Detainee died of gunshot wounds to chest and abdomen. Traumatic injury secondary to gunshot wound to the abdomen. Approximate interval between onset and death: 13 days.
CERTIFICATE OF DEATH (OVERSEAS
Acte de daces (D'Outre-Mer)
•renoms) GRADE Grade BRANCH CF SERVICE SO L SECURITY NUMBER Arm. Num& de ('Assurance Sociale
,•• (L) ( --7742 Alt, d5 6=7.4)r. 54,s-.
NAME 0 •
ORGANIZATION Organisation (e.g.. United liates) DATE OF BIRTH SEX Se
Date de naissance I
i . LE Masculin
1 \ ) r At.:ia.)/t../ . kML ie . FEMALE Femini
( a)l
... ____ • . _-RACE Race • Etat Civil RELIGION Culte
OTHER (Specify)
PROTESTANT
Autre (Specifier)
CAUCASOID Caucasique SALE Celibataire DIVOIIIED Protestant
DivoiCe i
CATHOLIC
NE,GROID Negreicle MARRIED Marie Catholique
, /
SEPARATED
OTHER (Specify) Separe
WIDOWED Veuf JEWISH Juif
Autte •
.4
, 6
NAME OF NEXT OF KIN Nom du plus proche parent RELATIONSHIP TO DECEASED Parente du deckle avec le susdit
kf /v h ivo)--, IJ
STREET ADDRESS Domicile 3 (Rue) CITY OF TOWN AND STATE (Include ZIP Code) Ville (Code postal compels)
6 C
MEDICAL STATEMENT Declaration medical.
•
CAUSE OF DEATH fever only one cause per line)
Cause du daces larindiquer qu'une cause par lignel
)
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH
tO
Cu condition directement responsable de la molt! Maladie
MORBID CONDITION, IF ANY,
ANTECEDENT LEADING TO PRIMARY CAUSE -Ac•...k N2L,J-
44; 4"e_
CAUSES Condition morbide, s'il y a lieu,
menant a la cause primaire
Sympteimes UNDERLYING CAUSE. IF ANY.
GIVING RISE TO PRIMARY r ail6 J re, /1,11C.- rs' Y-r 2e se cos-do-I-3 -.11
pricurseurs
CAUSE
/' Prs pc,-,--•,N.
de la mort. Raison fondamentale. s'il y a lieu, m ..5t} i--%A.:vv.() —1-‘-' rkz-
ayant suscite la cause primaire
OTHER SIGNIFICANT. CONDITIONS 2
Autres conditions significatives2
AUTOPSY PERFORMED Autopsie eflectude . YES Oui . NO Non CIRCUMSTANCES SURROUNDING DEATH DUE TO EXTERNAL CAUSESMODE OF DEATH
Condition de dScCs
MAJOR FINDINGS OF AUTOPSY Conclusions principales de l'autopsie Circonstances de la mart suscitees par des causes exterieures
I NATURAL 'dic=-.
Mon naturelle
ACCIDENT
Mon accidentelle -
NAME OF PATHOLOGIST Nom du pathologiste
SUICIDE
Suicide
SIGNATURE Signature I DATE Date AVIATION ACCIDENT Accident a Moon
HOMICIDE
Homicide
U YES Oui . NO Non
DATE OF DEATH (Hour. day. month. year)
PLACE
Date de tIce4 glen le tidy le mois, Connie) i
g-6 N6 a/ -5 ,/ 3 it, -..v
ni HAVE VEIWEO THE REMAINS OF THE DECEASED A ATH OCCURRED AT THE TIME INDICATED AND FROM THE CAUSES AS STATED ABOVE.
1..„.. J'ai examine les testes morels du defunr at je condos cue le dices est survenu a l'heure indiouie at a. la suite des causes inurner4es ci dessus
iiitaire ou du medicm sanitaire TITLE OR DEGREE Titre ou diplerne I/{4. c il
11.4, 0,
1
Installation ou adresse
GRADE Grade INS ALLA a
63
1
CATE Date SIGNAT
Stere disease. injury or complication %Ouch caused d . etc.
2 Saner conditions contributing to the death. but not related to the di austr.g death.
Prettier to nature de la maladie. de La blzuure oat eli.; compile^ oue a la mom. n=it maniire de moan,, cede qu'un emit du coeur. etc.
2 Prefer is condition quia, contribue a la mom. malt n'ayam ducal: rappson avec is maladie ou Ce . ail:0I1 qui pivuoqui la ma -t.
USAPA V1.00
REPLACES CA FORM .1.56E. 1 JIJ 1572 AND DA PC•?M 3SES•RIPAS), 26 SEP 197E. WHICH ARE 0BSC,LETE.
DD FORM 2064, A
PR 1977
MEDCOM -23867
DOD-037445
HOSPITAL REPORT OF DEATH
FOR USE OF TriiS,FORM. SEE AR A0.2: THE PROPONENT AGENCY IS OFFICE OF THE SURGEON GENERAL
Instructions - Medical Officer in atten nce wt, :
Send form, without delay to the Registrar or Administrative OfficerPrepare, in one copy only, Items 1 through 10 and sign Item 11.
of the Day, for necessary action and for preparation of required int or type entries.
!umber of copies
SECTION A - ATTENDING MEDICAL OFFICER'S REPORT PERSONAL DATA ,,. TIME OF DEATH (Hour-oay.montn-yeari 3. MEDICAL EXAMINER/
1. PATIENT DATA (Patient's ward plate will be used to imprint
CORONER'S CASE
identifying data if available) ...--7
YES NO
64)77
•,
5. CHAPLAIN NOT ED
4. RELIGION
...61-1:-.741/71/,c-- -..\
JJ YES NO
'71,106 -) i'-)(M//g
6. NAME, ADDRESS AND RELATIONSHIP OF RELATIVE OR FRIEND PRESENT AT DEATH
61 Lc —
Patient's name (Last, first, middle initial) Grade,I Social Security Account No., Register Number and Ward Number APPROXIMATE INTERVAL BETWEEN ONSET
CAUSE OF DEATH AND DEATH
DUE TO for as a consequence of)
DEATH (This does not mean the mode of dying, e.g.,
heart failure, asthenia. erc. It means the disease, injury,
7a. DISEASE OR CONDITION DIRECTLY LEADING TO
75 P/9 Y-5
ehest/71-6'nofi76/0
or complication which caused death) (26 *hi -^-10
.
DUE TO (or as a consequence of)
(Morbid conditions, if any, ( 1)
giving rise to the above cause, stating the underlying
condition last)
7b. ANTECEDENT CAUSES
(2)
a.
8. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING
A" X DC
TO THE DEATH. BUT NOT RELATED TO THE DISEASE
OR CONDITION CAUSING IT b. .1
/L144 S
/ kx
OF MEDI• NDANCE
10. TYPED OR PRINTED NAME AND GRADE OF MEDICAL OFFICE'
9. DATE
3 A/of r Z0o3 Lblo----(__
I
-ADMINISTRATIVE
DAY • I TH I YEAR INITIALS OF RESPONSIBLE OFFICERHOUR
• TYPE OF ACTION
TELEGRAM TO NEXT OF KIN OR OTHER AUTHORIZED PERSON
12.
POST ADJUTANT GENERAL NOTIFIED
13.
IMMEDIATE CO OF DECEASED NOTIFIED
14.
INFORMATION OFFICE NOTIFIED
15.
1 POST MORTUARY OFFICER NOTIFIED
16.
17.
RED CROSS NOTIFIED
18 OTHER (Specify)
19
SECTION C - RECORD OF AUTOPSY
"
21. AUTOPSY ORDERED BY (Signature)
20. AUTOPSY PERFORMED Of yeS. give dare and Place?
E YES E
NO
22. PROVISIONAL PATHOLOGICAL FINDINGS 25. SIGNATURE OF PHYSICIAN PERFORMING AUTOPSY24. TYPED NAME AND GRADE OF PHYSICIAN PERFORMING
1 23. , DATE
AUTOPSY
IT
2e. SIGNATURE OF REGISTRAR
27. TYPED NAME AND GRADE OF REGISTRAR
. DATE
.
........¦.......................m.....................
1 JAN 51, WHICH WILL BE USED.
REPLACES. CA FORM 6-257,
DA FORM 3894, OCT 72
r.
MEDCOM -23868
DOD-037446
BATES PAGE MEDCOM 23869 HAS BEEN WITHHELD IN ITS ENTIRITY PURSUANT TO FOIA EXEMPTIONS 6 AND 7, 5 U.S.C. 552(B)(6) AMD (B)(7)(C).
Photo depicting deceased.
MEDCOM 23869
DOD-037447