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BY: CHARLES E. SCHMIDT, JR., ESQUIRE
J.D. #19198
209 State Street
Harrisburg, PA 17101
(717) 232-6300
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Attorneys for Petitioner
IN RE:
ESTATE OF
KATHLEEN ANN CONN, :
Deceased, by
KATHLEEN A. SMITH,
Administratrix,
Petitioner
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
NO. cJl- {)(7- 6 /0 ~
ORPHAN'S COURT DIVISION
PETITION FOR APPROVAL
OF MINOR'S SETTLEMENT
FOR WRONGFUL DEATH
ACTION
PETITION FOR APPROVAL OF MINOR'S
SETTLEMENT FOR WRONGFUL DEATH ACTION
AND NOW, comes the Petitioner, Kathleen A. Smith, by her counsel,
Schmidt Kramer PC, and sets forth the following Petition in accordance with
Pennsylvania Rules of Civil Procedure 2039 and 2206.
1. Petitioner, Kathleen A. Smith, is the Administrator of the Estate of
her deceased daughter, Kathleen Ann Conn, who died intestate on November
12, 2006, at Hershey Medical Center in Dauphin County, Pennsylvania. (See
Death Certificate and Certificate of Grant of Letters of Administration attached as
Exhibits A & B, respectively.)
2. Petitioner, Kathleen A. Smith, is the maternal grandmother of
Aidan R. Self, a minor (Date of Birth: May 5, 2005), who is the surviving
natural son of the decedent, Kathleen Ann Conn.
3. Petitioner resides at 425 South Main Street, Telford, PA 18969.
4. Justin R. Self is the parent and Natural Guardian of Aidan R. Self.
5. Justin R. Self, lives with Aidan R. Self, at 4907 Delbrook Road,
Mechanicsburg, PA 17050.
6. The Petitioner's decedent, Kathleen Ann Conn (Date of Birth:
March 29, 1983), was involved in a motor vehicle accident on the Carlisle Pike
in Hampden Township, Cumberland County, Pennsylvania, November 12,
2006, which resulted in her death.
7. At the time of the accident, Kathleen Ann Conn was a pedestrian
crossing the Carlisle Pike and was struck by a vehicle owned and driven by
Tegan Ritchey. (See Hampden Township Police Report attached as Exhibit C.)
8. Ms. Conn suffered traumatic injuries, and was taken from the
scene by Life Lion. The decision was made to remove life support at Hershey
Medical Center, and she died at approximately 8:00 a.m. that same morning.
9. Ms. Conn's funeral and burial expenses total, $12,784.16. (See
Funeral and Related Billings attached as Exhibit D.) funds distributed to
Kathleen Smith will be used reimburse the petitioner.
10. Tegan Ritchey was insured by Progressive Specialty Insurance
Company at the time of the accident under policy number 14832666-0, which
was effective September 15,2006 through March 15,2007, and included bodily
injury coverage in the amount of $15,000 per person and $30,000 per accident.
(See Progressive Declarations attached as Exhibit E.)
11. Ms. Ritchey's insurer offered to settle the case on behalf of their
client for the policy limit of $15,000, and Petitioner tentatively agreed to accept
the sum as full and complete resolution of the third party liability claim against
Tegan Ritchey.
12. The offer exhausts sources of third party coverage. (See Ms.
Ritchey's Affidavit of No Other Insurance attached as Exhibit F.)
13. It is the opinion of Petitioner and her counsel, Charles E. Schmidt,
Jr., Esquire, that this settlement is for the maximum recoverable from the
tortfeasor. Petitioner and counsel believe that the settlement, insofar as it
involves minor, Aidan R. Self, is in the best interest of said minor.
14. The Department of Revenue has issued a letter approving
allocation to the wrongful death action. (See PA Department of Revenue Letter
attached as Exhibit G.)
15. The proposed allocation after attorney's fees and costs is as
follows:
TO: Kathleen A. Smith (for final expenses)
TO: Aidan R. Self, minor son of Kathleen Ann Conn
$ 5,000.00
5,361.49
16. Petitioner, Kathleen A. Smith, entered into a Contingency Fee
Agreement with Petitioner's counsel, Schmidt Kramer PC. The agreement calls
for a fee of 25% on any recovery obtained before suit is filed. (See Contingency
Fee Agreement attached as Exhibit R.) Schmidt Kramer PC has reduced the
attorneys' fees to $2,500.00. Petitioner came to engage Schmidt Kramer PC by
way of a referral from Michael Bangs, Esquire, 429 South 18th Street, Camp
Hill, PA 17011, who will receive one third (1/3, or $835.00) of attorney's fees.
17. In addition, Petitioner has incurred costs in the amount of
$2,138.51. (See Printout of Costs attached as Exhibit 1.)
18. The Petitioner requests that the amount to be awarded to the
minor, Aidan R Self, or $5,361.49, be distributed without the formal
appointment of a guardian, to be placed in a sequestered bank account in
compliance with Pa. RC.P. 2039(b)(2), by Justin R Self, parent and natural
guardian, in the name of the minor until the minor reaches eighteen (18) years
of age. Said account shall be marked as follows:
"This money shall be held in trust, not to be redeemed,
except by Order of this Court, before May 05, 2023."
19. A copy of the proposed Release is attached hereto as Exhibit "J."
20. Counsel for petitioner will pursue a claim against Erie Insurance
for underinsured motorists coverage (Erie is denying coverage).
21. The Petitioner requests that your Court enter an Order:
(a) approving settlement and allocation to the wrongful death
action;
(b) approving attorneys' fees;
(c) approving reimbursement of costs to Schmidt Kramer
PC; and
(d) authorizing the Administrator, Kathleen A. Smith, to sign the
Release attached to this Petition as Exhibit "J."
Respectfully submitted,
Dated: 9-'0 31, =8
By < , ~.:Jc
Charles E. Schmidt, r., Esquire
Attorney LD. # 19198
209 State Street
Harrisburg, PA 17101
(717) 232-6300
Attorneys for Petitioner
VERIFICATION
I, Charles E. Schmidt, Jr., attorney for Petitioner, verify that I am
attorney of record for the Petitioner, and that the foregoing document contains
no facts within the knowledge of the Petitioner, but rather, is based upon the
record or facts solely within the knowledge of the attorney; and, for that reason,
I make this Verification on behalf of Petitioner.
I verify that the facts contained in the foregoing document are true and
correct to the best of my knowledge, information and belief.
I understand that intentional false statements herein are made subject
to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsifications to
authorities.
By:
Charles E. Schmi t, Jr., Esquire
Attorney J.D. #19198
209 State Street
Harrisburg, PA 17101
(717) 232-6300
Attorneys for Petitioner
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7174324454
P.02
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'NAflNING: IT IS ILLEGAL TO ALTER THIS COpy OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
COMMONWEALTH OF PENNSYLVANIA
DEPAATME,'a OF HEAL TH VITAL RECORDS
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
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CERT. [\JO. '~,I 'II ,;' -..L ~ .1.
November 17, 2000
o.le of luu. of Thi.. Certtncatl:l
Name of Decedent
Kathleen
Ann
Conn
F,tSI
Middle
!..a&t
Sex
Female
Social Security No.
Mar 29. 1983
187-64-1542
November .12,2006
Date of Death
Date of Birth Birthplace
PI f D hHershey Medical Center
ace 0 eat
F/I(;llily"-arre
Philadelphia.
Derry Township
..' .. Dauphin County
COlJ~'Y
c.ly. 2k,(QOJgr1 Ot ~O"'t'\9hip
Pennsylvania
Race White OccupatiOn Student Armed Forces? (Yes or ~Jo) r-.b
Never Married Decedent's 4907 Delbrook Road, Mechanicsburg, PA 17050
Marital Status Mailing Address
NlAfIVilr . - . Stieet ,Crt or 1Jw" Stale
1 . Kathleen Smith F .., D' . t Jeffrey A. Naugle
mormant unera Irec or
Name and Address of ... .. .... ....... .... .
F I E t bl' h t Jeffrey A. Naugle Funeral Home, 20 N. A,mbler St., Quakertown, PA 18951
unera s a IS limen . ..
Part I: Immedlate Cause
Interval Belween
Onset and Death
Multiple Tr;lumatic Injuries
(a)
(b)
,
,
, .
Part II:
(c)
Manner of Death.
D...escribe. h.Q. wd.n;Ury occurr~d:
Pe estrJan vs. sUV
Natura! 0
Accident ~..
Suicide 0
Homicide
Pending Investigation
Could not be Determined
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(MD" D.O:,Coroner, M.E,)
Address
Name and Title of Certifier
1271 South 28th St., Harrisburg, PA 171.11
'.. ,.' .,
Patty J. Garber, Chief Deputy
This is to certify that the information here glven.iscorrectlycopied from an original certificate
of death duly filed with me as Local Registrar. The original certificate will be forwardedtothe
State Vital Records Ofticefor permanent filing. L ~,(;tcR.) ..{;.k( 09-106
November 17. 2006 '1U;980"K~~!~:n"e~"Road~ Ouakert6;Z~ "0
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REGJSTER OF WILLS
CUMBERLAND County, Pennsylvania
CERTIFICATE OF GRANT OFLETTERS
No. 2007- 00108 E4. No. 21- 07- 01C8
Es ta te Of: KA THLEEN ANN CONN
(First, Midd/e, Lasr;
Late Of:
HAMPDEN TOWNSHIP
CUMBERLAND COUNTY
Deceased
Social Securi ty No: 187-64-1542
WHEREAS, KA THLEEN ANN CONN
(First, Middle. Last)
la te of HJ'iMPDEN TOWNSHIP CUMBERLAND COUNTY
died on the 12th day of November 2006 and,
~~EREAS, the grant of Letters of Administration
~s required for the administration of the estate.
THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and
for CUMBERLAND County, in the Co~monwealth of Pennsylvania, have
this day granted Letters of Administration to:
KA THLEEN A SMITH
~v-ho has duly qualified as ADMINISTRATOR (RIX) of the estate
of the above named decedent and has agreed to administer the estate
according to law, all of which fully appears of record in n~ office at
CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 27th day of March 2007.
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i1'Oua CRASH RilPOR11NG FORM CtJlh NumlJl I
PlHJll'
AA 500 2 I /'010 u.. Clny I [C] W0046474
I
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! -I! rw o MotOf Vllhlde in 0 Hit 1\ Run Vehlrle o Illegally Pa;l~d o Legbily Parked 0 Non - MOlOfized COfNJ""dII( VtiirJ.., .
Tr~n!pOrt - o Vel 0'10 i
10 ;;; ~ o Pedestrian o ~destrian on 5l:4~, 0 06!lblell from o Train o PN~rom Vf!hic~
i! in I,','heelch.!lr. elc htvlous Crash (If Yer, Complete fOrm 0
:l (If '~tJi.n' or '~destrim 011 Sh~f, In 'Mlt.,ci't.'r .~', (omp/eft Form M, Section 18)
I
I Unit No flm NAlM MI bate of 81rt1l (MM-CO-YYYY)
'~ I TEGAN I ~ EJ ~ rl981 I
Delll! ? last iQme T.lepho"t Numb.r
0 I RiTCHEY I I 7177374312 J
Add...." I Ctv , 'Statt ZIp
t 15207 DEERFIELD AVE MECHANICSBURG PA 1117055 =J
I Drive, UC*IlH HumD.r Sian (laH
Is ' 125666472 IEJD
j . A~ $=/>fKh1<J 0/'1'_ '" ~ft'//IIl f>hnJol C~dhfotl
II i o No 0 IIlegbl Drugs o MedlcaOon o Appartl1tly o III!!<JII DrlJ9 o Fatigull 0 ME'dic.~on
Nom\ill I.se
I 0 Alcohol 0 Alcohol and Drugs o Unknown o Had Been o Sick o Asiet1) 0 Unknown
- I Dril1i(ing
J A~ Ten ~ Primary VtltJdt CoM 'I1oIlttJM
' 0 Test Not Gi""", o 8t~th o Olher Chatyed)
:Ri o !l1oOO o Urme o Unknown il I I Dyes ONo
~: T e51 Given
Almllol TIn 1f/lJll~ o T \!St Ref~sed a Unknown PrlI/W Pnnllfla I=Dr~ Operated
:>> Re~ulu 3~Driver Fled Sceni!
[Q].~ o Test GiV1!!1, EJ Vehicle 4=Hit and Run --L
Contaminated Results 2 =No Dn"" g"l,.'nknown
OWMl1'DrfV(j' OO=Nm Applicable 02=Privale Vehicle No: 04.St~te Po<i~e Whi~i~ C7~M~nic;Pbl Police Veh I
(j9;Federal Gov Veh
@.Q D1 =hivate Vehicle Oovnedl OwnedJtJ:a5~ by Driver OS~P€NNDOT Vehi\:!e C8~Ot~er MuniCipal 981lOt/1er I
le~~Qd by Driver Ol-ReNed Ythide 06=Olher Stale GOlf V@n Government Vehide 99-Un~nown
s.t1ll4!J &~ j ,Own., Flrn Name I DlNne, Last Name or Ills/nO" Name (If I'f1de5fria~ dip I/II~ S<<tion)
0''"'0 I~GAN A I RITCHEY I'
Add~u I City I St.lIt I Zip Vehlcl. "'ab "M.b Code
5207 DEERFIELD AVE MECHANICSBURG PA 170507050 I LSatum J )24 I'
VIN Modtl Vu, Ve/1 1(1. ~odtl {see cmrlayj
15GZCZ23D55SB10604 112005 I I VUE r
l.Janu Piau ~,Sbl~ Elt. SpHd Vf~ T9W1d Towed By
I FTR4-123 :- I~ 1040 I DYes ONo L ROADSIDE RESCUE I
~ ImurarKl! Company /'olley No
r: o ViS 0 No o ~~;""n I PROGRESSIVE ~ 1114832666-0 I
!'
JJ:ffliJR ~ 1 = To\.,;ng P~ss. Veil IL:Mobiieon.lodular HOOle 7-Seml.Tralle! r'2 No lay Year T.g ~t
No 01 @:] o Z=Towln9 TrUCk S=C~m~r 8=Cther r II 10
- TI~lllng 0 Y!1!! 3~ Towing Utilit; Tra'ler 6mFull Trailer 9.ul1known
t Units'
'I: DlrtctJon of ~ "V~icM Pos/tJon ~ .Movrment ~ "$<< ~al U.~
>. rr..,., O~rlay
v&hJd.IJ Cclor VIl1lIdlt IYJl:t OS=lJrge Trud 20.llnlcycle, BIC'jde, EJ 12=CommerClal
~ 06"Yellow ~ OI..,Automolllle C6x$uv 1r\cycle OC~Not Applicable Passeflger
07"SI/..er OZ-MOlQ((:y~le 07=Van Z I =oth@r P!dalcycl! Carner
OS-Gold o3=Bus 1 O=Snowmobll~ n;l~orx: & BU91t'Y 01=Flre Veh 13=Taxi
02=Amb~I."<e Zl=Trac!or Trailer
i 01..al~e- 09.Brown 0<k5mbJl TNC' 11 :F~rm Equip 23..Horse & Rider 03=flol:ce n=fv,in Trailer
02..Red ~ ?O~~~ge (II '01', Complete Form 12-Construdion Equip 24..rr~11l 08=Other Eme~ncy 2'l:= Trll"le Trailer
[' 03i1~l1ilte r : .=:F\il Pl~ AT. Sr;(t/on 16) 13:;;:A1\' 25:::TrcJ!e't I V.h,e e 3 i ./,j;';rti~'d 'V;n ~
04..GrCffi 1 2 "Other (If ";0' or ';21', Cr>mplHt 18=Otha Ty~! Spe<: veh 9&.Other 1 \ ..Pupil iranSf'<?r! 99~Unkncwn
05-Bidel: ~;J.Unkno....m Form <<. S'~ti()Il.?]) 19=Unk. Type Spec veh 99=UnKI1OWn
fnJdillmo.(t Pf>Jnt ClatnllQt Ind(~tof S!fidlt'2! 3=DtMf1hill .", A""'_'~
~ ~on-Colli"oli 1.1=UnderC<lrr"9" o O:None Z.Fun(t'on~1 ~l=lf\<~1 4=llottDm Df Hill QJ l~SValghl
... 01-12-Clock POlnts 15~T""ed un,r 2 I =Minor 3.Di:~bdn9 2=UDhil 5~iop 01 Hill t=LUrve1
13- Top 99-Unknown 9=Unknown 9=UnKnown 9=UnknO\'{f1
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II IlIlJ 11I11111 1
COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
M 5003 li'oli<oUwUnI'f_
J
ClBh Humbf
Pig.
ID
W0046474
11.1 ~=~.
11 A l~Orrl';1r
25>Pas~~-er
I 7"~Iran
8aCl~r
! 9=U nk now"
Sear!'jJsiri=
D OO=Ncl A Pu~ng<<r/O<CJD~ct
01..0n;.er - All Ver..des
02=front Se~l Middle Position
03.hont Se~t Right Side
04=Secord Row . Let! Side Or
MotO/';)'de Pas.se~ gel
05=Second Row, Middl! ~rtlon
06=Second Row . ftght Side
07"Third Row Or Greatir .
left Side
08= Third Row Or Gr!~ler .
Middle Position
09.. Third Row Or Greilter -
Right Side
10.Slttpel Secticn of Tli;ckc~b
11 ~II\ omer Endased
Passenger Or Cargo Area
12.1/', ~en Area
(6ack Of PlO:l,;P. Etc)
13" Trailing Unll
14=Riding On Whlcie Ext@r!or
15...8uI PalSenger
98..other
99.UnkrlOWll
sa~ ~~r Cr>.!'
E OO:None u\O!C I Not Applicable
o l..ShOllldtr ~'t UltO
02=l.1p Belt [Xed
03"lao And )I\Otiidf' 8@!1 V~
Q4..,Cliild SJfelY ~at Usee!
Os"M010rcycle riei/'r'et U!fd
O&'SlCYt!e Helmel Used
1 (}'5~fely Belt Used !mproperty
1 : =C hi'o S;;iely Se~l Used Improperly
12.Helmel Used :mpr~r/y
90=RtstrairJt Used. Type Unkno""n
99=-Un~nO'Ml
~J. -
G O-Net-Applicable
I =Not Ejected
2"TOt.ll!y fL~d
3=Partially Ejtctf'd
9.VN<noym
~
II
I
I
I
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o
I,! _'-.vA
..fI i C o..Not ,nJlnd
Ii. 1 =j(jlled
51 I z,.,.\ajor II1Jury
€. 3aModerale
lnjlJry
4-Minor Injury
8-lnjuly. Un~
~rlty
9~Unknown if
Injury
H l~", P.arh.
6.1-;01 fJe<led 1 Not ~oli(!bif
lMThtoogh Side COOt Ope,"ng
2= ThrOU<]11 Side Window
300 ThtolA)h Windshield
4>0 ThtOuqh Ba~~ Door
5= ThroUl]h Back Door Tailgate 0pe11f19
5= Through Root O~1'liP9 ISUr'd'OOU
Convertible Top Down)
7= TorOlJ9h 11001 Opening (COf1\ol!rtiIIe
Top Up)
9=Unknown ~ '
~:
I ll=Not AOpl!C3llle
".Nol Extricated
~.ExtriGlt.d By Ml.'d1aniCJj Means
3=Freed By Non. Mechanical Means
lluOther
!/=Unknown
SeE:
8 F sl'f!m.!le
M=Male
U ..Unknown
s.~ r!ll&ment rv,.,:
F 00= one ~d I Not Applic~ble
0' "Front Air 8ag Or~ (For Tho 54!.,-r)
01",Side Air 3a9 Deployed (FQr This 5il~1J
C3=Other Type Air Sag Otplcyed
04wMultlple All Bags Deplo)'ed
OS=<MotorC)'(le E~ Prote<tion
06:oSi()"::1i11 Wwing E ibcwlKneeRad~
10KAJr 8ag Not Deployed, Switch On
1 '-Ai, 8~ Not OeplOyed, 5w!l(h 011
12=Air Bag Not Deployed.
Un~ 5witth Stttlng
13=Air Bag Removed iPrior To Crash)
19..Unknown It Air Bag i)tployea
99=Unknown
tMS "iency: lWEST SHORE EMS & LIF
l M~dl<al hclllty: I HERSHEY MEDICAL CENTER
JI
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Aile 0 E F GHI
1[i][JE1~~EJ@]EJ[]
Unit No Plrson No DalV of Birth (MM-DO-YY'f(j
~ r;:;-;----r Otltte7 ~ ~
~~ 0 ~-~~11983
. Nlrne J Addretl I Phone
o ~me as 'CONN, KA THLEEN A 4907 DELBROOK RD MECHANICSBURG PA 17050
Operarot I'
j EMS TranljlOrt
Dves 0 No
!
UnIt No ""non No Date of BIrth (MM-DO,YYYY)
~ EJ D~~7 @.C]-Ej-fI981
Hame J Add/'l'iS I Phon~
o oSa,.,. IJ 'RITCHEY, TEGAN A 5207 DEERfIELD AVE MECHANICSBURG PA 170
peratol' I
ABC D E ~ GHI
JEJ[]@JEJEJQDQ][]@]
I EMS TranlpOrt
o YPl 0 No j
A BCD - E F C H ! ---
1[][Jl0JEJ~~EJ[]@]
Unit No PtNOn No D"J"t,,? Datu ~ Birth (MM-DD-yyYy)
~@O 0 ~-EJ-11982
Ham!: I Add~ I Phillie
O~~~ lIS 'ANDREE DIMITRA CARMAN 417 RICKY ROAD MECHANICSBURG PA 17
""l""ltOl' I'
I EMS Tran~port
o Ye< 0 NO
Unit No ".Non No DUll at Birth (MM.DD-YYVY)
DO ~ot.70-0-L
NalfHl I Me/rHO { Phono
o Same as I
o plll'lltor
ABC DE F GH I
IDDDDDDDDO,
I EMS Transpon
OVes ONo
Unit No Perwn No
DO
I Date crllMfl (MM-DD-YYYY)
O~te7 D-D-[
N.m& f ArId'M< I Phon"
.1.1 0 ~rn!: U [
~ Operator
i
ABC DE f GH 1
IDDDDDDDOD
:
I EMS Tr"fl$port
. 0 Yel 0 No
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IODDDDDDDD
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tlnlt No f'wrJOrt No i~t\! of j;iflb (MM-DD-l^lYY)
r-lO 0(;1"7 D-O-I
I ",,"''/Ie I Address I phone
o S.m" a~ I
Operltot .
] EMS TfllMport
o Yes C) No
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Print CRS W0046474
..J
COMMONWEALTH OF P'i::N~ISYLVAi\JIA
POUtE CRASH REPORTING FOI'tM
AA 500 4 I i'tiiu U!e Only
ril ~ OtJcriJItll>n ~ ~:~n;~CI1 ~;~!~~ar
g 1 _ (ijl\d(ing)
'! ~I' J"Ia~ Ul RNdwev fT1 l=On TrI!Ival LInts 3tM&Olen
~ ! W 2--Sl'Ioulder 4afloallside
., ~ t~l: l1um1Mt1on @]~ 1:DaytlgN 3oo~rk' Suwt
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" Hi Slreet LlJ1Is ""'Dusk
Iii WH~CootNtfons @] ~1:~~__ ___~_:':IH'II) _~
ai' ~Q S<irff<f ~ rTl D=Drl 2---Sand, Mud, Dirt,
: U ,.W,t ~Cavered
- Hlnn ~veflt L/1l Mom UtllliYPOJi ~mb.r -' --
, Unit Ifo 1 EJ 0 0 j - -
EJ2DOoI
7::~r3D Do I
S'QllCflv,'
Onhr4DDol
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Harm e"",t UIf MOIt7 Utility !"de Number
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or
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17
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~
00 nt:i ,... ltols Inivrm'lion on fl\!JI~ ~t1
Flm. Unit No Harm E~Qnt
~~EJ
Unit No Harm fvtnt
EJEQ
~ 2D 3D
II.Sllpper, Road Condllions !lcelSnow)
I Za$vbsUlnce On Roadway
13.Pothole5
14.8rO<:fI1 Or (ra<ked Pa-Ierl'@nt
1 s.. T<;D Obstruoed
1 G=Sofl Shoulder Or Shovlller Drop Oft
28=Olher Roadway Facto!
,9=0ti1~r Envitonmenlal factor
99..U~kJ1own
["vlron"-,.,,fJl/ll'oa(fwaY
~ FtcfWl (FAl) t
OO.NOIle
01 cW\ndy C onditioos
02..Sudd@n W~e( Co~d,tion!
03..Q\he< Weather Conditions
~eL'f k1 Roadway
OS..obsla,l! On Roadway
06..Qt~r Animal In ROddwilY
, 07..<;l,)te
lS OS-Work ZOO! Rd,ted
.~ ,: PosJ/hif VlIhlrle himI'M (V)
I:: ()(}':None oS. Exhaust
.2 : 01.firtS OhHeadlighb
.. 02.Sr.ke Synem OB~SlQnalli9h1.S
f!, 03=S~rin9 Syl~m O~=Oilier Lights
04"SU\Pen,lQn lO~Hom
05~P"""r Tram 11 ~Mi-rorl
],
12"Wi~rs
13;;\l,iwr Se.tinll'Ccntrol
14=llody, Door>, Hocxl. [IC
IS.Trailtr Hitch
16=Wheels
".A"bag5
18=Trailer Dverloade<J
19-UnSfcure'5hit1eo
Trailer Lood
20=lmprnpff Towiog
2 hObllrvaed Windshield
gg=Unknown
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Unit No r..ctc..- CU<!_
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W0046474
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4=>Angle ~5idEJ8Wipe 80cHn Pf1d~arll
Qa<=!~ (OIXlCIlI1I Dfnt<:1Ion)
Jr8l.~n) 7 aHiI Fixed Object ~erlUn/Jl"W1
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1>>81ot1 & Fog ~Un1l11tJo'/ll l
8~r
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4<<SIU8h 8=1t;lt Palches &cC1Mr I
5a1~ 7zW'\tvi 81M1d1ng I
=<..,~~, cr.,,, ~g _._"""_""--,~~==--.J
HanrrIuJ E\lfrltt(H.,.", f\orr!tl ~O;Hit Fence () Wall
o 1 =H~ Und J 31 =Hit Building
02~Hit UrVll ~l~HIl Culvert
03 -Hit Unit 3 3MJit Bridge ~er Or Abutmef11
04=Hit Unit 4 34=Hit P.rlpe! End
OS-Hit Unit 5 35-H~ Brldg@ ~aW
06-Hit Other Traffic Unit 36.0Hlt Souldel Or Obstacle
07.Hit ~ On R<l.ld'Mly
OS.Hit Ot~er Arimal 37aHit Wnp,lct Altenubltt
09=CollisacnWitn Olhtl Non 3S.Hlt Fire Hydr~nt
Filled Ob)O!Cl 39=1-111 Roadway Equipment
l1=>trud 8y Unit I 4Q.riit Mail eel
12=S:rtXt Pij Unit ( 41.Hit Traffi, Island
',.$100 By Unit 3 42=l-1il Snow BanK
14=5:rud 3y Jolt 4 43.0Hit T~rnporary Constructloo
15=StrucX ey Unit 5 Berrier
16-Str~ck By Other 'raro.: Unit 4ll=H~ Ot~r F~ ~t<t
Zl.H~ Tree 0, 5hrubbe"f 49=Hit Un,no"" Fi>2a Objed
22=Hit Embankmtfll SCoCverturrv'RJll O.er
23=Hrt Utility Pcle 5 hSllock ~ Throv.n Or Falling
24.H,1 T,a/fie S"ln Ob,e<!
2S=Hrt Guard Rad 52=~i Ho~ Or Dth",
26=Hit Guard RaIl end pa'lemenll'f1!gulalltll!'
21_rlit Curb 53'<Jacknife
Z8cHit Con,r~t. Or $.IeI'i,. In Vehicle
LO"9itudlnal Barrer 58=Ol~ NoM;olllllon
29=J-lil Dltdl 99~Unkl'lown H.limful E_r
5-<:lv14ioe Tl!lfficw~y 7:(>0It (FiIrTlllnltructloo)
Cain ParlltflQ Laller 9"UiWlown
s.0tJwn ~~
6-Derll - ~i<n0Wfl
AtWlwey LIg!ll!!?<l "
5xF'Qg
C..~ln & Fog
Ori\!1r ,4ctlon ID) 17..0rele$ 0, illegal
oouNo ContribVlin<) Actioo 9aI:~ing On <oidway
01.Drlvtl WoS Drl1ratte<J 18=Dming On The Wrong
02=Dri>;11<) Jslng fland Held Phooe Sid. of Road
03=DII.,;nq iJsing Hand~ Flee Phone 19-Mal:1nq1mprcper
()4.M<>lc.ing lIIegallHurn Entraoo To Highway
05dmproperl<:arele5l Turning ZO=Malting ImpJQ~r Exrt
Q6rTJming lrom Wrong Lar'M! from Highway -1
07=Procee(jing W/O 21~ca.rt!es.\ 1'arl:I~r\ln9
Clearance After Stop 22=OverlUnder
08rRllI\n;ng Slop Sig" Compen~oo At CUI\/!
09=Rutlning Red Light 23 S""^'"
10.FaillJre To Respond To = f'=U'ng
Ott.tf Traffic Control Oevlce 14-0r,l'ing Too Fm Fa< Condilia"ls
'l=Tailgdting 2SgFallur\! To Marouln Proptr ~
12DSudden Slowinq/Stopping l6-Dnvel fleeingl'olice (Pol Chasel i
I3rilltgally $IOweo On ~ooa 27,Dr~ !ne1plllier<ed ,
14.Careless P~ssin9 Or L.lne IS.Jailur. To Use Speda'ired Equip I
Change 91=.A.ffe<;1ed By Ph)"li<al Con(iliOl1 l,
15=Pa~ng In No Pbs~nq lo~ 98c0tl1er Imptoper Driving Miens
1(i=Or,vW1g The Wro~g W~ 0" 99c(Jn~nC>\'ln r
l-WayStrw :
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Spealied lccMion
O<_W.I""\l, ilunnino. Jo:iorno,
Or Play'"g
03DWO'ki~9
04-<P~ V.~"J.
C5::Ap;:~\::,ljHj en leii'v1nQ Vfh;d~
O(,=WOr\:'lng On V~hocle -
07=Standing
98=Ot~er
99.Unknow<1
~ UnitHo@I] ~
Unit No ~
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COMMONWEAlTli OF PENNSYLVANIA
POUCE CRASH REPORTING FORM
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WOO-l6474
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"ddress
695 SALEM R.D L T 132 EITERS P A 17319
1731917319
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7)79381421
Na/l'llltJve and additional wltne$~:
AccIdent Invts1lglflon Notlflcatlon luued7 0 Property O"mage 0
Unit #2 was travelling west on the Carlisle Pike in the are of the Holiday Inn when it struck
pedestrian #1 who had been running across the Cal1isle Pike from the south side 0 f thB
roadway. The front end of Unit #2 impacted pedestrian #1 causing pedestrian #1 to strike the
front end and windshield of unit #2.
:
~
~
i
Ii
Operator #2 stated she believes the Ir afflc signal was green at the time of impact and Ihat she
naver saw pedestrfan#1 prior to impact. Operator #2 stated she stopped her vehicle immediately
after impact with pedestrian #1.
VVitness #1 was driving her vehicle east boun d on the Carlisle Pike when she saw pedestrian #1
running across the pike from the south sldEl. Witness #1 then obsEll'Vad unit #2 strike pedestrian
#1 Witness #1 stated she thinks her light was green and Ihat she could not ten if pedestrian
#1 was in the cross walk prior 10 impact with unit #2. Unit #2 was charged with Driving
Unregistered Veh icle and Driving Without Certificate Of Inspection
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o Ilrick or IJlod:
o Slag, Gr_1 or
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o Ot~er
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~ bst1i<tion$ /k)(
o No ~ctIonsl 0 Compiled Wlth
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om- !'ndoI.-.nt 0 ~U;j~ 'With 0 ~~:r Penn$ylvania
~ 0 Required - Non 0 Unknown
o None It.tqulred Compliance Com~1I4nce
O llJ!qulrtd -
Compli.anct Unknown
O Not ~ui~ for 0 Unk if CDL or
V~hide OM COL ~~irtd
o fNoOr ~~~ Llunse 0 Not a !>enmylvilnla
...... Driver
o Hot lICAI'Il<<l V IId"- to
o ~ ......,n.. r 0 Unknown
a~
o Not a Plmnsyl~~ni~
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o Unknown
Compli.tJn!@
~
DrIIII TM TwIe
o Hone
Olllood
DUrine
QOth<<
D UroIv1<Mn if Trn
Givwn
Dtvrl TtIIt 1etIlJftr. tlhIID FOlJ( /mll~1
o. No Test Given 5 . Amphrumlnn
1 '" No Drug Itllported G: PO'
2 . M~r111la1\l1 8 . OilIer
] .. coc.a 1M !l ~ Unknown Ten
.. . Opiates Rtiult1;
~D
~OD
Unit No
~
j
l:!I j!
c
:J
1ltIwJr RwfrldJonI 0 lWtricllons
~ Complied WIth
O RortI1ctlon5 Hot
o No Ro!strlctio"" Complied WIth
Not Applbble 0 ~~~a
Drlww EndlltUm.nr 0 Rtqull1:d - 0 Not a Penn~y'~anla
~ Complied W!t/1 O,~
o Required. Non 0 Unkrnmn
o N~ Required Compliance Compliance
o ~ulo!d -
CanplJance UnIcJ10wn
o Not A.equired fo, 0 Unk if COL or
Vend. ctal4 COl ROQuiflld
o No Valid Ucrrl5fl 0 Not 0 Pennsylvania
lor a~ Driver
o Not ~ 0 Valid Lke~ for
Oass 0 Unknown
o No1 B PennwlY~nia
o river
o UnilMwn
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fJr1tq Tint TrPe
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o Blood
o Urine
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2 " MArlkl,na 8 . 000'
3 " (;Q{"lne 9 . Unknown Te-;t
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unlt Ho
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~ .tmoort ?aUlt
o Non-<:olU,lon
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o UndelUrriage
o Towt'J Unit
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o Military
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11 12 01
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Evidence
o stetrlng . ~vtden<e
or I)rl_ Slal!d
o ottIer AYOldlna
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o Incondu<iw
o Steerlnv Ind &lIklng 0 UnlllOWn
EVldllf1<:e Of 5tal1!d
LJndenidl!. No
o CO<rJCllItmlem
Imruslon
O OverrlOt, OtNr
Vehicle
IJnderrlde, Unknown If
o Compartment 0 Undtrrlde Of
In1l'u5ion UnltllOWIl DYrrrid!
EItlWtOO' V~ 0 ligl'rt1 Flashing
O Not In Eme'1lel1Cj
U~ 0 5i~n Sounding
o Bath lights and
Sinn
o Unknown
000
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o 09 03 0
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O NO A~ldilnce-
MaMI.M1I
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o MoJIu. Dri_
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(J",w Ride tnrfft<<fot'
O No Underride 0(
<Nerride
Underrldt.
o Compartment
Intrullon
[1l~"'11t0Ci Us.
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o Braking. Other
Evldern;e
o St~ng - evidence
or Driwr 5trtlld
o ottlcr AI'OId~/\(t
Uanl!lMll
o Il\condwl~e
o Steering lInd 'r~klng 0 Unknown
E~idenc! or Stated
Ur.cerTlde. No
o Compartment
IntMlen
lInd....lde,
D c.ornp.8rtment
InttUllon Unknown
o OverTld~, Other
V.hkl.
Unknown if
o Underride or
Override
o lIghu flall'lino
o Slr'n $<lunoing
o BI)!h Lights ar.-d
Slftn
o Unknown
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11130/2006
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Unit No
D EnglN SiU~ cd OM!' Prolllctl9n 1 ~.1rMt Typll I'Ijs.n941r P!'Cl'tNtkm ~ Helmo(TY}lI
0 DO. No Helmet o Ey@ ?rot~lion 0 0: rlO~lmec
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o Trailt!" 0 D Helmft has o 0 flelme!MIS
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LIghts? 1I<rl1ectol1il Lights? AetI~0Il7
Unl'l "It ~ 1Datim:l ~ Unit No "'du~ l~ 0
~ 0
01 s MiI!lr;ed C/'OS$Walb at Irrt...leC'icn 01 . Mati(ed C~ at 1l11trsec1lOn
02 " AllnttJSllldion . No CromiaA:s 02 . At lnte~jon . No C/OS$WilIk$
~ jOOtlt 03 " NOIl-lnters<<tJOtl Cl'051Walb t%sJftfrlftl S/gfl1tlJ 03 . Non-Intfts<<l!otl CrCllSWall:l
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j ONa OS = In Roadwiy ONO 05.. In Roadway
06 ~ Not jn Roadway ~ 2 Not in ~dway
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08" !sland OB = ~d
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Dti!J/lt 10" SidtwaJk Dugtlt 10 - S.dewalk
11 . ~ 10 Feet Off Road 11.. < 10 feet Off Rood
o Dark 12" > 10 klet Off Road O~rl< 12.. > fOF@@IOffRoad
D~ 13 ~ Outside TI.ffkwey OR~ 13 . Outside Trafficway
o UnknoY.Tl 14 c Shallld ?atttllTrllils o Unknown 14" Shared PilhYf rails
99,. Un~nown 99" Unknown
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o (Long Term) \MIming Sign 0 ~::~ Dttlur7
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httn://www.dot6.state.pa.us/icons/PrintImages/XmlFiles/20061136761 GUTSHALL 1950... 11/30/2006
UI/~~/LU~I ~4:4b
2157212307
SHITH
PA'3E 02./04
JEFFREY A_. ^ .( P
o vau~U
..... FUNERAL HOME:
NORTH AMBLER STREET, QUAKERTOWN, PA 18951
...WHERE MEMORIES ARE SHARED
STATEMENT
./ ,/"'-'''' ."~""""-'." .':~.".....,;"
,. \
i .
( June 25, 2007 \
\ )
" ~
\ ~
'................. ,-- .......
"-...""~...~,.."'-- .~.......~~
Mrs. Kathleen Smith
425 S. Main Street
Telford, PA 18969
RE: Kathleen Ann Conn
. .
Date of Death: November 12,2006
Form of Amount of
Received From Pu)'ment Cbeck# Date Paid .ra yro ell t
Dawn Bishop Check Nov 15, 2006 2,227. 75
Harleysvilte Nat'l Bank Check '6000000095 Dee 28, 2006 319.04
HarJeysville Nafl Bank Check 6000000100 Jan 23, 2007 319.04
Har1eysville Nat'f Bank Check .6000000105 Feb 23, 2007 319.04
Harleysville Nat'l Bank Check 6000000108 Mar 23, 2007 320.00
Harleysville Nat'l Bank Check 6000000112 Apr24,2007 32000
Harleysville N~fJ Bank Check 6000000117 May 23, 2007 320.00
I:-l,?rleysville Nat'/ Bank Ch 6000000120 Jun 25, 2007 320.00
Total of Payments: $4,464.87
Total Cost of Funeral: $6,056.22)
'-""-iate Fees Acuued: ~~uD.94.::~( llat)L'.( cl
J3RIRDcc: $1,792.29 J ll.Df~r-.
TERMS NET 30 DAYS. A service charge of 1 % per month or an ANNUAL PERCENT OF 12%~
applied to the unpaid balance beginning 30 days frorn.the date appearing on the payment
agreement.
(Seal)
OFFICE & FAMILY SERVICES
TREFFINGER HOUSE:
24 N. AMBLER STREET
MAIL TO:
P.O. BOX 13
01 JAKFRT()WN PA 'lRA!'i1~()n1~
(215) 536-3343
1-800-30A-4441
FAX ?1."i-!'\ .'h-?7F.n
UiIU~/LUUf ~q:qb
Ll8 iLlL::!U I
SI-'lITH
F't;i3E D::,./I]c1
Sunlllilt Memorial Pari< 0
Hill::ide CerrHltery " 0 ",,-
G~org& Washln.gton Memorial Pans... ;Q:~
......,"..
....
1 0 0 2 d, fjl..
Contract No. _ _
Contract cocl;--7. ,L i\/ .--
THIS AGREEMENT made this
hereinafter ~lted "Seller" end
.J ,~/
?" ;:;'''''i
..<;, j
day of
4'" ,/,JO)/ I
,..I'.i......"{!.,,I" (.....,.. ..
/'
,20 {) r7, by and betwe~m The Cemetery,
"
//
".;<.:i'./ ,J.-:r!" .,.:-'
PURCHASER-'./1>t?>>.,:: ,;',)~,.t ./
7' I '<,
~"....,/":~....") />-'-",. ,/ . .'~ /'<
",...,,~ t ,..) .;.Y' " : '.:" fl'- .. ,J,{'A'
ADDRESS . /~~.':--"~/ '",j..I.I-r.."'I...:;O
Street
~,,';
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. c":;~.<
r."/\2.~f('
i./.
9.S.#: .'
. ,,' .,,,,.......... -"J_"..'" __
/:....,;::}:-:;....TE~PH.O.,I','~....~.,.)y:~;:,~.;:... .:'
/' ,r '''./.9''''~ (" ..t~', _
'd~'</~ ".qt....!...., ,.' Statll Zjpi~Od'"
,
r\.. ,~o",t' /. .
Namo 01 Decoased:
, .
. .
.'~ ~.. ~ t.. .:' h
: .'.( .,
'. '; ::).... ": r'~
I "
I" /" ,/
.;'; ..' '1 ," .'
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~ " .
Doscription of Intenneilt Rights:
1./ ..
';,1 r
/ ,_. /,v..
.~.o .,' ,Jo
.
.7 F
, /:/ ."~" /
ji;,-,"' ,:
Property Owner:
Burlnl Rights
.$
Interment Fees
.' ,
l::;'"
1 .... ;/
. ~ . L 1
~)__~ .:.; k ci ('. ~. :)
,.-
. .
I
"\' . r. tl. ~.'.I, :,o'~i.
.~.I\~.J t t
.' \
r ! ~{,~
.;{,r;' t.
.". ,
'J ':,. ,,~"
"" :
Memoriallzatlon . Type'
Size
Memorial Base - Jype
Slze
Design
."
Color
MeomorlollnstallatiOnllnspectlon Fee
Outer Burial C'm~ainer - Material
'),t ,-"......~. . . /
Mod 1///:-,. '/ _..j"'';;/;"
E;..l'''' ,,;....( '(/, .,..(.: ~. r' .,,/:,.'
/'~/~"/',::':"~",:/)
,"'~' /".r / /.r<fO r;J .;~:;7--'~-
$upplier/<.(./,.....IJ ,0( ./"<" ,.( 0{
Urn
TYP$
Flower Vase - Type
... __'....... .'__ Nam.eplat!_
L&tterlng
Other
Processing F~
Size
. .,.....- ~'..,..~....-' -.
.. .411
~. I
'."" r..
60.00
Sal&$ Tax
TOTAL CAS":f PRiCe
lESS:
$-S~;_:-~;:::~ .<r!)
Down Payment Cash
Other Credit
/' ,./.....:1.
// ,'J ,(..-<~.
$ ./~.;r. ,,~~r' ~r /~. "
,..... (
. ,~<~'~.~~i.f:" >
--------~:--~.:::-----
../..- .' "\ ..~
I Y .....<.-f ""-
./ 1) //... d1 ;~;
$ .". .. ..'j"" /- .l ,..'/-:., \
\ 'r//~ ,.', ... ',- ., )
\ $- ,t
"-- ./
$
.....,-.....---..............-...
Total Down Payments
UNPAID BALANCE OF CASH PRICE
Purchaser agr~ee that ;IIi right, conveyed under tnl.:i AgrMmoot Q/'9 3Ubjoot to, and Pur~ ~ to at "" timoa comply .....ith. LIre fX(.W)(ll (<:>.....: or,IC1:'Y
bo hereafter adopted ~mende-d or aIt6~.Rules, Regulations and ByIa~ 01 $(lU&f. which i~U$ availabl& for Ilxamrr:<.rt.iOfl in SeUec--'s Orfi0\7
./ ,;:;., .....;;.'f /~cr 1''/ / .! ,.,__
,.. ,/ . ,f.# ".r. r.....'.... / _.... ." /.
Si;pedthis /, ,/ dayof// ,.o!':..r.'...:.~."'r..,.~_....-....<W,_ 20.(:.1(...-:- .~-- _T .-., /'. .' ."
Pur.'.h~"r '.' ''0/ ... -'" ,.<?~.:,.., ../.:..-.....---_..;.._-:.;;~.<.~.~.
- a,.-"tl By ..../J.A.A.....-..f._c:...!:.:j..J... ....:..... = _'. .....
,,' .-t, .
U(!U~!~UU( U4:45
2157212387
SMITH
F';':;13E O'~ ,/ I~kl
~'~ .LAND
II
I,
I I
ARK
ONUMENTS
P. O. Box 572 Quakeliowtt, PA 18951
..- Phone: 215-529-0318 / Fax:215-536-1090
'/' .' ,/MAn.KER ORDER F~R~
Ordered By; ',1 fIt.v ;; ~ (' t . Date: c;/ /1-.; d I
Address: ~(.l r; 'S ~ /"" ~). I-.f('.?'t".. I I 1 ~ {,
"/e;'/-J;;r/,,:/ F;1'f I~J!?:1 Install at: c;~'('8e, U)q,S{fl'tj/C;t_ /fle/GN"k:-.,{ l1z,!.'/~
Ph(1n~: -2/ j- -l/l/ - )/;.<S:/ Design #:
^] Pi 0 . C] i/ I /7 I i
,,-\ lemate lOne: ranlte 0 Qr: ..L':-::5l:.~:f:!.I,:B;":",,j:-,~!U~___ __,__
RefelTed By: ...E~~{~ ,4.:...-t~.,.f;~~~. Base Size: ~)~ (Z X / Y.: X ~"/
M k S. 'j lr X / ..../ X ii'~I-I.~~
1 ar rer lze:~"-f...- 'i GRA$S M<\RKER, BEVEL NL\RKER
!vfarker finish: _._.....~-~-;:~~.=~, Color' ~. iJ~.<:.J--:.
Top: SERPENTINE, OVAL, FLAT
Sides: ROCK~ SA \VN, MANUFACTURERS CHOICE
Top: POLISHED, STEELED
AJI tloral carvings will be shaped unless otherwise specified.
Layout: SCALED DRA \VING, FULL SCALE DRAWING (at additional cost).
EX..1.,.CTL Y AS SUBMITTED, FOR BEST COMPOSITION
SKETCH
If not identical to specified design mm1ber.
Be sure to print clearly and place names in can'ect position (i.e. man on right? OR left?).
Special Instructions:
\-n ~ (~ ~~
"-'-, ~.d"'::~ 0 -, ex
f)."11()S;t. j,) ('f, I lii rr": (TL':';:;::\"'--
.- \,.-. ....J... './~. v, (,1\. _ .'><;..)'-' . .t
-} !' ....(' -. ,.-~ 'L '"J 1...- .-
~~-.C;~~_~.....Z.7.--1_.P..t:'.._..___._ \ ,,~ \'
It is understood that a 50% deposit is required at the time of agreement and priorro any prepawtion or
drawing. No stone or foundation \v.iJI be ordered priono this. The purchaser or appoint~d agent then:-Qfv,i11
see ~l reduced drawing whic.h must be approved and signed by them before any work will b€'gin. AI!
memorials must be paid in full pt'ior 10 installation. For out of state purchasers a photo \\'111 be sen t tor
approval and payment received prior to in~tatlation. Any addiiions, changes, or COITections, of erroneous
data v..'hich \~,ere approved must be paid for prior to installation. It is assumed that <illY mistakes or errors that
were not according to the approved drawing \vill be corrected by the seller Ilccording to industry S!and~Hd:'i,
Any lHlpaid balances that are approved are subject to a 2% per month finance charge ifnot paid \\ itbif) 30
days.
I agree to the temlS of this contract: X
1'1onument: ~//f:,O ;c~~j~:-.-
Other:
Subtotal: 1PU):1 AD
"-10 I I il,"r ,""
" II.S(: ....,.... .. ~J',:J> I !i..-*">'
T otul:
Date:
DV,,', qr 1,';5 :NC
2CO IV MAm Si
ME:::-iAN!CS2IJRG, PA 17C55
~
t"! r ill.?
-
J'WI.l..l~'~'~
TEGAN A RITChEY
5207 CEERFlElD Nv'E
~1E':HA,lJI(S8UiG, ,;lA 17050
I CERTIFY THIS 10 Be A
TRUE! AND ACCUR.An COpy
8Y: Cindy Wat..gk2
OAT~: 09/24/07
Policy number. 14832666-0
U ncei"'\'th:te~ ~;:
Px;;'~~:l.e $pE'::JIr; lj;j!"nIK~ C~.
SC,;rem;.€: 1;, lees
P?llcy f>er:ad: Se? :5,2006. ~,!ar 1;)07
Pab~ j of 2
717-766-0770
DUNN .:n iNS INe
C:::>,~~Cl your a~rn1 for ;er,cna:.;:~d ~trc::,
Au10 Insurance
Coverage Summary
This ;s your Declarations Page
driveinsurance.com
Online Servke
Ma(2 payments. c~e~k bd!ing ar.I',itf. j~Calc
pelicy inform~ticr, cr (h~ck ,,3lUS of Holm,
800.925.2886
To repOIl J daim.
Your coverage began on September 15. 20C6~: the lace/of 12:01 a.m. arrhe etfectiw time shown ~n your app!ica:icn. Tn:;
!)c1icy period ands on March 15,2007 at 12:01 a.m.
Your inSIJr.lnce po:icy and 3ny policy ~rdDr.;arr:enr; ~ontain a full e~planillion of your co~rage. The polic'} ccntr:d is
forn 9608 PA (05/01). The cew.a is modiTied by fOfT;1S 0 101 (08/02),7951 PA (0:/03) and Z295 PA (01/1)6).
Underwriting Comp,,"y .
prog ressive Specialty Insurance Co.
P.O. Box 6807
Cleveland, OH .14101
800-925-2836
Drivers zmd household resid~nts Addl(Malidc,'t:'.ancn
,....................."......"..............."..."......""........".",...............,.......,......................... .....""....'1.....",,...........
TEG!\N A RI ~CHf.'( First Named insured
Outlino of COVGragQ
2005 SatJJm Vue
VIN SGZCZ23D55S810604 limits Dedu~ibl. . :. P:!I~IUln
li~'b'iiitY't~'i.iihe~""""'''' ..."....... '" ......... ..... .. ..... ..... .............. .........,... ".. ....'. .............. .......... ................. '''$' i i8
Bcdly Injury Liability $15,000 each pel)on/$3C.OOC each accident
Property Daflldge liability $15,000 each occident
Fii-si'Pa~y'8enefi't';;" . ........ ..... .... ,... ........ .......,....'.. ...... ............ ....'...... ..... ........... ............ .......... '....... .......... '......' . 29
lviedicaJ S:pen~es $5.000 each person
U~(~~u~d'~j~io'ri5i : N~~'5~d~c{"'"'' .......... ....... 'S'jS:oco 'e~Ch .pe~onj$3ii,COC.eaCh..icCidelit. ...... ..... .. ......'............'......6
Und'e;insu':ed 'Moi;;ris'!'~' ~Jo;;sia'ck;;d" .......... ..... . "$15;000 'eaCh 'De;Sonj$3ii:600'eaCh'aCCide~'t'" .....,....,...,... .....,......... ,,, 'j'j
ci:;np~hE;ns'i::e .. .......... ....... ...., ,...... ...... ...A.dl:al.czshVaili...... ....... ..... ..... ......... ......... ....550.0............. .' ~9
coliiibri........... .....,............... ............. ...A"ctual.Cash'V3iue..... ......'............'..........."....'$500.............. "325
T';i.1i's.monih.poiicy.jiremiiilii..'......................., ..................... ....... ......................... ......... . .....$6;'8
Premium discounts
W'ide
2005 Salul'!'1 Vue
....'...........,,,....,,,". """" '"....""...""".."....................... .., ...........
airbag and ant.rheFt devlCi'
Fc:rtr1 s~e9 f:;:' {ll:t~,l
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('l:I~.!d
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T~'~ANlr CrE":'
p{2. Ji 2
Lienholder information
Lienhcld@r:
'I....... ..,"''', ..............". .......... .....,..... ....,,,,,......... ..".,............""".... ......,..............." ."....."".....",,,
GMAC
PO 30;:( 5378 ~iMCNIU'vl.Iv!J 2:D94
2005 $aturr: Vue (SGZCZ23D55 SE 1 0604)
Tort Option
This policy provides limited ton insurance,
COlliSION COVERAGE FOR RENTAL VEHICLES
IF THIS POLICY PROVIDES COLLISION COVERAGE, IT WILL APPLY TO VEHICLES YOU RENT, BUT NOT TO
VEHICLES RENTED FOR 6 MONTHS OR MORE.
Penalty for Insurance Fraud
Any per;on who knowingly and with intent to injure or defralJd any jn5~rer files an application or claim containing
false, incomplete or misleading information shall, upon ccn',iction, be subject to imprisonment fOI up to seven years
and payment of a fine of up to $15,000. . .
Company officers
~b~~
President
~G.~
5 ecretary
rof~ 6~~'9 ?;.. 0 1.....:14)
AFFIDAVIT OF NO OTHER INSURANCE
My name is Tegan Ritchey and I reside at 5207 Deerfield Avenue,
Mechanicsburg, PA 17050.
On November 12,2006, I was insured under a policy of automobile
insurance issued to me by Progressive Insurance Companies, Policy No.
,.
v
14832666-1
As of the date of the accident, I owned no other motor vehicles in my own
name.
As of November 12, 2006, I was covered by no other insurance policies
that would apply to the automobile accident which occurred on November 12,
2006.
As of November 12, 2006, there was no person residing with me in my
household who would have covered me under an insurance policy to apply to
the automobile accident that occurred on November 12, 2006.
I understand that the statements made herein are made subject to the
penalties of 18 Pa.C.S.A. 84094, relating to unsworn falsifications made to
authorities.
Date: ll/It/17
,2,ec€ -'-<- c:ll_
I7~ ,12~
WEB ADDRESS www.state.pa.us
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
Po Box 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
January 16, 2008
Charles E. Schmidt, Jr.
Schmidt Kramer
209 State St.
Harrisburg, PA 17101
Re: Estate of Kathleen Ann Conn
File Number: 2107-0108
Court Number: CCP Cumberland Co. No.
Dear Mr. Schmidt:
The Department of Revenue has received the Petition for Approval of Settlement Claim to
be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action.
It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the
proceeds paid to settle the actions.
Pursuant to the Petition, the 22-year-old-decedent died as a result of being struck by a
motor vehicle. Decedent is survived by her minor child.
Please be advised that, based upon these facts and for inheritance tax purposes only, this
Department has no objection to the proposed allocation of the gross proceeds of this action,
$15,000 to the wrongful death claim and $0 to the survival claim. Proceeds of a survival action are
an asset included in the decedent's estate and are subject to the imposition of Pennsylvania
inheritance tax. 42 Pa. C.S.A. 98302; 72 P.S. 999106, 9107. Costs and fees must be deducted in
the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059
(Pa. Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this
matter. As the Department has no objections to the Petition, an attorney from the Department of
Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has
any questions or requires anything additional from this Bureau. Finally, the approval of this
allocation is limited to this estate and does not reflect the position that the Department may take in
any other proposed distribution of proceeds of a wrongful death/survival action.
Sincerely,
{~ .L ill CCQ~/\{)tctdL
~y A. McClintock
Trust Valuation Specialist
Inheritance Tax Division
Bureau of Individual Taxes
PHONE: 717-787-1794 . FAX: 717-783-3467 . EMAll: hmcclintoc@state.pa.us
CONTINGENT FEE AGREEMENT
THIS AGREEMENT entered into the _ day of March, 2007, bya1d
between SCHMIDT KR-\MER PC and KATHLEEN A. SMITH, Administrate;,: of
the Estate of Kathleen A. Conn, hereinafter referred to as "Client."
WITNESSETH:
The law firm of SCHMIDT KRAMER PC, will act as Client's attorney in
negotiating for a settlement, and in bringing a claim against Tegan Ritchey,
arising out of an accident which occurred on November 12) 2006, Route 11 ,
Hampden Township, Cumberland County, Pennsylvania. In addition,
SCHMIDT KRAMER PC, \vill pursue all claims for underinsured or uninsured
motorist benefits to \vhich the Client may be entitled under her insurance
policy.
In return, the Client will:
1. Promptly supply accurate information, as requested by SCHMIDT
KRAMER PC, 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
KRAMER PC, for its services an amount equal to twenty-five percent (25~'o) of
all funds or property accruing to Client as a result of SCHMIDT KRAMEj~ PC's
services in securing a settlement of these claims before trial; and an arnoun t
equal to thirty-three and one-third (33 1/3%) if such funds or property are
4. Claims for first party medical benefits and ::1come loss benef::s a:-e
separate items. SCHMIDT KRA.MER PC, will help you process these clair-;s. A
separate agreement \vill have to be entered into for fees if a major dispute
occurs requiring the filing of suit for these benefits.
The Client has read and does understand this Agreement.
Signed the day and year set forth above.
\VITNESS:
Clien t:
1<, . r ,/'\ C-"
f r~':, "", ;...... I
' \(t LX \ " ~L:~V_( .-:(~ _j) vie ("--:1-::
Kathleen A. Smith, Administratrix
of the Estate of Kathleen A. Conn
APPro~~
I /:
SCHJ\1iPT!; (~E:;
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I have received a copy of this Contingent Fee Agreement.
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1'ULL RELEASE OF ALL CLAl\fS W1TH Ii'iDEM~ITY
Page 1 of 2
KNO\V ALL Ii Y THl-:.~c }-,Kl:~Sb.NT::i, Ulat I, I\.athleen ~mlm, as we AommISUW!L'\ 111
the Estate of Kathleen Conn, for and in consideration of the sum of Fifreen Thousand and
00/100, ($15,000.00), the receipt whereof is hereby acknowledged, dO~$ hereby fo!' myself, my
heirs, executors, administrators, successors and assigns and any and all persons, firm$,
employers, corporations, associations, or parUlerships release, acquit and forever discharge
Tegan A, Ritchey, her agents, employees, subsidiari~s, and aftJliates (hereinafter "Releasees")
from any and all claims, actions, causes of actions, demands, costs, property damage, loss of
wages, expenses, hospital medical and nursing expenses, accn((~d or unaccllled claims for loss of
consortium, loss of support or affection, loss of society and companionship on account of or in
any way growing out of, allY and all k1lown and unknown personal injuries and damages
resulting from an automobile accident which occurred on or about the 12th day of November. at
or near Carlisle Pike, Camp Hin, Pennsylvania. It is understood and agreed tllat this settlement
is in full compromise of a doubtful and disputed claim as to bOlh questions of liability and as to
the nature and extent of lhe injuries and damages, and that neither this release, nQr the payment
pursuant thereto shall be construed as an admission of liability, suell being denied.
Ilis further understood and agreed that the undersigned relies wholly upon the
undersigned's judgment, belief, and knowledge of the nature, extenc, effect, and duration of scUd
injuries and liability therefore and is made without reliance upon any statement or representation
of the party or parties hereby released or their representatives.
In consideration of ule payment cir the sum, the undersigned further agrees r.o indemnify
Tegan A. Ritchey, h~r agents, employees, Sllbsidiaries, and affiliates and save them harmles:.;
from any and all fm1her liability, loss, damage, claims of subrogalion and expense, arising
because of any injuries and damages, sustained by the undersigned, and, if necessary in order to
save them so hannless, to satisfy Oll their behalf any judgment against them arising in any way
out of the undersigned injuries or damages.
I have read this release and underst.and it.
Signed:
\Vitness
date
date
Kath]een Smit11, as Administratrix of the Estate
of Kathleen Conn
\Vilness
date
1~1 6/2007 15:07 FAX
ProgressiveCaslnsCo
~ I.: ,~, II '~:
FULL RELEASE OF ALL CLALvIS 'VITH INDE~ITY
Page 2 of 2
State of:
COllllty af:
On rhis _ day of , 2_, before me personally appeared
> to me known to be the
person(s) who executed the foregoing instrument, and acknowledged this as a free act and deed.
IN TESTIMONY WHRREOF, J have hereto subscribed my name rtlld aft1xed my seal this
_day of ,2
My commission expires
Not.ary Public
Claim N a.: 060295942
Distribution List
Charles E. Schmidt, Jr., Esquire
SCHMIDT KRAMER PC
209 State Street
Harrisburg, PA 17101
Phone: (717) 232-6300
Fax: (717) 232-6467