HomeMy WebLinkAbout1126 2'736~~1 ffLEO Ah? KtCOR~EO ~
iT.LUC~E GOUNTY FIA.
R4G~ ~ ~J:TRAS ~
C~ERK CJ~T COURT
tIOSI'iTAI. CLA111 OF LIE~ RfC~R'~ Yf ~
J~u+ 31 9 ie AM'7~1
STA'I'E 01~ F LOltl[)A )
~ SS. 2'73641
~OU`Tl' OF ~?itB~ )
ST LUCIE
.~ha~1p~.s-,T.~,_Gj,lhpfe~.~-_~., bein~ over the a~e of twenty-one ycars and first
duly sworn, states upon his oath that:
1. t~e'is the ~gg~er~t_Sug. of Jackson \lemorial Ilospital, which is owned and
operated by Dade County, a political subdivision of the State of F lorida, and he is an agent of
Dade County and an executive officer of the said hospital. llis business address is Jackson ;~te-
morial Nospital, 1700 N.W. lOth Avenue, 1liami, Florida. `
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2. Dade County, pursuant to a contract with ;
Indiana ~
whose address is ~,8.0.$~aL.- '~i~a?i, ~lc.icida, has furnished care, treat- ~
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ment and mai~tenance to -_Sa~ba~a- - , at )ackson ~temorial Nospital, :
1700 N. W. lOth Avenue, 1liami, Florida. _
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3. 8~^~3~~?Jallz was ~dmitted to Jackson 1lemorial t~ospital on
the day of > 19 ~3.._ , and was thereafter cared f~r, treated and
maintained by Dade County, Florida at Jackson 1lemorial tiospital, to and including the _23rd
day of ~t).pr 19 ..Z_3- , the day of discharge. There is now due and owing
to Dade County, Florida for the care, treatment and maintenance of R~rb~a. ~a i~ ~ _ ;
the sum of f - ~9~93~•40 , ?
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~ 4. The afGant is informed and to his best knowledge believes that - g
f John Doe-accident at 6697 Howard Rd Rt#2~ Lakewood Park~ Ft. Pierce, Fla. ~
~
~ Lee Fisher(owner of prO.,perty) 306 Emerald Pl.~ Indian Harbjror Beach, Yla. 3
° ~ Z~opigas Inc. of Fla., 7570 Ai.W. 14 St,, i4iami, Fla.
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is responsible to - ~~~ara Walls for the injury or illness of
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~ Barbara Wal .
~ S. The amount due and unpaid is just and reasonable, and Dade County, Florida, does
~ hereby claim a lien upon any and all causes of action, suits, claims, counter-claims and demands
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~ accruing co _ Barbara ~~lalls and upon alt judgments, settlements, and settle-
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~ meat agreements rendered or entered into by virtue thereof on account of the illness or injury
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~ giving rise to such causes of action, suits, claims, counter-claims, demands, judgments, settle- :
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ments or settlement agreements, and which necessitated or shall have necessitated such hos-
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;:5 pital care, treatment and maintenance as furnished the:s~id Aarha~~9 ~ _
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by Dade County, Florida. 1~'~ ~ , -
~n ~L~~ ~ ~ .
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~ ~ ar s J. Gilh Qr, ~Jr -
f~ pital Service Supervisor
- Sworn to and subscribed befoce me this y of n~~. _ _
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19 . ~ ~ ; J ~ •
otary ~ublic, State of Florid~ e~t.~.ar • s=
r 1003 327 3128 t~N1~RY P~ri1C STATE OF F.QRIpA Af i +r~ ' '
µY co~~ss~o+v erP~ets eur ~ . ~ ~ ~
r~ , sQtu~eC tHBU Cs~r,~t~?1 ~4~R~ntL"E u~[o~t ~~c'-
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11y Commission Eapires: ~ _ ~
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= 121 .15-32 (4 -6~01