The Education of a Coroner CHAPTER 01 FIRST BLUSH
I first met Ken Holmes in 2010 when I interviewed him for my book The Final Leap, about suicides from the Golden Gate Bridge. I was executive director of a nationally certified crisis intervention and suicide prevention center in the San Francisco Bay Area at the time, and Ken’s office was responsible for conducting the autopsies of most Golden Gate Bridge jumpers, as well as for notifying their families of the death. After the book came out, I was recruited to serve on the board of the Bridge Rail Foundation, an all-volunteer, nonprofit organization dedicated to ending suicides on the bridge. Ken was on the board also, and we had numerous opportunities to talk further. It didn’t take long for me to realize that his experiences over nearly forty years in the Marin County Coroner’s Office and the cases he’d handled would make a riveting subject for a book.

I had another reason for writing The Education of a Coroner: I didn’t know much about the workings of a coroner’s office, and wanted to learn more. How do coroners approach a death scene and what do they look for? How are families notified of a death, and what psychological techniques are employed? How has the world of forensic pathology changed with advances in technology?

The first time Ken and I met to discuss it was in a brew pub in Larkspur, in central Marin County. He had been retired three years by that time, although he still had—and continues to have—frequent contact with many of his former colleagues, and also attends annual conferences of the California State Coroners Association, where he once was president. We had communicated by email before then and I had run my general idea by him. I would review eight hundred case files that he had preselected and copied onto electronic disks, then we would schedule a series of days when we would meet and discuss the cases that I thought were the most interesting. Along the way we also would talk about his background, training, responsibilities, lessons learned, and people he worked with. First, though, I said I needed to get a sense of whether the stories he told were compelling and had universal appeal.

“Sure,” he said, and with no further prompting he launched into a thumbnail sketch of one case, then another and another until after only a few minutes my head was spinning. He apologized and said that once he started talking about his work, it was hard for him to stop.

Holmes is a natural storyteller, and his deep, melodic voice is both authoritative and soothing. A barrel-chested man with sharp eyes—even in his seventies—strong hands from having spent years outdoors, and a handsome face framed by a trimmed gray beard, he is someone who makes friends easily and holds on to them because at the end of the day, and especially at this stage in his life, friends and family are what matter most. He is quick to laugh—especially at himself—and has a range of knowledge that is impressive. Whether it is medicine, politics, hunting, guns, home repair, sports, food, wine, or cars, he can hold his own in a conversation with anyone.

“Let’s back up,” I said, “and focus on one case for now. You pick.”

“Okay,” he said, and he proceeded to tell me some of the highlights of the Carol Filipelli case, which is described a little later in this book.

At the end, all I could say was, “How many more stories do you have like that?”

He shrugged and said, “Dozens?”

* * *

Some of the cases cast Holmes in the national spotlight because of who they involved—rock legend Jerry Garcia, rapper Tupac Shakur, porn kings Jim and Artie Mitchell, and the infamous Trailside Killer. It was the deaths of people who weren’t well known, however, that remain the most vivid and noteworthy in his mind.

Several cases took nearly a decade to close, two took twenty years, one took thirty, and one took forty-four years. It might seem like a luxury for a coroner to be able to pursue cases so doggedly—certainly that’s not possible in large cities and statewide coroner’s offices. In some respects it was, but Holmes’s belief—then and now—is that family and friends of the deceased deserve to know what happened no matter how long it takes. Coroners deal with death, but their purpose is to find answers for the living.

If the work of coroners were less dramatic, we wouldn’t have so many TV shows about it. Holmes watches some of them and says that they get most—though not all—of the details right. Even so, inevitably he comes away thinking that real life is more moving than any fictionalized treatment can be. Nothing beats a story that happens to be true.

It helps to have a glamorous setting, which is why the original CSI TV show was set in Las Vegas and there is now CSI: Miami, CSI: New York, and NCIS: Los Angeles. If the emphasis were on gritty, then we would have CSI: Camden, CSI: Detroit, and NCIS: Compton.

The setting where Holmes worked is every bit as enthralling as the biggest cities with the brightest lights. I say that not because I was raised in Marin—as an adolescent it didn’t seem all that exciting—but because the county has a national reputation, despite its small size. Part of that is due to its physical beauty. Situated just north of San Francisco, Marin is surrounded by water. The Pacific Ocean lies to the west, and the eastern and southern borders end at San Francisco Bay. Only the northern portion abuts land—the beginning of California’s legendary wine country. Otherwise, access is across the Golden Gate Bridge to the south or the Richmond–San Rafael Bridge to the east.

There are no large urban centers, processing plants, factories, or notable industries in Marin. Mostly the county consists of coastline, rolling hills, dairy farms, and small towns. Hundreds of thousands of people come every year to visit Point Reyes National Seashore, Golden Gate National Recreation Area, Muir Woods, Mount Tamalpais, Stinson Beach, Tomales Bay, and Samuel P. Taylor State Park.

The other reason why Marin is well known is its affluence. It ranks among the top twenty counties in the United States in terms of household income, and is home to rock stars, movie stars, professional athletes, and wealthy business executives. The median price of homes is just under $1 million, and in many communities it’s considerably more.

This doesn’t mean that all is rosy, however. In 2014, the Robert Wood Johnson Foundation reported that nearly 25 percent of adults in Marin engage in binge drinking during any given month—one of the highest averages in the state. More than thirty residents die per year from drug overdoses, a large number in a small county. In addition, Marin is second to San Francisco when it comes to suicides from the Golden Gate Bridge.

Marin also has pockets of poverty. In the Canal District of San Rafael, people from dozens of cultures, speaking a multitude of languages, live close together in low-income housing. In Marin City, built during World War II to house shipyard workers and immigrants, local residents—predominately African-American—lived for years in crowded tenements until gentrification started pushing them out, creating new sources of tension.

Then there is San Quentin Prison, the oldest prison in California and one of the largest penitentiaries in the United States. Built in 1852 on 432 acres of shoreline property in Marin, San Quentin is, almost certainly, the most expensive piece of real estate in America—and perhaps the world—that is devoted to housing convicted felons. In 2009 the land was estimated to be worth $2 billion, and it has only increased in value since then. All of California’s 750 male death row inmates are locked up there, as well as more than four thousand other hardened criminals, male and female. To a motorist approaching Marin County from the Richmond–San Rafael Bridge, the prison looks, at first glance, like a huge sand-colored hotel on the waterfront. As one gets closer, however, one sees the twelve-foot-high concrete walls that are topped by coils of electrified barbed wire, notices that all of the window openings are mere slits even though the view outside them is spectacular, and knows that San Quentin was built with a much different purpose in mind.
THE CORONER’S OFFICE
It’s in this setting that the coroner’s office in Marin County operates. Throughout Holmes’s career, it was on the second floor of the Marin Civic Center in San Rafael, the county seat. The building was the last one designed by famed architect Frank Lloyd Wright and features a roof the color of the sky, scalloped balconies, and pink stucco walls, all intended to blend into the surrounding environment.

The office, which has since moved, isn’t what one might expect. Before I interviewed Holmes the first time, in 2010, I envisioned it to be part morgue with shrouded bodies laid out on stainless steel tables, waiting to be autopsied, and part laboratory with slides being inspected under microscopes. Like many small counties, however, Marin doesn’t have a morgue because it’s too expensive. Instead the coroner’s office contracts with local mortuaries and private physicians to receive the bodies of dead people and conduct autopsies when warranted. The county also doesn’t have a lab for analyzing specimens that are collected at a death scene. Fingernail scrapings, pubic hair samples, vaginal swabs, and the like are sent to outside labs. There are only a handful in California that specialize in this kind of analysis, with the primary one operated by the state Department of Justice. Samples from any case that might go to court—particularly homicide cases—are sent there. The DOJ lab doesn’t handle body fluids, though, so blood, urine, and gastric samples are sent elsewhere.

Employee offices look the same as the offices of any other business with a modest budget—older desks and chairs, older computers and phones, and bookcases crammed with special texts, trade journals, binders, and miscellaneous papers. For all of Holmes’s thirty-six years, there was a staff of seven. Six employees—the coroner, assistant coroner, three death investigators, and a secretary—were full-time. One position—the medical transcriber—was part-time. He or she took the voice recordings of forensic pathologists during autopsies and turned them into written summaries.

The common areas are more distinctive. There are evidence lockers, an old bank safe to store money that is collected at a death scene, refrigeration units to store specimen samples, and dozens of four-drawer metal file cabinets that are filled with case files, some of which date back more than 150 years, to the time when California became a state.

The role of the coroner originated in twelfth-century England. “Crowners,” as they were known at the time, conducted inquests on behalf of King Richard I to identify the deceased, determine how they died, and—most important—collect death taxes on their estates. It was the height of the Crusades, the Catholic Church was trying to restore Christianity in and around the Holy Lands, and money was needed to finance numerous campaigns.

Coroner’s offices today are vestiges of this royal system. Coroners are either elected by the populace or appointed by designated entities, with the requirements varying state by state and oftentimes county by county. In the highest form, coroners are medical examiners, meaning they are licensed physicians who are trained and certified in forensic pathology. Most people assume that all coroners are MEs, but this isn’t the case. Many coroners are licensed physicians who have no training in forensics, while in hundreds of communities across the country—including Marin County—the coroner isn’t required to have any medical training at all, much less a medical degree. He or she just needs to have a clean record, meaning no felony convictions, be twenty-one or older, and have a high school diploma. Some counties don’t even require that, however. One county in Indiana elected a coroner who was eighteen and still in high school.

A 2015 review by the National Academies of Sciences, Engineering, and Medicine compared county coroners and medical examiners. The biggest benefit of county coroners, according to the review, is that they reflect the will of the people. In American political culture, elected officials represent a community’s needs and values better than anyone else because they are chosen by voters. In addition, county coroners have equal footing with other locally elected officials—members of the board of supervisors, sheriffs, judges, and district attorneys—which enables them to operate independently from these entities. The main drawback is that the coroner may not be medically proficient since it’s not a requirement of the job.

On the medical examiner side, the major advantage, according to the review, is that the overall quality of death investigations is better. In addition, there is more uniformity. For statewide medical examiner offices, there are the added benefits of centralized administration, which is expensive to start but less expensive to sustain, and improved service to rural areas, which often don’t have the capacity to operate coroner offices on their own.

Nineteen states—in general, the smallest ones—have a state medical examiner system. The largest states, including California, Texas, New York, Illinois, Pennsylvania, Ohio, and Georgia, have a mix of medical examiner and county coroner offices.

As the most populous state, California is unusual—but not unique—in that the coroner’s office is combined with the sheriff’s department in forty-nine of fifty-eight counties. In these areas the sheriff serves as coroner, too—despite having little or no medical training—and appoints another law enforcement person to oversee the day-to-day duties who, in all likelihood, has no medical training, either. The result is that the work of the coroner’s office is controlled by the sheriff, which can create problems. Because sheriffs focus on criminal activity, the emphasis of the coroner’s office in these counties is to support homicide investigations. Less time is spent delving into deaths by accident, suicide, or natural causes, and frequently in these instances autopsies aren’t conducted, in order to save money. Cases in which the manner of death is undetermined, but clearly isn’t homicide, also get short shrift, leaving families in the dark as to what caused their loved one to die.

The lack of national standards for coroners is hard to understand inasmuch as a death certificate is one of our most important documents. It is used by families to collect life insurance, file for payment from special funds for certain types of deaths, such as mesothelioma, and change names on deeds, trusts, and other valuable assets. Death certificates also are used by the government to stop Social Security payments, by businesses to change or eliminate pension payouts and health care coverage, by various public and private agencies to inform current funding decisions and future policies, and by researchers to track how society is changing.

In Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner, author Judy Melinek talks about the value of a death certificate. “It’s no big deal if you don’t have a birth certificate,” she says. “Other forms of identification will suffice to secure a job, open a bank account, even file for Social Security. However, if your survivors cannot produce a death certificate after your demise, they will descend into bureaucratic purgatory. They can’t bury your body, transport it across state lines, liquidate your investments, or inherit anything you have willed them.”

Coroners aren’t the only people who are authorized to sign death certificates. Depending on the state, a primary care physician, attending physician, nonattending physician, or nurse practitioner can sign. Most of the time, these signatories confirm a death by natural causes where no investigation is needed. In homicides, suicides, and accidents, coroners typically sign the certificate after an autopsy has been performed.
CAUSE AND MANNER
The results from an autopsy and the findings of toxicology tests help the coroner determine the cause and manner of someone’s death. Although cause and manner seem like the same thing, they are, in fact, different. Cause refers to the physical reason why a person died. A gunshot to the head, an overdose of drugs, blunt-force traumatic injuries such as those resulting from a vehicle accident or a fall, sharp-force injuries like stabbings, inhaling a deadly gas like carbon monoxide, and asphyxiation due to drowning, hanging, or strangulation are examples of cause. Deaths from heart attacks, strokes, seizures, and other diseases also are examples of cause.

Manner refers to the way in which a person dies. There are five recognized categories in the United States: homicide, suicide, accident, natural, and undetermined. Each one has legal implications for law enforcement and can have financial consequences as well.

A ruling of homicide means that there is likely to be a police investigation. Detectives collect evidence of criminal activity and present it to a district attorney, who decides whether or not to prosecute. If the case goes to trial, the coroner is called to testify, but only to the extent of explaining how a determination of cause was reached. Inasmuch as coroners’ rulings are fact-based and unbiased, there are occasions when the explanation is as helpful to the defense—mainly by discouraging the district attorney from trying the case—as it is to the prosecution.

A ruling of suicide usually ends any police involvement. In some instances, this is welcome news for family members who otherwise might be implicated for murder. Other times, a determination of suicide can end up voiding a decedent’s life insurance policy if it was taken out or renewed within two years of the person’s death (beyond two years, the policy can’t be nullified). In addition to the possible financial impact, a death by suicide can be stigmatizing and cause family members to feel guilty, embarrassed, or angry on top of the other emotions that a loved one’s death tends to generate, such as sadness, depression, loneliness, and despair. For this reason, family members may push hard for the coroner to rule that the death was accidental rather than a suicide.

If a death is determined to be accidental, it means that there was little if anything the decedent could have done in the moment to prevent it. A woman falls off her horse, lands on her head, and fractures her skull. A boat capsizes and someone drowns. An apartment building catches on fire and one of the tenants dies from smoke inhalation. Sometimes blame may be placed on another person, such as the driver in a fatal vehicle collision whose inattentiveness, recklessness, or drunkenness caused the accident. Alternatively, the victim’s own ignorance or carelessness may play a major role. A man is swept off a rock while fishing and is washed out to sea. A homeowner who is trimming trees on his property touches a high-voltage wire with his saw and is electrocuted. A farmhand loading bales of hay into an auger feeding wagon falls into the wagon and is mutilated. Each of these is among the many deaths that Holmes investigated in his career, and each was avoidable, but not in the instant that it happened. At that moment it was too late.

As for natural deaths, which typically comprise about 60 percent of the deaths a coroner’s office handles, these are the result of a disease rather than an injury. This doesn’t mean that the person died of “old age,” since young people can have a known or unknown health problem that isn’t treated or ends up being mistreated. Rather, it means that the person suffered from a heart condition, tumor, seizure, or aneurism that proved to be fatal.

Sometimes it’s impossible to determine the manner in which someone died. When a car goes off the road and hits a tree or catapults off a cliff, did the driver fall asleep at the wheel, swerve to avoid an animal, lose control, or intend to die? If the person had a stroke or heart attack there will be forensic evidence, but otherwise, in the absence of skid marks, it may not be possible to tell. Similarly, if someone is found dead in bed due to a drug overdose, was it accidental or intentional? A suicide note might provide the answer, but only 20 percent of suicide victims leave a note, so oftentimes the coroner has little to go on. Is a patient’s death during surgery merely unfortunate or is there evidence of medical malpractice? Every medical procedure has risks; the question is whether doctors bear any responsibility for the outcome.

In cases where the coroner doesn’t have enough information to make a definitive ruling, the official manner of death is “undetermined.” This can be altered if new evidence comes to light; however, it can only be altered once. The last thing anyone wants is for the manner of someone’s death to be perpetually changing. That would wreak havoc with law enforcement, the courts, health care providers, insurance companies, and families.

Marin County has an average of 1,500 to 1,800 deaths per year. Roughly 300 of these require autopsies because the cause and manner of death aren’t clear. Trauma cases, accident cases, and other cases that are out of the ordinary or unusual end up in a pathologist’s hands.

“On TV and in the movies they use the word ‘suspicious,’?” Holmes says, “but that’s not a word we ever used. We said it was ‘out of the ordinary’ or ‘unusual.’ Not that it’s wrong to use ‘suspicious’—it might be part of the vernacular in other coroners’ offices—it just wasn’t part of ours. To say that a death is suspicious is to offer an opinion; something doesn’t seem right. Instead, we presented the facts and left the interpretation to others.”
THE ROAD TAKEN
Holmes was raised by his paternal grandparents in the Central Valley town of Fresno, California. His grandfather was the fire chief of Fresno and a huge influence on Holmes’s life.

“He taught me morals, integrity, and work ethic,” Holmes says. “He also was a guiding light when it came to life in politics, which I didn’t fully appreciate until years later, when I entered the political arena.”

Most boys Holmes’s age were passionate about three things: sports, guns, and the outdoors. Holmes was, too, but he also was transfixed by something that his friends had no interest in—anatomy.

“I was the kid who tried to figure out how that bird died, or what happened to the jackrabbit,” he says. “When I first started hunting, at age eight, I was as interested in what happened to the bullet as I was in getting the animal ready to eat.”

He remembers the first jackrabbit he ever skinned. “Once I skinned it I could see the shoulder and the foreleg, and I could work the shoulder and I could see the shoulder bone rotating in the socket because the muscle there is thin. I said to my granddad, ‘Gee, look at that.’ He said it was called a ball-and-socket joint. I kept working it, and in my mind I was struck by the fact that it was so simple yet worked so well.”

Early on, Holmes’s grandmother determined that if an animal was wounded, her grandson was the one who would tend to it. One time someone’s collie got hit by a bus in front of Holmes’s house. Holmes was playing with three of his friends and witnessed the accident. He didn’t know whose dog it was, but he got a stick and two handkerchiefs and splinted the dog’s broken leg.

In middle school, Holmes had to write a report describing three occupations he was interested in pursuing. Two choices—being a physician and being a veterinarian—seemed obvious. Both had a significant drawback, though—all of the additional years of study that were necessary. Holmes liked school, but not that much. Even so, he listed doctor and vet as two of his choices. He had no idea for a third choice, however.

“You know, the coroner does autopsies,” his grandfather said. “That’s medicine.”

Holmes perked up. “What are autopsies?”

His grandfather explained that autopsies are postmortem examinations to determine how and why someone died. Usually they are done in a morgue, he said, but because Fresno County didn’t have one at the time, they were conducted at a local mortuary instead.

“Do you want me to set up a meeting with the funeral director there?” he asked.

Holmes nodded, instantly intrigued. He was even more interested when he saw the funeral director drive up in a big black late-model Cadillac. The man was wearing an expensive suit and equally expensive shoes. In addition, the funeral home was plush and quiet, the sort of place where Holmes could imagine himself working.

The funeral director affirmed that all autopsies for the coroner’s office were done at his mortuary, and he explained the process and what the job entailed. By now Holmes sensed that he might have found his calling. There was just one more thing he needed to know.

“How long does it take to be a funeral director?”

“Three years after high school,” the man said. “One year of mortuary college and two years of apprenticeship.”

That clinched it. Holmes wrote in his report that his third career choice was funeral director.

From the outset, he knew that his real goal was to be a coroner, not a funeral director. “I just didn’t know how to get there,” he says.

In school, his favorite subject was science. He also was enamored with mysteries, especially those that featured his namesake detective, Sherlock Holmes.

After he graduated from high school, Holmes attended Fresno City College for two years and started an apprenticeship at the funeral home he had visited with his grandfather. In those days, a person didn’t have to go to mortuary college first. During the apprenticeship, Holmes learned two important things about himself.

The first was that he had no qualms about death. On the contrary, when he watched his first autopsy, he was so enthralled that eventually his boss had to ask him to leave the doctor alone because he was asking too many questions. The person’s chest had been cut open, exposing all of the internal organs, and Holmes would point to various body parts and ask, “What’s that?” The doctor would explain, then remove the deceased’s heart, kidneys, and other organs and place them in Holmes’s hands.

“It was a mesmerizing experience,” he says, “and I couldn’t get enough of it. Throughout my apprenticeship, whenever there was an autopsy I went and watched, even if I didn’t have to be there. I continued to ask questions and listen to the doctor as he recorded his findings into a Dictaphone. The result was that I began to develop a good grasp of medical terminology when I was still in my teens.”

The other thing Holmes learned about himself was that he had a lot of compassion. “I didn’t know it,” he says, “but I did. From the beginning, I enjoyed working with families. I felt comfortable around them, and they, in turn, were grateful for my help in making funeral arrangements.”

San Francisco College of Mortuary Science emphasized the physical sciences—anatomy, pathology, bacteriology, and chemistry. One of the skills that was taught was embalming. It involves withdrawing blood and waste matter from human organs, reshaping or reconstructing disfigured or maimed bodies using clay, cotton, plaster of Paris, and wax, injecting embalming fluid with a pump into arms and legs, closing incisions using needles and sutures, joining lips with a needle and thread, and applying cosmetics to give a dead body a lifelike appearance. Holmes didn’t know it at the time, but the fact that he became a licensed embalmer proved to be a critical stepping-stone to his future career.

After he graduated, he applied to coroners’ offices around the Bay Area, but there weren’t any openings. Needing to work, he took a job at a mortuary in Sonoma County, just north of Marin. At that time, Sonoma County had only one coroner’s investigator. He was retired from the California Highway Patrol and responded to homicides and accidental deaths, but not to traffic accidents because the police could take care of those. Even so, there were more cases than he could handle so he commissioned every licensed embalmer in the county to be a deputy coroner. This meant that Holmes and other embalmers were responsible for writing a brief report—only a few lines—following suicides and other types of deaths that weren’t being investigated, leaving the investigator to focus on trauma cases.

One day the investigator was at the mortuary where Holmes worked. He wasn’t there to see Holmes, but he couldn’t help but pull him aside.

“Damn, Holmes,” he said. “You wrote a report the other day; I wouldn’t write one that long. You went into all sorts of detail you didn’t need to. I certainly got a great picture of what you saw, though.”
FORTUNE INTERVENES
Holmes was married and had a son and daughter by this time. In coaching his son’s Little League team, he became friends with another coach, named Henry. One Friday morning Holmes was at the mortuary and it was quiet. No one else was around and there wasn’t anything in particular that he needed to do. Although it was a hot day, Holmes decided it would be a good time to see if he could get the big fountain in front to work properly. He had always liked to tinker, and the fact that it sprayed water sporadically bothered him. Still wearing his standard uniform—black slacks and a white shirt—he rolled up his sleeves and was working on the fountain when Henry drove by. Henry honked and waved, and Holmes waved in return. Because he wasn’t in a hurry, Henry turned around, came back, and the two of them moved to the shade and got to talking. At first they talked about Little League, then Holmes asked Henry what he was doing there. Henry said he had stopped to see a man named Tom who worked at another mortuary nearby. After that Henry mentioned, offhand, something that would change Holmes’s life. He said that Tom told him the Marin County Coroner’s Office was adding a new position, a third death investigator, and Tom had applied for it.

Holmes was floored. He knew the two current investigators in Marin and the assistant coroner. Despite making repeated inquiries, however, Holmes had never been told that a job was opening up.

As soon as Henry left, Holmes called the coroner’s office. It was one o’clock. He said he had just heard that another investigator was going to be hired, and asked what the process was for applying. A secretary told him that interested candidates had to fill out an application from the Human Resources Office, and the filing deadline was five o’clock that afternoon.

Holmes closed the mortuary, told the answering service that he had an emergency, and raced ten miles to the Marin County Civic Center, where all county offices were based. The Human Resources Office was on the top floor of the four-story building, tucked so far in back that it seemed like Siberia. Holmes tried to remain calm as he asked for an application. It turned out to be six pages long, and a woman told him that he needed to attach copies of his high school and college transcripts. Holmes filled out the application as neatly as he could by hand, and said that he could provide the attachments but couldn’t get them that day. The woman said that since it was Friday, it probably would take a couple of days for applications to be processed, so if he could get them to her by the first part of the following week she would add them to his application. She didn’t need to be so accommodating, but she was.

On Monday, Holmes called his high school and college to get the transcripts. Faxes didn’t exist in those days so he paid to have them mailed overnight. Tuesday afternoon he delivered the documents to Human Resources, and the woman included them.

It turned out that there were sixty-eight applicants for the one position. As with most government jobs, people in the HR office did the initial screening. One of the requirements listed by the coroner, Dr. Ervin Jindrich, was that the person have a California embalmer’s license. Jindrich himself was a certified forensic pathologist, but he knew the value of an embalmer’s license.

“It meant you’re not afraid of death,” Holmes says, “and you’re used to people crying.”

Being unafraid of death is an obvious requisite for a coroner. Doctors, soldiers, cops, and firefighters become habituated to death the more they witness it, but coroners have to start out undaunted by dead people in all their forms. As for being used to people who are crying, this might sound cold or insensitive, but in fact it was practical and relevant. Coroners’ investigators have to be able to function in an environment where people are feeling enormous pain and grieving a significant loss.

“It’s easy to get sucked into someone’s grief and want to comfort them,” Holmes says, “but you also have to be able to step back and focus on other aspects of the job.”

As it turned out, half the candidates lacked an embalmer’s license and were eliminated from further consideration. Tom, the man who had told Holmes’s friend Henry about the opening, was still in the running, however. Moreover, he knew everyone in the Marin coroner’s office even better than Holmes. Tom had worked with them longer and more closely. In a moment of ill-advised and inappropriate candor, Keith Craig, the assistant coroner, told Holmes that Tom had the inside track and almost certainly would be hired. Hearing this, Holmes was despondent. His dream job was going to someone else.

Tom was so confident of his standing, however, that he hadn’t submitted all the information that HR required. As a result, his application was thrown out. Craig, among others, was flabbergasted to learn that Tom hadn’t made it past the first step. He had seemed like a sure thing.

That was the opening Holmes needed. He went through the interview process, which culminated in oral boards before a panel of five coroners from neighboring counties, and ended up being ranked the top candidate.

Looking back to that period of time, Holmes still marvels at the confluence of events that ended with his hiring. The fact that it was a quiet day, that he was outside the mortuary fiddling with the fountain, that Henry not only waved but stopped and came back because he wasn’t pressed for time, that Henry mentioned the position not knowing that Holmes would be interested in it, that Holmes had enough time to get to the civic center and fill out an application, that HR allowed him to add grade transcripts after the filing deadline, and that Tom’s application was thrown out because it was incomplete, seemed nothing short of miraculous.

After he started, Holmes asked Jindrich why he hired him. After all, Holmes had no investigative experience.

Jindrich was thirty-five at the time—only three years older than Holmes—and had been elected coroner a year earlier after working as an autopsy specialist for the coroner’s office in San Francisco. In appearance he resembled a young Abraham Lincoln with a narrow face, full beard, sharp eyes, and a sweep of dark hair.

Jindrich said, “Your understanding of medical terminology and medical situations was much higher than anybody else’s. You can learn fairly quickly to be a good death investigator if you have a natural tendency to ask questions. I can teach you what you need to know. It takes years and years to learn medicine, however, and I don’t have time to teach you that because in two weeks you’re going to need to hit the street.”

Clearly, all of the time that Holmes had spent standing next to doctors during autopsies and asking questions had paid off. When he succeeded Jindrich as coroner, Holmes emphasized the same qualities in hiring investigators as Jindrich had—that is, familiarity and comfort with death, extensive knowledge of medicine, an innate inquisitiveness and willingness to ask questions, plus compassion for grieving families.

This last is as important for investigative reasons as it is a requisite of human kindness. Investigators who relate poorly to families can’t always obtain the information needed to make an accurate determination regarding someone’s death. When they ask a question, they often get yes-or-no answers because most individuals are cautious. If an investigator can convince people that he or she is on their side, however, family members and friends answer at greater length, sometimes providing important details with little or no prompting.

This was the part of the job that Holmes found particularly rewarding, and some of the people he came to know after notifying them of a death continue to send him emails periodically and greeting cards during the holidays. Either they want him to know that they are well, or they just want to stay in touch.

At the time Holmes was hired, however, the day when he would be responsible for hiring other investigators was far off in the future. He was thirty-two years old, fresh-faced, with keen eyes and a receding hairline that he compensated for by growing long sideburns, and there was much that he needed to learn first. He was about to enter a different world than the one he knew.