HomeMy WebLinkAbout0634 .32.~~23
A'~ '~w
CLA I M OF I~RANGE I~MOR 1 AL HOSP 1 TAl ASSOC I AT I ON, i PlC D01 NG s,,,s
8US 1 NESS AS ORANGE NEMOR I Al HOSP 1 TAI.
F I LED UI~DER CHAPTER 59-1 a24 FI.OR IOA STATUTES ~ a`-'i'"=
~ ti~
.wco°~ W
STATE OF FLOR IOA ) ~ ~ }
~ SS ~ ' i~ ~
COUNTY OF ORANGE ) ~ O f
s~+ ; ~K . ~ t
t.7
J• D• W O T'~
A l l O F O R ~ANO O~ O
RANGE COUNTY ~ FLORIDA~ BEING FI ST ~
DUIY SVORN SAYS TNAT ME IS THE ASSISTANT CONTROLIER OF TNE ORANGE ~NORIAL HOSPITAL ~
ASSOCIATION~_ (NC.~ A NON~PROFIT FlOR10A CORPORATION~ WHOSE ADORESS IS ~~~6 SOUTH ~
ORANGE AVENUE~ ORLANDO~ F~ORIDA ~SO6~ ANC AS AN EXECUTIVE OFfICER OF THE ORANGE
N~MOR 1 AL HOSP 1 TA~ CERT 1 F 1 ES THAT FY'il@St O• GOO~'~CIi VHOSE ADDRESS AS 1 T
APPEARS ON THE RECORDS OF SAID HOSPITAI IS 6306 Emerson Ave.,Ft• P~@PCe~ F1. 3~~v i
HAS 9EEN FURNISNED MOSPITAL CARE~ TREATNENT AN~ MAINTENANCE fN THE ORANGE N~ MORIAL
HOSP 1 TAl FRON ],Z~O(~~'J5 TO THE DATE OF }lig p 1 SCHARGE FROM SA 1 O MOSP 1 TAL ON 1Z~Z3/ 15
THAT F,2'i]ABt. O. Goodrich I S 1 NDEBTE~ TO THE ORANGE N~MOR 1 AL HOSP 1 TAL 1 N THE •
3
SUM OF ~ b~OlO•~O FOR SUCH HOSPITAL GARE~ TREATMENT AND MAINTENANCE ANO THAT SA10
SUM IS NOM DUE ANO OMING THE ORAkGE N~MORIAI HOSPiTAL AS A REASONABIE AND NECESSARY
GHARGE fOR SUCH HOSPITAL CARE~ TREATMENT ANO MAINTENANCE.
TO THE BEST KNOWLED(iE OF AFFIANT~ SA10 E1'R@St O. Goodrich SUFFERED
INJURY OR ILINESS BY REASON QF AN AGCIDENT OCCURING ON OR ABOUT THE 6th CAY OF -
Dec embsr ~ 9 75 -
AN EXACT~ EXECUTED COPY HEREOF HAS BEEN FURPlISNED TO SA1~ ~yrnASL O. Goodrich
AT TME AFOREMENTIONED ADORESS.
TO TNE BEST KNOMLEGGE OF AFFIANT~ THE NAMES AND AODRESSES OF AlL PERSONS~ FIRMS
OR CORPORATIONS CLAIMED BY SUCH ILl OR INJUREO PERSON OR 8Y THE LEGAI REPRESENT-
ATIVE OF SUCH PERSON~ TO BE LIABIE ON ACGOUNT OF SUCN ILINESS OR INJURIES ARE AS
POl LOb1S:
NANE ADORESS
Ernest 0. Goodrich b306 rmerson Avenue; Ft. Pierce, Florida 33450
ANO THAT A COPY HEREOF MAS BEEN MAILED BY REGISTERED MAIL~ POSTAGE PREPAID~ TO EACH
OF SA1~ ABOVE NAME~ PERSONS~ FIRMS OR CORPORATIONS AT THE ABOVE ADORESSES OH THIS
3pth o~Y oF Dece~aber ~ 9 75 •
THIS CLAIN IS FURNISkE~ TO AND FIIED MITH TME CLERK OF THE CIRCUIT COURT~ ORANGE
COUNTVj FLORIDA~ PURSUANT TO THE AUTHORITY AND PROVISIONS CONTAINE~ IN CHAPTER
59-~OZ4~ LAMS OF FLORI~A~ ~HOUSE BIIL NUMBER 23~I~~ AND UPON TFiE FILING AND RE-
CORDING HEREOF BY THE CLERK OF SA1~ COURT~ THIS CLAIM OF LIEN SHAIL CONSTITUTE A
j LIEN ON THAT PART OMING OR BELONGING TO $PI1@gt, O. Goodrich ~F ANY RECOVERY OF
f MONEY OR SUM~ HA~ OR COLLECTE~ OR TO BE COLLECTED~ WHETHER BY JUOGENENT~ SET7LEMENT~
SETTLEMENT AGREEMENT OR COMPRONISE~ TO THE EXTENT OF THE AFORESAIO REASONABLE ANO
; NECESSARY CHARGES OF THE ORANGE N~MORIAL HOSPITAI FOR THE HOSPITAL CARE~ TREATMENT
` AND MA I NTENANCE OF SA I D j'y~`Iiggt O• (~ppol`~Ctl UP TO THE DATE OF SUGk PAYMEHTj s
~ AND REGOR~ING HEREOF SMALL CONSTITUTE NOTICE OF SUCN LIEN TO ALI. PERSONS~ FIRMS OR
~ CORPORATIONS 1~IH0 PAY ANY JUDGEMENt~ SETTLEMENT OR CONPROMISE TO SA10 ~ABt. O. 6oodrich
~ ARISING OUT OF ANY CLAIM FOR DAh1AGES FOR SUCH IIINESS OR INJURY MHICH_THfy-~~
Ernest 0. GOOd2'~C~1 HAS AGAINST SUCH PERSONS~ FIRMS OR CORPORATIONS~ TH
ASSIGNEES~ AGENTS~ OR PARTIES HAVINCs AN INTEREST BY OR THROUGH SUCH PERSOHS~ FIRMS
OR CORPORATIONS.
~ TME FEE OF THE CLERK OF THE CIRCUIT COURT COVERING THE COST OF FILING AN~ RE-
GORDING OF THIS l1EN HAS BEEN PAI~.
. ~
' AS SSISTANT CONTROLLER OF ORANGE N~MORIAI HOSPITA~
~ STATE OF FLORIDA )
~ ) SS
~ COUNTY OF ORAfVGE )
' / 30 December 1975
~ Oa THIS o~YIAPPEARED BEFORE ME J. D. Worrell OF ORLANDO~ FLORIDA~ TO ME 1~IELL
~ KNOMN TO BE THE PERSON MHO IS TNE ASSISTANT CONTROILER OF THE ORANCaE N~MORIAL
~ HOSPITAL AND HE OID EXEGUTE THIS1,C TI OF-
THE ORANGE N~MORIAI HOSPITAL ASSOCIATION~
~ (NC.~ PURSUANT TO CHAPTER 59-~~Y~ IN MY PRESENCE.
~ .
e:
~ ?~.i _ t : ,r.''~'iT ; ~ C~./
~ r ~ G . ~ ~ . . . ' .
:
~ . ` . - ' , . _ COMMISSION EXPIRES •3 Z I~~'r1,, ~ ,
, ~ ~
~ ~ . ~ . . - ' . . ~ARY r{tfiK AAT! OR RORIDA AT URliLi c~ : ' ~ , ` -
~01~lP 1l~1
~~d !fM! tt. 1~ - ' . "ti ~i 1. ,
~lRANC! 1I~~ . ~ , ~
-
BaoK247 F~~E 63~ _ .
# .
_ _ - ~ ~
y ~ ~ -
~ ~L _ ~.-~k.
~ _ _ W