Auutopsy reporting templates
 
PERINATAL AUTOPSY GROSS SUMMARY 
 
Surname: ________________________      Given Name(s): ______________Sex: M/F
 
Date of Birth: _____________________      Hospital File Number: ________________
 
Gestational Age: ___________________
 
Date and hour of death: ______________ Date and time of autopsy:_____________ 
 
Pathologist: ________________________ Prosector(s): _______________________
 
Attending physician: _____________________________________________     
 
Autopsy restrictions: _____________________________________________    
 
Postmortem lab tests: _____________________________________________
 
Gross photographs taken (specify): __________________________________
 
Specimen(s) kept for teaching purposes (specify): ______________________
 


 
 
EXTERNAL EXAMINATION
 
ID BRACELET/TAG: ________________________
 
Statistical data from _____________________ 
 
Means and standard deviations for weights and measurements of
 
[ ] liveborn [ ] stillborn infants at ______ weeks gestational age.
 
TOTAL BODY WEIGHT:       _______________g   (Normal _______________ g)                       
 
CROWN-HEEL LENGTH: _______________cm   (Normal _______________cm)
 
CROWN-RUMP LENGTH: _______________ cm (Normal _______________cm)
 
HEEL-TOE LENGTH:           ________________ cm          (Normal _______________cm)
 
HEAD CIRCUMFERENCE: _______________ cm
 
CHEST CIRCUMFERENCE: _______________ cm
 
ABDOMINAL CIRCUMFERENCE: _____________ cm
 
MACERATION:
 
            [ ] Mild: ______________________________________________________________
 
[ ] Moderate: __________________________________________________________
 
[ ] Severe: ____________________________________________________________
 
 
RIGOR:           [ ] Mild             [ ] Moderate                [ ] Severe
 
LIVOR:            [ ] Absent        [ ] Present: ________________________________
 
CYANOSIS:    [ ] Absent        [ ] Lips                        [ ] Nailbeds
 
JAUNDICE:    [ ] None           [ ] Mild             [ ] Moderate                [ ] Severe
 
 
 
EDEMA/HYDROPS: [ ] None           [ ] Mild             [ ] Moderate                [ ] Severe
 
 
RECENT INCISIONS:
  
 
INTRAVENOUS/ARTERIAL LINES:
 
 
CATHETERS:
 
 
HEAD:             [ ] Unremarkable        [ ] Molded        [ ] Macrocephaly [ ] Microcephaly
 
                        [ ] Flattened occiput   [ ] Prominent occiput
 
SCALP:          [ ] Unremarkable.       [ ] Defects: _________________________
 
HAIR:             Color:_________________ Whorl pattern: _____________________
 
 
EYES:                                      RIGHT                       LEFT
                    
Irides:                               __________                __________
       Sclerae:                            __________                __________
       Pupils:                              ________ cm              ________ cm
 
Position:                           [ ] Normal       [ ] Hypertelorism         [ ] Hypotelorism
 
                                         Inner canthal measurement: ________ cm
                                         Outer canthal measurement: ________ cm
 
Infraorbital creases:         [ ] Absent        [ ] Present
 
Palpebral fissures:          [ ] Normal       [ ] Upslanting              [ ] Downslanting
 
 


 
EARS:            [ ] Unremarkable        [ ] Low-set     [ ] Abnormally shaped helix
 
Meconium: [ ] None                [ ] In ears        [ ] Behind ears
 
 
NOSE:                        [ ] Unremarkable, with patent nares
 
                        [ ] Flattened nasal bridge
 
                        [ ] Upturned nasal tip
 
                        [ ] Beaked
 
                        [ ] Other: ______________________
 
 
PHILTRUM:  [ ] Normal       [ ] Long           [ ] Short
 
 
MOUTH:         [ ] Unremarkable       [ ] Gaping       [ ] Small
 
PALATE AND GUMS:           
 
[ ] Cleft lip                  [ ] Right [ ] Left [ ] Midline [ ] Bilateral
 
                        [ ] Cleft palate            [ ] Right [ ] Left [ ] Midline [ ] Bilateral
 
 
TONGUE:      [ ]Unremarkable       [ ] Protruberant (macroglossia)
 
CHIN:              [ ] Normal                   [ ] Retromicrognathia
 
 
NECK:            [ ] Unremarkable [ ] Short [ ] Webbed 
 
[ ] Nuchal fullness (cystic hygroma) [ ] Mild [ ] Moderate [ ] Marked
           
Thickness: _________________ cm


 
TRUNK:         [ ] Unremarkable
 
                        [ ] Small chest           [ ] Protuberant abdomen
 
                        [ ] Omphalocele        Diameter: ________ cm Contents:_____________
 
                        [ ] Gastroschisis        Details: __________________________________
 
 
 
EXTERNAL GENITALIA:      
 
[ ] Normal male          Testes: [ ] Descended           [ ] Undescended
 
[ ] Normal female
           
[ ] Ambiguous
 
[ ] Abnormalities: _______________________________
 
 
ANUS:             [ ] Perforate                [ ] Imperforate
 
 
UMBILICAL CORD ATTACHED TO INFANT:
 
Length _________ cm            Diameter _________ cm
                       
Number of cord vessels: [ ] Three     [ ] Two
 
True knot(s): [ ] Absent          [ ] Present      Details: ______________________
 
Coiling:            [ ] Normal       [ ] Increased  [ ] Decreased
                                   
Cord coil index (if abnormal): _________coils / 10 cm
 
Stricture: [ ] Absent    [ ] Present. Details: ______________________________
 
 


 
UPPER EXTREMITIES:
 
      [ ] Unremarkable
 
      [ ] Meconium in axillary creases
 
      [ ] Positional deformities: _________________________________________________
 
      [ ] Pterygia: ____________________________________________________________
 
      Number of digits:   [ ] Five            [ ] Other ________________________________
 
      Clinodactyly:          [ ] Absent        [ ] Present: ____________________________________
      Camptodactyly:     [ ] Absent        [ ] Present: ____________________________________   
      Syndactyly:            [ ] Absent        [  ] Present: ____________________________________
 
      Palmar creases:  [ ] Normal      [ ] Abnormal : _________________________________
 
Nails: [ ]Unremarkable. [ ] Hypoplastic   [ ] Meconium present
 
 
 
LOWER EXTREMITIES:
 
      [ ] Unremarkable
 
      [ ] Meconium in inguinal creases
 
      [ ] Positional deformities: __________________________________________________
 
      [ ] Pterygia: _____________________________________________________________
 
      Number of digits:   [ ] Five            [ ] Other _________________________________
 
      Syndactyly:                        [ ] Absent        [ ] Present: _____________________________
 
      Talipes equinovarus:        [ ] Absent        [ ] Right          [ ] Left
 
Nails: [ ]Unremarkable. [ ] Hypoplastic   [ ] Meconium present
 


 
[ ] SINGLETON PLACENTA                        [ ] TWIN PLACENTAE
 
PLACENTA "A":
 
            Weight: _______________ gm (Normal: _______________ gm)
 
            Dimensions: _________________________________________
 
            Fetal Surface: _________________________________________
 
            Maternal Surface: ______________________________________
 
            Parenchyma: __________________________________________
                                   
MEMBRANES "A":
 
            Appearance: [ ] Thin and transparent          [ ] Thickened and opaque
[ ] Greenish discoloration       [ ] Brownish discoloration
 
            Insertion:       [ ] Marginal      [ ] Circummarginate   [ ] Circumvallate
           
UMBILICAL CORD ATTACHED TO PLACENTA "A":
 
            Length: _________ cm.                   Diameter: _________ cm
 
            Insertion:       [ ] Central      
[ ] Eccentric: ________________________________
[ ] Marginal
[ ] Velamentous         [ ] Vessels intact        [ ] Vessels not intact
 
            Number of vessels: [ ] Three          [ ] Two
 
True knot(s):                         [ ] Absent        [ ] Present: _____________________________
 
Coiling:                       [ ] Normal       [ ] Increased  [ ] Decreased
                                                           
Cord coil index (if abnormal): _________coils / 10 cm
 
            Strictures:                  [ ] Absent        [ ] Present: ______________________________
 


 
[ ] SINGLETON PLACENTA                        [ ] TWIN PLACENTAE
 
PLACENTA "B":
 
            Weight: _______________ gm (Normal: _______________ gm)
 
            Dimensions: _________________________________________
 
            Fetal Surface: _________________________________________
 
            Maternal Surface: ______________________________________
 
            Parenchyma: __________________________________________
                                   
MEMBRANES "B":
 
            Appearance: [ ] Thin and transparent          [ ] Thickened and opaque
[ ] Greenish discoloration       [ ] Brownish discoloration
 
            Insertion:       [ ] Marginal      [ ] Circummarginate   [ ] Circumvallate
           
UMBILICAL CORD ATTACHED TO PLACENTA "B":
 
            Length: _________ cm.                   Diameter: _________ cm
 
            Insertion:       [ ] Central      
[ ] Eccentric: ________________________________
[ ] Marginal
[ ] Velamentous         [ ] Vessels intact        [ ] Vessels not intact
 
            Number of vessels: [ ] Three          [ ] Two
 
True knot(s):                         [ ] Absent        [ ] Present: _____________________________
 
Coiling:                       [ ] Normal       [ ] Increased  [ ] Decreased
                                                           
Cord coil index (if abnormal): _________coils / 10 cm
 
            Strictures:                  [ ] Absent        [ ] Present: ______________________________
 


 
[ ] TWIN PLACENTAE
 
Number of discs:                    [ ] One            [ ] Two
 
Dividing membranes:              [ ] Dichorionic, diamniotic
                       
                                                [ ] Monochorionic, diamniotic
 
                                                [ ] None (monochorionic, monoamniotic)
 
Abnormal vascular anastomoses: [ ] Present           [ ] Absent
 
 


 
CARDIOVASCULAR SYSTEM
 
HEART:          [ ] Macerated
 
      Weight: __________ g (Normal: __________ g)
 
      Pericardial effusion: __________ ml
            [ ] Serous
            [ ] Serosanguinous
            [ ] Sanguinous
 
      Pericardium:
[ ] Unremarkable
[ ] Petechial hemorrhages: [ ] None           [ ] Occasional             [ ] Multiple
 
      Epicardium:
            [ ] Unremarkable
            [ ] Petechial hemorrhages:    [ ] None          [ ] Occasional [ ] Multiple
 
      Right atrial appendage:
 
            [ ] Normal       [ ] Abnormal: ________________________
 
      Left atrial appendage:
 
            [ ] Normal       [ ] Abnormal: ________________________ 
 
      Right atrium:
           
            Dilatation:      [ ] None          [ ] Mild            [ ] Moderate               [ ] Marked
           
           
      Left atrium:
           
            Dilatation:      [ ] None          [ ] Mild            [ ] Moderate               [ ] Marked
           
 
      Foramen ovale:  [ ] Patent; diameter _________ cm              [ ] Closed
 
     


 
Right Ventricle:
 
            Dilatation:      [ ] None          [ ] Mild            [ ] Moderate               [ ] Marked
 
            Endocardium: Unremarkable.
 
            Myocardium: Unremarkable.
 
            Wall thickness: [ ] Normal    [ ] Increased: _________ cm  [ ] Decreased: _______ cm
 
           
      Left Ventricle:
 
            Dilatation:      [ ] None          [ ] Mild            [ ] Moderate               [ ] Marked
 
            Endocardium: Unremarkable.
 
            Myocardium: Unremarkable.
 
Wall thickness: [ ] Normal    [ ] Increased: _________ cm  [ ] Decreased: _______ cm
 
 
      Ventricular septal defects:
 
      [ ] Absent [ ] Muscular: _______cm diameter    [ ] Membranous: ______cm diameter          
 
 
Valves: [ ] Unremarkable
 
                                    [ ] Tricuspid:
 
[ ] Mitral:
 
[ ] Pulmonary:
 
[ ] Aortic:
 
      Chordae Tendineae: Normal length and thickness.
 
 
 


 
THORACIC AORTA AND BRANCHES:
 
            [ ] Unremarkable        [ ] Macerated
            [ ] Abnormal: ____________________________________
 
            [ ] Coarctation. Location: _____________________ Diameter: ___________ cm
 
 
PULMONARY VESSELS:    
 
[ ] Unremarkable        [ ] Macerated
[ ]: Abnormal: __________________________________________
 
 
DUCTUS ARTERIOSUS:      [ ] Patent         [ ] Closed        [ ] Macerated
 
 
SUPERIOR VENA CAVA AND TRIBUTARIES:      
 
            [ ] Unremarkable        [ ] Macerated
            [ ] Abnormal: _________________________________________
 
 
ABDOMINAL AORTA AND BRANCHES:               
 
[ ] Unremarkable        [ ] Macerated
[ ] Abnormal: __________________________________________
 
UMBILICAL ARTERIES:
 
            [ ] Macerated
 
[ ] Both identified        [ ] Only one identified: [ ] right          [ ] left
 
 
INFERIOR VENA CAVA AND TRIBUTARIES:
 
[ ] Unremarkable        [ ] Macerated
[ ] Abnormal: __________________________________________
 
 


 
RESPIRATORY SYSTEM
 
LARYNX:                    [ ] Unremarkable        [ ] Macerated [ ] Abnormal:_________________
 
 
TRACHEA:                 [ ] Unremarkable        [ ] Macerated [ ] Abnormal: __________________
 
 
MEDIASTINUM:         [ ] Unremarkable        [ ] Macerated [ ] Abnormal: __________________
 
 
PLEURAL CAVITIES:                                    [ ] Macerated
 
Pleural effusions:           [ ] Absent
 
                        Right: _________ ml               [ ] Serous       [ ] Serosanguinous [ ] Sanguinous
 
                        Left: _________ ml                 [ ] Serous       [ ] Serosanguinous [ ] Sanguinous
 
      Parietal pleura: [ ] Unremarkable           [ ] Abnormal: _____________________________
 
Petechial hemorrhages:         [ ] None           [ ] Occasional             [ ] Multiple
 
 
LUNGS:                      [ ] Macerated
 
Weights:  Right ______ g; Left______g (Normal combined weight _________ g)
 
Lung to body weight ratio: ____________
 
      Visceral pleura: [ ] Unremarkable.         [ ] Abnormal: _____________________________
 
Petechial hemorrhages:         [ ] None           [ ] Occasional             [ ] Multiple
 
Lobation: [ ] Normal       [ ] Abnormal: ________________________
 
      Parenchyma:
                        [ ] Unremarkable
                        [ ] Abnormal :_____________________________________________
 
 
       
Bronchi: Unremarkable.


 
DIGESTIVE SYSTEM
 
DIAPHRAGM:
 
            [ ] Intact
 
            [ ] Diaphragmatic hernia: ____________________________________________
 
PERITONEUM:                           
 
      Peritoneal surfaces: [ ] Unremarkable [ ] Macerated [ ] Abnormal: ________________
 
      Ascites:    [ ] None.
      [ ] ______ml of         [ ] serous fluid
[ ]  serosanguinous fluid
[ ] sanguinous fluid.
 
      Adhesions:     [ ] None.
[ ] Few and scattered, predominantly in the _____________ quadrant.
[ ] Many, with the most severe located in the _____________ quadrant.
[ ] Diffusely present throughout the peritoneum.
 
 
ESOPHAGUS:     [ ] Unremarkable   [ ] Macerated [ ] Abnormal: ______________________
 
Tracheoesophageal fistula: [ ] Absent     [ ] Present: ____________________
 
 
STOMACH:          [ ] Unremarkable [ ] Macerated [ ] Abnormal: ________________________
 
 
SMALL INTESTINE: [ ] Unremarkable        [ ] Macerated [ ] Abnormal: __________________
 
            Meckel's diverticulum: [ ] Absent       [ ] Present: ___________________________
 
 
LARGE INTESTINE:    [ ] Unremarkable     [ ] Macerated [ ] Abnormal: __________________


 
APPENDIX:    [ ] Present and located in right lower quadrant
                        [ ] Present and located in ___________________ quadrant            
[ ] Absent
[ ] Macerated
 
RECTUM:       [ ] Unremarkable        [ ] Macerated              [ ] Abnormal: __________________
 
Meconium:            [ ] Present                  [ ] Absent
 
MESENTERY: [ ] Attached              [ ] Non-attached
 
 
LIVER:Weight: _________ g   (Normal: ___________ g)
 
Shape:      [ ] Normal:      [ ] Abnormal: _______________________________________
 
      Capsule:  [ ] Unremarkable       
                        [ ] Subcapsular hematoma
                              Location: ____________________Diameter:___________________
 
      Parenchyma:        [ ] Unremarkable                    [ ] Macerated
 
                                    [ ] Focal lesions: _______________________________________
 
      Hepatic artery:                            [ ] Unremarkable                    [ ] Macerated 
 
      Hepatic veins and tributaries: [ ] Unremarkable                    [ ] Macerated
 
      Portal vein and tributaries:       [ ] Unremarkable                    [ ] Macerated
 
 
GALLBLADDER:       [ ] Unremarkable        [ ] Macerated             [ ] Abnormal: ____________
 
BILE DUCTS:            [ ] Unremarkable        [ ] Macerated             [ ] Abnormal: __________________
 
PANCREAS:   Weight:_________ g (Normal: ___________ g)
 
                                    [ ] Unremarkable        [ ] Macerated              [ ] Abnormal: ____________
 
 
 


 
GENITOURINARY SYSTEM
 
KIDNEYS:     [ ] Macerated
 
Weights: Right _________ g; Left __________g (Normal combined: __________ g)
 
      Cortex:     [ ] Unremarkable
 
                        [ ] Cysts present: ________________________________________
 
      Medulla:  [ ] Unremarkable
 
      Pelvis:      [ ] Unremarkable        [ ] Dilated
 
      Ureters:    [ ] Unremarkable        [ ] Dilated.     
 
                        Diameter (if dilated):               Right_______ cm;      Left _______cm
 
     
URINARY BLADDER:     [ ] Unremarkable   [ ] Macerated  [ ] Tubular      [ ] Hypoplastic
 
                                          [ ] Dilated. Diameter: ______________cm
 
 
URETHRA:    [ ] Patent                     [ ] Macerated            
                        [ ] Stenotic                 [ ] Posterior urethral valves present
 
 
PROSTATE:  [ ] Unremarkable        [ ] Macerated              [ ] Absent
 
 
UTERUS, FALLOPIAN TUBES AND OVARIES:
           
            [ ] Unremarkable        [ ] Macerated [ ] Abnormal: _____________________________


 
HEMATOPOIETIC SYSTEM
 
THYMUS:       Weight: __________ g (Normal: __________ g).
 
            [ ] Unremarkable                    [ ] Macerated
 
Petechial hemorrhages:         [ ] None           [ ] Occasional             [ ] Multiple
 
SPLEEN:  Weight: ________ g (Normal: __________ g) 
 
[ ] Unremarkable                    [ ] Macerated
 
[ ] Accessory spleen(s): _______                  [ ] Ectopic spleen(s): ___________
 
LYMPH NODES:
 
            [ ] Unremarkable        [ ] Macerated
 
[ ] Lymphadenopathy: ___________________________________________
 
 
BONE MARROW: [ ] Unremarkable            [ ] Macerated
 


 
 
ENDOCRINE SYSTEM
 
PITUITARY GLAND:                         [ ]Unremarkable        [ ] Macerated
 
THYROID GLAND:                [ ] Unremarkable        [ ] Macerated
 
PARATHYROID GLANDS:    [ ] Unremarkable        [ ] Macerated            [ ] Not identified
 
ADRENAL GLANDS:
 
            Weights: Right __________g; Left: __________ g (Normal combined: __________ g)
 
            [ ] Unremarkable        [ ] Macerated
 
[ ] Hemorrhage present: __________________________________________
 
 
 
 
 
 
NERVOUS SYSTEM
 
 
BRAIN AND SPINAL CORD: See separate neuropathology report.
 
Brain weight: _________ g (Normal __________ g )
 
[ ] Non-macerated                  [ ] Macerated
 
 
 
REPORT OF POSTMORTEM EXAMINATION
 
A/
 
 
Made upon the body of:                    , age
at the:                                                     Forensic Pathology Unit, Office of the Chief Coroner, 26 Grenville Street,
in the city of:                                         Toronto, in the province of Ontario,
on the:                                                   day of, 200X, commencing at hours.
 
Directed by Coroner:                                                          
Where death pronounced:                
When death pronounced:                 
Present at autopsy:                              (Pathology Assistants) 
 
IDENTIFICATION:            
 
The body was identified to me by a Coroner’s Office identification band on the wrist.    
Morgue ID#:        
 
EXTERNAL EXAMINATION:                         
 
State of the Body:
 
Temperature:                                 Cold
Rigor mortis:                                 Complete
Postmortem lividity:                     Posterior surface of body, fixed
Decomposition:                            Nil
Clothing and effects:
 
External Features:
 
Sex:                                                 Male/female
Body length:                                
Body weight:                                lbs  
Build and nutrition:                      Medium build; well nourished                                      
Scalp / facial hair:                        
Eye / conjunctiva:                        The irides were , the cornea were and the sclerae were . The bulbar and palpebral conjunctivae were free of petechial hemorrhages.
Face / nose:                                   No fractures or other evidence of recent injury
Teeth:                                             Natural upper and lower dentition
Breasts:                                          No abnormalities noted
External genitalia / perineum:     Unremarkable male/female
Skin features, other:                    
 
EVIDENCE OF RECENT MEDICAL THERAPY/RESUSCITATION:      
 
Nil
 
EVIDENCE OF RECENT INJURY (External and Internal):       
 
There was no evidence of significant recent injury
 
 
 
 
 
 
 
 
INTERNAL EXAMINATION:
 
Face & Neck:
 
Oral cavity:                                    Clear of foreign material
Tongue:                                         No hemorrhages or other evidence of injury
Pharynx:                                         Clear of foreign material
Larynx:                                           Intact with no mucosal lesions
Hyoid bone:                                  Intact
Thyroid:                                         Unremarkable externally and on cut surface
Soft tissues of neck:                    No hemorrhages or other evidence of injury
 
Thorax / Respiratory System:
 
Rib cage / sternum:                      Free of fractures
Diaphragm:                                    Intact
Pleural cavities:                            No effusions, adhesions or tumors evident
Mediastinum / thymus:               No tumours or lymphadenopathy or hemorrhages
Tracheobronchial tree:                Clear of foreign material
Pulmonary vessels:                      No thromboemboli identified
Lungs:                                            Right - gm; left - gm; congested cut surface with no tumours or localized areas of consolidation
 
Circulatory System:
 
Pericardial sac:                              No significant effusions or adhesions
Heart - external:                            Weight - gm; usual anatomic arrangement of chambers and great vessels
Right atrium / atrial septum:       No mural thrombus; intact septum
Tricuspid valve:                           cm; no vegetations or other significant abnormalities
Right ventricle:                             Wall thickness and cavity size within normal limits
Pulmonary valve:                         cm; no vegetations or other significant abnormalities
Left atrium:                                    No mural thrombus
Mitral valve:                                  cm; no vegetations or other significant abnormalities
Left ventricle:                                Wall thickness and chamber size within normal limits; myocardium red/brown, firm and unremarkable
Aortic valve:                                 cm; no vegetations or other significant abnormalities
Coronary arteries:                        dominant circulation; all branches widely patent
Aorta & major arteries:                No significant atherosclerosis
Vena cava & major veins:           Free of thrombus
Blood volume & state:                Abundant clotted / liquid blood in the heart and major vessels
 
Abdominal Cavity / Gastro-Intestinal System:
 
Esophagus:                                   No tumours or mucosal lesions identified
Peritoneal cavity:                         No effusion or adhesions
Stomach - wall:                             No ulcers or other mucosal lesions
               - contents:                      The lumen contained ml of tan/brown liquid  
Intestines:                                     No evidence of hemorrhage, obstruction or perforation
Appendix:                                      Present
Liver:                                              gm; red/brown cut surface with no tumours or other localized lesions
Gall bladder / bile ducts:             No calculi
Spleen:                                           gm; unremarkable cut surface
Pancreas:                                       No tumours or other lesions
Adrenals:                                       No tumours or other lesions
Retro-peritoneum:                        Free of hemorrhage
 
 
 
 
 
Genito-Urinary System & Pelvis:
 
Kidneys:                                        Right - gm; left - gm; smooth tan/brown cortical surfaces with no localized lesions
Renal pelvis & ureters:                No evidence of obstruction or infection
Urinary bladder - wall:                 No tumours or other lesions identified
                         - contents:            ml
Urethra:                                          Unremarkable
Male
        Prostate:                                Not enlarged
        Testes:                                   Descended
Female
        Ovaries:                                 No tumours or other lesions
        Fallopian tubes:                    Unremarkable
        Uterus:                                   No tumours; unremarkable endometrium
        Vagina and vulva:                No pathologic lesions
 
Head / Central Nervous System:
 
Scalp:                                             No contusions or other evidence of injury
Skull:                                              Intact
Middle ears & sinuses:               Not opened
Pituitary gland:                             Not enlarged
Dura mater / subdural space:     No evidence of recent or remote subdural hemorrhage
 
Brain:                                              Weight - gm
Meninges/subarachnoid space: Free of hemorrhage or exudate
Cerebral arteries:                          Free of atherosclerosis or aneurysms
Cerebral veins / sinuses:             Free of thrombus
Cerebral hemispheres:                 Symmetrical with no atrophy, compression or localized lesions evident. The brain was cut fresh. Coronal sections of the brain revealed a symmetrical ventricular system of normal size. The cortex, underlying white matter and basal ganglia showed no abnormalities.
Cerebellum:                                   No localized lesions
Brain stem:                                    No localized lesions
 
Spinal cord:                                   Not examined               
 
Musculo-skeletal System / Extremities:
 
Spine:                                            Intact
Pelvis:                                           Intact
Extremities:                                   No acute or chronic bone or joint deformity
 
Other Organs / Tissues (not specified elsewhere):
 
Lymph nodes:                             Thoracic lymph nodes were anthracotic; otherwise unremarkable regional lymph nodes.
 
Microscopic Findings:
 
Description of Blocks
 
 
 
 
Microscopic description
Heart:     -
Liver:      -
Kidney: -
Lung:      -
 
 
OTHER LABORATORY TESTING
 
Toxicology:                           Routine toxicologic samples were collected and submitted for analysis, please see Centre of Forensic Sciences report – CFS File No.: .   An archival sample of blood was also collected and stored.
 
Biochemistry                    A sample of vitreous fluid was collected and retained.
 
Tissue Retention              Selected samples of organs and tissues were preserved in 10% formaldehyde in a single storage container.
 
Photography:                        A routine identification photograph (Polaroid) was taken of the decedent at the Forensic Pathology Unit.
 
SUMMARY OF FINDINGS:
 
I
 
II
 
III
 
Information supplied on the Coroner’s Warrant and/or police report indicates that the decedent was a
 
The postmortem examination found
                   
CAUSE OF DEATH
 
Acting on the authority of a Coroner’s Warrant for Postmortem Examination I hereby certify that I have examined this body, have opened and examined the above noted cavities and organs as indicated and based on my findings and information made available to me, in my opinion the cause of death was:
 
 
 
DATED: ,
 
SIGNED: