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CL~=M p~' HO~RPI'1'AL ~Ef~
r Ul~IDaR OrF
- Cl~1?~'taR 59-984 GE~TERAL LA1~T8 OF MARID~1, 1959. .
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~3'1'AT! O~' 1ri~0~11 ) i
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. . PERB+OKALLY 1lPPE~1RED bsi~or~ nN, ROD~EY DORSETTE, who
aft~r bsing duly sMarn, ~ says t1~at he !.e the Assiatant 1~'Laitsia- ~
traboz of t1Ya lbrt Piezce Me~morial aiarpit~l,, a Florida non- ~
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, gro#it eorporatio~n, locsted at 7~~ ~lorth 7th Streets that ons
• A~'S 1ii00+T]~, of 1^ORT PiffitCS, 1rLORIDA, ~ra~ amnitted bs a patiant
bo said ~oapital on t~e ~2nd day of ~ov+~mber, 3.963. and was dis-•
~ chazqed on th~ 13th day of Decemnper, 1963: that oaid Fort Pierce. ~
- M~rwrial 8ospit~l Clai~+e tbe eum of b1~ HiJ~IDRBD NIbTBTY 7CW~D and ~
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66/'100 ($992.66 ) DOLi.AR.4 to be due !`or hoapital care, tseatment ~ ~
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and maiatenance pmvided to said pati~t= that to the b~at knawledge
of thie affiant, the names ~nd addreases of a~ll paraons, firma o~c j
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oorporatione claimed riy aaid patient or by t2ie legal repreaenta- ~
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~ - tiv~ of said patient, to De 1i:able oa ac~unt of said patient'a
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ill~aea or injuries, are set out b+elaw: ~
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NA!ffi ADDRa.S3
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State Auto~nobile Mntual Insnrance Co. P. O. Box 947, . .
~ , ~ake Worth, Florida ~
~ Morraw ~ l+~or~^aw, AttArney~ at La~w Suite 7~L0, =ngzaha~ Bldg. ,
~ • Mimmi, Florida _
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~ TAIS atfiant furt2ser certi~iee.that he haa sent by
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~ reqistered mail, postaqe prepai~d, a true oopy of this Elaim of ~
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~ Lien, t~ eacli p~e~rson, firm or oorporation at the addreeses listed
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' above. ~
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T~ filinq o~ thi~ claim of I+ien shall be a~otice
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' thereof to all peraor~s, fis~,as or corgorati~ons ~ho may be liable
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oa account of said patieat's i]lnea• or injurie~, ~Ihether or not
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. thay are mm~ed in thia claia~, aud ~!~?ethmr or not n oopy ot' euch
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; claisa ahall h~ave b~en =eceeived by them.
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