Pancho - DIA-SAM-68

Code: DIA-SAM-68
Mercy ID: V-01736-02
Encounter Date: 11/16/2004
Last: Diaz
First: Samuel
DOB: 09/08/1968
County: Gwinnett
Street: 916 Martin Heights Dr.
City: Lawrenceville
State: GA

Zip

30044-

Home

(678) 558-7942

Family Status

Single adult

COB

Mexico

Gender

Male

Housing

Doubling Up

Education Level

High school graduate

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