HHS - Request for Examination/Autopsy

REQUEST FOR EXAMINATION/AUTOPSY
Department of Health and Human Services
State Forensic Examiner
SFN 59166 (10-2023)
Name of Decendent (Last, First, Middle)*
Date of Death*

MonthDayYear
Race
Sex

MaleFemale
Date of Birth*

MonthDayYear
Age
Home Address (Street)
City
State
ZIP Code
Next of Kin (Last, First, Middle)
Relationship
Telephone Number
Enter the phone number of next of kin.
Home Address (Street)
Street Address of Next of Kin
City
State
ZIP Code
Name of Funeral Home
Telephone Number
Enter the telephone number of the funeral home.

Type of Injury
Date and Time of Injury or Illness

MonthDayYear

Hour MinutesAM/PM Option
Place of Injury
Location (911 Address)
Medical History
An examination/autopsy is requested to be performed by the State Forensic Examiner on the body of
Signature*
Date*

MonthDayYear
Coroner's Email Address (a PDF of the completed form will be sent to this address)*
Should be Empty: