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HOSPITAL CLAIM OF LIEN :
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STATE UF FLORIDA
COU:~TY OH I'A1.\i BEACH
PEf1RL H. 1.0\'G. .is the dul~• xuthorized .i~ent of GOOll SA~[ABITA:~ HOS-
YI1'AL ASSUGIATIO\, operating the GOOD SA~IARITAI` HOSPIT~L at ~Ve~t Palm
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Beach, Florida being dul~• s~rorn, depose, <<nd sx~•. thxt :
1. DAVID FRY~R (MINOR~ ,~~•hose address as sho~~n on the Hospital
~ LAMAR FR7C AR (FAT~R OF ABOPE MINOR)
~ records as 821 S~IITH 13th STR~T FT. PI~RCF~ FI,OR~A
! ~ti•as adnzitted a~ a patient in sucn Hospital
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~ oraECl'I''IBF'.R 28~ 1972 ~nd discharged on J~,JQ~y 31, ~ 9T3
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i 'L. The Hospital ciaims TWO THOIIS~IND NIIdE AUM)RED THIRTY 02dE
' DOLLAR3 AI~ID NO Cr~tTS ( 2~ 93~
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is due it for rare, treatment and maintenance of ~xid patient during the aforesaid periotl
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j of time. ~
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To tht h~.t kno~~~ltdge ~~f the undersigned, the j~atient (~,r hi~ tegal representa- i
1~ ti~e) claim~ th~~ follo~ring l,erson., firms, or ccr~?or~ition~, at the xdcires~ sho~ti-n, ar~ liable ~
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:~cc~?unt ~?C thr illn~~~ ur itij~u•i~: ~~•hirh m~?d,~ the <ifore;~iid hu,~,italiz<ition neces~ar~•: ~
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; \ A~IE ADDRESS j
!411stete 2nsurance Company 2271 Palm Beach Lekes Blvd. `
~ Claim ~ 1}1 F 50~;5 :~+est Palm Beach, Florida I
~ ~
; John 3lenton 1023 Sunrise Blvd. ~
f ' Your insured Ft. Pierce, Florida i
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~ FIlEO Alt~ oECOR0E0
_ fT. LUCIE COUNTY fLA. ,
ROC~R FUITRA$ ~ ~
~ C~ERK C:"CUIT COURT
~ RECOR~3 VEF.1~lEO I
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Ee y 12 i3 PH 73 24'7581 `
~ ,:i ~ul~:cr?1~~~~i .in~l ~.,ucn tu
~ j:; 1~f•f~?rc~ mc~ tiii~ ?~1 lla~• ~ I
~t r ebrusry 1973 \ ~ ~
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~ i~ / ~!!u~ lLC.i~~ ^ ~/~~~"L~ - - ~ 11 r:_} I'~~ari H. Long
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~ , ` tuta~ I'ul~lir Rillin~,• Sui~er~•i.~~r ~ i
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; N~ 11'hu•~~ ti!~:in~~•: .~?ddrr•• l::
~ PUBIIC, STATE ~
;i My COMINISSION ~F ~ORIDq AT ~
BOMOED iHRU FREL ~yRyEp~~i R~ 5~~ ~1•r,
t, f':ilm`~R~~:irh. ~;I~~ridau•d at I~'l:i~,•~~~r l>r~~-~~ i
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::y ~lailin~ ??~idn••:: I
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