ielehetiatpanat
,
teen enitamyinrctantitistoat
wifes
CLINICAL RECORD COVER SHEET
% ADMISSION ZOTES
2. Warp
3
@ sex!
Aor Ns xe
u
3. TYPE OF CASE
i pis
6, RELIGION
o
Kone
13. NAME AND
ADDARSSEE
2
Wa BASY Ramet — FIRST RARE —— BIDOLE GITIAL
C) ac
:
7. PREV. ADM.
8, REGISTER XO.
(2.
13. OBGANIZATION SND BRANCH OF SERYICE
js Qe
U. GATING O8 DESIE.
1615 hrs
/
k md
DEPARTMENT
OF
|
9. SERVICE NO.
24740
AUEISPHS:
ADORESS
10. @MADEZ
14,
Lt Col
FLYING STATUS
nb
Public Health Service
EMERGENCT
(@. AGE
17. RACE
44
tw)
18. LENGTH OF SERVICE
0
19. DATE OF ADMISSION
3 yrs
18 Oct 38
20. SOURCE OF ADMISSION
From Dety
Nots: Enter flying Status for AF Mili
Personnel only,
Civilians, etc., show type (Dep. af EM,ee.) in space 13,
21,
piece
9611
ADMITTING OFFICER
UR)
22.
CONTINUATION OF ITEMS 13 AND Zo.
LOMRIS M BOWERS, CAPT USAF
23. DIAGNOSES (See instructiony for recording as thewn on reverse rid.
Dg 1.
8501
Camp Mercury, Nev.
Include all required relateddata)
Concussion of brain, mild.
AI:
For
LDe
Yes
Semetime during the morning of 18 Oct 58, Camp
Mercury, Nevada,patient fell froma “runway”,
Fur«her
ae
ay aye
details are wakneown. Wes performing assigned duties
as Sanitary Engineer, was net on a military reservation.
w
~-
|
?
24. OPERATIONS AND SPECUL THEWAPEOTIC PaoceDtts Lkow date’fer cack; show atesthaths for etch operttions™ «.«
oa
]
.
-
tee Te
“
2
sae
-
Tap Crem
Ta taeele
on
.
rr
Sof
Geb
ae:
:
IT yy Te
ya
aur
rr
.
~
-
nae
4
25. SELECTED ADMINISTRATIVE DAT (Show nature of and dates for board proceedings; show fact of and dates for leave, AWOL, mabsisting elsewhere, detached service, etc
PRIVACY ACT MATERIAL REMOVED
26.
.
PHYSICAL PROFILE
SERIAL
TYPE
P
¥
L
SUFFIX
H
Ez
s
R
T
D
o
N
PROFILE Is
UNCHANGED
PREVIOUS
REVISED
27.
DAYS CURATION THIS FACILITY
AU
26.
-F
HOSPITAL OR
INFIRMARY-——_______-3-_SURSISTING ELSEWHER E———_—__—___QUARTERS
OISPENSARY.
SIGNATURE OF ATTENDING PHYSICIAN
/s/XHM WOMILLS, CAPT UsaP (NC)
CLES
,
32, MAME AND LOCATION OF MEDICAL TREATMENTFACILITY —
1 SEP s2 481-3
wy U. §. GOVERNMENT PRINTING OFFICE
OTHER
Replaces DD 481 (4 part set) which may be used.
1956-40714
_7
DATE OF DISPOSITION
21 Oct 36
R MEDICAL RACORDS OFFICER
33.
a
420thUSAF Metpita
DD
LEAVE
28.
Duty
39.
OR
NATURE OF DISPOSITION
REGISTER
NUMBER
—2eMO-