HomeMy WebLinkAbout12-12-78
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A F F I D A V I T
COIII)IWI<R or PlNNS1'LVQU I
S8
comrrr or CRISTa I
I, Stephan C. Mann. M.D.
to law, depose and say that: _
, being duly sworn according
1. I am a duly licensed physician under the laws of the State of
Pennsylvania and was licensed in the year 1974 .
2. I have engaged in the practice of medic:ine.since 1973
3. I am a graduate of Thomas Jefferson University
Medical School located at Philadelph~a, Pennsylvania
.
4. I have specialized in psychiatry since 1973
position is Staff Psychiatrist
Administration Hospital, Coatesville, Pennsylvania.
and that my present
at the Veterans
5. I e"amined John W. Ellenberger , SSfl187 16 6331
an inpatient at V.A. Medical Center, Coatesville, Pennsylvania
on November 24, 1978
6.
Ellenberger
~~ diagnosis of the mental condition of the said
is as follows:
John W.
Schizophrenia, hebephrenic type. Mr. Ellenberger is grossly psychotic
and obviously incompetent because of his severely regressed state.
7.
Ellenberger
The prognosis of the condition of the said John W.
is as fo llows:
Prognosis for improvement is poor.
8. As a result of his mental condition, it is my opinion that the
s~~d. John W. Ellenberger is liable to lose and dissipate
~ property and is apt to become the victim of des1.gning persons.
9. The welfare of the said John W. Ellenberger
be promoted by his presence in Court.
will not
S" 'l'O ARD s.-~:
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of ' :A' -v 19ZZ
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.. C.I 1_1011. baf._~y PUBLIC
ELLEN T. BR~ , NTY
CALN TOWNSHNIPE'Xpclr~~~T~~vC~~, 1981
MY COMMISSIO ......
" \ aniaAssociationofNotan-
Member,Penn,y v
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STEPHAN C. MANN, M.D.
~~ [}J;M-~ :5
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Standard Form 513 (10-751
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FPMA 101.11.10&.'
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CONSULTATION SHEET
REQUEST
lFROM: IR,qm;~g~~, .n.t,o~ Gd~tyJ -. . ~=-I DAle ~;~~U;!~. ..____
CLINICAL RECORD
TO:
Psychiatry Consult
_ .._________ .J,.._.._
AEASON FaA REQUESl ICorllp""." ..d /i.d.ng,)
X Please evaluate the form attached to this consult. We would like the
psychiatrist to come and evaluate Mr. Ellenberger. the information is
going to be IKKIXI used in a court hearing.
PROVISIONAL DIAGNOSIS
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PLACE OF CONSULTATION
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CONSULTATION REPORT
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PATIEN llEpO-lFICATION REGISTER NO.
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CONSULTATION SHEET
Standard Form 513
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513-106-01
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A F F I D A V I T 0 F S E R V ICE
COMM:>N101EALTH OF PENNSYLVANIA:
53
COUNTY OF CHESTER
I,
Mary A. Thomas
, being duly sworn
according to law, depose and say that 1 am an associate of the Veterans
Administration Hospital, Coatesville, Pennsylvania, as Medical Adminis-
tration Specialist
and that on the 11th
day 0 f December
19z.a
at 2:50 p.m., E.S.T.
1 served on John W. Ellenberger
an inpatient at V.A. Medical Center, Coatesville, Pennsylvania
Citation to show cause why
by reading to him and handing to him a copy of ~~~
he should not be declared incomoetent
and a copy of Notice of Hearing
on the same to be held on the 11th day of January 79 at 1:30 p.m. ,E.S.T.
before the Orphans Court Div., Court of Common Pleas of Cumberland County,
Pennsylvania, Court RID. 2, Cumberland County Courthouse, Carlisle, Pa.
~ . - I
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MAR A. HOMAS
SWORN TO AND SUBSCRIBED:
:Before me this /;2 ~:>ay:
of ~ 191f.
~-~j.~
Notary .public
My Commission Expires:
ER NOTARY PUBLIC
ELLEN T. BRENIS. TER COUNTY
CALN TOWNSHIP, ~I~~~ NOV. 30.1981
MY COMMISSION ~ AssociationofNotaritl
Member. Pennsylvania
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