Questions about the autopsy reports of Boris Vozrozhdenniy in 1959. Continuation

Our previous report, presented at the February 2025 conference, was devoted to the issues related to Vozrozhdenniy's forensic medical examination reports from 1959 Case files. The report also included forensic comparative studies of typewriters, conducted by forensic expert Vladimir Ankudinov. We continued our research, not only on the forensic medical examination reports, but also on the history of the Sverdlovsk Regional Bureau of Forensic Medical Examination as a whole, and learned new facts about its founder, Porfiriy Ustinov.

We also managed to find material from those years that was extremely useful for our research – the "Collection of Organizational and Methodological Materials on Forensic Medical Examination." This rare publication contains all official, instructional, methodological, and reference materials on forensic medical examination published before 1959. These materials helped us understand how forensic medical examination bureaus functioned in the 1950s, the period of interest to us. What departmental instructions governing forensic examinations were in those years? What unified organizational framework existed at that time, ensuring, on the one hand, that experts complied with the requirements of the Criminal Procedure Code and the Criminal Code, and, on the other, that forensic examinations were conducted using scientifically sound and appropriate methods.

Full excerpts from these materials are available on the Taina and Otrog 1079 forums; only those directly relevant to the topic of the report will be presented here.

1) We studied the staffing standards for medical personnel at forensic medical examination bureaus during those years. According to Order №643 of the USSR Minister of Health dated July 14, 1951, in addition to experts, mid-level medical personnel—specially trained medical registrars—worked in morgues and laboratories. These were nurses and paramedics with a secondary medical education.

They performed clerical work, and most importantly, it was their responsibility to print the completed forensic medical examination reports. Therefore, there is no doubt that the forensic medical examination reports from our criminal case, which contain a huge number of medical errors, were not printed by the Bureau of Forensic Medical Examination. They were printed by someone unaffiliated with the Bureau and ignorant of medicine.

2) Forensic medical examination institutions established controls over all output documents, primarily over expert opinions. The head of the Forensic Medical Examination Bureau personally oversaw the quality of work and the preparation of documentation, including reviewing initial reports, forensic medical examination reports, and outgoing accompanying documents.

3) Reports were compiled at the end of the year, at which time the report numbers were reset, and with the beginning of the new calendar year, the report numbers began with the number "1". Therefore, in March, and especially in May, the serial numbers of autopsy reports at the Forensic Medical Examination Bureau could not begin with the number "1".

Collection of organizational and methodological materials on FME. V.I. Prozorovsky, E.I. Kanter - 2nd ed., 1960

4) Furthermore, the accounting and reporting of forensic medical examination bureaus was standardized not only by special instructions and guidelines, but also by the introduction of standardized forms and templates. To ensure that forensic medical reports were compiled using a standard template, a standardized forensic medical examination report form was introduced. Standardized forms for referrals for forensic chemical and forensic histological examinations were also developed. The introduction of standardized forms for this type of reporting and accounting allowed all practical material to be subjected to rigorous statistical processing and used for scientific purposes.

5) Forensic medical examinations of corpses were conducted only on the basis of an investigator's order, in accordance with articles of the Criminal Procedure Code of the RSFSR, the "Rules for the Forensic Medical Examination of Corpses" of 1929, and by order of the Prosecutor General of the USSR and the USSR Ministry of Internal Affairs of 1954. The forensic medical examination reports from our criminal case mention these orders, but for some reason, they were issued in March by a non-existent procedural authority—the regional prosecutor's office. It is also the investigator's or Bureau Director's procedural obligation to obtain a written warning from the expert under Article 95 of the Criminal Code of the RSFSR for knowingly delivering a false conclusion. The State Duma case contains such signatures from forensic expert Churkina and radiologist Levashov, but no signings from forensic expert Vozrozhdenny.

6) Each forensic chemical and histological examination report was accompanied not only by an incoming accompanying document, which arrived with the biomaterial or other objects for examination at the Bureau, but also by an outgoing document, which was issued to the person who ordered the examination upon completion of all necessary tests. The accompanying document was signed by the head of the Forensic Medical Examination Bureau and the head of the laboratory, who thereby authorized the release of the examination from the given forensic institution. The accompanying documents attached to the May histological reports, for submission to the Investigative Department of the Sverdlovsk Region Prosecutor's Office, are missing from our Criminal Case.

7) We even found actual criminal cases from those years. For some reason, those who consider a criminal case, and the forensic medical examination (FME) within it, to be normal documents tend to assume that the FME Bureaus of the 1950s were little more than fly-by-night operations. But this isn't true, especially when it comes to the FME Bureaus of large cities, as illustrated by these examples.

Excerpt from a 1957 forensic medical examination report

The Experts' Report bears the FME Bureau seal. Furthermore, we see that the experts' signatures under the autopsy report are also certified by the FME Bureau seal. Also note that the FME Report is prepared according to all the rules: the experts answer point by point the investigator's questions posed for resolution of this examination.

And this is the expert's report from our criminal case - the difference is obvious:

Even then, forensic medical examination reports were comprehensive and well-written. Materials illustrating the expert's conclusion (photographs, tables, diagrams, drawings, etc.) were signed by the expert conducting the examination, certified by the Forensic Medical Examination Bureau seal, attached to the report's conclusion, and served as an integral part of it.

Case files from 1955

The same diagrams of skull injuries should have been included with Nikolay Thibeaux-Brignolle's forensic medical examination: a right lateral view to indicate the location of the fracture and the characteristics of the distribution of cracks in the cranial vault, and a separate diagram of the internal distribution of cracks along its base.

Case files from 1956

Please note - the bottom part of the sheet with damage diagrams is shown here, where the expert's mark is: "Diagram compiled", date, and signature, certified by the seal of the Bureau of Forensic Expertise:

Case files from 1958

Diagrams of external head injuries, such as wounds, abrasions, and bruises. Also visible below them is a sheet with a diagram of the base of the skull injuries, and another with photographs of the injuries.

The signature of the expert who drew up the injury diagrams is certified on each sheet by the Forensic Medical Examination Bureau seal. This means the seal not only certified the expert's signatures on the forensic medical examination reports, but also on the tables and photographs attached to the expert's report. But our forensic medical examination reports contain nothing of the sort. No diagrams, no photographs (especially for the May four with the most severe injuries), no Bureau seals. And yet, at that time, the Sverdlovsk Forensic Medical Examination Bureau was one of the best in the country.

So, what must be present in a forensic medical examination for it to be considered evidence in a criminal case?

• a resolution appointing a forensic medical examination;
• a signed statement warning the forensic medical expert of liability for knowingly providing a false opinion;
• questions posed by the investigator for permission to conduct the examination, on which the Expert's Report is compiled;
• accompanying documents from the Head of the Bureau, to the Reports of additional laboratory tests (histological, forensic chemical, or material evidence), attached to the Expert's Report;
• diagrams, drawings, photographs of damage, supplementing and clarifying the description of the forensic medical examinations;
• stamps and seals of the forensic institution where the expert who conducted the examination works examination.

This list is based on official forensic medical instructional and methodological documents of those years.

None of this is in our Criminal Code.

Now let's talk about what, on the contrary, should not be in our Criminal Code – the second copies of the May Forensic Medical Examination Acts.

Let's compare the first May Autopsy reports from Volume 1 and Volume 2 of the Case files:

Note that on page 345 of Volume 1 of the Criminal Code, the text is clearly printed. On page 23 of Volume 2, it is blurred due to the fact that the carbon paper, which had been used many times, produced a less clear and more blurred font. The other three May Autopsy reports were printed in the same way: the text on the first copy was typed on a typewriter simultaneously with the second, using carbon paper. The fact that Volume 2 does not contain drafts of the Autopsy reports that were simply handed over, but second copies, is proven by the expert's signature and the fact that the printed text there is completely identical.

Now let us turn to the "Instructions on the Conduct of Forensic Medical Examinations in the USSR", which governed the organization and conduct of forensic medical examinations from 1952 to 1978:

Collection of organizational and methodological materials on FME. V.I. Prozorovsky, E.I. Kanter - 2nd ed., 1960

Collection of organizational and methodological materials on FME. V.I. Prozorovsky, E.I. Kanter - 2nd ed., 1960

The forensic medical examination report was prepared in only two copies. Importantly, the first copy of the forensic medical examination report, in accordance with general provisions on forensic documentation, was sent to the investigative body or court commissioning the examination. The second copy (a duplicate of the report) was retained by the expert for records and subsequent transfer to the archives of their expert organization. These instructions did not stipulate any third copy of the report. This rule for preparing forensic medical examinations, adopted back in the Soviet era, remains in effect to this day. At the SBSE, as at all other forensic medical institutions in the Russian Federation, it has been preserved virtually unchanged.

This naturally raises the question: where did our Criminal Code get the second copies of the May reports, if according to the instructions, they are supposed to be kept not in the prosecutor's office's files, but in Ustinov's bureau? It also states that, in accordance with the current "Rules," the Report is completed only on a special form (registration form №242). A rectangular stamp of the Bureau of Forensic Medical Expertise (BFME) was placed in the upper left corner of the first page of the form (see below).

Why were such forms necessary for completing the Forensic Medical Expert Reports? The point of using them was that the expert's signature had to appear on each page of the Report. Each numbered page was signed by the expert, which completely ruled out the substitution or falsification of even a single page of the Report.

There is another significant point, which we have already noted: the strange numbering of the Forensic Medical Expert Reports from our Criminal Code. The May Reports should have included the numbering of the Bureau of Forensic Medical Expertise (BFME) because Vozrozhdenny, who performed the autopsy, worked for this expert organization, and these examinations were required to be registered with the BFME. But in May, the serial numbers of autopsy reports, neither at the SBSE nor at any other expert bureau, could possibly begin with the number "1." This is out of the question.

Also, we should not forget the legally required expert signature warning of criminal liability for knowingly providing a false opinion, which was required to be attached to each forensic medical examination report. Our criminal code does not have these signatures. But under such circumstances, the expert could have signed at least a third or fourth copy of something for which he bore no criminal liability.

So the question posed regarding the discrepancy with the Instructions for Conducting a Forensic Medical Examination and the Criminal Procedure Code, and those that will follow in the next part of the report, are completely justified.

According to the Criminal Procedure Code and all forensic medical examination regulations, of any year, it is the forensic medical examiner who is obligated to issue the expert report to the investigation. And in a completed form. This report must clearly eliminate any doubts or possible interpretations of the expert's written report.

In the State Duma case, this legal requirement was clearly violated. The printed texts of the May reports, from Volume 1 of the Criminal Code, contain numerous erasures and corrections, in the form of reprinted words – in virtually all four forensic medical examination reports. And these are the only documents in our criminal case that contain such corrections. According to any regulations and always, any corrections must be accompanied by an additional instruction: "the corrected version is to be believed." Okay, let's not dwell on this, because here the corrections don't change the meaning, but only add to it, specifically the medical one. Let's delve into the essence of these corrections.

Let's provide a few illustrative examples. Handwritten corrections to the printed text of the second copy of Lyuda Dubinina's forensic medical examination report, from Volume 2 of the Criminal Code.

We remind you once again that, according to the "Instructions on the Conduct of Forensic Medical Examinations in the USSR," the second copies of the May forensic medical examination reports were not supposed to be included in the prosecutor's office's files.

The person typing didn't understand what a chemical analysis was. Ordinary people—not doctors—of course know what a clinical analysis is, because they occasionally go to the clinic and get these kinds of tests, like a clinical blood test. So the person typing was something they were likely familiar with. But that's precisely how complete forensic nonsense comes out.

The word "clinical" was erased in the first copy of this same forensic medical examination, from Volume 1 of the Criminal Code:

Another medical nonsense, about "bath skin of bones" instead of "limbs" - corrections in the second copy of the same FME in Case files vol.2, and an already cleaned up version of the same word in the copy of the FME for the official Case files (vol.1):

Another important point here is that the number of letters in the words is clearly different. So, let's rule out the possibility that this is a handwriting problem, which could lead to a misreading, or simply a typo. The person typing this, and perhaps even the original writer, has a complete misunderstanding of what "bath skin" means.

All these corrections, in the form of erasures, are very visible, as are the traces of indentations from the original printed version of the text. There are similar erasures in the word "located," but the first two are more significant.

Or here are fragments of text from Nikolay Thibeaux-Brignolle's autopsy report. Corrections, and then an erasure of the phrase "cyanotic, red". Also a "masterpiece" of sorts, and not only medical but also everyday:

There are quite a few such corrections, followed by erasures, in the May forensic medical examination reports.

We also have information from Oleg Arkhipov that Boris Alekseevich Vozrozhdenniy had only an indirect connection with the printed forensic medical examination reports, as he couldn't type and always wrote all his reports by hand, like most experts of that time. Their retyping was always carried out by competent and specially trained employees of the forensic medical examination bureau. This has already been documented as a fact. But checking the printed report is the direct responsibility of the expert, since their signature appears on the document.

But if everything was retyped exactly as Boris Vozrozhdenniy wrote it, then the result is complete absurdity. Because the forensic medical examination bureau couldn't have printed such illiterate forensic medical reports; they were retyped by people completely incompetent in medicine. There are also numerous other obvious errors that are simply impossible, even for a simple medical student.

But in fact, we have forensic medical examination texts typed by someone not only unfamiliar with forensic medical research but also ignorant of even the most basic medical knowledge. Hence, the conclusion is that the texts were retyped and rewritten in the Prosecutor's Office by those ignorant of even the basics of forensic medicine. We can now prove this, too, thanks to a recently conducted handwriting analysis.

The fact is that someone had done preliminary corrections to the second copies of the May forensic medical examination reports, which ended up in Volume 2. The typewritten texts of these reports were mostly corrections of individual letters or syllables, but there were also entire words handwritten over the typewritten lines.

These two handwritten words, in the second copy of N. Thibault's forensic medical examination report, helped us determine who made all these handwritten corrections to prevent the same errors from being repeated in the first copies of the May reports, filed in Volume 1 of the Criminal Case, now as official documents.

1) In N. Thibault's forensic medical examination report, from Volume 2 of the Criminal Case, the word "cavities" was corrected to "hairy":

Next, in the first copy of the act, from the 1st volume of the UD, this error was corrected by erasing and typing in the correct word:

“Flaps of the cavities of the head”, this is of course medical nonsense, how one could be confused with the other. But now we are no longer talking about medical errors, but about the author of these handwritten edits.

2) Second edit, in the form of a separate word “brain”, inscribed in the same place, in the second copy of Thibault’s SME from Volume 2 of the UD:

Printing corrections into the first copy of Nikolay Thibeaux-Brignolle's autopsy report, from Volume 1 of the UD:

It is known from forensic science that over time, each person's handwriting acquires certain properties and characteristics. These characteristics, taken together, form a distinctive, individual system of features that cannot be completely replicated in the handwriting of another person. A developed handwriting always possesses a clearly defined individuality, and with sufficient handwritten material, the identity of the author of a manuscript can be accurately identified by its handwriting.

Researchers who have been working with criminal investigation materials for a long time are well acquainted with Ivanov's handwriting, with his distinctive manner of writing certain letters, such as "л," "з," "м," and many others. The reason for conducting the examination using handwritten texts in investigator Ivanov's handwriting, rather than expert Vozrozhdenny's, was also because if it turned out that it wasn't the expert's handwriting, it would be impossible to determine whose edits they were.

The subject of the examination was this fragment of Nikolay Thibeaux-Brignolle's autopsy report, from Volume 2 of the Criminal Case, containing two handwritten words: "hairy" and "brain." The remaining 10 samples of Ivanov's handwriting were submitted for comparison.

When examining very brief notes, more comparison samples are usually required than when examining longer texts. Therefore, numerous samples of Ivanov's handwriting were submitted for examination, sufficient to allow the expert to assess all the handwriting characteristics of the person suspected of writing the words in question. As a rule, several handwritten texts containing the letters found in the words in question are required as free comparison samples. This was done, as Volumes 1 and 2 of the Criminal Case Files contain ample documents, memos, and even handwriting in Ivanov's handwriting. Another condition was also met: all text fragments in Ivanov's handwriting corresponded to the document under investigation, with execution dates within the same year.

After examining the documents and conducting research, the expert concluded that the handwritten corrections in the May forensic medical examination reports, which are present in our Criminal Case, were not made by the forensic medical expert Vozrozhdenny, but by the prosecutor's investigator Ivanov:

Conclusion:

1. Handwritten text in handwriting samples A (handwritten text - "hairy", "brain"):

- A fragment of a page with typewritten (printed) text, beginning with the words "B. Internal examination. ..." and ending with the words "...The lumen of the larynx and bronchi is free."; and handwritten text in handwriting samples B:

- A page with handwritten text beginning with the word "Receipt," with the number "258" written in red pencil;

- Handwritten text, in the form of corrections and additions, on a fragment of typewritten (printed) text, beginning with the words "Subsequently ..." and the number "19";

- Handwritten text, in the form of corrections and additions, on a fragment with typewritten (printed) text, beginning with the words "The investigation carried out ...";

- Handwritten text, in the form of corrections and additions, on a fragment with typewritten (printed) text, beginning with the words "Party Bureau Secretary ..." and the number "22";

- Fragment of a page with handwritten text beginning with the words "At Doroshenko's ..." and the number "41";

- Fragment of a page with handwritten text beginning with the words "vitamins ..." and the number "16" written in red pencil;

- Fragment of a page with handwritten text beginning with the words "Dubinin Alexander ..." and the number "15";

- Page with handwritten text beginning with the words "In the future ..." and the number "18-a";

- Page with handwritten text beginning with the words "1) In "cowboy shirt..." and the number "42";

- A fragment of a page with handwritten text beginning with the words "Sister Kolevatova..." and the number "50" done by the same person.

 
Плешков Л.В.

Now we have matches not only on the prosecutor's typewriters, which we discussed in the previous report, but also on Investigator Ivanov's handwriting.

This raises further questions.

A long-standing question: how could such medical errors even be possible, from a medical examiner?

And new questions.

How could corrections even be made by an investigator, or even by the Prosecutor General, if forensic examination is the sole responsibility of the regional bureau. The bureau was obliged to issue it in its final form.

And this raises another question: is this really possible, even theoretically, given what we know about the then bureau chief, Ustinov?

Porfiry Vasilyevich Ustinov was born in 1897. In 1935, he was elected by all-Union competition to the position of head of the forensic medicine department at the Sverdlovsk State Medical Institute (SSMI). Since then, his research, teaching, and practical forensic work have been inextricably linked with the Middle Urals and Sverdlovsk. While heading the department at the medical institute, and until 1960, Porfiry Vasilyevich served as the Sverdlovsk regional forensic medical expert, and until 1963, he was a professor at the Sverdlovsk Law Institute, specializing in forensic medicine. Professor Ustinov served as head of the medical institute's department for 36 years (until 1971), and the entire history of the department—its organization, formation, and subsequent development to the present day—is linked to the name of this leading forensic scientist, organizer, and mentor of students and practicing forensic experts.

There's an oddity in the dates of the GD case and his biography, which may simply be a coincidence: in 1960, he resigned as head of the Bureau of the Forensic Medical Examination Bureau, the year after the case against the GD's death was closed. He was 63 years old in 1960. If he had intended to retire due to age, he would have left the Bureau back in 1957. He taught at the SUI's Department of Forensic Medicine until 1963. He remained head of his department at the Sverdlovsk State Medical Institute until 1971. This refutes the assumption that he resigned as head of the Bureau of Forensic Medicine in 1960 due to age or health reasons. Moreover, the facts of his biography indicate that he was an active scientist and leader until his death in 1975. Ustinov headed the Sverdlovsk Scientific Society of Forensic Physicians and Criminologists, founded in 1951 on his initiative, for 24 years, until July 1975. In other words, he held this post continuously until his death. In 1974, he was invited to the International Forensic Medicine Congress in Toronto, and in 1975, to the International Congress of Forensic Physicians in London. Thus, until his death, Ustinov was actively involved in the forensic medical service in Sverdlovsk, participating in all its events and attending international forensic congresses. So why did he resign as head of the Sverdlovsk Bureau of Forensic Medicine in 1960, the year after the State Duma Case investigation?

It's also important to understand all these corrections and other oddities in the forensic medical examination in our criminal case, to understand Ustinov's character and leadership style. Those who knew him described him as strict, even harsh, and "unyielding" as the Bureau's head. But at the same time, they described him as an exceptionally conscientious and phenomenally hardworking person, and he demanded the same from his employees: honesty, dedication to their work, and a love of work and science. His understanding of the law and his human qualities prevented him from adopting a comfortable, in every sense, conformist stance as Bureau Head. He didn't simply manage the Bureau—he created it, organized it, and raised it to such a level that it was considered one of the best in the country at the time. So, given his character, abandoning the Bureau - his brainchild, on which he spent so much effort - seems impossible.

Also, the forensic documents in our criminal case are practically unrealistic in their current form, let alone when they left the Bureau headed by Ustinov.

In fact, he wouldn't have even allowed such documents into his forensic institution. Perhaps that's why the second copies, which are in Volume 2 of the Criminal Case, remained unused. Ivanov simply tucked the second copies of the reports into his official papers, which he kept just in case, along with the crossed-out version of the Resolution to Terminate the Criminal Case, notes, receipts, and letters. Meanwhile, the Bureau itself retained the primary examination reports, duly registered and sealed, which expert Vozrozhdenny brought from Ivdel in May. Ustinov himself reported only to the republican expert from the Ministry of Health, and it was this expert who was his superior, not the prosecutor's office, represented by Klinov, the Sverdlovsk Region Prosecutor. An examination is, after all, an independent procedure. It's no coincidence that, to avoid direct involvement with the investigation, our forensic medical service has been located within the Ministry of Health, not within the investigative bodies, since the founding of the USSR.

Back then, in the 1950s and then the 1960s, party control over all aspects of life was completely normal, and no one even considered the possibility of it being any different. The Party considered it permissible to interfere in everything without exception; moreover, it didn't just interfere; it governed the entire life of the country. In those years, the Party believed it could do anything, and laws weren't written for it. Any request from the regional committee, expressed in the form of even a mild recommendation, was regarded as a binding order. Failure to comply would result in trouble. Further career advancement could be blocked, or you could even be removed from your current position. In short, going against the Party was a serious risk. So, given the character of the other, and then-chief of the region, A.P. Kirilenko, who also wasn't known for his weakness of character or tolerance for objections, such a clash is entirely possible. And as is often the case, "he who has more rights remains right."

Little can be found online about Ustinov's biography. We don't even have information on exactly when in 1960 he left his post as Bureau Chief. It's also important to know whether a new chief was appointed immediately, or whether there was an acting one first. These are precisely the questions for Komsomolskaya Pravda journalists Nikolay and Natalya Varsegovs. Only with their expertise can we determine whether Porfiry Vasilyevich resigned voluntarily, as head of the Bureau of Forensic Medicine, or whether he was forced to leave after the investigation into the death of Igor Dyatlov's group, which remained de facto unfinished, was terminated.

Perhaps we'll someday learn what happened then. In the meantime, memories of this extraordinary man—a talented scientist and expert in his field—as well as the undoubted recognition of his contributions to the establishment, development, and strengthening of the forensic medical service in the Urals from 1936 to 1975, continue to haunt many concerned people.

Bibliography:

1. "Discontinued Criminal Case on the Death of Tourists in the Otorten Mountain Area of ​​Ivdel, Sverdlovsk Region", 1959, Volume 1, Volume 2.
2. "Collection of Organizational and Methodological Materials on Forensic Medical Examination." Compiled by V.I. Prozorovsky and E.I. Kanter. — (2nd ed.). — Moscow, Medgiz Publishing House, 1960.
3. "Expert's Opinion on the Result of the Handwriting Analysis of Documents №78, Date of December 23, 2025", Stavropol, Regional Bureau of Independent Expertise LLC.
4. Permyakova N.V. "Porfiry Vasilyevich Ustinov - the founder of forensic medicine in the Middle Urals." - Journal "Forensic Medical Expertise", 2025; 68(2):63-68.
5. Publications by Victoria Mikhailyuk, Press Secretary of the Zabaikalsky Krai Court
6. Arkhipov O.N. "Forensic Experts in the Dyatlov Group Case." - Tyumen, Istina Publishing House, 2015.