| Date of birth: | 1937 |
| Hair: | Bald |
| Eyes: | Brown |
| State id: | 142557 |
| SO#: | 78375 |
| Booked at: | SALT LAKE |
| Cob: | California |
| Citizen: | UNITED STATES |
| Booking number: | 0428099 |
| Booking date: | Nov 29, 2004 |
| Release date: | Dec 1, 2004 |
| Booking location: | Salt Lake County, UT |
| Amount: | $280 |