Pancho - HER-DOM-79

Code: HER-DOM-79
Mercy ID: V-01908-01
Encounter Date: 05/10/2005
Last: Hernandez
First: Domitila
DOB: 05/20/1979
County: Gwinnett
Street: 4262 Pleasant Lake Village Ln.
City: Duluth
State: GA

Zip

30096-

Home

(678) 417-0585

Family Status

Adult coupie-no children

COB

Mexico

Gender

Female

Housing

Doubling Up

Education Level

Grade 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: G. Landeros
Data Entry: K. Aleman