Registrant's Name: Linda Carmel Clark

Father's Name: Charles Lee Clark
Mother's Maiden Name: Marietta Bernadette Strongheart
Birth Date: November 13, 1980
County/City: San Diego
Sex: Female

Reason for requesting certificate: Needed to obtain California I.D.

Ship to:

Linda Clark
729 S. Bonnie Brae #411
Los Angeles CA 90057

Requestor's Signature:


Date: 11/3-99

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