Autopsy Information Form
› In addition to the Consent for Autopsy and Donation of Brain Tissue form, this form must travel with the body. It will need to be completed by the pathologist and shipped along with the brain tissue.
To be completed by the patient / family: Name of patient: ___________________________________________________ Date of birth: _______________________
Name of healthcare power of attorney / next of kin: _______________________________________________________ Relationship to patient: __________________________________________________________________________________ Address: _________________________________________________________________________________________________ City: ______________________________________ State / Province: _____ ZIP code: ____________ Country: __________ Phone: ___________________________________________ Email: _______________________________________________
To be completed by the pathologist / diener:
Name: __________________________________________________________ Your accession number: ________________ Direct phone: _____________________________________ Email: _______________________________________________ Address: _________________________________________________________________________________________________ City: ______________________________________ State / Province: _____ ZIP code: ____________ Country: __________
Date of death: _____________________________________ Time of death: _______________________________________
14
Postmortem interval: _____________________________ Fresh brain weight: ___________________________________ Signature of pathologist: ________________________________________________________________________________ Date: _____________________
Information / Protocol for the Pathologist Thank you for agreeing to perform an autopsy to establish a diagnosis and to obtain tissue for special studies and research.
Please perform the autopsy as soon as possible after death, preferably within 12 hours( up to 48 hours is still acceptable if the body has been kept in cold storage).
Split the brain down the middle through the corpus callosum, cerebellar vermis, and brainstem. Put the right hemisphere in a plastic bag into the coldest available deep freezer( preferably-70 ° C). To prevent distortion of the specimen, put the medial aspect of the brain down flat so that it will freeze in its normal shape. Immerse the left hemibrain in formalin so that it is buffered to neutrality.
Shipping instructions: When ready to ship, pack the frozen specimen in 48 hours’ worth of dry ice in a Styrofoam shipping container. If you need dry ice provided, please reach out to the Mayo Clinic to coordinate having dry ice provided. Separately from the frozen specimen, wrap the formalin-fixed specimen in paper towels that are damp with formalin and put into a leakproof plastic bag in a separate shipping container. Do not tie the boxes together. Ship both boxes separately using an agency that will deliver overnight, such as FedEx or UPS. FedEx will not accept Collect on Delivery( COD) packages, so it must be prepaid, but we can reimburse you for this expense. Please call the Mayo Clinic Brain Bank directly for the FedEx account number. Please send this material early in the week to avoid delivery during the weekend. Do not ship on Thursdays or Fridays.
Ship both packages to: Neuropathology, Mayo Clinic • 4500 San Pablo Road • Birdsall Building, Room 347 • Jacksonville, FL 32224
Both the“ Consent for Autopsy and Donation of Brain Tissue” and the“ Autopsy Information Form” must be sent along with the tissue.
We will mail the report of our findings to you. We will provide a letter and a copy of the report to the next of kin regarding our findings. We are interested in other types of parkinsonism and neurodegenerative diseases and, of course, control brains as well, if they have been reasonably well worked up by the clinicians, especially where good psychometric studies have also been done.
Please contact the Mayo Clinic Brain Bank at 904-953-2439 with any questions related to brain tissue procurement or shipment.