eICR Document Bundle Example: bundle-eicr-document-zika - HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR)

HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm
2.1.2 - STU 2 United States of America flag

HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 2.1.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/case-reporting/ and changes regularly. See the Directory of published versions

Example Bundle: eICR Document Bundle Example: bundle-eicr-document-zika

Document Details

Generated Narrative: Bundle Initial Public Health Case Report - Zika Example

Document Subject

Unable to resolve subject ''

Document Content

Reason for Visit Section

title	Reason for Visit Section
code	Reason for visit Narrative ( 29299-5 ) http://loinc.org
Reason for Visit: Bad cough

Chief Complaint

title	Chief complaint Narrative - Reported
code	Chief complaint Narrative - Reported ( 10154-3 ) http://loinc.org
Chief Complaint: Bad cough

History of Present Illness Section

title	History of Present Illness Section
code	History of Present illness Narrative ( 10164-2 ) http://loinc.org
Persistent Cough REPORTED starting on 2018/03/05 Whooping Respiration not reported Paroxysms Of Coughing REPORTED starting on 2018/03/06 Post-tussive vomiting not reported

Problems Section

title

Problems Section

code

- Problem list - Reported
  (
  11450-4
  )
- http://loinc.org

entry

Common cold (disorder)

id

condition-eicr-eve-everywoman-common-cold

meta

versionId	15
lastUpdated	2019-10-10T21:21:49.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-condition

Medications Administered Section

title

Medications Administered Section

code

- Medication administered Narrative
  (
  29549-3
  )
- http://loinc.org

entry

Azithromycin 500 MG Oral Tablet

id

medicationadministration-eve-everywoman-azithromycin

meta

versionId	10
lastUpdated	2019-10-05T03:11:22.000-04:00

status

completed

medicationCodeableConcept

Azithromycin 500 MG Oral Tablet
- Azithromycin 500 MG Oral Tablet
  (
  248656
  )
- http://www.nlm.nih.gov/research/umls/rxnorm

subject

Eve Everywoman

effectivePeriod

start	2018-03-07
end	2018-03-07

dosage

route

- Oral Route
  (
  26643006
  )
- http://snomed.info/sct

method

- Swallow - dosing instruction imperative (qualifier value)
  (
  421521009
  )
- http://snomed.info/sct

dose

value	2
unit	TAB
system	http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm
code	TAB

Admission Medications Section

title	Admission Medications Section
code	Medications on admission (narrative) ( 42346-7 ) http://loinc.org
entry	1 ML naloxone hydrochloride 0.4 MG/ML Injection

Medications Section

title	Medications Section
code	History of Medication use Narrative ( 10160-0 ) http://loinc.org
entry	Azithromycin 500 MG Oral Tablet

Results Section

title

Results Section

code

- Relevant Dx tests/lab data
  (
  30954-2
  )
- http://loinc.org

entry

Lymphocytes [#/volume] in Blood by Automated count - Interpretation: High

id

observation-us-ph-lab-result-eve-everywoman-lymphocytes

meta

versionId	10
lastUpdated	2019-10-05T02:50:13.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-lab-result-observation

status

final

Plan of Treatment Section

title

Plan of Treatment Section

code

- Plan of care note
  (
  18776-5
  )
- http://loinc.org

entry

Trigger code
Trigger Code:
Trigger Code Display:
Trigger Code System:
Trigger Code Value Set: urn:oid:2.16.840.1.114222.4.11.7508
Trigger Code Value Set Version: 19/05/2018

Request for Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method

id

servicerequest-eicr-zika

meta

versionId	9
lastUpdated	2019-10-23T13:56:36.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-servicerequest

status

completed

intent

order

Immunizations Section

title	Immunizations Section
code	History of Immunization Narrative ( 11369-6 ) http://loinc.org
entry	pneumococcal polysaccharide vaccine
entry	Vaccine Credential Patient Assertion Observation Example

Procedures Section

title	Procedures Section
code	History of Procedures Document ( 47519-4 ) http://loinc.org
entry	Extracorporeal membrane oxygenation (procedure)

Vital Signs Section

title	Vital Signs Section
code	Vital signs ( 8716-3 ) http://loinc.org
entry	Blood pressure systolic and diastolic

Social History Section

title

Social History Section

code

- Social history Narrative
  (
  29762-2
  )
- http://loinc.org

entry

eICR Travel History: Eve Everywoman 2018-01

id

observation-travel-history-eve-everywoman-201801

meta

versionId	11
lastUpdated	2019-10-05T03:15:42.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-travel-history

status

final

code

Travel History
- Travel
  (
  420008001
  )
- http://snomed.info/sct

subject

Eve Everywoman

effectivePeriod

start	2018-01-15
end	2018-01-30

component

code	Location ( LOC ) http://terminology.hl7.org/CodeSystem/v3-ParticipationType
valueCodeableConcept	Fiji ( FJI ) urn:iso:std:iso:3166

component

code	Location ( LOC ) http://terminology.hl7.org/CodeSystem/v3-ParticipationType
valueCodeableConcept	Vanuatu ( VUT ) https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=1.0.3166.1

Pregnancy Section

title

Pregnancy Section

code

- Pregnancy summary Document
  (
  90767-5
  )
- http://loinc.org

entry

eICR Pregnancy Status Example

id

observation-pregnancy-status-eve-everywoman

meta

versionId	13
lastUpdated	2019-10-05T03:15:42.000-04:00
profile	http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-pregnancy-status-observation

us-ph-date-recorded-extension

2017-10-01

date-determined-extension

2017-10-01

status

final

code

- Pregnancy Status
  (
  82810-3
  )
- http://loinc.org

subject

Eve Everywoman

effectivePeriod

start

2017-08-26

valueCodeableConcept

- Pregnancy (finding)
  (
  77386006
  )
- http://snomed.info/sct

method

- Ultrasonography (procedure)
  (
  16310003
  )
- http://snomed.info/sct

component

date-determined-extension	2017-10-01
code	Gestational age Estimated from patient reported estimated date of conception ( 53691-2 ) http://loinc.org
valueQuantity	143 d

component

date-determined-extension	2017-10-01
code	Delivery date Estimated from date fundal height reaches umb ( 57064-8 ) http://loinc.org
valueDateTime	2018-05-01

Emergency Outbreak Information Section

title	Emergency Outbreak Information Section
code	Public health Note ( 83910-0 ) http://loinc.org
entry	US Public Health Emergency Outbreak Information Example

Past Medical History Section

title	Past Medical History Section
code	Past Medical History Narrative ( 11348-0 ) http://loinc.org
Past medical history

Review of Systems Section

title	Review of Systems Section
code	Review of Systems Section Narrative ( 10187-3 ) http://loinc.org
Review of systems

Additional Resources Included in Document

Entry 1 - fullUrl = http://example.org/fhir/Composition/composition-eicr-zika

Resource Composition:

Generated Narrative: Composition composition-eicr-zika

version: 22; Last updated: 2021-08-17 03:24:45+0000;
Information Source: #vMaRLlyzDNjGkVuc
Profile: Electronic Initial Case Report Composition
Composition Version Number: 1
identifier: c03eab8c-11e8-4d0c-ad2a-b385395e27db
status: Final
type: Public Health Case Report
encounter: Ambulatory Office Visit
date: 2018-01-02 22:13:23+0000
author: Henry Seven, MD
title: Initial Public Health Case Report - Zika Example
custodian: Salem Medical Center

Entry 2 - fullUrl = http://example.org/fhir/MedicationAdministration/medicationadministration-eve-everywoman-azithromycin

Resource MedicationAdministration:

Generated Narrative: MedicationAdministration medicationadministration-eve-everywoman-azithromycin

version: 6; Last updated: 2021-08-17 07:53:28+0000;
Information Source: #O8n4DNqcDuNHPfTJ
Profile: US Public Health MedicationAdministration
status: completed
subject: Eve Everywoman
Dosages
- Text Route Method Dose
* Two tablets at once Oral route Swallow - dosing instruction imperative (qualifier value) 2 TAB (Details: Orderable Drug Form codeTAB = 'Tablet')

Entry 3 - fullUrl = http://example.org/fhir/Procedure/us-ph-procedure-ecmo

Resource Procedure:

Generated Narrative: Procedure us-ph-procedure-ecmo

version: 5; Last updated: 2021-06-28 08:12:56+0000;
Information Source: #A9FdbPgUT95j7Itd
Profile: eICR Procedure
identifier: Uniform Resource Identifier (URI)/urn:uuid:b2a737f2-2fdb-49c1-b097-dac173d07afd
status: Completed
code: Extracorporeal membrane oxygenation (procedure)
subject: Female, DoB: 1974-11-24 ( Medical Record Number: 1032702 (use: usual, ))
FocalDevices
- Manipulated
* Device: status = active; manufacturer = ACME Biomedical; expirationDate = 2022-01-01; lotNumber = M320; serialNumber = AC222; modelNumber = 4.0; type = Extracorporeal membrane oxygenator (physical object)

Entry 4 - fullUrl = http://example.org/fhir/MedicationAdministration/medicationadministration-eve-everywoman-naloxone-response

Resource MedicationAdministration:

Generated Narrative: MedicationAdministration medicationadministration-eve-everywoman-naloxone-response

version: 5; Last updated: 2021-08-17 07:53:28+0000;
Information Source: #5sOf7BOr595JpyG7
Profile: US Public Health MedicationAdministration
US Public Health Therapeutic Medication Response Extension: Patient's condition improved (finding)
status: completed
subject: Eve Everywoman
Dosages
- Route Method Dose
* Gluteus maximus muscle Inject - dosing instruction imperative (qualifier value) 1 mL (Details: UCUM codemL = 'mL')

Entry 5 - fullUrl = http://example.org/fhir/ServiceRequest/servicerequest-eicr-zika

Resource ServiceRequest:

Generated Narrative: ServiceRequest servicerequest-eicr-zika

version: 5; Last updated: 2021-08-17 08:02:21+0000;
Information Source: #w4zRDqhjQ9EZHgCs
Profile: eICR ServiceRequest
identifier: http://lab.smarthealthit.org/061ef612-344f-4e7b-81a8-1059ae7bbe19
status: Completed
intent: Order
category: Diagnostics Procedure
code: No display for ServiceRequest.code (concept: Zika virus envelope E gene [Presence] in Serum by NAA with probe detection)
subject: Eve Everywoman
performer: Acme Labs

Entry 6 - fullUrl = http://example.org/fhir/Condition/condition-eicr-eve-everywoman-common-cold

Resource Condition:

Generated Narrative: Condition condition-eicr-eve-everywoman-common-cold

version: 6; Last updated: 2021-07-15 01:54:14+0000;
Information Source: #4g0ZpTNqldHFYLzr
Profile: US Public Health Condition
category: Problem List Item
code: Common cold (disorder)
subject: Eve Everywoman
onset: 2017-09-23

Entry 7 - fullUrl = http://example.org/fhir/Encounter/encounter-eicr-eve-everywoman-outpatient

Resource Encounter:

Generated Narrative: Encounter encounter-eicr-eve-everywoman-outpatient

version: 5; Last updated: 2021-07-19 03:02:05+0000;
Information Source: #Q5dlT8eND2UI2D6e
Profile: eICR Encounter
identifier: http://hospital.smarthealthit.org/9937012
status: completed
class: ambulatory
type: Office Visit
subject: Eve Everywoman
serviceProvider: Salem Medical Center, 22222 Health Authority Drive, Ann Arbor MI, 99999
Participants
- Type
* attender
diagnosis
eICR Trigger Code Flag Extension
triggerCodeValueSet: urn:oid:2.16.840.1.114222.4.11.7508
triggerCodeValueSetVersion: 12/12/2018
triggerCode: SNOMED CT 3928002: Zika virus disease (disorder)
condition: No display for Encounter.diagnosis.condition (reference: ->Condition Zika virus disease (disorder))
diagnosis
condition: No display for Encounter.diagnosis.condition (reference: ->Condition Common cold (disorder))
Locations
- Location
* Clinic Bldg A, Salem Medical Center, 4646 Brown Rd, Salem, MA 02368

Entry 8 - fullUrl = http://example.org/fhir/Observation/observation-pregnancy-status-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-pregnancy-status-eve-everywoman

version: 8; Last updated: 2021-08-17 07:59:00+0000;
Information Source: #bBlVx7OsNPsZVCbu
Profile: US Public Health Pregnancy Status Observation
US Public Health Date Recorded Extension: 2017-10-01
US Public Health Date Determined Extension: 2017-10-01
status: Final
code: Pregnancy status
subject: Eve Everywoman
effective: 2017-08-26 --> (ongoing)
value: Pregnancy (finding)
method: Ultrasonography (procedure)
component
US Public Health Date Determined Extension: 2017-10-01
code: Gestational age Estimated from patient reported estimated date of conception
value: 143 d
component
US Public Health Date Determined Extension: 2017-10-01
code: Delivery date Estimated from date fundal height reaches umb
value: 2018-05-01

Entry 9 - fullUrl = http://example.org/fhir/Observation/observation-vaccine-credential-assertion-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-vaccine-credential-assertion-eve-everywoman

version: 2; Last updated: 2021-08-13 04:25:18+0000;
Information Source: #12yO2DqhRxbXmEOy
Profile: eICR Vaccine Credential Patient Assertion
status: Final
code: Immunization status - Reported
subject: Eve Everywoman
effective: 2020-11-10 22:33:22+0000
value: Yes

Entry 10 - fullUrl = http://example.org/fhir/Observation/observation-us-ph-emergency-outbreak-info-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-us-ph-emergency-outbreak-info-eve-everywoman

version: 4; Last updated: 2021-07-15 01:22:52+0000;
Information Source: #oAXhG2HyvbL70uEB
Profile: US Public Health Emergency Outbreak Information
status: Final
code: Employee desk distance from mail sorter
subject: Eve Everywoman
effective: 2020-11-18 22:33:22+0000
value: 2 m

Entry 11 - fullUrl = http://example.org/fhir/Observation/observation-country-of-nationality-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-country-of-nationality-eve-everywoman

version: 1; Last updated: 2021-08-19 21:30:49+0000;
Information Source: #ABFWLRjmURVC23y1
Profile: eICR Country of Nationality
status: Final
code: Ethnicity / related nationality data (observable entity)
subject: Eve Everywoman
effective: 2020-11-10 22:33:22+0000
value: Australia

Entry 12 - fullUrl = http://example.org/fhir/Patient/patient-ecr-eve-everywoman

Resource Patient:

Eve L EVERYWOMAN

Identifier 1032702

Address 5101 Peachtree St NE
Atlanta GA US

Date of birth 24 November 1974

Entry 13 - fullUrl = http://example.org/fhir/Immunization/immunization-ecr-pneumo

Resource Immunization:

Generated Narrative: Immunization immunization-ecr-pneumo

version: 8; Last updated: 2021-08-17 07:51:35+0000;
Information Source: #EdjaILZHXKHi4bdN
Profile: US Core Immunization Profile
status: Completed
vaccineCode: pneumococcal polysaccharide PPV23
patient: Eve Everywoman
occurrence: 2018-09-01
primarySource: true

Entry 14 - fullUrl = http://example.org/fhir/Observation/observation-country-of-residence-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-country-of-residence-eve-everywoman

version: 1; Last updated: 2021-08-13 00:20:14+0000;
Information Source: #HDoLJzr0kfWKFp3F
Profile: eICR Country of Residence
status: Final
code: Country of usual residence
subject: Eve Everywoman
effective: 2020-11-10 22:33:22+0000
value: United Kingdom of Great Britain and Northern Ireland

Entry 15 - fullUrl = http://example.org/fhir/PractitionerRole/practitionerrole-henry-seven

Resource PractitionerRole:

Generated Narrative: PractitionerRole practitionerrole-henry-seven

version: 11; Last updated: 2021-08-17 08:00:32+0000;
Information Source: #KJ942UxvfdYWoHCF
Profile: US Public Health PractitionerRole
identifier: United States National Provider Identifier/9941339108
practitioner: Henry Seven, MD
organization: Salem Medical Center
code: Primary Care Clinic/Center
specialty: Family practice
location: Salem Medical Center

Entry 16 - fullUrl = http://example.org/fhir/Observation/observation-blood-pressure-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-blood-pressure-eve-everywoman

version: 2; Last updated: 2021-07-19 08:19:31+0000;
Information Source: #2PjceWUbU0gCYVZA
Profile: US Core Blood Pressure Profile
status: Final
category: Vital Signs
code: Blood pressure systolic and diastolic
subject: Eve Everywoman
encounter: GP Visit
effective: 2020-07-02
component
code: Systolic blood pressure
value: 109 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
component
code: Diastolic blood pressure
value: 44 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Entry 17 - fullUrl = http://example.org/fhir/Observation/observation-us-ph-exposure-contact-info-football-game

Resource Observation:

Generated Narrative: Observation observation-us-ph-exposure-contact-info-football-game

version: 4; Last updated: 2020-12-01 07:17:32+0000;
Information Source: #pMvWUdCWz4XOnrDf
Profile: US Public Health Exposure Contact Information
status: Final
category: An interaction between entities that provides opportunity for transmission of a physical, chemical, or biological agent from an exposure source entity to an exposure target entity.
code: Mass gathering (football game)
subject: Eve Everywoman
focus: City Football Stadium
effective: 2020-01-11 18:00:00+0000 --> 2020-01-11 21:30:00+0000
value: City Football Stadium

Entry 18 - fullUrl = http://example.org/fhir/Observation/observation-travel-history-eve-everywoman-201801

Resource Observation:

Generated Narrative: Observation observation-travel-history-eve-everywoman-201801

version: 9; Last updated: 2021-08-17 07:59:01+0000;
Information Source: #d6PrWfFFuxUIiLtX
Profile: US Public Health Travel History
status: Final
code: Travel History
subject: Eve Everywoman
effective: 2018-01-15 --> 2018-01-30
component
code: Location
value: Fiji
component
code: Location
value: Vanuatu
component
code: Type of activity (attribute)
value: Active duty military (occupation)

Entry 19 - fullUrl = http://example.org/fhir/Observation/observation-disability-status-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-disability-status-eve-everywoman

version: 2; Last updated: 2021-06-30 05:33:12+0000;
Information Source: #AVCvf6gXu6hyNuWr
Profile: US Public Health Disability Status
status: Final
code: Are you deaf, or do you have serious difficulty hearing
subject: Eve Everywoman
effective: 2020-11-10 22:33:22+0000
value: true

Entry 20 - fullUrl = http://example.org/fhir/Observation/observation-us-ph-lab-result-eve-everywoman-lymphocytes

Resource Observation:

Generated Narrative: Observation observation-us-ph-lab-result-eve-everywoman-lymphocytes

status: Final
category: Laboratory
code: Lymphocytes [#/volume] in Blood by Automated count
subject: Eve Everywoman
effective: 2018-03-07
value: 5.2 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
interpretation: High
ReferenceRanges
- Low High
* 1 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL') 4.8 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')

Entry 21 - fullUrl = http://example.org/fhir/Organization/organization-ecr-acme-laboratory

Resource Organization:

Generated Narrative: Organization organization-ecr-acme-laboratory

version: 4; Last updated: 2021-06-30 04:13:19+0000;
Information Source: #xp7CXcY2lPaNsDQL
Profile: US Public Health Organization
identifier: http://hl7.org.fhir/sid/us-npi/1144221999
active: true
type: outpatient laboratory
name: Acme_Labs
contact
telecom: +1-555-555-4444, mail@acme-labs.com
address: 7777 Laboratory Drive Ann Arbor MI 99999

Entry 22 - fullUrl = http://example.org/fhir/Location/location-ecr-salem-medical-center

Resource Location:

Generated Narrative: Location location-ecr-salem-medical-center

version: 6; Last updated: 2021-08-17 07:53:02+0000;
Information Source: #VI2Nm5Ps5HqZ5HXV
Profile: US Public Health Location
identifier: http://hl7.org.fhir/sid/us-npi/1144221995
status: Active
name: Clinic Bldg A, Salem Medical Center
type: Hospital
address: Clinic Bldg A 4444 Healthcare Drive Ann Arbor MI 99999
managingOrganization: Organization Salem Medical Center

Entry 23 - fullUrl = http://example.org/fhir/Location/location-ecr-city-football-stadium

Resource Location:

Generated Narrative: Location location-ecr-city-football-stadium

version: 1; Last updated: 2020-12-01 01:55:32+0000;
Information Source: #KLUFk4w6CXKqrFEC
Profile: US Core Location Profile
status: Active
name: City Football Stadium
type: City Football Stadium
address: 99 Football Stadium Road My City AZ 8562

Entry 24 - fullUrl = http://example.org/fhir/Organization/organization-ecr-salem-medical-center

Resource Organization:

Generated Narrative: Organization organization-ecr-salem-medical-center

version: 5; Last updated: 2021-06-30 04:13:19+0000;
Information Source: #xa4yJZjn68xVavoM
Profile: US Public Health Organization
identifier: http://hl7.org.fhir/sid/us-npi/55555555
active: true
name: Salem Medical Center
contact
telecom: +1-555-555-1111, mail@salemmedicalcenter.com
address: 22222 Health Authority Drive Ann Arbor MI 99999

Entry 25 - fullUrl = http://example.org/fhir/Condition/condition-eicr-eve-everywoman-zika

Resource Condition:

Generated Narrative: Condition condition-eicr-eve-everywoman-zika

version: 5; Last updated: 2021-07-15 01:54:14+0000;
Information Source: #rM2Pw6getjoE2UTV
category: Encounter Diagnosis
code: Zika virus disease (disorder)
subject: Eve Everywoman
onset: 2017-08-23

Entry 26 - fullUrl = http://example.org/fhir/Practitioner/practitioner-us-core-henry-seven

Resource Practitioner:

Generated Narrative: Practitioner practitioner-us-core-henry-seven

version: 5; Last updated: 2021-08-17 08:00:32+0000;
Information Source: #2MfA6kIjmOmtAlIb
Profile: US Core Practitioner Profile
identifier: United States National Provider Identifier/9941339108
name: Seven Henry
telecom: henry.seven@example.com
address: BMass Doctors 2100 North Ave Burlington MA 02368 US

Entry 27 - fullUrl = http://example.org/fhir/Device/device-ecmo

Resource Device:

Manually Created Narrative

UDI

Device Identifier: 99863313444317

CarrierHRF: (01)99863313444316(17)220101(10)M320(21)AC222

EntryType: rfid

Name: ACME Extracorporeal membrane oxygenator

Type: udi-label-name

status: active

manufacturer: ACME Biomedical

expirationDate: 2024-01-01

lotNumber: M321

serialNumber: AC222

modelNumber: 4.0

patient: Eve Everywoman. Generated Summary: Medical Record Number: 1032702 (USUAL); active; Eve L Everywoman ; Phone: 1-(404)555-1212, eve.everywoman@example.com; gender: female; birthDate: 1974-11-24

IG © 2020+ HL7 International / Public Health. Package hl7.fhir.us.ecr#2.1.2 based on FHIR 4.0.1. Generated 2024-10-30
Links: Table of Contents | QA Report | Version History | | Propose a change

Identifier	1032702
Address	5101 Peachtree St NE Atlanta GA US
Date of birth	24 November 1974