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JAN a _ g <br />BOOL <br />DOCUMENTS TO BE MADE PART OF THE RECORD <br />A___Approval_of Petition for Admission to Holley State Hospital <br />for John_ Spann,_ Jr_ <br />APPROVAL OF PETITION <br />FOR ADMISSTON TO <br />A. C. HOLLEY STATE HOSPITAL <br />TATE OF FLORIDA Patient or County must <br />arrange and pay transpor- <br />(AINTY OF Indian Paver Cation to and from hospital <br />n the matter of the application of Spann, Jobn Jr. <br />Last First Middle <br />or admission to the A. G. Holley State Hospital. <br />0 LI►e Superintcncic-nt of auld 110HI)LCal: <br />Upon filing of the petition of the above named person and the presentation of the <br />•eport of Doctor Espino; 0, M.D.s TB Control District IX , Florida, <br />Last First Middle City or"l'own <br />!xamintng physician, that the said applicant is afflicted with tuberculosis: <br />The Beard of C-ounty Commissioners does hereby grant approval to the application of <br />laid applicant for admission to the above stated Florida Tuberculosis hospital, and said <br />ivard docs hereby agree Lo pay to the hospital monthly $1.25 per diem for the care and <br />Iainteuance of sald appllcanL and the Ilospltal will credit this County with FirsL $1.25 <br />u]lected for each day from any source under the Fee Collection Program, ChapLer 4112.33, <br />'lorlda StaLutes. <br />The Board of County Commissioners agrees to accept responsibility for any, non-resident <br />,atient, when lie Is ready for discharge, if the, said Board had approved the non-residunt <br />iaticnt's admitstun Lo the SLaLu Tuberculosis Hospital. <br />The following action has been initiated by the County: <br />(1) 1111S Dorm 280 completed and forwarded to the Hospital <br />(2) 11RS Dorm 280 provided to client with appropriate instructions for completion and <br />submission to Lhe hospital. <br />(3) Other - Please explain: <br />(SEAL) Approved by the Board of County Commissioners <br />4 <br />ATT ST of Indian River County, Florida,DA'I ED A'1' iDe Date January 9, 1987 19 <br />1 <br />o cur oc J Chilli ,an <br />Petition approved by: 7 _._ M.D. <br />108 <br />