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Get Medical Examiner's Report Form

Name: (Last, First, M.I) Sex: Male Date of Birth: Female Victim s Address: (Number, Street) City, Town, Post Office State Zip Code Victim s Telephone Number ( ) Address Where Burn Occurred (Number, Street) City, Town , Post Office Date of Injury State Time of Injury Hrs. Percent Burned % Zip Code Degree(s) of Burn(s) st 1 Parish nd 2 rd 3 Inhalation Burn Area(s) of Body Injured Injury Severity Face Head Leg 1. Moderate - (treated and released) Neck Shoulder Foot 2. Seri.

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