Los Santos Emergency Services

Patient Information:

Patient's Full Name *
First and Last Name: "John Doe"

Date of Request *

Files Requested *
Please select all that are applicable.

Patient File
Recent Check Up
Laboratory Test
Autopsy
Narrative Summary
Death Certificate
Body Diagram

Requester's Information:

Name of Requester *
First and Last Name: "John Doe"

Phone Number *
Please give us the best number to contact you at, should we need follow up information.

Reason for Request / Proof of Warrant *
Please give us the reason for your request, or proof of the warrant.

Association of Requesting Party *
Please select the option most applicable.

Family Beneficiary Los Santos Police Department San Andreas Sheriffs Department Department of Justice

Additional Notes
Please feel free to include any other information you feel necessary.

Requester's Signature *
Please sign the request.