Forensic Autopsy Report

Agency/Office: [Agency/Office name, address, jurisdiction]

Document Status: [Final Report / Provisional / Amended]

Case Number: [Medical examiner/coroner case number]

Associated Case Numbers: [Law enforcement, hospital, and/or incident numbers with sources and dates] (If none, state "None.")

Autopsy Date/Time/Location: [Date]; [Time with time zone]; [Facility/location]

Forensic Pathologist: [Name, degrees, board certification]

Assistants: [Names and roles] (If none, state "None.")

Authorization: [Authority ordering examination and legal basis/statute/court order/consent]

Decedent Identification

Decedent: [Full legal name / Unidentified [observed sex]]
Date of Birth / Estimated Age: [DOB / Estimated age and estimation method]
Sex (observed): [Sex observed at examination]
Identification Method: [Visual / Fingerprints / Dental / DNA / Radiographic comparison / Personal effects / Other] — [Basis and details of comparison; identifiers used; agencies involved; dates]
Materials Archived for Identification: [Photographs; Radiographs/CT; DNA specimen; Fingerprint cards; Dental records; Other with storage location/reference]

Sources of Information

• [Scene investigation report — agency, report number, date]
• [Law enforcement narrative — agency, case number, date]
• [EMS/prehospital care records — provider, run number, date/time]
• [Hospital/medical records — facility, MRN, date range]
• [Witness statements — source, date]
• [Photographs/video — source, description, date]
• [Prior autopsy/ME records — case number, date]
• [Other relevant documents]

(If an expected source was unavailable, document explicitly with reason.)

Circumstances of Death

[Location and circumstances of discovery; last known alive information; dates/times as precisely as known; who discovered and notifications.]

[Reported events leading to injury/illness; resuscitation efforts including timing, by whom, and outcomes; transport and in-hospital course if applicable.]

[Relevant medical history, medications, substance use, and social history as documented; environmental context.] (Only include if supported by reviewed sources. Do not infer intent or manner from circumstances.)

Evidence and Chain of Custody

Condition as Received: [Body packaging/seals; body bag identifiers; condition of remains at intake; identification tags; refrigeration status; time received]

Clothing and Personal Effects:

• [Clothing item — description, condition, defects/tears/stains with measurements and locations correlated to injuries; disposition and packaging]
• [Personal effect — description, condition, disposition, packaging and recipient]

Evidence Collected at Autopsy:

• [Item type (projectile, swab, trace) — anatomic source, collection method, measurements/serial numbers, packaging (container type, seal number), intended laboratory]

Chain of Custody Transfers: (If detailed logs are maintained separately, include cross-reference to Evidence Log.)

• [Item ID/description] — Transferred to: [Name/agency]; Date/Time: [Date/time with time zone]; Purpose: [Testing / Release / Other]; Reference: [Evidence log number]

External Examination

Body Measurements: [Length]; [Weight]; [Body habitus]

Postmortem Changes: [Lividity distribution and fixation]; [Rigor distribution]; [Decomposition changes]; [Insect activity]; [Embalming evidence if present]

Identifying Characteristics: [Hair color/length]; [Eye color]; [Scars]; [Tattoos]; [Piercings]; [Amputations]; [Dentition status]; [Other distinguishing marks]

Medical Intervention/Artifacts: [Lines/tubes/drains]; [Surgical incisions]; [Defibrillation pad marks]; [CPR-related injuries]; [Medical devices and placements] (Differentiate therapeutic artifacts from injuries.)

Surface Examination: [Head/scalp]; [Face]; [Eyes/ears/nose/mouth]; [Neck]; [Anterior torso]; [Back/posterior]; [Upper extremities/hands]; [Lower extremities/feet]; [External genitalia/perineum] (Include when appropriate. Describe lesions with location, size, shape, orientation, and pattern. Reference photo/diagram IDs.)

Sexual Assault Evidence Collection: [Specimens obtained and collection kit identifiers; timing and rationale] (If not performed, document reason. Omit section if not applicable to case.)

Internal Examination

Body Cavities (in situ): [Integrity of cavities; adhesions; abnormal fluids (type/volume); device positions; prior surgical evidence]

Cardiovascular: [Heart examination including coronary arteries, myocardium, valves; aorta and great vessels; congenital or acquired anomalies] Heart weight: [weight] g

Respiratory: [Larynx/trachea/bronchi; lungs including parenchyma, emboli, consolidations] Right lung: [weight] g; Left lung: [weight] g

Gastrointestinal/Hepatobiliary/Pancreas: [Esophagus; stomach contents (volume/appearance); intestines; liver morphology; gallbladder/bile; pancreas] Liver: [weight] g

Genitourinary: [Kidneys; ureters; bladder; reproductive organs as present] Right kidney: [weight] g; Left kidney: [weight] g

Endocrine: [Thyroid; adrenals; other as indicated]

Hematolymphoid: [Spleen size/consistency; lymph nodes; marrow if examined] Spleen: [weight] g

Musculoskeletal/Soft Tissues: [Fractures; hemorrhages; muscle/tendon/ligament findings]

Central Nervous System: [Scalp; skull; dura/meninges; intracranial hemorrhage; brain external and coronal sections; brainstem/cerebellum] Brain: [weight] g (Include anterior neck dissection when trauma or asphyxia is a concern.)

Penetrating Injury Correlation: [Wound tracks from external wounds to internal organ injuries; associated hemorrhage; foreign body recovery and packaging details; photo/diagram references] (Include when applicable.)

(Document normal findings succinctly. If any portion was limited or not performed, document rationale. If organ weights unobtainable, state why.)

Injuries

(Always include this section. If no traumatic injuries are present, state: "No traumatic injuries identified.")

Numbered Injury Inventory:

1. [Injury type and location]
2. [Injury type and location]

Detailed Descriptions by Region:

• Head/Face/Neck: [Location from fixed anatomic landmarks; size (L × W × depth); shape/pattern/orientation; associated internal injuries; foreign bodies recovered with packaging; interpretation qualifiers]
• Torso: [Details as above]
• Upper Extremities: [Details as above, including hands]
• Lower Extremities: [Details as above, including feet]
• Genital/Perineal: [Details as above] (Include when relevant.)

Injury-Type Subsections: (Add subsections as applicable to case.)

• Firearm Injuries: [Entrance/exit designations; range-of-fire indicators; soot/stippling; trajectory; recovered projectiles/fragments and packaging; photo/diagram IDs]
• Sharp Force: [Incised/stab wounds; blade characteristics inferred; wound paths]
• Blunt Impact: [Abrasions/contusions/lacerations; patterned injuries]
• Thermal: [Burn depth/extent (%TBSA); charring; soot in airways]
• Asphyxial/Neck Compression: [Petechiae; neck soft tissue hemorrhage; hyoid/thyroid cartilage fractures; strap muscle findings]
• Restraint-Related: [Ligature marks; handcuff/strap impressions; positional factors]

(Use interpretation qualifiers such as "consistent with," "cannot exclude," or "postmortem artifact suspected" when warranted.)

Ancillary Studies

Radiography/Imaging

[Modalities obtained; key findings; foreign body localization; fracture screening; image archive reference] (If not performed, state reason.)

Toxicology

Specimens Collected: [Type and source; specify central vs peripheral blood and site; include urine, vitreous, bile, liver, gastric contents as applicable; collection times and preservative]

Tests Requested: [Screening/confirmatory panels; specific analytes; laboratory name and accession numbers]

Specimen	Matrix/Source	Test/Analyte	Result (units)	Method	Interpretive Caveats
[Specimen ID]	[e.g., Femoral blood (peripheral)]	[Analyte]	[Result]	[Method; LOQ/LLOD]	[Postmortem redistribution/decomposition considerations]

Histology

Tissues Submitted: [Tissues/blocks]

Microscopic Findings: [Salient histologic findings and relevance to cause of death]

Clinical Chemistry/Vitreous

[Electrolytes, glucose, ketones, urea nitrogen, creatinine; specimen type; interpretation] (If not performed, state reason.)

Microbiology

[Specimen source(s); culture/PCR results; contamination considerations] (If not performed, state reason.)

Genetic Testing

[Testing performed and results; or specimens banked for future testing with storage details] (If not performed, state reason or "Not indicated.")

Photographic Documentation

[Confirmation photographs obtained; reference numbers; storage location; diagrams prepared]

Pending Studies

• [Study/test pending — laboratory, expected turnaround, potential impact on conclusions]

(If no pending studies, state "None.")

Diagnoses

(List in order of medicolegal relevance. Label as provisional if ancillary results are pending.)

1. Lethal injury or disease process: [Primary fatal pathology or injury]
2. Other significant conditions contributing to death: [Contributing conditions] (If none, state "None.")
3. Other significant conditions not contributing to death: [Relevant comorbidities/findings] (If none, state "None.")

Cause of Death

(Line-based causal sequence compatible with death certification. Specify injury type and anatomic site for injury deaths. Do not use terminal mechanisms alone.)

Immediate cause (A): [Final disease or condition resulting in death] — Interval: [Approximate interval]

Due to (B): [Underlying cause] — Interval: [Approximate interval]

Due to (C): [Underlying cause] — Interval: [Approximate interval]

Due to (D): [Underlying cause] — Interval: [Approximate interval]

(Include only lines applicable to case.)

Other significant conditions contributing to death but not resulting in the underlying cause: [Conditions / None]

Manner of Death

Classification: [Natural / Accident / Suicide / Homicide / Undetermined / Pending Investigation]

Rationale: [Explanation supporting classification] (Use "Undetermined" when competing manners cannot be resolved; use "Pending Investigation" if determination cannot be made within required timelines.)

Opinion

[Narrative explaining how findings support the stated cause of death; consideration and exclusion of alternative causes/manners; role of toxicology/histology/imaging; how postmortem changes or limitations affect interpretation]

Limitations: [Decomposition/thermal damage; restricted examination scope; missing records; pending studies that could alter opinions with specification of what could change] (If no significant limitations, state "None.")

Addenda

(Add dated entries as studies complete or information changes. If no addenda, state "None at time of signing.")

Dated Entry: [Date] — [Study result received; what changed; why; authorizing pathologist]

Amendment: [Previous conclusion]; [New conclusion]; [Reason for change]; [Date]; [Authorizing pathologist] (Include only if conclusions change materially.)

Attestation

Forensic Pathologist: [Name, credentials, title]

Signature: [Electronic signature]

Date Signed: [Date]