Clark County Coroner 1704 Pinto Lane Las Vegas, NV 89106 (702) 455-3210 AUTOPSY REPORT Case Number: 17?10064 October 6, 2017 II. IV. AUTOPSY REPORT PATHOLOGICAL EXAMINATION ON THE BODY OF STEPHEN CRAIG PADDOCK PATHOLOGIC FINDINGS Intraoral gunshot wound.of head,_contact range. 2L Entrance: roof of mouth with abundant soot. EL Associated injuries: perforation of the roof of the mouth, the base of the skull (with internal beveling). the brainstem, the cerebellum, the left occipital lobe, and partially into the occipital bone (with external beveling); subdural hemorrhage and subarachnoid hemorrhage; contusions along the wound track and of the base of the brain; fractures of the supraorbital portions of the frontal bones, base of the skull,r the left petrous bone and the occipital bone: bilateral periorbital soft tissue hemorrhage. . CL Recovered: moderately deformed copper jacketed gray metal missile and fragments of copper jacket and gray metal between occipital dura and partly into occipital skull. JD.Exit: no corresponding exit. E.?Irajectory: fronteto?back and upward. Hypertensive cardiovascular disease. .A.Hypertensive vasculoPathy and atherosclerosis, per neuropathology consultation. B.IGlobally sclerosed glomeruli: glomerulomegaly, per histology. CL increased perivascular fibrosis and scattered hypertrophied myocytes, per histology. Blunt force injuries to extremities. dA.Abrasion of right upper calf. B.Eeint contusion of left calf. C.Abrasion of right knee. Overweight (BMI 29.6 kg/mz). 4A.Dilated cardiomegaly (550 grams). Degenerative changes of spine. Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane Las Vegas, NV 89106 (702) 455-3210 AUTOPSY REPORT Case Number: 17-10064 VI. Diverticula. VII. Mild degenerative changes of mitral valve. OPINION CAUSE OF ZDEATH: This Stephen. Craig Paddock. died of an intraoral gunshot wound of the head. WER OF DEATH: SUICIDE w/g DATE: 9/5: WGavin MD Medical Examiner Clark County Coroner Las Vegas, NV LG/ag Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane Las Vegas, NV 89106 (702) 455-3210 AUTOPSY REPORT Case Number: 17-10064 October 6, 2017 POSTMORTEM EXAMINATION ON THE BODY OF Stephen Craig Paddock ADDLT POSTMORTEM EXAMINATION An autopsy examination is performed on the body of tentatively identified as Paddock, Stephen Craig at the Clark County Office of the Coroner/Medical Examiner (CCOCME), on 6th day of October 2017, commencing at 1622 hours. Identification is later confirmed by fingerprint comparison. The body is received within 51 sealed body bag (seal #541486), which is opened on 10/6/2017 at 1625 hours by #421. The body is identified by a Clark County Office of the Coroner/Medical Examiner (CCOCME) ?toe tag" around the right great toe, which includes: CCOCME Case #17?10064; Name: Paddock, Stephen Date of Death: 10?2?17; Time of Death: 1200 hours; CCOCME Investigator: #342. The autopsy is conducted in the presence of Detective T. Alsup Detective BL Colon Crime Scene Analyst's. Fletcher of the Las Vegas IMetropolitan Police Department; also :present is Special. Agent I1. Marriott. and Special Agent G. Kwan of the Federal Bureau of Investigation. EXTERNAL EXAMINATION (EXCLUDING INJURIES) The body':n3 that of aa well-developed, overweight, adult White male who weighs approximately 224 pounds, is 73 inches in length (body mass index, BMI 29.6). The body is received clad jxlaa brown long sleeve shirt, black pants, blue boxer shorts, two white?black socks, and two charcoal shoes. Of note, during processing a brass~like casing adjacent to the head is found. Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane Las Vegas, NV 89106 (702) 455-3210 AUTOPSY REPORT Case Number: 17?10064 PAGE TWO The body is cold (refrigerated). Rigor mortis is receding. Fixed pink livor mortis extends over the posterior surface of the body. Evidence of postmortem change includes: green discoloration of the right lower quadrant of the abdomen. The scalp hair is gray?white, straight and short with. male pattern baldness. The irides appear lighter in color. The pupils are round. The corneas are clouded. Tache noire is present of the sclerae which are otherwise injected and focally hemorrhagic. The conjunctivae are a mixture of pale and congested. The nose and ears-appear normally formed. In the right ear is white tissue paper. In the left ear is bloody tissue paper. The decedent wears an unkept beard. The anterior teeth are in poor condition with a majority of the maxillary teeth being absent. The neck is unremarkable. The thorax is well developed. The abdomen is flat. The anus contains hemorrhoids. The spine is normally formed and the surface of the back is remarkable for nevi. The external genitalia are those CHE a normal adult male, with the testes descended bilaterally into the normally rugated scrotum. Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane Las Vegas, NV 89106 (702) 455-3210 AUTOPSY REPORT Case Number: 17-10064 PAGE THREE The upper and lower extremities appear well developed and without absence of dugits. Some pitting edema is noted of the lower legs, particularly in a sock?like distribution. IDENTIFYING On the left mid?aspect of the back is a 1 inch brown macule. A 3/8 inch light brown?white macule on the right ventral arm near the elbow is identified. EVIDENCE OF MEDICAL INTERVENTION: There is no evidence of medical intervention. EVIDENCE OF INJURY INTRAORAL GUNSHOT WOUND OF HEAD: ENTRANCE: On the roof of the mouth centered approximately 6?1/2 inches below the top the head and 1/4 inch to the left of anterior midline is emu entrance gunshot wound consisting of a 1/2 5/8 inch defect with. a Inarginal abrasion that appears widest at the 63 o?clock position (1/4 inch). Abundant soot is present within the roof of the mouth. ASSOCIATED INJURIES: Perforation of the roof of the mouth, the base of the skull (with internal beveling), the brain stem, the cerebellum, the left occipital lobe and partially into the occipital bone (with external beveling) is seen with contusions of the brain along the wound track. Contusions of the base of the brain are seen along with brain swelling. Fractures of the supraorbital portions of the frontal bones, the left petrous bone, the base of the skull, and the bilateral occipital bones are seen. Subdural hemorrhage and subarachnoiol hemorrhage are present. Bilateral periorbital soft tissue hemorrhage is noted. Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane Las Vegas, NV 89106 (702) 455-3210 AUTOPSY REPORT Case Number: 17?10064 PAGE FOUR RECOVERED: Recovered between the occipital dura and the occipital skull is ea moderately deformed copper jacketed gray missile; additionally Ininute jacket and. missile fragments are recovered in the same location. EXIT: There is no corresponding exit. TRAJECTORY: The wound track travels from the decedent?s front? to?back and upward. BLUNT FORCE INJURIES OF EXTREMITIES: On the right upper calf is a 1/2 1/4 inch red?brown abrasion. On the left calf is a 1/4 3/16 inch faint pink contusion. On the right knee is a 1/4 1/8 inch red abrasion. INTERNAL EXAMINATION (EXCLUDING INJURIES) BODY CAVITIES Focal adhesions are present between the loops of bowel. All body organs are in normal and anatomic position with apparent surgical absence of the appendix. The serosal surfaces are glistening. HEAD (CENTRAL NERVOUS SYSTEM): The brain weighs 1410 grams and is swollen. The dura mater and falx cerebri are not adherent to the brain. The cerebral hemispheres are asymmetrical due to injury. The uninjured structures at the base of the brain are free of abnormality. Sections through the uninjured. cerebral hemispheres reveal no lesions within the cortex, subcortical white 'matter, or deep of either hemisphere. Sections through the uninjured brain stem and cerebellum reveal no lesions. The spinal cord is not removed. Sections of the twain are submitted for further Forensic Neuropathological Evaluation (see separate report). Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane Las Vegas, NV 89106 (702) 455-3210 AUTOPSY REPORT Case Number: 17-10064 PAGE FIVE NECK: Examinatitnl of the soft tissues of the :neck, including' strap muscles and large vessels, reveals no abnormalities. The hyoid bone and larynx are intact. The tongue is normal. CARDIOVASCULAR SYSTEM: The heart weighs 550 grams and is dilated. The pericardial sac is free of significant fluid or adhesions. The pericardial surfaces are glistening. The coronary arteries arise normally and follow the distribution of a right dominant pattern with no significant atherosclerosis. The chambers and valves are proportionate. Mild degenerative changes are present of the antral valve. The remaining valves and cusps are normally formed,- thin. and 1oliable and free ?of vegetations and degenerative changes. The myocardium is remarkable for increased perivascular fibrosis. Fatty infiltration of the right ventricle is Immed. A focal area of pallor is noted in the lateral left ventricle near the base of the heart. The atrial and 'ventricular septa. are intact. The tricuspid valve measures 12.5 cm; the mitral valve measures 11.5 cm; the pulmonic valve measures 7.8 cm; the aortic valve measures 8.0 cm. The right ventricle measures 0.5 cm in thickness; the left ventricle measures 1.9 cm in thickness; and the septum measures 1.9 cm in thickness. The aorta and its major branches arise normally and follow the usual course, with no significant atherosclerosis. The orifices of the major aortic vascular branches are patent. The vena cava and its major tributaries are patent and return to the heart in the usual distribution and are unremarkable. Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane AUTOPSY REPORT Las Vegas, NV 89106 . (702) 455-3210 Case Number. 17?10064 PAGE SIX SYSTEM: The right and left lungs weigh 1060 and 750 grams, respectively. The upper and lower airways are unobstructed. The mucosal surfaces are smooth. The jpleural surfaces are glistening. The pulmonary is a dark red-purple in the dependent portions and lighter pink ?ll the anterior portions. The cut surface exudes moderate amounts of blood, particularly in the dependent portions. The pulmonary arteries are normally developed and without thromboemboli and atherosis. There is no saddle embolus on the in situ examination of the pulmonary trunk. LIVER AND BILIARY SYSTEM: The liver weighs 1490 grams. The hepatic capsule is smooth, glistening, and intact, covering brown fatty The gallbladder contains a moderate amount of brown- tan liquid bile without stones; some cholesterolosis is noted of the gallbladder mucosa. ALIMENTARY TRACT: The esophagus is lined by gray smooth mucosa. The gastric mucosa contains the usual rugal folds. The lumen contains approximately 50 ml of brown liquid. The serosa of the small bowel is unremarkable. The serosa of the large bowel is remarkable for diverticula. The small. bowel contains some :partially' digested food. The large bowel contains a mixture of softened and semi? firm stool. Diverticula are intact and present particularly in the sigmoid colon. The appendix is surgically absent. The pancreas contains fatty infiltration. GENITOURINARY TRACT: The right and left kidneys weigh 140 and 150 grams, respectively. The renal capsules are opaque and strip with difficulty from the underlying granular, scarred, and brown Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane Las Vegas, NV 89106 (702) 455-3210 AUTOPSY REPORT Case Number: 17?10064 PAGE SEVEN cortical surfaces. The cortices are of normal thickness and delineated from the nedullary pyramids. The calyces and pelves are dilated but free of stones. The urinary bladder contains a moderate amount of yellow 'urine; the mucosa. is gray?tan and smooth. The prostate is not enlarged. The testes are unremarkable. RETICULOENDOTHELIAL SYSTEM: The spleen weighs 140 grams and has an intact capsule covering a purple diffluent The splenic white pulp is indiscernible. The bone marrow (rib) is red?purple. There is no prominent The thymus is diSpersed in the anterior mediastinal fat. ENDOCRINE SYSTEM: The pituitary gland is of large size. The thyroid gland is of normal position, large size and normal texture. The adrenal glands have a yellow cortex and an autolyzing gray medulla. MUSCULOSKELETAL SYSTEM: Degenerative changes are present of the spine. The soft tissues are not unusual. The cervical spinal column is stable on internal palpation. MICROSCOPIC EXAMINATION (Slide Conduction node network of muscle fibers in subendocardial tissues; mildly increased perivascular fibrosis. Conduction. systenl SA. node ganglion cells and. nerve fibers identified. Coronary arteries mild atherosclerosis. Heart RV increased fatty infiltration. Heart septum scattered hypertrophied myocytes. Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane Las Vegas, NV 89106 (702) 455-3210 AUTOPSY REPORT Case Number: 17-10064 PAGE I GHT Heart LV scattered hypertrOphied.?myocytes: minimally increased perivascular fibrosis. Heart apex myocyte disarray. Lung right autolysis. Lung left autolysis; patchy areas of atelectasis. Liver mild diffuse macrosteatosis; portal tracts without increased fibrosis or increased inflammatory cells; vascular congestion; autolysis. Spleen prominent white pulp; hyalinized vessels. Pancreas increased fatty infiltration; autolysis; islet cells not identified. Kidneys several globally sclerosed glomeruli; glomerulomegaly; tubular autolysis. Adrenal intracellular cortical fat/lipid identified. Thyroid follicles of variable diameters; early autolysis. Bone marrow trilineage hematopoiesis; early autolysis. RADIOGRAPHS Radiographs of the head and neck identify a radiopaque missile just beneath the occipital skull at midline; additional minute fragments are seen. extending' a front?to-back trajectory. Fractures of the occipital bones and the base of the skull are noted. The cervical spine and hyoid bone appear intact. Dental restorations are present within the few remaining teeth within the mouth. Radiograph of the chest reveals a moderately enlarged cardiac silhouette. Radiographs of the chest, abdomen, and the pelvis reveal degenerative changes present of the spine. Radiographs of the chest, abdomen, pelvis, lower extremities and upper extremities reveal no clear evidence c?f acute skeletal injury. Metallic portions of clothing are visible within some of the radiographs. In. addition? a radiopaque casing' is 'visible within some of the radiographs of the head, neck and chest (pre? processing radiographs). Dissemination is restricted. Secondary dissemination of this document is prohibited. Clark County Coroner 1704 Pinto Lane AUTOPSY REPORT Las Vegas, NV 89106 (702) 455-3210 Case Number. 17-10064 PAGE NINE SPECIMENS TISSUE: Representative sections'of all of the major organs are retained. TOXICOLOGY: Heart blood, peripheral blood, vitreous, urine, liver, bile, gastric contents and brain are obtained at autopsy. TOXICOLOGY RESULTS: A Forensic Toxicological Analysis is performed and reported separately. VITREOUS SCREEN: A vitreous screen shows elevated urea nitrogen (35 mg/dL) and creatinine (1.6 mg/dL) levels; no evidence of is seen. MICROBIOLOGY: Bacterial cultures of the blood grew Staphylococcus aureus, Streptococcus salivarius, Clostridium perfringens and Streptococcus parasanguinis, which is Imost likely' due to post mortem overgrowth. Bacterial cultures of the right lung show scant growth of Staphylococcus aureus, Streptococcus mitis/oralis and Gemella morbillorum, which is most likely due to post mortem overgrowth. Bacterial cultures of the left lung show scant growth of Staphylococcus aureus and light growth of Streptococcus mitis, which is most likely due to post mortem overgrowth. Stool cultures for cytomegalOvirus and Enterovirus showed none isolated; no Shiga toxins were detected. No Salmonella, Shigella or Campylobacter were isolated; no ova or parasites were seen. Bacterial cultures of the urine show no growth. for Influenza and Respiratory Viral Pathogens shows no RNA detected. FilmArray for Respiratory Pathogens shows no DNA or RNA detected. URINALYSIS: A reflex tminalysis identified turbid urine with trace ketones, protein, blood, bacteria and epithelial cells. Dissemination is restricted. Secondary dissemination of this document is prohibited. STANFORD NEUROPATHOLOGY CONSULTANTS STANFORD UNIVERSITY MEDICAL CENTER 300 PASTEUR DRIVE, EDWARDS BLDG R?24l, STANFORD, CALIFORNIA 94305 TEL (650) 723-6041 FAX (650) 498-5 3 94 Hannes Vogel, MD Director Patlent. PADDOCK (TENT), STEPHEN Pathology N0: 436 1 CRAIG Med. Rec. N0.: Date of Procedure: Sex: Age: 64 Date Received: 11/27/2017 1:24:00 PM Date of Birth: 4/9/1953 - Account No.: Default Physician(s): LISA ANN GAVIN, M.D. CLARK COUNTY CORONER MEDICAL EXAMINER I704 PINTO LANE LAS VEGAS, NV 89106 SPECIMEN SUBMITTED: BRAIN AUTOPSY: DIAGNOSIS: 1. AUTOPSY BRAIN, PREFIXATION WEIGHT 1410 GRAMS, AND PITUITARY GLAND 2. STATUS POST INTRAORAL GUNSHOT WOUND OF HEAD WITH PENETRATION OF BRAINSTEM, CEREBELLUM, LEFT OCCIPITAL LOBE 3. INTRACRANIAL HEMORRHAGE, ACUTE, SECONDARY TO #2 a. b. SUBARACHNOID c. MULTIFOCAL, CONTUSIVE, PETECHIAL d. PITUITARY GLAND 4. HYPERTENSIVE VASCULOPATHY AND ATHEROSCLEROSIS VOGEL COMMENT: The hypertensive changes are commensurate with the stated age of the deceased and evidence from the general autopsy of hypertensive cardiovascular disease. The extent of formation of corpora amylacea as noted in the microscopic description is a known incidental finding in the brains of older adults. In this example of strikingly numerous corpora amylacea there is no apparent etiology, consistent with the lack of any published significance to this abundance in some individuals. GROSS NEUROPATHOLOGY: (H. Vogel, M.D.) Christina S. Kong, MD. Medical Director Page 1 of 4 STANFORD NEUROPATHOLOGY CONSULTANTS STANFORD UNIVERSITY MEDICAL CENTER 300 PASTEUR DRIVE, EDWARDS BLDG R-241, STANFORD, CALIFORNIA 94305 TEL (650) 723-6041 FAX (650) 498-53 94 Hannes Vogel, MD Director Patient: PADDOCK (TENT), STEPHEN . .. .. CRAIG PathologyNo. SHS 17 54361 Received through the courtesy of Dr. Gavin of the Clark County Coroner Office, Las Vegas, NV and by direct transfer from Coroner John Fudenberg on Monday November 27, 2017, and designated with the decedent name Paddock (Tent), Stephen as well as an autopsy report and identifying paperwork is formalin fixed brain tissue in a sealed plastic container. No dura is received. The prefixation weight of the brain is 1410 grams. The written record of the postmortem prosection of the brain is noted in the received autopsy report. An intraoral gunshot injury is described in which the trajectory included in sequence, the roof of the mouth, the base of the skull (with internal beveling), the brain stem, the cerebellum, the left occipital lobe and partially into the occipital bones. Also described are: contusions of the base of the brain with brain swelling; and subdural and subarachnoid hemorrhage, locations unspecified. The cerebral hemispheres were asymmetrical, prefixation, due to injury. Further quoting the autopsy report: ?The uninjured structures at the base of the brain are free of abnormality. Sections through the uninjured cerebral hemispheres reveal no lesions within the cortex, subcortical white matter, or deep of either hemisphere. Sections through the uninjured brain stem and cerebellum reveal no lesions. The spinal cord was not removed." Representative portions were retained for formalin fixation. The fixed brain tissue is received in pieces of varying sizes, as follows, with gross abnormalities if present. Neuroanatomic origins of all portions were substantiated by Dr. Gavin. Photographs were taken for documentation. Frontal lobe; subarachnoid and petechial hemorrhages Cingulate gyri Corpus callosum and partial basal ganglia, two pieces. Thalamus appears mottled Hippocampus, two pieces, sides unspecified; one with fresh contusion Splenium of the corpus callosum Cerebellum and injured midbrain, pons; several pieces Occipital lobe, side unspecified Representative sections are submitted as follows: A) frontal lobe, B) frontal lobe, C) corpus callosum and Cingulate gyrus, D) basal ganglia with probable anterior commissure, E) thalamus, F) thalamus G) possible amygdala, H) putamen, l, J, K, L) designated hippocampus, M) thalamus and claustrum, N) designated temporal lobe with contusion, O) occipital lobe, side unspecified, P) midbrain with red nucleus, Q) injured pcns, R) medulla, S) cerebellum, T)injured Vermis, U) pituitary, V) optic chiasm, W) basal ganglia and internal capsule, X) basal ganglia and anterior commissure, Y) basal ganglia and possible'amygdala MICROSCOPIC NEUROPATHOLOGY: (H. Vogel, MD.) Christina S. Kong, MD. Medical Director Page 2 of 4 STANFORD NEUROPATHOLOGY CONSULTANTS STANFORD UNIVERSITY MEDICAL CENTER 300 PASTEUR DRIVE, EDWARDS BLDG STANFORD, CALIFORNIA 94305 TEL it: (650) 723-6041 FAX (650) 498-5394 Hannes Vogel, MD Director Patient: PADDOCK (TENT), STEPHEN . CRAIG PathologyNo. SHS 17 54361 All sections are viewed with hematoxylin and eosin and Luxol fast blue/periodic acid Schiff The histological sections of regions designated as injured or containing contused brain are confirmed microscopically, evidenced by perivascular microhemorrhage. Grossly identifiable subarachnoid hemorrhage is also confirmed microscopically as acute. The pituitary gland shows acute hemorrhage. Sections including hemispheric white matter demonstrate hyaline thickening of arterial vessels with focal perivascular hemosiderin deposition, characteristic of hypertensive vasculopathy. No microinfarcts are noted. Large subarachnoid arterial blood vessels show moderate atherosclerosis. None of the sections show any evidence of an either acute or chronic inflammatory reaction, within brain and leptomeninges, providing no support for a diagnosis of either an infectious or autoimmune encephalitis or meningitis. The cerebellum is histologically normal and shows no obvious neuronal loss or reactive changes. The most striking abnormality in sections of the hippocampus, peri- third ventricular wall, optic nerve, corpus callosum, medial surfaces of frontal lobes are unusually large numbers of corpora amylacea in subpial, perivascular, and minor subependymal distributions characteristic of the usual age-related accumulation of corpora amylacea in these favored locations. Some of the subpial regions with numerous corpora amylacea display interface (?Chaslin?s?) gliosis. The stains highlight the corpora amylacea. No abnormal accumulations of corpora amylacea are found in gray matter as seen in Lafora disease, or except in rare foci, in white matter as seen in polyglucosan body disease. The following special stains and immunohistochemical stains were performed with results. described. 1. no evidence of demyelination 2. Bielschowsky silver impregnation, block J: no neurofibrillary tangles or senile plaques of the Alzheimer type 3. Beta-amyloid, blocks B, G, J: no vascular or plaque deposition . 4. AT8 (phosphortau), blocks neurofibrillary tangles or senile plaques of the Alzheimer type in the hippocampus; no subcortical expression of tau at depths of sulci or perivascular as seen in chronic traumatic encephalopathy, frontal lobe Alpha?synuclein, blocks 0, G, P: no Lewy body pathology blocks B, G, N: no abnormal cytoplasmic staining as seen in frontotemporal lobar degeneration (FTLD) 7. Ubiquitin, blocks J, N, Y: no abnormal cytoplasmic staining as seen in FTLD .091 Christina S. Kong, MD. Medical Director Page 3 of 4 STANFORD NEUROPATHOLOGY CONSULTANTS STANFORD UNIVERSITY MEDICAL CENTER 300 PASTEUR DRIVE, EDWARDS BLDG R-241, STANFORD, CALIFORNIA 94305 I TEL (650) 723-6041 FAX (650) 498?5394 Hannes Vogel, MD Director STEPHEN Pathology No: SHS-17-54361 8. GFAP, blocks C, E, F, M: some mild increase in perivascular and subpial astrogliosis, without obvious neuronal loss 9. Beta?amyloid precursor protein, block C: no axonal injury CLINICAL HISTORY: 64 year old man expired of self?administered intraoral gunshot wound. No known past medical history. I have reviewed the specimen and agree with the interpretation above. HANNBS VOGEL, MD. Electronically signed 12/27/2017 1:34 PM Christina S. Kong, MD. Medical Director Page 4 of 4 NMS Labs CONFIDENTIAL 3701 Welsh Road. PO Box 433A, Willow Grove, PA 19090-0437 Phone: (215) 6574900 Fax: (215) 657-2972 e-mail: nms@nmslabs.com Robert A. Middleberg, F-ABFT, DABCC-TC. Laboratory Director Toxicology Report Patient Name PADDOCK (TENT). STEPHEN C. . Patient ID 17-10064 Report Issued 10/24/2017 12.03 Chain 17314232 Age-64 DOB Not Given To: 10294 Gender Male Clark County Coroner?s Office Workorder MEMBER Attn: David Mills 1704 Pinto Lane Las Vegas, NV 89106 . P8991 0* 9 Positive Findings: Comm Result Lidia ?atworms Betahydroxybutyric Acid 21 001 - Peripheral Blood Arsenic 12 001 - Peripheral Blood Bismuth 0.92 001 - Peripheral Blood Mercury 37 001 - Peripheral Blood Selenium - 290 001 - Peripheral Blood Antimony 9.6 001 - Peripheral Blood Lead 7.3 001 - Peripheral Blood Caffeine Positive 001 - Peripheral Blood Theobromine Positive 001 - Peripheral Blood Chlorpheniramine 13 002 _-.Peripheral Blood Nordiazepam 42 006 - Urine Oxazepam 170 ng?lrnL 006 - Urine' Temazepam 140 006 - Urine See Detailed Findings section for additional information Disclaimer: Specimens for elemental testing should be collected in certified metal?free containers. Elevated results for elemental testing may be caused by environmental contamination at the time of specimen collection and should be interpreted accordingly. It is recommended that unexpected elevated results be verified by testing another specimen. Testing Requested: Analysis Code Description 91428 Cyanide Screen, Blood 26938 Metals/Metalloids Acute Poisoning Panel, Blood 04208 Betahydroxybutyric Acid. Blood 8054B Postmortem, Expanded with NPS, Blood (Forensic) 80928 Postmortem, Expert. Blood (Forensic) 8051U Postmortem, Basic, Urine (Forensic) Specimens Received: ID TubelContainer il/olumelr Collection Matrix Source Miscellaneous Mass Datel'Time Information 001 Gray Top Tube 10.65 mL 10/06i2017 19:00 Peripheral Blood 002 Gray Top Tube 965 mL 10106001? 19:00 Peripheral Blood 003 Gray Top Tube 9.65 mL 10/06/2017 19:00 Heart Blood 004 Gray Top Tube 5 mL 10/0612017'19200 Heart Blood 005 Red Top Tube 1 mL 10106201? 19:00 Vitreous Fluid NMS V3180 CONFIDENTIAL Workorder 17314232 8 Chain 17314232 Patient ID 17-10064 CHESS Page 2 of 9 ID TubeiContainer Volume! Collection Matrix Source Miscellaneous Mass DateiTime Information 006 Green Vial 10.65 mL 10I0672017 19:00 Urine 007 Green Vial 6.75 mL 19:00 Bile 008 White Plastic Container 32.47 102'06/2017 19:00 Liver Tissue 009 White Plastic Container 24.92 9 1010612017 19:00 Brain Tissue 010 White Plastic Container 22.08 10/0672017 19:00 Muscle Tissue SKELETAL MUSCLE 011 White Plastic Container 28 10i0612017 19:00 Gastric Fluid THIN LIGHT BROWN FLUID, pH=4 All sample volumesiweights are approximations. Specimens received on 10/10/2017. Detailed Findingsi Analysis and Comments Result Units El?n Specimen Source Analysis By Betahydroxybutyric Acid 21 mcgiml. 20 001 Peripheral Blood GCIMS Arsenic 12 mcgiL 5.0 001 - Peripheral Blood ICPIMS Bismuth 0.92 mcgiL 0.50 001 Peripheral Blood ICPIMS Mercury 37 mcgiL 3.0 001 - Peripheral Blood ICPIMS Selenium 290 mcgiL 20 001 - Peripheral Blood ICPIMS Result verified by repeat analysis. Antimony 9.6 1.0 001 Peripheral Blood Lead . 7.3 mcgidL 0.50 001 - Peripheral Blood ICPIMS Results veri?ed by repeat analysis. Caffeine Positive mcgimL 0.10 001 - Peripheral Blood GCIMS Theobromine Positive 5.0 001 - Peripheral Blood Chlorpheniramine 13 ngimL 10 002 Peripheral Blood Nordiazepam 42 ngimL 20 006 - Urine LC-MSIMS Oxazepam 170 ngimL 20 006 Urine LC-MSIMS Temazepam 140 ngimL 20 006 - Urine . 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: 1. Antimony - Peripheral Blood: Pentavalent antimony compounds are used in medicine as parasiticides. Additionally, antimony has been used in the production of pigments. alloys. and ?ame-retardants. Typical normal antimony concentrations in blood are less than 5 Patients administered stibogluconate sodium for leishmaniasis developed an average peak blood antimony concentration of 8800 mcgiL at 1.3 hr post-intramuscular dosing. NMS Labs has demonstrated that certain collection tubes can artifactually increase measured antimony concentrations rendering reported concentrations difficult to interpret. NMS V.18.0 CONFIDENTIAL Workorder 17314232 5 Chain 17314232 17-10064 W..- Patient ID Emiswu I Page 3 of 9 Reference Comments: 2. Arsenic Peripheral Blood: Arsenic is a metallic element. it is prevalent in the earth's crust and can therefore be found in numerous environmentally?related sources, well water. shell?sh and soil. Individuals who are exposed to these sources may have acutely or chronically elevated body burdens of arsenic. Arsenic exists in numerous chemical compounds as well as several chemical forms. Not all arsenical compounds are equal in toxicity. In unexposed normal individuals. arsenic concentrations in blood are usually less than 10 but may be higher after seafood consumption. Other potential factors causing increased concentrations of arsenic include consumption of well-water with high arsenic content. in reported poisoning fatalities. a range of 600 - 9300 mogl?L blood (mean. 3300 has been reported. 3. Betahydroxybutyric Acid Betahydroxybutyrate; Ketone) Peripheral Blood: Ketoacidosis related to diabetes or alcoholism can be an important factor in determining cause of death. The primary ketone body produced through ketogenesis is acetoacetate. Acetoacetate may then break down to form acetone and betahydroxybutyric acid. Ketogenic diets and other means of clinically induced, mild ketogenesis have been applied to the treatment of Epilepsy, Alzheimer?s disease and other disorders. in blood. betahydroxybutyric acid concentrations below 50 are considered normal while concentrations greater than 250 are indicative of ketoacidosis. Ketoacidosis may produce polyuria. polydipsia. weight loss. dizziness, nausea. vomiting. confusion. stupor and coma. There may be an odor of acetone on the breath. Severe ketoacidosis may result in death if left untreated. 4. Bismuth - Peripheral Blood: Bismuth is used industrially to produce low-melting alloys. pigments and chemical additives. It is also used therapeutically as astringents. antacids. skin powders, radio-opaque agents and to treat ulcers. indigestion. diarrhea, syphilis and warts. Normal blood concentrations are usually less than 1.0 mcgiL. The primary result of bismuth overdosage is renal damage. but encephalopathy and peripheral neuropathy can also occur. Other signs of bismuth toxicity may include discoloration of the tongue. gums or skin. salivation. nausea. vomiting. abdominal pain. tremors. ataxia. memory loss, mental confusion. and seizures. Toxic bismuth blood concentrations arising from the chronic oral use of bismuth subnitrate ranged from 50 to 1600 mcg/L. Two death cases associated with bismuth toxicity reported bismuth blood concentrations in excess of 1000 5. Caffeine (No-Doz) - Peripheral Blood: Caffeine is a xanthine-derived central nervous system stimulant. It also produces diuresis and cardiac and respiratory stimulation. It can be readily found in such items as coffee. tea. soft drinks and chocolate. The reported qualitative result for this substance is indicative of a finding commonly seen following typical use and is usually not toxicologically signi?cant. lf confirmation testing is required please contact the laboratory. 6. Chlorpheniramine (Chlor?Trlmeton?) - Peripheral Blood: Chlorpheniramine is a potent antihistamine that has been used alone and in combination with other cold relief medications. both prescribed and sold over-the-counter. It may also be provided by injection or as a nasal spray. Oral doses usually range from 4 to 12 mg with both normal and controlled release formulations available. Peak concentrations of 10 ng/mL chlorpheniramine were obtained 3 hours following single oral administration of 8 mg. Toxic effects have been reported in adults at concentrations greaterthan 400 ng/mL (serum) and in infants at concentrations above 65 (postmortem blood). The blood to plasma ratio of chlorpheniramine is approximately 1.2. Common adverse effects include sedation, dizziness. nausea and dry mouth. Signs and of acute chlorpheniramine toxicity include tremor. seizures, disorientation. loss of consciousness. fever. respiratory depression and cardiac NMS v.18.0 CONFIDENTIAL Workorder 17314232 Chain 17314232 Patient ID 17-10064 Page 4 of 9 Reference Comments: 7. Lead Peripheral Blood: Lead is an environmental toxicant that may deleteriously affect the nervous, hematopoietic. endocrine. renal, and reproductive systems In the general population, the major exposure routes are inhalation of lead dusts and fumes and ingestion of lead from contaminated hands and food stuffs. Drinking water may also contribute to the total body burden. In children, paint chips from lead based paints may be a' source of exposure. According to the US. Centers for Disease Control and Prevention (CDC), the blood lead reference level for adults is less than 5 For workplace information, refer to the US. Occupational Safety and Health Administration (OSHA) website. In young children. lead exposure is a particular hazard becauSe children absorb lead at a higher rate than do adults. and because the developing nervous system of chiidren are more susceptible to the effect of lead. The US. Centers for Disease Control and Prevention (CDC) reference value based on the 97.5th percentile of the blood lead level distribution in US. children aged 1-5 years is 5 mcgidL. 8. Mercury - Peripherai Blood: Mercury is a trace element. which is widely used, in industrial and agricultural products and processes. and in medicine and dentistry. Dietary intake of mercury in man ranges from approximately 1 to 30 per day. industrial exposure to mercury occurs through inhalation or by dermal absorption. Mercury exposure can be due to elemental, inorganic and organic forms of the element. Total blood mercury ievels of up to 6 have been measured in persons with low ?sh consumption and up to 200 mogiL blood in individuals consuming large quantities of predatory marine fish. Typically. 'normal' mercury blood concentrations are less than 10 mcg/L. Postmortem total blood mercury concentrations ranging from 20 - 110 mcg/L with an average of 60 have been reported in a Japanese population. The average oral lethal dose of inorganic mercury salts is approximately 1 gram. Toxic effects of inorganic mercury poisoning include gastroenteritis and tubular necrosis leading to renal failure. Elementai mercury is most dangerous when voiatilized leading to pulmonary and CNS effects. Postmortem blood mercury concentrations can vary according to the form of mercury and the time since exposure. In two cases of inorganic mercury poisoning. biood concentrations of 1700 and 2100 were measured. Blood concentrations of mercury after both fatal and non-fatal elemental mercury poisoning usually exceed 200 mcg/L. 9. Nordiazepam (Chlordiazepoxide Metabolite) - Urine: Nordiazepam is a pharmacologically active metabolite of several benzodiazepine anxiolyticisedativeihypnotic agents. diazepam (Valium?). Nordiazepam is also the major active entity in clorazepate (Tranxene?), a benzodiazepine agent used for agitation, seizures and anxiety. The action of this compound is based on its CNS?depressant activity. 10. Oxazepam (Serax?) Urine: Oxazepam is a benzodiazepine. It is frequently seen as the metabolite of diazepam and other benzodiazepines; however, it is pharmacologically active and may be given as the primary medication for the short-term relief of of anxiety and in the management of alcohol withdrawal. Signs associated with overdose with oxazepam are similar to those observed with other benzodiazepines, drowsiness, lethargy, respiratory depression and coma. . 11. Selenium - Peripheral Blood: Selenium is an essential trace metal. It is also used in various industries, electronic semiconductors and rubber. In medicinals, selenium can be found in shampoos and dietary supplements. The compound exists in elemental. organic. and inorganic forms. Reported reference concentrations of selenium in blood of normal individuals range from 60 - 230 mcg/L. These concentrations are diet dependent. Adverse effects to selenium have included irritation of the skin and mucous membranes. nausea. diarrhea. fatigue, alopecia. joint pain, abdominal pain, tremor, corrosive gastritis, cyanosis. coma, and death. NMS V.18.0 CONFIDENTIAL Workorder 17314232 Chain 17314232 Patient ID 17?10064 Page 5 of 9 Reference Comments: 12. Temazepam (Diazepam Metabolite; Normison?) Urine: Temazepam is a benzodiazepine hypnotic agent used in the short-term relief of insomnia. its major metabolite. oxazepam, is also a pharmacologically active depressant. Temazepam is also a metabolite of diazepam (Valium?). The usual adult dosage of temazepam is 30 mg, however, 15 mg may be adequate. In overdose. temazepam shares the same clinically observed signs and as other benzodiazepines, sedation, lethargy, loss of consciousness and respiratory depression. Alcohol greatly enhances the activity of benzodiazepines. 13. Theobromine (Xantheose) - Peripheral Blood: Theobromine is a alkaloid found in tea and cocoa products and has been reported to pass into the breast milk of nursing mothers. Theobromine has the general properties of the xanthines, including diuresis and smooth muscle stimulation. The reported qualitative result for this substance was based upon a singie analysis only. If confirmation testing is required please contact the laboratory. Sample Comments: 001 Physician/Pathologist Name: DR. GAVIN Unless alternate arrangements are made by you, the remainder of the submitted specimens will be discarded thirteen (13) months from the date of this report; and generated data will be discarded ?ve (5) years from the date the analyses were performed. Chain of custody documentation has been maintained for the analyses performed by NMS Labs. Workorder 17314232 was electronically signed on 10/24/2017 11:24 by: ?mo? Laura M. Labay, F-ABFT, DABCC-TC Forensic Toxicologist Analysis Summary and Reporting Limits: All of the foliowing 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. lithe 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 identi?ed as being present. Acode 04203 - Betahydroxybutyric Acid, Blood - Peripheral Blood -Analysis by Gas Spectrometry (GCIMS) for: 99mm awn 09mm R91. Limit Betahydroxybutyric Acid 20 Acode 26933 MetalsfMetalloids Acute Poisoning Panel, Blood - Peripheral Blood -Analysis by inductively Coupled PlasmaIMass for: gamma Rpt, Limit 9.0mm Bpj_Lmt Arsenic 5.0 -Ana ysis by Inductively Coupled PlasmaIMass SpectrometryUCPIMS) for: Bismuth 0.50 NMS V.18.0 CONFIDENTIAL Workorder 17314232 Chain 17314232 Patient ID 17?10064 Page 6 of 9 Analysis Summary and Reporting Limits: ?Analysis by Inductively Coupled PlasmaiMass SpectrometryUCPIMS) for: Mercury 3.0 meg/L -Analysis by Inductively Coupled PlasmalMass SpectrometryUCPliViS) for: 9.9mm Bpj_i_t. L'mi Compound Selenium 20 mcgiL -Analysis by inductively Coupled Plasmaiiviass SpectrometryUCPIMS) for: Compound BoLLimii Compound Thallium 0.50 mcgiL ?Anaiysis by inductively Coupled PiasmaiMass SpectrometryUCP/M S) for: Compound. . Li i Antimony 1.0 mcg/L -Analysis by Inductively Coupled Plasma/Mass SpectrometryUCPiMS) for: Compound 3mm Compound Lead 050 mcg/dL Acode 500128 - Benzodiazepines Con?rmation. Blood (Forensic) - Peripheral Blood Analysis by High Performance Liquid Chromatography;i TandemMass Spectrometry for: 7-Amino Clonazepam 5.0 ngimL Flurazepam Alpha-Hydroxyalprazolam 5.0 ngimL Hydroxyethyiflurazepam Alprazolam 5.0 ng/mL Hydroxytriazolam Chlordiazepoxide 20 ngimL Lorazepam Ciobazam 20 ngimL Midazoiam Clonazepam 2.0 Nordiazepam 5.0 ngImL Oxazepam Diazepam 20 ngi?mL Temazepam Estazolam 5.0 ngimL Triazolam Acode 50012U - Benzodiazepines Confirmation, Urine (Forensic) -Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry (LC-MSIMS) for: Compound Compound 1-Hydroxyrnidazolam 5.0 ngimL Alprazoiam Y-Amino Clonazepam 5.0 ngimL Chlordiazepoxide Aipha?Hydroxyaiprazoiam 10 Clobazam Bpt. Limit Bpt. Limit Bpt. Limit Lii Bot, Limit 2.0 ng/mL 5.0 ngimL 5.0 ng/mL 5.0 ngimL 5.0 ng/mL 20 ngimL 20 ngimL 20 ngimL 2.0 ng/mL . 'l 5.0 ng/mL 20 ngimL 20 ng/mL NMS V.?i8.0 -Analysis by Headspace Gas Chromatography (GC) for: CONFIDENTIAL Workorder 17314232 Chain 17314232 Patient 17?10064 Page 7 of 9 Analysis Summary and Reporting Limits: 9.0mm Rot. Limit Comm 891. Limit Desalkyl?urazepam 5.0 Lorazepam 10 Diazepam 20 ngx?mL Nordiazepam 20 ngimL Estazolam 5.0 ng/mL Oxazepam 20 ng/mL Hydroxyethyi?urazepam 5.0 ngimL Temazepam 20 Hydroxytriazolam 5.0 ng/mL Acode 524408 - Chlorpheniramine Confirmation, Blood (Forensic) - Peripheral Blood -Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry for: Compound Emmi 9.9mm Bot. Limit Chlorpheniramine 10 ngImL Acode 59708 Cannabinoids Con?rmation Panel 2 (Qualitative), Blood - Peripheral Blood -Ana ysis by High Performance Liquid Chromatography! TandemMass Spectrometry for: 1.0 FUB-AMB 0.10 5F-ADB 0.20 FUB-JWH-018 0.20 ngimL 5F-AMB 0.10 FUB-PB-22 0.10 ng/mL 5F-APICA 1.0 MA-CHMINACA 0.20 5F-APINACA (5F-AKB-48) 2.0 ngimL 0.10 0.10 ngme MDMB-CHMINACA 0.10 ng/mL 0.10 ngme MDMB-FUBINACA 0.10 ng/mL AMB 0.10 ng/mL 0.10 ngme APICA 0.20 MMB-CHMINACA 0.10 ngme APINACA (AKB-48) 1.0 ngimL CUMYL-THPINACA 0.10 ng/mL ?-10 EG-2201 0.20 ngme 01 0'10 FUB-144 0.10 ngme ??81 0-10 ?g?mL FUB-AKB-48 0.20 ng/mL ??220 0-10 Acode 8051 - Postmortem, Basic, Urine (Forensic) -Analysis by Enzyme Immunoassay (EIA) for: Bot. Limit Compound E591 (mi; Barbiturates 0.30 mcgimL Methadone Metabolite 300 ng/mL Benzodiazepines 50 ngimL Opiates 300 Can nabinoids 20 ngme Oxycodone I Oxymorphone 100 Cocaine Metabolites 150 Phencyolidine 25 ngimL ?Analysis by Enzyme lmmunoassay (EIA) forAmphetamines 500 ngme Fentanyl (Acetyi Fentanyl 2.0 ngme Buprenorphine I Metabolite 5.0 MDMA 300 ngme NMS V.18.0 CONFIDENTIAL Workorder 17314232 Chain 17314232 Patient ID 17-10064 Page 8 of 9 Analysis Summary and Reporting Limits: ggompound Rot. Limit ngpound R91. Li it Acetone 5.0 mg/dL lsopropanol 5.0 Ethanol 10 mg/dL Methanol 5.0 mgde Acode 80548 - Postmortem, Expanded with NPS, Blood (Forensic) - Peripheral Blood Analysis by Enzyme-Linked lmmunosorbent Assay (ELISA) for: Compound mm mm Betti?it Barbiturates 0.040 Salicylates 120 mcgimL Cannabinoids 10 ngimL -Analysis by Headspace Gas Chromatography for: Acetone 5.0 lsopropanol 5.0 mgde Ethanol 10 Methanol 5.0 mg/dL ?Analysis by High Performance Liquid Chromatography/TandemMass Spectrometry QTRAP QTRAP) for: Qomomi?d 5F-AB-001 5F-ADB 5F-ADB-P1NACA 5F-ADBICA 5F-AMB 5F-APICA 5F-APINACA (5F-AKB-48) 5F-MN-18 5F-PB-22 AB-CHMINACA AB-FUBINACA AB-PINACA ADB-PINACA Aim-2201 AMB APICA APINACA (AKB-48) APP-CHMINACA (PXS) 1.0 ng/mL 0.20 ngImL 1.0 ngz?mL 1.0 0.10 ngme 1.0 2.0 ngimL 0.10 0.10 ngz?mL 1.0 ngme 1.0 ngme 0.20 ng/mL 0.10 ngme 1.0 ngimL 0.20 ngimL 1.0 ngme 0.10Ingme 0.10 ng/mL 0.20 ngimL 1.0 ngimL 0.20 ngme 0.10 0.20 ngme 99mm FUB-1 44 FUB-AKB-48 8 MA-CHMINACA MDM MDMB-CHMINACA MDMB-FUBINACA MMB-CHMICA MMB-CHMINACA (MDMB- CHMICA) MO-CHMINACA NM-2201 PX1 PX2 8 THJ-2201 0.10 0.20 ng/mL 0.10 ngimL 0.20 ngimL 0.10 ng/mL 0.10 ngme 0.10 0.20 ngme 0.10 ngImL 0.10 ngimL 0.10 ngimL 0.10 0.10 ngme 0.10 ngimL 0.10 ngimL 0.10 ngi'mL 0.20 ngme 0.10 0.10 ngimL 0.20 0.20 ngimL NMS V.18.0 CONFIDENTIAL Workorder 17314232 Chain 17314232 Patient ID 17-10064 Page 9 of 9 Analysis Summary and Reporting Limits: -Analysis by High Performance Liquid Chromatographleime of Flight?Mass Spectrometry for: The following is a general list of compound classes included in this screen. The detection of any specific analyte is concentration-dependent. Note, not all known analytes in each specified compound class are included. Some speci?c analytes outside these classes are also included. For a detailed list of all analytes and reporting limits, please contact NMS Labs. Amphetamines, Anticonyulsants, Antidepressants, Agents, Benzodiazepines, CNS Stimulants, Cocaine and Metabolites, Hallucinogens, Hypnosedatiyes, Hypoglycemics, Muscle Relaxants, Non- Steroidal Anti-inflammatory Agents, Opiates and Opioids. Acode 80928 - Postmortem, Expert, Blood (Forensic) - Peripheral Blood ?Analysis by Enzyme-Linked lmmunosorbent Assay (ELISA) for: Computed BM Compound Bowman Benzodiazepines 100 ngi'mL Opiates 20 Buprenorphine i' Metabolite 0.50 ngimL Oxycodone Oxymorphone 10 ngimL Cannabinoids 10 ngimL Salicylates 120 Cocaine Metabolites 20 -Analysis by Gas Chromatographnyass Spectrometry for: Anesthetics, Anticoagulant Agents, Antifungal Agents, Antihypertensive Agents, Anxiolytics (Benzodiazepine and others), Hypnosedatiyes (Barbiturates, Non?Benzodiazepine Hypnotics, and others) and Non~Steroidal Anti-Inflammatory Agents (excluding Salicylate). -Analysis by Gas Spectrometry for: The following is a general list of compound classes included in the Gas Chromatographic screen. The detection of any particular compound is concentration-dependent. Please note that not all known compounds included in each specified class or heading are included. Some specific compounds outside these classes are also included. For a detailed list of all compounds and reporting limits included in this screen, please contact NMS Labs. - Amphetamines, Analgesics (opioid and non?opioid), Anorectics, Anticholinergic Agents, Anticonyulsant Agents, Antidepressants, Antiemetic Agents, Antihistamines, Antiparkinsonian Agents, Agents, Antitussive Agents, Antiviral Agents, Calcium Channel Blocking Agents, Cardiovascular Agents (non-digitalis), Local Anesthetics Agents, Muscle Relaxants and Stimulants (Amphetamine?like and others). -Analysis by Headspace Gas Chromatography (CC) for: Li i Competed BpLLimiI Acetone 5.0 mgi?dL Isopropanol 5.0 Ethanol 10 mgidL Methanol 5.0 Acode 91428 - Cyanide Screen, Blood Peripheral Blood -Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry (LC-MSIMS) for: Compound Bp_t._Lim_it Compound Li i Cyanide 0.10 mcgimL NMS V.18.0 Toxicology Report NMS Labs 3701 Welsh Road. PO Box 433A, Willow Grove, PA 19090-0437 Phone: (215) 657-4900 Fax: (215) 657-2972 Lamigfa??j e-mail: nms@nmslabs.com Robert A. Middleberg. F-ABFT. DABCC-TC, Laboratory Director Patient Name CONFIDENTIAL PADDOCK (TENT). STEPHEN C. . Patient ID 17-10064 Report Issued 10/30/2017 13.03 Chain 17322918 Age 64 DOB Not Given To: 10294 Gender Male Clark County Coroner?s Office Workorder 3732?? Attn: David Mills 1704 Pinto Lane Las Vegas. NV 89106 P8991 of 3 Positive Findings: Result Units MW Antimony 0.49 001 - Hair Barium 1.6 mcgig 001 - Hair Lead 1.3 001 - Hair Mercury mcgig 001 - Hair Barium 5.0 002 Pubic Hair Bismuth 0.15 mcgig 002 - Pubic Hair Mercury 3.6 002 Pubic Hair See Detailed Findings section for additional information Disclaimer: Specimens for elemental testing should be collected in certi?ed metal-free containers. Elevated results for elemental testing may be caused by environmental contamination at the time of specimen collection and should be interpreted accordingly. It is recommended that unexpected elevated results be veri?ed by testing another specimen. Testing Requested: Analysis Code Description 2693H MetalsiMetalloids Acute Poisoning Panel, Hair Specimens Received: ID TubelContainer Volume! Collection Matrix Source Miscellaneous Mass DateiTime Information 001 White Plastic Container 0.128 10/141201? 13:10 Hair SCALP HAIR 002 White Plastic Container 0.128 10(14l2017 13:10 Pubic Hair 003 Green Plastic Container 16.06 10/142'2017 13:10 Bone All sample volumes/weights are approximations. Specimens received on 101119017. NMS v.18.0 CONFIDENTIAL Workorder 17322918 Chain 17322918 Patient iD 17-10064 Page 2 of 3 Detailed Findings: . Rpt. Analysis and Comments Result Units Limit Specimen Source Analysis By Antimony 0.49 0.20 - 001 Hair Barium 1.6 mcgig 1.0 001 Hair ICPIMS Lead 1.3 1.0 001 - Hair ICPIMS Mercury 0.76 001 - Hair Barium 5.0 0.98 002 - Pubic Hair Bismuth 0.15 0.098 002 - Pubic Hair ICPIMS Mercury 3.6 0.76 002 - Pubic Hair ICPIMS 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: 1. Antimony? Hair: Normally: Less than 0.2 Not for clinical diagnostic purposes. 2. Barium Hair, Pubic Hair: Normally: Less than 2 Not for clinical diagnostic purposes. 3. Bismuth - Pubic Hair: No reference data available. Not for clinical diagnostic purposes. 4. Lead - Hair: Normally: Less than 15 Not for clinical diagnostic purposes. 5. Mercury - Hair, Pubic Hair: Generally: Less than 2 meg/g. Concentrations are diet and environment dependent. Not for clinical diagnostic purposes. Sample Comments: 001 Physician/Pathologist Name: DR. GAVIN Unless alternate arrangements are made by you, the remainder of the submitted specimens will be discarded thirteen (13) months from the date of this report; and generated data will be discarded five (5) years from the date the analyses were performed. Chain of custody documentation has been maintained for the analyses performed by NMS Labs. Workorder 17322918 was electronically signed on 10/30/2017 12:11 by: Laura M. Labay. F-ABFT. Forensic Toxicologist NMS V.18.0 CONFIDENTIAL Workorder 17322918 Chain 17322918 Patient ID 17-10064 Page 3 of 3 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 2693H - MetalsfMetalloids Acute Poisoning Panel, Hair - Pubic Hair -Analysis by Inductively Coupled Plasmaflillass for: Antimony 0.19 mcgig Lead 0.98 Arsenic 0.98 mcgig Selenium 3.9 mcg/g Barium 0.98 Thallium 0.098 Bismuth 0.098 mcgig ?Analysis by Inductively Coupled PlasmaIMass SpectrometryUCP/M S) for: . i i Li i Mercury 0.78 Acode 2893H - Acute Poisoning Panel. Hair -Analysis by inductively Coupled Plasmanass for: 2 . 'l . 'l Antimony 0.20 Lead 1.0 Arsenic 1.0 Selenium 4.0 Barium 1.0 Thallium 0.10 mcgig Bismuth 0.10 -Analysis by Inductively Coupled PlasmaIMass for: Mercury 0.76 NMS v.18.0 NMS Labs . CONFIDENTIAL 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, F-ABFT. DABCC-TC, Laboratory Director Supplemental Report Patient Name PADDOCK (TENT), STEPHEN C. Patient ID 17-10064 Report Issued 12/11/2017 11.02 Chain 17314232 Last Report Issued 10/24/2017 12:03 Age 64 DOB Not Given To: 10294 Gender Male Clark County Coroner's Office Workorder NEIHEBE Attn: David Mills 1704 Pinto Lane Las Vegas, NV 89106 Page 1 0f 10 Positive Findings: Command Beam; Units MW Betahydroxybutyric Acid - 21 001 - Peripheral Blood Arsenic 12 001 - Peripheral Blood Bismuth 0.92 mcgiL 001 - Peripheral Blood Mercury 37 mcgiL 001 - Peripheral Blood Selenium 290 mcgiL 001 - Peripheral Blood Antimony 9.6 001 - Peripheral Blood Lead 7.3 001 - Peripheral Blood Caffeine Positive 001 - Peripheral Blood Theobromine Positive 001 - Peripheral Blood Chlorpheniramine 13 002 - Peripheral Blood Creatinine (Vitreous Fluid) 1.6 005 - Vitreous Fluid Sodium (Vitreous Fluid) 127 mmolfL 005 - Vitreous Fluid Potassium (Vitreous Fluid) >20 mmolfL 005 - Vitreous Fluid Chloride (Vitreous Fluid) 112 mmoliL 005 - Vitreous Fluid Urea Nitrogen (Vitreous Fluid) 35 005 - Vitreous Fluid Nordiazepam 42 006 - Urine Oxazepam 170 006 - Urine Temazepam 140 006 - Urine See Detailed Findings section for additional information Disclaimer: Specimens for elemental testing should be collected in certi?ed metal-free containers. Elevated results for elemental testing may be caused by environmental contamination at the time of Specimen collection and should be interpreted accordingly. It is recommended that unexpected elevated results be veri?ed by testing another specimen. Testing Requested: Analysis Code Description 9142B Cyanide Screen, Blood 26938 MetalslMetalloids Acute Poisoning Panel, Blood 04203 Betahydroxybutyric Acid, Blood 8054B Postmortem, Expanded with NPS, Blood (Forensic) 1919FL Electrolytes and Glucose Panel (Vitreous), Fluid (Forensic) 8092B Postmortem, Expert, Blood (Forensic) 8051U Postmortem, Basic, Urine (Forensic) Specimens Received: NMS V.18.0 CONFIDENTIAL Workorder 17314232 Chah1 17314232 Patient ID 17-10064 Page 2 of 10 ID TubeiContainer Volume! Collection Matrix Source Miscellaneous Mass DatelTime Information 001 Gray Top Tube 10.65 mL 10(0612017 19:00 Peripheral Blood 002 Gray Top Tube 9.65 mL 10706/2017 19:00 Peripheral Blood 003 Gray Top Tube 9.65 mL 100612017 19100 Heart Blood 004 Gray Top Tube 5 mL 10106/2017 19:00 Heart Blood 005 Red Top Tube 1 mL 10l06i2017 19:00 Vitreous Fluid 006 Green Vial 10.65 mL 1010612017 19:00 Urine 007 Green Vial 6.75 mL 10i0672017 19:00 Bile 008 White Plastic Container 32.47 9 10206201? 19:00 Liver Tissue 009 White Plastic Container 24.92 10(06i2017 19:00 Brain Tissue 010 White Plastic Container 22.08 9 101061201 7 19:00 Muscle Tissue SKELETAL MUSCLE 011 White Plastic Container 28 9 1010612017 19:00 Gastric Fluid THIN LIGHT BROWN FLUID, pH=4 All sample volumesfweights are approximations. Specimens received on 10110r201'i?. Detailed Findings: Rm. Analysis and Comments Result Units Limit . Specimen Source Analysis By Betahydroxybutyric Acid 21 20 001 Peripheral Blood GCIMS Arsenic - 12 mcgr?L 5.0 001 - Peripheral Blood ICPIMS Bismuth 0.92 meg/L 0.50 001 - Peripheral Blood Mercury 37 3.0 001 - Peripheral Blood ICPIMS Selenium 290 mcgr?L 20 001 - Peripheral Blood Result verified by repeat analysis. Antimony 9.6 mcgiL 1.0 001 Peripheral Blood ICPIMS Lead 7.3 0.50 001 - Peripheral Blood ICPIMS Results verified by repeat analysis. Caffeine Positive megrmL 0.10 001 - Peripheral Blood ecrus Theobromine Positive 5.0 001 - Peripheral Blood GCIMS Chlorpheniramine 13 10 002 - Peripheral Blood Creatinine (Vitreous Fluid) 1.6 0.050 005 - Vitreous Fluid Calorimetry Sodium (Vitreous Fluid) 127 mmoliL 80 005 Vitreous Fluid Chemistry Analyzer Potassium (Vitreous Fluid) >20 mmollL 1.0 005 - Vitreous Fluid Chemistry Analyzer Chloride (Vitreous Fluid) 112 mmoli?L 70 005 - Vitreous Fluid Chemistry Analyzer Glucose (Vitreous Fluid) None Detected mg/dL 35 005 Vitreous Fluid Chemistry Analyzer Urea Nitrogen (Vitreous 35 3.0 005 - Vitreous Fluid Chemistry Fluid) Analyzer Nordiazepam 42 20 006 - Urine LC-M SIMS Oxazepam 170 20 006 Urine LC-IVISIMS Temazepam 140 ngimL 20 006 - Urine NMS v.18.0 CONFIDENTIAL Workorder 17314232 Chain 17314232 Patient ID 17-10064 Page 3 of 10 Detailed Findings: Rpt. Analysis and Comments Result Units Limit Specimen Source Analysis By 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: 1. Antimony - Peripheral Blood: Pentavalent antimony compounds are used in medicine as parasiticides. Additionally, antimony has been used in the production of pigments, alloys, and flame-retardants. Typical normal antimony concentrations in blood are less than 5 mcgiL. Patients administered stibogluconate sodium for leishmaniasis developed an average peak blood antimony concentration of 8800 mcgiL at 1.3 hr post-intramuscular dosing. NMS Labs has demonstrated that certain collection tubes can artifactually increase measured antimony concentrations rendering reported concentrations difficult to interpret. 2. Arsenic Peripheral Blood: Arsenic is a metallic element. it is prevalent in the earth's crust and can therefore be found in numerous environmentally-related sources, well water, shell?sh and soil. individuals who are exposed to these sources may have acutely or chronically elevated body burdens of arsenic. Arsenic exists in numerous chemical compounds as well as several chemical forms. Not all arsenical compounds are equal in toxicity. in unexposed normal individuals, arsenic concentrations in blood are Usually less than 10 but may be higher after seafood consumption. Other potential factors causing increased concentrations of arsenic include consumption of well-water with high arsenic content. in reported poisoning fatalities, a range of 600 - 9300 mcgiL blood (mean, 3300 mcgiL) has been reported. 3. Betahydroxybutyric Acid Betahydroxybutyrate; Ketone) - Peripheral Blood: Ketoacidosis related to diabetes or alcoholism can be an important factor in determining cause of death. The primary ketone body produced through ketogenesis is acetoacetate. Acetoacetate may then break down to form acetone and betahydroxybutyric acid. Ketogenic diets and other means of clinically induced, mild ketogenesis have been applied to the treatment of Epilepsy, Alzheimer?s disease and other disorders. in blood, betahydroxybutyric acid concentrations below 50 are considered normal while concentrations greater than 250 mcgimL are indicative of ketoacidosis. Ketoacidosis may produce polyuria, polydipsia, weight loss, dizziness. nausea, vomiting. confusion, stupor and coma. There may be an odor of acetone on the breath. Severe ketoacidosis may result in death if left untreated. 4. Bismuth - Peripheral Blood: Bismuth is used industrially to produce low-melting alloys, pigments and chemical additives. It is also used therapeutically as astringents, antacids, skin powders, radio-opaque agents and to treat ulcers, indigestion. diarrhea, syphilis and warts. Normal blood concentrations are usually less than 1.0 The primary result of bismuth overdosage is renal damage, but encephalopathy and peripheral neuropathy can also occur. Other signs of bismuth toxicity may include discoloration of the tongue. gums or skin, salivation, nausea, vomiting, abdominal pain, tremors, ataxia, memory loss, mental confusion, and seizures. Toxic bismuth blood concentrations arising from the chronic oral use of bismuth subnitrate ranged from 50 to 1600 mcg/L. Two death cases associated with bismuth toxicity reported bismuth blood concentrations in excess of 1000 5. Caffeine (No-Doz) - Peripheral Blood: Caffeine is a xanthine-derived central nervous system stimulant. it also produces diuresis and cardiac and respiratory stimulation. it can be readily found in such items as coffee. tea, soft drinks and chocolate. The reported qualitative result for this substance is indicative of a finding commonly seen following typical use and is usually not toxicologically signi?cant. If con?rmation testing is required please contact the laboratory. 6. Chloride (Vitreous Fluid) - Vitreous Fluid: Normal: 105 - 135 mmollL NMS v.18.0 CONFIDENTIAL Workorder 17314232 5 Chain 17314232 Patient ID 17-10064 mi Page 4 of 10 Reference Comments: 7. Chlorpheniramine (Chlor?Trimeton?) - Peripheral Blood: Chlorpheniramine is a potent antihistamine that has been used alone and in combination with other cold relief medications. both prescribed and sold over?the-counter. it may also be provided by injection or as a nasal spray. Oral doses usually range from 4 to 12 mg with both normal and controlled release formulations available. Peak concentrations of 10 ngimL chlorpheniramine were obtained 3 hours following single oral administration of 8 mg. Toxic effects have been reported in adults at concentrations greater than 400 ng/mL (serum) and in infants at-concentrations above 65 ng/mL (postmortem blood). The blood to plasma ratio of chlorpheniramine is approximately 1.2. Common adverse effects include sedation. dizziness. nausea and dry mouth. Signs and of acute chlorpheniramine toxicity include tremor. seizures. disorientation. loss of consciousness, fever. respiratory depression and cardiac 8. Creatinine (Vitreous Fluid) - Vitreous Fluid: Normal: 06 - 1.3 mgidl. 9. Glucose (Vitreous Fluid) - Vitreous Fluid:_ Normal: <200 mg/dL Postmortem vitreous glucose concentrations >200 mgidL are associated with Since postmortem vitreous glucose concentrations decline rapidly after death both in vivo and in vitro. care should be taken in the interpretation of results. Stability of vitreous glucose for up to 30 days has been noted by NMS Labs when specimens are maintained frozen . 10. Lead - Peripheral Blood: Lead is an environmental toxicant that may deleteriously affect the nervous. hematopoietic. endocrine, renal. and reproductive systems. In the general population. the meter exposure routes are inhalation of lead dusts and fumes and ingestion of lead from contaminated hands and food stuffs. Drinking water may also contribute to the total body burden. in children. paint chips from lead based paints may be a source of exposure. According to the US. Centers for Disease Control and Prevention (CDC). the blood lead reference level for adults is less than 5 mcg/dL. For workplace information. refer to the US. Occupational Safety and Health Administration (OSHA) website. In young children. lead exposure is a particular hazard because children absorb lead at a higher rate than do adults. and because the developing nervous system of children are more susceptible to the effect of lead. The US. Centers for Disease Control and Prevention (CDC) reference value based on the 97.5th percentile of the blood lead level distribution in U..S. children aged 1-5 years is 5 mcgidL. 11. Mercury - Peripheral Blood: Mercury is a trace element, which is widely used. in industrial and agricultural products and processes. and in medicine and dentistry. Dietary intake of mercury in man ranges from approximately 1 to 30 per day. industrial exposure to mercury occurs through inhalation or by dermal absorption. Mercury exposure can be due to elemental. inorganic and organic forms of the element. Total blood mercury levels of up to 6 have been measured in persons with low fish consumption and up to 200 mcg/L blood in individuals consuming large quantities of predatory marine fish. Typically. 'normal' mercury blood concentrations are less than 10 mcgiL. Postmortem total blood mercury concentrations ranging from 20 - 110 mcgiL with an average of 60 mcgi?L have been reported in a Japanese population. The average oral lethal dose of inorganic mercury salts is approximately 1 gram. Toxic effects of inorganic mercury poisoning include gastroenteritis and tubular necrosis leading to renal failure. Elemental mercury is most dangerous when volatilized leading to pulmonary and CNS effects. Postmortem blood mercury concentrations can vary according to the form of mercury and the time since exposure. in two cases of inorganic mercury poisoning. blood concentrations of 1700 and 2100 mcg/L were measured. Blood concentrations of mercury after both fatal and non-fatai elemental mercury poisoning usually exceed 200 mcgiL. NMS V.18.0 CONFIDENTIAL Workorder 17314232 MS Chain 17314232 Patient ID 17-10064 Page 5 of 10 Reference Comments: 12. Nordiazepam (Chlordiazepoxide Metabolite) Urine: Nordiazepam is a pharmacologically active metabolite of several benzodiazepine agents. diazepam (Valium?). Nordiazepam is also the major active entity in clorazepate (Tranxene?). a benzodiazepine agent used for agitation. seizures and anxiety. The action of this compound is based on its CNS-depressant activity. 13. Oxazepam (Serax?) Urine: Oxazepam is a benzodiazepine. It is frequently seen as the metabolite of diazepam and other benzodiazepines; however. it is pharmacologically active and may be given as the primary medication for the short?term relief of of anxiety and in the management of alcohol withdrawal. Signs associated with overdose with oxazepam are similar to those observed with other benzodiazepines. drowsiness. lethargy, respiratory depression and coma. 14. Potassium (Vitreous Fluid) - Vitreous Fiuid: Normal: <15 mmol/L Quantitative results for Potassium will be affected if performed on gray top tubes since these collection tubes contain potassium oxalate. 15. Selenium Peripheral Blood: Selenium is an essential trace metal. It is also used in various industries. electronic semiconductors and rubber. in medicinals. selenium can be found in shampoos and dietary supplements. The compound exists in elemental. organic. and inorganic forms. Reported reference concentrations of selenium in blood of normal individuals range from 60 - 230 mcg/L. These concentrations are diet dependent. Adverse effects to selenium have included irritation of the skin and mucous membranes, nausea, diarrhea, fatigue, alopecia. joint pain. abdominal pain, tremor. corrosive gastritis. cyanosis. coma. and death. 15. Sodium (Vitreous Fluid) - Vitreous Fluid: Normal: 135 - 150 mmoiiL Quantitative results for sodium will be affected if performed on gray top tubes since these collection tubes contain sodium ?uoride. 17. Temazepam (Diazepam Metabolite; Normison?) - Urine: Temazepam: is a benzodiazepine hypnotic agent used in the short-term relief of insomnia. Its major metabolite. oxazepam. is also a pharmacologicaily active depressant. Temazepam is also a metabolite of diazepam (Valium?). The usual adult dosage of temazepam is 30 mg, however. 15 mg may be adequate. In overdose. temazepam shares the same clinically observed signs and as other benzodiazepines. sedation. lethargy. loss of consciousness and respiratory depression. Alcohol greatly enhances the activity of benzodiazepines. 18. Theobromine (Xantheose) - Peripheral Blood: Theobromine is a alkaloid found in tea and cocoa products and has been reported to pass into the breast milk of nursing mothers. Theobromine has the general properties of the xanthines. including diuresis and smooth muscle stimulation. The reported qualitative result for this substance was based upon a single analysis only. If con?rmation testing is required please contact the laboratory. 19. Urea Nitrogen (Vitreous Fluid) - Vitreous Fluid: Normal: 8 - 20 mgde Sample Comments: 001 Physiciaanathologist Name: DR. GAVIN Unless alternate arrangements are made by you. the remainder of the submitted specimens will be discarded thirteen (13) months from the date of this report; and generated data will be discarded five (5) years from the date the analyses were performed. Chain of custody documentation has been maintained for the analyses performed by NMS Labs. NMS v.18.0 CONFIDENTIAL Workorder 17314232 Chain 17314232 Patient lD 17-10064 Page 6 of 10 Workorder 17314232 was electronically signed on 12/11/2017 09:12 by: Laura M. Labay, F-ABFT, DABCC-TC Forensic Toxicologist 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. lfthe compound is listed as None Detected. it is not present above the Reporting Limit. Piease refer to the Positive Findings section of the report for those compounds that were identified as being present. Acode 042GB - Betahydroxybutyric Acid. Blood Peripheral Blood ?Ana ysis by Gas Chromatographyliviass Spectrometry S) for: command BM mm Betahydroxybutyric Acid 20 mog/mL Acode 1919FL - Electrolytes and Glucose Panel (Vitreous). Fluid (Forensic) - Vitreous Fluid 4Analysis by Chemistry Analyzer for: Chloride (Vitreous Fluid) 70 mmolfL Sodium (Vitreous Fluid) 80 mmollL Glucose (Vitreous Fluid) 35 Urea Nitrogen (Vitreous Fluid) 3.0 mgz'dL Potassium (Vitreous Fluid) 1.0 mmoliL -Analysis by Colorimetry (C) for: Creatinine (Vitreous Fluid) 0.050 Acode 26938 Metaleretalloids Acute Poisoning Panel, Blood - Peripheral Blood -Analysis by Inductively Coupled Plasmall?viass SpectrometryUCP/MS) for: mm 3m .0201me 3mm: Arsenic 5.0 ?Analysis by Inductively Coupled Plasma/Mass SpectrometryUCP/MS) for: Bismuth 0.50 -Analysis by inductively Coupled PlasmarMass SpectrometryUCPiMS) for: Compound 3mm Command Bot. Limit Mercury 3.0 mogKL -Analysis by inductively Coupled Plasmanass SpectrometryUCPiMS) for: NMS V.18.0 CONFIDENTIAL Workorder 17314232 8 Chain 17314232 Patient ID 17-10064 [:274m8 B?j Page 7 of 10 Analysis Summary and Reporting Limits: i Compound Selenium 20 -Analysis by Inductively Coupled Plasma/Mass for: 99010?03104 Commd Thallium 0.50 -Analysis by Inductively Coupled Plasmanass for: Compound 13mm Compound Antimony 1.0 -Analysis by Inductively Coupled Plasmanass Spectrometry?CP/MS) for: Lead 0.50 Aoode 50012B - Benzodiazepines Confirmation. Blood (Forensic) - Peripheral Blood -Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry (LC- MSIMS) for: T-Amino Clonazepam 5.0 ng/mL Alpha-Hydroxyalprazolam 5.0 ng/mL Alprazolam 5.0 ngme Chlordiazepoxide 20 Clobazam 20 ngme Clonazepam 2.0 5.0 Diazepam 20 ngme Estazolam 5.0 Acode 50012U Benzodiazepines Confirmation. Urine (Forensic) -Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry (LC- for: . im' 1?Hydroxymidazolam 5.0 ngme Y-Amino Clonazepam 5.0 ng/mL Alpha?Hydroxyalprazolam 10 ng/mL .Alprazolam 5.0 ng/mL Chlordiazepoxide 20 Clobazam 20 5.0 Diazepam 20 ng/mL Compound Flurazepam Hydroxyethyl?urazepam Hydroxytriazolam Lorazepam Midazolam Nordiazepam Oxazepam Temazepam Triazolam 9.0mm Estazolam Hydroxytriazolam Lorazepam Nordiazepam Oxazepam Temazepam Acode 524408 - Chlorpheniramine Confirmation, Blood (Forensic) - Peripheral Blood . Limi RLii BoLLimit 2.0 ng/mL 5.0 ngimL 5.0 ngme 5.0 5.0 20 20 20 ngme 2.0 ngme 5.0 ng/mL 5.0 5.0 ngme 10 ngme 20 ngme 20 ng/mL 20 NMS V.18.0 CONFIDENTIAL Analysis Summary and Reporting Limits: -Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry (LC-MSIMS) for: 9.0mm Chlorpheniramine 10 ngImL Workorder 17314232 Chain 17314232 Patient ID 17-10064 Page 8 of 10 Comm Acode 59708 - Cannabinoids Con?rmation Panel 2 (Qualitative), Blood - Peripheral Blood -Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry for: WM 5F-AB-001 5F-ADB 5F-AMB 5F-APICA 5F-APINACA (5F-AKB-48) 8 5F-P B-22 AMB APICA APINACA (AKB-48) CUMYL-THPINACA FUB-AKB-48 I . 1.0 ngme 0.20 ngImL 0.10 1.0 2.0 0.10 ngme 0.10 ng/mL 0.10 ngme 0.20 1.0 0.10 0.20 ngImL 0.10 0.20 Acode 8051 - Postmortem, Basic. Urine (Forensic) -Analysis by Enzyme Immunoassay (EIA) for: Communist Barbiturates Benzodiazepines Cannabinoids Cocaine Metabolites Rpt. Limit 0.30 mcg/mL 50 ngImL 20 ngImL 150 ngImL -Analysis by Enzyme Immunoassay (EIA) for: Compound Amphetamines Buprenorphine I Metabolite -Analysis by Headspace Gas Chromatography (CC) for: Comm-11331 Acetone Ethanol I 'l 500 ngme 5.0 ng/mL l? 'l 5.0 10 mgIdL Compound FUB-AMB FUB-JWH-018 MA-CHMINACA MDMB-CHMINACA MMB-CHMICA MMB-CHMINACA CHMICA) MO-CHMINACA NM-2201 THJ-018 Compound Methadone! Metabolite Opiates Oxycodone I Oxymorphone Common Fentanyl (Acetyl Fentanyi MDIVIA Common lsopropanol Methanol Acode 8054B - Postmortem. Expanded with NPS. Blood (Forensic) - Peripheral Blood -Analysis by Enzyme?Linked Immunosorbent Assay (ELISA) for: . . 0.10 0.20 ng/mL 0.10 0.20 ng/mL 0.10 ngImL 0.10 ngImL 0.10 0.10 0.10 0.10 ngImL 0.10 0.10 ngI'mL 0.10 Bot?Limb 300 ng/mL 300 100 ngI'mL 25 I . 2.0 300 ngme I . 5.0 mgIdL 5.0 mgIdL NMS V.18.0 CONFIDENTIAL Workorder 17314232 8 Chain 17314232 Patient ID 17-10064 ?3?ng Page 9 of 10 Analysis Summary and Reporting Limits: Qompgund Bot. Li it 031mm Rpt. Limit Barbiturates 0.040 mcg/mL Salicylates 120 Cannabinoids 10 -Analysis by Headspace Gas Chromatography (60) for: ngpgund Bpt. Limit - ngpgund Bpj. Limit Acetone 5.0 lsopropanol 5.0 mgidL Ethanol 10 mgl'dL Methanol 5.0 -Analysis by High Performance Liquid ChromatcgraphyiTandemMass Spectrometry QTRAP (LC-MSIMS QTRAP) for: compound Emmi?it 9.0mm Li i 5F-AB-001 1.0 ng/mL 0.10 5F-ADB 0.20 FUB-AKB-48 0.20 ngme 5F-ADB-PINACA 1.0 ngme FUB-AMB 0.10 ngme 1.0 ng/mL 0.20 ng/mL 0.10 ngme 0.10 ngme 5F-APICA 1.0 ngme JWH-018 0.10 ngl?mL (SHAKE-48) 2.0 ng/mL 0.10 ng/mL 5F-MN-18 0.10 ng/ml. MA-CHMINACA 0.20 ngimL 0.10 ngl?mL 0.10 AB-CHMINACA 1.0 ngme 0.10 1.0 ngimL MDMB-FUBINACA 0.10 ng/mL AB-PINACA 0.20 MMB-CHMICA 0.10 ngl?mL ADB-CHMINACA 0.10 ngimL MMB-CHMINACA 0.10 ng/mL ADB-FUBINACA 1.0 ngImL CHMICA) ADB-PINACA 0?20 ngimL MO-CHMINACA 0.10 ngimL ADBECA 1.0 NM-2201 0.10 AMI-2201 0.10 ngimL 0-10 AMB 0'10 ngl?mL PX2 0.20 ngme APICA 0.20 ng/mL THJ-018 0.10 ngimL APINACA (AKB-48) 1.0 ng/mL ??4207 0-10 ?g?mL APP-CHMINACA (PM) 0.20 ngimL ?-20 0.10 ng/mL 0-20 ?g?ml? EG-2201 0.20 -Analysis by High Performance Liquid ChromatographyITime of Flight-Mass Spectrometry for: The following is a general list of compound classes included in this screen. The detection of any specific analyte is concentration-dependent. Note. not all known analytes in each speci?ed compound class are included. Some specific analytes outside these classes are also included. For a detailed list of all analytes and reporting limits, please contact NMS Labs. Amphetamines. Anticonyulsants. Antidepressants. Antihistamines. Agents. Benzodiazepines, CNS Stimulants. Cocaine and Metabolites. Hallucinogens. Hypnosedatives. Hypoglycemics. Muscle Relaxants. Non- Stercidal Anti-Inflammatory Agents. Opiates and Opioids. Acode 80928 - Postmortem. Expert. Blood (Forensic) - Peripheral Blood NMS V.18.0 CONFIDENTIAL Workorder 17314232 Chain 17314232 Patient ID 17-10064 Page 10 of10 Analysis Summary and Reporting Limits: ?Analysis by Enzyme-Linked lmmunosorbent Assay (ELISA) for: Commas 3mm Compound Lim' Benzodiazepines 100 ng/mL Opiates 20 ngimL Buprenorphine Metabolite 0.50 ng/mL Oxycodone i Oxymorphone 10 ngImL Cannabinoids 10 ngme Salicylates 120 mcgimL Cocaine I Metabolites 20 -Analysis by Gas Chromatography/illness Spectrometry (GCIM S) for: Anesthetics, Anticoagulant Agents. Antifungal Agents. Antihypertensive Agents, Anxiolytics (Benzodiazepine and others), Hypnosedatives (Barbiturates. Non-Benzodiazepine Hypnotics. and others) and Non-Steroidal Anti-inflammatory Agents (excluding Salicylate). -Analysis by Gas Chromatography/Mass Spectrometry (GCIMS) for: The following is a general list of compound classes included in the Gas Chromatographic screen. The detection of any particular compound is concentration-dependent. Please note that not all known compounds included in each specified class or heading are included. Some specific compounds outside these classes are also included. For a detailed list of all compounds and reporting limits included in this screen. please contact NMS Labs. Amphetamines. Analgesics (opioid and non-opioid). Anorectics. Anticholinergic Agents, Anticonvulsant Agents, Antidepressants. Antiemetic Agents. Antihistamines, Antiparkinsonian Agents, Agents, Antitussive Agents. Antiviral Agents. Calcium Channel Blocking Agents, Cardiovascular Agents (non-digitalis). Local Anesthetics Agents. Muscle Relaxants and Stimulants (Amphetamine-like and others). -Anaiysis by Headspace Gas Chromatography (60) for: 9.0mm 9.0mm Acetone 5.0 mgidL Isopropanol 5.0 mgde Ethanol ?10 mgidL Methanol 5.0 Acode 9142B Cyanide Screen, Blood - Peripheral Blood ?Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry (LC-MSIMS) for: Compound 3m Compound Rpt. Limit Cyanide 0.10 mcgimL NMS V.18.0 February 5, 2018 Dr. Lisa Gavin Clark County Coroner?s Of?ce 1704- Pinto Lane Las Vegas, NV 89106 Re: NMS file nos: 17314-232 and 17322918 Dear Dr. Gavin: You have requested that I provide a report discussing my opinions and conclusions regarding Mr. Stephen Paddock?s toxicology results as detailed in two reports issued by NMS Labs. Speci?cally, you would like to know if substances found in Mr. Paddock's biological samples may be the reason for the production of violent and aggressive behavior. In order to comply with your request, I have reviewed the following: Toxicology reports for Mr. Stephen Paddock issued by NMS Labs: 0 17314232 (initial report dated 10/24/2017; supplemental report dated 12/11 /2017] 0 17322918 [dated 10/30f2017] From my review of these two reports. Mr. Paddock?s toxicology testing showed the presence several of substances. The positive findings from both reports, with the exception of the vitreous ?ndings, are shown in the table below. ANALYTE RESULT Antimony 9.6 mcg/ in Peripheral Blood 0.49 mcg/ in Scalp Hair Arsenic 12 meg] in Peripheral Blood Barium 1.6 meg/g in Scalp Hair 5.0 mcg/ in Pubic Hair Bismuth 0.92 meg/L in Peripheral Blood 0.15 meg/g in Pubic Hair Lead 7.3 mcg/dL in Peripheral Blood 1.3 meg/g in Scalp Hair Mercury 37 mcg/ in Peripheral Blood 4.7 meg/g in Scalp Hair 3.6 meg! in Pubic Hair Selenium 290 mcg/ in Peripheral Blood Caffeine Positive in Peripheral Blood Theobromine Positive in Peripheral Blood Chlorpheniramine 13 rig/ml. in Peripheral Blood Nordiazepam 42 ng/mL in Urine Oxazepam 170 ng/mL in Urine Temazepam 140 ng/mL in Urine Betahydroxybutyric Acid 21 meg/mL in Peri pberal Blood 3701 Welsh Road, Willow Grove, 19090 800.522.6671 215.657.2972 My opinions about the possibility regarding the manifestation of violent and aggressive behavior are detailed as follows: 1. Elemental analysis was performed in blood and hair. Blood is used to determine circulating concentrations at the time of its collection. In postmortem cases, it theoretically represents what was present at the time of death. Hair is used to determine if there has been any chronic exposure to a substance. Because elements are ubiquitous, the potential for environmental contamination during sample collection and from storage containers needs to be considered before attributing the results to the tested samples. The findings show concentrations that are either consistent with normal amounts for barium in scalp hair, bismuth in blood, and lead in scalp hair or are above normal for antimony in blood and hair, arsenic in blood, lead in blood, mercury in blood and hair, and selenium in blood. Arsenic, antimony and selenium even at elevated concentrations are not known to be associated with the production of violent and aggressive behavior. Lead has been linked to cognitive effects, however, for lead at the reported concentration of 7.3 mcg/ml. in adults there is insufficient evidence that this concentration will cause violent and aggressive behavior Clinical manifestations of mercury toxicity are dependent upon several variables such as route of exposure, chemical form, dosage received, and duration of exposure. Some signs and associated with its toxicity may include bronchial irritation from mercury vapor exposure. gastroenteritis from inorganic mercury exposure, paresthesia, ataxia, and hearing loss from methyl and for ethyl mercury exposure, and tubular necrosis in the kidney from inorganic mercury and ethyl mercury exposure important considerations for this case are that the mercury has not been analytically differentiated, and that arsenic, selenium and mercury concentrations can be elevated as a consequence of dietary (seafood) consumption and/or environmental exposures. in samples collected at autopsy from a normal Japanese population, the arsenic concentration in blood averaged 56 mcg/L with a range of 50- 60 meg/L, and the total mercury concentration in blood averaged 59 meg/L with a range of 16?110 mcg/ There is also indication that the presence of selenium may have some beneficial effects on the mitigation of mercury toxicity My opinion is that if Mr. Paddock was experiencing toxicity to any of the identified elements he would have experienced a constellation of Speci?cally related to that element's known toxic pro?le. Caffeine is a commonly used central nervous system stimulant. It is found in beverages such as coffee or soda, and some food products such as chocolate. It can promote physiological responses such as diuresis, and increased heart and respiratory rates. Theobromine is an ingredient in chocolate and a caffeine metabolite. The reported qualitative findings in blood for these two substances are not consistent with excessive use. Chlorpheniramine is an antihistamine. Common adverse effects include sedation and dizziness. The reported concentration in blood (13 ng/mL) is consistent with therapeutic use. Nordiazepam, oxazepam, and temazepam are benzodiazepines. Nordiazepam is a benzodiazepine metabolite, and oxazepam and temazepam may be present as parent drugs and/or metabolites. Benzodiazepines are prescribed to treat a wide range of conditions including, but not limited to, anxiety, insomnia, and agitation. The finding of these substances in urine and not in blood show that Mr. Paddock had previously used or was exposed to this drug class. Substances present in the urine do not have any pharmacological activity. 5. Betahydroxybutyric Acid is a ketone body. This endogenous substance is used as a biological marker for ketoacidosis. Concentrations less than 50 meg/ml. are considered normal and, therefore, the reported concentration in blood [21 mcg/mL) is not consistent with an above normal concentration. if you have any questions regarding this report please do not hesitate to contact me. Also, in the event information becomes available, that may affect the above opinions and conclusions, please forward such to me for evaluation. r' ,r'f H. If . Laura M. Labay, F-ABFT, DAB Forensic Toxicologist 4 a ,a ?1?va REFERENC gram 1. monograph on health effects of low-level lead. NTP Monogr. 2012 sir-148. 2. Clarkson TW, Magos L, Myers The toxicology of mercury--current exposures and clinical manifestations. Engl Med. 2003 Oct 3. Sumino K, Hayakawa K, Shibata T, Kitamura S. Heavy metals in normal Japanese tissues. Amounts of 15 heavy metals in 30 subjects. Arch Environ Health. 1975 4. Spiller HA. Rethinking mercury: the role of selenium in the pathophysiology of mercury toxicity. Ciin Toxicol (Walla). 2017 Nov 10:1-14.