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HomeMy WebLinkAbout08-6713 ESTATE OF EDWARD F. SHUEY, and ROBERT W. SHUEY, Co-Plaintiff's vs. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 13 KEITH B. BURGARD, and : NO: o MELINDA A. BURGARD, Co-Defendant's : WRIT OF SUMMONS 61 W. Vine Street Shiremanstown, PA 17011 NOTICE OF WRIT OF SUMMONS TO KEITH B. BURGARD and MELINDA A. BURGARD: You are hereby notified that the Estate of Edward F. Shuey and Robert W. Shuey, the Co-Plaintiffs, have or has commenced an action in the 9m Judicial District of PA, Cumberland County Branch, against you which you are required to defend. Date: ?)? i?.?•LC /")- , 0206 F- SEAL OF Prothonotary THE COURT BSS/ /? A?l ESTATE OF EDWARD F. SHUEY, and ROBERT W. SHUEY, Co-Plaintiff's vs. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW KEITH B. BURGARD, and : NO: 6 4e 7 13 MELINDA A. BURGARD, Co-Defendant's : WRIT OF SUMMONS PRAECIPE FOR WRIT OF SUMMONS To the Prothonotary: Please issue a writ of summons in the above captioned action. Date: Zl dg Paul Bradford Orr, Esquire 50 East High Street Carlisle, PA 17013 Supreme Court IN 71786 (717) 258-8558 iA v W a 1 m .ra SHERIFF'S RETURN - REGULAR CASE NO: 2008-06713 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHUEY EDWARD F ESTATE OF ET AL VS BURGARD KEITH B ET AL TIMOTHY REITZ , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon BURGARD MELINDA A the DEFENDANT at 0018:30 HOURS, on the 19th day of November-, 2008 at 61 W VINE STREET SHIREMANSTOWN, PA 17011 by handing to MELINDA BURGARD DEFENDANT a true and attested copy of WRIT OF SUMMONS together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge i"ZI)OF So Answers: 6.00 .00 .00 10.00 R. Thomas Kline 00 1. 600 11/20/2008 PAUL B ORR Sworn and Subscibed to before me this of By. - day Deput Sheriff A.D. SHERIFF'S RETURN - REGULAR CASE NO: 2008-06713 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHUEY EDWARD F ESTATE OF ET AL VS BURGARD KEITH B ET AL TIMOTHY REITZ , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon BURGARD KEITH B the DEFENDANT , at 0018:30 HOURS, on the 19th day of November-, 2008 at 61 W VINE STREET SHIREMANSTOWN, PA 17011 MELINDA BURGARD by handing to WIFE OF DEFENDANT a true and attested copy of WRIT OF SUMMONS together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: So Answers: Docketing 18.00 Service 11.00 Affidavit .00 Surcharge 10.00 R. Thomas Kline .00 ix?lf1o? ,/ 39.00 11/20/2008 PAUL B. ORR Sworn and Subscibed to By: before me this day Depu y Sherif of A.D. ESTATE OF EDWARD F. SHUEY, and ROBERT W. SHUEY, Co-Plaintiffs vs. KEITH B. BURGARD, and MELINDA& BURGARD Co-Defendant's :IN THE COURT OF COMMON PLEAS OF :CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW : No: 08-6713 CIVIL TERM PETITION FOR APPROVAL OF ALLOCATION OF PROCEEDS Petitioner, WILLIAM M. SHUEY, Executor of the Estate of Edward F. Shuey, deceased, by and through his counsel, Paul Bradford Orr Esquire, respectfully petitions this Honorable Court for an Order of Court approving a compromise settlement of claims asserted under the Pennsylvania Wrongful Death and Survival Act and in support thereof avers as follows: Petitioner WILLIAM M. SHUEY ("Petitioner") is an adult individual residing at 2060 County Line Road, York Springs, Pennsylvania 17372 and is the Executor of the Estate of Edward F. Shuey, deceased, late of Lower Allen Township, Cumberland County, Pennsylvania ("Decedent"). Petitioner is the son of the Decedent and was appointed to serve as Executor of the Estate of Decedent by the Register of Wills of Cumberland County on April 14, 2008, to File Number 2008-00414. 2. Decedent died on March 21, 2008, at the age of 87 years as a result of injuries sustained in an automobile accident that occurred on November 24, 2006, when he was a belted passenger in a vehicle that was struck by another vehicle that ran a red light which was owned and operated by Keith B. Burgard, Defendant. A copy of the Police Accident Report is attached as Exhibit "A". A copy of the Coroner's Certificate of Death is also attached as Exhibit "B". 3. At the time of his death, Decedent was survived by and resided with his wife Marcella A. Shuey. On November 26, 2008, Marcella A. Shuey, Decedent's wife passed away. An Estate has been opened at Cumberland County Register of Wills with a file number of 2008-00414. He was also survived by three (3) sons, Robert W. Shuey, David E. Shuey and William M. Shuey. Decedent had a Last Will and Testament which he executed on September 23, 2003 which named wife as 1/3 Beneficiary and three (3) son's as 2/9th Beneficiaries each. 4. Defendant was insured exclusively under an automobile insurance policy issued by State Farm Insurance to Defendant carrying a per person liability limit of $100,000.00 at the time of the accident. Defendant does not have additional insurance coverage. 5. There are no other possible sources of automobile insurance coverage from which to assert any additional claims arising out of Decedent's death. 6. As a consequence of Decedent's death, Petitioner filed a Notice of Writ of Summons against Keith B. Burgard and Melinda A. Burgard, Co-Defendants on November 12, 2008, under the Wrongful Death Act and the Survival Act. 7. Defendant's insurer, State Farm Insurance, offered the policy limits of $100,000.00. 8. Petitioner believes the $100,000.00 offer by State Farm Insurance is reasonable under the circumstances. 9. An inheritance tax return has not yet been filed. Inheritance tax will be due on the portion of the recovery allocated to the survival action as well as any other estate assets. 10. The estate was duly advertised. 11. Since the Decedent's wife survived him and Decedent also had three son's surviving, Petitioner proposes to allocate the total settlement proceeds of $100,000.00 be split 50/50 under Wrongful Death and Survival Act. 12. Petitioner proposed the following distribution of proceeds: A. To the Estate of Edward F. Shuey, deceased, $59,853.50, for payment of any claims, debts, inheritance taxes, and attorneys fees of the Estate, with the balance to be distributed to the beneficiaries of Decedent's Estate; B. To the Estate of Marcella A. Shuey, deceased, $33,000.00 for her Beneficial interest; C. To the Law Offices of Paul Bradford Orr, $7,146.50, for legal services, and reimbursement of costs. D. Funeral Services were prepaid by Decedent or by Executor to Myers-Harper Funeral Home; 13. In a letter dated March 10, 2009, a copy of which is attached hereto and made a part hereof as Exhibit "C", the Pennsylvania Department of Revenue agreed to the above allocation and has no objections to the Petition. 14. Counsel for Petitioner believes that the settlement is fair and reasonable under the circumstances. Defendant is clearly liable for the injuries of the Decedent. 15. Subject to Court approval of the allocation of the proceeds of the settlement as set forth in Paragraph 12 hereof, Petitioner has agreed to accept his offer as representing, under the circumstances, a fair and reasonable settlement of the claims. WHEREFORE, Petitioner prays your Honorable Court to enter an order approving the proposed allocation of the proceeds of settlement in accordance with this Petition. Date: 31a3109 E FUL Y SU I ED: Paul Bradford Orr, Esquire 50 East High Street Carlisle, Pennsylvania 17013 Supreme Court ID No. 71786 (717) 258-8558 ATTORNEY VERIFICATION 2 3 4. 5 The undersigned, Paul Bradford Orr, Esquire, hereby verifies and states that: He is the attorney for the Petitioner; He is authorized to make this verification on his behalf; The facts set forth in the foregoing Petition for Approval of Allocation of Proceeds of Settlement of Claims Asserted Under the Pennsylvania Wrongful Death and Survival Act are known to him and not necessarily to his client; The facts set forth in the foregoing Petition are true and correct to the best of his knowledge, information and belief; and He is aware that false statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to unsworn falsification to authorities. Date: Respectfully submitted, LAW O FICES OF PAUL B FORD ORR By: Vi 6 Paul Bradford Orr, Esquire 50 East High Street Carlisle, PA 17013 (717) 258-8558 Attorney for Petitioner Superior Court IN 71786 CERTIFICATE OF SERVICE AND NOW, this 23'd day of March, 2009, 1 Paul Bradford Orr, attorney for Petitioner, The Estate of Edward F. Shuey, hereby certify that I served the within Petition for Approval of Allocation of Proceeds of Settlement of Claims Asserted Under the Pennsylvania Wrongful Death and Survival Act this date by depositing a copy of same in the United States mail, postage prepaid, in Carlisle, Pennsylvania, addressed as follows: Ms. Shannon E. Baker Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes PO Box 280601 Harrisburg, PA 17128-0601 David M. Smilek Claim Representative State Farm Mutual Automobile Insurance Company PO Box 142 Concordville, PA 19331-0142 By: Paul Bradford Orr, Esquire runt l tCJ rVO i Z-J-1.) j . CO14 MONWEALTVIVF MN14SYLVAMA POLICE CRASH REPORnINIG FORM I .t agr- I V1 11 CreshNumber Can Closed Reportable Crash rvo rZ»> AA 500 1 OYes o No O Yes ONO ! Patrol Zone indderrt Number Pollee Agency 20061101380 21102 !_J Name Precinct Data, (W-DD-YY`!Y) _ 24 -[2006 hi T All owns p. en Lower ?i Dlspateh n. (mil) Anival Time (mV lumber 0853 0854 rrL CHARLES BURCKHARDT 1829 Reviewer !!!a Number Approval Date (MM-MrrM 1841 11 29 2006 0 Arlen Lerslcer county Counts Name Mluni Municipalk Name 21 Cumberland 102 wer Allen Township Qer of IARrak O Sun O Thu O Mom O C Crash Date (MM-DD-YYYY) Crash Time (mil) NO of units Peopk Injured Killed' V > 00 complete O Tue O sat _ 200b 0848 2 7 4 0 I I 24 Form is C :),Wed O Unk , O Yes O No Sdical B O Yes O No ??e O Yes O No ='TO Yes O No Workmne p M a m 29) r IRMSKOW T-6 O 4 Way Intersection O 'Y' Intersection O lnMultU,,L U9on O off Ramp O Railroad Crossing ? 6 O Mistibiock O -T• intersection O TTraffic CAb"W O On Ramp O Croswier O other Round * see gymiff Route Number segment (Optiona4 Travel Lanes Speed Limit O North House Number (if applicable) 2021 FO-47 35 O South Street Name Street Ending O East For Mid-btock crashes only. Use DR O Wen pmt House Number and make sure WESLEY O Unknown pnnapal Roadway Street Name is f4W in if using this option um pRce O State O O Local O a? t o RPrwte O Unk n o O t O T e SSpu r ( ) n w stree s ) ( Route Number (OptionaQ Travel Lanes Speed Limit O North 03 15 1¢ O South r Street Name Street Ending O East BETHANY DR O West O Unknown Rogne ike State County local Road private Other/ ik Turn T m e p tr p e Interstate S O (Not Turnpike) O tEastl4Vest) O Spur O Highway O Road o or Street o Road 0 Unknown _ Intersecting Rt Num Or Mile Post Or Segment Marker O ? ? 0 North Feet . O South Or IrKaesecting Street Name St Ending O East Please Enter information O West Or Miles . r .? for BOTH Landmarks Intersecting Lit Num Or iW?Re Pose or segment Wiarirer a N - _ Oh . _ _.( pnce From Crash c Using S Ttus Option f 1 ? ? O 2 O South one to Landmark 1 ( • g Or Intersecting street Name S t? O East z (fir Crash between Landm rk i and e a ® fL__11 O West Landmark 2) 7 ? reel Minutes Seoonds Minutes Sewnds Latitudr. En = = = • • r Tlafnc Control Device O Yield Sign O Police Officer or R Crossing O OFlagman ther Type TCD A 9R O Not Applicable O Traffic Signal O c I Em O No Controls O Device Functioning O 5 e mip S o Flashing Traffic Q O Stop Sign Passive RR O Unknown Signal O Device Not Device Functioning O Device Not O Unknown Functioning properly Crossing Controls /?Q? of 'Abt APP . skip rest of the Lane Obsi a secdoro litlL?!! O North O East O North and South O All O Not Applicable O Parth* O Fully O Unknown O South O West O East and West (N,S.E." ILi?G Yes O No O ? ]I@t O < 30 Min. O 30.60 Min. O 1-3 his O 3-6 hrs O 6-9 firs O > 9 hours O Unknown Unknown O ? FORM r AA4= (12J PLAINTIFF'S EXHIBIT http://www.dot6.state.pa.us/icons/Printlr. t 3 1 18715121102admin52006... 11/29/2 --' rime L!C.b 1-vo /G?JJ !CE M AA 500 2 Po%m Use Only paw t P0672533 rage G 01 1 1 Gush lkin bee o Motor Vehicle in Transport 0 tflt a Aun Vehicle 0 0 Nh011OW O Non - Motorized . c oavratarri(II1-MaVrllr t z From eintt 0 Pedestrian O OVVhlldd?air, eSkates tc , 0 PNDisabled ridx Crash 0 Train O Phantom Vehide 0 Yes Q No (If 11,10111011,11W a or • in fit Ye; Complete Forte 0 Unit No FIM Name W f>I14M1 et YYYY) Ol KEITH 8? 03 1969 Delete? Lan Name QBURGARD T . 19V??t ?b505 .?J Address i Oty I Star zip 61 W VINE ST SHREMANSTQWN PA 1 117011 "M Liceirm Mt tuber Store, Claws 21765363 PA tt Q No O IWO DW Q MQdfl SWA Q O Use Dw9 0 Fatigue 0 Medicaw ` O Akohd O Alcohol and Mugs 0 Ur'JuKlwn 0 Had ? 0 Sick O Adeep O Unknown 4!2" Test Tnata Q Test Not Gtwn 0 Breath O other Charged? 0 Blood O Unite O Unknown it T'3t"3 12?A)?3 O Yes ONO Test w Atcohd Test Reso O Test Refused Oa 1=DriWler 171d 3-Driver fled Scene = Q Test Given, M 1 v t RaAdts t Vehicle 4-W and Run F U I 2=Io Diner 9= nknown Qwne+ wmr 00s1111ot Appii 02*Pdva" Vdude Not 04-St ne Rdim Vehicle 07-Mu ")A Police Veh W.Federat Gov Veh 01=i! Ate Vdlide Ov "& Ortvt MAaWd by Driver 05oWPOOM Vehicle tMwotlw Municipal 9aftottter Leased by Driver 03altented VAe kle 06-00wr State Gov Veh Government Vehicle 99=Ur4mown Same as Owner Fist Mom Owner lamt Mom cjr 200m iija of ped"bian, Skip d* Section) Driver O 11MELINDA A BURGARD Address / / Sixte / Zip Vehlde Maim 'N joke Code 1 61 W VINE ST SH1 lANS"TIMWN PA 17€f11 Chevrolet 20 VIN Loa" Year Vahide Model (see ove" 1 IIF12T617365204 112001 1 CAVALIER 4 license Plate Reg. stales Est. Speed VrMelale TovMad Towed By I DDX8418 PA 099 C) Yes 0 No I 8ECKERS -? Insurance insurance rolky No s` -- O Yes O O un- . STATE A:RM _. . , 3963W14 D z TraNil>9 1=rowing Pass. veh 4-Mobdeibbdwlat Home 7-Secri-Tras, T No T Year Tag St -'_ ? W El 2-Towing T? ?amr ?ihef T r 3 Towing Utility Trailer 6=Fu8 Trailer 9=Unknown U t a ni s: y 'Vdrwa Mom !KMNW l lTrareman m# of I .01 *see [9 O"rb L I ;1REWS _ _ y - 5- 1/owColor - 05=largeTruck 20=0ineeycie, Bicycle tow 1 0 n r I i t2= 05 006-yeN dl Ot 06=6UV 0 =N? 07-Van 2t=Other Pea6ak7reie Pms ge 00-Wt Applabk Carrier v 01 fi h T i 08=Gold O1=Slue 09--frown 03-Btw 10-5nowmobrie 22=Horse & ?gy 04=SmM Tnxk 11=fmm Equip 23-Horse & e - re 13= a)a 02=Ambulance 21=Tractor Trader 02=Red 10=0range 03=White 11=Purple (tf '02', Complete Form 12=Construction Equip 24-Tram Aif Section 26) 13?ATV 25-Trdley 03=Pcbce 22=Twin Trailer 08=Other Emergency 223.Tdpte Trailer f O c 12-outer 99 k Type Spec Veh 9?c?Flter ( Z1f" or '71 ` Conwil"t 11 pupil Transport 99=Unknown Veh nown =Un t9=lMk Fora" At Serton 20 Type Spec Veh W-tJttkrwrvR ksihW knw? Paint A? waft 3=Downhdl Ilolsf It 112 W-Non-Collision 14-Undeir iege 01-12-Clock Points 15=Towed tA1it r- - O-None 2=4wKt"Wl I=Minor 3=x"'"4 f 1 1=lam 4=9otlgm of "ii (i" 1=S6ri?ht 1 4=To) of HfR U 2=Curved ! ' 13-Top 99.Unknowri 9-Unknown I _1 2-Whiff 9=Unknown 9-Unknown FORM s AA-5w traffic PLOT Cwy ltttpjlwww.dot6.state.pa.us/iconsIPr ntImage&OCTti3Filesl2W6l l8715121142admin52O06... 11/29/2006 I 11111, Vi\U 1 VV I L?JJ II M OF PSRMSYLVAM ?•t POM CR SM REMOitTING FORM Page AA 500 2 m- use orgy I E] M I 11111MI Crash Nunnber P0672533 o Motor rVehicle in p Hit & Run Vehicle o pMegally Parked O Leg* Parked o Non - Motorized Cornmrrda/ V&Wde r Q Pedestrian 0 Pedestrian on Skates, O Disabled From o Train p Phantom Vehide 0 Yes 0 No in Wheelchair. etc Previous Crash (if Ye; Complete Form q Of 'Pedestrbn' or 'Pedestrfan.on Skate; in UVheeklrair, etc'. C Form M Section 28 Unit No First Name Ml Date of eirib(MM-DD-YYYY) Ol KEITH U 03 1969 Delete? Last Name Telephone Number O BURGARD x7178056905 Address / / State ZIP 61 W VINE ST SHIREMANSTOWN PA 17011 Driver Ucerse Number State Vass 21765363 PA Akohallrgw Suweded._ _ DOW ar..Ae&Odan !luveiw/ EonaFtlo+r Q No Q Illegal Drugs p Meditation O nat Misr 0 U U Vl Ong se O Fatigue Q Medication O Alcohol O Alcohol and Drugs O Unknown O Had Been O Sick p Asleep 0 Unknown ? Akvluo?! Test Toe t p Q Test Not Given o Breath O other ?rl»sWr VOWS Code Vlo/ation Cam? 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Veh 4=MobiWModular Home 7=Semi-Trailer Tag No Tag Year Tag St U,* [] 2=To,&*V Truck F.--Campw 8=Other iling Tra 3 T i ff T il F E a T - ow ng Ut ra er y - ull railer 9-Unknown Units: y of F1 *Veh,* PasMw *Aloventeut Ol *See soedal usage Overlay - - Vehicle Color VOW@, TWO OSdarge Truk 2d=Unicycle, Bicycle. 12=Commercial Fo o P 05 Ott=Yellow 07.Siher Ol 01=Automobile Tricycle cle 07=Van 21=Other Pedakyde 02=Motorc assenger 00~ Applicable Caffier 08 G l y 01 =Fire Veh 13=Taxi = d o 01=Blue 09=Brown 03 =Bus 10=Snovurrrobile 22=Horse & 8t>ggY 04=5mad Truk 11Tarm Equip 23=Horse & Rn3er 02=Ambulance 21=Tractor T Ar 02=Red 10=orange 03=White 11=Purple (1,f '02', Complete Form 12-Construction Equip 24=Train At Section 21) 13=ATV 25=Trolley 0 22=Twin Trailer 08=0ther Emergency 23-Triple Trailer 04_-Green 12=Other 05-Black 99=Unknown Of -20' or '21', Complete 18=Other Type Spec Veh 98=Other 19?1nk T Veh 99-Unknown e spec y Pup4 T 31=Unknow Veh t i upii Transport 99dlnkrovn . P i?am, A4 sectiwan 27) MIMI knoact Pbh?t Q 00=Non-Collision 14=Jrdertartiage 01-12-Clock Points 15=Towed Unit OMAN k>dfotor o=NOne z¢WxYional I=Minor 3=Disab&rng T6-Mew 3=Downhill )dens) 4=6ottom of FfiM 5= Top of Hilt Road Aparwrent ]=straight 2=Curved 13-Top 99-Unknown 9-Unknown 2=Uphill 9=Unknown 9=Unknown FORM i A4-5W (IM PENNDOT COPY http://www.dot6.state.pa.us/iconsIMntlmageslXmIFilesl2006l l 8715121102admin52006... 11/29/2006 rnni t.;KJ ruo l LJJS CCU ®KWALTH.OF 61aSYLVANA n POLICE MASH I OR9'Mf6 FORM Page: AA 5500 2 Police use 0* U 1' 1 AP0672533 ra.`c Crash Number 0 Motor Vehicle in O Hit & Ruin Veh de O ItlegaDy Parked O Legally Parked Q Non - Motorized 0 Commerdal Vehide Transport Type O Yes Q No Unit Pedestrian on Skates, Disabled From etc 0 Disables Crash O Train O Phantom Vehicle Q Pedestrian 0 in Wheeiclnair , - (If Yes. Complete Form q , C Form M, Secdon (if `Pedestrian' or 'PedesbUn on Skates. in Wheelchair, etc unit No First Name MI Daft of Wrth (MM-DD-YYYY) _ FO-27-1 ROBERT F 06 26 1946 Last Name Tela one Number - Delete? ? SHUEY 5186743509 O Address I / State 3 P O BOX 255 AVERILL PK NY 12018 Driver Ltaeme Number St"D Claw 50876405663514307 [ - ] I AkohoLADruos Suspected Driver or Pedaulan Phvsrcal Condition Q No Q Mtegal'Drugs p Medication `O IAP mat 0 IIUegal Drug O Fatigue Q Medication O Alcohol O Alcohol and Drugs O Unknown d 8 n O Sick O Asleep Q Unknown O Ha D ' Akohol Test Type 0 Test Not Given p Breath O Other Primary VW* Code Viofabw C? nknoownif Q Blood Q Urine O U O Yes O No Test AkoW Test Results p Test Refused O Rew ts Unknown T n t Gi t/tflAer Presence Operated t=Driver 3=Driver Fled Scene Vehicle 4=Hit and Run , es ve 0 C lts nt min d Re t a ? 9 U k o a a e su • nown = n LJ 2=No Driver Ovvne river 00=Not Applicable 02=Private Vehicle Not 04=State Pdice Vehicle 07=Mwicipal Police Veh W=Federal Gov Veh 01=Prorate Vehicle Ownedl Owned&eased by Driver 05=PENNDOT Vehicle 08=Other Mu wVd 98-Other O1 Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Ga mment Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name pf Pedestrian, skip this Section) Driver O ROBERT SHUEY Address I City I Stete I Zip VeMde Make 'Make Code P O BOX 255 AVERILL PK NY 12018 M-Benz 42 VIN Mode Year VeWde Model (see oveday) I 11 WDBJF65G5YA953531 2000 E32 License Plate Reg. State Est. Speed Vehkie Towed Towed BY 999 p Yes Q No BECKERS BAYONET to ivi anae Insurance Company Policy No o Un ALLSTATE, 0132716380 02/14 p Yes ONO Q known w - T fmy T 7=Towing Pass. Veh 4=Mobile/IvWula, Home 7=Semi-Trailer Tag No Tag Year Tag St UWT UUnri No. of Q ?{ 2=Towing Truck 5=Camper 8=Other o u T Trailing U Units. 3 -Towing Utility Trailer 6=Fug Trailer 9=Unknown Mqdmn of M *VWude Position 06 *Moverrrent O1 *See Special Usage Ov erlay Vehicle Color Vehide Time 05=Large Truk 20=Lh qde, Bicycle, =Conulnercial 12 Passenger OS 06=YeDow 07=Sitar 01 01=Automobile 06=SUV Tricycle 02=Motorcyde 07=Van 21-Other Pedal4de 00-Not Applicable Carrier 08--Gold 03=Bus 10=Snowmobile 22=Norse & Buggy 01-Fire Veh 13=Taxi 02=Ambulance 21 =Tractor Trailer 01=Blue 09-Brown 04=Smal1 Truk 11=Farm Equip 23=Horse & Rider 03=Police 22=Twin Trailer 02=Red 10=Orange (if "02', Complete form 12=Construction Equip 24=Train 08--Other Emergency 23=Tdpte Trailer 03=White 11=Purple M, Section 26) I3=ATV 25=Troliey 31= wd Veh Vei 04_-Green 12=Other I8-Other Type Spec Veh 98=Other (?f 20' or 2t; Complete Unkn T 11 =Pup1T Transport 99=Unknown 05=Black 99=UnkrxNvn Form M, Section 27) 19--Mk. Type Spec Veh 99=Unknown h?iLial hnoact Poirrt Daunaae hkilcator Gradient 3=Downhi8 Road Alleorrperrt 3 00=Non-Collision 14•4htderca T k P i t 15 07 72 Cl d U n t D=None z=Fwtctional 1=Minor 3=Disabling In 4_-Bottom of Hill Level 5=Top of Hill El 1 1=5traight ? 2=Curved n s owe n - - oc o - 13=Top 99=Unknown 9=Unknown 2 U ill ph 9=Unknown 9=Unknown r-ORM • AA-5W1(12W) PE.NNDOT COPY h4://www.dot6.state.pa.us/icons/Printlmages/XmiFilesl2OO6l l 8715121102admin52006... 11/29/2006 YTIT)I I.tCJ YVOIGJJJ c®?llflA Cif KI MSYLVANIA Poua cRc FOIR Paw AA 500 3 aesce use 0* r 0,1V C '-a (;1 I i Crudo Mamber P0672533 A D , E Not 2=Passenger 7??tnan. Oi lriver - AH 01 waaOow Doh Used ? Q mtt Seat P066on 0244 8dt Un d cled Ejected i T 9-her A 04.?5eca+d Cs fide or =&=tF? d Lw iMrtt Pile r+ v cHeurrct used ftsffiw 06 =Used o,,t :Z nd 06-Second 14g11t t0" p N o S ? emale M=Maie U =ilnkrxiwn 1= / Not abie OThad Raw Or Greater - 11 properly l t Used Im 9 left Side 12=ffelmet Used 2= Side YVbxlow . Used. ?yp known 3 ? `Po eater - 9 9 _ Unknow Npddle Posiidon =? W Door 09=Third Row Or Greater - 4 bAU 50M 5 Door Tail Opening 1o.rsecoan of Tnrciccab F ft to l / able F°0 T 00w hyured 1=lGfied 2=Major M1mY t t=in 0tber Enclosed ot=front As Bag Qaglpygd Ow TWO Seat) T Passpger 0r Cargp Area o2=Si(!e Arr Bag l ft T#?s 5 7= OP3 (C`' 12=1n 0pe? Ar:a 03=O1lier Type f?t?Mpl?llkplpypd T t Ot Pkl (B 3 e o ?'? rte""' 3=Moderate at cup, Etc) OqwMuioplP Air B D yed p Injury 4.-Minor Un Unkry 13=TraifnV Unit s t4- ' On Vehicle £xl®tior Seve" 9-Unknown if ?Y 91ba ther t 1-Air Ng Not , Switch off 99.Unknown 12 B h SOML?ye(, 1 Not E 1 8y Mechanical AAeans By Non Mew wkA Meares 13=Air Bag Removed To Crash) Smother 14-il? 0 Air Bag D%kryed g y EMS Agency LA IWS I HAWDEN EMS lllgw* t FedMf . 1 SIMY MEDICAL C Unit Me Person No Ol o go" d Yh#i 0^Fr -YYYY) A B C D E F G H i Q -? - I969 1 . J Oi 43 01 "O a + - -' on f Address f p1leMeer E Ne M5 T earnport 0 S as $tJRfiARl3, RNFW B 61 W VINE ST SHMEMANSTOWN PA 17011 '1 p Yes © No that No Person No Ol 02 Delete2 Daft of Kh (MM-D7 A ( B C D E F G (( HH I ( ?II p 03 - - 1981 L 4 1 03 03 O 1 L _ 1 L. J . Name f. f E] 13tJRGiARD; UELNVA 61 W VIII-ST SHIREMANSTOWN PA11 011 7 p Yes No Unit No Person No 01 03 Sei1 of 61h H I A B C G puerete? OS - Q - 1992 M[? 03 ' E] 0(0 Name !4tm -- Swne as BURGARD,f ER J 61 W VINE ST SI•TIREMANSTOWN PA 17011 71 O No t O No 1 p T ?5 00 F2 f;; t_! 104 [ 120 None 1 A*bm / Mmne EI S,aransport El Sae as URGARI?, TAYLORN 61 W VINE ST SHIREMANSTOWN PA 17011 71 p Yes 0 No operawr that No person No 02 Ol DeletaT ? fMM-0Q-YYM ?nA 8 j CC D ?E ?"} IF GG p?H `J F p Ch?- 26 .. 19Wt6? l?J Q U ?1 t t 'J LJ U Addrarai f ENlS Transport p SMO M. SHM, ROBERT W P O BOX 255 AVERILL PK NY 12018 51867435 p-Yes (] No opermor u No Perspr Mb O 03 - 13 - ' 15M21 a a 03E 02 F 2 Nye / J1dlines i " ERAS Transport El ?aw , 45$ EDWARD 1 0 Yes CD No r-0RM w AA-M (I-M PENNDOT'CO" http://www.dot6 state pa us/icons/PTintlmages( Wiles/2" 11871 5121102admin52QQ6... 11/29/2006 rIlilt Li?JIVU IL /?? COMMONWEALTH OF POLICE CRASH RREPORTINGNFORAHAPllA1 Page AA 500 3 rage ? ICrash Number 1 = P0672533 1 S I e: im Seat M ao xP /4 . t=Denier oo=Not A PassengerlOcoupant D 01?rhw - All Vehicles E 00=None uses /Hot Applicable 01-Shoulder Belt used wicaw G 1 2?assenger 7=Pedestrwn 02=ront Seat Middle Position 02-LV Belt Used l U d l =Tats E 2 3 8?iher 9=Unknown 03?rort Seat Right Side de Or 04-Second how -- LLee ftt Si se der Be 03dap And Shou t 04=C at used ild 9=Unknown ?Ir f - d ?? Hd h a * Hel U d d UsU mpr fe H - Right Si G t O y ope fJ se 10-Sa ty Seat Used Improperly Safet = Child O=Not Ejected / Not Applicable i O B F M- M l er - r rea 07-Third tRo y - Used t 12 ng pen t=Through Side Door 2= Side Window w - a e U --Unknown 08=Third Row Or Greater - 90-Restraint Used. Type Unknown i 3 Through Mme Position 99-Unknown Bad: D 4=Through Bads Door or 09-Third Row Or Greater - t gyp , S=Through Bade Door Tailgate Opening U Right Side f T xkcab ti Sl S - F Used I Not Its KWle ti=Through Roof Opening {Sunroo T o "V ari>x =Injured on o n t0= eeper ec 11-M Other Enclosed 01-Front Air Bag Deployed (Far This Seat) r This Seat) (F B owwn) op Corw e 7=Through Roof Opening (Converub)e 1- jor Mj 2?ut Passenger Or Cargo Area 12=Ir? Open Area a ag 02=Side Air 03er Type IUr Deployed Top Up) g=U,*? a 3=Moderate (Back Of Pickup, Etc.) 04=Mut6ple Air Bags Dyed .u 13=Trading LWt 05--MoUxrycle Eye. Protection 4Zor Injury Unk 8.Inj 14=Riding On Vehicle Exterior 75=Bus Passenger 06=eicydist Wearing ElbwdKr edPads a0=Air Bag:,Not'Depbyed, switch on 0=Not = . 98=0[her 11 =Air Bag Not Deployed. Switch Off 1=Not Extricated 9-Unkrwvvn if 99-Unknown 12-Air Baag No Deployed. Switch 2-xtricated By Mechanical Means 3-Freed By Non - Mechanical Means 13=Air Bag Renwved To Crash) 8 19--4Jnknown If Air Bag Deployed 99=thiknown 9=unknam ENS AgenCr. I'-" ' EMS / HAMPDEN EMS Medical FaCB;ty HERSHEY MEDICAL CENTER Unit No Parson No Date of B6ffi 0rM -W-YYYY) A B C D E F G H I Ol Ol Delete? 03 -?- 1969 l?Pa 01 03 Ol O 1 hone EMS Transport Same as BURGARD, /KEITH B 61 W VINE ST SHIRE1viANSTOWN PA 17011 717 O Yes O ope. Date of Birth (MM-DD-YYYY) A B C D E F G H I Unit No Person No Delete? In(? 1D Ol 02 O 03 -? -1-1981 2? F? 4 03 03 F01 Neale I Address I Phone ENIS Transport M same as BURGARD MELMA A 61 W VINE ST SHUMMANSTOWN PA 170117 O Yeses O operaw Unit No Pessorr No ? Daft Birth MM-0D W-M A B C E F G H Delete -1 Fff? 01 03 O OS - 08 - 1992 2? M? 0? 06 03 D Nam /Address /Phone C1 sane as BURGARD, TYLER J 61 W VIN E ST SHIREMANSTOWN PA 17011717 e EMS Transport O Yes O No lhrit NO Person No DektteT-of firth (LNMDD-YYYY) A B C D E O -- 2006 ???? 04 00 Ol 04 OS 20 ? ? I 0 I Nairn / Address / Phone cl Some as :BURGARD, TAYLOR N 61 W VINE ST SHIREMANSTOWN PA 1701171 ENS Transport O Yes ON. Operator Unit No person No Delet s? Date of Birth (MM-DD-YYYY) A B C D E F 02 Ol O 06 - 26 - 1946 1 M? 3? 01 03 G H I a fl n Name / Addrom / Phone SHUEY, ROBERT W P O BOX 255 AVERILL PK NY 12018 51867435 Sam as openstm EMS Transport OYes O No Unit No Person No Daft of Birth (MM.DD -YYYY) A B C D E F G H 1 2? ® 03 02 1? 0?? 02 02 p ? 03 - l3 -11921 Name / Address / Phone ETHANY DR MECHANICSBURG PA 17055 El Sam Open as SHUEY, ED FA-RD 45 N B Operator EMS Transport O Yes O No FOnM f A&M anent) PE.NNOOT COPY http://www.dot6.state.pa.us/icons/Printlmages/XmIFil es/2006118715121102admin52006... 1 1 /29/2006 YIlnt I?KJ YUb /LJS S I COMMONIMALZH OF PENNSYLVANIA I'OUCE CRASH I;EPORTM FORM Pill" AA 500 3 ""o* Q .t-age of t i I??N Crash Nranber P0672533 Tvae A 1ntrer 2 P Seat D00=Not A Pas9ergeNOccupant 01 i i D ll l E OQ=Norte edr, I frcable G plicable S ' = assenger 7?edesVian = r ver - A Veh c es 02=Front Seat Middle Position 01= houlder Belt 1=Not Used 02=tap Belt Used 2 Tots j ed 8=Other 03=front Seat Right Side 03=Lap And Shoulder Belt Used 3=Part' E 9--Unknown 04=Second Roar - Leh Side Or 04--Chid Safety Seat Used 9=lJrdcnown Passennger 05 i R ' P i 05=Motacyde met Used oar - M = os t o n 06-Bicycle Helm Used ?'?? F = B 06=Secant Row - Right Side 07=Third Row Or Greater - 10=Safety Beh Used improperly 0= Ejected 1 Not Applicable 11 =Child Safety Seat Used Improperly 1 =Through Side Door Opening o M--Male U =Unknown Left Side 08=Third Raw Or Greater - 12-Helmet Used im?opedy ndow 90=Restraint Used, Type Unknown 3=T?ugh Through Side Window Windshield - Middle Position 09=Third Row Or Greater - Right Side 99-Unknown 4=Throw Bade Door Sa rdranenr T 5;Through Back DoorT to Opening 10=Sleeper Section of Truckcab F OQ?IOne Used / Not Applicable 6= ConConvugherRoof Opening roof/ tble Top Down) g ?? kjured 1-- aced 2=Nfajor Urywy 11 =In Other Enclosed Passenger Or Cargo Area 12=Un Open Area 01 =Front Air Bag Deployed (For This Sit) 02-Side Air Bag Deployed (For This Seat) 7 =Through Roof Opening (Convertible 03=Other Type Air Bag_ Deployed TOP UP) 3=Moderate (Bade Of Pickup, Etc.) n 04-Multiple Air Bags Deployed injury 13=Trailing Unit 05=M.U cycle lye Protection 4-Mkxw Injury 8 Injury, Unk 14=Riding On Vehicle Exterior =Passenger 06=Bicydist Wearing Elba4*%ne&?ads Exlikapori 40=Air-Bag Bag Not Deployed, Switch On ? likable Seventy 9_-Unkrwwm if 98 99=Unk v0Wn 11=Air Bag Not Deployed, Switch Off 1=Not Extricated 12=Air Bag Not Deployed, 2=Extricated By Mechanical Means injury Unk Swtch Seto By Non - Mechanical Means 13=Air Bag Removed To Crash) 19=Unknown R Air Bag Deployed 9 -Unknown - 99=Unknown EMS Agency LA EMS / HAMPDEN EMS I M dial FadP?ty HERSHEY MEDICAL CENTER Unit No Parson No 02 03 Date of Birth (MM-DD-YYYY) A B C. D E F G H I Q ? Q- 21 -11944 FJFJ31 106 1103 1102 11 On ? Burma / Address / Phone EL S TTrarfipott 0 Same 8or CHURCH, ANNA K P O BOX 255 AVERILL PK NY 12018 518674350 Yes 0 No Unit No Person No >? of Bilith (MM E?-DD-YYYY) A B C D E (( FF? [[ GG H I O 7-U ??1??ULJQ? Name / Address / Phone EM Transport Same as Operator O Yes O No Unit No Person No c? o Date of Birth (MM-DD-YYYY) A B C D E F G H o T ?ooc?ooaa? Name / Address I Phone EMS Transport Same as Operator O Yes O No Unk No ' Perion No . D E-- Doge of Bithh FF G. 14 (MM''--'DD'-YYYY) . A B C . Q Q ? O Q`!?J ( ( ?aQL 100F QI Name / Address / Phone EMS T S ransport ame as Operatw O Yes O No (U'r'dtt'No Person No U 0 Data of Birth (MM-OD-YYYY) A 8 ('C''{ 0 E F G H I O 0-0 ?ElF] FTT] Name / Address / Phone EMS Transport Same as Operator O Yes O No Unit No Person No Date of Birth (MM-DD-YYM A B C D E F G H I z coo o -? - ?ooaa? Nance / Address 1 Phone EMS Transport ? Same as Operator OYes ON. FORM A AA-S90 ( 2IM PENNOOT COPY http-ll e.pa.us/iconsl?i intImages/XmiFiies/2006l l 8715121102admin52006... 11/29/2006 ,r?nt C K5 YU6'11533 t(2Milfl T" OF PPWSYLVANA PO KE ? A AA 500 4 Fifice use orar ---- 1 ?El 02sM UM 2 04mM Unit 4 O5xW Unit 5 06.dtit Other Traffic Unit 07-M Deer 054Rt 000 Animal OSr+vCaiision A* Other Non 11=Struck By LWt 1 1 L-SVU& By Unit 2 13=Smick By Unit 3 14-SBudc By Und 4 t5-Struck 9y tktit 5 16eSVV& 9y 00w Traffic U rit 71 -Hk Tree Or Uqubbuy 22 * Pair Sam 25-hit Guard Rid 2fiwH t Guard AW End 27=HR Curb 28-Hk Cowete Or Lor+gg, Barrier Z9*Hitt 'oftar Crash QL$CrfptFDO Relation to Roadway ev m ttireedrer CorrdlN7ans Rand SWAM QmWWm 1=Fiear Find I-on Travel Lanes &Shot*W &0AWO T*Mfl g Lane SAWNWAn ?ea 3Sbm (Wl 6-Fog 4=Srawslain & O-Aky 2=NK 1" OK 4.SkAgh IxW61 3e;adem CAMsd 5>alce Unr ?ur`a,ua 7 -7 t No t 02 l F5-1--1 2 Plaint Put;? F] o Events in Sequential Oder 4 = ? 0 Harm Event LIS Fiore PJdtaiber .. 1 11 ? Wilt no 0 02 2 L_J U 0 Mease Put Eaventms 3 ? ??? s in O Seguerrtial Order 4 = ? 0 L - first Unift Oi No a Ql W ,fpm, Erant 102 Om rot sae tlb inionewn a '•- e.... t ftft"W &" (am 07 2 ; . CD=None 11= Road Conditions (kta9iow) 02=Sudden WeWW Conditions 13wPorioles 03=MW Weadw Conditions MAWoken Or Cracked Pavemertt 04=Deer In Roadway 15-TCD Obstructed mi-mocle On ft" 06=00* A - imal in Fmft I$-" Aiplldrr or _ drop Off ' 8 n w 2 Rovdp4 Facbr 07=Glare onmentW Factor 0$=Work Zone Related Paraiik Vdrfde Fad (19 12=41(ipeis 00-None OE-Exhaust 13_=Driver SeatingrControi 01=Tires 07 L5 14. ., , Doors, Hood, Etc TB 15 i 02=Brake System rr H = tch == stem Lights O OS-POwerTran II=Mirfm IBmTruikrOverloaded Unit 01 Na 1 00 2 Trailer Load 2 21?d 102 Wo t ® 2 Wr 99=Unknown , kxkated/?irnfYcaar iatli i?bre?0on m ocamr oag E/R V D P 0 0 0 0 ff Prime Factor Unit MD Wan rage o of i i ?IIR tthaaii?er 110672533 7a6eet & F" 9.Lk*RD n S, 000 31 Fence or wA1- .f* Oulft 32mHit Cutveit 33.f* ier Or 34-Hit PaRpet End Atartnoet 35-dirt Rail 36-Hit or 04tKie On Roadway 37--Hit Impact Attent'ator 3&Hit Fire n-W Roads f ant qupntertt 4 41 Hit TraffiK Wand 421;i 5nwr flank 4 Terroor&y CQraudion. Barw 4&4* 0#W F"d Obpct 51 at Thrown or Faving 52? HalesfirOther pownent "Wanes 53= M 54cvre to Vehide SS00*1er Non{oikwn 99Aftnown Harmful fvem kw-- t On The Wrong Held mxm ? I2ds kee Phone broptoper 1 E T um ntrance o Rg1" 21 =tarede$Parlring1J rking Stop 22A1rtider t COMPerSaWn At Ctave , 2- - F orrtroi Dewioe 24-06sigi Too Fast For Conditions To "d On s S 2827.0" 4t:owed =F d T i l Lane 9 r pec a um n rzed Equip a 92-Affaded By Physical Condition In No Pa Zone The Wrorig Way On N maper Ork" Actions 99=Unknown Street 1101 2F5-9--1 .4 ? :ft ©2 9 F00----j 2? 3? 4? 280 AMC! EP? 03=working 00.4one 04=Push rig vehicle 01= Or Crossmq At 0 leaving Vehicle teamon 02aWa0txRummg,3oggng, D7 99-4Jnknown ihrk No d ] 100 um *.102 100 24f 0 an 46AO* . .. _ ?_ _. BmiNt'ISe eaten http://www.dot6.state:pa.usliconvPrindmagal m,lF esl2OO6l l87151211,02admin520O6, .. 11/29/2006 Ynnt I YUbIL?3J J COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM pays AA 500 4 r `m0* . ?n•C 11 24110d On Crash Desa6N3on a 1=Rear End Random to Roadwev (? izon Travel Lewis 3ddedien I q 2-Shoulder 4 - -Cl- - - - - - BIII# Crash Number ~ P0672533 8#Rt Pedestrian ?pa Diredlon) ben+e ectimDir v) m74ao*d 9.0dwrRn+la+ m S=OuNicfe Tmficway 7=(bt ( WIM k"nsection) 6=k+ Parlarly Ursa 9-=Un bw m r E RhrmUstion 1 't.De?1(- PiO r,9nu am - Law L..._J Sheet 4=Ouak ' Ffly B=unwawn - W"dw Carm9 lwrs ? i F ? , enflain R Fog Ba h r _? L_J 2=Rek1- 8 Pakift B=Ol ° Road Syr-fm condi + Mlud. Dkt, sA , o Covered ?_ Movn 1?Alet 3xsrrow :C: 21=1 11: UR umber - - Harmful Evrrtts [Naito Evdrtl 30=Hit Fence Or wall t 3,=frt Budding 1 Q2 F1 O 02 Hit ? 2 32=Hit Brig Culvert Or Abutment Unit No 03=Hit Unit 3 3"tt Parapet End 4 04--Hit Unit 4 35-Hit Bridge Rail 01 2 U O 05=Hit Unit 5 36=Hit Bowe Or obstacle ? 06.Hit Atha Traffic Unit pppOn Roadway 008>4fiHit Deer t Other Animal 37=Hk knpact Att emator Events Put 3 ? O 09=Cdfbion With Other Hon 38=Hit fire Hydrant bat 39=Hit Roadway Equipment Mail Box SeQ r ON r 1,= trudcUrM 1 40=Hit haki 4 ? O 12J5vuck By Unit 2 4241==Hit SnTraW ow now Hit Island Basic 13=Svuck By Und 3 c ? 14.l By Unit 4 43=Ha Temporary LOobns?ucctxtion i Harm Event L/R Mostl tlliitY Fote Number 15=Strudc By Unit 5 4 Barrier 16.l ey other Traffic unit Unknovrn faed Object 1 11 O 21-Ht1t Tree Or 5Wubbecy 22diit Embankment 51=S? Over Unit Thrown Or FAN 23=Hit Utility Fbie M 02 2 ? O 25=Hit ratlrc 5?n 52-ftt Holes Or Oder Guard 26=Hit Guard Rai End Pavement kregulanbes Please put 27=Hit Curb 5? WWI Events in 3 ? O 28-Hit Concrete or dal U 1= Ranier noMm Harrill 4 ? O 29=Hit Ditdc Or Regaf Unit No Harm Event Driver action iDl 17da dl O" F Imin" irst III No Harm Event amdril 00=No r_o* uting Action cr"g + Q l 02 f-01--j 02 otter Was Distracted 18?ri+?r+g_O" The w?On9 02?Drfving Using Eland Held Phone Side Road TIF +l oo .or wo -t ink k"pfO 04Mekng U Tum Entrance to 20=Mak0W Exit n:. a Pon&dLm:0m,1Snm) 03•Drinng. Using Hands Flee Pone 1 2 06=TumWrong cane From 07?rOCeedin9 Wl 21=Cateles PAk9UTm" - :a After Stop 22--OverAWK on At Curve 62--Su e Londitvma 12 02=Sodded Weather Conditiorn t3=Potltofes o Rem5nd To 24Draing Too fat For Conditions 03=Otlw Weather Conditions i4aroken Or ractO.F _ 5=TCD OW&KIed Odw Traffic to" Device 254ahn To Mamtan Pmpeir-Speed 044elr in Roadway Police 05=Obstade On Roadway WS0ft Shosld -()r 9=11 der Drop Off : f Z=T - 274river flee" tpol these) Mallpefimed 011 Amoral In 28--Other Roadway factor 13= IllegallyS?On? ZB=fadure To Use Specialized Equip Rol 07=1I 29-Odw Environmental factor 14.Cal Passing Or lane 92.AffededBy?hyOW Condition +s r 08.Work Zone Related 99-Unknown Change 98=Other knproper Driving Actions -° 12=N! 15=PassKg In No Passi Zone 99=Unknown a Pbadble Vehida Faiknes 06cEshaust 13?ri5eatirxyCa+bd 16=Driving The Wrong way On 00=None te_a?,d„ Doors. Hood. Etc 1-Way Street O,= Tires 07diead is 15=Trai-(er Hitch ? 02-Brake System s W O1 f 01 2 L. 9 3 .4 F ? 03-Steering. t0=Horn 1 ffi Pawe? Train n 11 PAim OrS 9- JJae Overloaded ,dime ad ed Un't o2 3 4 ? Odmprttper LoTowing No LLLL..?..?.... No Ql 1 2 2 Trailer 99?Inkrgwn Wi PldesVlen Action (P) p4-Pt?ng Vehicle 111102 2 oo1lone p,=ppproyng Or Leaving Vehicle No 1 U O1=Entering or 06=Ww ing On Vehicle Spedied Unk No Factor Code 02 aBuny Rwmk+g. logging• 07 kidca0ad Prima /irctor or Playing 0a nor ay..r v:c:.roma an F01--1 109 r9 ? D?9? E / R V D P Unit No 01 unit No 02 0Q O 000 H EIR is the prime Factor Type, leave Unit No blank sarnr • elides raozt PENNI COPY http://www.dot6.state.pa.us/icons/PrintlmageslXmIFilesl2006l l 8715121102admin52O06... 11/29/2006 rnnt -,Kb rvo//__).5j COMMONWEALTH OF PENNSYLVANIA POLKE atASH'REPOMG FORM par AA 500 e?rceuseony = 2 I , Crash Number P0672533 ....__...._.._....... • ------------- ........ ._..._..»........._...._.._.__...»__._._'.___ _?.._.:..._ ___.. ... _.. ... _...- --.. -- .._ _. _........ ... _ ...................... Witness Name Address f?tlOne 7 JEN OSWALD 7 ROCKFORD K-4 WILMINGTON DE 19806 7177613425 2 ROBERT CHEEKA 1077 LANCASTER BV#15 MECHANICSBURG P 7176918187 Narrative and addkkmal wium av Acddent it ation Ncd rkntiaa bmwe O Properv Damage O Unit #1, operated by Keith B. Burgard, was headed southbound on Wesley Dr. and failed to stop at a red light at Bethany Dr. Unit #2, operated by Robert W. Shuey, was headed westbound across Wesley Dr. from Bethany Dr. As he was cro ssing the intersection, he was broadsided by unit #1. From unit #1: Melinda A. Burgard and her child, Taylor N. Burgard, were transported to Hershey Medical Center an d released. From unit #2: Edward F. Shuey was airlifted to Hershey Medical Center Via LifeLron. Robert and Anna K. Church were taken to Hershey Medical Center via Y ambulance for unknown injuries. Cumberland County Accident Reconstruction Team was called to process the scene. Air bag sensor x from unit #1 was seized and will be downloaded pending a search warrant. V 6 a Investigation to continue. SUPPLEMENTAL NARRATIVE BY 1829 ON 11/25/2006 Unit #1, operated by Keith B. Burgard, was headed southbound on Wesley Dr. and failed to stop at a red light at Bethany Dr. Unit #2, operated by Robert W. Shuey, was headed westbound across Wesley Dr. from Bethany Dr. As he was crossing the intersection, he was broadsided by unit #1. From unit #1: Melinda A. Burgard and her child, Taylor N. Burgard, were transported to Hershey Medical Center and released. From unit #2'. Edward F. Shuey was airlifted to Hershey Medical Center via LifeLion. Robert and Anna K. Church were taken to Hershey Medical Center via ambulance for unknown injuries. fow# aaamrmw PENNDOT COPY hup:llwww.dot6.state.pa.usliconslPrinthnages/XmlFilesl2OO6l ] 8715121102 52O06... 11/29/2006 Y*_nt C!"Is Y()6'/2_1)33 Page 8 of 11 OF VA{tt1A i 1 CRA 1l I1IN ew O Now pme u:0irr P0672533 AASWN 19 1 © Narrative and mWitk wide mm. z Dispatched to a two vehicle trash with entrapment at Wilson La. and Shealy La. Upon arrival, it was found that the crash' Wok place on Wesley Dr in the mitre of the intwmolon wNh Wilson La. and Bethany Dr, these two roads are the same. To the west, it is Whon La. and to the right, it is Bethany Dr. (entrances to Bethany Village). All four directions of travel face traffic signals (red, yellow and green). Condltbns were clear with dry roadways. Upon arrival, I found unit #1 facing northwest; it was in the southbound lane of Wesley Dr. Unit #1 was 2001 Chevrolet Cavalier (PAIDOX8418). It sustained heavy frontal damage and had dual front airbag depioyment. Unit #2 was also Iticing northwest it was in the crosswalk of Wilson La., west of unit #1. Unit #2 was a 2000 Mercedes Benz E320 (WIBAYONET). it sustained heavy damage on the is side, crushing in the doors. 1 first spoke with the driver of unit #1, Keith B. Burgard. When asked what happened, he sated that he was head ad southbound on Weeley Dr., '...not paying attention and driving. All of a sudden, everyone yells 'stopl' I hit the brltes, but it was too late. I ran the red fight' I did not observe any indicators of Intoxication on Keith Burgand. The front seat passenger of unit #1 was Melinda &AVwd, who was bleedkwg fr®m her mouth. In the rear pes"nV s seat was Tyler J. Burgard, who wa s.uninjuabd. Taylor N. Bid (8 m1b) was in ft r r driver's seat in a child safety seat. Taylor was removed by her parents prior to my err . The shell of the seat was std beftd in a nd it was U ire rrxav+ed mutltt erne ti in one inch, per CSS standards. I examined.the a" for a mwwnt and wo t* d*s ks s were. twood; i was than called away for o#w des aryl Vw sett w u rAmmopantly taken by LA ENS to t he t ai, t AD In t hi l d th * d b l occupan s re ve c a e slate sy were vw o rig see e ts. I could see on Keith Burgard that he had a large bruise over his left collarbone area from wearing the seetbett. The wW d wiper sk* (on the pager side of ft steering wheel) t was snapped in unit #1. I collected Kelths and Melinda's licenses and insurance card. They were J transported to Hershey Modk* Center 'by LA EMS and released atworlly ftweO r. 9 Due to the heavy damage to unit #2,1 was u naEitie to talk to its omits on the some. The front seat passenger was Edward F. Shuey. He was entrapped in the vehicle, wltMtrled only passenger side curtain airbag deployment. Fire personnel from Laver Allen Township and Hampden Rescue were eventually able to fires him. I later taeerwd from RobertShuwy theft- idwerd suttehsd a fractured rib and a spleen injury of unictiowwt sev+srtty.. He was a~ Z Hershey Medical Center via Lifelion. Anna K. Church was the in the rear passenger seat of unit #2. She was partially entr apped with her foot caught under a seat; she was freed by a Pamnedit-. She su?carl-abr Aar-far rat ankle, right knee and ornate right skW-aUlrbr faae; she anti su#e red possible inju "to her right hip and rib cage. After the scene was somewhat sNibilized and traffic was shut down, I informed O1C Ott that I would like to call the Cumberland County Accident Reconstruction Team (CCART) out to assist me with the reconsbrurtdn the, t am was hed. 011c. Morn and Ok. C k" (LATP OI Ofc. Solve nberger (Hampden Tbwag* PD), Totem EcOwn ode (Cu wW County Camneft Olike) and i F?v P VM http://www.dot6.sme pa.usticon&WntImages/ %lF a/ l l 871512-1102adff in52006.._ 11/29/2006 ynnt errs rub iz?ss 494 OF PEOMMVMIA r0LiC9 GUM REPOMM FOIE AA 500 N 14"'0 * 1 Gl'. V Vl t 1 O New 1111111al Crash tfumber P"' P0672533 O cownuation Narrative and additional witnesses: Dispatched to a two vehicle crash with entrapment at Wilson La. and Shealy La. Upon arrival, it was found that the crash took place on Wesley Dr in the middle of the intersection with Wilson La. and Bethany Dr, these two roads are the same. To the west, it is Wilson La. and to the right, it is Bethany Dr. (entrance to Bethany Village). All four directions of travel face traffic signals (red, yellow and green). Conditions were clear with dry roadways. Upon arrival, I found unit #1 facing northwest; it was in the southbound lane of Wesley Dr. Unit #1 was 2001 Chevrolet Cavalier (pA1DDX8418). It sustained heavy front-end damage and had dual front airbag deployment. Unit #2 was also facing northwest; it was in the crosswalk of Wilson La., west of unit #1. Unit #2 was a 2000 Mercedes Benz E320 (NYBAYONET). It sustained heavy damage on the passenger's side, crushing in the doors. I first spoke with the driver of unit #1, Keith B. Burgard. When asked what happened, he stated that he was head ad southbound on Wesley Dr., "...not paying attention and driving. All of a sudden, everyone yells'stop!' I hit the brakes, but it was too late. I ran the red light." I did not observe any indicators of intoxication on Keith Burgard. The front seat passenger of unit #1 was Melinda Burgard, who was bleeding from her mouth. In the rear passen ger's seat was Tyler J. Burgard, who was uninjured. Taylor N. Burgard (6 m/o) was in the rear driver's seat in a child safety seat. Taylor was removed by her parents prior to my arrival. The shell of the seat was still baited in a nd it was able to be moved much more than one inch, per CSS standards. I examined the seat for a moment and saw that the straps were tangled; I was then called away for other duties and the seat was subsequently taken by LA EMS to t he hospital. All occupants in the vehicle stated that they were wearing seatbelts. I could see on Keith Burgard that he had a large bruise over his left collarbone area from wearing the seatbelt. The windshield wiper stalk (on the passenger side of the steering wheel) was snapped in unit #1.1 collected Keith's and Melinda's licenses and insurance card. They were transported to Hershey Medical Center by LA EMS and released shortly thereafter. Due to the heavy damage to unit #2, 1 was unable to talk to its occupants on the scene. The front seat passenger was Edward F. Shuey. He was entrapped in the vehicle, which had only passenger side curtain airbag deployment. Fire personnel from Lower Allen Township and Hampden Rescue were eventually able to free him. I later learned from Robert Shuey that Edward suffered a fractured rib and a spleen injury of unknown severity. He was airlifted to Hershey Medical Center via LifeLion. Anna K. Church was the in the rear passenger seat of unit #2. She was partially entrapped with her foot caught under a seat; she was freed by a paramedics She suffered:-abrasions to. her right ankle, right knee and on the right side of her face; she also auffe red possible inj raids- To her right hip and rib cage. After the scene was somewhat stabilized and traffic was shut down, I informed OIC Gained that I would like to call the Cumberland County Accident Reconstruction Team (CCART) out to assist me with the reconstruction; the team was activated. Oft. Morgan and Oft. Claeys (LATPD), Ofc. Solle nberger (Hampden Township PD), Todd. Eckenrode (Cumberland. County Coroner's Office) and PE vilaa i Wry http://www.dot6.state.pa.us/icons/Printlmages/XmlFiles/2006118715121102admin52006... 11/29/2006 Ynnt t_;Kzi Vub /Las .S rage Y u? 11 x ZOtd1SH = OF PMZVLVMIA p NOW ININI 0-asbUumbar P0672533 Nwrative and addhional wirummm David Ickler (Cumberland County District Attorney's Office) responded to the scene. Upon examining the vehicles, we found that unit #1 has a black plastic license plate holder in the center of its front bumper. We then looked for a matching imprint on unit #2; unit #2 had a layer of dust on it. We did find an imprint mark in the middle of the front passenger door of unit #2 from the license plate holder. I took digital photographs of the scene and of this imprint mark; Ofc. Morgan is pointing at it with a pen in the picture. We set up the Total Station on the northwest comer of the intersection and set up a reference point; this was marked in orange spraypaint. I marked the tires of both units with ora nge spraypaint as well. We then created a diagram of the scene with a prism. I had celled Forbes Chevrolet and aske d them where the Event Data Recorder (EDR) was located; I was told that it was in between the front passenger side are and front bumper. Both vehicles were towed to/by Backer's. Ofc. Ciasys called Forbes again and was told that the EDR was located under the carpet by the front passenger seat; it was then confiscated and later placed into evide nce. I will apply for a search warrant this week so that it can be downloaded. The roadway was made of smoothed concrete and ridged concrete (i.e. rumble strips on th e shoulders of highways). There were no visible tire marks on the roadway from either vehicle. Also, it should be noted that while looking south on Wesley Dr. (the vantage point of unit #1's driver), there was a strong and low sun. I did watch the traffic lights cycle and they were functioning properly. After clearing the scene, I went to Hershey Medical Center to speak with the involved parties. Everyone from unit #1 was discharged prior to my arrival. I called Keith Burgard, who told me that everyone in his vehicle was fine. He expressed concern for those in unit #2.1 told him that I would be mailing the driver's licenses and completed copies of the exchange forms to him. I told him to call me if he has any further questions. = At the hospital, I first spoke with Robert Shuey. He told me that he remembered picking up h'is father and stoppi ng at the red tight. When the light turned green for him to cross Wesley Dr. to go to Bethany West, he entered the intersection and never saw the impact coming. He complained of pain in his left leg. I returned a wallet to him whi le I was there. He said that he and his father were both wearing their seatbeits. t told him that 1 would deliver the crash exchange form to his father's residence, since he is not from the area. I next spoke with Anna Church, who was in a neck brace. She also did not remember the crash and was unsure whether she was wearing her seatbelt. On this date, I also called "Bobby," who is listed as the initial complainant. I left a message asking him to call me back. I called Jennifer Oswald and was unable.to leave amessage, as the - machine hung up on me. I called Sondra Wilkins. The number went to Bethany West, where she is an employee. I was told that Wilkins likely did not witness the crash, as she was at the receptionist desk all day yesterday. A driver named Jeri Oswald stopped at the scene and identified herself as a witness to the crash; she left DE information and is assumedly the same person as the one in this CAD. She was stopped FW= s AA?VNNW POW= co" hup://www.dot6.state.pa.us/icons/Pfintlmages/XmIFiles/2006118715121102admin5 ... 11/29/2006 !'nr' ;'mss vC!(?'1"l53 j rage loot 1 1 http:llwww.dot6.state.pa.uslicans/Printlmages/XmlFilesI2006118715121102admin52006... 11/29/2006 POUCE CRAM no Ow men raw NO O mo Cn* 1!1rpl'm ,. Pnnt CXS YFJU/n-A3 z COMAORPNIMALTH OF PEPMSYLVASNA POLICE CRASH FAVORiI@96 FORM ftp . AA_ 500 N jft"u* 0n1r 1 u?v • v va . i O blow Crash Manber P0672533 O ChanW con*mvdon Marrasin and additional witnesm on Wilson La. in the left tum lane to go north onto Wesley Dr. She stated that her direction had a green light (east-rest) and she saw unit #2 get broadsided by unit #1. This would further indicate that unit #1 was facing a red fight. She completed a written statement, which is attached to this supplemental PennDoT reportable crash form t0 be complete d. s I . ALO- ? PE GUM COPY http:llwww.dot6.state.pa.us/icons/Printlmages/XmlFiles/2006118715121102admin52006... 11/29/2006 t it Pnnt C XS !'`'b7Z533 a Crash Number: P0672533 Incident Number: 20061101380 Bethany Dr ifr Unit 2 rage 11 of ii Af LAT2006 11-01380 11124/06 - 0848 l O= Wilson Ln U it 2 f Unit Weslp%i Dr Unit 1 http://www.dot6.state.pa.uslicons/PrintlmageslYmIFilesl2006l l 8715121102admin52006... 11/29/2006 H305.905MS REV. 6/06 'This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953. Military Status H106.144 REV ilfm TYPE I W Wr IN PEF"k4 7 a"M #31-242 9?I e WARNING: It is illegal to duplicate this copy by photostat or photograph. Ito 9 Calvin B. Johnson, M.D., M.P.H. Frank Yeropoli Secretary of Health State Registrar 1389128 No. APR 18 2008 Date COMMONNIEALTH OF PENNSYLVANIA - DEPARTMENT OF HEALTH - WAL RECORDS CORONER'S CERTRUTE OF DEATH (S*s kwbucftm wW *xxw *w on revww) STA"M FD.E NUM WR 1. Nt=dD.MdW F* MAW. Wt. VAN 2. Sr d 9o" 8laa0y Mmbr 1. DIM dOMXt (Ncnrt, wl: MwA Edward F Shuey male 186 - 07 - 8713 March 21, 2008 5. AP NO Rit01W tAdw1 Undrt 8. Ow of 00 17.0 ' (M atpooftwe" .Roo,d DUth D*& dw PA COW 87 bw` t4., Ml- March 13, 1921 Hurtmlestown , Yn. ?Ipa*.w ?EM/QAPalrp []DDA Mrmp Mama ?Rewd, ?orw - am* 8b. CMAY d DUM Sc. CXy, ftMCe?W Derr 8d. Faft Ntm, (X not 10ft6m, 0" OW wW dr*r) B. Ww Dewdata d ftft* 0Pym7 N. Yar O. Rep: M wim bdr. R4dt. War, It Cumberland Lower Allen Bethany Village RM,W-1 itfiite 11. DaOldp,'. d"* dons mod,, x..00 V Sft 12, Wr Dr.dwndwr 1n ew 19. Dwedwfs E icolo W4 hwws rnyNNd) 14. Mnr1Xt]IIr: Aladad, IXrMr Mrneq 1s. SwviAnp SpaM (ft W98, ON Moiden mrm( ,*ddwwk Nrdd6Wmwl,.lwby Claims S rvisor Erie Insurance U.S.Amid Form? ?S.cMd"(D-/2) COXW(1-4W5r) lordorYQ,DId>,bad(Spsdy+t . M6 Ow 12 Married Marcella A. Elfreth it OrrYW'a*W"A*kN (Brat dv I bw d ft, zo coda) 325 Wesley Dr. D.Md.dh AMWAm tm ,7tSW PA 11 m a 011tl °ig0e1p Lower Allen _ _ 174 WP. tAleedld 1ivW b T ? PA 17055 Mechanicsburg ° ,71t ?M,DMaOp.LMd WXYn 1,b.oaMw Cumberland , Aewumra CXy I Rote t8. F.W9Nom, (FYI, nrds by mftb 18. M*.e,Nrw F#4 ttldd., mW.n rnwwl William M. Shue Sr. Mildred G. Ehley aR..tdrnMA*Nm (7jva/PtlaO 2W.IdDrarf. WitB Ad*aw (Blap. cAy/1aan,eW,?codel William M. Shuey,III 2060 County Line Rd L I k Stwines, PA 17372 21s MRmeddlprlUoo uowMtlon ?DonYm 21b.DWQ1V40AW0ot*d.Y,y«0 zk: PNMao'.vawr Pk" d wo"awapayadhtywo/l z/a laMlan ?IpjrN?R/Yk ?cddl) ftmoM*"so 0 March 25 2008 Holl Springs Hollin er Funeral Home & Cremato Mt PA , M„. W,?,. , . , g y m FWwY' anja moo) 47b.linmaMaom Inc. MMeWAddM6dFocly Myers-Hamer unera 1 - 1 014819 L 1190 Market, I;t_, CWXL& 10 PA 17011 CWSft Na'2"**WMnalAhi+r 0&1brwbMdnvkpwNdp..tMlhaeandY XM,ttrraobMplold.(3lghtlusiMWa) 28b.LIM ft*v 28c.DW0p4d(Iwl dW.yW . .. 181dw Uflr*rdd"o a,R,arwtdodub. -*d "aftobe aotlvt*r by Prrn '24 . lbw of DMrt 26. Dar PirMIIW D.ed4?t•'r, Y«?1 4 40 P 28.Ww Ce Wm-db Ngcdt n*wlCOan fw*FMM"DYrMCwmftnmommW WMyrtaus in : . - M:. March 21, 2008 y. ?rm CAIN[ OF DEA pw IrldroYOYOIts and "Who") , AMWAI..WPM Pan 0: Etwt oew A DNTawrm Ur CoebA io 0@01 - NMV-Pr1:Errs*t yopy(.ISMi-dlMws.k*Aww-.*kft--*r dNgydrNrwdntb.DOWTWOKMW"WMSVbMfitdw-MK I NWi. NO dd rat mpAM In to ttndv"wPw ihw M PWL ?YM ?F** a olMYy KOKd W#kW ftft*n Wrwd**dV1*"W.U11Q*MW MaMb M. t No wv ? ? r d.a r r tD ? ?. . Pulmpnsry Gympr??Aise ? sr.nFMw. Dua b br r a rarpiwta dj: i O w m9wW w*, P m Yw rpoorm.w ra r. b. Multiple Traumatic Injuries ?M rrw Mp Xm a N ? PwOrNr*n co" ?p r . pbb(r r, TRND*IMErNd E ? Na piprX, batgpMR WMn424ya =HUMP Motor Vehicle Csash 1 m WMa WlplRtW" i ? leuaavM 43 r1® t r.r b d. h.br drri ? IlXurnX taRM/'wrilM Mt -ar p , P Mt WookAm y ]W*WAL%w t* . M.mm -rdwo &L00dWT0 N^4 YW Mt.0ram."Nk"omdwd a pass"ger strucx :ft BRa PYr = Fift Bt$K Rwm Prbmmv ?,,,,,,, ? ,, ,?,,, Nov.24,2006 by vehicle that ran red light oft t . , reat y" 9 No ? YM ? No ( ? p-v w rood" 52.. k#n rwodcr ddy. rrmdPar*eatlpp.Y /Aad?Si 8?µ 1eo bt d qd, iBMa dy 11rY0. trM) Oftft OC WIftb0aWmmd 8:53 A.N. ?Yr JaNo OabIIDMtrd lPMwap. OPMrWe esle Dr. @ Wilson Lane sxCN.rMNrta,balN - 2aba>tiuwem +fM rt tdrw g.,d.tMarwwMt.dwl..eM.al.tPlrNpw aM?arum?dar reMl,PwI?aX«n2eJ r Coroner . M ----------------------- --------- ? r . 1+wMwW-?1r7Xi,IIiM IPw,dn.Nh Pww.wlnX..a rd 4M4wrdrr pi1PXE/ ltptsWVXld*r1Yr,40, 00080 *O? wdnoww OMM------ °----------- ? 9sa uwma Name - F Do iMO d n • w,rtrpwM/er,r DAiwWldttwtrniltaWrMrwdyrw bwllPrNUtYIMtlMUlaedtrlWAlMrtePMrrWeX,rvrwwl(gMrrPrwrrr K , 2 March 2 22 , 2008 March dl,.,MdAdyw. pwwn8?o o?p??m27? A?I:PTOiIII'?1PAd ?A1CI1ae 1d L ? [A17 t all I L I m0 . RPAAa17050te #1 Mech icab rB 3 2 u , an W MW0A.PWMN0. 0195849 PLAINTIFF'S EXHIBIT 13 w .% V March 10, 2009 Paul Bradford Orr, Esq. 50 East High Street Carlisle, PA 17103 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG, PA 17128-0601 MAR 1 9 2009 BY- '-p"s ........ Re: Estate.of Edward F. Shuey File Number 2108-0414 Court of Common Pleas Cumberland County Dear Mr. Orr: 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 87 year old decedent died as a result of injuries from a prior motor vehicle accident. Decedent is survived by his spouse and three sons. 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, $50,000.00 to the wrongful death claim and $ 50,000.00 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. §8302; 72 P.S. §9106, 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. Sin ely, n on . Baker Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes PLAINTIlrF's P?iora : 717 EXHIBIT cy -3467 • EMAK: shabakerestate.oa.us r ? ? ?} C_:: ,.. ? -t ,'., ' i r, , r. r-.? - _. ? ..?, ?? t.,r? -;G ? C'?% ESTATE OF EDWARD F. SHUEY, and ROBERT W. SHUEY, Co-Plaintiffs vs. KEITH B. BURGARD, and MELINDAA. BURGARD Co-Defendant's Estate of Robert W. Shuey. :IN THE COURT OF COMMON PLEAS OF :CUMBERLAND COUNTY, PENNSYLVANIA :CIVILACTION - LAW No: 08-6713 CIVIL TERM 17. On 3 zC Oq , Kevin Rauch, Esquire, counsel for State Farm Insurance Company, spoke to Paul Bradford Orr, counsel for Petitioner, and indicated that he concurs with the allegations set forth in the aforementioned Petition. Date: 3Ia601 SUBM D: I rani DraaTOra Urr, tsquire- 50 East High Street Carlisle, Pennsylvania 17013 Supreme Court ID No. 71786 (717) 258-8558 16. No judge has ruled upon any issue in this matter or any issue regarding the rl-a r r . 7 ESTATE OF EDWARD F. SHUEY, and ROBERT W. SHUEY, Co-Plaintiffs vs. KEITH B. BURGARD, and MELINDAA. BURGARD Co-Defendant's MAR 2 4 2009 :IN THE COURT OF COMMON PLEAS OF :CUMBERLAND COUNTY, PENNSYLVANIA :CIVIL ACTION -- LAW : No: 08-6713 CIVIL TERM ORDER AND NOW, this 30" day of Yn 0,a, , 2009, upon consideration of the Petition for Approval of Wrongful Death and Survival Settlement, and finding that the proposed settlement is adequate to protect the interest of the estate and beneficiaries, IT IS THEREFORE ORDERED AND DECREED that payment of One Hundred Thousand Dollars ($100,000.00) in settlement of the Survival Action is APPROVED. The settlement proceeds shall be distributed as follows: TO: Estate of Edward F. Shuey, deceased, $59,853.50, for payment of any claims, debts, inheritance taxes, and attorneys fees of the Estate, with the balance to be distributed to the beneficiaries of Decedent's Estate; TO: Estate of Marcella A. Shuey, deceased, $33,000.00 for her Beneficial interest; TO: Law Offices of Paul Bradford Orr, $7,146.50, for legal services, and reimbursement of costs. BY THE COURT. '' Paul Bradford Orr Esquire Attorney for Co-Plaintiffs -4s. Shannon E. Baker Trust Valuation Specialist ?David M. Smilek Claim Representative 4 l+ES' tnfatC£cl-c :3 1 - M FiLED-4)F iCE OF THE P 0TPDNPTAPY 2009 MAR 3 1 aM 13, I ?UF . T' ESTATE OF EDWARD F. SHUEY, and ROBERT W. SHUEY; Co-Plaintiff s vs. KEITH B. BURGARD, and MELINDA A. BURGARD, Co-Defendant's IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO: 08-6713 CIVIL TERM PRAECIPE TO DISCONTINUE ACTION To the Prothonotary: I am respectfully requesting that the Prothonotary mark the above captioned matter settled, discontinued, and ended with Prejudice. oa,. q 3 In Paul Bradford Orr, Esquire Attorney for Co-Plaintiff s David M. Smilek Claim Representative Paul Bradford Orr, Esquire 50 East High Street Carlisle, PA 17013 Supreme Court ID# 71786 (717) 258-8558 RLED-OFACE O THE P T-':OWTARY 2009 APR -8 AM IO: 4 5 ,UNITY PEN YL.VANO