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HomeMy WebLinkAbout02-06-09; .. , ns °v- .~ ~ ANNrtJA~ REPORT OF ~ ° ~ ~, ~ ...._ ~~ c~ ~ c.~ GUARDIAN OF THE PERSON ~~ ~ ~, . ~_~x ~.:: ~. ~ 3 :`; © .... _s COURT OF COMMON PLEAS OF ~~ ,;~ `~ ' ` ~ i . . CUMBERLAND COUNTY, p~SyLV~hq o . ORPHANS' COURT DIVISION Estate of NANCY M . STUCK --------------------- an Incapacitated Pcrson L ~~ ~i'I'RQDIICTION -----~----------- ppo DONALD B. STUCK----=---- was a inted ' ^ Pleaary~i,imited Cruardian of the Persoa by Decree of ~ • J•. dated ' ~ . A. 'This~}e ~,pn ~t,~t~port for the pcriod from ~l-Ol-2UU . ~ 1L-31-~UiJ ?f -' tthe `Report Period"); or • . ® B. This is the Final Report for the period from ~ ~ (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 IY. Forr~G03 rrv.IQIj.06 Page 1 of 4 ~a r • .. .. .. lstate of ~ ~ ._ .~ - - .... ~ ~ .. ~ an Incapacitated Person IL PERSONAL DATA Age of the Incapacitated Person: 8 ~ Date ofBirth: 4 ' ~'"~ - ~q a s III. LIVIl~TG ARRANGEMENTS A. Current address of the Incapacitated Person: 1t oa e.al ow~bus ~v~ ~` 1 L~vno~ ~,~ ~'a t~ a~3 B. The Incapacitatal Person's residence is: own home /apartment ~ . ®nursing home Q boarding home / porsonal 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 ~ V 6 E'Y Z C~` . If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: F~ Gos .~. ~o.~3.n6 Page 2 of 4 ~. - ~ ... _. ..- .. _ Estate of - -:~- - . - . - u°C .. - .. '..an~incapacitated~Person D. Name and address of the Incapacitated Person's primary caregivEr: ~~ t~ pO CDl dw,6us ~~~ ~I ~~ N. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: ~ov~ ~ B. Specify what, if any, social;~medical, psychological and support services tho Incapacitated Person is receiving. GOES TO -1~R . DOM I N I C M I RARCH I, D . 0:., OF I NTERN3 STS OF CENTRAL PA lO8 LOwTHER STREET, LEMOYNE, PA 17043, ON REGULAR BASIS.. V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: continue ®be modified ®be terminated Form Goa m /0.13.06 ' Page 3 of 4 .. . . Estafd of . ~ C - _ ... _ ~ - . _... -~ - ~.. .. . _ . ._.. _ . an Incapacitated Person .......... .. . . The reasons for the foregoing opinion are: B~. During the past year, the Guardian of the Person has ~~isited the Incapacitated Person '~ times with the average visit lasting `-~" hours, ~, minutes, . N~~ . The report of a social service organization emptoyed by the Guardian ~`o oversee and coordinate the care of the Incapacitated Person for the period covered by this Report tray be. attached to supplement this Report. DURING WEEK DAYS, NANCY .M. STUCK, STAYS WITH MS.'DANDRA E.•wIRTH AT 1429 RAVEN HILL ROAD, MECHANICSBURG PA 17055 FioR NURSING AND DAY CAitE .~ ~ " I verify that the foregoing information is correct to the best of my knowledge, infonrnation and belief; and that this Verification is~ subject to the penalties of 1$ Pa. C.S.A. § 4904 relative to unsworn falsification to authorities. ~ '. .JANUARY~2l~ ZOO q ~ ,~ lam • sYS„~„~ ate, ajv,. P ~~ ~' ~~ x~ ~rc,~rr~r~, ~ orb I I ©o C'O l av~n ~ ve ~ 1 ~~ D ~ • ~ D eau,: sue. zr~ Tslsplwxs Form GOJ ,Y,: ~o.i3 06 Page 4 of 4 ~ ~ E-SUPERBILL PRINTOUT INTERNISTS OF CENTRAL PA 106 LOWTHER STREET LEMOYNE, PA 17043 (717)-774-1366 r Nancy M Stuck 1100 Columbus Ave Apt 1 Lemoyne, PA 17043 Fold Along Tick Marks Above for Standard #10 Windowed Envelope Superbill:#61102 Account: #4283,Nancy Stuck Appt Date:10/22/08 Time: 4:OOp Diagnosis ~ Patient Nancy Stuck 1: ~ DOB 04/27/25 2: ~ Doctor SO-Dominic Mirarchi, D.O. 3: ~ Dr Tax Id 23-2146427 4: ~ Super Doc SDr Tax Id CPT/HCPCS Code Unite Coat ~ Refer Doc 1: ~ Location 1-Main Office 2: ~ Facility 3: ~ AcC Code 4: ~ Insurance 58-Advantra Freedom- Mcare "Estimated Claim" Total 0.00 NOTE ~ Personal Bal 0.00 Acoount Bal 0.00 Payment Type Check Number Payment Amount: 0.00 FUTURE APPOINTMENTS 01/29/09 Thr 4:15P Ov Nancy M Stuck W/DOminic Mirarchi, D.O. Location: 1-Main Office, 108 LOWTHER STREET (717)-774-1366 LEMOYNE, PA 17043-0107