HomeMy WebLinkAbout09-07-12FIRST AND FINAL REPORT OF
GUARDIAN OF THE PERSON
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
Estate of Ada Grace Cocklin , an Incapacitated Person
No. 21-11-1291
I. INTRODUCTION
Keystone Guardianship Services was appointed
® Plenary '~ Limited Guardian of the Person by Decree of Al Maslin , J.,
dated 1/19/2012
This is the Annual Report for the period from ,
to (the "Report Period"); or
® B. This is the Final Report for the period from January 19 2012
to July 28 2012 (the "Report Period"), and is filed
for the for the following reason:
1. The death of the Incapacitated Person. Date of death: July 28, 2012
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
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Page 1 of 4
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Estate of Ada Grace Cocklin , an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person:
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
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:
Date of Birth:
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:
I-'arm G-03 rev. 10.13.06 Page 2 0£ 4
Estate of Ada Grace Cocklin , 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 areas 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
Dorm G-03 ce~~. 10.13.06
Page 3 of 4
Estate of Ada Grace Cocklin , an Incapacitated Person
The reasons for the foregoing opinion are:
B. During the past year, the Guardian of the Person has visited the Incapacitated Person
times with the average visit lasting
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.
/ ~ /~ ~ L
Date tgnature of Guardian of the Person
Constance E. Stoneroad
Name of Guardian of the Person (type or print)
PO Box 804
Address
Eli~abethville Pa 17023
City, State, Zip
717-265-4056
Telephone
Form G-03 rev. 10.13.06 Page 4 of 4