§500.ILLUSTRATION B. Necropsy (NEC)1

 

NEC 1                                                                                                                                                                                CORONER

(Rev. 3/69)

 

Report of Coroner's Physician to the

 

Coroner of _______________________County, Illinois

 

			have examined have made a necropsy on the
I,		M.D.,

 

body identified to me by the coroner of this county as being:

 

Name __________________________________________ Date of Death ___________________________________

 

Place of Death (city, village, or twp.) ____________________________________________________________________

 

Place of Examination (city, village, or twp.) ______________________________________________________________

 

In my opinion, the cause of death was as follows:

 

	[Enter only one cause per line for (a), (b), and (c).]	APPROXIMATE INTERVAL    BETWEEN ONSET AND DEATH
CONDITIONS, IF ANY, WHICH GAVE RISE TO IMMEDIATE CAUSE (a) STATING THE UNDERLYING CAUSE LAST.	IMMEDIATE CAUSE
	(a)
	DUE TO, OR AS A CONSEQUENCE OF
	(b)
	DUE TO, OR AS A CONSEQUENCE OF
	(c)

 

OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL CONDITIONS GIVEN ABOVE.

 

                                                                                                                                                                                                                       

 

                                                                                                                                                                                                                       

 

My conclusions are based on the following observations and findings.

 

 

 

 

Date:		Signed:		M.D.
Coroner's Physician

 

 

 

INSTRUCTIONS:           1.   Prepare this form in triplicate.  Use typewriter for all entries except signature.

 

2.   Sign original and first copy in pen and ink.

 

3.   Mail original and first copy to the coroner.  Retain last copy.

 

(Source:  Added at 15 Ill. Reg. 11706, effective August 1, 1991)