|
CERTIFICATE OF DEATH (OVERSEAS)
<br />Acte de deices (D'Outre - Mer)
<br />NAME OF DECEASED (Last, First, Middle) Nom du decade (Nom et prenoms)
<br />HANSEN, JEFFREY J.
<br />GRADE Grade
<br />SSGT
<br />BRANCH OF SERVICE
<br />Arme
<br />USA
<br />SOCIAL SECURITY NUMBER
<br />Numero de 1'Assurance Societe
<br />506 -19 -9347
<br />ORGANIZATION Organisation
<br />HQ TROOP, 1 -167 CAV
<br />NEBRASKA NATIONAL GUARD
<br />NATION (e.g., United States)
<br />Pays
<br />UNITED STATES
<br />DATE OF BIRTH
<br />Date de naissance
<br />12 JUL 1975
<br />SEX Sexe
<br />pig MALE Masculin
<br />❑ FEMALE Feminin
<br />RACE Race
<br />MARITAL STATUS tat Civil
<br />RELIGION Culte
<br />X
<br />CAUCASOID Caucasique
<br />SINGLE Celibataire
<br />DIVORCED
<br />Divorce
<br />PROTESTANT
<br />Protestant
<br />X
<br />OTHER (Specify)
<br />Autre (Specifier)
<br />METHODIST
<br />NEGROID Negreide
<br />X
<br />CATHOLIC
<br />Cathouque
<br />MARRIED Marie
<br />SEPARATED
<br />Ware
<br />OTHER (Specify)
<br />Autre (Specifier)
<br />WIDOWED Veuf
<br />JEWISH Juif
<br />NAME OF NEXT OF KIN Nom du plus proche parent
<br />JENNIFER L. HANSEN
<br />RELATIONSHIP TO DECEASED Parente du decade avec le susdit
<br />SPOUSE
<br />STREET ADDRESS Domicile a (Rue)
<br />502 WEST EGYPT
<br />CITY OF TOWN AND STATE (Include ZIP Code) Ville (Code postal compris)
<br />CAIRO, NE 68824
<br />MEDICAL STATEMENT Declaration medicale
<br />CAUSE OF DEATH (Enter only one cause per line)
<br />Cause du deices (N'indiquer qu'une cause par iigne)
<br />INTERVAL BETWEEN
<br />ONSET AND DEATH
<br />Intervene entre
<br />('attaque et le deices
<br />DISEASE OR CONDITION DIRECTLY LEADING TO DEATH
<br />Maladie ou condition directement responsable de la mort.
<br />ANOXIC BRAIN INJURY DUE TO NEAR DROWNING
<br />DAYS
<br />ANTECEDENT
<br />CAUSES
<br />Symptbmes
<br />precurseurs
<br />de la mort.
<br />MORBID CONDITION, IF ANY,
<br />LEADING TO PRIMARY CAUSE
<br />Condition morbide, s'il y a lieu,
<br />menant a la cause primalre
<br />UNDERLYING CAUSE, IF ANY,
<br />GIVING RISE TO PRIMARY
<br />CAUSE
<br />Raison fondamentale, s'il y a lieu,
<br />ayant susdte la cause primaire
<br />OTHER SIGNIFICANT CONDITIONS
<br />Autres conditions signiflcatives
<br />MODE OF DEATH
<br />Condition de daces
<br />AUTOPSY PERFORMED Autopsie effectuee X YES Out ❑ NO Non
<br />CIRCUMSTANCES SURROUNDING DEATH DUE TO
<br />EXTERNAL CAUSES
<br />Circonstances de la mort susdtees par des causes exterieures
<br />MAJOR FINDINGS OF AUTOPSY Conclusions principales de I'autopsie
<br />g,,
<br />NATURAL
<br />Mort naturelie
<br />X
<br />ACCIDENT
<br />Mort accidentelle
<br />10411Sts
<br />SUICIpE 4
<br />Sue
<br />NAME OF A -IdLOGIST Nom du pathologiste
<br />KATHLELAI M. INGWERSEN, COL, USA, MC
<br />�
<br />m E 3 tire
<br />,J'1 OMICII>Q N�� \ `J SIG ,
<br />0 Th
<br />\r�` rl„'
<br />DATE Date
<br />28 AUG 2006
<br />AVIATION ACCIDENT Accident a Avion
<br />❑ YES Oui F9 NO Non
<br />D
<br />DDire
<br />E F D�1 (Her+I da, ono , yetSf
<br />4 I hearfe jautZle moil, ray „e e) _
<br />- °1 : P 21122, bl AUG� 00
<br />PLACE OF DEATH Lieu de daces
<br />LANDSTUHL, GERMANY
<br />7,-, ` i -- � I. V6 IWED SH REMAINS OF THE DECEASED AND DEATH OCCURRED AT THE TIME INDICATED AND FROM THE CAUSES AS STATED ABOVE.
<br />` . tes le deices est survenu a 1'heure indiquee et a, la suite des causes enumerees d dessus
<br />?rB Trine ree►' u Or tinta91
<br />NAME'aF MEDIGXL•OFFICER , 'Nom du rrybiiicin mititaieqoa gu.rriedidn patinae',
<br />KATHT EN M. ' INGWER EN, COL, USA, MC
<br />TITLE OR DEGREE Titre ou diploma
<br />ARMED FORCES REGIONAL MEDICAL EXAMINER
<br />GRADE Gra , } r , ; , '
<br />COL/6
<br />INSTALLATION ORADDRESS ” Installation ou adresse
<br />LA STUHL REGIONAL MEDICAL CENTER, APO AE 09180
<br />DATE Date
<br />28 AUG 2006
<br />SIG .URE 4, nature
<br />1 State disease, injury or complication which caused death, but not mode of ins such as heart failure, etc.
<br />2 State conditions contributing to the death, but not related to the disease or ( toltition causing death.
<br />1 Preciser la nature de la maladle, de la blessure ou de la complication qui a contribua a la mon, mail non la maniere de mourir, telle qu'un arret du coeur, etc.
<br />2 Praiser la condition qui a contribue a la mon, mais n'ayant aucun rapport avec la maladie ou a la condition qui a provoque la mort.
<br />201805123
<br />DD FORM 2064, APR 1977
<br />REPLACES DA FORM 3565, 1 JAN 1972 AND DA FORM 3565 - R(PAS), 26 SEP 1975, WHICH ARE OBSOLETE.
<br />USAPA V1.00
<br />
|