Coroners Forms Regulations

Regulation

Registration: R-065-2002
Source: Unofficial consolidation PDF (justice.gov.nt.ca)
Under: Coroners Act

This is an unofficial reading copy parsed from the Department of Justice consolidation PDF above — itself an office consolidation, not an official statement of the law. The authoritative text is in the Revised Statutes of the Northwest Territories, 1988 and the annual Statutes volumes.

s.1.1 amended by R-018-2017,s.2 in force Jan. 29, 2017
s.2 amended by R-077-2019,s.2 in force Oct. 1, 2019
s.3 amended by R-077-2019,s.2 in force Oct. 1, 2019
s.4 amended by R-074-2017,s.2 in force Oct. 4, 2017
s.7 repealed by R-018-2017,s.4 in force Jan. 29, 2017
s.form_6 amended by R-018-2017, art. 5 in force Jan. 29, 2017
s.form_6 amended by R-074-2017, art. 3 in force Oct. 4, 2017
s.form_6 amended by R-077-2019, art. 3 in force Oct. 1, 2019

Contents

1. 1 1.1. 1.1 2. 2 3. 3 4. 4 5. 5 6. 6 7. Repealed SCHEDULE FORM 1 (Section 1) FORM 1.1 (Section 1.1) FORM 2 FORM 3 FORM 4 FORM 5 FORM 6

The Commissioner, on the recommendation of the Minister, under section 64 of the Coroners Act and every enabling power, makes the Coroners Forms Regulations.

A warrant to take possession of the body of the deceased, issued under paragraph 9(1)(a) of the Act, must be in Form 1 of the Schedule.

1.1.

A warrant for the collection of a specimen, issued under subsection 14(5) of the Act, must be in Form 1.1 of the Schedule. R-018-2017,s.2.

A report of an investigating coroner, completed under paragraph 19(1)(a) of the Act, must be in Form 2 of the Schedule. R-077-2019,s.2.

A certificate of a determination that an inquest is or is not necessary, issued under subsection 21(5) of the Act, must be in Form 3 of the Schedule. R-077-2019,s.2.

A warrant to summon jurors, issued under subsection 32(3) of the Act, must be in Form 4 of the Schedule. R-074-2017,s.2.

A summons to a juror, witness or a person in possession or control of evidence, made under subsection 32(4) or 42(1) of the Act, must be in Form 5 of the Schedule.

A verdict of a jury, made under subsection 55(5) of the Act, must be in Form 6 of the Schedule.

Repealed, R-018-2017,s.4.

SCHEDULE

FORM 1 (Section 1)

WARRANT TO TAKE POSSESSION OF THE BODY

Name of deceased: ............................................................................ (given names of deceased) (surname of deceased)

To:............................................. or any member of the Royal Canadian Mounted Police, at ................................... in the Northwest Territories:

It being apparent that the deceased has died under circumstances that require an investigation under the Coroners Act, I issue this warrant to take possession of the body of the deceased.

Dated at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the . . . . . . . . . . . . . . . . . . . . . on . . . . . . . . . . . . . . . . . , 20 . . . . (name of community) (province or territory) (month, day)

Coroner’s name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (print name)

Coroner’s signature: . . . . . . . . . . . . . . . . . . . . . . . . . .

FORM 1.1 (Section 1.1)

WARRANT FOR COLLECTION OF SPECIMEN

Name of deceased: ............................................................................ (given names of deceased) (surname of deceased)

To: .................................................................... a health care professional

at ...........................................................................................

I authorize the collection of a specimen of

blood urine V.H. other ................................. (specify) from the deceased for the purposes of an investigation or inquest into his or her death under the Coroners Act.

That specimen should be provided to: .............................................................. (name of facility)

I authorize the above indicated facility to examine the specimen to determine the presence of the following:

ethanol carbon monoxide other ......................................... (specify)

And to make a report of the findings to: ............................................................

Apparent circumstances of death:

Coroner’s name: .............................................................................. (print name)

Coroner’s signature: ...........................................................................

FORM 2

REPORT OF INVESTIGATING CORONER (Section 2)

1. Information about the Deceased

Name of deceased: ............................................................................. (given names of deceased) (surname of deceased)

Gender: male female ........................................................ (gender other than male or female)

Ethnic origin: ...............................................................................

Location where death occurred: ................................................................... (community or approximate geographic location)

Community of residence of deceased: ..............................................................

Date of death: . . . . . . . . . . . . . . . . . . . . . . . Date found: . . . . . . . . . . . . . . . . . . . . . (month, day, year) (month, day, year)

Date of birth: . . . . . . . . . . . . . . . . . . . . . . . . Age: . . . . . . . . . . . . . . . . . . . . . . . . . . . (month, day, year)

2. Details of Death

Place where death occurred: ...................................................................... (name of hospital or institution, otherwise, description of place where death occurred)

Cause of death

Part I Immediate cause of death: (a) ........................................................ (due to, or as a consequence of)

Antecedent causes, if any, giving rise to the immediate cause (a) above, stating the underlying cause last: (b) ........................................................ (due to, or as a consequence of) (c) ........................................................

Part II Other significant conditions contributing to death but not causally related to the immediate cause (a) above:

.......................................................................................

....................................................................................... Classification: accidental suicide homicide natural undetermined

3. Recommendation

On the basis of my investigation of this death, I recommend that an inquest:

should be conducted should not be conducted

Coroner’s name: .............................................................................. (print name)

Coroner’s signature: ...........................................................................

Note: A description of the circumstances of death and any additional information is to be attached to this form.

FORM 3

CERTIFICATE OF CHIEF CORONER’S DETERMINATION (Section 3)

REGARDING INQUEST

Name of deceased: ............................................................................. (given names of deceased) (surname of deceased)

Gender: male female ....................................................... (gender other than male or female)

Date of death: . . . . . . . . . . . . . . . , 20 . . . . (month, day)

Location where death occurred: ................................................................... (community or approximate geographic location)

On the basis of an investigation of this death, I certify that an inquest:

is necessary is unnecessary

Chief Coroner’s name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (print name)

Chief Coroner’s signature: . . . . . . . . . . . . . . . . . . . . . . . . . .

FORM 4

WARRANT TO SUMMON JURORS (Section 4)

To: ......................................... at ....................................... in the Northwest Territories:

I direct you to summon the persons whose names are appended to this warrant to appear before me at the inquest referred to below, for possible selection to serve on the jury for the inquest.

Inquest: Name of deceased: ....................................................................... (given names of deceased) (surname of deceased)

Date of inquest: ....................................................................... (month, day, year)

Time of inquest: ...................................... o’clock in the a.m. p.m.

Place of inquest: .......................................................................

Coroner’s name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (print name)

Coroner’s signature: . . . . . . . . . . . . . . . . . . . . . . . . . .

(Append names of persons to be summoned to warrant)

FORM 5

SUMMONS (Section 5)

To: ......................................... at ....................................... in the Northwest Territories:

An inquest is being held into the death of .................................................... and you (given names of deceased) (surname of deceased) are personally summoned:

to perform the duties of a juror

to perform the duties of a witness

to produce the following evidence: ........................................................... ............................................................................................. ............................................................................................. .............................................................................................

You are hereby summoned and required to attend the inquest into the death of the deceased, that will commence on

. . . . . . . . . . . . . . . . . . . . . . , 20 . . . . at . . . . . . . . . . . . . . . a.m. p.m. at . . . . . . . . . . . . . . . . . . . . . . . , (month, day) (address or name of building)

in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , Northwest Territories. You must remain in attendance until your duties are (name of community)

complete or your evidence has been produced.

Failure to attend or to remain in attendance, in accordance with the requirements of this summons, will make you liable to arrest under warrant. Failure, without lawful excuse, to attend, to remain in attendance or to perform the duties listed above, will make you liable for punishment for contempt of court.

Coroner’s name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (print name)

Coroner’s signature: . . . . . . . . . . . . . . . . . . . . . . . . . .

FORM 6

VERDICT OF CORONER'S JURY (Section 6)

As a result of an inquest into the death of ...................................................... held (given names of deceased) (surname of deceased) on . . . . . . . . . . . . . . . . . . . . . . . . . . , 20 . . . . at ...................................................... (month, day) (name of community) in the Northwest Territories, we the jurors have considered the evidence and make the following determinations:

1. Identity of deceased: ................................................................

2. Date and time of death: ................................................................

3. Location and place where death occurred: ...................................................... (community or approximate geographic location and name of hospital or institution, or description of place where death occurred)

4. Cause of death

Part I Immediate cause of death: (a) ............................................................. (due to, or as a consequence of)

Antecedent causes, if any, giving rise to the immediate cause (a) above, stating the underlying cause last: (b) ............................................................. (due to, or as a consequence of) (c) .............................................................

Part II Other significant conditions contributing to death but not causally related to the immediate cause (a) above: ....................................................................................... .......................................................................................

5. Manner of death: accidental suicide homicide natural undetermined

6. Circumstances under which death occurred: ................................................... ............................................................................................. ............................................................................................. ............................................................................................. .............................................................................................

Our recommendations, if any, are attached to this form.

Jurors’ names Jurors’ signatures Date

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 20 . . . (print name) (signature) (month, day) (print name) (signature)

(print name) (signature)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (print name) (signature)

R-018-2017,s.5; R-074-2017,s.3; R-077-2019,s.3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 . . . (en lettres moulées) (signature) (jour et mois)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 . . . (en lettres moulées) (signature) (jour et mois)

R-018-2017, art. 5; R-074-2017, art. 3; R-077-2019, art. 3.