Maryland State Anatomy Board

AB:

Date of Arrival (Y/M/D):

Time of Arrival:

Last Name:

First Name:

Middle Name:

Suffix:

Date of Birth(0M/0D/Year):

Date of Death(0M/0D/Year):

Cause of Death:

Age:
Race:
Race Other:
Personal Affects
Personal Affects Notes:

Body Condition:
Body Weight:
Body Location:
Status:
Donor/Unclaimed:

Infectious Diseases

Hep B
HIV/AIDS
Other Infections:

AB:

Last Name:

First Name:

Unclaimed/Donor:

Status:

Death Location/Info

Date of Death(0M/0D/Year):
Time of Death:
Cause of Death:
Death Facility:
Death Address 1:
Death Address 2:
Death City:
Death State:
Death Zip:
Death MD County:

Usual Residence Location

Click if same as Death Location
Usual Residence Facility:
Residence Address 1:
Residence Address 2:
Residence City:
Residence State:
Residence Zip:
Residence MD County:

Transport Location

Click if same as Death Location
Transport Facility:
Transport Address 1:
Transport Address 2:
Transport City:
Transport State:
Transport Zip:
Transport MD County:
Reason for Different Site:

Body Information

Overweight
Approximate Weight
Stairs
Infectious

Death Report Information

Person Reporting Death:
Person Reporting Death Phone #(XXX-XXX-XXXX):
Police Complaint Number:
OCME Case Number:

Transporter Info

Transporter Company Contacted:
Transporter Area:
Specific Transporter Contacted:
Transporter Contacted date/time:

AB:

Last Name:

First Name:

Unclaimed/Donor:

Status:

Primary NOK #:

NOK# Getting Ashes:

Background

Date of Birth(0M/0D/Year):
Age:
Race:
Race Other:
Sex/Gender:
Birthplace (State):
Marital Status:
Surviving Spouse's Name:
Mother's Maiden Name
Father's Name:
U.S. Armed Forces?
Education:
Industry:
Usual Occupation:
SSN#:
Informant's Name:
Informant's Relationship:
Informant Mailing Address:
Veteran SAB-DD-214 Received

Veteran SAB-DD-214 Upload

Next of Kin 1

NOK1 Name:
NOK1 Address 1:
NOK1 Address 2:
NOK1 City:
NOK1 State:
NOK1 Zip:
NOK1 Phone:
NOK1 Email
NOK1 Relationship:

Next of Kin 3

NOK3 Name:
NOK3 Address 1:
NOK3 Address 2:
NOK3 City:
NOK3 State:
NOK3 Zip:
NOK3 Phone:
NOK3 Email
NOK3 Relationship:

Next of Kin 2

NOK2 Name:
NOK2 Address 1:
NOK2 Address 2:
NOK2 City:
NOK2 State:
NOK2 Zip:
NOK2 Phone:
NOK2 Email
NOK2 Relationship:

Next of Kin 4

NOK4 Name:
NOK4 Address 1:
NOK4 Address 2:
NOK4 City:
NOK4 State:
NOK4 Zip:
NOK4 Phone:
NOK4 Email
NOK4 Relationship:

AB:

Last Name:

First Name:

Unclaimed/Donor:

Status:

1a. Death Facility:
1b. Decedent First Name:
1c. Decedent Middle Name:
1d. Decedent Last Name:
1e. Decedent Suffix:
2. Date of Death:
3. Time of Death:
4a Facility Name [Place of Death]:
4b. City/Town of Death:
4c. County of Death:
5. Social Security Number:
6. Sex/Gender:
7. Age:
8. Date of Birth:
9. Birthplace [State]:
10a. Usual Residence [State]:
10b. Usual Residence [County]:
10c. Usual Residence [City]:
10d. Residence in City?:
10e. Address [Number, Street, Apt]:
10f. Residence Zip Code:
11. Marital Status
12. Armed Forces:
13 Hispanic Origin:

14. Race:
15. Education:
16a Usual Occupation:
16b Business/Industry:
17. Father's Name:
18. Mother's Maiden Name:
19. Surviving Spouse's Name:
20a. Informant Name:
20b. Informant's Relationship:
20c. Informant's Mailing Address:

Death Certificate Status

Death Certificate Type:
Doctor's Name Signing DC:
Doctor's Name Phone Number:
SAB Certifying Physicians:
DC Status:

DC Completed Info

Date DC Completed:
Date DC Signed:
Date to DVR:

Employee Name	Death Cert Comments	Comment	Comment DateTime

Death Location/Info

Usual Residence Location

Transport Location

Body Information

Death Report Information

Transporter Info

Background

Next of Kin 1

Next of Kin 3

Next of Kin 2

Next of Kin 4

Death Certificate Status

DC Completed Info

Body Assessment

Personal Affects

Flushed

Embalmed

Blood Draw

Specimen Request Body Usage

Embalming

RFID

Fluid Used

Body Details

Funeral Home

Reimbursement

Fees

Discount/Waiver

Reimbursement Total:

Cremation

Ashes Not Claimed

Veterans Ashes Burial

Ashes Claimed

Comments