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Report of Death Medical Examination Example
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REPORT OF DEATH DATE: COUNTY OF DEATH: DISPATCHED BY: AGENCY: TIME OF DISPATCH: DATE OF DISPATCH: DEMOGRAPHIC INFORMATION NAME OF DECEDENT: (LAST) (FIRST) (MI) ADDRESS OF DECEDENT: CITY: STATE: ZIP CODE: TEL#: DOB: AGE: SEX: RACE: SSN: WHO PRONOUNCED THE DECEDENT? DATE OF PRONOUNCEMENT: TIME OF PRONOUNCEMENT: AM/PM WHERE WAS DECEDENT PRONOUNCED (GIVE EXACT STREET ADDRESS OR POLICE LOCATOR IDENTIFICATION): GPS READINGS: WHO IDENTIFIED THE DECEDENT? HOW IS THE IDENTIFIER RELATED TO THE DECEDENT? IDENTIFIER'S ADDRESS/CITY/STATE/ZIP? CONTACT INFO? HOW WAS THE DECEDENT IDENTIFIED? FOR UNIDENTIFIED REMAINS , CHECK ALL THAT APPLY: JOHN DOE JANE DOE DOE (UNDETERMINED) VIEWABLE (IDENTIFIABLE VISUALLY) NON-VIEWABLE MUTILATED DECOMPOSED BURNED SKELETON/MUMMY SKELETAL/MUMMIFIED REMAINS - PRESUMED ANCIENT REMAINS (UNIDENTIFIABLE HUMAN/ANIMAL) BURN VICTIMS: DEPENDING ON WHERE THE BODY IS FOUND, SIFT AROUND THE BURN VICTIM FOR ARTIFACT WHICH MIGHT ASSIST IN IDENTIFICATION - CLOTHING, SHOES, JEWELRY, ETC. DECOMPOSED/MUTILATED REMAINS: A PHYSICAL DESCRIPTION AT THE SCENE BY SOMEONE WHO IS RELATED TO OR KNOWS THE DECEDENT IS APPROPRIATE TO ASSIST IN IDENTIFICATION. SKELETONIZED OR MUMMIFIED REMAINS OR PRESUMED NONHUMAN OR UNIDENTIFIABLE BODY PARTS: SKELETONIZED REMAINS SHOULD BE REPORTED TO THE CENTRAL OFFICE BEFORE ANY EXCAVATION TAKES PLACE. NEXT OF KIN INFORMATION NEXT OF KIN NOTIFIED: DATE: TIME: AM/PM NOTIFICATION MADE BY: NEXT OF KIN NAME: (LAST) (FIRST) (MI) RELATIONSHIP: ADDRESS (CITY/STATE/ZIP): TEL: OTHER CONTACT INFO: SCENE INVESTIGATION WHAT TIME OF DAY DID INCIDENT HAPPEN: WHAT TIME OF DAY WAS DECEDENT OBSERVED BY FDMI? INCIDENT OCCURRED: AT OWN HOME AWAY FROM HOME INDOORS OUTDOORS OTHER: DESCRIBE THE SCENE OF THE EVENT (DESCRIBE THE SCENE, PHOTOGRAPH, AND DRAW DIAGRAM INDICATING WHERE THE DECEDENT WAS SITUATED - USE SUPPLEMENTAL REPORT) ENVIRONMENTAL FACTORS DESCRIBE WEATHER CONDITIONS GENERALLY AT THE TIME OF THE INCIDENT: CLEAR CLOUDY HOT FREEZING WIND - SPEED: MPH PRECIPITATION: NONE RAIN SNOW SLEET HAIL FOG OTHER IF RAINING, WAS IT: HARD MODERATE LIGHT SPRINKLING DRIZZLING FOGGY CURRENT OUTDOOR TEMPERATURE IN THE AREA? HOW MEASURED? CURRENT INDOOR TEMPERATURE? HOW MEASURED? COOLING SOURCE: ON OFF - CENTRAL SPACE NONE HEATING SOURCE: ON OFF - CENTRAL SPACE NONE OTHER: DESCRIBE TEMPERATURE VARIATIONS SINCE INCIDENT (INDOORS/OUTDOORS): WEATHER CONDITIONS AT TIME OF DISCOVERY: LIGHTING VISIBILITY CONDITIONS AT TIME OF INCIDENT? DAYLIGHT DAWN DUSK DARK INDOOR LIGHTING STREET LIGHTING OTHER TERRAIN (WHERE INCIDENT OCCURRED IF OUTDOORS) MOUNTAINOUS FLAT WATERWAY TREE COVERED ROCKY OTHER: VEGETATION: PLANTED FIELD SCATTERED GRASSES GRASSES & SHRUBS OTHER: SCATTERED TREES: PINON EVERGREENS DECIDUOUS OTHER: HEAVY STANDS OF TREES: PINON EVERGREENS DECIDUOUS OTHER: DISCOVERY INFORMATION WHEN WAS THE DECEDENT LAST SEEN ALIVE, AND BY WHOM? DATE: TIME: AM/PM BY WHOM: RELATION TO DECEDENT: CITY/STATE/ZIP: CONTACT INFO: WHAT WAS CONDITION OF DECEDENT WHEN LAST SEEN ALIVE? IF APPLICABLE, WHAT WAS DECEDENT DOING PRIOR TO INCIDENT? DID THE DECEDENT HAVE SOME FAMILIARITY WITH LOCATION WHERE INCIDENT OCCURRED? WAS THE DECEDENT DEAD AT THE SCENE: YES NO IF DECEDENT WAS TRANSPORTED FROM SCENE, EXPLAIN: IF DECEDENT WAS MOVED PRIOR TO SCENE INVESTIGATION, HOW WAS DECEDENT ORIGINALLY POSITIONED WHEN DISCOVERED, WHO MOVED THE DECEDENT, AND WHY? THE DECEDENT WAS FOUND BY: WHAT RELATIONSHIP DOES THE ABOVE HAVE TO THE DECEDENT: CITY/STATE/ZIP: CONTACT INFO: DATE & TIME THE DECEDENT WAS FOUND: EXACT LOCATION WHERE DECEDENT WAS FOUND: WHERE WAS THE DECEDENT FOUND (BED, CRIB, SOFA, FLOOR, STREET, ETC.)? GPS READINGS: IF DIFFERENT FROM ABOVE DESCRIBE HOW THE DECEDENT WAS FOUND: DESCRIBE INITIAL ACTIONS TAKEN BY DISCOVERER(S): WAS THE DEATH WITNESSED? LIST NAMES & RELATIONSHIPS OF ALL PERSONS WHO WERE WITH THE DECEDENT AT THE TIME OF THE INCIDENT - INCLUDE ADDRESSES AND CONTACT INFO: IS THERE ANY EVIDENCE THAT OTHER PERSONS DIED IN THIS INCIDENT? EXAMINATION OF THE DECEDENT DESCRIPTION OF DECEDENT AS FOUND INCLUDING ARTICLES IN, AROUND, OR ON TOP OF
DECEDENT (CLOTHING, TOYS, BED, BEDDING, ETC.) - (DIAGRAM ON SUPPLEMENTAL AS WELL)? DESCRIBE THE POSITION OF THE DECEDENT AS FOUND (DIAGRAM ON SUPPLEMENTAL AS WELL): RIGOR MORTIS: ABSENT MILD FIRMLY ESTABLISHED IS RIGOR CONSISTENT WITH POSITION INDICATED BY OBSERVATION, STATEMENTS & INVESTIGATION? LIVOR MORTIS: ABSENT ANTERIOR POSTERIOR OTHER: IS LIVOR BLANCHABLE: YES NO IS LIVOR CONSISTENT WITH POSITION INDICATED BY OBSERVATION, STATEMENTS &
INVESTIGATION? DOES THE DECEDENT EXHIBIT "CHERRY RED" LIVOR MORTIS? NO IF YES, DESCRIBE: WAS ANYTHING FOUND IN THE ORIFICES OF THE DECEDENT EITHER BY HISTORY OR BY
EXAMINATION? MOUTH: MUCUS FOOD FOAM BLOOD OTHER: NOSE: MUCUS FOOD FOAM BLOOD OTHER: EARS OTHER ORIFICE DESCRIBE: DESCRIBE ALL INJURIES FOUND ON THE EXPOSED BODY PARTS OF THE DECEDENT: DESCRIBE PERTINENT ARTIFACT OR PARAPHERNALIA FOUND AT THE SCENE RELEVANT TO THIS
INVESTIGATION (INCLUDING LOCATION ON THE BODY, CLOTHING, AND AREA SURROUNDING THE BODY - INDICATE ON SUPPLEMENTAL AS WELL): RESCUE ATTEMPTS DID FAMILY OR OTHERS ATTEMPT TO REVIVE THE DECEDENT? NO IF YES, WHO & HOW (DESCRIBE QUANTITY AND/OR DURATION): SLAP ON BACK SHAKE PUSH ON CHEST OR CPR MOUTH TO MOUTH MOUTH TO MOUTH BREATHING OTHER: FOR EMERGENCY MEDICAL PERSONNEL - DID RESCUE ATTEMPT TO RESUSCITATE? NO IF YES, DESCRIBE QUANTITY AND/OR DURATION: INDICATE WHICH UNIT: MOUTH TO MOUTH BREATHING FACE MASK BREATHING INTUBATION OXYGEN CHEST COMPRESSION OTHER: (ATTACH EMS RUN REPORTS IF THEY ARE AVAILABLE) FOR HOSPITAL PERSONNEL - DID HOSPITAL STAFF ATTEMPT TO RESUSCITATE? NO IF YES, DESCRIBE QUANTITY AND/OR DURATION: MOUTH TO MOUTH BREATHING FACE MASK BREATHING INTUBATION OXYGEN CHEST COMPRESSION OTHER: EXAMINATION OF CLOTHING (ALL CLOTHING MUST BE SENT WITH THE BODY FOR EXAMINATION.) HOW IS DECEDENT CLOTHED? IS CLOTHING CLEAN, IN GOOD REPAIR, ETC.? WAS DECEDENT'S CLOTHING CHANGED OR ALTERED SINCE DEATH? WAS CLOTHING APPROPRIATE FOR THE WEATHER/TEMPERATURE OF THE SCENE? DOES CLOTHING HAVE ANY OBVIOUS EVIDENCE - (TRACK MARKS, BULLET HOLES, ETC.): MEDICAL HISTORY PRIMARY CARE PHYSICIAN: TEL #: DATE/PURPOSE OF LAST EXAM: VISION IMPAIRMENT: YES NO HEARING IMPAIRMENT: YES NO IS THE DECEDENT LEFT HANDED OR RIGHT HANDED? LEFT RIGHT UNK HISTORY OF TOBACCO USE? KNOWN ALLERGIES INCLUDING ANIMAL, REPTILE, OR INSECT BITES? NO IF YES, EXPLAIN: GIVE GENERAL DESCRIPTION OF THE DECEDENT'S MEDICAL HISTORY: HAS THIS MEDICAL HISTORY BEEN CONFIRMED BY MEDICATIONS AT THE SCENE, ON THE
DECEDENT OR THROUGH DISCUSSION WITH FAMILY AND PHYSICIAN(S)? HOW SIGNIFICANT WAS THE DECEDENT'S MEDICAL HISTORY IN THIS INCIDENT? IS THE DECEDENT ON ANY KNOWN MEDICATIONS. NO IF YES, HAD THE DECEDENT CONSUMED ANY MEDICATIONS PRIOR TO THE INCIDENT? WAS THE DECEDENT USING NON -PRESCRIPTION MEDICATIONS? IF MEDICATIONS ARE PRESENT, DOCUMENT THEM ON THE MEDICATION LOG. WHAT IS DECEDENT'S CURRENT AND PAST HISTORY OF ALCOHOL USE? DID DECEDENT EVER RECEIVE TREATMENT FOR ALCOHOL ABUSE? NO IF YES, WHEN AND WHERE WAS TREATMENT GIVEN? DOES THE DECEDENT SUFFER FROM WITHDRAWAL? NO IF YES, IS THE DECEDENT ON MEDICATION TO CONTROL SEIZURES? WHAT IS DECEDENT'S CURRENT AND PAST HISTORY OF ILLEGAL DRUG USE? HAS THE DECEDENT EVER BEEN HOSPITALIZED FOR SUBSTANCE ABUSE OR OVERDOSE? IS THERE ANY EVIDENCE OF ALCOHOL OR DRUG PARAPHERNALIA ON THE DECEDENT, IN THE
AREA WHERE DECEDENT IS FOUND, OR ELSEWHERE THE DECEDENT MIGHT HAVE BEEN? DID THE DECEDENT HAVE ANY BEHAVIORAL PROBLEMS WHICH MIGHT HAVE BEEN RELATED TO
THIS INCIDENT? DOES THE DECEDENT HAVE ANY PHYSICAL OR MENTAL IMPAIRMENTS WHICH MIGHT HAVE
CONTRIBUTED TO THIS INCIDENT DOES DECEDENT HAVE HISTORY OF ABUSE OR NEGLECT AGENCY JURISDICTIONS LAW ENFORCEMENT AGENCY OF JURISDICTION: INVESTIGATOR IN CHARGE: TEL #: POLICE COMPLAINT NUMBER: DISTRICT ATTORNEY OF JURISDICTION: OTHER AGENCY OF JURISDICTION: AGENT: CONTACT NUMBER(S): DISPOSITION OF REMAINS THIS CASE WILL BE: JT'D FIELD EXTERNAL DICTATED EXTERNAL PARTIAL AUTOPSY AUTOPSY NAME OF CENTRAL OFFICE DEPUTY AUTHORIZING THE ABOVE: WILL LOCAL DISTRICT MEDICAL INVESTIGATOR BE SIGNING THE DEATH CERTIFICATE? YES/NO IF YES, NAME OF DISTRICT: DATE SIGNED: IF AN AUTOPSY HAS BEEN AUTHORIZED, WHERE IS AUTOPSY TO BE PERFORMED? CENTRAL OFFICE OTHER: IF AUTOPSY IS NOT PERFORM ED IN THE CENTRAL OFFICE, WHO IS THE DESIGNATED
PATHOLOGIST? (NOTE: COPIES OF ALL AUTOPSY REPORTS ON OMI CASES PERFORMED BY NON -OMI PATHOLOGISTS MUST BE REQUESTED AND SENT TO T HE CENTRAL OFFICE FOR INCLUSION IN THE RECORDS.) TRANSPORTATION OF REMAINS WAS BODY TRANSPORTED FROM PLACE OF DEATH TO ANOTHER LOCATION: YES NO IF YES, WHO AUTHORIZED TRANSPORT? IF YES, WHERE WAS DECEDENT TAKEN? FOR WHAT PURPOSE WAS TRANSPORT AUTHORIZED: NAME OF TRANSPORTER: WAS DECEDENT TRANSPORTED TO ALBUQUERQUE FOR EXAM? YES NO IF YES, WHO MADE TRANSPORT ARRANGEMENTS? IF YES, NAME OF TRANSPORTER? DEATH CERTIFICATE INFORMATION CITY WHERE DEATH OCCURRED: IF PRONOUNCEMENT OCCURRED IN A HOSPITAL, WHAT IS THE NAME OF THE HOSPITAL: EMERGENCY ROOM DEATH INPATIENT DEATH IMMEDIATE CAUSE OF DEATH: 1. 2. 3. OTHER SIGNIFICANT CONDITIONS: WAS RECENT SURGICAL PROCEDURE PERFORMED (WITHIN 6 -WEEKS): YES NO IF YES, TYPE OF SURGICAL PROCEDURE (INCLUDE DATES): WAS DECEDENT PREGNANT WITHIN LAST 6 WEEKS: YES NO IF YES, ESTIMATED LENGTH OF PREGNANCY: (IF THIS DEATH WAS DUE TO NATURAL CAUSES, GO TO FUNERAL HOME INFO): WAS THIS AN: ACCIDENT SUICIDE HOMICIDE UNKNOWN DESCRIBE HOW INJURY OCCURRED (REFER TO MANNER OF DEATH CODE LIST): HOUR OF INJURY: APPROXIMATELY: DATE OF INJURY: DID INJURY OCCUR WHILE DECEDENT WAS WORKING YES NO PLACE OF INJURY (STREET, HIGHWAY, HOUSE, ETC.): CITY/COUNTY/STATE WHERE INJURY OCCURRED: FUNERAL HOME PREFERENCE: FUNERAL HOME DESIGNATED BY (NAME OF AUTHORIZING INDIVIDUAL AND RELATIONSHIP TO DECEDENT): PHOTOGRAPHY IF FOR ANY REASON A SCENE INVESTIGATION WAS NOT POSSIBLE, WERE PHOTOGRAPHS
REQUESTED FROM THE APPROPRIATE LAW ENFORCEMENT AGENCY? IF YOU DID AN EXTERNAL EXAM, WERE PHOTOGRAPHS TAKEN FOR ID PURPOSES AND TO
DOCUMENT INJURY(IES) OR LACK THEREOF? TOXICOLOGY IF YOU DID AN EXTERNAL EXAM, WERE APPROPRIATE SAMPLES COLLECTED AND MAILED TO THE
CENTRAL OFFICE? IF THE DECEDENT DIED IN A HOSPITAL, WERE ADMISSION BLOOD OR URINE SAMPLES
COLLECTED AND TRANSMITTED TO THE CENTRAL OFFICE FOR TESTING? RECORDS WERE APPROPRIATE MEDICAL RECORDS COLLECTED AT THE HOSPITAL OF ADMISSION AND
TREATMENT AND SENT IN WITH THE REPORT? INVESTIGATOR'S SIGNATURE: FDMI# ONE-WAY MILEAGE: (IF INVESTIGATING MULTIPLE DEATHS AT THE SAME SCENE LOCATION, MILEAGE CAN ONLY BE CLAIMED ONCE.)
DECEDENT (CLOTHING, TOYS, BED, BEDDING, ETC.) - (DIAGRAM ON SUPPLEMENTAL AS WELL)? DESCRIBE THE POSITION OF THE DECEDENT AS FOUND (DIAGRAM ON SUPPLEMENTAL AS WELL): RIGOR MORTIS: ABSENT MILD FIRMLY ESTABLISHED IS RIGOR CONSISTENT WITH POSITION INDICATED BY OBSERVATION, STATEMENTS & INVESTIGATION? LIVOR MORTIS: ABSENT ANTERIOR POSTERIOR OTHER: IS LIVOR BLANCHABLE: YES NO IS LIVOR CONSISTENT WITH POSITION INDICATED BY OBSERVATION, STATEMENTS &
INVESTIGATION? DOES THE DECEDENT EXHIBIT "CHERRY RED" LIVOR MORTIS? NO IF YES, DESCRIBE: WAS ANYTHING FOUND IN THE ORIFICES OF THE DECEDENT EITHER BY HISTORY OR BY
EXAMINATION? MOUTH: MUCUS FOOD FOAM BLOOD OTHER: NOSE: MUCUS FOOD FOAM BLOOD OTHER: EARS OTHER ORIFICE DESCRIBE: DESCRIBE ALL INJURIES FOUND ON THE EXPOSED BODY PARTS OF THE DECEDENT: DESCRIBE PERTINENT ARTIFACT OR PARAPHERNALIA FOUND AT THE SCENE RELEVANT TO THIS
INVESTIGATION (INCLUDING LOCATION ON THE BODY, CLOTHING, AND AREA SURROUNDING THE BODY - INDICATE ON SUPPLEMENTAL AS WELL): RESCUE ATTEMPTS DID FAMILY OR OTHERS ATTEMPT TO REVIVE THE DECEDENT? NO IF YES, WHO & HOW (DESCRIBE QUANTITY AND/OR DURATION): SLAP ON BACK SHAKE PUSH ON CHEST OR CPR MOUTH TO MOUTH MOUTH TO MOUTH BREATHING OTHER: FOR EMERGENCY MEDICAL PERSONNEL - DID RESCUE ATTEMPT TO RESUSCITATE? NO IF YES, DESCRIBE QUANTITY AND/OR DURATION: INDICATE WHICH UNIT: MOUTH TO MOUTH BREATHING FACE MASK BREATHING INTUBATION OXYGEN CHEST COMPRESSION OTHER: (ATTACH EMS RUN REPORTS IF THEY ARE AVAILABLE) FOR HOSPITAL PERSONNEL - DID HOSPITAL STAFF ATTEMPT TO RESUSCITATE? NO IF YES, DESCRIBE QUANTITY AND/OR DURATION: MOUTH TO MOUTH BREATHING FACE MASK BREATHING INTUBATION OXYGEN CHEST COMPRESSION OTHER: EXAMINATION OF CLOTHING (ALL CLOTHING MUST BE SENT WITH THE BODY FOR EXAMINATION.) HOW IS DECEDENT CLOTHED? IS CLOTHING CLEAN, IN GOOD REPAIR, ETC.? WAS DECEDENT'S CLOTHING CHANGED OR ALTERED SINCE DEATH? WAS CLOTHING APPROPRIATE FOR THE WEATHER/TEMPERATURE OF THE SCENE? DOES CLOTHING HAVE ANY OBVIOUS EVIDENCE - (TRACK MARKS, BULLET HOLES, ETC.): MEDICAL HISTORY PRIMARY CARE PHYSICIAN: TEL #: DATE/PURPOSE OF LAST EXAM: VISION IMPAIRMENT: YES NO HEARING IMPAIRMENT: YES NO IS THE DECEDENT LEFT HANDED OR RIGHT HANDED? LEFT RIGHT UNK HISTORY OF TOBACCO USE? KNOWN ALLERGIES INCLUDING ANIMAL, REPTILE, OR INSECT BITES? NO IF YES, EXPLAIN: GIVE GENERAL DESCRIPTION OF THE DECEDENT'S MEDICAL HISTORY: HAS THIS MEDICAL HISTORY BEEN CONFIRMED BY MEDICATIONS AT THE SCENE, ON THE
DECEDENT OR THROUGH DISCUSSION WITH FAMILY AND PHYSICIAN(S)? HOW SIGNIFICANT WAS THE DECEDENT'S MEDICAL HISTORY IN THIS INCIDENT? IS THE DECEDENT ON ANY KNOWN MEDICATIONS. NO IF YES, HAD THE DECEDENT CONSUMED ANY MEDICATIONS PRIOR TO THE INCIDENT? WAS THE DECEDENT USING NON -PRESCRIPTION MEDICATIONS? IF MEDICATIONS ARE PRESENT, DOCUMENT THEM ON THE MEDICATION LOG. WHAT IS DECEDENT'S CURRENT AND PAST HISTORY OF ALCOHOL USE? DID DECEDENT EVER RECEIVE TREATMENT FOR ALCOHOL ABUSE? NO IF YES, WHEN AND WHERE WAS TREATMENT GIVEN? DOES THE DECEDENT SUFFER FROM WITHDRAWAL? NO IF YES, IS THE DECEDENT ON MEDICATION TO CONTROL SEIZURES? WHAT IS DECEDENT'S CURRENT AND PAST HISTORY OF ILLEGAL DRUG USE? HAS THE DECEDENT EVER BEEN HOSPITALIZED FOR SUBSTANCE ABUSE OR OVERDOSE? IS THERE ANY EVIDENCE OF ALCOHOL OR DRUG PARAPHERNALIA ON THE DECEDENT, IN THE
AREA WHERE DECEDENT IS FOUND, OR ELSEWHERE THE DECEDENT MIGHT HAVE BEEN? DID THE DECEDENT HAVE ANY BEHAVIORAL PROBLEMS WHICH MIGHT HAVE BEEN RELATED TO
THIS INCIDENT? DOES THE DECEDENT HAVE ANY PHYSICAL OR MENTAL IMPAIRMENTS WHICH MIGHT HAVE
CONTRIBUTED TO THIS INCIDENT DOES DECEDENT HAVE HISTORY OF ABUSE OR NEGLECT AGENCY JURISDICTIONS LAW ENFORCEMENT AGENCY OF JURISDICTION: INVESTIGATOR IN CHARGE: TEL #: POLICE COMPLAINT NUMBER: DISTRICT ATTORNEY OF JURISDICTION: OTHER AGENCY OF JURISDICTION: AGENT: CONTACT NUMBER(S): DISPOSITION OF REMAINS THIS CASE WILL BE: JT'D FIELD EXTERNAL DICTATED EXTERNAL PARTIAL AUTOPSY AUTOPSY NAME OF CENTRAL OFFICE DEPUTY AUTHORIZING THE ABOVE: WILL LOCAL DISTRICT MEDICAL INVESTIGATOR BE SIGNING THE DEATH CERTIFICATE? YES/NO IF YES, NAME OF DISTRICT: DATE SIGNED: IF AN AUTOPSY HAS BEEN AUTHORIZED, WHERE IS AUTOPSY TO BE PERFORMED? CENTRAL OFFICE OTHER: IF AUTOPSY IS NOT PERFORM ED IN THE CENTRAL OFFICE, WHO IS THE DESIGNATED
PATHOLOGIST? (NOTE: COPIES OF ALL AUTOPSY REPORTS ON OMI CASES PERFORMED BY NON -OMI PATHOLOGISTS MUST BE REQUESTED AND SENT TO T HE CENTRAL OFFICE FOR INCLUSION IN THE RECORDS.) TRANSPORTATION OF REMAINS WAS BODY TRANSPORTED FROM PLACE OF DEATH TO ANOTHER LOCATION: YES NO IF YES, WHO AUTHORIZED TRANSPORT? IF YES, WHERE WAS DECEDENT TAKEN? FOR WHAT PURPOSE WAS TRANSPORT AUTHORIZED: NAME OF TRANSPORTER: WAS DECEDENT TRANSPORTED TO ALBUQUERQUE FOR EXAM? YES NO IF YES, WHO MADE TRANSPORT ARRANGEMENTS? IF YES, NAME OF TRANSPORTER? DEATH CERTIFICATE INFORMATION CITY WHERE DEATH OCCURRED: IF PRONOUNCEMENT OCCURRED IN A HOSPITAL, WHAT IS THE NAME OF THE HOSPITAL: EMERGENCY ROOM DEATH INPATIENT DEATH IMMEDIATE CAUSE OF DEATH: 1. 2. 3. OTHER SIGNIFICANT CONDITIONS: WAS RECENT SURGICAL PROCEDURE PERFORMED (WITHIN 6 -WEEKS): YES NO IF YES, TYPE OF SURGICAL PROCEDURE (INCLUDE DATES): WAS DECEDENT PREGNANT WITHIN LAST 6 WEEKS: YES NO IF YES, ESTIMATED LENGTH OF PREGNANCY: (IF THIS DEATH WAS DUE TO NATURAL CAUSES, GO TO FUNERAL HOME INFO): WAS THIS AN: ACCIDENT SUICIDE HOMICIDE UNKNOWN DESCRIBE HOW INJURY OCCURRED (REFER TO MANNER OF DEATH CODE LIST): HOUR OF INJURY: APPROXIMATELY: DATE OF INJURY: DID INJURY OCCUR WHILE DECEDENT WAS WORKING YES NO PLACE OF INJURY (STREET, HIGHWAY, HOUSE, ETC.): CITY/COUNTY/STATE WHERE INJURY OCCURRED: FUNERAL HOME PREFERENCE: FUNERAL HOME DESIGNATED BY (NAME OF AUTHORIZING INDIVIDUAL AND RELATIONSHIP TO DECEDENT): PHOTOGRAPHY IF FOR ANY REASON A SCENE INVESTIGATION WAS NOT POSSIBLE, WERE PHOTOGRAPHS
REQUESTED FROM THE APPROPRIATE LAW ENFORCEMENT AGENCY? IF YOU DID AN EXTERNAL EXAM, WERE PHOTOGRAPHS TAKEN FOR ID PURPOSES AND TO
DOCUMENT INJURY(IES) OR LACK THEREOF? TOXICOLOGY IF YOU DID AN EXTERNAL EXAM, WERE APPROPRIATE SAMPLES COLLECTED AND MAILED TO THE
CENTRAL OFFICE? IF THE DECEDENT DIED IN A HOSPITAL, WERE ADMISSION BLOOD OR URINE SAMPLES
COLLECTED AND TRANSMITTED TO THE CENTRAL OFFICE FOR TESTING? RECORDS WERE APPROPRIATE MEDICAL RECORDS COLLECTED AT THE HOSPITAL OF ADMISSION AND
TREATMENT AND SENT IN WITH THE REPORT? INVESTIGATOR'S SIGNATURE: FDMI# ONE-WAY MILEAGE: (IF INVESTIGATING MULTIPLE DEATHS AT THE SAME SCENE LOCATION, MILEAGE CAN ONLY BE CLAIMED ONCE.)