Pancho - DOM-MAR-62

Code: DOM-MAR-62
Mercy ID: V-01961-01
Encounter Date: 07/08/2005
Last: Dominguez
First: Martha
DOB: 02/24/1962
County: Cobb
Street: 1080 Pinemeadow Dr.
City: Morrow
State: GA

Zip

30260-

Home

(404) 608-8417

Family Status

Two parent family w/children

COB

Mexico

Gender

Female

Housing

Not Homeless

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: YES
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: J. Perez
Data Entry: K. Aleman