Medical Examiner File Number

(For Office Use Only)

Office of the Chief Medical Examiner

REQUEST TO ACCESS INFORMATION
(Use this form if you would like to request information for yourself)

If you would like to request reports, please complete all sections of this form and return by mail with a cheque or
money order payable to the Government of Alberta to:
Office of the Chief Medical Examiner
7007 – 116 Street
Edmonton, AB T6H 5R8

Applicant Information (please print)

Last Name First Name

Relationship to Deceased

Mailing address

City/Town Province Postal Code

Home Phone Cell Phone Work Phone

Decedent Information (please print)

Last Name First Name Middle Name (or initial)

Date of Birth Date of Death (if known)

Forms Requested (please indicate)

Amount Report Availability
Certificate of Medical Examiner
All cases
($15 per copy)
Detailed Autopsy Report Package (includes Summary Autopsy Report
and Toxicological Analysis if toxicology testing was performed) Autopsy only
($40 per copy)
Summary Autopsy Report
Autopsy only
($15 per copy)
External Examination Form Only
External only
($15 per copy)
Toxicological Analysis Only
If performed
($20 per copy)

_______________________________________ ___________________________
Signature Date

The personal information on this form is collected under S. 33(c) of the Freedom of Information and Protection of Privacy Act and will be
used to respond to your request. If you have any questions about this collection of information, please contact the Medical Examiner Records
Department at 780 427 4987.