HomeMy WebLinkAbout12-31-13 (2) . �
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GUARDIAN OF THE PERSON � � � � � �
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COURT OF COMMON PLEAS OF ' --a � �
G �� coulv�,P�rrNS�v� � � �' �
ORPHANS' COURT DIVISION
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� Esta.te of � -Qi� ��ti�'`-�- ,an Incapac�ta.ted Person . .
No. 2 I—I 3—�GI�-�i�
I. INTRODUCTION �
.
LiYU--, � 5�1�'�t . ,was appointed
Ple �I,imited Guardian of tlie Person b Decree of . ;J., . � :. ...
nazy .. .. . ..Y_
c�ated n���✓ 1�. 2,oj''�
��A. ' is the Annual Report for the period from ��t�J I S , �D� � _
to , Z (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 IY.
Form G-03 r�.�0.13.06 Page 1 of 4
Estate of � � ,an Incapacitated Person .
II. PERSONAL DATA : �
Age of the Incapacitated Person: �� Date of Birt�i: �����Ct� . �
� .
III. LIVING AF�RANGEMENTS
A. Cturent address of the Incapacitated Person: . . �
1201 Gt�-- -+- (za�
����5�2, �/� 11 01�
. . .B. The Incapacitated Person's residence is: . �
�own home/apartment �
�nursing home � �
Q boarding home/personal care home
�Guardian's home/apartment
�hospital or medi�al facility .
� �relative's home(name,relationship and address) •
oo��:
C. The Incapacita.ted Person ha.s been in the present residence since '��� . ..
, ..
� �� � � � . If the Incapacitated Person has moved withiri t11e
past year, state prior residence and reason(s)for move: . .
Form G-03 rev.10.13.06 Page 2 of 4
` • I
Estate of ��� �` 5��—�- ,an Incapacitated Person
D. Name and address of the Incapacita.ted Person's primary caregiver: . �
,
p��� 5��
120� G 1�- C=`��
`�� `r� � �! 1 �� ���
IV. MEDICAL INFORMAT'ION �. .
A. The major medical or mental problems of the Incapacita.ted Person are as follows: .. � -
. � .���,�a-� s..��--�--� . �
B. Specify what,if any, social,medical,psychological and support services�he
Incapacitated Person is receiving: �
. �-;�� R.s: � � c�-. �,�,� c�k,�,�-.� I�,���
- �
� ��(,� ���-�S C�e� Fy�'`� �— 5���� .
� V. GUARDIAN'S OPINION . �.
A. It is�the opinion of the Guardian of the Person.that the guardianship should: � .
�ontinue
�be modified
�be terminated
Form G-Q3 r�.�0.13.06. Page 3 of 4
, w ,
Estate of (/1��1��� ,I `� ,an Incapacita.ted Person .
� The reasons for the foregoing opinion are:
.
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C�}�.. ��,GC,�S G�.SS���z�c.C� iiv�G��l ���=-/� S�GfiC�S
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� � �`4��1�Pi�" ��SS • �%�t��S'� � S (�'�c,�,� .
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� �ti.�.�.,,�.c��.,�'..CCG`s�-S � �(�s ��s ,�.�--
t�d- ��d ' '
.
B. During the past year,the Guar of the Person has visited tlie Incapacitated Person
. ��� times with the avera.ge visit lasting 2�'�. hours, 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 kaowledge,
information and belief; and that this Verification is subject to the penalries of 1 S Pa. C:S.A. § 4904
relative to unsworn falsification to authorities.
12-3�— �3
Date Signature of Gaardian o Person
��C;,�.., . ���
Name of Guardian of the Person(rype or print)
1�� G lG��o�-t- (��-�
Address
C-�Y1��SL� �'�t- 1�c�1 S
c��;swre,z�
�l��'1— 25�—.� t � t
Telephone
Form G-03 rev.10.13.06 Page 4 of 4