HomeMy WebLinkAbout08-28-14 N_
ANNUAL REPORT OF c o r rn
GUARDIAN OF THE PERSON W z 0-:) n
;0 D r— ry M rn
ram CO -0 a)
X � o
L'7 l7 O =D —n
COURT OF COMMON PLEAS OF o -n r3�
COUNTY, PENNSYLVANIA rr- rn t
ORPHANS' COURT DIVISION
Estate of,q,?6 lip 5� 14i2k�s��� QA 17DJ—? an Incapacitated Person
No. IU —1c53
I. INTRODUCTION
T_ -)),Anld � Kocl e&e �Y1ClN�18 was appointed
Plenary®Lim1 ed Guardian of the Person by Decree of&1i 5k E✓ewc- 1VVW J.,
dated uaUS r AO/0
0--A-. This is the Annual Report for the period from Ju,,<_ 3 Oa l3
�-1
to 4W 1'J a8 1 c (the"Report Period"); or
El 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..
Form G-03 rev. 10.13.06 Page I of 4
,4bSAa- EVeAc s5)age
Estate of Ercou.-111,) 57- /lp-b6k #0/- 1 70/3 an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person: a3 Date of Birth: Ik"acl
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
B. The Incapacitated Person's residence is:
[9`6wn home/apartment
F7 nursing home
E]boarding home/personal care home
rj Guardian's home/apartment
r7 hospital or medical facility
®relative's home (name, relationship and address)
®other:
C. The Incapacitated Person has been in the present residence since dean �j
. 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 of 4
Fvefle SatiJ'�
Estate of FW Jk-b, ) ST (4411.sk Pf7 171313 an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
N,s�6�y A� L'OM�feK tlacfiaL Se,zsR*,.t �6NGfi�ron/ �v�,� ��a-Ly
'7rt hec. 1'ad . 't r QG'Pc'rJ= Gt,✓ctl ewc.Lur -TN ,, ,6,�
e ��-,vc// 4,,,d - o pwte- al, J- ddmn�w,ca'!c cfeG,s,oa5
IV. MEDICAL INFORMATION
A. The major medical or mental pro ]ems of the Incapacitated Person are as follows:
B. Specify what, if any,social, medical, psychological and support services the
Incapacitated Person is receiving:
I
SuNCfQy � aaL f"!'P' r y�o/v}tn=5 1(�oaf5
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
En6minue
0 be modified
171 be terminated
Fo m G-03 rm 10.13.06 Page 3 of 4
1
�Zr Yt/eftL `�,ratR�f
Estate of 44, Fnr,L t 51 /> f�1P j t 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 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 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.
Date S' ngture ofGuardiart afthe Person
Name of Guardian of the Person(type o pnw)
Address
rG/Isl� 40, /ZE 3
City,Stare,Zip
'71-) ) g3a 9ZWo
Tetepho e
Form G-03 rev. 10.13.06 Page 4 of 4