No one disputes the fact that Jacob Limberios' death was violent. What is disputed, however, is whether the 19-year-old father fired the shot that ended his life.
Ohio law requires coroners, who are elected officials, be notified when a violent or suspicious death occurs, but, as in many states, there are few guidelines regarding autopsies or an investigation. The state's larger counties operate on a medical examiner's system, headed by physicians with forensics training who are appointed to the position.
In Limberios' case, Dr. John Wukie, the elected coroner of Sandusky County, population 60,000, never visited the scene of the young man's death, interviewed witnesses or examined the body. After talking by phone to a sheriff's deputy, he ruled Limberios had died of a suicide.
In Lewis County, Wash., Ronda Reynolds' death was originally determined a suicide by then-coroner Terry Wilson -- even though the forensic pathologist who did the autopsy said the death was undetermined.
Barb Thompson, Reynolds' mother, sued the coroner and in 2009 a Thurston County judge ordered a judicial review -- the first one ever in Washington State.
During the review, the jury unanimously found Reynolds had not killed herself. The judge subsequently asked the coroner to change the death certificate, but didn't permit the jury to decide what it ought to say.
At an Oct. 2011 inquest, the jury was able to go a step further and ruled Reynolds' manner of death was homicide. A jury ruled Reynolds' husband was responsible for her death, though the prosecutor declined to press charges.
What these cases and many others have in common is a coroner system that varies by states, counties and towns and run by elected officials who may or may not have a background in medicine, let alone forensics or criminal investigations. The result can be botched investigations of untimely deaths, families left grappling for answers and murderers going unpunished.
"The type of investigation you will get can vary state to state and even county to county, and unfortunately what you have to deal with is the investigation of your death occurs where you die," said Dr. Greg Schmunk, president of the National Association of Medical Examiners.
"You may end up in a jurisdiction that has a lay coroner that may be operating the local fast food establishment that does this on the side and there are no standards," he said.
Schmunk is a proponent of instituting national standards for death investigators in coroner's and medical examiner's offices. In June, he testified before the U.S. Senate Committee on Commerce, Science and Transportation regarding the need for federal legislation to establish uniform practices, a discussion that he said has been ongoing for years but has been repeatedly stalled in Washington.
"What was done in Jacob (Limberio's) case was just not proper," he said. "A death investigator should respond to the scene, no question."
Jacob Limberios' Final Moments
Limberios, who was an avid firearms collector, took a revolver to a friend's house on March 2, 2012, the night of his death, said Daniel McGookey, the attorney representing Limberios' family.
The teen let each of three acquaintances take a turn test firing the gun in the backyard of the home, before they all went inside, where McGookey said Limberios unloaded the gun, letting the shell casings and a live round fall to the floor.
"One of the witnesses at the house picked both the casings and the live round up from the floor. Apparently, Jacob then reloaded the live round into the gun and then handed the gun to another witness whom requested to see the gun again," McGookey said.
He believes the acquaintances passed the gun around again, while the live round was loaded inside of it.
"Around that time, Jacob was shot in the head," McGookey said. "All three of the people at the house contended that Jacob shot himself."