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GLORIA HETIICH, Executrix of the
Estate of CARL R. GUSTAFSON,
deceased;
IN THE COURT OF COMMON PLEAS
CUMBERlAND COUNTY, PENNSYLVANL
Petitioners
v.
NO. 00 - S't.S '"
Cio;Lf~
CHRISTI S. SCHALE,
Respondent
ORDER
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AND NOW, to wit, this I 7 day of V ~' ,2000, upon
consideration of the Petition of Glorta Hettich, Administratrix of the Estate
of Carl R. Gustafson, for approval of settlement, the same is hereby granted,
and it is ordered that:
1. The settlement, under the terms provided in the petition, is
approved, and Glorta Hettich is authorized to sign all necessary documents
including releases, checks and taxes;
2. Gloria Hettich is authorized to distribute the settlement
proceeds as set forth in the Petition.
3. Glorta Hettich is authortzed to pay
set forth in the Petition directly to FREEB
TES.
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GLORIA HETTICH, Executrix of the
Estate of CARL R. GUSTAFSON,
deceased;
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANL
Petitioners
v.
NO. OV - J-r..s;;z. ew.v .,-~
CHRISTY S. SCHALE,
Respondent
PETITION FOR APPROVAL OF SETTLEMENT BY THE
ESTATE OF CARL R. GUSTAFSON
AND NOW, comes Gloria Hettich. Administratrix of the Estate of, Carl
R. Gustafson, deceased, by her attomeys, Freebum & Associates, and files
the following Petition For Approval of Settlement of this action arising from
the accidental death of her father, Carl R. Gustafson.
1. Petitioner, Gloria Hettich, is an adult individual who resides at
1251 Rittner Highway, Shippensburg, Cumberland County, Pennsylvania.
2. Respondent, Christy S. Schale, resides at 262 Walnut Street,
Shippensburg, Cumberland County, Pennsylvania.
3. Gloria Hettich is the Administratrix of the estate of her father,
Carl R. Gustafson, deceased, by virtue of Letters of Administration issued by
the Register of Wills of Cumberland County, Pennsylvania on August 4, 1999.
4. Decedent, Carl R. Gustafson, was bom on February 18, 1915, and
died intestate on June 27, 1999, as a result of injuries he sustained in a
motor vehicle accident that occurred in Shippensburg, Cumberland County,
Pennsylvania on June 27, 1999.
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5. At the time of his death, Decedent, Carl R. Gustafson resided
with Petitioner.
6. At the time of his death, Decedent, Carl R. Gustafson, was a
widower, and not remarried.
7. At the time of his death, Decedent, Carl R. Gustafson, was
survived by the following children:
(a) Marion Bolink, 6 Morrison Avenue, Bernardsville,
NJ 07924;
(b) Carol Williams, 3920 East Double J Acres, Alva, FL
33920;
(c) Gloria Hettich, 1251 Rittner Highway,
Shippensburg, PA 17257; and
(d) Robert Gustafson, Jr., 29 Clark Street, Casenovia,
NY 13035
8. This action arises from an automobile accident which occurred
on June 27, 1999, at 2:05 p.m., in Shippensburg, Cumberland County,
Pennsylvania.
9. At the time of the accident, Christy S. Schale was driving a 1985
Chevrolet Caprice automobile southbound on State Route 11 (Ritner
Highway) in Shippensburg, Cumberland County, Pennsylvania. For some
unknown reason, Schale crossed the center line and struck the left side of a
hay bailer which was being pulled by a pick-up truck driven by Kevin Kendig
in the opposite direction. After hitting the hay bailer, Schale side swiped a
1988 Dodge Aires automobile which was being driven by Robert Mackey in
the opposite direction behind the hay bailer. Schale then collided head-on
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with a 1983 Chevrolet Caprice automobile which was being driven by Erik
Hettich in the opposite direction behind Mackey. Carl R. Gustafson was an
unrestrained front seat passenger in Hettich's automobile. A copy of the
police accident investigation report is attached as Exhibit "A".
10. As a result of the accident, Carl R. Gustafson was killed almost
instantly. The ambulance arrived at 2:08 p.m. At that time, Mr. Gustafson
unresponsive to pain and verbal stimuli. Mr. Gustafson died on route to the
hospital. True and correct copies of the pertinent medical records are
attached as Exhibit "B".
11. At the time of his death, Carl R. Gustafson was unemployed.
12. At the time of the accident, Carl R. Gustafson was receiving
regular monthly social securtty benefits in the amount of Five Hundred and
Eighty Five ($585.00) Dollars. A true and correct copy of a report from the
Social Securtty Administration is attached as Exhibit "C".
13. Under a wrongful death action, Petitioner has the right to
recover the following damages:
a
b.
Funeral expenses:
Expenses of administration:
$6,509.00
$ 68.00*
*Cost advanced by attorney
Copies of the funeral expenses and the receipts from the expenses of
administration are attached hereto as Exhibit "D" and made a part hereof.
14. Petitioner, as the representative of the Estate of Carl R.
Gustafson, has the right to bring a survival action for the loss of future
earnings through the period of the decedent's life expectancy less the
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probable cost of maintenance for the decedent and less the amount of
contrtbutions the decedent would have made to his statutory heirs under the
wrongful death action.
15. Freebum & Associates represents Petitioners on the basis of a
contingency fee agreement for Thirty-Three percent (33%) of gross
recovery plus expenses. A true and correct copy of Petitioners' fee
agreements are attached hereto as Exhibit "E" and made a part hereof.
16. Respondent, Christy S. Schale, has offered to settle the liability
claim made by Petitioner, Gloria Hettich, as a result of the death of Carl R.
Gustafson for the sum of Seventy Five Thousand Dollars ($75,000.00).
17. Petitioner, Gloria Hettich, desires to settle claims for wrongful
death and survival damages against Christy S. Schale for the total sum of
Seventy Five Thousand Dollars ($75,000.00), and to sign a Release of all
Claims in favor of Christy S. Schale. A true and correct copy of the proposed
Release of all Claims is attached hereto as Exhibit "F" and made a part
hereof.
18. Petitioner, Gloria Hettich, desires to allocate Five Percent (5%)
of the gross settlement proceeds as "survival damages." The remaining sum
shall be allocated as wrongful death damages. This allocation of settlement
is sufficient to protect the Estate and interests of the beneficiaries, the
lienholders and other creditors, and has been approved by the Pennsylvania
Department of Revenue. A letter from the Pennsylvania Department of
Revenue is attached hereto as Exhibit "G" and made a part hereof. This
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settlement is in the best interests of the Estate and the statutory
beneficiaries of decedent.
19. All of the beneficiaries have been advised of this settlement, and
a copy of this petition has been provided to each of them.
20. The settlement proceeds will be distributed as follows:
A. Pay five Percent (5%) of the gross settlement proceeds or
THREE THOUSAND SEVEN HUNDRED FIFTY ($3,750.00) DOLLARS to the
Estate of Carl R. Gustafson.
B. Pay funeral expenses and expenses of administration as
wrongful death damages.
C. Pay Thirty Three percent (33%) of the total gross
recovery, or TWENTY FIVE THOUSAND ($25,000.00) DOLLARS, to Freebum
& Associates, plus expenses. Counsel has incurred the following expenses in
the prosecution of this claim:
1. Kenneth L. Peiffer, Coroner
2. Mid-Cumberland Valley Police
3. Smart Corporation
4. RC Photography
5. Capitol Copy
6. Kinko's
7. Cumberland Co. Prothonotary
8. Register of Wills
9. Vital Records
10. Postage & Photocopying
TOTAL
5
$200.00
$ 15.00
, $ 39.97
$113.95
$ 15.00
$ 5.06
$ 45.50
$ 53.00
$ 15.00 ,
S 84.36
$586.84
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D. The balance of the settlement proceeds in the sum of
FORTY-FIVE THOUSAND SIX HUNDRED SIXTY-THREE & 16/100
($45,663.16) DOLLARS, will be distributed equally to the following:
(a) Marion Bolink, 6 Morrison Avenue, Bernardsville,
NJ 07924;
(b) Carol Williams, 3920 East Double J Acres, Alva, FL
33920;
(c) Gloria Hettich, 1251 Rittner Highway,
Shippensburg, PA 17257; and
(d) Robert Gustafson, Jr., 29 Clark Street, Casenovia,
NY 13035
WHEREFORE, the Petitioner respectfully requests that this Honorable
Court enter an Order approving this settlement as set forth herein.
Respectfully submitted,
FREEBURN lit ASSOCIATES
By:
'Y ( ~'V:JL
RicharCl. E. Freeburn, Esquire
ID No. 30965
4775 Linglestown Road, Ste. 200
Harrisburg PA 17112
(717) 671-1955
Dated: 8/10/00
Attorney for Petiti,oners
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VERIFICATION
I hereby verify that the statements in the foregoing
document are true and correct. I understand that false
statements herein are made subject to the penalties of 18 Pa.C.S.
Section 4904, relating to unsworn falsification to authorities.
Dated: .S? ~ I () ... t) ()
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GLORIA HETIICH, Executrix of
the Estate of Carl R. Gustafson
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~_. )MMONWEAL~OP J'~VAf("
~ '--' POLICH ACCIDENT REPORT '--'
@REFER TO OVEllLAl SNEEn REPCRTABlE [X] NON-REI'OllTABlE 0
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i 1.INCIOENT r-.99-074 20.COUNTY Clllberl---'
NUHBtIl D.l..LJ,
Z.~~CY Mid-0Jnter1arrl Valley Regional PA 21.MUNICIPALITY ~
i 3'mm~~ roJRPD 4.~~~Ul 2 PRINCIPAl. ROADWAY IN RMATION
IS.INVESTIGATOR NB~GE.. '1"00 ...ROUTE NO.OR Ritner Hi""""~"
o c. Eric S. vanJeIC" un. '" $TRtt' \W1[ ""W""
16.APPROVEO BY BADGE 23.SPEEO 55 TYPE 0 !, S AttESS 1
NUMBER LIMIl KlllKIlAY: COIlTROl
.mE TlOlI 06{27/1999 8'~,~~VAl 1409 INTERSECTINGit.oAD:
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, PENNoOT USE ONLY
21
CODE 409
26.RooTE NO.OR
STREET NAME
27.SPEED
LIMIT
TYPE ACCESS
NI CHIlAY COIITROL
IF NOT ATINTEllSJrcnON:
lO.CROSS STREET 011 ~-~tgo"';","
Sl:GMCNT HARKER \...L..u..la,..~ L.LI-.L
31.DIREctION ""'N SEW 2.DISTAN E
FROM SITE I!Y FROM S TE
33.0ISTANCE WAS rxr'
121 EST MATED
TRAFFIC PRINCIPAL
CONTROL
DEVICE
FT. .l
HI.
yrXINOyliIND
IB.NAlAJI,DWS 0 IX1
MATERIALS Y N I;SlJ
12.NUNBER
OF UNIlS
IS.PRIV.PROP. r",
Accl~ENT Y N W
.VEHICLE DAMAGE 0
O'NONE UNIT 1 3
1-LIGHT
Z'HODERATE r-::-l
3-SE\lERE UNIT 2 l2J
INTERSECTING
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36.LEGALLY r N
PARUIlt Cl Cl PLATE BI'IWl156
39.PA YITLE OR 0
ClJ1'-DF-STATE VIN 492006634 1
40.DlIIle~ Schale, Edrrund
41.O\INER_,_.
"OR~" 262 W"_1.1Jut Street
4Z.CllY,STATE St.'~~~h~ Pa 17257
& ZIPCODE 'LL~~...~,
43. YEAR 1985 44.IIAI:E Cbev:rolet
.S.MODEL' CNOT ro."..,n' ~ 46.INS... 0 0
DODY TYP~1 . "1' '-~ Y IlY N UijK
DODY 04 SPECIAL ; VEHICLE
TYPE USAGE OWNERSHIP
Q IHI1IAL IHfAtY 1 VEHICLE lllAVEL
POINI 11 STATUS SPEED
VEHICLE 4 DUVER DRIVER
CRADIENT 1 PRESENCE CONDITION
257
. NUMBER 25380844
~D.~~ER Schale, Christy Sue
S9.~~~~~s 262 Walnut Street
60.~I~~p~~E Shippensb.n:g, Fa 17257
61.~H 6a'~mHOF 07/30/1978 4!1f~"'532-3490
2
99
1
FA
46,Ub [J
Y N UNKO
VEHICLE
DUNERSHIP 1
TftA~l
SPEED 20
DRIVER
CONDITION 1
'a.CARAIER
ADDRESS
69. CITY. STATE
& 71PlmE
70.USDOI 1/
ICC 1/
NUIlBER
SO.DRIVER
NAIIE
.DR vEIl
ADDRESS
60 .tnT,ST ATE
& ZIPCOOE
61.S!K 62.DATE 0'
STilTH
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VEM.
ClINFIG.
75.MO. 0
AXLES
CA CO
BIlOY TYPE
HAZARDOUS
MATERIALS
CAIlCO
BODY TYPE
HAZARDOUS
MATIRIALS
.R OF HAl MAT
V N Ul.
CElITEA FIlR NICItl/M IA'EH
PAIlE,_
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08- 1~99 11:48AM P002 #24
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,Aug-fl-99 11:03
lUESPC1:lJ1NG E~S MlE"C~ OJrrberland' '.ley EMS Cb.
7\> _,.leAL FACILITY C1~ llo"c;pital
P.03
I">{CII...:lN'r it: A ~9-U"'1 ,
~CID~ DATE: 06/27/1999
. B C 0 E F G ~AHE ADDRESS
01 1 F 20 3 1 0 Driver of Unit #1
03 1 M 37 :> 2 0 Driv= of Unit 1t3
03 3 F 37 3 2 0 Nancy E. Kendig 02-26-62 74 Kline Road, SHOO, PA
04 1 M 53 3 9 0 Driver of Unit It4
05 1 M 29 3 2 0 DriVt3r of Unit is
~ILLURlllAtIOll~ @. ~ 86. DIAGRAM:
\4EAT\lE~ 0
H I J K l H
3 2 1 J:l U 1
0 C o S 0 0
0 0 o B 0 0
0 0 o B 0 U
4 5 1 A 6 1
0
@.RDAIl SURFAce [2]
84.PENNSYLVAUA SCHOOL DISTRiCt
tlF APPLICABLE)
ADDRESS
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8S.DESCRIPTION OF DAMAGED PROPERTY
CMlER
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87.NARRATlW-IO;N!1FV PRECI~IJATlNG EVER~S, CAUSATlDII>FACTQIlS, $EQUENCES OF EVENTS, HITRESS STATEMENTS, AND PROVIDE ADDITIOIlAL
DETAILS Llkf IN5UIlANCE, INFORMATION AIlD ~OCATlDN DF TOUED VEHIOLES, IF 1'.lI0lIlI.
On the give date ani tima I investigate an accident on the Ritner Highway (Route 11).
~ w""" do total of G units involved.
I arrived on the scene and started to take photographs. I was advised that one of the
pas.gen3er'g had liiF<'!_ I bad the on duty eupervisor nake contact with Cpl. palrrero of Pa.
State Police, Carlisle Barracks to respond. I had started to rrark the final rest:in3
DJSitiona of all the tmits when Palrrero arrived. I spoke briefly to him of What II.'e had and
we finished rraIidIl3 the tmits and the tire rrmks. We then rreasu:red the rrarks with the
a:rq;n1terized insb:urent operated by Palmero. All parties involved in the accident were
interviewed with tile except10n of the deoeoo,*"l.
According to the investigation and interviews Unit #1 was travelin:! oouth on Route 11,
t.:I.ussed the double yellow line otriJdng Unit H2. At We point Unit #1 is pz=cedi:rrJ sr.:oI:h
in the northbourd lsne strikiIl3 the left side of Unit #4. Unit #1 pproceedaoouth then
strikeg th", rmnr. and left side of Unit #5. After strik:in:J Unit #5, Unit #1 travels east
off the roadway into a field. Unit #5 is sp.m axound and strikes Unit #6 on the front
right fender.
- The operator of Unit #1 stated that she was traveling sooth on Route 11 wIlen she
.LeuehL:ora heari.rg a lnlge bang. She did not krPI exactly at this point I<obere she was at.
lM'FlbN ~t~te Itlsurarlce CD. ~N ~::Jil'm Wide M.Itual Ins. Ch.
UN,IT p~~~y B53026 03119 U.~T POL5%~I?Cl49779
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88.
WI TNES$ES NAME ADDRESS PHOIlE
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UNIT I
UNIT Z
~USE
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CERTER FOR HIOHWAr SAF!TY
PAGE'_
R-95%
08-11-99 11:48AM P003 n24
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,Aug-11-99 11:03
P.04
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II\ JMMONWP.ALTIIOFPiNNsuVAJf
~ ',.. PAR CONTINUAl1DN SHElJT '-./
REPOIlTABlE EXJ NON-REPORTABLE 0
A~~IUENl COUNTY
DATE 06 27 1999 emE 21
~REFER TO OVERlAV SHEETS
"NCIDENT
NIJoIBER A 99-074
'8 \; U 'E
. tW<E
AJ)~BEt1;
PENNDOT USE ONlV
HUNIClrAL
COOE 409
B t J ~ L M
R 1 99 2 A 6 1
0 0 o B 0 0
0 0 o B 0 0
05 3 M 84 3 2 2 C3rl Gustafaan 02-24-15 1251 Ritner Highway, SHOO,
06 1 F 20 3 9 9 Driver of Unit 116
06 3 F 27 3 !l 9 Terri Eard 04-1 R-'7? 111. E. Fbrt St" SHOO, PA
she stated that she ranerOOers gettmg closer to Shippensburg am was gettirg excited
because she JUSt wam:.ecI. to get hare. She advieed Iff: UJd.L ..t... tbes not J.-=all CJ:OSsi.n;] the
dooble yellOll1 line at all or recalli11g hitting anythin:J. '!he operat= did state that there
~ i;l. ll",j= ban3 and she felt her face fly fO>:WOrd, chc sot up and saw blood eve:rywhere
fra\'I her. She stated at this !;Oint she was tUJ:O:i.Ig off the roadway into a field and <'.bes
=call seeing any l:.'aTB lit].. to the hoed be:in3 up. She stopped the car and oould IlOt get the
key rot.She was then aasisted bj the operator arxi passen;er of ttlit #6. The operator
atate:i that she was going regular speed. She stated that she was not tire:.l and did IlOt
have aT:rf lredical o::cx:lition.
The other statenents are provided UDder each of the unit IlUli:lers.
Ii
PAGE,_
DO
DO
.INVESTlIlATHII
talPLUE?
UNIC VES NO X
CENTER FOR HI'~Y ~FETY
I
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;~:;::'t...~ -~~~...-:
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if\ JMMONWBAJ.m'OF P~V~'
~ '--POUCH ACCIDENTSUPPLHMENTAh-'
REPORTABLE DO NOtHEPOOTABU! 0
P.OS
PENNDOT USE ONLY
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BADGE
9.:~~DENT 06/27/1999 SUnday
l1.n~E Of 1405 12'~~~~TS 06
13./1 KILLtD 14./llNJUIlED IS.PR1V.PIlOP. 0 IV!
001 002 ACCIDENT Y N ~
ZO.CClINTY ........_, nd ClDE
Cl",--.r " 21
I.MUIIICIPALlTY......., CODE
"''''' 409
INFORMATION THAT HAS CHANGED SINCE ORIGINAL 1lli1'OK'l'
PA NAME Ken:lig, Kevin Paul
59.DlllvEII 74 Kl~- o_~..
ADDRESS ~- """"'"
6O.CITY.GTATE S".~,,"",~
& ZlPtoDE ...~~,.,
61 .SEX M 62.0ATE Of
BIRTM
M.lXIlIM.VEH 6 .DRlVER
yo N CLASS
'T.CMRl&Jt
1900
1.INCIDENT
\ NUHIIER
I .AGENCY
NAIIE
J.SlA 10111
PRECIIICT
.INVESTlGATOR
afc Eric S
6.APPROVED BY
A 99-074
Mid-Cunberland Valley Regional PA
.......,.,"n ..PATROL 2
......v"'''' lONE
BADGE
Vd..Cller
UNIT #: 03 - COMPLETE ONLY
PAO''''l . PLATe 2N6722'9
~T~~F~m~E~IN 394550516703
40.!MIEO Kendig, Kevin Paul
41.OIINER 74 IO.il1e Roon
ADDRE$S .
42.CITY,Sl~TE ""'.~~l-o,~ Pa 17257
& llPCllDE OO"'M-='~'"
41.1I:AR 1987 ~."^Kli O1evrolet
45.I4OIlEl-(NOT 46.IH&.... Cl CI
BOOT TYPE) y~ N UNK
4 ~~ 50 0 4 ~~i~ilP 1
o IN!HAL INPACT 0 TRAVeL 20
POINT 00 spEED
3 VEHICLE 1 4 DRIVER r-:;--,1 5 DRIVER 1 VEH.
GRADIeNT PRtSCNC~ ~ CDUDl1l0Y eouFIG~
56.~~: 19632881 51.STATE PA 15'::E~f
~ IlRAIlVl:. Y PRECIPITA' l:VfUTS, C SATI ORG, seQUCNce t1 tV
DETAilS
~ l'r;'~.1
63.PHOHE
711 "'I?-'I7M
68.CARRIER
ADDRESS
9.ClTY,S ATE
& llPCCIlE
70.USDDT iI
PUt "
CARGO
BODY TYPE
MA1AIlDllIlS
MATERIALS Y H 0 UHK
NEe. STATEMeNTS, AND PRO IDe ADDITIONAL
4.GWR
-,
We obtained a written statement:. tran Kevin lterxtig. He stated that he was traveling
north on Route 11 tcM.ing a hay bailer When he saw a silver or grny colored car (Unit 1f1)
from a distance crossiIig U"" y..Ucm apJ;ea1.'il1g aa if it was going to hit them head on.
Kendig stated the car was traveling south. He stated this car (Unit #1) struck the left
aide of his hay bailer (Unit #2).
We also sp:>ke to a passerger in this unit which was the opeJ:atm"s wife, Nancy E.
Kendig. She advised us that she saw the silver car (Unit #1) cani.rl3 head on tcwarda than.
Her hlsband tried to !lOVe the truck off the :road as far ae possible but the sil1ler car
(Unit #1) continued to head direct!y towaJ:ds them until she iqlaCted wit!\ the bailer (Uni1:
#2) .
I tIi
INfORMATION
UNIT PO ICY
un NO
!01ation Wide MUtual IIIB. Co
583iCl49779
EYE?
YEI 0
NG !Xl
PAllI!'_
C!HTER 'DR HIGH~Y SAFETY
R-9S%
08-11-99 11:48AM POOS ~24
.Aug-11-99 11:03
~ JMMONWEAL71l OF PENNSYLV~'
~ .....i'OUCEACCID~SUP~LlIMENTAi,-
@.REfER TO OVERLAY SHEETS REPORTABLE DO NON-REPORTABLE 0
"-.-
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.lll:',
P.06
PENNDOT USE ONLY
. INCIDENT
IIJlBER
.AGENCY
lAME
:!.STAT ON/
PRECINCT
.INVESTlGA10ll
otc. Eric S.
6.JJ>l'llOVEO BY
--:'i~~~~~'i~~15"","~~~~ ,.~~~e:~~~B~~~~:[~ai..g:~E:~~~~
.....:~. ,....!~~~'......~ ~_"", ~-__..__ '. . _~.....3~~~:;~..... _.. '~,~...._:~.w.....,.............
11. 99-074 9.~~~llm 06/27/1999 10.0Al OF \lEEK Sunday
Mid-QJrnberland Valley RegionalPA 11.~~~ Of 1405 lZ'~r::TS 06
....ft"lI!Jnm 4.PATROL2 13.' KILLED V.. dNJUA.E.D 15.PA:l\1.PROP. 0 IV1
,....v"...' ZONE 001 02 ACCIOfNT Y N ~
BADGE ZO.COlIlTY -'-~ I COOE
1900 nn..r.r and 21
Z1.MUMICIPALI1YShi:' COOE
409
; UNIT #: 04 - COMPLETE ONLY INFORMATION THAT HAS CHANGED Sllllt:1!: UlUGlNAL REPORT
Cll.l -
8ADGE
PAll<.D? 0 " PLATE VJ:U791
I ~~~f-~m'~IN 40047292003
I'U'-'. M;lckey. Robert David
,
I' '1.0IiN!R 59~' thdal '" ~....d
ADORe55 .:;IIULI. .
'Z'i%~M~E ShippensbJrg, Pa 17257
\ '<S. TEAll 1988 44.1tAKIl Dodge
45.MOOEL'(NOl ~"'e~
BDDV TYPE) ...~ ~
800Y 04 SPECIAL 0
TYPo USAGE
[RITIAL 'NP/>'Ol 1 veKICLt 0
POINT 07 stATUS
VERICLE 1 DRIVER 'i'
&mlEllT P-RES1HCS ~
56.~= 13384499
.NAWKAIl .. IDENTIFY
DElAILS
P1l.
46.INli....
YI3I NO UUKO
9 VEHICLE
llWNERSHIP
lRAYiL
SPEED
DRIVER 1
CWDIlIOU
57. STAlE PA
IPITATnm EV
, CAUGATJ:ON fAC
1
~~
68. CARRI ER
ADDRFRR
69.CllY,SlATE
& 11pCOOE
70.U"""T . Ice II
PUCII
74.GWR
VEH.
toMt:1:R.
75.NO. OF
AXLES
, SEQUENCE OF EVENT ,
CAllGO
IllZY tyPE
IIAZARDIlUS
MATERIALS
T 1$$ $ ATEMENTS.
[) PROVID
Robert Mackey advised us that: he was travel1rg NOrth on Route 11 at 1:30 tM wlll:!11 1,.,
was followi.ng a pick tip truck (unit #3) pu11:ir:g a hay bailer (Unit #2) . He saw a silver
CXJlored car (UnlL #1) traveli:r.g south o::ming over on thl!lir aide of the :r:oad and hit the
bailer (unit #2) . He statM parts fuxn the bailer hit his winJshield ard bt:oke it. '!'he
oilver oolo=d car (Unit #1) then aid.. FMrlFd his vehicle arrl then st=k the car (Unit
#5) behind bim head on.
URAIlC~ ca.t~
I.FDaIlATlDN
IT POLl CY
NO NO
Nation W1de Ins. Co.
5B378252594
R-95%
PAGE'_
4.INVESTIGATI0N COMPLETE?
YES 0 NO 00
CINTER FOR HIGH~AY SAFElY
08-11-99 11:46AM P006 ~Z4
-
. '~iWi;,,;
Aug-11-99 11:04
,.~~~N1 A 99-074 9'~i~EDi;NT Sunday
~.~CY Mid-Currbcrlat'ld Valley l<s<Jianal?~ 'l'n~E OF 1405 12'~r~~~TS 06
3.STATI0lI1 ......",...... 4.PATROL 2 13.' KIllOE01 "OIN~URED 15.PRIV.PROP. 0 IV1
PRECINCT P>-V,,"" ZONE 0 02 ACCIDENT Y R ~
5. INVESTIGATOR IlAllGE 1"00 2D.caJNTY "-"-"l~'-.~ CooE
Ofc. Eric S. VaIner '" '-""""""- ~..... ;;)1
6.APPRD\lED BY BADGE 21 .MUNICIPALITY Shi coo~09
UNIT #: 06 - COMP~TE ONLY INFORMATION THAT HAS CHANGED SINCM OlUGlNAL REPORT
"""KED? . PUfF 0659 NAME Schultz, Tracy Lynn
~~~!~~EoelN 45696887605 S9'~m~s 16 Brindle Drive
4D.t1WNER SchuJ.t2, 'rra.:y T",m 6D'il~~p~~e Fayetteville, Fa 17222
: 41.=~;SS 16 Brindle Drive 61.SEX F 62.~t~~KOP 05/13/1'379 637~r~61-1006
14Z'il~r~m~E Fayetteville, pa 17222 64'r"'il"&r 65.~tls~ 66,~~1IER
43.YEAR 1'392 44.!IAKE Dodge 67.CAIIRIER
45':ilT~PE) Spirit 68'~m:
pooY 04 4 SPECIAL 0 69. ClTY , STATE
tYPE USAGE & 2.IPCOOE
o MIlIAl IMPACT 1 VEHlCll! 0 7O.USODT
POINT 01 STATUS
- Ii~m~ 1 g~~ce CO
56'~1m~: 24943353
11 NT FY PR IPlT4T1 1 EMTS.
DETAilS
. .
~ JMMONWEALm UI'l'BNNSl'1,VAl'
~ '---PoUCH ACCIDBNT SVPPLBMBNT&-"
REPORTASLE CXl NOlI'REPORTASlE D
P.O?
..'~~~~--<;..""-'
.~"i~. -.....'\ .
~REFER TO OVERLAY SHEETS
" .'
PENRDOT USt UNlT
Ice"
io'Ut;1I
CARGO
BOOY TYPF
6 HAZARDOUS
MATERIALS
$, WITNESS S
Tracey Schult,?; who was operatir.g unit ~6 stated she was driving North on Route 11 with
a car in front of her when she saw a cloud of amke. She stated that all she saw was a
silver car (unit ~l) hitting the blue car (Unit #5) in front of her. Then the blue car
(U1it #5) :In fronL u[ her struck the front of hcJ:; car with the side of their car (Thlit
jf5) .
Te:l:ri Bard, the passenger in this unit stated. that she !=ked up and 8aI/ arroke aul i:i
car on two wheels covered her head and face.
9.. MVeSTIQATIOK CDKPLfTE7
YESD NoD
PAG!'_
CEITER FOR HIOHWAY IAPETY
R-9S%
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,
,~ ll>l1~__
.~
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Aug-11-99 11:04
~REteR TO OVERLAY SHEETS
m. .,
, JMMONWEALm OF PHNN5YLVAJ!
. '--1'OLICB ACCIDENT SUPPLBMENTAt--'
REPORTABLE CXJ NON-REPORTASLE CJ
P.08
. "..,.,...._.._.-lll~~pr'....."........'-...Hi'~'!!'<"'="~' ~=.,.""''''"...~~.'''.''..,._''_.'..-~~ir..-"''''''''''''''"''
s?~?:~i5l~:;:~::~~, .~, >. <-',.-~.:.~gQ~~ ,,::~~~ -,...~: ,.........:-=:..=~ ~' ~"S~." m~:.:~...~;;:'.-:::~-.:~:Z:.:
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l.lNCIOE~T A 99-074 9'~mDENT 06/27/1999 1o.DAY Of ~m SUnday
NUMBeR -
Z .AGENCY Mid-Currberlarrl Valley REgional PA 11.HHE OF 1405 12.NLMlER 06
NARE DAY Of UN ITS
~.SIA.IIOUI M:VRPD T4.'ATROL 2 13.N m15&l 114.11I INJURED 1~.PAIV.PRDP. yO l!J
PRECINCT ZONE 002 ACCIDENT N
S . INVESTIGATOR BADGE 20.IXlIJKTY Cunberland COOE.,
ofc. Eric S. VIttneJ: 1900 _1
6.APPROVEll BY BADGE 21 .IlJNltIPALlTY Shi tooE
409
UNIT #: 05 - COMPLETE ONLY INFORMATION THAT BAS CHANGED SINCB ORIGINAL REPORT
r=LtIiALL1~F.Jrn;. 13..ST~lE )..~:~ Hettich. Erik
PARKED? 0 PLA1[ AIN0272 PA
39.PA TITLE OR 35162615 59'mms 1251 Ritner Highway
OUT-Of-STATE VIN
40.O\/NfR Hettich, Erik 60.eIlY,OTATO Shi~ pa 17257
& ZIPCOPE ,
41.0YNEA 17.'51 Ri t:nl'!T' Highway 61.SEll M T62.0ATE OF 02/11/1970 I63,PHONE
ADllR.l!$$ BU1" 717 530.!l-4Jl
42.CITY. STATE Shippensburg Fa 17257 64.CDMM.VErI65.0RIVER I 66.0RIVER
& ZIPCODE I yON!XI CLASS SSN
43.'EAR 1983 T "".MAKC d-Jevrolet &7.CARRlCR
4~ .HIIlEl' (NOT Caprice 146.INizt 68.tARRIER
DQOY' t'irE) Y N Cl uOKCl N)DREBI
[I9~BOPY 04 ~SPECIAL 0 ~ENltLE 2 69.tITY,STA!E
TYPE USAGE O\IIlERSNIP & llPtCDE
~INIT[AL IHPACT '~lJ;YEHI OLE 0 II8l ~lIAvtL 99 70.USDOT t leD /I I'UC'
POINT 12 SlATUS SPEED
IIWVENICLE 1 ~-~RIVER IT] I~?RIVER 1 (@oVEN. WCAR60 iKGVI/Il
GRADIDlT ~nE.ENC. ~lll~ CONFle. BOIlY TY~E
56.DRlVER 24226498 I 57.STATE Pl\. 15.NO. OF W~ROOUS [T1.~~EA~HF HA~ ffT
NUMBER AXLES MATERIALs Y N UIIK
57. NARRATIve . IDeNTifY PReCIPITATING EVENTS, CAUSATlDN fACTORS, SEQUENCE OF EVENTS. IIIITNCSI5 STATCMeNT$, ANti PROVID!! 1UJD1lIONAL
DETAILS
1\ccording to otticer David Herb, the i.nteJ:VieWing otticer spoke, to E:rik Hettich at
the Charnbarsburg Hospital at 1550 hours. Hettich stated that he did not rem:nber the
accidenL. He uuly L"I"'UWLW Ul<lL 1.. Wd>! ...L HdLu...:.'1:l f.l[1 W<:.!I:lL KirIl3 Street dr.i.r1kirg coffee
with Gustafsan prior to the accident.. Hettich believed that the accident =urred at ROlle
Road lAbich ill approximately three miles llOUth of the accident eC@!lQ.
Iii Stace j,'aIIll MUI:ual Ins. c..:o. 94.llMitTlCA1ICII COIIrILTC.
INfORMATION
UNIT POLICY 7111663-Dl9-3BF YES 0 NO 00
NO NO
PEN~OOT USE ONLY
PAOE'_
CEHTER FDR "' GIfoIAY SAFETY
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THE CHAMBERSBURG HOSPITAL
112 N. Seventh St.
Chambersburg, PA 17201
Pane I
"
EMERGENCY CAR.E UNIT
(717) 267-7146
GUSTAFSON, CARL R
Patient #: 2528925
Treatment Date: 06/27/99
D. G . Marx, M.D.
Medical Record #: 524471
Patient Type: 2
D.O.B: 02/18/15
CHIEF COMPLAINT: Trauma code.
mSTORY OF PRESENT ILLNESS: This is a 84-year-old male who was the unrestrained front-
seat passenger of a vehicle involved in a head-on accident with prolonged extrication for
entrapment. He was hypotensive and unresponsive at the scene. He initially had pulse but that
seemed to decline en route to the hospital.
PHYSICAL EXAM: On arrival, the patient was found to be intubated with equal breath sounds,
no pulse and no heart activity on auscultation. Head was cyanotic and pupils dilated.
DIAGNOSIS: Trauma arrest.
PLAN: Referral to coroner.
DGM/dbw
D: 06/27/99
T: 06/28/99
cc:
D. G . Marx, M.D.
~M__"
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PAGE 1
ECU NURSES NOTES
PRIMARY ASSESSMENT
INITIAL VITAL SIGNS
T , P
ALLERGIES
R
DR. yr;!j~/ Time Response
Notified: Time:
Tetanus
Time Response
DR. Notified: Time: WI
Time: Response
DR. Notified: Time: LMP
-
Description of pain upon arrival:
Abdomen
o Distended
o Guarding
o Soft
'!a.<1igid
o Tenderness
o Rebound
last Ata
BP
Gravida!
FHT Para
RESPIRATORY FUNCTION
OV ON
ONo OEoa
OV ~
Airway Patent
Tube Placed
Sponl. Resp. Effort
Chest Movement
Symmetrical ..Q"V
Shallow 0 V
Retractions 0 V
BreathsoundS'~
Clear c:- R
AbsenUDecr , R
Ra~s R
Rhonchi 0 R
Wheezes 0 R
Other
NEURO
GLASCOW COMA SCALE
EYE OPENING VERBAL RESPONSE
TRAUMA SCORE
RESPIRATIONS RATE RESPIRATIONS EFFORT SYSTOLIC BP CAP REFILL
10-24=4 Normal=1 >90=4 Normal=2
25-35=3 Shallow=O 70-90=3 Dalayad=1
>35=2 50-69=2 ona=O "
Retroaclive=O ) .--/
<10-1 "-----"'" <50=1 Subtotal =
cb 0=0 Total=
1. PUPIL SIZE (mm) '. __ 2.PUPILREACTION
. .. . S-Stuggl8h
. · · B-Btlsk N.Nonreacllva
123458789
CIRCULATORY FUNCTlON);'~;IE'&i'j 1t.>>',,*i!'~
4-spontaneous
3'\0 speech
2.to pain
1.none-
Bowel Sounds
o Present
Rectal Bleeding
NO Bleeding
Vomitus
Nausea
Other
,
Bladder
Distended
Incontinent
MUSCULOSKELETAL
[]=Intact
A=Abrasion
e=Ecchymosla
B.=Bum
C=Closed/Suspected Fracture
O=Open Fracture
L=Laceration
M=Ampulatlon
O=Oegloving
V=Avulsion
P"'Paln
S"'Stabwound
OY ON
OY ON
Other.
Urtne
Color
Amount
Heme
GUSTAFSON. CARL R
Acct: 252892-5
MR#:" 524471
DBte" 06/27199 M
D08iAge: 02/18/15 84Y Sex:
Patient Phone: (999)999-9999
MOTOR RESPONSE
5-oriented
4-coniuseO conv
3-inapp. words
2-incomprehensible
1-nooe
6-obeys
5-localizes
4-withdrawals
3.abn. flexion
2-ext. respons(\
1-00ne
AEIt
ON
zN (YIJ.J""-L
c:rN
OL
OL
OL
OL
OL
GLASCOW PATIENTS
14-15=5
11-13=4
8-10=3
5-7=2
3-3=1
Subtotal=
SKIN CONDmON
o Warm 0 Dry
o Other
HEART SOUNDS
o P....nt "" />baent
o Regular 0 Jrregul81
PULSes
nt 0 l\egu181 0 Irregular .NO
o S~ong 0 Weak Edema Pedal
CAPlUARY REFIll. Per\pharal Pul..
o Immediate 0 Delayed 0'\ ......... Radial
MUCOUSMEM~BRANes . Femoral
o Pink 1;1 PaleJGray Pedal
CHEST PAIN' Other
"IiI'Dlaphoresls
R L
OV;;tN ov Ia'FI
OY~OY~!
o Y JJ..N- 0 Y mr
OY.a1'l OY~
o Y 0 V -o"N'
.J
------.-. ---
(
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TIME PROCEDURE INIT. TIME PROCEDURE INIT.
/'11;3 02 Type: ,/ 00 % /h tfUUY,l ( ^ DC-Collar
Pulse Oximeter v OCID
Intubation /1.?tf.. . J- (, ~/l o Spine Board
CPA {/ Ch,est Tube A L
tit. ..,s.. Cardiac Monitor NG Tube: (Size)
'2 Lead EKG Foiey: (Size)
Mast On Peritoneal Lavage: Amt Results
Lab Values Reviewed Suturing Site #1:
Site #2:
PAGE 2
TIME
T
P
R
BP
GCS TS
SECONDARY ASSESSM~NT
Emerg!lncy Care Unit Nurses ~otes
02 PUP- PAll. PROGRESS NOTESI
SAT ILS SCAL~ MEDICATION 1&0 (0-10) PAIN SCALE
~t-L
~
Q..No Pain S_Moderale Pain 10"'Worst
'",Very Mild Pain 7=Severe Pain ImaginaJ:lle
3=Mild Pain 9=Very Se\lere
GUSTAFSQ
Acct: 25~8'9CARL R
MR#' 5 2-5
Date' . 24471
DosiA .06/27/99
Patientg';';~n~?1~195 84YSex: M
9)999-9999
PRIMARY ASSESSMENT RN
~.
INIT. SIGNATURES
THE CHAMBERSBURG HOSPffAL
112 North Seventh Street. Chambtl1lpuf'g, PA 17201 . (111) 267.3000
~
."Ill;'
l'enns)'lvania EMS Report
Servicc N:UllC Scrvicc No lncidcnl No Dalc
Cumbcrland Vallcy flose Ambulance 2201201 990083~ 06-27-1999
Incident Localion MCIl Rcrch';ng racility
RT II AT SOUTIl MT. ESTATES 21923 Chambersburg Hospital
PalienlNllme Phone No. ^S' OateorOirth Social Sec. No. Se:..:
p CARL GUSTAFSON (999) 999-9999 84 02118115 156-22-2381 M
a
t Slreet Address Crcw Times
i 619 CORTEZ AVE. Affl Frain, Brent E 069343 Dispatch 14:05
e City Slale Zip Aff2 Cohick, Barb E 041136 Enroule 14:06
n
t LEHIGH ACRES FL 33936- A"3 Arrive Scene 14:08
I ALS Unit A#4 Depart Scene 14:30
n Medic 1/84 Mileage Arrh'e Fac. 14:47
f 00' On-Scene Dest. '0 Available 16:17
0
6264 6267 6292 6303 In Quar1ers 16:30
Chief Complaint: TRAUMA CARDIAC ARREST
Current Meds. : UNKNOWN
Allergies (meds): UNKNOWN
PMHx: IOMI OCIIF UCOPD O^BP Omab, 0 CanccrU Non, Knnwn I UNKNOWN
Narrative: Dispatch for MVA with entrapment with Co. 52 and Medic 84. Arrived with Medic 84 to find MVA
invo1vin 5 cars. Above t. was found I in on seat and \loor board of car unres onsive. Pt. was
g p yg p
unseatbelted frontseat passenger of an old make car that was struck in the drivers side front. Unknown direction of travel
,but pt. car was on the side of Ihe road soulh bound in the north bound lane of travel. Other car was in a field east of Ihe
road. Apparently there were other cars involved but unknown how. there was heavy damage to drivers side of car.There
was light damage to passenger side of car. Inside damage was to the dash and glove box area. Passenger side door had to
be forced open by fire dept. Pt. had left knee wedged under dash and head was lying next to driver. Dentures were lying
on seat next to pt. Once door was open c-spine was maintained and pt. was moved to long board and stretcher.Pt. was
unresponsive to pain and verbal stimuli. Pt. had agonal resp. at 10 Imino Pupils were fixed rolled up and to the left. Pt.
had left leg injury. Pt. had clear lungs bi-Iat. with equal movement. JVD +, Tracheal deviation to the left ofpt. Pt. skin on
scene was warm dry and pale. Pt. had crepitus noted in chest region. No other DCAPBTLS was noted during primary
survey, Pt. was placed in full immobilization. Pt. was given 15 Ipm 02 by BVM. Medic 84 was assisted with pt. care and
monitoring en route to Chambersburg Hospital. Pt. went into cardiac arrest in ambulance just prior to us leaving scene.
CPR was started and continued to hospital. While enroute pt. regain a weak carotid pulse of 50. Pulse was monitored to
hospital. No blp was abled to be palpated. Pt. never regained spontaneous resp. Pt. was transported class I to hospital. Pt.
was placed in bed I at hospital and left in the care of ED staff. After pt. transfer no pulse was detected.
~.?~~~-r/
Provider Name
@ 1996. Med Media, Inc.
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EMS Form Number: 9662, .11
Prlnl Dnle: 07/07/1999
SERVICF. NMtF.: Chbg Arc. ALS Scrv (2840\) <IN IT ttl: 93
INClDr.i'IT l.OCATION: RimER HlGHW A Y (RT. 11), Southampton ICe, PA
DISPATCIlF.DAT: 14:05 June 27, 1999 NATlIREOFDlSPATCIl: ALS
INCIDEi'IT H: 8400374
- PATTENTINFO:--------------------
- -- ~--- PIlONE: DATE OF BIRTlI SEX:
PATlEi'IT LAST NAME: FIRST: M_t.: AGE:
Guslafson Carl R (999)999-9999 84 02/18/1915 M
STREET ADDRESS: SOCIAL SECURtn' H: MF.MBERSllIP IN SERVICE:
619 Cortez Ave. 156-22-2381
-=::-c- -
CITY: STATE: ZIP CODE: SIGNATURE TO BILL DIRECf: No
Lehigh Acres FL 33936 RELEASE INFO OBT AINF.D: No
- MEDICARE .: MILEAGE
PRIVATE PHYSICIAl'i: MEDICAID .: OUT: 94811
INSUR #1: SCENE: 94811
BILL TO (COMPANY OR NAME): PHONE: DEST: 94811
Gustafson, Carl R_ (999)999-9999 Group II:
ADDRESS: Polley H IN: 94811
619 Cortez Ave. INSUR #2: BILLED: 0
CITY: STATE: ZIP CODE: TOTAL: 0
Lehigh Acres FL 33936 Group II:
Polley #
NARRATIVE:
County Inc.#:CC9149.
Dispalched 10 above localion wilh ambulance I-53 and fire departmenl for an aulo accidenl with entrapment. Arrived on scene
to lind mulliple vehicles (probable passerby vehicles) parked around scene. Upon arrival to lirst vehicle, found a large size
passenger vehicle with two front seal occupants. Heavy front end damage with intrusion into passenger compartment of 12" or
more. Another large size passenger vehicle located behind lirst also with heavy front end damage. BLS assessing the occupant
of second vehicle. In first vehicleoriver was con lined between driver door and front seat passenger. C/O lower leg pain.
Second passenger showed agonal breathing with lower legs up into dashboard with his back resting on seat and head being
flexed with back of seat.He was pushed over against the driver pushing the driver up against door. Severe dashboard damage
with windshield damage on both sides of car. Weather-hot, humid, cloudy. Day time. Roadway unknown posted speed limit or
speed of vehicles. Unknown debris causing accident on roadway. Tire marks not seen on roadway. Also unknown direction of
travel of either vehicle. Vehicle two (with single occupant) facing west on north bound shoulder north of second vehicle,
Vehicle one (with two occupants) facing south on north bound shoulder. Driver of second stated that neither he or Ihe
passenger were wearing seatbelts. He couldn't remember the travel direction or speed.
PAST MEDICAL HISTORY:
There were no known factors in the patient's medical history.
MEDICATIONS:
There are no known current medications.
ALLERGIES:
There are no known allergies to medications.
PE-Passenger-unresponsive, agonal respirations of2-4/min. Skin-cyanotic around face, pink, warm, & dry other areas.
Pupils-midposition and sluggish to react. Negative obvious trauma to face or head. Dentures loose and removed from mouth.
Negative blood or fluids coming from moulh, nose, or ears. Negative anlerior neck Irauma. Trachea midline. Negative ND.
Chest-crepitus noted to left upper chest in the size of approximalely 6" in diameter around pectoris muscle. Negative
subcutaneous air noted. RighI side appeared 10 be inlact. Aller intubation-= loud breath sounds noted with = rise and fall.
Negative external trauma noted to chest. Chest became mottled over entire chest area upon arriving hosp. ABD-soft, negative
extemal trauma noted. Negative bowel sounds heard x 4 quads. Abdomen became rigid while enroute to hospital. Pelvis
appeared to be intact with squeeze and push of iliac crest. Negative priaprism, loss of bladder or bowel control noted. Lower
extremities-left showed multiple lacerations with slow blood flow over lower thigh, knee, and upper tib/lib area on anterior
side. Negalive obvious other trauma to either lower extremity. Negative pedal pulses noted. Negative pedal edema also noted.
Upper extremities-skin avulsion to left upper ann and hand. Weak radial pulses noted bit Negative movement of extremities x
Page I
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EMS Form Number: 966.. .,31
4,
Print Ilnte: 07/07/1999
TX.Summntion of treatment includes: full c-spine immobilization w/ c.collnr, C!D, LBB & straps, #7,0 nasnl intubntion in
right narcs. Ventilntion with 151pm 02 & BVM. Cardiac monitor initially showing sinus rhythm then reduced to junctional
with pulses, idioventricular without pulses, finnlly junctional/idioventricular with weak carotid pulses. 18g left arm with
1000LR wlo. Second 1000LR while en route infused into this site. 16g right foreann with 1000NSS w/o. Total fluid infused-
I SOOmls. Total of3-1:IO,OOO epi IVP. Total of2mg atropine IVP. CPR utilized appropriately upon absence of pulses and
stopped upon return of pulses. Initially Life Lion called to scene. LZ. set up beside accident scene. Radio report to MC 105 for
report and approval of waiting 10 minutes on scene for air support. MC 105 approved. Upon pt. entering into a junctional
rhythm Life Lion cancelled by ALS provider and transport began to Chmbg. hasp. Updated radio report to Chmbg. hasp. for
pI's deteriorating condition. No further orders provided ITom MC 105. Arrived hasp. with weak carotid pulses. Pupils-fixed
and dilated. Anterior ehest monIed with = bil breath sounds and ease with ventilations. ABD-rigid and monied. No resp. effort
ITom pt. Placed in room I with bedside report to ER RN and MC 105.
Medical command was,by radio. The command facility was Chambersburg Hospital (00360) and the command physician was
I 05.MARX,DA V!D (3050).
Response outcome was: transported by this unit. Patient condition prior to transport was life threat..
Patient condition at facility was unstable. The receiving facility was Chambersburg Hospital (00360). The 'research code' was
OS!.
BILLINO HELPER INfOR.MATION:
This trip is the initial trip to treatment.
This trip originated at the Scene and the destination was a Hospital.
Transport was to nearest facility.
The patient was not confined to bed before or after transportation. The patient was moved by stretcher and was unconscious or
in shock. Transport was in an emergency situation. There was visible hemorrhaging.
Neither a signature to bill direct nor a waiver to release infonnation have been obtained.
LOO:
Time Pul Resp BP
14:05
14:06
14:08
14:10
14:11
EKO
Dispatched.
Emoute.
Arrived at scene.
Arrived at patient.
Weight:60 kgs, Pupils:Equal Midposition Sluggish, Skin:Color-Cyanotie
Temp-Nonnal, CapRef:Delayed, Lungs:Equal Diminished, [Encountered pt. in front
seat of vehicle with legs under dashboard and back resting on seat BLS holding
manual C-spine.]
EndoTrach. Intub., Treated By-A I, - Unsuccessful, [Laryngoscope blade inserted into
mouth for intubation but due to position of provider and patient, intubation not
possible.] 14:15 Ventilation-Bag Valve Mask w/02,
Treated By-AI, [BVM ventilations began with 151pm 02.]
P= Weak Irregular, R= Shallow Irregular, Coma=4 (EI,Vl,M2l, [fire department
working on extrication. Slow weak agonal respirations.]
Immobilization-C-Spine Stabilize, Treated By-AI ,Other
Immobilization-Cervical Collar, Treated By-AI ,Other
Immobilization-C-Spine 101m. Dev., Treated By-AI ,Other
Immobilization-Board - Long, Treated By-AI,Other
Other-Extrication, Treated By-A I,A2,Other, [Moved pt. onto LBB then to ambulance.]
EndoTrach. [ntub. Nasal Tracheal, 7.0 mm, Confinnation:Auscultation, Treated
By-A I, - Successful, [Blade inserted into mouth with gag reflex. Nasal intubation
perfonned with = bi11ung sounds. Ventilations with ISlpm 02 & BVM.]
Peripheral IV . Ring. Lact., \ 8 ga, Left Ann, Wide, Treated By-A I, . Successful
----------Medical eommand contacted.--------
Departed scene.
Jun EKO, Treated By-A I, [EKG showing junctional rhythm with weak peripheral pulses.
Planned hot load into Life Lion but due to impending cardiae arrest began transport to
Chmbg. hosp. Life lion eancelled.]
14:13
14:16 SO 36195
14:19
14:20
14:22
14:24
14:27
14:30
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EMS Form Number: 96~, 531
Print Date: 07107/1999'
14:32
14:34
14:36
14:37
14:40
Peripheral IV - Ring. Lact.. 16 ga. Right Aml, Wide, Trcated Ily-AI,. Succcssful
EMD EKG, Trcatcd Ily-A I, [EKG showing idiovcntricutartrEA. CPR initiated, ]
Med. Admin. - Epinephrinc, I mg, IVP. Treated By-A I, - Successful
Mcd, Admin, - Atropine, 1 I11g, IVP, Treated By-A I, - Successful
Med. Admin. - Epinephrine, \ mg,IVP. Treated By-AI, - Successful, [Radio report 10
MC 105 for update. No further orders. ]
Med. Admin. - Atropine, Img, IVP, Treated By-A I, - Successful
lun EKG, Treated By-A I, [Slow junctional/idioventrieular rhythm with weak carotid
pulses. CPR withheld.]
Med. Admin. - Epinephrine, 1 mg, IVP, Treated By-A I, - Successful, [3rd epi
\: 10,000 IVP. Arrived hasp. Placed pI. in room I with bedside report to ER RN and
MC 105.J
Arrived at facility.
Available.
In quarters.
14:43
14:45
\4:46
14:47
16:02
16:30
Trip is CLOSED. Any information below was added to this narrative after Ihe trip was closed.
Crew Sienatures:
[Crew Chief] A#I: Electronically Signed ~ 'MEYERS,RICK (p026148)
A#2:
-Sommers, Benjy (I129097)
Page 3
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*** REC 1999293 090959 HEP~~FEO d8h6 CIPQYA5
PQA5
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***
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SOCIAL SECURITY ADMINISTRATION
Date: October 20, 1999
Claim Number: 156-22-2381A
Name: CARL GUSTAFSON
CARL R GUSTAFSON
3920 E DOUBLE J ACRES
ALVA FL 33920-9589
You asked us for information from your record. The information that you
requested is shown below. If you want anyone else to have this information, you
may send them this letter.
Information About Current Social Security-Benefits?
Beginning June 1999, the full monthly
Social Security benefit bBfore any deductions is. .....$ 0.00
We deduct $0.00 for medical insurance premiums each month.
The regular monthly Social Security payment is... .....$ 0.00
(We must round down to the whole dollar.)
Social Security benefits for a given month are paid the following month. (For
example, Social Security benefits for March are paid in April.)
Your Social Security benefits are paid on or about the third of each month.
Benefits were stopped beginning June 1999.
Information About Past Social Security Benefits
From December 1998 to May 1999, the full monthly
Social Security benefit before any
d",ductions was.'.....................,................. $ 585.20
We deducted $0.00 for medi~al ~nsurance premiums each month.
The regular monthly Social Security payment was. ......$ 585.00
(We must round down to the whole dollar.)
~
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Date of'BirtK Information
The date of birth shown on our records is February 18, 1915.
Other Important Information
FROM DECEMBER 1997 TO NOVEMBER 1998 YOU WERE PAID 577.00.
Medicare Information
You are entitled to hospital insurance under Medicare beginning February
1980.
Medicare Information
You are entitled to medical insurance under Medicare beginning February 1980.
Type of Social Security Benefit Information
You are entitled to monthly retirement benefits.
If You Have Any Questions
If you have any questions, you may call us at l-800-772-l2l3, or call your
local Social Security office at 941-931-0066. We can answer most questions
over the phone. You can also write or visit any Social Security office. The
office that serves your area is located at:
SOCIAL SECURITY
10100 DEERRUN FARMS RD
FORT MYERS, FL 33912
If you do call or visit an office, please have this letter with you. It will
help us answer your questions.
OFFICE MANAGER
f'''''''-'_k
August 23,
PHONE 908-234.0766
BEDMINSTER. N.J. 07921
M Estate of Carl R. Gustafson
Statement of funeral expenses of Carl R. Gustafson
LAYTON FUNERAL HOME
475 MAIN STREET
P.O. BOX 133
BEDMINSTER, N.). 07921
GEORGE R. LA nON
FUNERAL DIRECTOR
June 27 to July 1, 1999
Casket as selected including name plate and engraving,
standard chapel and professional services rendered
all assistants and equipment furnished in the removal
from Bethlehem, PA to funeral home, preparation and
preservation, dressing, casketing, procuring necessary
certificate and permit, listing and arranging flowers,
use of funeral home facilities, memorial book, prayer
cards, acknowledgment cards and use of funeral coach
day of service. $4570.00
Standard concrete burial vault including full grave
equipment,
875.00
CASH EXPENDITURES
Opening grave, Somerset Hills Memorial Park, Basking
Ridge
Name and date plaque for cemetery stone
Use of station wagon for flowers
Paper notice, The Daily Record,
Paper notice, The Courier News
Gratuities
Installment fee of naw.e and date plaque to marker
Telephone calls
Two certified copies of death and burial permit
$ 650.00
150.00
125.00
51.00
39.00
25.00
10.00
10.00
4.00
TOTP,L------------- ----- ------ ------- ----------- $ 6 5 09 .00
_.",,".~,,-
192..2..-
$5445.00
1064.00
,--
~~
RECEIPT FOR PAYMENT
-------------------
-------------------
Cumberland County - Reqister Of Wills
Hanover and Hiqh Street
Carlisle, PA 17013
Receipt Date
Receipt Time
Receipt No.
8/04/1999
12:28:58
1019152
GUSTAFSON CARL R
File Number 1999-00723
Remarks RICHARD E FREEBURN
AC
Transaction Description
PETITION FOR PROBA
SHORT CERTIFICATE
JCP FEE
Distribution Of Receipt ------------------------
Payment Amount Payee Name
18.00
15.00
5.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
Check# 1024
Total Received.........
$38.00
$38.00
"<~-,,~
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RECEIPT FOR PAYMENT
-------------------
-------------------
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Receipt Date
Receipt Time
Receipt No.
8/05/1999
13:00:08
1019169
GUSTAFSON CARL R
File Number 1999-00723
Remarks RICHARD E FREEBURN
AC
Transaction Description
RENUNCIATION EXECU
Distribution Of Receipt ------------------------
Payment Amount Payee Name
15.00
CUMBERLAND COUNTY GENERAL FUN
Check# 1120
Total Received.........
$15.00
$15.00
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iIIf~7 ~-. I I t VIT AL RECORDS lllb..'l'Jl.m{../l L
APPLICATION ''1R CERTIFIED COpy OF BIRTH OR P- \TH RECORD SC!iJ Other Side
R -ADS AVAILABLE FROM 1~06 TO THE PRESL
,
'RINT OR TYPE ALL ITEMS MUST BE COMPLETED OFFICE USE ONL Y
'miCA TE NUMBER 0 BIRTK [iJ DEATK tl social security number is \l.nown 01 deceased
IF COPIES IN BOX 54,00 53,00 156 - 22 - 2381
Date at Birth Place 01 Birth Caunty Boro.lCity,:Twp. File No.
OR OR
t. Dale 01 Death 6/27/99 2, Place of Death Franklin Chambersburg
Name 01 Birth Searched By
OR CARL R. GUSTAFSON ~1 5,84
3, Name of Death 4, Sex Age Now
Father's Full First Middle Last Typed By
Name l~illiam Gusta.fson
6,
Mother's Maiden First Middle Last File Date
7. Name Mildred Bunn
Kospital Funeral Refund Ck. No,
8, Chambersburg Hospital Director Layton Funeral Home
REASON FOR REQUEST. Date Amt
9. THIS ITEM MUST BE COMPLETED Estate Administration
10. HOW ARE YOU RELATED TO PERSON IN NUMBER 3?
Attornev for the estate
In accordance with ~4904. Unsworn Falsification to Authorities, I state the above information is accurate.
11. (If subject is under 18, parent must sign,l
Sianature ReQuired: Please siQn here,
Mailing
Address 4775 Linglestown Road, Ste. 200
12.
City, State,
Zip Code Harrisburg PA 17112
1& ,
Daytime Area Code: Number:
Phone ( 717) 671-1955
14. Number
FEE FOR CERTIFIED COPIES ARE: BIRTHS $4.00 DEATHS $3.00
NOT REFUNDABLE
DO NOT SEND CASH o Prey. Amend. o Adopt o Affid,
Make Check or Money Order Payable to VITAL RECORDS
PLEASE ENCLOSE A LEGAL-SIZE SELF.ADDRESSED STAMPED ENVELOPE FOR RETURN OF COPIES n Court n l~-,~.
n IIC:.<ln<:> "~Anr
tAW OFFICES OF RICHARD E. FREEBURN
IF ALL ITEMS ARE NOT COMPLETED, APPLICATION MAY BE REJECTED
.
Vital Records
Costs
gustafson death certs
(L;
\..
P A State Bank-ope Gustafson death certificates
SF6001.'
.~~~ UH!41j',r.. Sf SLIM CK7SQ6111M IIml
TO REOl'DER, CALL YOUR LOCAL SAFEGUARD DISTRIBUYOR AT 717-651--0070
1044
07/15/99
15.00
15.00
QTB7lJZl)010000 Ul98fO'1933t
-
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lAW OFFICES
OF
RICHARD E. FREEBURN
ATTORNErSAGREEMENT
TaIS AGREEMENT entered into this;). day of July 1999, by and
between RICHARD E. FREEBURN, Attorney-at-Law (hereinafter referred to
as "Attorney") and CAROL WILLIAMS AND GLORIA HETTICH, ON BEHALF OF
THEMSf;LVES AND THE ESTATE OF CARL GUSTAFSON AND HIS HEIRS,
(hereinafter referred to as "Client").
WITNESSETH: That Attorney, for the consideration hereinafter
stipulated, has undertaken and does hereby undertake and agree with
Client(s) to act as legal counsel in negotiating a settlement, and if the same
is not effected, in bringing, conducting and prosecuting actions including
but not limited to actions for Uninsured or Underinsured motorist benefits
against all parties that they determine may be liable for damages as a result
of the personal injuries which occurred on or about 6/27/99
ATTORNEY FEES:
In consideration for services so rendered by Attorney, it is hereby
agreed by and between the parties hereto that Attorney shall be
compensated as follows:
THIRTY-THREE AND ONE-THIRD PERCENT (33 1/3%) of gross
recovery if your case is settled any time before papers are filed with the
court to list it for trial. "Gross recovery" shall mean the full amount of
settlement proceeds or the full amount of verdict, including any pre-
judgment interest, without reduction for expenses or costs advanced or
incurred.
FORTY PERCENT (40%) of gross recovery after commencement of
trial. Commencement of trial is the beginning of jury selection in a jury trial
or when the first witness is sworn in a non-jury trial or arbitration
proceeding.
If you enter into a structured settlement agreement, our fee will be
based on the applicable percentage determined as above, applied to the sum
of any cash paid in settlement plus the present cash value of the structured
portion of the settlement, and payable in full from the cash portion of the
settlement.
If any additional work is required of us after termination, either as
consultants, witnesses or otherwise, we will be compensated for such work
at our regular hourly rates, and for costs incurred.
1
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ATTORNEY'S LIEN:
Attorney shall have a lien on any sum or sums recovered, whether by
settlement or judgment, for services rendered, costs advanced and
expenses incurred under this Agreement.
EXPENSES:
Any necessary and reasonable costs advanced by Attorney in the
preparation and presentation of Client's claim, and all expenses attendant
thereto, shall be reimbursed from the proceeds of any recovery. If no
recovery is obtained, Client shall have no obligation to reimburse Attorney
for such expenses.
LEGAL REPRESENTATION
We will try to keep you currently infonned of the status and progress
of the case, but if at any time you have questions or concerns about the case,
please feel free to contact us. We will furnish you with copies of pertinent
documents and correspondence in a reasonably timely manner. You agree to
keep us currently informed as to your condition and any pertinent
developments which come to your attention.
The decision to file suit and to list for trial shall be made by you in
consultation with us.
We will make a reasonable effort to retain significant papers in the file
for a reasonable period after the conclusion of the matter. All of our work
product will be owned and retained by us. Original documents and other
tangible things furnished to us by you will be returned to you at your request
at the end or our work and upon payment of any sums due us, unless such
items are consumed in the course of our work.
Legal representation contemplated herein does not include appeals or
post trial motions, but is limited to work up to a verdict or award. We shall
have the right but not the obligation, to prosecute or defend any appeals or
post trial motions or both that we, in our sole discretion, deem expedient,
economical or advisable. or to decline to do so in which event the
representation provided for herein shall be ended.
2
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SETTLEMENT PROVISIONS:
Client(s) will not settle, adjust or compromise the above claim, or any
proceedings in connection therewith, without the advice and written
consent of Attorney. Client(s) further agree to consider seriously any
recommendation for settlement made by Attorney and not to unreasonably
withhold consent to such settlement.
DISCHARGE OR WITHDRAWAL:
In the event that Attorney subsequently determines that the claim or
suit lacks merit, or Client(s) unreasonably withhold consent to any bona fide
settlement recommendation made by Attorney, or Client(s) refuse or fail to
cooperate with Attorney, or Client(s) conceal or misrepresent facts
regarding the above claim, or Client(s) commit a breach of this Agreement,
Attorney shall have the right to terminate his services upon giving
reasonable notice to Client(s). In such event, Attorney shall be entitled to a
contingent fee on the basis as set forth above, based upon the offer of
settlement procured by Attorney, and in order to secure payment of the said
fee, Client hereby assigns the said sum to Attorney out of the proceeds
finally payable to Client in said case.
MISCELLANEOUS:
Client(s) understand, acknowledge and agree that Attorney does not
guarantee the outcome or eventual result of the above claim.
IN WITNESS WHEREOF, the parties hereto, intending to be legally
bound, have hereunto set their hands and seals of this Agreement, in
execution thereof, the day and year first above written.
Dated: 1 /z-!~7
.
By:
RICHARD E. FREQ:
~,Z. r::/
Richard E. Freeburn, Esquire
4775 Linglestown Road
Harrisburg, PA 17112
(717) 671-1955
I
C" -,",,-~.\.D .A.":l~'>~
Carol Williams
rL9J ~{~~
Witness
~::F0 .;".. ~. o~~ :r \, ,
Gloria Hettich
Witness
On behalf of themselves and the
Estate of Carl Gustafson and his heirs
3
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CLAIM It 1553470012-827
RELEASE OF ALL CLAIMS
Thi~ IndE:1nlure Witnesseth that, in consideration of the sum of Fourteen Thousand Dollars ($14,000.00)
receiPt whereof is hereby acknowledged, for myself and for my heirs, personal representatives and
a$signs, I do hereby release forever discharge Edmund Schale and Christv Schale and any other
p~r~6n, ~a,rtnership, firm or corporation charged or chargeable with responsibility or liability, their heirs,
e~e~iJlofs,' administrators, associates, representatives, successors, and assigns, from any and all claims,
denjand~,damages, costs, expenses, loss of services, actions, and causes of actions arising from any
act or oclburrence, up to the present time, and particularly an account of all personal injury, disability,
property dama@e, loss of services and loss or damages of any kind sustained or that I hereafter may
suslain in consequence of an accident that occurred on or about the 27th day of June, 1999, at or near
Rt 1'1, Sthooimsburq. Pennsvlvania.
,
To procute payment of the said sum, I hereby declare: that I am more than 1 B years of age; that no
represen\ations about the nature or extent of said injuries, disabilities or damages made by any physician,
attorney <Dr agent of any party hereby released, nor any representations regarding the nature or extent of
legal liability or financial responsibility of any of the parties released, have induced me to make this
settleme~t; that in determining said sum there has been taken into consideration not only the ascertained
injuries, disabilities, and damages, but also the possibility that the injuries sustained may be permanent
and progressive and recovery therefrom uncertain and indefinite so that consequences not now
anticipated may result from the said accident.
I hereby agree that, as a further consideration and inducement for this compromise settlement, that it
shall apply to all unknown and unanticipated injuries and damages resulting from said accident, casualty,
or event, as well as to those now disclosed.
I understand that the parties hereby released admit no liability of any sort by reason of said accident and
that the said payments and settlements in compromise are made to terminate further controversy
respecting all claims for damages that we have heretofore asserted or that I or my personal
representatives might hereafter assert because of said accident.
I further understand that such liability as I, mayor shall have incurred, directly or indirectly, in connection
with or for damages arising out of the accident to each person or organization released and discharged of
liability herein, and to any other person or organization, is expressly reserved to each of them, such
liability not being waived, agreed upon, discharged nor settled by this release.
SIGNED AND SEALED THIS
WITNESSED BY:
DAY OF
20_.
State of
County of
On this day of , 20_ before me personally
appeared to me known
to be the persons who executed the foregoing instrument, and acknowledged that they executed the
same as their free act and deed.
My commission expires
NOTARY PUBLIC
General Release
rov,03/13/00
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.
OFFICE OF CHIEF COUNSEL
DEPT. 281061
HARRISBURG, PA 17120-1061
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
1l.1lqll"'t 7, 2000
PHONE: 717787-1382
FAX: 717 772-1459
Richard E. Freeburn, F,"<1-
Freeburn & Associates
Suite 200
4775 Linglestown Road
Harrisburg,PA 17112
ll10MM J. GOHSlER
DIRECT DIAl: EXT. :lOse
IgDhslor@state.pl.US
Re: Estate of Carl R. Gustafson, deceased
Court of Common Pleas of Cumberland County'
Dear Mr. Freeburn:
The Department of ~evenue received the draft Petition for'
Approval o~ Settlement Claim, to be filed on behalf of the
above-referenced Estate, in. regard to.a wrongful death and
survival action. .
Pursuant to the Petition, the eighty-four year old decedent
died as a resUlt of injuries sustained 1n an automobile accident
June 27, 1999. Decedent is survived by four adult children.
Decedent died intestate, and did not endure ~y conociouo pain
and suffering as a result of the accident.
Proceeds of a survival action are an asset included in the
decedent's estate and are subject to the imposition of
Pennsylvania inheritance tax. 42 Pa.C.S.A. ~a302; 72 P.S.
9~9106, 9107. Costs and fees must be deducted in the same
percentages as the procccdo Qre allocated. In re E~tate of
Merryman, 669 A.2d 1059 (Pa..Cmwlth. 1995).
Please be advised that based upon these facts ano for
inheritance tax purposes only, this Department has no objection
to, the proposed allocation of the gross proceeds of this action,
$71,250.00 to the wrongful death claim and $3,750.00 to the
survival claim.
,I trust that this letter is a Bnff,; r.; Pont' representation of
the Department's position on this matter. As the Department has
no objections to the Petition, I will not be attending any
hearing regarding it. Please do not hesitate to contact me if
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.
RichardE. Freeburn, Esq.
August 7, 2000
?"'YO:! Twu
you or the Court has any questions or requires anything
additional from this Office. I can be reached by telephone or
at my electronic mail address listed above.
cc: Cutnberl~nn C:ounty Clerk of Court
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