HomeMy WebLinkAbout10-08-09IN THE MATTER OF IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
Luz T. Palmere, :ORPHANS' COURT DIVISION
An Alleged Incapacitated
Person NO. o~ ~ - ~~! d~ y 1
INCAPACITATED PERSON
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PETITION FOR APPOINTMENT ~=Q ']~3
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OF A GUARDIAN OF THE PERSON AND ' - ~-_
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ESTATE PURSUANT TO 20 PA. C.S.A. 5511 - E~~„ ~ F- ; ~-
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1) Your Petitioner is Violeto T. Palmere by his attorney, Robert~L.~'Brierh,, ~ ;~ ~ ~~;
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Esquire. Violeto T. Palmere, an adult male individual residing at 720 West 170th Stmt, ~ .~
# 2G, New York, NY 10032..
2) Respondent is Luz T. Palmere, an incapacitated person, currently
receiving care at Manorcare Health Services, 940 Walnut Bottom Road, Carlisle,
Cumberland County, PA 17013. Respondent is an adult individual being presently 57
years of age with a birth date of November 11, 1951.
3) The Respondent has a mother, who presumptively under Pennsylvania
law is her sole heir. Her mother is Rosario Palmere and she resides in Tupsan,
Membajao, Camaguin, Philippines.
4) The respondent is a natural born citizen of the Philippines who moved to
this country many years ago and established citizenship. She worked for the Wyeth
Company for many years until her retirement approximately 2 years ago.
5) Ms. Palmere had lived in Parsippany, New Jersey for a decade or longer
while employed with Wyeth. On March 19, 2009 she relocated to Mount Holly Springs
where she resided with Mrs. Ging Sanders, at 311 South Baltimore Street, Mount Holly
Springs, Cumberland County, PA.
6) On or about July 4-5, 2009, Ms. Palmere suffered a debilitating stroke
which has rendered her incapacitated for conducting any of her affairs. After
hospitalization she received treatment at Healthsouth Rehabilitation of Mechanicsburg
as well as Manorcare. She is in the process of returning to Healthsouth for further
treatment.
7) Ms. Palmere has made some progress but remains largely unable to
communicate, her mental faculties seem significantly impaired and the physical function
of the right side of her are severely damaged.
8) The proposed Guardian is Violeto T. Palmere, her brother. Mr. Palmere is
a resident and citizen of the United States and resides in New York, NY. Prior to his
sister's stroke he maintained regular contact with her and since the stroke has
maintained regular contact with her.
9) On July 9, 2005, Ms. Palmere had appointed her brother as her health
care representative. A copy of this document is attached as Exhibit "A".
10) Ms. Palmere does not have a person appointed under a Power Of
Attorney, nor does she have a Guardian.
11) Ms. Palmere does not have any relatives that reside in Pennsylvania.
12) Your proposed Guardian, Violeto T. Palmere has no interests that are
adverse to his sister's interests.
13) Mr. Palmere has little information about his sister's income and assets.
He has or will make an application for Social Security disability benefits on his sister's
behalf. He understands that she has a bank account or accounts and a 401 K benefit or
other retirement benefits earned from her employment with Wyeth.
14) Mr. Palmere believes that his sister owns no real estate and that other
than her accounts she has some furnishings and other personal possessions.
15) Mr. Palmere seeks appointment as Guardian of the Person and Estate in
order to manage his sister's affairs during her recovery. His plan is to permit her to
receive treatment here in Pennsylvania with the eventual goal of returning her to the
Philippines where she has a large family and the costs of intensive treatment are
substantially less.
WHEREFORE, Petitioner, Robert L. O'Brien, respectfully requests that the Court
order that Respondent Luz T. Palmere be adjudged an incapacitated person and
Violeto T. Palmere be appointed Guardian of the Person and Estate.
Respectfully submitted,
O'BRIEN, BARK & SCHERER
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Robert L. O'Brien, Esquire
I . D. # 28351
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
VERIFICATION
I verify that the statements made in the foregoing Petition to Adjudicate
Incapacity and Appoint A Guardian of the Person and Estate are true and correct. I
understand that false statements herein are made subject to the penalties of 18 Pa.
C.S. Section 4904, relating to unsworn falsification to authorities.
ioleto T. Palmere
IN THE MATTER OF IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
Luz T. Palmere, :ORPHANS' COURT DIVISION
An Alleged Incompetent
NO.
INCAPACITATED PERSON
CONSENT TO APPOINTMENT
I, Violeto T. Palmere, of 720 West 170t" Street, #2 G, New York, NY 10032,
consent to be appointed Plenary Guardian of the Estate and Person of Luz T. Palmere.
I represent to the Court that I have no interest adverse to my sister, Luz T. Palmere.
Vio to T. P Imere
04/ 18/02
To Whom It May Concern:
This letter is to testify that 1, Luz T. Palmere of 1100 Parsippany Blvd.
Parsippany, New jersey 07054 of sound mind do hereby declare that incase of
my inability to make a decision for myself I authorize my brother Violeto T.
Palmere to do what's best for my interest. Also, let it be known that Violeto
is also authorized to handle my financial affairs and whatever I own.
This letter should not be challenge because I do not have a will
prepared for now. This should serve as my living will.
Luz T.`Palmere
Witnessed by: Lucy Rosa
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WER OF ATTORNEY FOR HEALTH CARE
DURABLE PO
(Proxy Directive)
If you wish, you may use this section to designate someone to make treatment decisions if you are unable to do so. Your Living
Will declaration will be in effect even if you have not designated a proxy.
1, ~ ~~~I ~ ~ (~i ~~~('(~ ,designate the following person as my health care representative to make any
and all health care decisions forme acting in my best interest, in the event that i become incapable of making decisions for myself.
c ~~ ~ ~'o-~h~~
Name Relationship
street ~ 02 C7 ~ ~ 0 ~~ ~~"
Ci ~. \~ State /~ ~~ Telephone ~~ ~~ ~ ~ ~- I ~' ~~ ~J~
if the person i have named above is unable to act as my health care representative, Thereby designate the following person(s)
to do so:
1. Name
Relationship ~$ P~f' ~ ~ ~ •-1 G.u~
Street ~ l ~ d ~'~'1
Ci ,v ~~ State 1~~L.-_ Zip 3 Telephone ~Of ~ ~ ~u~~'" ~~~
2. Name
Street
City
Relationship
State Zip Telephone
SPECIFIC DIRECTIONS: Please initial the statement below that best expresses your wishes.
My health care representative is authorized to direct that artificially provided fluids and nutrition, such as by feeding tube
or ILA :nf;!s.c^, he `~r~lthl:2lu yr .ti' hdrs.Lrn.
My health care representative does not have this authority, and I direct that artificially provided fluids and nutrition
be provided to preserve my life, to the extent medically appropriate.
Signed ~ ~
Date
Witnesses (cannot be health care representative or alternative representative listed above.)
I declare that the person who signed this document, or asked another to sign this document on his/her behalf, did so in my presence
and that he/she appears to be of sound mind and free of duress or undue influence.
Witness
Witness
Date ~~ ` Q
Date ~ ~v
*Reminder: Give a copy of this document to your doctor, health care representative, and other concerned individuals.
Page 4 of 4
9903046 (10/02)
INSTRUCTION DIRECTIVE `~
(Living Will)
To My Family, Doctors, and All Those Concerned with My Care:
~'
I, ~ ~,~( 'z ~ (1,~ 1e'~L1!'/~'~ ,being of sound mind, make this statement as a directive to be followed if for
any reason I become unable to participate in decisions regarding my medical care (Initial any that apply.)
A. ~ / 1. I direct that life-sustaining procedures be wi hh I or withdrawn a) if I become permanently unconscious, b) if
I have a terminal illness, c) if I experience extreme mental deterioration, or d) if I have another type of irreversible
illness. The above conditions shall have no reasonable expectation of recovery or chance of regaining a
meaningful quality of life. These medical conditions shall be determined by my attending physician and at least
one additional physician. I understand that I will be kept comfortable.
OR
2. I direct that all medically appropriate measures be provided to sustain my life. regardless of my physical or
mental condition.
B, This section asks you to think about the values that are important to you regarding treatment in case of severe
menta! or physica! illnes.~.
1. I do not wish my life to be prolonged by medical treatment(s) if my quality of life is unacceptable to me. The
following are conditions that are unacceptable to me. (Initial only those that describe a way of
livin that you could not tolerate):
a) Permanently unconscious with a ventilator breathing for me.
b) Permanently unconscious with a feeding tube and/or intravenous (IV) hydration.
c) On a ventilator when there is little or no chance of recovery.
d) Being conscious (awake), but unable to communicate (for example, with a stroke), and being fed
with a feeding tube and/or hydrated with IVs to keep me alive.
~~~. e) Living with a dementia like Alzheimer's disease so severe that I am unable to recognize those who
love me.
OR
2. I want to live as long as possible, regardless of the quality of life that I experience.
C. If you choose A. 1., above, the life-sustaining procedures that would be withheld or withdrawn include but are
not limited to; CPR, mechanical ventilation, surgery, chemotherapy, radiation, dialysis, transfusion, and
antibiotics. Initial the following if it applies to you (see "Terms You Should Understand")
~~ In the circumstances described in A.1 ., above, I also direct that artificially provided nutrition and fluids
be withheld and withdrawn and that I be allowed to die.
D. Upon my death, I am willing to donate any parts of my body that may be beneficial to others.
Additional Comments or Exceptions:
These directions express my legal right to request or refuse treatment. Therefore, I expect my family, doctor, and all those
concerned with my care to r gard themselves as legally and morally bound to act in accord with my wishes.
Signed W Date .~.
Witnesses (canno be health care representative or alternative representative if any are named on the other side of this page).
I declare that the person who signed this document, or asked another to sign this document on his/her behalf, did so in my presence
and that he/she appears to be of sound mind and free of duress or undue influence.
Witness Date ~ \ 4
Witness ~~ ~' ~ ~ Date c ~ - -
Reminder: Give a copy of this document to your doctor, health care representative, and other concerned individuals.
Page 3 of 4
9903046 (10/02)
BENEFIT
``ONCEPTS
December 17, 2007
LUZ PALMERE
720 W 170TH #2G
NEW YORK NY 10032
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IN~p~?=2TA~`1T INF'ORMA'TION ABOUT YOUR MOxV'THLY CONTRI~3UTIUNS
FOR WYETH HEALTH CARE COVERAGE
Dear MS PALMERE:
The cost of your health care contributions has changed effective
01/01/2008. Enclosed are your new billing coupons for this coverage,
which indicate your new contribution amount.
What You Need to Do
If you mail your monthly contribution
1. Use the enlcosed billing coupons along with the mailing labels to make
future monthly contributions.
2. Each month when your contribution is due, please:
- Make your check payable to Benefit Concepts in the amount noted
on the billing coupon.
- Enclose the billing coupon along with your check in a mai]_ing
envelope.
- Place one of the mailing labels provided to you on the mailing
envelope and affix a stamp.
3. A~.1 contrib~.itions are dus on tk~e first shay of eavh month. You have
a E G -d~~y brace period from the du~s date tc~ remii: each r<<~orith' s
contribution. If your monthly contribution is not postmarked by this
date, your coverage will be canceled retroactively.
4. You may pay as many monthly contributions at one time as you wish. If
you are paying more than one monthly contribution, please enclosed all
of the appropriate billing coupons with your check.
If you pay your c ~ ibutions vi automatic withdrawal from a bank account
There is nothing you need to do. Your new contribution amount
will be deducted ~ tomatica om your bank account each month.
- over -
~ ~ ~
WYETH
DIRECT BILL-PAYMENT AUTHORIZATION AGREEMENT
Please select one of the following options to remit premium payments for your montlily insurance premium charge:
^ Automatic Deduction from a Checking or Savines Account
I authorize Benefit Concepts, Inc., to charge, by electronic means, the account indicated below.
If this form has not been received and the bank information verified with your bank by the 10`h of the month (Note:
verification with your bank may take up to 14 days), the first automatic debit to your bank account will not occur until the
following month (between the 10`h and the 15"') and will include all past and current monthly premiums due. If all premiums
up to and including your current month's premium payment have been paid by other means, funds will not be deducted from
your bank account until the following month.
All subsequent deductions will occur between the 10th and the 15`h of each month, for the current month of coverage.
Automatic debits rejected for insufficient funds, will be attempted a second time within 48 hours of Benefit Concepts being advised of
the rejection. If the second attempt rejects, we will not attempt to debit your account again until the following month. You are
expected to send in a replacement check or contact the `JVyetli HR Service Center at 1-866-My Wyeth (1-866-G99-9384) to .process a
payment by phone. Benefit Concepts must be notified of any changes in your bank account details as soon as possible. Failure to
notify Benefit Concepts in a timely manner may result in an automatic debit rejection. Please note: A $10.00 banking fee will apply to
all automatic debit rejections due to insufficient funds, invalid account information or closed accounts.
^ Payment By Couaon
I will remit a check payable to BENEFIT CONCEPTS on a monthly basis for my monthly premium by the 1 S` of each month
for the current month of coverage.
^ Cancel Electronic Deduction -Effective:
(You will receive payment coupons.)
This authorization is to remain in full force and effective until Benefit Concepts has received written notification from me of its
termination in such time and manner as to afford Benefit Concepts a reasonable opportunity to act on it. I understand that automatic
debits will automatically cease if my coverage ends, is terminated or my automatic debit rejects for insufficient funds for two
consecutive months or three times within a 6 month period. Please note: only one checking or savings account can be charged for the
premiums due. I understand and agree to the terms outlined above and authorize Benefit Concepts to make appropriate changes to my
required premium deduction, as necessary.
Bank Information
Bank ABA#: Bank Account #: Account Type:
(ABA# must be nine digits) (Checking nr Savings)
NAME (PLEASE PRINTI SOCIAL SECURITY NUMBER
SIGNATURE DATE
ATTACH YOUR VOIDED CHECK HERE
Deposit slips can be used for Savings Account deductions ONLY (Please confirm the savings account ABA# with your bank as the
number listed on your deposit ticket may not be valid for electronic payment purposes)
Mail to:
Benefit Concepts
P.O. Box 246
Barrington, Rhode Island 02806
Or fax to:(401) 427-8701
BENEFIT CONCEPTS INTERNAL USE ONLY
~pMIN: Participant-Paid through Date:•. ACH to begin with next file.
ACCTNG: ACH ACTIVE for Month of / Retro to Initials
Q: PROC/ACCT/Participant ACH DR RET. DOC GVS 8/2/06
Important Legal Information for Retirees Paying by Check
Checks sent to Benefit Concepts for payment on your account may be
converted to a one-time electronic funds transfer for the amount of the
check. This banking process is known as ARC (Account Receivable
Conversion). Funds may be debited from your bank account as early as the
same day payment is received. Your original check will not be returned
to you; however, all relevant information pertaining to the check will
be on your bank account statement.
For More Information
If you have questions, please contact the Wyeth HR Service Center at
1-866-My Wyeth (1-866-699-9384), and select the "Health and Insurance"
prompt, between 8:00 a.m. and 8:00 p.m..Eastern time, Monday through
Friday. A voice mail system is available 24 hours a day, seven days
a week including holidays.
Very truly yours,
Benefit Concepts
Enclosures