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¶