HomeMy WebLinkAbout11-24-14 ANNUAL REPORT OF
GUARDIAN OF THE PERSON
COURT OF COMMON PLEAS OF
COT TNTY.PFNNRYT.VANY A
ORPHANS' COURT DIVISION
Estate of ,an Incapacitated Penson
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I. INTRODUCTION
was appointed
El Plenary[trLimited Guardian of the Person by Decree of
dated
M A T'f..1Q.:Q.ilia e nvaYlvwl Annn*4 few+11a TOr.nA
to 7" 1 (the"Report Period");or
Q 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.
Farm G-03 rev.10.13.06 Page 1 of 4
Estate of U� GJ �' • "` "' ,1 ,an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person: ,J / Date of Birth: , 9�
M. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Persony:,�,
l 9
B. The Incapacitated Person's residence is:
L_.__ ,_-___..._^_.
�OwTi iiwuc i aNaiuiicui
[]nursing home
Q boarding home/personal care home
Guardian's home/apartment
hospital or medical facility
relative's home(name,relationship and address)
[]other:
C. The Incapacitated Person has been in the present residence since D
If the Incapacitated Person has moved within the
past year,state prior residence and reason(s)for move:
Form 6-03 rev.10.13.06 Page 2 of 4
Estate of 'f " ,an Incapacitated Person.
D.
Name and address of the Incapacitated Person's primary caregiver:
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
B. Specify what,if any,social,medical,psychological and support services the �.
Incapacitated Person is receiving: �� VFX✓G �
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
' ontinue
Elbe modified
El be terminated
Form G-03 rev.10.13.06 Page 3 of 4
Estate of
an Incapacitated Person
The reasons for the foregoing opinion are: -,-��
Pf �iZ. I L
B. During the past year,the Guardian of the Person has visited the Incapacitated Person
times with the average visit lasting hours, minutes,,_
��� ��': '�j,cJ 'tom-t1I7i� �Y,�-�� ,/l'�Gcsy�i `�t�✓-�a-�' pt� �---MA��-��,:��..�C,, i�,�
.C� ,;y t�Tlae r pool a-slo`cial 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.
.>a- Z�i dLI-IC4
Date Signature of Guardian of the Person
Z"-) 17w Z Li
Name of Guardian of the
Person(type or print)
Address
Cupp,State,Zip
7 90 63
Telephone
Form G-03 rev.10.13.06 Page 4 of 4