HomeMy WebLinkAbout07-08-13 (2) ANNUAL REPORT OF GUARDIAN
RECORDED OFFICE GF
OF THE PERSON REGISTER OF 1:.'1LL S
COURT OF COMMON PLEAS OF 1.013 JUL 8 Fn 1 35
CUMBERLAND COUNTY,PENNSYLVANIA
ORPHANS' COURT DIVISION CLERK OF
ORPHANS' COURT
CUMBERLAND CO., PA
Estate of Raymond Clark an Incapacitated Person
No. 21-12-0040
I. INTRODUCTION
Keystone Guardianship Services was appointed
® Plenary '❑ Limited Guardian of the Person by Decree of Thomas A. Placey J.,
dated February 16, 2012
® This is the Annual Report for the period from February 17 2012
to February 16 , 2013 (the "Report Period"); or
❑ B. This is the Final Report for the period from ,
to , (the "Report Period"), and is filed
for the 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 H through IV.
Form G-03 rev. 10.13.06
Page t of 4
Estate of Raymond Clark an incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person: 71 Date of Birth: 3/1/1942
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
Golden Living West Shore
Secured Unit
770 Poplar Church Road
Camp Hill, PA 17011
B. The Incapacitated Person's residence is:
G own home /apartment
®nursing home
G boarding home/personal care home
0 Guardian's home/apartment
0 hospital or medical facility
C relative's home (name, relationship and address)
Gother:
C. The Incapacitated Person has been in the present residence since 5/3/2011
If the Incapacitated Person has moved within the past year, state prior
residence and reason(s) for move:
Farm G-03 rev. 10.13.06 Page 2 0£4
Estate of Raymond Clark an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
Skilled Care staff of the
Golden Living West Shore
770 Poplar Church Road
Camp Hill, PA 17011
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person areas follows:
Current Diagnosis(s): dementia, hypertension, CN Disease,general pain (he does not complain of
pain to them,convulsions(seizures)cognitive difficulties,CDA(Stroke)he is at risk of falls but had
none since May of 201 L(This info from G.L on 4/4/12 Care Pn). Medicine list attached.
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
Edward Lamarque, MD, Primary Care Doctor
Participates in the facility activities, likes to watch TV all sports
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
®continue
0 be modified
0 be terminated
Fo m G-03 mz.10.13.06 Page 3 of 4
Estate of Raymond Clark an Incapacitated Person
The reasons for the foregoing opinion are:
It is my opinion Mr. Clark lacks the ability to mental and physical to care for himself. He
seems very well adjusted and content with his environment, life style and care provided by the
staff of Golden Living.
B. During the past year,the Guardian of the Person has visited the Incapacitated Person
24-30 times with the average visit lasting 15—30 minutes
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.
(0 li3 .�
Date Signature of Guardian of the Pers
Constance E.Stoneroad
Name of Guardian of(he Person(type or prim)
PO Box 804
Address
Elcabe(hville.Pa 17023
City,State,Zip
717-265-4056
Telephone
Form G-03 mv. 10.13.06 Page 4 of 4
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