- or ooti{ riveRt DOD 003297

CERTIFIC ATE - or ooti{ triveRtkas)
. __.
Act
• . . tiees'
•
Ovot rO-reed
.
ME OF DECEASED (Last, First, Middle) Nom du decode (Nom et prertoma)
''
-8)(6)-4
ORGANIZATION
GRADE
otganisation
tirade
.
NATION (e.g.. 'United States) i
Afghanistan Detainee
Pays
BRANCH OF SERVICE
Arme
SOCIAL SECURITY NUMBER, :
Pittner° de ('Assurance Sociale •
DATE O BIRTH
Date de naissance
SEX &hie
.11.0
Afghanistan
MALE Masedlit
FEMALE Feminin
RACE Race
.CAUCASOID
,
NEGROID
• 'MARITAL STATUS Etat Civil
Caucasique
SINGLE
Negriode
Celibataire
DIVORCED
Divorce
WIDOWED
OTHER (Specify)
',twee (Specifier)
CATHOLIC
Catholique
MARRIED ,Marie
OTHER (Specify)
Aube(Specifier)
NAME OF NEXT OF KIN
RELIGION Cute
PROTESTANT
•Picitestant
,
SEPARATED
Ware
Veul
Nem du plus proche parent
JEWISH
RELATIONSHIP TO DECEASED
STREET ADDRESS Domicile A:(Rue)
Juil
Parente du decede avec le su tit
CITY OR TOWN,AND STATE (IncludeZIP Code) ,Ville (Code postal compre)
MEDICAL STATEMENT
Declaration medicate
INTERVAL BErlyE,tN
ONSET AND DEATH
CAUSE OF DEATH (Enter only once cause per line)
Cause du aces (Nindiquer qu'une cause par tone)
Intervaiie entre
rettaque et
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH(
Maladie ou condition directement responsible de In molt?
le- deces
Blunt Force Injuries to Lower Extremities Complicating
Coronary Artery Disease
MORBID CONDITION, IF. ANY,
LEADING TO PRIMARYCAU
SE
Condition morbide, s'il y a lieu.
menant Ala cause primaire
) ANTECEDENT
-
UNDERLYING CAUSE, IF ANY,
GIVING RISE TO PRIMARY
CAUSE
Raison fondamentale, s'il y a lieu,
ayant suscitl la cause. primaire
Sympternes
precurseurs
de la mod.
OTHER SIGNIFICANT CONDITIONS 2
Awes conditions significatives
MODE OF DEATH
Condition de deeds
1
AUTOPSY PERFORMED Autopsie effectuee
RYES Oui
n NO
Non
MAJOR FINDINGS OF AUTOPSY Conclusions principalis de l'autopsie
CIRCUMSTANCES SURROUNDING DEATH DUE TO
EXTERNAL CAUSES
Circonstances de la mort suscitees par des causes exterieures
NATURAL
'
Mort naturelle
ACCIDENT
Mort accidentelle
NAME OF PATHOLOGIST
SUICIDE
Suicide
8)(8)-2
x
HOMICIDE
SIGNATURE
—
Homicide
Nom du Patholoaiate
I LICOI, MC, USAF
E610)..2
DATE
DATE OF DEATH (Hour day, month, year
Da e de dines Sheure, q lour, le mois, le
ATH
0200, 10 Dec 2002
r
AVIATION ACCIDENT
•
Accident A'Avion
YES Oui
Er NO Non
Lieu de deces
Bag ram Collection
I HAVE VIEWED THE REMAINS OF THE DECEASED AND.DEATKOCCURRED-AT.THE TIME INDICATED AND FROM THE CAUSES AS STATED .ABOVE.
J'al examine leerestes mortals du de hintst je conclus quo le caves est survenu A l'heure indiquee et A, Is suite des causes Imumerees ci-dessu&
NAME OF MEDICAL OFFICER
...
Date
13 Dec .2002
)(8).,
Nom du medicin militaire ou du medicin sanitaire
Tilre ou diplorne
First Chief Deputy Medical Examiner
GRADE Grade
INSTALLATION OR ADDRESS
'' Col
Dover AFB, DE 19902
.$
.-•
TITLE OR DEGREE
,':E
Date
.2 6
Installation ou ad ease
S,'8)(6)-2
041 0
-l Stale disease, injury or complication which C8
State conditions contributing to the death, but not related to the diseaSe or condition causing death.
1 PreSser la nature de la maladie, de is blesiure ou de la complication qul a contribue a la mori,
M81.8 non la Maniere de mourir, tells qu un erre du coeur, etc
2 Precisir Is condition qui econtribuo a la mort, mais n'ayant aucun rappOrt avecla maladie Ou iecondllioaqui
a provoque la mort.
DD,FrA2064
REPLACES DA FORM 35650 JAN 72 AND DA FORM 3565-E(PAS), 26 SEP 75, WHICH ARE OBSOLETE.
MEDCOM - 170
DOD 003297