Maria: To get this ending, the player must make James seem protective and concerned for Maria and not Mary. This includes checking up on Maria constantly (eg revisiting her in room S3 in the Hospital)and not letting her get hurt much. It also involves running through the corridor at the end and NOT listening to all of Mary's speach. After the game is complete James is seen leaving Silent Hill with Maria, but Maria pauses to cough a few times, suggesting that James has learned nothing from his experiences in Silent Hill and that the whole thing might happen again someday when Maria's sickness gets worse. Mary's letter is read out with her voice-over at the beginning of this sequence.

In Water:After examining Mary's letter and photo repeatedly,Angela's knife often, spending long periods of time with low health, dont look after Maria,reading the suicide diary on the roof of Brookhaven hospital and examining the message to James in Neely's bar, the In Water ending is activated. In this ending James is transported to Mary at her deathbed. Mary forgives James and tells him he has suffered enough, but before they can part properly she starts to cough violently and then dies. James then carries Mary's body all the way back to his car and, in an unseen sequence, drives into the lake, killing himself! Mary's letter is then read out with Mary's voice-over in an underwater background.

Rebirth: After completing the game once, three special items appear in various locations. These items are called: White Chrism, Book of Lost Memories, Obsidian Goblet, Book of Crimson Ceremony. Once you obtain all of these items and beat the game it will activate this ending. In it, James rows to the center of Toluca Lake, to what appears to be a church, which the screen then focuses on, with a voice-over of James talking about "the old gods" still being alive. It is speculated that he performs The Crimson Ceremony to try to bring Mary back to life.

"DOG": After completing the game with all the three main endings ('Leave', 'In Water' and 'Maria') or once with 'Rebirth', a Dog Key item becomes available. If you obtain this key, it can be used to unlock a particular room in the final area of the game. Inside is a small dog standing on a stool at a computer console. James drops to his knees in anguish and exclaims, "So you're behind all this!" in Japanese. The dog then comes over and licks his face. A song consisting of pitched dog barks plays as the credits roll, accompanied by various humorous images of the game's characters!!