U.S. Department of Justice 

Office of Justice Programs 

National Institute of Justice 

Research Report 

A Guide for the Scene Investigator 

Death Investigation: 
U.S. Department of Justice
 

Office of Justice Programs
 

810 Seventh Street N.W. 

Washington, DC 20531 

Janet Reno 

Attorney General 

Daniel Marcus 

Acting Associate Attorney General 

Laurie Robinson 

Assistant Attorney General 

Noël Brennan 

Deputy Assistant Attorney General 

Jeremy Travis 

Director, National Institute of Justice 

Department of Justice Response Center:

 800–421–6770 

Office of Justice Programs National Institute of Justice
 

World Wide Web Site: World Wide Web Site:
 

http://www.ojp.usdoj.gov http://www.ojp.usdoj.gov/nij 
for Death Investigation

National Guidelines

A Guide for the Scene Investigator 

Developed and Approved by the
 

National Medicolegal Review Panel
 

Executive Director
 

Steven C. Clark, Ph.D.
 

Occupational Research and Assessment, Inc.
 

Big Rapids, Michigan
 

Associate Professor
 

Ferris State University
 

November 1999
 

The title of this report, formerly “National Guidelines for Death
 

Investigation,” has been changed in this reprint for consistency with
 

the titles of other Guides in the NIJ series. 
U.S. Department of Justice 

Office of Justice Programs 

National Institute of Justice 

Jeremy Travis, J.D.
 

Director
 

Richard M. Rau, Ph.D.
 

Project Monitor
 

This project was cosponsored by the Centers for Disease Control and 

Prevention and the Bureau of Justice Assistance. 

“Every Scene, Every Time” logo designed and created by Steven Clark, 

Ph.D., and Kevin Spicer of Occupational Research and Assessment, Inc. 

This project was supported under grant number 96–MU–CS–0005 by the 

National Institute of Justice, Office of Justice Programs, U.S. Department 

of Justice, and by the Bureau of Justice Assistance and the Centers for 

Disease Control and Prevention. 

This document is not intended to create, does not create, and may not be 

relied upon to create any rights, substantive or procedural, enforceable at 

law by any party in any matter civil or criminal. 

Opinions or points of view expressed in this document are those of the 

authors and do not necessarily reflect the official position of the U.S. 

Department of Justice. 

NCJ 167568 

The National Institute of Justice is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance, 

the Bureau of Justice Statistics, the Office of Juvenile Justice and 

Delinquency Prevention, and the Office for Victims of Crime. 
Message From the Attorney General 

The sudden or unexplained death of an individual has a profound 

impact on families and friends of the deceased and places significant responsibility on the agencies tasked with determining the cause of 

death. Increasingly, science and technology play a key role in death 

investigations. One of the hallmarks of science is adherence to clear and 

well-grounded protocols. 

In many jurisdictions, responsibility for conducting death investigations may rest with pathologists, medical examiners, or coroners, in 

addition to their other duties. There is little training available in the best 

procedures for handling these crucial and sensitive tasks. To help fill the 

gap, the National Institute of Justice, joined by the Centers for Disease 

Control and Prevention and the Bureau of Justice Assistance, supported 

the development of the guidelines presented in this report. 

These guidelines were produced with the vigorous participation of 

highly experienced officials and professionals who served on the National 

Medicolegal Review Panel. A technical working group of 144 professionals from across the country provided the grassroots input to the panel’s 

work. I applaud their willingness to take the time to serve in this effort 

and to hammer out this consensus on the best approach to conducting 

thorough and competent death investigations. 

Jurisdictions will want to carefully consider these guidelines and 

their applicability to local agencies and circumstances. By adhering to 

agreed-upon national standards, death investigators can arrive at the truth 

about a suspicious death. Families and friends can be consoled by knowing 

what happened to their loved one, and justice can be administered on the 

foundation of truth that must always guide our work. 

Janet Reno 

Attorney General 

iii
 
National Medicolegal Review Panel 

The National Medicolegal Review Panel (NMRP) represents a 

multidisciplinary group of content area experts, each representing 

members of his or her respective organization. Each organization has a 

role—be it active involvement or oversight—in conducting death investigations and in implementing these guidelines. 

United States Conference of Mayors 

The Honorable Scott L. King (Chairman, NMRP) 

Mayor
 

Gary, Indiana
 

American Academy of Forensic Sciences 

Joseph H. Davis, M.D. 

Retired Director, Dade County Medical Examiner Department
 

Miami, Florida
 

American Bar Association 

Bruce H. Hanley, Esq. 

Partner, Hanley & Dejoras, P.A.
 

Minneapolis, Minnesota
 

American Medical Association 

Mary E. S. Case, M.D. 

Chief Medical Examiner
 

St. Louis, St. Charles, Jefferson, and Franklin Counties, Missouri
 

St. Louis University School of Medicine
 

College of American Pathologists 

Jeffrey M. Jentzen, M.D. 

Medical Examiner
 

Milwaukee, Wisconsin
 

International Association of Chiefs of Police 

Chief Thomas J. O’Loughlin 

Wellesley, Massachusetts 

v
 
International Association of Coroners and Medical Examiners 

Halbert E. Fillinger, Jr., M.D. 

Coroner
 

Montgomery County, Pennsylvania
 

National Association of Counties 

Douglas A. Mack, M.D., M.P.H. 

Chief Medical Examiner and Public Health Director
 

Kent County, Michigan
 

National Association of Medical Examiners 

Richard C. Harruff, M.D., Ph.D. 

Associate Medical Examiner
 

Seattle/King County Department of Public Health
 

Seattle, Washington
 

National Conference of State Legislatures 

Representative Jeanne M. Adkins 

Colorado State Legislature
 

House Judiciary Committee
 

Denver, Colorado
 

National Governors’ Association 

Richard T. Callery, M.D., F.C.A.P. 

Chief Medical Examiner
 

Wilmington, Delaware
 

National Sheriffs’Association 

Donald L. Mauro 

Commanding Officer, Homicide Bureau
 

Los Angeles County Sheriff’s Department
 

Los Angeles, California
 

Colorado Coroners’Association 

Elaine R. Meisner 

Logan County Coroner
 

Sterling, Colorado
 

South Dakota Funeral Directors’Association 

George H. Kuhler 

Elected Coroner
 

Beadle County, South Dakota
 

vi 
Acknowledgments 

The author wishes to thank the Technical Working Group for Death 

Investigation (TWGDI). This 144-member reviewer network 

gave of their time to review guideline content, providing the researcher 

feedback from a national perspective. Additional thanks to the TWGDI 

executive board: Mr. Paul Davison, Kent County M.E. Office, Grand 

Rapids, Michigan; Mr. Bill Donovan, Jefferson Parish Coroner’s Office, 

Harvey, Louisiana; Mr. Cullen Ellingburgh, Forensic Science Center, 

Orange County, California; Ms. Roberta Geiselhart, R.N., Hennepin 

County M.E. Office, Minneapolis, Minnesota; Dr. Elizabeth Kinnison, 

Office of the Chief M.E., Norfolk, Virginia; Mr. Vernon McCarty, 

Washoe County Coroner, Reno, Nevada; Mr. Joseph Morgan, Fulton 

County M.E. Office, Atlanta, Georgia; Mr. Randy Moshos, M.E. Office, 

New York, New York; Mr. Steve Nunez, Office of the Medical Investigator, Albuquerque, New Mexico; Ms. Rose Marie Psara, R.N., St. Louis 

County M.E. Office, St. Louis, Missouri; and Mr. Michael Stewart, 

Denver City and County Coroner’s Office, Denver, Colorado, whose 

combined commitment to the field of death investigation is a tribute to 

the quality of this document. In addition, the offices that employ each 

member of the group share in this endeavor. Through their support, each 

member was given the flexibility they needed to support the project. 

The author also wishes to thank the National Institute of Justice’s 

(NIJ’s) technical advisors: John E. Smialek, M.D., Chief Medical Examiner, State of Maryland; Randy L. Hanzlick, M.D., Centers for Disease 

Control and Prevention (CDC) and Emory University School of Medicine; Ms. Mary Fran Ernst, Director of Medicolegal Education, St. Louis 

University Medical School; and Ms. Mary Lou Kearns, Coroner, Kane 

County, Illinois. Each made significant contributions to the project’s 

inception, eventual funding, and timely completion. Their dedication to 

the science of death investigation and to the members of the investigative 

community is apparent throughout this document. 

vii
 
The Director of NIJ, the Honorable Jeremy Travis; the Director of 

NIJ’s Office of Science and Technology, Mr. David G. Boyd; and NIJ’s 

Forensic Science Program Manager, Richard M. Rau, Ph.D., each share 

responsibility for the success of this project. Credit also goes to R. Gib 

Parrish, M.D., of CDC, for his support and commitment to the research. 

In addition, the true strength of these guidelines is derived from the 

stamina of the National Medicolegal Review Panel, whose members 

represented 12 national organizations intimately involved in the investigation of death and its outcomes. The panel also included two representatives of elected coroners. NMRP’s contribution was invaluable. 

And finally, the leadership of Joseph H. Davis, M.D., Medical 

Examiner Emeritus, Dade County, Florida, and Mr. Donald Murray, 

National Association of Counties, for their unrelenting efforts to get this 

job done and improve their profession, every scene, every time. 

Steven C. Clark, Ph.D. 

Executive Director 

viii 
Contents 

Message From the Attorney General .............................................................. iii
 

National Medicolegal Review Panel .................................................................. v
 

Acknowledgments ............................................................................................ vii
 

Foreword: Commentaries on the Need for
 

Guidelines for Death Investigation ........................................................ xiii
 

Jeanne M. Adkins, Representative, State Legislature ........................... xiii
 

Joseph H. Davis, M.D., Professor of Pathology Emeritus
 

Jeffrey M. Jentzen, M.D., Medical Examiner......................................... xx
 

Mary Lou Kearns, R.N., M.P.H., Coroner .............................................xxi
 

Scott L. King, Chairman, NMRP, and Mayor ..................................... xxii
 

George H. Kuhler, Elected Coroner..................................................... xxii
 

Douglas A. Mack, M.D., M.P.H., Chief Medical
 

Examiner and Public Health Director ......................................... xxiii
 

Donald L. Mauro, Commanding Officer, Homicide Bureau .............. xxiii
 

Elaine R. Meisner, Coroner ................................................................. xxiv
 

Thomas J. O’Loughlin, Chief of Police................................................ xxv
 

John E. Smialek, M.D., Chief Medical Examiner ...............................xxvi
 

Richard T. Callery, M.D., F.C.A.P., Chief Medical Examiner ............... xiv
 

Mary E.S. Case, M.D., Chief Medical Examiner .................................. xiv
 

and Retired Director, Medical Examiner Department .................... xv
 

Halbert E. Fillinger, Jr., M.D., Forensic Pathologist and Coroner ........xvi
 

Bruce H. Hanley, Esq. ......................................................................... xvii
 

Randy Hanzlick, M.D., Centers for Disease Control and Prevention ...... xviii
 

Richard C. Harruff, M.D., Ph.D., Associate Medical Examiner ...........xix
 

ix
 
Introduction ........................................................................................................ 1
 

Medicolegal Death Investigation Guidelines .................................................. 11
 

Section A: Investigative Tools and Equipment ....................................... 13
 

Section B: Arriving at the Scene ............................................................. 15
 

1. Introduce and Identify Self and Role ........................................ 15
 

2. Exercise Scene Safety ............................................................... 16
 

3. Confirm or Pronounce Death .................................................... 17
 

4. Participate in Scene Briefing
 

(With Attending Agency Representatives) ............................. 18
 

5. Conduct Scene “Walk Through” ............................................... 19
 

6. Establish Chain of Custody ....................................................... 20
 

7. Follow Laws (Related to the Collection of Evidence) .............. 21
 

Section C: Documenting and Evaluating the Scene ............................... 23
 

1. Photograph Scene ..................................................................... 23
 

2. Develop Descriptive Documentation of the Scene ................... 24
 

3. Establish Probable Location of Injury or Illness....................... 25
 

4. Collect, Inventory, and Safeguard Property and Evidence........ 26
 

5. Interview Witness(es) at the Scene ........................................... 27
 

Section D: Documenting and Evaluating the Body ................................ 29
 

1. Photograph the Body ................................................................ 29
 

2. Conduct External Body Examination (Superficial) .................. 30
 

3. Preserve Evidence (on Body).................................................... 31
 

4. Establish Decedent Identification ............................................. 33
 

5. Document Post Mortem Changes ............................................. 33
 

6. Participate in Scene Debriefing................................................. 35
 

7. Determine Notification Procedures (Next of Kin) .................... 36
 

8. Ensure Security of Remains ...................................................... 37
 

x 
Section E: Establishing and Recording
 

Decedent Profile Information .......................................................... 39
 

1. Document the Discovery History .............................................. 39
 

2. Determine Terminal Episode History ....................................... 40
 

3. Document Decedent Medical History ....................................... 41
 

4. Document Decedent Mental Health History ............................. 42
 

5. Document Social History .......................................................... 43
 

Section F: Completing the Scene Investigation ...................................... 45
 

1. Maintain Jurisdiction Over the Body ........................................ 45
 

2. Release Jurisdiction of the Body............................................... 46
 

3. Perform Exit Procedures ........................................................... 47
 

4. Assist the Family ....................................................................... 48
 

xi 
Foreword: Commentaries on the Need for 

Guidelines for Death Investigation 

Commentary 

Jeanne M. Adkins 

Representative 

State Legislature, Colorado 

Few things in our democracy are as important as ensuring that 

citizens have confidence in their institutions in a crisis. For many 

individuals the death of a loved one is just such a crisis. Ensuring that 

the proper steps and procedures are taken at the scene of that death to 

reassure family members that the death was a natural one, a suicide, or 

a homicide is a key element in maintaining citizen confidence in local 

officials. 

How local death investigators do their job is crucial to family 

members who are mourning a loss today and who may be seeking justice 

tomorrow. Most of us cringe at the idea of death investigations where 

important steps were omitted that might have led to arrests and ultimately 

convictions in those deaths. Justice denied breeds contempt for the 

institutions created to ensure that justice is done. 

It is with such thoughts in mind that I encourage State legislators to 

focus some attention on this issue and look at adopting model legislation 

that establishes death investigation procedures and encourages all local 

jurisdictions to spend some resources training those on the front lines to 

follow those procedures. Success in this national effort depends on the 

initiative of State legislators to take the first steps by making this a 

priority. 

xiii
 
Commentary
 

Richard T. Callery, M.D., F.C.A.P. 

Chief Medical Examiner 

Director, Forensic Sciences Laboratory 

Wilmington, Delaware 

As the representative of the National Governors’Association, I am 

honored to have been chosen to participate in the National Medicolegal 

Review Panel. The hard work and commitment by the panel resulted in 

guidelines that are long overdue for setting the standard of practice for 

death investigation of “other than natural” cases. We are all acutely aware 

of the ramifications of our proposed national guidelines. Each death, 

especially those other than natural, has a profound impact on society, 

particularly the criminal justice system. Standardization nationwide is 

long overdue. This panel can take pride in producing a work product of 

such high quality that will assist in establishing a standard of practice for 

death investigation in the United States. 

Commentary 

Mary E. S. Case, M.D. 

Chief Medical Examiner 

St. Louis, St. Charles, Jefferson, and 

Franklin Counties, Missouri 

As the representative member from the American Medical Association serving on the National Medicolegal Review Panel, I have had the 

opportunity to observe and become familiar with the development of the 

Death Investigation: A Guide for the Scene Investigator. I am delighted 

with this effort and enthusiastically support and endorse the guidelines 

that have been developed. 

As a faculty member at St. Louis University Health Sciences Center 

in the Division of Forensic Pathology, I have been part of our Medicolegal Death Investigators Course since its inception in 1978. I am aware of 

xiv 
the tremendous importance of medicolegal death investigation in the 

proper administration of justice and criminal proceedings, adjudicating 

estates, and handling of death certification; and, unfortunately, I am 

aware of the all too common poor level at which some jurisdictions 

function in death investigation. 

One of the most certain methods of ensuring uniform and proper 

procedural compliance in death investigation is to establish guidelines 

that can be followed in every instance. A good example of the use of 

guidelines in death investigation is the death investigation of an infant, 

for which many jurisdictions have established a protocol for conducting 

the scene investigation. By definition, a diagnosis of Sudden Infant Death 

Syndrome (SIDS) can be made only after the scene investigation, autopsy, 

microscopic, toxicology, and medical history have been conducted, and all 

have been unrevealing as to a cause of death. 

The first step toward uniform excellence in death investigation is to 

establish guidelines that can be followed by even those jurisdictions 

having minimal resources. The efforts of the National Medicolegal Death 

Investigation Guidelines Project to create a structured protocol for the 

necessary tasks to be accomplished at death scenes have been highly 

successful in fulfilling that goal. 

Commentary 

Joseph H. Davis, M.D. 

Retired Director, Dade County 

Medical Examiner Department 

Professor of Pathology Emeritus, 

University of Miami 

The objectives of the American Academy of Forensic Sciences are 

enunciated in the Preamble of its Bylaws and include: “to improve the 

practice, elevate the standards and advance the cause of the forensic 

sciences . . . .” Death Investigation: A Guide for the Scene Investigator 

most certainly supports the objectives of the academy when sudden, 

xv 
unexpected, and violent deaths are investigated by forensic pathologists 

and other scientists. Sudden death investigation is multidisciplinary, with 

involvement of scientists representing all sections of the academy— 

pathology, odontology, criminalistics, toxicology, psychiatry, questioned 

documents, jurisprudence, and even engineering. None of these scientists 

can be truly effective if the death investigation is faulted by errors of 

omission or commission during the initial scene investigation. 

Eventually, the States of the Union will see the wisdom of uniform 

quality of standards and training for medicolegal death investigators. 

However, such standards are impossible unless consensus is reached as 

to what subjects should be taught and how investigators should be judged 

as to entry and performance in the field of death investigation. These 

guidelines are the first step for the eventual implementation of proper 

standards and training throughout the United States. 

Commentary 

Halbert E. Fillinger, Jr., M.D. 

Forensic Pathologist 

Coroner 

Montgomery County, Pennsylvania 

I have been honored to represent the International Association of 

Coroners and Medical Examiners on the National Medicolegal Review 

Panel. The end product of the efforts of this panel in developing universal 

guidelines for death-scene investigation fills a long-vacant gap in the 

training and investigation of sudden, suspicious death. 

It has been apparent to me in my 40 years of experience as a 

forensic pathologist, assistant medical examiner and coroner, as well as 

death-scene investigation trainer, that systematic, specific guidelines are 

essential to good death-scene investigation. The guidelines promulgated 

by the National Medicolegal Review Panel fill a need that has long been 

recognized by most of our colleagues in the field, and this can only 

greatly enhance and improve the quality of our work. 

xvi 
With many of the deaths today having more and more civil as well 

as criminal implications, top-quality death-scene investigation becomes a 

must in any jurisdiction, and I feel that the product of the National 

Medicolegal Review Panel will fill this need. 

I am incorporating the guidelines developed thus far in the mandatory training program for the Commonwealth of Pennsylvania as directed 

by the Attorney General’s Office, and find that the guidelines are well 

structured and comprehensive, yet simple to follow. One can systematically start with an experienced investigator or a very inexperienced one 

and, by following these guidelines, a competent quality death-scene 

investigation can be carried out. 

Without the efforts of the National Medicolegal Review Panel, no 

systematic, universal, top-quality investigation can be expected with the 

diverse backgrounds of the coroners and medical examiners in the United 

States. 

Commentary 

Bruce H. Hanley, Esq. 

Partner, Hanley & Dejoras, P.A. 

Minneapolis, Minnesota 

The development of Death Investigation: A Guide for the Scene 

Investigator will be of great benefit to all citizens. The guidelines will 

help to promote consistency, accuracy, predictability, and reliability in 

death-scene investigations. As a criminal defense lawyer, it is a chief 

concern that a person is not wrongfully accused of having participated in 

a homicide. Complete, thorough, and careful death-scene investigations 

can lead to greater faith in the system by family and friends of those 

whose deaths may have been caused by homicide, suicide, accident, or 

natural causes. Elimination of unanswered questions, confusion, sloppiness, and the lack of attention to detail all can contribute to the genuine 

acceptance that the cause of death has been properly determined. Moreover, in the case of homicide, all can have a strong belief in the accuracy 

xvii 
of the identification of the perpetrator. The guidelines will assist the 

actual investigators in following the proper protocol and consistently 

obtaining all available evidence to show that the death was the result of 

either unlawful or lawful activity. Proper adherence to the guidelines, 

coupled with proper training to implement the guidelines, will serve to 

satisfy finders of fact in criminal cases that the State has presented 

accurate, reliable, and trustworthy evidence. Additionally, it will serve to 

defuse attacks by defense counsel on the investigative methods and 

techniques, chain of custody, and the reliability of any testing that may 

have been conducted during the course of the investigation. It may also 

serve to prevent innocent people from being accused of criminal activity 

when, in fact, a crime was not committed, or the person suspected was 

not involved. The truth is the outcome sought, and the guidelines will 

assist the system in obtaining the truth. In a criminal investigation, when 

the government follows the rules and properly conducts its investigation, 

it will win most of the time. When it does not follow the rules or properly 

conduct its investigation, it should lose. 

Commentary 

Randy Hanzlick, M.D. 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Variations in statutes, levels of funding, geography and population 

density, and death investigator education, training, and experience result 

in variations in the quality and extent of medicolegal death investigations. 

Front-line, on-scene death investigations are performed by people whose 

jobs range from part-time to full-time, and whose education, training, 

and experience vary substantially and range from minimal to extensive. 

The outcome of death investigations may impact personal liberty and 

well-being, adjudication of cases, public health and safety, mortality 

statistics, research capabilities, and governmental approaches to legislation and programs. Therefore, high-quality death investigation throughout the United States is a desirable goal for many reasons. 

xviii 
The creation of guidelines for medicolegal death investigations is 

one method of promoting uniformity in the approach to death investigations 

and improving or assuring their quality at the same time. Guidelines may 

also be used as a basis for developing educational programs, to evaluate 

work performance, and as a basis for credentialing or certification of 

death investigators. To those ends, the National Medicolegal Review 

Panel has taken an important step by developing this initial set of death 

investigation guidelines as a model for nationwide use, pursuant to a 

grant funded by the National Institute of Justice and the Centers for 

Disease Control and Prevention. 

The development of such guidelines will not be enough in and of 

themselves, however. The best intended and designed guidelines will 

have little effect if death investigators are not provided with funds 

adequate to meet the provisions of the guidelines. Funding for the 

education and training of death investigation practices and for the 

implementation of the guidelines will be necessary, and funding needs 

pose a significant obstacle to the long-term goal of nationwide improvement in death investigation practices. Governments at every level of 

organization will need to explore methods for acquiring or providing 

funds and providing the education, training, and manpower to effectively 

implement these and any subsequent guidelines. In the meantime, these 

guidelines provide a starting point from which we can proceed. 

Commentary 

Richard C. Harruff, M.D., Ph.D. 

Associate Medical Examiner 

Seattle/King County 

Department of Public Health 

Seattle, Washington 

A competent and thorough death-scene investigation provides the 

basis for a comprehensive medicolegal autopsy, and together the scene 

investigation and autopsy provide the basis for an accurate determination 

of cause and manner of death. Furthermore, following specific guidelines 

xix 
helps assure that all relevant aspects of all deaths are fully investigated. 

Representing the National Association of Medical Examiners on the 

National Medicolegal Review Panel, I believe that the national guidelines 

for death-scene investigation offer medical examiners and coroners a 

valuable means for substantially enhancing performance in fulfilling their 

far-ranging responsibilities. As the guidelines have been formulated with 

the consensus of several prominent forensic and legal experts, they 

represent a major advancement in scientific death investigation and 

deserve the attention of all who claim competency in this field. 

Commentary 

Jeffrey M. Jentzen, M.D. 

Medical Examiner 

Milwaukee County, Wisconsin 

As a member of the Forensic Pathology Committee of the College 

of American Pathologists, I would like to encourage my colleagues to 

consider the impact that national guidelines would have on the investigation of sudden and unexpected deaths. Most pathologists assist law 

enforcement officials in medicolegal death investigations during their 

careers in some form or another. We are aware that an investigation 

requires the proper coordination of a number of agencies and that the 

breakdown of the investigative procedures may jeopardize the successful 

outcome of the case. Death Investigation: A Guide for the Scene Investigator provides procedures for uniform death-scene processing, which 

ensures competent and complete examination of the death scene in a 

judicious manner that also respects the concerns of the family and loved 

ones. The guidelines set forth in this document have been developed by 

a diverse panel of professional death investigators who understand the 

common pitfalls of everyday medicolegal death investigation. Medicolegal death investigation has become a sophisticated process subject to 

critical review and high expectations of the community, the legal system, 

and family members. These guidelines provide the essential tasks for 

death-scene investigation and go a long way toward ensuring quality 

death-scene investigations. 

xx 
 

Commentary
 

Mary Lou Kearns, R.N., M.P.H. 

Coroner 

Kane County, Illinois 

Historically, the Office of Coroner has been charged with the 

responsibilities and duties of answering pertinent questions related to 

death investigation: Who, What, When, Where, How, and Why. Only 

when these questions have been answered correctly can all the proper 

legal issues that arise at death be handled expertly and completely for 

the administration of justice. As the representative of the coroners of 

America on the NIJ Peer Review Panel, I applaud the efforts that have 

produced Death Investigation: A Guide for the Scene Investigator. These 

guidelines provide the necessary policies and procedures for universal 

and professional death-scene investigations, as well as the criteria for 

when to be suspicious. And by having properly coordinated death-scene 

investigative procedures, the community, the legal system, and family 

members will be well served. 

I have long been committed to this quest for universal guidelines 

and the eventual training of death investigators nationwide. Coroners 

who are well trained in their jobs make fewer mistakes. The more 

training and confidence coroners have, the better our offices will run. 

An ideal coroner’s office is well prepared to investigate and evaluate a 

scene, to examine a body, to write quality reports, and to interact with 

the family, all in a professional manner. These national guidelines for 

death-scene investigations will go a long way toward enhancing our 

professionalism. 

xxi 
Commentary 

Mayor Scott L. King, Chairman, NMRP 

Mayor 

Gary, Indiana 

As the representative of the United States Conference of Mayors, 

I was pleased to serve as Chairman of the National Medicolegal Review 

Panel, particularly given the expertise and wide range of diverse experience of the balance of the panel. Because the duties of a mayor include 

responsibility for public safety functions, and because I served for 20 

years as both a prosecution and defense attorney before assuming my 

present office, I am acutely aware of the importance of establishing and 

utilizing appropriate protocol for death-scene investigations. These 

guidelines will, I hope, accomplish the goal of uniformity in the conduct 

of such investigations nationwide without requiring significant additional 

expenditure of budget funds. 

Commentary 

George H. Kuhler 

Elected Coroner 

Beadle County, South Dakota 

I would like to encourage all elected coroners to consider supporting national guidelines for coroner investigations. As a funeral director 

and elected coroner, I know firsthand how important proper investigation 

is to the law enforcement community, as well as to the forensic medical/ 

legal investigation of the death. With no “official training” required for 

elected coroners, it is difficult for the elected coroner to know what 

should be done in investigations. Most elected coroners have begun their 

jobs with little or no knowledge as to how and what they need to do. 

Having a set of national guidelines for medicolegal death investigation 

would ensure that at least the elected coroner would have a “cookbook” 

to follow and would have some idea of what is expected of him/her in 

every case. 

xxii 
I would encourage the adoption and use of the following guidelines 

for all coroners, medical examiners, and death investigators. These 

guidelines have been developed by a panel of members from all of these 

fields from across the United States. The use of these guidelines on every 

scene will ensure quality and uniform death investigation every time. 

Commentary 

Douglas A. Mack, M.D., M.P.H. 

Chief Medical Examiner and 

Public Health Director 

Kent County, Michigan 

As a representative of the National Association of Counties and as 

Chief Medical Examiner for Kent County, Michigan, I enthusiastically 

endorse the medicolegal guidelines developed by the National Medicolegal Review Panel for death-scene investigation and medical examiner 

system processes. An efficient, well-managed, and high-quality medical 

examiner system is a critical element in death investigation and benefits 

the law enforcement, criminal justice, and public health systems. This 

protocol provides direction for the interaction of these systems, and helps 

assure that the work of those involved results in high-quality investigations and outcomes. 

Commentary 

Donald L. Mauro 

Commanding Officer, Homicide Bureau
 

Los Angeles County Sheriff’s Department
 

Los Angeles, California
 

As a representative of the National Sheriffs’Association, I have 

been honored to participate with the very capable and diverse group that 

comprises the National Medicolegal Review Panel. The results of our 

efforts are the national guidelines, which will direct the efforts of fellow 

death investigators in “other than natural” death investigations. The 

xxiii 
procedures developed by the panel constitute a baseline protocol that 

should serve to support and direct the efforts of all of us who work in this 

field. Because each death has profound implications for family and 

friends, and because each investigation ultimately has financial, legal, 

and societal implications, we can take satisfaction in knowing that 

standards now exist for death investigators across the country, which, 

when followed, will yield comprehensive, high-quality death-scene 

investigations. 

Commentary 

Elaine R. Meisner 

Logan County Coroner 

Sterling, Colorado 

As a member of the Colorado Coroners’ Association, it is with a 

great deal of pride and sense of accomplishment that I have been their 

representative on the National Medicolegal Review Panel for death 

investigation guidelines. In the rural areas, the importance and necessity 

of thorough and proper death investigations have not always been 

thought of as an area of much importance, not so much by the agencies 

doing the investigations, but by the agencies who financially support 

them. As a lifelong resident of a rural community, I value and appreciate 

the importance and need of a thorough and proper death investigation. 

These guidelines have been long awaited by many death investigators 

across the country. The National Medicolegal Review Panel has worked 

hard to develop a sound, well-described set of death investigation guidelines. Today, the modern range of knowledge is much greater, techniques 

are precise and specialized. These methodically well-planned guidelines 

were much needed to ensure and maintain uniformity and to help decrease chance for error. This has been a unique experience with the 

display of utmost professionalism and collaboration by committee 

members. Without the unstinting cooperation and help of all concerned, 

it would have been impossible to finish this project. It is in the best 

interests of death investigators nationwide to utilize these appropriately 

developed guidelines for the purpose of improving death investigations 

and for other agencies to properly support them. 

xxiv 
Commentary 

Thomas J. O’Loughlin 

Chief of Police 

Wellesley, Massachusetts 

The proposed Death Investigation: A Guide for the Scene Investigator has been developed with the input of members of the various and 

many disciplines that are involved in the investigation of sudden and 

unexpected deaths. 

The investigation of the death of another human being is a weighty 

responsibility. It has been a pleasure to represent and serve the interests 

of the International Association of Chiefs of Police in participating 

in the development of Death Investigation: A Guide for the Scene 

Investigator. 

As a police officer and chief of police, I am well aware of the 

multifaceted and multidisciplinary approach that is necessary in many of 

these investigations. As professionals, we are all aware of investigations 

that have been met with professional success and those that have been, 

unfortunately, less than professional. 

As important as the actual performance of the investigative procedures is an understanding of the diverse and mutual responsibilities held 

by involved and participating professionals. Death Investigation: A Guide 

for the Scene Investigator will provide standardized procedures so that 

each and every participant in the death-scene investigation will have a 

clear and concise understanding of the professionally accepted standards 

and procedures necessary in conducting a death-scene investigation. 

In the long term, it is the expected goal that each of the participants 

within the death investigation process will meet these established professional standards and their obligation to fulfill their responsibilities in a 

competent and professional manner. 

xxv 
Commentary 

John E. Smialek, M.D. 

Chief Medical Examiner 

State of Maryland 

A major step in the advancement of the American system of justice 

was taken recently with the recognition of standard guidelines for scene 

investigation in medical examiner and coroner cases. 

Awareness of inadequate death investigation operations in jurisdictions around the country resulted in a project supported by the National 

Institute of Justice that has produced the new guidelines. 

The panel of experts assembled by NIJ considered the need for 

standards that were comprehensive but flexible and capable of being 

adapted to operations that utilize a variety of investigative officials 

including police officers, sheriffs, justices of the peace, physicians, and 

pathologists. 

Further progress in achieving a system of death investigation that 

meets the needs of law enforcement agencies and families will depend 

on the willingness of State and local government officials to support the 

introduction of these guidelines and provide the necessary resources to 

implement them. 

As a representative of the National Association of Medical Examiners, I strongly urge the careful study and acceptance of these standards. 

xxvi 
Introduction 

“Is it [death investigation] an enlightened system? No, it’s not. It’s 

really no better than what they have in many Third World countries.” 

Dr. Werner Spitz, Former Chief Medical Examiner, 

Wayne County (Detroit), Michigan 

The first thing one must realize is that the word “system” is a 

misnomer, when used in the context of death investigation in the 

United States. There is no “system” of death investigation that covers the 

more than 3,000 jurisdictions in this country.1

 No nationally accepted 

guidelines or standards of practice exist for individuals responsible for 

performing death-scene investigations. No professional degree, license, 

certification, or minimum educational requirements exist, nor is there a 

commonly accepted training curriculum. Not even a common job title 

exists for the thousands of people who routinely perform death investigations in this country.2, 3 

This report describes a study that focused on the establishment of 

guidelines for conducting death investigations. 

Purpose and Scope of the Study 

The principal purpose of the study, initiated in June 1996, was to 

identify, delineate, and assemble a set of investigative tasks that should 

and could be performed at every death scene. These tasks would serve as 

the foundation of the guide for death scene investigators. The Director of 

the National Institute of Justice (NIJ) selected an independent review 

panel whose members represented international and national organizations whose constituents are responsible for the investigation of death 

and its outcomes. The researcher organized two multidisciplinary technical working groups (TWGs). The first consisted of members representing 

the investigative community at large, and the second consisted of an 

executive board representing the investigative community at large. 

1
 
The study involved the use of two standardized consensus-seeking 

research techniques: (a) the Developing A CurriculUM (DACUM)4 

process, and (b) a Delphi5 survey. 

In this report, the author does not attempt to assign responsibility 

for task (guideline) performance to any one occupational job title (e.g., 

Guideline D4 is performed by law enforcement personnel). Research 

design and selected methodology focused on the establishment of 

performance guidelines for death-scene investigations. The research 

design did not allow TWGs to assume investigative outcomes during the 

development phase of the project; therefore, no attempt was made to 

assign a “manner” of death to individual guidelines (e.g., Guideline C2 

applies to homicide scenes), to maintain objectivity and national practicality. 

The author does not claim to be an expert in the science and/or 

methodology of medicolegal death investigation. This research was based 

on the collective knowledge of three multidisciplinary content area expert 

groups. The focus was on the death scene, the body, and the interactive 

skills and knowledge that must be applied to ensure a successful case 

outcome. 

The balance of this introduction outlines the study design and 

provides basic background information on the selection of the National 

Medicolegal Review Panel (NMRP) and TWG memberships and the 

research methodology, its selection, and application. The study findings 

(investigative guidelines) follow this introduction. 

Study Design 

Identification of NMRP and TWGs 

The methodology selected for this occupational research required 

collection of data from a sample of current subject matter experts, 

practitioners from the field who perform daily within the occupation 

being investigated. This “criterion” was used to identify members of the 

various multidisciplinary groups that provided the data for this research. 

2 
The following groups were formed for the purpose of developing national 

guidelines for conducting death investigations. 

National Medicolegal Review Panel 

NMRP members represent an independent multidisciplinary group 

of both international and national organizations whose constituents are 

responsible for investigating death and its outcomes. Each member of 

NMRP was selected by the Director based on nominations made by the 

various associations. The rationale for their involvement was twofold: 

(a) they represent the diversity of the profession nationally, and (b) their 

members are the key stakeholders in the outcomes of this research. Each 

organization has a role in conducting death investigations and in implementing these guidelines. 

Technical Working Group for 

Death Investigation (TWGDI) 

1. National Reviewer Network 

Technical Working Group for Death Investigation (TWGDI) members represent a sample of death investigators from across the country. 

They are the content area experts who perform within the occupation 

daily. The following criteria were used to select the members of the 

TWGDI reviewer network: 

◆	 Each member was nominated/selected for the position by a person 

whose name appeared on the most recent (1995) Centers for Disease 

Control and Prevention (CDC) national database of death investigation.6 

◆	 Each member had specific knowledge regarding the investigation of 

death. 

◆	 Each member had specific experience with the process of death 

investigation and the outcomes of positive and negative scene 

investigations. 

◆	 Each member could commit to four rounds of national surveying 

over a 6-month period. 

3 
A 50-percent random sample (1,512) of death investigators was 

drawn from the Centers for Disease Control and Prevention database.7 

A letter was sent to each member of the sample, inviting him or her to 

participate in the national research to develop death investigative guidelines or to nominate a person who participates in death investigations. 

Two hundred and sixty-three individuals were nominated (17 percent). 

Nominees were contacted by mail and asked to provide personal demographic data including job title, years of experience, and educational 

background, in addition to general information (name/address, etc.) 

necessary for participation in the research. 

Region 1 

Northeast 

Region 2 

Southeast 

Region 3 

Midwest 

Region 4 

Southwest 

Region 5 

West 

The TWGDI national reviewer network consisted of 263 members 

from 46 States, representing 5 regions as follows: 

Region Location Number of Participants Percentage 

1 

2 

3 

4 

5 

Northeast 

Southeast 

Midwest 

Southwest 

West 

32 

56 

94 

47 

34 

12.2% 

21.3% 

35.7% 

17.9% 

12.9% 

4 
The educational backgrounds of the national reviewer network 

members were as follows: 

Education Number Percentage 

Law Enforcement 82 31.2% 

Medical 157 59.8% 

Unknown 24 9.0% 

The types of investigative systems represented on the reviewer 

network were as follows: 

System Number Percentage 

Medical Examiner 44 16.6% 

Coroner 161 61.3% 

Mixed ME/Coroner 58 22.1% 

The average age of TWGDI members was 47.6 years. They had an 

average of 10.5 years of experience. There were 80.6 percent (212) males 

and 19.4 percent (51) females in the group. 

2. Executive Board 

Representatives from each region were selected to maintain consistency within regions across the United States. These representatives made 

up the TWGDI executive board. 

Criteria for selection to the TWGDI executive board were as follows: 

◆	 Each member had specific knowledge regarding the investigation 

of death. 

◆	 Each member had specific experience with the process of death 

investigation and the outcomes of positive and negative scene 

investigations. 

◆	 Each member could commit to attend four workshops held within the 

grant period. 

5 
TWGDI Executive Board DACUM Workshop. In November 

1996, the TWGDI executive board met in St. Louis to begin developing 

the national Delphi survey. The survey content was to reflect “best 

practice” for death-scene investigation. DACUM is a process for analyzing an occupation systematically. The 2-day workshop used the investigative experts on the executive board to analyze job tasks while employing 

modified brainstorming techniques. The board’s efforts resulted in a 

DACUM chart that describes the investigative occupation in terms of 

specific tasks that competent investigators must be able to perform 

“every scene, every time.”8 A task was defined as a unit of observable 

work with a specific beginning and ending point that leads to an investigative product, service, or decision. The DACUM chart served as the 

outline for the Delphi survey. 

This initial process resulted in six major areas of work. In attempts 

to simplify the survey for the members of the national reviewer network, 

the areas of work were placed into a logical sequence of events (as they 

might be performed while investigating a case). Within the five major 

areas of work (Investigative Tools and Equipment was excluded at this 

point because tools and equipment are “things,” not procedural steps), 

29 tasks were identified. Within the 29 identified investigative tasks 

were 149 discrete steps and/or elements. Theoretically, each step and/or 

element must be performed for the task to be completed “successfully.” 

The results were placed in survey format for NMRP review and pilot 

testing. 

National Medicolegal Review Panel Meeting. In December 1996, 

NMRP met in Washington, D.C., to review the DACUM chart and 

comment on the research methodology proposed by the researcher. The 

members of the panel recommended modifications to the survey design 

and approved response selections. Respondents would attempt to rate, by 

perceived importance, each of the investigative tasks/steps and/or elements on a five-point scale. 

The Delphi Survey. The Delphi technique, although it employs 

questionnaires, is much different from the typical questionnaire survey. 

Developed by the RAND Corporation as a method of predicting future 

6 
defense needs, the technique is used whenever a consensus is needed 

from persons who are knowledgeable about a particular subject.9

 The 

goal of a Delphi survey is to engage the respondents in an anonymous 

debate in order to arrive at consensus on particular issues or on predictions of future events. 

The Delphi requires at least four rounds in an effort to obtain a 

well-thought-out consensus. After the first-round results were received, 

coded, and recorded, a revised questionnaire was developed for round 

two. The second-round survey provided each member of TWGDI with 

the national median and mean scores for each of the task statements 

presented, as well as their first-round responses. Respondents were asked 

to compare their original ratings with the median and mean scores and to 

revise their original evaluations as they saw fit. This procedure was 

repeated for each of the four rounds of the survey. 

The Delphi survey was conducted during the first 6 months of 1997. 

The table below provides general TWGDI response data: 

Round Surveys 

Sent 

Surveys 

Received 

Cumulative Respondent 

Loss (%) 

1 263 199 24.3% 

2 199 163 13.72% 

3 163 149 5.33% 

4 149 146 1.14% 

As shown in the preceding table, final membership in the TWGDI 

national reviewer network was 146. This number represents approximately 56 percent of the originally nominated members. 

Guideline Development. During the 6 months of the Delphi 

process, both the TWGDI executive board and NMRP met to review 

survey data (to date) and to begin the process of moving task-based data 

into guideline format. 

7 
In May 1997, the executive board met for a 21

/2-day working 

session in New Orleans to begin the guideline development process. 

The consensus of the board was to establish 29 guidelines based on the 

national reviewer network data and present them to NMRP for review. 

Each guideline would have the following content: 

◆	 A statement of principle, citing the rationale for performing the guideline. 

◆	 A statement of authorization, citing specific policy empowering the 

investigator. 

◆	 A statement of policy to the investigator regarding guideline performance. 

◆	 The procedure for performing the guideline. 

◆	 A statement of summary, citing justification for performing the 

procedures. 

In June and July 1997, NMRP met for two 11

/2-day working 

sessions in St. Louis and Chicago to review the draft guidelines developed by the executive board and offer recommendations and changes 

based on jurisdictional variances and organizational responsibilities. 

Those sessions resulted in the final draft of the 29 guidelines for 

conducting death investigations. The 29 guidelines are presented in 

the next main section. 

Guideline Status 

Currently, NMRP members are presenting the guidelines to their 

respective organizations’ leadership (or appropriate internal committees) 

for review. This researcher is collecting anecdotal comments for future 

modification of the existing guidelines during the validation procedures. 

8 
Training Guidelines
 

The purpose of the second part of the national death investigator 

guidelines research was to identify training criteria for each of the 

29 guidelines. This research is now completed. For each of the 

guidelines presented in this report, “minimum levels of performance” 

will be developed and verified by the members of the various TWGs. 

These “training guidelines” will provide both individuals and educational 

organizations the material needed to establish and maintain valid exit 

outcomes for each investigative trainee. 

Guideline Validation 

In this initial research, 29 investigative tasks were identified. Each 

task was developed into a guideline for investigators to follow while 

conducting a death investigation. Although each TWG believed in the 

validity of each guideline, no attempt was made to validate actual 

significance (e.g., if guideline C1 is trained and implemented, a [%] 

decrease in poor scene photographs should occur). The researcher is 

currently developing a national validation strategy for the implementation and validation of each guideline. 

Notes 

1.	 “It is important to note that even the use of the word ‘system’ to 

describe a process that encompasses more than 3,000 individual 

jurisdictions is a misnomer.” Hansen, M., “Body of Evidence,” 

American Bar Association Journal (June 1995). 

2.	 Jentzen, J.M., S.C. Clark, and M.F. Ernst, “Medicolegal Death 

Investigator Pre-Employment Test Development,” American Journal 

of Forensic Medicine and Pathology 17 (1996):112–16. 

3.	 Hanzlick, R., “Coroner Training Needs: A Numeric and Geographic 

Analysis,” Journal of the American Medical Association 276 

(1996):1775–1778. 

9 
4.	 The Ohio State University, Center on Education and Training for 

Employment, DACUM, 1996. 

5.	 Borg, W.R., and M.D. Gall, Educational Research: An Introduction, 

New York: Longman Inc., 1983:413–415. 

6.	 Combs, D., R.G. Parrish, and R.T. Ing, Death Investigation in the 

United States and Canada, Atlanta: U.S. Department of Health and 

Human Services, Public Health Service, Centers for Disease Control 

and Prevention, 1995. 

7.	 Ibid. 

8.	 Clark, S.C., Occupational Research and Assessment, Inc., Big 

Rapids, Michigan, 1996. 

9.	 Borg and Gall, 413–415. 

10 
Medicolegal Death Investigation Guidelines 

Section A
 

Section B
 

Section C
 

Section D
 

Section E
 

Section F
 

Investigative Tools 

and Equipment 

Arriving at the Scene 

Documenting and 

Evaluating the Scene 

Documenting and 

Evaluating the Body 

Establishing and Recording 

Decedent Profile Information 

Completing the 

Scene Investigation 

11
 
Investigative Tools and Equipment 

1.	 Gloves (Universal Precautions). 

2.	 Writing implements (pens, pencils, markers). 

3.	 Body bags. 

4.	 Communication equipment (cell phone, pager, radio). 

5.	 Flashlight. 

6.	 Body ID tags. 

7.	 Camera—35mm (with extra batteries, film, etc.). 

8.	 Investigative notebook (for scene notes, etc.). 

9.	 Measurement instruments (tape measure, ruler, 

rolling measuring tape, etc.). 

10. Official identification (for yourself). 

11. Watch. 

12. Paper bags (for hands, feet, etc.). 

13. Specimen containers (for evidence items and toxicology specimens). 

14. Disinfectant (Universal Precautions). 

15. Departmental scene forms. 

16. Camera—Polaroid (with extra film). 

17. Blood collection tubes (syringes and needles). 

18. Inventory lists (clothes, drugs, etc.). 

19. Paper envelopes. 

20. Clean white linen sheet (stored in plastic bag). 

21. Evidence tape. 

22. Business cards/office cards w/phone numbers. 

23. Foul-weather gear (raincoat, umbrella, etc.). 

24. Medical equipment kit (scissors, forceps, tweezers, exposure suit, 

scalpel handle, blades, disposable syringe, large gauge needles, 

cotton-tipped swabs, etc.). 

25. Phone listing (important phone numbers). 

26. Tape or rubber bands. 

27. Disposable (paper) jumpsuits, hair covers, face shield, etc. 

28. Evidence seal (use with body bags/locks). 

A 

13
 
29. Pocketknife. 

30. Shoe-covers. 

31. Trace evidence kit (tape, etc.). 

32. Waterless hand wash. 

33. Thermometer. 

34. Crime scene tape. 

35. First aid kit. 

36. Latent print kit. 

37. Local maps. 

38. Plastic trash bags. 

39. Gunshot residue analysis kits (SEM/EDS). 

40. Photo placards (signage to ID case in photo). 

41. Boots (for wet conditions, construction sites, etc.). 

42. Hand lens (magnifying glass). 

43. Portable electric area lighting. 

44. Barrier sheeting (to shield body/area from public view). 

45. Purification mask (disposable). 

46. Reflective vest. 

47. Tape recorder. 

48. Basic handtools (boltcutter, screwdrivers, hammer, 

shovel, trowel, paintbrushes, etc.). 

49. Body bag locks (to secure body inside bag). 

50. Camera—Video (with extra battery). 

51. Personal comfort supplies (insect spray, sun screen, hat, etc.). 

52. Presumptive blood test kit. 

This handbook is intended as a guide to recommended 

practices for the investigation of death scenes. Jurisdictional, logistical, or legal conditions may preclude 

the use of particular procedures contained herein. 

14 
Arriving at the Scene 

1.	 Introduce and Identify Self and Role 

Principle:	 Introductions at the scene allow the investigator to 

establish formal contact with other official agency 

representatives. The investigator must identify the first 

responder to ascertain if any artifacts or contamination 

may have been introduced to the death scene. The 

investigator must work with all key people to ensure 

scene safety prior to his/her entrance into the scene. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall take the initiative to introduce 

himself or herself, identify essential personnel, establish 

rapport, and determine scene safety. 

Procedure:	 Upon arrival at the scene, and prior to entering the scene, 

the investigator should: 

A.	 Identify the lead investigator at the scene and present identification. 

B.	 Identify other essential officials at the scene (e.g., law enforcement, fire, EMS, social/child protective services, etc.) and explain 

the investigator’s role in the investigation. 

C.	 Identify and document the identity of the first essential official(s) 

to the scene (first “professional” arrival at the scene for investigative followup) to ascertain if any artifacts or contamination may 

have been introduced to the death scene. 

D.	 Determine the scene safety (prior to entry). 

B 

15
 
1. Introduce and Identify Self and Role 

Summary: 

Introductions at the scene help to establish a collaborative investigative effort. It is essential to carry identification in the event of questioned 

authority. It is essential to establish scene safety prior to entry. 

2.	 Exercise Scene Safety 

Principle:	 Determining scene safety for all investigative personnel 

is essential to the investigative process. The risk of 

environmental and physical injury must be removed 

prior to initiating a scene investigation. Risks can include 

hostile crowds, collapsing structures, traffic, and environmental and chemical threats. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall attempt to establish scene safety 

prior to entering the scene to prevent injury or loss of 

life, including contacting appropriate agencies for 

assistance with other scene safety issues. 

Procedure:	 Upon arrival at the scene, the investigator should: 

A.	 Assess and/or establish physical boundaries. 

B.	 Identify incident command. 

C.	 Secure vehicle and park as safely as possible. 

D.	 Use personal protective safety devices (physical, biochemical
 

safety).
 

E.	 Arrange for removal of animals or secure (if present and possible). 

F.	 Obtain clearance/authorization to enter scene from the individual 

responsible for scene safety (e.g., fire marshal, disaster coordinator). 

16 
G.	 While exercising scene safety, protect the integrity of the scene 

and evidence to the extent possible from contamination or loss by 

people, animals, and elements. 

Note:	 Due to potential scene hazards (e.g., crowd control, 

collapsing structures, poisonous gases, traffic), the body 

may have to be removed before scene investigation can 

be continued. 

Summary: 

Environmental and physical threats to the investigator must be 

removed in order to conduct a scene investigation safely. Protective 

devices must be used by investigative staff to prevent injury. The investigator must endeavor to protect the evidence against contamination or loss. 

3.	 Confirm or Pronounce Death 

Principle:	 Appropriate personnel must make a determination of 

death prior to the initiation of the death investigation. 

The confirmation or pronouncement of death determines 

jurisdictional responsibilities. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall ensure that appropriate personnel 

have viewed the body and that death has been confirmed. 

Procedure:	 Upon arrival at the scene, the investigator should: 

A.	 Locate and view the body. 

B.	 Check for pulse, respiration, and reflexes, as appropriate. 

C.	 Identify and document the individual who made the official determination of death, including the date and time of determination. 

D.	 Ensure death is pronounced, as required. 

17 
3. Confirm or Pronounce Death 

Summary: 

Once death has been determined, rescue/resuscitative efforts cease 

and medicolegal jurisdiction can be established. It is vital that this occur 

prior to the medical examiner/coroner’s assuming any responsibilities. 

4.	 Participate in Scene Briefing (With 

Attending Agency Representatives) 

Principle:	 Scene investigators must recognize the varying jurisdictional and statutory responsibilities that apply to individual agency representatives (e.g., law enforcement, 

fire, EMT, judicial/legal). Determining each agency’s 

investigative responsibility at the scene is essential in 

planning the scope and depth of each scene investigation 

and the release of information to the public. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall identify specific responsibilities, 

share appropriate preliminary information, and establish 

investigative goals of each agency present at the scene. 

Procedure:	 When participating in scene briefing, the investigator 

should: 

A.	 Locate the staging area (entry point to scene, command post, etc.). 

B.	 Document the scene location (address, mile marker, building 

name) consistent with other agencies. 

C.	 Determine nature and scope of investigation by obtaining preliminary 

investigative details (e.g., suspicious versus nonsuspicious death). 

D.	 Ensure that initial accounts of incident are obtained from the first 

witness(es). 

18 
Summary: 

Scene briefing allows for initial and factual information exchange. 

This includes scene location, time factors, initial witness information, 

agency responsibilities, and investigative strategy. 

5.	 Conduct Scene “Walk Through” 

Principle:	 Conducting a scene “walk through” provides the investigator with an overview of the entire scene. The “walk 

through” provides the investigator with the first opportunity to locate and view the body, identify valuable and/or 

fragile evidence, and determine initial investigative 

procedures providing for a systematic examination and 

documentation of the scene and body. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall conduct a scene “walk through” to 

establish pertinent scene parameters. 

Procedure:	 Upon arrival at the scene, the investigator should: 

A.	 Reassess scene boundaries and adjust as appropriate. 

B.	 Establish a path of entry and exit. 

C.	 Identify visible physical and fragile evidence. 

D.	 Document and photograph fragile evidence immediately and
 

collect if appropriate.
 

E.	 Locate and view the decedent. 

Summary: 

The initial scene “walk through” is essential to minimize scene 

disturbance and to prevent the loss and/or contamination of physical and 

fragile evidence. 

19 
6. Establish Chain of Custody
 

Principle:	 Ensuring the integrity of the evidence by establishing and 

maintaining a chain of custody is vital to an investigation. 

This will safeguard against subsequent allegations of 

tampering, theft, planting, and contamination of evidence. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 Prior to the removal of any evidence, the custodian(s) of 

evidence shall be designated and shall generate and 

maintain a chain of custody for all evidence collected. 

Procedure:	 Throughout the investigation, those responsible for 

preserving the chain of custody should: 

A.	 Document location of the scene and time of arrival of the death 

investigator at the scene. 

B.	 Determine custodian(s) of evidence, determine which agency(ies) 

is/are responsible for collection of specific types of evidence, and 

determine evidence collection priority for fragile/fleeting evidence. 

C.	 Identify, secure, and preserve evidence with proper containers, 

labels, and preservatives. 

D.	 Document the collection of evidence by recording its location at 

the scene, time of collection, and time and location of disposition. 

E.	 Develop personnel lists, witness lists, and documentation of times 

of arrival and departure of personnel. 

Summary: 

It is essential to maintain a proper chain of custody for evidence. 

Through proper documentation, collection, and preservation, the integrity 

of the evidence can be assured. A properly maintained chain of custody 

and prompt transfer will reduce the likelihood of a challenge to the 

integrity of the evidence. 

20 
7.	 Follow Laws (Related to the 

Collection of Evidence) 

Principle:	 The investigator must follow local, State, and Federal 

laws for the collection of evidence to ensure its admissibility. The investigator must work with law enforcement 

and the legal authorities to determine laws regarding 

collection of evidence. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator working with other agencies must 

identify and work under appropriate legal authority. 

Modification of informal procedures may be necessary 

but laws must always be followed. 

Procedure:	 The investigator, prior to or upon arrival at the death 

scene, should work with other agencies to: 

A.	 Determine the need for a search warrant (discuss with appropriate 

agencies). 

B.	 Identify local, State, Federal, and international laws (discuss with 

appropriate agencies). 

C.	 Identify medical examiner/coroner statutes and/or office standard 

operating procedures (discuss with appropriate agencies). 

Summary: 

Following laws related to the collection of evidence will ensure a 

complete and proper investigation in compliance with State and local 

laws, admissibility in court, and adherence to office policies and protocols. 

21 
Documenting and Evaluating the Scene 

1.	 Photograph Scene 

Principle:	 The photographic documentation of the scene creates a 

permanent historical record of the scene. Photographs 

provide detailed corroborating evidence that constructs a 

system of redundancy should questions arise concerning 

the report, witness statements, or position of evidence at 

the scene. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall obtain detailed photographic 

documentation of the scene that provides both instant 

and permanent high-quality (e.g., 35 mm) images. 

Procedure:	 Upon arrival at the scene, and prior to moving the body 

or evidence, the investigator should: 

A.	 Remove all nonessential personnel from the scene. 

B.	 Obtain an overall (wide-angle) view of the scene to spatially
 

locate the specific scene to the surrounding area.
 

C.	 Photograph specific areas of the scene to provide more detailed 

views of specific areas within the larger scene. 

D.	 Photograph the scene from different angles to provide various 

perspectives that may uncover additional evidence. 

E.	 Obtain some photographs with scales to document specific
 

evidence.
 

F.	 Obtain photographs even if the body or other evidence has been 

moved. 

C 

23
 
1. Photograph Scene 

Note:	 If evidence has been moved prior to photography, it 

should be noted in the report, but the body or other 

evidence should not be reintroduced into the scene in 

order to take photographs. 

Summary: 

Photography allows for the best permanent documentation of the 

death scene. It is essential that accurate scene photographs are available 

for other investigators, agencies, and authorities to recreate the scene. 

Photographs are a permanent record of the terminal event and retain 

evidentiary value and authenticity. It is essential that the investigator 

obtain accurate photographs before releasing the scene. 

2.	 Develop Descriptive
 

Documentation of the Scene
 

Principle:	 Written documentation of the scene(s) provides a 

permanent record that may be used to correlate with and 

enhance photographic documentation, refresh recollections, and record observations. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 Investigators shall provide written scene documentation. 

Procedure:	 After photographic documentation of the scene and prior 

to removal of the body or other evidence, the investigator 

should: 

A.	 Diagram/describe in writing items of evidence and their relationship to the body with necessary measurements. 

B.	 Describe and document, with necessary measurements, blood and 

body fluid evidence including volume, patterns, spatters, and other 

characteristics. 24 
C.	 Describe scene environments including odors, lights, temperatures, and other fragile evidence. 

Note:	 If evidence has been moved prior to written documentation, it should be noted in the report. 

Summary: 

Written scene documentation is essential to correlate with photographic evidence and to recreate the scene for police, forensic(s), and 

judicial and civil agencies with a legitimate interest. 

3. Establish Probable Location
 

of Injury or Illness
 

Principle:	 The location where the decedent is found may not be the 

actual location where the injury/illness that contributed 

to the death occurred. It is imperative that the investigator attempt to determine the locations of any and all 

injury(ies)/illness(es) that may have contributed to the 

death. Physical evidence at any and all locations may be 

pertinent in establishing the cause, manner, and circumstances of death. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall obtain detailed information 

regarding any and all probable locations associated with 

the individual’s death. 

Procedure:	 The investigator should: 

A.	 Document location where death was confirmed. 

B.	 Determine location from which decedent was transported and how 

body was transported to scene. 

25 
3. Establish Probable Location of Injury or Illness 

C.	 Identify and record discrepancies in rigor mortis, livor mortis, and 

body temperature. 

D.	 Check body, clothing, and scene for consistency/inconsistency of 

trace evidence and indicate location where artifacts are found. 

E.	 Check for drag marks (on body and ground). 

F.	 Establish post-injury activity. 

G.	 Obtain dispatch (e.g., police, ambulance) record(s). 

H.	 Interview family members and associates as needed. 

Summary: 

Due to post-injury survival, advances in emergency medical services, multiple modes of transportation, the availability of specialized 

care, or criminal activity, a body may be moved from the actual location 

of illness/injury to a remote site. It is imperative that the investigator 

attempt to determine any and all locations where the decedent has 

previously been and the mode of transport from these sites. 

4. Collect, Inventory, and Safeguard
 

Property and Evidence
 

Principle:	 The decedent’s valuables/property must be safeguarded 

to ensure proper processing and eventual return to next 

of kin. Evidence on or near the body must be safeguarded to ensure its availability for further evaluation. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall ensure that all property and 

evidence is collected, inventoried, safeguarded, and 

released as required by law. 

26 
Procedure:	 After personal property and evidence have been identified at the scene, the investigator (with a witness) should: 

A.	 Inventory, collect, and safeguard illicit drugs and paraphernalia at 

scene and/or office. 

B.	 Inventory, collect, and safeguard prescription medication at scene 

and/or office. 

C.	 Inventory, collect, and safeguard over-the-counter medications at 

scene and/or office. 

D.	 Inventory, collect, and safeguard money at scene and at office. 

E.	 Inventory, collect, and safeguard personal valuables/property at 

scene and at office. 

Summary: 

Personal property and evidence are important items at a death 

investigation. Evidence must be safeguarded to ensure its availability if 

needed for future evaluation and litigation. Personal property must be 

safeguarded to ensure its eventual distribution to appropriate agencies or 

individuals and to reduce the likelihood that the investigator will be 

accused of stealing property. 

5.	 Interview Witness(es) at the Scene 

Principle:	 The documented comments of witnesses at the scene 

allow the investigator to obtain primary source data 

regarding discovery of body, witness corroboration, and 

terminal history. The documented interview provides 

essential information for the investigative process. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator’s report shall include the source of 

information, including specific statements and information provided by the witness. 

27 
5. Interview Witness(es) at the Scene 

Procedure: Upon arriving at the scene, the investigator should: 

A.	 Collect all available identifying data on witnesses (e.g., full name, 

address, DOB, work and home telephone numbers, etc.). 

B.	 Establish witness’ relationship/association to the deceased. 

C.	 Establish the basis of witness’ knowledge (how does witness have 

knowledge of the death?). 

D.	 Obtain information from each witness. 

E.	 Note discrepancies from the scene briefing (challenge, explain, 

verify statements). 

F.	 Tape statements where such equipment is available and retain them. 

Summary: 

The final report must document witness’ identity and must include a 

summary of witness’ statements, corroboration with other witnesses, and 

the circumstances of discovery of the death. This documentation must 

exist as a permanent record to establish a chain of events. 

28 
Documenting and Evaluating the Body 

1.	 Photograph the Body 

Principle:	 The photographic documentation of the body at the 

scene creates a permanent record that preserves essential 

details of the body position, appearance, identity, and 

final movements. Photographs allow sharing of information with other agencies investigating the death. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall obtain detailed photographic 

documentation of the body that provides both instant and 

permanent high-quality (e.g., 35 mm) images. 

Procedure:	 Upon arrival at the scene, and prior to moving the body 

or evidence, the investigator should: 

A.	 Photograph the body and immediate scene (including the decedent 

as initially found). 

B.	 Photograph the decedent’s face. 

C.	 Take additional photographs after removal of objects/items that 

interfere with photographic documentation of the decedent 

(e.g., body removed from car). 

D.	 Photograph the decedent with and without measurements (as
 

appropriate).
 

E.	 Photograph the surface beneath the body (after the body has been 

removed, as appropriate). 

Note:	 Never clean face, do not change condition. Take multiple 

shots if possible. 

D 

29
 
1. Photograph the Body 

Summary: 

The photographic documentation of the body at the scene provides 

for documentation of the body position, identity, and appearance. The 

details of the body at the scene provide investigators with pertinent 

information of the terminal events. 

2.	 Conduct External Body 

Examination (Superficial) 

Principle:	 Conducting the external body examination provides the 

investigator with objective data regarding the single most 

important piece of evidence at the scene, the body. This 

documentation provides detailed information regarding 

the decedent’s physical attributes, his/her relationship to 

the scene, and possible cause, manner, and circumstances of death. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall obtain detailed photographs and 

written documentation of the decedent at the scene. 

Procedure:	 After arrival at the scene and prior to moving the 

decedent, the investigator should, without removing 

decedent’s clothing: 

A.	 Photograph the scene, including the decedent as initially found 

and the surface beneath the body after the body has been removed. 

Note: If necessary, take additional photographs after removal of 

objects/items that interfere with photographic documentation of 

the decedent. 

B.	 Photograph the decedent with and without measurements (as
 

appropriate), including a photograph of the decedent’s face.
 

30 
C.	 Document the decedent’s position with and without measurements 

(as appropriate). 

D.	 Document the decedent’s physical characteristics. 

E.	 Document the presence or absence of clothing and personal
 

effects.
 

F.	 Document the presence or absence of any items/objects that may 

be relevant. 

G.	 Document the presence or absence of marks, scars, and tattoos. 

H.	 Document the presence or absence of injury/trauma, petechiae, etc. 

I.	 Document the presence of treatment or resuscitative efforts. 

J.	 Based on the findings, determine the need for further evaluation/ 

assistance of forensic specialists (e.g., pathologists, odontologists). 

Summary: 

Thorough evaluation and documentation (photographic and written) 

of the deceased at the scene is essential to determine the depth and 

direction the investigation will take. 

3.	 Preserve Evidence (on Body) 

Principle:	 The photographic and written documentation of evidence 

on the body allows the investigator to obtain a permanent 

historical record of that evidence. To maintain chain of 

custody, evidence must be collected, preserved, and 

transported properly. In addition to all of the physical 

evidence visible on the body, blood and other body fluids 

present must be photographed and documented prior to 

collection and transport. Fragile evidence (that which 

can be easily contaminated, lost, or altered) must also be 

collected and/or preserved to maintain chain of custody 

and to assist in determination of cause, manner, and 

circumstances of death. 

31 
3. Preserve Evidence (on Body) 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 With photographic and written documentation, the 

investigator will provide a permanent record of evidence 

that is on the body. 

Procedure:	 Once evidence on the body is recognized, the 

investigator should: 

A.	 Photograph the evidence. 

B.	 Document blood/body fluid on the body (froth/purge, substances 

from orifices), location, and pattern before transporting. 

C.	 Place decedent’s hands and/or feet in unused paper bags (as
 

determined by the scene).
 

D.	 Collect trace evidence before transporting the body (e.g., blood, 

hair, fibers, etc.). 

E.	 Arrange for the collection and transport of evidence at the scene 

(when necessary). 

F.	 Ensure the proper collection of blood and body fluids for subsequent analysis (if body will be released from scene to an outside 

agency without an autopsy). 

Summary: 

It is essential that evidence be collected, preserved, transported, 

and documented in an orderly and proper fashion to ensure the chain of 

custody and admissibility in a legal action. The preservation and documentation of the evidence on the body must be initiated by the investigator at the scene to prevent alterations or contamination. 

32 
4. Establish Decedent Identification
 

Principle:	 The establishment or confirmation of the decedent’s 

identity is paramount to the death investigation. Proper 

identification allows notification of next of kin, settlement of estates, resolution of criminal and civil litigation, and the proper completion of the death certificate. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall engage in a diligent effort to 

establish/confirm the decedent’s identity. 

Procedure:	 To establish identity, the investigator should document 

use of the following methods: 

A.	 Direct visual or photographic identification of the decedent if 

visually recognizable. 

B.	 Scientific methods such as fingerprints, dental, radiographic, and 

DNA comparisons. 

C.	 Circumstantial methods such as (but not restricted to) personal 

effects, circumstances, physical characteristics, tattoos, and 

anthropologic data. 

Summary: 

There are several methods available that can be used to properly 

identify deceased persons. This is essential for investigative, judicial, 

family, and vital records issues. 

5.	 Document Post Mortem Changes 

Principle:	 The documenting of post mortem changes to the body 

assists the investigator in explaining body appearance in the 

interval following death. Inconsistencies between post 

33 
5. Document Post Mortem Changes 

mortem changes and body location may indicate movement of body and validate or invalidate witness statements. In addition, post mortem changes to the body, 

when correlated with circumstantial information, can 

assist the investigators in estimating the approximate time 

of death. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall document all post mortem changes 

relative to the decedent and the environment. 

Procedure:	 Upon arrival at the scene and prior to moving the body, 

the investigator should note the presence of each of the 

following in his/her report: 

A.	 Livor (color, location, blanchability, Tardieu spots) consistent/ 

inconsistent with position of the body. 

B.	 Rigor (stage/intensity, location on the body, broken, inconsistent 

with the scene). 

C.	 Degree of decomposition (putrefaction, adipocere, mummification, skeletonization, as appropriate). 

D.	 Insect and animal activity. 

E.	 Scene temperature (document method used and time estimated). 

F.	 Description of body temperature (e.g., warm, cold, frozen) or 

measurement of body temperature (document method used and 

time of measurement). 

Summary: 

Documentation of post mortem changes in every report is essential 

to determine an accurate cause and manner of death, provide information 

as to the time of death, corroborate witness statements, and indicate that 

the body may have been moved after death. 

34 
6. Participate in Scene Debriefing
 

Principle:	 The scene debriefing helps investigators from all participating agencies to establish post-scene responsibilities by 

sharing data regarding particular scene findings. The scene 

debriefing provides each agency the opportunity for input 

regarding special requests for assistance, additional information, special examinations, and other requests requiring 

interagency communication, cooperation, and education. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall participate in or initiate interagency scene debriefing to verify specific post-scene 

responsibilities. 

Procedure:	 When participating in scene debriefing, the investigator 

should: 

A.	 Determine post-scene responsibilities (identification, notification, 

press relations, and evidence transportation). 

B.	 Determine/identify the need for a specialist (e.g., crime laboratory 

technicians, social services, entomologists, OSHA). 

C.	 Communicate with the pathologist about responding to the scene 

or to the autopsy schedule (as needed). 

D.	 Share investigative data (as required in furtherance of the
 

investigation).
 

E.	 Communicate special requests to appropriate agencies, being 

mindful of the necessity for confidentiality. 

Summary: 

The scene debriefing is the best opportunity for investigative participants to communicate special requests and confirm all current and additional 

scene responsibilities. The debriefing allows participants the opportunity to 

establish clear lines of responsibility for a successful investigation. 

35 
7.	 Determine Notification Procedures 

(Next of Kin) 

Principle:	 Every reasonable effort should be made to notify the 

next of kin as soon as possible. Notification of next of 

kin initiates closure for the family, disposition of remains, and facilitates the collection of additional information relative to the case. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall ensure that next of kin is notified 

of the death and that all failed and successful attempts at 

notification are documented. 

Procedure:	 When determining notification procedures, the investigator should: 

A.	 Identify next of kin (determine who will perform task). 

B.	 Locate next of kin (determine who will perform task). 

C.	 Notify next of kin (assign person(s) to perform task) and record 

time of notification, or, if delegated to another agency, gain 

confirmation when notification is made. 

D.	 Notify concerned agencies of status of the notification. 

Summary: 

The investigator is responsible for ensuring that the next of kin is 

identified, located, and notified in a timely manner. The time and method 

of notification should be documented. Failure to locate next of kin and 

efforts to do so should be a matter of record. This ensures that every 

reasonable effort has been made to contact the family. 

36 
8. Ensure Security of Remains
 

Principle:	 Ensuring security of the body requires the investigator to 

supervise the labeling, packaging, and removal of the 

remains. An appropriate identification tag is placed on 

the body to preclude misidentification upon receipt at the 

examining agency. This function also includes safeguarding all potential physical evidence and/or property 

and clothing that remain on the body. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall supervise and ensure the proper 

identification, inventory, and security of evidence/ 

property and its packaging and removal from the scene. 

Procedure:	 Prior to leaving the scene, the investigator should: 

A.	 Ensure that the body is protected from further trauma or contamination (if not, document) and unauthorized removal of therapeutic 

and resuscitative equipment. 

B.	 Inventory and secure property, clothing, and personal effects that 

are on the body (remove in a controlled environment with witness 

present). 

C.	 Identify property and clothing to be retained as evidence (in a 

controlled environment). 

D.	 Recover blood and/or vitreous samples prior to release of remains. 

E.	 Place identification on the body and body bag. 

F.	 Ensure/supervise the placement of the body into the bag. 

G.	 Ensure/supervise the removal of the body from the scene. 

H.	 Secure transportation. 

37 
8. Ensure Security of Remains 

Summary: 

Ensuring the security of the remains facilitates proper identification 

of the remains, maintains a proper chain of custody, and safeguards 

property and evidence. 

38 
Establishing and Recording Decedent Profile Information 

1.	 Document the Discovery History 

Principle:	 Establishing a decedent profile includes documenting a 

discovery history and circumstances surrounding the 

discovery. The basic profile will dictate subsequent 

levels of investigation, jurisdiction, and authority. The 

focus (breadth/depth) of further investigation is dependent on this information. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall document the discovery history, 

available witnesses, and apparent circumstances leading 

to death. 

Procedure:	 For an investigator to correctly document the discovery 

history, he/she should: 

A.	 Establish and record person(s) who discovered the body and when. 

B.	 Document the circumstances surrounding the discovery (who, 

what, where, when, how). 

Summary: 

The investigator must produce clear, concise, documented information concerning who discovered the body, what are the circumstances of 

discovery, where the discovery occurred, when the discovery was made, 

and how the discovery was made. 

E 

39
 
2. Determine Terminal Episode History
 

Principle:	 Pre-terminal circumstances play a significant role in 

determining cause and manner of death. Documentation 

of medical intervention and/or procurement of ante 

mortem specimens help to establish the decedent’s 

condition prior to death. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall document known circumstances 

and medical intervention preceding death. 

Procedure:	 In order for the investigator to determine terminal 

episode history, he/she should: 

A.	 Document when, where, how, and by whom decedent was last 

known to be alive. 

B.	 Document the incidents prior to the death. 

C.	 Document complaints/symptoms prior to the death. 

D.	 Document and review complete EMS records (including the initial 

electrocardiogram). 

E.	 Obtain relevant medical records (copies). 

F.	 Obtain relevant ante mortem specimens. 

Summary: 

Obtaining records of pre-terminal circumstances and medical 

history distinguishes medical treatment from trauma. This history and 

relevant ante mortem specimens assist the medical examiner/coroner in 

determining cause and manner of death. 

40 
3. Document Decedent Medical History
 

Principle:	 The majority of deaths referred to the medical examiner/ 

coroner are natural deaths. Establishing the decedent’s 

medical history helps to focus the investigation. Documenting the decedent’s medical signs or symptoms prior 

to death determines the need for subsequent examinations. The relationship between disease and injury may 

play a role in the cause, manner, and circumstances of 

death. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall obtain the decedent’s past medical 

history. 

Procedure:	 Through interviews and review of the written records, 

the investigator should: 

A.	 Document medical history, including medications taken, alcohol 

and drug use, and family medical history from family members 

and witnesses. 

B.	 Document information from treating physicians and/or hospitals 

to confirm history and treatment. 

C.	 Document physical characteristics and traits (e.g., left-/righthandedness, missing appendages, tattoos, etc.).
 

Summary: 

Obtaining a thorough medical history focuses the investigation, aids 

in disposition of the case, and helps determine the need for a post mortem 

examination or other laboratory tests or studies. 

41 
4.	 Document Decedent 

Mental Health History 

Principle:	 The decedent’s mental health history can provide insight 

into the behavior/state of mind of the individual. That 

insight may produce clues that will aid in establishing 

the cause, manner, and circumstances of the death. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall obtain information from sources 

familiar with the decedent pertaining to the decedent’s 

mental health history. 

Procedure:	 The investigator should: 

A.	 Document the decedent’s mental health history, including hospitalizations and medications. 

B.	 Document the history of suicidal ideations, gestures, and/or
 

attempts.
 

C.	 Document mental health professionals (e.g., psychiatrists,
 

psychologists, counselors, etc.) who treated the decedent.
 

D.	 Document family mental health history. 

Summary: 

Knowledge of the mental health history allows the investigator to 

evaluate properly the decedent’s state of mind and contributes to the 

determination of cause, manner, and circumstances of death. 

42 
5. Document Social History
 

Principle:	 Social history includes marital, family, sexual, educational, employment, and financial information. Daily 

routines, habits and activities, and friends and associates 

of the decedent help in developing the decedent’s profile. 

This information will aid in establishing the cause, 

manner, and circumstances of death. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall obtain social history information 

from sources familiar with the decedent. 

Procedure:	 When collecting relevant social history information, 

the investigator should: 

A.	 Document marital/domestic history. 

B.	 Document family history (similar deaths, significant dates). 

C.	 Document sexual history. 

D.	 Document employment history. 

E.	 Document financial history. 

F.	 Document daily routines, habits, and activities. 

G.	 Document relationships, friends, and associates. 

H.	 Document religious, ethnic, or other pertinent information
 

(e.g., religious objection to autopsy).
 

I.	 Document educational background. 

J.	 Document criminal history. 

Summary: 

Information from sources familiar with the decedent pertaining to 

the decedent’s social history assists in determining cause, manner, and 

circumstances of death. 

43 
Completing the Scene Investigation 

1.	 Maintain Jurisdiction Over the Body 

Principle:	 Maintaining jurisdiction over the body allows the 

investigator to protect the chain of custody as the body is 

transported from the scene for autopsy, specimen collection, or storage. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall maintain jurisdiction of the body 

by arranging for the body to be transported for autopsy, 

specimen collection, or storage by secure conveyance. 

Procedure:	 When maintaining jurisdiction over the body, the investigator should: 

A.	 Arrange for, and document, secure transportation of the body to 

a medical or autopsy facility for further examination or storage. 

B.	 Coordinate and document procedures to be performed when the 

body is received at the facility. 

Summary: 

By providing documented secure transportation of the body from 

the scene to an authorized receiving facility, the investigator maintains 

jurisdiction and protects chain of custody of the body. F 

45
 
2. Release Jurisdiction of the Body
 

Principle:	 Prior to releasing jurisdiction of the body to an authorized receiving agent or funeral director, it is necessary 

to determine the person responsible for certification of 

the death. Information to complete the death certificate 

includes demographic information and the date, time, 

and location of death. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall obtain sufficient data to enable 

completion of the death certificate and release of jurisdiction over the body. 

Procedure:	 When releasing jurisdiction over the body, the investigator should: 

A.	 Determine who will sign the death certificate (name, agency, etc.). 

B.	 Confirm the date, time, and location of death. 

C.	 Collect, when appropriate, blood, vitreous fluid, and other
 

evidence prior to release of the body from the scene.
 

D.	 Document and arrange with the authorized receiving agent to 

reconcile all death certificate information. 

E.	 Release the body to a funeral director or other authorized
 

receiving agent.
 

Summary: 

The investigator releases jurisdiction only after determining who 

will sign the death certificate; documenting the date, time, and location 

of death; collecting appropriate specimens; and releasing the body to the 

funeral director or other authorized receiving agent. 

46 
3. Perform Exit Procedures
 

Principle:	 Bringing closure to the scene investigation ensures that 

important evidence has been collected and the scene has 

been processed. In addition, a systematic review of the 

scene ensures that artifacts or equipment are not inadvertently left behind (e.g., used disposable gloves, 

paramedical debris, film wrappers, etc.), and any 

dangerous materials or conditions have been reported. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 At the conclusion of the scene investigation, the investigator shall conduct a post-investigative “walk through” 

and ensure the scene investigation is complete. 

Procedure:	 When performing exit procedures, the investigator 

should: 

A. Identify, inventory, and remove all evidence collected at the scene. 

B. Remove all personal equipment and materials from the scene. 

C. Report and document any dangerous materials or conditions. 

Summary: 

Conducting a scene “walk through” upon exit ensures that all 

evidence has been collected, that materials are not inadvertently left 

behind, and that any dangerous materials or conditions have been 

reported to the proper entities. 

47 
4. Assist the Family
 

Principle:	 The investigator provides the family with a timetable 

so they can arrange for final disposition and provides 

information on available community and professional 

resources that may assist the family. 

Authorization:	 Medical Examiner/Coroner Official Office Policy 

Manual; State or Federal Statutory Authority. 

Policy:	 The investigator shall offer the decedent’s family information 

regarding available community and professional resources. 

Procedure:	 When the investigator is assisting the family, it is 

important to: 

A.	 Inform the family if an autopsy is required. 

B.	 Inform the family of available support services (e.g., victim
 

assistance, police, social services, etc.).
 

C.	 Inform the family of appropriate agencies to contact with 

questions (medical examiner/coroner offices, law enforcement, 

SIDS support group, etc.). 

D.	 Ensure family is not left alone with body (if circumstances
 

warrant).
 

E.	 Inform the family of approximate body release timetable. 

F.	 Inform the family of information release timetable (toxicology, 

autopsy results, etc., as required). 

G.	 Inform the family of available reports, including cost, if any. 

Summary: 

The interaction with the family allows the investigator to assist and 

direct them to appropriate resources. It is essential that families be given 

a timetable of events so that they can make necessary arrangements. In 

addition, the investigator needs to make them aware of what and when 

information will be available. 

48 
About the National Institute of Justice
 

The National Institute of Justice (NIJ), a component of the Office of Justice Programs, is the research 

agency of the U.S. Department of Justice. Created by the Omnibus Crime Control and Safe Streets Act 

of 1968, as amended, NIJ is authorized to support research, evaluation, and demonstration programs, 

development of technology, and both national and international information dissemination. Specific 

mandates of the Act direct NIJ to: 

◆	 Sponsor special projects, and research and development programs, that will improve and strengthen 

the criminal justice system and reduce or prevent crime. 

◆	 Conduct national demonstration projects that employ innovative or promising approaches for 

improving criminal justice. 

◆	 Develop new technologies to fight crime and improve criminal justice. 

◆	 Evaluate the effectiveness of criminal justice programs and identify programs that promise to be 

successful if continued or repeated. 

◆	 Recommend actions that can be taken by Federal, State, and local governments as well as by private 

organizations to improve criminal justice. 

◆	 Carry out research on criminal behavior. 

◆	 Develop new methods of crime prevention and reduction of crime and delinquency. 

In recent years, NIJ has greatly expanded its initiatives, the result of the Violent Crime Control and Law 

Enforcement Act of 1994 (the Crime Act), partnerships with other Federal agencies and private 

foundations, advances in technology, and a new international focus. Some examples of these new 

initiatives: 

◆	 New research and evaluation is exploring key issues in community policing, violence against 

women, sentencing reforms, and specialized courts such as drug courts. 

◆	 Dual-use technologies are being developed to support national defense and local law enforcement 

needs. 

◆	 Four regional National Law Enforcement and Corrections Technology Centers and a Border 

Research and Technology Center have joined the National Center in Rockville, Maryland. 

◆	 The causes, treatment, and prevention of violence against women and violence within the family are 

being investigated in cooperation with several agencies of the U.S. Department of Health and 

Human Services. 

◆	 NIJ’s links with the international community are being strengthened through membership in the 

United Nations network of criminological institutes; participation in developing the U.N. Criminal 

Justice Information Network; initiation of UNOJUST (U.N. Online Justice Clearinghouse), which 

electronically links the institutes to the U.N. network; and establishment of an NIJ International 

Center. 

◆	 The NIJ-administered criminal justice information clearinghouse, the world’s largest, has improved 

its online capability. 

◆	 The Institute’s Drug Use Forecasting (DUF) program has been expanded and enhanced. Renamed 

ADAM (Arrestee Drug Abuse Monitoring), the program will increase the number of drug-testing 

sites, and its role as a “platform” for studying drug-related crime will grow. 

◆	 NIJ’s new Crime Mapping Research Center will provide training in computer mapping technology, 

collect and archive geocoded crime data, and develop analytic software. 

◆	 The Institute’s program of intramural research has been expanded and enhanced. 

The Institute Director, who is appointed by the President and confirmed by the Senate, establishes the 

Institute’s objectives, guided by the priorities of the Office of Justice Programs, the Department of 

Justice, and the needs of the criminal justice field. The Institute actively solicits the views of criminal 

justice professionals and researchers in the continuing search for answers that inform public 

policymaking in crime and justice. 

For information on the National Institute of Justice, please contact: 

National Criminal Justice Reference Service 

Box 6000
 

Rockville, MD 20849–6000
 

800–851–3420
 

e-mail: askncjrs@ncjrs.org
 

You can view or obtain an electronic version of this document from the
 

NCJRS Justice Information Center World Wide Web site.
 

To access this site, go to http://www.ncjrs.org
 

If you have questions, call or e-mail NCJRS.