HomeMy WebLinkAbout03-31-14 NOTICE OF CLAIM
(Filed Pursuant to 20 Pa.C.S. § 3532)
COURT OF COMMON PLEAS OF
Cumberland COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF
Mary E. Dallmeyer , DECEASED
No. 21-2013-748
To the Clerk of the Orphans' Court Division:
Goldenliving -West Shore in the
Enter the claim of �cra;ma„r�
amount of$ g�644.88 , against the above entitled Estate.
543 Magaro Rd Enola, PA 17025
The Decedent,who resided at (Street Address)
, died on 06/25/2013 . Written notice of
(Date of Death)
said claim was given to Lerov M. Dallmever
(Persona(Representative or hi.r/her counsel)
at 932 Enola,PA 17025 �Addre.ss�
on 03/25/2014
�Date� Shyra Shelton - Golden Living Center
(Claimant)
P.O. Box 180970
(Street Address)
Fort Smith,AR 72918
(Ciry,State,Zip)
(Claimant's Counsel) (Supreme Court/.D.No.)
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Form OG07 rev. 10.13.06
Claim Against Decedent's Estate
ESTATE OF: Mary Dallmeyer
The undersigned hereby presents for filing against the above estate this statement of claim and alleges:
Golden Livingcenter—West Shore
PO BOX 180970
Fort Smith,AR.72918-0970
The basis of claim is: Nursing Home Care
Estate C�aim#-21-2013-748
The amount of the claim is: $8644.88
NOTE-If there is insurance pending on this account and the insurance fails to pay then amount will
become due privately.
Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the
best of my knowledge and belief. Enclosed is the$10 filing fee.
Signed On: March 12, 2014
�t9,�.',���',`i�''r;;•c-,,- RITA DONNELLY
- PAY COMMISSION#12370499
EXPIRES:March 26,2019 �
i�._;;�,,,,.� Sebastian County
. Shyra Shel n, Collections Specialist
1 SWEAR THIS STATEMENT IS CORRECT
Subscribed and sworn to before me
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