HomeMy WebLinkAbout08-12-14 IN THE COURT OF CON�ION PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA �,�
C� °�-',
Co -`� -,-,�
�� �, r:_s:., C_�
��� � �
IN RE: Estate of . Orphans Court ��=' � � �=
' '��
Heather Marie Coble, Deceased . No. 2013 - 210 ��j- rv =_c.; ;.� ;
. Register of Wills File #��-0021-.� _
�
Or�__ . _ --���
:� N ;'''::-�n
a � �,,, C•��
PETITION FOR COURT APPROVAL OF SETTLEMENT OF A DEATH -- �'�'
CASE INCLUDING WRONGFUL DEATH AND SURVIVAL ACTION CLAIMS
l.
The Petitioner is Michelle Hudson, an adult individual who resides
at 11 North Washington Street, Apartment 2, Shippensburg, PA 17257 .
2.
On February 21, 2013, the Register of Wills of Cumberland County,
Pennsylvania granted Letters of Administration of the estate of Heather
Marie Coble, who died December 31, 2012, to the Petitioner, who was the
mother of the Decedent. Attached hereto and marked "Exhibit A" is a
true copy of the Short Certificate issued by the Register of Wills.
3.
The Petitioner' s Decedent was pronounced dead at the Chambersburg
Hospital, at 1: 01 a.m. , on December 31, 2012, as the result of injuries
sustained in a motor vehicle collision which occurred about 12 :16 a.m.
on December 31, 2012 at the intersection of McKinley Street and
Cleveland Avenue in Chambersburg, Franklin County, Pennsylvania.
Attached hereto and marked "Exhibit B," is a true copy of the
Certificate of Death of the Petitioner' s Decedent.
4 .
At the time of the said motor vehicle collision, the Petitioner' s
Decedent, Heather Marie Coble, was riding in the front passenger seat of
an automobile which she owned which was being driven by Nicholas
Fortenberry. A third occupant of the Decedent' s vehicle was Madison
Perry.
5.
The said motor vehicle collision occurred when the 1998 Ford
Expedition owned by Gerardo Garcia and operated by Agustin Macias-
Marquez, which was headed north on Cleveland Avenue, proceeded through
the stop sign at the intersection of Cleveland Avenue and McKinley
Street and smashed into the passenger side of the Decedent' s vehicle,
which was proceeding east on McKinley Street through the intersection
and which had the right-of-way. Attached hereto and marked "Exhibit C,"
is a true copy of the initial Police Crash Report from the said motor
vehicle collision.
6.
As a result of the said motor vehicle collision, the said Agustin
Macias-Marquez was prosecuted at Franklin County, Pennsylvania Criminal
Action No. 282 of 2013, and entered a guilty plea to Homicide By Motor
Vehicle While Driving Under the Influence, receiving a prison sentence
of 42 months to 84 months at a State Correctional Institution.
�.
The Petitioner is advised, through counsel, that the other
passenger in her vehicle, Madison Perry, was hospitalized until January
10, 2013, when he died as a result of injuries sustained in the said
motor vehicle collision.
8 .
Attached hereto and marked "Exhibit D" is a letter dated May 8,
2014, from counsel for the said Nicholas Fortenberry summarizing his
severe injuries and substantial losses sustained in the said motor
vehicle collision.
9.
It is the Petitioner' s understanding that the only liability
insurance coverage available for the claims of her Decedent' s estate and
survivors, the estate and survivors of Madison Perry, and Nicholas
Fortenberry is a per accident limit of $100, 000.00 through coverage with
Travelers Personal Security Insurance Company which had been purchased
by the said Gerardo Garcia, owner of the vehicle which Agustin Macias-
Marquez was driving at the time of the collision.
10.
The said per accident $100, 000.00 limit of liability insurance
coverage has been offered by Travelers Personal Security Insurance
Company in settlement of all claims of the estates and survivors of
Heather Coble and Madison Perry, and of Nicholas Fortenberry. See the
letter from Michael V. Farrell dated August 16, 2013, with attachment,
true copy of which is attached hereto and marked "Exhibit E. "
11 .
The Petitioner' s Decedent was unmarried and is survived by two
children, Taylor Marie Brown, born November 20, 2007, and Tabitha May
Brown, born December 30, 2008 . The children reside with their father,
Gregory Brown, at 1700 Orchard Road, Chambersburg, PA 17201 .
12 .
The Petitioner is advised, through counsel, that the said Madison
Perry is survived by a minor child.
13.
The Petitioner, on behalf of the estate and survivors of her
Decedent, the estate and survivors of the said Madison Perry, and the
said Nicholas Fortenberry have tentatively agreed to an equal division
of the $100, 000. 00 in insurance coverage which has been tendered, with
one third of that amount allocated to the estate and survivors of each
Decedent, and one third allocated to Mr. Fortenberry, subject to Court
approval of the settlements of each of the death cases .
14.
The Petitioner believes that settlement of the claims of the
estate and survivors of her Decedent in exchange for the proposed one
third allocation of the $100, 000.00 in available liability insurance
proceeds is in the best interest of the said estate and survivors.
15.
The Petitioner is aware of no lien on behalf of Medicare, the
Department of Public Welfare, an ERISA plan, child support agency or
other entity.
16.
The Petitioner has entered into a Retainer Agreement with the law
firm of Keller, Keller and Beck, LLC, for representation in the
liability claims of the estate and survivors of her said Decedent which
would entitle the said law firm to a 25 percent contingent fee from
settlement proceeds obtained prior to the institution of suit. A true
copy of the said Retainer Agreement is attached hereto and marked
"Exhibit F." The Petitioner believes that a contingent fee under the
said agreement of $8, 333.33 is reasonable.
17 .
In addition to representation on the said liability claim, the
said law firm has represented the Petitioner in administration of the
estate of her said Decedent for no additional charge.
18 .
The said law firm has advanced $123.50 in payment of the fees of
the Cumberland County Register of Wills for opening the estate of the
Petitioner' s Decedent and filing this Petition, and, pursuant to the
said Retainer Agreement, the law firm is entitled to reimbursement of
such expense.
19.
The Wrongful Death Act damages recoverable in this case because of
the Petitioner' s Decedent' s death include funeral and related expenses
totaling $6, 325.10, ambulance and hospital bills incurred for the
Decedent following the motor vehicle accident, and the losses of the
Decedent' s above-named minor children of support and contributions from
their mother as well as the services, society and comfort they would
have received from their mother. See Pennsylvania Suggested Standard
Civil Jury Instructions 7.220 and citations thereunder.
20.
The Petitioner suggests that, as her Decedent' s said minor
children are the survivors entitled to Wrongful Death Act recovery as
well as her intestate heirs, given the small recovery under the
settlement proposed herein in relation to the actual losses of the said
minor children, it would be appropriate for the entire net proceeds of
the settlement proposed herein to be allocated to the wrongful death
recovery as opposed to the Decedent' s estate.
21.
Attached hereto and marked "Exhibit G" is a true copy of the
letter dated July 8, 2014, from a representative of the Pennsylvania
Department of Revenue, Inheritance Tax Division, noting that the
Department has no objection to the proposed allocation of all net
proceeds to the wrongful death claim.
22 .
The Petitioner proposes that, after payment of attorney fee,
expenses and the aforementioned funeral bill, the net remaining proceeds
be divided equally for the benefit of the Decedent' s two minor children
and that such proceeds be paid to their father, the said Gregory Brown,
for deposit for the benefit of each child in a federally insured account
or certificate of deposit until such child reaches the age of 18 .
23.
Attached hereto is an acknowledgement executed by the said Gregory
Brown of his notice and receipt of a copy of this Petition.
24 .
This petition is filed as an Orphans Court matter for the reason
that no civil action has yet been filed in regard to the aforementioned
wrongful death and survival action claims.
WHEREFORE, the Petitioner, Michelle Hudson, respectfully requests
that Your Honorable Court enter an Order authorizing her to execute an
appropriate release on behalf of the estate and survivors of Heather
Marie Coble in exchange for payment in the amount of $33, 333.33, and,
further, authorizing her to make payment from the said proceeds as set
forth in the proposed Order of Court attached hereto.
KELLER, KELLER AND BECK, LLC
By
Joh . el er
P Supreme Ct. I .D. #25577
343-B South Potomac Street
Waynesboro, PA 17268
(717) 762-3331
Attorney for Petitioner
Michelle Hudson, Administratrix
of the Estate of
Heather Marie Coble, Deceased
ACKNOWLEDGMENT
I, Gregory Brown, verify that I am the father of Taylor Marie Brown,
born November 20, 2007, and Tabitha May Brown, born December 30, 2008, the
minor children of Heather Marie Coble, deceased; that the said children
reside with me at 1700 Orchard Road, Chambersburg, PA 17201; and that I have
received a copy of and reviewed the foregoing Petition for Court Approval of
settlement of the claims of the estate and survivors of Heather Marie Coble.
Date: � �� �y
Greg r Brown
I verify that the facts set forth in the foregoing Petition are
true and correct to the best of my knowledge, information and belief. I
understand that false statements herein are made subject to the
penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification
to authorities.
Date:
M' c�lle Hudson, Administra rix f
The Estate of Heather Marie Coble
MAR-04-2013 04' 19 PM Keller Keller Beck LLC 7177621810 P, 4/ 4
COM1VIt}NWEAl.TH �F P�NNSYLVANfA SHORT GERT'I�l�ATE
C�UNTY OF CUtUIBEF�LAND
z, GLENDA FARNER STRASBAUGH
Register for the Probate of Wil�s and Grazzting
Le�ters of Adminjs�ration in arzd fo.x-
CUM.�ERLA.ND Coun�y, do hexeby ce.r�ify that o,n
the 2�.�� day �f February, Two Tlzpusand and
Th�r�een,
. Letters of ADMINISTRA170N
zn comm�n form were g�-az��ed by the Rega:�t�r of
sa3.d Ca�.u�.ty, on the
es�ate af HEATHER MARIE COBLE , �at� of SHIPPENSBUR� BDRDUGH
I��L Mlddle,Lesr/
.in said county, deceased, to MICHELLEHUDSQN
r��t M;6ene.lasu
a�,d that sam� ha,s not since been r�voked.
IN 7'ESTIMONY WHER�'OF, I hav� hereunto �et my hand and affi��d the
s eaI af sai d Qfr"i ce a t CARLTSL�, PENNSYLU.�IV2A, thi s 21 s t day' of �ebr'r�arY
Two Thausand and �'hirte��.
Fzl� ,�'o. 2073- 00210
PA Fi3.e No. �1- �3- D2��
Da�� of Death 12/37/2012
S.S. #
�� �
e9r�t6r
r r
� —V
B��
NOT V'ALTD WITHOLT�' ORIG��T.�iL S�'GNAT"+.1�E AR7D IMPRESSED SFAL �
EXHIBIT A
�....�;_�.�«_. :�,,;,.
�'� � � � _�, _ -"
br_S�xc^'� b ......_ � �rc� s c.L- � . �. � , �... . ." _ _ _ ' _ _' .. .._ .. . , "._ _ . t.
tT... _..,_,� ...v. ... . ,'�`� ..'�: �.... ... .._t ..._ ,. . , � . �..� .. . �, i_ .. ...
r'L�l. Lt�i tif ,. ..�..�.l�il_u._ ,Sl.��:jJ � �..... . , _�.-_ ._ .._ .. � '". Y ._. .J ..,.: "_, _
- ! - �r ' , .__ . ..__ . .. ��_ . ..__'` :.'j.
.��`�� . "- _.. _ �. .,. . �.." ..__... �' -,!- ..� i ..
c_ _` .,� �_ - -.. ., .. 1 \ _ . .... _ �.':.,.. .,,.
- .. 'r; .._ C�. „ �. �
r ,w� - �.
P 1 9a6 �52 � _ �4 �' .
-. �� .��:�� - - --� - -- -�G`��> 'G'-�,; '�`/,;
��,[1fiC31 �,� .�:U:li�� ' �---' _.._ _..,�... L�.� .`,:c�i:::'�t
Type/Print In . COMMONWEALTH OF PENNSYLVANIA�DEPARTMENT OF HEALTH�VffAL RECOROS
PertTa^�^T CERTIFICATE OF �EATH
Black Ink Sta[e File N�mber:
1.DecCEenY's Legal Name(Fi�st,Mitltlle,Las[,St�Nx) 2.Sex 3.Social Securi[y Numbcr 4.Da[e of DeaLh(MO/Day/Yr)(Spell Mo)
Heather Marie COBLE Female 237-59-7971 �ecember 3'I,20'12
Sa.Age-lart Birtf+day(Vrs) Sb.Unticr 1 Year Sc.Untler 1 Da 6.Date o�Blrth(MO/Day/Year)(Spell Manth) 7a.Birthplace(Ciry and Sxace or Forelgn Covncry)
MonthS Days Hou�s Minvte5 Burlington,NC
Z5 October'1,�987 �b.BirtM1place(cou.,cv) Alamance
Sa.Resttlence(Siate or Foreign Councry) 8b.0.esidence(Street and N�mber-Include Apt No.J 8c.Ditl Decedenc Live in a Township7
P'O` , 46�/2 West King Street �Yes,tlecetlent ilved In m.p.
8d.Resld<�+ce(COUnry)
Cumberland ee.aesmmce(2iv Goae) y7257 �[NO,decedenC IIveC wlc�in Iimlts of Shippensburg cicy/eoro.
9.Ever in US Arrn<A Forces? 10.Marital StaY�as at Tme of Deaih �Married � Witlowetl 11.Surviving Spouse's Name(If wlfe,give name prior So firsc marria6e)
�Yes ]�No 0 Unknown �Div c�d �Ncve�M rrletl 0 Unknow
12-Failier's Name(FIrsT,Mitltlle,Last,S�fflx) 0 13.Moth��s Name PrlO�to Flrst Ma�Hage(Flrs[,Mitltlle,Las[)
Tommy Lee Coble � Michel�e R Youngblood
14a.Informan2's Name P.6b.Relationship to Decedent 1AC Informani'S Mafling Atldress(Stree2 and Number,Ciry,SUie.Zip CotleJ
0
Michelle Hudson E Mother 'I'1 N.Washington St.,Apt.2 Shippensburg PA�7257
G isa.Pi,«or oeazn cn«k o.,i
""..."""'_...."""_'...""'_"""""......."�+,'..........._""""_......."_""""•"""'_""_"'_"'........_."'.._."""""Y.o..e... ....... . . .. w5
c If Death Occvmed in a Hasplsal: u Inpatieni .�f Death Occume0 Somewhere OCher Than a Hospical: [�HoSpice Facllity y Decetlent's Home
Emergency Room/O�tpaitent n Deatl on Arrlval O Nurs(ng Home/Leng-Term Care FaciliN Q Other(Specify)
15b.Faciliry Name(If not instf2�slon,give strcet and numberJ 15c.Clry or Tvwn,5[a[e,antl Zlp Cotle 15tl.Co�nry of DeaiM1
CFiambersburg Nospital Chambersburg, PA�7201 Franklin
y16a.Meihotl of Disposition Q Burial � Cremaiion 16b.DaCe of Dispozltion S6c Place of Disposltion(Name of ceme2ery,crematory,or oeher place)
m [7 nemo..ai from sxaee O oo.,a�on Hoilin er Cremato
p ocner(spcdry7 January 4,20'13 9 rY
� 16tl.Location o`Disposiiion(Ciry or Town,SiaYe,antl Zip) 17a�Signature of F�n �al e li o Person In Charge of Intermerrt 17b.License Number
Mt.Holly Springs,PA'I7065 FD-O'14351-L
0 17e.Name snd CompleCe Address of Funeral Fadlity �
Fogelsanger-6ricker Funeral Home'1'12 W King St.PO Box 336,Shippensburg,PA'17257
18.DecedenS's Etlucaiion-Ctieck che box tha:besc tlesc�(bes 2fie 19.Decedeni af Nispanic Orig"�n-CM1CCIC the ZO.Decetlent s Race-Check ONE OR MORE races to intlipte wha:
� M1lgfieY.degree or Ievei of schooi completed at the time of death. box thac best Eeseribes whether She tleceEent the tlecedenc consltleretl i+imself or herself io be.
Q StM1 grade or less �s SpanlSh/Nispanlc/La2ino. CFieck[he"NO" }�(WhYfe [] Korean
� No tliplama,9LM1-12th gratl[ box if tleceden[Is nof SPanish/Hispanlc/Latino. 0 Black or African AmeNCan �Vfernamese
]$Hlgh scM1OOI graduaie or GEO completeE j�No,not Spanlsh/Hlspanl4laci�e �Amerlan Intllan or Aiaska Naiive � Oth�er Asian
[] Some college cretlit,bui no degree O Y�s,M�xlcan,Meslcan Ame�ican,Chicano []Aslan Indian � Native Hawatlan
p ASSOCIat!Ceg�eG(e.g-AA.PS) O Yes P�aeKO Rion Q Chinese �f Guamanidn O�CM1dmvrrv
Q Bachelo�5 tllgrG¢(e.g.BA,A8,BS) O Yes,C�ban n Fllipino Q Samoan
Q Master's d�gRe(e.g.MA,M5,MEng,MEd,MSW,MBA) 0 VGS,oCherSpanfsh/HlSpanicJLatino �Jdp3n¢5¢ � Other Pacifc ISlande�
� �ocCOraie(e.g.PhD,Etl0)or Crofesslonal degree (Specify) �Oiher(SpecHy)
.M�,005.DVM LLB,JD
21.Decedent's 5ingle Race Sel`-Deslgnatlon-CM1eck ONLY ONE So indicace whattM1e decedent cor�sitlered himself or herself�to be. 22z.Decetleni's Usual Occupaiion-Intlicate iype ot work
�White []Japanese []Samoan tlone tluring mosc of work�ng Ilte. �O NOT USE RETiRED.
. []Bleck or Afrlan Amer�can 0 Korean �Ochvr Paciflc Islander _ CIe�fC
[]Ame�ican Indlan o�Alaska Nafive . �VI¢inamese O �on'i Know/NOC S�re �
•.. �Aslan Intlian - �OSheF Aslan L]0.efusetl 22b.Kintl of Business/Indusiry
� Chinese O NaHve Hawal(an O Oiher(SpeGfy)
C �Ffllpin0 O Guamanlan o�Chamvrro C01lVE1lleIlCE S20f2
TEMS 23a-23d MUST BE COMPLETEO 23a.Dace PrvnaunceC Deatl(MO/�ay/Yr) 23b.Signature of Person Pronouncing Deafh(Only when applioble) 23c License Number
BY PER50N WHO�RONOUNCES OR
C£ftT Fi E$OE.4TN
23tl.Dace Signed(MO/�ay/Yr) 2a.Time of Death `
�:O'I AM ss.wai nneaica�Exa..,�ne�o.eo�oner concaaea? $ ves p
CAUSE OF DEATH qpprox(mate
26.Part I. Enier The chain of evenL-dlseases,InJurles,o mo��cailons-that tlirectly causetl the deafh. DO NOT enier tertninal e e�LZ such as cardlac arrest. Interval:
resp�raCOry arreR,or venR�c�lar flbrlllatlon wlil+o�[showlnE th�cilology. DO NOT ABBREVIATE. EnCCr on�y one cause on a ilne.Atltl atltlliionei iln�s If necessary : Onsecio D�aLh
IMMEDIATE CAUSE > a Muitiple Blunt Force Injuries ? 45 min
(Final disease or contllelon . O�e So(or as a consequence aT]:
resurcn,g ir,aeach) . ' UnresTrainetl Ri ht Front Passen er of Siruck Vehicle
- b. 9 9
Seqveniialiy Ilrt tontliilons, _ D�e 20(or as a consequence o�: �
If a'+y,IeadlnE eo xhc eatisc -
nsced o.,u.,e a. encer xne c Vehicle Struck in Right Side
VN�EfiLY1NG CP.VSE � D�e io(or as a conseqvence o�:
(tllsease or InJury Lhat � �� � '
� Inlilated[he e�enss res�lcing d. a a cvnsequcnce
in tleaihJ LAST. - Dve co(or s of):
s26.Part II- Encer oLher I nlfl n 1 I n n rl ih but not resuiLing In cM1e untlerlying cevse glven In Part I 27.Was en ausopsy performed]
- Y¢s O No
� Est:'I'I week gestation Fetal Demise 28.�/�/ere a�iopsy flntlings avatlable
m so eon,e�ece sne c of aearn7
vez a o�
29.It Femal¢: 30.Ditl Tobacco Use ContFlbvte to Dcath7 31.Manner ot Death
E � Notpregnant�+IChlnpastyear Q Yes O Probably �Naiural � Momiclde
�(Pregnant at time of dcach �No � Unknvwn � �$(Accitlen! � Pentling InvesTigatlon
m �Nox preg�+an[,b�t preR^ant within a1 tlays of deatY �S�ICitic � Co�ld no[be decermined
� Not pregnan[,bv[pregnant a3 tlays to 1 year before tleach 32.Date of In)ury(MO/Day/Yr)�Spcll Month)
� V nknown 1/pregnan2 wlthln ihe pasi year 33.Tlmevf In)�ry
December 3'I,2012 Approximatel �2:'I5 AM
3a.Place ot InJvry(e.g.�+ome;constr�ctlon slte;farm;school) 35.LocaSlon ot InJury(5treet onE Nvmbcr,Clty,Sie(e,Zip CoEe)
Street Intersection of E McKlnley St H.Cle�eland Ave,Horo oT Chambersburg,PA'172D
36.In)vry atWOrk 37.IfTransportailon InJ�ry,Specity: 38.Descrlbe How Injury Occvrted:
p ves p Dri..e�/Oac�acor [] Pedesa�a., Unrestrainetl Right Front Passenger of Struck Vehicle
i1J �No �Passenger .Q O[her($peClTy)
� 39a.Certifier(Check only o�e): �
U Q Certlfying physlclan-Ta th¢besi of my knowledg¢,tleeth occvrretl tl�e to the ca�se(s)wntl manner stated
�Pmno�ncing 8.CertIN��+6 PhYSiclan-TO ihe best of my kno�✓�etlge,dea[h occ�rretl et the T�me,tlate,antl place,antl tlue to the cause(s7 nnd manner s2aietl
${Metlical Examin¢r/COroner-On She besls o/f�examinetlon,antl/or Inves[Igaclo�,in my vpinlon,tleath occvrretl ac the time,da<e,entl place,and tl�e�o tM1e cavse(s)antl menner scateE
Signatvre of certlfl¢�:�7 y��� �(� Tiiie of�e.cinen Coroner Lfcense N�mber:
39b.Nam¢,Adtlress antl 21p Cotle of Verson Completing Uus of Dea[h(Item 2GJ 39c.Oate Slgnetl(MO/Day/YrJ
= Mr.Jeffrey R Conner '1497 Loutlon Road,Chambersburg,PA'17202 January 2,20'13
� a0.Regisfrer's Distric[N�mber 41.Registrar's t�re 42.ReglsSrar File Oate(MO/Day/Yr)
v� - %� "` ..� d 3 ��i
43.AmentlmenCs
�
= EXHIBIT B
08 i 8889 H ios-iaa
DISPO5121on Permit No.___.__ -. REV O7/2011
� � Print CRS W0322637 Page 1 of 8
� �LJ�O�.SL�9��PO T�WG F06tRfl�4iU8A I IIIIII)II�,(IIII IIII IIII Crash wumber �
Case Closed Reportable Crash Page
� W0322637
AA 500 1 0 Yes �No �Yes Q No
Incident Plumber � J Police Agency PaYrol Zone
� 2012-13720 28401 �
� Agency Plame Prednd investigation Oate(MM-DD-YYW)
g Chambersburg 12 = 31 � 2012
� � Dispa4ch Time(mil) Arrival Time(mi!) Investiga4or Badge Plumber
g 0018 0019 PTLM IAN ARMSTRONG 269
� Reviewer Badge Plumber dpproval Date (MM-DD-YWI�
MATTHEW T CODY SGT 01 = 08 = 2013
Coun4y County Wame RRunicipali4y Rflunicipali4y Wame A�y o0 bbeek
a 28 Franklin 401 hambersburg Borough O sun O Tt,u
� � Mon Q Fri �
2 � Crash Da4e(MM-DD-YYYY) Cresh Time(mil} Wo of Units People Injured Kiiled' 'If>00 I
w complete �Tue Q Sat
� 12 = 31 � 2012 0016 2� � � � po�p �y�ed Q unk j
(If Yes,Complete School Bus Schooi Zone Mo4ify PEAIP]DOT
1flfo�tczone�rm M,Section Z9)�Yes A No Related �Yes o No Related �Yes � No �aintenance 0 Yes � No
g Utersection Tvne Multi-Leg : �
A !4 Way intersection � 'Y" Intersection � �Off Ramp Q Railroad Crossing �REfl21
3 r, Intersect�on �„� �0
�Midblock Traffic Circlel
� Q 'T' Intersection � Round About �On Ramp Q Crossover �Other �
�em CDvevB�
Rou4e Numher Segment(Optional) Travel Lanes Speed Limit House Wumber (if a�
0 North
� � � 02 35 m i._
� South
StFee4 Plame S4reet Ending � • East For Mid-block crashez only.Use
4 � d � y�eSY postal House Numbe�and make sure
g MCKINLEY ST � Q Unknown {Iled'Pn�if usinwthis��t Name is
g option
� � O Interstate � 0 7urnpike O Turnpike O Sta!e O County � Local Road Q Prfvate O Othed
(Not Tumpike) (EasUWesU Spur Highway Road or SVeet Road Unknown
� Route Plumber Segment(Optional) Trovel Lanes Speed Limit . North
� � C� � 02 35 .� p South
� S4reet Pdame Street Ending � 0 Eazt
° � � CLEVELAND AV � � W�-
s � 0 Unknown
:
g � SrBgn n° 0 Interstace Q Turnpike 0 Tumpike � State � County � Local Road � Private 0 Othed
_ w (Not Turnpike) {EasVWest) Spur Highway Road or Street Road Unknown
�
^Intersecting Rt Ftum Or RAile Post Or Segment f1Aarlcer
� s� 4 � �.❑ � � m Q South Feet
� S Please � Or IMersec4ing Street P1ame St Ending ��Ea� Or Wiiles
� Enter � � ��W�
e Inforrnation Q �.� '
e � m for BOTH .
� a Landmarks Intersecting R4 idum Or Mile Post Or Segment RAartcer !
� g if Using N °O North Distance From Crash
g � This Opt�on � � �.❑ � � Scene to tandmark 1
H�South
� x � Or Intersecting Street Wame St Ending� {FOr Crash befween
A � � �East Landmark 1 and
.9 ��O west ►�ndmark 2)
Degrees MinuYes Seconds Degrees Wiinu4es Seconds
� � Latitude:� �'�•� tonqitude: — � �°�•�
TrafOic Conero/Device Police Officer or �Fm�cfl°^r^°
�Yie1d Sign 0 Emer en
e u �Not Applicable �Traffic Signal O Adive RR Crossing �pther Type TCD � No Controls � ImP�e�Y��oning � preemptive
a Flazhing Traffic ConVols Signal
0 �Stop Sign Passive RR Device Not Device Fundioning
Signal 0 Crossing Controls �Unknown � Functioning � Properly � Unknown
b
(��(lf"NotApplicable',skip iest of the Cane Oowre secrionJ I,ane Closure � North Q East Q North and South� All
� �Not Applicable �PaRially �fully 0 Unknown � Q South Q West (N,S,E,V�
9 � Q East and West
g LC�LS Yes � No Q
� �� Unknown � � ��30 Min. Q 30-60 Min. Q t-3 hrs �3-6 hrs �6-9 hrs 0>9 hours �Unknown
- _ _...--- ------ —_-___=_——_-- --_= 3
Fomia R n,►aoo��ami) p�PIND07 CO�'Y �
/ EXH�BIT C
http://www.dot6.state.pa.us/crsapp/PrintImages/XmlFiles/201300251020130... 1/8/2013
� � Print CRS W0322637 Page 2 of 8
J ('�����S�iP9 ���6'2�9�k1�'a ����q �IBGv1 UI(I�I�I�III�I�� Crash Number �
Page:
� C,00 2 Pdice Use Ony ,�.
W0322637
6 TVpe � Tranor�Vrthicle in 0 Hit&Run Vehicle
Q Illegally Parked � Legally Parked Q Non•Motorized Commerciaf Vel�icle
io a Unit � Pedestrian � PedesVian on Skates, O Disabled From 0 Trein � Phantom Vehicie � Yes � No
� in Wheeichair,etc Previous Crash (If Yes,Comp/ete Form C)
(If'Pedesbian'or"Pedestiian on Skates,in Wheelchaii etc',Comp/ete Form M,Section 28J
Unit Mo Ffrst Wame RAI Date of Birth(MM-DD-WYI�
O1 AGUSTIN � 03 20 1985
Delete? ���ame Tele hone Pdumber
p MACIAS-MARQUEZ 7173329211
Address/G /State • Z�
R
° 358 AYCHER AVE WAYNESBORO PA 17268
�
Driver License Pdumber State Class
e 16PLUS pp �
c
d AlcohoUDroqs Susneded Driver w pedestrian Phvsica/Condition
�� � Iile al Dru s A a
� Q No � 9 9 �Medication Q NorPrnalnt'Y � Useal Drug � Fatigue � Medication
� � Alcoho� 0 Alcohoi and Drugs 0 Unknown Had 8een
b
- Drinkin O Sidc Q Asleep Q Unknown
� Almhol Test Tvpe
Primarv Vehide Code Violation Char ed?
p Q Test Not Given Q Breath �Other 9
e � elood � urine �Test Glven'f HOMICIDE WHILE DUI .Yes O ho
s
y Altoho!Test Results � Test Refused � Unknown Driver Presence 1=Driver Operated 3=Driver Fled Scene
Resuhs
�. 14 O Test Given, � Vehide G=Hit and Run �
Contaminated Resufts 2=No Driver 9=Unknown
Owner/Driver 00=Not Applicable 02=Private Vehicle Not 04=5tate Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh
02 01=Private Vehicie Owned/ Ownediteased by Driver 05=PENNDOT Vehide 08=0ther Muniapal 98=0ther
Leased by Driver 03=Rented Vehicle 06=0ther State Gov Veh Government Vehicle 99=Unknown
Same as Owner First Mame Owner Last Name or Business Plame(!f Pedestrian,skip this Section)
�r��er p GERARDO GARCIA
�
Address/City/State/Zip Vehide P/lake 'AAake Code
1315 BENDERSVILLE RD ASPERS PA 17304 Ford 12
VIPI RAadel Vear Vehide Npodel (see overlay)
1 FMRU 1 S WS WLB53132 1998 EXPEDITION
License Plate Reg.State EsY.Speed Vehide Towed Towed By
HZW9099 PA 999 �ves Q No RIFE MOTOR CO—�
lnsurance Insurance Company Poficy Pdo
p �Yes p No O k own TRAVELERS INS CO 977540210 ]01 I
0
€
�Z � Tral�in4 TY� 7=Towing Pass.Veh 4=Mobife/Modular Home 7=Semi-Trailer Tag Alo Tag Year Tag St
g Unh No..o( � Unit a 2=Towing 7ruck 5=Camper 8=0ther �� � �
� Trading 3=Towin Utilit Trailer 6=Full Trailer 9=Unknown
� Uniu: 9 Y
� Direction of a •Nehide Position D i *AAOVement �i °� Speda/Usaqe
mv�e� Overlay
Vehlde Color Veh/de TVpe 05=Large Truck 20=Unicycle,Bicycle, �� 12=Commercial
06=Yellow 01=Automobile 06=5UV Tricycle Passenger
�1 07=5ilver �6 00=Not Applicable Carrier
� 02=Motorcycle 07=Van 21=0ther Pedalcycie 01=Fire Veh t3=Taxi
08=Gold 03=6us 1Q=Snowmobile 22=Horse&Buggy OZ=Ambulance 21=7raaor Trailer �
01=61ue 09=Brown 04=Small Truck 11=Farm Equip 23=Horse&Rider
02=Red 10=0range (If`01'Complete Form 12=Construction Equip 24=Train 03=Police 22=Twin Trailer
03=White 17=Purple M,Section 16) I3=AN 25=Trolley 08=0ther Emergency 23=Triple Trailer
04=Green 12=0ther 18=0ther T e 5 ec Veh 98=0ther Vehicle 31=Modified Veh
(if°10"or"21",Comp/ete yP P 11=Pupil Transport 99=Unknown
05=BIack 99=Unknown fo�m M,Section 17) �9=Unk.Type Spec Veh 99=Unknown
lnitial lmpad Paint Dama4e Indicator Gradient 3=Downhill Road AJianmeni
01 00=Non-Collision 14=Undercarriage � O=None 2=Fundional � 4=Bottom of Hiil ❑ 1=5traight
C1-12=CIock Points 15=Towed Unit 3 1=Minor 3=Disabling I 1=Leve1 S=Top of Hill 1 2=Curved
13=Top 99=Unknown 9=Unknown z-�ph��� 9=Unknown 9=Unknown
Fo�+M x a+-soo(�zroz) PEMNDOT COPY
http://www.dot6.state.pa.us/crsapp/PrintImages/XmlFiles/201300251020130... 1/8/2013
' Print CRS W0322637 Page 3 of 8
�1 P�������G9���RFBR'!����R99G� UIiI�I�I��IIwI�� Crash fi6umber �
Page:
A� COO G Pdi[eUseOniy ��� WO32ZE)3�I
/V1 J
p � Motor Vehicle in � Hit&Run Vehicle � illegally Parked � Legally Parked Q Non-Motorized Commercia!Vehide
6 Type Transport Q Yes � No
io d Unit � Pedestrian � Pedestrian on Skates, 0 Disabled From � Train 0 Phantom Vehicie
g in Wheeichair,etc Previous Crash (It Ye; Comp/ete Form C)
� (If'Pedes[rian'oi"Pedestrian on Skates,in Wheelchair,etc',Complete form M,Sedion 28)
Unit Pdo First Wame PAI Date of Bir4h(MM-DD-YYYI�
p2 NICHOLAS � 09 27 1982
Las4 Name Tele hone fUumber
Delete?
� FORTENBERRY
Address/G /State '
r
d 43 1/2 W KING ST APT 3 SHIPPENSBURG PA 17257
�� Driver License Atumber S NJ Cia�
F66675900009824
6 Drrver w Pedestrian Phvsicaf Condition
`–° AlcohoUDruos Suspected
++ � � No � Ilie al Dru s �Medication � APParently � Illegal Orug � Fatigue � Medication
9 9 Normal Uze
�
� � Alcohol O A��ohol and Drugs �Unknown � Had Been � Sick Q Asleep � Unknown
m Drinkin
� Alcohol Test Tme Arimary Vehide Code Violation Charged?
p Q Test Not Given Q Brezth �Other Q Yes �No
�' . 81ood � Urine �Test G v n�f DUI
d
d Unknown Driver Presence 7_Driver Operated 3=Driver Fled Scene
y Alcohol Tesi Results � Test Refused � Resuhs �
�•� Test Given, Vehide 4=Hit and Run
� Contaminated Resulu a 2=No Driver 9=Unknown
Owner/Driver 00=Not Appiicable 02=Private Vehicie Not 04=State Pofice Vehicle 07=Munidpal Police Veh 09=federal Gov Veh
01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=0ther Municipal 98=Other
�2 Leased by DriVer 03=Rented Vehicle 06=0ther State Gov Veh Government Vehicle 99=Unknown
Same as
Owner Firs4 Mame Owner Last Plame or 8usiness Pdame(If Pedescrian,skip this Sec[ion)
�river p HEATHER M/ERI COBLE
Address/City/State/Zip Vehide Make °PAake Code
43 1/2 W KING ST APT 3 SHIPPENSBURG PA 17257 Saturn 24
PAodel Year Vehide Pfiodel (��ertay)
VIfN
1 G8N52F41 YS 84620 2001 L200
LiceMe Plate Reg.StaYe Es4.Speed Vehide Towed Towed ey
HYM0261 PA 999 �ves Q No RIFE MOTOR CO
lnsu�ance Insurance Company Policy Pdo
o �yes p No O k own NATIONWIDE 586416629
d
G
� Trailrn 1=Towing Pass.Veh 4=MobilelModular Home 7=5emi-T!ailer Tag Plo Tag Year Tag St
t2 e Unre s No.,of a U� �2=Towing Truck S=Camper 8=0ther �� �� �
— Trailing 3=7p�,��ng Utility Trailer 6=Full Trailer 9=Unknown ��
b Uniu:
°v
� Direction of � *Vehide Poskion 01 •N9ovemeni Q I *See Special Usa9e
rave Overlay
00 12=Commercial
Vehlde Color Vehlde TYpe 05=Large Truck 20=Unicyde,Bicycie, Passenger
Tri de
06=Ye1low � 01=Automobile 06=5UV �Y 00=Not Applicable Carrier
�4 07=5ilver �1 02=Motorcycle 07=Van 21=0ther Pedalcycle 01=Fire Veh T3=Taxi
08=Gold 03=6us 10=5nowmobile 22=Horse&Buggy 02=Ambulance 21=Trac[or 7railer
01=81ue 09=Brown 04=Small Truck 11=farm Equip 23=Horse&Rider 03=Police 22=Twin Trailer
02=Red 10=0range (If"02'Complete form 12=Construction Equip 24=Train 08=0ther Emergency 23=Triple Trailer
03=White 17=Purple M,Sedion 16) 13=AN 25=Troiley Vehide 31=Modified Veh
04=Green 12=0ther (�f'10"or"21",Complete �g=0ther Type Spec Veh 98=0ther 11=Pupil Transport 99=Unknown
05=81ack 99=Unknown �rm M,Section 17) �9=Unk.Type Spec Veh 99=Unknown
lnitfa!ImoaR Point Damaae Indicator Gredient 3=Downhill Road Aliqnment
00=Non-Collision 14=Undercarriage a O=None 2=Fundional ❑ 4=Bottom of Hill � 1=5traight
�3 3 t=Minor 3=Disabling 1 1=Level S=Top of Hili 1 2=Curved
01-12=CIock Poinu 15=Towed Unit g=Unknown 2=Uphill g=Unknown 9=Unknown
13=Top 99=Unknown ___
FORM Y hA-500(1?102) PENNDOT COPY
http://www.dot6.state.pa.us/crsapp/PrintImages/XmlFiles/201300251 OZO 130... 1/8/2013
' Print CRS W0322637 Page 4 of 8
J CORflPiiOPdli1lE�.dT'FG O���f�4W5YLN�+�11� �I I�I��IqIII�I�� Gash wumber �
�OLECE C6t�+5F� �dE�O��GWG �ORNN Page
AA 500 3 Police Use Ony � W0322637
Penon Twe: Seat Position: S��ouipment One: ElE�.��
A 1=Driver � 00=Not A Passenger/Occupant E 00=None Used/Not Appiicable �j O=Not Applicable
2=Passenger 01=Driver-All Vehicles 01=5houlder Belt Used 1=Not Ejected
7=Pedestnan 02=Front Seat Middle Position 02=Lap Belt Used 2=Totally Ejected
8=0ther 03=Front Seat Right Side 03=Lap And Shoulder Belt Used 3=Partialiy Ejected
9=Unknown 04=5econd Row-Left Side Or 04=Chiid Safety Seat Used 9=Unknown
Motorcycle Passenger 05=Motorcycle Helmet Used
05=5econd Row-Middle Position 06=6icycle Helmet Used H Fiecfion Path:
�x, 06=5econd Row-Right Side 16=Safety Belt Used Improperly O=Not Ejected/Not Appiicable
F =Female 07=fiird Row Or Greater- 11=Ctuld Safety Seat Used Improperly 1=Through Side Door Opening
g B Left Side 12=Helmet Used Imprope r l y 2=Through Side Window
M=Male 08=Third Row Or Greater- 90=Restreint tJsed,Type Unknown
o°�� U=Unknown 99=Unknown 3=Through Windshield
ra Middle Position 4=Through Back Door
09=Third Row Or Greater- S=Through Back Door Tailgate Opening
� Right Side U�1 1y��nment Two: 6=Through Roof Openin9(Sunroof/
s �rv v nN: 10=51eeper Section of Truckcab F 00=None Used/Not Applicable Convertble Top Down)
d O�--Not�red 11=1n Other Enclosed 01=Front Air Bag Oeployed(For This Seat) 7=Through Root Opening(�onvertibte
� � 1=Kilfed Passenger Or Cargo Area 02=5ide Air Bag Deployed(For This Seat) Top Up)
� 2=Major Injury 12=1n 0 en Area 03=0ther Type Air Bag Deployed 9-Unknown �
� 04=Multi le Au ea s De lo ed
3=Moderate (Bac Of Pickup,Etc.) P 9 P.Y
In u 13=Trailing Unit 05=Motorcyde Eye Protectton
4=Minor Injury 14=Riding On Vehide Exterior 06=8icydist Wearing Elbow/KneeJPads I Ex(rication:
8=lnjury,Unk 15=8us Passenger 10=Air Bag Not Deployed,Switch On O=Not Applicable
Severity 98=0ther 11=Air Bag Not Deployed,Switch Off 7=Not E�Rncated
9=Unknown if 99=Unknown 12=Air Bag Not Deployed, 2=ExVicated By Mechanicai Means
injury Unk Swrtch Setting 3=Freed By Non-Mechanical Means
73=Air Bag Removed(Prior To Crash) g_pther
19=Unknown If Air Bag Deployed 9=Unknown
99=Unknown
�3 E�t+s e►gency: MAR10N,FAYETTEVILLE �tedicai Facility: CHAMBERSBURG HOSPITAL,YORK HOSP
Unit Pdo Person No Delete? Dat�►Qh (�MM-�DD-YY�������a��
„
O1 O1 p 03 20 - 1985 1 M 4 O1 99 O1 0 0 0
Plame!Address/Phone EMS Transport
��"�� MACIAS-MARQUEZ,AGUSTIN 358 AYCHER AVE WAYNESBORO PA 172 0 Yes O No
operator
Unit P�o Person Mo Date of Birth (MM-DD-WY'� o 0 0 0 0 o a o a
� � Delece? �_�-�
02 O1 p 09 27 1982 1 M 2 01 02 01 0 0 2
Ptame!Address/Phone EWIS Transport
�same as FORTENBERRY,NICHOLAS 43 1/2 W KING ST APT 3 SHIPPENSBUR .ves Q No
Operator
Unit No Person Pdo Date of BiKh (MM-0D-YYI'1� A B C D E F G H I
DeleSe?
02 02 p 10 - 01 - 1987 2❑ F� 1� 03 99 01 0�� 2
{Name/Address/Phone EAAS Tra�poR
�same as COBLE,HEATHER 43 1/2 W KING ST APT 3 SHIPPENSBURG PA 17 -y� p No
Operator
Unit No Person Pdo ��ete? Date of Birth (MM-DD-YYYY) A B C D E F G H I '
02 03 p 06 - 30 - 1988 2❑ M❑ 2❑ 99 99 00 0�a�
Plame/Address/Phone ERAS Transport
�same as pE�y MpDISON 416 FRANKI.IN HEIGHTS SHIPPENSBURG PA 1725 �Yes O No
Operator
Unk Wo Person Pdo ��Ye� Date of Birth (MM-DD-YYYY) A B C D E F G H I
� � 0 �-�-�❑❑❑���❑❑❑
Pdame/Address/Phone EPAS Transport '
�Same as O Yes �No
Operator
Unit Plo Person fdo ��ete7 Date of Birth (MM-DD-WYY) a��������
� � � �_�_�
P1ame!Address/Phone EPAS Transport
�Same as �Yes �No
Operator
FORM I AA300(1?102) PEIdNDOT COPY
h,+„•��.xnxR� ��tF, �t�te.na.us/crsapp/PrintImages/XmlFiles/20130J251020130... 1/8/2013
� Print CRS W0322637 Page 5 of 8
� C�RI'iRf�06l9li1l�LY�v" Off ��V1�IVU�YL!lB�NlB,� flIII�I�IWIII�I�� crash kumber �
P��6��CRB�SP9 ���'�d��@I�1G �OI�Rfl Page
AA 500 4 Pdice Use Only . � W0322637
�Non-Collision 2=Head On 4=Angle 6=Sideswipe 8=Hi!PedesVian
Crash DescriDtion 4❑ (Opposite Direction)
1=Rear End 3=Rear to Rear 5=5kleswipe
(ga�i�) (Same Direction) 7=Hit Fixed Object 9=0therNnknown _
c �
0 0
1O a �2elation to RoadwaY � 1-0n Travel Lanes 3=Median 5=0utside Trefficway 7=Gore(Ramp Intersection
E o 2=Shoulder 4=Roadside C�In Parking Lane 9=Unkno`m --_ __
° -
c � 1=Daylight 3=Dark-Street 5-Dawn 8=�ef
�S � „ Illumination a 2=Dark-No Lighu �ark-Unknown -
A ° Street Lights 4=Dusk Roadway Lighting --- ---
� � 7=Sleet&F 9=Unknown �
1=No Adverse 3=Sieet(Hail) S=Fog �
: � Weather�onditions � Cond"dions
c 2=Rain 4=Snow 6=Rain&Fog--6=�er __-- __ _
� � Z=Sand,Mud,Dirt, 4=Slush 6=1ce Patches �-pther-�
y Road SurPace Conditions O❑ o-�ry Oil - - 7=Wat r-Standing— --
1=Wet 3=Snow Covered 5=1ce or I�ovmg
Hartn Even4 L/R Mos4? llb�rty Po�e Mum6ar {{armful EvenYs(Marm Even4) 30=Hit Fence Or Wall
01=Hit Unit 1 37=Hit Buildinq
9 �2 ❑ � 02=Hii Unit 2 3Z=Hit tulvert
Unfe fVo 03=Hit Unit 3 33=Hit Bridge Pier Or Abutment
04=Hit Unit 4 34=Hit Parapet End
Q 1 Z � ❑ Q 05=Hit Unit 5 35=Hit Bridge Rad
06=Hit Othei Traffic Unit 36=Hit Boulder Or Obstacle
07=Hit Deer On Roadway
Please Put � ❑ 08=Nit Other Animal 37=Hit Impact Attenuator
Evenu in 3 � 09=Collision Wilh Other Non 38=Hit fire Hydrant
Sequenfial Fxed Object 39=Nit Roadway Equipment ;
Order � ❑ �� 11=Struck By Unit 7 40=Hit Mail Box
� d � 12=SVUCk By Unit 2 41=Hit T2ffic Island
? 42=Hit Snow Bank
� 13=Struck By Unit 3 43=Hit Tem ora Construction
ib E 14=Struck By Unit 4 P ry
� Harm Event L/R Most? Uti�ity Pole Atumber 15=5truck By Unit 5 Barrier
1E=Struck B Other TraHic Unit 4�Nit Other Fixed Ob'ect
9 1 1 0 21=Hit Tree Or Shrubbery 49=Hit Unknown Fae�Objed
� � � Y 56=0verturr✓RdlOver
� Unit Rlo 22=Hit Embankment 51=Struck B Thrown Or Falling
�, 23=Hit Utility Pole y
� 02 2 31 D � 24=Hit Traffic Sign Objed
25=Hit 6uard Rail 52=Pot Holes Or Other
�� 26=Hit Guard Rail End Pavement Irregularities
� Please Pat 3 � ❑ � 53=Jacknife
27=Hit Curb 5q�ire In Vehide
Eventr in 28=Hit Cancrete Or
Sequential Longitudinal 8arrier 58=0ther Non-Collision
Orde� � � ❑ O 29�1it Ditch - -9�=Unknown Harmful Event
i
- 17=Careless Or Ille ai �
�rst Uoit Wo Harm Event RPost Unit Wo Harm Event Driver Action(D) gacking On Ro9adway
���� �ful OQ=No ConVibuting Action 78-Driving On The Wrong
�� vent in �1 �2 vent in 01 �2 01=Drnrer9 as 9isiracted Side Of Road
�h �h C2=Drivin Usin Hand Heid Phone t9_Makin Im r r
Do not repeat th:s infcmution an mul6ple WS� D3=Driving Using Hands Free Phone 9 P�
04=Making Illegal U-Turn Entrance To Highway
Envlronmenbl/RoadwaY 05=1mpropedCareless Turning 20=Making Improper E�nt
9 Q� Z� 3� 06=Tuming From Wrong Lane From Highway
Potenilat Factors{f/R) 07=Praeeding W/0 21=Carnless ParkmgNnparking
OP=None 11=Siippery Road Conditions(Ice/Snow) Clearance After Stop 22=0verNnder
o7=Windy Conditions 12=Subsiance On Roadway 08=Running Stop Sign Compensation At Curve
02=Sudd2n Weether COnditi0n5 t3=Potholes 04=Running fted light 23=Speeding
03=0ther Weather Cond'Rions 14=Broken Or Cracked Pavement 10=failure To Respond To 24=Dnving Too Fast For Conditions
04=Deer In Roadway 15=TCD Obstructed Other Traffic Control Device z5-failure To Maintain Proper Speed
05=0bstade On Roadway 76=5oft Shoulder Or Shoulder Drop OH 11=Tailgating 26=Driver Fleeing Pdice(Pol Chase)
12=Sudden Slowingl5topping z7=pmer Ine+c nenced
p6=0ther Mimal In Roadway 28=0ther Roadway Factor �3=111 all Sto On Road �
18 07=GIare 29=0ther Environment�l Fador e9 Y PP� 28=Failure To Use Specialrzed Equip
08=Work Zone Related 99=Unknown 14=Careless Passmg Or Lane gZ-p,ffected 8y Physicaf Cond�tion
� Change 9�-Other Improper Drmng Actions
° 1z_V�/i�R 15=Passing In No Passin Zone
m Possi6le Vehide failures M 99=Unknown
E 00=None 06=Exhaust 13=Driver Seating/ConVOI 16=Drrving The Wrong ay On
° 01=Tires 07=Headlighu 14=Body,Doors,Hood,Etc 1-Way SVeet
� 15=7ratler Hitch 3 �.4�
02=Brake Syztem 08=Signal Lighu ��yyheels ���t O1 9 �8 2 �
� 03=5teering System 09=0ther Lights 17=Airbags �O
� 04=Suspension 10=Nom �g_Trailer Ovedoaded
� 05=Power Train 11=Mirrors �g_Uruecure/5hifted Uni4 02 9 �Q Z � g � ��
c Unit Trailer Load iyo
� �0 01 1 �0 2 � 2D=lmproperTowing
21=0bstructed Wndshieid pedestrian Action(PI 03=Working
Unit 99=Unknown pp=NOne 04=Pushing Vehicie
Q2 � �� Z � 05=Approaching Or Leaving Vehide
�0 01=Entering Or Crossing At 06=Working On Vehide
Specified Laation 07=Standing
Indipted Prime Fador Unit No factor Code 02=Walkin�,Running,1o99ing, 98_aher
� Or Plapng 9g_Unknown
po not repeat this information on O 1 Og I
�q muhiple pagcs.
E!R V D P lJni4 Pdo �1 � UniY R�o �2
Q � � � If ElR is the Prime Fador
T}pe,leave Unrt No blank _ _—___ __ --—
FORA1�AA-500 I1L02) ���{�IQ'���ig��
�.,��.���:ntnv ,��r� �rarP „a u�/crsanti/PrintIma�es/XmlFiles/201300251020130... 1/8/2013
� Print CRS W0322637 Page 6 of 8
� COf1AMOPdWEALTH OF PEIdtdSYLVANSA �I�II����II��l�II� CrashMumber �
POL9CE CRASPi 6tEPORTIhIG fORM pa�
� 5�0 5 Police Use Only � W0322637
...._..............:. .
' ; ; : .. .. _. ... _... . _... _... _.. o
.................. ,
� : € : € ... .. ... __... _ _ ... __ .. . _.. _ _..._ _ -
A � ......:...........:......_...:...........:....... ..._ _ - - _
d ..........:............. : , ;
20 � : : : [ t ` ... ... ._ ... .___ ... _. _... ... ... ... _... ... ... ... _..._ ... ...
.o : t :.........i...........t..........;.....-- -.. ... ... ... -
..E.... ......... _..:.... ..
_:.... .
..... .
B ......................:.............. _ . : . ;
� � Address Phone
Witness Name
zt
1
2
Plarrative and addi4ional witnesses:
Auident invesrigation Notification Issuedl� Property Damage s
On 12/31/12 Chambersburg Police responded to an auto accident in the area of East McKiniey Street and
Cleveland Avenue. Units arrived on the scene to find a major accident with several severely injured individuals.
The Chambersburg Police Department Major Accident Investigation Team was contacted and responded to the
scene. The Major Accident Investigation Team is investigating the accident and will supplement this report once
the investigation has been concluded.
0
>
«
�
.
�
s
z
�
c
s
w
2 j
e
«
�
FORM i AA-SIXI(1IA2} PENNDOT COPY
hrrn•//www_d�t6.state.pa.uslcrsapp/PrintImages/XmlFiles/2013 00251020130... 1/8/2013
' Print CRS W0322637 Page 7 of 8
G�C�lf,�lO�i GJ�15�1 Of�[F'C�C'J�'Jg�'ll4.CIQG`30� O WeW �I II�IIII��II�II�II� Cras�Mum� �
� P�'�Dl�f�a G,�G3f�PC9�6�5��G`.7C����tRfil Paye W0322637
Change/
AA 500 F "°��""°� � � Continuatlon
S�daf��� O ���rta�Y � aher Federal Sites
Road Suriace Ty�2 �Bridc or Blak �Dirt
No Special Q Indian Reservation �Other
u � Corwete �Sfag,Gravel or Q Other - ���isdiction CoHegeNniversity � Unknown
- B��aP S� Q Unknown � Nationai Park � �mp�s
Please complete Unit Infamation for e�e unit involved in a fe4�l aash.Do not repeat the information in the fields above on muhiple pages•
Unit Wo PrrndMe I�Aad Pa�� O
01 �Non-Collision �I1 12 OlO '
�lp 02�
g����a�s �Not a Pennrylvania �Top
p�es�e�Lb°!s �Complied Wfth Driver �09 03�
�omPr�r+ce Resvictiorss Not �Unknown �Undercarriage
p 04O
y�Restrictiony �Gomplied 1M1rith Complian<e Q
� Poot Applicable �npliance �Towed Unit p7 06 05O
�Unknown �
o Required- Not a Pennrylvania Q Unknown �
a, pRye�Endor�t O���yy'�h 0 Oriver
� Avoidance IWarreuver
€ O Required-No� �Unknown
$ Compliance Complian�e No Avoidance Breking-Other Q Other Avoidance
� Q Mone Required geyuired- � Manewer � Evidence Maneuver
zs � �Compliarxe Unknown Brakin -Skid Steering-Evidence � Inconclusive
�
Pdoi Required for Unk'rf CDL or 0 Marlcs vident � w Driver Stated
D^�� �V¢hide Uass � CDL Required
� Braking-No Skid Steerin and Braking � Unknown
�Poo Valid ticense � No2 a Pennrylvania � Marks,Dnver 0 Eviderx or Stated
for Uass Driver Stated
� Not Licensed �Valid License for 0 Un��� ��Ride lndicator
❑ass ---- Underride,No pverride,Other
Other No Undertide or � Compartment � Vehide
Drua Tesi Type �Blood � s Overtide Irtrusion
Unknown if Test Unknown if
0 4Vone Q Urine 0 Given Underride, Underride, ��em�or
� Compartment 0 Compartment � ���de
Druo Tesf Resul�-N9 iv fuo/Res�tLS) a ❑ Intrusion Intrusion Unknown
0=Mo Test G'rven 5=Amphetamines goth Ligtns and
1=Pdo Drug Reported 6=KP D EmervencY Use � Lights Flashing � Siren
2=PAariivana 8=Other ❑ ❑ Not in Emergency
3=Cocaine 9=Unknown Test � �� Q Siren Sounding � Unknown
4=Opiates Results
Unit Qdo Prindple Impact Poirtt �
02 �Non{ollision �1 12 p�
�l 02�-
��--_� O R��io� �Not a Pennrylwania 0 Top
CompGed Wrth Driver Q 09 03�
�—ra� Restridions Not Unknown �Undercarriage
Plo Restrictionsl 0 ComPlied Vlrrth 0 Compliance �OB 04 Q
� Not App��cable �o���a� Q Towed Unit �� 06 a5O
�unknown O
o Required- A Not a Pennsylvania Q Unknown 0
a DriverfndorsemPnt O�mpliedWith Dr"rver
E °�i� 0 Required-Non �Unknown Avotdance A9aneu✓er
gCompliance Compliance � No Avoidance Braking-Other �Other Avoidance
6 Q None Required R�����_ Maneuver � Evidence Maneuver
u « �fompliance Unknown Breking-Skid Steering-Evidence �Inconclusive
� Not Required for �Unk if CDl or � Marks Ewdent �or Driver Stated
D�� �yehide Uass CDL Required
�� Mo Valid Liceiue Not a Pen ivania Braking-No Skid �Steering and Braking Q Unknown
�for Class �Driver � � Marks,Dnver Evidence ot Stated
Sbted
� Mot Licensed Valid licerue for �Unknown
O a� u�der w_'ee tr�d�oror
Underride,No O p�rerride,Other
��e� � No Underride or �Compartment Vehicle
Onw Test Ty�e �Blood Override Intrusion
Unknown if Test Unknown if
� Mone �Urine �6iven Underride, Underride,
Q Compartment C� Compartment �Underride or
Drt�Test RewtPs-NP ro�R��� a ❑ Intrusion InVUSion Unknown Override
0=tdo Test Given 5=AmPhetamines D O Both Lights and
t=tdo Drug Reported 6=PCP Emeroenro Use � Lights Flashing 5iren
2-pAarijuana S=�� � ❑ Not in Emergency
3=Cocaine 9=Unknown Test � Use 0 Siren Sou�ding �Unknown
4-Opiates Rewtts
�x�aaa�c� PE3�lT�DOY CCPY
, .. __,�__�_�.. a,.+� ����A „a „�i�,-�a„n/Pr;ntTma�es/XmlFiles/201300251020130... 1/8/2013
�
.- .
•- i �
�-
r �.:c�5. :,:L ���ig�, ��',�.�i'��'����is.��'�+S :� ��, -,� �r '� ¢M� M .
rk �- �� �� ���T- ..
Q�l� :�i. ' S.�. F F� . ( g �� . „� °"+a,w
.. �,� x � � x S �f'g ��,�
., �� � �� ..���� �
{ � a
. . #� 1 � s§� � 't� � � A .
a ?a �
� �gv. ,�„ _.
. -3 k �f k . � _ � �� � �..
� _�8 � �
8 g
{ $a.e.' --A -.p� �y;.
" ' � �� $ � ��F�t��� �"�'t��� � _
�.�9.' '4' �' h,``� #�" *� 4� �.�.
=..�,'�'e �'�'�' �`�'� ,�" ���&• .�
� . � � .�'�'��� ' �;�`
� " ,,,ppp - p �,'�„�
� r x� � p� � .��� � s
., � ... �, sr as _
�, 'x � ��� k a�!�{�,�h �� . . � .. � '.� �:.
� � ��-�, ,� �� . �' ��
� � � �>
_ : - ���:� �` `� ��� � � � '
4: t $ � �Y� � if � . - a��.
. �. ' . �'_�,�� # 3FP. .
.3 �{' �€ �
� , � � �`�-a�, A� �
��� � 'Yf z�� � " � �� � 3 . � � �..���.
�` r� � � � � .K � �. _ � ��
- � � ,�, � � �+r� � � �� ����'
� , _ � , � �
;� .. . ' ,.
�
� � - �a... : - � �
. ; ..- , j� -, � � fl '}tyr'�CL �' "
''� .:I. .. i M��
- } � � _ " _ : � � .
. ,.... . .- , .
�3 �
°w 9 ' - �
� :` - x� _��. `��;:. ��� �� .,• . - ��`
.., i S � �� .
f � � `; �� :�
r
�� ��� ;
� -._, ���- }�' � �� � ' �� � � .
Vs_�� `"€ � � � . � -
: �
�
<, # � � 9$
>r � � � "�� �;
y.:. } � ?k ae. .3�� . . _ .. � �
d 8
- �%' 4.�.� �� �ri . . x�6�d ,s.0� '� _ . . ,g . ..
� � � � �
� ��
�
� �;.
s � '" mmibi� ' ,. ��.� n ,. .
t � � *�� � . �,..�' � ,
�°zt. :.
�, ,��'. k-� �� �-._� � � .��- ,i: ,�q �. . �
��� 4 � "7� F' . '�-' .. �
- . ' '"� t �'t� �-_ .��� � ' �s� + . ..
- ���` �' -�� ti���� .s .. . .
� �� ,� � ,_; a e,. . � _ . .
�-
_ ... �4,'�� � `� $� _ . x}" .. ...
. .. ,�; ^=y�: �'v i�� '�.. .
� � �'�<
�� . ��w�.'� �� -. . � .
. . . �� - - ���'Y��' � ` .
�: �
.. `�r�.`'E F-,�., . x
. . � �` _I . �. �� � `�' � . �� �. � �
tiy �
��" � s� "" ���` � �e �ia�a`� # ..i. `;..
t s �
.� , . n' ..�.� �.
�.. � ,,
� '�_ ..�..� .
�� s . � . s� � .
1 il � � �
THE LAW OFFICE
� �F ��,.�`qc
* f[O�
y °�� JaMES M. Cu�v -
n V �
$
�� �, �„� A PROFESSIONAL CORPORATION �
t
��, + CERT'IFIED CIVIL TRIAL ATTORNEY
.�
86 Washington Avenue ■ Milltown,New Jersey 08850
MEMBER NJ&NY BARS Boazd Certified Civil Trial Advocace
By the National Boazd ofTrial Advocary
May 8, 2014
John Keller, Esquire
Keller, Keller & Beck, Esquires
343-B South Potomac Street, Suite B
Waynesboro, PA 17268-1646
Re: Your Client: Heather Coble
My Client: Nicholas Fortenberry
D/A: December 31, 2022
Dear Mr. Keller:
As you know, this office represents Nicholas Fortenberry
for injuries sustained in the above accident.
Please be advised that Nicholas Fortenberry was admitted to
York Hospital on December 31, 2012 and was discharged on January
29, 2013 .
He sustained the following injuries as a result of this
accident :
l . Transection of thoracic aorta from posterior aortic
arch to the proximal descending aorta with moderate
mediastinal hematoma, small to moderate sized
bilateral hemothoraces, right lower lobe contusion and
small pneumatocele posteriorly
2 . Right 8th to 12th rib fractures posteriorly
3 . Grade III liver laceration involving the medial
segment of the left hepatic lobe
4 . Right renal contusion with a small subcapsular
hematoma
Telephone:732-296-0500 ■ Fax:732-296-9090 ■ www.currantriallaw.com ■ email:curranlaw��yahoo.com
EXHIB�T D
. � , t
Page 2
May 8, 2014
Re: Nicholas Fortenbersy
5 . Small hemoperitoneum.
The above injuries required multiple procedures/surgeries.
Mr. Fortenberry' s medical bills total over $436, 000 . 00 with
outstanding medical bills over $51, 000 . 00 . In addition, the
State of Pennsylvania has a Public Welfare claim in the amount
of $160, 120 . 45 for payment of inedical bills through charity
care. They have agreed to take 500 of Mr. Fortenberry' s net
settlement.
If you have any questions regarding the above or need
additional information, please do not hesitate to contact me.
Very truly yours,
�-^�,� ,,f�
���'
JAMES M. CURRAN
/jer
� � Michael V. Farrell
Sr. Technical Specialist
������� �,�,����� �412 338 3'238urgh, Pa.
� 800-238-6285 x-3383238
t►��c���r��e, lr���r�ri�i�:� AUG 2 l
m�fa��e�@t�a�e�e�s.�om _ 1013
Pennsylvania Claim Service Center
P.O. Box 1538
Pittsburgh,PA 15230 � �'
.. .,.;4.:,.:.
-- . :.=,
August 16, 20�3
Mr. John N. Keller, Esq Mr. ,l�mes M. Curran, Esq Mr. Edward E. Knauss, Esq
Keller, Keller and Beck 86 Washington�ve Metzger Wickersham
343 B South Potomac St Milltown, NJ.08850 PO Box 5300
Waynesboro, PA 17268 Harrisburg, PA 17110
RE: Policyholder: Gerardo Garcia
Claimants: Esfates of Madison Perry and Heather Coble
Nicholas Fortenberry
Date of Loss: 12/30/2012
Claim #: HQC4119
Dear Gentlemen: "
As you may recall from our various telephone conversations, my policyholder elected
bodily injury liability limits of $50,000 per person and $100,000 per accidenf: On behalf
of Mr. Garcia and Mr. Macias, we are tendering the policy limits in settlement of aIC
claims. Since the available coverage is not sufficient to fully compensate your
respective clients, please advise as to ttie mutually agreed upon apportionment of the
policy limits. Obviously no single settlement can exceed the $50,000 per person limit
and the combined settlements not exceed $100,000. Also, as there are two Estates
involved, Court approval will be necessary before I can issue any of the settlement
drafts.
Once I have received the agreed upon apportionments, I will prepare releases for
signature and send them to your offices. Before I can issue any of the setflement �
payments, I will need to have all three signed_releases and the necessary Court
approvals on the Estate settlements. Travelers h�s been placed on notice of a DPW
lien and a chitd care lien that will need to be addressed before 1 can issue paymer�ts as
wei L `
I have enclosed a statement of coverage for your records. Please let me know if you
need anything'f�rther
Sincerely,
����a��� �
Michael V. Farrell
Sr. Technical Specialist
412-338-3238
EXHiBTT E
Tf�'AVELERS PERSONAL SECURITY INSURAN�E
COMPANY
Policy issued to:
GERARDO GARCIA
2 GREENWAYACRES
THO�ASVILL� , PA 17364-9700
Policy #:
977540210 - 101 — 1
4. Coverages, Limits of Liability
A - Bodily Injury
$50,000 each person
$100,000 each accident
B - Property Damage
$50,000 each accident
B�:
��
Michael. V. Farrelf
Sr. Technical Specialist
Travelers Personal Security Insurance Company
RETAINER AGREEMENT
I, Michelle Hudson, hereby employ and retain Keller, Keller and
Beck, LLC, attorneys at law, to represent me in the capacity as Personal
Representative of the estate of Heather Coble in a liability claim on
behalf of her estate and wrongful death survivors arising from the motor
vehicle accident of December 31, 2012 which resulted in her death.
I do hereby agree to pay said attorneys twenty-five (25o) per cent
of any settlement obtained in this case, if such case is settled any
time prior to the institution of suit, and thirty-three and one-third
(33 1/30) per cent of any settlement, verdict or recovery obtained in
such case following the institution of suit. I agree to reimburse said
attorneys for all costs and disbursements made in this case if a
settlement or verdict is obtained, understanding that said costs and
disbursements are to be deducted after calculation of the attorneys fee;
however, I understand that I am not responsible for the payment of any
fees or the reimbursement of costs and disbursements unless a
settlement, verdict or recovery is obtained. I further agree with said
attorneys not to make any settlement unless they are present and receive
their share in accordance with this agreement.
I do hereby bind my heirs, executors and legal representatives to
the terms and conditions set forth herein.
I HAVE READ OVER AND FULLY UNDERSTAND THE ABOVE CONTRACT.
/ " ` /� ,� /l �
Date. l //� C � /�� � ! `J'�L.�.,��
Mi:�helle Hudson, Mother and Anti,cipated
P�rsonal Representative of the
Estate of Heather Coble
KELLER, KELLER AND BECK, LLC
.
Date: � a BY
Jo . Keller
�;XHIB LT F
. '
� � . pennsylvania
. --� ______
� 1 DEPARTMENT OF REVENUE ��-{+^,,—_ (j �/J(L
� � u v !S
J�E'`�1 4 20i4
�,,,,r
July 8,2014
John N.Keller,Esquire
Keller Keller&Beck
343 B South Potomac Street
Waynesboro,PA 17268
Re: Estate of Heather Coble
File Number 2113-0210
Court of Common Pleas Cumberland County
Dear 1�1r.Keller:
The Department of Revenue has received your correspondence. Attached was the petition to approve a
compromise settlement to be filed on behalf of the above-referenced estate in regard to a wrongful death and
survival action. It was sent to this office for the Commonwealth's approval of the allocation to the proceeds paid to
settle the actions.
According to the Petition,the 25 year old decedent died as a result of a motor vehicle accident. Decedent is
survived by her two minor children.
Pursuant to the Supreme Court of Pennsylvania,damages recoverable under a survival action include those
for future earnings,even where those earnings may be difficult to quantify. Kiser v. Schulte,538 Pa. 219,648 A.2d
1 (1994). This is supported by the Commonwealth Court. Roberts v.Dun�,574 A.2d 1193 (Cmwlth.Ct. 1990).
Therefare,absent any facts to the contrary,a portion of the recovered proceeds must be allocated to the survival
action as compensation for decedent's lost earnings.
However as the proceeds in this matter are a minimal net of$24,891.50,this Office has no objection to the
allocation that you have requested.
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 net proceeds of this action,$24,891.50 to the wrongful death claim and
$0 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject
to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §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 Memman,669 A.2d 1059 (Pa.
Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this matter. As the
Department has no objections to the Petition,an attorney from the Department of Revenue will not be attending any
hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from
this Bureau.
' cerely,
a n E.Baker
Trust Valuation Specialist
Inheritance Tax Division
..� ._. F .�... .�, . _.�..-.�...., ._��. ............ ._ .._. _ _,. . . _ �
Bureau of Individual Taxes � PO Box 280601 � Harrisburg, PA 17128 � 717.783.5824 � shabaker@pa.gov
EXHIBIT G