Report of Autopsy
VS-69 (Rev. 8/66)
NEW YORK STATE DEPARTMENT OF HEALTH
MEDICAL EXAMINER - CORONER CASE
REPORT OF AUTOPSY
File #
Name of Deceased
Usual Residence
City or Town
Social Security Number
Date of Birth
P.l.dCe of Death
City or Town
County
Autopsy ordered by
of
?lace of Autopsy Hospital or Institution
Address City or Town
Cause of Death 1Enter only one cause on a line)
Death was caused byz
Immediate Cause (a)
Conditions, if any,
which gave rise to Due to (b)
above immediate
cause(a), stating Due to (c)
the underlying cause
last
Other significant conditions contribuUng to death but not related to the terminal
condition given in (a)
OUndetermined
[](Specify ether)
idannel'
of Death
o Natural Cause
o Accident
OSulcide
OHomicide
Des~ribe How Injury Occurred
T tme of
Injury Occurred
Not While 0
at Work
or To~n County State
J 'l>~L:~~r
Hour
am
Month, Days Year
19
While at 0
Work
Where did City
Injury occur?
rffi
Fl~cG of Injury e.g. in or
about home, farm, factory,
gfHce blda.. etc.)
CERTIFICATION
Fil ing Date
that I performed an autopsy on the aforesaid deceased person; and,
along with an attached detail protocol are my findings to be filed
the (medical examiner) (coroner) in accordance
of the County Law.
[Address
M.D.
Medical Examiner or Coroner
Date Signed
I hereby certify
that this report
...n the office of
with Section 677
Signature
Address
19
INSTRUCTIONS
By authority of Section 677, County Law, the New York Stlte
Commissioner of Health hereby prescribes that with this report the post-
mortem examiner should prepare and file in the Office of the Medical Examiner
or Coroner of the county in which the autopsy was performed d protocol covering
the detailed report of the findings.
If the autopsy findings add to or change the cause of death given in
the certificate of death, Correction of Certificate and Record of Death Form
\15-64, should be sent to the State Commissioner of Health immediately.
The procedures employed in the performance of the autopsy should be
thorough and orderly, following in a general way the outline given below,
modifications being made only in exceptional circumstances. The written report
should also be modeled on the same outline. A complete description of organs
and tissues should be given, stressing all departures from normal, particularly
in position, size, weight, appearance, and texture. Wherever availabe, weights
and measurements should be included. All pathologic lesions should be fully
described.
OUTLINE OF AUTOPSY AND PROTOCOL
External examination
Primary incision
Peritoneal cavity
Pleural cavities
Pericardial cavity
Mediastinum and organs in the neck:
Thymus, thyroid, parathyroid,
tissue and structure of the
trachea, larynx, and pharynx
Lungs, describing each separately
Heart and blood vesselsl Aorta,
pulmonary artery and superior
and inferior vena cava
Diaphragm
Spleen
Lymph nodes
Liver and biliary passages
Gastro-intestinal tract: Esophagus,
Stomach, small intestine, appen-
dix, large intestine
P ancrea s
Adrenals
Genito-urinary tract: describe each
kidney; bladder. Prostate, urethra,
Seminal vesicles, testes, epididy-
mides, and vasa deferentia. Uterus,
mucosa, os, tubes, ovaries, broad
ligament, breast.
Head: Scalp, calvarium, dura mater and
dural sinuses, lEptonmeninges, cere-
bral vessels, Brain convolut~ons
and sulci, consistence, ventricles.
Temporal bone. Eye. raranasal sinuses
Pi tui tary
Spinal Cord
Bones and joints
Bone marrow
Bacteriological examination
Toxicological and chemiCal examinat~on
Microscopic Examination
Summary
?athological diagnoses.