Contact Information
First Name	Sam
Last Name	Saalfeld
Address	12231 33 rd Court
City	pleasant prairie
Province	KENOSHA COUNTY
Zip/Postal Code	53158
Country	United States
Gender	Male
Injury Information
The injured person is	Self
Name of Injured	Sam - Saalfeld
Date of Injury	01/20/1993
Type of Injury	Obstetric