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HomeMy WebLinkAbout06-29-15 (2) ANNUAL REPORT OF GUARDIAN OF THE PERSON ry r Q COURT OF COMMON PLEAS OF r=r ` 3 X r71 CUMBERLAND COUNTY, PENNSYLVANIA on ORPHANS' COURT DIVISION ru rn -, Cry Estate of 4Z4, , an Incapacitated Person No. J ou -t4LO I. INTRODUCTION y� was appointed Plenary 0 Limited Guardian of the Person by Decree of -j, dated u n k— 3o, 2,o o(o This is the Annual Report for the period from )7�A- to u n-`. cg©, 6 /S'--(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 1 of 4 Estate of dG�n , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: Q Date of Birth: 's-e.P 1 q III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: P0- 7 o so B. The Incapacitated Person's residence is: E]own home/apartment nursing home 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 sinceC. 0 If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: Form G-03 rev. 10.13.06 Page 2 of 4 Y Estate of Jo /" y�— � , 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: Jo" l/1 C�, o4lr rz g e ys on o e-s L i' �' TT day SeQv i cess Aov, - r-/, r p; yak n up ry E)s4- we)ew-e�n d s (5q-+- 0-k- SU- � r,,, d► r — +- s 1,�p o,'v,'� - �-a v i s �- In,s V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: continue 0 be modified El be terminated Form G-03 rev. 10.13.06 Page 3 of 4 Estate of a 4 e� , 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 lastingl" 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 Signature of Guardian of th/e�Person Name of Guardian of the Person(type or print) Address Z&�l 6" P, City,State,Zip ?l? r> 23 4? Telephone Form G-03 rev. 10.13.06 Page 4 of 4