This is part two in a series on San Francisco’s unclaimed dead. You can read part one here.
One evening in October 2014, a group visiting Lake Merced made an upsetting discovery: A dead body in an encampment in a ravine by the lake. They called the police, and the medical examiner’s office took custody of the body.
Investigators struggled to determine the person’s identity. Their skull remained with the medical examiner’s office until sometime in late 2022, when Sonia Kominek-Adachi, then a forensic autopsy technician in the office, realized it was missing.
Before Sonia Kominek-Adachi made the discovery in December 2022, Executive Director David Serrano Sewell had allegedly been rushing to clean the office in preparation for an inspection. “It appeared highly likely that during his cleaning process, Sewell had inexplicably discarded” the skull, according to a lawsuit Kominek-Adachi filed against Sewell and the city in February. Without it, the decedent couldn’t be identified. The San Francisco Standard connected the missing skull to the Lake Merced death in February.
If Kominek-Adachi’s allegations are true, the skull’s disposal fits into a larger pattern in which San Francisco has neglected and mistreated its indigent and unclaimed dead — a pattern that dates back to the city’s founding days.
‘Our boasted respect for the dead’
Today, those who die indigent in San Francisco and don’t have family to handle funeral expenses are cremated and scattered at sea by Colma Cremations and Funeral Service under a contract with the city. In 2021, 2022 and 2023, the medical examiner’s office saw 378, 384, and 355 unclaimed dead, respectively.
From the beginning, San Francisco was forced to keep its indigent dead in mind. During the Gold Rush, many came on their own to San Francisco in search of gold or other fortunes, only to die penniless and a long way from their families. Just a month before the city was founded on April 15, 1850, it opened its first public cemetery, which included a large plot for indigent dead.
Called Yerba Buena Cemetery, it was bounded by Market, Larkin and McCallister streets, and it filled up quickly. The indigent dead were buried at the city’s expense, mainly in the triangle formed by Market, Larkin and Grove streets, according to a map created by historian and researcher Alex Ryder.
Within eight years, the cemetery filled with thousands of dead, forcing city officials to seek new burial grounds. City Cemetery opened in 1870 on 200 acres near Land’s End, where more than 11,000 indigent dead were buried in a plot where the Legion of Honor Museum now stands.
Although the city coroner and medical examiner have occasionally handled burials for indigent and unclaimed dead over the city’s history, more often San Francisco has contracted with a local funeral home to lead the work. By 1859, local funeral director Nathaniel Gray — who arrived in 1850 and immediately took charge of recording San Francisco’s deaths — held the contract, according to a contemporary article from the Daily Alta California.
It changed hands many times over the next three decades: to J.H. Mullins, who bid to bury the indigent dead for $10 each, in 1868; to James McGinn in 1870; to Fitzgerald & O’Connor in 1878; to O’Connor and Shea in 1880; and to W.J. Mallady in 1885 — who, by 1889, was charging the city $7.48 per burial (about $254 in today’s dollars), according to newspaper records.
Generally, San Francisco awarded the indigent contract to the funeral home with the lowest bid. By 1902, the cost had dropped to $1.48, which the San Francisco Call criticized in a brief item on July 16: “This is one way of translating into a dollar and some cents our boasted respect for the dead.” Earlier that month, the Call quipped, “whoever spoke of these outcast beings as indignant dead” — a common malapropism — “was perhaps wiser than he knew.”
Shallow graves, shoddy coffins, and human-skin leather
As prices to bury the city’s indigent dead dropped to the floor, so did the standards of those doing the burying.
In February 1870, the city ordered J.H. Mullins to bury the indigent dead in City Cemetery at a depth of at least four and a half feet, after hearing that “the bodies had been buried in the cemetery with but little sand over them.”
The city’s contract with funeral homes included strict specifications about how coffins should be constructed, but in 1880, the Health and Police Committee investigated charges that O’Connor and Shea (or Sheehy, as it appeared in the Daily Alta California in March) were burying the indigent in “only an apology for a coffin.” It was allegedly made from splitting wood full of knotholes, “smeared with asbaltum instead of varnish … and too short to contain the corpse — the feet protruding from one end of the box.”
In 1898, the San Francisco Call ran a lurid article claiming that local hospitals and asylums were selling the bodies of unclaimed dead to medical colleges, who then fenced the skins to local leatherworkers to be turned into belts and purses for social elites. “Women pride themselves in the possession of pieces of leather made from the backs of other women who were so unfortunate as to have died in a charitable institution,” the Call reported. It’s not clear whether there was any truth to the Call’s claims.
In April 1900, when the Hagan Brothers held the city’s indigent contract, the mortuary gave the body of 24-year-old George Ramsey, a Black man, to the local College of Physicians and Surgeons “for dissecting purposes,” the Call reported on April 13. Although historically many unclaimed and indigent bodies became educational tools for budding doctors and coroners, doing so wasn’t legal under Hagan Brothers’ contract with San Francisco. “The Hagans may be severely dealt with,” the Call reported.
Another Hagan came under scrutiny in 1904, when inspectors visited the Hagan & Kelly mortuary on 19th Street after fielding complaints that Hagan & Kelly were storing the indigent dead in a barn. San Francisco agreed to store them in its coroner’s office morgue until they could be buried properly.
Even then, Supervisor A. Arnold D’Ancona, then the head of the city’s Health and Hospital Committee, admitted that the funeral services weren’t entirely to blame. “The manner of burying the city’s dead has been no worse than it always was. The fault lies in the contract system that has been in vogue.”
SF’s indigent cemeteries, forgotten and built over
As San Francisco expanded, indigent burial grounds were treated as little more than obstacles to progress. Beginning in the 1870s, multiple rounds of construction within the Yerba Buena Cemetery footprint turned up hundreds of forgotten graves. And when construction began for the Legion of Honor Museum in 1921, workers tore open 1,500 graves in the indigent section.
Daily News reporter Vid Larsen and a colleague visited the site and reported seeing “piles of bones not completely covered by the dirt,” many coffins cut in half by the teeth of excavating machines and more coffins poking out from the soil along the bluff. Local colleges bought some of the skulls. The foreman told the reporters that his crews refused to touch the bones, saying, “The only thing we can do is to scrape them over and cover them up again.”
San Francisco banned burials within city limits in 1901. And, although the graves in Yerba Buena and City cemeteries were supposed to have been disinterred and relocated to Colma, many are still here. Hundreds are likely beneath the ground in the Civic Center, and 10,000 to 20,000 remain in City Cemetery, now the Lincoln Park Golf Course.
Undertaker A. Verkonteren, who held the indigent contract in 1899, was left in a quandary when City Cemetery closed to burials. He’d accumulated about two dozen bodies, but had nowhere to lay them to rest. He noticed an ad for the sale of lots in San Mateo County and bid $750 for two parcels in the Abbey Homestead division in Colma. Immediately he buried the unclaimed dead in his new cemetery, according to the San Francisco Call.
But there was a hitch. The lots were part of F. E. Luty’s estate, and some of Luty’s creditors protested when the issue went before probate judge James Coffey, who ordered that the land be put up for sale again. Except now it housed two dozen indigent graves, which potentially made it less appealing to other buyers.
“At present indications Mr. Verkouteren will be a lively bidder for the lots when they are again on the market,” the Call reported. Verkouteren’s widow wound up owning the land, which then sold to the Hagan brothers, who operated an indigent cemetery called Sunset View until it closed in 1951.
The Cypress Abbey Company later bought Sunset View. At some point, the headstones were removed and, in the 1960s, the Cypress Golf Course, also owned by Cypress Abbey, expanded across the graves of the indigent dead still buried there. The golf course shrunk again in the mid-1990s, leaving the plot undisturbed, and still unmarked, to this day.
Unsolved mysteries
No one is sure when San Francisco stopped burying its indigent and unclaimed dead and began cremating them instead. In 1971, the San Francisco Examiner reported that College Chapel Mortuary, owned by Hagan descendants in the Duggan and Welch families, was under contract with the city to embalm the indigent and unclaimed, which suggests they were still being buried. But by 1992, Pacific Internment held the contract and was cremating and scattering them at sea, same as Colma Cremations and Funeral Service does today.
Back then, Pacific Internment was getting “about 30 a month from the city,” similar to today’s numbers, according to a May 1992 Examiner article. “The dead fit no pattern, other than poverty. They are old, young, of all races, from all over town.” Back then, drug overdoses didn’t appear to be a significant cause of death for the unclaimed, but AIDS was, according to the article. Pacific Internment charged the city $350 per cremation — not much less than the $450 Colma Cremations receives for a basic cremation 30 years later.
If the person found dead at Lake Merced in October 2014 had been identified, but no next of kin claimed them, odds are good that their cremated remains would have been scattered in the Pacific. Instead, at some point Serrano Sewell will likely have to explain in court just what happened to that person’s skull. Their family may never learn what happened to them.
The San Francisco Medical Examiner’s office declined a public records request for the investigation files related to “DOE #82,” the person who died by Lake Merced. It also refused to provide photos of a clay reconstruction of the person’s face, which was laid over the top of their skull, ostensibly to help the office identify the deceased.
The office has been in hot water before over issues that affect San Francisco’s indigent and unclaimed dead. In 2017, it lost its national accreditation, partly because more than half of its death examinations were taking longer than six months, and dozens took more than a year, the San Francisco Chronicle reported. The office hired Dr. Christopher Liverman as its new chief medical examiner in May 2021, and regained its accreditation in October of that year. Serrano Sewell was hired as the office’s chief operating officer in December 2020, and promoted to executive director two years later, according to his LinkedIn profile.
‘We need to do better for them, as human beings.’
San Francisco’s unclaimed dead are among the city’s most vulnerable. With better resources — including stable housing, harm-reduction programs, and quality healthcare — many, if not most, of these deaths are preventable.
The medical examiner’s office is funded with public money, and taxpayers cover the costs of laying the unclaimed dead to rest through cremation and scattering. But when Mission Local filed public records requests asking the office to provide even the most basic information about who these people were — their ages and cultural backgrounds, where they lived, how they died, and how they wound up unclaimed — we were told the office didn’t have any readily available information.
Reuben Houston, the owner of Colma Cremation, says it’s an honor to care for the unclaimed dead, to “guide them through that next transition,” but he often wishes he could provide them a richer, more personalized sendoff.
“That would be nice,” he said. “We would have to cut through all the red tape and politics. We need to do better for them, as human beings.”
