OP/17/2014 WBD 10113 PAX 323221P7f8 ll.!002/023

COUNTY OF LOI AHGEUS DaPARTMENT OP eC>AONEII

AUTOPSY REPORT

I ped'ormed an autopsy on the body of -at _________ th=e....;D=F.P.=~==TMENT==;...;O=f'-CO=R:_O_NER='-=------_.

No.

201.4:-01724

JONES, DANA KATHLEEN

Los.Angeles, califomia on MARCll l.3, 2014 0 l.J.00 HOURS ----~---_.... ____ ...,_ __ "'-==------- cb•> mmi5

From the anatomic findings and pertinent history I ascribe the death t.o: BLUNT FORCB HEAD TRAUMA

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·-·- 9Vl NOT lllll.ATI:U TO THI!, _ __.• CAUS& OF l>'IIATH:

Laceration, sca.lp, occipital,

Fracture, skull, occipital..

Status poet left craniectomy and ventricuiostomy placement.

See Neuropathology report.

OP/17/2014 WBD 10tl3 PAX 323221P718 ~003/023

COUMn 0, I.OI ANNUi DIMIITME-.T o, COIIONl!II I

12 AUTOPSY REPORT

f>aae _ ..... 2..__

INJURY DATE:

03/03/2014.

CIRCUMSTANCES:

See Investigator's report.

EVIDENCE OF INJURY;

No.

2014-01724

JONES, DANA KATaLEEN

On the back of the head 5 inches below the buttocks and located in the midline is .an irre9ular laceration measuring 1-3/4 inches. The underlying occipital skull has a linear fracture extending from the midline to the left near the foramen magnum. The fracture measures about 4-1/2 inches.

EXTERNAL EXAMINATION:

The body is identified by toe tags and is that of an unembalmed, refrigerated female Caucasian who appears about the reported age of 50 years. The body weighs 146 pounds, measures 68 inches and is slightly thin. Rigor has presumably been altered as well as livor.

Examination of the eyes reveals irides that appear to be hazel in color and sclerae that are white. There are no petechial hemorrhages of the conjunctivae of the lids or sclerae. The oronasal passages are unobstructed. Opper and lower teeth are present. The neck is ~remarkable. There i~ no chest deformity. The abdomen is flat. The genitalia are thos, of an adult female. The extremities show no deformity.

EVIDENCE OF THERAPEUTIC INTERVENTION:

The following are present and properly positioned: Endotracheal tube, nasogastric tube and urinary catheter. There is evidence that the following surgical procedures have been performed;

09/17/2014 WED 10113 PAX 3232219768

C:OUNTY Of LOI ANC8'1S

"1!004/023

I

12 AUTOPSY REPORT

Pac,: ___ 3 ____ _

No. 2014-01724

JONES, DANA 10\THLEEN

Left craniectomy and ventriculostomy placement. There has been postmortem intervention for organ procurement, which includes heart, lungs, liver, kidneys, pancreas.

CLOTHING:

The body was not clothed and I did not see any clothing.

INITIAL INCISION:

The body cavities are entered through the standard Y-shaped incision.

NECK:

The neck organs are removed en bloc with the tongue. There is no trauma of the gingiva, lips or oral mucosa. Both hyoid bone and larynx are intact and without fracture. There is no hemorrhage in the strap muscleg of the neck or around any throat organ. The tongue when sectioned shows no trauma.

CHEST/ABDOMINAL CAVITY:

See "Evidence of Therapeutic Interventionu. There is bloody fluid in the chest and abdominal cavities status post organ procurement. The heart, lungs, liver, spleen, kidneys, pancreas and adrenal glands are absent status po9t organ procurement.

SYSTEMIC AND ORGAN REVIEW

The followinq ob9ervations are limited to findings other than inju%ies, if described above.

09/17/2014 WBD 10tl3 PAX 32322U7U flJ00!S/023 __

COUNT'f 0, LOI ANDILH I

12 AUTOPSY REPORT

Paee-..a4t---

MUSCULOSKELETAL SYSTEM:

No.

2014-01724

JONES, DANA KATHLEEN

There is no abnormality of the bony framework or muscles present.

CARDIOVASCULAR SYSTEM:

The heart is absent. The aorta is elastic and of even caliber th~oughout with vessels distributed normally from it.

RESPIRATORY SYSTEM:

The upper respiratory passage present is unremarkable. are absent.

GASTROINTESTINAL SYSTEM:

The lungs

The esophagus is intact throughout. The stomach contains brown­green cloudy fluid. The mucosa is unremarkable. The small intestine and colon are unremarkable. The appendix is present and is unremarkable. The pancreas is absent.

URINARY SYSTEM:

The kidneys are acsent. The urinary bladder is empty. It is unremarkable.

GENITAL SYSTEM:

The testes are absent and there is a scar over the area.

HEHOLYMPHATIC SYSTEM:

The spleen is absent status post organ procurement. The bone is not rem&rkable. The bone marrow of the rib is unremarkable.

0i/17/2014 WBD 10114

COUNTY Of I.OIi ANOnas

PAX 323221'768 ~006/0,_2..;;..3 __

· Dl!f'AA'TlllaNT OP CORONER

I

12 AUTOPSY REPORT

Page _,_5:;.__

ENDOCRINE SYSTEM:

No.

2014-01724

JONES, DANA KATHLEEN

The thyroid and pituitary glands are unremarkable.

HEAD AND CENTRAL NERVOUS SYSTEM:

See ~Evidence of Therapeutic Intervention". There is extensive subcutaneous hemorrhage associated with the laceration and therapeutic intervention. There is residual subaural hemorrhage. The brain weighs 1450 qram.s. It is soft. It is placed in 10, formalin solution for fixation and later examination.

SPINAL CORD:

The entixe spinal cord is not dissected.

HISTOLOGIC SECTIONS:

Representative sections !rom various organs are preserved in one storage jar in 101 formalin.

TOXICOLOGY:

Subdural blood and vitreous have been submitted to the laboratory. No screen was requested.

PHOTOGRAPHY:

Photographs have been taken prior to and during the course of the autopsy.

RADIOGRAPHY:·

The body is fluoroscoped and x-rays are taken.

I

o,/17/2014 WBD 10114 PAX 323221P7f8 ~007/02~--

l>INR,.....T Of' COM)NU

12 AUTOPSY REPORT No.

2014-0l.724

JONES, DANA KATHLEEN

PIIF-..1116--

WITNESSES:

Detectives zottneck and Johnson (LOng Beach Poiice Department) witnessed the autopsy.

DIAGRAMS USED:

Diagram Forms 20, 22, a:(ld 28 were used during the performance of the autopsy, The diagrams are not intended to be facsimiles,

OPIN:CON:

Death ia due to blunt force bead trauma. Manner of death i• accident.

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OC!bbtt/mp 0:03/13/14 T:03/19/14

DATt 1 '

OP/17/2014 WBD 10114 VAX 323221P768

COONfY OFl.09.\NCDD

20

llJ008/023

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COUNTY OP LOSANGU.U

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DEPARTMENT CW CORONEll

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DEPAJl'DIENT 01' CORONER

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Ot/17/2014 OD 10115 PAX 323221t7S8

COUNTYOPtnS·ANGEC£8 l'Oltt:NSIC CONSlJl.TANT .. S llll'ORT

13-

GROSS NEURQPATBOLQGX

BRAIN CUTTING; · 4J'2/2014

AGE: 50 ycan

DATE OF D:EAffl: 3/6/2014

REFERRING PATHOLOGIST: Dr. Ogbonna Chinwah

~011/023 _ .

2014-01724 Jones, Dana Kathleen

CJBCUmTANCES; The following information i& taken from the investigator's summary of . case and Dr. Chinwah's autopsy report. The .SO years old Caucasian female fell to the floor and· sustahled blunt fmce bead trawria while doing yoga e.xerciscs at her residence. CT scan of bead revealed skull fracture and subdutal hcmonhage. She died 3 days lat=-.

.. GROSS DUCIUPTIQN: Specimen consists of poorly fixed brain and complete cranial dura mater. Examination of the subdural surface revealed att■c-bment of small fresh blood clots on the right dura and a small BIDO\Ult on the le.ft There are more acute subdural blood clots in the posterior fossa. Unknown amount of subdural blood is icmoved at hospital by left c:nmiotomy. Dural sinus is patent without thrombosis. 1b8 fresh brain at rem.oval weighed 1450 grams. The brain shows marked . swelling and hemiatioDB. Gyri arc flat and snlci are narrowed. Uncal and parahippocampal herniations are present Duk red blood ia covcrin& on gyral crowns and sulci are full of blood. It is thick on frontal poles, orbital cortices and right cerebral hemisphere. The right fronw.temporo-paricto­occipital subaradmoid hcmormagc is severe BDd thick. Left and right frontal pole contusion/aubaradmoid hemorrhage mc88UlCS 11 ~ S cm. Frontal pole tissue disruption is more on the left than right. There is anotbt.r defect in the left middle frontal gyms measuring 3 x 1.5 cm. Oelfoam is covering on the inferior frontal cortex. Marked congestion of v~ is ser.n. Then is autolysis of brain stem. cerebellum md cmter of brain. Optic nervea, . chiasm, infundibulum and mammillvy bodies are completely autolysed. O,ri ,µ,.cl sulci are well formed and there is no congenital anomaly • .

The entire brain is discolored due to traumatic brain injury and caebra1 ede.ma At the base. rectus gyri and orbital cortex are covered with fresh blood clots and gelfoam soaked with blood. The cortex is oontu&cd. Oyri are swollen and sulci are obliterated. Brain pamnchyma is soft due to Nle:ma, ,iwelling and poor fixation. Inferior temporal lobes are coveted with thin subaradmold hemonbagc. Belly of the pons and medulla are swollen. Basal cisterns a:re small. Visible portion of circle of Willis vessels (basilar and vertebral) shbws no atherosclerosis.

09/17/2014 WBD 10115 PAX 3232219768 ~012/023

PORENSiC CONSVLTANT'S UP.ORT DEPAR:IlillENTOF CORONBR'

13 2014-01724 Jones, Dana Kathleen

PAGE:2

Coronal sections of the cem>ral hemispheres show acute contusion subarachnoid bemon:ha.&e blood clots covering over frontal pole.and inferior fronta1 cortices. Toe white matter bemoffha&e in the right frontal lobe meuUJCS 1 cm. White matt« ua markedly expanded. There is brain edema and swelling with 1tignlftcant right to left mldlme shift. The center of the brain is not fixed and showing softening. tissue breakdown involving white and deep grey matter. basal aanglia and thalamus. The ce2lter of the corpus calloswn shows btmoahaaea. V cntricles arc small and contain blood. Gray discoloration is present due to hypoxic ischcmic brain after blunt force tramna. c:dana, swelling aud increased inttacranial pressure. Grey white junctions are blurred. t>urct hemonbagea arc pmsent in rnldbrain and pons. Th«e is transtentoria1 hemiation. The right hippocampue is completely autolyscd.

. ,,

Representative sections arc retained in formalin. The following sections are submitted for microscopic cxammation:

l. Pronta1 lobe. . 2. Corpus calloaum. 3. Parietal lobe. 4. Left bippocampus. 5. Occipital lobe. 6. Midbrain/pons? 7. Medulla? 8. Cerebellum. 9. Dura mater. SDH, posterior fossa.

09/17/2014 WBD 10115 PAX 3232219768 fil.1013/023

COUNfY OFtOSANOEI:eS FOlll:NSiC CONSIJLTANT•S JlEPOJIT DEPAitrMENT OF CORONER:.

13 2014-01724 Jones, Dana Katblecn

PAGE:3

GRQ.58 IMPBE§61Ql!:

A. Blunt force head tJ:auma (fall). acute, severe. 1. Occipital scalp laceration, autopsy, 2. Linear occipital skull fractuxe, clinical and autopsy. 3. Acute subduI&l hematoma.·J.eft. sip cralliotomy and ve.ntriculostomy. 4. Subarachnoid bcmonhagc; tb.ick and severe. 5. Brain contusions, bilateral frontal poles, orbital cortices. 6. Intracerebral hemonbage, right frontal. 7. lntraventricular benlonhage.

B. Brain swcllin& and beuuationt. 1. Right to left midline shift. · 2. Uncal and parahippocampal hemiations. 3. TflDSt.ealtOriat hemiation.

Cho Lwin, M.D. Forensic NeUIOpathology Consultant

0P/17/2014 no 10:15 PAX 32322197t8

COUNTY OP LOS ANGELES l'ORENSiC CONSDi:rANT'S Jt.EPORT

13

BRAIN CUJTING: 4/2/2014

AGE: SO years

DATEOFDEATII: 3/6/2014

NEJJBOPATHQLOGY

REfERRJNO P~'IHOLOGIST: Dr. Ogborma Chinwah

flJ014/023

DBPARl'MENI' OP CORONER·

2014-01724 Jones, Dana Kathleen

CIRCUMSTANCES; The following information is taken from the investigator's summary of ease and Dr. Chinwui's autopsy report. The. 50 years old Caucasian female fell to the floor and sustained blunt force head trauma while doing yoga exercises at bet residence. er scan of head revealed i1ruJ1 fracan and subdmal bemonhaae. She died 3 days later.

GROSS DUCIUP'l]QN; Specimen consists of poorly fixed brain and complete cranial dura mater. Buminatfon of the subdural surface revealed attachment of small fresh blood clots on the right dura and a &mall amount on the left. lberc are more acute subdural blood clots in ~e posterior fossa. Unknown amount of subdural blood i& removed at hospital by left craoiotomy. Dural sinus is patent without thrombosis. The fresh • brain at removal weiped 14SO er;ams. The brain shows marked swelling and herniations. Gyri arc flat and sulci are narrowed. Uncal and patabippocampal herniations are ptescnt. Duk red blood is covertna on gyral crowns and suJci are full of blood. lt is thick on front.al poles. orbital cortices and right cerebral hemisphere. The right fronto-temporo-paricto­occipital subarachnoid hemorrhage is severe and thick. Left and right frontal pole contusion/subaracbnoid bemouhage measures 11 x 5 cm. Frontal pole tissue disruption is more on the left than tight. There is another defect in the left middle frontal gyros measuring 3 x 1.S cm. Gelfoam is covering on the :inferior frontal cortex. Marked congestion of vessels is seen. Thea-e is antolysis of brain stem, cerebellum and center of brain. Optic nerves, chiasm, infundibulum and rnamroilJary bodies are completely autolysed. Gyri and sulci are well formed and there is no congenital anomaly.

The entire brain is discolored due to traumatic brain injury and cerebral edema. At the base. rcctus gyri and orbital cortex are covered with fresh blood clots and gelfoam soaked with blood. The conex is contused Gyrl are swollen and sulci are o'bllteratcd. Brain parenchyma is soft due to edema, swcllin& and poor fixation. Inferior temporal lobes are covered with thin subarachnoid hemonbage. Belly of the pons and medulla are swollen. Basal cisterns are small. Visible portion of circle of Willia ve.sseh (basilar and vertebral) shows no atherosclerosis.

OP/17/2014 WED 1011, PAX 323221P768 raJ0l!l/023

COUNTY OP LOS ANGELP.S mRENSic CONSULTANT'S REPORT . DEPAKIMENT OF CORONER:

13 2014-01724 Jones, Dana Kathleen

PAGE:2

Coronal sections of the cerebral hemispheres show acute contusion subaracbnoid hemonhage blood clou covering over frontal pole and inferior frontal corticea. The white matter hemonhage in the right frontal lobe measures 1 cm. White matter is markedly expanded. Tbac is brain edema and swelling with significant right TO left mldline shift. The center of the brain is not fixed and showing softening, tissue breakdown involving white and dt.ep grey matter, basal ganglia and thalamus. '1b.e center of the corpus callosum shows hemolThagea. Ventricles are small and contain blood. Gray discoloration is present due to hypoxic ischemic brain ~ bll,Ult force trauma, edema, swelling and increased intracranial pressure. Grey white junctions are bhmed. Dw:et hemorrhages arc present in midbrain and pona. There is transteotorial herniation. 1bc right hippocampua is completely autolysed.

Representative sections ~ ~ in fOJ:malin. The following sections arc submitted for microscopic cxammation:

1. Frontal lobe. 2. Corpus callosum. 3. Parietal lobe. 4. Left hippocampus. 5. Occipital lobe. 6. Midbrain/pons? 7. Medulla'? 8. Cerebellum. 9. Dura mater, SDH, posterior f0$S&.

GROSS IMPRE$SIQN: A. Blunt"force head trmµna (fall), acute. severe.

1, Occipital scalp lacerati<>Dt autopsy. 2. . Linear occipital skull frac:turc, clinical and autopsy. 3. Acute subdunl hematoma, left, sip craniotomy and ventriculostomy. 4. Subarachnoid hcmon:bage, thick and severe. S. Brain contusiom. bilateral frontal poles. orbital cortices. 6. Traumatic axonal iajury. 7. Jntracercbral hemorrhage, right frontal. 8. Intraventric::ular heJDOJThage.

B. Brain swelling and hemiations. 1. Right to left midline shift. 2. Oneal and parahippocampal herniations. 3. Transtenr.orial herniation.

09/17/2014 WBD 10116 PAX 3232219768 fl.1016/023

COUNTY OF LOS ANGELES l'Oll£NSIC CO.NS'lJLTANT'S REPOR'I' DEPARTMENT-OF CORONER

13 2014-01724 Jones, DBlll Kathleen

PAGE:3

MICROSCOPIC DESClUPTIQN: 9 routine H&E stained slides arc e:irarninM. Pxoutal lobe shows acut.e cerebral contusiom with fresh intact red blood cells and mild acute inflammatory infiltrate, consistent with the dating of days old. The suaomiding cerebral conex has red neurons. Slide 2 of the corpus callosum revealed dilated vessels and no axonal swelling. Adjacent cerebral cortex has 1ed neurons. There ue severely congested penetrating arterioles and peri.vascular acute hemonhagea in the parietal cortex. Menin&eal vessels are m.arkedly dilated. The entire comu ammonia neurons are showing severe diffuse hypoxic ischemic changes. Slide 5 of the occipital pole section shows subaracbnoid hemorrhage. cerebral cottica1 m.ultifocal acute hemonhaaes and led neurona. Dum hcmonbage in midbtain is present. Posterior foesa dma mater section has acute subdural hemorrhage with mixed intact and pooling of red blood cells fibrin iDfiltration and mixed inflammatory infiltrate. consistent with days old.

FINAL NEURQPAJ'HQLQGIC DIAGN<ffiJS: A. Blunt force head trauma (fall). acute. severe.

1. Occipital scalp laceration, autopsy. 2. Linear occipital skull fracture, clinical and autopsy. 3. Acute subdurat hematoma. left. sip craniotomy and ventriculos1o:roy. 4. Subarachnoid hemorrhage, thick uid severe. S. Btain co.utusioos, bilateral frontal poles and orbital cortices {contrccoup). 6. lntracerebral hemorrhaie, right frontal. 7. Intravcntricular hemonhagc.

B. Brain swdling and herniations. 1. Right to left midlinc shift 2. Uncal and patahippocampal herniations, 3. Txanstentorial herniation.

Cho Lwin, M.D. 4-2(-~ IS., Date

Foret1Sic Neuropathology Consultant

0~/17/201& WBD 10111 PAX 32322lt768

COUNTY OF LOS ANGEi.ES MEDICAL REPORT AUTOPSY CLASS: A O B O C O Examinadion Only D

j 5 0 FAMILY OBJE TO AUTOPSY

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COUNTY OF LOIJ\NOel.U CAS!REPORT OVMTWHTOF C:OIIIONE" ~IIIXll

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~ I THE DECBDENT IS A.~ Y!A.R-OLD PBMALE. WHO ON 313114 WAS DOINO YOOA BXERaSBS ATlD lESIDENCI WHEN SHE A.PPARENTl.Y FEl.l.STIUJtlNO HBR ~ 111EHUSBANDHBA.RDTIIBNOJSEANJ>OBSD.VEDTimDECEDeNTLYINO ON HER BACK IN AN ALTER.ED UM!L OP • 9ll WAS DIALm) wrm PAllAMIDICB AIUUVINO ronm PREMISES. nm DEC!DENl' W>.S TMNSPOltTBD TO STl MARY MEDICAL CENTa WHl!JtB A CAT SCAN UVBALED A SICUU, PMC'ItJRS AND SUIDUlW. HEMATOMA. THE Dl!Cl!DENTR!aiJVID)SUROE!tY ANDUMAINBDAPATlSNTUNTD.HEJl !XPUtATJONON 316114AT 103S HOURS. THEDBCBOENT WAS UPOllTED TO HA VE EXl'8RIENC&D A PAU.JNQ EPlSODE ONE Yl!..U A.00 WHILE IN HAWAJL SHI WAS BVALUATSI> AND UP0RTED TO B! FD-IE. PL£A.SS NOT1Jl'V\ DETECnVES umNP.a'. A JOHNSON TWO HOURS PlllOR TO THE POST-MOJlTEM EXAMINATION BECAUSE OF POSSIBLE POUL PLA Yr

SH£RWOOI>DJXSON I ~ .......,.,,,, IIA ....

3n.2/2014 El.JSSA J. JILEAX. 3112f.2014

415916 , J5:0S IS:43 IIMffl!M'l'OA 'YIIII fflll

,ORM .:S NARRATM! TO FOLLOW, lia

OJ/17/2014 WBD 10117 PAX 323221J768

•

County of Los An&eles; Department of Coroner ... • · lnvestt&ator's Narrative · _.

Gase Number: 2014--01724 Decedent: JONES, DANA KATHLEEN

Information Sources: 1) Edwin Garcia, RN, 562/491-9866; 2) hospital raport/chart information

Investigation: I was aselgned thJs hospital Investigation on 3/12/14 at0730 hours.

Location: The initial location waa the l'9Sidenoe at 7053 E. Steeml St. in Long Beach. The decedent was transported to St. Mary Medloal Center, where she was treated :and later pronounced. The decedent was then transported to FSC for the post-mortem examination.

lnformant/Witn8$8 Statements: Aocolding to hospitat chart Information the following wae obtained: On 3/3114 the deoedent was at her realdence doing )40Qa exercllea, when the fell to the floor, striking her heed. The htaband wu In the adjacent room and heard the note•. He observed the dee.dent lylng supine on the floor While poorly reeponatve. 911 WU dialed with p:aramedk:a arriving 10 the premises. The decedent was ttansported to St Mary Medical Cemer, v.+,ere she received emergency treatment A. eat scan revealed a subdlnl hematoma along wllh • I.rt skull frllcture, A c:ranlotomy wu done on the same date. The deoedent remained a patient until her expiration on !IU/14 at 1035 hoUl'II. The decedent experienced a falling epleode one year- ago while In Hawaii. She reportadly fell and struck the back ot her heed. She WU evaklllled and WM r8f)C)IWd to be fine. During the pnt thl'N months, the decedent wu reported to be moving In 110W manner while having difficulty getting up In the morning

Scene Description: Not avanable.

Evidence: No evidence was OOl!ected at the hospital or at FSC.

Body Examination: A gross examination at FSC !'8\'8aled the decedent to have h8J head bandaged with a tube protruding through the bandage. She wat also observed to have Intubation tubing from the mouth. Sutures from organ procurement wer& observed to the abdomen.

Identification: The deoedent W81 ldentiffed et the hospffal by the husband, Caln Jonets.

Next of Kin Notification: ''ied of the expiration by holpltal pereonnel.

Tissue Donation: The husband gave consent for tissue and organ donation.

Autopay Notification:

PLEASE NOTIFY DETECTIVES 20TTNECK (5821244-9748) & JOHNSON lWO HOURS PRIOR TO THE POST-MORTEM EXAMINATION.

iJ020/023

OP/17/2014 WBD 10117 PAX 323221P718

• . . . . County of Los Angeles, Department of Coroner :'

Investigator's Narrative ~

Case Number: 2014-01724 Decedent: JONES, DANA KATHLEEN

Date of Report

llJ021/023

09/17/2014 WBD 10117

COOl'ITY OF LOS .\N0£L£S

PAX 323221970

ORDER FOR UUAS& - ORD£N DE ENTECRA

filJ022/023

f?EPI\RTMENT OF ~OR<>NU

Plff# m,d""" ClfUWfr all qua,iotu t,,/O#T ~ Case No:"Dal\G\ 1 _,.__.,._. ~ Ca~Name

W~ ~i w~~~~L~~-~~~-~~~~ .................... ~s DOES THE DEC£DENT KAVE ANY UVINO ADULT CHILDREN? =&D:

.20\4-0\72~

nvor"' IHr .'I' c'QIW#cr '°"" • ,,,..,_--., • /,,.,,,,, ;.El Fiaa,Jo lit• bijo, 6 h6- m_.)'OIU de II aiifx'! .•••••••• , .•••••••. -

6£1 Fiaado bl $itlo casttdo .-111t? . .......... . ........ , ........ -

HEALTH AND SAFI.TY copt: • CHAl"TU 3 • CUSTODY AND DUTY OJi' 1.NnaMINT

7100. The riahl IO conuol .._ diipolition ol lhl remaim of a dlcealt4 pmoo. aallleu other dlreaioi,s ba'IIS beea liVffl by the dec:ldala. Yel1S in. and lhl duty ol. 'inlmDml 111d 1bc liabillty for 1111 ,__.We COil or lntenDcnl oC siact- f'OIIWIII de\lOI.W$ upon_ tile followilll In tho Of-dcr named: ta> Thi 1wvivina ,pome. (b) The wrvMaa ldull ehlld or ad1Jk ~ ol the dcccdeal. (c) The nnMAI para_it t11t ~ of die deeedmL (d) Tbe peJIOft DI' ~ FC:1,cctr,,tel)' in Ille- IIIXl de&reel fl ltbldnld .. '" ~' MO\ed by 1M law$ cf Calilania II 1ntided '° aueeccd ao IM esme of the dcadfflL (C) Tha Public Mmlalltntor when lbl deceased 11M ~ -.CU.

-wAalffllG& n.,......_......._.._,_ ...._ .. ...._,_ .. .......,.aad.,-, N1r.W•••-,._., ,._ ... ,__.,. C...- ... s-tJCINll&rcdMflll).ltltalloa ........ ...._ .. ......, Ille a flllN .._. ••,,... • ........ ..-,. (r..l CoAI 5-- D5 _. 411)• Tocrcrc-. ploall nlwe tho body •JIOII _,.... ol)'Clllr l~ptlaa oldie dcash fllsaid ~ ta:

MOllTU,\llY; ttll 9>ul G ll\Oth ! 0 !IJ NAME(Plt.lNTED) ca,;n f. J>nes MetiollM.s,,,rn.~ - ::1053 Ei · 9ffll:'.ru;: Sf. a., .laJ'3 'Bet/Cb ._ ca ..,.,.,. "lo&IS

~C~5ld.lllllCt2J~lD~~ .... -_2_25 ... '1--'-----0... Slpect ___,;3;;;...--:..:13:;._~-I --------SIGNATUU

.lf'Ull!!atnmolklaisNCJwidla&, doc:umnlll, C.I, willl.. pow fl IIUCll'llly,

.... IIIIXl d kin _,.lllaliOn llelo'# and aplain wily they 1111 nol bllldlJni. Alladl Nppor1811 ........ -. .,,,._ ----------------Jff'lleuolilWp _______ TelepboM No.-------Addraf ______________ Qy _________ 5taa. ______ %.ipCode __ _

CODIOO DE SANIDAD Y SEGURJDAD • CAPITULO 3 • C\IICOdia y Obtipcion de Entieno 7100. El dcRcho de \"Oftlrolu la upoc.on de lot ratOt dcl fmado a mcnto1 do que olrll lnacruccione& bayan MD ct.du por ol fhlado, d•f autoridad. y ol ckber cld ealitno y la re&f)clnPbilidad ,or cl psio Justo de enlicrro de la)a testoa pa&& ,obre lo alpaitnta en el Olden nonalndo. (&) llpc,$0 o espon (b) hijo 6 hiju mayores de II aftol (c) padn o pact,... del fmado (d) penona o personu NlplCth,amnao en lol aradot de puePIOICO en d ordta noanbrado po, IN ltyea do California come, quo ticne deredto M suc:ader al lol bieDCI dcil finada (c) El Admlnlurulor Pllblk:o cuando ti lhlldo doM ~ l>lema. •

•AVISO: 1.a,.._,,. n■to_...._,_.~ ........ ~._...,...._ct ,_,_ • ..._ .......... r ■I 11D•--••- 1111 ....... W lhlC .... DISt .... t; ....... .,. .. _ ................... ,ra, tlta ....... lllt13illn ,_ .............. (~0. .... .... D5 J mr. Porao, ftwm-deemrepr lot ftlltal delftlllldo ... deoo,npllw la-~ a:, FUNQVJUk __________________________________ _

HOMBU ---------w-==--.,,~lmA....,,......,,..DE.,.,idJiiii-.-e-T __________ Plftlll.:o ______ -"

Dmllidio ----------Cllldad----------&udo------Z-,_... ___ _ 'Ncibto----------------PtdiaPmuda----------------fBMA

sr ao ea eJ pariea&e pr6nao, nr.., aplique porque el parienla lriximo • 1111a anqludo 1o1 tdmitat ea nae uunro.. Si• e1 .n..o.. del .......... bx:laJr ilDa iq,ia dll Wl•INlltO.

'l'ieDlepr6JCimo ______________________ ~---------

&.>miidlio --------- C\llda4I --------- 1!41..so------ Zoaa.Poeaal ---

ADDMONAL DJ!C!DENT INFORMATION ON REVERSE

09/17/2014 WED 10117 PAX 3232219748 llJ023/023

COUNTY OF LOS ANGELES HOSPITAL .AhlO NURSING 0~PARTMENT o, CO~ONE.R CARE FACILITY REPO!n'

1104 NORTH MISSION ROAi LOS ANGELES, CALIF. 9003:

. .

18 IO REPORT A 0!.ATH - PHONE (323) 343-0711 FAX (323) 222-7041 CC#-:::...=_..___--=~..L-=-.J C()MPl.£TE ALL LINES, USE IN"\- 11 UNt<N0WN OR NOT APPUCAeLE. SO $TATE.

s I . ,t,J<:.,~,'l JM.«1·0-1 C-rv,/-(',._ NAME OF FACILITY

HOSPITAL PHONE# S(;z "{'ff-~ c,

ORGANmSSUE DONATION INPORIIAT10N WN, THE ~12f;l<IN APPROACHED REGARDING ORGAN/TISSUE DO""'TION? NO D Y!S }a IF YES WHAT WAS THEIR RESPONSE?-------------------------0.A.TE AOMITTl!D 3/_:s /I'·/ TIME __ oei'---:;_~_3,;.. _____ -,--____ _

D SELF □ AMBULANCE (Name qt RA#) ______ .,...

FROM H!S?'IN'~ : yOS,"S C s±:t;re,\l s,.. u~ B:csc ~ (STATE WHETHER HOM!!, HOSPITAi. OR OTHER) GIVE ADDRESS (IF HOSPITi\L ATTACH THEIR HSTORV)

M.D. ADMITTED l!IY: H~•·r b,o."- SP.. M.O. PRIMAAV ATT!NDING PHYSICIAN /(-f.1 I\, .. o,_ J: ",. OFFICl!PHONE# ,i''lj ?1~_:-- SOSO OFFJC!PHONEt _______________ _

INJURIES-::'.'.""e'!~------~~-- PLACE ____________ CAUse ________ ,.....~------DATe . TIME (TRAFFIC, IIALL, ETC.)

SURGICAL MOCeDUR!S: STATI! TYPE, OATE. TIME ANO IIU:SUL.TS OF ANY OPERATION OR AMPUTATION PERFORMED

WA$ A QWD OR QlHER EQREK»f QBJICTJ HecQYfREP2 ~IFY ____________________ _ LABORATORY: REPORT ON PATHOLOGY SPl!CtMENS TAKEN _____________ DATE & TIM! _______ _

LABOAATORY PHONE NUMBER -------------MICROEl10L OG Y CULTURE RESUI..TS: _ NO _ YES (AlTACH Rl!PORT}

TOXICOLOGY SCREl!N: - NO _ves (ATTACH Rl!SUL.Ts,

RADIOLOGICAL STUDll!S: _NO _Y!S (ATTACH Rl;S\JLTS)

REMARKS: ESP!CIAUY SYMPTOMS PR~ING ~ DURING TERMfNAL EPISOD!

'l MV OPINION, THE CAUSE OF DEATH IS: _____________________________ _ dY ________________ M.D.

FFICE PHONE #

Hlt!l1~.Ml2l

NURSE/HOSPITAL ADMINISTAATOR

OFFICE PHONI! #

1. lllE BODY Will NOT BE Rl!MOVED BY TH~ CORONER WITHOUT THIS COMPLET!t) ftfPORT AND COPll!S OF ALL CHARTS. 2. ALL ADMISSION BLOOD SAMPLf.S/SPECN'lll:NS NEED TO ACCO .. P&.NV -n.es: D ........ -