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AUTOPSY REPORT

NAME: JASON RICHARD SIENZE AUTOPSY NO.: LC18-008 C18020067

DATE OF BIRTH: November 11, 1982 AGE: 35 years old

SEX: Male RACE: White DATE OF DEATH: February 5, 2018 CONFIRMED DEAD: 12:30 P.M.

PLACE OF DEATH: Lakeview Drive and Burpee Drive Nice, California

The full autopsy prosection was performed on February 7, 2018 beginning at

approximately 09:07 A.M. and ending at approximately 10:59 A.M.

Bennet I. Omalu, MD, MBA, MPH, CPE, DABP-AP,CP,FP,NP

Forensic Pathologist/Neuropathologist, Prosector

Michelle Hernandez, Autopsy Room Assistant

Also present at the autopsy are the following: Detective Jerry Pfann from the Lake

County Sheriff’s Office; Detective Jason Cox and Detective Denise Hinchcliff, both

from the Lake County District Attorney’s Office; and Elona Porter, Evidence

Technician Supervisor from the Lake County Sheriff’s Office.

mailto:[email protected]

AUTOPSY REPORT

JASON RICHARD SIENZE CASE NO.: LC18-008 C18020067

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FINAL PATHOLOGICAL DIAGNOSES:

I. GUNSHOT WOUNDS OF THE HEAD AND NECK [x2]

1. GUNSHOT WOUND OF THE HEAD AND NECK [THROUGH AND THROUGH] a. Gunshot Wound of Entrance: right lateral neck at the junction with the ear

1. Circumferential marginal abrasion 2. No soot deposits 3. No powder stippling

b. Pathway of the Bullet: 1. Perforation of the skin and soft tissues of the right lateral neck 2. Perforation, contusion and laceration, soft tissues of right lateral neck,

right sub-occipital and occipital scalp 3. Penetration of the right basilar occipital bone, with mildly depressed

focal fracture 4. Internal ricochet 5. Perforation, contusion and laceration, soft tissues, subcutaneous

tissue and skin of right occipital scalp 6. Patchy soft tissue and subcutaneous tissue hemorrhages, right sub-

occipital and occipital scalp, right lateral neck

7. Soft tissue hemorrhages and contusional hemorrhages, right neurovascular bundle

8. Patchy subarachnoidal hemorrhages, right inferior cerebellar hemisphere and right inferior occipital lobe

c. Gunshot Wound of Exit: right posterior occipital scalp

d. Trajectory of the Bullet: backward, upward and leftward

2. GUNSHOT WOUND OF THE NECK [BULLET RECOVERED]

a. Gunshot Wound of Entrance: right pre-auricular face and neck

1. Circumferential marginal abrasion 2. No soot deposits 3. No powder stippling

b. Pathway of the bullet: 1. Perforation of skin and soft tissues of right pre-auricular face and jaw

2. Perforation and fracture, right mandible 3. Perforation, contusion and laceration, right lateral pharynx and larynx

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4. Perforation, contusion and laceration, right posterior larynx 5. Perforation, contusion and laceration, soft tissues of the anterior

paravertebral cervical spine 6. Impacted the anterior cervical vertebral bodies

7. Superficial comminuted fractures, anterior cervical vertebral bodies 8. Internal ricochet 9. Perforation of the soft tissues of the right posterior neck

10. Contusions and lacerations, right lateral and posterior pharynx and larynx

11. Patchy anterior paravertebral cervical soft tissue hemorrhages, accentuated on the right

12. Contusional hemorrhages of the right neurovascular bundle

c. Recovery of the Bullet: soft tissues of anterior paravertebral cervical spine d. Trajectory of the Bullet: backward, downward and leftward

II. GUNSHOT WOUNDS OF THE TRUNK [x2]

1. GUNSHOT WOUND OF THE TRUNK [BULLET RECOVERED] a. Gunshot Wound of Entrance: left medial infraclavicular chest

1. Circumferential marginal abrasion

2. No soot deposits 3. No powder stippling

b. Pathway of the Bullet: 1. Perforation of the skin and soft tissues of the left infraclavicular chest 2. Perforation, contusion and laceration, soft tissues of the left axilla

3. Perforation, contusion and laceration, left axillary and brachial plexus and the left brachial artery and vein

4. Perforation of the soft tissues of the left posterior axilla and the left posterior proximal arm

5. Soft tissue hemorrhages and contusions and lacerations of the left

brachial plexus and the left brachial vein and artery c. Recovery of the Bullet: subcutaneous tissue of the left proximal posterior arm d. Trajectory of the Bullet: backward, slightly upward and leftward

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2. GUNSHOT WOUND OF THE TRUNK [BULLET RECOVERED]

a. Gunshot Wound of Entrance: left medial infraclavicular chest

1. Circumferential marginal abrasion 2. No soot deposits

3. No powder stippling 4. Abrasion of the left chest with embedded miniscule bullet fragment

b. Pathway of the Bullet:

1. Perforation, contusion and laceration, soft tissues of the left medial infraclavicular chest

2. Perforation and fracture, left 2nd and 3rd ribs 3. Perforation, contusion and laceration, intercostal soft tissues 4. Perforation, contusion and laceration, anterior pericardium

5. Perforation, contusion and laceration, left atrium, left pulmonary veins, left ascending aorta and left pulmonary artery

6. Perforation, contusion and laceration, medial upper and lower lobes,

left lung 7. Perforation, contusion and laceration, descending thoracic aorta

8. Perforation, contusion and laceration, soft tissues of the left medial paravertebral thoracolumbar spine and soft tissues of the medial lumbar back

9. Hemopericardium, approximately 50 cc 10. Diffuse extensive transmural contusions and lacerations of the left

atrium and pulmonary veins, left pulmonary artery and the left lateral

ascending aorta 11. Extensive transmural lacerations of the left lateral distal descending

thoracic aorta 12. Hemothorax, left, approximately 2 liters 13. Global atelectasis of the left lung

14. Diffuse extensive contusions and lacerations of the medial upper and lower lobes of the left lung, accentuated in the lower lobe

15. Soft tissue hemorrhages of the left medial thoracolumbar soft tissues and retroperitoneum

c. Recovery of the Bullet: soft tissues of left medial lumbar back, below 12th rib

e. Trajectory of the Bullet: backward, downward and leftward

AUTOPSY REPORT


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III. GUNSHOT WOUND OF THE EXTREMITIES [x3]

1. GUNSHOT WOUND OF THE LEFT ARM [THROUGH AND THROUGH]

a. Gunshot Wound of Entrance: right posterior proximal arm 1. Ragged margins with circumferential marginal abrasion 2. No soot deposits

3. No powder stippling b. Pathway of the Bullet:

1. Perforation of skin and soft tissues of right posterior proximal arm 2. Perforation of soft tissues of the right lateral mid arm 3. Soft tissue hemorrhages

c. Gunshot Wound of Exit: right lateral mid arm d. Trajectory of the Bullet: forward, downward and rightward

2. GUNSHOT WOUND OF THE LEFT FOREARM [THROUGH AND THROUGH]

a. Gunshot Wound of Entrance: left anterior forearm 1. Eccentric and intermittent marginal abrasion 2. No soot deposits

3. No powder stippling b. Pathway of the Bullet:

1. Perforation of skin and soft tissues of left anterior forearm

2. Perforation of soft tissues and skin of left anterolateral proximal forearm

3. Soft tissue hemorrhages 4. Ragged laceration of the left lateral proximal forearm

c. Gunshot Wound of Exit: left anterior and lateral proximal forearm

d. Trajectory of the Bullet: backward, upward and leftward

3. GRAZE ABRASION OF THE RIGHT ANTERIOR AND PROXIMAL THIGH

a. Abrasion of the right anterior and proximal thigh, with surrounding contusion

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IV. OTHER TRAUMA

a. Abrasions of the mid-sagittal and right frontal and parietal scalp

b. Penetrating wound, right lateral chin, with superficial penetration of subcutaneous tissue

c. Punctate and stipple abrasions and contusions, multiple, randomly situated, bilateral face, bilateral anterior neck and chin, bilateral shoulders, chest and abdomen, and bilateral arms, accentuated on the right; and bilateral forearms

accentuated on the left d. Abrasions of the right superior shoulder

e. Scabbing punctate abrasions of the left lateral proximal penis f. Scabbing punctate abrasion of the right lateral proximal penis g. Abrasions of the right scapular back

h. Abrasions of the right thoracic back i. Curvilinear abrasion of the left thoracic back j. Contusions of the left lateral hand and thumb

k. Scabbing abrasion of the right anterior knee l. Contusion of the right proximal and medial leg

V. ACUTE AMPHETAMINE AND CANNABINOID INTOXICATION a. Chest blood d-Methamphetamine level: 0.56 mg/L b. Cheat blood d-Amphetamine level: 0.14 mg/L

c. Cannabinoids detected in chest blood i. Chest blood delta-9-THC level: 5.9 ng/mL

ii. Chest blood delta-9-THC-COOH level: 32 ng/mL iii. Chest blood delta-9-THC-OH level: 1.8 ng/mL

d. Bath salts [Cathinone, Methcathinone, Methylone, Mephedrone, MDPV and

alpha-PVP], not detected in chest blood e. Synthetic cannabinoids, not detected in chest blood

f. Ethyl alcohol, not detected in chest blood

VI. PULMONARY EDEMA AND CONGESTION, ACUTE, SEVERE [LUNG WEIGHTS:

RIGHT- 750 GRAMS; LEFT- 280 GRAMS]

a. Congestive brain swelling, global, with diffuse cerebral parenchymal edema, acute, brain weight: 1450 grams

b. Selective neuronal excitotoxic injury, with selective topographic vulnerability

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OPINION: JASON RICHARD SIENZE, a 35-year-old White male, died as a result of Gunshot

Wounds of Head, Neck and Trunk.

/6624

__________________________________________

Bennet I. Omalu, MD, MBA, MPH, CPE, DABP-AP,CP,FP,NP Forensic Pathologist/Neuropathologist President, Bennet Omalu Pathology 3/12/18

AUTOPSY REPORT


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EXTERNAL EXAMINATION:

The body is removed from a black body bag sealed with a red tag labeled

“JASON SIENZE”

There is no other identifying nametag on the body.

The body is that of a well-developed, well-nourished White male weighing

approximately 165 pounds, measuring approximately 65 inches and appearing

to be consistent with the stated age of 35 years old.

The body is clad in the following articles of clothing:

1. Blue jeans pants

2. Black belt

3. Gray sweatpants

4. Blue-black boxers

5. Brown boots

6. Black socks

The blue jean pants show blood spatter and droplet stains and blood

smears in the anterior and posterior parts accentuated proximally. There are

perforating defects in the right anterior proximal thigh of the jean pants and

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the sweatpants, which appear consistent with evidence of gunshot wounds on

the body, which will be described below. The sweatpants are focally soiled by

blood situated anteriorly and on the proximal parts. The blue-black boxers are

focally soiled by blood situated anteriorly. The black belt is soiled by blood

situated in a patchy fashion. The brown boots are focally soiled by blood

situated on the dorsal parts. The articles of clothing are soiled by sparse dry

grass and earth. The articles of clothing are placed on clean white sheets on an

autopsy trolley, photographed, documented and handed over to the detectives

present.

No article of jewelry is found on the body at autopsy.

There is a black-white metal key holder attached to the right anterior belt

holder of the jean pants containing one white metal key. A white glass

container is recovered from the left front pocket of the jean pants. There is a

white metal tool socket lying in the body bag, on the right side of the body by

the pelvis.

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Recovered from the right front pocket of the jean pants are the following

articles:

1. A packet of Marlboro cigarettes containing 18 unsmoked cigarettes.

2. A certificate of title from the State of California #

belonging to .

3. Four United States one-dollar bills.

4. One United States five-dollar bill.

5. One United States twenty-dollar bill.

6. Six United States one-cent coins

7. Two United States five-cent coins

8. Two United States ten-cent coins

9. Four United States twenty-five cent coins

Recovered from the left front pocket of the jean pants is one white lip gloss.

Recovered from the right back pocket of the jean pants is one United

States twenty-dollar bill.

The recovered articles are photographed, documented and handed over

to the detectives present.

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Separately accompanying the body in a thumb drive are whole body

digital X-rays, which are reviewed and reveal radiopaque bullets in the neck,

left arm and left medial trunk, which will be described below. The digital X-rays

are reviewed and saved.

Digital pictures of the scene separately accompany the body, in a

compact disk, which is presented to the autopsy room by the detectives

present. The scene pictures are reviewed and saved.

The wrists are bound together with white metal handcuffs across the

epigastrium. The handcuff is removed by the detectives present and is focally

soiled by blood. The right and left wrists show eccentrically situated tan-brown

handcuff indentations and abrasions.

The body is unembalmed and reveals the following evidence of early

decomposition:

1. There is patchy green cutaneous discoloration of the right and left

lower abdominal quadrants.

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The body had been refrigerated and the temperature of the body is cold

to the touch. Rigor mortis is well-developed in the joints of the extremities.

Purple, non-fixed, marked livor mortis is noted over the dorsal surfaces of the

body except in areas exposed to pressure where it is absent.

The body reveals the following evidence of medical intervention:

1. There are multiple adhesive electrocardiograph electrodes on the trunk.

The body reveals the following other identifying features:

1. There are blue-black and multicolored tattoos on the bilateral anterior

abdomen across the midline, right and left clavicular chest across the

midline, left anterior chest, right anterior and lateral arm and shoulder,

right and left anterior forearms, right dorsal wrist, left proximal ring finger

and left lateral hand, left anterior thigh, right and left medial distal legs

and ankles, which are photographed and documented.

2. There is a 13 x 1 cm transverse surgical scar on the bilateral suprapubic

abdomen.

3. There is a 2.2 x 2 cm scar on the right lateral caudal lumbar back.

4. There is a 2.5 x 2 cm curvilinear scar on the right lateral hip.

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5. There is a 12 x 7.5 cm rectangular skin donor scar on the right anterior

thigh.

6. There are 18 x 15 cm geographic scars on the right anterior knee.

7. There is a 20 x 12 cm area of linear and irregular scars on the right

anterior and lateral distal leg and ankle.

8. There are other multiple randomly situated linear, irregular and circular,

superficial, non-specific scars on the face, trunk, upper and lower

extremities measuring from 0.3 x 0.1 cm to 8.2 x 1.5 cm.

There are blood rivulets and blood smear stains on the face, neck, trunk

and bilateral upper extremities situated in a random fashion. There are sparse

grass and earth stains on the bilateral trunk and upper extremities. There are

multiple pebble cutaneous impressions on the right and left thoracic back

accentuated on the right.

AUTOPSY REPORT


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The body reveals the following evidence of trauma:

I. GUNSHOT WOUNDS OF THE HEAD AND NECK [x2]

1. GUNSHOT WOUND OF THE HEAD AND NECK [THROUGH AND THROUGH]

a. Gunshot Wound of Entrance:

There is a 2.5 x 2 cm circular perforating wound of the right lateral neck at the

junction with the ear, located approximately 13.8 cm right of the anterior midline and

16 cm below the level of the top of the head, showing a 0.2 cm in width brown-pink

circumferential marginal abrasion without soot deposits or powder stippling.


The bullet perforated the skin and soft tissues of the right lateral neck,

perforated, contused and lacerated the soft tissues of the right lateral neck, right

sub-occipital and occipital scalp and penetrated the right basilar occipital bone

creating a mildly depressed focal fracture, suffered an internal ricochet, perforated,

contused and lacerated the soft tissues of the right occipital scalp, perforated the

subcutaneous tissue and skin of the right occipital scalp to exit.

Accompanying the track of the bullet are patchy soft tissue and subcutaneous

tissue hemorrhages of the right sub-occipital and occipital scalp, and the right lateral

neck. There are soft tissue hemorrhages and contusional hemorrhages of the right

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neurovascular bundle. There are patchy subarachnoidal hemorrhages of the right

inferior cerebellar hemisphere and the right inferior occipital lobe.

c. Gunshot Wound of Exit:

There is a 1.2 x 0.5 cm ellipsoid perforating wound in the right posterior

occipital scalp, located approximately 13 cm below the level of the top of the head,

and 4.5 cm right of the posterior midline, without marginal abrasions, soot deposits

or powder stippling.

d. Trajectory of the Bullet:

The direction of the bullet is backward, upward and leftward.

2. GUNSHOT WOUND OF THE NECK [BULLET RECOVERED]


There is a 2 x 1 cm circular gaping perforating wound of the right pre-auricular

face and neck located 12.5 cm right of the anterior midline and 15 cm below the level

of the top of the head, showing a 0.2 cm in width red-pink circumferential marginal

abrasion without soot deposits or powder stippling.

b. Pathway of the bullet:

The bullet perforated the skin and soft tissues of the right pre-auricular face

and jaw, perforated and fractured the right mandible, perforated, contused and

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lacerated the right lateral pharynx and larynx, perforated, contused and lacerated the

right posterior larynx, perforated, contused and lacerated the soft tissues of the

anterior paravertebral cervical spine, and impacted the anterior cervical vertebral

bodies causing superficial comminuted fractures of the anterior vertebral bodies,

suffered an internal ricochet, and perforated the soft tissues of the right posterior

neck where it came to settle.

Accompanying the track of the bullet are contusions and lacerations of the

right lateral and posterior pharynx and larynx, patchy anterior paravertebral cervical

soft tissue hemorrhages accentuated on the right and contusional hemorrhages of

the right neurovascular bundle.

c. Recovery of the Bullet:

A moderately deformed jacketed bullet is recovered embedded in the soft

tissues of the anterior paravertebral cervical spine. The bullet is recovered and using

a digital caliper the diameter of the base of the bullet is measured in two separate

planes and reveals approximate calibers of 5.05 mm and 0.20 inches. The bullet is

photographed, documented and handed over to the detectives present.


The direction of the bullet is backward, downward and leftward.

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II. GUNSHOT WOUNDS OF THE TRUNK [x2]



There is a 2 x 1.5 cm oval perforating wound of the left medial infraclavicular

chest located approximately 34 cm below the level of the top of the head and 3.5 cm

left of the anterior midline showing a 0.2 to 0.3 cm in width red-pink circumferential

marginal abrasion without soot deposits or powder stippling.


The bullet perforated the skin and soft tissues of the left infraclavicular chest,

and perforated, contused and lacerated the soft tissues of the left axilla, perforated,

contused and lacerated the left axillary and brachial plexus and the left brachial

artery and vein, perforated the soft tissues of the left posterior axilla and the left

posterior proximal arm where it came to settle.

Accompanying the track of the bullet are soft tissue hemorrhages and

contusions and lacerations of the left brachial plexus and the left brachial vein and

artery.


A moderately deformed jacketed bullet is recovered embedded in the

subcutaneous tissue of the left proximal posterior arm and using digital calipers the

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diameter of the base of the bullet is measured in two separate planes and reveals

approximate calibers of 5.4 mm and 0.22 inches respectively. The bullet is



The direction of the bullet is backward, slightly upward and leftward.



There is a 1.1 x 1 cm oval perforating wound of the left medial infraclavicular

chest located approximately 36.8 cm below the level of the top of the head and 6 cm

left of the anterior midline showing a 0.1 to 0.2 cm in width circumferential marginal

abrasion without soot deposits or powder stippling. Located approximately 1.8 cm

from the wound margin, in the 08:00 o’clock position, is a 0.3 x 0.2 cm red-pink

abrasion in which is embedded a miniscule bullet fragment, which is partially

embedded in the skin. The bullet fragment is recovered, photographed and handed

over to the detectives present.


The bullet perforated, contused and lacerated the soft tissues of the left medial

infraclavicular chest, perforated and fractured the left 2nd and 3rd ribs, perforated,

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contused and lacerated the intercostal soft tissues, perforated, contused and

lacerated the anterior pericardium, perforated, contused and lacerated the left

atrium, the left pulmonary veins, the left ascending aorta and the left pulmonary

artery, perforated, contused and lacerated the medial upper and lower lobes of the

left lung, perforated, contused and lacerated the descending thoracic aorta,

perforated the soft tissues of the left medial paravertebral thoracolumbar spine and

soft tissues of the medial lumbar back where it came to settle below the left 12th rib.

Accompanying the track of the bullet are approximately 50 cc of

hemopericardium, diffuse extensive transmural contusions and lacerations of the left

atrium and pulmonary veins, left pulmonary artery and the left lateral ascending

aorta, extensive transmural lacerations of the left lateral distal descending thoracic

aorta, approximately 2 liters of left hemothorax, global atelectasis of the left lung,

diffuse extensive contusions and lacerations of the medial upper and lower lobes of

the left lung, accentuated in the lower lobe, soft tissue hemorrhages of the left medial

thoracolumbar soft tissues and retroperitoneum.


A moderately deformed jacketed bullet is recovered embedded in the soft

tissues of the left medial lumbar back below the 12th rib. Using a digital caliper, the

diameter of the base of the bullet is measured in two separate planes and reveals

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approximate calibers of 0.21 inches and 5.57 mm respectively. The bullet is


e. Trajectory of the Bullet:

The direction of the bullet is backward, downward and leftward.

III. GUNSHOT WOUND OF THE EXTREMITIES [x3]

1. GUNSHOT WOUND OF THE LEFT ARM [THROUGH AND THROUGH]


There is a 1.5 x 1 cm irregular perforating wound of the right posterior

proximal arm located approximately 11.5 cm below the level of the acromion showing

ragged margins with a 0.1 cm in width red-pink circumferential marginal abrasion

without soot deposits or powder stippling.


The bullet perforated the skin and soft tissues of the right posterior proximal

arm, perforated the soft tissues of the right lateral mid arm to exit without

perforating any vital tissue or vessel. Accompanying the track of the bullet are soft

tissue hemorrhages.

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There is a 3.5 x 2 cm gaping ragged perforating wound of the right lateral mid

arm located approximately 17 cm below the level of the acromion without marginal

abrasions, soot deposits or powder stippling.


The direction of the bullet is forward, downward and rightward.

2. GUNSHOT WOUND OF THE LEFT FOREARM [THROUGH AND THROUGH]


There is a 1.5 x 1 cm irregular perforating wound of the left anterior forearm

located approximately 11 cm below the level of the elbow showing a 0.1 cm in width

red-pink eccentric and intermittent marginal abrasion without soot deposits or

powder stippling.


The bullet perforated the skin and soft tissues of the left anterior forearm and

perforated the soft tissues and skin of the left anterolateral proximal forearm to exit.

Accompanying the track of the bullet are soft tissue hemorrhages. There is a 1.5 x 1

cm ragged laceration of the left lateral proximal forearm located approximately 3 cm

below the level of the elbow.

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There is an 8 x 5 cm gaping avulsive ragged perforating wound of the left

anterior and lateral proximal forearm located approximately 5 cm below the level of

the elbow without marginal abrasions, soot deposits or powder stippling.


The direction of the bullet is backward, upward and leftward.

3. GRAZE ABRASION OF THE RIGHT ANTERIOR AND PROXIMAL THIGH

There is a 1.1 x 0.1 cm circular abrasion of the right anterior and proximal

thigh located approximately 15 cm from the pelvic brim with a surrounding 2 x 1.5

cm red-pink contusion appearing consistent with a superficial graze abrasion of a

bullet.

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IV. OTHER TRAUMA

1. There are 15 x 8 cm red-pink abrasions of the mid-sagittal and right frontal and

parietal scalp.

2. There is a 1.2 x 0.8 cm oval penetrating wound of the right lateral chin showing

a 0.2 cm in width red-pink circumferential marginal abrasion located

approximately 21 cm below the level of the top of the head and 7.5 cm right of

the anterior midline appearing consistent with a penetrating wound of the skin

without penetrating the underlying subcutaneous tissue.

3. There are numerous, multiple randomly situated punctate and stipple red-pink

abrasions and contusions of the bilateral face, bilateral anterior neck, bilateral

anterior chin, bilateral shoulders and chest and abdomen and bilateral arms

accentuated on the right; as well as on the bilateral forearms accentuated on the

left.

4. There are 9 x 5 cm red-pink abrasions of the right superior shoulder.

5. There is a 4 x 1.5 cm area of scabbing red-pink punctate abrasions of the left

lateral proximal penis.

6. There is one punctate scabbing red-pink abrasion of the right lateral proximal

penis.

7. There are 6 x 3 cm red-pink abrasions of the right scapular back.

8. There are 7 x 3 cm red-pink abrasions of the right thoracic back.

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9. There is a 10 x 0.2 cm red-pink curvilinear abrasion of the left thoracic back.

10. There are 10 x 8 cm red-purple contusions of the left lateral hand and thumb.

11. There is a 1 x 0.7 cm scabbing brown abrasion of the right anterior knee.

12. There is a 2 x 1 cm red-purple contusion of the right proximal and medial leg.

The head and face are symmetrical and reveal evidence of trauma, which

has been described above. The scalp hair is brown and of a short length

measuring approximately 2.4 cm in maximal length and shows frontal balding.

The eyeballs and orbits are intact. The conjunctivae are pale and reveal no

petechial hemorrhages. The corneae and sclerae are smooth and clear. The

pupils are central, equal and symmetrical and measure 0.5 cm in diameter.

The ires are hazel. The pinnae and external auditory meati are intact. The

skeleton of the nose is intact. There is no foreign material in the nostrils or oral

cavity. The maxillary and mandibular gums are not hypertrophied. The

maxillary and mandibular teeth are natural and are in a good state of dental

repair. The lips, oral mucosa and tongue are intact.

A brown moustache and beard are present measuring approximately 0.7

cm in maximal length.

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The neck is symmetrical and reveals evidence of trauma, which has been

described above. There is no increased mobility of the neck upon manipulation.

The trunk is symmetrical and reveals evidence of trauma, which has been

described above.

The abdomen is flat and reveals no palpable organomegaly.

The penis and scrotum are intact and reveal evidence of trauma, which

has been described above. The testes are palpated within the scrotum and

appear unremarkable. The ano-rectum reveals no evidence of trauma, and

contains no hemorrhage or foreign material.

The extremities reveal evidence of trauma, which has been described

above. The fingernails are short and regular. The toenails are short and

regular. There is no pitting ankle or leg edema. The palms and soles are

otherwise smooth.

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INTERNAL EXAMINATION:

BODY CAVITIES:

The body is opened by a "Y" shaped incision. The abdominal panniculus

measures 1.0 cm in thickness, at the level of the umbilicus. The muscles of

the chest and abdominal wall appear normal in color and consistency. There

are fractures of the ribs and spine, which have been described above, along the

tracks of the bullets. The sternum is intact. The domes of the diaphragm are

normally positioned. The thoracic cavity reveals of trauma, which has been

described above. The parietal and visceral pleurae are otherwise smooth and

glistening. The peritoneum is smooth and thin. The peritoneal cavity is moist.

The liver and spleen do not extend below the costal margins. The bladder lies

below the level of the pubic symphysis. The organs of the pleural and

peritoneal cavities are in the normal anatomic positions in relation to one

another in-situ. The mesentery and omentum are intact.

At this time representative samples of chest blood, urine, bile and

vitreous humor are taken and saved.

CARDIOVASCULAR SYSTEM:

The heart weighs 230 grams and reveals evidence of trauma, which has

been described above. The pericardium reveals evidence of trauma, which has

been described above. There is a moderate amount of epicardial fat. The

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external configuration of the heart is within normal limits. The walls of the

ventricles are not hypertrophied. The atrioventricular chambers are not dilated.

The endocardium and valve leaflets otherwise reveal no thrombi or vegetations.

The circumferences of the valves are as follows: tricuspid 12.9 cm; pulmonic

7.0 cm; mitral 9.5 cm; and aortic 6.7 cm. The trabeculae carneae and papillary

muscles are otherwise not hypertrophied. The chordae tendineae are otherwise

non-sclerotic. The wall of the right ventricle measures 0.2 cm in greatest

thickness. The wall of the left ventricle measures 1.2 cm in greatest thickness.

The interventricular septum measures 1.2 cm in greatest thickness. The

coronary arteries exhibit a normal anatomic distribution with a right

predominance. The right and left coronary ostia are patent. Multiple cut

sections of the coronary arteries at 1.0 cm intervals reveal no significant degree

of atherosclerosis or other anomalies. The myocardium is firm, red-brown and

reveals evidence of trauma, which has been described above.

The aorta is lined by a tan-yellow tunica intima and reveals minimal

atherosclerosis with accompanying evidence of trauma, which has been

described above. The internal carotid arteries are patent. The bifurcation of the

common iliac arteries is patent. The major veins show no thrombo-emboli. The

venae cavae are intact.

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RESPIRATORY SYSTEM:

The right lung weighs 750 grams and the left lung weighs 280 grams.

The left lung reveals evidence of trauma, which has been described above. The

trachea shows a smooth congested red-tan mucosa and contains a thin film of

blood. The right lung is distended and both lungs are variegated pink-red to

gray-purple. The lung parenchyma is of spongy consistency and mottled with a

moderate amount of anthracotic pigment. Multiple cut sections exhibit a

variegated red-pink to gray-purple, non-crepitant, parenchyma with evidence of

trauma, which has been described above. The lung parenchyma is severely

congested and edematous. No purulent exudate is expressed from the

parenchyma on compression.

The extra and intrapulmonary bronchi are opened longitudinally, are

patent, congested and contain a thin film of blood. The pulmonary arteries and

veins reveal evidence of trauma, which has been described above. There is no

peri-hilar or mediastinal lymphadenopathy.

HEPATOBILIARY SYSTEM:

The liver weighs 1220 grams. The capsule of Glisson is smooth and

transparent. The external surfaces are brown-red, smooth and glistening. The

borders are sharp. The parenchyma is soft, brown-red and shows the normal

lobular tissue architecture without hemorrhages, tumors or necrosis.

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The gallbladder reveals thin walls and a velvety mucosa. It contains

approximately 40 cc of yellow-green bile without gallstones. The intra and

extrahepatic biliary ducts are patent. The hepatic and portal veins and the

hepatic artery are unremarkable.

HEMOLYMPHATIC SYSTEM:

The spleen weighs 80 grams and is of a normal consistency. The capsule

is glistening and smooth. The corpuscles of Malpighii are blurred due to

congestion. The parenchyma is homogeneous. There is no central or peripheral

lymphadenopathy.

GASTROINTESTINAL SYSTEM:

The esophagus contains no foreign material or regurgitated gastric

contents, and reveals no focal lesions. The stomach contains approximately

350 cc of brown fluid without drug-residue, pills or capsules. The mucosa of

the stomach reveals the normal rugal folds without peptic or stress ulcerations.

The duodenum, jejunum, ileum and colon reveal glistening serosal surfaces.

The vermiform appendix is identified and shows no gross inflammation. The

retroperitoneum reveals evidence of trauma, which has been described above.

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ENDOCRINE SYSTEM:

The pancreas weighs 120 grams. The parenchyma is gray-pink and

homogeneous, and shows a lobular, septated parenchyma without

hemorrhages or necrosis.

The adrenal glands reveal the normal shapes and sizes. Multiple cut

sections reveal thin yellow-tan cortices and brown-tan medullae without

hyperplasia, hemorrhages or adenomata.

The thyroid gland weighs 25 grams. The parenchyma is red-brown and

homogenous.

UROGENITAL SYSTEM:

The kidneys are in the normal anatomic positions and reveal no

anomalies. The right kidney weighs 120 grams and the left kidney weighs 120

grams. The capsular surfaces are smooth and glistening. The capsules strip

with ease and reveal smooth brown surfaces. The cortices are not sclerotic, are

brown-red and homogeneous. The medullary pyramids are intact. The cortico-

medullary junctions are well defined. The renal papillae show no hemorrhage

or necrosis. The calyceal and collecting systems are unremarkable. The renal

arteries and veins are unremarkable.

The ureters are not dilated or obstructed.

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The bladder contains approximately 250 cc of clear amber yellow urine

and reveals a smooth, tan-pink mucosa with no papillary lesions. The ureteral

orifices are patent.

The internal genitalia, including the prostate, vas deferens and

epididymis, appear unremarkable.

MUSCULOSKELETAL SYSTEM:

There are no musculoskeletal anomalies. The muscles are well-developed

and of the normal color and consistency without sarcopenia. There is evidence

of musculoskeletal trauma, which has been described above. The spinal

column and vertebral bodies reveal no gross osteo-degenerative changes. The

sternum, ribs, and spine exhibit a normal bone density. The bone marrow

reveals no gross lesions.

NECK:

There are soft tissue hemorrhages of the neck, which have been

described above. The anterior strap muscles reveal no soft tissues

hemorrhages. The thyroid and cricoid cartilages, larynx, and hyoid bone show

no fractures. The larynx reveals evidence of trauma, which has been described

above. The epiglottis and vocal cords are otherwise intact. The neck has been

examined at the conclusion of the autopsy, after the blood has drained and the

tissues are dry.

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CENTRAL NERVOUS SYSTEM:

The scalp is reflected from mastoid process to mastoid process and

reveals subcutaneous hemorrhages accompanying the track of the bullet,

which have been described above. The calvarium is otherwise intact without

fractures. Upon removal of the calvarium, there are no epidural or subdural

hemorrhages. The dura mater is white, smooth, and does not exhibit any

xanthochromia or membranes. The leptomeninges reveal focal subarachnoidal

hemorrhages, which have been described above.

The brain weighs 1450 grams and shows contusional hemorrhages of the

right cerebellar hemisphere and the right inferior occipital lobe, which have

been described above. The cerebral and cerebellar hemispheres are

symmetrical. The pattern of gyral and sulcal convolutions appears to be within

normal limits. There is diffuse global expansion of gyri and compression of

sulci accompanied by bilateral symmetrical grooving of the unci and cerebellar

tonsils without necrosis. The cranial nerves are identified and appear intact

without atrophy. The vessels of the Circle of Willis and the Basilar/ Vertebral

arteries reveal no anomalies, significant atherosclerosis or aneurysms. Multiple

cut sections of the brain reveal an intact cortical gray ribbon with distinct gray-

white matter demarcation. The ventricles are symmetrically compressed and

contain no exudate or extravasate. The centrum semiovale and the

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periventricular white matter reveal central red-pink congestion and edema

without focal hemorrhages, demyelination or infarcts. The basal ganglia reveal

no hemorrhages. The mamillary bodies and hippocampi reveal no atrophy,

dysplasia, necrosis or hemorrhage. The midbrain, pons and medulla reveal no

parenchymal necrosis or hemorrhage. The cerebellum is of a normal size and

shows no vermal atrophy. The deep cerebellar nuclei including the dentate

nucleus are unremarkable. There is no gross autolysis of the internal granule

cell layer.

The pituitary gland is unremarkable.

The dura covering the vault and the base of the cranium is removed and

reveals a focal fracture of the right posterior cranial fossa, which has been

described above.

The dens, atlanto-axial joint and atlanto-occipital joint are intact. There

are superficial fractures of the anterior cervical vertebral bodies, which have

been described above. The cervical medulla appears intact without

parenchymal or meningeal hemorrhages or exudates.

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MICROSCOPIC EXAMINATION

Microscopic examination of submitted tissue histology sections reveals

histo-morphologic findings that are consistent with the gross findings and final

pathologic diagnoses, which have been stated above. The tissue histology

sections have been archived as part of the case records and will be made

available upon request.

[Six H/E Stained Slides]

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FORENSIC PHOTOGRAPHY

Digital gross images of the body and autopsy prosection were taken by

Dr. Omalu and the autopsy room assistant(s) and will be saved in digital

format as part of the digital case file. The images will be made available upon

request according to the governing statutes and standard operating

procedures.

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SAMPLES OBTAINED

1. Vitreous humor: one red-top tube, approximately 4 cc

2. Chest blood:

a. Three gray-top tubes, each approximately 6 cc

b. One purple-top tube, approximately 7 cc

3. Bile from gallbladder: one red-top tube, approximately 7 cc

4. Urine from urinary bladder: one red-top tube, approximately 10 cc

5. Gastric contents, approximately 200 cc, frozen

6. Blood spots on a DNA card

7. Histology tissue sections, fixed in formalin

8. Archival stock tissue sections, fixed in formalin

The DNA card is handed over to the detectives present.

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