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CL~?Il~i Ol~ 80StITI~1~ LIEN ~ ~
trND$R 1~1rJTH4RITY OF
CHAPT'ER 59-984 G~7SRAL LAWS OF FLORIDA, 1959.
STATE OF FLORID~I ~
) ss.
COUNTY OF ST. LUCZE )
PERSaNAI.LY APPEARSD before me, RODNTY DOR58TTE, who
aftear being duly sworn, aays that he is the Assistant A~ministratos
of th~ Fort Pierce Meaaorial Haspital, a Flor~da non~-profit corpora-
tion, located at 707 North 7th Street: that one MAURICE BROiWP1 of
Fort Pi~rce, Florida, was admittcd as a pati~nt tc~ said hospital
on the 13th day of December, 1963, and was discharged on the 31st
day of December, 196~; that said Fort Pi~rce Meraorial Hospital
claims the aum of ELEVEN HUAib~tED FYF'1'Y NINE and no~100 ($1159.00)
DOLLARS t.d be due for hospital care, treatment and maintenance
provided to said patient; tha~, to the best knawledge of this affiant,
~he names and addresses of a11 persons, firms or corporations
claimed by sai~d pati~nt or by the legal representattve of said pa~
tient, to be liable on ~cccsunt of said patier.t's i.11n~s~ injur~es,
~ are ~et out below:
NAME ADDRESS
Kirk SuZlf.van, Attorney-at-law, 92t1 Cameau Huild3ng,
Attorney for John Wesley Davis, indivi- West Palm Beach,
dually, and attarney for Liability Floric~a
Insurance Carrier of Jahn Wesle~ Davis.
Carlton & McCa1.n, At,torneys-at-Iaw, P. O. Bax 377~,
Attorneys for Maurice Brown Fort P~erce, F~orida
~HIS affiant ~urther certifies that he has s~nt by regis-
tered mail, postage pregaid, a true capy of thf.s Claim ~f Lien, to
~ each pexacon, firm or Gorporation at the addresses listed above.
~ THL filing of this Claim of Lien shall be notice theree~f
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~ to all peraons, firms or corporations who may be 13ab1e on accaunt
r
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of said patient's illness ar injuries, whether or not they are
named in th~s claim, and whether or not a~ copy of such clai~n sha12
have been received by them.
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