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24~~v~ FILED ~Kl~ ~E c.U~tUE~ ~
ST.IUC~c ~OUNT1? flA.
ROCE ~ ~'1 TR4S l~
CIERK G~. ~U•1 COURT
ilOSl'ITAL Cl.At11 Of~ 1.IF\ aFC' k^ v:.
sra~rH u~~ t.ot;iut> > FE8 I~ ll 56 AM'73
~ ss. 24'7664
ro u `•r~~ of~ ~r ~
St Lucie
^1~~,~_,~_~~;}p~,~}~~~.~.~, bein~ o~~er the a~m of twenty-one years and first
duly sworn, states upon his oath that:
1. He is the ~~2_~~Y
~'___?rT_ of Jackson 1lemorial Hospital, which is ovmed and
operated by Dade County, a political subdivision oj the State o[ H lorida, and he is an agent of
Dade County and an executive officer of the said hospital. tlis business address is Jackson !Ne- j
morial tlospital, 1700 N.W. lOth Avenue, Dliami, Florida.
2. Dade County, pursuant to a contract with
::,edC:2 ~
whose address is ~ 13~-~~--1-ry '--1-~'-a~- ~1+ar+u~ F~orida, has furnished care, treat-
ment and maintenance to - n ~ ::a.11s-- , at Jackson 1lemorial Hospital,
1700 i~. W. lOth Avenue, Afiami, Florida. .
3, r.art»Y+~ "a ~ ~ ~ was admitted to Jackson 1lemorial Hospital on
the -2.~t::.-- day of ~J~ , 19 Z~_ , and was thereafter caced for, treated and ~
maintained by Dade County, Florida at Jackson 1lemorial tlospital, to and including the
day of _r 19 T_3.- , the day of discharge. There is now due and owing
to Dade County, Florida for the care, treatment and maintenance o[
t6e sum of S-~ 1, 4. 3.('~ .
' 4. The af~ant is informed and to his best knowtedge believes that -
; ;7chn ~oe - ace~3ent at t6Q7 ::o~~~ard ''.d. ~ "t.;"2, La'.<e*~zoed Pa~~^::, Pt. ~i~rce,
~Z
.a__~___~ ,
_o~,
; ~r - ~ -~~ea~~-~--3~~a~ ^ ~ -r - - „ L:~ r ~or
~ Leac =1a. ~ ~roYioas inc. oi :la., 757~ ?4t:-, St., "~.ar::i, ~la.
! is responsible to for the injury or illness of
i
~
~ , y, r,,,, ~ i .
~
' S. The amount due and unpaid is just and reasonabie, and Dade County, Florida, does
~ ;
~ hereby claim a lien upon any and all causes of action, suits, claims, counter-claims and demands '
acecuing to -~~~~~-:ia~~b and upon all judgments, settlements, and settle- i
~ ;
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~ ment agreements rendered or entered into by virtue thereof on account of the illness or injury
~
~ giving rise to such causes of action, suits, claims, counter-claims, demands, judgments, settle-
~ t
~ ments or settlement agreements, and which necessitated or shall have necessitated such hos-
~
~ pital care, treatment and maintenance as furnished the said "~~r~,
_ ,
~'f by Dade County, Florida. , , /U
~ 4ti~~~iG1/ ~ ~ J,
_
~Y~s~ v.:arl~J ~1A .~'~-+1r1..7«er' U f/
td - .
ti : _es^:;.ta~-~ ~ervice ~uYa v~.sor
Sworn to and subscribed before me this _ ay of 4,
~ . . ,
:
19 -~-3- • U . oS~ . . % ~ .
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~ J~ ~ tary Public, State of Florida ai'~:a`~er'
s, 4'- `
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