| Contact Information | |
|---|---|
| First Name | charles |
| Last Name | vedral |
| Address | 4684 s atlantic ave |
| City | ponce inlet |
| State | FL |
| Province | |
| Zip/Postal Code | 32127 |
| Country | United States |
| Home Phone | 386 - 304 |
| Work Phone | 7393 - |
| Fax | |
| cvedral@cfl.rr.com | |
| Alternate Email | |
| Website Address | |
| Gender | Male |
| Injury Information | |
| The injured person is | Self |
| Name of Injured | charles - vedral |
| Date of Injury | 07/23/04 |
| Type of Injury | Traumatic |