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RLEO A~ RECORDED
IN --OIfkial..Record- ~OOK
196311AR 15 PM I: 36
ROGER POITRAS. CLERK
81. LUCIE COUNTY. fLORID
~,
HOSPITAL aLAIM OF LID
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,P;
STATB 01' FWRIDA. )
, :
ootJll'fi OF IT. LOom)
JOBll 11. WIMBR, JR., &s the 'duly authorized agent of
GOOD s>>wtIT.AH HOSPITAL'ASSOCIA.TION, operating the GOOD SAMAR I TAll
BOSPI'!AL at Welt Pal- Beaoh, Florida, being duly sworn, deposes
and .a,.1 tha't I .......
1. PLORBNCB KAY, mo.. addresa .a shown on the hospital
reoorda 1. 4511 Juanita Avenue, Ft. P1eroe, F'lorida, was admitted
aa a patient in suoh Bospital on Peb~ary 26, 1963 and discharged
on Marob 5. 196~.
2. The Hoapital olaims 'rHRKE HUNDRED TWENTY DOLLARS
(.320.00) ia due it tor care, treatment, and ma1nter~nce of said
patient during the aforesaid period of time.
3. To tn~ best ~owledge of the undermigned, the patien ,
(or her legal representative) ola~ms the following persons, firms,
or oorporations, at the addreases shown, are liable on account of
the illness or injuries whiCh made the atoresaid hospitalization
necesaary:
Name
---
Address
Borna P&eking House
Huttortl lneuranoe Co.
\Mr. Barne., Claim Agt)
CrawtoX'd &: Compm,. ,
(Mr. Brown, Clailll Adj\U!lter)
(Ft. Pieroe otrice)
Ft. Pierce, Florida
Guaranty Bldg., West Palm Beach, Fla
Ft. Pieroe, Florida
.....
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Adm strator
Subsoribed and sworn to
borore me this 14tJh d&1'-
or Maroh, 1963
Whoae business address 10:
~,
1)00 North Dixie Highway
West Palm Beach, Florida
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,:' : .'. '~!11 commission e~1rel5:
Mail address: P. O. Box 2851
'West Palm Beach, Fla
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