Family Request for Autopsy Report

Date: 
05/10/2016
Document Text Version

Form linked above is a PDF and may be printed. 
Please use the above form for mailing or faxing.

IOWA OFFICE OF THE STATE MEDICAL EXAMINER
2250 South Ankeny Blvd.
Ankeny, IA  50023-9093
Family Request For Autopsy Report
Autopsy results may be released to the immediate next-of-kin according to Iowa Code 22.7, item 41.
Name of Requestor
Name of Deceased
Date of Death
Relationship to Deceased
Address to Send Report (For privacy, reports cannot be faxed or e-mailed)
Street
City/State/Zip
Phone (Required)
(Please include area code)
Was the deceased married at the time of his/her death?     Yes     No
Does the deceased have any children age 18 or older?     Yes     No
Are the parents of the deceased still living?     Yes     No
Does the deceased have siblings age 18 or older?     Yes     No
Signature of Legal Next-of-Kin
Date
Please mail or fax this form to:
Iowa Office of the State Medical Examiner
2250 South Ankeny Blvd.
Ankeny, IA 50023-9093
Fax: 515-725-1414

Printed from the Iowa Office of the State Medical Examiner website on November 23, 2017 at 3:05am.