Records Request Form.

Entry Id

Records Request Form

To request a copy of the Autopsy Exam and/or Toxicology Examination Report from the Burlington County Medical Examiner's Office, please fill out and submit the information below.

Applicant's Name:*

First Name

Last Name

Applicant's Address:*

City:*

State*

Zip:*

Phone Number*

Email

Relationship to Decedent:*

Spouse Parent Child Sibling Executor

Other:

Decedent's Name:*

Date of Death:*

Decedent's Marital Status:*

Single Divorced Married Widowed Separated

BCMEO Case#: (Office Use Only)

Purpose of Request:*

Informational Legal Medical

Other:

Attach copies of Identification (Required for Next of Kin):

No File Chosen

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Miscellaneous Info/Notes:

Date Created

:

Created By

Last Updated

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Updated By