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ORIGINAL
,
ANNUAL REPORT OF
GUARDIAN OF THE PERSON
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
Estate of Edith Mayo, an Incapacitated Person
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No.21-05-1012
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I.
INTRODUCTION
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Kevin L. Ellis and Dorothy Ellis
, were appointed
~Plenary OLimited Guardian of the Person by Decree of J. Wesley Oler. Jr.
dated December 29.2005
, J.,
~ A. This is the Annual Report for the period from January 1. 2006,
to December 31. 2006 (the "Report Period"); or
o B. This is the Final Report for the period from
'-
to
(the "Report Period"), and is filed
for the following reason:
1. The death of the Incapacitated Person. Date of death:
2. The Guardianship was terminated by the Court by Decree of
, J., dated
For a Final Report, omit Sections II through IV.
Form 0-03 rev. 10.13.06
Page 1 of 4
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Estate of Edith Mayo, an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person:11-
Date of Birth:05/02/1933
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
Golden Living Center, West Shore
770 Poplar Church Road
Camp Hill, P A 17011
B. The Incapacitated Person's residence is:
o own home / apartment
~ nursing home
o boarding home / personal care home
o Guardian's home / apartment
o hospital or medical facility
o relative's home (name, relationship and address)
o other:
C. The Incapacitated Person has been in the present residence since
March 7. 2002
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
FormG-03 rev. /0.13.06
Page 2 of4
Estate of Edith Mayo, an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
Golden Living Center, West Shore
770 Poplar Church Road
Camp Hill, P A 17011
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
Alzheimer's
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
Alzheimer's Unit
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
181 continue
o be modified
o be terminated
Form G-03 rev. /0.13.06
Page 3 of 4
Estate of Edith Mayo, an Incapacitated Person
The reasons for the foregoing opinion are:
The major medical problems has remained the same.
B. During the past year, the Guardian of the Person has visited the Incapacitated Person
5
times with the average visit lasting
1
hours,
minutes.
The report of a social service organization employed by the Guardian to oversee and
coordinate the care of the Incapacitated Person for the period covered by this Report may be
attached to supplement this Report.
I verify that the foregoing information is correct to the best of my knowledge,
information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. ~ 4904
relative to unsworn falsification to authorities.
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Signature of Guardian of the Person
k'~IN tLLo
Date
Name of Guardian of the Person (type or print)
Add~~S- JJ /Iflttvj U./
If.if.!~.iLb:J'1fl 111 0 ~
7f 7 ~~/-9~~7
Telephone
FormG-03 rev. 10.13.06
Page 4 of 4