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Da 2173 Form
ORGANIZATION AND STATION 3. GRADE ACCIDENT INFORMATION b. PLACE City and State a* DATE SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR OUT PATIENT DEAD ON ARRIVAL 6. INDIVIDUAL WAS ADMITTED 7. NAME OF HOSPITAL OR TREATMENT FACILITY 8. HOUR AND DATE ADMITTED INJURY a* b. INDIVIDUAL c* IS d. W AS RESULTING IN DEATH Explain DISEASE DRUGS Specify Attach Psychiatric evaluation if appropriate. IS NOT LIKELY TO RESULT IN A CLAIM AGAINST THE GOVERNMENT FOR FUTURE...Show details
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