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ifOSi'ITAL CI.A111 OF LIE~
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St. Luci~
- , being ove~ the eg~e of twentr-one years and tirst
duly sworn, states upon hia aath that:
1. Ne is the Crwdit Y~~r _ of Jackson 1lemorial Ilospitel, which is owoed and
opetated by Dade County, a political subdivision of the State of Ftorida, and he is an agent ot
Dade Cou~ty aad an executive ofCcer of the said hospitei. His business address is Jackson Me-
morial Hospital; 1700 N.~Y. lOth Avenue, Miami, Florida.
2. Dade County,. pursuant to a contracr wit6 _~a~~~ Y~~a
w6ose address is 2~ Av~nug F~ F~~ Pi p~c.~ Mi~a+~~ Florida, has furnished cace, treat-
a '
ment aad mainteaaace to ~~~~p , at lackson Memorial Nospital, '
1T00 N. W. lOth Avenue, Miami, Flocida. ~
3. ~4~e Y~°~ was admitted to lackson Memorial Hospital on
t6e ~ dar of J~~'; , 19~1L_ , aad was thereafter cared for, treated and
maintained by Dade County, Florida at Jackson Memorial Hospitel, to and including the
day of Januas~++~_ , 14~~_ , the day of discharge. There is aow due and owing
to Dade Coanty, Florida for the care, treatmeat and mainteaance of ~a~e Younq
the sum of = ~ ,
4. The afCant is infocmed and to his best knowledge believes that -
; Royal Pa 1_m Ice G~_ ~~1Q1 D~fllas a. ~ lAi ~i Ft s. 8 I ~ h:.rt„~~ . ins.
~
! is nesponsible to ~~QP~@ YOUL1a foc the injury ar illness of
i
~ ~~gena~towng
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~ 5. T6e amount due aod unpaid_ is just and reasonable, and Dade Couaty, Florida, does
~ 6erebr claim a lien upon aay and all causes of action, suits, claims, couater-claims and demaads
~ aocruing to ~~Etp! YO~+?+~ and upon all judgments, settlemeats, and settle-
~
meat agreements rendered or entened iato by virtue thereof on account of the illness or injury
giving rise to such causes of action, suits, claims, countec-claims, demaads, judgments, settle-
ments or settlement egreements, and whic6 necessitated or shall have necessitated such hos-
~ pital care, tt+eat~oeot and maintenance as furnished t6e said Y_nun~
~r~r ~`=4; ' -
~ br Dsde Councy, Florida_ . ~i~~u~ii~ ~ ~ •
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Swom to er~ subscribed befoce me this llth ~y :
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~ 949783-1 ~ ~T~
ary Public, State of Flaida at Lar~e .
N~AitY Pf18UC STATE Of fWRtpri Ai tMi;E
MY COMrr,ISSiUn _~wrt~3 MAY 26, 1973
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~ 1Dir ~~f'~s D~ESI EUp1iA
~ ao~1~J ~73 - s.~~-7}
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