Autopsy report request form

Date: 
04/26/2022
Document Text Version

FAMILY REQUEST FOR AUTOPSY REPORT (MUST BE NOTARIZED)

Autopsy results may be released to the immediate next of kin according to Iowa Code 22.7, item 41.
Name of Deceased
Date of Death

Name of Requestor
Relationship to Deceased

Mailing Address to Receive Report (reports cannot be faxed or e-mailed)
Street

City/State/Zip

Phone (Required)
(Please include area code)

Legal next of kin is determined by the following hierarchy:
(1) Spouse, (2) Adult Children, (3) Parents, (4) Grandchildren, (5) Siblings, (6) Grandparents, (7) Other Family Member

Please answer the following questions:
Was the deceased married at the time of his/her death?
0 Yes
0 No

Does the deceased have any children or grandchildren age 18 or older?
0 Yes
0 No

Are the parents of the deceased still living?
0 Yes
0 No

Does the deceased have siblings age 18 or older?
0 Yes
0 No

Signature of Legal Next of Kin
Date

Printed from the Iowa Office of the State Medical Examiner website on November 28, 2022 at 6:30pm.