HomeMy WebLinkAbout12-06-13 (2) . •►
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Arf NUAL REPORT UF � � � � � °
F THE PERSON � N � � � °;
GUARDIAN O � � � ..t' � ,�
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COURT OF COMMON PLEAS OF `� � ...�,� � �
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�U�?/�e/C°�� _COUNTY,PENNSYLVANIA j
ORPHANS' COURT DIVISION
Esta.te
of r/ ��� � ,an Incapacitated Person
No.
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�. INTRODUCTION
G��°.��j� �//Yj ,�(���`� ,was appointed
Pl+enary OLimited uardian of the Person by Decree of �J 1��P kU�3����J.,
dated ��—
A. This is the Annual Report for the period from Ti�/U �: �a�--
� . (the"Report Penod");or
to
Qc�� � , a o�3
❑ 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.
Page 1 of 4
Fornt G-03 rev.10.13.06
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Estate of �G�G�� � � ��`�"P ,an Incapacitated Person
II. PERSONAL DATA
A e of the Incapacitated Person: �� Date of Birth: g �
g
III, LIVING A�tRANGEMENTS
A. Current address of the Incapacitated Person: v ��
�'�i�e/27vS �-l C /2 ee�' �
� a �sGa G�cG/c�p s z-� c� l.�I�P
�1'j�c-!T�/vl GS /3dfP�--'/ /�a /��G SO
B, 'The Incapacitated Person's residence is:
❑own home/apartment
ursing home
❑boarding home/personal care home
❑Guardian's home/apartment
❑hospital or medical facility
❑relative's home(name,relationship and address)
❑other:
The Inca acitated Person has been in the present residence since Se�T���-3e�
C. p
� . If the Incapacitated Person has moved within the
past year,state prior residence and reason(s)for move:
Page 2 of 4
Form G-03 rev.10.13.(Xi
Estate of /` D�E'�� [�'. /�L-1�1t� an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
�'��3e�zr ,�. !'7��l�j �s��
��o G/�c�k�� I� S'?�cl� 9,�I�
�t CC,ir�/�J!CS/3d I�G- ��- � �G Sd
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
,bi!�'i e�v z-��--
CJlP��t/�� �i�i��c T��tJ
� B. Specify what, if any,social,medical,psychological and support services the
Incapacitated Person is receiving:
�v�esi�6 c� �
,� C����r��� ��r�s�s
�'le�i�� �Ni � �U6°l�o���T
V. GUARDIAN'S OPINION
A. It is the opinion of the Guazdian of the Person that the guardianship should:
ontinue
❑be modified
❑be terminated
Page 3 of 4
Fornt G-03 rev.10.13.06
Estate of ,�!'J/.'e/� � ��`t � ,an Incapacitated Person
The reasons for the foregoing opinion are:
E'i�L 7`�l /S O 1� ��'! �E-'�`T�d �
/� /
G�/r�f� t 7f o/� C- U� l! �U�S �a
,�e C L! �(J -�.�-
B. During the past year,the Guardian of the Person has visited the Incapacitated Person
ith the ave e visit lasting hours, � Z minutes.
_��tunes w �$
The rep�ort of a sociat service organization employed by the Guardian to oversee an�
coordinate the care of the Incapacitated Person for the period covered by this Report may
attached to supplement this�teport.
I verify that the foregoing information is correct to the best of my knowledge,
infoimation and belief;and t11at this Ver�fication is subject to the penalties of 18 Pa.C.S.A. §4904
relative to unsworn falsification to authorities.
� Signature of Guardian of the Person
Date
�/3�°�-°T�. /�l��/Q--
Nanee of Gum�ian of the Person type or pn�tt)
��D G�co�c°� S�ZTC�' 'L�/�.
Address
� �/�`Cs/�!/���`�G�
c�ry.s�.�p l �v ��
�17 -- � .3� -- !�'�"�
Telephone
Page 4 of 4
Form G-03 rev.10.13.06
. •
Estate of f`����� �l ' ��L" ,an Incapaci#aied Person
The reasans far the for�going opinion are:
B. During the past year,the Guardian of the Pers�n has visited the Incap�iiated Person
_______times with the average visit lasting__._____hueus,_minutes.
The repnrt of a sociat servu�organization eretployed by tlse Guar'dian to oversee arrd
coordi»ate tl�e care of ti�Ir�capac�tatect Pea�ort fgr the period cov+ered by this Repvrt may be
attached ta sr�pplement thi�Report.
I verify tt�#h�e for�going�nformat�o»is correct�+u t�b�t�€my knowledge,
in€cnmatic>n sad�elief;and that this Verificati�is subject tQ the penalties of 18 Pa C.S.A.�4904
reiative to unswc�rn falsific,ation to au�harities.
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