New Case Application Relationship to Patient/Decedent Family/Next of Kin (Select this option if you are a family member or close relative of the patient or decedent and need our services.) Law Enforcement Agency/Coroner (Choose this option if you are a law enforcement officer or official involved in the case.) Attorney/Paralegal (If you are an attorney or paralegal representing the patient or decedent’s interests, please select this category.) Pathologist (Opt for this option if you are a Forensic Pathologist involved in the case’s investigation.) family First Opinion [Description on Hover to be Added] Second Opinion [Description on Hover to be Added] law First Opinion [Description on Hover to be Added] Second Opinion [Description on Hover to be Added] attorney Second Opinion Case Review – Innocence Project Second Opinion Case Review Second Opinion Autopsy/Tissue Consultation Child Dependency patho First Opinion Autopsy/Tissue Consultation [Description on Hover to be Added] Second Opinion Peer Review [Description on Hover to be Added] Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Today’s Date MM slash DD slash YYYY Case Type Deceased Adult Deceased Child Next of Kin Consultation Private Autopsy Case Type Deceased Adult Deceased Child Next of Kin Consultation Private Autopsy Case Type Deceased Adult Deceased Child Case Type Living Adult Living Child Deceased Adult Deceased Child Case Type Deceased Adult Deceased Child Subpoena Innocence Project Case Type Living Adult Living Child Deceased Adult Deceased Child Department of Defense Subpoena Case Type Deceased Adult Deceased Child Subpoena Innocence Project Case Type Deceased Adult Deceased Child Subpoena Case Type Living Adult Living Child Subpoena Case Type Living Adult Living Child Subpoena Case Type Deceased Adult Deceased Child Case Type Deceased Adult Deceased Child Name Name Name Name Name Name Name Name Name Name Name Email Email Email Email Email Email Email Email Email Email Title Title Title Title Title Title Title Bar Number Badge Number Bar Number Bar Number Bar Number Agency Agency Agency Agency Agency Agency Agency Address Street Address City State / Province / Region ZIP / Postal Code Address Street Address City State / Province / Region ZIP / Postal Code Address Street Address City State / Province / Region ZIP / Postal Code Address Street Address City State / Province / Region ZIP / Postal Code Address Street Address City State / Province / Region ZIP / Postal Code Address Street Address City State / Province / Region ZIP / Postal Code Address Street Address City State / Province / Region ZIP / Postal Code Address Street Address City State / Province / Region ZIP / Postal Code Address Street Address City State / Province / Region ZIP / Postal Code Address Street Address City State / Province / Region ZIP / Postal Code Cell PhoneCell PhoneCell PhoneCell PhoneCell PhoneCell PhoneCell PhoneCell PhoneCell PhoneCell PhoneName of victim Name of victim/decedent Name of decedent Name of decedent Name of decedent Name of decedent Name of decedent Name of decedent Name of decedent Name of decedent Sex Sex Sex Sex Sex Sex Sex Sex Sex Date of birth MM slash DD slash YYYY Date of birth MM slash DD slash YYYY Date of birth MM slash DD slash YYYY Date of birth MM slash DD slash YYYY Date of birth MM slash DD slash YYYY Date of birth MM slash DD slash YYYY Date of birth MM slash DD slash YYYY Date of birth MM slash DD slash YYYY Date of birth MM slash DD slash YYYY Date of birth MM slash DD slash YYYY Date of death MM slash DD slash YYYY Date of death MM slash DD slash YYYY Date of incident MM slash DD slash YYYY Date of incident/death MM slash DD slash YYYY Age at incident MM slash DD slash YYYY Date of death MM slash DD slash YYYY Date of death MM slash DD slash YYYY Date of death MM slash DD slash YYYY Date of death MM slash DD slash YYYY Date of death MM slash DD slash YYYY Date of incident/death MM slash DD slash YYYY Age at incident/death Age at death Age at death Age at death Age at death Age at death Age at death Age at death Designated Forensic Pathologist Age at incident/death Is the Coroner or Medical Examiner (ME) currently involved in the investigation of this death? Responsible Medical Examiner/Coroner jurisdiction Has a post-mortem examination (autopsy) already been performed? Has a post-mortem examination (autopsy) already been performed? Designated Forensic Pathologist Designated Physician Designated Physician/Pathologist Designated Physician/Pathologist Designated Pathologist Designated Pathologist Please provide a concise overview of your interpretation regarding the circumstances and causes of this person's death. If deceased, has a post-mortem examination (autopsy) already been performed? If deceased, has a post-mortem examination (autopsy) already been performed? Has a post-mortem examination (autopsy) already been performed? Cause of death Reason for requesting an autopsy Manner of death Brief summary of the official circumstances of death Brief summary of the official circumstances of death Brief summary of the official circumstances of death Brief summary of the official circumstances of death Brief summary of the official circumstances of death Brief summary of the official circumstances of death Brief summary of the official circumstances of death Brief summary of the official circumstances of death Brief summary of the official circumstances of death Type of examination requested (e.g. neuropathology, cardiovascular pathology, forensic anthropology, pediatric bone pathology, histology, other) Reason for examination Reason for peer review (e.g. criminally suspicious death, pediatri death, in-custody death, other) Name of Case (e.g. State vs. Smith) Jurisdiction County Plaintiff Plaintiff’s Attorney Defendant Defendant’s Attorney Agency Law Enforcement Agency Charges/Indictment(s) Next scheduled hearing date Name of Case (e.g. State vs. Smith) Jurisdiction County Plaintiff Plaintiff’s Attorney Defendant Defendant’s Attorney Agency Law Enforcement Agency Charges/Indictment(s) Pre-trial hearing/trial dates Funding Source (Public/Private) Name of Case (e.g. State vs. Smith) Jurisdiction County Plaintiff Plaintiff’s Attorney Defendant Defendant’s Attorney Agency Law Enforcement Agency Charges/Indictment(s) Pre-trial hearing/trial dates Funding Source (Public/Private) Name of Case (e.g. State vs. Smith) County Plaintiff Plaintiff’s Attorney Defendant Defendant’s Attorney Agency Law Enforcement Agency Charges/Indictment(s) Next scheduled hearing date/court deadline Funding Source (Public/Private)
