HomeMy WebLinkAbout03-24-06
IN RE CHARLES W. OVERTON,
An Alleged Incapacitated Person
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY PENNSYLVANIA
CIVIL DOCKET NO.: Ola ~$7
ORPHANS' COURT DIVISION
(--)
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PETITION FOR APPOINTMENT OF EMERGENCY GUARDIAN
AND NOW, comes the petitioner, Helena Train, by and through ABOM & :KJ1~LAIQ;~,
} ..
C,J
L.L.P., and files this Petition pursuant to Title 20 Pa.C.S.A. ~ 5513 and in support thereof avers lite
following:
1. The alleged incapacitated person is Charles W. Overton (hereinafter "Overton"), date of
birth is January, 9, 1915, with a former address of 11180 Rivercrest Drive, Little Rock,
Arkansas. Overton is currently a resident of Loyalton of Creekview, 1100 Grandon Way,
Mechanicsburg, Cumberland County, Pennsylvania.
2. Petitioner is Helena Train (hereinafter ''Petitioner'') of 3802 Dorset Drive Mechanicsburg,
Cumberland County, Pennsylvania.
3. Petitioner is the daughter of Overton.
4. Overton was predeceased by his wife, Patricia Overton, on July 31, 2005.
5. Petitioner is legally qualified and suitable to be Guardian of the Person and Estate of
Overton.
6. Overton was diagnosed by Doctor Yolanda Agredano in California on March 17, 2006 with
demential Alzheimer's disease. (See Diagnosis labeled Exhibit "A.")
7. Overton is incapacitated by this mental disease to the extent that he lacks sufficient
understanding or capacity to make or communicate decisions to meet the essential
requirements for his health or safety or to manage his estate.
8. Overton was removed from his home by Bill Webster in late February.
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9. Bill Webster is a biological son of Overton with Overton's Erst wife. After Overton and
mother of Mr. \Vebster divorced, she was remarried. Her new husband adopted Mr.
Webster, which terminated Overton's parental rights and responsibilities.
10. Bill Webster renloved Overton from Arkansas without giving notice to either of Overton's
children, who ate Helena Train and Charles Overton.
11. Bill Webster had Overton involuntarily committed to a VA hospital in California on
February 28, 2006. The involuntary commitment lasted 72 hours.
12. Overton "voluntarily" committed himself for an additional 14 days on March 3, 2006.
13. Once Petitioner became aware of Overton's location, she traveled to California and brought
him to Pennsylvania.
14. Overton was placed in the Loyalton of Creekview in Mechanicsburg, Pennsylvania on March
21, 2006 in the dementia unit.
15. Emergency guardianship is sought for the purpose of promoting and protecting the well-
being of the person and property of Overton.
16. Petitioner requests an emergency general guardianship of the person because there is
imminent danger to the life or health of Overton and imminent danger to Overton's
property .
17. Petitioner is unable to access Overton's personal accounts or information.
18. It is believed and therefore averred that Overton has not been paying many of his bills and
this may cause damage to his property. (See copy of one past due bill labeled exhibit "B" and
please note that this bill was paid by Petitioner to avoid disconnection.)
19. It is believed and therefore averred that damage to or loss of Overton's property may occur
if an emergency guardian is not appointed to handle these outstanding financial matters.
20. It is believed and therefore averred that Mr. Webster may have access to certain personal
property of Overton and it is unknown if he has disposed of any of Overton's assets.
21. Overton has a cat and a dog that have been left in a kennel in Arkansas and these animals
need to be brought to Pennsylvania.
22. It is believed and therefore averred that imminent harm may occur to Overton's real and
personal property if an emergency guardian is not appointed to handle his financial affairs.
23. It is believed and therefore averred that imminent harm may occur to Overton's life and
health if an emergency guardian is not appointed to handle his medical matters.
24. Insofar as Petitioner is able to ascertain, Overton's assets and income consist of the
following:
a. A bank account, certificate of deposit, personal vehicle, furniture and personal
possessions with a combined total value in excess of $50,000;
b. Pension and retirement benefits totaling approximately $6000 per month;
c. Home located at 1180 Rivercrest Drive, Little Rock, Arkansas, value unknown;
d. And potential assets of the Estate of Patricia Overton, Overton's deceased wife,
value unknown, which have not been probated.
25. There is presently no Guardian of the Person or Estate for Overton.
26. There is presently no known Power of Attorneys for Overton.
27. Insofar as the Petitioner has been able to ascertain, the persons who are heirs under the
intestacy statute in Pennsylvania are:
Name
Charles Overton, Son
Address
c/o Linda Overton, Guardian
85 Gay Street, Salisburg, Pennsylvania 15558
Helena Train, Daughter
3802 Dorset Drive,
Mechanicsburg, Pennsylvania 17050
Each of the above will be notified of these proceedings
28. The following-named agency from which Overton is receiving assistance will be notified of
the proceedings: Loyalton of Creekview, 1100 Grandon Way, Mechanicsburg, Pennsylvania
17055
WHEREFORE, in order to prevent irreparable harm to the estate and health of the alleged
incapacitated person, Petitioner respectfully requests that a guardian be appointed and be given the
general power by this Court to include but not be limited to the ability to investigate and handle
outstanding fmancial matters for Overton, to travel to Arkansas and handle the outstanding personal
affairs on the behalf of ()verton, and to make important medical and general health decisions for
Overton.
Respectfully Submitted,
ABOM & KUTULAKI5, L.L.P.
~'~v~
ate
J aso . Kutu s, Esquire
Au mey 1.0. No. 80411
36 South Hanover Street
Carlisle, P A 17013
(717) 249-0900
Attorney for Petitioner
VERIFICATION
I, HELENA TltAIN, hereby verify that the statements contained in this complaint are true
and correct to the best of my knowledge, information, and belief. I understand that false statements
herein are made subject to the penalties of 18 Pa.C.S. ~ 4904, relating to unsworn falsification to
authorities.
~\d.1l.;200 Cp
Date
~Jr~
HELENA TRAIN
STATEMENT OF THE GUARDIAN
(1) I, Helena Train, the proposed guardian, am an individual. I am a citizen of the
United States of Am.erica, and I able to speak, read and write the English Language.
(2) I, Helena Train, am not proposing that I, the proposed guardian, and the alleged
incapacitated person reside in the same household.
(3)1, Helena Train, am not the Fiduciary or an officer or employee of a corporate
Fiduciary of an estate in which the alleged incapacitated person has an interest nor the
surety or an officer or an employee of the corporate surety of such a Fiduciary, and
that the proposed guardian has no interest adverse the alleged incapacitated person.
3'(o.~. 300<p
DATE
dJe1Qu.-~~
HELENA TRAIN
:,': 1\ n. Of' CALlFnf;rNI^ . HEAL Tf-! NW f-IlJr,l/'.N : :FH"'f'CE~-; ,..CENCY
(~i\L1r("lf"~NIA !jU'!\,(TMLNi' i)!' -~")C;d :,[CP'j
PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILiTIES FOR THE ELDERLY (f~CFE)
I. FACILITY INFORMATION (To be cOfnpleted by the licensee/designee)
1. NAME OF FACILITY
...-:._t'~'7";'-\-r . Or' ~ t--:
Bt\ fJZl' e f'-' vl fh~i6rL"""-'~J \ .
3. AOO'RESS" ...-.
f I~
-?~?:~~___.___'~5 4. ..f-ve'J~~-'-"- .
4. LICENSEE'S 'NAME
~ ..=-... = : ('/1- lo/t7 -g 4 e '5( f3 I i<J?
---=\~ittvlt~(J... \ V {{(~c)\'L : '-1v'\'J , / . -(It} t.~) II '-. .
II. RESIDENT/PATIENT INFORMATION (To be con1pJeted by the resident/resident's responsible persol
1. NAME 12. BIRTH DATE : 3. AGE
C\v.~~il O\!e~L-\t\~ ! / Cf. 15 i q/
III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
(To be completed by resident/resident's legal representative)
CITY
'2. TELEPHONE
. (r.f(;;L<;" ) L;~ S/~~/ I. ~
ZIP CODE .
V~~.i2...fY~~ ~__ .. }.._uC:.._ ~~-
.-' i 5. TELEPHONE
c:'
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6. FAt,LrfYLlcENSE NuMBl
, hereby authorize release of medical information in this report to the facility named abovE
1. SiGNATD"f~E"(5"F"RES1DENt):iJ~-D7oR'R'E'S-f15ENf's[EGAL lrEPR-ESENrAffvE'
2. ADDRESS
)3. DATE
i
,
_.L _
IV. PATIENT'S DIAGNOSIS (To be completed by the physician)
1. D J"E 9f EXf'M
'OJ OlL)
6. TU ER ULOSIS (T8) TEST
~r~~'~~iven Ib]t;t~totbea-d.,.c...?r~ Te~t.
NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of
residential care facility for the elderly licensed by the Department of Social Services. The license requirE
the facility to provide primarily non-medical care and supervision to meet the needs of that persol
THESE FACILITIES DO NOT PROVIDE SKILLED NURSING CARE. The information that you provic
about this person is required by law to assist in determining whether the person is appropriate for care i
this non-medical facility. It is important that all qu.estions be answered.
(Please attach separate pages if needed.)
..-- --... -.--- ----.. '''''---. n. .... ...... >._-- .---.-- _n._ -.--.---. r----"- - _'h . -.-
i2. SEX
I ~V\Clik
!35 ~EIGHT!4i~~~~;Ht- JS:u ~i~7;~ESSURE
, -
?6;PI ase Check if TB Test is
'-- j gative . Positive
-'--------- --- --. ---- ... - - ..-
e. Results: mm _ 66__________ f. Action Taken (if positive): ________________________________
---------------------------------------------------------------------------------
g. Chest X-ray Results: __________________________________________________________
h. Please Check One of the Following:
:J Active TB Disease Latent TB Infection ~o Evidence of TB Infection or Disease
: '",_:-_-.:c..;=-.::~=_' C:..==-:'::. - -'.,: c:..:.:,-___::.:=.:..:....~. :.:"CC ~-'~C:':."" c,c:::: "::-C._ --.:C.:C--:.::::C-ccc :.'.'C'.::': C,-- "CC:__'C :-=:::/.:c.:::.:.-.:c.:.c:::.c. CO"C_-'. :- '.--..--::':c~ ..: ...c---::: ::C.:.:__._':;.,:c',_,,', _::. ....:. . _
lie f;02A (12104) (CONFIDENTIAL) PAGE 1 OF E
7. PRIMARY DIAGNOSIS:
a. Treatment/medication (type and dosage)/equipment:
A \ ~l1e,t n \efS cton ~~mi-1.
k€~nlt".h _h~) I:' 1....1 1^" Qli $
(\'\f~'\f~tt\:\i V\.(.., ~ \t~ {/'O Qf\'t\--'\
Can patient manage own treatment/medication/equipment?
b.
Yes
../'No
c. If not, what type of medical supervision is needed?
\v\ed\lL~~G,^ O~~^lV"l ~kvt{/k\Di~
8. SECONDARY DIAGNOSIS(ES): \'\V ri?v\-t.~'\ S (C Y\
a. Treatment/medication (type and dO~age)/eqUiPment:
[.t IY\ \Dli leI n e, / betv;n epliJ '.J- Cttp ~ t..d eo pD Q P
\v t v cu\ q r e) \ u f'( ''VtGv~~jl>{(' ~f 00
b. Can patient manage own treatment/medication/equipment? Yes /"No
c. If not, what type of medical supervision is needed?
v~l( L~C"'- OJJlv~~/(y~~ ~V'-J
9. CHECK IF APPLICABLE TO 7 OR 8 ABOVE:
r-] Mild Cognitive Impairment: Refers to people whose cognitive abilities are in a "conditional statE
between normal aging and dementia.
Y?ementia: The loss of intellectual function (such as thinking, remembering, reasoning, exercisin!
judgement and making decisions) and other cognitive functions, sufficient to interfere with ar
individual's ability to perform activities of daily living or to carry out social or occupational activities.
10. CONTAGIOUSJlNFECTIOUS DISEASE: . ~
y\..-6'v'
a. Treatment/medication (type and dosage)/equipment:
b. Can patient manage own treatment/medication/equipment?
c. If not, what type of medical supervision is needed?
Yes
No
+.. __ ..-- -___ ,_.,-_" __.___.____._____.._ ."nO' "_______ _ __.._._____."._ ___ _ . __._.__.__.___~_ ____. __'__"_"__ .,.,._._._. __.._...__._____" .___n._._ _____..._._._,_________._..____......____~ ___.~____..h._______ __._....___._..._...__._ _.___..__..____m._____..__
.._.___,.______....' __ ____.'.._____.'__.~~..._._ _.. ~ _____._____,___ - .__..._ ___u_"______.,__. __ '._".._ _._ __..____....____._._________..__.___n________._.._____._____._.." __.__.____0______ ~__ ___.__ ._.__._...._._ ,_ _..,~._ ...~...~. "~_'_' ... ~_.___ .~__._.____._ ____ ~
LIe 602A (12/04) (CONFIDENTIAL)
PAGE 2 OF 6
11. ALLERGIES: N~.(~\-\
a. Treatment/medication (type and dosage)/equipment:
b. Can patient manage own treatment/medication/equipment?
c. If not, what type of me'dical supervision is needed?
Yes
No
12. OTHER CONDITIONS:
a. Treatment/medication (type and dosage)/equipment:
b. Can patient manage own treatment/medication/equipment?
c. If not, what type of medical supervision is needed?
Yes
No
.-- ____.___..________.._____.__m_.....__..._.._ ---..-.-.-....-..-......-..1----...-...--.....-'''.....--....-. ..----.-------- --.......- .-....- ..-"'- ---..---...-.
13. PHYSICAL HEALTH STATUS I YES 1'-- NO I ASSISTIVE DEVICE
(If applicable)
--...---.-----.--....-.------.-- "...----,,-.------ -.1--.-------..... ----..........--. .....--------..------....---- -. -.--...-...----- ....---.-.......----..-...-...-....---. ........------- . .__.
a. Auditory Impairment I I ~~ ,
b.--V~u~llmpair,;~~t-- -- ---1/:- -- ~- -- T~~::~: i:- -~------ _n -------- --.
~~~;:~~~;;i~-~~=~:---~~I:-~:-t;_-:y:-:~--~:=~~--:--:t~-=~:~::::~=~~-::~=~:<-
e~___~p~iet___ _____~__ (....-::::::-:-1--- -- LJ,\~:',:~) ~d ~~~!V\ -1 . b lJr-- .t.i..~ vtLtJ_ I l8QO~_
f. Substance Abuse Problem! i ./" I I
-.-.. -------.-.-----.---.----- -----...---...... ........---------. ......-.....;-.- ---. ----/-........... -.----- - T-"'--"'- "'--.-.---.--.-. ..,,--_... . ----. . --1---"'--
g. Use of Alcohol I I i
__"_'_"_'__ ___.___._____ _"_ ._.. ___.....____...._. __... ....__...[ _..._ __. ....__. .~r...__..-----.1-- ----... .-.--...---...----------..._________ +-__...-_____...
h. Use of Cigarettes ;: _/'. I I
.-......------.-..----.---..----- . ----- .i-. .... -J-........ ....--.....-+-....--...........-...-........--..--------.... .--....-.--i........--- ..............---.. ......- ..""-....--..
i. Bowel Impairment !! /" I !
j:'-- .-8Iad-d~;-I~-p~~~~~t.-_.---.-..-- -T- -- ...----17--1----..------...---------.. -""-'l-- -----...-.---------. --.....-----------
. .....------......-.--...----......--.------------ -.------... -.-. ----i -... L_... ----.--....-----..- -- .----..,,-.-+ .-- '--... --.... .....--...
k. Motor Impairment/Paralysis! ".- I I
I.-Req-~j;:~;c;-nti~~o~;------n.-r--- ! /l-n_--.. - ._n.r ..- .......-.. _m . - ..- ---
Bed Care I I 1
,;. Hi;tory ~i Ski~-c~~diti;~--r-- T/f------------u - -------
-. _-.~-:.:~ ~ B.~:~~~~~~c'", .:::=;:::.::::=:::.:~.::_=:..-..: -:cc::.:......::-.::Je...:_:;::: :._C..'::::_ . -:1: ..:._ _ ...c::=-_ _.-=-J..:=-__ _=:.=__...:": :':._ -:: -=--=_::__-_:::---=_...c:-:::-::::-=_::J=:-: -=. .:::::::::::';::::'::::,::_c':.:=..::-:o:::::-;"".=:.:::--:-,,:::-:-=:.,::::::_.:,,:_=- -:-:-::-:-:C__
EXPLAIN
L1C 602A (12/04) (CONFIDENTIAL)
PAGE 30F6
14. MENTAL CONDITION
a. Confused/Disoriented
b. Inappropriate Behavior
c. Aggressive Behavior
YES NO
~.
EXPLAIN
".,...--
/"
d. Wandering Behavior /
e. Sundowning Behavior ~.
f. Able to Folfow Instructions ~.
-- . - --_. .._---- --- -- _..- --"
g. Depressed
/'
/'
h. Suicidal/Self-Abuse
i. Able to Communicate Needs ~
- _.' ..-.--.--- .--"--- "-'.. -----_.-._--.._._~-_.._- ---'- ---
j. At Risk if Allowed Direct
Access to Personal A"
Grooming and Hygiene Items
k. Able to Leave Facility
Unassisted :
I
15. ~_~~,6.~rT"Y FORSELF-CA~E L YES ~NO
a:_ ~~I~t~ B~!h~S~~f_ -- _ _ j _1_
i-~~~l~g~~I~;;ir::se'f -. f-?-f--
.-.--. .------..-----------.----.----..- -- -.'-_0. r.-'-' --...-...-.--. L... "-
e. Able to Manage Own I I /'"
Cash Resources
EXPLAIN
16. MEDICATION MANAGEMENT YES NO
EXPLAIN
a. Able to Administer Own
Prescription Medications I /"
- -.- --- ----- ------ 0- -- ------ --- -- -1------ --- ---- -- -- r-- --- ---- - 0-- --- -- ---- .-- .- - -- - -- - ---- - - - 0 - -- - -
b. Able to Administer Own I 1 I
Injections ~ i /
~~Able~p~ri~~~o~n- - --I----I--~~ r--.
Glucose Testing ,i \..J +
---------------.--..-.--------.-.-h.T-------.-..--.~r___-.-- - ---..-..----..----..--..-. .---..... -. ----------.-...-..-..-----. -.-..-.--.---.-..--..----
d. Able to Administer Own I I.... I
PRN Medications ii/I
.--------.--.--.---.--.--.---.---.--0. _. ... ----..- r'.--- -.. - -- .+ ___h - ._..____[U__
e. Able to Administer Own ! I /1\\ i
Oxygen I i A~ ,
.---------.- -----.------.- ."- -...-.. --.-.---.--.-- .-r----- .__h --+..--.--7~..-----_o. .--.--.... .-..---.--.--- -.-..- - ..-..---- - ..----.---...---0. ...-- '-'---'--- -"--
f. Able to Store Own I I VI
Medications i i
_-:-:=:::-.-=--=--c::::.::::-.:==:-.;::.:.c-.=.,...-=-==,.-= :-::;.=_.....:.:::.-.::-..c..--:--:::.:.c: ::=:.::-:-:.......)::::--=-=:_ .:-:= .c:..--..L.:....-..:::::=.::.:::::.::::L:;.--c=-=-:.:::::::.c . :.:::-.=:==:.-:_-.-::::-=_:::::-::::.=:.c':::::.c'====-.:.==.c::...--..=":-:",=._==-::,::: ::::::,:,::-,--:::::,:_:=::::,-:::o'.c.::::..:=-._::::::.-_-:: :::.:::c :.::::-..:.:;:. '-.
LIC 602A (12/04) (CONFIDENTIAL)
PAGE 4 OF 6
1'1. AMBULATORY STATUS:
a. This person is considered: /Ambulatory
f\Jonarnbulatory
! Bedridden
Nonambulatory: Means persons unable to leave a building unassisted under emerge!
conditions. It includes any person who is unable, or likely to be unable, to physically and ment
respond to a sensory signal approved by the State Fire Marshal, or to an oral instruction relatin~
fire danger, and persons who depend upon mechanical aids such as crutches, walkers, c
wheelchairs. (Health \~ Safety Code Section 13131)
.Bedridden: Means either requiring assistance in turning and repositioning in bed, or being unablE
independently transfer to and from bed, except in facilities with appropriate and sufficient care st
mechanical devices if necessary, and safety precautions. No resident shall be admitted or retainec
a residential care facility for the elderly if the resident is bedridden, other than for a temporary illnE
or for recovery from surgery. (Health & Safety Code Section 1569.72)
b. If resident is nonambulatory, this status is based upon:
i Physical Condition
I Mental Condition
! Both Physical and Mental Condition
c. If a resident is bedridden, check one or more of the following and describe the nature of the iIInes
surgery or other cause:
IIness:
Recovery from Surgery: ____________________________________________________
: _! Other:
NOTE: An illness or recovery is considered temporary if it will last 14 days or less.
d. If a resident is bedridden, how long is bedridden status expected to persist? ~,.-\
1 . _________ (number of days)
2. _____________________ (estimated date illness or recovery is expected to end or when
resident will no longer be confined to bed)
3. If illness or recovery is permanent, please explain: ________________________________
e. Is resident receiving hospice care?
~
Yes If yes, specify the terminal illness: ________________________________
Lie 6n2A (12/04) (CONFIDENTIAL)
PACE 5 OF 6
18. PHYSICAL HEALTH STATUS:
Good
/" Fair
Poor
19. COMMENTS:
20. PHYSICIAN'S NAME AND ADDRESS (PRINT)
'{ Wt,v# .(\t~'\'i~/W,\;~ \~~,p
21. H'TEL E-p-~f6NE------- ---. --,-- ---.---- ..... i-22:--LENGTH-Or=-TIME RESlDENT--HAS" S-EEN-yoffR: PA rfENt-
(~t;V ) '-V \ ~ C;C10 0 I \ ~DCtv
: ~~~~~~=:
PRr~ f\uthorizat-ion Let:te..
Date:
near Dr:
Re: You r Pa tien t: (',\;'\0.12... le4) 0 \JE'f/:::t0t.:J
To receive nonprescription and prescription PRN medications. state licensing requires that either:
1. your patient be capable of detennining his/her own need for the nledication. or
2. it)f nonprescription medication only~ be able to clearly cOlnmunicate his/her symptoms.
If your patient cmmot deternline his/her need for a medication, or clearly comml.micate the
sympt0I11S for a nonprescription lnedication, then you the physician, lTIUst be contacted before the
PRN Inedication can be given. Your completion of this form will serve to document your patient' ~
current ability to determine his/her own need for these medications.
As a licensed care provider, it is my responsibility to monitor your patient's continued ability to determine
his/her own need for PRN medications and inform you of any changes which indicate he/she can no longer
make these decisions.
Thank you for your assistance.
Signature
Title
(Facility representative)
Facility Telephone No.
Facility Fax No.
Please check which circumstance describes your patient:
t,
~y patent can determine and clearly communicate his/her need for prescription and nonprescription
medication on a PRN basis
iJ My patient cannot determine his/her own need for prescription and nonprescription PRN medication,
but can clearly communicate his/her symptoms indicating a need for a nonprescription medication.
C! My patient cannot determine his/her need for prescription and/or nonprescription PRN medication and
cannot communicate his/her symptoms indicating a need for nonprescription medication. (must contact
physician before each dose)
Physician' Signature: ~ ,./-,(,>-
\ ~.
~(y-)
.------ -; Date:
:3 \. \3 ~ c~,
Standing PRN Orders
Facility Name:
~.,~) d e f-.-) ~'\ f1Y1OlC J2 (~ f t.
Facility Address:
:~~~ l, EAs-l f\\tE~ .
Facility Phone No:
dS~ 4-l{-1- ~-711:)
Resident Name:
C/ {{ ~\.QJ ~ l~::-\ui~
Facility Fax No:
C7 ~~_') ~ 1-1-7- C~S-c~S
PRN and OTC Medications
Please verify the PRN/OTC medication orders for your patient. Please initial and amend as necessary next to each
medication order approved.
/I/~~OM................ ...
EJ...-.
,/
.../ Mylanta...............
ca//
,/
,_' /// Pepto-Bismol. .. . .. ..
.-
.B TylenoL..............
.....0 Neosporin Oint....
/b
~/~ Motrin...............
j...../r' Kaopectate..........
2 Tablespoons PRN for constipation. May repeat in 4 hours if no bowel
movement. Not to exceed 4 Tablespoons in 24 hour period.
2 teaspoons every 4 hours PRN for stomach upset. Not to exceed
6 teaspoons in 24 hour period.
2 Tablespoons every 4 hours PRN for diarrhea. May repeat in one hour if no formed stool.
Not to exceed 8 Tablespoons in 24 hour period and for no longer than 2 days
500 mg tabs. 2 tabs every 6 hours PRN for pain. Not to exc!3ed 8 tabs in
24 hour period.
Apply a small amount BID for minor first aid.
200 mg tabs. 1 tab every 6 hours PRN for pain. Not to exceed 4 tabs in 24
hour oeriod.
2 Tablespoons PRN for diarrhea. May repeat one time in 6 hours
Patient is capable of determining his/her own need for PRN medications:
DYES
DNO
Additional PRN Orders
According to Title 22, Division 6, Chapter 8, Section 87575, all PRN orders must include: medication name, specific
symptoms indicating need, exact dosage, minimum hours between doses, and maximum doses in a 24 hour period.
Please si n and fax to the facility. Thank you f /,
Ph~tn~S~jg~", 5(------ (V\/\O D::S-/_~'L>
PhYSiC" 's Name,,) ( ")4 ~
I (J \tc 1.,.~ . ~_~_-~e"-~1~M../\i\....c ('\/,\.0
<;\\)~O~
TerG~~)
~ &\ ') \-0 D DX :}.J-;) D'r
. .J
i'~~:~~>'),,'H~
, "~ , . ..... ''', ' :.r~:.~" :-" ..:, .. ,::'i"..~ ~,- ": ,i:. L:';~'ir.:'-:?t:':'."~:; :','.'::::j:" . "".
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.bISCONNEGT:i"NOTICE:
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; . , :,: ;1::. ~F :
. ':_:~.>- ':;'; .,:' .
Your" accollnt2lf?past due: You./must . pay .. " IF SERVICE IS DISCONNECTED... " ..
::::: :1~fO~::>:i~~o,j~~~t~d o:n ~~12={~~j;iO:~ Before service is
reconnected you must pay $129.87
· Also, you may .bebilledan additional deposit amount. PLUS, is Reconnection Fee of $35.00
Please disregard ,this notice if you have already paid
the past due amount. This notice was mailed on Total $164.87
2/28/2006. . Pay before 5 p.m., Monday through Friday and
service-will be reconnected the same day fora
$35.00 fee.
HOW TO PAY
To assure timely receipt of your payment, bring the entire
disconnect notice to any authorized payment location.
· Pay' after 5 p.m. but before 7 p.m., Monday
through Friday and service will be reconnected
the same day, if requested, for a $54.00 fee.
After 7 p.m. in cases of extreme emergency, call
1-866-377-3700 for reconnection. A $54.00 fee will
apply for the service reconnection. Please
reference your account number 3655453 and
quick pay code 05000.
PLEASE NOTE
It is no longer necessary to call to verify the status of
your account. All payments are automatically reported
and all reconnections are automatically scheduled.
If your electrical service is disconnected, your main
breaker switch must be in the "off" position before
I
service can be restored. 'If you need help locating or
operating your main breaker switch II please contact a
qualified electrician, landlord, or building manager.
o SP 000994 TU2B 1 A
KEEP
.
~Entergy
www.entergy.com
QUICK PAY CODE 05000
ACCT. NUMBER 3655453
DOCUMENT 30001025063
SEND
Please disregard this Total Amount Due $129.87
notice if you have already Last Day to Pay 3/8/2006
paid this amount Disconnection Date 3/9/2006
00000099401 MB 0.326 ***** MIXE:D AADC 752
1.11111.1111111111.1.1111.1 II .1.111111111111.111111..1.11.1111
CHARLES W OVERTON
3802 DORSET DR
MECHANICSBURG, PA 17050-7612
~ Our records show your account is past dUe.
D Your check was returned and we have added a fee.
Payments made after two (2) returned checks, must be
paid in cash, money order, or certified/cashier's check.
ENTERGY
PO BOX 61830
NEW ORLEANS, LA 70161-1830
I.
~.
5000000003655453000102506300000012987400000012987406703
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FEDERAL SQUARE STATION
HARRISBURG, Pennsylvania
171089998
4134870115-0096
;/06/2006 (717)238-2202 03:44:56 PM
Sales Receipt
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Qty Price
Final
Price
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[TTLE ROCK AR 72203 EM $14.40
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Label ##: EQ379805323US
Next Day Noon / Normal
Delivery
--------
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Issue PVI:
$14.40
otal:
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Account ##
XXXXXXXXXXXX5525
Approval ##:
Transaction ##:
23 903110237
Receipt##:
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Clerk:
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-- All sales final on stamps and postage.
Refunds for guaranteed services only.
Thank you for your business.
Customer Copy
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CERTIFICATE OF SERVICE
AND NOW, this aJ!!:.day of March, 2006, I, Jason P. Kutulakis, Esquire, of Abom &
Kutulakis, L.L.P., hereby certify that I did serve a true and correct copy of the foregoing
PETITION FOR EME,RGENCY APPOINTMENT OF GUARDIAN upon the following:
VIA HAND DELIVERY
Charles W. Overton
Loyalton of Creekview
1100 Grandon Way
Mechanicsburg, P A 17055
Ms. Sandra Gainor
Executive Director
Loyalton of Creekview
1100 Grandon Way
Mechanicsburg, P A 17055
VIA UNITED STATI~S POSTAL DELIVERY
FIRST CLASS MAIL
Charles Overton
c/o Linda Overton
85 Gay Street
Salisburg, P A 15558
& KUTULAKIS, L.L.P.
P. I<utulakis, Esquire
36 uth Hanover Street
Car sle, P A 17013
Attornry for Petitioner