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CI,AIM OF KOSPITAL LIBN j
UND$R AUTHORxTY OF
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,CHAPT$R 59-984 GENSRAL I~AWS OF FLORIDA, 1959. 3
STATS OF FLORIDA )
) ss.
COUNTY OF ST. LUCIE )
P~RSONA3,LY APPEARET) before me, RODNBY DORSETTE, who,
after being duly sworn, says that he ~s the Assistant Administra-
tor of the ~~t~• ~3~sRL~ in~i~Or~irli, riv^~rii~A.Z., a glcr3ua :,c ;=pzcfit
corporation, located at 7~7 North 7th Street; that one BIRDJ~T
NISSEN, was admitted as a patient ~a sai3 hospital on the lOtY,
day of Apsil, 1965, and was discharged on th~ 5th day of May, 1965;
that said FORT PIERCE MEMORZAL HOSPITAL claims the swn of
ONE R~IOUSAND TFiREE HLTPIDREU ONE and 6~/100 (Sl, 301.6~) ~OLLARS ~o
be due for hospital care, treatment and maintenance prov~.~?~3 to
said patient; t2~at to the best knowledge of this atfiant, the
names and addr~ss~s of all persons, firms or carpor~tions claimed
by said patient or by the legal =epres~ntative of said patient,
to be liable on account ~f ~aid ~atient's iilnesg or injuries, are
set out be2ow:
NAME R~ddress
Cantinental N~tional American Group 201 Pan American Building,
West Palm B~ach, Florida
Morten Jolles 12b4 Beacon Street,
Brookline, Maasachusetts
THIS af~ian~ ~urther c~rti£fes that he has sent by
registered mail, postage pxepai.d, ~ true copy of this Cl~im of Lien,
to each person, fi~m or corpoPation at the addresses list~d above,
~ THE filing of this Claim of Li~n shall be notice thereof
to all persons, firm~ ar cosporations who may be lia~le on acc~unt
of said patien~'s ~.llness or inj~aries, whether or not they ~re
nam~~ 3r~ tttis clairs~ and whether or not a copy of such claim shall
have been received by ~em.
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