Death Certificate of unknown Iraqi Male of unknown age. The deceased appears to have been a detainee and was shot multiple times to the back, chest and pelvis.
NAME AND LOCATION OF HOSPITAL
HOSPITAL REPORT OF DEATH
FOR USE Of THIS PORN , SEE 15 AO- 2; TOE PROPONENT AGENCY IS THE OFF ICE Of THE GURP,ION GENERAL .
Instructions - Medical Officer in attendance will: Prepare, in one copy only, Items 1 throdgh 10 and sign Item II. Send form, without delay to the Registrar or Administrative Of-Print or type entries.
(icor of the Day, for necessary action and for preparaticin of re-quired number of copies.
SECTION A • ATTENDING MEDICAL OFFICER'S REPORT
PERSONAL DATA
I. PATIENT DATA (Patient's ward plate will be used to imprint identi-2. TIME OF DEATH ((rour-day-month-yoar) a. MEDICAL EXAMINER/ tying data if available) CORONER'S CASE
On ..Dw0...) 0.1D IN YES'DEll NO
OPik-.--T M^
4. RELIGION O. CHAPLAIN NOTIFIED
III v [sDIN NO
,fu A
O. NAME. ADDRESS AND RELATIONSHIP OF RELATIVE OR FRIEND PRESENT AT DEATH
IIIIIIIIPlb L1_6z-Li
Patient's name (Last, first, middle initial), Grath-.
Social Security Account No., Register Number and Ward Number
APPROXIMATE INTERVAL CAUSE OF DEATH BETWEEN ONSET AND DEATH
7a. DISEASE OR CONDITION DIRECTLY DUE TO (or as a consequence of)
LEADING TO DEATH (This does not
mean the mode of dying, e.g., heart failure, 5e —
kw4\ itSp- C)-54-' asthenia, etc. It means the disease, in-jury, or complication which caused death)
1:1(...t.St 1. CL')Ir
ke.A.J,)
DUE TO (or as a consequence of)
7b. ANTECEDENT CAUSES (Morbid con-In
dit ions, it any, gi ving rise to the above -e -kt- ¦ v--0-'4\ .%"\.".
ill.P'-'-'"-',34"r L1A-L. cause, stating the underlying condition
last) (21
S. OTHER SIGNIFICANT CONDI TIONS CONTRIBUTING TO THE DEATH, BUT
NOT RELATED TO THE DISEASE OR
CONDITION CAUSING IT
......1
C(S/.
9. DATE 10. TYPED OR PRINTED NAME AND GRADE OF 11. SI FI CER IN ATTENDANCE MEDICAD TTENDANCE
ECTION B -AD A PIE ACTIO
TYPE OF ACTION HOUR DAY MONTH YEAR Or FIESPON-SIZILIE OFFICER
Ia. TELEGRAM TO NEXT OF KIN OR OTHER
AUTHORIZED PERSON
1*. POST ADJUTANT GENERAL NOTIFIED
14. IMMEDIATE CO OF DECEASED NOTIFIED
" 15. INFORMATION OFFICE NOTIFIED
IL POST MORTUARY OFFICER NOTIFIED
17. RED CROSS NOTIFIED
IS. OTHER(ip•eify)
IL
SECTION C - RECORD OF AUTOPSY
20. AUTOPSY PERFORMED (If yes, give date and place) 21. AUTOPSY ORDERED DY (Signature)
• YESDD NO
22. PROVISIONAL PATHOLOGICAL FINDINGS
55. DATE 24. TYPED NAME AND GRADE OF PHYSICIAN PER-29. SIGNATURE OF PHYSICIAN PERFORMING AUTOPSY FORMING AUTOPSY
2S. DATE 27. TYPED NAME AND GRADE OF REGI D 25. SIGNATURE OF REGI D
A I 3801
RE PLACES DA F ORM 8-257, 1 JAN 61, WHICH WI LL BE USED. 'U.S. GPO: 1997-418-29055263
OC T 72
A
MEDCOM - 23377
DOD-036953
CERTIFICATE OF DEATH (OVERSEAS) Acte de cleces (D'Oulre-Mer) --)ktl\--ci
SOCIAL SECURITY NUMBERGRADEDGrade BRANCH OF SERVICE
Nom du decade (Nom et prenoms)
NAME OF DECEASED (Last, hint. Middle) Numdro de ('Assurance Social°
Arme
si7/ ...p,[_,J A) Pc
U10 ‘'C '-' ff.QA-Q ¦
EXDSaxe
ORGANIZATIONDOrganisation
NATION ( .g.. United States) DATE OF BI TH
Date de naissance
Pays
II MALEDMasculin
. FEMALEDFdminin
DL.Pc ..
-
A)
IPT
RELIGIONDCulte
MARITAL STATUSDEtat Civil ti RACEDRace
OTHER (Specify)
PROTESTANT
Autre (Specifier) CAUCASOIDDCaucasique
SINGLEDCelibataire DIVORCED Protestant
Divorce
CATHOLIC
NEGROIDDNegrdide
MARRIEDDMarie Catholique
SEPARATED (........_ OTHER (Specily) Sdpare
r
•D
JEWISHDJ O
,DAutre (Specifier) ((A q citt
WIDOWEDDVeut
RELATIONSHIP TO DECEASEDDParente du decede avec le susdit NAME OF NEXT OF KINDNom du plus proche parent Vile (Code postal compris)
CITY OF TOWN AND STATE (Include ZIP Code)STREET ADDRESSDDomicile b IFlua)
MEDICAL STATEMENTDDeclaration medical°
INTERVAL BETWEEN CAUSE OF DEATH (Enter only one rouse per line)
ONSET AND DEATH
I. a 11 nt at equryeael I le l Cause du deces (N'indiquer qu'une cause par ligne) anceS
-
e difre
/ , ei- t),s:
AL.-) ci, .(' ( 6-c k-
C ' 4D
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH
1 Maladie ou condition directement responsable de la mort. 5 et/1-11-- CA•rd'tD"A-j 0--)
MORBID CONDITION, IF ANY,
ANTECEDENT LEADING TO PRIMARY CAUSE
...
CAUSES Condition rnorbide, s'il y a lieu,
menant a la cause primaire eee -
k2'4".-.-'C'r l.---....d
SymptOmes UNDERLYING CAUSE, IF ANY,
GIVING RISE TO PRIMARY
precurseurs
CAUSE
de la mort. Raison hmdamentale, s'il y a lieu,
ayant suscitd la cause primaire
OTHER SIGNIFICANT CONDITIONS 2
Autres conditions significatives
CIRCUMSTANCES SURROUNDING DEATH DUE TOAUTOPSY PERFORMED Autopsie eltectueeD. YES OuiD. NO Non
MODE OF DEATH EXTERNAL CAUSES Condition de dears Circonstances de la mort suscitees par des causes exterieures
MAJOR FINDINGS OF AUTOPSY Conclusions principales de l'au topsie
NATURAL
Mort naturelle
ACCIDENT
Mort accidentelle
NAME OF PATHOLOGISTDNom du pathologisteSUICIDE
Suicide
DATEDDate AVIATION ACCIDENTDAccident a AvionSIGNATUREDSignatureHOMICIDE
NO Non
Homicide . YES OuiD .
DATE OF DEATH (Hour, lay, month, year) PLACE OF DEATHDLieu de ddces Date de deeds (Meuse, It jour, It mais. Puente)
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 restes morcels du datunt et 10 conclus que le aces est survenu a l'heure indiqude et a, la suite des causes enumerees ci dessus
TITLE OR DEGREEDTitre ou diplame" Dou Liu medicin sanitaire
NAME OFD-D
Mrd
'D1 ou adrelse
NSTALLATIONDGRADDGrade
lit
t
ppp
SIGNATUREDATEDT
fr.
2 State conditions contributing so the death, but nor related to t
' State disease, injury or compliralion which mused daub. b not In ',maitre de 'naafi', tele qu'utt awe, du meet, etc.
' Precise' la nature de la inaladie, de la blesside ou de In complication
2 Prase" In condition qui a contribui A la mom Innis n'ayani anon
roue la mit.
MEDCOM - 23378
- - . . .. • • . C LAI LA P. CDC ammo FT
DOD-036954