Alameda County Sheriff's Office Gregory J. Ahern, Sheriff/ Coroner Coroner's Bureau, 2901 Peralta Oaks Ct, Oakland, CA 94605 (510) 382-3000 I (510) 382-3033 (fax) Coroner Investigator's Report 0 u. z ...I 0 TENTATIVE ID REPORTED BY REPORTED BY PHONE NO. REPORTING AGENCY REFERENCE NUMBER K. Hoodye #2190 (510) 667-3646 Alameda County Sheriffs Office-EIS 15-021753 BONARDI, John Jeffrey INVESTIGATOR Jason Henshaw HGT z w 72 WGT I 261 I 2015-03669 Removal Case 12/10/2015 22:20 DATE OF BIRTH AGE GENDER Male 5/5/1967 48 Years EYE COLOR HAIR COLOR OCCUPATION Brown Black Supervisor 12/10/2015 21:24 � � I CASE TYPE CASE NUMBER UNIDENTIFIED L., CALL DATE AND TIME DATE AND TIME OF DEATH I- .. , NAME OF DECEASED (LAST, FIRST MIDDLE) I RACE VET? MARITAL STATUS I EMPLOYER Never Married I C w w C Preliminary Summary LOCATION OF DEATH LOD TYPE Santa Rita Jail Other ADDRESS (STREET, CITY, STATE, ZIP) 5325 Broder Blvd Dublin CA 94568 :c I- w C Manner Suicide Cause A HANGING I Alameda Death Certificate Signed By: A. Gogna, Deputy Coroner Cause B Interval Minutes Interval Cause C Interval Cause D Interval Other Significant Conditions z COUNTY none LEGAL NEXT OF KIN RELATIONSHIP TELEPHONE NO. NOTIFIED BY METHOD DATE AND TIME IDENTIFICATION METHOD DATE AND TIME j:: j:: z LOCATION OF INCIDENT I- z w C z AT WORK Countv Jail ADDRESS (STREET, CITY, STATE, ZIP) COUNTY 5325 Broder Blvd Dublin CA 94568 Alameda INVESTIGATING AGENCY DATE AND TIME OF INCIDENT 12/10/201:20:55 INV AGENCY PHONE NUMBER OFFICER Alameda County Sheriff's Office a. K. Hoodye FUNERAL HOME BODY RELEASED TO FUNERAL HOME ON Tri City Cremation 12/14/2015 Full Autopsy Partial Autopsy I� - � Inspection .. Record Review ,.... -� -� Inspection w/Specimen '-- Date Printed 16: 15 EXAM BY Judy Melinek Saturday, January 09, 2016 L., ?f Alameda County Sheriffs Office 7' Gregory J. Ahern, Sheriff Coroner Coroner's Bureau, 2901 Peralta Oaks Ct, Oakland, CA 94605 (510) 382-3000 (510) 382?3033 (fax) Investigator Narrative Decadent: Jjoh Jeffrey Case Number: 2015403669 Investigator: Jason Henshaw First Call Information: On December 10, 2015, about 2210 hours, I (Henshaw) received a tele hone call from Deputy K. Hoodye, reporting the suicide death of inmate John Bonardi (PFN at Santa Rita Jail in Dublin. Deputy Hoodye told me, about 2050 hours, he found Bonardi in a cell, with a bed sheet wrapped around his neck and the other end attached to the top bunk. Deputy Hoodye cut Bonardi down and requested ?code medicaii response. The Alameda County FireDepartment responded and? performed fife- saving measures which were unsuccessful and death was pronounced, at 2124 hours. Deputy K. Hoodye said he last saw Bonardi alive at 2042 hours. 886) Medical Summary: While on scene, I (Henshaw) spoke with the Santa Rita Watch Lieutenant, V. Fox, who told me he had talked with the on call Criminal Justice Mental Health representative and was told Bonardi did not have any previous suicide attempts or suicidal tendencies. Description of the Death/ Injury Scene: Bonardi was pronounced dead at Santa Rita Jail, located at 5325 Broder in Dublin. He was in Housing Unit #23, which was classi?ed as minimum security/protective custody. Bonardi Was the sole occupant of Cell A34. Bonardi was found by Deputy Hoodye, with a bed sheet wrapped around his neck and the other end attached to the top bunk. (JDH1886) Body Identi?cation: I (Henshaw) searched- the Censolidat?ed Records Information Management System (CRIMS) and located a record for Bonardi I compared the photograph and general descriptors from CRIMS to the decedent and they appeared to be a match. (JDH1886) On December 12, 2015', 1(Henshaw) received a fax from Central Identi?cation Bureau (CIB) for a ?ngerprint comparison of John Jeffrey Bonardi. The comparison of ?nierprints from the decedent matched the ?ngerprints on ?le for Personal File Number (PFN) ssociated with the name John Jeffrey Bonardi on ?le with the Alameda County Sheriff?s Of?ce. 886) Next of Kin Investigation: On Friday, December 1 1, 2015, Depu Bordi searched for Bonardi?s famil in Accurint, (a search tool used in locating family) and located a_and who were listed as relatives. About 0715 hours, Depui Bordi and I (Lorenzana) arrived a 0 make the noti?cation to but no one answered the door. A card was left at the door so he could contact us. 2 Alameda County Sheriff's Office Gregory J. Ahern, Sheriff/ Coroner Coroner's Bureau, 2901 Peralta Oaks Ct., Oakland, CA 94605 (510) 382-3000 I (510) 382-3033 (fax) We then went to residence located at We met who ·identified ·herselfas Bonardi's sister. said Bonardi was never married.andhis parents were deceased. He did have 2 adult children, and said had Autism and wouJ,q not be ahle t9' 11,awble airangemen.t,s, was bis step�ctaughter whom b:� tai,seq since she was a child and she considered Bonardi to be her father, and Bonardi considered as his daughter. provided contact information but asked that we not call her, as she wanted to notify her of the death. We explained the Coroner's involvement to as well as the need to contact a mortuary as soon as possible. (RLl 702) Other Agency Repo1is: Alameda County Sheriffs Office Deputy K. Hoodye wrote report #15-021753, documenting the incident. I received the report, reviewed it and placed a copy in the case file. The information from the report was accurate with the information already provided to me. (JDHl 886) Prope1iy and Evidence: I (Henshaw) issued Coroner's receipt #36337 to Deputy K. Hoodye for Bonardi's body and personal property. (JDHl 886) Coroners Fees: There are body removal and body preparation fees totaling $321 associated with this case. {)n December 28, 2015, all Coroner's fees were paid in fu'U. (1DPI1'886) Investigative Details: On December 10, 2015, about 2308 hours, Deputy Unubun and I (Henshaw) arrived at Santa Rita Jail, Housing Unit 23. We were met by Deputy K. Hoodye who led us to Cell A34, where Bonardi was located. Bonardi was classified as a minimum security protective custody inmate and was the only person assigned to Cell A34. I saw Bonardi lying in a supine position on the floor of the cell with his feet towards the door. Bonardi's cell was untidy, but I did not see any signs ofa struggle. I did a limited external visual exam and noticed Bonardi's face and chest area were purple in color. Rigor and lividity were not present. I noticed slight abrasions on Bonardi's neck, but no oth!;lr visible trauma was noticed. On the top bunk, I saw a bed sheet tied to a blanket. The blanket was draped behind the top bunk with the sheet hanging in front of the bunk. Deputy Hoodye told me he found Bonardi in a seated position on the floor, with his back resting on the lower bunk. The sheet from the top bunk was wrapped around Bonardi's neck and was cut when he was found unresponsive. I saw the cut section of sheet under Bonardi's body. I searched the cell and was unable to locate a letter of intent. During Deputy Hoodye's investigation, he found that Bonardi had told-other inmates Deputy Unubun took digital photographs of the scene and Bonardi was prepared for transport to the Coroner's Bureau. On December 11, 2015, about 0049 hours, Deputy Unubun and I (Henshaw) returned to the Coroner's Bureau and processed Bonardi into the morgue, which included intake photographs. The scene photographs and intake photographs were later downloaded onto a CD-R and placed in the case file. (JDH1&86) Alameda County Sheriff?s Of?ce Gregory J. Ahern, Sheriff Coroner Coroner's Bureau, 2901 Peralta Oaks CL, Oakland, CA 94605 (510) 382-3000 I (510) 382?3033 (fax) On December 11, 2015, about 1926 hours, I (Henshaw) spoke with Santa Rita Classi?cation Technician J. Hall on the telephone. Technician Hall told me Bonardi was classi?ed as a rotective custod inmate Bonardi?s classi?cation ?le noted he was On December 11, 2015, Coroner?s Pathologist Dr. . Melinek performed an autopsy of Bonardi and determined the cause of death to be hanging. On December 16, 2015, Central Valley Toxicology performed a medical screen of Bonardi?s peripheral blood sample. The screen was negative for common acid-1c, neutral or basic drugs. No ethyl alcohol detected. Findings: On January 1, 2016, I (Henshaw) reviewed this case to determine a manner of death. Based on my investigation, the autopsy protocol and the police report, I ?nd the manner of this death to be a suicide. Bonardi was the only inmate assigned to his cell and was found with a bed sheet wrapped around his neck. This ?nding was also supported by the cause of death as given by Dr. J. Melinek, hanging. Bonardi also made statements to other inmates, 8 86) Supervisor Review: On Wednesday, January 13, 2016, (Sgt. Baron) reviewed this case and found it to be complete. I concur with the ?ndings and approve this case for closure. Alameda County Sh eriffk ce Coroner's Bureau 2901 Peraita Oaks Court, Floor, Oakland, CA 946055319 DATE: FROM: TO: SUBJECT: Autopsy Coroner' (Sllfegory?). Ahern, Sh tariff Director of Emergency Services Coroner - Marshal A December 11, 2015 Judy Melinek, M.D. Case File 2015?03669 AUTOPSY PROTOCOL performed upon the body of John Jeffrey Bonardi at the 3 Bureau, 2901 Peralta Oaks Court, Oakland, California, on December 11, 2015, at 9:30 a.m. II. IV. V. AUTOPSY FINDINGS HANGING: A. FACIAL PLETHORA B. SCLERAL AND CONJUNCTIVAL PETECHIAE C. TONGUE CONTUSIONS, CONSISTENT WITH BITE MARKS. HYPERTENSIVE ARTERIOSCLEROTIC CARDIOVASCULAR DISEASE: A. 450 GRAM HEART WITH BIVENTRICULAR HYPERTROPHY (LEFT VENTRICLE 1.6 CM, RIGHT VENTRICLE 0.5 CM) B. 50% RIGHT CORONARY ARTERY ATHEROSCLEROSIS. PULMONARY ANTHRACOSIS, SLIGHT. A. CHRONIC SUBSTANCE ABUSE WITH MICRONODULAR CIRRHOSIS AND HEPATOMEGALY (2,650 GRAMS). INCIDENTAL ACCESSORY SPLEEN. OBESITY (BODY MASS INDEX 35.4 CAUSE OF DEATH: HANGING. cc: EMS Dis trict Attorney Investigations Bureau ACS O?Detention and Corrections Div. Page 2 Sheriff?Coroner . . Alameda County Body of JOHN JEFFREY BONARDI 1 PRELIMINART EXAMINATION: VThe body is identified by a Coroner?s 2 label_ affixedi at the left .great toe, ,and 51 jail. identifying - 3 bracelet at the left wrist. When first viewed, the decedent is 4 clad in 21 green T?shirt (cut); red pants (cut at the cuffs); 5 brown kxn?m: underpants; and'tnM> gray socks. Accompanying the 6 body are torn segments of a blue sheet, measuring 30 inches and 7 50 inches in length. When bunched up, these can_be compressed 8 to approximately. 1 to 1?1/2 inches in diameter. These are '9 submitted into evidence. I 10 11 EXTERNAL EXAMINATION: The body is (IE a well developed, well 12 nourished, obese' (BMI 35.4 lbs/in?) Hispanic many Awhose 13 appearance is consistent with the reported age of 48 years.? The 14 -body is cold. (refrigerated). Rigor mortis is marked -and' 15 Isymmetric. Unfixed purple livor mortis extends 'over the 16 posterior surfaces of the body, and the head and neck above_the 17 clavicles, except in areas exposed to pressure. There is 18 prominent facial plethora. .19 20' The face is otherwise unremarkable without visible injury. The 21 head is atraumatic, symmetric, and normocephalic.? The scalp is 22 intact. and atraumatic. 7 The scalr> hair is 1mxnn1 and Page 3 Sheriff?Coroner . - Alameda County Body of JOHN JEFFREY BONARDI 23 gray, straight and measures approximately 1?1/4 inches in length 24 over the crown. The eyelids are atraumatic, intact} 'and 25' unremarkable. The irides are brown. -The pupils are bilaterally 26 equal at 0.4 cm- The corneas are translucent. The sclerae_and 27 conjunctivae are remarkable for left lateral scleral peteChiae 28 and right~lower?eyelid conjunctival petechiae. There is marked -29 congestion. No petechial hemorrhages are identified on the 30 facial skin or oral mucosa. The nose and ears are not unusual. 31 The decedent is clean?shaven. The teeth are natural and in good' 32 condition. '33. 34 The neck is unremarkable. The trachea is palpable'and-midline. 35 The-thorax is well developed and symmetrical With an increased 36 anterior?posterior diameter. The abdomen is obese. The anus 37 and back ?are unremarkable. The penis 'is circumcised. The 38 testes are bilaterally_descended in the scrotum. The upper and 39 lower extremities are well developed enui symmetrical, 'without 40 absence of digits. There is no clubbing or edema. There are 41 brown, dry macules on the skin of both shins, consistent with 42 venous stasis dermatitis. 43 44 45 46 47 48 49 '5o_ Page 4 Sheriff-Coroner Alameda County Body of JOHN JEFFREY BONARDI EVIDENCE THERAPY: Evidence of acute medical therapy includes four electrocardiogram patches on the chest and calves;' defibrillator patches on the chest; a-curved plastic airway; and- a left tibial intraosseous catheter. A 1?1/4 inch curvilinear tan abrasion. is on. the Inidline chest, consistent with injury from resuscitation. I IDENTIFYING MARKS AND SCARS: A monochromatic 'professional tattoo depicting' two banners and. a shield. possibly inscribed ?Colton? ?1e25-ll? is. on the upper' outer left arm? A 1/2 inch hyperpigmented patch is at the back. left thigh. A round 1/2~inch well?healed scar is at the outer right abdomen, and another round l/2?inch well?healed scar is at the inner lower' right abdomen. near the :pelyis. A Inonochromatic professional tattoo inscribed ?Tara? is on the upper left chest. A monochromatic profesSional tattoo inscribed is on the back left ring finger. .Additional identifying marks and scars are not readily identified. EVIDENCE OF INJURY: The neck is examined and a ligature furrow is not identified, but there are'areas of creasing of the skin associated with an absence of lividity at either side ?age 5 Sheriff?Coroner . Alameda County - . Body of JOHN JEFFREY BONARDI ?79the neck, with approximately 1 inch between them. 'There are no petechiae associated_with these creases. There is also all skin crease at the back with absence of lividity at the-skin crease. On internal examination there are no-fractures of the hyoid bone, thyroid or cricoid cartilages, or vertebrae, and .there is no hemorrhage into the Soft tissue. The strap muscles of the neck are dissected in layered fashion. There are no petechial hemorrhages of? the larynx, pharynx,' or nasopharynx. There is relative facial plethora. The tongue does not protrude through the teeth; but on cut ?section, "and visible. on the surface, there are a -l.5_cm hemorrhage .at ?the right lateral tongue and a 0.5 cm hemorrhage at the left lateral tongue. B'lunt? Trauma: Two punctate red abrasions, measuring 1/8 and 1/16 inch, are at the lower right shin. There is no additional evidence of injury. INTERNAL EXAMINATION: The body is opened in the usual manner with a Y-shaped incision. No adhesions or abnormal collections of fluid are in any of the body cavities. All body organs are in normal and anatomic position. The serous surfaces are smooth Page 6 Sheriff?Coroner 109 Alameda County Body of JOHN JEFFREY BONARDI .88 and glistening. The subcutaneous _fat measures approximately 89 1-1/2 inches in maximum thickness at the level of the.umbilicus; 90 There. is (diffuse 'visceral congeStion. There ii; abundant fat 91 surrounding the organs. 92 - I 98 HEAD AND CENTRAL NERVOUS SYSTEM: Reflection of the scalp shows 94 the. usual. scattered reflection petechiae. . The calvarium is 95 intact. The brain weighs 1,530 grams. The dura mater and falx 96 cerebri are unremarkable land. the leptomeninges are thin and 97 delicate. The cerebral' hemispheres are' symmetrical. The_ 98 structures an: the base (IE the brain, including cranial nerves '99 and blood vessels, are free of abnormality. I 100 '101 Sections through the ,cerebral hemispheres reveal no lesions -102 within the cortex, subcortical white matter or deep 103 of either? hemisphere. I The cerebral ~ventricles are CHE normal 104 caliber. Sections through. the brain shun and. cerebelluHL-are 105 unremarkable. The first portion of the spinal cord, viewed 106 through the foramen magnum, is unremarkable. 107 108 NECK: The neck is dissected after the thoracoabdominal and ?cranial contents are removed. Examinatimi of the soft tissues Page'7 . Sheriff?Coroner Alameda County Body of JOHN JEFFREY BONARDI 110 of the neck, including large vessels and strap muscles, reveals 111' no abnormalities. The superficial and deep muscles of the neck 112 are firm,-red-brown, intact, and unremarkable without hemorrhage 113 or laceration. The. hyoid. bone and larynx rare intact. The 114 tongue is otherwise normal. 115 116 SYSTEM: iThe heart. weighs 450 grams. The 117 epicardial surfaces are smooth, glistening, and unremarkable. ,118 The coronary arteries arise normally and follow the distribution 119 of . a right dominant Vpattern with 50% proximal_- focal 120 atherosclerosis of the right coronary artery and no Iother '121 significant atherosclerosis.? The chambers demonstrate 122 biventricular hypertrophy, and ?the valves bear the usual 123 size/position relationship, are erphologically normal and are 124 unremarkable.- The valves are free of. vegetations. The '125 .myocardium is dark red?brown, firm, ?and unremarkable. The 126 atrial and ventricular septa are intact and the septum and free 127 walls are free of muscular bulges.? There is no focal or 128 regional fibrosis, erythema, pallor or softening. The left 129 ventricle measures 1.6 cm and the right _ventricle measures 130 0.5 Cm in thickness as_ measured 1 cm below the respective_ 131 atrioventricular yvalve annulus. - The interventricular septum Page 8 Sheriff?Coroner Alameda County I Body of JOHN JEFFREY BONARDI 132 measures 1.6 cm in thickness._ The aorta and its major branches 133 arise normally and follow the usual course with no significant 134 atherosclerosis. The Aorifices of the major raortic vascular 135 branches are patent. The vena cava and its major tributaries 135 returnV to the. heart in the. Usual distribution -and are_ 137.Iunremarkable. 138 139' RESPIRATORY SYSTEM: The right and left lungs weigh 800 grams, 140 each. The upper and lower airways are patent and the mucosal 141 surfaces are smOoth, yellow?tan, and. contain ?thin foam. The 142? pleural 'surfaces are smooth, glistening, and remarkable for 143 slight anthracotic pigmentation of the subpleural 144- The pulmonary is congested and the cut surfaces exude 145 marked amounts of blood and frothy fluid. There are no masses, 146 hemorrhages, consolidations, obstructions ?or destructive 147 The pulmonary arteries are normally developedand 148 patent. 'There is no saddle embolus on in situ examination of 149 the pulmonary trunk.\ 150- 151 HEPATOBILIARY SYSTEM: The liver weighs 2,650 grams. The 152 hepatic capsule is intact, irregular and glistening, covering a 153 micronodular, fibrotic reddish brown The Page?9 Sheriff-Coroner - Alameda County Body of JOHN JEFFREY BONARDI 154 gallbladder contains approximately 35 ml of- green: viscid ibile 155 without stones. 'The extrahepatic biliary tree ?appears rto -be 156 patent. 157 158 SYSTEM: The spleen weighs 400lgrams and has a 159 1.5 cm accessory spleen. Both have smooth intact capsules 160 covering red?purple, moderately' firnx .The splenic 161 white pulp if; grossly unremarkable. The regional nodes 162 appear normal.? The bone marrow (rib) is'red?purple. 163 164 ENDOCRINE The pituitary gland His intact, normally 165 developed, and_ijs unremarkable without laceration, hemorrhage, 166 or mass lesion. The thyroid gland is symmetric and unremarkable ,167 with a firm, red?brown, ?granular and no 'cyst, 168 hemorrhage, fibrosis, or mass lesion. The adrenal glands are 169 normally situated and have soft, yellow cortices and soft, gray? 170 brown medullae. The pancreas has a soft, tan with a 171 I normal lobular architecture and. no saponification, pseudocyst, 172. neOplasm, fibrosis, hemorrhage, or mineralization. 173 174 GASTROINTESTINAL SYSTEM: The esophagus is lined by?gray?white, 175 smooth. mucosa. The gastric .mucosa is arranged the usual I Page.10 Sheriff?Coroner - Alameda County Body of JOHN JEFFREY BONARDT 176 rugal folds, and the lumen contains approximately 200 ml of 177 brown fluid.? There are no jpill fragments or foreign. bodies 178 identified. The small and large bowels are unremarkable. The 179 appendix is unremarkable. The colon contains soft, green stool. 180 181 GENTTOURINARY The right and left kidneys weigh 250 and 182 260 grams, respectively. The renal capsules are smooth, thin, 183 semitransparent, and strip with ease from the underlying, 184 Smooth, red?brown, firm, cortical surfaces. The cortices are of 185 normal thickness. and well?delineated. from the medullary 186 pyramids. The calyces, pelves, and ureters are unremarkable. 187 The urinary bladder contains approximately 20 ml of translucent 188 yellow .urine. I The 'mucosa is gray~tan and smooth. The 189 bilaterally descended testes are unremarkable. The prostate is '190 unremarkable. 191 192 MUSCULOSKELETAL The skeleton is Vwell developed and 193 without deformity or osteoporosis. vertebrae, clavicles, 194 sternum, ribs, and pelvis are without fracture. The supporting 195 musculature and soft tissues are not unusual. The firm, red? 196 brown muscles are well hydrated and free of focal lesions. The 197 cervical spinal column is stable on internal palpation. 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 Sherif Alamed Spec. Spec. Spec. Physic Forens Eviden JM/cah f?Coroner a County to Pathology: to Histologyz. to Toxicology: ian Present: ic Techs: ce: Page ll Body Of JOHN JEFFREY BONARDI Portions of all major organs are fixed in formalin and retained.' None. Peripheral blood, central (heart,l right ventricle) blood, bile, brain, gastric contents, liver, urine and vitreous humor. Dr. Judy Melinek. C'Mone Falls and Victoria Gebelein. Blood spot on filter paper for DNA. ?ee/L ?t I Mama Uudy Mblinek, M.D. CENTRAL VALLEY TOXICOLOGY, INC. Case Name: TOXICOLOGY Bonardi, John 16 ml peripheral blood labeled "Bonardi, John; 201 5-03 669; 12/ 1 1/1 5" Specimen Description: Delivered bYTricor Date 14-Dec-15 Received by Bill Posey Datel 4-Dec?15 Request: Complete Drug Screen Agency Case 2015?03 669 Requesting Agency Report To Alameda Co. Coroner's Of?ce Alameda Co. Coroner's Of?ce Attn: Acct?s Payable Attn: Dr. Melinek 480 4th Street 2901 Peralta Oaks Ct, 2nd Floor Oakland CA 94607 Oakland CA 94605 Specimen: Peripheral Blood Sample - RESULTS Complete Drug Screen: N0 common acidic, neutral or basic drugs detected. No Ethyl Alcohol detected. . EMMA gL B.L. POSEY KIMBLE I Directors 17 1580 Tolihouse Road Clovis, Caiifornia 9361? B. L. Posey December 16, 2015 Phone (559) 323-994. Fax (559) 323-7502