N.Y. Comp. Codes R. & Regs. tit. 10, § 69-9.3
New York State department Of Health Infant Autopsy Protocol
| Decedent's name | Age | Sex | Race/Ethnicity |
| Local accession number | Date of birth | Date/time of death | Date of autopsy |
| Pathologist | County | ||
| 1) FINAL CAUSE AND MANNER OF DEATH | |||
| 2) STUDIES | ||||
| Routine Studies | Normal | Abnormal | Not Done | Findings |
| Photographs | □ | □ | □ | |
| Full-body X-Rays | □ | □ | □ | |
| Toxicology | □ | □ | □ | |
| Histopathology | □ | □ | □ | |
| Neuropathology | □ | □ | □ | |
| Metabolic Screening | □ | □ | □ | |
| Blood/Tissue for future studies | □ | □ | □ | |
| Studies, as indicated | Normal | Abnormal | Not Done | Findings |
| Viterous samples for glucose | □ | □ | □ | |
| Microbiology/Virology | □ | □ | □ | |
| Genetic Studies | □ | □ | □ | |
| Electrolytes | □ | □ | □ | |
| HIV Testing | □ | □ | □ |
COMMENTS:
_____ DOH-4278 (9/30) p1
| 3) CLINICAL SUMMARY | ||||
| Maternal Age: | ||||
| Birth Weight (in grams): | Gestational Age: | |||
| Pregnancy Complications: | ||||
| Medical History | YES | NO | NOT AVAILABLE | COMMENTS |
| Maternal Smoking | □ | □ | □ | |
| Maternal Alcohol Use | □ | □ | □ | |
| Maternal Drug Use | □ | □ | □ | |
| Sibling with SIDS | □ | □ | □ | |
| Other Relative with SIDS | □ | □ | □ | |
| Other Infant or Child Deaths | □ | □ | □ | |
| Sleeping Position (put to sleep): | □ Supine | □ Prone | □ Side | □ Unknown |
| Co-Sleeping: | □ Yes | □ No | □ Unknown | |
| Describe sleep habits and bedding, if known: | ||||
| COMMENTS: | ||||
| 4) DEATH SCENE INVESTIGATION | ||||
| □ Indicated | If indicated, state date: | |||
| □ Not indicated | If not indicated, state reason: | |||
| COMMENTS: | ||||
| PATHOLOGIST | Date Form Completed | |||
| DOH-4278 (9/03) p2 |
Autopsy Format
• Final Diagnoses
• Final Cause and Manner of Death
• External Examination
• Portmortem Changes
• Scars / Other Distinguishing Characteristics
• Clothing
• Weights and Measures
• General Appearance / Development
• Injuries (External and Internal)
• Therapeutic Procedures
• Resuscitation Evidence
• External Integument
• Internal Examination Head Neck Body Cavities Cardiovascular System Respiratory System Liver, Gallbladder and Pancreas Hemolymphatic System Genitourinary System Endocrine System Digestive System Musculoskeletal System
• Post-Mortem Studies Full body X-rays Histopathology Toxicology Metabolic Screen Neuropathology Cultures Blood/Tissue retained for future studies Other
_____ DOH-4278 (9/03) p3