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iiOSPITAL CLAIM OF LIL'N ~~oRa v~rirtFp
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STATE OR FLARYDA ) ~ II f
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ST. LIICIE )
COUNTY OF ~(1~~
PEARL N. LONG , as the duly authorized agent of
C~OOD SAi4WRITAN HOSPITAL AS90CIATION, operating the GOOD SAMARITAN
HOSPITAL at West Palm Beach,Florida being duly sworn, deposes and
says that;
1. F~triiC 2•ICCILL , whose address as shown
. on the Hospital records as r~LINQrTON DR. '.^ST P!~LM BFACH,
~R~A 3~~ was admitted as a patient in such
Hospital on ~~~19?2 and discharged on A~IIST 2~
19?? 2. The Hospital claims ~EE THOII3AND FIVE ~RL~D A~ID
i~~z~-~t-~zv~: nor~.r~ ArID Two c~rrrs 3, 555. 02 )
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) claims the -following persons, firms
or corporations , at the address shown , are liable on account of
the illness or injuries which made the aforesaid hospitalization
' -
nece ssary ;
I
Name Address
Aetna Insuranae Co. ' Post Office Box 2609
(City of Ft. Pierce,your insured) Delray Beach, Florida 331~1El~
~ Allstate Inaurance Co. 2Z71 Palm Beach Lakea Blvd.
(Daniel MaQill,your insured) West Palm Beach, Fla.
4~ 35 s3~ AR
Subscribed and sworn to
~ befoxe me thi s 9~ Da?y
~ of A~,rust, ~972 `
• _ :
~ x T7'.
~ ~ (Mrs.) Pearl H. Long
~ ~ ~ Billing Supervisor
~ ~
Notary P,,`~;
~"t~~~~,~,,~, Whose Business Address Is:
~ - Palm I3each Lake s Boulevard a t
~ ' ~ Flagler Drive
~ : •t~ i A n,~:••
West Palm Beach, Florida
~
~ , ' ' - ` ~ Mailing Address:
.r ~ .
_ POSL Uff1Ce BOX 2851
WesL Palm Reach, Florida 33402
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