Citation Nr: 21022443 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 16-24 141 DATE: April 15, 2021 ORDER Entitlement to service connection for the cause of the Veteran's death is denied. REFERRED The Appellant indicated an intent to apply for survivor’s pension benefits in her correspondence to the VA received June 2020. The Board notes that as of March 24, 2015, a claim for benefits must be filed on the standardized claim form prescribed by the Secretary. 38 C.F.R. §§ 3.150, 3.151. The Appellant’s request, as outlined in her June 2020 correspondence, is referred to the regional office (RO) for any appropriate action. FINDINGS OF FACT 1. The evidence of record shows that a service-connected disability did not cause or contribute substantially or materially to the Veteran’s death. 2. The preponderance of the evidence shows that the Veteran’s cardiopulmonary arrest, cerebrovascular accident, urinary tract infection, respiratory failure, diabetes mellitus, gastroesophageal reflux disease, hypertension, and endstage renal disease were not present in service or until many years thereafter, were not related to service or to an incident of service origin, to include exposure to herbicide agents, and was not caused or aggravated by active duty service. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran’s death have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1310, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.203, 3.303, 3.304, 3.307, 3.309, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Army from October 1965 to September 1967. The Veteran also had additional service with a Reserve Component. The Veteran died in December 2003 and the Appellant is the Veteran’s surviving spouse. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating from the Department of Veterans Affairs (VA) RO. By way of history, an April 2004 rating decision was issued by the RO denying service connection for cause of death. This decision became final when Appellant did not timely appeal or submit new and material evidence within one year of the decision. Thereafter, the Appellant introduced new and material evidence. In the Appellant’s May 2016 substantive appeal (addendum election), she requested a Board hearing before a Veterans Law Judge. In May 2020, the Appellant withdrew her hearing request in writing. Accordingly, the hearing request is deemed withdrawn. See 38 C.F.R. § 20.704(e). In May 2019, the Board found the Appellant introduced new and material evidence sufficient to reopen the claim and then remanded the appeal to have the Service Department or appropriate agency investigate and attempt to verify the Veteran’s reports of alleged exposure to Agent Orange while serving at Camp Samae San in Thailand. In June 2020, the Board once again remanded the appeal to obtain a medical opinion to determine whether the Veteran’s cause of death was incurred in or caused by active service. The Board finds the required development has been completed and the matter is properly before the Board at this time. See Stegall v. West, 11 Vet. App. 268 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board apologizes to the Appellant for the delays in the full adjudication of her claim. Entitlement to service connection for the cause of the Veteran's death The Appellant claims, in substance, that service connection is warranted for the cause of the Veteran’s death because his hypertension, heart condition and/or diabetes mellitus type II, also claimed as contributory causes of death, were caused by his service, to include herbicide exposure during active duty service in Thailand. Unfortunately, the Board finds the preponderance of the evidence is against the claim, for the reasons set forth below. To establish service connection for the cause of the Veteran’s death, the evidence must show that a disability, which was incurred in or aggravated by active duty service, either caused or contributed substantially or materially to death. In this regard, it can be either the immediate or underlying cause, or else be etiologically related. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. In order to constitute the principal cause of death, the service-connected disability must be medically determined to have been one of the immediate or underlying causes of death or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b). A contributory cause of death is one not inherently related to the principal cause, but that it contributed substantially or materially, combined to cause death, or assisted in the production of death. Significantly, it is not sufficient to show that a service-connected disability casually shared in producing death, but rather it must be shown that there was a causal connection between the disability and death. See 38 C.F.R. § 3.312(c)(1). Service-connected diseases or injuries involving active processes affecting vital organs are given careful consideration as a contributory cause of death, despite being unrelated to the primary cause, due to debilitating effects and general impairment of health that such processes may cause. 38 C.F.R. § 3.312(c)(3). In all cases, VA must consider whether the evidence indicates that a service-connected condition was of such severity as to have a material influence in accelerating death. Furthermore, in cases where the Veteran was not already service-connected for the condition that caused death, service connection for the condition may still be warranted where the evidence of record establishes that the particular injury or disease resulting in death was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. i. Whether an already service-connected disability caused or contributed substantially or materially to the Veteran’s death As an initial matter, the Board notes that the Veteran died in December 2003. The Veteran’s death certificate lists the immediate cause of death as cardiopulmonary arrest, due to (or as a consequence of) cerebrovascular accident, urinary tract infection and respiratory failure. Other significant conditions (contributing to death but not resulting in the underlying causes listed above) of diabetes mellitus, gastroesophageal reflux disease, hypertension, and endstage renal disease are also listed. At the time of his death, the Veteran was not service connected for any disease, injury or illness. Therefore, the record does not show that the Veteran was service-connected for any disease, injury or illness at the time of his death, and as such, the Board finds that an already service-connected disease, injury or illness was not the cause of the Veteran’s death as a matter of law. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. ii. Whether the Veteran was entitled to the presumption of herbicide exposure due to his service in Thailand The Appellant contends that the Veteran was exposed to Agent Orange while serving in Camp Samae San Thailand, which is noted to be approximately five miles southwest of U-Tapao Royal Thai Air Force Base, from October 1965 and September 1967. A May 2019 brief, submitted by the appellant’s representative, indicates that the Veteran served in the Republic of Thailand as a heavy vehicle driver, “working in jungle areas.” As to herbicide exposure, VA laws and regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam war (i.e., January 9, 1962, to May 7, 1975), shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to the contrary. 38 U.S.C. § 1116(a)(3); 38 C.F.R. § 3.307(a)(6)(iii). The last date on which such a Veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he served in the Republic of Vietnam during the Vietnam war period. 38 C.F.R. § 3.307. For purposes of applying the herbicide presumption, “service in Vietnam” includes service in the waters offshore or service in other locations if the conditions of service involved duty or visitation to Vietnam from January 9, 1962, to May 7, 1975. 38 U.S.C. § 1116(a)(3); 38 C.F.R. §§ 3.307(a)(6)(iii); 3.313(a). The Board finds the Veteran did not have service in Vietnam for the purpose of applying the herbicide presumption. Id. VA has determined that there was significant use of herbicides on the fenced-in perimeters of military bases in Thailand intended to eliminate vegetation and ground cover for base security purposes as evidenced in a declassified Vietnam era Department of Defense document titled “Project CHECO Southeast Asia Report: Base Defense in Thailand.” Special consideration of herbicide exposure on a facts-found or direct basis should be extended to those Veterans whose duties placed them on or near the perimeters of Thailand military bases. The majority of troops in Thailand during the Vietnam War were stationed at the Royal Thai Air Force Bases of U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang. If a Veteran served on one of these air bases as a security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by MOS (military occupational specialty), performance evaluations, or other credible evidence, then herbicide exposure should be acknowledged on a facts found or direct basis. See M21-1, IV.ii.1.H.5.b. Turning to the evidence, the Veteran’s service location in Thailand – Camp Samae San – is not one of the Royal Thai Air Force Bases for which herbicide exposure can be based upon. Moreover, even if the Board found the Veteran’s duty station in Thailand qualified for an initial finding of herbicide use at the base, there is no evidence showing that the Veteran performed duties along the perimeter as a security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by his MOS (military occupational specialty), performance evaluations, or other credible evidence of similar duties during his service in Thailand. The Veteran’s MOS of heavy vehicle driver does not provide probative evidence, on its own, to show that the Veteran was exposed to toxic chemicals on the perimeter of the base. The Board acknowledges the representative’s argument that the Veteran’s duties in Thailand required him to work “in the jungles,” however, there is no evidence to support such a contention in the record. Tellingly, in September 2019, VA received a response from Joint Services Records Research Center (JSRRC) reporting there is no evidence to substantiate exposure of this Veteran to Agent Orange in Thailand. See PIES Response September 2019. Upon investigation, JSRRC reviewed the February - October 1967 Operational Report-Lessons Learned (OR-LL’s) reports, submitted by the 499th Transportation Battalion (499th Trans Bn); the November 1966 -January 1967 OR-LL, submitted by the 9th Logistical Command (9th Log Cmd); and, the December 1966 - January 1967 OR-LL, submitted by the US Army Support, Thailand. Id. Working “in the jungles” would, in fact, not be an area in which herbicides had been used, because if it had been used there would, in fact, be no jungle. It was determined that the 499th Transportation Battalion’s mission remained essentially the same, that being to control and supervise terminal operations at Sattahip Army Terminal, Sattahip Deep Water Port, and Klong Toi Sub-Port, Bangkok. Id. However, the records did not document the Veteran or personnel assigned to the 499th Transportation Battalion were at Camp Samae San during the reporting period. Id. Also, the records do not document personnel were exposed to Agent Orange or tactical herbicides while performing their daily duty assignments. Id. Importantly, the records do not document the use, testing, spraying, transporting or storage of Agent Orange or tactical herbicides at the above locations in Thailand during the reporting period. Id; see also October 2019 Formal Finding Of Unavailability Of Agent Orange Verification Report. Such a report provides evidence against this claim that the Board cannot ignore. Moreover, the Board acknowledges the representative’s argument citing several internet articles in support of the Appellant’s contention the Veteran was exposed to herbicide agents while in service in Thailand. See May 2019 IHP. Specifically, the representative argues that commercial herbicides containing dioxin and arsenic were used in general during operations in Thailand during the Vietnam War period which exposed servicemen to the downwind hazard area for tactical herbicides. In this regard, medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). However, treatise evidence must “not simply provide speculative generic statements not relevant to the [claimant]’s claim.” Wallin v. West, 11 Vet. App. 509, 514 (1998). Instead, the treatise evidence, “standing alone,” must discuss “generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion.” Id. (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (medical treatise evidence must demonstrate connection between service incurrence and present injury or condition); Mattern v. West, 12 Vet. App. 222, 227 (1999) (generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive (quoting Sacks, supra)). In this case, the articles submitted by the Appellant’s representative only provide general information regarding ground dissemination and commercial deforestation testing results from Thailand in 1967, general information on arsenic and force-wide Air Force use and handling of hazardous materials. Tellingly, the articles are not accompanied by any corresponding clinical evidence specific to the Veteran, and they do not suggest a relationship between the Veteran’s claimed exposure to herbicides and his time in Thailand with a degree of certainty that, under the facts of this specific case, reflect plausible causality based upon the objective facts of record. As such, the Board places little probative weight on this evidence. While the Board acknowledges that the Veteran served in the Republic of Thailand from October 1966 to September 1967 as a heavy vehicle driver, this evidence by itself does not meet the criteria for herbicide exposure during service in Thailand on a facts-found basis. Further, VA received a response from the Service Department stating there is no record of the Veteran being exposed to herbicides. In addition, the Veteran is not shown to have any active service in the Republic of Vietnam during the Vietnam Era. As such, the Board finds the Veteran is not entitled to the presumption of exposure to herbicides. 38 C.F.R. § 3.307(a)(6)(ii). The Board notes there is no evidence indicating exposure to herbicides during service. iii. Whether service connection is warranted for any listed primary or contributory causes of death Lastly, the availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran’s immediate cause of death is recorded as cardiopulmonary arrest, due to (or as a consequence of) cerebrovascular accident, urinary tract infection and respiratory failure. Other significant conditions of diabetes mellitus, gastroesophageal reflux disease, hypertension, and endstage renal disease were also listed on the Veteran’s death certificate as contributing to death but not resulting in the underlying causes listed above. A disability will be considered the principal (or primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § §3.312(b). A disability will be considered a contributory cause of death where it contributed substantially or materially, it combined to cause death, or it aided or lent assistance to the production of death. It is not sufficient to show that it causally shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § §3.312(c)(1). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection for certain chronic diseases, including hypertension and diabetes mellitus, may be presumed to have been incurred in service by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service (for Hansen’s disease (leprosy) and tuberculosis, within 3 years; multiple sclerosis, within 7 years). 38 U.S.C. §§ 1101(3), 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For a particular injury or disease to be “shown in service,” the disease identity must be established, and the diagnosis must not be subject to legitimate question. Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013); see also 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic in service, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Turning to the evidence, service treatment records (STRs) are silent on the Veteran having any diagnosis of cerebrovascular disease, urinary tract infection, respiratory failure, diabetes mellitus, gastro-esophageal reflux disease, or end stage renal disease inservice or within a year after separation from active duty. The February 2016 VA opinion stated that the Veteran’s STRs do not reveal any diagnosis which would have at least as likely as not contributed to the Veteran’s death. Furthermore, the examiner opined that the Veteran had a large subarachnoid hemorrhage that ultimately led to his death. This was likely contributed to by his poorly controlled hypertension. There was nothing else in the medical record that would have contributed to his subarachnoid hemorrhage. The July 2020 VA examiner opined that the body of evidence shows the Veteran died as a result of recurrent, long-term complications from a large hemorrhagic intracerebral bleed, which was due to uncontrolled hypertension. Due to the resultant debilitation from his intracerebral bleed, over time the Veteran developed respiratory failure, a myocardial infraction, renal failure, the need for PEG tube placement, tracheostomy and pace-maker placement and subsequently recurrent pneumonias, UTIs and a decubitus ulcer. Here, the Board finds the VA examiners competent, credible and their opinions highly probative as to whether service connection for cerebrovascular disease, urinary tract infection, respiratory failure, diabetes mellitus, gastro-esophageal reflux disease, and end stage renal disease is warranted on a direct or presumptive basis. See American Medical Association Code of Medical Ethics, Principle of Medical Ethics V (“A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education....”); see also Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011) (noting that, in the absence of clear evidence to the contrary, VA medical examiners are presumed competent). Tellingly, at this time, the opinions are also not contradicted by any other medical evidence of record. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Therefore, the Board finds that the VA opinions are the most probative evidence of record and service connection for cerebrovascular disease, urinary tract infection, respiratory failure, diabetes mellitus, gastro-esophageal reflux disease, and end stage renal disease is not warranted on a direct or presumptive basis because the Veteran was not diagnosed with any of these diseases in service or within the one year presumptive period after service. The Board notes there is evidence that supports the contention that the Veteran’s hypertension was a primary or contributory cause of death. See February 2016 VA Opinion. The Appellant contends that the Veteran’s hypertension was related to service and contributed to his death. Thus, the question for the Board is whether the Veteran was entitled to service-connection for hypertension during his lifetime. In regard to service treatment records for hypertension, the Veteran’s August 1965 Enlistment Examination blood pressure (BP) was 124/64 and his August 1967 Separation Examination BP was normal at 118/84. He had two intermittent episodes of elevated systolic BP (January 1966 ER visit BP 160/90 and August 1966 BP 150/70) and a single episode of elevated diastolic BP in February 1967 BP 128/96 while being seen for shortness of breath and nervousness. His blood pressures at all other times inservice was normal. See January 1966 (BP 110/76), March 1966 (BP 110/80), April 1966 (BP 126/84) and May 1966 (BP 130/70). In July 1985 the Veteran was seen and noted to have BP elevated to 158/104. He was diagnosed with mild hypertension at this time. Further post-service treatment records show BP readings consistent with uncontrolled hypertension after 1985. The February 2016 VA examiner reviewed the Veteran’s claims file and opined that it is less likely as not that the Veteran’s hypertension was related to his elevated readings shown during his military service. The doctor’s rationale was that the elevated blood pressure readings were not persistent. He stated that blood pressure naturally fluctuates due to a variety of factors. This means that isolated readings of moderately elevated blood pressure are of very little significance and do not constitute a diagnosis. Hypertension is diagnosed only when there are persistently elevated BP readings. The July 2020 VA examiner opined that it is less likely than not that Veteran’s hypertension had its onset during active duty service or within one year of discharge from service or is otherwise related to the Veteran’s active duty service. Citing to the Veteran’s STRs, the examiner noted that the Veteran was not diagnosed with hypertension or treated for hypertension in service, or within a year of separation from service. The doctor noted that the criteria for hypertension in the 1960s was 140 mm/Hg and/or the diastolic blood pressure readings 90 mm/Hg. (World Health Organization). Hypertension is diagnosed when two or more properly taken BP measurements on two or more occasions in a healthcare setting (office setting) are elevated. The examiner also stated that hypertension is not an intermittent condition. When hypertension is present, blood pressures are consistently elevated. Transient elevations of BP can occur due to many factors including anxiety, stress, exercise or pain. In addition, the examiner stated there are no post service treatment records to support the Veteran being diagnosed with hypertension within one year of separation. Therefore, the Board finds the most probative evidence of record shows the Veteran’s hypertension did not have onset inservice or within one year of discharge from service and was not a chronic problem for the Veteran since service. Moreover, the February 2016 and July 2020 VA examiner opinions on the etiology of the Veteran’s hypertension were based on a detailed review of the Veteran’s medical history, service records, the entire body of evidence and relevant medical literature and in accordance with accepted medical principles they both opined that the isolated instances of elevated BP readings inservice did not amount to a diagnosis of hypertension inservice or within one year of service. Accordingly, the examiners opinions are accorded great probative value and the Board finds service connection for hypertension is not warranted on a direct or presumptive basis for this disease. Lastly, the Appellant contends that the Veteran had a heart condition related to service that contributed to his death. The central question the Board must answer on this issue is whether the Veteran’s heart condition was the primary or contributory cause of death. In this regard, the Board notes the Veteran’s death certificate does not list heart disease as a primary or contributory cause. The February 2016 VA examiner opined that the Veteran had a large subarachnoid hemorrhage that ultimately led to his death. This was likely contributed to by his poorly controlled hypertension. There was nothing else in the medical record that would have contributed to his subarachnoid hemorrhage. The July 2020 examiner opined the Veteran’s myocardial infarction (MI) was the result of his underlying illness from his intracranial bleed and related infectious complications from this illness and the MI was not the cause or contributor to his intracranial bleed and hypertension. The examiner further opined that treatment records note the Veteran had chronic heart failure (CHF) on his problem list as of November 2003. There is no evidence to show that his MI at the time of his July 2003 admission lead to or contributed to his development of CHF. Ischemic cardiomyopathy is not noted to be a clinical consideration in his July 2003 or subsequent treatment records. In this case, the preponderance of the evidence shows heart disease was not the primary or contributory cause of the Veteran’s death. Rather, the Veteran died as a result of recurrent, long-term complications from a large hemorrhagic intracerebral bleed, which was due to uncontrolled hypertension. Even if the Board were to assume that a heart condition was the primary or contributory cause of the Veteran’s death, which is not the case as discussed above, the preponderance of the evidence remains against finding the Veteran had this heart condition inservice or within one year of discharge. Specifically, the July 2020 examiner’s opinion is the most probative evidence on the matter that concluded the Veteran was evaluated several times in service for chest pains and shortness of breath, but was not found to have ischemic heart disease or CHF inservice, or within a year after separation from active duty. Specifically, the Board notes that a service treatment record dated January 4, 1966 shows EKG, X-ray and PE scan diagnostic results all revealed that the Veteran did not have heart disease while in service. Moreover, post service treatment records as late as 2000 show the evidence does not support ischemic heart disease after testing negative on a nuclear imaging test many years after discharge from service. See Dr. H. A. B. Office Visit Notes, May 24, 2000. While the Veteran may have had indications of a heart problem in service, such as chest pains, shortness of breath and left ventricular hypertrophy (LVH), there is no evidence that his heart problem was ischemic in nature and there is no evidence that his heart problems caused or contributed to his death. In fact, the evidence is against finding the Veteran had heart disease in service or at any time prior to his hospitalization in 2003 for brain hemorrhage. Thus, the Board finds the July 2020 opinion along with post-service treatment records to be the most probative evidence of record on the issue of the Veteran’s heart condition being a primary or contributory cause of death. The July 2020 opinion is provided after a review of the record on appeal as well as because it is supported by citation to evidence found in the record and controlling medical principles. Tellingly, at this time, this opinion is also not contradicted by any other medical evidence of record. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). The Board finds that it is the most probative evidence of record and provides sufficient evidence to weigh against the claim. Therefore, the Board finds the Veteran’s heart condition, to include his LVH, was not the primary or contributory cause of the Veteran’s death based on the evidence before the Board and moreover any heart condition that played a role in his death, to include instances of acute MI, did not have its onset inservice or within one year of discharge from service. The Board cannot ignore the facts of this case, including the history of heavy smoking, frequent alcohol use, post-service medical reports and treatment records, hospital records, two VA medical opinions and the history of his illness that shows onset many years after service. The preponderance of the evidence shows that factors not related to the Veteran’s active duty service were the primary and contributory causes of his death. The VA medical opinions in particular (not simply the service and post-service treatment records, which also provide evidence against this case) provide particularly negative evidence against this case that the Board cannot ignore. In addition, the Board finds that neither the Veteran during his lifetime or his spouse at the current time are competent to provide the missing nexus opinions for the claimed disabilities because they do not have the required medical expertise to provide answers to these complex medical questions (i.e., what caused the Veteran’s post-service cerebrovascular accident). Accordingly, the Board finds that the preponderance of the evidence is against the Appellant’s claim that during his lifetime the Veteran was entitled to service connection for cardiopulmonary arrest, cerebrovascular accident, urinary tract infection, respiratory failure, diabetes mellitus, gastroesophageal reflux disease, hypertension, and/or endstage renal disease. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. Conclusion Therefore, because the most probative evidence shows that an already service-connected disability did not cause or contributed substantially or materially to death and because service connection is not warranted for cardiopulmonary arrest, cerebrovascular accident, urinary tract infection, respiratory failure, diabetes mellitus, gastroesophageal reflux disease, hypertension, and/or endstage renal disease, the Board finds that the preponderance of the evidence is against the Appellant’s claim of service connection for the cause of the Veteran’s death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. (Continued on the next page)   In reaching all the above conclusions, the Board also considered the doctrine of reasonable doubt. 38 U.S.C. § 5107(b). However, as the preponderance of the evidence is against the claim, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Davidson The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.