HomeMy WebLinkAbout11-19-12$ I
NOTICE OF CLAIM
(Filed Pursuant to 20 Pa.C.S. § 3532)
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
inl'~iTe~L ~ ~ATTL?S , DECE A SE.D
ESTATE DF
No. 21-11-949
To the Clerk of the Orphans' Court Division:
Enter the claim of
Mercy Flight Central, Inc.
in the
(Claimant)
amount of $ 14,894.34 ,against the above entitled Estate. (includes interest from
August 28, 2011)
The Decedent, who resided at 514 Partridge Ct.
(Street Address)
Mechanicsburg, PA 17055 ,died on August 30, 2011
(Date of Death)
Written notice of
said claim was given to Shaun O'Toole
(Personal Representative or his/her counsel)
at 2813 North Second St., Harrisbur , PA 17110
(Address)
on October 30, 2012
(Date)
i/~ ~
(Claimant's Counsel) (Supreme Court I.D. No.)
Robert P. Rothman, P.C.
(Address)
120 E. Washington St., Syracuse, NY 13202
315-474-6077
(Telephone)
Form OC-07 rev. 10.13.06
(Ctuimar%r1
Mercy Flight Central, Inc.
(Street Address)
2420 Brickyard Rd., Canandaigua NY 14424
(City, State, Zip)
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~Fr~~r:MultiMed Billing Svc 10/30/2012 13:09 #260 P.003/003
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Mercy Flight Central Inc Run Number:
PQ BOX 535
BALDWlNSVILLE, NY 13027 ~ ~_ '~ "l -~ O3rJ7$
Tax !D; 161427751
MultiMed Billing Service ~Ic Toll Free {804) 927-5845 ~k Local (315) 635-1789 ~ Fax (315) 635-3289
ADDRESSEE
To the Estate of
PAUL. MATTUS
C/O KlLLIAN &GEPHART, LLP PO BQk 886
HARRISBURG, PA 17108
48~2g/20'i ~ I Robert Packer Hospital ! Thomas Jefferson University Hospital
F'sxed Wing Base Rate ~~
Fixed Wing Mileage 174
05131!2012 Transferred to Collection
DETACH ALONG LINE AND RETURN STUB WITH YOUR PAYMENT. THANK YOU.
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REMIT TO
Mercy Flight Central Inc
PO BOX 535
BALDWINSVILLE, NY 13027
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Amount
^ Check !Money Order Ertc~osed
^ Visa ^ MasterCard
CFRO NUMHER EXPIRATK)N MUST iNCLUOE 3 D~GiT
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r / SECURfTY CODE FROM
HACK OF CARD
PRINT NAIdE ADD 6
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SIGNATtiRE
~ AMOUN7
PATIENT
PAUL MATTUS
C/0 KILLIAN &GEPHART, LLP, PO BOk 8
HARRISBURG, PA 17108
Optimed
Bill Pafient
11-103578
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10/30/2012 11 /13/2012
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PAUL MATTUS
$7,462.93 $7,462.93:
$34.50 $6,003.00
$13,465.93
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