Government of Ontario: Ministry of Community Safety and Correctional Services

Office of the Chief Coroner

Warrant for Post Mortem Examination

The Coroners Act - Province of Ontario

Name of Deceased

Surname

Given Name(s)

Sex

M F

Date of Birth (yyyy/mm/dd)

Age
years months days

Positive ID

Y N

How Identified

ID Band Placed By

Scene Visited

Y N

Place of Death

Place of Injury

Date of Injury (yyyy/mm/dd)

Time of Injury

Specify
A.M. P.M.

Body Examined

Y N

Time Pronounced

Specify
A.M. P.M.

Date of Death (yyyy/mm/dd)

Authority to seize issued for:

Hospital Blood
Hospital Medical Records
Other (specify)

Circumstances of Death (brief history, scene observations, body
examination)

If completing by hand, please indicate the number of sheets attached (if applicable)
Specify

Name of Deceased

Relevant Additional Information (medical history, medications,
concerns, police officer, religious considerations)

If completing by hand, please indicate the number of sheets attached (if applicable)
Specify

Reason for Post Mortem Examination (include cause/manner of
death, identification concerns, possible inquest)

If completing by hand, please indicate the number of sheets attached (if applicable)
Specify

Name of Deceased

I Have Issued a Warrant to Take Possession of this Body Pursuant to the Coroners Act

Recommendations for Pathologist's Examination

Full Examination
I have discussed this with the Regional Coroner and I am not aware of any reservations to conducting an external examination

I, the undersigned coroner, provide this Warrant for Post Mortem Examination as authorized by subsection 28(1) of the Coroners Act, to: (Name if known) a pathologist on the register of pathologists at(Location) to conduct a post mortem examination on the deceased.

I have communicated with the pathologist

verbally and/or via this form,
the above preliminary information concerning my investigation in order to assist the pathologist with this examination. Ongoing investigation may provide further clarification or may alter this preliminary information significantly.

My contact telephone numbers for oral communication with
pathologist following post mortem examination:

Office

Cell

Other

I give authority to release the body following post mortem examination

Yes
No (state reason(s))
Requires my oral approval or the Regional Coroner's oral approval

Coroner’s Name (Please print)

Date Signed (yyyy/mm/dd)

Coroner’s Signature

Personal information contained on this form is collected under the authority of the Coroners Act, R.S.O. 1990, C. C.37, as amended. Questions about this collection should be directed to the Chief Coroner, 25 Morton Shulman Avenue, Toronto ON M3M 0B1, Tel.: 416 314-4000 or Toll Free: 1 877 991-9959.