‘STATEMENT OF THE ACCOUNT 0A Retonce ne, 84 - B VITAL LYING IN CLINIC Parok 1, Bray. Bagong Slang 1, Labo Camarines None ‘Contct Number 09057273859 rlindsllaga2002@yaboo com PANGILINAN : SOPHIA patertName MANUEL, CANETA _tge-3 DANG Dates Tine Admited: [2-21-18 | 09° AG scares BUiGi. SAPANG HaRKCie, TARLAC CITY, TARLAC Ont Tine Dacrrps 0 AT oe Ceen, Frat Dagrens LIVE, TERM, BABY GIRL rat Caee tate AG ‘omerougresis | DELIVERED VA _NSD ‘Scand Cane Rate 2 Bi=4aso 10 im an “Amount of Biseounts ‘Phileaith Senetits | [var | senor "2 | rae | sconce rates season lle culo Eb tn | ENG Hi fees T T (TERT [foro t t t E “ee tea 8 | Sea | | Seats Roan Fae — Saae t aoe f ABS B50 = = weiep-=te e Poles Fa a | z ft = Bet | Subtotal P I [rot el a coves bya A win ital A pM as ‘Biting Clerk/Accountant CD Member () Patient C] Authorized representative (ete oer Pie Hane (Sorter Pre ae) Date Signed: Of 04-1014 Relationship to member of Authorized representative Comat No S672 bee Spres £103. 2014 Contact No: DIG AIS 2044 | OTUs HAOS