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[[preprinted form]] 
CHANGE IN FLYING STATUS FOR MEDICAL REASONS [[/preprinted]] 
DATE ^[[9 April 1959]]
TO: ^[[Commander, Hq. USAFE, APO 12, US Forces]]
FROM: ^[[Flight Surgeon 86th Tactical Hospital (K424) APO 12, US Forces]]

I. IDENTIFICATION DATA
LAST NAME, FIRST NAME, MIDDLE INITIAL
^[[DAVIS, Benjamin O. Jr.]]
GRADE ^[[B/Gen]]  SERVICE NO ^[[1206A]]
RATING, DESIGNATION OR FLYING DUTY
^[[Command Pilot (A)]]
ORGANIZATION ^[[Hq. USAFE, APO 12, US Forces (USAFE) (70)]]
TOTAL FLYING TIME ^[[3321:00]] AGE ^[[46]]

II. ACTION RECOMMENDED ^[[See Remarks]]
   |SUSPENSION FROM FLYING STATUS IN ACCORDANCE WITH PROCEDURES OUTLINED IN CAPTER 10, AFM 30-3, AND OTHER APPLICABLE DIRECTIVES.
   |REMOVAL OF SUSPENSION FROM FLYING IN ACCORDANCE WITH PROCEDURES OUTLINED IN CHAPTER 10, AFM 30-3, AND OTHER APPLICABLE DIRECTIVES.
   |EXCUSAL OF SUSPENSION FROM FLYING REQUIREMENTS BECAUSE OF AN AVIATION ACCIDENT IN ACCORDANCE WITH THE PROVISIONS OF THE AFM 160-1 AND AFM 173-20.
   |PERMISSION TO PARTICIPATE IN FLYING ACTIVITIES FOLLOWING AN AVIATION ACCIDENT OR EXCUSAL THEREFOR. (Not applicable if excusal has exceeded three months.)

III. FLYING STATUS
DATE FOUND PHYSICALLY DISQUALIFIED (Day, month, year) ^[[8 April 1959 (0459)]]
ESTIMATED DURATION OF PHYSICAL DISQUALIFICATION (Days and months) ^[[5 days]]
SERIOUS ILLNESS (AFM 160-1)
[] YES  [x] NO
DISQUALIFIED RESSULT OF AVIATION ACCIDENT
[] YES  [X] NO
SF 88 ATTACHED  [] YES  [X] NO
DATE FOUND PHYSICALLY QUALIFIED ^[blank line]
ACTUAL DURATION OF DISQUALIFICATION NOW BEING REMOVED (Days and months) ^[blank line]
LAST MONTH FLIGHT REQUIREMENTS MET
^[[Mar '59]]
ACTION REQUIRED BY HIGHER HEADQUARTERS
^[blank]

IV. INDIVIDUAL PRESENTLY SUSPENCED BY
AERO ORDER [blank line]
HEADQUARTERS [blank line]
PARAGRAPH NO. [blank line]
DATE [blank line]
EFFECTIVE DATE OF SUSPENSION [blank line]

V. SUSPENSION CONFIRMED BY
AERO ORDER NO. [blank line]
HEADQUARTERS [blank line]
PARAGRAPH NO. [blank line]
DATE [blank line]
DIAGNOSIS (AFR 160-13) ^[[7932: Observation, medical, suspect bronchitis]]
REMARKS ^[["Grounding as of this date, [[underlined]] 9 April 1959" [/underlined]]

TYPED OR PRINTED NAME OF FLIGHT SURGEON OR MEDICAL OFFICER. AVIATION MEDICINE  ^[[R.L BRUSENHAN JR, CAPT, USAF, (MC) FS]]
SIGNATURE ^[[Robert L Brusenhan]]

AF FORM 1042 15 DEC 53
* U.S. GOVERNMENT PRINTING OFFICE: 1954-283080
[/preprinted]]