Ruben Toledo - Jail Death 7-1-2017 - Cibola - Chronic alcoholism

Central Office Investigator Tom Conklin Field Investigator Tom Conklin Medical Investigator Matthew Cain, MD Decedent last name: Decedent first name: Decedent middle: Decedent suffix: SSN: Birth date: Age: Gender: Race: Hispanic flag: Residence zip: Residence address: Residence county: Residence state: Reported by: Reported date: Reported by org: Identification by person name: ID method: ID type: Pronounced date: Pronounced by: Place of death: Hospital/hospice/nursing home: Where at facility/scene: Pronounced zip: TOLEDO RUBEN /1974 12:00:00 AM 42 Male American Indian False 87020 114 McBride Rd. Ste A Cibola NM Seth 7/1/2017 6:30:00 PM Natalia Antonio Visual Positive 7/1/2017 2:57:00 PM Pronounced addr: Pronounced city: Pronounced county: Pronounced state: Bernalillo NM Residence city: Grants ID relation: Spouse GPS longitude: GPS latitude: Mortuary: Mortuary reported by: NOK name: Natalia Antonio Arrival time: 1/1/1900 12:00:00 AM Report Name: Deputy Field Investigation Page 1 Printed: 11/6/2020 1:45:18 PM Case Number: 2017-03741 Deputy Field Investigation TOLEDO, RUBEN Relationship: NOK zip: NOK address: NOK city: NOK state: Phone1: Phone 2: Regular physician: Regular physician phone: Law enforcement agency: Agent in charge: Other investigating agency: Other agent: Field external: Exam location: Exam date: Exam time: JT: Death certificate signed by: Cause of death: Recent surgery: Surgery date: Spouse 505-710-6489 False False False Surgery description: Surgery date 2: Surgery 2 description: Pregnant? Pregnant: Pregnancy length: Date of injury: Date of injury unknown? Date of injury approx? Time of injury: Time of injury unknown? Time of injury approx? Injury at work: Injury zip: Injury place: Injury city: Injury county: Injury state: Death circumstances: False True False True False No 87020 Grants Cibola NM Report Name: Deputy Field Investigation Page 2 Printed: 11/6/2020 1:45:18 PM Case Number: 2017-03741 Deputy Field Investigation TOLEDO, RUBEN Describe scene: Describe decedent: Past medical history: Seth advised that the decedent had been incarcerated in the Cibola County Detention Center. The decedent was found shaking on the shower floor. He became unresponsive and bystander . This investigator did not view the scene. This investigator did not examine the decedent. Diabetes Chronic ETOH abuse Diabetes Comments: Clothing and valuables: Medications located at: Medications turned over to: Medications turned over date: Medications turned over by: Medications counting witness by: Medications log: CODMI consulted: CODMI instructions: One way mileage: T.J. Conklin 0 Report Name: Deputy Field Investigation Page 3 Printed: 11/6/2020 1:45:18 PM Case Number: 2017-03741 Deputy Field Investigation TOLEDO, RUBEN CAUSE OF DEATH Chronic ethanol abuse MANNER OF DEATH Natural DEATH INVESTIGATION SUMMARY Case Number: 2017-03741 TOLEDO, RUBEN Matthew Cain, MD Medical Investigator, Assistant Professor of Pathology All signatures authenticated electronically Date: 8/24/2017 8:48:51 AM County Pronounced: Bernalillo Law Enforcement: Agent: Date of Birth: /1974 Central Office Investigator: Tom Conklin Deputy Field Investigator: Tom Conklin COI Pronounced Date/Time: 7/1/2017 2:57:00 PM Printed: 11/6/2020 1:42:34 PM Report Name: Death Investigation Reporting Tool Death Investigation Report page 1 of 22 DECLARATION The death of TOLEDO, RUBEN was investigated by the Office of the Medical Investigator under the statutory authority of the Office of the Medical Investigator. I, Matthew Cain, MD, a board certified anatomic, clinical, and forensic licensed to practice pathology in the State of New Mexico, do declare that I personally performed or supervised the tasks described within this Death Investigation Summary document. It is only after careful consideration of all data available to me at the time that this report was finalized that I attest to the diagnoses and opinions stated herein. Numerous photographs were obtained along the course of the examination. I have personally reviewed those photographs and attest that they are representative of findings reported in this document. This document is divided into 7 sections with a final Procedural Notes section: 1. Summary and Opinion 2. External Examination 3. Medical Intervention 4. Postmortem Changes 5. Evidence of Injuries 6. Internal Examination 7. Microscopy Should you have questions after review of this material, please feel free to contact me at the Office of the Medical Investigator (Albuquerque, New Mexico) - 505-272-3053. Printed: 11/6/2020 1:42:50 PM Report Name: Death Investigation Summary Death Investigation Report page 2 of 22 Case Number: 2017-03741 Summary Opinion TOLEDO, RUBEN Medical Investigator Medical Investigator Trainee Matthew Cain, MD SUMMARY AND OPINION Autopsy Findings: I. End-stage liver disease secondary to chronic ethanol abuse. A. Scleral ictems and generalized jaundice. B. Ci11'hosis. C. Ascites and bilateral pleural effusions. D. Dilated cardiomyopathy (550 grams). II. Nephrosclerosis. III. No significant injuries to explain death. Summary and Opinion: Mr. Ruben Toledo was a 42 year old man with a medical history of diabetes mellitus and chronic ethanol abuse who was residing at the Cibola County Detention Center where he was found shaking on the shower floor. Autopsy demonstrated evidence of end-stage liver disease with icteric sclerae and generalized jaundice (yellowing of the eyes and skin), ci.IThosis, and abundant fluid in the abdominal and chest cavities. The heart was dilated in a manner compatible with clu·onic ethanol use. Externally, there was no evidence of significant injury. Toxicological analyses of the postmo1t em blood demonstrated a low concentration of nordiazepam (a benzodiazepine) and metabolites of marijuana. Mr. Ruben Toledo had significant liver disease secondary to chronic ethanol abuse. Chronic alcoholics are at risk for a number of metabolic abnormalities as well as withdrawal complications. Severe alcohol withdrawal can result in seizure activity and death. It is my opinion, based on all the cul1'ently available investigative infonnation and autopsy findings, that Mr. Ruben Toledo died of clu·onic ethanol abuse. The manner of death is natural. Cause Of Death: Page 1 Printed 11/612020 1 :42:51 PM Death Investigation Report page 3 of 22 Medical Investigator Matthew Cain, MD Authority for examination: Body length (cm): Body weight (kgs): BMI: Development: Stature: Age: Anasarca: Edema localized: Dehydration: Scalp hair color: Scalp hair length: Eyes: OMI 168.00 83.40 29.55 Well-developed Well-nourished Appears to be stated age No No No Black Long Both eyes present Irides: Eyes corneae: Eyes sclerae: Brown Translucent Icteric Eyes conjunctivae: Eyes petechiae: Palpebral petechiae: Bulbar petechiae: Facial petechiae: Oral mucosal petechiae: Nose: Translucent No No No No No Normally formed External exam date time: 7/3/2017 9:01:00 AM Medical Investigator Trainee Means used to confirm identity: Other verification means: Location of orange bracelet: Name on orange bracelet: Other name on orange bracelet: Location of green bracelet: Name on green bracelet: Other name on green bracelet: Hospital ID tags or bracelets? If yes specify stated name and location: Visual Left wrist Decedent name Left wrist Decedent name No ID confirmed at time of exam: Yes Development comments: External Examination Page 1 Printed: 11/6/2020 1:42:51 PM Case Number: 2017-03741 External Examination TOLEDO, RUBEN Death Investigation Report page 4 of 22 Ears: Lips: Facial hair: Facial hair color: Maxillary dentition: Mandibular dentition: Condition of dentition: Neck: Trachea midline: Normally formed Normally formed Moustache and goatee Black Natural Natural Adequate Unremarkable Yes Chest symmetrical: Chest diameter: Abdomen: Back: Spine: External genitalia: Breast masses: Right hand digits complete: Left hand digits complete: Right foot digits complete: Yes Appropriate Flat Unremarkable Normal Male None Yes Yes Yes Breast development: None Chest development: Left foot digits complete: Yes Muscle group atrophy: Senile purpura: Pitting edema: No No No Muscle other: No Tattoo(s) Tattoos present: No Cosmetic Piercing(s) Cosmetic piercing present: No Scar(s) Scar(s) present: Yes Scar right knee: Yes Reporting Tracking Acne on back. External exam comment: Extremities: Well-developed and symmetrical Normal Anus: Unremarkable External Examination Page 2 Printed: 11/6/2020 1:42:51 PM Case Number: 2017-03741 External Examination TOLEDO, RUBEN Death Investigation Report page 5 of 22 Reported by: Verified by: Matthew Cain, MD on 8/22/2017 4:19:14 PM Reviewed and approved by: Matthew Cain, MD on 8/24/2017 8:48:51 AM External Examination Page 3 Printed: 11/6/2020 1:42:51 PM Case Number: 2017-03741 External Examination TOLEDO, RUBEN Death Investigation Report page 6 of 22 Medical Investigator Matthew Cain, MD Evidence of medical intervention: If nasogastric tube present, specify course and position: If endotracheal tube present, specify course and position: Tracheostomy site/tube: Chest tube(s): If Foley catheter present, specify course and position: Vascular catheter(s): Mediastinal tube(s): Right antecubital fossa: Recent Surgical Intervention Evidence of recent surgical intervention: Indwelling Tubes Medical Investigator Trainee ECG Monitoring Pads Present?: Defibrillator pads present?: Vascular Catheter(s): Electrocardiogram (ECG) Monitoring Pads Defibrillator Pads Reported by: Verified by: Matthew Cain, MD on 8/22/2017 4:19:26 PM Reviewed and approved by: Matthew Cain, MD on 8/24/2017 8:48:51 AM Report Tracking Medical intervention other: Medical Intervention Page 1 Printed: 11/6/2020 1:42:51 PM Case Number: 2017-03741 Medical Intervention TOLEDO, RUBEN Death Investigation Report page 7 of 22 Medical Investigator Matthew Cain, MD Body temperature: Rigor mortis: Livor mortis - color: Livor mortis - fixation (if applicable): Livor mortis - position (if applicable): State of preservation: Cool subsequent to refrigeration Fully fixed Purple Fully Fixed Posterior No decomposition External exam date: 7/3/2017 9:02:00 AM Medical Investigator Trainee Reported by: Verified by: Matthew Cain, MD on 8/22/2017 4:19:32 PM Reviewed and approved by: Matthew Cain, MD on 8/24/2017 8:48:51 AM Report Tracking Postmortem Changes Page 1 Printed: 11/6/2020 1:42:52 PM Case Number: 2017-03741 Postmortem Changes TOLEDO, RUBEN Death Investigation Report page 8 of 22 Medical Investigator Matthew Cain, MD Autopsy date: 7/3/2017 9:01:00 AM Evidence of Injury: Medical lnvestigator Trainee # Injury Location Injury Description 1 Blunt injury Head Healing laceration on forehead. 2 Blunt injury Chest Faint, black, 7 cm contusion on left side of chest. 3 Blunt injury Extremities Abrasions on left knee. Are there any injuries: Yes Reported by: Verified by: Matthew Cain, MD on 8/22/2017 4:19:17 PM Reviewed and approved by: Matthew Cain, MD on 8/24/2017 8:48:51 AM Report Tracking Evidence of Injury Page 1 Printed: 11/6/2020 1:42:52 PM Case Number: 2017-03741 Evidence of Injury TOLEDO, RUBEN Death Investigation Report page 9 of 22 Medical Investigator Matthew Cain, MD Date of Internal Exam: Chest cavities examined: See evidence of injury section Organs in normal anatomic position Other organ position comments Diaphragm: Serosal surfaces: Body cavity adhesions present: Fluid accumulation present: Fluid accumulation right chest cavity: Fluid accumulation left chest cavity Fluid accumulation pericardial sac: Fluid accumulation abdominal cavity: Fluid accumulation comments: Brain examined: See separate forensic neuropathology consultation report See evidence of injury section: See evidence of medical Intervention section: 7/3/2017 9:02:00 AM Yes No Yes Intact Smooth and glistening No Yes Yes Yes No Yes Yes No No No See postmortem changes section: Facial skeleton: Calvarium: Skull base: No No palpable fractures No fractures No fractures Fluid accumulation pelvis: No Dura mater: Skull comments: Dural venous sinsuses: Leptomeninges: Unremarkable and without masses Patent Thin and transparent Absent Date of Autopsy: 7/3/2017 9:01:00 AM Medical lnvestigator Trainee BODY CAVITIES HEAD Brain fresh (g): Brain fixed (g): 1515 210 mL of serous fluid in the right and left chest cavities. 1200 mL of serous fluid in the abdominal cavity. Internal Examination Page 1 Printed: 11/6/2020 1:42:53 PM Case Number: 2017-03741 Internal Examination TOLEDO, RUBEN Death Investigation Report page 10 of 22 Spinal cord examined: Middle ears examined: No No Epidural hemorrhages / hematomas: Subdural hemorrhages / hematomas: Subarachnoid hemorrhages: Cerebral hemispheres: Gyral and sulcal patterns: Gyral convolutions and sulci: Uncal processes: Cerebellar tonsils: Cranial nerves: Basilar arterial vasculature: Cerebral cortex: White matter: Corpus callosum: Deep gray matter structures: Brainstem: Cerebellum: Absent Absent Symmetrical Unremarkable Mild widening and flattening of gyri and mild narrowing of sulci Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Neck examined: See Evidence of Injury section: See Evidence of Medical Intervention section See Postmortem Changes section: Subcutaneous soft tissues: Strap muscles: Jugular veins: Carotid arteries: Tongue: Epiglottis: Hyoid bone: Larynx: Palatine tonsils: Yes No No No Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Spinal Cord Middle Ears Neck CARDIOVASCULAR SYSTEM See separate Cardiovascular Pathology report: See Evidence of Injury section: See Evidence of Medical Intervention section: No No No Heart examined: Yes Internal Examination Page 2 Printed: 11/6/2020 1:42:53 PM Case Number: 2017-03741 Internal Examination TOLEDO, RUBEN Death Investigation Report page 11 of 22 See Postmortem Changes section: Right coronary ostium position: Left coronary ostium position: Supply of the posterior myocardium: Right coronary ostium: Proximal third right coronary artery: Middle third right coronary artery: Left coronary ostium: Left main coronary artery: Proximal third left anterior descending coronary artery: Middle third left anterior descending coronary artery: Distal third left anterior descending coronary artery: Proximal third left circumflex coronary artery: Distal third left circumflex coronary artery: Cardiac chambers: Tricuspid valve: Pulmonic valve: Mitral valve: Aortic valve: Other valve comments: No Normal Normal Right coronary artery 0 0 0 0 0 10 10 0 0 0 Other - See comments Unremarkable Unremarkable Unremarkable Unremarkable Pulmonary and aortic valves: 7 cm; Mitral valve: 12 cm; Tricuspid valve: 11 cm. Right ventricular myocardium: Left ventricular myocardium: Other myocardium comments: No fibrosis, erythema, pathologic infiltration of adipose tissue or areas of accentuated softening or induration No fibrosis, erythema, or areas of accentuated softening or induration Dilated ventricles, globoid heart. Distal third right coronary artery: 0 Middle third left circumflex coronary artery: 0 Heart Coronary artery stenosis by atherosclerosis (in percent): Ventricular septum: Right ventricular free wall thickness: Left ventricular free wall thickness: Unremarkable 0.4 cm 1.6 cm Atrial septum: Unremarkable Heart fixed (g): Heart fresh (g): 550.0 Cardiac Chambers and Valves: Internal Examination Page 3 Printed: 11/6/2020 1:42:53 PM Case Number: 2017-03741 Internal Examination TOLEDO, RUBEN Death Investigation Report page 12 of 22 Great vessels examined: Aorta examined: Yes Yes Interventricular septum thickness: Orifices of the major vascular branches: Coarctation: Vascular dissection: Aneurysm formation: Complex atherosclerosis: Other aortic pathology: Vena cava and major tributaries: Lungs examined: See separate Cardiovascular Pathology report: See Evidence of Medical Intervention section: See Evidence of Injury section: Upper and lower airways: Pulmonary parenchyma color: Pulmonary parenchyma congestion and edema: Pulmonary trunk: Pulmonary artery thrombi: 1.6 cm Patent No No No No No Patent Yes No No No Unobstructed, and the mucosal surfaces are smooth and yellow-tan Dark red-purple Moderate amounts of blood and frothy fluid Free of saddle embolus None See Postmortem Changes section: No Aorta Vena Cava RESPIRATORY SYSTEM Other airway and lung comments: Liver examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Hepatic parenchyma (color): Early hepatization of lungs. Yes No No No Red-brown Pulmonary artery atherosclerosis: None HEPATOBILIARY SYSTEM Lung right (g): Lung left (g): Liver (g): 795 610 2530 Bile vol (mL): Gallstones autopsy: Gallstones autopsy desc: No Internal Examination Page 4 Printed: 11/6/2020 1:42:53 PM Case Number: 2017-03741 Internal Examination TOLEDO, RUBEN Death Investigation Report page 13 of 22 Hepatic parenchyma (texture): Hepatic vasculature: Gallbladder: Gallstones: Intrahepatic biliary tree: Extrahepatic biliary tree: Alimentary tract examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Course: Mucosa: Mucosa: Pylorus: Luminal contents: Macronodular cirrhosis Unremarkable and free of thrombus Unremarkable None Unremarkable Unremarkable Yes No No No Normal course without fistulae Gray-white, smooth and without lesions Usual rugal folds Patent and without muscular hypertrophy Partially digested food GASTROINTESTINAL SYSTEM Esophagus Stomach Colon Pancreas Small Intestine Caliber and continuity: Luminal contents: Mucosa: Caliber and continuity: Form: Genitourinary system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Cortical surfaces: Cortices: Calyces, pelves and ureters: Appropriate caliber without interruption of luminal continuity Formed stool Unremarkable Appropriate caliber without interruption of luminal continuity Normal tan, lobulated appearance Yes No No No Smooth Normal thickness and well-delineated from the medullary pyramids Non-dilated and free of stones and masses Kidneys capsules: Thin, semitransparent Mucosa: Unremarkable GENITOURINARY SYSTEM Kidneys Stomach contents vol (mL): 150 Appendix found: Yes Stomach contents description: Brown fluid. Internal Examination Page 5 Printed: 11/6/2020 1:42:53 PM Case Number: 2017-03741 Internal Examination TOLEDO, RUBEN Death Investigation Report page 14 of 22 Urinary bladder mucosa: Location: Size: Consistency: Other testicle comments: Size: Gray-tan and smooth Bilaterally intrascrotal Unremarkable Homogeneous Unremarkable Male: Yes Urinary Bladder Male Testicles Prostate Gland Other prostate gland comments: Spleen (g): Kidney right (g): Thymus (g): 250 225 Kidney left (g): 220 Consistency: Homogeneous Urine volume (mL): Urine description: Reticuloendothelial system examined: See Evidence of Injury section: See Postmortem Changes section: Color: Regional adenopathy: 95 yellow Yes No No Red-brown, homogeneous and ample No adenopathy See Evidence of Medical Intervention section: No RETICULOENDOTHELIAL SYSTEM Spleen Bone Marrow Lymph Nodes Endocrine system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Yes No No No Parenchyma: Absent (involution by adipose tissue) Thymus ENDOCRINE SYSTEM Spleen parenchyma: Moderately firm Spleen capsule: Intact Spleen white pulp: Prominent Internal Examination Page 6 Printed: 11/6/2020 1:42:53 PM Case Number: 2017-03741 Internal Examination TOLEDO, RUBEN Death Investigation Report page 15 of 22 Adrenal right (g): Adrenal left (g): Size: Position: Size: Parenchyma: Size: Musculoskeletal system examined: See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section: Bony framework: Subcutaneous soft tissues: Normal Normal Normal Homogeneous Normal Yes No No No Unremarkable Unremarkable Parenchyma: Yellow cortices and gray medullae with the expected corticomedullary ratio Musculature: Unremarkable Pituitary Gland Thyroid Gland MUSCULOSKELETAL SYSTEM Adrenal Glands ADDITIONAL COMMENTS Reported by: Verified by: Matthew Cain, MD on 8/22/2017 4:19:18 PM Reviewed and approved by: Matthew Cain, MD on 8/24/2017 8:48:51 AM Report Tracking Internal Examination Page 7 Printed: 11/6/2020 1:42:53 PM Case Number: 2017-03741 Internal Examination TOLEDO, RUBEN Death Investigation Report page 16 of 22 Medical Investigator Matthew Cain, MD Microscopic description: Heart: Occasional hypertrophic myocytes and increased interstitial fibrosis. Lungs: Abundant macrophages with brown pigment, areas of hyalinization. No significant acute inflammation. Liver: Cirrhosis and mild macrovesicular steatosis. Pancreas: No significant histopathologic abnormality. Kidney: Several globally sclerotic glomeruli and thickened arterial walls. Brain: No significant histopathologic abnormality. Medical lnvestigator Trainee Block Tissue Location Description Stain A1 Interventricular septum, papillary muscle A2 Right ventricle, right lung A3 Left kidney, left lung A4 Pancreas, liver, basal ganglia *Unless otherwise indicated sections are stained only with hematoxylin and eosin (H&E). Reported by: Verified by: Matthew Cain, MD on 8/22/2017 4:19:31 PM Reviewed and approved by: Matthew Cain, MD on 8/24/2017 8:48:51 AM Report Tracking Microscopy: Page 1 Printed: 11/6/2020 1:42:54 PM Case Number: 2017-03741 Microscopy TOLEDO, RUBEN Death Investigation Report page 17 of 22 Yellow Sheet Morphology Technician Identification Michael Jarvis Autopsy Michael Jarvis Evidence Michael Jarvis Evidence Michael Jarvis Radiology Michael Jarvis Retention Michael Jarvis LabOther Michael Jarvis Attendees Michael Jarvis Case Number: Date of Examination: Pathologist: Fellow/Resident: 2017-03741 7/3/2017 9:01:00 AM Matthew Cain, MD Decedent Name: TOLEDO, RUBEN Morphology technican(s) present Morphology technican supervisor(s) present Yellow Sheet Morphology Technician Lead Identification Jacob Chavez Autopsy Cassandra Toledo Evidence Jacob Chavez Radiology Jacob Chavez Retention Jacob Chavez LabOther Melissa Christian Attendees Jacob Chavez Procedural Notes Report Page 1 Printed: 11/6/2020 1:43:08 PM Case Number: 2017-03741 Procedural Notes TOLEDO, RUBEN Death Investigation Report page 18 of 22 Autopsy attendees Other morphology technicians present: Alivia Magana - Student Tech. Daria koehlert - Student Tech Angelea Maestas - Staff Tech. Procedural Notes Report Page 2 Printed: 11/6/2020 1:43:08 PM Case Number: 2017-03741 Procedural Notes TOLEDO, RUBEN Death Investigation Report page 19 of 22 Specimens obtained for laboratory testing Approach to autopsy dissection HIV serology: No HCV/HBV serology : Influenza serology: Other serology: Freezer protocol: DNA card: Metabolic screen: Cytogenetics: Med-X protocol: Urine dipstick: Blood cultures (bacterial): Lung cultures (bacterial): CSF culture (bacterial): Spleen culture (bacterial): Stool culture (bacterial): Other bacterial culture (specify): Mycobacterial culture (lung): Mycobacterial culture (other): No No No No Yes No No No No No No No No No No No Rokitansky evisceration: No Virchow evisceration: Yes Modified evisceration: No Viral Cultures: No HIV spin and store: Yes Procedural Notes Report Page 3 Printed: 11/6/2020 1:43:08 PM Case Number: 2017-03741 Procedural Notes TOLEDO, RUBEN Death Investigation Report page 20 of 22 Special autopsy techniques Tissues retention Disposition of tissues retained for extended examination Pericranial membrane removal: No Neck anterior dissection: Yes Neck posterior dissection: No Facial dissection: No Vertebral artery dissection (in situ): No Cervical spine removal: No Layered anterior trunk dissection: No Anterolateral rib arc dissection: No Back dissection: No Posterior rib arc dissection: No Extremity soft tissue dissection: No Eye enucleation: No Inner middle ear evaluation: No Maxilla or mandible resection: No Spinal cord removal (anterior): No Spinal cord removal (posterior): No Other dissection(s): Stock jar with standard tissue retention: Yes Rib segment: Yes Pituitary gland: Yes Breast tissue (women only): No Brain retention: No Spinal cord retention: No Cervical spine retention: No Heart retention: No Heart-lung block retention: No Rib cage retention: No Long bone retention: No Other retention,specify: Specimen outcome: Not applicable; no tissues were retained for extended examination. HIV serology: No Procedural Notes Report Page 4 Printed: 11/6/2020 1:43:08 PM Case Number: 2017-03741 Procedural Notes TOLEDO, RUBEN Death Investigation Report page 21 of 22 Number of scene photos produced by the OMI Number of autopsy photos produced by the OMI Evidence collected Personal effects Clothing Scene Photos: 0 Autopsy Photos: 21 FBI blood tube: No Blood spot card: No APD blood card: No Thumbprint: Yes Fingerprints: No Palmprints: No Print hold: No Oral swab: No Vaginal swab: No Anal swab: No Other swab: No Fingernails: No Scalp hair: No Pubic hair: No Pubic hair combing: No Projectile(s): No Retain clothing: No Retain valuables: No Retain trace evidence: No Retain body bag: No Retain hand bags: No Ligature: No Other evidence retained: Property Type Property Description Property Detail None Other No Clothing Items to Inventory Valuables Hair tie n/a Fingerprints Describe R and L inked Property Type Property Description Property Detail Procedural Notes Report Page 5 Printed: 11/6/2020 1:43:08 PM Case Number: 2017-03741 Procedural Notes TOLEDO, RUBEN Death Investigation Report page 22 of 22 NMS Labs 3701 Welsh Road, PO Box 433A, Willow Grove, PA 19090-0437 Phone: (215) 657-4900 Fax: (215) 657-2972 e-mail: nms@nmslabs.com Robert A. Middleberg, PhD, F-ABFT, DABCC-TC, Laboratory Director CONFIDENTIAL Toxicology Report Report Issued 08/21/2017 11:06 20141 New Mexico Office of Medical Investigators Attn: Yvonne A. Villalobos 1101 Camino de Salud NE- Ste B Albuquerque, NM 87105 To: Patient Name Patient ID Chain Age Gender Workorder TOLEDO RUBEN 2017-03741 81098 42 Y Male 17251800 DOB /1974 Positive Findings: Compound Result Units Matrix Source Nordiazepam 23 ng/mL 001 - Femoral Blood Delta-9 Carboxy THC 8.6 ng/mL 001 - Femoral Blood Delta-9 THC 1.9 ng/mL 001 - Femoral Blood Benzodiazepines Presump Pos ng/mL 003 - Urine Cannabinoids Presump Pos ng/mL 003 - Urine See Detailed Findings section for additional information Testing Requested: Analysis Code Description 8051B Postmortem, Basic, Blood (Forensic) 8050U Postmortem, Urine Screen Add-on (6-MAM Quantification only) Specimens Received: ID Tube/Container Volume/ Mass Collection Date/Time Matrix Source Miscellaneous Information 001 Gray Top Tube 11 mL 07/03/2017 Femoral Blood 002 Gray Top Tube 10.75 mL 07/03/2017 Femoral Blood 003 White Plastic Container 60 mL 07/03/2017 Urine All sample volumes/weights are approximations. Specimens received on 08/15/2017. NMS v.18.0 Page 1 of 4 Detailed Findings: Analysis and Comments Result Units Rpt. Limit Specimen Source Analysis By Nordiazepam 23 ng/mL 20 001 - Femoral Blood LC-MS/MS Delta-9 Carboxy THC 8.6 ng/mL 5.0 001 - Femoral Blood LC-MS/MS Delta-9 THC 1.9 ng/mL 0.50 001 - Femoral Blood LC-MS/MS Benzodiazepines Presump Pos ng/mL 50 003 - Urine EIA This test is an unconfirmed screen. Confirmation by a more definitive technique such as GC/MS is recommended. Cannabinoids Presump Pos ng/mL 20 003 - Urine EIA This test is an unconfirmed screen. Confirmation by a more definitive technique such as GC/MS is recommended. Other than the above findings, examination of the specimen(s) submitted did not reveal any positive findings of toxicological significance by procedures outlined in the accompanying Analysis Summary. Reference Comments: Benzodiazepines - Urine: Benzodiazepines are a class of drugs that are prescribed for their anxiolytic, muscle relaxant, anticonvulsant and hypnotic effects. The degree of each effect is dependent upon the specific drug, its pharmacokinetics and any relevant metabolite. This result derives from a presumptive test, which may be subject to cross-reactivity with non-benzodiazepine related compounds. A second test is necessary to confirm the presence of benzodiazepine related compounds. 1. Cannabinoids - Urine: Cannabinoids are chemical compounds derived from the plant Cannabis sativa (marijuana), including active components, chemical congeners and metabolites. Delta-9-Tetrahydrocannabinol (THC) is the principal active component. This result derives from a presumptive test, which may be subject to cross-reactivity with non-cannabinoid related compounds. A second test is necessary to confirm the presence of cannabinoid related compounds. 2. Delta-9 Carboxy THC (Inactive Metabolite) - Femoral Blood: Delta-9-THC is the principle psychoactive ingredient of marijuana/hashish. Delta-9-carboxy-THC (THCC) is the inactive metabolite of THC. The usual peak concentrations in serum for 1.75% or 3.55% THC marijuana cigarettes are 10 - 101 ng/mL attained 32 to 240 minutes after beginning smoking, with a slow decline thereafter. The ratio of whole blood concentration to plasma concentration is unknown for this analyte. THCC may be detected for up to one day or more in blood. Both delta-9-THC and THCC may be present substantially longer in chronic users. THCC is usually not detectable after passive inhalation. 3. Delta-9 THC (Active Ingredient of Marijuana) - Femoral Blood: Marijuana is a DEA Schedule I hallucinogen. Pharmacologically, it has depressant and reality distorting effects. Collectively, the chemical compounds that comprise marijuana are known as Cannabinoids. Delta-9-THC is the principle psychoactive ingredient of marijuana/hashish. It rapidly leaves the blood, even during smoking, falling to below detectable levels within several hours. Delta-9-carboxy-THC (THCC) is the inactive metabolite of THC and may be detected for up to one day or more in blood. Both delta-9-THC and THCC may be present substantially longer in chronic users. THC concentrations in blood are usually about one-half of serum/plasma concentrations. Usual peak levels in serum for 1.75% or 3.55% THC marijuana cigarettes: 50 - 270 ng/mL at 6 to 9 minutes after beginning smoking, decreasing to less than 5 ng/mL by 2 hrs. 4. NMS v.18.0 CONFIDENTIAL Workorder Chain Patient ID 17251800 81098 2017-03741 Page 2 of 4 Reference Comments: Nordiazepam (Chlordiazepoxide Metabolite) - Femoral Blood: Nordiazepam is a pharmacologically active metabolite of several benzodiazepines, including diazepam (Valium®) and chlordiazepoxide (Librium®). The action of this compound is based on its central nervous system depressant activity. Nordiazepam has a very long elimination half-life and may be identified long after the parent drug has been completely eliminated from the circulation. Psychiatric patients taking chronic diazepam doses ranging from 2 to 55 mg daily had steady state plasma concentrations of nordiazepam averaging 390 ng/mL (range 26 to 1600 ng/mL). Chronic therapy with a daily oral dose of 22.5 mg clorazepate produced reported steady-state plasma concentrations of nordiazepam of 660 +/- 140 ng/mL. The active metabolites oxazepam and temazepam may be present in low concentrations. The blood to plasma ratio of nordiazepam is 0.6. A fatal case was reported with a nordiazepam blood concentration of 5500 ng/mL along with 0.180 g/dL ethanol and 7000 ng/mL chlordiazepoxide. Alcohol greatly enhances the activity of the benzodiazepines. 5. Sample Comments: 001 Physician/Pathologist Name: Matthew Cain Chain of custody documentation has been maintained for the analyses performed by NMS Labs. Unless alternate arrangements are made by you, the remainder of the submitted specimens will be discarded six (6) weeks from the date of this report; and generated data will be discarded five (5) years from the date the analyses were performed. Laura M. Labay, Ph.D., F-ABFT, DABCC-TC Forensic Toxicologist Workorder 17251800 was electronically signed on 08/21/2017 10:01 by: Analysis Summary and Reporting Limits: All of the following tests were performed for this case. For each test, the compounds listed were included in the scope. The Reporting Limit listed for each compound represents the lowest concentration of the compound that will be reported as being positive. If the compound is listed as None Detected, it is not present above the Reporting Limit. Please refer to the Positive Findings section of the report for those compounds that were identified as being present. Acode 50012B - Benzodiazepines Confirmation, Blood (Forensic) - Femoral Blood -Analysis by High Performance Liquid Chromatography/ TandemMass Spectrometry (LC-MS/MS) for: Compound Rpt. Limit Compound Rpt. Limit 7-Amino Clonazepam 5.0 ng/mL Alpha-Hydroxyalprazolam 5.0 ng/mL Alprazolam 5.0 ng/mL Chlordiazepoxide 20 ng/mL Clobazam 20 ng/mL Clonazepam 2.0 ng/mL Desalkylflurazepam 5.0 ng/mL Diazepam 20 ng/mL Estazolam 5.0 ng/mL Flurazepam 2.0 ng/mL Hydroxyethylflurazepam 5.0 ng/mL Hydroxytriazolam 5.0 ng/mL Lorazepam 5.0 ng/mL Midazolam 5.0 ng/mL Nordiazepam 20 ng/mL Oxazepam 20 ng/mL Temazepam 20 ng/mL Triazolam 2.0 ng/mL Acode 52198B - Cannabinoids Confirmation, Blood (Forensic) - Femoral Blood NMS v.18.0 CONFIDENTIAL Workorder Chain Patient ID 17251800 81098 2017-03741 Page 3 of 4 Analysis Summary and Reporting Limits: -Analysis by High Performance Liquid Chromatography/ TandemMass Spectrometry (LC-MS/MS) for: Compound Rpt. Limit Compound Rpt. Limit 11-Hydroxy Delta-9 THC 1.0 ng/mL Delta-9 Carboxy THC 5.0 ng/mL Delta-9 THC 0.50 ng/mL Acode 8050U - Postmortem, Urine Screen Add-on (6-MAM Quantification only) -Analysis by Enzyme Immunoassay (EIA) for: Compound Rpt. Limit Compound Rpt. Limit Amphetamines 500 ng/mL Barbiturates 0.30 mcg/mL Benzodiazepines 50 ng/mL Cannabinoids 20 ng/mL Cocaine / Metabolites 150 ng/mL Fentanyl / Metabolite 2.0 ng/mL Methadone / Metabolite 300 ng/mL Opiates 300 ng/mL Oxycodone / Oxymorphone 100 ng/mL Phencyclidine 25 ng/mL Acode 8051B - Postmortem, Basic, Blood (Forensic) - Femoral Blood -Analysis by Enzyme-Linked Immunosorbent Assay (ELISA) for: Compound Rpt. Limit Compound Rpt. Limit Amphetamines 20 ng/mL Barbiturates 0.040 mcg/mL Benzodiazepines 100 ng/mL Buprenorphine / Metabolite 0.50 ng/mL Cannabinoids 10 ng/mL Cocaine / Metabolites 20 ng/mL Fentanyl / Acetyl Fentanyl 0.50 ng/mL Methadone / Metabolite 25 ng/mL Methamphetamine / MDMA 20 ng/mL Opiates 20 ng/mL Oxycodone / Oxymorphone 10 ng/mL Phencyclidine 10 ng/mL -Analysis by Headspace Gas Chromatography (GC) for: Compound Rpt. Limit Compound Rpt. Limit Acetone 5.0 mg/dL Ethanol 10 mg/dL Isopropanol 5.0 mg/dL Methanol 5.0 mg/dL NMS v.18.0 CONFIDENTIAL Workorder Chain Patient ID 17251800 81098 2017-03741 Page 4 of 4