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DEATH IN CUSTODY REPORTING FORM DOJ USE ONLY RECORD KEY ORIGINAL) AMENDMENT npr ce AGENCY TPE PC eo (AGENCY NCIC NUMBER: = : - @ Male © Other Asian: 1 Korean 8 Te aan 3 tae 450 PC: 245(8\(4) PC 3 een B faa eg 2 3 EEN ee oo 8 A a ay 3 Fea -fot 8 se, Be ee Ce are rma co0) BE = Ben 3 et 9 heer rer a 3 ee sakomon sent” = ems imutChe re a, eon are a eee Bt emiod 3 fen teat 3 oe 8 oer 3 oe DATA SUPPLIED BY (Please prin he following information) ‘Tite; Admin. Sec. II | Address: P. O. Box 939062, San Diego, CA 921293-9062 a Agency: San Diego Sheriff's Department Send completed form to: Department of Justice Criminal Justice Statistics Center P.O. Box 903427 Sacramento, CA 94203-4270 Facsimile: (916) 227-0427 or 227-3561 Telephone: (916) 227-3845

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