DEATH INVESTIGATION REPORT

Transcription

1 DEATH INVESTIGATION REPORT Investigator/Sheriff/Deputy Local ME (On-Call) Date of Death Case Number Primary Rationale for Medical Examiner Activity (choose one): Accidental Death Natural/Sudden/Unexpected Death Violent Death ( Homicide/ Suicide) Suspicious Circumstances In Custody Death Drowning Cause of Death t Determinable by Attending Physician Other (please specify): Autopsy Ordered by ME DECEDENT IDENTIFICATION/BODY INFORMATION (Last) (First) (Middle) SS#: Autopsy Ordered by CA Street Address City State Zip Aliases Date of Birth Age (if less than 2 years give months & days SEX Male Female Undetermined CLOTHING Clothed Partly Clothed Unclothed BODY TEMPERATURE Warm Cool Cold BLOOD se Ears Mouth Clothing WORK RELATED EMPLOYER: OCCUPATION TYPE OF WORK: INDUSTRY: MARITAL STATUS Married Never Married Widowed Divorced Separated Unknown HEAD-HAIR Partly Bald Blonde Brown Red Black Gray White EYES - COLOR Black Blue Brown Green Hazel Other: WEIGHT lbs. HEIGHT: in. RIGOR Neck: Arms: Legs: FROTH Present Color: Absent OTHER (Dirt, water, etc.) se Mouth Ears RACE White Black Hispanic Asian Other OTHER HAIR Mustache Beard MISCELLANIOUS Circumcised LIVOR Color: Fixed? Anterior Posterior Later (R/L) DECOMPOSITION Early Advanced HISTORY OF DOMESTIC VIOLENCE MEANS OF DEATH OTHER THAN NATURAL MOTOR VEHICLE INVOLVED DOT Crash Report Hit-Run n-highway Agency: Case Number: Investigation LEO: Number: FIREARM INVOLVED Firearm(s) Seized Rifle - Cal. Handgun - Cal. Shotgun - Gauge Other: Desc. INSTRUMENT INVOLVED Instrument(s) Seized NO Blunt Sharp Instrument Description: DRUG, CHEMICAL OR POISON INVOLVED Alcohol Other Drug Poison Chemical Other: 1

2 INFORMATION ABOUT OCCURRENCE ITEM INJURY OR ONSET OF ILLNESS DATE TIME (military) LOCATION COUNTY TYPE OF PREMISES LAST SEEN ALIVE DEATH (PRONOUNCED) FOUND BY By: M.E. NOTIFIED BY: M.E. AT SCENE VIEW OF BODY NOT VIEWED TO HOSPITAL BY: DONOR M.E. INSTRUCTIONS NARRATIVE SUMMARY OF CIRCUMSTANCES SURROUNDING DEATH 2

3 SCENE INFORMATION Scene Visit Date: Scene Visit Time: Investigator tified by: Photos/Video tification Date: tification Time: Address of Incident: (Street) (City/Township) (GPS Coordinates) Incident Date: Incident Time: Place of Incident (Check one): Decedent s Home Highway/Road/Street Jail In custody Living Facility School Emergency Dept. Hospital Place of Business Farmstead Farm land Body of Water Other: (Specify) MAPPING/PHOTOGRAPHS Thumbnails 3

4 Attendance of Death: Witnessed Death Body Found CIRCUMSTANCES SURROUNDING DEATH tes: Evidence of Alcohol Involved: Evidence of Drugs Involved: List of Valuables: See Attached Inventory Disposition of Valuables: INJURIES OBSERVED ON BODY RELATIVE TO INCIDENT CONDITION: Alcoholism Cancer Diabetes Drug Abuse Lung Disease Fractures Heart Disease Seizure Other MEDICAL HISTORY FAMILY PHYSICIAN Doctor: Address: Phone #: MEDICATIONS YES 4

5 SECONDARY PARTIES IDENTIFIED BY Decedent Identified By: (Last) (First) Relationship: Family Member Police Health Care Professional Friend/Acquaintance Other: Means Identified by: Appearance ID Card Dental Records Fingerprints DNA S-Ray Photograph Presumptive Other: tes: NEXT OF KIN tified: Kin at Scene tifying Agency: Relationship: Spouse Ex-Spouse Parent Sibling Child Legal Guardian Other: Name: (Last) (First) (Middle) Address: (Street) (City) (State) (Zip) tes: OTHERS INVOLVED Associated Cases: Was this Death Potentially Caused by a Secondary Party: N/A Unknown If, Relation to Decedent: Number of Associated Fatal Injuries: Number of Associated n-fatal Injuries: tes: WITNESS (1) Witness to Death Found Decedent N/A Name: Relationship of Witness/Person Who Found Decedent to Decedent: Family Member Health Care Professional Stranger Friend/Acquaintance Other: Address: City: State: Zip: tes: WITNESS (2) Witness to Death Found Decedent N/A Name: Relationship of Witness/Person Who Found Decedent to Decedent: Family Member Health Care Professional Stranger Friend/Acquaintance Other: Address: City: State: Zip: tes: WITNESS (3) Witness to Death Found Decedent N/A Name: Relationship of Witness/Person Who Found Decedent to Decedent: Family Member Health Care Professional Stranger Friend/Acquaintance Other: Address: City: State: Zip: tes: 5

6 OTHER INFORMATION 6