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HOSPITAL CLAIM OF LIEN
STATE OF FLORIDA
COUNTY OH' YALDi BEACH .
1'EAR1. H. LONG. .i~ the duly authorized agent of GOOD SAniARITAN HOS-
PITA1. ASSOCIATION, o~erating the GOOD SA11iARITAIv' HOSPITa1. at ~Vest Palm
Beach, Fioridx being duly s~~•orn, deposes and sa~•s that:
F4T ATF: OF
~ 1• i'.~~L L EANNr,r2i-IAiY ,~~'hose address as sho~vn on the Hospital
records as 1001i5 :~1. I?~JIG~J ST~' ~:T~ iil:~:~iI~ FI,ORIJ.1
I ~vas admitted as a patient in sucn Hospital
~ EXPIRFF~
on TJii~' j~ 1973 and J~~l on JUIT 1fi~ 19?,;
II
j 2. The Hospital claimsTH'cZ;:; '1~i0US1~i~1D ~IIT~; HUt~ :~I~~'Y ^l:l•~
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is ciue it for care, trextment and mainienance of s~id patient during the aforesaid period
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~ of time.
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3. To the Leat knu~rledge of the undersibned, the pxtient (or hi~ (egal representa-
~
ti~-e) claims the follo~~•in~; person,, firms, or ccrporation~, at the addre.s sho~+~n, are liable
un .?cc~?unt of thE iline~• or iti,~tii•ies ~~•hich m.ide the aforesai~i hospi~alization necessai-~•:
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~ :~I~\1F. ADDRESS
~t. Iucie r'arm Bureau 33?7 Orange Ave
;i c19~ ~ 40 44 45 ~ Ft. ~'ierae, Florian 33~5~
(Your inaured) ~
~erkin & Calvete sod Farme 11}36 W Avenue A
' Belle Qlade, Florida
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~ 973 :
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~ `ot.~r}• 1'ut?lic Y.iliing Super~~i~or
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UT~:~ FUBCfC, STATE ot FL4?I~q af (~~t;~
. t:? ~[~~Qf.i:AI~S510N EXPt=:~S JA!~. ~ ~ ~1 hu•~~ I{!l:tnt••: Adtl~'e.~ 1:::
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` ~P~1ttRU c~riEwu irrsur~rrcE ur~',,; ~
- ~ Palm lie:?ch I.akr. •
~ . . •''~t Bc~ulE•~~ard .tt I~'Ix~, i~~r Un~-e
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25'~8s6 «"t•xt f'alm fi~•.trh. Florida
F lfD A4^ ~ECORDED ~Iailing A~I~ir~~.::
a ~ S~. LUCIE COUNT7 f~~l. I
i~ ROCEF. v0!TRAS !
CIERK CI~"vUiT COUR1 (l. Kv~ 'i,~;,l
_ RFCORO VE~t~IED~.~.~ ~~"e~t Palm R~•a~•h. H'lc?rida :~;;-~U'~
,1~ 19 I zu PN'73
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