HomeMy WebLinkAbout72-0355 (2)I ~ 1•
ANNUAL REPORT OF
GUARDIAN OF THE PERSON
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
Estate of EDWARD E. SAMPSON
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an Incapacitated Person
No. 72-355
I. INTRODUCTION
Margaret Mellinger, Dorothy Kepner,
were.
Richard Kepner, and Darlene Ziegler , ~sl appointed
Plenary Limited Guardian of the Person by Decree of J• WESLEY OLER, JR. ~ J,~
dated JANUARY 24, 2007
A. This is the Annual Report for the period from JANUARY 1 ~ 2009
to DECEMBER 31 2009 (the "Report Period"); or
~] B. This is the Final Report for the period from
to (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
For a Final Report, omit Sections II through IV.
Form G-03 rev. 10.13.06
J., dated
Page 1 of 4
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Estate of EDWARD E. SAMPSON
II. PERSONAL DATA
Age of the Incapacitated Person: 57
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
an Incapacitated Person
9
Date of Birth: 10/ /1952
CLAREMONT NURSING & REHAB CENTER
1000 CLAREMONT ROAD
CARLISLE, PA 17013
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
Q relative's home (name, relationship and address)
other:
C. The Incapacitated Person has been in the present residence since 9/3/2008
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
NOT APPLICABLE
Form G-03 rev. 10.13.06 Page 2 of 4
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Estate of EDWARD E. SAMPSON , an Incapacitated Person
_. _ - _ _
D. Name and address of the Incapacitated Person's primary caregiver:
CLAREMONT NURSING & REHAB CENTER
1000 CLAREMONT ROAD
CARLISLE, PA 17013
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
MR. SAMPSON SUFFERS FROM CEREBRAL PALSY AND, AS A RESULT, IS
MENTALLY RETARDED AND SUFFERS FROM ARTHRITIS AND SEIZURE
DISORDER.
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
SOCIALLY, MR. SAMPSON ENJOYS TALKING ON THE TELEPHONE,
WATCHING TV, GOING OUT TO EAT, AND PLAYS BINGO, WITH
ASSISTANCE. MEDICALLY, MR. SAMPSON RECEIVES THE FOLLOWING
MEDICATIONS: CARBANAZEPINE, LISINOPRIL, MELOXICAM,
METFORMIN, OMEPPRAZOLE, PHENOBARBITAL, ANUCORT, AS WELL
AS WEEKLY SKIN ASSESSMENTS AND DIABETIC FOOT CARE.
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
continue
be modified
D be terminated
Form G-03 rev. 10.13.06
Page 3 of 4
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Estate of EDWARD E. SAMPSON , an Incapacitated Person
The reasons for the foregoing opinion are:
MR. SAMPSON LACKS THE CAPACITY TO MAKE RESPONSIBLE
DECISIONS CONCERNING HIS PERSON, CARE, AND IS UNABLE TO LIVE
ALONE OR TO SEEK NEEDED MEDICAL SERVICES
B. During the past year, the Guardian of the Person has visited the Incapacitated Person
_~~ times with the average visit lasting ~ hours, ~ minutes.
The report of a social service organization employed by the Guardian to oversee and
coordinate the care of the Incapacitated Person for the period covered by this Report may be
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.
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Date
Si a e f Guardian of the P rson
MARGARET S. MELLINGER
Name of Guardian of the Person (type or print)
8 PINE ROAD
Address
WALNUT BOTTOM, PA 17266
City, State, Zip
(717) 532-4216
Telephone
Form G-03 rev. 10.13.06
Page 4 of 4