Pancho - VIC-ADA-69

Code: VIC-ADA-69
Mercy ID: V-00955-02
Encounter Date: 09/03/2002
Last: Vicente
First: Adan
DOB: 02/26/1969
County: Cobb
Street: 3513 Mustang Dr.
City: Powder spring
State: GA

Zip

30127-

Home

(678) 567-1246

Family Status

Two parent family w/children

COB

Guatemala

Gender

Male

Housing

Doubling Up

Education Level

some high school

Home Owner

YES

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: R. Miranda
Data Entry: K. Aleman