HomeMy WebLinkAbout95-04531
4. Issues yet to be resolved; custody schedule for the minor child.
6. The Plaintiff's position on custody is as follows: Plaintiff indicated that
he does not want the Mother to have any custody with the child until he feels
secure that she has a stable environment. He suggests that hor living environment
In California is not only unstable but unhealthy for the child In that there are drugs
and alcohol abuse occurring in the residence. He did, however, indicate that he is
willing to have the child be with his mother beginning next summer for the entire
summer.
6. The Defendant's position on custody Is as follows: Defendant indicated
that she has been denied any access to the child since July of this past year. She
fled Pennsylvania aftef being beaten up by the Plaintiff. She took the minor child
with her. She returned the minor child to visit with Father under the understanding
that she would get the child returned to her. The child was not returned to hef and
when she attempted to pick the child up in September, Father then got an ex-parte
order which did not permit the child to be taken out of state. Mother related a long
history of physical violence between the parties while they were married and
suggests that Father has an unstable living environmont which includes the misuse
of drugs.
7. Need for separate counsel to represent child: none,
2
8. Need for Independent psychological evaluation or counseling: Father
suggested that he wanted a home study but unless he Is willing to pay for It and it
does not slow down the hearing, none Is necessary.
9. Other matters and comments: The Mother In this case lives In California
and the Father lives In Pennsylvania. There was some serious allegations raised by
both parties concerning the fitness of both parties to care for their minor child.
Mother Is currently In California and Indicated that she fled the state In June of
1995 as a result of being physically abused by the Father. She has not had any
contact with the child since July at which time she returned the child here to visit
with Father but was not given the child back. This court entered an order In
September prohibiting the removal of the child from this jurisdiction.
Despite the fact that both parties had major concerns about each othef, the
parties were very close to an agreement at the conciliation. Mother had not seen
the child since July and requested that she be given at least one month now with
the child. She understood that Father had a significant family situation that
warranted him having the child for several weeks over the Christmas holiday so
that he could travel to be with his family in West Virginia. She then would agree to
a schedule whefeby each parent will alternate physical custody of the child on a
four month on, four month off basis. Father did not want Mother to have contact
right now with the child and wanted a period of time for her to become stable. He
3
vs.
IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
No. 95 - 4531 civil Term
JEFFREY S. WILLIAMS,
Plaintiff
JEANETTE C. WILLIAMS
Defendant
CIVIL ACTION - LAW
CUSTODY
BX PARTE PBTITION FOR EMERGENCY RELIBF
The Plaintiff, Jeffrey S. Williams, through his attorneys,
The Law Offices of Patrick F. Lauer, Jr., files this Ex Parte
Petition for Emergency Relief against the Defendant, Jeanette C.
Williams, and in support thereof, avers the following:
1. The Plaintiff is Jeffrey S. Williams, an adult individual
and the natural Father, who currently resides at 32 Center
Street, Lot 13, Mt. Holly Springs, Pennsylvania 17065.
2. The Defendant is Jeanette C. Williams, an adult
individual and the natural Mother, who currently resides at 42622
Third Street East, Lancaster, California 93535.
3. The Plaintiff filed a Complaint for Custody with this
Court on Auguot 28, 1995, requesting primary physical custody of
the minor child Robert Paul (Robbie) Williams (d.o.b. 4/26/94).
4. A custody conciliation conference has been scheduled
before Michael L. Bangs, Esquire, for October 19, 1995.
5. The Plaintiff believes, and therefore avers, that the
Defendant is facing felony charges in California for welfare
fraud and child abuse.
EXHIBIT A
JEFFREY S. WILLI}~S,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
:
vs.
No.
JEANETTE C. WILLIAMS
Dsfendant
CIVIL ACTION - LAW
CUSTODY
COMPLAINT FOR CUSTODY
The Plaintiff, Jeffrey S. Williams, through his attorneys,
The Law Offices of Patrick F. Lauer, Jr., files this Complaint
for CUstody against the Defendant, Jeanette C. Williams, and in
support thereof, avers the following:
1. The Plaintiff is Jeffrey S. Williams, an adult individual
and the natural Father, who currently resides at 32 Center
Street, Lot 13, Mt. Holly Springs, Pennsylvania 17065.
2. The Defendant is Jeanette C. Williams, an adult
individual and the natural Mother, who currently resides at 42622
3rd Street East, Lancaster, California 93535.
3. The Plaintiff seeks custody of the following child:
Name Present Address ~
Robert P. Williams 32 Center St., Lot 13 16 months
Mt. Holly, PA 17065 (April 26,
1994)
The child was not born out of wedlock.
The child is presently in the cUstody of Jeffrey S.
Williams, who currently resides at 32 Center Street, Lot 13, Mt.
Holly Springs, Pennsylvania 17065.
4. During the past five years, the child resided with the
following persons and at the following addresses:
"
The Mother of
Address Dates
32 Center street #13 7/95-present
Mt. Holly, PA 17065
42622 3rd St. East 6/95-7/95
Lancaster, CA 93535
32 Center St. #13 birth-6/95
Mt. Holly, PA 17065
the child is Jeanette C. Williams, who
N.!!l!m.
Jeffrey S. Williams
Jeanette C. Williams
Jeffrey S. Williams
Jeanette C. Williams
currently resides at 72622 3rd Street East, Lancaster, California
93535.
The Mother clontinues to be married to the natural Father.
The Father of the child is Jeffrey S. Williams, who
currently resides with the subject of this Petition, at 32 Center
Street, Lot 13, Mt. Holly springs, Pennsylvania 17065.
The Father continues to be married to the natural Mother.
5. The Plaintiff is alleged to have participated as a party
or witness, or in another capacity, in other litigation
concerning the custody of the child in this or another court; to
wit, Jeanette C. williams vs. Jeffrey S. Williams, in the
superior Court of California, County of Los Angeles, North
.,
District, filed at case number MO-1113B on July 10, 1995, a copy
of which petition is attached hereto as Exhibit "A" and
incorporated herein by reference. Your Plaintiff, Jeffrey S.
Williams, has contested the jurisdiction of the California Court
on grounds that pennsylvania is the "home state" as defined under
the Uniform Child Custody Jurisdication Act. See 23 Pa.C.S.A. S
5343 and Exhibit A at page 3.
The Plaintiff has no information of a custody proceeding
concerning the child currently pending in any court of this
Conunonwealth.
The Plaintiff does not know of a person not a party to the
proceedings, who haa phyaical cuatody of the children or claima
to have phyaical cuatody or viaitation right a with reapect to the
children.
6. The beat intereato and permanent welfare of the child
will be aerved by granting the relief requeated because:
a) The Plaintiff can provide the child with a home
with adequate moral, emotional, and physical
aurroundinga aa required to meet the child'a needa;
b) The Plaintiff is willing to continue cuatody of
the child; and
c) The Plaintiff continue a to exerciae parental
dutiea and enjoya the love and affection of the child.
7. Each parent whoae parental right a to the child have not
been terminated and the peraon who haa phyaical cuatody of the
child have been named aa partie a to thia action. All other
peraons, named below, who are known to have or claim a right to
custody or viaitation of the child will be given notice of the
pendency of this action and the right to intervene:
Name
Address
Basia of Claim
D.t., ~ /)'11((;
NONE
WHEREFORE, the Plaintiff reapectfully requesta that this
Honorable Court enter an Order granting cuatody of the child to
the Petitioner and natural Father, Jeffrey S. Williams.
Re pe tf~.lY aubmittod,
\ ~ :t. ( ~ I \ .._ Od
Matthew J. Eshelman, Eaquire
Law Office\of Patrick F. Lauer, Jr.
2108 Marke Streot, Aztec Building
Camp Hill, ennsylvania 17011-4706
IOH 72655 Tel. (717) 763-1800
..
Jeffrey S. Williams,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
vs.
No. 95-4531 Civil Term
Jeanette C. Williams,
Defendant
CIVIL ACTION - LAW
CUSTODY
DEFENDANT'S PROPOSED WITNESS LIST
\"':'~; 0-
The defendant plans to offer testimony from the foilowi~:
p: ~ ~: ,;1 -'~ .r::-
:.: r.
1. Jeanette C. Williams, 42622 Third Street;/'.F!listto
Lancaster, California 93535, the defendant, will~~~s~1fr. to her
ability to continue to provide for the needs of ~e!~'~hi&aren.
She will also testify to the plaintiff's abusive 1.~tlhlW~~ ,toward
her and toward his relationship with the children;::~~ .-
- <&.0
llLO
2. Edie Williams, 42622 Third Street, East, Lancaster,
California 93535, the defendant's mother, is expected to provide
telephone testimony as to the defendant's ability to care for the
children. She is expected to testify as to the plaintiff's
behavior as it adversely affects the children.
3. Christina Hitchcock, 6204 Derby Drive, Bakersfield,
California, defendant's sister, is expected to provide telephone
testimony of the defendant'a ability to care for her children.
4. Allen Klein, 4804-1/4 Sierra Highway, Acton, California
93150, a friend of the defendant, is expected to testify to the
defendant's ability to provide for her children and to the
environment that she can provide for her children in California.
5. Mary Paul, HA, Children's Social Worker, California,
can provide telephone testimony concerning the positive
environment that the defendant can provide for her children.
6. Pennsylvania State Police are expected to testify as to
their confiscation of a revolver and ammunition which was being
shipped to the plaintiff from California at the time of the
custody conciliation conference.
7. Mount Holly Police are expected to testify as to the
defendant's abuse to the plaintiff.
Name
Address Dates
32 Center Street #13 7/95-present
Mt. Holly, PA 17065
42622 3rd St. East 6/95-7/95
Lancaster, CA 93535
32 Center St. #13 birth-6/95
Mt. Holly, PA 17065
the child is Jeanette C. Williams, who
Jeffrey S. Williams
Jeanette C. Williams
Jeffrey S. Williams
Jeanette C. Williams
The Mother of
currently resides at 72622 3rd Street East, Lancaster, California
93535.
The Mother continues to be married to the natural Father.
The Father of the child is Jeffrey S. Williams, who
currently resides with the subject of this Petition, at 32 Center
Street, Lot 13, Mt. Holly Springs, Pennsylvania 17065.
The Father continues to be married to the natural Mother.
5. The Plaintiff is alleged to have participated as a party
or witness, or in another capacity, in other litigation
concerning the custody of the child in this or another court; to
wit,
Jeanette C. Williams vs.
Jeffrey S. Williams,
in the
I
I
I District, filed at case number MD-11138 on July 10, 1995, a copy
;,
!I
I,
II
!I
Superior Court of California,
County of Los Angelee,
North
of which petition is
Exhibit
attached
hereto as
itA"
and
incorporated herein by reference.
Your Plaintiff, Jeffrey S.
Williams, has contested the jurisdiction of the California Court
on grounds that Pennsylvania is the "home state" as defined under
,
II
Ii the Uniform Child Custody Jurisdication Act.
II
See 23 Pa.C.S.A. S
5343 and Exhibit A at page 3.
The Plaintiff has no information of a custody proceeding
concerning the child currently pending in any court of this
Commonwealth.
The plaintiff does not know of a person not a party to the
proceedings, who has physical custody of the children or claims
to have physical custody or visitation rights with respect to the
children.
i
i
,
,
1
I will be served by granting the relief requested because:
I
I
I
I
I
i
II
II
Ii
,I
i!
d
1\
Ii
q
II
Ii
II
,I
"
\1
II
I
6. The best interests and permanent welfare of the child
a) The plaintiff can provide the child with a home
with adequate moral, emotional, and physical
surroundings as required to meet th~ child's needsl
b) The plaintiff is willing to continue custody of
the childl and
c) The Plaintiff continues to exercise parental
duties and enjoys the love and affection of the child.
7.
Each parent whose parental rights to the child have not
been terminated and the person who has physical custody of the
child have been named as parties to this action.
All other
persons, named below, who are known to have or claim a right to
custody or visitation of the child will be given notice of the
pendency of this action and the right to intervene:
Name
Address
Basis of Claim
NONE
ii
:'
,
WHEREFORE, the plaintiff respectfully requests that this
Honorable Court enter an Order granting custody of the child to
the Petitioner and natural Father, Jeffrey S. Williams.
,
Re p \ t~ lly, submitted,
\~ X-V k--...
:1
D.t., 'G1~<I\q~
Matthew J.
Law Office
2108 Marke
Camp Hill,
ID# 72655
Eshelman, Esquire
of Patrick F. Lauer, Jr.
street, Aztec Building
ennsylvania 17011-4706
Tel. (717) 763-1800
EXHIBIT A
_.._......... .,......._v." _..
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1);3-1 ~;-1 ~':15 06: C17PI'1
FF:W
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SUMMONS -. '. .JULY LAW
JEl'rHE'i ~l. WII.LIAHS
fell CQUHTU:.' OH"'''
(~oul P.ulAU50 Of. LA CUIIII)
NOTICE TO FlI:SPONDENT (Hi/me):
A\'ISO ilL DEUMInIl/lO 1IIIIIIIb,~)J
....-...-...- .. ,>
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TO
CITACIOH JUDJCli
976J42.l7
P,Ol
OERCCHO DE FAMILIA
L_~~~H.~:~~~U"U' II u,'ud ;. .~~~/'I/~~n;~:;~.J
fl~TITIONER'S NAME: IS: JEAlIl,'l"fJ:: c. WnUANS
fl. HOM/lIle veL Vf/oMNI/MJY'; I!S,
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Vou ha"c 30 CALENDAR DAYS Mtllr tn,s Sum-
moor: and potHlon 3ro Cljry~l.1 on you to 'Ilat a
AllsponsH (lorn. 12~21 ~t 1I1~ Coult and .mvo n copy
on lhtt (i(I\lti~r.l!r. f, loUtr ()r Poonlj cau 'Will not rJra.
l~el you.
II you dO not Ilia ;lOUI nc~ponc. on .,.,e, thu courl
may m~k. ord"r$ alf~CIIIlg your morriago. your
properly, .'lnu cu.tony 01 ycur CIIIIOlon. You Inay bO
0I.1Mo<l to pay support 0/'0 3tlOrnoy 100: ~nd to.lt.
II )'nu cannOI pay tile IilinO r~". ..k .It,. clerk for
a rllA walvAr lorin,
II you wAnt ICYl,1 3,W,r,), '~1ll0r;t ~ IJ'~,er Im-
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---
V~I~(/ tieno 30 DIAS CALENDARIOS u"Gpu6o drI roc/blr
ofjcl~"mcntQ a:.ta cltaci6n judic/al Y pc'dcibrl. pa;Q cOmplOtaf Y
Ilru:itmWr ~U lorMI/arlo de nd~jpufl:'UU (nusponco (orm f 2Sz) antu
I;) corte. UfliA 03rto:. 0 l..lO;' U,lIl1.Jd.J tttk.'tntliclJ nO It: Offl:C(J,tl pro.
tdoo,an.
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ff.ptJUIf 6rwfJ~~ QUv ofeclen ~u nmtrimoniO, t;u propiodlJd y QUO
oW.:tl.;" Qtld ustl'!'fl pn!JUt1 milntenCj~n. nonor-drios ad o'JbO(JlJdo
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Si dtJSO.l OOlC!fiCf consujo lufJ.1/. corr.u(lj'luC':$tJ de inmedltlto con
un olJooacta.
tlOTICE TllIlfOttrl1/f,i":7 ororJr9 con 010 vack llfO ~1I"cli..o ugili":>1 voU, 1.J!:/loncJ ana lvi/a u~~1 tlIU pam/on Is tI,srn,ss.'l1, a
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(orct:monr encer wno nlJ~ n.IC{Jr~'ca or C(Jon 41 copy 01 enom.
AVISO' La~ 1J(CJII;hit:jonr':~ jurJj('jnll':s qui: ll,?ltfr.'con III row..n:o do o~rJ c,racil.lI son flNCC;vl.lS piJftJ an4boS C6n.ivoc$. tanto el
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clQn(jIC~, Di"I1"~ I'ml,illic:/Onu!1 f'<Jcd~n Iwcu,,,e e.m,plir ~n cualQuler parto du Callomi.l por cu~/qu;~' .Jocn/a del orden pUOltCO
~'I!:-':1J 110)'" re..c:ili'~_'!..'!~.'!0~i.1 vi~~~coP/a CI,I ollas. ..___.._._..__________.
1. Tne MmA amJ ndW&~5 01 lOll COull IS' (I.' /lomom Y lliroccioin Cle la COIlIt "5)
SUPlmIOR coun'!' 01' CALIFORlIIA
1040 WES~ AVENUE J
LlIllCAS'l'EH Ch 93534
llOR'l'1i DIS'l'HIC'l'
2. ThO namp, "dd(e~n, ilnd tl!lQPhon~ Iltul.I.oIJr of poUtIOnK"s i:ltlc.rnu)', or pt1tltlonur wilhout an :stlornoy. ,!:.:
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JEANE'l'TE C. I'/IT,l.Il\HS :
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42622 JRD S'l'Rlm'l' !::AS'l' .' "I' .'.;,.... tJ
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(ro,l 1./1 (l)..,c'~o fUJl.1 ot>rano( i"fDfl1lllc,6n dO lItl/l'Jrwnc;;.t)
FJrr.tfot Cg(]i1." 13:!. :::11, .....l4U. nOt)
Calol. Jtul.' "Il,,;~ull. hi" toUl;
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1~iJ1(.IW J.lhIlM/'. "Ji~l
SUMMOtlS
(FlUllil)' LUw)
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08-15-1995 05:02Pi'1 FROII
I .nOll"t' a........ M""ulman", t I.;;;:;:."'....'"". ..,;....,t.
JE1ItiE'!'TE C. WILLIAMS
42622 3RO S'l'REE1' EAST
LAlICAS'l'ER C1'. 93535
TO
U:l..rf'HONC NO.:
97634247 P.02
('~t ,oun lU 0Nt.1"
.n"''''''.o.,......,. 11LP,l19 l'F.lt-__... ...- .-. -------.
. SUPERIOn COUR'r Of CALIFORNIA. CClUUTY OF LOB AtlGF:LES
~lIlm~tnm' 10.10 WES'r lNEllUE J
"1ol"'ONlon~" S1\NE
CI1Y""O~'PCOc., LANCASTER, C1\ 035301
OIlN'C"''''''' NORTH DIS'l'RIC'l'
-
RIGINAL FILED
JUL 10 1995
PEAlOR COURT
MARRIAGE OF
pc nTlON~n.
ncS~O.!!Q.CI!_rl.
JEANETTE c. WILLIAMS
JEFFREV s. \~I r.r.1AfoIS
'.-"-j"'r-------"
CME' fjUl.lUCP:
PETITION FOR
o Dissolution of Milrrlagll
[[] Logal Sopmlltlon
Q~~I!!l>, of }Aarriafjo
CIl And Dot:lnrnllon Undor Uniform
Child CUlltody JurlGdlcllon Acl
;;/ D ,- / / /.5 Y'
1. RESIDENCE (DissolutIon only) 0 polilionor 0 r.~sponll"nt r'J~ Doon .. ruclll.nt of tn'S stalo for ~tl~J~1 $Ik Inonths anll
"t tlliS ~ounty lor III il::ast U\r"e Iloo/ltr,slln",onl~t~ly pruc~uingtlle lolln!! olthie POliti on tor Oittol~lion or t.\1Hri..go
. :-.~-_.._-_._--_.~
? STATISTICAL FACTS
a, Oah 01 lI,arriogh.1-1-9 2
o. Oal~nn~pnrntlon: 6-12-95
c. Period botwdun murllago .:sn.'J ccparatlun
Voar~' 3 Monlns: 5
~. DECLMATION n~GAliDir'IG MIIIOR CllIl.DHEN OF nlls M,\RRIWE fon WHOM SUPPORT MA'( BE OflDEnEu OR WHO MAY
BE SU(l.IECT TO CUSTODY OR VISlfATION ORDERS
u.D There lire no nllnl')( ~rlilUron,
Chi/als nrllTltl
HOfmnT PAUL \'IILLIAHS
o. (Z] Toe mlotlr Children gre;
O,rtMate
4~2ti-94
~
14 110S
!!!!
M
c IF TtIl:RI: ME MINOn CHILDREll. COI'l1PLt:Tr: EITIIER (I) OR (2)
(11 0 EaCII CI,lIa oomoO in 30 Ie Currently Iov,ng VlIIIl D \l~lItloller 0 rospondoM
In Ine 10000wlng C.,Uncy (~p"(;jfy):
DUling tne 1'~llIvo }1:afC oaell Clllla Ii~t Iovo:! III no ~I..lll otnef Uo~n CalolorniJ ana IVltro no person alllOf tllan palilloner
or retpo(,dollt O( both P'::lltt(.l\.::r has n01 p~(hCiplt'(lflln Hnj'c:.pacH)' In hn)' 1It10atlOrlor proCgCdll"lg in tiny stn\d c:oncvrning
cu~tollY of any ""nor Clliltl cf 1I11n m;\rli~Qil. rot,hOn.r ':of. n~ InMlllalicn of any ponO'f,g C'JOlody procoodlno or 01 any
par con not a "arty to tt,i~ r,rnconnino wllO /lac p/lytiOhl cuCloOY or Claims 10 Ilav~ ~ustooy or vl.itallon rignth concornlng
any minor nnlla Olllll" mil",~ua, I
(:!l 00 ^ cUlhplctof1 Doclar:.alioH unOi:r UIlI"mil CHild Cu~tO'lf J\,Irisc1i.:lion Act IS nIUIClu::d,
4. rn petitioner rt:q\l.,~lh '::uollrm:.uon at' ~:l!pJ,f Jlc ,1Stc1S tHlU uljll\F~1l0nt Itlll items listed
o HI Atl.iCrltn~h\ 4 IJD IH:h~w.
lliHU . centum to
1\11 prop.;>t"t~'-,"Gquil:,.d by p,;..tJ.tiolloT. prior to the dot.. of m"rri.~gi:j, Ql.long
th.;, 1Il;,rri"g<: by 'Jlfl, illh~r1 Lilli':'" ct.;-vlst:: or u..-:sce:nt, or aiter the date
of sdp~ration with popt B~p~r~ticn u~rnings ~r ony and all right to
cQ-imhurseml!nl: PUrriUilllt te, l""mll\' Coo;;: ~~'l..ti.on 26.10 to bo awarded to putitioner.
::::::[~'~;~~~i ;;~; ~:Ili Hiqt,11l101 I': roi:;;/l';IO'~~~~~I~ ~:;;;;;:..;;.'"-;-;.. u','drduo ':~,ourl;--~t tM '~iQ~I' r~tu, whlcn 1:1 currenl1;. .,::~"
10 p",cunl Hilt can 1>" " 1M')" Iltl~"O alli"unl, .
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,,,,.......n'''"' n"IO '""I P~IIIIOtl
.1...1.1'.." \~.l\"'C" "I C::MQI"~ (I!a1l111y Lo.aw)
1 ~'II i I"IN". JIlIl"lIr'l' 1. "-b'. I
,.".;/1;00_. .~~3.W."'09
r..s.L ff>ll..i 01 Cown. I\.IlMI:!lfl
1.-
, ,
.
--.. -- - -- --- - - - - -- --- -- --- ---- - - - --- - -- -- ----- -'';''-'-
n8-1t~-1 "',,;. 0611Ltr'll FFOII
TO
97~3o.12..t7 P.05
Htlrf.e, Ao~,tr. ;,..,11I;1I1)M"_ tjl) tlIAuoOlt)("
:-PA:' B~OW l;,r Uu Df Court Clef)! Oflf)'
lonarnlJ)(.)for f .
,.,......f..... .
SUPERIOR COURT 01' CALIFORNIA, COUNTY OF LOS ANGELES
In r. Ih~ IRArrlage 01
. paUllooer:
CASE NUMBER
,MD-} J13~
CJ p"Utlonor'u 0 Re~pDndenl'u
unci
CONFIDENTIAl. COUNSELING STATEMENT
(MARRIAGE)
Ad~pontlonl:
I untl.rGl~na tholt eOI\~lIiatlo" ..rvlees aro avuHabla to ma thrDlIan the court In thiS eDlInty.
01 woUIO 11"0 lRJrriiil',jp. coun~eling.
CJ I woulrlllhe 10 lalk I>lth a Ir:,iMd parEdn about my present familY ~ltuallon.
CJ I ao not ae~lr" counseling otlnie \.111..
Mulling aaaross of IOClu~tt'"a parly;
NamOI
Strole!:
CitylStatelZ,p
Malllna ullclroc~ or otnur par ly:
Nome:
streot:
City/StOle/Zip
OiltUi
..___0_.
(~,~fl"IUfU'
----.-.-......-.- .-
1284
F'Cf" t..:IClPUIV 1;)' 'hJltf t-,;.,;4 0'
J\JQ.CIlll'=O\,.IIl.:.ltllC,)'lrtr(l101
tllctVlt: ..nul"/l. 1!1~
'roC'2TOR '.B'
RDOIZ
CONFIDENTIAL COUNSELING STATEMENT (MARRIAGE)
-------------------_.~--------
5
! . :! '>1'; .lli';i 'li;~~..(...lll"
, 't, _': ' '" ~ ,"..', ;,' .~~ ' 1) ,,'
.... "..,.,~ltl4~lljoliJ.tli4_<lWt.l.iM
,-- -.... -- -- ---
j.'"
:-..
,
.
08-1~-1<)"''3 0';' llFI'! FPOH
TO
97b3~247 P.O?
--...--.
APVEHTF.NCIA: I'U'" 10' MlOC'Oo dO I. dM./OII d. olona. .J /RO"""'o
dO ull. ,op.,aoldll 'cy'" 0 do la d/oolac/ulI dll uII m.,,/mOIl/O, 'II
I.ye. de Cali/ofn/. dl,pollon quo .. p",ouman como cl,"oo d, I.
ollclod." COllruy.' "qa""a' ~dqal''''"U on I",nt. oon/un', po, 'II
I'u,tc' du,,,"/o 01 ",,,,,/monlo. SI cu./q.'." d. I'" p.llo, d. ,.,.
uoclOn ",u',.uu "n'.. d. qu' '0 dl./don 10. OI."ftC on ,on.ncl' con'
NIII. d. I. .oc;oll"d COllYUgul, p,,,...Io,"'. .1 lollguulo "1.,,.0 · I.
,.lIollcl. dO 10' do,uchO' do p,op".dad OOIlI.IIldo Oil ,. ..e,"u" .
COl/lo. par .i.",plo, aop,oplod"d con do,ocho' d. .uco.,on I/oJnf
tunnncy), 'enulle/~ .n oomuII I,onanl: In common) 0 e/onU' do ,.
.oe/"d"d conyuu.1 Icommu.lty p,ope,'y) . 'I nO I" p,c.uno'on d.
QU. 10' b;ellOa ..11 do I. aoclud"d aanwugo/. U.,od d.co con..II"
" .u ocogudO 0 oOoo.>do 0/ douo qu" 10 p,uu,,,/clll dll qu. 100 cl,n"
.." dO I. I.cl.doll c..wuUuI aa copo,,"oua UII 01 /IIulo do ploplad.d
I".ri,1I0.
,.,-..-
WARNING: C~lilo"'"a I"" ~rQv"J"~ m..I, lor
IlUrpo~"" 01 dllll,,!on 01 ~rnnlll1Y Ullon diU-
ualutlon of marri~fJtf or IHnnl :ts'I'M~\lon.
proportl Required by Ih" part;"" Ollrlll\l IT,:.r.
riolJo In 101M 10rm I" Ilro~urnll<l to b,l ~orn'
,"unity ploperty, It ..lIner ll:ulY 10 tlll~ oc'
lion .hQuld ale Dotoru th~ Jo,nllY hold ""10-
munity proporty In CJil/lll~(l, tn. lanouage 01
hn..lltlo lu hold In Inc dllOd (I fl., Joint lun3h-
oy, IOhanlo In cmnmen, .or onllllnunity pro-
pOlly) ..ill bO cOlltrolllno and 1101 mol cnm.
mUltllY ploperty presumpllon. You :should
eonllult your attorney it you ..aliI tno com.
munllY property pro",umpllon 10 be. wrlllon
into m.. ,,,coraod till" to Ill" ~rorlerty, '
STANDARD FAMILY LAW RESTRAINING ORDERS
Slaltinglmme<l13Ioly, you 3nll your ~pnUt;c llr.. rll~tralllcrJ Irom
1, lomovin9 tno ollnor c~\la or chlloren of thO portlOS, II any, 'ron, tho state 1II11110ut thO pnor IIIrl\lon consunt of
tho OlhUr p..l)I or.n ornor ollno court:
2. casnmg, Dorrowlnu against, cano~IInQ. IInn~rOlrlno. ~I$pu~lng 01, ~r changln9 Ino Danahc'orias Of any Insuranca
or olllor coverage Inclu<llllg 1110, h031111, lIuIOO,ou,lo, aM OIsablllly Mid for thO coneflt ot the parties and melr
minor chilo or chllarr,n; and
3. transfarring. ancun,D.llng, n~pulnocatlng, concealing, or In an~ lIIoy dlSposong 01 any proporty, ,oal or pertonal,
whuther cOlomuOll/, qoo.i.communlty, or soparate, IIIltnout 1M wllttiln consent ot me Other party or en oroor
Of tno courl, tlxcoptlll tllu u~uol coursO 0/ bUSlno~~ or for Ih8 nocoSsltleS 01 life.
vou musl notify oocn olh.r of any propose<l o.1I0~roin.'y oxpenalturOs at loast Iova cusineSS aays prior to
Incurring IhUSO "xl/aordlnar>' e,pendlturas Qn~ accoon! to thll courl lor all extraorOlnary expenditures maaB allor
the Sa rest".lnlng o,OotS ore offoct'vO. ~o..evor, nolhlng In the r..tralnlng oroer. shall pracluae you tram u.ln9
community p,cperty to P;):I roasonaOle attorn.y 'eesln ora", 10 rOlaln legal coullsel in Ino action.
PROHIDICIONES JUDJCJALES f!STANj)ARES. DERfCHO DE FAMILIA
STANDARD RESTRAININC ORDI:RS. FAMILY LAW
PROHIEJICIONES-JUDICIALlZS F.STANDARES . DERECHO DE FAMILIA
A ullod Y 1I ou odnyuyo .. 'u. p,oh/LO
I. QUO ~oQUO" dol O~I;"]O 'Ji IlIJO 0 nljon mono/ll3 tJ~ ,". porte" ~I /:Js haY, sin CI c(lII.ont""/enro p,a'liO por asc,ito
tJ~ l:l 01'" parto 0 oln una ordM ,,~ I.. cO/IOI Y
. 2. QU" coor,," on ,,'OCIIVO, u~on COl/OO .:o'oloro' por,l PI"",wnoa, c.nevlon, b'Ms//tlrllll, OdacomJnUOII 0 oamlJlen /Os
/){n'e('CI~tio" 00, cuo/q"I.r pOh:a dd ~oau'o u oV.' CO"OrlUlJS dd 50lJUlll. InclUsi.e /Os dlt 'lid.>. sal.Jd, aurom6-.11
"IrtCuPur.IO..d monlolfllr/,) I'dro 01 o"ntllr.lo d" lac pnrt...O Y sU hip 0 /Iijos mono'o., Y
3. quo trull~/iOlnn, (/riIV...II. 11Ipvl<'(/UaI1, C"COlltJ~II 0 rN CU"""...r orr" mnMrll ollnjenOll CUOIqUIO' p,opl0<14d IJlI,JeIlItl
o Inmuea"'. yo 900n ,,1""00; U(} I.. <DC,oano CO,,>\l9"'. Quael roll>V(lalt:l. 0 alenao p,oP/OS ao us c6n)lJ90S, sin
01 con.onwlIl.nIO por utelllo lid '0 Olm pono 0 5'11 un.. oraen 00 10 cOrlO, ..xceplO on 01 CUISO nOrmal do /Os ne(lO'
clO:!1 0 pura IJlonai!f a l[j~ f)tfcC'~id':ltJ&:~ ae IJ \/ida.
U~I~ae5 dooell llohl,cU/$v .'n~o :;1 aoolO cu"I~'IoV' (lasCo ",,1100((llnorlo p,OIJUOSfO, POI'" monaD con cincO dl8$
dO "nlOlaclon (I lu ,,,cIlIA ~n Q~U ~d \.1r1 a IlIourror rJ/cnJO !p~IO" c-1r.>orlndarIOs y rosponcJd' unto la com pol tadO
(lastll uxtr"orrll,lnflO nOCllo ClM.('U'" w/ Q~O c,;l~' ptDIUW':'onos juU,ciale' Oll"on 011 Vloor. Sill ornlla/go, nadO dd
/0 conl~nlClO 011 los p,O/lloic,on..s ;"0,CIII\:5 k/ ,mp"",roi QIJ. U~o o'e'IUS 0" I~ SOCii:'<1da con>"9:>1 puril paaal nono,arios
l.uunpo/dS d~ /,ooOU,10$ ,on VI 1111 UO UOI"II.., ,cf./,v."nl"Clon/ogal (AJ,onto..1 proco'o,
~u-;-In -::-1-;-;-;:;-1 _._------:-UTAfiDAf10-1W~STH"'mi[G OHIlF.nS
I. 1I1..n,,' 1 ' . SUMMOtlS
, (Fan\i'~ LaW)
.---_.-..__...-..~_.._-
PIQetfwO
,.,.' . R _ _..._ .
. -- -- -. - - -~.
.. _ _ _... -:- _ _ 0..' _ _ _ _...... _. _ _ _ _ _ _ -.. .. - - - H
T
.----;--:--:
:..
'.
0;)-1:'-19;-: Ot,l 1:.1'11
FFOII
TO
"E17G3~12~7 P. 08
-iMJlHIAGC OF (lii:;t (h,Ulj\.', 'i,;;JII~ur.a r.11 Pilr~-
I'IIl.r.IM1S, Jr:AtlE'l'Tl~ C. & JEI'I'RE'. :J.
\"'
",\
~. Or:CU,nATION REGM'\DltlG COMI.1UtllW AND OUt.'51-COMMUIlIl'Y ASSETS AND OBl":l,\1'ICNS A5 CUHRENTLV KNOWN
:I.~~..~~" .8 T1ltHO :UU '\~l r.\Jr.tl.J,~.~...:~:..~~~~~tJi\tIOOG "~It~Ii:~t to dl~POC!tl~~ oy thU. C.2~I!~,t.~,~~l!~ ~r~Crl.~.~I~\J.,.. .......... . .... ...........-.
U. All ~uCh ,,::(0\: :J'llj OtllllJ~\I1,)1\51\aV~ h~...n lJl[WJSl1d or bj wrlltun n,Qrunmont.
c. nC] All tuch onccl'J ""J nUliUJ\lOn, ale litltlJ CJ '" Allachm~nt5 (Z] below (~PI'_"Y)'
'1'0 [lGt1tlon.~r:
$2000.00 cnzh out for oquity in Mobilo Home
1!109 l'onti<<c 'l'ruJ\s AlII, Licon:.!" ulllmmtn .,t filing.
'1'0 HL'lspone.l<1nt::
19B9,;11)OP Ch'\t'ol:oo, LicCll\!ic #"1"f9131 i;inc.l oncumbrance.
Mobile homu, In..\:f.l ancl tluriu1 # unknol/ll nt riling,
A.11 furnitUI:e, fUl'nishing!l, app1inl1col>, toolo, personal property in
his p05oeLl5ion.
6. PUlltlon~r rUCVJ..'rut. ' .
o. 0 D.tCohltlnll olUIU n'..1I .aU. bnr.nd ~n
(U 0 irror.cnclluhhl"hftotllncHc. rc 23l(J(;')
(21 0 ulcuratlie Ins301ty. FC2310(b)
I). C[J le~~1 SQpari\tiOn of thO pnttieC bO'icd I)n
(1) IJi.J Ineconcllable eJillornncec. fe 23\Oia)
(?) 0 ",cur,'I,le 1I\~""lty. FC 2311)(bl
c I ] IIUUllyO' '010"'allla9"na~"dcn
(11 0 lr,c~stU1)Ur rr..:urlago. Fe 2:<<.1
(2) 0 tjjfJ:tmouS rndru:Jne. Fe 2;;01
a. 0 IMlity ot vo,aalllnlnarrlago basna 0"
(1) 0 rln\ltlonor" ag" altlme 01 marriage.
fC 2210(0)
m B prcor .,Ilstlng rnalllage. Fe 2210(b)
l~l un~ouna 101110 FC 2210(C)
(4) 0 IrauO. FC 2210(0)
(5) 0 tor_e. FC2210Ie)
(6) 0 PhyElcallncapacl\)'. FC 2210(11
1. POllllu,wr rdquoot~ thallll" ,:ourt yr anI the abOvO ,,:1,01 ,M ma..lnJunctlvn lIncleO,ng reStraining) ano OIlier orders as 101l0WS;
Potitloner
a. loonJ cUSIOOY of cMorcn to .". .. . , .. .. . . . . . . . . , . , . .. . . .. . , , . .. .. .. .. . . .. 0
b. Pllysical custooy 01 cllIl'lIon 10. . , . . . . . . . . . . . , . . . . . . . . . . . , . . . , . , , :. .' . , . . . . [KJ
C, CIIIIO vlGlt,tlOn no 91,r,toa to, . . ,T\I'N?9~iJ\AI.'J;. . . .. ". ,.,.... . ., -..,. , . . 0
o tupmvltrO a~ 10 (sprc,ly):
d. Spousal ::upport p:a)'tiblll uy (,~~IjQ aSSlgnn'tHll Will bO i!fcueCJ) , . . .. , . . ., . . . . , f . . . . 8
11, AttOrnoy lees and C.O$t'J P;')'llt)IIJ oy., . . . . . . . , . . .. .....,. I . . , . . . . . . . . . I . . . .
f. G{] rcrm'"~te 1M CCUIt'S JUllSdlction (nUllity) 10 ~.ara spousal suppurt to respondcnt.
g. 0 PIOpdllY flgllts 00 deWIII,"Cd.
It (]] WI'.'S lurrnur IlJlno UI"ctloreo (speCil}'): DOUGLAS
I. []J Ollie! (spec"Y); RESPOllDf:ll'!' ~IILL Ph'l r>m'ITIOllER $150.00 PER I'lOtl'I'H AS CHILD
SUPPORT,
H. II Ihorll ole n\lnor ell"ll,"n or linG 0'011139., tile courl 11111 maha oroers lor tM supporl 01 tile chllorun wlthoul 'urlher nollce 1
.,tll.r pally. A wag' dS.,Yllo,onl "HI bo .SGlleO
R.uPOnCl.nl
o
~
Joint
0Cl
B
8
0, I hnvo read II,,, l(lolr"ln.no ard.rs 11I\ IhO hllcl, or Ihe SummOllG, 3110 I un<1Cr5land Ihat Ihoy apply to m"whon ltllll poUUO" IS Nt '
I duel,lle uMer Il0nJlty 01 per ,UI y ulldel 1110 13WS ollnll ~IJIi, 01 COII,ornlO,thOI tJ\u 1010golllg IS true anO corroct.
0,\1.
,1uly 10, 19!15
~:----.. ~"
~\. O(\.........?>'.~Q\. '.. ~ r. ~.\J\.~:._,"^'':>
l~lal.AtUHt ~F pftlllONI.RI
,
JEAN~StE c. WILLIAMS
,....J.F:~!1.~.nf.s.,.y~LI:I!~I..I~I............ .. ~ IN 1'110 I'Lm
~T1III. Oi, PiHllt ,.J..IJII cr ..rTr,Il"['r) '51~'''Jl,jRi 'l;-f ATld"i1itt 1 fCh P"f1110ftiPl I'
1I0TICU; 1'111000 IUVleW yOUI .,II,II\lUlanCU pOIlClO1&, lulllelT,cnl benut" fllaM, ~leOlt COldO, olnor "IuM o~~aulltn lno CIOOlt repollS, "'
Ollltl IIIollorS YOIl may W~lIt to CI,;,09'; ," VIOII ot tI\l' ClI,~olullon or M,nul/II"OI 01 your malll(lU,l. or your IUO"' ,..porallon. lIoweV
SOInO Cllon9115 1I1(IY tnQUIfl! IhO ;19"':0,Cllt 01 your rl,ouLU 01 " coult 0100' l~eo F"nlllv COil. totMn= 23\.23til
-----------. PEIIllON
'~'fU (llt"1 unololl'f" l'I~.f.,1
(Family ~all)
.- - ., -y-
8
Q3S01:>,N:I; "
rSQ'MOj3~'V:>la3W
~~S8~;C
'.'-.; \. _ ;,_," ) ". i 'I"".',~
...",.,. I ..,..,,~ I~''''''''''''''
~-, : ,
V1
o
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<(10"-
-0
..... \'
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we;::
8....
u. <('
Zu
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o
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0:0::....
0;:)<
o..:co.
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'I
06/09/95
,ntONtlflHAllOIH on lene-r.r.r.-.lU
WILLIAMS, JEANETTE C,
32 CENTER ST LT 13
-;);,J
I. '''.OU[/IU,t,IOfI . C.'4O
HOLL Y SPR I NGS. PA 17065
556-43-3959
0''''''
TO BE CHECKED BY ER DOCTOR
LAC AND CONTUSIONS TO FACE
BRIEF VISIT
ClASS I VISIT
ClASS 11 VISIT 26720
ClASS 111 VISIT 26730
ClASS IV VISIT 26740
ClASS V VISIT 26750
CONVENIENT CARE I 27020
CONVENIENT CARE 11 27025
MINOR SUTURE EDSO\
MEDIUM SUTURE EDS 02
MAJOR SUTURE EDB 03
INTUBATION EDB 04
IV SETUP EDS 00
CARDIAC MONITOn EDS 11
PELVIC EXAM EDS 14
NITRO SET.UP EDS 16
CAST, SCOTCII SIlOnT AnM 2603\
CAST. SCOTCll LONG AnM 25032
CAST, SCOTCII sllom LEG 26033
CABT, SCOTCIl LONG LEG 26034
/;,0.0
~'AI.L\ AllllmoNAli.CHAlIlln
, ----~,--------~
I II I
I II I
I II I
25000 \...___ .J \...___ __.J
26040 , - ~ , - - - - - - - ~
79670 : : : :
OOOS\ I I I I
\...___ ___.J\...________.J
26074 , - - - - - - - - ~ , - - - ~
EOTATI II I
I II I
POXED I I I I
28700 \... - - - - - - - _.J \... - - - - - - - - .J
,-- --~, -----~
26770 I I I I
I II I
I II I
\...___ .J \...__ ___.J
---~ ,------- ~ ,--------~
1\ II I
II II I
I I II I
_____.J \...__ _____.J \..._ ___.J
------ --,,--------'r- ------,
I I II I
II I I ' I
I I II I
____.J \...______ _.J \...________.J
ER.0508 InEV. 11941
CAST ROLl, PLASTER
BIP MONITOR
PACER PADS
GASTAOmEMO SLIDE
KIDDE TOUnNIOUET
OCL PER FOOT
F.soe.
TUOE GAUZE PEn FOOT
ED STAT
PULSE OX
EXTENDED CIlAnGE I
EXTENDED CIlAnGE II
r
I
I
I
\..._--
r--
I
I
I
\..._----
_,I
"IIU4/01l1[11[",I\.OlUI
LAKE VIEW HEALTH
BOILING SPRINGS. PA
Olwwnun 8 t.l1'lOlll
ll.l[II(lI.NCl'NOIlf"l'
WILLIAMS. JEFFREY S.
(7171486-5576
. 02
DICAL INSUJW<<;E
ED/AIIUP.o
JR, SEBASTIAN THOMA
REFUSED-
NURSING DOCUMENTATION - EMERGENCY / CONVENIENT
DEPARTMENT CARE CENTER
TRIAGE NOTE: Dolo: j - / (!. ~~
T,lngo Slnlus: Modo 01 Anlvnl: AnlJfr1-1/;ith:
[J P,lo.lly I [J ALS [) DLS 0 Pollco D Frlond
fJ P,lorlly II D Ambolnlory rJ Pn,onl D Fnmlly
[J P,lorlly III D Whoolchnlr 0 Soli D Othor
D FaSlTrnck" ,11 ICnrrlo~ ......"" +v (\ I 'Ct ),+
~~I,~05Inlnl~>R,'$t't~LJ~~r; (I'L0.l1..D.&-~
bl/;J(,- -~f'-I-J-!-1;S-~"'U- 7'
_ft--ouSCC -..3-../- _(&'!kdlL
Oosol 01 Symploms: -~t:el-
Norslng Acllon/Commonls:
Childhood Immunlzallons: D UTD D Novor D
Tr\"~ r~~ /111al:
@)Carlisie I-~t
COPy'lghII092
NA~E \1., U/1\A~b_:.LlG~'- LCLLJJ~
ROO"'iJ~--;- AGEOt~_-W.l) o/,-
VITAL SIGNS: TIME _:4.3'j~T~b~-i-j----'
P ~-~-'-R -I~ - DP-I-'--(-7~
ALLERGIES: ":'7:Y_/W
CURRENT MEDICATIONS: _ _
TETANUS STATUS:
~hln 5 Vonrs
D 5-\0 Vonrs
D Moro Ihan 10 Vonrs
D Novo,
COLOR:
. e-OOOd
[J Palo
SKIN:
-erwnrm
D
D Flushod
o Jaoodlcod
D Cool D Ecchymosis,
D Clammy D Rash,
= GENERAL APPEARANCE
I'lJjJle:
~ ~ogulnr D Inogolar
D Full 0 Wonk
RESP: D _ ghnllow D Rapid D Audiblo
D~ L:~rod B ~:~~or D ~~~:;I?on3
= TREATMENT IN PROGRESS ON ARRIVAL:
D CPR Down Tlmo min_
D Airway - D Orol, D Nnsal - Slz
D ^,rwny, Endol.achoal - Slzo
D Airway, Nnsolrachoal- 0
D IV - Solollon Silo
nlghl: 0 nalel C Whoeze
a Rhonchi 0 Absent
Loll:
D Olhor
TRIAGE NURSE SIGNATUR
Slzo
o Monllor - Rhylhm Rnlo
o Oxygon - 0 Mask, 0 NC - tJMin
o Splnnllmmobillzallon, ~
o Masl. --
o P,ossuro D.osslng U Olhor
~un Sound.:
o I
fA
Mental AII.llmenll
Mood/Alleel:
~opllalo
o Blunted'rlal
o Dolenllve
o Arlfuohonslve
o nestlosslComblttlve
Thought:
~rOnlan"ous
o VoguolOlsconneclod
o DllOllonlod
o Slow 10 Answor
o narel
o Rhonchi
C Wheeze
o Absent
Popllll t. .
RighI. Slle
Rooctlon _ 2. .
~SIIO
fA Reacllon_ 3. .
4. .
5. .
e. .
Vlloll Acll,lty.
00
OS
o Wilh Olasses
o Wilhout Glasses
SUBJECTIVE, yauso of InjorylHlslory 01
-b-(-M'~/y::d~
OBtECTlV/i1 Physlcnllnfo.mll1on (t'/ha'.1ou Of 0 ablo I")soo)_ =tt:s t9;bZ1D:::
-f-'lFt-t-: r-r-r.(1- -Y-'l~v:.~....b"(---fJ-tlt:C
-
PATIENT PROBLEM: Nursing Dlngnosls
_ Uoncompliance
_ Sell Calli Delicll
_ ComlOlt, ^'le,ations In:
__ CommunlellliOll hf1p.'\ired
_CopIng,lnflllocllvG
_ fluid Volume, ^'UHAIiOllS In:
___ 0:'1 Elchn"go, l/npAill!d
Tissue Pmlullon. All III
_ Skin Inleority Impal,ment
_ TtW'ugh1 Plocesses, All. In:
__ IfYflO,the,mla (Fevel)
_ Inl~ll"n, rolentlal
~,y. rolonllnl
__ Knowledgo Delicit
._._ Mobility Imp31100
__ .Othm
_ Airway Clealance. InellecUve
_Anlloty
_ Ufealhlng rallcfIls, lnollccllvo
_ Cordiac Oulpul, Doc'oltSod
Other
OUTCOME/GOAL: Expoclod by Dlschorgo: ___~__~__ __~b_____
[iE~~~__~.~iIl~:-~~.--_~_:-~:~--~_-_.._.~~.~~~:_. -~=
;> -- :.D
J;)~CiL-:::- ______~ u~_ _._.. m tlIlIlS(S SImlA1UIIE
En 2010 (4194)
c:..
.n:;
o Dusky
o Cynnollc
o NaUbods
o Circumoral
o Lacorallon
o Edomn
~..0.!:
DRUGS:
.--.
./""
.--
..
Speoch:
~'Clel\r
o Sirenl
o Tal1lallve
o nepolillvft
o Mumbling
...1\AJnDrY-
o Intact
o Impalloo
o nocenl
o Dlstant/PaSI
VI
~ .
~ M
M tJ'^
_#_0
LMP:
N
(-..I-{
-l:~f
-/
a
PLAN OF CARE:
o Malnlnln Pallonl Airway
Ll Monilor Cn'dlovnsculo, Slalos
o IV 0 DP Mon,lor
o EKG II Cnrdlne Monllor
o Sa'oly Moasurns
o no.lrolnls rJ Solcldn Procnutions
[J Solzuro P,.caotions
jJ-eldo nails Up
""t::f" Comlort Moasuros
o Pnln Conlrol
o Pasilion for Comfort
[) Prspnm lor Ellam
[) e.plnln Proceduros
[J Emollonnl SI/pporl
lJ Palool Toachlng
f I Dlschn,oo Insl'l/cllo.'s
U 01"0' ____________
1101"0'________
[I Olho, ___________
IJ Olho, ~__
a IV FLUID: c MEDICATIONS
-
Type/~ml. Bill Clth. 8111 lime Slonlturl Med, 00" Route 11m. Slgnatur. .
-- - -
-
-c - - /
- /
/
-. 7
/
a TREATMENTIPROCEDURES: , 7
o RESP. THERAPY TREATMENT
0 TIME TIME TIME = INTAKE: / = OUTPUT:
o OXYGEN UMIN IV PO 7 .
-
, Typo AmI. Typo Arpt( Urln. Emili, Other
o INTUBATION' SIZE TIME
o ABG'S TIME TIME TIME 17
-
o PULSE OX TIME TIME / -
o AIRWAY. TYPF TIME /
o NIISOoASTRIC TUBE. SIZE TIME = NOTIFI~~ OF:
o GASTRIC LAVAGE AMT o Ho.pll.1 SccI 011<" o Fnmllv Docler
o F.mlly o Coroner
o FOLEY CATHETER. SIZE TIME o pollt~ 7 a Consullanl
o ~ lnlorvo"Ilon o Olher
AMT. OUT COLOR I q..r titlIng Home [) Other
= VITAL SIGNS. 0 ON Bp MONITOR
o MANUAL
/
"
NOTES: ,
Time BP p R /
/
-:7
- ,
,/
"
- ,
-----'- .
, ,
-
-
-
J., EVALU~ON AND DI~CHARGE NOTES: (/1;; ~ -. /1 /. .J. .,.,~-j {':.fJ. . ~:!- j!:'~~,;-
AM" ., ~. .-j:~ ~i ~,7JQ 'd- /P f",..-o "I
1 -/-/ 'J - -v (.
I!Y"PATIENT I FAMILY VERBALIZED UNDERSTANDING OF DISC flOE INSTRUCTIONS.
DISPOSITiON:
o Admlllod to:
o For ObseNallon
to:
[) Translerrod to:
DISCHA!JOE:
t!1mbulalOry
o ^mbul1l1ory C A5Ilslanco
[) Wtu,olchnlr
o Ambulance
OIhot
o S~
ttvt"'Rmlty
o Fflend
o Police
o Valuables
~RlnEN INSTRUCTIONS GIVEN
o Cho.1 0 UTI
[) Crutches 0 Kktnoy StOflO
o Ab,l. Problom 0 Polvlc Inl,
o Wound CIUO 0 SpralniOlulse
o Clear liquid [) Asthma
a rever [) OCUCas'
o ~ n Il.od Injury 4J.
_6:.._~~t.. ' NURS~'S SIGNATURe
~I
o Other
o Other
o Morgue .. I'JJ. .
P:TltNI'C NAMe ;(/;dl"..~4c1r...,)rje~-
.
Name of
IIttending Phyelcian (e). t:.,/?
/;/9/fS"
(!it Carlisle l-bspital
CONSENT TO HOSPITAL ADMISSION AND
MEDICAL TRElITMENT
};),e
Date of IIdmisoionl
Time.
(AH)_____(PM)____
1. I, (or
lJ .dtt-er;'~
acting on behalf of)
~
r,UMI
conoent to ren ring of such care, which may include routine disgnostic proc.dur.. and auch
medical treatment as the named attending physician(s) or othsr of ths ho.pital's msdical
staff consider to be necesoary.
N.m. or AUlhnrbl'd R.p...Mt.th.
, ouffering from s condition requiring hospital csre, hueby
2. I understand that the practice of medicine and surgery is not an exact ncience nnd
that diagnosis and treatment may involve riske of injury, or even death. I acknowledge that
no guaranteoo have been mado to mo as to the reoult of examination or treatment during thin
hospitalization.
3. I underotand that.
(II) It io customary, absent emergency or extraordinary circumetancee, that no
oubotantial procsdures are performed upon a patient unleee and until he or
she has had an opportunity to diecuse them with the phyeician or other
health prOfessional to the patient'e satisfaction/
(8) Each patient hao the right to conoent, or to refuse coneent, to any
proposed procedure or therapeutic couree/ and
(C) No patient will be involved in any rusarch or sxperimental procedure
without his or her.full knowledge and consent.
4. I underetand that many of the phyeicians on the etaff of thie hoepital, including
tho attending phyeician(e) namod abovo, are not omployees or agento of the hospital but,
rather, are independent contractors who have besn granted the privilege of uning itn
facilities for the care and treatment of their patients. Further, I realize that among thone
who attend patiente at this hospital are medical, nursing, and other health care pereonnnl
in training who, unlese requested otherwise, may bo preeent during patient care as a part of
their education. still or motion picturee and closed circuit television monitoring of
patient care aleo may be used for educational purposee or for documentation of the clinical
coureo unleee a patient exprosely requeSte otherwieo.
5. I releass CIIRLISLE HOSPITlIL from all responeibility for all articles which I am
retaining' or will have with me during my stay at the hospital. I understand this includes
clothing, bridgowork, faloe teeth, eyeglasseo, jewelry, money, radio, razor or any othsr item
kopt in my possession. I underotand I may deposit valuablee in a eefe provided by the
hospital/ only if this io done will the hoopital assume eny reeponsibility for the
eafekeeping.
6. I hereby acknowledge that I have received written information on the topice of
Patient Rights and IIdvance Directivos.
(SIO lITURE
I..-
(If patient io unable to
Patisnt lio a minor ____ yearo
C'"f'A?~IJNATURE OF WITNESS)
conoont or io a minor, completa the following.)
of 8gS) lio unablo to conoont becauoe).
(SIONllTURE OF LEOllL OUIIRDIAN OR
CLOSEST IIVIlILABLE RELATIVE)
(SIONATURE OF WITNESS)
1\0 0315 (10/91)
CARLISLE HospiTAL
246 PARKER STREET CAhL,~LE PA 17013.0310
\\~
CONVENIENT CAREIEMERciENCY REGIS~A~dN
.
'~~ '"~ '-\ ..~ d V5~~\ ~ I~- _.'L I' 1-.5'1 I .
~N.f)~ Q)
, u .J I ,
FOR NURSING ASSESSMENT
SEE NURSING DOCUMENTATION SHEET
:;'.1..1 (# 0 0 ^.(.4 " \ ,,':'r.1t 1'0" ^"Y. /1 A ~ rA Vb-r>.A. \M! lk-
l.'~ . i -~ ,( .w- -h::.. c.j V-..: T (. o-.r1 On LO^A
(xt.f)r-- u ,
,
noY ~~ ~ ~ \. ,1\ r- "'.... 1Mt""L- I. ~ ot rC) r .r". f.L. ~(! (J f, lu
('j ... _(1:)1. J.n ., 'b-~ z .. .~O n" ~ f-__ ...
\ n fM. tC\ ~ ,
\ r ~ t r. n /r::) It.:.v. Co u. j) IAN>- L -d. C:" I. - Iv;.. r n'-.
\ /. Y 01...... -" .is ...... T .. ~/
.
'1_}c"'\O c.-.r '\A-tC) 'i-oll.rr - o~
.
II'" '}' I () fi7"'. I' n~ LMP:
.
"\.1 - . ,. -.~ -..J _
77
( )C-;,. ~ "' \
.,L? -rpg f\ ~ r AL ......... . '\
-
f)-I r n... A.J) ~ n. _ _ ..l- '" ~)~ )
\: ~ L 1'1'"
-
_....r..'1:~v
U).'-'
.~, r
:... -""
-tiC ~, ,n'd \1 ""'; ND '<.
. -
~_IUI'Ef,()f4~It<<l"ll!tJ'HJ ~'(
I
".~,.... ~H} It. { i:;-" ......... NONElJ
~:~., 0 0 0
~(I II(>>,lE ,AoliJ" OOS TRANS OIllEn
. 1-... Of Ol'll".J1AAO[ I COHtII~OH~Wtllf.~
i.\.,. ~\H.I (L.- ,.{(j....tA. 't.X IJ~~ IJv'-. 01 JtJ j o SA"'';... I'ROVEO
('tI.i \ J."-./) '^~. h '-,'1Jv.. \J.-Or-Q~ ifA. DISPOSITION FROM E1ED o CONVENIENT
CARE CENlER
I ;'l\a,f,' II ~ IIII' or , "'..,,, I'" NOll,llD T"'I 1HlT. "'11'01/010
I. ArE 'lSOI7 O~.
IEI... IIr! II [/ r ',It
~,."' -... 1 ,.,.Hf H'" 1","""''' ~ ., vI"'"
9064874 WILLIAMS, JEANETTE C. 1)",/3\" 'l~', ? f) : ~~l I .~(;v F /~il)r-I W
ER.0500 IREV. 7/04)
@CarlisleHoopital
Copyr 1992
NAME~ ~---.e.Je..O LOti Ild.rns
ROOM' AGE _~S:::. -I'(T.
VITAL SIG,N;;: TIME G..Olf S . T ..6p _
P _l5!f- R 7\7j.'?,d)_ Bp -I,08/B-
ALLERGIES: _/J.t:.VIJ .
CURRENT MEDICATIONS: .!\.Dn.e. .
En 2010 14/94)
NURSING DOCUMENTATION - EMERGENCY / CONVENIENT
DEPARTMENT CARE CENTER
Dalo:5.::..~/- 5
Anlvod Wilh:
o Pollco rJ fllond
o Paror'l HFamlly
o 5011 0 Othol
TRIAGE NOTE:
Tllngo Slalos: Modo 01 Anlval:
o Pllorlly r rJ ALS 0 BLS
[] Pllorlty II ~ Ambolntory
~ Prlollty III [] Whoolchnlr
lJ Fasl Tlack 0 Canlod
iif?d~J.itk..L> - - ~ .-:::..
,_=, ~_ _ ~,"-SfU1J~ ~Ck
On,ol 01 Symptoms: ',Ptl'1..c--
No..1no AcllonlCommonlsl _l.C.L
Childhood Immonlzallons: 0 UTD 0 Novol 0
Tlontmonl Prior 10 Anlval: J.C,.l..
TETANUS STATUS:
~lIhln 5 Voa..
o 5.\gVoars
o Moro Ihan 19 Vonrs
o Novol
,C:QJ.,OR:
IllS;Good
o Pnlo
~!S1N:
l!!Ol rm
ry
o Flushod
o Jnuodlcod
o Cool 0 Ecchymosis,
o Clnmmy 0 Rn'h,
o Othor
TRIAGE NunSE SIGNATunE
o RoloS
o nhoOChl
Pupllo: 1. .
nlghl' Slle
Aellctlon_ 2. .
Lell. Slle
~^ Roacllon_ 3. .
o Monllor - Rhylhm
o O'ygon 0 Mosk. 0 NC
o Splnnllmmoblll
o Mn
Slzo Isssuro Drosslno 0 Othor
Menlll AII,"ment:
Mood!^"ecl:~: Speech:
ppropflalo ~~tearISponlaneOU~lmaVClear
D Blunted/Flat [] VaguolOlsconnocled 0 SlIenl
D Delonslvo 0 Dlsorlonted 0 Talkative
o App'ohonslve [] SIaN 10 Answer C RepellUve
D RestlesS/Comballve 0 Mumbling
.
4. .
So .
So.
Vtloll Aell,lly,
00
OS
TIME: ,d:L
o MEDICAL 0 PSVCHOSOCIAUEMOTIONAL
[] With Olassos ~
tl WIthout Olaslos..---tJ NJA
LMP:
PATIENT PROBLEM: Nursing Olnono,ls
_ Skin Integrity Imp:tlrmonl
_ lhought PJOCftI501. Art. In:
_ tlyportho,mla (rovo,)
_ Inleelion, Polenltal
_Injury, Polenllnl
_ I<nowlooge Dencil
_ Mobility Impaired
OlhfH
_ AlrwaV Cleaumce, Incllectlve
_Anllety
_ Breathing PalloUls, InellDcllvo
_ Cnrdlnc Outpul, Dcc'eDlod
Other
_ Noncompllanco
Sell Cmo DillIe"
~Of'1lort, AllclRhons In"
___ Communication bllP.,hcd
_ Coplr\Q. Innlhtellvo
__ fluid Volumo. A'lornllons In:
_ 0". Elchnngo. Impaired
lllluo Prulu,lon. ^'I Irr
OUTCOME/GOAL: E'pIIctod by Dlschnrgo: '____'____'____
rn:1:su~t,.~-'=-=-.:,=~~--==~=~-.:::- :~- =::-- ----,-
'3 -----.,---.
'j~~ m______~-
o Ousky
o Cyanollc
o Nallbods
o Circumoral
o Locorallon
o Edoma
Momory:
n'rilit(t
o Imp,lred
C Rocenl
o Dlstant/Pasl
~
.-
..
VI
r
..
~
..
.
= IV FLUID: = MEDICATIONS
TyptlAmt. BII' e.th. BI.. 11m. Slanllur. 1010<1. Dos. Roull Time " Rlanllur. "-
, \f~ _ nA. .1.1- --r- InC'\ f.::I~.....' .,:)1(. h..J
"- . T
-, ]
"'- /
/
" /
= TREATMENT/PRoc'EounES: /
o RESP. THERAPY TREATMe..T /
0 TIME TIME ~. TIME = INTAKE: = OUTPUT:
o OXYGEN IN _ IV PO
o INTUBATION. SIZE / TIME Type'" AmI, Typ' Ami. Urln. Em/_ other
o ABG'S TIME - ""ME " TIME '"
o PULSE OX TIM= / TIME "'- ........... V
o AIRWAY. TYPE / TIM)". ...... ./
o NAS~~~~BE' SIIF TIME' = NOTIFICATION OF: ~
o GASTRIC AGE AMT , o Jlo,pllal Sodal WOI1<o'.7 .ml~ Dodo,
"'- C Family 0 Cor
~~Y CATHETER. SIZE TIME ... o Police --"'" 0 Conlulli'rir:.
o Cflsl~enUon 0 Other ..........
A T. OUT COLOR [J Nursing Home 0 Other ........
= VITAL SIGNS. 0 ON Bp MONITOR 0 MANUAL
TIme BP P R NOTES:
rb ~ "'^-".J\ d-- IJ. ~ ~
--.
-
= EVALUATION AND DISCHARGE NOTES: Pl: 0.( ~
Ja-nU. il-1I.~ bl c "~&oiF~'
PATIENT I FAMILY VERBALIZED UNDERSTANDING OF DISCHARGE INSTRUCTIONS. ,
DIS OSITION: DISCHARGE: P' WRlnEN INSTRUCTIONS GIVEN
o Admnled 10: )>fl\mbo'.'ory jr'!;." 0 Ch.,t 0 UTI
,I ci Ambulalory c Assl,lance 0 Famll~ 0 Crutches 0 Kktney Slone
o WheelchaIr [] Friend 0 Abcl. Problem tl PeMe Inf.
a Ambulanca 0 rolice 0 Wound Care 0 Splaln!8rull8
Other 0 Valuablos (J Cloar Liquid 0 Allhmn
a Fovor 0 OCUCB!l1
o unl 0 It.ad Inlory
...~~~ NunSE'S SIGNATUnE
~ General
o OIher
o Qthllr
o for Obsorvnllon
10:
o Trnnshmlld 10:
o Morguo
PATlENT'B NAME
.
(& Carlisle Hospital
CONSENT TO HOSPITAL ADMISSION AND
MEDICAL TREATMENT
Name of Attending Phyoician (D)'
Date of lIdmieoion. .J- 31 9C;-
Time.
(AM)_____(PH)----
acting on behalf of)
. or Auth.rbrd R.p....ft1'.t1..
, ouffering from a condition requiring hospital care, hereby
NIlm. or r. t
consent to rendering of euch care, which may include routine diagnostic procedure. and .uch
medical treatment a. the named attending physician(e) or other of the hoepital'. medical
staff coneider to be noceosary.
2. I understand that the practice of medicine and surgery is not an exact .cience and
that diagnosis and trsatmsnt may involve risks of injury, or even death. I acknowledge that
no guarantees have been mads to me ao to the result of examination or treatment during thi.
hospitalization.
3. I understand that,
(A) It is customary, aboent emergency or extraordinary circumstanc.s, that no
substantial procsdures are performod upon a patient unless and until he or
she has had an opportunity to discuss thorn with the physician or othsr
hoalth professional to the patient's oatisfactionl
(8) Each pstient haD the right to conoent, or to rsfuoe consont, to any
propooed procedure or therapeutic course I and
(C) No patisnt will be involved in any re.earch or sxperimental procedun
without his or her full knowledge and conoent.
. ,
4. I understand that many of the phyoicians on the staff of thie hoepital, including
ths attending physician(s) named above, are not employeeo or agsnto of the hospital but,
rather, are independent contractoro who havo been grantod the privilege of ueing it.
facilitioe for the care and treatment of their patiente. Further, I realize that among tho..
who attend patiente at thio hoopital are medical, nuroing, and othor health care per.onn.1
in training who, unlooe requeoted otherwioe, may be preoent during patient care a. a part of
their education. Still or motion pictureo and clooed circuit television monitoring of
patient care aloo may be uoed for educational purpooeo or for documentation of the clinic.1
couroe unloos a patient expreooly requeoto otherwioe.
5. I releaoe CARLISLE HOSPITAL from all reoponoibility for all article. which I am
retaining' or will have with me during my otay at the hoopital. I understand this includ..
clothing, bridgework, faloe toeth, eyeglaooeo, jewelry, monoy, radio, razor or any oth.r item
kspt: in my possession. I underotand I may deposit valuables in a oafe provided by the
hoopitall only if this 10 done will the hoopital asoume any reaponsibllity for the
safekeeping.
6. I hereby acknowledge that I have received written information on the topic. of
Patient Rights and Advance Directivco.
31-95
J
(If patient 10 unable to coneent or io a minor, complete tho ollowlnq')
Patient (io a minor ____ yearo of ago) (10 unablo to conoont bocallool'
(SIGNATURE OF LEGAL GUARDIAN OR
CLOSEST AVAILABLE RELATIVE)
(SIGNATURE GF WITHESS)
""" (I n 1995
GPS.t,bs"
LEGAL SERVICES, INC.
8 Irvine Row
Car\lsle, Pennsylvania 17013
(717) 243.9400
Fax (717) 243.8026
West Shore (717) 766.8475
November 8. 1995
FII""llnrlfmUIIf
OllllbtNou'" p'fI'"lMnll 11201
1'll)lM.llll
fn S. WI"'I"llnfl SHut
OcllJthl,a. hlu"r",."lt I un
(111)))4.7A1J
Carlisle Hospital
246 ~arker street
Carlisle. PA 17013-0313
Attention: Hedical Records
Dear Sir or Madaml
We would like to requeHt the medical records of our client.
Jeanette o. Williams. The records are to be produced for a
hearing on November 27, 1995, at 2:30 p... in the Cumberland
OountT Court of Common Pleas before Judge BaTleT.
A state law allows a health care facility to reepond to this
request by mailing or delivering sealed certified copies of the
medical records to the party requesting the records.
The records we are requesting are for the following dates:
June 9 and 10, 1995; May 31. 1995: and February 21, 1995, Any
other records pertaining to abuse should be included also.
Please mail these records to our office prior to the above date.
If there is a problem with mailing theBe records prior to
November 27, 1995, please contact our office immediately.
You should:
1. Make copies of the records. and attach a statement
reading as follows:
n(Full name of patient and medioa1 reoord number,
and a number of pages in the medical record for which
this oertification is made) are true and complete
reproductions of the original or microfilmed medioa1
records which are housed in (name of health care
facility). The original records were made in the
regular course of business at or near the time of the
matter recorded, This certifioation is given pursuant
to 42 Pa, C.s. Ch. 61 subch. E (relating to medical
records) by the custodian of the records in lieu of
his/her personal appearance.n
SERVING ADAMS, CUMBERLAND, FRANKLIN AND FULTON COUNTIES
.
UnGlIll
'11 VlOU8 E
SCHNITZLER
7I7-2l5.5500 CONVENIENT CARE/HMERGENCY REGISTRATION
, .
3 i 4 8695827
I
'XI
WILLIAMs. JEANETTE C,
32 CENTER ST LT 13
',' ,.
~T Ho~LV SPRINGS. PA17065
NAl,IE' AOOIll&!I I non; /11(LAllOf"POO , 5UC.5(C.UO
WILLIAMS. JEANETTE C.
32 CENTER ST LT 13
26Y F W M.
09/23/68
556-43-3959
MT HOLLY SPRINGS. PAI7065
556-43-3959
o
~I
Q~~ 5SlP I/-~ 6959
f1tA5O!I on V1SIT
PT ASSAULTED HIT IN L RIBS
BACK OF HEAD. L EYE
WIll MAIL IN INS I~FO
BRIEF VISIT
CLASS I VISIT
CLASS II VISIT 26720
ClASS 111 VISIT 26730
CLASS IV VISIT 26740
ClASS V VISIT 26750
CONVENIENT CARE I 27020
CONVENIENT CARE II 27025
MINOR SUTURE EDSOl
MEDIUM SUTURE EDS 02
MAJOR SUTURE EDS 03
INTUBATION EDS 04
IV SeT UP EDS 06
CARDIAC MONITOR EDS 11
PELVIC EXAM EDS 14
NITRO sET.UP EDS 16
CAST, sCOTCl1 SIIOnT ARM 26031
CAST, sCOTCII LONG ARM 26032
CAST, SCOTClt SIIOnT LEO 26033
CAST, SCOTClt LONO LEO 26034
CAST ROLL, PLASTER
BIP MONITOA
PACER PADS
OASTROIIIEMO SLIDe
KIDDE TOURNIQUET
OCL PER FOOT
F.SBS.
TUBE GAUZE PER FOOT
ED STAT
PULSE OX
EXTENDED CIIARGE I
EXTENDED CIIARGE II
r ----
I
I
1
'-
r ----
I
I
I
'--- ----
C. If ( [I IlK
I I
I ,[II
NONE
'A lit, 10 1l1llfUI\UyUl
SARA TODD NSG HOME
CARLISLE, PA 17013
OtJAflANlOfI S (""'01["
("'[IlQlPICYNQI.....
WILLIAMS. JEFFREY S.
(717)486-8995
. 02
UlO!CAL',5l/RANC.f S
SELF Il"y B
(O/AI1ENOtIO
KURLANTZICK, ROBERT L
NONE, REFUSED-
;J0l
All ADDmONAL CtlAROE9
26037 r - - - - - - -"I r - - - - ,
I II I
79064 I II I
I II I
26060 '-__ _____.J '-___ _.I
26040 (" -----, r--- ,
I II I
7907G I I I I
SOOOl I II I
'-_ -----.1'---- .I
26074 (" - - - - - -"I r - - - ,
ESTAT I I I I
I II I
POXED I I I I
'-_ ______.J'-________.1
26760 (" - - - - - - - -"I r - - - ,
20770 I I I I
I II I
I II I
'-_____ --.1'- _______.1
,r- ---- -"I ("--- ---"I
II 11 I
11 I I I
I I 11 I
_.J '-___ ____.I '- __.I
,r--- ---"I ("--- ,
11 11 I
11 11 I
I I 11 I
___.J '-___ _.J '-_____ __.I
ER.0500 (REV. 7/041
NAMBI WILLIAMS, Jeanette
KR.#1 685405
DM'E1 02/21/95
~ ROCH JUXXlU)
ailE!' CCI<<'U\IN1'I Evaluation after an assault.
IU8'l'<RYI 'Ibis is a 26-year-old wanan who states her husbard beat her this
eveniN1. Shs has told him that she wants a divorce. 'lhey have been married
for three years. lie has hit her in the rerrote past. 'lhese episodes of vio-
lence have begun again. lie hit her last week and she sustained ecchyrroeis on
the left inferior orbital rim. She states that tonight she was beaten with
fists. 'lhere was no loss of conscia.lSneBS. She was hit on the back of the
head, on the face, and on the left side of the rib cage.
Pl\ST MmICAL HIBTmYI Unremarkable.
MEDICATICHJI None.
tlLLERl3IESI None.
IHPI 3 weeks ago.
PHYSICAL EXTIMI TeI1p!rature 36.8, pllse lOB, respirations 16, and blood pres-
sure . 'lhe patient is alert with norma1,speech. She is ac:c:oopanied
by her daughter in the emergency departrrent. Head and neck exam sh<:7.o/S resolV-
ing ecchymosis on the left inferior orbital rim. Extraocular n-ovements are
intact. Pupils are equal, rourd, and reactive to light. '!here is no awarent
ocular injury. 'lhere is no facial scalp or skull bony deformity. 'Ibere is
mild soft tissue terderness over the forehead and scalp. Jaw excursion is
full. 'Ibe neck is S\W1e and nontender. Chest is clear. 'lhere is sare ten-
derness aver the left anterolateral CXlSta1 nargin b.1t no crepitus or bony
deformity. Anterior/posl:erior ..~JlIl'tession of the rib cage does not elicit rib
pain. cardiac reveals normal 81 and 52. 'lhe alxlanen is soft and nonterxler.
Pelvis is stable. All extremities have full rarge of trOtion and are neuro-
vascu1arly intact. 'lhere is BOIOO soft tissue terxlel1lE'SS over the left forearm
bJt no bony localization, joints, or full rarge of motion. Distal neurovascu-
lar status is intact. Neurologic exam is normal and nonfocal.
m COOR8I!lI 'lhe patient was also evaluated by the crisis counselor and was
given information aboot services for battered waren.
DINlmSISI Multiple contusions: face, scalp, left rib cage, and
left foreann
Battered waran
~ Pl1\N1 I advised her to report her estrarged husbard to the police
for protection. She will follow up with the crisis counselor's other recom-
merxlations as well. Ice packs and 'IY1eno1 shoo1d be adequate treabnent for
her exmtusions. She may return to the emergency departIrent as needed. She
will be stayirg with a frierd so as not to be exposed to her husbard's rage
tonight.
RLK/bjw 0 - 02/22/95 - 0027
T - 02/24/95
IP
ICI<, M.D.
CARLISLE HOSPITAL
EMERGENCY ROOM RECORD
CARLISLE HospiTAL
,
248 PARKER 8TREET CARLISLE. PA 17013.0310
, ~
CONVENIENT CARE/EMERGENCY REGISTRATION
l-ift,!,:: lOr? Tit" li~' J~/;:;l<1' :. I. ./J Kh!t-
d q//YI.R~
FOR NURSING ASSESSMENT
SEE NURSING DOCUMENTATION SHEET
~'7." OI"OOlY
I'lIV
.." LMP:-.q,. IJ, "",_,n- d4~': A_ _.
7; '. ~ /-- .7Z, --;z;::; . "0 .0 / , (/
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009 TnANS OIllEn
1IU(OflJ5CUAlIU( toNDIll;HOOoeo~fl
1.'M~'f ",I 'Ll ",I.LJ / - J. t, (...~ ' -../-nee. Cor ..IJI ([)~:' .,("1 ';:\::4/J () o SAME PnOVEO
IC7 lI.l" "'" hJ IL~ J/~ 1/ '1 1/ DISPOSITION FROM )(ED o CONVt;.~,~'
CARE CENTER
~ .~-', .n " I .., Non'lfD TUoII '\ lHtT,., .....POIlOIO.
PT ASSAULTED HIT IN L RIBS 95026
BACK OF HEAD. L EYE I,AUh-OIIS
98999
1,,,}6,~,51i211 WILLIAMS, JEANETTE C. I ". , 21: 39 IM'26yl"i:/WVM W
02121/95
ER,0508 (REV, 7/04)
'.
@/Carlfsle ~I
. ~lgh111l'l2 .
N^,AE W/It~:i("g.;f-~L.
RooM. AGE _WTrIit-
VI~AL SIGr'h~?n--~p I 'r:J.t;
ALLERGIES:
CURRENT MEDIMTIONS:
,
-'
ER allO (41941
NURSING DOCUMENTATION - EMERGENCY / CONVENIENT
DEPARTMENT CARE CENTER
Dat8:~-=-7~
Trlage Slatus: Modo of Arrival: Arrived Wl1h:
o Prlorl1y I 0 AlJl 0 BLS 0 Pollco 0 F'.!I'nd
o Pdorl1y 11 ~ a-Krnbulnlory 0 Porenl lll-f'iimlly
~ !dIre,II(111 ':III' 0 Wheolchal, 0 Self D Other
~~~~~~
Onsel 01 Symploms: ;> I 11 t1
Nursing Actlon/Commenls:
Childhood Immunllsllons: 0 UTO 0 Neve, 0
T,oalmenl Prior 10 A,rlvot:
TRIAGE NOTE:
-~
\ TEtANUS STMUS:
, iIl-6thln 5 Voer.
o 5,10 Vears
o Moro Ihan 10 Voars
o N.ver
COLOR:
o Qood
e1'ale
o Flushod
o Jaundiced
o Cool 0 Ecchymosis,
o Clammy 0 Rash,
II GENERAL APPEARANCE
~u E:
lIQulsr 0 Irrogular
ull , D Weak
RESP: 0 Shallow D Rapid 0 Audible
(;Hformal 0 Deep 0 Slow Wheele
o Labored. 0 Stridor 0 Retractiona
. TREATMENT IN PROGRESS ON ARRIVAL:
D CPR Down Time _ mill-- 0 Monl1o, - Rhythm Rale
o Airway _ D Oral, 0 Nasel- Slle _____ 0 Oxygen - 0 Mask, 0 NC - JJIIliii"':
o Alrwey, Endolrecheal- Slle ~ . OSplnallmmobllllollon, ,,/- .-
o Airway, Nasotracheel- Slle -- 0 Masl,
D IV - Solution 5110 SilO 0 Pressu,e Dressing 0 Other
DlIl~!!,Undll Righi: 0 RII.. 0 Wh.... "'"nl"l Alllumlnt:
o WA"'II LI~: 0 Rhonchi 0 AblOnt ~QOdIAlled: ThoUiJhl:
o Wheeze ~pproptlale ~Clea'lSponlaoeou.
o AblOnt 0 Blunl.diflll 0 VlguOlOleconDtCted
o Do'''''~. 0 Ol.o~onled
o AWlhenl~1 0 Slow 10 An....,
o R.,tI""Comb.t~e
,
o Other
SI1lN'
~~rm
TRIAGE NURSE SIGNATURE
o Ralel
o Rhonchi
Puplll' 1. .
RighI. SIlO
R.lctloa_ 2. .
Lift . Size
Ij(NiA Reldlon_ S. .
"
4. .
5. .
5. .
Vllull A.ti,IIy,
OG
OS
o Wllh Glall..
o Without 0111S.1
IlINmAL NURSING INTERVIEW:
REASON FOR VISIT: I!H11 UMA
pAST MEDiCAL HISTORY:
TIME:
o PSYCHOSOCIALJEMOTIONAL
Inlormellon (Whal you are ~ble lee),
PATIENT PROBLEM: Nursing Dlagnosl8
_ Nonc>mpllanco
_ Sell Clue Oencn
_ Comfort. Atferallon. In:
_ CommunlcaUon ImpaIred
_ CcpI"Il, lnelloct.1
_ tluld Volume. "~Dfa'lonlln:
_ Gal E1thange, Impaired
T)15ue Perfusion, Art. In:
_ Skin Integrity lmpalrmenl
_ lhoUOht Procelles, Art. In:
_ Hyperthermia (rlVer~
_ Inlecllon, PotentlaJ
_ InjUry, Potenllal
_ KnowIO<Ig. Oond
_ MobIhly Impaired
Olher
_ AlrwlY Clearance, Ineffective
_An.llly
_ brealhlng Pa"eml, Inelleetly,
_ Cardiac Outpul, Oecf881ed
Dthor
OUTCOMElGOAL: E'pectod by Discharge:
"
'2
'3
1.;tV -<f?I1 ,
NunSE'S SIGN~TURE
o Dusky
o Cyanolle
o Nallbods
o ClrCIJrno,al
o Lacerallon
o Edama
DRUGS:
.-
/"
,/
S""och:
&l....NormaVClea,
b-Sllent
o Tllk.el~.
o Repolnlva
o Mumbling
LMP:
~
o
PLAN OF CARE:
D Maintain Pallenl Airway
D Monllor Ca,dlovascular Slalus
o IV 0 BP MonUor
D EKG D Cardiac MonUor
D Salety Measu,es
o Rest,alnls 0 Suicide Procaullons
o Selluro Procaullons
o Side Ralls Up
o Comlort Measure.
o Pain Conl,ol
o PosUlon fa' Comlort
Jif Prepare lor Exam
. Ct E'p1aln Procedures
o Emollonal Supporl
D Palenl Teaching
o Olscha'ga Insl,ucllons
lJ Othe,
D Olhe'
D Olher
o Oth.r
Name of
..- n Carlisle l-bspital
((jj
CONSENT TO HOSPITAL ADMISSION
mDICAL ~NT
Attending physician (B)' t::.R
7 -~ 1.-:9S-
AND
Dat:e of Admissionl
Timel
(1\H)_____(PHI----
acting on behalf of)
I, (or
~ \ I i cunc;
NIJD.orr ...1
conaent: t:o rendering of ouch care, which may include routina diagnootic proceduree and luch
medical t:reatment: as the named attending phyeician(e) or other of t:he hospital'e medical
st:aff coneider to be neceesary.
, AuthorllOd R.p......lltl'.
uHering from a condition requiring hospital care, hereby
2. I underet:and t:hat: t:he practice of medicine and eurgery ie not an exact eclence and
t:hat: diagnosis and treat:ment: may involve risks of injury, or even dsath. I acknowledge t:hat:
no guarant:ees have been made to me aB to t:he reBult of examination or treatment during this
hospitalization.
3. I understand t:hat'
4. I underst:and t:hat: many of the phyeicians on t:he st:aff of this hospital, including
t:he at:t:ending physician(e) named ,above, are not: employees or agent:e of t:he hoepit:al but:,
rat:her, are independent contractors who have been granted the privilege of ueing itB
facilit:ies for the care and t:reatment of t:heir patients. Further, I realize t:hat among t:hole
who at:t:end pat:ient:s at this hospital are medical, nureing, and ot:her health care pereonnel
in t:raining who, unleos requeeted ot:herwiBe, may be preeent during patient care ae a part of
t:heir education. still or motion pict:ures and cloaed circuit television monitoring of
pat:ient: care also may be used for educational purposee or for documentation of the clinical
couree unless a pat:ient expreasly roquoets ot:herwioe.
5. I roleaoe CARLISLE HosPITAL from all responsibilit:y for all articlee which I am
rst:aining.or will have with me during my otay at: ths hoepital, I underatand thie includee
clot:hing, bridgework, faloe teeth, eyeglaoseo, jewelry, money, radio, razor or any ot:her item
kept: in my pooeeseion. I understand I may depoeit valuablee in a safe provided by the
hoapitall only if thie is done will the hoopltal assumo any responeibility for the
oafekeeping.
6. I hereby acknowledge that I have received writ:ten informat:ion on t:he top ice of
pat:ient Rights and Advance Directives.
(A) It is customary, aboent emergency or extraordinary circumetancee, that: no
substant:ial procedures are performod upon e patient unlees and unt:il he or
she hae had an opportunit:y t:o diacuss them wit:h the physician or ot:her
health profeesional to the pat:ient's satiefaetionl '
(B) Each patient hao the right to consent, or to refuse consent:, to any
propooed procedure or therapeutic coureel and
(C) No patient will be involved in any research or experimental procedure
without his or her full knowledge and coneent.
,
Dat:o of Signature, L~ 2..\;.9 e:;-
X. \"\~
.0 c.......~~o
~NATllRE OF PATIENT)
\A~,S~m~
(SIGNATURE OF ITNESS)
(If patient: is unable to conoont or is a minor, complet:e the followingl)
Pat:ient (is a minor ____ yearo of ago) (Ie unablb to conoont becauoo)I
(SIGNATURE GF LEGAL GUARDIAN OR
CLOsEST AVAILABLE RELATIVE)
(SIGNATURE or WITNESS)
AD 0315 (10/91)
....
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o ..,:J
Carlisle Hospital
(~C S
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V
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. '
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,
,.
PATIENT'S NAME:
INSURANCE CO.:
Slatement to Permit the Release or Medical Inrormatlon and Pavment or Medicare and/or
OIher Health Insurance Benerlts and/or Phvslclan.
I authorize Carlisle Hospital as the holder or medical Inrormatlon pertaining to me to
release the necessary and approprla1e medical Inrormatlon to 1he rlseal In1ermediary or the
Social Security Administration and/or to my primary or supplemental health Insurance
company or It's deslgna1ed review agency ror payment ror services rendered.
I authorll.c the Carlisle Ilospltal's and/or the physician's billing agent to submit a
claim 10 Medicare or other health insurance on my behalr, Gr to request, on a one time
only basis, rrom the Social Security Administration, such Inrormatlon necessary to complete
the claim submission process,
I am 1he Individual to whom the Inrormatlon/record pertains, or am authorized to
consent, on behalr or the Individual, 10 the release or 1he Inrormatlon/record. I understand
that any raise statement or representation knowingly and wl1lrully made or caused to be
made ror use In de1ermlnlng rights to Medicare benerlts or payments mny be punishable by
a rlne or not more thnn S 10.000,00 or one year in prison, or both.
I request thnt payment dr authorized benerlts be made on my behnlr.
I assign the paymen1 or Inpatient or outpatient hospital benents to Carlisle Hospital
ror those services provided by Carlisle I-Iospltal and/or I assign the benem pnyable ror phy-
sician services to the physician,
".
I cer1iry thnt 1he Inrormntlon given by me In npplylng ror pnymenl or services under
Title XVIII or 1he Social Security Act or ror any/nil other henlth Insurance Is correct.
X""-- ..or.c",-,\~e\.~~ X"-.,\U -l\~1,1\1'><. 2-1./-Cjf-:--
Ilflllenl'a!5lgndlure SSN Dale
Responsible Pertv II Pollont Unable 10 Sign
Relallonshlp
Dale
Insured Pornon's Signa lure
(II dllforonllrom pnllont or II pnllenlls a minor,)
Dale
Reason pollenl could nel sign,
\}-fj
Wllness
While Copy - Heallhcere Billing
Canery Copy - Modleal Records I Anclllerv Depertments
,
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Cumberland County Court
One Courthouse Square
Carlisle, PA 17013
ATTN: The Honorable Edgar Bayley
14 December 1996
Ref, 95-4531 Civil Action
Dear Sin
since my last correspondence referencing the above file number,
I am notifying the courts that I did (finally) receive my son
Robert (Robbie) Williams on 04 December 1996. This entailed
a second trip to the State of California to obtain him and a
long standoff with his mother, Jeanette Williams.
Jeanette took Robbie to my brothers house in Palmdale, CAjust
prior to my arrival without a car seat, proper clothing and no
jacket; all of which were asked for by item. My brot:her asked
her for a car seat: and was told there was none, he was too big
for a car seat (he is 33 lbs and 2 1.2 years old). He had no
coat and his shoes were too small, but, she didn't have time
to buy him anyother pair. We purchased a car seat before trans-
porting him to Arizona.
It appeared through her actions that she was once again partaking
of drugs. Jeanette has called my mother's residence approximately
three (3) times since my receiving Robbie and threatening my
mother that she had better have Robbie back to her by Christmas
else she and her boyfriend will be making a trip to Arizona.
I spoke to Jeanette two (2) of these three (3) times and my mother
all hree timeD '10 ahe answered the phone. Jeanette's voice
was very rapid and broken and high pitched at times. Very un-
like her normal voice. I am aSking that before I return Robbie
to her that a drug test be taken by the local child services
department. In addition, it appears Jeanett:e has no permanent
residenco, but, travels between her mothers home in Lancaster
(Los Angeles County), CA, a residence in Rosamond (Kern Co.), CA
and Fontana (San Bernardino co), CA. I have not been aprized
of an address where I can either correspond or visit Robbie
at a fut:ure date and am request:ing this information be made
available t:o me and recorded with the courts.
Your Assist:ance in this matter Your Honor is most welcome and
appreciated.
) I /,{\ (( Ii ((',:.,
Jeffery S. Williams (;F /l/ I I;).' 1,/,(71,
% 3520 Tarpon Dr
Lake Havasu City, AZ 86406
(520) 680-6730
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participating in illegal drug use. Respondent has exhibited signs
of drug use such as uncharacteristic rapid, high pitched, and
broken speech which peti tioner has witnessed.
In addition,
petitioner has been told by a relative of Respondent's that she is
exploring the possibility of drug treatment. The law enforcement
official who recovered the child informed Petitioner that
Respondent exhibited signs of drug use.
6. When Petitioner obtained custody of the child, the child
was wearing shoes that were two sizes too small for him. He was
not wearing appropriate clothing for the weather conditions and
appeared underweight. Since being with Petitioner for three weeks,
the child has gained four pounds. Respondent does not use a child
safety car seat for the child.
7. Petitioner believes and therefore avers that Respondent
has no permanent home for the child. The child does not have a bed
to sleep on when in the Respondent's custody.
8. On December 26, 1996, Respondent attempted to snatch the
child while the child was visiting relatives in Lancaster,
California.
Law enforcement officers were called to prevent
.,
Respondent's attempt.
9. To avoid further harassment from Respondent, it was agreed
to turn the child over to Respondent at the Sheriff's Department at
10:00 a.m. California time on December 27, 1996.
10. Petitioner believes that it is in the best interests of
the child to award primary physical custody of the child to
Petitioner until Respondent undergoes drug testing and evaluation
and until further hearing by this court.
.
.
.
JEANETTE C. WILLIAMS
42738 3RD STREET EAST
LANCASTER CA. 93535
. OCTOBER 10,1996
JEANETTE WILLIAMS,
THIS IS NOTICE TO yOU THAT I PLAN TO EXERCISE MY VISITATION
OF MY SON ROBERT P. WILLIAMS FROM DECEMBER 1ST 1996 THROUGH JANUARY
1ST 1997AS PER COURT ORDER ( 95-4531) CIVIL TERM RELIGATED BY JUDGE
BAILEY. PLEASE CONTACT ME SO THAT WE MAY DECIDE ROBBIES' TRAVEL ARR -
ANGEMENTS.
J
P 433 151 935
JEFFREY S. WILLIAMS
32 CENTER ST. LOT 034
Mr. HOLLY SRINGS PA. 17065
( 717 ) 486-8793
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V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 95-4531 CIVIL TERM
JEFFREY S. WILLIAMS,
peti tioner
JEANETTE C. WILLIAMS,
Respondent
CIVIL ACTION-LAW
CUSTODY
MOTION FOR CONTINUANCE
AND NOW comes Peritioner, Jeffrey S. Williams, by and through
his attorney, Jacqueline M. Verney, Esquire who represents the
following:
1. petitioner, Jeffrey S. Williams, filed a oro se Petition
for contempt with this Honorable court.
2. This Honornble court scheduled a hearing on the Contempt
Petition for February 24, 1997 at 11:00 a.m.
3. Petitioner temporarily relocated to Arizona in late 1996
to complete his one month partial custody of his son, Robert Paul
Williams, age 2 1/2, who resides with his Mother in California.
4. During this temporary relocation, peti tioner secured
employment which at this time he has elected to continue.
5. Due to his relocation and employment, Petitioner is unable
to attend the contempt Hearing scheduled for February 24, 1997.
6. Petitioner has not made definite plans for his return to
Pennsylvania, especially in light of his next scheduled partial
custody period wi th his son being June to August, 1997. Petitioner
may remain in Arizona to be closer for the transfer.
7. Respondent's counsel, Joan Carey, Esquire, has been
contacted concerning the Contempt \lea ring and has indicated that