HomeMy WebLinkAbout14-3693 itieFtr
R.J. MARZELLA&ASSOCIATES, P.C.
BY: Charles W. Marsar,Jr., Esq. #� �d�rC0� 4
N PA SUPREME COURT I.D.No.86072 +i�I;"
3513 North Front Street Attorney for Ronald Graham,
Harrisburg, PA 17110 Individually,and as Executor of
Telephone: (717) 234-7828 The Estate of Shirley Graham
Facsimile: (717) 234-6883
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA Ul
.RONALD GRAHAM,INDIVIDUALLY AND AS DOCKET NO.
EXECUTOR OF THE ESTATE OF SHIRLEY
GRAHAM
PLAINTIFF, PROFESSIONAL MEDICAL
NEGLIGENCE
V.
TIMOTHY HORSKY,D.O.;
WEATHERBY LOCUMS,INC.;
DONALD CHAPMAN,M.D.;
NICOLAU DACOSTA—NETO,M.D.;
TODD LUPOLD,PA-C;
JOEY WISNER,PA-C;
APOLLOMD,INC.;
RUCHI DASH,M.D.;
JULIUSz NITECKI,M.D.;
HOSPITALISTS OF CENTRAL
PENNSYLVANIA,P.C.;
LATOYA MONTFORT,R.N.
MEDICAL STAFFING NETWORK
HEALTHCARE,LLC;
BERNADETTE BRAZE,D.O.;
CARLISLE HMA PHYSICIAN
MANAGEMENT,LLC,T/D/B/A MIDSTATE
EAR,NOSE AND THROAT CENTER;
CARLISLE HMA LLC,T/D/B/A C
CARLISLE REGIONAL MEDICAL CENTER;
DONN POLSON,RN;
KATHY STUART,EMT-P;AND
HERSHEY MEDICAL CENTER
DEFENDANTS JURY TRIAL DEMANDED
PETITION FOR COURT APPROVAL OF WRONGFUL DEATH/SURVIVAL
ACTION SETTLEMENT
The Petition of Ronald Graham, who was appointed Executor for the Estate of
Shirley Graham, respectfully request:
1. Petitioner, Ronald Graham, is the Executor of the Estate of Shirley
Graham, Deceased, his late wife, as indicated by the Certificate of Grant of Letters issued
by the Register of Wills of Cumberland County, Pennsylvania on November 6, 2012.
(See, Certificate attached hereto and incorporated herein by reference as Exhibit"A").
2. Shirley Graham was born on January 18, 1940 and died on May 27, 2012
of multi-system organ failure, septic shock, and lactic acidosis. (See, copy of Death
Certificate attached hereto as Exhibit"B").
3. Allegations of professional negligence were resolved without the filing of
suit.
4. Shirley Graham died testate.
5. At the time of her death, Shirley Graham was married and was survived by
her spouse, Ronald Graham, Executor, who is the beneficiary entitled to bring an Action
for Wrongful Death and Survival Action under 42 Pa. C.S.A. § 8301(b) and 42 Pa.
C.S.A. § 8302, respectively.
7. A global settlement of$500,000.00 has been proposed to resolve the
Wrongful Death and Survival Action against all parties.
8. Counsel is of the professional opinion that the proposed settlement is
reasonable under the circumstances. The proposed settlement at this juncture negates the
need for continued litigation with the uncertainty of a jury trial. The amount of the
settlement ensures that the beneficiary will be adequately compensated for the loss of the
financial and emotional support that Mrs. Graham would have provided.
9. Petitioner is of the opinion that the proposed settlement is reasonable
given the decedent's age and co-morbid medical problems.
10. Petitioner, Ronald Graham, executed a Fee Agreement on October 19,
2012, agreeing to 40% attorneys fees. (See a copy of the fee agreement is attached hereto
as `Exhibit C").
11. Per the above-referenced agreement, Counsel requests $200,000.00 in
attorney's fees and $1,288.71 in expenses. (See expenses attached as "Exhibit D").
12. Highmark paid medical charges associated with Mrs. Graham's
hospitalization in the amount of$42,806.39, which has been reduced to $25,683.84.
13. There is also a Medicare lien associated with Ms. Graham's
hospitalization in the amount of$8,518.66, which has been reduced to $5,102.34.
14. The total amount of these liens totaling $30,786.18 will be paid by
Petitioner's attorney, R.J. Marzella&Associates.
15. Petitioner requests allocation of the net proceeds 50% to the Wrongful
Death Action and 50%to the Survival Action.
16. The Pennsylvania Department of Revenue agrees to the proposed
allocation in its correspondence dated June 9, 2014. (See a copy of the letter is attached
hereto as "Exhibit E").
17. In accordance with the above allocation, $250,000.00 will be allocated to
the Wrongful Death Action and $250,000.00 will be allocated to the Survival Action.
Wrongful Death Claim Survival Claim
Gross-$250,000.00 Gross- $250,000.00
Atty fees- $100,000 Atty fees- $100,000
Expenses- $644.35 Expenses- $644.35
HighMark lien-$25,683.84
Medicare lien-$5,102.34
Net = $149,355.65 Net = $ 118,569.47
18. Pursuant to 42 Pa.C.S. § 8301(b),the beneficiaries of the Wrongful Death
Action and their respective interests, are as follows:
Name Relationship Interest
Ronald Graham Husband 100%
19.. Therefore, these beneficiaries will each receive the following from the
Wrongful Death Action:
Name Relationship Portion of Proceeds
Ronald Graham Husband $149,355.65
20. Pursuant to 42 Pa.C.S. § 8302 and in accordance with 20 Pa. Cons. Stat.
§2104, the beneficiaries of the Survival Action and their respective interests, are as
follows:
Name Relationship Interest
Ronald Graham Husband 100%
21. $2000.00 will be held in escrow for the cost of probating the estate.
22. As Mrs. Graham is survived by her spouse, who is the sole beneficiary, no
inheritance tax is owed.
23. As part of the terms and conditions of the Release.Agreement, the
Petitioner's Counsel requests that the terms and conditions of this settlement be sealed by
this court.
24. As evidence by a signed verification, Petitioner Ronald Graham, Executor
for the Estate of Shirley Graham, agrees with the contents of this petition. (See attached
as "Exhibit F").
25. The Release on behalf of the defendant is attached hereto as "Exhibits G".
26. All parties are in concurrence with this petition.
WHEREFORE, Petitioner respectfully requests this Honorable Court to enter an
Order approving the settlement recited above and that the Court approves the proposed
allocation and distribution of the settlement proceeds.
Respectfully submitted,
R.I MARZELLA&ASSOCIATES,P.C.
BY: C. Lid AjAa/Lw -04-,
CHARLES W. MARSAR,JR.,ES IRE
ID No. 86072
DATED:
.t
CERTIFICATE OF SERVICE
I, Enjoli Neely, hereby certify that a true and correct copy of the foregoing
document was served upon counsel of record this 181h day of June, 2014, by depositing
said copy in the United States Mail at Harrisburg, Pennsylvania,postage prepaid, first class
delivery, and addressed as follows:
MARC LEVIN,ESQ.
WEBER GALLAGHER
FULTON BANK BUILDING
200 NORTH 3RDSTREET
SUITE 9A
HARRISBURG,PA 17101
ATTY FOR CRMC
STUART T. O'NEAL,ESQ.
BURNS WHITE
100 FOUR FALLS, SUITE 515
1001 CONSHOHOCKEN,PA 19428
ATTY FOR MONFORT)
CINDY ELLIS,ESQ.
FOULKROD ELLIS
4000 MARKET STREET
CAMP HILL,PA 17011
ATTY FOR CHAPMAN,DACOSTA,AND LUPOLD,WISNER)
SHAUN MUMFORD,ESQ.
STEVENS&LEE
51 SOUTH DUKE STREET
LANCASTER,PA 17602
ATTY FOR DASH&NITECKI)
t
PETER SAMSON,ESQ.
CIPRIANI&WERNER
450 SENTRY PARKWAY,SUITE 200
BLUE BELL,PA 19422
(ATTY FOR HORSKY)
JOHN STEPANIAN,ESQ.
MCQUAIDE BLASKO
1249 COCOA AVENUE
SUITE 210
HERSHEY,PA 17033
(ATTY FOR HMC)
NAOMI PLAKINS
PLAKINS&ASSOCIATES,P.C.
140 EAST STATE STREET
DOYLESTOWN,PA 18901
(ATTY FOR BRAZE
R.J.MARZELLA&ASSOCIATES,P.C.
BY: ffisoj�'
ENJOLIME-EMY,PARALEGAL
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REGISTER OF WILLS CERTIFICATE OF
CUMBERLAND COUNTY GRANT OF LETTERS
PENNSYLVANIA
No. 2012- 01170 PA No. 21- 12- 1 170
Estate Of: SHIRLEY J GRAHAM
(first,Middle,Last)
Late Of: PENN TOWNSHIP
CUMBERLAND COUNTY
Deceased
C) Social Security No: 195-32-0983
WHEREAS, on the 6th day of November 2012 an instrument dated
November 12th 1991 was admitted to probate as the last will of
SHIRLEY J GRAHAM
(First.Middle,Last)
late of PENN TOWNSHIP, CUMBERLAND County,
who died on the 27th day of May 2012 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA FARNER STRASBAUGH Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
RONALD G GRAHAM
who has duly qualified as EXECUTOR(RIX)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYL VANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 6th day of November 2012.
ba4
s
Register 6f Wills
eputy
**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
z�X� , �, �
B
105.805 MV(9/11)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph,
'ee for this certificate, $5.00JI - This is to certify that the information here given i
�'iN OFp
correctly copied from an original Certificate of Deat
duly filed with me as Local Registrar. The origin_
certificate will be forwarded to the State Vitt
Records Office for permanent filing.
P 18487808
9� ,,I �.c. O 2 9/201
Certification Number ' N M.1 111.
Local Registrar Date Issued
Type/Print In COMMONWEALTH OF PENNSYLVANIA.DEPARTMENTOF HEALTH.
Permanent VITAL RECORDS
Black Ink CERTIFICATE OF DEATH State File Num be,:
1.Decedent's Legal, (First,Middle,Last,Suffix) 2.Sex A.Social Security Number 4.Data of Death(Mo/D-Y/Yr)(Spell Mo)
Shirley J. Graham emaie 195-32-0983 May 27, 2012
Sa.Age-Last Birthday(Yrs) Sb.Under 1 Year 5c.Under 1 Oa 6.Date Of Birth(Mo/Day/Year)(Spell Monih) 7a.Birthplace(City and State or Foreign Country)
72 Months Days Hour. Minutes January 18 f 1940
y�� q y p Np, 7b.Birthplace(County)C umb e r 1 a n d
Ba.Res(de n f c y�ly �ci_oa trY) Bh Besidoficeka It ri u`tm t3 01V JRt t()d Bc.Oid Decedent Llve in a Township?
gd.Residence(County 1 t5 G G. =Yes,decedent lived in Penn two
C umbe r and Be.Residence(Zip Code) No,decedent lived within limits of city/bora.
9.Ever In US Armed Forces? 30.Marital Status at Time of Death }�[Marrled Witlowed 11.Survlvin pouse's Na (I ife,gLy prl To first marriage)
0 Yes ffi No 0 Unknown 0 Divorced 0 Never Married 0 Unknown �o n a 1 ae Cir agia m
12.Father's Name(First,Middle,Last,Suffix) 13.Mother's Name Prior to First Marriage(First,M(ddle,Last)
George P_ Kann Sarah Estella Billman
14a.InformanC's Name 14b.Relationship to Decedent 14c.Informant's Mailing Address(Street and Number,City,State,ZIP Code1
o Ronald G_ Graham Husband 1822 Walnut Bottom Rd Newv� ll
G .......................................................... .........'."'...........................;..._....iso:v.ace.�....eac...c ec on y one
¢ If Death occurred In a HosPlta l: In tient Occurred S ...... I�Hosplce Facility •• •' """
..............
Emergency Room/Outpatient Dead on Arrival Decedent's Home
O Nursing Home/Long-Term Care Facility Other(Specify)
15b.Facility Name(If not Instltutla.,give street and number) i5c.City or Town,State,and Zip Code lSd.County of Death-
M.S. Hershe Medical Center Hershe Pa. 17033 Dau hin
16a.Method of DlspositlOn 0 Burial Cremation 1 t f ry,crematory,Or other place)
P tl 16c.Place of Disposition(Name of cemetery,
0Removal from State 0Dgnatl� / � .°� Hollinger Cremator
0 Other(Specify) Y
16tl.Location of Disposition(City or Town,State,and Zi Charge of Interment 17b.Licens Number
Mt. H o 1 1 y S p r i n g s PA �)7 0 6 5 17a.s1g�t� of F� era'se Ice Licensee or Person In Char F D 1 3 895 5 L
E 17t Name and CQm plate Adtlress of 1 Faclli
8 gger unerai fTo l �nc 15 Big Spring ve. Newville, PA 17241
,- ie.Dacedent's Education-Check the box that best describes the 19.Decedent of Hispanic Origin-Check the 20.Decedent's Race-Check ONE OR MORE races to indicate what
highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be.
0 Sth grade or less Is Spanish/His
panlnot lino. Check the"Nat White 0 Korean
0 No diploma,9th-12th grade box If decedent Is not Spanish/Hispanic/Latino. Black or African American school graduate or GED completed o 0 0 Vietnamese
sian
Some colla not Spanish/Hispanic/Latino 0 American Indian or Alaska Native 0 Other Haw
ge credit,but nes degree �Yes,Mexican,Mexican American,Chicano 0 Asian Indian � Native Hawaiian
(3 Associate degree(e.g.AA,AS) 0 Ya.,Puerto Rican
0 Chinese
gree(e.g.BA,AS,BS) Yes,Cuban (]Guamanian or Chamorro
Bachelor's de
Filipino
Master's degree(e.g.MA,MS,MEng,MEd,MSW,MBA) 0 Yes,other Spanish/Hispanic/Latino 0 Japanese 0
OtherPacific Islander
0 Doctorate(e.g.PhD,Ed D)or Professional degree (Specify) 0 (Specify)(Other S 0
L-R.
MD DDS,DVM LLB JD
21.Decedent's Single Race Self-Designation-Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 22a.Decedent's Usu
$]White al Occupation-Indicate type of work
Japanese 0 Samoan done during st of working life. DO NOT USE RETIRED.
0 Blacko,AfrlcanAmerlcan (l Korean 0 Other Pacific Islander SCh001 BLAS Driver
8 0 American Indian or Alaska Native 0 Vietnamese 0 Don't Know/Not Sure
0 Asian Indian O Other Asian 0 Refused 22b.Kind of Business/Industry
0 Chinese Native Hawes Ilan 0 Other(Specify)
0 Filipino C1 Guamanian or Chamorro Transportation
ITEMS 23a-23d MUST BE COMPLETED 23a.Date Pronounced Dead(Mo Day r) 23b.Signature of Person Pronouncing Death(--I-
By when applicable) 23c.License Number
PERSON WHO PRONOUNCES OR �O
CERTIFIES DEATH
23d.Data Signed(Mo/Day/Yr) 24.Time of D ath
M 25.Was Medical Examiner or Coroner Contacted? 0 Yes 0 No
CAUSE OF DEATH j m
26.Pert 1. Enter the ch,ln of events--diseases,Injuries,or complications--that directly caused the death. DO NOT enter terminal ouches such as cardiac arrest ApproxiInterval:
ate
aspiratory arrest,or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines if necessary Onset to Death
____ x
IMMEDIATE CAUSE ----- ---> a. S}p�_n "Y
(Final cilsease or condition Due to(or corfstquence of): 1
resulting In death) C �+as a`
b. .lam 1C Yt�G�
Sequentially g t Gond cruse Due to(o sequence of): j
if any,leading to the cause /n� con 1
Ilsted on line a. Enter the _ I C,r�L N
UNDERLYING CAUSE
W (disease or Injury that Due to(or as a consequence of):
F Initiated the events resulting d.
In death)LAST. - Due to(or as a consequence Of): j
t 26.Part 11. Enter otherRnificant conlitions 900tribmtIngto cleat but not resulting In the underlying cause given In Part I 27.Was an autopsyiper� mad?
0 Yes ® NO
- 26.Were autopsy findings-.liable
• to complete thecause of death?
29.If Female: 0 Yes 0 No
30.Did Tobacco Use Contribute to Death? 31.Manner of Death
0 Not pregnant within past year 0 0 Probably Natural Homicide
r O Pregnant
o gnant at time of death �lNo 0 Unknown EJ Accident 0 Pendia Invests
0 pregnant,but pregnant within 42 days of death 0 0 g gallon
0 Suicide 0 Could not be determined
0 Not pregnant,but pregnant 43 days to 1 year before death 32.Date of Injury(Mo/Day/Yr)(Spell Monih)
0 Unknown If pregnant within the Past year 33.Time of Injury
34.Place of Injury(e.g.home;construction site;farm;school) 35.Location of Injury(Street and Number,City,State,Zip Code)
b36.Injury at Work 37.If TransportatlOn Injury,Specify: 38.Describe How Injury Occurred:
0 Yes 0 Driver/Opera tar 0 Pedestrian -
0 No 0 Passenger 0 Other(Specify)
\�
39a.Certifier(Check only
Certifying Physician-To the best of my knowledge,death occurred due to the cause(.)and manner stated
Pronouncing&Certifying physician; the best of my knowledge,death occurred at the time,data,and place,and due to the cause($)and manner stated
Medical Examine r-On a bas of examination,and/or investigation,In my opinion,death occurred at the time,date,and place,and due to the-..(,)and/manner stated
Signature of certifier: Title of certifier: M. License Number:\`�"C••t�T��
39b.Na e,Address end Zip Cod of Person C pleb g Ca Ms cSp'FfbWSf9 W Medical Center, Hershey, Pa.17033 139C.Date Signed(Mo/Day/Yr)
40.Registrar's Olstrlct Number 41.Registrar's '��` 42.Registrar FileD toMo pay r
- !��[►iVt �1 QC( a01�
43.Amendments
0
DI.Oa.Itlon Parmit H1OS-143
-Noma
j�03�
POWER OF ATTORNEY AND
CONTINGENCY FEE AGREEMENT
I, Ronald Graham, as husband and the Executor of the Estate of Shirley Graham
the undersigned, hereinafter called "CLIENT(S)" hereby retain, appoint, and nominate
R.J. MARZELLA AND ASSOCIATES, P.C., its members and associates, hereinafter called
"ATTORNEY" to represent Client(s) as legal counsel for all purposes in connection with
the death of Shirley Graham.
CLIENTS) AND ATTORNEY HEREBY AGREE AS FOLLOWS:
1. INITIAL EVALUATION — Attorney will undertake an initial investigation
and evaluate the merits of this case. No attorney fee will be charged for
attorney work in connection with the evaluation. Client(s) shall provide in.
advance a retainer of$ 0 (ZERO) to be used for the purposes of paying
the costs associated with the initial investigation.
Attorney will review the pertinent records and will advise the Client(s)
concerning the probable merits of the case. If the initial evaluation of the
merits of the claim is favorable, Attorney will advance the costs of
prosecuting the case. These costs shall be repaid by Client(s) as specified
in paragraph 5 below.
Attorney reserves the right to terminate the agreement after the initial
evaluation if the case is determined not to have merit, at which time any
balance remaining in the trust account after payment of expenses shall be
returned to Client(s).
2. ATTORNEYS FEES — In payment for the services performed by the
Attorney, Client(s) hereby agrees that (40%) attorneys' fees shall be paid
to R.J. Marzella & Associates, P.C. from the total amount paid in either
settlement of the case or in a jury verdict, including any amounts due and
owing as delay damages.
In the event of a settlement in the form of a structured settlement, it is
agreed that attorney fees shall be paid according to the above terms based
on the cost of the structured settlement to the settling party(s). It is further
understood and agreed that the amount to be paid as the attorneys' fees on
the structured settlement shall be paid on a lump sum basis at the time the
structured settlement is entered into by the Client(s).
3. SETTLEMENT — NO settlement of this case shall be made without the
Client(s)prior approval.
1
4. DISTRIBUTION OF PROCEEDS — Client(s) further agrees that from the
proceeds of any recovery, whether by settlement,judgment or otherwise,
the attorney may deduct the attorneys' fees to which it is entitled, together
with all costs and expenses which have been advanced or remain unpaid;
and Client(s) further agree that the Attorney may deduct the amount of all
unpaid bills for professional services and make disbursements of such
funds directly to the creditors involved.
5. COST ADVANCE—Attorney shall have the authority to make advances and
to incur such costs as the Attorney determines necessary in the processing
of the client case. Such advances and costs include but are not limited to:
(a) Fees for physicians, psychologists, accountants and other experts
which attorney deems necessary to assist in handling of Clients'
case; and
(b) Copying charges, travel expenses, court costs, deposition expenses,
long distance telephone calls,postage.
In the event of a monetary recovery, Client(s) agrees to reimburse
Attorney for the above-referenced expenses incurred. After the attorneys'
fees are deducted from the settlement and/or verdict, the expenses shall be
repaid to R.J. Marzella& Associates, P.C. out of the remaining balance of
the settlement and/or verdict.
If Client(s) reject(s) a settlement offer that Attorney believes is reasonable
and equitable under the circumstances, Client(s) agree(s) to be responsible
for any and all out-of-pocket expenses incurred during the pursuit of their
claim, irrespective of a monetary recovery.
6. WITHDRAWAL — If, during the pursuit of this case, the Attorney
determines that, under the existing circumstances, it is not feasible or
practicable to prosecute this case, upon notification to the Client(s) of such
facts, the Attorney may withdraw from representation under this
agreement. Client(s) agree(s) to execute all documents and take all steps
requested by Attorney that are necessary to facilitate the withdraw of
representation.
7. APPEAL — If the Client(s) authorize(s) an appeal of this case, the
attorneys' fees shall be increased by 5% more than the fee set forth above
to cover the additional work involved in handling of the appeal.
8. FEE DIVISION — In the event that Client(s) was/were referred to R.J.
Marzella and Associates, P.C. by a referring attorney, Client(s) do(es) not
object to the division of the attorneys' fees charged to the Client(s)
between the Attorney and the referring attorney. Client(s) understand(s)
2
that they will not pay any additional fee as a result of the division of the
fee between Attorney and referring attorney.
9. TERMINATION OF AGREEMENT BY CLIENT — In the event that the
Client(s) seek(s) legal representation elsewhere regarding the incident
described herein and after the instant Fee Agreement is executed, Client(s)
agrees to immediately reimburse Attorney for all expenses incurred to
date. Moreover, for the work performed by the Attorney up to the date of
separation of Attorney and Client(s), Client(s) agree(s)that, in the event of
an ultimate monetary recovery, Attorney is entitled to reasonable
compensation(quantum merit) from any verdict or settlement.
10. ARBITRATION —Any dispute between the Attorney and the Client(s) shall
be resolved by arbitration. The arbitrators shall be members of the
Pennsylvania Bar Association. The Attorney shall select one arbitrator.
The Client(s) shall select one arbitrator. The two arbitrators shall select a
third arbitrator. The arbitrators shall, by majority vote, establish all rules
pertaining to the arbitration, including determining how the cost of
arbitration shall be paid. If the dispute is not resolved, the rules of the
American Arbitration Association in effect at the time shall apply and
control.
11. TERMINATION —This Agreement applies only to the Attorney's pursuit of
the claim specified above. This Agreement terminates upon the final
distribution of proceeds recovered on behalf of the Client through verdict,
settlement or otherwise, if not terminated before such time.
In the event Client(s) desire(s) additional services performed by Attorney,
whether related to the above-described incident or not, the fees and costs
to be charged by the Attorney in the event representation is undertaken, is
subject to other Agreement.
12. MAINTENANCE OF FILE—After this matter is concluded and the Attorney-
Client relationship is terminated for any reason, the Client(s) file will be
maintained for a period of four (4) years. During the time that the file is
being maintained, the Client(s) may obtain a copy of the file upon written
request, and agrees to pay a reasonable copying charge. After maintaining
the file for four (4) years, the-file may be destroyed within the Attorney's
discretion.
3
1, RONALD GRAHAM, AS THE HUSBAND AND EXECUTOR OF THE ESTATE OF SHIRLEY
GRAHAM, HAVE READ THE ABOVE AGREEMENT AND UNDERSTAND AND AGREE TO ITS
TERMS. THERE ARE NO OTHER AGREEMENTS BETWEEN THE PARTIES HERETO.
�1
THIS AGREEMENT IS ENTERED INTO THIS DAY OF ( hbeer— ,2012.
jv� --r-rL, p
RONALD GRAHAM ATE
�J��ELLA SO ES, P.C. DATE
R.J. MARZELLA& ASSOCIATES
4
��rti,d, �
12:59 PM R.J.MARZELLA, ESQUIRE AND ASSOCIATES,P.C.
06/18/14 Account QuickReport
Accrual Basis All Transactions
Type Date Num Name Memo Split Amount Balance
Client Prepaids
CWM'S
Graham,Est Shirley
Check 10/23/2012 20103 Cumberland Cou... est if Shirle... Bank(M&T) ... 79.50 79.50
Check 10/23/2012 20103 Register of Wills VOID: Bank(M&T) ... 0.00 79.50
Check 11/15/2012 20269 Katie Adam Bank(M&T)... 59.83 139.33
Check 11/15/2012 20292 Healthport 0117909693 Bank(M&T) ... 125.04 264.37
Check 11/30/2012 20317 Healthport 0118454584 Bank(M&T) ... 253.59 517.96
Check 06/16/2014 Lehman Mediatio... Bank(M&T) ... 360.00 877.96
Check 06/20/2014 Cumberland Law... Bank(M&T) ... 75.00 952.96
Check 06/20/2014 The Sentinel Bank(M&T) ... 192.00 1,144.96
Check 06/20/2014 Charles W.Marsar Parking Bank(M&T) ... 40.00 1,184.96
Check 06/20/2014 Cumberland Cou... Escrow Che... 103.75 1,288.71
Total Graham, Est.Shirley 1,288.71 1,288.71
Total CWM'S 1,288.71 1,288.71
Total Client Prepaids 1,288.71 1,288.71
TOTAL 1,288.71 1,288.71
Pagel
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pennsylvania
DEPARTMENT OF REVENUE
June 9, 2014
Charles W. Marsar, Jr., Esquire
Marzella&Associates
3513 N. Front Street
Harrisburg,PA 17110
Re: Estate of Shirley Graham
File Number 2112-1170
Court of Common Pleas Cumberland County
Dear Ms. Marzella:
The Department of Revenue has received the Petition for Approval of Settlement Claim to be
filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has
been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to
settle the actions.
Pursuant to the Petition,the 72 year old decedent died as a result of medical negligence.
Decedent is survived by her husband and children.
Please be advised that,based upon these facts and for inheritance tax purposes only,this
Department has no objection to the proposed allocation of the gross proceeds of this action,$250,000.00
to the wrongful death claim and$250,000.00 to the survival claim. Proceeds of a survival action are an
asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax.
42 Pa.C.S.A. §8302; 72 P.S. §9106, 9107. Costs and fees must be deducted in the same percentages as
the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995).
1 trust that this letter is a sufficient representation of the Department's position on this matter. As
the Department has no objections to the Petition, an attorney from the Department of Revenue will not be
attending any hearing regarding it. Please contact me if you or the Court has any questions or requires
anything additional from this Bureau.
Jerely,
hannon E.Baker
Trust Valuation Specialist
Inheritance Tax Division
Bureau of Individual Taxes PO Box 280601 1 Harrisburg, PA 17128 1 717.783.5824 1 shabaker@pa.gov
�Xti � 6� �
a
VERIFICATION
I, Ronald Graham, Executor of the Estate of Shirley Graham, hereby certify that
the following is correct:
The facts set forth in the foregoing Petition 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 is
that of counsel and not my own. I have the read the Petition, and to the extent that it is
based 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 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 are made subject to the
penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities.
Dated:
Ronald Graham
Executor of the Estate of Shirley Graham
ck � , 6, �
FULL AND FINAL GENERAL RELEASE
(SUBJECT TO CONFIDENTIALITY)
1. FOR AND IN CONSIDERATION of the sum of$500,000(Five Hundred
Thousand dollars and no cents) paid to the Undersigned and/or Releasors and his attorney(s),
receipt of which is hereby acknowledged, the Undersigned and/or Releasors do fully release
and discharge Carlisle Regional Medical Center,(including its affiliates,parent
corporations,insurers,trustees,members,successors, directors,officers,employees,
physicians, nurses,therapists, technicians,agents and servants),Sedgwick Claims
Management Services,Inc., Community Health Services,Bernadette Braze,D.O.,Carlisle
Medical Group, LLC,d/b/a Midstate Ear,Nose& Throat Center,Ruchi Dash,M.D.,
Juliusz Nitecki,M.D.,Hospitalists of Central Pennsylvania,P.C.,Timothy Horsky,D.O.,
Weatherby Locums, CompHealth Group,Inc.,CHG Healthcare Services,Inc.,CNA,
Continental Casualty Insurance Company,Donald Chapman,M.D.,Nicolau Dacosta-Neto,
M.D.,Todd Lupold,PA-C,Joey Wisner,PA-C,ApolloMD,Inc, PMSLC Insurance
Company and its parent company,Norcal Mutual Insurance Co.,Latoya Montfort,R.N.,
Medical Staffing Network Healthcare,LLC, Carlisle HMA LLC,t/d/b/a Carlisle Regional
Medical Center,Donn Polson, R.N.,Kathy Stuart,EMT—P,and Hershey Medical Center,
and,with respect to all of the foregoing, their respective insurers,corporate affiliates,
subsidiaries, directors,officers, stockholders, counsel,employees,agents,servants,executors,
heirs,administrators,successors, assigns, independent contractors,Third Party Administrators,
as well as any and all other persons,employers,employees, agents,consultants,governmental
entities, associations, subsidiaries, principals and corporations,whether or not named herein,
their heirs, executors, administrators, attorneys, successors, assigns and insurers, and their
respective agents, servants and employees, both known and unknown,whether named herein or
not, (hereafter referred to collectively as "Releasees"), of and from any or all causes of action,
claims, cross claims,joinders,liability, damages and demands of whatsoever kind, as well as
actions,causes of action,judgments, levies,executions,and suits at law or equity,on account of
all known and unknown injuries,losses and damages, whether manifest or not manifest,whether
now known or not now known, including death, sustained by Shirley Graham deceased,
individually, and/or by Ronald Graham, Individually and as the Executor of the Estate of
Shirley Graham, hereinafter"Releasor"and/or the"Undersigned",and specifically from,
but not limited to, any claims,causes of actions, suits or joinders, for sole liability,
contribution,indemnity or otherwise as a result of, arising from,or in any way connected with
any and all medical care and treatment rendered by the above named Releasees,or by any other
persons or entities,on account of which.The Potential Legal Action was instituted,or which
could have been instituted by the Undersigned and/or Releasor, as set forth in Exhibit"A"
hereto, consisting of the"Draft Complaint",(hereinafter"Tire Potential Legal Action").
2. All sums set forth herein constitute damages on account of physical injuries and
sickness,within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as
amended. The Undersigned and/or Releasor does understand,and agrees,that the acceptance
of said sum is in full accord and satisfaction of a disputed claim and that the payment of said sum
is not an admission of liability on the part of any of the Releasees as named above,nor on the
part of any of their respective employees, agents, staff, employees,or third party contractors. To
the contrary,any and all liability on the part of the aforesaid Releasees,their staff, their
respective employees, agents, or third party contractors, is specifically denied,with the
understanding that this Full and Final General Release is based solely on a business
accommodation, and the mutual desire to resolve disputes without resort to costly and lengthy
litigation.
3. It is expressly understood and agreed that this Fall and Final General Release is
intended to cover and does cover not only all injuries,losses and damages,including death,but also
any further injuries, losses and damages which arise from, or are related in any manner to the
Potential Legal Action noted above, or which were, or could have been brought as part of said
Potential Legal Action.
4. The Undersigned and/or Releasor, as well as his attorneys and agents, hereby
agree to satisfy any and all valid liens,including but not limited to Medicare liens, that have been
asserted and/or which could be or may in the future be asserted for reimbursement of any medical
benefits or other benefits of any kind provided to Shirley Graham,deceased by Releasees or by a
third party as'a result of the injuries claimed in or arising from,or which could have been claimed in,
The Potential Legal Action referenced herein. Further, without limiting the foregoing, the
Undersigned and/or Releasor shall satisfy,by way ofpayment,redaction,and/or compromise,any
and all Commonwealth of Pennsylvania Department of Public Welfare and/or Medicare and/or other
state or federal statutory liens and conditional payment demands,or valid liens ofprivate insurers or
benefit plans, that have been,or may be,asserted against the proceeds of this settlement.It is further
understood that,if applicable,the Undersigned and/or Releasor shall satisfy and otherwise comply
with any requirement for a Medicare Set-Aside and/or other statutory and/or regulatory provisions or
requirements regarding the protection of assets from these settlement proceeds for future medical
care and treatment,in accordance with the Medicare Lien procedures.Additionally,the Undersigned
and/or Releasor and his agent and attorney hereby agree, as a condition of this Release, to
indemnify and save forever harmless the Releasees herein from and against any and all claims,
demands or actions made against the Releasees by any person or entity on account of, or in any
manner related to medical care benefits received by Shirley Graham,deceased,including but not
limited to claims,demands and actions on account of SSI,SSD,Medicare,CMS,Public Assistance,
or other state or federal public or private insurance benefits and liens of whatever kind or nature,
allegedly arising from the injuries or damages claimed or which could have been claimed in the
Potential Legal Action noted above. Itis understood and agreed that Releasees are not Responsible
Reporting Entities for the purposes of the Medicare Secondary Payor Act,or other federal legislation
pertinent to Medicare reimbursement. It is further understood and agreed that Releasees are relying
upon the representations of Undersigned,and/or Releasor and his counsel,that all applicable liens,
whether state, federal, or private, or for past or future Medicare benefits, have been and will be
properly satisfied and remitted from the proceeds of this settlement. Failure on the part of Releasor
and/or Undersigned or his counsel to properly satisfy the aforesaid liens, which results in the
liability or exposure to liability on the part of Releasees or their agents,insurers and counsel,shall
require Undersigned and/or Releasor and his counsel to hold harmless Releasees, their agents,
counsel and insurers, from any such liability,and.to indemnify said Releasees,their agents,insurers
and counsel,from any liability therefore, including reasonable counsel fees and court costs.
5. it is represented by the Undersigned, or Releasor, that there is no Medicare lien
associated with any care and treatment rendered to Shirley Graham,deceased,on account of the
medical treatment and care she received by the Releasees herein,or by any other person or entity.
The Undersigned, or Releasor, herewith also represents that "Exhibit "B" hereto is a true and
correct copy of the"Final Lien Letter"of CMS/Medicare,indicating either that no liens are due and
owing,or that any such liens have been fully and completely satisfied. It is herewith understood by
the Undersigned and Releasors, that Releasees herein shall rely and have relied upon such
representations.
6. It is further represented by the Undersigned,or Releasor, that there is no other valid
or collectible lien upon the proceeds of this settlement other than the attached statement of private
lien payable to Trover Solutions, which lien has been marked paid and satisfied in full as per the
attachment,Exhibit"C"hereto.It is herewith understood by the Undersigned and Releasor,that
Releasees herein shall rely and have relied upon such representations.
7. In the event court approval is required for the settlement,compromise or
resolution of this claim as represented by this Full and Final General Release, then such
settlement is conditioned upon Undersigned or Releasor and his attorney promptly undertaking
any and all necessary action to obtain same.
8. If this settlement as represented by this Full and Final General Release is ever
determined by any.court to be without effect because some necessary court approval was not
obtained, or if the Releasees herein are subjected to further legal action or claim which would or
could not have been instituted or presented had proper court approval been timely obtained by
Undersigned or Releasor and his attorney,then Releasor and/or Undersigned will indemnify and
hold harmless the Releasees for any future loss, cost, or expense, including but not limited to,
reasonable attorney's fees for defending,litigating and settling any such claims or action,and for any
judgment resulting from any such claim or action.
9. It is further understood and agreed that this is the complete Full and Final General
Release, and that there are no written or oral understandings or agreements, directly or indirectly,
connected with this Release and settlement,that are not incorporated herein. This Release shall be
binding upon and inure to the successors, assigns, heirs, executors, administrators, and legal
representatives of the respective parties hereto.
10. It is further understood and agreed and made a part hereof that this Full and Final
General Release, and all its terms and conditions, is STRICTLY CONFIDENTIAL,and that
therefore, the Releasor and/or the Undersigned, his family,representatives,attorneys,
consultants, witnesses, and expert witnesses, shall not comment on, communicate with,disclose
or otherwise inform, either directly or indirectly, any person other than Releasees herein,with
respect to any aspect of The Legal Action, nor with respect to any aspect of the terms and
conditions of this Full and Final General Release. Without limiting the foregoing, it is further
understood that the Releasor and/or the Undersigned, his family,representatives,attorneys,
consultants,witnesses, and expert witnesses,shall not comment,communicate or otherwise
disclose,either directly or indirectly,any aspect of this Full and Final General Release, or any
terms and conditions thereof,to any news or communications media, including but not limited to
newspapers,magazines,journals,radio,television, internet, on-line websites or blogs,Twitter,
Face book,MySpace, Linkedln,or other on-line social media networking,or law-related
publications of any kind. If the Undersigned and/or Releasor,or his representative and/or
attorney are compelled by operation of law or Order of the Court of competent jurisdiction to file
any court document(s) identifying the terms and/or conditions of this Full and Final General
Release, then Undersigned and/or Releasor and his attorney shall request that the court
immediately seal such document(s)and take whatever reasonable steps are necessary to seek to
assure that such document(s)are not publicly accessible. This paragraph is intended to become a
substantive part of the consideration for the Full and Final General Release,and evidence of
violation of said terms of confidentiality herein shall be deemed to result in substantial breach
with resulting damages without need for further evidentiary proof of same.
11. THE UNDERSIGNED and/or RELEASOR HEREBY DECLARES that the terms
of this Full and Final General Release have been completely read and understood; that he has
discussed the terms and conditions with legal counsel of his choice; that said terms and conditions
are fully understood and voluntarily accepted for the purpose of making a full and final general
release and settlement of all claims for the express purpose of precluding forever any further or
additional suits arising out of or in any way related to The Potential Legal Action..
IN WITNESS WHEREOF,I have hereunto set my hand and seal this MAY day of
2014.
(SEAL)
RONALD GRAHAM,INDIVIDUALLY
AND AS EXECUTOR OF THE ESTATE OF
SHIRLEY GRAHAM,DECEASED
RELEASOR
20Y - 21�-: - / D
Social Security Number
SWORN to and subscribed before me this
1 Day of PZAJ,2014.
NOTARY PUBLIC
� �WE�ILTN OF PFNNS•' --i
I
NOTARIAL 8EAr<
Elio Jane DscosU,Notary PabK..
susquehanna Twp.,Dauphin Cow;,
My Commission Exptm Ap Il A 211
MEYU11-PENNSYMNIAA I..
R. J. MARZELLA & ASSOCIATES, P.C.
BY: Charles W. Marsar, Jr., Esq.
PA SUPREME COURT I.D. No. 86072
3513 North Front Street
Harrisburg, PA 17110
Telephone: (717) 234-7828
Facsimile: (717) 234-6883
Attorney for Ronald Graham,
Individually, and as Executor of
The Estate of Shirley Graham
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
RONALD GRAHAM, INDIVIDUALLY AND AS : DOCKET NO.
EXECUTOR OF THE ESTATE OF SHIRLEY •
GRAHAM
V.
cv/Zani'-i
rS&OE (11J
PLAINTIFF, PROFESSIONAL MEDICAL
NEGLIGENCE
TIMOTHY HORSKY, D.O.;
WEATHERBY LOCUMS, INC.;
DONALD CHAPMAN, M.D.;
NICOLAU DACOSTA-NETO, M.D.;
TODD LUPOLD, PA -C;
JOEY WISNER, PA -C;
APOLLOMD, INC.;
RUCHI DASH, M.D.;
JULIUSZ NITECKI, M.D.;
HOSPITALISTS OF CENTRAL
PENNSYLVANIA, P.C.;
LATOYA MONTFORT, R.N.
MEDICAL STAFFING NETWORK
HEALTHCARE, LLC;
BERNADETTE BRAZE, D.O.;
CARLISLE HMA PHYSICIAN
MANAGEMENT, LLC , T/D/B/A MIDSTATE
EAR, NOSE AND THROAT CENTER;
CARLISLE HMA LLC, T/D/B/A
CARLISLE REGIONAL MEDICAL CENTER;
DONN POLSON, RN;
•
KATHY STUART, EMT -P; AND
HERSHEY MEDICAL CENTER
DEFENDANTS
JURY TRIAL DEMANDED
AND NOW, this
day o,
ORDER
014, upon consideration of the attached Petition
for Court Approval of Settlement of Survival Action and Apportionment of Settlement
with Wrongful Death Action,
IT IS HEREBY ORDERED THAT:
1) Settlement of this matter in accordance with the terms of the Petition is hereby
approved.
2) The distribution of the $500,000 settlement shall be allocated as follows:
Wrongful Death Claim
Gross -$250,000.00
Atty fees- $100,000
Expenses- $644.35
Net = $149,355.65
Survival Claim
Gross- $250,000.00
Atty fees- $100,000
Expenses- $644.35
HighMark lien -$25,683.84
Medicare lien- $5,102.34
Net = $ 118,569.47
3) Petitioner is authorized to execute all necessary relea
J.
Thomas A. Placey
Common Pleas Judge
Distribution Sheet:
Charles W. Marsar, Jr., Esq.
R.J. Marzella & Associates
3513 N. Front Street
Harrisburg, PA 17110
ARC LEVIN, ESQ.
WEBER GALLAGHER
FULTON BANK BUILDING
200 NORTH 3'D STREET
SUITE 9A
HARRISBURG, PA 17101
-uart T. O'Neal, Esq.
Burns White
100 Four Falls, Suite 515
1001 Conshohocken, PA 19428
-Cindy Ellis, Esq.
Foulkrod Ellis
4000 Market Street
Camp Hill, PA 17011
Cop l'Es P/L.i'LL__
tOtarip ti
./Shaun Mumford, Esq.
Stevens & Lee
51 South Duke Street
Lancaster, PA 17602
-ter Samson, Esq.
Cipriani & Werner
450 Sentry Parkway, Suite 200
Blue Bell, PA 19422
Thn Stepanian, Esq.
McQuaide Blasko
1249 Cocoa Avenue
Suite 210
Hershey, PA 17033
-omi Plakins
Plakins & Associates, P.C.
140 East State Street
Doylestown, PA 18901
R. J. MARZELLA & ASSOCIATES, P.C.
BY: Charles W. Marsar, Jr., Esq.
PA SUPREME COURT I.D. No. 86702
3513 North Front Street
Harrisburg, PA 17110
Telephone: (717) 234-7828
Attorney for Ronald Graham,
Individually, and as Executor of
The Estate of Shirley Graham
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
RONALD GRAHAM, INDIVIDUALLY AND AS : DOCKET NO.14-3693
EXECUTOR OF THE ESTATE OF SHIRLEY •
GRAHAM
PLAINTIFF, PROFESSIONAL MEDICAL
NEGLIGENCE
V.
TIMOTHY HORSKY, D.O.;
WEATHERBY LOCUMS, INC.;
DONALD CHAPMAN, M.D.;
NICOLAU DACOSTA-NETO, M.D.;
TODD LUPOLD, PA -C;
JOEY WISNER, PA -C;
APOLLOMD, INC.;
RUCHI DASH, M.D.;
JULIUSZ NITECKI, M.D.;
HOSPITALISTS OF CENTRAL
PENNSYLVANIA, P.C.;
LATOYA MONTFORT, R.N.
MEDICAL STAFFING NETWORK
HEALTHCARE, LLC;
BERNADETTE BRAZE, D.O.;
CARLISLE HMA PHYSICIAN
MANAGEMENT, LLC , T/D/B/A MIDSTATE
EAR, NOSE AND THROAT CENTER;
CARLISLE HMA LLC, T/D/B/A
CARLISLE REGIONAL MEDICAL CENTER;
DONN POLSON, RN;
KATHY STUART, EMT -P; AND
HERSHEY MEDICAL CENTER
DEFENDANTS JURY TRIAL DEMANDED
7;7 CD
PRAECIPE TO DISCONTINUE PURSUANT TO PA. R.C.P. 229
TO THE PROTHONOTARY, CUMBERLAND COUNTY:
Please mark the above -referenced action settled and discontinued.
Dated: I L 13 jrl
Respectful. -.. mi ed,
R. J. ! . rzel la & Ass 0 ciates, P.C.
y' A►k _.1`i�
arles W. M
Sup e Cou
Es
I.D. No. 8
ire
072
CERTIFICATE OF SERVICE
I, Enjoli Neely, hereby certify that a true and correct copy of the foregoing
document was served upon counsel of record this 3rd day of November, 2014, by
depositing said copy in the United States Mail at Harrisburg, Pennsylvania, postage
prepaid, first class delivery, and addressed as follows:
Marc Levin, Esq.
Weber Gallagher
Fulton Bank Building
200 North 3rd Street
Suite 9A
Harrisburg, PA 17101
(Atty for CRMC)
Stuart T. O'Neal, Esq.
Burns White
100 Four Falls, Suite 515
1001 Conshohocken, PA 19428
(Atty for Monfort)
Cindy Ellis, Esq.
Foulkrod Ellis
4000 Market Street
Camp Hill, PA 17011
(Atty for Chapman, DaCosta, and Lupold, Wisner)
Shaun Mumford, Esq.
Stevens & Lee
51 South Duke Street
Lancaster, PA 17602
(Atty for Dash & Nitecki)
Peter Samson, Esq.
Cipriani & Werner
450 Sentry Parkway, Suite 200
Blue Bell, PA 19422
(Atty for Horsky)
John Stepanian, Esq.
McQuaide Blasko
1249 Cocoa Avenue
Suite 210
Hershey, PA 17033
(Atty for HMC)
Naomi Plakins
Plakins & Associates, P.C.
140 East State Street
Doylestown, PA 18901
(Atty for Braze)
R. J. MARZELLA & ASSOCIATES, P.C.
BY: t/yduo,-)6__
ENJOLI NEELY, PARALEGAL