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    Pre-Embalming Observations: Arteries Injected: Veins Drained: Disinfection: (Check Appropriate Areas)

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    May Montano
    This document records details of an embalming procedure. It documents information about the deceased individual, observations made before embalming, and details of the embalming process including arteries and veins accessed, fluids injected, areas of the body treated, and how the body was posed and dressed after completion. Signatures and license numbers of the embalmer and any assistants are included at the end.

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    Pre-Embalming Observations: Arteries Injected: Veins Drained: Disinfection: (Check Appropriate Areas)

    Uploaded by

    May Montano
    66 views2 pages
    This document records details of an embalming procedure. It documents information about the deceased individual, observations made before embalming, and details of the embalming process including arteries and veins accessed, fluids injected, areas of the body treated, and how the body was posed and dressed after completion. Signatures and license numbers of the embalmer and any assistants are included at the end.

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    blank form embalming report for death

    Original Title

    main_embalming-report-template

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    © © All Rights Reserved

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    This document records details of an embalming procedure. It documents information about the deceased individual, observations made before embalming, and details of the embalming process including arteries and veins accessed, fluids injected, areas of the body treated, and how the body was posed and dressed after completion. Signatures and license numbers of the embalmer and any assistants are included at the end.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    66 views2 pages

    Pre-Embalming Observations: Arteries Injected: Veins Drained: Disinfection: (Check Appropriate Areas)

    Uploaded by

    May Montano
    This document records details of an embalming procedure. It documents information about the deceased individual, observations made before embalming, and details of the embalming process including arteries and veins accessed, fluids injected, areas of the body treated, and how the body was posed and dressed after completion. Signatures and license numbers of the embalmer and any assistants are included at the end.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    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
    Operation before death?  No  Yes Type/Area _______________________________ _______________________________________
    Autopsy performed?  No  Yes  Complete  Torso/Trunk  Cranial  Before embalming  After embalming
    Viscera:  Retained  Received
    Time between death and treatment: c. hrs. Time between receipt of remains and treatment: c. __________ hrs.
    Body:  Warm  Cold  Refrigerated: Duration c. hrs.  Thawed//Out of Refrigeration c._______hrs.
    Rigor mortis: Yes__________No___________
    Abdominal distension:  No  Yes  Slight  Moderate  Intense  Liquid  Gas
    Purge before embalming:  No  Yes 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) 1st _____gal. 2nd _____gal. 3rd _____gal.
    st nd
    arterial concentrate ___________ (%) or( Index) 1 _____oz 2 _____oz. 3rd _____oz.
    arterial concentrate ___________ (%) or (Index) 1st _____oz. 2nd _____oz. 3rd _____oz.
    st nd
    fluid modifier ________________ 1 _____oz. 2 _____oz. 3rd _____oz.
    humectant __________________ 1st _____oz 2nd _____oz. 3rd _____oz.
    st nd
    other_______________________ 1 _____oz. 2 _____oz. 3rd _____oz.

    Injection Method:  Continuous  Alternate


    Drainage:  Intermittent  Continuous
    Quality of Drainage ______________________________________ Quality:  Heavy clots  Medium  Light  None
    Cavity Treatment:
    Cavity fluid ____________(%) Quantity used ________oz. Method:  Gravity  Motorized  Delayed  Immediate

    Autopsied cases:  Viscera immersed  Preservative powder used  Additional treatment: ___________________________________

    Other:  Direct  Topical  Hypodermic Treatment(Check Appropriate Areas):  Arms  Torso  Face  Legs  Neck
    Distribution Exceptions __________________________________________________________________________________________________
    Additional Treatment ____________________________________________________________________________________________________
    ______________________________________________________________________________________________________________________
    Condition of Body at Completion (include comments on conditions noted above) _____________________________________________________
    ______________________________________________________________________________________________________________________

    Posing Features
    Mouth Closure :  Suture  Needle Injection   Natural  Dentures  Cotton  Other ____________________
    Eye Closure  Cotton  Eye Caps  Natural  Other
    IDENTIFICATION AND TREATMENT REFERENCE
    Indicate on chart all identifying scars, incisions, lesions and
    special body characteristics.

    Description of items marked on chart:

    1. ______________________________________________

    2. ______________________________________________

    3. ______________________________________________

    4. ______________________________________________

    5. ______________________________________________

    6. ______________________________________________

    7. ______________________________________________

    8. ______________________________________________

    Date and Time Case Report Completed:_____________________________________________________________________

    ____________________________________________________ License No. ________________________________________


    Embalmer
    ____________________________________________________ Provisional License No. ______________________________
    Student or Provisional Licensee

    E. g. “housekeeping” post-embalming checklist (re-aspirated, dressed, etc.)

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