HomeMy WebLinkAbout0264 ~
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235169 ~
' HOSPITA[, C1.AIM OR I.IEN ~
STATB OF FLORIDA )
) ;
) ;
St. Lucie )
COUNTY OF
PEARL H. LONG , as the duly authorized agent of
GOOD SAMARITAN HOS~PITAL AS90CIATION, operating the GOOD SAMARITAN
HOSPITAL at West Palm Beach,Florida being duly sworn, deposes anc~;
says that:
1. DAVID CONGROVE (MINOR) wh address as shown `
JaCK L CONGROVE FATHER OF AB4VE M~R
TEMP ADORESS 2932 TREASURE ISLANO
~BR~''gT "°c~8~ ~~i1 ~~6R~`~~ a S
was admitted as a patient in such
I
~iQ~~ital on~ULY 22, 1972 and discharged on aUGUST i,
y
2 l UNE THOUSAND SEVEN NUNDRED
SEVE~~TY SE~ ~~gLt~~S~~t~~1S~X~mOhiE CENTS (i,»6.6~ ~
is due it for care , treatment and maintenance of said patient
~ during the aforesaid period of time.
3. To the best knowledge of the undersigned, the patient ;
(or his legal representative) ~laims the following persons, firms :
or corporations , at the address shown , are liable on account of
the illness or injuries which made the aforesaid hospitalization
necessary: '
i
f Name Address
~ Mr. L. G. Gsborne 2932 Treasure Island
P~rt St. lucie, Florida
~ ~
h
~ Firemans Fund 95 Merrick Way
File # 233047 Coral Gables, Florida 33~34
( Your i nsured f+~~p Ay< <cr„?l5~E0
Mr. L. G. Osborne) sttutr~ ::~4„~Tr f«.
a~;~F :-..~:-S,~S
c~e=.: - ~J~RT '
R~C;::: - -
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~ ~ ~1 iJ ab aM'~1 . ~ :
Subscribed and sworn to ~ ~
~ before me hi 9th ~y ~ ~O~~ct ~
of Au~ust ~97~ ; '
~ >
r
~~f ~ t '
~ (Mrs.) Pearl H. Long
~ Billing Supervisor
~
~ otary blic Whose Business Address I s:
~ j,'.,,,, , Palm Beach Lakes Boulevard• at
~ . ~ ~ Flagler Drive
,y
~ ~ ' West Palm Beach, Florida
~ ` - .
' ' Mailing Address:
~ • ~ . Post Office Box 2851
~ West Palm Beach, Florida 33402
~ ~ - . ~0~2(}5 ~ 264
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