HomeMy WebLinkAbout3002 AMIriF.NDID LIEN
ST~IUCiE GOUNTY FLA• V°~ 26440
ROCE~+ POtTRAS z '
CLERK Ct~,f,~{T COURt ~
REf.ORO VfR~i1E0.....~....~
S~ t5 li 2a AN'Z3 .~644~z
HOSPITAL CLAIM OF LIEN ~
,
~
~
STATE OF FLORIDA ~
~
_ i
` sT. zvc~s ;
COUNTY OF~@D~D~I
PEARL H. LO~IG, as the duly authorized agent of GOOD SAMARITAN HOS-
_ PITAL ASSOCIATIQN. operating the GOOD SA4~A~RITAN HOSPITAI.. at West Palm
Bexch, Florida being duly sworn. deposes and says that: t
,
1. $ARBARA LEO ~ ,~~hose address as shown on the Ho~pital
records as 3~3 NORTS 2ND STREE'1'~ FORT PIRRCE~ FLORIDA '
;
,
~vas admitted as a patient in sucn Hospital ~
~ ~
on ~RC$ 9s 1973 and discharged on SFpT£S[~ER ~ ~ 9'j3 ~
_
2. The Hospital claims ~riTy gpIIR TgOIISAND TWO HIINDR~ °
~r~ norsaRS Arin ~r~c c~rrs. t~24, 253• 50) ~
is due it for care, treatment and maintenance of 5aid patient during the aforesaid period
_ '
~ of time. ~
i` 3. To the Le,t kno~~ ledge of the undersigned, the patient (or his legal representa- ~ f
1
~i ti~~e) claims the follo~ving persons, firms. or corpoaations, at the address shown, are liable t
I ~
I un .iccuunt of the illnes~ or injuries ~~~hich made the aforesaid hospitalization necessary: ~
;vpME ADDRESS ~
~
~ ~ '
~ CRAWFO~ & COMP~ 1726 OREECHOB~ ROAD
FZI,E# 111-1 ?597-B~ FORT PILRCE~ PLORIDA 331~0
R YOUR INSURED: CHAF~'I,FS LEO &
~ i BARBARA LEO ~
~
s
~
_ ~
. •a " ~
'.Y• , • ~
~
~ ,;~~5 ~y~ci~ be~ and ~~~~orn tu ~
~ . ~,~bc"^ ,
•~,~''~,s 20th lldy
_ .
~ : ~ ~a ~ ~ 9? ~,~c,~ t ~
~ _ . _ L,~ . (iirs.) Pearl H. Long ~
~ . ti •y; Puhlic - ~ ~ng uper~'isor -
- - • is•~i~i: ei flerid. er tw~.
,
- •~1 • J ¦ Z ~ ~
~ j"h ' «'hose 13!~sine~. Addres. I~:
. 1' •'A!~'~'" F'v~ a. Cesvohp Co.
i~
Palm Beach Lakes Boule~•ard xt Flagler llri~-e
~ «'e~t I'alm Iiexch, Florida
~
:4
Jtailin~* Addrt~••:
~
P. U. Ror 28~1
~Ve~t Palm Beach, Florida 3~3~10'L
' -
>
~ S~K2i8 P~E2~~98
~
~
~ _ . . _
~ x _ - ~
~ ~ : ~ y~.~.E - ~ ~ _ .