Laserfiche WebLink
CUSTODIAL RESPONSIBILITY <br />AT TIME OF DEATH <br />(Check One) <br />ˆ Process of Arrest <br />ˆ City Jail <br />ˆ County Jail <br />ˆ Adult Camp or Ranch <br />ˆ Local Juvenile Facility/Camp <br />ˆ Adult Operations and Adult Programs (formerly CDC) <br />ˆ Division of Juvenile Justice (formerly CYA) <br />ˆ State Hospital <br />ˆ Other <br />RECORD KEY <br />DATA SUPPLIED BY (Please print the following information): <br />Name: Title: <br />Agency: Telephone: <br />Address: <br />AGENCY TYPE <br />ˆ Police <br />ˆ Sheriff <br />ˆ Probation <br />ˆ State <br />ˆ Other Local <br />DOJ USE ONLY <br />CUSTODY STATUS <br />(Check One) <br />ˆ Process of Arrest <br />ˆ In Transit <br />ˆ Awaiting Booking <br />ˆ Booked - No Charges Filed <br />ˆ Booked - Awaiting Trial <br />ˆ Sentenced <br />ˆ Out to Court <br />ˆ Other <br />CUSTODY OFFENSE <br />DOJ USE ONLY <br />DATE OF DEATH SUBJECT NAME <br /> MM DD YYYY Last First Middle <br />CII NUMBER DATE OF BIRTH <br />AGENCY NCIC NUMBER <br />LOCATION WHERE CAUSE <br />OF DEATH OCCURRED <br />(Check One) <br />ˆ Not Applicable (Natural) <br />ˆ Crime/Arrest Scene <br />ˆ Facility -- Administrative <br />ˆ Facility -- Booking <br />ˆ Facility -- Living <br />ˆ Facility -- Common <br />ˆ Facility -- Holding <br />ˆ Facility -- Medical Treatment <br />ˆ Other <br />MEANS OF DEATH <br />(Check One) <br />ˆ Pending Investigation <br />ˆ Not Applicable (Natural) <br />ˆ Handgun <br />ˆ Rifle/Shotgun <br />ˆ Club, Blunt Instrument <br />ˆ Hands, Feet, Fists <br />ˆ Knife, Cutting Instrument <br />ˆ Hanging, Strangulation <br />ˆ Alcohol/Drug Overdose <br />ˆ Execution: Lethal Gas/Injection <br />ˆ Cannot Be Determined <br />ˆ Other <br />MANNER OF DEATH <br />(Check One) <br />ˆ Pending Investigation <br />ˆ Natural <br />ˆ Accidental -- Injury to Self <br />ˆ Accidental -- Injury by Other <br />ˆ Suicide <br />ˆ Homicide Willful (Law Enforcement Staff) <br />ˆ Homicide Willful (Other Inmate) <br />ˆ Homicide Justified (Law Enforcement Staff) <br />ˆ Homicide Justified (Other Inmate) <br />ˆ Execution <br />ˆ Cannot Be Determined <br />ˆ Other <br /> / / <br /> / / <br />Department of JusticeState of California <br />DEATH IN CUSTODY REPORTING FORM <br />BCIA 713 (rev. 11/05) <br />Department of Justice <br />Criminal Justice Statistics Center <br />P.O. Box 903427 <br />Sacramento, CA 94203-4270 <br />Facsimile: (916) 227-0427 or 227-3561 <br />Telephone: (916) 227-3545 <br />GENDER <br />ˆ Male <br />ˆ FemaleCOUNTY <br /> MM DD YYYY <br />FACILITY OF DEATH <br />(Check One) <br />ˆ Crime/Arrest Scene <br />ˆ Local Hospital <br />ˆ City Jail <br />ˆ County Jail <br />ˆ Adult Camp or Ranch <br />ˆ Local Juvenile Facility/Camp <br />ˆ Adult Operations and Adult <br /> Programs (formerly CDC) <br />ˆ Division of Juvenile Justice <br /> (formerly CYA) <br />ˆ State Hospital <br />ˆ Other <br /> RACE/ETHNICITY (Check One) <br />ˆ Other Asian <br />ˆ Black <br />ˆ Chinese <br />ˆ Cambodian <br />ˆ Filipino <br />ˆ Guamanian <br />ˆ Hispanic <br />ˆ American Indian <br />ˆ Japanese <br />ˆ Korean <br />ˆ Laotian <br />ˆ Other <br />ˆ Pacific Islander <br />ˆ Samoan <br />ˆ Hawaiian <br />ˆ Vietnamese <br />ˆ White <br />ˆ Asian Indian <br />Send completed form to: <br /> ORIGINAL AMENDMENT