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victim receive any medical treatment? 0 Yes J (If No, skip to Tell us about the health professionals who treated the victim for injuries related First Hospital Other Hospital First Doctor (riot on hospta0 Other Doctor First Dentist Victim s Counselor Full Name Complete Address rnfvtc f.-r(1-‘c sect
nsation If any other insurance or death benefits. list here. Do any of these policies cover the victim's burial expenses? Has anyone applied for the Social Security Death Benefit? K yes 0 Yes 0 No 0 No 14 Tell us about your financial situation. You MUST fill out ALL sections below. If none, enter zero (0). How many depe
2 mentions1 same-page
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o section10.) Tell us about the health professionals who treated the victim for injuries related to this crime: Full Name Complete Address Phone First Hospital Other Hospital First Doctor (not in hospital) Other Doctor First Dentist Victim's Counselor 10 Tell us about the victim's dependents or other
If any other insurance or death benefits. list here: Do any of these policies cover the victim's burial expenses? O Yes O No Has anyone applied for the Social Security Death Benefit? O Yes O No 14 Tell us about your financial situation. You MUST fill out ALL sections below.), none. enter zero Wt. How many dependents do you ha
2 mentions1 same-page
Page ?Same page
skip to sectIon10.) Tell us about the health professionals who treated the victim for Injuries related to this crime: Full Name Complete Address First Hospital Other Hospital First Doctor (not in hospital) Other Doctor First Dentist Victim's Counselor Phone It ) ( ) ) 10 Tell us about the vict
f any other insurance or death benefits, list here: Do any of these policies cover the victim's burial expenses? 0 Yes 0 No Has anyone applied for the Social Security Death Benefit? 0 Yes K No 14 Tell us about your financial situation. You MUST fill out j, sections below. If none, enter zero (01. How many dependents du you
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Mutual Connections (17)
Entities connected to both First Hospital and the Social Security Death Benefit
CA
Complete Address
PERSON3 w/ First·3 w/ the
New York State Law
ORGANIZATION3 w/ First·3 w/ the
HIPAA
ORGANIZATION3 w/ First·3 w/ the
the New York State Department of Health'
ORGANIZATION3 w/ First·3 w/ the
Victim Services
ORGANIZATION3 w/ First·3 w/ the
Medicaid
ORGANIZATION3 w/ First·3 w/ the
OVictim Assistance Program
ORGANIZATION2 w/ First·2 w/ the
Disability Insurance
ORGANIZATION2 w/ First·2 w/ the
the Death Certificate
ORGANIZATION2 w/ First·2 w/ the
Primary Insurance Company
ORGANIZATION2 w/ First·2 w/ the
Governmental Agency Name
ORGANIZATION2 w/ First·2 w/ the
The New York State Public Health Law
ORGANIZATION2 w/ First·2 w/ the
the State of New York
LOCATION2 w/ First·2 w/ the
the New York City Commission of Human Rights
ORGANIZATION2 w/ First·2 w/ the
Social Security Benefits
ORGANIZATION2 w/ First·2 w/ the
See the Court Ordered Restitution Information
ORGANIZATION2 w/ First·2 w/ the
S. Swan
ORGANIZATION2 w/ First·2 w/ the