HomeMy WebLinkAbout06-05-09 (2)IN RE: ESTATE OF CAROL M. KEENY IN THE COURT OF COMMON PLEAS OF
AN ALLEGED INCAPACITATED :CUMBERLAND COUNTY, PENNSYLVANIA
PERSON c ~ a ~ '~
:ORPHANS' COURT DIVISION ` ~ ~ ~..
~ t- r ;
L~7 ~ ~ i
. NO. ~ f - v~ - (74~i ~t ~ r> ~~ ~ - ~
.,:;
- :J rt ~,
AFFIDAVIT TO EXCUSE ALLEGED INCAPACITATED ' _a ~ ~"
p PERSON FROM COURT HEARING y~ ~
I. l 11~~Q ~G~LJ am a li~ancAr~ r~hvei~ian T ha.~o l~,oo., 1;,.,,,~,~,,,a +,. ,......,.a:~ ..,.
Pennsylvania since ~2c~ 0 I do hereby swear or affirm that within a reasonable
degree of medical certainty I believe that the above referred to alleged incapacitated person
should not attend the Court hearing in the Dauphin County Courthouse because in my
professional opinion her physical or mental condition would be harmed by the transportation to
the Courtroom and by her attendance at the Court hearing.
I have based my opinion on a personal examination of the person. My diagnosis is as
follows:
II,, r I,
(1ftPP~If C~(1( L~~'iC . ICIacA~~a~rU i r `~„(rtP _ 11...L Ih.~-.~ `Tl,~._ .rh~cl.,
Signature of physician
VERIFICATION
I, `S' r, u r^ `~'"`'"cl verify that the statements made in the within Affidavit are true
and correct to the best of my knowledge, information and belief. I understand that false
statements herein are made subject to the penalties of 18 Pa. Cons. Stat. Ann. Section 4904
relating to ux~,sworn falsification to authorities.
5/i goo
Date
My prognosis is as follows: -i _ ~