Preview
FILED: WESTCHESTER COUNTY CLERK 12/14/2023 11:22 AM INDEX NO. 72166/2023
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 12/14/2023
UCS-840
REQUEST FOR JUDICIAL INTERVENTION (rev. 07/29/2019)
SUPREME COURT, COUNTY OF WESTCHESTER
-
.... ,..~
Index No : 72166/2023 Date Index Issued : 12/14/2023 For Court Use Only:
CAPTION Enter the com pl et~ case taptiQJ1 . Do not use et al or et ano. If more Sf:),tce is needeq, attach a caption rider sheet. IAS Entry Date ·-
TATYANA URBANOVICH, as Admin istrator o f the ESTATE OF ALEXANDER URBANOVICH,
and TATYANA URBANOVICH,
-
Pla intiff(s)/Petitioner(s) Judge Assigned
-
-agai nst -
WESTCHESTER MEDICAL CENTER, WESTCHESTER COUNTY HEALTH CARE CORPORATION,
-
WESTCHESTER MEDICAL CENTER HEALTH CARE CORPORATION, RJI Filed Date
Defenda nt(s)/Respond ent(s)
NATURE OF ACTION OR PROCEEDING Check only one box and specify where indicated.
COMMERICIAL MATRIM ONIAL
0 Business Entity (includes corporations, partnerships, LLCs, LLPs, etc.) 0 Contested
0 Contract NOTE: If there are children under the age of 18, complete and attach the
0 Insurance (where insurance company is a party, except arbitration) MATRIMONIAL RJI ADDENDUM {UCS-840M).
0 UCC (includes sales and negotiable instruments) For Uncontested Matrimonial actions, use the Uncontested Divorce RJI {UD-13}.
0 Other Commercial (specify) : TORTS
N OTE: For Commercial Division assignment requests pursuant to 22 NYCRR 202. lO(d], 0 Asbestos
complete and attach the COMMERCIAL DIVISION RJI ADDENDUM (UCS-840C}. 0 Child Victims Act
REAL PROPERTY Specify how many properties the application includes:
- -- 0 Environmental (specify) :
0 Condemnation ® Medical, Dental or Pediatric Malpractice
0 Mortgage Foreclosure (specify): 0 Residential 0 Commercial 0 Motor Vehicle
Property Address: 0 Products Liability (specify) :
NOTE: For Mortgage Foreclosure actions involving a one to four-family, 0 Other Negligence (specify) :
owner-occupied residential property or owner-occupied condominium, 0 Other Professional Malpractice (specify):
0
0
0
complete and attach the FORECLOSURE RJI ADDENDUM (UCS-840F}.
Tax Certiorari
Tax Foreclosure 0
Other Tort (specify):
SPECIAL PROCEEDINGS
CPLR Article 75 (Arbitration) [see NOTE in COMMERCIAL section]
.
0 Other Real Property (specify) : 0 CPLR Article 78 (Body or Officer)
OTHER MATTERS 0 Election Law
0 Certificate of Incorporation/Dissolution [see NOTE in COMMERCIAL section] 0 Extreme Risk Protection Order
0 Emergency Medical Treatment 0 MHL Article 9.60 (Kendra's Law)
0 Habeas Corpus 0 MHL Article 10 (Sex Offender Confinement-Initial)
0 Local Court Appeal 0 MHL Article 10 (Sex Offender Confinement-Review)
0 Mechanic's Lien 0 MHL Article 81 (Guard ianship)
0 Name Change 0 Other Mental Hygiene (specify):
0 Pistol Permit Revocation Hearing 0 Other Special Proceeding (specify) :
0 Sale or Finance of Religious/Not-for-Profit Property
0 Other (specify):
STATUS OF ACTION OR PROCEEDING Answer YES or NO for,every question and enter additional information where indicated.
YES NO
Has a summons and complaint or summons with notice been f iled? ® 0 If yes, date filed: 12/14/2023
Has a summ ons and compla int or summons with notice been served? ® 0 If yes, date served : 12/14/2023
Is this action/proceeding being filed post-judgment? 0 ® If yes, judgment date :
NATURE OF JUDICIAL INTERVENTION Check one box only and enter additional information where indicated.
0 Infant's Compromise
0 Extreme Risk Protection Order Application
0 Note of Issue/Certificate of Readiness
0 Notice of Medical, Dental or Pediatric Malpractice Date Issue Joined:
® Notice of Motion Relief Requested: Change of Venue Return Date: 01/05/2024
0 Notice of Petiti on Relief Requested: Return Date:
0 Order to Show Cause Relief Requested: Return Date :
0 Other Ex Parte Appli cation Relief Requested :
0 Poor Person Application
0 Request for Preliminary Conference
0 Residential Mortgage Foreclosure Settlement Conference
0 Writ of Habeas Corpus
0 Other (specify):
1 of 2
FILED: WESTCHESTER COUNTY CLERK 12/14/2023 11:22 AM INDEX NO. 72166/2023
NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 12/14/2023
RELATED CASES List any related actions. For Matrimonial cases, list any related criminal or Family Court cases. If none, leave blank.
If additional space is required, complete and attach the RJI ADDENDUM (UCS-840A).
Case Title Index/Case Number Court Judge (If assigned) Relationship to Instant case
Urbanovich v. Westchester Medical Center, et al. 529805/2023 Sup/Kings Same case - request change of venue
PARTIES For parties without an attorney, check the "Un-Rep" box and enter the party's address, phone number and email in the space provided.
If additional space is required, complete and attach the RJI ADDENDUM (UCS-840A).
Un- Parties Attorneys and Unrepresented Litigants Issue Joined Insurance carriers
Rep List parties In same order as listed in the For represented parties, provide attorney's name, firm name, address, phone and For each defendant, For each defendant,
caption and indicate roles (e .g., plaintiff, email. For unrepresented parties, provide party's address, phone and email. indicate if issue has Indicate insurance
defendant, 3rd party plaintiff, etc.) been joined. carrier, if applicable.
Name: TATYANA URBANOVICH
â–¡
AlexanderT. Shapiro & Associate s, P.C., 250 Broadway, Suite 600, New York, NY 10007
OYES @NO
(212) 608-1140; ASHAPIRO@ATSLEGALNY.COM
Role(s) : Plaintiff
Name: WESTCHESTER MEDICAL CENTER
â–¡
WILSON, SAVE, CON BOY, COZZA & COUZENS, P.C., 707 Westchester Ave., White Plains, NY 10604
(914) 686-9010; william@wbccc.com and wbccc@wbccc.com
OYES @NO
Role(s) : Defendant
Name: WESTCHESTER MEDICAL CENTER
â–¡
WILSON, BAVE, CONBOY, COZZA & COUZENS, P.C., 707 Westchester Ave., White Plains, NY 10604
OYES @NO
(914) 686-9010; will iam@wbccc.com and wbccc@wbccc.com
Ro le(s) : Defendant
Name: W[STCH(STER COUNTY HEALTH CARE CORPORATION
â–¡
WILSON, BAVE, CONBOY, COZZA & COUZEN, 707 Westchester Ave ., White Plai ns, NY 10604
OYES @NO
(914) 686-9010; william@wbccc.com and wbccc@wbccc.com
Roie(s): Defendant
Name: W ESTCHESTER MEDICAL UNTER HEALTH CARE CORP.
â–¡
WILSON, SAVE, CONBOY, COZZA & COUZEN, 707 Westchester Ave., White Plains, NY 10604
(914) 686-9010; william@wbccc.com and wbccc@wbccc .com
OYES ®NO
Role(s): Defendant
Name:
â–¡ Role(s):
OYES 0 NO
Name:
â–¡ Roie(s):
OYES ONO
Name:
â–¡ Roie(s) :
OYES ONO
Name:
â–¡ Role(s) :
OYES ONO
Name:
â–¡ Role(s) :
OYES ONO
Name:
â–¡ Role(s) :
OYES ONO
Name:
â–¡ Role(s) :
OYES . ONO
Name:
â–¡ Role(s) :
OYES ONO
Name:
â–¡ Role(s) :
OYES ONO
Name:
â–¡ Role{s):
OYES ONO
I AFFIRM UNDER THE PENALTY OF PERJURY THAT, UPON INFORMATION AND BELIEF, THERE ARE NO OTHER RELATED ACTIONS OR PROCEEDINGS,
EXCEPT AS NOTED ABOVE, NOR HAS A REQUEST FOR JUDICIAL INTERVENTIO IOUSLY F · DIN TH NOR PROCEEDING.
Dated : _ _ _1_2/_1_4_
/ 2_0_23_ __
,,,,.,. ..,... . ._,f<
1531870 William H. Bave, Jr.
Attorney Registration Number Print Name
2 of 2
Preview
FILED: WESTCHESTER COUNTY CLERK 12/14/2023 11:22 AM INDEX NO. 72166/2023 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 12/14/2023 UCS-840 REQUEST FOR JUDICIAL INTERVENTION (rev. 07/29/2019) SUPREME COURT, COUNTY OF WESTCHESTER - .... ,..~ Index No : 72166/2023 Date Index Issued : 12/14/2023 For Court Use Only: CAPTION Enter the com pl et~ case taptiQJ1 . Do not use et al or et ano. If more Sf:),tce is needeq, attach a caption rider sheet. IAS Entry Date ·- TATYANA URBANOVICH, as Admin istrator o f the ESTATE OF ALEXANDER URBANOVICH, and TATYANA URBANOVICH, - Pla intiff(s)/Petitioner(s) Judge Assigned - -agai nst - WESTCHESTER MEDICAL CENTER, WESTCHESTER COUNTY HEALTH CARE CORPORATION, - WESTCHESTER MEDICAL CENTER HEALTH CARE CORPORATION, RJI Filed Date Defenda nt(s)/Respond ent(s) NATURE OF ACTION OR PROCEEDING Check only one box and specify where indicated. COMMERICIAL MATRIM ONIAL 0 Business Entity (includes corporations, partnerships, LLCs, LLPs, etc.) 0 Contested 0 Contract NOTE: If there are children under the age of 18, complete and attach the 0 Insurance (where insurance company is a party, except arbitration) MATRIMONIAL RJI ADDENDUM {UCS-840M). 0 UCC (includes sales and negotiable instruments) For Uncontested Matrimonial actions, use the Uncontested Divorce RJI {UD-13}. 0 Other Commercial (specify) : TORTS N OTE: For Commercial Division assignment requests pursuant to 22 NYCRR 202. lO(d], 0 Asbestos complete and attach the COMMERCIAL DIVISION RJI ADDENDUM (UCS-840C}. 0 Child Victims Act REAL PROPERTY Specify how many properties the application includes: - -- 0 Environmental (specify) : 0 Condemnation ® Medical, Dental or Pediatric Malpractice 0 Mortgage Foreclosure (specify): 0 Residential 0 Commercial 0 Motor Vehicle Property Address: 0 Products Liability (specify) : NOTE: For Mortgage Foreclosure actions involving a one to four-family, 0 Other Negligence (specify) : owner-occupied residential property or owner-occupied condominium, 0 Other Professional Malpractice (specify): 0 0 0 complete and attach the FORECLOSURE RJI ADDENDUM (UCS-840F}. Tax Certiorari Tax Foreclosure 0 Other Tort (specify): SPECIAL PROCEEDINGS CPLR Article 75 (Arbitration) [see NOTE in COMMERCIAL section] . 0 Other Real Property (specify) : 0 CPLR Article 78 (Body or Officer) OTHER MATTERS 0 Election Law 0 Certificate of Incorporation/Dissolution [see NOTE in COMMERCIAL section] 0 Extreme Risk Protection Order 0 Emergency Medical Treatment 0 MHL Article 9.60 (Kendra's Law) 0 Habeas Corpus 0 MHL Article 10 (Sex Offender Confinement-Initial) 0 Local Court Appeal 0 MHL Article 10 (Sex Offender Confinement-Review) 0 Mechanic's Lien 0 MHL Article 81 (Guard ianship) 0 Name Change 0 Other Mental Hygiene (specify): 0 Pistol Permit Revocation Hearing 0 Other Special Proceeding (specify) : 0 Sale or Finance of Religious/Not-for-Profit Property 0 Other (specify): STATUS OF ACTION OR PROCEEDING Answer YES or NO for,every question and enter additional information where indicated. YES NO Has a summons and complaint or summons with notice been f iled? ® 0 If yes, date filed: 12/14/2023 Has a summ ons and compla int or summons with notice been served? ® 0 If yes, date served : 12/14/2023 Is this action/proceeding being filed post-judgment? 0 ® If yes, judgment date : NATURE OF JUDICIAL INTERVENTION Check one box only and enter additional information where indicated. 0 Infant's Compromise 0 Extreme Risk Protection Order Application 0 Note of Issue/Certificate of Readiness 0 Notice of Medical, Dental or Pediatric Malpractice Date Issue Joined: ® Notice of Motion Relief Requested: Change of Venue Return Date: 01/05/2024 0 Notice of Petiti on Relief Requested: Return Date: 0 Order to Show Cause Relief Requested: Return Date : 0 Other Ex Parte Appli cation Relief Requested : 0 Poor Person Application 0 Request for Preliminary Conference 0 Residential Mortgage Foreclosure Settlement Conference 0 Writ of Habeas Corpus 0 Other (specify): 1 of 2 FILED: WESTCHESTER COUNTY CLERK 12/14/2023 11:22 AM INDEX NO. 72166/2023 NYSCEF DOC. NO. 9 RECEIVED NYSCEF: 12/14/2023 RELATED CASES List any related actions. For Matrimonial cases, list any related criminal or Family Court cases. If none, leave blank. If additional space is required, complete and attach the RJI ADDENDUM (UCS-840A). Case Title Index/Case Number Court Judge (If assigned) Relationship to Instant case Urbanovich v. Westchester Medical Center, et al. 529805/2023 Sup/Kings Same case - request change of venue PARTIES For parties without an attorney, check the "Un-Rep" box and enter the party's address, phone number and email in the space provided. If additional space is required, complete and attach the RJI ADDENDUM (UCS-840A). Un- Parties Attorneys and Unrepresented Litigants Issue Joined Insurance carriers Rep List parties In same order as listed in the For represented parties, provide attorney's name, firm name, address, phone and For each defendant, For each defendant, caption and indicate roles (e .g., plaintiff, email. For unrepresented parties, provide party's address, phone and email. indicate if issue has Indicate insurance defendant, 3rd party plaintiff, etc.) been joined. carrier, if applicable. Name: TATYANA URBANOVICH □ AlexanderT. Shapiro & Associate s, P.C., 250 Broadway, Suite 600, New York, NY 10007 OYES @NO (212) 608-1140; ASHAPIRO@ATSLEGALNY.COM Role(s) : Plaintiff Name: WESTCHESTER MEDICAL CENTER □ WILSON, SAVE, CON BOY, COZZA & COUZENS, P.C., 707 Westchester Ave., White Plains, NY 10604 (914) 686-9010; william@wbccc.com and wbccc@wbccc.com OYES @NO Role(s) : Defendant Name: WESTCHESTER MEDICAL CENTER □ WILSON, BAVE, CONBOY, COZZA & COUZENS, P.C., 707 Westchester Ave., White Plains, NY 10604 OYES @NO (914) 686-9010; will iam@wbccc.com and wbccc@wbccc.com Ro le(s) : Defendant Name: W[STCH(STER COUNTY HEALTH CARE CORPORATION □ WILSON, BAVE, CONBOY, COZZA & COUZEN, 707 Westchester Ave ., White Plai ns, NY 10604 OYES @NO (914) 686-9010; william@wbccc.com and wbccc@wbccc.com Roie(s): Defendant Name: W ESTCHESTER MEDICAL UNTER HEALTH CARE CORP. □ WILSON, SAVE, CONBOY, COZZA & COUZEN, 707 Westchester Ave., White Plains, NY 10604 (914) 686-9010; william@wbccc.com and wbccc@wbccc .com OYES ®NO Role(s): Defendant Name: □ Role(s): OYES 0 NO Name: □ Roie(s): OYES ONO Name: □ Roie(s) : OYES ONO Name: □ Role(s) : OYES ONO Name: □ Role(s) : OYES ONO Name: □ Role(s) : OYES ONO Name: □ Role(s) : OYES . ONO Name: □ Role(s) : OYES ONO Name: □ Role(s) : OYES ONO Name: □ Role{s): OYES ONO I AFFIRM UNDER THE PENALTY OF PERJURY THAT, UPON INFORMATION AND BELIEF, THERE ARE NO OTHER RELATED ACTIONS OR PROCEEDINGS, EXCEPT AS NOTED ABOVE, NOR HAS A REQUEST FOR JUDICIAL INTERVENTIO IOUSLY F · DIN TH NOR PROCEEDING. Dated : _ _ _1_2/_1_4_ / 2_0_23_ __ ,,,,.,. ..,... . ._,f< 1531870 William H. Bave, Jr. Attorney Registration Number Print Name 2 of 2