| Contact Information | |
|---|---|
| First Name | Tina |
| Last Name | Ciccarelli |
| Address | 40 marne Ave |
| City | Staten Island |
| State | NY |
| Province | |
| Zip/Postal Code | 10312 |
| Country | United States |
| Work Phone | - |
| Fax | |
| Gender | Female |
| Injury Information | |
| The injured person is | Self |
| Name of Injured | Tina - Ciccarelli |
| Date of Injury | 9/12/98 |
| Type of Injury | Traumatic |