Death Certificate: 39-Year-Old Male Iraqi Detainee - Internee (Civilian), Abu Ghraib Prison, Baghdad, Iraq (Homicide)

<p>Death Certificate: 39-Year-Old Male Iraqi Detainee - Internee (Civilian), Abu Ghraib Prison, Baghdad, Iraq (Homicide). Related to ACLU-RDI 1666</p>

Thursday, October 30, 2003
Friday, October 14, 2005

U. CERTIFICATE OF DEATH (OVERSEAS) ,---- -, Acte de dices (D'Ouire-Mer)E SOCIAL SECURITY NUMBER BRANCH OF SERVICE NAME OF DECEASED (Last, First. Middle) Nom du decade (Nom et prenoms) Arme N r ante Sociale imommir GRADE Grade NATION (e.g.. United States) DATE OF BIRTH SEX Sexe ORGANIZATION Organisation Pays Date de naissance {SIMALE Mascutin 12A C3 . FEMALE FerninIn RELIGION Culte MARITAL STATUS Etat Civil RACE Race PROTESTANT OTHER (Specify) Autre (Specifier) CAUCASOID Caucasique SINGLE Uhl:re tair e DIVORCED Protestant Divorce CATHOLIC MARRIED Marie Catholique NEGROID Negroide SEPARATED Ware u OTHER (Specify) JEWISH Jul Autre (Specifier) APLA ,1)... I C./ WIDOWED Veul RELATIONSHIP TO DECEASED Parente du decade avec le susdit NAME OF NEXT OF KIN Nom du plus proche parent CITY OF TOWN AND STATE (include ZIP Code) Ville (Code postal compris) STREET ADDRESS Domicile a glue) MEDICAL STATEMENT Declaration medicals INTERVAL BETWEEN ONSET AND DEATH CAUSE OF DEATH (Enter only one cause per line) Intervene entreCause du dikes (N'indiquer qu'une cause par ligne) ('attaque et le (feces I 6 LA 1,1 Sisic,..)-r IA) o;..k_ Nz -ro p&-Lvis S- t'100,A-5 DISEASE OR CONDITION DIRECTLY LEADING TO DEATH Maladie ou condition directement responsahle de la mort. MORBID CONDITION, IF ANY, — ANTECEDENT LEADING TO PRIMARY CAUSE CAUSES Condition morbide, s'il y a lieu, menant a la cause primaire Symptemes UNDERLYING CAUSE, IF ANY, GIVING RISE TO PRIMARY precurseurs CAUSE Y\-));TY‘ C:1- de la molt. Raison fondamentale, s'it y a lieu. ayam susciie la cause Pr imaire • OTHER SIGNIFICANT CONDITIONS 2 IL) )3\f"..-Y' Autres conditions signilicatives 2 . CIRCUMSTANCES SURROUNDING DEATH DUE TO AUTOPSY PERFORMED Autopsie ellettuee YES Oui ITeN0 Non EXTERNAL CAUSES MODE OF DEATH Circonstances de la mort suscitees par des causes exterieuresCondition de dices MAJOR FINDINGS OF AUTOPSY Conclusions prIncipales de l'aulopsie NATURAL Mort natur elle ACCIDENT Mort accidentelle NAME OF PATHOLOGIST Nom du pathologrste SUICIDE Suicide HOMICIDE SIGNATURE Signature DATE Date AVIATION ACCIDENT Accidents Avioy Homicide . YES Oul Illg NO Non •k DATE OF DEATH (liner, lay, month. year) L ( (2"--t Date de decay Pheure, le Jour, it limit. fanner) 3.,) 0,...--r 0 3 2.--2-04, / TED ABOVE. H OCCURRED AT THE TIME INDICATED AND F I HAVE VEIWED THE REMAINS OF THE DECEA J'ai examine les 'limes mortals du delunt et je conciusque le decay est survenu A I'heure indiquee et 5. la suite des causes dnumerdes ci dessus e ou du medicin sanitaire TITLE 1 4 .1''' Gr ade (-71' ' 7— ik) 1/ DATE Date ,' ;., e-t.',—/ 0 --; ' Stoic disease. injury or complication which COI ry 7 Store conditions contribmingsuthe death. but ase or condilim \'.?"k)' 1 lion qui a rontrilaii a lit mon. i rete de atomic. mile qu'un acrid du coeur, me. ' Pr!ciser In nature de to maludie. dr In blessure _. _ .... . _ - . ,_ ...__., .--, .....,.. . - ,,,,,,,,,,,,,r h, omiudie Oil a In con tow a prorogue In more. •e USAPA V I .00 REPLACES DA FORM 3565. 1 JAN 1972 AND DA FORM 3565.RIPASI. 26 SEP 1975, WHICH ARE OBSOLETE. DD FORM 2064, APR '1977 MEDCOM - 22446 DOD-036022 ... . - r- r HOSPITAL REPORT OF DEATH - :,,E PRo?, .E ,,7 aciisi.-, S OF= CE :7. TI-F. S'.:ACEON GEn.€3 , ' .;, •, •3C, I /n.5(tVitiOnS -Medical Off,E C. rrqS FO.v. SEi .AF, rr,jx;enoance will: Send form, without delay to the Registrar or Administrative Officer 1 1. Prepare., in one cop,' only, items 1 through 10 and sign Item E of the Day, for necessary action and for preparation of required PIM r or type entrie.s.E number of copies. SECTION A - ATTENDING MEDICAL OFFICER'S REPORT PERSONAL DATA 3. MEDICAL EXAMINER. 2. TIME OF DEATH ,...),--ea.,..,i0 ,, ::, -/e..3 ,7 PATIENT DATA (Patient's ward plate will be used to imprint 1. CORONER'S CASE leen r;:,,:ing de. ta if , ES & NO ( RA 0 t ).-)-0 5 E0 cfcl --d-C7°3 5. CHAPLAIN NOTIFIED 4. RELIGION Li YES NO 6. NAME, ADDRESS AND RELATIONSHIP OF RELATIVE OR FRIEND LY4,-. ) PRESENT AT DEATH Patient's name (Last, first, middle initial) Grade, Social Security Account No.. Register Number and Ward Number APPROXIMATE INTERVAL .. BETWEEN ONSET CAUSE OF DEATH AND DEATH 7a. DISEASE OR CONDITION DIRECTLY LEADING TO DUE TO (or as a consequence of) DEATH !This does not mean roe mode of dying, e.g., watA,No -ro pEz..N. Is 5 PCVAR. S newt 13ilufe, asthenia, ex. I: means the o'isease, injury, 61A-4.5-61-0 7. or complication which caused death I DUE TO (or as a consequence of) 7h. ANTECEDENT CAUSES (Ma/bid conditions, if any, (1) giving rise to the above cause, stating me underlying ca,dirion test) (2) No OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO THE DEATH, BUT NOT RELATED TO THE DISEASE OR CONDITION CAUSING IT b. „. ./E/ A, ) S. rm "2- NDANCE E OF frM EDICAL OFFICER IN 11. SIG - 10. TYPED OR PRINTED N 9. DATE ATT 30 03 AI il SEC N B - ADMINISTRATIVE ACT I YEAR INITI SPONSIOE OFFICER TYPE OF ACTION DAY :I HOUR TELEGRAM TO NEXT OF KIN OR OTHER AUTHORIZED PERSON 12. 3. POST ADJUTANT GENERAL NOTIFIED 14. IMMEDIATE CO OF DECEASED NOTIFIED 5. INFORMATION OFFICE NOTIFIED IS POST MORTUARY OFFICER NOTIFIED 7. RED CROSS NOTIFIED t IS 07,-ER !So-..cd7; I I 19 SECTION C - RECORD OF AUTOPSY AUTOPS'I CF.DEPED SY !S;cnr:ure) 20 AUTC.SY PERFORMED III yes, give dare and place) 21. Ei 22. P:..":;S ¦ C.`,NAL PAT:-CC::CAL F!::::: ,..-.1S . .E OF FHYSICI:-N PERFORMING Au7C.Sy 24. TYPED NAME AND GRADE OF PHYSICIAN PERFORMING 2E. 3:GNA7UF-­ 21 Z`ATE .. AUTOPSY I .,. k SIGNAT'_:=E CF REO:S7RA R. 2E. 27. TYPED NAME AND GRADE OF REGISTRAR . 2.7. SA -7E i U A V2. JAN 61, WHICH WILL SE USED. REPLACES DA FORM 8-257, 1 DA FORM 3694, OCT 72 MEDCOM - 22447 DOD-036023