St. Petersburg College
Funeral Services Reports
Student Name
Funeral Home
Preceptor
Preceptor's Telephone Number ( ) -
Record Number Other
Date
Embalming Report
Date of Death: Unknown
Time of Death: : Unknown
Cause of Death:
Gender:
Color of Eyes: Other:
Color of Hair: Other
Race:
Approximate Age:
Approximate Weight: lbs.
Approximate Height: ft in
Nutrition:
Personal Effects:
Identifying marks and Deformities:
Teeth: Other:
Post Mortem Interval: hours
Refrigeration:
Autopsy
Organ/Tissue Donor: Organ(s)/Tissue:
Rigor Mortis:
Tissue Moisture:
Post Mortem Pigmentation:
Purge (specify orifice):
Gangrene: Location(s):
Lacerations: Location(s):
Fracture: Location(s):
Burns: Location(s):
Arteries Injected:
(check all that apply)
Right Common Carotid
Left Common Carotid
Right Femoral
Left Femoral
Right Axillary
Left Axillary
Right Brachial
Left Brachial
Right Iliac
Left Iliac
Other
Veins Drained:
(check all that apply)
Right Internal Jugular
Left Internal Jugular
Right Femoral
Left Femoral
Right Axillary
Left Axillary
Right Basilic
Left Basilic
Right Iliac
Left Iliac
Direct Drainage from Heart
Other
Fluid Used: Total Solution: gallons
Pre-injection: Chemical Name:
   
Company Name:
Index:
Ounces:
Primary Injection:
(Arterial Fluids and
Co-Injection Fluids)
Chemical Name:
1.
2.
3.
4.
Company Name:
Index:



Ounces:



Cavity Injection: Chemical Name:
   
Company Name:
Index:
Ounces:
Other Chemicals Used: Chemical Name:
   
Company Name:
Index:
Ounces:
Areas Lacking Distribution:
Embalming Condition:

At Completion:
At Casketing:
At Service:

Special Post-Embalming Treatments:
Check those procedures that were performed by you the student and describe the technique or materials used for each procedure: Primary Disinfection
Rigor Relieved
Body Positioned
Body Shaved
Mouth Disinfected and Posed
Nostrils Disinfected
Eyes Disinfected
Orifices Packed
Mixed Fluids
Set Pressures and Flow on Embalming Machine
Injection Points
Drainage Points
Areas Massaged
Sutures Used
Cavity Treatment
Bathed Body
Washed Hair
Autopsy Treatment
Terminal Disinfection


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