Excerpt Of Marriage Certificate
SERIE: NE
No206/4/VIII/1989
FOR HUSBAND
“And treat you wife kindly” (Surah An Nisa’ Verse number 19)
There has been authenticated a covenant of marriage on Saturday at 3-1-1410 H or
at 5-8-1989 CE on 13.00 between:
A MAN :
III. 1. Full Name and : Ir. Helmy Said
alias
2. Son of : H. Salim Said Bawazir
3. Place and Date : Sungai Gerong, March 6th, 1958
of Birth
4. Nationality : Indonesian
5. Religion : Islam
6. Occupation : Pertamina Employee
7. Address : Pertamina Complex 6.5.181
8. Special
Characteristics :……
9. Bachelor, widower
or married : bachelor
WITH A WOMAN
V. 1. Full Name and : Lu Lu
alias
2. Daughter of : M. Baasir
3. Place and Date : Cilacap,10 - 8 - 1967
of Birth
4. Nationality : Indonesian
5. Religion : Islam
6. Occupation : University Student
7. Address : Sidanegara
8. Special
Characteristics :……
9. Virgin or widow : virgin
The Marriage Guardian
VII. 1. Full Name and : M. Baasir
alias
2. Son of : Saleh Baasir
5. Place and Date : Tegal, 14 - 6 - 1931
of Birth
6. Nationality : Indonesian
7. Religion : Islam
8. Occupation : Trader
9. Marriage Guardian : Father
Relationship/cause
IF THE GUARDIAN IS MAGISTRATE GUARDIAN
a. Name :-
b. Title :-
c. Cause :-
DOWRY
VIII. 1. In term of and : A prayer set and
in the amount of a sum of money of Rp. 10.000
2. Payment
(cash/indebted) : cash
IX. After the marriage
Ceremony was done
the husband read and
signed taklik/talak : read
X. Mention if any other agreement
besides taklik/talak : no
XX. Mention if the
marriage record
according to the court
decision
the court decided, number and date
Central Cilacap, August 5th, 1989
Excerpted pursuant to the original
Officer of Marriage Registration
The cost of the
SIGNED AND SEALED
marriage
registration
Rp….
Has been paid
H. MASKANAS. BA
Employment Identity Number: 150 102 113
