DECEDENT
, .
RACE
SEX
AGE
ADDRESS
MWSD Occupation
Unknown
TYPE OF DEATH
Violent ☐
Casualty ☐
Suicide ☐
Suddenly when in apparent health ☐
In Prison ☐
Suspicious, unusual, or unnatural ☐
Cremation ☐
Found Dead ☐
If Motor Vehicle Accident Check One:
Driver ☐
Passenger ☐
Pedestrian ☐
Unknown ☐
Notification by
State PD
Address
382 Mill St
Investigating Agency
same
Description of Body
Clothed ☐
Unclothed ☐
Partly Clothed ☐
Eyes
Hair
Mustache
Beard
Weight
Height
Body Temp
35.5 °C
Date/Time
2024-10-05 11:47:02
Rigor:
Yes ☐
No ☐
Lysed ☐
Liver Color
Normal
Fixed ☐
Non-Fixed ☐
Marks and Wounds:
Deader than a Nehru jacket
PROBABLE CAUSE OF DEATH
MANNER OF DEATH
DISPOSITION OF CASE
(check one only)
Accident ☐
Natural ☐
Suicide ☐
Unknown ☐
Homicide ☐
Pending ☐
Not a medical examiner case ☐
Autopsy requested: Yes ☐ No ☐
Autopsy ordered: Yes ☐ No ☐
Pathologist: ____________________
I hereby declare that after receiving notice of the death described herein
I took charge of the body and made inquiries regarding the cause of death in accordance with Section
21-830-33-60(b) Code Annotated and that the information contained herein regarding such death
is true and correct to the best of my knowledge and belief.
Signature
James F. Hamil, ME
Date
2024-10-05 11:47:02