ALAMAT : K. PANJAAN 4/42-C-2 SBY TTL : MOJOKERTO,30/06/1955 NIK : 35780530065500005 No. KK : 357805010108
ALAMAT : K. PANJAAN 4/42-C-2 SBY TTL : SURABAYA,27/12/1979 NIK : 3578056712790001 No. KK : 357805010108