HomeMy WebLinkAbout0823 - . . . ~ 4~- ~9~. ~
~ • . '~1
y 1 '
Whsn r~cord~d, return to: Opn '
~ f~CE ~ ;
~ + =1~ED FOR RECO= .g;~ ~
AT REQUEST OF
' ~ SANTA ~LARA VALLEI?
~~s3 MEDICAL CENTFR Q
Ma~ i 3 I;,~ P!~'~~1
i
OFFICIAt R~CORDS ~
3ANTA CLARA COUNTY• ~
Santa Clara Valley Medical Center QEORGE A tdANN ~ i
751 S. Bascom Avenue RE(i1STRA~RECOR^F~ ~ ~
San Jose, California 95-128 ~ COLI.ECTED ~
yyNE RE«ASE RECORDED. ~
(Abov~:poce for Recorder's usa.)
3- 3~- S~ -~8 AGREEMENT TO REUMBl1RSE Da~e a-~d - 7~
co:e ~ 33 - 37 - d d' . ~ .
' woNU?N ~cK~ ~T ~
MAN ~C 1~P ~ ~
Soc Sec ~~~~-~0- ~7~~ ~~'~ol Status `J!7 Soc. Sec. ~~,~-.~"_Q~/ ~rifo) Srotus
Moiden Nams ~
Alios Alios
Birthdote ~ O~-oZ.3 - 7 7 Birthdot~ 3_- 7
_ . ,
Present Atld~sss
We or 1(the uss of the plu~ol in this i~atrument to inciude Ihe singulor) herebr «knowiedge fhfl~ ~+e, or members d our
:rnmed'euls iomily (used herein to mwn spouse. porent, or chiW) ho~s reCeivrl relief, core. ond moinianorxe ond/or medi~ol
oid from the County d Sonta Cbro, Sta~e d Colifornia ihere~~oiter called Promisee), anci tt?ot we agree to make re~m-
bursemenl for oH oid ond ~;sistonce rendered us, or members d our immediote [omily during oll per~ods o( our dspendency.
posf, present, ond lufure. .
We 00 HEREBY V!'ANE the limibtion af anr statute for Ihe presentotion d ony claim for the ~epaymenl d soid relief,
core, and mointenonca ond/or medicol oid rw~w o~w~n9. or to come due in ~he lulure.
We ~O HEREBY AGkEE thot all monies so poid by the P~omisee sholt be secured by o lien ~n oll property thol we own
or ocqv~re; ond in Me evenl d cominp into possession d ony lu~ds or properly o) ony ki~, or if a1 Ihe time of dealti we
le~ve anr estate wholsuever, we agree thof wid Promisee shall be repoid lor oll monies so poid, os o prefened cloim•
The Follawinp is a ~rue ond cor~ed desuiption d a~~ ~eo~ W°P°rty awned by us or in which we have an_ inlerast:
~ F LEO +?MD REC~At~Ep
~~~t ~oPa~nr: / 8 9~ ~ /8 ~ ~ 9 s~. iuc~e couN Y i~. ~
~ ~ • CIERKCCI3L`UR
~a~
Addreu: P~~ ~ . ' RfCONDYfftIF1E0 .
~~a~ ax~~~: ~ r~ ~ 21 10 K3 AM'1~
---p~ _ ~ ~s~~~~
Noms d Co-Ownir. ~ ony
f~~w ~ ~ a'E~ i~'"
..~~~z~"_
L Cpr
enl to Ihs trsofion d o lien o~go
st e
bove-d~~ rd pr~~ in which I hove an
1, ths unde~siynsd co-sisosr, cons
~nterest, under tha terms ond cond~Yr~ns ss1 forth obo~e, but 1 a:sum~ no p~rsonol liobility for repaymsnt d ony oid and
ossist6~cs rsndsred lhsrevnds~.
V~
. , ~t
ST/1TE OF C/1LIFQ~`NtA Ci~d'RG~ ~i. FOWt.FS
County of Santa
~~rt~ - - } . Q ^
On this-- ----`--~,~..~ajr=cf . . 19_ 7~..before me. _ _ . . . r
County C~erl~ D~~Oed'GOunty of Senta Clara. State of Cet~forn~e~oersonally appeared ~
, - _ ~ ~%~1e.-- . _ . - - - . _ . -
C e. r
-.-----•--~=--i'~--~------- ~
; L Al /~r .C.lf'.e..r...%
- - - - - .
Rnown to ma to be•~he person. whase r.ame.S.._ .subscr~bed fo the wrth~n instrumcnt,
end acknowledged~fq mq.~at :.-~/t.~~ --e:ecuted the same.
j~
~N WITNESS WHEREfJF, 1~'ia~e hereunto set ~ry ha~d a~d aff~:ed my off~c~al seal et my off~ce ~n sa~d Cou~ty and State the
day snd ~rear in th~s cert~ficete f~rst eboye w.~tten_ •
County Ckrk . -
L' ~
(S~/1l~ Disp~sit~on: wh~te - CotlecUon F~Ie-perm ~
canary - Ctedit f~le-ptrm A~~~
pmk- Patient ~I,IZAB~ -
= 2"1 p. q a v R ; ~ by.. . . - - -Geovh . - h Gk.k - . , ~ . _ . .
- ~r -
:
r° - r_~