ARKANSAS STATE CRIME LABORATORY BODY SUBMISSION FORM
P.O. Box 8500 3 Natural Resources Drive Little Rock, Arkansas 72215	Please completely fill in form	Medical Examiner’s Office Phone: (501) 227-5936 Fax: (501) 221-1653
please indicate which of the following best describes the death. if none apply, please call the Me’s office before completing this form. criminal violence deaths in custody (non-natural) Intoxication skeletonized remains Infant/child unexpected acute workplace injury suspected drowning charred bodies police action electrocution unidentified bodies vehicular (when necessary for cod)
Name of deceased:	POSITIVE iD bY:
Age:	Race:	Sex:	Date of Birth:	Social security #:
Marital Status:	Single Married Divorced WidoweD Unknown	Next of kin:	Relationship:
Infectious Diseases:	HIV? Y N Unknown	Hepatitis? Y N Unknown	Tuberculosis? Y N Unknown
Date/time last seen alive:	by whoM:	relationship:
Place of Incident (Address):
City:	County:
Incident Or Found on Date:	Time:	AM PM
pOSITION fOUND:	fOUND by:	lOCATION fOUND (e.g., bedroom):
date/TIME pronounced dead:	AM PM	by whom:	title:
Place of death:	Same as decedent’s address? Y N	decedEnt’s address:
Investigating agency:	Person to contact for Investigative Information:
address:	direct phone: Email Address: agency case #:
City:	State:	zip:
coroner/deputy (Include title):	direct phone: Email Address: agency case #:
location of body to be picked up:
Contracting funeral home:
if known,	rIGOR: lIVIDITY:	Body Temp:	Ambient Temp:
if suspicious death, state reasons:
pAST mEDICAL hISTORY, mEDICATIONS, pRIMARY cARE pHYSICIAN:
SUMMARY OF CIRCUMSTANCES (Use additional paper if necessary):
name of officer (Print):	title:	signature: