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THE COMMONWEALTH OF MASSACHUSETTS <br /> EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY <br /> Department of Criminal Justice Information Services W <br /> 200 Atllngt St%Mee 2200,Chelsea,MA 02150 <br /> TEL;(11704840 I TTY;817 80.48081 FAX;817.880.5973 : <br /> MASHOMIS <br /> < u F ay a �` ^�„ � tb •.r]�'�, }?� ._ .. <br /> Please complete this section using the ifarmation pf the person whose CORI yog are requesting. <br /> 'The fields.marked with an attersk( }ate required fields, <br /> First Name, Susan Middle Initial: <br /> Last Name: _ mustO Suffix lk,Sr.,etc,): <br /> Former Last Name 1: Susan J. Labute <br /> Former Last Name 2: <br /> Former Last Name 3, <br /> Former Last Name 4: <br /> Date of Birth (MM/DDIMY): Place of Birth: Hyannis, MA <br /> Last SIX digits of Social Security Number: - C No Social Security Number <br /> Sex. Female Height 5 ft. 2 in. Eye Color: Blue Race: Caucasian <br /> Driver's License or ID Number: State of Issue: MA <br /> Father's Full Name: Gerard Paul Labuie <br /> Mother's full Name: Jane dean Labute j <br /> Current Address <br /> Street Address: <br /> Apt, #or Suite: *City: Mashpee State: MA *Zip: 02049 <br /> A�( a r e �/,qn v4Xt� d�S.A{M i¢ fl <br /> 3 uMlf' te. �Stlr- R• �p '�yT ., rv, 5y, r 1pMs <br /> ei1h� v yrtnj } z �+l'TUF` ity� r�B ary ,K y141t{ i ^(,V1�er3` 'N <br /> a .aw..rW.x�i.}ALdfldffi`.a,3F'F -WIN 1 + Y3.L. Ti-AF�i•.i� .1A�1+7FPtlh.•-'4,R....e r.v:t l.ir. <br /> The above information was verified by reviewing the following forms)of government•issued identification: <br /> Verified by: <br /> Print Name of Verifying Employee <br /> Signature of Verifying Employee Date <br /> 2 <br />