| Church/Organization | |
| Preferred First Name | |
| Street Address | 667 19th Ave Nw |
| City | New Brighton |
| Postal/Zip Code | 55112 |
| Home Phone |
| Membership Credential | |
| Mailing List | Yes |
| Marital Status | Remarried |
| Length of Marriage | 19 years, 10 months ago |
| Endorsement | ELE |
| Place of Chaplaincy | Hospital |
