Three months after the World Trade Center tragedy, mistakes in the tallying and even burial of the enormous number of dead are starting to emerge.
This week officials of the city medical examiner paid quiet, rueful visits to the homes of two firefighters killed in the Sept. 11 attacks, and admitted they had misidentified the since-buried body of one as that of his fellow firefighter.
A few weeks ago, Lillian Borrone, the retired deputy director of the Port Authority of New York and New Jersey who is heading New Jersey's efforts to help victims of the Sept. 11 attacks, received a phone call from New York City detectives saying she was on the list of the missing in the attacks. She assured them she had been in China on Sept. 11, and was alive and well.
As police and others continue to spend 18-hour days trying to identify and count the number of people killed, it is becoming clear that the task is a grueling process of eliminating mistakes as much as anything. Some of those mistakes elicit sighs of relief, others are heartbreaking. Each day the death tally changes slightly; Wednesday was no exception. Recovery workers pulled the remains of two more firefighters from the wreckage shortly after 3 a.m. The medical examiner's office identified another four victims from the thousands of remains on which they are performing genetic testing.
But Wednesday was also the day the body of Christopher Santora, 23, was exhumed from its grave in Queens, causing fresh grief for two families who have already endured a great deal.
Santora was erroneously identified by the medical examiner's office on Sept. 30 as fellow firefighter Jose Guadalupe, 37, and buried by Guadalupe's family on Oct. 1, with Santora's parents attending the funeral. Both men were part of Engine Co. 54, a midtown Manhattan fire company that lost 15 firefighters on Sept. 11. Santora's family, who had scheduled a memorial service for him for Saturday, will hold a funeral instead. Guadalupe's family will return to the wrenching pain of not knowing what became of him.
"I was just beginning to find closure; I didn't think they were going to find him," said Santora's younger sister Kathleen, fighting tears. "I needed to have a casket, but this is just unbelievable. I really hope this never happens anywhere, ever again to anybody. It's so painful."
Ellen Borakove, spokeswoman for the medical examiner, said the chances of such a mistake being made at all were extremely small.
"This has happened once, and we have had 10,000 human remains brought into the office," she said. "Because this is an unusual circumstance we extended our deepest apologies."
The explanation of events given by the medical examiner shows that even with painstaking effort, mistakes can happen.
Borakove said that X-rays of a body brought to them in late September showed a slight abnormality in the neck, and that X-rays provided by the Fire Department of Guadalupe showed he had such an abnormality.
"The Fire Department indicated to us they believed [the body] was Mr. Guadalupe," she said.
Three pathologists and a consulting radiologist for the medical examiner read the X-rays, which is standard practice, and concluded it was him.
The medical examiner's office had also extracted DNA from the body, a standard procedure, but it takes weeks to obtain results. Santora's family had brought in a toothbrush from which his DNA was extracted as well. This week, the DNA showed the body that was buried was Santora. It turned out that he, too, had a slight abnormality in his neck.
Thomas Antenen, the city's Police Department deputy commissioner, said the effort put into cases like that one and the phone call to Borrone in New Jersey show the extraordinary work being done to sift through what were initially close to 16,000 names of people reported missing.
About four days after Sept. 11, the decision was made to have the Police Department's internal affairs detectives take over the process of creating an accurate list. As recently as last week, police found that one of the female passengers on one of the planes had used her married name to buy a ticket, but was reported missing by her maiden name.
And as people return to their Battery Park City apartments near the site, other "missing" names reported by worried neighbors are being eliminated.
Police are still seeking information on about 200 names, most from foreign countries.
As that list shrinks, a new category has been added. Rather than force relatives to wait for answers about loved ones, and have insurance and other benefits delayed, Mayor Rudolph W. Giuliani set up a new process to speed up issuing of death certificates.
To reflect the number of court-issued death certificates, a "confirmed deceased" category was added to the official daily tallies.
As of late Wednesday, the total number of people dead or missing from the World Trade Center attacks was 3,380. That number included 959 people reported missing, 460 who have been positively identified and 1,961 confirmed deceased.
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Times Staff Writer John Goldman contributed to this report.