Pancho - GAY-DIA-78

Code: GAY-DIA-78
Mercy ID: V-03105-01
Encounter Date: 06/29/2009
Last: Gaytan
First: Diana
DOB: 11/24/1978
County: Forsyth
Street: 415 Cambridge Rd. Apt. 340
City: Cumming
State: GA

Zip

30040-

Cell

(678) 349-6952

Family Status

Single parent w/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: J. Perez
Data Entry: J. Manzo