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
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.

Name of Coroner
North Dakota County of Death
Telephone Number
Enter the Telephone Number of the CoronerFormat: (000) 000-0000.
Death Reported By
Investigating Agency
Telephone Number
Enter the Telephone Number of the Investigating AgencyFormat: (000) 000-0000.
Place of Death
ER, residence, work site are examples
Location - 911 Address
Address of death
Death Pronounced By
Date Pronounced

MonthDayYear
Hour MinutesAM/PM Option
Identified By
Relationship
Method

Type of Injury
Date and Time of Injury or Illness

MonthDayYear
Hour MinutesAM/PM Option
Place of Injury
Location - 911 Address
Address of injury
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: