U.S. Department of Justice

Office of Justice Programs

National Institute of Justice

JUNE 2011

Research R e p o r t

Death Investigation: A Guide for the Scene Investigator

Technical Update www.nij.gov
U.S. Department of Justice

Office of Justice Programs

810 Seventh Street N.W.

Washington, DC 20531

Eric H. Holder, Jr.

Attorney General

Laurie O. Robinson

Assistant Attorney General

John H. Laub

Director, National Institute of Justice

This and other publications and products of the 

National Institute of Justice can be found at:

National Institute of Justice

www.nij.gov

Office of Justice Programs

Innovation • Partnerships • Safer Neighborhoods

www.ojp.usdoj.gov
JUNE 2011

Death Investigation: A Guide for the 

Scene Investigator

Technical Update

Original Guide 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 

Technical Update Developed and Approved by the

Technical Update Review Committee 

March 2010

U.S. Department of Justice 

Office of Justice Programs

The original 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. 

The technical update was supported under grant number 2007–MU–BX–

K008 by the National Institute of Justice, Office of Justice Programs, U.S. 

Department of Justice.

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 234457

iii

D E A T H I N V E S T I G A T I O N 

Original Guide:

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

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
iv

R E S E A R C H R E P O R T / J U N E 2 0 1 1

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
v

D E A T H I N V E S T I G A T I O N 

Technical Update:

Review Committee

American Academy of 

Forensic Sciences

Julie A. Howe, M.B.A.

Medicolegal Death Investigator

St. Louis University, Division 

of Forensic Pathology

St. Louis, Missouri

American Board of Medicolegal Death Investigators

Roberta Geiselhart, R.N.

Supervisor of Investigations

Hennepin County Medical 

Examiner’s Office

Minneapolis, Minnesota

International Association of 

Chiefs of Police

Major Rustin Price

Commander, Criminal 

Investigation Division

Baltimore County Police 

Department

Towson, Maryland

International Association 

of Coroners and Medical 

Examiners

O’dell Owens, M.D., M.P.H.

President

Cincinnati State Technical 

and Community College

Cincinnati, Ohio

National Association of 

Medical Examiners

Jeff Jentzen, M.D.

Director of Autopsy and 

Forensic Services 

University of Michigan

Ann Arbor, Michigan

National Sheriffs’ 

Association

Sergeant Michael Price

DuPage County Sheriff’s 

Office

Wheaton, Illinois

vii

D E A T H I N V E S T I G A T I O N 

Acknowledgments

NIJ wishes to thank the 

original 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.

NIJ also wishes to thank its 

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.
viii

R E S E A R C H R E P O R T / J U N E 2 0 1 1

The former 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 of and commitment to the research. 

In addition, the true strength 

of these guidelines is derived 

from the stamina of the 

National Medicolegal Review 

Panel (NMRP), 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, 

thanks go to 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.

In 2010, NIJ convened a 

committee to perform a 

technical update to the 

guidelines. NIJ extends its 

thanks to the members of 

the Technical Update Review 

Committee for their work. 

NIJ also thanks Ms. Carolyn 

Allen, Consultant, National 

Forensic Science Technology 

Center; Brigid O’Brien, Ph.D., 

Program Manager, NIJ; and 

Ms. Robin Jones, Forensic 

Science Policy and Strategy 

Consultant, Bureau of Alcohol, Tobacco, Firearms and 

Explosives, for their assistance in the technical update.

John H. Laub, Ph.D.

Director, National 

Institute of Justice
ix

D E A T H I N V E S T I G A T I O N 

Contents

Original Guide: National Medicolegal Review Panel ....... iii

Technical Update: Review Committee ............................... v

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

Introduction to Technical Update ........................................1

Introduction to the Original Guide .......................................1

Purpose and Scope of the Study ........................................1

Study Design ..................................................................... 2

Notes ................................................................................. 8

Section A: Investigative Tools and Equipment .................. 9

Section B: Arriving at the Scene ........................................11

1. Introduce and Identify Self and Role .............................11

2. Exercise Scene Safety and Security............................. 12

3. Confirm or Pronounce Death ....................................... 13

4. Participate in Scene Briefing (With Attending 

Agency Representatives)............................................. 14

5. Conduct Scene “Walk Through”.................................. 15

6. Establish Chain of Custody .......................................... 16

7. Follow Laws (Related to the Collection 

of Evidence) ................................................................. 18

Section C: Documenting and Evaluating the Scene ....... 19

1. Photograph Scene ....................................................... 19

2. Develop Descriptive Documentation of the Scene ..... 20

3. Establish Probable Location of Injury or Illness ........... 21
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R E S E A R C H R E P O R T / J U N E 2 0 1 1

4. Collect, Inventory and Safeguard Property 

and Evidence ............................................................... 23

5. Interview Witness(es) at the Scene ............................ 24

Section D: Documenting and Evaluating the Body ......... 27

1. Photograph the Body ................................................... 27

2. Conduct External Body Examination (Superficial) ....... 28

3. Preserve Evidence (on Body) ...................................... 30

4. Establish Decedent Identification ................................ 31

5. Document Post-Mortem Changes .............................. 32

6. Participate in Scene Debriefing ................................... 33

7. Determine Notification Procedures (Next of 

Kin or Interested and Authorized Individuals) .............. 35

8. Ensure Security of Remains ........................................ 36

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 or Authorized Individual(s) ............... 48
1

D E A T H I N V E S T I G A T I O N 

Introduction to Technical Update

Death investigation has 

evolved greatly in the years 

since the 1999 release of 

Death Investigation: A Guide 

for the Scene Investigator.

This revised and updated edition is the result of a collaborative effort to present the 

most up-to-date information 

about the issues confronting 

death investigators today. 

The death investigator is the 

eyes and ears of the forensic 

pathologist at the scene. It 

is hoped that these guidelines, reflecting the best 

practices of the forensic 

community, will serve as a 

national standard.

The following introduction describes the original study that 

focused on the establishment 

of guidelines for conducting 

death investigations.

Introduction to the Original Guide

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.

The study involved the use of 

two standardized consensusseeking research techniques: 

(a) the Developing A Curriculum (DACUM)1

 process 

and (b) a Delphi2 survey. In 

this report, the author does 

not attempt to assign responsibility for task (guideline) 

performance to any one 
2

R E S E A R C H R E P O R T / J U N E 2 0 1 1

occupational job title (e.g., 

Guideline D4 is performed by 

law enforcement personnel). 

Research design and se-

lected methodology focused 

on the establishment of 

performance guidelines for 

death-scene investigations. 

The research design did 

not allow TWGs to assume 

investigative outcomes dur-

ing 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 main-

tain objectivity and national 

practicality. The author does 

not claim to be an expert in 

the science and/or method-

ology of medicolegal death 

investigation. This research 

was based on the collective 

knowledge of three multidis-

ciplinary content area expert 

groups. The focus was on 

the death scene, the body, 

and the interactive skills and 

knowledge that must be ap-

plied to ensure a successful 

case outcome. The balance 

of this introduction out-

lines 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 (investiga-

tive guidelines) follow this 

introduction.

Study Design

The methodology selected 

for this occupational research 

required collection of data 

from a sample of current 

subject matter experts, prac-

titioners from the field who 

perform daily within the oc-

cupation being investigated. 

This “criterion” was used to 

identify members of the vari-

ous multidisciplinary groups 

that provided the data for this 

research. 

The following groups were 

formed for the purpose of 

developing national guide-

lines for conducting death 

investigations. 

National Medicolegal 

Review Panel

NMRP members repre-

sent an independent mul-

tidisciplinary group of both 

international and national 

organizations whose con-

stituents are responsible for 

investigating death and its 

outcomes. Each member of 

NMRP was selected by the 

Director based on nomina-

tions made by the various 

associations. The rationale 

for their involvement was 
3

D E A T H I N V E S T I G A T I O N 

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

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.3

■ 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.

A 50-percent random sample 

(1,512) of death investigators 

was drawn from the CDC database.4

 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.

The TWGDI national reviewer 

network consisted of 263 

members from 46 states and 

representing 5 regions, as 

seen in table 1.
4

R E S E A R C H R E P O R T / J U N E 2 0 1 1

The educational backgrounds 

of the national reviewer network members are presented 

in table 2.

The types of investigative 

systems represented in the 

reviewer network are shown 

in table 3.

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 

Table 1. Membership of the Technical Working Group on Death 

Investigation National Reviewer Network

Region 1

Northeast

Region 2

Southeast

Region 3

Midwest

Region 4

Southwest

Region 5

West

Region Location

Number of 

Participants Percentage

1 Northeast 32 12%

2 Southeast 56 21%

3 Midwest 94 36%

4 Southwest 47 18%

5 West 34 13%
5

D E A T H I N V E S T I G A T I O N 

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.

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 deathscene 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.”5

 A task was defined 

Table 2. Educational Background of the National Reviewer Network

Education Number Percent

Law Enforcement 82 31%

Medical 157 60%

Unknown 24 9%

Table 3. Systems Represented by the National Reviewer Network

System Number Percent

Medical Examiner 44 17%

Coroner 161 61%

Mixed ME/Coroner 58 22%
6

R E S E A R C H R E P O R T / J U N E 2 0 1 1

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 defense 

needs, the technique is used 

whenever a consensus is 

needed from persons who 

are knowledgeable about 

a particular subject.6

 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 survey requires at 

least four rounds in an effort 

to obtain a well-thought-out 

consensus. After the firstround 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 
7

D E A T H I N V E S T I G A T I O N 

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. Table 4 

provides general TWGDI 

response data.

As shown in table 4, 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 taskbased data into guideline 

format. 

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.

Table 4. Response Rates to the Delphi Survey

Round Surveys Sent Surveys Received

Cumulative 

Respondent 

Loss (%)

1 263 199 24%

2 199 163 14%

3 163 149 5%

4 149 146 1%
8

R E S E A R C H R E P O R T / J U N E 2 0 1 1

■ 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 

sections.

Notes

1. The Ohio State University, 

Center on Education and 

Training for Employment, 

DACUM, 1996.

2. Borg, W.R., and M.D. 

Gall, Educational Research: 

An Introduction, New York: 

Longman Inc., 1983:413–415.

3. 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.

4. Ibid.

5. Clark, S.C., Occupational 

Research and Assessment, 

Inc., Big Rapids, Michigan, 

1996.

6. Borg and Gall, 413–415.
9

D E A T H I N V E S T I G A T I O N 

Section A:

Investigative Tools and Equipment

1. Alternate light source.

2. Barrier sheeting or tent 

(to shield body/area from 

public view).

3. Biohazard plastic trash 

bags.

4. Blood collection tubes.

5. Body bags with locks.

6. Body identification tags.

7. Business cards with fax 

and e-mail address.

8. Camera equipment.

9. Clean body cover (sheet/

drape).

10. Communication 

equipment.

11. Crime scene tape.

12. Departmental scene 

forms.

13. Disposable protective suit.

14. Evidence identification 

markers.

15. Evidence seal/tape.

16. Face and eye protection.

17. First aid kit.

18. Flashlight.

19. Hair cover.

20. Hand tools (e.g., bolt 

cutter, hammer, metal 

detector, paint brushes, 

pocketknife, rope, shovel, 

etc.).

21. Investigative notebooks.

22 Latent print kit.

23. Latex gloves.

24. Maps, compass and/or 

GPS.

25. Masks.

26. Measurement 

instruments.

27. Official identification.

28. Packaging material (e.g., 

clean unused paper bags, 

envelopes, metal cans, 

tape, rubber bands, etc.).

29. Personal supplies (e.g., 

insect spray, sunscreen, 

hat, raincoat, umbrella, 
10

R E S E A R C H R E P O R T / J U N E 2 0 1 1

boots for wet conditions 

and construction sites, 

etc.). 

30. Photo identifier (e.g., 

header frame, placards).

31. Phone lists and contact 

information.

32. Portable lighting.

33. Recording device.

34. Reenactment doll(s).

35. Resource material (e.g., 

death scene cleanup, 

grief support, organ procurement, etc.)

36. Scene safety equipment 

(e.g., biological/chemical/

industrial/disaster/fire, 

hardhat, reflective vest, 

steel bottom boots, etc.).

37. Sharps container.

38. Shoe/boot covers.

39. Specimen containers.

40. Thermometer (ambient 

and body temperature).

41. Trace evidence recovery 

equipment (e.g., blades, 

cotton-tipped swabs, disposable syringe, forceps, 

gunshot residue and hand 

lens (magnifying glass), 

large gauge needles, presumptive blood test kit, 

scalpel handle, tweezers, 

etc.).

42. Watch.

43. Waterless hand wash/

disinfectant.

44. Writing instruments.
11

D E A T H I N V E S T I G A T I O N 

Arriving at the Scene

Section B:

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 command protocol and 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 and security.

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) 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 follow-up) to ascertain if any 

artifacts or contamination may have been 

introduced to the death scene.
12

R E S E A R C H R E P O R T / J U N E 2 0 1 1

D. Determine the scene safety and security 

(prior to entry).

Summary: Introductions at the scene help to establish a 

collaborative investigative effort. It is necessary to carry identification in the event of 

questioned authority. It is essential to establish scene safety and security prior to entry.

2. Exercise Scene Safety and Security 

Principle: Determining scene safety and security 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, chemical, 

biological, radiological, nuclear and explosive 

(CBRNE) threats.

Authorization: Medical Examiner/Coroner Official Office 

Policy Manual; State or Federal Statutory 

Authority.

Policy: The investigator shall attempt to establish 

scene safety and security prior to entering the 

scene to prevent injury or loss of life, including contacting appropriate agencies for assistance with other scene safety and security 

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.
13

D E A T H I N V E S T I G A T I O N 

D. Use personal protective safety devices 

(physical, biohazard 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 and security (e.g., fire marshal, disaster coordinator).

G. While exercising scene safety and security, 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/equipment 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.
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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, time and location of 

determination.

D. Ensure death is pronounced, as required.

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 official 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.
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D E A T H I N V E S T I G A T I O N 

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, latitude and 

longitude coordinates) consistent with 

other agencies.

C. Determine nature and scope of investigation by obtaining preliminary investigative 

details (e.g., suspicious versus nonsuspicious death, multiple scenes).

D. Confirm that initial accounts of incident are 

obtained from the first witness(es).

Summary: Scene briefing allows for initial and factual 

information exchange. This includes scene 

location, time factors, initial witness information, agency responsibilities and investigative 

strategy. Note: Since current global positioning system (GPS) devices may have error, it is 

important to establish the location using other 

reference points (permanent landmarks) and 

distance/bearing from landmarks whenever 

GPS is used.

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 

fragile evidence, and determine initial investigative procedures providing for a systematic 

examination and documentation of the scene 

and body.
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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 to include 

scene log.

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 contamination of physical and 

fragile evidence.

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.
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D E A T H I N V E S T I G A T I O N 

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, document, 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, and by whom. 

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.
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R E S E A R C H R E P O R T / J U N E 2 0 1 1

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 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.
19

D E A T H I N V E S T I G A T I O N 

Documenting and Evaluating 

the Scene

Section C:

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 images. 

It is important to document in writing a description of each photo so that it can be used for 

future reference.

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 orientation photograph 

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.
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R E S E A R C H R E P O R T / J U N E 2 0 1 1

E. Obtain photographs with scales to document specific evidence.

F. Obtain photographs even if the body or 

other evidence has been moved.

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 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:
21

D E A T H I N V E S T I G A T I O N 

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.

C. Describe scene environments, including 

odors, lights, temperatures and other fragile evidence.

Note: If scene conditions have changed or 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 

re-create 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.
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R E S E A R C H R E P O R T / J U N E 2 0 1 1

Procedure: The investigator should:

A. Document the location where death was 

confirmed.

B. Determine the location from which the 

decedent was transported and how the 

body was transported to the scene.

C. Identify and record discrepancies between 

the body and the scene (e.g., rigor mortis, 

livor mortis and body temperature).

D. Check the body, clothing and scene 

for consistency/inconsistency of trace 

evidence and indicate the 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.
23

D E A T H I N V E S T I G A T I O N 

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 are collected, inventoried, safeguarded and released as required by law.

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 the scene 

and office.

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

C. Inventory, collect and safeguard 

over-the-counter medications at the 

scene and office.

D. Inventory, collect and safeguard money 

at the scene and office.

E. Inventory, collect, and safeguard personal 

valuables/property at the scene and 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. 
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R E S E A R C H R E P O R T / J U N E 2 0 1 1

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 

the 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.

Procedure: Upon arriving at the scene, the investigator 

should:

A. Collect all available identifying data on 

witness(es) (e.g., full name, address, 

date of birth, contact information).

B. Establish the witness’s relationship/

association to the deceased.

C. Establish the basis of the witness’s 

knowledge (how does the witness have 

knowledge of the death?).

D. Obtain information from each witness 

individually or as appropriate. 

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

F. Record and retain statements as needed. 
25

D E A T H I N V E S T I G A T I O N 

Summary: The investigator’s final report must document the witness’s identity and must include 

a summary of the witness’s 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.

27

D E A T H I N V E S T I G A T I O N 

Documenting and Evaluating 

the Body

Section D:

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 

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 (never 

clean face, do not change condition). 

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).
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E. Photograph the surface beneath the body 

(after the body has been removed, as 

appropriate).

Note: Take multiple photographs if possible.

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 the 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.
29

D E A T H I N V E S T I G A T I O N 

B. Photograph the decedent with and without 

measurements (as appropriate), including 

a photograph of the decedent’s face.

C. Document the decedent’s position 

with and without measurements (as 

appropriate).

D. Document the decedent’s physical 

characteristics.

E. Document the presence, absence and 

condition 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 or technologies (e.g., 

pathologists, odontologists, alternate light 

sources).

Note: If necessary, take additional photographs after 

removal of objects/items that interfere with 

photographic documentation of the decedent.

Summary: Thorough evaluation and documentation (photographic and written) of the deceased at the 

scene are essential to determine the depth 

and direction the investigation will take.
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R E S E A R C H R E P O R T / J U N E 2 0 1 1

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 documented, 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 

(which can be easily contaminated, lost or 

altered) must also be collected and preserved 

to maintain chain of custody and to assist in 

determination of cause, manner and circumstances of death.

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 

(e.g., froth/purge, substances from orifices), 

location and pattern before transporting.

C. Secure decedent’s hands and feet in 

unused paper bags (as determined by the 

scene).

D. Identify and collect trace evidence before 

transporting the body (e.g., blood, hair, 

fibers).
31

D E A T H I N V E S T I G A T I O N 

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 the 

body will be released from the 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. In some instances, 

identification of trace evidence may require alternative methods (e.g., alternate light source, 

presumptive testing). 

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 

(when authorized, a face may be cleaned 
32

R E S E A R C H R E P O R T / J U N E 2 0 1 1

to allow for identification after the initial 

photographic documentation is completed). 

B. Scientific methods such as fingerprints and 

dental, radiographic and DNA comparisons.

C. Circumstantial methods such as (but not 

restricted to) personal effects, circumstances, physical characteristics, tattoos 

and anthropologic data.

Use available technologies to assist in decedent identification (e.g., www.namus.gov, 

National Crime Information Center). 

Summary: There are several methods available that can 

be used to properly identify deceased persons. In some cases, the investigator should 

employ more than one method to confirm the 

identity of decedents. An autopsy along with 

authenticated in-dwelling medical devices 

may also be used to confirm identification. 

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-mortem changes and body location may 

indicate movement of the 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 and location of death.

Authorization: Medical Examiner/Coroner Official Office 

Policy Manual; State or Federal Statutory 

Authority.
33

D E A T H I N V E S T I G A T I O N 

Policy: The investigator shall document all postmortem 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 (e.g., color, location, blanchability, 

Tardieu spots) consistent/inconsistent 

with position of the body.

B. Rigor (e.g., stage/intensity, location on 

the body, broken, inconsistent with the 

scene).

C. Degree of decomposition (e.g., 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.

6. Participate in Scene Debriefing

Principle: The scene debriefing helps investigators 

from all participating agencies to establish 
34

R E S E A R C H R E P O R T / J U N E 2 0 1 1

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 an interagency scene debriefing to verify 

specific post-scene responsibilities.

Procedure: When participating in scene debriefing, the 

investigator should:

A. Determine post-scene responsibilities 

(e.g., identification, notification, media 

relations and evidence transportation).

B. Determine/identify the need for a specialist (e.g., crime laboratory technicians, social services, entomologists, Occupational 

Safety and Health Administration).

C. Communicate with the pathologist about 

responding to the scene or to determine 

the autopsy schedule (as needed).

D. Share investigative data (as required in 

furtherance of the investigation), for 

example, to disclose the possible 

existence of communicable diseases. 

E. Communicate special requests to appropriate agencies, being mindful of the necessity for confidentiality.
35

D E A T H I N V E S T I G A T I O N 

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. Complete processing 

of the scene may require an extended period 

of time beyond the initial scene investigation. This should be communicated between 

agencies beyond the initial scene, and investigators from different agencies need to stay 

in communication with each other throughout 

the entire time. 

7. Determine Notification Procedures (Next of 

Kin or Interested and Authorized Individuals)

Principle: Every reasonable effort should be made to 

notify the next of kin or interested and authorized individuals as soon as possible. Notification of next of kin or interested and authorized 

individuals initiates the disposition of remains 

and facilitates the exchange 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 the next of 

kin or interested and authorized individuals 

are 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 the next of kin or interested and 

authorized individuals (determine who will 

perform this task).
36

R E S E A R C H R E P O R T / J U N E 2 0 1 1

B. Locate the next of kin or interested and 

authorized individuals (determine who will 

perform this task).

C. Notify the next of kin or interested and 

authorized individuals (assign person(s) to 

perform this task) and record time of notification, or, if delegated to another agency, 

obtain and document confirmation when 

notification is made.

D. Notify interested and authorized agencies 

of status of the notification.

Summary: The investigator is responsible for ensuring that the next of kin or interested and 

authorized individuals are identified, located 

and notified in a timely manner. The time 

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

interested and authorized individuals and 

efforts to do so should be a matter of record. 

This ensures that every reasonable effort has 

been made to contact the family or interested 

and authorized individuals. When possible, 

notification should be performed in person. 

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 property and clothing that remain on the 

body.

Authorization: Medical Examiner/Coroner Official Office 

Policy Manual; State or Federal Statutory 

Authority.
37

D E A T H I N V E S T I G A T I O N 

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 

a witness present).

C. Identify property and clothing to be 

retained as evidence (in a controlled 

environment).

D. Recover biological samples before releasing the remains.

E. Place identification on the body and body 

bag.

F. Ensure/supervise the placement of the 

body into the bag and secure it.

G. Ensure/supervise the removal of the body 

from the scene.

H. Secure transportation.

Summary: Ensuring the security of the remains facilitates proper identification of the remains, 

maintains a proper chain of custody, and 

safeguards property and evidence.

39

D E A T H I N V E S T I G A T I O N 

Establishing and Recording 

Decedent Profile Information

Section E:

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 the circumstances 

of discovery were, where the discovery occurred, when the discovery was made and 

how the discovery was made.
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2. Determine Terminal Episode History

Principle: Preterminal circumstances play a significant 

role in determining cause and manner of 

death. Documentation of medical intervention 

and procurement of antemortem 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 the 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.

E. Obtain relevant medical and pharmacy 

records.

F. Obtain relevant antemortem specimens.

Summary: Obtaining records of preterminal circumstances and medical history distinguishes medical 

treatment from trauma. The history, relevant 

antemortem specimens, and electronic data 

collected and/or transmitted may assist the 

medical examiner/coroner in determining 

cause and manner of death. 
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D E A T H I N V E S T I G A T I O N 

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 obtained and taken, alcohol 

and drug use, and family medical history, 

including alternative practices. 

B. Document information from treating physicians and/or hospitals to confirm history 

and treatment.

C. Document physical characteristics and 

traits (e.g., left-/right-handedness, missing 

appendages, tattoos, implanted/indwelling 

devices, 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. Potential sources of medical 

information should include but are not limited 

to nursing homes, hospice agencies, intermediate care, and assisted living facilities. 
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Electronic media can be a valuable source of 

information for obtaining a decedent’s medical history. 

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 attempt to:

A. Document the decedent’s mental health 

history, including behavioral issues, hospitalizations and medications.

B. Document the history of suicidal ideations, 

gestures and/or attempts.

C. Document mental health professionals 

(e.g., psychiatrists, psychologists, counselors) who treated the decedent.

D. Document family mental health history.

E. Obtain relevant records. 

Summary: Knowledge of the mental health history allows the investigator to properly evaluate 
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D E A T H I N V E S T I G A T I O N 

the decedent’s state of mind and contributes 

to the determination of cause, manner and 

circumstances of death.

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, activities, 

hobbies and unusual behavioral patterns.

G. Document Internet activity (e.g., social 

media sites). 
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H. Document relationships, friends, caregivers and associates.

I. Document religious, ethnic or other pertinent information (e.g., religious objection 

to autopsy).

J. Document educational background.

K. Document criminal history and obtain 

relevant records.

Summary: Information from sources familiar with the 

decedent pertaining to the decedent’s social 

history assists in the determination of cause, 

manner and circumstances of death. Special 

attention may be required in dependent populations (e.g., infants, special needs and the 

elderly). 
45

D E A T H I N V E S T I G A T I O N 

Completing the Scene Investigation

Section F:

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.
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R E S E A R C H R E P O R T / J U N E 2 0 1 1

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, biological samples and other evidence prior to release of 

the body (indwelling or implanted devices). 

D. Document and arrange with the authorized 

receiving agent to reconcile all death certificate information.

E. Release the body to an authorized funeral 

director, medical examiner/coroner 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; 
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D E A T H I N V E S T I G A T I O N 

and releasing the body to the authorized 

funeral director or other authorized receiving 

agent.

3. Perform Exit Procedures

Principle: Completion of 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 and any dangerous 

materials or conditions have been reported 

and documented.

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 postinvestigative “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.

D. Alert family or interested and 

authorized individuals to potential 

unsafe scene conditions. 

Summary: Conducting a scene “walk through” upon exit 

ensures that all evidence has been collected, 
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R E S E A R C H R E P O R T / J U N E 2 0 1 1

that materials are not inadvertently left behind, and that any dangerous materials or 

conditions have been documented and 

reported to the proper entities.

4. Assist the Family or Authorized Individual(s)

Principle: The investigator provides the family or authorized individual(s) 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 or authorized individual(s) information 

regarding available community and professional resources.

Procedure: When the investigator is assisting the family 

or authorized individual(s), it is important to:

A. Inform them if an autopsy is required.

B. Inform them of available support services 

(e.g., victim assistance, police, social services, death scene cleanup).

C. Inform them of appropriate agencies to 

contact with questions (e.g., medical 

examiner/coroner offices, law enforcement, SIDS support group, etc.).

D. Ensure that the family or authorized 

individual(s) is not left alone with the 

body (if circumstances warrant).

E. Inform them of the approximate body 

release timetable.
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D E A T H I N V E S T I G A T I O N 

F. Inform them of the information release 

timetable (e.g., toxicology, autopsy results, 

as required).

G. Inform them of available reports, including 

cost, if any.

H. Inform them that they might be contacted 

regarding organ and tissue donation.

I. Inform them that they may receive inquiries from the media (this will be case 

dependent). 

Summary: Interaction with the family or authorized 

individual(s) allows the investigator to assist 

and direct them to appropriate resources. 

It is essential that families or authorized 

individual(s) be given a timetable of events so 

that they can make necessary arrangements. 

In addition, the investigator needs to communicate what information will be available and 

an approximate timeline for its release.

About the National Institute of Justice

The National Institute of Justice — the research, development and 

evaluation agency of the Department of Justice — is dedicated 

to improving our knowledge and understanding of crime and justice 

issues through science. NIJ provides objective and independent 

knowledge and tools to reduce crime and promote justice, 

particularly at the state and local levels.

NIJ’s pursuit of this mission is guided by the following principles:

•	 Research can make a difference in individual lives, in the

safety of communities and in creating a more effective 

and fair justice system. 

•	 Government-funded research must adhere to processes of

fair and open competition guided by rigorous peer review. 

•	 NIJ’s research agenda must respond to the real world needs

of victims, communities and criminal justice professionals. 

•	 NIJ must encourage and support innovative and rigorous

research methods that can provide answers to basic research 

questions as well as practical, applied solutions to crime. 

•	 Partnerships with other agencies and organizations, public

and private, are essential to NIJ’s success.

Our principal authorities are 

derived from:

• The Omnibus Crime Control and 

Safe Streets Act of 1968, amended 

(see 42 USC §§ 3721-3723)

• Title II of the Homeland Security Act 

of 2002

• Justice For All Act, 2004

To find out more about the National 

Institute of Justice, please visit:

www.nij.gov

or contact:

National Criminal Justice 

References Service

P.O. Box 6000

Rockville, MD 20849-6000

800-851-3420

www.ncjrs.gov

The National Institute of Justice is a component of the Office of Justice 

Programs, which also includes the Bureau of Assistance; the Bureau 

of Justice Statistics; the Community Capacity Development Office; 

the Office for Victims of Crime; the Office of Juvenile Justice and 

Delinquency Prevention; and the Office of Sex Offender Sentencing, 

Monitoring, Apprehending, Registering, and Tracking (SMART).
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