Death Investigation - Request For Analysis

Washington State Toxicology Laboratory - Washington State Patrol Death Investigation – Request for Analysis 2203 Airport Way S., Ste 360 Seattle, WA 98134-2027 Phone: (206) 262-6100 Fax: (206) 262-6145 e-mail: [email protected] Subject’s Information: (Please print clearly) Laboratory Use Only Laboratory # Name: Last First Mi Age: Sex: M F

Date Sent: / / Date of Death: / / Date: Agency Case # County Sent By: Name: Phone: ( ) Send Results To: Name: Agency: Analyst:______Address: Specimens Received: City: State: Zip: Blood

Suspected Manner of Death: Pending Tox: Y N ml

Natural Accident (non traffic) Undetermined Blood Peripheral Homicide Traffic Accident Suicide: Drug Related ml Other Medical History: brief description of the incident and attach copy of the investigation report. Urine ml Vitreous ml Drugs Suspected: list observations, drug history, prescriptions, etc. Liquid

Serum Sample Information: Analysis Requested: ml Specimen Collected Sent Blood Alcohol: Other: Please list Central Blood Vitreous Alcohol: performed if blood is pos Peripheral Blood Carbon Monoxide: Urine Drug Screen: Urine Gastric Drug Screen: Blood performed if urine is pos Vitreous Bile Other: (Specify) Liver Spleen Squeeze Other: Evidence sealed Y N Box sealed Was the subject embalmed before the samples were taken? Y N Bag sealed State of decomposition: None Early Moderate Advanced Tubes sealed Chain of Custody: (signature required) Samples leaked Y N From: To: Date: 1st Class From: To: Date: UPS From: To: Date: Certified Registered Comments: Fed Ex Campus Mail Hand Delivered

3000-215-002 (R 11/07) 3000-215-002 (R 11/07)