The thankless job of the San Diego County Coroner

Dead reckoning

Bodies arriving are weighed and measured before they are put on one of five stainless steel tables.
  • Bodies arriving are weighed and measured before they are put on one of five stainless steel tables.
  • Image by Jim Coit

County Coroner David Stark: "We're not afraid of bodies; it’s just a fact of life."

County Coroner David Stark: "We're not afraid of bodies; it’s just a fact of life."

He was dead The eyes that blinked open at his birth fifty-eight years ago were now closed, scaled forever. His withered face was drawn into a pose of peaceful non-expression. A victim of Lou Gehrig’s disease, his corpse was pale, almost wax-like. and little more than a slightly padded mannequin of skin and bones. A small puddle of condensed water filled the depression at the base of his neck.

Somewhere in San Diego his family was probably weeping for him, but here the only sound was the sporadic drone of a huge refrigeration unit protruding from the back wall. Here in the coroner’s storage facility he was surrounded by eight members of his new. lifeless peer group, each covered by a white sheet, each balancing a shopping bag of personal possessions on their ankles.

Coroner's tools. These professionals have made careers out of exploring the human body for the cause of its final malfunction.

Coroner's tools. These professionals have made careers out of exploring the human body for the cause of its final malfunction.

I never knew him in life, but this postmortem meeting, though brief, I will not soon forget. To inspect death so leisurely and so closely is disquieting. For most of us, it is a mystery, an abstraction made concrete only rarely. But for more than thirty individuals employed by the San Diego County Coroner’s Office, death is commonplace. In fact, it is their livelihood.

Every year the coroner’s office investigates about 2800 of the county’s deaths (12,400 in 1977) caused by accidents, suicides, murders, and natural causes. Each of the 2800 death certificates resulting from those investigations carries the signature of one man, David J. Stark, who presently holds the position of San Diego County Coroner.

“We certainly have a different perspective of death from the average person. It’s not gruesome; we're not afraid of bodies; it’s just a fact of life,” Stark said from behind the cluttered desk of his office in the coroner’s building, located in the county operations complex at the end of Overland Avenue in Kearny Mesa. On the wall directly across from his desk hangs a grim reminder of his most memorable working day: the infamous photograph of a crippled and burning PSA Flight 182, snapped seconds before it crashed in North Park. “I think many of the people here, in their relationships with other people and their families, have a little insight into life that other people either don’t know about or don’t want to know about,” he added. “That is that life is very fragile and very temporary. Some husbands left the house this morning and they will never come home again. So if you leave the house in anger, that’s going to be your last impression.”

Stark, a soft-spoken man with graying hair, wire-rimmed glasses, and a rugged face, was born the son of a Congregationalist minister in Ohio before moving to Southern California in the 1940s, during his high-school days. After returning from service in the Korean conflict, he decided not to pursue a job using his college degree (in sociology), and instead joined some friends who were enrolled at the California College of Mortuary Services in Los Angeles. Eventually he became an embalmer. In 1962 Stark joined the San Diego County Coroner’s Office as an embalmer. later became a deputy coroner, and eventually worked through the ranks to become acting coroner when Robert L. Creason retired early last year. After eight months as acting coroner, David Stark was designated coroner on October 18, 1978.

He said people can learn a few things about his office by watching his TV counterpart on the series Quincy, which stars actor Jack Klugman as a crime-busting forensic pathologist coroner. But Stark, who is not a forensic pathologist, also warned that the show’s producers are “dressing up the coroner image in typical Hollywood style.” To illustrate, he noted that Quincy has no trouble pinpointing the time of death down to the minute, but Stark’s men can only estimate the moment to within a couple of hours. San Diego's real-life coroner smiled as he recalled one episode when Quincy reconstructed the appearance of an entire body from nothing more than a thigh bone—no small feat considering that a real forensic pathologist could only determine height, sex, and possibly race if given the same thigh bone. Stark admitted, though, there was probably a little Quincy in all coroners. "There has to be. You have to be curious and not satisfied when you’re not getting answers. That's why this is such a demanding job. You can’t always forget it when you go home at night.”

According to Stark, those aspects of the job that his employees take home with them have more to do with questions of an investigative nature than with the assumed problems of reliving nightmarish visions of particularly hideous deaths. Deputy coroners are usually drawn from the ranks of military medical corpsmen, embalmers. and other occupations familiar with medical terminology and all faces of death, so even the sight of a violent traffic accident has little effect on them. ”I think most of our deputies would tell you that we are dealing with a mystery or a problem to be solved,” the coroner said. “We’re not dealing with death or with gruesome things.”

Stark’s thirteen deputies are very adept at solving the mysteries that face them. Of the 2800 cases they handled in 1977, they were stumped as to the cause of death in less than 25 cases, and were unable to identify only four corpses. These figures are commendable considering the variety of methods used by humans to destroy themselves and others. But the annual handful of John and Jane Does and undeterminable deaths stand in the way of the coroner’s goal of one hundred percent accuracy. “Accuracy is probably the thing we are striving for most, ” Stark noted. "If it takes more time to be accurate, then we can’t be as prompt as we would like to be." Occasionally, the extra time involved in an especially complex investigation can mean considerably more grief for the survivors. but Stark maintains that the delay is justified, for an accurate determination as to the cause of death can mean a great deal to the family in terms of social security benefits, insurance settlements, and other compensation.

In general, one of the county’s deputy coroners goes to the scene and investigates any death involving accidents, homicides, suicides, or natural-death situations in which the decedent’s personal physician can’t or won’t certify the actual cause. The coroner sometimes waives jurisdiction in situations where a doctor has seen the deceased alive within sixty days of a natural death (heart attack, terminal disease, etc.) and can attest that the person's medical history might account for such a death. California law, however, states that a physician must see the deceased alive within twenty days of a natural death before the coroner can waive jurisdiction, but Stark feels that closely following the law in many obvious cases does nothing more than put added stress on the survivors and added strain on his department’s workload.

In ninety-seven percent of the cases where the coroner chooses to take jurisdiction. the body is transported back to the coroner’s building, where an autopsy is performed by one of the forensic pathologists, fully accredited physicians who specialize in detecting the cause of death due to both natural and traumatic causes. These examinations can often become very involved; sometimes the research uncovers foul play.

Since all death scenes are left untouched by police until a deputy coroner arrives. Stark estimates that about twenty-five percent of the county’s murders (more than 130 in 1977) are discovered when the deputy moves the body for inspection, or later during the autopsy and toxicology studies. The coroner’s homicide investigation follows a rigid formula detailing everything from the original position of the victim to the amount of any particular drug found in the liver tissue. Most murders are obvious; the victim usually has a gunshot wound or other visible damage. But the suspicious deaths that may be murders, and many suicides for that matter, are usually discovered by the forensic pathologists or the toxicologists. These professionals have made careers out of exploring the human body for the cause of its final malfunction, and many times it requires a microscope to find it.

Stark cited two such cases that were resolved by the men in the “back room.” In the first, a known drug-user was found dead in south Mission Beach, the victim of an assumed overdose of narcotics. But the toxicology report, which is derived from the microscopic study of eight different organ (issues taken during the autopsy, revealed that a deadly amount of an exotic poison was the true cause. This discovery kept the police searching for an assailant, who was later caught and admitted to killing the person for a fee.

In another case, a man who apparently fell asleep at the wheel of his car was killed when the vehicle slammed into a roadside obstacle in a mountainous area of East County. Again, the toxicology report told the real story: The man had swallowed insecticide to insure his death, assuming that the resulting insurance settlement would support his family.

Determining the motivation for a suicide can be another difficult assignment for Stark's employees, because the fabled suicide note is left only about ten percent of the time. Even then, the note may only reveal despondency. But deputy coroners look for other clues at the scene that might suggest a suicide—prepaid funeral arrangements, for example, or insurance policies spread out on a table, or personal property wrapped up with someone’s name on it. Sometimes the motivating factor is discovered through the follow-up procedures required by some cases. Stark remembered the suicide of a salesman who was found dead inside his van, which was parked in a rest area along Highway 8 in the Laguna Mountains. The van had a pipe rigged up to pump carbon monoxide fumes from the exhaust pipe to the cab. The family vehemently cried murder, and claimed the salesman had absolutely no reason to kill himself. Routine procedure, however, produced the probable reason for the suicide. When the man’s fingerprints were forwarded to Sacramento for removal from the state department of justice's master print file, a rap sheet returned with the following information, which was unknown to the family; the salesman was due in court on a morals charge the day following his death.

Most families, when presented with incriminating evidence, will admit that suicide is a possibility. But in many cases, the grieving family is more likely to lash out at anyone, and coroner personnel are usually the target. “People say, ‘That’s a good department to work in because your customers won’t give you any problems.’ Well, that’s not true. Almost everyone has some family or friends, and those people can be very, very difficult in a death situation,” Stark said. In most instances where the family disputes a suicide and even threatens to file a lawsuit. Stark says that a substantial amount of money is usually hanging in the balance. For example, most $100,000 life insurance policies pay the face value for a holder's natural death, $200,000 for a murder or accidental death, and $300,000 for fatal accidents while riding in a common carrier (bus, airliner, etc.). The same policy might pay the holder’s family $100,000 for a suicide, but only if the death occurred at least two years after the policy was drawn. So, depending upon the circumstances, the coroner’s final ruling may decide if the survivors receive $200,000 or no money at all.

But by far the most undesirable duty associated with the job, according to Stark and several deputy coroners, is an unpleasant task known as the “cold notification.” Contrary to public belief, it is the responsibility of the coroner’s office, not the local police department, to notify the next of kin when someone dies. The notification is always done face-to-face at the family's home by one of the deputy coroners. “There is no doubt that that’s the worst thing you have to do." Stark said.

Most of the deputy coroners have developed their own techniques for breaking the bad news to unsuspecting families, and Stark was no different when he was deputy. His method was to build the conversation in such a way that the family could finally guess the reason behind his visit. He illustrated the ideal dialogue he hoped to achieve during his grim task, which usually took place at the family's doorstep or living room:

“Hello, I’m Mr. Stark. Your son has been involved in an automobile accident. “ “Was it a serious accident?”

“Yes, it was. It was very serious.” “Was he injured?”

“Yes, he was, very badly.”

“Is he in the hospital?”


"Is he dead?”


Deputy Coroner Stark's most heartbreaking notification occurred when he had to go to the same family twice within three years. While driving to the parents’ home of a young man who had been killed in an auto accident, the young man’s last name and El Cajon neighborhood became increasingly familiar. Suddenly, it was clear: Stark had notified the same family about the death of another son only three years prior. Shaken. Stark rang the doorbell and greeted the father, whom he had talked to on his previous visit: ‘ ’Hello, I'm Mr. Stark. ...” The father just stared through him. Finally, he said, “Oh my God, not again.”

In spite of carrying the stigma of being the county’s designated messengers of death, Stark and his deputies are extremely proud of the help, comfort, and guidance they can provide for the family of the deceased. They often aid the family by calling relatives, outlining the various monetary benefits available, and generally assisting the survivors as best they can. Stark recalled a case in which a North Park woman's husband died just after her son had been sent to Vietnam. When she told Stark that she was afraid the boy would miss his father's funeral. Stark called the Red Cross, who then arranged to get the young soldier back from Southeast Asia. Stark smiled as he remembered meeting the woman some time later, when she introduced him to a friend as the man who was able to get Johnny Jr. home from Vietnam. “ ‘Forty-eight hours later, Johnny Jr. was home.’ That’s what she remembered, and that makes you feel kind of good.” he beamed.

The coroner’s longest day on the job was, of course. September 25. 1978, the day of PSA Flight 182. When the airliner crashed at 9:04 that morning. Stark was in his office, finishing up his usual paperwork and preparing for his daily routine. More than fifty ambulances responded to the crash, but it took authorities about twenty minutes to decide there were no survivors, so it wasn’t until 9:24 a.m. that Stark learned that he was suddenly the busiest man in San Diego.

Ironically, the official disaster plan used by the coroner’s staff to guide their procedure throughout the day had just been completed in August, after two years of preparation. This plan still carried pencil-mark corrections when it was hurriedly thrown into use. Stark also based his procedure on lessons learned at meetings of the California State Coroner’s Association, where disaster plans are frequently discussed. “I think all the things I had learned in those meetings began coming back into my head again.” he said.

Supervising deputy coroners Jay Johnson and Warren Chambers grabbed all the deputies they could muster and went to the scene while Stark directed the situation from his office. The switchboard was quickly jammed with phone calls, so there was only one telephone line open, and that was connected directly to Stark’s office (this problem, like others encountered during the disaster, has since been corrected). Johnson and Chambers fed information through that line while Stark carried out his role in the plan. His primary duty was to get the right people in the right place at the right time, and there was plenty for him to do.

Stark didn’t arrive at the scene until about two p.m., and his initial reaction was one that exemplifies the almost casual attitude of men familiar with the vision of traumatic death. “I think my first impression at the scene was that I was surprised at how small it was. I’d expected to see several more blocks involved," he said, recalling that sweltering hot afternoon. “I don’t think any of us on the staff were shocked by the destruction of what we saw, or the destruction of the bodies that we saw. We had seen it before, but we had never seen it on such a large scale—that was the alarming thing. ”

By 2:30 that afternoon, bodies were being loaded into refrigerated vans for transportation back to the coroner’s building. There the forensic pathologists, forensic dentists, and FBI fingerprint men began the arduous process of identifying each of the victims. The staff also received help from a number of local dentists, who stepped out from the community to assist the two forensic dentists with the unenviable task of identifying bodies through dental charts. Four weeks after the crash, all but four of the victims had been positively identified. (They remain unidentified still.)

Out of the whole tragic incident, a few positive highlights managed to stick in Stark’s mind. He chose his words carefully as he recalled the most important one. “I think it was the way that everybody in the community responded. It’s true that all the different agencies had some plans, but nobody was running around with a book or a plan in his hand. We were adjusting that plan as we went along.” Summing up the effect Flight 182 has had on his staff. Stark commented. “I think it has given people around here a lot of confidence. They don’t ever want to do that again, but it has strengthened the office and it's strengthened the way people here work together. Nobody quit as a result of it, and, in a way, they are rather proud of what they did.”

There are three major entrances leading into the coroner's building..and a visitor's direction of entry is generally related to his health or occupation. Employees, policemen, and mortuary-supply salesmen enter from the public doorway in the front; bodies and ambulance crewmen come and go from two wide doors in the back, one marked “Examining Room, Incoming,” the other "Body Release, Outgoing." The front door empties into an unadorned waiting room; a few house plants add a splash of color; copies of American Legion Magazine sit on the lamp table. The only feature distinguishing this waiting room from any other is a small wooden plaque on the wall. It commemorates the coroner’s work in the aftermath of Flight 182.

Beyond the waiting room, just down the corridor from Stark's office, begins the business end of the building. Offices, conference rooms, and laboratories branch off from the hallway until it dead-ends at the door of the medical examining room. Along one side of the hall there is a window, but sunshine will never stream through it. Family members peer through this window to identify relatives. The corpses are illuminated by soft yellow light intended to lessen the impact on loved ones.

One doorway leads to a conference room that has two different walls covered with butcher paper. The paper carries a Flight 182 passenger list and a processing flow chart on each of the victims. Another door leads to the work room of the deputy coroners, where, depending on the work shift, either one. two. or four of Stark’s investigators can usually be found typing reports or talking on the telephone.

At the end of the hallway is the examining room. Bodies arriving here are weighed and measured before they are put on one of five stainless steel tables. The tables angle down slightly to large wash basins located at one end; grocery-store scales hanging over these basins are used to weigh each organ as it is removed during the autopsy. Next, the body is fingerprinted. the eye color is noted, and. if it is a male, the face is shaved before the embalmers begin their special service. Embalming is not required in California and is done at the family’s request for a fee of seventy-five dollars. During the process, which takes about forty-five minutes, a large pump is used to push the blood out of the body and replace it with embalming fluid, a reddish-orange solution of thirty-seven percent formaldehyde, glycerine, soap, and a few other agents. The embalmers tap into a major artery and circulate the fluid through the veins and capillaries. just as the human heart forces blood through the veins of the living. Finally, the forensic pathologist begins his search for the cause of death. If homicide is suspected, the work is performed, in moderate seclusion, in a small room adjacent to the main examining area.

In a large refrigerator used to store un-embalmed bodies, one wall is stacked to the ceiling with samples of assorted organs. each carefully labeled with its previous owner's name and expiration date. A piece of liver here, some lung matter there—all packed in specimen jars. Surgical tools fill countless drawers around the facility, and at the end of one table lies a plastic tray containing the tools of the trade: rubber gloves, razor, sewing needles, a comb, and a small wooden sign that reads. “Silence please, you are now in the presence of a genius at work."

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