Postmortem External Examination Report (No Autopsy)

Agency/Office: [Agency or Office name]

Case Number(s): [Medicolegal case number(s) and any associated law enforcement number(s)]

Decedent: [Name / "Unidentified"]

Date of Birth: [Date of birth / Unknown]

Age: [Age in years / Estimated range / Unknown]

Sex: [male / female / indeterminate / unknown]

Date/Time of Examination: [Date and 24-hour time]

Location of Examination: [Facility and specific area]

Examiner: [Examiner name, credentials, title]

Report Status: [Preliminary / Final]

(Complete all fields. If information is unavailable, enter "Unknown," "Not provided," or "Not assessed" with reason. Attribute information sources explicitly. Use metric units throughout.)

Scope and Limitations

Authority/Jurisdiction: [Statutory or legal authority for external examination; jurisdiction and case authorization]

Examination Scope: [Statement confirming external examination only; no internal dissection performed]

Procedures Performed: [External inspection / comprehensive photography / radiography (specify regions) / specimen collection] (List all procedures actually performed.)

Rationale for No Autopsy: [Case does not meet statutory criteria / Sufficient antemortem documentation / External findings sufficient for certification / Family or religious objection where permitted / Court order limitations / Other]

Explicit Limitations: [Statement acknowledging that external examination may not detect internal disease or injury]

Factors Limiting Interpretation: [Decomposition / Embalming / Prior handling / Medical interventions / Incomplete history / Scene limitations / Environmental factors / None] (Describe any factors that may limit assessment quality or specificity.)

Investigative Summary

[Narrative summary of circumstances of death] (Include discovery and pronouncement details with date, time, location, and by whom; last known alive; pertinent scene findings; terminal events and medical response including EMS interventions and resuscitation; relevant medical history; records reviewed versus pending. Attribute sources explicitly, e.g., "Per EMS," "Per family," "Per scene investigator." If information is limited, state what was available and what remains pending.)

Chain of Custody

Date/Time	Releasing Party	Receiving Party	Location	Notes
[Date/Time]	[Name/Agency/Title]	[Name/Agency/Title]	[Location]	[Body bag seal number(s); seal status: intact / broken; condition upon transfer]
[Additional transfers as needed]

Photographs: [Photographs taken by whom; photo log location; image ID format; storage system]

Identification

Status: [Positive ID established / Pending / Unidentified]

Method(s): [Visual recognition (by whom and relationship) / Fingerprints / Dental comparison / DNA / Circumstantial identifiers / Other] (Document each method used and confirming authority.)

Corroborating Descriptors: [Clothing; jewelry; tattoos; scars; documents; unique features]

Unidentified Decedent Profile: (If applicable) [Estimated age range; estimated stature; sex assessment; ancestry assessment if applicable; hair and eye color; distinctive features; dental status and odontogram summary; healed fractures; surgical hardware; radiographic identifiers; samples retained for identification]

Condition on Receipt

• Packaging/Seals: [Body bag description; seal number(s); seal integrity; tags present]
• Clothing Status: [Clothed / Partially clothed / Unclothed; description of layers and condition]
• Storage: [Refrigerated / Not refrigerated / Unknown; date and time of refrigeration if known]
• Prior Handling: [Evidence of embalming / Hospital transport / Law enforcement processing / None observed]
• Medical Devices Present: [IV lines; ET tube; IO access; defibrillator pads; monitoring leads; bandages; other] (Document presence and anatomic locations.)

External Examination

General Characteristics

• Body Length/Weight: [Measured or estimated length in cm; weight in kg; note if estimated]
• Apparent Age: [Apparent age / Consistent with reported age]
• Body Habitus/Nutrition: [Description of habitus and nutritional status]
• Identifying Marks: [Scars; tattoos; birthmarks; surgical scars; amputations; piercings; other unique features with location, size, and appearance]

Clothing and Personal Effects

• Clothing Inventory: [Garment-by-garment list with condition: intact / torn / bloodstained / displaced; wet / dry; contamination] (Correlate clothing damage with underlying injuries when present.)
• Personal Property: [Items recovered and disposition: returned to family / retained as evidence / transferred to law enforcement / released to funeral home]

Head-to-Toe Examination

(Document systematically. For each region, describe findings or state "No injuries or abnormalities noted." Differentiate therapeutic and iatrogenic findings from trauma. Use metric units.)

• Head/Scalp/Face: [Findings for scalp, facial bones, skin, soft tissues]
• Eyes/Ears/Nose/Mouth: [Findings for sclera, conjunctivae, petechiae, corneas, pupils; tympanic membranes if visible; nasal and oral mucosa; dentition and dental appliances]
• Neck: [Findings for ligature or furrow marks; abrasions or contusions; soft tissue swelling; medical airway interventions]
• Chest and Back: [Findings for rib cage, sternum, thoracic skin and soft tissues, posterior thorax]
• Abdomen and Flanks: [Findings]
• Genitalia/Perineum: [Assessed / Not assessed (reason)]; [Findings]
• Upper Extremities/Hands: [Findings for defensive-type injuries; needle marks or track marks; scars; fingernail condition; debris collection status]
• Lower Extremities/Feet: [Findings]
• Posterior Surfaces: [Findings after log-roll examination]
• Medical Intervention Artifacts: [Locations and types of IV or IO access, intubation, chest compression injuries, defibrillator pad sites, monitor pad sites, surgical incisions, chest tubes, dressings, bandages]

Postmortem Changes

• Lividity: [Distribution; color; blanching or fixation status; patterning; areas of sparing; consistency with reported body position]
• Rigor Mortis: [Distribution and degree: jaw, upper extremities, lower extremities]
• Decomposition: [Degree and features: putrefaction, marbling, skin slippage, bloating, mummification, adipocere; regions affected] (If none, state "No decomposition observed.")
• Body Temperature: [Obtained / Not obtained (reason)]; [Method, site, time of measurement, value with units]
• Insect/Animal Activity: [Presence or absence; species and stage if known; locations; specimens collected and disposition]
• Postmortem Artifacts: [Handling abrasions; skin slippage; purge fluid; thermal changes; other] (Clearly identify findings as postmortem artifacts where appropriate.)
• Parameters Not Assessed: [List with reason(s), or "None"]

Injuries

(Document each injury objectively using numbered format. Include type, precise anatomic location with side and landmarks, size in metric units, shape and pattern with margins, color, associated findings, and timing interpretation. Reference photograph numbers. Reserve weapon or mechanism interpretation for Opinion section.)

Traumatic Injuries:

1. Injury #1: [Type (abrasion / contusion / laceration / incision / puncture / other)] — [Exact anatomic location with side and landmarks]; [Size in cm]; [Shape, pattern, margins, color]; [Associated findings]. Timing: [Antemortem / Perimortem / Postmortem; healing indicators if present]. Photos: [Photo ID numbers; scale used: yes / no]
2. [Additional injuries as needed]

(If no traumatic injuries identified, state: "No traumatic injuries identified on external examination.")

Therapeutic/Iatrogenic Findings: [Medical intervention-related marks and devices with locations and measurements]

Evidence and Specimens

Specimen/Evidence Type	Source/Location	Collection Method	Container/Seal Number	Disposition
[Specimen type, e.g., peripheral blood for toxicology]	[Anatomic source and side]	[Method and devices used]	[Container ID; seal number]	[Sent to laboratory / Retained / Released]
[Additional specimens as needed]

(If no specimens collected, state reason.)

Ancillary Studies

• Radiography/Imaging: [Modality; body regions; key findings; interpreter; date and time] (Attach or reference report. If not performed, state "Not performed.")
• Laboratory Studies: [Tests requested; status: pending / received; laboratory name; accession numbers; results if available]
• Records Reviewed: [Medical records; EMS run sheets; law enforcement reports; witness statements; other] (Specify which records are pending.)

Opinion

Cause of Death: [Immediate cause] due to [Underlying cause(s)]; [Other significant conditions contributing to death] (Use proper causal sequence. If not yet determined: "Deferred pending [toxicology / records / investigation]." Do not list terminal mechanisms alone as cause of death.)

Manner of Death: [Natural / Accident / Suicide / Homicide / Undetermined / Pending Investigation]

Rationale: [Narrative explanation supporting the opinion] (Summarize how investigative information, external findings, and ancillary studies support the conclusion. Explicitly discuss limitations inherent to external-only examination. If deferring, specify what additional information is awaited and expected timeline. If undetermined, explain why determination cannot be made.)

Certification Status: [Death certificate filed / Pending filing / Amendment anticipated pending results]

Disposition

Released: [Date and time released]; [Released to: funeral home name or representative name and relationship]

Property: [Disposition of personal effects: returned to family / retained as evidence / transferred to law enforcement / released to funeral home]

Signature

Examiner Signature: ___________________________

Printed Name: [Name]

Credentials/Title: [Credentials and title]

Date Signed: [Date]

Attachments

• [Photo log with image IDs and storage location]
• [Body diagrams annotated with findings]
• [Evidence inventory forms]
• [Radiology reports]
• [Toxicology reports when received]
• [Other supporting documents]

(Ensure all attachments are labeled with case number and maintained per chain-of-custody requirements.)