HomeMy WebLinkAbout11-17-14 Claim Against Decedent's Estate
ESTATE OF: James Carmody
The undersigned hereby presents for filing against the above estate this statement of claim and alleges:
Golden Livingcenter—Camp Hill
PO BOX 180970
Fort Smith, AR. 72918-0970
The basis of claim is: Nursing Home Care
Estate Claim#- 21-2014-0903
The amount of the claim is: $755.46
NOTE-If there is insurance pending on this account and the insurance fails to pay then amount will
become due privately.
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Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged7ke true to tkix
best of my knowledge and belief. ;� o rr1 M
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*Included is the claim fee for $10.00 rn c
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Signed ON: October 30, 2014 "
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t�T@'gs•,, RITA I N#12 �' C�J�M�c r\� U7
MY CC)1' d! Co
��iON#12370499 /
_ :P eacp' Xt"iliL:'tfacCh 26 2019
Sebastian County
Michelle Webb, Collections Specialist
I SWEAR THIS STATEMENT IS CORRECT
Subscribed and savorto before me
c S.P;€.,oF••,; RITA DONNELLY
MY COMMISSION#12370499
On ='•Pva EXPIRES:March 26,2019
Sebastian County
Notary Public 14/CO/I
My Commission ExpiresJ, ,)t C�
NOTICE OF CLAIM
(Filed Pursuant to 20 Pa.C.S. § 3532)
COURT OF COMMON PLEAS OF
Cumberland COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF James W Carmody ,DECEASED
No. 21-2014-0903
To the Clerk of the Orphans' Court Division:
Enter the claim of Golden Living in the
(Claimant)
amount of$ 755.46 , against the above entitled Estate.
The Decedent,who resided at 7 Ronald Road
(Street Address)
Mechanicsburg, PA 17050 , died on 08/10/2014 Written notice of
" (Date of Death)
said claim was given to Mark Carmody&Michael Carmody
(Personal Representative or his/her counsel)
at Mark-6033 Williams Dr Mechanicsburg PA 17050 &Michael -4004 Boleyn Terr Olney, MD 20832
(Address)
on 10/30/14
(Date)
Golden Living
(Claimant)
1000 Fianna Wav rU
(Street Address) � fM
Fort Smith AR 72919 ;
(City,State,Zip) HT1 c C!1
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(Claimant's Counsel) (Supreme Court I.D.No.) Cn 7�1 -� CJ
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(Address) ��
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fV C()
(Telephone)
Form OC-07 rev:10.13.06
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