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BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT July 18 ,
1989
and Board Action. All Section references are to The copy of this document mailed to you is your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amount: $100, 000. 00 Section 913 and 915.4. Pl"LII9ty 61DUUb$0Jngs11.
CLAIMANT: JANE E. DILLARD JUN ? 31989
2087 Norse Drive #100
ATTORNEY: Pleasant Hill , CA 94523 Martinez, CA 94553
Date received
ADDRESS: BY DELIVERY TO CLERK ON June 20, 1989 CC
BY MAIL POSTMARKED:_June 121 1989
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
June 22 1989 PpHHIL BATCHELOR, Clerk
DATED: BY: Deputy
L. Hall
11, FROM: County Counsel TO: Clerk of the Board of Supervisors
`N ) This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: ?3 / 7 BY: Deputy County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present
(�) This Claim is rejected in full.
(/\) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date. 1
Dated: J U t 1 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in•connection with this matter. If you want to consult
an attorney, you should do so immediately.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above. i
Dated: JUL 1 9 1989 BY: PHIL BATCHELOR by eputy Clerk
I
CC: County Counsel County Administrator
M
i
VICTOR J. WESTMAN
CONTRA COSTA COUNTY COUNSEL
TO y �LyJ1 R \ P.O. Box 69. Co. ADMIN. BLDG.,
- �1�`L MARTINEZ. CA 94558
DATE \off.-SUBJECT,
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0 ,0PERd JUN 19 1989
AND C Ll N IC S lviartlne�, CA 94553
TO: Office of County Counsel June 14, 1989
Contra Costa County
FROM: Mark Finucane RE: CLAIM
Health Services Director Rhoda L. Birkholm
Record #442799-3
The attached claim for the above named patient was received by
Merrithew Memorial Hospital on June 13, 1989, via certified mail .
SP
Attachment
cc: Risk Management Department
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os Contra Costa County
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ST4 COUN'� `
A-301A (3/87)
CERTIFIED MAIL 2087 Norse Dr. #100
_- RETURN RECEIPT REQUESTED Pleasant Hill, California 94523
:-r June 12, 1989
Mr. Frank Puglisi, Administrator
Merrithew Memorial Hospital
2500 Alhambra Avenue
Martinez, California 94553
RE: RHODA L. BIRKHOLM, DECEASED 3/28/899 MERRITHEW MEMORIAL HOSPITAL
AUTOPSY REPORT #4427993 OF 3/30/89 (RECEIVED BY ME 6/1/89)
Dear Sir:
Please refer to Autopsy Report #4427993 dated March 30, 1989, in which the
first paragraph states: "The body is that of a well-developed and slightly
obese white female appearing as the recorded age of 90 years old...and the
weight is approximately 180 lbs. The head has a moderate growth of brown
hair of fine texture."
Mr. Puglisi, the above description is not that of 2X mother. The autopsy
was performed on someone else! !
My mother was a petite 124 pounds and had a full growth of snow-white hair
of thick texture. Literally hundreds of people can attest to this, includ-
ing everyone at Merrithew who took care of her for two weeks.
(Incidentally, have you ever seen a 90-year-old female with (natural)
brown-hair? )_.
Further, the autopsy revealed that the female had an "...old myocardial
infarction." MSL` mother had no history of a previous myocardial infarction.
Then, on whose mother was the autopsy performed on 3/30/89 - #4427993? And,
where is my mother?
It had been my intention to have my mother's ashes placed in the Memorial
Garden at the church to which I belong Lafayette-Orinda Presbyterian
Church. My mother would have been very happy to be there, near my church,
and where I could have "visited with her" in such lovely surroundings at
any time. It grieves me deeply to know that I will not be able to do this
inasmuch as the ashes that I have are those of a stranger. (Incidentally,
what disposition should be made of these ashes? At the present time they
are at Bryant and Moore Funeral Home.)
Now, please refer to Certificate of Death, #38907001752, signed by Roger
Barrow, AD., on April 5, 1989. This document is also invalid because it
applied to the other female on which the autopsy was performed - in place
of EX mother. Consequently, at this point in time there is no Certificate
of Death nor is there an Autopsy Report on Rhoda L. Birkholm.
RE'EI "
CLER HiL HEL
.A C U OVISOAC
BY ......
e y
Mr. Frank Puglisi, Administrator -2- June 129 1989
Further, on Saturday, April 80 at 11:00 pm., Dee from Medical Records,
telephoned and demanded that I have my mother's remains removed. I explained
to her that I was waiting for the results of the autopsy before releasing
the body. She was very rude to me and insisted that I release the remains.
0n Tuesday, April 11, 1989, at 8:00 a.m., Joanna from Medical Records,
telephone me with the same request and I again explained my position.
Later that same morning Dr. Roger Barrow telephoned me and was very insist-
ent that I have my mother's body removed. He said all the work had been
completed and that I could not continue to keep the remains there while
awaiting the results of the autopsy. He also was quite rude and unpleasant.
Inasmuch as I had been harassed about this since April 8th, I subsequently
visited Bryant and Moore later in the morning of April 11th, and they picked
up the body that afternoon. It was cremated on April 139 _1989.
In light of the gross negligence and mis-handling of this whole matter, I
have been advised to file a malpractice suit against the county for a very
large sum of money, including punitive damages. However, in lieu of filing
a-malpractice suit, I am hereby requesting a one-time payment from the county
of one hundred thousand dollars ($100,000)9 together with a letter to me
explainng.that this payment is in compensation for extreme mental suffer-
ing and anguish in not knowing: a The cause of my mother's death, as the
Certificate of Death is invalid; �b� why my mother died, when I believe that
it may have been a preventable death (but no testing was done in order to
prove or disprove this); and (c) where my mother's remains are now.
Very truly yours,
Jane E. Dillard
cc: Mr. Ted Signet, Director, Contra Costa County Health Services
Mr. Ned Robinson, Attorney at Law
Enclosures: 1. My letter of 4/3/89 to Dr. Kim.
2. Autopsy Report #4427993 of 3/30/89.
3. Certificate of Death #38907901752 of 4/5/89.
jd
• 2087 Norse Dr. #100
Pleasant Hill , CA 94523
April 3, 1989
Hye-Kyung Kim, M.D., Pathologist
Contra Costa County Health Services
Pathology Laboratory
Merrithew Memorial Hospital
2500 Alhambra Avenue
Martinez, California 94553
RE: RHODA BIRKHOLM, DECEASED MARCH 28, 1989, 7:40 P.M.
Dear Doctor Kim:
My mother, Rhoda Birkholm, was admitted to ER at Merrithew Memorial Hospital
at approximately noon on March 28, 1989, in an extreme and acute state of
convulsions. Several doctors at Merrithew consulted off and on for five
hours in ER and again, while trying to determine which ward should take care
of my mother. (Incidentally, I very much appreciate the concern and caring
that was exhibited by these doctors.) She was admitted into I.C.U. at 6:00 p.m.
Dr. Terry Myers was assigned to my mother's case and was her doctor for about
21.hours before my mother expired. Inasmuch as all those concerned about
my mother were puzzled as to the cause of death, we mutually agreed that an
autopsy was in order.
Following receipt of your Provisional Diagnosis of March 30th and before
Dr. Myers left for a week's vacation, she was going to request that you
check the levels of sine-quan in the remains and also the level of body
fluids. Dr. Myers was going to request that the brain be examined as well .
Sine-quan was administered orally once a day beginning on March 15th, and
the strength was 25 mg. It was discontinued March 21, 22, and 23. It was
resumed at double the strength (50 mg) once a day March 24, 25 and 26. It
was discontinued on March 27th.
The convulsions increased in intensity over time (41 days); they were uncon-
trollable, causing hallucinations and eventually an inability to communicate
because of the violence of the shaking. (It's possible that the severe
bruising of my mother's forearms that you observed was due to banging
against the bed rails.) Fluids were restricted to 1200 cc per 24 hours
beginning on March 15th.
I believe this to be an untimely death because, although my mother was 90
years old, highly successful hip replacement surgery had been performed by
Dr. Paul Nottingham on February 21 , 1989. He checked it at Merrithew's
.Ortho Clinic on .March .2lst and said that it was perfect.
Incidentally, the results of the extensive pre-op examinations, blood tests,
EKG, x-rays, etc., were all more than satisfactory. These results indicated
that surgery would not adversely affect my mother - quite the contrary, it
was expected that the quality of her life would be greatly improved.
Hye-Kyung Kim, M.D. -2- April 3, 1989
I hope that the above information will assist you in your efforts to deter-
mine the cause of my mother's death.
Sincerely,
Jane Dillard
cc: Terry Myers, M.D.
Paul Nottingham, M.D.
HOUSE MEDICAL STAFF
PHYSICIANJP AUTOPSY- 9 A 89
BIRKHOLM, RHODA
MTERS M.D. 4427993
"PR DOE: 1/31/99
:t
DOD: 3/28yZ89
AUTOPSY, GROSS ONLY DOA: 3/30/89
AUTOPSY, INCL. CNS GROSS ONLY
AUTOPSY, EXCL. CNS GROSS AND MICROSCOPIC
PATIENT J.D. AREA MUST BE READABLE ON All COPIES.
AUTOPSY, INCL.CNS GROSS AND MICROSCOPIC -PROSECTOR:
AUTOPSY,SINGLE ORGAN STUDY
..�- .OTHER'PROCEDURES'(SPECIFY Hye-Kyung Kim, M.D.
f REPORT-:
1
2ROyT5_70NAL DIAGNOSIS:
I. PULMONARY EDEMA, MILD, LEFT LUNG
IT. OLD CALCIFIED GRANULOMA, RIGHT LOWER LOBE
IT!. OLD MYOCARDIAL INFARCT, SMALL, POSTERIOR WALL
II
j
D: 3/30 T: 3/30/89
HKK:sk
HYE_�YUNG KIW, M.D.
PATHOLOGIST
A of ,
CONTRA COSTA COUNTY HEALTH SERVICES-PATHOLOGY LABORATORY
HYE-KYUNG KIM,M.D.,PATHOLOGIST
IRCHG-403 (5/83)
AUTOPSY: 9 A 89
PHYSICIAN BIRKHOLM, RHODA
C MYERS M.D. 4427993
DOB: 1/31/99
X PROCEDURE DOD: 3/28/89
AUTOPSY, GROSS ONLY DOA: 3/30/89
AUTOPSY, INCL. CNS GROSS ONLY
AUTOPSY, EXCL. CNS GROSS AND MICROSCOPIC
vwnEnt Lo. wwEw .V.l eE wE....LE on wLL COPIES.
AUTOPSY, INCL. CNS GROSS AND MICROSCOPIC PROSECTOR:
AUTOPSY, SINGLE ORGAN STUDY
X OTHER PROCEDURES SPECIFY Hye-Kyung Kim, M.D.
AUTOPSY REPORT
C! PROVISIONAL DI9GNOSIS :�
j ..
I. PULMONARY EDEMA, MILD, LEFT LUNG
II . OLD CALCIFIED GRANULOMA, RIGHT LOWER LOBE
III . OLD MYOCARDIAL INFARCT, SMALL, POSTERIOR WALL _
C
D: 3/30 T: 3/30/89
HKK:sk
HYE- YUNG KI , M.D.
PATHOLOGIST
CONTRA COSTA COUNTY HEALTH SERVICES-PATHOLOGY LABORATORY
HYE-KYUNG KIM, M.D.,PATHOLOGIST
I R C H G-403 (5/83)
��e t
PHYSICIAN AUTOPSY: 9 A89
BIRKHOLM, RHODA
CMYERS MD• 4427993
X PROCEDURE DOB : 1/31/99
AUTOPSY, G ROSS ON LY DOD: 3/28/89
DOA: 3/30/89
AUTOPSY, INCL. CNS GROSS ONLY
AUTOPSY, EXCL. CNS GROSS AND MICROSCOPIC
PATIENT 1.0. AREA MUST BE READABLE ON ALL COPIES.
AUTOPSY, INCL. CNS GROSS AND MICROSCOPIC PROSECTOR:
AUTOPSY,SINGLE ORGAN STUDY Hye-Kyung Kim, M.D.
X OTHER PROCEDURES SPECIFY
AUTOPSY REPORT
FINAL DIAGNOSIS
I. BRONCHOPNEUMONIA, PATCHY
II . CHONDROHAMARTOMA, RIGHT LUNG
III . MYOCARDIAL INFARCT, OLD, SMALL, POSTERIOR WALL
D: 5/1 T: 5/2/89
HKK:sk
f
HYE-K UNG KIM, M.D.
PATHOLOGIST
CONTRA COSTA COUNTY HEALTH SERVICES-PATHOLOGY LABORATORY
HYE-KYUNG KIM,M.D.,PATHOLOGIST
IRCHG-403 15/831
f AUTOPSY: 9 A 89
PHYSICIAN BIRKHOLM, RHODA
MYERS M.D. 4427993
X DOB: 1/31/99
PROCEDURE
DOD: 3/28/89
AUTOPSY, GROSS ONLY DOA: 3/30/89
AUTOPSY, INCL. CNS GROSS ONLY
AUTOPSY, EXCL. CNS GROSS AND MICROSCOPIC
VATIC%T 1.0. ARE.MV%l 0E RE/,OAHLX ON>•LL COPIES.
AUTOPSY, INCL. CNS GROSS AND MICROSCOPIC PROSECTOR:
AUTOPSY, SINGLE ORGAN STUDY
X OTHER PROCEDURES SPECIFY Hye-Kyung Kim, M.D.
AUTOPSY REPORT
GROSS EXAMINATION AND DESCRIPTION:
GENERAL EXAMINATION: The body is that of a well-developed and
slightly obese white female appearing as the recorded age of 90
years old. The body measures 63. 5 inches in length and the weight
is approximately 180 lbs . Rigor mortis is present in extremities
and post mortem . lividity is present in dependent parts. There
is a reddish purple discoloration of the medial aspect of the
left arm. The head has a modeate growth of brown hair of fine
C testure. Body hair has the usual female sexual distribution.
There is no palpable mass in either breast. Abdomen is slightly
protuberant. There is no cyanosis or clubbing of the fingers .
INITIAL INCISION: The usual Y-shaped incision is made through
the subcutaneous fat measuring 3.5 cm thick in the midabdomen.
The peritoneal cavity is free of fluid or adhesion and exposed
portion of the right lobe of liver is pinkish red and smooth.
The autopsy was limited to the examination of heart and lungs
as requested by T. Myers, M.D.
HEART: The heart weighs 325 grams. The epicardial surface shows
normal fat distribution. Rightcoronary artery shows approximately
50-60% luminal stenosis 3 .5 cm away fromits orifice by calcified
atheromatous tissues. Left coronary artery is widely patent.
Serial sections of myOtardiurl show yellowish tanmottled area in
the posterior inferior wall consistent with old myocardial, infarct.
There is no gross evidence of acute infarct. Tricuspid, pulmonic
and aortic . , :valves are unremarkable and free of vegetation.
Mitral valve shows calcific masses at the base ofthe mitral valve
probably age-related. Chordae tendeniae and papillary muscles
are unremarkable.
LUNGS : The right lung weighs 425 grams and the left lung weighs
475 grams . Careful examination of the right and left pulmonary
arteries reveal no evidenceof thromboembolism. Right lung shows
hard calcified nodules measuring 2 cm in maximum dimension near
the diaphragmatic surface of the lower lobe. REst of the lung is
CONTINUED ON PAGE 2
CONTRA COSTA COUNTY HEALTH SERVICES-PATHOLOGY LABORATORY
HYE-KYUNG KIM,M.D., PATHOLOGIST
IRCHG-403 15/831
:��Ki • 1
PHYSICIAN AUTOPSY: 9 A 89
M D BIRKHOLM, RHODA
X PROCEDURE 4427993
AUTOPSY, GROSS ONLY
AUTOPSY, INCL.CNS GROSS ONLY
AUTOPSY, EXCL.CNS GROSS AND MICROSCOPIC
PATIENT I.O. ANE^MUST OE REAOAOLE ON ALL COPMS.
AUTOPSY, INCL. CNS GROSS AND MICROSCOPIC PROSECTOR:
AUTOPSY, SINGLE ORGAN STUDY
X OTHER PROCEDURES SPECIFY
AUTOPSY REPORT
GROSS EXAMINATION AND DESCRIPTION (PAGE 2) :
essentially unremarkable. Left lung shows moderate pulmonary
Cedema with fluid exuding from the cut surfaces . There is no
gross evidence of bronchopneumonia.
D: 3/31 T: 3/31/89
HKK:sk
HYE-KY JFNG KIM, M.
'. PATHOLOGIST
CONTRA COSTA COUNTY HEALTH SERVICESPATHOLOGYLABORATORY
HYE-KYUNG KIM, M.D., PATHOLOGIST
IRCH63.4n3 IF/R31
jiFKsh�:c :rA_- � • 1.:-IHn I
. Yr3
-. AUTOPSY: 9 A 89
PHYSICIAN
BIRKHOLM, RHODA
MYERS M.D. 4427993
dy X PROCEDURE DOB: 1/31/99
DOD: 3/28/89
AUTOPSY, GROSS ONLY DOA: 3/30/89
AUTOPSY, INCL. CNS GROSS ONLY
AUTOPSY, EXCL. CNS GROSS AND MICROSCOPIC
PATIENT P.D. AREA MUST eE REwoweLe On wu Code].
AUTOPSY, INCL. CNS GROSS AND MICROSCOPIC PROSECTOR:
AUTOPSY, SINGLE ORGAN STUDY Hye-Kyung Kim, M.D.
X OTHER PROCEDURES SPECIFY
AUTOPSY REPORT
MICROSCOPIC DESCRIPTION:
HEART: Sections of the posterior myocardium show stellate areas
C of interstitial fibrosis and hyalinization with loss of myocardial
fibers consistent frith old myocardial infarct. There are scattered
macrophages containing lipofluxen pigment. Focal areas of cal-
cific deposits are also present in the area of hyalinization.
There is no evidenceof acute myocardial infarction. Random sections
taken from the rest of the left myocardium are essentially
Cunremarkable.
LUNGS : Sections of both lungs reveal patchy areas of acute
bronchopneumonia. The dilated bronchi and bronchioles contain
neutrophilic exudates mixed with clumps of bacteria. Rest of the
lungs show areas of interstitial fibrosis with hyalinization
and focal areas of bronchoalveolar cell hyperplasia associated
with increased mucus production. Sections of the calcified nodule
in the right lung reveals benign chondrohamartoma with areas of
( ossification.
The vessels are congested and some of the alveolar spaces contain
proteinatous fluid indicating pulmonary edema.
D: 5/1 T: 5/2/89
HKK:sk
HYE-KYUk KIM
PATHOLOGIST
CONTRA COSTA COUNTY HEALTH SERVICES PATHOLOGY LABORATORY
HYE-KYUNG KIM,M.D.,PATHOLOGIST
IRCHG-403 15/831
CERTIFICATE OF DEATH - Q ^ ^ ^ ^
_ STAT! OF CALIFORNIA J / U / V U �1 J -
STATE PILE NUMBER USE BLACK INK ONLY SOC^ "GISTRATKM DISTRICT A CSITTIPICAM MIMSSA
1A.NAME OF DECEDENT-FHA IS. MKIOLA IC. LAST IFAYLrI SA DATE OF OEAT�- Twis, HDI. 3. SEI
10VENI I M0011116 DAY.TEAR I 1
RHODA ; Leona BiRKf?OLL-I MARCH 28p 1989 ;1940 ; FEMALE
L RAC! S SFANIMVHIYAMC B.OATS OF BIRTH- 7. AGE IN60
NWR 2A IIOIIwS
MONTL DAY. M&A YEARS MONRNS DAYS Iq)UIIO wTj
White "° Jan 31, 1899 90
DECEDENT IL STATE OF S. CITIZEN OF WHATtOA PULL NAME OF FATHER ;I OIL
COIL STAM W 11A FULL MAIDEN NAME OF MOTHER I IB. STATE W
PERSONAL BIRTH COUNTRY BSTTH I Borth
DATA CA USA William Pascoe ; UNIT Johanna Durst ; UNK
12 MILITARY SORVIC97 13. SOCK SECUINTT' l< MART^ IS NAME OF SURVIVING SPOUSE(IF YV�L SHTe1 MAeSN ILLNIe
IS— TO 1S— N NDN[ s56 01-2747 Widowed -
ISUSUAL OCCUPATION I BB. USUAL KmID OF BUS I6C.USUAL CH L01O1 18D.YEAAns H M Vsu^ 17.MJMSY OF HKiNYT GIUW COM-
( W INOUSTIYY I I OCCUPATION 1W1 PLETED(1-12m COliSGE t�-17.I
Insurance Clerk ; Insurance ;Unknown 4 10
ISA. RSSeoNCS-SMYT AND NOMI MI OR LOCATION I ton.CRY CSC.LP COW
USUAL 100 Boyd Rd # 107 ' Pleasant Hill ' 94523
RESIDENCE 18D.COUNTY 118E NUMBER W YEMS: ISP.STATE W FOREIGN COUNTRY ]O. NAML R4ATfONOaF. MA AODltiss
IN TOD LW W RMANT
S CmPvv ANP COINPO
Contra Costa 60 CA Jane E. Dillard-Daughter
1SA^-ACE OF DEATHi,1Bl IF NDERAL SPECST I ISG 2087 Norse Dr 100
ppm W..same.DOA '-
PLACE Merrithew Memorial ; IP ; Contra Costa Pleasant Hi11,CA 94523
OF 150.STREET ADORES!-STRaT AND MAEq W UDCATIOR IEE.CnT I>m EfTYTAi 22.WAS DEATH WIORTED TO COROTOt.
DEATH I
2500 Alhambra Ave Martinez Are DEATH GWENT t1 Yn KESIRAL MSSEDI ND
21.DSAYH WAS CAUSED BY. (INTER ONLY ONE CAUSE"A L24E POR A R AND 4-T1PS M Pr I a1L WAS BIOPSY PERFORIN
IMMEDIATE pIN BRADYCARDIA �: MINUTE p.rb No
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CAUSE uA WAS AUTONr FERP01s0101
DAYS
DEATH ACUTE PULMONARY EDEMA 1 _ saa" D No .
MM To -_
I WAS IT USED M DETClW► -
S)Jf MS%ClLUSE V MAIM
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26 01NY SIGNIFICANT COTert10NS CONRtEIRMG TO DEATI BIR NOT RELAMD TO CMR[GPrpN M 21 28.WAS OPBMTeIN FIB- FOK ANT CONIOITION M REL 21 m 2ST
HYPERTENSION 14DNTLL DAT.YEAR
NO
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PHYSL NO PLACE STATED P1111011 THIS CAUSES WrATm -: Q.: /.t'l• fi/?
CIAWS Y7AL DECEDOIT ATTOeED SI NCd DECEDENT LAW Sm1 AIRF i Vol �
CERTPICA- MONTH. DAT.YEAw l 440MTK OAT.MAL 1 T7L1.
fT3eNQ114d PHYSICUMS NAME AND ADDRESS ..
TION 03-28-89 i.. 03-28-89 ROGER ,..MD, 2500 ALHAMBRA,AVE,.'MARTINEZ'CA --945531':
I CEmFT THAT DEATH OCCUMISD AT THE HOUR.DAM AND 2EA SIRUITW W CORONA W DE CawdNOl ,388. DAM SGOED
PLACR STATED PROM THE GUYS STATED.
I
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CORONER'S 21L MANNER W DEATH-wft IE asRll"*,L 30A PLACS W MAST 1 306 WAST AT WORD( I]OC.DAM W MAST 1 31. HOIA
USE GIDi IItdM peOIS rAatpum a 1x10 b to ONS�O I 1 INaNNT11 wT,
ONLY I °YY D NO
32- IM-riciN([MEET AND NWBeI m LOCATION AND CRT') 32.DESCIUY HOW AWRY OCCURRED NVWM WHCH WMATED M WAIT
PUM_ K.N. DISPOSITION 3.4i8�.nPLaACE OF FIt4AL DISPOSITION 34C.DAM W O'=T'C"
3SA S@IATUIM OF ldlMuml 3E6 LICENSE
1001lGTOR CR-RTF i "LUS IN E• Di I D lar -CA hteli Ma.n.w..rEAw NUMBER
orse r , Apr 12,1989 Not Embalmed
AND 36A.HAMS OP PUNIOUL OMlOTW1(m oq PSKSOM ACTAS SUCH 306 LICENSE NO. 37. SIGNATURE OF LOCAL REGISTRAR 36 REGISTRATION DATE
,�`°;";,R Bryant bT Moore Concord,CA F 873 � � y ^�✓Nti) APR i i 198S*
STATE 6 F. CENSUS TRAC^T
RBO�TRAR y`'
V611(REV. 1.821 MAKE 140 ERASURES,WHTTZ0KrM OR OTHER ALTSRATX3NS
-Certification This is to certify that the above is a true and correct copy of facts
Statement recorded on the death record of the above named decedent as registered
in this office.
'9
Signature of Certifying� gn Official Official Title
Local Registrar
Place of Certification Date of Certification
Contra Costa County Health Services-
Public Health Division MAY 10 1989
`lartinez, California
State cf Caiifornia, Health Services-Public Health Division, Bureau of Vital Statistics
Ty
.i
CERTIFIED MAIL 2087 Norse Dr. #100
RETURN RECEIPT REQUESTED Pleasant Hill, California
June 12, 1989
Mr. Ted Signet, Director
Contra Costa County
Health Services
Medical Records
2500 Alhambra Avenue
Martinez, California 94553-3191
RE: RHODA L. BIRKHOLM, DECEASED 3/28/89
Dear Sir:
Following extensive pre-op testing at Merrithew Memorial Hospital, highly
successful total hip replacement surgery was performed on my mother, Rhoda
Birkholm, by Dr. Paul Nottingham on February 21, 1989, at Merrithew Memorial
Hospital.
The healing process proceeded nicely, but my mother became depressed. . She
was moved from D Ward to H Ward for a week to receive specialized care.
On March 6, 1989, my mother was released and entered Hillhaven Willow Pass,
a skilled nursing home. On the recommendation of the admitting officer at
Hillhaven, Dr. Dennis Stone was assigned to my mother's case.
Apparently Dr. Stone visited with my mother some time on March 6, 1989.
See attached copies of billings for nursing home visits of March 6, 15, 20,
24 and 28. The only one that I knew about in advance was the March 15th
visit, because I requested it. (Also, numerous blood samples were ordered
by Dr. -Stone during my mother's 21-day stay at Hillhaven. What happened
to them? Where are the results? Where are the billings?)
My mother continued to be depressed and so I talked with Dr. Stone at Hill-
haven on March 15th regarding this problem. He prescribed an antidepres-
sant; discontinued the diuretic (which she had been taking for many, many
years); and reduced her liquid intake because of swollen ankles:
On March 20th I telephoned Lucy, the assistant director of nursing at Hill-
haven, and requested that the antidepressant be discontinued.
On March 21st, when we were at the orthopedic clinic at .Merrithew, my mother
was very unsteady on her feet while Dr. Nottingham was having her stand and
walk. She seemed to be terrified that she was going to fall. She said her
legs felt as if they would not hold her up.
On my visit of Friday, March 24th, I observed that the tremors were present.
On Sunday, March 26, one of the visitors to Room 108 told me that my mother
had been hallucinating the day before, and calling out that someone was trying
to kill her. He informed the nurse. Indeed, by Sunday she was con,�nzlsing.
I was told that it was the after effects of the antidepressant and that the
agitation would cease in a day or two.
Mr. Ted Signet, Director, Health Services -2- June 12, 1989
March 2
Monday evening I found my mother in a much worse condition, with severe
and uncontrollable convulsing and a fever of 1030F at 7:00 p.m. I asked
what they were doing about this and was told they would have to call Dr.
Stone before they could take action. I also asked to see the records
regarding the antidepressant. For the first time I learned that 25 mg
of sinequan had been prescribed and given once a day at bedtime March 16,
179 18, 19, and 20. It was discontinued (per my request of March 20th)
on March 21, 22 and 23. Sinequan was resumed, without my knowledge or
consent, March 24, 25, 26 - this time at double the dosage, or 50 mg once
a day at bedtime! ! (I have the LVN's notes on this.)
When I left I was assured that they would get in touch with the doctor
and let me know what action he would take to alleviate my mother's extreme
suffering. No one called.
I telephoned Hillhaven at 10:00 p.m. and learned that Dr. Stone had them
discontinue sinequan; he prescribed 20 cc Septra (an antibiotic) every
12 hours for ten days; he ordered a blood sample to be taken that night
for blood culture work; and ordered a urine test for March 28th to deter-
mine if fever was caused by urinary tract infection.
March 28
I telephoned at 1:15 a.m. Temp. was 100°F; pulse 96; B.P. 126/80. Blood
sample was taken at midnight. I commented to the gal who answered the
telephone at the nursing station that "I wonder how long you think that
a 90-year old heart can withstand the effects of the severe convulsing?"
Itelephoned at 7:00 a.m, and asked about fever: Midnight, 101°F; 3:00
a.m., 101°F; and 5:00 a.m., 1010F. They inserted catheter at seven o'clock
because my mother did not void during the night.
My telephone rang at about 10:30 a.m. on March 28th. It was Dr. Stone,
telling me that he had ordered a chest x-ray at 9:30 that morning. Fie said
the portable unit had shown that my mother had "double pneumonia" and that
the "...liver was pushed high against the diaphragm" He said he would be
sending her back to Merrithew by ambulance. I asked him, "Is this going to
be a case where the surgery was successful but the patient died?"
I arrived at Hillhaven at eleven o'clock, just as they were settling my
mother into the ambulance. One of the ambulance attendants told me that
she had never seen anything like my mother's condition, with uncontrollable
convulsing and with both forearms completely covered with dark, purplish
bruises. The convulsing was so severg that my mother was unable to communi-
cate with me.
' o
Mr. Ted Signet, Director, Health Services -3- June 12, 1989
When I arrived at the hospital, I found my mother in ER. The nurses were
trying to make her as comfortable as possible. The ER doctor in charge
asked me when she had first begun to convulse. When I told him 4� days
ago, he was indeed shocked. My mother was eventually taken to x-ray, where
the large machine showed her lungs to be clear - no pneumonia; no fluid;
and no liver displacement.
She was returned to Fit. Doctors consulted together regarding her condi-
tion until about 5:30 p.m., when they had her sent to D Ward. The nurse
in charge said that there was no way they could take care of someone so
acutely ill. Dr. Tremaine then consulted for some time with other col-
leagues. He decided, with my urging, to have my mother taken to I.C.U.
He asked me to be thinking about what decision to make if her condition
worsened and if she could only be kept alive by means of a life-support
system. I told Dr. Tremaine that the decision had already been made by
my mother - she had a Living Will. He breathed an audible sigh of relief
and said, "Oh, that's good!" I told him that I would bring him a copy
of this document.
At 6:00 p m. my mother was taken to I.C.U., where they immediately padded
the bed rails with pillows to protect her badly bruised forearms, admin-
istered oxygen, and did whatever else they could to make her as comfortable
as possible.
At 6:45 P.m. I told my mother that I would be leaving for awhile but that
I would return soon. I went home to look for the Living Will to give to
the personnel in I.C.U.
At 7:30 p.m. my mother expired, before I had had an opportunity to see
her again. How sad.
You may wish to investigate to determine if:
1. Dr. Dennis Stone is a sincere, hardworking, honest gerontologist, whose
first concern is for the frail elderly.
2. If Dr. Dennis Stone is abusing the Medicare/Medi-Cal and nursing home
programs for his own financial gain, at the expense of the frail elderly.
3. If our county Ombudsman, Lois McKnight, should investigate the practices
at Hillhaven Willow Pass.
Very truly �yours,
ane E. Dillard
cc: tlr. Frank Puglisi, Administrator, Merrithew Memorial Hospital
Ms. Priscilla Tudor, L.C .S.W., Merrithew Memorial Hospital
Mr. Ned ggobinson, Attorney at, Law
Enclosures: 1. Physician s Orders of 3/6/89-319/89.
2. Bills from Dr. Dennis Stone, together with Medicare Statements.
3. Bill from Dr. Camarda, Podiatrist.
4. Excerpts from "Worst Pills/Best Pills", by S. M. Wolfe, M.D., 1988.
Jd
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PH'r'SICIAN OR SUPPLIER STATE ME NT
UENNIS L. STONE , M. D. OF ACCOUNT
GERONTOLOGIST
978 'ND, STREET, SUITE 1(10
LAFAYETTE CA 94549 • • • •
415-2283-7777 • • • • • m! • • 101,1211 Lim
..:JJF,3605
PATIENT'S NAME ACCOUNT NO. CHARGES AND PAYME DE AFTER
DIRK01 DILL02 THE STATEMENT'DATE R ON
INSURED NEXT MONTHS STATE
JANE DILLARD CP� R1�f9g
^_087 NORSE DR. #100 �
PLEASANT HILL , CA 94523
ATEMENT DATE AMOUNT Of /
YMENT
M 0 3- - 9 ENCLOSED $
DATE PLACE PROCEDURE DIAGNOSIS TYPE
SERVICE
OFSEROVICE
C P.Ca� DESCRIPTION SE FRVCHARGES PAYMENTS
------- KHODA BIRKHOLM
3-06-89 NF 90320 HISTORY & PHYSICAL/COMP. 1505 1 117 . 21
3- 13-89 SNF 90360 NURSING HOME VISIVINTERN 43 . 6 1 18 . 64
+3- 15-89 NF 90360 29620 1
I 165 . 85- ---0 . 00
i - -IIETD ES INSLRANCE FILED
D
Tri K6
x 7 1989
CCH BU iNESS SER ICES
nn
F YOU iIAVE_ANY QUESTIONEGADtPAQ�1�1s 19 IS L. STONE, M.D.
CC'OUNT , CALL MARIE AT 415-283-77 I1H N `378 2ND STREET, SUITE 100
ffAYETTE CA 94549
31 - 60 61 - 90 91 -120 121 ->
0 . 000 . 00 0 . 00 0 . 00 165 . 85
YOUR EXPLANATION OF MEDICARE BENEFITS
READ THIS NOTICE CAREFULLY AND KEEP IT FOR YOUR RECORDS
THIS IS NOT A BILL
— HEALTH CARE FINANCING ADMINISTRATION APRIL 04, 1989
Need help? Contact:
## RHODA BIRKHOLM Medicare - Chico, California 95976
100 BOYD ROAD 107 Telephone 800-952-8627 NORTHERN CALIF .
PLEASANT HILL CA 94523 800-848-7713 SOUTHERN CALIF .
If you write or call, please give us:
Claim Control Number (marked ** below)
STATEMENT NUMBER 044377623-1 CHECK HUMBER 087450835
r•
"PARTICIPATING" DOCTORS AND SUPPLIERS ALWAYS ACCEPT ASSIGNMENT OF MEDICARE
CLAIMS . SEE THE BACK OF THIS NOTICE FOR AN EXPLANATION OF ASSIGNMENT. WRITE OR
CALL_ U.S _FOR -THE_NAME OF A_ PARTICIPATING DOCTOR OR SUPPLIER_OR FOR A FREE LIST_OF _
PARTICIPATING DOCTORS AND SUPPLIERS .
Your doctor o upp ex did not accept assignment of your claim
totalling X65 .85 . (See item 4 on the back. )
Claim Con of Numb ** 200489079174660 **
STONE DE Billed Approved
01 NH Visit(s ) 90320 1 MAR 06 , 1989 $ 117 . 21 $ 100 . 00
Approved amount limited by item 5b on back.
01 NH Visit(s ) 90460 1 M 1 89 $ 48. 64 $ 35 . 90
Approved amount limited by item 5c on back. 0
. Total approved for all services on this claim APR1 7 1989 0 $ 13 O
Medicare payment (80% of the approved amount)CCHP.BBSIBESSs�RVjor' $ 7
i
We are paying a total of you on the enclosed check. Please cash it
as soon as possible .
If you have other insuran may help with the part Medicare did not pay.
(You have met the deductible for 1989 )
Next time you request payment, use your MEDICARE CLAIM NUMBER as it is shown on
this notice .
IMPORTANT: If you do not agree with the amounts approved, you may ask for a
review. To do this , you must WRITE to us before OCT 04, 1989 . (See item 1
on the back. )
DO YOU HAVE A QUESTION ABOUT THIS NOTICE? If you believe Medicare paid for a
service you did not receive, or there is an error, contact us immediately.
MEDICARE CLAIM NO. 556012747D D � � �jd'
C3878 (S/BB)
YOUR EXPLANATION OF MEDICARE BENEFITS
READ THIS NOTICE CAREFULLY AND KEEP IT FOR YOUR RECORDS
. ' THIS IS NOT A BILL
HEALTH CARE FIHAHCIHG ADMIHISTRATIOH APRIL 11 , 1989
Heed help? Contact:
## RHODA BIRKHOLM Medicare - Chico, California 95976
100 BOYD ROAD 113 Telephone 800-952-8627 HORTHERX CALIF .
PLEASANT HILL CA 94523 800-848-7713 SOUTHERH CALIF .
If you write or call , please give us:
Claim Control Humber (marked ** below)
STATEMENT HUMBER 044462954- 1 CHECK HUMBER 087507046
F'
i
"PARTICIPATIHG" DOCTORS AHD SUPPLIERS ALWAYS ACCEPT ASSIGHMEHT OF MEDICARE
CLAIMS . SEE THE BACK OF THIS HOTICE FOR AH EXPLAHATIOH OF ASSIGHMEHT. WRITE OR
CALL US FOR THE F.. NAME OF A PARTICIPATIHG_ DOCTOR OR SUPPLIER_ OR FOR A FREE _LI_ST_ OF _
PARTICIPATIHG DOCTDRS AHD SUPPLIERS .
Your doctor or supplier did not accept assignment of your claim
totalling $48 . 64 . (See item 4 on the back. )
Claim Control Humber ** 200489087023210
STORE DE Billed Approved
01 HH Visit(s ) 90460 1 MAR 20, 1989 $ 48. 64 $ 35 . 90
Approved amount limited by item Sc on back.
Total approved for all services on this claim . . . . . . . . . . . . $
Medicare payment (80% of the approved amount) . . . . . . . . . . . . $ 8.7
We are paying a total of $ 28. 72 to you on the enclosed check. Please cash it
as soon as possible .
If you have other insurance, it may help with the part Medicare did not pay.
(You have met the deductible for 1989 )
Hext time you request payment, use your MEDICARE CLAIM HUMBER as it is shown on
this notice .
IMPORTANT: If you do not agree with the amounts approved, you may ask for a
review . To do this , you must WRITE to us before OCT 11 , 1989 . (See item 1
on the back . )
DO YOU HAVE A QUESTION ABOUT THIS NOTICE? If you believe Medicare paid for a
service you did not receive , or there is an error, contact us immediately.
MEDICARE CLAIM HO . 556012747D
ung
APR 17 1989 D
CCHP BUSINESS SERVICES
09870 (E/BB)
PHYSICIAN OR SUPPUER blI
1 IVi r V
DENNIS L. STONE, M.D. OF ACCOUNT
GERONTOLOGIST
978 2ND STREET, SUITE 100
LAFAYETTE CA 94549 • • • •
415-283-7777 •• • • • • • • - •
680063605
PATIENT'S NAME ACCOUNT NO. CHARGES AND PAYMENTS MADE AFTER
BIRK01 DILL02 THE STATEMENT DATE WILL APPEAR ON
INSURED NEXT MONTHS STATEMENT.
JANE DILLARD
2087 NORSE DR. #100
PLEASANT HILL, CA 94523
- $TATEMEMGATE AMOUNT OF ,
M 04-24-89 E►� $
TO ASSURE PROPER CREDIT TO YOUR ACCOUNT PLEASE RETURN TOP PORTION WITH YOUR PAYMENT
DATE PLACE PRD R DIAGNOSIS TYPE
OF OF DESCRIPTION'S C R I P T 10 N' OF CHARGES--` `PAYMENTS
SERVICE SERVICE CUBDO I rw SERV.
RHODA BI KHO M Items not Detailed from 03-22-89 214 . 49
-------- RHODA BIRKHOLM
03-24-89 SNF 90360 NURSING HOME VISIT/INTERM 514 1 48.64
'>
03-24-89 SNF 90360 276. 1 1 s� ,fsj
03-24-89 SNF 90360 71505 1
03-28-89 SNF 90360 NURSING HOME VISIT/INTERM 486 1 48. 64
------- -------
311 . 77 0.00
* DENOTES INSURANCE FILED
IF YOU HAVE ANY QUESTIONS REGARDING YOUR DENNIS L. STONE, M.D.
ACCOUNT, CALL MARIE AT 415-283-7777. 978 2ND STREET, SUITE 100
LAFAYETTE CA 94549
31 - 60 61 - 90 91 -120 121 ->
165 .85 0.00 0 .00 0. 00 a • 311 . 77
t,
f YOUR EXPLANATION OF MEDICARE BENEFITS
lREAD THIS NOTICE CAREFULLY AND KEEP IT FOR YOUR RECORDS
THIS IS NOT A BILL .
HEALTH CARE FINANCING ADMINISTRATION APRIL 18, 1989
Heed help? Contact:
## RHODA BIRKHOLM _ Medicare - Chico, California 95976
2087 HORSE DR 100 Telephone 800-952-8627 NORTHERN CALIF .
PLEASANT HILL CA 94523 800-848-7713 SOUTHERN CALIF .
If you write or call, please give us:
Claim Control Humber (marked ** below)
STATEMENT HUMBER 044546035- 1 CHECK NUMBER 087561787
r
"PARTICIPATING" DOCTORS AND SUPPLIERS ALWAYS ACCEPT ASSIGNMENT OF MEDICARE
CLAIMS . SEE THE BACK OF THIS NOTICE FOR AH EXPLANATION OF ASSIGNMENT. WRITE OR
CALL US FOR SHE _NAKE OF A. PARTICIPATIKG DOCTOR OR SUPPLIER OR FOR A. FREE LIST OF
PARTICIPATING DOCTORS AND SUPPLIERS .
Your doctor or supplier did not accept assignment of your claim
totalling $97 . 28. (See item 4 on the back. )
Claim Control Humber ** 200489093230510 **
STOKE DE Billed Approved
02 KH Visit(s ) 90460 1 24-MAR 28, 1989 $ 9 . 28 .80
$ 71
Approved amount limited by item on
Total approved for all services on this claim . . . . $
Medicare payment (80% of the approved amount) . . . . . . . . . $
We are paying a total of $ 57 . 44 to you on the enclosed check. Please cash ityi
as soon as possible .
If you have other insurance , it may help . with the part Medicare did not pay.
Assignment__wa5._taken. on your claim fox $8.7 . 00 from CAMARDA DO . (See item
4 on the back. )
Claim Control Number „*i 202289093127450 ** Billed Approved
///
01 KH Sur ery 1170 2 MAR 28, 1989 $ 65 . 00 $ 46 . 00
Approved amount limited by item Sc on back.
01 HH Lab 87102 5 MAR 28, 1989 $ 22 . 00 $ 13 . 36
Approved amount limited by item 5b on back .
CAMARDA DO agreed to charge no more for the approved
services than the amount approved by Medicare .
Total approved for all services on this claim . . . . . . . . . . . . $ 59 . 36
Amount for services paid at 80% of. the approved amount . . . . . . . . $ 46 . 00
Medicare payment for services paid at 80% of approved amount . . . . . $ 36 .80
Amount fox services paid at 100% of approved amount°`. . . . . . . . . . $ 13 .36
I CM78 (5188)
PHYSICIAN OR SUPPLIER STAT E M E N T
DONALD J. CAMARDA, D.P.M. OFACCOUNT
PODIATRIST
978 2ND STREET, SUITE 100
LAFAYETTE CA 94549 • " • •
415-283-7777 • • • • • • • • • •
{
PA •NT'S NAME ACCOUNTNO CHARGES AND PAYMENTS MADE AFTER
• THE STATEMENT
INSURED NEXT MOffiTF�,S STATEMENT.
RHODA BIRKHOLM
2087 NORSE DRIVE #100 :roup'.—
PLEASANT HILL, CA 94523 C
STATEM'W'ATE ;d .�IMlw� rO'F—�
M OOAAENCWSE' Y'--^-------
*-Tb ASSURE PROPER*CREDIT TO YOUR ACCOUNT PLEASE RETURN TOP POR11ON WITH YOUR PAYMENT f
DA - PROCEDURE a
OF OF SER1MCE CPTeO> DESCRIPTION C&tt 9 SERV.
------- HODA BIRKHOLM
3-28-89 SNF 1170OXMW2 NAIL DEBRIDEMENT 1-5 10. 1 2 65 . 00
3-28-89 SNF 87102 DTM CULTURE 10. 1 5 22 . 00
3-28-89 SNF 87102 40.9 5
5-01-89 kDJ AREWO MEDICARE WRITE-OFF 19 .00
5-01-89 MA MEDICARE PAYMENT 36 . 80
5-01-89 kDJ 3AREW0 MEDICARE WRITE-OFF 8.64
5-01-89 MA MEDICARE PAYMENT 13 . 36
7G Zvi D 3 87 .00- --77 .80
a D
1�1 Y a 19x9
JV
IN qLAIMS UNIT MA. 5CH 19 9
v. 55 _ .. J
WELCOME TO OUR NEW BILLING SYSTEM. IF YOU HAVE DONALD J. CAMARDA, D.P.M.
NY QUESTIONS ABOUT THIS BILL, PLEASE CALL 978 2ND STREET, SUITE 100
ARIE AT 415-283-7777 LAFAYETTE CA 94549
31 - 60 61 - 90 91 -120 121 ->
179 . 20 0. 00 0 .00 0 . 00 ° ' 9 . 20
i
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IPI] S
THE OLDER ADULT'S GUIDE
TO AVOIDING DRUG-INDUCED
DEATH OR ILLNESS
104 Fills Older Adults
Should Not Use
183 Safer Alternatives
Sidney M. Wolfe, M.D.
Lisa Fugate
Elizabeth P. Hulstrand
Laurie E. Kamimoto
Public Citizen Health Research Group
170
Effects on Heart Rate and Rhythm
These drugs can cause the heart to speed up. They can also cause a slowing down in
the conduction of electricity through the heart, which is especially dangerous if some-
one already has heart block.31 For this reason, a baseline electrocardiogram should be
taken before starting any antidepressant therapy.
ADVERSE EFFECTS OF ANTIDEPRESSANTS IN OLDER ADULTS
Generic/ Antichol• Sedative Hypotensive Heart Rate/
j' � Brand Names inergic' Rhythm
desipramine/ mild mild mild mild
Norpramin
' nortriptyline/ moderate mild F mild mild
Aventyl,
Pamelor
amoxapine/ moderate mild moderate moderate
Asendin
{� maprotiline/ moderate moderate moderate mild
Ludiomil
trazodone/ mild moderate moderate moderate
Desyrel
imipramine/ moderate moderate moderate moderate
' Tofranil
�oxepin moderate strong
moderate moderate
Sinequan .
amitriptyline/ strong strong moderate strong
Elavil
mild = mild adverse effects moderate = moderate adverse effects
strong = strong adverse effects
*see p. 169
As can be seen from this chart, the two drugs with the fewest overall adverse effects in
older adults are desipramine (Norpramin), which has a "mild" for all four kinds of ad-
verse effects, and nortriptyline (Aventyl, Pamelor), which is "mild" for three of the four.
Unfortunately, neither is available generically as yet.The drug with the worst adverse ef-
fects profile in older adults is amitriptyline(Elavil),with"strong"adverse effects for three
of the four categories. We list this drug as DO NOT USE.
If the adverse effects of whichever drug is selected are too severe, or if the drug does
not seem to be working, a discussion with your doctor about switching to a drug less like-
ly to cause the troublesome effects is in order.
HOW TO REDUCE THE ADVERSE EFFECTS OF ANY OF THESE
ANTIDEPRESSANTS
e Have a baseline electrocardiogram and blood pressure taken before starting.30
171
• Start with a dose of one-third to one-half the usual adult dose, meaning 15-25 mil-
ligrams a day, at bedtime..Increase the dose very slowly.3 It may take 3 weeks to
see an effect. A trial with one ofs t0se drugs should continue until it either works
or causes persistent side effects.
30
• Get a prescription for only 1 week's worth of pills since more pills increase the
chance of a successful suicide attempt by people who are severely depressed.sl
• Lower tlj dose gradually, as symptoms dictate,after successful treatment for several
months.
LIMITED USE
Doxepin (dox a pin)
ADAPIN (Pennwalt)
SINEQUAN (Roerig)
Trazodone (traz oh done)
DESYREL (Mead Johnson)
Maprotiline (ma proe ti leen)
LUDIOMIL (CIBA)
Amoxapine (a mox a peen)
ASENDIN (Lederle)
Imipramine (im ip ra meen)
in TOFRANIL (Geigy)
d-
�' Generic: not available Family: Antidepressants (See p. 166
for discussion of depres-
sion.)
es
e- These five drugs are used to treat severe depression that is not caused by other drugs,
` by alcohol, orby emotional losses(such as a death in the family).You should notbe taking
them for anxiety or mild de ression, or as a sleeping ill. Because these drugsRave —more
harmful side effects see chart, p. 170 than a wo antidepressants desipramine and
nortriptyline (see p. 180), we consider them to be of limited use to older adults.
If you are over 60, you will generally need to take one-third to one-half the dose used
by younger adults. If the initial dose is not enough and needs to be increased,this should
:j. be done very slowly.
1 F�MS
� i h
172
• Trazodone can cause painful, prolonged penile erections(priapism) in men. If you suf.
fer this reaction, stop taking the drug.and notify your doctor. Amoxapine can cause tar.
dive dyskinesia—uncontrolled movements of the jaws,tongue, and lips—an effect also
seen with antipsychotic drugs (see p. 161). Doxe in has especially strong sedative effects.
' WARNING: SPECIAL MENTAL AND PHYSICAL ADVERSE EFFECTS
Older adults are especially sensitive to the harmful anticholinergic effects of
i'> { antidepressant drugs such as doxenin_, trazodone, maprotiline, amoxapine,
and imipramine. These drugs should not be used unless absolutely neces-
�(
–`M[ENTAL EFFECTS: confusion, delirium.short-term memory problems, dis-
orientation, and impair�tenhon.
f PHYSICAL EFFECTS: dry mouth,,constipation.,.difficulty urinating (espe-
cially for a man with an en arge prostate), blurre3 vision, ecrease sweat-
ing with increased body temperature, sexual dysfunction, and worsening of
i�
glaucoma..
BEFORE YOU USE THIS DRUG
' Tell your doctor if you have or have had O epilepsy or seizures, not for maprotiline
Oalcohol dependence or doxepin
Oasthma* C3 fever or sore throat; blood in urine, for
r :
Oblood disorders* trazodone
Cl heart or blood vessel disease* * not for trazodone
Ostomach or intestinal disease* Tell our doctor i you are taking an
Y f Y 8 Y
Oglaucoma* drugs, including vitamins and other non-
C3 kidney
on-
Okidney or liver disease prescription products.
O thyroid disease* Ask your doctor to check your blood pres-
Omanic-depressive illness, sure, once while you are lying down and
schizophrenia, or paranoia* once after you have been standing up for at
0retention of urine or enlarged prostate* least 2 minutes, and to do an electrocar.
diogram.
WHEN YOU USE THIS DRUG
• Do not stop taking your drug suddenly. *,You may feel dizzy when rising from a
Your doctor must give you a schedule ✓lying or sitting position. When getting
t/ to lower your dose gradually, to out of bed, hang your legs over the side
prevent withdrawal symptoms such as of the bed for a few minutes, then get
headache, mood change, nausea, vomit- up slowly. When getting up from a
ing, diarrhea, or trouble sleeping and chair, stay beside the chair until you
vivid dreams. are sure that you are not dizzy. (See p.
• Until you know how you react to your 18.)
drug, do not drive or perform other ac- • Check with your doctor before taking
tivities requiring alertness. These drugs /any other drugs, prescription or non-
may cause blurred vision and drowsi- prescription. These drugs frequently in-
ness. teract with other drugs.
• It may take several weeks before you • The effects of these drugs may last for
can tell that these drugs are working. If up to a week after you stop taking them.
the drug works, talk with your doctor Avoid alcohol and heed all other warn-
'g { about lowering the dose gradually. ings for this time period.
• Do not smoke. Smoking may increase • If you plan to have any surgery, includ-
i the drug's effects on your heart. ing dental, tell your doctor that you
• Do not drink alcohol or use other drugs take this drug.
that can cause drowsiness. .
173
• HOW TO USE THIS DRUG
• Take with food to reduce stomach If you are taking more than one dose a
upset. For trazodone, taking with food day of one of these drugs other than
will also reduce dizziness and light- trazodone, take the missed dose as soon
headedness. as you remember, but skip it if it is al-
• If you are taking any other drugs,-take ° most time for the next dose.
them 1 to 2 hours before you take your If you are taking more than one dose a
antidepressant. day of trazodone, take the missed dose
as soon as you remember, but skip it if
• Capsules may be opened and mixed it is less than 4 hours until your next
with food or drink. scheduled dose.
• Do not store in the bathroom. Do not ex- If you are taking your drug only once a
pose to heat, moisture, or strong light. day at bedtime, andyou go to sleep
• If you miss a dose, use the following without taking that dose, do not take it
guidelines: in the morning. Instead, call your doc-
tor.
° Do not take double doses.
L�
INTERACTIONS WITH OTHER DRUGS
The following drugs are listed in Evaluations of Drug Interactions, Third Edition, 1985
as causing "highly clinically significant" or "clinically significant" interactions when
used.together with imipramine.They may interact with most,if not all,drugs in this fami-
ly. There ma be other drubs, especially those in the families of drugs listed below, that
also will react with these antidepressants to cause severe adverse ettearMake sure to
° � as your octor or a comp e e an e er ow if you are taking
? any of these interacting drugs.
r ,
s
r ` CYTOMEL PARNATE
epinephrine PRDAATENE MIST
liothyronine tranylcypromine
ADVERSE EFFECTS
Call your doctor immediately: 0prolonged, painful, inappropriate
overdose: confusion; severe drowsi- penile erection
ness; fever; hallucinations; restlessness Oskin rash, hives, or itching
and agitation; seizures; s ortness of 0abnormally slow or fast heartbeat
bred ou a r—b ea Fu'ng; unusually For amoxapine only:
fast, slow, or irregular heartbeat; un- Otardive dyskinesia: lip smacking; chew-
usual tiredness, weakness; vomiting ing movements; puffing of cheeks;
R' Oblurred vision or eye pain rapid, darting tongue movements; un-
5(confusion, delirium, or hallucinations controlled movements of arms or legs
O constipation If continues, call your doctor:
O fainting O dizziness
O irregular heartbeat or slow or fast pulse O drowsiness
',feeling nervous or restless O dry mouth
0impaired sexual function Oheadache E
lashakiness O'nausea or vomiting
trouble sleeping C3 increased appetite for sweets*
Rtrouble urinating 13unpleasant taste in mouth*
O sore throat and fever O weight gain* j
t' O yellow eyes or skin O muscle aches or pains; unusual tired-
For trazodone only: ness or weakness,for trazodone
' O confusion * notfor trazodone
O muscle tremors
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CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT July 18 , 1989
and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amount: $150. 00 Section 913 and 915.4. 1 Please note all "Warnings".
CLAIMANT: DANIEL WM. HASSELMAN'.: County Counsel
1140 Virginia Lane #30
ATTORNEY: Concord, CA 94520 JUN 2 8 1989
Date received MartinezJVCA gj5'51989
ADDRESS: BY DELIVERY TO CLERK ON ne ,
BY MAIL POSTMARKED: June 20 , 1989
1. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
June 23 1989 PpHHIL BATCHELOR, Clerk
DATED: BY: Deputy
L. Hall
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
This claim complies substantially with Sections 910 and 910.2.
( . ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: G ��3 ' ,9 BY: Deputy County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOA
RD
ORDER: By unanimous vote of the Supervisors present
This Claim is rejected in full.
) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
Dated: J U L 18 1989 PHIL BATCHELOR, Clerk, By S6puty Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult
an attorney, you should do so immediately.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above.
Dated: JUL 19 1989 BY: PHIL BATCHELOR by y Clerk
CC: County Counsel County Administrator
1
1
;LAID- TC?• BOARD OF SUPERVISORS OF CONTRA COFRUr�f RyiT1Av1 applicatlen t0.
Instructions to Claimant Clerk of the Board
P.0.Boz 911
A. Claims relating to causes of action for death or tor� injury�to4533
person or to personal property or growing crops must. be presented
not later than the 100th day after the accrual of the cause of
action. Claims relating to any other cause of action must be
presented not later than one year after the accrual -of the cause
of action. (Sec. 911. 2, Govt. Code)
B. Claims must be- filed with the Clerk of thei Board of Supervisors
at its office in Room 106 , County Administration Building, 651 Pine
Street, Martinez , California 94553:
C. If claim is against a district governed by the Board of Supervisors ,
rather than the County, the name of the District should be filled in.
D. If the claim is against more than one public entity, separate claims
must be filed against each public entity.-
E. Fraud. See penalty for fraudulent claims, Penpl Code Sec. 72 at end
of this form. ,
RE: la' by t ) Reserved .for Clerk' s filing stamps
Against the COUNTY OF CONTRA COSTA)
J U N•211989
r-i+a. -crie!o
or DISTRICT) aeas.� neoa.4O sUVVIs s
(Fill in name) ) cena:,cosr.ce:
B De ut
L
61
. The undersigned claimant hereby makes claim against the County of Contra
Costa or the above-named District in , the sum of $
and in support of this claim represents as follows :
-----------------------------------------------------------------------..
1. When did the damage or injury occur? (Give exact date and hour)
---------=--- ------------------=----------------------------------------
2. Where did the damage or injuryioccur? (Include city and county)
3. How did the damage or injury occur? (Give full details, use extra
sheets if required) WUt�p,,, (Y•cJ.a0e� I Z � k,\ V�
5e.g`iurn n- rtiavuo,l� c;AV%, , ' l:cLV a� . Sci�Awl -_�w1�S
9 . What particular act or omission on the part of county or district
officers , `servants \or employees caused the injury or damage?
CL
10`^^
0 (over)
'.:5..:a•J� zat: ar.e...the,_names of county or district officers , servants,• or_ 6
! employeescausing the damage or injury?
------------------------- -------------------------------------------
6 . What damage or injuries do you claim resulted? (Give full extent
of injuries or damages claimed. Attach two estimates for auto
damage) —_
--------- -------------------------------------------•------------------
7. How was-=-the amount claimed above computed? (Include the e timate
amount of any prospective,\inju y or damage. ) p, � v� V
0� \o24oyI, S IM� Q6ii�Yn � \S c �1tiYVQ-�lV�
--------------1)--1---------------------------------------------------------
8. Names and addresses of witnesses , doctors and hospitals.
-------------------------------------------------------------------------
9 . List the expenditures you made on account of this accident or injury :
DATE. ITEM ' 7--MOUNT
Govt. Code Sec. 910 .. 2 provides :
"The claim signed by the claimant
SEND NOTICES TO: (Attorney) or by some o-rson on his behalf. "
Name and Address of "Attrrney
Claimant' s Si nature
1\ Vic �s� n:a' L►n. acs
Address
q LEs a o
Telephone No. Telephone No. q- D9 3t
*•k*t******tr******tr****t,t,t*****�t***,t,t*,tt**,r**t*********,t**,t******x**,t***,r,t.,t
NOTICE
Section 72 of the Penal Code provides :
"Every person who, .with intert to defraud, preser,t.s for allowance or
for payment to any state-, board or officer , or to any county, town, city
district, ward or village board or officer, authorized to allow or pay
the same if genuine , any false or fraudulent claim, bill , account , voucher,
or writing , is guilty of a felony. "
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�� . CLAIM /�l
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT Jul 18 , 1 989
and Board Action. All Section references are to ) The copy of this document mailed to you i your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amount: $160. 08 Section 913 and 915.4. Please note all "Warnings".
CLAIMANT: THE CUSTOMER COMPANY County Counsel
P. O. Box 886
ATTORNEY: Benicia, CA 94510 JUN 2 3 1989
Date received �a� Z, � �4553
ADDRESS: BY DELIVERY TO CLERK ON J i29
BY MAIL POSTMARKED: June 14, 1989
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
DATED: June 22 , 1989. PPHH1L ATCHELOR, Clerk
BY: Deputy
—r
L. Hall
I1. FROM: County Counsel TO: Clerk of the Board of Supervisors
� ) This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed lateandsend
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: 23 Deputy County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present
(X ) This Claim is rejected in full.
(�� ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
�
Dated: J U L 18 1909eA PHIL BATCHELOR, Clerk, By Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult
an attorney, you should do so immediately.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above.
JUL U L 1 9 1989 BY: PHIL BATCHELOR by V"A�1��Puty Clerk
CC: County Counsel County Administrator
EMPLO=YEE NCT•: EMPLOYEE TRAVEL DEMAND
I ON THE TREASURY OF THE COUNTY OF CONTRA COSTA
QLJ.5Ta4M COMPANY (FOR REIMBURSEMENT OF EMPLOYEE EXPENSES) CLAIM MONTH: AT?R 29
(PRINT) .LAST NAME , INITIALS IMPORTANT SEE INSTRUCTIONS ON REVERSE SIDE MO. YR.
TRAVEL BY PRIVATE AUTO ITEMS OF EXPENSE
DATE FROM, TO MILES DATE AMOUNT
Loss of margin dollars (semattached) 160-08
TOTAL ITEMS OF EXPENSE
The undersigned under the penalty of perjury states: That this claim
and the items as therein set out are true and correct; that no part
thereof has been heretofore paid,and that the amount therein is justly
due, and that the some is presented within one year after the lost
item thereof has accrued.
MADE BYWay EiP-64LOYEIE'SIGNATURE
1 IO��YYdQ Y. DATE
—I
APPROVED BY
TOTAL MILES SUPERVI SORBS SIGNATURE DATE
(
ORGM. TASK OPT ACTIVITY IR LIEU REGULAR RECEIVED, ACCEPTED and EXPENDITURE AUTHORIZED
MILES MILES
SIGNED
DEPARTMENT HEAD OR AUTHORIZED DEPUTY DATE
EXPENSE DISTRIBUTION
DATE DESCRIPTION ORGN ACCOUNT AMOUNT TASK OPT ACTIVITY
2 OTHER TRAVEL 2303
2
2
2
(M8154 REV. 9/82) 1
Claim to: BOARD OF SUPERVISORS OF CORTRA'COSTA COUNTY
INSTRUCTIONS TO CLAIMANT
A. Claims relating to causes of action for death or for injury to person or to per-
sonal property or growing crops and which accrue on or before December 31, 1987,
must be presented not later than the 100th day after the accrual of the cause of
action. Claims relating to causes of action for death or for injury to person
or to personal property or growing crops and which accrue on or after January 1,
1988, must be presented not later than six months after the accrual of the cause
of action. Claims relating to any other cause of action must be presented not
later than one year after the accrual of the cause of action. (Govt. Code 5911.2.)
Claims must be filed with the Clerk of the Board of Supervisors at its office in
Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553•
C. If claim is against a district governed by the Board of Supervisors, rather than
the County, the name of the District should be filled in.
D. If the claim is against more .than one public entity, separate claims must be
filed against each public entity.
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this
orm.
* • * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
RE: Claim By ) Reserved for Clerk's filing stamp
The Customer Company j RECEI yE1.)
Against the County of Contra Costa ) JUN 1 198
or )
L R
District) oeu
Fill in name )
The undersigned claimant hereby makes claim against the County of Contra Costa or
the above-named District in the sum of $ 160.08 and in support of
this claim represents as follows:
----------- --------------------------------
1. When did the damage or injury occur? (Give exact date and hour)
April 12, 1989 5:40 P.M.
2. Where did the damage or injury occur? (Include city and county)
Food & Liquor #78, 81 Center Street, Pacheco, Contra Costa County, CA 94553
-----------------------------------------------���_---_ ------------���
3. How did the damage or injury occur? (Give full details; use extra paper if
required)
see enclosed letter.
4. What particular act or omission on the part of county or district officers,
servants or employees caused the injury or damage?
see enclosed letter.
(over) /'
5. What are the names of county or district officers, servants or employees causing
the damage or injury?
Officer - Deputy Dempsey Report #89-9413
6. What damage or injuries do you claim resulted?(Give full extent of injuries or
damages claimed. Attach two estimates for auto damage.
see enclosed letter
----------------------------------- --- --------------------
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.)
see enclosed letter
8. Names and addresses of witnesses, doctors and hospitals.
Mike DiLibero, 327 Magellan Avenue, San Francisco, CA 94116
John F. Roscoe, 4457 Park Road, Benicia, CA 94510
------ -----------------------------------------
9. List the expenditures you.made on account of this accident or injury.
DATE ITEM AMOUNT
see enclosed letter
# # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #
Gov. Code Sec. 910.2 provides:
"The claim q
yst be signed by the claimant
SEND NOTICES TO: (Attorney) or by some n his behalf."
Name and Address of Attorney '
lai S tune
Address
Telephone No. Telephone No.
# # # # # # # # # # # # # # # # # #
NOTICE
Section 72 of the Penal Code provides:
"Every person who, with intent to defraud, presents for allowance or for
payment to any state board or officer, or to any county, city or district board or
officer, authorized to allow or pay the same if genuine, any false or fraudulent .
claim, bill, account, voucher, or writing, is punishable either by imprisonment in
the county jail for a period of not more than one year, by a fine of not exceeding
one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in
the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by .
both such imprisonment and fine.
i
April 24, 1989
MUFFIVIV
Sheriff Richard Rainey
Contra Costa County
651 Pine Street
Martinez, CA 94553
Dear Sheriff Rainey:
$t
We operate a grocery store at Center Street, Pacheco, California. This
store is in the unincorporated area of Contra Costa County.
About 5:40 P.M. on Wednesday, April 12th, the State Highway Patrol shot and
wounded a man on our property. Shortly thereafter officers from your department
commandeered part of our property, blocked off our access from Pacheco, and
took possession of our gasoline operation. They remained in possession of our
property until after our closing time at midnight.
Our store sales were adversely affected. We made only two gasoline sales just
before closing. At no time did your officers ask for the use of our property.
They were uncooperative when we tried to get them to return our property. They
told me they would arrest me if I went to the blocked off portions of our property.
We are certainly willing to cooperate with the law enforcement organizations. On
some occasions we are willing to let them use our property. We expect to be asked
for our cooperation and our property. We expect this use to be for a reasonable
length of time. We expect our property is to be returned in good condition. If
the property is to be used for more time than is reasonably necessary, we expect
to be compensated for its use.
None of these requirements were met on the evening of April 12, 1989. We were
never contacted by your department. Our property was seized without our permission.
We were not informed when it would be returned. Your officers were abusive to us.
The property was kept an unreasonable length of time.
We expect to be compensated for our losses. Attached to this letter is a billing
for those losses. Also attached is a sheet showing how these losses were calculated.
I hope that your department will change its policies , procedures , and practices so
that the taking of private property is handled in a more professional manner. The
seizure of private property by government cannot be taken lightly in a free society.
Yours Jery truly,
John F. Roscoe
FHE CUSTOMER COMPANY, P.O. BOX 886, BENICIA, CALIFORNIA 94510, TEL. (707) 745.6691 , FAX (707) 746-0'
Bill to: Sherriff's Department
Contra Costa County
81
Loss of margin dollars for ffi* Center Street, Pacheco, California 4-24-89
Please remit to:
The Customer Company
4457 Park Road
Benicia, CA 94510
Computation of Loss: 4-24-89
Store Loss:
Average daily store sales three previous weeks.
Wednesday 3-22-89 $4,486
Wednesday 3-29-89 $4,403
Wednesday 4-05-89 $4,471
Average store sales for 3 preceeding Wednesdays $4,453
Store sales for Wednesday 4-12-89 39956
Difference 497
Times Gross Margin Percent _ 22%
Net margin loss from store sales $ 109.34
Gasoline Loss:
Average daily gasoline gallons sold, three previous weeks:
Wednesday 3-22-89 $3,542
Wednesday 3-29-89 3,496
Wednesday 4-05-89 3,492
Average gallons for 3 preceeding Wednesdays $3,510
Gasoline gallons sold on Wednesday 4-12-89 2,035
Difference 1,475
Gasoline margin per gallon for 4-12-89 3.44 cents
Gasoline margin dollars lost on 4-12-89 $50.74
Total margin dollars lost by 4-12-89 condemnation $160.08
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CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Clam Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT July 18 , 1989
and Board Action. All Section references are to The copy of this document mailed to you is your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amount: Unspecified Section 913 and 915.4. ; pl� ta �lVr�'ngs".
CLAIMANT: SAFEWAY STORES,'; INC .
c/o Martin, Ryan & Andrada JUN 23 1989
ATTORNEY: Ordway Building, #2275 Martinez, CA 54553
1 Kaiser Plaza Date received
ADDRESS: Oakland, CA 94612 BY DELIVERY TO CLERK ON June 19 , 1989 hand del .
Bl MAIL POSTMARKED: no envelope
1. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
June 22 , 1989 PpHHIL BATCHELOR, Clerk
DATED: BY: Deputy
L. Hall
11. FROM: County Counsel TO: Clerk of the Board of Supervisors
This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: BY: Deputy County Counsel
�T
III. FROM: Clerk of the Board TO: County Counsel (1) County Admini ator (2)
F
( ) Claim was returned as untimely with notice to claimant (Section 911.3). . �
,fi'
t
IV. BOARD ORDER: By unanimous vote of the Supervisors present
(�) This Claim is rejected in full.
(/ \) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date. oA
Dated: U U L 18 190' PHIL BATCHELOR, Clerk, By Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult
an attorney, you should do so immediately.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above.
JUL is1s89 `
Dated: BY: PHIL BATCHELOR by puty Clerk
CC: County Counsel County Administrator
a
MARTIN, RYAN & ANDRADA RECEIVED
A Professional Corporation
Ordway Building, Suite 2275 :UIN 19 1989��
One Kaiser Plaza
Oakland, CA 9461213
�1
(415) 763-6510 o�`'"c°o°r�ra°OosrncLO'R."""
By .. Daputy
Attorneys for Claimant
SAFEWAY STORES, INC.
CLAIM AGAINST CONTRA COSTA COUNTY HEALTH DEPARTMENT
TO: CLERK OF THE BOARD OF SUPERVISORS, 651 Pine Street, Room
106, Martinez, CA 94553:
SAFEWAY STORES , INC. , hereby makes a claim against the
CONTRA COSTA COUNTY HEALTH DEPARTMENT and makes the following
statement in support thereof:
1. Claimant' s post office address is: SAFEWAY STORES ,
INC. , 201 - 4th Street, Oakland, California 94607.
2. Notices concerning the claim should be sent to
Gerald P. Martin, Jr. , Martin, Ryan & Andrada, One Kaiser Plaza,
Suite 2275, Oakland, CA 94612.
3. The date and place of the occurrence giving rise to
this claim are as follows:
On or about January 17, 1989 SAFEWAY STORES , INC. , was
served with a complaint by Joe White, Jr. v. Safeway Stores,
Inc. , et al. (Case No. 093330) . The action was filed in the
Municipal Court of California, County of Contra Costa, Bay
Judicial District.
On or about January 17, 1989 SAFEWAY STORES , INC. , was
served with a complaint by Joe White, Sr. v. Safeway Stores,
Inc. , et al. (Case No. 093146) . The action was filed in the
Municipal Court of California, County of Contra Costa, Bay
Judicial District.
On or about January 17, 1989 SAFEWAY STORES , INC. , was
served with a complaint by Eric White v. Safeway Stores, Inc. , et
al. (Case No. 093328) . The action was filed in the Municipal
Court of California, County of Contra Costa, Bay Judicial
District.
-1-
Airabell White v. Safeway Stores, Inc. , et al. but to any
subsequent complaints or cross-complaints brought against
claimant based on the above-described occurrences.
6. Jurisdiction over this claim would rest in Superior
Court.
7. The names of the public employees causing claimant ' s
damages are unknown.
8. The amount of the claim and the basis for its
computation have yet to be determined.
DATED: toj lq jOq
MARTIN, RYAN & ANDRADA
A Profess al Corporation
By
GERALD P. MARTIN, JR.
-3-
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT July 18 , 1989
and Board Action. All Section references are to The copy of this document mailed to you is your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amount: $2 , 500 , 000 . 00 Section 913 and 915.4. ! Pleaseno all "Warnings".
BRITTANY GATTIS BY HER GUARDIAN AD LITEM, ANGb tl wvP `E
CLAIMANT: c/o Law Offices of Thomas C. Crenshaw
1999 Harrison Street #1300 JUN 23 1999
ATTORNEY: Oakland, CA 94612
Date received Martinez, CA 94553
ADDRESS: BY DELIVERY TO CLERK ON June 21 , 1989 hand del .
BY MAIL POSTMARKED: no envelope
1. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
DATED: June 22, 1989 PpHHIL BATCHELOR, Clerk
BY. Deputy
L. Hall
11. FROM: County Counsel TO: . Clerk of the Board of Supervisors
jam ) This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days.(Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: I Q y BY: Deputy County Counsel
—T
III. FROM: Clerk of the Board. TO: County Counsel (1) Cou Admini trator (2)
( ) Claim was returned as untimely with notice to. claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present
(X)
This Claim is rejected in full.
(� �) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date. n n
Dated: J U L 18 198 9 PHIL BATCHELOR, Clerk, By /%<A��, eputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult
an attorney, you should do so immediately.
r AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above.
Dated: JUL 19 1989 BY: PHIL BATCHELOR by , Deputy Clerk
CC: County Counsel County Administrator
JUN 211Jg ��
CLERK O ✓ t)F�;'� R
CLAIM AGAINST THE a - �• H3
COUNTY OF CONTRA COSTA, MERRITHEW MEMOR'I7a O F -A - °�a ty
DR. VAN BUREN
CLAIMANT' S NAME:_BRITTANY GATTIS, by her Guardian Ad Litem ANGELA MARIE
PATE
CLAIMANT' S ADDRESS: 11 Orinda Circle, Pittsburg, CA. 94565
CLAIMANT' S TELEPHONE: 415/432-4567 (H) N/A (W)
AMOUNT OF CLAIM $ 2.500,000.00
ADDRESS TO WHICH NOTICES ARE TO BE SENT: Angela M. Pate, c/o Law Offices
of Thomas C. Crenshaw, Lake Merritt Plaza 1999 Harrison
a an , CA 94612
DATE OF INCIDENT: December 21, 1988
LOCATION OF INCIDENT• Merrithew Memorial Hospital, Maternity Department
HOW DID IT OCCUR?: Dr. Van Buren negligently and carelessly delivered
Brittany Gattis ..causing the injuries described below.
GIVE LICENSE NO. , IF VEHICLE INVOLVED: N/a.
Fracture of left cavical, permanent damage to C5-6,
DESCRIBE DAMAGE OR INJURY:C7 innervated myotomes, permanent paralysis of left
arm
NAME OF PUBLIC EMPLOYEE (S) CAUSING INJURY OR DAMAGE, IF KNOWN:
Dr. Van Buren; Dr. A. Mbanugo; the entire medical and nursing staff of -Merrithew
Memorial Hospital's maternity ward.
ITEMIZATION OF CLAIM (List items totaling amount set forth above)
Future medical specials $ 500,000.00
Impairment of furore earning capacity $ 1,500,000.00
Mental and emotional distress $ 500,000.00
$
TOTAL $ •0
Signed t#X&X on behalf of Claimant7 MAS C
Dated: June 21, 1989
CLAIM
,sy BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT July 18 , 1989
and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amount: $500, 000. 00 Section 913 and yL
915.bs�.Pltnote all "Warnings".
6lffTl �/ {rOunsel
CLAIMANT: ANGELA MARIE PATE
c/o Law Offices of Thomas C. Crenshaw JUN 23 1989
ATTORNEY: 1999 Harrison St. #1300 Martinez, CA 94
Oakland, CA 94612 Date received June Z73 1989 hand del .
ADDRESS: BY DELIVERY TO CLERK ON
BY MAIL POSTMARKED: no envelope
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
DATED: June 21, 1989 gaIL BAATTCYELOR, Clerk
epuL. Hall
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
� ) This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: G �2 BY: I Deputy County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Admi ator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present
(,► ) This Claim is rejected in full.
(� ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
Dated: J U L 18 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult
an attorney, you should do so immediately.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above.
Dated: JUL 19 1989 BY: PHIL BATCHELOR by / eputy Clerk
CC: County Counsel County Administrator
RE
JUN 211989
CLAIM AGAINST THEOR
CLERK RCH'I. rr'.JPERVWRS
COUNTY OF CONTRA COSTA, MERRITHEW MEMORIAL P ,
....s` _ Deputy
DR. VAN BUREN
CLAIMANT' S NAME: ANGELA MARIE PATE
CLAIMANT' S ADDRESS: 11 Orinda Circle, Pittsburg, CA 94565
CLAIMANT' S TELEPHONE: 415/432-4567 (H) N/a (W)
AMOUNT OF CLAIM $ 500,000.00
ADDRESS TO WHICH NOTICES ARE TO BE SENT: Angela M. Pate, c/o Law Offices
of Thomas C. Crenshaw, Lake Merritt Plaza, 1999 Harrison Street, Suite 1300,
Oakland, CA 94b]Z
DATE OF INCIDENT• December 21, 1988
LOCATION OF INCIDENT• Merrithew Memorial Hospital, Maternity Department
HOW DID IT OCCUR?: Claimant witnessed the negligent and careless delivery of
her minor child, Brittany Gattis.
GIVE LICENSE NO. , IF VEHICLE INVOLVED: N/a
Fracture of left clavical, permanent damage to C5-6,
DESCRIBE DAMAGE OR INJURY: C7 innervated myotomes_ permanentaralvc,sof left
arm.
NAME OF PUBLIC EMPLOYEE (S) CAUSING INJURY OR DAMAGE, IF KNOWN:
Dr. Van Buren; Dr. A. Mbanugo• the entire medical and nursing c aff of Merrithew
Memorial Hospital's maternity department.
ITEMIZATION OF CLAIM (List items totaling amount set forth above)
Future medical care and teatment $ 250.000.00
Mental and emotional distress $ 250.000.00
TOTAL $ 00,0 0.00
Signed kyxRx on behalf of Claimant
TF�OMAS C. CRE .A
Dated: June 21, 1989
1 PROOF OF SERVICE -BY PERSONAL DELIVERY
2
3 I am a 'cii£izen of the United States, and am employed in the
4 County of Alameda. I am over the age of 18 years and not a party
5 to the within action; my business address is Lake Merritt Plaza,
6 Suite 1300, 1999 Harrison Street, Oakland, California 94612 . On
7 June 21, 1989 , I served the within:
8 CLAIM AGAINST THE COUNTY OF CONTRA COSTA; MERRITHEW MEMORIAL
9 HOSPTIAL; DR. VAN BUREN on behalf of ANGELA MARIE PATE and
10 BRITTANY GATTIS, by and through her Guardian Ad Litem, Angela Marie
Pate
11 on the parties below by personally delivering same as follows:
12
Contra Costa County Legal Department
13 651 Pine Street, Room 106
Martinez, CA 94553
14
15
16 '
17
.i
18
19 `
c
20
21
22
23
24
25
26 I declare under t>correc
f a Stat' 1i or is that
27 the foregoing is true an
28 Dated: June 21, 1989
OM CRENSHAW
I CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT July 18 , 1989
and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amount: $100 , 000 . 00 Section 913 and 915 4. unty Counsel Please note all "Warnings".
CLAIMANT: JULIEN LAGMAN Co
c/o Law Offices of John Gardenal JUN 2 3 1989
ATTORNEY: 1255 Post Street #800
San Francisco, CA 94109 Date received Martinez, ?q e4 �13. 1989 hand del .
ADDRESS: BY DELIVERY TO CLERK ON
BY MAIL POSTMARKED: no envelope
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
June 22 1989- PpHHIL BATCHELOR, Clerk
DATED: . BY: Deputy i
L. Hall
II,, FROM: County Counsel TO: Clerk of the Board of Supervisors
(�) This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: C 23 BY: Deputy County Counsel
III. FROM: Clerk of the Board-s TO: County Counsel (1) County ini trator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOX
ARD ORDER: By unanimous vote of the Supervisors present
This Claim is rejected in full.
) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date. e
Dated: J U L 18 1989 PHIL BATCHELOR, Clerk, By � . Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code'Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult
an attorney, you should do so immediately.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above.
Dated: JUL 19 1989 BY: PHIL BATCHELOR by ���; Clerk
CC: County Counsel County Administrator
CLAIM AGAINST THE COUNTY OF CONTRA COSTA
CLAIMANT'S NAME: Julien Lagman
CLAIMANT'S ADDRESS: 1783 Pheasant Drive TELEPHONE: (415) 799-4263
Hercules, CA 94572
AMOUNT OF CLAIM: $1001000. 00
ADDRESS TO WHICH NOTICES ARE TO BE SENT: LAW OFFICES OF JOHN GARDENAL
1255 Post Street, Suite 800
San Francisco, CA 94109
DATE OF INCIDENT: December 21, 1988 at 7:25 p.m.
LOCATION OF INCIDENT: Intersection of Appian Way and I80 off-ramp
in Pinole, California.
HOW DID IT OCCUR: Claimant was a passenger in a vehicle that was
exiting I80 at Appian Way in Pinole, California.
At the bottom of the off-ramp are two sets of signal lights facing the
vehicles on the off-ramp. One is for the vehicles going straight ahead
and one for vehicles turning left. The driver of plaintiff's vehicle
looked at the wrong set of lights and thought he had a green light when
he actually had a red light. They proceeded ahead and were struck
broadside. The investigation police officer stated that he and other
officers in their department have been confused by these lights. (See
attached Police Report. )
GIVE LICENSE NUMBER, IF VEHICLE INVOLVED: n/a.
DESCRIBE DAMAGE OR INJURY: Acute fracture of the left tibia.
NAME OF PUBLIC EMPLOYEE(S) CAUSING INJURY OR DAMAGE, IF KNOWN: Unknown
at this time.
ITEMIZATION OF CLAIM:
1. Doctors Hospital of Pinole $ 282.30
2. Pinole Emergency Medical Group 152.00
3. Kaiser Hospital Unknown
4. General Damages , 0. 0
Signed by or on behalf of Claimant
NNIFE A. STEW T, ESQ.
U.rrt
�u iU
JUN_21 fi 89
PHIL Q CHF; qR
CLE:ir'GO
A.RDD OF SDP&k✓IoC'3
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❑ ( ) ( ) CHP ME ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
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• ❑MOD. ❑MAJOR ❑TOTAL
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SEATING POSITION SAFETY EQUIPMENT � EJECTED FROM VEH.
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AL 2 TO 6-PASSENGERS B.UNKNOWN .. M-AIR BAG NOT DEPLOYED DRIVER 1-FULLY EJECTED
7-STA.WGK REAR C.LAP BELT USED N•OTHER V-NO -
a-RFL OCC.TRK_OR VAN D-LAP BELT NOT USED P-NOT REOUIRED W-YES 2-PARTIALLY EJECTED
2-UNKNOWN
O-POSITION UNKNOWN E-SHOULDER HARNESS USED
123 0-OTHER F-SHOULDER HARNESS NOT USED CHILD RESTRAINT PASSENGER
4 5 6 G-LAP I SHOULDER HARNESS USED O-IN VEHICLE USED X-NO
H-LAP I SHOULDER HARNESS NOT USED A-IN VEHICLE NOT USED Y.YES
7 J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN
K.PASSIVE RESTRAINT NOT USED T.IN VEHICLE IMPROPER USE
U-NONE IN VEHICLE
ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK(•)SHOULD BE EXPLAINED IN THE NARRATIVE
PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 1 2 g TYPE OF VEHICLE1 2 3 MOVEMENT PRECEDING
UST NUMBER(a)OF PARTY AT FAULT COLLISION
a A YC SECTION VIOLATED: CITED
K A CONTROLS FUNCTIONING A PASSENGER CAR/STA WGN.
No B CONTROLS NOT FUNCTIONING' B PASSENGER CAR W/TRAILER A STOPPED
a B OTHER IMPROPER DRIVING• O CONTROLS OBSCURED C MOTORCYCLE/SCOOTER `< / B PROCEEDING STRAIGHT
D NO CONTROLS PRESENT/FACTOR' D PICKUP OR PANEL TRUCK I C.RAN OFF ROAD
C OTHER THAN DRIVER- TYPE OF COLLISION E PICKUP I PANEL TRK W I TLR
D MAKING RIGHT TURN
D UNKNOWN' A HEAD-ON F TRUCK OR TRUCK TRACTOR X1 E MAKING LEFT TURN
a E FELL ASLEEP- B SIDESWIPE G TRK/TRK TRACTOR W/TLR. F MAKING U TURN
(,REAR END H SCHOOL BUS G BACKING
WEATHER(MARK 1 TO 21TEMS) D BROADSIDE I OTHER BUS H SLOWING/STOPPING
X A CLEAR E HIT OBJECT I J EMERGENCY VEHICLE I PASSING OTHER VEHICLE
7 B CLOUDY F OVERTURNED K HWY.CONST.EOUIPMENT J CHANGING LANES
C RAINING G VEHICLE/PEDESTRIAN L BICYCLE K PARKING MANEUVER
D SNOWING H OTHER% MOTHER VEHICLE I L ENTERING TRAFFIC
E FOG/VISIBIUTY FT. MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN M OTHER UNSAFE TURNING
F OTHER% A NON-COLLISION O MOPED N XING INTO OPPOSING LANE
G WIND B PEDESTRIAN O PARKED
LIGHTING C OTHER MOTOR VEHICLE P MERGING
A DAYLIGHT D MOTOR VEH.ON OTHER ROADWAY OTHER ASSOCIATED FACTOR Q TRAVELING WRONG WAY
B DUSK-DAWN E PARKED MOTOR VEHICLE 2 $ (MARK 1 TO 21TEMS) R OTHER:*
}� CDARK-STREET LIGHTS F TRAIN AVC SECTION VIOLATION: CITED
D DARK.NO STREET LIGHTS G BICYCLE DYES
❑w
E DARK- STREET LIGHTS NOT H ANIMAL: B VC SECTION VIOLATION; CITED
FUNCTIONING' DYES SOBRIETY-0RUG
A DR ROADWAY SURFACE I FIXED OBJECT: Cvc EECIION VIOLATION: CITED 2 3 PHYSICAL
tl OYES (MARK ITO2ITEMS)
WET •ICY J OTHER OBJECT: D O� A HAD NOT BEEN DRINKING
C
B HBD.UNDER INFLUENCE
D SLIPPERY(MUDDY,OILY,ETC.) E VISION OBSCUREMENT:
k k F INATTENTION', C HBD-NOT UNDER INFLU.•
D HBD-IMPAIRMENT UNK.•
ROADWAY TO
ITEMS PEDESTRIANS ACTION G STOP GO TRAFFIC E UNDER DRUG INFLU.-
(MARK 1 70 2 RENTS) H ENT _NG/ EAVING RAMP
A NO PEDESTRIAN INVOLVED - F IMPAIRMENT-PHYSICAL•
,
A HOLM DEEP RUTS- CROSSING IN CROSSWALK G IMPAIRMENT HOT KNOWN
B LOOSE MATERIAL ON RDWY.• B I PREVIOUS COLLISION AT INTERSECTION J UNFAMILIAR WITH ROAD '` H NOT APPLICABLE
K DFF CTIVE VEIL EQUIP.: CITED
C OBSTRUCTION ON ROADWAY' CROSSING IN CROSSWALK.NOT S.. DYES ( SLEEPY/FATIGUED
D CONSTRUCTION.REPAIR ZONE C AT INTERSECTION LSI it `-`�pF1O SPECIAL INFORMATION
E REDUCED ROADWAY WIDTH D CROSSING.NOT IN CROSSWALK L UNINVOLVED VEHICLE " :I . A HAZARDOUS MATERIAL
F FLOODED• E IN ROAD-INCLUDES SHOULDER M OTHER%
G OTHER': F NOT IN ROAD N NONE APPARENT
H NO UNUSUAL CONDITIONS G APPROACH/LEAVING SCHOOL BUS O RUNAWAY VEHICLE
SKETCH "SCELLANEOUS
O
GNOICATa
NOHT••
555 - age 2 ( ev -87 ) 042
TATE OF CAUFORNIA
ARRATIVE/SUPPLEMENTAL PAGE
DATE OF OOLLJQON, TIME'IZ4WJ NCICNUMBER OFf ICE ED ( NUMBER
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RATE OF CAI,IFOANA
INJURED / WITNESSES / PASSENGERS PAGE
DATE CFCOLLIMONTME REfpI, `. NCIC NUMBER OFRC R1.0. NUMBL
\ \ � \`t '� vo a va 1
EXTENT OF INJURY ("X" ONE) INJURED WAS ("X" ONE)N ONLY PAS�LYER 'AGE SEX ►ARTY PEAT gw'.' EJECTED
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FATAL INJURE OTMERYISIBLE COMPLIN NWBER IDS. [OUF.
INJURY INJURY NJURY OF INN DIDVFR ►AYi. PED. IICYCIIR OTHER
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DESCRIBE'BIJURIES
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LDAY YEAR IIFVIEWEr .. Y0. DAY YEA
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CHP 555-Page 3(Rev.7-87) OPI 042 87 43637