IOWA OFFICE OF THE STATE MEDICAL EXAMINER

2250 South Ankeny Blvd. ¿ Ankeny, IA ¿ 515-725-1400 ¿ Fax 515-725-1414

PERMIT BY MEDICAL EXAMINER FOR AUTOPSY

County of

Under the provisions of Chapter 331 of The Code of Iowa, in my opinion it is advisable and in the public interest that an autopsy be performed on the body of:

(Name) / (Age) / (Sex) / (Race) / (Date of Birth)
Who died on / @ / at the following location:
(Date) / (Time)
IA
(Address) / (City) / (State) / (County)
under the following circumstances:
Type of Death / Manner of Death
Violent
Sudden, when in apparent health
Unattended by a physician
Custody of Law
Suspicious, unusual, or unnatural manner
Disease which might threaten public health / Natural
Accident
Suicide
Homicide
Undetermined
Pending
Narrative Summary of Circumstances Surrounding Death:
Authority is hereby given to Doctor
to perform such autopsy on the body of the decedent named herein.
(Name of Medical Examiner - Please Print or Type)
(Signature of Medical Examiner) / (Date)
(City, State)

One copy each to the medical examiner requesting the autopsy and the person performing the autopsy

Form ME-3 (revised 5/2015)