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HomeMy WebLinkAbout04-26-10 r-~ ~-~ C7 O ,,.. `. 0 - mo ` -f ~ - o -r) ~ ~ - •; NOTICE OF CLAIM ~ ~ ~ - . (Filed Pursuant to 20 Pa.C.S. § 3532) - `" n COURT OF COMMON PLEAS OF ~'' N 1 A ."n {-~ r( n~'~ cl COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF _l__~~~2~1. i` I~~~1G~x ~ lL ,DECEASED No.:~1- rU-r~5..7/ To the Clerk of the Orphans' Court Division: Enter the claim of -' (Claimant) amount of $~, .ESL: H ,against the above entitled Estate. in the The Decedent, who resided at Iti21 ~,~:_~.l</1~t '~: ~~~ ~ . (Street Address) ~~~,`~-k-r~ ~-~t-~-re ~~ ' !'~ i -1:.~ 57 ,died on ;~2 ~ ;~'7 ~ 1~ .Written notice of (Date of Death) said claim was given to _ ~l'~:~3 Ld ~ri_~ } ~• , ~ (PeFsonal Representative or his r counse/) at ~1 `1 l,~t~ 7~ ~ r~cl ~rL~ -~ , ~h~ ~;2-~,+1 k~~rc~~i ~/I ~ ~;~~7 ~ (Address) (Date) ~~ ~` J / y ~~ 111 ~1 ~ ~ r /1 ~ '1% 1 i ~C ~ ! - ~-C.~'~.~ ~1~ + t~ / ~ ~/, !'~, (ClarmantJ ~ _ 1 d? i ~ ~.c't~l7.t ~ .~ F~, t1~7~~ ~~ (StreetAddress) J^ 1 l rj (City, Slate, Zrp) (Claimant's Counsel) (Address) (Supreme Court 1. D. No.) (Telephone) Form OC-07 rev. 10.13.06 Shippensburg Health Care Center 121WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 (717}530-8300 Isabel Maxwell 01596 Isabel Maxwell 121 Walnut Bottom Rd Shippensburg, PA 17257 Balance Due: 2,250.41 Payments/ Charges Credits 01/01/09 Balance Forward 0.00 0.00 01/29/10 Payment 11,628.00 01/03/10 ROOM AND BOARD SEMI PT 01/03/10-01/31/10 5,916.00 01/03/10 ROOM AND BOARD SEMI PT 01/03/10-01/31/10 5,916.00 01/03/10 ROOM AND BOARD SEMI PT 01/03/10-01/31/10 5,916.00 02/01/10 ADV ROOM AND BOARD SEMI 02/01/10-02/28/10 5,712.00 02/01/10 ADV ROOM AND BOARD SEMI 02/01/10-02/28/10 5,712.00 02/01/10 ROOM AND BOARD SEMI PT 02/01/10-02/26/10 5,304.00 01/04/10 OT THERAPEUTIC EXERCISES 01/04/10 1 29.37 01/04/10 OT THERAPEUTIC EXERCISES 01/04/10 1 29.37 01/04/14 OT THERAPEUTIC EXERCISES 01/04/10 1 29.37 01/04/10 OT THERAPEUTIC ACTIVITIE 01/04/10 1 30.96 01/04/14 OT THERAPEUTIC ACTIVITIE 01/04/10 1 30.96 01/04/10 OT THERAPEUTIC ACTIVITIE 01/04/10 1 30.96 01/04/10 PT THERAPEUTIC EXERCISES 01/04/10 1 29.37 01/04/10 PT THERAPEUTIC EXERCISES 01/04/10 1 29.37 01/04/10 PT THERAPEUTIC EXERCISES 01/04/10 1 29.37 01/04/10 PT NEUROMUSCLAR 01/04/10 1 29.67 01/04/10 PT NEUROMUSCLAR 01/04/10 1 29.67 01/04/10 PT NEUROMUSCLAR 01/04/10 1 29.67 01/04/10 PT - THERAPEUTIC ACTIVIT 01/04/10 1 30.96 Sub Totals 23,117.70 23,375.37 Carried Fwd Shippensburg Health Care Center page 121WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 (717} 530-8300 2 Isabel Maxwell 01596 Isabel Maxwell 121 Walnut Bottom Rd Shippensburg, PA 17257 Balance Due: 2,250.41 Payments/ Charges Credits Balance From Prev Page 23,117.70 23,375.37 01/04/10 PT - THERAPEUTIC ACTIVIT 01/04/10 1 30.96 01/04/10 PT - THERAPEUTIC ACTIVIT 01/04/10 1 30.96 01/05/10 PT THERAPEUTIC EXERCISES 01/OS/10 1 29.37 01/05/10 PT THERAPEUTIC EXERCISES 01/05/10 1 29.37 01/05/10 PT THERAPEUTIC EXERCISES 01/05/10 1 29.37 01/05/10 PT NEUROMUSCLAR 01/05/10 1 29.67 01/05/10 PT NEUROMUSCLAR 01/05/10 1 29.67 01/05/10 PT NEUROMUSCLAR 01/05/10 1 29.67 01/05/10 PT - THERAPEUTIC ACTIVIT 01/05/10 1 30.96 01/05/10 PT - THERAPEUTIC ACTIVIT 01/05/10 1 30.96 01/05/10 PT - THERAPEUTIC ACTIVIT 01/05/10 1 30.96 O1/05/10 OT THERAPEUTIC EXERCISES 01/05/10 1 29.37 01/05/10 OT THERAPEUTIC EXERCISES 01/05/10 1 29.37 01/05/10 OT THERAPEUTIC EXERCISES 01/05/10 1 29.37 01/05/10 OT ADL 01/45/10 1 31.35 01/05/10 OT ADL 01/05/10 1 31.35 01/05/10 OT ADL 01/05/10 1 31,35 01/06/10 OT NEUROMUSCULAR 01/06/10 1 29.67 01/06/10 OT NEUROMUSCULAR 01/06/10 1 29.67 01/06/10 OT NEUROMUSCULAR 01/06/10 1 29.67 Sub Totals 23,509.44 23,586.72 Carried Fwd Shippensburg Health Care Center Page 121WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 (717}530-8300 Isabel Maxwell 01596 Isabel Maxwell 121 Walnut Bottom Rd Shippensburg, PA 17257 Balance Due: 2,250.41 Payments/ Charges Credits Balance From Prev Page 23,509.44 23,586.72 01/06/10 OT THERAPEUTIC ACTIVITIE 01/06/10 1 30.96 01/06/10 OT THERAPEUTIC ACTIVITIE 01/06/10 1 30.96 01/06/10 OT THERAPEUTIC ACTIVITIE 01/06/10 1 30.96 01/06/10 PT THERAPEUTIC EXERCISES 01/06/10 1 29.37 01/06/10 PT THERAPEUTIC EXERCISES 01/06/10 1 28,37 01/06/10 PT THERAPEUTIC EXERCISES 01/06/10 1 29.37 01/06/10 PT NEUROMUSCLAR 01/06/10 1 29.67 01/06/10 PT NEUROMUSCLAR Oi/06/10 1 2g,67 01/06/10 PT NEUROMUSCLAR 01/06/10 1 29.67 01/06/10 PT - THERAPEUTIC ACTIVIT 01/06/10 1 30.96 O1/06/10 PT - THERAPEUTIC ACTIVIT 01/06/10 1 30.96 01/06/10 PT -- THERAPEUTIC ACTIVIT 01/06/10 1 30.96 01/07/10 PT NEUROMUSCLAR 01/07/10 1 29.67 01/07/10 PT NEUROMUSCLAR O1/0?/LO 1 29.67 01/07/10 PT NEUROMUSCLAR 01/07/10 1 29.67 01/07/10 PT - THERAPEUTIC ACTIVIT 01/07/10 1 30.96 01/07/10 PT - THERAPEUTIC ACTIVIT 01/07/10 1 30.96 01/07/10 PT -- THERAPEUTIC ACTIVIT 01/07/10 1 30.96 02/01/10 PT LIABILITY PER 2/18/10 2,146.10 3 Isabel Maxwell 01596 Please Remit: 2,250.41