"Embalming Report Template"

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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:
st
nd
rd
pre-injection (co-injection)
1
_____gal.
2
_____gal.
3
_____gal.
st
nd
rd
arterial concentrate ___________ (%) or( Index) 1
_____oz
2
_____oz.
3
_____oz.
st
nd
rd
arterial concentrate ___________ (%) or (Index) 1
_____oz.
2
_____oz.
3
_____oz.
st
nd
rd
fluid modifier ________________
1
_____oz.
2
_____oz.
3
_____oz.
st
nd
rd
humectant __________________
1
_____oz
2
_____oz.
3
_____oz.
st
nd
rd
other_______________________
1
_____oz.
2
_____oz.
3
_____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
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:
st
nd
rd
pre-injection (co-injection)
1
_____gal.
2
_____gal.
3
_____gal.
st
nd
rd
arterial concentrate ___________ (%) or( Index) 1
_____oz
2
_____oz.
3
_____oz.
st
nd
rd
arterial concentrate ___________ (%) or (Index) 1
_____oz.
2
_____oz.
3
_____oz.
st
nd
rd
fluid modifier ________________
1
_____oz.
2
_____oz.
3
_____oz.
st
nd
rd
humectant __________________
1
_____oz
2
_____oz.
3
_____oz.
st
nd
rd
other_______________________
1
_____oz.
2
_____oz.
3
_____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
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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