PROTOKOLAS Nr.
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(Įteikimo vieta) (Įteikimo data)
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(Įteikiančiojo vardas ir pavardė)
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(Pareigos)
Lietuvos Respublikos Aukščiausiosios Tarybos Prezidiumo vardu įteikiau Sausio 13-osios atminimo medalį šiems asmenims:
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Eil. Apdovanotojo Įsako Įsako Apdovanojimo Sausio 13-
Nr. vardas ir pavardė data numeris osios atminimo medaliu
liudijimo
numeris
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Antspaudo vieta (Apdovanojimus įteikusiojo parašas)
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