HomeMy WebLinkAbout1578 25'71'78 " ~ ;
• • iT~l~
E COIENCIttRfIA. '
- ROCER POITRAS ~
CIERII CI~CUIT COURT ~
RECOpD VfRIF1E0.~..~~ ~
,lu~ 10 10 pN'13 ~
HOSPITAL CLAIM OF LIEN
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STATE OF FLORIDA
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COUNTY OF PALM BEACH '
PEARL H. - LO~IG, as the duly authorized agent of GOOD SAMARITAN HOS-
PITAL ASSOCIATION, operating the GOOD SAMARITAN HOSPITaL at West Palm
Beach, Florida being duly sworn, deposes and says that
1• ROBERT CRIITCHF'IEID (MIAOR( . whose address as shown on the Hospital
RO~T CRIITCI~'IEID (FATHER OF ABOVE 1rIIlTOR ) 1109 NW 5th FT LAZIDER
~ recor s as ~ 301 N 17 ST~I' FT. PIERCE~ FLORmA DAIT
was admitted as a patient in sucn Hospital
on ~E 3~ 1973 and discharged on NNE 6~ 1973
2. The Hospital claims ~+y~p gQ~~p q+y~Ty DOLLNRS AI~ID TWEI~1'1'Y
4
Fr~v crxxTS (z2o.25)
is due it for care, treatment and maintenance of said patient during the aforesaid period
of time.
3. To the best kno~sledge of the undersigned. the patient (or his legal representa-
ti~•e) claims the follo~ving persons, firms, or corporations, at the address shown, are liable =
. ,
on account of the illness or inJuries ~.rhich made the aforeyaid hospitalization necessary :
NAMF ADDitESS
~ Gatexay Insurar~ae Co. C/0 Ceatral State Ad~. Bareau
; (Yovr inaured f
ather 1333 Coral way
; of abive Patient~ Miami, Florida
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~ ,ubsrribed and ~~~~orn tu
before :Me thi~ 15 llay
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~ . ~~3 ~ .
, , , ; .
~ ; c . j .A-`:
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; ~ ~ _ (Jirs.) Pearl H. Long
~ = r: • otarw Pu4iic Billing Super~ isor
_ _ t . i, ' . ~ ; ti .
tt Y(~T
et C;`STATE o1 FlOR;OA at Ll,R,E 1i'ho~c Ku.ines, Addre.~ I, :
,r} `r~' 11 Q dOxL•b~~~ E'XPI~:~S JAr+t. 3Q,_1976
' N"E~ii~U GEt' INSURANCE UN~rtt~Yr;tiERS
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~ Palm Be.uh Lakes I3oule~•ard at F'lagler llri~-e
' F( " «'e~t Palm Besch. Florida F
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BOX `LHal
~ We~t Palm Beach. Florida 33~10'L
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