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CLAIM OF HOSPITAL LIEN
UNDER AUTHORITY OF
CHAPTER 59-9t34 GENERAL LAWS OF FLORIDA, 1959.
STATE ~F FLORZDA ,
) ss.
COUNTY OF ST. LUCIE )
PERSONALLY APPEARED before me, RODNEY DORSETTE, who,
after being duly sworn, says that he is Assistant Admir?istrator
of tY~e FORT PIERCE MEM4RIAL H05~ITAL, a Florida non-pxofit
cornoration, located at 707 North 7th Street; that Jamesetta
Elizabeth ADrams and Elbert Abrams, were admitted as patients to
said hogpital on the 27t~ day of November 1963; that said FORT
PIERCE MEMORIAL HOSPITAL claims the sums o£ $195.90 and $190.05
respectfully to be due far hospital care, treatrr,ent and maintenance
provided to said patients; that to the best knowledge of this
aff~i~nt, th~ names and address~s of a11 persons, firms or corpara-
tions claimed by said pat3~nts or by the legal represent~tive of
said patients, to be liable on account af sa~.d patients` illness
or injuries, are set aut below:
Np,p,2E F,DD R.ES S
Liberty Mutua~ Insurance 2025 O}ceechobee Road
Company We~t Palm Beach, Florida
THI~ affian~ fur~h~r certifies that he has sent by
registerEd mail, postag~ grepaid, a true copy of this CLAIM OF
LIEN, t~ each person, firm or corporation at ~th~ addresses
1. is ted abave .
THE filing c?f this CLRIM OF L~EN shall be notice thereof
to all persons, f~rms or corpora~.ions who may be liable on account
of said patients' ~1lness or injurie~, whether or not they are
named in t.lzis claim, and whether or not a copy of such claim shall
r,ave be~n received by th~m. ~
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No relea~e ar satisfaction of any ac~ion, suik, claim, ~
counterclaim, desnand, judgment, settlement or settlement agreement,
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or of any of them, sha11 be valid or effectual as against this
lien unless the FORT PIERCE MEMORIAL HOSPITAL shall ~oin therein
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