HomeMy WebLinkAbout2519 ~
NU~~~3 FILEQ ANO RECOR~O ~
ST.IUCtE COUMTr ~
ROCf R PO~TRI?S
CIERK CIRCUIT COURT °
tfOSI'IT:1L (:1.A1~1 OF L(E\ RECORDVERIFIEO~
A~R 19 2 47 PH'T 1
STA'1'i: UI' 1~ t.0(ilO:1 )
~ ss. 2C~'792.3
cnu`~•~~ oh ~ ~
Sf . LUCIE
-____.~ep~,~*,~~_______-___ , bein~ over the a~e of twenty-one years a~d first
duly sworn, states upon his oath tt~at:
1. He is the _S~di~Yana.qeL__ of Jackson \lemorial ilospital, which is owned and
operated by Dade County, a Ewlitical subdivision of the State of Florida, and hc~ is an agent of
Dade County and an executive officer of the said hospital. F1is business address is Jackson Me-
morial Hospital, 1 i00 N.W. lOth Avenue, Niami, Florida.
2. Dade County, pursuant to a contract with .~ga=e~B-Simual-Slgiu_-4p~s~p#s~
whose address is 234~iisleah Ave. ~ Ft_ Pi~rc~~, F~orida, has furnished care, treat-
ment and maintenance to B1~lqC~1Q3~(=
~ner) at Jackson 1lemorial tlospital,
1700 N. W. lOth Avenue, lfiami, Florida.
3. Ric Elg~_~pt~ was admitted to Jackson 1lemorial 1lospital on
the 2~L_ day of Februarv , 19~~L , and was thereafter cared for, treated and
maintained by Dade County, Florida at Jackson Nemorial t~ospital, to and including the ~th
day of F~b~aY"Y 19$~1_ , the day of ~
is~iteRge~There is now due and owing ~
to Dade County, Florida for the care, treatment and maintenan~e o'f ~ El9im m ~ 2'
t6e sum of S - -
~ 4. The affiant is informed and to his best knowledge believes that
` _John Doe - exPlosion in utilit~roow at residence. _
f
is responsible to Ma]rgaret 8 Samuel El4in (auen~~or the injury or illness o[ ~
° ` Ricky Elgin (a minor)
s .
~
' S. The amount due and unpaid is just and reasonable, and Dade County, Florida, does
~
~ ~
~ hereby claim a lien upon any and all causes of action, suits, claims, counter-claims and demands
(Parents)
~ accruing to ~'9aret 8 Samuel Elgin and upon all judgments, settlements, and settle-
~ ment agreements rendered or entered into by virtue thereof on account of the illness or injury
~
~
~ giving rise to such causes of action, suits, claims, counter-claims, demands, judgments, settle-
~
~ ments or settlement agr+eerrx~nts, and which necessitated or shall have necessitated such hos-
~
pital care, treatment and maintenance as furnished the said _BiGJqt_ELgi~(ra siner~ _ ~
by Dade County, Florida.
X;: I
~
~ " ~
' ~ C-~resett Rice N~,.;tt+,r:rlii;~,~,~
' Credit Manager `.:1' • : +
Sworn to and subscribed befom me this _ "
th._ ay of ------~tarch-----;~'~~• , ~ • ~
; K~ ~
19~ 2L- . - - {
- - ' : - _
, .,ti ~
S.
r~: 9579U4~1 ~ otary 'ublic, State o l'lori~la at l.e~jC
~ . : c~
,c+
~~IAEt~ PUU1iL JI:,lt Jt ~•~~••u•, ~1 li..(`~,~~~~..•,~~Y~A~.
~+Y cu"~r~~?~tii.;~. :r . r.~.~Y 1~ ~
~ ~Z,.~S_~~ -b.o, 11y c:~~~IRt~ki~l~C~lrii~+i~~?.t~~E~~~~KS: ,
~ ~ R --S~~G -7~ ~
t~ s~~ 191 2514 ~
~
x:
:
F~^y _ ~`K
~ ~ . , ~ . _ ....F_..