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BaliOlRa Ma, tA~ urider~~gn~d tuLJwr~ty. p~rsonnaly app~ar~d J11J~S R. Mllir,
o! Or2ando, Orang~ Caunty, l2or~di, wbo, b~ing du2y s~wrn, s~ya tAat !~e i• tb~.
CJi~D~r 1~WAGaR of Orlando R~g~anal JlMdical Center, Inc. , the Lienor herein,
hsre~tutter r~f~rzyd to ai Jlotpttal, wbo~~ iddz+~s~ is I111 South xuh2 AveAUe,
Orla~r~do, llorfds 3?d06.
App~ar~ng on the r+~c~ords of this haapitil,
Patient 1lddreas
Marie L. Gagno~/minor Rt~3 Box 3268 Ft. Pierce, ~i. 3345~
has bssn furntsb~d haapltal cue, treataent and aa~ateriance in Lhe hosp~t~l
fra~ idwtaston 12_09_gp to the dite of hta/her d~scharge ou 12-14-80
rhs aa~u»t c2a~asd to De due for auch haspits2 care, treata~nt ~
maintenance is $1 711.02
ro tbe b~at kno~rledge of the Aff~ant, the na~es and addressas of •21
peraons, f~rins or c~orporattona clatasd by the patttr~t, or by the patient'a
legel repreaent:tfvs, to be 2table on ac~ount of auch tllness or injarie~ fs
as Fol2owa:
II1111~ JDDRBSS
Paul R. Gagnon/parent Rt~3 8ox 3266 Ft. Pierce, Fi. 33450
Sentry Ins. i850 Lee Rd. Winter Park, F1. 32789
Policyholder is Paul R. Gagnon
Tfiis Lien has been filed in the off~ce of the C1erX of tAe Ctrcuft
Court in St. ~ucie County on Oeceraber ~ 1980 , and a copy aailed
by reglatere~d ma~1, pastage prepafd, to each person, ffrs or corppration stated
above.
In acc~vrdan~e w~t1~ Chapter 59-10?4, aa a~eendsd, and Chapter 71-?!,
Laws of flor~da, tbe f~liny of the Lien sha21 be notice of the Lten clai~d by
the Boap~tal to a12 persana, f~s~as or corporatio~ns who way be .2.table on ac+count
oP the pattent's illness or ~njnrfes for a22 rdaaanab2e cl~rges uisiag fro~
the hoapitil care, treat~ent and ~a~ntenanc~e furnfahed to the patient. T1~ts
Lian sttachea to any and d11 causea of act~on, su~ts, claiaa, c~ountercla~aas and
deernda accruin9 to the pat~ent or h~s/lier Ieqil representativea and npan a22
judge~es~ts, aettleaients and settleaent agreements rendered or entered ~nta by
virtne of the illness or injuries givfng r~se to snch causes of action, ~ruita,
c2a~ms, ete., which necesaitated, or she1l lave necessitated, such hosp~tal care,
trestment and mafntenance.
l~o release or aatfsfaction of any act~on, suit, clafae, etc, sha21 be
va1~d or effectaal as aga~nst this L3en untfl this Boapital shall join therein
or execute a release of thts I.ien. In the event thia Bospftal ~s reqe~ire+d to
fils auit to enforce its rights, and prevatls, it ~s entftled to recover
reaaoneble attorneya' fees and e:penses incldeat to its action.
The undersigned haa read the foregoing claia and cert~ffes that the
ellegst3ons contafned therein are true and oorrect.
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Jaafid R. Miley, Credi t~Iana94t -
Orlando Regfonal Med~cal Csrster, Inc. _,. ~
Sti+orn to and subscribed before me this /~ ~day of ~~ /°f~
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~6Z7~RY POBLIC - , ~ _ : , _ • _
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Casaiss~o~n Esp~res =~~ :;'" ~
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This instrument was p~epared by t:.~.~,~ -;.., ~:- ~- ~.,~. ~,;.,~..x~T~
James R. Miley, Director of Credit ~
1414nS~ Kuhl Ave. OrlandoCeF1er32806~ 1~.~~ 23 ~~ 08 ~-~9~$~
S~ LI~K~ ~f~i ~ ~
511566 RpGER P~`~S
CIER~ ~w'iN7 COt~t~ _
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