ARC 9667C

ARC 9667C

PUBLIC HEALTH DEPARTMENT[641]

Notice of Intended Action

Proposing rulemaking related to county medical examiners
and providing an opportunity for public comment

    The Department of Health and Human Services hereby proposes to rescind Chapter 127, “County Medical Examiners,” Iowa Administrative Code, and to adopt a new Chapter 127 with the same title.

Legal Authority for Rulemaking

    This rulemaking is proposed under the authority provided in Iowa Code chapters 331 and 691.

State or Federal Law Implemented

    This rulemaking implements, in whole or in part, Iowa Code chapters 331 and 691.

Purpose and Summary

    This proposed chapter was reviewed as a part of the Red Tape Review process laid out in Executive Order 10. As a result of this review, restrictive terms were removed, areas that were duplicative were combined or eliminated, and editorial updates were made to reflect current policies and procedures. The proposed chapter outlines the duties and jurisdiction of a County Medical Examiner and the authority provided to a County Medical Examiner to perform investigations and autopsies “over deaths which affect the public interest.”

Regulatory Analysis

    A Regulatory Analysis for this rulemaking was published in the Iowa Administrative Bulletin on October 1, 2025. A public hearing was held on the following date(s):

     ?   October 21, 2025

Fiscal Impact

     This rulemaking has no fiscal impact to the State of Iowa.

Jobs Impact

    After analysis and review of this rulemaking, no impact on jobs has been found.

Waivers

    Any person who believes that the application of the discretionary provisions of this rulemaking would result in hardship or injustice to that person may petition the Department for a waiver of the discretionary provisions, if any, pursuant to 441—Chapter 6.

Public Comment

     Any interested person may submit written or oral comments concerning this proposed rulemaking, which must be received by the Department no later than 4:30 p.m. on December 2, 2025. Comments should be directed to:

Public Hearing

    Public hearings at which persons may present their views orally or in writing will be held as follows:

    Persons who wish to make oral comments at a public hearing may be asked to state their names for the record and to confine their remarks to the subject of this proposed rulemaking.

     Any persons who intend to attend a public hearing and have special requirements, such as those related to hearing or mobility impairments, should contact the Department and advise of specific needs.

Review by Administrative Rules Review Committee

    The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rulemaking by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rulemaking at its regular monthly meeting or at a special meeting. The Committee’s meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).

    The following rulemaking action is proposed:

    ITEM 1.  Rescind 641—Chapter 127 and adopt the following new chapter in lieu thereof:

CHAPTER 127

COUNTY MEDICAL EXAMINERS

641—127.1(144,331,691) Definitions.

    “Autopsy” means the external and internal postmortem examination of a deceased person.

    “Cause of death” means the disease or injury that sets in motion the chain of events that eventually results in the death of a person. The physician shall consider “but for” this injury or disease the person would still be living.

    “County medical examiner” or “CME” means a medical or osteopathic physician or surgeon licensed in the state of Iowa and appointed by the board of supervisors to serve in this capacity.

    “County medical examiner investigator” or “CME-I” means an individual appointed by a county medical examiner, with approval by the board of supervisors and the state medical examiner, to serve under the supervision of a county medical examiner to assist in death investigations.

    “County of appointment” means the county that requests a medical examiner to conduct an investigation, perform or order an autopsy, or prepare a report(s) in a death investigation case. The request may be authorized by the county attorney or the county medical examiner. The county of appointment shall be the county in which the death occurred.

    “Cremation” means the technical process, using heat and flame, that reduces human remains to bone fragments.

    “Cremation permit” means an electronic cremation permit approved by the medical examiner.

    “Day” means calendar day.

    “Death” means the condition as described in Iowa Code section 702.8.

    “Death affecting the public interest” means any death of a human being in which the circumstances are sudden, unexpected, violent, suspicious, or unattended, including but not limited to those deaths listed in Iowa Code sections 331.802(3) and 144.29.

    “Deputy county medical examiner” or “DCME” means an individual appointed by a county medical examiner, with approval by the board of supervisors and the state medical examiner, to assist the county medical examiner in the performance of the county medical examiner’s duties.

    “EMER” means the electronic medical examiner report.

    “External examination” means a close inspection of the exterior of a deceased human body for the purpose of locating, describing, and delineating any and all injuries or other abnormalities. External examination of a body does not constitute an autopsy, even if toxicology samples are obtained.

    “Fee” means an amount to be paid to a county medical examiner’s office as determined by the board of supervisors of the county of appointment for completion of an investigation, autopsy, or report(s). Fees for services provided by the state medical examiner’s office are established in rule 641—126.3(691).

    “Manner of death” means the circumstances under which the cause of death occurred and may be specified as follows: natural, accident, suicide, homicide, undetermined, or pending.

    “Medical care provider” means an individual licensed or certified in any medical profession, including but not limited to a physician, physician assistant, nurse, emergency medical care provider, certified nurse’s aide, pharmacist, physical therapist, and medical technologist.

    “Medical examiner” means the state medical examiner, deputy state medical examiner, county medical examiner, or deputy county medical examiner.

641—127.2(331,691) Duties of medical examiners—jurisdiction over deaths that affect the public interest.

    127.2(1) Jurisdiction. Upon receiving notification of a death that affects the public interest, a medical examiner shall notify any appropriate law enforcement agency not otherwise notified and take charge of the body of the decedent. The body shall not be disturbed or removed from the position in which it was found without authorization from the medical examiner except for the purpose of preserving the body from loss or destruction or permitting the passage of traffic on a highway, railroad, or airport, or unless the failure to remove the body might endanger life, safety, or health.

    127.2(2) Investigation. A county medical examiner shall conduct a preliminary investigation of the cause and manner of death and utilize the investigative protocol outlined in the County Medical Examiner’s Handbook as amended to August 1, 2025, available from the state medical examiner’s office. A medical examiner may perform or authorize performance of any scientific study to assist in identifying the cause, circumstances, and manner of death. A medical examiner shall cooperate with other investigating officials and agencies involved and share reports, information, and conclusions with these officials and agencies.

    127.2(3) Reports required.

    a.  EMER.

    (1)  Preparation and filing. A county medical examiner shall electronically enter the examiner’s findings in the Preliminary Medical Examiner Report in the EMER system. A county medical examiner must complete and submit the EMER within 14 days of the date of death and file a copy of the EMER with the county attorney within 14 days of the date of the death and retain a copy for the county medical examiner’s records.

    (2)  Content. The EMER shall be completed as fully as possible in light of all available information and may be signed by either a county medical examiner or a county medical examiner investigator acting under the supervision of a county medical examiner. If the cause or manner of death, identity of the decedent, or other information is unknown or pending at the time of filing, “unknown” or “pending” may be written in the appropriate area of the form. If additional information becomes available, this information shall be forwarded to the state medical examiner in written form at such time as it becomes available to be added as a supplement to the file.

    b.  Jurisdiction declined or terminated. An EMER with designated, abbreviated, or minimal information shall be completed and submitted in accordance with subparagraphs 127.2(3)“a”(1) and “a”(2) in cases reported to the county medical examiner where jurisdiction is terminated or declined.

    127.2(4) Disposition of body. After an investigation, including an autopsy if one was performed, the body of the decedent shall be made available to the funeral home designated by a relative or friend of the decedent for burial or appropriate disposition. A medical examiner cannot use influence in favor of a particular funeral director or funeral home. If no one claims a body, it shall be disposed of as provided in Iowa Code chapter 142.

    127.2(5) Coverage.

    a.  When an individual is required to report a death to a medical examiner and the county medical examiner cannot be located or is not available, the individual must contact a county medical examiner from any adjacent Iowa county to perform those duties outlined in this chapter. The responding medical examiner has full authority to conduct any procedures necessary to the investigation of the cause and manner of death. If an adjacent county medical examiner is not available, the state medical examiner shall be contacted and may act in the capacity of a county medical examiner.

    b.  The responding county medical examiner will be reimbursed by the county for which the service is provided for all fees and expenses at the rate that is customarily paid by the county for which the service is provided or at a rate agreed upon by the medical examiner and the board of supervisors of the county for which the service is provided.

641—127.3(331,691) Autopsies.

    127.3(1) Autopsy required. A county medical examiner shall order that an autopsy be performed in the following cases:

    a.  All cases of homicide or suspected homicide, irrespective of the period of survival following injury.

    b.  All cases in which the manner of death is undetermined.

    c.  All cases involving unidentified bodies.

    d.  All deaths of children under the age of two when there is not a clear cause of death, including suspected cases of unexpected or unexplained death.

    e.  All work- and farm-related deaths unless there is an obvious natural cause of death.

    f.  All drowning deaths.

    g.  All deaths of commercial vehicle drivers that occur during the performance of their job duties.

    h.  Deaths due to poisoning.

    i.  Deaths of airplane pilots who die as a result of an airplane crash. The National Transportation Safety Board and the Federal Aviation Administration should be contacted prior to the autopsy to request specimen kit(s).

    j.  Deaths due to a natural disaster, including tornadoes and floods.

    k.  Deaths in a prison, jail or correctional institution or under police custody, where there is not a natural disease process that accounts for the death.

    127.3(2) Autopsy recommended. It is recommended that a county medical examiner should perform an autopsy or order that an autopsy be performed in the following cases:

    a.  Deaths of adolescents less than 18 years of age when there is not a natural cause of death.

    b.  All cases that involve a motor vehicle crash.

    c.  Deaths from suicide.

    d.  All pedestrian, bicycle, motorcycle, snowmobile, boating, watercraft, three- or four-wheeler or all-terrain vehicle fatalities.

    e.  Deaths due to failure of a consumer product.

    f.  Deaths due to a possible public health hazard.

    g.  Deaths due to drug or alcohol abuse or overdose.

    h.  Electrical- and lightning-related deaths.

    i.  Deaths from burns or smoke or soot inhalation.

    j.  All deaths related to exposure, such as hypothermia and hyperthermia.

    k.  All sport-related deaths, including but not limited to deaths from auto racing and deaths resulting from injuries sustained in football, basketball, baseball, softball, soccer, or other games or sports.

    127.3(3) Other deaths. For those deaths not listed in subrule 127.3(1) or 127.3(2), a county medical examiner will determine whether the public interest requires an autopsy and order that an autopsy be performed. A county medical examiner may consult with the state medical examiner to assist in determining the need for an autopsy.

    127.3(4) Performance of autopsy.

    a.  Who may authorize. Autopsies may be authorized by the state medical examiner, the county medical examiner for the county in which the death occurred or the county where any injury contributing to or causing the death was sustained, or the county attorney who would have jurisdiction in any criminal proceeding related to the death.

    b.  Who may perform. An autopsy must be performed by a pathologist trained or with experience in forensic pathology, licensed to practice medicine and surgery or osteopathic medicine and surgery in the state of Iowa and board-certified by the American Board of Pathology, or under the direct supervision of a physician with these qualifications. The following types of deaths shall be transported to the office of the state medical examiner for autopsy unless otherwise approved by the state medical examiner:

    (1)  Deaths of adolescents through 18 years of age when there is not a known or preexisting natural cause of death.

    (2)  All cases of homicide or suspected homicide, irrespective of the period of survival following injury.

    (3)  Deaths of children under the age of two years if death results from an unknown cause or is unexpected.

    (4)  All suspicious suicides.

    (5)  All high-profile deaths, including but not limited to deaths of elected officials in municipal, state or federal government.

    (6)  All deaths of inmates occurring in any institutions under the department of corrections as outlined in Iowa Code section 904.102, excluding those deaths that result from a pre-existing medical condition.

    c.  Permit required—EMER. A medical examiner must complete the EMER. All reasonable efforts must be made to complete the EMER prior to the performance of an autopsy.

    127.3(5) Autopsy report. A complete record of the findings of the autopsy shall be submitted to the state medical examiner’s office, the county attorney of the county where the death occurred and the county attorney of the county where the injury contributing to or causing the death was sustained within 90 days following the date of death unless unusual circumstances requiring further investigation or testing exist. The report filed shall include transcriptions of the autopsy observations and opinions and toxicology reports.

    127.3(6) Out-of-state autopsy. The body of a decedent may be sent out of state for an autopsy or postmortem examination only if the county medical examiner certifies in writing that the out-of-state autopsy or examination is necessary for any of the following reasons:

    a.  A forensic pathologist practicing in the state of Iowa is unavailable;

    b.  Requiring an in-state autopsy would cause financial hardship; or

    c.  Requiring an in-state autopsy would delay the funeral or burial more than three days.

    127.3(7) Retention and disposal of tissues, organs, and bodily fluids. The office of the state medical examiner will retain tissues, organs, and bodily fluids as necessary to determine the cause and manner of death or as deemed advisable by the state medical examiner for medical or public health investigation, teaching, or research. Tissues, organs, and bodily fluids will be retained at a minimum for the time periods established by the National Association of Medical Examiners and may be retained for a longer time period at the discretion of the state medical examiner. Tissues, organs, and bodily fluids retained under this subrule will be disposed of without the specific consent or notification of the legal next of kin and in accordance with applicable federal and state regulations, including but not limited to OSHA-recommended biohazard and blood-borne pathogen standards. The anatomical material must be removed from the laboratory premises through use of a contracted, licensed, and bonded medical waste removal service to a medical waste processing center for final disposition.

641—127.4(331,691) Fees.

    127.4(1) Payment of fee and expenses.

    a.  A medical examiner receives from the county of appointment or the county of the decedent’s residence a fee for each preliminary investigation and report submitted in a case in which a death affects the public interest. A county medical examiner shall also receive from the county of appointment or the county of the decedent’s residence the examiner’s actual expenses. The fee and expenses are submitted by the county medical examiner to the county of appointment, which may immediately pay the invoice or forward the invoice to the county of the decedent’s residence for payment to the county medical examiner. If the county medical examiner does not receive payment from the county of the decedent’s residence within 60 days of receiving the invoice, the county of appointment shall pay the invoice.

    b.  A pathologist or other physician who performs an autopsy under medical examiner authorization shall be paid for the services by the county of appointment.

    c.  Invoices produced for services performed by a county medical examiner, deputy county medical examiner or county medical examiner investigator must be submitted as a joint invoice to the county of appointment when services were rendered in a case by multiple county medical examiner staff.

    127.4(2) Reimbursement.

    a.  County of residence different from county of appointment—Iowa resident. The county of the decedent’s residence shall reimburse the county of appointment for the fee and expenses paid by the county of appointment.

    b.  Death caused by criminal defendant. If the person’s death is caused by a criminal defendant who has been convicted and sentenced for murder, voluntary manslaughter, involuntary manslaughter, or homicide by vehicle, the county of the person’s residence may recover from the defendant the fee and expenses.

    c.  Out-of-state resident—law enforcement involvement. The fee and expenses of a county medical examiner who performs an investigation or autopsy of a person who dies after being brought into the state for emergency medical treatment by or at the direction of an out-of-state law enforcement officer or public authority will be paid by the state. A claim for payment shall be filed with the state appeal board.

    d.  Out-of-state resident—no law enforcement involvement. The fee and expenses of a county medical examiner who performs an investigation or autopsy of an out-of-state resident shall be paid by the county of appointment.

641—127.5(144,331,691) Death certificates—deaths affecting the public interest.

    127.5(1) Completion. The funeral director to whom the body is released shall complete the personal data on the death certificate. The medical examiner must complete the manner of death and cause of death sections of the death certificate within 72 hours after determination of the cause and manner of death. If an autopsy is performed by the state medical examiner, the death certificate medical certifier sections will be completed by the state medical examiner’s office.

    127.5(2) Filing. The funeral director shall file the certificate with the county registrar in the county in which the death occurred. A death certificate shall be filed prior to the issuance of a burial transit permit and prior to disposal of the body.

    127.5(3) Extension of time. If a medical examiner is unable to complete the manner of death and cause of death sections of the death certificate within the 24-hour time period, the funeral director must file a death certificate form completed with all available information. Such certificate is authority for the issuance of a burial transit permit. Within 15 days, a supplemental report shall be filed with the local registrar that provides the information missing from the original certificate.

641—127.6(331,691) Cremation.

    127.6(1) Permit obtained prior to cremation—cremation permit. A permit for cremation must be obtained from a county medical examiner or state medical examiner prior to cremation of a body of a decedent. Cremation permits must be completed in the electronic death registry system. For the purposes of this requirement, a hard copy or facsimile of a hard copy shall only be utilized if the electronic death registry system is off-line for four or more hours.

    127.6(2) Requirements for issuance of permit. A county medical examiner shall direct an inquiry into the cause and manner of death and determine whether the death is one that affects the public interest prior to issuing a cremation permit.

    a.  Death that affects the public interest. If the death occurred in a manner specified in Iowa Code section 331.802(3) or if reasonable suspicion that the death occurred in such a manner exists, a medical examiner shall view the body, make a personal inquiry into the cause and manner of death, and complete or cause to be completed all necessary autopsy or postmortem examinations prior to issuing a cremation permit.

    b.  Death that does not affect the public interest. If, following an inquiry into the cause and manner of death, the county medical examiner determines that the death did not occur in a manner specified in Iowa Code section 331.802(3), a medical examiner is not required to view the body prior to issuing a cremation permit. A county medical examiner must certify on the Cremation Permit in the electronic death registry system that the medical examiner’s inquiry into the cause and manner of death did not disclose evidence that the death occurred in a manner specified in Iowa Code section 331.802(3).

    127.6(3) Fee. A fee for the Cremation Permit by Medical Examiner shall be paid by the family, next of kin, guardian of the decedent, or other person authorized to act on behalf of the decedent.

641—127.7(331,691) County medical examiner investigators.

    127.7(1) Appointment. A county medical examiner may appoint one or more county medical examiner investigators upon approval by the board of supervisors and the state medical examiner.

    127.7(2) Qualifications.

    a.  Prior to appointment, a CME-I should possess a minimum of two years of experience as a licensed or certified nurse or medical care provider. A certified peace officer may be appointed to the position of CME-I if a nurse or medical care provider is not available.

    b.  A CME-I shall satisfy the following criteria:

    (1)  Prior to or within two years of appointment, attend the St. Louis University School of Medicine Basic Medicolegal Death Investigation Course or its state medical examiner-approved equivalent; and

    (2)  Prior to or within five years of appointment, obtain certification at the registry level as a death investigator by the American Board of Medicolegal Death Investigators.

    c.  A CME-I is not required to meet the requirements of paragraph 127.7(2)“a” or “b” if the individual has functioned in the capacity of a CME-I for a period of five years.

    d.  If a CME is unable to appoint a CME-I who possesses the qualifications required by paragraph 127.7(2)“a,”“b,” or “c,” the CME may request a waiver. Waiver requests must be submitted in writing to the state medical examiner and include the efforts undertaken by the CME to locate a CME-I who meets the above qualifications; the qualifications of the individual willing to serve in the capacity of a CME-I; and the period of time for which the waiver is requested, not to exceed two years. The state medical examiner has sole discretion to waive the requirements of this rule and may withdraw or modify a waiver request upon a finding that the CME-I has failed to adequately perform the duties of the position or for other good cause.

    e.  If a CME-I is unable to meet the eligibility requirements for obtaining registry certification due to the small number of cases requiring investigation in the county of appointment, then a waiver must be obtained from the state medical examiner in order for the investigator to continue the investigator’s duties. The county medical examiner must submit a request for a waiver in writing with documentation of the number of deaths occurring in the county of appointment that require death investigation. The waiver must be renewed every five years if the required number of investigations has still not been achieved.

    127.7(3) Duties. A CME-I shall assist in death investigations. A CME-I acting under the supervision of a county medical examiner may sign the EMER. A CME-I cannot sign a certificate of death or a cremation permit.

    127.7(4) Supervision. A CME-I shall serve under the supervision of a county medical examiner. A CME-I provides services under the direction of a county medical examiner or state medical examiner’s office. A CME-I can perform services in a manner that is consistent with the protocol outlined in this chapter.

    127.7(5) Fees. Fees for the services provided by a CME-I shall be paid by the county of appointment or by the county of the decedent’s residence. A CME-I shall receive from the county of appointment or the county of the decedent’s residence reimbursement for actual expenses. The fee and expenses must be submitted by the CME-I to the county of appointment, which may immediately pay the invoice or forward the invoice to the county of the decedent’s residence for payment to the CME-I. If the CME-I does not receive payment from the county of the decedent’s residence within 60 days of receiving the invoice, the county of appointment shall pay the invoice.

641—127.8(331,691) Deputy county medical examiners.

    127.8(1) Appointment. A county medical examiner may appoint one or more DCMEs upon approval by the board of supervisors and the state medical examiner.

    127.8(2) Qualifications. A DCME must be licensed in the state of Iowa as a medical or osteopathic physician or surgeon.

    127.8(3) Duties. A DCME serves at the direction of the county medical examiner and may perform any duty of a county medical examiner that is delegated by the county medical examiner to the DCME.

    127.8(4) Fees. Fees for the services provided by a DCME are paid by the county of appointment or by the county of the decedent’s residence. A DCME receives from the county of appointment or the county of the decedent’s residence reimbursement for actual expenses. The fee and expenses will be submitted by the DCME to the county of appointment, which may immediately pay the invoice or forward the invoice to the county of the decedent’s residence for payment to the DCME. If the DCME does not receive payment from the county of the decedent’s residence within 60 days of receiving the invoice, the county of appointment pays the invoice.

641—127.9(331,691) Failure to comply with rules. If a county medical examiner, deputy county medical examiner, county medical examiner investigator, pathologist, or other physician fails to comply with these rules, the state medical examiner may provide written notice of the failure to comply to that individual, the appropriate county medical examiner, and the appropriate county board of supervisors. Within 30 days of the date of the notice, the individual to whom the notice was provided shall submit a written response to the state medical examiner, outlining a proposed corrective action plan. If no response is received within the 30 days or if the proposed corrective action plan is unacceptable, the state medical examiner will forward copies of the notice and all pertinent correspondence and information to the board of supervisors for the county that appointed the individual, notifying the board of the individual’s failure to comply with these rules.

641—127.10(331,691,22) Confidentiality. Records and reports of a medical examiner may be confidential records pursuant to Iowa Code section 22.7(2), 22.7(5), and 22.7(41) and other provisions of Iowa law. Prior to releasing a medical examiner record or report to a member of the public, a county medical examiner may inform the appropriate law enforcement agency, the county attorney, and the state medical examiner to determine whether release is authorized under Iowa law.

641—127.11(331,691,670) Indemnification. A board of supervisors shall defend, hold harmless, and indemnify a county medical examiner and any properly appointed staff members to the extent provided in Iowa Code chapter 670.

These rules are intended to implement Iowa Code chapters 331 and 691.