VVii /1"-.7) ( -e 1-7/Y4-- 2/4--,-,11-4-..,cra.,.) .0,R.. ÷0 4 DOD

CERTIFICATE OF DEATH (OVERSEAS)
Acte de dices (D'Outre-Mer)
NAME OF
CEASED (Lair, First, Middle)
)0 1 Lt
ORGANIZATION
GRADE
Nom du decade (Horn et prenoms)
Grade
BRANCH OF SERVICE
Anne
SOCIAL SECURITY NUMBER
Numero de ('Assurance Societe
DATE OF BIRTH
Date de naissance
SEX
)
NATION (e.g., United States)
Pays
Organisation
Sexe
❑
Masculin •
MALE
❑
FEMALE
Ferninin
•
RACE
MARITAL STATUS
Race
Etat Civil
RELIGION
W
CAUCASOID
0
Caucasique
NEGROID
SINGLE
Negraide
OTHER (Specify)
Autre (Spec er)
NAME OF NEXT OF KIN
STREET ADDRESS
Celibataire
MARRIED
Marie
WIDOWED
Veuf
Culte
OTHER (Specify)
Autre (Specifier)
PROTESTANT
Protestant
DIVORCED
Divorce
CATHOLIC
Catholique
SEPARATED
Separe
Nom du plus proche parent
JEWISH
RELATIONSHIP TO DECEASED
Parente du decade avec le susdit
CITY OF TOWN AND STATE (include ZlP Code)
Domicile It (Rue)
MEDICAL STATEMENT
Juit
Ville (Code postal compris)
Declaration medical.
INTERVAL BETWEEN
ONSET AND DEATH
Intervene entre
I'attaque at le (Wes
CAUSE OF DEATH (Amer only one cause per line)
Cause du daces IN'indiquer qu'une cause par lignel
alel
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH
Maladie ou condition directement responsable de la mort.
7
A f- r A f-44 l"--
P—j
/VV ii /1"-.7)
MORBID CONDITION, IF ANY
LEADING TO PRIMARY CAUSE
ANTECEDENT
CAUSES
/3-evei
Condition morbid.. s'il y a lieu,
menant a la cause primaire
SymptOmes
,0-'1,1-
( -e
-'1‘"
/ s- - 7 0 ,+,--;v4"- E
1-7/Y4-- 2/4--,-,11-4-..,cra.,.)
Le1- 7-7- ,Ar4
.0,R..
÷0
,f"./yve,,,e4
i4 1 J / c4-VIIP
•,,,-.(3..,-K
/
J) 0 i/f- ,--'""
UNDERLYING CAUSE, IF ANY,
GIVING RISE TO PRIMARY
CAUSE
Raison fondamentale, s'il y a lieu,
avant suscite la cause primaire
pricurseurs
de la mort.
OTHER SIGNIFICANT CONDITIONS 2
Autres conditions significatives 2
MODE OF DEATH
Condition de deals
AUTOPSY PERFORMED Autopsie effectuee
❑ YES Oui
❑
NO Non
CIRCUMSTANCES SURROUNDING DEATH DUE TO
EXTERNAL CAUSES
Circonstances de la mort suscitees par des causes exterieures
Date
AVIATION ACCIDENT
MAJOR FINDINGS OF AUTOPSY Conclusions principales de I'autopsie
NATURAL
Mort naturelle
ACCIDENT
Mort accldentelle
SUICIDE
Suicide
NAME OF PATHOLOGIST
HOMICIDE
Homicide
SIGNATURE
Nom du pathologiste
Signature
DATE
❑
DATE OF DEATH (Hour, day, month, year)
Date de daces (l'heure, k Jour. le 171013, I . OlUtee)
PLACE OF DEATH
Accident a Avion
YES Oui
❑
NO Non
Lieu de deals
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 mortals du defunt at ja conclus qua le daces est survenu a t'heure indiquee et a, la suite des causes enumerees ci dessus
NA•
loin sanitaire
TITLE OR DEGREE
/IA
GRADE
DATE
Titre ou diploma
4
ou adresse
Date
SIGN
7 State disease, injury or complication which caused death, • n w'
dying such at heart faildre. etc.
2 State conditions contributing to the death. brit not related to the disease or condition causing death.
7 greciser la nature de la maladie, de la blessure ou de la complication qui a contribuia la mom malt non la manure de mount., talk qu'un curet du coeur, etc.
2 Preiser la condition qui a contribue a la more, mals n'ayani aucun rapport avec la maladie oud la condition qui a provoqud La more.
DD FORM 2064, AP R 1977
REPLACES DA FORM 3565. 1 JAN 1972 AND DA FORM 3565-RIPASI, 26 SEP 1975, WHICH ARE OBSOLETE.
USAPA V1.00
MEDCOM - 24806
DOD-039195
KCCO
NAME AND LOCATION OF -1-10SPITAL
HOSPITAL REPORT OF DEATH
FOR USE OF THIS FORM, SEE AR 40-2; THE PROPONENT AGENCY IS OFFICE OF THE SURGEON GENERAL.
Instructions - Medical Officer in attendance will:
Send form, without delay to the Registrar or Administrative Officer
Prepare, in one copy only, Items 1 through 10 and sign Item 11.
of the Day, for necessary action and for preparation of required
Print or type entriy.
number of copies.
SECTION A - ATTENDING MEDICAL OFFICER'S REPORT
PERSONAL DATA
1. PATIENT DATA (Patient's ward plate will be used to imprint
identifying data if available)
2. TIME OF DEATH
o q
3
VON
t
(Hour.day-month-year)
3. MEDICAL EXAMINER/
CORONER'S CASE
E
L
4. RELIGION
YES
D
NO
5. CHAPLAIN NOTIFIED
YES
NO
-4
6. NAME, ADDRESS AND RELATIONSHIP OF RELATIVE OR FRIEND
PRESENT AT DEATH
(j1/4'
Patient's name (Last, first, middle initial) Grade,
Social Security Account No., Register Number and Ward Number
APPROXIMATE INTERVAL
BETWEEN ONSET
AND DEATH
CAUSE OF DEATH
7a. DISEASE OR CONDITION DIRECTLY LEADING TO
DEATH (This does nor mean the mode of dying, e.g.,
DUE TO (or as a consequence of)
heart failure, asthenia, etc. It means the disease, injury,
or complication which caused death(
,2Arvt. 11--/ r".A1 Ir (
AA Ji-f .te ( P
vir.
e;12,
,
1.7.-e-4/-- „ -7
("JO
) 5 -
3 6,,.....:,,Ji,
(.-,A----c-C-
DUE TO (or as a consequence of)
7b.
ANTECEDENT CAUSES (Morbid conditions, if any,
(1)
,•-•
i
giving rise to the above cause, stating the underlying
condition last)
(2)
a.
8. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING
TO THE DEATH. BUT NOT RELATED TO THE DISEASE
OR CONDITION CAUSING IT
9. DATE
b.
10. TYPED OR PRINTED NAME AND GRADE OF MEDICAL OFFICER
IN
11.
.
IIA-13
0-y
ADMINISTRATIVE
TYPE OF ACTION
12.
HOUR
DAY
MONTH
YEAR
INITIALS OF RESPONSIBLE OFFICER
TELEGRAM TO NEXT OF KIN OR OTHER AUTHORIZED PERSON
13.
POST ADJUTANT GENERAL NOTIFIED
14.
IMMEDIATE CO OF DECEASED NOTIFIED
15.
INFORMATION OFFICE NOTIFIED
16.
POST MORTUARY OFFICER NOTIFIED
17.
RED CROSS NOTIFIED
18. OTHER (Specify)
19.
SECTION C - RECORD OF AUTOPSY
20.
AUTOPSY PERFORMED (If yes, give date and place)
YES
22.
21.
AUTOPSY ORDERED BY (Signature)
NO
PROVISIONAL PATHOLOGICAL FINDINGS
23i.. DATE
* •
24. TYPED NAME AND GRADE OF PHYSICIAN PERFORMING
AUTOPSY
25. SIGNATURE OF PHYSICIAN PERFORMING AUTOPSY
26. DATE
27. TYPED NAME AND GRADE OF REGISTRAR
28. SIGNATURE OF REGISTRAR
DA FORM 3894, OCT 72
REPLACES DA FORM 8-257, 1 JAN 61, WHICH WILL BE USED.
USAPPC V2.00
MEDCOM - 24807
DOD-039196