Pancho - DIA-EVA-61

Code: DIA-EVA-61
Mercy ID: V-03285-01
Encounter Date: 03/22/2010
Last: Diaz
First: Evangelina
DOB: 07/02/1961
County: Gwinnett
Street: 4156 Jackson Pl.
City: Lilburn
State: GA

Zip

30047-

Cell

(404) 604-9363

Family Status

Two parent family w/children

COB

Mexico

Gender

Female

Housing

Single Family

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