HomeMy WebLinkAbout0816 :
S? lb:t: . 11t~ F;~
. ~
c~ r._~ ~;s ~
HOSPITAL CLAIM OF LIEN ~f''~
STATE OF FLORIDA ) 10 ~7 ~}1
)
. ) i~s31313 -
) ~
COUNTY OF PALM BEACH)
, PEARL H. LONG , as the duly authorized agent of
GOOD SAMARITAN HOSPITAL AS90CIATION, operating the GOOD SAMARITAN
HOSPITAL at W~est Palm Beach,Florida being duly sworn, deposes and
i ,
' says that:
1.EDWIN L. CAAADAY , whose address as shown
on the Hospital records as POST OFFICE BOX 3870 FT PIERCS, FLORIDA
was admi tted a s a patient in such :
Hospital on I~iAY 4, 1972 and discharged onMAY 31~ 1972= _
#
,
f
l_~ 2. The Hospital claims THRE~ THOIISAND FIVE HUpDRID THIRTY~ ~
EIaHT DO~LARS AND FOURTET~1 CTNTS ($3,538•~4 ) ~
is due it for care , treatment and maintenance of said patient ~
7
during the aforesaid period of time. ;
~
_ 3
3. To the best knowledge of the undersigned, the patient
(or his legal representative) claims the following persons, firms ~
or corpor~?tions , at the address shown , are liable on account of -
~
;
;
the illness or injuries which made the afaresaid hospitalization
! ~
' necessary:
i
~
~ ~ Name Address
~ Auto OWners Insuranoe
Patient ineureuae
~ Policy ~630112 201064 95 09T03
~
Dri~er Cl~arged unknoxn
~
;
a
~ Subsczibed and sworn to `
~ before se this 9~ Day , -
~ of June 1972 ~ '
. ~ ~ _ ( L -
~ (Mrs. ) Pearl N. Lo g
~K~ t ~ ~ 4
~4 ; , Billing Supervisor , $
~ ~ ~1 ~'+-~-t '-'~~3~.. ~ ~ s~._-,-~~y
~ ~ ~ ' l~~+~!r'r!~l71~ _
~ Nota-~cy~_pub,~ic«~.• Whose Business Address I s:
~ - ' ' Palm Beach Lakes Boulevard at =
i
~ ~iW1f ~181.~C. S E
oi~~iOBto~ ~ uRGE Rlagler Dri ve
~ ~o E' tFE~fr,~i. $Q, 1976 West Palm Beach, Florida -
~ ~ t~c~,E ~ 1r+~a~xcE unu~~vr~~r~
~ , ; _
~ ~
Mailing Addre ss:
~i . '°-+i~ .
~ Post Office Box 2851
bnGK~~ P~f# V~~West Palm Beach, Rlorida 33402
~
sj
~ - V~ ' ~~~t_ „
r~-n,~
_ ~,-~.w3~. - _ _ _