Craig Harvey, the assistant director of the LA County Coroner's Office, says it is usually his office that notifies the families. "I can't believe -- I don't believe -- my investigator did nothing because all they do is identification and notification. In this case there was a missing person's report filed with a police agency -- the LAPD. What I believe happened -- I can't prove it -- is that the notification of next of kin was taken over by them. It's happened in the past where they will say something like, 'It's our missing person; we'll take care of it from here.'"

One of the reasons Harvey doesn't know for certain is that the LAPD hasn't relinquished its records of the case. While investigating this matter, the coroner's office requested the file but has yet to receive any response from the LAPD either verbally or in writing. Harvey concludes, "From what I know, it's one of those cases that gives you a sick feeling in your stomach because something went horribly wrong here. What's doubly frustrating for us is we're not being given access to the whole record so we can help decide what it was."

There are no guarantees

The areas David moved through on foot in the last hours of his life must have seemed as uninhabitable, vast and threatening to him as wilderness and untouched nature would feel to an urban dweller.

The City of Industry is a Southern California working-class melting pot. Sitting near the confluence of San Bernardino, Orange and Los Angeles counties, the place is about as imaginative-looking as the name suggests, "City" being a rather sneering euphemism for the sleepy warehouses, wholesale lumber yards and wide cracked cement parking lots that mark the landscape. Even the cement basin washes, which often run parallel to the highways, are cynically called 'rivers.' The signs along Valley Boulevard are more likely to be in Spanish than in English and just as likely to be Thai, Vietnamese, Chinese or Mandarin. The street is dotted with closet-sized taquerias advertising mariscos, Burger Kings, topless bars and auto dismantlers.

But the area where David died is barren. It is a quarter mile-long straight stretch of train tracks between two curves that arc around corners out of view.

"It was a long time between when he left the clinic at 6 a.m. and when he was hit by the train," reflects Sam Orr. "He didn't just walk out of the place and step in front of a train. He spent the whole day presumably either thinking about it or on some other plan like leaving town. Anyway, he was clearly despairing in various ways. Some of it was outward -- about the world in general -- but I think most of it was about himself."

Last week on April 7, the anniversary of the disappearance, David's family gathered on the grounds of the LA County Cemetery to place a marker in his memory. The groundskeeper had dug a small hole and they put some personal mementos into the ground and placed over them a simple marker: David Samuel Orr, 1964-1988.