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HomeMy WebLinkAbout06-7058 IN RE: KRISTIN BROWN, IN THE COURT OF COMMON PLEAS MINOR :CUMBERLAND COUNTY, PA PETITION FOR APPROVAL OF SETTLEMENT COME NOW, Tanya Brown and Eric Brown, through their attorneys, Saidis, Flower & Lindsay, pursuant to 20 Pa.C.S.A. Section 5103, and in support of their petition aver the following: 1. Petitioners are adult individuals who reside at 188 Conodoguinet Estate, Newville, CumberL•~nd County, PA 17241. 2. Petitioners are the parents and natural guardians of Kristin Brown, a minor. 3. Kristin Brown was born November 21, 1990, and is currently sixteen years old. 4. On Clctober 20, 2005 at approximately 3:12 PM, while attempting to cross Mount Rock Road in West Pennsboro Township, Cumberland County, PA on foot, Kristin Brown was ~~truck by a motor vehicle operated by Allen Lee Baker, also a minor, whose date of birth is February 19, 1989. The State Police accident report relating to the incident is attached :hereto as Exhibit "A." 5. At the time Kristin Brown was struck, she was in a school zone, where yellow school-zone lights were then flashing; consequently, the speed limit was 15 miles per hour. ~~ ~~ .. ~~ VERIFICATION I hereby verify that the facts set forth in the foregoing motion are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn falsification to authorities. Eric Brown Q ~~ T Brown November ~'~ , 2006 5 ~,~~., h,`~I-~ ._ ~.f ' l "tlP 7-0015 j3.20fi2) r PENNSYLVANIA STATE POLICE N071CE OF CRASH INVESTIGATION A5 REPORTED ON A COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM, FORM AA-45, THE CRASH IN WHICH - YOU WERE INVOLVED HAS BEEN REPORTED TO THE PENNSYLVANIA STATE POLICE AND WILL BE INVESTIGATED IN ACCORDANCE WITH SECTION 3746(C) OF THE PENNSYLVANIA VEHICLE CODE. CERTIFIED COPIES OF THE COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM (EXCLUDING APPENdED DOCUMENTS AND PHOTOGRAPHS) FOR CRASHES REPORTED TO THE PENNSYLVANIA STATE POLICE ARE AVAILABLE TO AUTHORIZED PERSONS UPON COMPI_E770N OF THE REVERSE SJDE OF THIS FORM AND ACCOMPANIED BY A CHECK OR MONEY ORDER IN THE AMOUNT OF 58.00. THE CHECK OR MONEY ORDER SHALL BE MADE PAYABLE TO THE COMMONWEALTH OF PENNSYLVANJA. GOVERNMENT AGENCIES ARE EXEMPT FROM PAYMENT OF THIS FEE. A POLICE CRASH REPORTING FORM MAY BE VIEWED OR PHOTOGRAPHED (WITH PERSONAL EtIUIPMENT) 8Y ANY PERSON INVOLVED (NOT WITNESSES), THEIR ATTORNEY, dNSURER, AND CERTAIN GOVERNMENT OFFICIALS ONLY AT THE PENNSYLVANUI STATE POLICE STATION LISTED BELOW. t~1 ~ ~~ y ,~ ' ©~~jp, DATE AND TIME OF CRASH INCIDENT NUMBER ~ 'tea rJ ~ ~ y p ~ Q ~ `-- { ~ ~ `~ t ~ LOCATION OF RASH - COUNTY INVESTIGATING OFFICER'S SIGNATURE BADGE NUMBER ~ C'cL- ~~ ~-r~~n-- ~ 5 ~ ~ PENNSYLVANIA STATE POLICE STATION ION TELEPHONE NUMBER STA ~~-Ct. Irk SL1= T i~ -~°~ ~ -~ ~ Z~ 1T 15 RECOMMENDED THAT YOU 0~4TAJN, AT A MINIMUM, THE FOLLOWING INFORMATION FROM THE OTHER INVOLVED PERSON(S) BEFORE LEAVING THE Si:ENE OF THE CRASH. THIS INFORMATION CAN BE OBTAINED FROM THE DRIVER'S LICENSE, VEHICLE REGISTRATION CARD, AND ANY PROOF OF FINANCIAL RESPONSIBILITY. DRIVER{SuPEDESTRIAN{SuPROPERTY OWNER(S) INFORMATION VEHICLE OWNER{S) INFORMATION NAME NAME /I ,, , ` ADDRESS ADDRESS CITY STATE: ZIP CODE CITY STATE ZIP CODE ~3,~wy ~ fit, >~ - ~. t 121( ~ ~~v ~~:,,~' ~. 1-? Zt-i 1 TELEPHONE NUMBER / `""1-1J~ TELEPHONE NUMBER 11 - ~ - ~,y ~ 1 ti~ ~1 b - L~'~ ~' ~ DRIVER'S10PERATOR'S LICENSE NUMBER YEAR, MAKE, AND MODEL OF VEHICLE ~Z~ ~it"~ t~5~'1 ~, ~L`iM~~rM ~• `t3 STATE OF ISSUANCE TRATIONJLICENSE PLATE NUMBER REGIS rr l.3'~ ~~ ~ ~ ~~ DRIVER'S10PERATOR'S LICENSE EXPIRATION DATE VEHICLE REGISTRATION EXPIRATION DATE NAME OF VEHICLE INSURANCE COMPANY POLICY NUMBER POLICY EXPIRATION DATE . • d T • tOMMOI~IWEALTki OF PENNSYLVANIA ff II 1 II `` II `` ~ ~ I POLICE CRASH REPORTIIVG FORM ~ ~l~ll~~ 1111 III~~ I~~~ 4I1~ Crash Number Case Closed Reportable Crash Page /riA 500 1 ~ Yes O No ~ Yes O No ~ ~ P 0 7 4 810 3 I ~ Incident Number Police A ency Patrol Zone }~ Z ~ s Zo ~ 0 6 8 u Zr3 p Agency Name Precinct lnvesti tion Oate (MM-DD-YYYY) y 5 `c- yam- ~ C'~•L-,cc,~ ~Prt- ~ .~ 5 ~ ~ ~ 1 - 'L ~ - 0 0 , Q ~ Q , Dispatch Time (mi!) Arrival Time (mil) Investigator Badge Number 1 s 1 'z- ) s 'S ~ ~ ~ ea c~~~tp.o ~l= S~tou~f~ s ° a Reviewer Badge Number A provill Date (MM-DD-YYYY) L. ~~ ~ 7 9' n ~ C.~ -~- 2 D D ~ Municipality Name Count County Name Munici a~itC ' ~ ~ ~ of Week O Sun ~ Thu m ~+ ~ , p ~.1~ Z 1 ~5 4"" P ~N 4.; 5'"`.3r~n' T L~i! J ~V r-• C~ ~JL.C ~ _ Crastr Date (MM-DD-YYYY) Crash Time (mil) No of Units People Injured Killed` •If > 00 Mon O Fri O Tue O Sat u com fete s - I ? - "Z. ~ :7 '~ ~ S 1 i~ ~ O ~ ~ ~ C~ +~ Form F O .'r'ed t~ Unk Workzane ill Yes, Complete form M, Section 29) O Yes ®No School Bus School Zone Related O Yes ~ No Related ~ Yes Q No Notify PENNDOT Maintenance O Yes O No intersection Tvoe ~ q Uyay Intersedio~ O 'Y' Intersedran Q Multi-Leg O Off Ramp Q Railroad Crossing Intersection ~-~s131 J ®Midblock O •T" Intersection O Traffic Circle! O On Ramp O Crossover O Other Round About • See Overla Route Number Segment (pptionaU T a l r ve L anes Speed limit Q N rth House Number (it applicable) r - - r ~ - 3 ~ ~ 4 "~ ~ ~ o O South C Street Name LL.__r___ _1LJ_J Street Ending ~ O East For Mid-block crashes only. Use u ~ d ~ \ ~ '~,` I~~- - R ~ O O west postal House Number and make sure Principal Roadway Street Name rs t ~ \ O Unknown filled in rf using this opGOn a ~ Interstate Turnpike Tumpike State County Local Road Private Other/ O O O ~ O ® ~¢ ~ O Unknown or Street Road (Not Turnpike) Road Spur Highway fEasVWest) ,o { Route Number Segment (Optional) Travel Lanes Speed Limit Q North ~ ~ ~, ~~ m ~ O South ~ t m Street Name Street Ending ~ O East ~ ~ ~ O O West v O Unknown '~ ~ Si~on~na ~ Interstate O Turnpike O Turnpike O State 0 County 0 Local Road O Private ~ Other/ .- M (Not Turnpike) (Ea~stlwest) Spur Highway Road or Street Road Unknown Intersectin Rt Num ~~r Mile Post Or Segment Marker p O N h Feet ~ ~ ~ `m t I mo. ^ ort O South .fl = ~ u Please .o Or Intersecting Street: Name 5t Ending ~ = O East Or Milec E .. -nt_r ~ Information °' for BOTH ~ t ~ 4 ~ ~ ~ ~ ~ ~ °a, `r 0 west n m • L.._! o d ~ v Landmarks ~ rf Using This Option Intersecting Rt Num (?r Mile Post Or Segment Marker n c ~ ~ ~~ O North Distance, from •Crash Scene to landmark 1 ~ ~ ° lll...~~~.111~~~1~111 O South N N ~ Or Intersecting Street Name St Ending ~ O East (for Crash between G ~ ~ Landmark t and . ~ ~ O West Landmark 2) Degrees Minutes Seconds Degrees Minutes Seconds ~ 5 (~ Longitude: - ~`} ~ ~ ;1 Z try 1 ~ y Latitude: ~ ~ Q ; Z. S~ ° . ~_.! p i Traffic Contra Device C Yield Sign O Police Officer ar Flagman >~ Not Applicable O Traffic Signal Active RR Crossing C O Other Type TCD 13"P functionino Device Functioning Emergency ~ No Controls Q Im r O Preemptive p openly u ~ Flashin Traftrc Controls O g O Stop Srgn Passive RR O Unknown Signaler-~ Signal Device Not Device Functioning O Unknown O Functioning O Properl Crossing Controls y 7 (a C7o_~ (tf 'Nat Applicable °, skrp test of the Lane Closure section) Lane Closure_ +~ North O East O North and South O All e t O Not Applicable ~ Partially Q Fu11y O Unknown O South O Went O East snd West ~'~•~ m j Tlsifftt Yes O No Detoured ~ Unknown O E~fl.-Il[~ O < 30 Min. ®30-60 Min. O 1-3 hrs O 3-6 hrs Q 6-9 hrs O > 9 hours Q Unknown SrgfEft t FORM ~ na-600 (72102) PENNDOT CC)PY ~..~.-• ~ ~o --- ' • ~ ~ ~ ~ COMMONWEALTH OF PENNSYLVANIA III ~IIII~I~~II~~IIIII~~~~f Crash Number PdLICE CRASH REPORTING FORM Poli se Only page P 0 7 4 810 3 AA 500 2 `~~_ i S Zr~~ _ ~ o ~ to o ~ ..___.. Motor Vehicle in Tvpe ~ Transport O Hit 1k Run Vehicle O Illegally Parked O Legally Parked Q Non -Motorized Commercial Vehicle . Unli Pedr~strian on Skates, Disabled From O Train O Phantom Vehicle O Pedestrian O O O Yes ® No ~ ~ Previous Crash in V~~heelchair, etc (If Yes, Complete Form C) (!f 'Pedestrian" or "Pedestrian on Skates, in Wheelchair, etc', Complete Form M, Section 28J , Birth(MM-DD-YYYY) te of Unit No First Name M{ D a ~ a) ~L ~ u ~ r+~I 1 c1 1 c1 8 ~i Delete? Last Name T le hone Number O g ~ yr >E >2 -~ -1 ~ ~~ ~ ~- G 4 S J Address / Ci /State Zi c 0 W 1 ~ `~ 5 ~...~ t~`~-1y n- ~;.~• r'r~ r-. ftc7 r u`~'",t~c,cs, ~P 11 Zy ~ H . Class te Driver License Number Sta ~ ~ ~~ c ~ ~ ~ ~ 51 r 1 L: L' J t: ~ _: a Alcohol/Druas Suspected Driver or Pedestrian Physical Condition ®No Q Illegal Drugs Q Medication Q Nopmalntly O 1~esgai Drug O Fatigue O .Medication ~ O Alcohol Q Alcohol and Drugs O Unknown Had Been O Sick Q Asleep Q Unknown ~ Drinking > •L p Alcohol Test Tvpe ~ Test Not Given Q Breath O Other Primary Vehicle Code Violation ChargedT -°; O Blood (~ Urine rO Unknown if 3 3 ~ ~ ~ Yes (~ No L Test Given ~ Alcohol Test Results O Test Refused O Resultos n T Gi Driver Presence 1=Driver Operated 3=Driver Fled Scene vehide 4=Hit and Run ` ~. ~ O est ven, C i d R l ~ k r.•.J~ ontam nate esu ts nown 2=No Driver 9=Un Owner/Driver OD=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07.Municipal Police Veh 09=Federal Gov Veh 01=Private vehicle Owned' OwnedlLeased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name (If Pedestrian, skip this Section) Driver O ~• ~ ~" '~~~ ~ ~ Y ~ Q ~. V Cr E"1 Address / Ciry /State /Zip Vehicle Make •Make Code 1 Q y S `-• r~.~v ~- 'c33 ~ c3~-. cto >r.s,E~,, .l .sts..~ PfP ~~ Pl.`(Mov; VIN Model Year Vehicle IVlodel isee Overlay} ~ P~ ~"SZ1c ~i~Gy f 9 W~~ ~~~ a R St t License Plate eg. e Est, Speed Veiricte Towed Towed By ~ ~ ~ ~ ~ - ~ ,~ Z- , ..~.~1__; L~~ ~ ~' Yes O No ~-C ~c Q~,~1SY'T='~~~ ~~ Poli No ty Insurence Insurance: Compan y ~~ tf [ ~ Yes ~ No O known ~{~Y'~~ 7~.V t'b T k~+ '~z~"3 ~~ ~ 5 S ~ -- ~~ . m Trailin T e• 1_Tnwing Pass. Veh 4=MobilelModular Home 7=Semi-Trailer Tag No Tag Year Tag St '= Unrt No. of ^ U~ n 2=T~~wing Truck S=Camper 8=Other ~j Trailing £J ^~J ~ ~ 3=Tuvvin UUIi Trailer 6=Full Trailer 9-Unknown L-~J Units: g ~` _ s ~ Direction of ~ 'Vehicle Position T eT-'- ~ ~ y 'Movement ~ `See O l ~eciai Usage rav ver ay Vehicle Color Vehide Tvpe 05=Large Truck 20=Unicycle, Bicycle, a ~ 12=Commercial Passenger Ob=Yellow 07=Silver 3 U1=Automobile 06=5UV Tricycle ~ll Ci2=Motor cle 07=Van 21=Other Pedalcycle 1 n' 00=Not Applicable Carrier D1=Fire Veh 13=T i 68=Gold (i3=Bus 10=Snowmobile 22=Horse & Buggy ax 02=Ambulance 21=Tractor Trailer D1=Blue 09=Brown C~4=Small Truck 11=Farm Equip 23=Horse & Rider 03=Police 22=Twin Trailer D2=Red 10=Orange 03=White 11=Purpie (!f "02", Complete form 12=Construction Equip 24=Train Section 26) 13=ATV 25=Traiiey M 08=Other Emergency 23=Triple Trailer 04=Green 12=Cnher , pf `20" or "21 ", Complete 18=Other Type Spec Veh 98=Other Vehicle 31=Modified Veh 11-Pupil Transport 99=Unknown 05=Black 49=Unknown porm M, Section 27) 19=Unk. Type Spec Veh 99=Unknown Initial ImPaR Point Damage Indicator Gradient ~ 3=Downhill Road Alignment 00=Non-Collision 14=Undercarriage 12 Cl k P t 15 T d U i ~ ~ (-5 i O=None 2=Functional - 1=Minor 3=Disabling G ^ 4=Bottom ofi Hitl ~ 1=Level S=To of Hill ^ 1=Straight ~ 2=Curved = oc s oin = owe 01- n t l3=Top 99=Unknown ~ ~ 9=Unknown p 2=Uphtli 9=Unknown 9=Unknown cnau . 4n.cnn ~»rnzti PENNDOT COPY _~ _i p~~ - - . , , ~~ COMMO`TiWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page: AA 50D 2 Police Use Oni~ ~ ~ 5 ,.7 ©G ~ IIIICIEIIIIitlI~A P07461D3 Crash Number o ~ Motor Vehicle in TVpe ~ Transport O Hit I1 Run Vehicle O Illegally Parked O Legally Parked QNon -Motorized Commercial Vehicle w Unit ~ pedestrian O Pedt~strian on Skates, O Disabled From O Train O Phantom Vehicle O Yes O No z ~ in vl~heelchair, etc Previous Crash (If Yes, Complete form Q (If 'Pedestrian' or "Pedestrirn an Skates, in Wheelchair, etc", Complete Form M, Section 28) Unit No First Name MI Date of Birth~MM-DD-YYY ) m ~. ~ 5 ~ ~ ~ --~ _ _ a ~ ~ ~ o Delete? last Name Tele hone Number p ~ tz a u "111 ~1 ~.--? ~1 y~ Address / Ci /State Zi c •a° ~ ~ g~ m _ Driver License Number Stat Class ~ ~~ t ~. Alcohol/Drugs Suspected Driver or Pedestrian Physiral Condition ~ No Q Illegal Drugs O Medication ~ NPR Intly O IUsegal Drug O Fatigue Q Medication d O Alcohol O Alcohol an j Drugs O Unknown Had Been O Sick O Asleep [' Unknown O Drinking a a Alcohol Test Tvpe ~ Test Not Given Q Breath O Clther Primary Vehicle Code Violation Charged? u ` O Blood Q Urine Unknownrf O Test Given O Yes O No N ~~~ s ~ Alcohol Test Results O Tesi Refused O Unknown Results Test Given Driver Presence } =Driver Operated 3=Driver Fled Scene Vehicle 4=Hit and stun , a' ~ O a~ i d R C lt ~ n ontam e esu s 2=No Driver 9=Unknown Owner/Oriver 00=Not Applicable 02=Private Vehicle Not 04=State Ponce Vehicle D7~Jlunicipal Police Veh 09=Federal Gov Veh 01=Private Vehicle Ownec4 Cnvnedrleased by Driver 05=PENNDOT Vehicle 08=Other Muninpal 98=Other O ~ teased by Driver 03=Rented Vehide 06=Other State vov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name (If Pedestrian, skip this Section) Driver Address JCity /State /tip Vehk}e NSake "Make Lode m VIN Model Year Vehicle Model tree overlay) License Plate Reg. State Est. Speed Vehicle Towed Towed By -_ ~ m ~ Q Yes Q No insurance Insurance Company Polity No o Q Yes Q No O known m E Z Tra ling T e 1=Towing Pass.:Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St ~ Unit No., of ~ Unlt ~ 2=Tuwing Truck S=Camper B=Other ~~ il g r °' 3=Towing Utility Trailer 6=Full Trailer 9=Unknown Uni ts v ~ ~ Diredlon of ^ *Vehide Position m 'Movement m 'See l Special Usage rave Over ay Vehicle Color Vehide Tvn~~ 05=Large Truck 20=Unicycle, 8icyde, m 12=Cammercial 06=Yellow 07=Silver ~'} C1=Automobile 06=5UV Tnryde I I t C2=Motor cle 07=Van 21=Other Pedalcycle ry Passenger ~=NOt Appl(cable Carrier Di=Fire Veh 13 xi T 08=Gold L_L_~ C3=Bus 10=5novvrriobile 22=Horse & Buggy = a 02=Ambulance 2 i=Tractor Trailer D1=Blue 09=Brown C4=Small Truck 11=Farm Equip 23=Horse & Rider 03=Police 22=Twin Trailer D2=Red 10=Orange (!f "D2", Complete Form 12=Construction Equip 24=Train 08=Other Emergency 23=Triple Trailer 03=White 11=Purple M, section 25) l3=AN 25=Trolley Vehide 31=Modified Veh 04=Green 12=Other 05=81ack 99=Unknown pf "20" or ".?1", Complete 18=Other Type Spec Veh 98=Other 19=Unk Type Spec Veh 99=Unknown 11=Pupil Transport 99=Unknown . Form M, Sec'ion 17) Initial Impact Point Damage Indicator Gradient 3=Downhill Road IU~nment 00=Non-Co1lis~on 14=Und~zrcarriage ck Poi 12=Cl t T Oi 15 d U 0=None 2=Functional 1=Miner 3=Disablin 9 4=Bottom of Hill 1=Level S=Top of Hill }=Straight ^ 2=Curved - o n s = owe nit Unk o 9 2=Uphttl 13=Top 99=Unknown n wn = g=Unknown 9=Unknown 11 t FORM ~ u,300 (12K12) PENNDCIT CpPY COMI1hONWEALTH OF PENNSYLVANIA ' • .r~ , ` 'POLICE CRASH REPORTING FORM page AA 500 3 Pour Use Ony ~_2-- , f S 2 ~ ~ W~IIIBItlIIIVIIGII P0748103 ~ i Crash Number Perso_.~Tvflg: Seat Position: A 1=Driver ~ OD=Not A Passenger/Occupant P 2 ~fety F~ioment One: Election: E DD=None Used /Not Applicable fj O=Not Applicable 1 = assenger Oi=Driver -All Vehicles 7=Pedestrian 02=Front Seat Middle Position 8=Other D3 Ri F h Sid t S :=Not Ejected 01=Shoulder Belt Used 02=La Belt Used Totally E ecrted ll lt U P E d D3 L p A d Sh ld rti B d = ron 3 t eat e 9=Unknown D4=5econd Row -Left Side Or n a y jecte ou r = a = a e se 04=Child Safety Sea Used 9=Unknown Motorcyce Passenger 05=Motorcycle l et Used 05=Second Row -Middle Position 06=6i de Hel et.Used F D6=Second Row -Right Side 10=Safety Be kl;ed Im roperl ~ - e ~ e .~~ B F =Female OT=Third Row Or Greater - y p =NoD t E J c d !Not Applicable t i 1=Child Safety Seat Used Improperly 1=Through Side Door Opening o M=Male Left Side U =Unknown 08=Third Row Or Greater - i2=Helmet Used Improperly 7=Through Side Window 9D=Restraint Used, Type Unknown ~=Through Windshield E 0 Middle Position 09=Third Row Or Greater - Right Side 99=Unknown 4=Through Back Door S=Through Back Door Tailgate Opening ~fPty ou)pment Trvo: , z fniurv SevPrirv: tO=Sleeper Section of 7ruckcab 6=Through Roof Opening (Sunroof/ F 00=None Used /Not Applicable Convertible Top Down) m a ~ O=Not Injured 11=1n Other Enclrxed '=Killed Passenger Or Cargo Area 01=Front Air Bag Deployed (For This Seat) ~=Through Roof .Opening (Convertible 02=Side Air Bag Deployed (for This Seat) Top Up) a° n. -Major Injury 12=In Open Area 3=Moderate (Back Of Pickup, Etc.) 03=Other Type Air Bag Deployed 9=Unknown 04=Multiple Air Bags Deployed injury 13=Trailing Unit 4=Minor injury 14=Riding On Vehicle Exterior 05=Motorcycle Eye Protection 06=Bicyclist Weanng ElbowiRneeJPads ion. 8=Injury, Unk tS=Bus Passenger Severity 98=Other I 10=Air Bag Not Deployed, Switch 0n ~ O=Not Applicable 11=Air Bag Not Deployed, Switch Off 1=Not Extrrcated 9=Unknown if 99=Unknown In/ury 12=Air Bag Nat Deployed, 2=Extricated By Mechanical Means Unk Switch Setting 3=Freed By Non -Mechanical Means 13=Air Bag Removed (Prior To Crash) 8=Other 19=Unknown if Air Bag Deployed 9=Unknown 99=Unknown EMS Agency: ~~~ru.~ ~ vLAu~Y~ Medical Facility: G ctt_r s ~-~ 11: s ~ l_ Unit No Person No Date of Birth (MM-DD-YYYY) A B C (~D ~ ~E-,~ F G H I .~ ~ ~ DO e~ O 2 ~' ~ ~ ~ ~I ~ ~ ~ L~LL..! i~ LJJ ° ~ Name 1 Address /Phone Same as EMS Transport Q Yes No Operator _ _ Unit No Person No Date of Birth (MM-DD-YWY) A B C D E F G H I -~~ ~ Deletel ~_ ~ t _ ' ~ ~ ooae~~e~ooa o a~t, o p 1 0 3 03 0~ 1 c, Name /Address /Phone _ EMS Transport S ~e as ^' i ~,(L,tss-(„fit f~. ~-~ o ~ 3 Q Yes ®No O rotor Q ~.~r~ c~ `l ~. 4 G-11 ~ 2 1 ~ Q~ CLP G Unit No Person No '`Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I cz ~ ~ o - ~ -2 ~ - ~ ~ ~~ ooo~c~~aooa Name /Address !Phone EMS Transport Same as Operator ~ Yes Q No Unit No Person No Delete? Date of Birth (MM-DD-YYYY) q B C D E F G H I `~~ t~ ~ Q~-CD - ^[~DCL Q~Q~{~0^ Name /Address !Phone EMS Transport Same as Operator O Yes ~ No Unit No Person No Date of Birth {MM-DD-YYYY) A 8 C D E F G H I m m DeOe7 1.~-m ~^~m~~^^~ Name !Address !Phone Same as Operator EM5 Transport Q Yes (~ No Unit No Person No Deletel Date of Birth (MM-DD-YYYY) A B C D E F G H I c~ m ~ m--m- aoommmao^ Name /Address /Phone Same as Operator EMS Transport ~ Yes ~ No t i r FOPMrfA0..500(1?/D2j PENNDOT COPY i - ~ r r _ __._ _. - - . POLI EO(RASH R PORT NG FO MANIA N~~~11~,III~I~I,I`~"~~ Crash Number AA X00 4 Pdice U~(D ly 'a'e P07481~3 1 tJ2.- 5 Z ~ ~'~ ~ u s. s Crash Deseriation O==Non-Collision 2=Head On 4=Angle 6=Sideswipe B=Hit Pedestrian c ~ 0 ~ 1=:Rear End 3=Rear to Rear (Backing) S=Sideswi a (Opposite Direction] (Same ~ireGion) 7=Hit Fxed Object 9=OtherNnknown ~ ~ Relation to Roadway ~ 1=:On Travel Lanes 3=Median 5=Dutside Trafficway 7=Gote (Ramp Intersection) s; ~ 2=:Shoulder 4=Roadside 6=1n Parking Lane 9=Unknown ~ 5 z ~ [1)umrnation 1=Daylight 3=0ark -Street 1 2=Dark - No Lights 5=Dawn B=CJther 6= ark -Unknown ~ a f Street Ughts 4=Dusk Roadway Lighting m ~ Weather Conditions ^ ~ 1=No Adverse Oonditions 3=Sleet (Hail) S=Fo 7=Sleet & Fo 9=Unknown 13 g v ,~, ~ 2=Plain A=Snow 6=Rain & Fog B=Other G Road Surfaw tonditions O=Dry 2=sand, Mud, DiR, q=Slush ~tce Patches g=p~r OII ~=W2~te~r - Standin g 1 t 5 W ~ 1= e 3=5now Covered = ce Df MOVIng Maim Event L/R Most7 Utility Pole Number Narmfu! Events (Harm Event) 30=Hit Fence Or Wa11 1 ~ ~ n ~~~ ® 01=Hit Unit 1 02 U i 2 Hi 31=Hit Building 32=Hit Culvert Un+t No ~f = n t t G3=Hit Unit 3 33=Hit Bray Pier Or AbutmE:tt Q ` Z m ! a 0 ~~~~ D4=Hit Unit 4 DS=Hit Unit 5 34=Hit Parapet End 35=Hit Bridge Rail 06=HIt Other T2ffic Unrt 36=Hit Boulder Or Obstacle Please Put Events in 3 m ('''~ ^ (~ C ~ D7=Hit Deer 08=Hit Other Animal On Roadwayy 37=Hrt Impact Attenuator Sequential 09=Collision With Other Non 38=Hit Fire Hydrant c ° Order 4 m ~ O ~~ Fixed Obyect 11=Struck B UNt 1 i 34=HIt Roadway Equipment AO=Hit Mail Box 41=Hit Traffic Island « 12=Struck By Un t 2 ~ 13=Struck By Unit 3 42=Hit Snow Bank Hi 43 T C o Harm Event L/R Most? Utility Pole Number 14=Struck By Unit 4 15=Struck By Unit 5 = emporary onSUUCtian t Barrier ~ t , ! ® C~ 16=Struck 8y Other Traffic Unit 48=Hrt Other Fixed Object 49 Hit U Fi ~ Ob k a Unit No 21=Hit Tree Or Shrubbery n nown xe = ject W M ~ ~., 2 (~ ~ ~ I ^ 0 ~ ~ 22=Nit Embankment 23=Hit Utility Pole n 24=Hit Traffic Si 50=OverturrVRoll Over 51=Struck By Thrown Or Falling Object _ g c 25=Hrt Guard Rail 52=Pot Holes Or Other « Please Put Events in 3 ~ ~ ~ ~ ~~ 26=Hit Guard Rail End 27=Hit Curb Pavement irregularities 53=Jacknife 5equentiai - 2B=Hrt Concrete Or 54=Fire !n Vehicle Order 4 m ^ O ~~ LongtWdinal Barrier 29=Hit Ditch 58-Other Non-Collision 99=Unknown Harmful Event First Unh No Harm Event Most Unit No Harm Event Driver Action (D~ 17=Careless Or 111ega1 ~mfu! ~ vent rn D ~ ~ ~vful r" '(~ 1~ 7 ( ~ ( ! O 2. ~t nn 'i 00=No Contributing Action 07=Driver Was Distracted Backing On Roadway 18=Driwng On The Wrong t e rash --- L-- -r ~ .rash p2=Driving Using Hand Held Phone Side Of Road (b nos .epear rru, nio~r,aiW~ oo mJUWe rang 03=Driving Using Hands Free Phone 19=Making Improper 04=Making Illegal U-Turn Entrance To Highway Environmental /Roadway Potential factors (E1R} 1 2 m 3 05=Improper/Careless Turning D6=Turning Frosty Wrong lane 20=Making Improper Exit Fsom Highway 07 W/0 P l C k 00=None 11=Slippery Road ConditOns flce/Snow) =Proceeding Clearance After Stop are ar Z1= ess (ng/Unparking 22=OverNnder D1=Windy Corsditbns 12=Substance On Roadway 02=Sudden Yveether Conditions 13=Pnthot's 08=Running Stop Srgn 09=Rurm+nq nao L(g t CompensaUOn At Curve 23-5 eedrn D3=Other Weather Cond~t rons 14=Broker Or Cracked Pavement 10=Failure To Respond To 24=DPrvmg Too Fast For Conditions p4=Deer In Roadway 05=Obstacle On Roadway l I i R d A h 15=TCD Obstructed 16=Soft Shoulder Or Shoulder Drop Off h 2 O d Other Traffic Control Device t 1=Tailgatingg d m 1 $I 5 25=Failure To Ma+nta+n Proper Speed 2fi=paver Fleeing Police (Pot Chanel n ma n oa er 06=Ot way way factor t er 2oa 8= O l F en owingl 2=Sud top y ll Ill d O 13 S d R 21=Driver Inexperienced r c 07=Glare 08=Work Zone Related ther .:nv+ronmenta actor 29= 99=Unknown y oa = toppe n ega 14=Careless Pass;ng Or Lane Chan e 28=Failure To Use Specialized Equip 42=Affected By Physical Condition a Possible Vehicle Failures (V) 12=Wipers g 15=Passing In No Prising Zone 98=0Yner lm ro er Dnwn Actions 99=Unknow P p g E 00=None 06=Exhaust 13=Driver Seating/Control 16=Driving The Wrong Way On 0 01=Tees 14=Boil ,Doors, Hood, Et[ 07=Headlights 1-Way Street _= = •02=Brake System 03=Steering System 15=Tsai er Hitch O8=Signal Lights 09=Other Lights 16=Wheels Unit No ~ 1 Z 2 ~ ~ 3 4 Z 3 m m a 04=5uspenslon DS=Power Train 10=Horn 11=Airbags 11=Mirrors 18=Trailer Overloaded - c ~ t9=Unsecure/Shifted Unit ~ t 0 Z Trailer Load No ~ m ~ 20=Improper Towing m Unit L~ ~ NO ~ 1 0 2 rn rn 3 4 L-L.J t~,L_-_J m 21=Obstructed Windsh(eld Unk m t m Z ~ 99=Unknown pedestrian Action (Pl 00=None 03=Working 04=Pushing Vehicle N0 01=Entering Or Crossing At 05=Approaching Or Leaving Vehicle ecified l0Ca11Or1 S 06=Working On Vehicle Indicated Prime Factor Unit P-o FaRat Code p 02=Walkin4, Running, Jogging, 07=Standing 98=Oth g Do nOt repeat ih~s ~niarrwtnr to ~~ m mulupse cages Or Playing er 99=Unknown F/R V D ® P O !f F/R i h ct P i F Unh No ~ C> ~ Unit No ~ ~ C~ s t r a or e me 0 ~ Type, leave Unit No blank FORM t AA•500 (72/02) PENNDOT COPY - .- --_ -- ~~ ' Q ,~ COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM (P''a'g~e `; ~ ~QO ~ Poke Use {~ ~[ ~ ~c~ri~iiioiuii~ P0748103 Crash Number FOflM Y aA-500 (Sy02) PENNDOT COPY -= Q ~fl s ~~ ~~ COMMONWE~iL$I~C OF ~PEhfNSYLVANIA ~~ulllu~~U[~~UlII~IIll Crash Number Pt~LICE CRASt{1 RE~ORl'{MG FORM Page ~ New AA 500 N ~°'1Ce`~.e.~°~.-Z.-) S Z~~ ~ c~ ~ O Cnnt nuation p o ~'i ~ ~ c7 3 Narrative and additional witnesses: ~.+ cY ~ s~ ~ ~.,. p.s ~cv-t ~ w~tJ A r : ~ ~4 SL-~N Otit \ o 'L. ~ o S^ 51 ~ ~1t1.. ~ C"'ta ~r ~ O Z ~.. p. s ~.+ ~tia ~ t v~ ~+\ ~v \.sG w P~L-11.~ C-~/SS i 111 ~Z.7 ~. ~j . ct Trt .F t~L r" ~, G Q. r• ice- r1 rG s Q,~ n ~ r-- 'Q tt_~ ~ v ti,a z .~ ss '~.- ~ P~ r r- v .~-i'1rr rep r' T~ ,f S c,s!~,f ;L' ~ ~ -~ mss" A ~, 1 5 2511 S ~u p s <- +,.~ ~+.~CU i M ,E tea. ~ -ass ~~ ~2 o Pte, ~ G ~Ct- N r" t"` 0 1s ,~ ~ ~ ~~ ~ d s ,. 4 m zs t a N N d C ?V } R ~~ . ' Q FORM / J1A•SDON (7znu- PENNDQT COPY C~l~y~- a DAVID C. BAKER, M.D. 1~- BROOKWOOD AVENUE, SUITE 104 CARLISLE, PA 17013 9- .+.,, .. ,._ 1 ~'~~~ NAME ,~~~5 -~i,~i ~~ /~~~~ ~~ AGE TODAY'S DATE ADDRESS ! ~ ~ ~~ - I V~.WV ~ <<~' ~ ~ _' SATE OF BIRTH ~ ~ :~ l' 9~ PHONE ~IIOME) _J ~ ~ ' ~~ ~ ~ ~' PHONE~ORK) ~-~~' ~/~~ INSUR-ANCE .t~ ~ry ~ ~• PLACE OF EMPLOYMENT FAMILY DOCTOR~~.~1,n~. ~'YI,~Q ~ REFERRED BY _!~ FAMILY/REFER_RED DOCTC-R ADDRESS ALLERGIES SMOKER YES Nt3 MEDICATIONS ____~__ PREVIOUS SURGERIES ____ HAVE YOU EVER BEEN TRE.~TED FOR DRUG OR QZCOHOL ABUSE? 'YES NO PROBLEM !- L I ~l~ ~ l:.J ~(!~ PREVIOUS X-RAYS ~ ~ j c: -~. ~_ 0 5 ~ . ACT 2 4 2Q~5 `~ ~ s I-~ C~ ~.~..~ ~~~ ~~--- ~-~ ~' HISTORY: Four days sr_at:us post left olecranon fracture, treated by ORIF. ~~ Left knee irregular laceration. SUBJECTIVE: She feels pretty good. She ;-stares she has mi_ni_mal pain. She is not taking Percocet. OBJECTIVE: Wound clean and dry..on the 1E~g. Neurovascularly intact i_n the upper extremi_i:y. ASSESSMENT: Olecranon fracture, status post. Status post irregular laceration of leg. PLAN: Dressing changes every other day. Follow-up next week for suture removal and x-ra.y of the elbow, AP and lateral wi_r_h the cast off. DCB . t r . ~`,~ _ I~OV 0' t3 c3 ~I ~ L b . a . o of ~ 1~~ ~o~,,.~, ~ ~ ~ - _ ~~ t~ KRISTIN BROWN I ~~ cc: Graham Medical V ~~ HISTORY: 13 da s status ost ORIF left elbow. SUBJECTIVE; OK. OBJECTIVE: Wound clean and dr N y. o ev~_dence of ~_nfect~_on or DVT. The elbow moves comfortably. X-rays good. ASSESSMENT: Status post ORIF olecranon fracture. Status post calf wound. Both doing well. PLAN: Start gentle range of motion exercises. I will see her back i_n 2-3 weeks. DCB NOV ~ ~ ~ f ,. ~,~- ~ a.. ~ a_~ V ~S~ HISTORY: 3 1/2 weeks status post ORIF:olecranon fracture. SUBJECTIVE: Doing better. OBJECTIVE: Wound clean and dry. No evidence of i_nfecti_on. She flexes to 1300, lacks the last 10-150 of extension. Pronati_on and supinati_on coming along nicely. X-rays show good early healing of the olecranon fracture. ASSESSMENT: Hea1i_ng olecranon fracture. PLAN: Continue adaptive gym. She can run, 1i_ft 5 lbs and dribble. I wi_11 see her back i:A one month. If everything looks good, she can probably staft~.p.~ayi_ng basketball. DCB t • _; DAVID C. BAKER, M.D. 19 Brookwood Avenue, Suite 104 Carlisle, PA 17013 (717) 243-9010 Insurance: Pre Cert Authorization Patient Name: ~~(~ ~~ 11 Y~GI.,~`~1 Date: ~ ~ - i ~ ~~ bate of Birth: ~ ~ ~ 2~ _ ~~ x-ray #: ~~~ ~-~ Area to be x-rayed: ~/1 ~~ ~G~ ~~ ~~ ~-~~t~,~~P o~--~F Fx Radiographic Findings: Initials: t .:_ _. r DAVID C. BAKER, M.D. 1~4 Brookwood Avenue, Suite 104 Carlisle, PA 17013 (717) 243-9010 Insurance: Pre Cert Authorization Patient I`1ame: r ~ ' ~'I In rL~L~ -Date: ~ ~ - 2~ O~ Date of Birth: ~ `- Z~ -~1~ X-ray #: ~~a~ Area to be x-rayed: ____~ ~~ -~' ~G ~-~~ ~~ Radiographic Findings: ____, - ~ C~~CG ,~ , r /i. (? ~ `'~----, Initials: _ _ - -- CE-RLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: BROWN KRISTIN L X-RAY~~: 359904 EXAM DATE: 10/20/2005 ORDERING: LAURA E CRIM,MD 245-5500 ATTENDING: DAVID C BAKER,MD 717 243-9010 CONSULTING JAY A TOWNSEND,MD MED 776-3114 HISTORY: MVA--MINOR INJURY MVA--MINOR INJURY TWO VIEWS OF THE _EFT TIBIA AND FIBULA REASON FOR STUDY: Motor vehicle accident. DIAGN05I5: Probab-'e laceration. P.oz MED REC ~~: 359904 ACCOUNT ~~: 9323518 D.Q.B.: 11/21/1990 ROOM: 0305 COMMENT: There i:~ some soft tissue gas lateral to the proximal fibula probably due to a laceration. There is no evidence for fracture or bony destruction. REVIEWED AND SIGNED ROBERT F HALL II,MD INTERPRETING PHYSICIAN DATE DICTATED: 10/4/2005 DATE TRANSCRIBED: 10/t'.4/2O05 10:27 TRANSCRIPTIONIST: JND 5735088 ATTENDING FAX PAGE 1 0 F 1 _. _. C1IRLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: BROWN KRISTIN L X-RAY~~: 3599Qq EXAM DATE: 10/20/2Q05 ORDERING: LAURA E CRIM.MD 245-5500 ATTENDING: DAVID C BAKER.MD 717 243-9010 CONSULTING JAY A TOWNSEND,MD MED 776-3114 HI5TORY: MVA--MINOR INJURY MVA--MINOR INJURY P. Q2 MED REC ~~: 359904 ACCOUNT ~~: 9323518 R.Q.B.: 11/21(1990 ROOM: 03Q5 LEFT ELBOW - ONE UIEW HISTORY: Elbow facture. There is a displa+;ed olecranon fracture. The proximal fragment has been displacecj cephalad by 1 or 2 cm. Otherwise no additional bony finding based on this single view. IMPRESSION: Displaced alecranan fracture. - -- - - - - -- REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: 10/11/2005 DATE TRANSCRIBED: 10/i'112005 9:59 TRANSCRIPTIONIST: AND 5735087 ATTENDING FAX PAGE 1 OF 1 , , CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: BROWN KRISTIN L X-RAY~~: 35990-~ EXAM DATE: 10/20,/2005 ORDERING: DAVID C BAKER,MD 717 243-9010 ATTENDING: CONSULTING JAY A TOWNSEND,MD MED 776-3114 HISTORY: MUA--MINOR INJURY OR LT ELB04f 2 FILMS FROM C ARM P.D2 MED REC ~~: 359904 ACCOUNT ~~`: 9323518 D.O.B.: 11/21/1990 ROOM: 0305 LEFT ELBOW - TWO VIEWS HISTORY: Olecranon fracture. Comparison is made to an elbow film of earlier the same day. Internal fixation has been performed which reduces the displaced alecranon fracture to anatomic alignment based on the views obtained. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: 1QI~'_1/20~5 DATE TRANSCRIBED: 10/x'_1/2005 10:22 TRANSCRIPTIONIST: AND 5734724 ORDERING FAX PAGE 1 OF 1 • 18!22[85 15:22.48 3ightFAX->~' ~ Ri 'AX Page X81 BROWN, KRISTIN L MS3 0305 D DATE OF OPERATION:10121/2005 SURGEON: David C. Baker, M.D. ASSISTANT SURGEON: 10/21 J2D05 359904 PRE~f ERATIYE DIAGNOSIS: 1. Displaced fracture olacranon, left. 2. Irregular lacerations, left calf - 9 x 6 cm, skin, subcutaneous tissue and muscle. POSTOPERATIVE DIAGNOSIS: 1. bispiaced fracture olacranon, left. 2. Irregular lacerations, left calf - 8 x 6 cm, skin, subcutaneous tissue and muscle PROCEDURE: 1. Open reduction and internal fixation, left olacranon with Accumed olacranon plate. 2. Irrigation, debridement and closure of left leg wound. OPERATION IN DETAIL: The patient was sterilely prepped and draped in the usual sterile fashion after being identified by myself. She was positioned in the lateral decubitus position and the left leg was done first. This was a stellate crush type laceration. Devitalized tissue was debrided. Wound was irrigated. There was n~ growth contamination. Any devitalized skin and fat were sharply dissected. The subcutaneo~~s fat was debrided of any devitalized tissue. At the base of the wound, it was seen that the wounc! extended to and through the fascia of the lateral compartment of the knee. This was debrided. "'he fascia was not closed. The skin was closed with 3-0 Nylon. Then our attention was dirocted to the left elbow which was placed at 9D degrees flexion aver a large roll of blankets. Then a midline incision was made, skin and subcutaneous tissues were dissected to expose the fracture subperiosteally. The olacranon plate was placed on and a 2-0 K- wire was placed through the proximal hole holding the fracture in place. Then the sliding hole distal to the fracture was securec with a 3.5 screw. Two proximal 2.7 screws were then placed. The additional two distal screw;: were placed in compression. Image intensification was used to verify accuracy of the reduction and placement of hardware. Then the distal to proximal 2.7 screw was placed where the Guidewire~ was. The elbow was taken through a range of motion. There was no block to motion of either flexion/extension or pronati~~n/supination. Image intensification was used to verify placement of the hardware and accuracy of tie reduction. Subcutaneous was closed with 2-0 Vicryl. Skin was closed with staples and a posterior splint was applied. DCB/le a: 1oJ21r2DO5 09:10:25 T: 10/2Z/2005 15:18:02 9323518 BROWN, KRISTIN L MS3 0305 D 359904 10/20/2005 11121 / 1990 BAKER, DAVID C Page 1 of 2 DICTATING PHYSICIAN C015Y CARLISLE REGIaNAL MEDICAL CENTER OPERATIVE REPORT ' 1B/Z2/B5 15;ZZ;57 BROWN, KRISTIN L C: David C. Baker, N.D. MS3 0305 D R i' __ r AX Page ' 8BZ ' 10/21!2005 359904 David C. Raker, M.D. 9323518 BROWN, KRISTIN L MS3 0305 D 359904 10/20/2005 11!21 /1990 BAKER, DAVID C - , .~: R i ghtFAX-> Page 2 of 2 DICTATING PHYSICIAN COPY CARLISLE REGIONAL MEDICAL CENTER OPERATIVE REPORT • t i ~r~ i.:AR1.i5L~ g It~1.AL11.J1~ o< « 246 Parker SL CdtlLsla, PA 17013 Ph;717.249•1212 caMP4lcAnaNs COMOR61pITYt1E51 PRINCIPAL PhpCEDUR[; f~~•., t e ~ ,r-.. ~'OWNSEND, ~'AY A ~ ~ ADMISSION RECORD 10/20/2005 II AID6`07A r 8333618I' II OOp03888p4 IIIINIIIIIlIIIIIIIIIIiIIN1IIINNIIIII VIII[r~lII1IhINIIIII~~II811IbiI~Illlli MEDICAL REC~l~DS CaPY I~fI011lIliNNllllllllil~lllllll~lil~IIIIIIIii~iIlN _.-•••••••~••• ••••w••~••• • nn~nn ttntt nn n-t L'l 1/~(~ .. . , _ .-,. r ~ _ ~ _ ~ ~~ ,---,. ~~ t~lisle Regic ~1 Medical ~ .niter Instructions: circle ositive -backslash he alive rovide additional eftinent information. NAM(:; BROWN, KR1571N L .. Pt#: 9323518 DA7B OF SE,FtVICE;1D/2D121705 . . DOD: '11121!1990 Age: 14 Yla 0 Mos 0 Wks MR#: Q000359904 Preg Tima: 15:59 Sex; F Wt: 68.2 t<G Ht: ' '~ Triage Tlma; 15:59 Chief Complaint: MVA--MINOR INJURY T: 98.5 T Medicines: NOND P: 92 Regular R: 20 Untebared Alter~ies: NKDA 13P:132/077 Sa02: 100 °1a Normal /.Hypoxfa EDP: GRIM, LAURA E MD PCP. TOWNS~ND, JAY A Arrival Moda: ALS Paln Scala: ~r,.• ~ • - -° °° ~ •'~" ALOC Ir-toxlcation 5eveti Unreliable 6zattl;.Tlmer (G° ry Hx kiy ati I Famll NH Translator Limited by-, ty G ! C ! HPI: (Narrative): co 1~ N E, ~ tea Emer eat ,~1 ~*- God , ,•~-~ .-~*-~-~-c...~ U-Z-- -~i-.~-~. ~.ar-~...-~.- . ~-~•~.. ~..~,..~,~F' Titrmtng: Sx starts sudden! I gradually ~"~ / hrs. I d k a corftlrNOUS ntermittent Quratlofl:' Sx lasl ml hrs. / da;/s / wks, at a time prase sent L:gGitJo11,'of Injury: head face nE~dc Chest back abd upper towers I~ quality;' Cannot deserl4a fail /height _~ ft MVA crush Injury punched kicked G5W stab wound Severity:: mild. moderate severe t-10 scale _ Ilfe threatening ~~~ • ~U Cootie acdda assaulted MVP, abuse found unresponsive ExaceCba d, by: nothing mo ma pal"' pa lo~t~'~i ReheVed. y: nothing r st Ice OTC meds ~_ ... Asso~c.8igns'&•symptorns,: none y9G"irE:f': ' ab in • sading Lir~ylfed~t)ue;TO:- ALOC Intoxication Severity Unreliable Contstltutlonal: fever chills weakness diaphoresis NeuroloplcaL:, HA seizures weakness confusion EN1't sore throat ear pain facia( pain Psychological:. anxious depressed Eyasi; pain visual changes Endoc'tJtttf~ polyurla polydlpsla Cardlov8scular: C.P. palpltatlons DOE PND Ihtagumetllu, rashes pruritis leslon9 Respiratory: S.O,t3. ceugh cangstlon HemB'tologic4: anemia bleeding disorders transfusion GI~ N ! V diarrhea / Constipation pain melena hematemesls Alfer~yllmm ~. frequent Infections aflargles hives G1,1; flank pain dysuria hematurla' frequency Qther: Mt19CUloakeletal; joint pal`~rnack J back pain exL pain ther Syslams Reviewed And Are NegaNva ~ a r- Medl, Hx; none IQDM / NIDpM asthma ~ Reviewed Past Med: Hx: NpNE Mads: NC7NE ^ Reviewed Alldrgles; NKDA (] Reviewed $urg. one Ap y TonsillectDmy Fatally . , . R / L Handed Lives A14ne: Y / N $oc:jgl htx:~` day care 5tuden cctlpatlon: TobaGCC: cks/Day ~ Years ETON: Y / N DrinkslWk. Drugs: Y / N Imntunlzatlons~ Up-to- Y 1 'Cetanus: under 5 ye Reprodtictive,Nzt: LMP: G P AB P-'l~-MED Maximus PedMtrlia - Trauma -rage 7 of 2 @CODYhCM 2001 l+gmEt) GINCe~ SYAUms, LLG~ ~°w' ~~ ^_ ^•^^^ ^' "' '^" •••• rvn•1n n~1.1 ^I11nT n"'lll 1111 /1h .ll ll 11/\11 (~fl l1~ L-7 1(~/~ . ~ - ~NY~tr1oN•~nrtal,AC~IreTanxl Cl A - ~,. Carllale ~'-onal Medical ~~r ~~str<"~ NAME: BROWN, KRISTIN L Pry: _ _. ~, iositlve - bacfr~ ne ativ~~u ssa~~~ a M12ak: t3ENERAI.d. NAO rate / serere distress~~~~ ~vIT• HEEN •: RRLA EaMI CV RR. MI NL murmurs /6 sys / dys rubs dicks gallops 53 / 5~~ I~SP,'', u~ ar/ qual bilateral Hasp. effort NL /distress roles rhonchi wheezes fit ~ a bowel sou,ds NL l ABN ender on-tender guarding rebound rigidity ~1j4''tn~v M5: ROM NL u bing cyanosis edema ,~I SKiN: wane • dry diaphoretic rashes NEURO;, GN 2.12 intact D7Rs equal ~ symmetric . _. ...f.~1-1-1.~~~- PSY.GH: AAO X3 playful ! approprlale for age r P 92 R 20 iyyu h...-w1 pertinent information. 00003599D4 t3P 132/077 LocatlonlDescrlpdon of Symptoms: ~".'.''`\ ~"t ~ ~..~ l,. r 1 ' LYMhHs adenopathy GU: NL 1 deferred ~,~ ~~- Other: .•• ~---y.~~ ~~~ [] Labs reviewed and era negative X-Ray: Gsplne: _ _._.. .._ •~~ CXR: NL /ABN NL / AB V pelvic DIFF 3 C,T.: head / ahd !pelvis 9 t:KG:NSR no acute disease -~ - ---- L ... ... _ . UA: SG Pt~t R8C5 WBCS Pufs® OX: % NL / hypoxla UCfa: +/- Other: ABG: pH 02 C02 pd~C:: concussion Cervical strain F.~c laceration hematoma skull Fx pneumothorax shock spleer 1nJury contusion child abuse other: 1. ,awe .. -~ o _ vz~s~.-a-.cam 2. ~ ~ / - 5. MED3: IVF: FOLl=1r: NG: RE-EVAL: Time: Improved Same worse Critical Care: 30-74175-90 ! 91-1041105.120 1Z1-134 f 135-18A Minutes n Pxcl. bfll8ble pros. Discharged to; Homs Nursing Home Family Follow-up with patlent'a Dr. In days. Other Inetructlons: Discussed wi4b-Dr. _ bisoharge Tlme Out: _ Admit • ~,~~~~ ~ Admit: OBS ICU PCU Floor Tele. OR PrescrlptlonSGlven: c low-up in 0 Ice 7ranstar: Old Records Reviewed Y f N AMA: Ravlewe Ist Y / N DDA: Cana /W patient 1 Family Y Condition: Improv d Stable D eased REtURN TD ER IF CONDITION WORSENS. Signatures: Prla-MED Maximus SCopifghi z°at )'rrL1E0 Clinical 5lwtome. L.L.C. ocedure form attached MD~D Rocord CompMta Pedta - raum>x - ~'Irge ~ of 2 Rau. °H°G/°d rv ~i..~n~i. Mini nriii iiii AL .l1 (1 li/11i 1.11/1'1 L-1 1/~h Of~'D~"R P~CEDURE F~RI'll~ - ^~--' '~.. isle Reglon~ "~`'4edic~l Genter ORTP~iOP~ . C EMERGENCI'L.~ h. ,z:BROWN, KRIStIh ~ !-M.9323518 Age: 14YRS D09:11/2111990 Sex: F MFt#:D000359904 r...., ~.,. an~nninnne ~mo• Ff]P~ c:RIM_ LAURA E MD PCP: TOWN$END, JAY A , . ~ - Y Y ^ ~ EMERGF~Y QEPARTMi~~' ~ ` •```Qrl/sle Region ~'~edica! Genfer aNra-N.. NURSING ASS1°~~ NfENT Na1~~a;gRpWN, KRISTIN ~. Pty:9323518 Age:14YRS DOe:i11~1l1980 Ssx; F MR#:0000359904 Date: 10/2012005 EDP: CFtIM, I.AUf3A E Mb PCF': TOWNSENb, JAY A itQll. ~f •~;.,: ~r~~_~ a+g~ll'~~1~ '~ k;11{1'S'',1`~" . err"I~flil?~Cifll~N'•'i '~. 1r~ tt... ~tP(.. , ~~"t' i~'tiri,• "~ ~".. , :'li .~,•', ~~i1~1~~'":.tryf/i 1 I ` '`I~a 'rt~,l ~~~. , 4 f 1' Airway Clearance, IneffeCllve Gommunlcatlon Impaired Infeotlon, Potential Sslf Care beflclt -Anxiety -~Coping, Ineffective -Inf uty, Potential -'Skin Iniegrlty Impairment ~9reathing Patterns, ineffective !_~luld Volume, Altarallon in -ICnowledga DsFlcit ~'hpught Processes, Impaired Cardiac Output, Decreased __Cas Exchange, Impaired ~Mohility Impaired Thought Processes, Alteraton in !Comfort, Alteration in HypeHhermis (ever) Non•Compllanca 'tissue Perfusion, Alteration In Other -- Other Vic. Yy 1 L~ ~~~~ ~ 1. ~ t7 ~~ ' '•y ~ -t, ~r ~k L Y yN~ L ,., .u 7 r~ I~,~ '- I~ 1 '2' '! ii Q~ ~ Bi ~ ~ 1 I I' ~ B IFI I Q '7 4~ i ~tf~l 'r F u -~~q f~ . ~llli,=1 { ,,~,,,I I'N' I ill ,N,~,.~ N 7 '1~ l~~I 1.i i~l Net NO! Not Met Mnt tnt Met Mqt tnt Illel Met Int [7 Fe REMOVAL II IMMOBILIZATION / PRDF'ER ALIGNMENt II IMPROVEMEM' OF t3REATHING Ca BLEEDING CONTROL C7 DECREASE / PREVENT SWELLING ^ STABILIZE PATIENT IN DISTRESS C] PAIN COiVTfiOL ^ MAtNTAtN STABLE I1OA4EO5TASIfi ^ meet ENVIRONMENTAL NEEDS ^ ALLEVIATE NN ^ MANTAIN SKW ~ nssU~ INTEGRITY ^ meet PSYCHOSOCIAL NEEDS p FEVER CONTROL ^ PREVENT FURTHER INJURY II moat SELF CARE ABILITY NEEDS Cl DECREASE ANXIETY II MAINTAIN i IMPROVE GIRCULATION d meet EOUCATIDNAL NEEDS [7 SAFETY IN THE ED d INFECTION CONTROL ^ D1har Int: N = docurneMatlon in nurses notes, other'cgdat;' per Hospltpl Policy. ir'i:`liL:~rl;@^;i•~'I"~=Ngl.r•,!_?n{G~..Slgt:{Ijt, ~' • ,+ """"•~.", B ,rlnrl:'i41' : i'. n!Iq! ',;t-~rl~ : a , ' ci, .I !1~'`J1'I V_, ~,•; ;;. : w~. it9"~,,, Gl.' C161' t f r .' '' d: 1CC !~ ,: 1 ,,,, il~l• 1 ,4 ~ t~{•~. ~' '•,k!< I IY, , N 1. ~?>-~, .1. ~' Nt, . L..I; ~!( p~,{"r a,~u~~a~! .. "lip ' y' 1' t . '"i~' :I •1, try ~. :I P'I,I' 4'. I , ~ I; L; r,. ,~i , nlll,•~i ,'~` 1. rN ! .I~,,f I~ ~ '5,,, ;I.I!!J'~' '~r'~:r{~ ,I~-` '~' I' r r;~; ~ I Ili,, , w ~I, ~~, ll, ~.~ ~I„ ~r;N,'~~~"'1'J''i~l~'{~t'i!~~i~ III'„ I%I ~'iF~ lrll~ ~J'~~y~I "'r11:~,1'`f '~ 1 LII,{d 4l~~~'tI' • '1J~'F,ltl1,'f.~ ~'~~r ~~~, ~I:,Idi,,, '~ p~~J I ~1 fi ~~B `~ill~ r , I. -;lIJ ..~ hl! l'iN ! i.-LJ r ~ o. m~F.. i' li I, ,'!:1 . r 1 1 i !r a r ~V 4~ ..i f'. I 'r { .. I c,av 'Dr . COY,-, ~ ba~sl. d.~ . ~~ ~~ ~... ~ ~ ~ d ~- c- c_ol ( c,a~S t~'-e..,~1 t_ cc~-~-~-~. ns o rc:~~.. ~ . o I `,1+,Iih'l'1~lj+lt~llrl•Ill l'-jl'~~~i '~„i~,i,fN ,~ ..,, Awn ;1'1~.•~, ~ r I>ri" g Ir,~' 'r{~dli'lyf 1 a'+'Y t ,~,li , I,.'i. h•"4 ,i:,-•:!~a;•r ..~!.$i• ,~ ~1~~p F .;ii1l•~'ild. 1~'r~,l~l~~ t:~.'r. bischarged in care of:~ C] Amb II WIG d 5bet II Carrlad Discharge instructions given to [] Verbal<zed understanding ° -~ Admit: Raom #: d~to Dr. ~!~ kQ~ Ready for Room Time: Report called at and given to t Transfered to ^ Transfer Vsrlfled r- _„ .Report called at ~ and given to ~ Left without treatment p Left A//gainst Medical Advise - Condition at Disposition: ^Improved P7Stable ^Serlous ttExplred Pain Scale: ~ >5 Fain Location: Patient reports that pain ts: proved ^Unchanged ^ Worse DlsposRion Vitals: T ~~ P ~~ R •~- Bp I ~ g 2D2 ~,,_ mm Disposition Date: f ' Zn Time;~Atarse - Rev. o3lD5l04 nn . , nnnn ni.--, i r , ,nu rn, , rvm,n n"'fV '711/1 T n'll i I1f I T F, . Ofl AI(V I r.nrr~ 3.7 1 /1/1 •••~•_• .' EMERGE" ,~Y DEPAR7'MEA-T '--'• "-'`'.~r~lsle Reg14-;r`'Ufedfcal Center PEDr1ATRj~. NURSING ASSI:a.~MENT N°- 'BROWN, KRISTIN ~ Pu..,323518 Age:14YRS DD8:11/21/1990 Sex: F MR#:0000359904 oats In•+ni~nr~nns Time' a , ~r EDP: CaIM. LAURA E Mb PCP:TOWNSEND. JAY A Subjective Notes: . ,. •~....~ i..,. , • .' R~F..pr,r~ ' n ` Jn ~ , -~ ,;" ;r k;,pn,.: "h" 1 ° , ,~'1'v. "' ~y~iilfll~ld A}I'r-,),. I: ' ~7,lyll 'tt I+i, :. u ~J in, p 1 ~y~, ~ ur. ~; ,fir ` y u I 7r 1~ ~`~i h ;Ji n~. R ~~ 1 ''~,'~q'i' ~I oil L„ rl ~I+ ,.1_~,.I ,I," r(,~I r!.~1, a':f fY,'1,1 ~, r : ,1 11: , 1. . 5~ l;.L 1 `• 41~ ~ i r~l: '~i'' 2 rR r . /' , , Y' , r~ P Lri PCI i' ,rl,.~ 1 ,Ni. 'F. al t.u it r.:~,a Looatkon: ~t,L_F Cdualit,': harp DC)ull dCramping DBuming t~ching O Rating Scale: /d Mode of Onsei• udders ^ Gradual i9 Intermltteni WONG/9AKER FACES RATING SCALE Onset Dale: Time: Dl9atlon: _ _~ ~ ~ rte. ~+ ,~. Onset ~ 24 hrs. medical attention Wes sou ht? ^No dyes bate: n l"~ Radla.ting: CtNo ^Yes (9p~ny1 p 2 4 fi 8 10 f,,l., ;. ;.w+,,,;~ ,•r',4' N ' "+n ;1 rrn,"4; .a . 4' . ' I. r. ~.ry p,l, -,..,L , y ' •„4 ,rr ;y,.. ', lr L t ~r"'+S"''';.'r ., ' ' !nl y9rN" ~ iii Ng4`dl fittJyy !f)"„ .qt h u{';; ~h„f z"P,,~~.. h'"' ;,, 4~!.~)r; rJI1Pr,ih ,; R'r rifc,lll.!~n"fl~,1~6~1, ,1 d., ~"! J9~I± ; ?1r~S~,i.11 L'Yi,;,i; ,II, ~?ftliJh~ll f ;,11~;,Vi~:f, ,~~` ~ ,,I•a~., ,q;l i .,, ,i R !~,/I, w,,.,4sr!>~h:I -:r,:,,,li ,r-,.!sir, I,. !(, I I. ~ , Il IC ~:~! L . Vii:' 7, `~P•,.... Caregliver: ^ Parents~vlothar dFather p Other: Envlrpnmant p No steps 0 Few step8 d Many steps Accompanied by: Nutritional status: ^Nvrmai D Csohatic d Obese Appearance: ^Glean DUnkempt C10ther Religloua I Cultural prefetettce: dNone (avedNl Activity level: pAwake dPlayful ^Smlles /Laughs Best learn by: (pt /caregiver) t7Verbal ©Written pReturn demo pother Leaming Barriers: .,,,,,...... ..,I'aruL(':r,,x.,,,,.{:1•,•,.•~J:}rS'r'[~I~III';i,;~;+ •$r;L';'.'.L(+,!F;i :,;y:+k',y~'%p' .R;v~+~,f:.w'.-',,s',ji;'''.i;t'`'t+"~i;r:"~1'r%'' 'I. ..~-: .. i e B L~ ~. r, ,-:, ,;:; be ~',. i ,,:,, ~,,, ,:~~hr.,L,,.. E.I1~~.., .,,:1',~hr,,~,•rZ'~r,l~!.II,;II;,;;~~!ay,..f;.,,alr , p(Irh,;~,n1Yt.~TI.. ~~+. ; 'i~,.~r i,,r6'~11' .~,,,,I!~`J ~.t,)1'~~~L~,r, ;.t,alh,:,:4: ''!Ilra_;!,...q,~.r ,II'.,,I:`( ~ILI~L; :.L1'J> 4~ 1~~,:, . ~~4~, 'f':. i i A~(jfaJ(d,'~,yp~,4 ~}ytd~k 4 ~bd$-~tIN~ Y~ ~f e;~pil+ I'Cy L~tl'taryyl~ Ili ~~: +r; ~ Abdomen: CI Soft C] Flat ^ Rigid A Distended ~; r ' I r 111 ; i, r,. , / L - Ih ~ r , l , l „ "-I , '' IrJCt~~~1~~Rr ! 1:)„` ~ t~l~br~~gte~l Iq d;1:U~i/tl1p';yFw,~~ gIM,~, , I I,~} ,Ih n ra~pi~tl'L ItJ 1` ' ' , a,. (~1 .J~ Cl T nder Area ' ;ill- i ..I{'~ r,rn, .:ai' 1 . , ~. x w '''f +; 1 .'I °~Iti '.~1 J ; ,n,-`; ~' 1tJ~ ~ ;.'!n:~hJ+ D Non-ender 9 ( ) ;%:~ ::;. ',.~ril!~ J „i• ~i!I':'tt`"!+'"1L'1 i;~~~~'I'I`,;J'tll,.l!r'~;''~~i~.•h7it'cCia71"i'i,'i.~{IFII%ijl,N!~)~:~~:~.,IVGI,,:~!~_,ufi!iir; ~',II~Rh :I~11__ ''~ll~;~C®q Cti~tl~;~'~' J•1:1.~„1 ri. ,~r o-~. ~;li,l~.h,n:'.Y..,tvlwnl'll°~ri k~,~~r:4!!. ,~, '~r,~~,li ,..,.' „, .,,,,, . ,, n `'Inl Bowel So nds: ^ Pre ant D D t '.,,w. ,:..:, r ,:...,.:~,_p.r+-.;•:r~~.,..;::.~..,~iwac, INT Gi I:h,!. ,au. A. .u, u s ecreased ^Absen :, „ "~C1k~ t' ~t +1G;;!i''1"rh'+: "I~il~ 'ul';{P' 'ry!.' r, s^';tq; rrt"r:'•r u, L;li.'I • r•,• Ellminatlon: D Normal ^Constl anon ^Dlarrhea # of Stools: ••R ~~~~ r , ! ,yf~i~~ll '~~ti+~;G~'ll) ,r Jli, ;'~~7q!1~11.1, ,:'yy t+~ h~l~' ij•'J P ::~~ ,i 4 ,,, :I C1 ~rti r G ~l b~i'f+, i I ~ , ;OGt 6 i 7J ~ L I ll 6 'QIk1 , Q~,OI~~. , °~(1 Jlui"G;, I r •', rn L;•', _r~r p. , -p,,r; ,y n • v r , ''I, I I , L' • C u,; ,! I,,,, ,,. ,.,, ,,,. 1< .'..,. ~ f ;, ,,, ' •; r :~,L: ~t11i~sY'Itl . ~... ,, ~ , r, i F ll~ , , ; t.. , , p;!l, Wyk 1,;..1.a. %rt '~ . ~ r, „l ,.: ,.,, . , .,., , , ,,., 1. ;~ h ,,~ ~~! }.y ~L., ,.i!! ,t! :; h;,h~~'~' t. 1. ~~;',.. ~~. ~ .~µ,,. ,,,,.y ,~ ~r,:,..,,'•,,,u,,,:~n. .. :, .. I+C?d.b_. ~J,I, .,,N, ~'I ~+Ln f~a;~. i,~'Y'~.,.a~•. ,;~, 7r.. ~;i~.r Ael. ,},rl(;~a~~.l..l ,c ..,.. ,~...'n~~. . '-r1~9~i~6~l~c~'~J/{9~'f.,rt:_il:it~l ,i.~~ ~iyl~.: Y ~1:"`;~~~>~~~~~^i~i'r~i Vol In Continan Dlncontihent dDla er DPot trained li:i' tr:°e.,.i:!~,.,, .., .ev,, ,,'ui,,G...,.e~t,,,,, ~Ia.J:.-,1~~,u::r,~.,u.4!r,,,;lt;~1r~,i~a...,.,~,,,t,n-~ir~wLif.LflL:~t'S~,rmc~l~::':Ir,a~„I.,u.,, ',.;iii 9: C7 p ~r ,,, Capillary Refill: D <2 Secs (Normal t7>2 Secs (Delayed) pbysuria dFrequency Color: Turgor: D Normal Cl Decreased Other flndings: Pulses: L Radial: ^ Present ^ Absent R Radial: ^ Present ^Absant "' L Pedal: p Present (~ Absent R Pedal: (']Present ^ Absent - y yL •!;'„Ifhi!ih i `'~I1 LIIi4 ';, ' a , n;: ~?"~,74~ it iti+;J;ql ' R '.'l i nr' : it iii' Ir n..,,, 1 Lmq. r •nyl q ply, a w L r'--rl ;t" if Vin. 11`~arY,1{,rLl,,..iil~i?:~':~I+~biit~. J ~ .Ilf1..~.~1.•y+~~Lrlli:,lrl,i I,~,r~ Ali 4~ ~.~`t ~1' I.. ..I;1yA,; L!%('C'~,J;,.~~'~'• rll~; J' i. 1, y ,.. '!1'~ lli- ,lr. •"t~, . + ht ;,l , li~yl ~ i `-i:l;i1(i I! r;qr ",f I:ii!, "Jl li=„r L;i: > I:rt L'" ;4r~LGi'"'I~irry,rq I"u., ~ r e~ ~ , . ~t .~w ;, i ~ „~-, .q,,,,;~,;:.1: ,. ' ;i,. ' 1 ,i~~l i .-t. , ~ ~G ., a!, ~!~:r~4,, n n ons ~~~~_ „i la r. t ...,I.!., ~c. 1, I.„ >7,~ r Laceratlo s I Abrasions / Co tusi . n o-r,~.; .'.i..!" ,!,~;' ~.ar;!; ;~ uw! I~:~ ~ ( Location- rii,; ' 4 Ill, +;''~1 nld"10' ^ I ,,, I ,:F. P: ~,~ I r i i:il{:i .; ,•'r,,.r~ . ~ C , t r ~', lulilr~~;'1rl',' ~ ~ r;,;,i;rr:;a, i;.,:.,.,r,: 1iPl L '+;~!!til~,r'P'-` i~ , 1; °t'M; Il') ~~y~ M~F.p "I,~ ,71t „'~( ..'r~~ ii;a(' ',r6t~~ ~ -.-_ I' k , I + t ri iul jt,,.'Ii ,r:,~~'q,h! ~ I °;:rL:t„p .;I t1;'i;,r;_~JS.~i1;~;~~~' ',,,tk~' NS~;Ia~!~• ~krLLr'``;;G~t! ! ~ Ali tsUiln: ~~ h: ~qi;'!"' S1ze: ,.f ~. 6n1';. . d•bq , , C ~;y,t,..~ ,1 ,r ~~, ,,, 1,l~ ., : ~, n,a,,,~nd..lti~ nn'•;J~ ;~,L?IN~I u r .oil J.,--. niti' ,- , Cough: ^ None pia Productive ©Non-Productive Bleeding: C2 Absent p Present ^ Spnt D Moderate ^ Hsavyd Pulsating Lung Sounds: ROM: ^ WNL D Decreased ^ Absent ^ C%I®ar D Wheezes d Rhonchi DCrilCkles d Diminished []Absent Edema: ©Absant t31+ D 2+ p g+ Dafprmlty G Yes ^ No ^R dL ^R DL ^R dl C]R ^L ^R ^L DID C)L Scars: ^Yes oNo Distal pulses: ^Absant OPresent `II,( ,., -1,- .,•,i .... .:. .... ...: rL;e ;{•.. .. `cr + m r a y r.r ~ 'r'. :r. ~ri+ tin I!~ : ,~. Hpu a 1 „ ;Gfk~.4~tk;ktl~abd~S, ?hy,~:1~~~r. I ~~~t91 !Y ~aJ 1 {? I~,.Pt(n~~' ., r,:l•,i t lq , .y~r,' ,,rr 1 ~ I' f,. v N?;>a t,: ,k, ,r "r !ShIAn1~'rt.c ~_,~.r1 1 r~,l,l~i,l ij;ii, Ill,u.,h{,'~~~~.. , R'~i'd~,l'!!,}:11~~ r',h;?~+If~4r;n~1 ~ L~' y~ .,~lll rh,!=1;i(?li:; ~11~4J`,rl~~ .L ,ti • Li• . I ~!1+~.• ., ~JWI.'~,,.~1. R ' l.! i I . '..1 d ^NEW BORN Aso o • + Month ^INFACt't + • +z monlhe Language: ^Crles Often ^Smues ^Coos /Gurgles []Babbles born at Tarm: ©Yes ^Na Delivery: ^Vaglnal CJC-Section Diet: ^ Breast Feed ^Formula type: Usos: Ot3attle ^Spaan ^Cup Elimination: ^ 3 - 8 stools a day Other _ „ Activity: Lifts Head: C~Yes C No Slt$ up: ^wlth help ^ without help Crawls: [d Yes ^ No Teething: C7 Yes ^ No Observation of Intsractloh with Caralalver Is d Appropriate C75ee Nursing Assessment C]T~QDDLER Aga +• 2 Yeare ^ pro-S Chool Aga a • e vaars Language: ^Few Words []Sentences C7 Easily Undarstpod Diet: ^FingerFoods CReguiarDlet C7FeedsSelf Uses: ^BotGa ^Cup Teeihing:ICYes ^No Elimination: ^1 •2 Stools per dal' ^Dlapars ^`Coilet trained ^Wets bed: ^ Rarely ^ Occasionally ^Fraquently Activity: Walks: ^Yes ^ Nc []Walks with assistance dWalks Independently Observation of interaction with cat'agl ver is ^ Appropriate IDSee Nurslnq Assessment ldSCHOOL AGE Ago 8 - ++ Yeare DOI_ESGENT Ape +z • +e Years Reached Puberty Yes ^NO Learning disability: ^Yes School grade: C»et: CJ Eats 3 meals/day ^Eating disorder: (speoify) Wears Braces ^Yes ^No Eliminatvn: ^ No problem reported ^ Wets bad: ^Rarely ^Occasionally ^Frequently Social Habits: Smokes ^Yes C7 No Us Alcohol: d Yes ANo Uses Drugs: ^Yes ONo Clbsarvatlon of irlteraGtlon with caraphrar Is Appropriate ^Sea Nursing Assessment Viti31 Signs: 15:59 T: 98.5 P. 92 Regular R: 20 BP: 132/077 Nurse Signatur ~ ,~'~'- • ap,,, oarosroa ~ - ... -. _ ~Nrr-ac,a~^ ,FSSMEN~`~ORh'' ~'~ ~` ~ ~~~yarlisle Region` ~'Nedicai Center PRIC)RITY: ~ Patieht'. BROWN, KRISTIN ~» pt#: 9323518 Uri@nt DDS: 11/21/1990 AGE: 14YRS Sex: ~ MRil; 0000359904 EDP: CRiM, LAURA E Mb worker's Gomp: PATE: 10/20/2005 PcP: 7c3WNSEND, JAY A Emp. Referred: ..,. Preser+tatlpn Time: 15;59 Triage Time: 15:59 Arrival Mode: ~-S Height: ~ u Walght 15D.u lbs. 68,2 kgs. LMP: Last Tetanus: under 5 ye Acc gy: Mother Chief MVA-MINgR (N,IURY Complaint: Brlaf STRUCK f3Y CAR. CN L SIpE. PAIN 1N L ELBOW, LLE AND ABRAI61CjN TO R KNEE Assessment: NIGHT SWEATS WEIGHT LDSS ANOREXIA SAf=ETY RE5TRAINEb DRIVER AIRBAG DEPLOYED VitelSi 8 T: 98.5 T P. 92 Regular rt: 20 Unlaboced BP: 1321077 D2: 100 °!o FZA Pain Inten8lty SGale: 5 / 10 Psin Location: Multiple Areas Sudden Onset: Pre-Flospital Treatment: Pediatric G81D App. for Age -NIA, immunization UTn -NIA, Height it in., Head Circ. -Grade - ,with Mother A$S26Sment: Past M9d1c21 NONE History: Allergies: NKDA Medicines: NONE Nurse Signature: ~.~.~ ~' SEN Additional Notes: '~'- _ ~~ ! 5 ~-{~ - ~ ~ti[ Rev t?5l143/04 -- ~---- ~~.- - ..~.. .... rn..n nn.• nr,ni nn,l ,111 nL A/1 11/~I1 (+/111-I L'-1 Il~l1 NO NO NO ND ND NO No HEMOPTYSIS NO FEVER Np ~~~ti } ~ r ~, ie Auto Insurance saFE avro 1/__,i/2006 1~ : 3~. AMAPAGE 2/OG Fax Server AUTO INSURANCE POLICY DECLARATIONS Policy No. PA00315655A-00 Policy Period :From 09/2D/2005 10:23 AM To 03/20/2006 00:01:40 Standard tim[ el the address of the named Insured es stated herein. Ttu9 Amended Dxlaration Page Supersedes prior Declaration Page Issued on ~~~ NAMEo W9URED: Endorsement Reasons: ~ ANITA D DEFIBAUGH Added Exd/L.is1 Driver(s) 1845 WALNUT BOTTOM RD Endorsement Effective t0l09/2005 00:07 :00 ~~ NEWVlLLE PA 17241 +~ IF YOU CARRY COLLISION COVERAGE FOR DAMAGE TO YOUR AUTO TN15 POLICY ~~ PROVIDES COLLISION COVERAQE FOR RENTAL AUTOYOBILE`3, BUT~OONNLLYY ~ 7HE RENTAL YEMICt_E IS RENTED A6 A RESULT OF A COVEReD LOSS. P~eA~FA~TE TNAT THE DEOUC7IBLE AND ALL APPLICABLE POLICY TERMS AND LIMtTA71oN3 APPLY. ~~ ~~ Thls Declarations Pagc along with th[ Policy JarJ~at (Form PAt 010/1298), your signed application (Form PA1000/Of;'f)0) and any andorsem[hts/torma listed ~' below cgmpletn the about Pdicy. ~~ The insurance afforded is only with respect to such and so many of the following coverages as ate indicated with respect to each described vehicle where appropriate. Th[ limit of the company's liability agoinst such covorage shall be as ,fated heroin, subject to all the terms of this pdicy having r[ferencs ihento. ~~ VEN ~ YEAR MAKE MODEL BODY TYPE SERIAL NUMBER SYM 7ERR DRIVER PTS t~ ~ SON ~ ~ ~ ~~ COVERAGE BODILY INJUflY 5 E D TOWING AND LABOR LIMIT QF LIABI~Y $ t5,0oD EACH PERSOW $ 30,000 EACH AGGIDEN7 ~ NT YEAH t ~~AL DISCOUNTS PER VEIiICLE: VIOLATION SURCHARGE PER VEHICLE OTHER SURCHARGES PER VENIGLE TOTAL PREMIUM PER VEHICLE TOTAL POLICY PREMIUM: " " 6 MONTHS PREMIUM + " ` VEH 1 I~ r r 0 In witness whereof, we have caused this policy to be executed and attested by our President and Secretary and countersigned by our licensed agent on i/29/20t76 (.a Jon P. Dia rid April D. Miller Countersignature of Licensed Agent President Secretary Dale issued: 7!29!2000 8Y 5423 Form PA1020/0202 ADDITIONAL DRIVERS: ALLEN BAKER Fx~i~ r-!' .~ CLAIMS CENTER - PO Box 182384 Columbus, OH 43272-5507 - ~ ~ 1-614/231-0200 AGE, 1-800/SAFE-AUTO o~PAi~. 1-800/723-3288 Brian C. Caffrey Attorney at Law 26 High Street Carlisle, PA 17013 RE: Claim Number: 23485 l DOL: 10/20/35 N/I: Anita Defibaugh Your Clients: Kristin Brown Dear Attorney Caffrey: MAR 1,8 2006 March 3, 2006 I am the new Claims Specialist assigned to handle the above pending claim. I have reviewed the information you presented to Safe Auto with your demand for policy limits. Our offer is $15000, which represents our policy limits. We have already forwarded a copy of the declarations page previously. Safe Auto requires probatE: court approval for the settlement of a minor. Please begin the proceedings for the judge to approve our settlement. Please let me know as soo;i as you have permission to sign our release and I will forward settlement documents as soon as possible. Sincerely, uri K. Sellers Claims Specialist 740-965-8876 1-800-723-3288 extension 6034 fax 614-559-5436 s ~xk~~ ~f E m Mutual Autatnoiblle Insurance Company estate Farm Dr rcordvil/e PA 19339 NAMEDINSURED BROWN, ERIC M & 7ANYA L 188 CONODOGUINET EST NEWVILLE PA 17241 38-6278-552 E ~~~~ DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. SEPARATE STATEMENT ENCLOSED IF AMOUNT DUE. R 52022-5-E MUTL VOL DECLARATIONS PAGE NAIC# 25178 POLICY NUMBER 686 3461-C05-38M POLICY PERIOD MAY 12 2003 to SEP 05 2003 STATE FARM PAYMENT PLAN NUMBER 0045517313 AGENT MIKE SHOPE 812 WEST HIGH STREET CARLISLE, PA 17013-2706 PHONE:(717)241-3029 YEAR ! MAKE MODEL BODY!STYLE VEHICLE lD. NUMBER GLASS 1997 DODGE R{>M 1500 PICKUP 1 B7HF16Z9VJ545483 1 B3H502 SYMBOLS` COVERAGES PREMIUMS 1997 e o" ' Se Ic i o co p y f r verage details. ODGE A" Bodily Inyury/Proc~tty Damage Liability . 9 Limits of Liability-Coverage A-Bodily Injury Each Person, Each Accident ..... ,: _ $100,000 $300,000 , Limits of Lability-Coverage A-Property Damage Each Accident $1;Q0,000 C2 Medical Payil~ent $17.23 Limit of Liability+-Coverage G2 Each Perso~~ $1 ao,0ao D Comprehensive $34.89 G50Q $500 Deductible Collision $47 :55 U Uninsured Motor Vehicle $2.56 Limits of Liability-.Coverage U Each Person, Each Accident $25,000 $50,000: W Underinsured Moto. "..~.._~_ y. w Limits of LiabiG __ Each Perso~ $25 b00 ' ''Tot` a N O N -IMPORTANT M~. ~ ~ ~ °-- Your policy c~ ~~ those issue r-N~ ~g~ Replace ~~ ~Q Yo' ~~ o~ .~ X- ~} 6 j . State Farm Mutual Automobile Insurance Company , One State Farm Dr ~ ' ° Con:.ordville PA 19339 NAMED INSURED BROWN, TANYA L & ERIC 188 CONODOGUINET EST NEWVILLE PA 17241 38-6278-552 E ~~P~f DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. SEPARATE STATEMENT ENCLOSED IF AMOUNT DUE. -` YEAH MAKE 'MODEL BQDY STY 2002 CHEVROLET TRAILBLAZE SPORT WG 07925-5-E MUTL VOL DECLARATIONS PAGE ' NAIC# 25178 POLICY NUMBER 671 0453-D18-38J POLICY PERIOD DEC 17 2004 to APR 18 2005 STATE FARM PAYMENT PLAN NUMBER 0045517313 AGENT MIKE SHOPE 812 WEST HIGH STREET CARLISLE; PA 17013-2706 PHONE: (717)241-3029 E ' " VEHICLE ID DUMBER CLASS 1 GNDT13S222140657 1 D3H502 .S COVERAGES PREMIUMS 20 See olicy for coverage details 02 A . Bodily Injury/Property Da-i~age LraE3ility CHEVROLET Limits of Liability-Coverage A-Bodily Injury .75 Each Person, Eaeh Accident $100,000 $300,000 Limits of Liability-Coverage A-Properly Damage Each Accident $10E3000 C2 Medical Payments Limit'of Liability-Coverage C2 $22.26 Each Person _: $100000 L> Comprehensive - U'500 ``-$500 Deductible Collision $55.37 U Emergency Road Service $87.23 , U Uninsured Motpr Vehicle $1.21 Limits of Liability-Coverage U $2.58 < Each Person; Each Accident ; _.. . $25,000 $5n nnn W 'Underinsured Moj Limits of Liar' Each Pers $25,OOn F FunerF' Lip a c u'~ N 2 J ~,~ O ~ V ;~ Zi ~a ~¢¢ N C a~ } J U o~ ~`~_" 1 t--~ ~n J moo; wrn o C.JN ¢ d. ' Oo y~ _ w QNr-+NOON Z ~IOM°-+ ~a N~ HOO.-iQ12 L1~lDlOlDI- p~ _ ~x~, d r~ ~ a r ~ _ a ' _ t ~ , t% ~ ~ t • .__ State Farm Insurance Companies October 2, 2006 Attorney Brian Caffrey Saidis, Flower & Lindsay 23 West High St Carlisle, PA 17013 STATE FApM {NSURANC© State Farm Insurance Companies 555 Southpointe Blvd, 4th Floor Canonsburg, PA 15317 P.E: Claim Number: 38-K769-581 FAX AND REGULAR MAIL Date of Loss: October 20, 2005 Our Insured: Tanya Brown Your Client: Kristin Brown, a minor Dear Mr. Caffrey: Per our phone conversation today, we have reached a settlement agreement for Ms. Brown's underinsured motorist claim in the amount of $45,000. I will await a copy of the court approval to issue the settlement. Sincerely, ~~ Karen Kardos Claim Representative (724) 743-4972 State Farm Mutual Automobile Insurance Company HOME OFFICES: BLOOMINGTON, ILLINOIS 61 7 1 0-0001 ~ ~ ~ ': ~ i ~ ~ LAW OFFICES ~ i !~' SAID~S, SHUFF, FLOWER & LIl~ D~-AY A PROFESSIONAL CORPORATION 26 WEST HIGH STREET JuHN E. SLII<E CARLISLE, PENNSYLVANIA 17013 ROBERT C. SAIDIS TELEPHONE: (717) 243-6222 -FACSIMILE: (717) 243-6486 GEOFFP~EI' S. SHUFF .EMAIL: attorney@ssfl-law.com JAMES D. FLOWEP., JR www.ssfl-law.com CAROL J. LINDSAY BRIAN C. CAFFREY GEORGE F: DOUGLAS, IIl MATTHEW J. ESHELMANt THOMAS E. FLOWER MARYLOU MATAS SUZANNE C. HIXENBAUGH CONTINGENT FEE AGREEMENT CAMP HILL OFFICE: ?109 MAP.I:ET' STREET CAMP HILL, PA 17011 TELEPHONE: (717)737-3405 FACSIMILE: (717)737-3407 tBoard Certified Creditors' Rights kepresenmtion REPLY TO CARLISLE THIS AGREEIvIENT', entered into this ~ day of Uecernber, 1005, by and between Saidis, Shuff, Flower & Lindsay (hereinafter "Attorney"), and Eric Brown and Tanya Brown, parents and guardians of Kristin Brown, a minor (hereinafter "Clients"). WITNESSETH: That Attorney, for the consideration hereinafter stipulated, has undertaken and does hereby undertake and agree with Client to act as legal counsel in negotiating a settlement, and if the same is not effected, in bringing, conducting and prosecuting an action against Allen L. Balser to recover damages on behalf of Kristin Brown for personal injuries suffered by ILristin Brown resulting from a motor vehicle accident which occurred on or about October 20, ?005. ATTORNEY FEES In consideration for services so rendered by Attorney, it is hereby agreed by and between the parties hereto that Attorney shall be compensated as follows: (a) Thirty-Three and One-Third (33-1i3%) percent of the gross recovery. (b) If the Attorney-Client relationship ends prior to the resolution of the case, the Attorney shall be entitled, in addit;orl to the compensation provided rlercin, reimbursement of costs and expenses advanced by the Atton~ey. "Gross recovery" shall mean the fiill amount of settlement proceeds or the fiill amount of verdict, including any pre judgment interest, without reduction for costs advanced or incurred. Attorney shall have a lien on any sum or sums recovered, whether by settlement or judgment, for services rendered, costs advanced and incun•ed under this Agreement. ,, , ~ ~ _1 . • - l_ ~ • r ' `." ` ~ ` ' 0 2. COSTS: Costs will be reimbursed to the Attorney from proceeds of any settlement or verdict. Costs include, btlt are not limited to, investigation fees, fees for court reporters, deposition and transcript costs, witness fees, filing fees, long distance phone calls, travel expenses, photocopy costs and other costs deemed necessary by the Attorney in order to properly pursue the action. Costs shall be paid in addition to payment of Attorney fees as above. SETTLEMENT PROVISIONS: All offers to settle, adjust or compromise the above claim shall be reviewed between Clients and Attorney before any such offer is either accepted or rejected. Clients.further agree to consider seriously any recommendation for settlement made by Attorney and not to unreasonably witlhold consent to such settlement recommendation. 4. DISCHARGE OR WITHDRAWAL: In the event that Attorney subsequently determines that the claim or suit lacks merit, or Clients unreasonably withhold consent to any bona fide settlement recommendation made by Attorney, or Clients refiise or fail to cooperate with Attorney. or Clients conceal or misrepresent facts regarding their claims, or Clients commit a breach of this Agreement, Attorney shall have the right to terminate Attorney's services by giving reasonable notice to Clients. 5. PRIVACY POLICY: During this firm's representation of you, we may receive nonpublic, personal information from you or from other sources about you. It is our policy and practice that otlr attorneys and staff do not at any time reveal information relating to our representation of you unless you consent after 1 ~, l ~;.,~:.~ ~ ~ .-~uci }f~. wYY.r -. ~ fi v t. '>CFn}~ 7 0 t;~nSaltitli3n, C~>i.Ept iGr u~~~lUSUrc>S that ai:; jlllplieds.y atithG~ • ~~ ~ ~ ~t.t r.. . ~pr~~t~.,.+tlc.u , ::sd except for disclosures required or authorized by the Pennsylvalua Rules of Professional Conduct. 6. MISCELLANEOUS: Clients understand, acknowledge and agree that Attonley does not guarantee the outcome or eventual result of the above claim. 2 ~, ,~ ~ '~ ~ ~ ~ . IN WITNESS WHEREOF, the parties intend to be legally bound and have hereunto set their hands and seals to this Agreement, in execution thereof, the day and year first above written. Eric Brown Tama=Brown SAIDIS, SHUFF, FLOWER & LINDSAY By: 3 ~~ ~ 1 ~~ ~x. ~ r6 y `~ ~- Y ^ ~ ~ r ~ ~ • ~ ~ ~ - STATEMENT OF PROPOSED DISTRIBUTION Gross settlement Less Expenses Less Attorneys' fees of (one-third) Net to client $60,000.00 30.00 $59,970.00 $19,990.00 $39,980.00 ~~~ ~~ q-s •S~ ~~ -,~~ -., ,, , , ,~.~ : 1, 1~~ X21 ~?~ 1 1 ~~~ ~OGZ ;t ~l ~J h~v'1 ~ 7 ,, ;~1 c;i 1',~ IN RE: KRISTIN BROWN, IN THE COURT OF COMMON PLEAS OF A MINOR :CUMBERLAND COUNTY, PENNSYLVANIA 06-7058 CIVIL TERM ORDER OF COURT AND NOW, this ~_ day of December, 2006, a hearing on the petition for approval of a minor's settlement shall be conducted in Courtroom Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania on Tuesday, December 26, 2006, at 11:30 a.m. By the C rt, / r !` r Edgar B. Ba~ey, J. James D. Flower, Jr., Esquire For Petitioners :sal ''~ , r- ~Y ~ ~~. ~ %. ~~,~ ~tc_~ , .~ ('.. ~~ _ ~ t F C.~a~ ! w~ { ~~-.~ ~+ .~ iV ~ ..~ IN RE: KRISTIN BROWN, IN THE COURT OF COMMON PLEAS OF A MINOR :CUMBERLAND COUNTY, PENNSYLVANIA 06-7058 CIVIL TERM ORDER OF COURT AND NOW, this ~,_ day of December, 2006, IT IS ORDERED: (1) Approval of the settlement of this minor's claim for a total of $60,000, with $15,000 to be paid by Safe Auto Insurance Co., and $45,000 to be paid by State Farm Insurance Co., for a minor, Kristin Brown, born November 21, 1990, IS GRANTED. (2) From the total settlement, a counsel fee of $15,000 to James D. Flower, Jr., IS APPROVED. (3) From the total settlement, costs of $85.50 to James D. Flower, Jr., ARE APPROVED. (4) The net proceeds of $44,914.50 shall be placed in a federally insured interest bearing investment at M&T Bank, in the name of Kristin Brown, born November 21, 1990. (5) The account shall contain the following notation: "NO WITHDRAWAL CAN BE MADE PRIOR TO KRISTIN BROWN, BORN NOVEMBER 21, 1990, OBTAINING HER MAJORITY EXCEPT BY AN ORDER OF A COURT OF COMPETENT JURISDICTION." (6) Tanya Brown and Eric Brown, the parents of Kristin Brown, are authorized to sign any releases or documents necessary to effectuate this settlement. (7) James D. Flower, Jr., shall file with the Prothonotary, and forward a copy to this chambers, proof of compliance with this order. 1 By the Edgar B. Bayley~J. ~s D. Flower •~r FCf711irP For Petitioners :sal ,~ ~.,.~ ~, c*` _ e~ -! r' asy __ ~ ~ _ p :~ t ~ _ \~`v ~ _ ~~~ ~ ~"~ '- ~~~ ~~ :J i . IN RE: KRISTIN BROWN, MINOR IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA No. 06-7058 CIVIL TERM To the Prothonotary: PRAECIPE In accordance with the Order of the Honorable Edgar B. Bayley of December 27, 2006, on this matter, attached is a deposit slip establishing a deposit of $44,914.50 in a Certificate of Deposit at M & T Bank, in the name of Kristin Brown. The face sheet of the Certificate of Deposit is also attached as is the computer printout confirming that no withdrawals can be made prior to Kristin Brown's 18th birthday on November 21, 2008, unless authorized by Order of Court. SAIDIS, FLOWER 8~ LINDSAY Attorneys for Plaintiff SAIDIS, FLOWER Sz LINDSAY nrto~~ys.,n:uw 2G West High Street Carlisle, PA January 0 , 2007 By~ , ames D. Flower, Jr., Esquire ttorney ID #27742 26 West High Street Carlisle, Pennsylvania 17013 Phone: 717.243.6222 Fax: 717.243.6510 ~~ ~~ ~ 16 - Time Account ^ Add-On CD ~ne~ isros) ~.,n "°diaRN"antli"°"'T""`°"'°"" D 16-Current Year Retirement DEPOSIT SLIP oATE~ ~ ~ ~ 17 -Prior Year Retirement NAME ^ f5 -Current Year Rollover RetiremenUDirect Rollover ~ ^ 11 -:Current Year Trustee Transfer. ADDRESS Prefix ACCQUNT NUMBER. L_J-L- ~1~~3917878~ bOLLARS CENTS CASH CHECK GHECK TOTAL. bEPOSIT ~+.. PreflX TIC„--,.,,..,.._... - ,..,,.,, ALL ITEMS ARE SUBJECT TO THIS INSTITUTION'SAULE8 AN0 Retlremerlf ACCOUnt 3500 REGULATIONS PERTAINIryG TO THE. ACCOUNT AGREEMENT: ~:0 2 2000046: 0 M~TBaI}k ~~~ King Street Office If you have any questions, please call our Telephone Banking Center at 1-800-724-2440 Today's Date: 01/22/2007 Time: 09:54 AM CD Deposit ****8092 Total Balance: Available Balance: Business Date: 01/22/2007 $44,914,50 $44,914.50 $0.00 6822 /04 137 E x y n C) z x w :~ x x TJ] LJ z :~ a W a ~, rn t H ~b H ~- ~ 3 x T,~ .Q; v H w cr v c p ~B~ 35-39 East King Street, Shippensburg, PA 17257 717 532 4132 Fnx 717 532 9422 MANUFACTURERS AND TRADERS TRUST COMPANY *** CERTIFICATE OF DEPOSIT *** DATE: 01/22/2007 OFFICE: King Street KRISTIN BROWN 188 CONODOGUINET EST NEWVILLE PA 17241 ACCOUNT NUMBER: 31003917878092 OPENING DEPOSIT: $44,914.50 ACCOUNT TERM: 12 Months INTEREST RATE: 4.97 ANNUAL PERCENTAGE YIELD: 5.10 MATURITY DATE: 01/22/2008 Thank you for choosing M&T Bank. """ NOT TRANSFERABLE (AS DEFINED IN 12 CFR 204) "~"' "'""` NON-NEGOTIABLE *'"` Member FDIC ~ LL Page: 1 Document Name: untitled RSHO 2 FSS RST HARD HOLD INQ/MAINT 07/01/22 9.47.47 RSMU CO 96 OP EBRN MS ACTION SUCCESSFUL ACTION FAD COID PROD CODE CDA ACCT 32003917878092 SHORT NAME BROWN KRISTIN CLASS: 1 (1,2,3) TYPE: 6 SEQ 1 CURRENCY TYPE CODE........... DATE PLACED............ 107/01/22 REASON CODE......... DATE EXPIRES........... 999/99/99 STATUS CODE............ 1 SPECIAL COMMENTS LINE 1 DF, 6822,717-532-4132 LINE 2 RESTRAINT REASON LINE 1 NO WITHDRAWLS CAN $E MADE PRIO}~ LINE 2 TO 11-21-08 ORDER OF COURT STATUS CODE VALUES 1 = ACTIVE 2 = DELETE A = ACTIVE PAID B = DELETE PAID PF: 2-CONY 4-CHG 5-FAD 6-INQ 9-NXT -DEL -ADD R r- ~ -~ ~ m ~_~ --~ :_. G: - ; `- _~ ~y r , _, .. _ F -' "r ~.• . V~ _~~ • . 'j ' v y y .N ^'~ f ~ IN RE: KRISTIN BROWN, : IN THE COURT OF COMMON PLEAS OF A MINOR. :CUMBERLAND COUNTY, PENNSYLVANIA NO. 06-7058 CIVIL TERM MOTION AND NOW comes TANYA BROWN, Mother and Natural Guardian of KRISTIN BROWN, and avers the following through her attorneys, SAIDIS, FLOWER ~ LINDSAY: 1. KRISTIN BROWN was injured in an automobile accident on October 20, 2005, sustaining a fractured left elbow and a deep gash in her lower left leg. She made a good recovery but will have some residual scarring. 2. On December 27, 2006, an Order was entered by the Honorable Edgar B. Bayley, authorizing settlement of a minor's claim for policy limits of $60,000.00, and directing that the net proceeds of $44,914.50, be placed in a federally insured interest bearing investment at M & T Bank, in the name of KRISTIN BROWN, which account was not to have any withdrawals until KRISTIN BROWN turned 18 years of age, other than those authorized by an Order of Court. A copy of said Order is attached as Exhibit "A". 3. KRISTIN BROWN was born without two of her upper teeth, and has SAIDIS, "LOWER Si LINDSAY ~.~:~W 26 West High Street Carlisle, PA been treated extensively for this over the years. Now that she is no longer expected to grow significantly, her dentist has advised that her partial plate could now be replaced by dental implants. The health insurer has declined to cover this on the grounds that it is cosmetic surgery. A copy of Tanya Brown's statement confirming this to the undersigned is attached hereto as Exhibit "B". 4. The cost of the dental procedure which is needed is One Thousand Eight Hundred ($1,800.00), and a statement from the office manager of her treating dentist concerning these charges and the insurance denial is attached hereto as Exhibit "C". 5. Petitioner and KRISTIN BROWN'S father, Eric Brown, are recently divorced, and they have represented to the undersigned that their savings are depleted, and they do not have sufficient funds to pay for this dental work. WHEREFORE, Petitioner requests that this Court authorize withdrawal of One Thousand Eight Hundred ($1,800.00} Dollars from the aforesaid bank account to pay for these dental services. SAIDIS, FLOWER & LINDSAY Attorneys for Petitioner By SAIDIS, ~'IAWER Sz LIlVDSAY ,,.~:~W 26 West High Street Carlisle, PA James D. Flowfer,`~r., Esquire 26 West High Street Carlisle, PA 17013 (717) 243-6222 I . D. #27742 vERiF~caTlOnl I, 7ANYA BROWN, Patftioner hefein, hereby verify that the statements made in the within instrument ane true and correct to the best of my knowledge, information and belief. I understand that false~st8tements herein are made subject to the 4 penalties of 18 Pa.C.S, section 4904, relating to unswom fals~~atian to authorities, ~ ~" ~~ anya Brown oet~:._ _ _~ ~~a~G 7 ~A~DIS, ~c Y.IND9A'Y' 7b War 1~Igh Srna Car~i~k, PA ~xh~bc~ A IN RE: KRISTIN BROWN, IN THE COURT OF COMMON PLEAS OF A MINOR :CUMBERLAND COUNTY, PENNSYLVANIA 06-7058 CIVIL TERM ORDER OF COURT AND NOW, this '2 day of December, 2006, IT IS ORDERED: (1) Approval of the settlement of this minor's claim for a total of $60,000, with $15,000 to be paid by Safe Auto Insurance Co., and $45,000 to be paid by State Farm Insurance Co., for a minor, Kristin Brown, born November 21, 1990, IS GRANTED. (2) From the total settlement, a counsel fee of $15,000 to James D. Flower, Jr., IS APPROVED. (3) From the total settlement, costs of $85.50 to James D. Flower, Jr., ARE APPROVED. (4) The net proceeds of $44,914.50 shall be placed in a federally insured interest bearing investment at M&T Bank, in the name of Kristin Brown, born November 21, 1990. (5) The account shall contain the following notation: "NO WITHDRAWAL CAN BE MADE PRIOR TO KRISTIN BROWN, BORN NOVEMBER 21, 1990, OBTAINING HER MAJORITY EXCEPT BY AN ORDER OF A COURT OF COMPETENT JURISDICTION." (6) Tanya Brown and Eric Brown, the parents of Kristin Brown, are authorized to sign any releases or documents necessary to effectuate this settlement. (7) James D. Flower, Jr., shall file with the Prothonotary, and forward a copy to this chambers, proof of compliance with this order. By the Edgar B. Bayley-J. James D. Flower, Jr., Esquire For Petitioners sal ~xh~bif ~ 85-l~9-' B7 P.9: 35 FP,OCI--CI & T Bank -King St 7~7-~.:,2~~7.2 T-`~~~ AQL~2/~B3 F-fib? 1V1ay 9, 2007 Mr. James D Flower Jr., I would like to give you a quick overview of what Kristin has been through with her teeth. Kristin was born without 2 of her upper teeth_ They just newer grow in. 't~V'hen she was in elementary school (3~ or 4`h grade) we started this process of getting her teeth. The Health Insurance Provider at that time paid for 80°/a of the procedures, which included: retainer, spacers, braces, another retainer, and now a partial plate. She had this partial plate since she was in ba' grade. The Dentist at that time said this partial plate will be good until it is time for implants, which she could not get done until she was finished growing. I guess her father and I just assumed that the Health Insurance Provider would cover 80% again. Though the years her fathers employer changed Health Insurance providers. I hope this information will help with the court. 'Y"ou will find an attached letter from the r3entist office. I can be reached at work. (717)-532-4132 or I can be reached on my cell phone {717)-386-6484. Please let me know as son as you can so I can make Kristin the finial Dentist appointment. Thank you, Tanya Browvn Exn-b~+ C @5-09-'(~7 @9:35 FB~JM-M & T Bank -King St 7.753%5422 -`- ~t,. 'fit ~ r :~y- ~. r ~ t - a ,r T-`?~~~ PP,P3/~~? F-fife,, Dr. Darnel ~ . ~ilXian AMU 305 S. Hanover St. CaT1151e, PA 14.7Q04 ~ 3 71 I j~ 13~V VVV May 9, 2007 To Whom It May Concern: lte: Kristin Brovvn Dental Procedures totals. T'he total ex tooth is $900.00 x 2 , $1800.00 Grrax~d Total This claim was denied by insurance due to cosmetic reasons. Thus is the final ~roGess of an ongoing process. f~~ Us~R, ~,~rr~ Officc Mana~- . __ ~.. " - R. RECEDED @5-@9-'@7 08;4@ EF~fINI-- 7172430172 TO- M & T Bank K~.ng St P001~0P1~ IN RE: KRISTIN BROWN, IN THE COURT OF COMMON PLEAS OF A MINOR :CUMBERLAND COUNTY, PENNSYLVANIA 06-7058 CIVIL TERM ORDER OF COURT AND NOW, this 2 ~ day of May, 2007, the within motion, IS DENIED without a hearing.' By the Co~rrt; ayley, J. ~mes D. Flower, Jr., Esquii For Petitioner :sal v ' This court will not allow the funds of asixteen-year-old to be used to pay for elective dental, cosmetic surgery. If this work should be done and it not covered by health insurance, her parents should find a way to pay for it. ~.~~ r cx , -~ ~ ~~~ , ~ L{ i i _. _. % - E y . . ' ~. _ ~~~ _ ~L ,,. ~ `"~ ~.J N