HomeMy WebLinkAbout07-28-11 (2)
Estate of
MIMI BLAZER
No. 21-09-1029
I. INTRODUCTION
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an Incapacitated Person
STEPHANIE E. CHERTOK ,was appointed
m Plenary Limited Guardian of the Person by Decree of J. WESLEY OLER, JR. J
dated 12-28-09 '
A. This is the Annual Report for the period from
t° (the "Reporrt Period"); or
Q B. This is the Final Report for the period from December 2.8 ~ 2009
to January 23 ~ 2010 (the "Report Period"), and is filed
for the following reason:
1. The death of the Incapacitated Person. Date of death: 1-23-10
2. The Guardianship was terminated by the Court by Decree of
J., dated
For a Final Report, omit Sections II through IV.
Form G-03 rev. 10.13.06
ANNUAL REPORT OF
GUARDIAN OF THE PERSON
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
Page 1 of 4
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Estate of MIMI BLAZER
_, an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person:
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
Date of Birth: 8-13-1923
B. The Incapacitated Person's residence is:
own home /apartment
nursing home
0 boarding home /personal care home
Q Guardian's home /apartment
0 hospital or medical facility
0 relative's home (name, relationship and address)
other:
C. The Incapacitated Person has been in the present residence since
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form G-03 rev. 10.13.06 Page 2 of 4
Estate of MIMI BLAZER
., an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
IV• MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
continue
be modified
be terminated
Form G-03 rev. 10.13.06
Page 3 of 4
1 -
Estate of MIMI BLAZER
an Incapacitated Person
The reasons for the foregoing opinion are:
Death of the Incapacitated Person
B. During the past year, the Guardian of the Person has visited the Inca acita
p ted Person
times with the average visit lasting hours
minutes.
The report of a social service organization employed by the Guardian to ovens
coordinate the care of the Incapacitated Person for the period covered b ~ this Re ee and
attached to supplement this Report. y port may be
I verify that the foregoing information is correct to the best of my ~:nowled e
information and belief; and that this Verification is subject to the enalties of g
relative to unsworn falsification to authorities. p 18 Pa. C.S.A. § 4904
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Date
Signat e of Guardian of th ers•on
Name of uardian of the Person (type or print)
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Address
City, State, Zip
Telephone
Form G-03 rev. 10.13.06
Page 4 of 4