HomeMy WebLinkAbout06-20-12Clerk of Orphans' Court of Cumberland Counfiy
I;~ RE: ~ 1 G Y1h ~~y~ ~ ~~ Docket No. ZOU~v (~G y ~~
An Incapacitated Person
ANNUAL REPORT OF GUARDIAN OF THE PERSON
1. ~ .live ~4~w ~y/-orr~;~t~ /~ri~/yy,~ , yni~er w• er appointed
Ienaz ardian s of the erson of c~ a hn N~ e l 1~ ~
p y ~ () P y by Decree of the
Honorable Judge _ r ~ e f ,dated -~ ~ ~~~ ~G 2G6 {c, This is my annual report for
the period from ` 'b // to ~~r~r,~ ~ l ~ , ("The Report Period").
1. Present age of the incapacitated person: .S~p Yrs.
?. Cu,rr~ent ad/d~r~ess of the incapa~cita/tamed person /~ ~y
<JUf7 fJ // Y ~ r~ s)!LG/~I~+C ~ VTl I~IQ~'/S~ / "
~/~iCS V~' / dS0 Dsgr ~qh ~ /~ e ~~c, a rcr I rih
l~/'// : //cr:°sf~ ~ /a ~ ~d3
3
T
' C4,n~, /r~.'i/~ t,~, /~7d//
.
he incapacitated person
s residence is:
p own home/apartment ~-_~
~O ^'
~, ~~
p nursing home ~' ' ~ ~
~; -r ~ `
~ ~
i ~
_
p boarding home/personal care home 0 ~.., ~
c~cy '-- -~ ~-`
~,
p guardian's home!apartment iii ~
~ --, o ;-'~ rn
~~
n.,
p hospital or medical facility
p relative's home
er (ivame and relationship]
.-p
other: i^Uv D~n~ d a~.e1- ~/~ ~r~"idescnbe) aOl~jjr,
~'~ The incapacitated person has been in the present residence since ~~ec•S~ , ~ ~ /0 . If
-~
the incapacitated person has moved within the past year, state change and reason(s) for
change:
~. Name and address of the incapacitated person's primary caze giver:
/ t '~ .S ~h ~'-- U ~?'- C~ ~j ~~? I" if % ~~ c°S - ~-2~j ~~' ~~ f
6. The ma}or medical or mental problems of the incapacitated person are as follows:
Se ~"ev~y /l ~~~r ~e
~ Specify what, if any, social, medical, psychological and support services the incapacitated
person is receiving:
~~ ~,'~ of ~ /~~~er~ 4 7r`y~ ~ (d C ~' ~f~6h, Irv ~i"~>~``,o~. S'~r~-
$ I`t ids our opinion as guardian of the person that the guardianship should: (check one}
id continue, ^ be modified, O be terminated. Eariefly exPta~n your respot,se}
9. During the past year, I have visited the incapacitated person times with the
average visit lasting
f State number of hourslrrunutes, etc.)
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 maybe 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.
0
Date ignature of uardian
* FILING FEE $1S MUST ACCOMPANY THIS FILING.