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LAW OFFICES OF MATTHEW L. OWENS, ESQOIRR LLC � "_ �' ' "
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BY: Matthew L. Owens, Esquire -� _ �;
Attorney I.D. No. 76080 � �. --� _
6310 Allentown Blvd, Suite 101 � � � � �
Harrisburg, PA 17712 �. `" `-' �n
(717)909-2500 � m °' -�n
Attorney fo�Pctitioner
IN RE: Estate of Dianne E. Bazrick : IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: NO.: 21 ' I�,�j' II� �
: ORPHANS WURT
PETITION FOR APPROVAL OF
SETTLEMENT OF WRONGFUL DEATH AND SURVIVAL CLAIMS
AND NOW COMES, Petitioner, Marilynn J. Willits, by and through her attomeys,the
Law Offices of Matthew L. Owens, Esquire LLC, and Matthew L. Owens, Esquire who avers as
follows:
A. FACTUAL BACKGROUND OF CLAIM
1. The Decedent, Dianne F.. Barrick(hereafter"DecedenY'), died as a result of
injuries sustained in an automobile accident which occurred on October 29, 2013. (Attached
hereto as Exhibit"A" is the Commonwealth of Pemsylvania Police Crash Report). Ms.
Bar�ick's date of death was Novembcr 2, 2013, three (3) days afrer the aforementio�ed accident.
Hcr cause of death was blunt force injuries due to a motor vehicle crash. (A[[ached he�eto as
Exhibit"B" is the CumberLand Counry Coroner's Repor[).
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B. DECEDENT DIED TESTATE /PARTIES AND COUNSEL
2. At the time of he�dea[h Decedent cesided at 304 Monroe Street, Mechanicsburg
Cumbedand Counry, Pennsylvania, 17055. (Attached hereto as Exhibit "C" is the Death
CeRificate).
3. Decedent died[estate. (See Exhibit"D").
4. Ma�ilynn J. Willits was granted Le[[ers Testame�tary in the Fstate of Dianne P.
Barrick, oo Novembe�2, 2013 (Attached hereto as Exhibit "D" is the Short Certificate).
5. Decedent Barrick's biological mother, Shirley Eaznest, was diagnosed with
Alzheimer's. Deceden[ was providing her nursing caze and support until her death. Once Ms.
Barrick died Ms. Eamest was moved to Thomwald Nursing i lome, 442 Walnut Bottom Road,
Cazlisle, Cumberland County, Pennsylvania, 17013.
6. Shidey Eamest is �epeesented by Joseph D. Buckley, Esquire, 1237 Holly Pike,
Cazlisle, Cumberland County, Pennsylvania, 17013.
7. The Fstate of Dianne E. Barrick is represented by [he i,aw Offices of Matthew L.
Owens, Esquire LLC, 6310 Allentown Blvd, Suite 101, Harrisburg, PA 17112 in settling the
personal injury claims of the Estate.
C. ANALYSIS OF LIABILITY AND DAMAGES
8. LLABILITY
a. Based on the Commonwealth of Pennsylvania Police Crash Reporting Form,the
dccedent was involved in a head-on automobile accident which occurred at the
inte�seetion of Trindle Road and Baze Road on Oc[ober 29, 2013. (Attached
hereto as Exhibit"A" is the Commonwealth of Pennsylvania Police Crash
Reporting Form).
b. Ms. Barrick was[raveling west on W. Trindle Road and Yu Sun Smedley was
travelling eas[when Yu Sun Smedley turned cight in an attempt to enter onto Bare
Road, into the direct path of Ms. Barrick's vehicla (See Exhibit"A").
c. Due to the impact of the crash Ms. Barrick had to be mechanically xemoved by
the fire department which took approximately ten (10) minutes.
d. After removal from the vchicle Ms. Barrick was transported to Milton S. Hershey
Medical Center by Silver Spring Amb�lance. (Attached hereto as Exhibit"E" is
the West Shore EMS Report).
e. Ms. Barrick was heated at Milton S. Hershey Medical Center for lefr chest and
shoulder puncture wounds, left leg laceration, left L2 tcansverse process fractuce,
lefl breast contusion and a seatbelt injury. He left leg received sutuces. (Attached
hereto as Exhibit"F" is the Milton S. Hershey Medical Center Dischazge
Summary).
f. Ms. Rarrick was released from Hershey Medical Center on November 2, 2013.
g. Unfortunately after being released fiom the hospital Ms. Barrick passed away in
hex home on November 2, 2013.
h. She died of m�ltiple traumatic injuries sustained in a motor vehicLe crash. (See
Exhibit"B").
9. DAMAGE5
a. Decedent was sixry-five (65) yeacs old at the[ime of the accident a�d was
working as a Supervisor. According[o the Social SecuriTy Administration's
Period Life Table, Actuarial Publications, based on her age, Deceden[could be
expected to have lived approximately a�other 20.57 yeacs. In addition, Deeedent
was a frequent source of emotional support, companionship, and guidance for her
mother and friends.
b. Decedent was pronounced deceased in her residence on Novembe�2, 2013. (See
Exhibit"C").
D. INSURANCE POLICIES/COLLATERAL SOURCES
10. United Services Automobile Associatioq (hereinafter"USAA"), the insurer for
tortfeasor, Robert A. Smedley and Yu Smedley,has entered into an agreement with the Estate of
Dianne E. Barrick to pay an aereed unon amoun[of fiftv thousand dollars ($50,000 001,their
policy limits. (Attached hercto as Exhibit"G" is the Declacations Page for the aforementioned
policy).
11. Metropolitan Group Property and Casualty Insurance Company, (hereinafter
"Metropolitan"), the insure�for the deceased, Dianne E. Barrick, has entered into an agreement
with the Estate of Dianne E. Bazrick to pay an a�'eed uoon amount of one hu�dred [housand
dollazs ($100 000.001, which repcesents UIM coverage policy limits for the applicable
automobile insurance policy for this accident aeeordine to Metronolitaa Decedent's counscl
disputes the amount of policy limits aod has filed a Declaratory 7udgment Action with this Court
which is pending. Administratrix and counsel seek approval now of the undisputed payments
being made, herein totaling one hundred thousand dollazs ($l OQ000.00) from this carrier, as the
litigation over additional funds on this particular claim may last for months or even years. Upon
resolution of the Declaza[ory Judgment Action, counsel will file a Supplementary Pe[i[ion for
Approval if neeessary. (Atlached hereto as Exhibit"G" is the Declaralions Page fo�the
aforemenlioned policy).
12. Petitioner's counsel is not aware of any collateral sou�ces.
E. PROPOSED APPORTIONMENT
13. The facts of this case suppor[ apportionment of fifteen pement (15%)to wrongful
death and eighty five percent(85%) ro the Survival Claim. Counsel for the Estate of Dianne E.
Barrick, Matthew L. Owens, Esqui�e, concurs in this distribution. This dist�ibution has been
approved by the Pennsylvania Depar[ment of Revenue (See Exhibit"H'�. Further, decedent was
sixty-five (65) years old and was a constant source of guidance and support to her mother and
&iend, Mazilynn Willits, and based on Social Secu�iry Actuarial tables, could have been expected
to live another 22.65 years. Decede�t was aware of her injuries and suffered some pain for a
period of time.
F. NO UNPAID LIENS, CLAIMS OR DEBT5
14. Undersigned counsel is not aware of any unpaid liens, claims or debts.
G. PROPOSED DISTRIRUTION OF SETTLEMENT FUND5
15. Undersigned counsel was retained by Marilynn J. Willits to represent the Fstate in
sewring a settlement oF the claims made against USAA, Ihe insurer for tortfeasor RobeR A.
Smedley and Yu Smedley, and Metropolitan, the insurer for the decedent, Dianne E. Banick.
16. Counsel fees in the amount of twenry-five percent (33 l/3%) are requested with
this settlemen[pursuant to a signed Fee Agreement (See executed Fee Agreement as Exhibit
«j��.)
17. The rotal settlement sum of one hundicd fifty thousand dollars($150,000.00),
s6ould be distributed to Marilynn J. Willits, as Administratrix of the Estate of Dianne F.. Barrick,
and distributed as follows:
Total Settlement Proceeds.......................................5 15Q000.00
Attomey's Fees.....................................................$ 50,000.00
Legal Costs and F.xpenses........................................$ 614.43
Estate ot Dianne E. Barricly Survival Beneficiary...........$ 54,477J3
Shirley Earcest,Wrongful Death Beneficiary.................$ 14,907.84
18. It is �equested that Marilynn J. Willits, as Administratr�of the Estate of Dianne
Barrick, be authorizcd to sign any and all releases of Iiability associated with ciaims against
Robert A. Smedley and Yu Smedley under the USAA and Metropolitan insurance policies.
H. CERTIFICATION OF JOINDER OF BENEFICIARIE5 IN THE TERMS OF THE
PROPOSED SETTLMENT AND PETITION
19. Mazilynn J. Willits, Administratrix, 435 North Mountain Road, Newville,
Cumbedand County, Pennsylvania 17245 (Administ�atiix) (Adult)has icceived a copy of this
Petition and joins in the terms of the proposed settlement (See Exhibit"P', Affidavit of
Beneficiazies Concurring in the Terms of t6e Proposed Setflement and Pelition.
20. Joseph D. Buckley, Esquire,counsel for Shirley Games[of Thornwald Nursing
Home, 442 Walnut IIottom Road, Cazlisle, Cumbedand Counry, Pennsylvariia 17013 (Mother)
(Adult)has received a copy of this Petition and joins in the terms of the proposed settlement(See
Gxhibit"J", Affidavit of Beneficiaries Concucring in the'Lerms of the Proposed Settlement and
Petition.
WHEREFORE, Petitiooer, Marilynn J. Willits, respectfulty request this Honorable Court
approve the settlement and authorize her ro execute all documents related to the settlement of the
aforementioned claims.
Respectfully subm' ,
Da[e: � z � �
Matthew L. Owens, quire
Law OfEices of Matthew L. Owens, Esquire LLC
I.D. No. 76080
6310 Allenrown Blvd., Suite 101
Harrisburg PA 17112
(717) 909-2500
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J COMMONNIEALTN OF PENNSYLVANIA IIIIIIIIIIII�I�III Gxh Number �
iOLICE CRASH REGONTING FOFM o��
AA 500 5 a..U,o,r �
W0376418
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Hamun�M aaamon�l wimews: ,ktltlent mvestqatim xoafwtion ksuM7 O imMnY D�m�9e O
Dispatch advised unik of vehicle accitlant a[Trintlle and Bare Rd.
Upon artival I saw the akermaM of a t�rae vehide motor vehicle a<citlent that occurred at inlersection of Trintlle
antl Bare Rtl.
Unit 1 tlnver,Yu Sun Smetlley was stanEing along ihe south sitle ot Trintlle Rd. She appearetl to have very
; minor injuries and was being checked out by EMS.I spoke with Vu bre�Xy anE sM1e told me ihe accident was her
_ fault arW iha[sha tlitln't see the other car coming.She was transported to Hershey by Wast Shore Ambulanca.
i Unit 2 dnver,Oianne Bamck was being tentletl M Ey EMS while s�ill in her vehiGe.This was tlue to�he fact tnat
the impa<t causetl ihe tloor ro ceasa to open and It hatl to Ee mechaniwlly removetl by tM1e fire tlepatlment.
G Banick was conscious and alert.She tlid have some blootl on her/ace trom laceratlon but was able to answer
� questions antl speak nortnally.
3 Unit 2 passenger. Marillynn NAlli�s was being�reated by Silver Spnng Ambulance and was transported to
Hamsburg Hospital with what appearetl lo be minor inlunes. (transpo�tlone West Shore AmDulance)
VJhile investiga�ing c2sh I learned ihat uni�1 was traveling eas[on TrinCle end Nrned nght onto Bare into ihe
tlirect Oath o/Unit 2. llnit 1 s hont le(t bumper impacted ihe front of unit 2 This causetl unit 2 to be pushetl to ihe
noM sitle oithe roatlway and impact uni�3,which was
���P� FENNOOTCOPY ' I
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passangers side of unit 2.
Afier about 10 minutes the fire tlepartment ana EMS was able to hee Bartick hom her vehick and get her I
into�he ambulance.VJe haa a quick conversa[ion on how the athe�unit(�nitl)pulletl in hon�of her vehicle.
She was Men ambulancetl ro Hersh¢y by SiNer Spring Ambulanca(Medic Haurk)kr what appearetl ro be
moGerote injuries.Bekre she left she tlitl tell me the oNer wrjust Nmed in front of her,
Unit i and 3 signetl offwith EMS and were not iransported, i
Miller and Sam iransportetl Uni�s 1 and Unit 2 to his secure/encetl area. Unit 3 was tlnvan hom ihe scene.
New Kingstown EMS ana New Kingsrown Metlic also assisted in this incitlent
Update-Unit 2 tlriver was fountl in her home deceased several tlays aRer accident Autopsy will be
peNormeE h try to tletertnine cause of tleath.
• Case remains
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Crash Number:W0376418
Incident Number SIL2013-10-01020
Bare Rd I
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Case# 2013-11-493
CORONER'S FIELD REPORT
CUMBERLAND COUNTY CONF����YT'�'"-
6375 Basehore Road, Suite 1 Mechanicsbu���' C(}��"(
Office: 766-6418 fax: 766-6419
NAME Dianne E. Barnck Sex Female Race White
HOME ADDRESS 304 Monrow St. CiTy Mechanics6urq State PA Zip 17055
If under 1 year
Birthdate 07l16/1948 Age 65 Mo._ Day_ Soc. Sec. No. 19538-9876
Pronounced: Date 11/02/2013 Day Sundav Time 1622 Married_NeverMarried X
Estimated: Date 71/02l2013 Day Saturdav Time +/-Z�00 Widowed_ Divorced
CAUSE OF DEATH: a. Blunt Force Iniuries
b. Motor Vehicle Crash
c.
d.
Other Significant Conditions: HASCVD Obesitv DM Heoatic Steatosis
MannerofDeath: NaWral_ Suicide_ Undetermined
Accidental_ Homicide _ Under Investigation_
Pronounced Dead By: Kann Location: Scene
Place of Accident, collapse, e[c. (include township or borough) Resitlence� Mechanicsbura
Next of Kin: Notified By: Cumbedand Comners Office
Name �iane Banacks Relation Cousin Phone 717377-7032
Adtlress City Slate_ Zip
Means of Identification: Pa Driver's License
Condition of 8ody: Fully Clothed X Partially Clo[hetl_Oescnbe: Orenoe shirt khaki oants
whife shoes antl whiie socks
Preservation: Well Preserved�_Decomposed_Describe:
Estimated Rigoc None_Complete_ Head X Arms X Legs X Describe Easlv
Broken
Livor: None_ Front_ Back_ Localizetl Back of the leas consistent with oositioninq
Blood: Absent X Present_ Loca[ion
Time Call Rec'd 1557 From CC911 Time O/S 7622 Pholos Taken Yes
PAGE2 ���.+��p�,'tiIT;,P_�
ApparentWountls None_ Gunshot_ Stab_�rBIunCFo�ce'�X �
Describe Pnmary: bruisina was noted on the bodv
Primary Location: Head X Neck_ Chest X Abdomen _ Ext�emities ��X
Hanging: Yes_ No X Means
DeceasedFound: Date 17/02/2073 Time +)- 1615 ByWhom PSPCarlisle
Address(if different): City State_Zip_
Location: Apartment_ House_ Townhouse_ Mo6ile Home_ Other_
Other(describe)
Entrance By: �oor Unlocketl_ Key_ Cutling Chain_ Forcing Door X Family_
Other(describe)
Other doors and windows: Open_ Closed X Locked Unlocked
Describe
Body Found: Dining Room_ Living Room _ Bedroom_ Kitchen_ Bathroom�_
Basement_ Other(tlescribe)
Location in Room: Sittinq on the toilet
Position of Body: Face Up X Face Down_ Other(describe)
ConditionofSurroundings: Orderly_ Untidy_ Disarray�_ Normal: Yes X No
Lights and other appliances: N
Evitlence of last food preparation: Yes_ No�
Location: 7yPe:
Dated materials and where found:
Mail: Newspapers:
Vehicle Involved: Yes No X
Make Model Color Reg#
Last Contact with Deceased: Date 11/01/2013 Time 1630 Manner Visual
Name of Contact: Maria A Loose Relation Neiohbor Phone 717-697-8439
Police or Emergency Personnel Notified 6y:
Name Carol Pool Relation Friend Phone
Address 435 N Mountain Rd City Newville State PA Zip 17241
Date 11/02/2013 Time 1618 Manner PSP- Cadisle
�Fi�G�'���}�'�� PAGE 3
^z�
�' ���neelDf��iratlons:(Prescription and Non prescripiion): Yes X No List Atlached: Yes
� �'� � —
Doctor Flemmina Address _Hershev Medical Center Phone 717-531-8521
Evidence of Drug Paraphernalia: Yes_No X Describe
Evidence of Alcohol Intake: Yes_No X Describe
Weapons Present:
Gun: Yes_No X Caliber Make
Model Serial No.
Knife: Yes _No X Describe
Other(tlescribe)
Disposition of Weapon (s):
Evidence of Sexual Deviate Practices: Yes_No� Describe
Investigating Officer: Tr000er Miller Affiiliation: PSP Carlisle
Disposition of Body:_ Hollinqer Funerel Home
Adtlress
Per V�A
Autopsy: Yes X No_ Reason: No obvious cause of tleath
By Dr. Michael Johnson Location LVMC Date of Autopsy 71/05/2073
Body Fluids Drawn: Yes X No_ Time At Autoosv
Valuables Retained: Cell Phone- Wallet Cash Kevs
Disposition of Valuables:
Operator's License Attached: Yes X No_ State PA OLN 08747699
Mileage from: OKce/Scene/Office7Home Totai Miles Traveled
��NF�OEG��#
Q� ��+Case#2013-11-493 Barrick
I was contacted on November 03,2013 at 1600 and requested to respond to 304 Monroe St.in
Monroe Township. I arrived at 1620 and met with Trooper Miller with the Pennsylvania State Police
Criminal Investigation Division who advised me that the deceased was in the bathroom.According to the
neighbors she was involved in an actident[he other week and hasjust gotten back from[he hospi[al
yesterday afternoon.She hasn't been seen or heard from all day.Pennsylvania State Police received a
call about checking the welfare by a Carol Pool a friend of the deceased who said[hat she has called[he
deceased severai times and hasn't heard from her all day. Upon Ihe troopers arriving Ihey were not
able to get a response at the dooa They walked around[he house they found her in the bathmom not
responsive they forced the garage door and summoned EMS. Upon making contact with the deceased in
tbe bathroom they found 6er to be beyontl help and<alled for the Coroner's Offire ro res0ond.
Examination of the body found tha[deceased si[[ing on the toile[in[he bathroom.5he had
several bruises on her body and it disrovered[hat she had been in a vehide acciden[on October 29,
2013,and she was[ransported to Hershey Medical Center in Pennsylvania. Rigor Mortis was present
and easily 6roken and liwr mortis was present and consistent with positioning.
Notification was made to Diane Banacks the cousin by the Comnels Office.
Medical Records were obtained from the Hershey Medical Center in Pennsylvania.
Due to Ihe Circums[ances surrounding the death an autopsy was ordered by[he Coroners
O�ce.7he autopry was peAormed by Dr. Land on November 4,2013 at the Lehigh Valley Medical
Center in Allentown,PA.There weren't anatomic findings from the auropsy. Fluids were obtained at the
[ime of the autopsy for toxicological tes[ing.
A death certificate showing the cause of death as Pending Investigation was issued by
[he corone/s office.once findings from the mxicological tests and the final autopsy report are received
a Fnal death certificate will be issued by the Coronefs Office.
The 6ody was released ro the Hollinger Funeral Home via Mariyn WillitZ.
��
Mark E. Kann, Depury Coroner
NF1D��r°��1A1-
,Q�1�"S'REhORT
Name: BARRICK,DIANNE Autopsy No.: C-13-779 Page: 3
F. Glucose: 59 mg/dL
G. Acetone:negative
H. Ethanol: not detected
OPIMON:
The death of this 65-yeao-old womac�,Dianne Barrick, is attributed to blunt force inj�uies
complicating hypertensive arteriosclerotic cazdiovascular disease,obesity,diabetes melGtus,and
hepatic steatosis. Blunt force injuries were reportedly sustained in a moror vehicle wllision.
/G���. �a�a3��3
Michael W.lohnson, M.D.,PhD.
Forensic Pathologist
MJls
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PORT
hame: BARR[CK, DIANNE Autopsy No.: G13-779 Page: 4
CIRCUMSTANCES:
Per[he Cumbedand County Coroner and medical records provided by the coroner,the decedent
was found dead on her toilct on 1!/3/2013. She had 6een in a motor vehicle collision on
10l292013. Reportedly, she was the belled driver of a vehicle,which collided with a pickup
truck. She was taken to Hershey Medical Center where she was treatuJ for multiple injunes,
including: penetrating injuries o([he leh breas[and shoulder, fracNred lumbar spine(transverse
proceas), broken nose, and bruises of the torso. These injuries were documemed by physical
examination and X-ray exams of�he chest, left knec, lefi clavicle,and lefl hand and CT exams of
the head, spine, chest, abdomen,and pelvis (on 10/29/2013). CT of the head did not demonstmte
intrecrenial abnortnalities. Incidental findings of these ezams included cholelithiasis,diffuse
hepatic steatosis, and mild rectosigmoid diverticulosis. Wounds wete treated,and Ihe decedent
was discharged on November 2,2013. She was discharged with the Collowing medications:
metformin QanumenQ, insulin (Levemir), naproxen, fexofenadinc,esomeprezole,meroprolol,
Hyzaar, atorvutatiq aspirin,oxycodone, and acetaminophen. Acwrding m medical rewrds and
the decedenPs Criend,she had experienced a myocardial infaretion in thc past and was known to
have wronary artery disease,diabe[es melli[us, and hypertension.
EXTERNAL EXAMINATION:
The body is received in a body bag labeled with the decedenYs name,Dianne Bamck. The
decedent is clad in an orange shirt, a pair of light tan shorts, wlute underwenr,burgundy socks,
and white slip-on shoes. The shorts and underwear are pulled down to the knees.
The body is Ihat of an obese whi[e woman consistenf with thc reported age of 65 years. The body
weighs 269 pounds and is 63 inches in measured length(47.7 kg/m'). Rigor mortis is broken
with ease in [he extremities. Livor mnrtis is fized posleriorly except over pressure p0ints.
Injuries of the head, neck,torso and extremities and associa[ed medical therapeutic changes will
be described (See"Evidence of Injury"). The comeae are clouded. When viewed through
clouded comca, the irides appwr bluc. The conjunctivac are injceted. The sclerae are white.
There are cutaneous shetch striae of the skin of the abdomen. Extremities are wi[hout gross
deformity or fracture. Tags on the decedenPs lefl wnst identify her az Dianne Barrick.
EVIDEVCE OF INJURY:
A 6 cm x 3 cm healing cutaneous abrasion is on the nght side of the forehead. Healing a6raded
cntaneous contusions(2 cm and ].5 cm) aze upon Ihe righl side of the forehead and m the right of
the rigtit orbiL The nasal skelelon is abnortnally pliable. There are faint conNsions of Ihc skin o(
the oral labia. The scalp is reflected [o reveal scalp and subscalpular hemolrhages over[he frontal
bone and hemorrhages of the left temporatis muscle. The skull is extemally atraumatic.
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However, the calvarium is removed m reveal a tliin layer of liquid subdural hemo}rhage over the
left parietal and occipital convexity and within the left middle cranial fossa. See"Autopsy
Neuropa[hology Report" for addi[ional infonnation.
A geen contusion is within the skin oflhe central chest. There is irzegular abrasion of the nght
breast On the right side of'the cheu and abdomen is a commingling area of healing abrasion(10
cm geatest dimension, discon8guous)within a larger area Q 7 cm x 3.5 cm)of cutaneous
wntusion. Bandages over[he left side of Ihc upper chest and leR breast are removeA to revcal
wounds packed with surgical gauze. The changes are consistent with penetrating injunes that
have been surgically debrided. Pu`ple cutaneous conmsion is in(erior to the left breast. Purple to
green cufaneous contusions are on the right side of the chest and right Flank. 77iere are multiplc
healing cutancous abrasions of the central and left side of the abdomen. Eaere are discontiguous
conNsions of[he ngh[inguinal area-Creen-purple contusion(Scm x 4cm)is upon the right side
of the upper back. Y-incision reveals subcutaneous and muswlar hemoahages subjacent to the
described extemal injuries. Horizonta] fractures of thc T4 and Ll venebrae are present. 77�ere is
discoloration(purple-brown)of thc upper thoracic paravertebral soft tissues,but there are only
trace hemorrhages of the fracture line wi[hin the lumbar spine. Post-mortem fractures do
somctimes occur at autopsy in the cldedy and/or persons with ostcoarthritic changes or
ostcopenia. Givrn Ihat these spine fractures were not dowmented by radiologic ezaminations
while the decedent was alive, 1 suspect that they represent post-mortem changes(artifacQ. The
spinal space is opened [o reveal no sigtificant epidural hemoahages. The entirety of[he spinal
cord is retained for addilional examina[ion (Sec "Autopsy Neuropalhology RepoR").
Cutaneous contusion and mul[iple abrasions commingle within a 7 7 cm z ]0 cm area on [he
medial aspect of the right knee. A grouping of contusions/abrasions and lacerations(some closed
with sumres)is upon the medial aspect of the left knee(I S cm x 6 cm). Purple discoloration
(ecchymosis) is behind the left knee.
Ecchymosis of[he righ[ foreartn may bc duc ro trauma or mcdical thcrapy. Abmsions arc
scattered over[he dorsa] surfncc of[he righ[hand. En�ensive lacerated wtaneous abrasions are
upon lhe palmar and radiat surface of[he Icft thumb and scattered ovcr the patmar surface of�he
left hand.
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g
ORGAIV R'EIGHTS AND FLUID VOLUMES:
Brain: 1240 grert�s
Heart: 630 grams
Right Lung: 615 grams
Lefi [,ung: S�p grams
Liver: 2450 grams
Pancreas: 350 grams
Spleen: 500 grams
Right Kidney: 210 grams
Left Kidney: 210 srams
Stomach: 725 cc ot[an-pink paste
Galibladder: 3 ec bile
Udnary Bladder: None
iNTERNAL F.XAMINATION:
A "Y-incision"is made through the midline paiuiiculus measuring up to 3 inches through red
musculxture into [he abdominal cavity lined with glistening serosa and containing Vace foul
smelling burgundy fluid(dewmpositional fluid). The appendix is present. The gallbladder is
present. 17ie abdominal viscera are in their typical in situ relations. The uterus,uceriue tubes,
and ovazies are present.
7'he mediastinum is in the midline. The mediattinum is widened. The lungs are typically
ieiflated. There is trace decompositional fluid within the plewal spaces and within the pericardial
space.
HEAD AND CEN"CRAL NERVOUS SYSTEM:
See "Evidence of Injury." See separate "Autopsy Neuropathology Report."
NECK:
Layered anterior dissection of the neck reveals no significant hemorrhage within muscles of thc
nech. The hyoid bone and thyroid cartilage are atraumatic. 7'he epiglottis is not enlazged or
obstructive oC[he eirway. The airway is lined by typical tan muwsa. The vocal cords are grossly
normal. T6e aincay is free of obstructing foreign material. The rongue is without�mss
pathologic abnonnalities.
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Name: BARRICK, DIANNE Autopsy No.: C-13-779 Page: 7
CARDIOVASCULARSYSTEM�
The heart is enlarged. It weighs 630 grams.There is a palpable induration of[he lefi anterior
descending ertery. Serial sectioning of the coronary vessels reveals an intravascular stent aithin
the lefr an[erior descending artery. There is calcific change of the srent. Proximal to the sten[,ffie
vessel is at least greater Ihan 50%narrowed as a res�lt of atherosdemtic disease with azsociated
mineralization(calcification). Seriai sectioning of the Ieft circumflex artery reveals a fceus of
greater than 50%narrowing within the proximal ponion of this vesseL Multiple foci of greater
than 50%luminal narrowing are grossly visible throughout the right coronary aztery. The heart is
sectioned&om its apex to approximately 1 em below the atrioventricular vaWes. The left
venhicle is dilated. Pallor likely indicative of myocardial scarring is distributed in a near-
circumferential manner at[he apex of[he heart, with extension inm the more superior anterior
lefl ventride and interventricular septum. The changes are consistent with remote myocardial
infarction.
The aorta is mazked by the eflects of ulcerative atherosderosis.
RBSPIRATORY SYSTEM:
The lungs are of typical lobation and weigh 6(5 and 520 on the right and leh, respectively. The
airways contain froth. The pulmonary arteries are free of ante-mortem thrombus. Serial
sectioning reveals pulmonary edema and changes of dif£use vascular congestion. Representauve
sections of each lobe aze collected for histopathologic examination.
HEPATOBILIARY SYSTEM:
The liver weighs 2450 grams. The capsule is smooth and grossly intact. Sectioning of Ihe organ
reveals slighdy sokened ta��-brown parenchyma. Gross focal Izsions are absent. The gallbladdcr
con4vns bile and mWtiple small pofygonal bro�m stones. The esvahepatic 6ile ducts are free of
stones.
HGMOLYMI'HATiC SYSTEM:
The spiecn is cnlarged. Serial sectioning reveals near liquefaction of the splenic parench}ma in a
manner consistent vdtA decompositional change.
The systemic lymphoid tissucs arc without other specific abnortnalities.
Sampled bone martow is without spccific gross pathologic abnormalilies.
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Name: BARRICK DIANNE Aufopsy No.: G13-779 Page: 8
GASTROINTESTINAL SYSTEM:
1'he esophagus is lined by typical tan muwsa. The gashoesophageal junction is wuamazkable.
The stomach contains approximateiy 725 ce of tan-pinF;paste. The gastric mucosa is typicalty
wrinkled. It is without erosions or u�ceratioa The pylorus is unremarkable. 'Ihe small intestine
is without goss pathologic abmrmality. There is diverticulosis of the disial colon. The
appendix is grossly unremarkable.
GENITOURINARY SYSTEM:
The kidneys are of similaz size and shape. Both weigh 210 grams,and both demonsUate severe
surface cortical granularity end pitting. Serial sectioning reveals blurring of the corticomedullary
demarcations. I do not appreciate focal lesions of the cortices,medullae or pelves. The ureters
attach typically in[he bladder. The bladder con�ains no urine. The bladder muwsa is light tan
and finely wrinkled. The vagina is without foreign material. The ecmcervix is unremarkable.
The uterus is opened in a typical menner to reveal tan endocervical muwsa. A uterine polyp(5
cm)occupies much of the endometrial cavity. Its stalk emanares from the posterior lefi wall of
thc uterus.
The urerine tubes are unremarkable. Serial sectioning o(Ihe ovary reveals no specific
abnomialities.
ENDOCRINE SYSTEM:
The thyroid lobes are symmetricaL Serial sectioning reveals multimdular gross changes
consistent with glandulaz hypelplastic changes.
The pituitary gland is grossly typical in size and shape.
"Phe adrenal glands are composed of typical yellow conical substance surrounding liquefied and
softened tan-brown medullary parenchyma.
The pancreas is enlarged. It weighs 350 grams. Serial sectioning reveals changes possibty
indicative of pazeneh}�nal saponification in association with apparent dilatation of the ductal
system. I do not appreciare papillary lesions within the ductal system or obsWction of that
structure by stones. A representative section of the head of the pancreaz adjacent to the duci is
collected for hisropathologic examination.
MUSCULOSKEI,ETAL SYSTEM:
See"Evidence of Injury'
'�L�l
��ca����ca�c���
�,U�pp��EPbRT
� , _
Name:BARRICK, DIANNE Autopsy No.: GI3-779 Page: 9
MISCELLANEOUS:
Donald Riley is the forensic autopsy technician. No one is attending the au[opsy.
Representa[ive samples of organs and tissues are retained in fomtalia
Represeniadve samples of organs and tissues are collected for histopathologic e�mination.
"I'he brain and its coverinss snd the spinal wrd and its coverings are retained for formal
neuropathologic examination. See separate"Autopsy Newnpathology Report"
Pos[mortem fluids and lissues are collec[ed and submiped for toxicologc analysis.
Photogaphs are collected and retained at this o�ce.
A blood card is collected and retained at this office.
�l�t�lJ
i:�'1 l�''..,
k}±�fi . `�d .r
','�UTQPg�'B�PORI'
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i' �' �'�``�
Name:BARRICK,DIANNE Autopsy No.: C-13-779 Page: ]0
MiCROSCOPIC EXAMINATIO'V
FTEART:
Moderate to severe multivessel coronary atheroscicrosis; myocardial scarring of septum and
anterior left ventricle(remote infarct) with su�rounding myocyte hypemophy;decompositional
changes
LUNGS:
Pulmonary edema
LIVER:
Decompositional changes; steatosis
KIDNEY:
Sampled renal tissue demo�strates mazked dewmpositional changes. There is widespread
glomerular scarting. A relatively cicrumscnbed area of central edematous tissue(predominantly
stroma), admized hemorzhages, and c'vcumi'erential clear celt proliferations is of uneertain
signfficance.An incidental clear cell renal carcinoma is considered but in the context of the
pervasive decompositional change,the ce11ulaz de[ail is obscured and such a diagnosis is
indefinite.
PANCREAS:
Decompositional changes;inereased fibrosis and patchy acute and ehronic inflammation—
changes consistent with acute and chtonic panereatitis
Microscooic Slide Index
1: lefr anterior descending coronary artery
2: septum, heazt
3:anterior left ventricle
4: upper lobe,middle labe,lower lobe,right lung
�: upper lobe and lower lobe, left lung
6: liver
7: lcft kidney
8:pancreas
. �
f� '`"�V
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� ,��.' �� ���� t� ���
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Porensic Pacholo�-��tfssociates
�� F P A ���
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NEUROPA7HOLOCY AUTOPSY REPORT
Patient Bartick, Dianne Prosecror: Dr. M.Johnson
Age/Sex: 65 ywrs/Female
Case#: G 13-779
Expiration: 11/3/20]3
Autopsy Date: I 1/5/?013
CNS ezamination Date: 11/20l2013
Final Pathologic Diagnoses
I. Acute su6dural and intradural hemoerhage(s)(also see"Autopsy Report")
II. Dural sidemsis
III. Cerebral microangiopathy
Clinical Information
Sce "Autopsy Rcport"
Gross Description
Available for exarnination is the braiq portions of its covenngs,and the spinal wrd and
its coverings. The spinal cord is 37.5 cm long.
The cerebral dura mater is without residual blood accumulation upon i[s inner surfaces.
There is fain[red/purple stnining of[he fulx and cerebellar tentonum. The dural sinuses
are frce of sipiificant thrombus. Representative sempies of�he dure are collected for
histoputhologic examination.
The cerebral hemispheres are symmetrical. They are without eztemal signs of mass
effect or hemiation. Disruption of the nghi temporal pole is aUributed to extruction.
Page lof3
�
_- 'Pattenh BARRICK, DIANNE ACE: 65 Sex: FEMALE C-]3-779
'`4 ' „
,. ".
i ' ya
. _ a - v
��.._� � ���,r j '* The leptomeninges are glistening and iranslucent. The gyral configumtions are typical.
�,f�) '�� �� Cranial nerves are nonnal. AAeries at base of the brain demonstra[e very mild non-
� occlusive atherosclerosis. These lazge arteries arc Gee of obstruction, abnormal
dilatation,or perforation. The brainstem is extemally unremarkable. There is very faint
dusky discoloration of the inFerior surfaces of both cerebellar hemispheres.
Upon serial coronal sectioning,the cerebral gray and white mauer are well-demarcated.
The white matter appears well-myelinated. The cotpus callosum is of a nortnal thickness.
The intcrventricular septum is well-fortned. 7'he ependymal sudaces are smooth. The
caudate nuclei and lentifortn nuclei are grossty typicaL The thalamus and hypothalamus
are without specific goss pat6ologic abnormalities. The amygdalae and hippocampi are
bilaterally symmetrical and without significant atrophy. ln the midbrain, the substantiae
nigae are gossly well-pigmrnted, pxjal sectioning of the pons reveals irtegular brown
discolorations of the basis pontis which appear ro represent vascular marAings. The
medulla oblongata is without goss abnormalities. Axial sections of the cerebellum
rcveal typical cerebcllar folia without wvitations,hemorrhages,or other gross pathologic
abnormalities. Becausc of the gross appearance of the inFenor sudace of the cerebellum,
a portion of the inferior left cerebellan c�misphere is collected for histopatholo�ic
esamination.
The spinal dura is extemally unremarkable. It is opened anteriody. The subdural space
is free of hemorthage. The surfaces of the spinal cord arc externally unremarkable.
Axial secfioning of the entire cord reveals typical gray and white matter swetures. The
anterior and posrerior spinul roots are grossly typical. Dorsal root ganglia are grossly
typical. Representutive sections of the cervical, thoracic and lumbo-saaal cord are
collected for hisropathologe examination.
Microscopic Description/Discussion
Routine H8E-stained seMions of[he tissues listed below nre reviewed. Sclect tissues are
subjected to iron stain(B I5, B 16, Bt 7, B 18).
Mui[iple sections of[he intracranial dura mafer are examined. Palchy in[radural acute
hemo�rhages and basophilic iron positive(iron s[ains) accumulations are within the
tcntorium cerebelli. Rare iron positivc linear and curvilinear deposits are within the falx
cerehri and convexity dural membranes. There is not significant blood,clotted blood, or
organizing hemorrhage upon the itmer surtSces of[he sampled dura.
Arterinles within the cerebral white matter and in proximity to the striatum/basal ganglia
demonstrate variable changes, including medial and/or intimal Ihickening and `onion
skinning' typieal of angiopathic change in persons with various comorbidities, such as
hypertensioa !n the putamcn/glnbus pallidus, the changes are associated with widening
of penvascular spaces and variable gliosis indica[ive ofischemic injury(sta[us cribrosus).
Pagc 2of i
��
: �
ie ARRICK, DIANNE ACE: 65 Sex: FEMALE C-13-779
.{.�� �
,-,";' r�.t
t'�� �i../t,
�-� �, � 1 do nol appreciate specific abnormalities of[he neocortices,deep gray nuclei, brainslem
�`J orcerebellum.
Sampies�of spinal cord reveal intrarnedullary,perivascular microscopic aeeumulations of
spindle cells(neuromata)at multiple thoracolumbar levels. t do not however see specific
histopathologic findings ofrecent hauma.
t
� ,q � 3
Michael W.Jof , M.D., Ph.D.
ForensicMeuropath ologist
Microscopic Slide List
B] —left middlc frontal gyrus
B2—left orbital frontal
B3 —]eft temporal
B4—left basal ganglia/basal forcbrain
BS—left parietal
B6—left thalamus
B7—leti hippocampus
BS —pons
B9—medulla oblongata
B 10—Ieft inferior cerebellum
BI 1 —cecvical spinai cord
B 72—thoracic spinal cord
Bl;—lumbosacral spinal cord
B 14—piNitary gland
B I 5— lefi dura mater
B 16—ri�t dural mater
B 17—falx cerebri
B 18—cerebellar ten[onum
Pagc 3of J
'a,�` L
" i 2024 Lehigh Strect
��s��;x� Iiralth;�cncork
/ i �n�+u � i u x i i . Allenrowo,PA 18103-4798
� (610)402-8170
�� , • . Toll Free: (877)402-3221
Date: November I8, 2013
Toxicolo�� Report: Tox-27341
Autopsylnformafion: Barrick,Dianne 65/F
C-13-779
Novembcr 5,2013
History:
Recent MVC-Hospitalized then discharged. Pound dead on toilet at home. History�of diabetes,
and H'I'N.
Specimens Submitted:
Blood (Heart). Kidney, Bile, Liver,GasVic Contents, Vitreous
Results: Concenlra6on Units Therapeutic Raoge Detectioo Limit
—__ _.—__ .__._
.._. _. _ _-_. ._____
_..—._ _.__—.- --.
Blood(Flean) Collection Time: I1/OS/13 10:45
Ethanol 0.06 �/
01
Sertraline 6fl n�mL 30-I00 2p
Ozycodone, Total 58.6 ne/mC 10-I�0 g
Oxymorphone, Total None Derected ng/mL Not established 5
Vitreous CollectionTime: 11/0i/13 10:45
N'4 �49 mFq/I 135-I50
K �7.0 mEq/I <IS
�� 107 mGq/I I05-135
Creatinine <02 mg/dl 0.6-13
Urea nittogen 12 mg/dl 6-?0
Glucose 59 mg/dl <200
Acetonc Negative mgldl
Ethanol None Detec[ed % 0.01
Sez attached Malysis Summary for complete listing.
� �
��oann�ASCP), SC, TC
; CertiCying Scientist
✓
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to tluplicate this copy by photostat or photograph.
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COMMONWEALTH OF PE\NSYLVAnIA SHORT CERTIFICATE
COUNTY OF CUMBERLAND
sli � �
T'� ���'�
I, Glenda Farner Strasbau�h, Re�ister for the Probate of Wills
and Grantine of Lztters of Administration in and for
Cumberland County, do hereby ceRify that on the 12th dav of
Nor:mber =013, LET:ERS "CES PAMENTARY in common
fonn were eranted by the Register of said Counry, on the estate
of Dianne E. Barrick , la[e of Monroe Township in said county,
deceased [o Marilvnn J. Willits a/k/a Marilvn J. Willits a/k/a Marilyn 1. Willitts a�d [hat
same has not since been revoked.
IN TEST[MONY W HEREOF, I have hereunto set my hand and affixzd the seal of said
otTice at CARLISLE, Pennsylvania, this 3rd dav of December 2013.
Date o}Death: November 2nd 2013
Social Securiry No. 19�-38-9876
Estare No. 21-L3-1198
�P-�,P� a�r � �,v �t-r���ec�e,�
R i cr
�il�(I Pr7,�PD ,�12U,1(?s�
Deputy
.\OT VALID W'ITHOUT ORGINAL SIGNATURE AND I�IPRESSED SEAL
Pennsylvania EMS Report
Servi<e Nvme S�a[ion Uni[Name,No.&T��pe PCR No. �ale
WmSLorcEMS FSta�ion-MICU 60i2102260/MICU 131]9fi5 Ia292011
In<ident Locatian Cmmt�.M1lunioipality&Inci�em ZiP PSAP Incid Na.
wTnndleRdBoixRd,Mxhaniaburg,PAl]Oi0 CUMBERLAN�,SilverSpnngTownship,17�50 CI55?97
Shect or Hlghwuy
Rceeiving dgenry
Unirersily Hospiial-Henhey
Patimt Nsme C[CW
Dianne E Bamck H+
Q Strre�pddrev CL GoM,William E11T-P IS]30l W
p30.M1 Monroe Slreet CE: Fox,Stephen ENT IY2820 �
F-I Ci7' S[au Zip C3: �
p Mechanicsburg PA I]O55 �a� �
y Sex wge pOB Phone No. Primary Caregiver: CI Dri�xr. C3
� Female fiSYears 09/16/1948 (]I])'/91-0344
a Petiem Number Social5ec No. Pt.N'eigL� Mileag¢
HersheyMRNO]514'_0 195d8-98]6 Out Ou-Scene Dest p�
Private Ph�sician Oricer's License 0.0 L6 26.0 59.3
Tronsponingassistllnils 4ssisr05 Time3
WestShoreALSM-88 13j� ReeponseTime: ? 911: �;;q7
Response0utcame Na�ureoflncident ER7ime: 5 Dispatch: 14:i3
Treared,TanspottedbyEb6-ALS ALS
OSTime: 2J Eurouh: IJ:iS
ERHTime: 3l prrive5cene: Ii:50 (J�
Ligh�sand5irens NOLigh�sorSirens �
DesfioafionTime: 13] Contac[ �q�,5�
ParientConAi�iononSrene Pa�ientCanditiona�Facility TotalTimr. IR6 DepartSrene: 15:13 �
bloderare Improved TimeOu[of IBJ p����e; �j.q� H
Quarters: .4vailable: I]:J9 A
O
IvQuarcen: lia9 p
CLiefComplainc h1V9,ChestPain.Lef�IOimPain,LeFlShoulderPain
Current Aleas: Allegra,Nexiuni,Me�oprolol,Hyzaaq Lipimr,AS.4,Alece,Fish Oil,Levemir
Nlergin(meds): SWfa
PMHc: Diabetes,Hypmensioq MI wirh 1 mmnary anery smnl,GERD,Hi¢h Choleshrol
Narrative
Dispatched class 1 by CC911 call center to the above location for an MVA wilh multiple pPs .
Immediate emergency response.
( AOS ) Greeted by Al172 BLS crew stating there are muttiple pPs, One pt was on the side of the road
with a ALS crew from MICU 482 assessing the pt. The 2 other pPs located in a silver Hyundai sedan
with BLS crew A/172 attending to the passengec The driver was entrapped with the steering wheel
deformed pressing down on her lap, the front dash pushing down on her legs, with airbag deployment
on the driver side. Driver CAOx4 to person, place, time and event w/regular respirations and strong,
Pri�ned On: 10/29/2013 20:08 �� � ��
Provider
EMS�at Reporting(c) I998-2013,Med M1lzdle,Inc. All Riehts Reserved Page' 1 0( 4
Pennsylvania EMS Report
Sen�ice Name Uni�No PCR No.
Was�Shorc EMS fi0/?102260!MICU Da�e
131796i 10,19;20❑
Po�ientName Da�eoBirtL SoaialSecurit}1Jmnber p$pp
DiameEBaniek 0]'Ihi191Y 195-J8-9Y]fi ��5�g�
regular pulses.
( CC ) Left upper chest pain, Left shoulder pain, left knee pain
(AssocSym/PertNeg) Pt denies any dyspnea, dizziness, nausea/vomiting, or any back or neck pain. Pt
denies any loss of consciousness and has full recollection of the incident. Pt denies any numbness,
tingling, or loss of sensation in her extremities
( HPI ) Pt stated she was traveling westbound on W Trindle Rd, approaching Baer Rd, when an
oncoming car heading eastbound on W Trindle Rd decided to make a left onto Baer Rd in front of the
pPs vehicle. The pt stated she applied her brakes but the oncoming car did not stop, and struck the
front of her car on the left side of lhe vehicle. The pt upon ALS arrival was entrapped in the vehicle with
the deformed steering wheel pressing down on the pt's pelvic area, the dash pushing down on her legs,
the windshield spidered just above the steering wheel in the left upper comer. The pt stated she had
full recollection of the incident and did not loose consciousness. The pt stated she had no back or neck
pain upon palpation, and had multiple abrasions, lacerations and a puncture in the left lower breast
area. 2 lacerations on her head, and pain upon palpation of her left upper chest. The pt also stated she
had pain in her left knee that had swelling, bruising and multiple tacerations with minimal bleeding.
Deformity of the lefl ciavicle.
PMH- Diabetes, Hypertension, MI with 1 coronary artery stent, GERD, High Cholesterol
MEDS- Allegra, Nexium, Metoprolol, Hyzaar, Lipitor, ASA, Aleve, Fish Oil, Levemir
Allergies- Sulfa
( PE ) CAO x4 to person, place, time and event
Airway- Self patent, speaking clearly in full sentences without diffculty
Skin- Pink, warm, and dry, acyanotic, multiple lacerations, good turgor
Heent- PERRL, neg facial droop, neg jvd, 2 small lacerations on her head, minor scrapes on her
face.
Chest-BBS CTA, minor lacerations left upper chest, and on the lower left breast
ABD-Atraumatiqsoft, non tender x4 quads, non distended, non guarded
PEWIS_Atraumatic, soft non tender x4 quads, non distended, non guarded
Exlremities- Pulses, Movement, and Sensation intact x4, Moves all eztremities with purpose on
command without deficit, Equal grip strength. No obvious pedal edema noted bilateralty. minor pain
upon moving the left knee.
( TX )Assessment and vitals. Pf extricated from the vehicle with fire and EMS assistance onto a
backboard, boarded and collared with o-spine precautions, strapped to the board via spide�aps, then
Printed On: ]0,'29/2013 20:08 � � � Provider
EYIStat Reportino(c) 199��013,M1led�tedix,Inc All Rlghrs Reserved- Pe�e: 2 0( 4
Pennsylvania EMS Report
ServiceName UniiNo PCANo. Dme
Wes�ShoreEMS 601210'260/M1llCU 1319965 10'_'9?OU
PatientName DateofBirW SocialSecuri��tiumber PSdP
DiuMeEBan9ek OUI611948 195-18-9976 CIi5397
loaded onto the litter and secured, then extricated to the ambulance. Cardiac monitor applied 12 lead
EKG obtained pt presenting with a sinus tachycardic rhythm. IV attempted enroute wi[h success in the
left hand wi[h a 20ga catheter, saline lock with a TKO rate. Pfs multiple lacerations bandaged and
checked enroute. Pt transported class 3 to Hershey Hospital w/cardiac monitor applied. Pt condition
remained stable throughout transport. Pt moved from the litter via backboard onto the Ed bed in trauma
bay 2. Care transferred w/ report to Hershey Trauma Team, with report given to Cindy L, RN. PYs final
EKG noted to be a sinus tachycardia. Upon transfer/termination of pt care pt noted to be CAO x4 with
chief complaint voiced of chest pain, left knee pain and left shoulder pain only. ALS provider explained
to the pt the Holy Spirit Hospital/West Shore EMS HIPPA pamphlet and signature form. Pt states they
understood both and made an informed decision to have the trauma nurse sign the HIPPA signature
form. ALS provider furnished the pt with a copy of the HIPPA pamphlet Available w/out further incident.
Trip sheet completed by William Gohn, EMT-P 157303
Time Eveuh Provider Commeuh
Ii51 Misa dsse<smrnoAdulr.Success: Vi;P�. Respo�e:Unchan¢ed p�p«
�' IS:Oi ImimlxExmca�ion�,PtRrsponse:Unchan�ed O;her FlrcmonrocTxp,kewKinesmwn
'� 1506 Irmnob-SpinalLmnobilizeuon O�ha Firc,BLS,A15ereusassi�sred
.vi�h invnobiliza�ion
I5�.10 Vitels:Pulsa: lOJ�,Rnsp-18�,Oximeiry:98°;;B.P.: I98'Ii��MammlCuft);GCS: GoLnWilliam AkdIc88 '
45�6;ResP EBon:Nannul
ISJ3 Misc:WoundCare�.5u�roess: lil,P�.Responm_Unchanged Gohn,Williein Muliiplalaermnonsbandaged
li'.H M11iec:EmnmeHespiml;5ucrose:0;0 GoW,Willlam
Ili'.18 EKG:Defib:CardiacMoni�or,Rhythm:5inusTacliycardia,RhplunatHospi�al�. Gohn.Willian
S�mus Tadiycardln;Lead-11;PWsc Ycr,%.Respotae_Gnq�angcd
Ii30 V➢als:Pulse. 102�,ftesp_IB:Oximeery_984¢;BP_�IJ6P(Palpa¢dCuR)�,GCS�. Oihev M..tlicSB
4f5'6;Rap Etion:Novnal
IIS'.2'_ IWIO_Venous A¢essExrtemiry;Sumac: VI;Loro�lom Han&Lzfi;Fluid:Sallne GoM,William
� Lock Sizm 20 G;Rz�e-TKO�,P�.Respo�c Unchaugaa
1380 Vi�als_Pul,e'. 101,Resp:30;Osiine�ry'.98%;B P._ 148B0(Monuel Cu[i);GCS. Gotut\4flliam
4'i-6:Reep.Ef6n'.Nonnal
ISJ3 Ivfism Contact 91MIcal Com�nand',Success 1'1;Pe ftesponse Unahvnged Gohq\4illimn Repoit Glven m�Iedieul
Conunond Dklucquu 9839
I5.75 EKG-�efb: C-Lead ECGObuin�,Rhyihn:Sinus Tachycardia�,Rhythm a GoM,\Villiam
Hospiml�.5lnusTadrvcardia;Pt.Response:Unchange�
li:�i Vi�als:PuLtt: 10'_�,Resp:20�,Oximetry:99%;B.P: 150:90(ManualCuff);GCS: Other J7etlLc3S
4ti16;Rezp.Efl'o�c Nonnal
li:�] Misc:Amrel Hospi�al;5uccess:00 Gohq\VilOam
PrintedOn: 10/29/?OI3 °0:08 � / / � p�ovfder
EMSm�Reporting(c) 199F-20I3,Dizd i\ledie, Ina All Righ�s Reserozd. Paoz�. 3 of 4
Pennsylvania EMS Report
s«,;�o n,me w���rvo
Wes�ShorcEMS b��� PCRNa. Date '
� 10'_160/MICU ❑I"l96i 10:79�70❑
PmiemNamc Da�eofOinL So<ial5e<uriry�,�umber PSAP
Diav�e E Bmrick 0]/16i 1943 I95-18A896
CIi5297
Time Even[s
Provider Comments
15 48 EKGiDefib_ 12-Lead ECG�Ob�ein;RFphnv Sinus TnchycaNla;Rhy�hm a[ Go1m,Williein
HospimP.Sinus Tachycardia;Leae:II�,Pulse�.Yes;P�.Response:Un:hanged
I5:50 MisaLart;krofCare;Succas:P'0 CohqWilliam
Pcinted On: 10/29/2013 20:08 ��� ��
EMS�at Reportfn¢(c) 199b-2013,Med hledia, Inc. All Rlghls Resaned. P�o�ide[
Paoe: 4 of 4
Pennsylvania EMS Report
ServiaName Slation UnitName,No.&T e
l4'est$horeEMS XS[ation-SquaA 35/L�2235/5 UAD PCRNo. Date
IociOentLocelioo Q �3�1961 1029/2013
County,hlunicipality&IneidentZip PSAPIuciO.No.
Imerscc�ion of W Trindle Rd&Bare Rd.,hlechanicsburg,PA 19050 CUMBERLAND,SilverSpnngTownship, 170i0 CI55297
� Streel or Highway
ReeeivingAgmry
Universiry Hospi�al.Hershey
Patient Nnme .
� �ianneEBartick C�ew �
p StnetAddress Cl: Parkinson,Timot�y EMT-P 196900 w
�"' 304 Morvoe SC Cl: Y-+
���+�' Mechanicsburg Sm�e Zip C3: �
� L+ PA 17055 C'�: Q�
G� � S°' �14� DOB PhooeNa �""�
� Female 65 Years 0]/I6/19i6 P^mary Cvregiver. Cl Driver:
'� (717)791-0344
� PafieotYumber SovialSecNo. PCWeighc MileegC
195d8-9876 IlBk Oo-Seeoe Des�.
PrivahPhysician Driver'sLicense g Ou` �°
TrensporfiugAesiseUoib Aais�05 . Times �
West Shore EMS A I-82 Iq:SO Response Time: 3
Rnpome0uhome 9��� 14W3
Ncmrtoflocident ERiimr. 5 D'upale6: ly;q7
Treated,7ransponedbyEMS-ALS ALS �
OSTime: 27 Enrmh: 14:46
Lighrs and S'veus No Lights or 5'vens ERH Time: 33 Arrive Sttoe: 14;5 I (n
Ues�iesfioe Time: 95 CoomcL �q;92 60
P+fiemConOi�iooanScme PofimcCondifioomFacility TolalTimr. 159 J
Moderam Deparl Seeoe: IS:IJ
Unchanged TimeOuto( 0 Arrivr. IS:i] O
Quarlen: Available: V22 W
InQuert¢rs: �
ChiefComplaiof:
curtem meas:
Allergin(meds):
P\IH::
Narrative
DISPATCHED- Dispatched class 1 [o the above location for a vehicle accident with entrapment.
Medic 88 responds emergency and without incident from WSEMS sta[ion X. Amb 1J2, MICU 1-82,
and MICU 4-82 are dispa[ched as well and respond as transporting units. Amb L72 is the first unit to
arrive o� scene. They advise CCEOC Iha[one patien[is entrapped and [o dispatch air medical. MICU I-
82 is the next unit[o arrive on scene. Fire Co 33 is also responding and has inciden[comtnand.
AOS- Upon arrivaf on scene, CI finds a gray sedari and green StJV sitting in the middle of the road
way. AMB 1-72 and MICU 1-82 are actively assessi�g the patieots. AMB 1-72 advise that there are 3
Printed On: 10/302013 10:50 ��
EMSte[Reporting(c) 199R-2013,Med Medie,Inc Ap Riqh�s Reserved. v P�oVider
Page: l of 3
Pennsylvania EMS Report
ServiceName Uoi�No PCRNo. Date
westShomEMS 35/210223i/SQUAD 1317961 10/292013
P��ieutName DateoBirth Soais15aurityNumber PSAP
DianneEBarrick 0]/16/19J8 19id8-98J6
CIi5291
patients. The SUV has one female driver who has self extricated and will requ've BLS level care. The
Sedan has two female patients inside. One female is sitting in the front passenger seat and is confined
because her door will not open. The other patient is the driver and is entrapped a[this time. Her door
will not open and[he dash and s[eering wheel aze pinned down on her right leg. Amb 1-72 advises that
the female passenger has minor injuries and requires BLS level caze only. The female driver has more
siguificant injures and MICU 1-82 is focusing their attention ou her. MICU 1-82 advises that[hepatie�t
is CAO x4 at this time, with stable vital signs, and no appazent life [hreatening injuries. At this time all
3 patients aze being managed effectively and Cl decides to oversee EMS operations. C] advises
incident command that air medical is �ot needed and to cancel them.
HPI-The sedan was driving west on Trindle Rd. The SUV was traveling east on Trindle Rd. The
Sedan struck the front passenger side of[he SUV with the'v fron[ driver side comer. The SUV was
attempting to make a left tum onto Baze Rd. The S W has minor damage. The Sedan has substan[ial
damage to the front end with dual air bag deployment, cracked windshield, and dash/s[eeriag wheel
deformity.
Rx/P�1'OG Cl advises Co 33 that both the front driver side and passenger side doors aze going to
need to be forced open and[hat the dash and steering wheel are going to need to be jacked up or
removed. Fire proceeds to start the extrica[ion process. MICU 4-82 arzives on scene arid C] directs
them towazds the driver of the SW. Amb 1-72 will handle care of the passenger of the sedan. C(
chooses to assist MICU 1-82 with the female drivec Co 33 gains access to the patient and Cl assist
wi[h extricating[he patient and obtauring inline spinal stabilization. At this time a fire figh[er informs
C 1 that an LZ has been se[up and Life Lion has a 6 minute ETA. C 1 was confused because they
thought air medical had been canceled. CI once again informs command that Life Lion was not needed
and to have them retwn to base. CI piovides command with their EMT-P wmber. All 3 patients aze
vansported to HMC. Cl rides along with MICU 1-82 and assist with their patients caze. Please refer to
MiCU 1-82 PCR 1317965 for more specific information on [ttis patient. Patient care is hansferred at
HMC and MICU I-82 re[ums Cl back to X sta[ion. Medic 88 then retums to serviee.
Tim Parkinson EMT-P 198900/Medic 8128
Note- Times are estimated and derived from various sources and devices.
--------- Nothing Follows---------
Time . � � Events � � � .
. . Provider. . . CommeuB
14:i2 Misc�O@eq Succesr.Oi0 Parki`uan,Timo�hy � Scene Assesmem
Prinred On: 10,�30/2013 10:50 ` ' —
EMSta�Reporting(c)1998.2013,Med Media lnc. AII Rights R¢served. Provider
Pa�e: 2 of 3
Pennsylvania EMS Report
ServittRame UnitNa PCR�o. Da�e
Wes�ShoreEMS 35/21�223i/SQUAD 131]961 10/792013
PetientNem< DahoBirth SoNalSecuriry4umber PSAP
DianneE6ertick 0)qU1948 19id&9816 CISi291
Time . � � Events � � . Provider Commenfs �
ISAS Misc:ONeqSuccess:0/0 ONer Pa�ientexvicazcd
Ii:OI Misc'.ONeqSuccess�0/0 ONer LifeLionwnceOeE
Ii:IJ Misc'.Emom<Hospi�al;Succcss:0/0 ONer
li:i] Mac:ArtivelNospi�ei;5uccess:0;p ����
Printed Oa 10/30/2013 10:50 "� ���Provider
EMStat Reporting(c)199840t3,Med Medie,inc. qll Right�Reserved. Page: 3 of 3
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West Shore Advanced Life Su�oort Services Inc. -Assiqnment of' nefits Authoxization
d�b,'a b' Shore ENIS,dib/a Cadislc ALS, d/b/a Chamb�.�oure ALS
PatientName: V� ���JN� � �R��� � b/d9��3
TxanspoxtDate: _ �
Pxivary Pxactices Acknowledgment:hy signing helow,the signer acknowledges�hat West Sho[e EMS("WSEMS")pio�ded a co
Nolice Of P[ivacy Pxactices to�he pa�ient or ocher pazty wi�h instmctioxis to provide the Notice to Ne patienL PY of i�s
*A copy ot this torm is valid as an oxigina]*
SECTIONI-PA�SIGNATURE�
Thepahent must vgn hete un]¢ge th¢paryp.nt is phy�cal�y Or mentallyincapap{¢of a�ung
: �� NOTE��[ihepahentuaminor,Riepazeniorlegelguazd�an¢houldmgninjtiieaecrtort �
_ ,. . . .. . . .. 4 '� �
I author�ze the subm�ssmn of a claim for payment lo Medicaze,Me&ca�d,oi any other payor tor any services provided m me by WSEMS now,��
in ihe pasq ox in�he(umce,until such hme as I rewke tNs auRiorizapon in wrinng.t undeistand ihat 1 am(inancially respoasible tox ihe services
and supplies provided ro me by WSEMS,regardless of my iaswance coverage,and in some cases,may be vesportsible toc an amount in
addition to that which waz paid by my insurance.I agree m immediately remit m WSEMS any paymenis Ihat 1 receive directly$om insurance or
any souxce whatsoever[or Ne services providetl m me and I assign all riqhls to such payments to WSEMS.7 authorize WSEMS ro appeal
payment denials or other adverse decisions on my behal[without 5uthex aulhonzation.1 authorize and direct any holder of inedical iNormation
ox other ielevant documentaRon about me to release such infoxmation ro WSEMS and its billinq agents,the Cenrevs for Medicave and Medicaid
Sezvices,and/or any other payoxs ov insurers,and their respecHve agents or contxacmxs,as may be necessary m detemtine these ox other
benefits payable for any services pxovided to me by WSEMS,now,in the pasq ov in the fuNre.
'I(fhe pa4enf signs wifA an "X"or oNermark,a wiNess should sign belaw.
X X
Patien[Siqnat�ue o[Mark* Da[e Witness SignaNre Date
Wimess Addiess
... . .. _.... . . ._. . ___ ._._ .
� SECTION II-ADT80RIZED REPRESENTATIVE SIGNATURE � � � � �
. �� CompleteWaaechongp]qv�¢��patien[isphysiiallyoimentallyincapaplao[�gNng. ��� . .
On the Iine below,explain(he cixcumstances thal make rt unpractical for the paiieN w sign�� � � - ��
[am signing on behalf oEche palient m authorize the submission of a claimfor paymem ro Medicaze,Medicaid,or any other payor Eo�any
sevvices providetl m the patient by[WSEMS]now or in the pazq(ox in Ihe fumre,where permived). By signing belo-,v,I aclmowledge�hat I
am one ot Ihe authorized sicners listed below. My signatu:e is not an acceptance o(flnancial zesponsibility(ox the servitts xende�ed.
Authorized representalives indude onlv the(ollo�,ving individuats:
❑ PatienYs legal guardian
❑ Relative or olher person who eeceives social securiry or oNev gover�nenta]benetils on behalf o(the patieN
❑ Relative oz othez pexson who ananges[or the patienPs treafinenc or exercises oNex xesponsibility tor Ihe pacienPs af(airs
❑ Representative of an agency or ixistimtion Ihat did not fuatish ihe services tor whichpayment is claimed(i.e.,ambulance sexvices)but
turnished olhex caze,services,or assistance m Me patien[
X
Representa[ive Signature Date Printetl Name andAddress of Repvesentative
� � SECTION III-AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES
� � � � .ComplereWsecponyp�yu:(1)thepahentwazphysicallyormentallyincapableofeigNng,pp¢ - . �� .
(2)�w auttiorieed repxe ta6ve.(Section m was available ov willinq ro aign on be3uV o(Ne pafient at the time of sezvice. �
A. AmbulanceCrewMember5tatement(mustbecompletedbycrewmember tHm [t � c1) � - � �
My signamre below indcates thaq at Ne time ot service,ihe patlent named above was physically or mentally incapable of signing,and
that none oE the authonzed xepxesentalives lis�ed in Sec¢on[I of�his to�m were available or willing m sign on the patienPs behatf.
My signature is m[an acceptance o(financial responsibtlity(ox the serviees rendexed.
On ihe line below,e�lain the cizcumstances that make it imprac[ical for the patient to sign:
PT r.�t J A �3«�a�c� e Ccsl�-�,y�
NameantlLocationo(ReceivingFaciliry: �N���'n.ac� (�cS��r�c K� � �7 � `� �)�
� � � � Time at Receiving Facility: / ) ` y J
X 14Lt£L' S . c✓ t 1�.nV. -�1���+., W5 t7� < c�r-r� . �Y,�.3
Signalure of Crewmem er Da�e � Pvmted Name and Tale of Crewmember
B. Receiving Facility Repxesentative Siqnatu�e
The patient named on this foem was received by Ws tacility at the date and time indica�ed above.
My signatue�e/is�n�/ot an acceptance o(fnancial responsibility for ihe seMces xendexed lo Ihis patient.
x "/i� � DA/ , i_.. 1..-. .. , . _ , t
PENNSTATE HERSHEY Penn State Hershey TeC (717)531-8055
Milton S. Hershey Medical Center
1� Milton S. Hershey Health Information Services, HU24
� Medical Center 500 University Drive
B0 Box B50
Hershey, PA 17033-0850
Patient Name: BARRICK, DIANNE E
MRN: 7514520 VisiWumber: 10514520
Da[e of Bir[h: 7/76/1948 Visit Type: Inpatient
Patient Gender. Female Pa[ient Localion: 3SAW; 3774; 7
_ ....._,._ ...,,.._,,.. ......�......_.._.�__.__"__.,_.___.,._,_,._,
� Discharge Summary ;
�.� ._._._.._.._.._..__._._.._._. �......__.._..__._._......_.___._...__ �
RESULT STATUS: Modifed
DOCUMENT SUBJECT: .D/C Summary
ELECTRONICALLY SIGNED BY: Dohson,Leonard F (11/5/2013 12:13 EST); Chandler,Juslin
D (1 V3I2013 23:D7 EST)
DISCHARGE SCMMARY
Name: BARRICK. DIANNH H
HMC Number: 7514i2(1
DOB: 07/lfi/1Y48
Dete of Admission: I02920I3
Da[e of Disc6arge: 11/02/2013
Physlcian: Chandler, Justin D
Service: hauma Surgery
Discharge Olagnosls: MWtiple Vauma
Mo[or vehide Crash-10/29/2013
Didation-1180201
Other Diagnoses: -Left chest and shoulder puncWre wounds
-Left leg lacerelion
-Lefl L2 Vansverse process fracNre
-Left breast conNsion
-Sea[bel[ injury
Cholelithiasis (gallstones presenQ
diffuse hepatic steatosis (fatty liver by radiology)
Mild rec[asigmoid diverticulosis.
MaJo�Procedmes and Tests:
suture repair of left leg laceration
Vaccinatlons Recelved This Hospital S[ay:
No vaccinations were given lhis hospi[al stay.
Discharge Medicatlons:
1. Unlisted medication (Janumet)one[ablet by mouth 2 times daily.
2. Insulin detemir(Levemir) .
DatelTime Printetl: 12131/2013 2t52 EST Page 1 of 335
Printed By: DiBase,Christina M
PENNSTATE HERSHEY
R�1 Milton S. Hershey
� Medical Center
Patient Name: BARRICK, DIANNE E MRN 7574520
,...._............_.......................____....__�..._.........._ _.____._...._._...._...._..._..,.�.._..�.....�.._....._.._........___.._......_.._.._...._._.__.........._--•
; Discharge Summary i
3. Omega-3 polyunsaturated fatty acids (Fish Oil 1000 mg oral capsule) .
4. Naproxen (Aleve) .
5. Fexofenadine (Allegre) .
6. Esomeprazole(NexIUM) .
7. Metoprolol (Toprol-Xl. 100 mg oral tablet, extended release) .
8. Unknown medication (Hyzaar) .
9.Atorvastatin (Lipitor) .
10.Aspirin .
11. Ozycodone (ozycodone 5 mg oral tablet) 1 tab by mouth every 4 hours, as needed for Pain-Mild.
12.Oxycodone (oxycodone 5 mg o21 tablet)2 lab by mouth every 4 hours, as needetl for Pain-Modera[e.
13.Ace[aminophen (Tylenol 500 mg oral ta61e[)2 ta6 6y mouth every 8 hours.
Brlef Hislory of Present Illness:
Date of Service: 10/29l2013
The patient is a 65-yearold female who was questiona6ly restrained occupant of a mo[or vehicle accidenG Posilive airbag
deploymenL The patient comes in Iransported on a long back board with C-mllar in place. She has a primary
survey ihat consisted of an airxay,which is patent, sponfaneously protec[ed. Her breathing was nonlabored
spontaneous, clear to auscultation except for a decrease in the left apeac. Circula[ion: Pulse rate was 102, blood pressure
was 150/90, respiratory rate was 20, saturation was 98%on room air, GCS was 15. FAST exam was deferred. Exposure
was comple[ed.
Second set of vilals will be added.
SECONDARY SURVEY: HEENT: Head,[he pa[ient had a right scalp laceratlon. Eyes: Her pupiis were reactive to light,
3-2 mm bila[erally. Ears were occluded by her collar, unable[o assess. Battle sign was not present Face, mandible was
nontender, no crepitus, no obvious signs of trauma. Same with [he mandible. Nose had some blood around nares. Smail
abrasion, no crepitus. Moulh had some blood but no obvious oral trauma. Den[ilion was intac[ DenNres were not
present Neck had no Gspine tendemess, no crepitus, no stepofts. Trachea was midline. Chest wall was tender over
ttie left side, no crepi[us. She did have ecchymosis over the le8 shoulder and a small abrdsion on her left 6reasL Lung
sountls clear lo auscultation bilalerelly on repeal exam. Back was nontender, no crepiNs, no stepoffs. Heart rete was
regular ra[e and rhythm, tachycardiq sinus in naWre. She hatl no abdominal�enderness, no dis[ention. Bowel sountls
were good. Redal tone was normal, heme negative grossly. Pelvis was slable, nontender. She hatl +2 radial pulses and
+p DP pulses. Femoral and PT were 1+. She had a mntusion over her ab0omen including an abresion. She had a
conWsion over her left knee and laceration over left lower leg. She tlitl have lacera[ions over her lefl breast. Cranial
nerves 2-12 were intact grossly. Motor was 5/5 bilateral upper and lower extremities. Her sensorium was inlact grossly
bilaterally.
HospiWl Course:
Ms Barrick is a 65 year old female who was admitted to HMC wi[h the above listed diagnosis. The patient was treated
with pain conVol and local wound care. She was normalized and PT and OT worked with the patient She was cleared for
tlischarge to home on 1112/2013 after both the patient and her friend were instructed in proper dressing changes.
Exam on Discharge:
Vitals Temp Puke BP RR SpOT FI02 �� Date Wt(kg) Wt�lb)
Date/Time Prin[ed: 12I37/2013 21:52 EST Page 2 of 335
Printed By: DiBase,Christina M
PENNSTATE HERSHEY
� Milton S. Hershey
� Medical Center
Pa[ien�Name: BARRICK, DIANNE E MRN 7514520
,_....._._......................................................................_................_.._..__.............__..._............_............__.,..,..............,...........,....................._........._......._._.___.__._^
;_ �Discharge Summary
_._.___._.__._�
11/02042636.1 76 125/58 20 98 — II 11/02 122.0 268
�vozozsz — — — ie — — II �voi ino zs�
11I0202:50 — — — i8 — --- II 71/01 117.0 257
11/020038 36.7 77 139/64 20 100 — �� 10I30 1195 263
11I01 2028 37.3 75 11fi/52 20 97 — I� 10/29 119.5 263
24 Hr Tmax: 37.3 at 71/Ot 20:28
36 Hr Tmax: 37.3 al 17/01 2028
Vital Signs are the lasf 5 in the past 48 hours.
Weights display the las[5 within 7 days.
Initlal W[: 10/29 kg 2591b
Phvsical Exam�
General :NAD
HEENT :EOMI, PERRL, abresion to forehead.
Neck :supple, no JVD
Heart:RRR no Mr/g
CheatlLungs :CTAB, L chest and L supradavicular lacs are packed, C/D/I
Abdomen :soft, NT/ND,seat belt sign.
Eztremitles :W WP, motor 5/5 in all 4 exC SILT in ail 4 ext, multiple abrasions on b/I LE near knees, small lac on medial L
knee clased.
Neurologic :AAOx3, CN 2-12 grossly intac�.
Most Recent 36hr Labs as of
11I01 2230
Blood Glucose 295 H
11/01 2228
Bload Glucose R See Fiowsheet
11I01 2126
Gluc Meter 295 H
Care Ins[�uctions:
-Do not drive until dearetl 6y a physician
-Wa�k at least 150 feet per day to help preven[blootl clots!rom forming in ihe legs
-Take an over the coun[er stool softener while on pain medications
-You may shower and clean your wounds with soap and water
-Pack shoulder and breast wounds once a day until healed.
-Resume your regular home medications
-Con[inue to use your incen[ive spirometer ten deep breaths per hour while awake
Ne suNres from your left leg will require removal and this can be done al your(ollowup appt.
Diet Guldelines:
Consistent carhohydrete/diabetic die(
Da[elTime Printed: 12/31/2013 21:52 EST Page 3 of 335
Printed By: DiBase,Christina M
PENNSTATE HERSHEY
� Milton S. Hershey
� Medical Center
Patient Name: BARRICK, DIANNE E MRN 7514520
��................�.... � __...._�.�_._._ � ��_.___ .._......�._...� __ _ . _ � ._._ _ _.
i Discharge Summary `
ActNity Guldalines:
As tolerated
Do not tlrive un[il you are ofl all prescription pain medication and your ac[ivity has reNrned lo normal for you.
Call yow doctor H:
You have fevers, chills, increasing pain, nausea,vomiting or with any other questions/concems
Call 717-531-8521 and ask for pager 2136
Call 717-531-7161 for ques[ions during regular business hours.
Other Instructions:
Please follow uo with your orimarv care orovider for the following incidental findin
1. Calcifcations in Ihe lower outer quadrant of Ihe right 6reasl. RecommenA correla[ion wi[h mammography.
Follow up wilh Trauma Clinic in 1-2 weeks.
Follow-Up Appolntments:
Fo11owJJo Imaging t �die�
as above, radiology recommending a mammogrem.
Electmnic Signatu2 on File
CQ Edward J Fleming, MD
204 Mumper Lane
Dillsbuig PA 11019
CC: Justin O Chantller, MD
Treuma Sufgery
500 Universiry Drive
Harshey PA 17033
EleGronically Reviewed/Signetl6y: Leonard F Dobson, PA-C, MMSAuthw SignaNre DU7m:11/05�20f3 1213 PM
Physician Assisfanl
Pznn Sfafe Sfrock Trauma Center, H075
Penn Sfate MiRon S.Hershey Medical Cenfer
PO Box 850, Hershey, RA 170.33 (717)537-6066
Electronically Reviewed/Signed by: Juslin D Chandler, MDCosigne�Signature Df/fm: 11/03/2013 11:07 PM
LFD/EEP DD: 11/02/13 DT: 11/03i130621
Date/Time Printed: 12/31/2013 21:52 EST Page 4 of 335
Printed By: DiBase,Christina M
USAA 11/7/2014 3 : 03:03 PM PACE 6/007 Fax Server
PPC� 5
� UNITED SERVICES AUTOMOBILE ASSOCIATION
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PBNLISYL7ANIA AUTG POLICY FY_YY1'FFRICL'7: (129+. P.M. standartl:ime)
ReNEWAi D:CLARATIONS EFFECTNE OCT 01 2013 TO APR 01 2014
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Named Insured and Address �
ROB3Y.T A SMELLEY
iSG USA R6T
3 SI�KWOOU LN
CP.�2LISL'n PA 17015-9397
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is po icy provi es t ose covereges where a premwm is s own e ow. e imits s own
may De reduced by olicy provisions anA may not be combined rep ardless of the num6er of
veh�cles /or which a �emium is listetl unless s ecificall authorized elsdwhere in lhis olic .
COVERAOES LIMITS OF LIAB�LITY
("ACV"MEANSACTUALCASHVALUE) r-oer, r�ee:ui�v r,-r,en veemiau c-cec vaemwM o=orr, vr.t'umu
AMJUN� 3 MGUNi 4 NOti�ll ; MpVpl" $
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EARPIEL A:CID'sPIT FOF.G:VEPiESS APPL nS W H FIJ- Yn CLE UAI IPIG WI� ❑S
FULL TORP APPLISS
TH3 LAWS OF THE COMMOLII43ALTH OF SNtiS VFS]IA, AS 'ACTED .Y T
GnNERAL AS3Ft4ELY, ONLY F.EQUIRE T T Y PURC SH IABILI C Fi
FLRST PARTY M3DZCAL B'nNEF_T ^OVH GES . hSiY DITI NAL C JERA. �S
OR COV�FAGES IN 5X^ESS OF TH6 LIPITS cQOIa3 PY W ARE PRGV 3G
ONL'I AT YOUR REQC3ST AS ENHAPICEM� ITS BASI . COV 3^cS.
TH3 PRHtAIUf-0 FGR THc BASIC COJERA S i5 :
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PD SCG� 5 55 .00
FIRST Pi,HTY t4^DICAL B3C15F:T SCO� $ 12 . 9G
�In WfTNESS WriERWF,the Subscnbers at UNf7ED SERVICES AUTOMOBILE ASSOCiPTION have caused IMse presen6 to be sgreti by
their At[omey�ln-Fact en this tla!e AOGOST 24 , 2013 �ru �' " �
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Presitlent, USAA Reciprecal Httome�pin-Fact, Inc.
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� SUPPLEMENTALINFORMATION
USAA° EFFECTNE OCT 01 2013 TO APR 01 2014
The following approximate premiun disco�nts or credits have already been applied W reduce your policy
premivn costs
NOTE Age or senior citizen status, if aliawed hy yov statetlocation was taken IMo considention when
your rates were set and your premiums have already heen adjusted
VEHICLa 07
ANNOAL MIL3AGc DISCC[7A*T -$ 12 . 98
ANTI-THEFT D?SCCONT -a 5 . cq
PASSIJB R3STFUlICIT UISCOU[.*T -$ F, . 43
PF.Et4I'nR DRIVER DiSCGUTiT -j 23 . 42
SUPDECCW pev. 7-95 e+i7GUST 24, 2D13
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� pennsylvania
, DEPARTMENT OFREVENUE
March 2,20I5
Matthew Owens, Esquire
Law Office
6310 Allen[own Blvd, Suice 101
Harrisburg PA ll112
Re: Esta[e of Diazme Bartick
File Number 2113-1198
� Court of Common Pleas Cumberland County
Dear Mr. Owens:
The Depaztmmt of Revenue has received the Petition for Approval oF Se[[lemen[ Claim[o be
filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has
been forn�arded[o this Bureau£or[he Commonweal[h's approval of the allocation of the proceeds paid[o
setHe[he ac[ions.
Pursuant to the Petitioq the 65 year old deceden[died as a result of injuries received in a motor
vehicle accident Decedent is survived by her mother.
Please be advised that,based upon these fac[s and for inheritance tax pucposes only,Ihis
Department has no objection to the proposed allocation of the net proceeds of this actioq $14,907.84 to
the wrongful death claim and$84,477.73 [o the survival claim. Proceeds of a survival ac[ion are an asset
induded in the decedent's estate and are subject ro the imposi[ion of Pennsylvania inheritance Imc. 42
Pa.C.S.A. §8302; 72 P.S. §9106, 9107. Costs and fees must be deducted in the same percentages as Ihe
proceeds aze allocated. In re Estate of Memman, 669 A1d 1059(Pa Cmwl[h. 1995).
I[cust that this letter ia a sufficien[represen[ation of the Departmen['s posi[ion on this ma[tec As
the Department has no objec[ions to[he Petition, an atromey 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.
Sinc r ly,
S nE. Ba�ke������ `—
Trust Valua[ion Specialist
Inheritance Tax Division
6ureau of Intlivitlual Tazes�l�PO eox 280601 I Harnsburg, PA 1]328 � 717J83.5824 I shabaker@pa.gov
CONTINGENT FEE AGREEMENT
I/We,the undersigned ("Client"),do constitute,appoint and retain as my/our attorney
Matthew L. Owens Esquire and the law firm of Matthew L.Owens, Esquire, LLC("AttorneW')to
institute and maintain an action against /1 and an � ther r i �ble
person or entitv in order[o remver da��pveges su3tai�� 6y in cause of
action which arose on or about the4}'tlay of �'�'r
I/We hereby agree that the compensation of my/our attorney for services rendered by him shall
be 33 1/3 percent of the amount recovered by settlement or verdict, plus reimbursement of all
expenses incurted and advanced by my/our atmrney in the institution and prosecution of my/our tause
of action. A[torney may, bu[ is not required,to advance the payment of costs and expenses. if a[torney
advances costs and/or expenses on behalf of dient,then client agrees to immediately reim6urse
attomey on demand with respect to any workers'compensation claim
Attorneys obligation to provide representation forthe commencement and prosecution of an
action is conditioned on attorneys investigation of[he claim to determine whether there exists a valid
and worthwhile claim. A[torney, at attorney'S sole discretion,shall determine whe[her there exists a
valid and worthwhile daim to proceed with the prosecution of an action as described above. Ifthe
attorney decides not to proceed with the commencemen[and prosew[ion of an action,then this
Agreement sha0 terminate upon a written notice by at[orney ro clien[and no party shall have any
further obligation except client shall reimburse ezpenses. In the event that a reasonable offer is
negotiated by and recommended by attomey, and client(s)do(es) not agree ro the pmposed
settlement, attorney may require dient�s)to reimburse all msts to date and advance necessary costs for
trial. In the event tha[dient�s) refuse(s) a reasonable settlement offer and/or refuse(s) [o bring[he
msts current and advance costs for trial,dient(s)agree�s)to permi[at[orney to withdraw from the case.
This Agreement does not provide for representation for any proceeding, matter, or for the
prosecution of a claim against any person or entity not descri6ed a6ove. This Agreement does not
provide for the prosecution of an appeal. Attorney is not o6liga[ed to initiate or handle the prosecution
of an appeal or collect anyjudgment The representation is conditioned on the ezistence of insurance or
other source of recovery for the damages which are the subject of the representation.
Attorney has made no promises about the outcome of Ihe mat[er for which represen[ation is
provided. Attorney has made no representa[ions ahout[he value of the daim and client understands
each claim stands on its own merits, and is unrelated in value to any other seemingly similar claim.
Client is aware that information is importantto attorney's representation of dient Client
agrees to fully cooperete wi[h attorney and [o provide informa[ion and ma[erials which will assist
attorney in the representation. Client must maintain contact with attorney by informing attorney of the
manner and means by which attorney can communicate with client by telephone and by writing.
Attorney is relieved from representation under this Agreement if client does not keep attorney informed
ahout the manner and means by which attorney can communicate with client.
I/We understand that in the event of no recovery in my/our behalf,then my/our atmrney is to
have no claim agains[me/us for any fee for services rendered. However, it is agreed that the expenses
and costs incurred and advanced y my/our attorney in the prosecution, institution and/or maintenance
of my/our cause of ac[ion are not considered as part of his fee for services rendered, but remain my/our
responsibilityregardlessoftheoutcomeofmy/ourclaim. "
I/We acknowledged it is not within the scope of my/our attorney's responsi6ility under this
Agreement to process claims for first party benefits and/or daims for workman's compensation
benefits. However,from time to time, he may intercede in my/our behalf as a courtesy.
Payment of inedical bills to physicians, chiropractors,therapists, hospitals and other health care
professionals and institutions is clienYs responsibility.
Clien[may termina[e the representation at any time provided the termination is not to avoid
the payment of a fee based on a percentage of the recovery. In the event that I/we decide not to
proceed ahead with my/our case of action and/or decide to discharge my/our attorney, Matthew L.
Owens, Esquire, then I/we agree to immediately reimburse Mat[hew L.Owens, Esquire for all expenses
incurred and advanced by him�in the ins[i[ution, prosecution and/or maintenance of my/our cause of
action. Moreover, I/we shall pay to my/our attorney a fee on an hourly basis forservices rendered by
my/our attorney in the amount equal to$250.00 per attorney hour immediately upon presentation of
an hourly bill for services rendered. In the event of nonpayment of his bill,then 1/we agree that my/our
attorney shall be permit[ed to retain all files pertaining to my/our case of action consis[ent with the
Rules of the Disciplinary Board of Pennsylvania and further agree[ha[my/our attorney shall have a
general equitable charging lien against any recovery in my/our tase of action secured by me/us or
my/our subsequent a[torney(s�. The aforesaid lien shall he and is hereby treated as a debt due and
owing by me/us[o my/our attorney. In the al[ernative, I/we agree to turn over to my/our at[orney
100%percen[of the fee earned 6y my/our subsequent a[torney�s) in[he prosecu[ion of my/our cause
of action,which amount shall be the first item paid from the fund recovered by my/our subsequent
attorney(s)at the time of distribution be[ween myself/yourself and my/our subsequent attorney(s�.
This alternative agreement shall apply to all subsequent attorneys and shall be and is hereby treated as
a debt due and owing by me/us to Matthew L.Owens, Esquire.
A[torney may terminate representation ot clien[ (1) if client breaches[his Agreement; (2)to
avoid viola[ing the Rules of Professional Responsibility orother rules which govern the conduct of
attorneys,or law relating to the conduct of civil actions; (3) if attorney decides, in attorney's sole
discretion, the claim is for an improper purpose; (4� if in attorne�/s sole discretion,decides the claim is
not worth prosecu[ing because the likely outcome will not exceed the expense associated wi[h
completing the case; (5) if attomey decides, in attorney's sole discretion,there is no probable cause ta
believe there is probable cause for the claim; (6) if in attorney's sole discretion, representation is in
jeopardy because the relationship be[ween attorney and client is not sufficiently congenial to allow a
meaningful working relationship.
I/We unde�stand that is my/our obligation to reimburse organizations/entities under a right of
subrogation to obtain reimbursement for amounts the insurer paid for, among other things, property
damage, medical expenses,or wage loss. Client understands client is responsible for, and will hold
attorney harmless from any subrogation or reimbursement claims. I/We understand that it is my/our
o6ligation to reimburse the following organizations/entities on a dollar for dollar basis forany lien they
may have against me/us deceden['s estate:
A. Department of Public Welfare;
B. Medicaid/Medicare;
C. Workers'Compensation;
D. Major Medical Insurance Plan (e.g. HMO's, Blue Cross/Blue Shield, ERISA Health
Plans�;
E. Employer/Employee Health &Disability Plans;
F. Uninsured and Underinsured Motorists Insurance (based upon circumstances as
determined by my/our/decedenYs insurence policy,<ourt opinions, all of which are
consis[ently changing and canno[be de[ermined wi[h certainty at this time�.
I/We hereby acknowledge receipt of a duplicate copy of this Contingent Fee Agreement.
iL D.�.� zo t 3 � Gr/� �C.�
Oate �
��, �x
Date
Bl': 9-latthe�cL O�ceris. F.aquirc
.Attornec I.D. Ko. 76080
b_10 Allentu�rn I31�d. tiuiic 101
Han-is6ure. P.a 17113
i7t�, �o�-�;nu
Anorne�for Peti[ioner
iti RF.: Estate of Dianne E. Barrick : Iti I'HC COLFT Oi C'OM\iOV PLE.4S
�. CI V1RPRI. anD COI:ST}�. I'k V'�'tiyLVdAIA
VO.:
oRrri,a�s cu��R��
,�FFIDA�'IT OF I3ENEFICIARF COtiCORRING I\THE
TERMS OP THF PROPOSED 9ETTLEMF,�T AND PETTTIO�
l�h�� �nntter ot in Re: Fsiar� of Dinnne 6 Rorrick h�been merol��ed �cith L'nfieJ �enices
automobile ,1s.ocialion f hercinatter ..I:S,��1"L iha ins�irer t'or tonRasor Robert ;A- $medle� and
Fu Smadle�. I�x a[otel of iitq� d�ousand dollar. IS50 OIID.00) and ;�1etropolitan fisurance
Compan}�. dir insvrer for the decedent. Dianne G B�rrick 11�r one hundred thousand dollars
l$IOO.00Q00). The mone� is going to be distriMuted as set innh in thi. Afflda��i�and 1 concur:
1. 1 am Dlarih�mi 1 willits.
_. bh�date ot hiith is 7 � ����___ _,
�'-�'-
,. �iv sucial securin� number is Z - ''�2- �� �
- �Q-__ _ . � _.—.
3. I am Admii�i.tra[riz ol ih�Lstnte nl Dianc E R:,rzick.
_. 1 undersk�nd tha� thc thirJ pnrrt liabilit� mmt�-r re�emnced nbove as In Rr. Estate of
Diamie F. Barrick has heen setded fx ell a�nil�ble und npplieabl}� �osurance proceeds tor
a ro[al ol fftv tliou,and dollars fb?O.00iL001.
6. I undertnnd th�t lhe lr I',��1 daim reterenced �ho�e us In Re: Istate ot Dianne G. 6arricA
hai been senled for a total ol undispu[ad furdc ot one hnndred �hou3nnd dollnrs
(S 100,000.001 uhich according m b1etronniitan represenrs die policc limits. I funher
understand decedeN�s counsel dispule�ihe amoun[ol tlie polic�� Iimlts and has fited a
Declaru[on Judgmenl :Aetirni �eth thi, l ourl n�hich i� pending.
,. I turther undrrsmnd dmt ihe :eltlemem pra.erds�+dl be dlstribu[ed xs follo�cs_
i
'Toml tiettlement Pruceeds.......................................5 IS0.000.00
Attornec's Fres.....................................................5 i0.000.00
Legal fusts and Expenses.......................................5 fi14.43
F.state oP Dianne E. B:�rrick,Sun�ical Renefician�...........5 N1,a77.?3
Shirle�� Earnest, R'rongful Dcath Rencficiun..................5 I�7,907.8�
8. [hereh��cenifc �cith this :Aftid�cit [hu[ I aeree nnd :orsent io srtdement oilhe easc as
re�� - :.htr.r .::'iM' � ; ,..�_ .� � � �..:.,.,�.
flate: �S,J� l� 02o i S ��mo0 /� (2/��
iSienawr�
�%_�!,� J ��/. �4
�i��t���d �u�„��
j��ieof /�i'nuiS� �C�CtiAi� _ ...
lrnmt�ot (a7l��O��SQ� )
� _�iC' �nis�
Qu �'S �nc oL �[2�� r,�-'n u� ��r,�� ('L_ , _ , i/
❑ Notan� Pubfi�. Flersor:alh pp ircd /���q 1�.���/�'t`j who pro�rd
to me on [I�e basis ot satisfsctnn a�iJenea io be�I�,�� nr:son ��nose nume is sob.aribed to ihe
��ithin insirumon� .3nd a�kno��l,cdeed ia n�c iha', hr .hc i�ccutcd �he ,:ame in hI>her euthorized
c�paein'. �nd ihat bc his her;ignat��rc or. thc li�strumrm ihr�e��ou. or the emitv upon behall o(
�chiah rhe prrsi�n atted. c�ecu�ei the in>tnmizn�
�
V��om �<.snJ ,uh'ai6 �i thi. l��+ � nP ��/ . _t)/�
` ""__—___ _"—
___ .._ ____ _r _ .
Cqmrtamxeatth of PennsylvanW
NOTARULL SEAL ���/J l�, �:YZA�,Q,
BECKY M. KNISELY,Notary PuDNc -•t��� �1 '------
� AnT.AR'i PI 'I J(
�11erLanl����� 1 . .
�3�Ck�m , Kn�c�
N�;�,<<,1 �a�„�
'�(�CommisaionFsprze�:_...�1�� °� GZ���
�
6l': �fat[hz�c L O�cens. Esquire
:Attornev LU. .'Jo. 76080
6310 Allen[o�in Bkd_Suite 101
Harrisbure P� 171 L'
(7 Ul 909-^Sp(1
Atlornev for Petitioner
tN RE: Esta�e of Dianne E Sarzick : 6�iliF COLR I OF CObIt�10K PLEAS
: CC11[3FRI.:WU COI_�.A"TT. PE��SI'LV'AtiIA
\i).:
�. 02PII:INS COURT
:1FFIDAVIT OF REIEFICIARI' C0ICCRRiNG iN 1'FlE
T�R111S OF THF. PROPOSED tiF:TTLEMEtiT AND PF.TITION
�[l�a mat[a�ofln Rz: hsteta af Diamnc E Qarrick hus hcei� resol��ed ��idt Cnl[ed Serv(ees
Automobile .4scociation �hereinafier'CSA.4�).tho insurer [or ror[feasor Robert A. Smedlec and
Yu Smedle�-. Por a to�al ot f fiv �housand doll.irs 15�G.DOQ00)and A4etropolimn Insurance
Compam, the inswrr lor the deceden[. Uianne IL Lim�rick. Forone hmidred thousNnd dot7ar.
($100.000.004 Tha monep is goin�ro hc distribuud as >et furth in this A�dT�It and I concur:
I. l am 7oseph D. 6ucklrv. E�quirc.
_ [ �m counsel lor Shirlev Farnzst.
�. Shirley Earnest is the 6iolo�ical moditr ot Dianne E3nn�ick.
�. Her date ut binh is � � 4 / �9 ��.
7 f–_ - —
�. Hersocial securih� number is_ _� ! � ' 2������
C. She Is a beiie[miarv nt�he Estntc oClliune E [3arritk.
7. I understand [hat tltt Ihird partc Iinbilitc matter reterenced abo�e ns In Re: Esmm ot
Dianne E. Barrick has been settled for alf availahle znd applicabk insurance proceeds for
a tot�l of fif'n-thousand dollars($�O.00Qn01.
R. I unders[aud thnt the l."IJT clr�iiu reCerene�1 abo�e ss ln Re: 1=state of Di2nnz F. Barrick
has been settled for a toml ul undisputed �i�nds of onc hundred Chousand dollars
(5100.000.00) which accordinp to Mevopolimn represents the polic� limfts. I further
3
understand decedent's counstl dispures die amount of the pnlicc Iimi[s and hns Yiled a
Dcclsra[orc Judgment Aclion �aith ihis Court �chich ic pznding.
9. 7 tiirther undtrstand tlmt the se�dcineni proceedc�cill be disttibured as tollous
Total Settlement ProceeJs.......................................c ]50,000.00
Attornet's Fees.....................................................5 i0.000.00
Le�al Cnsts and Ecpenses........................................5 6N.J3
Estate of Dianne [. 13arrick, Snn�ical Qenercian�........._5 8J,177J3
Shirlec Earnest,��'ron�fui Dentb Benefician................5 la,9p7,84
10_ 1 here6e certih� �cith this A�7idacit ihai I ugrte and con:ant to seulement of the ense se
«ell as�6e abnve described seltirmcnt disvihunoit �
Datz: �ll� �/ ��5 .
�enuture
����----a /3r—.���� �-
(Print: '.Jnme(f )
Stateol -Ctw. Z, Iss.
i
County nf Li.cu..�¢,�� _�
On7 d�� ot�u.�a- �OiS. hevicm Bew..y }d. I��HSE.�v
. �\otan-Pubhi. personeth �pF eared 3�k 7, tae u [s �chn proced
io me on dic ba,ic of s msYac[or�e�i auic�to he �hc p�r_ �.i �chose name is mbnerihed to tlie
u�i�hfn insnvinent snd ecknowleieed to ine that he.5fte ezecured tiie somt ln his�heraudionzed
capnci[�.and Ihai bc hi.her signamYe nn the fnstrwnent the prrcon.or the entitr upon beh211 oP
�chich the person ac[ed,rcecut,.e./d(the ins�rumem.
S�com to and ,ab.cnbcd this��da�ol _�v�; .U�+ 'U(S
COfIMIIOnNKNkh Of PlI�1�gyh�yflW _� (
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BECKYM.KNISELY,NotaryPydit � \()�I-;\R1� YI_RL4�J
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4
CERTIFICATE OF SERVICE
I, Surmi Elmore, an employee of the Law Offices of Matthew L. Owens, Esqui�e, LLC,
heceby certify under penalty of unswom falsification to governing authorities, that on this
/ Z/
� day of ( �ud� ,2015, I have served a true and correct copy of the
fo�egoing by United Statcs Mail, pre-paid, as follows:
MarilynnJ. Willi[s
435 North Mountain Road
Newville, PA 17245
7oseph D. Buckley, Esquire
1237 Holly Pike
Cazlisle, PA 17013
John L. Panzazefla
United Services Automobile Associates
P.O. Box 33490
San Antonio, TX 78265
Brigid Alford, Esquire
Marshall, Dennehey, et al.
L00 Corporate Ce�ter Drive
Suite 201
Camp Hill, PA 1701 l
�
_�--
Sunni Elmore