HomeMy WebLinkAbout01-6129IN RE: KRISTA COOMBS, Individually
and as l~a~ent and Natural
Guardian of KAYLA COOMBS,
a Minor
IN THE COURT OF COMMON
PLEAS CUMBERLAND COUNTY,
PENNSYLVANIA
No.
PETITION FOR APPROVAL OF
MINOR'S SETTLEMENT
HEARING ORDER
AND NOW, this day of ., 2001, IT IS
HEREBY ORDERED AND DECREED that a Hearing will be held on the Petition
for Approve of Minor's Settlement for Kayla Coombs, a minor, in Courtroom
No. of the Cumberland County Courthouse, One Courthouse Square,
Carlisle, Pennsylvania 17013 on the day of ,2001,
at o'clock, __.m.
BYTHECOURT:
Jt
IN RE:
KRISTA COOMBS, Individually
and as Parent and Natural
Guardian of KAYLA COOMBS,
a Minor
IN THE COURT OF COMMON
PLEAS CUMBERLAND COUNTY~
PENNSYLVANIA
PRTITION FOR APPROVAL OF
MINOR'8 SETTLEMENT
ORDER
AND NOW, this __ day of
, 2001, IT IS HEREBY
ORDERED AND DECREED as follows:
1. The settlement terms as set forth in the foregoing Petition on behalf of the
minor, KAYLA COOMBS, are hereby approved.
2. The Court specifically approves the Settlement in a lump sum of Thirty-
Five Thousand and no/100 Dollars ($35,000). The funds shall be distributed as
follows:
SCHMIDT, RONCA & KRAMER, P.C.
Attorneys fees (25%). ' $ 8,750.00
SCHMIDT, RONCA & KRAMER, P.C.
Costs incurred to date ........................... $
88.52
SCHMIDT, RONCA & KRAMER, P.C
Costs for filing fees and service .................... $ 145.50
COMMONWEALTH OF PENNSYLVANIA,
DEPARTMENT OF PUBLIC WELFARE
Lien ......................................... $
(The lien is $963.40. A proportionate share of
attorneys' fees and costs is $717.87)
717.87
WAYPOINT BANK, Camp Hill Mall, Camp Hill,
Pennsylvania 17011 to be deposited in an
account marked as follows:
~Krista Coombs, as Parent and Natural
Guardian of Kayla Coombs, a
minor' ..................................... $25,298.11
TOTAL ......... $357000.00
IN RE:
KRISTA COOMBS, Individually
and as Parent and Natural
Guardian of KAYLA COOMBS,
a Minor
IN THE COURT OF COMMON
PLEAS CUMBERLAND COUNTY,
PENNSYLVANIA
NO. O,--
PETITION FOR APPROVAL OF
MINOR'S SETTLEMENT
PETITION FOR APPROVAL OF COMPROMT-~E SETTLEMI~.NT AND
DIS~'~t'~'OTION OF PROCEI~D$ FOR KAYLA COOMBS, A M~NOR
AND NOW, comes the Petitioner, Krism Coombs, Individually and as Parent
and Natural Guardian of Kayla Coombs, a minor, and respectfully set forth as follows:
1. Petitioner, Krista Coombs, Parent and Natural Guardian of Kayla
Coombs, is an adult individual residing at 607B Geneva Drive, Apt. 14,
Mechanicsburg, Pennsylvania 17055.
2. Kayla Coombs is a Minor, born on October 15, 1998, who currently
resides in the custody of the Petitioner, Krista Coombs.
3. Kayla Coombs, a Minor, suffered lead poisoning while residing in a lead-
contaminated apartment located at 116 South Third Street, First Floor, Lemoyne,
Cumberland County, Pennsylvania {~the apartment"). Kayla Coombs and Krista
Coombs resided at the apartment for one year and three months between June of
1999 and September 21, 2000.
4. Kayla Coombs was tested for lead poisoning and it was discovered that
she had a high level of lead in her blood {Please see Medical Records attached as
Exhibit "A.")
5. A lead inspection was performed on the apartment. The lead inspection
revealed that the apartment contained lead. (Please see Lead Inspection Records
attached as Exhibit 'B.~)
6. Kerry R. Saintz is the owner of the apartment.
7. The medical costs for Kayla Coombs' lead poisoning are currently at
least Eight Hundred Forty-Eight Dollars ($848.00). (Please see copies of Medical Bills
attached hereto as Exhibit ~C.~)
8. It is most likely that Kayla Coombs will continue to incur future medical
expenses arising from the lead poisoning.
9. The Defendant had a policy of insurance with CGU Insurance.
10. The policy contained a pollution exclusion provision.
11. It was uncertain whether there would have been coverage provided
under the policy.
12. The liability limit on the policy was $50,000.00.
13. The Petitioner has entered into an agreement to settle the case for
Thirty-Five Thousand Dollars ($35,000). (Please see copy of Release attached hereto
as Exhibit ~D.")
14. The Petitioner is satisfied that the offer of settlement is just and
reasonable and is willing to accept the said offer if approved by the court.
15. In pursuing the claim against Kerry Saintz, the Petitioner engaged the
law firm of Schmidt, Ronca, & Kramer, P.C., under a contingency fee providing that
the said law firm should be paid 25% of any settlement obtained before the filing of
suit. (Please see copy of Contingent l~ee Agreement attached hereto as Exhibit ~E.")
16. Schmidt, Ronca, & I<ramer, P.C., has incurred costs associated with the
investigation of this matter.
17. The Commonwealth of Pennsylvania Department of Public Welfare has a
lien of Nine Hundred Sixty-Three Dollars and Forty-Eight Cents ($963.40) against a
recovery or settlement.
18. The Petitioner requests that your Court distribute the present payment
of Thirty-Five Thousand Dollars ($35,000) as follows:
Schmidt, Ronca, & Kramer, P.C.
Attorney fees (25%) ................... $ 8,750.00
Schmidt, Ronca, & Kramer, P.C.
Costs incurred to date ................. $
88.52
Schmidt, Ronca & Kramer, P.C.
Costs for filing fee and service ........... $
145.50
Commonwealth of Pennsylvania,
Department of Public Welfare
Lien .............................. $
(The lien is $963.40. A proportionate
share of attorneys' fees and costs is
$717.87)
717.87
Waypoint Bank, Camp Hill Mall, Camp
Hill, Pennsylvania 17011 to be
deposited in an account marked
as follows:
"Krista Coombs, as Parent
and Natural Guardian of
Kayla Coombs, a minor~ ........... $25,298.11
TOTAL .............. $35,000.00
19. The Petitioner requests that this account be authorized without the
formal appointment of a guardian of estate of the minor or the entry of security,
with the Petitioner, Krista Coombs, being authorized and directed to invest funds
belonging to Kayla Coombs, a Minor, as follows:
Ao
to invest the funds in Certificates of Deposit to
the extent possible with Waypoint Bank, not to
exceed such sums as are fully insured by F.D.I.C.;
and
to invest the balance of said sums which cannot
be invested in Certificates of Deposit, if any,
in a Savings Account with Waypoint Bank, not
to exceed sums as are fully insured with F.D.I.C.
Each account shall be marked as follows:
~This money shall be held in trust not to be
redeemed, withdrawn, negotiated, or in any
way alienated except for the renewal in its
entirety before October 15, 2016, except by
Order of this Court."
V~IERBFORE, Petitioner Krista Coombs requests that this Honorable Court
enter an Order approving the foregoing compromised settlement directing the
distribution of proceeds set herein.
Respectfully submitted,
SCHMIDT, RONCA & KRAMER, P.C.
//~Aterard C. Kramer
torney at Law
Attorney I.D. No. 44715
209 State Street
Harrisburg, PA 17101
(717) (232-6300
Attorney for Plaintiffs
VERIFICATION BASED UPON P~RSONAL KNOWL~.r~GF,
AND ~)RMATION OBTAINED THROUGH COUNSF~T.
I, KRISTA COOMBS, Individually and as Parent and Natural Guardian of
Kayla Coombs, a minor, verify that I am the Petitioner in the foregoing action and
that the attached Petition is based upon information which has been gathered by
my counsel in the preparation of this lawsuit. The language of the Petition to the
extent that it is based upon information which I have given to my counsel is true
and correct to the best of my knowledge, information and belief. To the extent that
the contents of the Petition is that of counsel, I relied upon counsel making this
Verification.
I understand that intentional false statements herein are subject to the
penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsifications to authorities.
Date:
KRISTA CO/~S, Individually
and as Parent and Natural
Guardian of Kayla Coombs,
a minor
209 State Steer
Harrisburg, Pennaylvam& 17101
71723263OO
Fex 717 232.6487
May l4,2001
2601 North Third Street
Harrisburg, PA 17110
Attention: Medical Records Depari~ient
.o _ ,,
Client : Kayh J, Coombs, a minor
K~ta J. Coombs~ parent
Ac[d~e~ : 116 Bouth Third Street, 1se Floor
Btrthdate .
Records Requeeted: ' ~ I~-/~/O0 to the
BlUe Requested : All bills from 10/05/00 to the prosent,
Dear Sir or Madam:
Our office represents the above-named patient. Please forward to my attention
copies of the following:
Ix]
any and ell hospital records, including but not Umitsd to: discha~e
summary, admitting notes, history, physical examinations, consultation
reports, x-ray or other diagnostic test reports, emergency room records,
pathology reports, operative reports, medical photographs, if any; all doctors'
orders, notes, etc.; t~ssue committee report, if any; employees' day sheet
showins names of nurses; physical therapy records; any and all outpatient
records for the dates requested above.
Ix]
any and an billings for services rendered for the dates requested above. On
your bill for hospital services, please do not show any amounts paid by
insurance, as we cannot use these ,n Court. Your b,ll should include your
Wtal charges for services without showing thc source of payment.
(Please bill us separatcly for your report or photocopy charges).
Polyclinic Medical Center
May 14, 2001
Page Two
Enclosed you will find a signed Medical Authorization authoriz/ng the release of this
information to me. Thank you for your kind attention to this matter.
Very truly yours,
SCHMIDT, RONCA & KRAMER, P.C.
er~ard C. Kramer
Attorney at Law
GCK/ det
Enclosure
ca' Billing Department
To:
POLYCLINIC MEDICAL CENTER
From: KRISTA COOMBS ~/N/G of KRISTA COOMBS and G~.RARD C. KRA~ER, HER
ATTORNEY
You are hereby authorized and directed to pe~t the e~amination of, and ~ha copying
or repr~uction in any ~er, whether ~cal, pho=ograg~c, or others.,
atto~ey or su~ o~h~r pa=son as he ~y au~hozize~ all or any portions des~r~ by h~
of =he felling:
(a) Hospital r~r~, X-rays, X-ray =~a~gs and repo~s,
l~ora=or~ recess a~ r~s, ~11 ~es~s o~ any
=harsher and rape=ts thereo~, stat~nts o~ charges, ~y and
condition, Crea~nt, ~a~os~s, pr~nosis, e~iolo~y or
(b} ~dl~l =eco~., induing patient's =~rd ca~, X-zays, X-
=es~s of *ny t~e an~ c~rac~er and re.rCs ~ereof,
otat~en~s of ~arges, an~ any and ~1 o~ my
per~a~ning =o ~cal care, his=cry, condition, treeing,
~a~osis, prognosis, etiology o=
atto~ey, or his ~lega=e, as repasted by ~ for any of ~he foregoing
By reasons of ~e ~ac= that su~ in~o~ion ~hat ~ou have ac~Lred as
s~geon is confid~ to ~, ~u are *lso re~es~ed ~o trea~ su~ infection
~nfmd~ial and =e~s~ no~ to ~u~ish an~ such ~o~tion in a~ ~om ~o an~one~
without wrl~=en authorize=ion from ~. I h~=eby re~ke an~ p=e~ousl~ da=ed ~c.1
~s ~thoriza~on d~s not pre.at ~e health care provl~r fr~ supplying billing
~d other lnfo~C~on to the fi=st pa=fy ~=rier or ~cal insult in or~= t~t the
bills are paid. It does, h~=, pre.at the ~1 provider f~
~nfo~tion to a third patty insur~ce adjuster or an adjuster for an ad~rse party,
I also au~o=ize my attorneys or ~ei= d~legate ~o photograph ~ person while
pzes~C in any ~spital.
~d valid as ~e orig~n~.
Date~ 5/14/01 '
o5/23/2OOl
11205
Name: COOMBS,KAYLA
H# : 180785446
ACCT: 429338851
~' PinnacleHealth Hospitals
James A. Piper, M.D., Medical Director
Harrisburg, PA
Age/Sex:
LOC: UNLISTED
DR: VARMA, BHUPINDER
W13589 COLL: 10/25/2000 09:30
REC: 10/25/2000 10223
INTERIM REPORT
PAGE 1
31M F
PHYS: VARMJ%,BHUPINDER
COMP METABOLIC PANEL
SODIUM
POTASSIUM
CHLORIDE
CO2
ANION GAP
ALBUMIN
ALK PHOSPHATASE
UREA NITROGEN, BLOOD
CALCIUM
CREATININE r
GLUCOSE
AST
ALT
BILIRUBIN,TOTAL
TOTAL PROTEIN
AUTO DIFF
CBCA
WBC COUNT
RBC COUNT
}{EMOGLOB IN
HEMATOCRIT
MCV
MCH
MCHC
PLATELET COUNT
RDW
MPV
WBC DIFF
NEUTROPHILS
BAND
LYMPHOCYTES
EOSINOPHILS
MONOCYTES
RBC MORPHOLOGY
140 [137-147] MMOL/L
4.8 [3.6-5.1] MMOL/L
101 [97-108] MMOL/L
26.0 [20-30] MMOL/L
13 [6-18]
4.0 [3.5-4.8] GM/DL
305 [80-450] U/L
5 [0-20] MG/DL
10.1 [8.9-10.3] MG/DL
0.3 [0.3-0.8] MG/DL
*56 [74-118] MG/DL
38 [0-40] O/L
'17 [24-65] U/L
0.5 [0.4-2.0] MG/DL
6.1 [6.1-7.9] GM/DL
REQUEST CREDITED
MANUAL DIFF ORDERED
8.59 [5.5-15.5] K/ul
*5.04 [3.70-4.90] M/ul
11.7 [11.0-14.0] G/DL
35.0 [31.0-44.0] %
*69.4 [70.0-85.0] FL
23.2 [22.0-31.0] PG
33.4 [28.0-36.0] G/DL
322 [129-366] K/ul
14.0 [11.0-15.3] %
9.0 [6.5-12.2] FL
20.0 [16-60]
1.0
66.0 [45-75]
7.o [o-8]
6.0 [0-12]
ANISOCYTES +1
POLYCHROMAS IA +1
MICROCYTES +1
COOMBS,KAYLA END OF REPORT PAGE
Schmidt, Ronca & Kramer PC
209 State Street
Hamsburg, Penns¥1vama 17101
717 / 232.6300 Fax 717 ! 232-6467
October 10, 2000
Polyclinic Medlca~enters~
2601 North Third Street
Harrisburg, PA 1~
Attention:
Medical Records Department
R~UEST FOR HOSPITAL P~CO~DS
Client : Kayl& J. Coombs, · minor
A~dxess : 116 South Third Street, 1~ Floor
Lm~ne, PA 1704~
s.s..o.
Records Requested:~~°rds from 9/1/00 to the present.
Bills l%eques~ed : ~l'bLlls fr~ 9/1/00 ~o the present.
Dear Sar or Madam:
Our office represents the above-named patient. Please forward to my
attention copies of the following:
an~ e~d &ll hospital records, including but not l~mited to:
discharge summary, admitting notes, history, physical
examinations, consultation reports, x-ray or other d~agnost~c
test reports, emergency room records, pathology reports,
operative reports, medical photographs, if any; all doctors'
orders, notes, etc.; t~ssue committee report, ~f any;
employees' day sheet showang names of nurses; physical therapy
records; any and all outpatient records for the dates requested
above.
Ix]
any and ell billings for services rendered for the dates
requested above. On your bli1 for hospital services, please
do not show any amounts paid by insurance, as we cannot use
these ~n Court. Your bill should include your total charges
for services w~thgut showing the source of payment.
(Please bill us separately for your report or photocopy
charges).
Polyclinic Medical Center
October 10, 2000
page Two
Enclosed you will find a signed Medical Authorization authorizing
the release of this information to me. Thank you for your klnd
attention to this matter.
Very truly yours,
SCHMIDT, RONCA & KRAMER,
Gerard C. Kramer
Attorney at Law
GCK/det
Enclosu=e
cc: Billlng Department
~d~oal Auth~etAon
From: K~ISTA J. ~OOMBS P/N/G of KAYLA J. COOMB$, A MI~O~ A~D GEEAED C. KEA~ER.
~ER ATTORNEY
or rep~uction zn ~y ~e~, whether ~chanl~l, photographic, or othe~ise, b~
a~o~ey o~ su~ o=her person aa he ~y autho=lze, all or any por=io~ desir~ by h~
of the follo~ng~
(a) Hospital ~ecords, X-rays, X-ray rea~ngs and r~o~s,
~n~lon, tzea~nt, ~a~nos~s, pro~osis, etxolog~ o~
e~se7
(b) ~1 reco~s, ~n~u~g ~ient's ~e~d ~, X-rays, X-
~ay readings a~ ~e~E~s, l~o:a~o~y :ecozds and ~e~rts, all
star--nra o~ ~ges, and any an~ all of my zeco~s
pez~nxng %o ~ical ~re, ~stozy, condi~ion,
~a~osis, p~O~OSiS, et~olo~ o~ expense.
You are furze: au~orized and directed to furnish ozal and written
stanley, or ~is delegate, as requested by ~ for any of the fo:ego~g
By reasons of ~e fac~ ~a~ su~ xnfo~tion that you ~ve ac~xzed as ~ phyaxcian or
s~geon is con~iden~ial ~o ~, you aze also ~ested to tzea~ su~ in~o~tion as
conZid~ial a~ ~e~es~ed no~ ~o Zu~ish any such xnZo~ion in an2 ~o~ to
wi~h~ w~i~en autho~ization ~zom ~. X hez~2 ze~ke an2 pxeviousl~
~s Au~oriza~on d~s not preset ~e h~l~ ~ pro~r fr~ supplyin~ billing
~d o=he= info~tion ~o ~e first par~y carrxer or ~cal insurer in or,er
bills a=e p~d. It ~es, h~r, pre~= Che m~oal provi~r f~m ~ly~g
~o~xon to a ~x~ palm insuran~ ad]usher o= an adJus=e~ for an ad~rse ~r~y.
I also au~horize my a=torneys or ~r delegate ~o ~ho~=aph my person ~hile X a~
p~sen~ in an~ hospi~al.
~ate. 10/i0/00
DATE TIME ....
~) PINNACLEHEALTH
Hoq~aL~
PROGRF.~S RECORD ~-'~' I ~
lo/o4/2ooo
00."28
PinnacleHealth Hos~ital~.
James A. Piper, M.D., Medical Director
Pt. Name: C00M~,j~__Y~A
Age/Sex: 23M(_._~-~_~ 10/15/1998
HOSD. No.: 180~_449j
Account #: 4299031~fT~
OrderinH Physician
T72156 COLL: 10/03/2000 1~:00 R~C: 10/03/2000 16:20 Dr. VARMA,BHUPINDER
COMP METABOLIC PA/~EL [137-147] MMOL/L
SODIUM * 138
POTASSIUM 4.4 [3.6-5.1] MMOL/L
CHLORIDE 103 [97-108] MMOL/L
C02 24.0 [20-30] MMOL/L
ANION GAP 8 ~ [6-18]
ALBUMIN 4.1 [3.5-4.8] GM/DL
ALK PHOSP~ATASE 293 [80-450] U/L
UREA NITROGEN, BLOOD 14 [0-20] MG/DL
CALCIUM 10.0 [8.9-10.3] MG/DL
CREATININE 0.3 [0.3-0.8] MG/DL
GLUCOSE 118 [74-118] MG/DL
AST * 43 [0-40]
~J~T * lS [24-65] U/L
BILIRUBIN,TOTAL 0.4 [0.4-2.0] MG/DL
TOTAL PROTEIN 6.4 [6.1-7.9] ~M/DL
AUTO DIFF REQUEST CREDITED
MANUAL DIFF ORDERED
C~CA K/ul
WBC COUNT 9.42 [5.5-15.5]
RBC COUNT * 5.20 [3.70-4.90] M/ul
~MOGLOBIN 12.0 [11.0-14.0] ~/DL
H~MATOCRIT 35.9 [31.0-44.0] %
MCV * 69.0 [70.0-85.0] FL
MCH 23.1 [22.0-31.0] PG
MCHC 33.4 [28.0-36.0] G/DL
PLATELET COUNT 276 [129-366] K/ul
RDW 13.5 [11.0-15.~]
MPV 9.2 [6.5-12.2] FL
WBC DIFF
NEUTROPHILS * 15.0 [16-60]
LYMP~OCYTES * 81.0 [25-75]
EOSINOPHILS 4.0 [0-8]
RBC MORPHOLOGY MICROC~T=S +2
WBC MORPHOLO~Y ATYPICAL LYMPHS PRESENT
COOMBS, KAYLA
END OF Pd~PORT
PAGE i
o9/28/2ooo
01,58
PinnacleHealth Hospita/"~
James A. Piper, M.D., Medical Director
Pt Name: COOMBS,KAYLA
Age/Sex: 23M F DOB: 10/15/1998
Hosp No.: 180785446
ACCOLUl~ #: 429903134
~oc.: ~ /~
W1588 COLL: 09/27/2000 UNK
Ordering Physician
REC. 09/27/2000 16:08 Dr. VARMA,BHUPINDER
CBC & MANUAL DIFF
WBC COUNT 11.37
ANALYSIS REPEATED
CONFIRMED
RBC COUNT * 4.94
HEMOGLOBIN 11.4
HEMATOCRIT 32.8
MCV * 66.4
MCH 23.1
MCHC 34.8
PLATELET COUNT
RDW
MFV
NEUTROPHILS
LYMPHOCYTES
MONOCYTES
EOS INOPEILS
RBC MORPHOLOGY
[5.5-15.5] K/ul
[3.70-4 90] M/ul
[11.0-14.0] G/DL
[31.0-44.0]
[70.0-85.0] FL
[22.0-31.0]
[28.0-36.0] G/DL
K/ul
[129-366]
PLATELET COUNT IS UNRELIABLE DUE TO
PLATELET CLUMPING
SLIDE ESTIMATE OF PLATELETS APPEARS wITHIN
NORMAL LIMITS.
13.4
10.0
20.0
73.0
3.0
4.0
ANISOC~'rES +1
MICROCYTES +1
ROULEAUX PRESENT
[11.0-15.3] %
[6.S-12.2] FL
[16-60] %
[25-75] %
[0-12] %'
[0-8] %
C00MBS, KAYLA
END OF REPORT
PAGE I
09122/2000
06:25
PinnacleHealth HOS~ltalu
James A. Piper, M.D., Medical Director
Pt, Name: COOMBS,KAYiJ~
Age/Sex: 23M ~B. 10/15/1998
Hosp NO.' 1807~46_3
Account ~: 210083-/3-z
Loc.: KLINE PED CTR POLY
Ordering Phys~cian
H61521 COLL: 09/21/2000 15:45 REC: 09/21/2000 19:33 Dr. VARMA,B}~3PINDER
LIPID PAi~EL
CHOLESTEROL FOR LIPO
TRIGLYCERIDE
HDL CHOLESTEROL
LDL (CALC}
VERY LO DENSITY LIP
RISK FACTOR LIP (CAL
H61520 COLL: 09/21/2000
195
274
48
92.2
55
4.1
RISK
1/2 AVERAGE
AVERAGE
2X AVERAGE
3X AVERAGE
[0-200] MG~DL
[<200] MG/DL
[29-89] MG/DL
[0-130] MG/DL
FEMALE MALE
3.3 3.4
4.4 5.0
7.0 9.5
11.0 24.0
· orderin~ Physician
15:42 REC: 09/21/2000 19:32 Dr. VARMA, BHUPINDER
RENAL FUNCTION PA~L
SODIUM
POTASSIUM
CHLORIDE
C02
ALBUMIN
UREA NITROGEN, BLOOD
CALCIUM
CREATININE
GLUCOSE
PHOSPHOROUS
AUTO DIFF
CBCA
WBC COUNT
RBC COUNT
HEMOGLOBIN
HEMATOCRIT
MCV
MCH
MCHC
PLATELET COUNT
RDW
MPV
WBC DIFF
COOMES,KAYLA
137 [137-147] MMOL/L
4.7 [3.6-5.1] MMOL/L
104 [97-108]
21.0 [20-30] MMOL/L
4.4 [3.5-4 8] GM~DL
10 [0-20] MG/DL
10 0 [8.9-10.3] MG/DL
0.3 [0.3-0.8] MG~DL
65 [74-118] MG~DL
5.6 [3.5-6.8] MG/DL
REQUEST CREDITED
MA~-dALDIFF ORDERED
10.43 [5.5-15.5] K/ul
* 4.92 [3.70-4.90] M~ul
11.4 [11.0-14.0] G/DL
33.1 [31.0-44.0] %
* 67.3 [70.0-85.0] FL
23.2 [22.o-31.o] Ps
34.4 [28.0-36.0] G/DL
* 369 [129-366] K/ul
13.3 [11.0-15.3] %
9.6 [6.5-12.2] FL
PAGE
1
09/22/2000
06~25
Pinna¢leHealth Hospital~
James A. Plper~ M.D., Medical Director
Pt. Name:
Age/Sex:
Hoop. No :
Accoun~ ~:
H61520
COOMBS,KAYLA
23M F DOB: 10/15/1998
180785446
210083732
Loc.: KLINE PED CTR POLY
COLL' 09/21/2000 15:42 REC:
Ordering Physlcman
09/21/2000 19:32 Dr. VARMA,BHUPINDER
WBC DIFF
NEUTROPHILS
BAND
LYMPHOCYTES
EOSINOPHILS
MONOCYTES
RBC MORPHOLOGY
FERRITIN
.. (CONTINUED)
17.0 [16-60]
1.0
* 76.0 [25-75]
1.o [0-8]
5.0 [0-12]
NO DETECTABLE RBC ABNORMALITIES
33.6 [10-155]
NG/ML
coOMBS, KAYLA
END OF REPORT
PAGE 2
CLIENT REPORT COMPLETED
Result Gert Lab
COOMBS ,KAYLA
Atn Dr: WILLIAMS RONALD J
732
Adm Dr: 09/21/00 OA Isol:
................................ 09/21/00
15:45 15:42
CHEM-ROUTINE 137
SODIUM 137-147 4.7
POTASSIUM 3.6-5.1 104
CHLORIDE 97-108 21.0
CO2 20-30 10
BUN 0-20 0.3
CREATININE 0.3-0.8 65*
GLUCOSE 74-118 5.6
PHOSPHORUS 2.5-6.8 10.0
CALCIUM 8.9-10.3 4.4
ALBUMIN 3.5-4.8
HDL CHOL 29-89 48
~RIGLYCERIDE <200 274*
92.2
LDL CHOL 0-130 ·
RISK FACTOR ' 4.1 T
CHOLESTEROL 0-200 195
o9/21/oo
LIPID EVALUA 15:45
HDL CHOL 29-89 48
TRIGLYCERIDE <200 274*
LDL CHOL 0-130 92.2
55
VLDL 4.1 T
RISK FACTOR
o9/21/oo
HEMOGRAM 15:42
WBC 5.5-15.5 10.43
RBC 3.70-4.90 4.92*
HEMOGLOBIN 11.0-14.0 11.4
HCT 31.0-44.0 33.1
MCV 70.0-85.0 67.3*
MCH 22.0-31.0 23.2
MCHC 28.0-36.0 34.4
PLATELETS 129~366 369*
RDW 11.0-15.3 13.3
MPV 6.5-12.2 9.6
09121100
DIFFERENTIAL 15:42
NEUTROPHILS 16-60 17.0
LYMPHOCYTES 25-75 76.0*
MONOCYTES 0-12 5.0
EOSINOPHILS 0-8 1.0
BAND
o9/21/oo
15:42
RBC,WBC, PLT
RBC MORPHOLO SEE TEXT
CKL67286
11:17 09/22/00 FROM CKD1,ZRPRTGF1
Result Gen Lab
coOMBS ',KAYLA F i / KPC
Atn Dr: WILLIAMS RONALD J CLINIC
Adm Dr: 09/21/00 OA ~sol:
o~/2~/oo
IMMUNOASSAY 15:42
FERRITIN 10-155 $3.6
.. [Mr#:' 1807854~
- --~-~--~i: %~ ....
a~al~O~
11:17 09/22/00 FROM CKDi,ZRPRT~F1
CKL87286
~EFERRAL DATE AND VPb LEVEL
FATHER'S ~E
~DRE~
~TERNATE ~T
ADDRESS
SIBUNGS < 6 YRS OF AGE
TESTED FOR Pb ~D Pb
H~LTH CARE PROVIDER ~.
~RONME~AL INFORMATION
DATE OF INSPE~ION
. Pb SOURCE
Does the (~hdd spend more than 10 hours .a week ~n another Ioca~on?
Does any careg~var work at an occupa~on involmng lead'~
Does any careg~ver have hobbles that use leacl~
Is the dwelhng located near lead related mdust~'~
Is the dwelhng located near a heaw traveled street?
Is there a wood burmng stove ex' furnace I,n the home?
Does the dwelhng have a mumc~pel water source9
How tong has the family i~ved st this remdenca'~
REFERRAL
. TELEPHONE
· , TELEPHONE # __
,,. TELEPHONE #
_ TELEPHONE # '1"] ~ ' ~ ~0
DATE q ',,~' ~
PATIENT NAME .. I~/O.. &Or~l~~'
DATE OF BIRTH I0 - I~ ' ~ ~
PHYSlCI~~
PINNACLEH~LTH .'
H~ais
LEAD POISONING CLINIC
EVALUATION SHEET
HISTORY,
BIRTH:
GESTATION ~(~, _WE~GHT?~G__.~_P_~ AB
FEI'At. ACTIVITY NORMAL
MED{CATION~ TAKEN_ ~0
DID YOU SMOKEY ~,/ USE ALCOHOL~ ~ ) O
DELIVERY VAGINAL. ,., SPONTANEOUS
NEWBORN H STORY.
~.E~HV.O*~VE. UN.OW"
DiAB~ES__<EL_____"RE-E~-~PS~A~
.PLU~~Rus_ (~ ~E~ATURE ~BOR
OR TAKE NON-PRESCRIBED DRUGS?~
INDUCED, C-SECTION _
CHILD'S
NUTRITION
$TATUS
MEDICAL
HWTO~
DOES THE CHILD EAT A WELL BAI~CED DIET CONSISTING OF RED MEATS AND/OR EQGS, DRIED BEANS,
PEANUT EUTTER, MILK AND/.OR CHEESE, ENRICHED EREAD AND/OR CEREAL, FRUITS AND VEGETABLES?
DOES THE CHILD EAT A LAI~GE AMOUNT OF HIGH FAT FOODS~_ ~,3
DOES THE CHILD EAT MEALS AND SNACKS REGULARLY SPACED DURING THE DAY? [1/! ~ .
ARE IMMUNIZATIONS UP TO DATE?
HOSPITALIZATIONS ~ o
SURGERIES T,~lo~ ' 3~,, g~O0
DETNLS OF ~ TRA'~MA ~ ,
iLLNESSES
PHYSICAL
MINOR MALFORMATtONS HAIR WHORL
HYPERTELORISM ~J PALATE
PALMS DPC ~ SIMIAN
SKIN
NEURO CNS
STRENGTH
.TONE
GROWTH & R. RAN R
HANDEDNESS, R_~.. L .... AMBIDEXTROUS WITH R / L TENDENCY ~/ -
8ELFHELP CUP_ ~"-~ _SPOON _f~'~ ..FORK
DRESSES SELF ~ ~ .c,,~ __ TIES SHOES _
USES FASTENERS BUTTONS, ZIPPERS, SNAPS
LANGUAGE, VOCABULARY (# OF WO D6) ~ WORDS PER SENTENCE
COLORS ~ ,- POINTS TO BODY PAP. TS_ ~
USES PRONOUNS'" YES~ NO..~. APPROPRIATELY
HOW OLD DOE~ THE C~'IiLD AOT'~...~dj.,(._ IS THE CHILD CLUM~Y OR COORDINATED?
CHILO'S
FAMILY
HI~'TOI'~Y ~ ANYONE IN YOUR IMMI~IATE FAMILY ~ ANY OI= THE FOII OWlNO?
/
ATTENTION DEFICIT DISORDER
LEARNING DISABILITY
FAILED OR HELD BACK A GRADE
BEHAVIOR pROSLEN!,S
SPECIAL CLASS IN SCHOOL
SPEECH THERAPY
SLOW/MENTAL RETAROATION
TUTORED
TREATED WiTH MEDS FOR BEHAVIOR
PSYCHIATRIC HISTORY
COMMENTS
DATE
LEAD LEVEL
HGS/HCT
FERRiTiN
SMAC 20
OT~R
TREATMENT
PHYSICIAN SIGNATURE
Y
Ranca &_Kra_mer PC;
209 State 8l~t
717 232 6300
Fax 717 232 8467
www srMaw corn
May 14, :2001
Jerome Korinchak, M.D. . .._.
503GreenhillBridgeFamilYstreetPractice ' ', [~A~ 7 9
New Cumberland, PA 17070 ':
Client : Kayla J. Coombs, a m~~ ' '
Krtam J, Coombs, pazent
Address : 116 8oath Third 8treat, 1'~ Floor
· emoy~a, PA 1
Birthdate ii 10/15/98 ~ ~/.,.~t'~
8.8. No. 1~78-~5
a~a Reque~ ~ b~s ~m 911/~ to the ~nt.
Or. gooch: :ib a-
Plea~ be ad~sed ~at I represent ~e above nmed ~ent. Please fo~ copies
of ~. ~cor~ you have~e ~diUon, ~a~ent, ~d pro~ss of mis
md,~dk~al from ~e~r ~3. ~ t9 ~ p~nt.
~ease include cop:es o~m ~p~m~r 1, 2~ to ~e ~a~
I~ve cnclo~d an ~ecuted Medic~ Aurora,on for ~, ~,ea, of ~s
to me. I ~ no~ at ~s ~e reqUes~ng ~y s~c~ p~p~cd med[~ ~po~.
If you have ~ny questions, please f~! free tn call or ~te.
Very truly
~CBMIDT, RONCA ~ KRAMER, P.C.
C.Krm'ne2~r
GCK/ det
~nc/O~Ure
Request//·
Pages '~' -
non
~at ~d
JEROME KOKINCHAK,
Mmcli. oal Au. tho z3.zm,4~L on.
~oD.
KRISTA COOMBS P/N/G of KAYLA CoOMBS AND GERARD C. KRAMER, HER
ATTOP/TEY
You are hereby authorized and ~rec=ed to pemmit the exmn~net~on of, and ~hm copying
or =eproductxon in any manner, whether mechanxcal, photographic, or otherwise, bM my
attorney o~ such other person as ha may authorize, all or any portions desxze~ by hxm
of the follow~ngz
(a} Hospital records, X-rays, X-ray reac~ngs and reports,
laboratory records and reports, all tests of any type,
character and reports thereoE, statements of charges, any and
all of my records pertaLnxng to the hospxtalxzatxon, history,
cond~tron, trea~ent, diagnosxs, prognosxs, etxology or
Medical ~acords~ includmng patxent'a record cazc~s, X-rey~,. X-
ray readings and =operas, laboratory records and reports, ell
testa of aa'Ay =~pe and character and reports ~hereof,
sta~nts o~ charges, and any and all of my recox~s
@erta~nxng to medmcal care, hxstory, conditLon~ treatment,
dxagnosls, prognos~s, etxology or expense.
You are further authorized and d~Lected to furnish oral and written reports to my
attorney, or his delegate, as requested by him for any of the foregoing matters.
B~ ~sona of the fact that a~ch inZormatlon that you ~ acquired as my phyaicaan az
surgeon is confxdential to ma, you are also requested to treat such xnforw-tmon as
confidential and requested not to furnish any such xnfozmatxon xn any form to anyone,
without wrxtten authorization from me. ! ..~ereb¥ revoke any previously dated madxcal
author£zation.
Thxs Authorization does not prevent the health care provxde= fr0~ supplying billing
and other infonuation to the first party cazrxer or medical insurer in order that the
bills a~e paxd. It does, however, prevent ~he medical provider from supplyxng ~his
xnfonuation to a thxrd party xnsurance adjuster az an ad]uste= for an a.dverae pa~cy.
I also au~horire my attorneys or thaxr delegate to photograph my pemaon whxle I am
present Ln any hospital.
I agree that i l~hotostmtic co~y of this euthorLzation shall ha considered aa effac~ive
and valid as ~he original.
Date: 5/14/01
HOLY SPIRIT HOSPITAL '"
GREEN HILL FAMILY HEALTH CEJ~TER
' PREVIOUS MEDICAL HISTORY
CHROI EMS AST MEDICAL HISTORY
ACUTE' PROBLEMS DATES
FAMILY HISTORY
JZP D
W REM
SC~EENING?ESTS
Breast
Cholestrol
Mammo
PAP
Prostate
Rectal
PEDIATRIC IMMUNIZATI O~S
DPT OPV HIB
MMR
, HEP B,,.
OTHEr_ _
NICO
ETOH
CAFF
OGCUP
DRUG ALLERGIES
TINE TESTS
DATE RESULTS
CONSULTANT
DATE>
ADULT IMMUNIZATIONS
TYPE DATES
1 1'~, 9~
lpg F6 5'¢6 G~,ILL
GRH 105
8/93
DATE/PROGRESS NOTES
D Iv~ one-t]urdq4h pm. ~oughandR!tnmn suspmmon one-thmiteaspm~n b t d 2 Inamse flmds, am Tylenol
3 The motl~ w~l call vath pmblcnn, otlm-~se she val~ ,~-tum for l~r ~an~al cl~,,~ nnd p r n.
HO~Y SPIRIT HOSPITAL
GREEN HILL FAMILY HEALTH CENTER
PROGRESS NOTE8
Gl:IH ~00
7M
1 1~ 9o ~154~?
180 Z~ 5446 GHOUL FH
-PROB#I SOAP
_ 5: ""if present, (or nol:e dm*a,t ....
DATE/PROGRESS NUT~
TELEPHON~ ME,~SAGE
r~z ~ o~. ~ ~m 1Oat,e last see~.
SO~ ~OAT SOB
, - , fl
,. ......... ~.~ ,
10 15 98 415&27
180 7a ~6 GHILL ~'H
GRH 100
7/96
PROB #
80AP
DATE/PROGRESS NOTES
2
3
P 1
2
Permten~ I~o~'tutts
Tum,Ckgmidm D ~L one-~u~d tmspomi q 4b. P r 1L cough and coarsen
3 ~q~ m~.~
5 _~.~_~ ~ m ~ ,m~' ~Prn ~
GREEN HILL FAMILY H~ CE~ER O ),I g L F M
PROGRE~ NOTES
PROB #
D~TE .~ '
.~"
A
2
P 1
2
She wdl ~ on m~n ~ and ...........
i: HOLY SPIRIT HOSPITAL
GREEN HILL FAMILY HEALTH CENTER
PROGRESS NOTES
J
,i,i '_l.
GRH
7196
Schmidt, Ronca & .Kramer PC
209 State Street
Harnsburg, Penmytvama 17t01
717 [ 232-6300 Fax 717 / 232-6467
October 10, 2000
Jerome Korlnchak, M.D.
Greenhzll Family Pract~c~
503 Brzdge Street
New Cumberland, PA 17070
Birthdate :
S.S. No. :
Reoords RequeSted:
Bxlls Requested :
Av. orne2 s and /ors at
Kmyla J. Coo~i3e, & ~nor
Lm~oyne, PA 17043
10/15/98
180-78-5446
Ail balls fro~ 9/1/00 to the present.
Dear Dr. Korlnak:
Please be advised that I represent the above named patient.
Please forward copies of all records you have kept on the condltlon,
treatment, and progress of thi~lndlvldual from Septenkber.1, 2000
to the present. ~//w/&~ .-
Please lnclude cop~es of all billings from September 1, 2000 to the
present. ""'
I have enclosed an executed Medical Authorization for ~he release
of this information to me. I am not at thls time requ~tlng any
specially prepared medical reports.
tf you have any questions, please feel free to call or write.
Very truly yours,
SCHMIDT, RONCA & KRAMER, P.C.
r~ard C. Kramer
ttorney at Law
GCK/det
Enclosure
' JEROHE KOI~.I~CP~tI~. ~
You ~e he~y ~u~ho~zed and ~ec~ed ~o ~ ~he ex~n~on o~ and ~h~
~t~o~e~ o~ ~u~ o~h~ person as ~ ~y authoz~ze~ a~ o~ any po~Lons des~ b~ hLm
of the follo~ng~
(a) HospLtal records. X-rays. X-ray readings and
laboratory records and reports, all tests of eny type,
characCer end reports thereof, statements of ~arg~s, any
all of ~ records pertaining ~o ~he hospi~alizatlon, history,
~l~n, trea~, ~a~os~s, prognosis, e=~olog~ or
~1 =eco~, ~nclud~ng patient's ~eco~ ca~, X-rays,
ray rea~ngs and ~epor~s, l~ora~or~ re~s and reports, all
tests o~ an~ t~ a~ chaza~e~ a~ repo~s thereof,
pertaining ~o ~cal care, ~s=ory. con~ion, trea~ent~
~agnosis, prognosis~ e~ology or e~ense.
You ar~ further au~horized and directed ~o fu~sb oral a~ wr=~en =e~E~s ~o my
By =eas~s of ~he fac~ ~ha~ such ln~o~lon ~ha~ you ~ve acq~r~
surgeon As Conflden=Lal to M. you are also re~est~ Co ~reat su~ info~tL~ as
~fld~=ial and reCesSed no~ ~o ~urnlsh ~y such ln~o~t~on in any ~om to ~e,
authorLza~on.
T~s ~orlzation ~es not prevent ~e health care pro,der ~r~ supplying b~lng
and other ln~o~tion to the ~lrst party ~=rier or ~cal insurer ~n o~er that the
I also aUthOrLZe my at~o~ys or ~helr delegat~ Co pho~ogra~ my person w~l~
p~s~ in ~y hospital.
SOAP DATE/li~OQRE88 NOTI=.~
HOLY
GREEN HILL FAMILY HEALTH CENTER
PROQRES$ NOTES
12 15 98
180 75 5446
"' P.ROB # [ 80AP I .DA~RESS NOTES
PROB # I' ~OAP I DATE/PFIOGFII=$$ NOTES
TELEPHON~
GREEN HILL FAMILY H~ CENTER ~ , ~ G t,, ,. L F H
PROQRESS NOT~
Atn Dr: VARMA B~UPINDER
/ 9b
REF Pt#: 429903147
LAB
AdA Dr: 10/03/00 0A Isol: Mr#: z80785446
09/21/o0 o9/21/o0
C~EM-ROUTINE
SODIUM 137-147
POTASSIUM 3.6-5.1
CHLORIDE 97-108
CO2 20-30
BUN 0-20
CREATININ~ 0.3-0.8
GLUCOSE 74-118
PHOSPHORUS 3.5-6.8
CALCIUM 8.9-10,3
ALBUMIN 3.5-4.8
HDL CHOL 29-89
TRIGLYCERIDE <200
LDL CHOL 0-130
RISK FACTOR
15:45
48
274*
92.2
4.1
T
15:42
137
4.7
104
21.0
10
0.3
65*
5.6
10.0
4 4
CHOLESTEROL 0-200 195
o9/21/oo
LIPID EVALUA 15:45
HDL CHOL 29-89 48
TRIGLYCERIDE <200 274*
LDL CHOL 0-130 92.2
55
VLDL 4.1 T
RISK FACTOR
o~/21/oo
HEMOGRAM 15:42
WBC 5.5-15.5 10.43
RBC 3.70-4.90 4.92*
HEMOGLOBIN 11.0-14.0 11.4
HCT 31.0-44.0 33.1
MCV 70.0-85.0 67.3*
MCH 22.0-31 0 23.2
MCRC 2B.0-36.0 34.4
PLATELETS 129-366 369'~
RDW lZ 0~15,3 13.3
MPV 6.5-12.2 9.6
o9/2z/oo
15:42 /
I FFERENTIAL 17.0
N~UTROPHILS 16-60 76 O*
LYMPHOCYTES 25-75
MONOCYTES 0 - 12 5.0
EOSINOPHILS 0-8 1.0
BAND ~.0
o9/2z/oo
',WBC,PLT 15:42
~C MORPHOLO SEE TEXT
13:37 10/09/00 FROM CKDi,ZRPRT(]F1
R~ult Gen Lab
~DOMBS , KAYLA F i / REF Pt#: 429903147
Atn Dr. VARMA BHUPINDER LAB
Adm Dr. 10/03/00 OA Isol: Mr#. 180785446
o9/ 1/oo
IMMUNOASSAY 15
FEKRITIN 10-155 33.6
13:37 10/09/00 FROM C](D1,ZRPRTOF1
CKL88899
Resul~ Gen Lab
coOMBS , KAYLA
Atn Dr. WILLIAMS RONALD J
F
/
CLINIC
Iso1:
KPC
Pt%: 210083732
Mr#: 180785446
Adm Dr: 09/21/00 OA
o9/21/oo o9/2i/oo
CHEM-ROUTINE 15.45 15:42
SODIUM 137-147 137
POTASSIUM 3 6-5.1 4.7
CHLORIDE 97-108 104
CO2 20-30 21 0
BUN 0-20 10
CREATININE 0 3-0.8 0.3
GLUCOSE 74-118 65*
PHOSPHORUS 3.5-6.8 5.6
CALCIUM 8.9-10.3 10.0
ALBUMIN 3.5-4.8 4 4
HDL CHOL 29-89 48
TRIGLYCERIDE <200 274*
LDL CHOL 0-130 92.2
4.1 T
RISK FACTOR ~
CHOLESTEROL 0-200 195
===========================================================================
o9/~1/oo
LIPID EVALUA 15:45
HDL CHOL 29-89 48
TRIGLYCERIDE <200 274*
LDL CHOL 0-130 92.2
VLDL 55
RISK FACTOR 4 1 T
09/21/00
HEMOGRAM 15.42
WBC 5,5-15.5 10.43
RBC 3.70-4 90 4.92*
HEMOGLOBIN 11.0-14.0 11.4
HCT 31.0-44.0 33.1
MCV 70.0-85.0 67 3*
MCH 22.0-31.0 23.2
MCHC 28.0-36.0 34.4
PLATELETS 129-366 369*
RDW 11 0-15.3 13 3
MPV 6 5-12.2 9.6
o~/2i/0o ~ -
DIFFERENTIAL 15:42
NEUTROPHILS 16-60 17.0
LYMPHOCYTES 25-75 76.0*
MONOCYTES 0-12 5.0
EOSINOPHILS 0-8 i 0
BAND 1.0
09/21/00
RBC,WBC,PLT 15:42
RBC MORPHOL0 SEE TEXT
CKL87286
11:17 09/22/00 FROM CKD1,ZRPRTGF1
Result Gen Lab
C00M~S ,KAYLA F 1 / KPC Pt#: 2~0083732
Atn Dr: WILLIAMS RONALD J CLINIC
Adm Dr: 09/21/00 OA Isol' Mr#: 180785446
o9/2 /oo
IMMUNOASSAY 15:42
FERRITIN 10-155 33.6
==== ...... ======================= of Report-==='===~==~==-"==-~=='"'=~lu~
11.17 09/22/00 FROM CKDi,ZRPRTGF1
cKL87286
October 10, 2000
Schmidt, Ronca Kramer' PC
209 State Street
Harrisburg, Pennsylvania 17101
717 / 232-6300 Fax 717 / 232-6467
Attorneys and Counselors at Law
Holy Spirit Hospital
North 21st Street
Camp Hill, PA 17011
Attention: Medical Records Department
REQUEST FOR HOSPITAL
Records Requested:
Bills Requested :
Client : Kayla J. Coombs, a minor
Krista J. Coo~bs, parent
Ad,tess : 116 South Third Street, ist Floor
Lemoyne, PA 17043
Birthrate : 10/15/98
S.S. No. : 180-78-5446
All medical records from 9/1/00 to the present.
Ail bills from 9/1/00 to the present.
Dear Sir or Madam:
Our office ~epresents the above-named patient. Please forward to my
attention copies of the following:
[x] any and all hospital records, including but not limited to:
discharge summary, admitting notes, history, physical
examinations, consultation reports, x-ray or other diagnostic
test reports, emergency room records, pathology reports,
operative reports, medical photographs, if any; all doctors'
orders, notes, etc.; tissue committee report, if any;
employees' day sheet showing names of nurses; physical therapy
records; any and all outpatient records for the dates requested
above.
Ix] any end all billings for services rendered for the~ates
requested above. On your bill for hospital services, please
do not show any amounts paid by insurance, as we cannot use
these in Court. Your bill should include your total charges
for services without showing the source of payment.
(Please bill us separately for your report or photocopy
cha~ges).
Holy Spirit Hospital
October 10, 2000
Page Two
Enclosed you will
the release of this information to me.
attention to this matter.
Very truly yours,
SCHMIDT, RONCA & KRAMER, P.C.
e~rard C. Kramer Attorney at Law
GCK/det
~l°~epartment
find a signed Medical Authorization authorizing
Thank you for your kind
MOLY ~P. IRIT HOSPITAL
~ioal Authorization
From: KRISTA J. COOMBS P/N/.G of KAYLA J. COOMBS, A MINOR AND GERARD C.rKRAMER,
'HER ATTORNEY
You are hereby authorized and directed to permit the examination of, and the copying
or reproduction in any .manner, whether mechanical, photographic, or otherwise, by my
attorney or such other person as he may authorize, all or any portions desired by him
of the following=
(a) Hospital records, X-rays, X-ray readings and reports,
laboratory records and reports, all tests of any type,
character and reports thereof, statements of charges, any and
all of my records pertaining to the hospitalization, history,
condition, treatment, diagnosis, prognosis, etiology or
expense;
(b) Medical records, including patient's record cards, X-rays, X-
ray readings and reports, laboratory records and reports, all
tests of any type and character and reports thereof,
statements of charges, and any and all of my records
pertaining to medical care, history, condition, treatment,
diagnosis, prognosis, etiology or expense.
You are further authorized and directed to furnish oral and written reports to my
attorney, or his delegate, as requested by him for any of the foregoing matters.
By reasons of the fact that such information that you have acquired as my physician or
surgeon is confidential to me, you are also requested to treat such information as
confidential and requested not to furnish any such information in any form to anyone,
without written authorization from me. I hereby revoke any previously dated medical
authorizstion.
This Authorization does not prevent the health care provider from supplying billing
and other information to the first party carrier or medical insurer in order that the
bills ara paid. It does, however, prevent the medical provider from supplying this
infozmation to a third party insurance adjuster or an adjuster for an adverse party.
I also authorize my attorneys or their delegate to photograph my person while I am
present in any hospital.
I agree that a photostatic copy of this authorization shall be considered as effective
and valid as the original.
Date: 10/t0/00 I Fa~6n~/Guardia~nis--~rator
Page ~ oI
Test Results
6,L )RATORIES
2211 Michigan Avenue Phone 800.'423.71 l0
Santa Monico, CA90404-3900 Fax 310,828,6634 -DOB:
Laboratory
~3 N. 21st Street
Hills,PA 17011
/ Fax:717 763-2941 / 717 763 2947
fician:
Client
Accession #
091
t Status:
orted
-10/15/1998
415427
Jerome L.
6:31:00 PM
Specialty Accession #
098-5197029
LT/00 4:05:00 AM PST
1:15:00 AM PST
,EAD WHOLE BLOOD
A.alyte _1{[Jesuit Il Reference Range
Specimen IiVen°us il
~FE~NCE ~NGES for Lead ~ole Blood:
Age Reference Range Ale~
< 15 years old < 10.0 mc~dL > 20 mcWdL
15 years and older < 10.0 mc~dL > 30 mcffdL
OS~ Indus~ial Alert .... > 40 mc~dL
Lead Whole Blood: Confirmed by repeat analysis.
This test result or one or more of its components was developed
and its performance characteristics determined by Specialty
Laboratories. It has not been cleared or approved by the U.S.
Food and Drag Administration. The FDA has determined that such
James It. Pele;. M.D., Ph.D,
Page 1 of I
~,,,,.//,,~,,~, a~*~,,~qnnrtmd eomffiles/17r26541447.htm 9/21/2000
', -- /SPECIALTY LABORATORIES
jJ~ ,~* 2211 Michigan Avenue Phone 800~421.7110
~',~ Santa Monica, GA90404-39O0 Fax 310 828,6634
Holy Spirit Hospital
ATTN: Laboratory
503 N. 21st Street
Camp Hills,PA 17011
Tel / Fax:717 763-2941 / 717 763 2947
Patient: IICOOMBS,KAYLA J
;ex: lip
Age-DOB: Ill - 10/15/1998
Patient ID: 415427
M.D. Jerome L.
Physician: Korinchak
Collection 9/7/00 4:49:00 PM
Date:
Client Specialty Accession #
~ccession #
0907K28-OUT 098-5130644
Received 9/9/00 3:57:00 AM PST
Da(e:
Result Status: Complete
Reported 9/11/00 2:47:00 AM PST
Date:
Report
Comments:
LEAD WHOLE BLOOD
Analyte l[ Result
Reference Range
Specimen IlVeno.s II
Lead Whole Blood ll4z.~* II < 10.0 mcg/dL
REFERENCE RANGES for Lead Whole Blood:
Age Reference Range Alert
<15 years old <10.0mcg/dL >20mcg/dL
15 years and older < 10.0 mcg/dL > 30 mc~dL
OSHA Industrial Alert .... > 40 mcg/dL
Lead Whole Blood: Confirmed by repeat analysis.
This test result or one or more of its components was developed
and its performance characteristics determined by Specialty
Laboratories. It has not been cleared or approved by the U.S.
Food and Drug Administration. The FDA has determined that such
clearance or approval is not necessary.
I James B, Pelet. M.D..
Page 1 of 1
http://www.datapassportmd.com/Files/17r25541615.htm 9/11/2000
UN DATE'~ 10/1~/00
UN TIME; , -~-~c
I-IflkY ~PlRIT HOSPITAL, C~P' HILL~ l~',~l I~LI!
I~r ~RTMEbII' OF LABORATORY MEDiC[NEt
STEPHENSON S~P. SNAMIDOS~ M.D.~ OIRECTDR
*~***DISCNARGE SUMMARY~**~
'ATIENT: COOMBS~KAYLA J Acc'r ~: 0000156472~0 L.{'C: OP R~8 U ~: 415427
AGE/SX: IY 11M/F ROOM: REG: 09/15/00
:EG OR: KORINCHAK~dEROME L MD STATUS: REO CI_I BOD: DIS:
REFERENCE LA8 TESTING
LEAD,BLOOD
ate T I me .......................
)?/1~/00 1839 (a)
~OTES: (a) SEE SEPARATE REF'ORT
* denotes PANIC value
Patient: COOMBS,KAYLA d Age/Sex: 1Y llM/F Acct~O00015647~90 Unit#416427
TIME:
***~*DISCHARSE SUMMARY*w*~*
~ATIENT: COOMBS,KAYLA J ACCT ;: 000015603962 LOC: OP R.~.G U ~: 415427
AGE/SX: 1Y IOM/F ROOM: RES: 09/07/00
{ES DR: KORINEHAI(~JEROME L MD STATUS: RES ELI BI~D: DIS:
REFERENCE LA8 TESTING
LEAD,BLOOD
)ate Time
)9/07/00 1649 (a)
~OTES: (a) SEE SEPARATE REPORT
* denotes PANIC value
r'a%ient: COOMBS,KAYLA J Age/Sex: 1Y iOM/F Ac,::%1000015603962 Unit1415427
PINNACLE HEALTH
POLYCLINIC HOSPITAL
CHILDHOOD LEAD POISONING PREVENTION CENTER
2601 NORTH THIRD STREET
HARRISBURG, PENNSYLVANIA 17110
(717) 782-2884 or 1-800-374-7114
TO:
FROM:
DATE:
RE:
Krista Coombs
~(Karen Orlando, RN
Public Health Nurse
September 22, 2000
Environmental inspection for lead-based paint
Enclosed is a copy of the environmental inspection for your child, Kayla Coombs.
If you have any questions regarding this inspection please do not hesitate to call me,
Thank you.
Enclosures (3)
This program is partially funded through a contract with the Pennsylvania Department of Health.
LEAD PAINT INSPECTION
REPORT
REPORT NUMBER:
INSPECTION FOR:
0912tl00 11:27
Kayla Coombs
PERFORMED AT:
116 S. 3rd Street
Apt #t
Lemoyne, PA 17043
iNSPECTION DATE:
INSTRUMENTTYPE:
09121100
RMD
MODEL LPA-I
XRF TYPE ANALYZE
Serial Number: 1528
ACTION LEVEL: 1.0 mglcm=
OPERATOR LICENSE: ooo51o
PINNACLE HEALTH
POLYCLINIC HOSPITAL
CHILDHOOD LEAD POISONING PREVENTION CENTER
2601 NORTH THIRD STREET
HARRISBURG, PENNSYLVANIA 17110
(717) 782-284 or 1-800-374-7114
Date:
Owner:
Address:
Re;
September 22, 2000
Kerry Saintz
731 Harrisburg Pike
Dillsburg, PA 17019
Lead-based paint inspection at 116 South 3rd Street, Apartment 1
Lemoyne PA 17043
Dear Mr, Saintz:
As owner of the above named property, you are hereby advised that a child who
lives at or frequently visits the above named address is being followed for an
unacceptably high blood lead level. An environmental investigation was conducted at
the above named address and revealed the presence of lead-based paint hazards.
Enclosed is the report of the inspection. The detailed report has the readings
segregated first by room number and then by type of structure with the exterior rooms
appearing first. This report is for your reference and shows all areas tested. A P (poor)
under paint condition designated a defective surface (chipping, peeling, cracked). An I
(intact) indicated the surface is not a hazard at the present time. The areas positive
and intact are not an immediate hazar(t, but would be hazardous if the surface should
fall into disrepair or if the surface is disturbed during renovation work.
The summary report is organized exactly like the detailed report, however, only
readings or averaged sets that have a lead value that is equal or greater than the action
level are listed. A lead hazard constitutes painted surfaces that contain lead greater
than or equal to 1.0 p.g/cm2 and are in disrepair, (chipping, peeling, cracked or
blistering), even if the leaded layer(s) does not constitute the top layer(s) of paint. The
areas listed in this summary report with a paint condition of (P) must be corrected.
As painted surface's age, lead-based paint becomes brittle and produces chips
and fine dust particles that are easily picked up on children's fingers. Due to the normal
hand to mouth activity of small children, this leaded dust is ingested. Exposure of young
children to lead can result in developmental delays, attention deficit disorder, learning
disabilities, mental retardation and in extreme cases death. The only way to prevent
and treat lead poisoning is to eliminate the child's intake of lead by reducing the lead
hazard in his/her environment.
Prior to undertaking any actions to achieve a lead safe environment it is
necessary to read the enclosure "LEAD BASED PAINT: HAZARD REDUCTION
GUIDELINES".
Our goal is to assist families of children with lead poisoning in their efforts to
reduce the lead hazards in their environment. Through our education efforts and your
cooperation in correcting the lead hazards in the child's home environment we can
reduce the risks of lead poisoning for these children. If you have any questions or
concerns please call the Childhood Lead Poisoning Prevention Center at (7'17) 782-
2884 or 1-800-374-7114.
Sincerely,
Karen Orlando, RN
Public Health Nurse
CC;
Cumberland County Housing Authority
Lemoyne Codes Enforcement Officer
Child's Physician
Cumberland County State Health Center
Famity
Enclosures: (6)
This program is partially funded through a contract with the Pennsylvania Department of Health.
DETAILED REPORT OF LEAD PAINT INSPECTION FOR: Kayl~a Coombs
1{3spection Datd:'
Report Date:
Abatement Level:
Report No.
Total Readings:
Job Started:
Job Finished:
09/21100
9/22/2000
1.0
09/21100 11:27
135
09/21100 11:27
09121/00 12:56
116 S. 3rd Street
Apt #1
Lemoyne, PA 17043
Paint Lead
Reading (mglcm=) Mode
No. Well Structure Location Member Cond Substrate Color
Exterior Room 001 Front porch
005 C Door L£t Rgt ~amb
004 C Door
006 C DOOr L~t U ctr
008 C Door Rgt
009 C Door Rgt L£t casing
010 C Door Rgt U Cfr
007 C Threshold
011 C Threshold Rgt
Comment: Reeding#'e 8-11 are for the entrance to
that she end the child do sit on the front steps, and the
access to the door. The front porch overhangris noted as
and peeling white paint. Unable to test with the XRF due
p Wood White 1.8 QM
I Wood White 2.0 Q~
I Wood Green 1.2 QM
p Wood White 1.6 QM
p Wood White 3.5 QM
p Wood White 1.4 QM
p Wood Green 3.7 QM
p Wood Green 0.1 QM
house # 114. Mom states
child does have
having chipping
to the height,
Exterior Room 002 Side Porch
069 B Door Ctr Rgt casing Z Wood
070 B Door Ctr U Cfr p Wood
071 B Threshold Ctr p Wood
072 D Window Lft Rgt casing I Wood
White 1.3 QM
White 1.4 QM
Gray 2.7 QM
White >9.9 QM
Interior Room 001 Living ~m
030 A Window Ctr Rgt ~amb p Wood
031 A Window Ctr Rgt Jamb p Wood
024 A Window Cfr ltgt casing P WOOd
026 A Window Ctr Sash I Wood
027 A Window Ctr Well p Wood
028 A Window Cfr Well B Wood
029 A Window Ctr Well p Wood
White 1.3 Q~
White 1.4 Qt4
Beige -0.1 QM
Beige 0.0 ~
White 1.0 QM
White 1.0 QM
White 0.2 Q~
Average = 0.6
025 A Window Ctr Ell1
032 A Window Ctr Part. bead
013 A Door Rgt Rgt casing
012 A Door Rgt Lft casing
014 A Door Rgt U Ctr
016 C Door Lft Rgt ~amb
015 C Door Lft Rgt casing
017 C Door Lft U Ctr
018 C Door Ctr Lft casing
019 C Door Ctr U Ctr
021 C Door Rgt Rgt jamb
020 C Door Rgt Rgt casing
022 C Door Rgt U Ctr
033 D Wall U Cfr
023 D Baseboard Ctr
035 D DOOr Lft Rgt ~.mZ~
034 D
Comment:
The
Wood Beige -0.1 QM
Wood White 0.6 QM
Wood Beige -0.1 ~M
Wood Beige -0.1 QM
Wood Green 0.1 QM
Wood Beige -0.2 QN
Wood Beige -0.1 QM
Wood Beige -0.1 QM
Wood Beige -0.1 Q~
Wood Beige -0.1 QM
Wood Beige 1.3 ~
Wood Beige -0.1 QM
Wood Beige 0.2 ~
Plaster Beige 0.3 Q~
Wood Beige 0.1 ~M
Wood Beige 0.2 Q~
0.0 9M
Door Lft Rgt casing I Wood Beige
Readings 9 34 and 35 are for the entrance to the dining room.
DETAILED REPORT OF I:EAD PAINT INSPECTION FOR: Kayla Coombs
Paint Lead
Reading Color' (mglcm2) Mode
No. Wall Structure Location Member Cond Substrate
recoa~nded treatment £or ~.~a £ron~ window is stablizatio- ~ith .-~,,~,~t and
than ~he well area covered wi~h aluminum coil stock and ~hen the edges
sealed with caulking.
Interior Room 002 Dining ~m
036 A Window Ctr Rgt casing I Wood Beige 0.0 QM
OS9 A Window Ctr Sash I Wood Beige -0.2 QM
039 A Window Ctr Well I Wood White 1.0 QM
037 A Window. Ctr Sill I Wood Beige 0.2 QM
043 C Window Ctr Rgt ~amb I Wood White 1.0 QM
044 C Window Ctr Rgt ~amb I Wood White 1.0 QM
045 C Window Ctr Rgt ~amb I Wood White 0.4 QM
Average = 0.7
040 C window Ctr Well p WoOd White 0.7 QM
041 C Window Cfr Well p Wood White 1.0 QM
Average -- 0.9
042 C Window Ctr Well p Wood White 1.0 QM
053 D Baseboard Ctr I Wood Beige -0.1 QM
052 D Window Ctr Rgt jamb p Wood White 1.4 QM
048 D Window Ctr Sash I WoOd Beige 1.0 QM
049 D Window Ctr Sash I Wood Beige 1.0 QM
050 D Window Cfr Sash I Wood Beige 1.0 Q~4
Average m 1.0
051 D Window Cfr Well p WoOd White >9.9
047 D Window Ctr Sill I Wood Beige -0.1
046 D Window Ctr Lft casing I Wood Beige -0.1
Co~nt: The side window needs to receive the same ~reatment as the living
room window.
Interior Room 003 Kitchen -0.1 QM
054 A DOOr Lft L~t casing X Wood Beige
055 C Window Lft Rgt casing p Wood Beige -0.1 QM
056 C Window Lft Sash p Wood Beige 0.0 QM
057 C Window Lft Sill p Wood Beige -0.2 QM
058 C Door R~t Lft casing p WOod Beige -0.1 QM
059 C Door Rgt U Ctr I Wood Beige 0.1 QM
065 D Baseboard Cfr X WoOd Beige -0.1 QM
060 D Door Rgt Lft casing I Wood Beige 0.2 QM
061 D Door l%gt Lft Jamb p Wood Beige 1.0 QM
062 D Door Rgt Lft ~amb p Wood Beige 1.0 QM
063 D Door ~t L£t jamb p WoOd Beige 1.0 QM
Average m 1.0
064 D Door Rgt U Ctr p Wood Beige >9.9 QM
066 D cabnt caeg Ctr X Wood Beige 0.0 Qt4
067 D cabinet Door Ctr ! Wood Beige 0.2 QM
05S D Cebnt ehlvg Ctr I Wood Beige -0.1 QM
Comber: Readings ~55-57 are for the m~rror/window above the sink.
Interior Room 004 Hallway -0.1 QM
073 A Door Cfr Rgt casing X Wood Beige
2
DETAILED REPORT 'OF'LEAD PAINT INSPECTION FOR: Kayla Coombs
Paint
Reading
No. Wall Structure Location Member Cond Substrata
Lead
Color (mglcmz)
Mode
074 A Door Ctr O Ctr P Wood Beige -0.1 QM
086 B Door Rgt Rgt ~-~ P Wood Beige 0.0 QM
085 B Door Rgt Lft casing I Wood Beige 0.0 QM
087 B Door Rgt U Ctr P Wood Beige 0.1 QM
083 C Door Lft Rgt casing I Wood Beige 0.1 QM
084 C Door '. Lft U Ctr I Wood Beige 0.2 QM
080 C Door Rgt P~t casing p Wood Beige 0.2 QM
081 C Door Rgt Lft ~amb p Wood Beige 0.0 QM
082 C Door Rgt U Ctr I Wood Beige 0.0 QM
078 D Door Lft Rgt ~am~ p Wood Beige 0.1 Q~
077 D Door Lft Rgt ~sing I Wood Beige 0.0 QM
079 D Door Lft O Cfr p Woo~ Beige -0.1 QM
075 D Door Rgt B~t casing I Wood Beige 0.2 QM
076 D Door Rgt U Ctr I Wood Beige 0.1 QM
Coammnt: Rae~ings 73-74 are for the door to the Living room. 75-76 are for
the side closet door, 77-79 are for the door to the Master Bedroom, 80-82
are for the door to the bath,83-84 are for the rear closet door, and 85-87
are for the door to Ka~laTM room.
Interior Room 00~ Bedroom
110 A Baseboard Ctr p Wood Beige -0.1 QM
093 A Door Rgt Rgt casing I Wood Beige 0.0 QM
094 A Door Rgt U cfr I Wood Beige -0.1 QM
091 A Closet Lft Door p Wood Beige -0.1 QM
090 A Closet Lft Door Casing I Wood Beige 0.1 QM
092 A Closet Lft Door J--~ I Wood Beige 0.1 QM
106 C Window Lft Rgt jamb p Wood White 1.0 QM
107 C Window Lft Rgt jamb p Wood White 1.0 QM
108 C Window Lft Rgt ~amb p Wood White 1.0 QM
Average = 1.0
109 C Window hft Rgt ~amb p Wood Beige -0.1 QM
102 C Window Lft B~t oaaing I Wood Beige -0.1 QM
104 C Win~ow Lft Sash I Wood Beige 0.2 QM
105 C Window Lft Well p Wood White >9.9 Q~
103 C Window Lft Sill I Wood Beige -0.2 QM
099 C Win~ow Rgt Rgt ~,,h p Wood White 1.0 QM
100 C Window ~t Rgt jamb p Wood White 1.0 QM
101 - C Window Rgt Rgt jamb p Wood White 1.0 Q~
&verage = 1.0
097 ' C Window P~t Sash I Wood Beige 0.1 QM
098 c Windew Rgt Well p Wood White >9.9 QM
096 C Window Rgt Sill p Wood Beige -0.2 QM
095 C Window Rgt Lft casing I Wood Beige -0.1 Q~
088 ~D Door Rgt L~t casing p Wood Beige 0.2 QM
089 D Door Rgt U Ctr F Wood Beige -0.1 QM
Com~mnt= Ka~la~s room. Bo~h window tracks and wells need to he stablized
with paint~ then the wells need to be covere~ with aluminum coil stock and
the ed~ea sealed.
Interior Room 006 Bathroom
112 A Door Lft Rgt ~mh p Wood Beige 0.1 QM
111 A Door Lft Rgt oeeing I Wood Beige 0.2 QM
113 A Door Lft U Ct= I Wood Beige -0.1 QM
3
DETAILED REPORT OF'LEAD PAINT INSPECTION FOR: Kayla Coombs
Paint
Reading ,
No. Wall Structure Location Member Cond Substrata
Color
(mglcm') Mode
115 C Window .Cfr Rgt casing I Wood Beige 0.0 QM
117 C Window Cfr Sash P Wood Beige 0.1 Q~
118 C Windo~ Ctr Well P Wood White 1.6 QM
116 C Window Ctr Sill p Wood Beige 0.0 QM
119 C Window Ctr Part. bead I Wood White 2.0 QM
120 C window Ctr Lft ~amb P Wood White 1.3 QM
114 D Wall U Ctr I Plaster Beige -0.1 QM
Interior Room 007 Bedroom
124 A Closet Lft Door I Wood
123 A Closet Lft Door Casing I Wood
122 A Closet Rgt Door I Wood
121 A Closet Rgt Door Casing I Wood
127 B Baseboard Ctr I Wood
125 B Door Lft Rgt easing p Wood
126 B Door Lft O Cfr Z Wood
132 C Window Cfr Rgt ~amb I Wood
128 C Window Cfr ~gt easing I Wood
130 C Window Ctr Sash I Wood
13T C Window Ctr Wall p Wood
129 C Window Ctr Sill P Wood
Beige -0.2 Q~
BroWn 0.2 ~M
Beige 0.2 QM
Brown 0.2 QM
Brown -0.2 QM
Brown 0.2 QM
Beige 0.0 QM
White 0.8 QM
Brown 0.0 QM
Brown -0.2 QM
White 7.6 Q~
Brown 0.2 QM
Calibration
001
002
0O3
133
134
135
Readings
.... End of Readings ....
0.8 Std
1.0 Std
0.8 Std
0.9 Std
0.6 Std
0,8 std
SUMMARY REP?RT OF, LEAD PAINT INSPECTION FOR: Kayla Coombs
Inspection Dater 09/21/00
Report Date:
Abatement Level:
Report No.
Total Readings:
Job Started:
Job Finished:
9/22/2000
1.0
09/21/00 11:27
135 Actionable: 35
09/21/00 11:27
09/21/00 12:56
116 S, 3rd Street
Apt #1
Lemoyne, PA 17043
Paint Lead
Reading Color (mglcm=) Mode
No. Wall Structure Location Member Cond Substrate
Bxterior RoOm 001 Front poroh
005 C Door ~ft Bgt ~amb p Wood ~ite
004 C Door Lft Rgt casing I Wood White
006 C Door Lft U Cfr I Wood Green
008 C Door ~gt Rgt ~amb p Wood White
009 C Door Rgt Lft casing p Wood White
010 C Door Rgt U Ctr p Wood White
007 C Threshold Lft p Wood Green
Co~nt: R~adingg's 8-11 are for the entran~ to house ~ 114. Mom states
that she and the child do sit on the front steps, and the child does have
access to the door. The front porch overhang ia noted as having chipping
and peeling white paint. Unable to test with the X~tF due to the height.
1.8 QM
2.0 QM
1.2 ~M
1.6 UM
3.5 QM
1.4 GM
3.7 GM
Exterior Room 002 Si~e Porch
069 B Door Ctr Rgt casing I Wood White
070 B Door Cfr U Ctr p Wood White
071 B Threshold Ctr p Wood Gray
072 D Window Lft Rgt Casing I Wood White
1.3 QM
1.4 QM
2.7 QM
>9.9 QM
Interior Room 001 Living Rm
030 A Window Ctr Rgt ~m~ p Wood White
031 A Window Ctr Rgt ~.m~ p Wood White
027 A Window Ctr Wall p Wood White
021 c Door Rgt Rgt Jamb p WoOd Beige
Com~nt: R~adings 9 34 and 35 ara for the entrance to the dining room.
recommended treatment for the front window is stabliz&tion with paint and
then the well area covered with &luminum coil stock and than the edges
sealed with caulking.
1.3 QM
1.4 GM
1.0 GM
1.3
Interior Room 002 Dining~a
039 A Window Ctr Well I Wood White 1.0
043 C Window Ctr Rgt jamb I Wood White 1.0
042 C Window Ctr Well p Wood White 1.0
052 D Window Ctr Rgt Jamb p Wood White 1.4
048 D Window Ctr Sash I Wood Beige 1.0
049 D Window Cfr Sash I Wood Beige 1.0
050 D Window Ctr Sash I Wood Beige 1.0
Average = 1.0
051 D Window Ctr Wall p Wood
Comment: The side window needs to receive the same treatment as
White >9.9
the living
QM
OM
QM
QM
Interior RoOm 003 Kitchen
061 D Door Rgt Lft ~amb p Wood Beige
062 D Door Rgt Lft ~amb p Wood Beige
063 D Door Rgt Lft ~m~ p WOod Beige
1.0 QM
1.0 GM
SUMMARY REPORT OP LEAD PAINT INSPECTION FOR: Kayla Coombs
Paint
Reading
No. Well Structure Location Member Cond Substrata
Lead
Color (rog/ce') Mode
064 D Door Rg~ U Ct= p Wood Be£go
Co~M~ont: Readings #$5-57 are £or the m:Lrro~/window above the sink.
>9.9 QM
Interior Room 005 Bedroom
106 C Window Lft Rgt ~amb p Wood White 1.0 QM
107 C Window Lft Rgt ~amb p Wood White 1.0 QM
108 C Window Lft Rgt ~amb p Wood White 1.0 QM
Average = 1.0
105 C Window Lft Well p Wood White >9.9 QM
099 C Window Rgt Rgt ~amb p Wood White 1.0 QM
100 C Window Rgt Rgt ~amb p Wood White 1.0 QM
101 C Window Rgt Rgt ~amb p Wood White 1.0 QM
Average ~ 1.0
098 C Window ~ Rgt Well p Wood White >9.9
Comment: Kayla*s =com. Both window tracks and wells need to be etablized
with paint, then the wells need to be covered with alv~4~um coil stock and
tho edges eaelod.
Interior Room 006 Bathroom
118 C Window Ctr Well p Wood White 1.6 QM
119 C Window Ctr Part. be~d I Wood White 2.0 QM
120 C Window Ctr Lft ~amb p Wood White 1.3 QM
Interior Room 007 Bedroou
131 C window Ctr Well p Wood White 7.6 QM
Calibration Readings
.... End of Readings ....
2
May 14, 2001
Kramer Pc
Jerome Korinchak, M.D.
Greenhill Family Practice
503 Bridge Street
New Cumberland, PA 17070
Client
Address
209 State Street
Harrisburg, Pennsylvania 17101
717.232.6300
Fax 717.232.6467.
: Kayla J. Coombs, a minor
Krista j.,Co0n~bs, parent. ·
: 116 South Third Street, 1st Floor
Lemoyne, PA 17043
www. srklaw,com
: lO/15/98
Birthdate .
S.S No. . 180-78- 5"
Re;ords Requested : All m ~g I records from 9/23/00 to the p~esent.
Bills .Requested : All~ lls from O / l /OO to the present. J
Dear Dr. Korinchak: ~
Please be advised that I repres~e~ ~t4 xe~abox~e ~°~ ~rw~r~d~..c~°pros
of all records you have kept on the ~tment, .and progress oz
individual from September 23, 2000 to the present.
Please include copies of all billings from September 1, 2000 to the present.
I have enclosed an executed Medical Authorization for the release of this information
to me. I am not at this time requesting any specially prepared medical reports.
If y0u have any questions, please .f~e!:free to call or write.
Very truly yours,
SCHMIDT, RONCA & KRAMER, P.C.
C. Kramer
ey at Law
GCK/ det
Enclosure
' ' N ~ ~CES, INC.
SP RI~ PHYSiCIA
205 GR'A,ND¥1EW AVENUE
SUITE 210
--~,.pHJ'~ PA 17011
DTL SUMMARY~! 600000594879 cOOMBS
GU 000000594879 CA 594870016
COV/AMT SCHM 1
D21 1 GUR 8
-90.00 .00
LINE# DOS SVC CD DESC
TYPE DOE PV DX BPO QTY
21 10/02/00 3501 MEDICAID C/A
10/02/00 077107
BD SUP #RESP PTY 0
22 10/02/00 1501 MEDICAZD PAYMENT
10/02/00 0771O7
BD SUP #RESP PTY
23~ 40O86 ~FS~.~
i0/23/00 O771O7 V20.2
B~ N SU~ #~ESP PT~
24 01/04/01 350I ME~ZCAZ~ C/~
F3~YLA J 05/24/01 0751
GHILL OFFICE VISIT TOTAL -90,00
BL P¥ GHILL IQ PV
BATCH# DTL# POS TOT AMT
INV# RESP RESP-TO RESP ~MT
87591 30 -25.00
23000470 D21 -25.00
87591 31
23000470 D21
1397 23 11
30000539 D21
14679 32
30000539 D21
-25.00
-25.00
.00
-5.00
-5.00
01/05/01 077107
BD SUP #RESP PTY 0
PF1 INQ MENU PF4 RESP PRTY PF7 CS LVL DTLS PF13 PT INV LST PF16 BDEBT TRAN
PF2 GU CA LST PF5 CHGE DTLS PF8 GU LVL PRPY PF14 PAGE BACK *LN#:
PF3 CA PV LST PF6 PYMT DTLS PF9 ADDL FIELD PF15 RETURN *ENTER NXT LN 25
NPARDL00
COOMBS KAyLA J 05/24/01 0751
GHILL OFFICE VISIT TOTAL -90.00
BL PV GHILL IQ PV
DTL SU]~43%RY PT: 000000594879
GU 000000594879 CA 594870016
Cov/AMT SCHM 1
D21 1 GUR 8
-90.00 .00
LINE# DOS S¥C CD DESC BATCH# DTL# POS TOT AMT
TYPE DOE PV DX BPO QTY INV# RESP RESP-TO RESP AMT
25 01/04/01 1501 MEDICAID PAYMENT 14679 33 -65.00
01/05/01 077107BD SUP #RESP PTY 0 30000539 D21 -65.00
26 01/23/01 99213 EP LEVEL 3 18506 24 11 57.00
~f/Z37qYl 077107 466.0 1 102600517 D21 .00
BD N SUP #RESP PTY 1
27 03/09/01 3501 MEDICAID C/A 28240 34 -32.00
03/09/01 077107 102600517 D21 -32.00
BD SUP #RESP PTY 0
28 03/09/01 1501 MEDICAID pAYMENT 28240 35 -25.00
03/09/01 077107 102600517 D21 -25.00
BD SUP #RESP PTY 0
PF1 INQ MENU PF4 RESP PRTY PF7 CS LVL DTLS PF13 PT INV LST PF16 BDEBT TRAN
PF2 GU CA LST PF5 CHGE DTLS PF8 GU LVL PRPY PF14 PAGE BACK *LN#:
PF3 CA PV LST PF6 pyMT DTLS PF9 ADDL FIELD PF15 RETURN *ENTER NXT LN 29
NPARDL00
DTL SUMMARY PT: 000000594879 COOMBS KAYLA J
GU 000000594879 CA 594870016 GHILL OFFICE VISIT
COV/AMT SCHM 1
D21 1 GUR
05/24/01 0751
TOTAL -90.00
BL PV GHILL IQ PV
-90.00
LINE% DOS
TYPE DOE
03/19/01
8
.00
SVC CD DESC BATCH# DTL~ POS TOT AMT
PV Dx
o77107 ~6.0 1~ 1o8100692 D21
30 05/09/01 3~1 MEDICAID C/A ~ 40947 36 ~ -32.00
05/10/01 o771o7 % 1~100692 D21 % -32.00
BD SU~ #RESP PTY 0
1501 ~EDI~ID pAY~NT 49947 37 -25.00
31 05/09/01 077107 ~ 10810~92 D21 =25.00
05/10/01
BD SUP ~SP PTY 0
BD SUP ~RE~PTY
PF1 INQ ~ PF4 RESP PRTY PF7 CS LVL DTLS PF13 PT I~ LST PF16 BDEBT T~
PF2 GU ~ LST PF5 CHGE DTLS PF8 GU LVL PRPY PF14 PAGE ~CK *LNg:
PF3 ~ ~ LST PF6 PYMT DTLS PF9 ~DL FIELD PF15 RETURN *ENTER ~T LN 1
NP~DL00
DETA]L OF CURRENT CHARGES, PAY IENTS ANL ADJUSTMENTS
.0/25 0264006 001 15.00- 15.00-
CBC & AUTO DIFFERENTIA85025
.0/25 0264006 001 15.00 15.00
CBC & AUTO DIFFERENTIA85025
.0/25 0265107 001 49.00 49.00
CBC & MANUAL DIFF 85023
.0/25 0265394 001 54.00 54.00
COM] 'REHENS IVE METABOL180053
BAL~2 [CE FORWARD 0.00.
SUM~ RY OF CURRENT CHARGES
86 LABORATORY 103.00 103.00
SUB-~ OTAL OF CURR. CHARGES 103.00 103.00
GUA~ RELATIONSHIP: P SEX. F ~UAR NO: 1807854~ 5
ACC DATE: TYPE: TI~ E: PL ~CE: ~MPL REL
DIA( 4OSIS: 984.9
PINNACLE HLTH HOSP
HARRISBURG, PA
~YPE OF~ ~ DATE QF
BILL , DATE OF BILL PREY. SILL
S~ N ~IST ST
CA'ri~ HILL, PA ~ 17011
717 763-~141
FEI # ~3-1~12747
AC~O0~R PATIENTNAME
BS ~KAYLA J
BIRTH-DATE ~
10/15/98 [39000~
GUARANTOR
NAME
AND
ADDRESS
KAYLA J COOMBS
116 S 3RD STREET
LEMOYNE,PA 17043
POLICY NUMBER
KORINCHAK~JEROME
014~8188
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. PAYMENT
DATE DESCRIPTION OF I SERVICE TOTAL EST, COVERAGE EST* COVERAGE EST. COVERAGE EST. COVERAGE PATIENT
POSTED HOSPITAL SERVICES CODE CHARGES INS* CO, NO.1 INS. CO, NO*2 INS. CO. NO.3 INS. CO. NO.4 AMOUNT
DETAIL OF CURRENT CHARGES~ PAY'lENTS ANE ADJ'USTME~ITS
)9/07 LEAD LEVEL,BL,G01~'S:I02369 6~.00 62.00
)9/0T SPEC COLLECT FE01E:E;101031 T.00 T.0
BALAI~ :E FORNARD 0.00
SUMMI ~Y OF CURRENT CHARGES
LABORATORY :300 69.00 62.00 7.(~
SUB-T3TAL OF CURR. CHARGES 69.00 6:::'.00 7,~
DIAGNOSIS: 790 . 6
PAYMENT IS DUE UPON RE ~EIPT OF THIS STATEMENT.
YOU MAY SUBMIT THIS F( ~M
TO YOUR INSURANCE CAR; IER
FOR REIMBURSEMENT.
FEDERAL IDENT. NO. 23-1512747
T 0 T A L ~ 69.00 62.00 7.~
PATIENT NUMBER [ REFER ALL QUESTIONS TO THE PLEASE SEND PAYMENT TO: i
I
BUSINESS OFFICE
1 ~& 0~g&~ 1717) 783-2138. HtSI V RPlI:IIT H{3RPlTAL PAY TH I S AMOUNT T. i
I
ADDITIONAL PATIENT BILLING MAY gE NECESSARY FOR A
CHARGES NOT POSTED WHEN THJS BILL WAS PREPAR
OR IF INSURANCE CARRIERS DO NOT PAY ANY PART
THE AMOUNTS SHOWN UNDER ESTIMATED JNBUR)tj~
COVERAGE.
503 NORTH 21ST STREET
HOLY SPIRIT HOSPITAL CAMP HILL, PA. 17011-2288
CAMP HILL., PA
PREV. BILL
OUTP. j
A R PATIENT NAME
CO0~BS ~KAYLA 3
S0~'~ ~IST ST
CAk. HILL, PA
717 T63-~141
FEI # ~3-161~747
1701 BIRTH-DATE ~
lO/ S/ss 9ooo1
GUARANTOR
NAME
AND
ADDRESS
KRISTA COOMBS
116 S 3RD STREET
LEHOYNE,PA 17043
1
KOR[NCHAK~3EROME
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. PAYMENT
DATE DESCRIPTION OF I SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT
POSTED HOSPITAL SERVICES CODE CHARGES INS, CO. NO.1 INS, CO. NO.2 INS. CO. NO.3 INS. CO. NO,4 AMOUNT
DETA1. OF CURRENT CHARCES~ PAYHENTS AN£ AD3USTHE~TS
9/15 LEAD LEVEL,BL,Q01E~SIOE~369 6E~.00 6E~.00
9/15 SPEC COLLECT FE01~5101031 7.00 7.0~
BALANCE FORI, IARD O. O0
SUHNARY OF CURRENT CHARGES
LABORATORY 300 69. O0
SUB-TOTAL OF CURR. CHARGES 69.00 6~.00 7.0'
D%AGNOSTS; V15.86
PAYMENT IS DUE UPON RECEIPT OF THIS STATEMENT.
YOU HAY SUBN%T THIS FCRM
TO YOUR INSURANCE CARR
FOR REIMBURSEMENT.
FEO£RAL ,DE.T. NO. 23-1512747
T O T A L S 69.00 6~.00 7.0
PATIENT NUMBER J REFER ALL QUESTIONS TO THE PLEASE SEND PAYMENT TO: J
BUSINESSOFFICEI PAY THIS AMOUNT 7.0
1 ~647~'9 01 {717) 763-2138, Hi31 Y RPlRIT HI3~PITAL
ADDITIONAL PATIENT BILLING MAY SE NECESSARY FOR AN'
CHARGES NOT POSTED WHEN THIS SILL WAS PREPARE(
OR IF INSURANCE CARRIERS DO NOT PAY ANY PART OI
THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCI
COVERAGE.
503 NORTH 216T STREET
HOLY SPIRIT HOSPITAL CAMP HILL, PA. 17011-2288
CAHP HILL, PA
8AUDD
C
KRISTA cOOMBS
116 S 3RD ST /, ',
LEMOYNE PA 17043 ' i,.~'/
DETA!
39/21
CBC
09/21
CBC
09/21
09/21
CBC
09/21
LIP]
09/21
RENA
OF CURRENT CHARGES, PAY
,115071 001
l AUTO DIFFERENTIA85025
~115071 001
AUTO DIFFERENTIA85025
115130 001
82728
TZN
Dl16023 001
MANUAL DIFF 85023
17043 001
80061
, PANEL
1117060 001
FUNCTION PANEL 80069
09/21 ',66420 001
EXP! ~DED VISIT - EST T99213
09/21 ~ ~421 001
EXPA )ED VISIT - EST P99213
09/27 16023 001
CBC MANUAL DIFF 85023
09/29 ~37499 001
SYS( EN MEDICAL ASSIST CONTR
BALAD :E FORWARD
SUMMARY OF CURRENT pAY/ADJ
RY OF CURRENT CHARGES 86 LABORATORY
60 OUTPATIENT VST
)l OF CURR. CHARGES
PINNACLE HLTH HOSP
qAPA
~NTS AND AC
43.00- 43.00-
43.00 43.00
76.00 76.00
55.00 55.00
26.00 26.00
68.00 68.00
15.00 15.00
43.00 43.00
55.00 55.00
262.00' 262.00'
iLLIAMS RONALD J
0.00
262.00' 262.00
280.00 280.00
58.00 58.00
338.00 338.00
101428188
HCI
I 10/16/00
Jl U ' I
PINNACLE HLTH HOSP
B¢ 2353
HARRISBURG
FEI 251
J COOMBS ~KAYLA
4299031471
10/03/00
ADDRESS
DETAIL OF CURRENT CHARGES, PAYMENTS AND ADJUSTMEINTS
0/03 0116023 001 55.00 55.001
CBC & MANUAL DIFF 85023
0/03 0117041 001 87.00 87.00~
COMPREHENSIVE METABOLIC PANE
0/11 0037499 001 124.00- 124.00-
SYSGEN MEDICAL ASSIST CONTR
BALAkCE FORWARD 0.00
SUMM~RY OF CURRENT PAY/ADJ 124.00- 124.00-
SUMM~RY OF CURRENT CHARGES
86 LABORATORY 142.00 142.00
SUB-1)TAL OF CURR. CHARGES 142.00 142.00
I
GUAR RELATIONSHIP P SEX F GUAR NO 180785446
ACC )ATE TYPE TImE PLACE EMPL REL
DIAG ~OSIS 780.6
I
~!~ iii iiPLEASEREFERTOPAT]ENT
~i;{i:~ i i~]iii!i~;i ADOITIONALPAT~ENT~!LLINGMAYBENECESSARY
*,o co~,~,o,oE,c~ ~*s ,,~,*~ o~ ~ ~su~*~c~ c*~,~s oo PAY TH I S AMOUNT O.
O0
PINNACLE HLTH HOSP
HARRISBURG, PA
Settlement Agreement and Release
This Settlement Agreement and Release is made and entered by and between:
Claimants: Kayla Coombs (a minor) and Krista Coombs (her mother)
Insured: Kerry R. Saintz
Insurer: OneBeacon Insurance Group
Recitals
The claimants have presented a claim against the insured for alleged lead poisoning
arising our of conditions at 116 South Third Street, First Floor, Lemoyne,
Cumberland County, Pennsylvania.
The insurer is the general liability insurer of the insured for the relevant time period
(6/99-9/21/00) and would be obligated to pay any judgment against the insured that is
covered by the policy.
The parties desire to enter into this Settlement Agreement in order to provide for
certain payment in full settlement and discharge of ail claims now existing or which
may herea~er arise out of the above incident, upon the terms and conditions set forth
herein.
Agreement
The parties hereby agree as follows:
1. Release and Dischar~
In consideration of the payment called for herein, the claimants completely
release and forever discharge the insured and the insurer, and their past, present
and future officers, directors, stockholders, attorneys, representatives, employees,
predecessors and successors in interest, and any other persons, firms or
corporations with whom any of the former have been, are now or may hereafter
be affiliated, from any and all past, present and future claims, liens, demands,
costs, obligations, actions, causes of actions, damages, expenses and
compensation of any nature whatsoever, whether based on a tort, contract or other
theory of recovery, and whether for compensatory or punitive damages, which the
claimants now have, or may hereafter accrue arising out of any and all known or
unknown claims for bodily and personal injury to the claimants, and the
consequences thereof, which have resulted from the above-described claim for
lead poisoning.
This release on the part of the claimants shall be a fully binding and complete
settlement between the claimants, the insured and the insurer.
Payment
In consideration of the release set forth herein, the insurer, on behalf of the
insured, hereby agrees to pay the claimants Thirty-Five Thousand Dollars
($35,000).
Warranty of Capacity to Execute Agreement
The claimants represent and warrant that no other person or entity has had any
interest in the claims, demands, obligations or causes of action referred to in this
Settlement Agreement except as otherwise set forth herein, and that they have the
sole right and exclusive authority to execute this Settlement Agreement and
receive the sum specified above. The insurer warrants and represents that it has
the sole capacity and authority to execute this Agreement on its own behalf and
on behalf of the insured.
Entire Agreement
This Settlement Agreement contains the entire agreement between the claimants,
the insured and the insurer with regard to the matters set forth herein.
Representation of Comprehension of Document
In entering into this Settlement Agreement, the claimants represent that they have
relied upon the legal advice of their own attorneys who are the attorneys of their
own choice, and that the terms of this Settlement Agreement have been
completely read and explained to them by the attorneys, and that those terms are
fully understood and voluntarily accepted by them.
Governing Law
This Settlement Agreement shall be conslxued and interpreted in accordance with
the laws of the State of Pennsylvania.
The parties understand and agree that the terms and conditions of this Settlement
Agreement are confidential and shall not be disclosed to any person or entity
other than: auditors, accountants, the IRS, attorneys, directors, officers, managers,
insurance agents and brokers, and reinsurers of the parties, or as otherwise
required by a court of law.
2
Constmction
This Settlement Agreement is not and shall never be construed as an admission of
liability, fault or wrongdoing by any of the parties, each of which/whom
specifically denies any liability, fault or wrongdoing. Instead, the Settlement
Agreement reflects a settlement and accord and satisfaction of contested, doubtful
and disputed matters, by which each of the parties has forever bought their peace
as to the claims released herein.
This Settlement Agreement shall become effective following execution by the claimants
and the insurer.
Executed this day of ,2001.
OneBeacon Insurance Company
And its Insured Kerry R. Saintz
Victoria S. Price, Esq.
Krista Coombs, Mother of
Kayla Coombs, a Minor
CONTINGENT FEE AGREEMENT
THIS AGREEMENT entered into the ~ day of ~i[~
and between SCHMIDT, RONCA & KRAMER, P.C. and KRISTA d. COOMBS
p/n/g of Kayla J. Coombs, of 250 Pleasant View Drive, Etters, Pennsylvania
17319, hereinafter referred to as "Client."
WITNESSETH:
The law firm of SCHMIDT, RONCA & KRAMER, P.C., will act as Client's
attorney in negotiating for a settlement, and in bringing ~ claim against
KERRY 8AINTZ and/or anyone else with respect to a potential medical
malpractice claim for complications relating to lead paint incident which
occurred on or about September 1, 2000, in Lemoyne, Cumberland County,
Pennsylvania.
In return, the Client will:
1. Promptly supply accurate information, as requested by SCHMIDT,
RONCA & KRAMER, P.C., and cooperate fully, including making herself
available for meetings with attorneys and for legal proceedings. Client
promises all information supplied will be truthful and accurate.
2. (a) In any claim brought on Client's behalf, to pay to SCHMIDT,
RONCA & KRAMER, P.C., for its services an amount equal to twenty-five (25%)
of all funds or property accruing to Client as a result of SCHMIDT, RONCA &
KRAMER, P.C.'s services in securing a settlement of these claims without
litigation; an amount equal to thirty-three-and-one-third percent (33-1/3%) of
all funds or property accruing to Client as a result of SCHMIDT, RONCA &
KRAMER, P.C.'s services in securing a settlement of these claims after a suit
has been filed; and an amount equal to forty percent (40%) if such funds or
property are secured after start of trial or as a result a verdict or judgment.
Trial begins at jury selection. In any matter submitted to arbitration, suit is
filed when the arbitrators are appointed or when a Petition to Appoint
Arbitrators is filed, whichever first occurs. In any matter submitted to
arbitration, trial starts the first day the arbitrators have convened to hear
testimony.
(b) Client agrees not to settle or negotiate the above claim or any
proceedings based thereon.
(c) If Client terminates this Agreement before recovery, Client agrees
that SCHMIDT, RONCA & KRAMER, P.C., shall be entitled to a fee based upon
work done and benefit conferred.
(d) Client agrees to read and follow SCHMIDT, RONCA &
KRAMER, P.C.'s ~Instructions to Our Clients."
3. Client agrees to reimburse SCHMIDT, RONCA & KRAMER, P.C.,
out of any recovery, in addition to attorneys' fees, all costs and expenses
incurred on Client's behalf in order to make the claim. All such costs and
expenses will be advanced by SCHMIDT, RONCA & KRAMER, P.C. as they are
incurred. Such costs and expenses include, but are not limited to, filing fees,
cost of medical records, copying costs, fax costs, long distance telephone costs,
expert witness fees and sheriffs service costs. In the event there is no
recovery, the Client will not be responsible for any costs or interest charges.
Costs will be repaid to SCHMIDT, RONCA & KRAMER, P.C., out of any
funds or property collected either by settlement or judgment.
The Client has read and does understand this Agreement.
Signed the day and year set forth above.
WITNESS: Client:
KAYLA COOMBS
Approved:
SCHMIDT, RONCA & KRAMER, P.C.
I have received a copy of this Contingent Fee Agreement.
Initials
~ ~-~'~ A'~V~_.~ 209 State Street 717.232.6300
:~h~-~' '~. ~:~ ¢~Pc Harrisburg Pennsylvania 17101 Fax 717.232,1~67
IN RE: KRISTA COOMBS, Individually :
and as P~ent and Natural
Guardian of KAYLA COOMBS,
a Minor
OCT 3 0
-IITTHE-CUI~ITDY COMMOI~
PLEAS CUMBERLAND COUNTY,
PENNSYLVANIA
,o. o,-
PETITION FOR APPROVAL OF
MINOR'S SETTLEMENT
HEARING ORDER
AND NOW, this ~'~ day of ~dV'~'~, 2001, IT IS
HEREBY ORDERED AND DECREED that a Hearing will be held on the Petition
for Approval of Minor's Settlement for Kayla Coombs, a minor, in Courtroom
No. ..~ of the Cumberland County Courthouse, One Courthouse Square,
Carlisle, Pennsylvania 17013 on the ~/ $~day of ~, 2001,
at //: .gO o'clock, ~ .m.
SHERIFF'S RETURN - U.S.
CASE NO: 2001-06129 P
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
COOMBS KRISTA
VS.
PRICE VICTORIA S
CERTIFIED MAIL
R. Thomas Kline , Sheriff of Cumberland
County, Pennsylvania, who being duly sworn according to law served the
within named RESPONDANT ,PRICE VICTORIA S ESQUIRE ,
by United States Certified Mail postage
prepaid, on the 29th day of October ,2001 at 0000:00 HOURS at
ONE BEACON INSURANCE GROUP PO BOX 9546
BOSTON, MA 02205-9546
and attested copy of the attached PETITION
with
a true
Together
receipt card was signed by SIGNATURE ILLEGIBLE
00/0070000
Additional Comments:
THERE WAS NO DATE ON THE GREEN CARD FROM POST OFFICE.
The returned
on
Additional Comments .
Sheriff's Costs:
Docketing 18.00
Cert Mail 7.16
Affidavit .00
Surcharge 10.00
.00
35.16
Paid by SCHMIDT RONCA KRAMER
Sworn and subscribed to before me
this /3~- day of T~
~ A.D.
~othonotary
Sheriff of Cumberland County
on 1 /06/2001
· Complete Items 1, 2, and 3, AJ~o oumplete
item 4 if Restricted Delivery is desired.
· Print your neme end address on the reverse
so that we can return the card to you.
· Aflach this can:l to the baok of the mailpiece,
or on the front If space permits.
Victoria S. Price, esquire
One ~eacon Insurance Group
PO Box 9546
Boston, MA 02205-9546
PS Form 3811, July 1999
~. Re~lved by ~ P~nt (7~ee~) Dete of Dai~ve~y
C. .~gnatum
m Agent
3. Se~dce'l~pe
X~ Certified Mall F1 Express Mail
[] Reg;~;~,,~l [] Return Receipt for Merchendlse
[] Insured Mail i"l C.O.D.
4. Restricted D~Nery? (Ex'ffa Fee) i-lYes
Domestio R~um F~pt
KRISTA COOMBS,
Individually and as Parent and
Natural Guardian of
KAYLA COOMBS,
A Minor
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: NO. 2001-6129 CIVIL TERM
ORDER OF COURT
AND NOW, this 17TM day of DECEMBER, 2001, at the request of Plaintiff, the
hearing on the Petition for Approval of Minor's Settlement is continued generally to be
rescheduled at the request of Plaintiff.
Gerard C. Kramer, Esquire
209 State Street
Harrisburg, Pa. 17101
For the Plaintiffs
:sld