>
  362. <td colspan="21">&nbsp;</td>
  363. </tr>
  364. </table>
  365.  
  366. <table class="disdukcapil data-subjek-saksi-1" style="margin-top: 0px;">
  367. <col span="48" style="width: 2.0833%;">
  368. <tr>
  369. <td colspan=48><strong>DATA SAKSI I</strong></td>
  370. </tr>
  371. <tr>
  372. <td colspan="16">Nama</td>
  373. <td>:</td>
  374. <?php for ($i=0; $i<26; $i++): ?>
  375. <td class="kotak padat tengah">
  376. <?php if (isset($input['nama_saksi1'][$i])): ?>
  377. <?= $input['nama_saksi1'][$i];?>
  378. <?php else: ?>
  379. &nbsp;
  380. <?php endif; ?>
  381. </td>
  382. <?php endfor; ?>
  383. <td colspan=21>&nbsp;</td>
  384. </tr>
  385. <tr>
  386. <td colspan="16">NIK</td>
  387. <td>:</td>
  388. <?php for ($i=0; $i<16; $i++): ?>
  389. <td class="kotak padat tengah">
  390. <?php if (isset($input['nik_saksi1'][$i])): ?>
  391. <?= $input['nik_saksi1'][$i];?>
  392. <?php else: ?>
  393. &nbsp;
  394. <?php endif; ?>
  395. </td>
  396. <?php endfor; ?>
  397. <td colspan="4">&nbsp;</td>
  398. </tr>
  399. <tr>
  400. <td colspan="16">Nomor Dokumen Perjalanan</td>
  401. <td>:</td>
  402. <?php for ($i=0; $i<16; $i++): ?>
  403. <td class="kotak padat tengah">
  404. &nbsp;
  405. </td>
  406. <?php endfor; ?>
  407. <td colspan="4">&nbsp;</td>
  408. </tr>
  409. <tr>
  410. <td colspan="16">Nomor Kartu Keluarga</td>
  411. <td>:</td>
  412. <?php for ($i=0; $i<16; $i++): ?>
  413. <td class="kotak padat tengah">
  414. &nbsp;
  415. </td>
  416. <?php endfor; ?>
  417. <td colspan="21">&nbsp;</td>
  418. </tr>
  419. <tr>
  420. <td colspan="16">Kewarganegaraan</td>
  421. <td>:</td>
  422. <?php for ($i=0; $i<16; $i++): ?>
  423. <td class="kotak padat tengah">
  424. <?php if (isset($input['warganegara_saksi1'][$i])): ?>
  425. <?= $input['warganegara_saksi1'][$i];?>
  426. <?php else: ?>
  427. &nbsp;
  428. <?php endif; ?>
  429. </td>
  430. <?php endfor; ?>
  431. <td colspan="21">&nbsp;</td>
  432. </tr>
  433. </table>
  434.  
  435. <table class="disdukcapil data-subjek-saksi-2" style="margin-top: 0px;">
  436. <col span="48" style="width: 2.0833%;">
  437. <tr>
  438. <td colspan=48><strong>DATA SAKSI II</strong></td>
  439. </tr>
  440. <tr>
  441. <td colspan="16">Nama</td>
  442. <td>:</td>
  443. <?php for ($i=0; $i<26; $i++): ?>
  444. <td class="kotak padat tengah">
  445. <?php if (isset($input['nama_saksi2'][$i])): ?>
  446. <?= $input['nama_saksi2'][$i];?>
  447. <?php else: ?>
  448. &nbsp;
  449. <?php endif; ?>
  450. </td>
  451. <?php endfor; ?>
  452. <td colspan=21>&nbsp;</td>
  453. </tr>
  454. <tr>
  455. <td colspan="16">NIK</td>
  456. <td>:</td>
  457. <?php for ($i=0; $i<16; $i++): ?>
  458. <td class="kotak padat tengah">
  459. <?php if (isset($input['nik_saksi2'][$i])): ?>
  460. <?= $input['nik_saksi2'][$i];?>
  461. <?php else: ?>
  462. &nbsp;
  463. <?php endif; ?>
  464. </td>
  465. <?php endfor; ?>
  466. <td colspan="4">&nbsp;</td>
  467. </tr>
  468. <tr>
  469. <td colspan="16">Nomor Dokumen Perjalanan</td>
  470. <td>:</td>
  471. <?php for ($i=0; $i<16; $i++): ?>
  472. <td class="kotak padat tengah">
  473. &nbsp;
  474. </td>
  475. <?php endfor; ?>
  476. <td colspan="4">&nbsp;</td>
  477. </tr>
  478. <tr>
  479. <td colspan="16">Nomor Kartu Keluarga</td>
  480. <td>:</td>
  481. <?php for ($i=0; $i<16; $i++): ?>
  482. <td class="kotak padat tengah">
  483. &nbsp;
  484. </td>
  485. <?php endfor; ?>
  486. <td colspan="21">&nbsp;</td>
  487. </tr>
  488. <tr>
  489. <td colspan="16">Kewarganegaraan</td>
  490. <td>:</td>
  491. <?php for ($i=0; $i<16; $i++): ?>
  492. <td class="kotak padat tengah">
  493. <?php if (isset($input['warganegara_saksi2'][$i])): ?>
  494. <?= $input['warganegara_saksi2'][$i];?>
  495. <?php else: ?>
  496. &nbsp;
  497. <?php endif; ?>
  498. </td>
  499. <?php endfor; ?>
  500. <td colspan="21">&nbsp;</td>
  501. </tr>
  502. </table>
  503.  
  504. <table class="disdukcapil data-subjek-data-ortu" style="margin-top: 0px;">
  505. <col span="48" style="width: 2.0833%;">
  506. <tr>
  507. <td colspan=48><strong>DATA ORANG TUA **(<span style="font-style:italic;">hanya diisi untuk keperluan pencatatan kelahiran, lahir mati dan kematian</span>)</strong></td>
  508. </tr>
  509. <tr>
  510. <td colspan="16">Nama Ayah</td>
  511. <td>:</td>
  512. <?php for ($i=0; $i<26; $i++): ?>
  513. <td class="kotak padat tengah">
  514. <?php if (isset($input['nama_ayah'][$i])): ?>
  515. <?= $input['nama_ayah'][$i];?>
  516. <?php else: ?>
  517. &nbsp;
  518. <?php endif; ?>
  519. </td>
  520. <?php endfor; ?>
  521. <td colspan=21>&nbsp;</td>
  522. </tr>
  523. <tr>
  524. <td colspan="16">NIK Ayah</td>
  525. <td>:</td>
  526. <?php for ($i=0; $i<16; $i++): ?>
  527. <td class="kotak padat tengah">
  528. <?php if (isset($input['nik_ayah'][$i])): ?>
  529. <?= $input['nik_ayah'][$i];?>
  530. <?php else: ?>
  531. &nbsp;
  532. <?php endif; ?>
  533. </td>
  534. <?php endfor; ?>
  535. <td colspan="4">&nbsp;</td>
  536. </tr>
  537. <tr>
  538. <td colspan="16">Tempat Lahir Ayah</td>
  539. <td>:</td>
  540. <?php for ($i=0; $i<16; $i++): ?>
  541. <td class="kotak padat tengah">
  542. <?php if (isset($input['nik_ayah'][$i])): ?>
  543. <?= $input['nik_ayah'][$i];?>
  544. <?php else: ?>
  545. &nbsp;
  546. <?php endif; ?>
  547. </td>
  548. <?php endfor; ?>
  549. <td colspan="4">&nbsp;</td>
  550. </tr>
  551. <tr>
  552. <td colspan="16">Tanggal Lahir Ayah</td>
  553. <td>:</td>
  554. <?php if (!empty($input['tanggal_lahir_ayah'])):
  555. $tgl = date('dd',strtotime($input['tanggal_lahir_ayah']));
  556. $bln = date('mm',strtotime($input['tanggal_lahir_ayah']));
  557. $thn = date('Y',strtotime($input['tanggal_lahir_ayah']));
  558. else:
  559. unset($tgl); unset($bln); unset($thn);
  560. endif;
  561. ?>
  562. <td colspan="4">Tanggal :</td>
  563. <?php for ($j=0; $j<2; $j++): ?>
  564. <td class="kotak padat tengah">
  565. <?php if (isset($tgl[$j])): ?>
  566. <?= $tgl[$j];?>
  567. <?php else: ?>
  568. &nbsp;
  569. <?php endif; ?>
  570. </td>
  571. <?php endfor; ?>
  572. <td colspan="4" class="kanan">Bulan : </td>
  573. <?php for ($j=0; $j<2; $j++): ?>
  574. <td class="kotak padat tengah">
  575. <?php if (isset($bln[$j])): ?>
  576. <?= $bln[$j];?>
  577. <?php else: ?>
  578. &nbsp;
  579. <?php endif; ?>
  580. </td>
  581. <?php endfor; ?>
  582. <td colspan="4" class="kanan">Tahun : </td>
  583. <?php for ($j=0; $j<4; $j++): ?>
  584. <td class="kotak padat tengah">
  585. <?php if (isset($thn[$j])): ?>
  586. <?= $thn[$j];?>
  587. <?php else: ?>
  588. &nbsp;
  589. <?php endif; ?>
  590. </td>
  591. <?php endfor; ?>
  592. <td colspan="2">&nbsp;</td>
  593. </tr>
  594. <tr>
  595. <td colspan="16">Kewarganegaraan Ayah</td>
  596. <td>:</td>
  597. <?php for ($i=0; $i<16; $i++): ?>
  598. <td class="kotak padat tengah">
  599. <?php if (isset($input['wn_ayah'][$i])): ?>
  600. <?= $input['wn_ayah'][$i];?>
  601. <?php else: ?>
  602. &nbsp;
  603. <?php endif; ?>
  604. </td>
  605. <?php endfor; ?>
  606. <td colspan="21">&nbsp;</td>
  607. </tr>
  608. <tr>
  609. <td colspan="16">Nama Ibu</td>
  610. <td>:</td>
  611. <?php for ($i=0; $i<26; $i++): ?>
  612. <td class="kotak padat tengah">
  613. <?php if (isset($input['nama_ibu'][$i])): ?>
  614. <?= $input['nama_ibu'][$i];?>
  615. <?php else: ?>
  616. &nbsp;
  617. <?php endif; ?>
  618. </td>
  619. <?php endfor; ?>
  620. <td colspan=21>&nbsp;</td>
  621. </tr>
  622. <tr>
  623. <td colspan="16">NIK Ibu</td>
  624. <td>:</td>
  625. <?php for ($i=0; $i<16; $i++): ?>
  626. <td class="kotak padat tengah">
  627. <?php if (isset($input['nik_ibu'][$i])): ?>
  628. <?= $input['nik_ibu'][$i];?>
  629. <?php else: ?>
  630. &nbsp;
  631. <?php endif; ?>
  632. </td>
  633. <?php endfor; ?>
  634. <td colspan="4">&nbsp;</td>
  635. </tr>
  636. <tr>
  637. <td colspan="16">Tempat Lahir Ibu</td>
  638. <td>:</td>
  639. <?php for ($i=0; $i<16; $i++): ?>
  640. <td class="kotak padat tengah">
  641. <?php if (isset($input['nik_ayah'][$i])): ?>
  642. <?= $input['nik_ayah'][$i];?>
  643. <?php else: ?>
  644. &nbsp;
  645. <?php endif; ?>
  646. </td>
  647. <?php endfor; ?>
  648. <td colspan="4">&nbsp;</td>
  649. </tr>
  650. <tr>
  651. <td colspan="16">Tanggal Lahir Ibu</td>
  652. <td>:</td>
  653. <?php if (!empty($input['tanggal_lahir_ayah'])):
  654. $tgl = date('dd',strtotime($input['tanggal_lahir_ayah']));
  655. $bln = date('mm',strtotime($input['tanggal_lahir_ayah']));
  656. $thn = date('Y',strtotime($input['tanggal_lahir_ayah']));
  657. else:
  658. unset($tgl); unset($bln); unset($thn);
  659. endif;
  660. ?>
  661. <td colspan="4">Tanggal :</td>
  662. <?php for ($j=0; $j<2; $j++): ?>
  663. <td class="kotak padat tengah">
  664. <?php if (isset($tgl[$j])): ?>
  665. <?= $tgl[$j];?>
  666. <?php else: ?>
  667. &nbsp;
  668. <?php endif; ?>
  669. </td>
  670. <?php endfor; ?>
  671. <td colspan="4" class="kanan">Bulan : </td>
  672. <?php for ($j=0; $j<2; $j++): ?>
  673. <td class="kotak padat tengah">
  674. <?php if (isset($bln[$j])): ?>
  675. <?= $bln[$j];?>
  676. <?php else: ?>
  677. &nbsp;
  678. <?php endif; ?>
  679. </td>
  680. <?php endfor; ?>
  681. <td colspan="4" class="kanan">Tahun : </td>
  682. <?php for ($j=0; $j<4; $j++): ?>
  683. <td class="kotak padat tengah">
  684. <?php if (isset($thn[$j])): ?>
  685. <?= $thn[$j];?>
  686. <?php else: ?>
  687. &nbsp;
  688. <?php endif; ?>
  689. </td>
  690. <?php endfor; ?>
  691. <td colspan="2">&nbsp;</td>
  692. </tr>
  693. <tr>
  694. <td colspan="16">Kewarganegaraan Ibu</td>
  695. <td>:</td>
  696. <?php for ($i=0; $i<16; $i++): ?>
  697. <td class="kotak padat tengah">
  698. <?php if (isset($input['wn_ayah'][$i])): ?>
  699. <?= $input['wn_ayah'][$i];?>
  700. <?php else: ?>
  701. &nbsp;
  702. <?php endif; ?>
  703. </td>
  704. <?php endfor; ?>
  705. <td colspan="21">&nbsp;</td>
  706. </tr>
  707. </table>
  708.  
  709. <table class="disdukcapil data-subjek-data-anak" style="margin-top: 0px;">
  710. <col span="48" style="width: 2.0833%;">
  711. <tr>
  712. <td colspan=48><strong>DATA ANAK</strong></td>
  713. </tr>
  714. <tr>
  715. <td colspan="16">Nama</td>
  716. <td>:</td>
  717. <?php for ($i=0; $i<26; $i++): ?>
  718. <td class="kotak padat tengah">
  719. &nbsp;
  720. </td>
  721. <?php endfor; ?>
  722. <td colspan="4">&nbsp;</td>
  723. </tr>
  724. <tr>
  725. <td colspan="16">&nbsp;</td>
  726. <td>&nbsp;&nbsp;</td>
  727. <?php for ($i=0; $i<26; $i++): ?>
  728. <td class="kotak padat tengah">
  729. &nbsp;
  730. </td>
  731. <?php endfor; ?>
  732. <td colspan="4">&nbsp;</td>
  733. </tr>
  734. <tr>
  735. <td colspan="16">Jenis Kelamin </td>
  736. <td>:</td>
  737. <td class="kotak padat tengah">
  738. <?= $input['sex'];?>
  739. </td>
  740. <td colspan=5>1. Laki-laki </td>
  741. <td colspan=7>2. Perempuan </td>
  742. <td colspan=4>&nbsp;</td>
  743. </tr>
  744. <tr>
  745. <td colspan="16">Tempat Dilahirkan </td>
  746. <td>:</td>
  747. <?php for ($i=0; $i<1; $i++): ?>
  748. <td class="kotak padat tengah">
  749. &nbsp;
  750. </td>
  751. <?php endfor; ?>
  752. <td colspan=4>1. RS/SB</td>
  753. <td colspan=6>2. Puskesmas </td>
  754. <td colspan=6>3. Polindes</td>
  755. <td colspan=5>4. Rumah </td>
  756. <td colspan=7>5. Lainnya &nbsp; </td>
  757. <td colspan="2">&nbsp;</td>
  758. </tr>
  759. <tr>
  760. <td colspan="16">Tempat Kelahiran </td>
  761. <td>:</td>
  762. <td colspan="23" class="kotak">&nbsp;</td>
  763. <td colspan="2">&nbsp;</td>
  764. </tr>
  765. <tr>
  766. <td colspan="16">Hari dan Tanggal Lahir </td>
  767. <td>:</td>
  768. <td colspan="3">Hari : </td>
  769. <td colspan=4 class="kotak">&nbsp;</td>
  770. <?php
  771. $tgl = date('dd',strtotime($input['tanggallahir']));
  772. $bln = date('mm',strtotime($input['tanggallahir']));
  773. $thn = date('Y',strtotime($input['tanggallahir']));
  774. ?>
  775. <td colspan="4" class="kanan">Tgl : </td>
  776. <?php for ($j=0; $j<2; $j++): ?>
  777. <td class="kotak padat tengah">
  778. &nbsp;
  779. </td>
  780. <?php endfor; ?>
  781. <td colspan="4" class="kanan">Bln : </td>
  782. <?php for ($j=0; $j<2; $j++): ?>
  783. <td class="kotak padat tengah">
  784. &nbsp;
  785. </td>
  786. <?php endfor; ?>
  787. <td colspan="4" class="kanan">Thn : </td>
  788. <?php for ($j=0; $j<4; $j++): ?>
  789. <td class="kotak padat tengah">
  790. &nbsp;
  791. </td>
  792. <?php endfor; ?>
  793. <td colspan="12">&nbsp;</td>
  794. <td colspan="2">&nbsp;</td>
  795. </tr>
  796. <tr>
  797. <td colspan="16">Pukul </td>
  798. <td>:</td>
  799. <?php for ($i=0; $i<4; $i++): ?>
  800. <td class="kotak padat tengah">
  801. &nbsp;
  802. </td>
  803. <?php endfor; ?>
  804. <td colspan="4">&nbsp;</td>
  805. </tr>
  806. <tr>
  807. <td colspan="16">Jenis Kelahiran </td>
  808. <td>:</td>
  809. <?php for ($i=0; $i<1; $i++): ?>
  810. <td class="kotak padat tengah">
  811. &nbsp;
  812. </td>
  813. <?php endfor; ?>
  814. <td colspan=4>1. Tunggal</td>
  815. <td colspan=6>2. Kembar 2 </td>
  816. <td colspan=6>3. Kembar 3 </td>
  817. <td colspan=5>4. Kembar 4 </td>
  818. <td colspan=4>5. Lainnya </td>
  819. <td colspan=7>&nbsp;</td>
  820. </tr>
  821. <tr>
  822. <td colspan="16">Kelahiran ke </td>
  823. <td>:</td>
  824. <?php for ($i=0; $i<1; $i++): ?>
  825. <td class="kotak padat tengah">
  826. &nbsp;
  827. </td>
  828. <?php endfor; ?>
  829. <td colspan=7>&nbsp;</td>
  830. </tr>
  831. <tr>
  832. <td colspan="16">Penolong Kelahiran </td>
  833. <td>:</td>
  834. <?php for ($i=0; $i<1; $i++): ?>
  835. <td class="kotak padat tengah">
  836. &nbsp;
  837. </td>
  838. <?php endfor; ?>
  839. <td colspan=4>1. Dokter </td>
  840. <td colspan=6>2. Bidan/Perawat </td>
  841. <td colspan=6>3. Dukun </td>
  842. <td colspan=5>4. Lainnya </td>
  843. <td colspan=7>&nbsp;</td>
  844. </tr>
  845. <tr>
  846. <td colspan="16">Berat Bayi</td>
  847. <td>:</td>
  848. <td colspan="2" class="kotak">&nbsp;</td>
  849. <td> kg</td>
  850. <td colspan="21">&nbsp;</td>
  851. </tr>
  852. <tr>
  853. <td colspan="16">Panjang Bayi</td>
  854. <td>:</td>
  855. <td colspan="2" class="kotak">&nbsp;</td>
  856. <td> cm</td>
  857. <td colspan="22">&nbsp;</td>
  858. </tr>
  859. </table>
  860.  
  861. <table class="disdukcapil data-subjek-lahir-mati" style="margin-top: 0px;">
  862. <col span="48" style="width: 2.0833%;">
  863. <tr>
  864. <td colspan=48><strong>YANG LAHIR MATI</strong></td>
  865. </tr>
  866. <tr>
  867. <td colspan="16">1. &nbsp;Lamanya dalam kandungan</td>
  868. <td>:</td>
  869. <td colspan=4 class="kotak">&nbsp;</td>
  870. <?php
  871. $bln = date('mm',strtotime($input['tanggallahir']));
  872. ?>
  873. <td colspan="3">Bulan</td>
  874. </tr>
  875. <tr>
  876. <td colspan="16">2. &nbsp;Jenis Kelamin </td>
  877. <td>:</td>
  878. <td class="kotak padat tengah">
  879. &nbsp;
  880. </td>
  881. <td colspan=5>1. Laki-laki </td>
  882. <td colspan=7>2. Perempuan </td>
  883. <td colspan=4>&nbsp;</td>
  884. </tr>
  885. <tr>
  886. <td colspan="16">3. &nbsp;Tanggal Lahir Mati</td>
  887. <td>:</td>
  888. <?php $tgl = date('dd',strtotime($input['tanggal_lahir_pelapor']));
  889. $bln = date('mm',strtotime($input['tanggal_lahir_pelapor']));
  890. $thn = date('Y',strtotime($input['tanggal_lahir_pelapor']));
  891. ?>
  892. <td colspan="4">Tgl :</td>
  893. <?php for ($j=0; $j<2; $j++): ?>
  894. <td class="kotak padat tengah">
  895. &nbsp;
  896. </td>
  897. <?php endfor; ?>
  898. <td colspan="4" class="kanan">Bln : </td>
  899. <?php for ($j=0; $j<2; $j++): ?>
  900. <td class="kotak padat tengah">
  901. &nbsp;
  902. </td>
  903. <?php endfor; ?>
  904. <td colspan="4" class="kanan">Thn : </td>
  905. <?php for ($j=0; $j<4; $j++): ?>
  906. <td class="kotak padat tengah">
  907. &nbsp;
  908. </td>
  909. <?php endfor; ?>
  910. <td colspan="4">&nbsp;</td>
  911. </tr>
  912. <tr>
  913. <td colspan="16">4. &nbsp;Jenis Kelahiran </td>
  914. <td>:</td>
  915. <?php for ($i=0; $i<1; $i++): ?>
  916. <td class="kotak padat tengah">
  917. &nbsp;
  918. </td>
  919. <?php endfor; ?>
  920. <td colspan=4>1. Tunggal</td>
  921. <td colspan=6>2. Kembar 2 </td>
  922. <td colspan=6>3. Kembar 3 </td>
  923. <td colspan=5>4. Kembar 4 </td>
  924. <td colspan=7>5. Lainnya &nbsp; </td>
  925. <td colspan=7>&nbsp;</td>
  926. </tr>
  927. <tr>
  928. <td colspan="16">5. &nbsp;Anak Ke </td>
  929. <td>:</td>
  930. <td colspan="1" class="kotak">&nbsp;</td>
  931. <td colspan="2">&nbsp;</td>
  932. </tr>
  933. <tr>
  934. <td colspan="16">6. &nbsp;Tempat Dilahirkan </td>
  935. <td>:</td>
  936. <?php for ($i=0; $i<1; $i++): ?>
  937. <td class="kotak padat tengah">
  938. &nbsp;
  939. </td>
  940. <?php endfor; ?>
  941. <td colspan=4>1. RS/SB</td>
  942. <td colspan=6>2. Puskesmas </td>
  943. <td colspan=6>3. Polindes</td>
  944. <td colspan=5>4. Rumah </td>
  945. <td colspan=7>5. Lainnya &nbsp; </td>
  946. <td colspan="2">&nbsp;</td>
  947. </tr>
  948. <tr>
  949. <td colspan="16">7. &nbsp;Penolong Kelahiran </td>
  950. <td>:</td>
  951. <?php for ($i=0; $i<1; $i++): ?>
  952. <td class="kotak padat tengah">
  953. &nbsp;
  954. </td>
  955. <?php endfor; ?>
  956. <td colspan=4>1. Dokter </td>
  957. <td colspan=6>2. Bidan/Perawat </td>
  958. <td colspan=6>3. Dukun </td>
  959. <td colspan=5>4. Lainnya </td>
  960. <td colspan=7>&nbsp;</td>
  961. </tr>
  962. <tr>
  963. <td colspan="16">8. &nbsp;Sebab Lahir Mati</td>
  964. <td>:</td>
  965. <td colspan="23" class="kotak">&nbsp;</td>
  966. <td colspan="2">&nbsp;</td>
  967. </tr>
  968. <tr>
  969. <td colspan="16">9. &nbsp;Yang menentukan </td>
  970. <td>:</td>
  971. <?php for ($i=0; $i<1; $i++): ?>
  972. <td class="kotak padat tengah">
  973. &nbsp;
  974. </td>
  975. <?php endfor; ?>
  976. <td colspan=4>1. Dokter </td>
  977. <td colspan=6>2. Bidan/Perawat </td>
  978. <td colspan=6>3. Tenaga Kes </td>
  979. <td colspan=5>4. Kepolisian</td>
  980. <td colspan=5>5. Lainnya </td>
  981. <td colspan=7>&nbsp;</td>
  982. </tr>
  983. <tr>
  984. <td colspan="16">10. &nbsp;Tempat Kelahiran</td>
  985. <td>:</td>
  986. <td colspan="23" class="kotak">&nbsp;</td>
  987. <td colspan="2">&nbsp;</td>
  988. </tr>
  989.  
  990.  
  991.  
  992. </table>
  993.  
  994. <table class="disdukcapil data-subjek-data-perkawinan" style="margin-top: 0px;">
  995. <col span="48" style="width: 2.0833%;">
  996. <tr>
  997. <td colspan=48><strong>PERKAWINAN ATAU PEMBATALAN PERKAWINAN</strong></td>
  998. </tr>
  999. <tr>
  1000. <td colspan="16">1. &nbsp;NIK Ayah dari Suami</td>
  1001. <td>:</td>
  1002. <?php for ($i=0; $i<16; $i++): ?>
  1003. <td class="kotak padat tengah">
  1004. &nbsp;
  1005. </td>
  1006. <?php endfor; ?>
  1007. <td colspan="4">&nbsp;</td>
  1008. </tr>
  1009. <tr>
  1010. <td colspan="16">2. &nbsp;Nama Ayah dari Suami</td>
  1011. <td>:</td>
  1012. <?php for ($i=0; $i<26; $i++): ?>
  1013. <td class="kotak padat tengah">
  1014. &nbsp;
  1015. </td>
  1016. <?php endfor; ?>
  1017. <td colspan=21>&nbsp;</td>
  1018. </tr>
  1019. <tr>
  1020. <td colspan="16">3. &nbsp;NIK Ibu dari Suami</td>
  1021. <td>:</td>
  1022. <?php for ($i=0; $i<16; $i++): ?>
  1023. <td class="kotak padat tengah">
  1024. &nbsp;
  1025. </td>
  1026. <?php endfor; ?>
  1027. <td colspan="4">&nbsp;</td>
  1028. </tr>
  1029. <tr>
  1030. <td colspan="16">4. &nbsp;Nama Ibu dari Suami</td>
  1031. <td>:</td>
  1032. <?php for ($i=0; $i<26; $i++): ?>
  1033. <td class="kotak padat tengah">
  1034. &nbsp;
  1035. </td>
  1036. <?php endfor; ?>
  1037. <td colspan=21>&nbsp;</td>
  1038. </tr>
  1039. <tr>
  1040. <td colspan="16">5. &nbsp;NIK Ayah dari Istri</td>
  1041. <td>:</td>
  1042. <?php for ($i=0; $i<16; $i++): ?>
  1043. <td class="kotak padat tengah">
  1044. &nbsp;
  1045. </td>
  1046. <?php endfor; ?>
  1047. <td colspan="4">&nbsp;</td>
  1048. </tr>
  1049. <tr>
  1050. <td colspan="16">6. &nbsp;Nama Ayah dari Istri</td>
  1051. <td>:</td>
  1052. <?php for ($i=0; $i<26; $i++): ?>
  1053. <td class="kotak padat tengah">
  1054. &nbsp;
  1055. </td>
  1056. <?php endfor; ?>
  1057. <td colspan=21>&nbsp;</td>
  1058. </tr>
  1059. <tr>
  1060. <td colspan="16">7. &nbsp;NIK Ibu dari Istri</td>
  1061. <td>:</td>
  1062. <?php for ($i=0; $i<16; $i++): ?>
  1063. <td class="kotak padat tengah">
  1064. &nbsp;
  1065. </td>
  1066. <?php endfor; ?>
  1067. <td colspan="4">&nbsp;</td>
  1068. </tr>
  1069. <tr>
  1070. <td colspan="16">8. &nbsp;Nama Ibu dari Istri</td>
  1071. <td>:</td>
  1072. <?php for ($i=0; $i<26; $i++): ?>
  1073. <td class="kotak padat tengah">
  1074. &nbsp;
  1075. </td>
  1076. <?php endfor; ?>
  1077. <td colspan=21>&nbsp;</td>
  1078. </tr>
  1079. <tr>
  1080. <td colspan="16">9. &nbsp;Status Perkawinan Sebelum Kawin</td>
  1081. <td>:</td>
  1082. <?php for ($i=0; $i<1; $i++): ?>
  1083. <td class="kotak padat tengah">
  1084. &nbsp;
  1085. </td>
  1086. <?php endfor; ?>
  1087. <td colspan=4>Kawin</td>
  1088. <td colspan=6>Belum Kawin</td>
  1089. <td colspan=6>Cerai Hidup</td>
  1090. <td colspan=5>Cerai Mati</td>
  1091. <td colspan=7>&nbsp;</td>
  1092. </tr>
  1093. <tr>
  1094. <td colspan="16">10. &nbsp;Perkawinan yang Ke-</td>
  1095. <td>:</td>
  1096. <td colspan="1" class="kotak">&nbsp;</td>
  1097. <td colspan="21">&nbsp;</td>
  1098. </tr>
  1099. <tr>
  1100. <td colspan="16">11. &nbsp;Istri yang ke (bagi yang poligami)</td>
  1101. <td>:</td>
  1102. <td colspan="1" class="kotak">&nbsp;</td>
  1103. <td colspan="21">&nbsp;</td>
  1104. </tr>
  1105. <tr>
  1106. <td colspan="16">12. &nbsp;Tanggal Pemberkatan Perkawinan</td>
  1107. <td>:</td>
  1108. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1109. $bln = date('mm',strtotime($individu['tanggallahir']));
  1110. $thn = date('Y',strtotime($individu['tanggallahir']));
  1111. ?>
  1112. <td colspan="4">Tanggal :</td>
  1113. <?php for ($j=0; $j<2; $j++): ?>
  1114. <td class="kotak padat tengah">
  1115. &nbsp;
  1116. </td>
  1117. <?php endfor; ?>
  1118. <td colspan="4" class="kanan">Bulan : </td>
  1119. <?php for ($j=0; $j<2; $j++): ?>
  1120. <td class="kotak padat tengah">
  1121. &nbsp;
  1122. </td>
  1123. <?php endfor; ?>
  1124. <td colspan="4" class="kanan">Tahun : </td>
  1125. <?php for ($j=0; $j<4; $j++): ?>
  1126. <td class="kotak padat tengah">
  1127. &nbsp;
  1128. </td>
  1129. <?php endfor; ?>
  1130. <td colspan="4">&nbsp;</td>
  1131. </tr>
  1132. <tr>
  1133. <td colspan="16">13. &nbsp;Tanggal Melapor</td>
  1134. <td>:</td>
  1135. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1136. $bln = date('mm',strtotime($individu['tanggallahir']));
  1137. $thn = date('Y',strtotime($individu['tanggallahir']));
  1138. ?>
  1139. <td colspan="4">Tanggal :</td>
  1140. <?php for ($j=0; $j<2; $j++): ?>
  1141. <td class="kotak padat tengah">
  1142. &nbsp;
  1143. </td>
  1144. <?php endfor; ?>
  1145. <td colspan="4" class="kanan">Bulan : </td>
  1146. <?php for ($j=0; $j<2; $j++): ?>
  1147. <td class="kotak padat tengah">
  1148. &nbsp;
  1149. </td>
  1150. <?php endfor; ?>
  1151. <td colspan="4" class="kanan">Tahun : </td>
  1152. <?php for ($j=0; $j<4; $j++): ?>
  1153. <td class="kotak padat tengah">
  1154. &nbsp;
  1155. </td>
  1156. <?php endfor; ?>
  1157. <td colspan="4">&nbsp;</td>
  1158. </tr>
  1159. <tr>
  1160. <td colspan="16">14. &nbsp;Jam Pelaporan</td>
  1161. <td>:</td>
  1162. <?php for ($i=0; $i<5; $i++): ?>
  1163. <td class="kotak padat tengah">
  1164. &nbsp;
  1165. </td>
  1166. <?php endfor; ?>
  1167. <td colspan="4">&nbsp;</td>
  1168. </tr>
  1169. <tr>
  1170. <td colspan="16">15. &nbsp;Agama </td>
  1171. <td>:</td>
  1172. <td class="kotak padat tengah">
  1173. &nbsp;
  1174. </td>
  1175. <td colspan=4>1. Islam</td>
  1176. <td colspan=6>2. Kristen </td>
  1177. <td colspan=6>3. Katolik </td>
  1178. <td colspan=5>4. Hindu </td>
  1179. <td colspan=5>5. Budha </td>
  1180. <td colspan=6>6. Lainnya </td>
  1181. <td colspan="4">&nbsp;</td>
  1182. </tr>
  1183. <tr>
  1184. <td colspan="16">16. &nbsp;Kepercayaan</td>
  1185. <td>:</td>
  1186. <td colspan="1" class="kotak"> &nbsp;</td>
  1187. <td colspan="21">&nbsp;</td>
  1188. </tr>
  1189. <tr>
  1190. <td colspan="16">17. &nbsp;Nama Organisasi Kepercayaan</td>
  1191. <td>:</td>
  1192. <?php for ($i=0; $i<26; $i++): ?>
  1193. <td class="kotak padat tengah">
  1194. &nbsp;
  1195. </td>
  1196. <?php endfor; ?>
  1197. <td colspan=21>&nbsp;</td>
  1198. </tr>
  1199. <tr>
  1200. <td colspan="16">18. &nbsp;Nama Pengadilan</td>
  1201. <td>:</td>
  1202. <?php for ($i=0; $i<16; $i++): ?>
  1203. <td class="kotak padat tengah">
  1204. &nbsp;
  1205. </td>
  1206. <?php endfor; ?>
  1207. <td colspan=21>&nbsp;</td>
  1208. </tr>
  1209. <tr>
  1210. <td colspan="16">19. &nbsp;Nomor Penetapan Pengadilan</td>
  1211. <td>:</td>
  1212. <?php for ($i=0; $i<16; $i++): ?>
  1213. <td class="kotak padat tengah">
  1214. &nbsp;
  1215. </td>
  1216. <?php endfor; ?>
  1217. <td colspan=21>&nbsp;</td>
  1218. </tr>
  1219. <tr>
  1220. <td colspan="16">20. &nbsp;Tanggal Penetapan Pengadilan</td>
  1221. <td>:</td>
  1222. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1223. $bln = date('mm',strtotime($individu['tanggallahir']));
  1224. $thn = date('Y',strtotime($individu['tanggallahir']));
  1225. ?>
  1226. <td colspan="4">Tanggal :</td>
  1227. <?php for ($j=0; $j<2; $j++): ?>
  1228. <td class="kotak padat tengah">
  1229. &nbsp;
  1230. </td>
  1231. <?php endfor; ?>
  1232. <td colspan="4" class="kanan">Bulan : </td>
  1233. <?php for ($j=0; $j<2; $j++): ?>
  1234. <td class="kotak padat tengah">
  1235. &nbsp;
  1236. </td>
  1237. <?php endfor; ?>
  1238. <td colspan="4" class="kanan">Tahun : </td>
  1239. <?php for ($j=0; $j<4; $j++): ?>
  1240. <td class="kotak padat tengah">
  1241. &nbsp;
  1242. </td>
  1243. <?php endfor; ?>
  1244. <td colspan="4">&nbsp;</td>
  1245. </tr>
  1246. <tr>
  1247. <td colspan="16">21. &nbsp;Nama Pemuka Agama/ Kepercayaan</td>
  1248. <td>:</td>
  1249. <?php for ($i=0; $i<26; $i++): ?>
  1250. <td class="kotak padat tengah">
  1251. &nbsp;
  1252. </td>
  1253. <?php endfor; ?>
  1254. <td colspan=21>&nbsp;</td>
  1255. </tr>
  1256. <tr>
  1257. <td colspan="16">22. &nbsp;Nomor Surat Izin dari Perwakilan</td>
  1258. <td>:</td>
  1259. <?php for ($i=0; $i<16; $i++): ?>
  1260. <td class="kotak padat tengah">
  1261. &nbsp;
  1262. </td>
  1263. <?php endfor; ?>
  1264. <td colspan=21>&nbsp;</td>
  1265. </tr>
  1266. <tr>
  1267. <td colspan="16">23. &nbsp;Nomor Pasport</td>
  1268. <td>:</td>
  1269. <?php for ($i=0; $i<16; $i++): ?>
  1270. <td class="kotak padat tengah">
  1271. &nbsp;
  1272. </td>
  1273. <?php endfor; ?>
  1274. <td colspan=21>&nbsp;</td>
  1275. </tr>
  1276. <tr>
  1277. <td colspan="16">24. &nbsp;Perjanjian Perkawinan Dibuat oleh Notaris</td>
  1278. <td>:</td>
  1279. <?php for ($i=0; $i<16; $i++): ?>
  1280. <td class="kotak padat tengah">
  1281. &nbsp;
  1282. </td>
  1283. <?php endfor; ?>
  1284. <td colspan=21>&nbsp;</td>
  1285. </tr>
  1286. <tr>
  1287. <td colspan="16">25. &nbsp;Nomor Akta Notari</td>
  1288. <td>:</td>
  1289. <?php for ($i=0; $i<16; $i++): ?>
  1290. <td class="kotak padat tengah">
  1291. &nbsp;
  1292. </td>
  1293. <?php endfor; ?>
  1294. <td colspan=21>&nbsp;</td>
  1295. </tr>
  1296. <tr>
  1297. <td colspan="16">26. &nbsp;Tanggal Akta Notaris</td>
  1298. <td>:</td>
  1299. <?php for ($i=0; $i<16; $i++): ?>
  1300. <td class="kotak padat tengah">
  1301. &nbsp;
  1302. </td>
  1303. <?php endfor; ?>
  1304. <td colspan=21>&nbsp;</td>
  1305. </tr>
  1306. <tr>
  1307. <td colspan="16">27. &nbsp;Jumlah Anak (jika ada agar mengisi Formulir</td>
  1308. <td>:</td>
  1309. <?php for ($i=0; $i<16; $i++): ?>
  1310. <td class="kotak padat tengah">
  1311. &nbsp;
  1312. </td>
  1313. <?php endfor; ?>
  1314. <td colspan=21>&nbsp;</td>
  1315. </tr>
  1316. <tr>
  1317. <td colspan="16">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; tambahan nama anak dan akta kelahiran anak)</td>
  1318. <td></td>
  1319. <td></td>
  1320. </tr>
  1321. <tr>
  1322. <td colspan=48><strong>Bagi Pemohon Pembatalan Perceraian Harap Mengisi Data di bawah ini:</strong></td>
  1323. </tr>
  1324. <tr>
  1325. <td colspan="16">1. &nbsp;&nbsp;Tanggal Perkawinan</td>
  1326. <td>:</td>
  1327. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1328. $bln = date('mm',strtotime($individu['tanggallahir']));
  1329. $thn = date('Y',strtotime($individu['tanggallahir']));
  1330. ?>
  1331. <td colspan="4">Tanggal :</td>
  1332. <?php for ($j=0; $j<2; $j++): ?>
  1333. <td class="kotak padat tengah">
  1334. &nbsp;
  1335. </td>
  1336. <?php endfor; ?>
  1337. <td colspan="4" class="kanan">Bulan : </td>
  1338. <?php for ($j=0; $j<2; $j++): ?>
  1339. <td class="kotak padat tengah">
  1340. &nbsp;
  1341. </td>
  1342. <?php endfor; ?>
  1343. <td colspan="4" class="kanan">Tahun : </td>
  1344. <?php for ($j=0; $j<4; $j++): ?>
  1345. <td class="kotak padat tengah">
  1346. &nbsp;
  1347. </td>
  1348. <?php endfor; ?>
  1349. <td colspan="4">&nbsp;</td>
  1350. </tr>
  1351. <tr>
  1352. <td colspan="16">2. &nbsp;&nbsp;Nomor Akta Perkawinan</td>
  1353. <td>:</td>
  1354. <?php for ($i=0; $i<18; $i++): ?>
  1355. <td class="kotak padat tengah">
  1356. &nbsp;
  1357. </td>
  1358. <?php endfor; ?>
  1359. <td colspan=21>&nbsp;</td>
  1360. </tr>
  1361. <tr>
  1362. <td colspan="16">3. &nbsp;&nbsp;Tanggal Akta Perkawinan</td>
  1363. <td>:</td>
  1364. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1365. $bln = date('mm',strtotime($individu['tanggallahir']));
  1366. $thn = date('Y',strtotime($individu['tanggallahir']));
  1367. ?>
  1368. <td colspan="4">Tanggal :</td>
  1369. <?php for ($j=0; $j<2; $j++): ?>
  1370. <td class="kotak padat tengah">
  1371. &nbsp;
  1372. </td>
  1373. <?php endfor; ?>
  1374. <td colspan="4" class="kanan">Bulan : </td>
  1375. <?php for ($j=0; $j<2; $j++): ?>
  1376. <td class="kotak padat tengah">
  1377. &nbsp;
  1378. </td>
  1379. <?php endfor; ?>
  1380. <td colspan="4" class="kanan">Tahun : </td>
  1381. <?php for ($j=0; $j<4; $j++): ?>
  1382. <td class="kotak padat tengah">
  1383. &nbsp;
  1384. </td>
  1385. <?php endfor; ?>
  1386. <td colspan="4">&nbsp;</td>
  1387. </tr>
  1388. <tr>
  1389. <td colspan="16">4. &nbsp;&nbsp;Nama Pengadilan</td>
  1390. <td>:</td>
  1391. <?php for ($i=0; $i<18; $i++): ?>
  1392. <td class="kotak padat tengah">
  1393. &nbsp;
  1394. </td>
  1395. <?php endfor; ?>
  1396. <td colspan=21>&nbsp;</td>
  1397. </tr>
  1398. <tr>
  1399. <td colspan="16">5. &nbsp;&nbsp;Nomor Putusan Pengadilan</td>
  1400. <td>:</td>
  1401. <?php for ($i=0; $i<18; $i++): ?>
  1402. <td class="kotak padat tengah">
  1403. &nbsp;
  1404. </td>
  1405. <?php endfor; ?>
  1406. <td colspan=21>&nbsp;</td>
  1407. </tr>
  1408. <tr>
  1409. <td colspan="16">6. &nbsp;&nbsp;Tanggal Putusan Pengadilan</td>
  1410. <td>:</td>
  1411. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1412. $bln = date('mm',strtotime($individu['tanggallahir']));
  1413. $thn = date('Y',strtotime($individu['tanggallahir']));
  1414. ?>
  1415. <td colspan="4">Tanggal :</td>
  1416. <?php for ($j=0; $j<2; $j++): ?>
  1417. <td class="kotak padat tengah">
  1418. &nbsp;
  1419. </td>
  1420. <?php endfor; ?>
  1421. <td colspan="4" class="kanan">Bulan : </td>
  1422. <?php for ($j=0; $j<2; $j++): ?>
  1423. <td class="kotak padat tengah">
  1424. &nbsp;
  1425. </td>
  1426. <?php endfor; ?>
  1427. <td colspan="4" class="kanan">Tahun : </td>
  1428. <?php for ($j=0; $j<4; $j++): ?>
  1429. <td class="kotak padat tengah">
  1430. &nbsp;
  1431. </td>
  1432. <?php endfor; ?>
  1433. <td colspan="4">&nbsp;</td>
  1434. </tr>
  1435. <tr>
  1436. <td colspan="16">7. &nbsp;&nbsp;Tanggal Pelaporan Perkawinan di Luar Negeri</td>
  1437. <td>:</td>
  1438. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1439. $bln = date('mm',strtotime($individu['tanggallahir']));
  1440. $thn = date('Y',strtotime($individu['tanggallahir']));
  1441. ?>
  1442. <td colspan="4">Tanggal :</td>
  1443. <?php for ($j=0; $j<2; $j++): ?>
  1444. <td class="kotak padat tengah">
  1445. &nbsp;
  1446. </td>
  1447. <?php endfor; ?>
  1448. <td colspan="4" class="kanan">Bulan : </td>
  1449. <?php for ($j=0; $j<2; $j++): ?>
  1450. <td class="kotak padat tengah">
  1451. &nbsp;
  1452. </td>
  1453. <?php endfor; ?>
  1454. <td colspan="4" class="kanan">Tahun : </td>
  1455. <?php for ($j=0; $j<4; $j++): ?>
  1456. <td class="kotak padat tengah">
  1457. &nbsp;
  1458. </td>
  1459. <?php endfor; ?>
  1460. <td colspan="4">&nbsp;</td>
  1461. </tr>
  1462. </table>
  1463.  
  1464. <table class="disdukcapil data-pelapor" style="margin-top: 0px;">
  1465. <col span="48" style="width: 2.0833%;">
  1466. <tr>
  1467. <td colspan=48><strong>PERCERAIAN ATAU PEMBATALAN PERCERAIAN</strong></td>
  1468. </tr>
  1469. <tr>
  1470. <td colspan=48><strong>Yang mengajukan perceraian/pembatalan perceraian ***</strong></td>
  1471. </tr>
  1472. <tr>
  1473. <td colspan="16">1. &nbsp;&nbsp;Nomor akta perkawinan</td>
  1474. <td>:</td>
  1475. <?php for ($i=0; $i<18; $i++): ?>
  1476. <td class="kotak padat tengah">
  1477. &nbsp;
  1478. </td>
  1479. <?php endfor; ?>
  1480. <td colspan=21>&nbsp;</td>
  1481. </tr>
  1482. <tr>
  1483. <td colspan="16">2. &nbsp;&nbsp;Tanggal Akta Perkawinan</td>
  1484. <td>:</td>
  1485. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1486. $bln = date('mm',strtotime($individu['tanggallahir']));
  1487. $thn = date('Y',strtotime($individu['tanggallahir']));
  1488. ?>
  1489. <td colspan="4">Tanggal :</td>
  1490. <?php for ($j=0; $j<2; $j++): ?>
  1491. <td class="kotak padat tengah">
  1492. &nbsp;
  1493. </td>
  1494. <?php endfor; ?>
  1495. <td colspan="4" class="kanan">Bulan : </td>
  1496. <?php for ($j=0; $j<2; $j++): ?>
  1497. <td class="kotak padat tengah">
  1498. &nbsp;
  1499. </td>
  1500. <?php endfor; ?>
  1501. <td colspan="4" class="kanan">Tahun : </td>
  1502. <?php for ($j=0; $j<4; $j++): ?>
  1503. <td class="kotak padat tengah">
  1504. &nbsp;
  1505. </td>
  1506. <?php endfor; ?>
  1507. <td colspan="4">&nbsp;</td>
  1508. </tr>
  1509. <tr>
  1510. <td colspan="16">3. &nbsp;&nbsp;Tempat Pencatatan Perkawinan</td>
  1511. <td>:</td>
  1512. <?php for ($i=0; $i<18; $i++): ?>
  1513. <td class="kotak padat tengah">
  1514. &nbsp;
  1515. </td>
  1516. <?php endfor; ?>
  1517. <td colspan=21>&nbsp;</td>
  1518. </tr>
  1519. <tr>
  1520. <td colspan="16">4. &nbsp;&nbsp;Nama Pengadilan</td>
  1521. <td>:</td>
  1522. <?php for ($i=0; $i<18; $i++): ?>
  1523. <td class="kotak padat tengah">
  1524. &nbsp;
  1525. </td>
  1526. <?php endfor; ?>
  1527. <td colspan=21>&nbsp;</td>
  1528. </tr>
  1529. <tr>
  1530. <td colspan="16">5. &nbsp;&nbsp;Tanggal Putusan Pengadilan</td>
  1531. <td>:</td>
  1532. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1533. $bln = date('mm',strtotime($individu['tanggallahir']));
  1534. $thn = date('Y',strtotime($individu['tanggallahir']));
  1535. ?>
  1536. <td colspan="4">Tanggal :</td>
  1537. <?php for ($j=0; $j<2; $j++): ?>
  1538. <td class="kotak padat tengah">
  1539. &nbsp;
  1540. </td>
  1541. <?php endfor; ?>
  1542. <td colspan="4" class="kanan">Bulan : </td>
  1543. <?php for ($j=0; $j<2; $j++): ?>
  1544. <td class="kotak padat tengah">
  1545. &nbsp;
  1546. </td>
  1547. <?php endfor; ?>
  1548. <td colspan="4" class="kanan">Tahun : </td>
  1549. <?php for ($j=0; $j<4; $j++): ?>
  1550. <td class="kotak padat tengah">
  1551. &nbsp;
  1552. </td>
  1553. <?php endfor; ?>
  1554. <td colspan="4">&nbsp;</td>
  1555. </tr>
  1556. <tr>
  1557. <td colspan="16">6. &nbsp;&nbsp;Nomor Putusan Pengadilan</td>
  1558. <td>:</td>
  1559. <?php for ($i=0; $i<18; $i++): ?>
  1560. <td class="kotak padat tengah">
  1561. &nbsp;
  1562. </td>
  1563. <?php endfor; ?>
  1564. <td colspan=21>&nbsp;</td>
  1565. </tr>
  1566. <tr>
  1567. <td colspan="16">7. &nbsp;&nbsp;Nomor Surat Keterangan Panitera Pengadilan</td>
  1568. <td>:</td>
  1569. <?php for ($i=0; $i<18; $i++): ?>
  1570. <td class="kotak padat tengah">
  1571. &nbsp;
  1572. </td>
  1573. <?php endfor; ?>
  1574. <td colspan=21>&nbsp;</td>
  1575. </tr>
  1576. <tr>
  1577. <td colspan="16">8. &nbsp;&nbsp;Tanggal Surat Keterangan Panitera Pengadilan</td>
  1578. <td>:</td>
  1579. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1580. $bln = date('mm',strtotime($individu['tanggallahir']));
  1581. $thn = date('Y',strtotime($individu['tanggallahir']));
  1582. ?>
  1583. <td colspan="4">Tanggal :</td>
  1584. <?php for ($j=0; $j<2; $j++): ?>
  1585. <td class="kotak padat tengah">
  1586. &nbsp;
  1587. </td>
  1588. <?php endfor; ?>
  1589. <td colspan="4" class="kanan">Bulan : </td>
  1590. <?php for ($j=0; $j<2; $j++): ?>
  1591. <td class="kotak padat tengah">
  1592. &nbsp;
  1593. </td>
  1594. <?php endfor; ?>
  1595. <td colspan="4" class="kanan">Tahun : </td>
  1596. <?php for ($j=0; $j<4; $j++): ?>
  1597. <td class="kotak padat tengah">
  1598. &nbsp;
  1599. </td>
  1600. <?php endfor; ?>
  1601. <td colspan="4">&nbsp;</td>
  1602. </tr>
  1603. <tr>
  1604. <td colspan="16">9. &nbsp;&nbsp;Tanggal Melapor</td>
  1605. <td>:</td>
  1606. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1607. $bln = date('mm',strtotime($individu['tanggallahir']));
  1608. $thn = date('Y',strtotime($individu['tanggallahir']));
  1609. ?>
  1610. <td colspan="4">Tanggal :</td>
  1611. <?php for ($j=0; $j<2; $j++): ?>
  1612. <td class="kotak padat tengah">
  1613. &nbsp;
  1614. </td>
  1615. <?php endfor; ?>
  1616. <td colspan="4" class="kanan">Bulan : </td>
  1617. <?php for ($j=0; $j<2; $j++): ?>
  1618. <td class="kotak padat tengah">
  1619. &nbsp;
  1620. </td>
  1621. <?php endfor; ?>
  1622. <td colspan="4" class="kanan">Tahun : </td>
  1623. <?php for ($j=0; $j<4; $j++): ?>
  1624. <td class="kotak padat tengah">
  1625. &nbsp;
  1626. </td>
  1627. <?php endfor; ?>
  1628. <td colspan="4">&nbsp;</td>
  1629. </tr>
  1630. <tr>
  1631. <td colspan=48><strong>Bagi Pemohon Pembatalan Perceraian Harap Mengisi Data di bawah ini:</strong></td>
  1632. </tr>
  1633. <tr>
  1634. <td colspan="16">1. &nbsp;&nbsp;Nomor Akta Perkawinan</td>
  1635. <td>:</td>
  1636. <?php for ($i=0; $i<18; $i++): ?>
  1637. <td class="kotak padat tengah">
  1638. &nbsp;
  1639. </td>
  1640. <?php endfor; ?>
  1641. <td colspan=21>&nbsp;</td>
  1642. </tr>
  1643. <tr>
  1644. <td colspan="16">2. &nbsp;&nbsp;Tanggal Akta Perkawinan</td>
  1645. <td>:</td>
  1646. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1647. $bln = date('mm',strtotime($individu['tanggallahir']));
  1648. $thn = date('Y',strtotime($individu['tanggallahir']));
  1649. ?>
  1650. <td colspan="4">Tanggal :</td>
  1651. <?php for ($j=0; $j<2; $j++): ?>
  1652. <td class="kotak padat tengah">
  1653. &nbsp;
  1654. </td>
  1655. <?php endfor; ?>
  1656. <td colspan="4" class="kanan">Bulan : </td>
  1657. <?php for ($j=0; $j<2; $j++): ?>
  1658. <td class="kotak padat tengah">
  1659. &nbsp;
  1660. </td>
  1661. <?php endfor; ?>
  1662. <td colspan="4" class="kanan">Tahun : </td>
  1663. <?php for ($j=0; $j<4; $j++): ?>
  1664. <td class="kotak padat tengah">
  1665. &nbsp;
  1666. </td>
  1667. <?php endfor; ?>
  1668. <td colspan="4">&nbsp;</td>
  1669. </tr>
  1670. <tr>
  1671. <td colspan="16">3. &nbsp;&nbsp;Tanggal Pelaporan Perceraian dari Luar Negeri</td>
  1672. <td>:</td>
  1673. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  1674. $bln = date('mm',strtotime($individu['tanggallahir']));
  1675. $thn = date('Y',strtotime($individu['tanggallahir']));
  1676. ?>
  1677. <td colspan="4">Tanggal :</td>
  1678. <?php for ($j=0; $j<2; $j++): ?>
  1679. <td class="kotak padat tengah">
  1680. &nbsp;
  1681. </td>
  1682. <?php endfor; ?>
  1683. <td colspan="4" class="kanan">Bulan : </td>
  1684. <?php for ($j=0; $j<2; $j++): ?>
  1685. <td class="kotak padat tengah">
  1686. &nbsp;
  1687. </td>
  1688. <?php endfor; ?>
  1689. <td colspan="4" class="kanan">Tahun : </td>
  1690. <?php for ($j=0; $j<4; $j++): ?>
  1691. <td class="kotak padat tengah">
  1692. &nbsp;
  1693. </td>
  1694. <?php endfor; ?>
  1695. <td colspan="4">&nbsp;</td>
  1696. </tr>
  1697. </table>
  1698.  
  1699. <table class="disdukcapil data-subjek-data-kematian" style="margin-top: 0px;">
  1700. <col span="48" style="width: 2.0833%;">
  1701. <tr>
  1702. <td colspan=48><strong>KEMATIAN</strong></td>
  1703. </tr>
  1704. <tr>
  1705. <td colspan="16">1. &nbsp;&nbsp;NIK </td>
  1706. <td>:</td>
  1707. <?php for ($i=0; $i<18; $i++): ?>
  1708. <td class="kotak padat tengah">
  1709. <?php if (isset($individu['nik'][$i])): ?>
  1710. <?= $individu['nik'][$i];?>
  1711. <?php else: ?>
  1712. &nbsp;
  1713. <?php endif; ?>
  1714. </td>
  1715. <?php endfor; ?>
  1716. <td colspan=21>&nbsp;</td>
  1717. </tr>
  1718. <tr>
  1719. <td colspan="16">2. &nbsp;&nbsp;Nama Lengkap</td>
  1720. <td>:</td>
  1721. <?php for ($i=0; $i<26; $i++): ?>
  1722. <td class="kotak padat tengah">
  1723. <?php if (isset($individu['nama'][$i])): ?>
  1724. <?= $individu['nama'][$i];?>
  1725. <?php else: ?>
  1726. &nbsp;
  1727. <?php endif; ?>
  1728. </td>
  1729. <?php endfor; ?>
  1730. <td colspan="4">&nbsp;</td>
  1731. </tr>
  1732. <tr>
  1733. <td colspan="16">3. &nbsp;&nbsp;Tanggal Kematian </td>
  1734. <td>:</td>
  1735. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  1736. $bln = date('mm',strtotime($input['tanggal_mati']));
  1737. $thn = date('Y',strtotime($input['tanggal_mati']));
  1738. ?>
  1739. <td colspan="4">Tanggal : </td>
  1740. <?php for ($j=0; $j<2; $j++): ?>
  1741. <td class="kotak padat tengah">
  1742. <?php if (isset($tgl[$j])): ?>
  1743. <?= $tgl[$j];?>
  1744. <?php else: ?>
  1745. &nbsp;
  1746. <?php endif; ?>
  1747. </td>
  1748. <?php endfor; ?>
  1749. <td colspan="4" class="kanan">Bulan : </td>
  1750. <?php for ($j=0; $j<2; $j++): ?>
  1751. <td class="kotak padat tengah">
  1752. <?php if (isset($bln[$j])): ?>
  1753. <?= $bln[$j];?>
  1754. <?php else: ?>
  1755. &nbsp;
  1756. <?php endif; ?>
  1757. </td>
  1758. <?php endfor; ?>
  1759. <td colspan="4" class="kanan">Tahun : </td>
  1760. <?php for ($j=0; $j<4; $j++): ?>
  1761. <td class="kotak padat tengah">
  1762. <?php if (isset($thn[$j])): ?>
  1763. <?= $thn[$j];?>
  1764. <?php else: ?>
  1765. &nbsp;
  1766. <?php endif; ?>
  1767. </td>
  1768. <?php endfor; ?>
  1769. <td colspan="12">&nbsp;</td>
  1770. <td colspan="2">&nbsp;</td>
  1771. </tr>
  1772. <tr>
  1773. <td colspan="16">4. &nbsp;&nbsp;Pukul </td>
  1774. <td>:</td>
  1775. <?php for ($i=0; $i<5; $i++): ?>
  1776. <td class="kotak padat tengah">
  1777. <?php if (isset($input['jam'][$i])): ?>
  1778. <?= $input['jam'][$i];?>
  1779. <?php else: ?>
  1780. &nbsp;
  1781. <?php endif; ?>
  1782. </td>
  1783. <?php endfor; ?>
  1784. <td colspan="4">&nbsp;</td>
  1785. </tr>
  1786. <tr>
  1787. <td colspan="16">5. &nbsp;&nbsp;Sebab Kematian </td>
  1788. <td>:</td>
  1789. <?php for ($i=0; $i<1; $i++): ?>
  1790. <td class="kotak padat tengah">
  1791. <?php if (isset($input['sebab'][$i])): ?>
  1792. <?= $input['sebab'][$i];?>
  1793. <?php else: ?>
  1794. &nbsp;
  1795. <?php endif; ?>
  1796. </td>
  1797. <?php endfor; ?>
  1798. <td colspan=6>1. Sakit biasa / tua</td>
  1799. <td colspan=6>2. Wabah Penyakit </td>
  1800. <td colspan=6>3. Kecelakaan </td>
  1801. <td colspan=18>&nbsp;</td>
  1802. </tr>
  1803. <tr>
  1804. <td colspan="18">&nbsp;</td>
  1805. <td colspan=6>4. Kriminalitas </td>
  1806. <td colspan=6>5. Bunuh Diri </td>
  1807. <td colspan=6>6. Lainnya </td>
  1808. <td colspan=18>&nbsp;</td>
  1809. </tr>
  1810. <tr>
  1811. <td colspan="16">6. &nbsp;&nbsp;Tempat Kematian </td>
  1812. <td>:</td>
  1813. <?php for ($i=0; $i<18; $i++): ?>
  1814. <td class="kotak padat tengah">
  1815. <?php if (isset($input['tempat_mati'][$i])): ?>
  1816. <?= $input['tempat_mati'][$i];?>
  1817. <?php else: ?>
  1818. &nbsp;
  1819. <?php endif; ?>
  1820. </td>
  1821. <?php endfor; ?>
  1822. </tr>
  1823. <tr>
  1824. <td colspan="16">7. &nbsp;&nbsp;Yang menerangkan </td>
  1825. <td>:</td>
  1826. <?php for ($i=0; $i<1; $i++): ?>
  1827. <td class="kotak padat tengah">
  1828. <?php if (isset($input['penolong_mati'][$i])): ?>
  1829. <?= $input['penolong_mati'][$i];?>
  1830. <?php else: ?>
  1831. &nbsp;
  1832. <?php endif; ?>
  1833. </td>
  1834. <?php endfor; ?>
  1835. <td colspan=4>1. Dokter </td>
  1836. <td colspan=8>2. Tenaga Kesehatan </td>
  1837. <td colspan=6>3. Kepolisian </td>
  1838. <td colspan=5>4. Lainnya </td>
  1839. <td colspan=5>&nbsp;</td>
  1840. </tr>
  1841. </table>
  1842.  
  1843.  
  1844. <table class="disdukcapil data-pelapor" style="margin-top: 0px;">
  1845. <col span="48" style="width: 2.0833%;">
  1846. <tr>
  1847. <td colspan=48><strong>PENGANGKATAN ANAK</strong></td>
  1848. </tr>
  1849. <tr>
  1850. <td colspan="16">1. &nbsp;&nbsp;Nama Anak Angkat</td>
  1851. <td>:</td>
  1852. <?php for ($i=0; $i<26; $i++): ?>
  1853. <td class="kotak padat tengah">
  1854. &nbsp;
  1855. </td>
  1856. <?php endfor; ?>
  1857. <td colspan=21>&nbsp;</td>
  1858. </tr>
  1859. <tr>
  1860. <td colspan="16">2. &nbsp;&nbsp;Nomor Akta Kelahiran</td>
  1861. <td>:</td>
  1862. <?php for ($i=0; $i<18; $i++): ?>
  1863. <td class="kotak padat tengah">
  1864. &nbsp;
  1865. </td>
  1866. <?php endfor; ?>
  1867. <td colspan="4">&nbsp;</td>
  1868. </tr>
  1869. <tr>
  1870. <td colspan="16">3. &nbsp;&nbsp;Tanggal/Bulan/Tahun Penerbitan Akta Kelahiran </td>
  1871. <td>:</td>
  1872. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  1873. $bln = date('mm',strtotime($input['tanggal_mati']));
  1874. $thn = date('Y',strtotime($input['tanggal_mati']));
  1875. ?>
  1876. <td colspan="4">Tanggal : </td>
  1877. <?php for ($j=0; $j<2; $j++): ?>
  1878. <td class="kotak padat tengah">
  1879. &nbsp;
  1880. </td>
  1881. <?php endfor; ?>
  1882. <td colspan="4" class="kanan">Bulan : </td>
  1883. <?php for ($j=0; $j<2; $j++): ?>
  1884. <td class="kotak padat tengah">
  1885. &nbsp;
  1886. </td>
  1887. <?php endfor; ?>
  1888. <td colspan="4" class="kanan">Tahun : </td>
  1889. <?php for ($j=0; $j<4; $j++): ?>
  1890. <td class="kotak padat tengah">
  1891. &nbsp;
  1892. </td>
  1893. <?php endfor; ?>
  1894. <td colspan="12">&nbsp;</td>
  1895. <td colspan="2">&nbsp;</td>
  1896. </tr>
  1897. <tr>
  1898. <td colspan="16">4. &nbsp;&nbsp;Dinas Kab/Kota yang menerbitkan Akta Kelahiran</td>
  1899. <td>:</td>
  1900. <?php for ($i=0; $i<26; $i++): ?>
  1901. <td class="kotak padat tengah">
  1902. &nbsp;
  1903. </td>
  1904. <?php endfor; ?>
  1905. <td colspan=21>&nbsp;</td>
  1906. </tr>
  1907. <tr>
  1908. <td colspan="16">5. &nbsp;&nbsp;Nama Ibu Kandung</td>
  1909. <td>:</td>
  1910. <?php for ($i=0; $i<26; $i++): ?>
  1911. <td class="kotak padat tengah">
  1912. &nbsp;
  1913. </td>
  1914. <?php endfor; ?>
  1915. <td colspan=21>&nbsp;</td>
  1916. </tr>
  1917. <tr>
  1918. <td colspan="16">6. &nbsp;&nbsp;NIK Ibu Kandung</td>
  1919. <td>:</td>
  1920. <?php for ($i=0; $i<18; $i++): ?>
  1921. <td class="kotak padat tengah">
  1922. &nbsp;
  1923. </td>
  1924. <?php endfor; ?>
  1925. <td colspan="4">&nbsp;</td>
  1926. </tr>
  1927. <tr>
  1928. <td colspan="16">7. &nbsp;&nbsp;Kewarganegaraan Ibu Kandung</td>
  1929. <td>:</td>
  1930. <?php for ($i=0; $i<16; $i++): ?>
  1931. <td class="kotak padat tengah">
  1932. &nbsp;
  1933. </td>
  1934. <?php endfor; ?>
  1935. <td colspan="21">&nbsp;</td>
  1936. </tr>
  1937. <tr>
  1938. <td colspan="16">8. &nbsp;&nbsp;Nama Ayah Kandung</td>
  1939. <td>:</td>
  1940. <?php for ($i=0; $i<26; $i++): ?>
  1941. <td class="kotak padat tengah">
  1942. &nbsp;
  1943. </td>
  1944. <?php endfor; ?>
  1945. <td colspan=21>&nbsp;</td>
  1946. </tr>
  1947. <tr>
  1948. <td colspan="16">9. &nbsp;&nbsp;NIK Ayah Kandung</td>
  1949. <td>:</td>
  1950. <?php for ($i=0; $i<18; $i++): ?>
  1951. <td class="kotak padat tengah">
  1952. &nbsp;
  1953. </td>
  1954. <?php endfor; ?>
  1955. <td colspan="4">&nbsp;</td>
  1956. </tr>
  1957. <tr>
  1958. <td colspan="16">10. &nbsp;&nbsp;Kewarganegaraan Ayah Kandung</td>
  1959. <td>:</td>
  1960. <?php for ($i=0; $i<16; $i++): ?>
  1961. <td class="kotak padat tengah">
  1962. &nbsp;
  1963. </td>
  1964. <?php endfor; ?>
  1965. <td colspan="21">&nbsp;</td>
  1966. </tr>
  1967. <tr>
  1968. <td colspan="16">11. &nbsp;&nbsp;Nama Ibu Angkat</td>
  1969. <td>:</td>
  1970. <?php for ($i=0; $i<26; $i++): ?>
  1971. <td class="kotak padat tengah">
  1972. &nbsp;
  1973. </td>
  1974. <?php endfor; ?>
  1975. <td colspan=21>&nbsp;</td>
  1976. </tr>
  1977. <tr>
  1978. <td colspan="16">12. &nbsp;&nbsp;NIK Ibu Angkat</td>
  1979. <td>:</td>
  1980. <?php for ($i=0; $i<18; $i++): ?>
  1981. <td class="kotak padat tengah">
  1982. &nbsp;
  1983. </td>
  1984. <?php endfor; ?>
  1985. <td colspan="4">&nbsp;</td>
  1986. </tr>
  1987. <tr>
  1988. <td colspan="16">13. &nbsp;&nbsp;Nomor Paspor</td>
  1989. <td>:</td>
  1990. <?php for ($i=0; $i<16; $i++): ?>
  1991. <td class="kotak padat tengah">
  1992. &nbsp;
  1993. </td>
  1994. <?php endfor; ?>
  1995. <td colspan="21">&nbsp;</td>
  1996. </tr>
  1997. <tr>
  1998. <td colspan="16">14. &nbsp;&nbsp;Nama Ayah Angkat</td>
  1999. <td>:</td>
  2000. <?php for ($i=0; $i<26; $i++): ?>
  2001. <td class="kotak padat tengah">
  2002. &nbsp;
  2003. </td>
  2004. <?php endfor; ?>
  2005. <td colspan=21>&nbsp;</td>
  2006. </tr>
  2007. <tr>
  2008. <td colspan="16">15. &nbsp;&nbsp;NIK Ayah Angkat</td>
  2009. <td>:</td>
  2010. <?php for ($i=0; $i<18; $i++): ?>
  2011. <td class="kotak padat tengah">
  2012. &nbsp;
  2013. </td>
  2014. <?php endfor; ?>
  2015. <td colspan="4">&nbsp;</td>
  2016. </tr>
  2017. <tr>
  2018. <td colspan="16">16. &nbsp;&nbsp;Nomor Paspor</td>
  2019. <td>:</td>
  2020. <?php for ($i=0; $i<16; $i++): ?>
  2021. <td class="kotak padat tengah">
  2022. &nbsp;
  2023. </td>
  2024. <?php endfor; ?>
  2025. <td colspan="21">&nbsp;</td>
  2026. </tr>
  2027. <tr>
  2028. <td colspan="16">17. &nbsp;&nbsp;Nama Pengadilan</td>
  2029. <td>:</td>
  2030. <?php for ($i=0; $i<19; $i++): ?>
  2031. <td class="kotak padat tengah">
  2032. &nbsp;
  2033. </td>
  2034. <?php endfor; ?>
  2035. <td colspan="4">&nbsp;</td>
  2036. </tr>
  2037. <tr>
  2038. <td colspan="16">18. &nbsp;&nbsp;Tanggal Penetapan Pengadilan</td>
  2039. <td>:</td>
  2040. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2041. $bln = date('mm',strtotime($input['tanggal_mati']));
  2042. $thn = date('Y',strtotime($input['tanggal_mati']));
  2043. ?>
  2044. <td colspan="4">Tanggal : </td>
  2045. <?php for ($j=0; $j<2; $j++): ?>
  2046. <td class="kotak padat tengah">
  2047. &nbsp;
  2048. </td>
  2049. <?php endfor; ?>
  2050. <td colspan="4" class="kanan">Bulan : </td>
  2051. <?php for ($j=0; $j<2; $j++): ?>
  2052. <td class="kotak padat tengah">
  2053. &nbsp;
  2054. </td>
  2055. <?php endfor; ?>
  2056. <td colspan="4" class="kanan">Tahun : </td>
  2057. <?php for ($j=0; $j<4; $j++): ?>
  2058. <td class="kotak padat tengah">
  2059. &nbsp;
  2060. </td>
  2061. <?php endfor; ?>
  2062. <td colspan="12">&nbsp;</td>
  2063. <td colspan="2">&nbsp;</td>
  2064. </tr>
  2065. <tr>
  2066. <td colspan="16">19. &nbsp;&nbsp;Nomor Penetapan Pengadilan</td>
  2067. <td>:</td>
  2068. <?php for ($i=0; $i<26; $i++): ?>
  2069. <td class="kotak padat tengah">
  2070. &nbsp;
  2071. </td>
  2072. <?php endfor; ?>
  2073. <td colspan=21>&nbsp;</td>
  2074. </tr>
  2075. <tr>
  2076. <td colspan="16">20. &nbsp;&nbsp;Nama Lembaga Penetapan Pengadilan</td>
  2077. <td>:</td>
  2078. <?php for ($i=0; $i<18; $i++): ?>
  2079. <td class="kotak padat tengah">
  2080. &nbsp;
  2081. </td>
  2082. <?php endfor; ?>
  2083. <td colspan="4">&nbsp;</td>
  2084. </tr>
  2085. <tr>
  2086. <td colspan="16">21. &nbsp;&nbsp;Tempat Lembaga Penetapan Pengadilan</td>
  2087. <td>:</td>
  2088. <?php for ($i=0; $i<16; $i++): ?>
  2089. <td class="kotak padat tengah">
  2090. &nbsp;
  2091. </td>
  2092. <?php endfor; ?>
  2093. <td colspan="4">&nbsp;</td>
  2094. </tr>
  2095. </table>
  2096.  
  2097. <table class="disdukcapil data-pelapor" style="margin-top: 0px;">
  2098. <col span="48" style="width: 2.0833%;">
  2099. <tr>
  2100. <td colspan=48><strong>PENGAKUAN ANAK</strong></td>
  2101. </tr>
  2102. <tr>
  2103. <td colspan="16">1. &nbsp;&nbsp;Nomor Akta Kelahiran</td>
  2104. <td>:</td>
  2105. <?php for ($i=0; $i<18; $i++): ?>
  2106. <td class="kotak padat tengah">
  2107. &nbsp;
  2108. </td>
  2109. <?php endfor; ?>
  2110. <td colspan="4">&nbsp;</td>
  2111. </tr>
  2112. <tr>
  2113. <td colspan="16">2. &nbsp;&nbsp;Tanggal/Bulan/Tahun Penerbitan Akta Kelahiran </td>
  2114. <td>:</td>
  2115. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2116. $bln = date('mm',strtotime($input['tanggal_mati']));
  2117. $thn = date('Y',strtotime($input['tanggal_mati']));
  2118. ?>
  2119. <td colspan="4">Tanggal : </td>
  2120. <?php for ($j=0; $j<2; $j++): ?>
  2121. <td class="kotak padat tengah">
  2122. &nbsp;
  2123. </td>
  2124. <?php endfor; ?>
  2125. <td colspan="4" class="kanan">Bulan : </td>
  2126. <?php for ($j=0; $j<2; $j++): ?>
  2127. <td class="kotak padat tengah">
  2128. &nbsp;
  2129. </td>
  2130. <?php endfor; ?>
  2131. <td colspan="4" class="kanan">Tahun : </td>
  2132. <?php for ($j=0; $j<4; $j++): ?>
  2133. <td class="kotak padat tengah">
  2134. &nbsp;
  2135. </td>
  2136. <?php endfor; ?>
  2137. <td colspan="12">&nbsp;</td>
  2138. <td colspan="2">&nbsp;</td>
  2139. </tr>
  2140. <tr>
  2141. <td colspan="16">3. &nbsp;&nbsp;Dinas Kab/Kota yang menerbitkan Akta Kelahiran</td>
  2142. <td>:</td>
  2143. <?php for ($i=0; $i<26; $i++): ?>
  2144. <td class="kotak padat tengah">
  2145. &nbsp;
  2146. </td>
  2147. <?php endfor; ?>
  2148. <td colspan=21>&nbsp;</td>
  2149. </tr>
  2150. <tr>
  2151. <td colspan="16">4. &nbsp;&nbsp;Tanggal/Bulan/Tahun Kelahiran Anak</td>
  2152. <td>:</td>
  2153. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2154. $bln = date('mm',strtotime($input['tanggal_mati']));
  2155. $thn = date('Y',strtotime($input['tanggal_mati']));
  2156. ?>
  2157. <td colspan="4">Tanggal : </td>
  2158. <?php for ($j=0; $j<2; $j++): ?>
  2159. <td class="kotak padat tengah">
  2160. &nbsp;
  2161. </td>
  2162. <?php endfor; ?>
  2163. <td colspan="4" class="kanan">Bulan : </td>
  2164. <?php for ($j=0; $j<2; $j++): ?>
  2165. <td class="kotak padat tengah">
  2166. &nbsp;
  2167. </td>
  2168. <?php endfor; ?>
  2169. <td colspan="4" class="kanan">Tahun : </td>
  2170. <?php for ($j=0; $j<4; $j++): ?>
  2171. <td class="kotak padat tengah">
  2172. &nbsp;
  2173. </td>
  2174. <?php endfor; ?>
  2175. <td colspan="12">&nbsp;</td>
  2176. <td colspan="2">&nbsp;</td>
  2177. </tr>
  2178. <tr>
  2179. <td colspan="16">5. &nbsp;&nbsp;Tanggal/Bulan/Tahun Perkawinan Agama</td>
  2180. <td>:</td>
  2181. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2182. $bln = date('mm',strtotime($input['tanggal_mati']));
  2183. $thn = date('Y',strtotime($input['tanggal_mati']));
  2184. ?>
  2185. <td colspan="4">Tanggal : </td>
  2186. <?php for ($j=0; $j<2; $j++): ?>
  2187. <td class="kotak padat tengah">
  2188. &nbsp;
  2189. </td>
  2190. <?php endfor; ?>
  2191. <td colspan="4" class="kanan">Bulan : </td>
  2192. <?php for ($j=0; $j<2; $j++): ?>
  2193. <td class="kotak padat tengah">
  2194. &nbsp;
  2195. </td>
  2196. <?php endfor; ?>
  2197. <td colspan="4" class="kanan">Tahun : </td>
  2198. <?php for ($j=0; $j<4; $j++): ?>
  2199. <td class="kotak padat tengah">
  2200. &nbsp;
  2201. </td>
  2202. <?php endfor; ?>
  2203. <td colspan="12">&nbsp;</td>
  2204. <td colspan="2">&nbsp;</td>
  2205. </tr>
  2206. <tr>
  2207. <td colspan="16">6. &nbsp;&nbsp;Nama Ibu Kandung</td>
  2208. <td>:</td>
  2209. <?php for ($i=0; $i<26; $i++): ?>
  2210. <td class="kotak padat tengah">
  2211. &nbsp;
  2212. </td>
  2213. <?php endfor; ?>
  2214. <td colspan=21>&nbsp;</td>
  2215. </tr>
  2216. <tr>
  2217. <td colspan="16">7. &nbsp;&nbsp;NIK Ibu Kandung</td>
  2218. <td>:</td>
  2219. <?php for ($i=0; $i<18; $i++): ?>
  2220. <td class="kotak padat tengah">
  2221. &nbsp;
  2222. </td>
  2223. <?php endfor; ?>
  2224. <td colspan="4">&nbsp;</td>
  2225. </tr>
  2226. <tr>
  2227. <td colspan="16">8. &nbsp;&nbsp;Kewarganegaraan Ibu Kandung</td>
  2228. <td>:</td>
  2229. <?php for ($i=0; $i<16; $i++): ?>
  2230. <td class="kotak padat tengah">
  2231. &nbsp;
  2232. </td>
  2233. <?php endfor; ?>
  2234. <td colspan="21">&nbsp;</td>
  2235. </tr>
  2236. <tr>
  2237. <td colspan="16">9. &nbsp;&nbsp;Nama Ayah Kandung</td>
  2238. <td>:</td>
  2239. <?php for ($i=0; $i<26; $i++): ?>
  2240. <td class="kotak padat tengah">
  2241. &nbsp;
  2242. </td>
  2243. <?php endfor; ?>
  2244. <td colspan=21>&nbsp;</td>
  2245. </tr>
  2246. <tr>
  2247. <td colspan="16">10. &nbsp;&nbsp;NIK Ayah Kandung</td>
  2248. <td>:</td>
  2249. <?php for ($i=0; $i<18; $i++): ?>
  2250. <td class="kotak padat tengah">
  2251. &nbsp;
  2252. </td>
  2253. <?php endfor; ?>
  2254. <td colspan="4">&nbsp;</td>
  2255. </tr>
  2256. <tr>
  2257. <td colspan="16">11. &nbsp;&nbsp;Kewarganegaraan Ayah Kandung</td>
  2258. <td>:</td>
  2259. <?php for ($i=0; $i<16; $i++): ?>
  2260. <td class="kotak padat tengah">
  2261. &nbsp;
  2262. </td>
  2263. <?php endfor; ?>
  2264. <td colspan="21">&nbsp;</td>
  2265. </tr>
  2266. <tr>
  2267. <td colspan="16">12. &nbsp;&nbsp;Tanggal Penetapan Pengadilan</td>
  2268. <td>:</td>
  2269. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2270. $bln = date('mm',strtotime($input['tanggal_mati']));
  2271. $thn = date('Y',strtotime($input['tanggal_mati']));
  2272. ?>
  2273. <td colspan="4">Tanggal : </td>
  2274. <?php for ($j=0; $j<2; $j++): ?>
  2275. <td class="kotak padat tengah">
  2276. &nbsp;
  2277. </td>
  2278. <?php endfor; ?>
  2279. <td colspan="4" class="kanan">Bulan : </td>
  2280. <?php for ($j=0; $j<2; $j++): ?>
  2281. <td class="kotak padat tengah">
  2282. &nbsp;
  2283. </td>
  2284. <?php endfor; ?>
  2285. <td colspan="4" class="kanan">Tahun : </td>
  2286. <?php for ($j=0; $j<4; $j++): ?>
  2287. <td class="kotak padat tengah">
  2288. &nbsp;
  2289. </td>
  2290. <?php endfor; ?>
  2291. <td colspan="12">&nbsp;</td>
  2292. <td colspan="2">&nbsp;</td>
  2293. </tr>
  2294. <tr>
  2295. <td colspan="16">13. &nbsp;&nbsp;Nomor Penetapan Pengadilan</td>
  2296. <td>:</td>
  2297. <?php for ($i=0; $i<26; $i++): ?>
  2298. <td class="kotak padat tengah">
  2299. &nbsp;
  2300. </td>
  2301. <?php endfor; ?>
  2302. <td colspan=21>&nbsp;</td>
  2303. </tr>
  2304. <tr>
  2305. <td colspan="16">14. &nbsp;&nbsp;Nama Lembaga Penetapan Pengadilan</td>
  2306. <td>:</td>
  2307. <?php for ($i=0; $i<18; $i++): ?>
  2308. <td class="kotak padat tengah">
  2309. &nbsp;
  2310. </td>
  2311. <?php endfor; ?>
  2312. <td colspan="4">&nbsp;</td>
  2313. </tr>
  2314. </table>
  2315.  
  2316. <table class="disdukcapil data-pelapor" style="margin-top: 0px;">
  2317. <col span="48" style="width: 2.0833%;">
  2318. <tr>
  2319. <td colspan=48><strong>PENGESAHAN ANAK</strong></td>
  2320. </tr>
  2321. <tr>
  2322. <td colspan="16">1. &nbsp;&nbsp;Nomor Akta Kelahiran</td>
  2323. <td>:</td>
  2324. <?php for ($i=0; $i<18; $i++): ?>
  2325. <td class="kotak padat tengah">
  2326. &nbsp;
  2327. </td>
  2328. <?php endfor; ?>
  2329. <td colspan="4">&nbsp;</td>
  2330. </tr>
  2331. <tr>
  2332. <td colspan="16">2. &nbsp;&nbsp;Tanggal/Bulan/Tahun Penerbitan Akta Kelahiran </td>
  2333. <td>:</td>
  2334. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2335. $bln = date('mm',strtotime($input['tanggal_mati']));
  2336. $thn = date('Y',strtotime($input['tanggal_mati']));
  2337. ?>
  2338. <td colspan="4">Tanggal : </td>
  2339. <?php for ($j=0; $j<2; $j++): ?>
  2340. <td class="kotak padat tengah">
  2341. &nbsp;
  2342. </td>
  2343. <?php endfor; ?>
  2344. <td colspan="4" class="kanan">Bulan : </td>
  2345. <?php for ($j=0; $j<2; $j++): ?>
  2346. <td class="kotak padat tengah">
  2347. &nbsp;
  2348. </td>
  2349. <?php endfor; ?>
  2350. <td colspan="4" class="kanan">Tahun : </td>
  2351. <?php for ($j=0; $j<4; $j++): ?>
  2352. <td class="kotak padat tengah">
  2353. &nbsp;
  2354. </td>
  2355. <?php endfor; ?>
  2356. <td colspan="12">&nbsp;</td>
  2357. <td colspan="2">&nbsp;</td>
  2358. </tr>
  2359. <tr>
  2360. <td colspan="16">3. &nbsp;&nbsp;Dinas Kab/Kota yang menerbitkan Akta Kelahiran</td>
  2361. <td>:</td>
  2362. <?php for ($i=0; $i<26; $i++): ?>
  2363. <td class="kotak padat tengah">
  2364. &nbsp;
  2365. </td>
  2366. <?php endfor; ?>
  2367. <td colspan=21>&nbsp;</td>
  2368. </tr>
  2369. <tr>
  2370. <td colspan="16">4. &nbsp;&nbsp;Tanggal/Bulan/Tahun Kelahiran Anak</td>
  2371. <td>:</td>
  2372. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2373. $bln = date('mm',strtotime($input['tanggal_mati']));
  2374. $thn = date('Y',strtotime($input['tanggal_mati']));
  2375. ?>
  2376. <td colspan="4">Tanggal : </td>
  2377. <?php for ($j=0; $j<2; $j++): ?>
  2378. <td class="kotak padat tengah">
  2379. &nbsp;
  2380. </td>
  2381. <?php endfor; ?>
  2382. <td colspan="4" class="kanan">Bulan : </td>
  2383. <?php for ($j=0; $j<2; $j++): ?>
  2384. <td class="kotak padat tengah">
  2385. &nbsp;
  2386. </td>
  2387. <?php endfor; ?>
  2388. <td colspan="4" class="kanan">Tahun : </td>
  2389. <?php for ($j=0; $j<4; $j++): ?>
  2390. <td class="kotak padat tengah">
  2391. &nbsp;
  2392. </td>
  2393. <?php endfor; ?>
  2394. <td colspan="12">&nbsp;</td>
  2395. <td colspan="2">&nbsp;</td>
  2396. </tr>
  2397. <tr>
  2398. <td colspan="16">5. &nbsp;&nbsp;Tanggal/Bulan/Tahun Perkawinan Agama</td>
  2399. <td>:</td>
  2400. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2401. $bln = date('mm',strtotime($input['tanggal_mati']));
  2402. $thn = date('Y',strtotime($input['tanggal_mati']));
  2403. ?>
  2404. <td colspan="4">Tanggal : </td>
  2405. <?php for ($j=0; $j<2; $j++): ?>
  2406. <td class="kotak padat tengah">
  2407. &nbsp;
  2408. </td>
  2409. <?php endfor; ?>
  2410. <td colspan="4" class="kanan">Bulan : </td>
  2411. <?php for ($j=0; $j<2; $j++): ?>
  2412. <td class="kotak padat tengah">
  2413. &nbsp;
  2414. </td>
  2415. <?php endfor; ?>
  2416. <td colspan="4" class="kanan">Tahun : </td>
  2417. <?php for ($j=0; $j<4; $j++): ?>
  2418. <td class="kotak padat tengah">
  2419. &nbsp;
  2420. </td>
  2421. <?php endfor; ?>
  2422. <td colspan="12">&nbsp;</td>
  2423. <td colspan="2">&nbsp;</td>
  2424. </tr>
  2425. <tr>
  2426. <td colspan="16">6. &nbsp;&nbsp;Dinas Kab/Kota yang menerbitkan Akta Kelahiran</td>
  2427. <td>:</td>
  2428. <?php for ($i=0; $i<17; $i++): ?>
  2429. <td class="kotak padat tengah">
  2430. &nbsp;
  2431. </td>
  2432. <?php endfor; ?>
  2433. <td colspan=21>&nbsp;</td>
  2434. </tr>
  2435. <tr>
  2436. <td colspan="16">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Buku Nikah</td>
  2437. <td>:</td>
  2438. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2439. $bln = date('mm',strtotime($input['tanggal_mati']));
  2440. $thn = date('Y',strtotime($input['tanggal_mati']));
  2441. ?>
  2442. <td colspan="4">Tanggal : </td>
  2443. <?php for ($j=0; $j<2; $j++): ?>
  2444. <td class="kotak padat tengah">
  2445. &nbsp;
  2446. </td>
  2447. <?php endfor; ?>
  2448. <td colspan="4" class="kanan">Bulan : </td>
  2449. <?php for ($j=0; $j<2; $j++): ?>
  2450. <td class="kotak padat tengah">
  2451. &nbsp;
  2452. </td>
  2453. <?php endfor; ?>
  2454. <td colspan="4" class="kanan">Tahun : </td>
  2455. <?php for ($j=0; $j<4; $j++): ?>
  2456. <td class="kotak padat tengah">
  2457. &nbsp;
  2458. </td>
  2459. <?php endfor; ?>
  2460. <td colspan="12">&nbsp;</td>
  2461. <td colspan="2">&nbsp;</td>
  2462. </tr>
  2463. <tr>
  2464. <td colspan="16">7. &nbsp;&nbsp;Nama Ibu Kandung</td>
  2465. <td>:</td>
  2466. <?php for ($i=0; $i<26; $i++): ?>
  2467. <td class="kotak padat tengah">
  2468. &nbsp;
  2469. </td>
  2470. <?php endfor; ?>
  2471. <td colspan="4">&nbsp;</td>
  2472. </tr>
  2473. <tr>
  2474. <td colspan="16">8. &nbsp;&nbsp;NIK Ibu Kandung</td>
  2475. <td>:</td>
  2476. <?php for ($i=0; $i<18; $i++): ?>
  2477. <td class="kotak padat tengah">
  2478. &nbsp;
  2479. </td>
  2480. <?php endfor; ?>
  2481. <td colspan="4">&nbsp;</td>
  2482. </tr>
  2483. <tr>
  2484. <td colspan="16">9. &nbsp;&nbsp;Kewarganegaraan Ibu Kandung</td>
  2485. <td>:</td>
  2486. <?php for ($i=0; $i<16; $i++): ?>
  2487. <td class="kotak padat tengah">
  2488. &nbsp;
  2489. </td>
  2490. <?php endfor; ?>
  2491. <td colspan="21">&nbsp;</td>
  2492. </tr>
  2493. <tr>
  2494. <td colspan="16">10. &nbsp;&nbsp;Nama Ayah Kandung</td>
  2495. <td>:</td>
  2496. <?php for ($i=0; $i<26; $i++): ?>
  2497. <td class="kotak padat tengah">
  2498. &nbsp;
  2499. </td>
  2500. <?php endfor; ?>
  2501. <td colspan=21>&nbsp;</td>
  2502. </tr>
  2503. <tr>
  2504. <td colspan="16">11. &nbsp;&nbsp;NIK Ayah Kandung</td>
  2505. <td>:</td>
  2506. <?php for ($i=0; $i<18; $i++): ?>
  2507. <td class="kotak padat tengah">
  2508. &nbsp;
  2509. </td>
  2510. <?php endfor; ?>
  2511. <td colspan="4">&nbsp;</td>
  2512. </tr>
  2513. <tr>
  2514. <td colspan="16">12. &nbsp;&nbsp;Kewarganegaraan Ayah Kandung</td>
  2515. <td>:</td>
  2516. <?php for ($i=0; $i<16; $i++): ?>
  2517. <td class="kotak padat tengah">
  2518. &nbsp;
  2519. </td>
  2520. <?php endfor; ?>
  2521. <td colspan="21">&nbsp;</td>
  2522. </tr>
  2523. <tr>
  2524. <td colspan="16">13. &nbsp;&nbsp;Tanggal Penetapan Pengadilan</td>
  2525. <td>:</td>
  2526. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2527. $bln = date('mm',strtotime($input['tanggal_mati']));
  2528. $thn = date('Y',strtotime($input['tanggal_mati']));
  2529. ?>
  2530. <td colspan="4">Tanggal : </td>
  2531. <?php for ($j=0; $j<2; $j++): ?>
  2532. <td class="kotak padat tengah">
  2533. &nbsp;
  2534. </td>
  2535. <?php endfor; ?>
  2536. <td colspan="4" class="kanan">Bulan : </td>
  2537. <?php for ($j=0; $j<2; $j++): ?>
  2538. <td class="kotak padat tengah">
  2539. &nbsp;
  2540. </td>
  2541. <?php endfor; ?>
  2542. <td colspan="4" class="kanan">Tahun : </td>
  2543. <?php for ($j=0; $j<4; $j++): ?>
  2544. <td class="kotak padat tengah">
  2545. &nbsp;
  2546. </td>
  2547. <?php endfor; ?>
  2548. <td colspan="12">&nbsp;</td>
  2549. <td colspan="2">&nbsp;</td>
  2550. </tr>
  2551. <tr>
  2552. <td colspan="16">14. &nbsp;&nbsp;Nomor Penetapan Pengadilan</td>
  2553. <td>:</td>
  2554. <?php for ($i=0; $i<26; $i++): ?>
  2555. <td class="kotak padat tengah">
  2556. &nbsp;
  2557. </td>
  2558. <?php endfor; ?>
  2559. <td colspan=21>&nbsp;</td>
  2560. </tr>
  2561. <tr>
  2562. <td colspan="16">15. &nbsp;&nbsp;Nama Lembaga Penetapan Pengadilan</td>
  2563. <td>:</td>
  2564. <?php for ($i=0; $i<18; $i++): ?>
  2565. <td class="kotak padat tengah">
  2566. &nbsp;
  2567. </td>
  2568. <?php endfor; ?>
  2569. <td colspan="4">&nbsp;</td>
  2570. </tr>
  2571. </table>
  2572.  
  2573. <!-- START OF PERUBAHAN NAMA -->
  2574. <table class="disdukcapil data-pelapor" style="margin-top: 0px;">
  2575. <col span="48" style="width: 2.0833%;">
  2576. <tr>
  2577. <td colspan=48><strong>PERUBAHAN NAMA</strong></td>
  2578. </tr>
  2579. <tr>
  2580. <td colspan="16">1. &nbsp;&nbsp;Nama Lama</td>
  2581. <td>:</td>
  2582. <?php for ($i=0; $i<26; $i++): ?>
  2583. <td class="kotak padat tengah">
  2584. &nbsp;
  2585. </td>
  2586. <?php endfor; ?>
  2587. <td colspan=21>&nbsp;</td>
  2588. </tr>
  2589. <tr>
  2590. <td colspan="16">2. &nbsp;&nbsp;Nama Baru</td>
  2591. <td>:</td>
  2592. <?php for ($i=0; $i<26; $i++): ?>
  2593. <td class="kotak padat tengah">
  2594. &nbsp;
  2595. </td>
  2596. <?php endfor; ?>
  2597. <td colspan=21>&nbsp;</td>
  2598. </tr>
  2599. <tr>
  2600. <td colspan="16">3. &nbsp;&nbsp; Nomor akta Kelahiran</td>
  2601. <td>:</td>
  2602. <?php for ($i=0; $i<16; $i++): ?>
  2603. <td class="kotak padat tengah">
  2604. &nbsp;
  2605. </td>
  2606. <?php endfor; ?>
  2607. <td colspan="4">&nbsp;</td>
  2608. </tr>
  2609. <tr>
  2610. <td colspan="16">4. &nbsp;&nbsp;Nama Ayah/Ibu/Wali (bbagi yang di bawah umur)</td>
  2611. <td>:</td>
  2612. <?php for ($i=0; $i<26; $i++): ?>
  2613. <td class="kotak padat tengah">
  2614. &nbsp;
  2615. </td>
  2616. <?php endfor; ?>
  2617. <td colspan=21>&nbsp;</td>
  2618. </tr>
  2619. <tr>
  2620. <td colspan="16">5. &nbsp;&nbsp;NIK Nama Ayah/Ibu/Wali</td>
  2621. <td>:</td>
  2622. <?php for ($i=0; $i<16; $i++): ?>
  2623. <td class="kotak padat tengah">
  2624. &nbsp;
  2625. </td>
  2626. <?php endfor; ?>
  2627. <td colspan="4">&nbsp;</td>
  2628. </tr>
  2629. <tr>
  2630. <td colspan="16">6. &nbsp;&nbsp;Kewarganegaraan Ayah/Ibu/Wali</td>
  2631. <td>:</td>
  2632. <?php for ($i=0; $i<26; $i++): ?>
  2633. <td class="kotak padat tengah">
  2634. &nbsp;
  2635. </td>
  2636. <?php endfor; ?>
  2637. <td colspan=21>&nbsp;</td>
  2638. </tr>
  2639. <tr>
  2640. <td colspan="16">7. &nbsp;&nbsp;Nomor Penetapan Pengadilan</td>
  2641. <td>:</td>
  2642. <?php for ($i=0; $i<16; $i++): ?>
  2643. <td class="kotak padat tengah">
  2644. &nbsp;
  2645. </td>
  2646. <?php endfor; ?>
  2647. <td colspan="21">&nbsp;</td>
  2648. </tr>
  2649. <tr>
  2650. <td colspan="16">8. &nbsp;&nbsp;Tanggal Penetapan Pengadilan</td>
  2651. <td>:</td>
  2652. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2653. $bln = date('mm',strtotime($input['tanggal_mati']));
  2654. $thn = date('Y',strtotime($input['tanggal_mati']));
  2655. ?>
  2656. <td colspan="4">Tanggal : </td>
  2657. <?php for ($j=0; $j<2; $j++): ?>
  2658. <td class="kotak padat tengah">
  2659. &nbsp;
  2660. </td>
  2661. <?php endfor; ?>
  2662. <td colspan="4" class="kanan">Bulan : </td>
  2663. <?php for ($j=0; $j<2; $j++): ?>
  2664. <td class="kotak padat tengah">
  2665. &nbsp;
  2666. </td>
  2667. <?php endfor; ?>
  2668. <td colspan="4" class="kanan">Tahun : </td>
  2669. <?php for ($j=0; $j<4; $j++): ?>
  2670. <td class="kotak padat tengah">
  2671. &nbsp;
  2672. </td>
  2673. <?php endfor; ?>
  2674. <td colspan="12">&nbsp;</td>
  2675. <td colspan="2">&nbsp;</td>
  2676. </tr>
  2677. <tr>
  2678. <td colspan="16">9. &nbsp;&nbsp;Nama Lembaga Pengadilan</td>
  2679. <td>:</td>
  2680. <?php for ($i=0; $i<22; $i++): ?>
  2681. <td class="kotak padat tengah">
  2682. &nbsp;
  2683. </td>
  2684. <?php endfor; ?>
  2685. <td colspan="21">&nbsp;</td>
  2686. </tr>
  2687. </table>
  2688.  
  2689. <!-- START OF PERUBAHAN STATUS KEWARGANEGARAAN -->
  2690. <table class="disdukcapil data-pelapor" style="margin-top: 0px;">
  2691. <col span="48" style="width: 2.0833%;">
  2692. <tr>
  2693. <td colspan=48><strong>PERUBAHAN STATUS KEWARGANEGARAAN</strong></td>
  2694. </tr>
  2695. <tr>
  2696. <td colspan="16">1. &nbsp;&nbsp;Kewarganegaraan Baru</td>
  2697. <td>:</td>
  2698. <?php for ($i=0; $i<19; $i++): ?>
  2699. <td class="kotak padat tengah">
  2700. &nbsp;
  2701. </td>
  2702. <?php endfor; ?>
  2703. <td colspan=21>&nbsp;</td>
  2704. </tr>
  2705. <tr>
  2706. <td colspan="16">2. &nbsp;&nbsp;Nomor Akta Kelahiran</td>
  2707. <td>:</td>
  2708. <?php for ($i=0; $i<18; $i++): ?>
  2709. <td class="kotak padat tengah">
  2710. &nbsp;
  2711. </td>
  2712. <?php endfor; ?>
  2713. <td colspan=21>&nbsp;</td>
  2714. </tr>
  2715. <tr>
  2716. <td colspan="16">3. &nbsp;&nbsp;Nomor Akta Perkawinan</td>
  2717. <td>:</td>
  2718. <?php for ($i=0; $i<26; $i++): ?>
  2719. <td class="kotak padat tengah">
  2720. &nbsp;
  2721. </td>
  2722. <?php endfor; ?>
  2723. <td colspan="4">&nbsp;</td>
  2724. </tr>
  2725. <tr>
  2726. <td colspan="16">4. &nbsp;&nbsp;Nama Suami atau Istri</td>
  2727. <td>:</td>
  2728. <?php for ($i=0; $i<19; $i++): ?>
  2729. <td class="kotak padat tengah">
  2730. &nbsp;
  2731. </td>
  2732. <?php endfor; ?>
  2733. <td colspan=21>&nbsp;</td>
  2734. </tr>
  2735. <tr>
  2736. <td colspan="16">5. &nbsp;&nbsp;NIK Suami atau Istri</td>
  2737. <td>:</td>
  2738. <?php for ($i=0; $i<19; $i++): ?>
  2739. <td class="kotak padat tengah">
  2740. &nbsp;
  2741. </td>
  2742. <?php endfor; ?>
  2743. <td colspan="4">&nbsp;</td>
  2744. </tr>
  2745. <tr>
  2746. <td colspan="16">6. &nbsp;&nbsp;Nomor Paspor</td>
  2747. <td>:</td>
  2748. <?php for ($i=0; $i<19; $i++): ?>
  2749. <td class="kotak padat tengah">
  2750. &nbsp;
  2751. </td>
  2752. <?php endfor; ?>
  2753. <td colspan=21>&nbsp;</td>
  2754. </tr>
  2755. <tr>
  2756. <td colspan="16">7. &nbsp;&nbsp;Nomor Afidavit</td>
  2757. <td>:</td>
  2758. <?php for ($i=0; $i<18; $i++): ?>
  2759. <td class="kotak padat tengah">
  2760. &nbsp;
  2761. </td>
  2762. <?php endfor; ?>
  2763. <td colspan="21">&nbsp;</td>
  2764. </tr>
  2765. <tr>
  2766. <td colspan="16">8. &nbsp;&nbsp;Nomor Keputusan Presiden</td>
  2767. <td>:</td>
  2768. <?php for ($i=0; $i<18; $i++): ?>
  2769. <td class="kotak padat tengah">
  2770. &nbsp;
  2771. </td>
  2772. <?php endfor; ?>
  2773. <td colspan="21">&nbsp;</td>
  2774. </tr>
  2775. <tr>
  2776. <td colspan="16">9. &nbsp;&nbsp;Tanggal/Bulan/Tahun</td>
  2777. <td>:</td>
  2778. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2779. $bln = date('mm',strtotime($input['tanggal_mati']));
  2780. $thn = date('Y',strtotime($input['tanggal_mati']));
  2781. ?>
  2782. <td colspan="4">Tanggal : </td>
  2783. <?php for ($j=0; $j<2; $j++): ?>
  2784. <td class="kotak padat tengah">
  2785. &nbsp;
  2786. </td>
  2787. <?php endfor; ?>
  2788. <td colspan="4" class="kanan">Bulan : </td>
  2789. <?php for ($j=0; $j<2; $j++): ?>
  2790. <td class="kotak padat tengah">
  2791. &nbsp;
  2792. </td>
  2793. <?php endfor; ?>
  2794. <td colspan="4" class="kanan">Tahun : </td>
  2795. <?php for ($j=0; $j<4; $j++): ?>
  2796. <td class="kotak padat tengah">
  2797. &nbsp;
  2798. </td>
  2799. <?php endfor; ?>
  2800. <td colspan="12">&nbsp;</td>
  2801. <td colspan="2">&nbsp;</td>
  2802. </tr>
  2803. <tr>
  2804. <td colspan="16">10. &nbsp;&nbsp;Nomor Berita Acara Sumpah/Janji Setia</td>
  2805. <td>:</td>
  2806. <?php for ($i=0; $i<18; $i++): ?>
  2807. <td class="kotak padat tengah">
  2808. &nbsp;
  2809. </td>
  2810. <?php endfor; ?>
  2811. <td colspan="21">&nbsp;</td>
  2812. </tr>
  2813. <tr>
  2814. <td colspan="16">11. &nbsp;&nbsp;Nama Jabatan yang menertibkan</td>
  2815. <td>:</td>
  2816. <?php for ($i=0; $i<26; $i++): ?>
  2817. <td class="kotak padat tengah">
  2818. &nbsp;
  2819. </td>
  2820. <?php endfor; ?>
  2821. <td colspan="21">&nbsp;</td>
  2822. </tr>
  2823. <tr>
  2824. <td colspan="16">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;BAS/Janji Setia</td>
  2825. <td></td>
  2826. <td></td>
  2827. </tr>
  2828. <tr>
  2829. <td colspan="16">12. &nbsp;&nbsp;Tanggal/Bulan/Tahun</td>
  2830. <td>:</td>
  2831. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2832. $bln = date('mm',strtotime($input['tanggal_mati']));
  2833. $thn = date('Y',strtotime($input['tanggal_mati']));
  2834. ?>
  2835. <td colspan="4">Tanggal : </td>
  2836. <?php for ($j=0; $j<2; $j++): ?>
  2837. <td class="kotak padat tengah">
  2838. &nbsp;
  2839. </td>
  2840. <?php endfor; ?>
  2841. <td colspan="4" class="kanan">Bulan : </td>
  2842. <?php for ($j=0; $j<2; $j++): ?>
  2843. <td class="kotak padat tengah">
  2844. &nbsp;
  2845. </td>
  2846. <?php endfor; ?>
  2847. <td colspan="4" class="kanan">Tahun : </td>
  2848. <?php for ($j=0; $j<4; $j++): ?>
  2849. <td class="kotak padat tengah">
  2850. &nbsp;
  2851. </td>
  2852. <?php endfor; ?>
  2853. <td colspan="12">&nbsp;</td>
  2854. <td colspan="2">&nbsp;</td>
  2855. </tr>
  2856. <tr>
  2857. <td colspan="16">13. &nbsp;&nbsp;Nomor Keputusan Mentri (Bidang</td>
  2858. <td>:</td>
  2859. <?php for ($i=0; $i<18; $i++): ?>
  2860. <td class="kotak padat tengah">
  2861. &nbsp;
  2862. </td>
  2863. <?php endfor; ?>
  2864. <td colspan="21">&nbsp;</td>
  2865. </tr>
  2866. <tr>
  2867. <td colspan="16">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Kewarganegaraan)</td>
  2868. <td></td>
  2869. <td></td>
  2870. </tr>
  2871. <tr>
  2872. <td colspan="16">14. &nbsp;&nbsp;Tanggal/Bulan/Tahun</td>
  2873. <td>:</td>
  2874. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2875. $bln = date('mm',strtotime($input['tanggal_mati']));
  2876. $thn = date('Y',strtotime($input['tanggal_mati']));
  2877. ?>
  2878. <td colspan="4">Tanggal : </td>
  2879. <?php for ($j=0; $j<2; $j++): ?>
  2880. <td class="kotak padat tengah">
  2881. &nbsp;
  2882. </td>
  2883. <?php endfor; ?>
  2884. <td colspan="4" class="kanan">Bulan : </td>
  2885. <?php for ($j=0; $j<2; $j++): ?>
  2886. <td class="kotak padat tengah">
  2887. &nbsp;
  2888. </td>
  2889. <?php endfor; ?>
  2890. <td colspan="4" class="kanan">Tahun : </td>
  2891. <?php for ($j=0; $j<4; $j++): ?>
  2892. <td class="kotak padat tengah">
  2893. &nbsp;
  2894. </td>
  2895. <?php endfor; ?>
  2896. <td colspan="12">&nbsp;</td>
  2897. <td colspan="2">&nbsp;</td>
  2898. </tr>
  2899. </table>
  2900.  
  2901. <!-- START OF PERUBAHAN PERISTIWA PENTING LAINNYA -->
  2902. <table class="disdukcapil data-pelapor" style="margin-top: 0px;">
  2903. <col span="48" style="width: 2.0833%;">
  2904. <tr>
  2905. <td colspan=48><strong>PERUBAHAN PERISTIWA PENTING LAINNYA</strong></td>
  2906. </tr>
  2907. <tr>
  2908. <td colspan="16">1. &nbsp;&nbsp;Nomor Akta Kelahiran</td>
  2909. <td>:</td>
  2910. <?php for ($i=0; $i<19; $i++): ?>
  2911. <td class="kotak padat tengah">
  2912. &nbsp;
  2913. </td>
  2914. <?php endfor; ?>
  2915. <td colspan=21>&nbsp;</td>
  2916. </tr>
  2917. <tr>
  2918. <td colspan="16">2. &nbsp;&nbsp;Jenis Kelamin Lama</td>
  2919. <td>:</td>
  2920. <td class="kotak padat tengah">
  2921. &nbsp;
  2922. </td>
  2923. <td colspan=5>1. Laki-laki </td>
  2924. <td colspan=7>2. Perempuan </td>
  2925. <td colspan=4>&nbsp;</td>
  2926. </tr>
  2927. <tr>
  2928. <td colspan="16">3. &nbsp;&nbsp;Jenis Kelamin Baru</td>
  2929. <td>:</td>
  2930. <td class="kotak padat tengah">
  2931. &nbsp;
  2932. </td>
  2933. <td colspan=5>1. Laki-laki </td>
  2934. <td colspan=7>2. Perempuan </td>
  2935. <td colspan=4>&nbsp;</td>
  2936. </tr>
  2937. <tr>
  2938. <td colspan="16">4. &nbsp;&nbsp;Nomor Penetapan Pengadilan</td>
  2939. <td>:</td>
  2940. <?php for ($i=0; $i<19; $i++): ?>
  2941. <td class="kotak padat tengah">
  2942. &nbsp;
  2943. </td>
  2944. <?php endfor; ?>
  2945. <td colspan=21>&nbsp;</td>
  2946. </tr>
  2947. <tr>
  2948. <td colspan="16">5. &nbsp;&nbsp;Tanggal Penetapan Pengadilan</td>
  2949. <td>:</td>
  2950. <?php $tgl = date('dd',strtotime($input['tanggal_mati']));
  2951. $bln = date('mm',strtotime($input['tanggal_mati']));
  2952. $thn = date('Y',strtotime($input['tanggal_mati']));
  2953. ?>
  2954. <td colspan="4">Tanggal : </td>
  2955. <?php for ($j=0; $j<2; $j++): ?>
  2956. <td class="kotak padat tengah">
  2957. &nbsp;
  2958. </td>
  2959. <?php endfor; ?>
  2960. <td colspan="4" class="kanan">Bulan : </td>
  2961. <?php for ($j=0; $j<2; $j++): ?>
  2962. <td class="kotak padat tengah">
  2963. &nbsp;
  2964. </td>
  2965. <?php endfor; ?>
  2966. <td colspan="4" class="kanan">Tahun : </td>
  2967. <?php for ($j=0; $j<4; $j++): ?>
  2968. <td class="kotak padat tengah">
  2969. &nbsp;
  2970. </td>
  2971. <?php endfor; ?>
  2972. <td colspan="12">&nbsp;</td>
  2973. <td colspan="2">&nbsp;</td>
  2974. </tr>
  2975. <tr>
  2976. <td colspan="16">6. &nbsp;&nbsp;Nama Lembaga Pengadilan</td>
  2977. <td>:</td>
  2978. <?php for ($i=0; $i<26; $i++): ?>
  2979. <td class="kotak padat tengah">
  2980. &nbsp;
  2981. </td>
  2982. <?php endfor; ?>
  2983. <td colspan="4">&nbsp;</td>
  2984. </tr>
  2985. </table>
  2986.  
  2987. <!-- START OF PEMBETULAN AKTA -->
  2988. <table class="disdukcapil data-subjek-akta-kesatu" style="margin-top: 0px;">
  2989. <col span="48" style="width: 2.0833%;">
  2990. <tr>
  2991. <td colspan=48><strong>PEMBETULAN AKTA</strong></td>
  2992. </tr>
  2993. <tr>
  2994. <td colspan="16">1. &nbsp;&nbsp;Nomor Akta yang akan dibetulkan/ditarik</td>
  2995. <td>:</td>
  2996. <?php for ($i=0; $i<18; $i++): ?>
  2997. <td class="kotak padat tengah">
  2998. &nbsp;
  2999. </td>
  3000. <?php endfor; ?>
  3001. <td colspan=21>&nbsp;</td>
  3002. </tr>
  3003. <tr>
  3004. <td colspan="16">2. &nbsp;&nbsp;Nama Ayah/Ibu/Wali (yang dibawah umur)</td>
  3005. <td>:</td>
  3006. <?php for ($i=0; $i<26; $i++): ?>
  3007. <td class="kotak padat tengah">
  3008. &nbsp;
  3009. </td>
  3010. <?php endfor; ?>
  3011. <td colspan="4">&nbsp;</td>
  3012. </tr>
  3013. <tr>
  3014. <td colspan="16">3. &nbsp;&nbsp;NIK Ayah/Ibu/Wali</td>
  3015. <td>:</td>
  3016. <?php for ($i=0; $i<18; $i++): ?>
  3017. <td class="kotak padat tengah">
  3018. &nbsp;
  3019. </td>
  3020. <?php endfor; ?>
  3021. <td colspan="4">&nbsp;</td>
  3022. </tr>
  3023. </table>
  3024.  
  3025. <!-- START OF PEMBATALAN AKTA -->
  3026. <table class="disdukcapil data-subjek-akta-kesatu" style="margin-top: 0px;">
  3027. <col span="48" style="width: 2.0833%;">
  3028. <tr>
  3029. <td colspan=48><strong>PEMBATALAN AKTA</strong></td>
  3030. </tr>
  3031. <tr>
  3032. <td colspan="16">1. &nbsp;&nbsp;Akta yang dibatalkan</td>
  3033. <td>:</td>
  3034. <?php for ($i=0; $i<26; $i++): ?>
  3035. <td class="kotak padat tengah">
  3036. &nbsp;
  3037. </td>
  3038. <?php endfor; ?>
  3039. <td colspan=21>&nbsp;</td>
  3040. </tr>
  3041. <tr>
  3042. <td colspan="16">2. &nbsp;&nbsp;Nomor akta yang dibatalkan</td>
  3043. <td>:</td>
  3044. <?php for ($i=0; $i<26; $i++): ?>
  3045. <td class="kotak padat tengah">
  3046. &nbsp;
  3047. </td>
  3048. <?php endfor; ?>
  3049. <td colspan="4">&nbsp;</td>
  3050. </tr>
  3051. <tr>
  3052. <td colspan="16">3. &nbsp;&nbsp;Nomor Putusan Pengadilan</td>
  3053. <td>:</td>
  3054. <?php for ($i=0; $i<26; $i++): ?>
  3055. <td class="kotak padat tengah">
  3056. &nbsp;
  3057. </td>
  3058. <?php endfor; ?>
  3059. <td colspan="4">&nbsp;</td>
  3060. </tr>
  3061. <tr>
  3062. <td colspan="16">4. &nbsp;&nbsp;Tanggal Putusan Pengadilan</td>
  3063. <td>:</td>
  3064. <?php $tgl = date('dd',strtotime($individu['tanggallahir']));
  3065. $bln = date('mm',strtotime($individu['tanggallahir']));
  3066. $thn = date('Y',strtotime($individu['tanggallahir']));
  3067. ?>
  3068. <td colspan="4">Tanggal :</td>
  3069. <?php for ($j=0; $j<2; $j++): ?>
  3070. <td class="kotak padat tengah">
  3071. &nbsp;
  3072. </td>
  3073. <?php endfor; ?>
  3074. <td colspan="4" class="kanan">Bulan : </td>
  3075. <?php for ($j=0; $j<2; $j++): ?>
  3076. <td class="kotak padat tengah">
  3077. &nbsp;
  3078. </td>
  3079. <?php endfor; ?>
  3080. <td colspan="4" class="kanan">Tahun : </td>
  3081. <?php for ($j=0; $j<4; $j++): ?>
  3082. <td class="kotak padat tengah">
  3083. &nbsp;
  3084. </td>
  3085. <?php endfor; ?>
  3086. <td colspan="4">&nbsp;</td>
  3087. </tr>
  3088. <tr>
  3089. <td colspan="16">5. &nbsp;&nbsp;Nama Lembaga Pengadilan</td>
  3090. <td>:</td>
  3091. <?php for ($i=0; $i<26; $i++): ?>
  3092. <td class="kotak padat tengah">
  3093. &nbsp;
  3094. </td>
  3095. <?php endfor; ?>
  3096. <td colspan="4">&nbsp;</td>
  3097. </tr>
  3098. </table>
  3099. <!-- START OF PELAPORAN PENCATATAN SIPIL DARI LUAR WILAYAH NKRI -->
  3100. <table class="disdukcapil data-subjek-akta-kesatu" style="margin-top: 0px;">
  3101. <col span="48" style="width: 2.0833%;">
  3102. <tr>
  3103. <td colspan=48><strong>PELAPORAN PENCATATAN SIPIL DARI LUAR WILAYAH NKRI</strong></td>
  3104. </tr>
  3105. <tr>
  3106. <td colspan="16">1. &nbsp;&nbsp;Jenis Peristiwa Penting </td>
  3107. <td>:</td>
  3108. <?php for ($i=0; $i<1; $i++): ?>
  3109. <td class="kotak padat tengah">
  3110. &nbsp;
  3111. </td>
  3112. <?php endfor; ?>
  3113. <td colspan=7>1. Kelahiran</td>
  3114. <td colspan=7>2. Perkawinan</td>
  3115. <td colspan=7>3. Perceraian</td>
  3116. <td colspan=7>4. Kematian</td>
  3117. <td colspan=18>&nbsp;</td>
  3118. </tr>
  3119. <tr>
  3120. <td colspan="18">&nbsp;</td>
  3121. <td colspan=7>5. Pengangkatan Anak </td>
  3122. <td colspan=10>6. Pelepasan Kewarganegaraan RI </td>
  3123. <td colspan=18>&nbsp;</td>
  3124. </tr>
  3125. <tr>
  3126. <td colspan="16">2. &nbsp;&nbsp;Nomor Surat Keterangan Pelaporan Pencatatan</td>
  3127. <td>:</td>
  3128. <?php for ($i=0; $i<26; $i++): ?>
  3129. <td class="kotak padat tengah">
  3130. &nbsp;
  3131. </td>
  3132. <?php endfor; ?>
  3133. <td colspan=21>&nbsp;</td>
  3134. </tr>
  3135. <tr>
  3136. <td colspan="16">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Sipil dari Perwakilan RI</td>
  3137. <td>:</td>
  3138. <?php for ($i=0; $i<26; $i++): ?>
  3139. <td class="kotak padat tengah">
  3140. &nbsp;
  3141. </td>
  3142. <?php endfor; ?>
  3143. <td colspan=21>&nbsp;</td>
  3144. </tr>
  3145. <tr>
  3146. <td colspan="16">3. &nbsp;&nbsp;Tanggal Surat Keterangan Pelaporan Pencatatan</td>
  3147. <td>:</td>
  3148. <?php for ($i=0; $i<26; $i++): ?>
  3149. <td class="kotak padat tengah">
  3150. &nbsp;
  3151. </td>
  3152. <?php endfor; ?>
  3153. <td colspan=21>&nbsp;</td>
  3154. </tr>
  3155. <tr>
  3156. <td colspan="16">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Sipil dari Perwakilan RI</td>
  3157. <td>:</td>
  3158. <?php for ($i=0; $i<26; $i++): ?>
  3159. <td class="kotak padat tengah">
  3160. &nbsp;
  3161. </td>
  3162. <?php endfor; ?>
  3163. <td colspan=21>&nbsp;</td>
  3164. </tr>
  3165. <tr>
  3166. <td colspan="16">4. &nbsp;&nbsp;Kantor Perwakilan yang melakukan pencatatan</td>
  3167. <td>:</td>
  3168. <?php for ($i=0; $i<26; $i++): ?>
  3169. <td class="kotak padat tengah">
  3170. &nbsp;
  3171. </td>
  3172. <?php endfor; ?>
  3173. <td colspan="4">&nbsp;</td>
  3174. </tr>
  3175. <tr>
  3176. <td colspan="16">5. &nbsp;&nbsp;Nomor Bukti Pencatatan Sipil</td>
  3177. <td>:</td>
  3178. <?php for ($i=0; $i<26; $i++): ?>
  3179. <td class="kotak padat tengah">
  3180. &nbsp;
  3181. </td>
  3182. <?php endfor; ?>
  3183. <td colspan=21>&nbsp;</td>
  3184. </tr>
  3185. <tr>
  3186. <td colspan="16">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;dari Negara Setempat</td>
  3187. <td></td>
  3188. <td></td>
  3189. </tr>
  3190. <tr>
  3191. <td colspan="16">6. &nbsp;&nbsp;Tanggal Penerbitan dari Negara Setempat</td>
  3192. <td>:</td>
  3193. <?php for ($i=0; $i<26; $i++): ?>
  3194. <td class="kotak padat tengah">
  3195. &nbsp;
  3196. </td>
  3197. <?php endfor; ?>
  3198. <td colspan="4">&nbsp;</td>
  3199. </tr>
  3200. </table>
  3201.  
  3202. <table class="disdukcapil data-subjek-ttd" style="margin-top: 0px;">
  3203. <col span="48" style="width: 2.0833%;">
  3204. <tr>
  3205. <td colspan=48>No. Reg :</td>
  3206. </tr>
  3207. <tr>
  3208. <td colspan=6>&nbsp;</td>
  3209. <td colspan=12><strong>Mengetahui : </strong></td>
  3210. </tr>
  3211. <tr>
  3212. <td colspan="35"><strong>Pejabat Dukcapil yang membidangi / Kepala Desa / Lurah</strong></td>
  3213. <td colspan="20">&nbsp;&nbsp;<?= $config['nama_desa'];?>, <?= tgl_indo(date('Y m d',time()));?></td>
  3214. </tr>
  3215. <tr>
  3216. <td colspan=12><strong>&nbsp;</strong></td>
  3217. </tr>
  3218. <tr>
  3219. <td colspan=12><strong>&nbsp;</strong></td>
  3220. </tr>
  3221. <tr>
  3222. <td colspan=12><strong>&nbsp;</strong></td>
  3223. </tr>
  3224. <tr colspan="12">
  3225. <td colspan=4>&nbsp;</td>
  3226. <td colspan="33">&nbsp;&nbsp;(..............................)</td>
  3227. <td colspan="20">(..............................)</td>
  3228. </tr>
  3229. </table>
  3230.  
  3231. </page>
  3232.  
  3233.  
  3234.  
  3235.  
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