| Contact Information | |
|---|---|
| First Name | Charlie |
| Last Name | Chancellor |
| Address | 2126 Clevland Place |
| Apt. 2N | |
| City | St.Louis |
| State | MO |
| Province | |
| Zip/Postal Code | 63110 |
| Country | United States |
| Home Phone | 314 - 853-1322 |
| Work Phone | - |
| Fax | |
| chuckchillout13@yahoo.com | |
| Alternate Email | |
| Website Address | |
| Gender | Male |
| Injury Information | |
| The injured person is | Self |
| Name of Injured | Charlie - Chancellor |
| Date of Injury | 10/5/2007 |
| Type of Injury | Traumatic |