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HomeMy WebLinkAbout1013 ~ 2 5C~824 HOSPITAL CLAIM OF LIEN STATE OF FLORIDA ST. LIICIE COUNTY OF~'6Q~ t PEARL H. LONG, xs the duly authorized agent of GOOD SAMARITAN HOS- PITAL ASSOCIATION, operating the GOOD SA~IAftITAI~' HOSPITAI. at West Palm ; Beach, Florida being duly sworn. deposes and says that: ' 1. BARBARA LEO ~ IN-HOIISE) ,~~•hose address as shown on the Hospital records as 32~ NORTH 2ND STREET~ FORT PIERCE~ FLORIDA . as admitted as a patient in sucn Hospital . ~ on MAREH 9~ 1973 THItU JUNL I~.a 1973 ~ _ 2. The Hospital claims FIFT•~.~~T TFiOIISAND~ `I'j~TO HITNDRID AND THIRTY- = ~ FIVL' DOLLARS ~rr~ ~rrEx~ c~rTS, t~5,235•20) : is due it for care, treatment ancl maintenance of said patient during the aforesaid period I ' of time. . ~ ~ 3. To thr Lest kno~~•ledge of the undersigned, the patient (or his legal representa- i i ti~-e} claims the folto~~•ing persons, firms. or cerporation~. .it the ~iddress shown, are liable ii - ~i ~,n accuiint of the illne~s or injuric:. ~•~hich made the aforesaici huspiialization necessar~~: ; ~ : 4 ! ~3A.lIE ADDRESS } ; Crairford & Company 1726 Okeechobee Road : ; File#~ 111-1759?-B Fort Pierce, Florida 33450 ' € YOUR INSIIRED: Charles Leo & ~ ` 3arbar~ Leo ~ ~ ; _ , ~ ~ ~ ' ~ y _ : ~ ~ ~ ~ I~ _ if ~E ~ ul,:cri~«t ~ind ~~~-orn tu C: ~ ~.:...4~;~;Vt•e m~~ thi, 5th Ua}• ~ ,~f• ~ June 1973 vQ cw~. l'n ~ ' •-s ' ' . ~ . _ ~ ~l r..) !'~arl ~I. I.ong ~ _ - _ ~ '`".'~o'~?r~' 1'ul~lic ~ Rilling Super~•i.or ~ _ ~ ~ . - -f . yQT~ilti' RIIB~IC. STATE of FLORIDA at LARGE , COMaII$SION ~XPIRES JAN. $0. 1976 ~1'h~,~cr li!~.in~~~~ ~lddre•~ l:: = i~' 3~IiD~FD ~t~RU GE!lEfiAL IHS:1RAi~CE UfillEnVlNtif~S ~ ~ • I'a~lm Ke.~ch 1.:?ke, I;oule~•.ird at I~'la~;ler 1)r~~~e + ~ ;:,l.~~ ~ 256814 ~i'~~~t f'alm Reach. Florida ~ I ; \laslin ~ :~ddr~,~~ . FiaED a~~~ ~:~t;C°OED ~ ~ ( ~t ST.IUClE ~GUNTY fLA. .rv=. P.G~~- ~::~tRAS I'. U. Rox ?~51 CLE~K C: :SUIT G'GURT ;=;s ,f qE~^~ j i~F'rlED.~.~-.. «~E~i ~~R~T17 ~~E.t~'~l. ~''lorida :i~3-10'L : y~ ~ ,Ju~i i~l 110~ PH'73 . ~ . ~ ~i ~ ~ ~~Kz15 ?~~~101i ~r ~ . , ~ . , _ _ ~ - . . _ - ~ ~~<<.~ ~Y~~: