HomeMy WebLinkAboutMINUTES - 04211987 - 1.32 CLAIM
BOARD,-.- SUPERVISORS OF CONTRA COSTA COUNTY, C �FORNIA
Cl-aim Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT Ap r i 1 21, 1987
ani, Board Action. All Section references are to ) The copy of this document mailed to you is your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amount: Unspecified Section 913 and 915.4. Please note all "Warnings".
.461:: DELTA MEMORIAL HOSPITAL
County Counsel
3901 Lore Tree Way MAR,l 9 19$7
ATTORNE : Antioch, CA 94509
Date received Martinez, CA 94553
ADDRESS: BY DELIVERY TO CLERK ON March 13 , 1987
BY MAIL POSTMARKED: March 12, 1987
1. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
March 16 , 1987 PpHHIL BATCHELOR, Clerk
DATED: BY: Deputy
L. Hall
I1. FROM: County Counsel TO: Clerk of the Board of Supervisors
( This claim complies substantially with Sections 910 and 910.2.
(}� This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: �/ 6Ch•C� �� g BY: L eputy County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: Byunanimous vote of the Supervisors present
This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
ZZ
Dated: APR 2 11987 PHIL BATCHELOR, Clerk, By , Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult
an attorney, you should do so immediately.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above.
APR 22 1987
Dated: BY: PHIL BATCHELOR by Deputy Clerk
CC: County Counsel County Administrator
DELTA MEMORIAL HOSPITAL
3901 LONE TREE WAY
CA
PA WT NO AUTHORIZATION NQ DkYS AWK)CK 94509 ADMIT DATE TIME MED.RECORD NO.
9390147 03/04/87 ol 16 :24 33521
PATENT'S NAME n 1 I ENSEN ,ERIC L PHONE 634-7608 PPAT PL E R
ADDRESS `_ __ _ . Z_-_-- VERY B A Y
ADMIT
CRY,STATE.ZIP :_ CA 94514 TAR NO. CLERK
IlIm'S BLROYC
ADDRESS
CRY,STATE,ZIP OCCUPATION PHONE
ATTENDING PHYSICIAN DR CODE Ft I NO9 SVC 51RT DATE AGE SEX I RACE MAR LEASE REL
STATUS TO PRESS
DR MARY F '- = : `':_':'� 10143 Q0 E/R 01/05/68 119 M W S
RESPONyBLE REL OF RESP. RESP.PTY. RESP.PARTY
PARTY NAME PARTY TO PAT.M SS.N. 54'--:-59- 142.9 OCCUPATION SEC .
ADDRESS r 'vL`i'i BAY BLVD RES.PARTY WILLiIIAM BOYD RE�64f 684-2276
CRY,STATE,ZIP = CA 94514 F� R ESS 617 0 B E T H E L I TL A WIG EMP.?
PHO;iE _ = CITY,ST,ZIP b E T H E L ISLAND ,C A
NEAREST RELATIVE RELATIONSHIP DAY PHONE
_ -.- �
�TENSEN FATHER +TPHONE634-2997
INSURANCE CODE NSURANCE COMPANY NSURED PERSON/LD.NO GROUP NO UNION LOCI SEX REL
pR IU Ali: 00"
CHEF COMPLAINT EMPLOYMENT IF NJURY.
_ RELATED? DATE 0 3/1"L8 7 TIME
REFERRED/BROUGHT BY HOW&
WHERE NRJRED _
e
A Ilm d •Kt DEI M 7r 1C�
e _ W CO ..T DEMO Olt r.,untoI IM
M
19
fir. f
r�sENrt MET�CATToriS J
T
t
»WORT Z
ftnSICAL Lu
[.6 c.
r Eo
4)elk 4J A ' 014AAA
L Zf ofi, r
TREAT `
"A LA0LAjJ'-jpj
- �Z ,o�'uA$.
2
w
T71ACrN0615 QN
CONDITION OF MTW ON OECKQM TYRE NOME HDMUL BOOM NO OILER
• r E3 C►IA [3 ❑ POLICE
❑BEIATKS lIVES ❑ COCO
RONER
RERFAM TO. NNOrf NO FAMRY nnslgry F WMATE INFIR KTION"ET GMK wiCAn wIRCN om
^1 I - i X4RAYS WERE TAKEN PIFAGF DFFFP to vrWo rv,rTro cro a IA, oc
'77
00000000000000 00!000, 00*00oocloo'066.10
00,00 ^m o .m
w 0 w w w wu w W.8 w WQ W Ej.8000
W WW W wu w EJ,L)W tj W LJ W(i w ti w w ti4i L) rn
00000000,0001000'000l000000i0000000o0000'00000000 c
AAAAAAAAAAVPto,Ol 01(A Ti lb lb 4b 4b lb 4b Ab 4b.4.4.
mmn.4�4 N.4%4-4 �4*4,,4 N%4-4 J�A 1-4%J�4 %A%4,%4�4-4-4-4 4�4*4 14 �4.4,14 14 4N-4,41*4 4 fn ommmmmmmmm''mmmmmm;mmmmmmmmmmmmmmmmma'oaQ -1 -4
V��
Q
1-4 L.4L1-4-4 -4-4-J WIJ%J 14-4 14 N � . . � .
%J%J %J%A NJ%4-4 j W V-4-4 j,4%J
fjr0000000IUOO-br,000000000--� 6000000000'000—.lb4b*A `
WViRuuUluuuWK)jh U L"LP Lp An U t+"b-b IU u U Lp u fu A).4b 4b
OLMOOr00- 000:0000-00--0-0000-0-00000000000000 ,
4b-I*fu
P.)fu7v-PJ,000;OoOK)FJOO O:OPJO �o4D0K)Oo---L)-b-L)OOrUIOQOO 0
ti
WOE- 4M--4��4 0 W W.1b-J-tj 0 Vdo
-OWW�000 PJO-�-40-00- 0%J V,CD 0 9A ti 0�
q N D�lu OU Pi r.0-0,0-1), &jL)Oa
C,MIX m u)Tn a a q om -an >vLconmwonmLoom)v) lo li
1 2,O:Cj
64 p -4-4 IM X m .0
z rn m =<< _4VOLP I =0=00=W02P
iornA. rn -400 f"ecu
rel zo m m2z r-lumnop "C w 0
M>W^Ownm m C,z I r-c .m Mz r N, .'a
m IV W-4 3.X0> 1 0 m m CA 2 3-)'ton licm--i r x 0=m r m AD
x w CO•b 0> wwOLOr -4-1
mozmxzxm mzm <n3. nu"wDxpmz -qzom<
VZOM. 4)- _40.<a « M40N Z Oarnm-6 0.%!WWMC- =0 V► n -I I m
ZZ 0 "Mm 0
DNI
0 -j V. > rcn Z-1. 3 m-1
3. �z LW 4�,e w z 0 n 73. !Z
K)>Dlum" O >t>r" o> c cl* v 2� + -4>_4or"v
m Nx-4 r-1 mmm n rn rain`-mina 0 0 mmx:• -4
OMM> MON xm V)I. or >'D Om mm co 0 a m m m
3 "r 0 m -1 v rm^ a 4% �-0 r-P.E 0 WC)"CI3:� tan10 -4 >
I w m to) I " W-4 1 3z w vl fn v rz
Poo C)0 Z M
n o z M
z Om z 0 z r 3p,v,on m z 00 m 0>
zc "a me w c mrww"-m-6-wC m tj"r-i m c rm
rn m ru w m \\ � iu j.A.)m r ru . , n . vu m m rn c
LD "o Dm w m r 2 OO"-< O . nmxr_ 0-.4 2 0 tj).w r- -4
r 30 Z in 0 3)."c M
DD 0-4 GC c-1-i c-4 m1 x c n-111
m m D Ax 9) 7.xati1 1z
r m 0 m
0 Do omm
c r c m z
m
z
Z z z
z
CD M.9h. w -ab M K)4b 0
CJb.&Pjv-f -pjpj k3fuK) cRPJ-0 WA %J CA .& m
P PD
0.0 -our Ow PV wP 00 wo D-�s 0
00 W%J 40 00 NO u 0 w m 0 (A 0 �j it) -b 00 -b Ab 00 fu too.0 c
O 0 N mmmmOjOODuoDO," U00 %300 00300 %)OODOO 0 0 D a to Lq o
:.z
JP.
10
-m Z 7,7, -
G V�O J - N C t C O ♦- \ --.0-6 C V O i V ♦ I.i N
' I ' 0w0w0wCwwOOw1CwCOCC• 10- A..W
OO Cw ' OOCOCCCOCGC O
W WWWWWWWWWWWWwWwCWWWWWWWWWW.F.) ww . InW
r o+-oo�000000'000'000�000:000000:000000`000000.000.o .-c r
-. ► I : fV0 : OI:O : • . m � mD .
ID CD m 1O m0 0.0- -0.0-a-OOVVV1*4.0 aID
07 M w w M M ID ID ID ID W ID ID W:W ID ID.ID W IMM m N ID OM W M M.0m 0)'m m m W m Gl.m m Ol m -4 CD
%J.
V. VVVVV.VVVVV,VVV'VVVVVVVVVVVVIVVV;VVV1VVV'VVVrVVVV mV
v 14Vw V 4:V V VV V*4 V W VV 14,-4 V V V1 V V V4�-4►- -4%4
V V'w
O 0000000.000000;00 « rr1A 00000000000000000x000 0;0..
U D-CD U U U U U0 U► 'U 00 r i " U C u U U U U U U U U U1 U U C U UU U U
O'Or00U0O -00!o00000000"000- 000"00000-000
: A '
V U O N N'N W V r N 0 0 0 0tA 0 0•\"-0 CA V O!V N OU 0]00 0 V O O V O V OIN V OHO +
L) W:ONNNOAWUPP0O:W0WPPw�OWIDANOW•00 00w'0 .OA.OAO,NN00,,,.
r r�+ .0 0•.0\+
",4 0•N N V V A r•0'W w.010\ •0,N ID V W V N'V V r'N W N.V\+V Ol V V�'
A PUIDID:IDUwiONW:W.0.0'OOP'NNAPAVr0.0.0Ww:•0'0A'W•Or'•0w•00N.0 �
� � � I I I 1 I i I I � .�
C n C 00.vOG►+G\+ +001NIDW��W�nCDcvv'cc\+!vvc wcwco!CCv� d w
c :o U cA t6 r Ic z,z 11 x o 10 a -4 M o-U 1 :W U z I I 1 z m►'�I �' i to Z 110 m •0
\••\ ',.fl ..'O Z L.=M ,4 m TTI w CA 3- O-:M ID L•\I •+31.0 Z U:V A�I'ca U«+'.�I O.0'U V 0X C w:O Ci O
Z Z' NID.nNC'C Ic3Z11 iZn2-10 !NOCI Z'Cm n •- n
D m a l r r Ir W ID!D N to;1A' Im m a x m'm D-4IW U- 'O A U)!' D N a w Voll 0]' IU.� m A D
r. IZ r!aoolow 1-+wr AAJ a iww 'IDr oA. -!AAr!►+z !A AIO�A.- VAI
<z0oIoZ31xzo:6wZv;mzn!rrnle T.w)nU'D o` v 10` woxuinautz o
WI 0MO0..i 0Zzra`�ommmm•• «Imnx:nwz:�� z m�- no>r�v -1 I m
.. nnn` n��- -1 �� zn -1In Ino I mn n , W •• z
Wn MPI •o'azz nCl32CI> i0 !c ="0'zz 'ozoIZMZU) zh • o m-I
�aWW'W\•\O.CNC.Caa �"55-r Dizv>:m c5 CDZ:>02-.0R) a9 _Z m
�UcuiU • COx3:3nn n�onn bvrn.mm3,nn nv;naC'j s ►+-1
nm•-.. «. c., N owrr maxxalW c,aoroxvrr �-iar►•rloor n�
0 0 000, 'Oz I rr►+ry r'mA I --i I cel -b . a
3 A A�A IN O O W W ►+` ZZ r� •-1< 1 W.a m O.W W V S<,W W I n W r z
.rr 11 1 0 a.0 a'a P P n m m z U ID,icy z DiP P D m 10,D PIU W 0, W
�a r U UtU'o C':A "�.4 r r C r r m W W�`C U)"!r r ►� (p!r p r W r 031,
r . m NNN OP rrNN .«+nth.\ Irl Nr.+rNN r m'NON �N Sn
IZ m In•+ «OO ozxxxr O-40<00 < -10-0 00 ID-+
IZ N�1 n M a a M N Z -4 r °F: M Y••�
l:a in MC••1�m.� �D .r r W 0
m me m10Om�x 0-4
m aminol0 0cm m . Zrn
�c
N M m N. z
._
c z m c
'r j r r r • �..r r r r ryr,r r r r r r r r r ,r r r r r r r r r r r r r r r r � � '
m I m' OD
D O
L I NPrr N N rr .p V A V:A r rrA Nr..' N R) r 3 m
A I L)I• EJWFFtJON-P«�OI�O• PP :b1 w VU V'wwV``PA00PPAOW PSD R)0 WP C
N _ 1'OODU�UCIW�UWO!oww000 Vo!NNATUW'Nr0�wCJR) JIDw Pw "Z 0.1
yrs yL- U 1-0 000 NOOK)OONNOOUO0CA 00NONOIDONNUOON'NON
.. ...r. _
•
• I I
II
V V IV V O.O P Q• C f 0 P C:: V ♦ L O L LiL L L L L 1: U L - W L' {:•'J - - 7 .-
-
�--- -� - _-�� i�Iia - C C O V 1 - J C 6J O Off♦ Y Z - O ti C OIO ♦ W N � Oi
L*
tom V
%4 I-4
0 id 00:0
911 0 to IN
0 00
C v0L)1.1 A I
m 4A m► i%o
W XD Or-?
m
i-1 -1 Z �N c O tj
o o xrmN- m
F b > m spa
0 min •+ �-�
ar fn-1 A I Z
_ m . m �31- r+n
z r z
T x�
0 ' in 3), Z W
ly m ..
I
Co
L*
K- I I . Z
f oim1m a m
a
x ►+ r i 1 3
N 1'N'1 IJ A0
m 1 rOPN .Z �..
D' N 1'-P 1 O N M-1
I
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County, or District governed by) BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT April 21 , 1987
and Board Action. All Section references are to The copy of this document mailed to you is your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to �vvernment Code
Amount: $10 ,000.00 Section 913 and 915.4. Please note all 1,FaVrRt*sPounsel
CLAIMANT:
MARIE SOUTHWICK MAR.2 3 1987
ATTORNEY: VAUGHN E. SPUNAUGLE Martinez, CA 94553
Attorney at Law Date received
ADDRESS: 207-37th Street BY DELIVERY TO CLERK ON March 23 , 1987
Richmond, CA 94805
BY MAIL POSTMARKED: CERT 790135 March 16 , 1987
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
DATED: March 23 , 1987 gy1L BAATTCYELOR, Clerkepu �4J o ,
Ann Cer elli
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
(� This claim complies substantially with Sections 910 and 910.2.
( . ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: Y,414L? 7 BY: L uty County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present
( This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date. /
Dated: APR 2 11987 PHIL BATCHELOR, Clerk, By �� �v Deputy Clerk
P Y
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult
an attorney, you should do so immediately.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above.
Dated: APR 2.2 1987 BY: PHIL BATCHELOR by Deputy Clerk
CC: County Counsel County Administrator
• Y l '
1 VAUGHN E. SPUNAUGLE RECEIVED
Attorney at Law
2 207 - 37th Street MAR ?3 1987
Richmond, CA 94805
3 (415) 6 2 0-0 3 9 8 PHIL BATCMEIOR
K 80 Of SUP V ORS
CON R COSTA
4 " • Byy
5 Attorney for Claimant Cert No. : �P 194 009 086
6
7
8 CLAIM AGAINST CONTRA COSTA COUNTY
9 1. Name and address of claimant: MARIE SOUTHWICK, 2437 Sullivan
10 Street, San Pablo, CA 94806
11 2. Send all notices to: VAUGHN E. SPUNAUGLE, Attorney at Law,
207 - 37th, Richmond, CA 94805
12
3. Date of occurrence : January 6 , 1987
13 Place of occurrence-At or near 2771 Sargent, San Pablo, Contra
Costa County, California
14 4 . Circumstances of occurence: A sidewalk covering was so
negligently installed so as to cause plaintiff to trip and be
15 injured.
16
17 5 . General Description of injury : Severe neck sprain, numbness in
fingers on right hand. Plaintiff .has also felt faint several
18 times since the accident.
19
20
21 i
6 . Amount of claim and basis for computation: $10 ,000. 00 for pain
22 and suffering and medical bills .
q.,, i
23
24
25
26 DATED: March 16 , 1987
27
28
VAUGH E. S AUGL
Attorney for Claimant
CLAIM
a BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Claim Against the County; or District governed by) f BOARD ACTION
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT AD_ r i 1 21 , 1987
and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of
California Government Codes. ) the action taken on your claim by the Board of Supervisors
(Paragraph IV below), given pursuant to Government Code
Amount: $474. 17 Section 913 and 915.4. Please note all "Warnings".
CLAIMANT: CECIL PLUMMER 0110"(,
11373 Rampart Drive Count
ATTORNEY: Dublin, CA 94568
Date received •-
ADDRESS: BY DELIVERY TO CLERK ON March 20 , 1987 GA g
BY MAIL POSTMARKED: March 18 , 1987
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
�aIl �e �tELOR, Clerk
DATED: March 25, 1987 p
y
L. Hall
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
(x) This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Gated: c � / BY.; Deputy County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present
(X) This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
APR 21 1987
Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or
deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult
an attorney, you should do so immediately.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the
United States, over age 18; and that today I deposited in the United States Postal Service in Martinez,
California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to
the claimant as shown above.
APR 2 2 1987
Gated: BY: PHIL BATCHELOR bXZ, Deputy Clerk
CC: County Counsel County Administrator
QCLATM TO: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
Instructionsto Claimant
A. Claims relating to causes of action for death or for injury to
person or to personal property or growing crops must be presented
not later than the 100th day after the accrual of the cause of
action. Claims relating to any other cause of action must be
presented not later than one year after the accrual of the cause
of action. (Sec. 911. 2, Govt. Code)
B. Claims must be filed with the Clerk of the Board of Supervisors
at its office in Room 106, County Administration Building, 651 Pine
Street, Martinez , CA 94553 (or mail to P.O. Box 911, Martinez, CA)
C. If claim is against a district governed by the Board of Supervisors,
rather than the County, the name of the District should be filled in.
D. If the claim is against more than one public entity, separate claims
must be filed against each public entity.
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end
of this form.
RE: Claim by ) Reserve � .;, stamps
RECEIVED
` 3 312 wvy-\pc, r+ 1�r Dubli nQ Ll
ggC4)
Against the COUNTY OF CONT C8STA)
or DISTRICT)
• on
(Fill in name) )
The undersigned claimant hereby makes claim against the Count of Contra
Costa or the above-named District in the sum of $
and in support of this claim represents as follows:
------------------------------------------------------------------------
1. When did the damage or injury occur? (Give exact date and hour)
a -, 9 8'7
-----------T------------------------------------------------------------
2. Where did the damage or injury occur? (Include city and county)
aLC-0-54'c;_- Cc.n yo 0 -
3. How did the damage or injury occur? (Give full details use extr
sheets if required) cA- Sa-�-v ►c- e Vr _o l-e- c-_)0--<3 &'"�' - 'r .
c_�1v L &Axo-"i b-'Z ,v�cu"" d i a"vr�e.4 ter- ctn-cl 'E l r L kgs V44')
I'
cl_�t,�- hs3-e �_S _q �.ctiJr o-,�{-t� _--v � . J.-� � cQ a(L
cn ( ` Lj _,,,,+ _4_, - ��
4. What particular act or omission on the part of county- -
or district
officers , servants or employees caused the Jnjugy or damage? -
�.� �,.AZWi_e_ Lx�
4-0
(over)
5. What are the names of county or district officers, -servants°70C.,�
I employees pausing the damage or 'injury?
A// V ri k ►2c
------ - - ------------------------------------------------------
6. Wh-at-damage-------or--injuries do you claim resulted? (Give full extent
of injuries or damages claimed. Attach two estimates for auto
damage) �� cQi✓wO1.0-2�
- - -- --- - - -----------------------------------------------
7-.--H-ow---was---th-e--amoun--t--cl-aimed above computed? (Include the estimated
amount of any prospective injury or damage. )
o V1 ttC.-
8. Gy iC�, 6
-----N--------and-------------of-----------,----------------------
---------------------------
ames addresses witnessesdoctors and hospitals.
(19 57) 710
--- ----------------------y------------------------------ inur y:.
9. � es ou made on account of this accident or
ITEM AMOUNT
4
•k'
Govt. Code Sec. 910.2 provides :
"The claim e y the claimant
SEND NOTICES TO: (Attorney) or b- so a on ,on his behalf. "
Name and Address of Attorney 1
1Z ber i A-- 6( d 1 f e-r n a-KE ' s Signatur
X4`50 T./ckvikc V
6a-K1cLv,,crl ress 97
Telephone No. eg (4 -0720 Telephone Noy' g�$' -307
NOTICE
Section 72 of the Penal Code provides:
"Every person who, with intent to defraud, presents for allowance or
for payment to any state board or officer, or to any county, town, city
district, ward or village board or officer, authorized to allow or pay
the same if genuine, any false or fraudulent claim, bill, account, voucher,
or writing, is guilty of a felony. "
� G�--e-Q �� Z--e...�.��
_ � ..� �l/��(,'-e ..tits
dz �� Cc�t.��n -�tel �� ���Q<��
�'��-�.� �c� ,�,� Cao��
�� � � ��
� � �-��
� � ��.�
e�