PORTLAND – A mix-up that caused the family of a car accident victim to receive the wrong remains has resulted in changes at the state medical examiner’s office.

Security policies were completely revamped after Derrick Cote’s family late last year was mistakenly given the cremated skeletal remains from two 19th century unmarked graves in Lyman, said Jim Ferland, the office administrator.

The situation came to light after the Portland Press Herald contacted the state about the historic remains that were being tested at the medical examiner’s office to determine their age and gender. They were dug up by a property owner while excavating a gravel pit.

Ferland said the remains were signed out for delivery to the Dolby & Dorr Funeral Chapel in Gorham, which handled the memorial service for Cote.

The error was discovered when the Lyman remains turned up missing and a subsequent investigation showed that a body that had been signed out to Pine State Livery Service was still present.

“I thought it was the end of my world that day,” said Timothy Dolby, the chapel owner, who gave the cremated remains to the family and later had to switch them with the proper remains. “My heart is still broken.”

Cote’s family was upset but “very understanding” about the mix-up, Dolby said. His mother, Yvette Cote, said she had no comment.

Ferland said he knew of no other occasion in which a body had been improperly released by the state, but that “one is too many.”

A similar case surfaced this year in Massachusetts, prompting that state’s governor to place the chief medical examiner on leave. The Massachusetts Medical Examiner’s Office mistakenly released a body to a funeral home. The body was buried under the name of another person, and it took a state police investigation to find the “lost” remains.

Maine Attorney General Steven Rowe briefed Gov. John Baldacci on the Maine case and the steps taken to avoid a similar situation, said Joy Leach, a spokeswoman for the governor.

Dick Gilman, owner of Pine State Livery Service, said he picked up the Lyman remains on Nov. 28, but doesn’t recall specific details. He was scheduled to pick up the remains of a 19-year-old who died in a car accident.

Although there is a difference in weight between a recently deceased person and loose bones, all remains in the medical examiner’s office are placed in the same type of bag and are transported on gurneys. In this case, there was no visual inspection of the remains between pickup and when they were cremated.

“It was my fault,” said Gilman, who has transported about 12,000 bodies in his 15 years in the business. “It’s kind of like a car accident. After 12,000 bodies without a problem, then I have one that becomes a problem.”

“I’m sorry for the families. … I’m sorry it ever happened,” he said.

Ferland said neither he nor Gilman could account for how the mix-up took place.

“There was an investigation, and he couldn’t explain it. He just said he’d made a terrible mistake,” Ferland said.

Under the new policy, an employee from the examiner’s office must be present whenever livery services or funeral homes arrive to pick up a body. In addition, the name of the deceased is now written on the body bag in large block letters, and all requisite paperwork is attached to the bag before it is released.

Dolby said workers at his funeral chapel normally do a visual inspection of the body before sending it to the crematorium, but in this case they were in a hurry to get the cremated remains to the family in time for a service planned for the following day. A visual inspection would have shown they had skeletal remains instead of a recently deceased person.

“We knew this was a timely thing. We had a signed death certificate and we simply made the transfer” into a container that was destroyed without being opened at the crematorium, he said. “If I had made the physical removal … [I] would know there was something awry here. We were trying to expedite the process for this family.”