HomeMy WebLinkAbout04-10-07
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ventures
April 2, 2007
Cumberland Register of Wills
1 Court House Square
Carlisle, PA 17013
To whom it May Concern
Enclosed please find an itemized statement and a claim form to be used to file a claim
against the estate of Mary Zeigler. Mrs. Zeigler incurred these charges while a resident
in our facility, West Shore Health & Rehab Center. Enclosed please find a check for the
amount of$10.00 for the filing fee.
If you should need additional information or have questions regarding this please feel
Free to contact me at 877-823-8375 ext 2270 Monday thru Friday from 8:00 to 5:00 PM
Central Time.
Sincerely,
Rita Donnelly
Healthcare Collector
Golden Ventures
P.O. Box 180970
Ft. Smith, AR 72918
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Golden Ventures
PO. Box 180970
Fort Smith, AR 72918
www.goldenven.com
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ventures
Claim Against Decedent's Estate
Estate of: Mary Zeigler
Case# 21-20070299
The undersigned hereby presents for filing against the above estate, this statement
of claim aDd alleges:
Golden Ventures/dba West Shore Health & Rehab Center
P.O. Box 180970 Fort Smith, AR 72918
The basis of claim is: See Attached
The amount of the claim is $683.45
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.
Slgnedon:~ ~
Claimant
I swear this statement is correct
Subscribed ami sworn to before me
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TWYI..A LENSING
Sebastian CowIty
My Commission Expires
JtrJe 17, 2015
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Notary Publi
My Commission EXPir.s~~ 11 J )D / 5
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Golden Ventures
p.o. Box 180970
Fort Smith, AR 72918
www.goldenven.com
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Golden Ventures
P.O. Box 180970
Fort Smith, AR 72918
Itemized Resident Statement
Resident Name: Mailing Address: RESIDENT ACCOUNT #:
Emily Reynolds 78899-00285-40578
Mary Zeigler 1060 West Limekiln Road DATE PREPARED:
New Cumberland, PA 17070 04102107
DATE I PERIOD COVERED DESCRIPTION DAYS I QTY CHARGES CREDITS
01/29/07 Beautician 2 $21.00
02/01/07-02107/07 Room CharQe 7 $662.45
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CHARGES CREDITS AMOUNT DUE
$683.45 $0.00 $683.45
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