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N__________________-20____

Sede : _____________________________

Ministerio Pblico
Instituto de Medicina Legal

Datos del Fallecido:

Datos de Inters:

Cadver

Feto

Restos Humanos

Identificado:

SI

NN

Restos seos

Entidad que realiza el Levantamiento


Fiscala y/o Juzgado

PNP

IML

Datos Personales:
Fec. Nac.

Nombre(s)

Lugar del Hecho


Pas ____________ Departamento ___________________________

Da

Apellido Paterno

Mes

Ao

Provincia __________________________________________________

Edad aproximada:
Semanas de
Gestacion
Hora(s)
Da (s)
Mes(es)
Ao(s)

Apellido Materno y/o casada

Documento de Identidad

Sexo

__________________________________________________

Urb./ AAHH./ PPJJ __________________________________________


Tipo/Via:

Av.

Jr.

Mz.

Calle

____________________________________________ N _____
Lugar Av. / Calle

Raza

Masc.
Fem.
Indeterminado.

DNI
LM
Pasaporte
Partida de Nac.
Carnet Extranjeria
Sin Documento
Otros

Distrito

Blanca
Mestiza
Negra
Amarilla
Indeterm.
Indoamericana

Lugar de Fallecimiento
Pas ____________ Departamento ___________________________
Provincia __________________________________________________
Distrito

__________________________________________________

Urb./ AAHH./ PPJJ __________________________________________

Detallar:__________________

Tipo/Via:

N Doc.

Av.

Jr.

Mz.

Calle

_____________________________________________ N _____
Lugar Av. / Calle

Estado Civil
Soltero
Casado
Conviviente
Separado
Divorciado
Viudo
Ignorado

Grado de Instruccin
Analfabeto
Alfabeto
Prim. Incompleta
Prim. Completa
Sec. Incompleta
Sec. Completa
Sup. Tcnica incompleta
Sup. Tcnica completa
Sup. Universitaria incompleta
Sup. Universitaria completa
Postgrado
Ignorado

Antecedentes Patolgicos
SI

NO
Hipertensin
Diabetes
Tuberculosis
Pat. Cardiaca
Insf. Renal

Ocupacin
Ama de casa
Empleado prof.
Empleado tc.
Emp. No prof/tec.
Empresario
Trabaj. Sexual
Trabaj. Indep.
Trab. Del Hogar
Estudiante
Obrero
Taxista
Cambista
Jubilado
Desocupado
Ignorado

Documentos Recibidos al Ingreso


Levantamiento Mdico Legal
Acta Levantamiento Fiscal o Judicial
Levantamiento Policial
Procede de Servicio de Salud:

Historia Clnica
Epicrisis

SI

NO

PNP

Privado

Institucin
MINSA

ESSALUD

FF.AA.

Otros

Nombre del Establecimiento:


_________________________________________________________
Fecha y Hora del Fallecimiento:________________________________

No Sabe
VIH/SIDA
Hepatitis
Cncer
Enf. Mental
Enf. respiratorias
Otros
______________________________________

NECROPSIA:
Practicado Por : Dr(a) ______________________________________________
Colegio Medico N ______________________
Y Por: Dr(a) ______________________________________________________

Fecha y Hora de Ingreso:

Colegio Medico N ______________________

Datos Generales:
Autoridades Presentes:

Fiscal

Juez

Otros

Autoridad que Solicita la Necropsia


Detallar: __________________________________________________________

Nombre de la Autoridad Titular

_________________________________________________________________

Motivo de Solicitud de Necropsia:


Necropsia de Ley

Tcnico de Apoyo:
Nombres y Apellidos:

Necropsia Ley Post-exhumacin

_________________________________________________________________

Necropsia Clnica
Otras Autoridades : _________________________________________________

Persona que Interna el Cadver:

_________________________________________________________________

Nombres y apellidos ________________________________________


Cargo:__________________________

N de C.I._______________

Fecha y Hora de Inicio de Necropsia: ___________________________________

Dependencia :______________________________________________

-1-

Descripcin de prendas de vestir y objetos del fallecido:


PRENDAS DE VESTIR: ( Describir Tipo, Color, Material )
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________

Objetos: ( Describir Tipo, Color, Estado )


________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________

Fenmenos Cadavricos :
Rigidez:

Fenmenos Oculares:
Pupilas:

Miosis

Corneas: Transparente

Opacas

Tensin: Normal

Hipertnica

Instalado

Parcial

Flacida

Mandbula

Midriasis

Cuello
Miembros sup.

Hipotnica

Observaciones ____________________________________________________

Miembros inf.

Livideces:

_______________________________________________

Obs :___________________________________________
Modificable

Poco Modificable

No Modificable

Dorsales
Ventrales

Temperatura:

Laterales derecho

Ambiental ... C

Laterales Izquierdo

Cadavrica Rectal .......................................................... C

En pantaln

Cadavrica Heptica C

Observaciones: ___________________________________________________

Obs :___________________________________________
_______________________________________________

Putrefaccin:
Fase Cromtica

Fase Enfisematoso

Colicuativa

Fenmenos de Conservacin Cadavrica:

Observacines: ___________________________________________________

Adipocira

________________________________________________________________

Corificacin
Momificacin

Presencia de Flora y Fauna: ________________________________________

Obs:____________________________________________

________________________________________________________________

________________________________________________

Tiempo Aprox. De Muerte:


Horas

Das

Semanas

Meses

Aos

EXAMEN EXTERNO :
Talla:

mt

Peso:

Kg.

Tipo Constitucional.
Leptosmico

Atltico

Pcnico

Dismrfico

Normosmico

Observaciones: _________________________________________________________________________________________________________
Estado de Nutricin :

Bueno

Estado de Hidratacin:

Malo
Hidratado

Regular

Caquctico

Deshidratado

Caractersticas Identificatorias:
Tatuajes

Nevos

Cicatrices

Deformidades

Observaciones : ________________________________________________________________________________________________________

-2-

PIEL:
Caractersticas: (Color, Elasticidad, Higiene, Pniculo Adiposo, y Observaciones )
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________

CABEZA:

Lesiones

SI

NO

Permetro Ceflico:

cm

Forma:

Dolicrneo

Mesocrneo

Cabello: Negro puro

Braquicrneo

Castao

Rubio Claro

Pelirrojo

Blanco

Castao Oscuro

Caf

Negrusco

Caf Oscuro

Rubio Cenizo

Cenizo

Pardo

Rojizo

Rubio Oscuro

Rubio

Entrecano

Otros: _______________________________________________

Pardo Claro

Caractersticas: (Tamao, forma, cantidad y Alteraciones) ______________________________________________________________________


_____________________________________________________________________________________________________________________

CARA
Tipo Facial: Ovalado

Recto

Romboidal

Triangular

Redondo

Alargado

Pentagonal

Anguloso

Trapezoidal

Caractersticas (Frente, color, simetra y Alteraciones)__________________________________________________________________________


_____________________________________________________________________________________________________________________
Ojos: Color: Negro
Caf

Pardos Oscuros

Pardos Claros

Azules

Miel

Verdes

Otros:

Gris Verdoso

Gris

______________________________

Caractersticas: _______________________________________________________________________________________________________
Nariz:

Tamao :

Grande

Pequea

Mediana

Caractersticas: (Forma, Simetra, y alteraciones) _____________________________________________________________________________


_____________________________________________________________________________________________________________________
Boca:

Grande

Mediana

Pequea

Labios: (Forma, Color, Volumen, Hidratacin, y Alteraciones) ___________________________________________________________________


_____________________________________________________________________________________________________________________
Dentadura: Completa
Orejas:

Incompleta

Grandes

Medianas

Con Prtesis

Edentulo

Pequeas

Caractersticas (Simetra, Implantacin y Alteraciones) _________________________________________________________________________

CUELLO:
Largo

Corto

Mediano

Caractersticas: (Simetra, Forma y Alteraciones) _____________________________________________________________________________


_____________________________________________________________________________________________________________________
Lesiones:

SI

NO

TRAX:
Permetro Torxico:

cm

En tonel

Cifosis

Pectum Excavatum

Asimtrico Plano

Escoliosis

Ofoescoliosis
Cilndrico

Pectum Carinatum

Mediano

Alteraciones : _________________________________________________________________________________________________________
Lesiones: SI

NO

MAMAS: Caractersticas (Simetra, tamao, consistencia)


_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Pigmentacin areolar: SI

NO

Secrecin mamaria:

NO

SI

-3-

ABDOMEN:
cm

Permetro Abdominal:

No

Si

Cordn Umbilical:

Globuloso

Excavado

Forma: Plano

Describir: _______________________________________________________________________
Distendido

Normal

Batraciano

Caractersticas: (Tensin, simetra y Alteraciones) ______________________________________________________________________________


Lesiones:

No

Si

PELVIS:
Asimtrico

Simtrico

GENITALES

Lesiones:

Lesiones :

Si

Si

No

No

Femenino
Vulva, Vagina, Introito Vaginal (Caractersticas) ________________________________________________________________________________
_______________________________________________________________________________________________________________________
Hmen: (Caractersticas) ___________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Lesiones : Si

No
Si

Contenido Vaginal

No

Detallar : _______________________________________________________________________________________________________________

Masculino
Pene, Bolsas escrotales (Caractersticas) _____________________________________________________________________________________
_______________________________________________________________________________________________________________________
Testculos: (Caractersticas) ________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Lesiones : Si

No

REGIN ANAL Y PERINEAL : _______________________________________________________________________________________


_______________________________________________________________________________________________________________________
Lesiones : Si

No

MIEMBROS SUPERIORES (Simetra, trofismo, lechos ungueales, punturas y alteraciones)


_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Lesiones: Si

No

MIEMBROS INFERIORES (Simetra, trofismo, lechos ungueales, punturas y alteraciones)


_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Lesiones: Si

No

EXAMEN INTERNO
CABEZA
Bveda: _______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

-4-

Cuero Cabelludo (Cara Interna): ___________________________________________________________________________________________


_______________________________________________________________________________________________________________________
Lesiones: Si

No

Base de Crneo: ________________________________________________________________________________________________________


_______________________________________________________________________________________________________________________
Lesiones: Si

No

Meninges Duramadre y Aracnoides: ________________________________________________________________________________________


_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Peso:

Encfalo:

gr

Medidas:

cm

cm

cm

Descripcin (Color, Consistencia, Superficie, Simetra, Ventrculos, Cerebelo y Alteraciones) _____________________________________________


_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Lesiones : Si

No

Vasos: ________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Macizo Facial:

Lesiones: Si

No

CUELLO
Columna Cervical: ______________________________________________________________________________________________________
Lesiones:

Si

No

Faringe: _______________________________________________________________________________________________________________
Lesiones:

Si

No

Esfago: ______________________________________________________________________________________________________________
Lesiones:

Si

No

Laringe: _______________________________________________________________________________________________________________
Lesiones:

Si

No

Glotis: ________________________________________________________________________________________________________________
Lesiones:

Si

No

Epiglotis: ______________________________________________________________________________________________________________
Lesiones:

Si

No

Hioides: _______________________________________________________________________________________________________________
Lesiones:

Si

No

Trquea:_______________________________________________________________________________________________________________
Lesiones:

Si

No

Tiroides:

Peso:

gr

Medidas:

cm

cm

cm

Caractersticas: (Color, Consistencia, Superficie, Simetra y alteraciones) ___________________________________________________________

Vasos: ________________________________________________________________________________________________________________

-5-

TRAX
Columna dorsal y parrilla costal : ________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Lesiones:

Si

No

Pleuras y Cavidades
Descripcin : (Adherencias, Contenido y Alteraciones) : ________________________________________________________________________
_____________________________________________________________________________________________________________________

Mediastino: __________________________________________________________________________________________________________
Timo

Peso:

gr

Medidas:

cm

cm

cm

Descripcin : _________________________________________________________________________________________________________

Pulmn Derecho:

Peso:

gr

Medidas:

cm

cm

cm

Pulmn Izquierdo:

Peso:

gr

Medidas:

cm

cm

cm

Descripcin: (Color, Consistencia, Superficie, Textura y Alteraciones) ____________________________________________________________


____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Lesiones: Si

No

Pericardio
Contenido: (Detallar)___________________________________________________________________________________________________
Lesiones:

Si

Corazn:
Lesiones:

No
Peso:

Si

gr

Medidas:

cm

cm

cm

No

Caractersticas: (Forma, Color, Consistencia, Superficie, Cavidades y Alteraciones) _________________________________________________


____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Vlvula Aortica

Mide:

mm.

Vlvula Mitral

Mide:

mm.

Vlvula Tricspide:

Mide:

mm.

Vlvula Pulmonar

Mide:

mm.

Caractersticas: _______________________________________________________________________________________________________
Paredes Ventriculares:

Derecha:

mm

Izquierda:

mm

Observaciones: ______________________________________________________________________________________________________
Arterias Aorta/Pulmonar: ______________________________________________________________________________________________
____________________________________________________________________________________________________________________
Arterias Coronarias: __________________________________________________________________________________________________
____________________________________________________________________________________________________________________

-6-

ABDOMEN PELVIS
Columna Lumbosacra y Esqueleto Plvico: _______________________________________________________________________________
Lesiones:

Si

No

Pared Peritoneal: _____________________________________________________________________________________________________


Lesiones:

Si

No

Cavidad Peritoneal:

Libre

Contenido

Detallar: ___________________________________________________________________________ con volumen de ___________ cm.3 Aprox.


Diafragma: _____________________________________________________________________________________ Lesiones

Si

No

Epiplones: _____________________________________________________________________________________ Lesiones

Si

No

Mesenterio: ____________________________________________________________________________________ Lesiones:

Si

No

Estmago: Caractersticas (Distensin, Serosa, Mucosa y Alteraciones) __________________________________________________________


_____________________________________________________________________________________________________________________
Contiene: _____________________________________________________________________________________________________________
Lesiones:

Si

No

Intestino Delgado: (Distensin, Serosa, Mucosa y Alteraciones)________________________________________________________________


______________________________________________________________________________________________ Lesiones:

Si

No

Intestino Grueso: (Distensin, Serosa, Mucosa y Alteraciones)_________________________________________________________________


______________________________________________________________________________________________ Lesiones:

Si

No

Apndice: ____________________________________________________________________________________________________________
Hgado:

Peso:

gr

Medidas:

cm

cm

cm

Caractersticas: (Color, Consistencia, Superficie, Bordes y Alteraciones) ___________________________________________________________


_____________________________________________________________________________________________________________________
Lesiones: Si

No

Vescula y Vas Biliares : (Distensin, Serosa, Mucosa y Alteraciones)


_____________________________________________________________________________________________________________________
Litiasis
Bazo:

Si

No

Peso:

gr

Medidas:

cm

cm

cm

Caractersticas (Color, Consistencia, Superficie, Bordes y Alteraciones) ____________________________________________________________


_____________________________________________________________________________________________________________________
Lesiones: Si

No

Pncreas: Peso:

gr

Medidas:

cm

cm

cm

Caractersticas (Color, Consistencia, Superficie, Conducto Pancretico y Alteraciones) ________________________________________________


_____________________________________________________________________________________________________________________
Lesiones: Si

No

Rin Derecho:

Peso:

gr

Medidas:

cm

cm

cm

Rin Izquierdo:

Peso:

gr

Medidas:

cm

cm

cm

Caracteristicas: (Color, Consistencia, Superficie Capsular y Cortical, Alteraciones) ___________________________________________________


_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Lesiones: Si

No

Suprarrenales: ________________________________________________________________________________________________________

-7-

Vas de Excrecin Renal: (Pelvis Renal, Urteres, Vejiga y Uretra)


_____________________________________________________________________________________________________________________
Lesiones: Si

No

Vasos: ______________________________________________________________________________________________________________
Lesiones: Si

No

APARATO GENITAL
FEMENINO
Utero:

Peso:

gr

Medidas:

cm

cm

cm

Carctersticas: (Forma, Direccin, Cuello, Orificio externo y Cuerpo) _____________________________________________________________


____________________________________________________________________________________________________________________
Cavidad Endometrial:
Placenta

Ocupada:

Si

Feto

No
Otros

Edad Gestacional:

(Semanas)

Descripcin: __________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Anexos:
Ovario Derecho: Peso:

gr

Medidas:

cm

cm

cm

Ovario Izquierdo: Peso:

gr

Medidas:

cm

cm

cm

Caractersticas: _______________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Lesiones:

Si

No

MASCULINO
Prstata:
Caractersticas: (Color, Consistencia, Superficie, y Alteraciones) _________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Lesiones:

Si

No

RGANOS ACOMPAANTES

Placenta

Cordn Umbilical

Caractersticas: _______________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

-8-

Descripcin Lesiones Traumticas Externas e Internas


________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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________________________________________________________________________________________________________________________
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________________________________________________________________________________________________________________________
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________________________________________________________________________________________________________________________
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________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

-9-

DATOS REFERENCIALES (USO INTERNO)


_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

PERENNIZACIN DE EVIDENCIAS (detalle)


Se realiz perennizacin de evidencias Si

No

Tipo :
Fotogrfico:

Foto-revelado

Digital

Vdeo: Cinta

Disc.compact

Memoria digital

Cdigo de las vistas tomadas:


_____________________________________________________________________________________________________________________
Responsable de capturar imagen
Nombres y Apellidos: ___________________________________________________________________________________________________
Se registro en cuadernillo de grficos Si

No

Detalle del Registro :____________________________________________________________________________________________________


Observaciones ________________________________________________________________________________________________________

EXMENES AUXILIARES
EXAMEN ANTOMO PATOLGICO
Muestra(s) Remitida(s): ________________________________________________________________________________________________
Examen(es) solicitado(s): _______________________________________________________________________________________________
EXAMEN TOXICOLGICO
Muestra(s) Remitida(s): ________________________________________________________________________________________________
Examen(es) solicitado(s): _______________________________________________________________________________________________
EXAMEN BIOLGICO
Muestra(s) Remitida(s): ________________________________________________________________________________________________
Examen(es) solicitado(s): _______________________________________________________________________________________________
EXAMEN ESTOMATOLGICO
Muestra(s) Remitida(s): ________________________________________________________________________________________________
Examen(es) solicitado(s): _______________________________________________________________________________________________
EXAMEN ANTROPOLGICO
Muestra(s) Remitida(s): ________________________________________________________________________________________________
Examen(es) solicitado(s): _______________________________________________________________________________________________
DIAGNSTICO POR IMGENES
Muestra(s) Remitida(s): ________________________________________________________________________________________________
Examen(es) solicitado(s): _______________________________________________________________________________________________

- 10 -

DIAGNSTICO DE MUERTE:

ETIOLOGA MDICO LEGAL PRESUNTIVO:

Causa Presuntiva de Muerte:


Causa Final ______________________________________ FORMA _____________________________________________
Causa Intermedia _________________________________ AGENTE ____________________________________________
Causa Bsica ____________________________________ TIPO DE AGENTE ____________________________________
Agente Causante ______________________________________________________________________________________

Datos preliminares:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Fecha y Hora que se culmina la Necropsia:

____________________________
FIRMA

DIAGNSTICO INTEGRADO: (DIAGNSTICO DE


MUERTE + EXMENES DE LABORATORIO)

____________________________
FIRMA

ETIOLOGA MDICO LEGAL DEFINITIVA

Causa Final ______________________________________ FORMA ____________________________________________


Causa Intermedia _________________________________ AGENTE ___________________________________________
Causa Bsica ____________________________________ TIPO DE AGENTE ____________________________________
Agente Causante _______________________________________________________________________________________
Conclusiones:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Fecha y Hora de cierre del Informe Pericial:

____________________________
FIRMA

____________________________
FIRMA
- 11 -