HomeMy WebLinkAbout10-13-09IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
In Re: Estate of Robert S. Musgrave, PA File No. a/
Deceased ,
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PROOF OF CLAIM AGAINST DECEDENT'S ESTATE ~ w ~~ -3
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The Church of God Home, Inc., certifies that there is due and owing b3~t~.obert ~
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Musgrave, Deceased, in accordance with the attached invoice, the sum of $2,293.90, pleas `"`
attorney's fees and costs, accruing interest at the highest rate permissible at law, and accruing
late fees for goods and services.
The sum of $2,293.90 is a priority claim under 20 Pa. C.S.A. § 3392(3) for the value of
nursing caze and services rendered to the Decedent within six (6) months of death.
Cm behalf of the Claimant, I do solemnly declaze and affirm under the penalties of
perjury that the information and representations made herein are true and correct to the best of
my lmowledge, information and belief. Written Notice of said Claim has been given to Shazon
Potteiger, daughter and, upon information and belief, sole heir of Robert S. Musgrave, located at
478 Wolf Bridge Road, Cazlisle, PA 17013 on October 9, 2009.
Respectfully submitted,
Claimant Information:
Church of God Home, Inc.
801 North Hanover Street
Cazlisle, PA 17013
(717)249-5322
SCHUTJER BOGAR LLC
By:
Brandon Williams
Attorney I.D. No. 200713
417 Walnut Street, 4s' Floor
Harrisburg, PA 17101
(717)909-5922
Attorneys for Claimant
ORIG`NAL ~^~
RESIDENT STATEMENT FROM
CHURCH OF GOD HOME, INC
801 N HANOVER STREET
CARLISLE, PA 17013
717-249.5322
Statement Date Due Date ACCOUNT NUMBER
08/30/2009 Upon Receipt 802779
AMOUNT PAID $
ROBERT S MUSGRAVE
c%SHARON POTTEIGER
478 WOLF BRIDGE ROAD
CARLISLE, PA 17013
Comments
$0.00 $288.77
_ -_
Balance Forward
09/01(09 - 09/02/09 Patient Liability
09/14/09 - 09/14/09 Payment Check k 1699
TOTAL BALANCE DUE:
$2,293.90
Please make check payable to CHURCH OF GOD HOME, INC
Remit To:
CHURCH OF GOD HOME, INC
801 N HANOVER STREET
CARLISLE, PA 17013
Please detach and return this portion with your remittance tc the address above.
r r •r ~
$0 00 I $0.00 ~ „ _ _ $2,005.13 ' ' $2,293.90
$4,134.95 $4,134.95
$(690.88) $3,444.07
$1,150.17 $2,293.90
FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
CHURCH OF GOD HOME, INC ROBERT S MUSGRAVE 802779
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Claim Against Decedent's
Estate and Notice pursuant to 20 Pa. C.S.A. § 3384 was served via first-class, United States mail,
postage pre-paid, upon the following:
Shazon Potteiger
478 Wolf Bridge Road
Cazlisle, PA 17013
Dated: ~ A O
By:
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Williams Keslaz, Paralegal