In the "Leave", "In Water" and "Rebirth" endings, James confronts Maria a final time, dressed as Mary and trying to get James to take her. James conclusively rejects her, and she transforms into the final boss with intent on killing him but is instead killed for good by James. In the "Maria" ending, Maria returns alive again after James has killed Mary and James decides to leave Silent Hill with her. As they leave she begins visibly coughing, a hint that she has the same disease Mary had and that the events of the game may repeat themselves.