Date of Visit: April 24th 2015 Name: Putu Wiyasa Sex/Age: M/39 yo Address: Br. Pendem Pendem Village, Negara Sub-district, Jembrana Regency Mother Name: Ni Ketut Sudentri Occupation: Making banten (means of ceremony) Ph. Number: 081916622718 Information: poor handicapped family Bank Account: Bank BPD
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