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CLAIM OF LIEN
STATE OF NEW YORK
COUNTY OF SUFFOLK
Before me, the undersigned authority, personally
appeared JOHN EVANS who, being duly sworn, says that he is the 1
agent of the lienor herein, SMITHTOWN GENERAL HOSPITAL, whose
address is Smithtown Bypass and Route 111, Smithtown, New York
11787 and that in pursuance of a contract with HATTIE BARNES
lienor furnished professional services consisting of hospital
and medical services of a total value of Ten Thousand Six Hundred
Thirty-five and 35/100 ($10,63S.35) of which there remains unpaid
$10,635.35 for which amount he claims a lien on the following
described property in SAINT LUCIE County, Florida: 1~'~994
527 North 13th Street . 190 NAR 18 pH ~ I$
Fort Pierce , Florida FILfO t?AC RECORUfD
51 LUCtE CO111lrrY.fLLA.
ROGER PQiTRAS
CLERK CIRCtliT COt{RT _
Owned by HATTIE BARNES . ~RR,~~--~., ,
He further says that lienor furnished the first of said
services on November 19, 1978, and the last of the same on Jan-
uary 13, 1979, and that lienor served his notice to owner on
October I0, 1979 by service on her next-of-kin. Under penalties
of perjury, I declare -that I have read the foregoing and the facts
alleged are true to the best of my knowledge and belief.
SMI ~~TN G E HOaPTTAL
Lien r or Authorized Agent
Sworn to and subscribed before me this 14th d of Mar h, 98
.This Instrument Prepared by: Notary blic State f N w York
GRUNDFAST & KLEINMAN
Attorneys at Law RoT~~ ~7~ORF N ~CRK
2297 Middle Countr Road ~ 52.6693015-gptLLtFtED tN ~Ft;,IK Cy:JNiY
Centereach, New York 11720 t~ ~ ~ 0
8327 P~E216'8