EFTA00130098

# OFFICE OF CHIEF MEDICAL EXAMINER
CITY OF NEW YORK

# Edward

M. E. # M, 19, 19432

Name of deceased: JEFFREDN EPSSTEN

Address: 9 571 $ \pi $ N/C

Date and place of birth: Brooklyn NY 1/20/53

Closest known family member name: MARK EOPSTEIN (BROTHER)

Address:

Telephone:

Cell Phone:

Did the deceased live with another person? If yes: Name:___

Relationship:___Address:___

Telephone:（___）___ Cell Phone:（___）___

## To your knowledge did the deceased have any of these following conditions:



High blood pressure





☐ Cancer





☐ Pregnant in the last year





Heart problems





□ HIV infection



If yes, the outcome was:



□ Diabetes





□ AIDS





Live birth





☐ Seizures





☐ Hepatitis (liver) ☐ Induced termination





☐ Lung problems





☐ Alcohol Abuse





Spontaneous termination





□ Tuberculosis





□ Drug Abuse





None





☐ Tobacco use





Psychiatric illness Date of outcome:___





Brain infection/disease





Methadone treatment: if yes, where:___





☐ Radiation Treatment





□ Other:___



[ ] Recent hospitalizations or travel: if yes, where and when:___



□ Dentist name/address):___



☐ Tattoos or scars (e.g., old surgery), describe:___



Any Hospice care in last 30 days? If so, where:___



If the deceased was treated for any of the above conditions, please describe the conditions and list the doctor's name/telephone, hospital, clinic, and dates of treatment:



Signature

Brother

Relationship



Date