6-10. RECORD OF PERSONAL EFFECTS (DA FORM 54)
a. Source of Information. Information for this record is obtained from:
(1) DA Form 3996, Patient's Deposit Record
(2) DA Form 4160, Patient's Personal Effects and Clothing Record.
(3) Inpatient Treatment Record, or patient's identification plate.
b. Completion of DA Form 54 (see figure 6-7). To complete this form, follow
(1) Items 1 thru 7: Enter name, grade, SSN, organization and station, status,
date, and place.
(2) Item 8: Inventory of Effects. Gather personal effects and clothing with
great care. Enter the quantity, number of pieces, for each item. List all patient's
belongings in the hospital room, clothing and baggage room, and the patient's trust
fund. Include all United States currency of less than .00 and foreign currency with no
(3) Item 9a: Funds Transmitted with Effects. Itemize all funds from DA Form
3696. All funds over .00, United States and foreign currency, is converted to a
United States Treasury check.
(4) Item 9b: Complete only if funds are exchanged, converted, or deposited.
(5) Items 10, 11, and 12: Complete as appropriate.
(6) Item 13: Obtain the signature (which becomes the receipt) and annotate
relationship. When the NOK or legal representative receives the funds and effects,
indicate that information.
6-11. DEATH CERTIFICATE
All Army medical treatment facilities must comply with state, county, and
municipal regulations in recording and reporting mortality information. Death
Certificates are provided by the state in which the MTF is located. The form varies by
state. The number of copies and the information required also differs by state. (See
example of Texas death certificate in figure 6-8.) The hospital commander is
responsible for ensuring that a certificate of death is prepared for each deceased
person in his hospital or dead on arrival at his hospital. In the latter case, the medical
officer pronouncing death must sign the death certificate.