Death Certificate: 25-Year-Old Iraqi Male, Detainee, Baghdad, Iraq (Homicide)

(OVERSEAS)
CERTIFICATE OF DEATI-: Acte de de:cbs (IYOutrr-Mer)
SOCIAL SECURITY NUMBER
55ANCH 01 SERVICE
GRADE Grade Numaro de l'AssuranceSociale
NOM du decade (Nom et prenornsl Arnie.
,ASED and. Fird,
.1ryr.
SEX Sexe NATION (e.g.. Unite•; guars)
DATE OF BIRTH Date de naissanca
Organisation Pays
ORGANIZATION Masculin
MALE
n FEMALE Feminin
RELIGION Culle MARITAL STAT US
Etat Curl
OTHER (Specify) PROTESTANT Au tr e (Specifier) Protestant SINGLE
RACE Race
1
Cetibataire DIVORCED
CAUCASOID Caucasique

Divorcd CATHOLIC
I
Calholique
MARRIED Marie
NEGROID thigrende
SEPARATED

Ware Jail
JEWISH
OLTIF:eERaptSepafi

ecei,f)y) WIDOWED Veal
1

(—CL Cie RELATIONSHIP TO DECEASED Parente du (Moeda avec le susdit
NAME OF NEXT OF KIN Nom du plus pr oche patens
Ville (Code postal comprislCITY OF TOWN AND STATE (Indurle ZIP Cosk)
STREET ADDRESS Domicile a (Rue)
MEDICAL STATEMENT Declaration medicate INTERVAL BETWEEN ONSET AND DEATH CAUSE OF DEATH (Enter only one cause per line)
Intervalle entre Cattaque et le daces Cause du daces IN'indiquer qu'une cause par ligite)
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH
Maladie ou condition directement responsahle de la mom
MORBID CONDITION, IF ANY,
ANTECEDENT

LEADING TO PRIMARY CAUSE
y a lieu,

Condition morbide,
menant a In cause primaire CAUSES
UNDERLYING CAUSE; IF ANY,
Symptomes
GIVING RISE TO PRIMARY
precurseurs

CAUSE
de la mors. Raison fondamentale, s'a y a lieu,
ayant suscitd la cause primaire

tit
T CONDITION2
OTHER SIGNIFI S
nificativesAutres conditions CIRCUMSTANCES SURROUNDING DEATH DUE TO
2. NO Non
0 YES Dui EXTERNAL CAUSESAUTOPSY PERFORMED Autopsie elf ectude
Circons fences On la most suscitees par des causes exterieures
MODE OF DEATH
Condition de daces MAJOR FINDINGS OF AUTOPSY Conclusions principales de l'autopste
NATURAL
Mort nausea
ACCIDENT
Mort accidentetle
Nom du pathologiste
SUICIDE

NAME OF PATHOLOGIST
Suttee
AVIATION ACCIDENT Accident A Avton
DATE Date
SIGNATURE Signature

NO Non
HOMICIDE 0 YES Oui
I

Homicide
PLACE 0
Date de dells (rhea,. le iota • It molt. runner)

DATE OF DEATH (Haar, lay. nsonth. year)
0 3,
S
I HAVE VEIWED THE REMAINS OF THE DECEASED AND DEATH OCCURRED AT THE TIME I dessus
a l'heure indiquee et A, la suite des causes enumerees ci J'ai examine les bastes mantels du defunt et je conclus que le daces est survenu
Titre ou diplOme
TITLE OR DEGRE
6 i
LTL
I
SIGNATUDATE Darn
State disease. injury or complicasion which roused dear
ark
S:ose colditicas conirddaing to the death but not related 1 reit do road. etc.
at a aero

?daises In notate de In tnaladir, de la blessure ou de In to ?reties la (0,0.'71v: qui a roatribui d 7c snort, snail Wayant °swan Nippur: aver In maladie eu USAPA V1.00
2
St, 26 SEP 197E, WHICH ARE ORSOLETE. REPLACES DA FORM 3565, 1 JAN 1972 AN •A
DD FORM 2064, APii 1977
di
MEDCOM - 22616
DOD-036192

HOSPITAL REPORT OF DEATH NAME AND LO P AL
, s.•A .,E C. 7'1:5 ;OZ,.1. SEE 1.24.)0, TnE

AGE ,“:v
C. rmE SURCEID,
Instructions - Medical Off;
Prepare, in one cagy only, Items 1 through 10 and sign Item 11.

Send form, without delay to the Registrar or
anistrative Officer of the Day, for necessary action and for preparation of required number of copies.
Print or type entries.

SECTION A - ATTENDING MEDICAL OFFICEP'S REPORT
PERSONAL DATA
PAT;ENT DATA (Patient's ward plate will be used to imprint
2. TIME DEATH
3
identifying data if available) 13. MEDICAL EXAMINER. 'CORONER'S CASE
ct ore g..3 v
' r.S
NO

OP LA
14 . RELIGION
15. CHAPLAIN NOTIFIED
)pi-L6Y NO
0 YES
1 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

CAUSE OF DEATH APPROXIMATE INTERVAL BETWEEN ONSET 7 a . AND DEATH
DISEASE OR CONDITION DIRECTLY LEADING TO
DUE TO (or as a consequence of)
DEATH anis does not mean tne mode of dying. e.g.,
near: failure, asthenia, a::. It means the disease, injury.
or complication which caused death,

C,v..J.s11 0 4-etvi S
DUE TO (or as a consequence of)
7b. ANTECEDENT CAUSES t•Worbie conditions, if any, (1)
giving rise to the above cause, stating the underlying ( c".

LI g GI o
condition :asci
(2)
3. OT?,ER SIGNIFICANT CONDITIONS CONTRIBUTING
TO THE DEATH, BUT NOT RELATED TO THE
DISEASE
OR CONDITION CAUSING IT

9. DATE
10. TYPED CR PRINTED NAME AND GRADE OF MEDICAL OFFICER IN 11. SIG ATTENDANCEATTENDANCE
3c-.)civ 0

Lic-
TYPE OF ACTION HOUR
DAT NT'i
YEAR -PONS;BLE GP:.1C.ER
2. TELEGRAM TO NEXT OF KIN OR OTHER AUTHORIZED PERSON
0-7;-EP /3,2,07;

9.
SECTION C - RECORD OF AUTOPSY
AtJTOFSY PERFORMED llf yes. ci,e date and place)
121. Au
-roPs'e CROERED SY (.5;plawrel
Li YES 0 NO

P.C. ¦.•:S:2,::AL

21 DATE
24 TYPED NAmE A::i0 GRADE OF PHYSICIAN PEP.FCF
—.w.G
AOTCPS''

29. S:GNAIL:R.E. CF PHYSIC;AN PERFCRmING AUTOPSY
I 27 rrPE:=`. .
,,..,:E ,.ND ,FADE CF REG:STRAR SIGN.:..TURE OF REGISTRAR

'A FORM 3894, OCT 7
REPLACES DA FORM 8-257, 1 JAN 61, WHICH WILL BE USED.
tic:....
MEDCOM - 22617
DOD-036193