HomeMy WebLinkAbout02-27-12~`~~ ~ ~ _~, ~ €t ! c
._~,~J
ANNUAL REPORT OF
GUARDIAN OF THE PERSON
COURT OF COMMON PLEAS OF
~ v~IBEf~~-~fwp COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
;~~1 ~~~ ~1 Fly 2~ C
CE.ERK QF
ORPHA~t'u COIIR r
CllMfi~R!_ANf} CO.. ~RA
Estate of ~ a 2~ ~ A , Pr ~ es~ , an Incapacitated Person
No. al- Q9- 6~7p
I. INTRODUCTION
-2wrs~ Fg„„~; IM Snx-~-cQo~ 6reg~cx N~~recbuv~~ ,was appointed
ire .
^Plenary Limited Guardian of the Person by Decree of ~. ~,~5~ 61•ex~ 7r . , J.,
dated 3cAr v~ v,Y.ri ~` ~o l~
A. This is the Annual Report for the period from ~ Ct~~~n~-- 3~S~ ~C~ll~
to ~Ey,~,,~~,,,,r ~~S 070 11 (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
J., dated
For a Final Report, omit Sections II through IV.
Form G-03 rev. 10.13.06
Page 1 of 4
Estate of t-~-~ 2t~ ~ , ~ ~ CS~'
II. PERSONAL DATA
Age of the Incapacitated Person: ~5
an Incapacitated Person
Date of Birth: I v l l ~ `~~ (o
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
~r a l a i pA t-7o a~
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
^ relative's home (name, relationship and address)
^ other:
/~ ~~~~~
C. The Incapacitated Person has been in the present residence since ( 9 C
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form c-o3 rev. 10.13.06 Page 2 of 4
~'
Estate of ~G.Z~ ( ~ . ~ 1 ~~ , an Incapacitated Person
D. Name and address of the Incapacitated.Person's primary caregiver:
~f w ~Sh ~0.r~.,~y ~Nv` ~ o ~ ~Q`~-ear ~rr~S~~r i one, ~~FS~
`3 3 33 PJor-lam, ~~-~s~.
t--~ o, ~ ~c ~ 5 ~..~ ~y ,PIA i~o~ v
l- i r`^i~le ~ \~ w~ G~w,~ G~ a `~ c~~ G ~
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
~ a ~ ~ h 0.s ~~-~m~ur~-k ~ c~, w 1.; c~ cQ m~~~ Sc..~ ~.~- ~b ~ f ~ }-~..~
~~ o ~i v~ a ~ c;~ a l nY moo. t~v~e ~. u~ Ica s~ ens ~` c 1~r z.e I~ . -}-~~ -u 1 re 9 ~ i ~ S
~~-I h~v.r Care, -~v ~ 0.u. ~ ~m~.ih i n ~r ho+~ , S~
a 1 so sv, C.C~C ~ ~- m ~ b v. l a ~ ~ dy s ~,,, +. ~,~!-~ o n c~. u ~.~; ,,~ ~~ ~
C~~c. ~~-\- o r~ ~ cn.re ~~~< ~ ~:t a, l~ d-~ ~nr l~ 1~ ~.-t\l. 1~4.~v-~~
C o Ste. ~ ~ v~ ~~~r.-.S C.r.;'v~'~i ~::~ ~ ~ c t ~ r.~ .
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving: ~~S ~ S ~,,~ ~ ; ~,~ a S ~ ~ a ~d ~ W~ ~ ~ o v~ r
~ G ~ w~, O V e,.r s.esi err d C c~ ~ ~~l i ~ncA ~-e. ~1 t 1 C~~v~r S ~ ~ d ~(~ swc ~ ~ c~, 5 , c-~ e.
hR~ c~.~ ~~ ~\ (7~ i rnrCL iQcnv~~G~~Sw.s ~~ ~nTs, ~Pr ~ est', or~
rc~ o.Y~ a v~,.;? h~ ~ l C ~ use d.~ cl s ~ ~ h ~ cn ~- are ~! cL ss e~,. v1 ~ \-~ ~n'L~ ~ h ~S
a ~l tir . ~.tn s o ~~-. \ eQY-Q, r ~,.~ `. ~ ~ ~ i ~. s ~em str.,~ `klr~ o. -~ dl ~ l d ~ h.t,,C'
Ab L's a.~ ~t o,r~ ~evJ~ ~ Sc~e_i a1i v~~-i ~r , !-bSpi~ c~.,o,s ihuolv.-~
~ c `~.rtsc~.l u.,~'~ s c~.. w~- ~ ~^r ~.ca ~ v~ i r ~•b ti, ~ a.+,' o v~ uv~+ ~-t w a S
ll ~ s cJv~ ~ ~ ~~ , C`~ ~~ c ~ I, ~~ it ~ CA s a ~ 0 ~'~.t rt ~ of Cl..
V. GUARDIAN S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
continue
Q be modified
^ be terminated
Form G-03 rev. 10.13.06
Page 3 of 4
Estate of ~ CIl 7~. ~ ~ . 'pr i ~ S~ , an Incapacitated Person
The reasons for the foregoing opinion are:
Y ~~ , Pr ~ ~ ~''~" C on~~ t r u~t. ~ '~ ~."e c. l ~ vV C p ~ u~ ~ -{-~ v~ ~ o `~ ~ ~1 1n y ~ I c u, ~ ~I,(
~1~ ,,~n ~ ~`~ a cal v.~ h~a. I `t'V~ i s ~ ~r{~t S . ~JS ~-c 1~ ~ s ~_ c c w.Q. ~o. ~ ~pc at RI~ i~1~4.~
ICS V ~'C..1'j \ (~ ~. q ~. ~ ~` ~tY1 bin 1 a.'~ V ~-( `. ~/ a ~V\N~ ~. ~. V~~ ~~ Y~~ ~. ~ ~ b (1^.~ t', ^~~. 1, i ' ` 1, ~v\//
C u ~ ~ (~r~ ~r_`es~ da~~~ ~~o-~- ham `t~v cr,~0.e~ `~ i`o c u+~-~ ~c~ ~~.a.~.~ ~it~ar~~c+~zllry
a~ ~hy~~c~~-~,
B. During the past year, the Guardian of the Person has visited the Incapacitated Person
h o~ It ss ~ o n '~ ~ rn.~ times with the average visit lasting ~_ hours, minutes.
q vr.oc:t~,
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.
~~ti ~
Date Signature of Guardian of the Person
~~-2~,:t- 01~-
Name of rdian of the Person (type or print) t ~ ~~~' ~.
333 N: ~ar,t ~~, 1
Address
City, State, Zip
Telephone
Form G-03 rev. !0.13.06 Page 4 of 4