| Contact Information | |
|---|---|
| First Name | Beth |
| Last Name | Derck |
| Address | 15193 RD 45 |
| City | Antwerp |
| State | OH |
| Province | |
| Zip/Postal Code | 45813 |
| Country | United States |
| Home Phone | 419 - 2582512 |
| Work Phone | 419 - 5061903 |
| Fax | |
| badkeds@hotmail.com | |
| Alternate Email | |
| Website Address | |
| Gender | Female |
| Injury Information | |
| The injured person is | Self |
| Name of Injured | Beth - Derck |
| Date of Injury | 09081965 |
| Type of Injury | Obstetric |