HomeMy WebLinkAbout06-6112
.
In Re:
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
.
; NO. Of,. ~ J 12 Cwu J u-.
ESTATE OF TORI LYNN BELL,
a Minor
PETITION TO AUTHORIZE SETTLEMENT
OF MINOR'S PERSONAL INJURY CLAIM
Pursuant to 20 Pa.C.S.A. Section 3323(a), Petitioner State Farm Insurance
Company respectfully petitions this Honorable Court to approve a compromise settlement
for the personal injury claim of Tori Lynn Bell, a minor, and in support thereof aver as
follows:
1. Tori Lynn Bell is a minor child residing with her parents, Randy and Robin
Bell, at 112 Forge Road, Boiling Springs, Pennsylvania.
2. At all times relevant hereto, there was in full force and effect a certain motor
vehicle insurance policy issued by State Farm Mutual Automobile Insurance Company, in
favor of one Paul Ranck, which policy listed as an insured vehicle a 1999 Ford F150 Pickup
Truck, and which policy provided BI limits in the amount of One Hundred Thousand
($100,000.00) Dollars. A true and correct copy of a Certificate of Coverage for the policy
at issue is attached hereto, made part hereof, and identified as Exhibit A.
3. On June 19, 2004, Ketha Ranck, wife of Paul Ranck, was operating the 1999
Ford F150 pickup as part of a church trip sponsored by the Carlisle Evangelical Free
Church.
4. Tori Lynn Bell was among the passengers in the Ranck vehicle, which had
been parked on the right berm of Route 11 , just south of its intersection with Fairway Drive
in West Pennsboro Township, as part of a caravan of three additional vehicles, each of
which was also stopped in a parked position on the berm of the road.
5. Thereafter, the Ranck vehicle commenced a U-turn from the berm of the road
onto Route 11.
6. As the Ranck vehicle entered back onto Route 11, it collided with a tractor
trailer, owned by Clouse Trucking and operated by one Michael J. Barrick, that had been
traveling southbound on Route 11 ; the collision caused the Ranck vehicle to travel across
the roadway, into the northbound lane and off the roadway, where it hit a small
embankment, and overturned. A true and correct copy of the Police Accident Report for
this accident is attached hereto, made part hereof, and identified as Exhibit B.
7. As a result of the collision involving the Ranck vehicle, the minor Tori Lynn
Bell, did sustain certain personal injuries, which required medical attention, to wit:
a. Closed head injury (subdural hematoma,
epidural hematoma, skull fracture)
b. Splenic laceration; no surgery required
c. Liver laceration
d. 3 rib fractures
e. Soft tissue cervical spine injury
8.. Tori Lynn Bell was transported to Hershey Medical Center from the scene of
the accident; she was admitted there for observation from 6/19/04 through 6/22/04. Her
medical records from that facility are attached hereto, made part hereof, and identified as
Exhibit C.
9. Upon her discharge from Hershey Medical Center, Tori Lynn Bell had certain
follow up care with her family physicians at Graham Medical Clinic. Those records are
attached hereto, made part hereof, and identified as Exhibit D.
10. On behalf of their minor daughter, Randy and Robin Bell have made a claim
under Ranck's State Farm policy, with respect to the personal injuries that Tori sustained
in the accident.
11. State Farm has extended a settlement offer in the amount of Thirty
($30,000.00) Dollars under the Ranck policy, to Randy and Robin Bell in their capacity as
legal guardians and parents of Tori Lynn Bell, which offer is acceptable to the Bells.
12. Neither the Department of Public Welfare, nor any other entity, has a lien or
claim against Tori Lynn Bell or her parents in connection with her accident-related injuries.
13. On behalf of their minor daughter, Randy and Robin Bell have reviewed and
approved this Petition; their concurrence in the foregoing Petition is attached hereto as
Exhibit E.
WHEREFORE, Petitioner respectfully requests that the parties be permitted to enter
into the settlement recited above and that the Court enter an Order approving payment of
the above-referenced settlement amount to Randy and Robin Bell, on behalf of and as the
parents and legal guardians of Tori Lynn Bell, a minor.
Respectfully submitted,
By:
Brigid . Alford, Es re
Supreme Court ID # 8590
Boswell, Tintner, Piccola & Alford
315 N. Front Street
Post Office Box 741
Harrisburg, PA 17108-0741
(717) 236-9377
Attorneys for Petitioner
Date: JDllflO~
V1NVl'\IASNN3d
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t'" .......'-' ',.' 'j, . .~,..- ...Jf' V
LO :6 ~IV 61 130900l
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Far m Ins u ran c e Ie 0 m pan i e s
STAn ,u,",
A
I NSU .ANe E
(!,
CER'TI f ICATS OF C0\iER]'~GE
State Farm InSUHH1ce
1 .! 5 limekiln Road
New Cumberl<!J1d Pt. I ']i170(),~':';'
Claim Number:
38-K461-021
The undersigned is a Claim Team Manager for;
Sta.t>" F3.rn', C:c-,unty Mutual Insu,.a.n'.:>:::,..OI',P,-U1Y (,f 1'",::c'".;
___State Farm Lloyds, Inc.;
--,-StaLe Farm Indemnity Company
,;.( State F:otrm Mutual Automobile Insurance Company
State'Farm Fire and Casualty Company
TillS c'ertifies U.'at policy .,!Umbel 0526-"7~2-38 OOl, C,='-IeLli1':j ~.
1999 Ford F150 rnckup, was J.ssued t.o Paul Ranck and was 1[; (;t:fcct
.~)ii tIle Ct\.:cidc!1t date of ..Tune 19: 200<l. The cc:\.:rprrl'~p~::; ;1!1d ! imi.r.f~
of liabllity for this policy on
j-' j-
'-.na....
cia te were:
A 100/300/100, C2 100,000, D, G 500, H, R1 80%/1000, U 50/100, W
50/100, F 2,500, Z2
This policy prdvides Full Tort.
'-"-r" +~ ~ )..
Karen'~'n'."BUrv', 'cpcT:J':,;1ELU, ChFC
Claim ITeam !v1anager ( ,
State of Pennsylvania
) ss.
County of York
,--'
~.\... (~
Subscribed and sworn to before me this ~ day of~, ' i ,
(Yea r) --).(1:. 1("""':
--. -.--\ .'
, I..~' ~ c \ 'h.\.. i"..-LJ.,--
Not;,if:y-'-publ ic I
,
\
My Commission Expires:
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Spring Gatdep r:(ip" Yak Qou:1ty
e~a.~o
Member, Pennaylvanla Association 01 Notaries
Sta
ile Insurance Company
EXHIBIT
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HOME OFFICES: BLOOMiNGTON, !lUNOIS 61710.0001
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Police Agency Patrol Zone ,
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o A~nty Name Precinct Investigation Date (MM-DD-YYYY) "
~ I f/cNNS'fL(/,J,A/111 '677fT~ ~PL/~- II {!.t;1U1;j~6 I @TI]..[ffi] -~ ~
1 5' Dispatch Time (mil) Arrival Time (mrl) Investigator Badge Number 1
~ @JiEliJ ~ 11l2a:J/)€~ UN U..JiZW/VIAfC-- I ~
:. Reviewer f Badge Number Approval Date (MM-DD-YYYY)
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~SI~~LL.l.1J"~ ~ ~ LE11J () lE..L!J Formf OWed DUnk
i.. ;- wo. rkzone (If Yes, ,Complete 0 Yes . No School BU:5 0 Yes _ No ISchool Zone a Yes _ No Notify PEN~DOr.O Yes . No I
l. ~ Form M, SeCClon 29) Related I Related Maintenance
II II ~ection Typ~ 0 4 Way Intersection 0 'Y' .Interse. cMn 0 Multi-Leg 0 Off Ramp 0 Railroad Crossing, ~~n @ElPt;';
J ..., Intersection................. L.I',
Ill. Midblock 0 OJ' Jnters~ctJon 0 TraffiC Clrclel 0 On Ramp 0 Cro~~over 0 Other. "
t.~J Round About ; " See OlJ<!,:Ia.y I
I ! Route Number Segment (Optional) Travel Lanes Speed Limit 0 North! House Number (If applicable) ';
IJ' CQIEILIT] CIIIJ 0I] Is-I~I ,~ . South ~I
i -. Street Name Street Ending 'i: 0 East .or M,d-blocl: cra'>hp~ on:y Use "
4. tI : mOJO We't postal Hou~e Number d'ld make sure 'I,
! -_~; 12.:r /' N t:. i?. t-J ;5 > PMclpal RoadW. ay Strt>et Nam~ IS Jl
... 0 Unknown f,',ed in " u\.nq th'\ option
! It \,. lJf,.~y;,g 0 Interstatt' 0 Turnpl~e 0 Turnpike . Stdte 0 County 0 LOCcll Road 0 Pnvate 0' OtherT.=l
"" '" (Not Turnp/KP) (EastN'lesr) Spur Hlqhway ROiJd or Street Road Unknown I
Segment {Optional) Travel lanes Speed Limit 0 North - -,
ITDJ OJ OJ .1 0 South ~!:
Street Ending 'i: 0 East
OJ 'o~ 0 West
o Unknown
=g 0 rnte~tate 0 Turnpike 0 Turnpike 0 State 0 County 0 Loc.ar Road
(Not Turnpike) (EastNJest) Spur Highway Road or Street
.
...J
FAT
COMMONWEALTH OF l-.....l'lSYLVAN1A
POUCE CRASH RE?ORTING FORM
Case Closed Reportable Crash
. Yes 0 No . Yes 0 No
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...,. .... ." .. ..a. .....,....'...............,.........
o Pnvate 0 Other( 'i
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Ending :::J 0 filst. :
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Information
for BOTH
Landmarks
If USing N
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Distance From Crash
Scene to landmark 1
(For Crash between
Landmark 1 and
Landmark 2)
. ..
Degrees Minutes Seconds
Latitude: ffiE] [I0:1 ~181.[ili]
"T~Hk~.i~ h, -. < 0 ~,:~~'S;~~'~' '-'..- .. 0 poi;c~ Offl~~r-~r "f' rm Fuo<iio~i';g'" ~- ....-..-- ' . ..-'"
, 0 . Flagman - 0 DeVice functioning 0
. Not Apphcab.e TraffiC SIgnal 0 ~~~~o~R Crossing 0 Other fype TCD - No Controls Improperly
o ~~~~~r~_~::~IC_., C:,~~~~_.s~,g:_ _ ..?5~~~~~2'~~~. 0 Unk:~~~___. c: f~~~~~,~~_,_~_ ~~~~I;~~~~~~.n:~._ 0
Degrees Minutes Seconds
Longitude: - W3 rn =~. ffi:z:J
.._c" 1
. e
...
'.---..Lo.- 't!
Emergency 1:1
Preemptive ,
Signal II
Unknown ~,
/.iI~ (If .Not Applicable', skip rest of the Lane Closure section)
o Not Applicable 0 PartIally . Fully 0 Unknown
~jJ.m 0 North
I2itJ:f;tjga 0 South
o East
o West
. North and South 0
a East and West
.......-4..-.~1
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'lr.af:fk Yes. No 0
Qe1DJ.I.LRIl Unknown 0
~ 0 < 30 Mln, 0 30-60 Min. 0 1-3 hrs .3-6 hrs
..._....... . __..... ,~._ ....."..... .._~..... ...:o...~...... . .'~I.._'_....____'...~.__..._,. ...,_~. .........__............_......
FORM . M-500 (12J02)
PENNDOT COpy
EXHIBIT
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."0~~~~~hl~iei~ JO H~'~'~~n Ve~;~'e' 0 Illegally Parked 0 L~gallY ;;r~;d C;'~o'r; :~~~;0;;l~'1~-~m;::rcia~h~~e --'l
o Pedestrian 0 ~edestnan on Skates, 0 Disabled From 0 Train 0 Phantom Vehicle ·
", .Qf_~P~~str~a,!'or '~ed;;:e;l~h;~~:~! in, ~he;~~~~~sf!~;~~~co.mp(~!e-F.orm MI. ~e.~t~9.l1.2!) ~f Y~~'..,~:~~:~~:,.(),~
i"~itI7 I . .. . ... 1;1-;:1i~1~1'tw:iliJ !
Delete? Telephone Number p
1717- 2.4;'-7970 I i
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Driver or Pedestrian Physicaf Condition
O Apparently 0 Illegal Drug
Normal Use
o Had Been 0 SICk
Drinkmg
Primary Vehicle Code Violation
I VC 332'f
FAT
.. I COMMONWEALTH OF PENi\:SYl.VANIA
::.....J POliCE CRASH REPORTING FORM
AA 500 2 1 ~()2.~ J l/ 0 "] <18 f&,
Page:
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A/cohoflOl1JQS Suspected
. No 0 Illegal Drugs
o Alcohol 0 Alcohol and Drugs
o Medication
o Unknown
t
,. Alcohol Test TVDe
S . Test Not Given
-a 0 Blood
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~
o Other
O Unknown If
Test Given
O Unknown
Results
o Breath
DUnne
o Test Refused
O T~t GIven.
Contaminilted Results
A/cohof Test Results
[Q]. IT]
Driver Presence
1 ::Dnver Operated
Vehicle
2:No Dnver
[[]
Owner /Driver OO=Not Apphcclble
I D I..... I 01 =Pr,vate VE>h!cle Ownt'dl
'" I Pil\pd by Drrver
Ol..Pnvate VE'hlcle Not
Ownpd/Lea\ed by Dnver
03=Rented VehICle
04=State Police VehiclE'
OS",PENNDOT Vehicle
06:Other State Gov Veh
I
.t
I Same as
I Driver 0
Address I Ci
3(,
Model Year
[lIT[ffiJ
Reg, State Est, Speed Vehicle Towed
~ 0ill . Yes ONo
Policy No
II
Insurance Insurance Company
eYes 0 No 0 ~~~wnl STA7E Fi\R.H
Chambersburg
m 11111~lmllllln SE~ra:h ~u~~~; I
P0632393
State Class
[eI!] I c..
'i
I
1
II
:1
,:1
I)
Charged? II
. Yes 0 No ~
I
:1
,I
II
I
,I
,
o Fatigue
o Asleep
o
.
Medication
Unknown
3=Oriver Fled Scene I
4=Hlt and Rlln --1-..
g=Unknown
07=MunlClpal Polrce Veh
08=Other MunlC'lpJI
Government Vehicle
09=Federal Gov Veh
98",OtI1l,or
99:::Unknown
Vehicle Model
j PIS;-O
'I
~ I
*Make COdeJ
III:gP
(see overlay}
1
Ii
Towed By
I L €/'!10S "'/oWt;J&
tJ c;- ?- f. "1 '-I rJ.. A
Ii
Trailinq ~
Unit No, of 0 _Umt
- TraIling
Units:
l:Towing Pass. Veh 4=Mob:le/Modular Home
O 2::Towlng Truck 5=Camper
3=ToWlng Utility Trailer 6=Full Trailer
7",Semi-Trailer
8=Other
9=Unknown
Direction of I ~ I "Vehicle Position
Travel C
Vehicle Cofor
[ill] 06=Yel!ow
D' 07 =5 lIver
08::Gold
09=Brown
lO",Orange
11 =Purple
12 =Other
99",Unknown
[QJ1J
"See
Overlay
20=Unlcycle, Bicycle,
T ncycle
21=Other Pedalcyde
22=Hor~e & Buggy
23=Horse & Rider
24=Traln
25=Trolley
98",Other
99=Unknown
"'Movement Cl.]]]
01=Blue
02 =Red
03=White
04=Green
05=Black
Vehicle Type
r:-r::::.I 01 =Automoblle
L.J?J.D 02=Motorcycle
03=8us
04=5mall TrucK
(If .02", Compfete Form
M, Section 26)
(If "20" or "21", Complete
Form M, Section 27)
Initia/lmpact Point
~ OO=Non-Colhslon 14=Undercarnage
l..QJ..:1J 01.12",Clock POlllts 15=Towed UM
13=Top 99=Unknown
05=Large Truck
06=5UV
07=Van
10=Snowmobtle
11 =Fdrm EqUIp
12=ConstructlOn EqUIp
13=A 1V
18=Other Type SpE>( Veh
t9=Unk. Type ~pec Veh
Damaqe Indkator
Q O=None 2=Functlonal
W l",Mlnor 3=DI~abling
9=Unknown
Tag No
I
Tag Year
II
Tag St
ID
Speciaf Usaoe
rn
12=CommerClal
Passenger
Carrier
13=Taxl
21 :Tractor TraIler
22=Tw,n Trailer
23=Triple TraIler
31 =Modlfied Veh
99=Unknown
OO=Not Applicable
01:Fire Ven
02=Ambulance
03=Pol'ce
O&",Other Emergency
Vehicle
11 ",Pupil Transport
Gradient 3=Downhlll
ril 4=Bottom of Hill
W l=level 5",Top ot Hill
Z=Uphlll 9",Unlmown
FOAM' AA.500 (12102)
PENNOOT COpy
Road Afionment
[] I=Stralgh~i
2=Curved
9:Unknown
'-'ltQlrn.,,"""---~ Q
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Fltr
CO~M:O~nnn:AL'?Y. G!= P'=WX$Y:'V~~~&
POl.~ltc t'AASii REj)()!l!!i\iG r~ll'ill:
. New
SEP 1. 0 200~
III WII~lmlllllllll~1 Crash Number I
p 0
AA 500 2
I Po!ic(' lM,4crz - 140 3 q 9 lb
Page:
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o Changel
Continuation
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-
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~ Alcohol Test Type
~ 0 Test Not Given
:G I 0 Blood
.s;-
~ I Alcohol Test Resu/U
I [Q].~
_ rr~~~~~hicfe in 0 Hit & Run Vehicle 0 Illegally Parked 0 Legally Parked 0 Non - Motorized
o Pedestrian 0 r~0~~~~h~~,S~t~tes, 0 ~:~f~~~ ~~~~ 0 Train 0 Phantom Vehicle
(If 'Pedestrian' or "Pedestrian on Skates, in Wheelchair, etc", Complete Form M, Section 28)
.....,.,...r~_____., .", , ..... ....'6._,.,"Ir.~'....:&'..... ,.......,...~.....,...' ....I'I\I.....,.r,..,.~. .............,.....-.-.. "....'--.........".. ~.,....:......., ....:...,'.,..--_.,...,..,.~..-..-
Unit No Firrt Name MI Date of Birth (MM-DO- YYYYJ
~ rn ~ QEJ CQIITII]
Telel!none Number
I 7)7 ,/1." -~-'1'iO I
2"
l~
I
com~;~i~-;;';~i:~: _''OJ
I
. Yes 0 No
(If Yes. Complete Form C)
State Class
~11t
. Breath
o Urine
o Test Refused
O Te~t GIVen,
Contdml!lated Rt~u\ts
GOther
G Unknown If
T est Given
O Unknown
RIi'\u:ts
Driver or Pedestrian Phvsical Condition
. Apparently 0 Illegal Drug
Normal Use
o Had Been 0 Sick
Dnnkll'\<}
Primary Vehicle Code Violation
o fatigue
o Asleep
o Medication
o Unknown
AlcohoVDrut1s Sus~cted
. No 0 Illegal Drugs
o Alcohol 0 Alcohol and Drugs
G Med:catlon
o Unknown
l/oAJ E
Charged?
o Yes 0 No
Driver Presence
IT]
l~Drlver OpNilted
Veh,cle
2 =No Dnver
3=-Onl/er Fled Scene I
4=-Hlt and Run -L-
9=Unknown
Own!JrlDrlver OO=Not Applicdblf'
rIiT3l 01 ~PrNate Vehicle Own{'dl
~ If!'a~t'd by Dnl/e-r
OJ ~Pnvdt(' W~,C:(' I\ot
Ownt'dll ['a~d by Dr'VE'r
Gl,RIi'''ted V!i'l1\(\E'
04 "StdtE' POIIlE' Veh,(\C'
O';~PF NNDOT Vph,(\p
06=OthE'r State GOY Veh
07=MunlClpdl Polocp Veh
08~OthC'r Mun:cipal
GOl/erroment Veh\{le
09~FE'dl'rdl Gov Vl'h
98=:Other
9g"Unlmown
&.11Z'-ISLtt:;
fJ4
; : Insurance
Ii ~! . Yes 0 No
;n
\ roI,;
~ ~ l Traillnq T e
, 1: II Unit No.. of r71, t.i~t
~ - Tralhngw-
.!! . Units:
~
l~
Insurance Company
o ~~~nl SII2. iLl S
iVjodel Year
:;.. I 7 I z I 0 I 01 oj
Reg. State Est. Speed Vehicle lOVled Towe<l13y
leE] 8JQI] ., Yes 0 No I {)f.A.,lJ..Je-1:-
policy No
II
6H
SG~ C'$
.. .1i;a~1! COOl!
I~
(~('E> overlay)
I
I
I
/701.1
I+H~l4C.14
loOt 3'71/L'JZ-
1 = Towing Pass. Veh 4.,Mob.leJModuldr Home
r:::l2=TOWlng Truck 5::Camper
L.LJ 3=Towmg Ut,:,ty Trar!er 6::full Trailer
7=Seml. Tra,:er
8=Other
g=Unlc~own
Tag i\!o Tag Year Tag St
fPrK?7Ql.O 11-;.(JD'I1 C&J
I Direction of [IJ "Vehide Position [EIJJ .f:llovement [Q[L] "See Special Usage
I Travel Overlay WliJ
I Vehide Color 'fell/de Tome Or;",large Truck ZO=UnlCyde, Bicyde, 12=(ommerclal
[ill] 06=Yellow ~ 01:Automoblle 06-:5UV Tncycle Passenger
; 07=Sllver o 02=Motorcycle 07 ",Van 2' =Other Pedalcycle OO~Not Applicable Carr,er
01=Fire Ve~ 13", Tax,
08.,Gold 03=Bus IO=Snowmob:le 22",Hor~ & Buggy o2=Ambulance 21=1ra,tor Trailer
Oh:Blue 09",Brown 04",SmaJl Truck 11 ",Fdrm EqUIp 2 3.,Horse & Rider 03=Po/(ce 22",Tw,n Trailer
I 02=Red IO:{)range (If -or, Complete Form 12'.(onstru(tlon EQu'p 24= Tram 08",Other EmergE"Ocy Z3.,Tnple Trailer
, 03:WMe 1 t ",Purple M. section Z6J I3=A TV 7S= TraCey Ve~lIde 31 ~Modrf'ed Wh
; 04=Green 12=Other (If "20. or -21", Complete 1 &-:OthE'r T ypp Spec VE>h 9S=Other 11 =Pup,l Transport 99.-un!c.nown
~ 05=Blac~ 99;;:J'lknown Form iVi, Section 27) 19=Unk. Type> Spec Veh 99"Unknown
-
~ Initial Imf'act Point Damacre Indicator Gradient ~...OoW'1hIH Rot;d AI/crnment
UJ2J OO~ Non-Co,:,s:on 14;UndE'rcarragp [I) O.-None 2...f"nctlonal IT] 1 :lE'vel 4..Boltom of H,li OJ ' "Stra'gl1t
, 01.12",cloclr. PO:'lts 15",Towed UM l::,lA'nor 3"OI'idbl''1g 5,::Too of H.:! } =<. urved
I t3..Top gCj=:Jnk"owl' 9=Unkrlown }",Uphlil 9""Urlknown 9-=Unknown
:J
L.
FOJr,: , AA.:.:"'..u (121OZ1
~= .~~::":': =.: ~:j'.::".'
1=.
.. -1' COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 3 I Police ui-1~ '1-* f 40 J Cf B to
A Person '[yjxi:
1 =Dn~r
2 =Passenger
7 =Pedestrian
8=Other
9;Unknown
t:
o
..
III
~
.2
.E
II
C.
o
:.
Sf!'
B F ;Female
M ;Male
U =Unknown
Injury Sevf'P1Y.:
C O=Not Injured
1 <:Killed
2=MaJor Injury
3=Moderate
injury
4=Minor InJury
8=lnJury, Unk
Severity
9=Unknown If
Injury
Page
[ill]
c '~sEiQn: .n"". 'S.~l;riE;;~iPment One7 ,,,....,",,
D OO=Not A Passenger/Occupant E OO=None Used / Not Apphcable
01="Dnver - All Vehicles 01 :Shoulder Belt Used
OZ=Front Seat Middle Poslllon 02==Lap Belt Used
03=Front Se.lt Right 5:de 03=lap And Shoulder Belt Used
04=Second Row. Left Side Or 04=Child Safety Seat Used
Motorcycle Passenger 05;Motorcycle Helmet Used
OS=Second Row - Mla'dle Position 06=Blcycle Helmet Used
06=Second Row - Right Side 10=Safety Belt Used Improperly
07..Third Row Or Greater. 11 :Chllcf Safety Seat Used Improperly
Left Side 12=Helmet Used Improperly
08=Th,rd Row Or Greater - 90=Restralnt Used, Type Unknown
Middle PosItion 99:Unknown
09= HlIrd Row Or Greater.
Right Side
10=Sleeper Section of Truckcab
11 =In Other Enclosed
P.lssenger Or C argo Area
12=ln Open Area
(Back Of Pickup, Etc,)
13= T r a,ltng UnIt
14==Rld'ng On Vehicle Exterior
15:Sus Passengl'r
98=Other
99:Unknown
~:
F OO:None Used / Not Applicable
01=Front Air Bag Deployed (For This Seat)
02=S,de Air Bag Deployed (For ThiS Seat)
03=Other Type Air Bag Dep!oyed
04~Mulbp'e Air Bags Deployed
OS=Motorcycle Eye ProtE"dlon
06=BJcycltst Wearing ElbowlKneelPads
10=A,r Bag Not DeploYE"d, SWitch On
11 ",Air Bag Not Deployed, SWItch Off
12..A,r Bag Not Deployed,
Unk SWitch Setting
13=AIT Bag Removed (Prior To Crash)
19=Unknown If Air Bag Deployed
99=Unknown
13
EMS Agency: IUF~ I.Ic.v J (~Ns.e,~8.Af;J iViedical Facility: I
.
I
-- -.<-...
. SEP 1 0 200;
~11111~mlllllll Crash Number I
p 0632393
~ '-G -'~it~i~;;~;e-~~_&F.-i
2=Totally Ejected I
' 3=Partlal1y Ejected
9=Unknown
!
H ~~. ~
O=Not Ejected / Not Apphcable '- II
1 = Through Side Door Opening
2=Through Side Window
3= Through WindshIeld
4= Through Back Door
5= Through Back Door T al19ate Opel'llng
6= Through Roof Opening (Sunroofl
Convertible Top Dowl'l)
7=Through Roof Opening (Convertible
Top Up)
9=Unknown
~
fMri.catlon'
O=Not Apphcable
l=Not Extncated
2=Extricated By Mechanical Means
J=Freed By Non - Mechanical Meall5
8=Other
9=Unknown
tA/Zu !Jt...L HtJ,.5IJT7k-j Jkfl..!1IeY Nt:b Oi?I;!
, ,I
Unit No Person No 0 I 1 Date of Birth (MM-DD-YVYY) ABC D E F G'H -,,_. 1-- -;I
14 [iIl] [ill] ate []]-[]]-ITIIJW[E]~0IJ~[[0[]@]~ :'
Name / Address / Phone
Ii7I Same as I
l,lIoJ Operator
I ElViS Transport ;
. Yes 0 No .1
!
Unit No Person No Date of Birth (MM-DD-YYYY) ABC D E F G H I 'j
[iliJ ~ D~te? ~-[1]]-~~[E]0~[ili][Zli]ITJ~~ It
Name I Address / Phone EMS Transport !
o ~~n;~a:~r 1Ce, ~ ~l' ~ Fr;(l.(;t, e" ............... . ... . 4f;q . .yesO:l
Unit No =P~~on No~; 1 'D~te-~fBirth (iiM~DD-YWY)""'-'''' --"'--,;, "i3" -" c -'" 6" ,. .'t ,.- ('" '''~-G~H-'''''i'= - -
0D ~ ate [iliJ-1 J-I~ 1-~[]J0[i]~0Z][ili]w(E]~ :
I
Name I Address I Phone EMS Transport I
D~~~:'a:~r [12.1(.ft /44.;.;,-1:... :J(, Cl.14.-jl)V ;Ie... f!.t.IU4St..t: P4 J '}013 717' eVes ONol
I,
.' --.,...............-.--......... -:-.-
Unit No Person No I Date of Birth (MM-DO-YYYY) ABC 0 E F G H I --I
[ill] ~ D~te? [iliJ-EllJ -CLliEEJ 00~~0i]0EJ ITJ~~ I
Name I Address I Phone I
C4-f '-f EMS Transport :t
. Ves 0 No I
O Same as B'n .J r...
Operator 1.../~ivNIj,.... I.:Jt.JFFIN
c=/rtAk.srtA-n: b~. ;tT.JJc/.~
__"'-wll"', ."-'-' -. _ .,.-.-..'...'Ji~..~d....,_-w'..........' ...........'4_.......... . w ~...~".~,~.:....<;;--... .... .,,~'--..,...._:.. ".-.r..-::::; ,.=-..:..,..'...,."._..._....._.a..."'._~,._"',...._, .~....-d
Unit No Person No I 1 Date of Birth (MM-DD-YVYY} ABC D E F G H r I
[tl!] ~ Dote. [iliJ-0IJ-~0~[Z]1 tJ 1~11 tJ r31~UJ~W
Name I Addre5$ / Phone
EMS Transport !
o ~:~a:~r ,4-u'iSeJ.V C. /3EA- I t,.<.JQ(1/)V1C......1 D M..J.<; eYes 0 No i
Unit N;"'-p;r'sonN~' . 1~~.,~.-'.Dat;"orBirth(MM::OD~i(y;,;}.._---_.._...-A-B---C-.- D E - F G H l-'.::'~
0J I ~t}':~~, JLI.1. Hili] -OJilll2]QJ0@]~~rn ~M~~rt !
o ~';:~~~:._?,t;~JJ MAP,i~ ;;/~~~.~~~ ~~._~_.. .~,~.._.~~.._s~~:~~_~~__::~.....,,_._...~.._ eyes ~ No I
FORM' AA-600 (12102)
PENNDOT COpy
CllamDer~Ulll ~
.. I COL(;li\JJONWEk1~F ~ro3\jS~L~!A:\:}~ ml~I~UlllllllllfEP .Cr~hONU~berO~ "I
..:....J Pf:DiQ05 CRASH REPORTING fORM . New U~
Page
M500P IPohcer~t_ 1403&(8(0 . I I t71~1 O~~~~:~ation p 0 to 3~~q _______.
Unit No Pe~-;;;;---'-- -D;t-;~fBi;.u,-(MM~D:mY)~------A BCD -E- F G H I
14 [Qill0lJ D~e1 OJ -OJ -ITIIJ OJ ~ [Q} ~ j 0 [31 ~ W [EJ [!]
~ Name I Address/ Phone EMS Transport !
~ f:p':~a~~r I: I 0 Yes . No !
t ilJETI 'De~; ETI~ffi1iITJDDod:ifim~Do-j
l\!ame I Address I Phone EMS Transport J
o Same as I I .1
I L Operator 0 Yes 0 No 1
iOS to. ~te' m1TI1IrrJooodJdJmoDD;
! l\!ame I Ac:ldress / Phone i
i.o~~1 . I ~~~~oj
\ Unitil:o Person No Date of Sirth (MM-DD-YYYY) A a C D E F G H I
1 OJ OJ O~te? OJ-OJ-ITIIJDDDOJCDCDDDD
Name' Address I Phone EMS T rt)
I I l ranspo\
[1 ~,fe~a;gr 0 Yes 0 No ~
Unit;\!o Person iIlo Date of Birth (MM-DD- YYYY) ABC D E F G H I
OJ OJ O~te? Q]-[T]-ITITJDDDITJOJCDDDD
Ci\!c:Ilt3/Ac:dr~s!..?~on! _ __ _ _ __ _ _ _ _ ___ ___ ___ _ _ -----, Ei'u.STransport
r- 1 Sc:me as ~
, ..J O~l!iator I 0 Yes 0 No
Uni>i':o Personi\!o Date of BiJ1jl (MM-DD-YYYY) ABC D E F G H I
OJ ITJ D~t97 [IJ-lIJ-Ul-UD[JDITJITJOJlJDD
li!ame , Address I Phone
r 1 Same as I
I _ Op3rator
-.J ElIf.S Transpori:.
o Yes 0 No I
Unit i'Jo Person il!o Date ofBirth (MM-DD- YYYV) ABC D t F G H I
OJ ITJ De2)te7 OJ-[IJ -[II]] D DO ITJ IT] CD ODD
~i1me I Address I Phone
[ J Same as [
Operator
I EiViS Transport '
o Yes 0 No ,I
UniUo 'erson l\!o Date ofBirth (MM-DD- VYYYl ABC D E F G H I
OJ OJ D~te? [TI-lTI-ITIJJDDDIT]OJCDDDD
il!zme I Address' P:1or.e ~ ,J
j EMS Transport I
[ ] Same as I '
Operator 0 Yes 0 No :
. ,_.. "
m ED D~te? ffi~l~J1IrrJoDodJdJdJoDo '
;\lame I Address' Phone ' ;11
L EMS Transport I
Same as
o operator I 0 Yes 0 No '
'-
. .'., . -., .....-
Unit i\!o l'erson il!o Date ofBlrth (MM-DD- YYYYl ABC D E F G H I
m IT] O~te1 [D-[TI-ITITJDDDOJOJITJDDD
, 1I!arne I Address' Phone
fJ Saflte as [
L O~Tator
::cr-: ,- :;';,s:::l ~ ~
ElV;s Transport
o Yes O.:J
~~XX~-:J.." ~:;::'!
~
PAl
CO:VJMO!'lWEAlTH oe: PENNSYL v AN!A
?C::";:O; CAAS;.i RE!>>O#t1'tNG ~O~M
II ml~lmlllllllllrE~~~ ~~+ -,
it,
_New
Page
[lliJ
V "(1111 UtH '" I"n." ;:,
o Changel
Continuation
AA 5004 I Pol;ceU;~z.._/4Q~ q ~"
...~.. ... .... "~_._' .
,.pc _ ~_~ ,~~~~:~~~s~:~~,..~~~~~;,~~r,~~~:iBY~uon). ;!i~~~~~~ _;:~
OJ 1=On Travel Lanes 3=Median 5=Oulside Trafficway 7=Gore (Ramp IntersecUon)
2=Shoulder 4=Roadslde 6=ln Parking Lane 9=Unknown
[!] ~:g:~~~~'~'~; ""3~~~ Street .\ ~~R:f~~~~:~:"-'--'8~Otiie"-' u ~ _. -''*~ ~"'l
"OJ' -/' .'C.- ,;:[~~~~-<=~ ~;;; (~~r;'-"" ~~ '5=F~d~~~~L. ';':5ie;' & 'F~-'" a< ,~z'~Unknown - ~
_. .. ,_ '. . . _ . ~Rain . 4..Snow 6=Rain & Fog 8=Other !
Road ;;';a; c:n;;~;;n:-" '-ro"KI'~"";':;~--= -'-,w2:~;tM~d: Dirt~'~. 4~'I~s;;~4"-"'- '-~--6~ic;p~~h;~';OL-_" ~-Qlher "'..'....
....., _ _. ..... '.' _ 1=Wel . 3=Snow Covered 5=lce 7=~~JvinStat<<ling I:
--- - - Hann 'Event TiR .'MOSt1'UtiiitY p(jie Numlier-.....~~ ,,-.~. Ha~ful Events (Har~ E;;;;~' .' , ";:'~it '~nc-:-o;.w:it"_.__r_..~,
1 fI'l"?:l D _ ~ 01=Hit Unit 1 31=Hit Building
Unit No ~ ~ 02=Hit Unit 2 32=Hit Culvert
[ili] 2 [illJ'1 [0 CIIIIIIJ 03=Hit Unit 3 33=Hit Bridge Pier Or Abutment
v {.. 0 04=Hit Unit 4 34=Hit Parapet End
05=Hit Unit 5 35=Hit Bridge Rail
06=Hit Other Traffic Unit 36=Hit Boulder Or Obstade
CIIIIIIJ 07=Hit Deer On Roadway
o 08=Hit Other Animal 37=Hit Impact Attenuator
09=Col1ision With Other Non 38=Hit Fire Hydrant
CIIIIIIJ Fixed Object 39=Hit Roadway EQUipment
o 1 '=Struck. By Unit 1 40=Hit Mail Box
12=Struck By Unit 2 41=Hit Traffic Island
13=5truck By Unit 3 42=Hit Snow Bank
'4=5truck By Unit 4 43=Hit TempOrary Construction
lS=5truck By Unit 5 Barrier
16=Struck By Other Trafflc Unit 48=Hit Other Fixed Object
21=Hlt Tree Or Shrubbery 49:Hit Unknown Fixed Object
22=Hlt Embankment 50=Overtum/FQ11 Ovef
23=Hlt Utlli~ Pole 51=Struc!c By Thrown Or Falling
24=Hlt TraffiC Sign Object
25~Hlt Guard Rail 52~Pot Holes 01 Other
26=H,t Guard Rail End Pavement Irregularities
27=Hlt Curb 53;::Jadtnife
28=Hit Concrete Or 54",Fire In Vehide .
Longlt\;dinal Barrier Sa..Other Non<oIlislon
29=Hlt Ditch 99.,Unknown Harmful ElII!f1t
c
o
16 i
..
-2
.:
:~ 1.-..
Please ~t 3 ~O 0
Events In ~
Sequential
Order 4 CD D
Harm Event LlR Most?
I UnitNo 'W D ·
u. @02CD DO
17
I.
l'
~
'c
:;)
Please P~t 3 rn D
i Events In
I Sequential
I Order 4 CD 0
First
Frafmful
Event In
tlieCfaSh
, Driver Action (D)
Unit No Harm Event ~ OO:::No Contributing Action
r:r-:-l r;-r:;;l 01..DriverWas Distracted
~ Ll...W ' 02=Driving Usmg Hand Held Phone
G3:::Dnllil1g Using Hands free Phone
04=Making Illegal U-Turn
-------.~ 05=lmproper/Care!ess Turning
06" Turning From Wrong Lane
07=Proceeding WfO
Clearance After Stop
08=Running Stop Sign
09=Rurrning Red light
10=Failure To Respond To
Other Traffic Control Device
11=Tallgatlng
1 Z=Sudden Slowing/Stopping
13=llIegally Stopped On Road
14=Careless Passing Or Lane
Change
15=Passing In No Passing Zone
16..DrilllOg The Wrong Way On
I-Way Street
~~lt @]]
o
Utility Pole Number
CIIIIIIJ
CIIIIIIJ
CIIIIIIJ
CIIIIIIJ
o
Unit No Harm Event
~rn
Most
Harmful
Event in
i1ii<TaSh
00 not rcp~t thl!!. infOrfTl4lton on mulcp1e paqe5
~=~~~---- .
c:
o
~
~
o
S
g'
l
~
c
(3
Environmental I Roadway
Potential FactorJ (fIR)
OO=None
Ol=Windy Conditions
02=5udden Weather Conditions
03=Other Weather Conditions
()4:;Deer In Roadway
OS..obstacie On Roadway
06.,Qther Animal On Roadway
07::G Iare
08=Wotk Zone Related
[Q0 20] 3CD
11=Slippery Road Conditions (lcelSnow)
12=Substance On Roadway
13 :::Potholes
14=Broken Or Cracked Pavement
15::: TeD Obstructed
16..Soft Shoulder Or Shoulder Drop Off
2S=Other Roadway Factor
29.,Qther Environmental Factor
99:Unknown
Possible Vehicle Failures (V)
OO=None 06=EJchausl
01=Tires 07=Headlights
Ol=llral<e System 08=Sigoal Lights
03=Steering System 09=Other Lights
Q4=5uspension 10=Hom
OS=Power Train 11 =Mirrors
~:it rn 1 @:@] 2 0]
~it [ill] 1 @E) 2 CD
12::::Wipers
13:0river Seatin9lControl
14=Body, Doors, Hood. Etc
1 S~ Trailer Hitch
16::::Wheels
17 =-Airbags
18= Trailer Overloaded
19=UnsecureJ$hlfted
trailer Load
20=lmproper Towing
21 =Obstructed Windshield
99=Unl<nown
_'. ._I"t,'~-,.,___"~'_."'l':_'._~--' __ __..........
Indicated Prime Facto( Unit No Factor Code
Do 001 repeat r"'s ""Off11d1lotl on r:;::;-rjIO I [Qllili
mullple pages. ~ 7
fiR V D P
00.0
FCiI!J t ~(t...
If fIR is the Prime Fador
Type, .!.!~~~ .I.!~i~~e,~!~'.'k
10141
~~it I 0 I z..l 1 rn
Pedestrian Action (P)
OO=None
01..Entenng Or Crossing At
Specified Location
02=Walkirt9. Running. Jogging,
Or PlaY'"9
Unit No CD
17.,(areless Or Hlegal
Backing On Roddway
18",Driving On The Wrong
Side Of Road
19=Making Im~r
Entrance To Highway
20::::Maldng Improper Exit
From Hjgh~ay
Z l::::C areless Parkmg/Unparking
22::::0verNnder
Compensation At Curve
n"Speediog
24"Oriving 100 Fast
For Conditions
25=Failure To Maintain Proper Speed
26=Orivet' Aeeing Police (Pol Chase)
27 =Driver Inexperienced
28=Failure To Use Specialized Equip
92=Af1ected By Physical Condit.'on
98=Other Improper Driving Actions
99=Unknown
20] 3m 40]
2CD 30] 40]
03=Working
04=Pustllng Vehicle
05:Approaching Or Leaving Vehicle
06=Working On Vehide
07 =Standing
98=Other
9g..Unknown
rn Unit i\!o 0]
~
~
~
0] n
I'
..- ~
?ENNCOT CO?Y
~
I
\1
'I
II
-11
:,1
-I
_'5.........__. ---.
FA
~ COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 5 I Po~~~ ~OZ _I U 0 3 q 6 "
Page
[Qfi]
-.~.-.:~,.~...~'t'~...~"')t""'C""";' ......,~.~.~4_~..-......,..,~........-"""'_.__.__.........
. .
... ,..,n. .".....,... .__....,._..... ......
.........i...
. . . .
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hr....... ...~..... -.... .1' ...
. .
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! ".... ... .,.. ........~ .......... ..!...-
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zo ell
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S.R.O~, " ~
.... .. ~"I:'..
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..+... .-.."'-'
. ." ........ .......~.
21
. . .
.' ,. ........ .. .1'..__......_: ... .' , . .. .;... j.=" .' ... . ~.. . '. .. 'r '~ ;
~b r i.T~..~~~bg;7~~" jp..OD.JI ,/ ~._r.l!f:..J)!y!.e.!~J;AI, fg~.l7fti #tStJY4.it.o/M~tt!.,R-*..""..".
Witness Name Address Phone
1 J(jN P. j4,qAJ/) I~ SUI'lL; /!JOIl-ltVc. 17 (Jo7 '711-2" - J2..'i
2 1.!.~..,,!:!:...I-lI4~!?_.~.,.1 q 51!.~'!:=-~_..w.I3.J?J}-,t.v,:. A/{,.S :~.!2.t1()1. I - ~'!.E::'Z;
Narrative and additional witnesses: Accident Investigation Notification Issued1 . Property Damage 0
UNIT 1: Cell Phone Present/Not in Use UNIT 2: No Cclll>honc Present
is-~kic-le-wUisioo-~{;\J.r-Fed-in till} slHltbhouHd lane MSROOII. Unit I wa;
, h.ed Oh th~ , ight bel m of SROOtt-with a cat avail of t1u ec additional,
..
>
;:
~
..
Z
'U
C
III
III
Z :I
c
..
i
o
.
complete a V-Turn across the southbound lane into the northbound lane. Unit 2
was traveling southbound and braking to avoid a collision with the vehicks entering
the roadwa . Unit 1 turned into the ath of Unit 2. Unit 2 struck Unit 1 in the left
~r to rear hed arell ofthe vehil'le. Ilnit I trftvelellacross the roaillDl r 'n 0 he
~Rd-lftne-.a.Rd-(}ff-tbe roadway. Unit 1 hit-a-smaU-embaakme.Gt,..{l.ip.pe
e10final rest on the east berm alld gra1i1i, f,u:'
lane of SROOll.
1'01\11 . AA-6IlO (12m)
PENN DOT COpy
~ COMMO~ek.TH OF ~NNSYlVANJA
POLlCE CRASH REPORTING FORM
M 500 N I PoIiceUm ~ -I L{ 0 5q r~
Page
I ~[i]
. New
o Changel
Continuation
SEP1 0 200L,
~llllll~UIIIIIIUIlII Crash ~umber I
Narrative and additional witnesses:
22
Ph sica v
from the tanker of Unit 2, Measurements from the be
marks to point of impact were as follows:
Right rear outside; 66 Feet
Ig t rear inside; 68 Feet
Left rear inside; 70 Feet
Left rear outside; 80 Feet
The distance from Fairwa
10 inches. Visibility was a
clear, sunny day.
Drive to Point of 1m act was 179 Feet and
roximatel three- uarters of a mile on a
~
~
~
.
z
~
II
I
Ii
!e-
ts
~
0(
rs, In ervlewe ltness , on atrlc
, OJ mg prmgs, a
· ~II III::; :a:;~t=e :=~
that the gr:~;:~ling ~ the wrong di~edion ~nd had'
ed to the right herm on SROOll snllthhoUDd to cl-1{'rk tbe dirediQns
with the rear driver, He stated that nit I was si ua ed behind him and
he then conducted a V-turn to travel northbound on Rt II. He stated
that he heard the collision between the units,
FOlW . AA-liOllN (121m)
_,_ _._ _V_ _ __ .._.~ ___ _ _..__.._~~._______.______ .._ __ _ ____._~__ ". ~_.
PENNDOT COpy
."1 fAT'
.;...J COMMONWEALTH OF PcaIlHSV1.VANIA
POLICE CRASH REPORTING FORM
M 500 N bo.z. ~ / if 0 3&1 ~b
. New
~1111l'11.llilm S:: :":~~
Page
rn
o Changel
Continuation
Narrative and additional witnesses:
22
the caravan
Turn from the ri ht berm in front of him, He stated that he was
braking and Unit #1 turned onto the roadwa ' in front of him. He stated
that he collided with the driver's side of Unit #1.
~
i
t:
III
Z
1
III
..
i
~
~
::g
'iC
:J
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Tbe juvenile passengers could not provide substantial investigative
. 'h II"
tlnn concerning t e ~o ISlon.
On 6/19/04 1130hrs Troo er HENNEMAN and the Coroner notified
the father of the deceased Gordon Scott BEATTIE,
..o.ul;AA.a:iil~c.:-i ---
PENNOOT COpy
<.;namoer :iI,^n 'i!l
.
~
FA 'I
COMMONWEALllI Of PENNSYLVANIA
pouce CRASH REPORTING FORM
M500N l~cei..f62.-1'40 3q~(o
Narrative a
Page
I UIQ]
. New
o Change!
Continuation
11111I1I~1 mlllllnlm S~} N:m~e~O~
lelo~~
22
Services Unit arrived at the collision scene and documented th
with a di ital and film camera, See Attached Su lemental Re
1
i
.
z
"
Ii
Ii
If
i
CII:
Troop H CARS was not called at the direction of CPL MAYS,
This is a final report.
~ II AA<<!llI': ~
?ENNOOT COpy
- .'_.~._-' -....-.. fij;J
.-J r~'1
AA 500 1
COlVlMOi\!~rr OF ~'. ,..JSYLVANIA
?Oi..lCE CRASH :tEPORTli\lG FORNi
Case Closed Reportable Crash
. Yes 0 No . Yes 0 No
tb New
IlllllllllllllllllllllllrE~~~ ~~41
o Change!
Continuation
" poii~;'"A9~-;'q; "-." ---, Patrol Zone . '-'~
02 1 ~I:LGIJ i
"!I.ng,:..... 'red"" f:i:ron.... (MM"D-YVYY) ;
[p~nn1'lYlv~ni;) St~tP. PnJice I I Carlisle I Rrn-~ I
Dispatch TIme (mil) Arrival Time (mil) Investigator Badge Number J
ITITI ITrn I CorE2t"al Jonathan L. MAYS 7789 I [ITIIJ ~
Reviewer Badge Il!umber Approval Date (MM-DD-YYYY) H
I' Cf-- ~Q e CnOU~Ol I 5I!liITIJ [~E}[ill]-~ 11
County County i\!ame Municipality iViunidp~iityName" .~. ,".... '.,. .."..' ....,-- .-.. Q;i.x..P~ cecIl
~ OJI ICDJI g~~ng:U:i
2 ~ DJC"'h Date rrT-P-,tTl ~ r:ti q'l ~ITJ:{iIIed* ~~iriDr~ 0 Tue 0 Sat i
b;-= .. ~ ~ _-L.iJ Fomif) OWed QUnk
, Worla:one(tf Yesl.Complete 0 Yes 0 No I School Bus 0 Yes 0 No School Zone 0 Yes 0 No ~'tJtYoy ~ 0 Yes 0 No Ij
I Form lVI, Section 29) Related Related' i\I'.a:nten~tlt I:
'~llil - - .\
to- In1l:l.~i9n Tlf9ft 04 Way Intersection 0 'V' Inter;e<:tlon 0 ~t~:~;~?on 0 Off Ramp 0 Railroad Crossing 1 ~l r-TI -"1
3 0 Midbrock 0 0 Traffic Clrclel I J.aGm.qn LL.J '
"'1 "T' Intersection RoundAbout 0 On Ramp 0 Crossover 0 Other, J,~, ~~..~~:!!l, J'
i Route i\!umbl!r Segment (Optional) Travel lanes Spel!d limit 0 Nort'1 liouse reumber (if applicable)
'i:!III] ITIIJ ITJ UJ .8 0 South 'D-I '-I U'
4 i ~; Street Name Street Ending ~ 0 East
1;/. ITJ 'ol'! 0 West
. ~; 0 Unknown-
,1::
J ... :
r
r7el/l
o locClI Road
or Street
for Mid-brod< crashtos only. Use
~tdl HO'~ Number and ma~e !>Ire
Pr,ncipal Ro.Idway StrPet Name 's
filIt'd 'n if wnq th~ apt:on
O Pnvate 0 Other}
Road Un!mown
:1
. 'U .
,~
r~
, ,~
,;
s: :;-;
ill
.~
, i'i
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t. \
. (
~P-U-1! -0 Interstat!' 0 Turnpie 0 Turnpike 0 State 0 County
. Jf!.U'!W (Not Turnp~kc) (fast^Nestl Spur H'ghwdY Road
J um DTTJ raTLzrS o't
I Street i\!aml!! .
~
~ B.~ 0 lnter<>'te 0 Turnpl"e 0 Turnp"e 0 State 0 County
~ ~ (Not 'furnplkel (EasvWesll Spur '" Highway ROdd
':;
Stre-et Ending
CD
o North
S 0 South
';:l
~ 0 E.d~t
.!! 0 West
o 0 Unknown
O LOedS I Road
or treet
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, \
lntenetting Rt Mum Or 'Niile Post
~nTOITIJ.D
.g Or Intersecting Street Name
c:
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i ~O North
51 0 South
St Ending ;:, 0 East
CD~OWest
;;~ 0 North
~ 0 South
St Endln~ ~ 0 East
rn~Owest
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for BOTH
landmarks
if Using
This Opt:on ~
E
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....
Intersecting Rt i\!um Or Mile Post
N ITrnITD.D
Or Intersecting Street Name
Distance From Crash
Scene to Landmark 1
(For Crash betV'leen
landmar.c f and
Landmark 2)
I'
.1
I.
'I
Longitude: -
Degrees iViinut2s Seconc:s
CD CD=m.ITJ
.' ,
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t\Jj;nutes Seconds
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.
! ?: U.!L'{ (:1.I1,;;;;rHlf "Not Applicable", skip rest of the Lane aosure section)
. ~l
:.~. 0 Mt App1lcabie 0 Part,a';y 0 Fu:!y 0 Unknown
D,ll'----
j ~. Th'i"liJ: Ve-s 0 No 0
LL. fl:,.otpllfl'.d. Unkrlowr. 0
;:o;c . i':'-.:::'~
o Y,eld S,gn o POlice Officer or Lc;Q.BmrtiP.JJiag Ernergency
o Active RR Crossing Flagman 0 No Controls 0 Devic.e functioning 0 Pree>mptive
C ontrots o Other Type TCD Improperly Signal
o Passive RR o Unknown 0 D~v,ce Not 0 Device Functioning 0 UnmO'Nn
Cros~ Iflq C on troIs FUnC.tlO!'1lng Property
lil'lflj~,S_o..atmL~Jtk.ft
8 i G' 0 Not Applicable C) Traffic S'g'1al
11-: 0 Flashing TraffiC 0 Stop Sign
i' '>'gnal
l.;l.n;'LOP,l,UI?
0((;;::#$111
o
o
North
South
o
o
East 0 North and South 0 All
WC'St 0 fast and West (N.S,f.Wl
F~._T.im?, 0 30 Iv'.
a.Q5?d <: ,~
030-607vtn 0 '.3 hI'; 03-6 hrs
o 6.9 hr, 0 > 9 hours 0 Un!tnown I
:: :::...~,.._--- --'=~,
. __'''''..-'_4 -"_. .
\j'f'\a'l'l'l'lJI'l:'" ~...-. ""
. ~
~ COMMONWEALTH OF PENNSYLVANIA
FAT POUCE CRASH REPORTING FORM
AA 500 N I~ICe~~z -1'10 3 ~ B~
CX)ttew
IIII ~1~llmIIIIUIIII S~~Sh ~~~o.~
Page
mO
Changel
Continuation
Narrative and additional witnesses:
2% On 06/19/04, I interviewed a witness. to this crash at the scene at approx. 0959 hrs.
Amiee Nicole HAND, 19 Shirley Lane, Boiling Springs, PA, (717;-240-1299, related that
ahe was the operator of the third vehicle in the group that was pulled on the roadside.
She advised that they had pulled over to check directions. She related that after
the were clear on \~here the \Jere oing, her husband, who was in the first ',ehiele,
did a u-turn to 0 back north on SRIl. Unit#l then attempted a u-turn to follow the
first vehicle. UnitU ulled into the th of Unit#2. HAND t:elatecJ that Unit#! should
not have ulled out and it was the rou 's fault. She also stated that her husband in the
first vehicle, should not have pulled out.
interviewed Shannon O'hara MCGUIRE, 2332 Ritner H~, Carlisle, PA,
at 1006 hrs. He related that he heard the crash and yTas the first on
the scene, He assisted a female
on he side of the road. This
er out of the
er identified herself as Erica. He also woke a
~
:w
~
:
'V
c
III
;
.s
(~f
! III
11=
'R
::I
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,
femal
or side 'n the back seat. She told him that her name
chest pain and trouble breathi.n .
On 06/19/04, I met operator #2 at the Penns.ylvania State
Dure operator #2'g
'I'
Police Statiofi-Ln carlisle.t
blood alGohol content. !'
II
;'
:;
f
t
.
!
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I
,
_1~__--- ------- -------
I
PENJiDOT COpy
(:4-
-.J COIVjiVIOi\!W::ALt:~: 0:= } ~SYLVAi\!IA
?OUc:E C;tAS:-; lE?O~TII\!G :=O~i\fi
Case Closed Reportable Crash
AA 500 1 . Yes 0 No . Yes 0 No
.iI!ew
1111111111111111111111111 S!11 ~u~;Ofirl
Page
[LIT]
a Changel
Continuation
. .'__ ____....-'~_....._'"t
Poii~e A~nty patTol Zone ?,
~ Will :
Investigation Date (MM-DD-VYYY) ~
1[~I<oI..[{]1]-~ !
~~
t~AMQw.s}:.l ?oZ 1 I L1-LLU (1
~ Approval Date (MM-DD-YYYY) I.:
I ~m,.CLED-~ il
. ..' , .... .'. . '~-"".4.. 0-, ','''' 4... ....;.:
County County i\!ame Municipality Munidpality Name DaJ{. of Wm:k jl
1! rn I' I IT]] I g~: g;: ~
z ~uta coCraSl1 pat~.(MM-DD-~~ I cTh,mero I Nco'OOfUnits IIP1e I Injured :(iIIed" ~g~p~~e 0 Tue 0 Selt ;11,
- LL-L-L.J CO form F) 0 Wed 0 Unk i,
1 Wor'czone(1f Yes, Comp(ete 0 Yes 0 No r5chool Bus 0 Yes 0 No I School Zone 0 Ye~ 0 No i\!~.' PE."\!l\100T.O Yes 0 NO!
I . Form M, SectIon 29) I Related Related' Mamtenante .,1\
0'1" . .,... ... .,....., .' . . -"
~ lntmel:tilm.I1l..llJl 04 Way Intersection 0 'Y" Intersection 0 MultI-Le9 0 Off Ramp 0 Railroad Crossing ! ~~~. CD I':
s ~J Intersection 1 ~.1\ .
... 0 Midblock 0 'r IntersectIon 0 TraffIC Clrclel 0 On Ramp 0 Crossover OOth JI
.!l Round About erj 0 Soca Overlay .
,~, .. .-.. ~".--"'.. ,... . .-1
\ Route j\!umber Segment (Optional) Travel lanes Speed Umit e 0 North House r.!umber (if applitable) r
11 DID ITIIJ CO OJ ; 0 South DIIIIJ ,)
1/ ii l Street i\!ame Street EndiM': 0 East for Mid-block crashes only U$e I;
fi [JJ ~ ~ g ~::~own ~~~OR:d~;~:e:~~":elS5ure (:
I:: ) ftl'ed ,n If u5:ng this optXln ._.', I,
t!
PoLl c.E.
Arrival Time (mil) Investigator
~ b-ibCTI'CI!. d~'c~
e/tIU.I~f.,t
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Ot\vl P ~
(,,,-.1...0.,.
0 local Road o Private o Other I
or Stre!C't Road U nxnown I'
;
c: o North ~
0 o South
'P
~ o Edst
c o West
l!l
'C
0 o Unknown
o local Road o Pnvate 0 Other I
Of Street Road Un!mown ;,
O Interstate 0 Turnp:ke 0 TurnpIke 0 Statp 0 County
(Not Turnptxe) (bl5t1West) Spur H,ghway ROcld
i ._' tl Route Number Segment (Optional) Travel Lanes Speed Limit
. ,~., ~ ITDJ ITDJ OJ IT]
i tr ~ Street i\!ame _ Street Endlnq
5:g j m LITITJTl 0 LOJ OJ
~.l c:
o -;; B..CW1f: I t t t T I, T k St t C
\ 1:':;' :i.il'tf);nn 0 n ers a e 0 urnpl..e 0 urnpl e 0 d e 0 ounty
I-I ~ =-= (Not Turnpike) (East/West) Spur Highway Road
f~l ~
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for BOTH
Landmarks
if Using
This Option :;
E
'l:l
C
3
....
"
-~O N h Feet II
o ort r-r-TIII'i
S:050uth~1
St Ending ;:) 0 East. I
[0 0 Or MIles 'I
~ West OJ 0 II
. 1~
~; 0 North Distance From Crash ;:
GI 0 5 th Scene to Landmark 1 I,
St Ending :s 0 ou (For Crash between 'I
[JJ East Landmark 1 and II
~ 0 West Landmark 2) "
cr:
Minutes Seconds
CD:CD.[O
Longitude: -
Degrees Minutes Seconds
m [JJ:OJ,[O
If.idtiLC9..D1J:J2Ln.,"t'!Js:.~
o Not Apphc.3ble 0 TraffiC SIgnal
O Flashing Tralt;c 0
Signal ~top 5:gn 0 Pa~slve RR
Crosslnq (O'ltrols
j ~ ~ I~I;;'tS1p."''''rt(lf 'Not Applicable', skip rest of the Lane Closure sedjon1'~!'~~.l/@'
~ l.i 0 Not App!lcab1e 0 Pa-tld1iy 0 Fully 0 Unknown Qu;;~1.Rt1
!l \1' .__._~. .-
, U I Wlf~if: Yes 0 No 0 l;.,;,i 17m"
I ~ ~. "~-u.-.J U 0 ;"j~~;' '0 < 30 Iv;," 0 30-60 M,n 0 1.3 hrs
~. '0".',,",- ~~... nX'lown 1-!H-l>'JA
;tCR:~ :! .lM!ll:l:'11M1Z)
o Yield Sign
o Active RR (rOSSI'lg
Controls
o PO:lce Off:cer or
Flagman
o Other Type TCD
ED..JP.n.c:ti...cmicrg.
o No Controls
o
o
Device FunctIoning
Improperly
DeVice FunctiOning
Properly
o
o
Emergency
Preemptive
Signal
Un~nown
o Unknown
o DeVice Not
F unctlontng
o North
o South
o fast
o West
o North C],'ld 5out~ 0 All
o East and West (N,S,E,W)
o 3.6 hrs
o 6-9 hrs 0 > 9 hours
o UnJ(novm I
:=.=:\!;\::c...~ '=C::::'l'
IvnamD~1 bUlIl ~
.
~
FAr
COMMONWEALTH OF PENNSYLVAl\HA
POlleE CRASH REPORTING FORM
AA 500 N I ~~elJsfOn~ Uo~- /,/oj 98lo
Page
I ITEJ
Ii New
111I1I11~111III11~11111 D S~Sh~~~~O+t
Iflo~
o Changel
Continuation
22
Narrative and additional witnesses:
OIV t""'V_ "Q I Q (/ T ..... .^ 'tr~€Q A ~,,).. (j~11E1i. ~;v.yJe:c:TJ C'V niV
{ J... ,1'"11 (J. AT l\t~ :<)~rlV~ .t!P;~IE'- 7u !L Nslc.CJ1C;N AC!lJ,t7-# Plio I S/ooOo 99
A C ("}~y 0 F '-'-If€' ..r:NsIECJ:jlCV d EAPr I~ I /I I A ~ /~/~-j);- IN-nip:
fJ11'fk/t(h.f>to..iT Pit...€: h..lt< THlj :IN J€. S 'j/(i. 4 ncf'l'
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FORI.! II AA-COl'l ....,
PENNDOT COpy
...
AA 500 1
COMMONWEALf;J; PI- .4SYLVANIA
POLICE CRASH REPORTING FORM
Case Closed Reportable Crash
. Yes 0 No . Yes 0 No
Incld;~t . N;;-mber -
[LiD
1111111111111111111111111 S~~}N~m~~OfJ
..J
,n OG0579""7 PO G,.3:;l3'9..3
t'i;i~l~ ,;,-,";i.;i I!
Investigation Date (MM-DD-VYYY) ~
I GGJ .. ru -GLIiliJ ~
Badge Number ~
Patrick MCKflIlNA Jr, I QID 1
Badge Number iP~rvat I Date (MM-DD- YYYY)
I GJJIiIilJ G.~ ,.[ili],.~
County County Name Municipality Municipality Name ~VJfflJtIr
!lUJ I I IT[] I OSun O,hu
t., I . 0 Mon 0 Fri
2 j; rncraSh Date <ITJMM-DD-YYYYITIIJl ITII]craSh Time (rml) NITJO of Units [OpeOPle [Olni\.lred [O:<.iIIed" ;:';;p~~te a Tue a Sat
! \); ., ". . . .. Form F 0 Wed 0 Unlc
lWOrltZOne (ff Yes, Complete -0 Yes 0 No TSchool Bus 0 Yes 0 No TSchool Zon~ 0 Yes 0 No lI!o?fY PENNOOTO Yes 0 No '
i Ii ~ .. Form M 5ectlon 29) I Related _ I Related Mamte~a~(.e. - ~i
3 '1' ~j ~ 0 4 Way Intersection 0 'Y' Intersection 0 ~~~;~on 0 Off Ramp 0 Railroad CrOSSing ,= [0 '\
"'! 0 Mldblock 0 T' Intt'rsenion 0 Traffl( C,rcle/ 0 On Ramp 0 Crossover 0 Other 'I
l} ~ Round About . .'. .. See OverlClY. )1
t Route Number Segment (OptIonal) Travel Lanes Speed Limit 0 N h House Number (if applicable)
11 ITIIJ ITITI ITJ ITJ .~ 0 S~~:h CIIIIJJ
~, Street Name Street Ending ~ 0 East for MId-black tra~he~ only Use
4 .... ITJ III 0 W t postal House Number and make sure
~; '0;:: es
I '0 I Prrnclpal Roadway Street Name IS I
r: \ 0 Unknown t,lIed ,n .t USlrg thiS opton . _ .-J
~; =g 0 Intl'!statl' 0 lurnplke 0 Turnpike 0 Statl' 0 County 0 Local Road 0 Pnvatl' 0 Othl'!1 --II
(Not Turnpike) (Edst/West) Spur Highway Road or Street Road Unknown
I ~'; ~ ITITIRoute Number ITIIJseoment (Omlnnill) ITJTraVll1 Lanes ITJspeed Limit c; 0 North C,!
l 0 v .~ 0 South L \1
.1 i; i ".... '.me ,..... ,"",ngi g ~::, I I
" ~. ~ ITJ 0 0 Unknown :
III I ... lkwts:. I
. t:'~ ~ <:;hM;nn 0 Inter;tate 0 Turnpike 0 Turnpike 0 State 0 County 0 local Road 0 Private 0 Other/ "
- .. ~ (Not 1urnplkel (EastJINest) Spur Highway Road or Street Road Unknown
~
,,,"",.. ~'g~E~ tLI -I-I-~
OJ~OWe5t ITJ.D
.ti
III
o ~ency Name
~ ~sYlvania State Police
1 i Dispatch Time (mil) Arrival Time (mil)
~ GJiliE] GIili:W
:,1 Reviewer
~ I
....,!.
CAeA_' s.t.E
Investigator
I Trooper
C/L
f)P(Vli>
P. G.:>ul.A>"1
---~.-- . ". - ,.
- -.---_. ~ -
... Intersecting Rt Num Or Mile Post
i: ~ .>i! ITITI DTI ,0
..
tV .c; '"
E .. E Or Intersecting Street Name
1 .. Please "'0
0 c:
.'] 'IS Enter j
E .E Information
. III for BOTH
e :t> Landmarks ,Interrectir Rj NUj em. D Or Segment Marker
... ~ If Using N
41 ~
'" ... This Option ..
c ~ ~
.l! II> Or Intersecting Street Name
'" :S "'0
0 c
.::l
,.
Minutes Seconds
ITJ:[O,ITJ
Longitude: -
Degrees Minutes Seconds
OJ UJ:ITJ,[TI
~ 0 North DIstance From Crash
<; 0 5 th Scene to Landmark 1
r Ern~1 ; 0 ou (For Crash between
East Landmark 1 and
~ 0 West Landmark 2)
~ I
.. --~ ~1
-t..~" .-CO -- -De-r~es
7 ~ t. Latitude: EEl
f
:;I
'"
o
· 0
.
c
:3
'-I)~
fJim1iJxl
K!2..CY~fDg .,",
o No Controls 0
o Device Not 0
Functlomng
o North
o South 0 West
I
~ ~~.~-.-"-'--l
DeVice FunctIOning 0 ~~~~g~ I
Improperly Signal
DeVice FunctiOning 0 unknown H
Properly Ii
~~.m
o Not Applicable 0 TraffiC Signal
O Flashing Traffic 0 5t S
Signal op 19n
o Yield Sign
o ActIve RR Crossing
Controls
o Passive RR
Crossing Contro:s
o Police OffICer or
Flagman
o Other 1ype leD
o Unknown
.- -<:....... ~
I..;vJeStrtifld Of "Not Applicable', skip rest of the Lane Closure section)
o Not Apphcab!e 0 PartIally 0 Fully 0 Unknown
o
Eas!
o North and South 0
o East and West
All ~.=-- --Ii
(N,5,E,W) II
t
TIPfk
~
Yes 0 No 0
Unknown 0
~
~ 0 < 30 Mm 030-60 Min, 01-3 hrs 03-6 hrs
o 6-9 hrs 0 > 9 hours 0 Unknown
.._-,,:~._'" ",'.h .
.......',.. ......,..
fORM' AA.SDO (12101)
PENNOOT COPY
E
e
20 l;Il
"
is
21
:
~
III
2:
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I:
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22 = I
c
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.- "-'...,--. -..,-. ~
~A-T
.J COMMONWEALTH OF Pl:.NNSYLVANlA
POllC:: CRASH REPORTING FORM
AA 500 5 I PolK:e110l_ I 't 0.3 q 6"
II mll~lllllllmllH S:;"hlN~:~O~
r 05057~F7
Po (p 3 2. 3 q 3
"..~.-,...." ---:_",.......1;"...,_.. -:-".- ..............~-n~i..
Page
[ill]
.~...-~~-r:-_ r;<" :'r~ ~ '-"'; St"'" '.. ,So........... ~.......... ....~...._~..~_..~. ('""'~
..t,," :;~ ....__~..,_..._.a.....ll".
.., ;_ ''-,~.;:';'.T--'~'-,.oooC'' -~"-" .
.
........
II
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. .j
Witness i\!a~e '
Address
__.~-__.,_ .~'...,. ~ --' "i.~'....__._...~. ..~,-.v,., ~:'j
Phone
I 2
I Narrative and additional witnesses:
I
I
!
!
!
i
Acddent Investigation Notification Issued? 0
Property Damage 0
On 06/19/04 at 1015 hours I was requested by PSP Carlisle station
to respond to the scene of a traffic accident on 2200 block of Rittner
Hwy.(RT 11), West Pennsboro Twp., Cumberland Co., PA.
The Investigator is Trooper Donald CHEWNING,PSP Carlisle, Patrol Unit.
I arrived at the above location on 06/19/04 at 1045 hours and
photographed the scene using a Nikon N90s 35rnrn camera, 28 to 80mm lens,
Nikon SB-28 flash unit as needed and GC400 Kodak color film (2 rolls).
A 60mm Macro lens was used as needed. Negatives to be retained by Troop
H, Forensic Services Unit. This officer also took 37 digital photographs
using a Nikon Coolpix885 3.2 megapixel digital camera. The digital
photographs are stored on disc and a copy was provided to Tpr. CHEWNING.
Film was forwarded with form SP4-136 to the PSP Harrisburg
Photographic lab at 1800 Elmerton Ave., Harrisburg, PA 17110, for
processing only. If photographs are needed contact Troop H, Forensic
Services Unit and refer to ID #2004-0433.
.011I.. AA-SOO (12JU2)
PENNOOT COpy
FA-r
~ CCMa;~O:\''Q1fF..A:':f'.rr OF h..'iireSYl..VAN!A
PClJeE ams~ flE]%lCRTlA'G ~':ORNl
M500F IPoliamn~_ I'T 03~eto
24
"~,""...;;--~~,.;;'--=.,~~~.-..-......;,.." .........,...-
Road Surface Jltpe
o Concrete
. Blac.ktop
Driver Restrictions
Compliance
. No Restrictionsl
Not Applicable
c
o
;: Driver EndOlJement
~ Compliance
o
i
. None Required
25 ..
i:
:::I
Driver LQnse
Compliance
o Not Required for
Vehide Class
o No Valid license
for Class
.. Valid Ucense for
Class
o Not Ucensed
Druq Tert T'lP9
. None
o Blood
o Urine
Druq Test Results . (Ug to Four Results)
o '" No Test Given 5 = Amphetamines
1 '" No Drug Reported 6" PCP
2 '" Marijuana B = Other
3 c Cocaine 9 = Unknown Test
4 = Opiates Results
,- - ------ - - - ---
Unitl\!o
@m
c
i
,f
15:
c
:::I
Driver Endcmement
Compliance
Driver Ucense
Compliance
Drug Tert Type
o None
o Blood
. Urine
Dnlq Test Results . (Up to Four Results'
o " No Test Given S = Amphetamines
t '" iIIo Drug Reported 6 '" PCP
2 '" illiariiuana 8 '" Other
3 = Cocaine 9.. Unknown Test
4 = Opiates Results
I
~-
F:r.::U , .'.:~~ca-zt
o Not a Pennsylvania
Driver
o Unknown
Compliance
o Unk if COL or
COl Required
o Not a Pennsylvania
Driver
o Unknown
o Other
O Unknown if Test
Given
~[Q] D
DO
o Not a Pennsylvania
Driver
o Unknown
Compliance
o Other
O Unknown jf Test
Given
~w D
DO
Page
[ill]
. New
o Changel
Continuation
1lllllllllllBllml S;:lN::~U~
: .....I:......rr-__~i.."'-.v..... -,7:., _......... "-.. .....--.. ~-'l"J'''''4'"",
PriOODle Impact Point
o Non-Collision
o Top
o Undercarriage
o Towed Unit
o Unknown
A voidance Maneuver
. No Avoidance
Maneuver
o ~:~~~~i~~~
Braking. No Skid
o Marks. Driver
Stated
Under Ride Indicator
. No Underride or
Override
Underride.
Compartment
Intrusion
o
000
01~1l 12 01020
. 09 030
00 040
07 06 050
o 0
o Braking - Other
Evidence
O Steering - Evidence
or Driver Stated
-.~.-
o Other Avoidance
Maneuver
o Inconclusive
o Steering and Braking 0 Unknown
Evidence or Stated
Underride. No
o Compartment
Intrusion
Underride.
o Compartment
Intrusion Unknown
Emerqency Use 0 ligh1:5 Flashing
o ~~: in Emergency 0 Siren Sounding
Principle Impact Point
o Non-Collision
o Top
o Undercarriage
o Towed Unit
o Unknown
Avoidance Maneuver
O No Avoidance
Maneuver
.... Braking - Skid
-- Marks Evident
Braking - No Skid
o Marks. Driver
Stated
Under Ride Indicator
. No Underride or
Override
Underride.
o Compartment
Intrusion
Emergencv Use
o Not in Emergency
Use
:~~~N;JOT C:l?'."
0.0
Ol~ll 12 01020
009 03 0
008 040
07 06 050
o 0
o Braking - Other
Evidence
o Steering. Evidence
or Driver Stated
o Override. Other
Vehicle
Unknown if
o Underride or
Override
I
I
I
=oJl
~.
o 8rick or Block 0 Dirt Special Jllrisdiction 0 Military 0 Other Federal Sites
O Slag. Gravel Dr 0 Other . No Special 0 Indian Reservation 0 Other
Stone Jurisdiction
_ _ _____ _ _- c: ~nknown . . .0 National Park O~~i:;Unive~ity 0 Unknown
Please complete ~t Inform-;tion for r!.d; ~~;ed i~ -af~'t~1 c~aSh~~ ';ot' ;;~;~t'th;jnfo;--m~-;;~~i;t"h;fj;jch;~;~.~~Iti~;;;~;:
. '\oIl""'lo:'~"'...~IIf'I,.~Ji01E--r__,.,..._~::'";.._-..,;"\""""'''''~.'~:",~ ~,'~ -.o<L.I._.s. ...- -~'.SO,."::_,,,, ,-.;r').;~-'lS,.,__,.~....~~'IItOo-"'."-~
Unit No
[Q]LJ
o Restrictions
Complied With
O Restrictions Not
Complied With
O Compliance
Unknown
o Required - 0 Not a Pennsylvania
Complied With Driver
o Required - Non 0 Unknown
Compliance Compliance
O Required -
Compliance Unknown
Driver Restrictions 0 Restrictions
Comp/lance Complied With
.. 0 Restrictions Not
. No Restfl~lons/ Complied With
Not Apphcable Compliance
o Unknown
. Required - 0 Not a Pennsylvania
Complied With Driver
o Requir~d - Non 0 Unknown
o None Required Comphance Compliance
o Required -
Compliance Unknown
o Not Required for 0 Unk if CDL or
Vehicle Class CDl Required
o No Valid license 0 Not a Pennsylvania
for Class Driver
o Not Ucensed . ~~~ license for 0 Unknown
o 80th lights and
Siren
o Unknown
o Other Avoidance
Maneuver
o Inconclusive
o Steering and Braking 0 Unknown
Evidence or Stated
Underride. No
o Compartment
Intrusion
Underride.
o Compartment
Intrusion Unknown
o Lights Flashing
o Siren Sounding
o Override, Other
Vehide
Unknown if
o Underride or
Override
~
~
.J
o Both Lights and
Siren
o Unknown
.d
FAr
C~ill!i'..r.O~WEA::"~1 Or }-._...tliSVLVA1\UA
PCc..L!::E CRASH REPORTING J:ORM
M500C
I PDIlce mly~ - III 0 .3 <r ~ f&,
c:
o
I
i
III
'U
23!
ii
I
"
Carao Bodv TVDe
o ft!ot Applicable
o Van/Enclosed BOll
. Cargo Tank
Hazardous fll'iGterial
o Yes . No
~- ~ ~.3::"~".._ _~ .-,_
- . -rrum1);;ofAxles
I A I r-] (Code Numb<< ofAxJt:S
V.) or '99' for unknown)
- SEP 1 I)
~11111~Ullllllllllm
[BillIillIIliMJ
Page:
I rIill
. New
200'-,
Crash Number
... ~ca;ri;"'Pho;e" .~.'. ~.. ."'~.~~~.-,~.-
([2[!E]) 0illJ - ~JRili]
TIIIJ
GVWR
~
Ovenize Load
o Yes _ No
o Unmown
State Zip
m~[[J]J
puc #
Vehicle Confiquration
o Not Applicable
o Passenger Car - Only Record if
HazMat Placard Displayed
o Light Trucl (Van, Mini-Van, Panel,
Pic.'tup or SUV with HazMat Placard)
o Single Unit Truck (2 AxII!5, 6
Tires)
o Single Unit Truck (3 or i\IIore AxII!5)
o Single Unit Truck (Un:(nown
iIlumber of Axles)
o Truckfrrililer{s)
?:::~!~iJO"t ~?'!
o Change/
Continuation
V.ehicle Confitluration
o Not Applicable
o Passenger Car . Only Record if
HazMat Placard Displayed
o Light Truck (Van. Mini-Van, Panel,
Pickup or SUV with HazMat P\acard)
~Single Unit Truck (2 Axles, 6
Tires)
. Ingle Unit Truck (3 or More Axles)
o Single Unit Truck (Un!mown
Number of Axles)
o Truclt/Trailer(s)
o
.
o
o
o
o
o
Truck Tractor (Bobtail)
Tractor/5em i- Trailer(s)
Medium/Heavy Truck - Cannot
Classify
Small Bus (Seats 9-15 PecIJ~a.
Including Driver)
Bus (Seats More Than 1S
People, lnduding the Driver)
Other
Unknown
o Flat Bed
o Dump
o Concrete Mixer
o Auto Transport
o Garbage/Refuse
o Bus
o OtherfUnknown
c
o
11
~
i
.
't;
23;;:
~
';
'E
III
E
S
CaraoBodvTvoe
o Mot Applicable
o Van/Enclosed BOll
o Cargo Tank
t flazardous Material
2 0 Yes 0 iI!o
I I
U:-~'-
FOI'~ I: f-~~:::: ltZmJ
Enter 1-digit hazardous material class
"'V" "'V" "'V" "'V"
DODD
DODD
~ ~ ~ ~
1 = ~o Release 2 = Release Occurred 9 = Un/mown
Number of Axles
rn (Code /l!um/r.!r of Ail/as
Dr '99' for unfcnown)
o Rat Bed
o Dump
o Concrete Mixer
o Auto Transport
o Garbage/Refuse
o Bus
o Other/Unknown
Enter 1-digit hazardous material class
~ "<;7 "'V' 'V
DODD
DODD
.c.... ..c.... ~ ./",.
1 ::! ~o Release 2::: Release Occurred g:: Un~nown
o
o
o
o
o
o
o
Truck Tractor (Bolr".ail)
Tractor/Semi.Trailer{s) I
Med1!lm/Heavy Truu. cmtnot II
aa~l~ I
Small Bus(Sec."tS 9-15 Peall:a. ';
Induding Orionr) I:
Bus (Seats More T/1an 15
People. Including tile Df.ver)
Other
Unknown
"
.J
.
State Farm Insurance Companies
STATE FARM
A
INSURANCE
@
August' 4, 2004
State Farm Insurance
11 34 Kennebec Drive
PO Box 6001
Chambersburg, PA 17201
Hershey Medical Center
500 University Drive
Hershey, PA 17033
Attn: Medical Records Administrator
RE: Claim Number:
Date of Loss:
Our Insured:
Patient #:
Patient Name:
38-K461-021
June 19, 2004
Paul Ranck
SS# 198-70-5295, D/O/B 9-21-89
Tori Lynn Bell
Dear Madam/Sir:
Enclosed is an authorization for release of medical information
concerning Tori Lynn Bell who was treated on 6-19-04.
We request the following:
~ Complete Medical Records
v Admission History and Physical
~ Emergency Room Records
~ Discharge Summary
Other:
If there is a fee for this service, please include your bill and
payment will follow. Thank you for your assistance.
Sincerely,
Heidi Saller-Judy CPCU
Claim Repr~$~ntative
( 71 7 ) 2 6+:d~::@:Q:$::::::::::j:f}:::
En c I 0 s $.:W$.:j::
Au t h~~i z al::li;,n
::>:::::::::::::;:::;:::. ...................... ..
Irt~..:anci::::::::lompaili::,::.'..
.:: ~t(tt~f:.:.:.:.:.:.:.:-:.:;:::;::::~{r~~~~tt:t.
:;:::;:;:;:::::::::::::::::::::::::::;:::::;:;:::::;:::::;:;:;:::;:;:."
;::::::::::::::::::::::;::::::::::::::;::::::::::::::::;::;:;::.;.-
.............. ....
.....................................
.................................
.....
....... ...... ..
........... .. .......... .,
.........................................
.;.;.;.;.;.;.;.;.;.;.;.;.;.:.;.;.;.;.;.;.;.;.;.;.;.;.;';':';';':';';';'.
:;;;:::::;:;;:;:;::}.;.;.;.;.;.;.:.:.:.:::::;::;:::=;=;:;:;:;:::;:;:::::.
..................
.................
....... ... ...
State E~~ MutuJP0Aut'llbile
.:::;:;:::;:::;::::::::::.
:.;.:.:.:.;.;.;.;.:.;.
.:.:.:.:.:.:.:.:.:.;.:
...........................................................
...........................,.....................................,.......
....,..............................
..................................
',;.;.;.:.;.;.:.;.:.;.:.;.;.:.:.;.;.;.;.;.;,;.;.:.;.:.:.;.:.;.:.'
.............................,.
. -..........................
. . , . .. .. . . . . . . . .
..................
. . , . . . . . . . . . . . , . . .
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001
I
I
err
I
-Ie
\(4 Ii \, 7yal
,S O,'jj
Chambersburg
AUG 27 2004
RECORDEX ACQUISITION CORP
SOURCECORP HEALTHSERVE
17 LEE BLVD, STE D
Malvern PA 19355
Phone: (610) 640-0600
Fax: ()-
Invoice No.
Invoice Date
Sales Code
Class / Type
Price Class
EIN
1-BQ-63825 .
08/24/2'004'
TM9025
INS / INS
STD
51-0370082
ATTN: HEIDI SALLER-JUDY
STATE FARM INS
1134 KENNEBEC DRIVE
PO BOX 6001
CHAMBERSBURG, PA 17201
Patient: ( TOJiL.Jl,ELJr'
Hospi tal : "-HERSHEY MEDICAL CENTER
RequestNo: 195680 Request Date: 08/10/2004
Birth Date: 09/21/1989
Reference #: SS198705295
SUMMARY OF CHARGES FOR MEDICAL RECORDS
CODE SERVICE RENDERED UNIT AM'T QTY. TAX EXT. AM'T
5 BASIC CHARGE 11.9400 1 N 11.94
10 COPY CHARGE 1.1300 20 N 22.60
10 COPY CHARGE 0,8500 11 N 9.35
40 ARCHIVAL FEE 4.0000 1 N 4.00
POSTAGE:
TAX:
2.32
0.00
LESS: PAID IN ADVANCE:
0.00
TERMS: DUE IMMEDIATELY
50.21
PLEASE SEND PAYMENT TO RECORDEX ACQUISITION CORP
\ l'
!/
PLEASE INCLUDE YOUR INVOICE NUMBER ON YOUR REMITTANCE.
PLEASE RETURN A COPY OF THE INVOICE WITH YOUR REMITTANCE.
Chambersburg
AUG 2 7 200;
RECORDEX ACQUISITION CORP
SOURCECORP HEALTHSERVE
17 LEE BLVD, STE 0
Malvern PA 19355
Phone: (610) 640-0600
Fax: ()-
Invoice No.
Invoice Date
Sales Code
Class / Type
Price Class
EIN
I-BQ-63825
08/24/2004
TM9025
INS / INS
STD
51-0370082
ATTN: HEIDI SALLER-JUDY
STATE FARM INS
1134 KENNEBEC DRIVE
PO BOX 6001
CHAMBERSBURG, PA 17201
Patient:
Hospital:
RequestNo:
TORI BELL
HERSHEY MEDICAL CENTER
195680 Request Date: 08/10/2004
Birth Date: 09/21/1989
Reference #: S8198705295
SUMMARY OF CHARGES FOR MEDICAL RECORDS
CODE SERVICE RENDERED UNIT AM'T QTY. TAX EXT. AM'T
5 BASIC CHARGE 11.9400 1 N 11. 94
10 COPY CHARGE 1. 1300 20 N 22.60
10 COPY CHARGE 0.8500 11 N 9.35
40 ARCHIVAL FEE 4,0000 1 N 4.00
POSTAGE:
TAX:
2.32
0.00
LESS: PAID IN ADVANCE:
0.00
TERMS: DUE IMMEDIATELY
50.21
PLEASE SEND PAYMENT TO RECORDEX ACQUISITION CORP
PLEASE INCLUDE YOUR INVOICE NUMBER ON YOUR REMITTANCE.
PLEASE RETURN A COPY OF THE INVOICE WITH YOUR REMITTANCE.
VUG .5~()
STATE FARM
S tat e Far m Ins u ran c e Com p a ncll&&bersb r,~,
@
AUG 2? 20a+CL )._ {Cf- 04
August 4, 2004
State Farm Insurance
11 34 Kennebec Drive
PO Box 6001
Chambersburg, PA 17201
-J-f G, - 2.. 2 -0 L{
Hershey Medical Center
500 University Drive
Hershey, PA 17033
Attn: Medical Records Administrator
RE: Claim Number:
Date of Loss:
Our Insured:
Patient #:
Patient Name:
38-K461-021
June 19, 2004
Paul Ranck
SS# 198-70-5295, D/O/B 9-21-89
Tori Lynn Bell
Dear Madam/Sir:
Enclosed is an authorization for release of medical information
concerning Tori Lynn Bell who was treated on 6-19-04.
We request the following:
~ Complete Medical Records
~ Admission History and Physical
~ Emergency Room Records
~ Discharge Summary
Other:
If there is a fee for this service, please include your bill and
payment will follow. Thank you for your assistance.
Sincerely,
~"Jq&.-~<-
Heidi Saller-Judy CPCU
Claim Representative
(717) 261-4805
State Farm Mutual Automobile Insurance Company
Enclosure: Authorization
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001
HEALTHSEFM:
Recordex AcqulSIlIOI1 Corp.
d:la SOURC ECORP HEAL THSERVE
SuiteD
17 Lee Boulevard
PO Box 3017
Malvem, PA. 19355
PH 610-640-0000
1-800-525-2922
FM. 61~44I2ro7
Chambersburg
AUG 27 200.
~
SOI.RCECORR
~
Recordex Acquisition Corp., dba SOURCECORP HEAL THSERVE has been retained by
the Medical Record Department of
Milton S. Hershey Medical Center
to fulfill requests for copies of medical records, Enclosed are the reproduced medical
documents specifically authorized by the patient or his/her legal representative~ We
wish to emphasize that the increasing demands for patient data pose a rising threat to
the confidentiality of the patient's medical information, SOURCECORP
HEAL THSERVE strives to take every opportunity to safeguard the patients"' right to
privacy as outlined in the AHA's Patient Bill of Rights. Specifically, all patients have the
right "to expect that all communications and records pertaining to their care will be
treated as confidential by the hospital and any other party entitled to review certain
Information in such records," As one such party, we ask that all information transmitted
herewith be treated with utmost respect and the dignity such personal medical
information warrants. Please be advised of the following state and federal disclosure
statements governing medical records in Pennsylvania:
:irn!~fto~""';"""""""""
. (i2LCER,.f?atfi2
:;:~I.t:.,
.
Based upon guidelines provided by the American Health Information Management
Association, the records should be destroyed after the stated need has been fulfilled,
We thank you for your cooperation in maintaining the patient's right to privacy, Each
medical record has been carefully reviewed to assure that proper disclosure goes only
to the authorized Requestor, If you have any questions, please do not hesitate to
contact us at 1-800-525-2922 and one of our Customer Service Representatives will be
happy to assist you.
~ The Milton S. Hershe
. Medical Center
iI b ~,,~ I ~.'S
TR!l1{ )00130
Challot/llfOD
attJoorsbUI ~j
.AUG 2 7 200~ 30 I
~;jAL '''It ,;.;, K \}~
-.
.?
MR 818
BP
Last dT
LMP
ED Pathway Room Time
PMH:
HPI:
Meds:
Pain: Y N
Location
Radiation
Unobtainable - Y
WI. Chan e N Y
Blu vision N Y
Sore throat N Y
Chest pain N Y
Cough N Y
Abd. Pain N Y
Hematuria N Y
Arm ain N Y
Rash N Y
Numbness N Y
Suicidal N Y
Quality
Quantity
N
Onset
/10 t ~ Factors
As noted, other systems negative
N Y Weakness N Y Fatigue
N Y Photophobia N Y
N Y Rhinorrhea N Y
N Y Palpitations Y
N Y Orthopnea
N Y Constipation
N Y Vaginal DIC N
N Y Leg swelling N
N Y
Seizure N Y Syncope
Ingestion N Y Depression
Allergies:
FHx: Cardiac Y N Diabetes Y N
Y N Other:
N Y Sac Hx: ETOH Y N Smoker YN PPD
Other:
N Y
N Y > -/ Neutrophil
N Y " Atypicals
"
-++// Ca
N Y
N Y '~ Mg
ROS:
Constitutional:
Eyes:
ENT, mouth:
. Cardiovascular:
Respiratory:
GI:
GU:
Musculoskeletal:
Skin:
Neurolo ical
Psychiatric:
Other:
. Ph sical Exam:
~
Rectal: Hemocult (+) (_)
Troponin I:
PT:
INR:
1. Bill:
ALT:
Amylase:
UIA:
Myoglobin:
PTT:
Alk Phos:
Lipase:
U-HCG (+) (-)
EKG:
ED course:
Treatment:
Drug Screen:
Cultures: Blood 1 2 Urine
Study #1 :
o Result:
6)
7) Study #2:
8) o Result:
Study #3:
o Result:
o See attached PROGRESS NOTE for additional information:
MOM I Differential Dia nosis: 3)
1) 4)
~ ~
Procedure Note:
Response:
Follow up with
within
days.
Return to emergency department if
2)
3)
~~
Where:
o Cobra form
ED TRAUMA/RESUSCITATION FLOW SHEET/ORDER SHEET
Jl..., 7 :.j). U'i. 'l.(
ice;:, \ ...~ 'i c. () I/O 1 i I '; ,
;::u; "".' }::iO hambersbUl ~
~) ~. (.' t ; ,) "y!, AUG,,2 7 200~ It b)/ I
PtNN~ IAI t
;11 Milton S. Hen. Medical Center
.... College of Medicine
DRIVER
~ASSENGER
MEt! I FRONT
BACK
PEOESTRIAN BED OF PICKUP
MOTORCYCLE BICYCLE ATV
FALL FT GSW CAUMM
BURN DIVING DROWNING FARM
WINDSHIELD
BROKEN
ROLLOVER SPIDER ED
ST WHEEL BENT
UNKNOWN
NONE UNKNOWN
DAMAGE
FRONT MIN
BACK MOD
r~O:DSI:DL r HEAVY
INDUSTRIAL
SPORT
STABBING
OTHER
+. TED _ PARALYTIC AGENT _
SPONTANEOUS RATE ~
_ 02 MASK UMIN_
02 CANNULA UMIN_
ASSISTED RATE
BVM RATE
_ AIRWAY (ORAUNASAL)
_ ETT (ORAUNASAL) SIZE
CRICOTHYROIDOTOMY
TRACH SIZE
PMH/PSH
MEDS "N
LAST TETANUS
Best
Verbal
Response
Oriented
Confused
Ina ro riate words
Incom rehensible sounds
None
Best
Motor
Response
SystOlic
Blood
Pressure
1. OPEN FRACTURE
2. AMPUTATION
3. GUNSHOT WOUND
4. DEFORMITY
5, STAB WOUND
6. BURN
7. PAIN
8. RASH
HCCHYMOSIS
A-ABRASION
C-CONTUSION
L-lACERATlON
S-SWELLlNG
T-TENOERNESS
S-SENSATlON
PW.PUNCTURE
WOUND
BURN - FT
PT
SC
I-IMPALED OBJECT
> 89mm H
76-89mm H
50-75mm H
l-49mm H
No Pulse
Respiratory 1 D-29/min.
Rale > 29/mln,
6-9/min.
l-S/min,
None
Total Revised Trauma Score
UR 690 11/02
Origlnal- Medical Record Yellow - Trauma Service Pink - ED
ED TRAUMA/RESUSCITATION FLOW SHEET/ORDER SHEET
Time
, ^"'..~ C-Spine
~ Lateral
_AlP
i- Odontoid
_ Swimmers
CXR
Pelvis
Cystogram
_ Extremities
TIME
~
TRAM-1 M
TRAM-1F
TRAM-2M
TRAM-2F
TRAM-3M
TRAM-3F
TRAM-P
T&C# U
T&5
LEGAL URINE DRUG
LEGAL BLOOD ETOH
OTHER
SITE
CRfTlCAL VALUES
CRITICAL VALUES
TIME BACK
TIME
DRUG
DOSE ROUTE INIT.
TET
o ADULT LOT #
o PEDS EXP DATE
*
CT
Cranial
Abdomen
Chest
Other
Angiogram
SPONTANEOUS
02 MASK
02 CANNULA
ASSISTED
BVM RATE
_ AIRWAY (ORAUNASAL)
_ ETT (DRAUNASAL) SIZE
CRICD TRACH SIZE
TIME
CC
CC
RCT SIZE fR
LCT SIZE FR A-LINE
R THORACOTOMY CUTDOWN
L THORACOTOMY BY:
PERICARDIOCENTESIS TEE ECHO
DONE BY
12 LEAD EKG YES NO
_ICP BOLT INITIAL READIN _
_HALO DONE BY DR
INTAKE TOTAL
NURSE'S NOTES^'(\ ./""~I: INCLUDES: 1.Assessment 4, Response
2. Plan 5. Ongoing ASS~W\bershurg
1020 .~- 'p\. 6 \ 70 if~~ ~ ,fr:.q1,..,t.ct.- ~\U-{j c- 3, Intervention 6, Disposition/Final Assessmenr
-he de -b (("'00 'l.\.kO.Q_sU.-t ..i:v' 'L.'i.>'F.L( C Ctf'L...1Q/0JY1lk1A..t"',)ou.,.I,Jl 11.11M(h:~ L: (\~~\\~ 'lv2l!!J!-.
jOq7~ \+. '-to cr..- es.cOyw. h{kV\'-'.cx.-t:Q(U~ :)c0 ItJ,.ltL \t D&.Q. ~\J..jJ ll'C,nfcVtfl.
c- ~ \ 'fV\IA.l\.cl'o,\ \2o-.b lY\. V\-\oJ-D /'-.L~(l.UJ.. P-;"1c,,-,\cl{:~' (\-d',~G..-~C) l N-cl-l 4
lOx,'" c, "n ,\D(.U...'1..D' ,0"'10 - Cf4-' -1-cJ C:D'0v\jY~~\ -- :2""'C,jlD_Q/I.:1/)'V'.-UJ.Jt- LVtLL~,LA.jCU;-
~'~~'\~ - 1050'. PO-.~ b~-t AD ~v~~ b\ J c\~a ~.-
\\Ctj'-V'hb <K1-cd.{:LQ~ vv\...~ c.orv\,.tlJ.-Q.'-tu Cv~.Q-Q..A_O rt 'V)c)... ~vV\V\o.. o.-r->...Lu:u-
VJ c:l\..u l.c. olD . (j)"'-\ i'-A. '-.Xil t ~ov-lo.. L. -L.l./Y'''-l.L:L---
,/'-Q.- \'---\. ~~ C '- L~ 1'L-u~L. 'm CLA.()\_J...D-Zo'~ - d.t/"U~
~ Sc- \~- 000--- , \::-- t
\v\-\ ~ ~~"), 'b-l ryJ.-Q. 1'-- --"~ c.~ t,
(20/'\""~J ~. ~ --
TEMP~RATURE COLOR CAPILLARY SENSATION MOVEMENT PULSE
REFILL
W-Warm N - Normal R - Rapid N- Normal A - Active S - Strong
G.-Cool P - Pallor S .. Sluggish T - Tingling W - Weak W - Weak
CD - Cold F - Flushed A - Absent NB-Numbness P - Paralysis A - Absent
H-Hot C - Cyanotic P - Pain and
A - Absent R -Regular
I-Irregular
BRACELET~ION: IDUrO l ,J ;(
.J R15875
BLOOD SA . /Vf.- R#_
( CH"R.T RECORD
Physician Signature:
Documenting Nurse:
Support Nurse: /{.{..u\
BVM = Bag Valve Mask
ET = Endotracheal Tube
ABD = Abdomen
RL, = Right Leg
LL = Left Leg
RA = Right Arm
LA = Left Arm
LCT = Left Chest Tube
RCT = Right Chest Tube
PH = Pre-hospital
LOC = Level of Consciousness
PMH = Past Medical History
BH = Bair Hugger
NS = Normal Strength
W = Weakness
FP = Flaccid Paralysis
R = Rigid
DCB = Decerebrate Posture
DCT = Decorticate Posture
Pupil Size (MM)
....e...
23456789
ADMITTED TO
TIME OR NOTIFIED OR READY TO OR
FAMILY NOTIFIED @ 1~/? .,-!3Y~'~
RELATIONSHIP ~
C-SPINE CLEARED: 0 YES 0 NO BY DR,
C-COLLAR ON:Cfj. YES 0 NO ASPEN: 0 YES 0 NO
VALUABLES: 0 W/PATIENT 0 SAFE 0 NON~ W/FAMIL Y 0 BELONGINGS FORM DONE
o EXPIRED CORONER NOTIFIED @
MATERIAL EVIDENCE TO POLICE: 0 YES 0 NO
OFFICER BADGE #
(t)~~t/1~~~~lh~:
EXTREM~
BURN: ~
OTHER:
TRANSFERRED TO
VIA
t"CI'lI'k)IAI C
. !51 Milton S. Hershey M
. College of Medicine
TRAUMA HISTORY AND PHYSICAL EXAMINAnQN
~al Center
70 ' ),~
~~i.'?;;:.
,~
Chanm-Iburg
o AlIGI2~q~&1.
4~3i)1
:$It t~ 11,
RAtjfolA 1000330
ALN(SS KPi
~'
R.O.S.
Airway:
Field Vitals: P:
~ Immobilization:
Field Notes:
IV's:
BP:
Fluid:
!
i,
RR:
I ~
Patent 0 Obstructed Intubated: 0 OT 0 NT 0 Trach
Breathing: S ~ Breath Sounds: == €. '14
Circulation: P: '?8 BP: 1\'1 4Ct RR: ~'L Sat: foc:l70AA
Disability: 0 Alert 0 Vocal 0 Painful 0 Unresponsive PMH:
~xposure: . I
Procedures: 0 NG- Tube
o Urinary Catheter
PSH:
o A-line 0 CVP(s):
Chest tube 0 right 0 left Last Meal:
Nose:
Mouth:
Neck: Tenderness: 00
Chest Wall: Tenderness: N D
Lungs: ~~
Back: Tenderness: ~ ('\D
H ea rt: (2...IUL
Abdomen: Distention:
Rectal: Tone:
Pelvis: Stable:
Vascular Exam:
Right/left
Resident S g ture
Eyes: R.pl h
Battle's: 9'
Mandible: ~~t
Dentitia: .'n.~ -\
Dentures: )\.II tv
Crepitus: {VO
Crepitus: N b
Last Tetanus;
)0 O2 Sat:
(k,~ e @
/r-r[/).,\"'-~ '",
(I '
t ",',f!
} .,'
. .
.--/
~, '
,/ -"::. , r"-'----.,
face:
Trachea ML: t.
Crepitus: tJ D
'BS: Tenderness: ~,
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Radial
u-
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Lt- ?t-
Date
lD I "r 0'1
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LEGEND:
L -laceration
C/x - closed ~ I I
fracture
O/x-open fracture
Ab - abraelon
C - contusion
Title
~,
TRAUMA HISTORY 'AND PHYSICAL EXAMINATION
Orlg . Chart
Copy. Trauma Services
.AUMA HISTORY AND PHYSICAL EXA. fA TION
Chambersbur~
AUG 27 200+
Extremity Exam
/~~,
/ ./ /
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Of x-open fracture
Ab - abrasion
C -contusion
Sensory: Pinprick ~s
Proprioception
DTR's ~
,. A ..
L 1-5
Glasgow Coma ScalelPeds
Eye Opening
1 - None
~open to Pain
- pen to CommandNoice
- Spontaneous
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1 - None
2 -Incomprehensible /Moans to Pain
~Inappropriate / Cries to Pain
- onfused / Consolable
- Alert / Oriented / Interacts
Motor Response
1 - None
2 - Decerebrate
3 - Deco rticate
4 - Withdraws
)i- Localizes Pain
~ Obeys "'I
Total: I :>
Troponin:
Myoglobin:
CPK:
Amylase:
ICa:
Trauma Score
Resp. Rate SBP
0-0 0-0
1 -1-9 1 - 0-49
2 - >36 2 - 50-69
A- 25-35 k70-90
\9- 10-24 19 >90
GCS
0-3-4
1 - 5-7
$8-10
3 - 11-13
-14-15
Total II
U/A:
++<
PT:
PH:
T:Bili:
ALT:
ALP:
Drug Screen:
TEE:
ETOH:
BHCG:
, t'JCP./.A.t.,
Att.ndlng Blgnatur.!Dale/TIm.
UR 811 R.v. 3198
TRAUMA HISTORY AND PHYSICAL EXAMINATION
fJk
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Copy. Trauma Services
t.ta AM
PROGRESS REPORT
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PROGRESS REPORT
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PENNSTATE
I!SI. Milton S. He~ Medical Center
., Conege of Medicine
Chambersburg
AUG 2 7 200;
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
E mer 9 en c y D e par t men t
Document
Not e
I
Final
ED SUMMARY
DATE OF SERVICE: 6/19/04
CHIEF COMPLAINT: MVC, loss of consciousness.
HISTORY OF PRESENT ILLNESS: This is a 14 -year-old female, rear seat passenger in and SUV that was performing a
U-turn when it was T-boned by a tractor-trailer. There were six victims in the car. One patient was dead at the scene.
The above patient was found walking, ambulating at the scene. The patient, as per EMS, did have loss of consciousness
and has been amnestic to the event. The patient has been lethargic. GCS of 14 to 15, The patient was collared and
boarded and brought to Hershey Medical Center. The patient is slightly confused. The patient denies abdominal pain or
chest pain. Moving all extremities.
REVIEW OF SYSTEMS: As above and per written chart. Other systems reviewed and negative.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Unknown.
PHYSICAL EXAMINATION: Primary survey - airway patent. Breathing positive breath sounds bilaterally and equal.
Circulation positive distal pulses throughout. Disability: GCS of 15 following commands. Secondary survey - afebrile.
Vital signs are stable. In general, this is a well-developed, well-nourished female lying on the stretcher. Collared and
boarded. HEENT: Left forehead abrasion. Pupils 4 to 2, equal, reactive, Nares patent. Oropharynx clear. Dentition
intact. Tympanic membranes clear bilaterally. Neck: C-collar in place. Trachea is midline with removal. There is no
midline tenderness along the cervical spine. Heart is regular, s1, s2, No gallops, murmurs, rubs, Lungs: clear to
auscultation equally and bilaterally. The abdomen is soft, nontender, nondistended. Positive normoactive bowel sounds.
Rectal deferred. Pelvis is stable. Extremities: Without cyanosis, clubbing, or edema. 2+ DP pulses bilaterally and equal.
Back: There is no midline tenderness of the thoracic or lumbar spine. Skin is without petechiae or rash. Neurologic exam:
Now GCS of 14, 1 off for confusion. Otherwise, nonfocal.
DIFFERENTIAL DIAGNOSIS:
1, Closed head injury/concussion,
2. Subdural hematoma.
3. Epidural hematoma.
4. Skull fracture.
5, Cervical spine injury,
6. Liver laceration.
7. Splenic laceration.
EMERGENCY DEPARTMENT COURSE: After the primary and secondary surveys, x-rays were obtained of the c-
Date Printed: 8/24/2004
Time Printed: 10:32 AM
PENNSTATE
IS... Milton s..~ Medical Center
., College ofl\fedicine
Chambersburg
AUt; 2 '7 2004
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
I
Emergency Department
Document
Not e
I
Final
spine, chest, and pelvis. Chest and pelvis unremarkable. C-spine unable to see C1-C2. CAT scan of the head, C1 and
C2 were then performed. There was no bleed, shift, or mass. CAT scan of the abdomen shows a grade 2-3 splenic
laceration. Level 2 blood work is currently pending, although CBC is currently back, Hemoglobin is 13.3~
Pediatric trauma team has been in the resuscitation bay. The patient will be admitted to (MC for further evaluation and
treatment.
IMPRESSION:
1. Status post MVC.
2. Closed head injury.
3, Grade 2-3 splenic laceration.
4. Abrasions.
DISPOSITION: The patient will be admitted to the Pediatric Trauma Service for further evaluation and treatment. Total
critical care time is 43 minutes.
475098
Review/Sigp.: Craig T Lauder, DO
CTL /EEP DD: 06/19/04 DT: 06/19/04 11:35
Date Printed: 8/24/2004
Time Printed: 10:32 AM
PENNSTATE
IS Milton S. He~ Medical Center
., Conege of l\fedicine
Chambersbur~
AlIG 2 7 200.
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
s p
n e
Study
I
Final
X-RAY CERVICAL SPINE LIMITED 1-3 VIEWS - PEDS
PATIENT NAME: BELL, TORIL YNN
PATIENT MRN:07000330
PATIENT DOB: 09/29/1989
EXAM DATE OF SERVICE: 06/21/2004
EXAM NUMBER: 359296
ORDERING PHYSICIAN: MEIER, ANDREAS
FLEXION AND EXTENSION LATERAL CERVICAL SPINE FILMS
CLINICAL INFORMATION: This patient is status post trauma and has a painful cervical spine.
FINDINGS: The patient has limited neck motion and was unable to fully extend or flex the neck. Indeed the flexion film was
repeated and somewhat better flexion was obtained on the second flexion film. Imaging extends to the T1 level.
Craniocervical junction alignment is nonnal with no evidence of craniocervical instability on flexion to extension. Extension of the
head on the cervical spine in flexion of the head of the cervical spine is adequate for this assessment. Vertebral body height and disc
space height remains normaL Cervical alignment is normal with no evidence of subluxatability,
IMPRESSION: This patient has limited mobility of the cervical spine. Nevertheless there is adequate flexion and extension to assess
these craniocervica1 junction alignment. Flexion is suboptimal from C4 inferiorly and thus anterior subluxation on flexion cannot be
excluded in the lower cervical spine at this time.
DICTATED: EGGLI, KATHLEEN
REVIEWED AND SIGNED: EGGLI' KATHLEEN /
DATE DRAFTED: 06/21/2004 09:45 AM
DATE OF FINAL SIGNATURE: 06/21/2004 09:45 AM
Date Printed: 8/24/2004
Time Printed: 10:32 AM
PENNSTATE
E!1 Milton S. Hersh~ Medical Center
., College of MediCine
Chambersburg
AUG 2 7 200.
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
~
H e a d
I
Nee k
S t u d y
I
Final
CT HEAD WITHOUT CONTRAST PED
PATIENT NAME: BELL, TORILYNN
PATIENT MRN:07000330
PATIENT DOB: 09/29/1989
EXAM DATE OF SERVICE: 06/19/2004
EXAM NUMBER: 358800
ORDERING PHYSICIAN: SALNESS, KYM
CT HEAD
CT CERVICAL SPINE IS RECONSTRUCTIONS
THORACOLUMBAR SPINE RECONSTRUCTIONS
CLINICAL HISTORY: Motor vehicle accident.
TECHNIQUE: Routine, unenhanced CT of head and cervical spine was performed, with head images digitally filmed in brain and
bone windows. Coronal and sagittal reconstructions of the cervical spine were performed, and coronal and sagittal reconstructions of
the thoracolumbar spine were performed from existing data.
HEAD CT: The brain parenchyma is normal, without mass, mass effect, infarct or hemorrhage. The ventricles and extra-axial fluid
spaces are normal in size and configuration for age, The visualized orbits, periorbital structures, paranasal sinuses and mastoid air
cells are unremarkable, There is no acute calvarial abnormality.
CERVICAL SPINE: The cervical vertebrae of visualized from the level of the skull base through C3. The cervical vertebrae are
normal in height and alignment, without acute fracture or subluxation, The prevertebral soft tissues are unremarkable,
CERVICAL RECONSTRUCTIONS: No evidence of acute traumatic injury, as described above,
THORACOLUMBAR SPINE RECONSTRUCTIONS: The thoracolumbar vertebrae of visualized from the level ofTlO through the
sacrum. The visualized vertebrae are normal in height and alignment, without fracture or subluxation. The prevertebral soft tissues are
unremarkable.
IMPRESSION: No evidence of acute traumatic injury to the visualized cervical, thoracic or lumbar spine, without evidence of acute
intracranial injury,
Dr. James H, Birkholz is the dictating resident.
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist.
Date Printed: 8/24/2004
Time Printed: 10:32 AM
PENNSTATE
!!!1.. Milton S. He~ Medical Center
., College ofMediclne
Chambersburg
AUG 2 7 200+
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
H e a d
I
Nee k
S t u d y
I
Final
mCT ATED: MCNAMARA, KEVIN
REVIEWED AND SIGNED: MCNAMARA, KEVIN / BIRKHOLZ, JAMES
DATE DRAFTED: 06/19/2004 09:02 PM
DATE OF FINAL SIGNATIJRE: 06/20/2004 06:34 AM
Date Printed: 8/24/2004
Time Printed: 10:32 AM
PENNSTATE
I!S... Milton S. Hershey Medical Center
., College of Medicine
Chambersburg
AUG 2 7 200,
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
Pel V
s
I
G U
Document
,
Final
X-RAY PEL VIS AP 1-2 VIEWS - PEDS
PATIENT NAME: BELL, TORIL YNN
PATIENT MRN:07000330
PATIENT DOB: 09/29/1989
EXAM DATE OF SERVICE: 06/19/2004
EXAM NUMBER: 358798
ORDERING PHYSICIAN: SALNESS, KYM
CERVICAL SPINE SERIES, PORTABLE AP CXR, PORTABLE PELVIS FRONTAL VIEW ONLY, FRONTAL AND LATERAL
PROJECTIONS OF THE THORACIC SPINE,
CLINICAL INFORMATION: MDL TIPLE TRAUMA
COMPARISON STUDY: There are no comparison studies.
FINDINGS: Cervical spine: The alignment is intact to the level ofT! without spondylolisthesis or radiographic evidence offracture.
There is no precervical soft tissue swelling. The vertebral body height and intravertebral disc spaces are maintained. On the odontoid
view the dens and lateral masses are obscured. ACT ofCI-C2 is recommended.
CXR: There is overlying artifact from the trauma board. The lungs are clear. The mediastinum is not proment for technique. The soft
tissues and bones demonstrate fractures posteiorly of the left 9th, 10th and 11 th ribs.
PEL VIS: There is overlying artifact from the trauma board, There is no evidence of fracture. The hips are located. The bowel gas
pattern is nonspecific. The soft tissues are unremarkable,
THORACIC SPINE: The alignment of the thoracic spine is intact. There is no evidence of compression fracture or spondylolisthesis.
The vertebral body heights and intervertebral disc spaces are maintained. Included portions of the lungs are clear. There is contrast
within the renal collecting systems on the frontal projection from patient's CT scan.
IMPRESSION: 1. There is no evidence of fracture or spondylolisthesis of the cervical spine, CI-C2 is inadequately evaluated. ACT
is recommended.
2. There is no radiographic of acute cardiopulmonary disease,
3. There is no obvious osseous pelvic injury.
4. There is no evidence of fracture or spondylolisthesis of the thoracic spine,
5. Left posterior 9th through 11 th rib fractures.
Dr, Edward J. Borman is the dictating resident.
Date Printed: 8/24/2004
Time Printed: /0:32 AM
PENNSTATE
IS Milton S. ~ Medical Center
., College ofl\fedicine
ChambersbUl ~
AUG 2 7200;
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
Pel V
s
I
G U
Document
I
Final
Attending radiologist signature indicates review ofhoth the images and the report and that the attending radiologist agrees with the
interpretation, Preliminary reports may not have been reviewed as yet by the attending radiologist.
DICTATED: HULSE, MICHAEL
REVIEWED AND SIGNED: HULSE, MICHAEL / BORMAN, EDWARD
DATE DRAFTED: 06/19/2004 11 :38 AM
DATE OF FINAL SIGNATURE: 06/21/200409:52 AM
Date Printed: 8/24/2004
Time Printed: 10:32 AM
PENNSTATE
IS Milton S. ~ Medical Center
. College of:Mediclne
Chambersburg
AUG 2 7 200.
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
A b d 0 m
n a I
I
GI
Document(s)
I
Final
CT ABDOMEN WITH CONTRAST-PED
PATIENT NAME: BELL, TORILYNN
PATIENT MRN:07000330
PATIENT DOB: 09/29/1989
EXAM DATE OF SERVICE: 06/19/2004
EXAM NUMBER: 358803
ORDERING PHYSICIAN: SALNESS, KYM
CT OF THE ABDOMEN AND PELVIS
CLINICAL HISTORY: Motor vehicle accident.
TECHNIQUE: Routine CT of the abdomen and pelvis was performed following the administration of oral and IV contrast. Images
were digitally filmed in soft tissue, bone and lung windows.
DISCUSSION: Comparison is to multiple prior plain film exam performed the same day.
ABDOMEN: Visualized heart and great vessels are unremarkable, There is a very rainy left posterior basilar lung contusion. No
pneumothorax is identified. Patchy hypodense appearance of the posterior spleen is consistent with splenic laceration; this likely
represents a grade II splenic laceration, There is a mild amount of adjacent fluid, which extends into the left paracolic gutter,
Incidentally noted is a left posterior rib fracture inferiorly. The visualized liver, gallbladder, pancreas, adrenals, and kidneys are
unremarkable. The stomach and remaining hollow viscera within the abdomen are nonnal.
PELVIS: A mild amount of fluid is noted within the dependent portion of the pelvis. The visualized hollow and solid pelvic viscera
are intact. No acute bony injury is noted within the pelvis.
IMPRESSION:
1. Splenic laceration as described, with minimal amount of fluid within the left pericolic gutter and within the pelvis.
2. Single left sided rib fracture as noted, with tiny left pulmonary contusion,
Dr, James H, Birkholz is the dictating resident.
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist.
DICTATED: HULSE, MICHAEL
Date Printed: 8/2412004
Time Printed: 10:32 AM
PENNSTATE
IS Milton S. Hershey Medical Center
.. College of Mediclne
Cha b
m ersb
AU L
6272flO4
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
REVIEWED AND SIGNED: HULSE, MICHAEL / BIRKHOLZ, JAMES
Abdom
n a I
I
GI
Document(s)
I
Final
DATE DRAFTED: 06/19/200410:35 PM
DATE OF FINAL SIGNATURE: 06/21/2004 09:53 AM
Date Printed: 8/24/2004
Time Printed: 10:32 AM
PENNSTATE
!!II Milton S. ~ Medical Center
.. Conege of Medicine
Charnb
4lJ(j 2 ersOtJr~
'l 2Do~
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
D
scharge
Summary
Document
I
Final
477268
Review/Sign: Jason L Pennypacker, MD
Review/Sign: Andreas H Meier, MD
JLP /MSZ DD: 06/22/04 DT: 06/24/04 11: 10
Date Printed: 8/24/2004 Time Printed: 10:32 AM
PENNSTATE
IS.... Milton S. ~ Medical Center
., College of MediCine
Patient Name: BELL, TORIL YNN
PSUHMCMRN: 7000330
Charnb
41JS.2 ersbur 9
7 1Oo~
I
I
C B C
6/22/2004
6/20/2004
6/20/2004
6/20/2004
6/20/2004
6/19/2004
6/19/2004
6/19/2004
6/19/2004
Tue
Sun
Sun
Sun
Sun
Sat
Sat
Sat
Sat
2
1
o
o
o
o
o
o
o
Procedure
Units
Ref Range
7:25:00 AM
9:50:00 PM
8:20:00 AM
5:55:00 AM
2:05:00 AM
10:15:00 PM
6:10:00 PM
2:25:00 PM
11:07:00 AM
WBC
K/uL
[4.8-12.0]
11.3
Hgb
g/dL
[12-16]
12.4
12.1
10.7
11.6
11.6
11.7
11.7
12.3
13,3
Hct
%
[37-47]
34.6
33.4
29,9
32.3
32.1
32.9
32.5
33.9
37.3
RBC
M/uL
[4.2-5.4]
4.27
6/19/200411:07:00 AM WBC:
Error retrieving previous result( s)
6/19/2004 11:07:00 AM WBC:
QA FLAGS MODIFIED BY DEMOGRAPHIC UPDATE ON 06/19 AT 1205
6/19/2004
Sat
Date Printed; 8/24/2004
o
Procedure
Units
Ref Range
11:07:00 AM
RDW
%
[12.0-16.4]
12.6
PIts
K/uL
[140-340]
160
Time Printed: 10:32 AM
MPV
fL
[8,7-12.5]
10.8
MCV
fL
[82-96]
87.4
MCHC
g/elL
[32-36]
35.7
MCH
pg
[28-33]
31.1
PENNSTATE
IS Milton S.~Medical Center
., College ofMediclne
('Ii.
-"i!
'"bers"
A(JS:!. 4l(Jrf;
, loll
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
C hem
s try
I
Procedure Na K Cret GIu
Units mrnol/L mrnoVL mg/dL mg/dL
Ref Range [135-145] [3.5-5,0] [0.6-1.1] [70-120]
6/22/2004 Tue 2 7:25:00 AM 140
6/20/2004 Sun 1 9:50:00 PM 139
6/20/2004 Sun 0 8:20:00 AM 140
6/20/2004 Sun 0 4:00:00 AM 138
6/19/2004 Sat 0 10:15:00 PM 138
6/19/2004 Sat 0 4:20:00 PM 140
6/19/2004 Sat 0 11:07:00 AM 137 3,9 0.8 110
Date Printed: 8/24/2004
Time Printed: 10:32 AM
PENNSTATE
!!II Milton S. Hershey Medical Center
. College of MediCine
Cl'larnl)
41Jr; <> ersbur&
7 ZOO~
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
Coagulat
o n
I
6/19/2004
Sat
Procedure
Units
Ref Range
11:07:00 AM
PT
second
[10,8-13,8]
13.4
INR
PIT
second
[29-41 ]
32
o
[0.8-1.2]
1.17
Date Printed: 8/24/2004
Time Printed: 10:32 AM
. PENNSTATE
IS Milton S. He~ Medical Center
., College of :Medicine
Cham/:;
4lJ{) < ersbUfg
7 <001
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
I
L
v e r
I
G I
I
6/19/2004
Sat
Procedure
Units
Ref Range
11:07:00 AM
ALT
unitlL
[10-50]
30
Amylase
unit/L
[20-80]
54
o
Date Printed: 8/24/2004
Time Printed: 10:32 AM
,: PENNSTATE
I!S Milton S. ~ Medical Center
., College of Medicine
Cf)q
tnber
4IJc Sbu1 ,
< '? <:QO# ~
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
T 0 X
C 0 log y
I
6/19/2004
Sat
Procedure
Units
Ref Range
11 :07:00 AM
EtOH med
mg/dL
[<10]
<10
o
Date Printed: 8/24/2004
Time Printed: 10:32 AM
; PENNSTATE
IS.. Milton S. ~ Medical Center
., College of.Medicine
''!''\/L
\....671,~
.1')71)
/I . t2r
"'tUG < sblJrg
'~~ .
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
I B I 0 0 d B a n k I
Procedure ABO/Rh Antibody Scr Spec Expires R Number Component
Units
Ref Range
6/19/2004 Sat 0 12:10:00 PM 0 NEGATIVE 06/22/2004 R15875 RED CELLS
NEGATIVE
Date Printed: 8/24/2004
Time Printed: 10:32 AM
; PENNSTATE
ell. Milton S. ~ Medical Center
.. College ofMedidne
Charnb
ersb
4lfG U(~
2 7' 2004
Patient Name: BELL, TORIL YNN
PSUHMC MRN: 7000330
I
D
scharge
Summary
Document
I
Final
DISCHARGE SUMMARY
DATE OF ADMISSION: 06/19/2004
DATE OF DISCHARGE: 06/22/2004
REFERRING PHYSICIAN: Kym Salness, M.D.
ADMISSION DIAGNOSIS: Motor vehicle crash, close head injury.
PRINCIPAL DIAGNOSES:
1. Close head injury.
2. Grade 3 splenic laceration.
3. Left posterior 9, 10, 11 rib fractures.
PROCEDURES: There were none.
BRIEF HOSPITAL COURSE: This is a 14-year-old white female who was a passenger in a motor
vehicle crash, evaluated in the Trauma Bay, and found to have the above diagnoses. The
patient medically remains stable. The splenic laceration is treated with observation.
The patient's cervical spine is clear radiographically and clinically. The patient had
adequate pain control. The patient tolerated oral feeds, ambulated to the bathroom only,
was afebrile, and hemOdynamically stable at the time of discharge to home. The patient
did have a cervical muscle strain for which a soft collar was about to be worn for comfort
if desired by the patient.
DISCHARGE MEDICATIONS ARE FOLLOWING:
1. Tylenol 650 mg p.o. every 4 hours as needed.
2. Colace 100 mg p.o. b.i.d.
3. Tylenol With Codeine 1 to 2 tabs every 6 hours as needed for pain control.
DISCHARGE INSTRUCTIONS ARE FOLLOWING:
1. See the attached trauma injury instructions for close head injury.
2. Regular diet.
3. Activity "2 weeks/2months" for the next 2 weeks. She is allowed bed or couch rest
followed by 2 months of no contact/impact activities such as no "wheels, jumping, or
climbing". The patient is instructed to call for any questions or concerns at 531-8342 or
after-hours at 531-8521 for the hospital operator and ask for the Pediatric Surgery
resident on call if she has a fever greater than 101 degrees, vomiting, increased pain,
paleness, or any mental status changes, The patient will follow up at Pediatric Surgery
Clinic July 14, 2004, at 1 p.m.
Date Printed: 8/24/2004
Time Printed: 10:32 AM
L-\'-O\/ W\Postedi2S5Si
~ ",~~~.I. ..~ ""ill''''''' >,
lax (IlIl'Jioses. No olher~celpt wUlbe ISSUI
bYtltltoftice.
I JOSEPlI A. PION, D.O.
Lie. No. OSOO7IIOE
GRAHAM MEDICAL CLINIC, p.f
FAMILY MEDICINE
100 S. lITGH STREET, NEWVILLE, PA 17241
(717) 776-3114
I JAY A. TOWNSEND, M.D., P.c.
Lie. No. MDQII039E
.
I CAROL K. ROBISON, D.O.
Lie. No. OSOO571OL
.
I SUZANNE McCOMBIE, PAC.
(0 -f}7,rP;
H
W
INS
PAT
. I II ... . .
099211 Minimal 046MQAnoscOjiY < ....... ... .......
99201 099212 Prob Focused - - 020600 ArthrocentesisSm.Jt.
39:.!1)2 099213 Expalld PrOblem - ~ 020605 Art~r\lCentesis Interm.
:19203 0 214 Deta...lled - - 020610 ArtlJrocentesisMaior
.> 99. . - - 020612 Aspif'ation Ganglion Cyst
J9204 .099215 Compreh-Mod _ ~ 092552 Audiometry
)9205 complex. .. _ ___ 0930lJQEKGwithlnterpretation
09llQ24 POSropVISlt ~ ~ 094Ei40lnhalationTrealment
New fit. PREVENTIVE MEDICINE 094200 PFT
19381 099391 Oc 1 Yrs Old _ _ 045330S19rnOidoSCOllY, Flex
19382 099392 1- 4 Yrs Old ... 045331 Sigmliiq Flex, with BX
~ (J993~ 5c 11 YrsOId =. ".. 092567Ty.lllpanagram. .
19~ p.993$4 12c 17Yrs Old. ~ OZO!l50 Tr~Ot!rpomtll1jectlOns
19385 09939$ .18- a9Yrs.Old - . .....CJ20550.lnjllclIOO Tendon Sheath
19.[;19939640. 54 YrsOld - 0_ RADIDlOGY
MIIIOR SURGERY . 070220 Sinus
_ laceratiOn and Repair _ _ tJ71020 Chest
_ Incision & Drainage 071101 Ribs
. i4150 Circumcision - - 072050 Spine, Cervical
I 0060 Abscess, I &.0, Single - - 072072 Spine, Thoracic
7110 Cryo:UPto 15 - - 072110 LS Spine
Exels.l.on Belilgn lesion - - 072170 Pelvis
073030 Shoulder
140_ Trunk, Alms, Legs Size_ _ _ 073060 Elbow
140_ _ _ 073090 Forearm
142_ ~,Neck,Hand,FM,Gen Size__~ 073130 Hand
142_ _ _ 073140 Finger
144_ face,Ears,Eyes,Nose,Ups Size~__ 073510 Hip
144 073550 Femur
-. .. -- 073564 K
Excision Malignant lesion 073590 ti~~~ib
160_ Trunk,Arms,L~sSlze_ -- 073630 Fo.Ot
160_ . .. .. ... .. .... ... ~ --:-:-- p73~50Heel
162~~'~'Hml,FM,Gen Size__~ 07~010 Abdomen
162_ .. /.. .. ... .. . ....._--...,..- 073110Wrisl
tK Fitcei~(Eyes,Nose,UpsSlZe~~~ P73610Arikte
164_.. O~ ..
I I' I j t
r&9.0_ AbdominalPain _ 786.50 Chest Pain 558.9
114.00 ADD wlo Hyperactivity 076.11 Condyloma Acumin. 530.11
114.01 ADD with Hyperactivity 428.0 Congestive Heart Failure 274.9
177.0 Allergic Rhinitis 372. Conjunctivitis 764.0
195.3 Allergy Symptoms 692.3 Contact Dermatitis 599.7
~1.0 Alzheimer 496 CO PO _ 455.6
!85.9 Ariemia 436 Cerebrovascular Disease 272.2
:13.9 Angina Pectoris 715.0_ Deg. Joint Disease, Osteo. 401.1
:00.00 Anxiety 296.2_ Depression, Single, Mod. _ 242.90
24.1 Aortic Stenosis 296.3_ Depression, Chronic 244.9
.14.0 Arthritis, Rheumatoid 296.34 Depression, Recurrent, Severe _ 564.1
29.2 ASCVD _ 250.00 Diabetes, NIDDM, Type II _ 360.4
93.0_ Asthma _ 250.01 Diabetes, 100M, Type I 760.52
27.31 Atrial Fib 787.91 Diarrhea 702.11
46.0 Back Strain, Low 451.19 DVT 702.19
00.0 BPH 786.05 Dyspnea 702.0
66.0 Bronchitis, Acute 692.9 Eczema 724.2
14.00 CAD 782.3 Edema 846.0
25.4 Cardiomyopathy _ 790.6 Elevated Blood Sugar 346.0_
54.0 Carpal Tunnel Syndrome 780.79 Fatigue 076.0
82. Cellulitis 535.0 Gastritis 785.2
URN:
Days
Weeks
Months
IRS No. 23-2I73798
PA Blue Shield to//38360 (Participating)
.
.
II
I .
PREvIOUS
INsURANC!
PREVIOUS
PATtEIfF
TOOAV'S
CHARGES
A!l.JUSn.1EN
TODAY'S
PAYMENT
- ~... CJ95hSAllergy Injecti!)n Single
----'--'--
_ ~ 090700 Acellular
- ~ OJ3420 B12
=. . 090746 Comvax
-- 090718 OT(Adult)
- - 090737 HIB
--
- - 090744 Hep B VaCCine, 0 -19 yrs. ___
- . 090746 Hep B VaCCine, 20.+ yrs. ___
~~. OG001o. Adm. Hepatitis BVacCine __ ~
~ - 090059 tnflu.ehza
--
o G0008 Admin of Influenza Vaccine
- -- 090713 IPV
-~
_ _ 090707 MMR
- - 090733 Menomune
--
_ _ 066560 PPD
- - 090669 Prevnar
- - 090732 Pneumonia
-- . --0
- - OG0009 Admin of Pneumonia Vaccine_ - 0-
= == 090716 Varivax --- 0-
--0_
= --Hi
_~O
. I'
Gastroenteritis 729:1
GERD 787.02
Gout 278.01
Headache 733.00
Hematuria 380.10
Hemorrhoids 360.12
Hyperlipidemia 381.01
Hypertension 381.10
.Hyperthyroidism 785.1
Hypothyroidism 332.0
IBS 443.9
Impacted Cerumen 462
Insomnia 486
Keratosis, Inflamed SeborTtleic _ 692.6
Keratosis, Seborrheic 211.3
Keratosis, Actinic 696.1
Low Back Pain 533.90
US Sprain 530.11
Migraine 391.9
Molluscum Contag. 724.3
Murmur 780.39
Dr. 's Signature:
~.;i',
0112947 FBS
082270 Hemoccult
087220 KOH
086308 Mono Screen
087430 QuickStrep
081002 Urine Dip Stick
084703 Urine preg. Test
036415 Venip.uncture
087210 Wet Mount, Vag. Smear
q~
o
.. -NCc15
D_
o
---0
---0
11,fJ
NOTES <] ~ [. /7 ,
~(J3$e f. n !P-J.dJV
ifJJ
I' .
Myositis, Fibromyalgia
Nausea
Obesity, Morbid
Osteoporosis
Otitis Extema
Swimmers' Ear
Otitis. Acute Serous
Otitis, Chronic Simple
Palpitations
Parkinson's Disease
Peripheral Vascular Disease
Pharyngitis
Pneumonia
Poison Ivy
Polyps, Colon
Psoriasis
PUD
Reflux Esophagitis
Rheumatic Heart Disease
Sciatica
Seizure Disorder
I'
I' I
Sinusitis, Acute
Sinusitis, Chronic
Sleep Apnea
S.O.8.-
Syncope
Tachycardia
Tonsillitis,A{;ute
URI
Urinary Frequency
UTI
Vertigo
Viral Infection, Unspec.
Vomiting
Well Child
Vaccination, Flu
Post MI
Well Patient
GYN Exam
461.9
473.9
780.57
786.09
780.2
785.0
463
460
788.41
599.0
780.4
079.99
787.03
V20.2
V04.8
V66.9
V70.0
V72.3
EXHIBIT
I-=>>-
. ~State Farm Insurance Companies
STATI 'AIM
A
INSURANCE
\!>
September 15, 2005
State Farm Insurance
11 5 Limekiln Road
New Cumberland PA 17070-0257
Graham Medical Clinic Pc
100- S High St
Newville, PA 17241-1409
~E: Claim Number:
Date of Loss:
Our Insured:
38-K461-021
June 19, 2004
Paul Ranck
Dear Dr. Pion:
Our records indicate Tori Lynn Bell is under your care for
injuries received in the above captioned automobile accident.
To aasist us in the evaluation of this case, please provide us
with copies of the medical records of your patient.
You may bill our office directly for copying services in
connection with the submission of this report. A medical
authori za t ion ":Es '01enclosed.
~
Thank you for your assistance.
Sincerely,
Linda Koch
Claim Representative
(717) 774-9015
State Farm Mutual Automobile Insurance Company
Enclosure: Authorization
HARRISBURG
OCT 3 1 2005
RECEIVED
"
HOME OFFICES; BLOOMINGTON, ILLINOIS 61710-0001
~
CARLISLE REGIONAL MEDICAL CENTER
RADIOLOGICAL INTERPRETATION
PATIENT NAME:
X-RAY#:
EXAM DATE:
ORDERING:
ATTENDING:
CONSULTING:
HISTORY: LUMP LT
TRAUMA ,
BELL TORILYNN M
230396
8/13/2004
JOSEPH A PION,DO 776-3114
MED REC #: 230396
ACCOUNT #: 7414065
D,O.B.: 09/21/1989
ROOM :. OP
ULNA
LUMP LT FOREARM
.,
LEFT FOREARM, TWO VIEWS: 8/13/04
HISTORY:
Focal swelling status post MVA.
Two views of the forearm demonstrate no fracture. The bones are
normal. There is no foreign body or soft tissue calcification
demonstrated. There is no dislocation at either end of the
forearm.
CONCLUSION:
1. NO BONY ABNORMALITY,
~
REVIEWED AND SIGNED
CHRISTOPHER LADD,MD
MATTHEW PASTO, M.D.
DICTATED BY
DATE DICTATED:
DATE TRANSCRIBED:
DATE SIGNED:
TRANSCRIPTIONIST:
6659308
GMC FOREARM QP & LATERAL
8/14/2004
8/14/2004 13:42
8/19/2004 11:56:21
KS
ORDERING
PAGE 1 OF 1
HARRI{"<n, p'. ,"
. ..:::' i:; :.J j "13
OCT 3 1 (LII I,"~
RECE:~' ,."".
.1 \I i:~I..)
CONTINUATION
N}ME
.
ADDRESS
DATE
c
Tory Lynn Bell 3
s; Tory Lynn was in an accident in June which numerous friends were killed in the accident.
Tory had a splenic injury and was admitted to hershey where she was life lined and her spleen was watched, and
she did not end up with a splenectomy. She does complain of arm pain now, and a lump. She apparently is 3
going for some counselling and emotional support.
the rt forearm reveals a soft fluctuant mass over the distal radium on the lateral aspect. She had full range of
motion of the wrist with no weakness of the wrist and no tenderness with range of motion testing. Because~ t
lesion is somewhat firm and nodular, we will proceed with xray. .
Xray was reviewed by me and it was noted that there were no signs of fracture. At this point, I think that th s J a .
seroma, we wilIleave it alone, watch it and if it persists for another couple of months, we may send her for' ----1
orthopedic oval. Poi Joseph A Pion, D.O. ~
/'
./
. fA r-
h "A.RISBURG
\
Del 3 1 2005
RECEIVED
ITEM Q7-05762151fll1 1 COLWElL 1800_637.11.:10
] JAY A. TOWNSEND. M.D.. P.C.
lk. No. MDOIl039E
] JOSEPHA. PION. D.O.
lk. NcAJpsoo71l0E
] CAROL K. ROBISON. D.O.
lk. No. OSJ,'()571OL
] S~ McCOMBIE. PAC.
.GRAHAM MEDICAL CLINIC, P.C
I r\. \n FAMILY MEDICINE
~ l\ ~ --O?- yGH Sdrt~~7~~~LE. PA 17241
IRS No. 23-2173798 i.
PA Blue Shield to/138360 (Particli 'iQg.)
-( ,oS-
H
W
INS
PAT
. I a ..f I .
099211 . MrOirnaJ q41l1iQOAnoscOpy . ..... </ >
MOID99?12 ProllfQcused ----- O~OQ^rt~fo~ntei;isSl11.Jt.
99202 099213 Expand Problem - ~ D:1Q605 ArWrocentesislnterm.
99203 099214 Detail d - - 020610 Arttlrocentesis Major
*,204099215 comp~eh-MOd - ~ D2061?~pi~tionGanglion Cyst
"'''05' - - 0!l2552~udiometry
J~ CQrnpjex _ ___ D9~OOOEKG with Interpretation
'099024 Post Op Visit . ____ _ 094640. In~alation Treatment
1feW.<&t.. PRE\lENTlVEMEDICINE 094200pFT
19381 099391 0.. 1 '(1$ Old _ ~ 045330 SigmoidoscQPY. Flex
_099392 1 - 4 Yrs Old 045331 Sigmoid Flex. with BX
19383099393 5 -11 Yrs Old - . 092567 Ty;mpanQg~am. .
19384~"94 I?" 17 YrsOld '. ... D20550Tr~gg~r PomUnJectlQns
.99!139$ J~-39YrsOld ....... g20550 Injection TendQnSheath
_r3~;40~~.YtsOld -- ~ ~ ~DIOLOGY
. ...RS.II~~~RY.. . . 07Q220SinUs
~~rltiOtJ and.llepalr ____ --'-'-- Ci71020Chest
___tnci$lOn&D~jnage _ ~ 071101 Ribs
"mO Clrcumclsron . 072050 Spine. Cervical
~.AbScess.1 &D; Single - - 072072Spine,.Thoracic
7UOCiYo-upto15 . 0721.10 LSSpme
. . '.' ... . - - 072170 PelVIS
EXcIIIOll Benign lesion 073030 Shoulder
140_ Trunk. Arms. legs Size_ _ ~ 073080 Elbow
140_ _ -073090 Forearm
142~~,Neck.Haoo,I1ieI,Gen Size__ _ 073130 Hand
142_ . _ _ 073140 Finger
144_ ~.Ears.Eyes,Nose,Ups Size___ 073510 Hip
144.. . . 073550 Femur
- Exclllon Malignant Lesion - - 073564 Knee.
160 Trunk Arms Legs Size 073590 TiblFlb
- . ,., - - - 073630 Foot
160~ ". ". .' . __~ 073650 Heel
162_~Neck.Hand, feeI,GenSilB,--,-_ ______ 074010~bdomen
162_ ............... ......... .'. --'-~07311UWrist
164:-i~f.vs~.Eyes./lQse., Ups.. Size.........'---'~ 073610 Ankle
I", . . .~[J'
. . J I 'l I I I
'89.0_ AbdOll1imlf Pain 786.50 Chest Pain ~ 558.9
114.00 ADO w/o Hyperactivity :.- 078.11 CondylQma Acumin. _ 530.11
114.01 ADO with Hyperactivity 428.0 Congestive Heart Failure _ 274.9
177.0 Allergic Rhinitis 372._ Conjunctivitis 784.0
195.3 Allergy Symptoms 692.3 Contact Dermatitis 599.7
:31.0 Alzheimer 496 COPD 455.6
:85.9 Anemia _ 436 Cerebrovascular Disease 272.2
13.9 Angina Pectoris 715.0_ Deg.Joint Disease, Osteo. 401.1
00.00 Anxiety 296.2_ Depression. Single. MM. 242.90
24.1 Aortic Stenosis 296.3_ Depression, Chronic 244.9
14.0 Arthritis, Rheumatoid 296.34 Depression, Recurrent. Severe _ 564.1
29.2 ASCVD 250.00 Diabetes, NIDDM, Type II _ 380.4
93.0_ Asthma 250.01 Diabetes. IDDM. Type I 780.52
27.31 Atrial Fib .-:. 787.91 Diarrhea 702.11
W.O Back Strain. Low 451.19 DVT 702.19
00.0 BPH 786.05 Dyspnea 702.0
66.0 Bronchitis. Acute 692.9 Eczema 724.2
14.00 CAD 782.3 Edema _ 846.0
25.4 Cardiomyopathy _ 790.6 Elevated BloQd Sugar _ 346.0_
i4.0 Carpal Tunnel Syndrome 780.79 Fatigue 078.0
32. Cellulitis 535.0 Gastritis ~'. 785.2
JRM:
Days
Weeks
Months
1;
,.
Posted I
12S68E
Pleaaeretain this receipl10r lnslirance a
lallP1irposes. No ather receipt wHlbe .ISSUI
by this office.
PREVIOUS
INSlIRANC
PREVIOUS
PATIENT
TQPAY'S
CHARGES
APJI.JSTh1EI'
TOOAY'S
PAYMENT
II
I I
t:J~51t5AlfergYlhjectidn Single 8294'1 pas....;,.
_ ~ 090700 Ai:ellular _ _ 0822'10 Hemoccult _ ~
-=-- OJ3420 B12 __ D87.220KOH __
- === 090748Comvax _ _ 086308 Mono Screen __
-- 090718DT(AdUlt) __ 087430 QuickStrep _~
. ____ 090737 HIB _ _ 081002 Urine Dip Stick _ ~
- ~ 090744 Hep B Vaccine, 0 - 19 yrs. _ _ 084703 Urine Prell. Test _ ~
_ 090746 Hep BVaccine, 20+yrs. _~ 036415 Venipuncture __
- ___ OGOOtO,ol.dm. Hepatitis B. Vaccine ~ _ 087210 Wet Mount, Vag. Smear __
= .. . 090659 Influenza ~ _ 0_ __
_ ~. ~~:~~:.~::in of Influenza Vaccine - .. O~ DTA~RfllSeuRcr--
- 090707 MMR ____ - ~ =:APR. . 0 42085 .
- - 090733 Menomune _ ~
=~086580PPD __~_
- - 090669 Prevnar - - 0
- - 090732 Pneumonia ~
-~ - 0
- - OG0009 Admin of Pneumonia Vaccine_ ~ 0 ~
= === 090716 Varivax - - 0-
-_0_
--0
--
__0_
-~ NOTES ,S 1-7 (j ,
_ ~ PJS € I, l7/tj ,1. J'-i
----.. ----
19L(;(
~~
I j I
Gastroenteritis ~ 729.1
GERD 787.02
Gout 278.01
Headache 733.00
Hematuria 380.10
Hemorrhoids 380.12
Hyperlipidemia 381.01
Hypertension 381.1 0
Hyperthyroidism 785.1
Hypothyroidism _ 332.0
IBS 443.9
Impacted Cerumen _ 462
Insomnia _ 486
KeratQsis. Inflamed Seborrtleic _ 692.6
Keratosis, Sebprmeic _ 211.3
Keratosis. Actinic 696.1
Low Back Pain 533.90
US Sprain _ 530.11
Migraine 391.9
Molluscum Conlag. 724.3
Murmur 780.39
I j I
Myositis. FibromYlllgia
Nausea
Obesity, Morbid
Osteoporosis
Otitis Externa
Swimmers' Ear
Otitis, Acute Serous
Otitis. Chronic Simple
Palpitations
Parkinson's Disease
Peripheral Vascular Disease
Pharyngitis
Pneumonia
Poison Ivy
Polyps, Colon
PSOriasis
PUD
Reflux Esoptlagitis
Rheumatic Heart Disease
Sciatica
Seizure DiSQrder
Dr.'s Signature:
I'
I I, I
SInusitis. Acute
Sinusitis, Ctlronic
Sleep Apnea
S.0.8.
Syncope
Tachycardia
Tonsillitis. Acute
URI
Urinary Frequency
UTI
Vertigo
Viral Infection. Unspec.
Vomiting
Well Child
Vaccination, Flu
PostMI
Well Patient
GYN Exam
461.9
473.9
780.57
786.09
780.2
785.0
463
460
788.41
599.0
780.4
079.99
787.03
V20.2
V04.8
V66.9
V70.0
V72.3
./
, .,/'
f'
/' .~.;;'~.,::;
~
,.
.
CONSENT AND APPROVAL
BY MINOR'S PARENTS AND LEGAL GUARDIANS
We, Randy and Robin Bell, do hereby state that we are the parents and legal
guardians of Tori Lynn Bell, a minor, that we have reviewed the terms and conditions of the
foregoing Petition and agree to the same.
Date: /0 h\ L lJ,
I .
Date: IO/'_5/0{.;
I I
Robin Bell
EXHIBIT
If
r-..) ~
(") ,;:;;>
~ c:.::>
C C!'" :?-:n
~ '......- C>
F ~.~
:x\'~?! C""'> tnr-:::
fr -' -~J ,,, ~
:bSJ 'J
".,..' u:> 9<;.(,
" $V ~:!~~ :I~ -u
r;:,., ~ r:-; ::P' ( ';o~
'"<' .::...- :.J;. ~~'M
~ '- '-" )'.?".(-"
-t -., v-.. : >:f; '-P. .~
~ "-J L--- ~ c:> ~
" d -l:
l,
O. C12 o~oo6Cjl
-~........_-_...__.
~--- "-.,'-
'V
In Re:
: IN THE COURT OF COMMONPf -0
'r'~ -.
: CUMBERLAND COUNTY, PE . YLVAMA
. .~-~ =
; NO, a(P - &/1 'J, C~ T~ ~
ESTATE OF TORI LYNN BELL,
a Minor
NOW, this l~ ~ day of
ORDER
o t-t.
, 2006, a Petition for Leave to
Compromise and Settle the above entitled matter having been presented to the Court, and
it appearing to the Court that the total settlement for the cause of action of the minor is the
sum of Thirty Thousand ($30,000.00) Dollars of which is to be placed in a federally insured
interest bearing account for the minor child, said sum to remain in said account until the
minor attains the age of eighteen (18) years.
NOW, THEREFORE, it is hereby ADJUDGED AND DECREED that the terms of the
compromise and settlement are fair and just under the circumstances and the said
settlement is hereby approved by the Court. It is further adjudged and decreed that Thirty
Thousand ($30,000.00) Dollars shall be deposited in a federally insured interest bearing
account or certificate of deposit with a notation on the said passbook or savings certificate
that no funds shall be withdrawn during the minority of the child, Tori Lynn Bell, without
Order of this Court. When the child, Tori Lynn Bell, attains the age of eighteen (18) years,
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at which time the funds shall be free of restriction and turned over to the minor, Up 0 n
payment of the total sum of Thirty Thousand ($30,000.00) Dollars, Randy Bell and Robin
Bell, as parents and natural guardians of the minor child, Tori Lynn Bell, are hereby
authorized and directed to execute a full and complete Release to Ketha Ranck, and her
insurance company, State Farm Insurance Company, for all claims, demands, actions,
causes of action which the minor child may have against her for any and all injuries to her
person or property arising out of the cause of action set forth in the Petition.
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Brigid Q. Alford, Esquire
Supreme Court I.D. #38590
BOSWEll, TINTNER, PICCOLA & ALFORD
315 North Front Street
Post Office Box 741
Harrisburg, PA 17108-0741
(717) 236-9377 (Phone)
(717) 236-9316 (Facsimile)
brigidalford@att.net (Email)
Attorneys for Petitioner
In Re:
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: NO, 06-6112 CIVIL TERM
ESTATE OF TORI LYNN BELL,
a Minor
VERIFICATION OF DEPOSIT OF RESTRICTED FUNDS
Pursuant to the Order of Court entered October 24, 2006, in the above-captioned
matter, I hereby verify that, on November 9,2006, the sum of Thirty-Thousand
($30,000.00) Dollars was deposited into a federally insured interest bearing account in
the name of Tori Lynn Bell, with the further restriction placed thereon that no monies in
said account can be withdrawn without prior Court approval before the minor child
reaches the age of 18.
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A true and correct copy of the deposit slip evidencing the same is attached
hereto, made part hereof, and identified as Exhibit A.
Respectfully submitted,
By:
Srigi , Alford, Esqu'
Supreme Court I.D. # 590
BOSWEll, TINTNER, PICCOLA & ALFORD
315 North Front Street
Post Office Box 741
Harrisburg, PA 17108-0741
Attorneys for Petitioner State Farm
Insurance Company
DATE: November 17, 2006
"\
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~R-Maintain Remarks
78407 - TORILYNN M BELL
No. Tlr Expires
Rec Remark
999 11 11/09/06
Date Printed: 11/09/2006
M
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COURT ORDER WiD ONLY UNTIL MEMBER REACHES MAJORI
EXHIBIT
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