REGIONAL AUTOPSY PROGRAM

To Be Completed by Referring Coroner's Office

All Fields are Mandatory.  If the Field is Unknown, Describe as "unknown".

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if your answer choice is "yes" to any questions below, please ensure that you fill out all fields related to that question.

IS THIS A LAW ENFORCEMENT CASE?
IF YES, PLEASE FILL OUT LAW ENFORCEMENT OFFICIAL INFORMATION
Is The LE Official Interested In Attending This Autopsy?
IF YES, PLEASE FILL OUT LE OFFICIAL'S CONTACT INFORMATION
Is This a Trauma Related Death?
IF YES, PLEASE EMAIL SCENE PHOTOS WITH BODY TO CSEVANS@ebrcoroner.COM
Was This a Hospital Death?
Please fax applicable medical records and death summary to 225-389-3447 ASAP.
Was This an In-Custody Death?
Scene photos will be required prior to autopsy.
Was This an Infant Death?
if yes, SUIDI form will be required prior to autopsy.
Were Blood or Fliuds Drawn Prior to the Body Being Transported to the EBRPCO Facility?
if yes, fill in the information below:
Is This a Natural Death?
if yes, Describe Circumstances.
Was the Deceased a Smoker?
Did the Deceased use Alcohol?
if yes, How Often was Alcohol Used?

Thank you for your submission.