1. PATIENT DATA (Patient's ward plate will be used to imprint
indentifying data is available)
NICHOLS, LEE R
MSG
20 02154 67 35
126839
7A
Patient's name (Last, first, middle initial), Grade,
Social Security Account No., Register number and Ward
Number
Additional information you need: Residence of NOK is Dallas, Texas, which is
125 miles from Ft. Hood. To initiate the notification procedure, start by calling the
Casualty Area Commander, item 13.
An autopsy was recommended by the attending physician to determine the true
cause of death. The hospital commander subsequently authorized the autopsy at 2030
on 14 Sep 9X, with no restrictions. The hospital commander's signature block is:
DAVID C. WHITNEY
COL, MC
Commander
The authority is to complete service member's medical records.
Additional information needed for the Certificate of Death: The deceased person's
middle name is Richard; he is not of Spanish origin. He was born on 18 Aug 1935 and
is a United States citizen. Ft. Hood is in Coryel County and the hospital is not within the
city limits. The precinct number is 147. The decedent is married to Shirley K. Nichols
(maiden name, Campbell). The deceased person's usual occupation is
programmer/analyst in accounting and his business is the U.S. Army. He lived at 4262
Heather, Dallas, Texas 75229, Dallas County and lived within the city limits. The
deceased person's father is named Harry Nichols; his mother's maiden name is Martha
Walters. He was born in Stockdale, Texas. There is no informant. The immediate
cause of death was acute cerebral vascular accident. The interval between onset and
death was 9 hours. The organization in which the deceased rendered service is the
Army. The post office address on the back side of the Death Certificate is the home
address of the NOK. His wife, Shirley is 46 years old.
MD0755
6-29