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FD-919a (2-20-01) VICTIM IDENTIFICATION FORM Highlighted fields are mandatory Date: CASE INFORMATION VWAP Control Case ID Referencc Case ID/ Seral 9B-HU-17853 Titie/Synopsis Seiotor Danicl'I nouye b6 b7C Casc Agent Name (Last First Middle) Vicum Winess Specialist (East First.Middle Prmary Contact Pcrson Ncxt of Kin Guardian Busincss VICTIM INFORMATION Name of Vicium (First, Middle, Last) Danie. L nou ye Date ofVictmzalion (MM/DD/YYYY) Date DeCcased (MM/DD/YYYY) Datc of Birth (MM/DD/YYYY) VicumaMuor? 06/19/2003 09/07/1924 Ycs No Social Security Number Racc Scx Asian White Unknown 575-/8-3613 Malc . Fcmale Black American Indian Vicun Homc Address (Home or Work Address is mandatory) 1088 Su.T 1009 State Zip.Code Country Codc Honole 968/3 300 Al4 11 # 7-212 Moana. Citly State Zip Code Country Code 96813 awarh' !Phone Number (Home) 54/-2.5.42 (Work) 5 4/-2542 (Pager) 1-mail Address Property to be Returned? I Yes 1.J No Total Loss Amount (whole dollar amount) Spoken Ianguage <sech inghsh Fench German Japanese ] talan Korcan Pohsh Portuguese Russan Spansh Victnamese sabhtes Visua! [Heanmg Speech WAP Brochue [] No Contact by yw's No ivice Reteuals (J Socat Serviees !7 Medical 1.cgal (] Suppont Gtoup - 9b-hN-178g3 <# b6 b7C 9B-HN-17853-3