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