Coroner Investigation Report Case Number

Coroner/Deputy: County: Date of Call: Time of Arrival: Time of Call: Suspected Cause: Person Calling: Natural Accident Pending Police Agency: Suicide Homicide Undetermined

Decedent Information First Name: Last Name: Male Female Address: City: County of Residence: State of Residence: Zip: SSN#: Age: Surviving Spouse: Date of Birth: Mother’s Maiden Name: Birth Place: Father’s Name:

Height (Inches): Pregnant Education: Employment: Weight (Pounds): Homeless Elementary School Employed Middle School Unemployed Eyes: Veteran Jr. High School Homemaker Hair: High School Volunteer 1 yr. College/Tech School Retired Race: Ethnicity: Marital Status: 2 yrs. College/Tech School Student White Hispanic Never Married 3 yrs. College/Tech School Disabled Black Not of Separated 4 yrs. College/Tech School Other Asian Hispanic Origin Divorced 1+ yrs. Post Graduate Unknown American Indian Unknown Married Unknown Place of Employment: Alaskan Native Widowed Pacific Islander Unknown

Next of Kin Notified by: Name: Relationship: Date Notified: Adress: City: Time Notified: Phone Number: State: Zip:

Incident Information Death Date: Injury Date: Death Time: Injury Time:

Place of Death: Place of Injury: DOA Nursing home DOA Nursing home Decedent’s Residence Other Decedent’s Residence Other Decedent’s Employment Decedent’s Employment Inpatient Address of Death Inpatient Address of Injury ER/Outpatient ER/Outpatient

Date Time Location City or County Last seen alive:

Death discovered:

Found dead by: Address: Last seen alive by: Address: Witness to injury, illness or death Weather: Activity: Position of body: Livor: Rigor: Consistent with position

Clothed Partially Clothed Unclothed Distinguishing marks: Body temperature: Body decomposition:

Cause of death: A) (Immediate cause)

B) (Due to or as Consequence of)

C) (Due to or as Consequence of)

Investigation

Evidence Collected: Date: Time: Toxicology Collected Collected by: Photos: Yes No Blood Urine Vitreous EMS at scene Admitted Name: Victim seen in ER Attending Physician Notified Number:

Medical History: Diabetes Medications: Medical Records Requested KODA notified Police department notified Autopsy: Organ donation Officer: Medical Examiner: Tissue donation KY fire marshal notified Death Certificate signed by: Cornea donation OSHA requested Coroner’s inquest

Body Trasported Cremation Cremation permit signed

Body released to: Alcohol use suspected Drug type: Cost of transport: Drug use suspected Funeral Home: Phone Number:

Poisoning: Street Recreational Drugs Alcohol Pharmaceuticals (Prescription) Pharmaceuticals (Over-the-counter) Pharmaceuticals (Unknown) Other Gas or Vapor Wound Location: S Insecticide, Cleaning/Home Supplies Head Other (specify): Neck Carbon Monoxide (specify source): Face Thorax Abdomen/lower back Spine Patient drug obtained for: Upper extremities Lower extremities Size of pills (mg): Unknown Number of pills: Additional wounds H – Head A – Abdomen, lower back F – Face S – Spine Estimated amount of liquid poison N – Neck UE – Upper Extremities T – Thorax (chest, upper back) LE – Lower Extremities injected (ml): Weapon: Weapon (not firearm): Other Firearm: Sharp instrument Firearm Type: Firearm Serial Number: Blunt instrument Caliber: Handgun Poisoning (drug and gas OD) Gauge: Handgun/revolver Hanging/Strangulation/Suffocation Handgun/semi-auto Personal weapons (e.g. fist) Firearm Owner (or stolen): Rifle Fall (pushed/jumped) Firearm Storage (locked/loaded): Shotgun Explosive Gun shot Residue: Other (see narrative) Drowning Dominant Hand: Non-powder gun Fire or burns Type of Ammunition: Shaking Number of Shells: Motor vehicle Firearm recovered Biological weapons Casings recovered Other (specify):

Case History HOMICIDE: SUICIDE: ACCIDENT: Brawl (mutual physical fight) Life crisis within last two weeks Fall Drug related Anniversary of life crisis Hunting Intimate partner left/threatening Current depressed mood Playing with gun Other relationship (not intimate partner) Current mental health problem Loading/Unloading gun Intimate partner problems Treatment for mental illness (current, ever) Motor vehicle Intervener assisting in crime Financial problem Target shooting Associated with another crime (see narrative) Physical health problem Self-defense shooting Argument over money or property Job problem Showing gun to others Gang related Lack of employment Cleaning gun Jealousy (lover’s triangle) Recent diagnoses Gun defect/Malfunction Justifiable homicide Intimate partner problems Celebratory firing Other argument, abuse, conflict Intimate partner left/threatening Other (see narrative) Hate crime Other relationship problem (not IP) Innocent bystander School problem Motor Vehicle Crash Random violence Alcohol/Substance problem Passenger Terrorist attack Recent criminal problem Driver Other (see narrative) Legal problems Pedestrian Recent suicide of relative/friend Lap belt used Mercy Killing Other death of relative/friend Shoulder belt used Child Fatality Involvement Perpetrator of violence/crime Helmet worn Infant Involved Victim of violence/crime Airbag deployed Child/Witness Involvement Other (see narrative) Hit-Run Child Protective Services Notified Non highway Victim was a Police Officer on Duty Left Suicide Note Vehicle Type: The Victim is the Disclosed Attempt to Commit Suicide History of Suicide Attempts NATURAL: of the Suspect Nursing Home/Hospice Diabetes SIDS/SUIDS Heart Disease Smoker nARRATIVE/COMMENTS: Personal Effects Inventory:

Bathrobe Handkerchiefs Overshoes Slippers Belt Hat Pajamas Socks Billfold (list contents below) Hose Panties Suspenders Blouse Housecoat Purse Sweater Bra Jewelry (list below) Raincoat T-Shirt Coat Luggage (list contents below) Scarf Tie Dress Money (list below) Shirt Topcoat Eye glasses Negligee Shoes Trousers Gasoline Nightgown Shorts Umbrella Garters Slip Vest Girdle Skirt Gloves

Billfold or purse contents:

Keys

Money (list the number of each denomination) Total Amount $ Bills: $100 $10 Coins: ( ) $1.00 ( ) $ .10 $ 50 $ 5 ( ) .50 ( ) .05 $ 20 $ 1 ( ) .25 ( ) .01 Sub Total Sub Total

Watch Make Rings, description (1) (2) (3) (4) (5) Bracelet, description Necklace, description Other

Clothing searched by: Date: Time: Valuables received by: Witnessed: Valuables stored (give exact location): Date: Time:

Release of personal effects authorized by: Relationship: Personal effects listed above received by: Name: Capacity of relationship: Witnessed: Date: