Embalming Report printable pdf download

Date _______-_______-_______

Total Time Spent: ___________________

Permission To Embalm: Yes No 

Treatment to proceed on basis of:

____ signed authorization ____ oral authorization

____ statutory 3-hr attempt to secure

Name & location where embalming procedure was performed:_____________________________

____ orders from _________________________ _______________________________________________________________________________

Deceased ___________________________________________________ Mortuary __________________________________________________

Age c.__________ yrs. Race _________________Sex:  male  female Weight c.____________lbs. Height c.___________ft.___________in.

Date of death ______________________________Time _____:_____ am pm

Time of removal _____:_____ am pm Date:____-____-____

PRE-EMBALMING OBSERVATIONS

 No  Yes

Operation before death?

Type/Area _______________________________ _______________________________________

 No  Yes

 Complete  Torso/Trunk

 Cranial

 Before embalming

 After embalming

Autopsy performed?

 Retained

 Received

Viscera:

Time between death and treatment: c.

hrs.

Time between receipt of remains and treatment: c. __________ hrs.

 Warm

 Cold  Refrigerated: Duration c.

 Thawed//Out of Refrigeration c._______hrs.

Body:

hrs.

Rigor mortis: Yes__________No___________

 No

 Yes

 Slight

 Moderate

 Intense

 Liquid

 Gas

Abdominal distension:

 No

 Yes

Purge before embalming:

Type:

Edema:  Abdomen  Thorax

 R. Leg

 L. Leg

 R. Arm

 L. Arm

 Face Degree _________________________

Discolorations:  Lividity

 Stain _____ in; ________________________________________________________________________________

Lesions: _______________________________________________________________________________________________________________

Comments: ____________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

EMBALMING PROCEDURE

Arteries Injected:

Veins Drained:

Disinfection: (Check Appropriate Areas)

Cm. Carotid

R-L

___ Iliac

R-L ___

Internal Jugular

R-L

Eyes _________

Other body orifices ___________

Subclavian

R-L

Femoral

R-L

Axillary

R-L

Mouth ________

Nose ______

Axillary

R-L

Radial

R-L

_____Iliac

R-L

Body orifices packed ____________

Brachial

R-L

Dorsalis pedis

R-L

Femoral

R-L

Remains bathed with antiseptic soap ________

Others _______________________________

Others_____________________________

Condition of: Arteries: __________________________________________ Veins: __________________________________________________

Injection:

pre-injection (co-injection)

_____gal.

arterial concentrate ___________ (%) or( Index) 1

_____oz

_____oz.

arterial concentrate ___________ (%) or (Index) 1

_____oz.

fluid modifier ________________

_____oz.

humectant __________________

_____oz

_____oz.

other_______________________

_____oz.

 Continuous

 Alternate

Injection Method:

 Intermittent

 Continuous

Drainage:

Quality of Drainage ______________________________________ Quality:  Heavy clots

 Medium

 Light

 None

Cavity Treatment:

Method:  Gravity

 Motorized

 Delayed

 Immediate

Cavity fluid ____________(%) Quantity used ________oz.

 Viscera immersed

 Preservative powder used

 Additional treatment: ___________________________________

Autopsied cases:

 Direct  Topical

 Hypodermic Treatment(Check Appropriate Areas):  Arms

 Torso

 Face  Legs  Neck

Other:

Distribution Exceptions __________________________________________________________________________________________________

Additional Treatment ____________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Condition of Body at Completion (include comments on conditions noted above) _____________________________________________________

______________________________________________________________________________________________________________________

Posing Features

 Suture

 Needle Injection   Natural

 Dentures

 Cotton

 Other ____________________

Mouth Closure :

 Cotton

 Eye Caps

 Natural

 Other

Eye Closure

Embalming Report

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