Death Certificate: Iraqi Civilian, Iraq (Homicide)

Death Certificate of an Iraqi Civilian of unknown age. Cause of Death: Gunshot Wound to the Head - Open Skull Fracture; Cause and location of death not included.

Doc_type: 
Medical
Doc_date: 
Thursday, October 30, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

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—, CERTIFICATE OF DEATH (OVERSEAS) Acte de (feces (D'Ogdre-Mer)
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NAME OF DECEASED (Lau. F - 1 Nom du decede Nom at prenoms) GRADE Grade BRANCH i:::NCH SERVICE
Arne SOCIAL SECURITY NUMBER iale
il
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div c t/
ORGANIZATION.

Organisation NATION (e.g., United Stales) DATE OF BIRTH SEX Saxe Pays Date de naissance
Ei MALE Masculin

ett(
--,r FEMALE Fdminin

• RACE Race MARITAL STATUS Etat Civil RELIGION Cilia's
OTHER (Specify)CAUCASOID Caucasique SINGLE Celibataire PROTESTANT
DIVORCED Autre (Specifier)
Protestant
r
Divorcd CATHOLIC '71.6 .5(i,.

NEGROID NegrOide MARRIED Marie .
Carhollque
SEPARATED
\(:., OTHER ISpecify) v.

Separe
Autre (Specifier)

WIDOWED Veul JEWISH Juif
NAME OF NEXT OF KIN Nom du I jy5 proche parent RELATIONSHIP TO DECEASED Parente du decede avec IS susdit
•f
STREET ADDRESS Domicild'a (Rue) CITY OF TOWN AND STATE (include Zit' Code) Ville ICode postal comprisl

MEDICAL STATEMENT Declaration mddicale
INTERVAL BETWEEN CAUSE OF DEATH (Enter only one cause per line)
ONSET AND DEATH Cause du Elects IN'indiquer qu'une cause par lignel
Intervene antra renegue et le daces
/DISEASE OR CONDITION DIRECTLY LEADING TO DEATH

i.
Maladie ou condition directement responsable de la mart. 1

25L°— 4N Lci

apfty30".1
MORBID CONDITION, IF ANY,ANTECEDENT LEADING TO PRIMARY CAUSE
CAUSES Condition morbide, s'il y a lieu,
menant a la cause primaire

SymptOmeS UNDERLYING CAUSE, IF ANY,
GIVING RISE TO PRIMARY

precurseurs
CAUSE
Oe la mart.

Raison fondamentale, s'il y a lieu, /
ayant suscite la cause primaire
¦
OTHER SIGNIFICANT CONDITIONS 2
Autres conditions significatives 2
',..

MODE OF DEATH AUTOPSY PERFORMED Autopsie effectuee . YES Out . NO Non CIRCUMSTANCES SURROUNDING DEATH DUE TO
Condition de dices EXTERNAL CAUSES

MAJOR FINDINGS OF AUTOPSY Conclusions principales de l'autOpsie
Circon stances de la more suscitees par des causes exterieures
NATURAL
MoN naturelle
ACCIDENT
Mort accidentelle

NAME OF PATHOLOGIST Noni du pathologiste
Suicide

SUICIDE

HOMICIDE SIGNATURE Signature 1 DATE Date AVIATION ACCIDENT Accident a Avian
Homicide

. YES Oui . NO Non
DATE OF DEATH (now. day, month. year)

PLACE OF DEATH Lieu de deeds
Date In aeces ((Van% le Jour, le awls. l'annee)
I HAVE VEIWED THE REMAINS OF THE DECEASED AND DEATH OCCURRED AT THE TIME INDICATED AND FROM THE CAUSES AS STATED ABOVE.
J'ai examine les mutes morcels du defun: et je conclus qua In (feces est survenu a rheure indiquee et a, la suite des causes enumerees ci dessus

NAME OF ea" " • ficin sanitaire TITLE OR DEGREE Titre ou diplarne
ft, ,, y)

GRADE Grade N R SS
-,,,

I•AAAcS g \ ....1
DATE Date SIGNATURE Signal
CI

' State disease, Injury or ranpliration which (cased death, but nor
= Store condition:contributing to the death, bur not ...4e;e4to the d)sea causing drain.
-

' &dam/ in nature de to whale, de In blessure on tie la cantpliention qui a caturibmi Pla moil. tnnis.nan in maniere de inottrir, wile gu'un arr.', du (Veal, etc.2 Preis., la .!-ontlaion gui a manila", I In mors. Innis n'avant aurone rnppart give hi "Wattle on a la condition it'd a provoqud la mart, — - - - - - - - - -
, APR 1 REPLACES DA FORA" " -.ASI. 26 SEP 1575, WHICH ARE OBSOLETE. USAPA V 1.00 MEDCOM - 22450

DOD-036026

HOSPITAL REPORT OF DEATH
%OA,. SiiARs.2.,.2.3. THE .s
.2; T•-•
Instructions -

Prepare. n one co.oy only, 1:ems I through 10 and si gn item • 1. Print or type entries.
1. PATIENT DATA (Patient's vyard plate will be used :o imprintidentifying data if available)
SI-

Tale, c; v
Patient's name (Last, first, middle initial) Grade,
Social Security Account No., Register Number and Ward Number

CAUSE OF DEATH

10. TYPED OR PRINTED NAME A
OFFICER IN 11 _NDANCEATTENDANCE

3D
SECTION B - ADMINISTRATIVE A
TYPE OF ACTION

HOUR DA"
•¦ 7:1
YEAR INITIALS Or RESPONSIBLE Crr:CER

12. TELEGRAM TO NEXT OF KIN OR OTHER AUTHORIZE-0 PERSON
12. POST .AaJurANT GENERAL NOTIFIED
SECTION C - RECORD OF AUTOPSY
33 AUTOPSY PERFORM
(:1 yes, give dote and ;lace)

121. AUTOPSr GROEREC By /.3iv,a;ceel
0 YES

0

2. PP.O','"SiONAL PATH.DLCG•C.AL 5
! . ;G -NGS

23. DATE
2. TYPED NAME AND GRADE Or PHYSICIAN PERFCR2IING
AUTOPSY

25. SIGNATuRE OF PHYSICIAN PEP.FORm!NG AuTOPSy

.:5 1 • if"'
27. TYPED N.AmE AND GRADE CF REGISTRAR
: •.
22 S:CNAT..rE CF REG:STRAR
I .
•-ilr

DA FORM 3894, OCT 72
REPLACES DA FORM 8-257, I JAN 61, WHICH 1.iVia RE USED.
USAPA ‘12.01

7a. oisEaSEOF1 CONDIT:ON DIRECTLY LEADING TO DEATH (This does nor mean the mode of dying, e.g., nejt? failure, asthenia. e:c. It means the disease, injury,or complicarion which caused death)
75. ANTECEDENT CAUSES (Morbid condition5. if any
giving ii.se tO the atho•re cause. stating Me underlying
condition:esti

9.
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO THE DEATH, BUT NOT RELATED TO THE DISEASE OR CONDITION CAUSING IT
9. DATE
NAME AND LOCATION OF HOSPITAL
Officer in attendance Send fform,
-orm ‘vithou: delay to the Registrar or Administrative Officer of the Day, for necessary action and for preparation of required number of copies.
1 2. TIME OF DEATH ..-,:..:r•ca,son..m• y eai-, 3. MEDICAL EXAMINER.
tiqc) 3Oc-+ CORONER'S CASE E YES NO
RELIGION 5. CHAPLAIN NOTIFIEDE YES E NO

6. NAME, ADDRESS AND RELATIONSHIP OF RELATIVE OR FRIEND PRESENT AT DEATH
APPROXIMATE INTERVAL
BETWEEN ONSET
AND DEATH

DUE TO (or as a consequence of)
GlIS L-1 "---

"La4

pe,' 30 04
DUE TO (or as a consequence of)
(1)

(2)

a.

MEDCOM - 22451
DOD-036027

Doc_nid: 
3957
Doc_type_num: 
72