| Church/Organization | |
| Preferred First Name | |
| Street Address | 8376 17th Way N |
| City | St Petersburg |
| Postal/Zip Code | 33702 |
| Home Phone |
| Membership Credential | |
| Mailing List | Yes |
| Marital Status | Remarried |
| Length of Marriage | 4 years, 10 months ago |
