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HomeMy WebLinkAbout07-08-08 C ~ :_~ ~J .i-~ ~ is f _ J ANNUAL REPORT OF =' ~~ ? GUARDIAN OF THE ESTATE =~?~~ r ~. 7 --a COURT OF COMMON PLEAS OF C u`m~e~•c (Q.~ d COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION t~ cx~ G._ C r°- -~, :~ N C..7 Estate of ~fl t f ~ C ~ a. ~ y na"~ , an Incapacitated Person No. - _ n2 0? ~ ~;~ _ ~-~c~ I. INTRODUCTION T c ~~(' 0. t,y _i1 _ ~~4,y - J r~! ~~-~ ,was appointed Plenary ~ Limited Guardian of the Estate by Decree of E w r d ~ ~ k.i flo , J., dated ..Sr.~f : g ~0700to . A. This is the Annual Report for the period from to (the "Report Period"); or B. This is the Final Report for the period from Ste, 0 ~ to l~l. 0 f + ~ q o t5 (the "Report Period"), and is filed for the following reason: _ ~ t' ,~ ~ ' C .7 :: ~° ; _~ -, 1. The death of the Incapacitated Person. Date of death: a P f i ~ ~ ~ .Z y ~ Name of Personal Representative: qe ~~ - r~ d ~-+(' 2. The Guardianship was terminated by the Court by Dt:cree of J., dated Form G-02 rev. 10.13.06 Page 1 of 5 Estate of ~G ~ f ~ C ~ ~_ s , ~~n Incapacitated Person II. SUMMARY A. State the value of the estate reported on the Inventory B. State the value(s) of principal assets at the beginning of the Report Period. (Same as Inventory if first Report, otherwise, ending balance from last Report.) C. What is the total amount of income earned during the Report Period? D. What is the total amount of income and principal spent for all purposes during the Report Period? E. What are the balances remaining at the end of the Report Period? I . Principal $ 3 u b . C,{ o f ~+ % r~ 2. Income $ o ~ 3. Total of Principal and Income 3 7~ •'" ~ R s x•39 PsL ~w III. ADDITIONAL INFORMATION (If more space is needed, please attach additional pages.) A. Principal 1. How is the principal balance listed above currently invested? (Please specify, e.g., real estate, certificates of deposit, restricted bank accounts, etc.): ~ j6 , ~(ofhc 3 ~,~°° ->=Rs 5 ~ ~. See ~ X173, iF3 'l~+-f y.a~ $ ~' ~ 3k~f.7~ Ne,=~~ ~6y.~j z $ 8r~3 ~~3 ~sce~` $ X67 • .3 ~j 0.00 c1 ~ 3uo,'0 = .L /lS te.nQ~s ~ed e.heek Recer Vr. d' (o -r3 -o 2. Have there been any expenditures from the principal during the Report Period? ............................ Yes ~ No If yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? ........ ~ Yes 0 No Form G-02 rev. 10.!3.06 Page 2 of 5 Estate of ~ , c,~ ~. S n cti , An Incapacitated Person b. List purpose and amount of expenditures: SoC. Sec. ~Ja., ~ f`v C~gc<morif$ ~~ycf,oc ~,. PS~CCc~. D~~ c~ ~o C/a~cmo,n,~ $ ~~. 7.2 ~ $ ~ .~ c. Was Court approval received prior to W expending the principal? ....................... ^ Yes ~No Were additional principal assets received during the Report Period which were not included in the Inventory or a prior Report filed for the Estate? ........... ~ Yes °No If yes: a. Was Court approval requested prior to receiving the additional principal? ................ ^ Yes ^ No b. State the sources and amounts of the additional principal received: B. Income l . State sources and amounts of income received during the Report Period (e.g., Social Security, pension, rents, etc. j: _~v e; a-I ~ scar ~ f~ $ 77y~. a o ~C=RS cCnrbM~ Co..l Sf;rr~u.~ _ $ 3J©, ey ~~cd N e,= c ~. ~ ~ n ~s ~cr c%s~~~ 3~ ~. ~r PSc c u chee_K; ~y 0.crt ~$ ro ~",F- 7a ~~ Total income received during Report Period: 6(r 3% . 3ov ' °~ ~- ~ RS C~ ~~ ~<e d 6 ~(3 r0 ~ I Form G-02 rev. 10.!3.06 Page 3 of 5 Estate of ~ ~ ~ S F 10. , An Incapacitated Person 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): Resfr~ c fcd ~j~~ 1~ ~CCv~nf ~ r°s~ c~ . ~ x.39 -Z~5 c-h«K ~~i d ~y Tt'"`C•1 Sf~q~ -Sri d ~e ~ =~3rJ~- Tbf~l ~3o7.3q C. Expenses for Care and Maintenance Specify what expenditures were made from the principal and income for the care and maintenance of the Incapacitated Person (e.g., clothing, nursing home, me/dicine, suppnort, etc.): SoC~q~ S~eur', ~y ~ai, 4 ~G 1.,~~q~f'euror~~ ,~S ~ C ~ ~ t~,r d S I ~0 c._. , ~t ~ G C (G~ ~(c m o n ~e~c~ ~t~n~.5 ~a~d f ~ C(o.ce ~e~f = TG ~o_ l ~ ~ c~ . 7 ~ ~` 36~~ ~/ ~ ~',t73_~13 D. Other Expenditures Specify what other expenditures were made during the Report Period. (Do not include any items stated in response to question C above.) 'iJ~ bt o w ~ d ~ ~~~.c~~.ori~ t~~-~~s~ n~ ~~. =~ fa,~9~aa7 E. Guardian's Commissions List amounts of compensation paid as Guardian's commission and state how amount was determined: .Amount __~ ~I~Iethod of Determination Court Approval Obtained Yes ~ No Yes ~ No Form G-02 rev. 10.13.06 Page 4 of 5 i e ANNUAL REPORT OF GUARDIAN OF THE PERSON COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLV~,NIA ORPHANS' COURT DIVISION Q ran -~ ~- l .~_~'~ " ~ c~ .r t -- `~ 1 -7 -G,~~ ~ ~ - , ~ ~~/~ „l . ~v'~ _~ ~ _ '.t 4J -J Estate of PATRICIA J. SEiAY ll , an Incapacitated Person No.`~~ ~~,.P ,~d` I. INTRODUCTION TRACY SHAY-SNYDER was appointed ~ Plenary OLimited Guardian of the Person by Decree of EDWARD E. GUIDO J. dated SEPTEMBER 8, 2006 A. This is the Annual Report for the period from , to (the "Report Period"); or ® B. This is the Final Report for the period from ~_~ to APRIL 9 %008 (the "Report _Period"), and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: APRIL 9, 2008 2. The Guardianship was terminated by the Court by Decree of J., dated For a FinaC Report, omit Sections II through IV. Form G-03 rev. !0.13.06 Page I of 4 V~ Estate of PATRICIA J. SHAY , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person:~~_ Date of Birth: ~ ©'a3 ` .3 3 III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: Cl~re.mon~` Y~~,rs; ~~ Dame, (o ~ ~ C. (ter ~ma n~ JQa~ . ~r ~ ~'sl Q ~ ~ ~ l~ a t 3 B. The Incapacitated Person's residence is: own home /apartment 'nursing home boarding home /personal care home Guardian's home /apartment ~ hospital or medical facility relative's home (name, relationship and address) other: C. The Incapacitated Person has been in the present residence since ~' c 6 6 U O ~ If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: ~~o,~,~~ cr-n,i ,~e~. In.13.nr> Page 2 of 4 r Estate of PATRICIA J. SHAY an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: ~ '7 [ 3 C' ~ ~ ~- rn b ~ a. i4 ~ ~ Camp ~ ; ~i ~ P~ ~ °]ar~ IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: Jq l z ~ c.; rr\ e t` 15 "~ ~ S e 0.s ~, B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: shy n~ ~. d s h~ j P r"`' .~u-~ , n b a.-~ h e n `~ J , ~ kcr ~ ~~ r~55',nJ w~ ~ -~.~' rr~~d~ca.-~;a,. c'`~n ~ a. ~ ~ a~ e u s o ~~~v~n~ . V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: continue be modified be terminated ~~ f ~ ~ C ( ~ s Gl ~ y r~,,.,c-o3 ,~~~. ~n.~3.nr, ~I e_d ~(~~~~ ~ Page 3 of4 Estate of PATRICIA J. SHAY , an Incapacitated Person The reasons for the foregoing opinion are: y B. During the past year, the Guardian of the Person has visited the Incapacitated Person ~' ~ V times with the average visit lasting /f hours, 3 -J minutes. The report qf'a social service or~unization employed by the Guardian to oversee and coordinate the care of the Incapacitated Person,for the period covered by this Report may tie 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. lhrtr ~: - ~~ Signature o/'Gua ian of the Persmr TRACY SHAY-SNYDER Nnrne o(Guardian of7he Person (type or Print) 2713 COLUMBIA AVENUE address CAMP HILL, PA 17011 Cilt~. S~a~e, %ip Telephone Fnr-nr G-0~ rei~. 10.13.06 Page 4 Of 4 OCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Far fin' this certifi~~atL•- h(~.Ol) Certifu~atiun ~~umhej REV 112006 PRINT IN 1ANENT K INK rte, :~ Thi. Is to certify that the information here given is ~t1,,r'~p,~jH Of pEy ._ rurrrctly copied from an original Certificate of Death t~~ ~~`r~` duly tiled ~~~ith me a~ Local 12e Yistrar. `The on >ina] ~; ~ \~~; g ~' g ~; ~ 1z~ certificate ~~ill he forwarded to the State Vital *~, ~~' *,~~ IZecurd; OI-ficr fur permanent filing. .y,,,~., ~ t~! °`~° ~,ttr' A R 1 2008 99TMf NT OF ;~~P~/ ~~2~'L- "~~ ~,r:%~' Local Rrsish-ar Date Issued r`a C7 O c" --~ 7_ i-t't 1 ~ -' _:_` ~-~ C-i ~ ~? ~~ ~ _«. -~-I -.J COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See Instructions and examples on reverse) STATE FILE NUMBER t Name of Decedent (First middle, last, suXix) 2. Sex 3. Social Security Number d. pale of Death (Month, day, year) Pa is J. Sh female 210 -26 -9049 A r.9 2008 5. Age (Last &nhday) Under t year Untler f day 6. Dale of Bidh (Monts, day, ear) 7. &rthplaca (CXy and state or foreign country) Ba. Place of Death Check Duty one) Mourns Derv Hars Mlnums Hospital: Olhar 74 yr: Oct.23,1933 Harrisburg,PA ^ Inpaliem ^ ER /Outpatient ^ DOA ~ Nursing Home ^ Residence ^Other ~ Specify: Bb. Count' of Death &. Ciry, Boro, Twp. of Death Bd. Fecairy Name Qf not inslitNion, give street arts number) 9. Wes Decedent of Hispanic Origin? No ^ Yes 10. Race: American Indian, Black, While, etc. Cumberland Middlesex Twp. pfyes,spacily Cohan, (SpeciM Claremont Nursing Mexican,PUenoRlcan,eta) white 1 f .Decedent's Usual Lion Klnd of work done tludn most of worts Ida. Do cwt stale retired 12. Was Decedent aver in the I3. Decedent's Education (Specvty only nigheal grade completed) 14. Martial Status: Married, Never Marred, 15. Surviving Spouse (lf wife, give maiden name) Kits of Work Hind of Business /Industry U.S. Armed Forces? Elementary /Secondary (P12) Calege (1-4 or 5q Widowed Divorced (SpeciM assembl worker electronics ^vea~,Ho 10 married bevies E. Shay,Jr 76. Decedent's MaBing Address (Street city / tarn, stale, lip code) Decedant'e Did Decedent 2713 Columbia Ave. Aqua) Residence 17a. Stela Pennsylvania Live ina pt, ~ vas, Decedent Livetl in M i d d l e s e x Twp. Township? H i 11 P A 17 01 1 C 17b. County Cumber 1 a n d 17tl. ^ No, Decedent Livetl wihin , am Aqual Limits of Clty I Boro 1 B. Father's Name (First, middle, IasL suffix) 19. Mmher's Neme (First, middle, maitlen wmame) Howard Stoner Evelyn Martin 20a. In/ormanYS Name (Type !Print) Tracy Snyder 20b. Informant's Melling Address (Street, city I town, stale, zip code) 2713 Columbia Ave. ,Camp Hi11,PA17011 2t a. Metfrod of pisposition Cremation ^ Donation 21b. Date of Olsposi6on (Month, day, year) 21c. Place o! Disposition (Name of cemetery crematory a other pace) 2f d. Location (Ciry 1 Town, stale, zip coda) 1 -~ Q 6 ^ Burial ^ Removal from State ;Was Crematbn or Danatlon ANlwdzad A r. l l 2 0 0 8 p ' H o 11 i n e r C r em a t o r g y Holly S rings A t ^ her-Speciy: byMWIwlExeminerlCOroner7 ~l,Ves^No p . , 22 Nre of Funer rvice Lkensee for person acing as such) 22b. license Numt»r 22c. Name aM Address of Fagliry ~ FD-013163-L Musselman FH&CS,324 Hummel Ave.,Lemoyne,PA17043 to Items 23a-cony when certifyirg 23e, To the hest of my knowledge, deaM occurred at the time, date aM place stafetl. (Signature antl Xae) 23b. License Number 23c. Oate Signed (Month, tlay, year) prysigan s nM available at Xrtre of death to wrtiry cause or deem. ~ j` ~ ~ ed-L1,~- r ~ ~ I "I b ~ D 1 L ~-) ; ~ ' „2 0 Items 2026 must be completed by cerson 24. Time of Death ,pate Pronounced peed (MOnm, day, year) 26. Was Casa Referred to Medical Examiner I Coroner fora eson Other than Cramalion or ponation? wlw pronounces death. e~,; ~ y f : M. ~ ~ r I 2 0 L ~ ^ Yes ~No CAUSE OF DEATH (See Instructlona en examples) r Approximate interval: Pen II: Enter others onircanl coMXons contnbtalpg to death, 23. Did Tobacco Use Conmhute to Death? Item 27. Part I: Enter the chain of events -diseases, injures, or canp'kztiaus - that tliregly caused the death. DO NOT enter tertninaf events such as cardiac arrest, r Ousel fo Death but rat resulting in the undedymg cause given in Part I. ^ Yes ^ Probably respimlory arrest, or ventricular Xbnllalkrl withWl showing the eX0lpgy, Llst only ono cause on each line. r IMMEDIATE CAUSE Foal disease or s ^ No ^ Unknown CmkXtkn resuXing in math) -~ a r 1-I/~(.i.~i ~~~l F3i /~~ r 29. I Female: Due Io (or as a consequ~rtce of)' ~ ^ Nol pregnant within past year list conditions, if an , C~~ ~ leafing Io cause Haled on Ime a. b. `~' ~~ 1 ^ Pregnant at time of tleath Enter the UNDERLYING CAUSE Due to for as a consequence oq: r ^ Not pregnant, but pregnant within 42 days (disease or injury That irutiated the c ~ events resuXing in dealhj LAST. I of death Due to (or as a consequence oQ: ^ Not pregnant, but pregnant 43 days to 1 year d. r t balare death ^ Unknown it pregnam wtthin the past year 30e. Was an Autopsy P nom d? 30b. Ware ANWSy FlMings il k A bl P l i C 31 Manner of Death / 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Ouurted 32c. Place of Injury: Home, Farm, Street. Fadory, e te r va a e r ro omp an e0 ,., I{J Natural ^ Homicide OXice Builtling, etc. (Spent') of Cause of Deam? ^ Yes ~NO ^ yes ^ No ^ Acddant ^ Pending Irrvestigalion 32d. Time of Injury 32e. Injury at Work? 3N. If TransporleXon Irpury (Speidy) 32g. Location of Injury (Street, qry I town, stale) ^ Suigtle ^ Coultl Not be Delerminetl ^ Yes ^ No ^ Dmer /Operator ^ Passenger ^Petlestnen M ^Other~ Specify: 33a. Certifier (chrM1 Dory one) 336. Signature and TXIe of Caniher • CMityinq physklan (Physician cerlirying cause of deem when anoMer physinen nos pmnamced deem acrd completed item 23) ' ~ ~ ~ " ~ To the bell of my knowledge, death occurred due to the oeuse(s) end manner as ateted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ ~ '. ~~~. , ' ~> ~ •-_ (P • Pronouncing end cedNying plryaiWan (Physician Dolh pronouncing tleath end cedi(ying to cause of death) To tM beet of m knowktl e death attuned at tM tim date d l o d t ^ 33c. License Number 33tl. Dale Signed (Month, day, year) y g , e, , en p ace, on ue o the cause(s) and manner as ateted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Medical ESaminer/Coroner /' f ) C~ ~-~~~ ~ ± ~7 ~ ~I ~ ~ " On the bests of exeminetion end ! or invesligatlan, In my opinion, tleath occurred of Ina time, date, end plate, and due to the cause(s) end manrrer es sWted_ ^ .. j / s_ _, i ('.~ l~~'7 34 Name antl Atldr s of Peron ANh~ o ed Cause of Deam (tte m 27) Typa I Print ,mplel ~ ~ ~ Rsgistrar's S' lure antl Distdc umbar/ 36 'led( ,day, year) l Q ~ ~ ' QA'/( `" r ~7` C~1 {Lt / J-L ( ' L art: ,/Y'lv ° ~~7~'ll.C `~~ 5 ! ~z Disposition Permit No. GUARDIAN'S INVENTORY ~-~ r-~ ~~ ~° COURT OF COMMON PLEAS OF Cc~-~t~ er 1 0.r c~ COUNTY, PENN~?>~, , NI~ , r: - -- ~ .-_ , ORPHANS' COURT DIVISION =-`"'~` ~..i C.~ 'i l -~~. _ _ -ice - Z,7 I ~,an IncaP~citated Pe~bn Estate of cx ~ r i C i ~ ~ _ Sl~~ , } ..~ - ~ a Minor No. Co ~ -- 3 aZ o2 ~ ~ ` LC ~ ,~ 1. Real Estate: (Location, by whom occupied and rental Estimated Value: terms, if applicable) a~ Sub-Total for Real Estate: 2. Personal Property: C-(o~hir.5' 3. Jointly Held Property: (Set forth real and personal property owned by the Incapacitated Person JOINTLY with any other person(s). State whether held as tenants by the entireties; ifnot, whether the right of survivorship exists.) Jointly Held Property Form G-04 rev. 10.!3.06 ~., o.oo Estimated Value: ~' 3~o_aO Estimated Value: 7~3y .3vo . ao Page 1 of 2 ~~~ f~ ~an Incapacitated Person Estate of ~. r I C t~ ~ _ 2 ' ~ a Minor 4. Anticipated Assets: (Set forth property of any krnd expected to be acquired hereafter, together with antrcrpated date ofacguisition.J Property Anticipated Date ofAcquisition ~ ~ ~ Sub-Total for Personal Estate: Estimated Value: ~--~ 0.~0 (Attach additional sheets if necessary) TOTAL OF ITEMS 1, 2, 3, and 4 : ............................. (o o ~7. ,3 `~ 0.00 Commonwealth of Pennsylvania . ss. County of ~um~~t~4.n d ~'``x-~-~ ~. s h~c,~~ ` ~Y~y ~e ~(' ,says that the foregoing is a full, ' Guardian ' true and complete Inventory of the Estate of ~a 1, ~' i~ C i cam, S . S ~ q,~ , the aforesaid. Incapacitated Person or Minor; and that all of the information set forth herein is true and correct to the best of the Guardian's knowledge and belief. I verify that the statements made in this ) Inventory are true and correct. I under- ) stand that false statements herein are ) made subject to the penalties of ) 18 Pa.C.S. § 4904 relating to unsworn ) falsification to authorities. ) 0.~ ~ ...~h - ~,~. Guardi / Attorney for Guardian: ~ rC' c-~. CC .(~c.~,r o ~ Supreme Court I.D. No.: Address: C.ft ~zzi ~ SSMC ~ 0.c;; ~Z93 I\I. o~n~ St a r°sbar fl f?Z to Telephone: '~ l? °-- a 3 3 '- ~ f U l For,n c-oa rev. tn.13.n6 Page 2 of 2 ~t ~ ~ ~ ~' "''~ -.} C- ~. +~ ~~ w :~ :, ,: ~. .~ .~ ~~ 0 -.,. --.Z c_ W i w ~ ~'"~ '~~ti ~" ~-_.~- } ~, ;~ ~, 'r ~' ~~ } C ..~ ~~~