Death Certificate: Iraqi Male, Iraq (Homicide)

-
-
-
„E ii /-!:!(:ATE O)' DEATH (OVERSEAS)
1
f dee;ar, jP/Ordre-Mer)
it* DECEASED
Nu.. ... •..1c9de (Horn el pre.iorisl
GRADE Grade
BRANCH OF SERVICE SOCIAL SECURITY NUMBER
, Army
Humeri, do l'AssuranceScciale
ORGANIZATION Organise
NATION (e.g.. United nowt)

DA rE OF EIRTH
SEX Saxe
Pays
Date de naissancc
MALE Masculin
FEMALE Forninin
.
MARITAL. STATUS
oat Civil
RELIGION Celia
I
CAUCASOID Caucasique
PROTESTANT OTHER (Spa•)DIVORCED
Protestant Autre (Tairnier)
I
Divorce

NEGROID Negrende
MARRIED Marie CATHOLIC
Catholique
X
OTHER (Specify) SEPARATED
Separe

Autre (Specifier) WIDOWED Vest
JEWISH Jud
NAME OF NEXT OF KIN Nom du plus proche parent
RELATIONSHIP TO DECEASED Parente du deckle avec le susdit

STREET ADDRESS Domicile a (Rue)
CITY OF TOWN AND STATE (Include ZIP Code)

Ville (Code postal compris)
MEDICAL STATEMENT Declaration medical°
. CAUSE OF DEATH (Entered), one cause per line) INTERVAL BETWEEN ONSET AND DEATH
Cause du dects (N'incliquer qu'une cause par ligne)
Intervene entre ('attaque et le daces
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH
ti 4_ 7-7 GJC_.4_17. GE.( /11.5 A.)61-/
Maladie ou condition directemem responsablecle la mort. 0.5 TC'
cs
MORBID CONDITION, IF ANY,ANTECEDENT
LEADING TO PRIMARY CAUSE
CAUSES

Condition morblde, s'il y a lieu,
menanl a la cause primaire

Symptemes
UNDERLYING CAUSE. IF ANY,
Precurseurs

GIVING RISE TO PRIMARY
CAUSE
de la mort.

Ralson londamentale, s'il y a lieu.
ayant 5050,10 la cause primaire

OTHER SIGNIFICANT CONDITIONS 2
Asset conditions signilicatives

MODE OF DEATH AUTOPSY PERFORMED Autopsie eflectude .
YES Oui
. NO Non
Condition de aces CIRCUMSTANCES SURROUNDING DEATH DUE TO
EXTERNAL CAUSES
Circonstances de la mort suscitees par des causes exterieures NATURAL MAJOR FINDINGS OF AUTOPSY Conclusions principales de l'autopsie
Mort naturelle
ACCIDENT
Mort accidenteile
SUICIDE NAME OF PATHOLOGIST Nom du pathologist°
Swcide

HOMICIDE SIGNATURE Signature
DATE Date
AVIATION ACCIDENT Accident 9 AvionHomicide
0 YES Oui
OATS OF DEATH Wear. lay. month, year) . NO Non
Date de deces (rheum, it four, k MOIL Penner) ; PLACE OF DEATH Lieu de daces

I HAVE VEIWED THE REMAINS OF THE DECEASED ANC DEATH OCCURRED AT THE TIME INDICATED AND FROM THE CAUSES AS STATED ABOVE. J'ai examine les testes morsels du &If unt et je conclus que le deces est survenu a l'heure indiquee et a, Ia suite cies causes enumerees ci desnes
1"
Nom du medicia oe du medicin sanitaire

I TITLE OR DEGREE Titre ou diplemei
CP 05

GRADE
fellation ou acre
IL) ( 12) —

GA TE Cute
State
injury or c ompliwtiou ...hien rouse
Sri. at. t Stele roudition: ron:ributing to the death, bur not related w the disease or !one:jowl, taurine omit.
r•lcirer fa now., de In tuolanVe, Cr In blerswe on at to complirerion qui r. ccwrilwe a lh mo: r, awes INI1:1 ,11¦74;;PT Oe diot.rir. telle qu'an orrA
2 , toe. •,

few r .ondit)o.. cal a contribue b is mow omit n 'weans 7..cutt rapp.vi MY; M maktaii t..” a :7 condition qui a orovad•.' la BUM.
DO P 0 W 2064, APR 1977 REPLACES DA FORM 35E5. 1 JAN 1972 AND 0A FOAM 2E55.P.(PAE), 25 SEP 1975, •'.51ICH ARE OBSOLETE.
USAPA V 1.00
MEDCOM - 23349

DOD-036925

OF HOSPITA L

HOSP!TAL REPORT DEATH
, S OFFicE 3 ,• 11•-• iefe7r'-

1r7,rructions -it; a;L:.r:dance wilt. I Prepare, in an c,:oy only, Irem s11 through 10 and sign Item 11. 5';a form, c'ekay rc rhe Registrar Cr Administrative. Officer
m Print or rips of the Day, /or recessa-ry action and for preparation of required Pu'rber or copies.
SECTION A - ATTENDING MEDICAL OFFICER'S REtORT
PERSOWL DATA

. PATENT DATA (Parie. r's ward plate will be used ro 12. TIME CF DEATH • —r•eay.,orm /ear; 1 3. MEDICAL EXAMINER: :e.ra avaj.
CCF1ONE:-I'S CASE
YES

//4c3

L. RELIGiON 5. CHAPLAIN NOTIFIED
NO

6. NAME, ADDRESS AND RELATIONSHIP OF RELATIVE OR FRIEND PRESENT AT DEATH
Patient's name (Last, first, middle initial) Grade,
Social Security Account No., Register Number and Ward Number

APPROXIMATE INTERVAL ICAUSE OF DEATH BETWEEN ONSET
AND DEATH
7a. DISEASE OR CONDITION DIRECTLY LEADING TO

DUE TO for as a consequence oil
DEATH (This aces no: fre317 the mode of eying. e g..
heart failure. asfnenia. etc. ft means the disease. injwy,

(", r­
10 ih 1(11-SU

or compfication wmich caused death) 1\1 u. I LT) P L E c__-,7aN .)-.
/40, 6-Vow \o5 it Cil DUE TO for as a consequence of) •
7b. ANTECEDENT CAUSES tA•sorCid conc.', font. if any, (1)
9,,:ng .1,.. to Me abovecause, staring rf:e underlying

•
concif)on 451)

(2)
a.
3. OTHER SIGNIFICANT CONDITIONS CONTRI3uTING I
TO THE DEATH. SUT NOT RELATED TO THE DISEASE
OR CONDITION CAUS:NG IT

b. I g ( LL_
--....„.

9. DATE 1C. TYPED CR PR;N -ED NAME AND GRADE Q MEDICAL OFFIC T ER IN ATTE1.1D.A.NCE
- • -

-9 A
111111111.111111111( - -ISTRATIVE A
TYPE OF ACTON

HOUR DAY m:ONTH YEAR
INITIALS OF RESPONSIBLECF;ICER

12.
TELEGRAM TO NEXT OF KIN OR OTHER AUTHORIZED PERSON

13.
ROST ADJUTANT GENERAL NOTIFIED

14.
IMMEDIATE CO OF DECEASED NOTIFIED

15.
POST mORTuAP.y OFFICER NOTIFIED

15 INFORMATION OFFICE NOTIFIED
;7. RED CROSS NOTIRIED
Z. OTHER 'SDev7t;
3.

SECTION C . RECORD OF AUTOPSY
23 AUTOPS r PO-RFO 9 .•.157 III yes. gi/e cafe and :dace) 21. AUTOPSY C.RCERED a" (Sia,'

.y:r s
9 AT-CL.C.O , CAL F;1)7.) , ::75

4. TYPED s:AmE GR-.DE OF;PHYS;CiAN PERFCP.mtf.G 25. SIGNAT,..;RE OF PHYSICIAN PERFORM:?, AUTOPSY AUTCPSY
7.R: CATE
27. TY=ED 2;At.IE 4 .3 00 05 OF REGISTRAR 25. S;GNAT,_:1RE OF REGISTRAR .
DA FORM 3804.. OCT 72 REPLACES DA FORM 8-257, 1 JAN 61, WHICH WILL BE USED.
MEDCOM - 23350
DOD-036926