HomeMy WebLinkAbout01-05803
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RICHARD LEBOWITZ and
DARLENE LEBOWITZ,
as parents and natural guardians of
JOSEPH LEBOWITZ, a minor,
377 Ronald Drive
Fairfield, CT 06830
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
: NO.: O,-S'~ C;o~L~~
v.
: CIVIL ACTION LAW
ASHCOMBE VEGETABLE FARM,
906 Grantham Rd.
Mechanicsburg, P A 17055
Defendant
PRAECIPE FOR WRIT OF SUMMONS
TO THE PROTHONOTARY:
Please issue a Writ of Summons to Defendant, Ashcombe Vegetable Farm in the above-
captioned matter.
BY:
Dated: /6/ 'i /6 {
WRIT OF SUMMONS
To: Ashcombe Vegetable Farm, Defendant
You are notified that the above-named Plaintiff has commenced an action
Dated: ()ri
Prothonotary
AChP -9 77lQ/J~
Deputy
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JAN-21 02 14:18 FROM:THOMAS THOMAS
7172377105
TO: 92406462
PAGE: 01
THOMAS. THOMAS & HAFER. LLP
ATTORNEYS AT LAW
(717) 237.7)O(J
STEPHEN E. OEDULDIO
"A.~N s MA;;'Ft~
TODD B. NARVDL
JAMES J. DODD-O
PAN'IZ'- L QRlLL
JOHN J. McNALLY. III
KEVIN C, McNAMARA
BROOKS R. f'1}LAND
JONATHAN C: DEISHER
JDHl< t'LOUNLACKIlR
JOHN T, HUSKI!', JR.
MICHELE J, THORP
CI-Al,JptO J. OIPAOLO
STEPHA!'IE L, HERSPEROER
HUGH P. O'NEILL. III
W, I>Al'ttltN f'Owtl.-'"
DRUMMOND B. TAYLOR
JOSEPH P. HAFER
JA~S.S Ie THn~AS. II
ROBERTSON B, TAYLOR
JEFFREY B. RErrlO
P.::T$tl J, CUI'IIly
R. BURKE McLEMORE. JR.
EDWARD H, JORtlAN. JR.
c, K.t.t'n I'Klla::,
RANDALL O. OALE
DAVltl L SCHWALM
PETER J. SPEAKER
DOUOLASB.MARCELLO
PA,UL J. OI!LLASECA
SARAH W. AROSELL
EUDENE N. McHUOH
OFCDUNSEL
JAMES K, THOMAS
:IU~ NUKTH I'KUNT STKJ:;I:iT
SIXTH !'LOOR
P.O, BOX 999
HARRISBURG. PA 17108
FAX (717) 2J7-71O~
WRITER'S DIRflCT DIAL NUMBER
(717)237-7153
m.il@tthlaw.com
Jauuary 21, 2002
Via Fax: 240-6462
Honorable Edgar B B~yley
Cumber11Uld County Courthouse
One CourthUUSI:: SI.ILIW't'
Carlisle, P A 17013
R.e: l.ebowit7 v. A~hcomhe Vegetable Farm
Our File No.: 220.11293
Dear Judge Bayley:
I am in receipt of the attached Order in this matter, The Order schedules a Hearini for
next Monday. January 28, 2002,
Please be advised that the Plaintiffs are residents of Massachusetts and will not be able to
physically attend the January 28, 2002 hearing.
1nerefore, J respectfully request that the Court consider the Petition based on the verified
....."rtions th"rein.
To the extent that the Court still deems that a Hearing is necessary, J request that
Plaintiffs be permitted to attend via telephone conterencc,
Thank you for your cOf\5idcration.
Very truly yours,
MfT/jlk
.
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I.IlHIOH VALLBY OI'fICll; ~4IlI1I!ATH "IKIi. SLJln 211I, llETHLEHEM."A I~UI7 (010) ~0~-107:; PAl( (010) ~0~-I7U2
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RICHARD LEBOWITZ and
DARLENE LEBOWITZ,
as parents and natural guardian of
JOSEPH LEBOWITZ, a minor,
PLAINTIFFS
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
V.
ASHCOMBE VEGETABLE FARM
DEFENDANT
: 01-5803 CIVIL TERM
ORDER OF COURT
AND NOW, this (b day of January, 2002, IT IS ORDERED that a
hearing on the within petition for approval of a minor's settlement shall be conducted in
Courtroom Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania, at 1 :30
p.m., Monday, January 28,2002.
Edgar B. Bayley, J.
Michele J. Thorp, Esquire
For Plaintiffs
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RICHARD LEBOWITZ and
DARLENE LEBOWITZ,
as parents and natural guardians of
JOSEPH LEBOWITZ, a minor,
377 Ronald Drive
Fairfield, CT 06830
Plaintiffs
: IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
: NO.: 01-5803 Civil Term
v,
CIVIL ACTION LAW
ASHCOMBE VEGETABLE FARM,
906 Grantham Rd.
Mechanicsburg, P A 17055
Defendant
PETITION TO APPROVE MINOR'S COMPROMISE SETTLEMENT
AND NOW, comes Plaintiffs Richard Lebowitz and Darlene Lebowitz as parents and
natural guardians of Joseph Lebowitz ("Plaintiffs") and file this Petition to Approve Minor's
Compromise Settlement and aver the following in support thereof:
1, Plaintiffs Richard and Darlene Lebowitz are the parents and natural guardians of
minor Joseph Lebowitz ("Minor").
2. Plaintiffs and the Minor reside at 377 Ronald Drive, Fairfield, CT 06432.
3. Minor was bom on June 11, 1990, and was seven (7) years old on the date of the
accident described hereinafter.
4. Defendant Ashcombe Vegetable Farm ("Defendant") is a Pennsylvania
Corporation with a principal place of business at 906 Grantham Road, Mechanicsburg, Pa 17055.
5. This Petition is filed as a result of an accident which occurred on or about October
4, 1997, at Defendant's place of business on Grantham Road in Mechanicsburg, Cumberland
County, Pennsylvania,
6, At the time of the accident, Defendant had a children's play area on its business
premises, with one of the items in the play area being signs painted with various animals.
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Generally, children placed their heads in the cut outs of the various animals and their pictures are
taken.
8. Minor was participating in aforesaid activity in the children's play area, when the
sign fell over.
9. As a result of the accident, the Minor sustained cuts to his chin and neck.
10. Minor was treated after the incident at Holy Spirit Hospital, where he obtained the
stitches. A copy of the Minor's Holy Spirit records are attached hereto, incorporated herein by
reference, and marked as Exhibit "A."
II. Since the accident, the Minor has had additional treatment, including removal of
the stitches and evaluation of the residual scar on the Minor's neck. A copy of the Minor's
medical records from Fairfield County Healthcare Associates, P.C. dJb/a Pediatric Healthcare
Associates and records from Rick Rosen, M.D. are attached hereto, incorporated herein by
reference, and marked as Exhibits "B" and "C" respectively.
12. At the time of the accident, Defendant was insured by a commercial liability
policy issued by Commercial Union Insurance Company, now known as OneBeacon Insurance.
Said policy was Commercial Union policy no. APR508858.
13. On behalf of Defendant, OneBeacon has offered to compromise this claim for the
sum of fifteen thousand dollars ($15,000.00).
14. Plaintiffs believe that this offer is fair and in the best interest of Minor.
15. Therefore, Plaintiffs request that this Honorable Court approve the proposed
settlement.
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16. Plaintiffs understand that the settlement funds will be placed in a restricted,
federally insured account, with no withdrawals from the account until Minor reaches the age of
majority, unless authorized by Court Order.
17. Additionally, Defendant requests that Plaintiffs be authorized and directed to
execute a full and final general release in the form that is attached hereto, incorporated herein by
reference and marked as Exhibit "D."
18. Defendant also requests Plaintiffs be authorized and directed to file a
discontinuance of record with the Prothonotary of the Court of Common Pleas of Cumberland
County.
Wherefore, Plaintiffs Richard Lebowitz and Darlene Lebowitz, as parents and natural
guardians of Joseph Lebowitz, pray this Honorable Court enter an order compromising this
action; approving the proposed settlement; authorizing and directing Plaintiffs to execute a full
and final release; and authorizing and directing Plaintiffs to file a discontinuance of record.
By:
~G\.Jw ~.~
Darlene Lebowitz
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ADDRESS :-- 377,<-RbNALD DRIVE ,
BfRTHtiATE~'pPiilr996 -'AGE:
i'EMPLoYER: 'ONEMPLOYED
ADDRESS:
, :" tHUR'CH :....,
COMMENT:
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OCc;UPATION: CHIi~D
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AMB:
99:7-06:;:,1.1 90
203-:-334-1';>09
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PH., #:
,NAME:
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EMERGENCY CONTACT INFORMATION
KRAU:3E ,SI::HER I REL TO PT: V '".I.:J.ORK PH #: 717.,.000-0000
~:700BARNSTAPLE IMECHANICSBURG /PA1l7055 PH #: 717-72:::-45::::7
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PH #:
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CASE
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INFORMATION
REG SOURCE: EO PATIENT TYPE: E
HOSP SERVo : ECI) FINANCj.Al;.~::LS: B,
VISIT CLINIC CODE: [::CUROUT
ICD-9 DX:
,ADMUDR:, 180018 ,ED
- 'ATTNti;~tiR,::.,.i:30d18 ED
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ADMUDX:
i:'i':'CIMPi':ei@'t: LAtERA'rIOt~(c8:r.N
AME1,BRT.IN BY:
-COMMENT:" .
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DESCI1IEIIO,i\l: PT FELL WHILE
NAME:
,ADDRESS"
" EMl='LOYER',
~;AD't;;::.;;,.;:'sS: '
R D LEBOWUZ
, 377.RON~Lti DRIVE
,AIFS INC
102 GREENWICH AVE
:Pt,..AN .', ,.~_ ,INg;lIRANCE CO
SUBSCRIBER
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LEBOWITZ ,RICHARD
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MEDICABE SECONDARY QUESTIONS:
~~::;Or:JI'1~~Ig:}, FMD: OUT OF AREA
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r ,PATIENT NAME: LEBOWITZ "JOSEPH
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BRT IN BY: PARENTS/FRIEND:::;
ACCIDENT INFORMATION
ACC.II\!D: Ci JOB RELATED: N
GETT I NG PICTURE TAKEN IN FACE
LOCATION:
SI13N .
GUARANTOR INFORMATION
PT REL TO GUAR: 0
IFAIRFIELD ICT/06432
CONTACT NAME'
IGREENWICH ICT/06830
SS :If:
PH #:
123-48-1269
203-:3:34-190'~J
PH #:
20::::-:363-60:37
INSURANCE INFORMATION
COB POLI CY # GROUP #
REL PC VFY CARD F'RECERT I AUTH # PRECERT PHONE #
O/P 1 XI3C01234:312 69 06:=:952000
o Y Y
INITIALS:
Mechanicsburg, PA Clailns &-ic.j-,'iS
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MEDICARE, SIGNATURE ON FILE: ~,5q
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AUG 1 7 19'11\'
/10111117736
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CONSE~ TO MEDICAL TREATMENT
I hereb) .sent and authorize Holy Spirit Hospital, its agents, and employees, to the rendering of medical care, which may inclu?-e routine ,diagnostic
proeedures and such medical treatment as my attending or consul~n~ physician considers to be, necessary. I also understand it 15 customary I absent
emArgency or extraordinary circumstances, that no substantial procedures will be perfGnned upon me unless or until I have had an opportunity to
discuss them with a physician or other health care professional to my satisfaction. If I am a competent adult, I have the right to consent or refuse
to consent to any proposed procedure or therapeutic treatment. I will not be involved in_any research or experimental procedure without my full knowledge
and consent. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of
injury or even death and acknowledge that no guarantee has been made to me as to the results of any examination or treatment in this Hospital.
I understand many of the physicians on the staff of Holy Spirit Hospital are not employees or agents of the Hospital. but ratJ:er are, independe~t contractors
who have been granted the privilege of using these facilities for the care and treatment of their patients. Further. I reahze this Hospltal!s a teaching
Hospital and at the Hospital are health care personnel in traioin who, unless expressly requested otherwise, may participate or may be present during
my care as part of their education. Still or tion pictuI(CS closed-circuit elevision monitoring of patient care may also be used for educational
purposes, u~I7sS I expressly request othe . e. "1"'1"
Relationship
To Patient
Date Signature
RELEASE OF MEDICAL INFORMATION
I authorize Holy Spirit Hospital to release to requesting health insurance carrler(s), their representatives and auditors. and any referring health care providers. '
such diagnostic and therapeutic information (including any information relating to treatment for alcohol and substance abuse andlor treatment of Dsvchiatnc
disorders. and/or confidential HIV related information), as may be necessary for them to determine benefit entitlement; to process payment claims for
health care services provided <Juring this hospitalization/treatment episode, and for continuing care/treatment. A photostatic or carbon copy of this
authorization shall be considered as effective and valid as the original. The undersigned also authorizes Medicare, when applicable, to release to another
insurance carrier, upon their request, medical information needed to make payment upon that claim.:
I understand and consent that the manufacturer of any implantable device i serted by my physician during the course of my surgery/procedure may be
provided with my identification informati , me ~ng so' security ber, ~s man ted by Federal Law.
Date llYll \ Signature /
INSURANCE ASSIGNMENT /-}
Date
rD\li
Signature
Relationship
To Patient
/ STATEMENT TO PE PA NT OF MED
TO PROVIDERS. PHYSICIANS A
I tequest payment of Authorized Medicare benefits to me or on my behalf for any servi rnished me by or in Holy Spirit Hospital including physician
services. I authorize any holder Of medical and other information about me, to released to Me:dicare and its agencies any information needed to determine
these benefits for related services. '
DATE: SIGNATURE:
HOSPITAL BENEFITS/PART A/EFF. DATE:
MEDICAL BENEFITS/PART B/EFF, DATE:
MEDICAL ASSISTANCE RECIPIENT
My signature certifies- that I received a service or items from Holy Spirit Hospital and Dr. on the date listed below.
I unders~nd that payment for this service or item will be from Federal and State funds, and that any false claims, statements, or documents, or concealment
of materIal may be prosecuted under applicable Federal and State Laws.
I have read and agree with the above statements:
DATE:
RECIPIENT/AGENT SIGNATURE:
RELEASE AGAINST MEDICAL ADVICE
This is to certify that It , a patient at Holy Spirit Hospital, am leaving the hospital
against the advi~e . of Dr. and the administration. I have been informed of the risk involved and hereby
release the phYSIclan and the hospital from all responsibility and legal liability,
SIGNATURE:
RELATION TO PATIENT:
FORM WITNESSED BY
D&te 1{~LlIC(]
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WITNESS:
TIME:
DATE:
Signarure
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HOLY SPIRIT HOSPITAL, CAMP HILL, PA
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CONSENT FOR TREATMENT/RELEASE OF INFORMATION
INSURANCE ASSIGNMENT
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hOLY SP~RrT hOSPITAL
E!t1ERGENCY DEPARTMENT -- PHYSICIAN REFORT
;:'at ~ ent l\.!ame ~ ~EBO~~ITZ. .jQSEOH
Pati2n~ complains of having a lac2ration on the left uoper cer~ical below
ffi.sndibiec i..dC8t"ation .:.J..?S calj~ed by blunt tr"auma apoi"'axima.tely ~ ;1GUr prim" to
ar'ri'/2l: 'Titere is no fCi'~eign oooy sensa'tion. Patient canles an'/
naurGva~c!ilar ceficits~ Patient ha! had a tetanus boaster ~itMi~ tne last -
(^
vears.AT PUMPKIN PATCH patient comolains of bruise foreheao
Nv Lilt) 'lI'-C' W<-k~""'! ~ d'(IlJ""""'J tv'Y,r
REVIEW OF SYSTEMS: Ail othe~ sy~tems are negatives
PMH: Noncontributory.
PHYSICAL EXAM: Vital Signs: Reviewed Nurse~s notes.
Pf~TIENT STi~TUS: Hlei""'t -=.nd cooperative.
1: Deec 3 em laceration of the upper neck below left mandible, clean. 1here
is no forei~~ body in the wound. No neurovascular deficit ~elated to this
injury. There are no signs of a tendon injury.
1: The affect~d area was precp€d with Betadine. 1% Xyiocain€ wi~h
ec:Irie,?h~~Tne~ LacEd blocl-t.,AFTER lAC APPLICATION tne la.ceration ~"'as explor'eci,t:-Q-"
its ba'5E. Thef~e ~"as no foreion bod v in 'i;he ~"'ound. v.Jollnd reo.3.it"ed: The skin
"as closed "lith sever'al 5-0 nylon sutures. ~1 \\ ~v.: r lA.I\
DIHGNOSIS~ /1
3 em LaC2ration of Neck, 874.8
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t:. D. Clinician:
Date:
O""TM~~"ORT
RAMESH ARORA~ M.D.
Sat Oct tZi4, 1 '397
P1ERGENCY
Page
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Initial r & X-Ray Orders:
Labs / lJ.".e Specimens
r 1 AcelE.minophen r 1 ESR
[ 1 Alcohol [ I Glucose
I 1 Amylase/Upase I I HCGS
[' JAPTI I JLlve,
[ 1 Blood Cultures Profile
[ J CBC ] Lyles
[ ICKMB I PTl'
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{ ] CAP1 Profile
[ ] Digoxin ] Quinidine
[ ] Dilantin ] Salicylate
Radiology
{ J AbdlObstr. Series
[ IAnkle
[ ]Clavicle
[ 1 Cerv. Spine Lateral
[ ] Cerv. Spine Routine
[ ] Chest RIn. / Port / TPA
1.IElbow R L
[ J Facial
[ ] Femur
[ 1 Finger
[ I Foot
[ ]Forearm
I I Hand
( ]Hip
[ 1 Humerus
{ ] Knee
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J Serum Acetone
I Theophylline
1 Thyroid Profile
I Tax Screen
JTl'A Labs
] Type & Cross --1t of units
1 Type & Screen
IU/A
]UrineC&S
1 Workman's Comp Drug Screen
] Other
jKUB
llJS Spine
I Mandible
] Nasal
lO,nit R L
J Pelvis
] Pyelogram IVf
1 Ribs A L-
I Shoulder A L
J Skull
] Sternum
lT/Spine
]Tibl Fib A L
I Toe R L
] Wrist R L
lim~/r:l=lTflnt
.
Time Seen:
Cardiac
"
I
[
[
[
.
.
Ii :l:t:,
] Monitor
I EKG paged at
I 02 lJMin.
] 02 Saturation
Respiratory
[ I ABG's paged at
[ ] Peak Flows Before/After Resp. Tx.
[ 1 Respiratory Tx.
Time
Medications !IV's ! Additional Orders
Date!Timellnt.
Special Procedures:
Ultrllsound:
[ 1 Abdomen
[ I Duplex Doppler
[ 1 Gallbladder
[ J Pelvic
CUltures
[ 1 Beta Strep AG I Cultura
[ lCarvical
( I Chlamydia
I )GCCulture
] CT Scan of
lVe Scan
lOther:
Billing Classification:
t J Levell [ J Follow up
t ILevel1l [ I Case I
!><(Lavellll
[ ) Level IV
I I Level V
Holy Spirit Hospital
Camp Hill, PA
Emergency Care Unit
Physician Order Sheet
206.ECU REV, BI96 JD,8R,MO
.'>;\""!~"," " ",""",__"'''''f'''''l''', ~,~~~ i
lime/CRTlln!.
lSputumC&S
]SlooIC&S
lStoolO&P
J Stool C. DifficiJe
1 Wound C&. S
P<1 Accident
[ ] Medical
[ 1 Medical Non.Emergency
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Initials:
Initials:
Initials:
Initials:
Signature:
Date:
rr-~~
IV: NSS! D5W! LRI D5!.45NS! D5.9NS
infuse at cclhour.
[ ] Obtain old records.
,
TAC
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Signature. '
Signature: /
Signature:
[f;
,I
R.N.
R.N.
R.N.
R.N.
MOIDO
Mechanicsburg p'" CI .
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Date:/11
Nam~
FMD:'-'
Mode of Arrivel: ~mbulato
!:JlRtAGeJ1 CHIEF COMPLAINT:
INIIAL;rRIAGE' P
L'
L ? ,'-
'P "" inin' occurr"d: H-Rome [ ] Industry [ ] Retreation [ ] Other
Information obtained from: _Patient _Family/S.O. _Records
Extremity Evaluation: Triaged' to radiology for:
Deformity Yes' No Skin Temp Warm' Cool
Skin Color Pink' Cyanotic' Mottled Pain (1~10)
. '-.
'1f!0;:6 / OJ), pj~
.
.
.
Age:
l
Log-in Time: 1/ iJ
Triage Time: I D
Time to Exam Room:
,/'-
,D(;tt..'-/~
/
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..-
_EMTlParamedic
Intervention:
(:i
Paresthesia
Present' Absent
Destinalion: [<.}ECU [ ] EDF
Time:
Signature:
Distal Pulses Present' Absent
LastTetanus!tp..-h
Visual Acuity:
espirations~
,. .)
SIP:
Pulse Ox.:
'j 'ASSESSMENT(
TemPe H( r? Pulse: I
Allergi.!s/Reaclions: Latex. Yes No
d....t')5/:::.J--- LMP:
0.0. o.S.
Weight: _scale/estimate (if pertinent)
O.U. _Corrective lenses
Subjective:
,
-1
Mf!dication/Dose/Fre
Last Dose
Has patient had exposure to measles. chickenpox orTS in past mo W-Are there advance directives? _Is copy available?_
NURSING DIAGNOSIS EXPECTED OUTCOMES
rdiac Output. alteration in _)-rrlprovement in cardiac output demonstrated by improved v.s. and diagnostic tests,
Comfort, alteration in -6.L Decrease or relief of discomfort
Fluid yoJume. alferaooT.] in _ Improvement in tluid vol. demonstrated by decrease in symptoms of fluid-vol. imbalance
Impaired gas exchange _Improved gas exchange demonstrated by improved oxygenation and vital signs
Potential/Actual infection _ Decrease in symptoms indicating infection Or potential for infection
Knowledge Deficit /' Improved knowledge demonsVated by verbalization' return demonstration
Past Medical/Surgical Histo
Assessment completed at
Data obtained by:
Admission Called: [ 1 Admission [ 1 Observation
Report called.~ Admitted to at
Disposition: [ ome [ lAMA [ ) at
Discharged:_ i I Lt-' I q 7 _ Discharge Instructions
by
'- .
R.N.
M.A
;,
Holy Spirit Hospital
Camp Hill, PA
ECU Nursing Assessment
[ ] Old Records Sent
Hrs. Transferred to at by
[ ! sartstaclO, ry [, ] J'i"J5!j>,g,d [ ] CllIical U D~ceased to morgue at
DIscharge R.N. ~&:::!::L at
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(71:-i) 763C~16., (717) 763-"2461_, ,
The exantiP.'ation and treabnent you have received in the Emerg~nciy €~re Unit (ECU) have been rende!ed nn aD emergency basis only, and are oOt intendOO,to be a substitute for or an etTon to provide
complete: medical care: If you develop new prob~~a~On{.fOrJ:tac.(,yp.l1r phy~ici8!l'or' the E~r:em:~ Care U~it. ~OLLOW THE INSTRUcnONS CHECKED BELOW.
a: - _,' '
SPEClF!C ,TRUCTIONS: Follow.,tllese instructions if they differ from the patienti)lformation sheet
WOUND CARE ,'....... ~';,-.:;,:, .EOLLOW~UP CARE
-- .~=---
D Return for suture removal in days, ,c,~,,: :'"~RetujJi,'t6ECU rFHC on for a recheck.
D Change dressing 0 See~;;:'6fn:.p1iysicjarr-or specialist if not better in_days.
and apply times a day until -, 'RenirniPECU'lf.unahle to do so.
o Tetanus/diphtheria booster given. gD8~e family I company physician / FHe Q~..:::;--n-for
}' 0 Recheck ~1:i Suture removal . / cC_ Q:..l..V
D Pick up your x-rays from the Radiology Dept on the 2hd floor
hefore going to doctor's office. (Call 763-2696 before arrival.)
o Your blood pressure was . Please get it rechecked
by your family doctor,
o Test reports'! E.D. record given to patient.
o CBC D CPRO 0 Renal Pro, 0 Glue,
o EKG D X-Ray Copy D Records Copy Chart
ADDITIONAL INSTRUCTION
D Off work I school: From
o Return to work on
o Limitation:
o No gym or sport for _days.
-0 See Workmen's Compensation sheet.
H
SPRAINSIBRIDSES
o Elevate injured part above heart for_days.
DAce 0 Sling 0 Splint 0 Crutches for_days
D Apply: D lee D Heat 0 Alternate ice and heat for
_minutes_times a day until symptom free.
D Wear cervical collar for _days.
MEDICATIONINe;RUCTIONS L)
G'rake \, 19~' , . Tylenol or Advil every~hours.
D Take the following ( O.T.C ) medicines
L \,po J.SU{J
2. NtfL''''' ,
3.
4. Your regular medicines except
D Do not drive or operate any machinery while taking
r
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D Other
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D Light D Regular duty.
of
Signatures:
I,' /J 11:;--,
!I / i /-! I
Date:
PATIENT INFORMATION: Patient information sheets contain important information to review and keep.
o Abdominal pain
o Akohol abuse
o Allergic reaction
o Asthma
o Back pain
o Bites-Human/AnimaVlnsect
OBlIm
o Chest pain
o Cc>njunctivitis
o COPD
o Corneal abrasion/foreign body
o Crouplbronchitis
o Crutch walldng
o Diarrhea and Vomiting I Ped. Vomiting
o Drug! Alcohol abuse/addiction
o Febrile conVulsion
o Fever/Ped. Fever
o Flu
o Fracture
o Headache
The interpretation of your x-ray is a preliminary report. The films will be reviewed by a radiologist and
you Or your doctor will be infonned if tllere is a change in diagnosis. I hereby:acknowledge receipt of
these instructions and equipment and understand them. I understand that I have had emergency treatment
only and that I may be released before all of my medical problems are known or treated. I will arrange
for fClllow up care as I have been instructed.
o Head injury
o Hypertension
o lnununizationsJ~us
o Kidney stones
o Laceration
o Neck strain
o Nosebleed
o Otitis media
o Pediatric head injury
o Pediatric URr~
./
~NTVERBmzEr:E
SIGNATUREY It. Ui
I ' ,
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/./,1-1'7 _1-..-
V: ,,:~'>j./.iA..,'/<---
M.D.ID.O.
R.N,
o PIDIVD
o Rash
o Seizure
o Sore throat
o Sprains and strains
o Threatened miscarriage
o Toothache
o DRI and colds
o UTI and pyelOnertiS
DOther
I <\NDINGI! b
,./ ~p.
HOLY SPIRIT HOSPITAL EMERGENCY CARE UNIT /
503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316 /
( ) Vanitha Abraham. M,D, 038840L ( ) Raben Hynick. 0.0, OS 004400-1/ /
( ) Thomas Aldous. M.D, 0I7075E ( ) Richard Luley, M.D, 029960-E ///
( ) Salvatore Alfano, M.D. 025502E ( ) Phillip Maguire, M.D, 01506 IV
( ) Ramesh Arora, M.D. 0l6727E ( ) Lawrence Paul. M.D. 0395 :E
( ) Gten Daughtry, D.O. OS006776E ( ) Frank Procopio, M.D. 00 '-E
( ) lon Dubin, D.O. OS oo6991L ( ) Ranjana Sharma, M,O, 3 65, <,;
DA'lE
& ,~'
------
SIGNATURE
/
/
IN ORDER FOR A BRAND NAME PRODUcr TO BE D\Sl'ENSED THE
PRl\SCRmER MuST HAND WRITE '"BRAND NECESSARY" OR ':BRAND
MEt>lCALLY NECESSARY" IN TIlE SPACE BELOW
7'
I
o LABEL 0 SUeSTITlIT10N PERMISSIBLE
T"'~,~,,~._
.
.
.
( ) David Spurrier, MD, 023502-E
( ) Alan Teplis. M.D, 03oo18cE
) Elaine Thallner, M.D, 057303-L
) David Zimmerman, M,D. 00S636-E
,)
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DEA#..-.lE RO',JI Tl . JOSE ~H
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ACCOUNT NUvffiER:71;1
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FAIRFIELD CGtJNTY HEALTHCARE ASSOC., Ii. C.
oba PEDIATRIC HEAiTHCARE ASSOC.
15 CORPORATE DRIQE
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FROM: 10/04/97
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1 :IENT: JOSEPH LEBOWITZ Acct: 4660
377 RONALD DRIVE Type: 8
FAIRFIELD ,CT 06430-0000
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BILL TO: JOSEPH LEBOWITZ
377 RONALD DRIVE
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Practice Info:
RICK ROSEN, MD
2600 POST ROAD
SOUTHPORT, CT 06490-1258
Fed Id 061207653
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Current 30 Days 60 Days 90 Days 120 Days+
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DATE DX DESCRIPTION CPT CHARGE PAYMNT
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FULL AND FINAL RELEASE
For and in consideration of payment to RICHARD LEBOWITZ and
DARLENE LEBOWITZ as parents and natural guardians of JOSEPH
LEBOWITZ of the sum of Fifteen Thousand 00/100 Dollars ($15,000.00), We,
RICHARD LEBOWITZ AND DARLENE LEBOWITZ (hereinafter sometimes
referred to as "Re1easors"), do hereby release and forever discharge ASHCOMBE
VEGETABLE FARM, COMMERCIAL UNION INSURANCE, CGU INSURANCE
AND ONEBEACON INSURANCE, (hereinafter sometimes referred to collectively
as "Re1easees") their insurers, employees, agents, and any and all other persons
and firms, of and from any and all actions, causes of action, claims, demands,
damages, costs, loss of services, expenses, compensation, consequential damage,
or any other thing whatsoever including claims not only for personal injuries and
damages on account of or..in any way growing out of,any and all known and
unknown personal injuries, debts, and property damage resulting or to result
from an incident involving the Minor Joseph Lebowitz that occurred on or about
October 4, 1997, at 906 Grantham Road, Mechanicsburg, Pennsylvania,
Cumberland County, Pennsylvania.
We hereby acknowledge and assume all risk, chance, or hazard that the
said injuries or damages may be or become permanent, progressive, greater, or
more extensive than is now known, anticipated, or expected. No promise or
inducement which is not herein e>.:pressed has been made to us in executing this
j
EXHIBIT
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Release. We do not rely upon any statement or representation made by any
person, firm, or corporation, hereby released or any agent, physician, doctor, or
other person representing them or any of them concerning the nature, extent, or
duration of said damages or losses, or the legal liability therefor.
This Release contains the entire agreement between the parties hereto and
the terms of this Release are contractual and not a mere recital.
We certify that we are over eighteen (18) years of age and we further state
that we have carefully read the foregoing Release and we know the contents
thereof and we have signed the same as our free act and intending to be legally
bound thereby.
IN WITNESS WHEREOF, we have hereunto set our hands and seal this
day of , 2001.
WITNESSETH:
RICHARD LEBOWITZ
DARLENE LEBOWITZ
RICHARD L. MILLER, ESQUIRE
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VERIFICATION
I, Darlene Lebowitz, Parent and Natural Guardian of Joseph Lebowitz, hereby state
that the statements made in the foregoing Petition to Approve Compromise Settlement are true and
correct to the best of my knowledge, information and belief. The undersigned understands that the
statements therein are made subject to the penalties of 18 Pa.C.S. 94904 relating to unsworn
falsification to authorities.
Date: ~
D
D lene Lebowitz, as parent and
natural guardian of Joseph Lebowitz
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VERIFICATION
I, Richard Lebowitz, Parent and Natural Guardian of Joseph Lebowitz, hereby state
that the statements made in the foregoing Petition to Approve Compromise Settlement are true and
correct to the best of my knowledge, information and belief. The undersigned understands that the
statements therein are made subject to the penalties of 18 Pa.C.S. g4904 relating to unsworn
falsification to authorities.
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Date: !.J..j/J..!OI
. chard Lebowitz, as parent an
natural guardian of Joseph Lebowitz
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CERTIFICATE OF SERVICE
I do hereby certify that on this day I served a true and correct copy of the foregoing by
first class mail, postage prepaid, addressed to the following:
Richard Miller
Ballin & Associates
151 Providence Hwy
Norwood, MA 02062-2630
Ashcombe Vegetable Farm
906 Grantham Rd.
Mechanicsburg, P A 17055
Thomas, Thomas & Hafer, LLP
Date: \ I "2-1 C:> ""'Z-
Michel J. orp,
305 N. Front Street
P.O. Box 999
Harrisburg, PA 17108-0999
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RICHARD LEBOWITZ and
DARLENE LEBOWITZ,
as parents and natural guardian of
JOSEPH LEBOWITZ, a minor,
PLAINTIFFS
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
V.
ASHCOMBE VEGETABLE FARM,
DEFENDANT
: 01-5803 CIVIL TERM
AND NOW, this
ORDER OF COURT
~q+- day of January, 2002, following a hearing, IT IS
ORDERED:
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(1) Approval ofthe settlement of this minor's claim for $15,000 for Joseph
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Lebowitz, born June 11, 1990, IS GRANTED.
(2) From the settlement of $15,000, counsel fees are awarded in the amount of
$3,750.
(3) The net proceeds of $11 ,250 shall be placed in an interest bearing fully
insured investment at the Melrose Credit Union in Queens, New York, in the name of
Joseph Lebowitz, born June 11, 1990.1
(4) The account shall contain the following notation: "NO WITHDRAWAL CAN
BE MADE PRIOR TO JOSEPH LEBOWITZ, BORN JUNE 11, 1990, OBTAINING HIS
MAJORITY EXCEPT BY AN ORDER OF A COURT OF COMPETENT
JURISDICTION."
(5) Richard Lebowitz and Darlene Lebowitz, as parents and natural guardians of
Joseph Lebowitz, are authorized to sign any release necessary to effectuate this
1 The parents' name shall not be on this account.
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settlement, and to then settle and satisfy the docket Counsel for plaintiff, Michele J.
Thorp, Esquire, shall file with the Prothonotary, and forward a copy to the chambers of
this judge, proof of compliance with this order.
~Ie J. Thorp, Esquire
For Plaintiffs
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RICHARD LEBOWITZ and
DARLENE LEBOWITZ,
as parents and natural guardian of
JOSEPH LEBOWITZ, a minor,
PLAINTIFFS
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
ASHCOMBE VEGETABLE FARM,
DEFENDANT
: 01-5803 CIVIL TERM
ORDER OF COURT
AND NOW, this ~ 1 day of April, 2002, the order of January 29, 2002, is
vacated and replaced with this order.
(1) Approval of the settlement of this minor's claim for $15,000 for Joseph
Lebowitz, born June 11, 1990, IS GRANTED.
(2) From the settlement of $15,000, counsel fees are awarded in the amount of
$3,750.
(3) The net proceeds of $11 ,250 shall be placed in an interest bearing fully
insured investment at the Peoples Bank, in Connecticut, in the name of Joseph
Lebowitz, born June 11, 1990, with the parents and natural guardians, Richard
Lebowitz and Darlene Lebowitz, as co-guardians on the account.
(4) The account shall contain the following notation: "NO WITHDRAWAL CAN
BE MADE PRIOR TO JOSEPH LEBOWITZ, BORN JUNE 11, 1990, OBTAINING HIS
MAJORITY EXCEPT BY AN ORDER OF A COURT OF COMPETENT
JURISDICTION."
(5) Richard Lebowitz and Darlene Lebowitz, as parents and natural guardians of
Joseph Lebowitz, are authorized to sign any release necessary to effectuate this
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settlement, and to then settle and satisfy the docket. Counsel for plaintiff, Michele J.
Thorp, Esquire, shall file with the Prothonotary, and forward a copy to the chambers of
this judge, proof of compliance with this order.
By the Court,
//
Michele J. Thorp, Esquire ,/
For Plaintiffs ~ ~ 'f.J..Y-6:L.
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THOMAS, THOMAS & HAFER, LLP
ATTORNEYS AT LAW
.
OF COUNSEL
JAMES K. THOMAS
(717) 237-7153
mjt@tthlaw.com
STEPHEN E. GEDULDlG
KAREN S. COATES
TODD B, NARVOL
JAMES J. OODO-O
DANIEL L. GRILL
JOHN J. McNALLY, III
KEVIN C. McNAMARA
BROOKS R. FOLAND
JONATHAN C. DEISHER
JOHN FLOUNLACKER
JOHN T, HUSKIN, JR.
MICHELE j, THORP
STEPHANIE L. HERSPERGER
HUGH P. O'NEILL. 1Il
W. DARREN POWELL
LAURAJ.HERZOG
DRUMMOND B. TAYLOR
DEREK D. BAHL
KIMBERLY A. BOHLE
MARK J. POWELL
JOSEPH P. HAFER
JAMES K. THOMAS, II
ROBERTSON B, TAYLOR
JEFFREY B. RETTIG
PETER J. CURRY
R, BURKE McLEMORE, JR,
EDWARD H, JORDAN, JR,
C. KENT PRICE
RANDALL G. GALE
DAVID L. SCHWALM
PETER J. SPEAKER
DOUGLAS B. MARCELLO
PAULJ,DELLASEGA
SARAH W. AROSELL
EUGENE N. McHUGH
305 NORTH FRONT STREET
SIXTH FLOOR
P.O. BOX 999
HARRISBURG. PA 17108
(717) 237-7100
FAX (717) 237.7105
WRITER'S DIRECT DIAL NUMBER
April 18, 2002
Honorable Edgar B. Bayley
Cumberland County Courthouse
One Courthouse Square
Carlisle, P A 17013
Re: ,Lebowitzv. Ashcombe Vegetable Farm
Our file No.; 220,1 1293
Dear Judge Bayley:
As you may recall, you presided over a Minor's Compromise hearing in the above
referenced matter on January 28,2002. I am enclosing a copy ofthe Order you issued approving
the settlement in that case.
The Lebowitzs have advised ple that they have been lmableto find a financial ins,titution
which will comply with the Order. For instance, Melrose Credit Union, which was the
institution named in the Court's Order, will not open an account for anyone under 13 years of
age and the Court Order states that the account must be in Joseph's name only. The Lebowitzs
did find that Peoples Bank in Connecticut will open a restricted account, but only if the Court
Order is changed to name them. The Bank further insists that the names of Mr. and Mrs.
Lebowitz appear on the account as co-guardians.
In light of the above problems, I would ask that the Court issue a new Order wherein the
actual bank is not named and the account is not solely in Joseph's name, but rather in Joseph's
name with Mr. and Mrs. Lebowitz as co-guardians. Accordingly, I am enclosing a proposed
amended order to that effect.
.
LEHIGH VALLEY OFFICE: 3400 BATH PIKE, SUITE 201. BETHLEHEM. PA 18017 (610) 868-1675 FAX (610) 868-1702
.
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Should you have any questioIls, please feel free to have your office contact me.
Very truly yours,
t s, Thomas & Ha r, LLP
MJT/akc:145021.4
Enclosures
cc: Richard Miller, Esquire
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RICHARD LEBOWITZ and
DARLENE LEBOWITZ,
as parents and natural guardians of
JOSEPH LEBOWITZ, a minor,
377 Ronald Drive
Fairfield, CT 06830
Plaintiffs
: IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
: NO.: 01-5803 Civil Term
v.
: CIVIL ACTION LAW
ASHCOMBE VEGETABLE FARM,
906 Grantham Rd.
Mechanicsburg, P A 17055
Defendant
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TO THE PROTHONOTARY:
Please mark the above-captioned case as settled, discontinued and ended.
Respectfully submitted,
Thomas, Thomas & Hafer, LLP
by
Date: C9 (5) /6?-
Miche e J. orp, s
LD. No.: 71117
305 N. Front Street
P.O. Box 999
Harrisburg, P A 17108-0999
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CERTIFICATE OF SERVICE
I do hereby certify that on this day I served a true and correct copy of the foregoing by
first class mail, postage prepaid, addressed to the following:
Richard Miller
Ballin & Associates
151 Providence Hwy
Norwood, MA 02062-2630
Thomas, Thomas & Hafer, LLP
Date: Ullb /O~
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RICHARD LEBOWITZ and
DARLENE LEBOWITZ,
as parents and natural guardians of
JOSEPH LEBOWITZ, a minor,
377 Ronald Drive
Fairfield, CT 06830
Plaintiffs
v.
ASHCOMBE VEGETABLE FARM,
906 Grantham Rd.
Mechanicsburg, P A 17055
Defendant
TO THE PROTHONOTARY:
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: NO.: 01-5803 Civil Term
CIVIL ACTION LAW
PRAECIPE
Please file the attached proof of deposit with regard to the above-referenced matter.
Date: U 15/07-
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Respectfully submitted,
Thomas, Thomas & Hafer, LLP
by
icll e J. ho',
J.D. No.: 71117
305 N. Front Street
P.O. Box 999
Harrisburg, P A 17108-0999
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'T".j>'!"ilr'"f",T~';"-':", ,---,c" "-, nr$ ~,
ID.2039755S24
I-:AY-2~-02 14 53 PROJi'l
......' """.~..' '~~~ ..CON~,!~~~_..PINANCE
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MAy 25, 2002
lUcbard D. LeboWitz
DarlemI Leb<lwitz
377 Roll8ld Dr
Fairfield. CT 06432
Rc: is" of loseplllwL t.ebowilZ
Ri\lhlrll Lebowilz. G\IIIdlm
Oarl.. Lebowitz, Guardian
Dear Mr. lIlId Mrs. Lebowiu.
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This !e*r i:a to eoufirm WIt on 5116/02. you opened up "cmificllte all deposit at people's
B~ ill_ abO'IIll referenced title ill 1tIc aIftOUIlt ofSll~O.DO. Per 0_ ofthl; couu of
COIlUllOD Pleas of CllInborlall4 Co\llllY, PClm,ylvallia. this aecollll1~ Ule followiDa
res!rictioD: No witbdfawa\S can be made prim' to Joseph Lebowitz. bQ~ 1U11t: 11. 1990.
obtainillg bls majorily exc;ept by order Df a court of competllDt jl1risclkjtlon. .
U'you IUlCd lII1'Y biller lDfarma\i(m. fllgauling Ws llIAUllr pleaSe do 11l1csitare to eontaet
me at 203-338-7057.
SiIleete1y.
~;:: ~np--:r-
Carole B. CroteAU
ClIStllmel' Sa-vice Manapr
Black R.oek Tumpikll Office
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PAGE 2/2
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CERTIFICATE OF SERVICE
I do hereby certify that on this day I served a true and correct copy of the foregoing by
first class mail, postage prepaid, addressed to the following:
Richard Miller
Ballin & Associates
151 Providence Hwy
Norwood, MA 02062-2630
Thomas, Thomas & Hafer, LLP
Date: Co 15 {DL
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