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IN THE COURT OF COMMON PLrAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE MATTER OF :
PHYLLIS DELL MARTIN, :
An Alleged Incapacitated Person : No. Z 1-(j- (��`�`,�
PETITION FOR ADJUDICATION OF INCAPACITY
AND APPOINTMENT OF GUARDIAN
AND NOW COMES, Petitioner, Messiah Lifeways, by and through its attorneys, Latsha
Davis & McKenna, P.C., and hereby petitions for an adjudication of incapacity and appointment
of a guardian under 20 Pa.C.S. § 5511, and in support thereof represents as follows:
1. The name of the alleged incapacitated person is Phyllis Dell Martin, hereinafter
referred to as "Mrs. Martin."
2. Petitioner is Messiah Lifeways, a continuing care retirement community located
at 100 Mt. Allen Drive, Mechanicsburg, Cumberland County, Pennsylvania, 17055.
3. Mrs. Martin is widowed and is 89 years of age.
4. Mrs. Martin has resided at Messiah Lifeways' personal care unit since February
14, 2011.
5. There are no individuals who are sui juris and entitled to inherit from Mrs.
Martin's estate if she dies intestate.
6. On January 17, 2011, Mrs. Martin executed a Power of Attorney designating her
great niece, Judith A. Ingram, her agent. A true and correct copy of the Durable Power of
Attorney is attached hereto as Exhibit"A" and is incorporated by reference.
7. The Power of Attorney dated January 17, 2011 designated James H. Foster, Ms.
Ingram's husband, as successor agent.
8. Ms. Ingram died on January 28, 2014 after suffering from cancer.
9. James H. Foster does not wish to serve as Mrs. Martin's agent.
10. Prior to her death, Ms. Ingram arranged to have Mrs. Martin execute a Power of
Attorney instrument designating Michelle J. Huth, a friend of Ms. Ingram, as Mrs. Martin's
agent, which Mrs. Martin executed on February 10, 2014. A true and correct copy of the Power
of Attorney instrument dated February 10, 2014 is attached hereta as Exhibit"B" and is
incorporated by reference as if set forth at length.
11. In an attempt to execute her fiduciary duties to pay for t}ie care provided to Mrs.
Martin, Ms. Huth contacted Vanguard, the holder of most of Mrs. Martin's assets, who has
refused to honor the Power of Attorney instrument designating Ms. Huth as Mrs. Martin's agent
and release funds to pay for Mrs. Martin's care.
12. Vanguard remains steadfast in its position despite attempts by counsel to persuade
Vanguard otherwise.
13. Mrs. Martin's attending physician is Jennifer Weber, D.O. of Capital Area Health
Associates, located at 100 Mt. Allen Drive, Mechanicsburg, Pennsylvania, 17055.
14. Dr. Weber is board certified in the field of family practice.
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15. On June 6, 2014, a consultation was performed at the request of Dr. Weber with
regard to Mrs. Martin's decision-making capacity to sign a Power of Attorney instrument. A
true and correct copy of the resulting consultation report of the same date is attached hereto as
Exhibit"C" and is incorporated by reference as if set forth at length.
16. The key findings in the report include the following, among other things:
a. The results of the dementia screening indicate significant impairment;
b. The mini-mental evaluation dated April 16, 2014 contained a score of
12/30, indicating progressive decline in cognitive function since Mrs.
Martin's admission in 2011; and
c. Mrs. Martin is not cognitively capable of making a decision to appoint a
Power of Attorney.
See Exhibit"C."
17. Due to her mental condition, Mrs. Martin is:
a. Unable to manage her financial affairs;
b. Unable to make and communicate responsible decisions relating to her
financial affairs;
c. Unable to make responsible decisions concerning her person, health,
welfare, and safety;
d. Unable to communicate her needs concerning her health, welfare, and
safety;
e. Unable to reside alone;
f. Unable to provide for her personal safety;
g. Unable to keep herself properly nourished and hydrated;
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h. Unable to tend to her personal hygiene;
i. Unable to medicate herself; and
j. Unable to make responsible decisions with regard to her medical care,
including, but not limited to, obtaining health care services and entering
herself into a hospital, convalescent home, skilled care facility, residential
care facility or similar institution.
18. Given Mrs. Martin's condition, her capacity will not improve, but rather
deteriorate over time.
19. Dr. Weber's Deposition of Individual Qualified to Render Opinion as to
Incapacitation is attached hereto as Exhibit"D," and is incorporated by reference as if set forth at
length.
20. Mrs. Martin has executed an advance directive.
21. Petitioner is without sufficient knowledge or infortnation to aver whether Mrs.
Martin has executed a Last Will and Testament.
22. Upon information and belief, Mrs. Martin has a prepaid account with Parthemore
Funeral Homes in New Cumberland for cremation services.
23. Mrs. Martin's deceased husband was a veteran of the United States Armed
Forces, and accordingly she is entitled to benefits from the United States Veteran's
Administration.
24. Mrs. Martin receives the following income:
a. Social Security $1,411.00 monthly
b. Pension $145.24 monthly
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25. Mrs. Martin possesses the following resources:
a. Stock holdings $3,595.60 as of 1/31/14
b. Vanguard Mutual Fund $50,064.45 as of 12/31/13
c. Met Life Insurance $3,027.83 as of 6/20/14
d. PNC checking $6,838.20 as of 4/7/15
26. Relative to these assets, the outstanding balance on Mrs. Martin's account is
$86,826.50 as of March 31, 2015.
27. Keystone Guardianship Services, located at PO Box 804, Elizabethville,
Pennsylvania, 17023, (717) 674-5757, consents to serve as the plenary guardian of Mrs. Martin's
person and estate. An executed Consent is attached hereto as Exhibit"F" and is incorporated by
reference.
28. Keystone Guardianship Services is qualified to act as the guardian of the person
and estate of Mrs. Martin by virtue of familiarity and experience and acting as the guardian of
the person and estate for individuals such as Mrs. Martin.
29. Keystone Guardianship Services charges a one-time start-up fee of$750.00.
30. Keystone Guardianship Service's regular hourly rate for services is $75.00, with a
minimum monthly fee of$200.00.
31. However, because Mrs. Martin is a recipient of SSI benefits, Keystone
Guardianship Services will serve as guardian of Mrs. Martin's Person and estate for a fee of
$100.00 per month.
32. Should Mrs. Martin become a recipient of Medical Assistance benefits, Keystone
Guardianship Services will serve as guardian of Mrs. Martin's person and estate for a fee of
$100.00 per month.
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33. This proposed guardianship is in the best interests of Mrs. Martin for the
management of her financial resources and healthcare decisions.
34. A Power of Attorney instrument has been considered as an alternative to the
appointment of a guardian.
35. However, this alternative is ineffective because the alleged incapacitated person's
incapacity precludes her from executing a Power of Attorney instrument designating a new
agent.
36. The severity of the alleged incapacitated person's mental and/or physical
condition and the lack of viable, less restrictive alternatives necessitate that a plenary guardian of
her estate be appointed to manage and handle all aspects of Mrs. Martin's estate, specifically
including, but not limited to: all issues regarding her cash, checks, and any bank or saving
accounts held in her name; her stocks and bonds; her personal property; her life and/or long term
care insurance of which she is a beneficiary; her entitlement to any governmental and non-
governmental benefit plans; federal, state and local taxes; claims tnade or to be made on behalf
of her or against her; the execution of documents; entry into contracts affecting her and the
payment of reasonable compensation or costs provided to provide services for her.
37. The severity of the alleged incapacitated person's mental and/or physical
eondition and the lack of viable, less restrictive alternatives necessitate that a plenary guardian of
her person be appointed to handle all issues relating to the person of the alleged incapacitated
person, specifically including, but not limited to: her living arrangements, her medical and
psychiatric care, the administration of inedication to her, and the employment of discharge of
physicians, psychiatrists, dentists, nurses,therapists and other professionals for her physical and
mental treatment and care.
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38. It is believed, and therefore averred, that neither the alleged incapacitated person
nar any interested party will contest the medical determination that the alleged incapacitated
person is completely incapacitated.
39. It is believed, and therefore averred, that neither the alleged incapacitated person
nor any interested party will contest this Petition.
40. Mrs. Martin is alert and able to communicate basic needs. However, she is not
oriented, suffers from moderate to severe dementia, and is unable to make and communicate
responsible decisions regarding her health or financial affairs.
41. No other court within this Commonwealth has appointed a guardian of the person
or estate of Mrs. Martin.
42. The type of guardianship sought is plenary of Mrs. Martin's person and estate.
WHEREFORE, Petitioner, Messiah Lifeways respectfully requests that this Honorable
Court issue a Citation directed to Phyllis Martin or her counsel, if so appointed, to show cause
why she should not be adjudicated an incapacitated person and should not have a plenary
guardian of her person and estate appointed on her behalf.
Respectfully submitted,
LATSHA DAVIS & MCKENNA, P.C.
� - - �� ��;'il,/� ,
Date: �9 �a By:
Steven M. Montresor
Attorney I.D. No.: PA 74244
1700 Bent Creek Boulevard, Suite 140
Mechanicsburg, PA 17050
Tele: (717) 620-2424
Fax: (717) 620-2444
smontresor@ldylaw.com
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� VERIFICATION
I, Kimberly Valvo, hereby verify that I am the administrator of the personal care unit at
Messiah Lifeways, and that I am duly authorized on behalf of Messiah Lifeways, the Petitioner
named in the foregoing Petition for Adjudication of Incapacity and Appointment of Guardian, to
verify that the statements made therein are true and correct to the best of my knowledge,
information and belief and that these statements are made subject to the penalties of 18 Pa.C.S. §
4904 relating to unsworn falsification to authorities.
�� ,1 \ r���
Date: �1_'i`,� By: � "I V
� Kim erly Valv ,--�
Personal Care Home Administrator
559726v1
� `-_�' �� NOTICE
THE PUIZI'OSE C3F THTS PO4VER(JF ATT(JRNEY IS TU GIVE THE PERSOI'�I
YUU DESIGNATE {YDUR "AGENT") BROAD POWERS Tfl HANDLE YOLJR
PROPERTY,WHICH MAY INCLUDE POWERS T!J SELL C7R OTHERWISE DISPOSE
UF ANY REAL OR PERS�NAL PROPERTI'WITHOUT ADVAIVCE NOTICE TO YUU
OR APPROVAL BY YOU.
THIS POWER t�F ATTORNEY DOES NOT IMPOSE A DLTTY QN YOUR
� AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED,
YQUR AGENT MUST USE DUE CARE TO ACT�OR YOUR BENEFIT AND IN
ACCORDANCE'tNTTH THYS POWER OF ATTORNEY.
YC?UR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT
YOUR LIFETIME,EVEN AFTEIZ Y4U BECC7ME INCAPACITATED, UN'LESS YOU
EXPRESSLY LIMIT THE DURATIC?N OF THESE POWERS C7R YOU REV{7KE THESE
Pt�WERS OR A COURT ACI'ING ON YC)UR BEHALF TERMINATES YC7UR AGENT'5
AUTHC?RITY.
YOYJR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S
FUNDS.
A COURT CAN TAKE AWAY THE PC7WETiS OF YOUR AGENT IF IT FINDS
YDUR AGENT IS NOT ACTING PROPERLY.
THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF
ATTORNEY ARE EXPLAINED MOI�E FUI.LY IN 20 PA. C.S. CH. 5b.
IF THERE IS ANYTHiNG ABOUT THIS FtJRM THAT YOD UU NOT
UNDERSTAI�ID,YC)U SHOULD ASK A LAWYER UF YOUR OWN CH JOSING TO
EXPLAIN IT TO YOU.
I HAVE TtEAD UR HAD EXPLAINED TO ME THIS I'�TOTICE AND I
UNDERSTAND ITS C4NTENTS.
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Princip : Da te
s�sza
POWER OF ATTORNEY
4W ALL MEN BY THESE PRESENTS, that I,,'�l���]�s v M i rfi�� , of
�� c� Tawnship, County, Pennsylvania, have cansrituted, made,
and appoirtted,and by these resents do constitute,make and appoint
v����n A� sr,�nr��,, ,as my agent(hereinafter"my Agent") tv pexform all such acts
as rny Agent in rny Agent's absolute discretion may deem advisable, as fully as I could
da�f personally present. If my Ag�nt shall be unable or unwilling ta serve or continue
to serve,then I ct�nstitute,make, and appoint Jc�n�_� H. r=u��i�,-- ,as my successor
Agent to exercise the same powers.
My Ager►t is hereby given the fuliest possible powers ta act an my behalf, to
transact business,make, execute and acknowiedge ali agreements,confracts, orders,
deeds, writings, assurances and i.z�truments for any matter,with the sarne power and
for all purposes with the same validity as I couid, if personally present,hereby ratifying
and confirrning ali that my Agent may do pursuant to this Power of Attorney. In
addition to the powers and diseretion specifieally given and conferred upon rny Agent
in this Power of Attorney,my Agent shall have the full power, right and authority to
do, perforrn and to cause to be dane and performed all such acts, deeds, rnatters and
things in cannection with rny property and esrate as my Agent shall deem reasonable,
necessary and proper, as#ully, effecivally and absalutely as if rny Agent was the
absolute owner and possessor thereof.
Without limiting the general powers hereby already conferred, rny Agent shall
have the following specific powers which are inciuded in the£oregoing genexal powers
and which are to be cons�rued and implemented in accordance with Chapter 56 of the
1'ennsylvarua Probate, Estates and Fiduciaries Code:
,� 1. To engage in real property transactions�, speci£ically including the power
�' '� to execute,deliver and acknowiedge deeds to my are�l properry known as
�
5 �7 ChtSSbr��tr UYtvc'. �.
E�"_;�.,�i l�c��k. 4:j�Y I'�102
2. Ta create a irust for my benefit.
3. To make addiHons to an existing irust for my benefit.
4. Ta disciaim any interest in property.
5. To rer�ounee fiduciary positions.
6. Tv withdraw and receive the income or corpus of a trust.
55823 �
Agent shaIl incur any liability to me,my estate,my heirs or assigns for permiEting rny
Agent to eYercise any such authority,nor shall any persar� �vho deals with my Agent be
responsible to determine or znsure the praper appIication of funds or praperty. Iv1y
successor Agent may execute and deiiver an affidavit that rny spouse as primary Agent
is unwilling or unable ta serve or to contir►ue #o serve, �nd such affi:davit shall be
conclusive evidence insofar as third parties are concerned of the facts set Eorth therein.
This Power of Attorn�y may be amended or revoked by me, and rny Agent may
be rernflved by rr�e at any time by the execution by me of a written instrument of
revacation,amendment, ar removal d�livered to my Agent, If this Pawer of Attorney
has been recarded in the pubiic records,then fihe instrument of revocatian, amendment
or remaval shall be filed ar recorded in the same public records.
My Agent is authorized to make photocapzes of this ins�rumene as frequently
and in such quanfity as my Agent shall d�em appropriate. AII photocopies shall have
the same force and effect as any originai,
-- �VIy Agenf shall.��}-be entitled to reeeive�reasonable�compensation;-��;
�y Agent shall be enhkled to reimbursement for actual expenses advanced on my
beha�f and #o reasonable expenses incur�red in connection with the performance of my
Agent's duties:�
This Power of Attorney shall revoke absolutely and immediatety any and all
pawers of attorney that I may have given to any other persons or legal entities.
This Power oE Attorney shall be governed hy the laws of the Conzrnonwealth of
Pennsylvania in aIl respects, inciuding its validity,construction,interpretation and
termination, and to the extent permifted by Iaw shall be applicabl�e to ali property of
mine wherever and in what�v�r state of the United States or foreign country the situs of
such property is at any time located and whether such property is now owned by me or
hereafter acquired by me or for me by my Agent.
IN WITNESS WHEI2EOF, I have hereunto set my hand and seal this f � day
of ��`�.
WTTNFSS: PRINCIPAL.
�.,� �'.�,, /,�'� �' ���u��,-...�
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sssa.� g
7. To make lirnited gifts.
8. To engage in tangible persanal prc�perty transactions.
9. Ta engage in stock, bond and other securities transactions, anci in
Commodziy and optian transactions.
�.0. To engage in banking and financial transactions.
11. To borraw money.
12. To enter sa#e deposit boxes. ,
13. To engag�in insurance transactions.
1�. To engage in retirement pIan transactions.
15. To handle interests in estates and trusts.
2b. To pursue�Iaims and litigation.
17, To receive governmenf benefits. �
18. To pursue tax matters. .
19. To authvrize my admission to a medical,nursing,residential or simiiar
facility and to enter inta agreements for rny care.
20. To aurhorize medical and surgical procedures.
�� �'21. To make an anatomical gift of all or part of rn��body�
1 �� `�22. Pflwer in my successor Agent to claim an elective share of the estate ot my
dereased spouse:�
THIS POWER OF ATTOItNEY SHALL NOT'BE AFFEC'TEI? SY MY
5UBSEQUENT DISABILITY OR INCAPACITY AI�TD SHAI.L N�T EXP�RE BY
REASON dF LAPSE OF TIME. No person who acts in good faith reliance upon any
representations my Agent rnay make as to{a) fhe fact that rny Agent's powers are�l�en
in effect, (b)the scope of my Agent's authority granted under t2us ins#rurnent, {c) my
competency at the tirne this Pawer of Attorn�y is executed, {d) the fact fhat this Power
of Attorney has not been revoked, or (e) the face that my Agent cc�ntinues to serve as my
55�23 2
-� ������-,����r�-� �
. COMMONWEALTH�F PENNSYLVANIA .
SS.
COUNTY C7F �•.�r�-��aer1�.;10� .
On this, the l�day o€��„�„�� ,,_, ' a l before me, the
und�rsigned o�ficer,personally appeared� �s'[�,�f�.���-�;n , known to me �or
satisfactvrily provenj ta be the person whose name is su.bscribed to ehe within
ins�rument as the Principal,and acknowledged that he executed the same for the
purposes therein contained.
IN WITNESS WHEREOF, I have her�unto set my hand and official seal.
' Notary Pu lic
C4AiMONWEALi'H 4�PENNSYLVANIA
Natatial SQaI
BeCsy A.Bamhart Nobry Publlt
Penbnook Baro,DauphC�County
My Commission ExRlres Jan.Z7,21124
Member,Pennsvivania ASsoaadon of Nebries
55823 �
,�.... ���,�o �. .r.� �
ACKNOWLEDGE�ENT OF AGENT
1
I, i 1�.��I_.,.have read the attached I'ower af At�orney and
am the persan identified as the agent far��/��I s �4 r.rh n (the"Principal"). I
hereby acknowledge that in the absence of a specific provision to the confrary in the
power o#attarney�r in T'rtle 2Q of the Pennsylvanza Consalidated Statutes wh�n I act as
agent: �
I shall exercise the powexs for the benefit af�11e P�incipaI.
I shali keep the assets of the Prin�ipal separate from my assets.
I shall exercise reasonable caution and prudenee.
I shall keep a full and accurate xecord of alI actions, receipts and
disbursements on behalf o#the Principal.
Gc.�..� �, b� ' I 7 / I r
ent: j v� ��h � Date
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, _ PI�WER OF ATTORNEY
Nt�TICE
THE PURPUSE OF'THIS POWER OF ATT�RNEY TS TO GI'VE T�]E PERSON YOU
DESIGNATE�YOUR"AGENT")BR�AD�'O"GVERS TO HANDLE YC}URPRt�PERTY,WHICH
MAY Il'�CLU1�E POWERS Tfl SELL OR QTI3ERV�ISE DISPaSE OF A�T''i' REAL OR
PERS4NALPRQFERTY'V4�ITHOUT AI�VANCE N(3T'ICE T(,7�OU+OR APPROVALBY YC)U.
THIS PO'WER 4F ATTpRNEY DOES N'aT IMF05E A DUTY t7N YOUR AGENT TO
EXER�ISE GRE�I�ITED Ft3WERS,BUT WHEN P(�R�'ERS ARE EXERCiSFi�,YOUR AGEIVT
MUS�USE DUE CAR�TO ACT FUR YOUR BENEFIT AND IN ACCORDANCE WTTH THIS
POWER OF ATT�RNEY, �
YOUR AGENT MA.Y EXERCISE TI-�E PO'WERS GIVEN"HERE TI�tOUGHOUT YC�UR
I.IFETIME, EVEN AFTER YQU BECflMME INCAPACITAT"ED, UNLESS YOU EXPRESSLY
LIM1'I' 'THE DURATIUN OF T�]�SE PUWEI�S OR YaU RE�OKE THESE P4WERS OR A
COURTACTING ON Y�.UR BEHALF TERMINATES YpUR AGENT'S AUTHOFITY.
YOUR AGENT MUST K�EP YOUR FUNDS SEP.ARATE FROM YQUR AGENT'S
FUNDS. '
r A COURT CAN TAT�E AWAY THE�I'O�V'ERS OF YOUR AGENT iF IT FTNDS YOUR
AGENT TS N�T ACI'IlVG PROPERLY.
THE POV�ERS AND DUT�S OF AN AGENT UNDER A POWER t3F ATTORNEY ARE
EXP�.�A.INED MORE FCTLLY IN 2U Pa.C.�.A. Ch.56.
IF T�RE IS ANYTHING ABOUT THIS FORM T'�-IAT YfJU Dt?NOT UNDERSTAND,
Y�U 5HOULD ASK A LAWYER OF YOUR OWN CHOQSING TQ EXPLAIN IT TfJ YOU.
I HAVE READ �R HAD EXPLAINED TO ME THIS NC)TTCE AND T UNDEI�STAND
ITS CONTENTS.
DA'TED: 0 ,2014
LIS DELL MAItZ`II�1
,�C,!���. KNOW ALL PERSOIVS BY E PRESENTS, that T, Phyllis Deil Martin, of 73e�1
C.l
�� �.�G771/�l
' , County, Pen�sylvania, ha�e made, constituted and appainted and do
- hereby make,const�tute and appoint Michelle J,I�uth my true aud Iawful agent and attorney-in-fact
- and surrogate to make health care and medica�tr�atment decisions for me. My agent may,for me
and in my name and on my behal.f,do and perform all matters and things,transact aIl business,make,
execute and acknowledge all contracts, orders,deeds,writings,assurar�ces and instnunents which
may be requisite or proper to effectuate any matter or thing appertaining or belonging to me,
including without limitation:
�1} t�l�.fY�lt f0 TTId�CO�if#S,
(ii} to create a trust fvr my benefit,
(ui) to make additiozxs to an exist�ng trust for my benefit,
(iv) to claim an elective share of the estate vf my deceas�d spouse,
(v) to disclaun any interest in property,
(vi) to reuoun�e fiduciazy positions,
(vu) to withdraw and receive the income or corpus af a trust,
{viii) to sell or transfer ownership of insurance golicies an my life, �
(ix) ta represent me in all matters involving�edera�, st�te,and 1oca1 t�es,
{x) to engaga in real pxoperry transact�ons,
(�i) to engage iu tangible personal praperty transa�kions,
(xii) to engage in stock,bond and other securities trausactions without res�rictions
' at brokerage finms or otherwise,
M (xiii) to engage in cammodity and aption transactions,
{xiv) ta engage in banking and�nancial transactions, �
(�) to borrow maneY,
(xvi) to enter safe deposit b�xes,
(xvii) to engage in insurance transactians,
(xviii) to engage in retirement plan transactions,
(�) to handie interests in estates and trusts,
(xx) to pursue ciaims and litiga.Uion,
(x�ci) to zeceive govemm�ent benefiits, a�zd
(xxii) to make an anatomical gift of all or part af my bady.
with the same powers,and to all intents and pwtposes with the same vaiidity as I could,if personally
present;hereby zatifyirig and confirn�ing whatsoever my agetzt shall and may do,by virfixe�ereof.
Tn addit�on,the agent appointed by this Power of Attomey shall be autharized to make health
care and medical decisions for me which shall includa,bat not be limited to t�.e follovving:
2
� ' 1. To authorize my admission to a medical,nursi.ng,residential or similar facility
and to enter into agreements for my care at the expense of my estate;
2. To�uthorize medical and surgical procedures;
3. To autlaorize the atiministratian of pain relieving drugs or other medical or
surgical procedures calculated to relieve my pain even Fhough theu use may lead to
permanent physzcal damage,addiction or even hasten the rnome�.#of{but not intentionally
cause} my death and ta authorize uncanventional pain relief #herapies whic� my agent
believes may be helpful to me;
4. To withhold consent to any medic�l care or treatment{including medical and
surgical grocedures);
� S. To revoke or change any consent previously given or implied by law for any
- medical care or treafiment(including medical and surgical procedures);
b. To arrange for my removal from any medical ar nursing facility; and
7. To grant,in conjunction with any instructions giv�n under this power,releases
fo hospitat staff,physiciaz�,nurses aud other medical a�d hospital administration personnel
who act i,zi reli�.nce on instruc�ions given by my agent or who render written opinions to rny
agent in connection wirth any matter described in tbis power from a111iability for damages
suffered or to be suffered by me; ta sign documents titled or peuporting to be a"Refusai tn
Permit Treatment"and"Leaving Hospitat Against 1Viedical Advice,"as well as any necessary
waivers of c�r releases frozu liability requirefl by any hospital or p�ysician ta imglement my
wishes regarding medical treatment ar non-treatment,
$. I intend for my agent to be treated as T would be with respect to my rights
3
. regarding the use and disclosure of my individualiy 'rde�ti�iable health information and/or
y other medical records,which I reco�nize my agent,frr�m tirne ta time,may require access to
in order to act an my behalf pursuant to this insmiment. This reIease authority applies,
,
without limitation,to any and all information,the dissemination t�f which is restricted by the
Heaith Insurance PortabiIity and Aecountability Act of 1996 (common�y refened to as
"HiPAA"),42 USC§ 1320d and 45 CFR§§160-164. To clarify my intent in this regard, I
specifically authorize any physieian, healthcare professional, dentist,health plan,hospital,
clinic,Iaboratary,pharmacy ar ot�er c�vered health care provider,any insurance company
and the Medicai Tnformation Bureau, Inc., ar any other health care ciearinghouse that has
pravided treatment or services tv me�r that has paid far nr is seelQng payment fram me for
such services(each a"Released Pariy"), to give, disclose and rel�ase to my agent,withflut
Iimitation, any and all of my individuaiiy identifiable health infarmation and/or medical
records pertaini.ng to any past,present or future medical or mental health condition. The
autiiority granted to my agent hereunder shall (i)supersede any prior agreement that T may
have made with a Released Party to restrict access to or disclosure of mp individually
_ � identifiable health r.are infonmation and/or med'zcal records,(ii)have na specified expiration
date and{iii) remain in full force and effect unless and unt31 T expressly advise a Released
Pariy of m�desire to revuke this release authority by delivering a written communiration that
zeferences this instrument by tit��and date of execution.
This Power of Attomey shail not be affected by any disability Qn my behalf, including the
event thaf T become incompetent to handle my affairs an8 shaIl survive such inca.pacitq.
Tn the event that legal proceedings concerning my incapacity,within the meaning of Chapter
54 of the Pennsylvania ProbaEe,Estates a�ad Fiduciazies�Code,ar for the appoin�neut of a guazdian of
my estate and/or person are commenced,I n�minate t�te agent appointed by this Power of Attomey
fbr consideration by the court having jurisdiction of those proceedi�gs for appointment as the
4
� r
�uardian af my estate and/or person, and�request th�court to make its appointment in accordance
with this nornination,excspt for good cause or disquatification.
My agent may delegate any one or more powers granted herein to one or more persons and an
such Eerms as the agent may designate and specify.
Tn the eveut that the agent appointed abave sball be unable,unwilling or cease to aet as my
agent, then I nominate,constitute and appoint Eric T.Huth as my agent.
IN WITNESS WF-�RE(�F,and intendiug to be legally bound hereby,T have hereunto set my
hand and seal this�r�ay of 014.
thi (���'�
�, ----� �����'���,(SEAL)
P LLIS DELL I+vIARTIN
����--
�����- n����n�
�
' CC}MMONWEALTH 4F P�NNSYLVANrA ;
� : SS.
�4UI�IZ`Y OF ���Q�-�' •
On this, the_ 10 day of �O , 2014, before me, the unders�gned officer,
persanally appeared PIIYLLIS DELL MAR ,who being�u�y sworn to law,deposes and
says that the foregoing power of Attorney is her act and deed and that she desires same to be
recorded as such.
IN WI'TNESS WHE ' +OF, � here�nta set my i�and an�natarial seal the day
and year aforesaid.
��
,CO#�thtONWFJkL7N OF PENNSYCYXfiU NOTARY UBLIC
ftOt'dtW� 5ea)
; Betsy A. Barnhatt,Notary Publ�c
1�test tornwatl 1'wg., lebanon Counry � a-t a�t$
��E�� . �y Cornm�sslan Explrrs 3an. z�, zois My Commission Expizes: a �
����in.�tu rrvti��ivaNi+►�ssaCtaTlot�ofNa�avF�. .
` ACKNOWLEDGMENT
I, MICHELLE J. HI7TH, have read the attached Power of Attorney and am the
person identified as the agent for the principal. I hereby acknowledge that in the absence of a
specific prvvisian to the contrary in t�e Power of Attomey or ir�ZO Pa.C.S.A. when i act as
agent:
l. I shall exercise the powers far the benefit o�tihe principal.
2. I shall keep the assets of tlie pxinczpa�segarace firom my assets.
3. I shall exercise reasanabie cautian and prudence�.
4. �shall keep a full and ac,cwrate record of all activns,receipts and disbursements
an belaalf of the principal.
DATE: �� �/D . 2014 �
MICHELLE J. HUTH
6
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. ;.
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� �ssiaH� - CC�i�SULTAT�C)N R��QUEST FC��'M
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at MESSIAH VILLAGE Room Numbe�; "��
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���Ml,Al1en Dmre PCP. ��y W ��
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(717}6g7.�4.ss6 Cons�Itan�/Physician: �� -
Special�y: S t,�-
Date of ConsultaGon. � � ��
New �ledicat�on Cirders
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�`�� � Resident Name:
at M�SSIAH VILLAGE
Enhanced Livir�glP+ersanal Care Home Room Number:
100 M#.AIlen Drive PCP:
Mechanicsburg,Pennsylvania 17t�5
(?17)59�-4ss6 � Consul#ant/Physician;
�pecia�ty:
Date of Consultatir�n:
� New Medicatian Orders
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
1N THE MATTER OF :
PHYLLIS DELL MARTIN, : No.
An Alleged Incapacitated Person :
DEPOSITION OF INDIVIDUAL QUALIFIED TO RENDER OPINION AS TO
INCAPACITATION
This written deposition of Jennifer Weber, D.O., a witness in this matter, is taken on the ��
day of May 2015, at Messiah Lifeways, 100 Mt. Allen Drive, Mechanicsburg, Pennsylvania
17055.
1. Please state your name and your professional address.
� e-n n� .�' t�2�4�-e.f' 1�-C�
� U v (yl�- � � �-� � ��--
�(.GC�-�t � cS �i�� �� l ��
/
2. Please describe your education, training and background with particular emphasis on
your expertise in evaluation of individuals with incapacities OR attach to this written deposition
your curriculum vitae.
'�— GY� J��o-.�aC C'1-���� �h F�i�'�' /'�'t���c-c,
� �� � ���
.�n 4 ��9� ` �y `� �
o� �v�.��s .�� � z� s
G�� -
560634v1
3. In your professional capacity, have you had the opportunity to meet with, examine, speak
with or otherwise become acquainted with Phyllis Dell Martin?
If yes,please state the following:
I first became acquainted with Phyllis Dell Martin on Z Ll y � ► 1 ,
when she was brought to my attention by /�-�SS�ct Li Lc �� s ����.�o
Gz���r,e CC��.
I have since isi � ok n with med or treate her on /rt a rt y other
(circ e app icable contac s ,
occasions with an average frequency of S�—� times per l�-��
day/week/month/year).
4. Please evaluate the present condition of this patient with respect to incapacities of the
type alleged in the Petition for Adjudication of Incapacity. In particular, please comment on the
nature and extent of the alleged incapacities and disabilities and also, insofar as you are able, the
mental, emotional and physical condition, adaptive behavior, and her social skills.
Based upon my education, training and experience, as well as my acquaintance with this
patient, it is my opinion,to a reasonable degree of inedical certainty, that her incapacities are as
follows:
Mental condition
���/j'lei��2 /�qT C+�i�-yull.�C � �.,�� �S�e G!?ulu y
/
c�r/a�u.c��i�— �
Emotional condition
�t-G� /j?o aci/ !S �-���'✓ � S/� � GZ�d' "'y �
�,�� fs«.
560634v1 2
. . .. . .. . . . . ... �i u � ■■ . .... .
Physical condition
Gv� �ri.�i���� /�c�,o���e,�s��.1.. �� �a
�- ,�Ze-c,e,�,�"
Adaptive behavior
_S -� �U!-� 2�/� ac�a, o�w�� l�l� .e.S . cs/�c�.e �S
/h � —'4�*i''r�c.t-�d sG�x� �s�. �+-�S' c�-c `.�,�¢,
Social skills J
,�,(�e .s so C�.��.� a/�/IX-e�/�� � � �S'/�
.�-C-G G��a/L° ...C// ✓i r'�'.y� /��'1�G.�� , u
��
5. Based upon your education,training and experience, and your contacts with this patient,
do you have an opinion, to a reasonable degree of inedical certainty, whether she is impaired in
her ability to effectively receive and evaluate information and to make and communicate
decisions in any way?
If yes,please explain your opinion.
""�S • .��-
.��� Gfd,ce iz.�� ��a.� �-e �a�e ��
,G�,rn� /Jo�4 — cz ��« u���-, � hor� Sk..�
�
�.��� A- cl�.s� .� L��,s�-�.� . .�.5lu
`.�GZev�
Some ax_c �.:e�J a/o.� n d.� �n� �Li o ,
��� w� � ����
„ � ,� .��.�,.�h�.� ���
�,(� �s��►�s �"'�
�•� :' � .���l�s
�..� /�.eurr���y��i G 1�y �✓�u..� �
��s-� ,�,�,�s
560634v1 3
6. If you are of the opinion that she is impaired in her ability to effectively receive and
evaluate information and to make and communicate decisions in any way, does such impairment
render her either partially or totally unable to manage her financial resources?
If yes, check whether such impairment renders her:
Partially unable,to manage her own finances
_��Totally unable to manage her own finance.
Please explain your opinion. �� %��G���S y ��.
��� �.Gso�'" �
7. If you are of the opinion that she is impaired in her ability to effectively receive and
evaluate information and make and communicate decisions in any way, does such impairment
render her either partially or totally unable to meet the essential requirements for her physical
health and safety?
If yes, check whether such impairment renders her:
Partially unable to meet essential requirements for her physical health and safety,
� Totally unable to meet essential requirements for her physical health and safety?
Please explain your opinion.
� .����Y�.�,IU�y -Q-�� ,
560634v1 4
8. Please provide an assessment of the severity of any impairments of this patient.
�G. G� �, ¢ �.�� �.� �ta�-��u�Sy�ha�f'�
G��� . `'
Imnairment (Circle one)
a) mild moderate severe
b) mild moderate severe
�) mild moderate severe
d) mild moderate severe
e) mild moderate severe
� mild moderate severe
g) mild moderate severe
h) mild moderate severe
9. Is the condition of this patient such that because of his/her condition, he/she would be
susceptible to undue influence by unscrupulous or designing persons? 1,�e� ,
�
If so, what services or assistance would you recommend as necessary to appropriate
management of this patient's finances? � �Qa� �'�,�L� /�Z a�a� �n-��,
10. What services or assistance would you recommend as necessary to meeting the health
and safety needs of this patient? `�/�c.
�� � � � � a' �S'�/��JoyS�i��... �;+r�S'�x.�� ��'�
��� � �c„�.�. � so �i �-
`�;E-� 'S �
a.� �.s ��"� �,r���-��.
✓� �'.c2ir e.�a�
S� ��-� Q- ��-
�
� o�`�`�S -
560634v1 5
. . . . . . . . . ... . .. �i u .� ■■ . .. .. . .
11. Are the services or assistance recommended the least restrictive alternatives?
Does the patient need the services of the guardian to make decisions regarding the
patient's healthcare, safety and financial resources? In other words, could the patient
evaluate, communicate and make decisions regarding her health treatment, safety and
financial resources in important matters without the guardian?
If not, please explain why less restrictive alternatives are inappropriate.
„�`7� G�o ea y�� �.o�✓�c �'� '�
JyZ2<� :.� cyCP�c�S<uc_-S ,
12. Based upon your education, training, experience and familiarity with this patient, what is
your opinion as to the likelihood that the degree of incapacitation will significantly change?
�� W/// �a� i r�'l�J.��/'� G�.�Gt° i�� L�c:,r�� �
�Q C-�-� s�_
13. Would the physical or mental condition of this patient be harmed by her presence in open
court? NOTE: Pennsylvania law, 20 Pa.C.S. §5511(a)(1), requires that the alleged incapacitated
person be present at the hearing unless a physician or licensed psychologist provides by
deposition, testimony or sworn statements, an opinion that her physical or mental condition
would be harmed by her presence in court. If yes, please explain.
�� GJ!'iwLc! �� �1 Clirh �1� � �-a V-•� �c C.�z�/�'�,
Gai2Gz�-G1S7�.�� �/'�-�-��C�eoC„tp� .
��G !�1 l/ /1�/� cI
560634v1 6
,
VERIFICATION
I, Jennifer Weber, D.O., verify that the statements made in the foregoing deposition are
true and correct to the best of my knowledge, information and belief. I understand that the
statements herein are subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn
falsification to authorities.
� \
re of Depon
Dated: �L�`/�
560634v1 7
. . . . . .... .. .. . .... . . . .. ... . �i e � ■• .
��HAR�T11+1G FflR: 511/2015 T�HROUGH: 5133!2�i15 PNY�.�I�'l��,C�';�C)F?�)E!��
� � � ` �
� Routine Orders - ALLERGIES -
SHELLFISH�IODINE�CORTISONE�
- DIAGNOSIS -
5/5/2015 DX: PAIN,HTN-LVH, LAHB, RBBB, PAIN,HTN-LVH, LAHB, RBBB,
' STOP/END DATE-05/06/2015 09:30AM NEUROPATHY, VITAMIN D DE, FICIENCY, R HAND CELLULITIS,
'AMOXICILLIN 500 MG OAB, GERD, DEMENTIA, P5EUD0 GOU, T
TAKE 4 CAPSULES(2000MG)BY MOUTH 1
HOUR BEFORE DENTAL APPOINTMENT
[TAKE AT 9:20AM ON 5/5/15]
�PROPHYLAXIS)
UROSEMIDE 40MG 4/10/2014
Generic for:LASIX 40 MG 08:OOAM
TAKE 1 TABLET BY MOUTH DAILY.
(HYPERTENSION)
GABAPENTIN 400 MG 5/18/2013
TAKE 1 CAPSULE BY MOUTH AT 08:OOPM
BEDTIME.(PAIN)
LISINOPRIL 2.5 MG 8/17/2012
TAKE 1 TABLET BY MOUTH DAILY. 08:OOAM
(HYPERTENSION)
LORATADINE 10 MG 9/11/2012
Generic for:CLARITIN 10MG TABLET 08:OOAM
TAKE 1 TABLET BY MOUTH DAILY.
(ALLERGIES)
OMEPRAZOLE 20 MG CAP 6/5/2013
Generic for:PRILOSEC 20 MG CAPSULE DR 08:OOAM
TAKE 1 CAPSULE BY MOUTH DAILY
' (GERD)*DO NOT CRUSH`
VITAL SIGNS 2/25/2012
, CHECK VITAL SIGNS EVERY MONTH 3-11
' B/P
PULSE
' RESP
TEMP
UNDEFINED
Pharmacy is authorized to dispense generics,assign quantities,and refill RX's PRN. CII'S Require a New RX.
' REVIEWED BY: PHYSICIAN'S SIGNATURE: REVIEWED BY:
Date: Date: Date:
Physician:JENNIFER WEBER Telephone No:
Alt Physician: Alt Telephone: DOB:7/7/1925
' Medical Record No:021105 . Medicaid#: Medicare#:
PATIENT ROOM NO. BED: FACILITY CODE
, PATIENT:PHYLLIS MARTW : CODE: MARTP1 435 A Messiah Village-
Assisted
Report Run:5/28/2015 9:50:41 PM Prepared By:AccuFlo Page: 1
�CFi�RTii�1G FOR:5/1I2015 TNROUGN: 5131/2fl15 PNYSIC1�aE�!'S .��F�E:�ERS
�m • o ' ��
� 'VITAMIN D3 1,000 UNITS TAB 11/6/2012 '
' : TAKE 1 TABLET BY MOUTH DAILY. ' 08:OOAM
, (SUPPLEMENT)
WEIGHT 2/25/2012
CHECK WEIGHT MONTHLY 7_3
' WEIGHT
PRN Orders
:ACETAMINOPHEN 325 MG 2/14/2011
Generic for:TYLENOL 325MG
TAKE 2 TABLETS(650MG)BY MOUTH
EVERY 4 HOURS AS NEEDED FOR MILD
PAIN/TEMP>100*MAX 4GM/DAY*
AMOXICILLIN 500 MG 9/18/2014
TAKE 4 CAPSULES(2000MG) BY MOUTH 1
' HOUR BEFORE DENTAL APPOINTMENT
(PROPHYLAXIS)
BLINK TEARS 7/29/2014
INSTILL 1 DROP IN BOTH EYES AS
; NEEDED FOR DRY EYES
DOCUSATE SODIUM 100MG 11/30/2012
Generic for:COLACE 100 MG CAPSULE
TAKE 1 CAPSULE BY MOUTH DAILY AS
NEEDED FOR CONSTIPATION
GUAIFENESIN 100 MG/5 ML SYR 7/1/2014
Generic for:ROBITUSSIN 100MG/5ML SYRU
' TAKE 10ML BY MOUTH 4 TIMES DAILY
AS NEEDED FOR COUGH.
HYDROCOD-APAP 5-325MG 4/10/2014
Generic for: NORCO 5-325 TABLET
TAKE 1 TABLET BY MOUTH EVERY 6
HOURS AS NEEDED FOR MODERATE
PAIN."*MAX 4GM APAP/DAY*'
Pharmacy is authorized to dispense generics,assign quantities,and refill RX's PRN. CII'S Require a New RX.
REVIEWED BY: PHYSICIAN'S SIGNATURE: REVIEWED BY:
':Date: Date: Date:
' Physician:JENNIFER WEBER Telephone No:
Alt Physician: Alt Telephone: DOB:7/7/1925
Medical Record No:021105 Medicaid#: Medicare#:
PATIENT ROOM NO. BED: FACILITY CODE
PATIENT: PHYLLIS MARTIN CODE: MARTP1 435 A Messiah Village-
Assisted
Report Run:5/28/2015 9:50:42 PM Prepared By:AccuFlo Page:2
�CHAR.TI�lG FO�t:5l112015 TF{ROUGH:513�/2�15 PNY�IC�A(�:'�vRC�EF'S
� s �s �
IBUPROFEN 200 MG 6/28/2014
' ' Generic for.ADVIL 200MG
TAKE 1 TABLET BY MOUTH EVERY 4
' HOURS AS NEEDED FOR PAIN
IPRATR-ALBUTEROL 0.5-3 MG/3 12/18/2014
Generic for: DUONEB 2.5-0.5 MG l3ML SOLN
USE 1 VIAL IN NEBULIZER EVERY 2
HOURS AS NEEDED FOR SHORTNESS OF
BREATH.
MILK OF MAGNESIA SUSP 4/10/2014
' Generic for: PHILLIPS'ORIG MOM
' TAKE 30ML BY MOUTH DAILY AS NEEDED
' FOR CONSTIPATION.
PNEUMOVAX 0.5ML SDVIAL 2/14/2011
5/11
Pharmacy is authorized to dispense generics,assign quantities,and refill RX's PRN. CII'S Require a New RX.
REVIEWED BY: PHYSICIAN'S SIGNATURE: REVIEWED BY:
Date: Date: Date:
' Physician:JENNIFER WEBER ' Telephone No:
Alt Physician: Alt Telephone: DOB:7/7/1925
Medical Record No:021105 Medicaid#: Medicare#:
PATIENT ROOM NO. BED: FACILITY CODE
PATIENT: PHYLLIS MARTIN CODE:MARTP1 435 A Messiah Village-
Assisted
Report Run:5/28/2015 9:50:42 PM Prepared By:AccuFlo Page:3
.� ' Vitals Report
From: 3/1/2015 To: 5/28/2015
FaCility: Messiah Village-Assisted
Building: Wing: T
Recipient: MARTIN, PHYLLIS Room: 435-A
B/P
Entered Resuit By Entered Result By Entered Result By
03/25 16:00 136/78 cmc
Entered Result By Entered Result By Entered Result By
04/25 16:36 120/50 djr
Entered Result By Entered Result By Entered Result By
05/25 16:34 110/62 bvh
Puise
Entered Result By Entered Result By Entered Result By
03/25 16:00 84 cmc
Entered Result By Entered Result By Entered Result By
04/25 16:36 75 djr
Entered Result By Entered Result By Entered Result By
05/25 16:34 68 bvh
RESP
Entered Result By Entered Result By Entered Result By
03/25 16:00 20 cmc
Entered Result By Entered Result By Entered Result By
04/25 16:36 20 djr
Entered Result By Entered Result By Entered Result By
05/25 16:34 16 bvh
TEMP
Entered Resuit By Entered Result By Entered Result By
03/25 16:00 98.4 cmc
Entered Result By Entered Result By Entered Result By
04/25 16:36 98.6 djr
Entered Result By Entered Result By Entered Result By
05/25 16:34 97.6 bvh
WEIGHT
Entered Result By Entered Result By
04/25 11:54 145.8 dmh
Entered Result By Entered Result By
05/25 10:32 143.8 bvh
Report Run: Thursday,May 28,2015 9:51:29 PM Prepared By:AccuFlo Page 1 of 1
, � � M E S S I A H CONSU LTATION REQUEST FORM
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�- at MESSIAH VILLAGE Room Number: "�.3
Enhanced Living/Personaf Care Home
. 100 Mt.Alfen Drirre pCp, ��', ��,j,Q,�'
. Mechanicsburg, Pennsytvania 17055 �
(717�697-4666 ConsultantlPhysician:� - �'� ��
Specialty: 'v�
� Da#e of Consultation: `� �� � ��
� I�e�r A�edica�on Orders
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� Additional Ord rs/R mmendations
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•
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY,PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE MATTER OF :
PHYLLIS DELL MARTIN, :
An Alleged Incapacitated Person : No.
CONSENT OF THE PROPOSED GUARDIAN OF THF PERSON AND ESTATE
I, Constance Stoneroad, on behalf of Keystone Guardianship Services ("Keystone"), do
hereby consent to the appointment of Keystone as the Plenary Guardian of the Person and Estate
of Phyllis Dell Martin, an alleged incapacitated person, if so appointed by the Court.
I understand that if Keystone is appointed as guardian, Keystone will be serving for the
benefit of Phyllis Dell Martin, an alleged incapacitated person, and I affirm that Keystone will
act in her best interests at all times.
I further understand that if Keystone is appointed as Guardian of the Estate, it is
accepting fiduciary responsibility for the financial affairs of Phyllis Dell Martin, an alleged
incapacitated person, and will be required to report to the Orphans' Court Division with regard to
these financial affairs and personal affairs on an annual basis.
I certify that neither I nor Keystone is a fiduciary of any estate in which Phyllis Dell
Martin has an interest. I certify that neither I nor Keystone has a�1 interest which is adverse to
Phyllis Dell Martin.
� a,o/S ��.,�¢. �
ate eystone Guardianship Services
Constance E. Stoneroad, President
571597v1
RECEIPT FOR PAYMENT
LISA M. GRAYSON, ESQ. Receipt Date : 6/16/2015
Cumberland County - Register Of Wills Receipt Time : 11 : 53 : 07
One Courthouse S quare Receipt No. : 1081670
Carlisle, PA 17613
PARR JOHN R
Estate File No. : 2015-00545
Paid By Remarks : BRINSER WAGNER & ZIMMERMAN
DMB
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
BOND 15 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 5300 $15 . 00
Total Received. . . . . . . . . $15 . 00
� i c � ■■ �
RECEIPT FOR PAYMENT
-------------------
-------------------
LISA M. GRAYSON, ESQ. Receipt Date : 6/16/2015
Cumberland County - Orphans Court Receipt Time : 11 : 56 : 17
One Courthouse S quare Receipt No. : 1058264
Carlisle, PA 17613-3387
MARTIN PHYLLIS DEAN
File Number: 2015-00671
Paid By Remarks : LATSHA DAVIS & MCKENNA PC
HMW
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION 15 . 00 CUMBERLAND COUNTY GENERAL FUN
CITATION 20 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 35 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 14540 $75 . 50
Total Received. . . . . . . . . $75 . 50