Smith, Gladys
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June 6, 1986
City of Clearwater
City Clerk's Office
P. O. Box 4748
Clearwater, Florida
33518...4748
TO ~hom tt May Concern:
r attest th~t Gt.....'~..'t'ilfs tndeed the daughter of
Emmett X. Smitfl ~nd Sally Jones Smith.
Stgned
SWQrn to ~nd subscrtbed before me this '6th day of Jline
19 86 .
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SEAL
RECEIVED
JUN 13 1986
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11M 1/ 4l19.,-f /I)
CITX CLERK
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FSH ADM: 5125165
FACE SHEET
I. Client Name (Last, First, Middle) 2. Cli6t N4m~er 3. Legal Status
SMITH, Gladys Iola LB 1 1 Vol I Incompt
4. Also Known A!l (AKA) 5., 2"jmlsslOn lYate and Hour 6. Change of Legal Status and Date
12 7182
7. Mai den Name 8. Discharge Da te 9. AdmISSIOn 'Umt or illiiIOIng
Unit 16
10. Spouse s Name and Maiden Name (if applicable) 11. Sex 12. Nationality 13. Birth Date and Place
Female American 2113 190
14. Client's Address (street, city, state, zip) 15. Race 16. Fluent Language 17. Social Security Number
218 East Bay St. Lakeland, Florida Wh it e English 267-21-4917
18. Next of Kin/Emergency Notification Name 19. Education 20. Marital Status 21. Religion
rIff! !'/iffl ,r/rlf/i! tlffffff nls Single Episcopal
22. Address (street, city, state, zip) 23. County of Residence 24. Occupation
271h fffff/ Jf/f! tfffN IffllllYfllfN lh Polk None
25't~~~tf l(rlie*~e~a~itrn'l tY~1E ~~D~~~~~ r L Y 26. Referral County 27. Veteran Status and Number
None
28'tl~,ei*r{if+t~t (r~eHTI tH aUUH II tt 29. Admission Source 30. Length of Florida Residency
31. First Representative (name, relationship) 32. Responsible Payor 33. PIc Last Discharge as In-patient
r,ft I tJlffl rflfffJl! rl flff!11
34. Address (street, city, state, zip) 35. Medicare Number 36. PIc Last Discharge as Out-patient
}}JJI ff}-'f/=/1Nil I-pll-f./ lPf}-P'Ppff/=/=f./ ! }-PffflN 267-21-4917 Jl
37. Second Representative (name, relationship) 38. Medicaid Number 39. KesponslblePioTesslOnal
Jp/1fPNJfnff-N f/ /JfPf-'P/=f
40. Address (street, city, state, zip) 41. Insurance Agency and Number
lpfn/Jpf./ !}-PffflN
42. Father's Name 43. Referring Agent or Physician and Address
E. 1- Smith .:;:;trJ i~entiJI !'( F"~ h~"'" . -". I
44. Mother's Maiden Name 45. Referring Diagnosis Inforrr, ,J; ill ()
Sally Jones t:.",. -
. - ,
4-6. Code 47. Dlscnarqe Psychlatrlc DlaqnOSes h-Aa,.;.:- . d"ur,e andl Date
, .0:1" t.i1U..1/"";, r, ..
;hatt~hO{'{:h~;...~. FL .3~)J2.',
49. Code 50. Dlscharge Physlcal Dlagnoses 5l. Slgnature and Date
52. Other
HRS-MH Form 2006, Aug 81 (Obb
tcs similar institution-specific forms)
Face Sheet
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CLIENT NAME: Smith, Gladys CLIENT NUMBER: B 61 411
COMMITMENT DATE: May 24, 1965 COUNTY OF COMMITMENT: Polk
STATUS ON ADMISSION: ~~~~~/Incornpetent Chanqed to Voluntary 6/30/73
CHARGES (if applicable) : I
I
I
I
I
Confident!:!! & P'l\' .\,... " ~ . I
NOTIFICATION PRIOR TO RELEASE: lidol. !l"tiCo) I
TUT I .....
ADDRESS CORRECTION OF NEXT OF KIN/EMERGENCY NOTfto:mU.'.))$~E HOSP'" i~ L,
(PERSON TO NOTIFY IN CASE OF EMERGENCY--RELATIVE, GUARDIAN dtfutURe{)c~n..ENJ'l3Z'4E)
5-14-86 Jenlaura Roberts (great-niece&Guardian of .Person and Property)
(Date) (Name & Relationship) (Address) (.Te1ephone ~ )
2843 Kiklenny East, Tallahassee, FL 32308 (904) 893-4120
(Date) (Name & Relationship) (Address) (Telephone #J
(Date) (Name & Relationship) (Address) (Telephone - \
~ I
(Date) (Name & Relationship) (Address) (Telephone :i )
(Date) (Name , Relationahip) (Address) (Telephone :;j
LEGAL STATUS CHANGE. HEARING EXAMINER REVIEW, DATE POSTED/
DATE OF ACTION
REVIEW OF FACE SHEET CLERICAL STAFF SIGNATC?E
INSTRUCTIONS: To be completed on all patients as applicable. Status changes & Hearing
Examiner Consensus should be recorded immediately. The Face Sheet will be reviewed. and
updated annually, and as indicated.
I
Section 2/1982-6
FLORIDA STATE HOSPITAL
ADDENDUM TO FACE SHEET
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