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Alex Shepherd wakes up strapped to a gurney. Glances to the left and right reveal blurry images of mutilated bodies and surgeries gone awry. Finally realizing what's about to happen, he starts yelling, demanding to be let go, only to be left in an operating room staring at a multi-pronged piece of equipment more suited for churning meat than precise incisions. An "A" prompt appears - jamming on it forces Alex to break loose in time to see a nurse through one of the windows completely impaled by a massive blade. Its owner is offscreen, therefore unseen to both Alex and the player. Alex exits the room and remembers how this all started: he was serving in a war, away from home for years, then heard his younger brother Joshua had gone missing. Alex planned to return home to Shepherd's Glen right after healing up in the hospital, but something's apparently gone wrong.
Not long after leaving the OR, Alex finds a boy happily drawing on the floor. Turns out it's Joshua, though he doesn't seem to recognize Alex and runs away. Confused, Alex continues searching the hospital, solving a few typically bizarre horror puzzles along the way (passkey numbers hidden in X-Rays, that sort of thing), not really commenting on all the bodies wrapped up on gurneys or how run-down the hospital appears to be. This is also the first glance of the Objective screen, a quick rundown of the next few tasks you need to complete. "Find Joshua" is all it says.
Soon enough he enters a bathroom and pulls a knife out of the mirror. After the knife's out, everything starts shaking anHOLY SHIT EVERYTHING'S MELTING! The sirens start roaring and now Alex finds himself in the familiar trappings of awful, awful Silent Hill. Not five seconds after watching the walls peel away, Alex is confronted by a mangled nurse that he's forced to kill.
Once again Alex finds Joshua coloring with no concern. This time he acknowledges Alex but demands a toy before he'll let him through the barred gate. Still perplexed yet desperate to get out of here, he scavenges for something that could pass for a toy, eventually spotting a rabbit doll hanging from a crack in the wall. After reaching in and nearly having his arm torn off, Alex hightails it back to Joshua and tries to hand him the doll - it reads "Lakeside Amusement Park," an area we all know from the previous games as a location in Silent Hill, not Shepherd's Glen. Joshua starts to take it, then suddenly bails and runs even deeper into the building.
Alex, tired of swatting giant bugs off his head and stabbing twitchy nurses in the neck, makes another attempt to follow Joshua, this time entering an elevator. As the doors close, the elevator lurches and a deafening noise erupts from all angles. The doors start to grind apart, and as Alex leans forward to see what's happening, the same blade that killed the nurse tears through and catches him right in the chest. Bam, dead.
Alex wakes up. He's in a truck on his way home to Shepherd's Glen. Just a bad dream, he says to the driver. The camera pulls out and we see that the driver is none other than Travis Grady, apparently hauling the same trailer he was in Silent Hill Origins. He looks like he's been to hell and back, so we know at least Homecoming takes place sometime after Origins. A pretty easy guess, but at least it's concrete.