HomeMy WebLinkAbout08-29-13 w
IN RE: ESTATE OF DAVID A. : IN THE C�IJRT UF C(JMMQN PLEAS QF
WEVODAU, Deceased : CUMBERLAND CUUNTY,PENNSYLVAI�IIA
: ORPHAN'S COURT DIVISION
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PETITION F4R COURT APPRC►VAL OF COMP�O�I�SE
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QF V�RQNGFUL DEATH ACTIUN �� �� „ ,,y;,
INVOLVING MINORS AS INTERESTED PA�TI�S ��`' :: �����
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TO THE HONC)R.ABLE, THE JUD�ES UF THE SAiD COURT:
This Petition is filed under Section 3323 of the Probate, Estates and Fiduciaries Code, 20
Pa.C.S. § 3323, and Rule 2206 af the Pa. Rules of Civil Procedure by Jack C. Wevodau,
Adrninistrator of the Estate of David A. Wevodau, deceased, by an� through his attarneys, Irwin
& McK.night, P.C.
l. David A. Wevodau died on November 18, 2010, as a result of an autornobile
accident wherein David A. Wevodau (the "Decedent"} was a passenger in a vehicle driven by
Jodi L. Shinault. A true and carrect cap� of the Death Certificate far David A. Wevodau is
attached hereto as Exhibit"A."
2. Decedent died intestate, a resident of Cumberland �ounty, Pennsylvania. He was
divorced and is survived by two minor children, Derek Philip V4�evodau and Kayla Celeste
Wevodau.
3. Decedent's father, Jack C. Wevodau, has qualified as Administrator of his e�tate
and a true and correct capy af his appointment and Grant of Letters of Administration is attached
hereta a.nd incorparated herein as Exhibit`B."
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4. The motor vehicle accident occurred late in the evening on Navember 18, 2010,
in the Borpugh of Marysville, Perry County, when the vehicle driven by Jodi L. Shinault
atternpted to negotiate a left turn onta Park Avenue, and instead left the roadway and struck the
Specialty Bakers building at the intersection of U.S. Routes 11/15 and Park Avenue. A true and
correct copy of the Pennsylvania State Police crash report is attached hereto and incorparated
herein as Exhibit"C."
5. Accarding to Exhibit "C," the Decedent was not wearing a seatbelt, multiple
airbags in the vehicle were deployed, and both the Decedent and the driver af the vehicle were
pronounced dead at the scene.
6. Also according to Exhibit "C," the Perry Caunty Coroner determined the deaths
af both Decedent and the drive to be from multiple traumatic inj uries, blunt force impact, and the
vehicle into a structure.
7. Based upon the investigatian by the Pennsylvania State Police and the resulting
crash report, it is believed and therefore averred that the Decedent's death was instantaneous.
8. The insurance carrier far the driver af the automobile, Jodi L. Shinault, is
Encarnpass Insurance,which offered the maximum policy limit of$SO,Q04.4Q. - -
�. Upon information and belief after making reasonable inquiries and conducting an
investigation,the Decedent did not have any vehicle ar persanal insurance coverage�
10. Decedent did nat passess a driver's license or own a vehicle and had no
automobile insurance. A true and correct capy of the Affidavit of No Insurance signed by the
Petitioner is attached hereto and incorporated herein as Exhibit"D"
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11. Upon fiirther informatian and belief after making reasonable inquiries and hiring
a private investigator, there is no ather insurance coverage applicable to the motar vehicle
accident in which Decedent was involved.
12. Petitioner therefore executed a Release of All Claims with Encompass Insurance
for the policy limits of $SO,O�O.Ot�. A true and correct copy of the fully signed Release is :
attached hereta and incorparated herein as Exhibit"E."
13. Petitioner has been infarmed and therefare believes that Jodi L. Shinault has no
assets.
14. Petitioner believes that the amount offered by the insurance carrier is fair and
reasonable as it represents the maximum amount for which the company is liable.
15. The entire settl�ement amount is distributable ta the Administratar af the Estate af
David A. Wevodau.
16. Whether awarded under a survival actian or a wrangful death action in this
matter, the entire insurance proceeds of $Si�,000.40 has been paid to the Estate af David A.
Wevadau, and the net praceeds thereof, after fees and expenses, are ta be distributed for the
benefit af the Decedent's two minor children, Derek Philip t�Vevodau and Kay1a Celeste
Wevadau.
17. Based upon the Petitioner's belief that death was instantaneous, Petitianer
suggests and therefore avers that na portion of the limited insurance funds be attributable to a
survival action, but that instead the insurance funds be attributed to the Decedent's wrongful
death.
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18. The investigation of the accident and negotiations with the insurance company
were undertaken on behalf of Petitianer and the Estate of David A. Wevodau by the law firm of
Irwin& McKnight, P.�.
1�. In addition, the law firm of Irwin & McKnight, P.C. is handling the
administration of the Estate af David A. Wevodau, and al1 associated forms and filings in that
matter.
20. Pennsylvania inheritance tax will not be due an the net insurance proceeds, an the
basis that Decedent died instantaneously and did not survive from the impact af the rnotor
. vehicle into a building.
21. The minor children's net cash settlements are to be deposited in their individual
names of Derek Philip Wevodau and Kayia Celeste Wevodau, with David A. Wevadau as
guardian/custodian, in savings accaunts or certificates of deposit at a federally insured ba�nking
institution and na withdrawal therefrom shall be made until the minors reach majarity without
priar Order of Court.
WI�EREFORE, Petitianer requests that the Court approve settlement with the insurance
carrier, Encompass Insurance, as above-described, apprave the attorney's fees far the persanal
injury and estate adrninistratian in the amount of twenty-five percent �25°l0} of the insurance
proceeds, and award the balance of Thirty-Sev+en Thousand Five Hundred and no/100 Dollars
{$37,500.00) to Jack Wevodau, Administrator for the Estate of David A. Wevadau for the
payment of any Pennsylvania inheritance taxes and costs of administration of the Estate and
completion af the administration af the said Estate, with the resulting net �ds ta be
administered and held by the Petitioner in savings accounts or certificates of depasit at a
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federally insured banking institution far the sole benefit of the Decedent's two minar children,
Derek Philip Wevodau and Kayla Celeste Wevodau.
Respectfully Submitted,
IRti'VIN&McI�;NIGI�T,P,C.
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Douglas G iller, Esquire
Supreme C urt I.D. Na. 8377b
West Pomfret Professional Building
60 West Pornfret Street
Carlisle,PA 17Q13-3222
(717) 249-2353
Date: August 22, 2�13 Attorney for Petitioner
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VERIFICATICIN
The foregoing document is based upan information which has been gathered by my
counsel and myself in the preparation of this action. I have read the statements made in this
document and they are true and correct to the best of rny knowledge, informatian and belief. I
understand that false statements herein made are subject ta the penalties af 18 Pa.�.S.A. Sectian
490�4,relating to unsworn falsification to authorities.
�c�e� � ����,�'����C.�.
JAC EVCIDAIJ,Administrator of the Estate
of D ID VVEVC.}DAU
Date: August 22, 2013
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EXHIBIT "A"
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1�ARNING: It is illegal ta duplica#e this copy by photos�at or pha#agraph.
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Fee far this certificate, $6:OQ �,,,�„m,•,�,,,,,,. This is.to certify that the information here:given is
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����►�`'�'.r_ ��_;,��'s"y: carrectly cop�ed from an original Certificate of Death
�, .u==�="= duI filed with me as`I.ocal Re 'strar. The ori 'na1
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��� �"._z� certificate will be forwarded to the State Vital:
� � <a� Records Office for permanent filing.
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P 2 � $ 0�1.� 9 , - �'�,E�����``�'`'�
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Certification Number a gis ar Date Issued `
�v�uma� COMMONWEALTH'OF PENNSYWANiA�DEP'AR7MENT OF HEAl.7H•VRAL RECORDS
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� CQRONER'S�ERTIFlCATE�?F DEATH
(5ee tnstruct[ons arid exatnpfes on revers�j
STATE FllE NUME}EH
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E�HIBIT "B"
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REGISTER OF WILLS CERTIFICATE C)F
CUMBERL.AND CC3UIVTY GRANT QF LETTERS
PENNSYLVANIA ADMINISTRATItJN
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�vo. zo1 r-oo�3s �A �va. ,��- ��- ���s
E,s t a t e Uf: DA ViD A WEVODA U
(First,Midd/e,Lasi1
La te 4f: EAST PENNSBORO TOWNSHIP
C(IMBERLAND GUUNTY
Deceased
Soci al Securi ty Na: 2n3-50-9941
WHEREA�', DA V!D A WF'VO1.�A U
(Firsf,Middle,tast)
Iate of E.A,ST PENNSBUR('� TC3WNSHT.P Ct�rMBERLAND CtJUNT�'
di ed an the 18 th day of Novembe.� 2 OI.Q and,
WHER.EAS, t1�e gran t o.f Le t ters of Admini s tra ti on
is required for the administratian of the estate.
THEREFORE, I, +GLENDA FARNER STRASBAUGN , Regi s t�r of Wi II s in and
.for CU�+2'BERL�ND Caun t�r, in the �`ommonweal th of Penns�l vani a, .�ave
this day granted Letters af Admini,��.r�atio.ri to:
JA�K C 4!1lEVC7DA U
whc� has dul� qual i fi ed as ADMINISfiRATOR (RI.X') af the e�ta�te
of the above named deceden t and has agreed to admini s ter the es ta te
accarding to Iaw, alI of which fu11� appears af reccard in m� office at
CUMBERLAIVD CI�UNTY COURT HOUSE, CARLISLE, PENNSYL VANIA.
IN TEST�Mn.N�' W:HEREOF, .Z have I�ere�nto set m�r hand and affixed the seaZ
o� �rry affi ce on the 2nd d�y of Februa�y 2f,��1.
egisfer a i/s
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t�?epu
**.NC�TE** ALL NAMES A.BOVE .APPEAR (FIR5T, MIDL?LE, L�1ST)
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EXHIBIT '`C"
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. ,�ncident Number: NOS-1986r$t�.' __� Commonwealth of Pennsylvania PAGE 1
Crash Invoives: Police Crash Report REPQRTABLE CRASH
�DU! Q Fatality Q Hit and Run {� ������,i Vehicie Q ����'�lice Vehicle �} Locai Police Vehicie
� Q N/A (�Work Zone Q AN {� SnawmobUe
Q Commonwesl�Vehicle Q l.acal Gov Vehtcle
� A9��Y���� Case Cbsed Patrol Zone lnvestigation Date
o PA STATE P4LICE-NEWPt3RT YES 41 91t18l2010
�Dispatch Time Arrivai Time inr�es�gatoi Badge Number
q 23:2Q h� 23:50 �� SHtVE,TBDD A 11095
� Approvai Date Reviewer , Reviewer Badge Number
o°, 0��23�7a11 . !.l.OYD,EDWARD R JR 08357 .
Date of Crash rme of Crash Day of the Week C�ash Descripdan
11l1812Q10 23;20 �r�, THURSDAY SIDESWiPE�SAME DiRECTiONj
County Muniapality
PERRY MARYSVILl.E BORO
� Weather Conditions Relatlan to Roadway
o N4 ADVERSE C4NDITlCENS t'?N TRAVEI.LANES
�
� llluminatian Road Surtace Conditions
cs DARK-STREET LIGHTS DRY
#of Units #of Peopie #of injured #Kiited EMS Agency+ Medical Facility
002 004 000 002 MARYSVIIl.E N{JNE
Schooi Bus Retated Schooi Zone Related PennDt3T Notified Type of interaecdan Specia!Locat�on
NQ NO YES "T'iNTERSECTION NOT APPIICABLE
Wark Zone YMark Zone Type Where in Work Zone
o N�
� Speed Limit W�arkers Present Offrcer Present UV�oric Zane Characterist�s
° Road Ciosed ������' Intermittent ar Flagger •
3 �Lane Ciosure� �Detour ❑ar Median ❑ Moving Wbrk ❑ ConVol � Other
v Route Signing Route Number Segment Number Travei l.artes S�Limit p�ientatiori
� STATE HIGHWAY �11 Q2 45 MPH N�RTH
� House Number Street Name St.Ending
�
� US H1NY 11 NIGHWAY
a
� Route Signing Raute Numl�r Segment Number Travel I.anes Speed Limit Orientadon
� Used in E,C�AL RpAD OR STREET TOOQ 02 35 MPH EAST
� intersection
Crashes Street Name S#.Ending
,� . PARK DRIYE
e
� � � Raute Number Or M'r!e Past Ter�ths Or Segrr�nt Marice� Ramp Use Only Feet
E � � .
�
� � � Street tVame Street Ending Or Miles • Tenths
� Q J
Q� � � Route Number Or Mile post 7enths 0�Segment Marker Ramp Use Oniy The above entry�s the
� � � Street Name Street Ending distance from the Crash
� Scene to�andmark 1
d � J
� Degrees Minutes Seconds Decimai Qegress Minutes Seconds Decimal
� Latitude: 40 20 ; 13 . Q02 �ongitude: . 76 55 ; 37 � 354
o Traffic Controi Device Traffic Contro!Funt�ioning
� N4T APPLICABLE Nt3 CONTROLS
�, lane Closed �a�e Closure Direction Tra�ic Detoured Estimated Trme Closed
� PARTIALLY SOUTH YES 3-6 HRS
Enviranmentsl 1 Roadway Potentiai Factors(E!R)
Faetar 1 Factar 2 Factar 3
NONE
o First Harmfui Event in the Crash �t Harmfu!Event in the Crash
o Unit Number Harmfut Event Unit Number Harmfui Event
� 081 HIT UNtT Z 001 HIT BUILDING
� indicated Prfine Facior Unit Number Prime Factor Driver Action
� DRIVER ACT10N OQ1 FAILURE TQ AAAlNTAIN PR4PER SPEED
� Prime Factor EnviromentaURoadway Prime Factor VehiGe Failure Pri�Factor Redestrian Action
u�
Road Surface Type Special Jurisdiction �
BLACKTOP � NO SPECIAL.JURISQICTION
� Rrinted At:PA State Police-Newport 01125/2011 08:39 AM Page 1 �arm#:HQS-19868Q7
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AA-5o0 TX PAGE 2
• Incident Number: Hos-�sss�a�� � Commonwealth af Pennsylvania
Crash Involvss: Palice Crash Report REPORTABlE CRASH
Q ou� (:�F���y �H�,�„��,,,, � ��„�,���,��ve�,���� � State Police VehiGle (� Local Potic�r Vehicte
.
(�N/A �Work Zane Q AN Q Snowmabite Q Coroma�weslth Veh�le Q �a�cal Gov Veh�cle
Unit Number Type Unit Commerciai Vehicie
001 Motor Vehicle in Transport No
First Narr� MI Last Name Suffa DOB Telephone Number
JQDI L SHINAULT 08/'16/19T0
Street Addtess City State Zip Code
201 WAYNE STREET ENOI.A PA 17025
Gender license Number license Shate Class Expiration Date C}uv�erlDriver
,� FEMALE 23124843 PA G Q8/17/2Q13 PRIVATE VEHIGI.E OWNEDl�EASEQ BY QRIVER
a
� Oriver Presence Physicai Gondition Primary Vehide Code V�oiation Person Charged
� DRIVER OPERATED VEHICIE APPARENTLY NORMAI 3361 NO
� Alcohol/Dnags Suspected cohal Test Type Alc:ohoi Tes#Results
� UNKNOWN TEST N8T GNEN
� D�iver Aation FAI�URE TQ MAINTAIN PRQPER SPEEQ
•o
m
� Petiestrian Adion Pedestrian Signals Pedestrian Glothing Pedestrian LocaGan
>
�
G
i st Harmful Event Lefk or Right Side Most Harmfui Utility Pafe Number
HiT UNIT 2 NO
2nd Harmful Event left o�Right Side Most Harmfui Utility Pate Numt�r
HIT BUILDING LEFT YES
3rd Narmfui Event Left ar Right Side Most Harmful Utility Pale Number
4th Harmfut Event Left ar Right Side Most Harmful Utility Pole Number
Ouvr►er First Name Owner M4 Owner Last Narr�or Business Name Suffix
Jt�Di !. SHlNAUl.T
Street Address City State Zip Code
201 WAYNE STREET ENt31.A PA 17425
Vehicle Type . Speciai Usage Gavemrr�n#Equipment Number
VAN NOT APPLICABIE
Madel Year Vehicle Make Vehicle Modei Vehicie Color ViN
1996 CHRYSLER TOWN 8 CI�UNTRY VAN GO�D 'IC4GP54L5TB326A�93
icense Plate Reg.State Est.Speed Vehicle Tawec! Towed By
HDN8946 PA 999 YES PHILLIPS
tn�uranc� insurance Campany Poticy Number Expiration Date
YES ENGt}MPASS 2404t18549 (13/13/2011
� Dir+ection of Travei Vehicie Pasitian Vehide Mavement Initial impact Point
� Nt)RTH RIGNT U►NE"CURB" G01NG STRAIGHT 11 C?'CLOCK
�
€ Damage Indicator Gradient Road Alignment Possible Vehit3le Failures
= DISABLiNG LEVEL STRAIGHT UNKNBVYN
m #of Units 7ype Unit 1 Tag Number T�g Year Tag State
'v
.c 0
�
� � Unit Make Unit Owner
c
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c Type Unit 2 Tag Number Tag Year Tag State
�
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Engine Size Passenger? Saddie SagtTrunk?. Ttaiter? Driver Education?
a� �
� Driver Helme#Type Helmet Strayed On? DOT/Snell Designation? Eye Pro#ection? Long Sieeves? Long Pan#s? Ouer Ankle Boots?
°
g assenger Helmst Type Helmet Staysd On? DOTlSnell Designation? Eye Protection7 Long Sieeves? Long Pants? t3ver Ankle 8oats?
� Passenger? Helmet?
u
�, �
a
� Head Lights? Rear Reflectors?
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printed At:PA State Paiice-Newparc ava��oi�as:39 AM Page 2 Form#:H05-1986807
�5a�T� Commanwealth of Pennsylvania F
- Incident Number: H05-i986�8t}7 .►
Crash Involve�: Police Crash Report REPORTABLE CRASH �
.
d��f �Fatatity Q Hit and Run Q Commercial Vehicle (� State Police Vehicie (� I.ocai Pali�
Q FIIA �Wo�lc 2cne Q ATV Q Snawmablie Q Cammonweaith Yehicle Q Locai Gov Yehicle - - _.
Unit Number Type Unit Commercial Vehicie
OOZ Motor Vehicie in Transport No
First Name MI Last Name S�x DOB Tetephone Numb�r
SEAN M MCCAI.EB 10/05J19$T (717)443-55T1
Street Address Cil�r State Zip Code
496 tANCASTER AVE. ENOI.A PA 17Q25
Gender �icense Number �icense State C1ass �Riratifon Date Owner/pciver
� MALE 279594Q1 PA C 10t0�2011 PRIVATE VEHIG�E NGT OWNEDlLEASED BY DRIVER
0
� Driver Presence Physical Condidon Frimary Vehide Code V'�otation Persan Charged
� DRIVER BPERATED VEHICLE APPARENTLY NORMAL Nt}NE NQ
'c Aicohoi/Drugs Suspe�ted tcohdt Test Type Aicahoi Test Resu�s
� Nt3 TEST NOT GiVEN
� Driver Action NO CONTRIBUTING AGTlON
�
�
� Pedestrian Action Pedestrian Signals Pedestrian Clothing Pedestrian Location
0
9 st Harmfui Event i.eft o�Right Side Mast Hartnfuf U�lity Pole Number
STRUCK BY UNlT 1 YES
2nd Ha�mfui Event left or Right 5ide Most Harmhal Util�ty Po{e Num�t
3rd Harmfui Event lefk ar Right Side Mast Narmful Utility Pa�Number
4th Harmful Event Left or Right Side Mast Ham�ful Utility Pofe Number
Owner First Name 4wner MI 4wner Last Name ar Business Name Suffix
SEAN M MCCALEB
S#reet Address CiEy State Zip Code
4861.A,NCASTER AVE. ENOLA PA 17025
Vehicie TYpe Speciai Usage Govemment Equipment Number
AUTOMOBILE NOT APPItCABLE
Modei Year Vehicte Make Vehicie Modei Vehicle Color VIN
1996 VOLKSWAGEN JETTA BLACK 3VWTD8IHTTNI075832
License Plate Reg.State Est.Speed Vehicle Towed Towed By
HLC5482 PA 050 NO
nsurance lnsurance Company Policy Number Eycpiration Date
YES PROGRES5IYE 66075892-0 04/19/2818
� Directian of Travel Veh�te Fosition Veh�Movement Initial Impact Point
� NQRTH RtGHT l.ANE"CURB" Ga►ING STRAIGHT 5 O'CLOCK
�a
� Damage indicator Gradient Raad Alignrnent P4ssible Veh�le F�ilures '
� MINt}R IEVEL STRAIGHT NONE
m #of Units Type Unit 1 Tag Number Tag Year Ta�State
�
.c 0
>
� Unit Make Unit 4wner
c
�
c Type Unit 2 Tag Number Tag Year Tag State
�
�
Unit Make Unit Owner
Engine Size Passenger? Saddie BaglTrunk? Trailer? D�iver Education?
d �
� Driver Heimet Type Heimet Stayed On? Dt7T/Sneii Designatian? Eye Protedion? lang Ste�ves? l.ong Par�ts? Over Ankle Boots?
0
� Passenger Helmet Type Helmet Stayed On? DfJTlSneii Designatian? Eye Protection? tong Sieeves? Long Pants? Over Ankle Baots?
m Passenger? Heimet?
i�
�
c�
� Head Lights? Rear Reflectors?
m
a
PriMed At:PA 3tate Police-Newport 011251xQ1108:39 AAA Page 3 Form#:H05-1986807
AA-50d TX
• Inciden#Number: H05-19$S80T j Commonwealth of Pennsylvania PAGE 4
Crash Involves: Police Crash Report REPORTABLE CRASH
�
� Q ou� fl F����t�r C��+�c a�R�,�, O co�+��t��v�n���� O s�t�Po�j��v,�ni�ie (� Locai Palice Vehicie
Q N/A �Work Zone Q AN �} Snowmobile Q Comrnanweaith Vehicle {� Local Gov Vehicie
Unit# Driver Restrictions Compliance Driver Endorsement Compliance Driver License Compiiance
01 UNKNQWN COMPLIANGE UNKNQWN COMPUANCE VALID LICENSE FOR CLASS
�' Principaf Impact Pant v�dance Maneuver Under Ride Indicato�
� 11 O'C�OCK UNKNOWN NO UNDERRIDE OR OVERRIDE
�
Emergency Use Orug Test Type Drug Test Results
NOT 1N EMERGENCY U5E NONE NO TEST GIVEN
Unit# Driver Restrictions Compiiance Oriver Endorsement Compiiance Driver License Compiiance
02 RESTRICTlt�NS COMPLIED WITH NONE REQUIRED VALID LICENSE FOR CLASS
�'Principa!Impact Point voldance Maneuver Under Rlde Indicator
� 5 O'CLOCK STEERING-EVlDENCE OR DRNER STATED NO UNDERRIDE OR t�VERRiDE
�
Emergenci►Use Drug Test Type [}nag Test Results �
Nt�T!N EMERGENCY USE NI�NE NO TEST GIVEN
Unit# Person No. Fi�t Name MI Last Name Suffix Dt3B
001 Q01 JODI L SHINAULT 08/16/'{970
Street Address City utate Zip Code
_
201 WAYNE STREET ENOLA PA 17025
RPhone Number EMS T�ansport Person Type Gender Injury Severity
� Np DRlYER FEMAL.E KILLED
0
c Seat Pas�ion Safeiy Equip�nt 1
a� DRIVER-A'�l VEHlCIES N4NE USED i NQT APPLICABl.E
a
a Safety Equipment 2 Extrication
MU�TIPLE AIRBAGS DEPLQYED EXTRlCATED BY MECHAIVICA�MEANS
Eje�tian Ejection P�th
NOT EJECTED , N4T EJEGTEOiNOT APPIICABLE
Unit# Person Na. First Natne Mt Last Narne Suffix DOB
002 002 SEAN M NICGALEB 10/05/1987
treet Address City State Zip G�e
� 496 tANCASTER AVE. ENOE.A PA �7025
� Phone Number EMS Transport Per3on Type Gender injury Severity
� (71T�443-5571 Np DRIVER NIAI.E NOT INJURED
0
c Seat Position Safety Equipment 1
. m DRNER-A�L VEHICLES LAP AND SHOULDER BELT USED
a
a Safety Equipment 2 E�ctrication
A!R BAG NQT QEPLQYED-SWITCH ON hIOT EXTRICATED
Ejectian Eje�n Path
NOT EJECTED NQT EJECTED/NUT APPLlCAB�E
Unit# Person No. First Name MI Last Name Suffix DOB
002 003 JAMES L EARLY "10/28/1987
Ureet Add�ess City State Zip Code
= 276 SUSClUEHANNA AYE. ENOI.A PA 17025
� Phone Number €MS Transport Person Type Gender Injury Severity
€ {717�732-7291 Np PASSENGER MALE NOT INJURED
0
_ Seat Positicu� Satety EquiExn�ent 1
m FRt�PiT SEAT RIGHT SlQE t.AP AND SHClU�DER BELT USED
a
a Safety Equipment 2 E�ricatiorr
AIR BAG N4T DEPLBYED-SIMTCH ON NpT EKTRICATED
Ejectian Ejectian Path
NOT EJECTED NOT EJECTED1Nt3T APPLICABI.E
Printed At:PA State Patice-Newport 01125720i108:39 AM Page�t Fornn#:H05•1986807
��i i��
.
�inc�dent Number: Ho�-��ss�o7 , Cammanweaith of Pennsylva�ia PAGE 5
CI'ash It1YOlVes: Palice Crash Repart REPORTABLE CRASH
�DUI �Fatality �Hit and Run Q Commercial Vehicie �} State Pollce Vehicle �} Local Pa#ice Vehtcie '
i
C�rvlA (�wo�z��� Q a�rv O s���i�� Q c�m��riw�izn v$n���� C� ���r�,►v$ai�i�
Unit# Person No. First Name MI Last Name Suffix DOB
801 0�4 DAVID A 1�VEVODAU OT122/'1968
treet Address City State Zip Code
� 625 TCIWER ROAD ENC3LA PA 1T025
� Phone Number EMS Tra�spart Person Type Gender Injury Severity
� (�1�)�3Z-2279 NO PASSENGER N1Ai.E KILLED
a
c Seat Posi�on Satety Ec{uipment 1
a_► FRONT SEAT RIGHT SIDE NI�NE USED/NOT APPLICABLE
a
� Safe#y Equipment 2 E�ricatitu�
MULTIPLE AIRBAGS DEPLOYED EXTRICATED BY MECHANtCAL MEANS
Ejectian EjeCtion Path
NOT EJECTED NOT EJECTED/NOT APPLICABLE
Owners First Name MI Last Name Su�x Phone Number
� JC?HN A P10TRC?YV3Ki (T17)957-2131
p Street Address City State Zip Code
� 45Q SflUTH STATE STREET lI�ARYSVII.LE PA 17053
�. Property Description
c�i. BAKERY FACILITY,DAlWAGE FRt?M GRASH
PersoniBusiness Natif�eci Phane Number Date Notified Time Natfied
'� PA DOT (717j 582-2191 11/19/2018 05:00 h�.
�o Reason for No'#�ication
� TRAFFMC C4NTRCIL
Printed At:PA State Palice-Newport Q7/Z5/20f 108:39 AM Page 5 Fonn#:H�5-1986807
I��II�� ��
AA-50d TX
� Incident Number: Has-i986887 j Cammanwealth af Penns�ylvania PA�E s
�� C�ISh Ir1YO1YeS: Police Crash R�pc�rt REPOR7ABLE CRASH
�DU! Q���� {�N}����R�� � �mmerciai Vehicle (� State Pollce Vehlcle (� Local Pollce Vehicle
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Crash Synopsis
Whii� in the area af Enola,on SR�I�1J15,The 12 ociock portion of Unit 1 struck the 6 oclock portion af Unit 2 while
both units were northbound on SR 11J'15. Bath Units continued Northbound inta Marysvilie Baro,with Unit�i clasely
foltowing Unit 2. Unit 2 negotiated a left turn onto Park Avenue. While doing so, Unit�1 also attempted to turn fieft
striking the right rear af Unit 2 at the 5 oclack posistion. Unit 2 continued anto Park Avenue,and Uni#'1 failed ta
negotiate the left turn,gaing straight aff the roadway. Unit 1 �en struck the building that houses Speaciatiy
Bakers.Both occupants of Unit 1 were pranounced dead at the scene.
��t�►�
ifUhile in the area af Enola,on SR11/95,the 12 aclock portion af Unit'! s#ruck the 6 aclock portion of Unit 2 while
bath units were narthbound an SR 11/15. Both Un�ts continued Northbound into Marysv�tle Boro,with Unit 1
clasely follawing Unit 2. Uni#2 negatiated a left turn anto Pack Avenue. Whiie doing so,Unit 1 alsa attempted to
turn left striking the right rear of Unit 2. Unit 2 cantinued onto Park Avenue,and Unit 1 failed#o negotiate the left
turn,gaing straight aff the roadway. Unit�1 then struck the building that house�Speaciaity Bakers. Both occupants
af Unit 1 were pronounced dead at the scene.
Upan arrival l abserved Unit 1 at final rest against Specialy Bakers#acility. Unit 2 was parked in the adjacent bank
parking lot with bath occupants standing near
Printed At.PA Stat�Police-Newport 01/25J20i 108:38 AM Page 6 Form#:H05-9986807
AA-500 TX
t Incident Numbet: Ha�-��as�o� } Cammonwealth of Pennsylvania Pa�E �
�, Crash Involves: POIIC@ CI'1Sf1 R@pOf't REPORTABLE CRASH
�dUt (�i ���� (�Hit and Run � Cammerciai Vehiaie (,� State Police Vehicie (� Locat Po11ce Vehicie
.
Q NtA Q work zone Q a't�v Q snc►w�mot���e Q commonweatm ven�c�e C? �o+ca��av vet��cre
it uninjured. There were numerous rescue and ems units on scene attempting to attend to Unit 1, Unit 1 was in an
uns#abl�lacation partialiy resting against#he bakery facility and partialiy through the raof of a utility roam
belonging ta the bakery. Physical damage to Unit 1 consis#ed of sev�re front end and roof damage. Physical
damage to Unit 2 consisted of damage to the rear bumper and right rear taillight assembly. Speciatty Bakers faciiity
included damage ta the,flag pale,front porch,wall�of the facility,rac►f to a utility room, hvac/exhaust equipment
and interior productian line equipment. A#the intersection of SR 11/15 and Park drive ther�were pieces of broken
taillight lens fram Unit 2lying on the Westem side of SR 11/15. There was 4Q'9"af#ire yaw marks from Unit 2
starting in the Southbound lane of SR 11/15 and continuing anto Park Drive,consistant of Unit 2 making the left
an#o Fark Drive.
, An employee of Special#y Bakers ceceived minar injufles fram the impact into the facili#y as he was working in the
room were Unit 1 struck. The employees infon»ation is:
Mauth M+QEUN vf 2942 Chestnut Rd,Elizal�eth#awn,PA 1T02�,PH#717-926-2571
Physical measurements from the scene are as foliaws:
SR 11/15 entire width of roadway 5t3' �
SR 11/15 East Berm 4'
SR 11115 North Bound Lane �12'
SR 11l15 Middle turning lane 12'
SR 11/15 Southbound lane 1�I'4"
SR'#1/15 West Bet�m 10'2"'
Park Avenue Width 38'6"
Park Avenue Qpenin�width
against SR'11/15 curb to curb ?9'11"
Yaw mark fram Unit#2 40'9"
North edge of Park Drive to
Specialfiy Bakers sidewalk 48' �
Sidewalk to flagpole 10'
Flagpole to office porch 16'6"
Office porch to 9s#impact with
building 35'
1st buiiding impact to 2nd
building impact 54'
Operator 2 was interviewed 11/18/10�2351 hrs.on scene and sa�d he puiled aut from Susquehanna Rd. a�PCN
bank onta SR 11J15 North when he noticed Unit'I come from behind him from what loaked ta be a high speed.
t?perator 2 said he was approaching a red light at the Sunoco in Enola and as he began to slow down he noticed
Unit 1 ftying up on his rear end. Clperator 2 said the ligh#turned green befare he came#o a complete stop and as he
started ta speed up he was struck in the rear by Unit 1. Qps�rator 2 said after he was struck he sped up to get away
from Unit 1 because he thaught the person was drunk and did not want to ge#struck a�gain. As Operator 2 sped up
ta try to get away from Unit 1 he noticed Unit 1 kept foliowing him at a close pace.Q�ra#or 2 said as he was
attempting to get away from Unit 1 still traveling Northbound he reached speeds of between 70-100 mph. Operator Z
. said as he came inta Marysville Baro he slowed ta make a quick left onta Park Drive in an attempt to get away fram
Unit 1. Operator 2 said as he was making the left he was struck in the rear by Unl#1 and as he continued onto Park
Drive he said he knew Unit 1 had crashed inta the Bakery. aperator 2 said he then called to repart the crash.
Printed At:PA State Potice-Newport 01/25/201i 08.39 AM Page 7 Farm#:H05•"[986807
Aa-soo TX PAGE 8
� Inc�derrt Nurnbert H05-198680T , Cammonwealth of Rennsylvania
^� Crash Involves: Police Crash Report REPORTABLE GRASH
+ �}DUI Q Fa#ality �H�t and Run Q Cammecciat Vehicle � State Police Vehicie �} Local Police Vehicle
C��ua Q Wark Zane Q anr C.� s��a��� C? co��„����tn v�n�� O �oc���o,�v�n�ig
Operator 2 was asked what pravoked Unit 1 to chase you.Operator 2 said he did not know what Unit 1's problem
was. Operatar 2 said he did not recognize the vehicle that was chasing him or the accupan#s.
Passenger 2 was interviewed �i1118/1a u�approx 2358 hr�s at the scene of#he crash and said he remembers being
near the Sunaco in Enofa when their venicie was struck from l�hind by Unit 1.Passenger 2 said th�ry sped up in an
attempt#o get away from Uni#1 because they#hought the driver was drunk. Passeng�r 2 said they continued North
on SR 11t15 and Unit 9 was fallowing very cl�e#o them as they reached high speeds. Passenger 2 said his freind
made a quick turn onto Park Drive to try and lose Unit 1 and he notic�d Unit 1 then go through the parking io#and
strike the build�ng. Passengec 2 said Q�rator 1 then called to report the crash that just.happened. When asked,
was there a reason for Unit 1 to chase you or did you know the accupants of Unit 1, he replied no.
Operator 2 was re-interviewed on 11/99/10 a�approx 2320 hrs via phane. Operator 2 was asked if he knew the twa
accupants of Uni#1 that were killed in the crash and replied#hat he did learn wha the accupants were and that he
did not knaw#hem.
Passenger 2 wa�re-intecviewed an 11119i'1��approx 2330 hrs.via phane.Passenger 2 was asked if he knew the
two occupants of Unit 2 that were kilied in#he crash. Passenger 2 said he did not know either of the two that were
killed and never have heard of them.
,
Gre�ner tndustri+�s of Nlaunt Joy,PA PN#7�17-853-8'i�11 assisted on scene with#he use of�TO ton crane to remave
Unit 1 from the building .
Perry Caunty Coroner Mike Shalonis pronounced Driver(1)5hinault and Passenger{1)Wevodau d�ad on scene a"(�,`d
11:13 pm, 11/18/10
Perry County Coraners office notified me a toxicology anatysis would be performed on Shinault, resuits will be
supplemented to this report.
Perry County Coroner M�ke Shalonis took into passesion the license of both deceased persans involved.
On 1�[l19J10 a#1205 Nrs. Death nati�icatian was made far the deceased f Wevodau)ta Jack Caok Wevodau
On 11/19/10 at 1�08 Nrs. Dea#h noti�cation was made for th�deceased(Shinault)to Ashley Loper
11/20/1Q Incident was added to the PSP Fataf Crash 5ystem
11/21/10 Perry Co.Goroner determined the deaths of the twa occupants from Uni#'f ta be from:
A.Muttiple Traumatic Injuries
B.Blunt Force Impact �
C.Vehicle in#o a structure .
Photographs fram the scene were taken by Tpr.Tadd A.SHNE,t viewed the images and they accuratly repcesent
#he scene, l burned the digital images,without alteration,ta a non-rewritable CD.
Aerial photographs of the scene were taken by Tpr. Ma#thew FRAMPTON. Reference Suppiemental crash
investigation completed by Tpc.FRAMPTt�N for detaits.
All photos are retained in the crash attachment file located a#PSP Newpart
Printed At:PA State Pofice-Newpart Q1/25/201f 08:38 AM Page 8 Form#:H�5-i886807
��incid nt Number: H05-198680T , Commonwealth of Pennsylvania PAGE 9
�s CP88h 111vOIVeS: Police Crash Report REPORTABLE CRASH
���� �Fatality 0 Hit and Run � Commercial Vehicie Q State Police Vehtcle Q Local Police Vehicie
J Q W/A �Worlc Zone Q AN Q Snowmobile � Commonwealth Vehicle Q local Gov Vehicle
Assisting officers on scene: Tpr. Michael BROWN,Cpl. Brian KNORR,Tpr.Stephen GRIFFITH and Tpr. Michaei
TERESKA. �
The following has been filed into the crash attachment file:
Fatai Crash System report
, Coroners report for both Operator 1 and Passenger 1
Copy of Newsrelease
Photos from crash FSU#H10-0335
Printed At:PA State Police-Newport 01/25/2011 08:39 AM Page 9 Form#:H05-1986807
��i��
� �'-�°°"7x � . Commonwealth of Re�nnsylvania p�� �
,� Incident Number: Ho�-�s�asao� Police Grash Report
, 5upplemental Narrative
� Supplementing Officer Agency Suppiementing Officer Badge Number
� PA STATE POUCE-NEWPORT SHIVE,TBDD A 1108�
� Irnestigation.Date O�iginating Agency Originating Officer
� 11/23/2010 PA STATE POLICE-NEWPORT TODD A.SHiVE
4
a� Reviewer Reviewe�Badge Numbe� Approval Da#e
a LI.OYp,EDWARD R JR 06357 1/11/2011
Narrative
This investigation was conducted by Tpr.Barry Calhoun with the assistance of Tpr. S#even Rradney.
On 11123/10 a#approximately 085Q via telephone(717-732-4848}1 intenriewed Chess ZiM,dob 12/47/4�,fi9yoa. Ne
cetated that he cleans the Rumors bar,Ne recalled that SNlNAULT was at Rumors and was sitting on a Steve
DIL�ER`S lap.SNINAULT had 1 drink and toak it outside.They brought her back in and then she left because she
cauld not get served.ZIM does not have a contact number for Christin�,DIL.LER,ar Geana(bar maid�.
On 11/231�10 at approximateiy 1815 hours 1 arrived at the Sunoco A Plus Mini Market lacated at G11 Enola Drive,
Enoia PA 17025(717-732-150�}. t sp+oke with a relative of the owner.He related that he did nat knaw haw ta
operate the surveillance equipment and#hat his brother Angad Siingh NAGRA�578-�12-0321j wautd be available
after 1400 hours on 11/23l10.
Qn 11/23/1Q at approximately 1426 hours 1 arrived at Bruners,607 Nor�h Enola Road, Enola PA 17025
{717-732-2928j. 1 interviewed Alan L.awrence BRUNER,w!n-m,dab 12/09/�2,47 yoa.He related that 1 could look at
#he surveiltance but he does not knaw haw to operate it.Upon viewing#he sunreillance it was determ�ned that the
system clack was approximately 12-13 minutes s1ow.During the obsenratian af#his digital video it was learned
that uni#2 passed the subject area at approximately 2319:57. Unit 1 then passed the sub�ect area at approximately
2320:.This time was approximately 2'fZ seconds apart.Their relative speed appeared average when compared to
other traffic passing by.As the units passed by the subject area going from sauth to narth it was apparent that
both units were applying their brakes as both unit's brake lamps were lit as they appraached the subjec#red iight
as indicated in the initial investigation.There is a 21 day reten#ion period of this surveiUance foo#age.This videa
system requires that#he foatage be transferred to a thumb dr�ve.This was not done due to the lack of a thumb
drive during thi� interview.
Ctn 11123/�10 at appraximately 1119 hours at Nathan's Caf�,2Q1 No�th Enala Rd.,Enola PA 17Q25 717-728-7526,!
interviewed Gregory Niel APGAR,w/n-m,dob 11/03152,58 yoa. He related that he is the awner operator o�'
Nathan's Caf�. He related that he was talking with his bar maid,Leslie 1�►MP(717-385•2970j,and she had related
to him that SHINAULT was in Nathan's on �11118C10 at approximately 2000-21�0 hours and left.at appraximately
2200 haurs.SHINAULT was with Steve DILLER�T1?-645-0069)of Rumors.She was also with her boyf�iend
WEVODAU.SHlNAULT at ane point was sitting on DILLER'S lap.SHINAULT and WEVODAU appeared to be
acguing that night.APGAR had heard that SNlNAUI.T and WEVODAU were involved in an altercation somewhere
etse but did not know where.SHINAUL.T and her boyf'riend came in together.They were not a problem.They had a
drink and went ta Rumars.They all sat a#the bar.There was no one harassing them. His bar maid Leslie wiit be at
work on 11t23/1U at appraximately 2Q00 hours.!t was noted that none of the subjects involved in this crash were
seen on surve�llance.
Printed A#:PA State Potice-Newpart 01/25t201108:39 AM Page 1 Form#:H05-1986807
.�.�..�.�.. �_.
• 'v�-5a°"�" , . Commanwealth of Pennsyivania P��,� �
� Incident Number: H05-,sasso� Police Crash Report
y � Supplemen#at Narrative
� Supplementing Officer Agency Supplementing Officer � Badge Numbe�
o PA STATE P81.10E-NEWP4RT CHEWNING,DCINA�D� 48�05
�' investigation Date Originating Agency Originating O�icer
� 1'i123/2010 PA STATE POLICE-NEWPt3RT TROt�PER TQDQ A.SH[VE
a
a� Reviewer Reviewer Badge Number Appraval Date
a HAMMAR,DAVID A 07002 ��.1'S�a"��
Narrative
INTERVIEW of Jeanr�a(Gina)PIZZINO,W/N/F,9/25/?5,618 West College Stree#,Yark, Pa, 17041,717-654-7515:
On 17/23/10, 1810hrs, 1 interviewed PIZZINO at Rumor's Bar and Night Club,251 North Enala Road, Enola, Ra
17�25. PiZ�INO related that she was bartending on 111�t 81�10 at Rumor's. She related that SHINAU�T and
WEV4DAU came into ther bac through the front door. PlZZlNO stated that she knew the SNlNAULT caused
prabiems in the bar before and was aware of her history.
PI?21N0 stated that she served SHINAULT on�beer in a plastic cup because she had broken a bottle before.
PI�'ZINC�stated that WEAVODAU had a black eye and he was not drinking, PIZZINQ s#ated that bath of them were
talking#o Steve DILLER who is a regular patron at the bar. PIZZINO stated that DILLER may have been with
another waman. PiZZiNfJ stated that she was unsure if they all came in#ogether but probably came in around the
same time f'rame after 2240hrs.
PlZZENQ stated that SHINAU�T and WEAYaDAU were nat fighting during#heir visit at the bar.SHINAULT walked
out the front door wi#h the beer and poured it on the floor as she was ieaving#he bar, PI�INti sta#ed that
SHINAU�T came back inside and she refused to serve her additional alcohol. WEAVODAU tried to get PIZZINO to
serve SHINAULT anather drink, but she refus�d to do so. PIZZINO stated that they eventuaily left the bar wi#hout
incident. PIZZINO viewed phatographs of McCA�EB and EARLY and s#ated that she had never seen them before
at Rumar's.
INTERVIEW of Leslie Eden LAMP,W/N/F, 12/13/81, 111 Herman Ave,Lemayne, Pa 717-385-2970:
On 11123/1Cl, 194Qhrs,1 interviewed LAMP at Nathan's Cafe,201 North Enola,Road,Enola,Pa 17025, where she
is empfoyed as a bartender. She related that on 11/18/1a,SHINAULT and WEAVt�DAU came into#he bar and sat in
the back near the bathraom. She stated tha#she had never seen them before in#he bar and identi�i ed them by
their viewing the PA OLN photographs. LAMR stated that she had seen SHiNAULT out before but did no#know
her.
LA►MP related that they started a�rguing and it was not a pleasant canversation. She stated that SHINAULT had a
Jim Beam and Coke and WEAVODAU had a Busch Pounder(Beer). LAMP stated that SHINAULT had several
ta#toos and that WEAVt�DAU had a black eye. IAMR s#ated that they came in arcrund 2200hrs. I.A�AAP sta#ed that
th�y met up with Steve DILLER and were there for about 3f!minutes. LAMP stated that they calmed down after
they started taiking to DILLER. LAMP sta#ed that they said they were going to Rumor's and they i�ft#he bar
without incident. LAMP viewed photagraphs of McCA�EB and EAR�Y and stated that she had never seen them
before at Nathan's Cafe.
Surveillance Video at Runac's and Sunoca Mart viewed:
Rumor's: 1 observed SHINAULT and WEV{}[}AU arrived 2018:56 with a unknown female. They left out the side
doar and their mini-van was observed leaving the parking lot after talking with a male in#ront of Rumor's at
23�7hrs. The times on the
Printed At:PA State Police-Newport Of/251201f 08:40 AM Page 1 Form#:H05-1986807
�I��
. AA�OON TX
� - Commanwealth af Pennsylvania �►��,� �
� Incident Number: H05-19�6807 police Crasrh Repart
� Supplemental Narrative
Rumor's video couid be oif 5-8 minutes fram the Sunaca Mart Vid�o. �
Sunoco: 1 a�served wha#appeared ta be a biack sedan and mini-van passing the Sunoca on Raute 11/15
northl�und lane at 23�1:01:32. The sedan was first with van trailing it at an incr�ased speed.There was nothing
alarmin�oc aut of the unusual. No breaking was observed. A volunteer fireman's truck w�th ligh#s activated was
observed traveling northbound on Rt 11i15 in front af the Sunoco at 2319hrs.
Printed At:PA State Police-Newport 01125/281108:d0 AM Page 2 Fo!nn#:N05•�1986807
, AA-500N TX . , @ Commonweaith of Pennsylvania Page �
,� Incident Number: H05-1986807 ,Police Crash Report
, Suppiemental Narrative
� Supplementing Officer Agency Supplementing Officer Badge Number
o PA STATE POLICE-HARRISBURG FRAMPTON,MATTHEW D 07573
� Investigation Date Originating Agency Originating Officer
� 11/19/2010 PA STATE POLICE-NEWPORT TPR.TODD SHNE
� Reviewer Reviewer Badge Number Approval Date
a M011VREY,WILLIAM M 05389 11/21/2010
Narrative
On 11/19/2010, I was taking aerial photographs of a different fatal crash scene,ciose to this fatai crash scene. I
decided to take aerial photographs of this fatal crash scene,whicie I was in the area.
On 11/19/2010 at appx. 1240 hrs., I arrived at the scene,in a Department helicopter piloted by Cpl.Jeff BRAID.
The scene was located on SR0015 at Park Drive, Marysville Borough, Perry County.
On 11/19/2010 at appx. 1241-1244 hrs.,I photographed the scene using a Nikon D3 digital camera and a Nikon
24-120mm lens. 1 captured forty five(45)digital images.
On 11/19/2010 at appx. 1245 hrs., I departed the scene.
On 11/20/2010 at appx. 1957 hrs., I downloaded the digital images to a Department computer. I reviewed the
images,and they accurately represented the items photographed. On 11/20/2010 at appx.2119 hrs, I burned the
digital images,without alteration,to a non-rewritable CD. i labeled the CD as a"Master Copy". It will be retained
at the Troop H Forensic Services Unit. I also uploaded the digitai images to the PSP Bureau of Forensic Services'
SAN server. I made one copy of the CD,which 1 forwarded to Tpr.SHIVE,via Troop mail.
P�inted At:PA State Police-HaRisburg 01/25/201108:40 AM Page 1 Form#:H05-198680T
• mm�.w��
, ap►-SaoN-r�c , , � Commanwealth of Pennsylvania P��� �
� Incident Number: H05-198680? Palice Crash Report
� Supplemental Narrative
� Supplementing Officer Agency Suppiementing O�icer Badge Number
� PA STATE PQ�ICE-NEWPt}RT DUDDY,DAVID J '����
� Investigation Date t7riginating Agency Originating Officer
� 11!'t912010 PA STATE PB�ICE-NEWPORT TPR.TODD SH1VE
a
� Reviewer Reviewer Badge Number Approval Date
a HAMMAR,DA1tID A 0T002 12/5J2010
Na�ative
On 11/19/10 at 1205 hrs.,Tpr.TERESKA, PSP Newport,and I delivered a death notification to Jack Cook
WEVODAU,W!N M,age 70, Dt}B�3122/�40,of 559 Magaro Rd.,Enala,PA 17025, phane{7�!7}732-Z2T8. Jack is the
father af the deceased David WEVODAU, Jack was also given informatian sa that he could contact Perry Coun#y
Coroner Mike SNAL4NIS.
Prirrted At:PA State Palice-Newport Ot/25/Z01106:4a AM Page i Form#:H05-1986887
�
�
s
EXHIBIT "D"
i _ .
�
�Y
, AFFIDAVIT�tF Nt�INSITRAN�E
Jack Wevodau, Administrator of
I, the Estate of David Wevc�dau ��` 201 Wayne Street, Enola, PA 17025
� (Full address on accident date}
NiA
: (Horne and Empiayer tetephone number)
was invalved in an accident on lI/l�l�.� at 45i7 �auth State Road, Marysville, PA
{Date) {Exact location of accidentj
when I was a passenger
(DriverlPassenger(where seated)/Fedestrian)
in a vehicle,or in contact with a vehicle,ownedlaperated by Jodi Shinault, 201 Wayne Street, Enola, PA 17025
{Name/Address of 4wnerlt?perator)
AS d II�Sttit Uf�Ii'iS ii4�it��ili,i�usi:airz�d persvtidl injury. �n tn�abo�e�ia�e,i titti�2Gi u'Vvii�i ic:�t�iit0��;V��lii.��,'rivi t�lu�Ft;Sit"�i."—.'vr ieii
any relative who owned ar teased a motor vehicle.
List aIl residents ofyour hausehold by narne,age,and relationship
. (Use adc]itional sheet if necessary} �
Name Date Relationshin Own or Lease Tf Yes.Insurer Palicv
� Of Birth A Vehicle? Num6er
Jodi Shinault s11�1�o friend Yes X No _. Encompass US 240408549
. . . � Yes No�� • . . .
Yes No �
Yes N4
Y�s Na
i make this statemer�t ta campel Gitizer�s Uni#ed Reciprocal Exchange to pay me personal injury protection or medical expense
benefits. I understand that any person who knc�wingly files a statement of claim containing any false or misleadir�g information is
subject to criminal�nd civii penatties. i hereby request an appticatian for PIP or medical expense benefits.
*,� } f ,:
-s � £_ � ,. �
(X} _:tc..��...��: �- ���.-'�.t�:�•��.:�'�'��.�'l..�.�„ __.._
�,.
Driver;s License#: N f A State:
(If none,so indicate)
State of y
�°`r��5 , �1c�!c�
� S �
Couniy of �- �`�` ` '° , J �,r� ,
��� t �', �c,.__
On thxs r da of _/} ,20 II ,befare me ersanatI a eared .,,,�,� � �r`t,.J } .:tc.G�
Y P Y PP
ta me known to be the person described herein,and who executed the faregoing instrument and
ack�nowledged that �� valuntarily executed the same_
�
__ �.f � � •� ,
tW,�-�
I�Iot Public
I�Iy term expires � _
�
� N6'�iiTaT'Seal..._.,._....�......�..,.
Kar+�n S.Na+�f,Nat�ry�ubiic
�a�ilsie p1�oro,�umb��lan��►unty
My Comrrtirs��n l;�lt�t�.�,�OIX
MEM�R„t�NNSYfYA�1R ASSi7Ct'RTIBN tiF NOTARIES
♦
Ciaim Number: Z0169569 HA
� ' �
' Insuring Company: Eneompass Home and Autt�
i Insurance Company
Date af Luss: Navernber 18,2010 -
Claimant Name: David Wevodau
RE�EASE C}F AL� ��AI�S
This Indenture Vllitnesse#h that, in cansideration of the sum ofi Fifty Thousand Dallars
($50,OCMQ.00!}, for myself and for my heirs, persanal represen#atives and assigns, 1 do hereby
release and forever discharge Jadi Shinault, Terrence Shinault, Encompass, its affiiiates and its
subsidiaries and any other person, firm or corporation charged ar chargeable with responsibiiity or
liability, their heirs, representatives and assigns, from any and all claims, demands, damages,
costs, expenses, loss of services, actions, and causes of action wha#saever and any c(aims for
pre-and post judgment interest and any claims for attorney fees, arising from any act ar
occurrence up to the present time and particularly an account of all personal injury, disability,
praperty damages, loss ar damages of any kind already sustained ar that 1 may hereafter sustain
in consequence of or arising out of an accident that occurred an or about November 18, 2Q1 t? at
or near Rou#e 1'!-15, Nfarysv�lle, PA.
Tc�procure payment c�f the said sum, I hereby declare: that I am mare than 18 years of age; that
no representatian about the nature and e7ctent of said injuries, disabilities or damages made by a
physician, attorney or agen#af any party hereby released, nor any representation regarding the
nature and extent of legal�liability ar�nancial responsibility of any of the parties hereby released,
have induced me to make this settlement; that in determining said sum there has been taken inta
consideration nat only the ascer#ained injuries, disabiiities and damages, but also the possibiiity
that the injuries sustained may be permanent and progressive and recovery therefrom uncertain
and indefinite, so tha#cansequences not now anticipated may result from the said accident.
The undersigned further covenant to indemnify and hoid harmiess the said party ar parties fram
and against a!I claims and demands whatsoever on accourtt of or in any way arising acat of the
said occurrence or its results both to person and property. This provisian applies, but is not
limi#ed�o, subrogation claims by any other party.
1 hereby agree that, as a fur�her considera#ion and inducemen#for this cc�mpromise settlemen#,
this settlement shall apply to all unknawn and unanticipated injuries and damages resulting or
arising from said accident, casualty or event, as well as to thase now disclosed.
I understand that the parties hereby released admit no liabiiity crf any sart by reason of said
accident and that said payment and settlement in compromise is made to terminate further
controversy respecting aN claims for damages that I have heretofore asserted or that I or my
perso�al representative might hereafter assert because of#he said accident.
! further understand that such liability as 1 may or shall have incurred, directly ar indirectly, in
connection with or far damages arising ou#of the accident ta each persan or organization
� released and discharged of liability herein, and ta any ather person or organiza#ion, is expressly
reserved to each of them, such liability not being waived, agreed upon, discharged nat settled by
this release.
The undersigned expressly covenants and warran�s that all ll�edicare, Medicaid, hospital, medical
provider, health care provider, medical supplier and other medica! liens, subrogation righ#s, rights
of payment, rights of reimbursemen#and c{aims of any nature whatsoever, arising now or in the
future, as a result of health care services provided to the undersigned have been or will be
satisfied, settled, compromised or paid by express agreement with Medicare, Medicaid, each
insurance carrier and each hc►spital, health care provider, medical provider or medical supplier by
the undersigned prior to final disbursement of the settlement praceeds, The undersigned
covenants and warrants tha#ai1 such ciaims, iiens, payment abligations and assignments have
been disclosed in wri#ing to the parties released prior to settlement. The undersigned agrees to
Page 1 of 2
Any persan who Icr�owingly and with intent ta injure or de#raaud any insurer files an appl�ca#ion ar cla�m conta�ning any fatse,
incomplete or misleading information shall,upon conviction,be subject to imprisonment for up to seven years and the
paym�nt of a fine of up to$15,000.
l � � Claim Numbes: Z0169569 HA
# � ` " Insuring Company: Encompass Home and Auto
i Insurance Company
Date af Loss: November 18,2010
Claimant Name: David Wevodau
indemnify, defend and hold harmless the parties released for any and all Icasses, claims, demands
or causes of action, and any damages,judgments, fees, expenses, casts {including interest}ofi
any nature whatsaever paid and incurred as a result of any breach of these warranties and
covenants. The undersigned understands and agrees that the parkies released have relied on
these material representations as part of the consideration and inducement for this settlement.
The undersigned understands and agrees that such liability as he/she may or shall have incurred,
arising naw or in#he future, as a resu#t of heaith care services provided to the undersigned, is
expressly reserved to each�and every health care provider or payar based on such senrices, such
liability not being in any way waived, agreed upon, discharged or settled by#his release. This
specifically includes, but is not limited ta, any liability the undersigned may have to any hospital,
heal#h care pravider, medicaf provider, medicai supplier, Medicare or Medicaid. If any
subrogation claims, liens or rights to payment of any kind against these settlement proceeds do in
fact exist, the undersigned shall distribute these funds in accord with such claims, liens or rights to
payment�or shall direct his/her attorney to do so}. The undersigned agrees to indemnify, defend
and hald harmless#he parties released for any and all losses, claims, demands or causes of
action, and any damages,judgments, fees, expenses, casts �including interest} of any nature
whatsaever paid a�d incurred as a resuit of any breach of these agreements and covenants. The
undersigned understands and agrees that the parties released have relied on these materia!
represen#ations as part of the consideration and inducement for this settlement.
Signed an+d sealed this 31st day of J�L� ,:�012
Witnessed by: ESTATE OF DAVID A. WEVODgII
Y �-' V ti/.X/1l Iir MZ�`"�"'V SC!'1�
r � �
JA C. WEYODAII, AD�INISTRAT(}R
{SEAL)
STATE(JF SS C�QI+IWEA,L�.'H OF PENNSYLV�IA:: :
:
COUNTY(�F carn+� oF co���.n • ss
.
On this 31st day af JDLY , 20�_, before me persc�nally
Appeared J�CCR C. i�EO'OD,�II , ta me known to be the persan whc►execu#ed the
faregoing instrumen#, and acknovvledged that he executed the �me as his free act and
deed.
My commission expires �
N ARY L C
coMr�arvw�r.-r�aF��sv�vac��a
Notarial Seal
Nfartha�,Noe1�Nc�ry Pablic
��g�ra�Gurr�eriand CountY
� ��e,Sep�t.18,2015
���,�nNSn.va�an Assoc�u►noN oF Nar�ax�s
Page 2 af�
Any person who knowingiy and with intent to injure or defraud any insure�f11es an application or claim containing any false,
incomplete or misieading infarmatian shalt,upon canviction,be subject to imprisonment for up to seven years and the
payment of a fine of up to$15,000.