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HomeMy WebLinkAbout11-3801 4_LV l1? s ii.ft.. Metzger, Wickersham, Knauss & Erb, P.C. ROTHONOTA k' By: Andrea M. Cohick, Esquire A A?R 20 AF110' 1,14 ttorney I.D. No. 307410 P.O. Box 5300 '"lisSftLAQ coUNT *j 3211 North Front Street PENNSYLVANIA Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 amc@mwke.com IN RE: GINETTA L. FAIINESTOCK, a Minor IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 1, '38'01 ?W ( PETITION FOR APPROVAL OF MINOR SETTLEM>? NT AND NOW, comes the Petitioner, Tammy L. Stricker, as parent and natural guardian of Ginetta L. Fahnestock, and petitions this Court for approval of a settlement of a minor's case in accordance with Pa.R.C.P. No. 2039 and, in support of the Petition, avers as follows: Petitioner, Tammy L. Stricker, is an adult individual residing at 10 Mountain Road, Dillsburg, Cumberland County, Pennsylvania. 2. Petitioner is the parent and natural guardian of minor Ginetta L. Fahnestock, who resides with Petitioner, and who is 13 years old, having been born on July 16, 1997. 3. Minor Petitioner Ginetta L. Fahnestock has selected Petitioner, as her parent and natural guardian, to represent her interests in this Petition. 4. On September 4, 2009, at approximately 5:45 p.m., second-row right-seat passenger in a 2006 Dodge Caravan owned and Tammy L. Stricken Petitioner was a by Petitioner, G qa, 061A aHA a t?sz ? 8y #317707 5. At the aforesaid time and date, Petitioner, Tammy Stricken and minor Petitioner were traveling north on Route 11 in East Pennsboro Township, (Cumberland County, Pennsylvania. i 6. At the aforesaid time and date, a 1993 Dodge Dakota, owned and operated by James Smith, was also traveling north on Route 11 in East Pennsboro T County, Pennsylvania, behind the Stricker vehicle. 7. At the aforesaid time and date, a 2007 Chevrolet Sil by Brian May, was also traveling north on Route 11 in East Pennsboro T County, Pennsylvania, behind the Smith vehicle. 8. The vehicle occupied by Petitioner and minor Petitioner was being stopped in front of them. The Smith vehicle also came to a stop p, Cumberland owned and operated ship, Cumberland due to traffic them. However, the May vehicle failed to notice that traffic was stopped and collided with the rear of the Smith vehicle. The impact caused the Smith vehicle to be pushed into the rear ?of the Petitioner and minor Petitioner's vehicle. A true and correct copy of the police ace hereto and incorporated herein by reference as Exhibit "A". 9. Minor Petitioner was taken by ambulance to Holy Spirit H the accident and was diagnosed with an abdominal contusion. See hereto and incorporated herein by reference as Exhibit "B". 10. The medical bills for Ms. Fahnestock's treatment as a report is attached on the date of records attached t of the injuries sustained in the accident have been paid by the automobile insurer, G> ICO Insurance who insures her mother. The medical bills total $1,063.68. There are no liens. A copy of the medical bills are attached hereto as Exhibit " U and i reference. medical bills or herein by 463205-I VERIFICATION I, Tammy L. Stricker, as parent and natural guardian of Ginetta 4. Fahnestock, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my ?wn. I have read the Petition for Approval of Minor Settlement, and to the extent that it is ba?ed upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of M?nor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn Tammy L. Stricker, as parent of Ginetta L. Fahnestock Dated: MY// are made to authorities. natural guardian 463205-I gyl?tr,-r COMMONWEALTH OF POLICE CRASH R PORTINGNFORM page .aw•??? Case Closed Re P portable Crash AA 500 1 • Yes O No 0 Yes p No 1 W01 2009-09-0087 21101 A Name Precinct In East Pennsbom Township ENOLA 09 t Dispatch Time (mill AMval Time (mil) In "or $ 1745 1750 OFFICER COVERDALE Reviewer Badge Number Approval D SGT. STUART A SPENCER 1603 p9 County Coun Name Municloulltv Municipality Name 21 Cumberland 101 ast Pennsboro Township 2 Crash Data (MM.DD-YYYY) Crash Time (mil)) Loaft n its P e iri 09 04 - 2009 1745 1 10 3 0 V Workzone Form MCSo t," O Yes No RNated O Yes No RN?at?edZone O Yes 0 No a Q 4 Way intersection Q 'Y' Intersection Q MUM-Leg ? 0 Off Ramp Q Railroad C Midblodc Traffic Circle/ O 'T' Intersection O Round About O On Ramp Q Crossover Q Other Route Number Se meet (Option ap Travel Lanes Speed Limit 0011 02 45 O 0 North South Street Name Street Ending O East O West C i O Unknown F O Interstate O Turnpike O Turnpike . State Coun (Not Tumpiel (EasNWesU Spur Hi hwa O Road Ty O Local reRett Route Number s maM (O tionap Travel Lanes Speed Limit r? g street Name O SO South s - Streat Ending O East C O West A O O Unkna Sj M Q Interstate Tumpike Turnpike State County (Not Turnpike) O (East/V1IesU O Spur O Highway Q Road Q or Street Intersecting Rt Num Or Mile Post Or Segment Marker q 1004 C? . o O S Please Or ItKer C secti Street Name St Endin O Enter O Information E e °? for BOmaTH 071 O ° Landrks Intersectin Rt Num Or Mile Post ? g if Using n Or ment Marker This Option A . ? C Q o Or Irttersecti ng St Street Name S O ® 9 BELLE VISTA DR di w O a Degrees Minutes Seconds Minutes Seconds r Latitude: Longitude: - Traffic control narice O Yield Sign O Police Officer or e 0 Not Applicable Q Traffic Signal O Active RR Crossing Flagman 0 No Controls Device O Flashing Traffic Controls O Other Type TCD O Improl Signal O Stop Sign Passive RR O Crossin Controls O Unknown o Device Not O Device 9 Functioning Proper 1AML0a W (f 'plot ApPrxabfe , skip rest of the Lane Oawre sertionJ North Q East Q I 2 O Not Applicable 0 Partially Q Fully Q Unknown DhKdm Tral?G Yes Q No a ESnG O South Q West Q E Deftwmd Unknown Q 02n, 4W < 30 Min. Q 30-60 Min. Q 1-3 hrs Q 3-6 hrs Q 6.9 hrs FOpN i "4W (12102) ? --- _-_-.-, PIENNOOT COPY http://www.dot6.state.pa.us/crsapp/Printlmages/XnllFiles/2009089619200909241 i ar'c i UJL IV Crash Number 2 04 -[2009 Badge Number ? 16-13 -12009 Oav of mllsk Q Sun Q Thu *If y Do O Mon 0 Fri completfO rue Q Sat Form F Wed Q Unk T- Yes Q No For Md•blodc crashes only. Use postal House Number and make sure Principal Roadvay Street Name is filled in if using this option O Private O Other/ Road Unknn O Private O Other/ Road Unknown Feet Or Miles c1.a Distance From Crash Scene to Landmark I (For Crash between Landmark I and Landmark 2) Emergency O Preemptive Signal O Unknown hand South Q All and West (N.S,E,W) 9 hours O Unknown 9/24/2009 Print U6 W0123767 Page 2 of 10 COMMORMEALTH OF J fPOLOC CRASH REPORTING ORbSJ ?'IBl<1 III ?I?I?I?III?I?111 Page: Crash Number AA 500 2 Police Use Only W0123767 ® Motor Vehicle in - _ c Transport O Illegally Parked (D Legally Parked Q Non - Moto ized Q Hit & Run Vehicle I Commercial Vehicle Type a unit O Pedestrian on Skates, Disabled From Q Yes 0 No O Pedestrian in Wheelchair, etc O Previous Crash O Train O Phantom Ve?iicle (If "Pedestrian" or "Pedestrian on Skates, in Wheelchair, etc", Complete Form M, Section 28) I (!f Yes, Complete Form C) Unit No First Name O1 BRIAN MI Date of Birth (MI L? 06 066 Delete? Last Name Q MAY Tole 71, Address/ City / state . ° SAW MILL RD DUNCANNON P A Driver License Number Li9334149 State P e; A Al h l a 11 co o /Druos 5usnected Driver or Pedestrian Physical Condit) '" Q No Q Illegal Drugs Q Medication Q Apparently Normal Illegal Drug O ? Alcohol Q Alcohol and Drugs O Unknown Use d Had Been Drinkin O Sick y Alcohol Test Tune a° Q Test Not Given Q Breath O Other Primary Vehicle Code Violation e v = Blood O Urine Q Unknown if DUI s a A!c ho/ T R I Test Given o est esu is 0 Test Refused Q Resuhswn Driver Presence 1=Driver Operated ?" 20 O Test Given, Vehicle Contaminated Results 2=No Driver 11961 800 Zi 17020 Fatigue O Medication Asleep O Unknown Charged) 0 Yes Q No Driver Fled Scene Hit and Run Unknown Owner/Driver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Pol ce Veh 09=federal Gov Veh 01 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=0ther Municipal 98=Other Leased by Driver 03=Rented Vehicle 06=0ther State Gov Veh Government 'ehicle 99=Unknown Same as owner rnsi roame Owner Last Name or Business Name (If Pedestrian ski) Driver Q BRIAN L MAY , Address / City / State / Zip Vehicir SAW MILL ROAD,P O BOX 2 DUNCANNON PA 17020 Che VIN Model Year Vehicle 2GCEK 19J471596505 Li Pl 2007 SIL1 cense ate Reg. State Est. Speed Vehide Towed Towed LYDN6004 PA 050 0 Yes Q No M AI F Insurance Insurance Company Policy No a Yes Q Na O nown ERIE Q03 1 8 1 0740H e Trailin --*--q T e 1=Towing Pass. Veh Unit TrNo, a n Unrt ? 2=Towing Truck Trailin 4=Mobile/Modular Home 7=Semi-Trailer 5=Camper 8 Oth Tag No e g g = er 3=Towing Utility Trail er 6=Full Trailer 9=Unknown d Direction of *Vehicle Position raves IF] 03 `Movement 01 See 5 ecia! Us Overlay Vehicle Color Vehicle Tyne OS 06=Yellow 01=Automobile 04 F 05=Large Truck 06=5UV 20=Unit le Bi de Tricycle ? , 00 ? 08=Silver 02=Motorcycle 07=Van 21 =Other Pedalcycle 00=Not Apr 03=Bus 01=Blue 09=Brown 04=Small Truck 02=Red 10=Oran e If " " 10=Snowmobile 11=Farm Equip 22=Horse & Buggy 23=Horse & Rider 01=Fire Veh 02=Ambulai g ( 02 , Complete Form 03=White 17 =Purple M, Section 26) 12=Construction Equip 13=ATV 24=Train 03=Police 08=Other E 04=Green 12=Other 05=Black 99=Unknown (If "20" or "21", Complete 18=Other Type Spec Veh 25=Trolie y 98=Other r Vehicle Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown it =Pupil Pit Tra lnit/al /moacY Point 12 00=Non-Collision 14=Undercarria e Dama°e Indicator O=None 2=Functional Gradient 3=Downhill g 01-12=Clock Points 15=Towed Unit ? 2 1=Minor 3=Disabling 1 1=Level 4=Bottom of H 5 T 13=Top 99=Unknown 9=Unknown 2=Uphill = op Hill 9=Unknown FORM * AA-sop (12102) PENNDOT COPY Make *Make Code rolet 20 Model (see overlay) TOWING Tag Year Tag St c? a 12=Commercial Passenger Carrier 13=Taxi 21=Tractor Trailer 22=Twin Trailer 23=Triple Trailer 31 =Modified Veh 99=Unknown Road Alignment ID 1=Straight 2=Curved 9=Unknown http://www. dot6.state.pa.us/crsapp/PrintImages/XmIFiles/20090896192009092316202120... 9/23/2009 Print CRS WO 123767 Fatigue Q Medication Asleep Q Unknown POLE E? CC4 ASH REPORTING FORM RIQ 1111111111111111 Crash Number A A Page: AA 500 2 Police Use Only -I LL-J W0123767 R Motor Vehicle in __. _ ELType Transport O Hit & Run Vehicle Q Illegally Parked Q Legally Parked Q Non - Moto i2ed Commercial Vehicle 10 pedestrian O Pedestrian on Skates, Disabled From Q Yes No in Wheelchair, etc O Previous Crash O Train O Phantom Ve?lide "Pedestrian" or "Pedestrian on Skates, in Wheelchair, etc", Complete Form M. ;Prtin. 7R1 (If Yes, Complete Form C) Unit No First Name MI Date of Birth (MM- D-YYYY) 02 JAMES E j 04 26 1956 Delete? Last Name SMITH Tele hoe Number Q 7178 45910 Address / State Zi 8 JEFFERSON ST DUNCANNON PA 17020 Driver License Number e 17120612 s A ? AlcohobOrugs Suspected tt a No Q Illegal Drugs Q Alcohol Q Alcohol and Drugs > Alcohol Test Tvpe ® 0 Test Not Given Q Breath O Blood O Urine s y Alcohol Test Results CCD) Test Refused State J PA ian Physical Condit! Q = Illegal Drug Q Use O Unknown k O Si c O Other Pnmarv Vehicle Code Violation O Unknown if NONE Test Given Unknown 0 Results Driver Presence 1=Driver Operated ?" ? Q Test Given, Vehicle Contaminated Results Ej 2=No Driver Page 3 of 10 Charged? Q Yes Q No ,er Fled Scene and Run I _.:nown •?y? Owner/Driver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh O1 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other Leased by Driver 03=Rented Vehicle 06=0ther State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name (If Pedestrian, ski this Section) Driver Q JAMES E SMITH Address / City / State / Zip Vehicle Make Make Cod 8 JEFFERSON ST DUNCANNON PA 17020 Dodge 07 VIN Model Year Vehicle model {see overlay; 1 1B7FL23X4PS147250 1993 DAKOTA License Plate Reg. State Est. Speed Vehicle Towed Towed y YWN5695 PA 1000 W Yes o No MA ARUS TOWING Insurance Insurance company Policy No • Yes O No O Un- PROGRESSIVE known 18201499-2 1 Traifino 12 I T e Unit No. of -fit 0 Unr Trailin 1=Towing Pass. Veh a 2=Towing Truck 4=Mobile/Modular Ho 5=Camper me 7=Semi-Trailer 8=Oth Tag No Tag Year Tag St g Units: 3=Towing Utility Trailer 6=Full Trailer er 9=Unknown a Di f " ti on o rec Vehicle Position ralVe --' 03 03 *Movement • special Us rI veerlay O e Vehicle Color 06=Yellow 03 07=Silver Vehicle Tvpe 04 01=Automobile 05=Large Truck 06=5UV 20=Unicycle, Bicycle, Tricycle 00 12=Commercial Passenger 08=Gold 02=Motorcycle 07=Van 21= Other Pedalcycle 00=Not App icabl e Carrier 01=Blue 09=Brown 03=Bus 10=Snowmobile 22=Horse & Buggy 01=Fire Veh 13=Taxi 02=Red 10=Orange h 03 h 04=Small Truck (If "02", Complete Form 11=farm Equip 12=Construction Equip 23=Horse & Rider 24=Train 02=Ambulan 03=Police ce 21=Tractor Trailer Tr il W = W ite ite 11=Purple 04=Green 12=Other M, Section 26) 13=ATV 25=Trolle y 08=Other E a er ergency 23=Triple Trailer 05=81ack 99=Unknown (If "20" or "21", Complete 1 8=Other Type Spec Veh 98=Other Vehicle 31 =Modified Veh Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown 11 =Pupil Tra sport 99=Unknown Initial Impact Point 06 00=Non-Collisi Damage Indicator on 14=Undercarriage O =None 2=Functional Grad/ent 3 =Downhill Road A//gnment a 01.12=Clock Points 15=Towed Unit 1=Minor 3=Disabling 4=Bottom of Hi 1 1=Level 5=To of Hill 1=Straight IT] 13=Top 99=Unknown 9=Unknown p 2=U hill p 9=Unknown 2=Curved 9=Unk FORM p M-500 (1202) PENNDOT COPY nown - -----" - http://www. dot6.state.pa.us/crsapp/Printlmages/XmIFiles/20090896192009092316202120... 9/23/2009 Print CJR_S WQ123767 Page 4of10 CQVJRfl3RUU(EAL7N 00: (?tIDIUCff CRASH REPORTING ORM ?'181?1 111111111111191 Crash Number Page: AA 500 2 _ Police Use Only ?. W01237 7 o Motor Vehicle in Type Transport O Hit & Run Vehicle Q Illegally Parked Q legally Parked Q Non - Moto ized Commercial Vehicle to. ? Unit o Pedestrian on Skates, Disabled From Q Yes No O Pedestrian O Train Q Phantom VeIiicle in Wheelchair, etc O Previous Crash (if "Pedestrian" or "Pedestrian on Skates, in Wheelchair, etc", Complete Form M, Section 28) (If yes, Complete Form C) Unit No First Name Nil Date of Birth(MM-D-YYYY) 103 TAMMY L 11 17 1977 Delete? Last Name Tele hoe Number O STRICKER 7177130428 Address / Ci / State q 10 MOUNTAIN RD DILLSBURG PA Driver License Number State Cla s c nE== 125020812 PA s Alcohol/Oruas Suspected Driver or Pedestrian Physical Condit/on 11 '" No Q Illegal Drugs Q Medication NoPmalntly O Illegal Drug Fatigue O Alcohol Use Q Medication a ' Q Alcohol and Drugs Q Unknown Q Had Been d Orinkin O Sick Asleep Q Unknown i Alcohol Test Type ® Test Not Given Q Breath O Other Primary Vehicle Code Violation Charged? v Q Blood Q Urine Unknown if NONE O Test Given O Yes Q No Alcohol Test Results O Test Refused Unknown Driver Presence Q Results 1=Driver Operated 3 ::Driver Fled Scene M]. Q Test Given, Vehicle 4 :-Hit and Run Contaminated Results 2=No Driver 9 ::Unknown OwneNDriver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Pol ce Veh 09=Federal Gov Veh O1 O1=Private Vehicle Owned/ owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name (!f Pedestrian, ski this Section) Driver Q TAMMY L STRICKER Address / City / state / Zip Vehicle Make "Make Code I 10 MOUNTAIN RD DILLSBURG PA 17019 Dod e 07 VIN Model Year Vehicle Model (see overlay) ID4GP24R76B527029 2006 G1 ND CARAVAN License Plate Reg. State Est. Speed Vehicle Towed Towed By GGBO157 PA 000 a Yes Q No AA Insurance Insurance Company Policy No a Yes Q No -D known GEICO 4074-04-76-40 E 12 $ Trafl? T e 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Ta No No. of - 9 Tag Year Tag St Unit 2=Towing Truck 5=Camper 8=Other Trailing 0 Unrt Units' 3=Towing Utility Trailer 6=Full Trailer 9=Unknown y Direction of a •Vehicle Position *Movement rave 03 03 see S ec/al Us e Overlay Vehicle Color Veh/de Tvpe 05=Large Truck 20=Unicycle 00 12=Commercial 06=Yellow , Bicycle, 03 01=Automobile 06=SUV Tricycle Passenger 08=Gold 07 02=Motorcycle 07=Van 21 =Other Pedalcycle 00=Not App icable Carrier 03=Bus 10=Snowmobile 22=Horse & Buggy 01=Fire Veh 13=Taxi 01=Blue 09=Brown 04=Small Truck 11=Farm Equip 23=Horse & Rider 02=Ambula :e 21=Tractor Trailer 02=Red 10=Orange (If "02", Complete Form 12=Construction Equip 24=Train 03=Police 22=Twin Trailer 03=White 11=Purple M, Section 26) 13=ATV 25 =Trolley Emergency 23=Tri le Trailer 04=Green 12=Other =Trolley p 05=Black 99=Unknown (/f "ZO" or '21', Complete 18=Other Type Spec Veh 98=01her Vehicle 31 =Modified Veh Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown 11 =Pupil Transport 99=Unknown Initial Impact Point Damage Indicator Gradient 06 00=Non-Collision 14=Undercarriage ? O=None 2=Functional 3=Downhill Road Alignment 01-12=Clock Points 15=Towed Unit 2 1=Minor 3=Disabling 1 i=Level 4=Bottom of Hi I 1=Straight 13=Top 99=Unknown 9=Unknown g 2=Uphill 9=Unknown 5=Top of lll 2=Curved 9=Unknown FORM N AA-500 (12/02) PENNDOT COPY - ---- http://www. dot6. state. pa. us/crsapp/Printlmages/XmiFiles/200908 9619200909231 202120... 9/23/2009 Print UZS W0123767 COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 500 3 Po ice Use only A 1=Driver ?cvi rulmurr. ? 00=Noi A PassengerlOccu ant 2_Passenger p 01=Driver - All Vehicles 7=Pedestrian 02=Front Seat Middle Position B=Other 03=Front Seat Right Side 9=Unknown 04=Second Row - Left Side Or Motorcycle Passenger 05=5econd Row - Middle Position 5ex: 06=Second Row - Right Side C F =Female B 07=Third Row Or Greater - M=Male Left Side U =Unknown 08=Third Row Or Greater - Middle Position 09 Thi d ® = r Row Or Greater - Right Side g Injury Seven 10=Sleeper Section of Truckcab e C O=Not Injured 11=1n Other Enclosed ® 1=Killed Passenger Or Cargo Area 2=Major Injury 12=1n Open Area it 3=Moderate (Back Of Pickup, Etc.) Injury 13=Trailing Unit 4=Minor Injury 14=Riding On Vehicle Exterior 8=Injury, Unk 15=Bus Passenger Severity 98=Other 9=Unknown if 99=Unknown Injury V ?--?n? E 00=None '-?1 Used /NotApplicable 01=Shoulder Belt Used 02=tap Belt Used 03=Lap And Shoulder Belt Used 04=Child Safety Seat Used 05=Motorcycle Helmet Used 06=Bic cle Helmet Used 10=Safety Belt Used Improperly 11 =Child Safety Seat Used Improperly 12=Helmet Used Improperly 90=Restraint Used, Type Unknown 99=Unknown safety faurwnent Two: F 00=None Used / Not Applicable Ot-Front Air Bag Deployed (For This Seat) 02=Side Air Bag Deployed (For This Seat) 03=Other Type Air Bag Deployed 04=Multiple Air Bags Deployed 05=Motorcycle Eye Protection 06=Bicyclist Wearing Elbow/Knee/Pads 10=Air Bag Not Deployed, Switch On 11=Air Bag Not Deployed, Switch Off 12=Air Bag Not Deployed, Unk Switch Setting 13=Air Bag Removed (Prior To Crash) 19=Unknown If Air Bag Deployed 99=Unknown Page 5 of 10 1111111111111MIlIMI Crash Number W0123 G O=No Applicable 1=No Ejected 2=Tot illy Ejected 3=Par ially Ejected 9=Un nown H O=Not Ejected / Not Applicable 1=Thr ugh Side Door Opening 2=Thr ugh Side Window 3=Thr ugh Windshield 4=Thr gh Back Door 5=Thr gh Back Door Tailgate Opening 6=Thro gh Roof Opening Sunroof/ Con ertible Top Down) 7=Thro gh Roof Opening (Convertible Top Ip) 9=Unk own Ltnca : O=Not Applicable 1=Not xtricated 2=Extric ted By Mechanical Means 3=Freed By Non - Mechanical Means ERNS Agency: (EAST PENNSBORO AMBUL Medical Facility: HARRISBURG HOSPITAL, HOLY SPIRIT Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F 0l 01 --?????? G H I O 06 06 1961 1 M 0 O1 03 1[61 110 I L 0] Name /Address /Phone t_1 Same to MAY, BRIAN L SAW MILL RD DUNCANNON PA 17020 7178343800 EMS Transport Operator O Yes ? No 11 Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F Delete? 02 O1 p 04 - 26 - 1956 1E] MH] 41 01 00 Name 00 0? 0? 0? / Address / Phone same as SMITH, JAMES E 8 JEFFERSON ST DUNCANNON PA 17020 7178345 ERNS Transport Operator _ 0 Yes O No Unit No Person No Date of Birth (MM-DD-YYYY) A B C D Delete? 02 02 p 08 - 16 - 1955 2I FIE] 03 OOE OOF 0? OC? 3? Name /Address /Phone L _J Same as DIANE L. SMITH 8 JEFFERSON STREET DUNCANNON PA 17020 717 EONS Transport Operator Yes O No Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E 03 O1 O 11 _ 17 _ 1977 1? F? pa 01 03 IO F El Name / Address / Phone same as STRICKER, TAMMY L 10 MOUNTAIN RD DILLSBURG PA 17019 7177 EMS Transport Operator O Yes ? No Unit No Person No Date of Birth (M M -DD-YYVY) Delete? A B C D E F G hl I 03 02 O O1 - 30 - 1986 2= 2 M 0? 03 03 10 E El El Name 1 Address / Phone same t. TORY A. KAUFFMAN 67 BIG DAM ROAD DILLSBURG PA 17019 7172 EMS Transport Operator O Yes 0 No Unit No Person No Date of Birth M.1DE y .1Y) A B C D Delete? E F G H I E 03 03 O 12 - 16 - 2005 2? 0? 04 04 0 Flame /Address /Phone a a Eli same tor FRANKIE ALEXIS STRICKER 10 MOUNTAIN ROAD DILLSBUR 3 PA 17 ERNS Transport Operator ?-? O Yes No FORM M AA-500 02/02) PENNDOT COPY http: //www. dot6. state. pa. us/crs app/Printlmages/XmIFiles/20090896192009092315202120... 9/23/2009 1 Print CRS 'vii" I23767 I COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 5003 Poke Use Only -'? .?4. A 1=Driver .?rer rusnrun: ? 00=Not A Passenger/Occu ant Z=Passenger p 01=Driver - All Vehicles 7=Pedestrian 02=Front Seat Middle Position 8=Other 03=Front Seat Right Side 9=Unknown 04=Second Row - Left Side Or Motorcycle Passenger 05=Second Row - Middle Position Six: 06=Second Row - Right Side B F =Female 07=Third Row Or Greater - C ® M=Male Left Side U =Unknown 08=Third Row Or Greater - Middle Position € 09=Third Row Or Greater - ® Right Side g In?ry Severity- 10=Sleeper Section of Truckcab y C O=Not Injured 11=In Other Enclosed 1=Killed Passenger Or Cargo Area ® 2=Major Injury 12=1n Open Area 3=Moderate (Back Of Pickup, Etc,) Injury 13=Trailing Unit 4=Minor Injury 14=Riding On Vehicle Exterior 8=Injury, Unk 15=Bus Passenger Severity 98=Other 9=Unknown H 99=Unknown Injury 00=None Used /Not Applicable 01 =Shoulder Belt Used 02=Lap Belt Used 03=Lap And Shoulder Belt Used 04=Child Safety Seat Used 05=Motorcycle Helmet Used 06=Bicycle Helmet Used 10=Safety Belt Used Improperly 11=Child Safety Seat Used Improperly 12=Helmet Used Improperly 90=Restraint Used, Type Unknown 99=Unknown d/ tV puripment TL•JO: F 00=None Used / Not Applicable 01=Front Air Bag Deployed (For This Seat) 02=Side Air Bag Deployed (For This Seat) 03=Other Type Air Bag Deployed 04=Multiple Air Bags Deployed 05=Motorcycle Eye Protection 06=Bicyclist Wearing Elbow/Knee/Pads 10=Air Bag Not Deployed, Switch On it=Air Bag Not Deployed, Switch Off 12=Air Bag Not Deployed, Unk Switch Setting 13=Air Bag Removed (Prior To Crash) 19=Unknown If Air Bag Deployed 99=Unknown Page 6 of 10 IIII?I'IAIII??? Crash Number W012376V G O=Not Applicable I=Not Ejected 2=Totally Ejected 3=Partially Ejected 9=Unk own H O=Not jepath tted / Not Applicable 1=Thro gh Side Door Opening 2=Thro gh Side Window 3=Thro gh Windshield 4=Thro gh Back Door 5=Thro gh Back Door Tailgate Opening 6=Thro gh Roof Opening (Sunroof/ Conv rtible Top Down) 7=Thhrpo P? Roof Opening (Convertible 9=Unkn wn E i n: O=Not Applicable 1=Not E tricated 2=Extric ted By Mechanical Means 3=Freed By Non - Mechanical Means EMS Agency: EAST PENNSBORO AMBUL Medical Facility: HARRISBURG HOSPITAL, HOLY SPIRIT Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I p - ? Q3 04 - 07 16 1997 L IF 4 06 03 00 0? 0? On Name / Address / Phone tJ LJ Same as GINETTA FAHNESTOCK 10 MOUNTAIN ROAD DILLSBURG PA 17019 7 EMS Transport Operator _ f? Yes O No Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F G H I Delete? - ?? ? ? D 03 OS p 01 14 - 1999 2 F 0 07 03 00 Name / Address / Phone 0? 0? 0 El same as LYNZIE FAHNESTOCK 10 MOUNTAIN ROAD DILLSBURG PA 17019 71 EMS Transport Operator _ 0 Yes 0 No Unit No Person No Date of Birth ( Zii,i I YYYY) A B C _ DE F 03 06 O Delete? 12 - 28 - 1999 08 02 00 a p? Name / Address / Phone Same as RYAN BUEHRLE 10 MOUNTAIN ROAD DILLSBURG PA 17019 7177130 EMS Transport Operator 0 Yes 0 No Unit No Person No Date of Birth (MM-DD-YYYY) A B C T D E 07 Delete? ? ? 03 p 08 - O1 - 1995 2 M 0 09 03 Name / Address / Phone same as JEFFREY J. LINDOW JR. 5726 HANOVER ROAD HANOVER PA 99999 Operator Unit No Person No Delete? Date of Birth (MM DD YYYY) A B C D E Name / Address / Phone Same as Operator Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E .? O-????I Name / Address / Phone E Same as Operator FORM 0 AA-500 (12102) PENNDOT COPY http://www. dot6.state.pa. us/crsapp/Printlmages/XmiFiles/200908961920090923 aoa EMS Transport 1 O Yes 0 No ooa EMS Transport O Yes p No E] EMS Transport 0 Yes CD No 120... 9/23/2009 Yrant C jt WU123167 I COMMONWEALTH OF PENNSYLVANIA (POLICE CRASH REPORTING FORM Page AA 500 4 Police Use Only Crash Descaotron c IT] m € E. Relation to Roadwav 1 n f/luntinati°n Weather Conditions Z I u c a Road Surface Conditions a O=Non-Collision 2=Head On 1=Rear End 3=Rear to Rear _ (Backing) 1=0n Travel Lanes 3=Median 2=Shoulder 4=Roadside 1=Daylight 3=Dark - Street 2=Dark - No Lights Street Lights 1-No Ad -- 4=Dusk v 00=No 01=Dri Harmful Events (Harm Event) 30: 9 Q2 ? - 01 =Hit Unit 1 31: Unit No 02=Hit Unit 2 32= 01 2 O ?- 03=Hit Unit 3 04=Hit Unit 4 OS=Hit Unit 5 33: 34: 3 Please Put Events in 3 1 0 ?- 06=Hit Other Traffic Unit 07=Hit Deer 5= 36= Sequential 08=Hit Other Animal 09=Collision With Other Non 37= 38= _0 Order 4 ? CD Fixed Object 11 =Struck By Unit 1 39= 40= 16 Yo € 12=Struck By Unit 2 13 S k 41= arm Event L/R Most? Utility Pole Number = truc By Unit 3 14=Struck By Unit 4 42= 43= 1 ff ? r 15=Struck By Unit 5 16=Struck By Other Traffic Unit 48= i U nit No 21 =Hit Tree Or Shrubbery 49= g^ 02 2 03 ? 22=Hit Embankment 23=Hit Utility Pole 50=, 51=' 24=Hit Traffic Sign Please Put 3 ? 25=Hit Guard Rail 26=Hit Guard Rail End 52=i I Events in Sequential 27=Hit Curb 28=Hit Concrete or 53=1 54=f Order 4 r-] 0 r Longitudinal Barrier 29=Hit Ditch 58=( 99=t First Unit No Harm Event Most Unit No Hann Event mful 17 veentinn 0 ] 02 ? O 1 02 t e rash te sh Do not repeat this information on multiple pages Environmental / Roadwav Potentla/ Factors (FJRJ 1 00=None 11=Slippery Road Conditions (ice/Snow) 01=Windy Conditions 12=Substance On Roadway 02=Sudden Weather Conditions 13=Potholes 03=Other Weather Conditions 14=Broken Or Cracked Pavement 04=Deer In Roadway 15=TCD Obstructed 05=Obstacle On Roadway 16=Soft Shoulder Or Shoulder Drop off 06=Other Animal In Roadway 28=Other Roadway Factor 1s 07=Glare 29=Other Environmental Factor C 08=Work Zone Related 99=Unknown E Possible Vehicle Failures (V) 12=Wipers 00=None 06=Exhaust 13=Driver Seating/Control 01=Tires 07=Headlights 14=Body, Doors, Hood, Etc OZ=Brake System 08=Signal Lights 15=Trailer Hitch 03=Steering System 09=Other Lights 16=Wheels 04=Suspension i O=Horn 17=Airbags 05=Power Train 11 =Mirrors 18=Trailer Overloaded c Unit 19=Unsecure/Shifted v No Q 1 1 00 2 Trailer Load 20=Improper Towing 21 =Obstructed Windshield Nun 02 1 00 2 99=Unknown Indicated o Factor Unit No Factor Code Do not repeat this information on Q 1 92 19 multiple pages. E/R V D P O 00 0 If E/R is the Prime Factor Type, leave Unit No blank 06- Page 7 of 10 11111111111111 Crash Number W0123767 4=Angle 6=Side: 5=Sideswi?e (Same nection) (OPF 7=Hit F S=Outside Trafficway 7=Gore 6=1n Parking Lane 9=Unkn ' 8=Hit Pedestrian D Direction) Object 9=Other/Unknown np Intersection) 8=Other I - - - _._ - 9=Unknown 8=Other Fence Or Wall Building Culvert Bridge Pier Or Abutment Parapet End Bridge Rail Boulder Or Obstacle Roadway Impact Attenuator Fire Hydrant Roadway Equipment Mail Box Traffic island Snow Bank Temporary Construction rier Other Fixed Object Unknown Fixed Object rturn/Roll Over ck By Thrown Or Falling act Holes Or Other .meet Irregularities nife In Vehicle 'r Non-Collision sown Harmful Event 17=C reless Or Illegal i Action Ba cking On Roadway acted d H ld P 18=Dr Si ving on The Wrong Of rn e hone Inds Free Phone ( 19=M Road e king improper -Turn En ranee To Highway is Turning rong lane 20=M Fr king Improper Exit m Highway 21=Ca eless Parking/Unpari Stop 22=0v r/Lindpr 10=Failure To Res ,6nd To Other Traffic Control Device 1s=nlegally Stopped On Roaa 14=Careless Passing Or lane "_"` 28=Fa Change 15=Passing In No Passing Zone 16=Driving The Wrong Way On 92=Af 98=01 99=Ur 1-Way Street Unit No O1 t 92 z O1 Unit No 02 9 00 2 C Pedestrian Action (p) 03=WO 00=None 01=Entering Or Crossing At 04=Pus 05=APF Specified Location 02=Walking, Running, Jogging, 06=Wo 07=Star Or Playing 98=0th 99=Unk Unit No Q j Unit FORM Y AA-500 (11/02) PENNDOT COPY - arse Conditions 3=Sleet (Hall) 5=Fog 7=Sleet & 2=Rain 4=Snow 6=Rain & Fog 8=Other O=Dry 2=S1nd, Mud, Dirt, 4=Slush 6=Ice Pat, 1=Wet 3=Snow Covered 5=Ice 7=W t r- Utility Pole Number _ - - or ovii - sensation At Curve g Too Fast For Conditions To Maintain Proper Speed Fleeing Police (Pol Chase) Inexperienced To Use Specialized Equip ed By Physical Condition Improper Driving Actions 3 ? 4 3 ? 4 Vehicle hing Or Leaving Vehicle On Vehicle 02 http://www.dot6.state.pa. us/crsapp/PrintImages/XmIFiles/20090896192009092316202120... 9/23/2009 Print CRS 'NO 123767 I COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 500 4 PoLce Use Only Crash Descnotion c m " € Relation to Roadway c21 1s N 28, =Lfffuminafion LMWL..t?her Conditions c w Road Surface Conditions No 1 ? a Indicated Prime Factor Unit No Factor Code Do not repeat this inlantation on multiple pagez 01 92 E/R V D P 0 ow 0 If E/R is the Prime Factor Type, leave Unit No blank FORMM AA-500412/02) ,>? t Harm Event LIR Most? Utility Pole Number Unit No 0 Please Put Events in 3 o Sequential Order 4 ? O _ First Unit No Harm Event most Unit No Hann Event ?mfu 17 ! vet O l 02 Pv f O 1 02 t eTi Zrash "'. 'Id3h Do not repeat this information on muhipk pages Environmental / Roadwav Potential Factors (E/R) 1 00 2 3 00=None 11=Slippery Road Conditions (ice/Snow) 01 =Windy Conditions 12=Substance On Roadway 02=Sudden Weather Conditions 13=Potholes 03=Other Weather Conditions 14=Broken or Cracked Pavement 04=Deer In Roadway 15=TCD Obstructed 05=Obstacle On Roadway 16=Soft Shoulder Or Shoulder Drop Off 06=Other Animal In Roadway 28=Other Roadway Factor e 07=Glare 29=Other Environmental Factor `0 08=Work Zone Related 99=Unknown m Possible Vehicle Failures (V) 12=Wipers 00=None g 06=Exhaust 13=Driver Seating/Control c 01=Tires 07=Headlights 14=Body, Doors, Hood, Etc 02=Brake System 08=Signal Lights 15=Trailer Hitch 03=Steering System 09=Other Lights 16=Wheels 04=Suspension 10=Horn 17=Airbags 05=Power Train 11=Mirrors 18=Trailer Overloaded coe? Unit Unsecur 03 1 00 z 19 7 ai er Loadhifted 20=Improper Towing 21=Obstructed Windshield unit 99=Unknown Page 8 of 10 IT] O=Non-Collision 2=Head On 1=Rear End 3=Rear to F 1=0n Travel Lanes 3=Median 2=Shoulder 4=Roadside 1=Daylight 3=Dark - Sir 2=Dark - No Lights Street Lights 4=Dusk 1=No Adverse Conditions 2=Rain O=Dry 1=Wet 111111111111110111 Crash Number W012376v 4=Angle 6=Side: 5= Sideswipe (Same Direction) (OpF 7=Hit F 5=Outside Trefficway 7--Gore 6=1n Parking Lane 9=Unkn 3=Steel (Hail) 5=Fog 7=Sleet & 4=Snow 6=Rain & Fog 8=01her 2=8and, Mud, Dirt, 4=Slush 6=Ice Pau 3=Snow Covered 5=10e 7=W$tp(; t l2 - - _ Unit No 03 a C] ? 0 Please Put -t Events in 3 ? o r Sequential M Order 4 ? 0 M Marmfu! Events (Harm Event 01 =Hit Unit 1 02=Hit Unit 2 03=Hit Unit 3 04=Hit Unit 4 05=Hit Unit 5 06=Hit Other Traffic Unit 07=Hit Deer 08=Hit Other Animal 09=Collision With Other Non Fixed Object 11=Struck By Unit 1 12=Struck By Unit 2 13=Struck By Unit 3 14=Struck By Unit 4 15=Struck By Unit 5 16=Struck By Other Traffic Unit 21 =Hit Tree Or Shrubbery 22=Hit Embankment 23=Nit Utility Pole 24=Hit Traffic Sign 25=Hit Guard Rail 26=Hit Guard Rail End 27=Hit Curb 28=Hit Concrete Or Longitudinal Barrier 29=Hit Ditch 8=Hit Pedestrian D Direction) Object 9=Other/Unknown np Intersection) 9=Unknown 8=Other 30 Hit Fence Or Wall 31 Hit Building 32 it Culvert 33- it Bridge Pier Or Abutment 34= it Parapet End 35= it Bridge Rail 36= it Boulder Or Obstacle n Roadway 37= it Impact Attenuator 38= it Fire Hydrant 39= it Roadway Equipment 40= it Mail Box 41= it Traffic Island 42= it Snow Bank 43= it Temporary Construction amer 48= it Other Fixed Object 49= it Unknown Fixed Object 50= verturn/Roll Over 51=5 ruck By Thrown Or Falling bject 52=Pt Holes Or Other Pavement Irregularities 53=J cknife 54=Fi a In Vehicle i8=0 her Non-Collision )9=U known Harmful Event VV=N0 ing Action a 01=Driver Driver er Was Was Distracted 18=D eking Roadway ving On n The Wrong 02=Driving Using Hand Held Phone Si 03=Driving Using Hands Free Phone 19=M a Of Road king improper 04=Making Illegal U-Turn En 05=Improper/Careless Turning 20=M ranee To Highway king Improper Exit 06=Turning From Wrong Lane Fr 07=Proceeding W/O 21=C Clearance After Stop in Hi hwa eless Parking/Unparking 22=0 08=Running Stop Sign C 09=Runningg Red Light 23=S 10=F il T rAJnder pensation At Curve ding a ure o Respond To 24=Dri Other Traffic Control Device ing Too Fast For Conditions 25=Fai 11=Tailgatingg 12=Sudden Slowinq/$topping 26=Dri 27=Dr' 13=I1l ll re To Maintain Proper Speed er Fleeing Police (Pol Chase) r ine i ega y Stopped On Road 14=Careless Passing Or Lane 28=Fail xper enced re To Use Specialized Equip Change 92=Aff 15=Passing In No Passing Zone 98=09 16=Driving The Wrong Way On 99=Un scted By Physical Condition r Improper Driving Actions nown 1-Way Street Unit No 03 1 00 a 3 ? 4 C Unit No 1 2 3 Pedestrian Action fP) 03=Wor ing 00=None 04=Push 01=Entering Or Crossing At OS=App ng Vehicle aching Or Leaving Vehicle Specified Location 06=Wor 02=Walking, Running, Jogging, 07=Stan trig On Vehicle ing Or Playing 98=Othe 99=Unk Unit No Q3 Unit own o = PENNDOT COPY http://www.dot6.state.pa. us/crsapp/Printlmages/XmIFiles/20090896192009092316202120... 9/23/2009 M-1 ]IT 1--11) W'J J L-? /b / COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM /? ry Page M 500 5 -'olice Use Only - I Witness Name 1 JAMES OAKLEY 2 SHAWN PETE ?4.AN Narrative and additional witnesses: Page 9 of 10 Crash Number W0123 128 2ND STREET WEST FAIRVIEW PA 1702 864 GRAFFINS ROAD YORK PA 17404 Accident Investigation Notification Issued? Units 2 and 3 were stopped in traffic in the left lane of Rt. 11/15 north, about halfway bet 1-81 South. Unit 1 was traveling Rt. 11/15 North. Unit 1 struck the rear of Unit 2, pushing Unit 1 traveled to the left and came to rest in the grass median between the north and sc 11/15 after striking and knocking over a °THUR TRAFFIC STAY LEFT' sign. Unit 2 veen Unit 3 and traveled in a large circular arc before coming to rest in the grass median betw 81. Driver 2 was knocked unconcious after impact. Unit 3 veered to the left after impact median. 4.1 e z C C a3 n d C Driver 1, Brian May, was arrested for DUI. FORM M M-500 (12102) PENNDOT COPY 7174603207 7175426102 roperty Damage f, i the ramps to/from 2 into Unit 3. ibound lanes of Rt. right after striking i the two ramps for I- I came to rest in the http://www.dot6. state.pa.us/crsapp/Printlmages/XmIFiles/20090896192009092316202120... 9/23/2009 Print CWS WO12 3767 Crash Number: VV0123767 Incident Number: 2009-09-0087 "THRU TRAFFIC AHEAD SIGN" knocked over by Unit 1 ?I Page 10 of 10 http://www. dot6. state.pa.us/ersapp/Printlmages/XmIFiles/20090896192009092316202120... 9/23/2009 ?rff 7 A West Shore EMS Patient Services Charge Form - PCR: 9006401 ] PCR Number: 9006401 Patient Name: Ginetta L Fahnestock Date: 09/04/2009 Patient Number: Station/Unit: D Station/79 Address: 10 Mountain Rd. DOB: 7/16/1997 City/State/Zip: Dillsburg, PA 17109 Age: 2 years Phone: (717) 713-0428 SSN: 09-76-1893 Sex: Male Crew 1: Brill, Deborah (EMT 164462) T Times 911: Arrive Scene: 18:06 Destination: 19:0 Dispatch: 17:55 Pt. Contact: 18:10 Available: 19:3 Enroute: 17:58 Depart Scene: 18:55 Quarters: 19:3 Nature of Incident: BLS Final Disposition: Treated, Transported by EMS - BLS Level Care Odometer Out Scene Destination In 63,429.0 63,435.0 63,442.0 63,445.0 Incident Location / Destination Transported From Transported To Enola Rd. / 1-81 ramp, Enola, PA 17025 Ho Spirit Hospital Picked U Taken To Scene of Accident Hospital Services Units Description 1 Emergency Stock Charaes Quantity Description 1 GLOVES - DISPOSABLE (PR) Round Trip Reason For Medicare 0 Moved b Stretcher (evaluation for post-gallbladder surgery after MVA ? Hemorrhaging ? Unconscious/Shock Present ? Pa tient Admitted ? Bed Confined Before 0 Medical Necessary - ? Di charged ? Bed Confined After ? Restrain ? S rvice Available ? Obese Assistina Unit / Referrina Phvaician Assisting Unit Referring Physician East Pennsboro Twp EMS +vy?--' vvv, ,Jt Vv r ? ,, q ?oc-k C.a Printed On: 09105/2009 16:03 D -?C) 7 D? p jS EMStat Reporting: 0 1998-2009, Med Media, Inc. All Rights Reserved J 1 of 2 West Shore EMS Patient Services Charge Form - PCR: 9006401 Authorization Insurance release not indicated. No Prior Authorization Number Signature Was Obtained Pi EI_ Stat Reporting: 0 998-2009, Med Media, inc. All Rights Reserved 2 of 2 Pennsylvania EMS Report Service Name Station Unit Name, No. & Type PCR No. Date West Shore EMS D Station 79 / 2102279 / BLS 9006401 09/04/2009 Incident Location County, Municipality & Incident Zip PSAP Incid. No. Enola Rd. / I-81 ramp, Enola, PA 17025 CUMBERLAND, East Pennsboro Twsp. / E la, C-116453 Street or Highway ecerving Agency Holy Spirit Hospital Patient Name Crew Ginetta L Fahnestock Cl: Brill Deborah EMT 164462 C Street Address , C2. 4.4 10 Mountain Rd. 0 C3. I City state Zip Dillsburg PA 17109 C4: y Sex Age DOB Phone No. Primary Caregiver. Cl Driver. Female 12 Years 07/16/1997 (717) 713-0428 Q Patient Number Social Sec. No. Pt. Weight I ffileage I 209-76-1893 Out On-See a Dest. In Private Physician Driver's License 63429 63435 63442 63445 Times Transporting Assist Units Assist OS Response Time: 3 911: Response Outcome Nature of Incident ER Time: 8 Dispatch: 17:55 Treated, Transported by EMS - BLS BLS OS Time: 49 Earoute: 17:58 ERH Time: 13 Arrive Scene: 18:06 Lights and Sirens No Lights or Sirens Destination Time: 23 Contact: 18:10 Patient Condition on Scene Patient Condition at Facility Total Time: % Depart Scene: 18:55 Minor Unchanged Time Out of 97 Arrive: 19:08 Quarters: Available: 19:31 In Quarters: 19:35 Chief Complaint: None stated by pt. Current Meds: None Allergies (meds): NKDA I I PMHI: Gallbladder removed on Tuesday 9-1-09 - outpatient I Narrative Cumberland ambulance 185 and East Pennsboro EMS were dispatched by CC( Responded immediately. Informed enroute that we had several vehicles involve are to use Ops 3. AOS and were re-directed to a white min-van on Rt. 15. The van is headed nor totaled. The back window is out and the tailgate is caved in about 10". The van another white vehicle that had been hit by a pick-up truck. The truck remained truck didn't appear to have much damage to it. Printed On: 09/05/2009 16:01 EMStat Reporting(c) 1998-2009, Med Media, Inc. All Rights Reserved. 911, class 2 for MVA. , unsure of injuries. We and the rear-end is -as hit from behind by i the highway. The Wee Provider Page: 1 of 2 0 0 01 00 to to Pennsylvania EMS Report Service Name West Shore EMS Unit No 79 / 2102279 / BLS PCR No. 9006401 Date 09/0412009 Patient Name Ginetta L Fahnestock Date of Birth 07/16/1997 Social Security Number 209-76-1893 PS C-1 16453 The occupants of the min-van were all out of the vehicle an sitting on the guar rail along side of the road. They were all self-extricated. There were 7 people total in the van. The m ther wants all of the children checked out for any possible injuries, especially this child because she had just had gallbladder surgery on Tuesday of this week. This pt. is a 12 y/o female that was sitting in the middle row of the van, secure with lap/shoulder belt. We remained on scene for quite awhile because the police officer needed info tion that only the mother could provide. PMH: Gallbladder surgery 09/01/09 - outpatient MEDS: None ALLERGIES: NKDA PE: Pt. is conscious, A&O x4, breathing is normal with to shortness of breath. kin is pink, dry and warm to touch. Eyes are PERRL with no double or blurred vision. Pt. denies hi her head during the accident. She denies any headache, light-headedness or dizziness. There are no formities, abrasions, lacerations, or contusions about her head, face or body. She denies any neck or k pain on palpation. Chest rise is equal bi-lateral and she denies any chest p2in or discomfort. Lung ands are present and clear in all fields. Abdomen is soft and non-tender to palpation and her surgery ite looks good with no seeping, swelling or redness. Hips are unremarkable, as are lower extremities. S e has good motor sensory. She is not complaining of any pain anywhere, even her surgery site. S is a very quiet child and didn't talk much. Pt. had walked to the ambulance and we placed her on the litter and secured her with litter straps. We placed a towel between her abdomen and the strap to cushion her Surgery site. The whole family rode in the ambulance to Holy Spirit Hospital because their v was totaled and they didn't have a ride. Everyone was secured with lap belts on the bench seat and th y smallest was placed in the child safety seat in the captains chair. On arrival at HSH the whole group was taken to room 19 in the ER where we m ved the pt from the litter to the bed by 3 person lift/carry. Report was given to the nurse on duty and pt. care was transferred to the staff m. the ER. Mother signed the HIPPA/insurance form for her daughter. Ambulance 185 went available. i Time Events Provider Comments 18:20 Vitals: Pulse: 98; Resp: 18; B.P.: 122/72 (Manual Cuff); GCS: 4/5/6 (None); Resp. Brill, Deborah Effort: Normal; Perfusion: Normal Printed On: 09/05/2009 16:01 EMStat Reporting(c) 1998-2009, Med Media, Inc. All Rights Reserved. West Shore Advanced Life SuRRort Services Inc - Assignment of; Benefits Authorization d/b/a West Shore EMS, d/b/a Carlisle ALS, d/b/a Chambersburg ALS Patient Name: a'_ [.. - Transport Date: -equest that payment of authorized Medicare, Medicaid, or any other insurance benef .,hone EMS ("WSEMS") for any services provided to me by WSEMS now or in the future responsible for the services provided to me by WSEMS, regardless of my insurance co- be responsible for an amount in addition to that which was paid by my insurance. I agre any payments that I receive directly from insurance or any source whatsoever for the se assign all rights to such payments to WSEMS. I authorize WSEMS to appeal payment dei on my behalf without further authorization. I authorize and direct any holder of medical about me to release such information to WSEMS and its billing agents, and/or the Cente Services and its carriers and agents, and/or any other payers or insurers as may be nec other benefits payable for any services provided to me by WSEMS, now or in the future an original. Privacy Practices Acknowledgment: by signing below, I acknowledge that I have Practices. ONE of the SIGNATURE SECTION: wing three sections MUST be SECTION I - PATIENT SIGNATURE SECTION II - AUTHORIZED RE' This Section is for emergencies or non-emer moica. This section is for emergencies or non_eme The patient must sign here unless the patient is physically patient is physically or menta or mentally incapable of signing. Reason the patient is physicall or r r i X h)(niV Patient Signature or Mark Date Authorized representatives include only the If the patient signs *Patient's Legal Guardian ? Patient's Hei p gns with an "X" or other mark, it is ? Relative or other person who receives goy recommended that someone sign below as a witness. This ? Relative or other person who arranges tre, can be an ambulance crew member. ? Representative of an agency or institution X assistance to the patient. °itness Signature Date I l amgsigning on behalf of the patient. I isnqt an acceptance offiroMial rewol Witness Printed Name Date of rr"1-AZLVZ.. 1V T S Complete this section gay if 3)_l of the following are true: (1) the call is an emergency ambulance transport, (2) the pt was physically or mentally incapable of signing, an (3) no authorized representative (Section II) was available or willing to sign on ehalf of the pt at time of service. A. Ambulance Crew Member Statement must be completed by crew member at time of transport) My signature below indicates that, at the time ofservice, the patient named above was physically orme tally incapable ofsigning, and that none of the authorized representatives listed in Section 11 of this form were available or willing to sign on the patient's behalf. Mysignature is not an acceptance of financial responsibility for the services rendered. Reason pt incapable of signing: Name and Location of Receiving Facility: Signature of Crewmember Date Printed Name of Crewmember B. Receiving Facility Representative Signature The patient named on this form was received by this facility at the date and time indicated above. This financial responsibility for the services rendered to this patient. Signature of Receiving Facility Representative Date s be made on my behalf to West I understand that I am financially erage, and in some cases, may to immediately remit to WSEMS vices provided to me and I ials or other adverse decisions 1formation or documentation s for Medicare and Medicaid ?ssary to determine these or A copy of this form is as valid as eceived WSEMS's Notice of Privacy :ncies. Complete this section galy if incapable of signing. of signing: owing individuals (check one): Care Power of Attorney ment benefits on behalf of patient ant or handles the patient's affairs furnished care, services or that signing on behalf of the paTient the services rendered r at Receiving Facility: is not an acceptance of Printed Name and Title of Recei g Facility Representative C. Secondary Documentation (required only if signature in Section B above cannot be obtained) If no facility representative signature is obtained, the ambulance crew should attempt to obtain one or more of the following forms of signed documentation from the receiving facility that indicates that the patient was transported to that cility by ambulance on the date and time indicated above. The release of this information to the ambulance service is expressly permitted by §164.506(c) of HIPAA. ? Patient Care Report (signed by representative of facility) ? Facility Face Sheet/Admissionsecord ? Patient Medical Record ? Hospital Loa or Other Similar F cihty Record ? Notice of Privacy Practices was left with ? Patient ? Other Arrival Info - Time of Triage: 19:36 - Reason for Visit: in MVA. mini van struck from behind b "drunk driver". all passengers thrown forward. pt. was in passenger seat. recent GB surgery. c/o pain at beltli pain increases with palpation. - N/V. - Language Spoken/Understood: English; unknown others - Mode of Arrival: Private auto - Means of Arrival: Ambulatory - Accompanied by: Family - Primary Care Physician: dr. kim F"reatment Prior to Arrival eatment prior to arrival Treatment prior to arriving No Presenting Complaints Presenting Complaints Chief Complaint Trauma/Injury;. Triage Level: 4. Vi tal Signs - Temp Fahrenheit: - Temperature: - Heart Rate: - Systolic BP: - Diastolic BP: - BP Noninvasive Mean: - Resp Rate: - SpO2 (%) : - Respiratory: 97.2 degrees F tympanic 102 119 mm Hg 73 mm Hg 88 mm Hg 14 99 room air Height, Weight, BSA Measurements (Adult) - (lbs): 119 lb - (kg): 53.9 kg .nmunizations - Immunization history: No recent exposure Current - pediatri _R qu`est`edo;rF?tQC) :?> x44 .a4 4a Sp=O"21!:38 011a U4 Medical History Medical History Details - Does the patient have any No medical problems? Surgical History Prior Surgical History - Previous Surgeries? Yes... - Surgical procedures Cholecystectomy Assessment & Interventions Assessment & Intervention - Airway: - Breathing: - Circulation/Skin: - Mental Status (Adult): - Visual Acuity: - Triage Interventions: Patent Normal Pink; Warm; Dry Alert; Oriented x 3; N/A None .6D Advance Directive Advance Directive - Advance Directive No Abuse Screening Abuse Screen - Patient states physically, No emotionally, sexually hurt and/or threatened Additional Question - Do you currently have any No thoughts of hurting yourself or others?: Allergies • No Known Allergies Triage Triage Disposition - Triage Disposition ER Cooperative Signatures Spaulding, Cynthia K (RN) [signed 04-sep-2009 19:361 tiuthored: Arrival Info, Treatment Prior to Arrival, Presenting Comple Height, Weight, BSA, Immunizations, Medical History, Surgical History ints, Vital Signs, Assessment & 14R600 JW .y,0?0*n;%si RIeen F(UC). ` 'te from Emetg®jti 'I??e ?t. Pa&I 00 Interventions, ED Advance Directive, Abuse Screening, Additional Triage "0458 ?? ?) l}S3gnsx1" 0 S a?ildrn? s.?. ..^.z?}. L. by nth1 ()? =ante T, P, R, Sp02, BP, ECG Temp Fahrenheit (degrees F) : 97.2 degrees F Temperature Site : tympanic Heart Rate (beats/min) : 102 Systolic BP Systolic : 119 mm Hg Diastolic BP Diastolic (mm Hg) : 73 mm Hg BP Noninvasive Mean Mean (mm Hg) : 88 mm Hg °esp Rate (breaths/min) : 14 102 (%) Sp02 (%) : 99 respiratory Patient On : room air Body Measurements Body Measurements (lbs) : 119 lb Body Measurements (kg) : 53.9 kg tion, Allergies, is = ?. ?y..• wR iWAX16W1 11 athIeen E (UC) 4, rated f1'bt11`^Fttl i?gedcy' qt ' 0_j?- 09E End of.Repart P,a>:e.3 6f,,3 N ,VO/ BEHAVIOR CHILD ooperative- Awake - Alert ?Appropriate nted-Person wo nonor' o e G anted-Place ? Ariented-Time ina hate ?Agitated words ?Uncooperative ?Persistent ?Verbally Abusive ?Combative inappropriate ?Anxious ?Crying crying screaming ?Confused ?Moans to pain I'll SKIN 1;0e - Color . cin Intact (visible) ?Cool ?Diaphoretic ?Abrasion ?Rash ?Hot ?Tenting ?Ecchymosis ?Burn ?Pale ?Flushed ?Puncture Wound ?Dusky ?Mottled ?Laceration/ Avulsion ?Cyanotic ?Jaundice MUCOUS MEMBRANES ?Bleeding ?n/a ?Pink /Moist ?Controlled ?Pale ?Cyanotic ?Not Controlled . ?D ?Crac Location: RESPIRATORY ;isfm-metricau unlabored ;War Ustridor Ulabored Jretractions ?wheezing L / R ?rales/rhonchi L ; R 0cough Jproductive U02_Uminyia_ %Sa MUSCULO-SKELETAL ?NIA Extremity: MAE Extremity color:?WNL ?Mottled ?Cyanotic Skin Temp ?Warm ?Cool Distal Pulses?Present ?Not palp. Edema ?Yes ?No Deformity ?Yes ?No Ecchymosis ?Yes ?No NEURO A GLASGOW COMA SCALE Score ?headache OPERL R L ES MWR RESPONSE HERBAL Ustiff neck Size_mm mm 4 pontaneous /1 6Abe s t( § oriented GU/ GYN Udenies s/s aurethral ?frequency discharge C ? RDIOVASCULAR es Monitor/rhythm: OChest pain area: y Uneck pain Pinpoint ? ? 3 To verb command`s Localizes pain ?A bisoriented ?urgency uvaginai discharge Severity /10 Ufacial droop Dilated ? ? 2 To pain 4 Flexion-withdrawal 3 Inappropriate ?numbness: Fixed ? ? 1 No response 3 Abnormal Flexion words Sluggish U U 2 Abnormal Extension 2 Incomprehensible ?Dysuria ?vaginal bleeding OHematuria Jfoley ?retention present _# ? ? pacer ?constant Usharp Odema: ?intermittent ?dull Uburning Upressure ?weakness: non-reactive) ? 1 No response sounds 1 No Response UOther. LMP ?N/A ? 0 IVD ?SOB ?heav :apillary refill: ?nausea Upleurtic GASTROINTESTINAL IA ?Denies pain /symptoms JDuration/ intensity Last BM UAbdomen tender ?nausea Jdiarrhea Jvomiting ?constipation?Hematemesis Bowel Sounds Odistended 0firm ?soft I ? Urapid ?non-radiating ?delayed ?radiating alf tender R / L EENT ?denies s/s A EYES UPain L / R Acuity: LEars Nose Throat ?blurred vision L / R R?Pain UR ?congestion Jsore ?double vision L 1 R Owith lenses )discharge 0drainage )drooling OPhotophobia L / R ?Other: OEpistaxis L / R )dysphasia NURSING ASSESSMENT Completed by: &44V ?Call bell within reach ?Compani ?SR up x2 UER I: aaq? RN Timer n i 1 pa nt ure exp ' ed IV condition(cond): 0=no inflammatiordcom lication 1=edema 2=e hema 3=etch mosis 4=pain 5=hardness 6=warmth 7=1eakin) MEDICATION S Date Start Stop Amt Solution Sz. Site Rate Attpt Cond Initial Date/ Time Drug / ose Route Site Initial Date/ Time Notes 1 i nat a Initial Si nat .? g ure Initial HARGE ADMIT ROBS ?TRANSFER DISCHARGED /accom Via: a to panied by: USelf OFamily 00ther Uw/c 0amb l To: ffhome ? u ance ursing home UAMA OOR Oother: Discharge instruc ions given to: ?Patient ADMIT/ OBS Repo OFamily UParent ?0ther called @ Room# -to 0old records se TRANSFER TO: t to floor Jclothing sheet done ?tra f h Condition: ns er c ecklist complete a factory mproved, ai ?Critical ODeceased to morgue scale /10 RN Si nature: Holy Spirit Hospital Camp Hill, PA 17011 John R. Dietz ECU Nursing Assessment/ Notes 205-ECU 6/06 11th Rev. LLW 7AFNES9'OCK , GII%TC TA L 12 F 07/16/1997 FL- GROrlp Ekl 3A4C.?0 09/04/x9 35404565 Please List All Current Medications: (Include all. over-the-counter, vitamins, samples, herbs & other supplements). Please keep any medications with you and show them to the nurse. Name of Medication Dosage, Route (by mouth, cream, etc.), j Frequency Medication is Taken Time Medication Taken Last time you took this medication? ban Li Patient has broouu ht a legible, complete medication list that is copied and attached t ALLERGIES? •; No ? Yes, list all allergies and reactions: this form. Allergic to Latex? No ??Yess Source of Data: ? Patient Z24Family ? EMS ? Bottles ? List Patient's Pharmacy: Patient's Family Physician: Patient's Signature: Dat Family Signature and Relationship if patient unable to sign: /Time: 1 Patient unable to sign and family not available ? Unable to clarify medication, dose, route or, practitioner Name Printed, Name Stamp, (MD/DO/PA/CRNP/RN): Dractitioner Signature (MD/DO/PA/CRNP/RN): requency at time of interview OHOLY SPIRIT HOSPITAL HOSPITAL Camp Hill, Pennsylvania 17011 T1se Sph* of C=V Medication History Form , F.?.?1?4..,5, 1 GCK ,GINS, = r, '?RC)t?F 544-01 C. 09/01'1/4 `I'A li 12 F 07; 1&/;_99',7T+ c„ ER I 35404565 Form MR 204 Rev. 10/07 FMC 10/07 17 MVA (5) L DATE: ''tom TIME: 1 ?I ? on arrival ROOM: : ?.'i EMS Arrival EMS treatments ordered HISTORIAN: patient spouse paramedics AGE r1- M / F 1 _HX /-EXAM LIMITED BY: HPI chief complaint: njury to: occurred: just prior to arrival osition in v6liclb: I driver passenger front back context: Gar collision verturned vehicle motorcycle ATV multiple / single-car accident ( lost control / fell asleep / unknown ca ) i ?? ; Z; 4 Ps other Z f t i location of pain / -right- -Left- iniuries: shldr hip € shldr hip head face mouth arm thigh arm thigh neck chest abdome elbow knee elbow knee back upper mi r f-arm leg I f-arm leg radiating to (R / L) thigh / leg wrist ankle wrist ankle hand foot hand foot severity of pain: as ciated s m toms: ild lost con iousness / dazed duration: moderate remembers: impact coming to hospital !vere seizure site of impact: restraints: = primary "S" =secondary none lap 1 sho r doegn 1. .1 ' car seat air bag deployed helmet damage protective clothing thrown from vehicle force low mod. high ambulated at scene direct glancing long extrication RS r----------------------, I°ssss eeling / power arms / legs trouble breathing / chest pain merl+ory loss loss of bladder function heache / neck pain ;skin laceration doublb visi n /hearing loss recent fever / illness nause?t?Cvo),g pregnant confirmed w/ home test abdomin ? all s stems ne except as marked ----------------------------------------------- SOCIAL HX smoker- drug use / abuse ; recen OH lives alone lives at hom lives in nursing home FA HX -negative ----------- --------------------------------' PAST HX -negative -prior records reviewed diabetes Type I Type 2 diet /oral / insulin HTN heart disease Meds- -none / see nurses note Allergies- _NKDA / see nurses note ©1996 - 2006 T-Siveim Inc. Circle or check a firntatives, backslash (I negatives. Holy Spirit Hospital Camp Hill. PA John R. Dietz Emergency Center EMERGENCS' PHYSICIAN RECORD P- nF / T) / 06 Pave 1 of 2 ? Nursing Assessment Reviewed'a /itals Reviewed ? Tetanus immun. UTD PHYSICAL EXAM GENERAL APPEARANCE -c -collar ( PTA / in ED) / backboard - no acute distress - mil / moderate / severe distress -T%rt - anx ious / lethargic- HEAD - see diagram vno evidence of trauma - Rac coon Eyes / Battle's sign NECK - see diagram non-tender _ ve ebral point-tenderness i. ainless ROM* _mu cle spasm / decreased ROM L wachea midline pain on movement of neck ,AlExus criteria neg EYES ,,,.--PERRL -g-OMI ENT ?nml external inspection +'-no dental injury RESP/CVS chest non-tender _no ecchymosis • breath sounds nml (heart sounds nml G1 (ABDOMEN) -non-tender _no organomegaly _no distention _nml bowel snds* GENITAL / RECTAL _nml ext. inspection _nml rectal exam _heme negative stool _no vaginal bleeding NEURO/PSYCH i, 6riented x3 6-mood & affect nml v N's nml as tested +''ssensation & motor nml SKIN -- warm, dry 'intact BACK '*' no CVA tenderness ?o vertebral tenderness _mi line tenderness / distracting injury-alt red mental status -recent ETOH m _po t-surgical pupillary defect ( R I L ) _un qual pupils R-_mm L- mm -EOM entrapment/ palsy -sub conjunctival hemorrhage he iotympanum _T obscured by wax _clo ted nasal blood _de tal injury/ malocclusion _se diagram ( on reverse ) -tenderness / seat belt bruising _cr itus / subcutaneous emphysema -splinting ! paradoxical movements -decreased breath sounds _wh ezes / rales / rhonchi_ _tac iycardia / bradycardia _te no palpitations rr," _se diagram ( on reverse ) - t5 _tenderness / guarding / rebound -ma 3s / organomegaly FHT' L' G I _pet ineal hematoma blood at urethral meatus _ e reased rectal tone_ _co fusion / disoriented _fac al asymmetry_ _ _un teady / ataxic gait- _se sory / motor deficit - - _re eats questions Ref eY.eS _se diagram _cr pitus / diaphoresis- _ec hymosis_ se diagram - Glasgow Coma Score SCO Eyes Open- spontaneously (4) to Soh- nml (5) disoriented (4) i Motor- nml (6) localizes (5) with bral point-tenderness tenderness* le spasm / limited ROM ice (3) TA 1, 2 F ;L;S 'COCK , GI:C E- T: r44C.-10L? 09/0 /09 to pain (2) none (I ) (3) incoherent (2) none (1) flexor (3) exten (2) none O'7/16/i99"7 r-11,1 3540455°' 'EXTREMITIES %e,atraumatic ?pelvis stable ,?_/fiips non-tender -no pedal edema ,-nml ROM* ::?at pulses nml -see alagram -bony point-tenderness -painful / unable to bear weight -pulse deficit Joint Exam: -limited ROM / ligaments laxity joint effusion ? ? n't Rvo L' R L R r `` L R R LJ .PROCEDURES ------------------------------------------- Wound Description /Repair length cm location superficial *subcut. 'muscle linear stellate irregular clean contaminated moderately/ *heavily ; distal NVT: neuro & vascular status intact no tendon injury ; anesthesia: local digital block mL lidoc 1% 2% epi / bicarb marcaine 0.25% 0.5% LET ? moderate sedation required; see attached 23d template prep: Betadine / normal saline irrigated / washed w/ saline debrided minimal/ mod. / *extensive minimal l *mod. / *' ^extensive wound explored undermined ; foreign material removed minimal/ mod. /"extensive partially completely "wound margins revised minimal/ mod. / *extensive multiple flaps aligned foreign body identified repair: Wound closed with: wound adhesive / Dermabond / steri-strips SKIN- # -0 nylon / prolene / staples ! ethilon interrupted running simple mattress ( h / v) *SUBCUT-# -0 vicryl / chromic interrupted running simple . mattress (h / v) ; *may indicate intermediate repair "may indicate complex repair `----------------------------------------- XRAYS ?Interp. by me ?Reviewed by me ?Discsd w/ radiologist . . . . . . . . . ...................................................... . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-Spine T-Spine LS-Spine Pelvis -nml / NAD -reversal / straightening of cerv. lordosis _no fracture _DJD / spo6dylosis / spurring -nml alignment -fracture non-displaced displaced- _soft tissues nml CXR -nml / NAD no infiltrates -nml heart size -nml mediastinum . ......................................... OTHER F]See -rib fracture infiltrate / atelectasis LAti, CBC normal except Chemistries normal except WBC segs_ RBC Na Gluc_ __ bands-- K BUN ; Hgb lymphs__ CI - Creat_ Platelets HCR _ C02_ Ca - UA- -normal WBC__ RBC bacteria- ; =rum / urine preg- POS / NEG . oxicology ASA_____ acetamin ETOH _ '-------------------------- ------ ---------------' Underline indicates organ system I * equivalent or mininnpn required for organ system exam _I F ? B 11 T=Tenderness PtT=Point Tender ess S=Swelling E=Ecchymosis B=Burn Lac=Laceration A=Abrasion (0' without ni=mild rend=moderate sv=.severe) Evample- T.vv = T uderners on Palpation tseverel PROGRESS Time improved re-examined -initial fracture care provided: -Discussed with Dr. will see patient in: office/ED, ---------------------- Counseled patient/ family regardi lab/ rod results diagnosis need for CRIT CARE TIME (excludingsepc ' 30-74 min 7 follow-up ---Time- _ hospital -- g: Additional history from: ollow-up family caretaker paramedics ' _Rx given ,ate)y billable procedures) -104 min min ------------ ---------------' M VA arm R I / L sprain / strain e lbow R ! L neck thoracic lumbar forearm R r . L sacral- wrist R .L e hand R 'L head hip R ' L concussion face thigh R ' L with LOC w/o LOC ' knee R L abdomen leg R L laceration back ankle R 'L shoulder R / L foot R L DISPOSITION- Mbaffle- ? Time CONDITION- ? unchanged ATTENDING NOTE: -Resident / PA / NP's history revie? Briefly, pertinent HPI is: My personal exam of patient reveals: Assessment and plan reviewed with i I m the diagnosis of: Care n r vl wed. Patient will nee d: lease see es en / midlevel note for details. Physician S nature RTI # :d ICU/CCU ?transferred Rroved ? stable -RESIDENT I PA / NP SIGNATURE patient interviewed and examined. ent / midlevel. Lab and ancillary Physician Signattpe emplate Complete ? Additi turned care over at RTI # assumed care at T-Sheet ? Dictated Addendum MVA - 17 Rev. 06 / 22 / 06 Page 2 of 2 HOLY SPIRIT HOSPITAL ? (717) 972-4300 The examination and treatment you complete medical care L you develo have received in the Emereency CcnteFhave been rendered on an emergency basis only. and are not intended to be e substitute for or an etlon to pros'idc p neu problems or complications contact tour phNsician or the Emergency Center. FOLLOI' THE INSTRUCTIONS CHECKED BELOW. Patient Information: Patient Information Sheets Contain Important Information to Review and Keep. I ) Abdominal pain O Alcohol reaction O Corneal abrasion ) Croup/bronchitis ( ) Headache O Head Injury O Pain Management O Pediatrid Head Injury ( ) Threatened Miscarriage O Toothach O Allergic reaction O Asthma O U Crutch walking O Diarrhea and Vomiting/Ped. Vomiting O Hypertension O ImmunizationfTetanus , O Pediatric, URI O PID/STD e O URI and Colds O UTI and P elone hritis Back pain U Dislocation Bites-Human/Animal/Insect O Drug/Alcohol abuse/addiction O Kidney Stones O Lablynthitis O Pneumobia O R h y p ( ) Wound Recheck O Burn O Febrile Convulsion O Laceration as (i Seizure O 24 Hr. Pharmacies O Oth ( ) Chest Pain O Conjunctivitis O Fever/Ped. Fever O Flu O Neck Strain O Nosebleed O Sore Thr O S rains oat d St i er ( ) High potassium containing foo O COPD ) Fracture O Otitis Media p O Suture 4 n ra ns are & Removal 1 WOUND CARE MEDICATIONS ( ) May gently wash ove r wound in 24 hours with soap and water or ( ) Continue present medicatio ns except: peroxide ( ) Change dressing __ times daily. Redress with Bacitracin/Neosporin and sterile dressing or leave it open if advised. Keep wound clean, dry ( ) covered ( ) uncovered SPRAINS, STRAINS, BRUISES, FRACTURES ( ) Elevate the injured part for_ days to reduce swelling. ( ) Apply ice packs intermittently for -days to reduce swelling. ( ) Ace wrap for support for_ days. ( ) Wear splint ( ) At all times until follow-up. ( ) For activity as needed. ( ) Use sling for support. ( ) Use crutches: () As needed, weight bearing as tolerated. ( ) At all times. NO WEIGHT BEARING NECK/BACK ( ) Wear cervical collar for support for days. ( ) Rest, avoid bending, lifting, strenuous activity for-days. ( ) Apply moist heat for minutes times daily beginning in hours. ADDITIONAL INSTRUCTIONS ( ) Encourage fluid intake ( ) Clear liquid diet. Advance to regular diet as tolerated ( ) Off work/school from to ( ) Return to work on ( ) Light Duty until: Restrictions: ( ) No gym/sports until ( ) Follow instructions on Workmen's Compensation Form. ( ) Wear eye patch for hours. ( ) If nose bleed recurs, pinch nose firmly for 5 minutes continuously, return if bleeding not controlled. ( ) The interpretation of your X-Rays are preliminary reading. Your films will be reviewed by a radiologist. You or your Physician will be contacted if there is a change in the diagnosis. Use Advil (Ibuprofen) or Tyle according to package instruc Use the following medicines 1: 2: 3: The following medicines m DO NOT DRIVE OR OPERA The prescribed antibiotic/medi of medication you are currently or consult with Pharmacist. FOLLOW-UP This is our reco insurance (HMO) requires a ph IT IS YOUR RESPQNSIBILITY - ( ) Follow-up with: . P) Urgi CE Family in ^<. days ( ) Take the following test results ( ) CBC ( ) CMP ( ) EKG ( IF YOU DO NOT HAVE A FAMII FOR PHYSICIAN REFERRAL. ( ) Call as soon as possible for a ( ) Pick up your X-Rays from the your follow-up appointment. C ( ) See your physician or speciali ( ) Return to Emergency Center especially if O YoutC,plood pressure was ele ._JLY SPIRIT HOSPITAL 503 NORTH 21ST STREET JL)HN K. DIETZ EMERGENCY CENTER CAMP HILL, PA 17011-2288 (717) 97_2-4300 oaivatore Alrano, MD 025502E Ramesh Atora. MD 016727E t) Nikolas J. Baran, DO OS004697L Luke Chetlen. DO 0313145 Nicolau DaCosta. MD 053288L. Jon Dubin, DO 053288L I hereby acknowledge receipt of I understand that I have had em be releasep"6-e oreall of my me I will arrange for folGo -vp care responsibilit ,to notify my>VrRar SIGNATURE: of as needed for pain, fever ons for age and weight, etc. ccording to package instructions: cause drowsiness: MACHINERY WHILE TAKING: tion, may reduce the effectiveness king. Check package instructions iendation for follow-up. If your cian referral for specialty consultation. OBTAIN THE NECESSARY APPROVAL. r ( ) Occ. Health/Company Doctor ocior or )r: ( ) Follow-up ( ) Suture removal o your-physician: X-RAY REPORT ( ) OTHERS PHYSICIAN CALL 763-2900 3adiology Department prior to 11 763-2696 to have films ready. t if not improved in days. you feel your condition is worsening, ed. Check with your physician. Room Report is available to your 33-2660), if not already sent. r. se instructions and understand them. ncy treatment only and that I may problems are known or treated. have been instructed. It is my are Physician of this visit. SIGNATURE Patient or Res Bible P^rson-,r__y,,,., _ Date ( ) PATIENT/RESPO N VERBALIZES UNDERSTANDING SIGNATURE gal t - Nurse FIN ' Date I Kevin-Sean McGann. DO 010969 Pushpa Mudan, MD 051514L r a Aaron Palmer. MD 423830 f Lawrence Paul, MD 039524L Ericka Powell, MD 424145 <) Ranjana Sharma, MD 031265E A copy of your dictated Emegen Physician from Medical Records Clinical Impressions: t Uavid Zimmerman, MD 005636E Lorraine Bock, NP TP003409b Susan DaCosta, NP SP007624B r i Pam Darden, NP SP006066B < > Selena-DiPad1o, NP VP005264B r Theresa Williams. NP TP006126B Denise Beltowski. PAC MA0018761 William Buckner, PAC MA052332 Matthew A. DiRodio. PAC MA000969L Jeffrey Horean. PAC MA01;11n., HE , E CONSENT AHD AU7HORZE hay SM l' _ti As .-ns ant eT,D y _ t., i'a& '-, uda:! IIbizie move dw [?Immi G,'o_,wi e_ am Such h: L U v _. , ._. -noI: _.c M,, atan:l, 1, G'- Co ww b.` ,l\'sl..la ,•,,,m U_' l _ M ' iS a we `o - smn 0 -,U orna arse ,.!'1=''^ _7 m. _ dmE .._.. d i ,-. ?A _ a I - sEnimE A c ,_--..rl_c '. m me u'lim ..'iii: ._W rid_ c.. ,y?..•;'•'t r O_+CWS - e!. d?IIT ._!lyaa' J c ?- a! !1?„S. O :_....1=,, ._ ll?J??,. 'i' lllci`il..al. IG!1E aJ'.;I_ olE t l Ip'I ( =nyy u ' - onss W IM 'I I 'I ;Yum 'il !m an: su a ! c. SAW, L I ". : 01 m an ina1rne - rn I wow 'Sl.c I!lIJ _, a J,,..,.r an: jCI.inme..,ru v a !- pua ..nwe Iu_ Doe Sao- . 171' _. En`. rnlr,nc-! G , Eci I n. li iiai. wwa'...a' !_ n lET! _ j!;r Dr to _ta` G '- 0r, li Dyka are no m PL em v ap u G' Pl_ Spila Uu at le' a! _ II IocG !10e. i`. sy-ammys vm nave tear- ammec Me p iviepe G us, Mesa lac!Ili!v'_ TJ life wEgE snc uEarven- J ,er Dc,t!.;' L ' urinei M IQE L11? os;J : a E YC acnin .: ,ospRc a!ll a WE `!osolia' an nsakr cafe D ' onn, !r Ira!', n[ wx u'-i n ( r:'s -ns i_o Omerv !n, in,, parl!IpM& ',11 ail 11L? niq in presem own; nt cut as DY7 two ::ot;,mi, X111. G° 'I , -OUs r UIC1Uiea c'l^ cIGSe? ^ .,I oI!l_ ; - ?a_Ir1. Cc'e n?a\ a?S_ ;i - -c US6C 1:, BdU..ati0'!c ,Uri) W u!lles ex;D! BSI'. ! .OUes` 1T'1_ w!a_, u!no mane i la'. it I iur i '.!nar a Safe environnle!1. 10 Pallenis ` isltorE Eric Slat al' I !'ODEI V or to Di'e!Tllse' sibs , . 10 !casoriabi_ sews h ano'ol SclZUle a an', 111'ic V111thU'Ui 1urlllel notice RELEASE OF h??EC?fC?:?I?.L NFOr M/,7IOI,,l I Whorle Holy Spirit ido3pual t0 reieaSE to I equesllrl0 Knamn Insurance cal l e (C;. ti la!f rewnIi lives a cwv providers. Such dlagratic ano ihHiapeuflG Inion-nall0!I (including any !IliCr1'llAon rf',1;3i1rIQ t iramy allrJ!(,I i Y;altl_iG--1=' 0' Sj!c111 ?l i(; r_iso d f d' l(?! JI CUI iIUP!la )I ?`;? I_ClctBd Illl il'lidll I _ rna.'y ((? 11L- ;f ter. herner t, is pracess I q IG-!li Clallll` br il"eaHl1 u I C services I I!Yivid d durlnl t'lIS i t :`:IJlt all _c.IiG! I/Li ::.t! lr l man! and hOSPKal l PGl. llcil l:: /, photocopy or carbon cq, of M is auihorl°atior. shah A (;cnAdein as unde-rSlpwd alo authoh s I`,lledicare when a1 oicablc, to rehase to another I ICJ nce came. upor thei EC t( make payment upon ilea" clailil. understand and consent tha-, the mianufaciurer of any irnplaniable device inseried b + n-ir.,!physiciar, during ivaF! be provided w1" iv Idelntlilcailon inforinatlon, Including social securlly number as manda1• C by Fecl A( _"Q0VVLEDGEME?4T OF RECEIPT OF NOTICE OF PR!'VACY PRACTICES 1 n. ceived a cop, 0' tnle No-Lice o` Privacy Pra,tl„es. The Notice descrioea novl' m\' healt! iniorrnatiol sand that should ! a0 r? ca'etufly. ' ann aware ma-, ri Nonce vial' be 3hanged P--. any iin-ie.! iacting this Drganizatl011 s Pass o7 or! tniE Jrpanlzatt!on' 1h'2:?SIt a N'IAN'.ilS;:.Orc. INSURANCE ASSIGWl ItnEI?T OF BENIEF,TS authorize pay? -1 l'e th' W H Soul-, i-i °Dua! a I my king pn:'S!Sw o'9 Arnim paVa& mom I aril respons,ol_ lr.: the ospta and JVtOwn w al' charges I)U, covele0 o- this G Jlryil! I? :. ST; TEAtEi T TO PER[AfT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS. Pi-IlYS11 request payllnem of Ivithoil?ed Medicare NelleflT? i0 111E or on my behait icii any se.!-Oces iur!ll. i ed rile I, plysban service:. I autho ze any holder Of inedical and other inTormatiun about me, to release TC hfi dic needed fo determlrlc- JhesE benefits to! rel?led Service:. I'?I EI.J 1C/''. L My Ahgrfatures c( rt!fim V ! ! c`ce!ved a service or (terns Iron-i Holy SON I iogAal also 1X _ I Un! erWand tllaf pa;lrl an for ihis service or Hem vl+lli be Ran Federal and State f1.1! dq and that any Ilse con_:eadnent of material !iiaV be pl_0sccL!ted under applicable Federal an b State I_avm I uilCloWn0' iha; be re!r!l1=uzed by FedwBi and State funds and that I may be r'esponslble for !ion covered charges. Nso, 1 and not eligible- f0! Idledica Assistance. I wlli be responsilie for balances owed to Holy - ipir!t Hospital. I have read and understand each of the sections contained above. I understand that by signing providing the uthori21ation/ copse it Montage ' in each of the above sections Were nW initials are % t?+ to as?; 9 e ors regardinc acii o to ions and all such questions asked have b l ansk Sign atur ` Vkritness jq? PeNtion ip to Patient Time CA ?= 1-C LL t PA 1.701:1_ OF 1"? %hOl i?:; T1 0A.' 7_%\') UJ 4?', CE c'S.7G?\ ?i, G!JT Y F FNESTOCK , GIN 1inlliail io audl c,'r:, i:nl a!iy referring I eaiti I 11 fa ui o!i0_!_ 1 ),Iliawm abusr- 1O'" t.11 7i iC:..,J'.r!Yllll bweiii O'nti- .i.Asodl, iDl Wive ii A Wid as the onoinal. I i i+? =QU I!-Cl _??. IlliOllilatlvi-, he Cours rd-1 rl la',' '.)E us° tn?,S i Uri0E1_ revisE4 0 Tice b'• l? ?r. n-,..? , `i!cls=`?a3erslan? ( 01 Tw 024 IisIG-d Wow. rims. Staienlellf5, or documents, Gr main test: anti p!"GCHILlr 'nay not 7rce out H vice: If 1 lllltlal? lis docum"n m agreeing and Dcated. i have had the opportuni- rred to my satisfaction. I!lllial5 r 0; I'1 i-% _' Splnl HoslllTal IIiCIUdL 'i0. ;f and ,i? n(I(Iirle& any lrlf'71111atI0rl ii iitlcil Date E'_7 GROUP 544030 09/04/09 L 12 F 07/16/1997 ER1 35404565 ?,YH?giT vvtb I SHORE EMS - BLS 205 GRANDVIEW AVE SUITE 211 CAMP 17011 Phone #: (800) 367-0512 HILL, PA Federal Tax ID: 23-24613002 VVEST ot: SHORE PATIENT NAME: GINETTA FAHNESTOCK PATIENT NUMBER: 85066 ' : INSU INSURANCE: CALL NUMBER: 9006401 13 IREV DATE OF CALL: 09/04/20 09 TIME OF CALL: 05:55 P O CALLER: 9006401B FROM: 1-81 RA p GINETTA FAHNESTOCK TO. HOLY S t IRIT HOSPITAL 10 MOUNTAIN RD REASON(S) UNSPEC HARRISBURG IFIED DIA , PA 17109 GNOSIS FOR TRANSPORT INVOICE DESCRIPTION OF CHARGE UANTITY UNIT PRICE BLS EMERGENCY BASE RATE A0429 AMOUNT INF CONTROL GLOVES (PR) A0382 1.0 824.74 824 74 1.0 BLS MILEAGE A0425 3.83 r . 3.83 7.0 13.73 I 96.11 al Char es 924.68 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT MVA WRITE-OFF Auto Insurance Payment - GEICO -FREDERICK N84420628 12/22/2009 510.96 12/22/2009 413.72 PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ..r RETURNED CHECK FEE - $31.00 i $0.00 DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT ATIENT NAME: FAHNESTOCK, GINETTA L CALL NUMBER AMC ATIENT NUMBER: 85066 9006401B AMO BILLING DATE: 05/25/2010 ENQ DUE 0.00 VISA AND MASTER CARD WEST SHORE EMS - BLS 205 GRANDVIEW AVE CAMP HILL, PA 17011TED FAHNESTOCK, GINETTA L 35404565 - 9/4/2009 DETAIL 9/11/2009 1 pg HCI # A HOLY SPIRIT 'HOSPITAL PAGE N0. TYPE OF DATE OF BILL BILL ? PREV.BILL CYCLE 09/11/09 . OUTP. 503 N 21ST ST CAMP HILL, PA 17011-2288 7117, 763-2138 BIRTH-DATE HOSP.MO. FEI # 23-1512747 07/16/97 39000 T E PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS FAHNESTOCK GINETTA L 35404565 F 12 1 09704/091 1 f.04 '.; INSURANCE COMPANY MAKE GROUP NUMBER POLICY NUMBER GUARANTOR TAMMY L STRICKER 1 -. AUTO INS NAME 10 MOUNTAIN ROAD 2 GATEWAY HEALTH 2049927 AND .: ADDRESS DILLSBURG PA 17109 PAUL LAURENCE OUNT OF S AYMENT ATE OF DESCRIPTION 0 SERVICE TOTAL EST. COVERAGE EST. COVERAGE .: EST. RAGE O. EST. COVERAGE ::.::..,:.. SERVICE HOSPITAL SERVICES CODE CHARGES INS.CO. N0. 1 IN CO. N0. 2 . INS .CO. 0. 3 INS.CO. N0. AMOUNT 09/04fiLEVVELCIRFCNT CHARGES E139.00J AD139SOOE?JTS CE FORWARD SUMMITRY OF CURRENT CHARGES EMERGENCY ROOM 450 SUB-TOTAL OF CURR. CHARGES DIAGNOSIS: 922.2 0.00 139.001 139.00 139.001 139.00 PAYMENT IS DUE UPON RECEIPT OF THIS STATEMENT, YOU MAY SUBMIT THIS FORM TO YOUR INSURANCE CARRIER FOR REIMBURSEMENT. T O IT A, L S 139.0.0 13.9.00 PAT IENf U MSEq PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY NUMBER OM ALL INQUIRIES FOR ANY CHARGES NOT POSTED WHEN THIS STATE- AY r HIS. AMOUNT T , O ...0 O AMD CORRESPONDENCE. MENT WAS PREPARED. OR IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN HOLY SPIRIT HOSPITAL UNDER ESTIMATED INSURANCE COVERAGE. CAMP HILL, PA Page 1 of 2 GG.??l?lT CONTINGENT FEE AGREEMENT I, Tra M ?? individually and as parent and R y an 4,?e?, r??tc? G? a r-?..h h G s t?c?. , lny n z?? rend' anc au orize the I rrcr IfA r"'Wickerr4t am, Knauss & Erb, P.C., to do whatever they deem necessary represent me and my C6 (d/Nin all claims for compensation and reim injuries, wage loss, medical expense and other damages that occurred on 1. ATTORNEY'S FEES: The fee of the attorneys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US O LEGAL SERVICES RENDERED. 2. EXPENSES OF LITIGATION: N, 4 .S j I acknowledge responsibility for all expenses incurred on c claim/case and my attorney shall be reimbursed out of the balance, after fees, of any recovery for all legal expenses which have not already been I do hereby agree to pay all expenses incurred by our and presentation of this case and do understand that these expenses inch limited to, costs of medical reports and records, stenographic expen depositions, expert witness fees, photocopying charges, and mileage charge; rendering of legal services. I understand that I am responsible for paymei regardless of the eventual outcome of the case and further understand that if c atural guardian of firm of Metzger, desirable in order to •sement for personal ;suiting from an SETTLEMENT, ANY KIND FOR ro-'20`-ud Goof- ialf to pursue our 9fir'v"t! u tion of attorneys me. in the preparation , but may not be connected with connected with the of these expenses attorney deems Page 1 of 4 it necessary, I may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. 3. APPEAL: I hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the proceedings in other courts are necessary because of the change of circum other reasons. 4. AUTHORITY: I hereby further agree that our attorney is hereby settle and compromise the claim, to execute all documents pertaining acts requisite for effecting the claim on our behalf. 5. MEDICAL EXPENSES AND LIENS: is appealed, or if of a party or for to bring suit or to and to do all lawful I further authorize my attorney to pay out of any proceeds ?)f settlement or trial any unpaid medical bills or liens for treatments or services or workers' compensation liens made necessary by the injuries sustained in this accident, or back child suppo? payments owed to Pa.SCDU. I understand that my attorney is not guaranteeing the payment o?any medical bills or liens, and they remain solely my responsibility. 6. INVESTIGATION OF MERITS OF CASE: I agree that our attorney accepts this employment on the investigate this claim, and if it appears to be a recoverable claim, he will that he will to handle the Page 2 of 4 claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. EARLY TERMINATION: I hereby further agree that if I decide to terminate this I authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. I agree that reasonable compensation for Clark DeVere, Esquire, or any other attorney involved i$ the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, and other em?oyees One Hundred Dollars ($100.00) per hour, or such higher rate as shall constitute his/her sendard billing rate at the time that the work is performed, or the agreed upon percentage fee in paragraph one of this Agreement, whichever is greater. 8. WITHDRAWAL: I agree that our attorney may withdraw from this case at any ?ime after reasonable notice to us, and I agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable otice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. 9. CONFLICT: I also understand that if the investigation reveals that a part nt is contributoril y negligent in causing the accident the attorney's representation will sc lely be limited to representing the injured minor and there will be no representation of the pare?t. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. Page 3 of 4 IN WITNESS WHEREOF, I have signed below on this S 'day of 2010. 11 j CLIENT: METZGER, WICKERSHAM, KNAOSS & ERB, P.C. ATTORNEY: Clark DeVere, Esquii Andrew W. Norfleet, Page 4 of 4 ?GXthgi?r eooo?o METZGER, WICKERSHAM, KNAUSS & ERB, P.C. P.O. BOX 5300 HARRISBURG, PA 17110-0300 (717) 238-8187 TAX I.D. 23-2871395 March 9, 2011 Billed through 03/09/2011 Miss Ginetta L. Fahnestock 10 Mountain Road Dillsburg, PA 17019 USA FAHNESTOCK, GINETTA v. May Ginetta L. Fahnestock v. Brian Lynn May Invoice# 0CDV Our file# ,40387 203752 Balance forward as of invoice dated January 01, 1900 $0.00 Payments received since last invoice 0.00 A/R adjustments made since last invoice 0.00 ............................. Accounts receivable balance carried $0.00 DISBURSEMENTS P160 ' 04/13/2010 $15.00 04/13/2010 HOLY SPIRIT HOSPITAL & HEALTH SYSTEM, prepay medical bills. 15.00 P160 04/28/2010 $34.85 04/28/2010 HEALTHPORT, medical records from Holy Spirit Hospital (rec'd on 104/23/10). 34.85 P160 05/04/2010 $32.31 05/04/2010 HEALTHPORT, medical records from Hershey Medical Center. 32.31 P160 05/28/2010 $27.28 05/28/2010 WEST SHORE EMERGENCY MEDICAL SERVICES, medical records and 27.28 bills. P150 03/02/2011 $92.00 03/02/2011 CLERK OF ORPHANS COURT OF CUMBERLAND COUNTY, fee for minor's 92.00 petition. P101 03/09/2011 $16.92 03/09/2011 Photocopies. 16.92 SINCE 1888 '40397 203752 Fahnestock, Ginetta L Invoice# 0 P110 03/09/2011 $7.59 03/09/2011 Postage. P122 03/09/2011 $6.00 03/09/2011 Fax. BILLING SUMMARY Total expenses incurred $2 1.95 Total of new charges for this invoice $2 1.95 Total balance now due $2 1.95 PLEASE MAKE CHECKS PAYABLE TO METZGER WICKERSHAM Page 2 7.59 6.00 $231.95 ?xthg,T GENERAL RELEASE CLAIM # 010171053109 For the consideration of One Thousand Five Hundred Dollars and no/cents 1,500.00 - dollars ($. _ receipt of tivhich is hereby acknowledged, I/we release and discharge, and for_myself/ourselves my/our heirs, representatives, executors, administrators, successors and assigns, do hereby remise, release and forever discharge Brian Ma _y heirs, executors, administrators, insurers, successors and assigns andtany land all other persons, firmsh?COhreoration?s, associations, of and from any and all causes of action, suits, judgments, claims and demands of whatsoever kind, in law or in equity, known and unknown, which I/we now have or may hereafter have, and/or which the minor Ginetta Fahnestock now has or may hereafter have, especially the claimed legal liability of releasee(s) which liability releasee(s) expressly deny(ies), arising from or by reason of any and all bodily or personal injury and/or property damage known and unknown, foreseen and unforeseen which heretofore has/have been or which hereafter may be sustained by melus or the minor aforementioned arising out of the accident on or about 8_egtember 4 Ma ille _ 2009 at or near . __ r2v__...____-....... _--- _._..._._........ .______._....... ._____-...._? , in the County of Cumberland gat _ Penns Ivania -°'?"-- in the State of in which the minor aforementioned sustained personal injuries and/or property damage. I/We agree that the consideration set forth is specifically applicable to and paid to me/us with respect to any and all damage to any property, either real or personal, of minelours or the minor aforementioned, and with respect to any and all personal or bodily injury of mine/ours or the minor aforementioned, whether presently known or unknown, foreseen or unforeseen or which may subsequently develop and the consequences thereof, all as arising from the aforementioned accident. I/We further agree that the consideration set forth above is specifically applicable to and paid to me/us with respect to any right of contribution that I/we or the minor aforementioned may have against the releasee(s), his/her/theirlits heirs, executors, administrators, insurers, successors and assigns relative to claims of others that may be brought against me/us or the minor aforementioned by reason of said accident. I/We further agree that the consideration set forth above is specifically applicable to mylour agreement that I/we or the minor aforementioned will not join nor attempt to join the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns in any capacity, in any action that may be brought against me/us or the minor aforementioned arising out of said accident. In consideration of the aforesaid payment, I/we for myself/ourselves and my/our heirs, representatives, executors, administrators, successors, and assigns do hereby: (1) agree to indemnify and hold forever harmless the releasee(s) and his/her/its/their/representatives, administrators, or assigns, against loss from any and all further claims, demands or actions that may hereafter be made at any time or brought against the releasee(s) by me/us or the minor aforementioned, or by anyone in our behalf for the purpose of enforcing a further claim, for which this release is given; (2) warrant that I/we have received no money or other valuable consideration from any other person or persons by reason of any causes of action, suits, covenants, agreements, judgments, claims and demands of whatsoever kind, which I/we now have or may hereafter have, for injuries to person or property arising out of the aforementioned accident or for the other matters for which this release is intending o n. legally bound thereby, WITNESS my/our hand(s) and seal(s) this _ day of NOTICE. Any person who knowingly and with intent to defraud any insurance company or other pew riles an application for insurance or claim contain false atetem hereto commits a ing an fraudulent eteriaranca act iwhich is a crime and nformation or cconcealshfor the purpose of misleading, information concerning any fact person to criminal and civil penalties. WITNESSES: f a:hrr-..Guardian _ _.. _..... Seal) e (Seal) (Seal) t not _ C-GiM-PA (R) 04105 Z Metzger, Wickersham, Knauss & Erb, P.C. By: Andrea M. Cohick, Esquire Attorney I.D. No. 307410 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 amcgmwke.com IN THE COURT OF COMMON PLEAS C- CUMBERLAND COUNTY, PENNSt V XII A? IN RE: GINETTA L. =-n FAHNESTOCK, a Minor ?? -?tM r NO. 11-3 N z c? ° o p W o m ORDER c? co AND NOW, this ay of 20_&, upon consideration of the 4) 101- Petition for Approval of Minor Settlement, a hearing is set for 201, at (?,' (7 -o'clock A,_.M. in Courtroom #?of the Cumberland County Court House. cc: /Andrea M. Cohick, Esquire, Metzger Wickersham, P.O. Box 5300, Harrisburg, PA 171 10 /Anne B. Lamm, Erie Insurance, P.O. Box 2013, Mechanicsburg, PA 17055 ,y?a?l?Ke 463205-1 BY THE COURT: w Metzger, Wickersham, Knauss & Erb, P.C. By: Andrea M. Cohick, Esquire Attorney I.D. No. 307410 P.O. Box 5300 3211 North Front Street a -- Harrisburg, PA 171 10-0300 Attorneys for Petitioners -Q = -j (717) 238-8187 xm c '? rn- r- amc()mwke.com ?=? ?rn IN THE COURT OF COMMON PLE xo CUMBERLAND COUNTY, PENNS A N4,k ? "' IN RE: GINETTA L. '' --+ FAHNESTOCK, a Minor NO. 11- agor CivZ?7-?r-r• DECREE AND NOW, this IT- day of 2011, upon consideration of the Petition for Approval of Minor Settlement, it is hereby ORDERED and DECREED that the Petitioner is authorized to enter into a settlement in the gross sum of $1,500.00. Petitioner is authorized to sign a release for the settlement. The settlement amount shall be distributed as follows: (1) To be paid to Tammy L. Stricker, parent and natural guardian of Ginetta L. Fahnestock, the sum of $893.05, to be placed in a federally insured and restricted savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated or otherwise alienated until Ginetta L. Fahnestock, reaches her majority on July 16, 2015, except upon prior Order of the Court"; (2) To be paid to Metzger, Wickersham, P.C., for counsel fees and expenses the sum of $606.95; 463205-1 Tammy L. Stricker, as parent and natural guardian of Ginetta L. Fahnestock, is authorized to sign the Release, attached to this Petition. Proof of Deposit of the amount set forth in paragraph 1 above shall be filed within 20 days of the negotiation of the settlement payment. BY THE COURT: rstrjL1 cc: Andrea M. Cohick, Esquire, Metzger Wickersham, P.O. Box 5300, Harrisburg, PA 17110 V I? I 7 V21?1 Anne B. Lamm, Erie Insurance, P.O. Box 2013, Mechanicsburg, PA 17055 COP4 C - rn r- ~ -0 r i 70 C:) C Q C =C a ) C? 463205-1 P.O. Box 5300 ?UMBERLANO COURT;' 3211 North Front Street PENNSYLVANIA Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 amcnmwke.com ?_ ? 6 i? c o1V 1 ?i?(?4J #t?ti\ Metzger, Wickersham, Knauss & Erb, P.C. By: Andrea M. Cohick, Esquire Lill 0 CJ ! 3 AN 11: 104 Attorney I.D. No. 307410 IN RE: GINETTA L. FAHNESTOCK, a Minor IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 11-3801 AFFIDAVIT OF DEPOSIT OF MINOR'S FUNDS The undersigned, counsel for Tammy Stricker, parent and natural guardian of Ginetta L. Fahnestock, a minor, hereby certifies that the net settlement amount of $893.05 as set forth in this Court's Order dated July 12, 2011 was deposited on October 11, 2011 by Tammy Stricker into a certificate of deposit at Members 1st Federal Credit Union marked "No withdrawals prior to age 18 without prior court approval." Proof of deposit is attached hereto as Exhibit "A". This Affidavit is made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: Andrea M. Cohick, Esquire I.D. No. 307410 P.O. Box 5300 Dated: I b f I a it l 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Petitioner 479762-1 A St. MEMBERS In PRIArent.r;rmer unrY?iar Dillsburg 5 Tristan Drive Dillsburg PA 17019 Inquiries Call: Acct XXXXXXX587 Eff: 10/11/11 Tlr: 0447 717-502-9992 Date: 10/11/11 Time: 2:27pm Deposit to REGULAR SAVINGS 0000 ?rev Hal: 0.00 Amount: 5.00 New Sal: 5.00 Seq: #389780 Comment for CHECKING 0011 DEPOSIT FOR GINETTA'S ACCT Deposit to 36 MONTH CERT 0040 Prev Sal: 0.00 Maturity date: _ Amount: 05 New Sal: 893.05 Seq. #389782 Check Received 893.05 4c? Authorized by ID Source: ? Drv Li, ? SigCard ? Known ® Other VISA Balance Transfer 1.90 APR No balance transfer fees. Ask an associate for details. GINETTA L FAHNESTOCK CERTIFICATE OF SERVICE I, Andrea M. Cohick, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of the forgoing Affidavit of Deposit with reference to the foregoing action by first class mail, prepaid postage, this /-41' day of October, 2011, on the following: Anne B. Lamm Erie Insurance P.O. Box 2013 Mechanicsburg, PA 17055 The Honorable M.L. Ebert, Jr. Cumberland County Courthouse 1 Court House Square Carlisle, PA 17013 A 14 Andrea M. Cohick, Esquire 479762-1