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HOSPITAL CLAIM OF LIEN .
.~TATIs^ OF FLORIDA
COIINTY OF PALM B~ACH
PEARL H. LONG, as the duly authorized agent ot
a00D SAMARITAN HOSPITAL ASSOCIATION, operating the GOOD 3AMARITAN
gOSPITAL at Weat Palin Beach, Florida being duly sworri, deposes and
98~i'e ~lat! t
1~Al~.ADSRO VICENTS (E7~PIR~j ,~hose addresa a$ eho`+n ,
28~s covRT 45~g s~x~r ai~oRn '
on the Hospital records aa , TH , ,
FIARIDA _ uas ac~nitted as a patient in euch
Hospital on ~Y 18, 19~1 Qnd e~ ired on ~y 1971.
2. The Hospital alaim9 ONE ~'HOUSAItD FIGHT t3UNDRED 3IJCTY ~
3
1
FIVE DOLLARS AND TRIRTY FIV$ CENTS (~1,865•35) `
is due it i'or care, treatment and maintenance of said patient
during the aforesaid period of time.
3. To the best laiowledge o~ the undersigned, the.patient '
(or his lega2 representative claims the folloWing persons, Piz~ns,
1
or corporations, c~t the address shown, are liable on account of
the illness or ir:,+,uries which made the aforesaid hospitRlization
~
necessary:
Ne~me , A
d~___re s s ~
Mra. Bem11e tTicente 2 8th Court, l~~h SZreet ;
~xite o! above patient) ~strora, Florida
Inaurnnoe ta~lawwn at r~ieo ,~M~ efG r~u
t•2~ia time) st~u~~c c~u
RGC£n FCITRA3
CtERK GtzGtl1T COURj,,,y
ftEtORJ YFQ~~'~EO...~.~1~.
Au~ 5 i! ~a 1M'11
~
~133U3
5ubscribed snd aWOrn to ~ ~J~~
beSora me this 3rd Day •
~t ~ A~~ tr ~ 19~j • nC. [ '
~,4i,~,. ~ (rtrs. j Pea~ H. r,ong
~ ~ ~ ~ ~ ` Billing S erviaor
.
_,~'~o~+et~ blio l~ihos e Hus ines s Ad a Ia s
~
M~~r ~ Pa lm Beach Lakes Houlevard at ~
• Ny CW~tMiSS10N EXtIRES MAR, s,~ Flagler Drive
~ ~ " ~ ~ w• ~~T West Palm Beach, Florida
Mailing Addreea s
Poat 01'Pice Box 2L~51
~f ?~A W~et Pnlm Beach, F'lorida 33t~02 1
b~ ~ 1 Y
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