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Katelynn Owens - 1.2.1 Autopsy Report Guide

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Decedent Information

Historical Summary Height (in) Examination Info


Type List the type of autopsy being
Name Jon Doe
John Lewis ------in Type
completed. Autopsies are
Age ## Weight (lbs) classified as “forensic” if they
Date seek to find the cause and
Sex ----- ------lbs manner of death or to ID the
Date of Birth Place decedent. “Clinical” or
Eye Color
Month 00, 0000 “pathological” autopsies are
------ completed to diagnose a
disease or for research.
Date of Death Hair Color
Month 00, 0000 ------

Clothing/Personal Effects
add item List any items that are found on the body
1 before the autopsy procedure begins.
2 This may include clothing, jewelry,
3 wallets, or other personal items.

Medical Intervention Features of Identification


Yes No Describe how an ID was made and confirmed.
Identification of a decedent may be made through
Details
N/A ID by a family member, but more often happens via
photographs, scars, marks, tattoos, identification
carried on the person such as a driver’s license,
and even the last known clothing. Further ID may
include fingerprints, dental records, surgical
records, medical device records, and DNA.
Evidence of Injury
> Describe any wounds, cuts,
bone breaks, or other invasive
injury, including locations and
Postmortem Changes
measurements. Detail evidence that may be linked to determination
of time of death (rigor mortis, ocular clarity, etc.).
Anterior Posterior

Document the location of


injuries noted on the report.
NOTE: Photographs are
also taken.

Front Analysis Top Analysis Side Analysis


> Illustrate damage > Illustrate > Illustrate damage
to the skull (if any). damage to the to the skull (if any).
skull (if any).

External Examination
> Document the overall condition of the outside of the body – as determined visually and by
palpation. Include information on scars, marks, and tattoos. NOTE: This section will not typically
include injury and trauma – as this is recorded in a separate section.

Internal Examination
> Document abnormalities or injury to internal organs as well the presence of normal structures.
This surgical procedure includes an examination of the organs in the body and the removal of
these organs for examination and weighing. Tissue samples of each organ are typically collected
and sent away for histological testing.
Toxicology Results Lab Results Histology Results
Describe the results of > Describe additional blood > Describe the analysis of
routine toxicology testing or urine testing results tissue samples that were
typically completed for all (outside of the toxicology taken from the main organs
autopsies - a drug screen of screens). of the body and may
highlight traumatic injury,
evidence of cancer, damage
due to a natural disease
process, or events such as a
heart attack.

Case Summary
(Opinion of the Medical Examiner): Provide a narrative about the overall findings and details of
the case.

Cause of Death
List a cause, mechanism, and manner of death

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