HomeMy WebLinkAbout0220 210~62 ?~~E ~u~~i~~ ~~4: i
~ ~ ~~~ER PO~T~A1 (
H03PITAL CLA~i OF LIEA Rt~o~o v~a
?~~p OOYII~
STATS OF FLORIDA ~Ii~ll I O ~ ~l f n~~ I
210462 ~
COVl~TY QF PALIi BSIICH
P~tL H. ~Ol~, sa the duly authorise~ agent o!
(~OOD 3AKARITAN HOSPITAL ASSOCIATION, operating the (~OOD 3AMARITAl~ :
H03PITAL at i~Teat Palm Beaah, Flarida being chily axora, dago~ea snd ~
„ asya thats ~
l. KCEINNEY, JAKS3 ti,i. , xhose add~eas as ahoMn ~
~ an the Hoa ital reaorda as 2 0' EUCLID 3TREAT R P E S ~
p 4~ ~ FO T I RC , FLORIDA
33~l.54 xas admitted aa a patient in auoh
Hoapital on N~Y 23, 19~1 end dieaharged on JUNS 2, 19?1.
2. The Hoapital olaima ONE THOUSAND T'~f0 HIINDRID TSIRTY
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THREE DOLLARS AND TEN CE1~iTS (~1, 233.10 j
ia due it !or care, treatment ~nd maintenance o2' said patient
during t~he atoresaid period of time.
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3. To the boat 3moxledge o~' the undersigned, tha patient ~
(or hia legal repreaentative claims t,he follo~it~g peraona, lirms, ~
~or aorporatioas, at the addreaa ahown, are liabla on aoaount o!
~ ~ the_ illneaa or in3uriea which made the aforeaaid hoapitalization
neaeasary: _
4 Nerae Ad_ -
~nna Inaurence Agenay Fort Pisros, Florida -
(Mr. NaEinns~~s insuranoe) . _
i 3
/ ~
8ubaaribad aad a~orri to - ~ ;
belore me thia 8th Day ~ ;
of Jtaie, 1971• ~ ~ - ' ;
: ( Mra . ) Pe 1 H. Long .
~ Billing per~isor
~ - -
,
blia Whoae Buaineaa Addreaa Ia:
_ , _ - -
"~:~J~ PBRLIC, AATE OF F10R10A AT 1AR6E Palm Beaah Lakea Houle~ard at
MMlSSIOK EXPIRES MAR. 5, 1974 Flagler Drive ~
:~,~t n+su ~ w ui~sr~soRSr Te?est Pa]~ Beach, Floridn
'
. .
Mailing Addrea~:
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P~at Qlfice Boz 2851
West Palm Beaah, Florida 3~02
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