This article originally appeared in the September 2010 edition of City Limits magazine

We know that the dead man was 54. He was white. He was an organ donor. He drank too much, and it gave him a fatty liver. His heart showed signs of disease, and he had genetic conditions that made him susceptible to blood clots. He died in 2008.

The Office of the Chief Medical Examiner (OCME) knows what killed him—a brain injury sustained in a fall. But the OCME does not know whether he fell, jumped or was pushed.

About every 10 minutes, someone in New York dies, and in the vast majority of cases the details of the death are clear. Most die of “natural causes,” like heart disease or cancer. A few thousand die in accidents, kill themselves or are killed by someone else.

But each year, nearly 200 deaths are categorized in the Department of Health and Mental Hygiene’s vital statistics report as “events of undetermined intent.” These are cases in which the city’s medical examiner cannot determine whether the person died of natural causes, accident, suicide or murder.

City Limits obtained redacted copies of autopsy reports on deaths in 2008 that were categorized as events of undetermined intent. (The OCME, intent on protecting the privacy of the dead, initially rejected our request for those documents but relented after we appealed and withdrew a request for identifying information.)

If—hypothetically—the 192 deaths of undetermined intent in 2008 were all murders, the city’s murder rate would have been 34 percent higher. In the unlikely event that they were all suicides, the city’s suicide rate would have been 41 percent higher.

To the layman’s eye, few of the cases seem likely to have been murders; the uncertainty seems to be whether they were accidents or suicides. In any event, these undetermined cases don’t necessarily reveal an alarming increase in suicide or murder. Instead, they present a stark commentary on how some New Yorkers die, and the unheralded mysteries behind those deaths.

Several cases suggest lives of considerable hardship, of substance abuse and chronic health problems like obesity, diabetes, emphysema and seizure disorders. Other cases feature unusual elements, like the man who was killed by police or the formerly conjoined twin who died of a drug overdose.

The Office of Chief Medical Examiner, which determines cause and manner of death, does not declare deaths to be of “undetermined intent,” a term only used by the Department of Health. The OCME leaves “intent” out of it but can decide that the cause of death (whether a person died of a heart attack or drowning, for instance) or the manner of death (whether it was natural, accidental or intentional) was undetermined. In some cases, both cause and manner are question marks.

“Sometimes the cause of death is known—say a gunshot to the head— but the manner of death might not be figured out, as to whether it’s accidental, suicide or homicide,” says Dr. Michael Baden, a 25-year veteran of the OCME who was chief in 1978 and 1979. “Sometimes one finds skeletal remains and cannot tell the cause of death, but from the circumstances, one can tell it’s a homicide.”

Since 1967, more than 20,000 city deaths have been listed as “of undetermined intent” (or, in earlier years, simply as “ill-defined”), a mere fraction of total deaths over that time. The categories used to describe deaths have evolved, so year-to- year comparisons are imperfect, but the highest number of undetermined deaths was in 1971 (1,206 deaths). In the ‘70s and ‘80s, undetermined deaths averaged 730 a year; in the past decade, they averaged 217 a year.

The falloff in undetermined-manner deaths partly reflects the general decrease in death in the city. In 1968, more than 91,000 people died in New York; in 2008, only about 54,000 did.

The OCME provided City Limits with 103 autopsy files on deaths of undetermined manner from 2008. Most (42 percent) involved white people; Hispanics and blacks each made up about a quarter of the cases. Three quarters of the dead were men; one person’s gender couldn’t be determined.

While the age of a few victims could only be approximated—one was listed as “30-50 years old”—about half were in their 30s or 40s. The oldest was 91. The youngest was 1; he died of acute bronchopneumonia.

The bulk of the deaths (40 percent) involved blunt trauma, including several falls, a person hit by a train and another who died after “exiting motor vehicle.” Another 18 percent were overdoses. Eleven percent drowned. Two died of smoke inhalation.

The cause of death can sometimes lend itself to questions about the manner, says Baden. “There are certain causes of death,” he says, “where the autopsy may not be sufficient to determine the manner of death because the injuries will look the same whether [in the case of a fall] the person jumped, fell accidentally or was pushed. The same with unwitnessed drowning or people dying in fires.”

In such cases, medical examiners need to see more than the body. They look at the circumstances and scene of death too, according to Ellen Borakove, spokesperson for the OCME.

The OCME, which has bureaus in every borough, has a 24-hour, seven-day-a- week communication center at its headquarters on First Avenue. Whenever hospitals or police officers come across a death that seems suspicious, they are supposed to call the OCME.

“Our investigator gets on the phone to the officer on the scene,” says Borakove. “But we also do our investigation. [The police] are looking for who did it.”We’re looking for what happened.”

The OCME examiner visits the scene and examines the body. Depending on what’s found, the body might be released on the scene. But if something warrants further investigation, the OCME will take jurisdiction. In 20,000 cases reported to the OCME in the first five months of the year, the medical examiner took jurisdiction in 5,500. In 4,000 cases, autopsies were performed.

The OCME can do seven or eight autopsies a day; each can take up to four hours if, for instance, the paths of multiple bullets that struck a person must be tracked. All those efforts are aimed at determining the cause and manner of death and avoiding an inconclusive answer like “undetermined.”

“We do whatever we can until that moment when we say it’s undetermined,” says Borakove. And even for cases in which the scene investigation, the police report and the autopsy cannot isolate a manner of death, the case is not closed. The manner of death will be listed as “undetermined,” but, says Borakove, that can always change if new information comes in.

That’s true for all deaths, not just those of undetermined manner. Baden recalls a case from the late ‘70s in which a family brought in evidence questioning a determination that a 1932 death had been suicide.

“They brought in documentation 45 years later that the landlord in the apartment had been fined a number of times by the Health Department for having carbon monoxide leaks,” he says. “They brought in sufficient information that we changed the cause of death from suicide to accident because it was an accidental leak that the landlord tried to cover up.”

Adds Baden: “No death certificate is written in granite.”