_____________________________ ___________________________ __________________________ RTK REQUEST NUMBER DATE RECEIVED 5 DAY RESPONSE DATE

COUNTY OF LUZERNE

RIGHT TO KNOW LAW REQUEST FORM

NAME OF REQUESTER:___________________________________________________________________ (PLEASE PRINT CLEARLY) LAST FIRST MI

MAILING ADDRESS:______________________________________________________________________ STREET / P.O. BOX

________________________________________________________________________________________________________ CITY STATE ZIP CODE

PHONE #____________________________________ FAX#_______________________________________

EMAIL ADDRESS:_________________________________________________________________________

SIGNATURE:_____________________________________________ DATE:__6/7/2017_______________

RECORDS REQUESTED - Requesters MUST specify the document(s) sought. Please use additional pages if necessary.

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

PLEASE CHECK ONE OF THE FOLLOWING: _____ I AM ONLY REQUESTING ACCESS TO THE DOCUMENT(S) _____ I AM REQUESTING A HARD COPY OF THE DOCUMENT(S) (PAPER, CD, etc…) _____ I AM REQUESTING AN E-FILE OF THE DOCUMENT(S) (IF AVAILABLE) (PDF, EXCEL SPRDSHT, etc…)

PLEASE NOTE: LUZERNE COUNTY IS NOT REQUIRED TO CREATE A RECORD WHICH DOES NOT CURRENTLY EXIST OR TO COMPILE, MAINTAIN, FORMAT OR ORGANIZE A RECORD IN A MANNER IN WHICH THE AGENCY DOES NOT CURRENTLY COMPILE, MAINTAIN, FORMAT OR ORGANIZE THE RECORD

OFFICIAL USE ONLY

Re: REQUEST FOR INMATE RECORDS PERTAINING TO FORMER INMATE:

Robert “Bobby” Joseph Lee, Jr.

DOB: 11/28/1980 DOD: 9/20/2001 SSN: 161-62-4689

Dear Medical Records,

I am writing to request copies of any and all incarceration records in your possession regarding Robert Lee, Jr. As Mr. Lee is deceased, please find attached a release signed by his father Robert Lee, Sr. authorizing the disclosure of his son’s records. Also attached is a copy of Mr. Lee’s death certificate.

This request includes, but is not limited to, the following:

• Commitment and release dates with listing of citation numbers• Inmate book-in sheets and book-in photographs• Inmate intake and classification records• Visitation lists• Disciplinary files• Medical Records, including mental health records, medication administration records, and psychological

records and/or evaluations• Activity logs• Mail logs

Please send a certified copy of the records to me at the above address. Certification requires a letter on letterhead from the agency stating that the enclosed records are true and correct copies of the records in their possession. Please contact me if you have any questions regarding this request. Thank you very much for your assistance.

Sincerely,

Matt Silverman

Matthew Silverman, LLC

T: 520-261-8923 ! F: 800-309-9556

1201 E. Jefferson St. Ste. 5 ! Phoenix, AZ 85034

Silverman.Mitigation@gmail.com

Email 6/7/2017

To: Records Captain From: Matthew Silverman

Agency: Luzerne County Correctional Facility Pages: 5

Phone: 570-825-1500 Fax: 570-825-9343

2016

HIPAA-COMPLIANT AUTHORIZATION FOR RELEASEOF CONFIDENTIAL INFORMATION & RECORDS

From: , I—Date of Birth: s/jo/J-7Social Security Number: O ' 3

l2o hereby certitV that I am theJSA/.

of the deceased *J ■ -J~h. _ /i(2^9'/bo /O-^.'3. ^ /zx^J QfI hereby authorize agencies and institutions to release all records in their possession to any dulydesignated representative of attorneys JOHN PHILIPSBORN, MICHAEL BLRT, LAURA ROGERS,and KERRY DEWOLFE, including, but not limited to investigators MELANIE CARR, MATTHEWSILVERMAN, ELIZABETH VARTKESSIAN, KEITH MacARTHUR, NANCY STEVENS, andELLIS ARMISTEAD for the purpose of legal representation.

Disclosure should include, but is not limited to records of: birth; death; adoption; marriage;dissolution and divorce; academic and school (including counseling, attendance and medical records);incarceration; corrections; probation; medical and psychological treatment and evaluation, including CTscans, MRIs, x-rays, EEGs, psychometric testing protocols and raw test scores and all other psychiatrictreatment records including psychotherapeutic notes of counseling sessions, admission and dischargesummaries, nurse and physician notes and orders, progress notes, discharge instructions, laboratoryreports and records, and information relating to sexually transmitted diseases such as acquiredimmunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV); pharmaceutical;autopsy; dental; employment; law enforcement; military; rehabilitation (including alcohol, addictions anddrug rehabilitation); financial; social security; disability; private and governmental social services,including DSS and HHS records; benefits (Medicaid, AFDC, welfare, etc.); Child Protective Services;foster care and other children and family services records; juvenile court or any other juvenile records;government agency records of any kind; and, any and all other information, records or documents,including correspondence, checks, raw data, notes, research, receipts, bills, photographs, diaries, testresults, reports and recordings, diagrams, computer files, time and billing records, income tax, estate tax,and other tax records, accounting and other financial records as well as any legal files or files prepared inconnection with civil or criminal litigation, and any other correspondence or documents pertaining to anymatter with which 1 have ever been associated, either by name or implication.

In addition, I authorize any physician, psychiatrist, psychologist, pharmacologist, social worker, nurse,aide, lawyer, paralegal, legal assistant, investigator, mitigation specialist, defense expert, or otherpersonnel active in or familiar with the treatment, services and/or representation provided to

JZo QeiiT J . (aa. , at any of the above-named healthcare system, medical center or hospitals tocommunicate orally or in writing with attorneys JOHN PHILIPSBORN, MICHAEL BLRT, and

Initials:/ZJl.

KERRY DEWOLFE, including, but not limited to investigators MELANIE CARR, MATTHEWSILVERMAN, ELIZABETH VARTKESSIAN, KEITH MacARTHUR, NANCY STEVENS, andELLIS ARMISTEAD, concerning his case, history, treatment, prognosis and/or other topics, includingbut not limited to otherwise confidential information of which treatment personnel may have knowledge,or may have received from, provided to, and/or exchanged with any and all past or present physician,psychologist, social worker, nurse, aide, expert, investigator, lawyer, law enforcement officer, witness,prosecutor, judge, probation officer, corrections officer, counselor, or any other individuals at the above-named healthcare system, medical center or hospitals.

In authorizing this disclosure I explicitly waive any and all rights I may have to the confidentialmaintenance of these records, including any such rights that exist under local, state and federal statutoryand/or constitutional law, rule or order, including those contained in the Pennsylvania Mental HealthProcedures Act, 1976, and the Pennsylvania Drug and Alcohol Abuse Control Act, 1972, and the HealthInsurance Portability and Accountability Act of 1996 ("HIPAA"), Pub.L. No. 104-191, 110 Stat. 1936(1996), and under the Confidentiality of Alcohol and Drug Abuse Patient Records regulations, 42 C.F.R.pt. 2 (2009).

This consent authorizes disclosure for use by attorneys JOHN PHILIPSBORN, MICHAELBURT, and KERRY DEWOLFE, and investigators MELANIE CARR, MATTHEW SILVERMAN,ELIZABETH VARTKESSIAN, KEITH MacARTHUR, NANCY STEVENS, and ELLISARMISTEAD in connection with legal proceedings. Information will be used for any purpose deemedappropriate by the recipients in connection with the legal proceedings, which may include re-disclosurewithout my further authorization. In consideration of such disclosure, 1 hereby release the above-namedhealthcare system, medical center or hospitals (in their individual and/or institutional capacity) from anyand all liability arising from the disclosure of otherwise confidential information. 1 understand that 1 mayrevoke this authorization at any time except to the extent that action has been taken in reliance on it, and itshall remain valid until revoked by me in writing. A copy of this document shall ser\'e as the original forthe purpose of obtaining records from any and all custodians of records included in this release. Theabove-named healthcare system, medical center or hospitals are instructed not to furnish these documentsor this infonnation to anyone other than the persons named above, without a written authorization fromme.

This authorization and release expires 12 months from the date it was signed.

1 understand that this authorization is voluntary. 1 have read this authorization^d fully understand theresults of and any risks of the actions 1 am taking.

Witness;

Name:

Date:

OH-PHS-OTH-89C

06685 LOCAL FLE NUMBER

t DECEDENT'S NAME (F"QI. Middle. WI)

DEPARTMENT OF HEALTH VERMONT CERTIFICATE OF DEATH STATE FilE NUMBER

3. DATE Of DEATH ("'onlfl, Day. Ve.,}

rvPE OR PRINT IN BLACK INK Jr. 1'

2 SEX

. male S ep, .;J 0 I ;)..oq .4 Soe.lAl SECURITY NUMBER So AGE IV ... } 5b UNDeR 1 VEAR 5c UNDER 1 DAY 6 DATE Of BIRTH (UD.,

16162-46Q -uft20 lAonlh. loa,s Ho,,, rin" .. November 28, 7 BIR1liPLACE (City and SIa'1l (J( Forevn eounllY)

Brook11ll, New York 9. FACILITY NAME (II noI instI.,ution. glw &/fHI .00 numtwrJ

8 pLACE Of OEATH IChec. onIYone} IlIlmIAL liI'lnpatienl 0 0 00'\

= o HISSing Home 0 ""Residence 0 Othllr(Sptocily)

Me:CO: ..... 1.. Ce .... i\"(EA-/

'0

<;'T. 12 MARITAL STATUs 13. SURVIVING SPOUSE (lfwH •• maiden,name) t •. DECEDENT'S USUAL OCCUPATION kindofwo'*dorw

Ii Married. Ne\lef Mafried. ,during n'tO$I oINI •• Do lJRJ us. ffttirad.) w.reler ..

Marrie (N/A) Studemt 16. OECEOENT's EOUCATION

(SpociIy only hlghe&, grade "","","led)

J. 24. 'NfORIAANrS NAME (TypoIPtIntJ

Robert J. Lee, sr.

17 WAS OECEOENT OF HISPANIC ORIGIN? (Specify No or Yes Cuban. Muican. Puerto Rican. etc.)

lI§No

'Lee,

Myes. specify

15 KINO OF BUSINESS J INDUSTRY

Educati::on. 18, RACE

White

PA,

00.101 18431

1980

18431

25. PART 1. Enter the diseases. injUries. or complications that caused the death. 00 not enrer the mode of dying. such 8S cardiac or respiratory I interval arrest, shock, or heart failure. list only one causa on each line. I Onset and

IMMEDIATE CAUSE (Fmal disease { W '(i&lQ:C 1 7-"<. 0' cond"lon ,esultlng in death) =OfJO:;..:....::...:...:=---''-'-.!...:.--=------------------+--''-'-''==.:...J'-1

{

b, fb'i:T «t;c:.LI.:lC.1.'t""V-.rc:tV ! 7-"(hc.:u ... • SequentIally list " OUE TO lOA AS A OF}: I

any. leading to immediate H 7 <J L • cause. Ente,UNDERLYING ...... __ 1

CAUSE (Disease 0' InjUty that OUE TO (OR AS A CONSEQUENCE OFI events resulting In 1

___________ +-_______ 1

PART 2. Other signifICant conditions conlributlng to but not 18Su"lng in the underlyiflQ cause given in Pari 1.

21. MANNER OF OEATH /,27b. OATE OF INJURY (MotJt/t.llI,y. Year) 27c. HOUR 0"" ... ,01 0_... OS"''''''' C l , o Homicide 0 Undet -seendlf'Q G""i. U J ) UOI 1

2ea. WAS AN AUTOPSY PERFORMED? (YN or No)

28b. WERE AUTOPSY fIIoIOINGS AVAILABLE PRIOR TO COMPlETlON OF CAUSE OF OEATH? (Yes or No)

Yes 27d. HOW OtO INJUAY OCCUR? (Enr.""IftOfInjuryIn p.n, orPa"2) AJ,.. .... VJ 1 ........ _........ .... ..,.... r;-V\--"'. c....... til.::,;;." .... "'') ..

21 •. INJURY AT WORK (SpM:Hy f27f. PLACE Of INJURY At Home. Farm. Factory. SIrHt, 0fticfI 27Q.lOCATION (strMI. or R.F.O. No. ClfyorTCMn Stale) V .. IX No) :... I Bldg •• ole. S

'va NO<CPl WesT Vr r!? THE BEST Of' MY KNOWLEDGE. ON THE BASIS OF WE CASE HlSTORY. EXAMt,..."TION AND/OR zs.. DATE StGNED 0.,. Yr.) 129b· HOOf:! Of DEATH 'INE. STIGATION.O? __ OS"._ <:' . ..... / "' ..... -a;;,-. 281>. ADORESS OF CEllTlAER (Tn- Of POnti • L \. c:.u fU' K. ¥\"". 130. NAME Of ADENO'N<> PHYSICIAN If 0lHEA lHAN CEllTlf'ERp .... Of PrlnO

''''Au,L. L. YviDIt,w ..... , 1M.<l ..... .> ..... liT. 1 31 •. METHOD OF OISPOSlTJQN 0 Ttmpcral'f Slarage 31b. PLACE OF TEMPORARY STORAGE (c.met.ry. City or Town. State)

&_ 0 CfemI"n 0 Removal from S ....

.... 00 .... 1Ion 000:: (SpodtyJ _____ _

31c. PlACE Of FtNAl OISPOSITlON (Cemelery at' er.m.twr. CIty or TOMn.

S_) OalvertOlt lTatiGll8l. • RiveThead, 'New York

TOUSIGNE 351,lRU COpy Clert<-SIf'\"', _) ,P5b.TOwr;r 35<.OAre_c.y.V_} '\

.'Lr.A..A ,-<=PI St . Albans City. Vermont October 5,2001 1

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