Pancho - PET-BEN-76

Code: PET-BEN-76
Mercy ID: V-00593-02
Encounter Date: 07/10/2001
Last: Lopez
First: Benjamin
DOB: 10/10/1976
County: Fulton
Street: 5320 Roswell Rd. Apt F3
City: Atlanta
State: GA

Zip

30342-

Home

(404) 784-6428

Cell

(404) 784-6428

Family Status

Two parent family w/children

COB

Mexico

Gender

Male

Housing

Other

Education Level

Child, not in school

Home Owner

No

Parents Information

	Name	DOB	COB
Mother	N/A	N/A	N/A
Father	N/A	N/A	N/A
Step Parent	N/A	N/A	N/A

Driver: No
Relative: No
Stranger: No
Lives With: N/A
Name of School: N/A
Grade: N/A
Who Can't Pickup the Child
Authoritation Parent: No
Authoritation Child: No
DOY PERMISO: No
Limitado Educativo: No
Limitado Impresos: No
Limitado Caminar Latino: No

Intake: F. Perez
Data Entry: K. Aleman