Pancho - GUT-ROM-82

Code: GUT-ROM-82
Mercy ID: V-01137-02
Encounter Date: 02/25/2003
Last: Gutierrez
First: Roman
DOB: 08/08/1982
County: Dekalb
Street: 628 wood TerraceWay
City: Doraville
State: GA

Zip

30340-

Home

(678) 768-9463

Family Status

Two parent family w/children

COB

Mexico

Gender

Male

Housing

Doubling Up

Education Level

some high 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: R. Miranda
Data Entry: K. Aleman