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."
In Oct. 2012, seven months after Limberios was buried, his family—who refused to believe their son had killed himself--paid for his body to be exhumed so a private autopsy could be conducted by Dr. Cyril Wecht, a forensic pathologist.
No gun powder was found near the entrance wound on Limberios' left temple, according to Wecht's autopsy report, meaning the fatal shot wasn't self-inflicted and must have been fired from further away, he said.
"There is no way that Limberios could have shot himself, either by accident or with suicidal intent," Wecht wrote in an affidavit filed in Common Pleas Court in Sandusky County. "The shot had to be fired by someone else, and that Jacob's death was the result of a homicide."
In April, against the wishes of the Limberios family, Jake was exhumed for a second time, this time so his body could be sent to Lucas County, which handles all of Sandusky's cases in which an autopsy is requested.
Lucas County deputy coroner Cynthia Beisser disagreed with Wecht's finding and reported that the bullet appeared to have entered the right side of Jacob's head, not the left, as Wecht had determined.
According to the Lucas County report, Limberios' death was found to be "not inconsistent," with the original ruling of suicide. However, an official cause of death was not listed on the report and noted that the autopsy findings would have to be coupled with the scene investigation to reach a conclusion.
'Violent Deaths Need to At Least Be Examined'
Qualifications to become a coroner can vary in each state and county that operates in the system, with some officials appointed, while others are elected. Some states don't even require the person elected as the county's chief authority on death to have any medical experience.
The National Academy of Sciences has recommended abolishing the coroner's office since 1928, a recommendation that has been repeated throughout the years, urging counties and states to shift to a medical examiner's system with someone qualified in forensic science at the helm.
However, the coroner's system continues to operate under an amalgam of rules and often minimal oversight.
"There needs to be a standard," said Dr. Kevin Whaley, a medical examiner for the state of Virginia and a spokesman for the American Society for Clinical Pathology. "There has to be some wiggle room, but there needs to be an overall standard of care, such as all violent deaths need to be examined."
Brady Gasser, Jacob Limberios' best friend, is on a mission to change the standards in Ohio, spearheading legislation called "Jake's Law."
If passed, the law would require all county coroners and medical examiners to conduct or order autopsies on all violent or suspicious deaths. It would also increase the standards of qualification for coroners, who in Ohio are currently required to take 32 hours of continuing education during each four-year term they are elected.
"These seem like very logical and reasonable things for us to suggest," Gasser said. "We're fighting to find out the truth about how Jake died. We also want to make sure this doesn't happen to another family."
Rep. Chris Redfern, an Ohio Democrat, has spoken with Gasser and the Limberios family and said he hopes the case inspires reform in the state's coroners system.
"I do believe that coroners in the state of Ohio need more training. More specific however, deputy coroners need more training," he said. "[And] I think it's time we look at how causes of death are determined, how they're determined and by what means."
Criminal Probe Opened in Teen's Death
Last month, Ohio Attorney General Mike DeWine took over the criminal probe into Limberios' death and promised a "thorough" review of how the case was handled.
Wukie's office referred all calls to his attorney, Dean Henry, who was not able to be reached.
"Look at the scenario. It's not one of someone who wants to kill themselves," said Jacob Limberios' father, Mike Limberios.
"I don't know what happened to my son at the house that night. All I want is the truth."