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Home My WebLink AboutReel_0023E°E STATE OF WASHIN N I °` / No. '??c9? 2 §6TRAfFICWAY RaieeeolMluN, NUMSI POLICE TRAFFIC COLLISION REPORT ?PRIVATE wnv ...y couNtY \ coumv yp. OttN F.E C.ISI D°. lu i`AF OURI GSD..? t/!J- O 1, uN. in f b WILIO f51vff10v HIGHWAYS C31 C3 CITYCRI.- ?N G?/J(7.?iCJ Y/? / 1 wles o l w 15&F(?,) '•sfcuoN 2 &?opD $,l7iTjZiJ `R"?% (SfC1ING NtiH: S,PFftOR ROAD .e!I/Z L//Fi?la'/ D SIR,I `U' O stAN F6 P M f' FEFI ? .? .. cou sroNl vavm IOVAI NO CR [N ClfS I •/? .."cl SIR I- ' y _ DRrvtP'3 NR+Ar SlvtFi ADDRF ,` :1 or S G ??. ,? fR'S UCENYN r ?`w occuR=iwN CHHEECK ^t CODES b, „rts N ` NH YfAR S 4? 7lO vtH eIaNNFR ?? RlG15RRfDOYR M ry' y AD..I,5 ?o -11.0.11i • ; ;DAB; DIAGRAM i i NAw. I . Huu`tt j0 At?ltt N ! ?I RDlwnt? S 3 e A n .rt« .MF t DAMAGEo- A H? v."PUN CN s tv 0 . DAa ° GL^O COLLISIgM, Vv I I 1 NAME ADORE nrrl IvANTS / S,REfI t ACCIDENT 4. MILEAGE CODE ? SPILLAGE ? H116 RUN w pnviH INIFj CIS U Glf V/ ? pESfl%I[D Cl S1FH CNIf tSt.DAMAGE SifCW CODWG ?.f;. S,JTi s ? ?C L IRfEl ADDRESS A / Pfro ENO. D r !O R f NO. Q b 7?b / ns GH, Hfle E CURAioN rIRrANAMea NoneNc i s y R ? CHECK (.? ! ! s LNPi ,Hfe' CODES ? t 7 4 s ° /I p« N 0M I. 1 S,YI£ODR. GN , N ,LNG. D., E °tR H KN N N E R ?r' C >,ZoG ocf?, • ? ? ?? x1da2.s?G_. L INJURIES OF PERS N5 INVOLVED ' CODE: IuSfSWrtIS4N,Al5Hlft SlX At TNESSES ra AOpnwNAl NArusl f . Ni .9 NO [J- - Y iNN?S f SP e „,Ia ?, I ?? r t MR 1 yG _ > IvsL rr I y t ? n,? T ? 1 t " ? } .i + I iT1,1 lh?t S ( ? P le ;t t % I aNt {I?( , I I ` [ ? 4 4 t 1 , y ? { ?r 711 ' ' N ; I , , ? `.r ?' f 0 a E ,c U E ws41w IREV.I.IwI STATE OF WASNGTON Tor I INn. jn? A, POLICE TRAFFIC COLLISION REPORT Lj TRAFFICWAY pOUCECWARMNrN-R ' PRIVATE WAY DA.f oE. au. N c umf IusF]AW NOURI 17, courvn courvrr NO. c11r r1rwA ?u4eAN ON OE ®N DIIYORIOWN NAmferv0 Or3r4Ff10PN1GNWAY CIS ROOT LINGER LONGER Avlts ?s ?w ?ar QUILCENE ION 0,(110 I iNIt43fCIING WI In. SIRftt O440AO NON 1IfR3E1t ON .E-,NLEADVILLE RDk-T a -DEAD END*Sr4tFT IRtFIM F MILL NST / D1 AN D f ,CROSS SIRfF OR NfARESi M1lE 3 M l[S mR SvE E W tar or LEADVILL AV, ACCIDENT MIEEAGE CODE OAA < N1NVavm, ve4nr ?SGIIUGE ?n16 RUN N° INIURED NO SIIfD wIRM wN INR as C °f A?33 [LORROAp . _ _ O,. NO. Or V[NICIES © ® RRoKRIr DAMAGEONtr ? pFSUtIED p VFaClf `r ???p -- 4 09,ECI SIRUCK INAMEOF 091fC1 SUUCR ANOOWN?R'S NAMtI F31.OANAGf SYECW CODRIO US! .-. ? -* S UNIT NO. I UNITNO.2 ESTRIAN C) PEDALCYCLIST' p VEHICLE ? 7 R' DRrvtR'S 14Mf: U51 1931 M1 LAKENESSR KIMBERLY D 1 ' N[4'3 NAME: U31 04 ATKINSON, REBECCA JO - e 314lfl ADD4t BOX 445 BROADSPIT RD P O - RtEi ADDRf3f P.O. BOX 483 CLARKS TRLR COURT -172 . . v 1A11 ZIICODE RHONE ND. D My- AE 1 WA 98376 765-3286 R QUILCENE WA 98376 765-3733 1 B8Z17V1 ul KS F Ol 16r OR• I N rv u N ATKINRJ322JK A WA FA DA e1 N 04 12 68 OCf.tIRA1WN MNAM[RffgNt rq. fYES 1ONt .fIONI E OCCUPATION iRM NAMEt RHONE NO. "YES WEIGHT 1t1Gn1 Z STUDENT BRM .17 O3 R STU04°T BRN 140 50 0 CHECK (.1) vt 11 A orH[vN AN pCHECK I?) l-If ASANl-0yFI1AN01HFR - S . e ODES ?" 7 • c , iv 5 IA<rwN a sAnn ' u * CODES ? * 7 2 1 r2 C wl a J o f1a:. ? ? M WI ? Elm. ? ,'n"Z,'cRU p ? M.A F ? A,° ? ? K KII ? r..? A n vlH. r{M MA[t fDDOOf CnlVl IIDARi.NOVAI "uf7D4.. ' n.Y I V.1 l10 Al I 1985 PONT FRB CP 2DR E 1976 PLY VOL 4DR P° '/ Ru 1 N sue rvAILLR wsn NO. vA H vlH. oR 5 WO a RES WA ** ** C GREEN LUM123 WA ** -* 3 3 vtnlelelwefnrN:t1RAN NO. I F IS 181 7 F L 6 214 9 916 L vtH1 11DlN 1 H P 4 1 1 G 6 F 2 p 3 5 1 7 3 nersrt4eoowT+u'. IAS1 "All M1-1 SAME AS DRIVER vnow NO. O W I Wr! . lu n4sl m1 ATKINSON RICHARD J. M RICHARD J. D? ADDRf550rOWN{q N , E 2 18 LAKE HIGHTS DR EVERETT WA 98204 --- 1 FIJI NAmu•DORtasa mwuNeeeoa•oal 'L R N ' Eli 71 ZIA DAMAWD ? D r.«:ol. Ca-A.. N ?ReMMNm uD a CE A ? 1 A ? lowtD f 50.00 r S 1500 A 3A n N n Nr A fe tl FC t3 vn rM l s 3 _ t su t s u a s •u oln DESCRIPTIONOF COLLISION: IIANN- f DIAGRAM OF COLLISION: Sa _- S I N S _ P A S _ A I S H E - W rDRIVER- Hl-CLAI6fED-T F A T } } -J •-1- ' Q 44T Z I I 1 I WHEN -DRIVER- OF-VEH_02-PULLED-INTO-HER-LANE_EORCI HER 11 jlt. RIVRPOiVEH?A2 CLAIMED THAT THE DRIVER OF VEHi qt D I? I? I T ^ L_ _ L BACK INTO. THE. RIGHT LANE AND CLIPP -- {( I -' E I T ) VE IICLE. HER iOi ALLESUABLE TO IDETWAS -- DETERMINE CWHZCHAS Y TARRI _ V _?.. .- j I-_.._E..?_r.... t._.__.. rORRFrT M NAME,ADDRESSB INJURIES OFPERSONS I NVOLVED 'CODES I - 2 3 5 6 OCCUPANTS WI TNESSES irnim111o?NU?.w s 3IR AGI IAIU 'NNN '1111" '-'MI' 11 InstR inci TANY]\ N'M° DINESEN :n 765-3925 F 1 2 1 3 1 4 1 __, ., R_ .DO.nt.. 31 MT VIEW RD .. ILCONE WA 98376 .,At oaa NONE ..... . AM e ?1 0-- 0 ;x p7&Nt. o -'_-- .DO.ns N•rw or F wu. ?AMe ? ?co . ?.?+ ? :° NAw ra I _.._. .,._ _._.___ wars .... __. _... ..._ N A'I..; t°` . rNf er ?•Me ?%;:' pc?':n. pw: ? :':;,o ?NVO ?•,GaICIR t.wnf•AN. X DEPUTY ROBERT E. KLATC a soDw A 9A M,INCr JCS. .. B7? actD,.•.c?Fn >,a,SOs Na ct AR. vtD p 2 .??Rs D•na nron • - 3o - e6 All f5]l s n if I -a ?r j srC ??9M1k awr pf. 1,9R9Lkp79•I-yifCRn4 M9tApV'fL ?!•,'.l1C ,r'?a??.,?,i -1.,GJ.:EwgZ t:..'A6 ?Py's b siF, rslt.r rq? t,I ^T ?Y N ' 5 ? Y? ?r' "11 Sr f .t ti E f fI I r i r rl •?qin rt 711 r I ? I !' 4 y;? ?1 { ??. .. ,. :. ? ? ' ' _. ,._..... .._.. a , ... ...? _... ,v_. _. r ? F - w5P 13919FV. I NI 4; STATE OF WA GTOIV / JF l No. , q 1 9 ;J s POLICE TRAFFIC COLLISION REPORT RAFFICWAY -1.1COMPWNIN ERR -- PRIVATE WAY DAFFJF COtIr DMF <OVN?- ? ? " 9,r ..P °?r? .IR rw., "., r IN E ]/Deco I Gfi%Ei25o,..) COUNTY NO. CIfY NO. / (o rNwA pUPBAN / W _ crro9 wwN AJAEa NOO r 9ncnwAr ) N f RM rcr as / p pN / M(f5 ps pw o' ,LG< ? ON ,L , wlF4sfcr NC VnIN. srvFFr oR AD NoN ?NrfquaioN Rourf sqf (?SS 4 vnFl IJ /J /?C/L- efM1VFIN r T /Z SrPFEra /3rQL3OO L?.?r MRE V,ur /./5 /Sv D?SIANCfaO'r r M4 tIEeFNECR055y1RffrO9 NfARESrMIF'S ACCIDENT RAM DIA-TA ° / MODE E " 5 t w OF 25' L I/ S IFfr <OllrfgN NVIXVfO SFV r. N IMF M"'sir. N ? Or.t NO NO f?I?NO.INlURFO_ 11 SPRlAOf NUaRUN wNgnD.r. Cl5 09055 IF[r09 POM 90AU09 P[FfR[N1 IFO /]] / OvFNiCI[5 'gOR9rY DAMAGE ONIY ? vIII ?vr it BE-51-K INAMF OF Od]F -RUCK AND OWNER'S NAmfI ESr.DAMwE y'ECW <ODING I.6[ .... ((( E 3 UNIT NO. 1 UNIT NO.4 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST DRw[R'y NAM[ IASr 9 : 5I D lE [4'SNAMf. USr mi 3 /? ova - A zs G 7. sr Er Anoefu FFIAODR[u c A4,9o.- ?? 79 7 5TAIE lIPOODE 'NONE NO. o? 1,a1G.y /? G DewER'y <FN•1 D R yrAl[ Y 1 u -Io 98335 y J U SrAif FM A I D w 1NINO. E A aBI 1n G L ? a O ' S OC UAiON? MN-I. NENO. 5 GII IE Onr /?? s S oy3TL=/G ?.j E R gm <UPA-, pNO N NO. fs cNr F9?cnr 7?fJf+.? TS9 rT ?t ?.? ? CHECK (.? rcl[.siN [mvlov[F OFANOrNFe CODES ? * ? CHECK(/) yEN CIF AS AN [M0.OYFI OF ANO ' y/p s 111 I O e I.,s . .srl C.. CODES ? 5 u e w ""- ` ]r IN WIt 5 0 SlI..11..DM ? A ? ro v`f ? zsm. ? „Y.IF D xs.1- p AY-c ? Ml l ? T8.II ? Nv S,I r. N r o YEN .G9 MAKEII ECNIVI /97? ?o et] llI0A91NOVAI SIrlE1]0C V.I is S E N 1A 1 fII -111 - vAl GY /o/?J Sa I l i ,7 d. ' n. UCEN 31AIF Al re Art[R0.Arf ylf C f l J _- ?- E ,J Q vlNiCl[D[Nr NCArpN NO Gol - SS - OWNER. vIW5rtPt0 lode PNONINO Sf - LA51 yr loaf IS ADDVt150l OwR+EP qY? ???A?/ / [ J N AMMS Of OWNER a -7p E _ HI AMFeADDgyy Cr ?NSU9A ICO OR AUNT /Jf R ?uA r.1/o11) C9 oAMwl ARtA •"<"'D r r •MwE AREA x eNAVU -? a.vee ? w" ' g , r• [ .. y IG iorio9 Ear DA .KCLL W ow?r OtMUNlD ? A Y o -MN ? ?9lmAINEo AWAY , -, AM fs?0 I aorio? D 71 :w v er ? W er ? lei DIAGRAM OF C.111ElON: ID l INDKAr[NwIN - sw[r racaswrl er DESCRIPTION OF C,OLLIEION: VISE yueryEmANrnl yN[eru mCEysA9rl J ?!i? s3?/,?5 Ui43 0-3 7.9,`03ro Z e "As rr..?? dE?i / Wir? c?i? a,J ?i¢FQrr3oolt? N C/J oS N G dG// T S D . o / E Sw//?6.. I , NAME. ADDRESS 8 INJURIES OF PERSONS I NVOLVED *CODES 1 9 4 S 6 OCCUPANTS /WITNESSES - j AcE ur , ".!" ° . all EAc AMr ?w? lL :o -G J s 00 •lu9E o. [ NA - r, Nx.fss o n ?A7?L:?6JJ./'.l?. ?" '0L?v Y NIYI r.oM pAMe p?OrKl ?.,? cl G 141 ;4 +oowss 7 Nn,`4°?s d ll., ?• a ?u"?F'o:.n ?:i ?^` P r . vn c Yr S , . , A;< ,c . +ou? .uF¢. .,. / sg ,SFr r.IO ?? yro o+na a ArPROVEOe. AN X T712 i ? as? N /3..1 $/R?L ? r N r D ` qq?? , r l N R s? -nnmv '` r, 4? r r r a f i s ?f ? I r, t r -,4 i .?y = .? dn kU I'M JS 1' iII ? 41 FS L a .?{??/?}7? " ` V ?L ? ? ? ?v ? ? ? ? 'i i u?Y.?... ` r?Xl? . E tl .,..._ - R '( - • tt?? STATE OF WASHINGTON GE / GF / N T y ?ZTRAFFICWAY 1 P' '., V .,. 1sfRx•? ?. POLICETRAFFIC CO ON REPORT Ja roL eRluNrn uR I ,tr• PRIVATE WAY ? y toycal pv Ar N ? / ? p 6 w, +•c. rY f : X u? Au lu t+9°ilpO 55 co?u?N,-r• /? \ - J??iCLC?G.$O?..f mu ?r arv NO. f-A Duve u / r DN 1 DIN cnoRlowN nNO M!'---A MILES s pw or / G-' ON v`GL 2 ROUrt sr 70/C3? f t ? • - ?Nnvs[cr NG W+r« sear oR ROAD NON INnRStaloN '` eFIWF[N / % SIRFf, 6 f7 ?GL?/PCJ etRFFt x . Mx1 PO3??? o .t E .: O?SIANCt6DPt?t ON FR01m vHERFN F CROSSSIVt[r O?Y jNE•RFSIM LE RO51 3 5 F W ACQ-1 E M P P OIA RAM DATA . _ M r ' ?? nA ?. ' '1? 'a • Y .. ,ff1 OI X?O l7G/ZJ COIISONINVOt- FR rr. tOIAI N° NO .IItD?NO rN1URfp? DSV„L•G[ DNt6vuN (y of«CI[S PROP!Rty DAMAG[ONIr ?eF5V11lD 0"I"c', [CI <. •NDOwv[RSNAMF IC1 1R Nwv E O, OB Oe C . CODE ,•.ND.ID,. mISNS ESt ONn N SRECIAE r IMFR l5 C CODING.. N 1 R 10RVW0DII NifRENCE R°SSSiR[[IORROADff O?IlJ ...2E I ?? ? _ 3 '?z ? . , 5 U a1 1 I - 5 J .J GO. SIO? UNIT NO 2 UNIT NO I p VEHICLE D PEDESTRIAN ? PEDALCYCUS7 yc,k Y ' y h S . r RsI mlDDll RrvIXSNav.l V31 / D . -I-NAMt' N51 1 = { ' - - a ,¢- Lori rREFr ADDRESS L IAOpvus boa vy l,.?aE/2 lz _ , YE L ol. still "Ic.. PHONE NO R r EIAIE IPC D I .H. } R'SU<INSI NO " S I A H M ° I I rv IICFNSt NO. AI! x pAIE •rB P'H ••O D r. I. I e GS '? / I ? NT?G/// G/J/ E R OCCUPANON RA NAmf 6 PHONF NO Frt3 WFIGHi HIGNr ? ?? G D CHECK (?I fMNOnFaAr?orH[aA' V-CIFASAN CODES ?' ] 5 1 6 mD; A. - ~ V pCHECK III 'E. i CODES 1. * ] v A 5 me aN a is , ' ;?... 2 , C s s D 11 4 ? •mm ..R O D 7b: R ros° yorwm p •».,.•NC1 o ? ti:kN o"'- n.-/on"'. IDOW[<«tV / rE7lo '?iY/s fJ? MODfLIDARi.NOVAI Slrlf I20R 1 X12 E V rG 1 Nfv l r IIDMI.NOVAI (} R. v l °O1' , ov Al sure Anty AnN vuE H vl« aoR I n C t« It Df NIrFICAIgRI NO S 30'2;7 0, o;/ ?I i ` V-11 DFN III r v{aSR RtD ONMFV Wt NRSI MrDDL[ WqM IYO ?iOC O W of ISR FDOwNtR. FIeSi MIDIXf [ li_ A DR[BS Or DwNfR A tR - Amt•ADORI alNwvANU CO OR AGINI R muAl . ,. DAMAW MfA 1 r,?<IDHM a•rx1 D+WI ^• CHAPW ?? CNAR "ws:.,Np gAmAG1p'AREA -` r ,. S 1 roeonorl ISI. DAM ?D4 vIN ?REMUNEC Aw•r tD ?AW'AVN ?REMMNID [SI. DAMAGt io: eo . ?y,?`?,? T QT-il _ 1 Gl?J 1 Aw:v°er ?,e?/ ,,5 Aw•r er A P _e k ,f T? DORun ov c5 ou ISION lslEu U{uuf aCisux•1 ? _ND eruARlRNOOm Vt« ®- DESCRIPTION K QF COLLISION: lus sIAIMENYAESf[fr F NfCSARYI -- 1/C`/? r O Q L//?u?/J .._?/??. DQ?.2 SWE2J?j. TrSS_ %/ t - . xx G IQ ?FEi2 rG /? T o Q / 0 O C TAEa?? s J a ray i / ? p0 pC? ? . , , ,fit .. E ? C Q ` rtta f t ,1 . IR NAME, ADDRESS & INJURIES OF PERSONS suvnlMlNUI sH INVOLVED m * CODES 1 - 2 3 4 5 6 - .y. OCCUPANTS / WITNESSES i Do MD?r101,AL N•MI S U. AGE IA1US y n • Mar PlSrO I,ICI 1 L ,Ir •J mf , NO P I E,?ax Ndv, or na w. mDAm e 0M, D^? . ?„^. 0M'- .. 1 5 i y ? ? • ? I : 1 CA y?] q II _ e E (? 4 fo ? ••,r,^V'I.: Y Gr H Xr µviDrXOm D AMB D "" I D n . D ? ? riD Y Br i 'rH ? •.nr tl ' 2 1 -t f J • V 1 x U?? `N.riirJW . y P [ - • [ 15 r rNr e: "" D•me D ?: " Do..r. ?'A"• 011-11 P ' ? .. I' ° t1{ -' e•x . JC :I ' .ct m J? ' crX X IDe. DA r?[ tr }.? Ffl,.l x ? Z ? \\ ?S/-i '.? 0??/ 1M«v3 O ?r >u7L7 wX3 ; V?? > ® R V /V/ I rs r - rax w1 h f z ? a STATE OF WAWINOTON. PAGt Gr / InI r r: I 'J POLICE TRAFFIC COL MON REPORT /ma'r' TRAFFICWAY rolls[ .,aAININ B[q L PRIVATE WAY r r AJ 1 OA CIXII N F O ?j f cou`N',?r?// 1 / V: '' Iwl I -?t.i, IVSf CWN r CITY NO. 1 rNWA ?UY URA, N ?F ?IN CITY OR TOWN OO Siv[[lOR NIGNWAY (? MIlfS ?5 ?W Gr U - CON ocJ clcl/ 10D, INIERSECIING VAIN: 51RFf, OR AD NON INIfg S[C1ION Cl5 1 b PR gOUIf OR Rf ?? 290 O // //?? // ???? B[IM'lflv(.t7? ("T/CESrRff16 (?CiZi51Rf[I [fl% f MIlf PO51 c?Oa 1 / DISIANNCCF.Die[M1`ON MRffI VtNC .CROS551Rtf NfARfSI MIlf V05 ACCIDENT V [[15 N 5 F W « f? COD MIODE E R -P 11A RNADAIA COIIISbNINVOtVFp: Nf of PITY: N O %Ill[D_NO. MJURfD_ ?SPIIIAGF ?NItd RU IOIAI NO 'V?, oi" avfN14es ® Paoagrro wtoN y FIRE IN FY C I gfFi R OR RfIfRtNCE N IMFR 5p IN CIt 55TREETORROA[F 4 .32 9 Am l ? ?_, OBJtCIS,RUCAINAMt Or pBJFCI S,PUC%ANDOWN[R_S NAMEf F5I DAMAGf SHCR4 CODING IbE f 3 UNIT NO. 1 UNIT NO.2 DRrvkq'SNAME: ATI ? VEHICLE ? PEDESTRIAN ? PEDALCVCLIST I MI f 1ES L E ......... f: l q S GYGSo SE/? ,ID D. vG ?//? SIYa,ADpRF55 !,?/ !op7 1 " , 514[[1 ADURf SS ?O / ? •2L _ fN ?. y1,Rr( IIPGDDf PNGNe NO. D 1r 1A't ' - ,J .? Fl3/ DPrv[R lI[FNSF NO 73'/3 R G/? a Z g833S' 8S7.gR3 /2 . STAY aG.2i/Z y3i i? GJ/? A BIRIN s IS' I V V 111 O. S%CIJG?/=/o6 LSY7 GJ/d DA pBIRIN I rR - `772 OCfy?Al:01.I? MN.W.[6PNONf NO. lvE; WF GNI HIGNI - E _./ IIRM NAMf6PNpNf NO 7 ?/ 5 SS ?C G N, HfGNT 49 ;V1 yr -? Co 772 R G .Z GU AOL 4, - ? CHECK (V) nN a[AS:N rMPiv rtfaAUO1Ha I CHECK IFFn[ASAN CMao o 'AI w CODES' ] S E e rE[ rAN N1R CODES ? G a .:: 5 IA a - '/n o ' s e P WN.rfAR M%f (DOO GI CNfV.f :7 -1 5r1R <Oy,1 a? biL E N 1 NFV Yf 9A 2 1 I I r I R. ??./ I 6 Y l f s1An nfR WAIF NO vwn H C N n l N nIDaElaNrlr¢AIKJN /-,?olc!i?Ilc19L-99!sy -4- almsne[poW*+Fe usl ngsT MlDOIf PIroNt NO ` wl le lpNll _ ._. 12 1>16 I(o!G11/1! 3 331 ! n l wN R, 1A51 NRSI Mloae fNO S/J w f A.n? w . Q7 8571 ( 'Go I ADDRlssa oWTna N E o - f ` s1/f O6 6? ?-LO NAMfaADDR-ORINSURANCICO M AGtN1 R i T / C s WMw?O MIA R p <rpN, I I ?- -- " 4AMAGIDAREA I10P IGio1TO? A wlrD SI?1?GI OO CNARG[ ? It-NED pWTO CNAFOf .,?• EA-IPW^? lOWeO `'?A ?RIM4NID _RD 151.pNA P I•???--• S = Br O AY f O D - I E N I NoI<An NOYN' DIAGRAM OFCOLLISION: I ..,. . -SH{1 SSARri - arA Row DESCRIPTIONOf COLLISION- Iuf SUatuNlµ SNtU Rr? eC [S S M WWW .JJg .0.3 sr?o .: e R I. iJD .-. . _7 -; <'T,1 +?f T.fl I ... /J ?/E/? ?"/ .l.Ji¢S ..??/3 .V?.+ .?•l.Lo t,J C?C6C? _ r I } a x ,/ T ;, /B I • r ?-I } G?i3iP? G.Ji .CAS c .l?G// TF+--- I . I I NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES 1 T 9 A 5 6 OCCUPANTS /WITNESSES is Sw"I:,"IN I F -Al N.x1 t , it% Ace a vi '? ?" ° ,?? o isir len 1O a.5? 7 A E /. S? y3 P p - A MNSS " N A11?a 0 ' "J a+-sG Nrer AM ? iYl'cl Q . II '. , ? H . Y:L N ,MI _._.. `O O/ ...... .. 3 3E5 38 I s. A Mw151 URId .. •I MVIUrY(vA OAx! 'r+IKI .I?i N? ep ,xl ? h , oars id- , a ' ;rru??a 1 IMYB. ?AMB ? .". ' ?'."r . °I ?ri Oi` ? ,. v P,ocvr<L SN•xI RR x B.DGI O. Io ra wlNC. , 6 `.R?,g RU %c! 9?O wn IroP 7 .ovfpe. DAu W - i J?r..,.i r,mNn ? WSP ISV Iq[V. I.BQI ksxvi4 m t I W L ? ? ?N L ? E &C J . -- POLICE TRAFFIC COLLISION REPORT I&IRAFMY-Y 40lKFCOM4WNt NUMBER f [:] PRIVATE WAY - AI N 0 FU I wr IR I .. .t F lU3F]S_ I courvrr J6? o? muNrr arcNO. yN Q] ? i1RAl CIV OR rUwN M. ?1p E w OD•Q COVER rvgME 6NOO3rvfn0R nIGNWAr N F US' .I......... 352/D .,, IN t95(Ct NG SMrn. 3rvEfr O44OA0 rvON NIF95FC1 STRffi BtrWfEN I-TlIT vRGI% C Ml1E 4051 ? ? O - ' D13I CF {D R[?1 ON MPFff 4FN F C405551pFfT04 Nf.11111M1E^4051 /A/? ES 5 F X- CL7CC /LOAD I OE ACCIDENT MILEAGE CODE 4 DIA RNA DgrA 5 NVOIVED COll1 T NONIURFO? ?S4flAO[ ?nr6 RUN -LIFD wnpnvt, RD I IM[R Cl5 C N CIN RE ORNOAD 044[FfR[NU RCd551pfEf OR VOA D ? OTAL _ NO TOTAL q vEnKIFS ? 4ROM41r DAMAGE ONLY ? vf3Ut TF0 ? VFafIE J __ OTT IEt I SIRUC[ IN AMf OF OBJECT 3rvuC% AND -E p'S NAMFI f51.0MNAGF SRCUL CODING USE rq EE E -rit UNITNO. 1 UNIT NO.2 ? VEHICLE 0 PEDESTRIAN ? PEDALCYCLIST ?•' S - D4lvtv'S rvawt: c kso.? 43i Q '011111114 _ SNNAf. IAST Ip II l EETAODRf SIRFtI O4f55 e 2SI O'9 Bo Q O oAb 1 S?tg1F/? ZI. GOOF _ ?ngNE NO. LCE.yE Gf3 a3 6 D R N N SIAtf t14 _ Wrv R'S Cf?// , I ?VOY 6 • j. A/// 9/1 O I1nr, V v v l N NO ATF EA ?OIIE4grBlpinF e 2 r ? vMN E{4NONf NO, FYF3 IOn1 MF GNt gU14 f ® ?/t us PmsrsF?/cam / (V E R CU4gr ON EIVMrv f64.gNt NO. [Yt5 Wf GNI ItIGni CHECK (.7 As AN IMR FA Awornta Al [I CHECK (.7 r(N OF AS IX1rovTTq ANIII A I r CODES ?' ] . °.iil 5 tan a 'y.°.i°, - CODES ? T ] .u " s. E IAC N e ''s"°N1°r •a. ._ v y ? ? P FS F 7 zRa'.W °M ? u ( ? m'. ? 4 C3 -NCI ? ? W'\[] ? ? z v[N V(AV -11 IDOOGE CnEV.I El10ARI.N05•AI 5I'll (ZD4. CON- ) Wd Pcc E nfv.l rn r 1 /MDfI RINOVAI M7 V.1 = DR n E N srATE ? TR ER nA1E ra. sr.lE " H vEn. aoR r q 1- ?O (? P C Nl FIGr ON v( ?Cl 3 31 2?• 91 , ` vfnlClf lOfNllfl N ?" N451 MiDOIt IT— NO vtOISRV{DOWNER'. Util - O 9 IF t WNFR. tA51 FIRSr MIDgF SA /w IF W /FJI ODRt55q OWNIR N GWN(R K N.M1 uoD4essq lNSURA«ct co oo AGENT E S CO, GN R AD-Is INSOLIANCIC., CAT A-1 „E4 ?.MAGEn.REA ' A IIAII IN ,. DNAAG ATTIA, ° NA a - ' cnuo -? avr 5 ts??DAM IvFN ?{eMMNfD I O cn.RGF ?nwevN ?RE Am1D is oArAGe o.onS? 0 E ?F eY A ? rowfoer: E I{ IACA OF COLLISION I "Al IND An I°Rln . LIUtIMUS.RrI r• DESCRIPTIONOF COLLISION. I-l(J-1-TAl 3.11111 NEClssA I _ // I G iD _ ..ur0 Trt' 6E . _ _ -? ? as r c , I ? 9 A ? ? t ? SAC i ? ?? ?/f?SN'L?'D ? ? P /MA1'/?F. ROS ; / I NAME, ADDRESS B INJURIES OF PERSONS I NVOLVED CODES 1 „ 2 3 5 - 6 Me su•nl Mlmu sw OCCUPANTS/WITNESSES gmal oNU N.MI n SI i1x of uius f(CT -is, AMI G NA N .144E - AM Aer e ?M ?, .?.i, ? .. 32 sYmnRv? f //,I N? ' o 1 , % .?.. / 11 - vovlDl4oM ?.Me ?uNt D..I O O: ?., ? ? ? vo.• glvl.3 N.M.a?... '-r o. ?vlr.+ m, o .nq.Iron •.ROaDe D.n K I f ' I x"I I? w, Ott 11 „ ? f ;'v '-ws"QK rfffg 'Mill, A ' d f L 1 llY. S 4 J/. L r ^ i ti T Y ' I? r??aa 9 G V ( 4 ? y 1 Lti{ I •, Ir +R`e , ?I. { 1 1 rF rj1' r 1 J I I I? ~, R? r f IA ??f?l r t ? t f y J C/ ` ' l D 1• 1 t k I F J 1 J I I l •? y ? 1 '- r I I fi T fil ? 1 t ? ,f +fJ?. I ? 1 Y I C '? 1??? Ik I 5 Jr fiI A E - f A a 9 r{ GTON STATE OF N . ;R w o. 49 DoPOLICE TRAFFIC COLLISION REPORT ?TRAFFICWAY iolleec°MVwmN aeR ,. 131 Co PRIVATE WAY arv Na i«wA 1 O 7 y fO,E.G94 ... - " I, 1,. w, 9 .a nMF Erg counlr couN N . 0 I QUe AV RA ?R1 03 S? I , SEFF RSon A Y SraffI OR HC W l Cl3 RdJI OR 1 E , ?, C1Y RIOwN fINO.O rr ? KE ? " c Kd. ON `:•?dS?+ Oi ? W 6 33o/D X v,y V, Ml[5 ?S Q fa Gw,IH 11.11TO.ROAD NON NIN, 1. ON SC fDO6fWI w RRfi1% FO. M11E 105i IERSECTN S a.I ` F9fS SIREfr I BE1WfE N ?? 6 O O 1SIAN-.REMLONI MR1 1. CROSS 31REE RNEARESI _E R01 E E w S s :-k Rd eP ACCIDENT MILEAGE CODE R DU aAA, DATA . » .? of ORC iffy R rv MIl,N %RO 1 R 9 ROMOR KEF fNU IN M O MIa u CeC5S5TR[nOR R I w...... Q«Ir COlliSWN NVOIVFD. SEV[ OElLFO?-NO.iNJURLO? ?5>tIIAGE a RUN I ? J TOTAL NO E^LI ?clSULNO ?STOLIN Ci VEHICLES I..LI ? iROfER1Y OAMAGEONIY -ICIE NERSNAMFI Es'.. NAMF SRCW COOING USt ... - `? OBJECT3IVUa(NAMEOJOBJECT51R1 1-OW Tfsz UNIT NO. I is DUNIT N0.2 vF95NAMF: M1 OI S' I Q VEHICLE ? PEDESTRIAN Q PEDALCYCLIST IASf i' ' R ORNteS NNAE'. USI 1? .A ' Jf O 1--1AT V^ve - Yl IRfEi -RE. 519EP O :k AUe (a ' 663 & 2 . - .U COOP RHONE NO. 3IAtf D NE Y - - 5 A E . o 83716 -Q- A R 4...t6 L STATE E% iRX I L N L'b 'v At °A F M IMYeR HE ORNFR'SICtNSF NO. ?-rN//78KQ B (.JA M Eisl ig lS3 v oy t{RI,ONf NO. EYES IGMI K*Ht NON E OCCURAT- NRM-1111HONE NO. EYE3 IGHI HE GHf e 2 OC LaCURA YEr ML?kE G?En 6r0 tS(6 ;68 l a RCIA Q CHECK (n vtH CIE ASAN Unxortta ANOIHEV L oK ? CHECK 41) E«afA A MvwY L ANNA ND'.. 'O;Z N s l wN 'Z ei": CODES 9- * 7 n 5 I% a i° "?P•O Z . rN CODES ?` 3 C IT" s N QIES C FvA? rEr \X lac nl'l lncrrWH.w D 1 ` yol ?AE QGU ??. ?oo Klf QCs w ? J "'N •1 b Nwl+ ? 4, H]. ? LOIR. ? h»?a, ? Hfv.l MOULIOARI.NDVA1 R ? ' I YI r VFH MARf IOOOGE CNFV.1 Y.. STYLE IR DR- ONV I f110A9TNOVA1 . ' 30 ?', S S55o H(c. E = 5 .3z3 y789 '- 51Aff RAI1lR0.AiE NO. 31Ark H VFN oIOR- 6 612 o 6 91 Y A (a 1 c " 2 , EiannncAnoN NO IC L yEN UEIDENIH EH I i ? 2$ I i G % 1 I I 11 N. I I wNER. A3I Rst MDaE a ' .. ' Mioaf 1 Refnsrt.mowNFR: , 146r r [Eu f LE? vNONE NO. ?T< O w NFa A R 31 X 2 ADOR U fl f uf ' E! L /1 Ic?UCIC C 1 ?1 E Q l x E u 33 AMEa MORessa iNSw+NCeeo. 09MkNr R N r Iv+r `?+ o,.xINO .-z z .y. 'DQ LsAMMFp ARUM 0 All MU SNRWG n CNAaGf OrNioi"AOl I IGA '""nON" f • 1 eHARGe E u [e t lSS ... OAMAee E R .roA 5 u1rnDAMAGk AwvEN ?REMUnko ?eww ?R[MAmm to iurro? 5 3 o irdib. ?•? f f$OC)`= :wiD. N.3HR? ? ow[D.y ESUrnEMeNUIS«Ekr rNeee55ARr1 1a _ -_- DIAGRAM OF COLLISION: lu u l ND UIe NO DESCRIPTION OF COLLISION M sNUSU Y er+v9 wC o £ ud?. %i _??C6 _ T_ T ? _ . ' T ! 1 J T .f I't I L- . - ._L .. - 21 f?d,ti-Peaiz oFR, ?'ZZ'SALKE E/E _ NAME, ADDRESS 81NJU IES OF P RSONS OCCUPANTS/WITNESSES is moowi:i u:w INVOLVED i' CODES 1 SET, -1 - Z 3 '15- 4 7,1 5 6ES1d Z 6 MF ?l ?.. { fsLtill d L P w + „ -tf'• 3EO SW ° ° r 1 AMe 1 E2C" ?'i" . ?H ?w.:. aY ? ` AA Y,Sd *.T .,I„ Loy GL r. M .n ' .. - .or .. ..- a DnE3M i}:w1ir Q.Me Qucl?"o ?D ?: RD AN.1\5 Avl NO ". 1 ? DA I Ern„ M.. f A F a .. r A'. li t R lEll 01 r RiM l? N POLICE TRAFFIC COLI I-ION REPORT J61 TRAFFICWAV t • N , I ? PRIVATE WAY W`-;-`-! - [OUNtY _ .Pf.EFI9.. Q4J ' _ _ [ 'l. IME so tou"rr G AMF ON ?E ?IN z I t w Cxce D or ?s ?W ON BfiWFEN sief[t e ' S N 5 ! W ACC MILEAGE 1A Or S /O i '.L Itt I CODE D y COIIISgN MVIXVED fellr'_ H116 RUN TOTAL NO No%IILED?IIO !.NIUVtD ?s4BlAGf ? ff OVFn CIts 10 ?vaOIYRTrp?MAGf ONIY 7-•• ?psulTED Dv[aCiE Mvtsrv wnRNRI. IrliF CIS OR04SSTRF[104 ¦orn ?"1 OBIECl ST4lK%INM+I Or OpItCi SraUC[MIOOWNf4'S NAMEI ts1.pMAAGt SRCIAI CODa1G .. f UNIT NO. I -UNRN0.2 . ' VEHICLE ,.' - ? Pffl EAN ' ? PEDAEC atv ASt ?. 74 S q LivIVFR' NAM[: I,ASt 11 st MI IXt Ci9WYtR V/RG-1 L C £ to DervEe s NAMt. I Gc /FFoR 8/tRBRRA 'p/"tiE 6 slvf(t ADDRESS 2 W /o' TRfft AppRis 720 LER LANG ?L£y RD. £• Z . Clly s1AtE ZIPCODE PHONE NO r AN s w 9fl3G Z 5?5?-l213 D R Ilv STAIF IP t .1 NO Qurt cgWC w14 991376 765-397y R1H B 1 -- L piwFas UCFrv•A NO siAtt C W vL53205 Wig [% /'1 a BI4 Hr ?A'2S1 7 ( ? IvF' H lNSf NO Alt Cr/9918 Ir2 LE wA NE NU F% F I OAl! 2-5- ISz Erts wNGHt raleHi /i a 2 TRwcK rIVMNAMESHmNF NO38•,r 7007 ens wElenT t<IGHt ? Ivue tq wcf TRucKr.uG St41b'oSo E R ii??' CARRIER rI4M NAMEev"o . QurteEnrE PosrlPV/ gEUlzoSo6 A - CMECK(?) vFHItIEA i FF Or APMiornFa I E ?CMECK Its vI HI CIE ASAN fMP{()YfF OrANOtnfe "'O 3aa 4 °19°•'^? nomrv w•c.rn CODES ?' 6 ,,,a cl?oN rtrv CODES ?' 0 c 7 . Is.IM 5 r% ( 6 Io Z NKLf LL4 SRM CX U IN ei N L irp rKWEt RIES m 2o' -) °( » K . roll Io .D D . I.rvct D 10 DHEVI 1 .1" MIA. 9. K ? i9 MGDtlI I NDVAI ?M M Er., 1 t l9 3 srca crag E H /973' ToYorr¢ GO%20LA yo2A 3 T ATt- ?° 3 6 v u stun AIIeR AAte NO sett R IX o c r v 4 o N 33 25 H d 1 9 ? ' t o t M S 0 c N w A l NlI N DE v nu4 Tlo NO. L Rewut t l d 9 ll9 s r i I I a _ NtI r A I fw u D f v y 13111013 £ MIDae 6316 et+o. RlasrtamovmlR. I/Sl rlasl MIDIXt L GL/FF Iron 0;771- 7 W I a WMR. -1 rlnT BvEre q..; ADpmssa oWE+ea y/ pfw /o Po,er ow s w N E wN I u + n NAMI a ADp4ESSOr IN I.GNK UIRANCE CO ov A eanl CI" R F R//7 s FOB S7 TawNSEn/O r•?fY• DAMAGID MIw .tor s II^C1ON" lstpDAMAOe 2 DAAS?n?Gl,D?,Er?tA CHARD cHARa N Ho:` o; O1 1 [st. pAMAGt R N ?alMAwtD ?iw?i" ?¦I-NED s y _ t Io iolio? ? A 1pS.YIC+a?.? S 53000 ewA ° ° ?- f ?00? r er S?PAIP er IC/(SONS NIT AM u,. } FCOL IAGRAMO ._ - T-1 I LISION: } _.? I .? 1 u NDIUI Da DESCRIPTION OF COll1510N lust 6ueelE ENTAI BNIf FCESSA 1 _ _- I . __._ _.-.- .. I L_.Q -.r .. IE 7 i'c1o - ----- -- ----- P??._ _ ? S £t Sc?P_PLtE•?fiv_T _ ._-_--• ?„ ADDRESS 8 INJURIES OF PERSONS NAME INVOLVED 'CODES t - Z 3 + 5 6 , OCCUPANTS /WITNESSES : s1 pct iArus BE s'. "I IT n. Nuu _- ,I "aualor - .. .__ F DAM .n e D%'tF ,•„ O H .O= ' ? No. .p H.Mt ._ ApD•!ss .. w s} m B. O . <I AMe O.. D o . O » O .. - NAME 1 Axulss NATU „a .,.A.e ;s:` ' O"«.u O'.': ? n. er Dwe 0 u r D4 nlsT •rwal<I•s?wew N.^• e..wE O• 'men C-•. t.I narAlc,np out FAR•mD DAN d.I PORt X IDNG ,.t^I /SyS /?,06. W?7f0! g `l7 .rk? ;, •, .. _ ? ' -?D?FICAY)ON,:OF COLLISION a ,,,„ .:,a ,. , r/rw?w,.?Jrokii?.?i^ '? ' "?.i cgSE No. ERITY OF COLLISION ? FATALITY INJURY ? PROPERTY DAMAGE ONLY r ?, T JATE OF MO. - DAY YR. - COUNTY - - CITY -STREET, ROAD NUM8EI: OR NAME --- - f I COLLISION J ?ZS?t?SEOCnnoN ,-EFPtRSou SNoW. NAMC N DRIVERS V/R4lC L. ('hW,l/FR NAME Vs 8/}ltBf}iC/Y ?, (milFi°pR0 VS (U A USE FOR AOR ANY INFORMATION WHEN SPACE IS NO' ATEORIGINAL REPORT OR AS A SUPPLEMENTARY IN L FORMATION SHEET TO CORRECT DRIVER'S NAME. OCCUPANT : LOCATION OR ANY DATA NOT KNOWN AT THE TIME E THE THE ORIGIN At REMEPORT WAS COMPlE1ED.) VtN/?L£ / wrEsT goavo? ?own? GR*rDE OA) cu,e?t oncT vr/{acL£ _?6 z? F,.1-,57 604.v0., 4P 4e4ol .-o _ 4R?C t /SOFT wfir or mio.2. Vsh, f12- w,+ /F S. . CLOS£ fts /osstgtC To XPKC OF e0OPAPPQaX,.ZD?iPN. V£OV- 1 ypov£ t¢Rou!?D Curd APPRojf.lRu /JtlDOlt of ?PM??R/PQoX. ?gifJPbE?DRlv?¢*/szi9TED ON_/Nr r/.¢L /A7PiK7? I 1£P!' FRoA.,r vlav^e +F4vOCR ST'RucK LEFT feowr' "Ii tcA-2 Pao u of V£t}, Jd?co?vTiwu¢o 9*s _,OFF 7ht- No rl S/O£ oP RoA9t B?tcx )W c.eosS •fo4p wp -,940 _.PA) ITS H S/GE I Aa4YAlX7 fr 7i2££ on/SVk 1;Y SivE of Roy R, ,?. R'4'DRI/ERVEDEIAF/ NAMES Wr , E ;' f +., ,:..L., . s.a..:. _ .. _ ...• . 5 _sa. '-''?o ENFORCEME4ffr?RION. ,?+a.*? .. sOeFD[tV-'j?gRN.OILEMIIING-(p4.d? ES .. Y^'H •Ai1RY"..'R000N {aIAIMR ?t.,.a??y+, t?,CHARGE ;", .. CITATION NO :I .VI44- /l y S, 9p "o Frrsr Fort o 72SS ? ? Gawpt77oNS ? % ? ? % ?dai'r?i4f .;..; .n ;: ,.wr:.;r:"'E,eF'?I;,o`a";'DIACrRAM-OFcCOLLISION -•n -- ,,;s. .x??>:wr?:•3tiftrEa:'. DRAW DIAGRAM OF COEUSION SCENE IN REASONABLE PROPORTION5. PROPERLY IDENTIFY VEHIOES AND HIGHWAYS SHOW SKID MARKS AND OTHER MEASUREMENTS. __...! oT TU SG.gGL ?r.nc.n'rn.m y n n? ® . 30 czwg ?sxu MrMK mm ' 1 J a ?c J'o/lNSoN/?tPurY !/ Tcs o __.s-.. z Xr R _ a R . ,rE• >j wSP I'A ERN. I.qI `c .. STATE OF WA INGTON PAGE GF 'A j 'A L I I E x, ' y 1 •- 1 ': r y ANCgx,. ? No. rAV POLICE TRAFFIC COLLISION REPORT WIT?FFIC IcECOMPU N 3 PRIVATE WA - 1 DA EaE 1 22 ,A _.. w. I.R..rP w X,'?r uMf (USf ].? NOURI SOO couerr E E cou n N ? alr .. FHwA ? WB RAt CItY OR 10WN Q`?a NO,.Of t9C7EfAt N»IUG»WAY AYlES oS 00- ®01 E ON lMV4X. o. (/CLS 1 Ri -I 3437D I INIFRSECIING VAIH: S,REEEOR POAD NOM INfE`9 Le ce ? PREEI% E MRf POSt ?{Df/ fTa a SREEI Spool 7 OSIANCF 6018 ONE MR EfP .CR05551Rff1 RNFAPFSt MIIf Sr MIFS 5 E W EET Of ACCIDENT ?GE `l RAMP DIAGRAM DAiA ;. COll15pNINVIXVEO: SfVFR rY: IOiAI NO INO KIIIFD?NO.INIURED ?SPRtAGF ?»Ia RUN '?????_%%%% I Fy [IS IM IN FR 1 f O440AD RWF NCE OIOSSSIRfETO4 POM J S a'VENClf3 m-RNDAMAGEONIY ?pE3Ul1[0 ?vI-IE / Y 0 JS _,ECT5TRLICKIN OB1fCi StRMKANDOWNER'SNAMEI EST DAMAGE $ SPECIAL CODING IGE - UNIT NO.I UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST J R+ S .', 9+` DPIVtR'S NOME: UCSI FIRST 9rvfR'SNAME: NSr i1 Avz . S,RfEf AODeF LYrB L{(o3 IOLv Vr-lVa.•C. . SpwEQi ADDRESS Vr..• 'ELt T. ?"VB E 1 2 STALE ZIPCODE HONF NO. D D R I SA f '" 1831 NE QA?r,, LOA. N ll) - 2 ORNfR SUCtN5FN0. STA1E A MD I D 1 w . DCEN NO All DATE-1.1. M DAr Ir. G Q :?n so V E B ! J ?'(lp \.?Y\V -NI -76S- 77 FYFS GNt YEIGNi F E ? C IEIONr «{??-L L FIRM NAME a PHONE NO.765-3760 EYES IGHI ?' 2 R I.S - as Al _ ? CHECK (?) :N vIwEA ANOmFw ? CHECKI7 Aw i AN My ovffwNDrHieu cu CODES ? G a S e a "s',°Rn r . + :sn 1iD' T t :5; 5R: » Rry .PA CODES 9 a + is 5 ex E v n n A` NIaEE , =W- ? .MFDIAMI ? u1" ? Ed.nR ? K KS ? "r'NE. M ;»<•'" ? AM NEF ? MEl ? 98:R. ? n ? 1&1 KIE VEH YtAR AN[EIDODGf.G»EV.1 EIIDAAi NOVA) SiV1E 1l DR.C V.1 Mr 1EV.) tIDMi.NtIVA) L 1 E E 7 IG ? I,I, v PLAT StAIE MIfR MEE ND. R StAIF H 'T A 1 nq. ilia C 02 l r w»IE:If IDENINGEION Np. G R, O 0 I j L UI1N AF»ICINrF.AS Z, 13 Z. S 21 S, I ' 4[GISRR[D FIRST M iDDIf PIrOK NO O F 15R t OWNtR: I fIRSr MIDOI . ` ' D 2 AooRFssvowNER N E P owNtR NAME.ADDFIMOIINSUeANCECO.ORAGENI R ff NAM-ADDIF-I-R-0 --113p r..ZO A O N _' wMAGE ARU Y G?O Or r nEa ESI.DMUGf U F?AIXL ®AD A ?REMANfD ? . CHARGE 7 R. ?REMAN[D rvi M t51.rO Df e?ucf DAMAGEMIA _ S AwA 1OW+oen IOWtD ? Awar BvN -mw S DIAGRAM OF VISION: lu u N INDICAIf Na4tN s iu Nt SSMrI er AeROw DESCRIPTION OF COLLISION: Wsunt-Ats»EEN, NEC[s5ARr) I! eg VEH• # l was Bpr t<v, CG Oux of a_ :... .. vplM. CAM,, 6.Wq`{l OMlD OLD LELAN.D ALLEY RD., AAAD tJ90-kc-0 rNTt7 THE ._ r FRONT GOR/.AER, or- l/t?.HE # A WHO &G {?AlH?D eee.A.A , QOU,?AAO GLV OCAD CAND UgLLF-Y Ro. . l/SH• H,9D Prm CFWD Y . I 7b STOP, Bur WAS 0A/H8C.E 7.0 00 So, P. --i? o.IE our_ Try C.OAAPACT ESAOCU AA7ED SCE ON 7HI& M;kgo &l Qr--iaE. I? NAME, ADDRESS & INJURIES OF PERSONS INVOLVED 3 * CODES C 1 - Z 3 1 5 6 5 OCCUPANTS/ WITNESSES io4 iu?Dli?orRU r?..wi ii \ AGE s 1 enn, t NAMa o uw15s NuuR or ° .nr ? AA !e: Al ' ? " • ? MY ? a44M AMF F 10 A-. NAruR a P. P.vovlo IeoM? ?m"?"r • ?H ? r AMe NAAU ? UORTSS Uo INIU1 ei0F ZM eY ?UAe ? 'UE?.Ta e?Nw ? Am s a b« Ac,ENC a? E,n K:IO •AlcrKO K%%E9" o D ArEawwiP o n ? Em es EEm s 2 lS r^aF'e?`[ty.'??Y'st ?. ,r ?' m'Y,yt?,4c.y,s?-??. ':- ,I, !.. t.•. 1 n . ? rN? `. xS r5 .6'we L of E R RR't I WsY p ? I ?5tl4 w7`,? 1 1 1 ?? ?E I +1 ?jh 1 1 ? J I ' ? Y r 1? ? l l f f " 1 ? 4+ ; ?f 1 1 ?A f l k 1 ti h - l l 1 f ????-- JJ?? 1 LLN REPORT Ip TRA?fIOJ?,v • ,eeeoM,l"""'Mx f POLICE TRAFFIC CO i'•. .. PRIVATE WAY ) ? 2 n courvr. cnvfa. IAVA D puR N o1c«us • w. 9R, 191) .fR ,., r I? 8°' ?EG??2sorJ ,; ' gs b 1 NOO SrR11, ON Ni4NwPY ! C{5 ROUIF Ef I DIlYOR 10WN Ie w ? N ?V 1 Lc ? ON DA OB 1ZD• N 4 ' 71 G/ ? NlE3 ? O s f REP 11, CENTER RI -1 -1 PRI fl % f Rff, DA,A . ACCIDENT CRO55 v frv NP 5 E MILEAGE r o ; lF5 ° w P m ' OR HIE NCF ] V I E M ? $o f, CIXl'o ?NVIXVFP '• Sfvte,Y. 5U aDrw N 't O.IIfD?C-NO. NJU9[D O ? SgiIIPGf OS 41) IN Mf CIS CROSSSiRf[l OR'nROAD Y - I FQ< 1N0. O ' ?PROPER,ro-GEONLY (] p E•1 OrV[NICI[S fS, -E V SPECIN COWNGIAE - •- DRJtC,SiRLKYINaA ODIC, 5,9UC9 PND OWN[R'S NPMtI S _-? UNIT NO,2 ?VEHICLE ?ffDESTRIAN ?PEDALCY0.15T UNIT NO.I DIE 11 FIRS, El-1. SNPM1 - f ' 3 . { DRNER'S ???f: IAS, G A I ti E LAV2l` $ ADDRESS °^ n °19EEi ADDRfS° 'DA bob 'R'D r ?? . QoX 12L 0 D IP DE SIPIF fqN Y - .y L IPCODF fN Cl,r S,A,f I?O(LT ? tJDIOW WA. qM s ?1a5-327 All l R R NER UCFNSfNO -1 E DAreD r°9,: . l DRNIR'S UCENSF NO S, A (o? AINEL' 4Lq.flC WA o? o3 v IFIGNI f(IGHi O YES -.11 IGNi E CKCUPAI Oti rA NAM[6 PHONE NO. EYES V °? unf6NWNE N YJnr, ES flvMrv ID2 50 A A N'MiS RES?r R . I tE AEA snF IAI No CHECK(S) A w ? CHECK (.? vrN tiEAS •N tmaorft AE Pr?orNte"' L- ; ` " ' I tj ? V-Clf AS ' 7 n":ii +'s: nM"r S ucrroN ° ?vr Ycl COD n v N«,rt». 6 ;• " 5 IN as CODES ?? cl• 2 eo, ' ~ R p 9 .Na p WE ? M; ? ? ? e •Nn °>f1M e. 'O ? AVRr c) CIO.1,C' ? <bvn ? M w N rEP9? l E CnEV 1 rnOal lO"Rl NOVA1 Kul v 1 De prvl lf12 NOVA DARI M Y . I EIOODGf CNty 1 Av)DEII -YEA S ? uN- A - A ?3 FotZD mvsT• E 6 _ u s,A,t AR NO sure H vE LEA- _ ••pp ?ZZ WA IF ?/? E C-11LllDfNitUl NN fD?W? IAS, N9S, AuD«E 9f 11 ED wN RfGISCR,REIDyO?w?NER: 10 All- fO/IN[?NEOr O IASI?V GC- PJ.'/•/V Elf WNER ID ADDRI .OVnJF9 N SAME. AS A&VE. E ;] AMf ° AD-a wweANCf co. ao r elNr R t?bNE ED AREA, Ag -- es, o/uAAGI Erc L_=':--.•{s • P -- o s s'?E.'?MO?.?vca w.v ?REaAIwD ? -AV ?RfJnwINEn Io:Srib: AY Ily ° AW EM N AI Irvte owln DESCRIPTION Of CpUISION: Eusf suonfMlN,AI srrtH If NfclssA+rl DIAGRAM OF COLLISION: 1°?nli liiussARrl N,a? I Wq5 f•1?,ST SDVUD ON VABDB 1iF AND WAS N&COTIATIOG A 1t.F7- NAn7D I c - ? ?$ MIT N H F(koE.2T of V64U Wit -rNb GRop-r-EQD OF vEl1Ic1 \ jr o AND V&gtu-t, ATTemp-re'D Ta op 51-11) INTO sourN DITC , _ NAME. ADDRESS ,,NJURIES OF PERSONS INVOLVED ' CODES 1 - Z < S 6 SI. Am IA, +tsrR. WE w ' °S1 :A vsi +9 °uro.i:i i OCCUPANTS/WITNESSES ic N NAA,f ONE- NAO 9 of ? 0 P1"' p., ?N ??E AMe F AERi+Iss .I IV AVJVlU1ROm ?4MR ?["[I ??rM+?N ?vD q I AD +IS1 NAw N•°,Aw?of rEP Ar ?-11 p K1 ?'rRrl. pw'd ? W DAn ., 'SS +•!FA (.+ AGI NCr --_... .. .... ., ..nlc. «K?nf?lcwD P WXNiD DAII 019-1 .1"IttyP n ,.. Lr ? ?LC?? A. i1) O .( IXI ho-f- I "'iW I- I-n ? I.^.r- '. . e } HA I, '. s t .oaf ' ? I [ e? I" ? f } 1EQ. t?+AQGn](1'7'd" i=4rf+4iTMRE+Wv7^4+,",T'. _ •v+• •yNlp[I .«:n tiry) ..+? ICI t 1 r. ;.p6?"jl'n' V?'t .;i, ?kdtdl6. `E.''` ( ? ?- • . r 1 K'f-IJ 1 r ?1 1 '? T ? l N v r ? I; Ki hri +) ' ? f 1 } 1 ? f16 j . ? P 62 ff STATE OF WASHINGTON oFFICU 9E ONLY ' I MOTOR VEHICLE COLLISION REP NO. ' Vxr O11 ay N an? °1?r? " Ads ' ? .Y5 J uon w DU?T .H TY /? ? BBMI x" u 5' ?I x,nwn Au[.xo ur.sln Llun nwA. r.yu as. [ xaurt loP Lrun cooE x° ? ?[ ? x c , ?5 E]. ?., ONS [cJ C Cc D / px x , N xSLLIxRwI xrxL o U/ Z90 o x°A x xrln [cl E 41,,:. 4 L ' ' trrE o?X O; O O .ErvII.rvPI rvI I lunIx nxxlA PMaM oArA III ? A c cOU S u x xr ? r? Iv,EMOCIp CCff > ?'? °X ° ? "I" ?Ln I?i, I O ,'" REHxFNL Owoee er ? ? 8co O Nox :`s ???"°n nI "CI nin Rv"A O [ I I V BJECT STgUCN .W p,OMLC XI OWN€fl OF OBJECTS NAME AND AODRESS (g [PA xOwlcr S,[c COOL US[ s ORIVERSIAST • .' . • ? , 5 ° NAME FIflST NAME , l„yJ 1"/k1i: I!1{}f{lFr; . u . _, EP x Ep DRIVERS LAST NAME - -. :s FIPAINANS:I.iS;t?::v,?7 i. .MIDAL?$iiY..ru CAw E'R !/YR&/L STREETADDRESS - pOUTENO AHp B51%Mp - 50 AwUIE STRE A RESS F3 lA/esT /O 7 ^ +y„OUTE NO. . usE A AL4GLIO% N AIE '? 7 O / B I4C/1/C? v R? L O CITY STATE.' ZIP CODE DRIVERS OCCUPATION P r E'S s TRUCK OR/uF ' .? FaOaO" CITY STA1El) L'>{ P,000E DRIVERS, .0q / DRIVER S LICENSE NO. I:rtC':: 8TA E 9EX ;cDAT BIRTH: AqE O r rx N r NO V R"' El?u?tgQ s;BTATE SEA DA 0 IRTH. .Pfv :. f /'+ A?? N -W - v N W . r u0 M ( VEHICLE YR. M RE (C . DODGE) MODEL INO A•DA 4 73 nc' 47 96& VEHICLE Yq. MANE ICNEV. DO ) (H •p I ,?ppDY STYLE:(?IINLl: IMP 5 7- 1 LICENSE PLATE N' TPAILERPAJFN?; O STATE ATE . N 1 O CAR 4DR LICENSE PLATE NO. STATF,uy4.; „, 7LA NO. , ST'TE;AI?? ..,. §, Wit/ n VEHICLE IOENIIFICATION NO. ? a"i K 5 a . , ? ? / VEHICLE IOENTIFICAf10N NO I A ter. `: : ??? REGISTERED OWNER (LAST•fIPST-MIDDLE NAME) .91YEP'S.LICENSE NO,, + ? flEGl9?EPEO OWNER ILAST•FIRST•MIODLE NAME)-_! DRIVER'SLIC"IS&f10 OWNE 'S ADDRESS (STPEET, CITY ANp STATE),. ,.;.x-RATE OF BIRTH OWNER'S ADDRESS (STREET, CITY:ANR,STAJ.EI";:,,:s?., ?`.,,w GATE OF BIRTH: MD D DAY YR 7 G / r u T PARTS OF VEHICLE gMAGEDs 11111MM"I OF VEHICLE DAMAGED p R 7 fAID - - $ . Al0 mR_ t . L $ LIABILITY INSURANCE INFORMATION-VEHICLE NO, I- WAS THERE AUTOMOBILE LIABILITY INSURANCE II?TJ11 COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR IAI YES ? NO v?!1SpRpU NAME AND ADO B,5, L I BILI NLC?ow10a>FATf?DE/PT (L ??r ,'I ,n `?? NAMEpFLMBILMINSURANCECOMPAW, N N /iTN /P c ttI - L1 ANGE 2 " -R . NAME AND ADORESB OF LIABILITY INSUANLE AOENTy {p A.?N, SiA LIP LIADI ITTj-IGY NUMBER ,- 1ST INJURY " AL AGE' 2ND INJURY _ -u'.F++l „A?, FUSE SEPAR LP POUT IDp ADOITIOxA. INJURE 1 _';JY ?AD?, NAME GQ NAME ADDRESS { f 'e EA SEA F AOD.ESSI NATURE AND ' INJ NAIU.E AND ? EXTENT OF URIE S I ®? 1'I 1 EXTENT OF INJURIES ? ??ss E%DM NATION BYOB DOCTON> VllO NAME R S j9P C I t I .IDMINATION DYOA IDOCTOR> O HOCEOR'S S?v'us OF INJURED MARK FIRST ONE THAT AP LIES BJATUS OF INJURED I G IN V ICL ^- rc" ro '' nIdARK-F1R9T ONE THAT AF?pLIE9 - ,. KILLED s[ IN C vAS )NV Hr •HO Vxi" L XILLED ? NO _1 j . . IMvrRG NO% +? ? 5? r" ?ND[stxux urvonl xA MOTORCYCLE SAFETY; ? HELMET USED HELMET NOT USE. MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SIO HOPI ARROW IN CIPCE l pESCRIDEBELOW WNATIW ?q?EHICLEB B'?l/IJI140ER)?i ... o„nM r..r XH1 -?' SIPrX>wI?[ ? f l No r.? VENIC 1•E wA5 wTST.._J13DwuD - m.U .. 5 c,l&ck RD XAL1 'r tvh:rr E rM/a mfA-6 ZN j NPH; l.[rv R P. V 111 1 JSrF 1/ENit/E l Ra?AVJ?.../f- R6/r .ruRN I„XILIXW W rX2 [1,AAPw , . 1 HxIn IH IrIF..wr.Y -.[? Q~ .---.. ?LtR?E LnYN? DOW n/ N/t L._. WNEJV FEN/GGE_:.. I .$YCJ/rEn ?ElI/cL? ? EAsTljou,?D ru.?s I AND :- NpP?rd i?RNKES_, vex UEy/CLEF- $rAArea SKi pGwe. _A9,va STRuc-k_ rLEN/.C ,OA+ ny-r- AAer %K lGSro ?•I. _. L CRE ' . SA1cu1 i a Rahn ;r/n1JAoE,? 77fCN c'??:se'D Tic..-.. ? D /{CND A,•'D S7RtYC'K JLf/"r ROHM O*Vg VEHICLES POSITIONS BEFORE COLLISION or YrN . Y[w«E wai ° w? INVESTIGATED BY VEM?F '] N 5 E W IN STREET OR HIGHWAY NAME 00 OR NO cM W"v w r?LY rwE° v oc c o Yy [ ? :r? ? 001 r rw x ? ? ? ? ALONG '? PIIOM' tiTO k " - PEDE5TRIAWPEDALCYCLIST WAS USING ' I?NM L?WU s?S.rc W ? w .?%: •?ao [?on r?n A?Ao PEDESTRIAWPEDAL CYCLIST CLOTHING COLOR' , , Hn nR X[nlcnrl nmx xlrucrNl .xr„ll ?w ,??•, r?u.?•I 10 : x. NI ,Xn..MUxs lrc ROAD EWIlACE WEATHER 416NT CONOITNIM{', ? :'; .! JRAFFIC CONTROL TYPE OF ROAD 1.+•r,", 3*x;''.-, DPIVERNEHICLE AQfgNIl.,;iy,,;y;.r;" ®MYIIGNI IUKC, aHI nw NOn[I ' "c 1 rKl Ic 1GWOA IAMII • (fir ' ?F11N1 I?w ?r?M J ?DAWN ? I ?61ONAlS ? ONE WAY I ? ® OOINO SNIAtdHT AHEAD 12 "' L ?WIl ? T?NMNINLI ?npSX ? 2 ?STOPSIGN J tI IWOWAY ? } ? ? 2 ? OVEPTAXINOANDPAELING S?SNOWINO ? 1 ?vIEI. MON • ?1141I,B ON y JR 5 ty IIOAOSIBLS ? S ? MAXINOBIGHTTURN ? J ? SNOW' A ? lOO S ? LNPX 11IM11 ? 1 C] fl ASrnNO N[0 ? • ? 1,lFOAYNG9 E] L ? MARINO LEFT TURN ? • ?"F 4 ?ol.'"1.1 • ? U- "It f...HIS ? S [3 1LASHINO AMBER I ? S ? AlltY ? S ? MARINO M•TDAN o TIR Sf-, S ? 11 , ?SP.11 ILI/Y ? t ?BR SIGNAL T'O WAP ? L ?"1ILWN N[9 ? E ? SLOWING A AT 1 RO ' ADWAY SURFACE TYPE ? T ? 011-1111A.... T STOPPED FOR TRAFFIC ? , p GI DYrYi ^•? ? S ?OIIrtB,BKC1r ? n I • ' , ROAOSEPARATION.i "'-" ? L ? SIOPPLOATSIONAL ORBIOP SIGN v ?iV , ??M INl?.NHF+ . T0 r L?'1 pY1pID [Y^'nI?S?IF'-6f?wew..?. #.tA ? S ? STOPPED IN ROADWAY nJD.-?._ul•.Ir lin..I?ie_-____-_. F I y?y 'y a POLICE TRAFFIC COLON REPORT OTRAR)CWR T IYII I f r?? PRIVATE WAY DmE or cans N A%ICEC1 ...A?-- m. :ou oN " I m pl •• r r •.?. ,u u ,.• ?Sf t.OD OUe. ur r cG u CWrvrY NO. CIrv NO. town I SO J X ,T£? E/G.so n? ?uRe.w / c. XN OE 0'N De IOwN N laN, O 114f[, Ox»iG»w,r (o M"S ? S ?w FdD, QL cu c£/v? ON /slow C ROUTE OR 31 E ORAL r CI ? S S f Nrreae, NC w+m arsr cR aGAC , D , 11 D. . SG y(j I OSIANCfaDRf 1IOV MP1wnKt.<ROSSS,FlrURrv1ARF5,M.ItuDS srenra 3TR[fr MI ES N ° t ACCIDENT w wen. a mI1F405r ?.OGr Pun D -- IS 2 I'll OI s /O I MILEAGE Con ,wN wvorvfD x.lRr.. - CE IA RAMDA,A OIAI NO O.iutED-NO ?N,uRID 2 ? "u"AGE O»n AR «?•LS?h, "4 wNpuRpr? i1 dVI»ICL[S QeROMerr D1N AG Irv Irv cu ff RaoAnoR R[lfLE- IMF CR CROSSSIR-oR ROAD . E OIL r IXtN RflulrrD ?va CIE onna vaucR lrvAME Or oeF¢,s,RUa ulDOwN ' F9 w s NAmn Sr-AGE SKOALCODING E ... s UNIT NO.1 De,vl NAml a f. : wsl n4S, ml a! UNIT N0.7 D-1.SN 19 VEHICLE ?PEDESTRIAN CPEDALCYCLI$T Rx ? C -L W t 'f&J p,to swEE, AUOxus ? IFFoR 13ffR6f}R/? l7/iA?vg I z z w ?? • ref Er ADDRESS arm s,Alf NO R,RCDDE R„oNE D 720 L £R[RNo v4;'-l Rv E, 4E v „x ',. o r 46 £s tti 9fr3G Z ySZ-1213 R c „rt oD »ON1 Np Q ^ Z DR !4 R r» I u/tcgNE. w? 7 6 7GF397y S3 I 5 w?9 3 - rx C w vL S3z 0 V -E 1- SE. DArlDlpa» cr /FFOB R » 1 oc IRAr RfcF"K 38',s- 7007 Errs c»r »Ew», E F 2 S SZ ff2 A ^ Z o rvt.e LR wc£ TRueKivG Stk IFfoSo CHECK(?) vni R D A«t a NE rvo. E.ES wf G»r »t c»T C R? to pu/tcEVt FoST OFF/ g!u Lzo ro6 ,- A o v!»arAS rmRlo u ANOr»te N CODES ?CHECK, rvfN C11 A A o? o O A` Z r i ] iin I 3 r rn °•'o x• c I „o n` a S N Unel rnN rt r»r4 .cl o CODES + 7 c"?F 7 sus iv N' S r I V a . c NFUC ES NXGL ![( SNo w C Nl l I A y k1wpl.o« C AvAl,hcr1= ? £ rl. O a '. " a iw L FT KNE£ et . 7 7 b I ?N R IDODGnC»EV 1 mODIL 1-1 NDVA, .FIRD. C , y o ;I ? so ` ? es.1l. >? W. v5C tm 'r 6 /9 3 •rcK uurvSE 4ua t rv 7 T29cro oi' E r A 1 [4 »lv 1 -H IDARr.NOVA, /97s TO>10T,y GOROLA v 1 O Nv.l y o 7R 'All ARla RAIf NO SIA,E „ H «E» caoR D N , • ` ? 3 OpA,va c H.v 23,33 I.vq I L AND. A E - 4oL0 w Nl1S.-D11- IGNND. C ,9 AcM GSS vw?aElDErv,lrl SR . t9'7 L!SIT l /,I 9!l L .$- l i RIG15RR[DOWNtR IDGL[ 4»DN[NO E 13,/ to i3'J/''6 3!61 Rt ivc GL/FF SS--7007 o O ISTl41DOWNfR LAST 1RS, IDIX[ » f NO. u ADDRESS n wNER ?, ? °?£? 4el /ORT AD wrvw Ohf s !J NA1«IanDORla mwo oR??, E weA DM,G R F /p/ry s /'od 3,7 TOWNSENG W?9. 4R ' A Z ur.ior•I C»ARG! DAMwGlDG . S ' ariu: o N !v . DA.HAGE ?'°?w: [3 RtMAmrn I., 3, D° I O00 aARa /""IN ISI.D ,I I RR??rr ?RfmAlNfe; u DIAn°AC E 5 A o ° p ^ e DIAGRAM OF COLI C? o v Iu r EM N I$ION ,AI1 NDRI» DESC .. .. sNufn r - s °y ? wmr °r n/Q f $3000 NOF . ,, 1 1 , - sARn a a RROw _.- COUISION: Iust su4eltM[rvrAL 3,»[[,n NteeS3ARIL ^ F£S uPPC f?rj FiriT I ? I Sf? SeePPGEnr?!_.vT _ , L? NAME, ADDRESS B INJURIES OF PERSONS INVOLVED ' S1 swnr«Ihan» OCCUPANTS/WITNESSES ' - !n CODES I p 3 4 5 6 A , , wW ?f10N•I n,Mr ntM n3, 51 aAArmrp SIR GI TAruS .,. 'h RfirR EII[E 1D h f I a N xt e. CA«R 0'A" ?^ . C:i ? A nnarx I ? R a , Mw NArt Rl Gr v I..+I, ti1RS? «u R.N, o an s rM"`e: G•«a ., C ? .. I . - 1 • . 11 1 l, , 10, 19 77 PSI LL? raf,? ' Y h h 1 ?? ? j t 5 STATE OF WASHINGTON SUPPLEMEfTARY POLICE TRAFFIf?COLLIS1 IaEPQRTa AGE, z 'f9 a « 6a % C JF COLLISION ? FATALITY 2n INJURY ? PROPFRTY DAMAGE ONLY CASE NO ?F ;1/ DAY p•YR. ?E^ COUNTY CITY STREET, ROAD NUMBER OR NAME ,,ISION LOCA110N J ?SO/l/ Show C/CLL/C /et) 14y"' 2 NAME E'A^'E NAME DRIVERS VB 81TR B?4R/Y (?I FFoRO Vs DESCRIPTION OF COLLISION IUSE FOR ADDITIONM INIORMATION WHEN SPACE IS NOT ADEQUATE ON ORIGINAL REPORT OR AS A SUPPLEMENTARY INFORMATION SHEET 70 CORRECT DRIVER'S NAME, OCCUPANT LOCATION OR ANY DATA NOT KNOWN AT THE "ME THE ORIGINAI REPORT WAS COMWFIED . VtH/CL£ &/ wEfr BoaNO? PowA/ (..erp£ o/) C",e?r /»GT va/ftcLg #a_? 44Sr BOCrNp/ 40- GitAGL oAN Ct11R?6-j 150 Fr W£ST of A),0.2. vE//, P2 W/95 /}S CLOS£ f?S /ossegtt To £pcG£ of RoF9OS /IPPRoX, ?ofiPH. I/sh? F'E1 QeOVt /}/Qd4Np G 4J[?t S)PPao?C, /RI /,ilODtt of PPur0? /9rPRoX• ,?5 ?1N/S??O.et ?GF'y / 57ry-rEp 3S..??H? . av /lvirlfz VE/f. W /s ltfT FRONT 8u/vP£PWF£ND£R STRueK THE L£f7 FRONT ?fi,QFAR 1)0o es of I/£N. F"'z . 119M, 1# 4b'CONT/A?K£O ?.g57- v£/} *2 OfP Ty£ NaRT/! Slps of ketw, A4cov Xgceoss Feo,gp twp 44,vgsp oN !TY R/bH-T S/OE 1 /rl?tsvsT /4 T9£t otiSOKTf/ S/DE of ?2o/t?. DRIVER /PEDESTRIAN NAME ENFORCEMENT ACTION SOBRIETY -HAD BEEN DRINKING (CHECK) CHARGE CITATION NO. ANIFI %OF BWDD ABIEDr V/RG• tG M? ? y FSf £ ED Too F.¢•s r Fore O 7 2 SS AL?o oL r mot IwwnED Gowplr7o/vs ? y ? DIAGRAM OF COLLISION - DRAW DIAGRAM OF COLLISION SCENE IN REASONABLE PROPORTIONS. PROPERLY IDENTIFY VEHICLES AND HIGHWAYS. SHOW SKID MARKS AND OTHER MEASUREMENTS OT Tp SCSI` G ""' •°• O rxc OH„„ D<.L eFRD ?, ? #? r\ Yr JON/VSoAJ/fJ?PuT1 // fCSp Z 9?2j? J PIRIRINAI "'O IM T P 3 - .. f i Gfl N E IA t 7rrrn , w7 .. .T 4 - { 4C f ?' r ?' wL 4h1,_ y?nb, .>t 1 f?fL?fj????FPr r. E, i ?r 6?( ?td, T uk? ) s L 4' c I "t?+3jl , r I ?T , + r ?t ? 1 n r? ? 1 + 1 I.i. r, iT { y 1T ?` F? }, , ? ,, +.1 I I I a E s rrFl?i !•?l{+Y?. _iF, L I i-1 , c Ir yam' ?r E I ? ??'•?11r?T np n r }? „h 1 A V i l .• t y - l l, 4 ?? i fT I" 7 111 Sit' R ? I " "T9?`? ?? I FIB I 1j w I . D?I? r E I , ?' E •I i.?T til 7 R', "?b?h ?1 'rll Y .r?kaT ..-vg vv 4 1VV1MY PAGE 1 or 1 N R? ° Pn IfFTReesl r r•1IEES Ene No. 1 w "f [] _ ? .cuvw.VlnwAUER ? A E ? PRIVATE WAY ox orcau n DA r r 1 Di. rR oolwFOH run A wv «av u . TIME IUSER.DD«OURI ? COUNTY WuNIr,NO? cln Np. 3 / Of{rWAp ?N ?E ON Crv OR TOW St N E ( J AMF6N0 «Slxffl URAI Oe «IG«WAY PCT. __?7 ROUTE ON 1 5 ppr ONT NIERSECTIfI?GlF.1. S"I'l 0. F R., ry4 ' 3oA5vd FRSFCiION a PR[f1X F A1Rf pst -/ f111WFfN SIRF[I a SIRE[t 07 I? DIS1gN<EADiRE RENRtN CNOSSSIV[fl a gxfSt MUEPO31 MITES [5 5 E ACCIDENT RAMP DIAGRAM A MI 1lfi (7 p{ MILEAGE CDIIIIN VFD SEV OER x 1 ' T ?. l OIAL NO O. NO AIIIEO?NO INIUR[0 _ ?SPIlAGk ?rR1APUN {frjppp"r IN iF CLS t,N RCNV Rif LICE IR . 'R 9 M [E TOR ROAD Oi VFNI<I[5 PaOPERIYDAMAGEDNIr ?rlRf OSIQFN 111. DETEL 1x«XIMAM"IOET-TItRUCXANDOwNERSNAMfI «ICIt 3Rio/ ITS ESIDAMGt SPfCINCOOINGAf s UNITNO.I UNIT NO.2 ?VEHICLE Dxnte's NAME: LAS, rw moo PEDESTRIAN 0 CYCLIST. I If I 'S NANf %Rr C : 51 I I t a SIxlEt ADDRf55 SlRfft ADDRSS 14 • 2 CIIT qlf O D GI1Y PNON s X R gre IPC q 31 °RWfR'SU ..NO. STATE A O IN ( IV R' IIC[NSF NO. IAIE D TE X 1 A eIRIN Mo wY ..a. C al 1 «euP,sl MNAM PNONE NO. wE EYES HI -IT E occuPAUON nRM z N- a P«oryE No. X 6? R E- IGNT -1 tgs ?2. ?CHECK (?J [MPiovF[o{Ar?Oi«Fa? ?CHECK (?J v[N C w "v" O H ?l IF AS ry rWVaorIE F ArE ol Fa CODES?' s s I a« 1 b y CODES ?* 0 'c" a i S Fx A° 5 rte. d I <I Ilrr nff nmNl CIroN r[n r[u lUV n o Yl? °r .DM ? AMNA.NO ? :o ' ? <7S:nR ? ' ? tt°' NIIA. E ? AN I ? <I ? E9.?I ? :° xl«r. vtn vFAx DOD F <«FV ? 1 a Y I El IDAIII -AT I 1- CON V.I CH V.1 MOD yDARt NOVAI SI IiZE E fiR 1 ILL- W c w PlgreN p \? H x E a o Ix. AI nna a A Ul WA. _. r ' m . LG. `14 EI tJ C" µ^.,?1 7 2 1 3 G !Ml .8RfcrsrtRtooWmtR: vsr r Rs1 DDSE Sa1ti ID ADORnsEr owNFR Z NAMI { ADDR[SS OTINSURANCE CO. Cv AGINI i x ,DAMAG?( AR(A? die. y n?inw? CHAR _' 1V? `1115 EST. WMg4t Y-AF ?Pi^IH C]R[MMNID f ION -IDeY ' DIAGRAM OF COLLISION: IU AY N INE -IMI I! SNLEI II NECESSARY f J V-ApPwox 200' ----{ -- ?A7 ? ?'E BECt\ RD. If NAME, ADDRESS 8 INJURIES OF PI OCCUPANTS /WITNESSES ,N N.AT AUE „ M. -RLEAI0 LEI- 'AIpnND. M 2 to C 1 'Z„ 1 3 E O S,S R 4 A 9 L kti 111 s?CX T yTK CI APT' p 1Q Vv ORfM-D is .DANA t f1OP OIOwTDer: f?p I Idiorib? TID iIGN Of COLLISION:E' ' yv tb A. qw6 BACKED \NCO P N D CODES [ I I- 2 9 4 5 6 'IX I?AGGr_ IAIU•.' . eIAR ExCL wir y av k Y' V I" x POLICE TRAFFIC COLLI 1 REPORT 14 TRAJFIC"0 l _.cFC -9 _ PRIVATE WAY DAE OrCIXII r Ol{? SON ImF 1700 COUNty COVNt?NO, CITY NO. MVw c1 CHV O410wN 6NO Or SI4Ef104 HGHwA. ' l5 ROUiF Ml fs ?s ?W Qn ON ,2 5T _ / BO N1[45tC1 NG 1 S fE ORro O NON rvIERSFCI RETVE[H 1REN 6 Si4[fl R4tNx F MRE 4011 Oi ?? ?' / D?.I?C DiR FI FRFN CeOSSilRfflpR Nl•4t3t milt 4O1 MnFi s f W ACCIDENT M EAGE A RAMP DI RAM-IA Nti or 6flA? itiG. TON ST t I l J causKm lNVavfD cute lr T ---- ?vllACf ?""'.rv NO A' NNO `uu ^i•? -R x. o IM CIS oR UrERFrr? 1AO31siR Fi OR ROAD F } RORf iv DAmAGf ON I- Or VF , ? R[ ? aFH CIF -" ? D /' ?1 /t? V - , .^ R OBrtCI S1q?.w..mE Or ollncl Slvuca rumowNERs NAMIi $ FSi p?pmAGF T L sRfclucoDlNC IaE UNIT NO. I UNITNO.7 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 3 IVtR'l rvwml' IA,St NRSE m It O41vt91 N-1 UST 11R '' D / a ryi ^ 1 HfI ADDeI < OT S/Lp ? S/'pP/N4 A/L'- 4'0 L?v 1 ?5? I4f t1 wD0R[55 - 2 I s1Alt z?acoa FNO D WAII zl°c Ht ! /NGsTdnl cv 9ff3?/6 5Ti8=3r1 R - s uCFNSEN D?/ SCAP/ AE 3 51 9 SIAIE FA W/j F A Otli4N 3 z 151 I V WF "N.NO. tAl[ Fx Dw1f Or 01RFn R CKCURAIIpi MNwm, 64«ON1 No fns 'HN GNI E OCCUNT.- I'll vN0Nf NO Ens wt IGHI 4[IONI ;Z? /Z Non/ lclZ (/U ,j° R ? CHECK (e) IcN AN FMROVF o AN r olHle.I CHECK I?) W AI ? vfH IMROVNaA rNFa 3 4 CODES ?' D i S r ei a ?o CODES ?+ D 1,1, 1511.11-0. n z N, AIf3 7 soLDM O .,r44,ANI{ 0 N LII ? ;S: I. ? „ 3r 111- ? M.«rwrvll ? ? Tbal. O " KI{ ? "W- v(Ae r[IDODGfCN[v !9751 ro aT mODt1 IDARi NOVAI Sirlt l}D COrvv coRo? z ?'z V E rfw4 WN Rtl D CNEV, mODfI1DA41.NOVA1 I 1}D4 v.l _ a lrvik RAlfN Stwl[ MIfR RA[f NO Slwlf H N VtN CIXOR A A. N wf w/r/TY DPrhz?z LJi} I c e° V[HKIF IDEMIrH:A1gN 410 "E u 13Fz3 8 -td L vfHICIF Dfrvir CAli N l - RIGISnRtDOYrtRR DSt EIV31 AiDIXf 5 ;Il NO. scaf? /V&/W b-3lI y O W t ISIFP[D WNt4. I., NRii MIDIXF E . LA - 2' •DOREUOOWNf4 ?.80X !J$ !(/NlLST°N c?/} E A IR m Nuef aADORessomwRUrtf eo wwef«t N aNE R I u A+ } DAMAGE Ap[• J.V ' tl ON DAMwcfD N. r D _ ' w' CNARG CHARGE ?? _ 3 l31 WmAG ?'wv v[+ ?RfMAINfO tOr D ?AWIrN 0.1-- IO fD t1DA MAGf S E3 S Q ^ Rr Aw ? W A. Al Rr E Ie DIAGRAM OF COLLISION: 'ED AI -711 .... ,sigT wc[ss•Rrl ew DESCRIPTION OF COLLISION: (Mf slN-NlkS111 NEC-ARV) s ?. '?--+?* I L. V_£/f/c[E xf`/ ? klesT o.v <t'oJi s/oE?L '° ? :- ? + I _ I ' SrRvcK_. t-?f£L W l7/1 /L}IGH,- FzE'v? rFivDF•C .. . L.r__I ..} r , p2/G£.!'..7?f? NuT .(Nu-? w/iiti"'HN/'/LN?._ 9 1 TR°sE 's T NAME, ADDRESS R INJURIES OF PERSONS I NVOLVED *C ODES 1 - 4 3 4 5 6 OCCUPANTS /WITNESSES ' suvnlmlHlwl sa i(w ADD?IpNM NAMI n STl S SIR •OI Rt119 4e. IKCI , AMI r.Ay. - rA •DM 111 114101 ' O •I . O i ?:n N MOH I4 •DDRISS NAtIIRIM . ul mAVIU I40M ?•mR 011.11 ?m.nE ? H ? :' Y •D wl Ho DMIR ' I$°fs0{ Srl?n?: ?•mA ?? ' U'"? . ?N Cn . tY w)IL•r+,rYrAwiuw i^ - 3`", R .,a qr .' 'I?'^jr•.,rtG N ?u;wvle r•n "I -•e/wA9fr. ?DAn_ n? ii 1 sP d ;yX J??lA 1 to '? r'/r? IY i{ t ,` '. I .._t P ? T1t k GY? I.I11. iF b f 7y?'.?' .14y1.D$ ynF.i `?s# 1 ? ? f I'? ? axe "?i i E fi? ¢ ? .• ? F ? ; ? ?? r 1 r , 3 }} )? rW 1 ` I?4 y '' I? L 1 1 I ? 1 11 , L? 51 ,?I 1 1 I ?I 1 POLICE TRAFFIC COLLI REPORT ESI TRA7FICWAY raco .- 5 ? PRIVATE WAY DOLE OI COUI N C LL ?? J f OII ON IIMf w Yox IYIS •ro rwu, r. '.I(uSF t•DO NOURI ?/ Y COUNTY COUNTY NO. / CItY NO. fHWA ?uR { D D 3 !- ? ?N Erf ? N Cur OR TOWN uAfAN0 Or 51ktf1own GHWAY 3 9 ANItS ?5 ?W ?Df pN , ICIC R x ROUTf OR SIREE 3z?so SE I „ IN ERSlCI NG MEN, -11.OR NOAO NON NItRSfCIIOrv OEIWEIN 1'\.P StREtI r{ M. 4 SIYfEI A F MIlf-T y ?s R..?, / SIANCtRDIVlCAIi iPoMRIFFN(rv<E CROS551REll UR NEARf51MLF POS1 TES N S F W ACCIDENT MILEAGE P DIAGRAM WIA (p M P 3/ Ffl OF le, S S4v1 rIF1YO : "T"'UN \ O _rv0. •1lUVID ? SP IIAGf ? a E 5 N t» N TER I x. N1F CLS IN R•CIIN SIRF OR ROAD OR R[ifRENCF CA(ESSfl[EI OR ROOD I11"'C lS / I`FQ PYOh4tY aMafI ONtY ? pF UItFD ? [IXCIF U oZ O ( q S OBYCI SIYUCAIN MF a,RUC. AN OWNt R'SNAM11 III DAMAGI SHOW CODING USE ` S UNIT NO. I UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIGT ! Wrvlv'I NAM!' WT NYSI MrDUIt NAME. -11 IR 7E6111 7 ? e 514111 ADDRESS w T Ag SIRIFI DDNE55 ? G. OrY 51 /.p- HONI NO D , IIATI 111 -1 -N 983 l R 1 ' DRWFV' UC[NSf NO C.. S SIaIE [ M UAtO E-N S I V W uCtNYN AIf FA J BIRTH ADAII (0 DAY r. _ e OCCUPANON NRM NAmlevfgN[NO ErtS wEIGHI wrGHi E OCCVPaxON PMFe PHONF NO. ETES wFIGHT wIGNT 2 X x TJ 200 S• R ` ? CHECK(,) lN rif.; N io ANSnr ? w N ? CHECK (.1) IAL f AS AN [MPIOY(f aaxo y F vtH A v 'c ?' L 6 'o .cam CODES 1 + D i' CODES ? v 2 ..u ac » 6 °nn <q ? TD I ?., rxlDRros w ? M F vl. NA4 IfDODGF Cnlvl NrU R1 WVAl -P.,, CONV.) S IIAR IDU I'.Ev) vI IDARINOVAI O IA L fl 1 p F ? E ' ? GR N F lNSf vlAil NU C . AIIV nAlf n0 -IL H !HLGIGR N FA A A f E L y 1(. Wqa - - I w ' 3 Vf HKIf IW xI NCAigrl.q \ F T E F l 4 `2 9 F P Po 1 7 1 i vfwCIE rMNIrNCAI NN " _ RIGISRG[DOwNI - N5T "R51 MIDpF vlgN[NO O .I IFYI OwNll I FIRST ' _ 13 W ]I rl ADORI55 d(rMNw P N A t OwxfR ` u\ E AMtaaDlwlssa lNSUR SURANa <o. -NT ' R N A r ' s: - FDAMACiD ARIA 'v""?"" 1 _ 1 cruRU ?. nuvcr a "'• ' ' oA•n ARU y ? pO.MAt.I ?Inx?i ? IMNNID ' 10'oiioii 5 151 (Y O NMG{ DFwAVN ORIMa N[D 151 ? , t fllaA O; 'a . AWA.DRr $ I ( DIAGRAM OF COIUSI "I 'Ll IN ac^fNOM'oerH SrgFI IN[Cf55ARYl Y DESCRIPTIONOFCOLLISION: IusFSUPtteMexru -T rNEtISSARrI _ Yw ??r, I _ D" T iI//J,_r ` lrrf l.?` Y 14F6T•8M1 ? \ V ENL?-L wAS TiEfrolaTEU OVE0. A bm4w. CQ, E . C'V.\tltNE RA • %N ?'kwPLFO ?i 1,tJKlG.M.AR.? r ? I ///? ? ' t\ \ O?.i ARRIVPF. AT T{1E ?.WE CE TIE ALGOp?T n " Y Qf11? A???/f? ??? I !,\\ .?` I Co ?AC?F.c AWKIAt?E.w? PNA k?E E1f?Ol.?.g3Et? _ , ? V Okt 'MA'C T -w't. 'aws w LAcRt.'ra lpkfmt VR-r . RGAO IA „ •NE ?' ' 1 ?+WNY a'GEGJ4r Arab ii, ' GUER? TIE ?EH'S411S p.m. -T Y - ? •- ,i ' y '? Q,O • ? AFav \.KE M1,0.K6 CO I'4ty-xR CFlER6 Wq5 ?in WUCRE 'tVIE ?IEN• I E6[ ZU MPO . VCHICIS'IFOLLED UWEa E "??'?"?•. r . l,_.J E•? "1yE, SANK .OK1Vlq 6PLD Ary??1ER.VEH\GlE FGKOED NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED / •} ' CODES 1 - 2 3 4 5 6 k u ' ' OCCUPANTS/ WITNESSES slA Are zeros RE R fna _y , IY k t p ' xAME. R\CNwgt?\YJK?ENxA.J :.o ' '?(a5-39'6l h 1!SY? ' i ' ,DD.1„ AluYlw H ?A D on" .?N2 ?C:;.'r.E. ml r yy R?I{ MI I Ai ?f 1 1 b Af%xltl i, UYlp r a'-Ni ':' ? ?ni?.l ?i'irll.?N? ?iiA- ;- ? ? INfr155 '' ??°f vNe ? AMR ? "' ? ,w,l. O N: ? Y x '? { ? 4?? ,u Y h,t J?. E.. ? ?I ? - 1 rK.A1NG p.KIrS X T b eAMA ? AOf NCr ? C S Q IP SVAIOgU ? }?r5 p IARY NU ?? 5 DAil fv M[N?R1 5. 16.85 DAI{ 1 r ?L.ur M ? MOTOR VEHICLE COLLISION REPORT O L? orca u?oN wu's "? U" [ ,M B„ + .• Nwl ?a wCPiiM, / ?l? ?? e 'LTs"- T ' 'u n UN1NO. C{?'t? ?BW1` NO V 1 7 BeJI . . vo3 n`L . f3G M L „ ?N ? ? ?-B ?h p'or ?; rle,I E. ON LA' P.•Gn.^J' i/?>Ar. - W 1? M,aDRarAaf ,CO .7 a D O.C30cao a,„/S' a (/ R IN " F vale n[l YN SS A°n "N o,„' P yy [BE ;°: o .NB .„. l„ .„,tea [ (3 >2 u ®4 a.A ? ?r „ , .. F?Rua?l.C.l 1 '? , a YD r. Nv ?ao l; \ ? x[ ? 6¢ [ l' WlMDDIM WiIAlAl10a,RSD q. B con B •u 8 An of , r ErEAENCEDDCPB09381PEET Oq qO OBJECT STRUCK [orow[c rnucnl OWNEFIOFOBJECTSNAMEANDAODRESS lg?ili^r[I?cu°TrL,p -., a-m1a - C97A?e? (7 7 lb?! i /!_? - Sra,? Ce o/ aI $ .- IF ICRE THIN OIIIYER81iABT NAME _,,, ,, FIRST NAME u •-FIIDOLE wvOLV o DNIVEflB LAST NAME „•„ FIRST;NAAIE?:.., .Syol'yLyAr.;'J;-, L?IQj1I,?A,yya I. T "I n ?.rf Hr/-eln.+. f.[ft0/.XlL? Is ONO?U 1\s K, LpH ? BTPEET ADOflf:S9 POLITE NO lV.IP,d 0IUN..:. ?. e7•?J -` ~ ' FIF_ w[nE —A N N A STPEETA ODflESS - '?* -i_NQ47,E!!O•AMQ.B91(t? •? < a. G('O JZ Tf'J ALL ryJ\`'? Clmd .- S fife CITY STATE ZI CODE '?? // 99pp1? Q4v/.•ve L' /L/s]S`I 70 0 IVER 5 p000PATION g 7•f!,•%tY-+JniC.o-L to s nFYOn HaRm -- , STATE, ZIP CODE CITY I- `Sl'S 1.atYT L0.4 I •. •. (i DRIVERS OCCUPATIOIj p /7 OgIVEflS LICENSE NO,... ,., STATE SEX OATE OF pIRTH AGE UHIVtKL LICEN5E NO. STATE SEX DATfi OFBIfl7H,..AQE: o /7Yq. MrAw??KE{CN/EYr DODOEI M DEL (N VMn a .J . 7 (J /O.s.>'I itC S.[K?•/LA- ,.c? a. - :. VEHI`C -LE YR. MTA-F+E.I /HOE ,Q.,4Q. J /M? D y,INOV •0 „{ ...gOPY 6- (2LNL1. I0.1?'IDS ri%YUL. l'On }I'NF.LLLsII U NSEVLATENO. STATE TRAILER PLATE NO;. STATE LICENSE PLATE NO.. STAT :,;:.TAAILEIi,P(.ATFSiQ•:.. ?. 'tSEATFd':' , VEHICLE IOENTIfICATION NO 6c 5-,e •,Ylf:DIDLEIOENTIFLCAI14Nj(Q.1!yy6MYL:v".CY-:i,'"':]' ..f'i,.rf.S:n'`utYlr-riY:w?l' 11BPISTEq;:o OWNER `{LLAA,ST?FIRST-MIDDLE NAMED;;.; QijIVE93LICENSENO ::;, "•Y..+ CT e GS l)t. ?P? REQISTEryED OWNER JLAST;f1iJ5j.11}JLJpyE.NI?M€I. ;.:-: .. pg1YE$;{s41?FJJs??,FjQ r.y a:L,_ OWNEFTSADDRESS- (STREET. CITY AND STATE) .... ,,., . DATE OF BIRTH uo oAr rn OWNERS ADDDRES(($$??,u-, IlTRREllT, CITY AND STATE), '?'.a?s. µ :.!, e'.J'OFr (i-? FA .WC pt/J G ,: MTE,Qf' I$TI{,: D B M PANTS Of VEHICLE DAMAGED „?`y+ ETLo ?? olr,o pARTS.OF ICLEDAMAOEp 1.QFf feu/ to 1 vr?" LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YO CAR YES O NO NAME AND ADDRESS OF LABILITY INSURANCE POLICY HOLOEFL „ J1 I.IIYy 4 cko/? (( D` n}Pe? 1 .( r 'P. 41? QrNeJLtaA S'}c n? vLa ?as Tl? "A NAi, AQgflESS OF LABILITY NSUPANCE AGENT- ,_?y??r;?... OTV r •.-:.. T iE_, HIV LIJIBILITY,POL(/C/T NMIa18EH: <^-,y-y;i'ys?y,,? ./>` Ly B . o.>LY-J.HIr?II?N_1,-J .?.l?i'.o.%3r[Jii, ?/frA?„lA..KGrv,. id.?45' O?-'/b '"/u/ -(o/o .3 Gr..J IBT,IWUflY AOE TND,INJUflY IYEE4VMATC?IYUPi FQq ADD1110WLLM?II?BRAn'I' J„ l-? Y TqT IrLgXIN NAME ADDRESS R:E: AO: NATURE AND EXTENT OF INJURIES - O EXTENT OF INJURIES ? ? q BID INJURIES REOUIRE DOCTOR 5 DID INJURIES PEOUINE O I] DOCTOR'S f XAMINATON I , DOCT- OO NAM[ EXAMINATION UYADOCTORT NAM ' r.O&TATWQFUYURED L YA IK FIRST QKTK L ES.: Y...aTA7 Q/JNJVRFJt' ?I? Dtlf]tlSE o r wN ?"D `I" p LAaY NO KILL[D a ND r y KILLED uro[. r o V " - , 5 ? B O O 7O . 1Or.D[ or70 o- 11 i1i ? 5 O I ] MOTORCYCLE SAFETY: ? HELMET USED ? HELMET N OT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED 5 OW NORTH OY ARPOW NC C E ?_-?-+ - IOR II+cMAIIAy G"?r?WTanale © I :rwAgIM""DN ?lrw a, p? kq '`, .'. ?- -o .du.[e 4 a TInJA.A ? _., DLLCflIBE BEL?pY???T NLpgF,_IF? 1RLJ(p }pryeN??Lty wY.• ,{ p -..I. sz,Ar{.,.?a'd?cL?L.. 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W N.Maa N,. , '"cLM INYEeT10ATED BY ON I [Nllr lr^.gi O C l V[r CLTL? N 5 f W ON STRCET OR HIGHWAY NAME OR NO. Lo a l2eM P r N uUrl [a ranGlO ani CUNIO ?rwL ?IO'i'MKl ?O ? Oo O ?.o YO Qa W "'F ir '" Kl ? O ? Q M D ' V I ca D AYll s . d t A? 1 ? ? ? Lf"??" ? D. N ? O O O uoNG A' ,r.) S'• t , , l rNeN. A°al..":. ,:1 :'..-FROM ;' i 1.` 0.4• .: L ':Y< PE ESTRIAWPfOAL CYCLIST W J SING' I?MDr I?N.l ,?NA N4 • M .?u ,?us"" aOorwR r??. a?AD PEOESTRIAILPEOAL CYCLIST NNO COLOR' ?o,A. J ?I,n„ ,?.u •?nr, [?,°,a, [,. Iwi i[i[pfiir"?"" .,.ROAD SURIACL WUTHEA LIGHT CONDITIONS,., .L. TRAI'IIC CON4AOL , TY/SO?gOAO tINryEN('?!I11 ACTIPIAr1i1.4[L'I': H•KC. Nrtl , r IwM1 ?•MYIIGHT rr.[A Iew or'll .. 'o 1 I • H ' Y 11 , rwS J? I I[MC, prE W IroAll ,KIA O' 1 ? l ? pA WN ?1 , ? 1KrMAlE ? ? NL WAY IrIW?DYI ,/ ? DOING LIRAIONT AHUD L- -T [Jyl. l ? [L"IIh FO [a s lf M Y ? 4 ? l . o ? T ? .... E'nN WO WAY ? L r, p gTANINO AND YA611N0 ?/L LT 1 O ? LILLI Ll ? l ? OSIGN ' T' II ? ? t ? qO,D I? NLrl40N ? i YA NIND RIGHT TURN 4 11 A ? L ? SHOW D -HU 11 1 ?100 f L,J MT ? L ? IIAEHMD P(D ? ! ? ? prU4 0 1 ? IAOHAIq! alq l[FT TURN ha/i/I ICI ? I ? YA ? a ? 1 Y?YGITI Y ? 61n11 tiM11RR f ? Ilw4N'hp AMAIN ? 4 ? AOWrRAMII ? 1 ? YAAINDU-TUAN O f ?01.1 w / Ulnln WO WAY [ ? fRTCIIY ? t ? AP 810NA1 ? 1 ? 1 1 M ,M11 [3 1 ? MOWING 1 , 1L A CNMA ROApWAY WA1ACf iY/E. ? I ? OIIIC/A.N AGM.N ? , Q'wHa.AT ? 1 ? STOM1O IDR II Iq r [ ? •C 1 l ,... r l ' ?•N ? ? O1rNA 6M Clrr N(7,LBLL A1V1710N ? t ? BIOM(B AT SIGNAL (J (_? CJ OFT STOP LION Q Ly E MOLD 1 ? ETDMOIFIRDADWAY r, r KM L lrwln ?a ,, u1 Feu. k !k- I 7 ,i= k ?ri ' . Oyu n % >4Y 3 ?7J PO LICE TRAFFIC COLLf6TN REPORT EN TRAFFICWAY PIXICfC Ni NUMBER 1I PRIVATE WAY pp t E , I N tIME couNrr OZ zye-f 50x1 EDDwrr NO. mNO. /(v ENWA pUDRA p 3 NAMEa NO OPenlFIORnGNwAY ?N dr, IC211F 1?;Z Mllfs ps LL0 ? E QvILG. ON E.• Qvl>.Gt?J[. RD, W R t Z7S0 „ INIf NSI<IING YAINsIRF[104 ROAD NON INIIRSECIION BFiWIfN G ! b.sma' B TRIG ' S1R[FI 0 9 PPEfI% ! MRl?t ?e% / D157 -±C D-11- CPO': R NtA SrR[t 4E . - Cl ? [5 5 ACCIDENT Mlw D? Irn of MILL- PaA-r / MILEAGE Coo! J COIIISgNINVIXVFO Ex1IY. I.-No O%Ill[0 A -N-,D_0_ ?sYIIIAGE ?NIIa RUN GVfNILIf$ p PRMERIY- ION,Y ?'W&TID 13 Vfw<IF -r IME/4 C13 ./L R 61AI 01 u QOBBS@[FTOR ROAD •ct OBIECI Sr4UCY INAMI Of OB,FCI SIRUC%AND OWN(R'S NAM[I ?FSI O_M^AAG-J WECW OODWG NO.I ..,,t(.. _•.:.,: + .UNIT ::' UNITNO,2',:. OVEHICLE' ?-4.O PEDpIAN ?PEDALCYCLIST. - ?• MNtR]NAMF: wr RAGor•1 MIC}Ai?L- M?• lb? NF4 NAMt: _ B siRtfIAWRF55 1280 •-. QviLCZMf- RD, Po,&K 1110 , IPffl ADD4f55 Z s1AlE OD{ ?i>C P I AIf E ???? , C?S Q-LI OEJJE, W A. R ' E NfPS UCFN N RAGONM?6331?4 • U1• to ?Z. i37 ? `! E' l N UPAr10N 114 -Ea PIgNENO F BIR N Ens WFIGNI NfgNI -upAl oN MNAMfaNgNe NO rcs GahE DEPT WAS}l. ST' COLE 4L11 mNi Nllenl I55 // R . MI p CHECK (? ,ANrN V1n A?orNF4:' p CHECK (V) E AsAN IMPiOY[F of ANO1NIOA' ,°{?" 7 Aix A i 5 1 w ( 6 CODES ?' 7 ? CODES ? ?? • i; 5 IxuaN a ','.° ' 13 w ? \ nglI NdJ 4TM.jo..D.. p AAw ' ? Rs° p E&- ? H«K,7 ? al ? m p E W" ? 7S:11? .1 11 ? C: Y r _ EN vfAR MA%[IDODG[.CNfvl I FolCD MOOEl1IXAR1NOAI SIYF IV DR ONV.I T Z ?R E: A NN v.l MODI IDA INOVM V.l 1 - t V OR PV.N SIAIf IPAIlFR0.Alt NO. s1Alf I'1 vFN.CIXOR A AIF ?- RE,-D. T(33?7 WA - - 1 C '3 fNIRFIDlN11f1U110N NO. P;I?,S:B•?(;?;F1??2 l'?.ABl 9i??1 (D L vfN1 L IDFNII I AI N I I I I l I eeasrt4FDOw*uR lASr n4sr MIDDII PNONI NO. O 1 m wNER. IASi Nnl MIDpIE E --- IS ADDOE OwNt4 ' tR 8 6 E• QuTI_. ROP ?• Pax 11 6 17 N aADDnlssa lNSU4ANCtco --TNT NPG`M 5 £/a 7-7/- £. R IN u N Di _ S oAm cm ARU CN1 D N SAXAZK. MU w:B"Li /w? CNAPGI Oll?rx •i P ?RWNNID Is1.0[; ?f I . S IS1 DMU01 wwv ?41MNN[D ?i' ? 1 ? W Y ' AWA III SLOG FO KLIMn Al I IOwfD D ? IOMD S - Y BY Y , DIAGRAM OF COLLISION DESCRIPTIONOF_COLUSION: INSI- -Nlu sNefl w[CtsBARYI _ T ?YL ?. V __.. _ _ _ .__.. .. 1 .I m ? VEHIC.t,r.''?I WAS_ WESTBov_f.7p qrl aJ.pulcc,c,N.?.. ._ 17 ._- -} ANa__41.1.0..OtJ. S./JOVJ.P. V6NlCA.G L"ALJn?_-. I !. •? QUI 1 ? C N E _ •.? I ; ; I. . . oa cAti_RcDF'.u?s,oc mown ..Tr!._.Dircdr•- --- ' - IF I T_ 1 1 1 , p' 17 NAME, ADDRESS 8 INJURIES OF P OCCUPANTS/ WITNESSES ERSONS I NVOLVED ' CODES 'u; ACi 1 I.ius - 2 „V °'; 3 :' 4 5 ns1R rucl 6 : NAM A.!?f R is _? :rants ? w A4, kl-Jt pAMp pF»'U^ .pn . m WIT M - ess . m N•lup a r4oM p•Mp . p 71-1 ? 11, =41. OFT`" .? N +B U 46 -1 1 .ma ss ?rola KIM BY p•MS 0,1.1.110 oP.01. p". A X r, n AI.% po IM • GINCD ?{?[I?PS CMD ?!? ND P•1-p?1 A pl ? ? s.,/Jrcti,IfkSnh?.:ki.7Y rxlui?l ?,. lu 1 iA t I ` 4 . a?ilu+r/ST[?y 1'?5s ?d r yl kwur . I N 1 4 i ? r &7 d s el A ?- d i»".. <fw^ tf a r ly I ;,Mt11 I ; 9 4,??'1L a T? ?""?rf1? ( 1 - r " r L L 1( Pr I i' * f' f F . T.. m, l? !r`7r a rrx 1 i?lsly 1:P1 1 ? I ? 1, 1 17 r<I ? f 1 ! yl,l I ? r o-xa - T L C & STATE OF WAS NGTON RAGE ! G / W o °"' ° No _ POLICE TRAFFIC COLLI M REPORT TRAFFICWAY' IKEC NI UMBf4 RRIVAIE WAY I, OwrI OrCIXL SOON ? rCOLV N i?m ` ? I E (OUNIr IVSE }yp NGUR', COVNrv NO. CITY NO. fNWA OUR ?N Wl ? Crr ORrOlN ttr.00r sleFFr OR«G«wa MIFS ?S i?'? o Q?_ICtn.c ONGra.?S /f,l? ? nRStCr r t G iCT 03 RWRORSI URAI <; 33a/O - , NXIN S efEIORRpaO NtRSFCrrON BF1W[fN MP z 51Rff18 KP3 SlRffr OS NCfflU RFC MR 9 r PRfr'X f ml1f 905E ?•X9 t$'' E f f NCF. <RU5551Rft109 Nf49ts1 MIlf WSr NIt[5 N S f W CCIQtNEi rFFr p ? RAM DI 4AM DATA COlf iS?ONINVOLVEp NfvFR Ir: L rOIAINO OXNrf0??N0 rN1URED ?5>RwGE ?'l`RUN Of WHICI[S CR1Rt[t OR M ??V[.iCl( S ..OD'. s UNITNO.I. vevs NroNE -wsr N9sr UNITNO.2 VEHICLE PEDESTRIAN ? ? PEDAL CYC115T ' o v mrp If B ? DenE/RSN AMf, wsr o2 F? AZ jR2R f?vt?I v DRtss 1 i?/t?Sor?j / O r?i ?pv Li6? R? P?(?xY7S i .Eds l?il Rd vettr wDRFs /23 G&-T?c Z ©Ut ?GLLE sun zlRCOa oNE URNfRSIIGFN NG ri 98376 745 39r SIAIf « D R r 5T I s R6Sr--e39JZ Q?l 41.9 18 ! f1 61317 C JA 3 ,a H oel: RA oN N 1 F 51X DATi-RN JDSN5E N0 P / 'd , $O w r ! `O Ci3 / °e+Z .y m AME n=_oneNn Ens n e«r HI O? 20 /.30 SO E 7IR , oe? / NRy NAME n R«oNf No ! ? 'GHI r41GH1 JE FL I !? ?CFIECK (?) 'w«Kif,SwSNfM9iOrff Of,t?OmfeAl ! ?CHECK(?) ' N MM oAl io CODES?' <.s < i>'• .9n 5 r r?oN a i°i° - ,I< ?`•`r vfwcLE AS AN fM9 rFfa ANOr«f CODES ? ' s ??. °• < i:i?; :'"' s r. i; . , 7v 1 N,wros -f7'A740 A)Oil.t ^ p -- a 57R?iG0 .?E ?? n : j . ? ...NR,NfI ? ? Z6- ? N..rr vl tA yI I flID,91NOVAI sty fr]D9CONVlr CC . MD.,Rr ? ,.N,,..,., ? g ? 7. ? : ? :O1 vl"rt• '" !( ? / y } 7??Z. R .- - . E 1 FC«vl mUUfIID vAI 7 4f? t?? N ?lfb Vf p A Y oR 1 « CFNSf 9lArN SIAIF nR 0.wrf NO. Sr,if U RL 877 M H ? vE«CIX09 A NO 6avi GN 7329 L,c4 ,l ?? Y[NKE D[ frU1roN «CIfIIXNIrE A N I 1 I ' RmisnmoowNfR: wsr n9sr s ' L ; m oat waN[NO w ne lnsl -ST MIDae S•t'G' Sr Appnm aw W A N ? f a A DDR[SS CY INSURANCE CO OR AGENT, E ` `?- ? ? , A ,. / (f?f[RjK .1 Su C?G?C.?•l(?? (yrirrAOV..z t?@ pAM.Ge wu a>. c ' ' R l CG.? S1J?t - f?t?'y LErLC,' (.1?- ' SJ] r ] a°rev r S r 1St rOAMAGe S•3CC7D CN DGf IwN E ?RE D owEO ? rE CHARGE f, .' 9vlN •NID oAD ,w.r Br " WOU 0 n? O?uOr fe C Q DAMAGID.IA I ]f ?/ . DIAGRAM OF COL LISION 1 A NORI« D c n O V s 'T' --; -I r ,51WIU tUssARrf a ROw ESCRIPTION Oi COLLISION: SE SUf EM[ µ1111111 NECIS5,9r1 ,R V d.. _ _.1., l 1 I I r ;_.f T.-1. L a/6. C J /?farr? ?jb_ A„a ' Goo L f; Fia.evc_L_ L 8 I -r 1 _. ' ? LJ ?.4.alr_r Ptu' Cs?-frcL .F (Y ? _K_d L o s,t-t_ Yp 6? 4 5, c- a c -I u S l b In L , r c . p . • e v?3 T-" P. E g h8 G 6 s 7b Rom, NAME,ADDRES581NJURIESOFPERSONSINVOLVED ' r CODES 1 - 2 3 4 S 6 OCCUPANTS/ WITNESSES Ilusf swn[vrr,uL 111 A r r DD ME pE ?pNAE NANlS SIX 'Cl lAIUS w o-Df",i r 91510 11!<I ?ri: .-For DR A ISB NO n DMISS Y V I CR 9?EMC'vEIU,ROM?AM ?ti "'?ri •?~ ?ri' n ?rN . ,N,r tl C, 1CEalft ' r lS o . ?X' n ??, ' ?%"...rr Li :P',: ? ::1, 75 7 1 Q ?f?5?? ? ? * r I ` .(JL?11??• `?W ? 1 4A 1 r'?? I 4? i? ?Y?? + . rt f E ? ' . l t ?, r A ?• 1{ S c ? r f ; ( I r ?, i 5 _ A . 1 r 5 11 LZ ii r' ? - I ' Il'IXn i r ? 1 N Id Y C X t, t + .9f7 I ? s rn 84 1 N Ilea '_ o ? im _. i c o Uo I I O ? II mo I ? ? M ! ?r( 1°. f i F Y} 7fi F ? i P4 wR ? I I 4 r STATE OF WAS NGTON I?a?F oR No. M TRAFFICWAY RAKE O POLICE TRAFFIC COLLI REPORT ? PRIVATE WAV 1 I ME COUrIY CODN a(f OR<IXNS I N'S Or ul IUSE RXAHOURI CITY OR TOWN PME6NOORSIXFFTOR WOIIWPY CL ?" Uf ON .cE Sr V ANIFS ?5 Ow ?OT Q /s_O.- .• PRtRD Ins SPYUOE CVFF N=. S -7/ -?"? s?lf nRCOOf RnorENO. D ?? ?// Ct83 LS uo IR A 32F dS IwA I??a/ /; 68 rAWlavroT+E rw T wlc I?IC E a . ..rlr_Yd.IR A N-A CITY, No ouRB RSAN ROUIf OY SIR[ ? Y 3 ?aiia MlE pOSt DI RAM N•IA ;. D CTI f OR CR TGTERfNCE R Is CROSS STRIETOR WOlbl 2 X ys lsl.O=OI Cl DWR,IV ? YIMMNID " ?AWw1DPY .....•...., s rJJ f iW?YDDY ,-S 'M'y'v ?uurrly T" DESCRIP110NOF COLLISION: Iu,[S I-T-NTVNNICISSAYYI AA F COLLISION: SIRTT UiRic[u?RY?® pQ.I JLd( OIfNIGLF L a1M DawN / ?`? ?VO/1eR? WIwN A-N FTIa-" ?'yR YR WAS f?Yt ^R4 RN Tv ORrcw TOWAAY4S P u+.?s o rc.. S.. vaco AA I Ax r F CODES 1 - Z 9 4 5 NAME, ADDRESS 8 INJURIES OFuP PE.' R.SONS INVOLVED sIR ArF w 5 ,".?;,,, XfsIX ula .", wv raAl SIYn _ OCCUPANTS /WITNESSES ,Y ADUnux+M NAARV *,: JSSO _ lla.A VI 5/[RR?NY,?- Y:.nwYla AMn ?.ti' O" R O? r 0 j Q 17?s •. [ XW MOTOR VEHICLE COLLISION REPORT l DATEOFCOLUSION DAY OF ON TBIEOFCOWSION ? sw 4x x f DAI NO N Np A ITR°/ cnNO •, ? L COUN Y CITY. TOWN ' sOF MILES QO GfY.TOWN APLIC L9 PfJFFI% xpTRtfl RWrt O 0 00E SEUTNON '- .• ? - D w ©© OF 1 ICJ / 1 / ] ?V??V - IJrr GIVE NAMEOF ?IflFF?T. AOOR MOHWAY wiERSECTWG WITH: STREET OR 110A0 " ' L PNERX EO MILEPO6i FD : / /i TCSPfiiA/A1 NONWIENBECTION.LOCATION OF 1L1510?_.' rW,fp. I%AGRMI TA DATA %:IWFI:N Y / / ) ISTREETAND STREET / lu RAXxOADCROSSNO NAIroslon o[NtNrwu,Anrlu.pill"IyMMx. N`- NON X RD HIED <TOA IOAO Ox S VNTEfl WT CIS. ! " CNC pp[PfEion NOAO . [ ?vNl?clf vu clr ?rNa,E lucrnF ?ON?ln wwHH EP„EIptP.L?E'N r D 1 ?WIM,I?N.fGr ? `sP?33 ,x.w YFx?,I ; ? 0 ..,Y .. ,,. , ?.N.AHLIDIaHw.,. C 3== N ?I„IN,w 00l?? ' .:. ... OUJECTSTRIIC% INAU[ar N%uF<rplxut%I OWNER OF OBJECTS NAME ANDADDRESS IN ROADWAY ?© roREPAw aBIFCt F FEET [DOE S " OWNERS LAST NAME FIRST NAME. ,. ..MIDDLE rWO CU,s OMVER9IASTNNA IJ,..f:N FIRST NAME ... •: r MIOIXE., 77 STREET AOIXEE55 :,. ROUTENO.ANPBOXNO. Wo $7flEETJ1DGRESS:: r{{. yy,i L...:...: ROUTENO.ANPSO(NO. " .:n1 ITY STATE IWCOOE BRIVERSOCcUPATION AN CITY $TATE ZIPCUDE GNNERSOCCUPATION F-T VERSLICENSE NUM I STATE SEX 0111111T" AGE ORIVERSLKENSE NUMBER STATE SE% OAfE OF TH. I AGE vENOLEYR. MA%EICNEV.000GEI MODE INOV DARK BODYSTYL 1111 VEHICLEYR. MA%E(CHEV DODGE) MODELINOVWDARR BODYSTYLEIYDR.) LICENSE PLATE NO.. STATE TRAMLER PLATE NO. STATE r ? ?rf LOENSEPLATENO. .;STATE TIWLERPLATENO. STATE E H ICLE IDENTIFICATION NO. IIBBB MOOELS6NEWERI ODOMETER (MREAGEI VEHICLE IDENTIFICATION NO. I. ( ISBBMODELSDNEWERI DOMETER IMILEAGEI / I N REGIST RED OWNEA (LAST FIRST MIDq.E NAMEI ORIVERSLICENSE NO. REGISTEREDONNER ILAST-FIRST MIDDLE NAMEI ORIVERSLICENYNO. r1`Ir ) ) r? /' WYERSADDRESS I$TREEi.CRYAND 6TAi DATE OFoRT" O ERSADDRESS (STgEET,CITYANDSTATEI DATE OF BIRTH 1 4115 FvENICLEO FO r4AND S xwx Ex ,o rL p.WiS OFVEHICLEDAMACEP E M[Orr?vr, $r ?P? - AS rNERE LIABILITY INSURANCEINFORMATIONVEHICLE NO. I- AU covtaY,GEwe TOMOBILEUABIUTYINSURANCE FFECi FOR THIS ACCIDENT ON YOUR CAR YES ?NO "'' I NAME ANDAOpiE550FlJABIIJTY WSIIIWNCE POl1CY1gl11FA-- arr si_E -,.:... to I NAMEOFLMBIUTY WSURANCE COM ANY NAMEANDADDIESSOFl1AILITYWSURANCEAGENT RAN IlAB1Un POUCYryUMOEq. t??.a EP •.r?, •?n_? . , • n : ? .i ri?J? ?Lf'j`?i 1 ?' 7 fir; 'lt'? ? ? ? , S? JUN , ? -- AGE RY: NEE //y BOI ESS SE% 7 ADDRESS FF SE%F N_ 13 VA U., ®? ooc M" I OM •^ 1 '' SlAI--I-UU; MARK FWSi ONE THAT APPLIE9 "w uAn ?INY IN VEHICLE 01.6 ?'YI vl lr A. • wAxvJ ?PA.. n 4lLED uvln I4hd11 [ CNWnAnI STAIU90F %uUREO MARK FlRST ONE THAT APPLIES ?MI INVEIIICLE R9AUNwG ON IxtAIAYrO PJ?'ixc w w_nr ?PASS[Nlux XILLED Ise"'Y . 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RROPfR1Y0AMAGf DIIIY ?I+FSUI,[O ?vF?'(if // '' OBLFCI SIRUC%INAM[O(OBIICI SIRUC%gNDOWNfRSNAMN 151. 1- SxfCW CODING USF E UNIT NO.1 UNITNO.2 *VEHICLE ?PEDESTRIAN ?PEDALCYCUST {e4 s 4 ' -1 1-1 -.E °VLRSNAML DxNER'sN AME: W51 IM Mi - /nJgdF? /V ? SINffIADpkt55 IES NA iara^' 'D•B. - C/1T SIRtFI AOURt55 . S GrY NONE NO. D Y srAlF ixcoDE RraNf / L.CW4N1C WA C)R e> t- 61X. 2H1 ?I R pfNffr3LtNSE NO. II sIATF - N °A I IV R LICENSE NO. SIAIE SF% AIERp BiRfH 3o 69 v e OCCURAIidR MNAMfaMONF NO. fY[s - .11 E OCGURANON MNAMEI RNONE NO. EYES WFiGHI tEIGNI 2 r 1 Y 3U S? .• R ? CHECK (?) NNKA f 15 AN a"FF Of ANON(R ? CHECK I?) VEHICLE AN fMROV[F Of ANO,f R Hµ V CODES ? * 3 5 1 rH z e i °;°YC •t ? CODES ? * 7 u a is Stn a """„ ' TT 10 Z Iwns 1 INI fw q S.+f Sy61Ar CvJN(%(1S%oN INA 4i ) Lfw::' ° ? ?'c'II- ? 'M' ;; ? p.° v ? MN ^ l ? uq"t ? "coilly ? ? M PoV ll" '; vtN.YLAR aE IUOW[CNEV.) 3 14. 11 MOOR 10AxTNOVAI SIYIf I]UF. CONV.I X R lU ?t?-Bi1 - E n fAR MA% 1 MV.1 0AR1.NOVA 1 bff /1Eld 4 FB Ylf IR OR, vl 4m "--- SIAIE NIER nAIf NO. SIAIE H l F -- f 490 [ 26147/ rrq - '3 NNKIEIMNOfIUlgN NO 'S H Z HE Doi og U kZoo,S-o! L -ICIE 1-111 i 6 ! Sd'b RI-TIRt-III. -1 riRSl MiOpf PRRI /E9 `/ -NFNO . 0 151E . WNFR. IAar 11- M. /n[.,CL. N N0.••11A! Q NO. ?s I] AOOR- IIWN[R A f OWN[ u11 rz N E Z8J ?.l H 'E3.C .?oN6[;tC ?, /t w EtZ NAL a%DDnss OF msuR.wcECO oRwGiNI N R Ft- DAMAGED AY[A ' ' rurRl'p"r°iN gNAAGFO AR[A rNVra^i N l " b _ CNAN? o-i5 ISI.IWMAOE ? IAYN ?RIMNNIO iliwlD CNARCF ??? re I3 ?^RNIN I?Ay1,M,UNLD 150IO?o. lowrD wAr r, R sTUrpf- wAr er CA U!M ? n l INUKAIe NOVrN DIAGR.OFCOILISION: I $.U. NlCFSS"wrl .,A.- DESCRIPTION OF COLLISION: lusfswnLA,tNrM SwHlr rxcl-yl 5 4f9- .1 CA OIAr .$./cG L?.rw µOR/?.e2 AN-0 •rw0 /?SSf.-NLr.fS)fAfA3 /?. dogad ON TNE. " Mo'1406A of TNE 904-d 1v1r4 A/o 1.164 rS 5R H6.v it H/r TNE QRCK m, .4 /A. A... /=f_tAA.N( '4 4CAOSS '40,10 ovw< r 4it-a< 0 , , ' THE TRA/f-a,rf CAb36.Y6 Ho d4m4«r ra 7µC >e - TfL AjGiI 1 bar roracY dtcsrteWiAot 7-me t4 Xep The w'7A•1sf:S Aar 7-Ac 20vird Or row 1I,Err _......?_ Rr 4o t, r NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED N CODES 1 - Z 3 4 .1 6 OCCUPANTS WITNESSES i[?A, ux Ac[ AM '„Y'" ' R mR fLln ; " NArCBURE)7f.rtd 1• IJ?.eSc>^+ f^D 765- 32T/ A ODR1a3 Z N Qa. NA,ux ,W.1ri AM B ?W' . kAvoau q. Ilotr o o AMe 0?t O"w?r 0 hJ C1 ::.1 g '0 " '4 d 91 u?6y- ?,^ 0 ."' O?"rte . ?:?N ? +RN3,%SAIrrOlYEA1RaM Nv OAOGIp Aq K+ qKf DiNAICMO 15lt Kt MxIND DA11p RIIOEI AWRONOa1 DAII jX D r4 S??c. ,I .I,I zs.?„Ra z?°N? bz y N w: vl T'''?x?dx?w •Fg ? SU yAfiT? ! I I - I V ? I L d ` ? kR is ' } I t' ?L n ? S W ? 4 (4 , t•t ,p t{, 1.1 % ?kt? a q j'I a,, ' 3 4 AG ., `, WSR 137,RtV. I.DDI STATE OF WASIJINGTON RAGL ! OI / 1ni,l IziiitI, 'ZP POLICE TRAFFIC COLLI NREPORT IZSI TRAFFICWAY rc(ICEa NINWABER I PRIVATE WAY at(OfCIXlrSC]N .. m DaY f Ott SON RI, RIA rI„ .,IY 1 r. 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U?r'I••y courvrr NO. urr w. rNwA ' ?_ X X00 .SCE o? ?UpOAN ?? ON ?1 0 N LOP IOWN OOp$IRE.,oNNIPNwAY DA KICI M P N1aNNO mI.(?srNt rr Qg of V, v ZAL ON UNN ROB ND V e51CI,oN , pOUIf Op 5l ft SEc O I N e[fl% E? ??Q 1Z . 5? _?? Btlwffr RDG I MIIf IOSi - ON', cgccx SINAI N f N ! mN11leI nCf <NOSS SINlfION NtANr51 m111 pOSi x ACCIDENT -•"' f ?I ,! > O? L Q 9AM MIA A7 "I I I I, C? Of MILEAGE 2 CO E r,vlxvlD N IA C m,1S•" rA ,Nl- ?-,I L ?"IxR '. Npn?,.. IN %-RO INIY 01- 1—Oe-OR R[IERENCt tD ' CI W pproNaLp>mxcEONI wNfrs NUn( ?>e'w,lnD ?' HC?I '--• q r,AVr olwxcl slNlK. umof IMfp CIS ClIMSSIREE10-. LZ90 I '`. esr Da,(ACf I snclu coowcfut h 7 -a - s ?w ?f Iv1 M..t UNIT NO. I ` MIDIXt UNIT NO.2 - ? 45N ppmps NMnt- ? VEHICLE ?PEDESTRIAN ?pEDALCYCtISi J u - yI 5 Rtfl AppNf'wS ? --?4 < Aq :Iprom NO D I p rv r urf N .i."?` 4 " 7?d3a w rN SI,nNV NO L W A! E -NE - - 7°+^, M o x '7R 1499 IN D of IICtNSf NU oa '7 ? I,VC 'All Stx DAIl Cr Bleln E , ' A NI ( O (' p R p, , n_ ,.oNr No . )". fav tvls I iw"1 E occup.l oN L " MNAmEa pNONf NO. Erts mcNl •<cNI - Y _ p wCR -?1ou?rsJ,cs fl n0 S'-ro R Q CHECK L? _ ( ) IAL 6 In.A INta " O 1 ) ! v A '? . V 5 AS '_A NODES ? fWwo rE ( ,T n iE „rrolf°Ee P III P ( CO <:ii IN N<1r A Y„ sl%(, UN .(U DES K 7 N 11' S «np.mN, "I ,m C] ? ,/? ~ ?F: p,1N Or Ni`e:"n ,1 m%.rocl o,lv, apmxnlDApl NPVA s ? " O Avlr....o O •Iri,.`N ? Plw11, O." ? { i '?, - I n x I n0N cn N rur ?I,; G . ;h'^ /7? V <"{vl woalm%NI NOVAI n'apu.. 1 _•. ? & 1 E ? A , o UOR L r AA " x Irvv run" It r,<• sun H veN <aop ? " . ? - I K R A RG"w CIl A A, ? ( PI! ? _ ,ptNi iN:ArgNrq L vINI«t 1pN1r AI 3ay30(??561 7? V d NIC. SN N1p VA'rAN U 151 mlpDll pNONl rvo ^],9 N! ISI{410 WrvtN (ASI I pa .: IN51 MIDIXF fNO. "'? c.. N AMI,AUDNSSVII SUY -_ I1 %(•t Ni E w- O R I DAN sl nAMAC1D wee _ -,•„ULMACI E S CNANLI p.'1?r ?vl. DMAAOlU ApfA 31 I51 ? 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" U s Q S E f A C(eUe1 I Nvf NCt. CNOSSSIR[ti OR NfANF5lM if p011 N ACCIDENT MILEAGE ANP DI RAN OAIA - It ? OI Q ,? D cOIUSIGN INVOIVfD 5tvtx rv NO -ND-1 URfD? ? Sp11LAGf ? IId N IOIN NO w? „ urvYHDIH I" I Nrf CLS CROSS SIxFF10R RUMS gA009,AwRENCf (RB I HCtfA RDnxn Do"Ek ONIYSNAM ? wFiul l(D ?c.F OBNfI SINUCR INPMtOf CBJtCI SNUC%ANp OWNFRF) [SI DAMgGF SRGW C OWNG IbE / Q 9 S I-S W 1 s UNIT NO. I RvtY SrrvnF: IASI Flxv 'IDDIF UNIT NO.2 DRww sNAME: ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ust EI M r } 6', ?N SIrI11ADDNti1 E?kJxt:. ? r' - A/Ea4 I a SIr[FIAUDYESS - e'. ,?; uiy '?2YA i-? Z z >< 7yt c VAlf E,pCAIX pNONE NO . D nr "---51IE Ip GD . vNON N . - G6Al 8 /? Id glNtR'S IKINSF NO. SrAIF k AIf BIR H NawEirl Z 6'z [,J F F zz oX R q `/ II R IK N. IRO. IAIE Sf% If D tICCUFAl10rr RM NAMFe TgNf NO. FYt1 WEIGHT wWNi E OCCUPAIKMV FIRM NgMfA prKNE NO EYES WEIGHT wIGHI -Z a (O R . ? CHECK(.) ?[ As AH IMVIOr o "u AN 1 ? CHECK (?) A"A N CiE ARAN lMgOYF[Of ANOIH[PAl '' CODES ?'r D e ;" „"" I clw J e ;° 5 t• I CODES ? * 6 A ° 5 fn Ew^D xr 2 " 0 G ' ah E AM, ?F ? -t-HIV) u ? es:lr ? p tC ? v? IIDMINOVAI SIYIf IRDX. CCNV.1 "MIDI ? N A~ft ? mc, ? Cs.nr ? ? HtAR 1HFV MODf R 111zf: ? ;?? Ran CI-F6J 46, 4 t 140 E .1 I IDA INOVAI Y 1 I , ae 4 3 vOV N pN it , SiniE AI[NO Alt H nCgOR N l of AIf A 4 ^ LA.I/f C bA - P 3 KH O[IIXNI 1KwrKW W C S' R y If 4 / L .....f DENIIEI A N RFUSRxfoowNle: D\st NRSI MIDgE vNOra NO I tD wNER h, ' . SAM : O : lwsr NRSr MluaE -EW '.: . ,,-v ID z. ADUYISSp ONtv{R W N A {p 411ll' j r [AADUet SSOINSURwNCf CO WAGtNI ti R INU AN Y 1 r r' Nom. DAMAf.IU Art • ;: ? ' CNARG (HAYGf DN.1AGfDN(A y 'f y' IG iOflOii S ISI Op.MALI v A L o wWwv" ?RIMA NED ?011D ' DNIVtN IMNNlD ?AWAY ?R O 1St 10AMA01 ' 1 IC Hp DR 1 _. r r . eY V ?AWAV eY. S E 1_ NaT? DIAGRAM OF COLLISION Swlu11YNEcl cAlto wIH -11 OW DESCRIPTI ON OF COIIISION IUSf 51RpI1wNlN SweNlwttssAerl y r FENdd CA4 ,! 74-V40-0 77 04".% (n/pK '? l rerr) , ?. '>;, + Ir Tar D:r?w 66f? sroiO..va AGAANST + p ? M? PENCa PoJ rr 1 . . 021 J8I( OGaES war A(n). p.l FgJpAr 714 E %tr.? AA I PXlAjC, .y Stte d Acteo our Q.cr 7NFs (S NNKN 1 f ' I - r - y L• NAME, ADDRESS & INJURIES OF PERSONS I Iuv swntwrn.I Sw NVOLVED tl F CODES I - 2 J 4 5 '6 i f J l OCCUPANTS /WITNESSES ADp14W N SI 51% •GI TAI N iN ,: N r I;IR. INCI i 1 yl w11\ IUV d scw ? wM e ?ri?l ? rv'n• ??in ?gi?.wM k1L (l A p(N? " . N-0 INRI (M ?f.?? uY {tr I ? - Y y, 1+{ IAMI SS r lwnfD IPGM ?AME ?H\vl?r?»n. ?ws:: ? tl i? ? }' - l ?yl 4 N MSI\\ • Nw'IWrd N ANV1 rw rr ?AMe ? :.'??r T ? ?gT Ii I ?1y q,. p_ t I f rN11k:A,NGtkl%ir\MArEE ? AA[XA (n ID w1 N.[wr I'rul I CRG IY• EArvIV1 LJS J?y II Q U•IIp NroXI 0 n. wwpNDe? r MIl Y E• t ' + '? t rr 1 f ? „? c sD S.Y s Y.W r D 2 I ? ' 3?Cv, a 2 rf'i r ? c Ir R N 'y A N I w.Y. !• ?? ? r r ` A(wj,s I ? ':. ? ?' r f,,?,L, a uu ??Si 'ACTr??5? y 1 5. y 4 .r 1 7 ''++' E • l ? r _ 4 ? ? ? 1, •Ife?A1{- 1 A u ;?• C S-. .f L r ? ' y ;01 Ay t ,{ ( ? U 1 I L 1l?n I ? ti ? ? A 7. i l '? dy I + 1 i 1 ( 1! ,k l f 1 ? /4 t f -. 1 ? y. 1 ' .. .. ',.,' '- .... :. ..:... .. :... ... . ., r.r..,. ..r a ,... «. ... M. _. _.. ..?.....,aWAatfi.l?'rr+l3 Ipp'I IYU. LV TRAFFICWAY valcE COM:wNrnuMAEx PRIVATE WAY (?I ? --,ITpj+•e oar c I IImE couNlr mu"EYNO. cnrna I . . usf RRaD noun rHwn ? by f t?; r au r. } STATE OF WAS NGTON DE GF W-IR" , No d• u , 'O POLICE TRAFFIC COLIfa N REPORT ED TRAFFICWAY i nT? _ I •.• ME. , _,JIAININWARE4 DAtI Or OR" " ? PRIVATE WAY DAY TIME " C 'I's' T s OUNTY A ?%INtt ! U. U, IUSEavmRRMI I NO. CIttNp, iNWA Iw ''V' VV ?U N' sO.. O UR OS OI CITY OR TOWN NAME6 TIISi ?IN OHWAY Cls ROUTf OII SIP[E Sf 1 f 8 Av N ' l[s ?G UI E,hJG ON SnT CR?.E, ?/ Qa . jCS290 INTERSECTING SM T» Ste111 OR RpgD a NONINtFRS[CTIOn PYtfl% E MILL NOS _. IOI-1.163LYW)pfs j. km ?D L? LK•{ ?'Rs E ? - DISIANaEDIx T MllfsFVO NYf N[E.000SS STRFEtOR NEAREST MILE POS AC.CIOENI RASP DA.C.-MIA n 5 M P n Q DP 1-6 R0.S LAkr uk? izD .M DE E N • _ C OGIIISIONINVCIVfD VE NI'r: IF -1-CII SIREITORROADORRUIRfNCf TAI NO E %ILED_NO.INIUR[0 ?s;IIIAGE ?N»6 RUN wn'aui"iw IN 'N", Cls CROSSetpfEl OR R'OM R O VURCIf! ' as ? PROKRIY DAMAGE ONLY ? Ft ? V[O'CIf ???Ajl? ORRCI STgUCR INAMI OF LbRCI STPUC%ANDOWNfR'S1KMF1 ' FS,. DAMAGE -CULL CODWO USf - -D-IJ• R. s UNIT NO. 1 s c. DRIV[R'S NASSe: u FIRST MI [ UNI ? PEDESTRIAN ? PEDALCYCLIST c VEHICLE al A3aIRS SNArn R av Ti?mas P SIRFfIADORfss 2 RD. 1?6 3 IYEEI ADDPF55 - TY SIAIF EIP CODE NIONE D Ily STATE uL A. q 302- 83- 033 R DRIVIRSUCINSENO. All f IIY WI PNONE 12. ?l31L1 BI H I m oq zo d" IVEx U [NSE NO. All SEA DATED Ill, MD Mr ,Y - CUPAIION ???nfp??Vlj{ry _ FTFS WFIG»I IEIOHi E ? RLO KNr OCCUPANON FIRMNIME6 PNONf NO. [Yf5 Wf10»I IEION T . t tJ 2z0 6-0 R - ? CHECK (? « sAEMgorEF OF ANOTN[v''M A ul ? CHECK (?) s N usaor oE ? A A °""' CODES P 9 A `s S I a .D .> .su .Irl,y+ ,Yr. a tF ANOTI Fe CODES Do- * 9 Ass ' I? Yc.c I R iy S I%a DN ar es ° NNr1AMA."- I-.) Cl f°AC?R'?'I?•wvA® "I It ° e ONV ? eu Mnr ?,+ •rxl ? uCl ? [o:IY ??, ?Cv ' [ri E]DR . 8f SuoFir4.LL GI_ s W E ?u ».r R 1 »[VI MOMI IDARTNOVA) r la IT URCIF 11 IN.". 3r@ - »ATENO, suR H K?D7?9 WA I nn eaoR a C- n A tno. AT 10 K»Kll Ct III UIroN NO. C _ L of»ICIt OfnTN A N 44 R{GISR VE00WNty. WI 11451 MIOgf NE NO O (YE 106, W??' Sth1?E W ' RE ISR V[OOwnf R: WI flPSr MIDgF FNO. , N I ADw+ess of DINNER N A FOYYNIR 9DI NAMISADDRISSOFIN-NC[co --,IU E ONAAGt AREA . R ' A I u AYI I as a _ I ? a ,; 151 DArMGt C... e1MNNID ? ?W? ? ? - C.IAYGI N w[ ?'iwu gAMAGED NEFA ? V.A... :TOTAL. l :°w:v°er er ?RFMNNEO ? AWAY Aw`^'E° SST. UAMAGI ?IOeono? s DIAGRAM OF COLLISION: lU I N IN. e ORI» IFF, SWtI IF KCt SSAY,I a ? o-? I' DESCRIPTION OF COLLISION; lus[suPYl(MlNru swfrR NlclssAxrl PRlR&)O UEI. Moo (DW TPZ RA4D GMPJIJG-A ftA ?,?( J i I ^ r't TREE AWN, 31 FOE Tke P4gDEAFEI Cl4peEX_\EA _ FFAE J611ZAVE?fZ APPIC. 6'2 MORC FT: STRIkIW y?rdi 7 Ak)oT;JER CEDAR 6r A)"WXq FrABOJ9"[Ac „ rO _u -MCO SPIT IL)G ARCx1A•2D ,AA)D TiPPI OUP O/1Jb I IT S SILL FAM Or, C'ASrAPPX' 10 r R20M ZLIG r I? i V 12' "h S%?ND CEDAR TRH AuD DjPXoc7LYADJfK?7 'M 17-. TRACKS WENT 5 ZRA1C'{TOFF G ? sIDC F IV0 SkI D 1?AR/G. D/aT l S 67 Iv !2 U L NAME, ADDRESS 8 INJURIES OF PERSONS T ' `P ' ' 4 ? INVOLVED i CODES 1 - 4 6 . OCCUPANTS/WITNESSES ;D 'v:naTl o?'rYU rNiA:sE1° NUAI _ ?I..IMAA.1 ??LJ si uR Aa TwrD YI STR tlitl ' " a?- 317(a ».... - ?. - l ?. ADO.IS NAMI O L-19 R7J5 ?• N upf .r ?AMe ?r<:1' ?" , ?C. ?C`.' Y a roA,N . Acw.N SS wla IDIRW ?AMe ?q; A'?ro' .?: ?:' RD o NAI I y AfNW1. r nII _1• s ?N RAI%R Or N.N.c. U {sw iiY%e.- ?AM ?": "'?<? . UN ?': - ? . x LY4I1 I ?SO ?}.y? (M)?cNfD aTFLE ?r o I6Dgnanwn ArpvovfD r 'Ol•1 . Mn 5.. I 1 ?W7 POLICE TRAFFIC COL NREPORT V'i .At'ILWAT Palcl wNIBNIIER PRIVATE WIN UwIf OI ClNI15x)N ?8 /S- 85? IUSf %wOtNOV4I Wx Y,I I °I;W "x, uI U7/Z cOUNIV SFF pIc rAUNIY,a. A,, cITYNG. IHWA UURBAN Dxa, 17 ON UI UIN CNYM IOWN rolls ID] ?W RiD' D?Sto? B -1- Di51RIt10Rir GIIWAY ON N-?L?.G 1 45 ROUEfM$IRE 7 SECTION NlluN NNG In'SUfIl U4 WaD NON INIFR ZON ° DNWErN Z,O! SlYffi e sIYNI -FIX E0. MI. POSE O 0,3 ?I _ nSIgRICI AUxI?NONIwMVEItvINl CYO1511e[tIOp NFAxI51MIlf P051 OP .S ILEO /cO n Its l7 n / J I ACCIDENT -EA E CODE RAMP DIAGRAM MIA 'ICO VIO Y U]PU?gGI Un18 RUN NO NIV4ED? Ri IID 1,Irv wpm L5 INI[R Cl5 CrNG SER[Fr RIK)AOOR pIrtRFNCE CAOSSSTP[EIOR ROYD I» S ? Q VOltuIV OAMAGf ONIY LJ vF?'CIF D SA4 /O/ / UIVICI]I4UCY INPMFOi .,EC, W R-M4D OWNlx'S-,I S t51.DAMAGE SPtc. CODINGm UNIT NO. 1 UNIT NO.2 U VEHICLE U PEDESTRIAN U PEDALCYCLIST -_ - Nef UCI iluA mNUtl D„F oHe°i? lar 2 Eli GEO 6 IVYR'S N-I. UI, rwST-? MI I slut FE nDD4F 5 513 l `7 ST, ' tPRE ADDRESS 1 1t nP COOL ONF NO. rN ?r1 > rfa c» ?/a;6 z vs? 73o ? J / D R Nr sure zlP PIwN _ rv tx uctNSE NO. 's suif rx I RIVIR LICENSE ND. sAII slx AIE MCIpm ;' R U CHECK(?) NlasaN, R CODES NA- w,r"Nrl p M"I ? M.". ? ? 1.0- av :O? M .°' ? S1.II4 ? 1. C'17 ? ?; r W ? ,D,Gl 1enty) mODN 10ARI NOVAI 11 De UUNV.I ?Zo•n L L E n EAx Nsn I Nevl NOUFI rUARE NOVaI r Ix Dp,. vl ve . ,.. r. PI.II ur., Na N x f H A u A n - No. Alt n t Y tLlol? ($ 294 T lJA I ° niCf pENTIFICA,IOPINO. i VEN CIE IDENrN AI NN '? yA4 FI 56397 ?' _ Iv1DOwNiv IAIT IIRSI MIDDY Y Ross VAA¢L 1Q , rulN[NO. PITS7-SoI T O W 4t IItvO WNtN. tA51 NR51 MIDpI Nt i I'S ODxISS1-11 X06 lJ. IoT? ST. Pa.A WA `!8367 N E A E OWNER NNnf LADM155 Ol IN-A-D. 0R-fNI R A UAN N • ]t DAMAGID Ax1A ' 5 ' "'"M""" lSl. r,"DNAAGL cNa DY VtTNHULJO I 0RIMNNID . 1IRIVIN ?RfMAIN[D ? SI fUAMALE DAMAGITTARIA t 111111 ?(?(?( ?????L `` IY u. or ffNVIU aJQlPL S 1a.Y:A. Al nr A. U A ? WAY MAY OM ` ? Sppp???pppT R I NAI INUrcArINMN' DIAGRAM OFCOIIISION: Iu S14111i NLCtS5ARY1 Ar A4POw DESCRIPTION OF COLLISION: lus[SINP1[AVNIN StanlT Nfcu5ARr1 tL L I Jt L L <d L S L - ET, opws - _ J A A SIDE G- 7 oyA VF A?I, I ' To ts J.Ib {?f . . G pawd b&. L,JA c Sl8 sLEAOI X11• \O L N ? ? p DI+V..LC. . 1 WIG on ?u kkL Ocl E43' F1;gw ? C. eN TttL rakls?do. s setw d ,TLtA1C. 751 - 1 Wt aj- ?Zl Er -' F-k-S,eI,:j(?brLLL O 'W-, .? NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED .P CODES 1 - 2 9 < 5 6 OCCUPANTS/ WITNESSES ;°o''„DwD",ziiarNiuS:i si ur TAEUS "' 1" „ r l wvR. un ,"' ISS W. Z-S-)D •" o n L wl? 650 4 M 14 3 1 1 ` I?r+1?,C15 91 E L)A U41d AArt6 IM llv. AM D Uiil'1I ? '? v ?n ?itiiiY fq4" ,wlp DrYasS UAw 0M"11141 O]^. U.: MI uv' Ixw wfM wR UAM CJ.":.'r?^ .Uax ?; IA IRYNnM188A,•Y X 1ZH1 «? w.f DFW- RADGtM A p? G NCY se.so S?I ? KI D{IYAATCND ,eYYAS D??U D p.pnlurs AN OIRN711 9-IS•6( AYtY(TrIP Rr MII yr t •v, tf b" S'(vWW#X""'fSYMb??M1Al6 ii AA1 L '?Cb'S._"- ? I -?e`` •ae? u?ss"s r?e''," `f'+n?dY,??..,3 BA4?'2'?t-[' tK1LU r}?' `1::Z...ii>V..d:.. F s vM' - caurvT arr o Y :. F X J A% » • NDx wFD Ux 1 rvDBN" ` ,. ? 3 ? r ? .,J f ? xloxn [6 D FET GrI Y ?N ?E ?N it ? x°°rE ls •OM . Z C/2 G ML3?s ?w ?oF?GL/?e'rA r ON l ctNe C. ? xs .nO w.nl srn[ET aP Ixi[PSFCiIOn H-HN ? ? I ??Sl?/'Y/Li69f' N ?E PPEPD,wcxossN._jlp TOn[oFnrviirlNOLANGnwxK. O HIT na[tnaN ® W ELISION xVOLVEO C] LA ? DIALxo K flo011 MATE TNPN i E 5 e Ix TFfl i i F PPOAo EPF CF CLS ? ? L ? OFVrvCIE M e? P .. e OBJLCTSTNUCK E uC 1' OWNEfl OF OBJECTS NAMEANDAODflE55 i,t P[rPIx OHttT.: '. SE - DRIVER'SLA57NAME, e ?.-FIRSTNAME. .-.-i: .._MIo.LE _.-;. ..:.::.?, ... II TMOPETHS -.LV wFP.lnvolv[O DRIVER'S L0.5TNAME ,......;__.:.....FIRST NAMF MIDOLE- 1 ?,? • x Tnls cotuuo»on u xE nlPn Two / r ,,fL T'AE /` 1 F ? I ' ? ?? I??` . EE D PE' ,. p r[nsOxf wEnf ! L 'f.N ?- RG E55 flDUTE .'•"•_.,-... ..-:.,_, ,AND 00%NO..... .' . l? n/ 1 v Inun[OUSeP SE1Ax•TE CDELIf10N V!?o t LILY .. .. ... .... ....... ....:STATE.- ZIP CODE ,:•-.._..-. ORIVEfl'S OCCUPATION -PT FOP. ...STATE .... . .. ..,..- .:..... :...:.::-21P CODE• CITY. -. DRIVER'GOCLUPATION.:,,.- •1 41 ?• lu9hr.H R ER'SLICENSENO. :- STATE.,SE' .;.OAT F TH .AGF... DRIVER'S LICENSE ND '. -,,:.:.L.....-.. ? STATE SE%: _.ATE OF BIfl yq.-: :.AGE_ ' 'W !o 'ir SRS' i' J' Y VEHCL YR. MAKE I C XEV, DO DGEI. MODEL INOVA-HT) BODY SttLE U DR.1, VEHICLE YR. . -. BODY GTYLEf]OR.1._ MAKE ICHEV,GODGE : MODEL.NUVAOAKTJ. 7 ,L ? ?/ /, /-! C.' 14 I'll ?l 5,41 ?r LI N LA -. STATE. :. TEND -..TMILEfl PLATE ND. .. STATE ,.. STATE _,:.. LI NSEPLAT ND.. _ . TRAILERPIATE .. r• E? 11 ?l ? n LU d6h VENICLEIOENTIFICATIONNO..- ....: .. .........:. ....:...::..... : .....:..... /1 . A Z c, u G 7 VEHICLE IDENTIFICATION NO..-... __.: .:--:. W?:..:..._ ".'..:.:..:... REGISTEREDOWNER ILAST-FIRST-MIDDLE NAME): .. DRIVE R'SLIC ENSE NO.. ... REGISTERED OWNER ILAST-F]RSTAUDDLE NAME]...--:,: .. DRIVER'S LICENSE NO:.—.,?:..,,.. +. Wh lq,lpli tA'I17 "r( !':I lCZ OWNEfl'SAOOflE55.. .. ISTREET,CITYANUSTATEI .......... UP`OF BIRTH OWNER'S A...E55 ..(STREET, CITY AND STATEI.-.. ....::-..-.. . mODATEOPVtlIR". J r i r = 1?h M° P. PART50F VEHICLE DAMAGED - ASJjin"Hp, T PARTS OF VEHICLE DAMAGED . ............ ...: ...: •.,. t;,,L-., [,PIP HcLI!,'... LIABILITY INSURANCE INFORMATION-VEHICLE NO.1• WASTHERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ?YES NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NPMF OF LIABILITY INSURANCE COMPANY. ., _ ..-.. . 211 ?( I I` . ? OC CITY -11 V \ LIABILITY INSURANCE AGENT. ......:.. .. LIgBILITY POLICY NUMB R .. ..:. :...: ......:... ... .:... NAME AND AO ORES50 C111 .,All IV ISTINNRYt NAME ,V LE Al AGE TOTAL NJURED ]ND INJURY: IUSESIPAPATf P[IGxi FOR POOITIOl*L INNMESI - NAME AGE ADDRESS SE% M F ADDRESS FEN M F NAIURF ANO EKTENTOF INAIRIES ? ? f NATURE AND E%TENTOF INJURIES ? ? E%?iAINATION BYOA DOCTOR( ® NAME RS DIDIN E%AMINFTION OYFDOCiOP> ® NAME RS STATUS OF INJURED MARK FIRST . 1 THAT APPLI ES STATUS OF INJURED MARK FIRS T ONE THAT APPLIE S - - 1N VEHICLE SilnO[A ILLE oat txF1 D °Niu I'soNIiNG 1,pIiE C I O I aii IN Vf111CLE s5[MO[P ILLED ,s[ tP O Rfl nlwlonl " CO iYEI 11, fi .1 NO ?rt O[fSPIPx ?..IIH.I.H;HY•: ? 5? 6[:] I i P.H Ii 70 NO O(SIRIPM ?„N..I,:Y.rH[II, ? 5E I 6? C PIN 70 ? MOTORCYCLE SAFETY: ?HELMETUSED ?HELMET NOT USED MOTORCYCLE SAFETY: ?HELMETUSED [3 HELMETNOTUSED 5HOWNOATHfIV ARROW INCIRCLE DE5CFH E BELOW WHAT HAPPENED: IREFER TO VEHICLES BY NUMBER] NBKA?P;MTmFIG ^ EI?„D.[»r ».M,»a I» "-G f AJV d C• /U ?L__UF_ 1 T - /a' ? v.__[Qk-?? ?.- : r c" OIL _,,, ? Ii PIII DN x?fAn•v J VEHICLE POSIT( NS BEF ORE COLLISION A" n`wm»° [ IY LmPUVi inB Vl...... WH0 11. INV SIIGATED BY P VlMLLE N 1 / W ON{i RElIONMIGHWAYN•AMEORAO. U:n[t,. vII AO vll x0 ... ?i11 A ?i0 OWAI ? ? ? ? ? ? ? ? ? ? ItFIL ?Wl tl ©W[ w„rvl.l ? ? ? ? ? ? ? ? ? ? ?MI[PIII ? ? ? ? I AIGNO O"OSSING /ROM i0 PEDESTFlIANfPEDALCYCEIST WAS USING: , ? 1—— > ? --1 r ? rc L ? ?,;,"w^O 1 ? } 1 ? DI r ?„ 1 ..A.Al PEOESTFlIANIP@DAL CYCLIST CLOTHING COLOFl; I ? °• l ? LIU [ ? M.. .0 Mrn........ [ [f MOPO WAIACI WIAInER LIGHT CONDITIONS TAAIIIC CONTROL TYfE0FR0A0 DRIVERNfNICIl PCi10N1 fAC+11 vlnKll 1 (D DAYLIGHT VlrvKll KPAt•O»U 1 v rvK 1 frvl 1 OA [will [ 1 V[rv.t[I .."KONI OP WMH »0I x0.1 +O I I Q =19+ 1 E) o.- ? 1 ? SIGNALS [3 1 ? ONE WAY ? 1 [3 GOING STRAIGHT AHEAD ? 1 a CRY [ 1 RAINING 7 [3 WfK ? ] ? STOP SIGN ? ] ? TWO WAY ? ] [3 OVlRTAKINO AND PASSING ? ] QWIr 30140RHMG E ?BANKfONl IT ? ] ?YHID{ION ? 3 C] REVERSIBLE ? ] [] MAKIND A IGNTTURN ? ] ?NOW E0r00 (3 i DARK 1.141 "aw FI ? 1 ?IlA{nIMG RED INiIRCNAN01 E 10 ? AC AMI, E MAKIHO tf FTTUNN ? ? ? l ? IC! O1NIR { ? RKNO DA IGHif 1 1) T ? { [] (CAWING -011 IL C3 { ? A Y l l l [I 1 [3 YAKIXGUELPH ? 1 ? YIGiY ccIll, I OT^IR 13 VIbIY LIc ? 1 ? RA SIGNAL r W p yP Y ? e ? LE/i lyllH ? It ? LLDWIND OAIWPAYCU N . ? '?:' ACr PI ,• CiG{ rZITYPE 1 :WOw ? 1 ? OFF,CEAIFLAGUPN ? 1 ? DRIVEWAY ? / ? IWfO FOR TRAFFIC [. L .JJ:; ?.'Ram1. -. PL:•.-r?^ l.Y[l S'. •!f?IE::T { onn A,ulnrY n A {INM I N ., V:•?&r'. ftorrm AnlDrul. i •1 e3 +Bl ?E?J9R -: 2 ,y V ?.^ ?? ? b I, _ ^TLy-?'° ..a ?. en"n5? •_ E2 7' ?°rt ".' ? _ ,try, X /gyp SIAIL OF WASHINGION LL Ua. unv QE7 MOTOR VEHICLE COLLISION REPORT N0. suN Non iruP r IrNI n T A' N '. LINTY HD LITY NO. er» n 1 'N»? N i, WE'' t n? »NN?i`)to»nu,rW.. /? [ i » 0?NyA&y?i?'" .n N ?E 0 PQ. ILI, O»?N».. ., FIAI 1:; , , . •?tti _. sn ,..,.._ _ . .4LY? _. W.l.lO MILES FIS, rIW nDF f-I Lm XP ? A IA bo N D•i, I o a 11 11 11 . RAN, nlLR LSII! F6 Br.HnCLlt" ? !?, ?;-,kiSl , o o[nLDxl. 0 3 -?-T,? L _ _ RDaq ..... , a o? tTNAYS MIDDLE Dfl1VE_5LASTHAME FIRST NAME MIDDLE I ROUTENO.ANDBD [D sTq O R TE O. DBO%NO. Mt A ZIP E D I 5 UPATIO [roni son eTATE _COOE OR1vFRSO[tun•irnn l(.I r l..r 31LC .Ili, No RAr v» _f ._...__?_......._....... unicn?r in,n al 6 r ARTS OF VEHICLE DAMA _ lo r; Ri?w ? L? AgTSOf VE IC E GE Pw $ $ 8l NSU ANCE INFORMA j)?1IlJ????? d-WkCLEF NO WAS THER OMO ILE ' C : .I EINEF B THSAC OENTFIN YOURCAR YES NO g LIAR LIINSURANCE PO.ICY HOLDER NAME OF l1AINUTI NNNSURANC E I INTY ANCC A GF LIwe LITY POLICY NUMB X IST INA1gY: AGE ZNDINAIflY, NMM•Mwil RlroRi rOA ABRIT ONwI,n uRESI AGF ?On IN VEMKLE oluel pisAM, - ?FA NO R LLEO r5ivi?Uuluu ?r! lf111I•N _O ? 5? 6? 7(5 MOTORCYCLE SAFETY: ?HnMET UUD QHELMETNOTUSED MIOW NORTH RY ARROW IN CIRCLE ,i?BIViE ID UNt1"icon ?1 ! ) r-27 t 111 u, »wxNr ?RR FHILLE oi'irli, Un n,v. purv ? rA NO V LLEp ruvrxll n"IIxORr Cw.rt O reo :.a..» 0_L50 r 6?r Ra`i;Fl, MOTORCYCLESAFETY: ?HELMET USED 0HELMET NOT USED DESCRIBE BELOW WHAT N-ENED: IREF[R TO V EHICI 11"I NUMBERI L-CJCJI? ?.c? boT'f 1 ?c I'ELV'f'izwl s ?hr?r?zcQ'Into [v?Ji?5t ctnd .IxLOce-c fve, t,'C N"VdJ Ovr 7F YYIL? I7rIJzL.::c 11.1 _E E In? V'l??l?.?Z.t .Zy uroun x VzL'hIte""? .>JT L!app rw 00?r PC r)." vl% N u I ; VEHICLES POSITIONS BEFORECOLLISI6N J _i_ -- - -----" -" '- -' , xlx r- r i ?vi i ,ri nw• NVf SIIOAIfO BV \'ENKIE N [ ON BTREET O""""*,YNAVE ORNO. 1rx1c„ rIL •Rn rrl AMA vlxx'.,r,NCUnI ? ?DiI,LI 0 np H?, :L?I r?x.LN?R ? w`L? 1,rW b I.N.I ? ?S ? ._Cl_ItZ_M?G "',I ?a M; M1xI„ ? ? ? ? 50 ? ? t? ?_? ? C3 13 ? •LONO _ CROSSING FROM To PEDESTRIANIPEDAL CYCLIST WAS USING: I ? vm r Q .. I Q N; , ? .,'. t ? 6'?"' , ? pI 1 ? ! ?,u .., r..n nINP ,nn »IR NIA.nu _ ALwnr unwu: ,Prxm A?•+ PEDESTRIAN/PEDAL CYCLIST CLOTMNO COLOR: I ? D... r ? Lw„1 ) Q NmB .0 rnp,ut.BXV! t 0 ;;;„p;;I7:::'iir"'"n6 -- uLHTCONUtli1N,1 iH•r IIGCONINOL ? rvi of eo+o .____.. .._.___, ,.x1 r,M, DRIVIRN[HKL[ACTIONf • x iI 1 NDAYlILI1T Ir.+I, wxlrrlwlN'. rI H w 1[nrfF DRI UR M•N ?1"DRY 'I? TQOALW? QrI QiICNwli QlrlQ ONE Wn^µl,AYC• Q'll IM?r G01NGfTNAIT.NiAHEAD Q Z Q WlT )Q R•WINO 1 ?,RB STREII ? ) QSIp SILK Q r MU WAY Q ) Q OVINIARING ANO PASSING Q SMOrI S Q MOw1N6 S ? L DA." IT ? ) 13 -o SILK Q S Q IRIUApRi1b11 S 4AR1MG RIGHT TURN RQ 100 ED" ? e ?...M".G RID E it Tp FIT _ DIARR OMII Q ) 0 ' ? N S QGNT IG 1.111 TURN ? B ?YIpIY B?UYICA YI B ?.I N....ICH1f ? S QIl•NONG AUefN O S p 1AIµwLO'.; ? ? S ? 4AIING II TURN r ? VIb1 r ? E Q RR 4GNrt ? S ? hN IU1IN Q B Q ScOWIHO ROAMAY AAAf.11R RO•DWAY..H.. TTFI ? 1 ? OIrICIRnl.ALYAN IG r Q UBIVItBwAY Q r Q STOMIOrOR TRAFFIC it?.Y.' ?.'.^L pI pNFW..lll j4j':'ij':.. W r 1P:S1).I .1 F:42._ •H Q B ?D1NI R, ?If.H. RN.R U....rw. 1?1 r, LTrwrRa cmN., 1 L - 1, 101 V "I POLICE TRAFFI ® TRAFFICWAY V N0. in C COLLISION REPORT PoUCECOMPU NINUMBfR PRIVATE WAY ,. . Ecau N ?.. wi ?lJluiF N. lusE loos u 1 counrv OA ? ?b? '° '?" ?r 3 R I 11 ?'? O2Sp? rTlaFF? P S6T.1 munrrno. c rvNO. IF 17A /(o pAc'Pu ?N'gE ?IN CITYORTOWN NANFeNO1'asINEEIOR'H1IGHWAY 3 All- ?5 ?W ?Of P ON y? Jv IHILN-ING WITH; $1REFi0 NONINtf-1.1 N -Cm I RO)UIE>ORSIfi . 3 .JG;.Y SECTION } BETWEEN - STREfl B SrRFEI PREEI% EG. MNE P05T ?J 70 `. r, OISIANCE6pIPFCHONR MRf RN .y1O5551NFEtOR NEAREST MRF ACCIDENT ' ttE5 . r" MILEAGE PAMP DIAGRAM DATA r fFft Of / CODE '- 7 COIIISK}N INWCVEO; EvfRltrl ?rw IH iOIAI NO. NO. NIIIED?NO.INJURED_ !]J SPIIIAGE ?H 6 UN Y10H N «VEHIClfS PROPFRI O O EY P I ORgOPDRROAUQRMfFRNfE IMER C45 CROSSSTRFfl }5 .1 ? ? Y AMAGE N ESUIiED ? E ? OBJc-N,UCK(NAME Of OBJECT STRUCK AND OWNER'S NAMFI FSiDNAAGE g SnCIAI CODING lISE -?- 5 - $ - 3 UNIT NO. I UNITNO. 2 D NIfN'SNMSF: UISi M G I ? VEHICLE 0 PEDESTRIAN C1 PEDALCYCLIST - IIR 1 I p E CSS1 ZE 7 I2D RI NPMF: FP'S 1A51 1 DDFE -' - SIRFEIA ...T` SINUI ADDNE55 _ 51All IIPCOOE HONE NO. D TIT STAIE R ' R %? L?6 Lo M S A E I m T O gIH zo I " T IICEN ENO, 5 Alf F% AZE Of elRllf I I ° NO. MNaMO. IGHT IGNI !46 6116 E R CUPA110N FIRM NFB PHONE NO. EYES IGXi IGHI ?., CIH EC?K f CIE AS WAN FM gOYFf OiANOTHFR.u Y ? CHECK (? I HlciE as AN EMViorEF «arJODIfeI. Y_ CODES?* < " 5 UKH e'3',° -- Srt CODES ?'+ n e a - °t LJ- JURIES i M;olpM r ? uKr ? W, HIT ? -at ? 3- .-c. MACE 1:1 I- N wAIKHFV A 10R ' SIY f C ) ° M ? MN C] U F ? S:nq ? n ? r.°? rt . . l ??? ONV.1 I I 71 --4 D P, v R lCf" Y t E ' .MEAN MM ! E H V.) A1ODFl IDAk1.NOVA) rl E]DN. V.1 ? 1`/'ITV l ? IA ??o Fr 1?a Ii,•J•J` SrAIF , '.µ?`^'L 14AIlFR 0.A1E N0. 51 1?- ( I I C VEH.CIXOR N A A Al M At - Rp VFHICIC IRfN1141CArN)N NO. ` VEHICLE IarN11EICAl NN . i RfGIS RR[OOW [R N D2}%UEIDOLF HOMNO. :AME EAST A6 2 M S O L ISIFNEDOWNER: -1 flgll. MIDaE P NF NO. . W 1Ly ADDRIII-11 a CWNLN w'I N `l NAM A R E ADD E ESIS «^INSURANCE CO. OR AGiNI 0012 =NS. 'IOw>)} Z WA, R }} DAMAGE ANEA ' fASIHO (jM1AG[D ARU ? 5 . ruHCHDN vlctiowf IRP DfwrRMGr CHMG[ Cr1A4G[ ntwK w•cr _..__. > fSi, DAMAGE CD APi^YN ?P[MNNEO E ? ' OWIVFN ORFAWN[D fSt,DANAGE IO eu fTOT 1W? 1BY UKEV ?AW mDBY: AY R R IB DIAGRAM OF COLLISION pE5 5 Al I ay oorlxrH RIPIION OF COIIISION usueneMEM uU EREfIr NfC65M11 liufl fN[c[ssAPYI, C 20 ?Dj.. sm mEJT/I O V l{ 6. ad oE7J/t: GO: p2iU/A / 6.- - A n Z A- A t.AJ UP 0,0 7&6 D /hISS5 /1 1 GlP iA2/ . - z? - 90&Z CA IF ? 1 20?11? /??/ IG T •- ? I ? I ? ?'?1 ? "? `, ?XI7?.D.O,? P.95s, ?'[o?• UEU t?scs2T? ° ' .... DAMAGE $3500 °-. <.. NO.1)Ls ? q5 A Y 1' ?f .NAg20..PACKED.W/TA% A0656.&OE- o?iF?I f I ?e NAME, ADDRESS 8 1NJU TES OF PERSONS I NVOLV D + CODES I - Z 3 4 5 6 OCCUPANTS/ WITNESSES IDSESwnEwwNSw Iw ADa110NM NAAV fl 51 . lU_ 5[K AG! lAl iHNHN MiI cr?i _ yl SIR. EHCT ulEir W - - A60RU5 N 1. NAruRI« Ne nn ? AMe. O ?:1 ' ? w' . ? f+IY ? i3Hv NAMr PrNeV.rROM CAMS. ?iO1C1 ?O.rex OIi°.?o .'0 ?. - a eruR « nnls? INJUR,?? slMeer vl for ?w.wEUNC sADGiw AGENCr IC u. 1 inp rol I o A ?,arAR. ?'K°i.11 ?iom.?(: ?? Dana Nl 4r H o A ;t lisJgrJ 'd! . u' L. an ro ArreovlD er ',tltl ?: Kr. 1 j ! ?,IfeJRNill fllEtl. y 4 '.:eU !V .W 1 "i,l! S/.VJ""fIIStW '1 F 5, P V }yl X + E k I T { f }r E ? 1? J ; } Ir y E r ( F y TRAFFICWAY Li • rgKECOMRAMINUMB[N _ POLICE TRAFFIC COLLISION REPORT •' ` r ' PRIVATE WAY -A O ` ION 1IS50N rIM[ COUNIr W,gD OA f 1? _ yIx Rw oult wlv Iwv K F? IUS(1.00 fIWR1 '` ?M, L W N CWN?NO. CIfYN . p AN U l/?Y URAI RWIEC SFCIION -- I 1 AY V wGtW ON Ip3 OW CTymTOWN eM 6NO Of sIR O 5 ApW por .Rust: rC1 U5 `3 1327.5 wy Mnfs p INIt45FCtINGWIIN: St f,0 ROAD NINIFVS[CIION vuffl% f 7,6,6- N-1-111-1 N SIRfE, h UOSS51RFfi09 ACCIDENT f RAMP OIA RAM MIA C 0151ANCE60v i`Orvl Nkf M ES 5 W MILEAGE P[[t F Of C - C?.UTG'? /I LE MO XRD N F45fC0 SIR[F10R ROAOOR MifR[NU I" r y . SFVER,r nC SP IIAGF ?N ?RUrj- wr?°ulol„ C.I. -l" I] II E D_yL-NO. NnlefD fly I NIfP Cl5 C11=51REElOReW?AD '? / 0 l ? ,o-NO. © ?P p VENCIES RR,YD AGE LNIV p pEyUI,ED Ea a { [S1 ONAAGE y SRCWCOD NG USE 9 , OBhCf S,v«KINUXfaoehC, SI4«A AND OWNIe SNAMH F 5 L2ET - N 1 UNIT N0.2 ? VEHICLE ? PEDESTRIAN ? PEDAL CYCLIST S UNIT NO. M?DDI rvfR'S NAME: wyl 0-T ORWERSrvAME. wsl ER "sI o<F - SIRE ,.DD^VFSS 30G -33 ' 1, ?• o FEI ADOU(55 Y SIA,f IF<ODF NE E, 1 ZI4CDDF ENO. on P? 0 -B 9 R 1 Q 5, f rvO ' AEaBI41N I CFNS[NO. 4 a vf s1A,F uA w,faB RI. ' MD B . S UCLNS R D4 WA F / !! fv V noN ?Fa RroNFra. EYES wE?cN, fe1GNr E -PANOrv 11- «cuPA R ' O „ ? CHECK(/) tN CIF AS AN FMPioIIIIII rtEa Arw Nt ERAI ,NFe p CHECK (?) s: rftorAN c,- ? c nR A s, A CODES ? t 3 5 r 54». 6 y A,? ,1c is CODES ? i 7 ?: ?- ^ 2 0 M..I' ? C°' IN -- p b! p Skl s'IMv°n 0 p e ? M p ro6° ? Eoal. ?„ ?Nolw r[A4 1 NV.1 MDDFl1DARt NOVAI mule 1 rN E*{NFV.1 Ell 'A1 slrlf lrDU CCwVI K A !O O CQE' 2? E - /. 7 1f ty t . RMIER RAZE NO. SIA,t y,31 I? N lA VfN.<OIOR A Ml RA A , 10 l ?s?? `J /' ? R I y° r I C/ , l i vF C[DfN,If1UI Kll10EMPIU,RXI NO. T i3' 112! 1 o : (,r 3 11 R WNFe USI NRS, M.-L NO. - .FGRR4ED0 wl 51 DIXE SRC /.1lc4 S b, PIgNF NO. 325 4 W A DWNER u;. ' ADwnssaowNtR e JEA Al 9B/2 N 3 E N D A NAMIeAOO4lssalNweANa co. Lm!_C..VU DA'K' R r' x w ; ?uncEDnnu, OAAIKA Anu A" 'i veeE "o N ' y ESt. OAMAGI ? AWIAY ? ? AWAY ?RfMA1N[D ES 1p OSV(D IV[N l YiOnO? E .ID. ,, .[AWNID S t t ? A " S NJIR :w:r°er: er f [ees5A4Y1 le IAGRAM OF COLLISION; fD NAl " DESCRIPTIONOF COLLISION: IusESVR[AUNlu srlE[rlr N s.atUrriaSV.vY o 41 U6µ. I?AL660'CD NCCOTLATE A ShGRRG 61-oA70 1TiW.1 (vEASt OM-MO ROAD 126 CLAW !00' DOWN AN ma rt CoM * T6 REST A csAvisr A TV6 u uDFe- Sra6 AsATNSr xus 7r,5;I=. RfJ' ! 5 AARRD[J R10a pa f . ,,' DRtUE2 Apntl Tc? Tb 54 F1xnY? ?4 oer4, C-45fAG , „ EC J.MWU 73 Isl6 MANNN16N-4Y)1fO3llA'KD ?/{QNCRIE •? '?lrl.: I • fi . ,? , ER. DROP OLF-bT146 L69rAN0 CUi -OAS ZRGPiC NAME. ADDRESS 81NJURIES OF PERSONS i WITNESS ES iwu ? R INVOLVED ?ii ' CODES 1 - 2 7 A 5 6 uK wr ul wsn. eha A .A r l OCCUPANTS/ 1. F L NAAUI RAL1 A'lY0 /?????fJ??' S,E. ? K? AI»NSS O 'N'A°nnra n 98 0''w, p..,,. h7 TE'"t. eY AMS - ? y ""yJJ ' sz? -?l 1 V N:iu.Ea MDVlD r4oM pAMe p""%' ? Rx O :° Ar ! "ArYI?G a ' 323 ^ 6 I .IU a INA»as iNF er: C]". ?'prf+'4. pqx p$.Nt. 7(KC Wi • NA,U a Ipl AP/ROVIDer DAn V. AIt[ HO I ? .DO I E S K1.1.wN l.AN. .-,A AGENCr V'., 0. J1f0,CE. ?K1 A N4s Y2dMS X 5?"r ___ _ i.an f 'ACJs/ lrA/At,[i _ _ ? r 'X Gay 6 ??ur E X? O yX,r , :L '4 ?+Hfl:"1 ?•.•w:va+h?Aii 'Sr"?i .y 'r° r 2a1YYt ?? rE:r uXl +kW,A4nd(W7ua ? 'd?E,a . r i. .. i± IMF + rj?} q?pr '??41.q'. r }1?} Tr rr y •,@ 5 it I q t? r r ,! 5:? 'ir } ' % t '' ? fie f 1 f i?b4 , r,; t nr 1.'"?Yr1 V 7 ra R h ICY) :? ?? I ? A A?F i s 1'ATE OF WASHINGTON G E GE / No o1 U 1 - . POLICE TRAFFIC COLLISION REPORT rLy TRAFFICVJAr .- I POVCE COM - lIAINi NUMBER ? PRIVATE WAY Dw al lfof a so Wq , 143_ . S rv' lul (USE 21"OHOURI COUNTY COUNIYNO. CTYNO. FNVFA ... o .? IYI,,If1 ?. - - Di I I oo EFL 2 ?r^? //v o?°Reµ ?IN CItYOR toWN E6N0 Of SIRFfiOR MI i<t CES ApM ROME 09 [FI SFCI ' A IS 05 0 ?Df u /GCEvc- .ON ?r aos N//c e 3 ?33oio INIfRS[Ct.NG WIIH'Siq ft ?ppp0 NpN INtER5fC11pN Ora F d? •(1 p • PREP X F MItE PO51 hG r Cilt/GCE?/t` ?•D ? B D TI I. t , . F 0. ?? DISIANCf6DIRK110 i fNC .CR05551PFfi OR NEARE5r MILEPOS ?1+IRLr 6' /LO}}? 6PA,?P,tp '. MlES q _ 5 I v.Yx - W ACCIDENT RAMP DIAGRAM 0.g1A OO REt OF MIREA, E [Glll$ION NVIXVEO N 5 EVERI F IYI /LcEtiC /Z--,) i IOTALNO N.No/ N' EIFD_NO.INIUAfO? ?5PIIUGF ?XIy UN yypp[p? N D N [I, RfE OR ROAD OA RFFF fNCF d VEH CI[3 ynRpPfATYDMAAGE ONLY ? IN / INtE co CRp555iRFETORRDAO HSULtED VE OB LC Z] ` y J r StRUCq-f OF OeIE0 Sj-X AND OWNER'S NMAE) t?Z /SO .: xE F YY ' Si O MAGE SP CIA--oll G LGE I ER SNAmf: UNIT NO.I 3 UNIT NO.2 ^? LAST I ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST J DRWFR'S NPMf: 5t / _ I KC O C ' a _ U A o Es5 •?UV ccHS ?. 1 5f9EEr ADDRESS `/-7 FBA, ??- _ S1AIE ZIP CODE PHONE NO D IIY SiAIE ZIP OD PXON G? Cc AI 48So3 y ,7a>9R DR IVEa'Sl CINSF NO. StAIE ry? uk , % aqF fBgIH 7 C/ s , ?j I RrvER IICEN5E N0. StAIE FX DAt Ofe RIH cu ? A'1 o « 63 V AU' I I YR «CUPAi or9 FIR e 1 k " • M NAME 6 PHONE NO. EYES WF GNl HIGXt E «cUPAIION iIRM NAME 6 PHONE N b) ES 7E2N NO q' R, EYES wtc Iflcnr O SI?2 ylE tl J SO ? CHECK (? i : ". .. ??y?J E?_- ` v fNC EAa efMawvffoFprprXf c. ?CHECK(F? EHClfgSgNGAROYFEOFANO IAL v CODES P aii? v v ,,., T+-"v R7? I rnF s NI I e snu pig ,UU. R •_.. Au A i ,°C•< CODES + J a a ' ;'" .cp : s !u IN n L r? . ? ? H p E W s N .rin .E.ar E v los T ?/ P JU..c E ? n R " lwR MAOIpOWF.CM fV 0 F fL?jOMbl.pgVAI VS O la ?CONYI ? FM Nc! Q u?CE ? cblfiq ? v(gKU ? Iq?rvEP "FARe EXfv l MoDEL[DAar NOVA)) r I a, vl E F?/L.? 'I NSGEIC-•A a _ , ' •rtlli O4 UCEN. PEAL N SIAIE IRpIIF4 ftAff NO. StAIF I"I vfH IXOR O 0 a0 4 1 '. ' ?cc6 KC-?`/.a Cu? - I A N . ATE. ( A ViF1 CLpfOtN11NCAlI C X K L vt LE IDfrvI cAN rvN ?? JM -4 fM t ,:T 910151LR(p OWiV(q; IASH. 3 '?y'rv (I45t MIDDI[ pNpNE I,O. ( R[ FktD OWN[R. IA31 fIRSr MDY O Np J , vl.? ApDgt3 77 {1_y . W A ..,? 50F It G wNta -- , N L al N-f a A-L. OF INSLIPANCl CO. CR AG[rvi E t R ?F JC' A// !• R s IN u pN --?? ` + 7 ' I 1 . uAACE .(A to µ. 41N c ON T 1 / 4 v 1 4 rn:«:o"N:41 cnARU °wnml°IN 4/`"AG cHADCf ? VMAO eD Ip _ xf ? DWA`Y ? PI-N(D ? AWAYV ? lit to vpvO! SItDP / TOWED PFMNN[D AAxAGI 1 IOW[D IOUx S w O BO I ( 3I :_ r i I; - - .. I i wr er -,0 [J ? 6Y: ,f DIAGRAM OF COIII$ION: i AWAY I:o1cuE NO.Rrn Y ' - , - ? (EniNee •• p arA99ow DESCRIPTION OF COLLISION ILnL SUVnf ` ` Lyn ? - : u as^ Fn(Nrq $nanr N(assgRr( .. G. L GE- y N7 Rn p?'y? D.t.rv6/f• f'Er-t 4sc.E•E/? '? 1. _, : V 1 I LLi /IS.. 7L.L rLNInJ6 O',r)•7)..._.L /AI/O ._. L . ?? .. d / ? N a '"? S" N I C o6E rvCi?rc rz^ . k '?/?'•; rr / C2:1 7Z) ^ vr TC t Ac v J 4 - . /?2 r s.z ..?Z. 77c?.,.P'?c7-. ,??Ryeo rocrnc?rn? EAR ~t i a E t S tr • YAw p ? _ V cw - PL f V &c r(/ O r At- C@•t/ s - l:: ?' 1 r } _ t \ _ . J. , _....... 7fT , .._.. _ .. ro r ?.. a h • A __..._.-_._.... NAME•ADDRESSBINJURIES OFP ERSONS INVOLVED ;.I } y, 55'' ? ++ E K ? 4 s + 2 OCCUPANTS /WITNESSES IicNR:opuro"`.,u ?°.N!'!i CODES 1 H rv 3 4 5 6 E . )o???'ry? k ?• ? i of ??i"` .?' f?Y 1_. YIH 4 1 Y Aw. PI<u se eF uru5 ,,,, (sIR, eun i gel. Appx114 .. N?IIIYE OI . i x r y`Vf •f { ?? ? ?'. ? NI .1 ?EXIAI O"..0" gr3N? <S t r? n _ r n{ ?,:? ° ?. I **'ryrnnssnr "Mr'• ca..vla - R7 i F ?I Y 1 / 1 1 -'1 lr '7 °t ? 4 1 EXS t 6, 1 T',+ tq 1 ;' y IF I' _ WIUIUII VL'EIIULt L.VLLIDIUN HUVQIVI NO. sqi Hs V COUNTY NO. CITY NO. ? PYn ?N $IE ?IN CITY TORN R Ulf A [. Np VIE OP SINF[t pp 1-7 : []S DW ?OF uilcat? HnpW .1,x[[LDN R,.Ew Hp ON 3 ?DiO 1 s Le n? .IK X y e N[[n y 0;33 'p e ?Guo DFYF e4 eFIRLTN D,ALnp. -DE [a PLO HE EN IRHN Cs pp ° o; 1.1 p D1YD.LIF1? ? EM ? e D e RI. e OBJECT ?Z?? RTflUCK ul P ;.: OWNEROIOBJECTS AME ANDAOORE55 NFIAVJMOCi „:. slfc COpF U;E OTIVEP'S LAST NAME, fRST-HPME, '., .MIDOLE_ IFrw°p"cANe" f DRIVER'S LAST NAME FIRST NAME,?,;. ..• ._,:':: MIODLE,'.- ?/olover_ ?jP S?j e? ?2diZ STISEET ADORE LITE NO AND BO O LDLLIHEll I., B AR 40N1 nuR TRD P . X N .. n 'v1 O G? I[ SOns wfxf INUNEp usEA STREET ADOgE55 _. T . CITY BTATE .,. ., ZIP CODE D1 )u?lcen ?, 837 ONI FN'S LICENSE NO. . .. . . STATE SEX DPI EITSOCCUPATLOII C - DA f B1HT - AGE C nFro..n.... fOxM CITY- ,.,STATE .,. _ ...... ,... ,....... ZIP LODE . ' flIVEfl'SOLLUPATION ,.. . - ,, , o IFIVI" SLICENIENO. ..: .:.:.....: ...?...:. : STATE OgTE OF BIRTH :. AGE, PAY VEINCLE.YR. MANE ICMEV; D000El M'IDEL WOVMDAHTI,. BOD STYLE LIOHJ /97L e VEHICLE YR. MAKE ICNEV;OODGEI-::MODEL (NOVA DARTI:. , BODY STYLE II PRIA ,. .GLrv u LICENS PLATEN -ST E, -:• _71LAILERPLATENO..., ATE VEHICLE IOENTIFICATIONNO.. .. .LICENSE PLAT NO..: STATE.-::. ...TflAILEfl STATE:;;.; . , VEHICLE IOENTIfICA-R, NO.•-.. ... :.;,. .r,_, REGIS EKED OWNEgI AST FIPSTMIDDLEN MEI OPIVEfl'S LICENSE NO, d52, PEGISTEflEDOWNER LLASTFIRSTMIDOLENAMEI - ORIVEq S LICEME'40-?,:. OWNERSADDPESS SSTREET, CITY ANDB TEL. .... - BINTN S V DOPESS... ISTREET.CITYANDSTATEI DATE OF BIgTH : R D• G/ L • &yx PANTS OF VEHICLE DAMAGED y O 10 ^Y P . ._ ,. . 40 0^Y YP. P So {Y g? NvE"I ARTS OF VEHICLE DAMAGED ARTS _.. x A WIN 11 L ?, oe s ??.?. f= $ S- THERE AUTOMOBILE LIABILITY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO.I - COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR .rYES ?NO NAMEf NDA DUETS OFL ABILITY INSURANCE POLICYHOLDER N EOFLgBILITY INSCECOMPANY- te 2 c a, ,, / ( L,l/ , NAML , ANO A(OUE55 OFl BILIT INSUgAN T LIABILITY LIOY NUMBEq ... CITI C 00 IST INNRY: s[ p0IT0 ]NDINJ Y. AGE jkZ ."' NAME TOTA NJURE L NAME ?? .. .. . .. .. O .. NATURES ADDRESS AND NATURE NATURE D M F EXTENT OF INJURIES [ j AN E%TE OF INJURIES ? ? OMINATIO BYNEOUAIUE OOCTOflI e -RIES E%AIN GTAT. ATUSOf INNPFO O GDC TORS MARK FIPSTONE THAT APPLIES __ DID INIUPI[S gEOUIPE AM NATIONDYADOCT FI ER © R NEE P5 ?.. IN VLNICLE O []rA5 ILLED S[v[x[ rn IOR wOisp e Ir^IiOPI rosi PE. C_NRieLF RR STATUS OF INJURED IN VEHICLE 11 DN ? rA ILLED MARK FIRS ISAeLI R-UI r T ONE THAT APPLIE x 1O "lHO s.e II x S ' rossl lF 111 F p PF AR -' HO I . i?rv[tt ? , -6a --?- I, O El SO 6 ? 70 MOTORCYCLE SAFETY: ?TELMETUSED ?HELMETNOTUSED MOTORCYCLE SAFETY; [] HELMET USED ?HELMETNOTUSED SLOW NORTII Y ANPOW INC LF m ^µ H4nx[p ti1R1. IprrW,r ?':MU pR ^ 4 IL.rpR d. ..pro,: ? i -_ DEICfl BEBEL0-HATN,A,P/PENFD: IUEFE R TOVFNICLFSBYNUMDERI ,? /COT ! G1lI fJ -72 _.- - GDa ._ /> /` Dlier_ OCOdIb&_ a. Ue,t seep rrv>l?ianl',m S q -Ir In ?Io , -, ?.- oNI, ,rW.Y 6 _ _ S the bucl` wiv?da? s m cK - -_a?r wlndow;gol? d" -hhe.__ou _{ctr?e ? r i{? wujt.o ro d. elnbclnment / cJ _ _ _ was_so._sk a . ll ar?_.?C1J_..-61ow.1_P?laJbq __Lab_mph o=4G51eI;_ VEHICLES POSITIONS BEF ORE COLLI ION N ie i. ? wi INVEll-1EDBY ll 'NICl1 N S 1 W ON STREET 0PINCIPPAYNALECH 10. Dlxmr cR L NC .u LI D I; xp I I rn xD Y ? ? :ieix ?ioi¢i !'IiDlsq?r?ill?c L,riG ? 2 ? ? B ? roiinR W 1.1 ? ? 11 ? RII ? ? ? ? ALONG --___ . IROM TO , PEDESTRIAN/PEDAL CYCLIST WAS USING: I D ImI" SO ....... I ? w . C] °,""• 1 ? "" . ? 01x1. I ? HE, 1 ?.D ° PEOESTRIAN(PEO AL CYCLIST CLOTHING COLOR; C]. - T?u ,?4 r .0 .......... OY 1 \?,°,' „??'irt'" E C NUAU AUN?ACL rx.T?1 •[I"Ir I D- ME ? F ?wYl r, ? 0 S Ow wFAH.IA IrGn1 CON01TrONS 1 ?D.".GHII yy11 Iq'YE S` y'?}^ f ?DAWH t[] RAINING 1 ?OUSK 1 [] fMOW1NG 1 [] DARKS tOY[II 1xA1HC [ U151r.UL U [ wx.L•VN.r ?I I^ ?EIGNALS ? 1 ?LIOI SIGN ? , ? n11.D LIEN IYf, OF FORD vlx NJ 0^?'pnI rl`r? ONE-AY i ? TWO WAY , N! ERE'.,[ D ? ROAD ORIV EPNI HIL:/',CTrONi ME r.KFipt K.RIN.10r, AAE1 1 11 ? GOING STRAIGHT AHEAD ? 1 ? OVERTAKING AND PASSING [3 1 ? MAKING RIGHT TURN 1 D 1 ?IC 0 RK . ? FOG ST F f ? LILrN. 011EI DTRIR ? 1 ? IIA.PNL FIG ? 1 ? I`" ""GF ? 1 ? MAKING LLIT TURN ? \ ?YECIi?Y \?IfJ1LIIYl . $1.19 0 []oPARK IT\ \ 1 A ? ? L Lwui AMNfA D 1 ? ALLEY ? \ ? MAKINGU TURN ? 1 ? YI r ? . ? R S C 1'y?AY ? C] 1 LI I 1 NN ? . ? SLOWING ? U DrV1Y CNAN _. ,..,. ACIIF ROADRAYW Ctl Pl :•Ir,S,. _ tY. I U CI LA44AN „ .. Ir. .4 .:'t... !:. All S ,,,?,,l ?yi1"P"'?IiJ,IYI?1?'<: 1?q',lTi ????ih?-. . lr -, . ,?•. ^, .,, .I. eur. Na: wm wLD mal fw ya \ ulrr 0 ?N ?E ? x OhOR TOWN Elrq. 11 ip & y Ee ?5 m??.D> I ,ssL Ir 0C `? P i'? Ci, CL` MM OLe HOVIEOn 31 I[LT CODE b'tC1,i , i . e1 . and li. a RO l Dx d se3?o ? _? ( , L ??14 c> L r_'?dr/ 1/L 5 „Di RIGwxE NE PEf. ED DaS:' / •. x E ET N a Ar xa 5 Al AAMDApER?„a NLLE't?i a pDN f,'w?LANa,N P MP ?? ©®° /l.? iEAb[O IOx. f WvOLVEO I M Z OWUSMATEfYAL9 BOM TKWSMXIIIR L I • ? OF VE t5 d ? ? SU.1E0 ? CiE ? R0 E ATE. B ,MHpyVES Q IGiD10 E ? Oµ5 wAL cL9' 0 Wa . O C ,,. , a1 PO,n OGIECT STRUCK _ ?IxNAE Of DDIEOT Ruch OWN R EJECT NAME AND ADDPES9 I nu AEl°ow 0 SPEC,000E wE $ ::I'. , „? ' i e • • • .. If MORE UAw DRIVERS LAST NAME '.• .. .....'..:., :. 11 INST NAM.. .... ..-MIDDLE -C 'R iNAM WERE U 1v01`r9AD OflIVER'S LASTNA ME DOLE ' . - .._ ...• . I'1 I ? Tr1T?3NT VYlatytitl? ?Dw,?;,pR ' STP ET/A OgE$5 -ROUTE NO.MD BOX NO, wPtNnE it ul rvro ??? •;,,. aOxs wEl,E STREET ADDRE99,.. r ._....:..w'. UTE NO:MD00%NO., . : y 9 I . , . . l (? xluxtu usE, r SEP, GI,Y? II9TATLP CODE DwVEfl 9000UP ARON COU ? ltnrC4 U Ol T O ` xM ISOrI CITY ... STATE,...: LP CODE:: OflWER'9000UPAT N .., ? A ( EPpf R ( ?1 Ill r;?i7/ E1l?N, , p7 DRIVER'S UCENS N rfal M , ..::rJ..:.: :.: DATE OF WRTH. . ADE. VEHICLE YR. MAl(E ICHEV;.D000EI ?.MOOEL (NOVMOMTI •.. BODY STYLE I2 CR.1 OHIVER' s UCENSSNO :. STATE: 9E% ; DA .AGE.. VEHICLE YR M . . AKE ICHEY D6 ..MOD 1 OA TI::. .-BODY STYE 12 DR.1 ,. 5 . UCEN5EPLATENO.. PLATEND. ..-STATE.,.:". /I LIC EPLwtE NO.. ::....97ATE ??.,,;.TPAILET PLATE NO.::t;. .•HTATE:...::; VEHTLEIDENHF j TIONNO y-f -.-?1'.. , VEHICLEIOENTIFICATgN PEOI9TER?0 OWNEq lLASTFIRS ?MIOOLE NAMEI ::_., ?.. _-: DRVERS LICENSE NO. ,:.:.. , fit , S??JuI:.L •vl .,. 'gym 5; s• 4 p RE619TF1iED OWNEfl ILASTFIflSTM100tE NAME) :: DRIVEq'S UCENS NO....... .., . a. •.t . . f? GINNER SADDE .. .ISTPEET.Q YAN08TATE1..'.. ,.....DATE FSIgTH.... OWNER'S ADORES9.:.:.:_ ISIN-.CITYAID A -•? ?. PART 90F YE OCLE OAMAOED GL%'Iff rO s, Cam, S Vc, 11 _. ARTS OF VEHICLE DAMAGED .... ...... .. _ mac:;: H , _ $ LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1. WAl rHERE AUTOMOwLE UASIUTY WSURMCE COY TUSE N EFFECT FOR THIS ACCIDE T ON YOUR CAR ES ? NO N E MOADOPE99 OF UASIIRYINS ~ : :' UflMCE POLICY HOLOER n, ` NLAMFOF U1fLUTY IN$1UBA1N\CE COMPMY:_ 'TAT NAMEAr DADDRESSOF U V3IUTY S " ? ,` - . IN EAOEAIi, . ,?,; "Y- HAIL m.. LMONTY POLICY C'x,1 : C4'r1tiTeR ??c,?'rCGkl,US.J?.;J? f .?. : ISTYIJURY: NAME ? L 0 2NOINJURY: : _1-11 ARMERLPa1I OR App IONKINAJWE9 NAME AOE 7" .I ? ADONES9 SEX AGGRESS EX- NATURE I Q O EXTENT OF IrUURIFS TENT F I ?? D INJUfl ES REGUIRE EXTENT OF NJUfl1E9 DI ,p DOCTU R[9P - EXAMINATION IIT AOOCTOPT ? NAMEORS a01NJ EOUIRE DO CfOq'S y : ., ?: W 'AA." 1 A OOOTOR2 S NAM SIANSOF WJUNED : MMKFIRSTCNE T AT SN ` ? E Ay „ , H APPLIES NJUHED. OFI MMKFWSTCN THATAPPUE9:_ '[]p IN VEHICLE 04 O Nau psA Ulrq p0.t -'E STATU ?IA.,. IR NILLED fU [)pN NVCI ICLE A. w0 NON-Al OSS 1 xI 1 KILLED ISEVERG MpE51 iL T O " E n n BO 07 E INNOIP IE 1 ? I 5 ? Pt r, NO. . 07 w?NL1C11 PO ° ? 5? B? U a 1LI MOTORCYCLE SAFETY: ? HELM Er USEb ? HELMETNOTUSED MOTORCYCLE SAFETY: ? HELMET U9E0 ? HELMET NOT USED + ] - '•• :. ;. 3UWNGIIDDY A0WWCRCL 1?{y . \ E CRPC OELOW WH TI1MP - ` nlt , I _.,_0 ___ A ENEDLREFERTOWHICLESOYNUMSCRI MA MIIN teie?. Otl, tT r I a`l? C1;',? ( (?C:Nl \4L1'!l. l\LIV fUI'.d1_. J1 C-44_- lt-U UI\ r.`1 « 9?P.NL x w 1;?.. ,?. 1 - 111 Ij:_ lv -?rT fJ4LG_.. l t'?(-! \fIr M,wwl t¢rI rEmaE Ax5 vlow Y• I •.• ( I )' I l1 \ . _ r ?, T roxpIH,WL•4R,pw <, , • a y? ??' Y\ Z(TC'h1 !? ???SGIyQ°iV nllCl I - y i LL ? I c•1?1 d C 1 t ?a V ? , ? Il ? L ?q ? A? y / CT ! j krz __ _ _ _ .-•vd g 4 It ?ll?\ ?? <1Rv1? \'Ll\ V,(•71J,?1'V \?--c-. _?' lr 1 ? I CI H?? (11 ? L T ` p J j , L Ll yc l?J ?.) \??1 ?4Y? i H nNtnoRwrol! ` ?!illl?s? V? P. I s r r ? It -? (111 Ilf/A!(1S? ?(\?:C?l C'1`7 61'it' fdlr 1 Aa( tl l'? U l ( 'XrJ T X 4 _ , VEHICLESPOSITIONS BEFORE COLLISION r l .AEpw,e wvesraATEODr EH LE0 ROIE 4LV 01,r,lv,O 0 A E ,AEG N ! E W W E IKL OCCLS tO r?1 y4 1 ITPEET ON HIGHWAY NAME OR 1. p,,,Of,?y, Oln€t O r O A. S x0 ? IWL ? 1 1 ) , ?TL, npW ? ? ? ( ? R1 ' ;y,^I h4 . /T ?,? ? ,..0.: ?? ?O, _..?....z.? ? OuCt I.11 a6110N br. h AT".., ? ? El ? B t f r ] Ai 1 ? ? IL'lJ ? ? C] -? r { I}a?' 'Y i' `f ? ? KONG mom DIRECTION..ro 01RECT10N EDESTRIAN/PEDAL CYCLIST WAS USING: 10-.A'! A?w4 e?•rwwul l r?ir? a?c,,., ?_- I? 1 i + N •?roww.r Nelaul d 1 :'A ISr', !} 'kDES11ilAN/PEDAL CYCLIST CLOMWO COLOR: 1?o.AA 2?wrn a?M 1?NnwruruelNE e? r tO ? 1 ! r } k yJ' M1'T ++ a f•.lfc F*ADSuowc VA TNER ., lXrrli GpIg11011l IRAf 11C C0e1R 104 VH.G«YPE Of HOAO ECXp,! '. . DIiIVCR VEI CIE ACT10N9. CnC.I wI CI .• r ,t:e K"EC, Or.II 1 .f 1 DAYIX:ni w i? LIro a yf _ cnrcAaNL al uoxG ?Jon, 1 ?OAA .-M, 1 Z ? OANN ? I ? SDI [-3/, r ? IONC W?4Ont1 O ODING DTRAIGHT AHEAD ? RA.rNq 7 ? pUSX ? 2 ? SICw f+(4N ? 2 ? I WO WAY f ? I c) o.P, KING AND PASSING 1 U 1 L.1 WAq 1 ?IW I LXI T'1 ?DRNIIS SI ON NLET C3 D ? Y No. [3 2 C] MAKING RIGHT TURN J tr. l?'•`t F? L ?,L(yCV r90f fLT ? 1 ? fLASIPNG C] A5rI N0 f1lR G ? REV[RLOLE NTCHCHANGF 5 f ?7JJi 1 I ?ICE ! Olr 'A Ey ? 1 ? L ? 1 C) MAKING LEFT TURN D R NO 1 MIrrRAMPI . y • ? ? ! ' , L d y y ? ST `YJ I5f tGNI ? ltAS1 HG AMHI T Lq j ll E3 ! ? c) ALLE ? E (j MAKING U-TURN ! UtiGIY R T 7 . CR A TW9 WAY 1 y, r ?, i ?4fa1'•A ? ! ? wl lKY.K ? E ? LLII TIAIN ? ! ? SLOWING ?, ? ,? VLOHIWAY CHMACTCiI ROADWAY FNIP A I LNVES J ' 1 p At f ?L ` 1 'rdt? 1 rl S'(' . t t ? ] ? Ofi Kf Ni«A(:MU! n I ? aUVEWAY ? 1 ? P10PPE0 POT TMIFIG ??1?mnue 1??? e II ?If (•l ? ?GTnfR .TEL OPP fD if1011A 1 P I t S ` ,y ? 1 IIOM lE MAIKXI ? • L) On LT On bRN y / e M ?., I. :''t .e MY, E: POLICE TRAFFIC COLLISION REPORT ,IJ IRAFFICWAV ?? 101 ICE COMPIAMI NUMBER PRIVATE WAV '. r21 }} DAIE,OF C9lll;,,.BN, Nu w0 Vwv tIMF COUNTY d? I "let vH:??a- I.?I?,H-tl.?. I?fSEya)_NO?uR, .--V'y.T•ri-1s,_11? I ` ?3 - v COUNTY NO, city NCI fMWA, ?• IOWN N -L NNpO .1 SINf[IORNIGMway 1?9 ?E ?IN CIITOR . • c) A41F5 ?5 w ?OF QUlke4SUE ON LIpB nrN INIENSEClINGWRIH; EIT ROAD NON I1411-C1ION CLS M ROUIEONSI EE SE ION. 3 .3F/68o - / 11'' {?1? BEIWEF ?f 9Lf1•,_J.JYce RZ, SiREfI DISIANCE8D19 I FROM RE EN PR Y f0 ry>5! ©e VrB M TI ?A E .CRWO. 55 STREET OR NFARfSTMILE PO51 ACCIDENT 5 FEET OF ,(.Z- GFNTER MCODE E RM,P UIn04 , COUI5RDN INVIXVfO: VE9IIYI //?? TOTAL NO. NO. %IllEO NO.11,12D?/ ?; LL., ?NE?k{RUN wEwipv(oir, OF VEHICLES ED ?PROP[RTYDAMAOf ONLY ?FFSU ? LM ' 3 • INIIF' C15. COSSSIRFp(10 NROIbk FOnL OR fI+CF-. ? 22 liEO • FNI C OBIECl51RLK%(NAMEOFOOBIEC151RUC%ANDOWNERSNMAFI R f51 . 0 AMAGE /Vj?S? SPECIAL CGJi?vG IGE i" , , n IST Vl I Y1 T $ k _ 3 - ,. UNIT NO. I .DRIVER'S NNAE: V,St Iq 1 MIDDLE UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ' A 7-A DNIVfR SNANE: SI E - SIRfEIADDRF53 51REf1 ADOR[SS ° 35d1LL5 12D, CITY SIAIE D 21P CODE PONE i r` tw O 6 R II SIAIE IP CO Y NIN . DkrvIR'S UCENSEN AN F:t MO E RITH Ip4Q, / GJ I V IVER' IICENSENO. AIE % DAIEd BIRTH D Av). AY IYR. .. B OCCUPATION F- NAME 6pMONF O. EYES WI IGHi H:GHi MEMP E OCCUPANON FIRM N- PHONE NO. EYES WEIGNI NEIGNi „ - , R ? CHECK (,I ' VEHICLEAS AN rMPior EaFAAMioIHlaAI * Nl ? CHECK (") N nER Ix FNIRE aS AN EMMO_ OFA IMFR D ? 2 C ODES ? D n 4 i s r y oxr ,E<tIw i s vslim . CODES ? ,vG. * s Ass 4 it iMwl 5 In uoN eEry rcu / ,'Si I nelfs .-I! 3 nH Irenq ee ? MIC, ? c8:il. ? vi z, L] IvAN:r NAAE ( f CNFV.) MODEL IDANi.WVal SITLE I]OR CONV 9' ? AM s<r C] u;:n. ? .° w°A ".Y:,sP. I` ? ID . .1 6a cq EV CO2(1Af2 `J!W E N FAN ( F NfV.I ., NODFL IDa9tNOVAI Y (20R: pJ . SE YLAI -E -MIL PLATE NO. VAN H VEH. OIOR A ° 37 W - - I N. AI IHICLEIDENIIFICAI-NO. 3Q 121GIS 05 7 T& 1 C L VEHICLE IDENII I I I 1 1 RLG151[9LDOW (4 ! I I V I I I I l l l l i N? :?!'' N[S?t C A9MIDDLE "ONE NO 1/4c ?-J iJ FDV? O R -11FFD W-: L 51 FIRS! MlpLµf H NE u ADOR[ssd owNLa W A WNLq BI - ante AS 'DQt0GR_ N E I N-A004E530f INSURANCE CO. OR AG[Nt •UMSU-RNA--?? C(, w DAMAO[D AREA SAl1ND I - R . rFDA owl:oucE CHAR. 12 WT- c oiMi o p AMAGfO AEw 3 A 3 15?1.,(DPN,AYA1G[ ? OVty REMAINED IOWLO • ?AWAy ?REMAINED A E51, DAMAGE E flop M 3 $ IMh. ? AWAY BY 1 C] TOWED VBY; $ 10 ?01iO Ie DIAGRAM OF COlL1510N I u .u INDBrC E O M 1 :- - SH[fln N[ s5Aar1 A91i'ow I/l I ? ? ? ..[ ? (fin'. ??+ 1. ? /?,? j t 1 ? S I ( DESCRIPTION OF COLUSION: (usESwn[AaNru SHEfnFNECI55A9r G 1 t•Isti1 ? uF.H was .Ir%r C?17._©N DA?g RD G'?p,.?F?. CFII}lG g2DUI?D A 4bF"% C,u2r.C co,unuLAeD uftd116v? 'I+? , I 3 {q U A? F APPX• sv Fr, AOD. TT•IGV_wei oNTa_7R0 SK0u&D0Z, 0 „ . .. ; .' FiuAl IWO 4 M AIWA 4WA)G A_OPWAAACe 017-64 !3o rr, frl7rtnc A 712E 6lUNPP mYviiuc i}pcret» ?j - - _-- 4VIO F?/P7 UE G/F QUIY)(1 /TS 7Or? q/?Cl E J C SB ?Jr 3U . / . 6W/N6._ ?'f 'C'/? llP?•4?Nr /1 U0 C , i , OAUs7AY//? O•U ,gq?/,tJ,q/LpS Fro 1 D? r y1 I A /..1? L/l1RS9i,F'C'/hE.UI'flU07llER 8 F7' lAG co .cJ S AS' 0 • 1 Y 41 W rj cc1ZDour. r ,Cuu-WRlaL 61 ??ht57 14 NAME, ADDRESS 81N 11 RIFS OF PERSONS INVOLVED F CODES 1 2 3 OCCUPANTS/WITNESSES IUSf SUPRIeVNIAI UHII Id ADDII ONA NA 1 _. A - -RAr. 4 5 6 4 5 6 N I l M 51 AAy SI AGI UN5 M W I i A iua DDk S ( MAU?S CIE ' I N E , (,(_ Q? Lm,a l pIt wIw .nn er AM e ?E21`E ? "' . N ?.^. ? A N (%N $ AME • Gf d " ? ? I , VOV10 F40M ? ? ra nR y ,D u _. 4vrs No ° A d - - W yNO H U? ? u1Ni eY ?AMe. ? X hStq ?I a1 yAW {4NV r. wID KT? O p MD pUK INp DAIId RIgv N µ t IOINE ??a:n. ?Li+ ?"IT , APPkOVED IY DAII [i? I l { ? v gtGIW?3 ?1`{M;T _'?ty?'2AIR S 1?9E1?.Y.?Vih i .? t? rlV 1' ,.>?. ;IV1 , t I, .' rt .? ,tr T.. . ? ?} tVfy'{is • 1A tl ` (i 1 I ( s E I ,rI??3T? ? I L I ' ? . T Fati !! T, .;r I ? ' % r n l ' li 9 W sue' 49 tl 41 A Ir., I \,Y POLICE TRAFFIr rnn rangF ° 'nY TGAFnrulev P 1 Of-US PRIVATE WAY P r c oN .w "Al nMH C.-Y ? •, couNrrNO. cnr NO. Q r.f? Rxi I• 41. iDr. IUSF Nro OURI ?IFFEi N /? PU OA N X E Lj IN CItYORfOWN gMfe NO. U-IIIIOR HIGHWAY 1CICls 4 5 " p RURa I /!x?? ? /? 1 , r ROUT>f O451Rff . MIf5 [(S ROE `Yl liE+l.e G ION y V?7J Q 1l lRS Ct NG NaI SIN(ft RNOAO NON NIFRSf[f1 0 N ' SECT ON pRffl% F0. MiIE WST F ? /?? ' BEIWLEN C{` IS SiREO 6 SMEE1 ev pSIANCLeU <IION lkOMU FtNCt.CROSSSIRIfIOR NEAREST MITE VOSI ACCIOENI RAMP W DIAGRAMMIA 11 5 E i[EI ?- GEti7C/{ /QD MILEAGE Fl Of (?` CODE , COII SpNINVIXVFU Sr V [ IY tofgl NO © NO KIIFD- N0 IN1URfp ?• ?SVIILAGE ?IR&RUN ? LIFT N rN 0 NENSE 111 S(RCOOR ROAD04 RflERENCE a VN CIfS lI'llw CIS CROSSSIRtEfO RIIOAL 9RORRIY DAMAGE ON IY 0 pl$III D yyFl?ICIE [? UCK INAmEOF0 01[ ?. OO1tCI SIN CI STRUCK PNOOWN[R'S NAMEI fSI DNAAGF SRC AI CODING IGE -' ?- s UNIT NO. I ' p4 vfx sham -1 , f UNIT NO, Z ? VEHICLE " ? %E STRIAN ?.PEDALCYCLIST DRyERSNAMt 1: Mo Gtv IADp4I,5 A13 ?- : I ISTRAIrob ST2FPkp rl1 '- 59 CIY - SIRIIIADURISS MILI..C BA ?'D SIAIF )1P COpf ONE NO D C??u11.0 tJ? Q 37? 732 4058 R ` x .'PA SIAIE C Of HONE lLl Z IAA 370 5363 q I2 SIAIF E% EU RI I ( 4,o VI4 C nIU2G?L93BMZ Gt14 M 7 C' I ENSENO. -E f% pAlF OiO IH _ OCP ON 15775 G !37 ??+ M or?7Sy E...... N4I IF I-N1 E u OCUppI O N 1111 N-1O PHONE NO 1E J .^ O `?"? mr^^• • ".D Ilh I QC f 5•1o R ? n )??1? i'- /y EYES WEIGHT MGHi l'1 I? 1 - CHECK rH of Ai nN rlPinvfi of OINf4A prl . o .0 CHECK (?J A CODES d D n 5 I IH CIE ASgN EMPlorrr NO CODES D * ia Em 5 s cl % ? s E Dtp ., N t e sNOA 1 11 ;:« , p1 Ao _ ? u ? "s,rlx o c r ;; ? I? 41 N.- S Y F -) " ?` , D o mD„A«c ; Y? ' y v u 0 ".Z! ? rR. ? 8g:'I. ` l J) J TYLE p OR CON /U 1C I 1 `W f G M ?/ ?z T E ? 7 lr+. UE04 ICINSEPUIFN SIAIE , j I . H[v l ?, moon ID I VA1 YIl D°. v.l U i/2 Il 14A lE4ftAlf NO. SIAIE H tai I (o9G33 Wa - - I yt II ,. [?GR?? _7 !44 CMQk) c /l 7 '.1 Al N . AE E EAa -' - VUPCIf IU( NIIIf Al - . NO. C ? [ •" N4UL1D[NIp1 AI ? + l 5 0 211-L? 2? FIRST 6, L ) RIG15114{U DwNf 4. 1POIf ON[NO USI 1451 F77E1= 5 1wi :P15.11 Z1 4 1 1511 PlOO ' S,4VtitG AS °Df2ifJEl?- x:11 ApORI SS Ca DWNIR ?W . W EN'. lAsl {IPSI MUDIL EN , ?"?"" PH H ?/ SAm? E N-A.L)F--NFA14ANl(C° CR GINI ` E S p NFN A^I`-" . Yrn }?i.74 GU- R L p N ? s ES S ESL rONAAGI ep CHANX MANGE ? f IN ?REMAMfD Llr p - V uSAI D-EfI G pA _` `.,! 4. IDEAL S ? r I AWAY 4rVU! LJ 4(MNNFD W 6d:° ?T DR ' ° FSI DAMAGE oeorE04 ?E I ° DIAGRAM Of COltIS10N: w .I? IUE I!?. ,°1?: BY 'S lu n.D+ c, 1 - -11 $ 3dD0 '?. ^ ?. -RO W 510 1 Il NfCESU 4 Y) DESCRIFIDUNOFCOLUSION; (USE SUPPLIMENIM SNiv If NFC-A4r) I tl AOW Y 1? `y a , S ?-Ot U6itlCli5S APPROAgte r-'ACR 67T4IFP- MUD- CaLI ?v Cite 4UinP ) P C A = 5, , ? I J Me ZAD IJCI7l{E2 C ? '? Gt;I0@Z DUO ?- Ct F AT WAS C0111 Y - F u L m _ r "? , BC-uj.-<e - 7ttL" S CC ` 1 g _ GPNG55 C) F TFCE WUM P. C' uslolo P ylr f< r '72e AeE SUG'N ?y U ~ F? ? ? c T A aQJlloi ?- ? F. i 7TE AeZ? ,ps G CC? T -E /Z /5 /I p ' -' - C / . C) / F,"I L ld/7!T " •? ,. ? "` l -, NcJ C'CNTE2J/JEb'17 4C) l -hl ??! 6ZWj2 ? y TO Z'714. WIP-1V C= 7T-!E RT de c /c I NAME, ADDRESS 8INJURIES OF PERSSINVOLVED CODES 1 ^ 2 J 4 5 6 1 OCCUPANTS/ WITNESSES """'nnrnAl a + +„ DDrrn% M N,ISI n r ??'? :IK ncr ums 'N it ? N ? 4f51R. rnCl I c,. "! f'lCNARD 11 i' ^ At''_tltl so f1NV?.QJ?d24G?K,ldf?8339 I "°' , A A1tl 'r N' NC1 c o aAI c,.+ o _ ? o w:T r.J,y - r -- m, _??-•-?'-' -_ q:'II` 101 ? ?. N` fr f• ?rr T.«,vIFF. r,I - wlcfn A:lr,cr +ri'wi ev ?•1e '."?C:? l]i? nn n11 x ^."PF Ka F? p unNa Nroll ;' I L ?s 50? ? AProonD er DnN P ur O k4 'y I 'IF J ? t'P 4 P E ' ?+ I . ? ., t 11 ? 4 ' I y? 1:KI r ??( ? H1 , L atwl ,r `' h F l I r h I t + J fE L(? _ } I to ? ?k t 8 ourriLtMtrv I ANY F'ULICE TRAFFIC COLLISION REPORT PAGE Z OF z IDENTIFICATION_ OF COLLISION '""ICASE NO. SEVERITY OF COLLISION ? FATALITY ? INJURY N-PROPERTY DAMAGE ONLY I - DATE OF MO. DAY ' YR. I 'COUNfY CITY___ STREET R/O?AD?-N.^UMBER OH NAME - ' COl11SION 03 /QO/U3JOCATION y1Wa?Cr ]T.-...Q?N .-/.f'll?.?,l?/_41?.•. K[!I'_t? NAME _..:._. NAME RIVERS NAME _ NU MORGER VS STEP41ZiJ W [ST2APP VS IUSL FOR AD011IONAI INFORMATION WHEN SPA DESCRIPTION OF COLLISION... IS NOT ADEQUATE ON ORIGINAL REPORT Ok AS A SUPPLEMENTARY INFORMATION SHEET TO CORRECT DRIVER'S NAME, OCCUPANT ' LOCATION OR ANY DATA NOT KNOWN AT THE TIME THE ORIGINAL REPORT WAS COMPLEIED.I G7NiJlNG 'OF. ME SkID?AIJD..?11.. JRIPACT?.I'75.. /2LGL/.T__.Cc1!IEE?S. ?cJ.E2G 5_?BrK FRCVS') 77lE. 0AD_ sx1cu1DER-_. E..DENS/,DE..._i?...??!1T?5/oE-_?7/ [f?l4TrL__UJAS- 00 ueH. 2 , TOrawuG_ r 2'2 "• _UF,.?I_#.1__k,=FTJo_sKLRmARK---- A?JD GJAS STANDIti?C7.. WUCr` ._ 7r4s..IC»pracT_-_c R)G61T_ 00WEELS b)E2 ..) 5_"__F 01Y1._...ZGI -._T201?D.__ l0(1LDER._LVl_Z I.A C`XlT51DE t:IRC.. CA R. ?74PAc.T)w1v2 __/ _ q A_ ST__sKLD_A'T.__2oMPr-l_T?Ra D- A7J_S'_v SKIOr» RK.._-T l _-1 f 2_S ED_la?Y?IT...a.S._? )._MP_.N. 7Et ___. VRIOER, OF M H -I"._I'.AOD__Wls PA55ENc,?.2__STA7ED---vim ?2_w1?5_ ?U?!-N G?. TCn CAST. S.I O _- . #2._?RlUE2_ST13 R_FIE/?AS_ //. 4_M.PF{, 7_ -PRO QF=1 I SID_ N AS FPO ), K AUD WA- SAS FAR RIGHT AS T6550-e, DRIVER/PEDESTRIAN. NAME ENFORCEMENT ACTION SORRIETY . HAD SEEN DRINKING (OIECKI CHARGE CITATION NO IY - -o L o F-A9m?r ;?? '(?th'd . 1?+tla2ei+?rs I ' h Vht2???AXavlA RCW 4G • 2D.1WCEs.Etl?o?nW. ..._._ fZ( lt? QUO . ?c { • by t S.WfESIRAMD !WeEsi'IGegir'DIZli I . __._ ? _ .._.._ ._ .! ? I y .._? _ ? DIAGRAM OF COLLISION GR f SC ' OKAY! DIA AM O COLLISION ENE IN REASONABLE PROIONIIONS. PkO,ti1lV 111fN IIFV Vf IIICI[S AND HIGHWAYS. SHOW f ? I I \t- fib 1- - 3 I I ` 'T ?? r . SKID I MARK '-? S AN ? 71 D OTH I ER MFASURE MENTS. If _F I— - - I I I I L..? ??. I. ? I ? i I I T IrA T, •`/ -.LYS r?AMl AND NA?N(}J? LNUCd NO AC-.IYI-X?'.]Y UNHiDISl. Ul 1. P 71 I PROVE 7 DY I OAIE 01 111 091 LOA ;c'"G 1 air, P? t? ?F , .x ??. b+Y ? s• ? i ?t1 '`rr 3,,,? ?rr•."i .,Ci.?? ? x ? ,., r f? F 5i n' t Ya c v N O O, O J i i t a ? I ! ??? qr fr. = r YI Y i ;?} ? ti3 w e I v' ! u).Ya . '•. POLICE TRAFFIC COLLISION REPORT TRAFfICVJAY RU. F ,, PRIVATE WAY -' ] 0 7= Im, 0 EOi N COUNTY ? .. POLICE COMPWNi NUMDf9 ? T I??L % L /• I Q ?[ o. lu i lu IN'IyN TU I .. ILL SE 1bD1N'OVRJ COUNTY NO CITY NO. iMWA BAN ?U . ' NAME&NO.0f S1Rf.l ORMIGHWAY C3. QE ?IN (('•?' CITY OR TOWN f AL'm OS OW ?0, ` Va L ' ON `,"I/lC titi t V?LC C { U fRCtS RAL I ROUT 04518 $F pN -1 . ? a INIFRSECIING KITH: S1Rfft I9AD NON IMLN6{QION \ ` PRfpl%. E MITE POyi .. T' BEIWEFN I GA Cam' si4EEid 'F1 YMI:vIASTREEi D151,W E DIR I / // ?J (/tiyO (: •\` LEI I MRf RE CR05551RfE RNFAR IM f ACCIDENT [ W MILEAGE 7j CU FEET CODE of l-?1.i 10.?'Z' COll15pNINIXVfD VER I OA RMA DATA. : I YI vU51N TOTAL NO. NO.%ILUD_?NO.INJURED_ OSPILWGE O HI d UN wrv4atO1H CF VFHIUfS XRD IN R NCf IMEe CU CROS551REET0 R fi ROAD dfR T C PROPERTY OAMAGEONIY ? RESULIfD ? fH OB E L9_ oi7 ' . I C15tRLC%INAMf Of OBJFRSiPIIC%NfD OWNER'S NAME) EEI.DPMAGF o SPECIAL CODING IA. -'- S s q "UNIT NO.I ? IA51 IR •UNIT NO. 2' ' Q VEHICLE PEDESTRIAN Q O PEDALCYCLIST 2. _ f?l 1,?? IBC, Il V? DR.IR S NAM.: -1 I f ... L la DDaEss / J C ?? REfr ADORfss L , . UlY SIAIf D ZIPCODE PHONE NO. h }iI YL C ? 6 ti'C?LUg WER'SUCENSEN V I R IIY SIA1E IP PHq A E IJ( BI4N I IV ' U NSFNO. All E% DAIEOF BIRIM q OCCUPATION IIRMNAMEI-ENO, EYES GHi MFICNt E CUPAUON FIRM NAMEb pIpNE NO Z ':],? - l% •1 L'V\ •DL R . EYES WFIGryI IEIGHi Q CHECK (.?.. vlHl TEA A '6-oiAN 1HIa. + r ? CHECK (,I ' VFMIC[E ws aN fMNOYFf 1 R?L ipM R CODES1 D nAss 1 L Sr 5 [ B ryn=r4L s`' JwIwH ?' Oi ANO + HF NMN1 CODES ? D o 4 i ' ,elf :ii '^D 5 ? ? JuRIDS ??Ti? tii. - U o i [ ie e%erorv D s ,, . r 1 ? • R[ O anlR Q „YAi[ ? ray ? VEH. YFAR ^ f(OODG[{MfV.I ft IDMI•NOVAJ LE (204.-,I STY u„a Q M4MAMEf Q '..6" ? sm. ? H?K? ,. .1 Y HEY,) ?M? AgOfI IDMIVA) Y (T V. / _ U 1S ,c.k ?ti? >L C.Ov z--. E . ll U 51M tRAIIER RAit NO. IA H I A 10 113 HKl[I MIFICAIroN NO. ?I.='?' 17! -ila iC,ll I? `1 ? ? ?- ? I I I C' L. VtHICIE IDlN IN I N I I I I I I I Z . [GISRREDOWNfR: LAST {1451 MlDgf PHONE NO e I I I I I I ? ? ? [ . 'I IJ. PIN 1's •? O WNfR: 1A51 FIRST MI D- H f A ONN[P w WNF ?Yl?"L t= 4? S 1> i'L N NAM[bnoDRtS10f INwRANC[CO C4IAENt E DAMAOl "IA . T ?a'wiI4MDiM CHMGE ?• IIsAarrvD AMAGf MG a 4 HAt ,[oi CHMG[ C r , 10 ?ORO? L [St. DAAUGI, ? AWAY UR[MNN[p Off [ 110. I OgIVEN ?R[MAINFD IS.O I 1f V•? TI, 1 . '.' ? 1Oµ D AWAY 0 M S',A L To AWAYBY A 0 BV E DIAGRAM Of COIIISION IIu N RO BYAP NW DESCRIPTION OF COLLISION EUS[SU-!A NTAIswyma&LAR ) SR[[I FNEQSSARYI bYA4 - _ N kt `" ...I Qi_ V b LA? 1. r\•'S 1V 1?.1n? lo.L \vLLc:. ? ?i I f"'.a--1--t`r `i'?--i-Ht-t-f-H-'?-H-1' 1:1 L • ? ? ? ; \t c ? •? ? , ? , ?.t? L h, , , t I I? \r d t 1 1 l f l ? _l\? t? , i '° ? v \? < ? ' r .. . I 1 . 4.I. J1I.17 I ..r ?'\C .. •a?a:) ,1 C (LI i?J ?? C) 13LC I . SB S_J r NAME, ADDRESS 8 INJURIES OF PERSONS 2 INVOLVED + CODES 1 Alsw OCCUPANTS WITNESSES Iln[SUf _ FOR DDIIpf n _ _ - 2 " 3 4 5 6 H A UI NAM MLL: TSI Y Sf% AG[ TAiLJ rh UAi I P I• [SII. ego Itr a Ir ev r "....._ N wM NAruR or Y. AM L. ?[RI I ? I. "' . OpIY i' 3:,L. ? Al N IM155 NAI 0 d .'-• .......... ..... 4 MOVI4IR ?AMI. Q,MKIOw [0 MY ?i[0 p .... A AB MI\f 101gROpfAi R'ShAA4L ' ?SS N a. .._I. M ?AM,. ?Ci ?dYlf?iY C] a A ,n .... ??LO? ...» i t E j 1 1 r ] ,T) R 1y yl 4, ? I ' r? i? 5 r ;1 {, ,1 7 I I l ? ? I ? _. I y t![ p i t la I .;, i'. fir All .. Aa a r,*t >•.?u«'?ju.v, w+ '. v 5.1.}'!itl/v »< Nc,7?+Ra? ft .1141!'i f• r NatfaF!' ':V k ? a s I ti r_rH' - E -dh I T/ P??A9 r- I E i ?(?? d" r '?Y.. ? Y I l ? 1 Ilil ya lT? ??Y .?w!. E5' ? iE Y(E M1 Y a.9 e : I ? n?lyyk £ r t 1 ^ti I f 4 I ? a? y?n r { N ;I A 9sS II.?y'T ?? ? ;1 C w(I?? k? ?HI SI?r?i h k iy I0 Y ®TRAFFIC wo. WAY POLICE TRAFFIC COLLISION REPORT pOpCECOMPEAINTNUM&R PRIVATE WAY l30/,30?J 1 sl O{lI mw.I ".N r is Iiz' TIME COUNTY EusED.DDN?I FF ui0 COUNTYNO. / lP CIYNO. ?ueAN uau ?N ?E ?IN CtY 0910WN NN.IEONO.Of SIRlFi OR HIGHWAY MLFS ?S ?w ?Df !!/,[,GENE ONLTn/6E.2 [a?6F.CRc (CT US M RWtEOR PFE 3 Sf N INIERSFCIING WIIII; 51RFEi AD NON IN1Fg5FC110N eETVfEN `- • STIEEI a sIRfET pgffl% E0. MILE PoSi !? ?'- D151ANE110MII N pfiERFN pO5251RfEi OR NEAPESiMIIE 51 S W ACCIDENT MILEAGE RAMP DIAGRAM MIA - FEET OF Q CODE COLIISgNINVOIVfD: fVFRIEY: l IOTMNO. NO.NILIED_NO.INIURED_ ? SPRLAGE ? a %.RD IMEa C15 R I tRf R AOOR REFER NCE CROSS SIREE/OR ROAD. ss - OfVENIClFS m PROPERTY DAMAGE ONLY ? 1.1,16 D tFVfHiCIE S? /0? _?_ 001FCi 51RUC%(NAME QF'A?JT? ytjANDOWNER'SNAMEI: fsI. DAMAGE = °Q SPLOALCOOINGLAE _ E1 FEJLSON f=C)?'1D .1?.."I?i. FEn/G•E $ (op UNIT NO. I UNIT NO.2' ? VEHICLE - ? PEDESTRIAN ? PEDALCYCLIST sA DRIVf9'S NAME: USi fIp51 MI OL RIVfR'SNMAf: UST I E 0 Z ]19Lf1A00f : pEIApORE55 7m UIY SIAif zIPm. PHONE NO. D c IIY 5-1 N +. R t DRrvER'S IICENSEN SIAIE % MO . DAYIiN Y ( V IV LI N ENO. AIE % I _I IEDA1'OIR N YI, e OCCUp/:IION FIRM NMAE E PHONE NO. EYES IGNI HFIGNi E OCCUPATION F IRM NAMEe PHONE NO. EYES WfIGNi fEIGNT _ R ? CHECK (? FH:RF AS A"NOnAOYEF OF ANOMFR.AL C' CHECK (? . VEHICLE ASAN EMPLOYEE Of AN0INFR CODES?+ D 6 A v5 5 1 a's'A° CODES ?* O u A i 5 IlICTION O 5 3n RlES ? AM]MM,RI ? N e l ?'"AL- ? „?U ? rv.1- ? AM,M ' ? WE ? W6. ? „a2D ? r. N. wl.YEAR fMAE IDODGf{HfV.) DEl (DA91-NWAI StYIE IR DR .<ONV.I ( NEV.) G EI/ e_ 6H- d E U PI S1AtF MfE NO 1 SiAI F V B?3 Z/ I i IDEN1I t aEG15hPtD OWNER: {M1. "IsT MIDDI[ PHONE NO. EA ,4 1G r F}- - O W 151 D WN[R: VSi fIR]T MI DLE N NO. ODRES O OWN S ER ADDRESS OF OWNER I ?a/ "f ' . /. ?GvNCENJJ N E . -1.AWNa OINRJ- cO.qaA?I ENr R6e-7- l?}FCtlf?A?4 R SRIf+SD4?F2i [G m N Vler,/G - DAZA ARU A ' DAA-I AMAG10ARfA V "iOHN cNA90 g '" eIOP OI:AV PVCI CHARGE - OovcE • 1 4 DNAAGt , flOP S !--? IU e0110? > tll. DAMAaO ? D-IN ?a[MNN[D ?AWAY L,JRFAIAINFD t5t, tEiorto+ f °w:vDeY Z A/ D S 70 ? AWAY BY, 0 Of COLLISION lu Al INDCANNORIN DESCRIPTIONOFCOLLISION ILRESLNPLfWNUISHEETIFN[CE5-rI DIAGRAM .. SIUEI N[ [SSARYI I eYANEOW .. qq Aow ArIL4 VG'l. (? ._.. . _.._ ._ .. ty .JJY'c'LU?,C -..QiSfi/.OC/SCr GO!^/a._!4't" t4 . ?il'oNq 4C b ILI.. r I ,.. FELA:[?C!/. .RA-i E /LOST' .GdN77?OC.- oZ ?GtR T4 - _ '. :' ".Sf!Ec'T- %7rE aDL?L!!E/Z_.. tali}-S.F__iA'?L •' // A f C>Cck1-?,9vTS 4-YI!,/6-..M _-.vi_E Y ._._ >a rro1'y I , NAME, ADDRESS & INJURIES OF PERSONS INVOLVED + CODES 1 - Z J < 5 6 OCCUPANTS/ WITNESSES (ra wDiius.v «f si -stx AGi iems '",,;,F" °i _ wI 91sn. urn Y' .. NAMC c_ A21 STY . r- /?•a t T/¢a .. '0 .. o d r 4 -^ ADOfFSf 130 y d J ? JTJ U/ Nll: N . NAlloe OI . -........... FPO V. ? AM e. ? c?I[l ? IVU. v ? D ? W." r. "MI A7XIC/4 OvIER ?t 4?k . L ADD911f /01 f N " .. AT E OF . .. ..-....._....._.. R p19 ?fwle. ?faKl ?MU. ? W' ?,iiulf M AMI: n f10 ADOeleS NA/NrOI.. INMItS O O u 1- IN eY AMe. . O«,r :7n' ?.:°. wV/S1pA1wG pIKIe INAMIe9ANR eADOIq AGINCr 1C:pA1CMD FOLKI AOaIVID DAll Of algRl w?90SV'10 eY DAIf ?? crnr?c na ?nincui?reYE•'?wr e.?. ,.. I,F POLICE TRAFFIC COLLISION REPORT K?RAFHCwAY Y U. IOIICECOMnaNI NUMBER C] PRIVATE WAY 1 ?I .0 DAII OEC.IIS N U I N -. "I x IUSEW_DHOUR) ?;,Y1 county l? • G - : CCtb.I '1 COUNTY NO. Orv NO. fHWA ?UU AN RaL ' ON ?, ®IN CIIT OR TOWN ,./ NPME6NO.OE STREET ORHGNWAY MILES ? 5 ?w OE .I CL. Y 1,50-1O N 1 t ,, i•: r- 5r. ICICLS j AOM. ROUT 3 SfC110N 1' INIFRSECIINO WIlH: STREET NON NIERSfCrION E-EfN s1RFf1fl 51REET FRffl% f0. M IlE YO51 ^ .? J D•D? l DISTAN f60 RtCll R REFER SS St9fE1 RNEARfSIM IE _S MLFS W 0 C, OF I.? i.r.Y?F li . ill ACCIDENT MILEAGE CODE RAMR OIAGRAMWIA ' REIOR OD R- CE i?5 COll150NINVOIVFD: fR TY, IOIAL NO. NO KtEED_NO. INJURED- ?SPBIAGE ?" ERU 6VFHIClfS Q m FROFERtY DAMAGEONLY ? n[SUEIFD ? VfNiC. x+sFSRT WNDN H %'9 N CIN EREN O INTER CU CROSSS111EFff10R ROAD C3 A"• 570 IL OBJECT STRUCK IN— OF OBJECT STRUCK -OWNER'S I-E) ESIDAMAGE SRECWLCODINGUSE w $ UNIT NO.1 UNITNO.2 ?VEHICLE ?PEDESTRIAN ?PEDALCYCLIST Y 1R% F 91VER'S-: LAS, L \S % ) J , ..) ?? ?r emu' tJ MIDDLE RI-SNAM. LAST -T T i? ) SIRft1ADDRE55 -Y- r L4 Ju iQl I- ^ 1 f^G. '?< x ; L R?EfI gDORF35 r / Y.r, IY STgIE ZFCOUE FHONf NO. D SIAIE K f F N 7 D9 V R'S IICENSEN EFAr F% A H I ll N N ATE % OAt B RiH ?'- l L42 on W?j I D•r lo ND 1 S' ? I74L t>J r OAY , o ° B OCCURAlION iIRMNAME6RHON NO EYES IGHi HEIGHT E 1 L,. .I GHi HEIGHT IIRM NAMf6RWJNE NO. .?.. a;jl EYES WE - ??'[ •"r.•u?- !a y?i-Ob R i, r )':T. p l r.^. S:i 1 Y •J ACJ,•?'• D °7. - ? CHECK (I E nEAS nN woaovFf aE ANOrHFa •u Y ? CHECK(?) UAaone of ANOiHFe.A` VEHICLE AS Al , I e e ,"', CODES ?+ D q "sir ^ .inN 'Jlc"D" rln CODES $. + 3 a a i. 5 u 0 is Ass snM Tcl x nN T , Er,A ILrroM ? AYe Nil o -n" ? :R- ? »K ? V01- NOVA 51YtE12D4-GONV1 MODFI DMt DM ? RA „El D WE ? "W- ? Y ll ? rs„ E VHY tR 1 F{HEV 1 ngOFIIDARI?NOVA1 Ll VI N Vf YEA9 MAKFIDODGE CHtVI I . I I • . -78' OR Sf R1AI N SIAIE 11-l" fUlE NO. $IAIf H VfH.CIXOR A t T aE [MICR IDFMRICAlION NO. L HI IE ID Nilfl A ?? EL REGI5RR(DOWNER: IA51 CASs MIDDIE _) ?II:F FHOCNf NO. O ytl E 11 ED YINfR: Ust fIRSi MI DLE N a ?. :l/F L I ID ADD9ESS1 A a rvt / _7j. AF, l?. AC?EV . N E 1-11 ADDRESS OF INSURANCE CO. OR AOEnT " 2R 1 L. ON DAMAGI ANIA _ Q_ II ? DANAG[?MfAe ?• =CSiOrDiu J1 C o? . ? Tow' CHARG4 Rion ! •IDF WAN -.ED IGi t t11. DAAUGf E] A Y ???? OAMAG[ ` DAWVAY C3 REMAINED ESI SOlOitO? S AW TOWID ???JJJJJJ AWAY I ? TOWED ,Y: : _t ) AWAY DIAGRAM OF COLLISION: y°T IiNiu " q INm INOrRm er®o DESCRIPTION OF COLLISION: I'll"I"I'mEMAL SHFnD NEcESSa9rl __-- \1L.F1. .!t- ^? t.Urb W?'.iC!;c'vl.>.1? ON,.,. arT4 J*g,7Cr 4:f oJ3 C' (I), IdP A ( I Cliid: c?xT,T E^Q' ? ??.'t.V(='c• / APJfI VFIt `?'' „ ?? l.l:.:tvf•. Nl•ah v???-l'S6;:\? W.T?i ?JrrH, ?": ? _ {•ti 1 ?:t:;T a\:?r`IV:?6. „I.,'C' V:IL??.I.J SttL' ?-PPL?Cf,?;? t' r zi V L ( f>r 5 L ? :1 /?E.::./JrF . Ex).ct_ .NcEc ?sT . Tt; <rr::. 6L•1• f l1 ?_.. I'?:-?? Tir„t(; 'Tea CF'rinl?ct;;i .•if.in,),D nV_TF\iL ??F`? NAME, ADDRESS B INJURIES OF PERSONS INVOLVED +CODE S 1 - 4 1 < 5 6 ' _ OCCUPANTS/WITNESSES iuotlli?ooogMrliNAir'xiua si sT% AGe IATus '„"" .",. ln. NAME ADDRISf NAIURIa TW An ?A M. C]MAL "" .?N» ? i i,Y NAME. " A AWRIIS NAIUR M 101 DKOM 0AMO. ?-110xls , OR M _ NO I ADORI44 NAM?a RY. ?AEA\ ? M."0f6FBE?U» ?iED l KSATRIOO [IPt t 4,ADW OR AGIHCY {DI 1 MD KA D OAItp911W1 AIKOViO BY OAIt b M?'p b ?{y?W d°p.Q R tlJ h ??*,*?}??" y YY`(.Y ?4KW Iy M h? / v? 'TAh rfNRes 1• YM i? ..m. ?1AT5WY 'llkaf? rJ 11?' .. ?'1d •'.1eWadh n h 'N':sw {v :-Tnhb?M? L? 91 .A ? : \.lJ L".: If1;1? ".? YjxESw .a?•?n,.: a r? C'r AVIC r1C \A/A OL3111LI.+-..n No. ©TRAFFICWAY POLICE TRAFFIC COLLISION REPO RT PRIVATE WAY PoIICECOMFIAININUMBFR I Dwre ofeaF SroN f l on - nmE eoufJn p. R „ I IuS 1 R H ^ eounrr NO. nrr no, fnwA 8 I r a ID . .I..'.? r1S' O I .% et`Ie SDO ?4R / / CITY OR TOWN NAMfaN Of SIRFE,OR EUGHWAY ?N ?E ? N ffl Cl3? M S P l l% ROU TE OR SINE I O SfCIIROpn` ? _ES ?s ?w ?a NJ/G 4,EE ON " ! Ji .e .e INI(RSF<IING WITH: 51RFF10R WAO NINIFgj C110N p J j ?Z7JD ; r ? lYVC "' <, BEM1YEEN J/ yV // j /fic PR- EO . MIlE P031 7S Z J ' t Stq[E1 It dGX f DIS? C[n014F?I1E5 r{?•Sp(' f'CROSSSER[EIOR NEARESTMRF POSt (!f 9r?mi A[[IDENi . RAMP DIAGRAM WIA C% Frti ? Of - ,/Q A!. %C%V C3 .0 X MILEAGE IN CO111 NVIXVFD: vfRlr, lo TAL NO. NOKll ECINLRfD? ?SPIE 6RN - - wx0 ipi„ 6V(HIClfS ? OAMAGEONIY g S RO R IN SiRFET RROwDOR R[ifR(NCf INIEP ?C15 CROSSSrRFET WPD OR / RD TRIKKA FSlUL7E Il1FD ? ? fNCIf OBJICI51R110K INN.SE Of OB1EC1519UCK NDOWNFR'SNAMFI EST DAMAGE .?.3oio t SPECIAE0001NGUSE 5 5 UNIT NO. I Rlv[9'S WMF: WI IR, UNIT N0.2 ? VEHICLE ? PEDESTRIAN' ? PEDALCYCLIST RVfR SNAMf. 51 D1E ' 1 SIRIlI AUDxf55 , H7 J / !I .4 2 H? ?J .rN SIwTF II CODE ? D S Rffl ADDRESS ,,ccrr JdX [ IHONF . I SIAiE IPC E PI E 2 DRI FR'Sll<ENSEN WAIF f% A S vs TIN (J 4 1, ( VER'IICENSf NO. SATE S(% OAt EO fDIRIH /1 p OCCUPATION FIRM NAMEa PH_NO. FY[5 IGNIHEIGHI E OCCUPATION RMNMEaPHONENO. I— WEGNII,E I'1 L r? 2 Id 75" R rtJrlr-> > ' , ei,a' Sa/i. = , . ?CHECK (.? 'v(NKIf AS:N fmnl &TNFR- . ?CHECK (? s io " o Oii iaw' v CODES ? * 7 < s i;, 5 oE<I w / 6 ° rin'c• l S M r• AN rml r r AN tf l CODES ?' 3 c; ' in tcl f c < i 5 l%DN 6 Ass eM„' c xP 2 uul C/% /'J/ f? S A m l '/ q Rr.O IF :. ? ? w l F%,.. ? Ll!U! N„`iaQily YtM M fIDODGfCnfV EH t a„oV lor.D -c, l Kl„l er ?? roe ? FbiilR ? vi Ku ?i.?i,v. " J . .l l (DAR,NOVnEa /gIF2 .I f?/Fl S /w/ o VEn, l SE P1w S1AIE t9wIUR RAEE E H u ( HEV.1 2o'Dw91.NOVAI I R: .1 78 ur e .S °r .P ?6J r B rq. SIAIf EN. c aoR ll A Il AI NO. A f M J //?D 3 ?// C / I '. Ll/n, rP Z- )7 C4% VtHICI[ NIIiICAIION N O L e"glf mFnl A IN 113 i 1 2 275 871 fD L G 1, 3;q;212, 8K3 S, 0 III.4 REDO-M LAST 11451 MIDOIE PHONE NO ?LA7rJ/. /J/? ' O rFC C O 51 Rl OwNfx lASt {IRSI MIDDIF H N NO. /1 LA .S ECR Er !nl f' ??/ 7P) I DoRESSaoW*IER W < t A fOWNf4 /JJ1 !.. 'n?res C-2 S),9 3/ N N-1. D0RE55 -N SURANCE CO. OR AG[NI -?s6J/(t% ::5 Cv c%?x• d.9 /, .r/? R IN T.vira.?r4-1 DAM.WI -IA S R . G OrtO.S lil'DCAM•G[ CH Oµ?N r •C'nr CHARGE eul?t prGlRy tAlAAGt)D MfA C] IIDI < ?1,(2INto O A?fN ISI.ONAAGL RIM ? I • -L A N(D I r 0 ii 'a4 5 CCC??'^^Teelll ) S 1? AWD X ?J 5r; n S ) ®:wvnv. e! c/ S %••,:K) S G n _ DIAGRAM OF COIIISION: 1 M %C I' DESCRIPTION OF COLLISION: Eln[sugPlfMfrvrwl sl(ErD N[us5Aar1 SHlEtIf MCt35ARYl. r OvJ t er,cin.c/ayQ c/{Ie ?/<? u?Kr S as rJuand o,, A; • !!'AO' ?ir'dc, %?o rif ,/r./,, C/NS ;,?l rrc C•/'!'S ri %/.9 N`i•7/ d•/dam r/uarC /„Frfr.v/ J /NR?/? F/c,AT r E /?o GB??rc//ii/? X NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED * CODES 1 - 2 8 n 5 6 OCCUPANTS/ WITNESSES (Taxi ,SrD?D'i!o?rlu'M+N++ NAw .i u% •GE IAr „W„" R ' Rts1R Incr ul ra .DD.m NAIw or ENi r ? Am e. ? u "' ? " . ? ? q C'."„ N -? ; Mh3i NAW NO ' NAf 1 d 9 ID IR ?•Me ?ML'OWIn. ?Nli ?riiiN x0 • NO n0n ?t rHJ??a s1r,(nr ?%Me ?E.:'??ri:n. ?:i? ?? vUrpAtr G ar ClR r l l Wa'AN' 04Kd OK I) Kos Kl D D HaRt"T IApp.oVIoeV?j DATE . n. f ,vr: : : . . . 1 e ' ' . . r .., ...,e... . .. . .. . .. . pf?? . I L ? 4 i . E. =. yE•1n R - . ")xJP? I 'I I ';? _ [? CITY OR TOWN v NANfe NO. OF 51RE Ef ORNIGHWAY p g ? -11 RWIEOR 1R Sf i0' 3 p _ _ s". L MITES W S oF s ON INIfRS[CIING WII STRfFi OP-- ? NON NIERSFCI O N ' p A.??/88 Tk ? . I E?? ??fFF yy 11 I E BE1lVFFN ilC- STREET a ?lAil 10 STREET PRff % E M fPOST ` I OISIANCfI Gf 1 Rff FINCE. CPOSSSIRLfT OR NEAPESL MILE MtES R ACCIDE NT RAMP OAMOAIA AGR - 5 E FLEI OF MILEAG E COEt1510N INVOlVEO ER tY: I.IAI NO. NO.RELED_NO.IN1URf01 ? SPIIUGE H,rvooE n UN %.RD N of R OR ffR IME CLS CPOSSSfgFFi 0RR0AD LS aEHCEES ? PRCRRTYDAMAEONLY ?pTSUI.. ? VENICIf p c? OBIECI SIRUCI INAME OF" ACT SIRUC%-1 OWNER'S -Q E51. DPMAGF IIIIAL COOING 11 UNIT NO. I- UNITNO.2 - ? VEHICLE ? PEDESTRIAN ??'PEDALCY LIST' s DRWfR's NAME: psi MIDDLE D IVF -AME: IASI I ^ EA &J ? ?fn S?FfI ADOPf55 FEET-Rf55 c tY StAIE LIP CODE PNONf NO D I Y AlF I cooE "? 5 ) l?J ?? c U v? IW R - ORNER'S UC[NEENO. SIAIE f% N I I 0 N N AL % B1N D ?C^at?1 Zj D,r I r R V IYR. I DAY S S''. f'RL g) p OCCUPA110N FIRM NAMEIPHONFNO. EYfS IGHI HEIGHT E CUPATION iIRMNAME{PHONE NO. EYES V FFIGNT FfIGNi n U AILvI 175 R fi ? CHECK (?I yfHICIF AS AN fMNOYEf OFANOIHERµ ? CHECK(, v[H Of ASAN waorFfdANO1HER. . v . n oRK,Ta CODES IF, * 7 a u 5 IxD,wrv ( e CODES 11 * u' - `1'aMN, oec,<IE 7 c { e. S txolDrv a sAn ? N;6 s ?wi N 1 1 1 a f1NI t. ro a U ? u M el C] ? ? ; s? . 2v L RDm ? Au ? ros°` ? Es x. ? ? val IOU [ VEN.YWf MA%E IDOOGf 11) fLIDARI-NOVAI STYIEI%DR:CONV.1 11 HYFM 1 HV.J A,ODfI IDARi. VAJ [ R. ?. I 66 o C12 11?(Z E Se L ..1 U tAIEN STATE TRNEER GATE NO. SIAIE H VFH. OEOR Fl 1 , A i N r- z; wA I C wl. V NIUfI N111CATRDN NO. L V HGE DENII 1_. y ' '' 181 19131 I I I I I I 1 1 1 1 1 1 1 1 1 1 1 1 Sal!-; R[G15 1[RFDOWN[R: I,AS{- 11951 MIDDLE PNO NE NO. RfD WNfq : U51 IIgSi MID H N G 1 ,, O IS ADDRESSd OW W A NIR ADDRESS OF OWNER { a? , 12 OU E '? , - -JL.AODRt-NSUR-CO. OGAOENI k D R DR ". ? •J L' WA MU CNAPG[ ' CHARGE AMAGlD.NFA1 ? C ? +. {? f 131. OAMAGt ? DGlvty 0.1-D L DRIVEAY N CRfMANEO IN D AAVE.1 10lOTlOM AW M ... A . ,. wAr er. _?. __ - -f IOWLO ?IOWIO Ar ar: $ I , Y- _ ® l?? ? ' ?/ I_I AC'm SR i _ . T '-hiLT 04.C S v? 1-4 r _ Q > -ld6a To 5 - j P K - A WAS'_,c:Mk $ rwc . NAME, ADDRESS 8INJURIES OF PERSONS INVOLVED +CODES 1 - 2 3 4 5 6 r 1 + ?,:,; OCCUPANTS WITNESSES I a?"ONXL .Y" 5) u% ,io TATUs _ '- ""; om{ I- ar tiI,L., , rlAw: P, ? I ^`: NAME: ° KI H111. ,D, wnY. ?AMe, ?u'l ? a, On: OL.NE, , }}} . p L 'r J :J!}V ApMll1 r l UPid P P IF- . IROM [1 ?TD,KI ?rel F ? N ? i,?i,N AMe. , 1 ` r NAwf. . No 1F1?' ', !: ` ? " !? 'Y .00111 SIGwt (+ F : NNR??SOI - N V. ?AM. ?IA. 05.[355 ?n f 4 , !; L?'- T 1 A/ I I q U1 NAM1{4N[ [^ 1 eADCA 01 /GIF,Cr K1 IcwD ro wFn. ?iwl h7? ta tOND DAn of 1 1 AmOVID {r DAII Il?C7 _ I_e l.. 4 MIMI P 1 F! 4 `. C N O r0 JO ?. `O U O. 1 O I . rl O OD O Ol 0 ! ?yNM ll y R. ?- 1PfJ!tGT ryry VIED, 55? ? STATE OF WASHINGTON RAGE / pf ' ` P , ?A RT-. / POLICE TRAFFIC COLLISION REPORT ?TRAFFICWAY roElcE COMRUWINUMRFa PRIVATE WAY L2 oAE . .LIME muNrv u (USE 7.00 R .. R„ D rR : mulRrv NO. arvw. r«wA , I „ ) l E I 2/? TF?=exsa oURRAN /?a RAE oN of rv4N cIrY OR TOWN NAMFS pFSfR Vp, fETOq rKGN'NAY TCTUS RCIUR OR SF ION . ..cTINO VA INs EEt ROAp NO 1 . t ! E J 9 N IN faS Cr M,, y)?` .p 1 BETWEEN Q U"? STREET 6 ?/` ?r 1 RfH% E MI1f105f ?r/?/i??/r-_ ,r l ?VCO'? E.?" : UI RUr ( ANC 6DR I REF I1C .CrnJS+slaFf NUNS II mitts r N 3 f W MILEAGE ; RAMR OMGRAM PAIA D ` / Q(J fFfr d CODE Cp LL15 NINVgVfO: fR rv. NUF« TOIAS NP. NO. KF4E0?NO.INIUREO?_ ?sRREAGE '" S[[RUN wN05f01R dYENIQE3 ® RRORER"DAMAaawr oFTRE TFO ?vfOiliCl[ W I-IN -G INTER IN- cf3 cAOSSSTRfFfO?I?Egp?A?p/? Z!Y/f?->?p?IO ?V OS EEC151RUCKINAMEdOB1KTSrRUCK MROOWNfIYS N,ME) FST OMAAG[ SRECLU.CODWGUSE -- 0 UNIT NO. I UNITN0.2 ".. R'S NAME GESr ? VEHICLE. , o PEDESTRIAN . : : MI ORWFR'SNPMF. M51 N 7z SIR Efr A00 5 , Je 5 RfE _ORf 5 S L n p srAlE p D a/•S 32 n•E RnONENO. R Y iE I Q 2 C A 7 IV " [ V 73,-2 ld E Q .. - CHECK (.I 0 nN A AswN .ion A N A ? CHECK(,') vE«Kf[ASwN Emlti YFE dANO a? v An• i3h xr 0« xOIOTK.cu CODES ?t 3 u" % s S u rvl 1 CODES ?+ a s Y 1 ?yT inr "'O s n z WIWIES ?, K 5 fecm« a 5 A,y , ro =17- ? E ? l o cs aR a ? rs« xlr.f e . ;I- 0- OM- ? M? 0=1. :? R. ' veN. TEAR MAKE EIKlOGE.CHev.) EoAgr.NOVA srvu lpR..e ! ( 11 F T E N Ac ( ?y Evy)E rnOOEI EO . A! / ) (2 I [ 6 n ttA SIAI IRArtf Etnrt NO. { F N.cao - A 10? 1? - 1 A SS ?/ _ ? 3 vFNK[l IOINiRIGflpE rq. P 14, ,4 0;3; o? F -.6 C ` v nIUE10frv I I SiFio?s13;019i01 i i i i WG II[OOWNlR. C,.yS '?y` f143T MIOpI! REgN[NU '// CnU IS ONNER: VSr I.- s NO, Ia I 1 S S- AooRtssao U O W V1,9 77 e wN N AMt aAppRessdlnwRANfECO. aAeeNT Q .. 71 DAwAU ARU ' a 4AMEiif µluy ?µ cNA OEARU ! r .,. ?, fr0• IrQ? 10 .TOR- y IC ?01)C? t ISr. MMAG! -Al NwNtp I[:LAWIAY ?RfAWNED 151.0 Or 1 D OU "'• IOIr f O I-To ? IOWlp I AWAY BY: " A Av er• f3? ,'t. A DI,RAMOF000ISION. I r.TT_islfanu Swr/ --? sr IEROw IN DESCRIPTION OF COLLISION: (EUeswneM[NrAS SlrttruneefssAnrf ? ?- ] SyE'-- /AAA Tus 7 - 7 1 IE , ------------ NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED + CODES 1 - 2 3 ; S b Iuu surntwwq sm OCCUPANTS/ WITNESSES Id AOgt Nq NAW f r I EEK ,o tA WRn« MLI- -Wi ' Resn. tier' .ryry: N AM[ l ,? ?r a.p/"/ .... .... ...... .. ' w 76 e; 313 y. A N lu . (1' 2 . ATURld A AM l ? I O rKr:. N?i {i?rN1y r . AMT' A pp•rsy wl o/JAa ?IUKIOM • ?N? on wey, ip . ..__ - _ E r o RMa o'[°.:1 ?'KT>nr. O D7r O r..«v Wvrt MWGarc 1rwVS1 K RAOrCyE OR AuNC• K:tpn.ArcEKp lOE%EAnnno DAnd n?frwpr ArrKOwp Rr an a ? ? ? 1.0( 5 I(7}° E 1 ) ?S Muy w - 9 ? 1 ®TRAFFICWAY IVU. -? _ POLICE TRAFFIC COLLISION REPORT , y COMPWNfNUMOER. !z Y PRIVATE WAY . . ?? DAI O C LI I N_ _.. _N'M 4 E COUNTY 1 a • R I?lu. 11Ar (USE27HOUR) I5 X Al COUNTY NO. CiYNO. E03 HWA Rem • 10 1 81 I i I I 1 1 Jefferson 1 pN pE ?IN CITY OR TON _ 4/NGlEvO• E.E,IOPRl. WAY - s Cl5 IEOUIFOR INE IN)N Av«s ps ?w of @uileene 0N Clay Banks Road S INIEREECIINGWNK ETA NONINTERSECDON \1J ?vV (•?Rv BETWEEN Rogers St StYFFt e•fle8d end 51X[ft YRfil% F0. MIE POSTHT O-7- 1 DISTANCE Da tI MRFEEgN ,[gO555rREF1 RNEARESi MIIf 51 AC CIDENT Mltfs F RAMP OIAGgAM DATA ` .1 W F F[EI W DF ' Rogers Street MILEAGE Cj CODE , t:OIlISIO NINVIXVfO: SEVER IY: l lOiAL NO. NO %ILIED_NO:INlUREO_ ? SPILLAGE ? HIpLBA U/N © FIRE ? runORiolHS M11 N11. 1 I M[ 0 Cl3 C R I gGOADOR RGERfNCE ORZIR«IOR ROAD.,, ., ]S /.? aVEHICIFS PRO«RIYDAMAGE ONLY ? TEO ? fHG C /1??<)f" ?fJ OB1fC1 S1gI1CK INAMF Of O01ECTSIRUCRANDOWNER-5NAME) - Es'-All SPECMLGICH.1-E , 5 . ' UNIT NO. I - DR ' UNIT NO.2 ? VEHICLE.: p PEDESTRIAN . , p PEDALCYCl15T sA IVER NAME: 151 FAT AIIDDLE RIVER'SNAME: Is, IR , /- / Walterscheidt Joe i - T R SWEET ADDRESS Rt 1 Box 446E - ? W i l Donald #am p ?-}1 Rt 2 Box 682A OIY SIAIE EIp COOS PHONENO. D I SIAIE I"D HE Port Ludlow Washington 365 1-2224 R Quilcene, Washington, 98376 None agrv(R'S UCENSf NO, ,SIAIE fX BI H N Y I IV U FNSf NO. Al IA DATE BIgIH WALTEJL616LB Wash M 6? 2 139 V KE4MDW613RC Wash. M 121 3 139 -` q OCCUPATION fIRMNAMEe R10NE N0. 77(]_[]111 EYES I— HEIGHT E OCCUPAr10N EIRMNAWE.1.0 ENO. ETEs WE G"1 NEGHI 11 , Troo er Washin ton State Pat lb u 1 6 Logger Unemployed Brn 20 5-1 ? CHECK (?} yEMiCIFA3 qN IMPivIV EaFANDrHEU p CHECK (? EASgN Im«oYFT 9F AND E n CODES ? + G a. . i .n 5 1 r DN e O ° is M 1 CODES ? + G % 5 IR- N B L NlU9K5 10 O ,TgteDw ? AMAMAME ? u6' ? 78nE. ? K,t ? a 3.. ur° poRa tM ? AMN%AEKe• ? u!° ? ?L'HI ? 55n ?NO- KN ]FAR Mq%f IDDDGF{HFV,) M "IDMT- 5TYLE(2DR.CON ) N YFAR ( Kv.) NODEIIDARI?NO A) Y IR DR ,1. 1 N _ ? Plymouth Fury 4 door E 1960 Chevrolet z ton Pickup ro De L, n. IX R U N PN N SIAIE iFMIER Mi[NO. SIAIE H KM.C010R A H AlE White 8P0617 Wash, I Lt. gre T10317 Wash. >9 KNICIF IDEMIfIUTION NO. RIL41Ui8A16 16 6 L VEHI.-INIIN N 01 "21'0'" I I I I I I L A 7_761 REGISIEREDOWNER: -T FIRST MIDDLE prgNF NO. State t _ rol, W E ISIS I _ ER: USI N., MIDOIE H NENO. Same as driver . ` 3 ADDRessaowNER w. 2 a tin Wa Wash 0 E As above -1.ADDRESS OF IN5-CE Cn. oR AGENT aN 1 IC Self insured R None _ DAMAGE ARU _ I I 5 ,tOr • wC b ''' 1 T CHARGE CHARGE OvwC ?o' OF DAMAGEDAREA' s J' r IU ioTT4ii s f31. 0AMAGf DPIVlN ® AWAY '?RFMMNED ? I} ?L ?WAIY ?REMAINED E51,DMMGf , •1 1aP o4 s OO?i 1 SO 0 TOWED AWAY B -' TOWED ? AWAY BY, 100 O $ i I 10 DIAGRAM OF COLLISION: lu lMN yAt,wln DESCRIPTION OF COLUSION: IusfswaLFM[NrKS «ilf N¢[ssMr1 _? Vehicle , : in pursuit, of a_motorcycleE__was >e raveling south on the Clay Banks Road Vehiel ?- r( G I / 2 was traveling north- on the..Clay._Banks.Road.__ ? ???` /? - ! The vehiclee.eollided on_a sharp.curve._..Road...._ is 16, wide at point-of impact._..Th6-16ft.front I J I ?? Ti _ tire. of vehicle #2 waa 10E from., east aide cf ro , to (at impact) I IR r • _ NAME; ADDRESS 81NJURIES OF PERSONS I NVOLVED + CODES 1 - 2 J 4 5 6 I03 SNF. ENTAL SK OCCUPANTS /WITNESSES /dl ADDITIONK NAMt IT 51 3[% AG! "" iAlU3 uAr ' N Ai - 1 R CIA - - ESIR. EIECr LEI, u N AMt: .... P + DDaEU t'. I N N aY ?AMe. ?c'4. M. ?M11O P ?CiIY ? C31r3.. A Dntu rNpAi pR a...._ _... _.:- R NDV1orRGM ?AMe, p' :KI Oc "mr ? Crx' ? :°?5. '0. N AMI: r ...... .... .... _. .. a .... A lKrru ........ N rut OP al?s E Ira er: ?AMe. p'c°,rcl ?HD„ ?wAB` ? :°.NIP X 1 u a E Er F agNR s a EcINCr AIoH, r K E D IS p ala AgalpED DA«or REroar Ar D D« r , ?S • 1 ?PAY3 b9d?lt3 10-05-8 r YEnK:AE N A E W ON STREET W AID, ? ? p?j ? ? ..-AN ? PEDESITRANWREIVERNG ? ? ? KONG I?SIDE- PG`OSIIRFAC[ KMC. aMI WEAIHLR IrWTCONOITIONA HrtlE M I r(q?1 ? 1 •-• DRY 1 F71Kr 7 yTJy1 MMMKI ?.,F 1 Eyl DAYLIGHT f TjLhl DAWN S WET { 7 ?bNOY.vq 7 ? OUBK Sr10W A ?FOG , ? ?OK'?ET ? A ? O S ? OtNtA S ? IONiSOPIR THER C,`r O S e I S ? " O ASON pil N0 5F[E.G OMA[R K+mCIrNe MIOr MTB•Dlbrl lrCl , 19TT MONTS ? OTHER SPEGIY NAM{l 09. ND " _- M auBe3 wND"E Ytwct( LEJDQ4'?'lr IrANw ?LI/O vINCL. «"lv ?? YlF-Rtow VlrrIlF MRO ? . D_. --'INVESTIGATED ?O??Y? (QI'?ina ? AOI,DI ?'[roir[UINEE ?0 NOMVFn ELI. cewuw FRD M DIRECTIO N , TO DIRECTION .-Al 30&ICKLDF.R NA fC O ' A?clV.iwlVV so =- .1. 0 OTHER _ ERIEHCLEACTCNA DA m IUrKCKONH P NTI T c C4 MYIr ? I ?SICNKB TYPE OF ROAD dE MFI ?IRDr ? 1 ONE WAY Y v[wCl1 - -Krrt.CIt OnL bI MOMI p{E 1 OOINO BTRAHWTNIEAD ? E ?STOP 4GN 7 I- WAY ? 7 0 MAKING AND PASSING ? 7 ? HELD BICrN D FRIGID, 90LE ? S C3 MAKING RIGHT TURN ? A ? RASH.0 RED ANG IN? ? A ? C ? A [3 MAKING LEFT TURN C) B ? FLASHING AMBER I Pj RA P ? 0 ? ALLEY ? 0 ? MAKING U-TURN ? 0 ? M DONK ? E ? LE'0 TURN ? S ? SLOWING ? I ? ou""AmAGMAN n n ?..._? ?_?.•.. LINES .-. .--. ___._.___ ? 7 ? Aromil, Ton TRAFFIC n _ f"1 BTOPP(D AT EIGNAL ERIC r A P'Re l nY? 1 - '. c. ACTOR VEHICLE . COL _ LISION . REPORT NO NO. ? ., GATE OPCOLUYON ., D YEM 9Ury WN , AY OFCOL I UYON. TIME OF fALUSTEN n P fPo 5 W MwOiES AM COUNTING / CIiv NO y ^ G.A " . ..COUNTY CITY.70WN.. .` N .MILES., ?© _CITY. TOWN- ANALCLLSS? pPEFx rneE eooE SEC ION .CUnxAD A), oil 1) 0 - 2 Ll OF T'^' , ST EET,ROADORHIGHWAY:_ .... _..: PITERSEOT.Wa,WITH: STflEET OR ROAD E W .-,.. GIVENAM F PnE Il EO N EPO S Gn ..?F i dT A ON INTERSECTION-LOCATIONOF CpLUYON - D G DATA NP BETWEEN 01A STREET AND STREET L 0 E fnor GGTTE? © s*INT-EECCw°onfAEHiiv1rwia-QUSAEr?P-EP_DDE AIEPSEC,IW:.PJ?VrEEt ® OF I WGC C/?+l n ?CIJr • ? rrtEn iAE xLS . EI(/ o,? . w??LL?ur.;vis`I ,noAo 1 QDNEAIw'NIEI p F CO SON WVWVTO NCIf VENCLE ?V£NCLE-E 0 I , NICIE OWI I ?YIUAOLE TRAIN OrvE LES ? L.z- 0 I,CLE PEx INAN ONOAC slo ?.0.. ` SPEC CDDE USE • „ OBJECT STRUCK _ I NAE or.Oa"T ,I .. .. ...::...OVINE90F OQIECTSNAME MDPDDRE39 ': ?LOCA ?.INROA N TI ON ?© rOE+yp@.IECr. DWAky FEET SS A - • • IF MORE THAPI • r • - .. i .- DRIVERS LAST NAME:., ?..,..... FXR5T NAME:. ,.: .-._MIDDLE. ,.. 7.t?A?-t S? f?Dr' TDe LF i B WFPEWVWVfD .- D BqN OP OnIVEfl9 ?ESTNMIE. .... ., FtHST NAME,.... :MOOLE .. NM0??? . I/1AABIL` Ir ?/?I ICS _ ROUTENO.ANOBO%NO• - MC TE IHAN I-1 EPSON—-FE YREPDBE A STREET(N?ONESS /? / ?j -.. nOU[ENO ANO80%NO ,, - -' + CITY STATE LPCOD ORIYE CUPATION ,. sEPAnae causon CITY.. E lac to •av REPDRTFDPM u ?e? 6 E _ DRIVERS LICENSE NUMBER „..:: STATE SE%. ; pA OFOIRTH AOE LB -tc?} °° B" AI l -( -,. DRIVERS IJC[fISE NUMBER .. ...:, -.. 6TATE; SE%. . DATE,OF 811j '.: .ROE ?cvA ? 03 ' ?-I eC? I?vt6ADtu bl3 'N w T? Gv o( . VEHIC?Yfl.,, MAKEiOHEV: D00GE1.,, MOOkGry0VA0ART),.::: BOGY TYLE12 DR1 _ . , VEHICLE„ MA%E NCH V: DODGE( M00 INOVMOMTIl.?:...: BOOY.STYLE I2 DR.1. _... '? NSE PLATE NO_ .,,.51ATE „,,;: .:. TflNLERPLATENO,•: ,..:. STATE_ -0C?1 cuA. - UCENSE PLATE NO. STATE .t.-: ,lRNLElIlLATENO _, C'0 17 .:.,STATE.:..,:. a VEHI El0 TIFICATION NO., IIBBSM LSI NEWERI.;:., ODOMETEfl IMILEAGEI ? I U 8 A ??9?1, 5aas VEHICLEIDENTIFICATIONNO.,, _ -(190a MO0ELS&NEWERI...«.- O o? ? I2oR OMETEP.IMILEAGEI - REGISTENEDOYMER_.; ILAST'FIIISi MI00LE NAME( ,. ,.. ",;. DRIVERSLICENSENO ,_.!; REGISTENEOOVMER,:,• ,ILAET FIPST.MIOOIE,NAMEI. ... .. .._:.::DflNEflSU GEN5E N0 ', :'. , 1 :. r OWNERS ADDRESS .....:.:.... ....IST. EET,CITI', AN 9T(!TEI .»-...:. .. .OATEOf BIRTH,'',', OWNERS ADDRESS, .:-.:... 19TREET.CITY NiDSTATEI.:.:. .. .,.. : pATEOF BIRTH.,.. EP E7 L (? t T4 a.-. GGYY VES ONO LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- Crisvsr%EwR1EwEFECBFOR THIS ACCIDENT ON YOUR CAR - +' `? ,•, NAME MDAODR-OFLMBIUTYWSURMCEPOUCYHOLDER NMIE OF UAYUTY WSURMCE CQM MY NAVE ,OGRESS A/Ade"•L1 IAII?? ,E Ew I N / ? n 4 , . :.:. G(r BTAtE„ I UABIUTY POUCYNQMBER ... NAMEANDADORE5SOFUABIIITYWSURANCEAOENT, .:.-_• . . .' - E ISTWJURY 1 , I NAME 1`••'ONC.? .. AOE 2N0IWURY: IuBEB[ln, EnGIg11 iO AWI KwALWWUE 1 _ ,,. AGE ., -AL NAME 1't ADDRESS .,• SE% ADDRESS SEX A F raAM rvAlEi01 rAIXX:,Om ® 1. NAME? MMKF RST ONETHAT MPUE9 9 ONrvA,o OIAOOC"OM ®? NAMI STATUSOFWJUREO MMKRRSTONETHATAN''S . I STATUSOFINJUREp It W NlOrI pBABI OP/15tNG[ IN VEIIICIE FILLED 11OAVryIn I wpR I "° I / /V I R W VEHICLE ° NWwJOOAPnuq POSY lE InvE 0 ABSFNGEP IsEVLNEI Iu Ngil 1 O£•-Ell NO Of PAW FICI( o ncI" O d LF J5 o-'.!RIAM B? 7? O 6 '? p:. e. I 0 80 SHOWNORTHBYNIROWWGRCLE \ V DESCRIBS BELOW WHATHAPPENED: (REFER TOVEHICLESBYNUM°?eI i-Srnzs { A + A1-90L Ao lieu-* I -_wAsff106m olAlca slorl xEre NAMC• oR \ 01L E.- O ? wMIIn exN wl.cLf MA. _ ._- ,:?. ?l?°Tl? _ ?or? #z.J4PpKot ?Uk.. ZAK ? I t?S ? i. ?•, ?' A . ?q f}?=68 EO4E off' _. HI ? 10 1 Y' T -- -7 'Rt AAu?A k r =Ti•ief--?I, 4s 4:0 S Ca r gym' C r - _ 4w . _. - j..._ THE. E - _T 0? '>n GC 1tiY 1 K ... - _ VEHICLES POSITIONS BEFORE COLLISION raaLN,u nNC.e YINKLL vP.AAmw INVEITIOOATEOBY M[ ltONlr trAN MONI r A. vtNCIE KO Lin[ OMLR ?s nY , 0. PWDI [ OA NO. DA[CII?" rtl rt1 rn NO f N STREET O MOHWAY NAM O VEHICLE N / [ W ' T - I A ? / A I?J.J ? nau• ? ? ? 0- O ?. O.: lJ "For ?,roa?NMI (?• - 1 t ? • IOIMAI ? ? 1 0-tAtl MAQK!? kb, i r ;Tr ?,' * 77 nE.aww. ? ? ? ? ,,?pND u?wp mom DIRECTION,... 10 DIRECTION. " ° sr n ? y ' A 6 ? omen .r:L IN OESrwAN wA.R usING I ? YcewNK J ? wNKwAr a ? SNquLDEn . ? 50 ;A ? ?dt MI ?'Sr: IaAD SVI1r AGe WE tllEn L"ITC04grIO11B InNFMCONTNOL' -C,wN TYPE Or ROAD DnNERrveHK:Le ACraN! Ib,ICNMI V4.CLL vi CR ONt V[IrCLL IDIROAp11M WA[I [ YD , li ,?fl ?. ftl.,, LS 4 f y 7 Nr.c4 ?MO It AADWI ONe WONI 1 !DOING/iRNOHT AHEAD var ! 1Wp? pC.rM 1 DAYLIGIIi ? 1 ?YONAL! OII AID' ? 1 ?DRY JY-I RUMNOI } DAWN ? J ?STOPYON J ?VJyr T- WAY ?1 J OVERTAKING MO PASSING U k 1 ..., T(?Fy yt 1 Eh''.H t L W '45 REVERSIBLE ] L! ROAD ? ] C] MMWO now TURN 2 WIT a ?YNovNfo ] [] DUSK ? ] ? rrt LD tl16N REVER J ?61Aw ! C3 FOO ! DMI%tPEET ? rLAlNNO RED . Wl[PCHNNDC ? ! ? MAKING LEFT TURN ?LOHTSON • ? O ?ILOOP.RAMPI y AITA I?OM/ OF%6f ? It O Fy'YwA Am6ER ? 6 ? ALLEY ? 6 ? MA-O U TURN 6 O It O ? ! ? ,{ 1 1 rt j f { SaTI +M1V } L ?tCIFYI OmER gN1/ ? 6 ? M YONAL ? 6 ? LR TURN ? 6 ? /LO'MNO ? / ? /Nbfv It ? S pl6 K .0 LM!! T I xry J a00AN0[ REASpN/ONNotsil R ? 1 ? /10PP[O FOR TRA/TIC ? I ? OIC[R ILAGMM ,I%x11.OHEOf M +CrA'hl I C 1 7 OTHER [LiFY O AT SIGNµ '. ? 6 ? GB 610P ? • ? OTnT0. SMCIrr ? 1 ? B[IMAIfD GA, . Ylr 1 1 l1 OMEOMIROADWAY 1 r rt?".?&I{7Y •'•T i.:_.L .• f-..:.: ,.: .?) q'.: ...I N' is 1:..:- .... .. ...?ry•?.n.. _ .; L. . WI - l A v r ? : i ' 7 l r, , M - Y M1 ? 4? . r • N HII 4 r h \/ M070R VEHICLE COLLISION REPORT N Y OATE?Y OGLLISIGN •• •• t30?30?/ 3 Y ? DAVOFCOwsION. NO y 'vaYl ul rq TIMEOF CODUtOSN _ s w SAr XW? • AM COUNTY NO. CITYNj? k /' cE CO NT CITY. TOWN. PM UnMNI' I - rio[NT ? uisbE MILES . ' Qwlri4 ' eLwKEO ' vrlawi ?N © .. .CITY, TOWN AGM` / PHEFM Pnun ` I I ' iF ai 4fTC0oE. ' GIVE NAMEpF SifEET, ROAD OR HIGH AY SECTION ?w ©© OF C.ReO C - wiEfl9ECTW0 WITH: STREET OR flGAG / CugxEV PHEFL'( EO MILEPOST 1 WTER$ECT NL t LOW& N ,J/ ( r .9? ,N' , 4 TWEEN RAMP OIAOpAM DATA /t' SJ ;;{'}?"'" SiREFTµO / '9VV}, rWr ®© p O ?NE I?THEET ? , j FPSFCrbN ( ©® CNQ95wQ MLLEW i gbFNNWOIMO urKUUSEq. NaDGE. ?N f I 7 Ef X or n nlw INTER CIS w:fl9EG? _ LNO O/ rSSGCOIS99ynEElOn XOAp A ['-+- WVOlvEO -- ®VF KLE VE- C g INTEqq ( rO VEHICLES ?Y? I?VEWGfOBIECi Qor wifl t/??q/ Ilat +?M I Es )QvenKLE PECESrw,N QvNpgCLE igAw qV 6PEC CODE USE ? <OWSbx ,. _ .. I OJECT9TRUCN IrvA4EDFOprFCTStquCNl n Onr x ` U OWNER OFOBIECTS NAME MO ADDRESS LOCATION U in INFIOAOWAY .. .. ?N [ O Tea FEET F ?KF? r VERSLASt NAME IE rgnF inµ l $ n 131111 Flg9T NAME MIDDLE twOCMs wE..-,EO WIVERSL?15TyAM wt's l? C i.'CZFIR9TNMIE MOG.? y '"? a TRFETADOriESS ROUTE NO.ANDBONNO. catuSlox Oq----???- -E THNH rwo STREET AppgE39 r r? Tyr 1.• -NAAE 3wENE flOUTE NO,µ0D0%NO i 4 ' ,I TTY - STATE _ LP LODE DflIVEA9000UPATION I EEPAq? A , f J 'I •. \ ? .^^.. ^: I r. n.n Q WA CDLU3bx CITE .. STATE rJ . \ l 21P CUGE„ OgryEEIS000UPATpf! ,. NERSLOENSE NUMBEfl RENIRiFWM • _ . STATE uE f.. ,DATE OF BIR YN AOE / I ? 1 ` [- / I ?I '? L??? l?. ??( ` . j'YI m "' DAV EAa DIgNEgB UCENS NUMBER ' S? I' I11 rt - STATE SE% lJ :DATE OFBIHAI AGE yy. t EN lE Y0.: MAKEICNEV: DODOEI :MODEL (NOVMOMTI;..BOGY 9TYLE1 OAl: •J1:? '•/L L?C.jL-? r. fM- s r'4. VEHICLE Yfl. MAKEICMEV: OOp0E1 MOOELINOVA.DMTI_ BODY STYLE(2DR) tf }t -? - .LICENSE PV.TEN'O. ....STATE TR4LE PUTE NO. STAi? ?? _ C r11,?; LL's:. ? `N y'•{ I _:• DL•7Y (? LICENSEPUTE NO. Uh lN" /J ...STATE. .-TRAILER PUTE NO.. STATE._ _ r EHICLEIDENTIFICATIONNO. ?Y1?/?p (J)IB u j^1 ??? __ IIBSB MOOELSENEWERI ?ClU - ?;,J` VEHICLE IDENTIFICAiN)NNO. (1BBl MODELS°NEWEAI,_ GOMETEH IMILEAGEI EGSTEgEOOWNER (LAST-fl/ vJY-OL NAM /?J Y- ORNERSUCENBE NO. n REGISTERED OWNER fUSi FIg9i M?ODLE NAMEI, DEUVERSUCE/SEND; aP$ wNERSADpAESS ISTREET, CITY ANDSTATEI l-J1? r. / D //?? .. DATE OFBIfiTN OWNERS ADDRESS ,- ...... ?1 Lt l J l L )r' P, u,r YE ISTpEEi CRYMDSTATEI DATE OF BIRTH MTSOF VEHICLE DAMAGED C IJ (.. ??`-?/ Av [An ,g /rl iL fr 1i1 1 MarEOC?', PMT F VEHICLF DAMAGED sE?E f / IABILITY INSURANCE INFORMATION-VEHICLE NO. I• Y I ' f• - S -pJ??F ? yE J, WASi EqF AUTOMODILE WDLITY INSURANC ,r tEµEDADDgE58 .-I OF UAIKLAY w9URANCE POLICY HOLDER AGE IN EFFECT TOR THIS ACCIDENT ON OUfl CAR ' AoDRF. orr - NAME OF UA& ? YES? NO s ? i / TE ,(? I UTy WSURMCE COMPµY.. - EµDADOgESS OFUA&UtY WSURMCE AGENT rv Y? nn G`" 11y} L aiY sr,rE Ev ?C T ° Y .Q r. .LIABILITY POLICY NUMBER, C y TWJUgY 9 0 r I ?.. E M'E 2NOINJURY; IUEESVAMT?EPOKriW ADa DDRE59 ------- rbN41NNgIF31 - k IDEAL NAME AGE 0 ___ M. wAmE - rxrU .... _.._.. _ SE% ADDRESS --?. ,___ 3 OubE I n,NfgE3 .. _ ® O SEE - .i lbN Ur AaDtrogr . _ _ - Ea r[NTO FS .. ----- S7ATUSOFWJUREG MARK FIRST ONE THAT APPLIES w4"?vA bN viroecranr ®© WMEaH4 pPASS NCEK IN VEHICLE DwY?HO rlDN asAwWO ynrE STATU90FINJUgED --.' QPF quN NO. OLLE0 s[nHI ly,xpil ?MWFq MARKTIRSTMIETHATAPPLIES CWPV.wr oN-o snww0 ull (3 ": ? 50 eQ IOfTPOFTCI [3P-HSIN NOVENICLE KILLED YK [I N IN' ql Pau S _ ?, UW NOpTM OY ARgOWWGRCLE 0,;. CKR no YIrrwCwf I?.t waC,tf W nxsaKgAU O '? ,PXU%O, WN.Yr n '? DESCRIBE BELOW WHAT OPENED PPOgTO VEHICLES 8?YNUMUEgI roLW cr%u , - U I { _' I IN41 inE ?r mv,? rY"?• ,.`D°'« ? ?`?'? ? ¢J-.1 e.,l v. N y t ntLK"`EltNrgl01 rw r N4c - `,.! ._ Yl .. c:f.i rn `.,I Ina ?? ,1rj_ t ' 2 NUa•lu f/KX YGFYF ,ND / , ?? . /??r _l T n r, 4 . r wrcloNOP lruvFLerAwlow do,.. 'c•L.S n.__ _ -?C? C?•- rulc' d 11CJ m p _-0-. __ _. Q I • re Oql ?lw 5 fi' u a `sh ' J.r l.a.r!?-10 .'1 7-7 77-7 ?i P PAa MIKLmAr ' I iG ___ 1 t 1', IIIKr r{ Y - E „E? EMICLESPOSITIONSBEFORE COLLISION , t L 4 w a LI ??_ { a 4. HOLE N ! F t) 1 , W ON STREET OR NGHWAY NAME OR NO IN DNI tDAllr eT-aVO L[041?VAUMEO v[n,CtE OCCV40 N L? y •, M F 51 I ' IYWV tlI ? ? ? DulrCrpN I INVEST gATEO GY 1 0 us ? WI "° ?i:i:a ?P°ar",u '.i IJ ?S', !c } W o°I"KWN « --pp 1 ?1' OCSTRµ WU USINO ? ? EMNI w ' ' 'p 1 Yi? F4 RGAOSUn/ACE 1 ? SDEW4K 2 ? W4KWAY GAOSYq _ 1 ?tC I5i 2?GIIDt1lMA FROM DIRECTION ?T YM9++• f' IfMMpAI W[ANrER EXLIiCONOiION! A?C TO DIRE 6 ? CTION ;y` 1 tiLr* '' Mf! F HY?I iMF/IL LONfROL Iavty oxrl TYPE OF ROAD w4v CWesw4K ! k? J .jF„? t,' C OTHER ? ''1 { 1 M)• 1 ?CO?tCaYU1iorM It GWERVVENICLE ACTgNS r'1 rA„ r 1 Bp ur .ACaEr E QwrLTalli ? 1 ?EgN4a Ylwat t c6P«?c?wL IwCLHe1 ie?weli aetn wnl' ° :'? vyy? S J% V .p? ! Q WET S 0 ?? I?a AWN ET Q 2? "OF SIGN ? 1 A0 1 ONE WAY r 1 ? OOWO ITANdR 41EA0 y;rye°?r 1 M I •I t .. , ?' r l Q ypW, WlK ? 7 13 YIELD SKIN ?? 7 BJ OVA S BLE 13 TWO WAY 2 ? OVCF INO AHD PAS&W Ya ^ 1 ? 100 DMK.l1R[ ? D ? P WII L. 5 ?r }Y "F • ? IC[ LO=T! ON { ? E ? IUSNEq q[0 ? ? ? 2 ? MAKNO RIGHT TURN p 17 it tTJ W O1MEn OT OM79rR(!TFI • wiG.CN y111"' M ! ? SPTGfY IW G=!Rryl ° ? LO=1 O ? f C) ILAyNp A40Eq Il00PJnAMµOP1C ? • C] .0-C) Lfli NRN C8 NOT llC V i q'y 2 fil 4 .T AION IDII PA 0AN0fq ° ? irnicrMOLIDIEr! ? ! ? AA LsON4 ? ° ? ALL wAr. ? ° ? MAKwO u.ruml ?? rYCM•DYgW WTK,CtbnElrtl C] O SPECIFY THER / ? ?lllT fUAN ? ! ?SLOWINO ? ?x ++yy l C /? ? OFFK:CA:FLMMAN Lµ L! a i'riy ` G ? • ? OT K0. wO/Y ? 7 ? STOPPED FOR rflArrq E , I t 1 SEPAIEAtED , lyyis3 ? ? ? ? ? ? ° ? oe aionDaO iaN'u ?,, I ?. L Ir E 4 A t ..h, I?b L dpi nw, ???,? ? I I I r e l ?b F C F { ? ? I '•l r? 1 7 7 / i i' t I I I T ,'jl ? 1 h of I "?- `dZ ?,. UEVAH I' MEW 'f - ADDITIONAL INFORMATION SHEET/OFFICER'S REPORT S u ROM n? LC?'tS?tie ?'?^? GATE TIME ' .! CONTINUACI ?7,lsu?aj-t7cn C I f Y: 1 w .. .L./ I.! YY OFFICER'S REPORT REOAR[?INO D '7 f _ f Y ESTIOATINO ORRICCR C•302 I? - I - J ?n J UNIT PPR 01 Y~11" Z PAOEB ' a OR g/ ? . Pl,U r Iti I ? + f ,rsla9 ? 114y T ?} u'rrJ v 1',1 aI t yr' , ? ? t k ^ k tl! "? \tl ' e w ?,.1 Y? a2 ..t w„ sac w lM.}:.?? -.y6 ??' _ }? I +1P?r+. ;-n 1 1 •7- +s f ; I I:E .ISM e?9 Ist F ? • C Fr .. I Yyfw??? e lu+2y)? r sY,l TE OF WASHINGTON AGE E OF ( ?u ? ,j??{x , SM No. POLICE TRAFFIC COLLISION REPORT ITRAFFICWAY pp11CE COMMININUMBE4 PRIVATE WAY 7 I f.C l IIMf COUNTY COUNTY NO. CITY NO. {NWA ! - 1 ly A?rj . i lusf a.DDNOURI pURR aAN" >u. ER. rwn; J..E. ?.ILU .?:r1=?9.S:r:1 u q yJ,.?•?' u pNmE N CI OR TOWN E6NOOSIRFEIORWGHWAY IS I'ADMISI ROUTEONSIRE1 I SECIITI a y` z ANLES ?5 ?w aOF ON Z. u_?C_il.'l}• ?:1 A3 J-77" as s . INTERSfCNNG IVIIH: SINE 40M NONINifRS/fOC10nn /1 I ,?jj [L PREfI% EO. MITE POST nZI'EN 'Ll STREET 61 1 •1 JL.1.'• D</ p(Rtfl O • / / f?f i l DI 1/rN f pl f NfifR[N CROES S1NfEr O4 NEARfsi MllF S ACCIDENT aAMP DIA RAM MIA •y E I1.. T"F ' W ' ILrtf5 EI CE.vrE,4 Ra M Of C a- CODE E COlLISgNINVOIV[0: LRIIYI FIT. %?RO IN IN Rf 04 OR Rf RNCE {aJ TOTAL NO. NO KILLED_NO. INJURED- ? SPIILAOE NI°T?a'6E"RRfffUN wlMio°io'i" IMER C15. CROS$SrRfETOaOaOA?p Cf V[NIClES Q Q PROFE41Y pAMAGE ONIY ? FEIRST)LIFD SFNICIF) OBRCI SIRIKK(NAME OF OBE[Ci S1RUCK AND pWNfR'5NAMFI .1 DAMAGE sF -CODINGLbE UNIT NO.1 UNIT NO.2 p VEHICLE p PEDESTRIAN p PEDALCYCLIST 5 W 4' NAMF: LA51 I 1 RIV NAME: LAST r 1_:°1 `, nt`. bra (lInF1 S?I)RFEtADD ADO4l55 _ •? llREfI ADDRESS S2 f Y ?I7_. ..?-L.L I_r11J All qt'-CD. IJ -CDIJ Op[ SIDE PHONE NO. D IIY 51ATF IP P KNO. L• LJI DNNfR511CENSEN SIAIf tlIRH I UIRV717MINSE NO. ATE k DATE tlIRIN Ills A) r. c. V e OCCUPATION FRMNAMIAPHONENO. FYfS VrFIGHI HgHr E OCCUPATION FIRM NAMEA PHONE NO. EYES f IGNI KGNI ,2 PJJ ICa 514' R ?CHECK(f7 [ASAN VnFE rF[of ANpm[e°LL pCHECK (?) sA uMaorn of ANOIH[eu ??DDmm ^[T' CODES ?* 7 n y, vFN A ip1. 5 I plus a s'MOM,?ac.uf CODES?+ ] a u HnFAk °in rv1 5 u " e'AN" ?a> J INEIRU' `il T"lvL'E. ? M /. F 7° '° p AN«A H F ? ME ? MI ? O MIVI. Cr S? AM O u6" ? 86? vl co V:j A la? li "E.. YEAR AMK[IDODCf?CHFV.) 110Aa1 NpvA1' SIAIf Ia DR. + ( wun V.l MODfL(DART NOV ]7- E IIA A mE;: A vorKEFIDENnFgnuoNT°o. _ C HI LEI Nu I A N ` 1 L RFGISRRl00WNtR: LAST IIRST MIDDIE %gN[NO. O VrN[R: 1A51 fIR51 MIp r Rt55 of OVMtR _ NER /F]I } ADDRESS Of D n t I 'v ?.17 17 r.C 1)a ,nj•, ?? { r? •L?V I v1.1GU N F2 AAIE 4 ADDRESS OF NSUeAIA:f CO. OR ADENI R R- OF I U-CE OR ?_ ]] 'f Nt I ]- M ?I(:?L?('.l?_1 rE 5...?E I:C•LC ??lE?'C r_. '1? !nf ]DAMA jI AREA wMU ' puM RD 4AMAG1 AREAM 51 t H Nu IIOF , prwKRMa CHMGE CHARGE O114KOMf 1 111. DAMAGE DRIVEN • ITOP 1 ` Y,I E 10 ?OIlDii ? WAY Q1[MNNIp _ ? AWAV ?a[MAIN[0 ! I D I .. fE}U',I`"y ioE?per ?l E.. `ICI ti 1 ?rper: = IuiorTbFf Aw 'In DIAGRAM OF AWAY __?IRerRN[ussARn IN ?rA?PnRr oRIH DESCRIPTION OF COLLISION: ILn[5-L1W TALSI@IIFNECfSSARq ! t41•. L Lr C"U. V£L LI I.?T [.E 1•.I` 1 ?}3 u. Ql-.?." {].?? I`r? .. `. 1 CF, L.L L. 1+ r l_ 4 t' 1 1 I 11...1 55 tl. (.. f 1 c !,+E ,.._._ ? l .ar[< C?• ? Lr^. n;.iL h.• ?? R?_:i?/) !'"It7?- j) r I . it yRL •' .., ? ?? ? L f? e?L!' E NAME. ADDRESS 8 INJURIES OF PERSONS INVOLVED u CODED tAtU e" ?r ?+ RES 4 5 N? rna ra.6? T Y hall,` ?f?' , N ' ' C CCUPANTS NTS /WITNESSES I Y t L) TIP t' 'r f ' I .L pT ?R a \? I'7 1 E ' r ='Sl 11 ,t O r Iho Nl.rt pro e Q RI ) Y 1 1y - ADD- R Of .. ly rR 0AM, Ofo ' OT" T "I""- F" . I r N ^ J A,-t" tus?: O?:`EO"D«.Opx OBI. ua RAasroAl..DafefrS ljwf el NK eMOUa AGENrf KEOn uWO -...1 ouETn 1 APIeorTOer DATE ,? } P I T7 ,! { ?? i I? , q H0. P E 7. ( 1 v t ? O? M M Ly ?? TRAFFICW Y 2 A 1 POLICE TRAFFIC COLLISION REPORT PoucfcoM ANENUM6Ea Z J] PRIVATE WAY • IRi _ DA .Q j' 4 N Ia7` I / } A SwY. Ni IXT wIDI I IGSF RKaDHOU4) COUNTYE?}?., EI-IT fY`?R LT)UNIY NO I(/ GIITM1Y ' /HWA ?VRe Z , CIIYOR TOWN NNAEINO.d51PFETOR HIGHWAY ON Qf JVIN Melts ?5 W ?oF (,J.11.,.CElJC-" ON C45 RWIEOR i j „3295 O GRA as INTERSECTING VnIH iRff RROAD NONINiERCCSEC..110N 5•?1? RE,wEE-:5on m 5TREET IRffl% E - MILE /-` i ./. ?? (T..? DI IAN DIq .CROSSSIgfEtOR NEARFSiMIIf I M4E5 N . Sq E W LJMDW NET OF ACCIDENT MILEAGE CODE IAGRAMMA COIII TOTAL TDTA N01Vf0: NO.KILLED KIIIED NO. -ND. INJURED- ?SPIIAGF ? 16RUN luY(oiH .q0 IMF CIS IUI N ,k ElOq OR MHaf, Cg0'.,s Sig E[i OR ROAD n d w6pas p IR PROKFINDAMAGEOrLY ? FI[SULTEO ? VFUiCINE > J ?J?J OHO _I,_, Oe6iSTIIx:KINAMEd IIEa STRLKKANDOWNER'5NAMEI EST.DAAAot rompODING E V $ - UNITNO. 1' ; UNITNO.2 ? VEHICLE O PEDESTRIAN - ? PEDALCYCLIST S D IVE's NAM: W l rvFR' NAME: V.Si I 2 STMEi ADDRESS FL H b REETADDRE0 iAIE ZIPCOI% PHONE NO. D tY TAl Rl(1110n WA, 3 o R lz wrvCR'1 UCLNSN STALE d N A -lF M 3b 2 0 b)A f% H M pq l R.. lG ( IV R' LICENSE NO. A f. DAi BIRTH MD. I R. . OCNPATION STUDEIJT NRMNAMEe PIWNE NO. [YES IGHI HEIGHT Al /Y j Sa E R OCCUPATION FIRM NAME a PHONE NO. EYES WEIGHiIEIGNt - ?CHECK (V) YEHKIfw IYFEdANOTHER. ?CHECK(.l) vfwClE ASAN NAnonfdANOTHEa CODES ?? 7 a .° s i 6 NO . CODES ?* 7 a .ss A°SM1r 6 5 Fac roN s Hr Ti Z - 1 xMIE r ?tµ iB: RDM ? AM. KI ,I ? m. ? K ? iuL . tH e,RrgaM ? -- p Mc, ? MIT. 11 Y, T ? iLw1. VCH, YEN IMKtf?IDODGE•CHEV.1 IDM1.NOVAI SIYTEITDR: V.). 19(o7 VODGE DART , .DR E V.) NOOfIEDARE•NOVAI m CEN U S1ATERA I[R RATE NO. SIAIE H VFn R n U ! Z U6 GGS626 WA VEHKIF IDFNTIFIG110N NO. LI I 13f I 15.1 I 10161 II I' I I I L V HI ID N I A - f l I I I I I I I I 1 ! R[G,SRRtDOWMR: Wi NRSI 'MIDDLE PHONE NO. l 1.1 U. O IS WrER: IASr NRSI M . • . 1. ADDRt53d OWNIR N ADDRIESSCROWNER ISI NA _GGRESSdINsuRA co.GRAGENT R t[sSFR'iFSgrtA7CfC R MMAGI MIA pW'C qMr ' D HI.YMOI CHARd • I Re oI{.k?HO l1WMOI ARIAA CHARGE Oia1RD u 1 -1 H S I 101 10?OIT0? t "I,- ?AWIAYH ?IFMNNlD . - 1 • ?AWAY ?RlMNNN i$T.DAMA 11- 1 IO If01T01-, ?OT $ AWA DeY: A 1 ?iON•ED eY: s Is DIAGRAM OF COLLISION u I N INDKAIE NOgro .., ( Row .._ 310E UNCC{SSAR 1 r I . I , I i ; I i I J 1 . NN .. ._. ? DESCRIPTION OF COLLISION: (aR sdIRMENTAL-1111 NEO-Y _ _ _ ;DQiMQlaw1).Osr.. comorr one _cuR0 wt?r? -.:u ` 1 11`1 :T, i. WESr•,C?OD.If?TA_E11Si B?.c.Au ____. ANP - { ;. 0 °` SP41?.f..NILT- -.UP-IN .01TCR rACIAG_. , ; - I -! •- J` L R NO TN- ORTR EAST. MIDDLE aF CLtRU TD_. WIJER E J . i E V H IMPAMD... 1PPRX .100 SKID rNKS RAG $ • I - Y • .I I I ? E S& INJURIES 0 PERSONS NAME DD INVOLVED * CODES 1 - 2 3 6 ? Occu A TNESSES lusesu/nV%eR. X. AMl S I lx AO! IAIUi - u. r. '« .... , Mmc ...- __.. 1-111 IIsta, fjtcl NAME: .. _. .owns HArrR d r ! er. AM e. ? W, ? M ? l ? IL41I NAME YMOVIDIY ?AMe. ?m,,Oy,,..nMy ?MW b A .own " 1LIIRI R t sr. ?AMS. ?'c`,".H ?co:n. ?UD` ?r".°.:.Sr •'u Jim, IKII'/.NAM 41 x I.Ofil01 .G/NCl' KI D,SI TCND x].IIMO WRdllnwl AIIIOVID eY DAL! OT, 0 u.. _ l: :?c'i1e R.'L.. ., U• 11?':'k -?F'?' _c'?ii.. -?MZN'?1id `,v 1 ?z'? POLICE TRAFFIC COLLISION REPORT l--}TRAFFICWAY IpICE COMNAWr NUNBFR ' PRIVATE WAY y OA t N 9? DAY ° 9a'/ `r u0 NIS A10 lM ?er Yr " (USER<p? MfH [ UR) Me' OUNIY ? ? f COUNTY NO. -'No. ?fUR•wN N CITY/ OR TOWN Fa NO.Oi SigfEf OR WGHWAY ?IN DN [5.E IGl ClS S I RCNIt OY SE1: 10 rV AuuS OS DW 6Df L%C (GG ON `G2.,;(i cI< rNl[45EClIrvG wrM: SlREfr N Ap S ?? 13Z7S0 `: / / NON INT R CrION _ / n ?{ lY NCB. BFIWflrv L . k N'AEiiIUE}a F Ml SiR[[i 0159NCE6pl 4 R C`y 5551RFEtOR NFARf51M EV05? ACCIDENL I PRFfI% FO. MREPOSr RAMV pIAGRaM UAfA V_ \,y?( I1F5 ?F /? / { ?E D 1FLi Oi Lj CS MILEAGE <I,I-Cf CODE CRIISIONINVOLVEO? VE l - t M FS NrH TOIAI NO. O%ILIELED-NO.INIUR[D_ ? SIRU.LE ? 4?qUN ,YNDND M Rp 1 q TOR OR lNCE INTLR CLS CROSRSSIRlFIOR ROM ,(Ty OFVlH [,}PROHRIrDAMAGEONLY ? MSULIED ?vf icll OBRCI SIRUCR(NAMEOF OBFFRSIRUC%af10OWNER'S NAMFI III. DAMAGE 330/4 svE[IALCODIN- - UNIT NO.I UNIT N0.2 ?VEHICLE ?PEDESTRIAN -? PEDALCVCl15T 21 3 bl K N U,_ 1 I LSe SlgttlApDRf Rff1 ADORf55 Po M srwrc ngcoof PH frvo Y'n W 9G-'i73C D R II swf zIP PfAN t N C[NSFN 84 i q?7 51A1E l. oR I ' tlruN A off, Ii d" I V N9'1 UCEN NO. SIAIE X DAI Iql? OCNIAiIOIJ fIRM NAMEaPHONF NO. FTES IGHT le- E OC4A"- 11RMNNAE 6 PHONE NO. EYES IGHIN- -- a RrA ??SO R . D CHECK (? ) vtHKiE ws nrv Maornw wrvorHru? ? CHECK(,I ' WF ,CLEaSr NrMRlOrffOFANOrnfR A` Pp. a . CODES ? 7u i 5 e 6' ' ° . . CODE$?+ 1a %° s ? `r E> , OS s „ wnu ex 6s ,,, r ?w DISpM o- ? roS ' ? E3nl• H ?:c e ? C8 .DU a;IdYf ? MS N r ? M" ? b41 ? ?,:° VlH. Y GHfV.I MElOFI IDKiNWA I S1YlE It UR 1 vn.I AR ( f HEV.1 Av?pEl1DARNN VA) ( ' ? ' 77 ' F 6G R SI? ` E l1 N Ilr. SrAIL Nltq MIf NO, StAlf H vtn.caoR 1 - T 1J 542 W #? C VIHKIl IplNilfKA110N NO, vtHr IF IUfN III e H'T!01315!OI L ! 1 1 1 1 1 1 RIGI?tf^!O WN[R: LAST {1451 Mlpgf P1gNF N0. 1'f WNFR; IASI IIRSI MIDDI w " IS J ti ( till 76ti Y73 ADDgess arowrves W "? G ?Y`)i (?}? r N E w FR Ia AOOlessolNSURArveE CO. oR Aeervl U"k, R DI ` GAMA MU n NSRrnoxK C y 3 HUU .. CHARGI uu<noNM EAMAGI,DMG• r? 5] ?• gq AMAG , _11D1 .. iilom. a l51 DAMwGI AIAI ?•LAWNfo 5 ??WAY ?REMNNIO lSi ID IOWID ioTTOU $ g? lowED 1 ,S ? w wY •r Br $ DIAG OF COILI$ION• AWAY 1 _ sllenli fnauAl 1 j?+?Ae?rn DESCRIPTION SION \/ Luse suP ?fN ..f to eeesSAYr) I I T ! I I I ? 1 eL -7-- ..-OS n,Oli..E'h l?wy?y? o i ! I f I - } +. ; r Fwd . .L a/ B-y ?d ..A4. 1 ?. s T .._ !__.. .tiY6E.lE..a? C.S.Y-v.s.. CrOS C r _ 1 -f oT ._YD? ..4t Y t)... CU i+- ueSkE' r ` t ._{ t i - _ I d >I 1- A. © or;!?s/>-0E , _ .c o, i? plc( ? i ?? ' ? ?S >e P ? ( -'... j?( vti _ ;.FIrP rl?? _ o,., __ t 3 rl I 1•+el _ x I 01. NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED CODES I _ 2 9 4 5 6 Mme su.nlnvNrAl sr OCCUPANTS/ WITNESSES nADplww NAM •u l51 AGf ,Al U. G N N rlx u ' •rn w - ll l• w F N AM/: u jA DC o 11 n D 1- y736 r - . N oD.lSS rvu Ea , DAME ?F41' ?N .D? D": D ._ ....... ...... HO. -. A DwESS NArE»!a .. ID rvEm ?AMe. D'r`,`R' ?^F . ? ? D ;° No w eona ?NV5s1 +if oar< • lalllrvi' irw rir DAMS ? ? :° ? t,,;;,. ?N? D :°- , S NAMIauN% I x / . eAUU D• AuN[. 1G. SJ• °v l? Kl r5f cxo O?o?1 nXK1 ARrIV,o own l»n,wr 7/) y-a yl . Aro•ov1D•r oAn l?lY r+. r r Nk r/ 4 c - r: ez. .r„Ar.v. r . .... _;r-. r.,,y. ..--vvya,/rE•, ?,1....- F aU 7,;v d J ? Prj11 a yyy???} H? 1 I? ?_. Ir yA14rf l:' - 1 1 (' T I r n? 1 ' Y F ?S L ?4 '-x . ti?i '11 r1 - {Y. (} + r } _ l 3 F v Y f I s f 1 ..(fir 1?9 r E ai?hrl + ,a3' V? ' 1` i I ?? L Lr I? .°c K ift OF WpSHINGTn"1. ,f. Jl ISrlq(y.Lq,,, td \trF V" P GE / OF ^7,• NO. ... 1 ' POLICE TRAFFIC COLLISION REPORT TRAFFICWAy PoIICf COMRAININUMDfR DAU OE IXu3 N ? PRIVATE WAY^al yq W - ' .- .... wu[Irr 7 (usf a roDloua( wurvrr NO crtr NO. 1WN ?E IN CITYOR TOWN Of S211rR(1f1t1OR-A /? ?URBAN T ` ? I NPME6NO. WGHWAy 013 RAl fMEES ?3 W ?Of In ON Js- 7 .? ' IN,FRS[CtING VAIN: fi 9ROAD NOI N IC INTERSfCs IION^ c,l, ? r RWiOR 3iaC .......... /7J?L? C( Pq[il% f . MIfPOSO 9? / / Y *` AJ p151NICE plq M '? ! BEIw[fN SIRfET 6 SrADT D' 1 REf ,CgO5551REEl Oq NFARfSiM if 5 L '•] F A W ACCIDENT RAMP• DIAGRAM MI -a. f[Ei OF C , f: I Iii ?ENT? ?A. MILEAGE COlLISK)N INVOIV[D: F fR tY: ?OOE y IOIAI NO. ® NO KIL(ED.No-Al ED- ? -LL1AGf 1I UN WNpvrO?nt :.AD N IN T R 0. RO At as Cf VF NO PROPERTY DAMAGE ONLY FIREU(rFD Si INI C, CRp553iR(Ei OR aOAp S •? OBIEC, STRU11 is CK(NAMF Of OBIFCI STgUCK ANDOWNFRS -A) ? RS -I' f51-AGE SRCLLL CODINGIISE _ - - t s DH A ww.E: usT - LINITNO.1 UNIT NO.4 • flq r / m' m pglvEgsNU,lf: f9SVEHICLE ? PEDESTRIAN [01 PEDAL CYCLIST g /l N Cx S! i i 1L RT r L _ STREfr AODFFSS / ? SIREfi AppR ??-1• t4? kt// R -_ ?u ? '73 8 A , Sf K aP'?' ? d3o r-i StArf ZIP COOS PNOIJE NO. D rr /3I A /??•/t SIAIF ZIPC D p ry( ti ORIVlR'3 CENSfN CN wa' SIAIF ?? ??5??/9S R Y4,/Ce WAI, C NI, MD" p, ly /6(s -P) 6 732- 4 v s F- "E r'IS N !N B v (I f t F/N,SE NO. )? If DALE) BIg:, - B OCCWAIION iIRMNAME6PWDNE NO. it? ` ?• _„1 ?? m L[? ••/r ?f/ W /1 Ji?% ?2 I Fp I?/ EYES IGN{ ERIGNt E cwwr oN ilgM NAMf d PNONF NO. V - qz 19o &I, R fns wfIGW{ [cmilr p - _N ? CHECK (?EN nEwswN OAROYFf o$fAr?omfa'N I(/ /4S ./( '} r CODESNo.+ G nA,. rv/ d W' C 5 EuaoN / B WInecrc ? CHECK ((? I VFNIClEAS AN fMROY[E OFANO{NE- 2 INwelos .sll CODES ? + 6 sMA° r a> ?'"°"'" M ? c$drre w:I"ru a uq; p r r O 5 Ixer r onic,cu It7 a °? v[ Yu. AMKf I00DGf.CNFV.O n(DAxr.(IwAI .fsns(IaDO pnv? s°2Y°e: ?.wN%.I;n ? P n ? EBdne ?p.°.„t. ?~ MAA 1F t I 1 ?T7 / C•u R-ol !°l Al 2 Q/? E ?//JN r 1? M ( NFV.I NoDE((pARr.NOVAI KuE(? f. lIC[N fPUr N Stiff IgNIfR P,AIE NO. SrAlf I"I VFM CIXOq U 5 Dp W ?/Ev ag Gam::, vTRS'£f s wI I N . t VFNICIf ID1-11CATIONNO. C I I Y 14.5 t+ ( Vf CL IDfNII N I k .?J !1 'O. II lyl7!OII L3'2' 12 (>I '.'J PFGI31{R(DOVMEq: USi RSf MODII PHONE NO. olz i. I I ' l i 1 O IFR[ OWNf4: LASt flg5i MID LE 25' N N. - li- AODRf53OONN[R C Ct J I UO.n 5n N Cc rvr /T/ W Q. S r E - N (R ?I NAMFRADDRt53 Of INS(I4ANO,CO. CfrAGINt E a R A I-R n c ?1 L: b C O ?• 11 DAMVLfDIAG Z.ri {.. //fI IC t, S. t/l0 ?a y l I t5f%MNGt C-Aia CHAR( AG U. I - . . i ' \ I OK Or ®A ? P[MNN[0 R Ornlepupe f ` Q O(7 11=6 ? MWID AWAY ?RFMNN[D E AG?f s { '' AWAY Rr -crirr DIAGRAM OF COIL ISION J. N AL INDICAI NORTN AwAr ar: S Oaf JI 1 ,' !n[/fUNee[3sAgri er I?ROw DESCRIPTION OF COLLISION lui[surn[fri Tµ3 [[{n NEC[is 4Yf D r // :V@. 1.. 1 W.h? QC. A I f ...C.4 ?.. Ol' .... _._ 4 ? .z"/fc..??dip Ti c// /rL-r(.( .y. .{ Till.: {•,? (L ..?[?vA?"t... ? ` { I 1,;. p<;A '. ? 1[ f.irlav_ V 4 L r.,l rL rn.?_6'?ftK ?/, yp 1 Lvlr "[ (ldf?ifCL.... ri./y6 1 <rs{ 5° q , I r' rn NAMEP, ADDRESS A INJURIES OF PERSONS INVOLVED + t- OCCUANTS/WITNESSES lus+swnlMfNUlslaa CODES I L ? xI ? roR ADOnIOrfA(NAMSSI __ ...... 2 9 4 9 y ? ?' , {L I NAMr S!% AO[ 5l IUS rvnn M,r l - M,Cr f. uAl eR Iq S/ ?OY. N iv<!rl S ;p e01 Iy faer AMe FeRfsr4. (ntr .r s f 1 31 r? ! h}I 'L° r?„r I ' Ii i`t' C ADO4ns .. .. NO ? a 4 Mwto rR ?-11 ? KI ?me ? Nx ? i:lw ° '?rt "U?'rlf7n 1 `I b l f J J}Ft, IW1Cn JJ I,1L tl DOel14 l5gpwlrp OllCf YS NAW dRAN[ ?? _ NA INAleYS 5 A4 er ?AMR rM i t,s ?'t,.: "E a } `' Y:" x T,. - Il . s h elD w0° AaNCr Nv.(w K1UISrw10aD Cl K%AIIII- p.,..,,.._? `'xr Oco:?I. ?6 ? ;°;,I, Ti r r+ s. L. . Jam -V < - - S'I AIL YAONINUI u,, MOTOR VEHICLE COLLISION REPORT . J. . GATE OFCOLUSION -_ NO [w y ?.MY.OF Cpl490N ,TIMEOF000"IB - lEAN -, 5 TuE4 WED t W E.ET lauq _.E. AM CCVNTYNO CITY NO v - -?, vim .COUNTY GTY. TOWN.:I.:.: enE M0.E9.;V 0 WN..:..,.. PM C C S © PNEEx 2remsr cT ; cccT CN:?wq?.l D'ee rc VS 2D M1 " .:.GIVE NAM PAn ®B ?..5 .S 7? 1v?{]I Y'f S, flEkT.flOADOflryIOMWAY.:..i.._.<. ?,;:, yTTER9ECTWO WITNI. TREET,Ofl.ROAD.. PIjE 1% EP E OSi. L y .T NONINTFA TK)NO C SIGN V : 1 / /. ??? CrncljAM 0 TA 1 r 7 , BETWEEN 6iREET.VNO HnMP C f HOr © UHOVY SECTWO9TgFEtN bH .-114. 7f '.,?(L .1-.1©® OF PAAAOAOCPG•S STREET QAT. A, IT W4uLEM5TOR rIAOL BE TFVWO 'TEN NO %( U INg1yEfl C4. I FF KE L 9 Irow Or LEK1rIHrVLVfO ® EIKLE VEHICLE ? E CLE ? BIWRTEI :? P? ?j/J p . 'M T.? OPVEKKLE9 ?IEwCLE09KGr ? E E SPEC.000ELGE, J l +3d.. , .;?? ? ?) 1 a( Rq4? I Hy?..'F( OBJECTSig OCK NNLE-PEOESTHAN ?raH ? HIT H .Y)'+ } .TNAMFDPm1ECT97PVC1 ,. OWNEROFODIEC78 NAMEMDADORESS ..- `-'LOCATN ,J - Al f R Ap - ? © cr ET TO • • F NAx ....I FE DP u?o?w E } DRIVERS LAST NAME .: _..E1R9T,NAME -MI_. m CATS x ..._..:.:: E vEO -VERB TNAME ? ' FWSf NAME MI E.? . ,i.. Si ETAODflE59 ...flOUTE NO.ANDSO%NO _. W THAN Iva RE A E9A - SON WFILE .._ 53(D:;w....eDsR€NO.JIJJDBOJjO ;:. .'?ryy2y' Sa CITY EO UEE A pa- STATE:'_.. _.._LPf.ODE DTPYE9@CCCUPATION fPNUrE CITY nIWN cowslDN ^,.:: flTATE. Lv};-M"7?T'S9.OE:' P91YE@39C64P IJ 2'? . pl RE TiOTW Wd V fa? > I ` ' PJ ORIVERSAFEN. NUMBER :..: ? ? /Q NEB 4Cy'.. .._?A ATE -SEX -;OATEpO y&R(F .AGE... DRIVERS UCEN9ENUMDEfl.:.:?.;:__.,,,;, , STATE. 9E%. :?D.?TEOF &NrH;,;,E, Y vENICLEY x A ?? ., y w6 M P Aa D.r rE.wy?T4 J- LICENSE P MAKEICN V M DELINOYADARTL'. AODY SLYLEI2 DRT;?_ YR. tGm C CoA3rc O?P VEHICLE MAKE ICHEV ?pODOEI. MOOEy( YA DARTI.;,;_ OODYSfYLE1BOR1. ' y. . j -A ;:? UJJ:f(O? ,?,STATE,•f `:.TflAILFR LNaTENO'-.:. STATE ('f Z Ur_ .•"., "' ' NSEPUTE NO 1 - ;. STATE <.-,32? ?? +._TRNLER PLAfENO. ,? VEHICLE IDENTIFICATION NO STATE L ,S II B88 MODEL96NEWERI :. ODOMETER IMILEAOE) VEHICU"--1 IFICATION NO.; I k ?? S/I/BS9 MODELSE NEWERI.. . DO METE8(MILEAGE) ' RE019TEREDOWNER. I.T:IFINSTMIDMENAME' n I... + .i';;.DRM1'ERBUCENSE NO..._ REOISTEREDOVMER (UST FIRST. IDOLENMIEI... pnryERS EN N M LK: 9E 0 -u,., BWNENl AODflE^w (SIR Ej.,H -STATE)., „"..';;.. ,?OATEOFpIRTH :.. OWNE-SAODRES " ; G a uo wr rEAq „)::.. ISTPEE;CRY.AND9TATEI ...,: «.:..r..:.; DATE OF BIRTH iL? ?? u0 wY vFn.. TS OF EMICLEO AGED. u.TEOCwr. ? O ' `OL - PARi90F VEHICLE pAMAOED 1A ' ......u. ..:. S!. P _ LE _r LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- WAS THERE AUTOMOWLE UABIUrY wsuRMCE ^ - NEE ANDADDRE590FLMDIUTYINSURANCE P.01JCY1OLpER COVERAGEIN EFFECT FOHTHIS ACCIDENT ON VOURCM ?YES Dd Ey .:I. NAMEOF LIAEIUTYIISOR CECOMpANY- ?NO N EMDwEADpRE5S0 IUTY WSUfWNC T.. ,_.. • S ,..' . prT N G€AS 014 ..: :' T J TM1?r. L S LC„. -..:. 6 Fv Sony ra+: ?- '- - _ 2NDIMUnY 1 SESF?AAAIE RCPOgri011 ACDfK1NAL WAIrvE51 .. _:. NAME V .J ' .;.... .. TOTAL NAME ..... ME y ... ADORES,,/),L, [J ? --•_- ..... WJUIiEO .. .: ..'.. r _ SEX e. „w U _ r 9i.AiU4OF IUUREO MMKFFiST ONETHATAPpLIEB AlOxnrAOOCrom ®DDOyEOn ?IKw[n II VEHICLE IwAN .Aey a xOrI OISAOI+rq xE ATUSOFINLURED MMXRRSTONETHAT,-.-,- ?R AV [ILLEp Era wwOn1 1 F PA55FK0lA KILLED OI9AULW OSSw { r} t ?UNUP1':P1Tnr1 ? 5? 8? O?O[TCI ?P[CESINAN NO INIT. ..-I B I ; erCIT M SHOWNORTH 9YAMOWWGRCLE ONITI Wq N.lel ? eO sO 70 (• ,,.. HLVCn[oq man.mHN OESCR DE BELOW WHAT HMPENEB IREfER TO VEHICLEy BY NUMBER) WWITIIAPP[ .. Nt0 y :...... 1 ?MCL THL ttMer r .IL.. _ n .J? ,J TO, J Nuuefn LACM WNKAL ANO M.OVN '? CHO Its •*•m a VlNKY! _.._ _•"""• wwuM• vlHCU v[NCu N ! [ W ON STREET OR 7WAY NAME OR No. DnlC 1qH UONLV LtAnDWB UDAMV rAE AK[ Aa ?rcuB .. ? ? ? ? a ND m blNR 00 0 ? 0 0. .?0,?OKD , nn[IAAK ? ? ? ? ALGKI ,W wAI INVESTaATEODY ' OCCKD ?S.MDL ?DIOUGI Mutt ?DArpN ? O1lMI W 1 MOLSNY lWIfM WASACULEq CnONNp???,', j VJ I '?90[WALR 2?wu%wer ? . mou. OIECTION,.'. TO .DIRECTI 11 .m+ nOAB ] swuLDEn . ? ? 'A•! ? ! WEATHER LgHrCONDrION! _ 5 !B ' 1 KHI a orHEn j ^ C, LYSI TRWFICCONyRDL. IwC, OKi TYPE CFO— _t Or ROAD. I .! Y[r.cu auvenrvEHIOLeJLCiroya ) IJ T? KoI I ?fLiR I `OI 'er.cut ?;:cdilaf ru.cu a c:?w[onigqu• y r r-L?%r,:{ I ® ®DLRCV 60 DAnKKr ? I 9O u! pKn Y y A iI f 7 tg MY J ? 20 nMrAJ 1 I Y!1'??[WAY ? I O'CGHO STRAIWT MEAD` t r .• ( V [01 2 O WET ? ? DAWN O 20 SIOP SKIN O 2 O TWO WAY 0 B O OVERTAKINBANOPA9NNG E L I .. T ? ! O °hOPI L ms • ? DABUS. RK SIRE[! O ] ? YILLD SKW ? ] p1 REa 5101[ ? ] ? MAMWO RKINT TVRN I ?' T 7 'a 1 U b' I ( `. O • OK! ? roo OLIONIS ON OS ? [ ? IuSNKq nLO ? E Y? ? ol Wl[RCHANO! 1 MAKING LEFT TVRN J ° OTHKG[nIY ° ? IKC Np [ ? DOMllii O!I T ? ° ? ILAM•NO AMC:n ? S O'AU ffl nAMPI ? p T 'I IS I L k 11 DMKM ? S ? S O MAKING U-TURN 1 C, J k l ? C] STAICT LIINr[ ?'N' LIDHAI ° r ? 1 MA"IFIDANOTINAMDANG( ? ° n ° p RN l[LI ° ? µOW 1 tn? V. ': KfYVIPNAAIA D[IA,t ndrp lrtl ? O TWp l[R TURN WAY- 1. I Y Gr F ? SP[GR ? F ? OfICl0.riLA0MM LM[S r?'I J I T T} 4.' f ? / ? 8TOMND FOR TAVFIC t y- ? 3 ?OIN[0. O'[Cf O 1 O![PMAr[0 ? R OBT M0PPfD0P 6i AT bOEIAI t +?? DB" Y" A L, rde ?, 3: ?,{?m5???• ) B llOtw[D •1110ABWAY I? I I ? , ? ?, k?y"` a }- r ?L' .r >r = AI 'Azk -' ?I o- PATE OFCOLUSION :,._, DAYOFCOLUSION LEEON,'.. . ' IES A •? EM 5 MOx 5 r w sAt GTY TOWN COUNTY GTY TOWN -' C MILES ?/ ,,, ,,. L Y U OL .L: v. w °C FAA ©® OF qo M ... WYE NAMEOFSiflE i,hUADORMIgHWAY. 1......WTERSECTWq WTTR.SinEE Ofl.R0A0 ..r„r.A, DDD? ED r TI u NONINTERSECTIONi ATION OF O ON . -IT Y ( C iY ? d ALML S PFEFLY ?IE u v E( OOF CCT or, 5u 70 v EFx EO r EPOST = y5- .< I 11 OETWEEN V? Zr f1[I GD>6pMO\ ? (J?.. I l• L1, Ip Lr 6(f0 ? MMP D GRAM • " r, M E{;. ATNpr 0 ?;I. Q w[EgsECi a i 0 CP 55x q.B DOE. © ® fYW6 I? 9r Oq DExI LAA WIEPSECrgx I?? r NON RD .,[ >C5? OII INTEP IIiER CLS I fF _ FEET VF II c c , 1? 9 Aso SKw HVOLVED I??) I En,cIE ENK;LE ? VLE ? OINEPIwwtn i VEKClE9 n ?? ?L[UECr Q . Fn.K: E IFAW IPUN 6PEGCODEUSE ? f OvE ,cLEPEDESlwAx ?wvca KW ? nDx OEMECT STgUCK _.._."... aI INAME aVE e1gVC I -' " ,L yy _ 1 t P ?„1 .ti' ( . . .. _. - : OWNER OF.OBJECib NAME MOAOOflE59... .?-LOCAT OAO ION ?N ® wo WAV NF °P '- Nf FEET .81 DRIVERSIASTNAME .. ... FIRSTNAME ..r.,;:...1 MIDDLE_ - TY0 CAgvln E DRIVERiLASTNAME FWST NAME - ,:A IIODLE / L• r {' / /1'1 3 ^ STREET ES$ ..,_,,,,,:,•, ROUTE NO,ANO BOX NO.,.' ?IO S a LIO rwD son ! ST,REE7MQRE99 __.__:?, ?: .:_.....•A_.RQ?€tIA.AN:. CITY. A ?•1 FTC-Xd 11 OfA CI C 1+ P, ,. .p?gCOg.. PWYERSxcuPAPDN_..' ' Ii E COLLWN CRY_.; : STATE L p p v bo ? E tFagM _.? ?9 ? ¢ C: PTy Eg cgupATwN E L; ? n ? DflIVERS LK?E`NS'E NUMD fl /??? STAT SEX• „,PATE ?F8 RTf1-.:. ,ApE ? S HA- YAb- E R" 0 W? 0 ? . WL I L CS Z? I ?t7 DRIVERS LKENSE NUMSEP ; STATE SEX !:_OATE O'BIRTN a. AGE / /? l W VEH CLE YR MAKEIC EV F? o- N-SC-A41 M3 w? - DAr Y .., R .-0000EI MODEL(NOYA-0MTL;i: OODY 9TYLE(Y ORI :?, -' VEHICLE YR MAKE G O tl \ ' rC ?1•, : ICMEY;OODGE),.. MODELENOVADMTI;,' BODYSTYLE( OR) L A ' I r LKENSE PLATENO._ ., STATE" TRAILER ,TE N0 STATE < ? GVI 'IF ( C . . . ?. ??? ' ?A' V I?YAAAA .f •! UCEN TEND. ATE ._TPMLEH. N0.-;. !_STATE., /. l /) µA M V? " ? VEHCLE IOENTIf, ATIONNO. _ ...._AIBBBMODELSSNEWERI.:?-. ODOMETFR(MILEAGE) ' 1 " A- VEHCLE IDENTIFICATION NO,.' ( IBBBCODEl56NEWERI_: ., GOMETER,(MILEAGE) AEGISTEREOOM ' ' (LAST• fir,'' I '? TY SO FK „ .,?: F RST _MIDDLE N,AMEJ , +'_OflWEflSUCENSE NO. Sh r t REGISTE ` RED OWNER- ,(EAST-FIR^STMI NE ?_DDLEAMJ;;;_.. - -ORIVERSUCENSENO.,, rtn ? OVmERS ME59 OR I EET? ITYMDSTATRI .:.PATE OF aRTN :. OWN 9 -""?' ? OSE (,LJ PMTS FVEAIKLE pAMIOED f tiS o1? T••rc,ceS ApDPE59 ::; >:: (STREET CRYAN STATE) -._ ?._M OF BWTH MD IE rEM Ia I'/ Lf/? ?E;;J t ,E. T s - E ; G 1 i ? Y ? d L S;iOPCED Cpsr Agi3OF T (CLEpEA??AGEDJr. E o9 aX EU.T 1.1.1 JO nlP m.3 LIABILITY INSURANCE INFORMATION-VEHICLE NO I- wns rHEREAmouoaLE UADIUrvINSURMCE ^,-3 NE NIO ADDRESS OF UAaUTy_wSVRANCE[OUCYM?IDER .. CDVEP GE EFFECT FOR iH 9ACCIDEM GI AM -RCM 9 rES ? NO STATE_ """ - t • ^ _,I NAMEOFUMLrTYWSUfMCECOMPANT NAME MDADDRE OFU WSURMCEAGENTO_?_ w C• 3 V rGC L A . A i.UAWUTY.P000 NUM h A?E c r3 /+ y8, ` 1ST wJLRY - - AGE " 2ND INJUflY I SESEPMATE PEPOnTFaI ADdrKNAI VAAWE 1 ?I NAME .. __.:_ ; '... ..... AGE TOTAL NAME .. ,... ,..? a • vhF7..Fgw ADOREBS_-__. T)1ATMPMES i' I3-. WVEHICLE IMSwL NCn au ppa, ! •"STATUSOFINJURED _,; MMN FlRST CN_ETHAT MPUES i ?nA1tr//Dµ WILLED ISEVEPEI IMwOnI IQ pN 0-l IN VENKLE DrF05.? - pp vpEF ? KILLED1 I T la f AN 1 EjN PAS3t I I I o ? 6? 8? 7? ? 5? e? D7?nc1 V?, T Sr1Wrp oCTnOWIN RpLE /O "c f OESCMGII DELq;?+AT NMPENED(REFEn iO VEHICLES SYNUMDER)' w a « ° aE aR E a ® ? dCraFa.?/1? ..`... ) k/ t ///GtS="I N.WEa an_? cl?_?JSIn_ ?dEt _?lk f1.._.' 1., aw?wu Ea...aa uROw?ON I_?__/Et?AY_. _'IMI P.M ?C Tr•CL//yG11I -,IC? Q? a?aterpn .oN CLr ..i Trr'vrlFMIC rL/(1/LI'_/n 2-fl,VLE, ?_1y t _(aS_3?S k .-ca, _1_c(,r sIL 14'cIJ / -Ei^.n? ?_i ^Atn c . ? lp 'G?e 771LJ . o-pt lsrj? aj,no?Lo ' 4 1. __._ ? l?u?-ti_r_IA•?f sr ????ts_L.tct'? L _ r h/_/??;'t? (r k Iotf ?CC 1 t w_V rsLC '1 _ ct Irn 2d ; e?--Al cv._ J ( -? ??i??J`''IkrF._vn or itr cL?vC?-?FO(4f S[I,(,1nat i LFf% ct?_ ? n?f?C•Qutu e }va Vf.drtY '7_ t , ? MMalon NCN?v.Y / X Q?(rL'n?2.?_ _ ._?CaE??„LS ?LTT tt4!?? [b [.L(M1n .T?.y'?.. VEHICLES POSITIONS BEFORE COLLISION aLANes we rPNM ° A VnIK:I A VENKL! N b c W ON STREET 011-WAY NAME OR N0. v.IA?N Eleul? a1w? E INVE8IOATEp A? A T IEDALLY AED VEN,CSf OCCMaD ?Nrg4 ?POt C! YLI V 1 Nn IrEAA. Es Ea ND w IprwPE ? ? ? ?.? ? ?,'??:.Kf ?o".°r""rlfn t• 4! naalwl ? ? ? ? AIONG ? ? ?'T ? nrr A{ iSyy?`` reusTwMWFaus,Fa C'I iO .: FROM DIRECTION To DIRECTION +?aDEWNK a?WALFWAY ]?SNOULDER /pcAYns 6? y a OTHCn 1' L, T t IOAp 9V11r ACe YKAINER WNTCONDITIONS ,. IF FF1000N IDL ICNECKENn , TYPE OF AC W. MIV RD ER/VENKLE ACT 4115 .. ?itA? (f NO?tt/ N.°Vf/ I LOp E LEI N^YLaNT ?I I F llWlµ! vLIKAI? f Ipiu0N11 F MvILr.CL? f wNic,ioxi on'Aann `I 1 I ?'? I ` rr t} Y L 03" L(JE'^Y e ? n. ] ? DAWN ? ?' 1 ? ONE WAY ?I NO STRAIGHT MEAD Y 1, ,1 Yr r ? F ?w[T ] ?SNOwvq ] ? E ? SIDP SON C) ] ? TWO WAY ? } ? mfATAKIIOMGPAGSINO F 7 1 ? a ? SI10W ? DUSK BTRFFt ? D ? WfEO bOH rona0t! ? D ? MAKING NGIIi runty J f ??Y ` T / 1Y IJ ? A ?K! A ?FO0 A ? LON1a pN ? A ? FLAGNPIO RED 11 A ? VLTFnC1IMOf. C] A ? I L[FT MAN Ia :1 1 i 1+4 w1 ?'?yF r ti OfNfR S ? ?6MGIY1 S ? ?OH1S 01r T ILOOP/RAMP( ?,???t/yc???•K 1µ ?E [1 6 ? iLAGNWO AMpfN ? 0 ?ALLEY 0 ?MAKING U TURN ? 61`TCY'Y +i I N' r I + Y, ! J 1 1 REAw""N0T 61EM00MF0[R e ? DermETMK NO IONTS ? e ? RR SIGNAL ? e ? l[A iIKIN ? y ? 0 ? GLOWING 7 vFrA 1 FGA._._ DYIA.CtAYq atCl r ot.t ? I ?OIfK[R/ILAGMM LANE TIJFN tl I '? ? a I ? or-cot wfc." tA I ? ? SEPARATED ? 0 ? O sTo"ro m SIGNAL y.qy EI 1 S"" F b f _ IF GIOF SIGN 9 T t T / T t, ? ? dNOFO ? B ? erprrfD w nOAGWAY i f. t p" E r r wT+< ttia?"w4-N w'4 i.:L, 1.,,'y It l • '(°,.. r 1 _Y ,7. r' + t ?i1; 0• R.t;,,hT I? 771 I.!- t,',•v,> .;t, I r?, .,?, f' rl . I "A L.U YFFI ?4?? ? ? wi ? a, a { ;? '?: '?i ?? r ' t ? ?, ,. . , 4°'"F's' ?????? r ?„ .. .? ? ' ? I'r?f Y POLICETRAFFIC COLA N REPORT Ifj TRAFFICWAV Roucfa rrvuMEFA [3 PRIVATE WAY :`•ap,: _. DnlFOr IXu, c uI UME couNTY wuercw. Grew, NwA y u xl I H Ir MI ID5f x.00 HOVR) /? ?EUef.W I ?N E ? CITY OR TOWN NNEENOO SIREEEOR HIGHWAY i GS AM ROUrl04 Et SECTION ? AVlfS s ?w (?oE , , . E' N O 'i F • riJp e? 3 ?' v 1TE95EG11NG tH RITT-ROAD NONINI[RSECIgN HEfil% f Mnf POET bEIWFEN !G/ smTE, -Am" DISIANG:ADIRF Rf 9f NC CA03551RfE1 A V,AITITO?l ACCIDENT R OIA RAM DATA `4. M0.F5 N S f W / MILEAGE L Nfi or / AJ r 6;T, .I C CODE x] CIXDSgNINVIXVFO: FPIIY: 11 w %i TOTAL NO. Q RIROREAfY fMMAGFONLr [U? ? jR,LSlUlnO LJ VEIN INTE CLS OIOSSS1Rft09 ROAD ?? xncx rj Oi LI OH4m IN S. D_ L-_ OnJECtS UCK(NAMf OEOe1FCr 51RlKK ANp OWNER'S N-E) ESI.pAMAOF SPfGN OOpN6l6E ?!• _ 1 UNITNO. I UNITNO.2' -.? VEHICLE ? PEDESTRIAN ? PEDALCVCLIST 5 RN-NAMf: lAS1 IR I R' NAME: -1 ' -/ /rc • A. 55C i do _ 17 D /J FE ADD t ADD9Ess 2.1 COO! L S / SV SIAIE ZIRCOO! 9rgNf NO. D -TE CIIT erE a 3393 R G?i:E Gdn 837 ?f/3 2 D4 vF9' YUCW 5 A D tlIR H I C NS NO. 5 E % T Y0. Q 6 a % 33 v R ar?n %D `' l OCOJIT-ON NRMNAM16R•ONE NO. EYES IOHI IEIGHt E R TION MNAMEf9HONE NO. EYES qHl rtgrr} I 2 4 TTJ ?CHECK IV) 'yFHI'i AS -Z,- UE eMRIn'r fA ANOIHFa? ?CHECK (.? 'yfHICIEASAN fMHOYfFOfANOfHf4. r CODES ? * 7 s 5 F 6"5'0 CODES * 7 nsi + i:i eA'"r 5 e T4xN 6 ?q'owrtrcu n 2 IN, ?Ip, s:rt ,KIw.I ,?oRK.tD r ?E^ AG ?? ,? ;e. NR.AAHCE ? roeEf ?.?, L1 N ? .r ,.. f. ? AM.%AfKE ? ros f ?x1. ? w?2u E] FIDDDE'.E{HEV.1 t ID,9INDVA) Sirlf lx DR.C V.I KHEAR?M MM 1 Hfv.l MODFI (DART-NOVA) VEH.YEAR ( rl Ip 7 p( ' d?•C- Dr0 //ri° E . n D? ?jxa 5 n. (. N RN SIA1( iRAIlFRM1F N0. SIAIf I'? EH.CpOR l N A (J V_. ' VFHIGf IOtNTIIIC.ATION NO. L VEnICE Df If A1N '3 I S '..'r7 , pOWNf NlAS (1451 MIDDLE Q RtG15R9EDOWNi9: WS1 IIRSI MIOIXE / hgNflq. O 4 W A n A 550 ON 4E9 N -- NAMEtADD4f35OrIN5URANCL CO. OR AGtrv1 E R i . AGENr ?x t ' _ C , a N l OAMAOI ._ 1A Dur?f M OAMAG! ARlAR ]] r a l j a ,r pw GIB > : a CNAl. in srp. A' > U=A fsLO 1 -.. 5 IW RLNNN[p p p •O !1O' tsl. DAMAee ? uRI a ? etMAINa ? AWA 1pI •? ?Ort S AWAY ?. rOWtD YN t S i ®IoWSr^eper ,?6 ? Aw er: SC Ca I AORAM OF COLLISION: Loft rNEGSiwrl-- ec y 1N DESCRIPTION OF COLLISION. (USESU -I TAT-11RNEeesu rl U '= _. ! 1 ..1.:u1°, ,(,•oyPP ?? ,O. _. //E/l•./ «/d. ri'd?B/?/z9.7•t.0? T1fr " .'. ' ,_F ! _:.. I L . I ;_.? (_i. Oi,9e? /'Colt,/ C?Pr•Td?f/A'S ?`•/est?i?9 .._ ? I, F '? y. I ?,c?et•.ve/,?/Eo //Eil.s?v?•u/? .TY?tp//?/.f9 .. b+R o•a f77W Yr 1C '; .' '; ? ? ? ? ?.?? .?'., aKiz.9 /?r•/i.•sto'Y.o, T/?../bsd.Gv?l'_. ,._... Y •_ ?- DAC /Cdl ?' G A7/ 11 YO /r /?7 . ` , orLV.. ?- T/ Eds/'Deuno?/di?e_ 5, IP! 1 NAME ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES 1 2 3 4 5 6 S} I L P OCCUPANTS/WITNESSES ,a io?olx`Ita?xNANlreuvii six ACT urus ",•W„ m,: ':? Rlsn tnn t.•ir ) 1 1 rk° ° ' i "E t tlYf3 N,M9 /• 'a'1 W/ L- 1/ 1-3 1/ 1 1 ds? ?exe ?qad -r. HD.SC3-G2S ,a Mn f aSL' , 1 r or Iw sr A Mwt NO, ? MMl?ri, e B t S? e ! _ R M ._. .. a1?l0 rIgM AMf '°: ?. 4 ?:T4, ? ::.. ? - ; ? rT ?.. .ppntt E C rnr ? ? '* Atrpfn 7' U ... . L° . I A`WT °r - I.x tr ? AML. ? c?i f ? ""' 7:i; ? ::'H.. 1 I _ ¢ ±iV (5 t a W' 4vvItAWIWOEyr:Cf9i N,wf9,NK • sADfw (v AuNCY 1 f IG4D a yeD D naHroer mD DAn f7 p Np /J X y/_ 5 }l1t il:i RI I ' C?j N, ( a !! d f ,alC. .ryy , , W. nq. 4k kG$ Ax e r,Lrd Nt 1 .?4 ,ddl: 1 1 ) a E il, n?,6.AfRli J C11L Ha°,' i FSr .II yttl - (e7y, tT f(' •? F?` r !i !/p1 .: r ff 4t l ?L? 4 '?.? e i t ?'. Its 41 / r ? 'r 'S v 1!A,,'?i?`d L r ? OCCUrAiION N¢M NA ? ? CK (,? I • CODES R * J n° - '? M , w vFN YlAR MAAF IDODGf l `f a Po 6o? S6 / , r a AuoRtss a I su9ANCe eo. oR u RFSmrro u -Elie S.9. 'N'N•el f51.DAMAGE SnfeM1 COD9aG l6F - - UNIT NO.2 $§1VEHICLE ? PEDESTRIAN p PEDALCYCUST MI IXF ORWER'SNAME' NSf r EEi ADD- e*ctt• ?d b66 N. ITIasun IIFCOM HaD srArf E . zip ,All - Ar GFbIgrH R T R? FNSF NG. WP, ' 98 4167 75-f-Wy,2 f DAr 1 M O° 9' y? ! YEl) Th S602 T W4 M E/IYFS GH! MIG7 E OSCUGANON FIRM NNnf 6 FEgNE NO. y / (JEYESL. WE GHI FE GHI 1K pit( -Q) 60 R Sf.ffl:JJi3Y t? y/4 (wp r Ya cc-. 21, 1 W v ? CHECK (,? iN Cif ws AN rMnor"ffa ANOrwF9. S r e y CODES ? D a is 5 N rrovAt srru: p . coNV I E v c». JnurOV ?? ANeEv`.I ° MODEL 7 Vv ibr+oYA ° ?' v un p•n I ra neR rENO. srAlF H vfH.c«ou e l Y ?'"o 14 Ig Cw. ?CCA23o SWA L VfN2FE IDENNRCA4 N ?K `/ 2/ oso 3 . M?DOFf ,, PNONf NO. 4EGi FDOWNEy; ?l,?r 51 MIDW rp. T - w V ly_In) l av, ?tl 7S? 7?y E saown'fR ' v. G'cJ. Qn.t. ?(AYl E 3008 N • Mtsf.,,? Te Cyaty yj . R I'll aacTRr- c• I/?_. M D __ rwC . iAr C.A. . 1 f rw n0"Drw ?AMwG[a wRFA CHARD! - 5 _ f . DAM1«Gf ® AWAY ?9fM,UNFD 1 IGioITOi• s iOiW[D DRIVEN m"r. RVC. ?9fMAlNFD ES .4AMAGf AWAY A SO-?S rbWlD I ,p" u N DIAGRAM OF COIIISION; lu Rry iNOC Ip e swrtu tassA W eY. AW U S/S? rN pESCRIPiION OF COll151 N: I uSe SUOV MtNr 5 -f NFCf55wRrt Rs , ___, _ , .. ?a K 7 1Y ( r b ;. /?? _, Veh ?? wqS FIeAa?%'tE . Wtfi? cr. nh upHrl? ? ?a t ? + , T l ? l ' ? Z? ' Y. Gt t r l tii ve <s hca? alt ?(. YSe.? 6r (.`?w-. Iv?¢.SC.a.c.lll VC?.d CJCE. •Sq2 '??o \ ; . ' (ham rcKa l/ L I ,. ' . / G . t Z F?.I OYe.Y.Siitwa. S ?: ... Vo,."?_` .^• II }I?eJ •?0.tl Wc.y. Vel, *?z IriAC?1 'L • ' Yl NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED f CODES 1 - 2 J 4 S d OCCUPANTS/WIT ESSES j40x9 Md?WWNAYN1fl ' vl" N S IS AG " NWI , S c •DDa tf • ? ,51VI " l ~ C l IAlui , ai RIf19. f11Cr C: H n "O -? ? ^?iS r'! U M1 A r 1 e I w.Mr. "" Sc.?.?ypCoy? ?. ADD9f SS f'? ?e ( ,I 1 /,VF•J -? F"• c.! Z N A I fD rpn " inner ?AFAa ?P:1`3vo .?„ rb' g}-.yes3 ? NAIIJI ? N<n14140M 'r [ M - n? i} ' N,wE -t---,t ?-haJ C?o lalZC.) `? A- $ f3 Gf(I C •• n nY p AMn. ? •i p? ?' ?33-4z33 :".p?^ 1Rd::,, b - ? Y ?J ?.IR ronrr,o orrKln rw.u.wNn nI ADG » G NC? r X t t ? f I;,r?Y11 v.w ! <rnrrir ?AMa p, r?^"•.?G" ?:` » r I " .N•A pI.1 CNlU fl ?V?u DAIrM aFN11 ROV Der 4Arl nN ! v Arr ?' "4n?4" ? M , 1 1 t ? rn7mrylRnr+vIY9T ?.zx? { -'+?`?'i n r?(is ;:?f ?_fiTY? .E '? 'C? t? ?, f ? xd y i i W ? I ( '.,' .d' '?RIYd I (w< sd1 i11„ Rb :i 1] hY .. t??`I-0 C` rT t I krtl Lli I w S e?, ?f ui by r t? tMf I I ?tE??Xn rr I ra Ivu. POLICE TRAFFIC COL NREPORT RTRAFFIWV IOD< MINLLMBF4 2 ? PRIVATE WAY f Owl of ll, D8 .v oAOc n. u5 N I ; 4R IE , X y IMF (U5E9.J0fqu91 3 couurc c ?so? wunn NO. /lo CIn ND. iNWw puRe.Ei RN 2 CItY-1 NNMfGNO.Oi SlaEfr09 iIIGHWAT y KI CIS 4 ON ? M:,ELo5 pW (.J Of ?1720 ?1 INIF95ERIN IW St4tlt Oa a0A0 NON INIERSKI,ON BE1WfFN SIRFEta 4 D.ilSffi aatil% EO. w,E POST D'OS DIStANCE Rf .CR0553f9EE AEA4ESrM,E 4 M%t3 Nay ' ' ACCIDENT MILEAGE RAMa DI RAM A rEFi a OF An ! a CODE - CIX4 toNINVIXVFO: fRI1Y: rOtAI NO. rAD. %IlIfD?NO.INIURED_ ?SaIIIAGE NILE OiVCNIR[S © iv0f491YDAMAGFONLY ?pEqu D ?VEHICLE IYxoNDm IM c{$ OIOS5319tROR ROMP'??? 3z/3o 9 OBIKtSiRUC%INAMf Of OBJlR 31auCK PND OWNERS NUAE) EST. DAMAGE SiECw WCING IA[ 5 UNITN0. I UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCUST . / s 9 DarvE4 NAME. ,NI I I G rv sNAMa I/31 I I 0 Sii?REIIADDYC c .f MUaf53 / iY AfE Ia CODE iHONEro. D I AIF , R rvER' u<[N N -All 14 O 2 r .. 1 Iv NSF NO. A E W 141 MD i RAY r OCCUVwiION NAMEaROI"NO. EYES IGHI EEIGM E uiAIION f19M NMSEa %oNf NO. 1- -T . I 2 4 [S R I 0CHECK (0 vfNlaEASnNMwvl ••NOrxE ?CHECK(!') vtwaEAS.NUwoYElofANOlHfi ` ,4y.E CODES ?' 2 niti a i S um?oH 6 D"'ON,r'Dr" - = 6 yNO,,rrn ' CODES ?' 4 `s;snM"I 5 -T /i f 2 PIlS / a°.',.DN 0-- ? M" ? *:;t. ? =C*., V r 4 ° e4.r D« p MN x E ? IN, ? M6. ? K r ? "f°6Ei. VIN. YEAS NNEE (DODGE{HfV.) lIDA4tNOVA{ sluff FRDR; D O.i .) .H a 1 EV.1 EID A) .) /q V 1 E c/{EU J?9/? r IICAN 4 , RAILND. 5 E A l ^• SIwIF H C vFH.caoa V n tii-b, VEHICLE IDtNtIfK.toN ND. . L v fHl EIDtNllfl N / a3 i 3 2' 2 o s 2! 6:9 Z. 0i,Z16! / atG13R4tDOVME9: VSt f195t MIDDY r /Q PfIDM NO. S w a I x WNfR: USr rIRSt MI tYlLeieK p S23S7 ? u' ADDnuoi ovmeR O E A F AIA. --'404 446 N•NeaAOOaessaww9ANeeeo.oR wr ?Lp R . a , G'? • DuA/4lDMfA • c..u C'A9Gt xD NpnY,E.?DrK A gAASAG! MfAa 3 R rOf 3 t31. DA.WAG! ?-1. ?RlIANNlD AWA f ?AWAY ?-NfD ISr.D 1 RTDa. s Sao ?wYBY: ?AMYe1: f a DIAGRAM OF COLLISION ?NelTn5 In surer _._ SAA,JylL ( l DESCRIPTIONOF COLLISION IEne S,wrteAUilru sNtnRiaaiwq vt?,:. L:__ rti'ur.! /rt*H- z-rv . ?.) ..? ...... l ! ! _ _-._.._ .9_ `3 . _ rn e n U • ? 6 ..A o c u G f w,Jl /i'Ey T _- - t3 G 3 / ® o.n Noma _ Q ' L C?ucfl ?,._. Cc/RyAV --- - Po of /?(o __ NAME, ADDRESS S INJURIES OF PERSONS INVOLVED ' CODES t - 2 2 4 5 6 Euu surnfwNta sN OCCUPANTS/ WITNESSES r09.Op110N.1 NAw eu . 31 ._-.. $01 AGE TAI -._._... _. .. Meer nfA. InCI Aw: N ? ___ ._ ,._-_. _._... _ _.....__.. _. -. .._...__- ADO.tss NAIw o. AM e. ? "A" O "" . ? Q CX65f N AvE L .-m N'pAMa, ? ? p? ? .0 NA.I 0 Aro.rSE INM?S .._. ...... !Neer. ?AMe p'fO1K'?co.ll. ?G"X ?n nMSRG DI.KIfY NAW av e i?c?, x 4ou OV w No flANCY 'c.So r E IKIDISAAICNeD 3 z Igld .vvlHO D.1lpvl KNti Afl'vOV/D1Y DATE ., q? r 1 .. ?! i,Ut3?r'`," L :"?T:(iazLa.' ri?lt'.?5.'.? :'cl.? ,ctr ;'?t,' f 7''wk•tl `?' , I M , fg ?v e ! fx. POLICE TRAFFIC COLMN REPORT 0TRAFFICWAV NHxE ..nNNraweura / S NL? PRIVATE WAY I untf u, cRxu:A,.+ z ?? unvu w,l NR « ,YI{ 914,, ;., k (US[)<4NW41 of/o U Iv u /, 'rson iTe cpuNryr,rp /? cHV NU. Nwn nUpnNl Nm L' p E < MN ?(e SIN arr o4 wwN cx; Io4 mu,wnr rags ; x 4omeoq m4lu CO >IUIa+ [ , / MxtS OS p{Y qDr 5 ' .e a ON??cu?,/?d 3 27S h g. 3 Nr1Y:lCIINGN,IH SINIIr NUN,N,teSICI,ON G n TC.[ I ? 1, ? PrrWt[ ? rgFft < /? / Srqrtl ONtl,x FO. n{IIf YUSr //'' ??)) v /? '. O ru piSrA+C <a4t ,I I tr f.0905; SINIF 9Nlnvt5l Mll( ACCIDENT 4 M. V.A --A MIREACE CODE - 0011,1'0,1 INVpVtD vlgVY jj UN OrN KO. Iq.xelF' NO ,NN14{p?(? n5pIllAGf ?N m S a MnISiN N,Nwor"{ In rA%RD Ir+ CIS cRm p SRwAD RNUAU09 Flfl4lNCt CeO535ip » ' Kv[N,CIl3 9 AMAGF ONLY ? p[SUIt[D ? t CiE M,lCIS 'tuCR INAmE OF MAC(SteUCa ANp O V t9'$NAMI q ? ? ? \ N I FSr.OAMAG! [CUt CODING IAF S UNITNO. 1 UNIT NO.2 ? VEHICLE n PEDESTRIAN Q PEDALCYCUST t' r s Y. D4,n9s NNAr lA r r,N r mloa! S gntq's rl,mt: usr rIq m. l p ?Ay ? / . ` D ? // `L IYFH AD t31 "'y 'a --'7 pfflAWef33 j?x . STAY tIe W -E No. D ." r. Dxmes uaNSrw Are S ex Alt of elRlH 1 u4W1quc Nsf NO. Fx pAtm nI n • 39//?K n Z V MD OCCUVAI,KI MNAMf <YNpvtrq. FYFS ,GHt K,Gr11 E -,u-"- NqM NAME6p ENO. ... IGNI K,GHr , '? '? OJe D nS/G R CHECK (.? .ir,R aN rM9l "r orANOeHrea ? CHECK (,? IvlHICtE nx AN [MlioYeiF eA wrHraAt A 'S° ' p CODES ?? ] nis 5 urcrb, A „K •c < CODES p T ] n.v 5 tnu eN a i.iin `c` s. ,r« et Z " zits v C '.I > x Lw.;D. D FC AMNA...cl 0 c 'Al ? 2;:,r. ? : 13 ? u1{. « o M xl O Nvct ? Fdia. Cl w n 411- I! ? Ip U4 O (DOCGt{HtV., vo/9e mOglIDA4r.NOVA1 SrrtE ItOR•CUNV.i e?d/'xe/' OR lr< E H.Y 4 mM 1 NEV.I Y MpDEI O 4r.NOVA ' I A ' I ., .C+. ID r. ? N. aoq iUl L-?L/ 1 TG?211 surr , rvAneq nA{e w. sure H 1 C « N ENC«op N A nA N Al YIN,aFIptNnrKArHV+w. 2 8 B 3 0,f R 7 9e r e o t. e vfH,ett meNnfl II.NN g I ?() s• '- wA e rt m LRSr usr ,pole .Large lq ef1'.Y . d Rrm O W ewsr p o wNt9: IAtr N4sr M,oae 4.. IS„ ADwessoovmle A G ? N E NAND nooassp, SInANCt co a,anr R I u AN A St V . ? v ?W"'1rrJ ?J, "A" //l :n U w.r CHA g/JAALlO A4[A, C.uYGI ' v 'j w" ! ` .u A E'r C'.J L ? Y? D ? . ' ' lyC?{?1 ? v AYN ? r.NNNID //? n i v O R f109,NN ?.1-fO ISL. p.vAAO _'?O' LI AWAY ? fOi? 5 j) . rq ?O.NOnv ) GY ?. ' 5 90r 0 ? IOWIO DIAGRAM OF 00111510,1: u - tNOYIN Klrll WCl5Y9Y1 Ow f' P ? N •Y•L? DESCRIPEIONOF COLLISION: lull SUmtmfNrN SH1UpNeussAVr, / .? ' E <<w? E o vN E?ic/E / tJd 5 dr)rsT o? a' sT ! . cQrJ.%r?la ?<Idd, dl?d /+i.y/i / do vs? ,r r X ? S/oar+d S/?o? dcJ'oSS Talc C?+*ay1°i3 /iroC r o' dis / oFF T/ r. Jou./ Ji -?sf e, J ;i Cp No r?<2ry ? ..^ Tl r.?fi3S.S,?fcr SiaU 4/' /tee YKSIi&fB. ^ a, r ?i ?e ?P`lii/at cud s <i, d ?ldrT/e?/ PO//o ?M U/D?! i , ? '0'r' Pe' :. NAME. ADDRESS $ INJURIES OF PERSONS I NVOLVED ' CODES 1 - Z 9 .4 5 6 OCCUPANTS /WITNESSES .nn {{ J ,'?..S?L'[?C?QP_a'J14 AY' t?' # ; ...i d: •u., ar Amn N /lnd.`c<t a ?r rn:?cN 1 ;E„ Ir C9 / ,11ZT ITS Li ... ' % ` " ? a'; - t /?:z, r «<!Ct??!c .>rr.!yxrl?r.a/_ xAN na: " ern n /?./'r'l/?A'<`/.i ?/.?rT_.,... .:?45'S J'S•i / 'J ?L??-T-1 ??L . _ L7F ^f,?TcrL II 1/'ry (1 N nr .fa", n:1.,. X / O'DV 1 /n p y p, All, s EI I I It??; } V .'3 l : R I 77 .z 1 s 1:111 . rr c ' ARY POLICE TRAFFIC COLLISION REPORT PAaF V (1F % .RITY OF COLLISION ® FATALITY QATE OF MO. DAY YR. COUNTY COLLISION LOCATION DRIVERS "'? u:r FRO. ? INJURY ? PROPERTY DAMAGE ONLY .,. ...._.._..._. ._......_.___._..._._.. ' CITY STREET, ROAD NUMBER OR NAME ___--__ J NAME vs vs DESCRIPTION OF COLLISION (USE FOR ADDITIONAL INFORMATION WHEN SPACE 15 NOT ADfOUAIE ON ORIGINAL k[fOkf OR AS A SUPPLEMENTARY INFORMATION SIIFEI TO CORRECT DRIVER'S NAME. OCCUPANT LOCATION OR ANY DATA NOT KNOWN At THE TIME THE ORIGINAL REPORT WAS COMHETED.) f? ENFORCEMENT ACTION SOBRIETY • HAD BEEN DRINKING (CHECK) CHARGE CITATION NO. pmm %01 8000 MIIIfY ? EsdOi /9F S/S/i2i1't?/T- ?SSE+c9Fr - ? % ? _ ' DIAG DRAW DIAGRAM OF COLLISION SCENE IN REASONABLE PROPORTIONS. I RA ROPE M O RIY ID F C ENTIF OL Y VEH LISI ICLES ON AND H IGHW AYS. • SHOW SKID MAR -_ KS AN _ D OTH ER ME ASUR i EMENTS...v. I- ? 1 " " 1 I I. I F IT!al» I • „ I I x ? r } ?I AL I .I - - _ -- - ?- -- ? T I NSIK:AIUb. UTAIkSNAMI MITI RANK _DMA:I FA) .Af:I HCY uu H rnlt ,....-?•_I--? A_s- lu_ E vs II AE^tiI1C, ^•I--YSYSBBRSCMIEPI?IlFMM ?_-_. . Y ) r r '? + Ty7i 11 t K T r71 ',L JI' FI+NLG!81a? /G"??l'i21c?Y'?? 7 ICI I I ? ? ' 1„ 'Y?Tg"5 Y r a I .J ? 3 I. ? (:? ' ( 1 I ? t t r '1 3 ? ? I ? ?t J ? i F ! ff ? I 1 ;! iftE ,1}, I 1 'V^ ? ., r I P F 1 ?5 t??. ? I? }? 4 1 J I t ¢ r ? / ? 1 aYA ?` I I t ?1 I f 1 ? ' i! I 1 C I iE fr 11 1 r 1f ? NN f' }T ( ' ? ( 4 / I CO P& -CITY,. OWN MILE. Q .. . CITY,: TOWN -" --- PDM L9 PPEFI>? OVTf _ 3 o7s e D® DP ?: he z?sa _ GIVE NAME OF STREET. ROAD OR HIGHWA M INTERSECTING WITH. STREET OR ROAD PREFIX ED - MILEPOBT ,. r "`" - or j T Z TO NON INTERSECT( N•LOCATI OF COLLISION RAMP DIAGRAM OAT. T L, BETWEEN STREET AND STIIEET ( r ?S IV OF II"LI'n•orxnss x¢ulilros. oR loHl Her AC.•AnwnxA, w.l• r xOn O ? I.T. IN E C_ rExE a tiuA D.?o?--- ?VF xrx nxHO t SFEC.CODEUSE' E ofsrn o. sx ? µ OBJECT STRUCK ME OF OBJECTS NAME AND ADDRESS LOCA OWNEfl w INRO p - rI N N ?E ADWAY o (Ci" au l I Or r? 1 \t cFEr s w x 00 ' DRIVERS LASTNAME?_.,. FFIRSTNAME .. MIDDLE •"•"•" .o DRIVERS LAST NAME FIRST NAME ,'. MIDDLE. .? Oh k= tha. ? • , STflEETAOORESS ROUTE NO. AND BOX NO. STREETADDRESS ROUTE NO.ANDBOXNO. 0 CITY .: ..... _.STATE _..-• ..._ ZIP CODE R IVERS OCCUPATION D "••""' CITY STATE ZIP CODE ORIVERSOCCUPATION h!]A W /F ((?? .s CJ ?_s " ?ORIVE LICENSENUMSER RS STATE SEX GAT FBIRTH AGE. DRIVERS LICENSE NUMBER STATE SEX GATE OF BIRTH AGE n ^ v4n- - f9 F lye F.R I DAY YEAR VEHI M Ctfi YR MAKE Icxw._oo Imo. ODEL --. SODYSTYLE ODA.I. VEHICLE A. MAKE lufv.-w- M ODEL IxovAO+Rrr BODY STYLE Doxl LICENSE PIATE NO. . STATE-.-:;.: ,TRAILER LATENO" STATE LICENSEPLATENO. STATE., PUTE NO. ,:,STATE TRAILER -t' -1 W vesNOO ns_..:r. VEHICLE IDENTIFICATIONNO.. H _ DOMFTER wKUCO D Hw se xsnsxl VEHICLE IDENTIFICATION NO, vcoEL ODOMlTEfl WiuAUO ry Q REGISTE.... EH.: _,•IU Iwiaxaouxs I _: DRIVERS LICENSE NO., ,, ,... REGISTERED OWNER., ,IUSr rlxsr MlooLl xurx DRIVERSLICENSENO- r; r 0? ter L 040- - Not" . OWNERS ADDRESS .ti:.a ? 1 EETCTY T I,w E GATE OF BIRTH • ., ?L .NQ v R OWNER SADORESS IS T•CITY ANDS TEI .. . . DATE ORBIRTH DA DAY YEAR Q ?t PAHTSOF VEHICL DAM AGED .:,.__._.' _ESnu•reoemr "ID Vl- I CLEDAMAGED. nrH+NOCmi •. LIABILITY INSURANCE INFORMATION•VEHICLE N0.1- cov elinciw ec°FECT BILE LIABILITY INSURANCE FOR THIS ACCIDENT ON YOUR CAR DYES ?NO NAME AND ADDRESS OF LIABILIWANSURANCEPOLICY HOLDER NAME OF LIABILITYINSURANCE COMPANY-; ? - -?' --' C V SITE .3P I ?y ADDRESS NAMEANDAODRESS.OF LIABILITY INSURANCE GENT. •.. Si TE _,?;,,•: ,_.., ,,ZU:;, ?,. LIABILITY POLICY NUMBER,,; iSi INJURY_^ - --}I,? AGE _ ... 2ND INJURY:;,. IV SEPARATE REPORT FOR ADOITIONALIHKJRFI,. AGE,: ._. ,.....a. ......?. ..,... ..v,..._. _. ........... . . ...x_,r.. .... NAME it .GDR E55 SEX.. SEX.: ap 0_0 ? " ", ' _ ,y Q FonMl ° . ""' •ov"i. ? wcrw'Q?'1 x.., STATUS OPINJUR[D MARRFIRSTONETHATAPPLIES ". STATUSOP INJVRED MARK PIRSi ONE THAT APFLIES,,; - I'? IN V[MICLB oH•FL xo Oro S"F KILLED uivenil wNO i xl ?? IN VEHICLE KILLED v Iu ?? i' I F I FSLT215 Nm __ GTnER .nlTe IN ? 5 ? 6 ? rc 70 LLXXJJ No. ___ 7 Oc.I C-I "ur 6 ? D urHEn rmITL !v ? 5 ? SHOWNORTH BYARROWINCIRCLE ,. xw.. W O w :I R....r•1 Tr c F ?iR a ;t AC. Ku o TDESCRIBE, BELOW WHAT HAPPENED: (REFER TO VEHICLES BY NUMBS RI,? „?:•; ._fA15?-Q ?C -?_ihf?P tw??o? -l.Otl-c? JOCtM omp-d t?p?rG Deep ?` 1 Z P F I?. _ . ` 1 C{- i S ?Qe_.'., Oki Y,_e' O. W_ YN .-?_ Y µalatlc - i VEHICLES POSITIONS BEFOR ECOLLISION"" L er10• IHVUnD.rlD Er 11 H H VEHICLE lADIO w OHST R Oq NIGHWAYN.ME..NO, "c' ?ii ?1011M IYOUN)., : ,.? ? ? ? . Y•'" .. - ?: l ? ? ? ? ? KF ? -TN+.IOR I()- ? ? ? ? ? ? ? ? ? N PEOESTRIAK_p?IIt Y?DA LN!FMrYnt?7l:d ,(?y?""yf. ',w (:}rI'??„CROSSINO?.'k lii•?iC(I'W+•liu?IS.l 11fP?!'-'7=ve><t.Y.F+TI.i'is.'TO„^I?wksw' rews?4i,? PCD(STRIAN WAS USING I, ? HMw•tA T O• 30-1.1- A 5? B o ` x W ROAD R ACl..:.. WIATH(R',. -LIGHT CONDITIONS I TRAPFICCONTnOL % OF ROAD TYPE ORIVERIVENICLEACTIONS, , 11 ? IK 'ORV 1 wilu IX`-i+• I INO 1 DAYLIGHT 2 DA N oxfl ?xl ?SIGNALS rw Vx AD I EWAYr V r C] Ix 00 IClllta ulDAwA A. ? IK?GOINGSTRAtGHTAHFAD t W ? 2 ?STOP SIGN ? f ? 2 K TWO Y ? Z ?OVERTAKING AND PASSING ? ] ? wfiT O ?INOSYINO D ?OUSK " ? O ?YIELOSIGH " ? 0 ?R VF OAO ? D ?MAKINORIGHTTURN ? D ? SNOW ' ? FOG K STr Ef T A ? VA XSON ON l ? . LJFLAS•.tNOIIFO r ? ;1ANCr( LJ A DINT T'" IAMPI C] A ?MAKINR LEFT TURN ? . ? ACC E 5 ? NlCriv S 5 ? LIDARGHT%S 01/ ? 5 ?FLASHING AMBER N / ? 5 GALLEY C] 5 ?MAKINOU•TURN ? S ? eii CY?r E ?STREITOLIGHTS C) R ?AH SIGNAL OD ?1-11TI I-INLANFS ? 0 ? SLOWING KBAW.00RT S astvvrr_DNO ro-s IIINO OANGIR':Y r.-rM1'Ire T?srTt ClHr ?T ?OFFICERIFLMMAN ? 70 STOPPED FOR TRAPP IC ? D 0= I St IAR.TPO 0 AT ? B ? oR ST111 OP SIGN 6NAL ___-____-____ ? 2 OOIVIDfP ? 0 ?STONED IN ROADWAY ?0?NO TRAFFIC CONTROL ?O?Ur101V10E0 ?Ip ?TRAFFIC LA WIiNiS3 tiLADOR(SS:Ji """..1 •.?, r! 1Vr i?•"n? f+ r?. ws.. 'IP%; 'Afi[•J•-. OIT ?It ?FARK ED POSRINON 1 ?I( ?MFRI}INGIENTERINO TRA/PIC n11nIACKIHG •IL• S. cT I i3 fA ?{ I 1, I? „I ' • POLICE TRAFFIC COLLN REPORT ® TRAFFICWAY IOI,CE(mrNUmBER r PRIVATE WAY ,NW^ WYNO wUNIY NO 7 DA EOfC is N OAY Of cola lON LIME COONrY rvR No r,.,.5 N s.; (USF 7,WONOURI o . . // ?uv . r ?y r u r , • Y3rf IC StCIION It O RW NPME6N0 Of5rcfFi.O/,RHG"WnY b;w C] E ?IN CIIYOR TOWN ,/y ET. MIlE3 ?3 E?W ?Of 7? ?? :%' ON ?/E/,' ?j' • ftI CIS A 2 / / J ? ?7?30 .- ED MIIE Poif INIf95f?l NC WrIH. 31REEr OR PoAO NON Nr[RSfC110N ! /1 / 1 BfiWfE !/ /•? LFEEia J/ n/ SIM, ACCIDENT ?•? . P RAMP DIAGRAM DATA STAN WIN ION c .CROSS SIREF104 NEARtS ml PoSI D...r MIlfS N RE SR Nf MILEAGE ,tfr W Of /a C/I CODE D v3Ki ST OR Nt E COIUSIONINVOlVf6: XV[R IY. U[. qVN H 6VfH E ? ee Iv!n- ttoi TO?/yNO. NO.IE[ED??NO.INIUR[D ? ? FIRE L' ? faLl[ ,ClE3 D ? PROPFREY DAMAGE ONEY ? RFSO" ' IMf CLS CA0553rREE10R ROAD 9 DOSVNIRSNAMFI ESi.pu AOE OB,tC SRUtxINAMEOP OB1ECr31RU S SRl NCODINGU UNITN0.2 .. UNIT NO, 1. OaE OvIVER's NAME: ? VEHICLE ? PEDESTRIAN ? PEDALCYCUST HR3f----mliif-?' IASr S E DRIV1-A'AME: IASr ry /?INSI 7 ` l ? L •• nX am" • r SvfE ADDRESS SlRfIi ADDR /' '• ? ' ?F?r e 2 ,J / / ' COa PHONE NO .1y SlptE 21P D 111w. sr.rE Pw. E y L • ? /?? ? ? ? 45 R / ; - .S Y o • SIAM [x UA EO DIR H I IV N' LICEe,SE NO. rnrf Ex DA fa,Rm MO , DA, .e URNtR'SU NSE NO. C mo D•+ / V MIE L PHONE NO rtIGHI EYES 6-1 OCCUPpiIQV AMfBNANE NO. Etta IGHI 14 E . Dc-TION FIRM N B . Gr s R m 1A' V O nH MR ? CHECK I/) VEHIaf ASANfmaorEMANO"ENpf A o CHECK(? HKIF •i EF O S eR<rDN b ,.° rlN P+ D 4 CODES 5 to b H CODES * a n a s. e: n '? _ °.b ;s S o r A? Q F :' ? Mf ? <l ? 06, ? KD o ray ..Dm o AyW N I . a ? zs.11. o R F 1 ECHfv l mODfl (DARINOVA) l 1 yl T VEH.YfM NAxf IDODGE-CHfVI lt ly DR-CONV.I MWEIE-DART N V;A) sr . YA ° x ° , , JOD E ^ 6 o c Cfrv !H S[AlE rNA IFR RA[E W. SIAIE H vH.Ca N A H l NO STATE Y ?? f??? R9 / VtHKIf IUtNll ,tall NN . wH,aE 1-tItIIHCAA-NO. L t NO H 1A51 .10.E IS fRfDOWNtR: -Sl R . R[GISRRfDUWNtR: IASI f1R31 MIDaf PNON O N' A N Nlv l I ADDgessaowNER N l E ADacTS l u A A )' HAMe a ADDRw v INSURANU DO. w AGFNI R >?S4C / 7 i ' r .. o< re . G ' c• a ••' +aV'rN"rCnp NDwAx, 4AMAGE -A. YN DµUCEI1 ARG Mw4 ' CHAIU f • rE y S ?vfMAINFD fs1.ONAAGf 'S LYr- GE ^RIVI^H ?AWAY ;)'?Y. e 1 ? El "-t' I ?S?LJ _ • ew,tt.+ $ M IDB T 9 C+[L1 C] er• CA J A DIAGRAMOFCOLUSION I I-CAIIyN?°'Ir" PESCRIPiION OF C9ELISION: lus(wvnE tN1Al3HElI If NECt3NRYl __ HtEI f ECf SSAEY) BY A f f t 5'r/al le. s. 0 < • c? I ? E??+Sr/ s :> •eJ ? . G ed?r a Fite ZeYalS / _ VAC I.J•Y.Q. ?(? C1IV 7j? ' /, ? lrvU • C.1 /.; ?i't- 'cl td X / u/!< r>;.• G d •To- T i cirr /i . ?YS r r So</rJ <!. /C% , r oi? it in ?% 'NS • Tsrt, ? / '? ADDRESS 81NJURIES OF PERSONS NAME INVOLVED 'CODES 1 - Z 7 A 5 6 , OCCUPANTS/WIT14ESSES Iro+woli?a :n rM.A3M' ^fii si. W[ rArus'„"" ° I nve uetr rr,xl Aw ADIWit . .. ND ruvld 1 rA py V ?AMB. ?ci1Kl ?r4 . ?V•+i ?IP:lrl ? AVF q fr rwra NrMOVrD rvoM ?AMB ?'; . ??".°• a •m.r53 Noel, iiO •` N AD wrSs M IlMAIwGfRr<IIS NUN •IA? L ^[xl KArKY ?+ K?tS?F••ED rCI K??NO DAt10r Rl Rl11 A Mrl ,? 'LT?i3 ' f i:D1,.3 ). R. _? X !L, /!/L.itl/?, !f• y ?_;)5 e?5r ? ? -- - - --- - - .?D?fB?„•AINTNDMBER - PRIVATE WAY D A r EOECau N DAr U rd +' S1 . IU muNrr -UNn NO. 1".. Grv Pq. .A a'W• .. Wa. ,W AIR ,wM, ,FI Yi TADD ODNO - ?URBAN III atr Lr e.Nrs o r\ i6 [ IN CIIYORrOWN URAI ?rF ? ? f M1faN0.0 SrRFEIOR HIGNWgY ICi ClS I ROUtEON SfC ON Z -ES ?s...?w gal 7 QyQ ONI?. ' r<7CM 'S ...x•%370 INIF4EE-NG WI SIREEIDR To T: NONINTERSEGION G..°-<q NUU l < PRfIIA EO. MILEPOST Lk G/tA f i r ..R9 , O ?8 afivJfeN DSIAN EaDIR 1 f .CROSSSIeEE N SiRFFI a L. STREET 5 MIl PO t 4IS S E W / ACCIDENT RAMP DIAGRNA DATA FEF1 ff S r MILEAGE CauSgNINVOIVfD: ERrtp CODE 101. NO NO KIUED??NO.INN4E0 I ?Spaz Nit RUN wwD'iv IN IN1FR Cl5 CROSSS1RfE104 ROr OR E - C[VENICIES p ? ROR9tY DNAAGE ONLY ?AESUSRD ?V(R'tlt Oa1f I C 51RUCKINIMEOF OSJfCi51RUCK ANDOWNfR'S NAMN FSt DAMAGF SpfCIAI CODING US! S -' UNIT NO.1 IwnExsNMtf: LAST e 1 UNITN0.2 ? VEHICLE Q PEDESTRIAN ? PEDALCYCUST ' .-e •••) • DRIVER NAME: IA.Si IR I l SIRffr ADORE -`+^I?/. , SIREEt MDRE55 R GIY t IF =IpcwO -ENO. D IY STATE 68 ^ R IP co -? f4'S CEN 1< M S h na w STATE I U a IH I ND V I D" 16 !?? n lI NSFNO, Ai[ ST. AIE BR I ND. I D B OCDDpAIION iIRMNNAf IFIgNf NO. Ett5 GHt NE ?N7 E 11 P o CIIAIION FIRM NM1E 6 p3gNE NO rLA BYO ?` R . EYES IGHI Io- ? HECK (4 wHK9E ASAN D 'YET oFANOrrefR:•u CODES ?? 7 r?iA"'°SSr iifT xCIIPI IDRCrO1 S E ? CHECK (rlj AE VEH ClEAS AN FMROYFfOF ANpMfR. ' 6 wm I ` & AR• CODES lb- + 7 aw < iinrA.rvr 5 FA<roN 6 ,RM°1 Y? IN I wl r D, Y? r ? tt °D'N 'rr t VfH. FAR ..Kf IDODG(.CHFV, ( A.I.-? 51TlE ROO O sC Kr ??irt ?H ?Iu D ? ?[m l Fo NV1 I -f a >7 E , V.) Y I R: tv) 1 lIDA4 w) r e 04 L H K T ? 9FS S t feAllt4 MIE NO. SIAI H -- - , VfM.COtOR NJ. A ` " 1 vENKEt IDENTIFIGrgN NO. C Il !D: 8 L Rl04RRfD UASI 11951 MICOIF prgNF NO R Vtnl1.IOENNfIUN Nrv I I I I I I t , '? . DoLVri O ' L• IFREO w--ER: mt -.1 NRSI .1 ADDRfss or oW+ree W A o D y /'29 L` sf. ?arT N wNER r NAMIa•DORt53 OF IHSU9ANCECO «AGtNi E 6 E R MNAGE M(A ^ A y ° CH CHA9GF per: o ? gM1AGf/3 A4U ES ' 1 TfON i ?AWAY ?RFMNNID ?DRnEN ?p[MAINED AW i•I r ISI. MR- I 10. S $ 0 IbMDaY. AY ?AWAVDa $ i Ono. DIAGRAM OF COLLISION: ? i I rc rE NORTH 16 NutUNG ar Row a i DESCRIPTIONOF COLLISION: Iln[ KIIVEN- SKIT IFNECt55ARY) _. I 4.1 .. - _ ._ _ __ .^-=- ?? ?T k r 6 \ c\ es 6 Y t • i v ' N NAME• ADDRESS INJURIES OF PERSONS I NVOLVED CODES 1 OCCUPANTS/ WITNESS ES iaia~IEDMUµ e? ii - 2 9 4 5 --- 6 A NAMf: NnR u.i 0. H y Z I / ME: .- ESA?c. /14 crt•E?H 3v ° r Is ?\ S ? q r ..- A ED ... -_ i J . ANWSS 7• ^ GS- 3X7G t I ? Op ? A.i ° w NAw ? rv vEMn.•ar rvrJM ?.vAa ?,wRr?r' ?r'i AIK.rYS NAnI,RR/oF u'nn e. ?AMa ?Rr ??I,.n.?mrT NfrggrlVr plKlrf lNAVadN : ;w•. ' ' 9 tAOGt (A AOINCr KE? SIAtCHD ?y.R DMt Or RIrOKI Rn,OV, DATE ? ©E ?l•?- D ru '?` SI F Nr 1 tL{?j;n r/µ ?( ) ?E .?Dr' E ( Kw 8? ? ° r Q .-. t i v r t.n3 ? ?? 1 ^r1M ? s. n 3 y ? ?.wk ,.:.. pppp LL Y?I 6t>c??i F1,?f ' D J ?P kA t T _ r'1ri allA I 1 l \l 1? IJ RdJy yy?F * y )S ?Y? 1 r r! 7 'k'•IIRRM-'?'ViYw•+*'-A i`Yt'J'4y`E.. l.}ti'SC?+?wr-+M' 41 ?,q{ ?.% I } 1j ! Ip (' I. • Yv' dr I b K 1 - ? k?fi yy}1' y J ` ?'l ? ? t ? n (? 11 l f F > I t .,1 r o ;, t IT + r3 I W? ? l F FF?? fq, ??ri? Yi"1L1 1 I r ? JJ { - t 1P e 4' 1 I I E 1 1 m o, t ? . Y r ? r t r 8 1 , nartux L r , .+h ky?'„P R?S"F, a ( Y My I .?` .?11 7 , 7aR .E? : ? ?g ? A ? kk$i7 1 I 1 G I? 4?E { ` 1? I Q ?'"-f 1 .rrRn4EejtnS. PRIVATE WAY DNf i xpl D D l NNR _ IIMf COUNfY ILI LR+DO HOURI ?? • ?, YI. 4 R x ,.r WUNM1 /NO, all NO. INWA ? so,? 2 QDR /W 9LL (?N Qf QN C! OR rO'WN 5 EEIO IGHWAV • ct%!J `;G p/ Id.F 3" iCr CLS ADM 5 1 ROUE YSR ? AVLF3 ? 3 Qw ?r .ene? ON ? o! w. I IE ,/ { .3¢370 N 45fCtINO W,t rR(fJ OR ROAD NON ?? C 96?M? / G RRff% FO. Mttf POSt R R I 0tM'ff •.. O SIREFt6 C 519fEr /O? / J ?p C E V ++ WmR E .CR055Sr4fF WFSr AJ,E 5 ACCIDEN' MI[f?..}?S E W ?'G /A?/i >-pF'F- R4. MILEAGE , R v RAM MrA r[Er W -/ - .:/ CODE - CIXlISIONINVIXVFa Sfvf9ly: ,y mH,N TOTAL W. NO. xIUED??NNI ?SPILIAGE yHrLByRr w,0.fotH CE [HICI(5 © E ? E I • S I? IN D I ! R 0918 et _ INr[R CLS UOSi SrRIETOR ROAp SS ? PROHRIYDAAEAGI ONLY LY ? P D C fHM1rfD L J V HI Oett<i SIRUCK(NAMfW OEJKrSrRUCK ANDOW0.ER'3 NAME) FSi. 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CR 9igiE 4' Z LUWUTY POl1CYNUMSEt1 IST WJUgY .. I _.. -. .. w NAME ?1 1 ADE 2NG INJUgY F-E fl ' 1 , t_ C I SESE-ATE1 vW1 OR %pc,i,Ox E I ADG{E85 J'^ TOTAL NAME NE !Yq?r SS % L ! Nn ¢ qE f M LF,I- AOOpE '__ µw ON cOC Om ® _-µClOR3 [?_. ? y o M? ) >f STATUS .WJLIREO O Mx ESA(cV ®® OOCrO 9 I , ` -.. ?pWER MMKF KgT O"ON-AAPPLIE9 OOCTOM t .• . .? ? A9 -E WVEMICLE. KIl)?O .. WD ArRra Bllq Posve _STATU90FINJUREp ' ' IS[KRO MMK F193T ONE ,TTaUE9 ?PECFSIMµ FID' pl IIE COMPUNr K 'IN YEN ryO ICLE FWO bWA4WO ? ? D53b12 ? B? OQEFCI 31RA93 i3N1.1 .V TIIi.IN 5? F R KILLED PFOE NO IsEffREI N IMwpry SHOWNORTH DY MgOW WCIRCLE ?..HE !R [ ? s? 60 I; ETCj ' wcc•r{a O .. •\ I . Ys WxAiHAP:FK ?. ? . ? . OESCRIGE OELOW WHATHMPENEO IgEFEq TO VEHICLES GYNUMDEpJ ? 4JI ? I V?[C nh[WrIWI THAT w[llECi9 \ .. '. .. I 9rR[fi l9rOrl9c[Nl wnTVq W - ,-+-- ? ' 1 r 4L tl?. s ? ?? 1 xW0{A9 HOHWAY MANES dl I .?•?_,??? ,? f M1W[R [Kw KwdE'µ0 WKAY - -' -- - -.,_ _ r ? !1 fr L .. OIRLCrKW MrRAKl9Y ANpW \ I _--_ r U? T + / I cltE i __ VEHICLES POSITIONSBEFORECOLUSiON f _ J. ••J-LL?•+rU_ I J i VEHICLE xOlqa'lAN[9 vlxCK f__.- -I. /,. ( ., r/• ?IJ 1 it` 1, MO (t??NjY a [ rWq ON STREET Oq HKW WAY HAKE OR N0, [ u041r Wµyq , O wA4 ?NVEaiNATED 0Y b j1,(t I'D- 1FA?? ? 11 ... ,I •I,. 1• aA{CiDx t[ NO M[s r•EO fNCS OCCBP(O IAT[ MTR V fI 41 { t/ypp r q ? NO ?IAIg0. ?otlrm I 1'xx.. ? ? -? ? ALONG El El ? tout[ OD.rNN9{ ULHp ? ?[nfRFI Y R? . PEOetTRIM WAS 1 ? TPAFg9ND ! ? f7 A IIOM;LN iE MAINCR. ,,WHTCOtIpT10HS7?WALKWAY AY D? GSIIOULOEq f?clui?w aO ' ? IRE TION 10 .:DIRECTION: - f L?t i rrNCt[ NTPOL KH{M041 cbsRw a OTHER^ t 1 TYPOPA O'D 1 JI' ,1'FIA4 AO I [ I ? 0-0 20. ? o ut 1 a DAYLNNT OiHCU ? SKIP WON ?e 1 N ? ONE WAY yOA4 ?VF ? LppWO IT SRNOt1/ EAD V I 1 f i,I S ' ly } `` rT Y ? I ?DFIY 1 aNNAIa bi.i 2 1 t I!?•?4 !' , r'T i 1 S 0SNOTW a ?W'DWwD D 0 Ws ? 3 FJ YIELD SIGN ? 2 ? TWJ WAY ? [ ? OKRTA WOMDPASJINO 11 'I{ V f?/00 f'J IOMiI pi ET q ? 0 ?ROFD ue I [ l pp(( 1 F ?' ? NE : [ ? ttER OMK.Si R[ET ? ? FLAT `NO RED ? f ? WTERCHMO[ ? 2 ? 4AKW0 RNHT TURN 1?{ l { N li 1T' IJ S ?8 OTKn wr I2P[CMY( S ? OT LNT!OlI ? ? ? ? I (LOOP/RAMP ? A ? MAKING LEFT TURN e DM%rlp 4 FLAWUVO AMBER 6 I I 1' ALLEY M T l ? 7 ?,( PDR N016[SIq ? tTR[[T LNHit ? [ ? PONAL ? ? ivrO WAY. ? S ? mumo u-MAN i1J 1 ? . OAaDANO[R[rt [ ?! (OFY LEFTTWN ? a ? SLOW", d ri'I k j-. P' DwwcN LUTA.[T ; a 1 ?l-. T1 A a ,, 1 ? 7 ?OIfNlRrFlAOMM y \ LMlS , ? STOPPED FOR TRAFFIC I .?.( T I I h I i j I `{ %: , I Lt) ? e ? OTNEA, SI coy ? 1 ? SEPARATED I ? e ? aTOPI'[D AT SIOtIQ 0116rOP SIGN ,, I R I •.?' (4 J`1 7 ,' •+:1A1, Y' (< J, ?, I,d{F Tq P ?, '1 1 ?( a L I ? 1 '.''"r P9MWF I Ati Ir ? ,]! l I- r f'`?+?d ?k T - s.•r.c er;,.v;"e ? Nt -b:???_>.IEI.?I M.w iIS.Y?CjG i '?7.I utl ?,. Y y,l 1 Ih ?? } I ''}J try !, 1 I???' ,,44T 7 'F 4 )q', 1 I ' 1 4 1 ,It c t kt i„rl ! t o p t 1 N,.? ., .. F.. mot. pia .. ` y{f _. t If4;_Y? f (' ' N? S ? 1 1 t t 41 d Y' L ? ss v T ± L a. ? 'f y ? i I 1 ? ? 1 ? f r ?? 1t ( .1 ? -1+ -? r ? • ? 1 CFI 1 ` t 1 \ t 1L ? "( ? yI t s?p} rr ( - J t 1 t O t } - t ?t i > yy 1 1 ? O _ W .1 CK O O 1 O O M N ,( r 5 i> 4 {, ? r??Y z 4b yasfl . 'i' :.1 '? Mr,-I"BC) P"'Irt{?r& ut"'NfFb"rru?q " _ s< DAL L INSTRUCTIONS: T. SHADE^ AREA OF SEVEREST IMPACT. DAMAGED VEHICLE NO. 1 MEE THIS SPACE 101 SKETCHING DAMAGE TO TRAILERS, M0T0PCYCLES, [,— DAMAGED VEHICLE N0.2 • J IB Y - . 0.r 1) ••lyrv Jr_M1' ? SEVERITY OF N GE VEHICLE N1.1 1 ? DISABL NGO GE ] 2? F NCTION OAMwGE -` y ITY OF DAMAGE. IO,HEPVEp LEI SEVEN TY Oi DAMAGE: VEHICLE NO2 ITHERMV DAMAGE 10 pSABL NO DAMAGE ] OTHER M V.OAMAGE 1 ? pSABLIN00AMAG ? OTHER M.V OAM G E `• I U L ? NO MADE 2 ? FUNCTIONAL DAMAGE A ?...AMAGE -. T ?FUNCT ONALDAMAG[ L ? xO DAMAGE. ' r TOWED BY / S To EST. DAMAGE TD WED BY ES).nA... TIDWE!BY T. DAMAGE ?At TO ?YGI 1 f TO S ,G S DIAGRAM OF COLLISION L' ;DRAW _ _ 1 ! I dS S F/??p/' - DRAW ARROW SHOWING 1. 1 T s 11 `- I NORTH IN CIRCLE 10- ROADWAY DN° -.. A Af. r A, IMP M-1 ACT ., w [ GA A B,n[n GO DESCRIPTION OF - IINDCA WHAT PROBABLY HAPPENED BEFORE. DURING AND AFTER THE CRASH NCLVUFNFOPMATD O GIAGR .DRIVEN •? CO LLISION . L,r REDUCED VISIe LFTY, PEDESTRIAN CLOTHING COLOR, NSTRUCTION CH REPA A WORK, Crc.l - _. - , / i't'/V/_C?L"??-.????/J a"i?.5cvl??[?Yr?!*ia='?'F?;..+f/Yi?A /s t?,9t ia9 cf?a__5 ro I.r__SJ•-vl'/o.. -. . /?E i![ % f < lE`.L!-?NS.[?ne!G/E iC /?:'d.'lF i?F ? // Ic•ST Tl'.!C /ci?, S'.rnf%'/ ^F1._i? lLS.<rt.+L??c..itc! F L Y ? „raj;, / ? . ? .JJ_7l7?J'.Pc!!r_S.'FNi. i7c/?JC LLIICd/c/?/.LSAE_/???v//'.•..?J.fT?r"T??C//'i ?LN/'anc?Oc><SS_4?L??'/' 1E / L 9a7" ?S - / I l [ll_?G-1 _i C/1 / yG-/i• E f /A..1_/1LTs? F G'r1L -.,,A •60U?/? Gam!'%3 `_c c d.SS ?%1p.9?°?G_/t.!S ?GI J Y,?-{_C?G?_GYQLL?l7 ?!!/1.!?_?UIIJr`.d?. L/i_!dP/' /?JE f/LdJ!>;?/--IC_1-/,?PI LsOl T.?i E? - - ? / _F.? J_GhN=Ld C`_-? 1I C°- /NGLLLG_LL/c!5..?1'J_/!F/?eJ S C T/?L-+ Z,; ecc 14 • - -- -IIO E F DED NBEFORECOLLISION MILE POST - D N STREET OR HIGHwq NAME OR NO - NO.D s IN ONE . S PEED S IM [ VEH CLE Ly EG IF PARKED SAS VE. O s E IN N INCREASING DECREASING - n PARKED J E° ? E . I / I? El I ? J // J N YES YES .0 Li ID E) PED f 0NGS Orv pS PEpIBICYCLISTw $USING ' ` ISIDfWA SIDEWALK '71ILKWI, 3, I SHDULOEP A MARK OSGEML B R L I CR !C OSS IG p ), w : eICVC E IOUTE %1 I O ' JJ dF?d ROAD5UR ACE: C CK ONEI_ WEATHER N K CO NTRIBU TIN K G ONEOCUMSTANCES'- RMONEI .. > - R E u wcnpN w7 CA _ t IVE2 DRIVE)R D -N NO E2N G0 D. _ 5 p 11 -i OY O Cm _ I _L DER INFLUENCE Of .LJ1 COBOL_ OL WING 1.J_.?= clDSFL= ?JG DE WARN. J ?_IC I B AREA. 'A o G J]'_J. Ass LNG 1 ?- WET r I nANING T L.JLDRuGS LuFrvCEO .. ?. O ER - , APPARENTLY I7 .-I G . PG T H XiEl j - . J SWITI. IP SPEED ELI i F -L rl 5 1 RKING L wfAF?fB r ? I -? CE. GG . _ ?. < RFAS. sAE[s E[0. _ _ M FR 0 T _ _____ OPERATING EiE£TIVf EOUP? _ l 5- ]UP. N f-1 I T - I srl TOONIT L c L ..m I- _I OISRf OSRp }.° DOLE 1 z , _ B. J ,slpwm.... n OT FYL F SEC 1 r B SS° I NAL ° C 1 ( B O OTPI%R ?1 ?,. OF G q LIGHCONDITIONS ,CHECK EI RAFFIC CONTRO ND.J E C E E "1,' TYPE OF ROAD D I C ONE 0. UDR[ VEHICLE CO D I T I ON- Nr . .5UUHI%m ate,. - IC f O ST ED r GNAL I IBS] ^1 SIGNALS (?T I1. ONEWAY fl J[ O4 AD J Oo HIC ]E Ij?!$n`fLriAUt OI NEI C L CLE INO.T O f 0 SG jB^I N ?.1 ORowerN L 1 p uGNr 17 ]' iGN ` /T T '.L w -----_ nermrrvE blEAgtE RD B rtr _IMPAIPEO 1 ID'? ITANTINGw rIC LANE 1 ] _ 4_ - .L?,S 6. L IT R.AG1 ELF _ NIAOCI1GPT _,--_ '1I ' N.11 HEO_ J' PARKEOPOSIiTION ! 1 W IAI IR. - INTPPCNANG[ LOOVIAMLT . .IO1U11 LIGHTS __ HBp SOBR fTY I IT _uNK.__ _ j TNRF LNG IEN1ERIN6 J A rlCl I ? 11 DARK- fl E[ :.LL GNTf ON ... .. - 'NG 1fl .. AMBLII .. r_Y ALLEY . I?l-_... ----, - 1INES wOI1N .L _ I ?._.PH SMOOTH HAD NO 0[E1DRIxKINC I . ( IYB.LCKING .. ^ ......... [F tG.lfD f 'i .. L_?sG L... - ,wD wnv_IEF, n [s F- ? I IB 11 Hclulltu II. . D 0. t.. _... CHEM. TCST f. .I--. J 2 B fAw if i.i0 if " N B--?-?- . _I Tf5 .IVFN NF R IBPF CIFYI r' 0, HER Dlvl ?NO DEFECTS I 71 El ,[ST RE rU50 - _ OTrrfw lsiCll c rvl TESTRESULTS 2 _ - X NvE61rGA,ING DFI I'INS N AM[A..NA [fTILATINGOr IIC [w'f NAM E B xA N I NA UGf ND. Gf NO "JIM llt I, CNlO OLIC[AHIUVE.D )Eno ANC[ TNAF III ILOW - nIVLO PE00 At )ADO A ATN Hn6 R - HRf M Cr III IIfT • UET. 11111 OI nIPORI JAIIPOIII GALE jjj::I?t III 1 OU/IICATC COPY LOCAL LAW EN, OR Cr M[NT AGf IECY?SCOPV ?TII IPIICAT EACOPV? I NVEST I OATOII?S COPY t q3.5'° T tir - r r I T Y L, ? ? ,G >! ;s? ? aw ? ? ? ' " _-. _ . P - .,..... ? . - fV•0. _ . r ,,, ` ^ t l.l? b v rC'?'F`?t !?? ?"`?v? v r Df Pou...OMPUm....... F • UNIFORM POLICE TRAFFIC COLLISION REPORT . f W I1? P rc D OATEOF COLLISION DAY OF COLLLSION TIM[ COUNTY NO UTY 110. NOURI )• /? ? RBAN ^O M DAY ' 2 SUN I = 2 lvf5 3WEA iNUP 5 iR1 S 5/.] IUSE Za d - - J" C UflAL . O Z 41rM C COUNTY ?gACI OR STREET CODE SECT ON a:- " : PREFI% POUI , , i E .. ?STATE ROUTE gCWNTY ROAD ?CITY SIR[ET O ? Jg? ` • -?'(?,/???n ?OTHERISPECIFYI _ LU L/o Y^? . r .... . D I I' Q- C ? IN /? CITY OR TOWN N 5 FiEyy,? (FW ? _ MILES 2 ? L1 OF--dz- -4 ?/? _ W U P REFI% EO MILEPOST _ yrp4 rr ' A NAMESNOOFS EET HIGWAY TERSECTING WITH' STREETOR ROAD U. R AMP r % OI CLS. E Ofl AD R NTERSECINGSTREE1 RENCECROSSS SSTREEEET&V),. AN / l '1 ' ? N 5 E W ? MILES HurvWF?i I •- , . _. .. J q. fT-'I OF C.r OrJ'?ALOI"F.?O? . _G?? ?? JOG ©FEET .. L? El E-3 ??: ... .:. _ _ , Y u . ? HIT A RON ? VEHICLE•VEHICLE ? VEHICLE BICYCLE WRITE OIHER SF E TTY u : I I COLLISION INVOLVED: ? ' •' - _NO LULLED ?SiOLENVEXICIE .. VEHICLEOBJECT -?VEHCIC ggTRAW ? TOTAL NO. (-3-1 NO INJURED " ? P OF VEHICLES ?VEHCLE-PEDESTRIAN NNON-COLLISON _ ?HAZARDOUSMATERAL ) ?PROPERTY DAMAGE ONLY ,,I 5.\ D Y" i OBJECT STRUSNIIIAME.OFOBIECI STRUCN?JIDOWHERS NPAIE)___.???_.._.?_,-__...? /G///w1J /L/J ,I?/ _LOCATIONOF O&IELI STRUCK' .. EST. DAMAGE N 5-.E-W - •: ?ROPOWAY FEET [3 ? ? ? OF EDGE f C VERS AME AST _ FRST MODE DRIVE. SN E1ASLf PSTM DOLE. I _'??. SLOB IDjS 1,0 C (.L 1 A rJ l R P ?. STREET ADDRESS___._.._-_1_:_Ia-______ V E ?? 1 m CITY ... ..:_ STATE ZIPCODE PHONENO. E . PHONFw CITY ;?- STATE ZIP CODE.. 44 1 N OILVER E SE NO: - STATE SE OA E OF &RIH N DRIVERS LICENSE NO. ST lE SE% DATE OF BWTH Q I. • Ord a Q 0 :DAY Yfl 'Q; O OAY Vfl r ( - G DRIVE RS OCCU TION ,. fNM NAME _ PnONF O '1 0 RIVERS OCLUV ON E _ P EH FRM NA _ " s? '.CODES > 131•CU:.. TAI. SEAT BELT -• I'I FJECUON _??_ CODES 3 LiAS S.?- 1 I. SEAT BELT?r_ 151 EJECTION?__ _ II EOF n1 HATURE G "JURIE L L 1 ,,p ) . E R SCENE BY TO ED - REMOVED i- - O SCENE BY " TO I ^y0 A VEX YEAR. p MA%EIDODGECHEV.1 .??}/Qd._ MOOELIDARTNOVAl SlYLE12DR.CONV1 ,L7 /'17rP JSrn° _v . VE YEAR M EIDODOECMEYI i MOpEL10ART•NOVAI.' STYLE 120R.40NV.) 1 .. E y VEN. C LOfI. llC. RAZE NO.". ? STATE . TRAILER PIAIE NO. STATE E VEn.COLOR. lIC PLATE NO. STATE • TRAILER PLATE NO. ]TATS ? _ (,` FXICLE WEMIFICAT1pN MJMBE -F -• METER C VEHICLE IDENI IFIC T10N NUMB R .. . OOOMETER ^•-'? - O. -EG15TERE0 OWNER-LAST - ;: FWST DOLE TC'/S?S"JJ Tl6iJ•rAa?S N... Q•. REGISTERED OWNER LASL_.; FWST - MOOIE .: AD . OWNER -'. .. : ADDRESS OF O ER - ,. :,.. . ? NAMEAHDADORESS OF MSUHANCE CO. AD rNi? A.E.. IT RESSOFINSURANCE CO OR AGENT ._. H ' ? }' ..... ENFORCEMENT CHARGE .. ,.. TMIONNO. ?' •; - ACTION .. :. ._ _..... ._'. .__.. :-.. .____ ___.... .:- ?. . : CODES' - ]' •% S ? °4 i J . . . , t .. ] NAME,'ADDRESS & INJURIES OF PERSONS INVOLVED," . AI At "i SE% AOE STATUS rv w EJECT, P L t? C / NAME /4! !i / /.lI ? S'?t J/(?(r 'fi'r_Y?Gr.LL? «v G ..I- L S :, lI 1 I C 7? •?F •? y?E / ? L / ?/ : I U P N Ipflf OG NL MOv[DI M / vUURIES { / /N i?JL? SCf N[Rr rl 1C .Ci ,T O ./F I? Jl `p /Fr s I I r , `: I? - • A T NAMEL ?3y ADDRESS /S''t? (j LI JC S/G•rA t` yl/?!_1? . T_LJ l' 8 Fes- !? .? . . f - ti f J?!.: r i; ' $ I NA V OF EMUVkD{ROM SCEHf Rv -U-E. TO _ W NAME _ ADDRESS... T N AEZrv oiR M NC[HF RV MA TO - E -- NAMf, S AIX ESS .,• . - t " EP.,. V wRI uifTRCbTRbEr`- To /1 ' 11151AIVY 11151At POSIt ION I]IrvJVRY LlA55 III SLAI BELT . 151 EJECTION f ' 1 •- C Q ° 2PA55[AISCq J PCDFS1RIUI IBICYCWI 6-F53 _ 1 I1(`rl?b 2 1.O1nLR V05igH ter 6 f ! 1POLIK, U'OV"mI oIIIJURY AD AI SC[NE 20[ JDf AO ON ARRNAL ApIf pIH HOSPUAL SOISAOL NONJURY bAOH OSABLING ILNOLNIIINJURY 11`O'v510L[uJJURY 1M OT INSTALLED 2N0IIIIUSE 3USED - SSEAf pELiFNIURF NOT EJECTED ED 2 TOIALLYtJECI ]. PARTIALLY EJECTED 4UNKN EON IF f IC: 4 r ';I,? f tP'?(I R ?4Y !?rr FI ? 1 rl ? T1 1 ryarh?YO{i' ?M?'•EmI'A'(r [R+: X?+T .•?-:fim J ]1 .J [?GY.A.V? T^L'f1N 1A y r ' Jb.4J W1 .?, YJ..?`J Y7 11 - A ' ?? :'?! 1IlnY 777.-T7 t ¢3 1 r ? r L I 1. I 4 f P,Iyry'I? ''. Ii ?CiIV I <?G 1 T 1 L r? 1 I l ri:± t 1 I a> >i ,. I y, r ? ? T r GJ - '; 1 I _ r ;Iia ICLE 110.2 D V E H M°raPCrcLFS,flc.l AGE HIrv. DAMAGE TO T-10S UUIIUIV , MAGEDVEHICLENO.1 Ius[iHIS SPAC[FON SKLrc DA !9'CE E. T .. r.I N ? V ? 16, •p II ..,urn HW 1 SEVfvITY OF O:.MAGE IOiHEPVEH CLEI SEVERITY OF DAMAGE, v f HCL NO. OTHEnM v. DAMAGE 6E VERITY OF BAMAGE?VEHr O.I . O o1HEn M.CE AMAGE ; ?OV LINO DAMAC C 8 MADE NO J? F E" '_GE 1 DIS SIN E AMAG L T O 1 ? D seallx6 DAMAGE ] oT " D DArAn GE EST. DAMAGE A ]? ED OT G1 u U'GT' sT DAMAGE T? wf° ° EST s TOwEDBY DAMAGE TOwfD9Y T s To ARROW SHOWING DRAW DIAGRAM OFCOLLISION r I, UIN A, w fl _I I { RTHIN CIRCLE 1 _ Q , .-l?-O? -..µ. ?G(?/-Y /ILJ ?L?oj/i C']J? L f I L -- i - - - - - - ?- a'9 -t 1 I I DESCRIPTION OF D WHAT PROBABLY HAPPENED BEFORE. DURING AND AFTER THE CRASH. INCLUDE NFORMATON NO' ON DIAGRAM. EG DRNE9 _ ,CITE OsemurY, REDUCED Ylsle P[DESTRIAN CLOTxINGCOL.OR,CONSTRUCTION OP RfgAIq WORK. ETCI COLLISION , LCTB-t? _Oro_T/SE O/d..0/Y!]lf]?G f??•t?J?._LtJit? ?J_?? N./' -- !i'--_ z _ __ /l.._.'/'Ne+[._/?L3-. L° c°CL dC/P1' T/•c= __ N ) ? ) - _?_/?U fi=O / l C!!d J! r?I`-r !c. J/I-? /7d )'r? .S _c!?E;-...CT? T?G yl?dcr 1?/'??%N/_?/ l`?'r?" %C 7 !° / d ' ' ? ? . __ /_ J _ - ,f?T_i / '- )! .G n)_6d,nl?asr_i_-_?,?.o ./•rS_%?%__-S ?c/rc: ?/Nxr sd?s ?v_:=/nL'r ?n'.arla s __, GN G' i/ / J - ? , C v?drvod ; C//Lia, /c G/c JS ' T/ ? L .l cl rS ??/!S_?i1? tiFd cJ!)o T ? o n _ ?e l/ 3 EEO AEVV AD L- I' _ IARKED n GHwev xwME DEi ET OR EAOED MI TnE uilNC oicREAVrvc o L; F? No.' Z7= E YES -"M._ Es NO No J _ TDIF PED. lF i 1[- 71 ' nG * ] _ - ]^" c u 0 TE o E TI I FP E O FDIB,CSUIIFAS USING ACE OAD SUR 1 I SIDEWALK -WEAT Efl j ISHOpLE CONTRIfSUT O .. SS ING CIRCUMSTANCES ICYCL _. ° cLE clip Os rvo N <KO EI E I PWER VEP - - GOING STRAIGHT AHEAD ORNV ER F F LOU ? NO gINFIUkNCE OF 1lG4HO wtncE lv I NO.1 J ?I FOLLO I9 j E L R ^ ° D[ W R T OVERYAKING G G DAN ET NRI G II ]I I o%uis - r [ LD G A STTEO i I ls T E UTO S f C? E" PARKING NIAKI ] r FTiuRN - F ! xG I OG' v. E4L. t .-- [KC[FDI SMGPEAS X xl O Eb E 5 .I•--1 •- - O D I Nc S. IC,._`! NO _ R - O ? f1 1 C YI U .. .?r- f C[ T D w F O9G0 iG E S 0510 __ T O SP[C FY ING S ? ] STOP" FOR I P!C FYI IH[ . S [ aT E flAF EP ?16I ¢LE TYPE OF ROAD I ]:.? 5ON/s GNAL 'VEHICLE CONDITION I 18'. O UAI ON ILRECK ONEI ?", TRAFFIC on°s*o1 EI..i cxAL. H NDI,, ICHIC ON o ] VEHICLE ..1 NO.] IL ELK ONE OR MORE 7 1N,CLE IICC }Cf II?{{p,p[r?{[ (1 0'2 i`?QNT^'^u?k'DI CLI O 1x ] B1 11.111D. 7 SIGNALS d y?] ONE wer 1 x], TWO IJ ? ?MKLS :-? PAIEU_ ` I TRAFFIC DA IG ] } DA s 5 vI[l0 ]I- [ [ BL! N.A. _ ,.. vE -..1i. ?.?E D LE IS 1 __11!_1 .1.OT AHCU O ° Fut", _-- 1 NG FROM I. I n ?vKFp POSITION _ HR' RI J ] g i Wi ASH G G[ IOUJiAMP 1 0 [Ll F 1 S l ] -?- I J A F CI - ] DA K i fl qFU_. G ..._ ?- { 1 f Wa11r i 1 = I T Rf ]I SM001H O NOT R HFA [N OHIxKING I BACKING .7 L? M9Fq., F i CHLM. TEST DA DARK ' -lRffi IGNAL _lI ?- ?' H 0 OTHIR.-C.", «.LA...4Pf Bi SET LIGHTS , --f-f R y. • , [5 GIVEN TESTI fFUSED D - n ] p D ? NO DEFECTS "niHl v--'c7' i n X.' A K x]I I °•° !F 7e ICST RESULT[ M xv ° ARRIVED A a CI 2 Mie C - OW 1 .011lc S NAME •ANA vEi AMC, oQ. POLICE D ARR pfO I f IN B .]7 'A Bt1 l1t07_CJ_ -« V . A u NO N unn nuoxl A.nm AGL cr on 01sT a utr An o 1 veD?r DATE X iiA11 IN -__._.._..... .....? ....•.nou A TNn In weSIIINf.TON STATE PATROL- OLYMPIA, WASHING1ON 011501 W/LICAi[COPV. LOCAL LAw r.r[rU"r,rw.En, nur. n....r.....-•??•.•??•. ••--? ---_?------- 1 Kim k? ?? ?. ',yryµE !iB '.k? 'mil a, .lam' -8k! r I, 4 f . Yi V 9 T".' i Flq°"TT ?.-+'j I '` IT (I?'j?y 1 to ?itr'i";'?'if 4' V ,•..J 1' [Il'zz?; ?1?•( / 'h' 1 HI, 111 71-77 ? . i i 1 i r, '? r a , sI . xa.• - Yr 1 I I r p ?[ -e I 1IL r I ?i 1J ,C ! Ai110 f .4 T ,, AMR. STATE OF WASHINGTON PAGE / OF , No. - r UNIFORM POLICE TRAFFIC COLLISION REPORT POLICE COMPLAINT NUMBED -417 FY - OF LOlLI5K1f4 TIME DAY COUNTY NO CITY NO. FHWA DURBAN Z Q GATE OF COLLISION DAV ?' T SUN 1 MM 3 IUlS ] WE A INUR S 1111 D A (USE 3400 HOURI URAL 1 ADMCLS. PREFIX POLITE OR StREEI CODE LiION t COUNTY ?STATE ROUTE KCOUNTY PDAD ?CITY STREET W •-? V?0 ?OTNEfl ISPECIFYI m PREF. ED MILEE-1 CTV OR TOWN II ? I W / ^? ?V / / L4 C --- U _C 1D??II ?/_ F. MILES ? ? Y?I' ? Y / _ ___?_ _? IN TERSELLING WRN. STREET Ofl ROAD LL O gAMP DIAGRAM Al. D I/ N FSTfl TO UG T p ENT NTER NO N INTERSECTING STREET Oll ROAD Ofl RE T OR ROAD I N NCNWTE EL JO ACCID MLEAGE T cUS CLS. ERE CE CROSS STREE N J r t ? BETWEEN STREETAND -STREET CODE . COOINGLIRE SPELT EAST CE AND DIREC1101!FROM R.FEPENCE OR CPOSSRiPEET. / IMILER S n A v NS urIInFT O r_ f_ _ „S ® O?/SGO!/t%/T??llFy?CKa FEET 01 - I...J ._ 11-1..e.1 1- ?- 1-INIT1.UN NO KILLED v E H C N 0. 0. /•r /1 t F '? DRIYEflS ODDUPATION FUUA NAME ONEND. •j _. DRIVERS OCCUPATION r J</? CODES > 1]J cuss--I 141 SEATBELT_ ISI EJECTION _[? COD OS > 1] c"i COLLISION INVOLVED. LJ YEHILLL VenI?IC ECT --- - - ?VEHILLE-RRTRAIN - ?StOLEN VEHICLE TO-NO LJ ®LEHICLE OBJ ICLE-PEOESTRAN ?NON COLLISION ?HAZPRpOUSMATEHIAI OFVEHICLER L_ ? VEH LOCATIONOFOBJECTSTRUCKS , OBJECT STRUCKINAMEOF OBJECT STRUCK ANDOWNERSNAMEI. - ?ROADWAY FEET ? ? MIDDLE DRIVER'S NAME LA51 FIRST MIDDIE,.I ?,DCVCI D UVEgSNAM E lAST ...: _..... FIRST .' .: . .. :.: .. ....:... . -,.. D, A , D,'• T S a-, G? / : STREET ADDRESS R - ADDRESS TREED ..._ ._ • ,..._ . . ....... , : _. I V V / (? ` ? 3 S ' E STATE E all ZIP CODE PHONE NO R . CITY R Ss'19A P.7aJ : STATE iH A OF & BDATE N DRIVEAS LICENSE NO. . N -E LICENSE Y D y J 0. NO I DAY YR fIRM NAME' P NEN •, Y. UPY I4I SEAT BELT- TIE' EJECTION ?__? A55- TO IDGE.CHEV.I .- MODELIDAAT-NOVAI SlYLE13OR.LONV.1 f / G E VEH COLOR tlC. PLATE NO. STATE TRAILER PLATE NO STATE • IJG.PUIE lb. RAZE TIUULEN FLATE W. STATE H sl • /-Y. (/ ' ' METER ..., I ?OOOMETER :..:. C VEHICLE IDENTIFICATI N NUMBER ., .. - •`--•-' 1 NTIfKATWYJ NURSER '--- "?J Y e MIDDLE. g F RST' - - r. sl RED OWNEfl-LAST ..:::FIRST ... _ .... .. ., ._ .MIDDLE . .. I REGISTERED OWNER -UST •N I' [,: Al ?S 0• ADDRESS OF OWNER . _ .: __..::..-. -: .: .: .. :. 1 2 " NAME AND ADDRESS OFW UPANLELO. OR AGENT '. - •: . AND OOTiE?WSUFUNLCOOR AGENT ...- .. ,.. ITATIONN CHANGE ".I CITAf ONNO .. ENFORCEMENT. A, t w d ?7/A/i"Ly'??+ ?GFr > ?dl r1 o 1-..11?? ALf1GN N / CODES 1 - ] ] D EJECT STATUS AAA RIES OF PERSONS INVOLVED NJI ? NAME ADDRESS & I T TTT sf% AGE AE ' _ D p .. A,UNE, iuuRlES A N NiME . ADONESS. M vMA r. N TO S: LINE wAIRIES SC[NE PV W. , NAME L T Aoon Bc' ro N I s EI I Li S NAMC?? - S SS ADINLu?IE AIpI[S E W • IfCETbvElSifl SCE NF RV' ?A1 f0 1415EA1 FILL" DI[Jk Ci%MI . $ 11151 A1U5 1315EAt POMfgN I]IWJURYCLAss -MJURV olsuanlG WJURY , 1 NOTINSTAIIED 1. N07 FJEC)ED ] IOlAlly EJECTED ] PA5sEIbFP - PI DLDt IDAN OLAO At SCENE ]DEAD ON ARRIVAL 0 ON DSAHUNO I_D, INJURY t NOI USE ]USED ] PAR11AllY FJCCIEO NI) Ow 4 : O .ROT+::151 6 ) 111[ fl POLIKYI i 0 IDUDMOIONCYLI[I 4 DEOIN HOSPITAL ) 054PLE JURY P SCAT DELI FAILURE D O EJEC D D OIHLn 6 ] B POSIf10N UNKNOWN . r 1? w. v }" k?18, ? L .,yr - Y I 'IY?} 4 JI A,A 1 E Il 4 {?' L I 12+ h?i 1 p I ' r E ?. L 411, :FrrtL• a f . NO. INJURED ?,PROPERTV DAMAGE ONLY - _ EET.OAMAGE - OF ? ? RD EDGE S ISi OFI VkOf SiNIAN CHEC%)D ? "'.'. x? . LP CODE PHONE NO -q? n cn MAt LOLLISION REPORT SAT OF C LL jl E O 310 7 1 ? ' NV O C / ?? 77 a ca M x 1 A? - Ty;:. L,C?, TO .. MIlE3. ;'??.;?,,.,•`?y.: CT T N I ADM-CL w rw[nf orv - .E. ? 6._r .,? /U ??C1 DF? rJ- .:? 3 x I J-20 y .;a. GIV E.T!AYEO+.STR[ETA,ROA..?R,.,GM1'!AYV?M.•;y1NTER3ECTIJIG W.tH 3, „ETO PO, yv g, PRCiI% EO - MILEPOST r F..' us of ` L r Z ,O 0 O31 N IN-.... TION OCATION OF C USION RIIP BUGRA4 DAI. y ? UETWEEN REET A STREET. b T ?N - - [ ?o a[ rxa. xr.[ro•T on :o,xrrryr........n. n• oxrua INTE CLS . • no,• •',?-- rx•n lwx,[I / / xr .c cac a[ / EC. CO ELISE } ' I v O JECT ST i uM -OV(N[R,.OF,:OSJECT3; NAMEANGAUB [SS,L.;,y?y,.L _ .,. -_... '4 ,:,:s.J - . ?N 'u...• Ra T N'^+'y,?y ac. ?? r4 ,"_. ADWAY "• . ,wRI „ FEET FIR a. YERS LASi?N _C*;•,??,1y?FIgST, R.. E+v MFi.•.. L.. w.w NIODLE. ,.-.? ° ORIVEPS A3T:NAME:. ?..G.i? .. ?•:ti MIDOIErw:. ?tk_ Fin c) < ne I< a3 alC) more r i '' TRHET•AB E•. •Ay(,'yr,`.q+.w•v,?.rw+y^?, R•II[E N4.[... BO%.N0. [ STRCET.,.BO-ESS'?• 110UTE' 6, D.DO[ _ >uVr W..._. N.ANNB• Siar UPI J iJ61x S0` ?, .? CTY f-..•..a STAj[+„w?vw•?yL £OB?/ vaR ERSOCGUP TI.N",• SM.i r.•.-.:LC.'.YU A?wl.:.?'C'YiCIP,000E BRIVERS_OCCUPNTIOX:r t S S .57109 Iear?Ie? i., e,d ti7a ll.9PJ?Y ?T'^1 ', o V G ?v• s,[R?y?_ ST _ % BAT[ FB TM_ EA , . r. :DPIVEflS LICEN3[ANU,.M1 _ TIFTE SC% D T£OP'BR M. AyEy H IG1as0 Cda N X n9 a? ? 3/ ^ 2= Y?1T %3 wo'e l V... imi MAq_6" 4h •°d[I NODEL,jvTwY,w 1 0 ?Y E: 2 ?1 _ . Varccc(?. M.NtLY_w1.• woem.l MOBE[,?;ilrava rl- BOO,•Y,?ST?f.C••?.2'.? 7 lcevv Vnn Van -au a. Or 2 • LICENSE, PLATEN Z,sTATE+jpl Co?O ,?RN1?6R?PLA ??qy. -1f.S?ATEjv+ CD70 _ S LICENSE- ?_tiE : -JET.tTC `•% Ye d[1 u ALEAPLT N0:y 3TJTE Vv •IGlFj10[ TIP IG t10ff;JI0y;4 CI9aB?Y°o%y_OK ;jw[FI OOQNITS- ra3 ?li60 ge- 04E9341Pa t70 , .' i - x .I R_?ID HT,.,IG LR VIN: b[q :?;?rou:a s;r[p,.Rl ooow[T[?un.u.eq ... 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AA l PLOGOIAM "`f,.? ? ? ? D StR t1NG .'A1O•IB .?. ? .. " CROSH NG ?. ?, 1 FRO y ?I IT?Ow 'Y SCE.. a~El J ? .,u• ]? a,w•• ]? m IC,A 1 . O Ot IK[ ry`,w[ T [ LgMTCdrdTMNt TRAFFIC GONT d TYK ROw[I- Icarc.Ox[ ' O xrN ttf yCLCACTO[lyr,}l rJ+?+[ n, 11 n JH[ WAY •rI ] I LrJ M 1 DA YLIONT L711 l l SIGNAL[ 1 ?^.? II ? OOIND GTRAIGNT ANLAO + ..h , 1 ORY 10 PAZ- ] C, DAWN Q I CA STOP •ION ? ] ?• TWD WAY ? ] ? OVERTAKING AND PASSING -.'.. r r E, I ? WCT ]? SNO WINO ] ? OU SK CJ ) ? -L. SIGN l..J ] El NOADRtiRI.[ ? ] ? MAKING 1I0N1 TURN I SNOW •?.? IGG A ?? LDNTi DN[[T 1-1 A El ILASNIN. RED n A ? rIOOP?RAUe? J l ._ ? A ? MAKING 11" TURN - 1 ( ARK 1 1LAININ4 .-I u 1 ? All" C? A CJ IC[ !? 'll",1I ) (? D. .11[T _1 % u S n MAKING U•TURN rr'' iF C ?? O•RK HO "? WO WAY rJ RP 41ONAL CJ K r] T[It TNRN l_J L ?.? [ • C) ?tq F[t Lrf.N It L7 F r 1 I? A M L' SLOWING ( F IAlON IOw MOT iI[IM6 aANa[R: T U SFEf.,/Y ?_.I t l._? Gr'/iC[R/ILaf.4AN 1.ANrF 1 T r 1 6T-F..O FOR TRAFFIC 1 o.awmr.o+x maw4uex. n<i ? ? • U rciv Ih R W ueeroi Smbla NAL ? rAgt _. SRP•w AT[D OIVIGRD?Jy [? ? • ? IO? s)GPPr.D INRO,AOwar f,. T , ? ,. ,, a 7 ('7 G • l l CO GL E n ? UNGIVIDID _---_.- -- ?. ?-__.___ -, n I1 t•-1 TRAIFIaL M[ .T.RTINa FROM ? ? n•,..In nnw...,... 1.. ? ?,? ,T °,-?'x?"" ... : , .."?°-?.?*N? _ .,'t°?t?rYrx° Tr•??^,??v+°.'.?r,l °.awFa'p...,,?.LR?r,w° :.1; ;"? ,'e'F" ? a'? ? I ` 1 ui, Il T 5 i PAOTOR VEHICLE C LLIS?IUN EP t °FIa' y ?? (\ rAl m by h?4 `i "? 1 - ??Y J I? 1 1 rJL ,y 1' L {{Fl'' ru. ts'?M Fz 15i n .,'- - . I i I 1 A R+f? D it I ?'i s - a' ORT p reoFCpuISIDN 77 o ' i!4\ ryI-.G?/. 77 YoFw u DN .x x u?EO c d r. •.u??.1„un I?°" r r r,a _ ,, wuTV rw clrv NO. ?? ? x"..x ?nnt ?COTYCITY TO I /t? ) 1 MILES --CITY " a , :OWN DMi:LS VREFI% HOVrE OH SHEET COUe SECTION ' •D / DIVE NAME OF STflEtT( OID OR HIGHW AY ? D 36 4-2 0 ? 9 NS ECT ING WITH: STR EE /011101/ PREFIX ED MILEPOST. NON IN (ERSECTION.LOCATIONOF COLLISION BETWEEN / / ET.E.1- s,.Ecr RAMP OIAGRAMOITA N E xnrE. -: ....... l,.,s, YYY r ? O DF [ ,. _-- D NON A H?R ?, D x c 1x111 .V E...3r?.s?v?a ' \ '? ?VE" D SPEC. CODE USE OBJECTSTRUCK V.wEDl px.tc MA CKI r Y ) pr • . V OWNER OF OBJECTS NAME AND ADDRESS tz IN HOAONAY Oa , prxEVUx UwF QJ DU F? IFFY IS Y!I ',?..:? ' • • CRIVEfl3LASTNAME FIRST NAME .. MIDDLE xuox•ixw rxu ••••^••• - DRIV ERS LAST NAME ' ' ' G FIRST NAME .. ,.. . MIDDLE' >TflEETApDflE53. R UTE NO. AND BO%NO. "•'"•"`^" x,^. STREET AIDRE55 flOVTE NO. AN O BOX NO. Lt7/D - ?2" ?11?'Y - ttN• CT-r?? q STATE -E 21???6 N7 c? '!? ' ERSOCCUPATION F "^r CIT l??e TqS ZIP CODE ` \ I ? V ^ _\ - DRIVERS OCCUPATION ORIVERSS LICENSE NUMBER STATE SEX DATEOFBIRTH AGE Wr?7•1, r? (Vi 4 r 1' Ej, c ? - uv, ,L F X ?AIY , ? OIIVE8 1 LICENSE N U M B R E STATE SEX DATE OF 01flTH AGE ". EAR VEHICLE IF MAKE t72y . rexev-N'¢ 1 MOOEL xov. D.xr 1 BOOYSTYLE ' ?`' nJ? ) c (off( f? S, K 1 EF goDr VEHICLE VA. MAKE I Ev, maG MODEL IxOV x.D.x [x N )DA.1 OODY STYLE I LICENSE PLATE NO. •STATE _ a n?38 TRAILER PLATE NO. STATE LICENSE PLATE NO. STATE TRAILE R PLA TE NO. SipTE VEHICLE IDENTIFICATION NO. _ vODE TEP [I.c NSxb Lsb M1Fwk PI rMr el UDONE VEHICLE IDENTIFICATION NO. 00 ' HNx vOD¢tsANk r HEAGN ntx OMETER.M aor9ocs IV r wFl REGISTERED OWNER sir op[1 x. VERS LICENSE NO. t ),tin 0 Mel v E g/ L. DRI mow. I[ASr REGISTEREDOWNER DRIVERS LICENSE NO. . x CWNERS gODRE53^ __ - STREET, CITY ND STATFI DATE OF BIRTH JD- A V /A? MO OWN Efl. ADDRESS 13 EFT. CITY ANO STATE: ',;- DATE OF BIRTH A PARTS OF,VEHICLE DAMAGED •, •,., .._,_:.. , esrrVArtOCOSr DIVE px[..xYFx[LL qM _._ pq¢r.rR`?»Kr LIABILITY INSURANCE INFORMATION-VEHICLE 10.1- W^s THERE AUroMOBILE LIABILITY INSURANCE ? YES ? NO COV ERAGEI EFFECT FOR THISACCIDENTON YOUR CAR V< AND ADDRESS OF lIA01UTYl DUR 111 POLICY MOL1ERrv ,;,' '. . S ... .:. ....' NAMEOF. LIABRITYI ANCE COMPANY ,.r slL.N_ h" ? h} x of.R Af- ?2 ?BYa.?_ U n i9 M A jt/hi 83'3 ? ? 2 Irx? 0.s ME CDD OF La ILITY INSURAN-wz v II UE/ Vv: ga 3 /Im ? • .xT E " TTLI YNUMBER3 g q? . _.. 1111 INJURY::. Ru . SEPARATE E ORT __.,_Mt E ( NAME. .... .. _.-. .. •....? SEX DRESS SEK:r - rtw.r IA F F F-1 rl STATUS Of INJURED _-' ' MARK FIRST ..; ONE THATAPPLIES STgTUSOF INJURED' - MAp%FIRSi ONE TNATAMLIES--', IN VEHN:LE [] INVEHICLE KILLED ie? n ?xi?io ro e I1 r i ar ro KILLED slvi is vxrwsr pM 4C N " 1 6? D. ? Di7iO e. Q..i.. c. r.E.N ? rj ? T O. 11 ri. ? 6? 6 ? SHOW NORTH BY ARROW IN CIRCLE D ESCRIBE, OELOIY WNATNAPFEN[Or IREFEH TO VEHICLES OY NUMBERS ?, _„ - __Qst'Co Ern q I ?a.QQct ???c,F G1 i Q? it,eaS `?(Loa. Z. -33"Mi? a ?, n. " B 10- ? . L .?r . .. 7 L .n ? / _ J ? ? ? tl D- J.!L•C_ e-a'"7'- `"... ?LCw'?' t_1'H"'L g l o> ?C? rtR d i ? J, ?A w. ? ? f _ a ' O W.t? I.va.S C 1? G w?1J C L : A o.,?i o r? ? _? ? ?o ?1 nxefw S ? ? ,y -y Tt - ?IJ•'!^ =v?^-'(?Yapn ?-T ./?.o .??`^?-2?Y1.cvsAS - I I ,: VEHICLES POSITIONS BEFORE COLLISION NvrsnDAreD sr R VEHICLE lylAOFD ON STREET OR HIGHWAY NAME OR NO. ??? ?A 1 1x:[11 ,xtx r - IYOURI ? ? ? ? ?I ? ? ? ? sN.NDN -- 1 3 IOT FRI ? ? U ? C7 ? ? ? ? PQO[STRIAN..??.?? ALONG'.' ' f ' O ' .,• F . R M .CHOSSINO .X•TM..i1.T?T3,nFr}AY,E;.ex':s1i' PrOESTRIAN-S USING 1 nll....t. •?•? •][]:xuu.ur ?.? r'l .- 001x1. S LJ w.l? B ROADSURFACE WFATHfq L4GHTCONDITION3 TFAPFICCONTIIOL TYPE OF ROAD DRIVFRNEH:CLE ACTIONS < r. :ITN NrKlr wl' " 1.1>u?vw ro11AYLICIII rl 1[ d'[I v' •4 rc•,', .xr Kr•[cr Ur[4w+xJws y11[L OHr 1 []RAISING, T []DAWN ?x1 []SIGNALS C] I PONE YEAY?~ , 1 []GOING STRAIGNTAHEAp ? WFF 1 ?SNtlwING ] []DUSK ? 1 ?STOF5IUN [] 1 QFWO WAY [] 1 []OVERTAKING AND PASSING U ] ? SNOW A ?Fm A ? Ol.. STIIIET ? ] ? JFIOSIfN ED ] ?ROA(IISIRLF. ? ] []MAKING RIGHT TURIN SLASHING 1110 INrFRCNAI GE T? 1.1 r MAKIN41.EfT TURN ITR ET A ? ? A []:LOOP, IIAMPI A ? 'ii ? A G IC[ 1 ?D4Lir? ^' ? IIRK P F 30 Ll!H ARK N O ? B ?rLASMING AMNffl ? O []ALLEY ? B []MAKING V•FIIRN lJ B ?V.c?ir D N ?SrR FT LIG r e H ! ? F. ?IIN SIGNAS• ? R ?IY.r IVII.nY 1. Y11 ? O ?SLOWINO RFATON FOR NOI 3I FINOO YOER )? ?rs' ?. ' , , • • n ) L r lnsrlfrR:ELAI:NAII ? 10 STOPPED FOR TRgFf IC 1 I A ? ) _ '.1 I' . -LT. L) 5[PAHAIID ? A ? ST41PPE AT SIGNAL i L O R STO 9 GN r? J [](11V 11f0 ,.- Q O XSTfMQ01N ROADWAY N??. ( r A . CONTROL [] F ?UNOIVIOFO . ? IO []TRFART AFFIC LAIIC '.' _ i 4 5 ? ..?EFEd11+ _ 1EFRR ?,.. T.e 1? +?F ? 11 '\I ' { ? ^V^ 1 1• . . . ! y Q n Y? 1K bv?' (( \`T.I MOTOR VEHICLE COLLISION REPORT ?rF.AVUnsYlwyA.'NJ+Im m.?i_, DAIL OF COLLISION DAY F NO. O COLLISION TIMEOF COLUSION iRA? jE? Svr uJn rULS NE xuR r SM • Mwu,FS AM II • PM COUNTY NO CITING. ... O PLACE COUNTY TQyrI(- ,/_. L rlpylSOE MILES OO i CTY.TOWN ) CLUn'" r ") ADMCLS FIEF)%. .1EORS Fr OM CI ON O EY./ /yC,_ Ti .y /( / Ow ?w /Z ©© OF LLC LCt?itC/ R p D L lD N oN _CQ ENA.VE OFSiPEETIROAD NGH AY INTERSECTING WITH. STREET OR ROAD PgEFI% EO, MILEPOST NONINTERSECIKINL A OC TION OF COLt.I$ION I / n ? ` f RAMP ,. pIAGRAM DATA •. ? BETWEEN C• ? •6TREETAN0 STREET -. . ' ? n `pl RAEROMCaosyicpM [[vosrsop`KII "wGiµwiaKUU R ?E' %RD sFCRM) E OR qo,b OR . fF © NIF0.5FC,KXI « )TER I CLS - R 5 REEIDgIgAp ??/] oU SK%.-VEO Lj VE-LE rvcLE OvEn,aEacrcU I.F. ppwR Tel DFYIBALES ? J ? ?vEr•cLEOeIECI ?v[nKLE ,BALI, pvFrvKL[P(IXSrw sPO ccoL - AN ?Nwcausox O.-UN OBJECTETRUCK INAVEOF AVCKI OWNER OF OBJECTS NAME AND ADDRESS LOCAt INROAD _ ION WAY ?© qo FEET EDGE Fp DRIVER5LASTNAME, P£IRST NAME MIDDLE o? Ccii Nes uORE TnAN FIE -l. GPIVERSLASTNAME I F.FGTNAME MIDDLE ? % ie.N?1ZD STR EET A DORE55 N O UTENO ANDB X . NO, O ? l E ? J PE B. INJURED USE E STREET ADDRESS ROUTE NO. AND BOX NO. CITY STATE ZIPCODE DRI1ER5000UPATION ?ui ?,a ll/?c 9837 J7r' ye,- SEPAAA,E DMS? P TPORU CITY, STATE .. LP CODE pRIVER5000UPATN)N DRIVE-LICENSE NUMBER ,,. STATE X DATEOF&RTH AGE ev mw / TG?A C s RA 3 o s m DRIVERSUCENSENUMBER STATE SEX DATEOF BIRTH AGE Mo VEHICLE YR.- MAKE ECHEV.-DODGEI MODEL(NOVAAµTj BODY STYLERDR.) ?il ?%[> ?A .' /? L { l S ? VEHICLE YR. MAKEICHEV. DODGE) MOOELINOVA DMTI DODY STYLE (]pR7 . •t • am. ,. .,_r•I L L'? ?. L MENSE PLATENO ? STATE TRAILER P ATEN < ? . L O. STATE f7c L' -I- - UCENSEPLATENO. STATE TRULLERPIATENO. STATE No VEHIICLE IOENTIFIC.;3. OEBMODEIs NEWER) ODOMETER(MILEAGE) VEHICLE IDENTIFICATION NO IrBBB MODELSB NEWER) DOMETER (MILEAGE) REGISTERED OYMFJE )LAST-FIRST MIDDLE NAME), DRIVERELICENEENO. REG15TEREDOMER BAST FIRST MIDDLE NAME) DRIVERS LICENSE NO I•y Q\YNERS ADDRESS , ISTREET,CITYANDSTATE) OATEOFBIRTH OWNERS ApOPE55 (STREET,CITY AND STATEI GATE OF BIRTH ?; .. MD D,. YEAA , PART$(F VE; )CIE DAMAO'O f) iltvua T E PARTSOFVEHICLEDAMAOEp ES,w.LiF000SI C- - - vtn L S Io P LIABILITY INSURANCEINFORMATION•VEHICLE NO. 1- WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENTONYOUR CAR, YES ?NO AME µD ADDRESS OF LIABILRY INSURANCE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPANY x.u1E ADOR[SS orY sIAT[° NAME µOADDgE550F LIABILITY INSURPNCE AGENT„ orv SrM[ T UABIUTY POLICY NUMBED I ISTWJURV '.. AGE --UP.Y: IVSESEPAN.TEREPOPirCAMIOIKN IUU S NAME TOTAL NAME -J ADDRESS SE% ADDRESS ' O 1 - - - M CIO - - -- p ----_-- _ A R"" ® F © ` ST TUSOFWJWi •(rA MARK FWST ONE THAT APPLIES STTUSOFINJURED K RRST ONE THAT APPLIES YI/7 Bc.R ? PR_ W LIn xoy pLgAfit qty E =."' !H. pIASA[NGER IUUED I.KR M IRV =." pw?IVER IN VEHICLE Ir 11 oN OapRlrv 0, 1 11 P R KILLED IS[ r [REI AG O E E L FT l ?REIXSImAx O rO AN NO. -.... r OE I pRp[sIw C p .,.. "... :F.I. ? SO 60 7 pOniuI UPLL.Ia' ? 50 60 7 I SHOW NORTH BY MROWIN GPCIE \ I DESCRIBE BELOWWNAT HAPPENED (REFER TO VEHICLES BY NUMBER) I NbcAIL OI_4 'DgAM I? ? I.D?,.Y _ 2 1919• ,?? I a M, ?iR [FCmm? x D Srv? I 1 ? . .. .. , _VV? {, d? ?F,,?_ ,? - __ _ r(; - LICENSING p Q'? _ . -- 1 - C VEHICLES POSITIONS BEFORE COLLISION waL.N[5 IDUi ou PPwn0 W.5 INVfcTlca[D Dr i . wE R u :a re ve0 vexKL[oee Ar v[HK:L[ u<p M S [ W ON SI-1EI OR R--AY NAME CA NO O RlCI,OV qO `rE[L`RIp ??A,R4 ?IgICI L»A ? ? B1 ? ? ? ? ? ? ?1_"_ ?W N " ? ? ? ? I - Fa ( o-r. / ? ? ? ? ? ? t NFF ,? nIXA,•R+N ? ? ? ? IUD"6 a '-D FROM DIRECTION To DIRECTION TNJ?1I c AYp[SIRIµ WASINrA lp UDf WALK. ]?WA.KWAY Os DIIOULDER X?? 1 6?cwosiw4K S OTHER w NGAOSUFIACL -Al." LKYrt CEWDRIONS 11-ICCw"OL ..-o I[I TYPE OF ROAD 4 puVER/VEHICLC ACigNS , C-_. •. ."^ [ ' !C•ON[ v[rKL[ KNC• CA, d1AAA':REI vrRcIl -1 I C'.. MIT ~ 1 A R ) ?C1 E?bl 010+cuQ 1 ? DArIItLli ?1 ? SIGNALS ? 1 ? ONE WA Y WI [ ? GOING STRAIGHT` AHEAD 7 1 `91EY L•? `• . ] ? R4rANO E ? OEKH ? ] ? STOP ScN ® ] ? MO WAY ? ] ? OVERTAKING AND PASSING ? ] 0 W T J ? SvOW+NO ] ? DUSK ? ] ? YIELD YGN 0 D ? ??FSBIL[ ? ] ? MAKING RANT TURN ? ] ? EAIOW CA B T E T " ' U E ? A ? FLASIIPM RED ? MTEP A F? ? ? •I D . ? CHAMPINGE 0 A p MAKWGLEFT tURN S A A ? NY SIPE ( ? llGrlTSOFFET ? $ ? ILASK' . LMRER ? S ? ALLEY 13 0 ? MA%EIGU TURN OT ll1 S `? RCB-Y) 6 ? ? S ?S P [ AC Y S.m SIP[EIT?l10MS ? S ? NN FXGNAL ? S ?ITVFAl 1.. ? S ? &Ow1H0 PE ASON ION NOT EE 1A MA04 W l 1 . I ? 4IEOFY ? F ? OIF KlI11I1A0Mµ LANES KKIACLPAO M+<W pMAAt,cWS/ICI 0 T 0svO ro FOR TRAFFIC ^- 0 [ 0 0714A &Pf CIFY 0 1 0 EJ,PARATED ? S 0 SIDPPED AT SIGNAL 0 ] 0OVIDED 0 P ? S10M'FO IN IIOMYNI dLA ' ^ _...._ ,.. _ __?_._.__. ._. _....... -..__ ... .. ... 7 ' J rA 11 IC Lw'? ,l ?U f v¢11D ? 1O 0 fl ARIFCIG. ?'*<rsrm?,c,Fr?[Y?a.....-.-?Y;.•,.......?.. - __ T I .,.I n 1 n• F?, Y n? ? 1• ('? UYa LnUU I IUNJ: - SORAW IRROWISI TO SHOW PNNCaAIp„Ep}Ipy CFFORCE ®' DAMAGEDVEHICLE N0.7 V (USE THIS SPACEFORSKEICWNO DAMAGE TOTMIIERS, MOTOHCYCIES,EtC.I / 1O ' DAMAGED EHIC LE N0.2 .2 HOOd ID ' i . fi ° •-Ibol ?P • l gEM IS TnnM (?. IJ qOd 1 ° ? •, a 1 1 , IYTVIk U' T' 1B UrMaOVMlpE L/ 10 lzaan,rnR SEVERITYOFONAAOEVEWCLE NO.I 1zpr.In.R 10 pISABUNp0AMA0E a? V,OAMAQE SEVERITY OF OAMAGE:[OTHER VEHIGLEI OTHERM.V.DAMALiE SEVEPoTYON0 DAMAGE DAMAGE VEHK:LEN0.2 D-A 1Q gSABI1NO DAMAGE aQ QOTMER M.V.OAMAOE ° FUNCTIONAL pAMAOE { NO NO DAMAGE ! nNCRONAL DAMAGE , N00AMAGE 1 QDL5ABU NG a FWI DAMAGE • NOOAMAOE TOWEDBY ?'1}l?G yErBT.ONAAGE TOWED BY EST.ONAKiE TOWEDBY ESi.OAMAGE TO- II ?? TO ° s DIAGRAM OF COLLISION A?o0P1f1AOw Igowr nRla -. +_ _--! I`Cf-i l -4 .=c t 1 -- TO I •I . -I-l [DRAW ARROW SHOWING NORTH IN CIRCLE M/ AOADNAY ( 1 I - i ' ? T (? ? I 'T I 7 ( rw.y ABlAa,e wrummxnw 2LDCATerP09AYEPGWI •.s?ngO•eAraLP°LiiueErGFan! Ar'9AI FADDLLI 1 -? .?' - 1 '+i.. _Il.. ? ?f_? I - =?? 77I I i - - r ;? i -? j t` _ _ t_r t -r-- , fi 1 \` /% - ' _ DESCRIPTION OF COLLISION ?INgCATE WHATPV d9ABNTY, flEDUCE ASLYHAPPENED BEFOflE DUNNO ANDAFTERTMECg D VISIBItlTY, PEOESTRLW CIDTHING CoLORCONSfRUC A91, INCLUDEINFORMATON NOT TIOH pq gFpAlq Vlpgl( ETp ) ON DIM311AM.EA. DRNER .-__ -//?..? ?. 7 /J .c i.:+.^.,_:•GI LrC? r.U C c _ ilk - _ -- - 1'1 /' T.i,r`i."s<J iii r= : 1 iC•r`- _ /'/Jr - / c?-Z = No HEADE NO. D MILE POST DR. •wpN srgEETOR HgHWAYNAMEOq NO Oi ONE WRENOTION ,mom 9AlE LEGALLY WASVEH. INCR EASVq DECflEASPNa - PARKED OCCUPI ED a a Q r"- 7 f- - --_ YEB NO YEB NO - - FED. ?''I - l__i I J [. " FETanaamA _ ME TOSECgaepalET L ;--- cDa9HD FEOIq CMTWASUSM : ! 'Smr.u I?wAUwAr "(. ?awulnw ' CBM""osswAM? °I .icy "(loc^?ON+c?g1FpN,! T.I"-1 '' M ROADSURFACE.; MHE.. q10 DR,lR. ;;;?,; WEATHEp •,,? QCONTRISUTINOCIRCUMSTANCES IGECl OHEI 01YiFA ? K:HECH?? MORE[ : 1 NO S VEWCIE. ' y I awr OwrFR a _. . • ?raC I? rt•veAD , ® WTACpl9L0UTw?._ a _l TDOCirbE r a'? P01C9M°Ep wAM IL?- 0?' m ??!__J ? v A ' ? RAr'•'p ?a? ? "°?°p' Ce? ,? cExrw u(1 ArvAHlxrLr Ca? RIDHr?fiOiLwl - 4 ? ?' ?"' - ^ La uvaro ^^ a °M0N"O _ l._I' L_ Ilvi`ar^ AnP - r..nau ruwn '. '--1 M.xw _ _-? aaHRl -_i °Li Laaml ?' U lt - .. J!L 1 ILY , rnm CEE[ltl lCili _---_-_ JLj IOO 0101 ' nn,RROr_FA -. r1E?0Elfp,N1 EOM, ?a•? ,AjUM l E O,HGISPECrYI l I ? ala OOYyR ^1? (-10.-} 6lONfU LIOHTC -. I?nr' ?,1? OYgE4?A95Y I !nAI>gY I^D'q -1 L T? ONOMONS K:HFCK O,M .TMR9CCSIEIESL ivm.aa;;,TYPE OF ROAD .VEHICLECONDRION _ rA wr a ra. l rc+scK aH! oe Mono r.clc (? - oHe oRad..SOSRI:;i:wd CI a Dw°1O°'eemr° ASO„°pM°'• "CK ONO , N6 ! B01 ? ? ? 'l ..J L ora WAr L [q H6 ! , „ W° I. L-i CO, irn 1 AanRY.: 1 1- , , ? ?' ' *w C °? ! ? awH -?? ? •• 7 l I?Y,e I•? --T _ I (..1 f 1 °°". L..1°L...I ? - __4a6..I reA°?oln rs 1 HDr •"OYRnEO L1 _4 ro m ? _ , .. a r L_: :J - ._.._-.-__ '? lLD1GYIntW CI6? aAOAY10 r ° J lagre'or ° `1 ne y'^yw,L a .-? ,wcw.ram 1-1 ,a?Ea nncnlan awTn _ rUlwl nn lJe a„anH ,qp! CHEM. TEST r `- .. ' s,REnuoNn T ,,-- '. n°Agw..p1w !?-vAAN,ieo -' ? 1.11 ? , rmomN gmalErvArrl M. L_I'. E onAan - , rm nvualo l- p ?r l' 1AnwEO .eU{oiioiirefvrl... ` 'w'1C :?:a o wru,aA,warr,nn , c Hrlu i % % TEST RESULTS 2 .: ! EHRNa - I X Rn..a wNETO• pD, ClREr?•N - nNa ?RppE Np ..DOEW ?! ° ?O wcpA w . wr! '<`? ?. c`r,? `'? ,u,'i; :? -• AOlHOV aEi WOwr.LOE,` W,l DInIHY1I A.N,WLD ar "" nA,aal,rr. _ t - , .. <.s /?"f'_'s• I iJ ?vr:.wwtuwENFORGCNENi AOENCY'SCOPY-TflIPLI-CATE --COPY: wVE -.iiW1iiii IGi`TOR'•SCEOPC- Y ? R 3 sR Y .MA y? B Jry i ,f t 1 t ?a.' x I } .nu' b I of 'oval `t 3 y SI •_ ' ,. i ??f '•^ ••, ,,,.? UNIFORM POLICE TRAFFIC COLLISION REPORT . -?. POLICE CCMPWNT NUMBFfl 1.. .. ..• D DATEOFCOELSION OF O NUrI F gAi I TIME RI A o? 'DAY YR. SUN MON NES WEDI COUNTY NO / CT'NO. FXWA NURBAN CO NTY STATE ROUTE COUNTY ROAD ?CITYSTREET O J URAL OMCLS. PREFIX ROUTE1185NiEET000E CTION i' :l ?•C [?-AW OTHER(SPECIFY) N 437 L C] ?N //.I I CITY OR iOY1N W O ?1/ E GLt( F PHE??/fl% E0. MILE POST I J_ (? L@L ILE9 ® ? ? ®OF A,: - O C ?•rS `? NAMES NO.OF EET RWGHWAY INTERSECTNOWITH: STREETORROAp ???C.i O TON LEZ '?•4 L RA., DIAGRAMDATA Y _ I NON INTERSECTION (t?' ?n N BETWEEN ?!? O ( G? l l/?-I c ACCIDElIT MILEAGE INTER NOrvRO EiiSECTING Si T R AD OH REF I T CU4 EREYOE CR EETOR flOAD . 1 .. g.EETAND ST EET 045TCtq{ry1.CE ANOOIRECTION FROM REFEflENCEORCROSSUREET MILE 9 N g E W ? ( 7- NODE h5 H Y . gPE IaLC OWGUS E ` / l ?1 • 1 NFE ET OF 6n, JL ) A COLLISION INVOLVED: ?VEHCIEVEHICLE ?VEHICIEBICYCLE OTHERIWRITEI XIid RUN gEVERITY ` ?VEHICLECOWECT VEHICLE HR TRAIN (/?? TOTALNO ?J?-%L? OF VEXIC-F ? VENCLE-PEDESTRIAN ?N ?$TOLEN VEHICLE NO. KILLED f NO.I`UURED ONCOLLISION ? HAZ.ADOUS MATERIAL o PROPERTYOAMAGEONLY OBJE TgUyCK INAMEOF O&IECT STRUCKNIDOW ERg NAME) LOCATION O F OBJECT STRNCK T.DA M ACE ES - - • . , S E ?- ? ? Y S .' ^ V?AP-I "•?l C-i ?ROADwaYG CFEE?T®???PO EDOE OflNEflS NAMELA T . i x S FIflSi MIDDLE DRIVERS NAMELAST FIRST M100- 1" UDC 1-1 ,^,R PEKSIHIA•• CH KI.,. R- ??1 U ,,?5 5 Y - lT? C .nom SiREETA ESS. R r EN p - I STREET ADDRESS V L„I'`?-R- V E ?- STATE LP cd COOS /PHONE NO. E CI"fY STATE ZIP CODE PHONE N( qus?c?vE o3 - ? R LUP • l (? A ON. DRIVERS LCENSE NO.? STATE . SEX pATOE OFO&YTH YR pgNERS LICENSE NO. ?LIATE SEX GATE OF 1111 A V C. MO. DAY Y0. ((-tt 4 98 ORNEgg OC FWM E ? U?-S®?PNOrvENO. 'j DRIVERg OCCUPATION FIRM •l` NC V 04- Eq? v - tA' edA E H VEM.I A R.... UG PLATE NO. STATE -ALEN PLATE MO. STATE E N vCEZ 5 ZL1 C. L YEM WEHtI ATKMI NUMBER •25 ?C 5255-t1 k.' D L '• j? E . _ A E . . RE015TEIIED OwNFA-LAST FIRST MIDDLE / S 0. S / ? p E-CA -E ` • AOONEg9 OF.OWT'IEN O• ?.. G?/7TYKE) 2 ... 1 NAME ANOADOflE$g OFINSUgANCEfq.OHAO aifJT _ •••••••••••••• ENFOgCEME/ET ACTION Unwut A I NAME, ADDRESS & INJURIES OF PERSONS INVOLVED COOE9 _ , S :N!"; SE% AOE 6TATU9 X EJ CT. C NMIE E ± O O S: IL ml 14 1) l$4,0 Z 4 I L I - U - U NA LI E RE F N CENE gO ?RO? A A ME. NAME. S TO TO N T ADDRESS' . 5 gUU Y RIEg' D OM SCEN BY- TO W NAME ? T ADDRESS: E I NIURIF gf,ENE RY' M TO S N AME S A DDRESS. E N S. I NIU I.S ISE S ENERV TO • ? SI? U] 1 PAgSENp R itl>t A. X IKYI .JI IIIJUHr CIA>g • Utt I 151EJEGIION ( E 1 A 1 I ! DISARUNGINJURY If IS TALLFi 1 NOTEJECiE0 N orEJCTED • ; O I 1 D?vCU91 ! OTHER Z T.OTNEHPOSTON DEAD A T . DEADT SCENE 3DEAD04 aggrvAl I d•.O•ipISABUVO N, TWMURY ZNOTIN USE ]USED Z. TOTALLY ED • s E ° i ••^TI'° IOUs MOI0 CYCLEI POS T A. OIEO I.I HOSP TAL ) POSSBLE YJURY UN%NOWY 3. PAAFALLY iJECTED A UNKNOw'NIl 1 wN UN%NOwN ISEATOELT JRE EJECTED I I r 7, yy P P i N 1 -E.+ pp; - ..r? Ian `'....i - z?.a rtrsal??la ant-:.nti>r..:..?`t' ?,5.u?_ rti ut"?YErx..._;ae`E?r?:..._._..:ve+.YdS•`S"' ^ ? r. r STATL• OF WASIIINGION ='LU LD LY _?'••..a ?? MOTOR VEHICLE COLLISION REPORT NO. "I•• ai rnLp(? DATEOFCOLUSION uC{JDAYOFCOLU- TIME OF COLLISION COUNTYNO. CITY NO. 0v?ntl.r. 'N / / Sun Wn nun FH s.t n : ?? uwUr ES PM -f L PIAR? LOUIiY GTY.TOWN E Ml 6• ®® CITY. TOWN DM PREFIX RIAREw STIE"CI- $EC1ION :.. Ai' 1 wn «c' ?C?eFbun (;ollcenexowi' 0 ©©OF ?U u M1R• A 3Y-Z7C7 ROb OV -ENAMEOFblNEET.ROADORHIGHWAY INTEflSE T1N0 WIT STREET OR fl0A0' PRER% ED MILEPOST P a °?RED S n OL.v G R _c a? - ?? O. NONINTERSECTII?OyNy/-LOCATXJNOFCOW610 MMP BETWEEN 'j71 ?1LLrA STREET MO rVaf•7/ /OUSrfl? • CEg99 RR ON ROb Esr pp rSOAfD[nlMrup L.- R ??. NT ER NT ER CLS. IE+fRPRtFD I ?aaFa g : /o ©® DF « "ass `f "? E 0 3 4-Z 30 WCIXUSA'NxN%KO ??D?K nEwttE DK ?F.E DOTNCPIWRTE SPEC CODE USE _r n OF VFNCLES J 'K D F IRXN © DIAGRMI DATA DvEHDLER-fDEIR Si Ax WN<0. Sqn Dwi RU11 C.. OBJECTSTRUCI( IruuE Qi 081 STRt1G10.. .: OWNER OFOBlECTSNAME MDADORESS LOCATION D© OF E rEDCOSt/ _ J'O' 1NROADWAY ROO TO OartCt FEET .1' ICMf DI EASUST WAIE'. "^ST NAME. MIDDLE w(RE wvoLVEO ORIVERSLASTNAME E FWSTNAME MIDDLE.. ) Z e Scher ?9nn ?/i z a/i niw5 STREET ADDRESS ,... ROUTE NO, AND 80%NO. LA'1nE INAN STREETADDAM ROUTE NO. ANp BO%NO.. 4V' '. - PERSOVS VrERE .. .... . lwunfO USER v. UFxxG CRY STATE ,,..-.'ZIPCODE DNVERSOLOUPATION CITY - STATE:. ZV CAGE DRNETi5000UPATgN un l c ene tu;9- t` 3 r 5 Ffe i«b R r ORNER6 Lgw5E NUMBER STATYyE SEX GATE OF BIflTM AGE aau DRNERSUCENSENUMBER .: - ... STATE ATEOFWRTH AGE L f - 5+(-Ht3 £yS-'9M1 zj ss z3 IS- F MD DAY r M VEHICLE YR. MAXE 'Go E) MODEL(NOVA DART) DOOYSTYLE120H1 VEHICLE Yfl. MME ICHEV:DOMEI MOML(NOVA?OMA... OODYSTYlE13 M1) ?iS 7rICL•-n Q-Tpn SfiaKz I I PIATENO. SATE 1PULER PIATENO. .6TATE LIC?E(S'E?PyLA?TF/NO( STATE CV . TRAILERPLATENO. STATE F--s.._EN1 Ie?'f'1'/7?D 7 pN No. T..e.OML65NEWERI DOMETER (MILEAGE C VE-EIMNT1igATIONNO. (18SBMOMLSENEWERI ODOL?ER(MI?/EI IFICAT X 3 2 zG I G A/nJ REGISTEREDONMEN R-,'FWGI-J.ENAMEI. DRIVEflS IX:ENSE NO. REGL5IEREDOWNER (LAST FIRST-MIDDLE NAME) OflIVERS LICENSE NO. VSDR V,5F5 - t; OWNERS ADDRESS ISTREET.CRY ANO STATE), Y,q ?ATEOF 81flTH OWNERS ADDRESS ISTfl[Ei,C11Y MOSTATEI .. MTE OF &RTH U( r'1 If_ YlafTOna1 FoCs? l(7R DY YFM MD NY nd PM160F N EDMAAGED iM'MFUA COST F1T1O1YEN1LE DAMMED. : -. ESnM.TfD005T b ' ...:::` SiO REP.w v[wCTE A m e Mood w ,K s E T WAS THERE AUTOMOBILE UMIUTY INSURMCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CM YES ?NO a"P NAME NIO MGiE55 OFUARNJIT"6URANCEEVUCI HHOLDER s IP NAME OF UA&UTY NSURANCECOM.ANY. .. ... ` %T ~ .TE nN`.S Crov+ G'Y NAMEANDAOORES60FUAITUIYNSVRANCEMENT GrY _ si.r[ to UABIUTY POLICY NUMBER 2NO - aFF 1 Y? I.. .R.IFREPORT FOR A-1- -ER ME- i ?5gq?5y¶. 1ST IN Y ME INJURY: _ _'_ rTST ?.,. + O N E 'T NAME AODRE6S SE% ADDRESS SEX L 7 -. M - --- F DDaiaR ® o:'DR ----- u ..Mn."r nR..&T- ®? n.nE STATI OFNAIRED MARK FIRST ONL THAT APPLIES AMIR E STATUSOFINJURED O MMRFIRSTONETHATMPUES ' 0(? NVCNICIE D Ala r1O1? Nw0 Dprvv(A IN VEHICLE s^DLM Or1 Drs.r1(W Pow?BIE I . XILIED IvFM N luwaq 11OF COMPUx1 WW, WlLEO KREI NHDN [iC lli D.56L " . ?. x N+ QNnainNl NO ? 's? eD 'IOiO DPfOfa HO ? s? sD 7QC1C1 N ?OT-wRllI IN IN l410W NgflTN BY MNOW NGRCLE DES IMBEI.M ATHMPENED IREFERTOVFHICLESBYNUMMFJI ', .,RGw;rr a ?>Y.oRM, ? ? ? ? __d fl u 1 n ae? ?l, _v eh.i r.CQ_ ?.o? ------ r. rYQRACI?MMLn?n.l Nf1[CiN O \ \I 1 _ __.brJVnc¢cf.__?n- t??irOMV K wrf M ?__ / 9 ?'' 2 nIWLeNfRFACR .K.LaE.HOMXXI -_skouI c(,Rr= _ i.r/_0G,__'fU_'.?P.nl •' • , r , TAREawoE m .Know V. acr" on_ .`-x- Sun k,n .OF,I? ? V N/C {{ ? .Cli?ty^r avrwA? I I I IIr 7•k? _ MrE1Nl J T,h r l 1 i,r ?ti 1Y r...t ?•d1'f?l VEHICLES POSITIONS BEFORE COLLISION L.Ma Hcu i '+, Dw.E NvEaraATEB By ,1WI 51?` v[NICLE N s E w 11-11 orA ua.u. FrM.oxO +Ea w.aE xcunrD ?,:in w rN Tun nt w na T `w na No aL cerrer o rT aH ET OR HIGHw.LY NMAE OR p} (( fq DrneR p r {4?'w) C.fd r.aAY ? ? ? _ u ? ? ? ? ? ? D0Rq t1 W?o In 51 Y???d1??[?J!!? [. 30->'.5 ? O ? O D O ?a'? a L,T D1.R D?OO Je f( °.{ Y? ,y+, Ir nwvAR.Y D 0130 A,- cAOaE.u moM DIRECTION io DIRECTION /fl v j;`,?N. J ?( Pe OES,ww wlJ Lnw I?&MWALN 20 WAI.KWAY a?t+rOULMfl 1??rN'r,'Infw.1. 0 UN.- 1 a?OTHER ?iYl4,. yh[a, ?, R/VE NICLE ACTIONS M1i(I Ci I L ?yh?? 4 ROADSURFAC! MTATHER UGHTCCNGTICHS fNN/q CON1ROL RrrEC+wfI TYPE OF ROAD OflNE K _} I ' ,?-'C¢'?. u.n<. orn K nor w ?[ r rc ae Na?2 K1Ra.ne arLUnEI ?\j 1?Y,3y1' Ay1 A ?J.S n T rr AO E I ? ?N ?u 1 DAV4gHT D 1 ? y1pNALS 1 DONE 1 ? G04NO STRNOIIT AHEAD I1N w lr`r ' P "'S I I f A 1 ?11 ? my a© RA- 2 D DALE D 2 D STOP SIGN 2 D INO W WAY AY 1. 2 D OVERTAKING AND PM51NG rt i _FI "kl? [? 2 Di 2 D MaYAw a D wsn D ! D YREp 5qN { 2 D roves YD [ ? 2 D MARINO Rglli TURN 11 1 '? 111r ?l L A7Y` 01 Dwow A Oran • D °n is 1o"NIET ? A D rusraa RED U ' ?M1'o ?rAUh y L 1A DqE 5 OfMR c) 1 D MAXUIOICFT TURN 1 r OIrnR ?ISPI GrYI 5? ? lW DMA ll EIRI OEI (1 ? ! DFlASHwO -Ell D E (3411E(3411E, D 5 DMAKNGU TURN I T ' I'm DE DlPI CNV 5 OMR HO ? s DRRTACNAL ? 5 ? li IT TURN ? 5 f D5L0•MNO •R 6vr l D lgrN! p??yYI1 1 F I Pf ANON TCR NOI EF[LNO DMGLR i O1MR lM[E ??4? I rv^ 1 '} yY L( ,. v,wn.+rSV1 Mr.K1on 11C1 D6Pfm, ? I DOIIgIR.IIMMM ? 2 DSIOPPLU FOR TRAFFq f J ?I\7 IA$ (? 1R F1:'ff ; 1 _ ' - D IT D o,HER.!"c- D 1 D MPMAIfD ? 5 C] ON slop E1011'GNAI 1 1?1 I D?,ry 2 DaaMO ? 2 D STOPPLOwpoADWAY 16Hf 1 :5 _ ` ?*, E ?', n0111Lr TIE L^J , DI DvD/C D , 1"Y RIMIn16N Y ?' ? efB?++TA^' r ? +1,' I f E ? _ ' [ V J , C1 A1 N ',lf} } 5) E + }•'1 a 1 i ( F 4 L ri{ 1 ? C Y L1J ? { ? r iA /Y A '_ ' I f Sit ? 5 ( + ASS., w a <@ a , ... aP.•r... .. .+-? Pi^-u':n .ti...._y Yl., iL °' 4 .G L` .r 'L? ` ..i y ' T .. ' ?,,,?v ;,, .? i.> x L? MOTOR VEHICLE COLLISION REPORT ? DATE OF COLLISION v DAY O CO LISION NO. " TIME OF COLLISION COUNTY N CITY N0. nu SAT rx ? MIS AM tµ . H • •'q. COUNTY CITY TOWN ?• a F MILES TOWN U??E CITT TOWN gpM.CLS PREFIX PDVTF Ox fT COOt. SECTION Mi'io \ 1J I" C?/i .1?/I/ ?o r ?S ® n 1 Dom f• OF . , • : GIVE NAME OF STflEE T, ROAp OR HIGHWAY INTERSECTING WITH( STREET OR ROAD PREFIX ED MILEPOST :w. ? i /?nul /71, 5550/ NON INTERSECTION LOCATION OF C LLI51 ' • RAMP DIAGg - 1 AM CATq {? J BETWEEN T J ,/t/r ?? 1 v ? 1 STREET AND L STR T V P nouM LNJ Al RA LRO•o<noislH'cquELFrrosT OafoirilMrlxo LAN.... ocE. nE SO ^Fi '? ? C F NG 1gos5 5 1xFF INTER N E L FclKfx. FEET O ? 353 ?A O DF vF. cM SOx IAYD D ? p cu p ,Y ry .e parwtr r« x,o [/ prF" SPEC. CODE USE 1orAL 1 . t R t 4} - Of vfx clFS Ku.[DHTx pxox Mu L=S Qv[x Mw p"rxux ' A OB CTnSTRUCK n T sTR CN OWNER OF OBJECTS NAME AND ADDRESS LOCATION f.? J IN Ro wqr ?N I A E T . o nFP oDJF Ro.tD S FEET S W EDGE $ n5+n Y T111 .. L E DRIVERS LAST NAME FIPSTNAME MIDDLE IF C•RS DRIVERS UST N AME EFIRST NAME. MIDDLE 7• ST ET AID EBB ROUTE NO. ACID .0% NO. uoRE 1- 5ax5 o STREET ADDRESS W;w POLITE NO AND BO% NO L . . ? Ss3 u Ixy • CITY Dl•wiM . STATE ZIP CODE DRIVERS OCCUPATION /+. RFPoRTSroq Cltt STATE ZIP CODE DRIVERS OCCUPATION Ir n)? r a PTsrv/ /nP r ,fit DRIVE P5 LICENSE NUMBER STATE MF]t DATE ODF BIR`E GE DRIVERS LICENSE NUMBER - STATE 5 OATF. OF BIR EN AGE M F M D.r o R . A VEHICLE. YR MAKE (CHEV: DODGE) MODEL (NOVA-DART) BODY STYLE (2 DR.) VEHICLE YR. MANE ICHEV DO G 5 n : D E) MODEL (NOVADAflT) BODY STYLE (2 DR) . LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE rV?ti LICENSE PLATE NO. STATE TRAILER PLA TE NO. STATE S /J) VEHICLE IDENTIFICATION NO. (1968 MODELS d NEWER( ODOMEIEq (MILEAGG VEHICLE IDENTIFICATION NO. 0950 MODELS & NEWER) . ODOMETER IMIL.. Q t+ - REGISTERED OWNER (LAST-FIRST-MIDDLE NAAMM?E) DRIVERS LICENSE NO. / REGISTERED OWNER IUST.FIRST- DLE NAME) DRIVERS LICENSE NO. r,. ', ..' .. . ? f/ ;., //)n/ //-- /Y .. O E RS ApDPE55 ISTREET, CITY AND STATE) Lu DAT OF B RTH OWNERS ADOPESS. (STREET, CITY AND STATE) CAT OF A '? A? . B TH Al IUR O o . , i PAR79 OF VEHICLE DAMAGED L01 , r: R[PMxYf PARTS OF VEHICLE DAMAGED _ 51 46.wD y J EC3 6 WAS T $ 1 Y ?? 1 - - HERE AUTOMOBILE LIABILItt F p LIABILITY INSURANCE INFORMATION-VEHICLE NOT COVERAGE IN EFFECT FOR THIS ACCIDENTINSURANCE ON YOUR CAR Ip YES ? N , O NAME AND ADDRESS OF LIABILITY. INSURANCE POLICY MOLDER NA NAME OF LIABILITY INSURANCE COMPANY ADDN II J [ t J • r / , /?0. 1/J l ?O/,D ; I •">). ti 3 ?,,.!f'/1/O / •J? ez /L••' /" ?/ (J Sl ' 4 •,r,_ , NA AND ADDRESS OF LIABILITY INSURANCE AGENT : Orr ar 1E _. br, LIABILITY PoLICY NUMBER l 1.4 I , Y. TST INJURY .....:.. AQE 2ND INJURY: ur.,.N I rax •avrwx wlweN AGE TONAL NAME .,.RED - t. . ADDRESS - ??1L" ?1<1 /CCZeve-, BE% ADDRESS vSE% 1 7....,•:L:A ME? p r/, .II. p?L.uNW R?ES'/YJS["S/?'r/•i 5:1-A.51G,??-Gt?£i /.<_ ?.C- I_LI tooL_T a-"a o€s_- [STATUSOF IN RR xo x MARK FIRST ONE THAT APPLIES r•STATUS OF INJUN D xD [ ooc MARK FIRST ONE THA DP ER IN VEHICLE KILLED M 1 n[un ND"IVJU SL ro pDRIVER IN VEHICLE xq 'rossa "-,PASSENGER T APPLIES EIC p vFR M?nO n4 fan pIAS In KILLED . E ?(]PEDESTR ITF IN 550 60 /I I ? pPFDfS, IIIAN NO ? ISFV 5 ? q s? NO ? [1 of?•n? OTHEH IVR iC N Fa no Iv hOn [I ViixRE LI OTIEF t•JPri na 7? SHOW NORTH BY ARROW IN CIRCLE lJ DESCRIBE BELOW WHAT HAPPENED: (REFER TO VEHICLES BY NUMBER) I. A, ON T S d GP M ? I / f? I I ) Wxt T M `PPl ED O y/ ,. ,^`? 56• ?L,rC f r_- d/da+7_ ?le7f/ c7..c_.1 i?;.r? -.cN?..rQ?_ ? fT OR n?cRWAr --- -- - b,G•lC?-G.e,CLC_/./??'4cn2 ?r y `SP i uirts.fdesl eu?v? rLras-?1 6?'j I - ---"- ' ....,?__. y ? v J ,. it/_ _-_L) E / LA?RSG ??tdi'd / lcs i C'.t/J•?E/ ? L_-?? ? ? (`t? g DE._GiI1.J4.I?'? 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DAYLIGHT OxC WAY W 11 O [ : \TJ! f 1 ? 1 0 SIDr1ALS ? 1 ?] I1/g1 GOING STRAIGHT AHEAD` } ? t ? CRY ] ? RAINING ] ? DAWN ? 1 ?IT P 1•RGvyl ? E WET ] ? SN 2 BI YIELD G 610N ? ] n TWO WAY El ] [:3 - 1" IJ ] (L=J ? ? OVERTAKING AND PASSING OWING ] El DUSK ] E] YRL I} ?y I REVERSIBLE i .` S.n 1 ] ? • ? DA.F( STREET [ FLASH NG to ! El l A r? ROAD ? ] ? MAKING RIGHT TURN I v SNOW 1flAM GE .-+ y) 1 /T q 4 [ MAKING LEFT TURN 1 a l^J [ ME S ? OYO^[R 5 0 DARKdINI ET I? ? l I100 L '?yy/1qS??` C'"T S - OTHER ISPCCIFh Din KIR ? S 0 FLASHING AMBER 0 S ? ALLEY F-1 S ? MAKING UTUPI[ yB[•yJ" [.J 1J 1PCCIFY [,1[IEFI LIGHTS ? 6 0 NIL SIGNAL 0 0 TWO WAY. fi ? tltl f ?I REASON FOR NOT SEEING DANG[C1I SPLGfY ? F ? OIIIC[RIUGMAN 6 lANC9 URH fJ l 3 6 ? b10PPICD FOR TRAFFIC T T F 1f OMACL!RID vI/S/bN D St C1MNf I IC J _ L 6 ? 01 ER SP[CIFY 0 1 0 NEIARATEO ? 1 ? STOPI'fO ATSGNAL I •l + Th r, _ J l _ OR STOP SIGN fkL h7 L XE>Il r,Rt .?'(•.A? //SCI t [./ ?'( ryr n,J? ?? 2 DVOEO ? Y 0 SLOPPED IN ROADWAY )4' upl.? k'Y1 1 i •! J5Y :- "... I 1 V 1 I Gil. tFFIG ] r? l tRfO IJ t0 1 J iAl RF C1; iNC (1 Fl, 1- 1) 11 t ff?f J k 11 r 1 a? Arz S? y TYaI rti J t i> a,il q,.nf mI J . .:f JTrrli?•2 ?`. +w """1? > ) / 'yid p ?, ltmf `- h>r.F7?( s 0 I 44 r I `' 1 1 ! I L 4 l F t f 1 , •I 'N ?,J)li 1 J 1 'I y" Iv , DAMAGED VEHICLEN O.1 I-tH-IACE FOII AIEFCIUNG-AGE TO TIIAILER$.IAOTOIICYCLF., FTC.I y, " DAMAGED VEHICLE N0. 2 T :EVE ,y-E ? RIT OF U 10u t. O . I lY•, •. - 11ow / U E 19.T --1 •I 18. u O • I) I n pIVE Y AMAGE: VEHICLE NO.I ONAL DAPlAGEF ] pTNENM.V.UAMAGE FUNCTIONAL UAI UNCTIA a Np DAMgUF 4 ]EVENITYpF OnMAGE: IpiNER VENICLf.I 1?OISABLINti DAMAGE ty-,? IIFN M.V. DAMAGE )[]FUNCTIONnL DnAIAGE <LJ NODAMAGE . .•I rA 5 RITYOF OAAIwGE: VENICLENU.)' I n E UI•.gNLI11G DA H MAGE ]UIDIIFNM.V. DAMAGE ) 0 FNNf.TIONAL DAMAGE AMAGE 0V E) T.DAMAGE TONED CY E- DAMAGE TONED DY F]T. DweAAGE TO T. TO I 'I'r t r - ,.r .+7rn: k ,cn; d?,T G?Wn JIC1-r{ •e; r:. 7-1 Y L" t I:1 ? I p1L t?:,? 9HI G P rncE o PULICE COMPLA NTNUMDE f ? UNIFORM POLICE TRAFFIC COLLISION REPORT y ' - ' .4i 4 , i eD DATE OFCOWSION DAY OF COLON ME COUNTYNO. CITY NO. FKW /Y[1 p C 1 1 T SUN I MDN 2 IULS D WED A 1 5 FRI D SAI (USE'VOOH 91 J I / / URBAN L T . / CO ON ' CI- VV -' UflAI ?STATEROUTE ? C O UNTY ROAD ?DITYSipEET O DMCLS. PREFIX I OUTEORSUREEiCODE CTION ?OTHER(SPEGFY) N 3 4 z:3o L O L / N 5 E W - CIIYORTOW ,. MILES E3 13 El ? DF ,^-U tl ` P""' EO. /A IAILE POST Al lji?ME bNU OF [?iEETOq``qMIGH?VAY INTERSECTINOW .^ STAMORROAD LL RAMP DIAGRAM pgTA I D NON WTEPSECTN)N -- aCGILENT I NIEN ION X-RD TERSECRNG SlPEE flHOA00P REF " I T N BETWEEN MILEAGE CLS. ERENCFf,RIr iJSTR_ ROAD STREET M(p STREET DISTANCE AND DIRECTION FROM REFERENCE OR C /PQ55G --T, - 5 E W L I CODE I S u,vull n a? /? SPE IALCOOINGUSE I OFE E ET OF 'a•a O ???/ / fF !.7 ?VEIIICLE•VEwCLE ?VEHICIE HICYCLE OTIIERIWRITE) A RUt SEVERITY COLLISION INVOLVED: ?? ? ?HIt NO. XILLED ' TOTAL NO ©VEHICLE OBJECT ? VEHICLE RR TRAIN ?STOLETAVEHICLE O -RED & OFVEHICLES ?VEHICLE*PEDESTRIAN ?NON COLLISION ?-ARDOUSMATERIAL PROPERTYDAMAGEONLY OWECTSTRUCK(NA EOFOME/C?TST9YCKANDOWNERSNAMEj Iy) LOCATION OF OBIECi STRUC IK? y?E'I EST.OAMA,IG?E. ?ROADWAY.b FEET? LYJ6? HD EDGE SO'fFC H ; OHIVERS NAME i FIRST MIDDLE (y ?1< / -,7` . -: GUAM /1LU J L'? D' DRIVER5 NAME-LAST FIRST IV- I IF.1-IS10RPEDESIIIIANCHECKIU E SiflEET AGGRESS R Y STREET ADDRESS -- R' CrY?...: ,:, ?9TAtE. .._ 21P CODE ... .PHONE NO E CITY STATE.. 21P CODE ... FHOHE NO. - N ° ORNER9 LKENSE NO_ STATE. fret-i fS7b Y? ? ?N 'E%, I DATE CF BIRTH z? N O. DRNERS LICENSE NO. STATE SE% RATE OFBIRTH MO. DAY YP r r ?Y / L OPN(E?RS OCCUPATION FIR?M?NAME [J /I.l .PHONE NO 2" DRNERSOCCUPATION FIflMNMIE. N CODES > ul Cosy _. "- lEATDELT _ I EJEcTCN CODES >1,3, Iwufl r SEATS ELT__-_ I!) EJECtION :'. INIUR ES F'LIAF -L??'/f ?d? ?• 1. ' ?(n-- J NATUR I II ROM bCENE BY ?•%Vli'/l/ -? T C-rV . OV FROMSCENEBY T V M. YEM MAKELDOOGECHEVJ i W AN : VA) STYLE(t DR^ONV.I M ? VEH YEAR MAKEIDOGGECHEV.1 O MODEL(DART-NOVAL SRLEIt OR•CONV.) .. v J 0 / 1YD k C :?? v E H - VEH. G ... VC. PLATE NO. ? STATE TRAILER PLATE NO. ? ? L STATE E H ' VEH. COLOR C. PLATE NO.'. LI SLATE TRNLEq pIATE NO. .. STATE E1?f0 c t' ., C V HI C Ip RATIFICATION NUMBER ,. .,., OINNAETER i C VEHICLE TI M NUMBER- ,. E:.. l/ Gi E;' -`. N REGSTERED OWNER-LAST ....FIRST ..'. -.. ... MIDDLE WEGSTEREDOWNER-LAST-.. ... ,. .. F4RSi..:,:, NUODLE . . O ADO(i SS OF OWNER : ... . ...,..' ...:.: .. D?J %c?oZ ?aP,. r ANCclcs l? . '. 2 ADDRESS OF OWNER .. NAVE AN?ppgE550F WSURANCED-AGENT .-.?.. NAMEANOAODRESSOFWSURANCECO,ORAGENT ,. ..:.. .,..., I CnMOE ,:.. ,. ... -. GTAi - CHARGE A ENFORCEMENT, ' ? ? ACT" /( ONt NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES SE% AGE STATUE -ZM- EJECT. C: N UAE: d -;TL-' c A DDRESS' Y 1 U ?:T fr J - F 3 J U N P. u _ ATUHE /, If ?q REMOVEOf ROM uURIES O I% ?.A V l SCENERY. .A" N AME' . N T A DDRESS: S N A lull, R M E FA: NFO '.TO I ADDRESS' N' u Nlnm Fg? [? M E S NAME. SCFN v TO S ApM(ESS E NMUA " $ F. N43 Nf Rr NC to . .'. AIUS 120-Im IIO.Y IJI VIJVIIY CI A SS IA)SEATILELT - IOIEJCCl- C ]pAsu NaLR l(DfsTRIAN A I 1 NO VUURV G U&V 5 OL7AOLINOIwUPY I. NOTWSTALL[D NOT EJECTED 1 D "'CYCLIST y ?_ I.OTHf RP051f10N 21 OFA A ENE 3Df AD ONARLRIVA 0 NON GSA[NItIO OENT INJUNY " NOTINUSE 2 TOTALLY [JECtED Tot TED D ODN,EII GIYIINE35 a IRUS MOIOROYCLC) L AGCDIN M05RTAL I .ss-EPIJIIRY IF DUSfU AUNKHGVrT ] LYEJC 4vIINNOWN If Otto E - APOGIIONUNKN01411 SLCAT UELr MLIRE EJ[CTlO Ali; Ai .( p r h 'x 4 aJ([?e....tYS?,.k _a ?' C !? ?X• h R DIPPED ofPCD il IN rEi ROADWAY 77 7 r - 77 R W A , ,, , 7W , M L e ` r, I u , , ?:rrr / S1ATEO (- l AS ? 1 `ry V.!.J MOTOR VEHICLE COLLISION REPORT y _a _ _ w..?.. ?.n.,e..w ...., - ... >r. Jfl ... NO. - _ J -DATE 00: OL 161 OF COL ?- N . LISION- TIME OF COiLISION I L . un uI COUNTY O C1TV NO. F '1 Yom. -?• / % 7 0 } } SS IJ PM • ? I . 1 ?' WnoH [ .T n nv[ COUNTY CITY, TOWN 'rvov`rv. M14E6 L ?L ? N CITY. TOWN ' ADM CL6 PREFIX .ou,[ a, arw[[, coon 6EClION , •1 Y ,.? . •` of G+ur O ?W M O /<c?., 34 z3 ? y-,?OIYE N/"Mi?Qj, 6TRE 1. ROA00R HIGHWAY .[c Pa'w'n J /C 1LG ?7, /Or S' O/ INi ECTI NG WI STREET OR ROAD EFI EO E r CT>. S U .f NON INTERSECTION-LOCATION COLLISION / MP .11 AGRAM DATA Y ( ` BETWEEN /(„ 1 /-'? TK'7'/i J 6CREET ANO 6TREET ? . cnoaalrvc, n 4[Pesr on IDCrvUI•Inc unONAwX. [w. en,o[[. T ?O w NON HD IN 1 TE 'ELS. w[[[ ?[[ryug F['irt:[?r qg nq+ H+ y O?W OF w J , Lr U I/ ? •r?io TI-Al oI c ?1 ? M n[w Iwnir[I w H n Y LLJ1 rvc[[.r[o[nwM LuMen ,nwuN SPEC. O U6E . .A • O TgQCKy,??;` a•o! oucC,, [,wuu _ ., _ ,. OWNER OF OUJ ECTB NAME AND ADDRESS - IN RO ?OWAY• "" ?N E? M' aarlH.T[o FE I .. ,_ - FIRST NAM! .. .... .. .. 'MIDDLE OR ER6 LAET.{IAME.,?,??.--,_.,?_ { Irrwoc.ncrv wcn[Irvvo[vco Ininlc e .. DRIVERS LAST NAME.,...... FIRSTN E MIDDLE „- ? \ ?' ? - { 1 Tf Hew[,rvArvTwe I C-• I cv.cP- -/n n ? ?a ., r AND BO% ND. 6TREET AD REe ??•?i•. •?_,???.,??!IOUTE NO_ '..?. ......... [ •^n^Ti STREET ADDRESS _ „_- -.. ;,,.' - ROUTE HO.:ANO BO%,NO.. - ° /2/2 1[ie;T S. {HC • ew 7S 7C NGr SAt.[i CITY_•Y-r .•--. 15eTATE ,LPC DE ORIVERF,000UPATION„ CITY_,,,-_,.?•".._.....STATE,?.;_'....._.::.::.ZIP CODE RIVERS OCCU_P\TION i / •3C .HC/C ?i{r=4'• { .&- I c/'7-, / 0.h Opel LA - ERS cJC eE ?AJTE ATE O H. AGE, U.151 IVER6 uC Eq• ATE SEX PATE OF BIRTH E " V? 17?- K4 G/ c e 1 M D I vYAIC\% rP: MAKE laev, oooe[I MODEL 1n ..... 11 BODY STYLE Ixo,.l 1977 Pi 7r ' ?L. / l'Jt: ?A Gt. / -7;-a to,- MANE cn[v: EL I +-.A.YI GOOY STYLE !11: p /9!b A:.[?-<.YC [t:FL [ T s. 7-,e. I, - LI<ENSEPLATE O ??6TATE-.?_• ER PLATE NO. STATE l? NE/S7 I L e . - b'' VEHICLE,IDEN7IFICATION HOs,.?,11988 noo[L+S n[wcnl ODOMETERIV L[ACa LICENSE PLATE NO. TATS; TRAILER PLATE ND. /f -1:=/'; 5? 4•tL iVc $zJ c/ G VEHICLE IDENTIFICATION NO. ...?1 BFB. nooa[[ a ncwc,l OD STAT - OMETERIMi[[AO[ RE EKED O\ N , I,un-! oo[[_nArv RIVERS LICENSE NO.., _ .??CIS •Ti•uL /n4 C REGISTERED OWNER I-T•F INIT-H oou n... DRIVERS L nC T SCU.TC! f"C S?.L O.- ICENSE NO_ • ?- yp R O HEM _DRE _;I r•.rv 1.. ,,. D F. p, B n/Y/ A0.7 4 /sL .H. W D_, _..... laT ....- O AT q PARTS OF VEIIO E DAMAGED ELF AKI'd- T ra w[I?n v[n,cLE r.?T•:.-v ?+t/ - ?.eTi-Xn, sTi s ?.ccc R OF VENICE O MACE.... _ . _.._.. ., .w .? ? ,- fJc.sf:, ' ? •a. r«,. nrG[[ Tt •.e wtl - WASTHEREAU O BLE LIABILITY INSANCE / ® yES. [0:] NO COV EIN EFFECT TH CC E TON YOUR CA VEHI c ENO 1 • ATl O WfORM T?l Bµl NS c A A we r - ? o o HOLo ER H POLICY MEO !APL rr Ns R MP N F Uwo ANC o A i [ • _ `t..o `?G' 3 /9 ,?r•LtG' . T. [ ?.g Nj6?% Qe.L`-?ec.r GvL(:A??U?J-., TAME ANDMDRE$S OP B_4 ,I SURANCE [TAT _ IP PLIABILITY PQI.ICY.IIUM R _. - •m••? yam : ?I ¢ fir[ c% i6T IN1U •- " AG 4?A c78 3 6v 1 I ! i9srf a o E ., x I URY: I [r.nniaw .... [al AOE g "- L N E DO E _ M F' ADDRESS, ,. _ _ _ MEF '?. _. _. ._. .. ? •?iye I O? o,[ ?? uw[ a.rarv,ell ,Y -------- • A oonew IJ ? A [fool 8 T O/INJURED' - ARKFIRST ONE THAT ALIES fiTATU501 INJ RED RN FIRST ONE THAT APPLIES L H VEHICLEI O1 "o" IN VFHI<L8 uno NorvHAT LD KILLED Aw NO.... I 1' rv U[vanl INlrvo,l 1 ?'> •¢R w, r 'S O" 6Oe e.7 OaT[ ... ? 5? 8? . 7O[n F R U A fl 1 CLE DE TINIC. BELOW WHAT HAPPENED gCFCR TO VCHICLEB BY NUMBCRI , \7 '.... - ? ; ? 1 eR. I ©\ •? .,.a .? . x. Irv.R. . r.r« IFA[ .. new :: , ?' Lrv!{t/ •Y Liu/{hC _[L.LCt Y u-4 sI/ ,- ? y' L-j; __ /clcke. IE/ Tc L,c{ [fj .7,'!C/ r. L-T, !,„ -C,. Lvf{'L-[ t••[ ( 'j'T. ['[[ Y: lax ar o! ! y '` f '1 l [ Fr.[? Q „ew ? A•[ ?ac? 5 /r > ? 11J../,t < { \ ---? 1 2 f- '. _ D f-? Y"( v ry / - - - X L ?? y Q - i ?. _- - _. Lvlr Frc VA• / ? 1 I ... 1t ' 111 I "'• Y'"'c\• "rA' INVCSTIGA DY j{I SION VEHICLES POSITIONS BEFORE COLL AM C OR NO, ,erv ON STR[LT OR HIGHWAY N VEHICLE ore ? L ? w" ?Ka Y ; T "? " N ?1, .qp J) NO iiouwl•:5.4`?!J®? ... ••.cJV i.kle HC• / ', lT y i ? ? ? ? ? ® , x , ALO410 v P[DF8 T11 'AIL 'LLD 13 0 1-J LRMSINO .+A'+ V M M 1 i 1I ' IEDL11-00 AS UlINO 1?N ]? • ]? C LONTgoL ,A ,ir" oH[I T E in I a E Hr co ? ? ? WD RN[R/ K Oi 4 J ? O ' j . t 1?4'! l y? N I .•. H PwI PDAR6SlIIIJ!'flL. '!! a '•[• ,J ' 1177 cam .. 1 DAYLIGHT ? II ? x . BIONALS I M I ?[ +ao ?.. ! t = ??on o, O <H•o a ow I ? 1 ? ONE WAT u 1 ? GOING STRAIGHT AHEAD e a 4 N x E] DAWN ? ] E] ?11 ? ORT E RAINI G ? [ ® WLT ]g SNOWING ] C] DUSK ? ] ? ] SHOW FOO DARKSS..... E] A ? ? A A ? IIONT ON E3 ? STOP SIGN YIELD SIGN ILA NAM& q[D OVERTAKING AND PASSING [ ?' TWO WAT ? x El \f ^l ?' ? ] ? ROADREIOLE ] MAKING RIOMT I-IM 151-1 , E] INI.OOPLRLNANGE I?,1, ? MAKING LCIT 3YNN ( Y L, /R[MPI l/ ? ] ',-1 ? t ? ILL ]? ?PCCIIVI S ? OARK:0IIET E) S E] LIGHT FLASHING AMBER ? E] S [3 ALLEY S [] MAKING U-TURN ?• ? ? S ?/?[LIIY S ? STR[CT LIOHTE ? a ? OTH[M E] T ? REA[oy.LgR WT?[SIMO?A'?QER T ? [PCUrY Rq SIGNAL OFFICER/ILAOMAN ? A ? LEFT TURN ? • ? SLOWING LANES C] 7E] STOPPED FOR TRAF/IC F1? T I' N }I - M..aP YI ro: an..c.r . nc.l U F ? In• wifiY mNAL ? E [] on RAT P ? El 1 , f[I 0 TRIIC 1 tE A [G ? S ? ST IVID[D {T ? i ? D ^10I''7 ?All RTINO C LANE l l IJ f? ply 1 n n I. GL ' ?R? ] {? D v nr n f l 1 T. •,T iE ?i,' a a A l E O !/ ASHINGT®NPADE / OF ! ' .. NO 4 UNIFORM POLICE TRAFFIC COLLISION REPORT IOLICECOIPLAINTIM Eq -Tr ? DATE OF O S - ? ti LL ION• COLLISION - - ? OAVO F O. Y E6 T I COUNT Y / CI - RI / K SA HOUR) J E T _ - QDRtl (/ COUNTY ? STATE ROUTE COUNTY ROAD ? CITY 9TREEf 0 PNE E O EE' 00 Z1 A ? OTHER ISPECIFYI W .... / I. n IN CITY pq TOWN ?? ? 7 ? _ Ed E 5 O FT 'TI ff? T r ^ MI IJ LIno -,Lt. S OF - U 1 z5 A A MEGNO.OF STREET Ofl HIGHWAY ,.. TEflSECTIND WITH:STREETOPgOq ? N U. W .I J I .. T I : _ l HINTE INTERSECTION ol 0 N A -Ell f NOF MI 1 IN EHSELTl.YD 9TPEETON POaD ON REFERENCE CRO S STREE N TWEEH ST EET ANO EET J 9TAnCE D 01 ECTtOH TgOM ENCE OP LPOSSSTREET % S T OP POAO _ E OF Z. / ._ COLLISION INVOLVED: []VEHICLE-VEHICLE []VEHICLE-BICYCLE []OTHER IWRITEI []HITG RUN SF VERITY L O, KILLEp 63Y []VEHICLE-Rfl TRAIN ?STOEN O/ fMICLE-OBJECT VEHICLE -_ O O F VEH L NO.INJURED ES []VEHICLE-PEDESTRIAN [] NON-COLLISION []IIAZARDOUSMATEHIAL O PROPERTY DAMAGE ONLY OBJECT STRUCK (NAME OF OBJECTSTRUCK qND OW- HAME1 .. ?...... LOCATION OF OBJECT STRUCK - E ST. DAMAGE ? ' POADLAAY FEET ???? fl..E. S ORIERS NAME-LAST`- FIRST MIDDLE D' , ... D pRIVEPS NgME-LAST FIRST M!OOLE II F PE OESTFIAN CHECKID - R 1 17 STREE ADDRESS. ....,,;'., _,:,,.u, ,. ,.. STREET ApOHEES- _ CIT NO. CITYTATE 1 N STAT RIVERS LICENSE rAT s£x DgrE I . t A Ope R H 'plo ORIVERSOCCUPATION FIflM A E ONE NO. p CODES n 5 TtlELT '' 1'+1 EJECTIONL ATU =Y CODES I- T RELISI EECTI ? •I RES F OVE ? ON URE OF U, ItS p F ME- VEH YEAR MAKEIDOOGE-CHEV.) 0 MOOELIOgHT-NOVAI STYLE I]DN.-CONV.) .. SCEN BY: TO VEN.MYEAR EAKEIDOOGE CNEV M V' E V - , ELIDAnT-NOVASTYLE IJ OR.-CONV.1, - N• O q ,',,: LATE NO,, ST TF - RAILERPLATENO S ATE.._.::: E', VEH.COLORLIC.PLATENO STATE:' TRAIRPLATE .. . NO STATE ;,; •;.., :, D. VEHICLE IOENTIFICATIONNUMBEfl ODOMETER...; :. . V EHICLE IDENTIFICgTIOrv N - . UMBER: ,. .. .. .ODOMETER ,..., -... E P[pISTEPE00WNEq LAS :..:.... ?.,....:, FIRST , M IDOL. :..::.;-. E - R EGISTERED OWNER-LAST ,.FIRST-. .. . MIDDLE N1 N . .:.... O, AODRESS.O f 0'A DOflE59OF OWNER„_ 1 , <. f ' 2 NAME AND ADDRESS OF,INSYRANCE CO, DR, AGENT , ,, N AME AND ApONFSS Of IN•vUHANCE CO, OR,gGENi C HARD! ' CITATION NO. ENFORCEMENT CT ION' CHARGE . ,... .?. .. - CITATION NO. NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ,. - CODES _ J SE X AGE STATUS T EJECT, Q AMe: C Dfl[ss: U, ? F x p DPROM +?ilnl ¢s sCENSVOV T p AS Aur N " A S" N ^pN K rust OF EMpveD PgoM FS . W N AM\I 1 Dp rss? u He D1 N G LMUVeu Pn M To S ' S S. I as- Hkl I I VED FNpM . II TO N II (` 1 I STATVi . PASS\NGlN SI GOAT P.T!IITIUrI :])INlU11V CLRP S ' I[LT tl1 E IF C TION D : D 1 PlOleTRIAN lICVC . 1.16T . O 1 EII e l E F ), OTHlIF POSITION IOU T 1, NC INIUR Ap ATS LN! J. oe ADON ANR AL F.HONtlLIND INNJUR DISALINO I I[VID[NTI IDJURYY : IJ ] . 1 NOT IIN NST USE LLED +. USED . . OTEJBCTlO t:TOTALLY EIECTED r PARTIAL LY[JFCTED (: 1 1 TNLSII E J S. POS?TIOn UNKNOWN ) BD IN IIOSNTAL T , FOSSIpL INJUNY UNKIFOWN E.SEANELT FAILURfi . NKNOWNIF q EJECTED y -- - FPIO tl,N:l; dt T1 J I •. h E?JI? - -P' ?'hl l I I^}? f T4J? I flfl y? ?l t ! ? ! +^E? r ? I 5;• DAMAGEDVEHICLE N0.7 USE"I'sSPACE sox sAf)cHING DAMAGE TO TnaILEns,Mprogcrct[s, ETC.I Pp. r. DAMAGED VEHICLE NO.2 E6 Tru ?^,r r oiT?•E f6 T tu., I] Ortxurn I I . Orn, OF DAMAGE: VEHCLE NO.I ? SEVEgITV OE OAMPGf VEH CLFxO ]FI IS 0 E J M GE O SA RLIONG MAGl IOAMPGETrI THEN M 1. AMAGE DISABLNDAMAJ IV) AMAGE OTHER M.V. N NA, er C AcE l ) 2 EIFUNCT MAGf Eq. ? ND A.A c ? ruxCTmxAL D? f rawfEST,OAMA - ., s ... s To D S 1 DIADGRAM AM,OF COLLISION SHOWING -'T -I 71 1 0. 1 _ _11- 7 T- I It _ _ ° ,A.N..,Ht.LtD ," I _ I I -1-1T? I v I .NDAI,tRGpLLItINL , DESCRIPTION OF INDCATE"ATPAGSAAIV HAPPENED BEFORE. DURING AIDAFTEx THE CAPE H, NctupE NFORMArIaN NOT px caAM, Lr.. DwvER - COLLISION DISAFILITY.REVUCEOVI S x LITY, PEDESTRIAN CLOTHING COLOR,CONSTRUCT ONNC @EEA OR A. ETC) - ?'" .. .. POSITION BEFORE COLLISION LAN. VEHICLE IEH' HEADED "I" NO.~ ING.-NGO CAE SIxGI ON STREET OR n GHWAY NAIVE OR NO ONE DIRECTION . r lpppALLV' L?CCUPIED C A ED + S E IN 1 C1 I 7j ] x0 G nCl ^1 F J C ?? !' G_ SING L r fROMDrrtA ravel dtL^' PFD/B CYCL ST III SING: ?SIDEwgi ]i- r 9?? ROAD SURFACE WEATHER HECK DNll ICHLCA ONE) nWER or. ] ??IICI f OR, I` pVE0 5 ` -- 371 SNOW ] SNOw_ •r= ICE . OG.___... 51 OTHER ISPEC-1 OTHER UPE&Y TINA (SMOULDER CROSSWALK .. CONTRIBUTING CIRCUMSTAN Ca ONE OR MORE I DRIVER NOEi I I NFLUf CEO 1 w, ?C4tlDLJ 0] I)r? opU i_FLUENCE OF = OVER Gin -I E[EOIML S1glEO ILINGI ??.. OL.,IL__ -_SIGNAL_ EE N4 REAS f-L_' I uPnorfn DNA ??E[?f , a Nprye-. r HO.I v ) C REGAR OE AqN. _i 5 AHEAD n Ixc J J ,;He PAID' f APPAR ENT nsS€fP AIUN. HT -r L. 11 RIG _ APARING LOG. i . 1 TI _niic Filv_ fOU_ I s j u , ..- F . _S`J SLOW'," NOVIO-O1EY1 SOBRIETVN ON -' ntc O ] LSCGf I r?_ C CA FOR ORE [ 01L ffbGd4'??dST{01 U)E IC f O CI°i0 U-0 O GvIGNAL f 6EN0 1 ]ttl Jlle .'. aq'A ETI Ut ?I A Ir 1 I I O _H PMRLO __ ._1 ]1 .1 ] I I D E S[ 1 .-]' 0 C E ?].? DAAILIrY ^1 l""I S NE V 0 _1 A G It ?.NOI IMPAITIfD_ --I I J O l10N I °C pt's _ L ILAIIIINIT L P ?- l_ DTs lT??l rmD SOSnIfr - rtJ .r: In1 nG .. nto I a -I CT u J 1 r DA [F F 15 WpHN _LIGH)]or A]EH r I of somn_ S 1,.. 0AN S 1[T R f ''s •I 1 U O ' LIO T50 ? ?. E ONA _ ._I, LLrun 1 v UH-TTY' o+ R -NU )r 1 ._ ° ,lESlnu -L.' Al' S C n U] A._..__. I T _ )I 1 -' °, oTH[n ] pWlptU _ NODEFEL'TS DIHtR ISrICIFVI E l ,J r___' UNO VIU[D TrNHiSVlti)YI NVlfl III- O r( t O ) X NGU nct'.' ARANA OGI H0. PG 1 ?u`unrnls OIp TRIRUTIOW ORIGINALCW'Y. SEND TOWA5rHNGTON STATE PATROL-DL DU LC ATCCOPY. LOCALLAWCNI ORCr ME NT AGENC V'5 COPV-TRIPLICATE( N T HAD NOT NKINE 1? SrJ, I Cr NG CHEM.TEST E-T 2.. TEST GIV[N R ISPICH 1[ST NEFUSEO L _ >6 TEST RESULTS NED I III AU'R fO t :.. n L ) fIl _ I• - L U IIIPUIII A- II - W ASH INQION O85N IN HVESTIGATOFI'S COPY ' A vft) r?a? fie... ,w iv?Q`??J veer 7h` T °9 r<?l s a - I ?j, _# 1, h kyn ' _ GAU ,Y. GITT rC (( 1• ryT-- - L r LES LJl G el ?]]If ADM 1 cLs ?" ?? 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T U,IANy ICI . jr l 1 ?N . ;Y _S ROA SIIRPASK - ,4 ,VLAYN[R?:, LIGHT COMpirON °1y _ I 1 •wtl .. E TRwII1C COH TROL T [ O r'O n IJ ["n.v».[, ? -? ??" - Y r I i` L t 1 /.P vlrH r°[] I? rauu°r rr, I DAYLIGHT yr+ca, x `O D._ O"vr4ct V[N CLE CTIOMi. lryry'{yIl ?Ay?AA 1 X71 CI II [J ..^•IGNALB = I [ , ILn,r[ n,[ P++i.o;:•IbC C J` L 1.4PIIN4 I11Ly??J I ? UNY T IZI AAI NINO 2^ DAWN 3 ? BTOP 61ON r<w I, II C? O 'E W Y "rl[ •ro I' ?? 1 • ; I:Y]r . r' JJi//iII OINO BTRAIONT ANCAD •+. _ ?JJ WET ]? SNOWING ] I 1 O_ ? (L' ? T 17 G 1 ^ h ?? ] ?? SNOW AC? IpO A D,NYAf Rr[T Ll ] ? YIP.LU EICN f'-t ] RL'V<gSnBLC ED [:1 -VCRTANINO AND PAHSIN6 1 ,Y d 1 f 1 t n ? ?rON TRON ? A n rLAHHINO TIED l1.-11 T [j U ?•f. nO E1gC NANOC D ] ? MANINO RIGHT TURN I , A y""V tll 1 4' El rrj 1TH ?? ISP c?i ANR frSOORrrt U E' 1 •. I__I A I? rv Y S Lrc•?T Ir ? S L I ILASNIO - ?? , IIOOP.RAUFI • ` r- ? MAAING LLPT TURN ' JI 1 r,/1 1*" H E- AMULR p ?' LLrY T R1 4'[111 CNf LIONT, •+ ? eIGNAI ? S A.M.INp U•TURM y { J ,} J 1 L Np•aoN nlr N[T(aH[?INp DwNOU r s N ? ° D L AY , tl •^ •.• , -`-!`T, vY--_--_ ?? T n /r Rrn /a LACVnN LANViVRN ?? ^ ? U.-NO f 5 •? •• r • pr rr sro ne nh `TRwrirc Al !I 2 1 1GIr'r nAl 11 T bT ` r ^ ? ,Ir - r.rP I. NArrD L? 11 I) OR ,1 ? rA 7 ?? ?yy 1 , iN.l II1C T L I OI VID(O "'A"-' N RO DWA? ill l l?l •f7< 1 IAN J ,TARTINpIH R L D q } L I G-u of 0 T D i ?o II 'i' I i+, ?S h z t... rd.It,. w? a [ t r- 1; I t.a ,iJHt, 'N'+• T ,,y}ame " ?t rl -,?Y:..w r?.!r.4, L ?lwrAa?V? 1T ,. ?? r ? 11 > • ?' 1 h A `I t I { 1 '1' - f Y ) j? Y l?l T? ' STATE OF INA$NINLi70 (:t) MOTOR VEHICLE COLLISION REPORT NO. DATEOF COLLISION OAV OF CO TGWN[un 'ITY " LLISION TIME OF COLLISION QPM ?• CITY. TOWN (MILES' COUNTYN CITYIO AD-LS PREFIX ! ?u SE ON , Y LOU - y K •• O oWDF ] e 3 3z 750 INTERSECTING WI H: STR ET OR ROAD . EET, OAD -1 GHWAY GIVE NAME OF- PREFIX ISO MILEPOST 57 I SIO NON INTERSECTION-LOCAT N OF COLLLI -STREETAND STREET BETWEEN RAMP - DIAGRAM DATA ?aiiA •il?si Vw[in'v '? / orviCGEi N I •/? OF L . INi?Ea I c `[3 E?/ D:o CU 1" Os vIn r°i[sveL?o.-_ _. [ ?o ,[ o?? ?xTSi„d 'IN d'ctcN1•4- r c1 rv c l sen [o+sTn,n SPEC.C OESE, - a ? OWNER OF OBJECTS NAME ANO ADDRESS LOCATION - q? OBJECTSTRUCK IwuE Or eAJECTSTpucxl o IN ROADWAY o •nOel "I FEET S IN b, • DRIVERS LASTNAME FIflSTNAME: MIDDLE '.a I r • DRIVERS LAST NAME FIRST NAME MIDDLE i i J so., STREET ADDRESS flOUTE NO. AND BO%NO. - , 77 xu Ie STREET ADDRESS ROUTE NO. AND BOX NO. , STATE,,; ,., 211 COLE CI _ ,. DRIVERS OCCVPATION •+•'"•'• n,er •rro•• CITY ,._., .: :....STATE ZIPCODE DRIVERSOCCUPA ,- - ?Ll -STATE?E% ENSENUMBE q 1111 DATERTH AGE wu DRIVERS LICENSE NUMBER STATE SE% DATEOF BIRTH. EE • - 3 ?4 p N 1. O AY -n maH VEIIICLEYa . MAKE I ne..D, M DEL ' xN n BODY STYLE I, LE Va. -1C MAKE ' - PDa MODEL BODY STYLE ? ? .'r, LICENSE PLATEN STATE. TRAILER PLATE NO. STATE.. LICENSE PLATE NO, STATE TRAILER PLATE NO. STATE I? E IDENTIFICATION NO uon[[s ax[w[AI OD OMETER Iu ,[.cO VEHICLE IDENTIFICATION N(l [uAn[nlnl 5 3t, 1•?`f5 u ODOMETER IuIA[xcH 7:G?s9 VEHICL . -_ REGISTERED OWNER[ ID DRIVER LICENSENO, - "EGIST19ED011ER AAA- lxst ulOD,[rv,u[I DRIVERS LICENSE NO, ,S,6.6. arV l J h'4"V 'OWNERSADORE STNEEI. <I ND-El DATE OF BIRTH OWNERSADORESS ISTREEI. CITY ANO STATE) OATEOF BIRTH !TL, f3ox /7: .. MD D YEAp T YE FD A VEHICLEDAMA D PA F 'I PARTS OF, VEHI LE DAN ED - . Os sfv xD° ?A - [••nv 6L[ t , L C' Th s ' AUTOMOBILE LIABILITY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE N0.1- 15 TovERRAGE- IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ?.YES ?NO NAME AND AODfl 'SS OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPANY: AODBESS STATE 211 - Q AGEN STATE 2P LIAD LITY POLICY NUMBEq J NAME pNDA RE F ABILIT IN U ,- IN 9? 3 41 el I ST INJURY '.? AGE No INJURY: IUSE SEPARAIE HCPORT FOR ADDITIONAL INJURIES AGE NAME TOt•, NA SEX xNn[D AU, S -.__.._ ...- SE% __ _.._-:-. .... _. M F ADORFaS .... ... .-_ ...... ...... .-..._-A1 F ... ?.i 00 0 F ] - Y ' STATUS OF INJURED MARK FIRST ONE THAT APPLIES STATUS OF INJURED MARK FIRST ONE THAT APPLIES ie xe KILLED ,.r• IKILLSDI e i c xO rv 'Ixc 'a V EHICLE Iiivlxi N4 uon ?tire[??rv . ., IN VEHICLE ?inin rviuo [Cwoii nx"•r - IN 1 I nl r x xl Ne I A ? • , N I. 1 1 N - 5 60 ?noll 7 ~I:Ik ?•,. I.. ?'-__ ? 5 R7 ?.e ?Ix::rl?t I: ? ? ?E 6 ? 6 OWNORTHBY ARROW CIRCLE DESCRIBE BELOW WHAT HAPPENED (REFER 10 VEHICLES BY NU SERI ft-a HnI[T DA -L heE 1 C4'?cc li7 in l GG°L_:.{-?lE ??fti_ !A D ,x.I .., i 5y • PM[IIPn CA GL N_C._• 7e.4 ink- C-PEQ ^LLlqw .57 C S't ?t iii -- ,-- ECOLI.ISION - --------?--- --'-,_, - -•-- --- INUksTICATEDSr VE ICICL ES POSIT I ONS RE F 08 _• w'nn •''? :r• xics• [wsI [] ii . ? ra o. VEHICLE `LAD?D ON STRLET OR HIGHWAl11 on •[, Ms w KE ` t N I'N f? w I ? N.A ? ? ? ? ? K[ ? ? IYou"I lJ 1_.I .-_-._---- _ _ .(J O_ _f7 ? C> Hr IoTIIfRI UUf ]['] _ .T-_?--- ._ f-OM To OHOSS NO F Yf OF SYRIAN J ?? ? f? E„1 ALONG y ^ r ( PL D[STRI AM [VAS 461Yu 1 [^el.... ) 1_J ._ ] `?_ .......? I?-_ .. "--'- "--"""-'- ------< ^[I LP LOf b D 7;Z, ,.,F/VEHICLE nLTI0N4 CONUII ION$ Tp !IC [OhtpOl RO OSVRf ACf NEATHtR IT DRIVE o lUn NnII ^ I P [,:,.,, 1 r? -? e IMI p 1 -feA OAV IIGNT f'l ? GOING ST R AIGHT A14FAD I IJ SIONALs ? 1 [ONL WAYxu I i JJ J rv I (, ORY a[,RAINING J?LAWN [ [- J• ? I ' S 1,1 a []TwoWAY u)? OVERTAKING AND PASSING ' I ) 1 P LGN 4 r tN ?? - ? I ) -T T flwl'rG ] dIISK ] YIItO SIGN r-T fl t?][_]INdAO'Slfllk lI-fJ )?MAKING RIGHT TURN L J IJ fT ? t, . II--?'? - [J a u SNOW A ?fOG E [.? LIGHISON C] A ?1-1111rIGHED l_J A (JiiooiiiIANIE A (:]MAKING LEFT TURN I r ' [7A[.]Icc ]l?Y1CIf• ][_? LIGIIIS Off ET S 0 FLASHING AMOLR S[] ALLEY 5?MAKING U-TURN s OInEK r-l UASI K.NO II'' IwD w•v ? f, V 6 6111iF fl. IC HIS u B ?RR SIfrI Al El A El TIUIIV IANIA f? A 06L01'lIHO II[ASONVOIir OTStI GU CIR If?UE f?Tf70111('.klt,TlAGS+AN [ 7[]STOPPED FOR TRAFFIC ., ..I e•+r'rv •..r.^I II - SI OYYTDATSIGNAL , r ._,......_._ ,,. _ 1.? A [?.+11??• I ] 1 [?SI.PAII AITO [, fl [OR 6101 SIGN ]c-,TO [.] 0 [ST orrrD IN R OADNAY ' h," .Il ,JI i ,1. 1,? I7. _ I (lI (? t (TIN)T IN ?.: w Lit fr 1 1. yM s INSTRUCTIONS UA IAGEOV R SH DE EAC E H ST T LII. ] JH4 n ONI51 TC 5 f C Y 4 U C IU Oi 1I i ? :? t HICLE MU.1 I --- .: / l = u:E r.IS •L. FOA ,r.r .L..u ct T° ss,r c t - 'r - ""'" O.if Lr U VEHICLE AIO q' ' - ^ ? ? M 1 F CLE NU I ?-? p / El 0. SEV 4 C'. A % t ] I] 0 E °fUHkN M.v.FUA...E Cl ? HO :(.ETq ]an U 'ENIC.<•'r0 a ? ? aG a L? ,{ OTNFFM V 0 v U+M+pE - D ! CIEDAI +' 1'i,) l E. d I<?.. .l1 , + . . 'UIaL..cUAC' LJ rAGE - r p c s, ? T // par A 11 OF SIGN • -. . I ' _. inE ', -- " " : -- .• /-1-0 Afl RON/SHOWIN ING --` _-L", F"c..?L LG c.1,:'r N F UHTH IN CIRCLE - a? ajit? . " . ffA" otj a 1? YY INC, 7-7 ucu _ DES RIPTION OF - Enp ¢ E, DUn COLLISION orsAe Irr. REDUCfp vls trurr >f EStR AHC OT.- r'OT UnO Grid YE G?pa rj''? i i LUDE , . l r !. ".AK. ETC.I v COLUR CONSTAUCtloh UN -CIA r - ?- d/? r1- ?ii ' -- POSITION BEFORE COLLISION - VIA 'NE . ADFp Mr prN NU IxCNFwSrMf pfCREASrNG V, S NEET Oq NrUNrv4r NAME Oq M1D E>EE UB OHE OvF C"F , V I I VEHI CLE NKFD n L O } PEp I J _ CC Ep ES NO vES ' 'NO E ONO _ . Ilw.l l,n.v,. - Al T gOtSlNt PEDBICYCtrSrLV+iUtrNL_. r. S K ALN <Cn"nll I I UNt U 8 D TE Hf - O ?. CAL_ D SURFACE WEATHER CONTflIBU 7INO CIgCUMS7 ANCE S W OrN cA ONEr BECK DM1Er NECC'C01E on IHCUro I E BICICLE ACUTE ° vER ° ND } rN E r CNV ,CLEA Ov oM1O!} NO. t CaBT UHUE EfICE OF V nLlO L ?O Ho. T E O } a N tl O iOU CtUE- av ) 0[D RtR f } WkT } NwIHIND -. rvr LUFNCE Or U >LV SIG. a p ASSt4^. g nvFIi CE Nrtn AYrtgtN I.r ... __.. F r [ .• ..- ' .tk LffP M 3 S.YOtT }. -SNpv L 13 E 0 GST+iED r+NINU TN rt•VNOVF RIGHT 4 TOO ?? t S U N 16 IN - NE T R D N t Fn Nt45 V¢fOUIV. ' p?5? OYr 8 0 nNt ° IffT i nr F v C 1 OrxfN ISV C _ O F r ?b UOrt f.N SL G i L i GFf COf1 su? vi 1 t l"' o I ? . L 0 Tvrotn n Ep oN E IONS FIAFFICCONTROL N ¢ t I IcKONEr ho.}vtN E p} TVPE O'F TOAD VElIICLE CONDITION N ICN ECK nNE px MOriEI SOBgIE TY I SL LS VI r10}r O6 R4m FitlLST?Or VI N°I]! ICIIECK CNFI B Icxwt ! ,. IVA N °P DN . t p } 0 ....... .11 ( i iW E D"A<[t VY i 'I V L -/I } ! r NDA E t ] t } D ] Y [ n Int! } Dl nu°i A ICI t A V RANK[ppy m_' " C A LF'" O I i I N L OY RAtI1 GU O NIEIV NFFICTIVE MTEH, E LLrIRUN!( ! _ r r ,_ kAH LIGHTS U N TIFi NL _ FICI '-' -. ._..A BERMO t ALY rINFi VrvI IN IAN NUr --? - 9 O Of LN nII NKINf. DACKINC " S i S fET q liF 1.. _. . t0 TS F.._ D 'l 4NAL, E TUNN LAxrt ! .Ills rvfli CHEM. TEST" /\ si T L 3 ¢ N SF fL'. D IIYECIF Vr Imo' IvFN .. t l } f' ? YE / (F" ?. rC??'i ?.•°Lm'U rRrrusfp 1 r F clFrr; " ' rN DMFK V 0 vrOFU nTrN I uYIE Fvr S WINO OF (fR ` wn H r. nIC Ir a" 9 TEST IIESUL LSa 2 L t.IJ 1l I ?SCrlc^ !(:-' ! (-' cj ? E- F A - i u ° . ? _.?, ?` uu rN J/rflrs NUM n/K tNfa Na mlr / ' u / U ! ? L? iI CL - Ur?onnruN C< r t[ .JJ ?"?'-"arv. IuNT'avx uArE ,IIY ( •LL :. ..l -1 rL( -i:)?(? ?L F- - E ON IO Y f L 7? !!? ' /? IC CO - AL OUILPLICAT ,UYY SEr10 f04V431II GTDNS! i[I t1LYNlvi4. VlALIIINGTON EIgSW C'- • " [aY. LOCA L LAWFNFONLrq NT AGFNLY +CURY TIIIPLICA rE UOYY: INV Mrs CONY •'t .. 1 7 z w.y'?Q 5???t7?5r'J 1iV GT-dNIADE ! DF / ?? POLICECO PLwIN1 NUMUEA +Y f "• _ UNIFORM POLICE TRAFFIC COLLISION REPORT N PATE OF COL I310N DAYO OLL q - E MEL rL YR. 2 ?,; c 0451 CO0n3 F.1 IUSE lIMF JVRI OUNT cl it n0 E A Y z / o pAN ? CI - -A °?? \ T 3 wTE ROUTE M r > r:hfff .I1vl T l'Y UnTr NOAU 9TNFEi O nJDMLs I EFI% O EO i EE CO E SECTION orq EH ISPECIFYI y L ? s E ? clrr OR rown Ea E Hw r -MV o:. _-rT A Q 9 7' : C I?MILNASM r' L' 0 `?J ' q - - - Lam, yL EeN0.0 S"LIT AN n AV• nTF 'ECTIN°wITN:STREtT°H AOA LL ggalP - AM A I ON NTt RYEC'll N Oy ` !? T E ° T EET cc-ell oN }V\'Y?• l` D ??\ (,?-j,}y L3 EfERENCE Cq°SS STREET0 O.R NOAO lI. F N : ETn EN STR E F•L ?j -? O MF CLS. InG USE. _l DISTANCE ANO 01gECi10N FgOM REFEq CE OHECA AN ET 1 u nTN r .IE;3 OO E ?#? EGIALG p c", I COLLISION INVOLVED: L'VENICLE-VE ICLE IlVENICLE eICVCLE. ?OF-IwNITEI 3 E " TOTAL NO. fL-II VENICLF_p T (~L•+fi' VEHICLE-RA T1111 O D.K u it ENICLES STOLEN VE,IICLE ° u °f ?vENICLE-PE ESi NON-COLLISION 0ry gR0003 MAi q ?Y OIERTYE°AMA°E OILY ?'.,L SyFI E{r OH,ECT STRUCK INAMf OG O3JECT 3Tq UCKANO owNERS NAMEI. E IAL R 1 EA! .. -El Of ONJECT3TRUCK EST.OAMAOE ,.?. f' "' _ ^3 AY F ?O w A.? OF I ' M1I OAIVEg3 3 LAST.. .: .. 13i _, MIpOLE UI5el °DLEO ....... - T F-Ill MI 41CYCUST On fE Es' Ian CnECKI.Q, .' R STREET CORE-, R V 7 sTHEET ADDRESS - •?? • ?, • E CIY ....... ... - STATE 211 CODE.',.... FNONE NO. E CIiY. STATE R PCOOE QC//GLE-rJ?/lL. Cl7c R fnp q ,('. N R A7 LICEMf NO. SE% GATE Oc a TH 9TATE I ? ? V... LICENSE NO. E FV TwTE TE Oqy .DAIVEAS pCCUVw? G?? -III AMe... - (HONE nO pAI VEAS O<GGPAnan FIRM np E L'i.C;?YI?L 2 CODES 1IF I+I SEAT SELi' IsIE?ECrroN __ CODES 141 SEAT BELT j rs - " UnE Of EIECTI O.v O E V EAR 10 E EKI MOO??}}I T-NOV 1 C NVI Io00G MOOEl10T AsiY LE 12 OR.-CO 1 E G 0. 3TA (E r ,LEMIL iE _ r I 1'1 N L 1, A'TE/N r? NO. STATE E-. VEH. COLOR IC. En si ATE .. ? AILATF MO STATE x ' C FNIC IOENTIIICATIONN MESA ,?, OOOMETFA1 VFNICLE ,pENiIfI A ION NUMBFA '1 (i yam) L//? t y E _' °I E I %EG 3 r J f .S L ppDME TEN N I3TERE OWNER-LAS FIRST MIUpLF E NFGISTER fA- LAST ?, ?^ EO OLE ?.N Ya'Yl?f N FIAST .. MI° r yy Q• OH OnNEA - Q • AOONESS f W ?'._ ° 2 GwnEq I F NAME wND pORfi590F INSU RANCE CO. OR AGENT , J! „ .. LAM NO ADDRESS OF CHA f O TSB u fh%IV CITATION NO. NT ECNAHGE "?'. pt? Ij? EnF ACT... _ rATION rvO. f' `NA?D SS& INJURIES0FJPERSONS INVOLVED ( O SE% AOE sTwTU3 N 2 ' ] T FJCCT. I YoAi t' ••e+ r '. C E u 9E I, - j U: eor HEMOv p' '3Z L H q . : TO A' AMr, IS N p ! T eE Or / E 3 M fi Y! { I A T N - IM S' A{ hay PA I S. C l :4Y 1 Iv n .".Arms p,bu NV ,. 2 ..... ewgL Iu:Enr inT TmN {,?J?1,{ O ! An Ar!CE nr Y ra OI IN:IiINH Rr N. rYAt LrO I rNof aLl,AY uEICTrO creusiN r ornEH romr n Nnn-un I n u E 2'rn iGnp O. a rnrR N`- r aN ANnIVgL klfvlDkNnlwl„?r ), I L 179 dC f? ?• T f' Irxrss s a cols-MnroR ILeI DIfi Tiln r.osrlrAL .osalgke NT nwN IKn Ii'ECTFO y r mk t ti 1 rhjl - E v irpN un ?y ??11 II .iAf AELi /AILU?kJECrEw? ?µ WW1{Z?r"! M??yt h?S _. fN x? W aQa;?, , yk(?7Z?"?tt 1 ?}Y }yy ^' '4?Y1'Ikr' rl nn , MPI?'AY ii I: ?- NY 7' 11 ` as Lam, ?' yt TAE rr ?, ' kyN,? I r 4 .. i !, - e l1 gH ??i,Y 5 I 7 o? r r 1 in 'lf \, r S ? a 1 . . Fn - rv . o- M' Lell XAMPLF VEHICLE DAMAGE UIFACHbOX,CRCtCTIICNUMHEf(OFEACH DAMAGED AREA. ]. SHADE AREA OF SEVIREST IMPACT _- x)11 .: ytl? ,+v ` INSTRUCTIONS: 7. DRAWARROWI]I IOSHOWPRNCIPALDFIECTIONOF FORCE Q/ n`.S "VE11..ICLE I"ETHR S- SKEICH NDDAAMAGE I.,RA L[n M.--- "I.' DAMAGED VEHICLE NO.2 vOF ? • ?un..x Wrt. SEVERITY OF DAMAGE VEHICLE NO.1 pAMAGE IOTHER VEHCLEI SEVERITY DF OwM GE' E fryer, DISABLING DAMAGEAGE ] 0 E M V. DAMAGE SE 015Ael "G DAMAGE ] ? OTHEII M v DAMAGE O ¢ABL NG U E ] -.- -V . DAMAGE ] LI FIINGT DNAL DAM A N pGE } Q FDN ONAL DAMAGE '1 O N .DA MADE ] FUNCTDNAL WAGE , S NO AM,GE TOWEDBY E?dAS` TOWEDBY [T fST DAMAGE iOwEDBY E¢T. DAMAGE 1. 10 P.'-? 1±}+;' DIAGflAM OF COLLISION. I DRAWARROW . Ro unfs ^r i- ... .. ?. _ De? NORTH IN CIRCLE .O NC _ I Rro. DNFA, rv. ?' -j r 7 7- Dw.np.,FL[Y[HIL[ - I AND. IDLt¢IPrv I , "DESCRIPTION OF I LATE WHAT PROBABLY HAPPENED BEFORE. DURING ANDAFTER THE IRA U HFOPMATION NOT ON DIAGRAM. E.G.ORIVER COLLISION',; DISABILITV•PEOUCFD VISIBILITY, PEDESTRIAN CLOTHING COLOR, CONSTRUCT ON OR REPAIR WORK, ETCH - - /e/1i c%! Ll?o!S. uJP r T c a . Q?i /G pn_e-?c°od o ccpJ'ubtlJ d o??r 1 1 7 G/DSS/h_.9_.?•7,c ?dd?!_r?bi7.S'adY1i %a ?brr?? ds,yr+po?da?'oss.i'?C CN,ir?'?/' .-- / te?? 06_Sei^? __?? s>?ou,s_./es?cJe a?-rl/Ed6_ 1_ ? s? sulmrd?ol. 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O EC , FEO N I DID GRANT SR I EG D i 1Ii} $ s I ¢.E TO E.__ 11?.. sloY. 4L H_ L ING 11.ERIWECIFTI 6THERISV[c1F 1 r.. - OPLp f- 3 3 P 1 O1 HfR ISPICIF 1 - 1 A? ; O f DR IWGNAL ?¢.._ NO VIOIAIION r TLS ll L ,j ¢r S G } SIGN RAIFIC LIGHT ONDITIONS RAFFIf CONTRO E HILL TYPE OF ROAD VEHICLE CONDITION SOBRI ETY_ I ¢T f[o AT SIGNAL 5q I on AID tnkt O fl NO]V F ING.} C F E VEHICLE p FQ fHICI[ ICIIECKO E - - i IB -I O O SIGN f D, sc A 717 E INAI I.DI 'ggj.?ll?ut?im ING.} _? I so°ow Y" I N ?'{ I D+ Lc T I} [ X TWO . 1 r HeD AMU1Y -. 11 I n.c IN ..SON ?nA Ls. 1 A LD. CLANE TT A, F? J !.L I Y OAW la fAL "--I b!. _ I OF DLIGI TS >..-1 AIRED PT 7110 rR M w3 E? NOT IMP__ J D POSITION OUI G AfI <I,xG[ l]I IDEf [CTIV[ }. 8 SO klY RGP•G INTER N6 f?' I Z" ., [O. _- DO RAAIf _ 1. RLM LIGHTS NK ?• } T {IC 1 ri tlito etT -I¢ 1..{wL BER D 1¢ L `..:??us ool ?+ G I- ¢ I n c.INC 1 7+ ¢ DA nT t[r. 1¢ I ¢"' o T ,¢"-? A o CHEM. TEST ,q '_uo TtGtf x cNAL Is •,M E? I ?;,,, P DA K.rm I r o 1 CiEO T'? 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UNIFORM POLICE TRAFFIC COLLISION REPORT PoucE eOMPUNTNUwpeR I D A GATE OF COLLISION DAY Of COLLISION THE COUNTYN O CITY NO. FH'Nq 0 D Y Y i 51 I up1 2 tU(5 D W[ inUP S (NI G SAi IUSE >.O4 HOU?1 > / ggAN , i - e1 Z RURAL LINTY ?STATE ROUTE COUNTY ROAD ?CITY STREET O AgACLb. PREFI% RO'ITf OR STREET CnpE BECIIOH R JJ RA L} ?O ?OTHERISPECIFYI W 3 a? N J C ?IN CITY OR TOWN PREFIX EO. MILEPOST / MILES N ? ® ? OF_ _a?.lc.e?.? LL O F i,: J AM 6N0. OF STREET OH HIGHWAY INTERSECTING WITH: STREET OR flOAD LL RAMP DIAGRAM DATA P r . 0 N ,Pd o n '?:- NQN MTER INTER 011 %RO I TERSECT NG Elo. ROAD OF REF s A O , . s ACCIDENT EAGE R' Clb. ERENLE CHOGS SIpEET RgOAp M - ;{ N ? L ' BETWEEN P/GVVG/? _.V. STREETAND (,O= /' ` ? THEEi CODE 3 l/O -: , pIST CE AND OIRECTION FROM REFERENCE OR CgO55SiREET MNwutLESNns SPECIAL CODING USE (}}MILES _.. Hu 5 w N '. 17, ?J /J y i- ? ?F EE ?O T ' EHICLENENICE OVEHICLE-BICYCLE ?07HERIWRITEI ?HIT A RUN COLLISION INVOLVED: SEVERITY NO.KRLED IoTALNO ® ?VEHICIE OeIECT ?VEHICLE RR (RAIN _ ___ ?STOLEN VEHICLE OF VEHICLES ? VEHICLE PEDESTRIAN ?NON COLLISION ?IIAZARDOUS MATERIAL _ NO.INJBRED PROPERTY DAMAGE ONLY -4- / OBJECT STRUCK (NAME OF ODIECI STRUCK ANDOWNEHS NAME) LOCAiIONOFO(UECTSTR CK ESL. DAMAGE N S `r-E W O ED E ? O O E O O LE,. DRNEPS NAME-LAST FIRST MIDD p11NCRb N AME tl 1 F Cl1S LOk S AN.CHE CKI NST,iIg5T MIDDLE <1 K " . - R R'. o? ?'GX J'la?i /LJC J^iT f • ,1 ., y r ' I E ST[IEET ADCAE55 ... ... .: ?. ? ?._ f 'f I v b BEET d?38a . '- ! R GTY .. .STALE n p ZIP CODE PHONE NOO. F // 7 V?Jiv 7-.?c O ? E R CRY STATE !1 - ZIP CODE .. :.PHGJE NO, E LIJ /mod ,3110 _ 3s"' k "y O L N I LN.Ell. NO.. STALE SE% DATE OF BIRTH N R ER' LICE. SE NO.- S T p iE SEX GATE OF BI NNTH f O. / f?O /?7 h M0. OAY YR O. / ?4(J C S / I ' / (//2 L MO. DG S9 I DRNERSOCGUPATION FIRM NAME: PHONENO. 'j OHNERS OCCUPATION FIRM NAIAE. -, P NEN o' ? CODES > IGI Cum __ NI EEATBELT_yc._._ I:'I EJECTION _.. _ CODES J IJI Cu55 l -? 1..I SEAT BELT_? /I51 EJECTION _ _ - •: NATURE OF IIUURIES N LURE OF INJURES - EM VED FROM SCENE VEH.YEAR BY. MAKEIDODGE-CHEV,) TO MOOELIOART-NOVA) STYLE 12 DR -CONVJ REMOVED F OMiCENF VEH. YEAR BY MAKEIDODGELMEV.I TO MOOELIOARTNOVA1,-' STYLE 12 DR.-CONY) Ka ?i 'r E H.:. VEH. C OR . TIC. PLATE TAO. Lr-.. 'Z C/o'Z STATE t!) TRAILER PLATE NO. STATE E t{ VEH COLOR tIG PLATE NO. it e d 397 STATE. TRAILER PLATE NO. !? STATE d & C L E VEHICLE IDENTIFICATION NUMBER - ... - ?l d 9Yal ODOMETER Yfo? (", E VEHICLE IOENTIFICAII N NU BEfl .. - _ ., -93 O I ` Skj ODOMETER , ?3Lrs'y ?? ' N 0. REGISTERED OWNCH-LAST _. -. FIRST MIOME e N O. PEGISTENEO OWNER-LAST FIRST MIDDLE sd E ,T-. r', .. .. r, 55 OF OWNER AOOR[SS OF OWNER .. .. . . ... - .,. ? NAME A)IOADDNLRSOF MSURAN ECO.O(1 AGEN1 NAME AND ADDRESS Of INSURANCE CO. OR AGENT t C CHIIIOIL ITATION NO. ENFORCEMENT CnAfIGE - CITAiI NN . J'n CODES _ NAME, ADDRESS & INJURIES OF PERSONS INVOLVED - ry sf% AGE sTAius EJECT 14=1 14-16 1 d C, NAME'. C ADDRESS e1 ti I ) U' p A NATUREOf TFMOVEUf110M uwwEs SCENE nr To NAME 1}Yk J .;. N n FS y ? ^1'L ?cu°rwo (ROM TD N i ., ADDRESS' - -- T N NATURE MATURES - -?--- M)V(U(IIOM Sf.[Ni RY 10 E NAME' S ApORESS E S. ",I F M1' NfA N ?"- - R'CuaC SCf NF rTY 1 To Ulub Eg JI ELAI D WSLA1 BE? SILJEDION C ; nl OlS RAN E t CEOAIIAAiHS CD L IdI A'9u ii14IY 1 ilI l O k I lLYO nf HnT a ID C CENE DEAD ON U 2 N I 2 T L lS N, "It. 5 I I i 2 iO A E.RCICO 3 PARTIALLY LCICD l p e Mn e :!Ls I ? j WCDMEIO SPIIAL e OHIOOIK` j 1 P0 BLE INJURY s ..o ii J op A E Hk r L• -- - VA N UN O (ulunE i CJ(C 1 R 7. six Y ' INSI HUG] IONS: "D. ORAIN Ann OWISI TO SHOW PR INCIPAL DIRECTION OF FORCE. y' O a/ •IIL}? , pr, DAMAGED VEHICLE NO.f ,IUFTll IS SPACE FOn 3KETCNING DAMAGt TD rHAILtns,MOiOnCrCLtE.ETC.1 I l d . IT - DAMAGED VEHICLE NO. 2 L`V'f[ .. IBS. T F c .. F H! g r 1. 1> D.YN (-.-A N'. " ' 1a ' , l T•f?• I F SE9VERITYOD AGl. VEMCLENOI Urn ]E VEITYO{OAMAGE'1 TNERVEN CLPI Ie. UmNrr.r dal, ] C3 OTNEnM V. OAMgGE DISABLING OAMAGE ] RITY OF DAMwOE VEryCLE X0.7 I •, 1. t1,-TH ; W f J[J FUNB A MAOEI (`;, Q N°DAMaf.E UNCTIONAL DAMAGE NOOEn DAMAGE ?E®OUNABLNG BgMgGE ;?OTNEIiMV'OAMAGfrIO 9 TOWED BY " .. + EST.Ow G OWE. BY CTOIIA AGE ? OD,MAGC• TO / [ r r:OAMA E U E BY T.OAMAOE 44 I N TO i TO ` - S k DIAGRAM OF COLLISION IDRAW ARROW -f SHOWING 1 rDINL. qq`.`r...L,TxxL3 I/-•?" I '.1 Lr. -k-'- {--?-I iF'?i?r"nlol?ho ,r Y, _? f - ?? ?L _.. I_ ISis >•rr. 1-- RTH IN CIRCLE x mom -?-? ^j• aT"` S PT_ B ? ? .L..DNTDI - _ ` r - i__T =V 491 r NP 4. SHOW1111AILI V-CLI ON - DESCRIPTION OF .` DSABILITY,REDUCEDVISIBLITY,PEOESTgIgNCLOTNING V ONDICATE WHAT PROBABLY HAPPEN- COLLISION COLOR,LpNSTR9GT10NNCLUDEIRFWORK,EOOHINOTOHO GAM, E.O. DRIVER d t ? i, -•P05 TI BEFOH COLLISION - - E E E HEADED D O ST.- OR MILE O NIG AYNAMEO.N ?'`• '? E E NO - INCREAEINO DECREASING KED 1 ONE. ETO E 3 (:. N S E VIN W - ! Y ..`? P 'ED OC U Ep C.1 U1 L-. ` - ES NO ES r. T - - m n cgDMHgK lB lawl .. + F./BICVCLIST WASU9NOe I [ LN BIB Ai 1AIARKG SI :SIDEWALK WA (SHOULDER CRO ED `- IOESG q EO \)i ( D SUflFACE WEATHER CONTRIBUTING CIRCUMSTANCES LN 1 BICYCLE OTHER E L 1?--- + (- (CCK ONfI ICHFCK GNEI ICNEC14 ONE OH MORFI ROUTE OTHER RV. In ] .DRA1VHEE' f DR - oR Eq 42 f`E 'SRS r91 # .1 r l I--? 1 AIDS" .} N0.} Dp EN l ( n0 f 1 I ORY CLEAR. CBOuO 1 UNDER INFLUENCE OF l?_'- f 1 } ?JF I- ST.CG ..T AHEAD ? C? [[DYERGASL_. I.?' ALGO119L??? ,JLCbF1I"G I? r.3 0AR0 D WAR" L_ ANO YAS51N6 1 11 'XI]r WET ] IY, PAINING } NOEn INFWENCE OF p3.CLQSF4= I J - OV-ANING DINE CENTEp - RF TLY IHO 1 1 SNOW ] ENOWIN6 ] E EFO MG STATED J tiS fE '?]t 1 RIGHT TURN P 'A S `T?-.?I?1IQ ?- ] SPEFO 1 S t TO L?C?1_ARKINO IYU MAKING t?. A I {p0 (- E CEE 0 E 3. - I LEfT TURN J...L_ L- ?S+SFESPFED I I IMPROPER f LOCATION_ 1gl OPERATNO R IM • ? ]Sn - - EI pE ?SI'?-Ii AKING k - _ .1 Ia L(_TO Vf < Ni R/W FFCTIV E FOVIP. , -? DS EO -"7 ',f - `-' U.TURN I f IMPROP 1 OTIi[R IY(.IAYI f+1 -- OT [II S FC 1 1 I I BGQL Gwj I.. IJ___ 0B0 6LOWINO P !--'' SSREG D O AS Nfn ° ONDITIONS RAFFH CONTRO F c E B G I} - bN'SIGNAL -,I HB E s VIOLITIONY' C)? STT .FOR :, I i AFFID l u:NECK Oxu INO.}VEHKLE IND.} TYPEOFROAD VEHICL1E[CO€N 1 QDQITEEIpQOSN _ ` [ .-C1 AT SIGNAL ONFCKONEOR ORF 'NICLE ??ON rTSTE01 0} SODRIE TY 1 IIrJ, EIGNALS 1 r. HE WAY VO.J Fsd Vi NICLE ICNFCK BNEI OR BTOPS GN 1I I DAYLIGHT 1-I]I I a OF - I -- -'- STOMEDIN, LPL LLLJJJ /.]'?WO A OEi fCTIVF? N D LTY ST gTINO IN _ .d_B _ a[O. ]I I DAWN 1} I FLO f-- DARES. WYAWED 1 r qE F S BL[ } _ -l.s SOH ?] I -I ]I f Of FECTIVE ( TRAFFIC IANL 11 I ? 9 S 1 p SK LIGHTS- NOT PER, -ANIE IrLRK[UOSI D?? q ? .EI[CT EAOIV( I IIIC? TOION u '•? .. NT' Ll L.LTERCIAN, J _ •f"- a ? OAp K-tTRElT RED i -_ - .FEAR LIGHTS- - I,•N I+DKSOeR ET=- -- ( ' 1 TRAFFIC( O L°I I ALLlr r ' I [S WO N i-7 I I NON q; ?I]U Fn6 NO Tfn 1 r? ; I LIGHTS ON ??? 1 AMBfR TW IS? c CK N0 1[" - 4 wDotH.. SfE NK N6 I [ L . DA K_ST [(T ?° "'I p l '- O WAY-LIFT 0 ? AnK-IIOF iDN L D ruRNMANES ..? .1O 1 o••f-'-i-??1. ... CHEM. TEST O i .. 0 i '-{.`"•S1P ESTLGITi. ?'..? UM[NA" R AAA". l l-_TfS OVEN. OTHIIIIS11111 r ¢¢¢s l % Or E IYFC YI .I.'i J I DI DlD - J I'^I N.DEFECTS 1 i__i Tlir R[FUS[D I i L Il _ { f r•-bl f VEClf vl N J uN r ,tZ 1t 1??, ??1 N I31Ow DGt O o rolrct U -% % TESTA SVLT9 Z ? ? N00 KI '] lA V ?j[? ' rol.<iANYIVtO AM u AFF t?? 17N. ,.,_{C']E00 ( /r. NgBO ARRIVED CF/ wnBB MFLDFDILUW J AM1,. / .../ DTI /I i TIGAf Nb0 IIL[q'SN [ SAD t N NC "' ?? a 'f f NRS h I6yV 46 i.H0313 fl 0 T[0 EDIT YIgpVED SY I DAI ay -0 4 OIS TIIIBUT ION ORIGVIAL COPY SEND TO WAS( NOTON STAiF PATROL-OLYMPIA, WgSN NGTON 9BSO/ I y DUFLICATFC , LOCALLAWENI ORCLMENTAGENCY YCOPY-TRIPLICATC COPY: INVEST IGATOR'S COPY ..^ tl '? .. 1( xa I •-- _. -_ _??_ Y -- --- - f IAt ? ?3?li??r'?"1 I I F7*s f.9'p t ??kY it 7 r? I (? T.4 +^ ^>fi I L ?? I Y I ((( r Er ?Lr1 ? ?? ? II ?:h 7,.,~ 4 LI ?ti ., _..., N 5 r... ? lr li,r„?1 Y 4Y-0?? N't 71 T ?? } Ir 6Y K'' r r ?!, t,?1 rl t roily ? u ?f' I s 4 r AM1Y I ` -r ? ?f 4f, 1 ? ?I YS r.? ' - 1 L14 t i ?' ?i 4Fr I D GATE OF COLLISION - - DAYOFCOLLIGION TIME COUNTY NO. CITY NO :. FHWA j A AlD Y Yq. 2 SUN 1 Mp1 ] IUCS ]WED, INUq S FRI a AL IUSE ][DOHOURI j / URBAN E = UTRAL COUNTY ?SIAIEflOUfE ,©000NTY ROAD ?CITY STREET O A KA CLS PREF IX HOUTEORSIREETCODE B CT N T vQ ? ON ?OTHER ISVECIFYI CITY Ofl TOWN N ? P 3 - gEfK ED ',•32 50 MILEPOST -: IN C p? ?M MILES ? ?,lyl ? NTERSECTING W T R R AD LL NAMP • DIAGMM D '01( ATA A. ... NAME d NO OF STREET OFIHW :. .I.. .. I I H: ST EET OR O , - J T .- ON c.e ao :. ..,. X • - N-ATTERSECIION. - - ACCIDENT NTER N 11 q %RD I CLS NTERSECTING STREET OR ROAD OR nEF- r - N RO P E M v ERE C C SS AD • N BETWEEN _...??RI_.D-__ dTREET STREET CODE ' - DISIANCEANOOIRECTION FROM REFERENCE OR CROSS bIRE T q MILES N 5 E E?HS S PECIAL C ING USE : - 1 . y •D LJFEET ? y ! - VEHICLEVEHICLE ?VEHICLE BICYCLE C3 OTHER IWRITEI ®HITARUN O ? NO XIlLEO VERITY , COLLISI NINVOLVED: ? VEHICLE-OEMECT ? VEHICLE RR TRAIN ?STOLENVEHICLE _ NOAW RED T V E HIC?ES ® TRIAN ?NONCMLISION -RDOUS TERIAL _ PR P RTY M GE ONLY ?H ? VEHICLE' PEDES ® DA A O E OBJECT STRUCK (NAME OF OBJECT STRUCK AND OWNERS NAMEI .,. - ,. LOCATION OFOSIECTSTgUCK -,'E-,: _ EST.DAMAGE ` b ?ROADWAY FEET ? ? ? r) RO EDGE S ^? ... _ '?-- --M -- DRIVERS NAMEIAbT - ?- FIRST .--._..-._... '. ..._ 77 -- - DRIVERS NAME-ST FIRST MIDDLE DFUICYCUSTORPLIESIRMNCHECItIU-"':" ' r :.. D D' R'- STREET ADCFIESS :: --T ADOHESb -.-: V V:: E CITY. .. .: .. STA ....21P CODE: 111- NO. E CRY.. .. STAT :.....'.. 21P CODE .__ PHONE NO. S A N DRIVERS LICENSE NO. STATE SENT GATE OF BIRTH N DRIVERS LICENSE N0. - STATE SEX DATE OF BIRTH 0 MO. pAY YR O• MO. DAY YR. r r +. ' DRNERS P-oii FIRM NAME . .... .. .. PHONENO. 2 DRIVERSOCCUPATION FIHMNAME X + y r :.... P NO. CODES >1- OI AU55 TAI SEAT BELT 151 EJECTION CODES IGI CLASS IA SEAT BELT_ 151 EJECTION_ ' . N 7URE F .. -U EG F 1 •` , FR I S -ENE BY: TO FNOAOi SCENE e Y' 10 J A " VEN YEM CMEV.1-. MAKEIDODGE MODELIGART-NOVN STYLEI2 DR-CONV.1 VEH YEAR MAAEIDODGECHEV.1: M OELIGART NOVAI..STYLEI]Dfl.CONVJ.. 'T ' Fr , V_. E H ,. H. OLOR UC. PLATE NO. .. A51 I'S'l STATE TRNLER PLATE NO. STA E ,.,E H' I VEH COLOR UC PLATE NO.. ST TE TRAIL Efl PLATE NO_ - - ', - C VEHICLE ENTIFICATION NUMBER .'....?...:. ODOMETEfl _ C - VEHICLE IOENIIFICAII N NUMGEq _I :, ... - - E -7 c? E RE E O MIDDLE. REGISTERED OWNER-U i FWST.. ., .. J .: MIDDLE 1 ..t o: uce C/ AFC o:. I , D t - . . -_ ,-. ... ? - -_ ..... ADDRESS OF OWNER .._ .. _.: .+_ .:: .:• ...... ? ADDRESS OF 0-ER I ' ?P. ?o? 36y QuF/F„? Z NMIE AN ADDRESS OF Rr URANCE CO flAG T. : NAME AND ADDRESS OF INSURANCE CO OR GEM I '..• ,.. .. I, - ., CI CHIP"- l Al1UN NO. •. ,. CIIFORCCMENT C ARGE .'.;:;':':. ? .: :..: ........: ... IATI N ... '.. S• ACTION I ADDRESS & INJURIES OF PERSONS INVOWED ' NAME Coors _ ] e , SE% AGE STAIU9 EJECT. `. NAME - C ADDRESS U p ruIGRE OF ILL MOVepmoM -PRES SCENERY TO A NAME T ADDRESS' S 1 M LUFROM LIP ? I SCENF HY TO E ' µF HAMS. ., J?. N NADDRESS AD 11 .J . .. A WfNF T O - E ' S NAME ' S +nDR[ss E I m unrc _.L7sx07n t o S 1118 AIDS 12IS A POIWIX%F IJIINAIRY DLA55 TAI SI AT e[ll IN [JCCTgN I 'A? T- 0 O r P b,RFNp[R .1 lD1.b11MN P YC161 ??. S. R POSITION' 1.OT I 1 ILO IN1Ufl OI AG II SC[Nf ] MABON RNAL S fA5 RLI 0 AIRY 1 NOIIN5TALLED 1 OT EJ[CIED ; N1 RL NO 9 N011 "USE ] f01 LIV CJ[CIED ] P flf ENtI N WIY r ] U.CD l uJ[CTCD If ' ; m I .?Hl ?1 4' . D E ` -- e01 IR awTTFT SS L S NU•u M01011CYLLt1 ePOSIIIpFUNAN.' AIALOWrgS(STJ,L,-_ lO I ^- - ` U A NOWN U TU.IC IURI firArb-rAA.URE LJfc1EO yI?) -? I II .w . IBlI![YLtlRT t ,.Fl.?tt"?"`•u-iy t'?' ?` 3T 4 J f cA? "' ICJ r G'" - .] . t.,n ^rti T r n +r• ? r !Af L ' I 1 t 1 r t ,, CI ?''r ? Eil I >ar, . c fT t q F? ,? r ?, 1 '•1 ,, .aii axe F rgS a.. gg ?Y a s. 1 ! x'Ybl'?? - DAMA DAMAGG D 3DRAW ARROYRSI I09NOW PFiNCIPAL O,+ECIIOM OF FCPCE .. .. -._--.. ._-._ _.? ? '-. ED VEHICLE N0.1 IuSEnwsPADE FCq suFrcNWDDAMAGE TO TRAA=ra, MOroRCrcLE1 ETC.) DAMAGED VEHICLE NO.2 ' ! x I . ° m.NO°. , + z 1 a ? ? . 3I +a 15. Tlu+k • I•.P°d• ) 1S. Unaxcwrlp ?. •... LL i_ - --- .laI• I? Iiinn,' 2 ).Ox,lnm SEVEi°IY OF DAMAGE VEMA;LE NO., 9EVEW)YOF OAMAGE:IOTNEfl NOO VENcw SEYEfl OFDAMAGE:VENICLENO.2 0Lu BUNAAGE . S?O IHER M.V.ONAAGE. IQOSASuNODAMAOE On MM.V.DAMAOE 1 ? ?.. -' N 2 FUNCTWNALDAMAGE A NODAMAGE GE DQOIHEA M.V. bAM',v3E A -... FUNCTIONAL li-- OAMA(iE NO t OAMAOE 2 FUNCTONt DAMAGE NO TOWEDSY SandyF6 Ow`..n$ ES). DAMAGE TOWEDBV uw ro3-:. ?. EST.D +Y'+'?fi10WEfl BY EST DAMADe TO driven away . $500- _ a To .. DU1GpAMOFCOLLJSION.a ruvY ^1P° + ? I f m O 11 .fORAW'pRROW SHOWING THINCIRCLE I 1- 7 9 wfr.crE Y '` ' ? f ( 8 .Q I r r eee lI +++ Arr`? Ao.DwAr a< rPO61f I . I i o ?EPAr? I bi+i,dge I I ' ?"' s?"1? I L :I I ° ,: , •o,.a.Ew,wroF I I I . ?. I I ? ? I I I I ..aNDwFPD,M,?EYD.DLEa,? ??•`? I I i I I I .. I I . , - . _ w?w??1`ra.` z a? I I r I i I I I I DESCRIATION QOLLISiONR-Y'OF$ y F .-.. w11, DNDICATE WNATPROBABLy HAPPENEOBEFOPEWR.q AND AFTER TNECflASH.INCWDEWFOflMAMNNOTONDIAORAAI EO DPoVEfl oSADR1TY, REWCFOVIEI&llry,PEDEST{WW CIDTNUgCOIOR.CONSTPUCnON Ofl REPANiWOC): n1['• =..1 'F .:.:: _ _ This road is very Darrow and the driver informed this RHO that there was a S/$ gehicle.and he pulled over. for the vehicle d an not to close to. the edge and went down it t hIInl6lent and and t k s ruc sat-E4 Of small alder trees. Moderate damage to1,the ven3cle,-.,, - r VEN.??HEADED_ . NO. ..- .. N .... °?DFFAGMODECREA?tl - " ' A?7•"=an. ..l+^.-++= ON STRE D11NKiNWAYNAME Ofl NO. ... ... _. -. No OF LANES WOKE O,iECDON .-.. SPEEDS VEFIC 9"? LEGALLY WAS VEN. 3 i ?. PItEO M occumED W E O !'.Oz O 37:0 Y ld C.R. 18 :Q?" T . 7 1.._I '? ?.. ? 2 D ? ? n YEs. ND yes= NO PFD: G D D ALCNa DP 9rPEF! r'O.+w. M mw.(gi aG lei wA PEO/BICY ? 2 l''? ? a CUS)WASUSWD: 9L<wAN( w llyeuaR" L,i 'M' ?c°ms oeyoN.i[4r:'. ) WA®ix xr '. lM i_flOADSURFACEy' ?:,WEA rcNEC.GNO rcN?o+U _ rWT •••. COMTRIDU rc TINQCRiCUYSTANCES1 +c« 6rE an wrrr? a,Palre 6T. K '?. ey rte` i:E:` ' :upMnv.?n,etaAC CNa Y. "` r _ _ ND , + ? Maro ? j ? ^ wlvua f1 f"'?.r aa°?rcN ° "'w. _ D-0 ?a?. w a 0 a LP ? oaAr,D - L ) IDP'!saa ! . . _.. A 0 ... 1 sr+ To .. '•'^d'e+ {?'a? Iwd.•A MRM3 -:ur n . .. ?A ?' ?rVln •?_ -. I-la .. nw A?iwrnnv 11 omcavo aroP rwo ?? r -0_- . ) .. .- . _°sl? 'rM.0. -I •r-T" i _. orNFAI,vFC)rl onenlarFLSN I-? .. •ooln.R 0 Flatw.,D _. ._ _ J a L LIGHTCON D ETWtl S yJWF'i9C CmE®DL'i rAa°1iO .J•? a ' DI,D mN.aD...•n° E - ,D ^t w+wlAnox+n ?r°. a°vmeon .iRwFKa.. -. .« ? , a : : 10 y ou.:L OiRDAO;, J, ICLECONDITION.L ""^gSOBRIETY • • •. °s ? anarc.°4 OM"? aiwl L ' ="f m.rrcLWr: ., _. - a0 wra..! _.. ?.? ._ j .'. .. I??Der+owc.....? ?'7- _}a.L1 cdEr:^`r! ?IWNbwa a oee`?rve wAAUDNn -L ? ?*t. ;i a °°wEn D a _ ..._- ? o?+r rrte?.' .M,w nn. SJ 'uDOwlDnowM '? V? ?_ I• AMmw . _ • Au,r =J _ ?? o°anoarN +c _ w I ,,wNOOwwcro ? i,I mvrlq la ur+uo •?w-.-n, o.r?"_ ?•°:W.. • °^b1 n nwu.• ? ? ?E° °. , CHEM.TEST . ? D ?tY menuoNr,. r n r ? n ww r_eo . I rearaN? _.... .. .. olFnlxuni' L_J ;. , . ? NDi, C ... f? I.1 L`J' lJ I ?: n rta)IrtrwcD 1 4-: ? +^ fr ? 'H , •).,srnAi)ovrcewaN.N.Enwlcwrw? , WPMO 1 I l I , OPIw IY,Vw ! <•? ^ ° K K TEST ResuLTS y. +c 2 ? '^ ..,. .«. ztt Deputy WX. Geb •N 1?G.rwoD..cPMM. 6 art 3 .1 0l on vip 0120 D ,Y°a 0 °? : m M p Raw 15 ,. ?? ? l % 1 ..owND ^D•?' u•iaour .•oer. DMeprYrosr Ar M N+w rw.eon N oAn w ' .i .•/?- , r ? .:? 6 JCSO Quii cene 110577 ,? w.w++c? LwAL?UWFNFOflCEMFM AOFNCY9 COPY?IAA1CAif COPY'INVF311(IATOK9 COPY .. .. ty H. 'h I+'ll?+ + Atv ? f !r? I ? I Y III 5 sl? - I '.'l%;`-.'>.-+',IO;i LmN,yln..- W+aTAaFn9"e71CsN"Y?'-?;`.'fl4""°p; '77-7- 7 + . C p IEi IItY' T ." ? F °? `? VTJ9T 0 ??TO *ASH PAOE OF NO • ? •? UNIFORM POLICE TRAFFIC COLLISION REPORT GOUGE COMPLIWTNUMEER-- -- - _ ' ?? ', I. 1 • A,: A DATE ERA SION MO. Y Yfl. DAY OFCOWSIC .' T I MGn 2 TILES S WE X 1NUP 5 FRI e s T TU.E (USE2ADOLKXLR) >. J COUNLYNO. CTfY NO. iH ?U OAN COUNTM ?STATEROUTE ?COUNTY ROAD [jCITy Si-EET ZQ OM<:Lti. PHEFI% ROUTEORSTREETCOOE UAAL B TKIN J • •,? .D `, ?OTNERISPECIFYI - N B E W IN CITY OR TOWN MILES El ? C] OF uilcene wdshia tOII N = U 3 PPEFl% EO. Z '72, O MILEPOST O. b = 4vlY<? A NAME a NO.OFST ETORI MWAY WTERSECTV+G WITH: STREETOR ROAD O ..F DIAGRAM DATA ' T. ON Old C.R. 8 C. R. 18 " . F a. !" N NONWTEflSECRON O R ACCIDENT MLEAGE IRT R O XPO INTERSECTING STREET FIDAD OR REF. I CLS ERENCECROS$ STRFETORROAO in T E NEEN 9TREETAND STREET DISTANGE.wDDWECvO __ OMHEFEHEHCE OR CR STREET ODW O 1 32 ~ L - MILES N S E W ? ECUL000P10USE r - . 00 ® FEET OF C-R. 18 ft - - nnF?yIVENICLE•VEHICLE ?VEMICLE,EICYCLE OTFER (WRYER ?NIT. RUN I COLLISION INVOLVED: ? SEVERITY NO LULLED ?•tS TOTALNO. VEHICLE OEIECT ? VEHICM.RR,_I,t ?STOLENVEHKLE LCI = OFVEHICLES= NO.IWUREU ?VEHICLE•PEDESTRIAN ?NON-CG ION ?HA2ARDOUSMATERIM ® PROPERTYUAMAOE ONLY OBJECT STRUCK IHAMEOFOBLECTSTRUCK ANOOWNER -E1 ::.. .....,:.. LOCATION OF OBIECTBTRUCK - E6T. DAMAGE . . . 0?i x 1 Small alder trees N? o,0 IN IN -. . .. .., .. ? 1. DRIVERS NAMEiAST .:_-.FIRST .. MIDDLE ROADWAY FEET RO EDGE s Skinned 6NVEA'S NAME-LAST FIRST MIDDLE IIFBICVCMTOHPEDESTRUNCHECKI ......... .... R TARR! Eugene Harold D. • I S_E AADOREES., ,,..... .. .. .:'.? :?:. .. •._.. _ ..::-.. .. R STREET AODR 5$ V E P.O. Box 417 Wash & Chas _ y i P ° , Cfry ..::.,. BTAT e ZIP '• .:.:_ .:.::: CODE PHONE NO. RE CRY' ,:.STALE v -: ZID CODE PHONE RX). QuilceneE wn, 98376 765-3440 N DRIVERS UCENS NO, , STATE SEX DATE OF BIRTM N tJINER$ LICENSE NO. ... . :. STATE SE% DATE OF -H O• TA-RR-*-H4o5oF w M 1 MS a O• . . M0. OAY YR r n. g a 'I - AM ORNEA9000UPARON. FYiME '. ,.. :.._: HONE NO. 2 OCCUPATION P N . Student uilcene Junior Hi School ' CCDE$ > IDI ALA y AI SEAT BELT 51 PjEC 0 CODES >1131 Cu53 AI 6EAT BELT 151 ELECTION ?€ N?NP eOF. CL.. L..a % ___ NA .R REMOVED SCENE - - RY: - V h -= OVED PpM SCENEE, TO VEH.YEAR MAKEIDOOOELHEV.1 J AIIODELEIAATWOYAl 5TYLEI20RCCNV.1 YEH.YEAR• M. (OODGEGNEV.) MODEL(DARTFgVAI,- STYlE120RtONV.1:.., : V' ' V STATETHAILEHFLATE. STATE'-.., - E YBL COLD,.:. LK:. FITE STATE' ;'. TFWIEgPUTEND. STATE H 1 , Blue EG 6 H . . C -., VEHK:LE IDENTIFICATI N NUMB R..-' .. ,, - (,` lE IDECIOFICATI N NOME R . ? .. - Ed LP23B7 120641 4 4 4 . s_. 19 0 flEG13LERED VM E -' ER. MIDDLE REGISTERED OWNER-LAS .: ..:..:..... FWSi. _.. ,. ,.. .. MIDDLE N O• TARR Marvin A. N 0• ADORES9 OF OWNFA ,' : . ACONE390F O\YNEfl .... ' - ?- P.O. Box 417 uileene Wn. 2 .....,n ,.... ...+. ..w'Jr...: NMI AND ADORES9 W.OR i .. ..... KMAEANOADDRESSOFINSURANCECO. ORAOETIT, -' ... Homer Smith Port Townsend Wn. . CM ........::.. .. _ :....: ......... G N0. .::_: ENFORCEMENT E'.: .:... .. ,.... .... '.:......:.. U A Lim.., .:- None j Noae ' ACTH NAME, ADDRESS & INJURIES OF PERSONS INVOLVED cones _ 2 a A s P ' A NAMe: SCENE TTY' N T ADD RESA I UU PLLUR.3: SCEN Br y? xAMe: Z ADDRESS: N IWUIne' serNe sr _- E E NAME• S ADOMM _ III3, rh 12LSL.AT PO."DIN ,;II IWURY CUSS C O 2. PASSENGER PEOCSTHIW OCYCUSf A 1 a 2 1.OTNER Po5RIU1 1. NOINJURY 2.OEA0 AT SCENE D. DEADONARRN ' SDISAOUNOIWURY l.NON DISAEUNO IEVIDENT)IWURY D E' e.OMEII LVITNESS a _ e D IpUSMCfORC TTOW YCLEI a UNIUgWN I A DIED W ROSPITA I. P09LOLE INJURY .?f f .. x i ?1712ei' li I. NO ED I. NOT EJECTED ?j9YJ 2. NONN fW USE USE 2.TOTALLY EJECTED D USED S. PARTIALLY EJECTED L UNKNOWN A. UNKNOWN IF 5.6EATDELTFN1UR6 EJECTED _ (Ell I Y ? I I>?iN 4 11 - _... .. _... OTOR VEHICLE COLLISION REPORT M mC• _ . ...TIME OF COLLIbION OAY•OY COLLISION er[x [-I » , ? 6 45 ? NM 1 Y{IO. UN CIiY NO J/O_ x 1y nAl ,'J _y3,iC,0UNn?s:w,n,{,ai .;Yh TOw n NILES.?.?? w'.. c _ta 7owN ,.-,, . OM.cLS nR[Ilx .eVr. n.aT CUO on 30 S 7p Jefferson ?f? D rP e -?,?};owp_N,IeARTppaTFFICFL rtPAO,o.R,yw.,wAT .. HrcnseeT-uww.i -t iNe[r.9R.ro.n.,; DR[rlx tG MlLenobr O' 3 8 Count Road 8 /? NON INIERSECTI-LOCATION OF COLLISION / HI AORAN OAi BETWEEN PennV Creek Road I STN O Bi'- Ouil Dam TNEET T 1-10 N e a»a,n r :»r[n,cc x»....eca. LLJJ `•p,f OM 1"•»n..l»o ..»o».».. s IN r ER OH INT[R .RD CLE. I r,aOKaoc,oa ,ay @O I Penn Creek Road E d- qq ..» Iw[ NI LC. ADD[ Ni[ .eD-2- t1» ?. a .[»,?.[. [.a,r ceLLH e» .r.Nen OBJSfTT '.. 3aR' ?;. NirL..''ii:J:fnAWNCArOP;OalECT1_NAMC.?'ANO.AOOR .:ui?h'In R MW?Y-'r•'1•Uu'? ?H ?E asn?,. cu..- ` •[•• r } rveR r:.nAME-....ds;.a,•?sslR T...MNe:'.::.:w.r::....:riPPLS? ., aAS .uix_.'6" ?'n:t:J?':,TvN.wg„?t.,;a:s[aa.avw 0 srflena' •?'••[ Rink .c/T?2!cU.?wn?ao74Ro• sTAU., -;'S -:....:. .•+::.ti-:.Ra np.[]_s:l o.wno_sov?, wA a»Le» P. 0. Box 621 N CITY..3:..._ fr;,?v_;;?.'T s[iy';; ?(yt;?(,;L?cooe .PgN.CnapECV ?xloy_? C - -• _y " i41ilaf LOOe, 'jpjlniRlL,000UMTIOr?a: Ouilcene WA Q8376 Port Townsend- wA 5. IwTey: - s 3_4,DFJ.14? ........,.._. . zr?s a[x: •DArE.aR•awY]I. ' _;?,...:•: w.ueutirc,HUra, ue-: '. I 7 :s is x f4O-NR-OJ-3433OR WA x vx .. +1O°'Si.T.!R°_'R'"•'.^-° e?oyirne;nS_?°'21 i? , ?.. _..;::wNa.?vIL .aAKe?,yw?.?..,,.1 wooEr~,.;_o+«.,?.?._I. eacr sTx?418.t? 1971 r a qii7.iiki PE 250 . ?t!,R[N?IGS["?? w:ti.4TATf. ,y,? '.: !^,1. LlGitta[fLAiE.f10[. AT[',tB:i .TPLRLLI!LRT¢N.?TS - T.A-T1Se' LLJCAd.NOI I y.; OVH-471 ?lash. ? :, v[yrse, WennrlcwnoN!19Y?':;?«oea,MOO..us:f:,..R1 oooNC'TS9!._..? ygwcei Il a+.?ege;.wir••....Y Py 25o 1 -. 2MWi1b. LICAVaC?as.iui u_.?dti:NCWT[116p PW [F.:J.•.m(pNtcw.oV I?M?.I .:tPR1Y,CRi LIC[cI6CI.NJPa?-YiS 10-41R-OJ-B . " OR F ap - ? ..;, -yscYx:s ?!]Ii. DMR!ms;? . _ • .:.:7,?""..-:..-'!.?!R?.na:.:.n.: :..A: ?•'tY:? :.m'epprian*.S1A a P T r 621 P.O. Box ort ownsend , d 1 x b ilcene Nasn. ?rRls.uas-:s D .. - :• Toni 'woMtm i Y ? O)C:W(3Z%.:..:- x'wMdy] $ F 5 LIABILITY INSURANCE INFORMATION -VEHICLE NO.1• COVER?ceui evFECT FORS-I.E.IONYOUR CAR ? YES ® No ?' :CEriuf-'?--'rte-L'::?__'°I.°._'u:'.:....R'auR".e'ee.£°"".?,LT`.. / r?a?d !ICC .tir;''.,,`.+:?A...?:. ?".ro?'°RS,.w.M..?..1.•' _ ? •Aa '. NAM[ Jeffrey S. Monroe 1 '°'AC e .._. . ADORE55 P n ti ''•a PP CS - NA T _ _ TINY .1 1 ar Gorman M. D •Y w [' ] M . n'su °N? Al1_YJ® r-".?? rvaK yRl[II[Ip.sq • J araR KILL[D larvam ?I , ?Irro,i'ro I' ]1?U5'yOF'R1JYR :iit''i6 O1'» G?'r??F(4L b»iuni• »u IN Y[IIK:LC N LEO la[»[x[t IN ?u Nr^.. ' `» ? 6[] ? ' I ? 5? 6? • 7? 7O`T 5 3 NeR WIITC.IN c SHOW WORTH BY ARROW IN CIRCLE OI Vehicle No 1 heading north on -County Road n7$ and- met vehicle2-_ N.» .. N ».a iNV :) __on_.blind_corner.[.__..._..-___----.---.---__- h VEHICLES POSITIONS BEFORE COLLISION Y n INV[sTICATeP aY VCIIICL[ N S [ V OH Tfl C[T OR AT HA f OR O O» a INO[e can o " ow, + : ? ®.: „?,.*?'.."T.?:?LI e, I II ? Gcl ? ? ? ? p ? ? e ? ? ?-]? _ OmRr'YOMd' Y. v CROt O IRO w }O'1, ••. yl •'r, ©ruj?,j? ° I DCDLpRI W Al USING Ir], ][]w J?. [] b? ;,FWO,WRI_-_,,,'. .. AT?o.Xa ,IN.LgN'f CONPRA]N[ „-, TRYIPOONTROL.: c. s,}.. } Ir[?Clr?? Ic»[caeN? RIV[R/YtMIGt[AGTIO k,-X]V$y GA, [r.Nl 1 [ c r[. I' ?TSION- ?I. ?=ONE WAY n•I N 1 OX GOING STRAIGHT AHEAD IL? c,»uar Nn 1 'R PAILI.NT ? 1 », [ L TWO WAY ? 3 0 OVERTAKING AN. PA[[INO ?j RAINING ] ? OAWN Cj 3 ? STOR SIGN [ ] ? UNY i 1 rj r Cj s ? WLT ]? bNOWINO ] ? OUAK Cj ] [] YIeLD bIGN ? ] LJ R.?UNbInL[ 3 f l MAKING RIONT TURN ?-J IJ pANRS(nrtT , FLASHING RI.D IN IERCHANG[ MAKING LCRT TURN L j RMOw .? I , NA-, ? A ? ? ] j^ C O O DN , ? LIGHTS ON ? ? ? A ?_ , O ? A 3 -1.4 U• L L C ? c? OaHTUTFT [j n ? "7 ILARNING A-11 E] TURN 0 , [I 1- ? ! 1:.1 IYI b ? L ? S u Lw0 . TMRN ? It ? [LDwING Y}.I 3 V?Y :?:Y GraVel A ? ?' A?q1 ?IGUT, [] R CJ HR SIGNAL ? n ? E[}WAY n]A.AVI rVL NK]{ett'Aq DANG[R ] [] °,R?,,, ? T [:) oIIICENILAC aIAH Lwrl., ? T ? RTPRIED vow TRA.IIC ?H[N - -----? b ? ^TDIREDAT,PHAL w?oon•n OR STDR G- ?H L=J n Ll :' •° °„° -----'"- j IL Nr - f_j Ll verlAlv.D L_1 I [.J ? G LJ O}ORRCP IN RGAPWA, U IVICfO (??77 3IARTINO IN '? TRa[Ilf { J IU ? IRAIIx; LANt ' L I ? , . J it CONI nOt iM1) ] [ UHINV[OID [}ARTINO IROU ' r I --- nl -r^- n n D _ -'___ R?y ??[RR??,w,t .>,??'3'9ffiIFA"?11[iT,t ?,- .d., !a}w.r: t:,+S J?'t%1'.r 1?r .? ,1'k-•.:,?_. ? e_ ?. ,. .r. A..' _-. „a I w ? g P+k t , ,a VEHICLEDAMAGE ',`w EACHaox,?menTMeia+MeEnoFE IDnMacEDiaEw:? "?` •` - ° 2 SHADE AREAOF SEVERESTI'JP M INSTRUCTIONS: a.DRAWARROW'ISITOSHOW PRrt+CWAL Otl•ECiIbI OF FORCE. DAMAGED VEHICLE NO.1 (USET MSPACEFORSNEfCWNODM, TOriWLER9,MOTORCYCIES.ETC.) DAM AGED VEHICLEN O.2 3 .I+ Y. 13. H°°0 ,a. H°otl I..R°°1 11. Yb°1 T IyUrM«wm?q ° a I „ IB. UnOarrxrwD? SEYERnY OF DAM :VEMIClEN0.1 I D.w"UAGDAMAGE a DOTHERM.V.DAMAGE 9EVENiY OFDAMAGE:IOTHERVEI C ) 10 Da`sU DAMAGE acloH M.V.OMAAGE SEVEPITY DAMAGE: VEHCLENO.: 1?.QABl1NDOMAADE a[]oT mM.V.DAMAGE. a TFUNC?IONALDAMAGE { NDDAMAGE 3 FUNCTIONALDAMAQE ? HODAMAGE a FUHCTICNAt DAMAGE { NODAAAGE ' TOWEDDY mp_L( , G EG(Te WEDSY ESTDAMAGE. TOWE08Y EST.D TO ?x,II?vE ;UE i o TO nl? TD M40F COLL{570N.a a7' I I I. •• .. PRAWARROWSHOWINO uNPFY• ?ADWArarowr.aAnACY 9 x ' I i, NORTH IN CIRCLE O ?Yy 1 t? I I - I IDARFM.ETG1'?I?'?I xLDCATE wcuAel.EPaHra. J' ?' J I I _ I' I' I I I I i I° ?' AcT. 'DD?LCTWJIX£DO•<ATPIF"M""ADF A V -FM ? «r - I I I . .I I __I , - 4 {.? e BLE C . - m s Ew"ivw8F1O E C7 <lE /V Yy Pi I 5L DE$GAIFT70td0 `' 1 - IIIINDICAIE WIIAT PR US YHAPPENED SEFORE DUR MD AFTER THE CRASH INCLUDEWFORMATXIflf TON DtA IAAA ea DRNER (`QLLISIQ(•NlA*" d9AB°ITY,flEDU , O CEDVL4&UTY, PME5fWAN CI O N 0. C DTUN CCOL 6U , . UC TONORREAV ORKETG) 1 _ n - I n / . ' ":SIwa"ia,YfX ...__ .... 'E HEADED MILE POST pR INCRE VSwD C i1EA 9 W 777 _ M(.T!?<i?S•*.+??^l!aMd. '.fAis.5A?3lYy?".•' r f, .HG. of LANES sPEED9 v PAR D DS O/H??ODON J asfl LEO WA6 VEH. DNSTREETORNK3HWAYNAMEORNO. PMitNao ED OCCUPIED W0 . . . . '' 11 1__?? E W N _ _ CJ _ / .•Y OLD ??-/v/VE? LV? /, Q.. - G/A ??E. i, ?'. ? ? .? YE9 NO YES NO ' rl 1 PED. L_ ? ? r __ dfPEET I?IE 1 wLr,D PED/61CYCUSf WAS USW G: '?aCEnrut i^^ 1._!anPAm1 I''? ° Iro.SYw {I,-I?no sm•Mr< I °?csryD??E "•T?-D? _- 1 ROADSURFACE,'ty rcReu oND WEATHEgjµ•- KReCw aAn - SO . ai TINO CIRCUMSTANCES_q ca, a.e ai MDRq o a F •RA C Maln omnA -? .. j , .. ? 1 o tlFMTADA) - , r ? - _ ..DD° ^ aTl 'Y ? ???- • oa? M_ •DO YrtT.. a (-i IIAe.Hp I L =J 1i (- .J l 1 w?wY6CED. ?e r l Pn,RCpRq ? I i?=uHNnY f L J ?ia 111'? e1.Dw a,ww,i a ? [ ].o a o g=-Alm ... _ ?°Q Wnw. TO F?7 L? ° ? ?!El (?.? ,ce . (? roo f_ ..''•.1, 7 w _ °Piec,'rve°rauP. a? u",A?wMa. 1 ?K1-' •. e ... ° ?mK..ai aryaD°M°DUGHr ? '.,. .: Y Q! Q "El -0 etwY.o. ISFECVq onf ?s(On ;- _ _ i?? r I--? ?lal_..? m1iD?Ew °f° ( ? D°C_f -W'RDtAnan -I ••• t.- ?T? ron UGHTCONDITIONS oco o+n Y • T U M ;% a *-A. &TTPEOFROADy uu oia M g11EHI CLE CONDITION?.y r,,,e ;•;j•,+,?•'S08RIETYrF.??u;y;,lpyj ?'? (( ' _ u1?= Ao.M, ? _ Un ora Y .. ,DKU -1 HwaR M0. P '01mdr.Mlulml cxEU OHe ) '? -U?vleuv?vFV y ,?'? -Alf ~ . wnl0wl t ' ? C O -? ? ,? 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DUPUCATECGPY LOCAL IAW ENOl1CEMENTM)ENCYBCCVI- !?jy, ,1 TAWUCATE COPY:WVESTIOAfOR'S COPY 4'1 ? cl 1 ? w ' ( 1, ti ? ? tY Y}11 i ? , 1_'t i 1 , "P"-7777,777 7 7 u STAT I _ . ra - : E OF iVK5HIi11GTON PA.E,. OF G l I .. UNIFORM POLICE TRAFFIC COLLISION REPORT PIXICE COAIPIAJNThUMBER --- - -? 11 A DATE OFCOLLLSION DAYOFCOWSRJN THE A1 D COUNTY N02 / CITY NO. FR N l E 9. AV YR. T 5 N 1 VON 2 NES a'NEO A inUN 5 FRI S SAT IUS HOUR) j ?/l/? Ufl0'W p ., - COUNiy ?STATE ROUTE COUNTY ROAD ?CITY STREET O J ?OTHE P JE s ADMC PREFIX,, ROUTEORSTREETWEIE UgAL L o, RIS EOPYI N 370 , - LL C / N W ?IN CI fY ON TOWN W (0 MILES ? &15)0 OF U Ce -A' `C U PREFIX EO. .... MILE POST??? T TUNE d O. EETOR HIGHWAY INTEASECIING VRTH: STREETER ROAD LL ON O RAMP DIAGRAM DATA - .--ER t +? N (?\ ? L? ,q P B ???E ? D E, ?b ACCIDENT MwEAGE WTER NON CtR.AD INTERSECTING STREET CROSSTREETOR ROAD ` ETWEEN 'F••'G/Z 1 . EJ /..STREET ANO DISTANCEANpgflECTIONFRO.N gEFERENCEOfl CROS98CP 1 / 5 AEI N S E W OF w l? (O ? 00 CppE THS - SPECIALC ING USE - ?? ; 55 ,? COLLISION INVOLVED: ?VEHICIENEHICLE ?VEHICLE-BICYCLE OTHERIWRREI SEVEPItt ?HIT6 RUN NO KILLED KILLED F p TOTALNO. -I ? VEHICLEtJ61ECT ?VEHICLE-R MAIN -IhenS!5 Q ? STOLEN VEHICLE NO. IWURED ^ CF VEHICLES ,?f ?VEHICLEREDESTRIAN ?NONCOILSION ?HALIROOUS MATERIAL . DOPROP ERTYDAMAGEONLY '- L y! ! OBJECT STPUCKINAMEOF OBIECTSRiUCKAN00.W?NE,0.Sq N -:_.. ?... -,..... -_ LOCATION OFOWECT STRNCKS E 111,D AGE N?A?E)-?v?: I t ' , °' ? { ? ?' ? ROADWA EET ? ? ? 2.', EDO E S DRIVER9NAME'?I?$jT, Jn , FIRST MwOLE DRNER'S NAMEUBT FIRBTMIDDLE IIF tlICICLIST ONPEDESIRIAN CHECRI 'F ' R STREET AO ESS R : , '' I • ? I _ . ... _ STREETADORES4I zi I Lt'-tm6 APA v . • , CRY :.. ..... BTATE. N+COpE . PHON NO. E.. CRY. R .,?.. J) '. .... .. Fv`J?, BTATE ,.. .. LP CODE PHONE NO. ' N O DPNEPJi CE S STA TE .. SE% DATE & TH N DRIVERS LICENSE NO. ? STATE SEX DATE OF BBiiH . J? 1 O: ? Ult. I?L. f o MO. DAT YR x -: Y pF/??t,Ej]R,LB??OC(000PJATO?N' FIRM NAME_11 .`.. ,:..1 (1I'.--,A- PHONE NO. 2• pRNFAS OCCUPATION FIRMNAME - I i - 'ry 1 CODES > lal CU53 I<I SEAT BELT 151 EIECDON . ' NATURE OF CODES > lal cLADSy MI gl IWURVS NATUR IWU ' - R M ENE VEH. YEAH BV: T MAKEI CHE`Y.1 MOO RMRfH+OVAI STYLEI2 NV.1 F ' 2 OVE REMOVED FROMSCENE -YEAR BY: MAKE(DOD HEV,) MODE v 7s - so P WD - A A 5 E N vEQQH. R :, IJ PLATE NO. STATE .. RWIER PIAiE NO. STATE:. ?. -- - E. VEIi COLOR . UG MTE NO.- ? 9TATF I K.7?l.?Y CSZ ZL1 H 1 C E VEH?y?LIOU ATI pNL1- ;, ^t'ekM1IC?Lb4 L?g Z9 ., L C E vEHK%E IOENTIFICA ON NI1M0 ?. '.. RESISTEREO .OWNER- ... ....,., FEST _,...,..:_:..., '.....•.,,..MIOpI L REED REDOWNER-LAST , N O. ?J?*7'KE O .... .. .. . ADDRESS OP OWNER - . 'r . .:. ,;, 2 .. .. . NAME ANO MORE950 2JSV (A OR __. ? =I P . NAME ANDADDi1ESSGF INSURANCE= OR AI A tL sccts tj - ENF ORCFAIE M CHARGE A CTION NAME; 'ADDRESS b INJURIES OF PERSONS INVO LVED copes - .R _ . p l VAALRIES: IVFJI?)C ISCENE BY ?? A NAME' N T ADDRESS: s WUfiES: NVEDFROM w NAME: i T ADORE" N INwN v SCENE BV' E NAME: S ADDRESS'. S K RE 'A U IFS I D . CENF BV . VISTA IUS 121>EA f PO YIXNJ IIWURV CLA:IY' C' OF CENGER C T A 1 NOIWURV 2 DEADAr SCENE 6 DISABLINOIWURY eNONIX5Abuw O D OI YCUS 1 CER S 2 T,OTNERPOSIRON IflUS4UTORCVCLEI . D46AOON ANRNAL I EWDEN IW TIURY d E e1N(NESS 6 ] e. PovTKaN IJNwJOwN X. OIEDIN NOBPITAL T. 0851BlEIWURY 'all 1 NOT INSTALLED I.NOTEJECTED 2. NOT IN USE 2. TOTALLY EJECTED J USED ] PARgALLYEJECIED UNKNOWN ..UNKNOWN IF S. SEAT BELT FMLUPE EJECTED rA f 6 ?'3 °k? I'a',ask I, III IACH BO%, CIRCLE HE N tBtR Of EACH DA,FD AREA E%AMr LE _ Kr VEHICLE DAMAGE }, SHADEARCAOFSEVERESIIAACT o? (l OL INSTRUCTIONS: O. DRAW ARRowISn050oWPRIILCIPAL DIRECTION OE FORCE 67 DAMAGED VEHICLE NO. i wst TN s sPACL FON Sat,cN NG DAMAGE Ta TNA LEnx MptON v L s ETC. DAMAGED VEHICLE NO. Z • ?'', 1 / • • ' 1T. D.••' nl'•P• ITVO AMAGE IOiN.YI.CLE SEVERITY OF DAMAGEAGE vEI ] O Cll NO. >N O- E•t MY. „ }?j' Tv Of DAM G[ v D1CLE N0; ? D,NEn M.v.OAMAGE I E OROS LnG OAMAGF ] ?OTH[R M.v. DAMAGE , ?DISNABLING DAM No . DAMAGE A_NG A_ t E ? AUE - l! ML GE • D NO DAMAGE ] Q f CT , NO DAMAGE ] U F UCTIONAL °AMAGE DI.. CTION t DA n pp.? ESTDAMAGE MAG 3 LOWED BY C/i10? ?? /E TOWED S1 D DE TOWfO BY • RAM FST DA TO 2 QOl' '-s. TO ° TO ell, dbw = hf / O S d (° ?. G DRAW ARROW SHOWING . •- -DIAGRAM OF COLLISION F Y? NORTH IN CIRCLE 5 ? DN.,kEN,KPL siP Bv?a! D,EM.LDNG,px3 E IT_ _ -- F T? PIF ----i-t- .fPL51.,AN.,,,,5.f.pKt .ND.E,fALpLL,SDx - DESCRIPTION OF I Dc Ew oe B E [ E ° N ° F IER TIE c p INFORMATION NOTON DIAGRAM.EC.°RIVER _ f COLLISION - OISABLLITV, REDUCED VIS OM1RV,PEOESTRIAI CLOTNNGCOLDR, LO 1TIIUClI.N ON REPAIR WORK, ETC.1 ye/ T?/_LJds i°esSn?. 7'/e_?La??s.LdX?.Ge?/°- rd-d r?erro?.J__ d_S/i glA%..._._ v ?. a Te_T/e.:/`!5i1. /e•,_._i+_o d_1or?-Go/daL 7e Tie_rr9/ >.. Ate, T.Ce r?9h r.S-Je_of ??._r'ca_s??dy,.rrr_c's1.?9 a?%?/__dra'd-?n?/d srv,w,t!: L IN PE PDSII U BEFORE COLLISION ON STREET Oar GMwnr AMt R .O. ON Olne lwx . , pg4A%Dv ED ADEO MILE ST UIR IEC r INCFT MILE O pECNEAS1NG - j• 1 K 1 EASIN D L_ 11/v _e ES O ES :_L71?(_Ii =1 [ ' .W. - DSlfPN , O d P :.I D D 4 -- DE _??_ 70 E TIC G LE OUTF )I E ° I J !SIDEWALK }C wA ] SNOULO I SF w OS DIB CYCE ST 5USING. R E E C t LK CONTRIBUTING C flCU ogEIANCES K D) N , 4 EROAO SURFACE ----?,FEAT ER CHfCKONEO DR MPA 7t ICNECK ONE. CHECK ONEI l' vFN ??// EN I °H I— GN ER O.} 1{'L r l GTIMG T -AD OF!_ !.- QL_ MAKING O-' /V A51_ XOI )ALCfEINFLUE.C EO f I?10FRCENT- G OE p( PARKING I -I) °O ASS NM1G } L'NG TO d { } LT } 1J.. OR 5 _ a 1 1 1. OW 1.? 3 G 1 SPL LIMIT ° -.._._LOGA IDN U1^ Un -ER J CMY ?i 1 I I C[ - OG S CEDE O N N A' IG.' TURN 0 G O fG G P S -oD NOT GRANT ? i? EG X71?R'fl?d5? fJj^/?/wPJ?e L wxc E LL[ Via..IIO ° . -6i.. ISPfC FYI '? - O t ECN 1 PAS p It - 51 USTO N E S FC 1 }' O PED POn ° SING }.J 5 GNIS GxAt 0 "OLAT ON iFlt O GLE TYPE OF ROAD VEHICLE CONDITION SCURIETY. EO AT SIGNAL IGH CONDITIONS RAFFIC CONTR O .) IC MO E VE NILIf 1144NN €II,,??jj??••?QQSS ICLL ICNEGK ONEI I STOP SIGN 't T ICN!'CAONEI O.) l,IILL <K ONE OR [ ( tNO.) I?ot)xT 11rIBU{[DI tNO.) Ig? STOPPED IN ....Ty WAY HOADIYAY SIGNALS I ON 3` ! ? -. _- ] OIN ?,? DAY x f C l x N00 ARIL j,. G T S14H CLANE TWO— I,- P K[D YDfRITION OA. ] son:. (_=.. ! 0 DAU UCIiIS- 1) NOI WPAIPLD _ NG 1 +' d t j a Dus uaN c •L '- Loo _n Mx4f ?]-.,J_°ntw °iicuTS I) _ N..DSO IT .. .. ,J )I J T AfnC11fNTENIf RLO nN LKIN6 SY ([ - y IeLH G I I SWD EHD i6 nA T' `yF'+,,, 44NTS ON. ,-_I EN 1 °L ! 1.1 ,J DR.S OOTN tNK ND „I t I CHEW, EST 10r}_I DTNrn lance .l ?,?y,. ,} 'f1 GN,Sp GN L Z°4--.C-_ CINr rl ON, ._ E i r s c EN D iii 1. 1 KKL 1 , T F ° )? D ptD ._ _ I\? NO DEFECTS 6 H[ Fp 1?Q(p "''11? S t 1 Orr,A vfc r K x.) plvlOtD ] %% TE57 RESU LTS 2 d l l `I I l .1' ,??? ?` r 1F(?S ,C NVON AD O,IICENSNAMIL NKL WA NO POU[lpOPA OILFANNIVm e10IVlULL (DEOILOW L??i'AItl`' i?, n?s?nnlfec:1 3 ml's??r P Dl.ys "„° M nID)? n3 ) r Y .fir cA, cDn mcf NO lrorr n pen ,11ffsVr,? I aw=, * X „ _ u1S J° W F ?,T?I L1 OISTRIRUTION ORIGINAL CCPY, SEND IC TO WASHINGTON STATE PATAMPIA, WASHING'S O ' LOCAL LAW E E PINT FORCE ME PIT AGENCV'$COPY -TRIP4 ICATICAT E COPY ' INV [STIGATORT011'S COPY E 1L 0.? ? DUPLICATECMr LOCAL rI1 k ? r + V ti f`1 1 vrtilCt ft ur r? ?'?t 7777 7T ^., „ " 7 ?ti,;- n?111: I STATE OF WASHINGTON PA, % No N UNIFORM POLICE TRAFFIC COLLISION REPORT POI ICL COMVU Nt NUMRE - . .. / DD ? OATEOFCOWSCN M ? OA1'Of COLHSION i SUN 1 MDV Z IUlS S YC A INUN 5 FPI E SAT TIME Jq Jnfl?Upl IU E LOUNIY NO CRY rvO /? yy U ? i Y ? rS J K / URAI S 1 C UNiv ?STATE ROUTE ®COJNtt ROAD ?f,ItV STREET O AOMCLS. PNEE M ROUTE Ofl STREET CODE FICTION 1/ -Yi e ?1 1 ? ._ nOTHERISPECIFYI w ? /7 ? EI L CITY OH TOWN W ?IN + N 5 E W PREFI% EO MLLE POST ?1 /? ) (( ? LI ? /G ? 2 f? I C OF ?iC- _ /J. _-_.__ . I MILES ? YJ+ - . ____..__._ r C/ _E A OR HIGHWAY INiER5EC11NG WRM. SiREEI ORPOAD N EA O.OF STREET U. RAMP DIAGRAM DATA . A T' ON C NDNINTERSECTIO ACCIDENT INTEP NO %qU INTERSECTING STREET OH ROAD- REF T ^ . '-' r O t/J /J ? MILEAGE C15. ERE CECROSS STREETORROgO / " l . N STREETAND BETWEEN Gam,' _.T" CODE 0 ` J '? y DISTANCE AND OINEC ION FROM REFERENCE OR CROGS STNEEI Nun[Sw VAn t1n3 SPECIAL CODING USE J ? X%/ QfEETS ? S ? W OF S/1_ICI ?VENICLEVENICLE ?vEH VEHICLE BICYCLE ?OT E 1WRRFI ?HITSRUN SEVERITY 1?0 COLLISIONINVOLVED: VEHICLE -OBJECT ?VEHICLE PR TRAIN TA N T ?STOLEN VEHICLE NO. KILLED IN E NO KILLEDO d L O E. Of VEHCLES I? ? VEHICLE PEDESTRIAN ? ONCOLISION ?HA2 DOUSMATERIAL . ?PROPERTY DAMAGE ONLY 'EF ' OBJECT STRUCK (NAME OF OBJECT STRUCK AND OWNERS NAME) LOCATION OF OBJECT'TRUCN ,. EST. DAMAGE fr ' S E W ? OADWAY FEET ? ? ? ? O EDGE S EINVERS,NAMEHAST FVi51 __, .... .... MIDDLE DRIVER'S NAME UST FIRST MIDDLE ., II UCYCL1I. OR Pl DL51N AN CH-KHj _ STPEE ApORE55. .. A STREET ADDRESS. ...... :. v Timex E Y "STATE ZIP CODE. PHONE NO. E CRT STATE : .ZIP CODE PHCNE NO. R 95 SIZ X R N DRIVERS CEASE O. STATE 5E1 DATE OF BIRTH N DRIVERS LICENSE NO. STATE SE% DATE OF BIRTH O.. 1 J MO BAY TR Q,' DAY YR NC / 7 S I ] 1 . PHONENO. DRMERSOCCUPATION FUiMNAME '1 pRIVEflS OCCUPATION FIRM NAME _ PH N NO. Y ?n ovnn RiT U/Tan /_a95rii?4' 17.X ' CODES > 1G1 muunr MI SEAT EELT_ p7 EJECTION J CU55S IE OF UR CODES >1,3, INJU CLASS - °I SEAT nEI.T_ NATURE OF 151 EJECTION ` e9 a: ur F. /.I a1r 9i/ (' 6 NJIIRIES INJURES CE E FEOM S EH.YEAR Y J ? MARE E-EVJ /? PTO MODELIOART- .. STYLEIZ DR CONV.1 REMOVED GROM SCENE VEH. YEAR BY. TO MA%EIDODGECHEV.I MODEL (DART-NOVA) STYLE IZ SIR.CONV 1 _ r It &eep '77- v H VLL UC PLATE lA. STATE iRNLER PLATE NO. STATE H VEH.CULOR UL. PUTE NO... STATE TMILER PUTE NO. STATE 1? JI _ / S • , ? C VEHICLE IDENTIFICATION NU BEN .. MOVE- C VEHICLE IDENTIFIC ATION NUMBED ,ODOMETE R ... - ? ? y ' ' ; E SD7 d?y ?G7 /. ^ E MIDDLE REGISTERED ER-LAST FIRST ,. REGISTERED OWNER EAST - FIRST .... .. MIDDLE ik o. S'd, n E - o. ` ' ADDRESS OF OWNED - - ADDRESS OF OWNER NAMENNDADDRE55 OF INSURANCECO.OR AGENT NAME AND ADDRES50F INSURANCE COORAGENT - C?C CHARGE CRALION NO. ENF ORCEME NT CHANGE CITATIONN. C )1G1.,Z? ? y_LJl (LS$ r ?5??/? ACl10N 1 "I NAME ADDRESS & INJURIES OF PERSONS INVOLVED DD s ACE sE% stA us W EJECT. C AM SS D P =IS E OIIEMOVCU FROM . SCINE DV TO A NAME. I t T ADDRESS. S NAIUREOf Rt 1AOVk0 FROM / URNS RCTNL nY N T O NAIVE ? _ T A URESS' ' T N ^ Ui- nLMCiVE DFHOM .RNUES SCFNF RY. TO n r ? $ ME. )'I S IMAI S5 -' J E Ma'viD 01 IN- S SCENE (IY 10 _ IIISIAIUS 11 Al POSIIUN I]IMNUHYC1155 III ltAl HEL1 ISILJkCIpN S ~ C 7 PASSUA:En OINJURY s nauatlw lruunY 1 -INSTALLED NOTTJECTED , O MLCDCLLISI'AN ] nEAD AI SCENE L ( 6 N0111NSAULIIKI 1 1 J Z NOT INUSE. Z TOTALLTEJTCTED JCC D a OlNi 11 a Z 4 0 DNIIOSPITAI 1 I'OSSItl LE INJURY n n viit ILD NR I d d E 6 -I""% POS TIONUNNNOWNN BE FAlw SEAT l [JCCIED 4 ?j °INT , Ih It'll C i I i i i L I 1 } J i ,moop a 1'?S 1 I?o !v . I ,a ? t o 1 o i, ti ?>i,m;s . I, •? -? >7y Fxf? C i'Ih'f ^ Y a n':. S ?,« = STATE OF WASHINGTON No. • s POLICE TRAFFIC COLLISION REPORT (_ ;j{ yy rq I ll .:?? I. ®r, Y?I R AY P KeeoMRwiNr NUMeLR /(?? jp PRIVATE IVATE WAY .. . DA tprtau N_, wr N - t, NouRI couNn rq cln No 4 E I], C ORIOwN F6N0 d5rR!lr09 rRONwAY rC CI RAI ", MRfs OS ?W or U/CLF/JE - RWn 0R 51 c ,A? s, wreRUCr NC W(rN. vRttroR ROwD NoN NrwseagN ON 2-:- e? ?p{?! t'?I vrtrK (o MRFPoSr {? - s 066, 4.xE'? eervnw I SrRffr E CJ?i.J?Gl$srRter ?. 00 (Q j{L( / Di?jwNCt IO RlMNr R yRK CeO553fR(tr OR N[AR(Sr MilfPo ACCIDfNt EAAV Di RAM wrw 15N KF/ JO re[r d Q? MILEAGE CIXli3gNINVIXV(D of Rin. CODE NO KillfO?rq.IN1URt0 ?SAIIUOE ?N__ w11A." '" -R ri 51 fr RROwppq HLtHNCt dVfNS 0 pPortfrv DAMwG[ONIY E SiOI{{N ?? iN1f° Cl5 CRC655rv[[r04 Powp x? ?'i OelfCiSrRfd Oer(CISfRUCKANDOWNtR'SNAV(r ?R[SUIr[D ?VfNCIf ?y / I •? ??..??//LL//JJ ESr.DAMAGf3 5 RCiA1COWNG USE AQV ?_ , CO s -, - - _ (' 3 DRN(R's NAMt: wi UNIT NO, r rRSr UNIT NO.2 O VEHICLE ? PEDESTRIAN F ? F ? Mao DRntIS NAM[: usr ? ? PEDALCYCUST 1E - &-.? srvln AOO°tss ,? rxe wDORISS ? rN•. °? 3-4 Ir SrwrE ?KCOOf fNONf NO D I Y 5 Art / n srwl MDi c•. INn I rE l eN No. Ae DA s ?N` c oe<uvArioN AMe avNON[r.o. ens wNr rEgNr E eu.wNON MNAMtavrK,rn NO. Mo I wr In _ EVES IONr HiONr R ? C K ('q ' mncl ws: ncw^v: ANO S1. 3 ? CHECK (? ' VINKIf AS AN Uworf[dw - 4 it iv I s r oN a o^•c? CoDES ? 7 c .^ e a o'i ,l:?DS ED ?i-C M 9% ,Nr?` /cs u "' in." r, rq•. ?? .cu D? ?• ?' J veN prfnR M MA of a"err OKASoi wvwr .MeuD???vr > M'i4' ?•^^ r ?C. ?c0l ?v1 ?:°u'.v E /8O o.3,D? C di Gl „? LJ N. ?.I lIO rwr Ku I r xe Y " lrwr eR 0.Mfrq SIAr I'I V(H. ?_ ; 1%i7"-39 ??.9 I- a vtNKIt IGMIIKwIgNrb. C 1 qN L ncnnRlD a wi sr M,ool[ NI II" I lu nRSr I I I I I I I NaN( ro Oil- .DOft35d oWNt. w -11, 1-?-J,:5 S/ diLGc?..JE N NAML • ADREESS d mwK.NCF co a AOF r E I v / R 1 •v?'N CNAKU -? C.A. rwCriO"RNN 4AM.YAD AWA + x rdi'ono'+ ,!J-0 rho RtM,uruD ? ?w?r W., 0 I ?11-NID is . D °p 7 S 10M. Y. = rbi"orio:: E 01AORAMOE COLLISION sN HV Iasi..ip a"lfgw DESCRIPEIONOPCOLUSION: Iusl,urnrw"rAl svn[rr ssA rl i _: ? ?f ' _? _ c?? ?1..?.xIK,?=i7?sr_.?:.5'r/,?_: ? ,? ?• s ..: {.l'lIF? j ? r i --I A , rf _.?- I `r J 6.i r ( r _?i?seF?/ FT T/6 ?ry?yN?7?a L f { /? _f_._I 'QfLSf'_rsel?,?-_L-f',.-.i fr?-.I _7??...__LG?i. T_-?!_sT.fGu.??i,-?/f/s? r" . I ?? GiR6 ?eess . r t r• 1-171- 7,1 M r t ? 4 a._ _I---{ 1--f..-f-f j .I ? (-?--?-I-- f- f 1 _i .?._._.va?rf?cl?.. _iy7?./lo? ;r ,?? ' 1 I E NAME ADDRE5381NJURIESOFPERSONSI4VOLVED Il / w,untwN N s"° 'CODES -I r Z J S e OCCUPANTS WITNESSES t 4 ' n wargNr'"'..wu uK Aw uru '^" u.r -wr- u?c. is a Lai.?i??3?,,yhS ;?7( ?f '•I was lu.rd Y k1 ,M. ?EYl' ? n. c y sti r k r.t? r „ ? .?v. tY^ t +•-,f?N? Wis Roves _ .. - ai0rwrd_... ..____-- wamr r qy 7,{1°'x, s -,..} w ?wMl O .n, ?:D rur " O J r, f r? ? Vxr' ? Sr n( I b. } t' ?1' r , i Lis ? J q?,I??.>,k?'• I?? JT:Y f t 1 i ' 1 ! t L rI l 5. (L 1? I 2YABA14 r „ ?, ?y? Y ,l.' 7 r s51 ?9 _ _ ? ??? ? YID?^ E ? S i ./'? ?' K 1 I ?' r I j b ? ?! i I i i 1 f i a I+ f .? ti,? t. i; irS.Y ? w?;i;.d ??K ` ? ;i.. . . ?.' ?7'_?i', iii:. °? ?? ?, .. :t4 j l STATE OF WASHINGTON SUPPLE TARY POLICE TRAFFIC COLL N REPORT PAGE ? OF / in3Ell`d9TtP?F W YIOM = .... . « F_v]?+t ... as . ,... (? CASE No SEVERITY OF COLLISION 2( FATALITY ? INJURY ? PROPERTY DAMAGE ONLY GATE OF MO. DAY YR. COUNTY - CITY STREET, ROAD NUMBEROR NAME ry IOCAiION _ COLLISION... DO /O? -E_ NAME._ .. ..... TA?/Q/JDRICE... N DRIVERS cL?iOil ?? vs Vs KNOWN AT THE TIME THE DREVER/PEDESTRIAN NAME ?^ I .. .";;: EHfORQMEWI,.;ACii014r :. „? ;: ..:::.. sowaTf;;, 1wlo.u[N DnHFUFFEF EuacIEF. .?1:u.a?A._.?L.i?r. i $.Lf.L,.:.'.y , ORATION NO _e ,' IrrE ?,1.sAw Fo io?`; woi I v?Alm ? ?R . k l5l . •.. , ElY ID( NTIFY VEHI CLES AND HIGHWAYS SHOW SKID MARKS AND OTHER MEASUREMENTS. I 4H.b? i ._i.. 1 L t n; Y? 5 L E, a ? {ete ?F.' ' , ?SG 7 7 ?K 1 , i „r Y ? r 'Y POLICE TRAFFIC COLLI REPORT TRAFFICWAY '• v 1 Paluc ' I PRIVATE WAY +I t Cq II v »p y,r I?° uls, (USE ]WB?IOUaI COUNrv O (O 7 i ?,/, ?,•` ppoo JiZGF??GSO"? 1 ? COUNTY Nq.? OTYNO. ? ?E ?IN CUYOR rOw-N J ?f?6?NO gSivF?F r/OR rRG»w•Y AVl[S 5 ?w mOr? ^?i ON uaAE rCTClS ROUTE IEd1ML /KO t/E? U 1S•Qi NIFRRCI NO M'RI». STR[fTOe ROAD NON Nr(Ryf Ct ON 3 p cc // BfM'F[Ne(iS^/J'TTLJ=j RRFEt 6 SYgAMO+»v C?rNFtt PR[fI [O. MRE PO51 4 DIST•rvC[6DR <µON ONPtt[v NC ,CROSS SIRIf OR NEAVE51Mlf POST ACCIDENT .?S' r(RS 5 E W Or Ss?T??f? MILEAGE COD RAMP DIADATA . N <OLLSCINVOLVED -1-Y . OTAL NO NO REIFD??NO. NEUR[D 3 ?SVLLAGI ?»TIRUN w»DNOt» d -1- S PROPERTY D•M•Gf DNIY ? p5 LiFD fgCN Ct 51 RUCs AND OWNt R 5NAM[1 fR DAM-, ul INRR Cl5 CYCYSSTRORRtR tpM OR ICffHPICE [R 1 O SRCIAI CODING IAE _ S . s UNITNO. I UNITNO.2 . ? VEHICLE O PEDESTRIAN O PEDALCYCLIST y ff R 5t MIDDLE Z %o d ?AS uc/ .0,6" RATE IIP CODE ONF NO sro.? tJp 4835do 638-?bz D R CITY E.I EIP vte'S[ ENSEN WAIT » I I IK N NO. ATf ?DITE? BIRI vR e u? -a -ON, No '€ ns c»r.NT I- A E OCCUPATION rIRm NAM(a PNONE NO. Ens Ic»T r<IG»T r7'7 lip R ?CHECK (.I „[ c., ANM,noY [A Arvo r OCHECK (? io O A' CODES?» 7 .sn+°.N? I S gclwN ( e's",°,?ry ' f»d[ws.Nfmv fEOr AN SNFe ?uPC.D( CODES 7 ?I:°•Y ^'°°" 15 ss s.srv.Y rro r ? ? N a5 G ,clG M ' ?'? o" Vt ? M OEDOWE E:»(v ( N0&1. MOORIDART tvAl ws,vu u O Onv ? ?,»N r ??,[t 0 ;bnrV ? K RY V » KLL ? ? ° b 73 2),trsu ? . < ; E Al A 1 E. N Y t mODeL 1 I _ ,a oR "I IN PLATE RAZE Au(R KATEND. VAR H n».c r<»nna.nmurroN NO Li l/10 o171t13141/ I Rwnrtemowrv[e IAZI R mDIXE I I -N C L t» nE ID NT AT Y I I IIII I I ?' 1] ?jeua/E.G _Su?l r3/ /? •ODa(SSOrOWN(a E NO O W aE I m w ER L t NRR MmDIE ervo. S/ D/ 5/s ?f 6dT'TG ? N E e 1DI AMeaADORt INweANn eo ao AC(NT u A f Go R ^> D-1 •uu o-v?wc I ?3D? S ?w<IroNM c»Ae w N DAmAGEOYau c»Aact s c o°?c i ? • - f ( RoP ' Ins :: > u DAmAw ? AWAY - ?RfmuNtD DRrvw RuwNro [s? o ?AWAY ? - ? s f I [YDn Q/ ?AwWAED boF nioirn? - ir B DIAGRAMOf COLLISION 'Z,, aC[N E eCAIINORr» DESCRIPTIONOF-I.ISION IUSISIAREMINrAI S»[R rN[aSSAeYI Ygot 14 T i I ..1:.?r /A ?f Er 7D ' U.I .,- ^_ I • .. 1 7dfo e.%D E , 1 I - - I. I I _f I ? I NAME A SS B INJURIES OF PERSONS I NVOLVED 'CODES 1 - 2 J 4 5 6 OCCUPANTS /WITNESSES in ioDm :i •w?i ii H i RO' -^ N • AM( xP a Bs p H 'sTy °r rjE ?a •c T.ius ; Ir isilr inc+ " N (+s ? Ars ,MiO.iAocd.Y to uef a , Pl' n. Ame O 6^' O" OMIT` • IT^REU rN E :TUR a ---R nt/ocY?a? 1,.oYror Ds lNln. ?Ame -w:tl?h. ?:° oc 7.1 b R . [R+ns x ^ ' r s uw NP a.pn .I OR ° .cINCY o ra ?•.. . N` q¢r oaP,ICraB sar""'.r e: - ¢ u RR?YED - OA a O o ry7 INDer ?s10^Y;:n. ON; O»D. D•1. V ? ? .1?i? YD WSP $ b °T; . y ?7 ? t ? 7S / ? P5 N / [ ; / h14 41??' ? ;fy/1 N1 C. 7" •?:d f 'ti ' A ?i JA' '2' 1 f rI t % POLICE TRAFFIC COLLISION REPORT J(?J TRAFFICWAV 1 PRIVATE WAY u r „ couN IUS[]10D NOURI 8? G 87 Nl . X ,. (1 2330 Jefferson p p, pIN C Y04, YM N ,<N0 GS glFl Of aO WAr 27 µl15 ®a ®o, Pt. Tmsend ON Thomlyke Road _ a.. INinxcr NO SnINv IT 44owD won iNrlexaloN ? ?. ?; .. N,vnw Seattle svma Kelly 'r s I 6 sam > r t ?5 wH F D •M4t5 5 ! [4033514( M 5 MII ACCIDENT Y .2 ar Seattle Lane McoD?EE W ?, • ti , ._ :. <IXI SqN NVpvtO vtRlrv r O,M NO NO [Ill[ NO.IN11HtD? pSrlllw0f pNI1egUN IYNDN4r" QP ? 3 ' ]] ? 01 VlN Ct[S prROn •MwC.[ONIY ?NSUInD p tw KIE ?(+ } "3 OeACi SIRUC[INNAIO1 OeRCi S,g V C[ ' 1 O M DOVma S NAMn ,51 DwMAGf ' UNIT NO.1 ':. UNIT NO..Z ':`..[1 VF QE FEDES PEDALCVCUST RnR ]• '' 9CADSEN, Craig J. SwSr l - F2 smerwooglu 4805 Sheridan Drive w e m.cou rrq"e W D . w r 98661 R Mers uews se 9CADSCJ4D9P5 RA M 0 25 60 i v M0 °" 1 •,. 111* aeurA,IaI N•MeaNroNl NO. ens ILNi NgNi E u w I [ alone NO ens mN, It(gM - 2 D 8LU 180 511 D R p cHEC II w A WE, ? CHECK Ile wsw rt tIr• CODES 0. ] c 2 1 KI s 1 a l e "; _ I.5 CODES ?* • s u<ro» a 2 IN AR o' ,• =W- p • . - ? u ' ? bm I% ti,l p v W. IAR !10000, CNIVI IDKI • •1 S,vIlI OR v l u Myq. " p . p ?L° ? 61 O c0 ? :°r N N . 1985 ii3zada 626 2DR E 1 "OOfll •I 1 I -re 6 N u l sul --I.- w v. H RSFP _ P4r'OOII LJ6963 4U4 - - 3 v[NKII IUMRKwigN NO. J 14 -7-G C 3 1 1 9 F 1 7 2 8 3 2 2 r w* - - ? L R I ID N I I N - w a o .Nn usi nest MI,AtI rNON fa vm lASr rIm MI - ] aaAwq W A-EM 2 Sap N E 1 N•MIewDDqusv?Nwq.NCl co m-- , _ D/K R None "" b:" cNUU awIDI _ gr O1 •Ru I "I -AG' ? W^:" ?IIMM; ID ? W??Y ?tVMiNlD 1P 410r - 'a- A IT n6j s 7000. AWAI SY Sa S Tows nmq iowtDer s DIAGRAM OF OLLISION; ?nurei Ni""• ?e•I No11N DESCRIPTIONOF COLLISION: I1 .. 5l SUM[MlMAl 5.4nn Neaswn ( ? i Vehicle #1 northbound an Thortxyke Road in 25 hPH zone at. _ .1 high rate of speed. Exited road to left, going over an - p5. .? arbaNaoent and striking a tree broadside on the passenger side. After striking the tree, the vehicle rolled, carting - to rest on it's wheels. - T? r _ AME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES t Z 3 3 6 OCCUPANTS/ WITNESSES is S•o'''o?rt3w.w"'.?..SM~i f` x. •IR 6,u tntrq t]la w DD1133 5412 Gossett Rd. Pt, Armles ILA 98362 wl u1 w , s d Bruise .M . 171 W. p N„ , a;; 106. A NO • 001153 •MI NnlN7 11 [AM1 p.D,KI pNI p'a: pn• NO ' . 00115 IKI1 M111•N1 e•D 01 •GINC• w'?'L'?5° ' Sr•rCNO r r :. p •w p b;<I ? ie:nq .^r. O"O..',N X ro Di1 ?DA O1•{??I-D-j IXK]•11?HD 0•x101 nral •rr40vID4r D•R r L ala ' , R ?TS3?a _ ??:ti?fnarPSUR"C?;:'v:HAWI..}',r? rir'~,L?Y&?t?? wRr?EA a'S-a?Rts I{ ?}ry??b k? A lF ? i.C F Iir =•' ' I ,r { s' . 1 3 ? T, ?a t S S [ fq 7 w 6 ! taw E] PRIVATE WAY .®.?........mo., P forCW[.5. qp_c a f. .!_ _ imE Courvrv CWNIr Orc NO. I .i x.. fut lnfR. wv v. TS•1. Iu5f Rb0 NOURI NWA - ' - i I 1 45 8 71 E t.J ?wBAH L'N ut C]IN givd [OWN Mf 5 r NMtf6N0 SiP[(I O4 NIGNWgY iL7 qs gWrtOR SI ci RAF ?w HOr lfs 29 -40N C.11vt .6 N gSFCI NG VnIN SrgEFI O4 gpAD rvON Nrt45tC10N 03 O CQI4P PREFF. F M4f PCGt 4Qg DSIANCF6DPFM1 dJrgOM RF fgfN B[rWtFN CP OSSSIPFFr 04 ntA4FSi F fjDyK6, r4F[i[ l POSt $14111 /?5 8 / o ' Y I S N 5 f E[tr Jr g DU MILEA Ni RAMP U AM MtA E cou soN NvdvfD. vtgnr CODE TOTAL NO NO . LUD_NO NJURFD_ dvtN Cl[5 ® ? sp LIAGE ? N r[ 4UN n115 ?x IN D S RLLr ROAD. RiHKNq w 4wD IMF C" d05551Rt[TOR RS ' • ®RROPfRiY DAMAGE ONI Y F ? .1 IltD SIIXFN ?vFNCLF Q ? -11c,111"CR IPIAMLO{OBl[Ci S1vUC4 gNDOWN[43 NMtl A / Fsl DAMAG[ SRCNI COaNG 1JSf E s vFgs NUAt wr UNITNO.I d rlgsl UNIT N0.2 Cl VEHICEE ? PEDESTRIAN Cl pEDALCYCl15T 1/ mi t O4 f s NAMl: StefFr ADDRESS 0 tE.a ? ? dFr - - /'? ? sreEFl boPF s CW.TOC.C1.ntPPS? S? Z `p a r , slgre npeoa ENO D nr -TI IF, t F ' R B dH[P ?C? NU OCCUpA1fON mNAMt6 PNON[NO 5 Alt F T INY 4^r V 4Wt4 t FrvSF NO. V AF DIEdBR1NP MO I t 2 ?CHECK (?( n Y [YES l wfcNl E UCCUPAtfOH HFm NAVIA PNONE NO F FS IGHI wfGHl R vfN [AS AH EmR raa.rvN rNF ?CHECK (?) W 4AI vFN Cif O O 2 CODES` 2 n i S L wrzs a a0 ASAN EMR r[[ [ANOINl CODES ?` G p . is 5 Fn D clw n FY° ? • N-A O u6R' O 5' R. ? NN'YtA wM k v o VD E] i O O ES MOD 4F IDODG[?CNEV.I Fl IDA4iN A s1Ylt 17DnC ONV.I Q O .:KIT ? "„n FnR moon N Y V N. q lgNSt PIA lPJp S1AIF AflFR0.Ai[NO OVAI rtvn I Q/'? YE I r.l E H Nv O ' ' , ? ? . SIAIf I 5 A VtN CIXOR ^ VEwKt[IDEMrCAIgN NO. FNKIt DFNI rKw RR ?. - 1 ele4rtefDOwwe USi NPSt MfDaE PHONE NO ` ? tGf5lFgfD OwNlR NNL ISr GSoo ! 2l 'I ` - ADdISS CP V [ O 5 W NAIL Sr DIXF r 1. 1 i' I J[a O NI P N TpI - .[? AMt aADpglssd wsugANee e° dbtNi E y ( DfIMAJ;IO AR _ (p R Apia? ro N n:M n."?NI cNAqu n cl A q . L . iolib? a EaE °wwla ?AwwSr" RtMAIHlD ?^RIVEN AY ?R[MAMfD es.rDemAF! D! f p l G OIAGRAMOFCOIN SION: Ny PAUu? ssARY eYAl cow l IOWED BV AWAY DESCRIPTIONOFCOUISION I- 5-FM1NrAt Sw[l rrveees5AR _ r1 _ p- 4E,' -I _ 1 EC.I % ?6u. 1_ ?:r zzi eotwD.p,n?._CoY 7it>?N -- VE4 ? 2 tVER DR 11 r . , __ . _ EJLf J i_{_i_ _ t -.. ??. CIASZNG.P1 U?S?1nouJ .. ?Em-z?4,?1E WRS_ ?- 1I I I I -- - /ICY RI ?.?s?CJ FRO I "ke Ab W T u, 4A, eAAx).A%qDk' i-? I -r- I I 1 I ? .• I .?' _. n-F1? BE.(ORE. CABPIUG Of3Z't? TFkE-.RoRO. J ._ 1 l? tast? TJa 7"cr- S-TCN H I..4 2 _ SROKk .. Ex-- _ P 1 ?..._ 1_.._ I r ? FROn 1t?E."fa?_BAR..FWD.RfXJrEA OUF1i.QT-- ?. i r ?r C " ' O .NG ME REJY N Pb4E PP?JaG£R .? NAME, ADDRESS & INJURIES OP PERSONS OCCUPANTS /WITNESSES ?uu swnlwaunw Ub db • INVOLV D lr ' CODES 1 - 2 - 3 4 5 aF N D INAMl .DdlS, ET Si NAI 51. AGI IAINI N I gSIR InCi M r? nn ', e :fy A AA., ? URid 0 R i I I U-1 1IDE V uN O •N ? rt. r a" v 0 N ? i. b •rdl5. r P NAr[ J• o..awr,cLSN.MI[..r„ q,:.un. Acn,cY j j arua+ [ 'JO•MB ?•." ,*,' O ?..O N ?7.:,. x .n ,,.? C. 07 D ? .?nD S ( ? D•n o'ql POa All D•rt ° oZ ' x3 $ ( 1 f } 1 hdl !'"Vf'.._ ? ?H?4 Y f ? i .f.7M, c) ...1 }PI h''°'jr ?' T'.'.y.,- v..ryH ,:R4 )•'. r1r' 'A .F?' .JCiL) F .: 1?? ? Y'fltY'I t?,.15.. h4J[? .W I} l'? ?T ,?! C ,fib 1 1 } q? J { r L l } ) J 1 ? `11 s:i } Y I?? ! /l ,,{ Z 14y? 1'M, y? 1 I .I T ! 1, i 1 Y f E4 'a( ^ ' E I \ * UH t 1 j' f y t! 1 ?? ( I... 1 I t ?q « v ? a t t. 9P7 1 ';?P' POLICE TRAFFIC CO ON REPORT VTRAFFICWAY PRIVATE WAY • f r IXtI M' COUNtY l - - I , ? wx. xa. run w IDS[7 OURI LPMT CITT IxO , "A w - pN pt MIl1l ?3 N CITY Oa rOwN ?w ?DL F NO SrRFFr Oa INrFRSfCr NGVnrN S,at[t Oa •OAD INrtRSlCigN C ROllEpt ..l7 ? ensnw LC near a /i L{ DDS A"t r ,c.-ST-1 NIA. Mgt Al IS a 5a NF vF R, w Or -/ ?/? {tR[!1 ACCIDENT MILEAGE CODE NE{fl% Miff 1051 D• v OIA AM TAB ... ?.. cal. I-1. vfR re. To,M NO O a¢l[D-ENO N1uatD/I/) D ADE []._.UN w'ono"x F "? Nf[e [l5 els p -'"A"" "v TFD D vw N .11 SIROLIINAM[Of OB1lC, STRUCa AND OWNla's NAM[I IST IS- . - -1.1 CODING VS UNIT NO. I Darvta's NA«T us, UNIT NO.2 PE D VEHICLE DESTRIAN PEDALCYCIiST 1. G'LG 91v1a'S 7" Sr TT - o stattrAOOetss V/l ?? ruff, ADDalss - StA1F 71•COIX O"(Np D IrY A,t z,pcm 338?v R 2 11451IClNSIN S All All Rx. I u N N0. A! 5 n B / a•r o < V •0 e.3Y r• "? u e a+ ea •NONt NO -1 nT ul7 /?o )C 3 O E R CC-ArloN rIaM NNAta •rgNE NO ens 71- 0 CHECK (?) nt A AN E ANDT. R eAf CODES ?* 7 . i o?D.c.c ' " U CHECK Nttl ASAV tMROn1wA rNFO E '?° s r ? y eC CODES ?' 7 a•a a 5 ...... 6 ='?W ' S ? -A- I p q iFrtl tB' D p A nn rGa MAMI wM•<NFVI y<l D FB N. D " ' r FIIDAaTrgvAl Srrlt 7 R CuY M7:' p •« D sl° Dbm D Kn ? 9 0 , l l rA 1 v.l lID vAl I1 N _ ]e I O!N Sr rl AIFR -11 NO H vF Oa f'?A b `• vtnlCtFl MIIICAl-NO. E So 2? o o s3 e1GI RRIDOWN1a' lhfr Mlpq[ r C I. lnlCl I v N "' N i 6 ADD'. a`R HJ RONt Np .5.9 o1E O W 5 WN a. y { 1I 3r _ AMIaAOD• wsuRANClI* -A. E ?l DAMAC1 u[. S.NmG R - rto. ::e°.:ci cN ua aA• gAArAG13 A,aEA f onY? roe (Sr DAMAG! ? A'V ? RI-11, iosAnroer Aw A`- r N ?ifMMNED ,omo Aw•r en ! O , i •ID• l0 ioriC: S - ? -' xNM DIAGRAM OF COLLISION: c I. nr u Nee ffAn7 eOw v ?, ?7 J,?TE i?L' i7o/ lnf sur•uMtNTM SreeturllClssARri N: dGi? ?/ .c5 A y w/?c?l nJo/mi2 - d _. Gy?c . G ?/r1sE . T?•f=ssE?.?/?s ..:. Wr i?E J CiLv.?4 o zi ? / -' Q m i .l /> / !7 /7445 13 ? - - -IXI- - /-"ooT YtPU.J o../ <<rtorwA To f/A116? / aN/ /c. ? /,7 ?C. LvAS _4?/o/??s5..?.G ? w.f E NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED ' CODES 1 - Z 3 5 6 N OCCUPANTS/ WITNESSES ISM lS,p'AD?j ON4 Mu4A .Mt SEA •G! oral"r'" M$re IM01 N d E !1 SS/ / .JSV ; A u. a . "° y /O AMe Ox" 3 , :r• f) fe r A DO•rls! , wa• «? D'°' l per, , 0" D I:: No . x.rN},uI-•r..Gar<nsw«r a..N. ewct o• A; "?w'?s°' r i. D•«e p fL`ED " " X u INC. o-'?i on °< c r •..D D.n N • o DA I YIA Y! _ x.,Ilr I.S•(?i;,'I?t?a-r ?..i wl M+yy .?.??4?l,5 X iT`Nx .R 1 71 + ?? J . i 1T I t I L/x Ix ?ir t r t l ? 1 l S ??EL .. MI r J Y '1, N/ Iµ?hD I s 3 I I? i I ?J a?.?Y, 1 I S y ,"? } 1 Wu t? I .1 `t _ a E 'R& x? d f k r YF1+.A ISV IRFV..e01 STATE OF WASHINGTON PAGE POLICE TRAFFIC CC REPORT OTRAFFICWAY Pao[GOm Numefa -„' I PRIVATE WAY - -- ^. Q'G. !+ couNrr Dmt L I wx?IwN IIT 11 1- D .OD HOURI couNrr an NO iNwA- f 21 87 O I 13 0 RAN t Cr ...OwN - ?N ?f N 0.«EeNO.0i S1vfF10R nIGnwAY f C45 Roul OR }O M s W N RURAL sfcu us O O OF ON .?103LZ0 IN f4uo NG.T-IalEro4ROAD NoN wrFRS[aloN 1 T (? ? '1? ?5 I PREFIX F DiS1AN f d 011 r {ROH R iFR N Mllf POST BITVFIN t A(AOS lt'E SiRFl16 ?J .&.. IS?ffr 3• .C405551PfFl RtsrmIF POS Ml[S E W •? 1 iFfl OF ACCIDENT RAMP Du 4AM UrA MItEAGE ' CODE - COLl11gN NVOIV[O OKRiIIFD?NO.INIUR[D 1 ?SP IIAG[ ONI18R IOTAI NO UN dV(n CE[3 OVROPfR1YDAMAGf ON Y cil S' ruNppfo.x IMFR CIS CA?SS1RRrpR ROADR ROA° .11 NCf L ?pj5ulnp ? p OB1fC75T-KINAMEOr OBJlC15rRUCR.WDOWNfR3NAMFI FSi pAmAGF SPECW COD NG IA[ - Danw NAM[ UNIT NO. I s : IASr N 3. ml Dl UNIT N0, 2 O VEHICLE ? PEDESTRIAN O PEDAL CYCLIST - SToNe `dab e.-r ?? sNAmf. S '" " e 2 SIREFtApDR[51 8 i ??nd ? ad cI'. ST4fkr ADDRESS U £A/L6 P<oa PnDNF ND R r Art PC P l DRMR'S ULFNSF NO. S2/ S1Alf CA./( I v Iv U<fN NO. An pA1FpBR AO 4 ?-77 'G /O/C_CUPAIIOPF { 4M AMF dPNONf NO. NFIGNI "" IGH1 SIO (,l'E N P], Co ,07`DL!'d7 R ISO E R OC<UVAtION AMf6 PNDNf NO . mN wF Erfs IGNr HCHI O CHECK (? I v N a[A : no [ ANOINIC' l 'f ' ' ' O CHECK YAI I Nn CIf AS AN LMNOr([Of q?.. CODES 1 D q y -- c ,:, , : ' % oa.Y r 5 . e ANOIHF CODES ? * 3o ii: 51-NDN eH :u ,M"' ?r .KD 11 % l's D?o k M w?YEAR M ?IDOpGF cnn wMODIfOj `a? rwA) "' Sr D p .«wl.Ha O " uya ? pS.11R O H:KI? ? io°;,s. P? y M cheL N 3 y L E, 1 <H rl mDDfI FpARt NDVAI Y I R. r., ?^' . p O sun r1An NO MAIL ill. (J?ir }?d l G KS /s t GL7A H y ca a K [ N. A a0 -FERENr N-1-NO. ? . vtN CIF DfNr N • p Ic I z1I b yi9 6 i of ll [R .. . lASr lesr Dpu ADDRM i.-I. r PFWNI NO. -37 O Ml Isn ° wNfR: lur Fwsr mlpal INO. O' X39 C G NLrE' BDCJ GE1A E NAmld ADOWIS1DF INSU4ANeee OR AGINr R. WAIi DAMAGF AAfA sS?rl; n wA , R ' - E ___ rwir ov "` CHMG! O1 ? ? CNARGI -.:- .. GG IVNCtp"r°i4 DMIAClD MfA 3 y r - - 5 13 MMAGt ^W;Y; ORtMMN[0 wA R`_ DWAY.. ?PfMAINfD ' w`'rt° cl /31 rDAMAGF t Iniorio+ R. DIAGRAMO OlL u I510N: I eYAo OW DESCR IPTI l , ar:. ON OF COLLISION: IIn[ SIAPIIIAINTAESN(F $ TIFinassARYI I - -- - 51@-Cay?56Gu. l.4 $+a ? T r w t i - ? - - -, _ s . . ? .> . a A.S.dQ UB Ca'oss ? ; - - --- ? Ro(1b3-- - - - - _ - o.s+_Cpf?tp =J l.•lst>_ lF --- -?? -1 _---. _ LEOr..S? i? Rai rta.? ;f L/oaaT _. ' le+a!Cur - L 1 E -- 2 be ! R NArvvt ADDRES f{ s% t Ri6d 74k?/ o I 'J 58 INJURIES OF PER50NS lus! slrnFMlmAI sr OCCUPAN INVOLVED Rn 'CODES I - 2 3 4 5 6 h TS /WITNESSES AMr Idl ApDlncrvAL NAM IlN SIK ALI lAlU1 iNN? -U -'-N' RISIP IllCl i P Np r fl. . .D r. wnS A rI ?p I r N n: ? AMe O14Ls' ?'" • O rvN n " - _. NAruR F _-_ (o MUrID IaDM IAMB O D.". O Mx O b .. . . - +.orlrlRSr upw oR wlr,c. w1s ScrNx e. 0- ?N,?N ?I? .0?: ? ::«.. Cl U1P.Inlp -.1 AIR VEEI pAll 1 UArI ip Ilo S' ' 2 ' 0 z)CIS . z? g S 7g 87 y Y ? T I P v tx`'< r r ma > ? ? .? _ . c 4( r HN STATE OF WASHINGTON PAGF ( Dl / } I?I POLICE TRAFFIC COLLIS REPORT TRAFFICWAV JQJ No L ^ 17?r' 9 7 -.1c !. r ?PRIVAEWAY 1 - -4Ai QSDI I c( 25187 w, . P" ° E I. a1 ?YO410W ?, CH IUSE]b0HOU91 c N oin ?? .-I. N 1 SI E[ O 771(' CItt NO p`uRe? R' ['LL ` d f ( O. 0 R OR H GHwgY aIN S gVlFS a5 pW OF - = ON - Kt CIS ' 3 l F Y` / O. 1N fF5fLlING V l - ?/ . ID3 ' ]J N H 514(((OR ROAD P/pry lNf(aSfRION PR[llx f0. MIF PO51 . BF1W[[N / SiREFI { OR.v DYKE 51 EE DSfANtFe EMp iROMRI4Erv .CgO5551PEEt O4 NfgvF5lmlF PO51 ACCIDENT 2. RAMP O G I w 3 N 5 O COLLISION 1-11U. Rug: Oi TOTAL NO. NO. KILIED_— INJURED ?3P WGF ?Hit]RUN MILEAGE w IpI" M " A RAM DATA IMf C15 C40S33IR[[TO[EEET [OW 098H9[NCF ROAD R ]] { CYVFH Clf3 [71 PROKR7YDAATAGE0,Ay ? MSUIrFD alraf 3' So' OBl[CT STRUCK INAME Oi CelLCT 519UCK qND OWNERS NAMF) III I-AGE SPECIAI CODI"111 - J..9 S UNIT NO. 1 pp vERs NAme. usl Iasi mmEx( UNIT NO. 2 RIVeR's NgmE: a VEHICLE p PEDESTRIAN ? PEDALCVCLIST usr ] ?p I 5 i4 MIDDLE v O ° STpIETA D [55 'tv vE CuY SIAM 21P CODE RHONE NO . D SINtFI ApDp[35 Y SIAM n= 85a7 lw ' R IP F ' n NF9 S LICENSE NO. E FA IH I I UCFNSL NO. LATE SFK pA FOIBIRH R-i B OCCU IOPq MNAME A-Nf ND. fyfl 'r yp G I IEIGHI V E OCCUPATION IIgM NAME{PHO E "? J a R N NO. FYES WFIGNi HfIGHi - aCHECK (?( vF NI_ASAryl RT, vlol ANO1.1R:Al V° ' aCHECK ((? yFHCIf ASAN fmv?OYfFMArbiHFRM ra 'I c l CODES? a n. nn 5 I c1roN a ss { CODES ?+ 3 o:is is 5 u N e y,°R'Or rtu r a n:"I n ]> '. Vs m Iy? D $ _ , fS ;. pM a -N" SKI a 81- ? ', 0 0 cl ? MA a rPD M ° O0016. a K ?.° vn ' MA VfH TEAR IpODGE.cH[vl ?f`7/ /?ruG m OpEI(DART NOVA) STYLE 12DNCONVI o D E H. ILA I Hfv l MCKK l10ARi.NOVAI l v.) v°"' -„ Atl "ccAA N IXOR IICENS[PIATEN y SlAtf AItR {{AIf NO. STAI, H VEHcam l A Il A Alf 1 ' lTP7o c{?i. ' VfHKIE IEFNlIHCATIaa NO. v 3t3 i E 3 PfG131FRFDOWNIR c L tHiCIf IGFNTINCAU N i 1 O : uSl 11- M-l S PHONE NO. O I RRlOOYMFR; 1A51 11 T MIDpIF NO. 1 ] AD04[SSa pWNf4 W A D -It _• Z N f. NM1l { ADOR(S3O MSU9ANC[ CO OR AGtNT E 1 r . T ( ?FiG? R IN I ?SJT .*/ -A.1 IN DAMAG[ AR[A _ ~ ic o ? • (? ] ' T r 1 NM i cHAR u c ARD[ n«cio°IN gAwAGFD.nu ? . 1 . ' 0 Tl 3 5L0? ? AVNAI D [j REMAINED C3 1- Ar er WlD El AWAY ?R[M.UNtD El 15o'D'O''AGf DIAGR . (u wN i N Aw BY, $ A M O F COLL ISIO N eY MNNRTH DESCR IPTI ON OF COLLISION: Il5[swn[m[rnu sHEn 11 NecfssARr) s S .n - _ 11?H-./ i1/11s1 dnJ roy?< IPLt v :1 k R _ _ _ SLJIC!CLI?_J? A[I?LD_19?F.>".P i , - - - - - 'Al.[.r_?i?S?_DiT_Ce;-I?M11?Q OII E?C?"W ` ? v _ . GoDSI.??_L'd_NJ8U?J9.:??-?3D1L/aJl_O_v1`? `x y .'. ? I _ H +1 I ' NAME ADD RESS 8 INJU RIE S OF PERS ONS INVOLVED + CODES 1 - 2 3 4 5 6 a If ._ ?. N IUS(su OCCUPANTS /WITNESSES roR Ap AM pPUwrpAI $H pnwNAI NAM IM ES - aK Gi raud Row _.. _..... Li Am e 0 c^.'1u a w'H a?iw o s, P ' "' / ': N 2=1 _-_ - AM N 1Ja d n MOVe1D iPOm ? aAMe • rK.NV rd ?y G I _.___.... .._ __. ... .. ". . o AT,.re .. n 0A e ikA ti 7mT.' ..O14AI NOw 13+.AW {RAN• eAW?R K.1 N:? aOD.ngMC r SCFNr pIX Cl HVVID Me DA11W Vlroal APP40vIDer rt. DATE .n '? 1' t' qT ? d i x - B / Y/ /]ZD2G J r 1 a t ?S Pi r I ?TRAFFICWAy \? POLICE TRA! OLLISIONREPORT ru. PRIVATE WAY _DAIF p CG l N cfcoxru ,NU eta. ?'.',. IiMf COUNtY /t?? l(D T I , I K? yt. IU [ OV91 i l/L I(7 5.? ' CItt NO. ?'b HWw / f s 3 oN of o1N EI _<r 9,0 N" NE D55 t, DR iGNWAY Marrs OS - 111.1 R? V rRM1 ON L ?_ Q U90AN f S aU9A eou,e o9 c < iN,1e5F< IN. WS l..$1.tErpe PoAD 9t,WtFM [ •.? lo? L r1.OF-n Lk'e. R S,a[F, 6 S,Ktt D SI/y.ICt60 RF t a 9ttN% aE ? -To rJf I ? f' C9055p9ff , Mi 1/ I[5 N e55R Nt W AT CCIDEN If c? MILEAGE COOS COi iN SK) ,I` R ou09AM D•rw. ® N N VCM1VLD. v(KtY lO1M NO NO R9L(D_NO.iNNR[D? oeNII-I ?H 16 RIM rvoqurv DS VlH CIlS RRORerYDAMAGf ONLY oe'Sl LT 0e,fN 091tC1S,RUCRIrvNAt Oi 091 ,5,9UC[ANDOWNl45N•MFI VtHOI cif 'N rl tSrDANAO[ N % IN EV%C,IN45,REN09 WAD Oq KStRtNCE 141M 1R[ITOa PoAD ?/ S SKCW COD NO IAF .- S UNIT NO. 1 s oa vtRs N•Ma. tAS, E,gsr t RUNIT NO R D F95NNAl O VEHICLE ? PEDESTRIAN Ej PEDALCYCLIST ? III IIADIRM SoDE.E. LE : US, i , . n?? T KF, ADD9ess Iz 1-n4aUJsIWR, I65 y ??95C8 R <,. S,AIF R ? wNFR'S UCtNS[NO S,Att , I A?LEcTL 315DK W O?, l1 L ? - V 1 NsENO. A,f w DAtweRrvR I e e ?uywnay rM-A-NENO. Ens , NEIGHr GHH E =VRADON M NAM I S O 1- ?•' Z ??( CHECK • ? r1J ,5' i51 R 1 N . , Exs Iwr 1EwH , vFH: IIA.Ary Na.NOt"re CODES ?* 3 s t a wir°r°cr Sul I-y- 2 ete ?CHICK(?) vrHttr ASANrMKOnrof ANO,HfaAl CODES 3 6 arO• ' 11i S!"»"D:.D ? .NeD,.rv<, ? A,EI o cmr. ...,, 0 nH nw9 rv e tDDDCE c"ev r MooeuDA9, NOVAI Es c M ?N1?a;:N>u ? r o SEE o •., zsm. o a o ?.. H a . wvl l°1B rnRzoA Slow c-v?o E 1 MDDItID ,ND w, " f ' DfN P erA,t IRMIE90.Alt NO. SlAlt '"COI l ? - ° W 1 del WIC, I 1 N. A .11 C vtH CEF DNUN A i N tMl2_N IC Z!7- OfG15rt9[ ' rl St [ 783 S L I I Wlt ?cE DL RErDM ND k3 ?i 1 ? 5 O :S D WMER: , M NR=r , ? l Ily N•ryaA ua AwNr wwuI a E S DuAACI A.u R u . _n cNAa „N gAM•uoAeu u CHMG( wrv m ? 5 roe"orio: e s ^DA?AU1°t ?3 o IF tMArNtD 0 M A. ?Aww ?a IS, -. t So. s 3 { `W r t-NID o:oi,biT IC.KS41 1 SD ? BY S a v N a DIAGRAM T COLLI SIO AWAY t su>:I[NCtiiuiry?? e< Nor SCRIPTION OF COLUSION: luf[SIFKtNtMM Y4NnNECfsSARV) 1 1 /•- IF e wE - --rfrL??oi ?_ 4- v d _p 1 SFt/- ` - -f 1 -} v [ar V S - aetwP, W ?4 vl I^ ia"._ h- -- -? V CUB E 4 - i -i-- - - -- --- NAME, ADDRESS 8 INJURIES OF PERSONS ; CUPANTS / W T ESSES ioo s W ^! 5e w ? u INVOLVED ii + CODES - ? ? - S ; 6 ,,, D n u 1 [ . ss 1 N•wt R ? Ir ry N NR AG[ IA,US ND n wr ' • - -. c5^ KSre NICI . rr rv.Mr N ? ,: r N ti 0 AN. Mer cc Cl "n •MV _ .. .. _.. .. ..-.. -__ ...._. _ •Nwf SS ... NIIEjsrSDl.. ?•Ne oM"r otdnE ?M? ?riirv X Mrt,:? o•r , sr waa•N. e. •uZI,, u«1:r wN ?g?cHrD fa, y7?Aepry.r,D o'•r/r a)K r A.. vtoe. D• u.? (fj srr:HES ls:oDVHn TEJ ?? ??E 5 f?RC 5 4 I I a: . D 1 ._tu E ENIERSICONG VgtN SrgtUOR ROAD , ? - r?l ?? I" r ti0390 NON NIf45fCr ON •t'- ? Yr. •r ?? (J IO4' I I SIRfEr6 014&a FU SrRffi PRfN F MIIf POST O. 7O BfIWEfN SR ?DISrANCESDiR Mh0N rROmq rFgfKf.CVOSSSIR[f O4 HURf5rM if PpS • E .i 5 f /? ACCIpENE VAMP DAG AM DAI Pll[ W Of DCC 6o6 /?O, Ra• MIEEAGE _ , CIXLISION NVIXVFD: O -K?-/l ? OpE ry 1llfD iN IOIAL NO N ?I R ? . AGI UGF MIIE eVN m D SRE ORROM 04 R[EERFNCE . OP [HIClfS ? pROP[gIY AMALF ONtY LY ? F E SrIXFN w"DttD IMF CIS CAOSS$igl[t CRW? L 4fSUlrFD ?vFHICIE '. ? 6t ?? J/ ? OBIFCt51RUC%INAMf Of OBIECr Ste C ' ?. T U %PND OwNFR l S NaMFI O0 ?4 ..// ? Il ?; fSi.OAMAOf SPECLLL CODING EbF - v ?I ca $ u UNIT NO.IrRSr UNITN0.2 - ? YEHICLE ?PEDESTRIAN DgN[q's NgME: Insl MI IX Dq vFN srvAml ? PEDALCYCUST @ ?1' s : SrvffrnDD FSS t q, ' I4fE1 g004E55 UIY O ? F SlntE ZIPCODE HONE NO. D Iry P I ?3 _ SUIf f IP ? R ? dtt4 3`• DRNFR SU fN5E N0. Srntf f% Iv 4 U » i D"'?' ? ? HSE NO. 5fx rf OY614EN D*l ArE L i l , occuvgnoN rv PHOrvE Eris cnr IcHr E DccuvgnoN ? M NAMf S PNONf NO, a ? S w • , G t K GHI , F 5 sI R ?CHECK (? 'vEHCEFASaNEMPEV VFFaAPMiorHl¢s ?CHECK(? a CODES?' J a%u A ss1° S e r -1-1 AN lhWO_A AIgIHi o •ut " I rv y,? A?° . CODES ry .ES W' J n..R . s:9R "' s E H n ar .cn a R ?,. ?F 6 F dBrRD" MEMA t ? ycl ?brE. ? ? H ? u; N FAR MA%E IDODLECHEV.) f110MrNpvw) 51yIf IRDR CON reorp . " 4 1NFVI MODEL R.HOVgI YrIE y rwm ? E V) ' ?, v Oe tKENSEPUIE SIAIE AI- rE NO. EyIAtE H " vfH COLOR = . Il H ? ?? .I _ ?. WHIC RX-N T-NO. C tHICI DfNNi u I I 1 ? I ` v ' I r I I I N I ' eFWSIFPEOO N - ?.. - f4: U5 W I I I I NR$[ MIDDEf PHONE NO. O ISftq DOw"t R: EASE AI `? NRSE MICOtf N ? ^ 5 •` '._). S ?C t , . I] ADOR[SS OP gVM[4 w N[4 W --- ? 7 , ?1? E ??` NAMf I.." SUR NAHCfCO. Oq ACeH w '--? .? ? EE R ,) t o weD A4[A N • S _ ' r"wi CHADGV[N C GE V i [r0nN IIANAGIOMU E A S tl ^r?•4 P EU?OI10? 6AMA? ?A4WAV ?P[MUNED , • . T i ?y;. RS %%f l ! r ?A= ?REMANED 151 ?AMAGt r AOW"U NEA ?AWAIVSr VO?Oyfuii S AG FCFjElI ION- IuA A eH AI w $ f tt N . ' N O 1 . . ,? ,. .- 1( E 10 Eu ev AR ROV DESCRIPTIO_NOFCOtl.151ON: Iusf slronfM[HUt s»e[r rHlc[sss4rl 9i' LED ??r I I L _ilr EF?S_orP-o?!b'Tk_RE61?r- X - T2' 3 5 6 tU5 Nvl" _? R[SIR lvlCl ICY ^l MR. ?' ?M1 • ?N ?ia'-?Wl A I AMR ? ? . ? •r y ?iD (I A e ? I ? " ( ;F .? ? E or M > - '^tt' - -*?wxvw w,+??. ?? ,yr?l'{$pP?A?n?"-di' ?r72?.? ?21°- r l+?k, t? E ? 1 ? E I A '. , 2 ?%t - i?' ?; ?ti? ? ?a'? {' qv y a,??' i.,?`)'? t N'td? ? ; M r ??E?f?I ' or?r I I! i ri ^E;) r E f s I h )IA4. ,lr,. 11 f 4 I I _ ? 1 a y,C i4 y 1 ? { *',I ?y { r,, 71 V?j ? ? I) t .% I r E .,T? I t i - u?pd'? I wSV ISV IREV. Leal STATE OF WA, NGTON vAOE L OF III IniD TRAFFICWAY ' POLICE TRAFFIC COLLISION REPORT PoucfcamPlAM umE - i PRIVATE WAY _ LIP' P DA ED call _ .. D,IAr f cE>. - - .. uMf courvrr s t fi Sexx COUNTY NO. Clrvfq. fHwµ 1?. 'ui'1.x cr. If ix I •' I IDSE] ti0OU91 LO C1 / x.lx I 21 e o "'. ?? ?u ?N ?E ?>,N Crv091pwN C_ NO//?? 519fFTORHOHWAY iR/CU 90UIE OR/51 ?/) Cl?u ?V Mlf2 L ?W FC'f ?•?1w[L LE.E. ON_Sal.i+k lG',]i'Ll'F (/' ?¢?(OC INIERSf<NNOwItN51PFf10R ROAD NONINTFVSfCIION ? ? ?J f0. MIlEP05T /J BFRVFEE yC ?'-T sNRLFi ??? a c YvI'{?' K Efi TRlil% Or ?7 DISf-E .Rt ON I.OM9IILI . CROSSSIRfE10R Nfae- ILI Ig51 ACCIDENT 9AMP p1AORAM MIA - Ml[T 5 E ??JJ MILEAGE I•' ),.Co Ff" OF !d CODE _ C IDT OfI N IXVED Evt9rv. %.Rp R CD IRFE ORIggDO4 RFfF9ENCE fb Kll[D. tq. NIUR{D? SP EIAOE ?HIARUN ]] IOIM NO wwDMOiP N MFR Cl5 UOSSSIAEFTOR ROAD/ I__ CFV[H CSfS PROP[RTYD-EONEY ?p[SULIFp ?SFO1ClE w?/Ovf/ -ICT STRUCK INANE Of OeIECT STRUCK AND OWNE9 S NAME) [TI DANAOF SRFCIAL CODING TAE F S UNIT NO. 1 - UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST O41vER SN IAST H9T1 .9S E DR VfR 3NAMF. NST Nv ? ? M -- f R IRffi aDORfST IX I r. l ??e. StvFFT ADpF 5 ' ` V? Y' OIY E ZIR CODf ONE NO. D NY SIAIf IP RHONE ` Q?V IJxt ?i ;fib 9?-3C5'? R: DRNFR'S IICENSt O. SIAI! E Of H ( Iv UCtNSf .q. E OCCUPAtN)N f ePHONf NO. [Y[5 IGHi IE OHI E IXCUVg1ION fIRM NAME a PHONE NO. FY[5 WF OHI IEIGHI z i L.&C L.L Y t:4 ?3a G'e R CHECK afMiorHfR •L ? CHECK (?) I CA I aN (MNOVfE Of ANO1Hf R"E 'i - CODES tR? D n..s vEHC F.s?A ?rM^ S ` e i°w,°. CODES ? t s n.ss vEH ,..snMN' S ene N n +i ulaRrcu -n ES Q.).AJ °i ' K.cu , rO .NIY 5F1."D.,D voM ? .»•MAHCI ? N ? L2.rl. w:xl7 ? .u«:. o: ? AN ' ? mll ? Zg- ? UT:c3 ?..°1s.. ' VtH YEAS IWDOf CHtv.l MOD[tIDMr.NOVAI ISIYlf 1]D9.COrvv.1 N. EIR 1 HVI -L1DARI.NOVA 1 r 1 vl 10 C ?o T^L?? C??d2dCcc Z?r E H M A Ian IXOR IRAI(FRRAIENO. -.1 I'I v C OR Af is?. vEH 1-NI NCADON NO p Clf O NII11 II FGIS DOWNER. 1/Sr 51 MIDp[f NgMNO. It tD wN[R. LAS! NIT MILD- O ND. ??yt S !'?tivrlberL ADDRfST C•OWNIR W . Nf9 ]I ^' 22Q] l ?j 3e?I«rSc? pl_YCl-/?i ySIC N b NNAIe Ap II Dfww9ANC[CA a9 AO[NI E V N . ?., R 5"DE IN x D ARIA 4AMAOE a fu..cloH.l cHARU cHARU°tA"•ulo.°Ir S ?AW!tVN"?rucE.f?F. ?AWAt'+ ?REMAINfD !SY'DAMw°t tlOf ' °Y JVV Iov +DeY ?AWAY°eY. Y f. ' Ibi"orTe? T ] I 4ssARY er Ai9'?wO°'H DESCRIPTION OF COLLISION EusE SUn1 ENIU SHEET If NI DIIArT AGRAM O(F 'COLLISION: (?I lu _I_.. ?. .., - '}-??"j-i'?._i ?I-'? ._..?J?o.t?7?-t'`.__.?4-?<'1ti?4=E'1•i_]'.'C.?r,_l.lrty r.? TT L I _0 b?4 CL •• V.t' e rest C? T 1'O i J j. E.. 4. t. - - - o. ---- -- --` -- --- - I NAME ADDRESS BINJURIES OF PERSONS INVOLVED CODES I - 2 3 4 5 6 Ip CICCUPANTS/WITNESSES iovi u°r pwa."t'H a'iii -sex Tee urus '?,°1° -v ';' oisnnfa :e;. ;P N- IN • 2? t ZI NO o9EOr er ?5 ?^' . ?r.Y ?t?6N mhw s a' L ., fro Ex ... .. ...... .. .Me T !* .maSS _. - _ No or. __ .... 9 MovID IPOM If " r> I NANe M1 ? N NO O::" Oro.. ? C?: ? ": vs. i0 , I ? ?t?t??. ,f ern k rt ,' .Mal Jy . _. _ Nod lT°' __ s ENE°e. ?.Ne EI ?+, cl ? 7.,.'- ?'N'.T ? o:N.. e ? L 4 rf h? 1?'?P .slr S...NI S..... .DU O• Au.K. `tip. r:?.nc Eota±q. TED DAIT Of 9TroR1 vt°e o Ir ? XfC ?E r" ep ?° 2E U-Arp T 'l 1 ] b S )wl x?f ?r l ?, r , E [ T r ?xa I ? , b T ' I 1 '° I,? 7? F I 1 ' r,s ?J a ??, • w IE I I I ? ? ?, 1 f t ???Yrr?o??Yr??ttttt???wwEEEI?II???i a { r] STATE OF WA INGTON :: GE / Or / Nu, b POLICE TRAFFIC COLLISION REPORT ZRAFFICWAV iOEK[comrulNr N UM E ?$ PRIVATE WAY `.,? , _ .? p.1f OfCIXI?,Sf?'S?r v Qy 1 • A V / W u13./1 1 I - 1 UM! IUS[]WO MOUV? COUNTY I COUNTY CI SYNO. iMWA , '? 6°i -.'j'B` DN 01 N -yo Tow N 6N0 Of 319fFt09 »?GNw 3 f V9µ -6 0$ Ow DOr uF9seawc w+lN sl4m o4 ao ? .e1.F.°_J ON NONi . Y CICl3 RWif OR IRFF ION Ni[a5lCI ON BFM1VE[N R9Fri fO. MilE9J5r ''^^ 519ffi6 ?.SNCfM1paF ?_. DMRIS N°[Sa Nf 'C905s 314FF104 N[.4f3lMilf Sf4ffl ACCIOENr 9uA9 plAGan Dom pp" }' `+ .: r: .'..Ei... F -_ M V,. .. . kl3lfD??'q. iN]II4[D ? FMR C] NCI ,NN9wor.3 9aOR91Y DAMAGE ONLY ?1[D C]31IX IN T- ANp OWNf R'S NAM[, vFNKIf FSI. DAMAGE S R V E ? G F C r l 0,8,1_ 0 . °.rF Np1 a =OG F ifV., M IIID,.Rl.egv., I-P acO nv) ?X E ule sort r4u3FR turf w. VA1 H ?I/12171/I /!71 I ! I I c E R 6 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES I OCCUPANTS / WITNESSES MI R+ AG lAlp 'N v.l" iN? .....- __.__ Nrty wv1514A1tiOprKJ?lrwSwtEk.?W3 M1ApGf Oa AGINCv ,?.Wm q-'Fm CSt '-. ?'yX u fi ?nx n '. I i BRIM +J0. ,w , t I I ?„i fs?l m?`? r. a ?? E , 1 1 I 4 ` 1]"111 I 1 '?'?7 P( tly, - .F l I ? r ?? 1 V l Jl rr t F ?, x l1 ` 4 f. 4.j'?.,tl I l? i l 1 1 ?'? i S F h ?' 11 rs.,? 7 ? w , d 1`? ?h Y ,? 1 Iti It 10 I? S; r? r.. ....,...... ... .. ?,...r ..... ._, 1 E 5 , NO. t <TRAFFICWAY POLICE TRAFFIC COLLISION REPORT POl¢ECOMPwN eE . . a ? PRIVATE WAY _ A EI - .I ° _ i It.l lR. I OiC; LS N v.'V 'IU OIwaS.INN. ?.r R IUSFtp°NOUP ' 1 COV`Nt?y ^ -` V crT -",Iso ?E "7 `-- OIHWA RURAI t ?IN CIIV OR TOWN -E&NO Stefft Ox HIGHWAY ?N QF MllES ©a ?W SO, P6rtr NSA ON om s D «e- S ROlIif OA E ' pima tRSECTING VAIN. SIPfft OR PoPD rvONINTERSfCTION BEIWEFrv .Q 57REET{ PxlFIK F MILEPOST //JJ pp p(. ?O -ANCE {DIRfCtIONI M4EFfeN .CROSS STR[EtOx NfARE31 MIlf VOS Mn[s 5 E M ACCI NT MILEAGE RAM' Du--1A Ftlt OF DQ • S COKISIONINVOIVIDI ........ {{{{ 2 HnnRUN IOTAI NO NO KIIt(D NO.INIURFD? O svIfLAGE ? CODE wN orH N x CIF R oR ROAUOR RtR nca Mf CIS CRC655flfET oII O _? Sr E C VEHICLES Po PRR OAMPGF ONLY ? yE VEwIC -T1. 0 J ??63Jf ?Q (? OBIICi 51RUCK INANEOF OBIECTSIRUCKANBOWNER'5NM,EI FST.OA'nAGF SRCW CODING USf retcx]a s UNIT NO. I UNIT O.2 ? VEHICLE ? PEDESTRIAN O PEDALCYCLIST. ORN(R's NAMf? USr fIR51 MI ME rip- 1) RIVER'Srv- .11 ?fIRST- MI l -- SIP[ft ACD f5i r v ?0 ` IRlEr PDORF53 TY STAiE MOrvE NO. D I lAif f yG - R DRNER'S 4CEN5F rv0. - A £loP STAY ?1A4 f. A 'i IHY I v rv IICFN5FN0 . AI f 11 BIR1H A I DAr a OCCUPATIpE MNAME I-ENO. trt5 " IGHI HEIGHt E OCCUPATIO1 FIRM NAME 6 PHONE NO. EYES WEIGHT HEIGHT a I NM xJ SE R ? CHECK (? IMPliorfE OF AHOTHle? ? CHECK (F') EASAN riorEE AUM V ' CODES ? ] a 5 CODES ? 1 ] nis n , 5 1 6 a 91E5 M J dolro O PMN H I 0 u fE ,Kt ? C"&.- 4a 7,.Z; 01"865. DAA- STY RDR ONV f E ? NR . t 0 M", 06. 0 I RI NGVA H„YfARp w-- ,'.Z; 0 :.„5P. Y R V VEH, YEAR NAKt (DODGE.CHfVI 1 C 85 Su d? .. .I I( ) J L I aT Pu E I EV.1 MOD LDA I . .) P Y OR lIClrv UEN STATE AILER RATE NO. StAtf H vEH.caoR N I QI _ KHKIEIDINIIF-IONNO. I! 161 "! ! "-I /3l F'i=1 i vEHKIF IDfrv1IN I NI I I . I I I I COLt RFOISTFRfDOWNte: WI NP3I MI PHONENO. ( t4 uD, u -2n7P ADDxess fR O ISTf xtDOwNtR: tASi IIRS1 MID0.E ENO. A ONrv[e - LI ? N JJ jI, O LF 4 $i1La1 RON- EA)G^ wt E z AME{,DDRtssalNSURANCICO ORAGENI N l- AerLS w1 R .u AN n DAMAGED MIA u , ??oM i N<iiO D DAMAGlO wRfA I r ' c U , CHAV CHARGE r iu ' 1 IU iOnOii 1 DAMAOt t3T. ? Dw III ? ' .,-N'. A ? AW IIN ?.1-1D ? DAMAGf !SI I1OF IUiGT*aii 5 - ??•• ???? F l?pp ?n A LT -Al 11 W[D ,V 6Y. S DIAGRAM OF COLLISION ? I. R 35AAx1 I {CA qI NPo '.. i { f --r _ 7 ? i t r f t ? l DESCRIPTION 1ust t SwREME LSE'enFNtcfssA1 wOF COLLISION: ?lsi "L ECS__TF1a ?p?t?RO _06T,, +A 0_tn NCC?IYA R _. Rw+r tborLCn ,EJ_ CUB Pa 0_ k'?l, 1 ._ 4 } ------ L'RaSS.D_ Mn_.Ca»octlwG._.t 1 //?, F_! f ! ..-f_ ! I 'Nc w g SW- Dh 'Ili VeN,t.Jc_G?r? R .r t J '1U Ma T F 1 ?4 I i ?? ._ _ R _ ? I f ? ? u. ?_ ,Pt, I a.l a_ ucl?.SlOc NO.._ Vlsletc_ p + i 1 4 t ? ? ? ?Yl4?v? IShI?N .AOWSOry Si6FJ . l0_1h tst- / - .. ... .__ I I I? I l l r l i l I I I I. NAME. ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES I - 2 9 4 5 6 OCCUPANTS /WITNESSES fo-"OOe:inui ii _ nw - °A,- -n:) nvR fT n' NAVE D CUL F N ?-rZ]70 _ .x.na d- L , a Ax R. "? f ?'? e.R"E.. ? ,M e ? M, ? 0 vn, r. N AMl ? r• / nrvras P 0.." ?w? N•v Axe p N ANI •6DNa wls w°{r MD,MB UI. ?"m' .?H ?:" • • L.ru.G O'I KIE1hAMt t.ANt BADADf?OR AGINCr SPPIC?IL KI IIVtO PAII OI RIFet .OVI v l nI/ P?_ AP ?NY131 / ?AJ.G-? La-,p P q " 9 M??Eiui?E'?M LI E I W J ? 5 ? d Y a• .. 4 vA 1. . P ?- .ln.. ,. ,..: - oN°'f'°^' 1Nf IIF/5}'?.tM? j ryy 1Y IPl'I kIT P ftY (?vj^I*f.A)]?li ?. 4 1 .? YTX LY t J V I I Ix?^C? I 1 1 )1?1?I,? , , _. ?? I}f 1 5 4 {h ) ? ,L ? 1 I' rt 4 y;j i I 1 t S (, 1 7 I J IS?a?]I I L.T IT ) 1 T ?Ii^ ?r - -rv T , l 1 ? i T I '. Ott' l }+ bm" 1 % - F ??h air ti z,w I„4,??? ? `? ? ? r - ? ? , i ? ? ?,_i .. .. .., _... ,, ._ ''?., .. _ I \Z-- J POLICE TRAFFIC C'MON REPORT "TRARSICVw / C ?? UM9 PRN AT WAY al I _._.. _ D i TIME ?. i fjJ i .I nlo.i ?[?r 1 mNOURI WUNIY rq CIfY NO. Fl- ?UR ON ry crtr o4lowN qM ! OIrv F6W OiSTPtfIOq H G / URA( . I HWAY 5 F0 [t RWiF OR SIRE C Mus 0 / F ON D y IMI95FCl NG wTTn:-Ill OP WAD ............ ON -5P/87Q : ? l B[TYfkN Y SIREFr 6 1J?T $1PUT rON IROM DIS ANCI6DR[< eEIFS NCf. CROS53TRIEl OR Nfa9F51Mr1t P05 c PPEIN, I MRC-1 p / ? I . n(5 5 E W I[n of 0 a NT A[['DENT MILEAGE CODE A RAM pAtA - - COln9rON INVIXVFD. S[vFRnv: SPgjAGF ? NO.INIUR[D TOIAINp OKgIFD nn 6q U y? q rv IN -RD R ORRLFER(N0 q as _ p VlHIClFS m p PRORRl-A.I.NIY O gyUlllD ? OB1tC1$IRIKKINMAf 0[09110 11R-ANDOWNlR'S-0 vl? ? c? y d iC f ESr DAMACf IMf CIS CRf355STP(ROR R/OAD 47COD ' SRCIAI COD ?- . f? ING IEf 3 UNIT NO.1 Denke's Namt. MI IXf UNIT NO.2 OVEHIQE PEDESTRIAN PEDALCVCtIT 0 C $T a• 'D• DPIVe4s NAME. UST r1 IX -- 514[!1 ADO4ISS 00 94 ST4lFIADOR[SS o )DID T? .V.w. CITY f ZIP CODE PHO D Nt NO. W19 R Y Tgrf IPC rvf l ? DVrvt4's 4CFN NO. LOS, L??DER 51A1F x M eI n poi R. I V I-11C NSf NO. IATf SEx DA11191Rin MD I N. Ir. 9 OCCUPATION R E 6 PHON! NO. EYES W(IGNI 11"T E OCCUPATION IIRM NAM[ 6 P+gNF NO. EYES N41GH1 HIG 0 CHECK NEYrJ 11JY L4 b I YI AI b R HI (, v1HICl[.snN fMPi r[ioF.HOTHlP: CODE$ Y* 7 5 I w 4 o Da.c +,T 0CHECK(,,) v[NIae ASAN VAPioYOACQM1N[eAI CODES ? T 3 iii 5 urnlox • 4CQ Z o i ° pb« (, a e ?° r «eM i 0 0 N Kf IDODGFCHFY.1 , 0 E >n. s ? vIN MODFI IDAe1?NOVAI eIYR NDR.CONV o ?o,w« C] « G + ? zs:nR ? K H V ur Ktr o ° 1. ^A /v V, .I cG E . Yfgg I Hfvq MODEL IDA9LNOVA) -9 U CtNSE VIATfN STAY Anfq RATE NO. S1AIf H vfH. coloR + l H ( NO. A VINICIE 1IXNIIlICAIION NO. L vfHClf laNn r A 40 i i03 410 RFWSR9FDOYM[e 45t U lIRSt MIDDLE PHONE NO. I RtD WN[9: !Ail FIRST MIDIXL NO. AD09lSSp OwN[q W A vmfR M N E NAM-DDR-OFINSU9aNCLCO. OPAG[NI E D AREA .A . R ....... .I-ANCTOO-A-1- v i?o N c.-Of CHAR.[ w?tprDiN I?AM.OlD AR[A e Ell ?Jp//A(SM/?AL(Gi $)2 TOVrtD RIMNNED ' ^wAV ORtA(AIN[D IDWID tS?DAMAGt e lOr _ loeonor, ^ Y ? AWAY er f .--. e DIAGRAM OF COLLISION: ID w l T TH siFav Nev:1a pW DESCRIPTIONOFCOLUSION: _ IUS[SIgR[MFMAtSH[I If MCLSSARrI NR?GJ7• ^J VL Y - .. E-?, I I - NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED l CODES 1 2 J 4 5 6 N OCCUPANTS /WITNESSES ia wowoa:i i?Y?i? .«r 'ii poi T.7_D '.."l N•r -P';? R isTR- _ncT "P; r ». 0AM e0 r0 OI" ? P 1 rH R!ro o ? wM II4o«DAM. OuO?N ?i:` n N •? +.cc l?rv sNA«1 u.+r e•cw GV .ur srr?n e+ Oahe ?. x m .r. .c. s.O ., 3 ¢x?a .n.. r„n A94 c_ ?F7D C?7yiS wnpgE'W n vLD e. A Den 1111- '41 x t2& 1. .! ?? I - / A t ; ? ? ' Y ' " I . 1+ J 1 t l T l EAfr. ! .l ..}.. 'fY? n xa@ le 1 1t ! ;1? Y1I 4f J 1 f ^ ?, T tY1 i f Y 1 Lh'?Y,INF ti .N T l maw ;-T l^rm? I I , f 1R' I T ' r i E! , F E d t 7 STATE Or wASHWGTON / WS ISR,REV.LBO, '. G L1 1 GE DE TRAFefCW FEY I No. . POLICE TRAFFIC CO N REPORT rotlc w Met 2. PRIVATE WAY 4/1 Z f .Ol? I s?jllWmf OUR couMV ip"` w. ?Nl,vlc n ,,. ul ! X73 0 I Fr/C s'OI?I S COVN r/yl??? ntt NO. fL' rlrv.•n ?uRenl N ?ry OE CIlY OR 10WN AME6NO.Oi elRlft OV HIGHWAY 3 / Mnes s pw or j?fflNSr D ON C o f'? RWtE OR Cll NIFRSFCIING VAIM SWtEl OR AD NONIMERS(C110N ?E REM'f[NM Q Sra[Fr 6 /r? STRE.I PREfIx t /(pD 3 DI IM ERDRt ION MRfiFRtN .CRO5551Rtfl OR NEARFSi MIIE .41 ME,T" 5 E w Or /";o ACCIDENT MILEAG D AMP IOIAL NVavm- ERl cou NO. ,. LIED?NO INJURED- ?SPRIAGf ?N16 RUN IOIAL NO I„NRnOrv w IMFR Cl5 Irlc Rft asv,.u oR CCr,RENa Ca O'SSmF R O VvOM Da _ . Ca VfNICEfs IROKRTY DAMAGE ONLY ?Y[SUl1ED ?VfpCIE .y // ?? Oel[C15rRUC%INANf Or OexCr siRUC%AND OWNlP'S NNAE) ESI.DAMAG[ 5 5R[C COdNG USE -' ' UNIT NO. I UNIT NO.2 ?.VEHICLE ? PEDESTRIAN 0 PEDALCYCLIST _. DRWEa's NIRME: wsr sl M3.1 DaweRs NAMe wu tE US (= oTF Fi4FY F 51REEIADDRESS L e SERttr ADDRESS '7- 5 ME ONF NO SEDL r D ,tY lA f IP N i ?w lsr a E.fJl1- g83C•? 3$S'oq?? R EI rz Ev'S UCENeIN /`7/ONSFdF3 P4 51AtE % w rA j8 1 N ;2V 7O I V IV 'SU NEENO. AF OA1EOr BRN AY OCCUPATION A/A 6RHONE NO. EYES IGHI IEIGNr E OCCUP,rION IIRM NM1te'P110NEN0 IE , [YF5 w[IGHI - ?2 YGOFrV CdRNEIQES7?nJQ Rv I?5 7 R CHECK (.? vEN,E,r,s:N rmPiov lA A,miorNIRIA` ? CHECK(,? ENInf AS AN VAPiorlf or ANOrNEIiAI CODES ?' 3 s E e CODES ? * O 5 Lx a 2- wn drts S tF .ji ' DM p M N A Kl ? MCI ? EdmR ? KS ? a?Y. ? MRM,N I ? n?v X u° " ? E8m. ? <,I ? ,,"R. - VEN YUa MutIDODGE.cNFV.I ?o T?y077} g ,IDARr.NOVAJ Sl IxDR..c-' T?/QCZ, yVQ S".,; E UR 1 FV.1 NOIXIIDnRr.NOVx 1 Y I °?' De 1J at l R u 963 SrniE iawllfR RAtf NO. SlAll wf} H I Vf N. IX 4 VENKIf IDFMIfIUtgN NO. 2A 8 2L, X 3 L 3 3 7 i v [NIGIE IpEMI A N RIGISRa[DONNtP: Wt oast MIDDY S NNEy N PrgN[NO. O RR WN[R: DMt oast MIDMF ENO. ? . W S r nooRlssa D+mtR E ex NAMfEADDRt330r INSURAN?rC-E CO. oa-1 W U foM.ACE M[,' ' yS4 G?.O . ', g,mAUDAau cNAecxSPdM 7D I:faT d _ _ cNARGE ??n mo . S Es?IMMAee Awl^: ? Xe1MWryto o' 1 wvvfry tsl.a ce t ? wnr ?e[AUIry[o - AItO,Op M+DeY 0 ?towEDeY f. DIAGRAM OF COUISION: Iu s:?RioNOOM•r" DESC RIPTI ON OF COLLISION; (IasF S.K-N-s 11 lr MaSSARYI _ _ <t 1TGL I€?nuZN_B.a•ENJ_?1'.S2e?2€D S PFt•e r F _ S >".3H?QeE?,v.Da_N?___?} s.,, nos ro ??- _ AEin ?d-Fig D'ri.41,AYJ_ 40 _ DE?iveEl_s.5'7hTC,0 vtA.s.T1PYtN_G _71J?dy_O.N- _ _ _ ?4F?2-(!. wJ??ef,v w,'PFiy-_,gNJ?LRUr_f ew?a ? - - ?SJfo?W.EiQ,_l?F/ire STifn7n'O-2v s'/t_[D ? _. -- - - - _ I - _ ._.. _. .o lam! h---r P_P_nok I rT rtRY !o _P_U1tN w._Qnur ySd__/Le t C.w?y_EdLS _? S_F?!? _ P/e[N??? ±? TI°_ ,'._ J_f? . D.?n.eloy_?e?:,r_.G-O?? Td Sl1C vROdx_ F?/Y . G F tT RZrove' /PCr„LEJ L- OunJ 70luJV ABM ?, F NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED * CODES 1 - 2 3 4 5 6 OCCUPANTS/ WITNESSES I-$--A-- 1 _ sir 'TGI umi v:r 7! MI. 'foc' :lE;•, NAMI 0 EJ v u Lr7 S p F :a F. 2. l 113 1 1 11 9 _. _ .. . ? 'N U-7, ? AM e (] 'Mcl O w, , n ? Nw' ? ,u:?v NAMI R, v •" Moll- I --_ ._ No _ . _.. - ___ _ ... _._. AUMtn N•rEn?Dr _. _.. __--. Nxw f i ee. AMe O,.. cl 0r.,r?t. ?". 0 ~^ i"V vlf,x.Al X .+ W rKl r D ? G? A.•IN:• wsP •,:, 3' R?? ?,yCMD 2 S ? Ryles Rji D a J DAN'?d •I K?!1 Cr fF. AH OvlDly ?? M1 •xn 1 m 1 1 1 f ?? r 5 STATE OF WAS GTOPV I OF w5P1%,4EV.LBO, .91 Q W; s t POLICE TRAFFIC COLLI:.FON REPORT (Z ,-,?Cw6u iVpCE GGmaAINI BI 4 9 4 9 PRIVATE WAY R' ITATEO oursro ....._ co N_ .. r. uar' S'. ?, Ir (USf .OO rfOU91 C OUNTY / couNrv rp. arr rvo. Frtw. I ?? O ' 1 ?N ! ? pU µ RAl '? p { CI1v0 OwN Fev0.0 SI4EF1OR nIGNWAV N ? ? ' GS R(:UIf OR I SEC M llS IQs p moo ON E (- N'T"Ictll.-ST4fEt OR UOn0 NONIN1Ej5F[IpI E ?n :') ?GL390 ey.-ND` I•IV ••J '-G ?'Jr•7f' R4ff% VU-T ?J ] BETWEEN "Y S'SIT'. STREET p51ANCFeD4Ft1 NiROM4fifRU?CF CROSSSIREEIOR NFA.ESI-E40s1 I ACCIDENT I, L'S s E w p Kn „/..'rO MC ODE E iVE N OF -P LU RAM-A - - COIL;ONNVOLEO? O[4ED_N0. INJURED--L QSGIIIAG ? OTAI NO to RUN ? pp{p ua- F N CIE E44hh 3311 Ci vEn CEFS P40KRrr DAMAGEONIY ?vESUItFD QSfa OB1fCt STRUCK INA[AF OF 011E STRUCK AND OWNERSNAMfI IN S1 ORROAp OR RUfRENCE IMFR CIS CRO]SSTp/?IROAD T/G (//1 I]] q Sr D4 AGF SP CAL COOING USE 3 UNIT NO. 1 UNIT NZ. I D4NF45 NAME: IASf Q VEHICLE ? PEDESTRIAN ? PEDALCYCl15T N45T 10DLF ?WE EJ•pI S 1 pRI ER'SNAME'. C? - _- 5TREf t-RE555 SIRIEI AODRESs V? 444 E "PC.. -NE NO. D I P STATE 37(. )y pRrvERs cfNSENO n StArE D R 1 C DE N IZ G -hyl 9J ?? .1R n 1 ? Iv I ( p v LICENSE NO. 1AtE F% t 00 I OCCUPAT NAMf 6 PrlO N { f GNI FF Gnl E OCCUPAI ON iIRM NAME 6 PIgNf NO Fvfs N41GNt Gnr Z CLC E / H aN I R Q --CK(El) cLf AS ANimaorFE OF Ar?ornFR l Q CHECK(?) EN CI[.s AN FinaovEE OF N 1nErtAl A CODES ?* r 5 rEaIoN A .ro'DPC.c? • i•ss TI .crcE o io CODES ?* S N G "' ET N :ss i± I n 2 luc os rt u . ! ;. DM meW r p C-V" ? 8'.,r. ? : 1' ? Tu E IDODGE CNfv ) f OAR1.NOVA STYEE D9 C Q M l Cl M", ? 181 6. „ ? T:XT :° TI . T 0 OW I 19?? TDy GU Up E n V.I V IDARl1 VAT Y R MOMI I V I °l Al-ATENO. STAIE STATE H v n cao4 1 u'Di5F11TFi72f- R N ro LV - - I V[n CIE Cf.111c.i-NO. 1I 191 I I ! ` C F v[nICLF10EN11EI N -- I i l l I I I T b tG15RR100wNER VSI IRS, MIDDLE a.ONE NO. s ME - O 114FD 14: IASI IRS, - AR E,t.{ 11411sar owNl W A WNi4 ]. L M N E NAME E ADO4155 I INSURANCE CO OR AGINI N 0 w,V R A TL4 INSURANCE CO DAmwf ARU O,U A.E I DAMA AREA »"b?N cNARU µ ]`w? E CnARGE !St DA.WAGE rT ;41EyN 4[m.me0 D4rvEN RUTAIMD EST .-A.1 ? AwAr ? lamrtD 00 l?J IOw1D iOweD SLJ(?p ,,,L] 10 - : BV ? eY , w•. Aw r DIAGRAM Of COLLISION 1 NDCArt N141n -r-TT " - ill NlGSSAR .--) "A"SO, RIPTION Of COILIlION Iu5[SU4a[m1N1.411111IM[ESSARYI t V 1 v95 cS4 8ou,Ua aN 1 r??ic : w. 21 ? < 6?J6- w ? _ ._ < fi i ?.a ( I I . _ __: :_ ; 1 a 77?E 1Q09?9?f 4i? FF ?}1E ' E Q?. + In r O W6M _%? _ . 140 WE ov -- . ELY /_C:vfn'waCP7D AOLL., 0D9?NE - -v 67 - ADDRESS INJURIES OF PERSONS INVOLVED ' CODES I 7 J 4 5 6 OCCUPANTS / WITNESSES -` Aa r.rus - uo '" r -_.__._ wc+ nvR rxcl 11 •m e A M] Mr RI Dr a0YlDr. ? Q 01P.11. Q T ?x Y Ame r A ?jM?I?,.1 mQ.Me p?. II ? ;,:, ? :?,-' '+n Hhp•,,? - .h. e.OGr O. AA YC ...... a?l /7" /ll? 1 P fdaTNl .f.1OYID?' p•TI ' C?tO °SeW?P 83 M_f, ?n.S D q QT ) v t,I 1 I 1 .. t I ? .C ?p 1 9C' v I : r T 1 rI ? Y I 1 E t E r?, r I ? ti Y' rb ll A kN ? Sy a POLICE TRAFFIC COLLISION REPORT IN TRAFFICWAV RIXICFCdAMININUMOEv 2 PRIVATE WAY DAppFCOLtS N 3 ?. S t,ME (USE]WDNOURI w COUNTY O COUNTY NO, ?? arv NO. rowN N. ohsrREEroRncnw.r ?N OE E]w c,rv o . as 1 3 I'D '0 23 MtfS QRS ?w ®°f o 3 ECirNG WITn. vFEi C9 ROAD NON INtfRTSECtiON BFIWFf Ffl 6 StR[fi RRW% Mll f . E ? ANCE lo-TIONF [REN E. CROSSSTRFt10R NEAR„ 1Ff05 F[Fr5 5 f w? Gh O D sp 14 ACCIDENT MILEAGE CODE v DIA RAM WFA COED A NVIXVI° 50. RIIED Ll ie4U NO.IN,URED? ? Sv,IIAGF ??' N ruNRttorrr N INFER CIS 11 N R 11=1 I cl. L TOT ? r0t•N0 (<vFniCLB m ? hRORERfY DAMAGE ONLY ? VFSUItEp ? v[?iCIF I r q OBJECT 5r4UC1 INAME OFOB,ECT ST-1 ANDOINER'5 NAMEI ESTDAMAGE SfFCUI COOING USE - UNIT NO.I UNIT NO.2 0VEHICLE ?PEDESTRIAN ?PEDALCYCLIST 21 ml l 1 t DURESS 2 C SrAif Z,vCOD vnONE NO D r 5 AIF -CODE x NE t y 7=usu,?, Wick, p -r _ R DRI INSt NO. f SIATf Sf% DA 91 n w UCENS O. VAT 11 ATEOhe1R n ° c_TJVTP G- 2 PIT 71 RAr ! V I 1 6 OCCUVADpf mNAMF6vnONf NO. (YES wEIGnt 1{IGnt E GCCURATION gME6 vNpNE NO. EYES YIEIGnt ,flGnt ?• z I R CHECK(,') AuorN[eAt OCHECK I?) CiE ASANEmviorf[o ro A n '' CODES ? ] n 5 1 6F"•°,ir°v°Cf1L. C S • a •SR roN CODES ? 7 u" .s 5 r y3MO t iii snr•• N ANnCrCI . F> z • m f as' ? • ? ncl b A ? v ? A M" c& ? ? v cR v[n r[A4 AN%fIWDGECNfV.I ELIDAR-VAT -kEI2D4..CONVI ( D V 1 n rFAR n V.l m00[ll RI.NOVAI vom ' E = x t L-NSE VLAI[ 111 AIttR RATE NO. SlATf H R All A A FN. Y XAROC) c : ?Y ',? v[nIal DENTNCANQNNO. IS R?F? i ? I I I I ` vfn CLf lDfNt r I N I I I I I I I i l ? Rfe?srtRlDOwNE4 IASi NRSr mlDwe RnoNt NO. ? W R ,rtxf ownw: usr FIRV e N Il AUp4fSSp Ow+,lR jwNjq 2 E &ADD;r INSURANCICO OR ACENr Jh1 R 7""- , l] EArr Q A ,U V - •/nAGI AvfA ?•••• I?AMAG 'ARU ?ur?tepiN CNARU D? CNARG a iiOwE 3 r .a 3 l3r. D UAMAGt 09lMAIN[D 0AwA;N ?RIMAINED III OAMAGF Rtp G!0 0 tOMD • ., 0 M f 3 E v R DIAGRAM OF COLLI_SI + IC _ riwEru Nleissi.R 1 -1-11,W11 DESCRIPTION OF COLLISION (IAf sw e l TAL SMErF FC-Rr?) OAi ?7CxfTKPa TjirC 1.. ! ' I/E1J,_ L CtJF7S ApR7h(BOU! D - I I? . , I . V56R4W_ ONTa._T7i? '01 G 77V WUND r k1U MIS TF1EJv A . , .. , -. - ,. TH& eA4BANKMVv-r. CN...7f/E. sOf.(7Y18G.1? E,f.»E.j , .. .. . , _ ' AA/b S UAJ A MAJD_ CCAAZJLJG• 70RE$T Uw-rq 'Me I . ;.. ... /C .. NE. T.rr CND 7? TEJp-. 30"TH80UN,p __ De . "--- ... x=?p STET-E o aE was R?cusNe Forte a . . 6ETTE WHEN_ HE. VEERFA_ OFh_.TyE ROAD _GA ANo E e C RR T ( - rOV r EC .O &D CAUSCr. HZS VEr f If NAME, ADDRESS 8INJURIES OF PERSONS I NVOLVED CODES L - 2 3 4 5 6 I sI sungMFNru Sn OCCUPANTS WITNESSES ,OR ADD.-—NAME nT S•. iu '.of Tsius'N;F" R ise i,fa wa „ NF ? Np Rea U4.Y ?•Me 0EY.°E ? " . 0 ? %X w ME ApDRES•. URIM 5,L 41veD,rOM O.Vl1 ?". [r 0" •0?i ?ri° p NO v R v S A 1 Y O . f } v wo moo wSV r5v I4[v. I.IwI STATE OF WAS-HINGTON RAGE j Gr j Inl R TRAFFIC COLLrdfl'cTN REPORT W TRAFFICWAY) ,,,..POLICE ». _ 1 NUMBER x•3'1 ! ?' PRIVATE WAY tt orcqu rorv DA u?v?oN 1'ME couNrr ? n e .u. .n lu Iv I r yl IUSf ).OD rvOU41 COVNrY Np. CITY NO. rU4 fff1??'?{ - ? BAN '? ?N ?W °Of Clrr OV lOwr, OOSiRffr09 MGNWAr MIES ?s ON C L r I n4ssctlrvc vnlNslRlfl oR wAD NoN INtFVS(c•' rR l5 r!7 % ROUlF 04 J1 C %GLd?IJ J 11 ] a1n w. ff.. BFtWFFNT/•/vRHQ1n2 Si9fFll Jv'1 O EI Fo. Mnf POSr 7 9O / Dri NC16D'9t?rlON rxOrn REf ExINCF CvO155rv1f10P Nf neEJt Vltle J ACCIDENT / x5 I v 4 DIAGRAM MtA /C rFFI ? ? D P MILEAGE CODE I COIVSIONINVgvFD- J[vlrlV[D x? NO IN,VU(0 C ? SvrtiAGF ?MiB4UN + rOIAI NU 3.1- =P IN SfRING St f10R gOAp 09 RPER[NCf N IMfR Cl5 C405551DEflOR ROAD )] av(Nlcus Q,.[]4xoRf4IrDAMACrorvI" - ?o?sunm ?vi°ilai CBRCI SiRUCVINAMt O.OBIlR SIeUf. •NDOWNt4'J wHf• ' i//B70 / f51 AGF SvECIAI CODING USt UNIT NO. I UNITNO.4 eIV(R'J NAME NSr r' ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST -vCJ?r Mi Dlt rvIR SNPMF' NSl rIR MOW Y StvfftADD E (3o t yr E• .Qr " wDAI nP C D JI9EFI ADDRFJS OIX N^?lo. c r salt :I4 coot NF r+o. DRIVERSIICiNSF NO. JIAIf E Al OrB4IN I Iv95ICENSf NO S1AIF B occu4ATI01 rMrvAMEIRNOrvENO E.ts wflcIt MIGNI E occuPATZN IIRI NPMf 6 PHONE NO. Fr[3 wFIGNI NEIGNi R ° CHECK W) 'vrN CiI.RS:rifMno Avo"INiv°` ? CHECK I?) AvA A 1?4 CODES 10 ] "' S I ?. j D s r, 73 GrEE CODES ? ' ] ii «A 5 II, 6 .p u (4D n IN, w pA M . ,.. l ? ^ IDODGf c.1V . Dl? AY1 ' E) : ? r n+0 tC Ira l)pe CO ? ? D.II. ., o ? ED rt..R MA4f DGC<nEVI -11 DAI-11A 'i E H 1 , -1 N. WA rt 1 F All vEMRFlgrvnrlunoN NO. S/ 72 R cl - L wlcu lgNll lull NN Y b xrolsnwoowntx fAV r14st wpolE QM r A PrwNE NO f rsnxfD wNix. lnsr n4s1 MIDmE N No I] ADD111 OWNl4 N OwN19 ]I L E NOME A ADD— a INSURANCt CO Qo AGFN1 I u wN A -r C ST Tc ALl 0 DAMAG?DIVI(A M G »' r -= = •;?•. • r or„ ?'µ . r L O,AaG(, wa'd`., o u gAMAGE)D AREA I ] x Is DAN;41 vrvlN 4(AU.,tn ? ?:wAVN ?4tMAINIn [.r mDwaACf 1 ?J TO w::°,r ' r A ?"w:f S -? Il DIAGRAM OF COUISION. u , A iwnlr racess:Rrl By AOOO°.vRlrv OL DESCRIPTION OF COLLISION: lust suvv11M1N1Af 3Mrrn NFC[ssARrl .1T6 c.1 Yvc ri-J6 n2,L, A=(? v4.`? /V, r5o•./vo orF Cnyea° ?c.aa. ..•ar(-nn V?JS D;Si?.1.•c?•<a'? Lij A FNi c•'¢,INE 'YN c? °. iC?c"r+, rl r?oti , THr L'C'!?!• CB?' Orr•To Tr-J Ai Sa•J'j` 0"JnA-,P, r/D/?C AMO /jrdp • CVt-vTo ARA, ADDRESS 8 INJURIES OF PERSONS k NVOLVED CODE 2 5 6 NTS/WITNESSES G ° AA IS ° rri ? iiiA ?? n A I ? ti+:ryt ? ? ~ , I I ;. BA(v u?1rKr r7' <. r a ,SI (;iJxA-CMD KlI ^ •elxvip DAII (w xI PD41 Ar ?T DArI POLICE TRAFFIC COLLA !REPORT xTRAFF4VA'6r'. , p?ICFC .. IN - PRIVATE AA,4.•'I i Olu N q f lL N i1ME COUNTY " V , •_.•,.. D? • x,x[.. rxli, w rN. s (USf ]KO HOU9i _ •I ^ - COUNt CITY HWA BUR URAI ` { W N pt 0IN CIIYOR NO. Oi SiRff10R IGNWAY N ?Ef O N 45 gWIf OR MR(5 S OW G l> ON ¢Q390 ^? 1M( CIING WI1H. SlvFEt09 AD MEfI% MItf POST BFTWF[N 51RF[1 S .4R St9f[1 51A 4 0 [ / 1 N FSD? FM1pNE OMV[{FVFNCf.CR05531RtF10R NFARE51 MllEPOS ACCIDENT 4I5 5 ! / MILEAGE "ET W 0[ / CODE 4NM DIAGRAM DAfA NO 411lFD?NO INJ 1D-1 ?SV11lAGF ?HN6RUN Iut01Al NO V ?r f Yp TJ'??0."" N IN RROgD OiFR IMFR CIS OI ]S 1 N CY VEHKlES • J ? PROMR1Y pAMAG(O 1(• ? pESUIiFD ? VEaCI F ?. CB11C1SIRIK%INM1 OB1tC1 SIRUC%AND OWNFR'I NAMEI FSI AGE ?"?O L? SvEGR4 CODR9G IAf - UNIT NO. I UNITNO. 2 ? VEHICLE El PEDESTRIAN ? PEDALCYCLIST 3 RIVIR'Sti UST 11951 IDOI . / 91vf93NM1F: N51-$r? 1 l % ' f' 5T9F[I wp 55 /xC? ".??/ IVY/, SiRfEt AppRE53 Z CODt c p9rv R'S pCEN E NO D R Cl Y SIAIf t1P CO PErONF NO. ` S Iwif ' 7 /- /, ?? ('(J [% '? Bl N I V 1VF uCENSl NO AIE Sf% DAll Of BI91, Ar rv Ir vA- MNAME f1-1 rA s WEIGNI NFIGNI u f E OCCUVAl10N MNANff vNONF NO EY[S WEIGHT HIGNI Z ?LA)r J / R (] CHECK(,) yENlclEws v-N-C -Wl- I ? CMECK (?) vNnclE AS AN [MPiorE[of w"olr"faAl ' CODES 3." 5 r rc 6,",°I?? °c` I ?? CODES * ] «I 5 rn A ,"'." ` UcIFS / .fI ° x& n"Cr ? 9E IDOWIV , a ? 1841. O K 2S ? IMl- IDwRl?fgvA1 SIYIEIRDR CONV M11 O ? g' ? 8,1- ? v1 ? 1:° Y 9 lf N _ . v uCFNSFPN . .1 Siwtf t A , H I HV.) MODEI Ip-I-AI Yl l .) - ?? Q 4 e(R0.AIENO -IL Vt R ,(FIE l NO. Af //L ((? C x HH1CEf IIXNNEICw1gN NO 5`T91 I I L VEHICff I NSIN w I I N I l i l l l l • I 9(Gl RtDOwNFe U51 451 DDIF PHONE NO. f bCkLk?r O Ymf9: 1A51 rI43t MIDIXE u ADDRlssaovml9 W N [e ' :71' ?/ 19? E , AMIf ADDeESSp IN5U9-lCO 09 AO[M R NDAN . oAMAC Ar I P- YM cHARG( CHARD pAMAGfDMN ' I Tit IMMwL ? ^v+:vN 01-INID • ?AN'?? [DI,I-IID FS UAM f s 10! 1O• flD L: 0'20-1. s .Ww A DIAGRAM OF ----f ION_:r -,SlDwfly( Fss.pYE f pc 4 TH DESCRIPTION OF COLL151?0NL /?lus[suPIPU,MtNUeI SNEtTI?E nE[FSSAe 1 /f ??7?1C T 1'-.i- I r ?- r ? ; . f i + i..?- 0 ?E__L7? VGi'I,f ? W1?V (SOUr'1-,`OLK7./, ?.U. .l.E..f!?S.L - I I ... Rc.tu ?ll,? m1? z, ?E_ ,l ?GcJhF? .. d, _ TJ?J O/Johou ?. , oizcr ( h • I uTB JI?e I L, . + r I I Et2tJl CIJ?t [X ?,?O._ aSB CO? G hSt?iziLl?? G `-'. I ?c _ ?.Q - TTn 1 St?G?'?ya c? f -.4& 7o Fop lvfi _ I 1 [?+ NAME, ADDRESS 8 INJURIES OF PERSONS I l l " H S w 1 M t NVOLVED ' COD I - 2 4' 5 6 OCCUPANTS/WITNESSES io f i:iu a AD D?I o i, r u s? \!-.•' .? s(f Au unn '",`,'" R•; nr9 utn «IC. „MI AIJCII , I?Ep •U 3`Id0 NO a/OS . l+lwiss z CUR[ S AMS O. .O."f 0.2.,1 . EAU, E., R pr :; e }ID19DM ?,."l o<~MN9 o a o i A W-1 NIOr ti ll!Mygr 1X ?AMB ?< r ?rv+n . ?Nw ? + ?( ?.'??.. f.yp•y..T.... f D'?'E.o = q .1.? ? • yyn n.n n aroal DAn x - - ? TR 140. 9 e, n AV POLICE TRAFFIC COLLIS ON REPORT KECOMq,UNiN IT r E] PRIVATE WAY_) y ' }' .; DAIf Or<IXU N 3 2. g DAr I N DMF r,0x surf xrD Irun rr IUSEDVDO NOURI 20 goo COUNTY -' a COUNTY N1O_. [ItY W. W rNWA ?URpA El .1REETOR-1- ?N ?t ? IN NflahfaaM N rv Of5 fCT QSS R aW iE a, . v f Or 0 E 19-S ON 1 '' / '? ?39? ? p_` - ' INif 5[UIN(E OR M, F1 NON INTEPSFUNDN BETWEEN SMILE 8 AZU ?/ SILIEt PREfI% E MaE IbST ?B i ,5 ,"'ANCElDIafC11 iPONa NeF .CWSSS1vtf10aN ARES,mIIF fE'S N 5 f W ACCIDENr MILEAGE RNAP III - JET - / Or /- CODE ' t CIXUSpN NVIXVED: '. Slv[RIIY. ?HIIIRUN TO,Al NO ffO KLLIfD?N01NEURED ? SPRLAGE m rsrN I D K IMfa W n tREETOe ROAD OfOS3 D ?PRORRn DAMAGE ONLY (YV-clIS O Yf?Ei- ? FNCIF u x '9 OplfGt SIPUC[INAMEOf 4Ci5iYE1CR ANDOWNER'S NAMfI? f3i.0 SPLCW 000410 - • UNIT NO. 1 UNIT NO.2 O VEHICLE- '..O PEDESTRIAN O PEDALCYCLIST aR ?p P ! DRNfA' NN,f. IASE rIRSI r DRNFR' NAME -1 : T 1 \ / A ' S-1 Rf55 87 d ?o i4 1) InfTADDnSi ` `? rT 2iP LOGE PNONENO. A D Y STATE IP N f1 . P A4 3 U 1. c6 ( R I '., ll FYS UCFrvYrv 1-1 11 " a h4 ii i'IRy I v NSENO ATE SfK DA11 BRT.a & X66 *• I° • p z.. N O[CWA ON meKNEIRgNt NO FrfS IGNI If,Iy i O 26U (o j? E R CUPAtIp! MNNAf6P-1 N0 EYES WEIGNI HIGNi ?,". ? CHECK (?) vENKIr AS:N fMno MolNra"L AN O CHECK(,.) IN Of AS AN rAwarff OPArvOmINAI ? u. rlopc.c I CODES ?' D w ' a i± Nrc1 S OD r n?i •inM ' [< rox i P:.c I CODES ? D n A^ S r a 1 6 ?C n? R ? .Mx .N l °t ' O bk O „x,11 ? u?v y;r.D ? --. NCI O M"' ? gib. ? N ? iuv P KIr Y GO 1100DG[CxfVl ? FIIDART IAVwI SITIE IRDV Cp+vl Y R ( .MODEIIDART? YAI - ) ( V.1 ? G44 L ,r /c up E /nl N NS[IU s1Al! ImE ER RAifNO iPll H W. CIXOP A ETATI b Y s u oo a C VFNM:IF IDFNEUIGEION NO. pz c/ y! .? L Y W LEr N 1 r nWSn ONMtR E "ITS, .1-1 t?/LlUE2 %qNF NO. O W RIGIStILW -IT: LAST 1101 MIDDIt :Lj 1 r ADDRESSaoxrua N rvR , 1 .uvAI IADOVE330r INSIfvANCECO OT-T R I U 7 r / pAMAGEO MIA E? eT01 ' ?OIIOM °1??'? IS' O CNARU ? MfMNN[D CNARG[ ? AWAY ?RlMNNfD or'NinCiow.l DAM 1 DAMAGED AREA ' IU ?G! ? S 2.M voer. IH E ? i,w? EY f L, INaCA E rvDR,N DIAGRAM OF COLLISION: sM/I Ir MUSSARYI eY AVgOW DESCRIPTION OF COLLISION: (uB SUPn WAL SrKEi lr NlCI-I I mr, d., O The witness's stated that the driver wa• in the vehicle behind the wheel when tht arrived. The, vehicle ovi,tontl,y drove , straight off tho rd, no brakeing marks a j were prosent, The vohiclo traveled 1G8 . through the 11Ttch mid brush after the ?- right front Lnd right rear wheel. le.l't ti e rd, The driver F,GFited that he just drOVE ';+ O off' the rd i,,.: did not know how he got E 4 NAME, ADDRESS B INJURIES RSSONS 1 OF PE 'CODES I - Z 9 < 5 6 i L u , OCCUPANTS/ WITNESSES rw ADprllirvAirvwwE i .• ??, " AGE sums u M nsla. IA • WI 1 NwMI. /? 3 ?? 1 D A LKnIN D 6 IUR d H X H pv. AM l ? 2h"' ? C3irv br 1 L Lc G a6w ra8q I J ; , ' a D ?? AM11Lf •, , • ; r R Mp ID ream ?-4 ? ° 41r „x HM ? l - ?. : L z. - 7Y q , ? , 1'?'('? dQF ' A nalu NAtIM mwEefp x.4 er ?AMe 0O"»R. O:iS ? } , 1 r?r? ,:•, 1O arKlel IeAN[ X pADU (. ?' KY u.r. JGro S,:' KIDr1/AILMD Ze?oo"n YOI f.1 AIRIHD 2o?fN OAE{Of nrWl 7-zf- A.PPONDIY Mtl 3 3 SS l , 4F? ^IS A E t+?-'x,4.41,• .'? 11"r Af !4'Mlf J ?? 1 >" 5{.t And ryn?. T R ' m {A n '. 11 ? E,Y 1f1 + 'I I ? ih?' I rt l ti E6 ? f :I tl ' r '! f t j y 5 f i A , r ? r y tA? ?k I~? F j r ?, ?b Iti f r . a 1 A ltlJ' (fl( t R') A STATE OF WASHINGTON ..rn g4H,.r ,I MOTOR VEHICLE COLLISION REPOflT NO. A Y courvH co s uDN Es w °Lirs , J H N ?:u \ ,u `fP uerEI N UNTx 0. CRT N0.? ?PrR u r !-?9 N ?w ? TYD DwN Lj 1 NeYll '?°N .: ?I ?w?DI ON N onnwLT°PP: .E j ;re 1 Ixsen,n,.w N, v1«LLt ax u1` NaN ?? I rQ?w A ttc R4 • slFfiY. AL 0.1 .OO ) NE II iEV w Ds W] ,6 1 - INIT. - V V ? r w ?A 1 ? >v E II•i•ARPPIM- YtwP TANMrow .\ ? ?. r?IP "(?a °? 1.1 E Boo B.c B A ? T ' r v o EET OR EOESOSOF OALTCgAG PSJECT STRUCN _. 1,PFPwci• c'II _.j y'QY/ E9 QF QBJECTS NNAE ANO A00(IE66 ?$idvu?°oa S DRIVERS UST NAME FIRST NAM D DRIVER'S UST NAME :flfleT,NAMfu;, 1AIgPl4 i..'.'•l t3 yl G T"S 1 I o s c ' " IN °w0 "I"I STRCETADDRESS ..- ROUT IIWiNRNPX NO.;; ,. T FEF...T WIFE STREET ADDRESS ?.. dwbv ris"' "_BOVTE HCI_(J1Q80?4kQt/,? L^I ND, I ' .FEB - ATE CITY' STATE .; `.,.' _CODE DRIVER ON; UPATIO sAION CITY 9T • V P OE DRIV ATO ERS „30GIP....,,...F ;.I N 4s 0 mat v FON. DRIVER. LICENSE NO. 91ATE 31E( OTE0F,81RTH; i. AOL DRIVER'S LICENSE NO. : .' ,:ihTd' .B E SE :OA EOF, BIRTN':AOE:. y F 41/ A 'G u rF. 40 P:r Yn EHICLE YR. MA%EI E .0 DG E) MODEL INO -DAR .1 y5 L G? ) P• V 1 Y '?' L 1•L VEHICLE YR. MAKE (GREY DOA M, NpVA- AR ) BpGY_BTYLRLi:DR.)' LICENSE PLATE NO. STATE .TRACER PLATS,rIL}•;I2 m6:t@TAT%sw1( ;. •.. .- FICEN8E PLATE NO, STATE.:;', TRAILER PLATE NO. STATE,,,v 300 w VEHICLE IDENTIFICATION NO. VEHICLE IDENTIFICATION NO . ,,J D 1,5",g 5- C D R STEREOOWNER(UST-FIRST-MIDDLENAM )„ ORIYEI)BMCENSE NO.. REGISTERED OWNER (LAST-FIRSTMIOOLF.WME);6 T:;, DRIVER '5 LICENSE NO Mn J F. ,e- 4ielaC IT 5 OWNER. ADDRESS (STREET, CITY AND STATE) T?, ".:kYJ'el.,11 "DATE Of GIRTH OWNER•SADORESS (STREET. CITT;AND STATFUc..: OAT' 01 BIRTI1 $•4 CL),D Vt PARTS OF VEH C E DAMAGED $Li;uui '? PARTS OF VEHICLE DAMAGED "•1 Saoeo+ le f? le¢.CA?/ CLLIa 4'L dsb; eL? ? ?.. _ _ _ _ - - - - 1 WAS THERE AUTOMOBILE L RILIr INSURANCE LIABI LITV INSURANC OR E INFMATION VEHICLE NO - . RYES E3 NO COVERAGE IN EFFECT FOfl THIS ACCIDENT ON YOUR CAR NAME AND ADDRESS Of LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILItt INS RANCE COMPµY NAME AND ADDRESS OF LIABILIT/YIN-SU A^'{E GENT P STA LIABILITY. POMCY.NUMBEfR ••;. LIFI ?? eL, ,!IiJL.GL7_1.d.1'-c a urYlA L1- / IST INJVRY / / SIT AGE 2NDINJ RY NLS.1UFAA IER TFURAPI% W 1 NJjES! NAM N-B NAME ADDRESS M F A R"SS' ! M DD NATURE AND NATURE AND r( )I EXTENT OF INJURIES E3 ? INJURIES ?? EXTENT D ID INJURIES ES REOLNNE DOCTOR. EXAM NAT ONTO ?A'DOCTOR'' '?' "?' FDiANCiE R S EXAMINATION BY A DOCTOR'' "?' O NAME STATUS OF INJURED MARK. FIRST ONWINAT APP LIES. STATUS OF INJURED - j•O NETHATAPPLICR I V HI L ? 0 %IllCO iYIVIFU x NaN ? rv ?R IN I L t [J v XILLED ?'•0 51 IxF r rOi snN n u,., Dun I NG ? ... u... El 6? 6? xA M1713 P ND ,.,.•., ?, ? 6 11 AA u70 ° 60 MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SNOW ORt D RAO CRCIF ^:{OCSCRIDE 08lON NMAT HAPPLNC0.. (RL/CR NUYSLR ;•A, ) Y,pt E •°nAl1 JT.-. I I . O 4( y w a3 o K?y?IJ If,__ T! eR N 11 /_ . ? F 1 IJ P } wyCeoy>6vl0rhaa_C Rd, lu?Lrn ? - _u! -. ?+ dd h 'E'er ?1 k 1 .,,°W -rA. a er+Fec o. /V!• o• - el tua -?.S. a .e ? ?i r ?t k b K AL•I ,°,w,. ?, _ p a/ v e- rA es cve-. w Ou ,J yke slrp/x?y eon?+ l ^A pptC $ _G. ... e?RI% ?e S.I..we. ? S .drip a ve r A 30 -w uF . b.Rnl? - l D trv l %? ?y! c d .. 4 M Ya r?s?rE,y _40 buf t f 5 VEHICLES POSITIONS BE - FORE COLLISION EET OR HIGN Y Y NAME OR NO ON ST A•c1 ` Mtp To Y r N HA:L: o°u"Iw-1P IN INVlanpnT'p Dr ? ii [3 0 VLy1OC[ N S C W R F ,, 111 ???? ? ? ? ? ? ? ?- 'rte r•PU1A,w ? ? ?, ? AL040 "dT+.S,1,R ` ° o LarAl• -I :;FROM TO. Iv n PEDESTRIAWPEDAL CYCLIST WAS USING' ,?Ixw F?+u +?PY>w •?u v?w .?PI, F?LA. .?AP w n • s? ww _ FI PEDESTRIAWPEDAL CYCLIST CLOTHING COLOR' 4?••,,, MI I?I,P„ 1?w, '?Mw ROA08URIACd <•••,, Y/GTII?IL.'.. LIGHT GGF;•'jlONeyi TRAFFIC CONTROL ,iY,;,. , w. , c•WI TYPC OF ROAD • A ,w" !;{y11VL/1rVEHOI/ACTION ?,?L 1y.: :. -w..u Icnlu P„• •F I I 1 1 ??r n? M 1 ? UAYIIGNt a ?DAWN ? 1 ?MONAIS uwN ? ?a ohl WAY 1 ? DOING SNUIGNt AHEAD 1 ? DNY ? • a IG nMNING E V a ?DUSr ? J ? S1-ION a ? FWD WAY ? L ? OYLAtAEINO AND FI IN0 ?W[I J ? yDW.,ND I ?"IC?II]ONEI El ) ?Y,lLD I1UN ? l ??O?DItIML ? L ?.-ND RIGHT TURN ? I ?]AOW ?,m L ?..A" *`,N I ? • ? II ATN Nfi FfD ? • ?11wWCaNING1L ? J ? MA.I.GlEll TURN [] Lf s ? II11.,1t1 Ol G••11 11 I • R ? s ? 11 i AMAIN ? + ? AIIIY [3 I ? 4AXIND U TURN )IHIA YICIIY Ot r,IR 1 ? ]IICNY p ? U Y ? Rfp AL TWO WAY' El • El `IAN11Lr1N E) I E) SIUW MO A A AY L?7 IL RO AOWAr rU111 ¢J w I] I ? O cf. 11 AGYAN ? I ? MIMWAt ? I ? STOPPLE FOR TRAFFIC !y ? ? LJ J rrF ? { ? ? • ? O tR NlL11Y ROAD ILATI !? ? I ? I 11 SIGNAL DR IT O FPs DN ? I ? RIOPI LD NROARWAY L . I ? (] 4• 7, . 7t F . i f. Iti,^ \ Ap! ?? I O YlSi,p ` aOVOlO [F.V?](?s1.AT? W i i ? P,Y C'FW ° S I (IILT/eIE•.RA,y 9 ` w ' R F 7r { g91Iy9YY [ r s4 J Igo s g 1 I;'.i yl C? L h '?JJfC 1} t IAZ L ? ?,J ' 1 U !?I' ? >Y t ^ ( 1?n 7 P tJ ? ? I I 2 .t -h 1, , €J "'• STATE OF WA INGTON RaGf orf C ' POLICE TRAFFIC COLL NREPORT TRAfI!kCw/ f'KE i INr woof .. 1 PRIVATE WA'!• Datf OtCOll,S 50N ME COVN,r .e n v. v, • .e ,e +•• /St ' SCS' .(.' ^^ a J E ?f COEMir ljO. C'tr rv0. ?iU??AN l/O_ RAl ?., 1 , O tI ,V`"rGNWAr J'J / t Cir OR,OwN ON ? 110N i Ll5 ?OUif 04 ' or Milts ?"' IRfll% f M?E EOSi vSEarrvG N+n SIVF!'OV DAD r r ECrrONo [? " tlFTNFfN S^/O7 519ffiA $' Stvfli %??? U S,urtE tN, fOS rROM VErSRf rv'l C?0555'vt O ARE 11.05 CC EEi A vr'N PA A . NS COllr50N NVgvED NO• Ii,, No -.E. ? ?IIPGI ?"1.9UN r? Cl5 C?C5.551?EFTR?POAOn ?jj?? ?? IO,M NO ? vfUl,[D ? N. CltS DAMAGF 0- OVtN RPO'ERrr [ODINO lSE "? !G LL [51 DAMAGt Dena smuc.INAMI Of oB ruvuc. aro owmvs N.Mn E 51FC9LL '.r • . - UNIT NO. 1 UNIT NO. 2 MrDgF '" - ? PEDESTRIAN ? PEDALCYCLIST VEHICLE I ' P ` rrasl DR ''"AAA1 .11 `l(, 57( CjrjS 5 CVV `Cw 1 r 0"( ^" S,RfE, ADDRt55 „? I 1 ZSy ? Z S '. ` ADDRt55 r?E Poe 40M 2-S-- - _ 1-1 R GNtrv b tG% S,AIt n K I /l STO'/I ( ?f? 4?J`(?S R 77-190 ' u 1S?o Li'l `18370 ? ?• . v[ sr arvu Dar?RlCec?3 ZQ?? s1A1[ c>? F `o N I v , Iv CErv5f N0 LIL UCD38yP? w? stA I- DA E a o » In, A Z Ell GNI GM IA 17 JtiiS ds (isrA??.a ?T I'ati A E R O CuRA,ION zc RM rvAME a argNE NO E S m GNI H GNI 3wu t ub l PEw?s6? NR boo Q3 A - U CHECR (v :rvf«nv. Eo ANOE"EVU ? CHECK f?) ye As AN M nvfia ANO,?1e N N °? CODES' 7?AS+vfNn ,i% 5rncrD 6 rqr. /" CODES?' M, j .. t ? O ? b ! w sor.D p . M, .", ? ? ImaECNlvr : ° ? 2E:,r. ? ?:K k ? P3 MGDIIrDAe1.r.OVAI unE UDR.corvvr ,R Nr. Krr t ? M ? ? cnEVr D! aaw NOVAr l Iv V f: S rcrr 7 S C I Lt a Noire ea l b 2Dr E fc? d My s .z[ 2 Dr 7 E L - '° / Darvx t rv 1 An rro s,Af1 H Alr N (?4 ?l???t CR2 I ? ` >o ?JPo ??? I Z w? ? A t , v rtr<lt D f VEMKI1...1NCA1-NO. L, I! i i ,3 I ; I i? ? vfasn9e°owrvty yy?' r "All MrpOEE IRNOrrt NO W I I I I I I l l l MI "fv ow,aE1=, C lorE/kS 1 LO U E° !?r r5 aoottssa Ev t ??L?/ ra o N E A o r n c , N fIADDRts50rrN5yRANCE CO Oa AG[NI R , ,Q { ! J w ?r DIAAIACAD NlA ? CIW [MMAGI MtA t5?e,n~ r ? °'q•D • ? ` 11 . +.crr.. CNa9G1 . [NA Cf '. ! 1 E rnw.9wA Iw 1 - • , u, -A., ED OAw.r wr«A mo ?° " e1MMrvto 1 Aa di . ewi: ,omD /'?U OWi DCO Ar ? er. _ S Z000? ? . r [et In tte e as ail E . wu otl DESCRIP IO OFCOIIISION DELISION w DIAGRAMOF .. iw,.? Z pie), p? (rt S?w?cS VFJ &J_ i 1 2112 _ 7 4 Lh?CuwG a_ FC 1 , tit., 1: ' I { ` o J 4 -- Rif ?wwa T 1 'te uio 5 a C ( 'L r ., _ ..-/. ' ADDRESS 8 INJURIES OF PERSO S NAME INVOLVED 'CODES 6 « , OCCUPANTS/WITNESSES i°os9E wwr?a u?i:re ii sa • I -Ul N°E" rn „ REV? Ino . . w a G 2 7 .. T? - (.!L AE%M,, St-S EK OL?1 NO Rt o? 1, fNr n. is AVe ?,.c ?'" .?a ?:4.'" «.To?r 4 L), IE?c1 Z`r Z 36$3 vp E] All 0 4 tD U.? C ST LC tY ? 7 'Y-4o '?• „ ' r ? . ? . ANEt 9rot r r ?"„r.?? ?" ,'<rM`fr r.ve C". ,•-T ' t-!4r R.-,: tl. r t t s r tA'v a t ?r Mru r! i ,} r 1kl} 7Yl r kjl,?' ' ssp: ny?tf t r?nE.1E4 a 11 g5iY,?}1d?,.M??? i j. yl its , .r E L.11` ti 4 r 1 A . I a v. l? { E L rv 1r? t L ! r s?? `? h I ?7 tll IaJE..i wl ° _ ,r y lr?r?,f ZS"h r. +jrls ra t' :[ ! v - 4r Ne" i p y ?? F '?'}'' •S al 7.i??>F,v???7??'-f?a ? J S ?c :.? ? <W 7 Arai fr,-? r :_?? t f u ! Cv ?y 1 t y ra 1 S t '. 3 • P I 1 a r• _r j t$g i '. ??x of .s> 41 41 N 027 i?aN 0 1 avo ? o TR W . POLICE TRAFFIC COLL N REPORT ® rolKEC wsetR 12 VATE PRIVATE WAY fMNA Lw COUNir a al «US N 5 IUSf a.(rJ HOUVI ?,T r ? 1 Qw ? V 111- 4 TION l f 1t N Ql QIN Q ??11 jj w?O w R., OR ROAD NONI,ERFC,N PvPff, y // L/.OO = BF[ EXII.1111ef ,Mef ", s f w, LEA cODE I RWAD «1 RFHRENCF R CTI cOIIIN NVIXtD NINIEDQSpIIAGE °SIT 901N O ,olAl NO oEllleD_N ? g i EFIOV POM ZS30 ul,f0 F «v[nlclfS m °PRORR,rDAMAGE GNIY ? vFHI«E E51 UAMaGF CODWGIbF SPECIAL OBIlc151RUCK4EAM[Of GUIIC,SIRUCK AND O'wEIER'1-MlI 5 ;^ UNIT NO. I UNIT NO.2 MIpOIF IvFe SrvaNt: Q VEHICLE ° PEDESTR==-55 YCLIST U NRS S DRIVFe'Sw 1 `IAJ51 NR51 ` cp 1,RtF, ADDRts1 S,RIl1ADDPFI3 PHONE ? NO ' D Ir 51A alPCOD H NI NO. 2 PCo pE SIA,F I my W 3 - IH 1 R I .v R II -NO TAR F DA, o«DIR1H ?? ` sur s LINO Dervf CA E p o,r rv A w ' C N2G„r HIGHI f'F! NNAFLNgNf NO E OCCUPaIION MNaME6 vHONF NO E115 WEIGHT HEIGHT e pC? pA1 ON U EYnPL6r w Ib 6 R A A` w K I,` l a QCHECKI/1 _Z'ALI'wftOVFfOaNOHfR ,HfR A rEF a 0CHEC I?) v[HOIAS D 5 I DN 1 e 'S",°,,, - RY • rI ,v. CODES ?' 7 ns < ?; MNI S , e i ,ola' CODES 10, D ;: 2 Qc INI Ne5 s µ.. M MRA, r Q b ?<<"SrnA Q V JNV I fl1-1 -Al :[ 11. AR °" „' ? QR rNDrAI uD MAK I Fv l v N YtAV MAKE IDODGI{XEV I (] ` • E D / 1 FUrutN S S,all AVER RA" NO IX H STATE vIH C«Oe l IF In N A,f '^ Ww l - O ` C i vIHICII IpUI1nI All NN rc qN N vFwcII ID[ . Si 8 I !' ?Q I? IJ i Ivt Fp wrvw lASi 1-1 MroplE H Nf R' LCSI fIRSI MIDDY I RfG15RelDOWN -NF NO O l ? ?? l.•• W A e NFR ID 2 ADDRlssaovmu N M E SAG , R AMIl ADORflSp wwR•rKECO ORAGW ••J O Orx / ATE, D AR s,.mG ' c µ? i.NrcNr DAMAGED -AGE. IA 1iCiOr'M <HARCe L •VT r L MARCf , -•? FSI DAMAG! N ?DRIT ?RIMNNID , I K R?S a 1 r = A.Al WMAGI ?.-I ?REMUNID ISI. _ ,5 S Y `LILC TIE ? nw:ver er ' l lu • j-.,A11NORIN DESCRIPTIONOFCOLLISION? lust suPRIM[N,AI SHfII Ir Ntassa DIAGRAM OF COLLISION _?, ..,5w?i ur4455•Rrl. e A?ROw (?,(i VE111GLtb? WAU I7D(29TIBD.wO nN •JTIE COV?LC._.. ' I ? I I. .I V(F)`))C LE +D 1 MET THE 5CR11H C3Ln4• n R0A0 ... , . ` ?'4ITNE ?S T JoJhltvf0 DfxK ?}-'rL^ r1FS L?1rC. ..• I `,?F. O f /)2?v EL, \/[}JIL Lf b / n/C?" LO'. S CL:aaIN??? ' 2 ?- i ? ' fc„r Wf)•+T 73Rs?AD51De THEY c?, ?'13n i-• , ? ?.. ?" ?„ • / CLJ +C IJ9c AL/?L'+S ?' NLN U7Lam. \1041 C • fOY g ?E RLADN? f5%YzatCic A ?ilf? ADDRESSB INJURIESOFPERSONS NAME INVOLVED `CODES L - 2 " ' " 9 4 5 6 , OCCUPANTS/WITNESSES "I :`c"D.i?o::'??..'M ii? sn Act .,•ms :; , , PnaR nrcl ^?HY c• w -EWmAI/ ADS"39br I. 4 ? " Qa ? RlG Q " rA IRI Ol vlw vA QAMP Q". Q,i •Darss wl O oEl sr urn,. r 'o 1: Q N ' ;]Q= 1,, 1 n ? 51 " H l•r14 Fr p I • .IL U•,I ,!+I ItNI aMIRr11 1 ? ,;,IrrM?YI41r 1r?.MI EE,r.v 5.:,%t• .^ llrV r v ,R to_,u•w A3! e, it y 1?1 -/ I13 IT .^.r " , ? ? y , _ X E QAePLV M. R_DLU3 w?- a ? I ? 1 Y ?1 r X11 1 f / 1 7 ?, ?qqpp l 7 I X ?;N I j r? ? t5 S I^ I - I I i / 'L{Si •.It I' ?, ' { 1 t l f 4?? I [ 1 I f}rf ' L. ? % f POLICE TRAFFIC COLLISION REPORT TRAFFICWAY coMPwNr NlmaR 1 } PRIVATE WAY 8 A,[OfC _ D Cglf54N _ ME COUNir W?r.?u r O iu. t lusF] aO NOURI 10 MI Ca%+n MO. CIn HD. pWiF OA SIRff ?rNw U 'W 1 .;?N JAE ?IN CIYO410wN f6N0 dS,PFf, O4 NONWAY G,EAnt3 ?3 ?W ?Dr /Lcc oNLO Gc o fCi CLS 3 ?a39a .RR INIERSECtING WIIN. SIRff, 09 A0? NO IN IMtRSlCIION BwffN SIRFEI 0 SIRF{I PRtfl% f MIlE P031 7. SD - ' DIANCF 6DIRF ION ROM ENC-ROSSS R[f, vNtAPES,MiIf WJS W G M4F5 t OF It[I /'/L L- ?O ACCIDENT MILEAGE CODE RAAV DIAGRAM -A E 11 Iptfl RROADCME 03ERfNd D CIXUSIONINVdVlO. ERNY ?NLIAGE ?NIt6 RUN NO INNRID lD ?uNDwO,w ' INIfR l3 CYOSSSIIttLI ORROAD ? . NO.K II ? dVlNIC IS PROHRI-AMAGE ONIY ?pEwI,FO ?vEdF •??8 _ OD1tCI31PUCKINw OBIf IS-3 MIDOWN[R'-, FSI. DAMAGE - /A E v F iYitiGTU.? ? a - YECRLL COOMKF Ifif .K.. '- t UNIT NO. 1 UNIT NO. 4 AME ' ' ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST - rl4 MI - S LiF IAtI NRSt MIDIXF ORrvEe'S NAME:. 4- L? E' J /c L vE.R SN : - -IEI AWRF3 . Ivt[I ORF33 2/ss M/r?yE?? ,fir,'2o SIAIf 21PCOa ENO. P !x/¢ 9 $7G'SOU O D R I Y IAIf EIPC Nf d4l rvER'SUCI SGS T Mt VAR % N.4 .11 D" ' A I V Ivt4' IKfN FNO. SIAIt AFOdbR,n MO I v ? N N, Grfl frJ3 (K IqN {IRM NNAf CUPA E «CUPAIION rIRMN I. PNONI NO nt3 WlIGNI IEIGNI - III G! 9v R ? CHECK (?) V{NKIt AS:Nr A- INOAI 1-1 ? CHECK (,11) vfNKit ASw Pii aANa,HFeAI ^-7 CODES ? * D " 3 I e ^,;°,ii °`? - R I?oN CODES ? " ° s N¢I oN a .w %.uWr UN ? V Cd+v „c Y 1.) MODFI vwl Ku1R V.1 °UM VEN r MAKt IDDd.E{Nfv,l R y EV .l II IDARTNOVAI IYIf Ix U E -? r N t 1-1-ATI.. S,AII SI I'I A f N A A N N Ct%04 vt ? ? o 9 1 Gs c vlNKltla 1/KAIpN NO. G ?i 7/ i I L Y-cll IXNII I A N I i I Mmat E feDlsmtoowµp. wt NRS, IDaF PNDNE ea. I nR D wNfR: l 1 rI4s1 R - GL S a? , W R IE: NWAE KADwtsfd wwRwEa co GR AGENI : n CxA . - x = CNARdI ?' pRW p f .AGI WMN t31 x DAMAeeo AREA eNARee ? YIMAINID ISI DAMAGI III I.•,V'..- 3 -IIY ? [ r p . ?pIMMNID 1 •••••• AWAY 10 ROI10? .. AWAY `? 1 IOVftD s ,? AWAY S A RY AY. ? 1 DIAGRAM O F C OLL ISIO N I I- )-_ Swfl I ? 1 1 Noel Yf? I rN assA 1 _ DESCRIPTION OFF `C'OLLISION -I/lnESwnt Nw ...... vYIcL?I"d E/psr(% !i/C??? W/fi_ d . L ,1 - -- _ .. i I Fl- t I ? ! ERSONS 1NJURIESOFP ADDRE558 NAME INVOLVED 'CODES 1 - Z ? 4 5 6 jE. , OCCUPANTS/WITNESSES Iv51 wrM1IMIN1Al S rd ADUNCN..I NAM N11 ISI -N% AGI uws '; _ Ytv4 ulxl ; El 7.' Q r A .. ._ ._._`. •mPld Jvln NCW. ?AMe ?° "0", . ? T ? .a+f u NRA.E Aawrt uD4 n. u v . DAN r? drKlp NAMI SPAN. e.' A:IrKr C? c '. X AL . -r. A 11 l Ix T 7 t 1 7 y rla ?G f _ I S f p?tl ? I ? M ,i ? ra ^ i a xT ?? STATE OF WASHINGTON GE / o'/ No. POLICE TRAFFIC LOLL N REPORT TRAFFICWAY ?^ ,@! y VdICF INT NUMB[a YT; J ? PRIVATE WAY OfCgl' -y- COUNTY OtY NO. HW IUSf ].fD NOURI ?rUp A r' '1.??. )v ?? uRAE 1 .; ?N 0, []IN ur. oR -N m nNO o SIRIETURl OHwAY rct ns aomf ox staff c cu N N' 3 Mnfs s pw or ?r+. i' / N / ON - /1+h'NUI/S sx If R3[CIING VnIHileFli OV eJAD INI[PS[CNON PREfI% ED. IT t NDN /. %9 / 4 eETwFFN Co t /, slaEEt nS[+v%7f tc/1/ 'stanl 't? DI tANCEn IV t IROMVFilRtrv [.C40333tafE1OR NFA E3tmllny I ACCIDENT v DIAGRAM W1A EM If N 5 F W J 3 MCODEE a 3nr? rEE1' ? of COllISgN Nv«vf0 SrvtxnY v NO NO aIIfD?NO.IN1U4E0_ ?3P llAGE ? tnI41JN wl.mvlon? INtfa IT I CI NG SIN[f10RROAD OR affFR[NCf '13 -A, ? pmnRtr DAMAGE ONIY IT CRNEO353F51aFEt OR ROM v vFH¢RS Oaf OSEO1clE D. OB)[CI SIRUCa INAMF OF 0811Ct -.-E- -1 131. DAMAGI 31CINCODIN111 b i N[ NAM9. «sl UNIT NO. 1 r s1 mloIXl U NIT NO. E2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST C. 1 /i r2,h <' 1 ' L i. !n !:. /r)r/ RIUE 131 r / Lri. v?f/f rs. J rlxs M a1 rvfu ADDVEss SlvlEI A-- Sic. .u rn i?" TN ? ?. PH LAn[J TrcE%° j. Otr SIAtE 1vCOIX ONE NO D uE LIPC DF RNONI rvO. vi -TclNUNO. s1A1t f% I Iv RS LICENSE NO 31AI1 E DATE 01 BIRTI '. M 4 k A/ BIR/t V 86 l N T,/ P .. D,r r. B IX-AIION MNPMF nrIgNE NO. EYES WEIGH114 1 E OCCUVAIION IIIIIN EYES WEIGHT MIGHt - CHECK (? cif AS nN wnovtE OF A:,o1HEalA' ? CHECK(,:) ' oN 0- -111 ALAN mPl"I n?nNO1i°fvA' ' r CODES ? ' ]'" v/ "'L s , u"•;,;;"'° CODES -1 `"• / r ] v S I„Ixrr, 6 :iiir?•c H Amxu. Kt ? <Iirllr vR ? u v .wdx,Ntl ? ^ ? i ? v ? ?aiuv x rtnu vf'r mA%F IDq)GI'CHtvl fIIDARENOVA 'rll ,rNE vl IIUUU4l CH1v1 %NII Aul rvOVnl I I]GP?? ?t?• T N tr x . ON E ,<„I P. .. I,y. Y 1 x A 8 N « N, All IIIRHANNO Al H va C«ox N. l N .ra RHAIl rvo AIt Yt.. N q/•. Tw FA'i1 a I _RR i t HKII NIIrKAt ON rvO C ICIF DINT UCAI )NN ?? ?IsnalD v ENO .nnxmuwwv lASI x?'Z M r' A _ t A I.?:, . mIDDU Drr . Na,l MIDI%E N[ No I ID DDPISSq OWN[9 Uvf3Sq Uwrvly ?*p N ti AMEAADDITI-NSU 11CO 01TA-1 E 1 u AN A R L 1 4, AVAIL[ MIA ?, DAMMIJ AAG nl".R?: wN 1ARq 1•N /• [HA9GI , 'un'wr ]5 I + P ist. DAMAGE f1 N IO PEmAINID ?^wvlN ?xIMA r1ID I+I,DAMAGr..C.t:. °OM• lJ Wl r o? A, IT, s SA?nCO Atrer ?IOw1D S I° ?JS +)? ?` DIAGRAM OF COLLISION: iipeNiNicissner'I A'u9owalN DESCRIPTION OF COLLISION: III survu ml Nln I r rls5nvrl y 3 /rJ: rrHLlht\V, _ ^•IQ" Vt'Nr / a.. AS AJ°R.. e. 1.IlL Nhn /. b? fs! r d 1\) 4+ J... oll rJ•r,1.,J:NIU/h1 r'lAfiU /+a<?T• I r; ? _ _: Aloe)/J/ r•. F'+ ?r•-•Jr•/f?l,I rrp ih/ ,Ti'?a I T e., 5''y A.-"'r A r'•.,1I.1?16// Dn I ?.+. ?- .... ??•.? Iro L Mnl .+i Jh lu 7Na -„!',.n tr ?J.q IlCo - LY'?'+f?rq{y„. t V Nn 1 ,r .J, it )r IT, Ail+ N:1 1 fYbt E,, 1 L?: Fl'.?ad'y?.i'A'`'. Trlc, d?I'Ari AhrP r{or +.eRi Win' J,,.,1•N A?I ?;'ul It.Lr tr1J5nNhMrfrJ'- e O/. L. r? ^P, b's:NJ• '?? ,, 1. 1: J(CLv •... C/jt- v'' l? .rtrrL' p/.? f, L). x - t- NAME, ADDRESS 8INJURIES OFPERSONS INVOLVED 'CODES 1 - a a a S 6 t? ?R ""'vrnwlrvtAly«yl OCCUPANTS /WITNESSES i1. [W ADD IrtxrAI NAMI I SIV AGI IUS •, n, RE 519 NECt 3 p ,IRxnx ovl or er ?• B,O".4"' C7f'..0;;,: ?i..vv ? ? F In, r1 ?KSI(v1' nrrn3 AIUYI Ex mwmlxOm 0AM^•" ?," . O r ?IC u ?'? +?1i?k'JIk' 1 I ?P 'C. AMNI53 .Arinoi°r u1?i nr O +MV N I 1 ".': M;". 0:{.: ? x flfiAlrw,Or,AIP3N+VISrAN. sA{RA E+P Ar.IrKr +' x KI rr ND UAN r UAII Y ?C 1-111111111 X CK) 7r 7 yes' ?? } ?f POLICE TRAFFIC COLLISION REPORT UTRAFFICWAY rgKfcanN-NINAbtN EIPRIVATE WAY - E E l au'YII rIME couNl Ip/( W Nav levl 7fn ,+, Nr ul f p ?<1lU Nt T'"":V"l '?'V r^ (q(? L.-.?^ ? V ?-F- \ (T, ` F ' • IYIUNiV NO. CliY fq. {XWA // ?RUNAI f ``GIVSOyRl10w/N.1, R 1 \J AVIfS N5 0W ?OE { ??1 1 y M1 FeNOOSiNIfIONXaI W q Y $ R N N ? O ? iCI C15 q RWI[ON SINFE SfR ON INIfvSFCiIpJG NItn: fr OV WqD NON INI[ N ? IIOrv • • sza `? O }}}}.. .y ) ( ? ? E??E ]l ??AA EE-- yy?tfL( y OEIW[[NA?IJID Y, 05(.Q? SINfEtB'i1lh? ?'- SINFFI ?;IX F pp51 / / ST-Cl. Fl Xt CE CNOSSS,NEF I(5.?( NE?ppl pUSr ACCIDENt v[rv MILEAGE ?? S f S F NAJAp DIAGRAM WIA ?'I?JV 1 '{.Cr )1\ [] Oi f? FfFi CODE -? cgid- v tHVfN Ir. ! O rRt[D?NO. IfUURED? ? -L-E ? nUbvulu OIAt rV"D"'U'n 'N° INIfN]tCllrv SINlFI OR WADOR f6FfR[NCE INIfR Ct5 CRO5551?j ROgO 6 VfNICIlS pNONNiv OaAAGF ONIV 0 N f SlpfN RESULT[ ? VUrICt! ?/ OT OBJfCI SIRUCKINAMf Of OBJ(CIS xIKA ANDOwNt R'S NgMfI FFSI.pAMAGf veh?G?a SNC4I CODING tbf $ ^ . UNIT NO. I N DRWfR'S Dlf ? R a VNb Q UNITN0.4 ? VEHICLE ? PEDESTRIAN ? PEDALCYCIIST rvuAf: NSI S??UIF NN DRNtN 'S v, &I h 1 :. vEEt ADDRESS ?• ?h I Ka SINFFiti D SS U P.11 ? ??? ? O <ODf 7G3 D R IY SIAIE Lrp<Opf O ?? NO I DN SUCENSF .lid rD)9 T A ?s'^'`' c - g „ Ni I o. y L l sFa p faolNn Y R -r I , - ,1 r-L-V 0 i U s , h M 3?? IVV\ C cup-?n+oN nRM NAMf6 oNE?NO ENS rEwnr TDcnl E R DccupAl NRm a-E wnl ...-IG ?J? ?1 1\ ?J??s I1 O ? CHECK (?J vfn ArMiolniNrAl , onf a c ? CHECK(,') ' fqs AN fwao vrNp f orq ni iuAE .RI . ; M ncl,w ox.c I CODES?? D n u d- 5 1 e ?,° ` N n , `: ;MNr 5 I N e ; CODES ? E ? n:55 l ° n Fart i ? AM .A.Cl ? , I K ? 11 46 . ? °rx. ,w p ? M Ar r o UYI ? < um nv N ? Lr , oiII Ar Kn. Y[/?N MUCfI? ?FV.I V?^ ' A %1DE lIDA R I NOVAI SIV11 r+UN? CONy,I _/L ` • D ` 1'y°'1•7 E ? v c 1V.1 AYjgll VAI R C vl ?-- ' ? '^ 1?J8 4 n. ql LI NsE PlA1EN ylAlA IIN RAIt t AI s E NO \V,? c uN'? pPs?l Il NAIND E .. YtNKLf lIiNiIFKAIgNrq. A >~ o L y I?KIK t',) 4 -C Z? Z5-] 7 ?f Ail' REGIS -1: -1 INSI D 1 ??tmtA? pnONF NO O W P II UIDOwrvFR: USI Mlppl! fN0 c NNs?e. 7 3?4? Y+? ADONssIDroWwR E q Gwnw DI R _ n?r rW, ?....... -ono o-no N DIAGRAM N: 1 IUssA N Yl AFVOwIn SrYllu Y ? 1-i-1 ? fL 3 ih? 1J s d . 1 l y ? . L • a ?9 aun . Ln?iS ah P?cyyROB (Z b r ?b goe?bct NAME, ADDRESS & INJURIES OF PERSONS l E ? INVOLVED 'CODES I - 2 8 4 5 6 " OCCUPANTS / WITNESSES iti . r Aa ii uA AGF Ig1US " N N sI ut u ( N .w i A avvu vuta -INYw. ?*M . Or.: ? , . ON ? t: > u ' y° '? ?,v d I ;: , DDnss q t ?cla ? }i+rio rNaA ?AMe ? :."' O H? ?,.`.- ? t ' t (( 1 r, 1 N ,MI N; ,? ry ? M '?yy>y>y??..,, r IWAA wINfISa rr N I ?,/AD [??i.rr, r'•.nrl• Dim ?11?u.rp ? MD'r IX MM I Fr. »4; + +A ? INHSIKMfNGpIK1A1 N,MI Rp,N. AAUG'fE?CA ?? I' •rA' I G I}45FV( Iu.iO pA/ll?a ?NSMyp l? NwWED 1IY UAII ° \ 1 f?.. nY _' / >,LwmJn'VNts cF 4 v-E , y kat ? lJ?il?'I: >ri 11 r1 ? ? l ? E W y?6,1;;i n,. ?, j}? m , tE>,,+3 lrX ,v< z q an A ' '?, an ? 1 ' rky t 1 d ? xn?1.5 ti ?? {tl of ( l-] t 1h ?,1 °I I I - W ar rfAN • i - ""• rmcLx wfuSlOS AY - sw rav x E ar ` uwulE COUNTYNO. CRYING. ? CO TY CIt tOW PM I .. , N Fou'smk MILES OO CITY, TO WN ADMCLS PREFIX AWI L?"`+'^` nIYD ,l??l'1 ,??, r'] 1, {,^-Ia nOwi ©©OF EOn.-Ei CDDF SECigN IwNW (OVE NAM SIpEEI, O DOIT HIGHWAY INTERSECTING WITH STREET OR ROAD V PREFIX E ?7COD O MILEPOST yy .I NON NTEnSECI ONLOCAIION OF ?OLLISION IY twE[N 'T ''- r / RAMP r- DIAGRAM DATA r ?ro- S,fl.,ANO •? E / d L, TFIEEI ?N© RA wr. axwu.« Lx. m«DDk IrosIDx DFrvr, NON X RD a? © ® W HI. m, INTER INIE CIS. EnEricE pa598fpFFI DgroAp w v roa1 - «1 ? . „n W1e1. ?«krv n . ? %.5,q •• !? / O? A. O,,u•ca.?wN Ox.r,A.. -.. __ '. 7R' :+-r .....,i.: ?tl :4 oDlLCr snlucx r asnlVD«I p OWNEROFOWECISNAMEANDADORESS LOCATION .: IN RCR.AY ?® FEET OOE RE OI}tm,•ECI S ' I NOII[ Ix.W '1jL+r f t 1. 01.11E.S.,LAST NAME FYIST NAME MODLE Ivu cAxs ? I Y /C?I.T/7 ?? /1/1 ,avWfp OWVEflS LAST NAM P04-41 EYLtt NAME •.,,,b..l MIOOLE t C.L y 'IREEI aOpRESS POLITE A'Q.ANOBO%NO//.' n sW RAN T. RTREETA{IpRgSp ' MK _.. ,. .POHTE NO,N(QITO%flD. .T CI,T, .•^I x STAI[ -Y EIP 000E OMVEHS./000UP tIOH IF ' C17Y STATE ., LP CUpE DIWERSOCCUPA710N ,. ql VEnS LCENSF NUMBER STATE SE% DATEOFRIHTH AGE .eG f y OWYER9 LICENSE NUMSEfl -.. STATE SE% .. N DATE OF BIRTH AGE ,• ?.? / EL n N /' % O%p (: I M F aY vful ? ,1 ti l EYR. MARE ICnEV.'Dp[IGEI MOOELINOVA DAgTI BOpYSTYlE f2 DR1 VEHICLE YFE MANEICHEV: DOpGEI MOOELINOVADAgT)BODY BTYLE IT OH.1 y_ ••O/> .. r7 LICCnSE PIATENO. STATE TflMLEq pIATE NO.. BTAYE LICENSE PLATE NO. STATE.. TH Ell RATEHO. 'STATE v ClE OENNFICAtgNAb. 119EAMODELSBNEWERI OOOMEIER(MILEAGEI VEHICLEIXTITIFICAICTINO 11BSSMODELS6 NEWER) ETEq IM%EAGEI 1 r NLU"IEnED OWNER (LAST FIflBT MIpOLE NAMEI OPE SUCEN5E N0. REGISTERED OWNER (LAST FIRST MIpOLE NAME) IXOVERSLICENSE NO. Y O NS AOgiE85 _ IST T,O DSTATE7 kOpATEOFBILrtH OWNERS ADDRESS :. 12iFIEET.O(TYANOSTA7E) TA_ / / Ax .. OATEOFBIRTH ( F 1 nX -1 1EM i• ISOF VEHICLEDNAAGED _- NMED COS PAgi90F VEHICLE OAMAOEO kID rmneR YE _ .. 'o IMAUN VfHflf 1 WASTHEREAUTOMORILELIABILIIY INSURANCE f LIADILITY INSURANCE INFORMATION VEHICLE NO.1 COVERAGE IN FFECT MR THIS ACCIDENT GIN YOUR CAP 1 NAAE.wDAOURESS OF -TI-RANGE ? YES ? NO FOUCYE?LOER NAME OF TMOUTY INSURANCE fgMPAN Y NNkI ,r y ^U ITIAIE 1P N 1 AMf NIOAOptFSS OF UA&U WSUiM,CE AG NT sMIE UABILRYPOUCYNUMBEq IS,WAAIY AGE 1NO INJURY: IU1E>fPAIMIERfPW Ox Apl>ImN4 NANKs NAE NAME I AGE E'.. } I M TES SE: D ADDRESS ... T?:? Ixr Ar», M F SEXF F m I ?.? STAIUB OF NrU1E0 ?Y4 MAq%fYiSTONE iIUi APPLIES `f • SIATUSOFINIUREO •Rf ?U«vlx WyEgICtE Om4Awm xar, dsM» rosS« MMN EXIST ONE THAT APPLIES ?IA.y MAn IulLEO Hnf wipir w,rA ?WI?N NVFHICLE o->Alxrw WpxAq POS•. ?PA Lx KILLED Istv[n[I N Ik,+n,y oHl»sNMN_ D sp r NO 50 °7 ' o D JI,« N oiOElc ti' Hw,A)IIN, IIr ANROw INORCLE ? 50 50 r 1, DESCRIBE BELOW WHAT HAPPENED. IREFER tO VEHX;LES DY NUMBER) Y t c r?Y N.;;Yw ,•/ ?, ,. .:./ink ?•l.?d.-r irk •l, ti.?r .: /; w'"Y .'uc A/s •'-. to ., f? .i.•L, lir d rir" N.r!.< '?' ''? ??••" rrrH, .1:?F<,? ?tlT?ar,.?vl/! f1iJ/i,E? Y?cNA"iy/t ?r ti r-'-., i ,«,,.,N S /I?/? L-'Al.Dir•?r/ /!.l (n,??: tiF? /-i':/ A/!r• ? f ? y,y 5 };?«*;• - ,c.0•y %? oJr?,•/• o / 'C.? r, it •. f, - o./`l= Y-fl,'? AEA F't / /r7o y/ o ANf I s >< Prl.^. (?„/rdN,? b rosy ,L Ei F ,Ll S 1 k? $ VEHICLES POSITION: FORE COLLISION xow,wnA r,slu? ruwu PN.Hnw., ar E>? iK•',v y ?' E, VI11KY,r.w N 8 E OVSTRiff OR HIGHWAY NAME ON NO D,ACIiOrH LL,I>T Ax kl F'NlT« 1m vHK1A rJCEkP,O IN.FSIX1AfED pMx 'l r..f• Yp?RMM +, O O D O L D?.I?« O;•aLL ? ? O O ? D ? ? ? 13 ?°OllmE Orliii>u Lp . D O ? D ? ? ? Murr EY ?f h O O ? D ALONG ({). a 1 z wASUwI IQGIxwNA 10 1WAr aD>k,a .A.r FROM DIRECTION To fd 4L Wt IT IQvIDInan ,uu. U DIRECTION 7 L .M ° I I.: A':,, fAli C(NOIIION9 1'UIIA:CONIIIpL rW [«rrtill TYPE O°F ROAD „•,• eD rrrw.w?. S O1HER I ' p - t" " IF, ORIVERr Y{IIICte ACTgNq ' A ? jt • Cv u,l rlHr,'I, rC,ACA WI UIMgCI ? ONI WAY wXNI '.` 4 • ?11wO DRr 1 LAM, OVLKY? 1 ?. DAYINII 0 I.1 0-,s O 1I Qf GOING STRAIGHT AHEAD 1 ]?RANM ]QwWN ? 1 0 s10PTsG ? I ? n ; ?> wAt ? 1 TAO Al w)YfA +. ° ] QvA],vYA1 ] DU>II 1 ° ? ] ? ovfnrA%Np ANp PADSWp ,h A ? 1 O'h)w ? ? ? rEID S,fr, ? ] DRUMISIOLE D ] ? MAANG TMIH7 TURN 1 V , Q,W A Q KlMga,,l D IWSrrwp HIT, n . D r ?HCI 'DON.. A UAHASIAI FI ? ? ' °IlX10pp RAMP; D I ?MAIINGLEEITURN ).,,- r IlbY 11 ANC•YI ?1_110,1 ? Y 0", ..'R ? e ?4lCY w. y'M t}? ("' D D•Ax CxT IlTHE TT -1 8E L rq DANG, R O BTRL {I 1 y 1, b ?F?. ' j, a l [IN Maw ° TV,O wpr r ? V / :11 I MIT LXA118 ? A x OI«13X,,4 ? S }. M f f M v,. tr. ».r. r. x.. rr„ 1 ? r DU,IrCIA IL 4AHL3 pl 1.Y 1.. ? -AN ?'fIi IUIN o n °liIIH.YpFG,I1kA1,IC ) F ?I r 1' -- ? ? oNxn ? I ?.JPNIAI{D 8 AICATEO AT !KWµ wecr. D alaTOpsrNt 6L D t D ? Id T1AFlIC ? ] ?prVIpEU ? A ? 8IOIWFONIIDAOWAY I 1 - r 4 y, hI ) Y-.NN4N _.1 Hi V ? ] ?UUOO ? 10 ? IR?fICIAN WXXS i,E 1 ?(( l1?1 ?,?? 5t AGC D II ° ui Ll INfl .{j(T kY . 1 `} ?1?? { (`/; 'f Ayd r•. Z- II O 1NlN ! 1 1 I M)_ 1_. 11 hfl ti I,•? r a. I,xu x IF ? .t- .,.. .,tf+P,I r.t v?,,, ? tr I i 1 11r I 1 ? ??„ z1 x , 'l ?1 N :-yc H S r ' `- ' D? STATE OF WASNGTON aDf DP No . POLICE TRAFFIC COL-,ON REPORT ® TRAFFICWAY RkN1 ANNrNWA&R PRIVATE WAY ?r - I.... .o.. gyp, ?N ? ?.N 2141 <IV OU 1OwN S ? W 6C OF NTH 5 EEIUp i.V NONINNp"", (?1 Y IRIWEIN S O? ArIFX iROin BLtxtN<,<pO5551REE10TR N?EM[SI h,iLf Iffl 0 0 [7 OF L MoRNn D P Iv )? NO -iR fD el ? OFER IYDMAAGI— D RaM Oi-R STR«RANDDWNfR$-I) UNIT NO I USI HpST l .RWPrwcE Cnr. L?.u•.-. RDnD? - - LJ ?w?: LJ RImAUrtD - _ s 1(AVID DIAGRAM Of COI II SION: ID aY Ar al iNt SHAT Ii NIIIESURYI Pno"s. f NAME, ADDRESS 6 INJURIES OF PE OCCUPANTS/ WITNESSES ; W sA„`"D^ 1'aw U.)CbnDWtifZD ?EI.1f.?Z? ?, .DnES_? /9? iRFA!c f YY 'lR 27 P. Stieics P03E.R-r Iz_ . Aw COUNIYND C T z3 J . I Y NO. PHWA 6N0 «Sie[[I Oe wOHWav 4S ROUTf OR r F R.SI {> " {?. . - T?101z?aD`EKrL PRfrIA f . Mh.r l ACCIDENT RAAV MILEAGE -ADDAMWTA D • CODE R ?HrS RUN ?uvogpiw ' ` RD I N R ? ?Sii°I'cli V Nt[R (ROSSSiR[F104 ROAD it/?7d ' ? ? ? ,?y`` , ESI DAMAOf SPfCL4lApNG TEE Ys UNIT NO. p ? VEHICLE ? PEDESTRIAN ? PEDALCYC115T E sl riR ? .,' [ DRESS ?r I ? D .Y SIAI! »C P R I _ I ? I R L NsE s AIf DA,F ei H ' :- T E «cupanaN fiRiA AMI E PETDNE No '?' . fns IcHI icKHIr R ?CHECK(,l) vIH<if z HfR^L aN ? CODES 3 S - t ' W Ciro N 0 wi ' xx i i p? ?.w. ?)i'nR ' ? i. ? 1 ? ? i rf ' N A ID Ev1 IIDARI Igvwl 11 1 _ H nH caDR . L N I a ' A i vtH Clf1 NIIH D ';? n R! 61f etDOWNER: iWSr M,Dae E „- - WD ?-YiN ?AWAY w.AV PfAWN10 IS .DAW ! ! IU, .... •.. DESCRIPIIGNOF COIIISIDN: ILEI1UPRIAVNIAI SNII»WCfS5MV) 1 R_?S X y, VEH. #I Lugs 1N0RrH8o(AAED oA! Lfo4rM- aSAIT Ro. ,f.(olkA-r ocir OF CiOMTRO(., TSjrn'- ?' F AGRoSS 7HE JOLtTf1$OGxvD (.7nxE, ES7R4Gk AW ENBg1U kA4#LN r, ROLLCO VV(,R , AND CAME To Tiff /VEST ON r--r s WHEiLLa. D 13PAkfiz HAD ? ED WHS N CAlse.D HWA Yo J. -so C..osE. c op mQo(„ . WOLVED i CODES I - p w q '(. s e o u.l OR A(.1 "Alu'. 5 R[SIR fMCT fuiir ? .. l?' .I S 1 9 I TD I I I Z t ? " hJl ? An»IS .IwAlwc. i • I.:E r w `a'ria e. ?AMe ?."3"?<.yn. 9Rx ?,:°;,. /` i , t i l? ^ANr D 1W KE ARRr D DAII (M NK»I AHYOVSORY WI! ? - 1 t 1 .:i+r ' ff?,? I ?u °?/? rI ;Aw IT Ik, .,[s -.A Nti ,? n, acr^•t? f ? ?`, r r 1? ? 41 ,l^I_I ? ?T x < I T Af u.,al ,iy I J ?`?1 y t 1 t I t ' ? ?'? ?r ;f ?? ?7yy,,? c t, I r y99 r 1 1 S I tl,? 1•yf. , T? t r. S IRI ? •? : is t s xY "? Y ?? i y ?9n^ ® 2 TRAFFICWAY POLI CE TRAFFIC COLLISION R EFFORT PRIVATE WAY rIX43 CpMw MNLLMBa r) DAiE OfCgI N O.+, '° /.? A I wB • IuI i I: DME (UiF]+NrvOURI i( COUNTY EI?FE?50/J OOIMIY NO. / UN INWA ? ?C ?N ?E clrDRlDwrv faNOpsratnoawcNwnr NR5 ?s ?w 001 t LIR ON Jr yes ?7O x INIERS[CtING N ivFN OR ROAD F+p+INIFRS[UION -EN STREET d rr 51RRr Gw NWUI MRFBDSI ' ? ? ]? . . OStAN E6DIRf EERfNU CRW SSSIREF104 NGVfitM ll 51 ACCIDENT O "I'lT ry 5 E OF 1?:2U ST MILEAGE 2 ? . DATA % <IXlISgNINVOIVfD. SEVER IY. 1 TO1.LL N0 NO RIIIfD?NO.IN1URf0? ?SR IGGF ?NITa RUN DIn CE VEHICLES Oi PRORRrv DAMAGEONIY ?NIIE ?vT R ITESUITED Jf0 IMFR 09 NICE CRC655TGfEi Qa aOM " OBRCI SIRDC<INAMF Of OB1ECISIR«KAND OWNERS NAMfI AT u[J ESI.DM1wGE IS - Oo t SFEDIM 16E `D?-D9 E NO. L UNIT LINITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLLST1?: 3 DRIVERS NAME: IMI f E Gp RWER'SN- -1 ATILF s1RFft ss /? D # /-0 80 RFN Amatss rv PAR -CO. INE NO. 8J$ R ?U 7617 404 P / O N D R TIT EAR Z. DANf ee NSF i+ V. 36,0 .I( Of BI. '•` ? ( I N. NO. AIf -UX OAI BI N i ' a «nvA " I nRM Ens ctN1?M AiT O r? R- E R 1ONr «cuewnoN RM NNAfa %pNF NO. EYES GMI ? GIN c ECK (r7 vfNKTEAS AN rww e? A 1 ?CHECK (?J C+FMANrM 0- ?'A' MANOrNR N NWI CODES ?* r e :s n<I n i° D 5 ss nM T ,- iry rD CODES II- 3 a a° 5 exc a sMO.w 2 N1uv 1 0 !w!. °O ? -N ? K' ? c8auv 9I2ni ? D„ Weofbx ? ? ? uS I ? &.. ? ? T:; Io nN. OODG .crltvl 7'/ MMt '?71 E? MODEI IDNI.NOVw1 s1TU:1]DR c I I G E .) MDDEI IDAAI.NCVAI I11? a N Ke Fu l,? sfATE IEa NATF NO. sTn GIA zo W/t H c vEN.egoR DIRT ry . V[NKIt IDFMI/FKAIIONryNO .3 1/ ,3 O S L. Y I D Ntl I I I REgSRRfDOVRHR: 1/31 NRSf MIDgF E.vL?tX' C r RKINNO. 300 O W MI IS RFD WNfR: lAtl FIRST Ty. - Ap0MS3p OM+N 7117 ` 2?Cll, fI N E fR NAMtaADgnssp wwRANa co. oRApM DMfA 6ARG .R$ ciw vFN d 3 ISI.'DAMAGk WRGWNED f ? TOWED AWAY BY: R DAAUGEDMU <nnacE rw aN,f DRMN IT-NfD tSt Bi ( f R1DF ? iOWFO ? AWAY ? s ?Oi1GY AWAY ar: DIAGRAM OF COLLISION: I INOICANNDRIN Sr[rU NUSSMYI Br A- O -+? Gaanu DESCRIPTION OF COLLISION; (.f sINFI[AVN1M SHEET IF NCesuR1) bRJuca C"4w-f f?F. Xer Tnt ceps To aw yl/&- ??afcme r VW40t /(pdfl ?fe t'un r s Ef . p.Yc.f_a,•0aceccr -r7 ll? PAEG?w: a °!' 7,W rPr „ NAME, ADDRESSB INJURIES OF PERSONS I OCCUPANTS/ WITNESSES NVOLVED +CODES MIT 11 AG[ 1 I- - 2 I" 3 .' w 4 5 s1R. Exa 6 ° . nDRrss DRIP . AM a ? w, ? " . ? C. ? m.. N AA.1 ? " A lq.lif NAIUR p FMVID IYOIA ?F,,,N_ ?M"0'cl . ?H ?n p N AME Fi0 m.fss H11.JDF n u1Ner. ?AVa ?1?o.rr.?t; ??N,. L rKNaNw1 •• aADCap Af/fl[Y uM1 ?GS'O N y KI ODIAICN r'Ot M.inO DANpg1d1 - AIFVOVID RY OAII I rj I { rM- T x S,Y K 1 f'"'{M r`i.?IG'?SMIL ? xl•?YP'1I'UIyIRiN SY4y? I« ??"?1kIJ Y?.?'a,'J"R?{AI'lr" W.? ?JAflyM1Yt tl I 4 ti y < ? ? l 2 6 ? ` 1 'r i ? I t k }R J. ? ? fl ? i111 t l ;'r !r ? E _ 4 I 11,E t ?:IY I r '" f I 1 I '- ' J r ?1 I ryp r++. 1 ? f I 1( 1 1 I f 41 1 If . I - 4 b?V / 1 1 j yry I 1[1 - 1 ' t'-. II ? 1 I Vv? l R Y ? rr v '`Xe a ?. vxme. J?uM ra arr?i«a£??.l3tn. M+s: v , «vsvrr.?unw - m^ 4:.w `;2' .s4w..si .I a $ +. ? k 3ssw.'i ?. ?• ..? L??tim 'r?•'^?`` .LSN' __???. !$6Ck`. 5? ?u'.,?kYM'+'(, ?;.t?.ZrX . f?"? ??`fr ? A STATE OF WASHINGTON GL 01 ®TRAFFICWAY No. - f l POLICE TRAFFIC COLLISION REPORT PRIVATE WAY i'DCECOM-TNUMaER - DAZE OF ', AY I MU O. OH wIR1 I r I wwluox.?un.? ( Ptl .,. USE II RNOD ME I NOVRCI J jUN11 7 5 _ G:Ea COUNTY- //?_. C? OTYNO INWA ?URB N AL / pN ?f pIN CTYOR TO WN 0 NPMFarvO.OFSIX EfORHIGMWAY -Q M I RoU1EON5'PIEC SI010N s w Joe' CJ y ON p O v?GL3-9 q p /( AuLES 7vL IER)EECIING.111: STREET OR ROAD NO INIE11IFON IN PPEI% M MILFPOST?,?,/ 55 Y, L /{ LE fFN SrREFi 6 _0 C U151ANCt8DxfC NiNOMR ifxfNCE. Nw OSS STREE'OR NEARESIIA- MILES N 5 F S1R[Fi ACCIDENT MILEAGE RAMP LMGRAMDATA E TESL Of J COLLSON INVOIVFD. ERi IAI NO. NO KRIS ?N INIUR[D ?SPLLAGE ? BRUN E Ez'OVEHCIES ? p PROR GE ONLY ? PE ?v I CODE wn9HRln INTFR ' %-RD Cl5 C N TIN FIOR ROAD OR REFERENCE ROSS SLR[ELOR ROAD TD F F? ! cUl S l1E0 ' EST D GE SRC AL C D G USE t - 9 . AMA S NAME) O01ECt SIPUCK (NAMEOF IFCT STRUCK AND OWNfR IN O UNIT NO. I DIIVIR'11 E: EAST IP i MILIERE UNIT NO. 4 [ DRIVER -E: 1 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST. EAST MIDDLE FIRST ,.F ? S .,9 o fJ _ t .? SIN[FIADONI 5 _ ..EI ADDNESS ? OI STATE 1.1- PHONENO. D p STATE IP DE PH NE NO. 7 En . &1A 376 Al R IE F% BR IH I S rA AIE E% DAIEOFB RIH UENSENO R .L : xY. _I V RSIICFN5E N0. /? // '' // 0A)4MM,5 W? O I ! MD.I07J R V E ES t E . IV OCCUPASION RM NAMEa PHONE NO x9. I oAV IYR FYES vhIGH' IEIGNi . p. 0 K UPAIION NRM NAMF aPMONE N Y IGHi HFIGH R - ? ? CH G 11 _EMtnaEASN MMOVFF Of wNOIHERM 0CHECK (6 ENCLf ASAN EMPLOYFEOFANOTHERµ ` "O „y. A r.11 L fVl- CODES ? D i s [ ° wo ' 1A1U11 11 E CODES ? 0 q Psv s u a -U1111 ., 9l.;°Yno roM AK.NAA.KI ? U KE ? 1*11. ? 1? K 1, ?.11- AMOOFL 11-1 -11 1- (RO ?CONV 1 H [AR MAKF DOOGF{HIV YE Ye°' ? AwwIAH?t ? C] ?°6C1 • Yb:HR ? KKK,! ? uH TARN ( HFV 1 MODFI IDARNN VAl Yu ) ( 2 E OR J LICE PAifN SIAjM IPMlt9 RAZE NO. SIAIE II VfH IXOR NO. AIF 6 ' NUCI[IWNINUII NNO. L VEH CIEIDINII I II NN Q c: S, y, s 112: 13GI ?I I I ! I I I I I I I I I F PN N[ MIOD O t T 4LGISRR[DOWMR WI 11951 MIOOI[ PHONf NO. O .PSe S?1 ,E'ou ,J NU Ilk[ WN t 9 1A51 f1RSi ` ID W AD 15f f OwNtR 0 C A WNR ?' :? EP A //?? , F? ?. , Ur?b' N G Q3 ? l (TV R INSURANCE 7FRT?-? N ' HAMEA A-1. Or I-RANCECO. OR AWN' g6wc ' ADI w . I a? + E TAXXI rau - pV'yKa I r CHA oq .. CHARGE 'oR"iiP' oucr ?mnA wav,. P ? S1 2 ? , S 5 DAMI.GE EST VfN [3 RIMA. NED • AWAY ? 0k VWAYtN EAIN[D !SI UAMAG( , s oe ,' , 'OWED ?? ' low[O ? S - S Q Aw.AY er. P nwar ar: h) y ` le DIAGRAMOFCOLUSION 316[lu f TAI cAlt NOxtn ? ernv9ow 1 CEssARYI. i OF 4 SCRIP ,d TIQNOF COLLISION IUSf SUPPLEMI jAL5HEE'IFNECfESARY) _.. - Cclrevz,T' .. al/ ? R/dG'•L'. Loi;'- Criri?n'? r I ? , ' , I I i . _ Gi( nsS Iva-9th J/a a . ox? ° f I ( T l TJ ' ( olf o>n r in .. /9E4 T ui YrzS• Gu R / L E° I W4r r0/PiJ?? S7fJnsYJ' /T .FEt7' L/F -. ? ?_??? _ ..sorrT?'T/1/4)!r /3/7dKr jAJ TCr' ° -?-- n ou r L'a',o NVOLVED F J 4 5 6 E ,. OF PERSONS ADDRESS NAME, INJURIES uP,I w NTA SH - I I M CODES 1 - Z _ CCU . OCCUPANNTS TS / / WITNESSES I' OS ADDU1orvu NAM - r si FADE urus w .,? nCL ,HI Y, ami. ixcr 1 T WEG '. ?J r 1RUS -. ]" ' n M K ?. Me. O 'lcl p ? Mn ? L,.NA A ` 1 A 7 u Ix,Nns Iwra RIMwIOr9oM 0-- pro, Kl ?w p ?X ? :O1..I. vo a ? i wvl „priI yjE ? U.r?v? f ?Yri ? ,inP? X ? .m ' p r ??r . 9 T LHS 1 ^K I' A.? V1 YF?E! O U PS .AWI O wGIF KIDt ORU KAKI NU 010eY 011 ian 4 '1Tr ?7 Ylilk ?E+'1R " ? fi ' 1 F> , ? '?.h )'A ff n tJ? '!dWt 51 11 ? W11 ^S54 'U'i- ktY LUY 1 44 ,[ 1 P 4 h Ak ' ti T - ? ?siFS I, h .r . / . ?yl p,ry. }? ry . r i 'I ,? r rl lT > AI' Y h E ? ( 1+ 1 t 1 V ' f A ? ) I ( 1 i 1, 41 U?,V ? YI _ - - p ; EC 11 ?f Xkr• ? t I } 1% kk .E A aC fl f?bW UJ 0-. L '/ kt ?a, ra ,v N , r i I _ yc , I , ry-.^ E • ... IIYUIUN xxr MOTOR VEHICLE COLLISION REPORT ' OFFICIAL USE ONLY NO. .3 { n ONUQEEOO ux Q W _ •OOII COUNTY N . CITY NO /? y AN L???; w rn -Ir,G own MxxD w.r I t r.s . saxerxsncooE , ? cr oonMRlu s ? s ?w ? o ON LS N Gr. .Pd• no wnn srReer n. xxi-RSen ox / , I ?a 0 , ?? ? y ?p/JD%N s: u,VG: ?"N uM - lu' 'T r oo L? 07 N E xA Lrgxnc ER.nwooe. x055 na uL-POSr ox loFni sr x-LAxUwx. • eaAU DATA Q O 1 a M,rMMM BNW .MRrD E]IUIL o= V ?-n p-os ES - ° ? x u l M -- fa089B1 • EfEPENC[O LPE T rv lox n- or n vE ci[S ? w ros v [u?renA e;: x I MaNA no ACr vE UAr[HiuS O E ORROA OBJECTHRIUfIL, J. .', „OIWf GeosmcT ?iM,eN :: OWNER OF OBJECT-NAME ANOADORESS "Wall . ape-------- a DflIVEA'8 LAST NAME .:•'RRBT NAME MIDDLE E AN OR ro v O DRIVER-LAST NAME..... ,FIRST NAME MIDDLE P GN Lio/?-l L . Co IN T115 "?c s STflEE1 AODflES9 ,, ROUTE NO. AND BOX NO. EO STREET ADDRESS ROUTE NO. AND BOX HO.. / AI?E A CITY BTATE ZIPCOOE DRIVER OCCUPATION COLLIS- CITY STATE ZIP CODE DRIVERS OCCUPATION a , , . ^ . ESL a DRI Eq'S IILENSE SATE -EX DATE O BIRTH AGE M I M - DRIVER LICENSE O. I STATE SEX DATE OF BIRTH AGE N EX G 1%, Gn M DAr .A O VEHICLE YR. MAKE IC E . DOE) EL( 0 A•DARTI BOGY TYLE 12 .1 VEHICLE YR. MANE I-- DODOEI MODEL )NOVA-DARTI BODY STYLE 12 0n l 1471 , ATATE.,N:.%,vTMILER PLATE NO, -STATE. LICENSE PLATE NO.- STATE TRAILER PLATE NO. BT ATE &I Al NO.' r, ." VEHICLE IDENTIFICATION NO REGISTEREDOW -Flfl T- IDMENAMEI IVERS ICENSE NO. ILAST-FIRST-MIDDLE NAME) DRIVERS UCENSENO P /] JJP p m EET CITY AND STATE) DATE F BI OWNER'S ADDRESS (STREET, CITY AND STATE) DAE OF BIRTH Gn EN PARTSOFVEHICLEOAMAOED re LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ? NO NAME AND.ADORE-BOF LIABIMTY IN-WPMA OEP.OLIOY NOLOE{L.;:? ru-.:::, 11 t +s ). -NAME OF LIABILITY INSURANCE COMPANY NAME AD. '.. i s G NAME AND.MAAF-9 'S'Y[i :.il'iR+ir `SJY 1Ys.. P.!A der v. ,'J.1 W .: L1401 _. ? .S b - LA u / Z - F GS Y1v????? ?...;wrrAVevi.zl r ?iu" 'Hn'Di rk is .T'. wY.v.'95u v' IW4RY.r':. -5 rIUEYI?j?l4?gppp?.Fplt?00-i INt INA1Ng1,. .. .:... f10E . NAM G 1' NAME ADDRESS ' ADDRESS -EX NATURE AND EXTENT OF INJURIES M F ? ?EEI??? NATURE AND EXTENT OF IN ? ? EXG_UR,?S RE EXAMINATION BYDA IDOECTORI NADMEOR5 .1. INIUR EXAMINATION BYOA DOCTORr O NAME RS RTA. .OE7N,l11RE0;f,', '...? , Z K .MARK. FRIaT Aeu i n u ONE THAT APP SAN nc 1 LIES' ross .,STATU-Of INJUIIE[I O ';. M=.HH ST O NE THAT APPLI n„uN ES NO "O naMRUn LLEp u v i ir ur?rn [tw _, u. W cI pA NO ` e KILLED r51v-xrr rurn,Ml nr ? ,r,.,. A.... ? 5 ? 1 s ? ? ? ?PYnt r Ax ? 50 6? pA orT Oc MOTORCYCLE SAFETY: ? HELMET USED 11 HELMET NOT USED MOTORCYCLE SAFETY: 1:1 HELMET USED 1:1 HELMET NOT USED 4HOW NONTII BV MnOW W CIPCIE #yti."Ie1 r Eor, ? O .hF'r._.ilA 'T? .J,i-i'ylF;::. D' I,TD. WRS AWXIC0 /.v feRRy .CV40iA/e, za,vg ,... . n.MEa , VC/Y%L_C / S719RTt'D y/o dFTo &mrD N.-xR ArWRY s o/?Ai UE Zo UE 1 VEh )?)L E # a .6%/?D l7oa e a pF v. -? ?.- (UJ(ST Si o? d?. Ri r Dx - w., TRA/cK R FL4_A1.0 EN o F U Eii'iv C E fi'r ' "&0 o"94VAL ?' ?4dr/T /?ri0 o f U?aR o f' _U A£Hia l,G ;iv r: T? Q - tIFF? e ?j c'ia 6 Q%R?z7 no 1 ,.,. VEHICLES POSITIONS BEFORE COLLISION i INYESTIGATEDnY Ix ac rarAnnrq N IMI? --r rul N VEHICLE 5 [ W DH STREET On I11G1IWAV NAM[OR NO " • wip ?Yi ? .LO vNiSLI OCC rnN iA1cr 1 :POJII` p ? ?? x°a ? ? ? ® ? 0.1.1'.. 1 ImIarRIAN. ? ? D. D 40"" i.'` A2;%c..' : I•''.tt . ?: ?iol[iR'::,. ,.. FROM TO PEDESTRIAIDPEDAL CYCLIST WAS USING. I ?a.o1 • 10- 10 "R w . K I ? : r ?= I ?orrnn . ? e: 1 ?ro PEDESTRIAWPEDAL CYCLIST CLOTHING COLOR: ~?o, 1?.Kw 1?... .?Rir 1? Rii ROAD[URIACE ,W[ATHIUR UGHTCONDITIONS TRAF`CONTROL. TYPE OI gOAD pRIVER,VENILLBAOTION4 r1 a I ? GAIIK.Hr • wncx Dull DWI I:.. 1 r N 11 I r rxc l Icwc. MI W MTxII I I? p1Lx(x , c] SK1nAL5 'AOl iw ?{r• ) ?D•V.,1 ? I ? 0N(WA, ? ; M ? riOlNn ]T11AInNt MI[AD r I ? ) C]." ? N r NY, , ? mu ? , ? 41 OI SION ) IwO WA, ? ? ... _ L-1 ) ? OY[OTAMINO AND VABLINO ? ) [].- w ?sMOwI"D 1 ? . roN I. UN ? ! ?n1mv ? 1 ?HllvtilMnlE ? , ? ..-m NIGH, rUnN ?1 ? • ?I? 1 ? 11401,[1 ? 1 ?II AMmrn-, ? 1 ?I?WRnA4PL ? 1 C] .-Na LEI) TUIIN . ' , ? ? s CM I ?InPILM,I 4 ?f,.ITT I IONI, ? ! ? ItAMIiNO AMMIR ? f C] AIIEY NIV ? s C) MAKINGD.1UnN 31[ Y I ? ]i[LIiV ? 1 ? RR In,MAI ? I ? I?AAl, ? a ? Mo.'NO ' i I "' Y AC[TY/[ 1 G//X;(RrIAGMLN ? 1 ? (M VI'WAY ? ? ? {? pLJ C) , ? 4TnlrtD lDn rnMflL L.l Ll ? ? OT I SN CIIV ROAD /MA El ?] El I ? 4r OPPEO i810N L OR 61OP 610N - ? ) ? dV G(D ? ? 41 tD NnG DW Y w 9 i 'Y ? M t ! a. l y ? t V ? I ? i ,?4 ? i?4 1 k ;. ,p Y, ----------------- jmm N:i ' A in, r J ..: IVU. ?. `f POLICE TRAFFIC COLLISION REPORT ®iRAFFICwAY ' / POLICE COMRA NI NVMBER + .Dn pE[OLI _. ? PRIVATE WAY '.'. I I .. R I K _ ui nmE ' I I IS '', I /C ` I Q n x. Cx 01?y?y IH (USE LOOHOUA) COVNry NO CITY ND fX A 3 (n - L Su_ lu - Igo w[, I ( s J -.1. o UR6AJ{ ?Y?'4X3 z7 y 1 I @/" DYJ ,IMP p•[[Gq,(e TOWN NAME6 NO.Of SIREfIOR HIGHWAY US Ei O MILES ?S ?ty ?IN CITY OA loll" RWIE OR R 3FCrI0N '••.I ,; O OF °? INIn3EC11NG WIIH:3 EE RROAO A dCU1f/ '1?N ?' ? LL??;O ? IrONINJFRSF ION lY? • .Urd' ?IdO nEfIA' E MISSPOSi ? .? I ? / B[TVfEN SIREET d SLRtEi ??• 0151 Cf IDIRf rl 14 of JJIEN ,[ROSS STREET NEAREST MIIEP I , E, MRE 5 F W ACCIDENT PAAIP DIAGRAM DATA ,' O i[Et Q MILEAGE COIIISIONINVOLVED: .-AL 0 pF o' c DF "? IC)L'o. NO.KI IELD NO.INJURED. ?SNLLAGE ?X RUN 1J.. ., RD N N TREi ROA Oq REfnf CF ]] +"`• 0`,` HICLES m ® PROPERTY DAMAGE ONLY ? FIRE F0 F IMn CIS N is$lR[Erpq ROAp' N ODJfCISTRUCK INAMEOi OB1FCr STRUCK AND OWNER'S NAME) [ .--x " 9?/Oh?O Y 1 5,+ I EST.OAMAGF SRCW [GOING IGE s Dglvn• WANE; Usl UNIT NO. I - ' - UNIT NO, 2 ? VEHICLE ?? - = L ? Si PEDESTRIAN -? PE ]x DALCYCLIS7 q ERSnAME: U I D ? ?- 31RfF1A00NlSS ? ? I S. IREEi ADDRESS STAY ZIPCODE PHONENO.' D ly ' , AE x n's uCeN$1 o. T4/J h D 91' f/ R " :` I hL -'f n SIAIf 1L fH I U FN N I. 3,. 1 - `{ A`/7 A R YB RTX 1 I OCCUPATION fRANAASE d PHONE NO. S?. RAx 1 y? u '3 l EYES WFIGMr HEIGXi E CUPAJION I IYA, , I NRM NAMEd PHONE NO EYES WEIGHT HEIGMi [l_ 'I ? CHECK (6rl 1 R.J 7t -7 R ..?. . v .Of ws AN fMVior[[GfANOmfa. ? CHECK (? I; I 2 NODES ? * 7 e,s x °y jjl a U[CIgH K VEHICLE A3 AN D ROVfF Of ANO F4 e u CODES ?'f n x1!41 MW ' q Kvl 5 1 f Iq a ASD LL. ` ! ]) I. a EH ruA E(DODGF MfV.I A, FL ART. VA) SrylEl]Dx?.c_ll `.gfoK e ? s? 0 eE C - .O Ylx ? .A ,. ID 3 I .1 -LALEOAIEi NOV 1 -?I•. ,. . N 2 ?? E I 9 '?,• IICE ILnI N ,. lf. iRAItn RATE NO. SIAI li V H. -- 2 n RAE 11<1EEI A ? 1 r vIn¢ulDwnauiroN NO.'. J ;.' C V X Cl ID N 11 11 I 13 IG L31 IG 12 11 I I I I I? I L I' I I I 1 I I I 11 I i' I1.. - v[G131n[OOSYN[q: IA51 IIRSt mIUDIE PHONE NO. I O D .VN! tASi 1 _ iIR3i DL N N S 2 A004t330 OWNfA 11 ? N A NER I NAM[ A ADDRiff GI INSU4ANCE CO. OIf AGlNI E .: I T R EssmRSDaArtrra ao e ?d? ]] ? A S RRU RµA.,ND ' OS327 = '. jl 3 .tOf Olw CHMGI r..Y SI' CHARGE B 1u gNAAG,omEAA ]3 S IG ?OTlOii E tai ONAAMMGt ? UWAY ?R[AWN[D AIV(N OM1• f1D1 , f l? 0 omlyoey .xJ ?° I]AWAY ?R[AWN[D f51. DAMAGI ' DIAGRAM OFCOLLISION: /1u AWAY aY u ND CnIt ryryoAln f 1 TD no'u f - R 1 I SHl III N( SUAYI_ lCA 40W DFSCRIPTIONOFCOLLISION IuSFSDIPttAUNIAI SHfltIINECESSARY) I q d .. ..,------ f ad? s sT - j ? r f I I L. ? GursA on..d_i?j? .vaC?F.;" 'l , I . I I I J I ? L- I_ I _ S/icr?.???nls .T?e tdoiTbr/iif 9..d.r.c?_er/anr• „ ' e r eE/ 6 I I _T.l T? t u ? f FIF11 I f I * .f .. -=-- NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED I - - Y OCCUPANTS/ WITNESSES (US[SWRNAINI.IlI ,CODES 1 - 3 4 5 6 NAM(: TOR ADdIK1NAI NMVSI f 1 I ? • ? ??t ' ... I s[R Act iglus 1N?x. •u, - NAIU. OF AaT { ?TI'?^' .OQa'' I:4;,LR. I }I,'r SIrJ a #r J T' .. _ . _ ...,_ f _. 1 Dwn3 _ _~_- R N ton i1Y5N_?` 4 ?' l t r E. 1, N[ N ?ANE. ? .il[f k 1 yy . " D0.111 .... N IW d E••S x],KI ? i a. 'J ? ..,i. ,'1 ..??:.i •u [ asr??rli`J??'r[„;fil. a.vullGAn.aalKn..........._ uq f n.... _.._. /.•'???? !C'E' A'fC etC\At A CLI I P IPT/?\E I - .... _ _ . ....,,..........1. I OF I LJ TRAFFICWAY `'? ` POLICE TRAFFIC COLLISION REP No. ? ORT E] PRIVATE WAY DAZE O{<q u5 N qY <Oll. N E COuN 11 PCII-CAl-IN-EIR yl' l +"' VSfa HOUR) 10 6 w" Rp„ IPIS A1p.Iw.s rH '?, ( U??1 J cFrf'S C?ALJ NO, iHWA rI11yBDArR ?Ry ?iJ z ON GrE C] N F1 CIY OR TOWN OOi S?°E?t O]HIGHWAY 7 W1(s 05 OW 00, 00 7LCVEG ON C l fid f ? % ROUNORSHEI CO S[CIION INURS[CTINGWIIHNINIFR/_?-?/J? J SIRfFI 6 / ' •ViI/??J MI[E 4 6 HIREN E.CR0 ACCIDENT I 7 .ryE MILEAG R-.,A-.R- DA TA , _n 0 Oi CODE COll1 TOTAINVOLVED CiVEH SfVFPItY: NO KIIIED-NO.INIURED_ -"GE GE TOtTINO ICLES a O PROPERIYOAMAGEONtY 4FU NIER [CIIN S1NE ORROAD OR[IERENCl CRORTNTREETORW / G/ H[IE OOIICI SIRIKK (NAME OI DBI[CT STRUCK AND OWNEW5 NAME) ESI.DMIAGE , ?Tg?? SPFCW CODING USE UNIT NO.I UN 0.2 Ogrv(N'S NAME: 10.51 NR I IT ?VEHICLE ?PEDESTRIAN 0PEDALCYCLIST ?? 3 S MI E ?211?`t..•..A GOA, R7_ NAMI. UST NR MI Ot! STREET ADOR[55 SIREET ADDRESS CIIY IAIE aIP CODE PHONE NO. D CITY SIMF IP Dt PHONENO R . DRIVER'S LICENSE NO, STATE F% TTA EOF BIRHV ( V V 11 ENSENO. LATE SF% DAIEOf BIRIH e. B OCCUPATION 'I'M NAME a PHONE NO. EYES IGHT IEIGHI E OCCUPATION {IRM NMAE6PNONE NO ETfS VhlGl r f G l ? R . l l l H ? CHECK (?) AF ASa ° PoYrt of ANOmra Al li ?CHECK(?) C ONl A ^I r J % V r?oa.cly CODES P * 7 ?;: s UKltw + s is 5 E e'S",° - VEH LF A$AN FMP[ o ANOTHFR rpl CODES III, D 'D" a iY 5 D 6 'S1Ofin ' „:' 's?eAA"' lc1:DN . SR 10 : 5 ()A N%;wlos VI E..%?L ' vaM / ? until F ? u YEAR EIDODGfOHfV 1 o ! ? cbnly ? mini ? iwilu IDARTNOVA) STYIE CIORCO sncin er°1Po Aw.euANCI ? C. P. ?Cbirte ?v:r,c,, El ie.„v . 73 ! NV) I Y ' 7 E n ruR I H[v l MOD[11DARr.NOVAI aDq . 1 ? 6 UN tN ?,?y,?r,?1T $IAIf TPA ITER-11 NO, IIAIE H HCaoR a A N AE w GJG 85 I CJr[I I N ' 1NCE DfN111CAt10N NO i VtHICIE DENHf .Al N G AE CM$2'2 3'86' , 17- NfGIS1IR(DOwNLR: WI IIRSl M-1 PHON(NO, /?[AVE? nl n LJ. J2 O W I I RfD OWNER: LAST {IRSL MIDDLE N NO. ADDPISS 0I OWN(R 72 7 So, 2`/S'Yl' PL, ?dFl.p/ E A OWN. - AM(tA°ORf530PIN5URANCECO EAT-1.1 N U-E-v1 R as l i AMAC(D wu I A. N EN... DAMAGfO M[0. // wi CNARGI wC oHA! a??? AWAEY R[MNNfD DRIV[N IST DAMK.f I ' L? _ TID S ?ADWAY ?R(MAINED - f ,? IO ID G ? L .li - W 0 - IOW[D ? s &,} 'uA ? AWAY BY: S U w It 7, DIAGRAM OF COLLISION: $H s INI N(%IDIDESCRIPTION OF COLLISION: IIb[sINA[MENTAI SHUT 11 N[ceSSARr (II II h[CLSSAR Y I Y APROW 1 n . _E> lYr ?'? I WAS -1-C Au?tl/ ,Arl N I ?a COy I 11. . c. (Pv LJtl.r.lt. / £ ?d ? Fwlctr.0. ,{ t?LJG S+'t l?llt ?Y A'? 'Lc? Q A y'6' OR a `,, _ / . ? . ( . • ?-STLE Luzr l L ?,rr Ql lr . tf.G l 1 - 4 ? c, R0 0? 0n4v fl,. U _ At tl l?l L2lT„ ?2E CJAS 6,0.,<I, vZI,I;.IL _..._ __ ~ J , C - Ff ? .. ..?, , -ti. Scs.n.S. 0.°t NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED + CODES I - 2 a S 6 l µ OCCUPANTS/ WITNESSES ,w ball w iu eluvii s(K AO'pp" _u ( t QUS Ran ¢I ; ANF, . n ixE uxw'IU rumR p w? AM e ?ESKI O ,.I... ' 0is:'Nu 0 A IA . 9 -.. „ WISE NAh. OF e MOVlD 14pM ?AM4, O ?nu. • ? qw ?ieI b NO F A I4 [xwlss HrM?q Ir,leY OAMe Of•cl?'r"o.Hl O li ?:" . ?, .,-;'7 Ill r?•.'r+F n; -.. ,uENvr P6„ - •ArT;if,I (Yis+' a -r ?.r ?.rbFSAr .r._ai ar..:A; 1. J11, 14 E r a dSifOi]2NLti :v J. ? v PRIVATE WAY o OAt OEC4ll ?... LI N rIME COUNTY ! Swv IUSE RED)HOUR) iS._ ?50AI COVNiY NO. CITY NO FHWA ?? °°GRU ?N ?E ?IN CHYOR tOWN NAMESNO. OFST DR HIGHWAY FCf S pOUlEON51NE ; INiFRSfCt MILES ?5 ?W ?OF ONCb L ING YAIH: SrRffi OR NON INIFRSf C 11 0 N 3 sa3?o IIR [ ? n n BETWEEN 57REET 6 C/L STAU, D PRffl% EO iV NJ51 II CE IRfCiI N ffgEN ,LROSSSIPFEr OR ` NFARFSIMIIE FOST ACCIDEN MR ES 5 T RAMP FEEL OP ?1 CODE MILEAGE 3 !J C IIS IV[O SE . M : VEILLE Nll[Srv TOTAL NO NO,. NO. KILlFO-NO.INlURFO_ ? SPIIIAGf ? RUN WrvOVEgrH OFVFHIOIS f Irv 1 I / INI[R? C C4'OSSSrc ETORRRO?CND FllEgfNCE SS ? PROKANDAMAGEONLY ?PFS UIifD ¢/87O OeJfCTSIRUCKI--... OSJEC.SIRGCK AND OWNFR'SNMSE) EST. DAMAGE SPECW CODING W`E - DE/ $ 3 -- UNIT NO. I . '.'. ... DRIVER'SNAME: UNITNO.4": IASt f : ? VEHICLE. ? PEDESTRIAN:? PEDALCYCLIST -.. Rn I[R?51? I IXE ? O S7' v/Y sv? DRIVER'SNM1E: V1 H 51 - 0?J STATE ADORES .Yye?3 ?/ A IY STATE II CODE PHONENO. D Ily SIAIE ZIP CODE •J P ORNfR'S UCFNSFN a," ej,? ?• H Ii ( V LIEN NO. pf AT BqM Jnw I pnr In ..: q OCCUPAl10N NMEE E PHONE N0. ? EYfS IGHr frtlGHi E 'UPAIION FIRM NAME a PHONE NO. EYES WEIGHT fE1GNr F l 2' e 6FP Cu Sf.E?IUfG eU // R ? ECK vEHlnF nswN UnrioriF OFAN4IHEli.? ?CHECK (?) HICEFAS AN UIPIOYFE OFANOIHE' 2 S DE CO ? * D A i S e e° CODES H 7 a % i. 5 [x 6 u '' ]R ro lmlFS :a,RD ? A ? ue [ ? 06. D ? „yA:[ t M Dr Po ? M rvD[ o ue<E ? zs ?R ? P ° ? r,°? h AU VfH. YEM MA RE TODDLE{HFV.J ILLDARr?NWAJ SIVIF ERDA.CON J -7 ?RD LTA ?/ 02 E . HyfnR Y IMAKI 1 HfV.I MODELLDARr-NOVA! T T DR. .J J„ Y NSE SI rE rRAIIER MLE NO. SIAIE H vEH.caoR TR[R1 N fAE w' ? F? ( VEHICLE DfNTIFICATIONNO. IN! I'll/FIJI I/I !ZI ! I I I! .......... OWNfq: lpyl I C L VENICIF IDfNrI 1 I I I I I 1 I 1 I I I I ,I E•"It J ly IRSI MIDDLE PHONE NO. - aev 38? =383% AOfIRfSS OF OWN[R O W S t D WNfR: IA51 FIRi MI Dl - N GJ l JG % 7D ?H Amt N E 01VNfR I NAMEtA0DRE55QINSURANCf CO. dAGfNi NAME 9 ADDRESS OF J R DR RD/V.SA j[ ARG • ZINC iOHU O I AMAGE MEA FED. 10 "OR" rnr%r p.•cl F 1St. DAMAGE dEJ ? CNAPGf DRIVEN R ? AWAY ? REMAINED IOWE CHARGE ? DNIV[N ?PfMNN[D AWAY a n1 0 [ tSi,DMMGE t g p FLOr 10 ?OTIGU S •? 55 S • D wpv en ?AW VeY = le DIAGRAM OF COLLISION: w DFU k ND Utf NORTH - - sHE[ uCRtuRYI- ? e R G iq,- d'b O DESCRIPTION OF COLLISION: (WE SGrMEME iA WET IF NECFSSARr - ... _ _ _ ) ' ?c vE l ?ryo? y- [ oJ1. i o H/ _CC{ RO G s..?v ?Srir?*pcw I Ina vcaalC / /m? /3?/C i r c/r s ? ? . F_ air 6? r. !G ZU. _L-- _; (! __.( r C.:6t2 F/1b1+ /jeeuS?/ D?f G/rFT S!O/ Of , F ?rocaa I . _ __._ _ _ r_ 2a?iv7D/?!U6?Y Hir_.FS s%rr/JOC??-- ` ,, _ j. _ ', ^ z 7 r !/.r_.. A???._ AT. ?7kF?_/S?4G}' ` , ?`-"z7 ?l1Kl N ev/>?eFr ?4PY?U? p A?/.UFr?.-yd0 .cyi_Tiy?__._ teip /tr u /tv Eu k c 70 /!/467 ^../1/e4brl ../169 .. (uMfEG Gk!<? --- CG v l O , , tD ,wr ewer !?Te eoc O PlAlW ., /32¢A6s AAfL/G G V 6m /&;p 4 NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED * CODES 1 - 2 3 4 5 6 OCCUPANTS/ WITNESSES I`w MqIo?NU'NUR I siK Aae Taus '"Z"" -'?' wJ g Elrq. UFR .Ky S . ' ...._ .. - . • .. ... r ep o?7 ?' _ / A N O m L/g 4 •WCOC. K I?KS I AMI. A uR Try, p? tt??? NI eY: ? AMe. ? F ? ~D. p ~ pJ ra?,r. n h DDnu AMI: P N eY. ?M. [0] KrDr. cl ?oM ?T ? :v Ra , ., .-..._ .._ _... _ ... H A nnrns Prv AT IWf LICE uENE - v ?AMe °,c 0-6 GA,F,u ?'mm. ?N?Y ? li°.??w X -..ANC ? ergD r r2 Q rp }vfD ArrgpVlD Sr IAre j Ian TI - F r - _ •cu 1 -1 ??? "•V? vrv un 1 [L r D Iv U. w c0[tissOx?M! <OUxiY LY s MOn ?FS DAv Y • 1 up G arMa ca PM J c FFF/7 Sr ti COUNTY Np. CITY NO ??u?v?aA" /lA• p'xaaAL ?N ?E ?N rOwN FE E i =4 GJ7Aca? S ?K ?w PAl RCUIC.. ST.1111e F ` oo ?W ?D„ tJN o l 3 11-1122 a,IxawNxeYx![r x ,x,EgEFDTWx e[,w[ N ra[[r * E s a xw,r x0us[ YMtl o AD Axlsrss T[as[c :.I `oFNn YINa L.xoN.x. /° F![ a P J A?ILFi AS'[l/?FFP7'D 1 v agANO a loirN/ Y/IF {D I`? J OM ,[ M "a µ ` x [wE ro a.a : 8 8 E 9^: [ 0(01111 ?:E a ??T, , v M[ OBJECTSTflUCK IHAW E OFOertcTerRYCe1cL FOWNEROF OB E O y/?70 [ Y• ? J CT-NAMEAN.AG.RESS cW OFYSF - f DRIVER'SLASTNAME FIRST NAME MIDDLE E "I DRIVER'S LASTNAME 1 -STRANG MIDDLE ST BEET A .E55 ROUTE NO. AND O0)NO. F 11H.Cl AOOgE1$ flOUTE NO. PND ...No. A.' SXIAATe ' Cs Y STATE ZIP CODE ? . ? ORIVEg50LCUPATION -1111ON --.A. CITY STATE. 21-CIDE DRIVER'S OCCUPATION ? ? • zL.,o. sal, DR E ' ?/A, _ IV R S LICENSE NO, STATE p A. OF IN, AGE SEi DRIVER'S LICENSE.G. STATE ' OF BIRTH A ' O u II S' .: 'v N Fvi• tlA a 7 1? b'g , . _ GE S F M F Al DYq. MO VEHICLE YR. MAKE ICNEV: DODGES MODEL INOVA DART) BOOY6TYLE 13 DR,1 i? VEHICLE YR. MAKE ICHEV:OODGEI MODEL INDVMOART BODY STYLE ODfl.I l L rvno r LJ F u c? J' u • LICENSE STATE ?? ? Y q 11 TRgILF........ . STATE LICENSE a STATE TRAILER PLATE NO. STATE 4? . 1 LL'q . VEHItIE IDENTIFICATION NO. ?,5P c7 t•=/X1143'• - VEHICLE IDENTIFICATION NO. REGISTEREDOWNERILASTfIflSTMIDOLE NAMES pRIVEflS LICENSENO. REGISTERED OWNER(LAST-FIRSTMIOOLE NAM E) pRIVEfl'S LICENSE NO, ?'v HK• - ' _ OWNER S AODRFSS ISTgEET. CI TYANDSTATEI DOATE OF BIRTH OWNER'S ADDRESS ISTflEET, CITY AND STATES IA I BIRTH 1 GA M PANiSOf VEH CLE DAMAGED RIPtiA ?cFs r PARTS Of VEHICLE DAMAGED a C-r7/A. L 4CC ? s 345 E- rHD[ ^$A -LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1 - WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIGENT ON YOUR CAR ? YES ? NO NAME AND AOpflESS OF LIABILITY INSURANCE PO.-Y No -ER NAME OF LIABILITY INSURANCE COMPANY -`.'Cl F C1 c G"CJ CITY AlE n. ?` LF Y1 - I NAME ANSI ADDRESS OF LIAR LITY INSUflANCE AGENT CITY ITY "All 2P LIABILITY/O LIO NUMB R FFyL TKaP' ISi INJURY: AGE 2ND INJURY: AME SEPARATS'UNI NAME TOTAL INJURED NAME T FDR ADDITIONAL NWIRSI AGE CDR SS ME F ADDRESS URE AND X KTENT OF INJURIES T ONO ? ? r C ENTOFINJURIES SEX M F ? ? IO?INIURIFS REQUIRE ® O DOGE R5 ? J N1URIE4 RE0U1RF OOCTOg5 NA^ION BYA D DIpINJ OCi0R1 EXAMINATION EYADOLTon, ® V NA ST TUS OF INJ Rf0 MARK FIRST ONE THAT APPLIES STATUSOF ME INIUNEO QDx IN VEIIICLF DMe! ONa1A POSSe ?PA N0. KILLED luv[?I ,N wOal Caur ?aR IN VEHICLE KILLED IoY '- ?P"S E OsMgnK FIRST ONE THAT APPLIES Passe rinn NNMS qe I"Mn IuvlxN IM NOxI Ir ;- ?n P A NO ?nD«,a ? D ? 5? 60 ? 0." 'A. 1 60 7 0 - MOTORCYCLE SAFETY: ?NELMETUSEG ?HELMETNOTUSED MOTORCYCLESAFETY: ?HELMET USED ?HELMET NOT USED is MIDw Honm Br ARnow IH cIRaE S mDKOI[w nx.aAAA.N f'I)'f 1 uuuu,l ?na,wA. x.Nli DA ? 1\ DESCRIBE BELOW WHAT HAPPENE .... ..._ - D IflEFfR TO VEHICLES BY NUMBERS - _. _. .._ __ -' 'r i ). Mwe[a u .1 44=111L, xwY. wDAnFxoA o . ff I - _rN rirrTyF n/? _ _ __ 1 C G -- 3{ }F a+ VEHICLES POSITIONS BEFORE COLLIS I ON VfIFICIi ---- ------- .10 ?uNS YSI Ip LL ,,,,p ND A: [ [ --- - vi?Kiiacv":ip INVESnOATFOSY - a S vA'k4,. N 3 [ 01[STR[[i OR IIIGNWAY NAME O^ND. "CAR, 11 Iff ? ? L = W J DIeIC,I YII YII xo xo ?' ? ? ? YIE No ?i:iaa ? ? ? r r : " O1 ?' ? '? ?, «+ W11NIA1 ? ? ? ? I ? o ? ? D u cl ? c:iio? ? ? ? ?wEAIFF .V 1 nIwSIMAx ? ? ? ? ALONG O?.1[I YF+OIIA/1 VI If IR A C POSSNO FROM TO 5 PEOEST RIAN/PE DA L CYCLIST WAS USI NO I ? uD ^ I ? ».»A I ? uw I I» - I ? ?eoiw, I ? ? Dr I ? I ? ^u A A • PEDESTRIAN/PEDAL CYCLIST CLOTHING COLOR: I ? D- 10 1, S ? .-, .0 xueo..... vl N- ;jjlrfrWl e ? °„ IM1' np .„ w A IACf wlAlH1^ LFCU,T-DRNINs r^AFFIC A p , S °"+C L ` rl K ? I al+Cll ?'/j1?a A I 1 ? DAruGHT 2 ?DAWN I- ROL rx [ K•p.DNO 1 Kxa? rrrF Or^OAD ?,[qKr o ^iwL [ u¢u DgrvFnVIwCt KACTIONS., NU^DNI IL ' : l ? I ?0^Y "" o!'In[iE? Io FAINING S?OVSK ? 1 SIGNALS ? 1 ? ONl WAY W ? I ? GOING STRAIGHT AHEAD , 11,J Rk? 1 I ?-! IKJ?y?i 2 K?"I.'Mw ]?WOMNO A ©.RX IT ? ] ?STOP$,ON ? 7 ?VIE O ZI KQ S ?TWOWAY ? ] ? OVERTAKINO AND PASSING GG P ? s ? WO.V OM UG.TS L ON ^IVINIILI ? S ? ^DAD 7 MIXING RIGHT TURN ? ? A I ? ? A ? FOG I ? LIIGHTS I T ? 1 ? SLAW INO ^IO A INTS ^CNANOI ? ? ILOM/^AMFI ? A ?MAKIND LIFT TURN _ ,.. S O! 1^ ? ? VICIIY 1?IOYnICII YI 1 ?FT^II iL IGNTS ? V[C11Y ? 1 ?FLASHING JARS. ? E ? ^^ MORAL ? I ? AAtttlYY ? F ? LIST rU^N ? 0 ? MAKING U MAN ? s ? /LOWING „ J 1?,',l( •, AO DWAY p1A^ I t'P;;`f 1 1 ACTII M I F N;7CSL A I Y W^IACl fYII ? F ? DIIICIIUIL WAN LAr1ls ? r ?D^w1 AY ? F ? norrm FOR r^An¢ v. F %" ? ?FgpK "U . ?W Y t?a?n .1 N -: vv Rx ixR hull l 111 I1 IUSf DxW HOVR w... WUNIY N O. CIn NO. I'D iNWA // -- /C( Z ?Uq W C]N QE OIN CIIYORI NAMEa NO. Of SiR TOR HIGHWAY iCTClS M RWI O R E R SI Ml[5 ?5 W `A?' ' INIFRStC11NG WIIM: SrPf IDAD NON IMERSFCIION ON "' ?i??? SECTION R PREFIX N T STREET TRUt - DISIANCFa M? MREIE E 555TREE 5rRFF -N IM f y / EO MIlEPOSI 3 N?Q t[5 5 w ACCI DENT RAMP DIAGRAM OAIA FEET pl MILEAGE COU13gNINVIXV[O: FRrtyl CODE ?. .'. TOLM NO IIO.KIII[O N1URfD? ?SPIIUGf UN W 111NN %GD N RE R OR ERENCE CF VfNIClES IMFR Cl5 R FAAGE C OS.SSTREETOR ROAD PROPERLY DAMAGE ONLY 11 RFRSU ILED 6SEMCLF x?,A OB FCiS RUC IN FOf OBEERSrRUCK ANDOWNER'SNAMEI ° T/'7(OO ' BE. DAMAGE SPECWI CODING USL -" _ s UNIT NO, Ir., UNITNO.R R NHAE: usl IRSI l D VEHICLE ? PEDESTRIAN.' RR ? PEDALCYCIIST IVER $N-1: usr STREET AD E55 -? f 5? Ut NL ?? , Rffi RESS -If ZIP CODE PHONE NO. D IIY / ' .-. DRrvexsueENSEno. - AiVf 6 5 IIfY)NC R tAtE I C PMON EX i y l N N. rArf X DATE B R N C3Pl?'j' / ?. DAY I o B OCCUPATION fIgMNM1Et%q(yE N0?o5??? EYES FILM-HT E OCCUPATION flgM Ee PHONE NO. EYES IGNI IE GM r T R E K ' ? C 11 VENIRE AN nowIvEEafANOwER ?CHECK . . (? lu CODESP ° n 3 u wn SMOlox.cu + vtH CIE AS DYF1OYFEa ANOTHER. nvT I ° a n In `' CODES ? ] 1°AN =-.' K sr 3 IRCI ON y NI UPIF 2 ? D1 FIN17r DM ? AxNAUKI ? UeGE ? p6.- ?AMNRxNCE C] PGOeK ? m ? p q ?rnN IW VIN.TFM .MAKE IDODGE{NFV.1 ?OD GIDART N H O Ku R ` 7 . OVA) StYlE1Z4 ONV.1 I N y,l MODEL r. V t N IfOx AI l V.) E H OR l N P SIAtf - fgAIUR PLATEN L'I H N 3? d? GtJA - r A IF .1IIXNIIIIGIION NO. i VEHICLE IDENDfI t OIPIFPI(;-FI 'I ?+I I I I I t I I I I I I I EGISiFRt00WN[R: USI IIR51 MOplf PHONE NO. O ISLE ED WNER: N ?^ `n LAST iI45r MIDDLE NO, I ?v ? gE53 OwNiq w "ER ' //J11 1 N . C ? NAweaAO ssafwwRANCe eo. aR ACw E ' NS, R 1 F-E AREA -10 l'E OIMOi i nxG 1lOP I ........ 1 f3i. PAMAGF CHMGE ORrvIN CHMGI dL41N0 /UN<nONN gAMAGI MIA e OYr S ? C] AWAY R[AWNfO IOWEO ?• AWAY DY: {,- ?A( ' DRIVLN []RIMNNED O AWAY OS TOWED I]A OrxnoMD "T.0 ' ei0. I ........ 5 IOeOIIOx P DIAGRAM OF COLLISION: ° 4u au N INm r?NORtn wnueuassARY er w.Sr ev: DESCRIPTION OF COLLISIO f S n rtow I ! A O N: Luse sV.PItMWTAIsHEQIFN[CESSARYJ _ .. WARfV/NG- SANS _ . /3 mOh' gyp, tyaE- : ?: Vex. Gv;n STHIG!/> dacvv TXucAl IWAS e ? ? / . &;W'j? f Cvn/cRcrc F r/G'H. JET E.SLoGLJ D' IDOGt1n? list!/ Oi3e5?/n _.!J Sk??7 b o (C Se D Si OQwF ,,y? ?G'FT ?Ca,plct!{? L.?I %HL?7J FL?NFL•7J I i Ir . OnJ 7p ?c}Y? Y SiOC- NAME, ADORES INJURIES OF PERSONS INVOLVED ` ' 000UPANTS/WITNESSES iae u` "f N ` ? S ii CODES I - 5 6 3 4 -' - - ? o oNl il f iA a t NAA4 v ..... 1 NPrx .v r... r Sf% AGE NklU3' I MSIR. ENCI ?11 AOMISf NAtW Of NAMI: O ... NO ... " INEOY• ?AMe. MK. ?MI q ?H ?i'E9...1. .. .. i ADOLEU OF Q.fR AMa. ?HKSI O'K p'iT ?n tl ApOF141 ., ' Y "??I?01 1 er' (]AMS ? OYa''R ??x O.:° ?M ??} 4fIRb?' : kf POLICE TRAFFIC COLLISION REPORT ®iRAFFICwAY • 1\U. Z IgllcccarnPwNt NEwaE9 PRIVATE WAY wxl o. NN.(y?, IUSf ].IW HOURI COUNrr ? o3'oz?Z I I?IAI DN I i J-E.FFE,esa.? CAII it Np. FMWA ?' ?NNBA ? ?G „ y UN QE UIN CITYOR TOWN AMF6NO.OFSIRFfr OR HIGHWAY L gulfs 5C]WIZOF ! a5 ON RA u I N INtER5EC11NG WIIN: tQ RROAD NON INIFgSECTION BROAD, ION PREf ' T DI AN 6 BETWEEN 5TREEF 8 ? 51R[fI I% FO. railf N51. L 0 /, ? Q:-/ - CROSSSTREI RNEARESIMII --E Mll N 5R F W ACCIDENT I Y OIA RAM WIA //O FEET pp MILEAGE . COllISgNINVIXVFO: VF511Y: CODE OIAL NO. NO.NIIIfD?NO.INJURED_ ?SPIIEAff N16RUN d S R NICE MFR CS CAOSSS.FETO R ] VEHIClIs PAoFERIYDAMAGEONLY ? pE UITED ?SFOICINF yy? OBEfCiSTPUCRINAML OB(fClSfRlq%ANDOWNER'SNAMF) FST.DAMAOF R ND SPEC4LL[ODINOIbE UNITNOI -YE s xsFwn: uL51 F R Sr ml l 5tq[f1A DR UNITNO. 2- QVEHICLE ? . PEDESTRIAN-.:? PEDALCYCLIST D9IVtR's NAme usl I Flq ]I _ -` I Y ST TE A EIPCODE PHONE NO. . D I T STATE IP v rv R'S UCEN N R A N MO DAI Y9. ?F N A %. M0, I OAYB 4I YY. A B OCCUPATION FIRM NAMEa RgNFND. EYES nEIGHi HEIGHT E CUPAtION FIRM NAME 6 PNONf NO R . FYESWEIGHT NEGNI DI CHECK (F7 v[Hln[AS aN FMPiorF[Aa ANO1N[a r ? CHECK(?) vENIttEAS AN NAP a a v CODE$? N i 5 F 6 ": UeIFS EOrEE FANOrN[ . CODE$ ?? ?.n A is 5 Ix A y N NN 7 n HKie ?NIM FYMGR AVOIDODGfCHfV.??N9DFOBIIe 13 l NOVA) 51TU ] CO O } FRDM 0- ANCI C] qWl Y O ??? N . NY.) S ??E? / . 1 H .) MODfIDIoN vp r E v.l E J ?7 N E Y 11 DIN. FLAT l Alf 19MlfR RAZE NO. StAIF I"I VH. IX R RE (,( / I ICL[ID[MINCAI CRI i V I l ID[NI I ? 3 a J.oIO aI S ? RIGISif R[DOWNlR: - I.Y51 N." i i. i _ MIDDIE PHONE NO. WILSov D/gtiA o IS WN IASI {IRST MIDOL N ApDRISS p OWNtR W N NFR NAm[t ADOIT Cr INwR— CO. OR-[NI E _ ?-AD, AREA ? P N R N A I r v, C I4n.l CNAPG CHARGE Fw CiOrOiM gAMAG1. AREA R IO?OIiOii3 ISI. UAMAGF ODwMN oR[MNNID DRIVEN 151.IDMSAG! to, RlMAINlD I I=DBr . (T 4! ?TOWAED AWAY t IUlOIIOw 5 DIAGRAM OF COllI510N: ?D InwuNNORIN H[ er AR IiVN[[lS5ARY1, DESCRIPTION OF COLLISION; fuse suvruMENlu swtt IF NECESSAAr) ROW aQAr ® V4ftc4e K U/J V/ICISGj .S•d!{Fw.,Qpu N? G ati S.9fv01 Z'IAaxG 2D_ _.TaO F7aSi = . Cf} vl E OZcT o CLI 2 ?E iZ? 77r-- 9o gAC(n /?! lfh'T' /ti ?'7/ ..S.C?iaO Si i7g S/a D -' f}cACuSS Royr9 S1JweCK ?D/'cT S4-ay SIh d E Ril / S??K Y RO LL E !? O, l /? / T'S fi / r ?hT S/ OE DAI d?K r EFT , _ S c ENE ' _ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * , ,! OCCUPANTS/WITNESSES 'x ?as N'H K si CODES I 2 7 4 5 6 ppl p„ , ,, NAML S A ACT IAfU• '" 5 Rt StA. lMCI ° ADDRIE, NO AIVR d NAA4 10 ?N? :I INYY AMA L?CTI? E Q? • 0 Ciii []ra2NO MDOBItf NAI A d .... 10 Y Q AMA. ?] La CF ?,.:I. O QiT' ? Ei?i,Sr p FS d Y M1III AIHOd(IEIYSNAU aB.N. .? YI A!DGIa KANCr vIk13 uNHo- K1DUrucMD IfY ENTRY' 0 ?c?%F OCnnE. ?]",? ?jj x, ... ,n ..... ---- H ?rl W ?s'._;.MLC•^J-s? 1. ...M.?taEl.....d.... Y. .?.G?...?.-'?'".;?. .. .m,fN.:.. ?, IWU IUIS VLhILLL LUS-LI.MU14 REPORT ![;./LI S-11, . Su "ux uLf w IND x Ntu![s"? [ounrr CDUN7YNp. CITY ND. ?noen v..? - 4 ?Mn?E!?RNID'=rlrDx,DNN N":,DLL ?tLNO?CFFErLSc)r.J p MILES Dr LJS D UW ?DFJDN 61 ? ON l?:: T[t cJNi w JLO 1.:9J vI. IIIb Q. w fff, LII.LDIINN NI ••? © ,w1E M srxFf ST27 ?2 '[. ON F FEET xlx ax ocEJ r"rlr"ia'iiL::ni 0 ?W ' MI??EnD o,uriiro`s__ v cnAN D.rA P NC'rc /..'? n D[v ?s`: F ?nv t[m !c- Eofnn d. ,I? °I:"?fD=? ?nE O t B.. A vl BBADRN ?DT OF L EFsyiBoxf.aNNp,TTOOIF? D 00"'A ER. UBJECTSTPUCK FOr D{RCT "RI OWN ER010-CTSN AME ANU ApOPESS i ?ltR r. xo4 eT C.DODFU3[ DRIVEH'SLASTNAME FIRSTNAME B -A MIDDLE DRIVER SLASTNAME fINSTNAME PIPE MIDDLE ??•f E21 /' C71? CiLL.i h-I 1. . j. STflEET gpDR ROUTENO. AND 80% NO. IRLSOx3wfn[ ST ET AODPE.S I^1• 1[1 S y /(50 -!H AJE '• uNfous[ gQurJ; - ,ANDeox o. CITY SfP. .. Il, _ STATE ZIPCODE DRIVER'S OCCUPATION tbLRi50 f,l 1 {•, I?'G[F_? '? :? rp4}(?s rD N CITY 5e Y DRVER-SLICEASE NO. STATE ZIP CODE pglVEq'SOCCUPATION 71 Q[?CELA-IS f-• - STATE ?SE% pATF OO; BIXTq AGE OPIVER'S LICENSE NO, J STATE SE GATE OF BIgTH qGE a '6!zvww ES s 6q DJ , U1,a w 37 DAY rR MD. VEHICLE Yfl. MAKE ICMEV: pODGEI MODEL INOVAOAflTO BOGY STYLE 12 On.) •, l r'. lern VJW VEHICLE Yfl. MAKE ICHEV.OODGEI .MODEL INOVA-0gRTI 000Y STYL 12Dfl.1 LIC N E LATEN STATE TRAILERPLATE NO. STATE r :rHp LU/V, ENS.PLATEN .? STATE THAILEflP ATENO. STATE VERICLEIDENTIFICATIONNO. V 7--Z1 2-Z 1.3 L: f) 7 VEHICLE IpENTIFICAilON NO. }v N GISTEflED pWNER1LA9T FOR9TFRIDGLENAMEI GROVEq'9 LICENSE NO, flE019iePEp OWNEfl ILAST•FIRSTMIpOLE NAMEI pglVEq•S LICENSE N0. Cio-vtJ G2i? 5 OVJNER'SADURESS Br Cu[NcS/?? ?I ISTPEFT, CITY ANO STATEI OATEOF BIRTH OWNER'S gODRE /•li sy Yvo•rK N?j(,(•?V[/G ?/1 2j/ ISTgEET.CIiYANO STATEI OogTE OF BIRTH @qy_ V`IICLE ONAAGED T R ry IL / PARTS OF VEHICLE DAMAGED G` J N- t ' 1 t:J2 .-H - $ ."n x, L $ :.ev Hr LI r. LIABILITY INSURANCE INFORMATION-VCHICLE N0.2• W"i.EREAUTOMaBILE LIABILSTYINSURANCE tt COVERAGE INEFFECT FORTHISACCOENTON YOUFCPR Tµ' AYES ?NO } Y NAME Np F gOpgES$OFLABILITY INSURANCE 10H.11 OLOFR 5 AD, - tA; (NAMED LIABILITY INSURANCE COMPANY ,K •'J EAND ADD ESSO LIAtlILITY INSURANCE AGENT 1 1 ?' N , . 1 J LIABILITY POL CYNUMBEfl ngt _ IS INJURY: T IY.,. STATE ly xr AGE 2NpINlUflY: MI SEPARATE "MIT Fox I-FILI, tM NAME TOTAL AGE - - -- ADDRESS SEX RED NAME p,f All M F ADDRESS SE% _ E%TENT OFINJU FREE ? ? ATURE AND M F y? E A INA IES PEOUI.E DOCTOR'S E%TENTOF NJURIES ?? 9 %MINATIONBYAOOCTO.I ®O NgME E%AM"INATION RE0CCT0R1 ® Q NAMEO.'s S STATUS Of INNXED MAR%FIRSi ONE THAT APPLIES F1 ?o r. IN VEHICLE Dr?gNG NON NJY^{L xp STATUB OF INJURED MARK FIRST ONE THAT APPLIES 21 I ? INCIR KILLED If1Vl.[I urNOxl roiu?vl ?ORlvlp INV HICLE ofAlt nc xONNMa wn Na NO IN , Q I3,.Ax ? 5 I'0l ri ryfiio?r O 1 NO. KILLED 3[vinm MNaRI CGOV INr cn ? 6[3 70 ? N ? 5? 6?r D70 t MOTORCYCLE SAFETY: ?NELMETUSED ?NELMET NOT USED x v MOTORCYCLE SAFETY: ?NELMETUSED ?HELMETNOTUSED I" U40ANOXTH BY ARIMAN, CIRCLE -. INDK„E DN I.MNIO R,M i DESCRIBEBi LOWWHATHAPPENEDr IREFE.TO VEHICLESBYN ..., _ .. .. 1 - „„'wiiI, L MIN r, x,"„°NZca? V hx` I was_ P/•.RY.-l_p ..L•N (' ILN T'. StcOLs ' nUM.LN1 c»W,. N.Nn 7 ?U L_YL,2 L rI T NNM.tn 1. H Yrx,cLf AND .NDW ! t ? ?'? w?iS . ?L: H. INL.A -.?.y t~?>`!D R - '( ??'[7' ' aneeNDN ?r rx,vlL Er ARxDn I ?NIQ.U .V 1+34lLLfi. 1?L41. V•, ?Aj -'J ?•jr?•glUt7 ?-ay 1L ?C.? ?t- \ I I TRIITDR ._. -!.'..n?P_.!iNV. T/lrl?rL.Ir?c lu `Ar!'l? 910.Gc71u? _?1 _ A f ? veKw•6, ?lr_.vb.nttl..__tat?_w_r?s_r?f??=?=s? --- ' ?` w 'f V IN I- -.4-CIUM- '.% I _.ltkr .RcNO Vur?"i._.rz%.T2C»Ir.,?(_lCy! VCnIG? _ I ? ' ? / ? _-?? w_ILtS_?ZOf_CGD oN_•;xYc1L.Y41'C2T? ?}I.P }1' 4Ci ? { t - ? -' ? _ ;.' ?f 3 ?N J? ?'A.cIYI...$!2L<.:L£Fi11? It•1_LGP-?LE?? -, ?' 1 1 S i 7 00 ? ?)? 3 ? ? y v?• zHlcv vb.ri[cCfi VLy?v+?-s?.I? ' S,.IIiD.IIN,H. I ?» ?? lr r IJ lad L,f,+4{.?' 3 >A3 Irk' VEHICLES POSITIONS BEFORE COLLISION (TII /}, ?,.. rye ?7Ivyyy V[IIMt( M { I t LLV MD,xa SICALIY RR[U vlxlCll a[CUMIa IHVEYTIOAi[p BY {' a, `'?1{ /f "j rrw.1 ? ? ? ? , DM {T. Ef T OR HIGHWAY NAME Ofl NO. OI.fCNO. Ir NO YII Np I{ NO 1? B ?' ~ ? Y( M' ?r;iPt ?ioiL J L cnr hnI Jr d IU11,px ? ? ? ? A1M0 pq • , } t Jay y r / 1 {{ PEDESTRIAN/PEDAL CYCLIST WAS USING: 1 0 P" , 2 ?N, cgoulNO FROM rp 1 L E?wavw3R 3??:oii.°.u L?c "ow :i 3?o,xu TRIEDiri 3?ROADw.r 4 ??'•p PEDESTRIAN/PEOAL CYCLIS CLOTHING COLOR: I?D. ?a ?t r' npgn wnrACC 'c"r 1?"•ID .?..........agvr W' ? / \ 1 K"I C, ONM WEAIMI. LOCH' CDNUIIIONf , r.Airle Cpllgot 1 ?4I NN M Ii SO Yle A.CfIA.ONf DAYLIGHT ',{ Y Jy Y: 'L+? . »K 11 1 1 %Hr<. or,1 r 'YI{ Or ROAD Dn v[NCt E P r" K aflx?[R JN.I r x 1 ?• '? .`' I ?/ {{(( CHIC. MI D. MO.11 y ` • ? 1 ?rO.Y 10 L:T'A'Yi QR I ? DAWN ?I 1 KN`? fIGNALf No I ' L 1 No I r KL t 1 - ?1 leiu'>N 11 ? E ? W[Y T?.AMII,O ) ?GUS. ? 2 ?,Toe SIGN tI ? ONEWAY C3 1 E) GOING STRAIGHT AHEAD Jx ?T 1 1I .J' P r 101"UXG c ?0... ON fr ? ] ?YI[LO SIGN IT:JX 2 diM'OWAY ? 2 [] OVERTAXING AYIN0 AND PASS1 t µ e# ? f ? SNOw F ? roa [ o,R%vgrn ? O 5 ? ROAD m[ 2 Al ?! G(.,. ?LGMtOIr 1 ?ILAS"ING.10 ? x [1 iiooI: ? ? MAKING tIeFT TURN NN + r? 01 41 1 I ? Ri1b IY1 I ? .01.11T we is ? I ? ft-No AMTS. AMi°E ? A E) MAKING r??., , ? L ? I . yyy(((ppp ? [ {r T ?yc?i 1 '(Y - ? B ? 7(AL?W1. 1 1. 't? F DT,9IrVYiJi YY ? E ? MAKING UTURN S ?YY ? { ?.. MGNAI ? ' ? lAN[IU N ? { ? 3LDWIH0 A t!? 1 )j f4M .o OWAr CHA.ACn t r .p pMArw SURFACE ;nt ? 1 ? '"Y 41 ' N,N 1 OIIKI. ILApMAN Q 2 ? D.v[ r (72 [j 117CH'PID TOM TRAFFIC r ? ? 1 , to yr+ld4 1 ? ? I we ?i{° ?+ ? 1"? S?v'??`?,???"?4r??9 ? '?• real ? ar +?I'• . P?? ? Ir' + 2 ??, v{?1f„ "h T L 1\j tg q., F,?? 1y? ?,? t _f I 1, - V CITY NO Th,edr?J?,eEdP?es?,v mr??E 94y?. o? /&' LS PR FM RWtE gISIREfi CODE o , SECT NMxe - Da m ; n ,'L L og t EO MILEPOST yon w????? S . I OIAGRMI DATA Y1_fJ /1,? /Z>oCC.?}7C ?uef Tou?n?? tv/? f NON %RD IME? CLS. EE t 6 rop - REffxE KfIXU54 C. 5IP[EIOn Caf4eea( .000EQuse O . ? b o s s .} ? /e c/hE pLs?s? C Y ??nn J/ (( ?? ?J p EP ^ ,I ?? ?? // O R ' 1 xR . ? S . d/r Ck«JO/t !P`N4U? . I FEET [ . _ l FIRSTNAME .... •... MIDDLE we A/ ?. F tue•nt Ta Ernda?e?ccy ?pp? As 19 Pl6enl7'lV.>_ A-.Cy A9et. 0 ? ? I [ 67tJ7- i cr'.Q cT .ES.? Iz j. I kj ` YES d AAE OF UABIUTY INSURANCE COMPANY t z? ' ABIIITV'POUCY NUMBER - {/oG [??3s3-A/?l-?7 MiEREfORI fIYIAapiKINALINNVE91 [ MMKFlRGT ONE TM AT MPLIEB ?;.. ?. KILLED -1.0 xilnl Il NDN hNG I ORI 'fix E AT IUPPE R TO V NED'. IJ EHICLEBBY NUMBER . 1 reL d Ad _ /yJA' rU(e . ,E . r [ w..,[P [.-N wN?[ .,....... aNC[Kwaf lP[v[Ln.MVaw IFIf Top-wAr . I, I..,[_ _ c,[.t .nL?Pe.(?. Er>E ?O .70 ? ?, Q { (tiViyT.f'.dawn - .Saean.d-p?xb.L?lt.n[e. ? Llcr. . , I ,?j . t;e Q t .fht R mph 0 ?? 3s S d - Pee , 5 y _- -T W) . I - VEHICLES POSITIONS BEFO RE COLUSION x0 p WNt woN[ vNt1[ I[nuL.uAM.n V[ I uownf[nxfo M [n a vn«cuoccLPKo INNVE; .t ? t ? ? 7 KraCIE N C E W IwAA. D ? ? ON SInEET OR IaOIIWAY N E OR NO oR[oTnN xD ? DI we xn ? Ia IK[ ? (? A ?r f ?; olwa ???? ? ? ? ? O ? ? M OINEC710 ?[IP`I N TO 1 RwaRw D ? ? ? PEDESTRIAN WASU9IA uara crio[aao FR o 10 1106.41K t ? WALKWAY ] ? WMULOER / ? ?NMaa[ S ? pl"NlµK w[11 4 . iUADk111IAOE Otb4 14AINEPI LIO,ITOONOTIONS TAMIKICONTAOL ICMG-l V(xOtl TYPE OF ROAD vlHOll CIII010r11 ?VK)IUI OnRER/VEHICLE ACilON4 Hlp[! C 1 ' ' I IW 1 W?f M I w I I[?E EpEpLLgqpprr 1161 ONADNOI 1 OAYLgNT D 1 ? l16NALS ? 1 ?IONE WAY N01 NOI 0 10 -1- STRN I N OVEATAKIN A ' ? 1 D DRr E ? AAFNNO ! [3 GAVIN [3 E E) STOP WON IE D so, ® 7 D TWO WAY ? S ? AIVEAWELE f C) 7 ? C) O [] MAKING ANT f WET ? El ? ] ? SNOW 7 ? W40WNO 1 ?FOG S D DUB[( I ? LdKSTR ET f Y L C) ? D / D FLASW40 FED 11GID ? 1 ?M1OO:?nu?N°A?E ? 1 ? MAKIIGLI/ 1 3,. lk' }0 AEIT ?S w E IIASHWO AME[R ? E ?NIEY WAY ? IT ?MAMa10U1 r, y yy BLOYANO j. r l k { 1 J/f' An': I ?Y" {N ? {I ?y1n A C .' t t 5? k LN}I} •? ( r a . ?I ? I k N 1 t '? 1 ? .. YI It ^ A, •CP, A ; 1 A Y.' 1? ?.'? p A 1 I ?- 6 , ? ¢ Y, I 1? 1 r Y' 1 t2 N 1 >f? .? 1 1 i;r 1. e + f r ? r mwNa.euroaxYr. RR ?? ! H " arw: .R p..ay?'. . V/'t.VY ••Yb?i 1 r./1N DA1 oEC /? OI /? ?? MJlfS FRSECIING NI POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY ? PRIVATE WAY A - }L . ... NME COUN}Y •n Wx.lu , D. w1D. iry)i;I. iyal. (USE I.DO H-OUR) L?-N ?IfW ACCIiYOR 10WN /S ?? Qh N NAMFe IIO.OPSiq[EI OR IDGHWAY ?S ? Z? Oi y•9dIef0 ON IH:S E RROAO NON INIERSF??rr ON ' Sd • [1J A? /?.9.fi'aO.(.SE ?Y .ems PopCE COMGUININUMBfR CO NiY Np.,, <]v NO,.. 111 WA 3 UITT /? ? ClS ??R ryE: NCCif cv Sl. ? ?/r? PRf11% F .. :nxf Pcsr . ? . BENlFEN SrPfFt 1 ?' Q SiREEI Q ? i? IS1M/ f50 RfCll , ROM?jRFNC ,CRO555iREfi NFARESIMIIE i ' ?.Y MY 5 F W ACCIDENT RAMP Du0RAA1 wtA C LEFT IF © 0.9-f' BAy ? MILEAGE OE1I510NINVOIVfD. fVFRIIY, CDC IOrAI NO. Na IUED-NO.INJURfD_ ?SPIIIAGE ?H RUN 41rH .RD R TIN RfEi ROAOCR REIfRfNCF R1 OF VFNICEf3 ®PRO MR}Y DAJMGF ONLY ^0rv IMER CES fRWSSIREE}ORROAD I ? JIECi S1RUCKINM1E 01 OBJECT STRUCK ANOOWNER'S NAME) RFSEUlifO [ F W (fjJ/Q/J/Q,.. I_ ESI.DAMAGE SPECW COPING USE I WA C4IYN12 C I TNO.I U51 iWSr E UNIT NO, ' VEHICLE ? ? PEDESTRIAN PEDALCYCLIST ' 2e II,, pRIYfR SN E: w51 TRUT ADDRESS I SiAIE 21PCOpf PHONE NO. D ° TDQ A D 2 ?? R ly rnre H N N. ?``is SIAIF A FBRH I ? // rJ .) /C iT SO I V I ll [N N A f - IT If O B R l r (4. LL IIRMNAMEIPNONE NO. EYES WEIGNIIIQGi E CUPA}ION IIRM NM1E 6 PHONE NO . I I .e.J 7r =7 R , EYES Wf GNi MFIGNr Inf AS:pIMaoYf of ANOr EErcu aw r / e 5 IwH 1 xrc si , ' a ° ? CHECK( «?H of AS AN FMAOrfF OfAN01 F qnE E r 6 , , n CODES ?+ ° nN°r I xw Nr UUU . i 5 N Iprv S / 6 / ]) :Y" '$ EH+ la ? ? W ? ? ° r r _ IOOUGf.CHfV. fO AR1.NOVAO SI,U: I'DR C_v.) eNY Ar : " ?AMYUwNO ? UD6el ?EbMe ? I H v ) O NC ? w" v E . , M DfI IDAgr. vA) f r II •? I r ICf PUIEN IAIF IRAII[R PUEIF NO. SrAlf I'I VfN.C FRSFTAT[ Jd J '.$. 7 Lr) ( N IN No. C v wa PEN 11 A r N L .. G31 IG121/ /I ' I I I P I I WI NRSI MlpgF PHON[NO. 111 WNLR: } I U Q SS 1195! 10 I l ?. W N NE9 suRANU CO. oR AGENI E $ r? a /o? R .. DR O -d27 i CNMGE pAG a ?'?- S 1St. pAMAGE UR fN '•'yA"34 CIIAPG! fv, ,iWN F ARfA ti ' D 'ono 'xE M ? wwr ?9EMAINfD Zv ' ? fsr S M .Al 6 . AWAY ? ewnv RLMN m pAMAee 1L6? DIAGRAM OF COLLISION. .J I INDUlf NO9m ? r °Y, s In ?° u -N, le t , I i. I I SM[EIII ECfssARrl,-. I e w now DESCRIPTION Of COLLISION: IUSlswvlJMfNr lsrufr rNECESSARY) a i ,i `? c •; ( I ?Xi iJ^./ d /?frGurv? o? a..vp9r>>-K,/e, --- ( yy'? cKO rx.• ..YP -elLviAl" ' ?. 6eri/ n erJeuay NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED i OCCUPANTS/WITNESSES IU11fUPNlMSNINNY? 'CODES 1 - 2 J 4 5 6 ... { HAMS. IW ADp110NAl NAAY 31 _.. .. rHNH SIY AGE rAllJi YAI.. '••? ?- -- -' ulCr .. P nlsu fnn ., ,, No F NArw a NA.M : a. .. ? . ?CIX ?Cul,o " NAw ..... _. EDIR ?AJAI. nNACI ?.,?, 3 RY •. IAOao AuNC "^ • u -- . LI4 Uie:H,• "*? 1 t rvo aws x??wJ4asD rglypLn?lD o naE sro s noovEDSr onn ? a ; '" i ??J?"r 1 , A ory .? / ?i 1.mHn 2K0 s -:l ? ?. I !1 9 ? ¢ ?? ?w'Lr n'v?i Yfs k L •1ti2't c t i ? .? ? ' J r H ? s stNLr ? i? r { I d•.4`L? 14TH R '14 ? J 1 ?1 ly? c-. f d I _ i +?f• ?? v1C ) _ y 7'LL1 1 ?k Ih rr r ?? S E 1 ? ,,, w J ? yF 1 a _ FM;?1 STATE OF WASHINGTON PAGE OF I I11_ 1 - 9?y POLICE TRAFFIC COLLISION REPORT OTRAFFICWAY -? PRIVATE WAY DAZE Oi OLL PotICE COMPUINTNW.1eFq ,NC I N OF CO o y 1RR(up OHOUR) CO iT IU u1 r,ARDl1 IE, l COUNTY NO, City NO. FNWA ?ugeAN 5 ?N pE ?1N CIIYOR TOWN N f d N0 OF51REfT ORNGHWAY .R AI CIS ROUIf ON SIRE S lfs?s ?W ?oF ON Ir}c-'-}?-F-tF =j' INi{SECT G t;SlRffi OR RO ry0 tE 5 CNON „? y74S0 ]R ryl R FC10N TFJG.[1 A.SNO.GC PREFER EO MILEPOST POST . 5IRVEEN STREFi 6 -- STREET OISIANC[ DIRE M ONE MR RE C SS 51RE{IOR NE E-RE - ry Q I 5 l '? ' P ' ? ACCIDENT MILEAGE RAMP DIAGRNA W,A l OF .1 FEET . ?"SI l rl 51i 1 .I? CODE COIIISgNINVIXVEO: fNItY1 LOIN NO. O. KILLED _NO. INJURED ? SPIIEAGF HIid RUN WvOVlIiHS OFV KS FHfs O PRORRTYDAMAGf ONLY ?UN ?STOL'" .RD Nr CIN S R ETOR ROAD OR REFERENCE IN IMf CLS CROSSSIRFETOR ROAD _ - ' UITFD OBFFCI SIRUCKINAMEOF OBE [iSIRDGK ANOOWNER'S NAME) ESTDA?GE -/ T? f SRCWLCODING USF '5 5 UNITNO. 1 Dqlvl' NNA; IASr l UNITN0.2 ? VEHICLE ,. PEDESTRIAN (:1 "?.PEDALCYCLIST ' _ rvfR NAME: N51 MIG- STREET DO 55 STREET ADDRESS EIAIE EPOODE PHONE NO D NY ?J . _ DR V[R S Cf SE 0 STAR fR A IV R' lCENSf NO . ATE R DAIF B R H q OCCU tON FIRM AME6 PHONE O ttEYES WEGHT EKEGHT 14"v I R E DCCUPAION FIRM NAME d PHONE NO. EYES WEIGHT HEIGHT p CHECK (,0) V EHNi nN CMP oriE NOT.' R EAS O A L E ? FHICIf AS AN ? CHECK v IO O R? I ' ; q p '"! CODES?? J p 5 I pF ,' e"Dtrv Yc fMP YEE FANOTHE CODES 10- 3 n aPSr + P.rcMN1 5 E Inns s N a p f M::r DM p AMe KE ? FH YEAR AW[E DODG u E ? CRA" ? H K p . DE of p , p Y pM U IO E] p ES. [ Gl 2ff ? ": x i . E.CHEV.) ( V OR NINSERAH, EL IDARINOVA) STY1E 12DR.CONV.) STATE i H, EAR MM I HER.) v. MOOEI IDAg1 NDVA) L ( pq, ,) RAHER RATE NO. StAif H vEH.caoR uFF5T91i' Al l N A _ [ ICLE DE t CAVDNNO. C if DEN11I A N .T ' RtG15H f00 FR: wsr N.St MIDDLE PNONENO. W Su U - ASt {IgSt MIDDLE % DRESSao NIR W A HER ]I I -? Hl 1f'i''E. v E NAM[d ADDR(SSpINSURANCt CO. DA AGEHI DAMAGE AREA pfAEEIH •.••,. R UAI n _. N gNAAGF ARM _ Fwcla M CHARD( CHARG cn'au E E S ISI? f DAMAGf DRIVEN f5 'DANA I E IU ?Oi10u OR[MNN[D p^9NIf1 pRFMNNlO EfOn WAY ' s'ii(.: S IO?OTOM . AOWfDeY ?AW?eV: 1_ ~ le DIAGRAM OF COLLISION; lu IND1<AIe NOREH DESCRIPTION OF COLLISION' IUSF SUPREM{NrN SH[erlf NeoESSARr) S !li1F N[Cl SLUtY) OY ARROW E ! ? r I L r .: t F Y I L ?. I i t PIL I / " •' 1 r 1? C ^J 11I C IL i i f' I ' ' SF . jl .r K I ,J.Il ti,.. „ LL/lf i ?tl ` r 1. 1 NAME. ADDRESS 8 INJURIES OF PERSONS I NVOLVED + CODES 1 OCCUPANTS/ WITNESSES ?u ? W - $ - 2 3 4 5 6 AME I o N. AMC SEX AGF TAIUS .15" IAQ :?c'1' A pe N D A1 UR f 1 AME. O nRnV AM p WE p e w1 . p N p I13Hf. A Sf q N . NUR of R L rAOTroiROM pA,E1e ?ED`R' p1.1 E ? RD' ? :° q0 0 A DD.nf liF" 11a { r, pAMe. p'z`,".iz1 pio%nE pftx ?". wvISIKSAIPRGprKlt'dHA W feAN[ IAUGI Oe 9"I IffCr . KIOISPAICMD ICI p`WVtD OAfIp AFpET AnPElppDer OAT/ IE DNO n p t r ? q ? ' 1? EYM, f [?^yp, ?1e i 1 Ht i. ''M< 4r ?} f,, 1 a, ',? ? G 1. '?. ?W.?R.E .?+'SR .. '. ret{', d*F• 1 N. ?v ,Y>11*?INl`i',V? SA'. N ',' ! x1A lHilnnxek?llF ? 7-71 1 ? { ? ? rJ 4 i i tl 4 u I V I; a a I "• u o 'o ' uo 1 1 1 ?0 '0000 ?(d I t { ? ? i r r ?;. ? f E ;r f i 5 1 ??" 41Z t. ?.:Iin ' .. ...` .-.? ..rte. .a?:? /?•.. .,... _. ?.. ... ?? .? ?...., ... r .. . P?. .?4 1 ?•?? STA-rE OF WASHK9GTON PAGE OF ? No. 1 TRAFFICWAY POLICE TRAFFIC COLLISION REPORT 1'OIICF COMRAINTNIYABFX 1 T ill r ? 7 I FF -. PRIVATE WAY L I t r i 3 44 AAft Gl Lt }E E COUrvTY E I v Wx Iv.M. IYY. { ft . J,ul3 11?L1. I l1A) p Y f ' COUNTY NO. GI(YNO FHWA / { 0 O ' I D? / / 1 '` C/ ) 1 { ? I / _ ?' 1 ., :k; ' DRAL Ev _ f [3IN CIIYORTOWN NAMF6 0. FSIRFFIORHIGHWAY ON ? MRIS s ?1` OGF ON UNC s /Jil gd. CF. cdg C15, •, 4WfE R t '3 '??%9'O Sf E N T { . INIfRS/[SCIING WITH: SIREEl OR ROAfJv?1 NONINIE15FCfION i 2 I BE(WEFN STREET 6 STREET PREFIX E MINE POST -"-' /?{ J C?. IS AN E{DIR hU1lE5 N, 5 A,..w'u SIRFETOR NEA9ESi Mlt y ` ACCIDENT MILEAGE E DIAGRAM DATA -` 1 IF FEET OF • # f 2 ' COLOSIONINVOLVfD: VtPll , f0(A NO. II??1 NO.KIILED? NO.INFURED_ ?SPItLAGF l(R1RUN Of V(HIcles L'? ? PgOFE1TY DAMAGE ONLY ? FIRE FESUL11 Vf_N (Slrv HNnnvl0ml D I INTER Fly C ? AROAD OR ERE -, NIERS ROSS S1?Rt/(i•O'4 AOA? : - ' / j 17,--l Ii]D J. T_ J „q OBJECTSTAUCK INAME OF OBJECT 31RUCK AND OWNER'S HA,EJ fST.DANAGE SPECW CODING E ? ry F '. UNIT NO.1 ..:- UNIT NO.2 . ? VEHICLE ? PEDESTRIANED PEDAL CYCLIST ° J '9 y ORIV Ws NNA: IAS( l Aw! TITIZ I t RIVER' NMI. IS, ?_ SIRE[LA ORl `' STREET IDDRSS R .!N IY -rte 51At ZIP CODE PHONE NO. I D I Y A 1 N /Z ? to A.I. A P a S = S S ' ? R • j" 091V[9'S LICEN H TAI % ! AT P I CC M 1- U N N SEAEE 5 A Iq ? ?-w •is 'L.? A m D M ? s l y9 ? ;. ] •»o I oA.' IYA ?PY i`OI+, 11-NNAE+PHONENO. 1 IGHT HEIGHT E CUPADON F IRM NAME a PHONE NO. EYES IGHi HEIGHT 8 :2 a EJV 3 s- S5 • 81 /ZD S, R ''+ 11 OPI HECK (? yFH CIF AS INENDIINF3 OF wNOTH[9 ? CHECK (dJ VfN ClE wS wN EMPIOYEf OFA O 9. CODES ? * n. + i:iwM"'I O S 1 KIwF a =ozca LSY CODES ? + n.uY + i+innW 3 ucron 6 s,rin r I > Q :? 1 F6 INNU 5 13,k J- 41 f AN. Z1311411 y O 151F.DM ? AMNA: KE ? WE o <sm. El K? r ry . M 7or.DM ? - ? n" ? Eb B. ? Y i KD ? ice' VEn.RwR' MAKE IDODG6CHtvd G{pAAM1rvOVAI STYLE -1 I M -L{DA11•NOVA l9 h ,-J T L TN K FM P R 2 E 1 To 6 IICtN PlA SIAI TRAILER_ iENO. STA H C w__ } ' VEHICtIMINiIFICA110NN0. ( i81/ I,DIaIpl/ IZI /l/ 1 1 1 1 L yryl l l N V I I I I I I' I I I I ! / a/fG,l5ltalDOWN{9: WI iIRS( MIDDLE -N[NO. L7uK• • E S.an.?.r Lo RS-.ASS 0 W , 1 D WNf1: 1A31 I PoDRwOF-E. ADDQLSS OP OWNER 01. 8c) le ? ED I A! - 10c It 7? o A S w E NAMI S ADDRESS Or INSURANCE CO. Oa ADEN( R ` -11 -RISS OF .5URANCICO. OR AGENT 5 DAMAW AR[A GL.SIOMM ?. H= -W AEA. • F CHMGE CHARGE ° vRVCI I f • ?' 1101 R 151 DAIMGI ? DPIVLN ? ? AWAY ? ITOP D , 1 101 SOU ,...?? AWAY 9lMAINlO 041V1N RE NID IST. cn 101 ? ? ° ? 6N :. Yc T iwv er ktECC•kSuL ?i,w?°r°er: s ` DIAGRAM OFCOLLISION ?D LmN INDK (?NO1T SCRIPT OF LIS N IIKF SUPIIEMtNIA SXU11F NfCt55A9Y) 1aW DE ION COl 10 HeRn e A L _ r I S 7? (g h. F? I • 111 ?? VV.I1r x ..-.W.nS .-_-1G.0 ?_IA QI.CA.ar:./1 ° I l ? ? _I .Ot'r__.. _Ser rq.ge .. .gyp;p.lNS /t^E'e/d f.•? ..E 1 I I 1 ?? F ` x L ?, P 5 .. _?.. ND:I W1]t6 4rI1 E}. G'k•.- ._.S EL.?.__/?•Ct.r-_ I ! cW EE N f p'E!'? J r•/..r 6o N 1°'/J_..?Y./ I I . . SF I Jw ' I I ? fA _ ..Kel ., 21 -- I 1 ?---- Ilk r NAME ADDRESS 81NJURIES OF PERSONS INVOLVED + CODES 1 2 4 5 _ OCCUPANTS/ WITNESSES iof°:oD"fxD?iN+irAIiuuii sE% IaE twtus RFT'" G•E' "" •• . - nsu thin.• 41%, h'.? r ??, f H-, - nAMI - ' L 1 •DOn1s NAT w1 or AM e. O tip ' , O,"' . ? aX' ? i,aN, rh •. K ? 1 FR NAME. ..- . _....-_..._ ._ _ _ F ?IgK1O 011 wLF Yp t 7 . a .. L,.. HW .s,: M'J i y s B ?V • V Y'E9? 1 Y F>< I 7T 1 ? ?' + I ,x Jt 11 s i I w? ? ' ? ? /rs, r- ? .ELI, ? , (II r `Y'74 E l L {Qf ? , f' r ???;?? IW Ci Y 014 P cf I of t No POLICE TRAFFIC COLLISION REPORT ® TRAFFICWAY No. lW ' q?. pAl[ Oltl IOtICE COMPIN NIN WIRER: rv tl k PRIVATE WAY , al G ?y L K w: 'MaNa wpaa l n? co'u'rv'it'Y . I '2.7 111 I I i"' 11M? IUa i,-HOUR) i, COUNTY NO. CIIYNO. 'yy .C. O t..-•Sl?l? fnwA. rS ON DF DIN CIIYOR EOWN ?tJR?AN u? NAMF6 Np, Of SlRtEi0R NI0MWgY !I ES 5 DW DOf .may-rLU,?J S µt Ct5 (r7 RAt' Ci N .C1_LC ROUt ORSf E U0, ?+ JNI(RS[ NG IIn: N INKtON Rpgp I O• ? y 1 NONINI RSfRION/(?/7/O ^T { i J PREFI% E M LE P05i 60 ,M Dlfll' `F OIR M11111 N R R iFR _NC . 40 BFIWE(?I' f//?.f/?% R 1.6•? ?(EE?)t( ,)D ? OROO AS yy r/ _ C SSSIREEIOR NEARESTMIlEP05 /?,L ,- NT 6 E w ^ ACCIDENT RAhv DIAGRgMDg Z IFFI Of \??"C L( MI(E tUSN TA. CO IO AGE INVOlVEO: VEwfv1 (.('r'T- SCODH ? ` ? •M ' S - ,LTOWN0S ,[ N0.KRtfD_N0JNJURED,?_ ?5PIlLAGF HJt6 VN IuliouroM3 kRO I - A PROPFRIY OAMAGf ONIY TIRE yS1 INrfR Cl5 Cg05551R[ET0 R qO/,p OR R[iERfNC ITJ 1,k -/II OBJECT STRUC?K (NAME Of OBJE STRUCK DOWNER'S NgME) D RFSUtifO D/JFI N 1 (?) cy r [SI.OAMAGE SPECI.LL COPING TAE ?I ?? _ _?•ER UNITNO, I /G? ? '' ? s Rn 'Nurse: UNI1N0. Z ' ... :.. -T VEHl ICLE D PEDESTRIAN D PEDAICYCLIST f 'p l v R' NuA. D 8 mNEn Apox[sTCI?S• ?-FI ? L ? , --F?,_._---- l -- , °? ?0? ?I IgffI ADDRESS 'Y g TTY ?ln I ?S- SIAM 1 n ZI CODE P??O?NIE NO. /• D IIY, , 5 _?ORIVFR StIClNSE7N?.- YII? ZuA, ? `•?+?'LI?4 R Af N .xr?f lJ , `x A k q 10 +' T 7--30-7 S EOIL(?SIAIF k I U NEN •/ U JL F M 'I' yAr i ' A E DAi 0 91REH B7 OCCUPATIONN/ iIRMNAMFb PNONE NO. ? rl V I 'Al iYf ?Y??l? - `LSE-y V( -- EYfe WEIGHT of Onf E CUPgiION fIRM NNAE6PIpNEN AS1'L D CHECK (,I R A EYES WFIGni NEIGNt , H CODES?T fAl AN Fm%OrFF Of ANOINFRA( x ns 3 otawN ? CHECK (?) yFN RFASA 1 k R INJV4 fi • sY ""N b "siOloxrn? .CODES ? + n orFF Of ANO r _1 . e91gD Es N R "Y u s NtnoN a P Y eq A ? AMfuNN4 , I LL i° D M" V[n VFAR N MA.Kf pODGf. n ? CbrltR ?iNKif O {f°V Fr. I<7ti YIDIgDM I C EV.) [L (DART laoR..c 1 n.rq ?A`I"^A ? r4DOn D c8ku ?YrN CD Di'R°AHSr. RoM ILL C-.. E I l MODfI IDARr?N VAI .?y'k V NAY R lly5 P_UEI.N Q SIAT IRA.1 AMlE NO. SIAlF I"I V N. l R l 17'lFU !??J tDU WA. t oae ';:m I A N A •1 • S?.R,lE10[NrLII?ICArION NO, - i ( ?} ??I?Y1&IL?.I II I L VHI IFI NII ,' '^ ? R[GISRR[OOWNIR: WI ) I y' 16 ` i 11RSI mIDDI[ IPHO IE NOI I O IS R I I I I IIR51 I I .?• p I. I I I A)" 'i !T!'fA USI N N il r. 1 N l - I] ADpR[SS R•OWNF9 W J) N N R ;: { - - N.W.f bAp04[35Of INSURANC[CO 09 AO[Ni E (?nnC+AN R rsst¢rsl' ua StrtL S ROW -S PTA aDAMAGI ARtA •? Uln' D] C S M °iwc?NOr°iAl ol. „J. S10P t.nrGl CNMG qL P ' CY OfOno? 3 ESt O.ASAGI AW?vN 4lAWNID CNAROF Iw?gH; gN.1AOffS ARIA ' TA LDMc S I IQC,C ? ORIV[N O1N DJ s ror 1, Awgr eY' Lo - KtS ?AIA° Awgv ?RfnwNeD Eseo E rf . ,DIAGRAM OF COLLISION: (hD T NO eV. o¦ no • e 4 - I .I -?'-I'-•I? TV hfnssA4r),...I e`'a?4ow RIM DESCRIPTION OF COLLISION; IVSl3UPPgMFNIAI aN[Fro NfeneARrl ,?[•'GEJ77/?d/Nr , Q0?9/I ' s ` r E L a :, - --- f _ ?1N .rev l-br ? A y c R. Hl r r3X41I CS ua a ?/ f Dam/ `??6 Lst ?Nnvu;. Q ,405(. [ Ij4?-4 LO?j - t° 6 1` P'$T i 1: F&-Of I I I?I ?OSrS 210...E Ci ?G. dClC.,F.GY4ACJJ<. j?? I I NAME, ADDRESS & INJURIES OF PERSONS INVOLVED T i .p OCCUPANTS/WITNESSES^faM'."tr?u5tlesr l +,CODES I - 5 6 ?'q,1p; NAAy; •1 '+q? •? 1 I. nO°4111 1 J 3[K AG! TAtUf 1N?N wrA AJL { ` hAme uuN or ... [ , t i 1 ."Will er AMe •o,ct D y '? ?'•;: l??. - nAM : ... .' -- horuR a .. .... [Jf ? "'; ;7 D {'K°:, ? t { ? I T ,?3 a? ?? h H w' RMOr1Y.14 DNNUKI it 1 , t .?1 NW RowlsS _ No ?AV . ? . ?w N f D H1: O :°;,y D rc I ?? Ik r„!`fi. ? ? N??sO1 mKt ? ??IS I !] r ?, r NL k? t r.a 4 Iwe ? ¦ D ,L; g D C"r GX' ? A ri?..5 L J` rtI"? v v .?L?• f,,`?h9C,hs AL^2r v @ I Y .tV"?,. ry J fi I Ag1J?" 77 ?1x,d,K 4r tl ,? a,`.4 , ? ?? d .I J 1 ! 1t ? ?I ?! ,%r )r I+ Ev fL JF i r ? I N9 I I rf ? l,t E ? 4:` f 1,` JaS??b? 5 k, s M S ?a E i r ?' ? ? .tiI I r ]' ( ;I ?`< •?? 2 J I I 1 yIt I 411sIM? )q41 r? l I I ' 1 I r TI 1"I K .? I - 0 FY ?R x . u[ a pk.-,V1 SiAIk OF WASHING70N PAGE 1 OF( InI[I ?-w POLICE TRAFFIC COLLISION REPORT ?TRAFFICINAY -UMBER PRIVATE WAY „ ?a .Dw E Oll?S N, Y LI N NME COUNIY W t Iui (VSE ]%DDNOVRI 0'7 0 / .LD j S, FF,rS o h COVNIYNO UIYNO, NVIA BAN QUR wu CiY OR-N N6 No- 51REfIORHIGHWAY - N N QE Q CLS ADM ROUIE 0451REL SfC110N O F 016 W O"' 2MIlf5 ? x/0390 ]] IN1ERSfC11NG 7 Siq[ OR ROAD NONINiER//S CfION GO'G^C BEIWFEN?p %_ „ SigFFi AC SEfT 'E". EO MICE PO51. ?I /1 .-CE DI f I M ff N .CROSS 5IR[E109N ESt MIEE POS G??/7 ,e, PAC D ILEAGE [ w A?? F[ EiFS o'c'c' • C?J S MCODE E M R- DIAGRAM MIA COlLISNJN INVIXVfD: StVfRI IOTM NO ND 9llfD?ND.INIDRfD QSPIILAGf y'Hit¢pUN rungrt9m ?L X-RD Nll IN SIREE7 RROADORREIERENCE IMEf• CLS CROS55igFFiOq R0A0 ]J '- CAVEHICEES L;J Q PROKRTYDAMAGEONLY QFESUIIFD VFpOH ICIA L/ OASQ __ q ODJfCi 319UCKINPMf Of OB1FCTSIRUC%A9 OWNIR'S NAME) e'FE fS1.DNAAGE K SnCW COD NG USE - T NO. 1 UNIT NO.2 Q VEHICLE Q PEDESTRIAN Q PEDALCYCLIST E-21 -_' FIRST MI -VI.EN- -1 11 IX __ M r7 (.7 STREEIADDRf55 P CODf .1 D city 5TATE n 98 3 7 R . o r bv?fi A OBIgH ?? av oa+ i; I V IRSIICENIEN0, SATf EX MD MY YR I- e 2 HT La es ?l?/F?UY Yexsa? ?« - SD o9 F E R OCCUPATION FIFM NAME6 PHONE NO. EYES WEIGMI HFIGNI : Q CHECK (?) wN fMPiov O OTH[R. + ODES ? * D? n,Q / 5 f e C len rot :in " QCHECK(r7 UF EHAS AN FMH'VEEOIANOmfa.M CODES?* Da a°, su esu A4° siertMR'' fcrloH n •cD 7n 11 .Z Q ? Dlo; 2 Car Y? N R NAIU. w Q MxuN 1 ? ml l M6 .c Cl ial- VEM Yfw9 SF w C] «eM Nn Q n0 bPT1R Q K Q; D ' . -L?1 IDODGECHEV.) (] IoM a MODEL IDM1NOVA1 IIIYLF IJDR-CON') E Y .YA ( f HEV.) MODEL IDA4T.NOVA1 Y ( I? ? R .$ k L !N lA1EN 1S 1s STAI W v? 1RAILER MY NO. -? SIAIE ?. H I c R VFH. N . VEHICLE IOENIIFICATION NO . s p 0,80!3 S; I VEHICEIDE NII I I i I i i i i RfGISRRtDOW??NfP: I!M?I FIR51 "0", PHONE NO. ISTE D W1- -1 FIRM MIDDLE L ' W u ADDeESSao wNER n q I Z N E NAME a ADOR-Of I-R NCE CO. O9 AGENT NAME . n A , R ]] DAMAl [ AREA I e S • ?iw op Gi CNAR. CHARGE DW iio N DAAUGf?MFA ] • Jl elOr IU?OtIOU S EST. DAMAGI ?AWVY ?REAWN[D` ?RFAWN[0 ? AD-ZANY v CE [51,D ' •lOr e w oioT IOM1D wA eY: 1 ^ ? TOYED AWAY BY, S io I ` 0 DIAGRAM OFCOLLIII.N• 11 L 71',"1 1EogIN .SKEIDNEQSSARY) w s?; 3??nKes I !. :,i,O DESCRIPTION OF COLLISION: (USE SUPPLI-tAI SHI[I If NECESSARY) r + 1_ ?2?. I ?l rifl'ts ? G?p(JIArtSf! o+. 2J. l7 IY rou;,ti(? -ac V? a s e c 2k ' 7RG'b .. s L J C ohm inste.? lit" I ..._ ?E deLrv%? tR Jt.? ': fi. ..+ NAME, ADDRESS BINJURIES OFPERSONS I NVOLVED +CODES 1 - 2 3 A S b OCCUPANTS/ WITNESSES IuulL+naaNIA/5w rd ADG1XJNAl NAME 11 SI j St% AGI TA 1=1 .. .__.. -_ 91ST., IHCI Mln A /4 "NONE . d uwl5s NAME Il?° d ? 1 , r er. AMe Q F21 ' ' . Q F^1' Q i LYln. .V ... .owns ra0 Nuwla RfMOYIO rR QAMe Q RI?H'°.n. Q::W Q111 wMl w A uwP's I "MURFOf NMES I. er QAMe Q'c°`A' Q'E"1„ H. Q'IS ?"v° ,,. ' x ESTpA1 w0 pIK1nn.'SrKMIt.AN( eAD ?q AGIKV Nw n1 KG?I Dt11?ATCHE to IAe I D OAIIw Rlp9t Arr ovlDer DAII d?E6taRE:, ('uE'o>!?E!?5 s? . ?9?~4 ?1 ?O ? I ??. Uyy?r -u_y' ,7* m>aYx.r utiaw-'a+Rwlxwwua?xw,urarlarlq,R.'+3?+r 'Nk2ts4r 4it.l.i1^Y? w.t:a:?w+?rvrsrma• ...,r?crml ? .ugvL:??;" I -: ?.vt ?".? I nr , ) ? ! r? ? 1 l ? I I s , 1 ? fe F 6'} 'Y L r ? i f S ( I 11 ( I l ?r T 1J } . k 1T ? I r Y 1 w C ;rr c y l f I 'i I%r? ?.AI tx a.Ry I J? . P UP" c I S-rA-fk OF WASHINGTON } POLICE TRAFFIC COLLISION REPORT vgcL ' OF No. ?RAFFICWA' PO UCEUCE COMPIAINiNUMDER .DAIEOrG a N- AT t N PRIVATE WAY _ COUNT CDUNEY NO I pL I i ( ?tf"S'j I ?I?.I41 (V CtY NO. , y T Z.E(? 2 1 ?N ?E IN CISYOR TOWN I? MILf3 M, rlW ,-?DP r 14 1 _ NA11 6NO.Of slRfEIORNGNWAY w nc A j 9URA » . _--. •••••:? 117-AD - NON INIF45fC110N _? `d 1 - ?r ,T C/f?g0 ?'.? I %IFEI% ISrANCf Iq CI BLIWf[N IE STREET e M f ICES 5 ENE µ05551P-- Oq NLARESI MILE 5 IRFFT ?, o ifLf ACCIOEN7 P Of DIAGPAM ¢AIA 00. MILCAGE DLLISION INVOIV[D: SfvE411Y1 ?_ 1 ACDpN T.T. ,NO. [D NO ----?NO. INJURED I ? SPIIUGE ? 1pI[ iONw[pM R dVEHIClFS ? PgpPERI W-GEOWY ? pESE LIED ? V[NI IE IME CLS CxO5551R[Ff Oe ROMR OR REifRENKE _ fl IlfCl}IRUCK INA?Oi OgJfCr STRUCK IND OWNfq'S NNAf) u• S,(88Q', -I n Fs1.pM1gGF SPFCIAICOD GIGS '.1 M4 UNIT NO.I $ rvfas E: IAtt NPr M m UNITNO.Z ` ORIVfR'S NAME: ? VEHICLE ? PEDESTRIAN .'? PEDAECYCLIST ]? 'h rl iTt 1 '?7 fftA00 15`Y/ 'J O'rn C5 PV SRffi ADDRESS T F n SrgrE ZIPTCODE PNONE NO. D 9&a33 IIY srAt S s3 z? 23-o-776 g I D PH N I.. u srAlE { W uCEN5EN0. 6 lu Y} F' 3 2&38 V - Arf x pA LdDI m V ?IdL.t NqM NAMf6 H ff1' IIf GNii E OCCUPADON I ?Y (Yl O VC EYES WfG -TRIMN EaP-ENO. CHECK (11 GY„ A?O OD R Ett5 N'EIGHi NEGHI v(Hlnf AS •N UUio i ov " ANOIHE4? )ES p. 3 n"i x s'Y 271 5 F C rsnDlnsc.c:i ? CHECK (? VFH CLf AS AN fA1ROYFEdgNptNEN^' i 'in Jrclw CODES ?'* G a•i°s' z ?.O1RAN 5 FxciroN nlo7'' r 6 vrrwKYO' - ]] ^- ':5}n ? AMeIn],HCe ? rGD•,I?n ? HaxKi' ? N R srtM IfAR MM[IOODGELHEV.I It DMr.NWA ' RD""" V01 ? M.N•.NC( 0 u6' ?c5'GhR ? W I ?? 1 SIYlE um-c-,' +V sOr.S ?ru 4 ?? X V.J MODEL IDARi VA1L gpy 4 lCf / E t N SIAM rRNIfR PLAIEND. slAr I'I y H pt y b x ' ? ? h 78'1 w vt- r ,? LfEAIxMINC/yrION ^ /. ,. '1.'r I,J,., ?, _] , i VEH Lf D-N fl I rA 1RFDggWW?NJJER. IASI NR51 •••) eC i gl I ?!i I L I I i I I I I I I I I` I I I I ! 3 YJ U4\r ( MlDplfr IrbNE NO. O 1R WNfR: Wr N ?IVV\\ ??? \ J G1 C fIRSI MI E T-N ss a owrJAU W . /P 1?^ N NER tADpglSSO INSuRANCLC0. O4 AGE N1 E R r RSOemtr 3asztr r ---- ]] N M(A L4 NO I DI Drr..p5 ""0' gARPAGfp AAfA twt 7U:onoii s Lv DAMAG( El .-N [HARGF ^ ^ wq o y AWAY ^^ v I PLEM(N L INOI Al NORTH u Y e ?acui sw[r PN Liswrl ,e?S(Aa?40v DESCRIPTION OF COLLISION USES IPL(MFMMSWlII/N[CLSYWYf l B ,'40 f4C Ls j { .. J _'EI[` VC-t<s11 ?_ _. SoL.E 604i.WJ Dh. _ b> coy G? ? fl < _: N wf?`?E, - J k 'l (NJ son?Lk 41- 7' le-Fr- _G.o{._.` p T o? .?aElpN+F` OiW?RSOANESINVOLVED DRJESS WITNESSES ES I' I _ OCCUPANTS +CODES I ' vAAy. GR •DgIIEdWEM N . __ _ 3 4 ,?. 0.Y '?- AMeii sfz Aa r ros "W": `RS LLSn 0 ' a I icrv ?nse 7.?/_ PAL fNpAi:R OF um .... 1 eY AMe. O isLKl IR::. • ? au ? i'iRuLL. TAW. NAr R a .. _.._. .-_ R 1. FROM ? IaKI ? NII. ... r r Y AMe. ?•f L [I ax' ? I'iiM 'D sxoGYOR,w-NCY er'-^IJARU. ?e:'? ?G ?'? ??N? s>• wNO ds in[ JOQ'xo empp Ed [fGVI ape pOu „Ir f ejF (' , 'A{I tll? 4 j'fY ird rl _LS lu.. I/$St4 J Ab t ,? F..v ib? I 4 s H rt?1. ,?1 r' d S d? ?? If' ? d 11 J 1?v C J Y tF; 1 4 rk rr 1 5 1 , I : I 1 L 1 i f ? 5 1 s ti } tY ? lu?N;?? p ?Ep .? ?....... .n.. UYy? u Nl 1 yu{CLJ r ? 'ya a aYX L ? r? ? P. } I L.tiX t I r/ lJ'MOTOR VEHICLE COLLISION REPORT NO. GATE OF COLLISION .A? [NA Y OF COLL ISION TIMED F COLLISION ?AM i 0uR COUNTY NO. CITY NO. Oa11 I v ..COUNTY CITY, TOWN M ILER OD CITY, TOWN_,. ApM C4R PREFIX TRUfCCRE SECTION r r-r rl fl t Pcn1 o A? . L o j GIVENAME O?ET,ROAD Ofl HIGHWAY INTEflSECTING WITH: STREE70R ROAD.,. PREFIX E Oi -. P E " tu5_- FsG 79' / NON INTERSECTI N•LOCATION OF COLLISION f/AZv°L ?O/NT ?, BETWEEN STREET AND STREET RAMP L.., . DIAGRAM DgTA Enow o xF "` as[crlxG STRE[T.Incnw.v, nova ;n°?n 4 ` NTER InTEP CS, asECrixD eia[[r°n F e [tr I °nE?5o[ a a IDf a Nrui?r i c u s ? oaoo TOTAL R. R Y[nicLla¢rtt[ .I.-H11 ' SPEC. CODE USE oOFIIIIEU ven¢LAreDEnnun xoxtOUmDrv r.wrv OBJECT STRUCK IxAne or DeN[cr[TaucFl OWNER OF OBJECTS NAME AND ADDRESS LOC TI N N 0 N NRCA?WAY or 111I7AT[DCOSr oa[rAia DFSCCr FEET S W DRIVERS LAST NAME FIRST NAME •: MIDDLE. ° D VERS LAST NAME .., .,. `FIRST NAME.. ...MIDDLE tt? STREETAOORESS ROUTE, NO, AND. BOX NO. YO"sr"'"r^O • STREET A RESS... .. ...... ........ .?,: FEOUTE NO.ANO BOX NO.., CIT STATE ZIP CODE 121"'fD?vNS?? q '?6g DRIVERS OCCUPATION ??vv,+tOaa?ts ur.".rs toss u°x.rn"r CITY .,STATE, ,. COO E VERS OCCUPATION . . 'DRIVERS LICENSE NUMBER STATE SE% ALAI-NIA S14 -SR W11 M 'pATE OF BIRTH AGE nsa( DRIVERS LICENSENBEfl, S E OF GIRTH DAY Y EAR AGE VEHICLEYR MAKE xlv:Dom l MODELAD.PI ... STYLE VEHICLE YR MAKEICR t MO BDDYSTYLE I]°N[ 981 NoNv)a uvlG . +t113K . - LICENSEPLATENO. STATETNAILERPLATEND, STATE H5 l43 LICENSE PLATENO,-STATE;O.- ,STATE VEHICLE IDENTIFICATION NO.• Isva MOOSLSAn[wEal ODOMETER IMiLe.cll VEHICLE IDENTIFICATION NO,.,. IlmMOD-U w[M:? ODOMETERPSR[AGH REGIS ERE. WNER HASr.NnsrAnoD[e nAMV DRIVERS LICENSE NO. ?4 F11NC meg(lvz Ur?PJ S=RI- ! - Tm? REGISTERED OWNER Iu[r Nnsranoo[e xwvel ,,, _, .., Oql RS LICENSE NO. OWN ADDRESS SSTREET, CITY AND STATEI .. .. C- - DATEOFBIRT'H MO DAY YEAR OWNERS ADDRESS IST EET iY ANO ST TEN - .... .. .. .. ......: ... - 0 EOF BIRTH MO UAY TEAR PARTS OFVEHICLEDAMAGED IS [:::r pcosr 61 p rDR[r ARTS OF VEHICLE DAMAGED-_ . ... ...: .. ....: ... ....•.,:.-,., esrlM.r[D sr Dn[.Alar LIABILIT INSURANCE IN ORMATION•VEHICLE NO. ''I- WAS THERE AUTOMOBILE LIABILITY INSURANCE ? NO CO, ERAGE IN EFFECTFOR THISACCI DENT ON YOUR CAR YES NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER ME Of LIABILITY INSURANCE OMPANY. NAM IP ATE " ADORE -. = C-nes - W °d[ C O NAMEAND AO RESSOF LIABILITY INSURA AGENT ITV STATE ZIP LIABILITY POLICY NUMB :^ ,:. 'o r C F I I ST INJURY A G ]ND INJURY IUSESEPARATE REPO TFO ADDITIONAL .U ,cs AGE -. . . ..... '? e /? T' 1 OC AL NAME N E ,1 VL.rJ .INN. c C y[,?s .lT I? - SE 1O A D Ess SEX ? LJ DDRt15 OQ I ?`Fl( V , [ [ ? ..DfS^IC3Vr\y?.E\?:C1L 11QCLCI (?yT ?w?Q ?_ F r' , 1 I r . STATUSOF INJURED MA Rv, PIRIT ?s1' I(. IN VEHICLE °s L KILLED a ro ONE THAT APPLIES t " n ST RED ATUS OF INJ IN VENICE! MARK FIRST 1Lx D ONE THAT APPLIES xo x rs• A!pr o [ ^ L®J N •. C, B?[ ` A,,? o70 ic ?J I U KILLED N0,_ - rII ? ° BO r. 8 no Yr IA ? rT Oci SHOW NORTH BY ARROW IN CIRCLE [a ?"; , ;A[.L,Grr D "';.';:C,7°a \I of e `? DESCfl10E,DELOW WHAT HAVypPEN(DIIR EFER TO VEHICLES DYNUMBER) Btr AMA _r w6y,K UP 6>u m_iG jn; eLtCF19?u iY 5)10C OF1?_12S tLtSEZ=?_ ] L WAR17S LF c V r. N . -_ LSIIC -P!1(3F1NK _ICr7-L _F?RftECTEfJ_CL9?ci?L?__ _ ?- _si•o:-v?a;l n__rYnrset?r,-ctt?•?ar??s_ : .,.•.9?? c CAuGrrt? A64. _M0-SHoT 80- cANylm_?t 14- TAr-W. IE° II ?.1: It - 100 _ E " VEHICLESPOSITIONS BEFOR E COLLI910N"°'-""-" -' xo. or 1-1 uDZ.....".1o i'?u ' ° "wn NvlanognDFr VlHICL! H SSAD? w ON STRI[TOR NIONWAY NAME OR NO. D"?lciiDY r D c c D 11 xD — ?iiiioL ?io?ici IYOURI _,ny ?? 1 C3 ? ? ?. I_ ? ioirtE ?xo lnvtn D.riox E] E] ? IOTHCRI ? ? ? ? ?sx[n rr /DISIfl1AN . .. ».._.....,.....?.?.?. ? _ A}ON6y. '..k.4I , ._ I:-CRO'EINO w?...c i:d sACSA1+.L..IF[[ "- •Ir TO { PEDESTRIAN WAS USING 1 S ?". ] E• `r A B 6 ?aMFA E [" q0?0 WwPACI K WIATNER Lt0 TCON DIT IONS. f1,_.. L I ? " K ct 'A KI IC CONTflOL r x ; TYPI Of ROAD,,, nK 1 [ K•? • ORI?INNENICLI ACTION' " Kn[c. oxE Un Mpnll I ?OqY L J , 1 OAYLIOHT avTATiJQ Z?RAININO Z?DAWN l ?fIGNALI ? ?1?ONEWAY ? IOGOING STRAIGHT AHEAD ? 7 ?W/T ]?SNOWING ]?DUSK ? ] ?STOP SIGN ?Z ?TWO WAY ? E ? OVERTAKING AND PASSING ? ] ? SNOW A ?FOG ' C] OARK STREET T ? 3 ?YI(LO SIGN ? ] ?ROAO AEVERSIBLE [3 ] ?MAKIHO FIGHT TURN ? A ? ICE LIGH SON S C) PIC," 1 ? IIIT ? A ?P LASHING RID ? A ?ILOOIRAMIIE ? A ?MAKINO LIFT TURN ? 1 11 Bl L G T' O DARK•NO 1 ? 1 ? PLAIRINO AMIIA ? S ALL/Y ? ? ? 6 ?MAKINO IITUflN Ic VII {Tq 117 LIGHTS CD ! [DNA SIGNAL . ? 1 ?Lt rTwTsrTUAY AN IANII ? B ?/LOWING REASON POR NOT / KvA1Brr[ronD 1/ING OANOlq ] ? OT IA •<1-0xLlrtl ..... ? ? f [DDIF CERIILAGMAN C] 7? STOPPED NOR TRAFFIC ? B ? VI • I S[IARATCO ? / ?ST STOI IIGNIGNAL t r-._ _ ? Z ?DIVIDEO ,?,e 1-1$TOPPED IN ROADWAY ' 3 1 J 7 1 I?iIA I1?N3 1' SI I t I Al Imo" BSi?t. r 1 :(. .Illy 1 Jti?. N1 I+I TI( 'd ' l+J MOTOR VEHICLE COLLISIONN REPORT p a F 'Al ..... IVLA. M0. ED m Npu -1-171 F 5 ? C?r 1, ?` : :V Il C 11 : ' ' • FFI COUNTING CITY NO. COUNTING El A m '? n WFt ._. . 1 :I C ? x?E pp nIXl rOwx FLxO.a srREET ON NgNwAr nppDAAEp :? MLEa ?n ?wG??'u:ncJ. fir" } oN C ,a /c?I WTEASECraK, Yn{M eIKET OP POAO MTENSEOIKW n' [•?. Ct cLCLS PPEFYt PO F Er OODE C .3 ?O D W L r. i µr. L/un C. BETWEEN LKLT. EO ;j?DST,L;. 8. ®il :- - Tyr © AAAAMOAKKEE aPOSSwuria__Sr Hf-aj4f?-ME 2T ?' wrEP5ECION: 0 RMIP MOIIN.1 Ln w..: .... , / FEEr /L.%?• N CowSKw WYOLVFO -'1 DilAOE? rta A2AP MAT BBXI TR DSYElrr ? MABIELKMO LOSNE9 E ? C ' I i J MFq Eq FNCE CR0996TKE{01 PROM K -. R OLEO O VFnOlE9 . ? SLLTFD ?VEwttE BCOPMSNEMA{FBAL BAYMnxM ? OACTNEM ?' 7O S OB ECTSTflUCK INN EOF ae-T III— n: OWNER OB TS NAME AND ADORES jgVZX?1 ? .. .... .. / l SnEC cOce we n $ I e • a - - IF Mon-. ^ - . ^ ' ,. DRIVER'S LAST NAME MAN .... .... .. 'MIDDLE wFRTWBcms E wvOLVED ?. E S DRIVER'9 LIST NAME . FIN T N . _ .... .MIDDLE .. .. .:•? ??L-/?' L(IZL;LI N11 G/LEL pOwsHWaGi K STREET ?ADDflE33 rW '..1 ROfl7E„N\O. AND BOXNO. ? HAN TWO EPAPA?K rE SIflEET ADDRESS L10. Ni080%NO. piY STATE .. 21P CODE: D 'S OCCUPATION )J 1 //C G s . oU . PEPOPTFOPM CITY .,.,:STATE.. _..,. ZIP CODE. DRIVEA'9000UPA N. , ' "JL I / 1 D/f?IVER' ENSEN _. - _. .. ITAI DD TEO FBIRTH GE i 1 F DRIVER'S LICENSE NO. .......:... .... STATE SEX .:. OA & AGE_ ?E{/ II II .l L V I n(/ I ?j'1 C' M1 Y ?% N M F MO [IAY YR. itt+; VEHICLE'., MANECHEV: DOME) :.MODEL INOVA'DMT1.:. -, BODY.STY 120BI VEHICLE Y0. :.MAKE ICNEV: 00 EI. :. MODEL (NOVA TI. BOUY.STYLE120111 ^ I 777A ,.-SLATE :..TFWLEfl PLATE NO..n '.-,'.STATE .:.; :. TE ,.... ..: _,STATE.:.:.?' -.:: TRNLER PLATE NO...:-. .:..:.STATE.,..:, . r '. a VEH CLE IDENTIFICAT ON NO... v ,. / , :ice - .r. OLE IDENTIFICATION VEH V V+ a REGIBTFAE00 ERILAST-HAST yPJOLE NAUEI'.., ...... to C o 1 7 7c /? 7773Hia F REOISTFAEO ONNER IEA.ST FlRSi M100LE NN.tE1-.+.... Y,..;.. OHIVER'S UCENSENO_:, .. m c OWNER•SADRES9 ST ' ( REET qTY AND STATE):'. '..: -.::' -""'BIT" M0. w ? ? I G ? Y" WNEfl'9 ADORES3.._. ISTPEET.CITY AN A::.•.:;?:. ',..:: :. OFB n .,/.CJ 4?. I J !%I CC r?JIC//L,? OI L'l.Y.? w . y PARTS OF VEHICLE DAMAGED I. .- ...... .... ..... 4- f 3 / f w? qEi Tp AflT3OF VEHICLE DAMAGED " NG ?r LV i JC a h s LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE AUTOMOBILE IIABGRY INSURANCE COYERAOE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ? NO •[4'j,, NAME AND ADDRESS OF LABILITY INSURANCE POLICY HOLDER..:. FLMBLITYINSURANCECOMPANY., r ...:, ,... _E,_ .: -=NAMED NAMf• ES . .•-.. i .:. p ' , yy S. / pi aTA E 'T' n)? uclc/S 7-1 ,, ' - NAME AN ADOflE590F LIABILITY WSUflANCE AGENT ,. ... :. _.. CT' E ... .. ,. pP,. .. WBIUTY POl1C.YNUMBER '::u. .. .. _. ., b .7-1 PLI-T A,'111 /i )n. >G • ?G i r? .73 d - / .LrJ17 7 / ISTWJURY: -' ! _ ' AGE 2ND INJURY: IVSESFPARA E V-FDAADDp0NALVYDBF81 AGE R NAME ()/%Or E p NAME I ADDRESS M F' A R SEX 2T/`W NATURE AxD Q ? E] RENT OF INIUNES r DD ESS NATURE AND ExTENi OFIN "' ? ? EXAMWATIONRBYOA OOCTOW ©® ryVATE RS STATUS 0F BULwD MAflK IflB T ONE THAT APPL19 AP DDYAMWAT WJURIE9 REDUIRE ©® DOCTOR EION BY CTORi A NAME OO A' 0- WVEIIICIE ? ASSErvKA NO LIFD pSABFwO Iw AEI NOnA wJURr IMWORI . POSSBLE xUURV IIE ppAPUWT STATUSOFj!! ?OxNEP IN VEIICLE PEA 13 LLED M K FIRST O ERApLINO sev[Ai NE THAT A?E B .,PO95oLE;. IF ?uxg ? p{PMx '" --' Oi PAw E1CI _ _, ? NO.- *ElTl AN I l IWxORI AWl I Oi PAW F1C1 Ra ?: ,_.. I,. ? 5? 13? 7? ?.. ..H wI,n l:m D 5? e? 7? I I MOTORCYCLE SAFETY: ? HELMET USED D HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED ,. ' SHOWHORTH DY?ARROW W?CiAC E w.u APn ?Y• ? ?•i KE a rt?t A MKEiD0i1?`wplM iE-xAM M `. " DESCRIBE BELOWWHAT HAPPENED IAEFEFI TOYEHICLES BY NUMBER) __ ,..? GC?/ 7/ / 'ry / T ]J-!C 17 /• ?/ Y!! /C /. /? .. / ( ` I '. Fe ] wwpEcex LApn v[Htt! Axp v.Ow' I a1raXW OrrwnLe. NWOw ? , . '/ ?( `1 Y/G -?(l G %( / -. . n r 11 /f { -rya wt . f? Co °// e 4l ?c c? a - _??/ I Ib c,v_ Rl?r 1 ? _._-._._._.___•_•-__-__- - "TMy a2 ?t'F !}\ ) k 1? J1 - It I ,R,] :..''B T VEHICLES POSITIONS BEFORE COLLISION W V[ ICLE ON STREET OR WBIWAY NAME OR NO p 1['NTT,, n f 1Y A wLCLE YD.cM F Feo w.a I LINE.- WVESTMATED BY wON [ps -T-0 LLn ARxLO Vlwt' No p ? ni1NpL D IOiKI - ,J r tJ F ?G kd k ?J Irgaq I:l.? ?. ? GU /G Ior eN D O O ? / 7 .. ? ONL{E{1 O ? O O ? ? ? -FF 2?1 A c? y ' KOLA PMw D D D ? uOO ' a oSANp FROM, DIRECTION to DIRECTION r P I ' l' }} ik 1 PEDESTRNW/PEOAL CYCLIST WAS USMIG: I?Bplwu !?wrxw.r a?MwaA .?cweiwALx ° x?WOx m roulw.r E D cloaew K L? mwA ? roD E L ? Y f: E PEDESTRIAN/PEDAL CYCLIST CLOTHING COLOR: ?p :?uw{ a?Mxep A?K{MKFLLC{M a?= E . ?''{ ! ( T tfL, 5x LI1 C } F ? ROAD SM,fAC[ HHiOLL Q,1 GORY _ pW T WEATMR .lAA , ?ONipUl 7 On- a D SNOWING SNOWING LKL T CONDITIONS 1 ? DAYLOHT 2 ?DAWN ] WSX DANK-DTn[FT .. °pTRAFFIC CONTROL TYPE Of ROAQ KI .. OFVVER/VE ICLE ACTKIN9 ! __, --N K OXOn1 KLL K;nfLKOxF OP MOxFI "O I I a Iq , ! MMl1 b AO E Q 1 Q SKY/ALS 1 DONE WAY 1 Q GOING STRAIGHT AHEAD Q 2 Q STOP WON 7 ? TWO WAY Q 2 Q OVERTAXING AND PASBNO ! lfa ) ] p ygW I 1---,, ! LOHTS ON REV[RSIBL[ ? ] p YIELD SON C3 ] C) ROAD C] ] p MAKING RIGHT TURN l L t , •r G K:L D A D A I? HER yy r'1 LLlIlJ ? S 1 ? .Owtl Off LT S D XIO F ? ! p FLAB.NG REO NTERCNAIq! ? a DM1COPVRAMPI ? 1 QMAXWOLEFT TURN S D 5 qy .1' l ,I iS F i U OTNLA D S El V , FyECMYI 6111L TLOHT9 L (LATINO AMBER ? S C] MAKING U-TURN ? ? S ? LLI il \ Iq SRC Y 1/. II`I IJ OTHER 7 ?TT M WAY.N ? S 0 MbONK p S ? I'M TW ? S Q KOVA'W l ; 1 q kA ?- , - Y , , ? ' bW il1F AY GNV [S -18 yy ' . ?`J?[ / ra?rl L p F ! "tfyl?ggl+` 's'?xIL fl.KhEY T 1_ II 3 r q 1w ` { t I 11. da" ra M ?f? r ? orrlcen rLADMAN T ? wv[war 7 ? r Q STOPPED FOR TRAFFIC nTD nAr SIGNAL y I) y < -; n Sr " IT . Y' aR [Aw ?, •??r ,rv -W.. f? t 1 f { ? I ? 1?rer ? i?; I{r I `,, f - J kErQQ+r , . r n `' 2 1, POLICE TRAFFIC COLLISION REPORT 13J TRAFFICWAY DICE COMPWNIN RABR RI PRIVATE WAY ? ( ? L Ei . vx ?xOxlull xfR .'tlRl. (• IMFH FUSE ]YDWRJ COUNTY COUMY NO. %/ !Y ttNO. ilrv/? . []RUu DAt ?N ?E ?IN OIYOR iO O.Of STRfErORWGMWAY y MIES ? oT r? d ON NAMEIN Cl5 ROUIFON IHIMSEaING N11H: t R-- NON IHIERSECTION r TRFEr a >? SIREET .-EE. ro[ilX E MILEPO51 , s 6 DI DI CROSS STRFETO NEARf51 IE RES 5 E w r ACCIDENT AMR, DIAGRAM DA,A e 1 e 1 FET OF 6 CODE -19- 1 -19- 1 ? COLLISIGNIN-ELI ERIIT. lo-NO. NO.KILLED__NO.INIORED_ ? SRLLUGE H ' aVENCLES m gPROPERIYOMAAGEONLY ?p(SULlFO ?VEHICLfN HEN NIlK 0 IMER Cl5 C R ED 099[iRNCE . R05557R?Fft /OQ qOM./.. ,.., OBIECISTRUCK(NMIEOFOB1fCr51RUCKANDOWNER•5N t) FSr.OMAPGE SnCDLL CODING TAE ` UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN J [I PEDALCYCLIST 5 - DRIV[a'S tYM IASf I M F: RIVfa'SNM1E IAST I / ?y' • IR fi ADDRESS x ,' '? S REEIADDIII. - - 2 IY StME ZIPCODE PHONE NO. ??? 7 r ' DR CODE TTY IAIF ZIP D9 fR' CEN$E N . SIAtE f% OAlEOF81RIH D? ) I V I UCENSENO.. AE % i CBI l; N FIRM NAMF IPHONENO TA n Y T HT E OCCUPATION fIRM NAME E PHONE NO EYES WEIGNII - B 2 TIO OCCU e1??i P - d.,+ e 7 HEW WEIGH R . ? CHECK(/) vfH If AS nN rmn I Ea ANGrHEa. ? CHECK (? VEHICLE ASAN FMNOYFf Of ANOIHF4u QM 10 CODES ? * J a sY 5 e e s;',- CO"" I' * J n °s. 5 1xcIxJN a I. CLt n 2 ORIES N tE st"1.D ? AM. x N l ? «? aan. ? K K,I ? ra., tr 7olR ? M Aa "C' ? W:x ? V ? W.. VFM.YfAa MAKE IDDDGE c-11) 11.111I.NOVASTYLL (30.: NV.) .1 A• 11DARI. VA) ) --' E ._ m 10 G N N SrA F iRMLFR WAIF NO. SIA1 I'I H p R ? I ° OJ tr C 13 V[HKl[IaN1111CA NO. I I I !317 I !31 18191 '? L V XI ID N I' I I 1 I I I I I l' I I• I I - .EpSRREDOWNIR: WI IIRSI MIOOIF PHONE NO. d/t n P+ O I f OWNf WE FIRST MIDDLE N _ J ADDaesspEMN[a N A-1. OF - N. OO E NAME ADDRE. INItHI-CECO. ORAGFNI I DR zt — CHMGF gAMAGf ARUM y 1 f/ - IN A'Y. 4f-(D ? WA ? RN0 ? AWAY ? ESt. DAMAGE IG lOl10M 5 IOM001 T ? TOWEYD Bv: w% = I RA ISION 1..S A` I I IH A S AEaSSAAYI 5 A?" d DESCRIPTION OF COLLISION (MESUIPLWWALSN[[IIINECII-RY1 IPr?..i(Io'S .T!rHl?/..`•4.>P._./?/? an ?? . p b ! d 77SDikid .rid p/erdiz. d_9i's ?c r r? Gtrr ._. ? ' ; o? rig/rY byrdOar CFdddl?? To /Me 6 i .. -i- . _ . .:. ._ ._ . i ?bd.?_ a/ _>!? /7,a sJrs?r si?,/a dy ohs 25 _ ^ . _ .. . _ , I ' ' ` .. I. On 10 /?? 5... 'y'a GI A•WAdF! .. 0/?1 I f . NAME, ADDRESS & INJURIES F PERSONS INVOLVED * CODES I 1 6 . Iutt su nTwmu sH OCCUPANTS/ WITNESSES 1pi ADOIIgNAI NA,W a 51 _ SIX_ AG -ITAWS ?x i E ESIR lJ/Cl Mar u r HAM1. I ,'001455 rulua or AM B. ? W ? 1 ? ttx CS'N,A , "O r ADD1115 '... IaKI Mu. DI40M ?AW. ?rA ?M a17- ?n? p hAW IQ. 1Dp1 51 ... .. INxpM ? f BYE ?MLL ? roIIEI wI. uNIT ? ii r,V X I?SIWp K SNAAVIRAN[ RALWp AO(nCY / rn I ST/?CIR IVIO D Ilp InD11 ro VIO Ja t ?Rx /+? 1 #+? Er s D? 92",, -A 1.a... .. . nod. - - .avr.! nr n. `^tr^?.A;?Ci/ f$?i cx,vml}.w,aey? •'??IV a;l: JLr%Ecur mmbrlING I UIV POE OF N POLICE TRAFFIC COLLISION REPORT ZTRAFF]CWAY o. / IVUCE COmpwNtNUMBER. El PRIVATE WAY ..OAIF OF CGII N AT l .. .. fIMF COUNTY , /rE JISC px. ?lulf N, jMl (USF Z.OO HOUR) 3 ' ? ?^/ COUNINO. CIrv NO, ,. ?fu WA ?N ?E ?IN CITY OR TOWN % N E. .Op YEEI RNIGHW Iwi Blfs ?s F Y FCICIS ROUIEOR I f 5 URAL . . ON Al OR INIf9XCfING N'I SIR N All NON INTERSECTION , IRffllf E M ]] E) <1 ?/ BOWfEN STREET] SIREEi IE pOSt. 1/ ./ ?// DI` Cf l01 f 11 1 Si - R NEARESIMILE 5 4f5 R E W ACCIDENT MI I[ RAMP DIAGRAM pA}A Et OF OOE NIIISION INVIXVip: CODE IOTA. NO. NO. KIIIFD_NO.iNIUGfD? ?SPILIAGE ? NI N wnottOMn OVEHICIFS PROPERtYDAMAGE ONLY ` " D9 pOAp OR RfFE9ENCE INI C45 CR1551PIN 0RRROP R] r i ? RES ULTED ? F O01[Ci SINUCK INMAF OB)EC1519 C ' . / T 1fH GO - 11 K PNDOWNER SNAMFI FSi.pAMAGE $ SPECIK COOING WE f ' UNIT NO. I ONIVf4'SNNAf: ,.\51 r-[j ST E UNITNO.4 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ' -? ]R G+// DRIVtR S NAME: IASi EIE31-? SIREEIADDNf55 IFITI-DR f55 IIY 1 tf Z P D ? . I pF P, NENO. IIY 51Alt IP E. / y y J ' R RIVEN 11 M NO; SIATF FK MO 0 HY I V IV EICENSf NO. All E% All BIRTH u0. f OAY IY4 0 R CUPAIION FIRMN 161HON fKJ. EYES VhIGHI N:I 1 E -Al- FIRM NMIE 6 PHONE NO. Erfs WEIGHT NEIGH r . R ? CHECK (r? ..'FIT Al AN [Mwo aoF ANOTHER: y i' r ? CHECK (.1) ' V[H CIF AS AN (MROYfE OlAWT µ COOE$? d y °M^°T ,0 7 p Ass 5 1 6 °C ?in N U HER CODES jl? 'I" D o d iv 5 ert 6 y ?si DM N 7 ar ) ? I )I MR; 0 ?w?z- R °:: RDM ? K ,MNA. I ? ? bme HN.I[ p, W ? NRT4 VOM Cl WH. TU4 MAKE f.CHfv.l [IIDARf. AI• SIYlt1]DR .c[xNYI wN ?AM ?4e r ?IiA:, ? CSiOy ? KU n Y R ..?./. r ??? E F A) [V.1 MODEl10ARi. _ r ae O CtN I A StAIE NIER-,I W. FIAT( H VfH. ot F' 1v r. ? - ? ?? I AI NO. ? VtHICIE I NIIIKAINNI C HI l ID NII I I Y ,? Y / L??? IY I ?? R[GISRR[OOWN[R f I L r I I 1 1 1 1 1 1 : U51 IIRV MI-IT p-NE NO. ` O R IIT ED -III LSI FIRS) MIDpIE f E] ADDR[SyOI ONN[4 IN / Yom/ N WNfR NAME EApDRl33d INSURANC([O. prAGFNi y /yIl t ^}.(,,. .A? o)Rn,ae ARU o ' ' R t. AI'i[F ]] vM<wKx?Nr CHARD( us..elNO DAX I AR On . T01 O1 IA 11 VN I M ) • ? ? o y tU ?OllOii 3 (SI.pNAA E? ^?ID '0 ED ?AWAY ?RtMA1N[D f51.'DAMAGE I pf01 W 1O DIAGRAM OF COLLISION: N[CIssAR 1 A INOerKAII RNOw41n DESQI'IIPPTIONOFCOLUSION: (U SWWIIEMINTAI Sw I:I SARY) Il 1 s NAM ADDRESS 8 INJURIES OF PERSONS INVOLVED t COD OCCUPANTS WITNESSES Irawupl.N1. 11 " ES . .. 1 1 - 3 - 4 5 6 AMT. If. A CI ' ATU5 'H , PLSR GfO MRr: IU i? ' .I RrW A H g rK) ' r -60 RIK'?^';,e?Cix ?W'.o • Cd113 - NAIWId ... eMOVIDIOON?AM6. ?n.At?IRI e;?N ?iep b . NO Dal.( "NAB cF.. - ?<.:'hOG?' ?t:°.:n. X v m31UAI 0 ;G SIMWRfAH( RApGrO Aw NCr R Rr ?AMR ?<<"D:. K 5 Em IOIK -LINO D IIVRIIWI IIROwG1Y D IE D n I ?- i AIV 7 u 1 ?. 3 ';Td I r ` l , I ? r M E I y ( . GIB' ?J S t Y . INf SFCI NG WIIN. 51 fl PO Y VIV'n ' ?fIBTIJ NON INIERSECIION RR Ppffl% to. MITE PO31 /?}} Bf1WEFN SIRFEI6 SIREEr Z 7B DIS AN ' i CE eD f l iR RIIIRENC O55 SIPfEIOR NFARESIMI Sr lF5 W. ACCIDENT RAMP UTAGRAMDATA 5 9 FEET OF MILEAGE 11I51pNINVOIVFD SEV[RIIY: CODE I k . Of TOTAL O. ?. NO KIIIED_? NO H., RED ? SpIIUGf ? RUN WNOR RD IN R SIR EIOR ROADOR RE[ERfNCE. as PROPERLY DAMAGE ONLY M't EO'N ' IMf CLS CNO5SSrAEfTOR ROAp CE ' ? Rf5?lR0 Vt C- - - ? t OBJ[CI SIRUC%INAMT Oi 00 fCI SIRUC%NJDOWNER'S NAME fST.OAMAGE SPECIAL CODING USE E? VY 3 ORWfP UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ' F: NSi ,R r D ? PEDALCYCLIST aR R fR3NAM •I Sr SIREEt DNf53 1 '?' IRfEI pDORf53 I '" GI SIAIE . ZIP CODE PHONE NO D ?Y R _ -IE P D HON ORNtX'S UCENSfN Slgl F% j IRIH I V N IND. Iv ...I 1°$Id MO OA 7? r , e AE E% DAIF e n G ?' V Aw I OAY Y - ? 4 ly,,yr.'. 9? CVPAIION {IRM f tPMONF NO. EYES IGHi hEI HT E occuPANON FIRM NAME L PHONE NO. EYES WI {E 1 . IGHI I R C) CHECK (?) 1 EM Nr or arPOrHFRPa ? CHECK I?) = % O ' I . +? VEHCIFAS 1 AS OYEE CODES ? FANO,HFR? ? D A s ssRn S r cI D sxMO CODES ?* 7 u -n E„D INJUprz g a ; .DM MH %f ? E ? bNfR ? ct l ? r? fsl ? A NfI ? 'IV" E DOOG ? s R x C em i { R. I R v.l EII [{N[ .Y R l ? ray I DM, NOVg. SrcIEIaD orvv.l U V I EV.1 MOpfI IDARI.NOVA) la VI reoM 1 17 ! ', % n n V fq E IICEN N SIAIE IRAItfR P ? H t w ' ? ro LATE NO. STATE VLH.COI A ,. ?, fN .?} Y + ' vEHIGEI tNU r1 oN NO C vEH if D[rvn a° N ( 9 - _.? Y ? ??'ff V/. .?C: ? ? L I A RfGOtfRf [R. IASI rIRSi MIDIXf PHONE NO W? I I i l N l! R 5 fD FA ' f . O . L051 IIRSi MIDIXf NO, ah Is Aooerssa owNER W A wrvfR N ' D "g NAMEeAODP[SSq INSURANCI CO. OR AGENT E R u Il __ as l AMAGID AR[A e k ?lOP ^??^u ?a CHARGE CHARD[ OMAAGID AVfA N N f u i J ?? • . W' S t•DA1NALI ARIVIAY ?RIMNN[D ' DRIVEN I f ,CIlOIlOii TOP E3I DAMAGE I ._ 3 1 E No ` -TO IOWED ?AWAY ?REMAINED .. •' `' AWA eY AWAY uX ? BY! E 0 A D A ' . I u GRAM OF COLLISION. lu N[C[j5ARY) cAI?RNORIH e .. !ND DESCRIEK1 ION OF COLLISION: (VSE SUPPI[M[NIAl SKIT D NFc sMY) I ,5 eli r e P N i I. - r Al l, \ cJcjF^ Li v?RwG. osl?y <tJ/?c r x_,z, .' NAME ADDRESS & INJURIES OF PERSONS INVOLVED ' .,' CODES FEE 4 OCCUPANTS (WITNESSES is A50?DU'oNAM_M_ I .."': ., l DEIM Ml: ,1, 1? y 1 r .?? SI JCL OF 1?vliSY-YYIVIGYOYJ PAGF I OF 1 No. POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY I'OLICECOMx11N1 NUMBER F4 PRIVATE WAY [] D' pwt FC Ill rv ,. 2S ',t AI IUSE-HOOK) 2100 [DUNIY ?Ce2SoA COUNEY NO. ClrYAO. FHWA °pDRA CtYOR TOwN NAMF eNO.Of SIREETOR HIGHWAY ?N ?E ?IN ?j MllES s ? ?OF T--(d±GUiIJ$ ' NG[ - FCICLS M RW,FON f E ?/°/71x0 SECT IN1tRYCTING w,IH IRlf(ON PoAD NON IN/I?wE.SE,CfIO/N]1 ?7? ?.1 1 11 BFTWEPV-?(. a/!C.'?/v% N 6 /LT????D ? f 'LL x051 OEOp / p151AN/?f BDIRE II N REE Rf .CROSS-111 RRNNEEAR-MILL 51 i[IT 6•..F W OE ?.?cf.E.< ACCIDENT MILEAGE E RAMP DIAGRAM MIA COILISIO 1-VED: SLVERIIY; Ji H E UN TOTAL NO NO RUfO-NOINEURED_ ?Sx IIAGE MI15Iw0rv IuHOiN5 kRD INtfR Cl3 C CIIN 5RE 4 NR[ifxfNCE ROSSSR[Ef ORROAD IRa y y OFVENCIES Fmi-fYDAYLAGEONLY ? gSUlTEO ?NfF N ?? ?? 70 OBEECISINIKKSNAMEOFOBEE SfNIKR OOWNER's NAMFI Cz) ffl n, -,S - a.l?A?- FII-AGE s !GC m 5KCIAL CODING USE -- UNIT NO. i UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST IV(x'S NNA: -1 MIDDLE IV NAME: 151 I l E TcRS @ tI c L L . _ e AR{fi ADDRE35 30 5, 5 S IFEft-E. -'? 2 IY SfAIE ZI CODE EN O D C 5 Alf ITY I TUA, 255 4C ?- 111Vi 382 R , . ?? 41VERSlICENSf crsEc? y?3o? 5 ATE -cuA. DATE OF BIRTH N eA. 53 I 0 V 111111 U NSEN . A E EE. OAI pBlRin N? i R Y Y.. B OCCUxAIION FIRM NAME ePHONE NO. ETfS WFIGHI wGHI E 1.AII1N 111 -11 I-NE NOW III WfIGHI 111"T z N0.I.LSE1lJI -- ?- R . ?CHECK L?) S:N iMViorEEOf wrvomfNµ A ?CHECK I?) HnEA3A vE A ' '.5N uEC, ?oxc.cl, CODES P- 3V:` .Q s a a<I N •Kn . l CODES?* a?v sE ' rv 1ibI YrG U t 'J9'- ? wM.NEAHC, ? c% .6 ' ? cShl. ii ? ".°A?v ui'H°t 19' ?'W' ? m" ? MT. ? „ ? t1°._ D O EH Y[M MAL E(pOWF{nfV.l <<0 fIIDARI•NOVAI STYLE(a ON.CONV) cz E H YfAR bD[110A4 NOVA) ( R. -A m ? ^ OR ll tN x1 SIAif R ILfR RAZE NO. 51Aif ?RIV X7IU8 zuA. H V EH. OLR A N ATE ?K}LFIU/^ITIDFN(IILiICATION NO. L V EHICLE ID N IFI A REGISRPEDOWN[R: LAST IIR51 MIDDLE S,4i c xHONF NO. O W I R 151 FIT$1 MIDDLE END. la ADDRESS OE OwNFR N NER 5 E I. NAAe ADDRES?Sa m'sURANCe eCo? GR AGerv1 '1 F..A[Ef?ll? J"TG?'S / 51-FOI? -'S Ullt R u1 D•MAG! AA1 •n T • C ': DAMAGE ARU I Nu P N HARGE oEI iio N S] R NED DROT,OY C ?"? S I O' I N w,E , f1 S ?AWAY ?R[MNNfO ESI.D IO OUf10H `O K,V I• I I vDOY.' s $ ?AWWVD BY, DIAGRAM OF COIIISION: w N I INDIur[ flONln N[CFS1Rr1 ... Swnu er ARROW DESCRIPTION OF COLLISION: Iwl SUPPLVM[NTA 5HEETIF NICETARYI 4 Ie /CGE#(- Nt>cT7lBCCi All .LJ_. / G/ ? - •- - - - - Sf br N Ro 4,au ,4 y .44 W R y AE r , 1 r([F? 1 C AI ! V --.? ?' `d clsl 0ew,dLc- - -Lain-10'r ti(QCiPDS(4s:-,- Cr 14 70 B - PS A(Uh Oe UhO 101r7{ ?J ¢a u '4 v 6 9 I . P Q T 0 (oA uc PoSrS 7V N t NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES 1 - 2 9 4 6 S OCCUPANTS/WITNESSES "al.3mDPmilto?Nw --" Is'; SEX AGE IAN) H" R 'p ; RlSiR. M EEI. . NAME. Nc+ ^ ;,D ?. c AmREx rulux a w ^r. ? AM e. ? nff' ?,•u. . ? ?^A S' ? C3t,o NAMI Np F ApORltf IV. 0I N VOVIU FYWA ?AMe. ?1. ?"" . ? CiD• ? :" " 1.1 q NAME. w •EN)M5f - - 'x" fOF - W w'v er. ? R ?, LST ? :' w 5 N11 N: f •ewN p e/DEA X ? D AGM1 DMAIEIIID 4•R.I D f ? D IB/ RIFOR Ax De. 1 / IT J A C; 1Y. J '..'?, r.. F ...._ _ .. Y`A. i ?I,. Hx K? S fA E OF WASHINGTON U-01 GE °` POLICE TRAFFIC COLLISION REPORT ?TRAFFICWAY No. J DAT(OF.COU n qT t N a F I ? PRIVATE WAy PoIICE COM f c I cc2f / (?? ..^ ' C?rI RI i IIRXj n.' Ital. tp$f ]ROO COUNrYNO { ?N QE ?w ICI,YOR TOWN N rl 11 5 13 asJhf AWf 6NO.Of SiREEIOR MICHWAY ?W ?Of I' ' wf) WIERStC11NG I Mq?'•E Eh QEa? ? ? ) iCI C[S ". •. j ••a! YAiH; SiRtEl OR N . NON INIERSfCION I f.a ?1 `- K'R' 1 ?.? .G N,uRlts rffr ,S'Xn A' i O Y frau SEVER FYI ° OF NO KlllfD??NO.INlURFO? ? 5P l1AGE ' ? ? PROPERTY OMV1GE ONLY f ? A ? iEli lE NAM[Of Oe,fCi STRUCK AND OWNER'S NgME) D ?' VE ' UNIT NO. I .. Iwsr , ' r ?/7 G . .7 Dy Sr'Y'f/ ZIPCODE PHONE NO. ?i?Gtits: D I uJR 953G2 R r F d! St ATE EX ?q A ND e -A, . rIRM eNO. NAVE R NF EYf$ wrlc,fr wwrlr E of rEHlc?czraaw W-te?T? AN ,R v O u /15 d •C R wN0 r5 ?+ +: / s f pNy e»a I cc r r M,NKAwt ? w I ? cdh ? Gf Q I oD cNEV.) fl lpwgl.NOVA) StYIE IR DR .cONV6 ' s u.e?.e .?fE R ll tN PN STwI rlA 35 3 z'A I4ARLR RAIf NO SIBS( H v I l_ ' 1 /' l '. ? I Q ?? I I L YfHIE N { R 'I9 aMll rl c : y ? AaN.1nHCl I f X . CIrYNp. , iXWA ? URBW rF OR p kAl SfCll N IMIEE POST O.sr .3C) cents arA m} rh§ Y rl' f ? Awgra Nm A S l„•JJ I rOwlO I ? ? TOWED AWAY ?RfMAINfO F510 U MA 1,,4 DIAGRAM. Lll ION: AWAY eY 'NAME, ADDRESS 1NJRIESOF I PNVOWED OCCUPANTS/WITESSES +CO2 Ft J{ l4y ?I I I ApDn13. ,iO.p ?nr ACt OrAMe. r Rple.. UtR riv .....,, ,. ;1. 4y',.- 1kM 4 ` Nqw, .. R D Nnw val N r A? , W,, NwwR or Y rj'}F ? j NAruR a V,? 2A wrrl ss... ......... .. .... ? R N IrR ? AMe. Q ? , Qwon. ? H ?. Q K;IN ? u ?t +15fa tj rI ?Y:... r I } Sd ' ? H??p X r, i t q I. '? t I ?',.? r '7.;pyi .. X wvtu wlprc orrlcfrs NAMf`uru e.pct oR wctNCy ... wer- QAMe Q?wcl? o.nf ?px' ?r?°w? ? ?' .'rl I 1 I D w IeeD? IewD Palcf KVIp D Itanroer PPROVIDer DAre Y C, C. ? ?1 1 ? t 1 i a R .71' .? A' q ? uJ. 1 I I ? 1 ? I` ,I '1 '? 5 < Y? ` t I } ;ti C} P ? ftRsc d 1 v .mV I .?Ik J ? N I., ? ?S8 t?! M b A 1 ! ? ? F?? I n; ?' ii ft t y e? I t r 11 ?1 T a t l l 7; Y I ]V 1 ".W h /i??? f i l t I I I A L? ]3 I!r ',a I t1?1 ?' _! 1 E lm:. 11 a?l?t yy???,^?, - 1 F4 p f??7 1? ? a D E1 1 rv POLICE TRAFFIC COLLISION REPORT TRAFFICWAY pOLICECOMPIAINi NUMBER . y PRIVATE WAY x DAl lcoul n o nmE counTr / rEp I .AY rPl fur 5.iwlo IS..r. IUSE]tlpMOUR) COUrv/? CItY NO. ?iNW Y 3i; 0 2 15 3-9 ' 's e - u n eie QN Qf [j IN CTY OR TOWN ;Z;;.. Oi -11! OR HIGHWAY CLS RURAE 5 W ?GFPdK f' RWIFOq R[ SfctI AULfS ? cu s zndON 104 E l. , t87d- IN E95ECTING KI1H: SrgfE I O R NON INi[RSf?I ON p xx , ? pR[pIx EO MREPo51 11 , R /0l BFiWFfN ./ 51PEFT 6 STRfEt OISIANa aD Rt it MIRE ql F, y555TgfEi NEAREST MILE 1 7' R ' ' 5 7 NAP DIAGRAM MtA MIL E5 N .f? MILEAGE 10 FEET OF C) SR 0 CODE VISION INVIXVED R : [ ITYI W ,A' REFERfN E TIN STRf TO RO.ADOR 10TA1N ? NO. _YNO.INJURfO_ SPILLIAGE HIr RUN IurM'ipvl0'iR INTER 'Cl3 CROSS f?x E VIR FEfOR AOAp a • VfNIClE3 m ? PROP pROPfATY"AMAGE ONIY ? H'SUITFO Y 3 OB1ECi 5IgUC% ENNAE OF ORIECi 51RUC%NF OOWNfR'S NM1E) f51. DAMAGE SRCIAICOp NG IbE. S UNITNO. 1 NqT DNIVFq'S NAME: MID LAST UNIT .2 Q EDESTRIAN VEHICLE ? P ? pEDALCYCLI3T xA t 10 l[- StRfEtADDR a 4 `? I H OgNfq 'SNMAF: IA SI I C ' ' 1RfEt ADDRESS S E ZIPCODE PHONE NO D Y . E sucfNS;Eno. a>( tj? S ? e-V3a•-Lr• Dgn R SI 1 SIAIE N N IP </ / y IS 24 A E r /N ma 91 rH ! €3 Svc I V IV NC NT SF NO. All F% DAT w1.1 1. Mp. I ( . 9 2. OCCWAIION m?HAFS?r fIRM NAMEaNgNF NO. EYES g GHT / Anomf S 9 E R cup-15, FIRM NI a PHONE NO. EYES WEIGHT ry1GNt - Q CHECK (,I vEHICiE AS AN rmpior"EE Of ANOmER: ? CHECK(/) I vEHIaE AS AN EmP'O O O v CODES ?* 7 ass 6 D. .5H <rl r? K. S e pN / u YEE i AN 1HIR CODES 1. 1 3 a d i+ 5 THE' 6 s"OU "? y? •IHT H ?? •EH -) ff I's e e IN, ali To M:. p AM.M N F ? 5y E ? E8mp 13 ? G.2a u? IN.YIAT M _T DOpo H 1: rW ?- A N E ED u6cF ? 6:p ? K ? M IA/ f E{') fl1pAR1.NOVwi, STYIf Ix RCOVV.I 7 a/t'`?"sust lbb0 5x 'Z orR E R [ I I HFV. MODfI (DAR.AI F.? 1 H SEPIA IN SIAIf iRMEFR MIF NO. STATE F'I VEn.CIXOR A N. A ®Rn a 1 63 rpgy C 1 YEN.111 PHIH Al'ONNo. L IDfNllfl A R[GI5R11OO N111: IA51 1 1 1 1 1 ' FI43i MIDpIE PFXJNf NO. G )1 (?lj l)I t> •l• O [ E f WN[R: lASi FIRST MIpCtE NO. PHONE Il... l'?C RT-Z AT'.RES30FONNF1 N WNFR -11 195 w ?? f 136, 4oa Y ITT. DRt550F INSURANCE CO. 09 AGtNf E E IN la • I_A 'At o4 .eri} rte afar pAM.m M[A IvSP.NIHG ' R xx 9Tpr o.,'-?iiowNCNi CHARGE CNARGF IwSa" ,.u iF`M'??O Mu C1; D( I y ISI. (1V,V\Gl wHYI 0%O O C] ?RtMA NED $ / aa Jr , p I I pTOr ?AWAY ?RlMNN[D fS1.O iou y Ueo O J ? e $e aKSeE T eV : I aG, ?Aw DIAGR FCOlL1510N lu SHftrUL NNCC[SSA4YI IN." 1rroTH, e ARROW DE SCRIPTIONOFCOLLISION: (USfsupalME T II-IIl Nfa3M Y) a $.? : lk 1e wr ... ?la5a SJ `eti v r qn'• )SJ.. In Otteg .9' ,. al??•a ' ' V ?C?{ ? S La ff.. ?d.raa.? F4 t$f .St .? tl h N t gr . ' ,, L..-? Z ' ? _ .e . as _ SIE'.It.. a ..__ Lyt ._5u C +1V -- . rx. .a , .. .... ....__. ........._... NAME, ADDRESS 8 INJURIES OF F PET PERSON S i L NVO VED 'CODES 1 2 3 4 k H IUSl E OCCUPANTS /WITNESSES "' rM ADDIIIONAlNMV _ - -- --- 5 6 ..._ _.. N 3 AMir 1 SfR AG[ rxiUS i . r [SI R. bfR N'C1: A N P pplrss E: r u4 a - ' R a er?AMe. ?rhNl ? "rIH O Hx ? C3'r,;r a tYf A r 001115 A .D .. , . Y? Ap N " Ni1f AIN d R A R Mpylg l1 ? rp AMe FI m-, I r ? Ciw ? li°. 1 A w HI raG plKUlwwealAN[ a Al p1 AGINCY iw?I 5IMer ?AMI 0-R1?'.10 v ?l_rlfr lp ?Pl pr Kl DS Al HRD IQKl M91 X ElIIOI11r09i A,HH,, W DAII 3 ? I l I Id LTq ?. S 'q" .? ? I 7 k7•A1 1 P t la I A ' A E l ?y 1y, l 1 iY, l ! +` ( 1 1i r Y ? ? y I ,. 1 } 1 1 Ti 't I 1 ('l -t I I 1.. t fly - ? I ?? r } S E A ' " Y+ STATE OF WASHINGTON GF 1 Nn POLICE TRAFFIC COLLISION REPORT TRAFFICWAY -T-TER 2 PRIVATE WAY - L` Al 10111110 _. Ali E?Olll, N ,1.1 N _ -. t_ (USE R.OS XOURJ COUNN Li '"RR - -fu 1 COUNTY NO. CItY NO IMWA R /6 ? 11..5 i0 1Y .1"%<p t --F :. •S r) '. Ru rY 1' ON ?f ?IN CITY OR TOWN NPMEBNO Of51R[EIOR HIGHWAY '' ItT 015 1 ROUIf R 1 CI /''? JJ (tiJ MIlfS ®5 ?w oo -• 11`U.1 .1S-N QN`!ll a :?f?f760 INIERSECIING N11H: 5' Rq}AO NON NIfRSECt ON `y?T/r JnC ?N ?- IY J PRFFI% E MITE P051 - /J 7 BETWEEN %'.'. /,., j/L•'? SIRFFi 1 (/V51REfi h? Re / DLL CEB DIR MIIESER 51REFt gNEARf51MIlE i ACCIDENT MITI, OF MCODE E E RMV DIAGRAM WIA.,, COllI50NINIXVfO:PIfYI co mLL31N tOipl NO. NO KILLED_NO IN,URED_ ? SPILLAGE UXp.... OFVEHCIES ®AAVWE ONIY ?HU N D N REfi R AOOR AEfRf NCH u C IT. CG ET II. %? ],21 n OBJECT STRUCK INMAF OF 001[CI STRUCK AND OWNER'5NAMf) ES1OPMAGE F7 39CMl CODINGUSE E [.tom $ UNITNO. 1 -. UNIT NO.2 IVf ' NAM ?SI ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST -3' : NRIT Cleo rvER'S NAME: IASt I MIDDLE - - 55 (j n STATE E P CO D I I PHONE NO. 33s-69/ NSf NO 1 IIY N g . m A eIRIH '.1 LC' (3 o pa 3 I v . (r f RM NAME f PHONE NO. ? CUPAION FIRM gMF 6 PRONE NO. EYES WEIGHT 11GHI FFS'TI?. T o CHECK (,? -.1.EAS:N FMaYIV ANOrXFR'u ?CHECK (.? VfXI<SE AN FM.bYFFOfANOTTW- ,Iy l: ,Y a,NI JKI?. ? PR.RI CODES?* D? +i 51 6;° ' I,I?Y<R CODES?* D +s)%cbX 63NO, "? 2 N GIG, ? SRI . °« ? w.AN<, ? u Kl ? iR. ? s ? r? ' CI r 'I [] Aw ? u ? <z l4 c) ? :° II . EAR MMfIDODCF{XCVI MOOfl lD afI NOVAI SiYIE IR DR. GNV.) H.YFAR 1 XV.) 5l0ARt-NOVA) Y I V.) V _ Ilc ; UJ Ar O E / pRe O fNSE VU SrA3f AVER GUTF NO. STAI H V EX. R 111 11 PITT NO, -TEND ITAII Gr,., cry . - 232 r? C . J VEHICLEID(NIIIICA -NO. 0'c?10IS:I R I L VEHICLE IDENTIFICATION :?I I 1 1 1 1 1 LIQ EGISRRlOOwNFR: I. 51 {IRSI MIOOE PIgNE NO. ?ht/1 (a:S ?r011 ? W I Tf D WNfR: IASi 1115T MID f1 N . / ADDnsSaowN1R E R OWN' D1 NAMIEADDRl5 -jURANCECO.OIAGENT ' rAr n / SEgTT (F_ R RR DAMAG! ARIA , vW wl CHARGE w b • O NWOi N'NrOiN 1AAUG()?ARFA ?, ? r . .TOP 10?OllOii fE51.DMNG0.^?AW?IY ®yCAWN10 CHARD( O,X 1L ?AWY 0IIU-NfD f51.D1? ! 1 I4?0.O 'S v 1OWE0 AWAY tl TONED MAWAY tlY: f _ _ la !N 61C RryogTX DIAGRAM OF COUISIONo iiuEUFN y.S,ARr) Y AR OW DESCRIPTION OF COLLISION: (WE SUPMWN1u SbR11F NECCSSMY) . - . ® V?ti t WK, hxTRl1i1301JNp QIV 59 1Tk1 . ?t ? ; . ??oa.I.lT ?'U . Ia.IJU STF?UC.k A ?k..Fk? 'SIJ TFIE - < ? ._T ?T._y,? . . NAME, ADDRESS E INJURIES OF PERSONS I NVOLVED * CODES '1 - 2 3 4 S 6 OCCUPANTS WITNESSES IU -`K, M TOR ADO1gNAl NAMC IT 51 S[% AGE IAIUS ' y RISitl. FACT .ICY N AA4: PrY,N A KISS r. NAIU.101 P L AMe. ?F ?,n'. ?, 1 ? MI., ? . . A 6DRlss Awl. . .. .... NAIW d ZOO IROM ?AJAA ? '? ? ? ' ?IiiM O NO. A lYM11, I NAx?S a-t.0--o-E, ?- 1 ?0%6. ?0 ?1. H. Sr•OAi.v a.Slf11 ERAN. POCA 01 AGLK;r K D AI[.RU IOl AR ND OAIIORIPWI APPROy(DEr DAR ' x 11l! ?D o°7ia1 Oj,J O2c ° YYt,Lt .'I r t Y v15t@ i k i1?I, b u4 ..r:vr E A i wR?A ' s I r ' ,.{ N ?' o j v J ,v a . ? ?,- i J v, o Ry M •.-i o • U o O U O Nrt u? ; - ' O. ? Fryy O O 7.?0 ? O --_._, 1 f / -. 1 j i '??= ,l';??}$" . 7 1 U PRIVATE WAY .. E b F ' AT O[C ,. !ll} ySL ,Yf w o 1.r. ) I Y 11 IME IUSF N30 H0UR 1 COUNtt r T CDUNiY NO ? CIttNO. ... WA iM DURAN B ' v , . O /` , ^ CS .C CJ /O/ al F 7? CS O R e I U RAI ' ` 9 DN Df DIN Ct OR IOwN EANO.Of5TFEET0RHIG«WAY / mttf3 W ?r 1 VV\MG V\\'V\ ON 0 CJ 'C'04 '. pp l(ORSyp SCION ?.' QJ / ly _ . INI[¢YCIING N:-11 OR ROAD NONINI[RSf c"ON Phf1% FO M1lE POSt ?! } S o / BE1WFfN G O Sl¢FFi A -IET . OSB _ I .. 1 DIlIAN A01R M9 {fR( .CROSS STRffiOR NEAaESIMllf p031 m1l[3 N 5 E N e L rEFi w Of L: ACCIDENT MILEAGE CODE DIAGRAM MEA 0? -? COll1510Pr INVOLVED: 5EVf RIrYI NO %I" NO. IN;URED? Re ;PIING DHIIL IOTµ NO. 1A I '? '[5 AD NI. EY Cl3 FI R¢OAOOR Hif 4tNCE CROFSSiREEiO ROAO 113 OF V[HICI[5 © PROPERND-GEONLY D.FIR 11.1TED DV[ CLf Y D ?J/S© 'x R ?{tCT 51RUCK(NMIf OE OBJtCI3IRLK% AND OWNER '5 NAME) ESi OAmAGE SPECW TAD NG LAf -. '? ? p rotASac Pole r u eT l a ?QK s 9,60 . ;. ' ? ' UNIT N , 1 - UNIT NO. 2 D VEHICLE D PEDESTRIAN - D PEDALCYCLIST' Sc - ? ! OaMR'S NAMl: Iµ1 119 ., ORIV[R' NAME: LAST i T??? IVIDDLE s -- _ SiRtEI ADORE D. 776 B R[Et ADDRESS rc UIY 1'C 51ATE 211 COCfi 76 ' R I Y IAif P 1 [ _ MR S UCFNSEN oRNG F at`I{) SIAIE WP E% A m0ioVH.. ( DRIVER '5LICENSE NO. AE 5 DA BIRTH pAY ?. OCCU-ION r1aM NAMEA P1gNf NO. E- GNt MFYiHi E CUPAIION iIRM NAME a PHONENO. E- .1-1 T ? nA.e b,; c t a? R - HECK (? 'v(«nf AS AN Asviort[OE weM.or«Ep. ? CHECK (,? 'Al 'vE«nE ASAN EMPIOrtE OEAE:or«eR ' i CODES 1.- * 7 n;"a A s 3 NKIb« a ;° vin ,i r°r s1rR<rcu CODES 0. + 7 c is s ERC1aH 6 •N i1f nM ID n NIUp [' N S 0-- u V" D nl D i ?' O D AYeu.Nn D a", D 0 D w HYKU MO.. F VFH. YEAR MA[E IDGOO CNIV,1 (L(DARI-NOVA) 1111 (30R.• ONV.) H.rUR Y MAB 1 -E V.J AgOEI IDAR VAJ ( ? EVM T 1 I '\ E SB Y y'+1 5 L '-/g 5 E? X D C'I SIAI E iRAM1 Alf N0. G 251// 5'A? ? V H c V[H.COIOR Il N A ?+ )R 3 «KEtIpM111GIgN NO '6?d6.il-ISi II NIF?? 7s? I L vENI LE D M1 I H N .I i i I , I I! I I I . I NRSr O D wNfR: , LAST flRSi M" '.E NeN D11 ?No? No. Rll(AR`o F, f ^' - u vy 1 (U C u M k ADOylssor owNU ?,/ W A s wrREa 'i L?CS ??? 1 52n 1!/C N ? ,m tw, t E -? NAMIAAOORESr Or IWURANQCO. DV_ -tAADDRMDFIN$URANCtC R 3R UNK _ ' IIGN MMA jDALIA A•N?ND „ OYN NO gAMA6! AAUE pN ?toµ CHARGE f"'??ROUG 1 O E O CNARG[ Inw 1 [ A 7) ? I F 1lOP S ESI. 0 ? DRIVIN EST. DAMA DAMAGI PDiWAY PIMAIHID AWAY ?RGUINID IO?OTIOM Y 10 OrIOY _ S row o C S, ? 11A 6a Aww l AowsvArm f BY, Y DIAGRAMOF COLLISION: I n N wo1cAN NORTH -s_TPNEcE_'j -Go. DESCRIPTION OFCouSION IlESesIIPP NiM $r N[assARrJ _ J I I Q ??? ( .?wc.rV e G? `p: Iw ?r?'ro 11111 I (? IA ' m ....rr _ p?I ..a> * .. eNU E W cL T Lll VA ry CC << V - .,•, .., A _ _ . ;1 iI, L ca z GONE, Ih?1 U.J IE r &ceS I?? fa ?d F % ._ . .i _.. I II... iD n:n 3k off C'II. V?Li. Y K ('cam [jam.' s/_..,¢.. Ill I t o Y i-1 NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED ' CODES 1 - 2 9 4 5 6 ' OCCUPANTS/ WITNESSES TOR MdtIOWNµ NEAal el SEY AGt vd .1 1161P /NCi " X_ jfl 1.2 5 O + S { t : A ? - s DMI,f K. wDfi: E•,h' T"(ME.Y' IuR10r? .I " xIMlr D- 1 D'i,`D " ZUX DE"'.0 ' J t ,?y N AYU. _.1` ? 11 ' 1 l A BOpn! NA1ulIW ut?h' 1 ? AMe , DrD. r.` Oro .0=* D.° . , M AmII . a l aj . onlll AT.`"?iE t er ?A 1 O ? o.I[. ? D :"'H I )1 IY . M Nv1,1 IWG pI,(1 SNwEt c '.t )I? 1A0C1 OE AGINCI ACID MO b II o P p Iro11 ih.tll.}jr J.?' _Jl .. ,a'. Y• .., lf.V.,, B a lh'.. AHROVID II DA t Lw •.J.i.li(... IY.Ahl..i.. ti.Y .. m J V w @ ? d ? i' I t ( S ) F Ill r;, ? ? r' ,rs P Y T1 P • Z ll?l , I - ?d 46. 4 ? r S ea? v6'm "Uo 3 h Rr I/ TRAF1.1 POLICETRAFFICCOL .1 REPORT RI PRIVATE WAY ¢¢ 7GO q OA. O, IXD! D .a. D OFCOI ? .. lvD; s. iu ,-.1 ? DMf lure xonlroual COUNtY i O G ? S ? C011ND'/.NJ- // LO UlY 2XJ. FlrW.9 ?u ,w 9 L / Oa H IG 5 t9FE l CI YOR IOWN NAMEa NO.OF HWAY ?E ?N ?N Ct3 I , YS N I O /? ?W o, l?/Mlf s )? ` ON ? ? Q- 1 f(VIflN? SlRffi 6 O SLRFEI ?I 0 .J 6 D'77 60 of R .C40555tRE RESlMIE - Mlles N S F W FEET Oi ACCIDENT MILEAGE CODE R-1 OI RMOAA - CO USY NIT1VO VFD: IN1 ERI Jy wG uI. ?SRIIE ? NO K IIfD NO Wrv m NI[9 CIS p?55 RfETOR9W0R In ? . . iO1MN0 pvtHICtES ? vgOFF9rv DAMAGEON[Y ? H1Rw ltFD ? [HiCIE : OOIKi319UCK INNAlp Oe,KTS9RUCK ANDOWNEk3 NAMfl ESr. DAMAGE SRGK CODING USf ? ' - ' UNITNO1.1 ' ::. UNITNO.2 ? VEHICLE ? PEDESTRIAN- ? PEDALCYCUST 2. ORWE43NNAf: I, 51 T la I '-G L= V rJ7G-? G f DaIVERSNFme wsl ??i4'?- - SIREf?//Ap)DRf R?,?/ ` ADORtSS G Y SIAif 21RCODf RKINE NO. D SIAtE I R DLGL l? f} 33 gs !?/ R D9WFxs uctN Ez-? G 3.d sae Gl/A Nl A .° I °.536 I V Iv N . IlAll I" •?. i DAr OCO»AIpN FIRM N/wrEa hq NO. ErE5 GH(HFMiHT E NRAIION FIRM NAMEa RNONf NO. EY[S IG,II IEIGl9i 5 ,2 • nv, Corps criaw B /7 •/ R ?CHECK (.) VfHKlF w2 AN fMR fpANOM 9 ?CHECK(.1) VFHCIE ASANfMAO pA CODES?? 3 n ss Rs 3 u1cIKR, r e sum 07 CODES ?'* 7 ?.%+uRr • isn: s 3 uGR9N b suss rw - r z R / oa 1 ,w.Y °? ? WKAN ? u ? Mn w 1 ? r N . O % ? NR ? M ? M.. ? :zD ? rx D.. ? % ` vEH.YG9 MMEIDODGE'CH ) S DR. V.) IllI w) V .1 slwR. AS l V.) ME p !9 Fa E ,a StA1E 11WLE9 gAlE NO. SIAtE H vfM Q E 7ii !r C VtHICt[IDINI IrICA910N NO. V L FNIUF IDfN1I A I N I. i FAZi6 ?', 7 O? O' l I! I I I I I I I I I I. RfGSRRtO t9: IASI IIRSr MIDOIf rMOw NO. Y!a/ ?,°, E wrvfR: ulfi FIRST IDDI IJ D lSSp OVMf9 N NfR i E/ SC7 ?.J pL E NAMeaADD9essa lNw9 0. err R DAMAGe A.rA I"?A""cDOM 4AMAGt3 Axu %D+tlr ' • ;.m • t OR. ESI. OMAAG! OADY,I^Y aLN[D ?AWAY ?9[MNNIO t3.0 f IO?OIIOii 1 r ? = 3 AWArovnDeV OWED • / -Al .Y: r ° MAGRAMOFCOLLISION: I iE euo rH DESCRIPTIONOF COLLISION Iuse suFntMENEM SwUIr Nta3wr) 1S4li1 rlpS3AaY1. I I_L. { I ! I I I I 1 I x _ y p At Vic' a w _?I Ca ?r? Zo .;dy'v- _ _L. i f I 1 I a ADDRESS 8INJURIES OFPERSONS NAME INVOLVED *CODES I - 2 3 4 5 6 , svLLwvFrrAl OCCUPANTS /WITNESSES I"'tFOdIgNUNAA4 Ip sl SI -yx Aoi ra'' Har,R -w'E "r wre. inci M1t1' ??) NWI: ? G` 9TZ? S ? •ss . VO`t? / _ 1 13 .4 .. W _ .eo.rif . :t 3 e _ Hb Iw nr N wt .." .... ..... ...._. ..... "_.. - .. ._. .."."_.. _. AOONil NAIIM Fp _.._...... ....... _... 91MOV101 OI ?AMa. ?. CT" R ? ?• ?n , AO N M! NO AgN113 (up IN,WMS N e ?AMa. ?rpKt?[M:IO?` ?:°' rv X N WKtRS NAMl1R ? eD 101 Ka NCr ?t?r SJND OKK/??FJF.RAO DATIp RtIWr ARR9WfDRY WII I ?So lRw Hn f.[o w/ 77'z `fl 2 Y' l 54 ?DD V'"I '°E, lr, 4 ( t say,.. - f 1 ,ll t- 2N 1 L r r s ? if `fL .4 s - _ Y f 1 rr ? I 1 _ F 1 1 ? ? ..?: ' A f + r NI I 7r ( 0 _ . . i RR? , a. 1141 R t? ?V J POLICE TRAFFIC COL=bN REPORT LJ TRAFIFICWAY wilt A.uNINUURFx Z PRIVATE WAY G09 l OAIE Or IX I 8? •v V wip muff IN >•r LIME 1 ? RI COVNIY ??)• ? .r a? COUNtr NO // b YNO / N YA i pu- RAE Q pN pt ow EIIYORIOWN PME6NO.O :19fElO4HIGN AY 18 as s pw poi Ui-h wt 1, 11 ON S6t ( CICS 09 r ON 3M -??87a P rNrf45FCN GVrI,N. Sr^9EE'l D.9 ROAD NON MgSten ff,?Fr `/,'II''iiE{???E I S-I. ?I oq- 5TRIE16 R?``µ6t°FFI FRENX E ?Ob" U tr.>AN ! .C905351REEl09 NfA9E5 MIlf P05 FR N 5 F W '?I 'J_.' ACCIDENE MIEEAGE R DI pAI =TJ7.r .. tVVV f IE[I Of IO ( / e. CODE Cgl15pNINVOlVFO: FRIiY: ?H 6RUsE E Gf IOTAI NO. NO XIUtO?Iq.INNRFD?? m ?NI W 1? fR IM CAF. n 1n FIR CEwNICIts cj,WKQ"DAMAGEOMY pRFI1 RD ?St?i<INF -yf /O L!(. OaEEC SIMA:RINAMEOi Da 11 AND OWNER'S IAMf) ESI DAMAGE 7 Z7 SplUAICOD NG IbE Do v 1012 A713 tFt 1, A? . . UNIT NO. I UNIT-NO.-2 p VEHICLE p PEDESTRIAN 0 PEDALCYCUST s' 3 DIErv R'S NAM y }I I Sr . MI Yu L;7_ Lu k c, 9rvFR' NAMf. USt TIES I - 5T9Ffi ADDe n p T- ( - S OurLk . No P r9 E A D9E55 Z rY SLATE ODE HONE NO D Y A I . Z4IF 33,j ? llVtlq alCA4 l60A_ ?(r R -_- mwtPSUCEN SIAIE X -11 MOW.- I Iv ll AI OA z AfION BcU{) IIRM NAMt?a "°Nf NO./?? Lt Ch)` LX1mspr fw: IGNi HIGNT IZ 4iE E R CURAIION iIRMNAMt611gNE N0. EYES K:NI I! i - pCHECK (? YIN uwsANl lor ANOrN eu 0CHECK (/)vENKIlwsANGW oFlgANOmFR? r?« ' CODES> * 1 n .° S . 1- 1 e y r R,r CODES ?+ a aA . i S EXCmN 6 w n Z 9 INEIpKS N S w? S - S :°..D« p A«NRAN I? I p Mil; p 19- uY911oIH « p A«NA R: p WE p MIR p MZ; p. A D VEN.?? {NEV.1 (?? AI Srv}FI R CONV.) ' [L Ir, E v H. YfA I fV.) NCOEI IDAR VA1 I V.) I 5 N Al N f1Ar? 1 Allf MTf NO STAY H vEN.CIXOR ??? 3? =. C Klf lq lM:AIKxV NO, I' (R C' S 8 L vfNICEf IDtN II I ptGSR VlOOWNtR: WI 119STC MIDgF G pIpNE NO. O W R r WNf 1A51 11.1 lDIXf 1- ;[. ADD9lSSCI OWwiR N E NAMeaADORe weANCt eo. oxAUM CiRAX E - . `ra ?v t? SbL7D R jl ? l p I I . , ?, AMAIX ARU _ ? A IM fiOt = 79 EST?./M?3M,,A, ,G! ?WAV QpIMNNFO DRINN 9MWN[D S 1 A TDwfD AWAY I] fD?oROIE 11 S 7 IOMD tGCl Aw a DIAGRAM OF COLLISION 3iueluwu3isA r) IN1? 9?EVO°IN DESCRIPTION OF COLLISION IIbt SEIPII[M1NIAl5Mllli M(lS5ARY1 ,?^" ?" .._T? s_..r-site Poi jCd - ? ?c ret?- 10?/ ..Seelrf ivQOAJ.EAY?iTtT -- ? d ? ' !?E A ? C C -. -^ - ?.EJ7 . ?CO ! r 4clT__OE T G [[fCt!E---. . xvVcsnGArtA?.b' TXc??? 6?e-r?s ?4ee? c? IR r NAME, ADDRESS S INJURIES OF PERSONS I NVOLVED +CODES 1 - Z 3 4 S 6 OCCUPANTS /WITNESSES wa5anl3uMU5a Ip ADdIgN4 NAMI ? SI .-_ _.. SEX AGI __.-' TAI xlaN _ -.Ir. H Sla. 1)lR R N AMI ?. ? ....... . mRnt r w a p w+ Ea. ?cY1 p ,ur. t p ral,lt '" N AM ? 1 U A [tIa11S NAT Id -_.. 1-01-0-F.. 0M"0M .0T., pn c ,p A IXare ' ".AID'D°.11sO1. N. ! er pw.ue a:! OG"x ?? ?? ANlfiwlAOOtKIRSNAMEaura. X f ..72uAGr? C? lC? sIAOOrwa ErwNC r cv IE - fors Alc Nlo /4l o polKt AAnvsD oANa F r own r r, , ka??ffi iT"''1' 1?, 1^ -?«+?^4. +v r ,? t:J° r 7 %'7 41T \ r ? -, S x ? STATE p OF WAiNGTON I AGf' J O F No. s R??':. lRdfi.. 'J F f e `? 4 •` POLICE TRAFFIC COLL NREPORT QTRAFFICWAY 1'.. ._• voila NTNUMBfR n K PRIVATE WAY -- '•f?47 . . 1e7 al 2 norcaL N RD . 3r ,, ?y? ,. nr of au N Wx rul5 wip r?l 1 E 1 /?OO c5-UNIT I ?e G U COu., ia. /? clrrra. N-A Mfr Q [ 0 U1r OR TOWN NVO. OF S 1RFr ON iil n\YAY IN z 8 / Mu Qw Qoi OKT Io.uH • ON So.IfFY IP'f. k ? INiLR5EC 1 ING N 519ftr OR ROAD rvpN INTFRSECIION iC[CLS M tE SE DON ?? ?JO-' p11fi I f0 as VV FF S I / O y BEMELN STREET a S-T IX . M LE POST ?• SD ?? 1 I D S IANEaDR TI IROMR ER NC .CROSSSr9EfTOR NEARESTMIF 5 ACCIDENT S DIAGRAM MtA ) •'' '') S [ w Of MILEAGE °V /Z rFFT ' COIDSIONINVOLVED: -R.11: NO.%ILI[D_-NO,IN1U4fD ? ?VILLAGE [JHIT FuN iOTAINO. EE Rn1x Q ONIY ? Ci VfHIClES ® ppppERtY DAMAGE F. ELIRD ? VfaVIF %.RD i R f RROADO4 f4[ntE INTF9 OIOSSSIN[ETORpIgA° :LS ..{. E?.' h I . 1 9 OSIER SI¢UC%INAME OP OBJKI S(4UCS 0.YOOWNE4'S NAMEI fST.OAMAGE SPfCMI CODING TAE _ _ - UNIT NO. 1 UNIT NO.2 Q VEHICLE Q PEDESTRIAN - Q PEDALCYCUST z 1 DRIvEYSrvwNL: lASr NF" mI a D-IF-E:- uu II I - 1 7-0e L Lea -- /AJ L St¢EFI ADD4E53 3v3 ?/ c2ld i t2 6Q, A D 51Rffi ADDRESS r Ulr S-1 a1PCDDE PigNE NO. 0.11 P, HR R Ln+A ?/6 R 11 S- a ' ONNfR'S DClN NO. T? EG /o P P STArf fA w 4. oa?DA+IR?y I v Iv DCNS. NO. At X IR mD i e D r ir. R OCNPATION rI4M NAMf6PFgrvf NO [YES IGnl nFX5N1 E CUPAl10N MNAMEa rHONf ND. FYFS IGNT HIGILI h /'J 5 5' R Q CHECK(,,) I VEn Lli AS:N rmnor [orANOrNf4: 3 ? CHECK(/] I VFH CIE AS AN rMROYFFOFANOTn[R`A ' - CODES ? 5 EX .04 INI . Qj mN A Q ? n"' ?? %EIDODGF e?e DART.NDV E %PIA K TH C AIgN NO. '3 S c 1 1 13 7 ? L R F4. USi F.- mIDOIE A S rE u PHONf NO. W fGIS1fRFDOWN R D 5T IIRSI MIDDIF N rl . IZ ADDRFUaoWNf¢ N A 4 owNER Ail E NANF{ADDRf550r INSU9ANCf CO. OR AGFNt T A R 'a oAMAGfonRU I 1 n o-x"5.s xo a.. ?uAACe! ARU< IwcuoNU enA{ee cNARG! °f?"' ?OMG r X erop I • IST, DMUGE ? v ? fMA NFD ?DRNEN ?RUAA N[D LSf.D w? A AWAY lO TOM S T S °er: Qi/?S L_,f reso ?towFOeY: S T O: v Aw A DIAGRAMOFCOI115ION; lu Al I I4unNO4rn DESCRIPTIONOF COLLISION; (.1 SUpR FIT. Sn[n lr NE-1) _.. _._ _ SWFf [N[aSSARrI er A94pW I . . .... RIVER FAILED-TO-tMOTIATE'A-SHARP"CURVE;-'-"ANI) do•{'fJ! ...Rd ._.. ..; .3' N-OFF ROAD-'STRIKING -A TREE. ---'--'--- I •Q I R I , . . x NAME, ADDRESS 8 INJURIES OF PERSONS I RS NVOLVED + CODES 1 - Z 3 4 5 6 rdE OAI OCCUPANTS/WI MESSES s"' ADanorulNAme Er u % AGE -" w IwHx5i,r- E. °---- nsr4. eKR I[r: ., . N AVI. W4)N r eY ? AM e. Q E24<' Q ^"" p Q A'; i 1:'nFa N AMI- No A °Dnss 7 NAILm[IY _ _ No RMwe+IwM QAMe Q""RF Q"" .0 ?E:°v , r 'm•nY utun or . nAwns rNr er. ?AMe. ?r',%K' ?rdnE QG"x Q xv x uRVISwANNGaIKr•a N,w a•AN% elAr ?o¢ / AraNCr o-5i iar ('SO Kl DlsrAlcntD ?m w? rala/E ARm+?7L° /S.w N¢i pAl[ornwrr 'y'('b Arr¢ovlDer I i own P , a ` lI 7 11, f . o S kt STATE OF WASHINGTON C? TOR VEHICLE COLLISION REPORT NO. ' v OA rEOFCOLUS10N .. .. .. O «o` p, /9o sl,l w« AY OFCOL Nt:,.fp LWON. .rlWa rWEOFCAWSNSSN AM- ?UIE Rrpx Fw ., - - COUNTYNO. CIIT NO. .,;. : ./G Y..•.: ?.. pwwL. H,I r?• COLWiv CITY, TOWN ?« M` Te?FFtCSah ?R UrIµlE b Fµ MKE9 OO DITY, TOWN. /S? ®© OF i c ADMLl9 PREFIX 3 xOUIEORSrnEErCMf yCLs90 SECTION DADW G ENAME OF STREET,ROAD ORHIGHWAY ., r G OY L E? RD Iv ' WTEPSECTWO rM: STREET OR ROAD PREFIX ED MILEPOST ?• //ASL//ryG l .: c gO g CO a ONIlTENSECTONLOCATWN OF 00 LISIO STREET IIYTWFEN STREETMD MMP - DIAGRAMDATA 'r(19 M v.I's,ERNUMDHI, on SCE ®© IMFAUApcnOS.InO ML[oOSi oq winirri L N INTER IN ON XRD TER CLS ASEC VrO mEE ntFfn tou+atTamF ONAa.y 11 N FEET D P%IE14LE V EncLE ?11- DgYCLE Q0Td"I-IEI 'WtvEO SPEOCODEUSE . IvTIKVES L• ?vtHCIEONEGi ?vF«qlF lnwx l.- ?VEAKLEPESE ..1 ?-c-,-- OM,- OUJECTSLRUCN 1«wYE DF ONERSrnuCAl OWNER OF OBJECTS NAMEMOADOREW LOCAT ION Oa ER, FAp IDNIPAN - FEET FnDE _?- 5' NUVERs LAST NAIE IRST NAME MIDDLE -CARS DFWSTNAME MIDDLE, !urn OR /ti?CL /E/!/il/i VU ST.R?FE?XET ?AOgiES9ROUTEHO.MDBOXN . VF?T? IRl iv,O USPFpn? /T?A00PE5LS ` : ROUTING. AAOBO:INO. CITY STATE ZW CODE dI er/ Goa 9PsG ONVEfl3000UPATION ?? CplusOx nfFDnrrOnM CITY STATE 21P WDE. i?. -? 6 OOVER9000UPATION Ho!J.S?ov?e to IVECRS LKENSE NUMBER iP 5' 'TIE SEX ?E1 BIRTH .AGE DRIVERS WcUM.1 __? `-/C J/ E/ ^ DATEOF[4RT11. AO. VEr1KLEYR. MAKEICHEV:OODGEI., MODEL?OVA-0Y -. 'P BODYSTYLE(20R). V", 7 M r ? E) Fk 0-:F 1765 /-,XD , ? ; ? D LICENSE PLATING. _ aTATE ..,.. TRAILERPIATE NO. L '3 !? Ft<3 lsJq sM STATE. I yKCUec pLAf4 //T/.•Lj I7//f7 XE TIRAURFtATENG J^N(/=P STATE vEMKLE TOE TIFO7ONxNO, ?/leNEWERI -' ?O OIOO VE? IFl? p.. (,BBB MOOEL46 NEWER) .. METEM E ?T/ REGISTEREOOWNER IU3??FlRSi MIDDLE NAME) - DRIVERSLICENSEHO. r? ?e 7J tier CITYMDSTATE aTREET 111111 REGASTE A WN REOOWNER IUSTFI RBT MIOOLE NMIEI, .,:. V/% SENT / ?r?? BTR pFWERS UCER5EN0.-..,: . rOWNERSADCRE :., ( )..:, O ERSADDRESS ( EET,CITY MOSTATEI •.... ._ . . MTEOF9RM:, Y YEM PMTSOFVEHKIEDAVh.ED IU«MATFD ? PMTS OF VEHKLEDAMAGEO EerWAlEDCOSr WAS THEREAU LIABILITY INSURANCE INFORMATION-VEHICLE NO. t- CAVERAUEWE TOMOBILE Y CE FFECT FOR THIS ACCIDENT ON YOUR CAR ?YES ?NO •NAME MOADDRESSOFUABIUFYWSURA'CEPOLKYHOLDER _. NMIEOFUADLITYWSLIRANCECOMPANY ,' .... :..:. ..... sT.LrE 2P NAVE MDAGGRESSOFUABIUTYWSUR EAGENT L 9rA*E TP UABILITYMMYNUMDER. _ - , ISTIN-Y '1 . - ..- AGE 2NDINJURY: NEESfPAMTE nEPIXIrrOxAmnOnKwMEe, -,. ME N E nOpNC.S r_ -?-- SEX p TOrAI NAME Es d omt :°AUwu`gs-ro+°;aocron. ® f n.,.Epn U DOC MnMpxerA DDD ON ,Om ®'® x.uE STATUSOFINJUREO - MARK FIRST ONE THAT AFPUES .. Q prNEn VEHKLE DGA&? p Mvras?.BUNp IgsvIKE ?PAevENDLR gLLEO IYKnFI WWDn B I STATUSOFIWUREO AIMKFNIST ONE THAT APPl1E9_ p _R W VEMKLE pSAUKKI NwNRDgIURAMAVO POS4ME ,g9FxGFn KILLED IsEyEnEl LMMIiI BE CM•N? ?PEDEerm.W Fq. on nnE.P. D e? BD `;F]", FfGI O ,TwSTBIM N0 70 ??IIICx•:Nn;rF-x D SD e? 7 SOWNORTHBYARROWWCIRCLE \ DESCRIBE BELOW WHAT HAPPENED' (REFER TO VEHIWS BY WIFE")..: ~ • IrnA[E,"l WflwF. Tn.I Pf/LICIT YDIAIDpLNeAPreDNIf WIq;?, \ ?, erNfl p« ?'=. esr/laQ- m_uT ..off pY<_u!?-T°' Ri_?ew_ _ ? NINPEw t „D?nln t.?r, YEHDLf A«p e.qW -- ur _r? oy t !q _ ?h d 2ir .Let ! x:Nv_ _. T__s m ,n?- - ? p«LCrgxOIKANLe+Anxpw -•? Q•- •, 6,IVE FAor,.T.sF-2Ga-2....cuHe...l ??f-n-d--- I, V4 d I FDN Q ' i VEHICLES POSITIONS BEFOR MINK', N B E V, E COLLISION ON STREET pI1W11WAY NAME CA NO. NOMp`re le -cIKKr lfaui+e ."navo yI! Irp Leav`u".i;?rro rte AIO Ke INVESTIGATED SY 0iiFLinFF4 O= HDLAH ? O ? D D ? D ? D, ? , oc-1 ?ar ... pr A. D 0001 D? D D . D D ? Z^FF ? D D D &cNo u roewo FROM DIRECTION TO DIRECTION {KD[STRAN YIAa UBplO 10 510FWALK 20 WALKWAY 20 S HOtALMA KD[ «MA O? WYK a?OTNEn R0ADSLWFACB Kwcx lyw, NrKII V•E A,MFM UG11rCWGr10N5 TRAP IKCONTAIOL IMLC - v1rKLI b T rYPEOFROAD OR W-1 6-rcA-n IO V rK1 t M ? NEn/VEIMCLE ACTMYFa N KMCK-.-, 2 Y q r? l/ , .,L,e 1 OArI qNT ? 1 ? SIGNALS ? 1 ? ONE WAY I ? DOING STRAIGHT MEAD ? r ,T , MY 2 ? RAIMxO 2 ? DAWN ? 2 ? STOP soGN ? 2 ? TWO WAY ? 2 ? OVERrAKiNO ANTI PA s&Nm D 2 OWE' D DWWANG .T ? WSK ? 2 ? TFLO SON D a D AEEVE S&E D now 2 ? MMNO Rmw TURN ? ' ? SNOW K D TOO A D DIOIIIICR ET ? A ? FLASHING AED ? E D WTFRCHMNOE D A D AIAKINOLE" NnN ? e ? KE a D O,R,n e ? DARK 50F1 f I'll's ? e ? Ft ASHIND AMKF.R D E DI'00.1 AMP( D LLEY e D MAM WO U TURN OTHER O s D sne»r I+ torvj I ? s° rz iw ra D e ? m rx?u ? e ? i? Terri ? e ? R"No RLA'ION FOR N015e[E ARV.Lrrov+vAW WInr ND DAIAFR rXM LICI e i ? Dr.t. ? I ? OIFK[N IIADMMN LMFS ? r ?ai0PPE0rORTRAFFO ? 0 ? OTHER. tPFCIFY D , ? SEPMATFO D 0 ? OR ST? A DON T SIGN AL .._ _ __ .. _._ Mr K e ? 2 ? DMDED ? 1 0 ? STOFPFO W FLOADWAY 3 10 El j ' M " .` rS?.A ,li 1?L4,w.. - yn ?.. rHn D 3 ?UNDIVIDED R . . . ? 3 ?F11 MOTOR VEHICLE COLLISION REPORT --'--' NO: - . DAIEO +COLIJ.AOH I - DA 4 YOF DA W Ell- WSIONr - TIME OF COLLISION AM <: ' n ». :LCD Ua FM ? COUNTYNO G ( ' t »o 0 COUNTY C iY,TOVM .. FW YDf r MLE9 ? E? CITY.TOWN - OM CL PREF S n p GrrOn / (.,! /: OcCUnxE t [ wo- u i is ?© OF I J C ??'j?n ROAa EW CIVENAMEOFSTFE .M.ORHIGHWAY WIERSECTM6"1"'5181EI OR ROAD... PREFIX Ell MIL[ 03T????v/,y<ir%C eD , G 71717 A061101 NON INTERSECTION LOCATION OF COWSAA EETWEEN -•?w??STREETAND STREET WIMP D GRAM DATA - ©© nMna DMKEFO iO,iEOfxrrrasvWa Wlq„n. ER.IVUeDE. N INTER IN ON XRD (E C13 ?E < 9PEE9 np ?!? FE EK nSfCrK» FEET D ® D -1?W»cLErE- aOvOVDLEnC?E ?01-IR w TEl D ? / SPEC. musE O/V[NKtEs ? /_iA ? 0--t P[p-. ?MHCpUSMIn ?nrxvx OBJECT STRUCK INAN -ECISrPUEKI OWNER OF OBJECTSNAME ANDADDRESS WLOC ROAD ??zE--II F EMIMMEUYOS WAY N?LJ qp l ,p TO xEPAVi (kuECT - FEET EDGE § - ' F ManE rnAN [ ORIVERSIASTNAME :.; LFIRST NAME ; MIDDLE' rx e/ Ze6(_ T-C.. E RI OR pN.-ILASINAME... FIRST NAME MIDOLS - r? - /? - - e STlIEET ApDNESS;..OUIE NO. ANOBOXNO.. RE nux iq SiREETA00RESS _ NOUTENO.ANDBOXNO. t TY ., .' STATFC 21PCODE lam! . 11.Y? ORIVERSOCCUPATION ?t 5 Ca' n[FOnTFrnM CITY STAT LP CODE ?i% 7 c' s ORWIFSOCCUPATK)N , f/%I /? r fl/1 OR ,IE?RS/UC?E!N•SE NUMfiEp- .. GV C7L .ZD STATE SE% ?(? M F DATEOyF/&R?TTH 7 Y L7 AGE -VERSUCENSENUMBE STATE SE% pATEOF BIRM pGE MO A V MAKEICHEV,LJ000EI.. MCOELINOVAOAATI BODYSTYLE120R1 E"L El M OU?L NOVA DART) BODY STYLE I2 DR. 70cc STATE 111LEflPLATENO. STATE # STATE VEHICLEICENTIFICATIONHO ODOMETERIMILEAGI TIFICATIONNO.. (1909MODELSD NEWER) 0011118 ,(MILEAGE REGISTEREDONNER .?,. ILAST+IRS-14XENAMEI .. ,. .. DRNERSLICENSE NO. RE I?iERED WNER IL45T FIfIST-MID LENAMEI DWVERSUCENSENO.: OWNERS AOOHE59??/7,., ISTREET,CRYANOSTATE) _ DATEOF. TH MD n OWNERSADOR 55 y? ISTRE CITY DSTATE) _ PATE OF BIRTH Mo wr AT TflhITELES L 1 /f/L l? PMi50FVEHICLEpAMI.GED To.EPAR YE»K E P SOFV HICLE DAMAGE ESTI»AreOCasr . / .LIABILITY INSURANCEINFORMATION-VEHICLE NO. 1• WAS THERE AU COVERAGE W E TOMOBILE LIABILITY INSURANCE FFECT FOR THIS ACCIDENT ON YODR CAR AYES ?NO ' NAMEANDAOORESSOFUA&UTYWSURANCEWIICY IgLDER NAME OF LIABILITY INSURANCE COMPANY : . . ' . _, n.WE urr Sr,IE ".. . /1fli5- ?tIrACFw, e Ss%?iz ryrs 1_4W .) ?ZAs 6dli'. NN.EE ANOADOIIESSOFUABB[TY WSUR4ECE AGENT --_.. : U!v srME UABIUTYPOLICYNUMBER -, .. 1ST WJURY. .: -.. - NAME AGE 2NO INJURY: IuSEEE-TERV-TFOn AOdrq -L-L,E I ,• ti, NAME ADE,..,. ADpRE..4 __ _ .____ o AWES _ _.__. ._ SE% M a - ED .ED 7L ADDRESS ? S M 0 ._ __._____ R.. RE n,MwaKlle.A000rdn 1 N © _ ... _ , ®? P.Ne s _--_.__-_. AM»,roNnr.DDCron _ :6rAlrOF[UUflED paNV, WVEHICLE ? Ass[nun D .',--, MAAKFWST OeAMW6 IYNNAFI CNE THAT AFFUE n0»o-YMM MAKnI S 1aS4 rR 1 E STATUSOFINJURED 0DRVEn INVEMICLE ?PASSFnarn XILIED , MARK FIRST PSADUNa Ig[H?lI ONE THAT APPLIE NgI?KSABLWO I_ G - II ON- nw NO pOTRvlZl1 C- ? 50 611 dPAW 1CI 7? ?INDEarW ND ?Gnrtn vn 1 ? 50 00 O O F PFW fTI 7[:] S.qW NORTH DF AAROW [,dRCtE \ AoWMOrc . [InECp,IRrnONrE Cf3 O , \\ ?a wTArwAY NNAEa eA - MSCPBEOELOWWRATHAPPENEO:IREFERTOVEHICLESBYNUMWAI. / - '?'? //r? -? iQ Qf- alnuron EKww,r - ;- 04/ /7ah?_.?7ClGlSG- H --- - -------- VEHICLES POSITIONS BEFORE COLLISION No wA,KS vrHKIF Klr nlAHpvp u vN .ILFm l[ .. rP,A.e w,a I eSrlonlED ar V[InGLE N 8 E W ON DllIF.E1 [M110.:HWAl NAME CA NO .-'AN n [s u v[IUCLE xc?Kn ?°PiiIIpEL ?°u°KLi „D IrpAK ? Q ?Q (?T ? ? ? ? ? ??pK1 OO?INW 611• t Or,KW OvYl 0 ? . r/,F /' } ? ? ? ? ? ?WKI.1F nw,r w ? ? ? ? ILLoNU UI wo,.wG FROM DIRECTION ro DIRECTION. IYM.9IRAN WAS lAS1I10 I0 ronew4K 2?WNKWAY 1Q WM)Ul OER AQcru iwNl 5 ??1hPNrrwK 60 OTHER ROAD SURIACE C•IY.AI WEATHER I UGNTCONC ION] TmAffcc ONn10l KINCKO»rl Ylr,tll TYPEOFIIOAD d vnKLe KR CKGnr nVER.NEHKLE AClgN9 r »K [ [ Heal f E AvvA??,q?..??J ?1?DRY plu 1 LA='Y ,+ 1 ITIDAYIrfJII E Q 1 QSIEW4S > ln+Dr1 QI I QONE WAY Q I K,RCM fw MAtlnrl I fAING STRAIGHT AHEAD ? 7 ?N,T RMMA SNO 1 2QDAWN 1 Q 2 0510F WON w Q 2 I- WAY ? SOLE l ? ? OVERTAKING AND PASSING ? trlOW ? O Q WNO [ O'ca Q DUSK T"I El E ? DARK Q 1 Q [ID SK:N ? A O FLASITY. .t {j Q J lKIM WTInCI1NKiP ; Q ? 1 ? MAMIN6 fIK111T IIIRN S ' ? , ?DI I!R D ? CKYI ON EL'AK D A A-141 ? ? IlA5HrM0 6 ` A Q ? D ?ILLIYDP/IIAMVI C A LLY J E Q MAKWO IEI l TURN ] 0 O MAKDIOUTUNN ? 1 ? SIiVY [ O DARK I ? D Q RF _AI ? A ? IWO WAY, ? D Q stoWI n 1tt AAMIfOn Wf Y[W K,rKlwOV,xT MIAY FIDAA%Nq, rKM ITC( .,. TRIET, F OTHER ?EVLOry ? / QUFFICER.MADMAN LEFT T URN Ancs Q T Q SIMT'Fn FOR TRAFFK) Q [ Q Drnin. EFFCIry ? I ? 5FPMIAIrD 1: 1 S ? (AGO, VAN SKAAL .. -, AKI _ _.._ 0,0 moo ? '0 TOFIND NROADWAY ,i4H I i I ff , 4 %AY Y. Rj,1 ?.; Y 5 l?yf I. y "' A i rIl I T D? D131AN<t Di Rf 9E e[M'EEN 3fRFFi 6 SIPEft Di? MILES N 5 E ,CROSSSI4f f RNFA4f5f MrlE POS ACCIpENi NAMR DIAGRAM DATA N ?*? rEE! OF `3 -Q ?'- G?y7E-?J MILEAGE n CODE - CQII$ION MVIXVED r J - : of 41 Y, lolAlNO. NO. RIEUD_NOINIURED_ KSPIIIAGE ? II gjWN WNOn9m µ'13N {$ OEOSSSRf dVtNICUS p Y IMfP E10RROApR -KREYDAM ON ilRf sra q - [[ L ? RFSUIRD ? VENICtf N1K1 5lRLY:R ENAMFOf 091ECi 3lRUCE AND OVMf4's N4AE1 3ISO ESi. DAMAGE SRCI.ALIpDINGUSE ' ,E ? r UNITNO.1 UNITN0,2 wneR's E: IA31 F,qt ? VEHICLE - ? PEDESTRIAN ? pEpALCYC115T 09 ' ?? 1V q 3 NAME: sr SlRfff A004f 1 4ffi ADDRESS a1rRT. 2 /30X A7 O B ' SfAIE Zq CODE -N. W. D I Iwif c6tic- 1Q. 9 3?6 76s-34Iz6 R r 09N E45 UCFNSE I Iv l N NO. 8R-`l F9-N8-A3q`IQS LJq ?? %% %0 6% AEE MD. ael n T ?YR a OCCUPAIIQV 4Y NAMlaRgNf NO. EYES IGNr rtIGHt E UPAIIpR f14M NAMfa PNONE NO. Z SfUDE dUILcEU6 1416 ;14. $RE,o ISS ?f11 R e es GNr NE GN t . p ? CHECK (.? w 'u -, .NNC s ?. CODES?* J u A4AS ANOMU4. E MOrN . ? CHEC+(.7 wcEf ns AN EMVt°Yff aANO1ANFa. ti+ :inr:" s rcnaN c" CODES J a ss'v • i r ?c.cN i.en e ? 0 ?? ^•s a r N IN?IO, R^ . lr ., y I t '?? N ki- ? ? u DE NN YfAR A 0(pppGf <NEV a M ? vEiIKU ?Cn tt?j PI.egVAa NSIYU IZDR.GONN wE ?r•? ) _ aR . r 0 1 fv.) AMJDFL {DARr• VAI ( .) IQ Cl ? FD+/.D MusTAN4 2D2 E .?j G? t Siwft ? R 1gAl[4 MtFNO. SlwlE H NN CIX 4 KwIi7 wpi. w NNI - CIfIIXNtIFI(AIION Np, i VFNiCU D Nl fl A I N' cf F o ,z'F i y So s .` I tG31E9EDOWNt9: N51 Sr IwDIXf RgNf NO , E EDOVMfR lA3! FIRS! MIDIXE ?2%AQU% /aRdJOLb LJ. 76?-3?2? O R App9E3300VM[R W OWNtR 2 SAMC- ?? DQtu?cZ N " . pt 1? f. % 1' n•MEaw°DlEeafxwswANCeco. o9ACeNr E - Y R ? - # Fk . DAM•ce Aeu F r 3 ' - " ' O A 3 lOr C ? CNA9G oI+rnONOrrnl AM/4t NSSA• I {31 DAYAGt 1 N q , t . Q D 3 N^RMDr aTer N ?R[AW NED D91NN f31 AT ?~ ?RfMAINm _ t ° 1 ? tog ly uio nor er; AUO S c kE?ROJ *ovrtD ?AwA er DIA . ( ` GRAMOF COLLISION: I D InDr-wRNORrN IS ,- 1 T -. SwtluNea yf.,.., .. ?A,vyow DESCRIPTION OF COLLISION: fu3f3w. ..... srrcel FNEU3swy1 ? F - • ..? _'-r - 1 -i. :..;.. r _._ ?. •- 131...., . ' L.?E NiCGG TRAuEtI.VG /wI SG_De24G'ipfJ? .--, 1 00 CO QD, (2 A A PATCH o ? --- ,: F 13WCK ISF:-.LISP co!.R ROL,.!u A.._ LkfT gfDE f R ! o AAp ?L,._ .?•? ? ,- ? ovERTu2ntEO la+' ' r ' • ? "' PnfERSONS INVOLVED * CODES 2 +vNlusE9 1 I S 6 4 E??? _ 'I.F ? ? A001 ION l NAMI 1 1f!t AGI IAI y .. - IN N/MAF. Dpi 9E3lR EMR I. .. I r rr I . AMe. ?FYI3 ?"" . ?N M'. o - : 1 _ •tro9fu ilueeor ........ ._.-. ? NwMf , "' Movlgr ?AMS. rwc l ?^'• 4 ? Wx ?NO.:N. '° 1 ?, 1 x' R .?. e ENCi1N El25 OFFICE _ •DDne E N• .. C . L • I Kq r ? F p ,? I'?.?'4S ? ,. fa ^ SDD InDarrcFnr•wea YAN{ ewpefa •eFNCY IN fw er ?AMe ?f•?? " ?f:x ?^NO1•NI. ?'; M W Kf DRr•ICMD FOl wRYIND D ? t tipg 1pl X C ? 1 , 7E ? : , y w 1 .r' p r .m Nn ?? E 1 . • //1 _.____-.. ,,y D1 I r . Da NfC t I?t? ' ?v.i ??F?{fiFsFS . -d.n0w,?, ?! I SI t ?? ly+i? !I W.d ? rqf I id f U lm t i I F V ?? ?? p r, ( t+ 44 L.. rh? y 1' rt } ?1Y F e! 'W .....-.7 ." ' .1 1 © No. TRAFFICWAY •. ,• POLICE TRAFFICCOLLISION REPORT • K%KE COmaAwFNL1MRE4 - ' •. PRIVATE WAY E DA, of : c L D 'yc,l, x? Wn • L D,1Wu N.l L,. "C 6 MI /` umf ?O?HOUR) cou:vn Je FFc:.cs on COIR T1 W. /lo alv NO. HwA pUiBAN l GIY OR 10wN aNO.M i4FE10R HIGHWAY RONN DE DIN MRFZ Irn- uW BAE ,1/(IE ('.G EAY/N ON NAMEO Ca. ?O GE 9 fCi l2 , fJ7 ROU1t04 1}/} QJ7? CIION ?t INIERSLCIING N: S,Rfl, OR NOAp IpNINiLRlf C iION Pafl% f0. MRE NJZT / ' BEM'tfN ` Ip O S1RFfi a ZIRLET Q O'•SCJ OISiANCEe IR R[iLREN .CROSS SIR[ti poixt Ea 11 MR[Z N 3 f W G ??c F ?0 A' a ?! + "IT or /l UyIZT ACCIDENT MILEAGE CODE DIAGRNA DATA Y COiLIZION INVOLVED: IIO%R IFD?NO.INIUR[D_ O. S.RUGE pNlle OfV NIC[3 PRORR}Y DAMAGE ONLY ? ? aIILTtD 03< CLE N DaD 1H D Y IM-f% C4 IOR RO,D OR aftRENCf Cgp32d1RFEiO1E ROAD 93/so 'ZJ .7 q? cr slvu I.AMFOroenMSIRUC%AND-RlNAAU1 W.DUAACF sacIALCODINCIaf [ / roLA3ac ole- u - -__ k-3,0- -- UNITN .I UNIT NO.2 0VEHICLE 0PEDESTRIAN 0PEDALCYCLIST S DRM4'Z NAMF: NSi NRSi D.l P DR-R'-E: IAIL NR T? L a I— I 776 B aL, ADOa55 3 AEF ZIR CODS PFIONF NO (c 76r-3Y9/ D R ., SIAIF EN. .- wmR•s ucLN oRNE zON? s,An VqR D°.o,rlR R I v Iv 's LICFNSt ND. An sx D L mD "y 11 - OCCWAIION __'NO. i EYES I NEIGNf GHI E CUPAEION FIRM NAME A PHONE NO. EYFS W[IGN, -111 a r.AJ: Dr; •? c?tsan a.1 R HECK (.? HICLt AS ?N ANOiHFR? F A p CHECK (,l) ' .ICIF AS AN EMrioNNGAC NNVAI IAL 1 CODES (? T 3 ?: " % ivsn 5 ercelro.4 a "O11°r°cr N e YN[r reN CODES ? 9 Ass S F%p n ro nil RS - ` , s *;%N ° p .D,AN[L u O Ictl- O O 11811,. 1 0___ 0 O E6m, O IH ?D O,NR4. pm N. TEAR IM%F IDGDGDCHEV.1 N L(DARCno.YAl S,TL 1104CCNV.) E H?xFAR MA% I 'E nFV.I MODfI IDARI-NOVA) Y 1 V.1 _ m S x:eNSE au cr+. K A? SIAIF A1F N0. SiA1f R N. A u R.Y FH.eaOR 1 , AE ?/ °"/ fF ?86a ,Gag?t y cv I. j ,o nICEE IO(MRIO%,gN NO. 6?a6 L•s?ilVlrom -rs i VEnKIE DfN,INU N ? I I ' usT non MIDDIl a l?` F C 11?- PHONEw.. O rs EpowNeR:. LASF Nal MI DLE NENO. ? , . ?iR,. ?NO .uhk W sI R5 elg,y [R A ,.,/ AD i 2t5 I ?? Ste., IJ/e N E E wn•EV A NAMtaADDnsyyv?pwRANO CO. o4ratNr R -k L AlDlk!4 OF INSURANCE 71 ff:7 fi N K, PVAAO fDN[A w gAMW.Z EA S Z I C?ciN CHARGE • U?OlTOM DAMAG( 1 0 Dw -y ? RIMNN[D ?RFMNNfD VAN A= F lIOP ! IG ?OTfOM S 5 AwA. ev S S' Icle IOWFD ? Aw%r ev: S DIAGRAMOFCOLUSION: iHUIUN[aswrl wD U1e NDRIH DESCRIPTION OF COLLISION: (US(SWK[WNTAl SNELTDNECISSARY I s -.. ;- 1 ,Juba i •. 4. ?.. l t fGJ't ? ? ? _ >^ ICJ -;4v?. S>o1 FGr.. •a. 1_.. c t 1. ? . ._ `-, le .. _ Cru E•Y..?Lc.,. Veil ? /--w[L T tt.h n ? _ , ,E? tb N 1.. h?1 C?J1 Ir ' O Fr ly 1. JRt /S rw(DnnlCmcN3 tL?sJ C?%.•.c.. ?D C)Ff Till: vai,, r 14- c ^ rtz S J .1 t I! NAME,ADDRE5581NJURIES OF PERSONS I NVOLVED *CODES 1 2 3 4 5 6 OCCUPANTS WITNESSES Ill- ILroNr!(FN.IiF"iuv ii u% AGE alas '„'„" ° „a lso. nlcl .: . NAAM: •// ritcHar ?° aNr, / 1s •- - . ? ^ . ADdnfe K. wDrx rwlt Yr..E.Y• I..ta..r, H scEN,eY2' AM e pP: ' O " OMLo NAAU: No F ADOn1s N t, I. RE FArnID IROW pAme. 0 011 O<".'1.11. O.T: 01:: NAMI: i ? A Lrilff NAtb,TM v,. eY. ?AMe. p.,,,Al Ofd.N. O:: ?iI° • NvEn AING WE(K^I?i`MY1lRANR X+J`Lt.u... RAIX,Ip %Hp ,W H[? G f<,I Klpt, MD I /,.?O n.O / /q Kt A4Rn?V?/D UDWIS. D ?TO/r IFORI ?U/2. AnOIDRY MA ii to a Y"gym MOTOR VEHICLE'COLLISION REPORTY'YFr I ti DAreoFCOluyon - 1 NO '..y a ' .DA?OFCOL SON .TMEOF DAU1510N CGUI[ ' !An TYNp y 3 I'[AY}.MV_X.M?VXVX 25 80 X 3- PM : eF PM t '? bt a '? `` a".' P?1 ?®pUxAL 14 COUNTY. .CITY TOWN- Durso[ MEE9 O :::pTY. TOWN 'Rf r E ADM{Ey, }rHEFlx lOg9 r!.eptax SECTgN Coyle Road Jefferson Cou ! 20 Di uilcene WA r? ox fivENAMEOPSTpEET.igADORNgNwAY ?M-?_ ,?11 5•.R.S iO.T?+,r MILEPOST `:x4.A ft l i! "wK Naw ] o Road Tonandos Peninsul Coyle a w }; u I?:?{' ONIN,EPSECTgNiOCATgN OFCOW ?t "??i Y f7[?i T DETWEEN GO le COmmLLniC SIREEi AND Dabob "W'j. x o Bay Rod STPEEi t -` rt • ?N © A:u±obttgOSmia wirvn araFFr. n:rnw.rinoWU?wunFx.wrrocE p[TET' NCf?nC lrO?fi ?Pob? 1 StorKW ©® o roYron otxr ITER NON 1%iRD.(rallTOR?•- ? q -a i raCOC ?o IOwrncttoWFGr OvFlr:ctE?f ?OmtarwwrN SP?_DT}E, USE„A yi ,?T] ;. T rvt I_J?'Er.clFatafarwu. ?NCxcotusa ?wraux amIKY OBJECT STRUCK ?.s,-v,,, KAAA!DlosKOT':.:wbiv:i,+.n •.? LN:. OWNER OFOHIECT9 NAME ANDADp1rE39 LOCATq Y?1 •.' .•. .. INROAD AY';??w ?_••':. DN Efrf a0a• TO f lD?Lr } Y ET Loo! 1 pp ._? • • 'rF ACaE I.. ?•» A. _ :. ?. DPWEP9LASi NAMEr?St_ :.?, ,,....?•;_FlR9T NAME,-, Dp-E?'_ m4 cAaa '.. .; ( fE CUMMINGS Adrienne -?• Ra w?IT•VERSLA9i NAAlE .. .FIRST NAME ... MDOIE siREETADDRESS •;>c;ET... -?,,. Yle • coLUSOrIb+ Unknown _ EIOUTENp'AND BO%NO_. +wo STflEETAObtESS... ,...lgllfE NO ANDfq%H0. ,: ?' Rt 2 Box 782E fIi ME?(u E?' ...•.">:...::vcL STATH Tu'AL:ZIPCODE . DHIVFASOCCUPATpN ,;: - k%fi - R pry ...-. ,.?. STATE... ::.': LPWOE, pNVER8000UPATK)N t\ - - ` aF Quilcene WA 98376 upervisor aaN ? ?' . . DirIVER9UCEN9EHWBEI.7G'I:1u.rAai,rrliE 9rAR. ?SE]4 ci OATEOF DIPI'ra,S fDE._ ?. DI(VER9LICFNSENUMSER qq jj .,?[?LL //.. ) ?•a 1 OP 9WtF., vAGE.: , 'k DAY 0 GD¢AtIAD6O3iiD WA AS 12 4Y yfJ 39 •- '. STATE. SE% DATE •,M f Y M Y n;' 4+A-y VENgLE YR'_ MAKElCNE1l?OODE4:i igOe,INOVAOMTIy HODY 9TYlEf20it1 Y.? ':LEY". M.uE1CMEV: 000GE1 MOOELINOVA-0 77 Subaru 4wheel dr. Sta. WA aomsTYLElabal VNl LgElISEPUTENR:' .,di.':STAIE;.1?JiL •r Tf1AKFJ1PYalENO.-.;y :.STATE .r " KYCOSl WA `IJCEMSEPUTE mAAER PLATEAq,,- ._,STATE,.n?„ ?? ? NA NA " "? ,: vEHgLEgFNT6qATqNNp 'y?,;:•uT11MSAF00EL9ANEWEiR.;?„000MEtEA1LelEA0E1 .. AG71.016622 78,000 vENgLEgEN FCA gNNO -•„''11989 MODELSf NEWER) .,. DOMETER IMAEAGE 5 REOL4TEREDOYAIFA Ar„zI:IfASFFpS11MgCLENIIAEi'1.:. .}uJi',,.DNVEpSUCEN9E N0 ;x;E4. REGI9TEREOOYMER_.NAST-FIRi..MgptENAM .^ A. G. CUMMINGS n :--.... DRIVER9LICEN9ENO..;M{j;p? - CMIlAO603RD L. t ?f 'V• OWNFH9ADDpESgx?i3'p.a... 19TPEELCIfYANOSTATEjr .A YDATEOFHIRfN.•;. OWNER9AOORESS _ - -19TREET,CIIY ANOSfATEI::^.-.. w. N•DATEOFBWTS-• Rt 2, Box 782E Quilcene WA ?PARi90P VENxtEDAMAPA® -?_,.:i.,,,w? ?.,y-G .-..'._'y,.?F ,^„?.::. otwr.... PMT90F VENKXEOMIAOEO ? _ ' 1•r}' t S aVMrvExgaj LIABILITY INSURANCE INFORMATION-VEHICLE NO 1- WAS THERE AUTDMOWLE LLAWUTY WSURWICE _ COVEPAOE IN EFFECTFOfl THIS ACGOENT DN YOUR CAR NAMEAV ?YES ?NO :{k f, d W{RHHJyN5?lM{PG?OL?g ? Tk', Nwf F.UCICI1LVli) Abb/t L fyX' 8 2E T.C -'-W r 6 '. .. NNAE OFUAWUTY W9URIwCE COMF.WY...K? - t. HBT?'ISHV ? +' « kI. NMIEPNOMpiES90PWHR[i•I kEURANOEAGEM - UDai1 ? - ... r ..:.:. .,: m ..."•_..PA.•,y .surf;:, .. .. [P..• , lqY u . ?. TVFO anNM9ER Kathy Halderson AAA 2515 Burwell, Bremerton, WA CLAIM I! 45-507-92 0 CV4'.N^eC 'i.^,.Ih?Fi Lw.wYV:.T'RS?M,fi .?r`4.. AGE ]NDIWURY: luaEa FAMtEaFMlarfoa AODMNALWwmtaF ?« l NAME NONE ,DUU NAME none ....'. :: 4 ;:' . .: - ADpRESS JEx - _ UDRESS __ S? ?- ^• '# uwaroxb ooC OIP xa o 1 A STATLq Oi(LIlIpEp •, 11L`2$' ? ?© „bi,;MMKFNST METNAT APPLIES _ - 9TATW OF IWURED '?• QMNIe YENICLE P6Aauxo r.d ollAwlNO v!a '.p ARKRRSTONETHAf APPLIES 1 a -o lYK a MLIEO IaFvEall riwoal -I]ow IN VEHKIE SMItwO PCA DyyglE ?RDFarnw ? ?PAeNxDEP ? KILLED ' f. r - ?OTYfP •Awre+N ? 5? 5? o??w Erel p,eofsswAx "D Ir.EVFxFI iW.+o"nl I(p SNOWWKH HY ARRDw Nr:lmc ?rnn.x rvalr=.N _ ? I 5? I 81--I I 7flfre I IKtar(dNlaOaPM,; ..'V \ :. '"•?"'r bti[Jrvwn TMAPPENED:IREFER TO NEN w`'v,+MT""^O'4? \\\\I Car Ill mines_travelling ?erx! v.t n..rw Ern N. oc ,rM nEpu .ale... Ir.r•t oP Rr ° °°"(^w°w { : at 50 mph car /12 ap _Eoached t! > Mh.[P [Aa WwR(Aw N•Dw Irnlcwwo. rrMYaa..wcw ? R Car-#2.swarued-onto-my-lane-apF i Q?- O alKlioe o .Y -10-to_15 feet-from-my--vehicle; A ard-ditch-on, r-ight?_overcorr emntrnv-rn .....aa - 44 Ji8dk pff_road_on__lef t-Other car-did_not__ - -; ??? , _ stlop ,possibly,intoxicated _White,_older sta tion wagon ForQ ot Qhev -, JJJ 69 to - 71/72 _ _ ,.-approximately__ // . p " J r VEHICLESID ITIONSBEFORE COLLISION I " 7 -_ 1 1 J VENgtE _ N 9 E W OV SrpFlf ON 1AON H(! _ YRT• wawa x WAY NAME ON NO pµClpe vnau 'Yer«r.Fe UDALL raAHxO ITnut .ar n INMMATED1IY A vPw to I Il oCC •o ? g." "o ?orxlR ArPR Po i ?xl ? im D ? b L( O l o( ` NM,I. DD?D.0"'1 ? D D D D pA«PI c " - 1-r Iti DesrNANwUUSPq ''" '`" amLw'. 1?eADEWALK ]?WALKWAY ]?SNOIADER HD 9tKI ACl YAAI ! o A ?1-_ ^ w'• inOM DIRECTION To DIRECTION LD r?iafur.. "u. R? 1 ` l r[a t KN W „y N ";lgxrCCNbT10N5 v rct! .. tRUIICCONiPOI KelCfbNl. v l r TYPE OI IpAD vr OINFR NAVrNNENgif ACigNS' ' '.•; h - 7q n'1 QORY 1 ?Ia1.,rKN, 1 DAVLgNi [ 4 K?I 0 l D -6 :X ALS w . rK11 [ G:I W;al ? I I ?ONI. WAY AI +f11 IcIKCA ONl bIMMI' l 1q 1 p1 0O?M 9TNN011/AHEAD Y I ? (?RMN(q ] ? DAWN ? ] ? •u10P 9KN 2?0 TWO WAY ] OVFpr-_M"AS91N6 ? y -'? I (t • ' ? MSK "IF ? 1 ? AwW ] ? DAPK Sf ? ] ? YrllD 3qN ? 3 ? rTOFyn •YHl! D ] ? NAK(MingNfTUR C?? r i•fl I P'' oD C] ! ?C[ DOTIrfR ! DAR ? r pt D ! ?llAU.wO PEO ? • ? O vYE H N ? L D MAKWOL[PT TURN r I I A ? l s K 9T [T a DNI(R ?19PECWI ?lgnfSOf, FD I L O D ? S ?itALwq AMPLER V iN NOO D S?ALLEY ? s ?NA.PYDU•TURN , ` v. ?I ? t ' E1P[f ..11 HfVON IOTSlfWf1DMAEP.•yydSw • T G R ??.-L ? 8 DLTEi IIIPN SLOWxMI ? S D r . ! yr : I. w.L lwoY•vAw dlrea,YMIRI '. ? . .IiCIIY ? I ? OFF, KfR/ILAOMAN AHES I-1 ? T y SiOF1fDi011 TnA1iq If I 1 I 4 ,f •, ' D ( ? OM(P SEC IY ? I D SEPARATED ? S [] STOPP(DAI gSfJAL OR STOP Wr. ' 1 iP M ? ] ? WGFD ? 9 ? Sf01vLD W nOADWAY t7 j 1 f J" Y(A ,. ?_ } N .Y r:C Y LV r ? L:y ] Dlv orn ? l0 C)"Ar.;;P, W ue *,? { t,hGr ?.;iEM"'A"r'+? , ,.r?,. ;."?I'?... ? « ' ? ? ,.•.t?l ..1,?, f ' 'r?? m : . tC 14 , "MOTORVEHICLE COLLISION REPORT'''- NO.`-? - DATE OFCOlLIS10N •, '. DA Y OFCOl LL40N .TIME OF COWS-n t AM GIYNO. . COUNTY NO. ?uABw rlE.a\n sw a•M V &E5 wtu nN11 n D yp• [5 C./ PM + / .. / CtD Gr?^URr. t•, COUNTY GTY.TOWN' Fn01RSOF CETY•TO_ MK Oa ADM CLS PREFIX ndnewstxEEr COIKE. SECTION t? 'ovFO W S DF G! c c. vat c3 4iA?o W TERSECTINOWKH' STREET OR ROAD OVENAME OF 9TREET.ROADORHq WAY PREFIX ED UnST 5;;,, 7j NUNINTERSEGTIONKOCAigN OF COLL N /, 1-WEEN OyG _ ST-EETAND U ` ,ETPEET P-P GASRAM D.STA r xuu _ tLG MJ/`"S O© }oF Sr NIERSa EV.o orinixn we NEN dRpGE. ? n • G E L NON %RD INTEfl INTER LS ? R <roasrR[lroRNOa OR IENENEEDCROSSBtR!ltOx ROa r..•L . T. // f i' i'i' s[ar.. «Y. ©L or S r -4 ! /?U C O ¢ mEUS10xr.:h•.EO -?? vENOLE-KLE ?v[wCLEIRCYCLE *rOIII[nlw EI y- /. lOBIECr ?HnCI[Inun /l / ? SPEC.COOEUSE ; G vErvOlES j_ _ j vENCLE PfOE9rwax ?wNCIX[LSION ?u (? / "1 0- OBJECT STRUCK HxaME Or O3IECi srNKxl OWNER OFOBJECTS NAME AND ADDRESS - INROb o nM O?aRGi WNY ?© rOiD f S iEET EIIO OWNERS LAST FLAME PFIRSTNAME MIDDLE 11E T- MFEOVOVEO DRIVERS UST NAME [ FWST NAME MIO E TOh n t O 'l a n e. Sc P_,_r- TnwsNOSaa STREETADORESS .: ROUTENO.ANDDO%NO. MORE txa iw0 STflEE ROUTE OSO%NO. R PO ooK /!75 PEn-0NO! YKRE A CITY STATE VPCODE q RSOCCUPAnON COUP GTY STATE 21V DREVERS000UPAVOl 127- _f-cta[>' !Y/a. `Jb36ry LSS?EI?I REPORrrdW 7 1 DTUVERSLICENSENUMBER STAFF SEA "DATEOFBIRTH AGE DRIVERSUCEPIMNUMBE ST SE% DATE OF &RTN AGE .TO-Hl)-- 5,37.568 (.?G M F /aq d,g fiJ / ) 6 F Mo wr r VEHICLErR. MAKIFCREV: WOOEI MODELINOVhDARTI BOOYSrnEI201t1 VEHK:LEYR. MAKEICHEV:DODGEI DEl11gVA-0ART DOOYSTYLEI2 DraI 97 Peoymo r ?o y Y Dr. ) STATE TRMLER PUTS NO. STATE N E PILAT ? LIyE S EN ?O LICENSE PLATE NO. FATE RAX.Eq MTENO. STATE t! y I . ` , , l Tl/\/3100 Y?Ia • VEHICLE IDENTIFICATONNO. It9BBMODEL53 NEWER( ODOMEfEA (MILEAGE( VEHICLE IpENTIFICAt N0. I19f18 MOOEl9AN EO OOMETEfl IMILEAGEI 50 Y4coP-773-915IR " P15fEREDOWNER. .. (LAST FRST?AIODLE NAME(,, DRWERS UCENSE NO. - REGmTERE00YMEP ILAST-FINSTMIDOLENAMGF D_ SL`CENSE`K` ? ?ti 5?r?m a . , , ISTREET,GTYANOSTATEI OWNERS AOG[ESS .,%,. DATE OF&RTH 11 , (STRFET,CDY ANDSTATEI _ - SAOF&RTH • , ., Y ? ?+ ? Atl vEAR 7 b HM PANTSOFVEHICLEDAM ED EsnM,reoc /17- S.`t/P. floc- bound s• PANTSOFVEHICLEDAMAGEO rv s:o MvFI•CIE WAS THERE AUTOMO&LE UASIUTY WSURANCE OYES ?NO LIABILITY INSURANC E INFORM ATION•VEHICLE NO. 1- COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CM NAMEANDAp FESOFUA&UTY WSURANCE POIJCYIglOEN WUAEOFUA&UTYINSURANCECOMPANY "JrAW -^e ?/s j dP ! 3 u s nSLj F4rnLe 7 t-ow?3+ G3 CrtT/ul 7-QTYD" re-4 , GO. NAMEh%DAOORESSOFUA&UTYINSURANCEAGENT OI ]P UA&OTYPOUCYNUMBER LAG mein /'r??n [•?al wcr. 183681 ISTNJURY NAME AGE l9tAl 2NOINJURY: IUSEBEPARa1EREPORTFORa n0r•4NANF_4 _ NAME 'AGE i _.... ADOnESS -- SEX ADDRESS 9E% t<rH•r9rwx,wlB ... .. O.l? f: toFNww[5 ._.. _.. _._.-._...___ -__ ..O_?. I _ __ _ . [OCtOR3 IrO wx. Cr?B 000E0m 1 ® ?I. axinordrs ®?.:.FORD A Rp-AC S 9iATU90F WAJREO MARKFW9 TONETHATAPPU ES STATUSOFWJURED MARKRRS TCNETHATAPPLJE S wvew W YEHHCIE Q PASM VBFR KILLED I'AHnEI Nov nsaN IMMd11 roi lu[ Awr I.E =f 0[IIHn W VEHICLE QPMSExOER KILLED Rwa If[HRFI xur[OSAprMi IA ORI POSVgI[ Oe fArl xPlAMr (]r•[O[SrMar• 0 60 -40 l 7 3 NO. I]PLOCSr&AY 3'. IT' 0 50 60 OINwFtCI 70 SHOWIiORTHOYARROWNCIRCLE \ DESCIIIBE BELOW WHAT HAPPENED: (REFER TO VEHICLES BY NLIMBErH ', \ r.GCAr[OH tlRf PAGAM wHarxuPEreD © ? ••, a r. tnK[rxE?OUtMxwxrat H?l1[?C ?l \ -' tK rtt'w ERMSUV aC[M. wH ...... ?. ??.?/lwv/?....?y ._. /? ?? ? ??. ?. ..?C4V/- /Y /!.(f ... ?... - /?G/!MM'r /.+VIlL. ^ ? «uMNAS ?\ ? E WwMw [aH HrrCtl ax0 bwfw dRlCrOr or mAHLAY Uwdr \ l wTOA, -- ..7T/[' •?.s Q ??jn?I ? - -,.?Q.A _ . -.._ tiGrv ?-•? / _ wc.as?-?•?•-?-. ??y?Yto ?????•/? u ??? Qty \\ ? binE[I On rgNwar Z'-?..` '- ._^'-'?--" -b-____ .. T' ?' _. •- ._?. . _...... _.__. ......_ ..... _._... Dtf.12 alp ?, _.. _ . ..__ _. .--- . SrxLEF,x,..,..A.• a VEHICLES POSITIONS REFO RECOLLISION N O 1110N 9T MC[ WAY NAME R NO O dr CrRW «o.;;,;,`: f LEnuro v?.crtriccLiio ?Si10ATEDDY ?1l ln` ?D WG VIHKIF N 5 [ D ? 0 ? , p ? n _(JTp .??.?- ITV V ? l rq ? ? HL NO ? ? t[ M ? ? . [ OL [ ?iMK:[ omen f$(?.KW A ? ? ? ? ? O ? ? ? ? C3..-, ' Y1i P""ax O ? ? ? -Or cwoMwo FROM DIRECTION TO DIRECTION i Y.DFSttxaY WAS LITRrq 'ovoc.WMK 2O WALKWAY 3D sRm D[n D ACi:,;h«MR SD cn . 3 OTHER gAO:IRFACE WE 11 Ht" LX ICOIOTIONS TRAFFICCONINOL ICMCw Oxel TYPE OF ROAD ORIVEnl[H IEACTIONS "' I T IIT 1 ? DAYL K r R+Eal yGN49 1 H•rtlE I?rvl??d1 ONE WAY I YI ! KWCx OxI dlaOMl M, 1 ? MHOSTRA1011TAHEA0 D I D[MY t ? ?Hx[?a i ] ®RAWWD • 2 ? DAWN ? ? ? ? 9ipP 6H]N 1 D D O ] ? TWO WAY O 2 D OVEnIAKINOANOPAK&NO + ] A!i 3 DSq\NML 3 D DUSK O 3 D Tfto5 O 3 D FPrW ,.F ? 3 C] MAKNO nXlHT TURN ?3?SNOW •OTOO E?OA i50n El ? [ OIL.SRFKIRED D A OINTERCHAIK•E D A DMAKWO t[FT TURN D A ?'C[ D OtrYll S I ,Wcn, I f ? tG 1150 I l C) fIASrIW6 AYRCR ? (LOOPln-P) ? S D-, ! D MAKINGU fun. ff3?11 OT, EP l.J B ? St GFr 3 L10[nlRN .,,, ? 3 ? .Al, FF TURN ? 3 ? lWO [] 3 (3 mo ma I?t A'ANrOA rU If.FCW t+ rrA.E ry DANGER rA'r S OC I D U'[CIfY ? I O Or FEC[•FLADMAN LANES ? / O STOPPED FOR TRAFFIC n I A Otr•FR.s[CIFY ? ? LPMIAICO ? 1 ?E ? 3 DVCN'EO At&ONAL OR STOP&ON _ .. ? ?oomo ? 2 ? 310E fl) IN ROADWAY ?.,/ LU o D miloV 3 ?IWp ,. ? 10 ?FF Iiw FMLARe ti. ._.7,'???.+.:,_.. .. i?'.<.IF?'v.I?X_`? 'T??n .DI'r?y'"'AD^"°?Gi"'? .,nr--m+r, ..v,.F 'wgQwr •u [?1 nl A neJ lm•'*PI^!RTI?mPJ16_..![fitwn. _. . r A 1, v 7ri I. I.V lt)t I I T. Im I, I 5 1 n $ ???: :wta?a. E? ?rdvr. NNi f?d? { rr1 un1l ?, G, pN pF pl CIIYO4-1 !2 AYl 14s pw ?oF?.'rsa? v5"ud NAI.4aN0 OFSiR[EtORNIJM1'NAt ON o??4" -- M RWIt Oe C ION J - 11-1,12 ?1?? 7a INt[RSECt! vnlHatefk104 ROAD NONINEF/R$'{{CrI?ION ,F ?-? ? ?/ CC aNEfl% FO. MRE POST , -_ BfM'FEIT?' ?E• INlft 6 &C- wTE/SiR- T 1 DISIANC Bp' f MR E t .CROSS SteEE1 ON NEARfSt Mltf MnES N 5 F /?y- I•Z RET w OF 6t' i /QGGI 4ccIGENT MILEAGE CODE F a UTAG4AM Mfw CIXUSpNINV(llVfD: N VtNI1Y: ?,,,//E ???!j, TOIAI NO. Q%IlOO?NO.INlURfO ?3FI.UGF ?Ni /? IN N? oStD 3 IN INtEW D CIS 11 t ! 4 O RfF FENCE CR0535iI1EET09RNOAD -- as - ti OFVEMCIl3 m ? PRORRrv DAMAGE ON[V 0 R[SULTED ?VfNCtE N /' y? ??? d C/ ___ ?! `' t51.OM 1 E OB,[Ci StRUC%INAME OF OB1KISfWJCLAND O;N??51? - SRCIAL COD NG USE S a F G/? UNIT NO. 1 ? UNITN0.2 ? VEHICLE ? PEDESTRIAN p PEDALCYCLIST ^' - Dervtxslw,E: IASr Iq r MlDaf ?B ?A?'rL? c rte. Nlvfa?.rlAmf: as1 IR lu - _ 31RtE ADDNf53 `T2o ?v. ALvo;d/B-? St4EE1 ADDRESS 2 ulY SIA1E nacace oNE w D Ily siAtf N Fq . ?1 rr /7fJltLLG-3 -cuss. 62 R rvfx3 UCEN5E O. X06?? STAtf E% A BIF N ev4. ? I 'I/9Y 6o I V rv L NSENO. 1 tF L E% OAI Blq H R.r i... _ 2 OCCU wiION NRMNAME BF-FA NO. Yf3 EIGNI NFIGNi O!Lbx 7nC1?lc ?i.Yll //Z ` E R OCCUNAfI FIRM NAMEa RNONE NO. !3 EVES WFIGNi 1fIGH1 v ? - p CHECK(F7 'NNIRF A3 AN EMROYF OF AN-RU ? CHECK I?) NInE ASAN FMR E of ANOrNERa` lrc - CODES. a n a y "I Z S r 6 " ' ° 5 EA B y CODES a s < ivs I n 3 , . w ro Z uw:E3 Sc NpeR77.*10s t AMBV?. D q..DN ? ul ` ? WA . ? x".'-' ? ".°A.:. ?4"OM'4:r».. p ArNA,NTF f;4 ` ? M'.. .O w?KU ? 1 NSF. I AN. YFAe MA E( CNEV.1 7q , fll R1.NwAI TYIEEDOR.CONV.I ? E .Y ( MODEI,DART? vAl R, V,1 °?'^ ?e D S SMIE IRAIIIRRAIEN 51Atf H AN.ca All N A - au. 0?1s4? zw, - I ? ? wNKlE IDfNnFIU1gN NO. C?T;LIJ;YIliS;l11;8;2 L VfNICIF IDfNtIFI A l l i l ' IV RFGISnefDOWN'FR: N31 fIRSt MIDDLE PHONf NO. A/rocesov o O w I nFE OWNfR' -I FIR31 MIDDLE F Il AD04ESSOrOMNf4 /<'? ?? N F ' ' - wMfaADOFessnlNSUFANCeco. -AGENT x R LPFAGENT' . In D A ZEZG: Da 1 A„ NE,NwO ' I i 5 DAMAGf MEA Y rlACroNN cNAFCt _ • y lst.IVNAAGE N AEy 0FEMNNFO io Cl or:o w? • I] 041VEN ?FFMNNtO FSI. DAMAGE F Awer luiorio? s u wm S/?? 1owrD S AwAr ev: - DIAGRAM OF COLLISION?i( INDC No 1H .r .. `CSC xtl NK[SSARYI B _ ?? i L 1 DESCRIPTION OF COLLISION: lusesu Rf eN AL S"eer NC[SSARY) Y col[ _ xudeuvo...o? .lARSav Ge:. a - r .w3?, _? ? ? _; I ? '_ ! ffiGN.KA o? S1?c?1J Sr.G?ow?OG? . ?, L. '. !... ; ? !._ I t .., _ TOP Oy??l.T . SJr4?ert?e-2 T ?c??DF.o_ c?Tp - I .:? ? /?pl? p V? ?a 1. F;.. ... . . 5 .. .. ... ?..._. . ... .-.. .. ._. ? ` 1U1 e to NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED * CODES 1 - 2 3 4 5 6 OCCUPANTS/WITNESSES tilo?gi aR11EOa,iui+uAe si $L. ?cE.. iA' '""" ,D"'' I "' I. -' M10r' aes1F, txeT r . NAMF' ll0r1?/ EPSoN I °" 5 7 •- ADDgSS : .( I. L{?D r- 9? l J Y AM e. o I ' F ?.mix ? n.Na , / /^? NAMI. ?AYI/YJC ??(/ rAM. N o Y a) ,?. .. .... Y ADTNIU A' L u/ G! .. Aru.lp - ._ ___. l l r N Mtl i<?IFOM pAMB ? ? ?.?".. ?i:wv NU N AMT . ... - _. ilo A _ _. . ro.E s NAnfl 01 INlu.IJs .. ..- ,r sc?e ?AMB ?'r`l"' ?? pRa' ?i° F .FVnrnAlrROar,clrs NAMFa.AN. X x ?,JrU,4e'^- S?i/Fa BAnw of ( ,cfNC• SUS DIKE D[R), AlcnlD TmlR/Sp lu< Ae. vfD ??Z4d < wn Ftyy'?'1 sG/e'a IF ?? .?R FT Y ?'I L 1 'N Y E ? ?1n ? 3 t ?L^G9a1 Cw H! .IArf Mgr• rji:APk ?kEl ?i ,3111 °M y,J r'?, ) 4 -L (tr?ElMha '?l!}S 1 ?` 'kd , 2 t ?C?r ? ? 1( 4 S t ?, ?J ? q 1 1 / ? T f 1 r y } V 1 f !.S ? J ! ??f41 / ,? F + 1 T r ?? ryry @@ Iti I:? YW Y ?? tt1 : f? f / E ? / ?I ! Ip l 1 F JU1?cYS?.? r 1 L tY F 1- I I i ( - L STATE OF WASHINGTON AGE J DF ? No. ? W? POLICE TRAFFIC COLLISION REPORT ?TRAFFICWAY hOIICE COMRNNI NUMBER ' PRIVATE WAV ? s U Y CCC 5 '.I_T,GI IIMF COUNTY COUNTY NO. CIfY NO. iNW ? N b'? ? (r?o5R1 .7r-Ff?,?co.lJ /? D ,N i ? RAE ... ? . ? ';- ¢ MOTOR VEHICLE "COLLISIO L r N REPOR7 tc '..T ui tvp 1 • DATEOFCOLlISK]n 'ui: . OA OFCOLII&bil - N v»c OF COLIWON.;. F9 n,r E FD mup i Y O IE9 PM COIJMIY?/P,' CIttO , ?/ f! ? r»?' rr}?/}?? n 5 ,Lyt,? 'Ifr' ? O A ` V pE OCC .. CAUNTY e•rv J1IDCR'f?Z? iWisOE MKES Epl?®f GTY. TOWN.: M O IX©Y .:1•r .I Qrr RLL , GMCLS* PREFDt J(GIfE 5 pET?GOyOE 9fCTgN T ??'' t I I+,?'t f? ,i O L DF ? . a* I'^ri?A„H„ 3? :i ?tf /U ?r:.i• q F ,, GVENAME 9TREET.OAp Oq HIGHWAY :.. WTWSE SECfWGYA1N STREET ON AD. _. I? A Ol P? NON»NT R PREFIXS,; EO MI ???Q.Q. Ty??p}7r? ? as SMfTZS ? -P y ( E S RETWEEN s ECTIOnLOC NO CO} &ON Sc, <y-?$TR E T AND OL STREET RAMP 1 GAGRAM DATA" :7} /'Z: f r`X PMyeH ?l 3> J+ G. _ 'R ? 'f wr 'rl nsF<rrN V IµIgqf t?'uuriVUefA nNOOE ?J ?? Kf© SDU?? n bCnsgtyyGp EVOS ONIbfuR •.irwcL } O ® NON %RO VKI fE PO,O NTER .TER CLS- 0015 [ei0 W Y ,_ 8 . Er Fd L, t 1 o'wWLV[O ' ? vFwc rcLi ?OmFnlwNr F VE i SPEG COOE IISC , r qy F ! o L» vCr,KlFS n LJ VE»AY ECT ? ! ??vFclf vF0F5tw.N nurv ?i vF» ?NONOOtuSKN ?rlr T, F.., fli. r"?: is "?.Pfi CA'72,T.T"c'a.tl.? -.. 3Yti•., ? t,•.n . ,x ; 5"• ORJECTSTRUCK I EOPO&ECrsrpuc w OWNFAOFOWECTSNAME.WOADORESS.. - 'IN OOCAn ON N ..,11-? WAY ?© DE . " r -1 AD r 4 FEET ? f OPIR Oi;, `? y G S. . • • ? * .r • v pIVERSLAST NAME _ FIRSTNAME C,NS . NVODLE wvOLVEn DRIVERSLASTNAME ( FWSi NAME - MIDDLE ,K )ck r c«USp»Gn roLUn HOUTENO,AHDOO%HO.:; Aq ,x two STREETAC RESS t F , ER-. R No. SO%NO. - GTY - b TATE w ? - - ? S .:LP LADE DPoVERSOCCUPATON ' sOn CI(TY' ,:,-- ;,. ' h /O Y ntPOnnfVW STATE ,..;, ZIPCUDE MWERSOCCUPAON.. - •a :: -` r'•.' DRIVERSLKE ?2C cl{'1441 NSEOM R:.. STATE SEX DATE OF ADE S . • r& A.L GINER ENSENUMSER: _, STATE. SDI OATEOF&RM:: :AGE Se . VEHICLE YR. MAKE ICNEV.-0o DGFI MOOFI.IOVA-0MTI ROOYS efz DRI VEHICLEYR. MAKEICHEV.O000q,; MODEL(NOVA-0ART). ., BODY SrYLEI]Dlf) .k1 Sy 'Cartel Six Eck 'truck LKEnSE PLATEAKA .. STATE TRMLERP TENO. '. ...:,:.STATE. LICENSE RAIENQ .STATE... r.. TflAIIERRATENO.. STATE;,.:. . q . VEH f 1NTIwA (IB9SMOOELSb NEWER, _ ODOMETER IMILEAOEI VEMICtE IpENRF1CAT10N NO., I199BMOOgSb REWERI METFA IMXEAGF 31 JC ?Q?S IOO/GOO REGSTEREDONNER (LAST-ST-MODLE NAM E) ,:...:OPoVERS LKWSEO „:„ REGLSTERED OWNER IUST.FIRSTMOCp NAMq ., DPoVERSLOENSENO !-?zrirrama giros L•oc?- r C., a ?!vle _... p. F. OLVNERSADDRE59- r;113TRFEYJ I,F r•F? DATEOF&RTR ... OWNEgSAODRE99. (SIRE CIIY/WOSTATEI areoF.&RTN:, U? wr rFWI w PMlSOFV HK:LE AGED -..? .. ESnu,iE000Sr PARTSOF VENN;I.E AMAOED sr•iAtEG a ")ds -.,...:. IO v vHK ... ?, .. 1 e S m e s GlFw eNC. LIABILITY INSURANCE.FORMATION•VEHICLE NO. 1- WAS THERE AUTOM MLE LIAMUTY.SURANCE COVERAGE. EFFECT FOR T.SACGCENt ON YOUR CAR ?YES [I NO i EIANDADp1E590F UA&UTV WSURANCE fK] YIOLDER :".: .. tF. W I..V% AI fV..2AINMIEOFUAGRITYWSU(ANCECOMPANY r 59 Gtv .. 5, O C yP, w LL%f rJU L, NANEAN ADDRES90F Ur ENT 51ME .. .. _. :..:'...EP. ., i LVbUTYPOIOYNUMBEfl - ` 4A14 d? Ca4?ir?4LL W iST NJURY AGE ]NOINJUflY ILUESFPAM f lFORAOMtK»µ vu%KEA r .:.:.. ::. N.. ._ .. ....':(_AGE. E. vS NAME '- 101. NAME .. ADpRE33 __- SE%g- ADDRESS C,°.uA» rKWpr,LOCram ® I' S a ,.rv,rKxnr,DDeran [ °rv°Ctt°n9 ---._.--. STAIU90F WAXIEO MARKRRSTCNNIHTAAFF E9 BTARTUSOF WJURED ®© -nRSTCNETNATAPPUES QIJ ?? V W VEHICLE IIIllEO o-l R O ..PO.cv ? pmt W VEHX:IE '. D?TMF »M? Ou.6 rosy f OPf ? 5 WOnl IIOFP 011 ??PAlsEnOFn ND KILLED ISFVFAFI IANKYn nt CM i ?t1 6? T? PEOtStR,N DPP. [rC l ? pIP IN ? 5? 8? ]? 910. NORTH SY APOWWGRCLE - '.' OEuCflKiEOELOW WHAT HAPPENED ,., '. .,..-. -_.r..., (REFER TO VEHICLE90r fA1MSPA1 _•? ' T ,r Misty \ \ Cqv 1 we?s ?0/???04? 1_Dr?f?f¢.53nt? f » <?. s. -\ VVi -- _?slacr?l aka_/2cL-Car fiwo__wa??o/ _ --?? ®?-- \1- SInEPr _--/le Ab_o??,(a._SQnd?Skore._//al?¢. scorner /vL s? E[m- _? Jt Ca-v l ?u?nu..?---n•d-i.?4?lslr__cr.?r co?..1?1^?op VCIpCIC N Ipb [ W ON spur on I•CHNAY NAME On NO Ga[ClKM L[Ot'r aI p M-1 ? O WnK'L OCC? O br,l[ Om[p ?7'. Ir.X,• ?J! ? ? N rQ, ?CfY PgICHS 0 ? OIK[ ??a,IKW Fd Gt.FNI . ? ? ? i a ? o ? : o ? MMwPr ?' ?'qd aI c WasrA?AN `• IsIIrNove, "k,,, ? 11 r- ? ? [3 ? ? ? ? Aiono "? A LV 1 Ti9mWD AS FROM DIRECTION To DIRECTION c- '. ?Y r 1 L )'' PER[SIIhAN Wll&N(1 I?&OEWN.K ]?WN.KWAY ]?&IWIOER ,? Iw,K 6?[Im+vwi?K b?OTHER J I : ?I OKOSWM1ACE W[AMW lO»TCCNGTIONS TRAFFIC CONTROL KwLKMl1 TYPEOC p0A0 [ ptlVfRVVEHX:IL ACTION] r? 1'Y' 1 VIr.KM fl v KM?T WrKT ?I KL'[ VINK:M K-04.04 I "ffY{y??lJq'. y I OQ1O 1 WAYt*NT ?Irl ?SKI1ALb II ONE WAY NOI [ NO TOGiO9TRNOHf AHEAD ?!I a 11 ,??YS 't F?'' r t ?I ?'GIV 7 pNVgAr B ? DAWN ? ] ? STOP MON ? [ ? TWO WAY ? ] OVSRTAKINO AND PAS&NG J J t V I A' ???Y[1 ] 1!?y4R W(T ] ?sllow O ] ? GISK ? ] ? rwLD WGN ? ] ? ?FEOR&OLE ? ] ? MANWO AgHT,URN 1' al II i `Y1 V y.,:l Y]1 ] WSW • ?100 f ? CIINi90N Er ? t C] iIA:HWOREO W1CIICNUOE !Ij 1 + '? S OT {R OPET ? • ?AMiry ? • ? MAKING LEFT TURN Y'.r44" I. y, tt 1 ^:.', ? S ? R000/p ONrFR ? IEA'CLIFYI [ ? L*"T5 VF C1 5 C) 11SHM A.M. ? 6 ? ALLEY ? b ? MAKXO V TURN f Hty Al,'? AR SiR IuF4 + r . rl ) C'(1 I ? ? SfTCMY A ? b1AIRi!(0IGrllb ( Tn SHINAL b TWO WAY. t 1 11[A]O4IOAIIDT'JI(WOUA40ER ? ?[ C] ?L(PT -N ? b ? PIOVAH(1 A At ll 1 , r.,A»n.wnr Mr„LrCnX lrcl F ?Irf CliY ? l ? OII Kf nvil M:uW LNf(S ? ) ? BfOPFEO FOR TRAI/Ki 1 t ? A ? onNn IDfc", STOFFFDACGf&GNAL J.. ? 1 ? ftPMAf[O ? b ? OR" { lrh A Y' OP& 1 ? ] ? Dlva(D ? 9 ? bTOwED.f IaAOwAr l ? ? l t d N 1 1 •.. NO IgUIK: bfMITW(1 ?Rf r ? T ?upmlDfD ? ID 13 tNl. i t 1 - rTr 7,14y.rd iq.LiE• «..w-a [DI a erAilT ?Arl[[UiWnnu lr L r ltl LI ' j ?? ,fTt<? rlc ,cr<.?1M.cwr.l,1.. i ?k •1u?a(',., - ? AF4?r -Yn+f i ...M?f. ?^? ?: :?? '(°' ? `4 ? ' 4E1'i?? i. r" 1 ? ? y r 11 - ? ? t f2 1o- ,, x f F. V ?i'rl L-AA ? SRN r.. - p 'COVITY.>m-CRY: TOWN ?OU?` WLF6-•O© .._.?.__..: GTY. TOWN _- f N f PERSo LdFN D=;w ©® OF DML1S.. PREFIX. 3Y, 3 ROUT N[T COOE_ SECfldl; ¢?Ga O?6A...,..:..'..,aVENAMEOFSTREET, ROADOHNIGHWAY.., .,..... ... NTFRSECtNO WRN: STREET OR HOAR ; FREFI% EO M%EPOSf . , NOHINTERSECTKMIAOCATgNOFCOLLRIOH $ov7N oI NT IUMP. aAGRAM OEEA _. v 3x TSwa'x:, BETWEEN s ATIH /i STREETAND.' F,4RRy STREET x•i °R'^. /r G•.P^""'^ '{"' ^ r HOr ?Q ` O YrMLANw•nv Fn.BwOOE. PAiPOAOfi+OSWq uREWSi OngENr NON is AlfCrW lrMEiOnnO.O M-. itFfAeNOeeco•!lrRUionpOAp.J . FEETI 10, INTER WIER C19. ?vFIRCLf VtNDIE ?vEXCLEeCVRE ?OmtnlwHrPl / Onwv0.KO Kwtteoeltcr ?vENCUrm+N 1 SPEC. LADE (LSE 3jZ ?T?I.Y'.,T y Jr' ? ? `-^ L ???((( or vERr:LE! ?KNr:u Rfo[lrHAN 0-..- ?. .ww w ?, L? ,,yr ,rl r..- OBJECTSTFRIC% q',: IXr.Mf OCaKOI l1MKR1-:- .. OWNEROFOBIECTSNAMEANDADORESS...,-...- I T . INHOAO OI elnMArPOCOSi' ION - IWO WAY. -.. ••."": IO MAMOMlCf .,r(..-..: FEET m .. .. ' ONVERSL NAME............. ?. _-FWSTNWE. .'. MgaP,.. v AAOnE m m0cw4 DRIVERSLASTNAME ..... ..-._..._FwST v Rabcrt` J. wEAE xvOLKO CZ=- ST ET ADOFIESS ...:.•.. .. .. :.' ..: ROUfENO ANOBOYNO.:. `O MORemNivq !D lwEne STREETADDRESS.. :..._ .. HOIIiENO.ANOBO%NO :. a3 N F_ I 3 PMUAEO VMIA .: GTY ..:' ..STATE ?P COOE ..:..,_.._,,._ aWERSOCa1-..,. COGRON ,LFCWE.. _,..... •. •. -•. ........ STATE. OTlVERSOCCIp•ATgN '. _ L Lo" 4rJS 0.S .(wo vA r WIVERSXENSENWBEH-, _..-.... STATE 6E11 DATE OP BwR/ AGE ORIVEP9 LgENSENUMBER ... ... STATE, SEX DATEOFWRTN ADE u O M F W O+ro A M F 0 OAY YWI VEH[D.EYR. IaIEY.L000ET:. MOOELINOVAOMIR ... m"11211 '. VEHIG Wl. MA%E(a W.DODGID MOOELINOVAAAR))... BOOYSTYtE(]OR) CB /q7? RY,Stt COR b H ic) 1) IQ L[EnSE FLATENO... ,TRA%EI1 FIAlENO. ..... :..., STALE„ N R.. O 1Q .tgENSEPLATENO. .;.:SrATE ZGUC- 8 7 l J A ' vEXICLEIDEN[IFICATgNIq.:..,-.:..I[SEBMOCEI.Sa NEWER( :.' OOOMEiER IMILEAOEI ..:. vEXICLE IDEHTIFICATgNN0.:':.-...:.:. (tieBMO0Et9aNEWFRI .... DOMETER. IMp,EAOEI a o REOLSTEREOOMNEfI, :,;. (LASTMiST MIDOLENAMEI _. DPoYFRSUCEN6E NO. ... REGISTEREOCVMER (A -FWST.MIDOLENNIE, _. OWVERSUCQ(SETIO ?: ;.:a.; - ' l X5 R N 4 6 P g 00 a I .3 F_ . AIPAS L? EVE O0 UWmERSADO11E35 4_'::...._..:ISTREET,CRY DATEOFBYifN ' . OWNFRSADORE6S Asmeu..CRYANOSTATE,::.:. .:.:.... :. DAIEOFBWRf:;.. o N. F, 1. .5A & ME ° o `E w 1565 JGyTN .E• gaV4 WA ?° Dr EM _ PARfS??R / O.vdAOEn ,v ':. ..' ? ..•.- _ .:• 6 •E A V O " Sr0llirNCO3T.. ? ? N TY INSURANCE 1 IU WAS TN R UTOMOEItE L1 AS E LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- COVERAGE IN EFFECT FOR THIS ACaDENT ON YOUR CAR MYES ?NO NAMEANOADORE33OFMAB%lTY NSURANCC^POLgYMLOFA.':. .:. .'.? - :., :'.; ! +..:_. .: ::I NAMEOPLMB%ITYw.WIIMNCECOAiANY.. .•: HAN[ Aowess E BP ..__. .. .. NAMEANOAODFESSOFUABl KSURANCEAOE)R c E 1 NSw cE C o MOD Z ?l '• o - E/5/-y lmad)v IST NJlR1Y '. .. -.. NAME! AGE w: wpr'Im 3q WJlN1Y IusESEp eROMTFCRAmrgNKNMfHI .. NAME --- ADORE59 6E% AWRE ` -Dar. ?'. -___._ _____-_ gg Oq E Iiine°fp""'r' s MF,TF? CLQ .uwlieolur mcron• ® L oociolis r A RAr.e i :wirpri v°: onocrom ® x '© N°O•Me°ns STATWOFw,N1HED MWln W VENICtE ,; IDUE - MAR%FNST BM+O U CNETNATAP rICw Aelx NJES - p O p&L STATUSOFNgRED OwvEn W VEXN;LE %ILLED . MA(MFtlgi O11M CNETHATAPPI]L -O[:A61M N,..., .. . ?• nn ?fAy9ENOtn IJi. 13EKN1 FErgr[I O«FCp/WCi ID--. lTRw PE I51 1 Awr O! O? OF lICI ?NWrRwr ?o,.,)A WRRt.IN ? 5? 80 70 ? OE 1 n. ? 50 B? 70 SHOWNORTNBY ARHOWWaNCLE \\ DESCRIBE BELOWWHAT NMPENEO:(REFER YOYE)mm BY NVMeEI1I. ': .::; "°""'°•'"°°"`""' O \ ;??? ?; ? ? ? /.ARGE L•JOUSP ,"R?1Lt?2 ?AS?iIIEAQ C T O 2 T F N J ?2 ff ?? , ; ;?, ? \ '° \ OF IG i7o _ A N 35 f_ E._ _Ie ? Ot NE 6! 1 a c) f R a yE ! WA%R [NH KKL! Aw BOW K D'nr c.y c . _ I ._ . l v _o. rt- ?n C JE eHl ' Q \ - ? Z , _ • ,? ?aan_? Of T_/ie_ 4 N,¢._Tr?_m?d ?.a.tcLy?!L?! ?a?.d_s? en Ly_ pwI,-At LS1/Z?e1? P - Di Mmtr On MUw.i SOVTW Po1N i - VEHICLES POSITIONS BEFOR E COLLISION MO,NOiNO uoALiirL?oNO Y`viuweo veic[e «cwo Ir^'Eammmom KNIcLE N 8 f W ON 6IIIEETOR IIg11WAV NAME OA NO MR[<IgN N) K! M Ke ?i?i CL ?FDOmlitnf ro 1[aul ®? ? ? ? ? ? ? ?.. ? . ?rco'RUCe ?oNOnD?wen. '° ror RI ? ? ? ? ? ? ? ? ? ? wRlr ? ? ? ? K ONG r ,ROae.n - . FRO. DIRECTION.-, To DIRECTION ENDfsT.. WA6VSIH0 1 ? bKWAL% ] ? WAL-Al ] ? SHOULDER A ? c"nMO'.iwu. s ? 'C=T. a Omem FOADSLNPACe KMCErwI WVAIMn UGNTCONDTIONe Tf-fccO l01. A'rNC+OMI rr?YA1 rYPe0Fn0AD KNCI[ gNftde MKR/V[I•aEAOTgrp wHDLe KMdwe WMORPI rr•KI• r 'b l )AA I Al fur 1 OAY.gNT ? I ?6 .s NO I ) C] 1 ?ONE WAY b r ) I OOwO BTnNd1I MEAD ??AII R1 ?DNY ] ?NHNYq ] ? DAWN ? ] ? 57O s,OM f X TWO WAY ? ] ? OWATA%NOANDPAS ? ] ?WEt ] ?SNOWRO ] ? OUS% ? ] ? KELDSq ? ] ? AEVEFRDRLI ? ] ? MANPOA HTTUIW ? ] ?SF.Ow A ?ro0 ` ? W.K StONET ? L.H A ? FLASN•q RED A ?NTEPOH-M ? ? A ? MANINO LEFT TURN ? A ? ICE Oiwfn R ? ORNn ISFNGIVI ? DAA%]TNET ? s L O'f ? ! FLAS• -8" ? ? ALLEY AMA 6 ALLEY ? s ? MA%NOU TURN ? ! ?!J'FaIY AAK [3 a ? ? ! [3 NII SgN4 ? e ?lT OWAl ? e ? SIOYMq IIf AVON POR MOf S(t•q DAE%IFn ncr.vO WWAA WSrw.[rRw•)rcl nTW [ qNI! ) ? ,C FY ? ) OFFICERfFLAGMW ? LAN'. ? E ?610A DFOIL TRAFFC ? • ? DRM.. TfaFY ? 1 ? TIFNIATto ? a ? pggT01 l) DONAL wON ? ] ?"wo ? IT a 8TOPFYDNROADWAY /p 1 P IG Iq rRNIIC ] UN Ho 10 ? to ? TPNR'Na Acov&%• 1'.:: _,?__ ..'. i.;?'F3) ?•,t1fY,i;.i,": [v!. S ^, d3 A0C,'?f L ? 11 ?6TMTNOfROM PM%ED 0 . ? is ? M ME IWTtRIO ? Is ? RADw _,-.- .rr.. l EgIrl+?wrw N?yppp "' '91fAN..-... . !--• " ' ^._"8},13"" 77, rr t q ` 7Y'. "' T -747 i 177211 ti• I f !?- ; a c c r. ?ZJ MOTOR VEHICLE COLLISION REPORT NO. rIN F l,D» yLD,i^ , ND - ? COUNTY NO. CITY NO. ?uH ` f oow j ? ;_r ;: •:. • G D.IA.L D L'IN ?E ?IN NvaX i4wn nO.OF STX[[i xnlc war II .L L ff x041F Ox SW[F'i cDU jj ?s ?w ?aF °: ,.It. ?'.?`k-;.nAl. ??i o ns ON s:1*1,. :a.T' C'...'. ?f?/7GG L»slcnnumrX rx x xOaD , S, NIJx W;l [cN4n , Nx "ILI1IT xfF i O.<Z O ?_,.__ XaNx4ADDX4ssInG,NII[.DSi4x`or,..rlx4lANDIAa f { L GX MDA,A / ?5 Ll - , l LoL µ A xp ,.[[IpXxDAD E [ o E o 8 e svF e.: a-i NS'F TI CB o 9 o 'S a[ OBJECT STNUCK INAMf Of OOJtCTSiX x OWNER OF OBJECTS NAME ANO AOOflESS C.CODt 45[ 1 1 • 1 , DRIVER'S LAST NAME FIRST NAME MIDDLE 11=6 T?Is. DRIVER'S LASTNAME FIRSTNAME MIDDLE .-- • S-CTA OPE ROUTE NO. ANO BO%NO? TREET AOORESS _ ROUTE NO.AND BOX NO. GIIY 'STATE JIPCODE I - DRIVER'S OCCYPATION 1-F... CITY STATE -c-I! DRIVER'5000U1ATIO1 DRIVER'S LICENSE NO: STATE SE% DATE OF BIRTH AGE A DRIVER'S LICENSE NO. STATE SEX DATE OF BIRTH NO A AGE ' I ^ VEIIIGLE YR. MPKE ICHfV; p0UGE1 MODELINOVAAARTI .. GODYSTYLEN0R.1 VEHICLEYR. MAI(EICHEV:DODGEI MODEL(NOVA OARTI BOGY STYLE 13 pH.1 LICENSE LATE NO. STATE TRAILER PLATE NO. STATE LIC NSE PLAT NO. STATE TRAILER PIgtE NO. STATE VEHICLE IDENTIFICATION NO. VEHICLE IDENTIFICATION N0. r•.v Li! It. NEGISTEHEOOWNEP (LAST FIRST Al1 00lE NAME( DRIVER'S LICENSE NO.- REGISTERED OWNER ILgSTFIP5TMI0DLE NAME) DRIVER'S LICENSEND. 11 OWNEfl'S ApOHESS ISTHEET•CI TY AND STATE( DAtE OF BIRTH OWNER'SAOD.E. ISTREET.GITYANDSTATEI ATE OF BIRTH I .. BAY PARTS OF VEHICLE OMAAGfD n x ' iT:InVP `[L[ PARTS Of VEHICLE DAMAGED RM vLXICi114 AIX P,r.?/ 1 S,, S LIABILITY INSURANCE INFORMATION-VEHICLE NO.1- WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FORTHISFCCIDENTON YOUR CAP ?YES ?NO NAMEANO AOpHE1550F LIABILITY INSURIWCE POLICYHOLDER NAMEOFLIABUTYINSURANCECOMPANY br [ • C iv d / -:?iil ,L.:-L/b-AEI' ?l:;l f ( / i/ll?.ti ::l.-I? ; 11-f??_^I , 1 AME AND AOD ESS OF LIABIL NSUq €AGFNT AI, LIABILITY POLICY NUMBER ISTINJURY: AGE TNO1NJUNY: 1.1S[IMAit x[tORi NOR ApOIT10NAL 1NJURHM AGE NAME TOTAL NJURED N NAME ADONES$ ME F E NATURE AND %TENT Of INNRIES ? ? URIES &T??T M F ? ? INANV BYY PICOCTOa1 NME R S EQUIRE BY A DOCTOR I ©ONOME R5 .1ATU5OFINNNED MARK FIRS T ONE THAT APPL IES STATUSOFINNRED MARK FIRS T ONE THAT APPLIE S ?Ox IN V[IHCLC DirvHnl NMINAM.1»c roSNq ?DR ENICLE IItiNA xDlsax rosslx ?I+ NO. KILLED Islvlxll IuWDxI :Owl I or ?IA N E KILLED iSlvtaN ;uinoxl Ourl DF IK " ?IIOIfIxIAn 13 ? 50 6? 70 aN ?IfDISi N ? 11 50 6E] 7? MOTORCYCLE SAFETY: ?NELMETUSED ?HELMETNOTUSED MOTORCYCLESAFETY: ?HELMETUSED ?HELMETNDTOSED CI-1.11TH0 ARROWINCUICL[ , DESCRIBE BELOW WIIAT HAPPENED: (REFER TO VEHICLES BY NUMUENI - _ _ . . ._ . . . f _ , _ _. . . .. w I ar f: VEHICLES POSITIONS BEF ORE COLLISION 1 nrv[suegteD er YEHML[ N f E W ON JHACET OR HIGHWAY NAME OR NO. 0111. r µ0? AD ?I ? 1 ? ? D ? T ? ? ?ipLK1 ? ? ? ? ? D O 13 ? ?Wla,ll D [1 ? D ALONG C ROSSING FROM To PEDESTRIANIPEDAL CYCLIST WAS USING: I[:] u to ....... 1 ? v . C] { ? { ? Drnu i ? ?! 1 ? xnADw,r PEDESTRIANJPEDAL CYCLIST CLOTHING COLOR: 10-1 ID LKxT -10 !?au....... [ {?w " - ROAD SUKIACL axH s4 WIAIN[. LIGHT CON01T10N5 TNIIP1000NTROL TY IOF .A. -ItFILHICLIE ACTIONS hCL1 1 @OAYL1411T x Kxlca JxlH AO 1 pIl I Oa+pall xO v KxICKOMI On MVPH I tx > 1 1 r? }x1 I L'.J 6112.?ij(" I ? DAWN ? 1 ? SIGNALS ? 1 D ONE WAY ? . NO I 1 [0 GOING STRAIGHT AHEAD DRY ? i L ? J ? WLT I D IAININO J? BUSK ? J D Ito, SIGN Q 1 ? 1W0 WAY ? J D OVERTAXING AND IAfHNO J ? SNORING [ ? LIGHT OHIIT ? J ? YIILD SIGN ? J ? ROAORIIIL! ? I ? MAKING RIGIIT TURN D I D WOW B ? 10G 1 D L.Grtt011ET ? [ C] lLANNNO RIO ? 1 13 L001 NAw1G1 D R [] MAKINOLIFT TURN ? 1 ? ICE 1 1 D RING"V1 / D CHINE.. HUGH,, D f ? IIAO[INOAMIIR ( ? E [3 A L LSY D / D MAKINGU TURN ? f ? V I D °vlcl Rr ? 1 ? Al SIGNAL AL O JAI, ? ? 1 ? It ? fIOW G ( 9 ? ?{ J 1- I 1 -IP f 9 1 1„ f? i? F I `J J?? ??M11 ? ? 11 S rL N I?IJj_EIY11,1 ?; T I CFO t .1 I , rUr 1 lj. 0 c 1 LL Z f W 0 U- j O coo' coo I i LLJ O ? l`?, rm4r ?K tir ?; STAI"E OF WAaHIN(AIUN? xb• MOTOR VEHICLE COLLISION REPORT - N6• DATE CF COLLISION DAY O CO ISI N TIME OF COL 11 610' COUNT/Y/N/O GTY NO 1 uo `t A. _h,3E.a aYP RA ?y nw? :Vn Inu PM ! (O x«.I { 9 COUNTY CRY,TOWN SV 0 MILES ? CITY, TOWN AOMOLS PREFI% nW[E oab Et CppE BE TION ?? Csll!n'1 OF %/!rte/'?l??' 3.p/ Q Gk ?u?wP GIVE NAME OF STREET, ROAD OR HIG1jWATCG•Ir INTERSECTING IIN: STREET OR ROAD PREFIX EO EFOST NON INTERSECTION-LOCATION OF CO SI N 4sm-RD DI Gan D i . P " BETWEEN STREET AND rsE T R a sE uSTREET - f ! E•NESI aw MEP ewOGE. iR FipOO 51PE0fx c 11 NOT pS EO t5 GrIH wa EI ? ?4 x§ °y oTM5N0 nvo?ve ur[OLSVa.x eve ?ol?n /. ; 44} P F{?l rl ?, YEa!cLfs ?rE.K ?xo„oELe.w0- /l? 2 ?t?}.., '+a,.,•.'?"`'?Sa'". +dr. OBJECT STRUCK NAME OF OBJECT 51-) OWN ER OF OOJECTS NAME AND ADDRESS LOCATION ??E pF _1 T -ly N ?nI NAME RO WAY_ DNFPMR ELT FEET S W S DRIVERS LAST NAME :.. FIRST NAME MIDDLE iw0 CAPS N DPI EFB LAST NAME , K FIRST NAME _ MIDDLE/ l?+p W ERE INVDLVED Irvin s COLLSOrv OR BT EET ADDRESS - ROUTE NO. AND BOX NO. MOPE Ta•x two STREET A00??ESS ROUTE NO. AND BO%NO,. - . /.'. .. PERSONS wEPE .. - ?. '- ry " STATE. _'.. .. ZIP CODE OAIVERS OCCUPATION torus on CITY ,.:: .. -? •..\.STATE: ...:: _.:- LP CODE DRIVERS OCCUPATION REPOaTfoaM .,. '. K DRIVERS LICENS NUMBER::..: STATE SIX ... DATEOFBIRTH A O E .. DRIVERS LICENSE NUMBER, '. .... STATE ; y DATE. OPBIFLHp AGE _ 4 / % ?/ / / / VVII? u 1 / j? /Xr7 ` I CLE Y0. MAKE (GHEV.DODGq MODEL (N OVA -DART) BODY STYLE 42 DR.) H I j VEHICLE YR MAKE (CHEV: DODGE) MODEL (NOVADAfiT)_ . BODY STYLE R DRU - ` l ` / / , , MY ?k• ' LICENSE PLATTE NO., TATE TRAILER PLATE NO. STATE .. -;TRAILER PLATE NO:,: .. ,.STATE ' LICENSE PLATE NO. STATE ?• - VEHICLE IDENTIFICATION NO.. I'm MODELS a NEWEPo ODOME RIM LEAGfj TE VEHICLE IDENTIFICATION NO. I1888 MODELS A NEWEPo - ODOMETER IMLLFAGD ' / 10 NA ME REGISTERED OWNER (LAST-FIRST- DRIVERS LICENSE NO. REGISTERED OWNER , MST-FIRST-MI DLE NAME) DRIVERS LICENSE NO ; • OWNERS ADOfl 55 ISTPEET ITY A D N STATq / DAT OFBRTH OWNERS, AODFESS:, .. (STREET, CRY AND STATE _ „._,,. DoT OFDREMR , ? , ? J - PARTS OF VEHICLE DAMAGED /n 1OTR CLE DAMAGED: WAS THERE AUTOMOBILE LIAB ILI" LIABILITY INSURANCE INFORMATION VEHICLE NO. 1• covEM IN EFFECT FOR THIS ACCIDENT INSURANCE ON ON YOUR CAR ® YES [I NO NAME AND ADDRESS OF LIABILITY WSURAN E POUCT NiY?lR ..' NAME OF LIABILI INSURANCE OBMAaNY .Mf "• 5 T ?` i ? ' • /l ?I . i / r% Min /Gl%G- ? / ? Ljl 7ESS/O'yF LI ILITY IN URANCE AGENT // .111 STATE LIABILITY POLICY NUMBER ._ , NAM A , TST INJURY / - .. AGE 2ND INJURY'/j. rAa?/ / •Odlrox [`w+uAe AGE F h NAME INJUnEO NAME C1L ,??(?JJy r??/1(??L:JVt? P _ _ .{JS ADDRESS SE%F ADDRESS -SIX . G _ A- 11 w aTDP, o „? -%O / / ^% G IBC I ?4u :a E RP.°: aDairva, xP % /J?' % /) U ' STATUS OF N R MARK FIRST ONE THAT APPLIES STATUS OF INJURED " MARK FIRST ONE THAT APPLIES 7 ? OPIVEq IN VEHICLE rlOr+dSAe[INO roSVpif `r IN VENT LE d wSSq f '?T}?UA' 'ST KILLED in+uar wear LYPASEP KILLED IN+u" ? 4MTS` ?NASSENOER R[VEREIM xpP CW I ?PASSENGER M 3[vER[I 1, . PEDES NO. Iy'1 ? PEDESTP AN NO.. ?I - OTHEIPINAN VIP!If.IfJ ? 5? 61.LI UF7MN ? OTHER INNITCIN ? IS? 6?nI P`F7? NT , SHOW NORTH BY ARROW IN CIRCLE I DESCRIBE BELOW WHAT HAPPENED, (REFER TO VEHICLES BY NUMBERI ,:. 4. NpG1E ON w U r•u [ o © [p vnala?ve WN THAPPF ED. \ I ? J// 9T/l+T/J nJ'L 4:I,FI^ry AA :/J/" E= Ciq =2 l MaEfT M nNw/[r VEHICLES POSITIONS BEFORE COLLISION VfHIfAE N EB E W ON STREET OR NO. AOIIN ? Y]I ? ? ????i HOtBiNAN ? ? ? ? •tONO i• r ' xo or L.Nfs E c E "" ' 11 N0. MWLLY fT•MG+G If-111-1. Yfr d lnwa YES NO Yfb O ' 'EDESTRIAN WAS US ING 11 1 SIDEWALK 2 WALKWAY 31 1 SHMLDER 4 I_ _1 AI. ROAD BURFACE M<K Oat1 K: - WEATHER LIGHT CONDITIONS TRAFFIC COMML K'.a[CK -1 HaK4l TYPE OF ROAD YFnx:t C [CMI HKICl1 -A I GIO 7 1 ? DAY ?1YY[[ p(? 1 Jul OH K?EiK t ?? 1 ? DAYLIGHT ? p t ? 1 ? SIGNALS 2 I ? ?I I C3 ONE WAY SI 7 ? WET 7 J1 RAINING lL S ? SHOWING DAWN 7 ) ? DUSK ? 2 ? STOP SIGN ? ) ? YIELD ON f®5 7 ? TWO WAY RSIBLE IJ ) ? ?) C] SNOW A ? F00 A El LLIIGHTS OII? E] A ? FLASHING RED ROAD ? A ? INIERCHANGE LOOPIRAMP 7 A ? ICE S ? OSPfGfY S ? LL ITS OFF S M311IN0 AMBER ? ? ? ? ( S ALLEY S OTHER ? BPEGFY ) T,T1 -NO E yy STREET LIGHTS ? B ? RR SIGNAL ? S ? TWO WAY- LEFT TUPN REASON IOR NOT SEEING DANDER 0INCUBI O YISKw pSI AALI K]NS [IC s ? ) SPOTHER ECIFY ? T ? OFFICCNFLAOMAN LANES , 1 ? F ? OTHER. SPECIFY ? 1 ? SEPARATED ....-_ _. _..._... ___-. ? 2 DIVIDED • }}q Ho 1,n?rIIC I' I Y n n, n NG+DIYIDID DIRECTION , TO DIRECTION LRNEN = ACTIONS ua. 1CnECK Oaf oK MOnD O) I ? GOING STRAIGHT AHEAD 7 ? OVERTAKING AND PASSING ) ? MAKING RIGHT TURN A ? MAKING LEFT TURN e ? MAXINO UTUAN S ? SLOWING 7 ? STOPPED FOR TRAFFIC F STOPPED AT SIGNAL OR STOP SIGN S T?^7 STOPPED IN ROADWAY ID L J iuiff f01 INC ?,?OR I! t?r?l1 ?/N^LV nJ'iT k,? %TCv1 YI' J ? J Jwr? (? 111 '7 F J,B`y?F,yaT' ?> ?? w } LL ., ?faY ;° t1t 'd?dlAWk L[ns .15G a.RA F hY I? :? 1(?+? JI * ,1 =?'F.` V ?' ?._"Wi ? ??'YT+?BEVTBh?4!'K?I I ''JJ S r-xLTT I ( F I Y l - -Y ht ? 1i{ / _ ? y? ??? T ? •{ r / E Jfii+r? ?G lt? I ? (? 1?i ?/Rf1 l ' ? ?1 T ; 1 }I ? - _. - t } _ t T ?J13 ?F tF 4;41 i 111 ?'. I { '^ ,?t 1 t IbeIY . I. -ICJ I (w_i I,I I 7 .7 f .it'Y „". ?;A"idS?,.•.'T7°..^'TP 1' ., 'T :.^'TIS"Nw;*??RG'?) r,.' ) X11 y -? fit I .., ,H I -'.-uvmvwput:'u9'r`-- LL, .. - _...... zb ? iuati _ ,wl :.:?:-_.. _ 1iw f: • ' .: A2-,--- . -__.., ,. , MOTOR VEHICLE COLLISION REPORT NO. OATEOFCOLU$CN D AY OF CO WSON TIMEOFCOLUSION H R` U,FS AM i .? V Mw vM COLNTYNO. C lir lq. ?w RA --.I r-, /CITY. WN Ac ?m? r l C^ L I? o0.0 w"pwEr"af MILE`S k]lO V IIEE©[B CITY. TOWN/ OF ? . L AOMCL6 ...... t,,?g[1.1/E??GI BiafET 000E SECTION .n ON GIVENAMEOFSTREEI. ROADORHIGHW''A?Y MERSECTWO WITH. STflEET OR ROAD .CU.' Z1 UC 1 /g i? O ?? PREFl% - EO MILEPOST -.. NONINTERSECHONLOCAHONOFCOW9 N BETWEEN SEREETAND STREET RAMP pAGnAM wTA vwT No ID?w9 EAR m,e rosion m??ileHw wsE DGL D Sp "- : 5 / N N n oN XRD _ " FRSEE,K ©®p D G o COIUSKHNVpLVEp ?? ?VE KKIF ?WH HERIW iFl / HK°.iB IT] pO =1 :11ECTA, OYEaH ? M' v -IC I rf { SPEC CODE -E L .. ? OWECTSTRUCK f-EOFOBIECT STRUCK) , .. .. ,. OWNEROFOEUECTSNAMEANDAOORE IN ROAD -4 ' WAY' ? © EAU lEETIfMW N iONCrArim <T • • DRIVERS UST NAME ... .... FI.STNAME- .. .. MIDDLE Ir AKME 1HAN CAA'9 - W-YE. • DAMI'ISLAST NAME FIRST NAME ._,. MIDDLE cm-. THIS STREET ADDRESS ROUTENO. AND BO%NO. I 7- THAW vO NnUAE 505E STREETAODRESS ROUTENO.ANDSOXNO. CITY SPATE ,• /.9 LPCOpE C? LCarN?' L(Jq .??? MIVERy^SyO?'CfCUPATION /Yl ???. sfP.wATE CQl15Xn REPOaIrIXM CRY -'-: - STATE. ZW CODE pRIVERSOCCUPATION VERB LICENSE NUMBER ,:_, - Ear/-17C--??L G??S ,_ STATE SE% wA 0 TEOFBIRTH AGE E 30 ORNERSLICENSENUMBER .. STATE SEX M r DATE OF BIRTH MD pAr rEAR AOE VEHKX.EYR. 7 .. MAKEICHEV: DODGE) . M rd ODELINOVA-DART), . SODYST111MI C' ylf? ?? VEHICLEYR. MAKE(CHEV:DODGE) . MO DEL(NOVADART).. SODYSTYLE12M) LIOENSEP TEND. STAT TRAILERPLATENO, STATE C UCENSEPUTENO. STATE TRAILERPLATENO. STATE V HICLE IOENTIFK;ATIONfq. [1088 MODELSB NEWER). ODOMET EA (MILEAGE) L 7L 6-96- ? c VEHKLEIDENTIFICATIONNO. IID(IBMODELSSNEWERI OOMETER IMREAGEI RELL REDOVMEfl )LAST-FIRST-MIDOLENAMEI DRNER CENSENO.. REGISTEIEDO-ER ILAST-FIRST-MIDMENAMEI DRIVERS LICENSE NO. OWNERSADDRESS ^J i1 W jM (pSTATE)„ /S? GATE OF &RTH OWNERS ADDRESS ISTREET•CITYANDSTATE) PATE OF&RTH ? • c- 'y G CCi??' P IS 61 1 eA--,/- EsnuNM?Eppcos, Ll •C? E uEl . PMTS OF VEHICLE OM.IASEO snMA ?.pY E . WAS THERE AUTOMOBILE UM UT-YNSURMCE JARJ- NCEINFGRMATIONNEHICLENO. 1- COVERAGE IN EFFECT FORTHISACCIDENTON YOURCM YES ?NO NAANMEEAND MOADDRESS AIWRESS OF UADLITI'NwRMCE PoIX:Y HOLDER :.- - _ NAMEOFUMILITYNSURANCECOMPM JG F L ?= T? 5? 7 C mr !? -YYE BGi/ P I ?O T?,PS l? S . N/?? DADDRE?SuAAD? INwRME?, r.. .. j_ _: ..::. Y' G_ L-? ._ ......? OUAV POLIWol ?a C JJ ,U ISTNRIRY AGE NAME M % 7 2.Dl URI: I.. SEPARA TE AFRGIT 10A NAME ADDRESS P _ ' O_ STATU9 OFNJMED MMKFNSI WETNAi APPLIE S STATUSOF WJURED MMNFlRST OVETHAT MPLIE S ASyEHCEAVEMIOIE ?. KLlEO prM YKa(1 HW USUUAq MF+parl rosvlxE r wML T p F QWVE NVENICLE ?nAS. fm KILLED g0 IMVEZI oa dSAH>• H IMVIp,B PDBNIXF ip NPiANI 1 E p[IIwAK Q (]D•nrR Wnn Y.N ? 50 60 1 7? ?RMS Aa A ? 5? 60 ETC) 70 SIOWNORTHSYMROWINCIKLE \ .?d,D,r \ F.?'E?AC ?v 4WC a DESCRIBE DELOWwHAT HAPPENED: IREFER TOVEHIOLESDYNUMSERI __ `"7'?E" ?GI?!/_? _A f_,C .I?<-_ Ty.?? _ A L • ,MIS ? necl'4/ F- - 1 17e A-1 E E VEHICLES POSITIONS BEFORE COLLISION HD Or A Wp%aMS W E T•?E:N uo. n W U K.,RaoWU pIVESTIGATED DY V[MCIF GFA o & 0 0 ON STREET ORI.OHWA HAMS NO PAEC,XN / ur U o o FoµL •Aw W o o p I.KU TX:Gn•p o o 0111 ?OINfK ??E '.A i° K,Mro ? ? ? ? ? ? ? ? . ? ? ?uKIETI MnFO•W.. ? ? ? ? AL ONO I: AOBIIw moM DIRECTION TO DIRECTION P[D[STI•AN WAS ] 1 ? woew LK e ? wN.-AY ] ? S HOULDER 40 c1w•I• 50 CROi+wuA 1 OTHER ROAO-FACE C•C WEAN.. LgIE1CCNGIICNS IRAFFIO CONTRA K.KG•o-rtl TYPE OF ROM DTU YERM ME ACTIONS MI vFHQ• W I AO [ 1 ?D.Y IQ? I OHACMI F ? pAYL10HT vr.K11 ? 1 ? tNWALE Nf I?EAp E IO+WKI F ? 1 ? ON[ WAY VEHKUt KMGI Da[OR MONI 1 ? DOW STRNdIT MEAD 7 RN11VIp ] ? OAWN ? 7 ? SipP;pN ar .11 ? F ? TWO WAY ? F ? OVERTAKING AND PA95N6 ? 1 ? wtT ] ? SrO-00 ] ? DUSK ? ] ? W[Lp NON SIIK[ C ? O ? mm ) ] C] MAKNO A011T TURN ? 1 ?BHOW • ?TOD E ? DARIK pNET ? E ? FLASHI OA[D ? A ?•R[AC.-c ? • ? 4A.ING LEFT TURN ? e ? Dl[Kn ° ? IOSI'[CIFYI ° ? =14 a, SET ? B ? FIJI&- AMR[. ? B ? 1AILEYrRAMPI ? 1 ? MAX•XI U TuRN ? e ? SFFdY • •ot OA.K ND ? e C] rw SKUTAI ? B ? TMO h ? ? kO IKVASONrw NOT 1[[• + pvsn N o-uA.c W q DANOIn ,O•,F UU IdlT1 SIR[F1 l r ? m[pnh' ? r ? O"c(A ADMAN L T y LM[S ? e .14 r ? BTOPPEO FOR Tl4lrrlC / ? y' /V A;4, TO 's Z ,? ? A ? OTHU..,C" ? 1 ? 1[PN1A1[D ? e ? ?Bjap yONWNu ? I I /? ,Jcrl` F-T 20 1 N e-vV lr ? 6- -- F ?..,. ? ? F ? svwrDINMADWAY • ? NOr'RA IC TT[ [?lII ] ?lI•.^.MDTD ? • ID ? BRAlFICI AHE __._- -. !{ .-_ AA L ., A T O ..a.': N PATE OF COLLISION MO? DA? ^!j? /y DAY OF COLLISION LIME F SUN I MDN 2 V O WEDA IINHS (NI E SA1 1115fj,OfJNJIgI , J J COUNTY NO LITY NO. ?UPBAN /? COUNTY ?{/, Jr\iHClL3Ory ?STATE ROUTE COUNTY ROAD ?OTNERISPEOFY 6 ? ?CRY STREET _ O HUnAL ADM. I'LS. PER. ROUTE OP STREET CODE :• CIgN 3 I N a39o 5 E N ? ® ?W 2O 1 Cli OR TOW AI ?C Q N /? PREFI% EO MILEPOST U1 MILES ?OF.. C QN . . U AME NO.OFSTREE TOHHIGHWAY INTERSECTINGW m ITN. STPEETOP ROAD O RAMP DIAGRAM DATA ON m 039 b NON WTER$ ' ACCIDENT INTER ON %RD NIENSECIIND STPEET OP pAp OP REF. DETWEEN. _. ._ . STPEETAND..... B T MILEAGE CODE as ERENCE CROSS STPEET.FROAp ._, DISTANCE?ND DIPELTO FPOM REFERENCE OR SSSTNE T CRO EE cr•.• r..... I O ?.... x # , ? OF Q O /\ . _ COLLI TOTAL OF VEH O R VEHICLENEHICLE ?VEMICLE BICYCLE VEHICLE"ODJECT ?VEHICLE RR TRAIN ECISTRUCX ANDO ®NON"CIXLISION JECT SIRUCN AND OWNEPS NAMEI FIRST -. MIDDLE qpk ?OTNERIWRIT EI HIT d RUN SEVERITY ? STOLEN VEHICLE ?NAZARD HAZARDOUS MATERIAL 0 INJURED PROPERTY DAMAGE DAILY LOCATION OF OBJECT ETFUCITRUCM DRIVERS N?AMEaLAS?fIP..9T MIDDLE OILVLtI?SI O?R rERESDNMN CHECRIu - ' R I SIyfREET D DRf / L R SiREEi ADpgE53 [? R A V - I' E " CRY . . '.,.. STATE ;... - 21P CODE PRONE NO. E CITY ' R R STATE ZIP COOS PHONE 1 - N A o C. r, At DRIVERS UCENS NO STATE O. . . SE% DATE OF BIRTH MO. A N DRIVERS LICENSE NO. - ?, TSE_?_ WA M Z P O• R OPrv OCCUPATION FIRM NAME PHONE NU. '1 DRIVERS OCCUPATION CODES 13 I 1 CLASS- TAI SEAT BELT,__ _ 1ST EJECTION. NATUREOF CODES 1131 MJL CLA . ` - gUNESO a•C=J?ea ' 1 V? eq T ??LLpRyJ.E F F ? a SCENE BY: TO VEH. YEAR MARE 11 DO NEVI MODELIDARTNOVA) STYLE I2 DRLONV.I . FR OM ENE VEH. YEAR MANEIDO . v 9 X Y 4 9 S//OOF , MA v E VEH. C LIC. PLATE NO.. STATE TR UIiR PLATE W. STATE E VEN COLOR LTC. F u i c I eR9$5.Z WA. N C L VEN IDENTIFICATION NUMB P ODOMETER C VEHICLE IDENTIFICATION .? ?. E /d 2Y.I7j 6 L . E FEGISiERED OVMEfl-LA$I.?:. .:FIRST - '..:. -. _ MIDDLE REGISTERED OWNER-L N O. F N O ApDRE 35 OF OWIfER. .. - ApDRE53 OF OWNER n NAME DADONESSOFWSURANCECO.ORAGENT NAME AN ?" I P?Q t r awe 2? wF?, 9R,3?6 CHARD D ADDRESS OF IN - I GITAIION NO EIIlO A RCCMLN CTION i CHARGE NAME, ADDRESS & INJURIES OF PERSONS I NVO LVED 1 p wuw[s A N' NAME: T S ADDRESS' NATURE ' MIMES NI NMIE: .. I ADpRESR' N itlnr E N S AME. E A p(O1ES3. S. s I 1151ANS IASLAT r VT O RI N C P[Dlsil ` - r, ; T 1 1 1 4-.... .. ... . ... .... . IDwMETEI ... FE15T , ._.. IfAT N?? TD JI'NJURY CU55 INISEAT DELT. ISI[JECTON q EUURY IS p15ADLPNO 111.11Y 1 NOYINSTALLEO I NO/EJECTED 2 DCAD AT SCENE ErprN q,^,AOLIrq• 9NOIM USE %^OiAL.LY EJLCTCO^ YR. 3 TE 'TIM F k `? ?? ?"f ? Y,=..'., li'vr Lr1 ErL'Idr tCTj? 1, •"!'i".. ._ ?...?.. .. }tr I L ?4,rG I h?' +`i' `?> JJ }.r@rT4 f !.• yn 1 c;? . ?.! r i. t"fG.'u »i'!Fa': ";:i AA1:. r 1 } } I ;p Y'C fKZ I 1 l.:Y 1 T Y Ihyll ? +? L r 1 T Y9 ?01 % A VLI III;LL' DAMAGE IN EAC DUA 111 LL II E NUIIGC 101 EACI UAIJAGEUAHEA ` OL S AREA OF SEVEREST , INSTRUCTIONS: ] DRAWEARROWIGI TO SHOW PRINC PAL DIRECTION OF FORCE O / I L? nvan DAMAGED VEHICLE NO 1 wse7 H1 CE FOR SKEic NG DAMAGE 10 TRAILERS MD,OPCYCLFS. ETCLljDAIMACEICLE 6 ELI l' IT U.r SEVEPITY OIF10'A'AIG'E`V?E-IVHII_C`LETIINO.1 rIV'w ,•w SEV TY SE? OF AGE IOINEP VENICLFI RTYOF DAMAGE. VEHICLENO.} •• v ??a? Y IO01SAtLING OAMwGE O JOTHEPM V.OAMaGE 1ORp LOAMING OMAAGE 5[] OTIIERM.V.OAMAGF H DISABLING DAMAGE Spp0TNF V MAGE } ? FUNCTIONAL DAMAGE . ? ND DAMAGE } O FUICr1DNAL DAMAGE A CI No DAMAGE - a FUNCTIONAL DAMAGE . ? NO DAMAGE A TOWED BYn/ S •n EFT. DAMAGE G TOW ED BY FST DAMAGE TOWEDBY ESi DAMAGE ' tiL TO To T To t "3 .A . DIAGRAM OF COLLISION 1 DRAW AR ROW SHOWING 1 NORTH IN CIRCLE i '011-114=1F P11-Y I I L _ ?.. DNS KNP 3 -? 1 u 7 7 ?l iC , tc / D..FU ELL DR. _1 , I° NPATH..tFGTL ?; NLDLLTDN - DESCRIPTION OF NN01CATf WHAT PROBABLY NAPIENEUBEfORE. DUR NGAND AFTER THECTASH, NC ENFOPMATION NOi ONOAGRAM, E.G.OPIVEP :COLLISION DISABILITY. REDUCED VISIBILITY. PEDESTRIAN CLOTHING COLOR. GONSTRUCTDN 01 REPAIR WDRK, ETC.1 - - VP/y[4/P _ / ___!L!? 5 SO4ry ?o4h _ ?/I ?C?e_ `P(/e__,c oG C?.._Re %G p/ 4 `E ..!"apia -n..,c o4 d_.... q... _./r'F•/ar d.. __--.e.k Rve /, v.---. /05 ?i_7?.:TUf;? J° __h..s-__n,oioxneye%r_ 7. paol?oncyIt ?c_ 1'A4..-lea?-.- --./A'v /1L9 A. _.. ?ia /neJdo4.C t/G ? . "A a.l ve stKUCk._I1a-d s?,a// a!..tf n,oonp!__ gFF?! ?5.., x _ y5[ ? ?,_..'.:. .-0.K ._._ a.K...._ ??. Q. _ e_@../.•----- . _ .. _.:__._ _ ___. ___. _-- _. _.._ ;. POSITION BEFORE COLLISION NO DIi n[cis d E HEADED E O ER E OCCUPIED STEEDS ON TIFF TORHG1iWAY NAME OrT NO. ING I ON I. F0 SVE ? 0 INC E 5 G G R E '"T 'j ?t So nl__ I? led O ES _ ET _ O _ I _ _ } iJ!?C 11 1A ED c i I ?CnD5T1HG_ _ _ D _ _ - 4 PEER1CYCLITTWA 5ENG WALK }t WALKWAY S 1 OLDER AI. 1C 1NALKTI O 1l YCL SSWA ?BFC NnoUTE 1'..iOTHER TO a'?' 'ROAD SURFACE WEATHER, CONTRIBUTING CIRCUMSTANCES DRIIERNEFICLE o ICNECKONE ICHCK ONE) ICHECK ONE RMOREI D}v RICLE aEJ GOING 2, f.• } DRIVEN } S OB} X t _1I STRAIGHT AHEAD S N. DVVAR 6........, f OS _ I,} E E } O ERTIKING n'?? ??? ORY X bOVLLL',6 T-_ L -.. I I .ALC01101 E CE FOLLOWING.. O. f _ .... _ IJ PASSING AN. r- }I wET rvG v Z UNDE ENCE O DR GS F BI O C TER .I ASLEEP__ RIGHT APPARENTLY ; L ?J } sNOw a I EXCEED ED I F c . SA PR0FERPA-NG LOCATION— b, ....LJDn SPEED L T .. 5._ .. LIe TU 0 B DE_FEC_-`.O P__ I E?1 MTUING URN f _?? G G To LE1-U ! I I C I s LEYEEO J J' AKINGR is tJ°r 1 . DO f r."°y J i i ._ n o c i now NGN _ `:? GTHfP ci;-FYI OTHER ORECIF11 RO R 1S G DSTOP ,•STOPPEO FOR r' } LI H CONDITIONS RAFFICCONTRO VENLLE v } scNS GNnI NO VB SOBRIETY N rI l._ STOPPED {r' TYPE ROAD VEHICLE CONDITION SOBRETY ..PIED AT SIGNAL IC f` HtCK ONEI NO,} VEHICLE 0} C C ONE L MORE yI NOI R&HIbNF01 NVEHICLE ICNLCK ONfI . S - STOPSIGN 1 5. ..5 C f NEW I DL I onow?v L,j TWO W- T -1`? D LGHT tlRB LS B 1 HPA flfDiY D--1 TIIAifC AN _ ,..... ..... NI I __ 1 E A.N 1 } I T GI S -[ 5 Lf FCT ?} N L T Pit 11POM AIRTY r, - S ? I D ROAD El ... 5 OT ED - PATKEOIOSITION } S OUI ! PLDT. G 1 C GB CLIGHT SET MER"NO ENTERING t B OOPR M _ EA '.U 'OR. 1 _ A LI K D -Tl ![T IE ALASIONG L I T11ON MBU, I? lB l _ O E 5 0[I H AO OFI NK Nf. 3 BACKING D I GNP— sT fn 1 1 TWGPAY-IIFT ,n ew..N tv I ryo[H CHEM, TEST l 1 B NT1 OP S GNAL t 0 K-NO T 01 KEPI ?bG?- ' SETT GIV EN OTHER ISPECIFYI r.'. STR[ET.L G Tt FLAGMAN qq?? _r _ 1 P CY. i1T ._ ._ OTNtP .. ... ' L > i t}1 DIV 10[D I 1[51 NO DEFECTS INFUS[O T NISPfG1f YI 0 , IC 1 } UNDIVIDED 9G TEST RESULTS 2 d t gwfl O C AMl B RANK UG[HD LI EU fD OL1Cl wHNwLU u Lf i F CILOW f 1 bA,D IO A IV{D IuVFOED Jf? All 18 5!5 IN ..1_ U Y"L Hn"Me HANK PenaVtD_ r BATE I vT i ';j NMONK• R NOIIESOd p 9? J f NMOf1]r]Mnl ^ I TlOllrl NOH11N? I I nw tlf1M1MlOl pw+?""/l lV11J5011 N1030 P 11310A]!IOOWGHO^ f ; B I SS]NIIA1 pI 3 I 1 Trn slur NOOr10t Nell a ?'I ' IF ]Flog Qr ,u'TT. J , 1 M kY ri ?T DATEOFCOLUSION DAY OF COI I ISION TIME COUNTVNO CITYNO M0 DAY T SUN T " £ .... D WL . INVN S F I e SA( $USE a00 G R) 16 . FBVA COUNTY ?STATE ROUTE mCOUNTY ROAD ?CITY STREET J O AN N UPA ACM C45. PEFIX flOUTEOn STREET CODE 5 CTION Q ?OTHEP IbPECIFT') to /S C 0 I / O CITY OP TOWN N b E W ? IN MI F1 EO E POS T C ?.)) MILES El ® ® ? ?OF. T ; 6 NO.OFSiflEE. On HIGHWAY ON INTERSECTING WITH' STPEETORROAD ILLY O RAMP pIAGPAM DATA O NONIMEflbE N LL 5? ' ? ? Q? 1 ACCIDENT I MILEAGE NTER ION %RD IMERSECTINO bTREE OPR MOP REF n CLS. ERENCEC O:SbTPEEET`n ROM DETWEEN/ IAl 4J `. Y _ STPEEYAND . GO C_ /L _ S FEET DISTANCE AND D R CODE VV I ECT FHOMnEFERENC... CROSS...... S S W uwai[iNS SPF AL LODI USE I' 9?FEET OF ? ® COLLISION INVOLVED: ? VEN KLE-VEHICLE VEHICLE BICYCLE 00i ERIVINITEI ?HIT6PUN SEVERITY ? . TOTALNO. ??yEHICLE VEHICLE OBJECT PEDESTRIAN ?VEHICLE RR TRAIN NO KILLED ?STOLENVEHICLE ?NO.INJURED OF VEHICLES ?NONCIXLISION _ LLLJJJ HAZAPOOUb MATEPIAL ___ _ PP.OPERTY DAMAGE ONLY OBJECT STRUCK (NAME OF OBJECT STRUCK MD OWNERS NAME) LCCA710NOFOBIECTSTPUCK EST, DAMAGE ?POApWAI FEET ? ? ? ? RD EOOE S !!RIVERS NAME{AST FIRST MIDDLE M R , - II D ONIVERS NA ElAST iNiST MIDDI{Il pKrCM11 OR PE OEbIWANCHCCKIO I ST T ESS .. R I STREET ADDRESS . _ I.... :. E .',70? . bJ^iddn [/.(' sT/?lJOtc?st "I R CRY STA ?.. 21P CODE .... PHONE NO. - E CITY STATE - LP CODE E NO PHON - 115,0' ;T, ?3? s TAB R . , N 0 IXBVERS LICENSE NO. - STATE. SEX DATE OF BIRTH- MO N " DRIVERS LICENSE W. - STATE 6E% DATE OF BSTTH . Q r d !an DAY YP. o O. MO. DAY YR. DRIVERS OCCUPATION FIRM NAME .. :. -. PHONENO. T. DNNERLR OCCUPA ION FIRM NAME KEN. CODES > m CtASS., _ III SEAT BELT 1'I FjECTION ?_ _?. NATURE OF CODES >!JI IM^RY CLASS- I<i BEAT BELi__ ISI EJECTION __.?_ INJUPVES r'J'.4 S P S n NAIUNE F INJUNEb FIT SEC NE BY! TO Rq MOVED F OM SCENE BY VER.YEAR MAKE( OODOECHEV.I MOOEL(DART-NOVN STYLE I2 DRCoNV) VEH.YEAR MA%EIDOOGECH£V.I MODELIB-T-NQ1A). bTYLE12DR .CoI v S n d x -? v . E UIC. PLATE NO. STATE TRAILER TE ND. STATE - E vEH COLOR UC. PLATE NO. STATE TIAILEP PUTS NEI - STAEE d I) I . C V MY ATION NuMBEP . DOMETER. C VEHICLE IGENTIFKATI N NUMB IT E GG 8 2- 37s.S" L E ODOMETER ., GISTERED VMEA-LAST FIRST MIDDLE REGISTERED OWNER-LAS FIRST O ? s N .... MIDDLE . dM O ADDRESS OF OWNER,. .. .. . . . ADDRESS OF OWNER NAM M+DADDPESSOFWSUPMCE CO. "A ?YT N AME AND ADDR ESS OF UlSUNANCE CO. OH MEM C CITAT NNO, ENF NENi CHARGE - ATI . ACTI jrQ ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED coos _ a s S EX AOE STATUS H EJECT. c NAME' C ADDRESS U NATURE OF ???-? I C P i MOVED iROM P11tIRKS bCENF BY To A N NAME'.' T S ADDRESS N A U P l 1 RIES SCF EfEiv RHOM TO W NAME T AOdiF93' . T IT I N E u A RFLi0VEU7N uORIEE. SCFM nr To S. N AME S A DDRESS i E N N 77FLTj$y(07 r S I I a PCENF PY' TO OSIAI" 11)S[ATP 110,, pI VEIUnYCU55 i C SMWSTNGGE" A T No1NJUnl b 05A.INFi INJUnr IQSEATBELT 11101 P+STAllEO ISRJLCTKM O p BCTCIIST orwn e S 7 r'?BUD 4010RC C I I ! D 1, NOT EJECTED I JECIED O E e mTNEm l E) a PoslTwN UI+Awovm pICDW OSPITAL f I 'pSSIDI WNIIY UNNNOM/II a l ? V K sur n£uruwP£ u[CTfO 1 f i i I ISt d bJ ? e AEI . J ?7L t ?•? ?? ? _ ??E6ImKYx ? ?1 ?? T,s I w T _ ? ° ,?yH'VJl ? Y?' L ? 9 7 1 r ? t I I 1: 11111 D ..]xvv h..., '•„},'v? .wL'" , AHAmAGEOAREA O OC . 64 F 111111"11.111111 VEHICLE DAMAGE ] . SHADE ARCAOFSEEVERRESEST T IMPACTPACT . •? INSTRUCTIONS: ]. DRAW W ARROW IS) TO SHOW PRINCIPAL DIRECTION Of FORCE. DAMAGED VEHICLE N(. T 111 III 55-IO1 IIETCNING DAMAGE TO TNAILEHS MO ORCY<LES, ETC.1 DAMAGED VEHICLE NO.2 T ? A Il. H ,• noel Ell - 16 T 1 '? TrunY n• •'• m I. IF I6. U II U HY „ I]. O.wlu n HP Ie - • • r , X } IUrn . Or• r SEVFRI OF OHMAGE VEHICLE N0.1 SEVERITYOF DAMAGE: IOTNER VFH CLEI BEVERITY OF DAMAGE VEH-E NO. I GE I ? D SPBLING DPMAGF S ? OTNEN A. DAMAGE I rI7 D SAIL Nf, DAMAGE S OTHER M,v. DAMAGE A OISABI NG DAMAGE ] O OTHEAM.V OAM AMAGE S lJ FUNCTIONAL DAMAGE A D NO DAMAGE l FUNCT ONAL DAMAGE A O NO GAM ] YJ FUN<T ONAL DAMAGE . NO D rlv? A l U O D O A E ED BY III lAMAOE TOWEOBY ET. DAMAGE E MAGE py , S'L 05'yS r TOW TOWED DY To E To ^ F, ' r DIAGRAM OF COLLISION HHOWSHOWING (t - I N RTH CIRCLE ?a .' I 1 - - ,. _ D..L<,FDNrDFFRDADwA. ,A,.F«D«iRDL, ]xrGMYRK. t :Fades ' ? __.; _.. _ ? . ? . u«owA..,Fw. cDNmnG«. I ( ? i I ? R - . DN.RD.,.LEYEn<LLDA - II DESCRIPTION OF UDE IN VB IBIL HAPPENED FCDAF?CONSTRUCTSONORLREIn pFWOPRMIA EOC INOTOxpIAGRAM, E.G. DRIVER - REDUCfD N CLOTHING GLGN osps_Y COLLISION , N. '41f /r. Cddl'0'16 6' .4 %/f f ? /(fd S -r'14? C'7 111 i Gle .. .. . - " ? _ --._- /r r s_ E //' . dfn??/e•p'_? in..?E .91v[re/ ar+?l /_'c/?/p.d!.d /??^.Gc!ra+?v? io ?'as: o? i d?.?/J/%rij r'/.'Gllr??_ ?0%dl`/S? ? djteL ? ? ' ' / ? ? d r? J j {. i .o p / /6/ts/ ? s,,<r i eEne_? ?_ /' J?c;?il?•?cv c?s.SG/'/ aY/44 r" fd _td Q7 ? __ / _ /17D. `?r?1 e G/6 _iB POSITION BEFORE COLLISION - - O ND OFLANES 'NONE DIRECT ON ' ED S H<LY LEGALLY ED B EII. H x0. EAOEO N 6 F w K!Y, 7i CREASING DECREASING 'j?/ aF HIGHWAY NAME OR N . iREEi DR DNS YA, ?( - - ED _ NO PRO I--1 L.J NO EE I.? ED ?L ALONG osSING A WALK 5I ?U R 6? F NETEO r I KED fL E T. ICI DIICVG I UlUIG ILpE.WAEK WALK Y ISHOVL FR CROSS C OSSWALK cI ROUT I ) ER ACTIONS ROAD SURFACE WEATHER CONTgIB STINK ONF OR MOnEIANCES INO.]venlnF Ea '?. CNfCK ONFI (CHECK ONEI I IIER S NDVE pE7 L?L, l s n-AHEAD I NO 11 ??OARIINO ] 0 DIATIN o rlrva SOVY[.LAS7AL000L_D .. O LOSE} a OE -- ] AE NG I^I AR t G _ s 7 AND WET I DEN NFLU O I I O E TE E TLY MAKING e er c rvc _ r I IL D cs 1_.J._. Tun _j MPHOPEI OTO JS??..-LIXPTIOIF RKNO J.LE TTURNN E w ] IS M NG ]I I Y[ D TS fp i01 IF ?A 1 ..., CE OG I '? S EICEEDINGIIAl S. l,0 I O " fEECTWPE IS .TTV IN TURN r. J 161 1 S I 1 , 51 D OTCLE G I S O A"111* -.1 O NL LC 1' Oi E AFC ( C r S G S N v C ID 1 OR I,2 S_ G .?0 SG ONA I F O OLAT ]I.._I '111110 F C IG[sT CONDITIONS RAFFICCONTRO EH'cLE TYPE OF ROAD VEHICLE COINjSD]ITCIQON SOBRIETY - Bu sto v[o AT cAL CHICKON[I NO 2V[NICLE (IND'1 .] ICNECKONE OR MORf VI HO. OE I?EL'r EES{EIDI VFHCLE (CHECK ONII I- I OR SIOPEION I '^ ONE WAY N kr O.] ]TOP PED IH ROADWAY /? IGHT t STOP xL-0 - I ,tlIAL EE VE 1I IA REO 0 -, IT nTINIL H } r ]... U 5.. .SCN B ]I1 .). DL ICI.Vl J? NOT MPA R LO ? J RIE'OPOSTION I AWN .G LIGHTS. l TfPC I]1 SO fT I ] TRAPFCI IFNTE]11Na ] WSK A; FLASHING Al HANG[ ] OEf L RL LOWnAM1.. ._.I REARCLG yE TS -HNO NOT. ... _ I 7 _.I ' D ST EfT S WIRN , N B B.LCKING ei KING .1 :.L Tso 6...I Auoi o 1 TWO NELS Ui -l 9r s ooiH rE? IN CHEM. TEST pwx IyY S a Tf OREfTF SIGN L B• Aw SET- _ N - OTHER 111E.-1 B 0 MO [ Or C AT 'p. D 1 GVfN t` ,. { L c TS. L IT .,.,A ... ?_:.. TN11 u11O - T B ] 0 OID Il NODEFELTS I [3 ' YOIHEn IYEClrvl , XJ..l G IHi. (SPECIFY( 94 TEST RESULTS 2 BI ?]I OIWDfD I f (WI ll. NVISIIGAtIND OFr I[n'SN M BADGE NO 1.OlIC[GSPAIGVEG POLICE Al1111V[D ANCE ?? 'MYL'OEDFL E ?/ I .... i-w I • n ..,,,. a o.m AN V E vm X IIA EETIGAi w F w._.. -_-_ I- --- - I s? s r' I e d ,- I ? I °'I I? s . , ?. 2 k I. ? ?E emu. v T h C g I ,is O E A I O ' xnxlr. I ? 7 - 1 C, GT (, c u ,? ?-- z??(,,-Le?j r ? E TOw r t ???1_?-? yw T LL ..7 rHLF a39 D c D q E. E O BEET P I NW N E C,ING W T STREE NEFI. EO M LEP S . e 13 4- 1 ON INTEHRECTION-L N O. CO I MP AGRAM DATA UET WEI:N /'Fr REET ANO OD 'x.[x. yx, <[ t ?r^iry?[ I TE INTE Cls c, [ 6;o:.a[,o. w? [[ [ ? S?c z r _ .r ?. ? ? ?. ,..` ? ?/T-I-...?. 4 ,L. •?- Wit:-cJ? H , e BJECTR.. _ NO, ADO E[ ; ;_ Ri OCATION wa.n ..Ow[oT ? T R otl ?v.c? •^ w ink DR RLAST RST ;.?- MOO I DRIVE LA ;NAME ;i Fl TN E_... M O E L BOX 10 - ANO _ UT O E T O E55 . -I , :, ,??•, -?;?, ,? • _ - REET A E •_ r??,,,, _?• O E XO A y %,NO V TH r x0 Y; - vV COOe wE ac rA JON;. T ^, -e,r .;- - coOE O _ „u T IN . r. 9 ez>tiL..??-z E% 10 P. TN GE O IV w _ ENU ERA ST TE ! D T6 x.B NTH, A 1- OR WERS LICE Sf NU -ft ` TATE EE%O T D 3.?5 B Yin LE f2' '1 Iu[r. L J _[V 1 GEL. O TYLE .I - alto AKC' .. 'MOO l' y??` _ L<EN EPLA NO dA. TAT:- J-r E PtATF,,__O_.?,?,?.S?, TPI;?, +j -NO. +_ ST TEfk-SAL 1.A E ?,n ,•,,, LCEN.E T I // __ OD6 ETE VKLE 1 MT FKAT ON NO 4? l)OM W L[ Nil 6 _ E E -1 KATIO / cc?D,,?_ _!)_L ? /?'1 IC OCt DO E.. TEA ,.-- yL_ - I?N? ' R E 5 LKf ENO JMr,y„ ,J,` EGIS E fi0?0, -HER 1 _ -, , ;Mr - 1 y1.yORl, CRS LICEjI, t HO' av/NERS D R[a' o a ;N-_' PARTS.oivLNU[:,DnN?Aeeo„:F:;S::.".c.r?r.l:_,.e,.'ru,.?i.?r?°w.M»r[n1aLi P.. .oR V[,Nlccc_oww_w .r.f,....:^:itid urbi'ea.?.k71 "ac.a:'-=. ,p RV.!f.ys!!?i LIABILITY INSURANCE INFORMA ON-VEHICLEN ftAGEIN EFFECT FOR THIS ACCIOENTON VOURCAR ? YES ? No .?ti;??,A E.WLIA 'TY', NS?RAMC-L:COMPw 1MVi?w SOF CI.BILITµ,'INSUR NO _oY NOCO -.?J u..?w)?..-;{ 5jy ,y .may. . p ? ? n r :;4 4. N6.. AM O ; AB NSU [.}? {„ Sf 'kAroi[.L w eti ,- LI 'IO'-?Y' U [ftgl-tml>v_.+--+y-su>!^i 9 9? « _ rURiti ?O A66' 3 DINIU?,??-HMS ?.na.?.w._.+Rr[++.M,...-Ra[LZUV 2 r l',? ... . ,n ?v EF ADD ESS a _ M !m-Ss I rr .1 A STATUS F. UR[D di MAR IIRSTO ETH T I[ TATU OFI JU 60 '' ?i_;,;,MA, PRST NLTHAT -1016Y j,.,,,}.-,• V I N V[MK 6 It LLED N 1 MILLED " c 11 t l'N lw M No. v larv[n[1 O IFav[w[I IxIN^wl 7 . 7 6E] n 5E] r O B AR D CI C E t I DE?S?CR- ?BB[ L W WHAT HAPP[NLG[IR! CR.TO'ytNIC [qS DYf?al D[ M / [ ... o \ ' I? -- 4 n /? ace - . 3 .rR [wow 1 ? -P? Q~ > ?' Gi ?lJ? / ???? C 6L40: !^ 'L \ L__?._ - -. - i . --_ .._ . . t - I _ I . ju .w a .ru VEHICLES POSITIONS BEFORE COLLISION F INI-TIG o.EO DY Y- HG [oc o NLADCD Nr w V[NICLC OM [TR[CT OR HIGHWAY NA [ O NO, i^ C ? I?.... ? rotlc[ N R F W NO . • Ra? ? ? ? _.. .. .. _ ... ? NO IYO . ? ? ;: ?'. . ? real[. ? No mvOn[,boK :. .. r' ? ? ? ? ? ....... N[ C N_O IOTl El ? ? PLD[ETf ALO _ ?'. C O H6 INOM I µ TO ???? - ^ PCDC>T[R wAl UEIRG In I? w ]? [• n [ S l l n^ ...-U. AC[ WL'Af?ir[a, LIGHT CONOITIONf TNAFPIC CONTROL [. Rw[I T It OI nRO.O D L /VENICE[ C By ?y•... n•?[tr - - vrx r IO [noH 'Vn. [t[ Hwre. urlo•.R..7°` _ v <x[c. ?Iw[I 1 F'j! , 1 ??DAYLIOHT n 11 ISIGN... ? 11 Ll[ONF. WAr •[I ??11 ? GOING STRAIGHT AHt.AD r I ( n[.? I, ORY J13 RAIN N4 I F-I "AWN ? J 0 RTOr >IGN 1?j3 L-1 TWO WAY n J C] OVERTAKING AND PABEINO ? '' ' "{yCRR aLE (( ? 1 I ? WI.T ]? KNOWINR ] ? DIIA% ? , ?? TIINLD R16N ? ] ? HOAR ? ., L MAKING RIGNI TURN r " - R[[T E] SNO f , r 1 -AIRING U{.Ii•NGF A U RFO f? A E) L OP/RAMwI ? A E] NAMING L[Pl' TURN [ ), Y06 J l_? W lJ ?? UN ( 1 ( -] MAKING U-TURN IL-L !1 ? Awf CAF l J D OTI T l? T ?J -4 Nf. All]? It ALLEY E] S r j ? [ C Y (? I 1? ( (?? 77 ( A (( L ? R,nSt, LIONT> rj. F] 1.] RR 610N.L Ll A Cl eIltTURY Ll A I. >LOWING `, L,:.w> LJAw,?C w? ? 1 l n IITOPPCD FOR TRAFFIC N tA?ONiO11 NOT EL[I[M OAM[N 1 ? ?.[E,r C7 T ? OI'1'IC[II /It .GMAN ANaD 1 [ lJ ITRPnCO.T>ION.I . v..wr.., nr [. ••[ror, I.c ^^! ?? Ol N[ily ErANA [.l R ? srorreD IN ROADWAY C [] J I_] mvmro IR T•Rn.rG IH NAIIK L.N[ .f . Ir j ri TR IIC 1'1I1- 1 UNOWIO[O 'ARTING rRGM f.ON}ROL J Q ° V • ti . _ I I s f 9 t i? .s? S. ' osw 1 }I i?Iyyt'lh r Y '?. 'kl?, a raa ) G a :F SPATE OF WASHINGTON PAGE UNIFORM POLICE TRAFFIC COLLISION REPORT D OATEOFCOLUSION OAYOFCOLLISION TIME COUNTY NO. CNY NO. FHWA A MO OAY R. Z SUN ( 1. "' 2 IU(5 D WE a IIIUP S Flil 0 SAi 1 J E 00 HWRl >. / - . ?URBAN Ci J f0 9PURAL OLIN rv ?STARCROUTE ?aCOUNTY ROAD ?CITY'STREET O ADM CLS PREFIX ROUTE OR STREEET000E SECTION ?OTHERISPECIFYI GII1ORT011 1 LU 3 PREFIX EO -17.3120 MX. POST L O . N G E W ?> MILES ? ? 1:1 El ROF W V LL . p 7 / C .fIAMI6NO OFS TREETORHIGHWAY INTERSECTING WHH: STREETOR R.- I L RhMP DIAGRAMDATA ' T ON c . '. .. NON INTERSECTION.. ACCIDENT INTER N ORREF? -SECRNO STREET OR O ., 'M ILEAGE EER CIS. I TREETOR ROAD ERENCECCAOSSS N BETWEEN STREET AND .. _. . 1 . STREET CODE ^ ST r-.,a.0poo DISTANCE ECxONFROM REFERENCE ORCROSSSTRE M.1?E"'KS SPECIAICWING USE RMILE fILES S E W QFEEi ? OFiCL COLLISION INVOLVED: ?VEHICLE-VEHICLE E] VEHICLE-BICYCLE F&OTHERIYIRITE) ?HITBRUN SEVEWIV x0. P.ILLE TOTALNO C] VEHICIEODIECT ?VENICLERR (RAIN o/ f"'>v'hj _ ?STOLENVENICLE I, NOIWURE O OFVEHICLES?VENICLEPEOESTRIAN ?NON COLUSION ?NAZARDOUSMATERIAI ? PROPERTY DAMAGE ONLY OWECTSTRUCKINAMEOF04JECTSTWCKANDOWNERSNAMEI, _ LOCATIONOFOBIECTSTRUCK „-, ESI.OAMAGE • ?NOAOWAY FEET ? ? ? ? NO E. S .. FIRST: ?, ;--,!MIpOLE DRIVERS N-LAST. ,. DRIVER'S NAME-LAST FIRST MIDDLE IF EICYCLIST OR PEDESTRIAN CHECKIU .'. ,..-..,. R . = .J R STREET ADDRESS, _ ..'. ,. _ I STREET ADDRESS .v ?• G? 2 A v, , R I ... ..... STATE .:.'..... 21P000E PHONE NO. E R CITY .. STATE... '. -.. 21PCODE '._FHON NO. N 71)WVEii9 LICENSE x0.„ .. STATE.. - SEX. DATE OF BIRTH N OBIVERS LICENSE !KI-. •. . . SLATE. SEX OATE.OF BIRTH 0*" MO DAY R. 0. MO. DAY YH. ?..rA N ? bvA • S ";, .. PHONEN . DfIiVFA CUPADON FIRM HAME.:'?.-...:.. . •.'. 'j DRIVERS OCCUPATION FWM NAME. :. •. .. r.?. .:.•.., .P NEN . CODES >1:3I ;V-- _ MI SEATBELT__._ I('1 ELECTION __.. _ CODES >1131 CiaSS -----'aI SEATBELT___. 151 EJECTION _._ NATURE OF IMAYHES NATURE O N,VB,ES NEW SCENE BY V'L A 144,0,,; J %t• F.01 SCENEFlY TO -.YEAR MAKEIDOpGE-CHLV.1 M00ELI.-PNOVA) 511E IZ DR CONV.I VEH. YEAR MAKEICODGE-CHEV.I MOOELIDART-NOVAI STTTE (ZOR:CONV.) V !5? ?* q? "l V E VEH. TE N0. SiAf TRN R PLATE NO. STATE E VEH CULOR UC. PLATE NO. STATE . . I-LEI PLATE NO. STATE .. J 0 VLHI b ICA 0 R lR , C VEHICLE IOENTIFICATI N NUMB ..... OOOMET R ,.r.. - - E. r r 7iEr 1 z E .. HE'STEREDUWHER-W1. .., ..FIRST MIDDLE REGISTERED OWNER-LAS FIRST .. MIDDLE. o. LL l? N o. `. ADDNESS OF WNER ._. ..:... :: 2 - ? - AMEANDADOIIE u+511RA ZN ECO SR AUENr NAME Al1UADOHESSOFINSUIIMICE CO ORAGENT. . .. .. .. ..::.. AJ ?. CHARGE CIIAII NO.. ENFORCE VENT CIIAROE C. A NO, . 1 /JaN ACTION ADDRESS & INJURIES OF PERSONS INVOLVED NAME coxs _ D , SEX AnE STATUS r EJECT. C N:ME aa?s 1((<%J?LL1L'/??,L?1_^ L ADDRESS ??. '_C!? Y•? (f LCI :( 1? ?Y7j U p I _ . _ ,. - - NAIDIE OF ILMOV1?f1i3M nuRUS scr NF nv TO A NAME _ N T ADRRE4S S -10A OF Hlrs S?.iiin F D•.i TO W T N e s s E s' 1 i'10FA1NAI T, !i A,I;ATII INO VHIIIIr %fl n1 I!.E i ^Aii NTa it v.tiir TII.PK.I` l N..I (1 .'.C a ) ?f '? ? ttT 41 ?? t ?®(ixR ! Y,JANM}5l4 Nx1NU ,I 1 " i . - •du 1eF- Ahfo A 'et' i F Ys'A M'¦ y' .'V. A?.`f/t}Q'1'? ? , 4? ? , I I " C ?( ?' Lr C H I l G (r1 1; i L, 1 ?, I F+ 1j J t ? ) ? I I I i l • t 1 1! ? ? i ) ? f( ? ^nW ? t " I r ; t ?NY?' i 1i ,,? 0 Y rc}i, b VIP, ?au 1 , VEHICLE DAMAGE MAMcI - E%0.•aPLE f°?Y•"1`1 1. IN EACH BO%, CIRCLE'HE NUMBER OF EACH DAMAGED RHEA. f(i'--" Q ERESTIAIPACT INSTRUCTIONS: r . = SHADEAREAOFSEV I re t. ! O. ORAWARROWN) TOSHON PRINCIPAL DIRECTION OF FORCE. O/ 070 OAMAO E VEHICLE NO. (USE THIS SPACE FOR SKETCnWG DAMAGE TOTR-AILERS.MOTORCYCLES,ETC.I DAN]AGED VEHICLE NO'2N? ? Jr ''.r..+.vr /"1 ?I rrorc? .lI I nlf Uru? rn • ) S Hru VEHICLENOI ) St YO 4- SEV EIII ITY•OFDAMAGE: OTHEFVENICLEI BLING DAMAGE U ?OTHENMV DAMAGE E ITY OF DAMAGE' VEHICLE NO.3 DISABLING DAMAGE S OT.EH M GEAMAGE nRDI A STOS NG GE l ? NTHf(1 M. V DAMAGE DISA GE I FUNCTIONALpAhIAGE ?NODAn,A )L ? GE ] MAGE CT ? )pFUNCTIONALDAMAGE ? AG OAMAGE ESf _ ESTOAMA E (ST. DA pWEDBY T LOwEDRY /?"? . t-.l T OWEO BY 5 To TO t DRAW ARROW SHOWING DIAGRAM OF COLLISION Ber,.W. o,la+rtnv+v,rt„uNLS ._ CIRCLE N CIi E NORTH .. v'.Ktps+NS Fen's: DufcTSONoff AO,oAA. v+frmconnmis sRroxws - •. ', I -._ ! '- ( • ??., I ' t : I 1 BNB]x,Lr„x. EDNDrT DAS tTRBDT DN l ,. "A E-N1G1 I I ..- y ? I I ? i 1 r t ° ] Ia,T'.ADB.eLE.DrNTO• ? _ ? I ?b tt `` I -I l ? f - { I lsr,Ff, ' v.,n - - _ I I II ? ? ?, _ I try ' f I E IL w N„fF'D I ` OF DESCRIPTION ,"l-TE wNAT PROBABLY RAPE E E E DUNIIIG AxO AFTER THE CRASH, INCLUDEINFORMATION NOTa ,190RAM,E G.ORIVEn D FOR M6, O E WORK.ETC.I. PEDESTRIAN CLOT GCOLOR, CO NSTRYCII REDUCED IS IBILITY SABILITY COLLISION , , DI I '?C ?N?3KC? ?fl4', ([/HEe!! ?Ocu.v C? r Il ?? ? ' • ,_ • . ,c>< ? . jr77 . G ?t.-N•::IAS_-,??-cceeCll•cG..l"J ._?ifG -/t 2 LCrT..__ t ?r?-_ jT /17Yr'dJ.._GOar?r'? O/J._f? -?IGHTCt%sL)E .?. Rf -V V : / { - c_l?o?•?< I°Ft?..?_?a4,?iNG ?eei.__.llO?.?.Li_? Tf/e.-` --- .? irro,-.u c?as z ??s ct ? . .'.? " b ? _ - E?/?)=Gr9.vC rlcrT ?i`?fy'?'F-,t=_/G!0/ J?/e CyF l f _.- ._ r _. O7Td/ P?,(/.FJ_ !a .. "`_._. ..SC?cc:?? / -- /?fU•up/GG?J - c7tr.?,_.,-:? _iy is-a?c?t ._,O/4c?.?G?: ??w? L /r [u o_s wyleC- U? M i ? _ ._ G __.jur?t/?ccJ /LOis7 -? !!G',! It, ED IF PARPE LEGALv SITION BEFOREC I.LISION - - - IN oNi DRECrION , NON. HEADED MILE POST DIR. ON STREET OR HIGHWAY NAME OR NO. PAARKED OCCUPIED ..CREASING DECREASING l _ •' ro3 1111 E'. w N. 1 O YES G . N r c,::. A Li Lj 1 E f 1 I fD I I KONG- ; _ - CAOG _ _ RO _.? TOE .. ' t[ MARED fir )UNMARKED eC' DESIGNATED L BICYCLE TO T O f ] lsrw srxp• ?s DtwALK ere F . SNOULDFR CROSSWALK I CRO33 AL I ALKwAY oxa . . I eAC F 1N"1 IDRl l NATHER AD SUR ACE .R.e ,Cl CONTRIBUNING CIRCUMSTANCES .. u 1 ' ,5R`M`,? . ..... IC EcK OnE OR MORE) ` , IC NECK ON,, IC ECKONEI ( •: ylr GOING DRIVER ? DRIVER DRIVER tTRAG,LT KNEAD I NO ] DRIVER I N0 1 (?? .rllr i flnr 1?CLEAn„LLYAF yyyENpf]L . IND. ] 1 OER"I'LUExCE OF -I IOLLOWIN6 r- DISNEOAROfD WARN. ?]? OVERTAPONO -Ili uN }I i9GAO3Elr__.?s.al -SID_1S!tl,,,, AND PASSING . 1.?-L-L ALCOHOL?__- J-1_... -, A%INO N f r •' Y _ _ " - - n6 _J]r] I I i APIA. [NTL 16 n1? DRUG] LUE CE IF C t C[N EP- S _ ASLEEP L RHT TURN f OW G I fNOW ) II 5!f FL00 LtTATF=.? lel]._ b 0 O L I19( -IOC OH A KIN6• L%TNRN A?INQ ?? G . L y _ ICE FOG . O I ,SI 1 MA%IN t%CFF FAS (? I RO F I?tF , EE RAT I , 1 I I TV .. 4-- -_-DEFECT FEOU U_RN - - ( '1 - ('6 ]LOWING I I• fi I } 1 1 r-1 - 9 D70ID EO G HT NAY I I II DISREGARD OO.t OJ.L _ r- I 4 O'ECIfYI Or f 4-C.", Oi f ? ? T S ` ETON EO FOR -? L I OTHER LY6C 1 ip • CR ] O NON THAFFIC 1 I IMP ? G G 1 II CONDITION T mlfcK ONH RAFFIC I NO i CONTRO VEHICLE ., GNAL ?- SN 6 6 '.nf9 ING c E TYPEOFEIOAD VEHICLE CONDITION •. SOBRIET ':.:. ?_ e?? nOFlID Ar SIGNAL' N -] ICNECK ONE OR MO ! EHICIf''441 [ FPAAP [p9ff HICLE ICNECK ONE) ( I OR $TOP I.G. 1"1 IND.} 'ToyRUIEDI NO.] ROADWAY ?1 G ALE ONE ( 11 ?. 1 1 ' B \ -r - TOP .] DAYIIG r '...:. '.SL IX -, vE NeO rtrtr to Ae Y , Dl FG I , : _ ,? .R ;I C L? E Al AK[6.-. _MPUnILITY .-. I $TARTING rnOM EII ?. __ r -? BOAR LITY IT . } DA1W ] llO 1__ I ,xl Ib eL[ 1 I n fLTIVf ] NOT) AR[O._._ 'ARKED'O.ITION READ HEAD LIGHT{ (... I SG N SIIINp I OLLK RED - N NO ILNTlnIN6 I iE CHANGE •] OFF[CTWE Il. -N... RPE lP 1} ! TRAFFIC) -1 N I... .... .- l00'HA.' .. ...: II EA. LIGHTS n. UNFL, BACKING T."""N I fl OT K `ARK-{i PflT t FLASHI NNG AMBt ImNS UN T ' A l P NMN• 9 ALLEY ON SM-H - '-' ?s n I Twpwnr-un CHEM. TEST p1iin } I re nwr I • f LrG•HffO Ill! • {IGNAI l •-Er )LST 61V[N ONNR O'lCIIYI t F NO I Or MINIM j Oer[IT UGR6 uiN IAN 1 10 ! Rl ruf 11 .1 ' IIfT OvD<O NO OEITS • • N.r ru•r OrH'n v[crr Yr µl• ? } DrHlN rw(cR rr g, TEST RESULTS 2 ) Ur, rOLf OVe fi ANL tL U N _- ' - ?-- - ?' r, rGan 'r' U,Ir•H I HI?.N+I I S ) e•ll r+r lr{N?,U v ICI nIINWIO 4F ?tp/( }tM 1I RFO MHP, I ?„ IN ?'j NUI A I N'?.C l?? Te U'/,l! I'll NA,r AF DYINKr 1 ,r ' . AIL X • I ,YV -..... ...... ,..,...,? .r (? r ?. t. 4" k k ?y ?>S q? C '.q } i. s ? sr ?Y. 1 1 1 1 1 r b? I t. JI ?N Ily I? ?? ,r?4•, Es °J MOTOR VEHICLE COLLISION REPORT NO „yu,. L"1.. N T1MB Orrv-C LL SIOn., - _ x cou y ey It n ?.jlUl!L•SSa:L:u,b?+?.rr?OWf(. .. ?r 4..:. +1?...OTrJ h;:as... ADM.CLS REFI% co F ,..E I a., a AF?f? N 0V? / ?o ccF JE T ?3 b :' YL?WYS,CA_'O: ?'°ESTeBP.N O_I1 ..Vr._e`i_va ':t. ?. T.. SE TI-...-.T111'L.. -.6 _7L.. .-R .?4 YREFI% EO LEVOST 4oa0 /1, N IH rF 1MN-LOCAT1oH Dr coulslaN Ja owrA J TW E ,ic ,. EIT REET AND xr ' T Qu , ?? AHwo N?uwaa ax iocxr?rriHC a.rvuV.x,. ax, xx?ucc. o? DF v kF .,. ?x NO A H ax ,o I ? a rva y ?J ?HCa'a V?' E L ......... E ,,. x LJ rv {??? ??- iC 5 RUGKZtti}H•,M4?f (FT >:rAVCKI .?!. .u OWNER Or OBJECTS NA 'AND AODRE5 Iri HO . O A ?N ° q ? " /yrvSV StAJ7:E :?.vgY,?•6 7 /' Sk/ A•toiS<.Ij •7vJj ?' r sn R S OR ILR ?4ASS.ILAA+.rh3-.i„e. 'FRET NA . .e N. IGOLEy. .. J DRIVERS.LA E FlJwokO ??tPGFSoN EM??- c ?L IS EET- ORES Zf 'a-F ?.'Ly'!.e'R UTE NO:; AN09 X.HO.. Sl'RFCT'AG E55,????';•-,w,?t?:,„?¢;;;ROUTENO. ANR U,O%.,[C]?' ? x t 9 ,f5 ki?SN tS S w,.ox x 9 y ,; I y -, S-T SW SE?? s` ,- Y' ^+r' Ate." 4' ;Z1V CODE ANE U AiION ST _TE ZI ODE 4fll OOOUFAT ON LAo93VM Sc -rCL cJp H q?1df, ?'??RNEJ(S.LAIOEILSEJAUMOErc ATE f : DATA BIRT AGCY I EP E BER - AT % OYE, .BIRTH E Ale) Llreore- /d Y vify- IG?E+pZ,Nasy?-w.waN I ?OOFyI`,??rov BO 9T. E,I3 ? MAKE - ODEL I ). B OY 5TYL2,-_ 3.. '7( Cd/ !/ L9GU/YA 3d?' fa7 ort? SJ/?•T1on tcJ a Qf' Lt EyPGAT_?N..-Oz :.- ?L•TF?'1CK- LRIUL-€R+.-_TE:LIS ?-.r. STAT£r"..5.. LICEN EPLATE O. .ti TI^EV T: - ?R-LER PL TLLI?s jwE•.SZ!ST.E•• X A 94 ,v,EHI?,Lg ?ipy,'ppl}?,R;;;?J.4g4_!ruoo:•'a.r:•...rr10pOME.TQRIgµ/wo 6N CLE?DENTIF CATION NO.?.?:.rt96E,ro ,ccsa O;,,, ,, g1000MFy-tF?N•?Crw° '?q,ooo a Rv-cL -. - -iq?o =h!!MSL:Si. OISIVER9 '1 ¢vNSf (a0 ? .,.. . RR..I¢TERen o [R.'.Iwi -IHrtrw; •J••MEF SCnoR1VjRS.nKidt!4RuN0 F c soly em,? E R6 EE e ee ''V!1?? If3e4r4T.$.Yn. 'W E' ?BIRTIT? QW §fl 'AGO 5. 1:.??e71J!(?'.f373Y1^14!VFCa?u+ Of?1R P.o IR- rot; 3 D. 1/3 /yr`S ser?rrl e;;i - •, ' • •• P_ $ rwiN0.YgKLic PART.SO yVEHIaI MAG60.-. yt?`...SJr LeFrPrnyir. DRIVers r)ppR- LIABILITY INSURANCE INFORMATION -VEHICLE NO. 1 - covERACCIrAicF°Fec°BVoAril A.C.. ENT ON YOUR CAR :6POL1 H OER:T??!O'?"a f?,_? ,.F. _y,??y r. AN INS IaAYE OF2L:ABIC[TY?NS?R.aNrCE'x?4M ANY.Y.4 'dh.-^<r•4':S I [ %Y?,yrtJJ4L oi'- cnumc°w Pnu?nc/NUl sk ? Hsu D,r?LSaa?:v?s?Y?LSVCEa•ale?a!}?xnsr?e4cN?? :sr?••--?y d:..a .,?nT?h--r??„?-„rt,;?,.,IAOI:?T?e?!4rnw?t??: •: - S/io/a iNSuv}ntlce CSC, cr ! 7l0 SIN A° `?,"J ", CE' .2N61NJUR?.zfv..,v ?..ar.,.1uza.-•. AMf N -R... oe(4 :JY ±DORESS S ' M F 00 Vwsclw? o?ocr LJ xw "_- [ D rf! *n [f q -T- J _ GGGGL ? .-•> R.IJy KILLED wN ONATA RI cm Hu ' En-3.+A Jd...fd' I sSATn?pF1tUUREDr '. N V4 I L6 r ': .1.M•?!!FSI64 ??SfJ. ,TAV' IILED „ K n I..I,A N u?l,rQ.IN 1 1. ? SE] 1 . 1. xw1 6? w7?n O ai,lAx -NCH •.vR *E.r If 'Ixlxo,l x? ? 5?[I 6? w 7?a W -T. .1 C IRCL C ?iwCR18>§.?BfLO .WHAT `NAA?6 [O[: EIS.Tq VElIGL;; mLM ? ? O P t,?gs?R,vi_nG oto?v_n L,?LC.__o.r_1?k pwv C?Rt2ueL_8o?ar orLrrmy SJ_DI? Luhe ', e..: 7-7,h hi9.cL1er-CY?r_,.C..gme_.(Jyo.-ELI_Gl. m,Arnw a sgA.n n AA,w. ---.? Q? Yq oCyO • Sr ,,,,[;,,„,„,„„ }9_Y_Lr11s/-_S?DG__O..-roun.t?_Y?--CpY1JBY_: [u.nen _-- r-7i" -- - • 1 VEHICLES POSITIONS BEFORE COLLISION Hvcsna%rcD Rr N(AD(o " °• I OH STR[fT OR H O C R H w ? a,arr VC LC • ? L !?w N B F ay xo[rc[ a 1 ,Nl y , ? F ?? : , o o °?:? M o ?? ..` . ?gi ? ?.:? . ?.? rx...rl< as :111E®??ro:? ?.? - ? ( ? N' --N- , ? ? n ? W .„.ql. ?O { I ? 0 , ? ?1^ ?TTrT? /L• r?? ?u kr•J rITOl4TRrti..[•,At.0Iw ..rw..J 7i,i:?- !L'(J.??!.%.JiS..x /r. awofMNa. .n?1a':uT} ....l.,.n.i IROM. .:::i7AA::r'%.•J .m uvrro I? Mo..r. a[?,.H,... ]? .°. A ? f s ? . , tao rev r WAS .NO^GGSNNKsI. _ ?han;y SrL1??Ni.4W!Dlrlpr9T; TnArllc coNi., a:.y;ln«aL,wn; nrED ROAO -r, t ?. Dn v[r [?c4F25 I„ ,Mi1 r' ,' [ tc« X Irx.u oxrw w, ' r a ? r a a _ KAr ? SIa NAL! ? 1 ? ON[ WAY,r. II a 601M6 STRAIGHT. AHEAD a 1? Aw 1 DAYLIGHT Il 1 1 ? 0.1 a? RAI VINO l ? OAWN ? ] ? STOP SIGN ? a TWO WAY ? a ? OVERTAKING ANO PASSING ? w91St[ ? O G . ? D... ? ] ? YIELD [3 SN WIN ] 61 ] ? MAKIN6 RIGHT TURN ? 1 ? WET . . ? ] ROAO p 9I.E[T IhttPOHAhGL ? ] ? SNOW An I06 A ? ALIGNwK IA OH ? A E3 ILASNING R[O ? A C] 11 ? • ? MAKING LEFT TURN N OIN(w /[[} ? A E:) ICE. S? reHT.OIIYr S E] .... TO LIGHI] I ? , El ILASNIN6 AMOCR ? 1 E] ALLEY E] S ? MAKING U-TURN O C l A (y(ryIN[w ANLK El RR SIGNAL E) LTWrf,T W.-.N ? A 2 ¦LOWINO E] STR e ? 1 LL JJ C Y K IT LIa N„ El • •IPf A ON jGAI.ILOL.1[[M100 SR, T ? SrfONY ? T f-] O C(R/ILAOMAH LANt[ r, T ? [TOI•r[D rOR TRA/fIC p 1 . _ I I ?? 1r?'7 7 . n r?,•n.. °.,r„['Nmn. ..1 ? A r? l(,1 f U S 1? On Sllfr T 91GH L ?, Vu ? 1 ? [LPARATED r_1 uj5 ?n l'OTf?tf - T ? 9 ?J ETOPPI.D 1 I. N ROApWAT j Y S i C (1 a i Ov, m pNm[O ! SIAwTINaI Aa i _ l_J -I ?. D_ wA l G ?IG RA..C LANE s.IC ? *'7'eUdt?i "?' •!J.l,?.., ?C^'1'e.n ?! n rrc ETIKD•. .?Li .,. n f Vii. I: IC! % sst x.. l J. n i I h ' n M 6i d t 1 mµ l 1. i. L r ,,??,, STATE OF WASHINGTON FADE 1 f C? UNIFORM POLICE TRAFFIC COLLISION REPORT W NAME' - I AOORE55' _ ? '? ' N ??? ROM wnlnm@__. ISC???? 5 NAME S' ADORCSS g• _ NA?TL - DI NE nvTnS. I IISIAIU5 1213[AI 1'Q•+IgN iJIRWRrCU33 r' O ; Pf W S1N0.uN RiCYCll3T ; )OTHER EEC" M 2 W ADAI SCENE O. WADON ARnNAL I a NICN D.5M.NO11 J IEYIDENT'NJUnY E S OTrILR e WIi N[SS MOTORCYCLE' a roaTONU 1 NOWN . A. DIEDPIr1OSPITAL 1-POSSIRLEIN4URY I. NOi NSTALLEp 2. NOT IN USE 1 1. NOT EJECTED 2TOIUly EJECIED USED UNRNOWiI J PARTALLYFJECTCO A UNNNOWII If R 3 SEAL RE IT FAILURE CJECTCO by S5?„f ,? ? !L w y, 'N t?r+??l { ?e "IT If ??fY?j I I r'?7 ti?? Y , ?T ti_? YY ' ?r `S T I , ? , Y: K yJ `hdL t ? r I w ? sY , llK{1: DUPLICATErCOPYV LOCAL LAW IHE ONCE MENT AG F ACV'S COPY-TRIPLICA7 E4COPVm INV ESTIGATOR?S COPY VEHICLE DAMAGE ?p? .. I I ACH O LLETI NU OP EACH DAM ] s A AREA of SEVEREST IMPACT. INSTRUCTIONS A EA VN2u • AGED __ A.EIE .• ? . --_ : ] DRAW W ARHOWISI TO SHOW PRINCIPAL DIRECTION OF FORCE ? 1 '" D _ DAMAGED VEHICLE N0 usE THSD CE-SKETCHIHGDAMAGETOTHa LERS, MOtoncYCLES. FTC I DAMA GED VEHICLE ND I Il 1T. 0.•rlurn sEVERI rY OF DAMAGE : VEHICLE NO.1 [? DISABLING DAMAGE ] Cl OTHERM.V.DAMAGE SEVERITY OF DAM AGE IOTNLR E CLEI 1 ? DISABLING DAMAGE ] ?OTHER M.V DAMAGE SW ER ITV OF DAMAGE, VEHICLE NO.] 111ABLING OAMAGE H OTHEp M.V wMAGE ] ? FUNCTIpxaL DAMAGE a ? NOOAMAGE ) ? FUNCTIONAL DAMAGE I 0 ND DAMAG E AL - ] L_J FINCTI • Ll 10DAMAGE O D _B.BY I ST. DAMAGE GWED By CST. Og'AGE I -.. EST. pgMgGE TDWED BY 3v TO _ - TO S TO S , DIAGRAM OF COLLISION DR NG L AW ARROW SHOWI NORTH IN CIRCL [ -ClIF O SLI A IT - _ ? - - - DH 1 T . ?? T 7 /•I I _ I L I D TF f0rv DESCRIPTION OF ENDICATE wIwTVpoBABLr HgvvExfo BEFORE. ROBING AHD IF TER THE CHAIR. INCLUDE INFORMATION NOT ON mAGRAM. E.c. DRIVER - COLLISION RISIBILITY, REDUCED VISIBILITY. PEDESTRIAN CLOTHING COLOR. CONSTRUCTION OR RFFAIP woRK, ETC I POSITIO HEADED N BEFORE COLLISION E S ' ON STFEEi 013 HIGHWAY M RNLI LANE FCTEDN SPEE.S VEHICLE LEGALLY IF r "11D WAS E NO E w , N INCREASING OECRf ASING . 1A K.D P ED 1 1 1- r I r - No ON NT L K w.nr HTasFm , FPO r - r }? ] ES GHATEO ) UNIAIKED 6 L II ICICLERDUTE : ._iOTH 5E C PEDIDCCL,ST WAS USING i50f A K I. T WALKWAY l__? SHOULDER I-1CROSSwALK ROSSWALK D EI ROADSURFACE... ICHf CK ONEI WEATHER._-. CHECK O.F. +»• '. +'.;; .- CONTRIBU BC TING CIRCUMSTANCES IECAONEONIOIEE RIIERNLHICLLAC7101S 02 V[MKl[ ?nl•[. '. xOE} RIVER 1A_ FR ER D O.] DRIVER - 1 } GOING 1 AHEAD Ilr DRY. _ CLEAp.C UOY Y?YEBfA ( ,HfluFNCF Of J_. _7_dL llQL f0 OWING 1?=?_44S1Qs v ISH I J]=j D Ic. OED __-- U]? prvO PASSING _ L } I wEi \• pwIHING O x INFLUENCE OF E OAVGS. rt O TER Ell ENTLY SLP_ ]n MAKING I- ERG, TURN T ?. ¢naw ( -`?_NOwlnc ?E%CEfD NG ?} I SPED LIMB STATED r -?9 5 N A _K U _.L.OS9141L_IN Fri TURN D - CE ? L- 1 I r?' roc 1 - -_ %l cFEnI c AS. [E ( DPEn N - I-? r-7 RAnrvc l_ FFCTIVE FOU-__ ' c " ISrJ, UTURN EE ?II , 6` ? F 6 I 1L1A"T FEW 1 INTO AFI Ov . GIJ ? I? tLOwING J • - ,. ?UTNER ISrECirY- n[ii LVECIivI ? ? P N ?- STOP ISHD N FCIFVI t (J ( (--?? FOR C JD vnSi N G 5 NEGGI +AL ? hi N I)L' TRAFFIC LIG CONDITIONS. ICHf<KUNEI TRAFFIC CONTROL ,N.7 VEHICLE - - VE O ] ICTYPE OF ROAD NECK ONE OR GR - VEHICLE CONDITION VEHICLE I4bI.EGK.%7F _.'SOBRIETY jE IC FC OE+EI VEND ?-IBE- j oOVVED AT 51GHal L STOP AT sIGHAU l 1 ,. HE WAY ( ? ... y DI Z fMAA {( . L_I D[] STOPPED.. I ,,? 0 -___ l]', ftOP ._ .. .. r r I Wp A - ? Of FEC BD ABILITY PAIRED _ lEBD STAR G N ANl RA IT IN L ? AENS HILF ?ROO , ) I IpilADLCM L L --- IL TY LIMPAIRLO .. i.. ?„?-) STARTING IRO" I. L-. PARKFOPOSITION }" -'- fIAMIING . CI IN r Br ... _. 1 —FICTIVE _.__--._ .. . - .... HO SOBRIETY . GIN G IlNTfnING TRA ICI E? D.NK-iTRLf LGHTfON ._. A [ -TDi -' SHHG ._ ?l_._1...A E(• ' M RA - -' All Cr D REAR. LIGHTS- ...' 111[5 WONN _. --OIl,DM0O1H. .. .:. ..._LJ-LNK ?•?._? HAp NOT _ _ ._ HEFN DRINK NG --? _-1 -'71ST 1 IIKING ?C _ _ STREET D.? CA. Gs0Efi L.t_._ •.: D "'1 __sc L •_ o cF ' -?D LOA rT lSF[- -•? n u L , ._ v n CHEM. TEST I 1 _. I S ' T THER IsPEGIF YI i iteT °GN 5 .. r o f LI t - T )' \ IF O r' ] DCD i\ NO DEFECTS ) L¢i n(FUSFD OTHER W(LII YI S, I Gov L 1 } uxOlvrO[D - ?Olil[ri uPl Clr Yl - A. TEST RESU LTS 2 _ NvIfIIGATIH40fiICLRY NAML APANK BwOGE NU? OLIC[UISrwICH[U RITT J vplltF wR Ivfp u1vLFD LE ITMrltlEO/LOW Z_ RRI HE, NN MIN X ISl6 GO C[RY NAMI GE nu r .1 N<? '7 O URT N 1 pwlt ` - . 7 :EUE V T 5 !Lilry.. 1,?? ? L,v _ Tr 'I IF??'rl??4y'x 7f ..'F/nIS L1 M14' ?; IHEIE?E', ?1 JI'?il h W'T'KO? I.L?(? ,1r ?,I. E r * ?1 t I '1?f1'kl ' ? I ' r 1 If t I { ' . \ J} Y ? J L ? ?? 1 '¢ I ta ? E ? ' I ? 1 I I; . z f ? r YS I 71 ? ? r yy}},, 1 I I??+k?i ? I I?i 1 ( I I I?? % N . a 291, STATE OF WASHINGTON, ADE l DG z 1+IO. -- _ _ _ ' UNIFORM POLICE TRAFFIC COLLISION REPORT ucECOMY wlNreuMBLR E A COLLISION OG COLLIYION tlMe COUN v rv NO r T uOwTE OG 1 Y -] FNI IUSE ]sOOHOUPl 71 E ...II^_ vR. T A 3 s A Zoo Z i 1 U F ??k.AISA . a CO nI ION ?STATE ROUTE COUNTY ROwO CI ET OElt15 PEFI% E R RfE...... lr - ? ? -? ? {yl E l(J G ? OTHER ISIECIfYI ' . ,w, r-341 k ] l (7 a ?OP-.-..,. arY OR TOWN .. 2L'('uILNS ? 5 [}? 'N ?r2-C.?)dl?.?-E'o81.7L? AMEENO ST TO U P Enl ea M F POST . ' r. J y T .. L- n HIGHWA INTEAZECTIN°WITH:STREEr°RR°A ON C ?D aruTtt p0 ? i LL o LL M ,` 1 t l cLE 1nrERSernoN - , N _ D E?? ETWEEN mil- L..l EFT I E xO I T Er R a X. Re RENCE NnosT;?TRecT OnAOA d? O 1 _ ? STANCEA(1N°°IRECTON FROM REFERENCE OR CRp655TR J T. S ? W ??? 1 Q? ? LfFEET3 ? ECIw 6 5 `. p1 . COLLSdON INVOLYFD: [7J VEHICLE-VEHICLE VEHICLE-BICYCLE ?OTHER 1 TEI ? N E ITY I - I 0. xlLl ' TOTAL N4 VEHICLE-OBJECT I ?'- - L J VEHICLE-R TRAIN ? E EH C F - 41TI.IUREO OP VEHICLES © - '" ?,.,,1,,/{,,, 'dtVJJ(N ?VEHICLE-PEDESTRIAN ?INON-COLLI ION ARDOU3 MATERIAL ?PRWERTY OAMAOE ONLY A2 O OWE<T STRUCK INAMl OP O E ' u• BJ RSTRUCK ANOOWNERS NwMEI LOCATION OP OBJECT STRUCK- _,..:'.: lST. OAMAOF - " ? .ED ?IN ? p IEET E ORIVl RS HAVE-LAST FIg3T NIDOLE E ??? F R ES F .... J . R IvEN NAM I LSr EDES qI RST uIOOtE . C?Se LUtLL( 10 Atit L 1 srREEr w owEss . TPEETADOgES3 r -f?, Bza t - E cITY STATE _ 211 CO fNON! E CITY TAT S IP - ? ' I•? 1`?/?t? ??• A ? ? CODE. , .,. E NO / n p ?`v? , ? D. ORIVEH9 UC! E O. - N ?ZZ83ll STATE SE% O E R D AY N O ORIVEn9 L5c 3B STATE. SE% EOD TE OF yIR °" ? 1 II D ,? ORIV EI4 OCCUPATION PIR NAME, q . .. -.,. ., NO F O ?" 'C C S/?( l [[ 5 S !vt N k • .., .' Z O ORIVER3000UPATION R , fINM.NwyE _ fMOnE NO f\1d1? rst Ou Se?.tJ . ?'. N3 '}-t7 (L D l ?f V`' COLOR LIG FLATS RAIIER PLATEN. TATS E I' :.... '._._-.._ 05 ' ooonlemR_:....: zoo . . v[HwLE IDe nFlcwnON NUM E a•A Bs n,52o i ,..._fIR3T .... . .:::. ....?MIOOIE..-...- E '. REGISTERED 2l LC /) <'.N ::.....:..?., .. -. . ?.:: i.. -'O • AOORE55 OF, Ow E wa k Pao 7141 ) a ' , n ADENr ,., „ , ,,, ,. - ADOREss oc INS RANCe co ow ncENr a ? tom,., c?, =- sE .' ?'-...:.... ._ CHARGE..... ' CNAf16E _.... GITATIDR ND: AGTIDN Nr // E ORCEME •. W? NAME, ADDRESS & INJURIES OF PERSONS INVOLVED c --- C . Rl- U P TUnl OP nlF3 ovlo PnoM RSCexc eY TO A" N wADge g n"?5°f ove°PPOM 12 w AMF: 1 Reu: N wt°ne or E S rn S 5. NIE U1 yAIINIF 1 `I II IM I A ? SI fIUN 1]INJUPV CLA 91 T° C T. PA%SIND[n N 5 INI NY IEIAT OeLT O Pf OLSTnIwN u 1 ^ F J [ DISABLING I NIUIIY A NON-DISABLING B 'NI]TALLFD 1 NOT T ND US[ MYCLIST aI°.ITN?51 y a T i. OTHER rO31rION leus-MOroner<Lel D E AOOh AN P VwI .Oleo 1 SrI N IIDrAL .6VIOf NTI IHEUnY d ossIBLE INdunr TUNNM . OwN E e. POSITION UNKNOWN S. SFwI IIELT PAIIURf A Siv LE 13 OR.?ON 1 F? ?'{?' ' I, Ie CTION Edl CTlD IrineYm.crfD v LLY EI[L'CEO [G DON IF ?..yntr }`kST?q??I ' rig I'I?FYVZ7? r' d1 1- J a ? - ? I ? 1? a rh',1 ,, 4 ? 1 rt L } r t t I ? ± ? ? " I 1 i - t Y J r fir.'.: .. _ ...,.. ?,. ?, .. ... '.. .•. ?.... I. .- _ ?:'... ,- • '.'...... ., '.a n ?.. ....M,..,..... .? __. !. ?•JI 77 7 -a VEHICLE DAMAGE wEACH aoA cIRCLEi G UN9 ROF EAIH .,...IaO D E 1 Et T •x ?R'Y','/ I11IS T R UCTIONS: ?.. U.F iHOE O SE 3.DRAWARROWI5I TO JHOL•/ PR;NCIPAL DIRECTION C.OC SVEREST ItrPiCT, a L a CvCI.S Erg DAMAGED VEHICLE NO. 1 PACE Fa F.FTCH NG Da MACE TD rR s. t•pTG 11 OAM1ti GEO VEHIIE NO. I t. Ty. ?3 T' 0 OFlra E VEHICLE N0.1 ;EV ER(TY OF O.wa,E. (OTHER VEHCLEI Iiv pF p..L,AGE VEHICLE HO.) ! rJ O S GOw.4aaE ] ? CTHFq LI V.OM,AGE T 10 OISABII".OAMaOE J ?Oix EH SI Y. Oa _S 1?E O ( N013abLING Oa.VAGE l pi E 0 MACE ? ;t ^ f L-I C O 4wAG 40 n uaaGE ]? FV A [] NO DA.E J U FINCIICNAL ON vtaGE A H aGE [PTye; rawfo ev. .^..1 I S Esr, oA«ACE. TpwED b1 1 EsT' ov.AC: TCYRD by Esv. oA A- r .L.7 A 6111 1,1 OlACRAM OF COLLISION ..• FF.ruges G?/?yS ?,1}l?lUc I LcU h Lr•? - - DRAW ARRON/SHOWING -'?'? ?? j - ?? ??S NORTH IN CIRCLE .?{ - F 0 ,nonF ON° It ' iA PLT ?? r LDLLewN Q u lz D'cSCRIPTiON OF -" HND TE WnAT PROBABLY IUaPENEO BEFORE DURING AND AF TER THE CRASH IN I FO COLLISION , , CLUDE N RUATION NOT ON D pfn IAG,EG. CRIVER olswenlTY.nE000ED V(mewTY.PtoESrRIA.YCIOTRINC COLOR,eollsrHUVroq GR RES,u......Eic;r 1•JF:•>'CC/Cc..'?:.?-.?.?Qi?i7'_•Q4'./.!/Q:i1?tJ_7/i?Di,[1._'?jAd.lJ?t?:?EiG?!'.=i2Gt%Jt?... ? - ? S?iY,Q?sG6.t/.O.C.rJ-6?i'?rdi/JT/CD J/sGc?j_.?.'y ? rJE?/ c? LC!C- - ?. C c: G F•d G[1??, ? ? /,cJ, S1?/T'/.e3w?/JD Lsiu..? ?.t./•O L?:)? vuEiZ ?Jc _ j'JN GGE/-`r/ LE? dl ? A/TG5 -' /IGE lU 9LL u ? ' . _T? . n ? T- J c . .._ ___ ?7 ?E-?.//c?.?%z U65?,?c^s%-z?_G:zuslvd..?,I?/T!7•?/.??• /(JAS//?T T /?1J?:/D cus/vW _? / POSIT O N BEFORE COLLISION Y DF LAN Y E D S 4 NI ( Y- I?EgOEO ,'. H DILE IOSr pIq: CE G OE FAST a .. - DRHIGMWAV NASii?OR ND. .. _ uONE DIRER ON P ?EMGALEO WAS ?EH? OCCUPIE X ' ?fl -. aCr?Pvi r? - ?A. ' r G w EJ ND J xD " ; . N ,- F D LONG D _ . mxD favor _ To FED 3 C C IS E ) RK S N K1LK C R06T CRO35iV 3 ' $,CY SIOEVYLK SHOULDEx- CH05511 w4 BICYCLE LE ROUTE -OT HE ROAD SURFAC (C E ONE) WEATHE0. (CHECK COTRIBU TING CIRCUMSTANCES FC D HdL ?„ D)Ai` ?E DN9 , CH ER O) a cL Y aR S No EOF U G I1OE] VST G n _ ORY S X WET , _ :. `. c n. S RAN G :/l C. (NFLUENC! Of ) ocLDSE O' R CENT l N S _. ] Lf Oi P rA- ) ; o fRT c D a HUER r E _ _ • ASL Ea E ? ] " 0. ] SNOW ] SNOW G ] EXCEED S T D • 9- S ILI t _ R D I J OCID G K G I lE R . ICE - fOG 4 %r EDI G fAJ.. N O wEH IN RwT G _ oP N - { I ''. :_ E9EE0 e I wel ' OE ECT EE P,? UT - J SIEt(l Yl OTHER S ' s OTOgANTR•w TO t -LIE SREGAAD STOPS GO LIaNT n I ? LIGHT CON?I TIONS O ER 19[C 1 . RAFFICCONTRO 0 FR 3 t C )E TYPE OF ROAD ? DISREGARD S7 ) SIGN SlGxat• VEHICLE CONDITION H I EC ll, DL ON SOBRIETY O ] AFFIC ` O C T " . 1 o.)V( CLE K 1C fOH LIORE V ICLI FC ((11? pp?CpT; IISS??x? I V CHICK ONE(, I 30 L B 0 S OP J 6N I L SIGNALS OHE WAY I NO') DON Ff a TH NO ) 0 B ". 9 N . . OA L a T. I ] y OP 'Y) X TWO v EFR F SHAKES V H S r n t C A C ! dT 6 IRA" CtA E ) Dw -?. e o ] - 3 !' U [ sls owo - D AEC E 1. fAO Hrs L D - LIP r A, ¢ ' ..IR.. II ARNED of r aH `. ] O S N ! 5 IHC ?.' NT[PCN aE L-RAW ] DEffiR E E '' ] CSOB ItTY 0`x0I[MTfgIM16 i i . ~,- L O K-STRElT ..- . L O TSO _ ... fU3«INO S '.,/IN!!N . AL111 .._?E _.. _ g AAt GnTS iIREJ WOrIM1 OfI.-T . K '- HAD; SEEN OH(N%ING '. Al u:r CK M1G S 'B [ D q sm[er L ! '1 TYKI H AY L '. I: ?.D ID i No) CHEM. TEST y E I r? STNII EVLOHTi M ] l f "A' 5?_ .'/\ X GI ?L T[ST GIV EN `-- NF R 19t CllY1 ? T ' _ X!. .?PU•Ii LI LTi= ' Dmpto . IlST pElI]SED I ; .•: -OIHlq (9lCHYI '!, L ] x.UNDIV10t0 ' '• OTHEN ISIECIFY. TEST RESULTS 2 i xV IIGAiIY O.y.l ?-f t ARANK I' I/I?- liL/l DADA[ NO POL C[ OHPA CHfO POLICE ARII VFO IL A.11 A C D WFEDID W 7' zgfk-,, 7c-5 ?nHIGr' ^r 'a; 15 INVE]T;aATl..yp tERS NAHE BgANK ?1 BLOGe xo. 3 1N o+rL Of nvmlr nROVeo sr xquAle ?atNCV 7"1, 1 ] 11151HIBUTION. DgIG11FAL COPY SEN D TO LY0.3HINGTON JTAIE Pq rROI-DL'INPIA, WAGI7(•YGTON D9561 DUPLICATE COZY: LOCAL LAY( ENFORCELIENT AGENCY'S COPY-TR IPtICATE COPY: INVESTIGATOR'S COPY ?p' fal. 1 }l 1? qi, ? I?' ,t 'tf 4 d ? , n s 6 1 T uMl]Si FEC? n? A T DwiE OF COI.usIaN O fJ?Y vR. I ISIDH DAY OF COLL 'uN t x 7 S iRl F 5Ar T A E T IusE LJOOS -n}JP) T S Y C J uNTY y G 0/ '.,: e'P U n E ?(?L? .a??p A?/ E TY " EE COUNTY POA° ? CI ? ...... E ? OTHER ISPECIFYI Cp C D zQn ° A N ( M' LS ! DU T ET E ? OST EPI% EO 5E OH o TY OR iOW IMILES o o o oF - - . C NAME 6NO.Of ET NIGNWA •. n11N:STREFTONROA NTEPSERI NO LL LL T _ ON E EAD ?+vD ° O ON I.TERSERI- LR.4 8i[rl?c CN GREET O°PO ° {fC . . rf EH STREET ANO _STPEET E V 1. ? O 1 5 ° T CE?IJ InER1 ON ipP?IOMNEFENEHCEON GR0S5.5L?fET ) g _ IAL GU5 3u I 0-T I ? pI ? 11 AAATTT COLLISION INVOLVED: ?VENICLfi-VENICLE - ,?VENICLE-BICYCLE' -' ?OTNEP IWRITEI NITA PUH ? LU-r TOTAL HO. VEHICLE-OBJECT VENICLE-RR TRAIN _ _?_ STOLEN VEHICLE - SEVERITY ?.MO. KILLED -.O. INJYP.. OF VENICLE9 ?VEHICLE-PEOESTPIAN ?NON-COLLISION ?1-00US MATERIAL PROPl RTY OAMAOEONLY OBJECT STPU<%INAMf DF 08JER--- A AND-.-NA- LO'wTION OF OBJfR STPUCK .. EBT.O-All . 11 ???? R OG.1 ?--Y FEET O. E : i DRIVERS H.M!-LAST FIRST J _ MIDDLE ?R ?? .. _ .. R ORIVER•SNAM-1 FIRST MIOOLE`IFBICVCI ST OR VEOESrpRIwH H.CKI. L.L'_ ?. J'U-r(-D /V 1 ^.1 ?7'1/l c J Tr R.. ST PEE T AOORESS T...T ADDRESS v V, -S - N. CITY ATL 2IP GOO. PHONE O ... .. E R PHONE O of .. Rp t? CY I ' f ? R . ? }. Gt? L1FC?1-?F-1 uJv " DRIVERS LICE MENO. -..? ,, _.. STAT! 13E% OMOE OF BIRTn A N DRIVERS LICENSE NO. ', STwTE SE% 831 E `M DATE ODFABJRTN M5 °• o. Zz ACI ? IVEI6 OCCUPATION FIRM NAM! INOnE NO. - z RS OCCUIw1IOn D'Gl5 N IRM HA ,. ,. PHONE. ru ssM ?- v! ? CODES' 171 C"Im, MISEAi BELT ISIEJECTION , CODES I]I«?sgT _ I]I SEAT 8ELT..2-- ISIEJECTIG.V_ R ,NATURE F U S? V OV I... CF.. TO EH. YEAR MAKfID006F-CHlK1 OOELIOwRT-NOVw)SiYLE1xOR.-CONV.1 -74 (?OJ?liE bAp:i 4D2 V V1 vEgR K??tEV. 5V/1 TO MO°Eya p?IOVA STYLE I3 DP.7COnV1, Y1// E " EH COI LGPLATE N6.. 4A 1(3 TAT6 ILlRPLATENO. TTl. A. E.. ". YEN. COLOR LGP ATENQ ?iP.N, ?l D3 STAT£„- ?a TPAIIEPPLATE O I STATE C ENICLE IDEMTIPICATION NUMeEn, LN41? 0316 ODOMETER g? L ENICIE IOENr)iICwTION NUM ER .... -, V 3A 5q L 101 R")`!; DOOM! fR -+. oz6?3S E N PEOIliEPtOOWMER-.lAST,_..:.. ._..., fIRST .,: --uIOOLE, - N11?250 ?zM E _ E, N REOI EwED OWNER-LAST ?Rr; T?-2RILL Go0aWI)j 0. O• a >.. .;° .. .,..,.:.,o? .. woo "4 Z u N ST u I 71 , Z "TWo A Z?oks, )u NIWE AND U. K ? ...ANDADOREss of lHS eco, oR Aae ,,, .. ... _ - Q L K. CNANO! -.- -,` /? .. ;.Iv G??.I_. ?•...- CITA O .. lNFORClMlNT ACTION: CHAPO 0-4 PIA?Lj ,,.._ ... ...: 4.1 H GITAT O :i 496 PERSONS INVOL ED A D S O [! COO I _ x 8 0 F V NAME, D RESS& INJURIE Ex Aae STATD. N u ICY- C AM!• N ? Oa . U P p w a ° fnoM °f S"cewe eY TO ales wMl ,. N l ones A T S .TUR or ae oveD inoM 'TO W. 1 HADUecR+: N R?ei F Nl141N, F"OM E 5 M., I. Tn ?.. 1 ro?nmN uI wJON. cuu N ul SUr HELr "I -_ION DISAeLINO INJURY NOTINSTAILlD 13. NOTt CTEO C •AIES y..N. I. NOINIURY ] 3IN USfi . P[ Ta1AN ! 1 T. OlAD AT BCl! 4. O 1. H-OISA8LIM0 - ' NUHSlT P ].IAHT TOTALLY IV E L JLJECCTEO TED O .lICYC?IST ® T.OMRn POSITION I. O IAD ON ARIIRIVAL If. IIVIOETIINJUNV ]. E 7 A.U %HOWN 4.UNKNOWH If O HJURV 1. I! IRUf-MOfORCYCIl1 D18OINNOSTAI i 105318LR I E E. VN wlrrvetif e 7 E. 1041110N UnKNnwN 8.8LwT HILT lwIIUHf EJlCTE. 1 ?a ?. r u _+ Ny ?• ?I 4 '? '. v-""'_?_ ?-______ ?-` ?i,...8tL:4?3EIG?K('',--_ L .-?+?k?.•`fb'SSfRI ? .1?•«,..7?4. . 1 » r. INEACH PCLETHE HOf EACH DAMAGED AflcA. ----- j VEHiCLE DAMAGE -' - C--.'lE ?r -r- I •.cs' {' W 'y. i?;Y 'T ?', SHADE AREA REA OF SEV ERES HES IMPACT. P ;INSTRUCTIONS: , pHAW ANHO P T . r A H HI NCNCIPAL01flECTIGN OF FORCE O5HOLV WI31 - Q/ K^ u DAMAGED VEHICLE N O. 1 ._sE T.11 SPA scE rcnlve uAlAALe TO rRAHens r -CPCVCLES. ETC., DAMAGED VEHICLE N0.2• w y .=P! It! w -". Il. O•vuun PITY OF DAMAGE. VEHICLE NO t I IJ OISARLINGOAxAGE J O'9THER V.I. UAYAGE • Iir OF OAY4GE; IOTNEAVECLEI IEI]OISA9LINO DAMAGE ][]OTHEP AI.v OANA4E SE EPTV -A MAGE: VEHICLENO.t ?}-?r OISAeLING OAUAGc ]CI OTIALTY ANAGE II C GINCTIDNA, OA GE. a Q eip O:YA GE t (]FUNCTIONALOAUAGE t"(]!-0O A4.tAGE tIJ FUNCTIONALOAVAGE a NO lI EDGY -' 1 _ I ....?I.c _ :. A.WA4E S TOWED BY EST .O.vLAGE TOYED RY EST.pAYKF b [ y TO S t .? TO S TO Y? 1 vhV"1q '.. DIAGRAA40FCDLUSIGN DRAW AHHOWSHGWING l ORTH IN CIRCLE IN N r j?T I j\`1^/j t rv.i 1 L •. {?'U•C%?? _ RP4Aa,ete, mL<TIw ,..? _ _ `?-? _., _-eL- 2 1. [ <o °rl?R re w°" 1 ' F}., (? __ ` L i i 1 1 : ?r +? ? ' DESCRIPTION OF III ICATE TPPO ,E%50 BEFORE DURING AND AFTER TNE", INCLUDE O ON rWTO OIaGnAU E40gIVFR COLLISION _ . . , C-LITY. RECUCE VLSRI-,PEOESIPIAA CLOTH— COLOR, CONSTRUCTION OR AVA,-G-ETGI. I 1J7J_ _ ` ? ' -j rfc -'4-k-•-- ?- - ?I?A-;J--,L-.t..:- .?j?_r?? ..lJ:: Lam' _ _ ?..._?!.?X : ? r t i .I_ .,? . - - ?, 1LLt`? /'t.7L-t.?r=1 ? ? IF F ,.. C :rte ? c? lt'_ h.=?" 1?41?? _ ur POSITION BE RE COLLISION LANES ARKED SPEE0. O n :., : VE NEAOE NO '.. s E R NILE MS InCREL,fnG T W0. '_ E•RSWG NV SIR- Oq HiGHwAr NAME OR NO ' .. (p' Co I' ? 1 %D G' •yONE 61RECTON tJT +osrF9 a i, p?C RI[E 3 OCCUViE4i . `. -L 7 } t EAD F:? C / -L/ ?. In, G. I 1 NP » o Es t RrPH 7f? h t ,ED- iEO?O C C STw4S LLSI AL SI. T ' w ] ER q EO K 3 ttx 0 E TE TE T Ou 0. ROAD SURFACE IECKON41 WEATHER ICNFCK O[SE - CONTRIBU C TING CIRCUMSTANCES. HECK a E 0 E ENIC E D .+C o [ _ + y' q UP E rNO Oq ! .. IN03 OR E xI E .. f -[ CO ry f ^ V Cr.F /\ X ....._ 'CIPAR LCOUOr ..X_•6vH CL,ST_ _}?t ?/ NOtP IWt EYEGf ?} /?. ALCANOL .... O] fOLLOw G TOOCLO L '.. NO EGM - T ..:SIGN?SIa :-.. •.-._.-__ -, µERTAKINGE? t 6 ?N0 .: (° y .. ,, ". _, ' ] WET ?• ] SNOVr' t IIIG yl' VIG UNDER WrLUENCEOV 2 ?. OROGS. ] FMCEEUINa STATED EP C111 e INO TO 9 APErvT t OvER q x0 r 4KIM I I T TURN NG ... .... K0 3 ....._ _. _..,. ra. S _,.. ,... YEEO LIUT„ .. E E G EL,S 3 EEO TPM ". ".SGNAL PORE O n 0? T O ..LOCATIDN_ rR 1pyOIEECi nECW/)j _, Xtr LEfT PN - f?5 N TU- -&-M16 y OTI 19f< f O iN IY[C 1 TO [ C. G II Ic ICtD .U G ? ? a W f LA It f '- LIGHT CONDITIONS T C ` Y R vf - ] O SKEW 0 TO G SGNAL 18 OT P 5 i< DI 0 0 ?V I PEDFOR < + 1 • f -';: ICIIlCK ONEI RAFFI CONTRO b]vEH CLE - TYPE OE ROAD rNa] I.,. ROAD VEHICLE CONDITION ^I I S08RIETY ... E - sTb 9ArsIGV?L j' _ ' • t ...I PGIAtt .. Y VILE VEHICIF F9 §f?.91 ? IND.] x? Y r I for vHICL! ICHE KOEI 'ND ] OH 4 SIGN tD v W 9 ?. ?,I ' t D IGHT ---. ] Sr4Y -...f Y x rNq Ar • - _ OLf ECT c _ '. ePAKtS N AI LDITY /1 A xa IN START TR fIL [AN[ i Nb `--r fUA 3.. RDA. 30 f ?._ TEI I I .. t MEAOCLIG EIS I ...? Of I ED NO - A CUMSITIOI Rr ] OU K ..: _, e .... l0 Tf GA. R ^A. ..RED ! µtl? e PI CHA 30! _, tAOP PAY AL", ], OEPERIVC PFM LIGHTS ONE OOTN RD SOeRIETV ] -UNI E NO INKING MEP61N61LHTERINO TRL,FFICL - S eKKW6 { f T. f ,OMTSOfiF E AIL,, .._..f TV wo uNLI r S OxR FV wni INOEL CHEM. TEST .H 1 6 0 K-n0 X .1191 MON. . [. O fK R/ _ RLAGIAN r . [ ft1 _. y I, ? K O I IS TLST GIVER OTIL P IWEC IfVI '? r -} I R [ OT E 1t r ] -?!O T[ST PEPUStO - ± 1„ {{ ' 0- isri-I I . .. NO 9[ .1 ] X unOtvlO[D : OTMtP ISP4C RY TESTRESULTS Z /Ll j, (_ '.," p g r CS 6L, YOO C[N'f NA4Eb • eAq•e NO. R ? N) CEWSVA, O FO U ILO* r,. Tn •? Ae,i -- Nri ryJ lp ,Ir -r 1?i ?wEr1? ? l. M , ?I c ?n a 1 ? n enlwnNGO f t sNAV u tNO. ' tncr 5 r aDe f ? rt or lrtPOgr11 CA ? A PYnovm nr Ru+rE gy _^• b_• /, r ? In l;.IT"' vt , H L,.+' P GIALLCWV GSEND TO Ac(vE WASHINGTON PATgOC SNING DUPLICATE LICATF CCP`CVY Y: : LOCAL LAW ENFORC[NENr AGENCY'$ '3 COP- TRIPLICATE TETF COPY. INV NN ESTIGATORTOR?'S .. COPY 1 fR i1 L 1 d ,iF t? r k? L ? Id la ? k. E t 1 f? , 1 1h ?1'+( Fi 1 '? i ` + I a I } 1 _ 1' ? } f r I • r 1I - - 'r_I, .3 1 r '1iIS - i r 7, Y?r - uy. • - - ?* ....•...., .- .. ?:" _. „+-, ?`?hY?M. by r - M13 OTOR VEHIC . ' ' LE COLLISION REPORT NO- i • DATE OF COLLISION DAYOFCOL LISION fl\EO pLLISION rv n COUNTY O ""NO , A O1 nr\I T • / .lj r V A v UN Y TOW.. .11111 LE _py/. ?yn/?? ¢ ?f ?CITV, ,riUtIN 20 L'J E'l OF /?A?[ Lll_?C'_L_L4 " GIVE NAM1IE OF STREET ROAO ON HIGIIlIAV •~ ' " pM CLS PREFIX 0 uEtrco E TION /o1t S r •OOti , N f. -ET OH ROD ITEHSECNG I1THST P[I[FI% EO •ArLEPOST ? yy,? F--T' NON INTE.SECTION-LUCATIONOFCOLLI6i10U ///??T illy lt ee11 A BE-EEN ST L R EET AfIO fT [63LSnL[LS]?. O STREET RAMP OIAGRA40ATA ^ I {L=rilr.? .r•. .. ... ?,. er ,.. ?e+f S ri•c v ? H NiE C r r°i .U°, c / ll^? OF IJ 1\ O + ` I--L!_L vn D a ?? L 3 • 1wa ? .? ?nr,r. rt,r,r[• L it ?v[ ' ?v[• f/+ SPEC.C BE USE ?v.r [o utCrn aN nr. LLrs °x OIyryEH OF OB i? OBJECT STRUCK • ^ ' JECTS NA^ ,E AND A .D ES u LOCATION IN ROADWAY N?E o s ro loe rx .- 171 .. FEET SI W E. ? tT S 1?CN G . I ? b 1 ORfVERS LASTNAME FIRS g - TNAVIE \ MIDDLE pRIVEg5 LA3T NAME FIRST NAME -- MIDDLE 36, + »Y en STFlEET AODREBS - t .. N - .. } ROUTE NO. AND BOX NO. 177i, -5 CITY STATE P ` STREET ADDRESS ROUTE NO. AND BOX NO. y ZI COOE LdJtene wA 4$376 DRIVERSjCCUPATIO CE7CA S„? ,, 4-nr CITY STATE [IPCOOE ORIVEH$''=UPATION M?c k 4 4 (15 WA M io YP z, , c. ArD , / CLEYR 1'7 MAKE K D To eta. MODEL rx0v, ?•r- u c kxrr UODYSTYLE R0r•. ? VEHIDLEYR. MAKE K ev. 00ue MODEL rr,c,.PAxr UODYSTYLE U.. / LICENSE PLATE NO. STATE TRAILER PLATE NO. X N 16175 WA STATE L ICENSE PLATE NO. STATE TRAILER PLATE NO. STATE VEHICLE IDENTIFICATIONNO. HYMUC°lts,°Enl Pl A 2 1EG13TERED OWNE ?Lasr xru DDCE wutr ODOMETER ?,rrtt - q7c c DRIVERS LICENSE NO EG:S VEHICLE IDENTIFICATION NO. I:an NOPt LS SUFrverrl ODOMETER Nrltacer T R a ' (<rm i k IQ Set% J3YNERS ADDRESS ISTREE'r CITY ANDSTATE . I DATE OF B . EDOWNER rus:rrxsrA•iDOtexwO DRIVERS LICENSE 110. , IRTH RE. E-13 ) en t A 2 ;o s=ue 'AgTS OF VEHI LEDAMAGED , a L E -RS ADDRESS r3TPEET,CITY ANDSTATEI GATE OF UIRTH HD DAY Y PARTSOF VENICE DANA ° r F: E Rumper.rrnd?r oo?fW S?C? s%x '`OtCO g a? t'klE So LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- 'Al THE.I_ AUTOMDNILE LIAUILITY INSURANCE YES ? NO COJERAG=.N EFFECT FOR THIS ACCIDENT ON YOUfl CAR VAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY INS R [ U ANCE COMPANY "' ((rra AD99 2 fir x9?E=a fcenz5T9' S. c e M' "' F r Jm L _ a m - VAME AND AO4 G SS OF IABILITYIYSURANCEAGENT CUY STATE EIP LIADILITYPOLICYNUMBER FrifZ. -Tcra 40.0. R,,,/ mz9 ,nmrJlCllr, VIA 45t-,q7n 3cLf1_ r,,,,_J1l^11_1A?-J Fz . " E NOI JURY. IUSE SEPAPA E 0 ORA 0 JUR E31 AGE r .. ._. ._ -... - . ... NAME T01- 1A.e ADDRESS SEX • -' - .... .... M F ° ES -- - -_. 3EX E M C1 E ,..,P.. ?? .. STATUS OF INJURED RIAgK FIRST ONE THAT APPLIES 3TATU30F INJURED MARK FIRST ONE THAT APPLIES ? ? .•L IN VEHICLE IN VENIGLE KILLED nn?ir hrw rP x nw+ KILLCO °itiriEr nox,^xo+ ° [po 0 .. ! Nf ... ? 5r?rr. 6?r a? Orc`t r=.lo[ar, .. N°. r rorr J ? ? 5 ? 6 ? 7 ?c. IIOW NOHfH BY fIROW IN CIRCLE ; DESCRItlE, BELOW WHAT HAPPENED: IREFER TO VEHICLES HY NUMeERI r IxOKA•l°Y,H FO•, ,ut ° O ve hlcle 2 was .+rauelr'nq _ sloe 1}i ,.c<RrID [Lrxl,»,r;,,,"; ahead o cehi ,D°» SOLD[ Dr ,c[x. 1. xY ,•xF?,[H YtxKIE .r° ..° a lE E cF vehLcte Y .11efan s/awinQ_ a,D ° I, YrL..P dcwn buf 1,-- -.? ?F 3TPF[ sudden[ req lczed_he,? an black ice _ crud- u oul _geun. able fc Vow dow'v-, Feu d vedlicle 2 (n:.t . co Te rryht rEeu cF..uehlc(e. ..?__--? ?'hcrnctyl<Q, Rcl. 1? '. ? t t 1 ? ? A +r ? 1 VEIIICLCS POSITIONS BEFORE COLLISION » c?i Lrx .s. Lwwi INYtSncwrlO xY - \ + t VCn CL[ H A4 ON31IICETOft NDHWAYNAME OR N0. 'r'r ? +iwol ?rriira ! }y i, ' xn IYOURI x??5/? ?_ ??'Hor_ad_v._•ke._.Ed l,r., L? . D ?t??° I LI;.,.ct N--..,•A„Dr srel C 'r, '? IO1HFf!r r n7 a tJ -. ? ? .JMt••Hr P^r l ' PEDESTIEIAN C, '11-1 ? ALONG + G I? CRO33 G FROM O 1 4 „3 'To PCDTSi .IAN WAS USINEi [ ?.-__Iwa.a J ? x...n•. 3 ?,.__ . ?_- ? fi ? - pyV IJ ; ., `J RUAq SURFACE HER LIGHT CONDITIONS I1IAFFIC CONTROL TYPE OF ROAD DRIVER VEINCLE ACTIO S Cagly I .. l. •r e • Lt 1 Yil + :7 n,tr n, DAYLI .Nf w »[I.r OrID..... f ? J A41•' ?' t :.141 L U.rv I .\ •NG 1ITAwN 01 ~?3f LS C) I agNE '/AY ...... ? 1 ?OOINO ST RAIOr17 AHEAD f 1 I J. + S I 1 4 ? J ?3i 3:: `I F,? 1 mo YAY (?I W telIl ? 2 []OVERTAKING AND PA93ING . f C3 7{j ??.yY r, t ) V rJ 5.1:1 T? 00 rNE. J ? L _Xi JO .IY ? T ?? [lR5 TLI Il0AO sIRLr fl 3 E] -KING FIGHT TU11N l IIIIANGE rL''II 1 I NI C, .E.. 111 1-Y aI f K (` '[ 9 r .:.I' .r• ^r ? 1 ICkF ? A `-1f L ? A ? LOOP. [I AMPS LI 1 []UaKINR LEFT fIIRN`'IE N' r rN( # r» n ( IIIA ( 1 T C-T 3 L'T1 :.{q [] G I?? ALLEY ? 5 [] VAINIi 11. Yt1IIN 1 t Y }k'N r I I 1 fM I r. 51 _ - - - _.? I Lt I t\ LJ, 4 ?JI El L..1 Yia ?rY'All P_4.I. [] I } rlA 1' iL SLTY. N.i II` I 11 L YFO [ T3E1 f[ Nf.IH /L? a V'. ?.I. /?/ [] I [] STOPPFO r0•I TRAFFIC . I f y ?yll '4 r Yid not seg. ILE2 _.- _-._.? L_lA? l_1 L Y \tffl R T:]PPFfI AfM1glIA4 / - 1 ??A t41 "1 ? ?en STOP 3rrrnl 1 1 ? L7 STOPPEDIN IIOADWAY t J ! 1`'? ?? 1 LAI1t11 t UPS O11 l? aI IvnEO U ? ?n? ,?A••??t f I, I /. / Y >r''s'rl? > 1 FI_ ( ..HL I_J E I J V (f (1 f-l q rl TAII TINE N Ip f ??d 4 f "f1' „Ir?r r'r'V' .tr.?r :;''- r- t 1 AFe n ; 7 -J 1,0 lY ?? r LS a.n; .4 ?R, 7..' 4 ?J ,r''1,.1 .?? 1.? . xd r J 1 T?1?11yi I?f 1 f.. 1 Jt E?v, lT I /p i Ila Fol. ?, d std"Y ' 4.' :,ib y. AWN, y 1y ?{ i ?1? "off pae . DAT Ol115lON .'C DAV OF COLLISKNY i1ME COUNTY ND. CRY fq . FHWA AY YR MO- " 1 SUN i MM 1 IULS D WED DIUN S Ffll SAI EaOHUUPI J _ . ?URBAN COUNTY J STATE ROUTE PA COUNTY ROAD ?CITY STREETI fT O ADM CLS PREFIX ROUTE OR STREET CODE - - U UL 5 CTION r - [?•T'•?«+SciY(,i • C3 OTHER ISPECIFYI y - '' 3 O r CITY OR TOWN E ?IN W PRER% E - MILEPOST O ,/? t? F ? C] [1] 61 5Q / Lr U .: - c L._ O L-+^IIES 1 - G-IL? LL ... , , ..- ,_ NAM 0 FSTNEETORNKiHWAY :.-..:. .. :. INTERSECTINGWITH:STRE TORROAD LL P UAGRAA, DATA ...._, RM ) 1 D NONINIENEECT ACC DENT T P ON 1 RU Cl + -ECTING STREET OR ROAD OP REF.. EPE IX : %? F • r A J MLEAGE . ' ECRO SST RROAD N T L BETWEEN- ? ___.-.._.___.. STREET AND/L 6v MEET LODE 3 D15T. EiI RECT10NFROMflEFERENCEORCRO55 T.EET MILES N 5 E W S PEC JO OUSE 3. DFEET , Y N 1 ` COLLISION INVOLVED: ® VEHICLE•VEHICLE ? VEHICLE BICYCLE ?OTHERIWRITE) C] HIT A RUN SEVEN- NO KKLED TAL OTALNO NO ff? ?VEHICLEORIECT ?VEN,CLEflfl TRAIN ?STOLENVEHICLE OFVEHICLESI _ . O.INJUREO ?J ? VEHICLEPEDESTRIAN ?NON.COLLISION ?HAZARDOUSMATERIAL PPOPEfl1Y0AMAGE ONLY OBJECTSTRUCK(NAMEOFOWECT5TRUCKANDO NERSNAMEI LOCATIONOFOOIECi STRUCK ?:;,: - EST, pANAGE,;. CIN ROADWAY FEET ? ? ? ? N, EDGE S e OWVE DOLE-_ -, O.:%_v ORNEf1'S RAME LAST 11-T MIDDLE-NF.DICYCUST OR PEDESTRIAN .NECK) . «! ,p !R =.Sc?/U D R ? . Sfi/j! SCIOTT T . STREET AOpIC59 :-•..: .; ..^ -:. .. :':.. ... .. STREET ADDPE55 ..:..:.:: V /[/ a?_d NLIJ v GGc4 Xle /70 E R CITY - STATE .... ZIP CODE PHONE N0. E STATE. . , _...., ..: ZIP CODE :-.»." PHONE NO. 5??777t, cc?f1. R lJCTf/?CL.?_, . v&e,// =?15J/ N K—NO. .. URWERS DC STATE S E D IE A OFURTH N DRIVERS LICENSE NO O. , S T lO ? ? ZC-A • ; ., M ip C^AY ,j O r 3 e AS OLGIMATH)N FWM Al. N- :....-:... .. ... PHONE NO, Z DRIVERS OCCUPATION,.; FIPM NAM PHONE No ?71z[/J . CODES > w ,NIURV TAI SEAT BELT_Z"_ 151 EJECTION- cuss. U ODES 10 - G' NI SEAT BELT 151 EJECDON ?. __? :- NATURE E OF ? PUU E5 = N Al FP SCEN W M ODEL-NOVAI -CONV.1 ECHEV)MOOELIDART-VA) STYLE120RLONV fl G ? s O v n2 - v. o E STTE TRAILER E C. PLATE NO. .. STATE : TRAILER PLATE NO.,- STATE- ,_.. C ; VE IOENTIFCATKNL NUMBED :...:+ _ , - - O OOMETEfl _ _ ..... C VEHICLE IOENTIFICATI N NUMBEfl ' HEGLST; WNER-/LAST - FIRST MIDDLE.: - " REGISTERED OWNER-LAST .,_ _ .......... ........:. MlpplE ' o; i9C<«rG. o; 04L`_ ?.l> ?v?KIS 7s?. ApdiE55 OWNER ADDRESS OF NAME AND ADpIi OFPLSURANCECO.ORAGENI NAMERNOAID4110 SUHANCECO. OR-Ell .. T 11 , ? CHAR ,. GT ATION NO. - ENFORCEMENT CHAR E .. •. ..: ., „ TAL I ..-. ACTK)N / ?` ' -z--fn / C,/L-'a..'t C../•'i ? f?i ! /yT?S 7.1 NAME ADDRESS & INJURIES OF PERSONS INVOLVED Lopes' I - , _ y A , SE % AGE STATUS N T EJECT. NAME. 1 ) -^ ? C ADDRESS i?+. _ ".l Jy I N / ? / D P MJU AIU1Of SCENE BOTPOM TO A ". T NMAE: 1 1' /' /? ADDRESS.! NATURE S WALE' Dwm N .uw,E SLI HE RI R .F 1 r J TO \ G ,() 5 NAME. .:.E-i' _1JC<ATL, ?• • • S Y ADDRESS •, .?1 1 _ - /L /I 2 3 !C ? , Z % ' . SI w , B f ) Y111 u , RV +?- e' A Tp ?- 1. I I II STATUS IIISLAIPOS ION 11 IJI NLJURYCU55 ILL SEAT DELT 51 [JECTION C 1pPASSFHOER INo ".1' S D,SABLIND INNRY N LNOi MSTALLED USE NOTEJECTED TOY [C 0 R T L L O O D O,EOMIIOSWTK I / f E'OS iOLE PUU?Y USED N TED 0J , E d 59 _ M 1 A r Np WTj POSRK% i UN fARI'RE S EA ELECTED ?P . { Fx4 A v E , a 1 ? 1'1 1 f IH ,?f'1 yP YIi ???r 1 I-I t? r I )& Y. 1 r ?I ,i '3 I I t Y: i ' fi ?r? rv j? plo D, K e? I VEHICLE DAMAGE +-s? ? 1. IN CACN OO%, CIRCLE THE NUTAUER OF CACn DAA AGL? wH EA. ""+'-r INSTR UCTIDN$; 2. SIEAOE AREA OF SEVEREST IMPACT. J. DRAW AgROW151 TO SHOW PRINCIPAL DIRECTION OF FORCE. ni 6. ? r F 0C r -? DDAMAGED V?EF?HI-CLE NO.1 wse THIS bPACE COx sKETCHINC DAMAGE IO TRAILERS,MDloxcrcLES, ETCH DAMAGED VEHICLE N0.2 y ? T? +i I, ,H000 9 Is •"x IEU Y )nr ? 6E FHOITY pF M GE V HICLE NO.1 FE''TI SEV ERITY OF °AMAGE CLEI SEVERITY OF DAMAGE VE 1) +^ BLNI G G }I OTHER AGV AMAGE ) O O IING °AMAG10ETH; EO OTHER M V ...AGE I CJ °ISPBLIxG °AMAGE ] O OTNEq M.V. ° °E FUNCTIONAL ] DANAG E LL1I > n S UN o > ? DAMAGE . ? NODAMAO ?JIF TOWED BY Z-4, 1)Lf AGEST.OAMAGE IOWFOBY CT AESl. AOE DAMAGE TtlWEOOYCT /??i ?J ES AOE + To IS NAL I t / L F= L :: s, DIAGRAM OF COLLISION I I j -.,tom SHOWING w i-IDRNOflTH IN CR E I 1 c -XA 77 T? I O x p.,. [ N x, Dr .«i.[Dt[TRIAx 1 KNN9CT xD.064 °s;wt.:, [:IMDePZ[n ^ ronD r,I D -'j - a A DESCRIPTION OF 1 c AT PRCBAEILT NA.PENLO B EF Oqc ° x ° r EcRASKfycylr E niogMAnoN NOT oNDIAGRAM. EGbgWEq COLLISION _ Dls urrv,Repuc[o WSlea Tq PEOtsTR ANC OTx rvecoloq.eoNSrqucno\fgn EPAIA woRK. ETeI PQSIT16N BEFORE CO LISION -- x. DF LANfs ICLE T,. NEON Ew EO INCFCA HGUEC E SING O STREET OR HIGHWAY NAME OR NO. IN IM.ON DE OgECTION r ypgKEO OCCU E.. / IN IS E I II _ _; E LI C.IJ. A O55 G N LxA n, S I SU , 1 e¢ ` Dr I !SIDEWALK pLJ OULOE 1I SWALK S CROSS 1 E TE _ fl ADK DIE) WEATHER_ .CONTflIBUTING Cl RCUMSTANCES DR .3•.: IC (CHECKONEI CHECK ONE OR MORE). - 'LC E? 'D q . ° .] - OR VERR_. .. OIL DIG - I NO > h n , CLEAR. CLOUDY 1 OF Ov I "AI°xr AHEAD WET ° _ hOYFPCAS LCp ° 1L_LJ1._r..v LQ.GL4Ely D 5 E Imo] ONE G -L I fJ R gFwSSI O I) 1? 7I RA NING )F DER INFLUENCE OF a ?1 F TER ASl[j_Y Jr--oaucs A r I>r Ow ?_1 SxOVIING ' 1 zE,:.NG STATED ?I_I I.. GTO 5r?I i.. OE I.. RIGHT TURN - 11 G ARKIN. _j MAKIN { 1-11_.I- -[ It -'71 a:.._. l 1 L?M2en. _ rTURN ICE L-? ^ °° I o0. .SPEED '? E .- ?_? _r OC EEOUI= ?L^'7 RN 'f(-?I1I ?I?II I-1 ? '7 B _I?1nl?L- .a IK? T_ C F TgIW OV661CQyjOH I LI L ! SLOWING _OTHER IYFCIFYI [ IY[CIr YI - 1_-. O ?'' I Pn55Hf.q I.i LIGN SIGNAL T- I _pBI ] N.._ ONYI LI)? TRAFFIC ISlElIF LI T CONDITIONS IRAFFICCONTRO LE TYPE OF ROAD VEHICLE CONDITION (' OR 1 SOBRIETY a' _ I STOPPED SIGNAL -].[] CNLCKONEI 1 N ] E CLE 1N0] ?C.-I, ON, OR C[ ?I x$1R ?CQ3 ICxfCK ONE ?)- G ONEWAY I °' I iglTt]k Dl ]E OR STOP SIGN -,-_-- E1B0 TOPPED IN i »l DAYLIG I)' M r] TWA- ? OE iGl vF ? -I HBDABILITY ' BI. NGI - BM ES__ _ J-,IMPAIBLO__?_-_ -JIG AFF ClA 7 °L ° ° scn _ I no ....... .6 A r IB-°tAo iiclirs_ ( I...noT IM. HED_ ARKEO POSR ON, ION FL' > DUS r?. 5 O f IN HAHGE 1 DEFECTIVE ?- _1 j_ [° L .LOO AMP 1 x 0 OB i E 1 I,]- 1 MERGIHO IF E NO 1 1 DARK- f [C __ -L---RFlJ1 IORNS__. r-LNK?_. .. ?.? L.JI rJJ Tqw IFlCl AMBEIIN4 Iz. Al [ I. II T [ r' OnINK ING e%.CKIN. N ... r- DARK- rFE B f ? nT 'J L Rn ,vFp if Pr (- I Y IN 1 NvOEl CHEM. TEST L- O R.._. N. _._ -._ B STR[[T l 6 Tf ) G N T C i Tt51 G FN - OTHER INLCIFYI "I { ._. _.-. . xfey E.O ; DIV D )ti-NOOEFELTS lA II TfLf IIFIUfFO T?' ^ OTHER IYFCIFYI "[' , ]1-. UN OTHIH ISPECHYI L .fin ° 9C iEST RESUL75 2 ! cMING O4KFR SN [ eAGG. POLICE A H A NU jE _. • ` I LAlC "?. a ( _ _ An iu:iocn _ R rr' flx}AI C A l NAOGt NO Alir NC . ?) On T. O ORr. OvEO BY / HROAII ` MM i II L... DATE ._ r 'D)STRIOUTION. ORIGINAL COPY: SEND TO WASHINGTON STATE PATROL_OLYMPIA. WASHINGTON GRIMM OUPL ICA7E COPY: LOCAL LAWENIORCCMENT AGENCY'SCOPY-TR IP LICATE COPY: INVESTIGATOR'S COPY F al F '/-?- ?1®? u / STATE OF a kr POLICE COAPLAINT NUM E ? ' UNIFORM POLICE TRAFFIC COLLISION REPORT 96- A A f coulsmN DAY of wuISIDN couNTr N 1 3 J Ffll F sAJ (UtlL-I V?/ql J .. I/_ -R. T '? E CuuNTY E O+D- J u s Z / 111000 } [- - ? 1 ?' STATE ROUTE COUNTY ROAD ? CITY STREETCLS P PI% HO E OR sTREET V\L• -_ ? OTHER ISPECIFYI IL A $ . r _ ? 1 // n - N O E W ?IN CITY OH TOPJN F-I.. M MILEPOST O - fl ILH: ? ?? DF- ?•=?kLI:?L+_L?.?C LWi S J`?? C ME f? ,? . I- O.Of 9TREET OR n G A CTING WITH:STIIEET ON POAD LL N 1 ® T , . •! IJJkk ?N I ER9 0 / f I L D^ 1/ /` )) [/YJ E NO 5 LJtJ L( `F /ill l r CLS REPERE CE CNOS35 E + ? E N' BETWEEN TREE ANb "e" `^ r C'1"[n?J?+ E GIST NCE ig EATION FF R---O EpCRF??N?CE Oq CHO555TREET THE OOE §f, O r ui Y f E ECI ALC I j ., LJ FEET ? ? ? W /? ' l .. OF )I 'I? ? ,??? t • TAL COLLISION INVOLVED: ®VFNICLE-VEHICLE VEHICLE-BICYCLE ?OTNEq (WgITE) ?NITb RU I N ?,?.1 SEVERITY OTAL NO. VEHICLE-OBJECT VEHICLE "KILLED $?} E a Ire, © -RR TRAIN ?STOLEN E H VICLE C<j OF VEHICLES ?yEHICLE-PEDES No. INJURED R r z : . T N ECT9TRGCK DOWNEN9O EO COLLISION ?HA$AgOOUS MATERIgL ? PROPERTY DAMAGE ONLY „OBJ (NAME OF OBJECTSTgUCK AN :-'- - CATION OF O e "+ . '- ,.. . BJECTST C ?, FIgS ?ROADWAY FEET ???? OF - SST. OAMAG6, - O RS NAME T - GE • 1 ° T ., •- -?.-_,.. - - DLE - AME-LAST FIRS MIDDLE R ???/r D,. Oq E(q^!Y/ ??J? I F PECESTRIAN CHlCK113 - l STREET ADDRESS J e R s 1 ur ..? _. 1, ?D CLG v 5a vim 7 J ?D t s . ' - . , ?t . , tZ6 c Tr V ?? 41, ' a . „ nP coDE ''//"''-' .'_•. : ._.. :PHONE NO. 'CITY STATE,. R. !7`i4?J$ll/GGErATE E". HONE NO z J + cu? rvv 771 I ER ENS O ,ST TE SE% 63RrHl OR f N MO, y Yq DRIVERS LICENSEN r STATE ,SEX DOqTE OFB yM /'7` lD G- O.?1 / W UL'h /K / ! Q 0 / fL" / /` L ?..:.. ..C??< . DAV R.' DRIVERS OCCUPATION PIRMN E + ? O EN OgIVER5000UPATI ,. UA l?!{L iYJ FAD 2 , ..UGl v Q? - D LX?? CI? " a ' _ . CODES ISI CLAL ? _ 1 SEq BELT 1?1 EJECTION CODES a ?J gTUREO (AI SEAT pELT.?c.N ISIEJECTIO V ? ' ` . , e NATURE OF ? RE E JU _ - m ,? 5 ue ' A T! R M K (O pGEKHEVI mOOEL1DA T YLFI /? CONY) E O G/-YCHE V. E 1 S..L I? GDNy.I.. k - - ?1 E ` VE C q.. LIC. LATE N4 5TATE: r I f(?L?? S AA ER ATENO F , I '1 STATE :: ?., E EH. COLOR . ?,. LIC L TE NO... TAT.., TgAlt gpLATE NO 5 TAI.g, _,. I H, ` , J ( VEHICLE IOENTIP C iION NUMBEq OD E TER M E IC F O Eq (.J1ELE('(?J U/P /y L I V 59535 __ f D G E gEDISTEgIgOVI ` , 1 1 V _yLST... .s _ .... . FIR T ,.-yAE-.,:.'T MIDDLE ?,T:?,,,, E REDISTERED OWNE { r ? q _ ASr,-W- N ... N ' ? ? I I'., ' _ ?R f-piWA'/? AODHl590 WNE O• ,. _.?).'r .i::::r_,4,. O•: ADORBS.R.Gf DWNgq /C? y , { ?? NAM ADDRESS F G 4ME NDA. ORESSOF R, CO DFAOE T vA / A?1 CH O y,J • CITATION O /Vl m` <+'?-•?J.. L.. !J 1 :. ..'..-.5 . EN OR f E CITATION.NO ?-? /UL.-GLlGc?i '' LT .H ?D?E +5 S NA164A DRESS& INJURIES.OF PERSONS INVOLVE D' CODES Z S 6 _ E- u' NAl... a P -.1H.. Lr, RE Ne ev •nDM 'A NAME, N T N DR , . OP ^I HE J S URI.S O OPHOM / JUR SC¢NE A ' W NAML: 1 ODRtSS : N Neon FR- UPNUM E TO 5 S E NA, ' 6 rll s/ l A PUS 11, ? EA:POSt f11GM SC. NP CI NP qv O C 'I. 1A.1-04. S. Pf O[ ION t 1 'OI INJURY C1.- OINJUR Y t DISA[L III -Al .ELT ' - IDI [JF.CTION CLIST .BICYCLIST a. onleq OTHER POV B YION 6 ] ). J.OEAO AT et[NL ., pEAO ON ARRIV) L , INOINURY 6. NON-OSA.LNJO IeV DlMT I1 INJURY . INSTALLED ]. ..TRY USE USED I. NOT EJECTED t. TDTALLYEJLCTFD 3 E B. WITNf SO ( US-M TO CYCL a SITIO. RN SPOSI TIoN UNKNOWN I .DIED IN HOSPITAL T,fDlSISLl INJURY .,U NKN .OWN . PARTIALLYE -too A.U O IF 6. GCAT GEIT FAILU gt ECT ID EJECTD ?A? Ii1,W J ,h1i xl>i I LIT > ?L 1 ? 1, M1AY - J - i l.' kJ ? t f r - a UA ? J'',,'{ d y) r l?l Y?? x n -'. a SIDE 2: COMPLETE REPORT ON THIS SIDE. VEHICLE DAMAGE 1. IN EACH BOX, CIRCLE THE NUMBER OF EACH EAMAGED AREA. INSTRUCTIONS 2.SHADE AREAOF SEVERE OW PRINCIPAL 7. DRAW ARROW(S) T SHOW PRNCIPAL DIRECTION OF FORCE. EXAMPLE' 1 1- I? ` • ?'? i-' @ l _ DAMAGEOVEHICLE NO.1 naa.c¢s. MOra°crc Eici °AMac DA MAGED VEHICLE NO.2 t .. .. x i i . ! s 1 1x noAY N -. ; ;? HIO T HL 11- _ O Al D 1E _ Y . 1,O Er ' I EIE Sv of DAA...E: vEHIC; [3 OTHERM.V.DAMa O E ] [ FUNCTIONAL DAMAGE e n NO DAMAGE 1EQOEAeIIHG°AMFAGEX JQOTHERIM.v.DAMA°E 2 TI O E A]NOOAMAOE SIQR-ABLNG DAMAGE'CLLN D0.- A.. FUNCTIONAL DAMAGE <QNDDA.- TOW- cD Y ° ES M T WEO OY er OBY u S EDT. DAGE e TO o OV /? / f W .12- co DIAGRPM OF COLUSION I I _ DRAW ARROWSHO WING - "1O I NORTH IN CIRC LE VS e.es aNDwr. FEATURES ee ( ?Y? I OW 5 ESiN°c°rAORnsADwav ZFTIC _ y I .. oi;srCOlu°ciio°r".s HCE' p I _ y I I s E ei I I FND-LE POINT OF OR 1 T. OEM Ci POSIT ONE AT IMPAC 4 t EI,Ow vNOBABLE VEHICLE OR PATNE AID-TEACOLLISI.N. + H DESCRIPTION OF COLLISION LA.FEN Dare pRE I- N I L INFONMAn ON ro maclAM, E.G.DIVER s COLOR cansincurno:. ow ai nIN w°RK, Eru .IS°A'a uir .NAT ce°D BA sl sr " ' £' tG ? ? 'E 5?-l?gLr:t,{D d.cJ Tf{p - •D .. _T£?GE£ .... POSITION BEFOR rNa o0o E COLLISION . - ...,...., ...r_ .._ MILE r3 STREET OR HIa Ar NAME OR NO. , n?o o Ina .7?oQNa CB I LA- `r DrjEaT ) P E 'L PA EL pR,o EB N eO END p p x _ ? ?- ? ?".: -_ - , , O MG 1 .. O n [] ? ? p EO. ? ? ? R I wAY NE O E ET 1 a ALO1 [POSEIN N S E. COP _ or IE. TO wl I ?EIDf LK >p WA-Ar >p al,ouwER .pMARKEDCNOSSHALK' Ep INMRKEDCNDE w.LK E?DrHER_ ROADSURFACE 1 DRIVER N° WEATKER 1 -Y DY CONT IvE - 'h°? DENCEOI RIBUTING CIRCUMSTANC (CHECK DIE ON UO1 RIVER ;°' FDLLDwN O ES„ R O p,>? R N. H VEHICLE '(CHECK O O 11 A6 ET 6 pf SON 1 ER AND " a > p EnDw pE plc( RAINING > ? Errow NC A El Foc p] pOADQj INFLUENCE OF ] p SF_ LtM rETATD K ?E..?`H°J: pR[AE p,?B ERCENi¢R ? B ? sI?»: a TD ?IDpIMFRa S. TURN p,.pAFPANENTLr AELEFP p IEp LOCwi OR YANK NG OHIOOe.E"AO W'FOUIF ? ? ? O ? TDKN D Nlanl ? + ? NO LEFT !ftA "N 13 B ? T €eP? MT CONDITI NS ICHF.CK OHtI r ' B ? nfRl n r TRNOFI enOicL[AOL O 1 p SIOHALE p F ?r ',„;G EANT R w B u.ROFERPAEEIHa v cu.TYPE OF ROAD RMOREI NO aICNON[ wEUKAlONEO ?„ ? ?o. STOP x DI DsraP EHICLE CONDITION -".LE ECKONEOR 1N0 ,''O CHCONIn InUT[°I 0,,0 B o He L-A.n -.SOBRIETY... VEIIII??1WlI.F-.JC1HlS EI YY ?L((??I7// •• `a pep MAKIN31I:TLRNN 0. 0 cLDwiHO ' 0, 0 NAL ? B ? ON MOiEi6N16 pDArL1aHT p > ?E,DPE1aN ] TwoWAr ?O[ EC,IrE ,DNAKfE pIpnROAEILITTIMPAINEO ?Bp?b >0DAm ?]pYIfLDEIaN JO.-IIElE1LRO,O p]p?G„;;IV1'E" >pMVw"nFOTrnoT p,OpiN;F CLwNf DDEK ?.?FEOH1Na p,?.'T':q:v:Gi p]pa,A. ONiB Ol0HRDSDE.EIYU.IK. ?1OEA E ? ?IOMiY OM tFT p 6 p Aysi";"° ? E p ALIFr p A ? EVOOT ONN ON ?A ? DH,N[?vn fEN pl> p in?FOP C° IFNTER,NO ^?°lo".."E O:: Er ?e pRRBmNAL pe ?:6Y'WAVTLaIT , pa?" u"rDRED Dr. [N CHEM. TEST pl,p eaeKIND _ - , "L' [] 00 0 p T , NFFUSCU + YNa 0 0 C B pcO N DfD RItR 15PlClfrl r. SULTS TEST RE ? ? OrHfRl srtulrl ,'OAT H40 rIG[1TE rra ME A RANK I • w LLt N D?( .1GL D15PA,CIIEO = I il??, All rNNVtD 111 LICE A .. >E00 HAS LAME AFHC ILUW RRIV[D? .4 >fDO IMILOED X , v[Y raATINO 1 I [nENAM<BNAYK UVr. NO INCr OFN I Y A L V,.l11RDV IIVrv: UHIIYIrvHLl4VYT: OCrvV l LFYICLUYT. LULHL LFIYY ENFORCEMENT AGENCY'S COPY-TRIPLICATE COPY: INVESTIGATOR'S COPY 31 .1 uy? • +EAlll ?. rl t l m 1 ?ip m ,11? ???rrr??? YF -1: t 17 W?'?'"' j _,: A..._' ?.F.^M._?. _,_s_•.,... _ _ p.. NE3'!i4? _;:..;_, rs ,A.?.J,.,..1+?TaE"s!.3t.-.-. ?..'?' . - - -` i.?.i?:-, - "? R STATE OF WASHINGTONFFAGE OF 9lIO J ' 7 POLICE CO AINT NU / UNIFORM POLICE TRAFFIC COLLISION REPORT .7,?9 D Y GATE OF COLLISION DAY OF COLLISION TIME -NT". r T O, (D =R. un 1 x J s FRI E sAT IUS I?1?,i F) J _ . E vCUI Z ? STATE ROUTE ACOUNTY ROAD ? CITY STREET O ACMCLS PREFIX H EOHSTREE L C . J \ S`? ? OTHERISPECIFYI N 1870. 1 T L N s r/ ?'clTlr(?o/RTOLIy?N EFI%Ea MI EP ST DATA C r LIILNAME b?N O.OP S?i a 7`C TOR NIGF .. INTEP9ECTIN6 WITH:9TREEi Ofl qOa U' OE NTE IN. T ON -nAo d ? _ a s C t "y T IN. ION / CC T P CLS E AENCE CROSSSTR Efl RR P NON INTEPSEC 6 N BETWEEN STREET MFOE FFF? ,A, • O T N ND OIgECTION FHOM DEFERENCE OR CROSS9TREET AL C O USE T C MILES ., ? FEET ? ? ? W OF U f ^ 1 Q,/( Nuni E I .,. SE ERITY fKq LIISD ' COLLISION INVOLVED: ?VENICLE-V EH CLE ? EIICLE-SIC C E ?OTHER IWRITE) ?NITbP NO. INJURED ?m OTAL NO. © ?VEHICLE-PEOESTfl1AN ??NOICOLLISION Ir ?STOLEN VEHICLE a ,1 OF VEHICLES ? HA2AP000S MATERIAL ? YgpPERTY DAMAGE ONLY OBJECTSTPUCK .:. .: EST. DAMAGE OBJECTGTRUCK(NAME OF OBJECT STPUCK AND OWNERSN Mel .. ..s.. _. LOCATION OF ?POADWAY FEET ???n OF EDGE 3,JM, 0 OL A 1, "f ! ,I OPIVERS NA -LAST ',F ST ._MIDOLE ME T ' FI 10 IIF ED CHE ) 1 711 Q. ° /tClGTiJ'I/7 U J?C?IJ/S D T?LCC(4 t t §s STREET AD E59 :•,..,. ?.... '_. ... -..: EET ADOflES - k! v 567o Nf= zdi?LsuJ.?D v 5a2? Ar SE E ... .. '.,,P O END 'V' "- x• CITY STATE :... PCO ,; PHONE,NO.-E CTY ?., ,, ,,.,: BT TE ,i.i .. IPCODE ,? "''? ? R .. ? (`t{,T.USY/ LGE .., ? 6,?Q- ? JG?GL>=YGIL?' 'lvA• IfW- ! ??' E OF ORIVER9 LICEN NO. STATE SE% Oao, DAYB I;? DRIVERS LICENSE „,. ...,...STATE SEX ATE OFPBIPT No, IN. °: ,P. l l xc le9 o. /f i 2 5 85 u? IY .Yy, NAME. , :.FIRM NAME _..._.,_PHONEND. iNr DRIVERS OCCUPATION FIN?V?L ?•? E O. ,2 DRIVERS OCCUATION pg• CODES 131 CInSITY ?- IAI SEA BELT-,& ISIEJECTION - CODES I31C?AK9 IAI BEAT DE LT-+2-x• "HEJECTION?I? ^. Y U SOF L/ NJ RRE90F E O EO ?? TO _ q.. SCENE EN. EAR M'Ry1 E'-CnE V.1 MO,O E/I(O _7,.. DVA ..SYLE 130R._LD 1 YEAR P'(?I O G - EV OE lDA YLE 13 ?" CON 1 V ??.Z Ax ?l {? Z V; Yf?Orc I;X.lle' K .3? ?Ji?l..) _ ply, ?`•'.? E E CO L ENO. STATE ._ fl ILEfl PLATENO STA E - VEN. Ofli:, -FLAT EN - TE' -ENO, 3 TE,a,J, NNN r ? `t 21.x. ?.• ? ?;; H r p H EHICL E C VEHICLE IDENTIFICATION NWBER V .} .', •C EIDENTIf ..A U E ..ru: ! 4•is/-1JT111/Jlyq_ 2•j?tjkf _ f?' ?f. A L 5[63S L 5 oI a ?. IV,),) Bzulp 43 p E EGSTEPE En-LAS ___n. 'M D E EGI9TEREDO E AsT?a _...Y...r:.+:.F.IR OD fi r W !t . DoPESS,or aw H n...a:?". ur .n?wr..w...o.3.Er«c „ 'O.. AODflES O ' j?' N?..._, • d A ....... ESS F 1NGUwANCA CO_ OE y ,: AOD ' CE C O .,_,,.JL^1 U 1 F SIU1P?1,?•?-J? J? T MRE c :?:_ e..'n...::..,..• ..... C A O • 1.: { i x. Cl TIONN ...;;1 ENFORCEAH T norv `HARUf I UO,UE- z3 /U?GLtGC?T ! Z ;" .1 Co.,. 1 _ > ] K E - NAME, ADDRESS & INJURIES,OF PERSONS INVOLVED Be% AGe srATUS N u' EJECT: p'- ..... O 's` - IIE pV ED PROM ^ F. N.TUM s f •I - r LT - p I _ A' AMEI IN T ADAUF S I REMOVED Fnam , S UREOP. W E Es, cfN Y ? ? 1 , DD ssoF ncMDVfD FHO To - IN rti E S r E D ED FnDM I S r - Rv. To ' x WI N n L s In BEAT DE LT ISI EJECTION 1 f'1 OT EJECTED ?. 9 "At 'sI 1. O IN UR I. DISABLING INJURY 1. NOT INSTALLED 1, 7011 C 3 SSENOf II F 1I N 3, I DAT SCENE E NON-DISAILINO >. NOT IN US! 3. IOTA LLY EJIGTEO piHER POSITION ]OfADON ARRIVAL I IIVIDENTI INJURY +•USlD ]. PA N TIALLYLJECTED ]F[O[STRIAN K 1 :. S EICYCLIST 6 ] UNKNOWN UNKNOWN If , T O • DIl p S W,IILII ZEUS-MOTOPCYCLCI ,,,,DON HOSPITAL ,POS3I ILl INJURY ..SEAT O6 LTf ILURf LJE LI ED / „ I TNE33 I S POSITION UNKNOWN r C ? 1 J a ?Ae 1 P`Y -• - ,yam, F` t' ?. ?J J n J 1: ? t 41 ' ?? '? & 1 4t; I J ! it i 1 dM1 1 .} r' 1 ? k r rl I r'?F. ? r t?t ) `'I?I? ? r l:y,.,,,??yY,; r 7 FYI! r. [ y8 a 1 fm VEHICLE D•F T?LMAGC I. IN EACH BOX, C I RCLE THE NUM BE R OF EACH EAMAGED AREA. INSTRUCaI'ONS• 3: DARAWW ARRROWS) WIS) TO TO SI1OW 0WPRI SH P RACT- • DNCIPAL DIRECTION OF FORGE. EXAMPLE ' ?_- O F DAMAGED VEHICLE NO.1 wsE THlssPwcEfoxsKElcN A AcE THMLEHS,MOrORCrCLEa, Er'c"i ° DAMAGED VEHICLE NO.2 aaHT I -,in 9 Unanen S GAOL nG IC LE NO. 1 GnMAD a C] OTHER M-v, DAMAGE a' T TOWEp RVC TO DD? CIAG OF COLLISION ! 11 rOOiSwOL NO OnMAGE THE300111EHIM.V. DAMAG CTIONwLOAMAGE 40NI WEODV .Ow«A E I I I ,S - - I e E 10 DISABLNIG DAMAGE 'CLE" a00THEH M.V, DAMAGE O I CTIONAI. DAMAGE 40NODAMAGE i. °AMA°E TOWED BY A's TD e¢ Zen I I DRAW A RROW HOWING I Dq"T": flOwr. FEwiu E¢ - ! S NORTH IN CIRCC LLE IT ?? ? TRA'FICC F RsOwAr ALI E CONDITIONS ,ICE FA °HsION ? + ETCI Il , ) . LM ATE PROBABLE POINT OF I PACT. i 1.-., • ` OW FCTEPOSiTl01°[`s wiiMVwR." I fill - (_ I •. SNOW PROBABLE VEHICLE OR E Y AN A DESCRIPTIONOF COLLISION : o,"s°„'ul°ALiiv°'"nETOUCe°o "vase LA°PFNED BEfDRE DU ,E.a DRrER PEOESTnIAN.<L. NG COL°onT. CO NSTnouCON RPEMII R°WORK, ET.INOT „ 4 b£G A s rrJ o ?UE ? °cJ4?m t.UG ,.' POSITION BEFOR VFF L ?' "OED ??? E COLLMON+:- IO R nME N - -?_- N<o [ 0 IN 7A1aA).Drf'ke ?p F NES DIIEC O v EED S SAFE VEHICLE ? ? wREeo OC. ?,000IEEl ? ? ? IL 10- IN,E.C o. IE. PFOESTRIANwwSUSIn G: 1051 ... TO ? x ULDEw •?MARKEDCROSGWwLK 0UNM w K .- - I. In T ? OTNER OWDSURFACE 1 CK ONEI WEATOER :. (_.C OI.p •.. .CONT RIBUTINGCIRCUMSTAN I C H CK O CES RrvE c Na ' R E ON. I LC _ p N moms, D R f ?q .. , 1?° O I., VER \ ] F IC C K ONE OF NO— A ti( T G qy r FRCF OF ,LC ' ` FOLLO III .. IT YaL WET a?RAINING UA r I-NCEOF OaOON 0. El -...G a ? enow a ? s«ow..KS a ? s:Eeu°„", rOTArtD ? E ? FAIL ° TO DIE[] oc rrpNInRKInG ? a ?iuwn:ia R,cH, • U ICE roG • 0:: e`YEFD ° 01001MPROPER TURN O,e ? oere2 (76 [DUI. ? • ? MAKING LEFT ? .0 U ^ ? ? 0 ?TO V..,C,E "`"" ? ? S'GDEG??DaTOP . 0110 0 0 0 MAKING U-TURN N CI rI orHan cI r e IM.RO.En Pavan«D n 01sRFD. RUaroP B Dr FRl rl , 060 SLOWING IOHT COND TI RAF ZIC ?N ROL VEHICLE TYPE OF ROAD o EHICLE CONDITION SOBRIETY - - ? i '• 0 ICHC ONeI' O F OI ?SIUNwIi . ?ICNECKOne OR MOREI ," c v NO'E MORE -.. eKO«e oR IN-' . verWA.rl_?-fl el - T ? ? o PPFOATSIG«AL T R w° 1 ODAVI.IONI, 0 a Os,GP S1nn a iwG wwv 1 ? [It C?I VERnnw KEG wBIi1Tr IMPAIR ?' ONnD eO fi O 00 I Ww 0 .. ? aOa+WN j Oa OrIeLOSION a ORFVl nSIBIE ROAD Oa O?Or°?TK IVE 11tA° a?,MP?wn60,r nor I r . 0100 TPAPIiC " 1 ouaX l EE • ? • ?nEOS"'"° E-l t r lNO 0 • ? spa,"n?4?pE - ? a 0 .EAN<iia rts ? a 0 NnOeonRlerr uNK. u6 1 L 0„ 0 Pwn"[3oioi^°oN M ?°O?;f e A N Oe ep J L ? ¢OALLlr ?•?600rN°RN OR ?•?On°.Or?O FeN N OIfiNTERING S ?L°IaRii oTxEe e 0. AL o O 0.1 1ED VCru«e ORwER CHEM. TEST O C 01a0111nf' ` Or _ ?OP - T} ,, `f f ;°en D_ 1 TE¢T pWE« ? 1 nA CHIN O - E r ?U ryL - -- ? 0 0 ? 0 RF[V_ K GOIRa ? 0 WAI"° 1FFE<Nr, e ?caN a Grrrea lsPEClfrl • TEST RESULTS ? ? prnrn,¢ P[Clr rl sna+nnoo rlcrP'lra NAMU NwN. o DL¢E msPA,cne Rn,v JIGLICE a•ao o I S eu AN wnm now wnnlvEG" EDtD Hgj N_ .11 - - X inVFf IOA,INO OIiICLRY N+V!•R+NK uGl nO GENCV I i .bD[ ATL Or /ILPOnT • . P O J , ° ,v k 1 ----- --- --- ------•-••••-••••••+•.,•. -.,..I rrrlnvL-LJLr ...... vvnnn-I.N-DUPLICATECOPY: LOCALLAW ENFORCEh1EN7 AGENCY,SCOPY-TRIPLICATE COPY: INVESTIGATOR'S COPY t 1 p, I . I' Y A :.L 1 V , [ 7 I ? I r` I l)r ? fi 1 .5 L L ?,•I l I i t i I A ti I, d ' 'l ¦sa• +rt STATE OF WASH] NG l OIV + No L ,.E OF t UNIFORM POLICE TRAFFIC COLLISION REPORT . POUCE COMPUWiNUUBEP - - N - o ?a xx x? GATE OF COLLISION DAY OF COLLION TIME SI C OUN TY 110 CrTV NO. FMWA TAO. DA'. ?R SUN M1IUN IUFS WE p RUIN Fril SAi IUSE T.400 NOUfll } 1 ?STATEROUTE WCOU- PDAD ?CITY STREET Y 0 A OIA - PREFIX ROUTE on SSTREET CODE S DTION ?OTHER(SPECIFY) UJ 3 /X 7 LLC.•/// 0 L OR TOWN , & E, ?' o F P REFI'K E O. MILE 1 ES 7. Qu?c c?? 5 1:1 RI-0 ®G 6,36 ' NAMEb NO. F-7TORHIOHWAY INIF.RSECTINGWITH:STREETORROAD ILLY - 11, DIAGRAMOATA J I ON 'TI4 o DEIKE pz, o O NONINTERSECTION TI ACCIDENT TER O` %FD IT=PSECTING STREE OR HOAR OR REF. I T CLS. ERE:IC CROSS GTREETORROAD N BEtt/EEN-?+LCLE /?y• SHicET AHp ?CCt7TFPOINT -4FHEEI MILEAGE CDE D O '. DISTANCE ANUDIPEL'iION FROM HEfERENCEORCROSSSTREET F 1 c S Irv ?} neins PECIAL COOING USE RILES. N S E v, I? pO yy r .O UfEET ? OF ?'FYQ?.VI •^1 I??R 1 COLLISION INVOLVED. 0 VEHICLEVEIIICLE ?VEHICLE•BCYCLE ®O' ER IWRITEI ?HI ARUN 5 VERN, TOTAL NO ?VEHICLE OBJECT ?VEHICLERRTRAIN {?.. ?STOLEN VEHICLE _ NO. KILL t NO INJURED I OF VEXICLES ? VEHICLE PEDESTRIAN ?NON COLLISION ? HAZARDOUS MATERIAL . ? PROPERTY DAMAGE ONLY OBJECT STRUCK IN-Of OBJECT 1 ANDOWNEflE -E) U LOCAf10N OF OBJECT STR CK ESIDAMAGE 7 / AI-re ? N B E ?RUAO'-IAYtSFEET®.??? kEDGE ORNERS NAME-LASI FIRST MIDDLE Ds L DRIVER '5 NAMELAST FIRST MIDDLE OF UC'r CUSI GR FELES n..N L:nECAI..: D U C l?tlGl1 Yyl. D STREET ADO 55 - A I STREET ADDRESS ;, T z PAX 78S-A E R CITY STATE ZIP CODE PHONF NO. 65 E R CITY STATE ZIP CODE PHONETIC. u i tee : c -,v,4, 9 so 6 10 N o DRIVERS LICENSE NO. STAT E S EI DATE GF BERTH No N DRIVERS LICENSE NO. STATE SE% DATE O'DIfl TH . -m-7 0PC' I I \ Z??f4. yv I DAY DA VZ O. MO. OAV YR.. ?- Da,"y RS OCCUPATION FWM NAME PRONE NO 2 DRIVERS OCCUPATl N FIRMNAME PHUNENO. - `.a://vtE1-Ji Cc7L7YLC ?c! ?CNS?? ODES >1(31 cuss 161 SEATBELT I`+, EJECTCN CODES >1,3) INJURY Cu55 IAr SEATBELT 151 EJECTION NATUREOF IWURIES --,C --ALP WJTUHI SOF M - REMOVED M-ER FF M SCENE - n TO F N E PY: TO -YEAR EOODGC CHEVI MOOEIDIOVAI STYLE I2 GR.CONV.1 VEH.YEAR MAKEIDODGECHEV.1 MUDEL(D-NOVA) STYLEMDR.-CON11 v -77 R D E VEH OLOR UO PLATE W. STATE TRAILER PLATE NO. STATE J VEH. COLOR MC. PLATE NO. STATE TRAILER PLATE NO. STATE E? R 9" 'ZC.1 H C ODOMETER VEHICLE IDENTIFICATION NUMBED ODOMEER_ E ?25BkOZQ030 20 43`7 E REGISTERED ISINN -LAST FIRST MIDDLE R EGISTERED OWNER-LAST FIRST MIDDLE N.. Jf?/?lE N m O ADDRESS OF OWNER A DDRESS OF OWNER ?ldy?9 E 2 NAMEANDADIGHESSOFINSURANCQE CO. GRADIENT ?A2,UsE ,r/C?7/lfJAt? -??.v7a.tl N AME AND ADDRESSOF INSURANCE CO. ORAGENT CHARGE C ITATION NO. ENFORCEMENT CHANGE CITAn N .. ? ) ? ^ NE?. ,e 1. V/N(r- ?2 g0? AcnoN NAME, ADDRESS & INJURIES OF PERSONS INVOLVED coDEB _ x D I SE N AOF. STATUS W 9§1 T' I ?'L? 'Al FLT EJECT. D NOy%U 779-?' C ! U P HEMOVFFROM SCENERY: TO IN ?9 T EOFH M F n I TO W 1 A GGRESS' -- N I "V 0 R M VLAJRrcg. Y GCFNE PV, TO U S N AVE S A DCAES5 T T E N rLJ FFIGM ,n F Sr I1 .I , Cf NE PY T O r V'AllrS 1:1 TA I 1.O S?Ix>N G(AS•J I 11111AT111T I SILJFC11011 D ? PAS..EI+f.ER i[D':rIRiAV "T 16 t NO PIIURY SDEAUAi fiNE r pISM1HL11:G 1•+JURY I.IIOTtV$i ALLED I.NOT EJECTED 1 CnISt Oi ? I 5 1 S ? II i DEO H A ONONOISARUVIi E I ' 1 TNOTINUSE E D 2. TOTALLY EJECTED F ECTED 5 D b F YA T! CTV 1 1111 6 J CYC; 1 IN OSV l IL I 1 U U OS':I T. t ILE I:UU.1V 4,1111 I ( 1 ,OVI:1 F 4 UNKNOWN E , ... . ? r. I S SEATBELT FAI;VPE EJECTCG - }L A?; ?Yar? n Aai + + INSTRUCTIONS: j + RCLETHH DAMAGEDAREA w Q(' + 2. SNARE AREA OF SEVEMUM PACT. A --- HOWISiTOSHOW PpthCIPAL dpECTION OF FORCE O DAMAGED VEHICLE NO ro DSE TH n 1 S SP + I . I ACEfW SNETCHINOOAMAGE TO-A-, MOTCRCYCLES, ETC. a. I 3. DAMAGEDVEHICLE N0.2 ?T HaDB A B 1 :pool 1] HaM ihON 1 I rf ibol - 15. Trunk + ti , fROZ ? 11 n IL 8 WN1wCOPlapa S. Trunk 1 B T'? . UrgwonypR 1.OvwWm EERIT? OF NQD GE. VEHICLE NO.1 5 T EVERITY Of DAMAGE:IOTHER VEHICLE 1).OVFnum 1 QF I D ;EVEPVtt OF pAMAGE. VENClEN02 ' 3 Q OTHEH M.V. DAMAGE ISABUNGDAMAGE 3 OTHERMV DAMA Q UNCT ONAL A . GE 2 FUNCTIONAL DAMAGE O NODAMAGE ?DISABUNG DAMAGE 3QOTMEp M.•/.pAMAGE 2 MNCTIONALDAMAGE NODAMAGE 2 -CTIONALD-GE l NODMIAGE TOWED BY J)' A.I•-(.?_ EST. -AGE TOWEDBY EST.OAAIAGE TO WEDBY EST.DAMAGE TO EI UI(lr::C 5?? ^ io -DIAGRAM OF COLLISION TD I s I I _ I `` 71. ;/ I 1_ I I DRAW ARROW SHOWING vA EA B NOf RD THI CIR 1 CLE PF w"s v uY Va..rRDES CG PPOBA&EfdNIOf -? . ,1 J [[ ' - I _ I 1 I _ KT ' ..1 V / .. I+hI„ lI ~? ?E a„ r i f 1 f< ? OfhW Kl K: ROBVEEYEwCtE 09 • • - ' -.. `, L AfiERC DESCRIPTI ON OF 1INDCATE IYHAT PROBAVI9BLY HAPPENEDBEFORE. DUPING ANO AFTER HECRASN,INCLUOENFOPMATIONNOTON OIADRAM, E.W ORP/ER -,.COLLISION bISAOUtt,flEWCED1BILliY,PEPESTp AN CLOTNINOCOLORCOHSiflUCIrON OR REPAIfl WORK,ETC.) -;,;:. PO ITIO BEF R CGL ION O _ ON NO.OFLANES SPEm. HFApED VENiC PARK D MILE PO ST dR ON STREET ORHKiHWAYNAMEOR NO ?1 A -'• (NONE OIPECRON No . INCR EASING rpg fuG LEG.LLLY WASVEH. LYO NO DECREAS TEO PARKED OCCUP IED n? f--r r,?;?%v. tea, / r? -v IJ ? .r - -" ° i- `._I YES NO . 2 _ ^_ PEO _ ? ! I I? t AtOND 6 1 GGWEA OSE + _ DalEiOw+ PEO/&CYCUSi WASUSUq. rI xI? p -- -?O'---- 1 IBRWIOER , 'Chp%wA I? ROS. wa:x piCVClNE E 1 I •,. , O ROAD SURFACE,_ _,.,.WEATHER. CONTRIBUTINGCIRCUMSTANCE$_ 1 ECNWG ( ECMOVO ..• wFV - R/ESLRC? YGfIW - E :z ' f. 11 iCK ON OR -j, :.•• RR OER yfpR^44ND 3oLE" O uKONgO E-ER NO ? bmflOM? y ?CLWDY ? DP! ` CUR WfNCE00 I>` E RoF J iW? R!A _ I N J uo PASVra LJ 2 Lh 1 "'" r uwcs °"E ?" if"-l f' 1 a AfEE U L 6REE0 J Nu T f ] .__ l J_.. r', fLfrorG g __. Ar N A M PE -1 j Ce f? f00 ! X E M IOnE 6 , y,yryg B ? _I 1 -_ - - - 77 F _ __ DE ECTrvE EW LLN 1 .-.,? f i I? I oM PYw -'. rt?OP Ou6 J x ? rD SCYrvq ` -. OINPAIfcICIM.' _.OMERIY[CWI.... _? _.. -. _. ? _ [ --? ? TA?P x' T lPA? v 1 DfOR SOMA N +' I'I) E NfLT LIOH7CONO i ITION3 TRAFRC CUNTHDL vFr.ae TYPE C PNEw -1. OFROAD VEHICLEONDITION SOBRIETY --II roPFD AT Bm++u Nox-LYH?cue No rcNECk one oR MORe+ YEweu¢ c r•EC oHe DR o :'. •• I ?°? I ? ? v?,eEE Ie LCIi oN R naP CIDH 1 ?? f _l c Ew _ 0 x f co rmeeu iol ' E S =v ' wnF N wow -AD '"? I? mv'wie EUIF - - OLI6 Ef9 r= FD , 11.11 ^ I Pl M F Po g .., J i M XEp pg jT N fLABHRq D I .l' W ;A ED I- , wifKNfNGF .. fFCfIVF .. -. - ]WRIE .. LGORRAMR ] I PfAR UD 9 I.. Kf0 F1Y I ITIfNlEnhO a I F Rf j '? : lF 4!!Y _... lfw .. I .._ . I . p ONN / . .. .. ont .1 Om , HE4 DwNPY10 - f I BKRM B O if fsi` ••.. I- wOWfY LFfI 1N[f NC RED i CHEM E .T , ST, ._. uNLf DAeioY. F o.w.. x a e ¢Rx .a.el . D> ?-rL.1LVr.: a EEl LOnr ... . \? _.. EAD .R i u Awrto ' • -rzsroneN DnRnIM•eom `. .. ... ,.. . I t x _ x f ` ... . WR .___.... ... _. .._.... DID rp 0[ C e ilfTAFNY.O - ? 0!+lRISrFNn OhrEP1YELiiYj _. r +x u o f MrMq? 4pV1M % , % TEST RESULTS 2 moor w Bl'A.E AD w;E v'? ,, n ra,c .EO , F ip e w1 x00 ? ' v>[Df IAw ) D 1 - i00 ?? X i, rfq OlEf R3AAVFf Mr / SE + r - IGE- UrYiMpAI +:E wrFOrNf01f AfVPDYTp i dhlh nllTUw n on v" r n. ? ee...... .. 1;, I/( rv,..w+EurvEnrpHCEMENT AGENCY '3 COPY-THIPUCAf COPY7INVESlrOpTOR'BCOPY ' ? .. _..??• ''?'?o '_..:o?SR_. 5 +.led3d&'i..w, fY1 ?' r - Y', 'ia •"L.rati . u.._. _ ??? VEHICLE DAMAGE HE ..... 8, 5011,11 1 p wo F, ' ? A r? ? Ae rkFYNtm".,,cV=F.m'?+ F.... f'3•:. _.._ .-...-A'SL',-. F 1 do 1 i??r wH'iNUiuw -5 ? PAGE O , 1'y ' POLICE COMPLAINT NUMOEfl IJj• •. `? +•? UNIFORM POLICE TRAFFIC COLLISION REPORT •7 A - t/ • - PATE OF COILSgN ... ( Y a DAY OF COLLISION T SUN) MDI Z LUIS 3 WE , iN11N 6 FRI S SAi TIME (U551AOA )01181 Ll1 1 i j (AUNTY NO CITY NO. ?:uZ 1 I FM WA Mµ RAL 1 - 7 C COU Ntt . • '.?STATEROUTE COUNTY ROAD ' ? . i CITYSTREET o O AGM -CLS FIN 'p ROUTE OR STHEEJ CODE D GM>N 4. k _ Jefferson ?OTHER(SPEC FYI W GO 4ZB90 . CITY OR TOWN IN El I- N r PREFI% O M ILE 37 .i?? ) , . , JJ dd &"? r 11 ®•® ? ?OF MILES MGNWAY T e SS: -: -'1NTERSECTINO WITH STREET OR ROAr, ILLL N-F. D T• J A b ? , N ..OF yffiEE ON r : °_ e Q a 1-9 i 14 ON C unt Road #> , ? T ?= _ O. NOH MTEaSE ACCIDENT E Ea S XRD W CLS. E 1EflSE TWG STREET OR flOAD OR REF REIICEC 5T EET Ofi ROAD T 11 l Y N'= N 'SR 104 -STREETANOSandV Shore -STREEi COOE • L .YA fnlv 2 E ^ µ i, BETWEE DISTANCEANO DIRECTNXI FISOMEFFERENCE ORCROSSSTREET H SPEGI CO 11 :; ND i9 F t t i T7 1 +V ) '? ??jjTT?'?? ?? IfJ t X ? " MILES _104_.. ... 1 ?FEET '? OF SR . , x ¢ , A ri"T ...•n ., 1 .?.N'W: aS,dy+P•i4'.;1.r?LM"'4 . . OVEHIMeNEHICLE []VEHICLE-SICYCLE ?OTHERIWRIT EI - ?HR A.- SE ENtt NO. KIUEG _ COLLISION INVOLVED: r ? '' -• VEMiCIERR i,iAINi []STOLEN VEHICLE VENICLE-0RIECT ? _ NO -INJURED ! e n j , 1 TOTALNO OF VENICILE © ?VENICLE-PEDESTRIAN' []NON COLLIS ON ?NA2ARDOUS MATERIAL ?L PflOPEflttOAMAGEONLY r P OBJECT STRUGKINAMEOF OBJECT STRUOIt ANOOWNER9 NAMEI ;:'.`='.-:.::'??..............??-LOCATNNV O_OBJECTSIRUCK.:;;`.•Y :.•...._•='•'^ ?^ ES[•GMIAGE N SE in u r ?20A WAY FEET ? ? ? ? RD.EWE S L 3 4r . O)iIVERS AME,LAST :!..- ..:i.?.'; tUL.T?•y-w,y?.,'^y'X"-''..`-•-MIGOLE ORIYE9'SN•V•IE LFST'.FIRST MIDpIE,JIF DICYLU5Ii0R PEUESIWAN CHECKI O,RIL,r ¢_ ( h ,L D`2 y PAFF John W. o- BROPITT Jackie. A R STREETAGIXiE99 .ALrrv.'srJ• ll- ' r.....1.? '?` Z•rG--=•-?•••- :.p STREET ADDRESS i.S.t JE..-' ?•+?•+3...w ..i `• `.+.ri:dJi.-•e y 26 Helm Lana i ??, :V Court House - - E ' cv::...2 P CO E PHONE ND CT)YS...: :..:, -... ...STATE.... STATE •^ I ZIP CODEAI.L PRONE W 1 R' Port Ludlow Yin. 98365 437 2760 a Port Townsend, Vin. 98368 385383 •• ' .-OFBIRTHJ N - ..... a .:STATE;. - OHIVENS U?ENSE{IO : : - SE%< GATE OF UWTH <u.+ •'?` N DfIbEFt4tlCENSE NO: ;.... .a--.. -ATE .:. SE%,. D Y .:, . •. . . . o . . 390I5 i din 14 A f = • Vin. 552Gtk T ORNET13000UPATION .: FWA NAME,...-?• . J.?,..i.:c '.t? ..?_ M(%JENO A . 'J, ORIVEfl5000UPAlION?.:_.,,F771flM NAME•'?::r_ - r n - Y -- - EN 383 3831 437 222 Laborer Pope L Talbot Deputy SYTef? 0?' ce fs n ' CODES > (31 ICNLISURY S IQ 1'vl SEAT BELT EJECTION _1`- :- - IWURY CODES > 131 OLA53 lAi SEAT BELT 151 EJECTION-- F J _•A - - ' NATURE OF --E. - .... E a. NJUR ES RE OVED -GVL ' CENE R MS YEAR VEH BY MAKE IDODGECHEV.1.' TO MODELIDARTINOVN :I STYLE IZ ORLONV I..X . OMSCENEBY. -H YEAR .- MAKEIDDOGE{HEV.)..:. TO MOOELIpART•NOVAI? STYLE(]pRCONVJ .. *.' .' _ .. . 72 Intl 'Q Tort P-II L , 78' 01C. Subarban Van ?%• y E• J ' ARER PUTS NO STATE • ' E :, VEM. •:.. own B LM: TEND-. XN6 70 STATE::.. TRMLER "LATE•NO:. Wn STATE '.-.. ... H. VE-OLOR +. . vi it. M. PLATE.NO_..? C35848 STATE?? Wn. .., :. TR m. - H r ODOMETEfl N' (.. Lr VEH'cUENU GATI II NUMBEfl.. 6 uruxuwew.•.. OOMETER 7709 ,._ 1 C '_ Ljr VEHCEIDENTIFMAT NUMBEfl-Wuo ti TCS 266 F52 1281 i:,YS• 10684 E' 7281 B12 108 b?2 E - F - .,a.. ., REGISTERED OWNER FWST-.,•.u. >:; •s..:..i. -•:..MpOIE ; i - N'. O PAFF- William L Pauline G o., Jefferson County Sheriffs Dept - " Si ,.w.. L ADDFICW OIF OWNER •:e ! . ....,....1:T.C-<. rv. J ::: J?•.s.?.. - 2 - 6TU•..... ADDRESS OF OWNER...... ,. .. av-,vim-v....- v a Port Townsend, Vin. Court House Game , R AGENT - '• 1 _ NAME AND ADORESSOF WSUflNICE CO.Oi1 AGEM ... ... All tate--Bremerton NN.tE ANDADORESSOF INSURANCE CO. O - Homer S itti ency, Fort Townsend . ... . C CHARGE..:. .:.: i ..-:,.-::... • ... :..;. .IATIONNO. EJI FpRCEM. ENT CHARGE". , J None ecnaJ 'a.? None «"S .T r .r 4 L.I ) i 'i CODES 3 NAME ADDRESS & INJURIES OF PERrN .!NVOLVED - SEX AOE STATUS Ww- . A EJECT p T NAME Samuel B. Swanson ' ' 2 1 2 1 c" u rn. AnGRESS R 1 Box 574 Port Ludlow I. 13 2 1 U. NATURE NEMUVEU FROM TO - F uLtt1wE3' SCf NE ev a' NAME. Ted nmi Wurtz T ° APO Es3 FOB 1 Gamble Lane Port Ludlow Wn. V. 15 2 1 3 1 2 1 y d , `ti' N MOVEDFHOM PLUPIES' SCENERY TO p. • , j W NAME: kf - T ApOF1E53-. ' t H - H SOENE BV. N TO GI G j,. -s, . NAMF.• ,,al 1 - ' S S ADMSS. - .. :.CFRE MOVED_FHOM NAT R .. TO f jL ?TA? j T ' A / Al IIISIATUS 1]ISEAI POYIION .,.-.YCUSS Iq WURY 5WARUNGINAINY IAI SEAT BELI 1.NOTWSTALLED ISI UECTXIN INOT EJECTED Z 4 ) , C }PASSENGER DESTRWI :PF )' _ _ C 1 7DEADAT SCE NE DIED W?1105AT?L E tlNON OISABUNG T. IPOSJEOLE.LMIY 9.NOTW USE : 3 TOTALLY EJFCTFD N1f ECTEO UNM A 1 J - ' 1 y . •' Y-?V%Lr, LE.: . °OTLIFI E 3 B 1z`TT`ON- K NOWN . BELT FAIWRE l.SP 1 p ??`?(?,?M,, I .•.e.,.. 1 mC t IPci9 v' xkrT AX k I;S ]1Y1N{(41'41Z?d7.rtL#6. Fa y+ ' 1'?e 1 1 }tn v?wn `' WIN I I D, X'I L?'? P 1 ? li , Yt? r f),r , ? {fir ry;.? ).t !V 1 ?:i ,t •. G?fF gyp'' L'I fi'? L',i: -.?t,;.T r•x:1?1111 :!• ,"'!?y?" J1'r 1 t) ?':. .T I v I ?nl? - ? J ,? 1?{b t ,It j ,r Ly1 a I ) - 7 L V N INSTR , D twx! - k lEiRRITIOF I? SA., ? ? iUNCT OwEO.Y ?$ AS G To ' Ch THA- y?.? 7a?IQtit. d _ a .s?,L11. ?§,..WacL. 2. ENAO C?NREA OF SELjEREST IMPACT. r xx UCTIONS: O, DRAW ARROW(S) TO SHOW PRINCIPAL DIRECTION OF FORCE. Q/ t t .. AMAGED VEHICLENO IuSE THIS SPACE FGR SKETCHING DAMAGE TOT LE s, MOTOICICLE5. ET I DAMAGED VEHICLE NO.7 Huoa 1 NOaJ •. R I '' t,.-1 M O. .yt-?y ruin 3T1'-' DAMAGE' VEHICLE NO. I EEV ERITY OF DAMAGE. (OTHER VEHICLEI SEV?EtRITY OF OHMAGE. V"""' INO DAMAGE ] O HERM V.OAMAGE ? CI DEAGLNGDAMAGE ?NOHOAMAGE IMAGE I Ly DM CTLOHF.LDAMAG ?O E- .E LJ T.E.MGE+AMAGE IONAL DAMAGE AGE o AJ w Bills TOwin Esr. DAM cE roweDFev cT T DAMAGE T-Dev Driveable T. GAMACE ina um E500.0 r : T E700.0 AAI DF COLLISIOf?„ I 1 .( 1 .I 1 i .j.l (. .? 'I 1DflAW ARROW SHOWING M.+? CIRCLE iiC F r_ I CO} Q ?t xOB _ I 1 ? r rT { -i-T -1 - . I 1 j` r ±._ -'1- a width 17117' 44UI Gravf 1' road-no; der_terline : I i-1 1 Paot1 1 I i I I 1 n DISTRIDUTION' OIIIGINALCWY. SEND TO WASHINGTON STATE PATROL OWL ICATECWV. LOCAL LAW ENFORCEMENT AGENCY'S COPY-TRIPLICI 1 -7- 1A I *1N 1r 4 l ?' ?1 n 1 t '? p '? y 1 YI 5 ? i ? A• '?E ? ?4'm•,I',? t t i%1, ?`?,P? ??? ski'---'3?WVA F? `? ? A d?Agyy 1 t rt L I a' , K r , o ,P_1 I l 1 'L ,?4 1 +,} 7 1 I1J ??7 _ t -- ----------- MOTOR VEHICLE COLLISION REPORT. NO. GATE DF COLIISON W Y OF COL LISION THE OF COLLISION COUNTV CITYN[ ?? Hp PAON • AB IU+ A tUFS w[D a%P Mwut ES AM nun I 6At n : / P- PM ? - - COUNTY CITY.- NIV DLTI L ElE %W MILES OO CITY.TOWN EFiX NUVIE OaS ETCOUE . 6E 1ON .. WIEflSECiWG WirN: 1111IR801 O OH GIVENAMEOF SIHEET• ROAD OR HIGHWAY SO Urf/f f2D/.v f AeA qJ J MILEPOST NONINTERSECTK]N-LOCATKJNOFCOWSION eL ?/ BETWEEN fi-A'?/V"T'I FF STREETAND IF nOL w © 2 C AT aSEG o iw•N. © ® O OrnE wwHl ?[ K:LE B LI ? C O f ? \.4 F K: 0 ?. ?vE ? LE txMI 01 wCLEG,uEG - n, PUN 1•E 0,S Aw ? O coMlvoH ?v[nK[EP .. 04LECT OBJECT STRUCK: InAM[O/OIIECi 6,P KI.. ..,OWNEROFOBIECiSNAME ANOAOUPESS '. LOCA '' IN ROA TION ., ?N © 0 TO PEPAF O?IIECI DWAY ,. FEES E -" WIVERSLASTNAME .. .. ,FIRST NAME •... ... .. _,. MIDDLE IF -E TILA EOwvOLVEU wFB OFT-SLASTNAME . .. •. FMSTNAME .,. MIDDLE STREET AODi1E5S .. .. ROUTENOANDGO%NO.. 1 '•Ct. hvCX .i `// - 'la /'E I? h Y.?'( LA ./-f T- aE A STFIEETADDAESS ROUTE NO. AND BO%NO. 7\p OL /CT I /?On i3 / GTY.,-. STAi i, ,...:. JP CODE DRIVERS OCGUPA?IIL]N?.,/ 1'P,--?r L '??cL.J cv}. %i•?t ?le.ecrn'Y.2.. Cr'a E rF CRY STATE : 21P CODE C?/HflGu</ CUriJ GYVERS OGCUPAiM)N DAVERSLICENSENUMBEq-,...- STATE 11 DATEOFBIRi Cam, AGE - - ? v OBIRTH AGE DRrvER9lKEN5ENUMF1Efl STATE UATEor AF vEAR M F M '/s._({L-LC-H ffy/.7J 1J Ct%/?, r F l6Y /:' 6 VEHICLE YR. MAKE ICHEV:DODGEI MODELINOVA-DMn "OOOYSTYLEIZDR.I VEHICLE YR.] MAKE ICHEV:DODGEI .. MODELINOVA-DART)'. BODY STYLE (3 DR.) T„ TRPJLEHPUIE NO. STATE LK:ENSEPLATENO "STATE LICCNSEPLAtENO. STATE TRNLERPLATE NO ..y-, .STATE VEHICLE IpEMIFICAT10N NO.. •.. .11868 MODEl58 NEWERI.:. ODOMETER IMILEADEI VEHICLE IDENTIFICATION NO 1198BMODELSINEWERI DOMEIEfl IMAEAGE PEGISi EI1EDOWNE R, ILASTFWSTMIDDLE NAMEI DRIVERSUCENSE NO.. REGISTEflEDOWNEfl IIAST-FIRST-MIDDLE NAME) DRIVERS UCENSENO . vMERSADDREW ,.. ISTREET.IU1YANDSTATE).. O DATEOFBIRTH OWNERSADDRESS ISTREET•CRY.ANDSTATEI -GATE OF BIRTH PM150F VEHICLE O7A pED .'_c:..•v E9t pua vt _ •? -A ~ " I ^ F , PARTSOFVEHICLEDAMAGED RPAUnvEnKlE WASTHEREAUT COVERAGE IN E LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- OMOBILEUABIUTYNSURANCE YES ? NO ® FFECT FOR THIS ACCIDENT ON YOUR CAR NAME AND ApDRE55 OFUA&LDYINSURANCEPOLICYHOLOER .., NAMEOFUAEVUTYINSURANCI:-.1 T, .,_ ..,. . 1 -. ?aI .c ar,niF? 3? Na,i„ ?A T, s? -? ?r -G«-L•^ SA- ,an.L? Re, Y, STATE NAMEANDADCLESS OFUA&LRYwSURANCE NT 0066-Cr Gn'r32Acu ?zr ?:,.?sr«> Gc•a, JP3 cSy?• ._G7FG- .i-"i-c•n 1ST MJURY -? /t/C AIL •- NAME .. ALE T Ivscs[PME [nElroar FOaAm IOx MAIa[s, ?: ]NDINJUflY: ,., ?._ - +..... NAME AGE ADDRESS DE% A DRESS i Ks - M -? ? -- __-_ _.__----_.__ O E - ..___ _ - p a.om ® I. aas Ea Ai ° ..rKK:taI. ®0 MI" STATUS OFWJURED ?p EA WVENKYE ? u ..... KILLED MARK FIRST wp^ JTx[ I CNE THAT KPPllE "D".OMU?n1° MwORI S -, ="E COM CT Dw i" STATUS OF INJURED OOIWTa NNVEHICLE pPA5a[B D KILLED MARK FIRST Os.xlw0 S E"aE1 ONE THAT APPLIE onµnax I S r0?6U EcWnrc G irlT µ ?Mrxs "D' 0-'•+I+Warc.?w ? 50 60 FA. G 70 ?MO 51I"uI rFCP waIiE.IN' ? 50 60 7O S+OWNCIFI-AHp]W.-I, .NL.,L O •? AK[ tnF GP raM COUen•. G.'. \\ e.wn rn aK:PmAr K.MIa a orAT ? OESCRIBEBELOWWHATNAPPENED:IREFERTOVEHICLESBYNUMOERI C/J/J!<'/--FOJ- e..1.1_JIAe.__62r /1 !ei>'sc.,= a 2 _?ql-? ?i5 2F?C:•.L=?_W/FCN__LA? '. TC B f /fAC? DA%•E_,CC /I /PIE' ?l1 /'K.f ?'N fNTC \ A LFCH Wlrtt AHO 6Mw 1 down Hl.sT1.. Mwow --? ? ?t'-' ' ? . - ? > .??p tt? cN //AA 7 G.vO L !N ? ? Lccc _..- N 5 1/ SK G Z ? T ? J C(, L. ?L+- rr L ? W /! -. [.,? F A J US R- -- G +?' ? - A ? ?• IG s_/ ._ PaL ,?,J---_ A .__ G?L...I.:?l__. Na__._Gc'4 ? - I :. VEHICLESPOSITIONS BEFO VT.,C1E E RE COLLISION ON STREET OR HIGHWAY NAME OR NO N0O'D`n,NO INECIKM 4 e°pwo xOIS Z. rRwr Mlp •«<<"«?urIT M WVESi1GATEDDY ?iiiraR ?OP rOF"II[[ W N S H%.a O ? OA ? ?, p Jc / s k'n." /.. O O ? ? 0'0 . ?IOGT'UCl 131.1=111 M K I A, O O 17 O . 00 O O ?? ?.- MIKPwu ? ? ? Q FROM DIRECTION..-TO DIRECTION .. K mSTT.ANWA.SUSM 10 [EH'[fi:wFIF 60 CMri{wi10A IQOTNF.R IQ,LO[WK% 70 WALKWAY 0?TPIGAOER RDADSLMFACE N(AIHCR LIOHTCONOTIONS TRAFFICCONTROL •.KnILKOrt,-. wC 1 TYPEOFROAD_ HHIXt r 'L 'rYt: HMLLE ACTgN9 ,:,.1?... •. K L OnI OA.WIFI.? tnClE NHL1.<A OrA'I u0 , AO l 1 Q o.Y.cUi , Q DAYLIGHT r ?? S10AI AlS ?1 1. DA{ bAEI M , ? 1 AO Q .ONE WAY ' (t 1 OGHO SIRU0N1 KICAD 01 QMV S©quFINO ]Q DA- Q] QSIOPSKo, Q t (9 TWO WAY Q S Q OVERTAKINGANDPASSINO Q P Q WEi ] ? W4- S ? DUSK Q ] Q YIELD SIGN ? ] Q AAEN Ow SIDLE Q I Q MAKMO RIGHT TURN ? S ? S'O'AP t IOD ? 1 0- STRE PIG SON" F,ASI.ID AEG ? A ? MIgI HANG/ ? 1 ? DP/MMP D 1 NMOICFT TWIN ? ? MA ICE ? 4 ? c OMEN S ? DARK 51 HE41 S ? ARIK 1 .I O S Q 1LASIPKI AMBER I M1 ALLEY Q S ? Q S Q MAK MG U TURN A. 01.1 ? I ? SMCIY P PEGFYI I Q S1nt LI?10MS O S Q FIR E/ONK ? I ? lTf 01UFEN ? I Q GEOWINO RE.SON .DA NpISEEW OOANOLR ] ow. O SPECIFY' Q F Q OFFKAFI11IAGMAN LANES ? F Q STOPPEDFORTRAFFIC KIwDY•Kw INrAKrAM ErC, Q I Q (,Y.(. w,C,FY O 10 SEPARATED STOMPED AT TJELNK ? 5 ? OR6TOP.O J Q F QOVOED p ? I ELY SIOPP[DMROADWAY .. .. ... .... ... ..... ? Y QEq taU? ? ] ? ,KYIDIU ? 10 ? TAI i?Kj AN[ - _r O D I40N DAYOFCOLL OATEOFCOLLLSION TIrAE C-1- FHSVA' fTL A i M r fJ//j Y.R T SUN MBN fUf) J VIED IIIUN 5 FIL B 71 IUiC. UO HOUNI j. XRURAL COUNTY O LIITY ROAD ?CHYSTREET U A ROUTEOIl4 IREET CODE OECTItlN j O.CLLS ( ?S??'?? L IN ? E •I N s, :3 MILEMl41 I 0 r ? ?J I ?7MILES ? 9??? LSJ OF i• L ' C NAME B NO. OFSTREETO.j HIGHWAY INTERSECTINGVIIrr1: WREETORROAO W fI IJAP O:AGHAM DATA N O 1 NONINTEIiSECiION -? A CCIDENT IN TER `AN IL PIT "HER 'ECIINO STREET DR ROAU OR REF. ER C45. ERE NCECITOWSIREETORROAD IT N / ?,/ BETWEEN OO STHEEi MID/F)•E' STREET M ILIAGE CODE ? / /?• 07O DISIANCEOMDLREcri N FROM fEFYnENCEORCROSSSMEET- {? / „ g S PECIAL COOING U5E ?FEET ?_ LbL OF ./ . SFVERRY CO ® EHICLE•VEFFCLE ? VEHICLE BICYCLE N INVOLVED: ?MIi ARUN ?OTHERIWPHEI NO KILLED . . ?VEHICIEOWECT ?VEHICLEflRTRAIN YOTAL NO. -0, ?SIOLEN VEHICLE NO INIUREO / OFVEHICLES ? VEHICLE PEDESTRIAN ?NONCOLLISION ?HAZARDOUSMATERIAL _ PROPERTY DAMAGE ONLY OWECT STRUCK INAME OF OWECTSTRUCKAND OVINEM NAME) LOCATION OFOWECT STRUCKS E. W EST. DAMAGE. ?POADWAY FEET ? ? ? ? RD. EDGE 4 ORWEITSNAIAE-LAST ,. ...FIRST -,MIDDLE ICVCLISr OR PtUt51HNN CHECnI(J D DRIVERS NAME-LAST .11-1 IAIODLE IIF O. D. / ? JAG<°i1G XO/Jd%c% A -._.. .: ,....:... ::. STREET ADORE59 :.: ... .. a SiflEET AODHE53 .... .. •.. •. :.. :.. •. .. V E . PHONE NO pTY..: ,- STATE .. ... 21P CODE EE :. PHONE NU. CITY STATE ZIP CODE . N DRYERS LICENSE NO. -- STATE. SE% DATE F BIRTH N DRIVERS LICENSE NO. - GTATE 6E% DIRTH DATE OF DAY YN MO O MO OAY YR. O, . . pINER9000LIPATION FBIMNAME 'j ORNERS OCCUPATION . FIRMN NE' .. ...+.,.. „;-- P N . VWRY CODES J IJI IASEAT BELT.____ 151 EJECLION _.____._ C1A55 -.... __ _ O DES >1` CLASS---I.-.. TAI SEAT BELT_v2_ 151 EJECTION._ • NA R I lu I - NJURES L es V11NE R SCENE RY: TO EMOVeD FROM SCENE RY' TO VEM.YEAR. MAKE( CHIS MODELIDART-NOVAI :. SIYtE12 DR.CONV.I VEH YEAR MAKEIDODGECHEV.I MODEL IDAR-TIVAI. STYLE(2DRCONV.1 v $ ' i? ; • ??? >" ?? V E VEH. PLATE NO. STATE TRAILER PUTE NO. STATE E VEH.COLOR lw. PLATE NO. STATE. TRAILER PLATE NO. STATE H ?d G•Gi`" u), i amide ?.r.1• O VEH N H NU q ,: ; ? M tEP O IT VEHICLE IOENTIFICAtI N Nu UM.B R ODOMETER. E, •,. ass?? E 7.i /l?e/:4 IODIE - MDDLE REp4T D YMFA ?LASi. .. ,. -FwSi ........: HEGISTERE OWNER-L ST FBtSi .. ._ ' N O ?,/ O, L 5 C/!J -J cJG!'S ' AO RE OWNER . ... .. ,;.... ... - .. /o )h • 2 ..... ADDRESS OF OwgfH' nS ,Se 0., r?Nsn.i i??r ' NAMC AMO FWSUHANCE O, r - NAME ANDAUDRE590FINSURANCE CO. OH AGENr cll . .. CIIAiI?N NO. - ENF ORCEME N .... I A I NT CHANGE ACTION I n ,v e C r /' [?i1 r OC<•! ?4// r1 J V`? 1 CO DES 2 D 5 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED sE% AGE srATUS - ? E Ecr. C NAME. L• d%SL/1 r 1 ,.? fr , r!`• C . 5'- •S LO (/?/I;?,y rC/J .1?P?F /Cliff llJig _ _ ?_ a Anrn tss ' ? D p ? ? a . F mw o wroE4 SCfO ;Uff101 .1 10 A NAM[' T ""? rtn tD rnoM to 5 wwiArs i 1 i I I !jAtF f ADOIVS.K - Tfliuvi'n i rZ-----`- ' N . P Acnrc uY TD E NAVE E U, -5of W- S I I ' L. O Y S 2 J,A•fn r«L? Lr i N A 15 121Y1 AI V K I _... I r }?. y_ ? 1 ?? I r n p ( N61•,JWH r IT R 1. r Po qI I i ur uL ^rE r f i ..... IO clo A DED YNI_ •HrAL OP. PIf wnnlY I MO J E 'I IUD Ir I. A U , .. _.... .. h Itr 1 J h„ Lyt'1 .i L 1 f S.v T,../A 7 fl >z y, y?r,?lA y r? 1 R Yl1'.r f jkw ? t" 'TRW, MTU ? Ah' '1'i SIC ,??{1 M. 4 39q? N?4?W... I ar ?, I{ W1'I F ! r:l Y ) f ' "TNM :.L. Y __y 4 1 Y ? ?;? (? I ., I,I I ; ?' 1 ? Ir(•?i ?rn I ? l? I??TYr y y i k ? ?,v: 'I' 1 I 1 ?y11 • J ;??; f ? T L f ? t r ? ? ?? ` I I f I4} 1 H I i ? Ty, l ? ?? I 1 { Ifi 1 " j I F I kSll? {?s I r k I 1 b 1 , >1 IJ I 1 I ,? 1 i. ?ry?, J# ? !y ,, ?{ ?PJ /i' 4 (? I 1 ?? 1 ( I r l Uk 1 S r !l? 1. ?' r?/ASJx T. t ? 1 7?` Ir 1 , f ? I} f,• L 4 l ? I f 1. ?5? ? ¢ v ? I t '.tl YGL ROAD F1 CITY STREET L N f?S{ E W ?IN ]f/!) ?CI•TV OR TUwN rl-. n_, U MILEB ? G 1:1 ? 03 Of C T O NSTTORPOPD P RA M DATA 0 NONINTERSECTION N BETWEEN 0,1,/ DISTANCE AND DIRECTION FROM REFEFENCE OR C ?MIUS N S E W ?FEET OF COLLISION INVOLVED: ® VEHCLE-VEHICLE TOTAL NO r-? ? VEHICLE OBJECT OF YEHICIES F ?VENICLE-PEOESTRIAN O81ECr SigUC -ItoFoDJECT,STRUCXANDOI DR VFJSMAMEiAST _FRS I _. N " DFYVERS LIC O. p lug V E H I C L E N 0. ACCIDENT MILEAGE CODE WTI-, 4 SEVERITY ?NIT6PUN BILL ED NO Y' A STOLEN VEHICLE NO INJURED ,y . r.1 _ /PROPERTY DAMAGE ONLY UECT SiRUCX ESi. DAMRGE FEET ? ? ? ? q0 EWE S MIDDLE IIF,BIC VClIS1.ON,PLUE5IFIAN CHECn1U, STATE - PHONE NO. uI jiDj?l slG B ??SJ ....... STATE SE% DATE OF HIRTH MO DAY IN . 'I MNPM E , ., PH NEN , / ..?-. q SEAT BELT. _ra2. 151 EJFTnnN J NON-COLLISION ?XAZggDOU S MATEflIAL IN ?ROADWAY ^,•-•..._-. ^AVODIE. ORNER'S NAMEL/STFIR ^. «• I.: STREET ADpiE .,.. V PCOOE PHONENO. E CDY...; .,. R E% DATE OF BI TH N DRNERS LICENSE NO N MO. DAY YR _Q. . ' 33dG S .. ........ .... PHONENO '?.. DR.,--CCUPATION ,. Y N LIMES B : T I WV(MOODS HEY.) MOGEEry AR T•NOVN - STYLE 13 Gg LpN.1 iROM 6C VEM. M ? J ? • ]It LlO PLATE W STATE T LER PLATE NO. STATE' E VEH COL ! 62? / - H . Lt il x c WM I JIG GER ..:. .,.... ETEF VEHICLE •@.Pf3 lam( E DEAST '.. FDLBT .... _, MIDDLE EGISTER ADDRESS 1 ?ilri.r<.r/!1/ ? .t4i"iiiilnJr i J •? 2.. t n IMNGE CO.OIRAGENT p, N M M!D car' S - orr>n .Yobs CITA I Tj Al N ENFORCEMENT ! ACTION l? l NAME, ADDRESS '& INJURIES OF PERSONS INVOLVED LV , Z r?C? pA Lk. PUTE NO. STATE.; 1RMLER PUTE NO. S'ATION NUMB R ODOMETER ;A- pip 3'Gl3 s. OFINSURAN ECO, ORAL NII I ATIaN?- II COgES _-f C ADDRESS 'D SF .SP G/<?/c IniY ?,.? ir,<S <1?+1 a? ?Z I 1? F U NA UREOr ?F WJIIRlEB NLMOY[DFlIdA N NAME: SCENE DY T ADDIRESS' . ? 6 I Is ^IfNF IID n?Ll ..-- W NAME TO T A-C-1 -- N E S NAME SCr NI HY TO S Acrnra E N 1, S. A, . MISUIUS UILJAl 1.OSIl A)v v Ni DV 1o J IX H 3 PAa!rNCER C ;PLDI STIPAN 0 RCNCl13r • _ 1 A, r GIANG 11N0WN11r 3 Dr•OATSCENE IDSAp IW{WJURY IT ON DO HUNG 4ISLA11NL1 IUI DlYJ11 NOrINSTAIII'D 1 NOI CJt[T!'D WISE p SOTH(R )OTH[RVOLTgN HUD M I ]OFADON MIIWµ EVHfLN1 NAIR 11Y ' -,R : NO DU}r0 110TAlLY L.ILC'lO At E O iNCS3 OICIICYCl F1 ] O POSllIaI UNgWOATI • pIOWNIOD1yTAL r 1 OS:?UL L UNK OYYN A PAnflAlly 1.1 f.itCl X 6 6l'A1 Ull1 FAq.URE [JCCILOV ?N f.. ?Tl a, STATE OF WASHINGTON PAGE DE No. PULICC CO PLA NI NVMNERD L - UNIFORM POLICE TRAFFIC COLLISION REPORT - , • a_ •- O A DATE OF COLL SIGN Il pAV i DAYOF COLLIS ON SUN ' E i' 1ME ' COUNTY/410 CITY NO f .v. El i ? .T G S// I 1 1 IN 2 1L15 G W Ot " 5 R 0 SAi [IyK'yl( O l..l ? / UR L { _ • - COUNTY ?L . •) . - ?SIATEROUTE COUNTY ROAD ?CNYSTREET ?OIHERISPECIFYI Q W OMCLS DREfIA ROUTE OR SIREETCDDE O _ SECTION `•? T„,.a L N 5 E W 1N CRYORTOWN N W P EfI% O flJ MIL POST , )K°F O C MILER ? ? ?OF_.__.__..__...?-._ .. R 'GN V INlENSELIING V/IIM?biREEI ORROAD AME NDOF STR -. O Q U R AMP DAGRAM D ATA A T ON .obi. A . y, 'x '- y I ' NONINIERSEC _ A CCIDENT I N1EF NON IT %RD CL5 INTE11EC11N0 STREET OR ROAD OR RE ERENCEGROM STREET OR ROAD •Q .ws, ' y . 'I t O N. BETWEEN _ . ......_... . __ SiFEEIAND __.__..__- STREET OIST?NCEIIAL?NDORECiION FRO MRREREl+CEORCROSS -.1 MILEAGE CODE Nu USm VvPA[In5 S PECIAL COOI NG USE 4 S .. a A ?/I MILES N S E W ?FEET ? n N1 OFSO ,/ _? yV1 -' .. Ni6RUN ?YEHCLEVEHICLE ? VEHICLE BICYCLE ERIW ITEI ? COLLISION INVOLVED TOTAL NO. 1 `?E I ?VEH CLE OGIECT []VEHICLE RR tRAIN 'NpI1 ,??D• ?STOLEN VEHICLE __NO INJU EO ERITV NO KILLEDEV OF VEHICLES L?J ? VEHICLE PEDESTRIAN InVON COLLISION ?MAZAFDOUS MATERIAL _ ?PROPEflTY DAMAGE ONLY OBJECT STRUCK NNAME OF OBJECT STRUCK ANDOW'NERS NAME) LOCATION OF OBJECT STRUCK _ EST.DAMAGE ? ROADWAY FEET ? ? ? 1) RD EDGE 5 h T DRIVERS NAME-LAST F FI ST MIDDLE DRIVER '5 NAME-1 FIRST MIDDLE of 04YCLI51 ON PEDESTRIAN CHECK)[] • w. R, STREET ADDHES3! FF "_ ..: -" Q (i1-s F ?hr?? aa? 144 R v STREET ADDRESS ?. ,. _. _ . .. E CITY STATE ZIP CODE PHONE NO E ..: PHONENO CITY STATE: ?: ' : ZIP LODE ..: R_ . R?°olo(!14 L.A.-C. `f S33`I 385%,7 R . . . . . N DRIVERS LICENSE N0. S T A E EM, DAZE OF BIRTH N DRIVERS LICENSE NO STATE . - SE% DATE OF, BIRTH k F O. /4 'A //? ?? /? 11 H `LI E l 1 19 4i?' Q. MO. .DAY R 1 .,.. pRNERS MCUPATIGR FIRM NAME PHONE NO. 'j DRIVERS OCCUPATION FIFlMIlAME .;_.PHON NO. y RV/ . . C> III CUSS TAI SEAT BELT 1?'1 EJECTION ODES CODES >1131 C1n5 5 1AI SEAT. BELT 151 EJECTION----- } NATURE OF _U ES AT RE f NJURES EF< ' '_'"" iRMM SCE NE BY: TO - FROM 6CENE BY TO _A - v VEH.YEAR 76 MAKEIDDDG-HEV.) Qk2 v MODELIDARTNOVA) Sly b STYLE 12 DR-CONV.I \/5 VEH. YEAR MAKEIDODGECHEVI. MODEL(DART-NOVAI d7YLEI--ONV.)_ - " ' E H VEH. C ?qr? 11 lIC TE?F0 { wLtl /7 1ClJJ V STATE ??10. THALER PLATE NO. STATE ^-r E H VEH COLOR UC PUTE NO, - STATE TRNLER PLATE NO STATE ' A ', C . VENICtE JDEMIFICAIM)N NUMB fl _, 3 I f ? G O METER ... _ C VEHICLE 1DENIIFICAiION NUMBER . ss - M E ER-LAST T R D O F R T M D V , OOLE REGISTER?ED? OWNER -UyST?._ - FIRST :. REGIS WN I I pLE E E S .., .. • . ' l . " r 1 • ' i O I ApDRE5 OF OWNEfl ° ADOflF55 OF OWNED . 1 ' 7 5 NAME ANOADDRESSOF INSURANCE CO.OR AGEM . 2 NAME AND AGORESS OF INSURANCE CO. OR AGENT "?'.. - !'• LHNIGE - CI 1AR0NNO '' ENFORCEMENT CHARGE ,; ., .. CIIATIONNO ?A ? ACTION . f.; .. .,.. .. . . . CODES , NAME, ADDRESS & INJURIES OF PERSONS INVOLVED - u; ' ° t _0 C ' N/.ME. SE% AGE' _. STATUS EJECT ' A 7 7 { I C AMwE55. ICyF_v__A_\t1V_lI _.T. SAM 11 v>- AtURF OF REMUVE DIRO%- N '.• .'' { I J [ P .,,. p I N JURIES SCFNE BY T O r ' ` ?? A y •2 r I T ADDRESS OV pfHOM AT OF 1 1 { 1 5 n x SCF ES ' T O... : S 1 W NAME. 1 ri T FROM RATP a V OF S R TO "CFN OV f I E NAME _ -- • T `f M S ADDRESS y i 5 . IffLLTSF- e67R0iA T o t -4,, N I C f . r I( +'•.YL f O I IS IU5 2 P SSt MGER : LD 641c, 51 s '""'" 1215(A11'p4TgV 1_ I 1 OI fRPOVIgN AA ?? IJIIHAINYCLASS +OVUURY' Cr OATSCENC DOE OON ARRIVAL I SDIS-1.41NJURY E ONDSARUNO IE iF11i11NlURY 111111AI BELT J 1 NOl INSTALLED 21101MUSE BUSED I5IIJECROR 1 NOTEJECIED 210TALLEECTFD 11AlLV CJECT[D ] PAR ) ? S. { - tt Y• 1) {",J?? ` 'ly' 1 E 1 ,1 f D 501 R O.I 5 Ne s R OtORCYCI[I I 16-'? IIII ???III / PPOl Nq1 UNKNOWN AM[DM HO51'RAL TIOS dl[INJUM fUNKNOV/t! 'v SEATHELt FALUR[ I R NOwNIi EJECTED . rl? ?v ?! ? hi{r - 1 Ti Y 11 f r?? T ,c 9 ? rr DAMAGED VEHICLE N O.T us[THls SPACE raR S+E rcH NC DA ee TD RA tls, M0lDnc tttS Ere.l DAMAGED VEHICLE N 0.2 ? l OF DAMAGE' VEHICLE NO. I ! ORA RE"'. DAMAGE l ? OTHER M V DAMAGE VEnrtr OE..... '. IOTNERVE CLE 'o 0 SADL NG DAMAGE 300 IHkR M Y U.MA.E SE RTY OF DAMAGE: VEHICLE NO] I OD SADL NG DAMAGE ] ? OTHER M Y DAMAGE x RACE DAMAGE rONAL O ]OluncT OVALpAMAGE .?N1DAMAGE AGE . NO DAMac E ]OFunn ONAL DAM Y OwFD Br f?T pAra?E /y 1 TowEO ev T DAMAGE s t OwEO by esT. DAMA4 ------------------ (Y111G T E TO S N L DRAWARFOWSHOWING DIAGRAM OF COLLISION ? NORTH IN CIRCLE ?? ins h TRH e D,1 _. _ .. .. GH .N,L,,.M. [ Ir4,'T 3 =I.I.-IDr3;R .NDR ,[Dri,R,N.,,HL1I,DRE DESCRIPTION.OF R _ RROCIIE ATFIO.ARLy HAPPENED REIORE. DURING - ANDAIT" THECRASH. INCLUDE INFORMATION'NO RAM.ac: DRYE ETC 1 CED V S HRITr PEDLSTYRAI CLOTHING COLOR CONSTRUCT ON ORREPA I WORK v RED COLLISION , . rsA a ui U GA, C.LA' V< Rau' H ! r ' - POSITION BEFORE COLLISION no. or LANES sl'tEn v[N' L ED LEDALL !NONE 0 RECTION rDHtu T OR IGHWAY NAME OR rv0 • ? H HEADED M lF YO BEE . ARKED YE- , DCCUPIED Np N NCREAS DECREASING .. Np t YES 1. , PH WI - M ON --_ w PED RoM >.. O • 'A""' AIARIE. """A"' SHOULDER I-1-STWA sNc' I SIDEWALK v?ROAD SURFACE WEATHER - CONTRIBUTI? orCI on ManEANCE - - p - ..o RI of - NEW [! ?CHtCK D E ` KON I v?I GD _.-. A n - -YET 11111R NIYE. No N _ . p I NO., 1. -' -J GDE - ^ -I r AR o GOI I ARN ?tJ 'Ox s.INc OVER[ SL 04 SSo w 9 an w i ?\ ] WET > INI I _.] I IN F E0F I I OVNEERCE17EI APPARENTLY Jx: =TTURN i - - - - '- AR ' ? FA I ?] ? !LG D RI KNG MA SuRN G E Cf N 1ED °N 1 _..,J.. _'_ w__ I s!• E y t ?_ .._...LJ. c . ?S Loc. p -_- .-_-- ME - MAKING ? ?• N 1.?P?H?GPER R, . II ! S. .. ' -PAYING s. C[ OG - ... V .. __ - ._. _ 3 - .w _• I r D.DVNGY FIRAI ARD GRANT 49,c LG _I L SA G t 5 ` S S 1 E E, i" ? C -'.`01 E v[c n _ ' G la I ' T N tlGNA1 DLa ` I ln° Ec ° 1 Y OAO -VEHICLE CONDITION SOBRIET OF . 1 RAFFIC CONTRO H E TYP o H IGHT ONDITIONS D tl ID + 3 S 1 d ?d C ONlI EN { x E< o I 0 >ri IS sf{3 f {SL I NO xF I_ ?O WAY G - 1 n V i. I AIR L,71 Lrp \_ - - i t S b G t ] S IWO RIKE ' MPA RL0. G t w .• ._ f 1 _;. ? i ? •ianTlrvc FROM j ] P ] C N ] ROAD °t LIL US I O. _. _ I L. ARKlDroSITIUN f S IMPAIN Itrv, [RING ° ° i { fl I CI µ( 3 A 00 r - L NLI 3 N I -A. NOT .6 [ wp \ O31 ING. tlACK .0 DIS o0 1 DG T30 T .--. C _ 1"YL" CH TEST ..lG f O?_ `TC---N-T- _ nn ] tt vC - `J .•O WICIFVI 1Ir'f sY . ' . S H r LIGHTS . } •1'F F NO OCFI I ]-- S T ] R \ I P ? t vrt 1H. II . 41x1.-. rr c ` fVltl?vr S• un0lvlDIO .v TEST RESULTS 7 TLS -y.? O , , \ . e ` NI'?• ` -. T ceH' . LAH , 4 1 11 5 SA'T`E NO ;u+?NO D Cl yl;.rnl ip " rf ,5 W'i J ' O ?i?iy{yy?` ] pT C Ow. 4 J'? r. y? r fn?'?? IIDV1unr`J An S!"1 ?? ln 4' C ? `Y Ii4• ? ? ' r jy , 1- J '! I-_ i "u,?' h s •f?:M }. OISI111 SUTTON. ONOINALCCA' v SEND TO 11ASHRIG-H SLAT E PAY I IOL-OLYMPIA, WASHINGTON DK'v01 [SU1'L1CA,I COPY LOCAL LAW FNFORCLUINT AGENCY'S COPY TRIPLICATE COPY' IIYVCSTIT;AIOR'.TC01'V Y ? - t ? ?. t -4 [3 _-Al °`?., r. °'?I sr 'a ST?TF C)F WACHIAIf?T(lAl _ "T Inl,. "..° "?, a ? lPa"YI P F V POLICE COMPLAINT NUMBER ... .. UNIFORM POLICE TRAFFIC COLLISION REPORT t PATE OF COWSION DAY OF COLLISION TIME COUNTY NO. CITYNO FH A A U. DAY YR. T SUN I MON IUL$ 3 wEP A 11 pn 5 ; HI P SAr NSE"HDURI } -../ OR AN U.L COUNTY ?STATE ROUTE aCOUNTY ROAD ?LITY STREET Q ADMCLS. PREFIX ROUTE Ofl STRE ET 000E 5 l 'o', ? / f .''eferfann ?O1MER14PECIFY) y - - 5i O ? ? L/ L N 5 E W E ].N CITYORTOWN > PPEFM EO MLE POST ryv l /? C MILE ? ? ? ? OFSf^? T T. 1 i n U © (/?' J ' A '•.l-.- N EbNO.OF STREET ON HIGHWAY-;Y,::: .. .. INTERSECTING WITH: STREETORROAD LL RAMP OAGRAM DATA - f° {v r " Rt R e -, ? 7 :., .:. ... '. a .. t HD+INTEILS INTER NON %RD NTERSEC ACCIDEN ''IN' STfl E OR OAO "" T OR REF. MLEAGE CLS EgENCE OR053 REETORRO N BETWEEN C STgEETAND - 'war '? ____ _ ST ODE l DIST EANDDIRECTIONFROMREFERENCEORCROSSSTRE REET CO NO USE N 5 E W iH8 R -MA p S OF I ! y In- fEET f•. i?_t 1:1 El VEHICLE-VEHICLE C] VEHICLE-BICYCLE ?OTHERIWRITEI ?HITARUN- NO NILLE SEVERTY ' COLLISION INVOLVED: ? D n '!A _. TOTALNO VEHIC-OBJECT ?VEHICLE-RFTRAIN _ ?STOLENVEHICLE NO INJURED L ? . OFVEHIC ES, ?yEMICLEPEOESIJMIAN. ?NONCOLLI$ION ?HAZAHDOUSMATERIAL ., ?PROPERIY OAMAGEONLY „OBJECT StflUCN INAME OFOBJECT STRUCNANgPWfIEASNAMEI.. .._. ..... •. :- ;-.-,.,;, LOCATION OF OSIECi,STRUCR-;,.: :.: -:W...s ., .. EST. DAMAGE V A IN S E W OF T1, n 1nM, hr f+^h'1. ) T`f ?ROADWAY FEET [3 ? [:1 ? RD EDG 4 s E a DWV NAMEiAST„-, --.FRST. -,,, -- --:_._-MIUDLE,--'---DRNERS NAMELAST FIRST MIDDLEpf BICYCM$T'OR PLPESTWANCHELNIO': : : Dai D ' U tICiL . F of T:EIV ?', SRRECT AD DRESS: :...•.._ . :.:.-:..-.:. _.__.,_ __. _... ?..-_ ... .. R...:' STREET ADDRESS..:- -.. .. ...._... _..; .. .. v .. V ?i}i ti tT ?i ,;..f.? . -- ..?. :' S'V•a _ r• f . ... ' -r .. r? v E CRY...: f ..? .. I.V, STATE T. O ' . 1:'. ZIP OE : •.- DONE N(} E GR11 9 :. .i . ?.... -. ATE. rn1 J'. 0. 21Pr000E1 - q q JST Dr PMONE NO. eaL•tle `''n. ?'10? cET+-S7r',SJ -a-'- "f ? 1 ... J N DRVERS LICENSE NO.... _ .... , STATE - SE% DATE OF X- , N DRIVERS LICENSE NO. ... . :... STATE . 5EX D TE OF BIRTH '_ O t r .. i Mj OAY ^L^.?.Fv;t1 'Yi' .n. F G' '>7 ':YR. O. MO.,' DAY YH, 5;L7 DRNERS OCCUPATION FRMNAME ..... .: ... :. .... .. , PHONENO. 'j DRIVERS OCCUPATION FIRM NAME....:.. .. ..... M P NEN . ' 1 Std C O^Slr ;eat tle ?'12TJ11C :'RC/10G16 ?1 CODES ,> 131 CLASS 7 MI SEATBELT 151 EJECTION I _ CODES >1.,U '.CUM 1AI SEAT BEL I51 T EJECTION ' I—- °F Stated back hurt NATUNE OF ' IWURIES - _ FR SCENE SY: TO PEE.-E. OM SCENE BY' VEH.YEAFI_ MARE Doo ECNEVI. MOOELIDANT O VAI STYLE130R.CONV.1 EH. YEAR MANE IPODGECMEVJ TO MODEL IDAgT•NOVN.'... STYIEIZDR-CONYJ V 1954 Volk- tncor V- o " E VEH. COL -, UC PLATE NO. STATE TRMLEH PLATE NO. STATE E VEH. COLOR L1C PLATE NO. STATE TRAILER PLATE NO.. STATE.-.::a .. f ' I 731ue YAG 902 V'n• H_r' - C VEH1GlE OENfIfICATION NUMBER.... .:..:r .:..:.: °:.. METER:: .. C VEHICLE IDENTIFp;ATI N NUMB R :a.r..?.•. . . , OPOMEIEfl..zL.:A:4'JdLAE. ? ' REGISTERED OWNER-LIST _, ,Ji'._-. FIRST ...::'. MIDDLE , REGISTERED OWNER-LAST. 1••. : .. FUiST ..:.....I.. . a. MIVMIOOIE ! `N• ans as d i N' . • A r ver . ADDRESS OF.OWNEfl :_.'"..? t z ? i.AAME ANDAODMES90f RSVRANCE CO.ORAGEHT -,:I_... •_,.. ... .?... ...' .....- NAMCANOAPpRESSOFINSURANCECO.ORAGENT .,..:.i_. „?.::?....'.:.1 .:? •.`• ? f?:CO Insll• Seattle Wn• . :. ..._ , ' a •. :: .., _?._. ...:...,. CRATNDNNO.: P V . 'ENF OEA!E gC NT CHARGE ITAr :.:._ . _ ........ -., _.. -.. .,A.d':iJ'L -: ..: ,' iJOne •. A CTION FR7 NAME; ADDRESS & INJURIES OF PERSONS INVOLVED • • - coD[s 2 1'j 5 .-; -' SE% AGE' STATUS M ; s SA m EJECT: `. NAME ?:A•tt?i ?•at'Irvn t I 'C ADDRESS: 1529 J:Jtic`ri Rand d 5ocso 1'oolev ur.. I 1-'1 2 1 3 G 5 1 t ' p' LMOVepfnoM ,., :uu WE0 °F fieD'? SOENEpY J.ar. in h1 rriv-te moil Jeff Cert PD 1. : A . . NAME. N T ADDRESS' `g G . BMURIES RCFN DDFROM TO W NAME = ADDRESS N A 9' ' ? 'N I iLREa T[fDfnUM N GCENSBY TO ):1 E. . S.. NAME K f DDRESS Y EC A Po TY Y1 ' ' . $?, b UU a SGf NF BY' y-. TO C ° •.H.. .. ' ` . : I I ISi.LTVi 1t16[Ai WSIi%JrM I ° I'1-YCU55 IAISEATBELT ISM EJECTION fI C D D E 3nAg5(HGEq' 3 PEDESTRIAN A. PICYCUSi aOTHER .-'KSS 1I'rr A ) .11 IDU340fDICYCLEI 6 3 A POWTIONUNXNOWN OIWUnY Ia OISADUNGIWURY ] DEADAT SCENE ANON DISABLING 3 A DEAOON ARRNAL IEVIDENTI NJURY DCDIN HOSPITAL T. POSSIBLE—- I.NOI INSTALLED ENOIUM USE ;USED UNXNOWT! S SEAT BELIFNLURE NOT EJECTED 7fOiAtlv[JECTF.O ' 3. PART ALLY EJECT?D IUNXNOW N IF EJECILD y ? u ? J ?'-.ui, e V1 tL4itlL sbaf AmU",. - : a R. VEHICLE DAMAGE IN EACH BOX. CIRCLE TIENUMBER OFEACH DAMAGED AREA .- - ? . •X.-awaP EXAMPLE . INSTRUCTIONS 2 SHADE AREA OF SEVEREST IMPACT. DR 3 '• DAMAGED VEHICLE N . AW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE. O 1 [USE THIS P O? r I . S ACE FOR SKEICH HG DAMAGE To TRAILERS. MOTORCYCLES. ETCJ ID Imou DAMAGED VEHICLE N0.2 E A. Pool I . x . T-1 ' - - IS IT. W.nurn Fw Iv " ' s u, US rNw EVERITY OF DAMAGE: EHC ENo.1 DAMAGE: IOTNFfl VEHICLE). IQpISgBLINO GC ]? OTHERM.V. DAMAGE I SEVERITY 0 DSABLNGDAMAGE ]Q ] ? E 1] W.IUrn VENILtExO.] 1 pjNER M. DAMAGE FUNCTIONAL DAMAGE. A ? NO DAFAAGE ] ? V. FUNCTIONAL DAMAGE A ?NO DaIAA I CI DISABLING ? 1NGDAMAGE : O °T RM.V.OAMAGE F * V ., OWED BY Billls Gara a EST. DAMAGE TO D BY EST.pAMAGF T O E CTONALOAMAGE ? OD MAGE TO Chimacum Nn, ` TOTAL T s W D BV EST. OAMAGE DIAGRAM OF COLLISION .`;, _JQds}}j.IIe Rcad I I? TO ? s . ( IDRAW ARROW SHO ; 1 -1 ?I -. I WING ., .YA AOW.,ruivRE : I I I I I -- --- - - I . - ? ? vex a[s ., ??? I ? I I I I I - NORTH IN CIRCLE' oertcT-101FAOAOWAT - - rnurK: coxTgou LKMARK] ?- -_ I! ': ? I - - _ , uxv[uqur[ur, coxolr oNF Hc[Mrcx. coxslqucnpx _ :- I ? . i. - S AA W_',- - Mr I I I I I 1 I T I I I_ Z I I I I I ` I I I 1 ? t •I -I IA _ _ _ :1•: . - . -DESCRIP TIONOF- I [INDICATE WHAT PROBA I L I. / COLLISION BLY HaPPENEO BE OIIF.OUPING AND AFTER THE CRASn NCL pE ;O M DISABILITY. R EDUCED V IS BIL ITY PEDESTR AN[LOTHIN OT NOIAGR FG ON VEq _ . G COLOR. CONSTRUCTION OR pE gPWORK E . T , -Driver-in.formed_-this-_R/.0 that_when_she-star_ted_tQ- QUnd thp slight curve sh t h - _ e 1 a atc _.'of_ic arid-lost.control-af--the_eehciel_c-,I-usink-the_y_ehxcle to go_o er the enbankme t - _.striking_the_large_ _ rocks . I - - _ -.; .. . - ^ POSITION BEFORE COLLISION - - HEADED R MILE POST ND DE WL G pI 0 STREET WAY AM IN N E OR xO.- •--'?-- ONE OiaEC 10 CREASING Dsreo E NKND - F W G n S W r Old Shine Road 1 '±? AIVE. EO CUP C . . zo ESE, ] jZ v M E ND ^^ fD ??L?11 IWLDx I " LJ ? 'L,.J . $ y ` - N NG A ED vfD c is wqs_. ] 1 I [ ?sHOUL°ER AL lcnoiswALK sL 1 o KE° SI? c RTE WALKWA K AL .. ROAD SURFACE .' WEATHERK ?oT 1 F ONE) -- CONTRIBUTING CIflCUMSi .• -~. F [HECK ONEI E q NLES 1 IC ° MOREI D qnE CLE ACi s O ] [ C O ] 1' I DRY ?C E CLOD A OYF p 0 O Y EP 0 LLO ING n, n ° v fi• G EAD AXI ti . " RLAa Ec ARDED wARN r11. WET ] A.N- n]n pAU°51 UENCEOF S OVER CENTER ? PPARENTLY OVERT ;IG a O]? I i SNOW 2-r?j SN-o A UNE S, E, E _ ??PEfUDIMO STATED S IMPROPER .o.Nl rLi?Oro w4i RKwc. c ?'? MAK NG RIG ?]? iTURN CE I FOG I I{{?? 11 IS F c F RE PAIR Ai ^ r OPf RATING 1 ?AEESPFED 1. _1?B -, F<T VF E°uly. Do 'IT GRANT RAV ?5? TN RN ° uRN ?.. RISPFCIFYI OTNFR ISP ' I ? S _ pSRE u TO VEHICLE I? SVP_ 40.F! 'IT 17 u IB R °P L 160 SLOWING $ I HT COND TIONS. RAFFIC CONTRO KHF<K ON[I INp,)yI.-C I_ SLJ °O LSP C 1 J S G 1-&< J FIGNrS V. All -'yE c O rN°]' IcMICio?i op uai "VEHICLE NC O{1N..__- SOBRIETY y;,-r TE I ?N jD?I E ' T TOPPEa ° ..- oT E TSONAL D r_I?_Gxgl3 ?.y 1 ? DAY HE , I? E v ?}I?ASTEDI 1 .0. ]E I[ C NFI OxF WAV 1 O] F11 aL'ON 11..? y ? 0 R TO SGN ? O n0 E IN 11 • LIGHT _ L]I? SIGN.- J ' I ?I _? YD 4 .J TWO WqY ?- DEAKTIVE, ..ABILITY* r ?,B0 R N I :. '' ?D 17•rl YIf LD 1''? -T---'-?••(?_S°N?- l 1 W K x G ^ ^ .u _ nIA0p5BE I °lA°CLIGIfiS I]I ROAB LITY : -TJMPAIRLD n Ej TP E. i G 1 START INo FROM ? FARKFO P ' N L? qcD (( ? EIS; E[T L-'' _ 1 L1-1 N °OPAAMPG ?J I E ECT c J, ID SOBRIETY u 4-'1 LAN LIG TS . OSITION GING I[NT[RING ai ] ( ? ?L.1_LI4NIS.ON 1_1D?AMS EA? K-STREET S (1 ?? (( ?? ( ) ^ (? ALL sl_f_. pHSMGOTM !.! I I NE MORINKING TR TRAFFIC) SACK NO. l I lGH7EAE.- L?°; I Sa L 11 T [ T I?e`? o EFT ns? or„ CHEM.TEST b-E7-- -[ , H OFFICER' STP[[TicHIS ..f LAG MAN S p I _ J F51 GWE ,, -Ml tYl i 5 -1. - O [ LfC 1 / NO DEF ELTS n f_, TFTFST REF USED C111 -Ts I ? i L t ? Ae ?r L NVESOGAbNC On K[Nt NAMS IRA NK -.. ?OIH YI P ? uNDrviDt % % TEST RESULTS tq[NO O - Z s' 1 ` ; e31ut W C. Gebl? I . I -Al I. L OLICE ANIPV[U AMnI E CE 4w I . 6 n1TF 11"24! 0802 00 r 0820 AR 050 ] 0 DCC V 4 r q N ,I IS I.Cl. -Al " x y? ?? HP, °qrc Din[rogT NO IX D F 10- Al- UY D ATf '? E i =!?% JCSO Quil 6 uilcene ene 11248 l,I 1 OI'TRIBUTION ORIGINALCGPY: SEND TO WgSI11NGTON STATE PATROL-OLYMPIA, WASIIINGTONGS50E DULICATE COPY: LOCAL LAW ENf ORCEMENT AGENCY'S COPY-TRIPLICATE COPY: INVESTIGATOR'S COPY ygu ?r?i`, f ' I ! ?T,F, •pq 5TH h I ? t 7T ? ? ?'71 J ? ' r I} -? ? ??.AVfs f I tT?' } :,S`'. ?'11. i? ?. C -J . S?uAi .JU'?i '?ppppDp?E1???"1F;v 'JUF?I'I rP' f f ? F ?' k yJ n °? }I L ? I I .._ I titr ell, .T F { M? M 1 f ?. 4A1 ir51 c + ii T 9?? L 1 r? i?l Yp t:.l ?-5 :4 Inv,, rgGL DF Q __ __ HA E01' X 1 UI.CE COI.IVLF NI NUMI3EN 44? UNIFORM PO LICE TRAFFIC COLLISION REPORT .dG sv2zdAeE _.. d p' A E T - -FArEbF COUls orv'- /O DAY Y / ,.,a yA (Cl_?Lc -- MY -6'F G&LI7,T0 NCD A i UN all IU ! )4pp HOUR1 UN MJN IS Z' 1 t U 3 5? I? ? 2 COUNTY .6 ? []URBAN RURAL COUNTY ?STATE ROUTE &COUNTY ROAD ?CRY5TREET O ADMCLS PR[FI OR S I g EEI CODE 'OUT' Sc TION ?p?ON LR ?OIHERISPECIFYI # y I'RFFI% EO / - -? / / l/ ((?? W ?Iq, LITYOn/0VM C P j W MIEFOST ?? O .UaC-OL oRT_.... MILES ? 1'^J 11 ? ?DF:_.' LL Q, C NA/M10 OF STREET OR HIGHWAY INTERSECTING WITH. STREET ORROAD l L RAMP DIAGRAM DATA T O N ?T R o a O O I NONIN ERSE ON _ ACCIDENT INTER NON %RD TNTERSECTINO STREET OR ROAD OR REF. O N BETWEEN STREET AND. REET MILEAGE LODE 1 T CLS. ERENL ROSS STREET OR,TROAD Q ?/.._Q _' UISTFNCE AND 51-B EC ON FROM RELERCNLE OR CR0555tflEEi ?]M1LE5 S Eq FW (-]FEET ? I1 f OF COU ROP o.. _ O.. M4L+N HIII METHS _ 1 SPECIALLOUINGUSf VEHICLE VEHICLE ? VEHICLE HICYCLE ?OTHERIWPREI ?HITBRUN COLLISION INVOLVED: SEVERITY NO. KILLED ? VEHICLE-OBJECT ? VEHICLE RR TRAIN ?STOLENVEHICLE TOT- F NO INJURED ICLES ? VEHICLE PEDESTRIAN ?NON COLLISION ? HAZARDOUS MATERIAL OFVEH ?PNOPEHTYDAMAGF.ONLY OBJECT STRUCK (NAME OF OBJECT STRUCK ANDOWNEflS NAME) LOCFtION OF ODJLCT StRUCNS E. EST. DFMAGE _ ?ROAOWAY FEE' ? ? ? ? RO. EDGE S DRIVERS NAMELAST FIRST MIDDLE DRIVER'S NAMELA51 FI115T MIDDLE IIF BICYCLIST OR PLRESTRIAN CHELKI? D RD ' /UZ(GS?/1 Cry R ?ATT ?1q5_LX S1gE t ADDRESS - 1 STREET ADU SS R Cv-??,R -.S- P. U Sox 99 E R CITY STATE ZIP LODE PHONE N0. owp?sr?rvp?_(t) 32s-28d R CITY SLATE .. ZIP CODE PHONE NO. Pow'r LtAocoLo,_(1J 3 N O• OPIVEHS LICENSE NO. STATE n 5Ex DATE OF UIRTH O DAV YR N O• DRIVERS LICENSE NO. O FM STATE. • SEA DATE OF BIRTH MD. DAV YR O R5000UPATION FRM E ONE NO. OR N E DRIVERS OCC? ATI N F ME PHONE NO. ((,, ?f , J C F <Ori 2 R " ? B L /j ORE N q . _ F 3 c u` '. > (.`ODES IJI CLASS EA SEAT DELT=/._IEi1 EJECTION._I-__ p_ CODES 71JI CLR55-.-_ AI SERI BELT_<_. 151 EJECTION -NATURE OF NIURES NATURE OF noun Es CixTS ON f-0Ri?jEAD 'i-o G OM SCENE BY TO REMOVE FRM SClN[ ''?Yyy 6.rI•?(/f/f.A?? F o GFkR oIv _7 RA. VEH. YEAH MAKEIDODGE,CHEV.I. MoDk IDRT-OVAI STYLE IZDR CONV.1 VCH. YEAH M EIDOpGES11EV.1 O F,{(QAN 'Al yLOSTYLEIZUR-CONV.I KK LJ HH 69 ?1[ LP ?9? Q r ((Cr R ? ?7 O ? AR F L O IwArl E VEH COLOR UL. PLATE NO. _ _ STATE TRAILER PLATE NO. STATE H VEH. COLOR UC. PLATE NO. STATE TRAILER PLATE NO.. STATE H 1 4 NCI: CC29 7 WR - I t/c sKZ VG- ,Z (dJA . c VEHICLE IDEr TIFICAT10N NUMBER ODOMETER C VEHICLE IDENNFILAiIOi NUMBER .ODOMETER E 2?i} E 2N _ S z 7X 13s6 34?9s7. FIRST MIDDLE REGISlERE00WNER- T -LAST ERED LYNER O REGISi: FIRST . MIDDLE N O• / ?' F F F IR.Sf? N L,01,tN-- O. e=F?- --.10?? ? ADDRESS OF OWNER _? ADDRESS OF ( YNEII .. Sa±?E as[io_vE E NIp AUURESSOf INSURAHL.E O/OR AGENT SL?!?S?/ ?oRr _owN?ND__ 1tL-R NAME AND apORE55OF INSURANCE CO ORAGENT . _ HANOE L IIAT,ONNO ENF N( K NI CIIAFGC Itg110N NO. ACTI ACTION ADDRESS & INJURIES OF PERSONS INVOLVED NAME coDES _ u ' , , SE% AGE STATUS A 1 EJECT C NAME. __ C A ORESS' -- - 1 D p ^ III:MOV[U iROM N IURE OF _-- INJURIES SCTNF pY TO A NAME' T ADDRESS. _._... i ?- ' S HOM TO SLFINFA NATU SF W NAME. T ADDRESS --- - - N . - OTE b?-._-.--_ tMv OVr:BY To tiT uRKs E E S q 'o N ItaI ~_-_-_- _ - a 1IuWA1U5 IZI SC AT POSIIIp4 MJUgY C1AS5 p15G1UELI AI H O N07 FJf 1 i oOeo Fi°.SCCN[ %°1iiN-Anlnw Y a ART iii Usc[D i 1007 LLy UD COt[D vi fTd NPR _ ; '' 3 PAR AJCCIFO roSs' 11r iiunr wi SNT? ' ° ? 0 p L T . I • O of 1 A D ED 1'o n oOIOH'NOW[ S S[Ano"FAILURE A E N O e ' E N n 1 JECRD wnNF55 _ ll ..AA J . F K ?Iv 3 ' ' 1A,? ?I 1 1 L I i I yY? 5, ki 8 +?q4 ' ? L ? A ?' T' i Y kS ? , d 1 r. ^i ?.? 111. dog VEHICLE DAMAGE I IN IA C111A•clHUL 1111 r.pl. xfn nEACH DAMau[Dlnfa '' INSTRUCTIONS: ] SHADE AREA OF SEVEREST MNACT. }IhP.?I/I -(, •,- • ,. '` ]. DRAY. AHHOW SI TO SHOW PHINCIPAL DIRECTION OF FORCE [ TD iAHIN+ MGT ncrcL[s [ Tc, DAMAGED VEHICLE NO 2 '44 1 71 1 G(l?tL-? SEVERITY OF IT _ l DAMAGE VEHICLE NO.I 1 4 DSASLING.AMAGE ] ? OTHER M.V DAMAGE ] LJ FUNCT ONAL DAMAGE A 11 NO IMAGE WFO BY _ EST. DAMAGE SEVERITY OTHER VEN CLEI I ? DSAeLll IAMAGF ] ?OTHE.I V DAMAGE ] O IUNCTIONII DAMAGE . NO DAMAGE CSi DAM ISEVERITY O V DAMAGE ] NO ] OTNENM V'?AMAGE ? 4GE O EHICLE 61 a ? NO DAMAGE CT T OwfDBY AGE 701L O aY - EST. DAMAGE TO.. DIAGRAM DF . S TO S ,. . ( 1 I _ _. _ - ' DRAW ARROW SHOWING ciis ,FtA)uNls .. NURTH IN CIRCLE 9 nRSnTaels UNUIV "I, LT sraucNON - - 'i... ?- I , . i Aa • YINiIE LD[.,N.NDA .? __-- Flf?LaLFea ___: - _ _ , _ I I DESCRIPTION OF. (INDICATE WHAT D F° COLLISION Dagp RE ucE VIqN u]v,I""EOfsiranHECicT•NOic c"ooloN, eoniinua?orv oelner`Anwo nK iyTCI NDIACa M' ' . . _ MEN I FC?SITION BEFORE COLLISION HOED E O 11 { p INCREASING CREAS NG '5 E NEIN ET ONHGNWAINIMEOHNO ONEOINFC ID T I y nKED PA ME. • I X14 ' a - , - YES NO 1. ND. : J - . •- o. rII ED c o i ..,. Ea , I D,L su.D A,? P )I MAR O^-^_ST SING. DFwALK SHOULDERA EROS `D I el OSGN EO rl- o. . -'- ICNFC ONEI I NO INNVIR =.CLIAR, O. _ET WE 2 c_ INO S OW G CET A GO IeI f1 I ` I T N s c Frl r: L CK ONti O ] [ L[ t! I f 5 1 O ONT ,jr OP O SIGN )I O ] E ] O ( 5 SIG TS ON [fT ie: MB,. F B y ; 1O• IF Ts SIGNAL. ..e; -NO IF ..CONTRIBU I TING CIRCU MSTANCES NF cCA ONE On MOnEI •'• • Ir °nnE ACTJ?IS O D i" : .) 1.0 RIVER 1 10 7 E '"IV I N „ E.- ME I DER INFLUENCE OF _ LGDnoI_ _.. , 7 1ILL11111 _ f C 1 NO. I rsc .EO .ARN -- -1 STRAIGHT AHEAD OVERTAKING HO S 2 UNDER"' ?. I I OR G LOLICE OF - I _ N FLY - ARE ` NA SING 1--1 r. M 3 I f I ( - E G O . 1 l G TO tj E " -KING N GH T TI RN I SF C E G AS. ` 0 S l CA N - MAKING •-' LEFT TURN _ E SIT [ IN r0 F.AT?VECIEGLNP DI G S G I'D NGRANT OA F CF G l R .. .. ,FNNLR . p O O S TP LIA"T S' IT SIGN SIGNAL .1 O F I FC , N.VRRA7.O I O G -? SI [ O ) G TYPE OF ROAD ICNFC K ONE DR MOREI 1 I t-.. ON[w _ VEHICLE CONDITION ff?? =?I?jy? Qp(@t O. )` I$C?(tnT11??5tED1 N SOORIETY Vt`NO )` CHICK ONE, .All.. H DOf N A L f R'_I Pe1GN S E N ROADWAY W 1] J 0 O [ C F Kti R [ O 1 RIO.. ,' 1R TC A E 5 FITf iN0 .. NiI NC ANOE 1 ) HEA I ] NOT A CU t' ..... - ARK OPOSITION •..tpO!,I AMn„ -, ( I ...- All[v HE .V ).. ..• 1In[S WD Irv .... . -., .. _.. ?i 17 ATIN. NO If N1ENING ..: TRAFIICI .Z-N"ArIN .-ELsEFT e _ R ON SMOOTH _.. InN, °uN„uafu 5 Dn mo»N bFIN U INKING DIHa[' -CHEM,TEST , le PICKING :.. ?..., -y : RI L TS C AR 1[O I111G VEN O en[CIi YI 4R I T:I e R ) OCONO DE FECTS i1 sI N[f U2[D t?III?.111- I t tt t f ] Div DID Of,r ,SKICNYI TEST RESULTS I 1 I T-'?.........._ ._ .-. - • I O._. I PPNUVI.U? 4Ai1. OIST OFIGINAICCII, II1 TO IVASHINfi TON STAI[ IAIIIOL?TOLCV^IPA WASIIINUION JOJM -- DUPLICAIEGOI•Y: LOCAL L IAW Ill DR1EM(NI Af•!' NCY S COPV-TIIPII VV ..., [.._ ._ _.. `1 tl f 4 4 ' i 11'c r , ?; "<'k? Af ? ? I ??i ; N'?''c3Ta?.':'iW.7??r:ir'. c ;i:R^! .,,??" I,R ..-,y '^;: ?`ri,'b•'rn'?'?t { ,II ? I? ? < .al I I ? t T° s ai {fF 1 L ,! i ?`P15 l 1 1 ',,I 5 )fit l t ? l i• to ¢ Ufa, ?' ,t ,I _ ifs.; .1 :? 1 7• s D DATE OF COLLISION OAY OF COLLISION TIME COUNTY NO CITY NO. FHWA ' MO DAY SUN NUN UI WED 1 FRI SAT IUSET<g0 URI Y 72 1 PU !R AL E C- k`yf o DM CLS. PREFIX ?STATE ROUTE 1000NTY ROAD ?CITY STREET O ,ROUTE ORSTREE CT TCCODE ?,J VGf ET _ ?O Sin ?OIHEfl ISPECIFYI In 3 N ? 1 ?K]yy?1pp•• // CITV OR TOWN / W 7 -EEO. MKE POST //•?? o 'O Pr ? .._ ? J 80 / MKES ? ?yOF /_ L^J /! . C LF NAIEdNO.OFETREET ON HIGNI?'(JY _, INTERSECTINGWRH: STREET OR ROAD LL RAMP DIAGRAM DATA R ' NON WTERS CTroN ACCIDENT N ER ON %RD INTEflSECTING STREE OR OAD OR REF. JT CL! EPENCE CROigF ET ROAD O " O _ /J /J MILEAGE F. N.. BETWEEN C ID! STREET (/?J!Fr? T CODE - ' E _ E ? .• GIST EANODIRECTro FpOM flEFEPENCl OPCRO55 STREET- nur?I>r•Elil5 SPECIAL CODING USE : (a / L) FEET L^L OF C%? • 'lY ? : /C/ I ' I?" EYX' , __ ..__ "____. .. . .__ VEH CIEVEHICLE VEHICLE BICYCLE ?iNERIWRITEI ?HIidRUN SEVERRY COLLISION INVOLVED: ? ? A? t _ NO KILLED VEHIC TOTALNO ?LE•OBIECT ? E ICLERRTRAIN ?J/?L?;f ?STOLEN VEHICLE ANO INJURED . OF VEHICLES ?yEHICLEpFOESTRIAN ?NOIJ.COLLISIONAJgPDUUS MATERIAL ?pgOpERTY DAMAGE ONLY . 0&1ECi STRUCK [NAME OF OBJECT STRUCK ANOOWNEflS NAMEI :. :'.. LOCATION OF OBJECT STRUCK - EST, DAMAGE ?ROADWAV FEET ? ? ? ? ? RD EDGE 5 - DRIVERS NAME UST : :.. . FIRST : _ - - MIDDLE ONNER'S NAME LAST FIRST MIODLE.I F BICYC45/ OR PEPES AN CRECKHO "':.w.. V . I . STREET ADDRESS .,... .:.. '. '. -'. _ .. I ... BTFEET.A00.ESS , E'CRY ..: .:. ..-. STATE_...:- CODE"..,PHONE NO, E CRY:.. ... ..J... .. _..: STATE.._ ,.." ,,. ZIP CODE .. ._._PHONE NO, e R y I:, r - ' 7?/S9 N DR- LK:ENSE NO. STATE SEX. DATE OF BiHTH N DRIVERS LICENSE NO. STATE SEX DATE OF BIRTH .. O . MO DAY YR. O, MO. DAY YR. DfIrvE.. OCCUpATKJN. FUIM NAME ., PHONE NO. 2 DRIVERS OCCUPATION FIRMNAME ... .... .. .. ... ..':.. :„ PH NE NO. CODES nI CLASS-- HI SERI BELT- _ I'+1 EJECTION CODES tJl CUSS IFI SEAT BELT I51 EIECNON Jf 5? N IuNE F NAAU 4. R Ei INJURIES MO V D FEN SCENE BY: TO FROM OM SCENE By TO VEH.YEAR MAKEIDODGELHEVI MODELIDART'NOVAI.: STYLEIZ OR-CONV.I ., VEH. YEAR. MAKE IDOWECHEV.). MODELIDAflT•NOVAI._ STYLE I]DR.CONV.) v 77 V E YEN. LIc. PLATE NO.., " STATE TRAILER PLATE NO. STATE H VEH. COLOR LIC. PLATE NO.- . STATE .::TRAILER PLATE NO.:: STALE , .." H ?? 5wG 1 C VEH lE ID MIfICATgN NUMBED :. ,, :......: ... .. ODOMETEfl. .., C VEHICLE IDENTIFICATION NUMBER .. ::::.: .. 9dE L: _SS /t' 3 9 _ ' flEGG TEREO ONNEP-LAST _.. :.. IRST:. ,;-,,.:,: MIDDLE REGISTERED OWNER - LAST.. .:,. FIRST_ MIDDLE q N. N _ D, ]. a om. .. - ADDRESS CF OWNER ,. ., ?__. . '...'. .... _.. ADDRESS OF OWNER ..: .....:-.,:... .:. _. .. .a ": .::-.; 2 .1.. .,lrnF NAME ANOADD"Ed50FIN5UA_-cO.WAGENT .-..: .. -.,. .. ..., - N AME AND ADDRESS OF INSURANCE CO ORAGENT. IV,? CHARGE .. GRATION NO CHARGE - . ' ENFORC[MENT IIATI NN ., NAME ADDRESS & INJURIES OF PERSONS INVOLVED " coDEe _ . •2 : `+ s , SEX AGE STATUS H EJECT.- Y • D RAME• C ADDRESS' I L'/. fN DT/ // fJ" /1? ^t J O" P 1 G/ 7 / r U p NA URE nuuMF As ,? r S%G F Gt. A + NF G Sfl r sci ?ye F LYYAY J pJ A:l , r?Y TO / • J te?'JA•d A.' NAM[ ]"?Nl_E/_?• /c°Tl n , 1 N IT 11 1 / 7 1:,A I ADORE59 3c/ i t ?C d„r/c^? i `? o S Y "PUURs .+ /r nftr? dr/' $ sciovnDF ,]] 1 To T J/. .A•,¢AaJ NI NAME T ADDRESS 4 ' N laEMs EPFPOM SCENE flr To TO 'S AME' :1 S ADPR[SS S. SCENE BYfGrSaM - TO - 1{1 I n I IISIA1u5 I]ISL FOUNGN JHNJURYC455 l SERI BELT " 151FJEC1roN (?` :u5 ( E `'? INO NJURY AT ]OCAD SCENE 5Ut5ADl Nf.INJUflY ANON OGAB ING l NOT INSTALLED ]N T OTEJECIED I T I y ? DESPAL L URY 1 O IN USE IDTALLYEJE CTED L Y FJf CTEO IBC D infN 5OTHE 55 I .51T'o 0NC YClF1 ./ A III IL M1K OWN 1 = 5 4 K. URD IN IN HO HOSPITTAL . POSSIBLE OSStOIE INJURY NKNOWN i FAl1 S SEATIIf UR O IF U Kr A U..NO 1 M. 1 .......... E . L [ YtD F: I 06k F i ? • ; TS" -h 4 ? ,. • ? .. _ ?F 1St t INSTRUCTIONS: i SHADE AREA OF SEVEREST IMPACT. R ?- S$ S O. DRAW RROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE DAMAGED VEHICLE NO. 1 ID T I S. ACE FOR srcETCR NG DAMAGE TO TNARE GTD CYCt ES,ETC DAMAGED VEHICLE N0.2 r F 4'3. ? r k i? :d IS. ,.w r o..,,.,.... f I? y T OF DAMAGE VEHICLE E N0.1 MgGE IOTHER S T MAGE VEH CLE NO.] 1? sBLING DAMAGE ]OOTHER M.v DAMAGE I PQ OSA.LINGDAMAG E 30DOTHER IV,,, MAGE IEOIDSnBLHGDAMgGF ]?OTNEgMV.DALU ,. ]? ci OM,LDAMAGE A?NODAMAGE ]? FUNCTONALOAMAG E ?NO DAMAG]? FUII[TIONA LDAMAGE A N B ODAMAGE' -ED y A? E /O[J ST DAM !"' wED BY AMA OWED BY EST. DAMAGE To ^ n J f c'D To 5 To s y b - E DIAGRAM OFCOLLISION 1 _ I I URAW ARROW SHOWING 'CgsA e> yTd - o - DRY I - - NORTH IN CIRCLE N N. 85...f.D,NT y \ - - - i - - 5 M.p.YYLHTLL.FBts,AMNpR ? -y ?- .. P,F,LHC°ttSDx. _ _ - ,Qo/?EOJI *-t__,I I I i 'DESCR IPTION OF IINDIC-WHATPROBABLV HA11NE.S61O1E.DURNGANDAFTER THE CRASH INCLUDE INFORMATION NGTON IAGRAM,EG.ORWER COLLISION DISABILITY. ED V SIBLITY, PEDEETRIA cur NG COL co sTqunD OR REPAIR V.FK. Ercu - y??_ ?!`! !R!e? s :a Gle'' I , DOSITIONH FORECOLLISION' olOiE oI ox --- NEH. ' rvE OFD M L R ON STREET OR HIG W v NAME OR NO. IN lA11 LEGALLY WA O S VEM O. ^'• SA cREa51e.G0DEC.IASING - a[ci SPEEDS EE ED - OCCUPIED YES E 7 LJ H , AEG. A O G.-_ _- _ --- GniO53ING. NAY oW DES GNATED ] TO -' AEDRRC!CL ST WAS USING s Of I wAt NwA?SNGULpER Ar MART[ O __!cu0 - rv ' - F ._.CROSSW N .....8 C E UTE OTHER NEE _ ROAUCKR FACE WE ?K OER CONTRIBUTIN G CIRCUMSTANCES. DRIVERIIE"I'LIACTRUNI C. N.. N C E RMOREI O ICHE Iv ER ] o rye- - _ o ] NO N D o^ GOING _ xr AHEAD L KING c O 1 I-x nC ._:_a Cano IF FOLLD.,NG oGS.@E (_ zj_ E E L? OVERTA UNDER J]._15 F IMGTAT f I .._.. Gl0 R I- O APPARENTLY -l G G PASSING I CIN VG -LINT x, ] 1 E _ KING X aY, 7P"-R PAR x ' N C X. A - 5 FC E i E I _ i BI- I `" Gq - DID NO G TG--H N- F- _ O^ILGG041G{{ I 'B SLOWING N y 4 ;' p1rvfR ISifCIFVI 3-i"O t ISI'f C13vI I A -? C R - OSNFGAND ST O f S E v1 - 1 I NO P ] s GN SIGNAt B. _ N 0 O J) f LIGHT CONDITIONS RAFFIC CONTROL STOPPE OR TYPE OF ROAD VEHICLE CONDITION SO fl1ETV I<II[cA0 tl S O ICL[ ] C C < N n - E O AT SIGNAL t r NE ORM F FN NO, I C E ICHECK Ux EI ?.-J3 O 5 OC GN y uNALS I ONE ND. IF R?FB??tm N0.T -YINIPIT ] X C I STOP ABILI SIG, A TY 110, S A T .. D _I REO t' J q C E ] O N -] f 0 O l ^ D S T NOT A RE[I_,_, NO IN F III 1 TT 0 OM [ ApG[ TS ' U DSO E 11 ], I n EF G ES THUNO FLAIRIING a s EE IB __ ?? c B xa ?• yrYl. G Tf ON ,. ER _. H N ' I IT IGI D I AW _ F.IGnN fV o ND n FCNEMM.TEST O -II t^ ,c I DA. Nv. 3 B aM3 S lE -LIST GIVEN L:I ` OTHER IY[CIFYI t f HI! / )} arc LG N U ICE/ f EE ] i NO f]N FECTS I TLSi NLFUiFO 1 I Y4? J UT,IEN IYI 0 l ?] t OFD I rlc lv, 76 TEST FESULTS 2 j(,ve W S .11, A O !' r 1-lt+ F? AMbULAN/C Fr f IL W .Y lS WATINU UrI rc[M fy.u?.ARANa' `/• B/ ?? ^cIN?-?E.?K"-'T-,lr ' ].bu A?/L >NOp iAlr"?DfuHl&t"T MIN. }±y ?, A f Dl'RSPDIIT HOV<D TAIL I? ?' X - -----?!?-rs?° _INI, g ? IFI ?o "/_?•JJ PI; ? ? ; ? , 7? DISTRIDDTION ONILIIIAL CL.•? •lNU 10 WASHNGTON STATE PATROL -DLYMPIA,NASIIINGTOIJ INSM DUPLICATE COPY LOCAL IA'N I"I ORCf MINT AGf ACV'S COPY TIHPLICAIE COPY. INVFSTIGATON A -A1 '!fl[ly1?k' • £ 4ypY?+•^:r+y , xl `, r dA ?b'`_?S'1., .;;^??u, ..•..,.:-_.,z ...._-a.4#t.. Fq`M d I3ir.u qw Ya 4' MOTOR VEHICLE COLLISION REPORT ?••?? DATEOFOOLUSION DAY OF COL LISION TIME OF COLLISION CO!NTYNO / CITYNO J O.h, p{ Q I gEe?rh Efy wN NES wE0 Mup [w S.r n ' i _? U U,ES vM //W PLACE COWTY CITY.IOWN F sloE ' MILES O CITY. TOWN N ADM B PREFIX -EOpsTRE c CTIOTE J?Ffers.r, IX WA I-- ©DFI lac - s GVENAMEOF STREEIROADORHIGHWAY NTERSECTWOYnTH. STREETORROAO PREFl% ED ILE1O3T.' °"nEO COLk,, Koa to (] &190 NONINTERSECTIONLOCATIONOFCO SION BETWEEN SIREETAND STREET RAMP dAGRU., DAYA - N0, powN?ARFSr -- nWwAr ® © sSrln.upETrosr oA DE ECT- FEE, ©® DF .`1m ; do so v_,{=K o ( Ca ?n MM1v -41 O INTEfl INTER . ? -, I "' CLS. An Bona 950 IUCLE'sio_ ?oiNFplwnrEl ? WSKW NWIVEO ?W W WEC.CODC IGE D o Oyy u o s 0 EI.?'c.EO xnR.N $noNC« o ONr IMn k•? :` - - OBJECT STRUCK INNA 0ILICT.I.-.l _ OWNER OF OSJECTS NAMEAND DR LOCA . .. .. IN ROA ' '' TION .. ? © n oplP OmwECi DWAY - FEET DNVERSLASTNAME •FIRSTNAME. MIDDLE Cv, Mar ,? (3or?eif F EwC:STD cm-w E DRIVERSLKSTRAME - FIRST MAME.•-. MIDDLE STREETADMSS .:. .. :..: : ROUTE NO. ANODOXNO.. PD Bo x by uopE,nArI Two "'UREA wE NM E usE A STREET ADDRESS ROUTE NO. AND BOX NO. . ZIPCOOE CITY Y SrALE I?aAlncA(_ W 9833 } IVER5fI000PATKIN encktr SEPUU,E pE DR, a M MY STATE ...... ZIPCODE DRIVERSOCCUPATgN DRIVERS LICENSE NUMBFJI:_-: : STATE SE% DATE OF&RTH AGE ORIVERSLICENSENUMBER .' .... STATE SE>F ATEO F&RTM AGE CN -phi- mvl- la so UJ(1 lr SS T3 EAR VEHICLE YR. MARE ICHEV: DODGEI MOOELINOVA-DART) BOOYSTYLE I2 Dt) 'll Yfl.. MAKE ICHEV:D000EI MODELINOVADART): BOOYSTYLEI2DR.) 1°117 ToNdi-a Celica 2AL I LK:ERSEP-ENO. - STATE TRNLERPLATENO., ,., STATE LICENSE MTENO.-. -. STATE -.-.- .:,TRNLEfl PLATE NO...:. STATE VEHICLEIDENTVICATAJNRO. RDBBMODELSB NEWERI ODOMETERIMILEAGE) ApE) VEHICLEIDENTIFICATK)NNO. :. IIBBB MODEL96 NEWFAI DOMETER (MICE ?R 2`1o5sy? l g 35,?? REGSTERED OWNER, (LAST-FIRST-MIDDLENMIE)_ ,. ORIVERSLICENSENO. REGIBTEREDOWNER IIAIT-FIRST?MIDDLE NAME] pRIVER5l1CEN5E NO. 4.C41WJ,°-6VEN K. IC,"-1M-(US-KGI3W9 A " LATE) OWNERS ADDR ESS- ,.,_... ... (.REEET,CrtY D . -. ATEOFF DIRN OWNERS ADORE. ISiREST•CITYANDSTATE),_ _ - OFBIRTH ,,. MTE RE I A -PC) (sox (A OwLocr_ ? ? } (A TT n Tb O PARTSOFVEHKIEDAMAGFD ESRMArFOCOSr IL. $ PARTS--i-ICLEOAMAGED, i P wovDaCIE', s W THEREAUTOMO&LELIABIUTYWSURANCE ,,mo?{t LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- COVERAGE N EFFECT FORTHIS ACCIDENT CN YOUR CAR ;91 YES ?NO NAME ANDADDRE590F LIA&l1TY W5URMICE POLICYHOLDER- _: -.. ;- aRi NMIEOFUNNITYINSURANCECOMPNIY.- :..:.. EANDADDiE530F LIABILITYWSURAN EAGENi-..-..... .: : biv sA,E SP UA&IITY POLICYNUMBER 2 7Z-11(,N k_ CH IfvtJ C?fA1CC?Q- i ?Q - k 17 9? ,STNJURY :. ,. NAME IJDtiIG AGE 2NDINIURY: IusESdAp.ATFPEPpR FDp AOdIKNUx/NnlE41 NAME - AGE' - ADDRESS SE% ADDRESS _ SE%F M ° M D p ?j NAME - ----- ?_ ? !? ??:? ,?-® ?• -°'? nW R _ _ © ? E.NwHA.b?o°:'"?rDp, ®? VEDAS w MARIEFIRSr ONETHATWFEJES STA-OFNAXIEO 0CpNER o mM NyI AIXPq 1 PDSSS[E DPA54[NO[AVENICIE LULLED SFYEA[I NROIiI IE V?F C 1 I STATUS OF WURED MANKRRSTONETHATAPPIJES p WVEM GE. o.n 0 WasAa POSVpU. KILLED IsEWRFI R Iw nOAYI? IIO DPA9rErrtFR i P F Y 1 D P[o[:rRAK aT? D o,.,e.?wm,T..IN ? 5? B? i NO. - I l ?nols&AR roap wplrz.ol ? 5E] 80 70 I SNOW NOrtiN BV ARROWWCRCLE \ I NaD.E„AU OESCNBE BELOW WHAT IMPPENEDIflEFERT VEHMAE98Y NU BER) - V i?L: _ic?ct _N i 1 ?? VEHICLES POSITIONS BEFORE COLLISION OII IK) OM STREET OR HIGHWAY AMj V I Aow?ANLE YENCU Yacu E Mo4lY M1lANbq 4oALLY PANtI uA DN %.ARAro w.4 O Y[HKI[IKCIPEO ?iVESTK1AlED .10BY NZ?. „ E NCLE N 9 E W w RoIA. ??? ? .TITi .In H6 ? ? 13 ? 1 RO : ?. ? ?:D ?oAiloN°T b Io,NTT ? ? ? ? 41 ? ? ? ? ? ? ®4KNI IKnww ? ? ? ? ALCMO "D""" FROM DIRECTION, . to DIRECTION P[DESTRANwASLLSWG 1?DOEWAIK 20 WALKN'AY 30 "OULOER 60 w°.a 50 OTHER • ROADBURIACE KNIbIM WEATHCR UIWTCOITMIONS TRAYICOWROL -!X Y[NGl I l ? DR-R/ RICLE ACT." Y- - -KIK'CK WE GI MDAXI I rr,cLE alu Aa , [ I w I No E Ao I .1 [ a a 1 ? OAVLIOHT ? 1 ? f+f ks ` 1'1 WA? I ? GGMG 5TRNOHT MEAD ? 1 ? ORY ] ? RAINING 2 ? DAWN I ? ] ? DIOP SIGN - N •I ?Al, I, .q 12V N ? 2 &NG ? 2 ? WET 3 ? ANDYMIO 3 ? OUSK ? 7 ? E Dfi0 I ? j MVfN4 Rl? ? 4?[I? 2 ? SAW !d A ? SE A ? 100 S ? DTT' . ? OAAR D gC[I 6 [3 "EOIL T ? E ? /IASIINO PLO ? S ? ILAsRNO --TER 1 \ I :A ???rIL'M IQ[ - WWI : A. ? ` : I,o ? a?q, M ER ? 6 clot. SRGIY [GIY) S ? BlR[XEfOL41T8 ? S ? M 6KNAL - . /? W{Vp?? ? fW ?IIT tUI1N \ " I L NASOMOlOR MOT 6'EEE ra,A.C Wva q 0AN0[R ,A%n l It 2 ? Y KR WED, ? / ? ONnarn'FLMIMAM I ` LAN's T ST [ l OINf.R. EPECIFY ? S ? - tit UWAV , C.D ' IT ( [ ?Y IpAIIIC NO L!J I J ° n1iM ? l U DMO[0 N:? . • ll M ETT11NI1i1 ?U d r, I IV, RL? ? MOTOR VEHICLE COLLISION REPORT owz F cPws7oTi- p o< L E NO .?.,....» _.W -"-'- I slo Jug, 1977 .c `I"'I couNry y Ufa:.. UNtSGot±?CITY n LE f:.I TY TO N ' AON CLS ,w? L J _ IJ .. Jefferson, Port LudloAl 2.6 (?t? Nets rlats grocer RFF P I% x°ur[o rnrci .. oa .ECTO. o.P O., y„y-?GVFjJLW y_-?SiME ,Ff;,AOAD .fll .? ,,vtinTER EC GWITH.._S R U OR gOAO - - --•• CFI ¢O M LE I h / ?? INlt HSECi10N LOCATION OF LO LI O DIAGRAM p _ ""? ATA vEEn ( 1 i. 11 -T aoprox . ° .. ° ° non ' P.,n•.I"° "°". °x1,50Rt 0 South Bay Road / .NOR I ..L ["["°..arx.[ ~ °O •^'o®I 2 r"rH Iwnlr.l EC CODE USE , w" nl ?,Ir"u" ti O CT f_• ll<Rg?ypl^? _ R ,.n,R ._?:r,..._. ?.. ER OF: OBJECTS NAN[ ANpA0oRE3 ? -. - 1-1 C? [o coar AY .; u ? F E nn rvEA}LASSJI,AMEa,?; y>? ?,FIRST.Nw E ?;,.,.?-, ?, IDULE. .,. RIVERS L ME,,.., - •F STN a ter,.;-c., _ r.NIpO M o Eb D th y oro y N Courte?r Jon s aE ' - " , T TvD4Aq t y. t_.v •:a?..?I?_.'.'.g0 NO; AND BO% NO- : STREET. ADO E .... _._• :. ._.. (Spruce St, Paradise ) ---.. r:..ROYTE NO?.,?ND 90Ir19 ' Rt 1, Box 460 P Rt 2, Box 123 "" `-ZIP CODE ,OnIVER O<CUP.AilO .. + sTAT - PCOOE ONIVEfls.000UGAT OW'; Ch imacum Wa 98325 housewife Poulsbo Wa 98376 ? ., N 4',IJCENyY`MpE ?M: TAT[ G %' - A _.TC, THE AGE: O ..... LENE UME T E sE% ,DATC F,p H; (IG[? -??._ •- - _.. . DB Y+ *D N 8 - 7 3JA Wa 55 Not in his posse ssi o cVV? -' BO LE.: -y ? ?" "_-•"-" M,:3f?m wM, ,M?OR'•-(NOVA-u ox-I '. cv, oooRCl MODEL' owwTT BOOYtiSTYlET12.ow:1 1975 Chevrolet Monza Town coupe ? Tirumph cou s p L .K R:A?.I[O• "' BTATE?- ? SjWLER PL.A G_ ,_-• ?sT E .,K-, cENSE PI,A C No N _.. .,- __-.-•• u.,. - TR ER_ LATE ATE ••?? FRJ 324 Wash CFX y42 Nevada VENILLE:jOfiMjjlJr`-11TJ01Y•ypy^y??pee?-Rm ,e..?w,M OOOMGTEPoNNrAO ,_,.. VEMICLEIDE ., ICATION-, .IIB66-w°t.s Yl?[r161 1"270,5C214224 16641.5 REOISi?F?p?HQy?(ti -y,P.??,???,.. .ORIVGR}LICENSC'. .J..(..... ,_:-•?.R a15[ERED GWMCR,?Iwr.rlsT-Pro°LS'.NUS) n;Y,DRNERSI:1EE113C.J?,Oyy"i Eby, Dorothy Eby N. Y D N 783 JA ? ?w.T.!?x$}Ip.? ' I_ rT1Tr!,?,'?.'"•,;,,y'-„ca4 OATE,OF B ,,, OW RS,AOaRl95 - IsTll Sams as above ° " .""'?. o,• •[,^ PARTS:OF.'.•yCtFGTCW.YIW[U Ly:r:«••-v.ti.?Y,T3YrrF.:'u; PMTA r VEN CLC OA ED .T -; .3.'.,.t'u?i.hnL'LlY.. Left rear Lander and side light cove '° Al?$ Y1k5"` none -v- 3 LIABILITY INSURANCE INFORMATION • VEHICLE NO. 1 • covEAACEINEFFEC*FOR TNBSACCIDENTONYOURCAR YES ? NO N • AUi;ANDwOppE _SQICIABK{rY•INSUgAMCE?OI)CYN?OCDE . " L?[?/. r -. • ??• / N EOF'CGBI?[Ty NSUnANCC OOMPANY. ' " a Cotswold Farms! Inc Rt 2 Box 2557 Kennewick Waa?L 99336 ?L.E Johnson Agency GB . . u cM4?f44P1[6s?571!?RrTF ww!wLe;wcEM" "•:.w <RT ....i:>;.:.? .. :a*.._ :. ,, _:'* a... 1-.14TJ]u 4tP:,f<. ' L.E. Johnson Agency- PO Box 6418,$ennewick, Wash., 993 _ 1L GB5697 ^s nuuR,rv. AY.rr./? °"4t.; -T r ,2NDRUUR 1 ._ T . NONE HONE - - _?• AD RE55 -- SE j•5C ocroR, ®t? o-oCro.. [A.O..rwx n w -}?wrp[pgCp-y'" - F . - --_-____ _ or l"/un ea " .._- T- .1 A I? , ,A[M1[F R}T ONETN T PPL Lb"_}' C Cl.C NI LLED _°IINVU xl y vr l r r "T's oJUR ,yy,r AAH IIR TaNLTN/L:AP[CI¢Yyl(?+? N E A, a LLED A ° uu Ir . _ , / ? w :1 LJ I garll 5 ?.•[R V.NIT 6 °r7-?'? I IR H Mtvt". v e:lr 6? 7 S„ MTN NY CIRCLE \ I ? I I I rR?IymyvOV?I„%{:' I' 1. uva 61 -:'. OCSCgIBE,: BLLOW TMAPPE Lq?l Ef[RT V[ ICLEBBYIMUMSlRL?. r Vehicle 1 going east on brow oY-hi71, salr --- vehicle_2 begin to pass: 1 oould-see onto - station wagaon,3;"and drode onto the rigfit"- °?"'Q \ 4 shoulder and almost stopped when attack by--' - " _ vehicli 2; on * left rear fender. Tehicli 3 --pulled onto-the left shoulder and iii opoosit - 1 bbhicle"I when atopped -Tehicle-2 spun apd-- T ?I? • ; -'skidded and stopped after-impact heading'3n- r ? / I ``IIejj6` the opposite direction ---- e? I i / Aa 1 . ` VEHICLES POSITIONS BEFORE COLLISION [ nv b rlcArtD nr v[HC L NC a[D ST R 7 :_ ? a .Ic ? ? No. oug1:.?,CQQ ., ? u M LJ ?r I El El I 1 lJ P[OCb,R W'(.Q?t'J?'LLD .t. C O .. No PIP 9 1111N. 1(, .. )L_lw .. ? urn ( ].., 10CP..awn• ?... .'. n •RO D[UgFKRU, 1`4A... R LIGNTGOMDITIONn TR FCC NT L ,. YPL 01 O O ORrvtR/ t CL[ACTIO 0.u '??.y y • a "' l • l vl • p J(-1?. I [? -L...1 b nALN 1 ?? o r w r ?I [A-jIIaalNa arnwmnr AnrwB El. ? nR1 tr] q ININa L LI DAWN D > n s,OP SIG ?7 N IJ ) C TWO WAY n 2 ( ] OVEnTARINU AND PAebINO (?J ) (1'1 W!T )Ll GMOWING ) C] DUSR L r-1 -Vr..IRLE f'-1 ] ) P TlEln .14 - N E] a T O NAMING RI-NT TURN r E-1 ) (7 SNOW A ? FOO ? 0 DAR rM1 ON L' Q L [ -J FLASHING N- p-1 { E_ C YJt l(-11 1 D MARINO LEFT TURN ° " n I . 0- ? ?s:Sdhl S ? icw I NOaTr r0 !• r0 fLAM,InG A—. -l ! I " r? ? S NAMING U-T U A IIR ?1 Y El C-l + C l•:J,<: nnA A ? nA t' l . Y N[[T Ia H,M1 _) L ? r I „ ixl w(?SLOWING A/. 1.4.Ob Fnr qDT GF.IM DANA , CJ (?f C : L C 1 C? IP. 1 Y . i' LI / L „ C] , ? a,DPP.n IGN TRAFFIC Ll oR rro ! T ( [ I a rrn E3 L) I o rorD ? o .-.t. . 1. N RwowAr . (1 , ( ... - •raN•Ina IN r-I n nc (I 1fl onnrvmrn n to ? r rrR; unr I ll ILt? M1jMM. •Yritl. ., f I 1 1 I iw 1 I I t 11• 1 [ .?R.?••:AT , :IM' MOTOR VEHICLE COLLI51 ON REPORT NO. -• r O =?'.yx, OAFCOL LIS ON.: TIME :J •v - w UNT CITY NO 1 , ?( 2 j77 M 1, 1 1 ''rt .may Otl,_r??,ys,? TT??4WN M LES:? O? ,r C OW[l a• - OM<LS PRE/ x , , n ni c ea SECTION ?e?YSGnvv ?. d(a• `.?, i?}uD u ox-'"' QJNja-__Y QF re'...eOn?O;_j1,IG11WAYa?y,{ a j•L, TER. _T G WIT j5 ET„ PH EPI% EO MILEPOST "=^ Pvr-T'!x•cLdl-o?-Sh),ne Qadl /. On INTERSECTION•L.OYCATION O COLLISION 1 I , oETwEEH ?UYI CLCIbw CL??STREET Li ID ?L , a NEE't MP AGRAM DATA r .. ?v E? c,o o. w roarvrrnrrvc tArvox.nA. DO " a K.P« I[ [r I TER INTf CLS. , w w w,?rt 1 / SPEC. USE rrvo®i ( ?"C?akY 1 C E? Cl.? .. ? x LJ x x xur OµIET°T U - cuA?4FF41'_,•+'®L? 1 t1u.,, .NQµNfR.OF O-CTS;HANEAN,O, AOORE - w _ .".:xlw.'INR OWAIl,""?^':w. as o-woA, ? FEET rS w o^R' S OA,Y_r• u - '?`?•P .TISIAM ' ` ?',aawv.H?MIODLe,.,3' L: p ORIVERAUBT, MANE?ai:l'.uw:?CIRST.nAM E,n:liyy'. _.• j? p{IgD1.F?.?(jJ , .xiwe 1-f a I v o,? --eROClTP.(-nOay HD?X? aoul[• STR€ET1100n E55+^'-. C?'y'iROUTG Mq?./1ND.?G.X,NC ;.?..-- ,r7, ?iCJa .1-6-d 2 I wrP., 4 _-. SOOE ORyVER,{.G.GSUP.AT,IOH}i cl'SY..•?:':-...:'+..'?..._.?.SSATE?r-'?CJ'r •'•.miuc'-;IPCOO€ OR!V[RSQG?S!!A_?I.?- seal-I'le W a, ? ? 5 !'!eT FxoveYn? •'y?qR T6 ,j,04 DATCOF_BIRTNe AGE Og1V-h-,RS UCEHSE NUMBEq?y??? SLAKE SEX :?,},TxEIO/:BIRTH. rAa i J v? " 7 R-PIE-SN-bOGJ9 Wa l c? 29 -vr.'?A. .-..:: sOOY'-STY4E?.12e-Ryl .:- •wx?I,E_?i.L: MARLy-.Iowv?Pwml MOOIL'.uS:.wwh?wm.? BOD}?'SMC?c AbA FjZ O/ds+noble /a 2®, [ICE(16[-?FL'AFP.N4 - - IIfA1LEwy?CATEi '- ".: .Si TC?•?? :.: .. =' L1CWlryVU1TE,[IG_ ...I S?rAT[?x- ;?RAILE)i- VtAT?L14_•? - <TATF?7 =yxr1 _ _'-• NpoaCFwijNVEwI OO//O??M//E?,TCRIwilua - ,i; , ? VEi11G€E?? . TIFICATIOW)-(p0-i=!ItYegyoeayN.?DOM4TEi1c-_-- C„ NEGIS)J:A[ _-. -_ .-1G ^DNIV ER3?ICE1134NO?;x•.'i? . . ,irPEG15TEREO.DMrNER?, I_PncwomlaM.H,I - 'OFNRR6 LICL[16Ei - S? P OWN -,?w,hr?,rs,/Y/It ??.i.•,yvyya ' MTE OP BIRjM ; • : 015 AOOR[E.,?y'.y"y`.:?,,yl . . Y::eri('s] CATE. F'BI jT - Y Zti.?.l^ CA 0 0 1) YMTS.Pf+.1(EHIf.LG DAMA0E0?-.._..••••4.t?.•..`L';?)•••^•.•••:•-....nrN.ico cosY..:. LIABILITY INSURANCE INFORMATION - VEHICLENO.I - COVERAGEI N EFFECT FOR THISACIIDENTONYOURCAR ? YES ?'NO _ ter_,Img[w?,??,..r?.?yTy???-:?M ??y,,-?'-:.? „w?Awe,o[ uw, 1?ar• _?IHauw?wce?;cwa_t.:'[c•?? M a3 VDY r e?? ap, O, SS02(SE-dtl'?C. ,Twa Sl53' F'avTnc'r5 !-r? $, Co. ? ?•av-TVr.eys ?v.S.Co Po Z'"i'E]wti.5er2L. Lea, gsJ3Gg 79-??7 i-Z7 o2.x?f L...a..... _•s"'", "?'"?9,?,g?la.rpE; ?HOBu? a ' ....._.Ga,..y`.?,r.? w•I?.- .E_+?r??. - - ME NA AMEG •Y\ (? ? _ _ - - _ -S? , ADDRESS ADDRESS MOF _ --- ? _ - - ao a o o _ F -- : .: ' - - ? r ° '-TRII® ®® [>]s^:1 T41111?kRe•T„orrilulT'N?IESnit'io'? u:,? srAjusor lHl ro'.;.r d.rsL'Y L!MEylRaraM[Tnwrr.PT:I€9iSc'4K"MJ" _ Ku.L[q I rx.u: In ewcLe ucD a, o R N,o,r xo oxn H 1 .veal 1 1 , rT I n ?••? . i «n,w rlo._ N IA [ 1 ? 7? - ? 5[3 6 ? 3? 6? T or E w nrcI'M El rt SHOW NORTH BY ARROW,M C IRCL •DESCRIBC BaLnW.-wnA? NAP»PENaW.cgEFERa)LO ?[Nln[S- .BTw MUMe[w E wvH««. a _ Qo+%1 l 41&10 w - s' _ y - ----- --------- -------------- .n•o. n... .. A I? VEHICLES HOSITIONS BEF vc cLC 'a A i ORE COLLISION wMC Ill No, o T E[r IaH r H x[a ox v w. "'" IN EarroATCD Br El . ? H L N o; S °•"^R r m 0, '.1 Lr O M -_ c? ?61? S(l L'1•! a ? ND ?' Ica ?•'o rxvanr«now 1:10 0 IOTI aR ? El ? O , ar q-1 3 ('"? a^ r. Q : .D.MW.At :1... :. .. .. CwO FR S ;'TO'ra}..:.r.•'?,L.....,9+.'.:T! - Prnc3rnMM wwE U «Ha r[-ls a?. a?. w ^? +?? a?i e?o ,1•GKI?40.?K_ Y!uTnrg j+ y fj?L1aMT CONpjIOMf ., jPAIIIC COHYR0. ICMac wl? [ a TrrR OF ROAO?IC a DnIVLCIV[MICLLACTIOH?n.r' rl1,Mx+E I a w • 10 OAYr.IGHT ?TLIOHAL. [_] 11 ? II ? ONE WAY,rI !!!! r1 ? GOING STRAIGHT AHEAD IIL Y ? r ? ONY !? Al.... R ] 0- E]. E] STOP LIGM D& E ? TWO WAY [] 2 C] OVERTAKING AND PASSING t? I ] E ? WL'T 3E] %HOWIN G a ? DUSM1 ? ] YI[LO LION ? a ? nOiDPlIRL[ ? ] ? MAKING RIGHT TURN bNOW ] C -l +? FOO +? LIOHt} OH ET ? + ? FLASHING RED ? + ? rLOOpCi PANEL ? A E] MAKING LEFT TURN 1 F, l . YJ IC[ B? r3P[<IIT I , D' 14H...O%ET ? ! E) FLASHING AMBaR C] ! ? ALLEY n S C] MAKING U-TURN E] ! ?M[C:Y , 'LY 6TM[t:° IaH IL 0 L U RM EIa H.L ? •1 ? l[ °T IU?;N ? [LOWING C] , ? - D[w![MJOn,RVj xMV«,•r x w fEEV+o OAHOrw l,, me ,, a,c T ? lPIGI/r ? T [1 OaFKCR /FLAG MAN t•rfH LANCE [ ] ( T l ] !TOPPED rOR TRAFFIC lIOPPE-AT SIGNAL . ? FrYIIIY 1:3 ? , ? OR IIOMalal1 El [PARAt[D E Ell _. I l L p E ] M1TOPPED IN ROADWAY TR.IFIc . [? a L] mWOro . ? o? TAnn,G IN Al C ] uao v1o[D rrc LANE t N10I UR VEHICLE C.ULLISIU N hLV UR I IYU. DATE OF COLLIS U 0 A J >RN _??? /) % ?? ,,,, r?,. l OF COLL X . n ?• ISION 1 1 J -L-I- 1'' nnI OuH „ I .,, /U01F% RCA COON u. CITY NO. /? / ?u xwx.L CUUNTY CITY, TOSYN 're 4 CO/TLL'iGLLI M r•=;r:.` ILES N a CITY, i01'IN OF fpri-uJL0L\/ ADRICLS , PREFLY R u STHEEi L'OD gS//v SECTION GIVE NAME OF STREET, ROAD OR HIGHWAY iFR/ c,sr ??'l culJlJ ?c/)7 INTERSECTING WITH STREEC OR If0A0 - I-IX ED MILEPOST .0`JINTERSECIT/ION-LOCATION OF O,LJ1I510N ?f ETYEEN /OR.T LU •LC+/,,?! STREET AND (?'/`rJ/?l%G //!] / STREET ff RA ND DIAGRA\I DATA ?•.hR3 1-R6X N ?l.°in"?S"°S:r «I':?` .??nlNr?r.?•.<.? .. +x. .a.x...E. ?? LL •„n r !,_J a L.A915, A,L IIIIER cisD 0 er>E rxeEnxD.wlw ro -. 01? ?Y - v ?W.JCi U111111111111111 orxR......H SPEC.C OE USE px, d/JL - L ^« OBJECT STRUCK -7. O3 aZ OWNER OF OBJECTS NAME AND ADDRESS LOCATION 1 IT-- IN ROAOVIAY LN es 1Nw 1o r+,xoaR[ ?. j1 Fcci 9 r! S DRIVERS LAST NAME FIRSTNAME MIDDLE ••'-" ^ ORIVERSLASTHAME •FIRSTNAME MIDDLE Hec't--r AA PzyM l CI A STREETADDREFFS--SSS ROUTE NO. AND BOX NO. °"""•" STREET ADDRESS ROUTE NO. AND BOX NO. CITY STATE 21P COD'S? c%RT L11PlxLV 0? 9Y?G DRIVERS OCCUPATION NeJSLW,FE CITY STATE 21PCODE DRIVERS-0CCUPATION DRIVERS LICENSE NUMBER STATE 1 I I •?A /lL'CL"! /7G?y SEX nr ? DATEOF pIRTH AGE n Dny ?AR jC DRIVERS LICENSE NUMBER STATE 'SEX DATE OF BIRTH. nIO r vEAq AGE VEHICLE YH. /9 ? MAKE I[N MODEL 11 vARf BODY STYLE lion. I'V& HICLEV . MAKE icxsv. v0 M ODEL ?«ov_oAx,? IODYSTYLE I ox. LICENSE PLATE NO. L-L; !71_6uj STATE TRAILER PLATE NO. WPB' - STATE - LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE VEHICLEIDENTIFICATIONNO. s I[sA «EnIxI ?N ?i ??tR/73 79 DrAE1-n •+x[sae VEHICLE IDENTIFICATION NO. Ilsne wovl.se .Inlx, ODOMETER 111111111 REGISTERED OWNER ,/sr FIA3,uI `f /TDEI_T//1G DRIVERS LICENSE NO. /IO-EL fl ICt_ n1 REGISTERED OWNER I-TrlRSrv?voLENAMEI ORIVERSLICENSENO, O1'INERSAODRE59 /y 13TREET, CIi wNDSiATEI 5P-1*5 DATE OF BIHTH 1,10 YEAR OWNERSADDRESS ISTPEEi. CITY AND 3TATE1 I TEOFBIRTH MO PARTSOF VEHICLE DAMAGED 10r 11 FRrJIJT L Nr/ S?y1?0LE :7 ' VEHICLEDAMAGLD Esr?w ER[wr I A ,onE.+nrExl[[L WASTHEREADTO.MOBI E LIABILITY INSURANCE ®,YES ? NO r- LIABILITY INSURANCE INFORMATION•VEHICLE NO COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAq NAME AND AOIO/R ESS OF LIABILITY INSURANCE POLICY HOLOER NAME OF LIABILITY INSURANCE COMPANY. A,r L/}hI ITdEL-TIfC`? ADORE Sr.O ?[X d? cr ,erLo,?u?ul3Tu./r- 98 /yS r94 H,20 .. .. NAME AND ADDRESS OF LIABILITY INSURANCE AGENT CITY STATE ZIP LIABILITY POLICY NUMBER PURLCY ATKI!'IS 57-owRk1- 1.ro WG577?°!C? Nd SE/iT2E 9$ll, f A/ 9V716 1ST INJUR AGE IND INJURY: (USES-RATE nmAT O ADDITIONAL E3I ,.. ?: AGE AVE NA;IE PRI,?M ?Yfr?iU?i lea[ ? rlrlr? 51o _ - - ADDRESS SEX SEX ADDRESS 7 F oo ? E J . .??J 1- STATUS Of INJURED a; N VEHICLE / ILLED MARK FIRS S EO Diiivfn T ONE THAT APPL o u•' "?uAF IES Dnurl * f « STATUS OF INJURED ?q, , No EHICLE " - KI LLED MApN FIRST ONE THAT APPLIES !SF fMe iM?von - I I«r D A « ?. ? S a b? 07 ? c ., ? 7 6 6 SHOW NORTH BY ARROW INCInCLE t DESCRIBE, BELOW WHAT HAPPENED: IREFER TO VEHICLES BY NUMBER)..;;., /)fYRdA_ /D 3dgM, _w/tl?_...RGTJA_N/N6 rA+DI„IOU,[WFrx ,Y 14111[DR11 j 1•xr1, ,. x,Dxn x.wr Y Wa15LUW.(Ltrw S,DE TI VP.To_f)RRcL) ['a/NT-a/?_ wHx1 3 .9Y.1. E YIx[[1 .«01x0. 1jR„ldR,p??> C-X?/tJUkyJQ _w'cr r3UT_Ndj /C? / ,I[n oIS 0 .x.YI1 .. «xxRN `? j Re4pS dN E:N ' E 7- PyTC ,RCP. L HIT / s ? -?? ??- a .c_ D"w+• '•. I I E _0a hL 4 Gl= .51US/{_ dER (C EO /N. R MRT7r [_-EE __._ N.lL:r; G RT gPA6 x _3SroP.ils/1t CAJL IAib?_ /NTD g SP,nJ-,S, wft5._!L!`_/!IBC? 7"D Ivety lMCRSctnt fAJv 1 I LtNTRGc /}r/ji-,Wc --,/NTd ./}/J OPEN___O_Lr_cd. CfJ? VL }!1'? Fr GyL-! 7? 6rRIKING O 9127sS_ ?. r'.uS c°JCAL?a;WC TrtE BdrTC/J? ar T A? 0 - Y _ . . _ _ d/J r/!r /C)BRoe D17Ch! cP?•? - . - - g , -- - --- T! h?t.L.?,tJC. tslr=ST VE)11CLES POSITIONS BEFOR uIIROLC '1 A0?0 E COLLISION ON STREET OR HIGHWAY NAME OR NO. ?,rcu0 n n. [Na'D I''T NYESTIOATEDDY ,_J i. I. ?vull «? IVou" ? ? ? ? n p? /GR T"Laru J) 7b / r -Mo EYIM .1" ? ? ? ? ? ?y? c ?nD INVHHaAIa« C ? IOTHUO ? ? ? ? ? ? ID ? y'ANY PEDESTRIAN - ? ? ? ? PEOESTnIAN WAS USING ALONG COOSSIND .'_. .. FROM :. ,;. W?D%JA1,.aT • - , ? sir 7 ? n. ] ? .. A ? c, 5 ? ?? ¢ ? 4'J /n? 011E R / ( ROAD 3V RFACC WFATIRR LIGHTCONOITIONS L•nSS TRAFFICCONTAOI. Prr TYPE OF ROAD pRIVFnJVENICLE ACTH 1 ,..(.sue 1 RI IA Y LIO .HT ! • ! « n.?rri r, st ,C.u[x u«s ox waxr ?"I,[]SIGNALS ?1"IYr[]ONE WAr r4` ? 1 []GOING STRAIGHT AHEAD , ' Dr1Y 7 UIIAINING 7 ?IIAWN K J ? V.Cf 7 C7SNOWI!:G 0 nIUSK ? 7 []STOP 31Gt1 S I []TWOIYAY ? S ?OVEII TAKING AND PA491NO ..-. CCT C] D ?Y,FLDSILN ? 0 ?IIOAI191BL! Gl J ?MAKINGRIOHTTURNPC4 W .1 ? SVO.VE A []FOG A ? LICJ?119 t1 N - H.T FHCHAh'E ?'i ?iL.SSIHe10 HED ?A ?ILDDVI IIAVnI ? A []MAKING LEFT TURN C A[ 1 5 t Hr STIitCT [ 1IaIIG ?S111.1 SLI LIGSITS OFF C y LASHING n4BCR B ALLOY ? ? ? ? ? 5 []MAKING U-TURN "ARK --• •- SIRFEr LIfiHT^ - R[]1111 SIGNAL ?D ??eit TV??h to«13 G[]SLOSYING r ` 'Hx•« RE ASON F0?I IIDT 511'.IYIi UAIInE rI D .i?. r, II ,• . - - e? '??r GIJI ?N4??: ' _ Li tr?USSICIIr rLALRI.IV ? T CSTIPProo,on TRAFFIC `TOPPF,D AT5IGNAL. R SFVAl1ArrR D l U ? ?? ?` ? 7A/ L ? ! I C/,)Iii UA a/r.` P/.'[,..,J?[rJ.` C?n7C ?/'C !v lflu<S u ?O R STOP SIGN ?7 ?m QI,Ij ? D ? SToPPro IN HOAOWAY J /S Jc.7.;TIZI u/ J?[r /ic by ?)u;?. <?Ur`I ? ' -- 11C CGrHNIL f.? T ?L. 1 CED ? TAII1.NCIN Y [ ?r JIII ?in FFIC ARE , , _ - I K _•C r r vM r? a i??y ' V S ? J rk }f r . * 1?, JY. OFm 4 DALE OFCdUSiON MO. Y COLLIS ON TIME- SUN Gv D t EN H 1 UtiF ) F I COUNTY NO. CIfY NO. FHWA' O .1up NOUNI I AK ?? ? - nUNA . UN(Y C _ ?STAIETIOUIE XCOUfliY nOAO ?C Iv STREEI YO A . I'MCL'' PItEF1A I'OUiE llil L U E I 1YCI.cA15.6 ? L:LLG:I`I ?OTNEHISFECD,) N 1 O 3 y?Lw/?Jy L CItYO11i OW N N S E VI ?IN V IIEFI% E O. MILEPOST T ?/ 1 - O C . 1 L.c /?li1l MILES ? GO-? ?OF.. .{C ._ // /_tJDZ4Ld_ ....... LL - ^ ? y . ?A/ i NAME AtI??F"TRf ETOIIHIGIIY/AY INTERZEC HNG VOTH: SCREE TOR ROAD LL R AMP DIAGRAM DATA T J ON c .0 SA,lts?_Zo_yq?2 ? N ° O NO INTERSECTION 1 ^ ACCIDE IT ITF.N JON Y. IID tE115ECIING ptn ET OR OAD OR REF. CLS P I N ?'y''1'•(?? / 'A 'T} - ' ??/ (? /? ?py DETIVEEN 'I fCY•W ?"+?Li .. KCJY??. NRltCirANV ?(d121,9'Lix •'!+1 I+*•InldiC:4! MI LACE co" E ENCE CH/O/?S?SS9REE'/i7?OR?ROAD _ UIS(AN CE({A??NU OIIIECIION F(II?OMI H?EFERENCE OHCfiO`:S/SiREE( ) /? T . //? _ _lJ EE_S ? S-1_ICY? OF LL )1L .L Y>v ?C ? EI __ 1 S ru;t tN TI^'?- PECIALCODINGUS. VEHICLE-VEHICLE C3 VEHICLE BICYCLE ?OTNE I11VInREI ?IIR 6flUN SE VEIDfY COLLISION IN VO LVED: ? ND -ED . E? - VEHICLE RR T ? IN ?STOLEN YEIIICLE NO.INJU RED F C ? O ?G W VEMICLEPEUE TnIMI Nd l COLLISION ? ? ?IIAIARK US MATEIIIAL ___ ?PnOP[RTVDA LY , DAM UBJECi STRUCKINAME OF OWE CT ST RU L K ANOOWNEfl9 NAME] LOCATION OF OBJECT STRUCK EST, DAMAGE 5 ? ? F? j . [ /? I 3 dF8 A- O _ ? OAOWAY FECT ? n ? ? I iD EDGE S URIIEPS IiA1AE L1 T 5 ,. ,.. ,FIflST? MIDDLE DRIVERS NAME LAST FIRS)MIUDLE II H-CLISICHPLDkSHHANCHECKILJ ... , I • J STREE ADOHE55 . .Y-...-:..,. ....:.-:. . V - . . . R.... STREET. ADDfiESS E . ,. ? ? ??` ' ? • CRV..: E .' CRY STATE .; •. .. ZIP CODE .. +. .. PHONE NO. N N I O UNVEJLN LICENSE NO. ,?, _ Sini E DA TE pF pIH N URIVERS LICENSE NO.. .' ,: .. i. STATC .. SEX. DATE OF DIPTH -;', 'q'L G I Gi OR •/ERS P ' ?/ ? 4JQ FFI rJ? f. YP DA J 0,. ... MO. DAY '.YR. I DCCU ATION .. PHO E NO .2 : DRIVEfiS OCCUPA(ION. FI{IMNMI .... .. .. -. ..., r.. .. - ,,-_ HONENO. G'S 9A) 5 lN?c zzz CODES > rl S?__ f _ I+I SEAT BELT __.I _. I EJECTION CODES > I]I INJURY CLASS I•II --_- _- SEATGELT _ ISI EJECTION. NATURF.OF INJURIES -_ NAi NE OF INJURES - VEU FROM SCEN[DV: TO 1F ROOM M SCE SCE NE DV }O VEN.YEAA MAKE IDODGELHEV.I. MODELIDAIIT-NOVAI.. . STYLE120R.{ONVI VEM. YEAP: MAKEIDOOGE CMEVJ MODELIDAR1-NOVA1 STYLEI2DR;CONV.1 - E 39 p U DC0 H ` VEH. COLDI MC. FLwTE NO. STATE ifWLER PLATE NO- STATE E VEH.COLOR UC. PLATE NO.. SIATE TRAILER PLATE NO . STATE . . I CeA 1C i :( C VEHH, bENTIFICATION NOMDEH .. _ ...._ ..: ,,. ODOMETEH... C VEHICLE IDENTIFICATION NUMBER ... - .._ : ODOMETER L E L + .5A 1 ; L: REGIST RE O OWNER- ...- ., ...... MIDDLE E REGISTERED OWNER-LwST... _::.... .,;.. FWST ....:.., ..... MIDDLE N I - O. ADDRESS OF OWNER. ... . ..:.. :.:. .?.:.. -. '. ... - . A DDRESS OF OWNEfl .: i.. :. ..';-.i :... ..:: ;.. .!.;:'r: :•.:. ' 2 • . .. . NAME nNDADDRE590F WSUPAN ECO. pIi AGENT '.. - N -EANDADDRESSOF WSUR.WCE CO. ORAGENI ... ::. ........:........ ::. CHAliO .: ..: ... •' . .: ... ... ..... C IfAT10N NO...., . . . CNFORCEMENT. CHAHGF... ..:, ?. .. .:. .: :. CIT A IN ...-:.. _, Y_ 1.. AC110N - .. . ... . - : :- ..... .,-.:;..' NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ,., ` CODER - 2 0 4 5 S EX AGE STATUS EJECT, `. C U 1NOM F; `EI TO A E T AR?E" O EDN M FNE RYTO W T ADDRESS.. bT 0)fl M TA U X l iC(NF n TO $ H AMF S A ODRFSS S+. S ??f NF T O 1 11'+1 AIU+ 1]I SE A 11'OSI IKJN 1]I PMUNY CLA'J.R IAI SCAT MILT I SIEJLCIpN C' 2. MSG[NOER 2 P)fNS111IAN A DICYLLIGT I 1 1 y 2 i.OlllCnPOSlildl ?? 1.110INJUM 2 UE . ADAI SCENE ]DEAOdlAMNAL OISAULIHOINNRY 6NON DISAWNG VIDENTIIWURY I. NOT INSTALLED 2NOfIN USE ]DIIIG .NOTEJECfF.O 2, lOfALLYEJCCTCG ] PAR LYEj JCEED E ,,L T eIY'IITNEW 6 ] Si('IOSITgNUIlIKNOWN) ADICOIN1g3111A1 OSEVR.E WJUnY 4 SGEAT IT pNIF A P FNLURE GECiC L i NU ?? r 4a Ul? a? 4???wwLtlr y7 I r ? %?r , Tt 6 ?':' ?J " r I ??J•; t h r?7 i J G'I. Y iku I VEHICLE DAMAGE INSTRUCTIONS: IEwly ?t°:Ye-f L. 1 IN EACH "ON, CIHCLL TIIE NUMUTIi OF [.ICHUAMAu?OAR A. 2. SHAOE AREA OF SEVEREST HR ACT. a. DRAW AnHOWISI TO SHOW PRINCIPAL DIRECTION OF FOIICE. ?? ? ?? I"y s?xr~n e 5 ?H?`` [[ q 7 Q/ UAMAfEU VEI5ILLE fJU.2 Ia. rluw + ? ?,?, RITY OF UAMAGE V[r11LLl NO 1 SL AAAIA 1 CLLI SL C TY NFNAMwGk: VL C Jst ISAE, GDAMA.E a ? oTHINn N c ? P eE ]tf5 DnreruN V U cE CI sn9uxc nmagce a l 1 o I Fn v weE x CI ruxcT Onnr nnuACE + O N Hatt U Acr a ? no AIL CJ '40 BwcE _ NO I uUCT FUNCTIONAL W TONED bYti(I.I ,%`.nn nr+r LST. NnAIALE TOYIED BY ST.I Mnf.E iOWlUIIY LST. UAIAAOE ORAYJ DIAGRAM Or COLLISION .I. I - .. 1 L NURTHI CI CL Cr I nIA9L3 GN+r .. I ?.. Axl+. Lrc c9rvrrnV<I 9N ? , : I .. .. . LDL+,r.RDB,eIE1GINTDF _,. ?? ? ? c.LO[srRI+N OII :. _ ,/: __. ?j j ?? teCFCHr rID 1 i Ions+r VPArr ? I 66V L[v[NILLt Dw I I.-.1 I l ?•J`J+ I I r... I DESCRIPTION OF NND¢ATE wugr PRrnaNLY RAPPENeooFmlE DUmNCnNDnFTEnm IASL,INCluGf lrvorO.arwrv T mncnAM, E.c. Dxrvbl COLLISION —ABILITY, REDUCED VISIBILITY. PLOESrINAN CLORINO COLOR, CONSTDUCTIOIJ Oil IW-RI WORK ETC.(U - 1,5W1C: ':. N?A??o _eil.rLsrt3ovo© on _eL? S>}?N ._Ze?a{ &7pwtvuR c? PV?d_,?I"? __?voto. .?N. ?Nt,rn9G....Vw 7ufi.?(?a?ao ylFir'r F?IGP1`T_.?aiuK-?.GfdRRCtnE1?_ d? 1' ? GCS ?+?` ?c'nn?..- '----_ tx:?ror..cvc:.R_,?'ou7'N__ti_ArJK 'f???o_Uu?a. a,?ci? :?owroc?n,? ?u llts- ??ca??sr-- w'o:>HG_'"i'RCts ------- ----------- __-_- POSITION BEFORECOLLI ION onF OI E o L w E D NC OED T TrIFET On M GHWAV NAM! OR NO OCCUPIED No. INCREASING Cn SING PARKED IS E IJ t L 1 _. I OLD SNIt116_?0??' )_ roc 5d 3 ES N< L-Ii l It _I -2 - L._I _ - ALONG -FROM ------ .. _.TO:._.;.._ PED/ICVCLISTWASUSIxf. (SIDEWALK ]I IWAIKWAY ]? ISHOULDEn AI ?CRO-ALK .000SIGIALKG .?BILYCLEnOUTE I. IOTIIF.n HOADSURFACE IC EC ONE( I WEATHER ILIIECK ND CONTftIBU [C TIN One CIRCUMSTANCES -. HECK :. vfHFLf ACNONG ? _NN •?E a •I• - ° D V 1 U] 0IF.n V O °nIOE] On VErI L rv0. ] .. g. ? I GO , ` STRAIGHT nHEAO ?.' I CL[A D Dv gOVEflCAST INFLUEICEOF : IT ND L-J. .ALSONOL_-__. ! LLOW NG I I.. 100 1 DISREGARDED . I ' OVERTAKING D PAStInG .,, ''• .`' I] WC ln Ixc I I uNDtR INFLUENCE Of Dnucs vEn CtxiEn I ° LINE AIIAIEITLY ASLEEP _I]I AKIN -:I MAKING TURN ,....._ ?SO .. _._._. a l ? ° SKCEDL T.. TL I Iar I rI i 1. ?FINANLG O O _... _. I IL OCOQ K G JA: EFT MAKING '. . I CC _ ... ` , -.-.. /\ F .. E. CC $o 3 E _.... O E I I u N j1 O - EE -r _. -. L I :S "Al T 1 N 1.• '" [ _. 1 I C 11 S ? I I I .. E C LC Nl R/W I S.O E .OL GIIT 3 O G . . u ' I YFCIPY . _ 0 E ViIIER ISYf Ctf Y1 f OYErI PASSING NISNECANU STD, ). SIGN'SGNAL oT C 1 EC B NO VIOtAI UNYI DFaP )?....., TRAFFIC ' LIOH`ICONOI'rIONS K ONE. RAFFIC CONTRO INO.)VF II CLC . vEluclE TYPE OF ROAD NO] (CHECK ONE OR MOHEI - VEHICLE CONDITION . VEHICLE ?'bIl?I?F ?1 ) I • I t SOBRIE rV ON ItIC ICN[OK E) 0 ] a' - I OP FORT SIGNAL I. I I_ OII STOP SIGN r . 6'i . ? SIGNALS 1 ONE WAY 11 7 1NO knl C ON FR T 1 11 . i9__I ROAOWwYN 1.1 DAYLIGHT JJ ?].. I 0 -.._.._ .?b . )I T OW _...... I I.0 nKCS . I PAI EII. :TO, TRAFFIC LANE . ] UA Y l ,..? ] I fLD ]r REVERSIBLE __. 1-3 .IIOAD 12 I C 1 Vf1 .. I! D G I ) I N .. NUT P 11[O _ _ I 1 t ] PA IK E.N1I.ION _ ] I OU K I ° [ OOP L 11 C I GE -' L CfA C G I I I mDfO IRRETY UNK ENG- IENTEmN- IN FICI L + I L OIG TSORFE nLU . - ?11BI LASIIIN. gMBEII 1 • 1 L M I yl 1 ALLL 1__? L_. R LI II II IRISIVONN L_l_r. .OII YMnDlIr IIA11 OfN NIN N, nF[N 1. 161 I 0%.CKIN6' I -. ._. 3( .DARK-STnfL ,LOUTS OIf-,-- _ . ._ . la?__I ?,..._SIONAL, _ wOWAY-LEll TUIIN Nit I ) I I Ilf N V CHEM. TEST f i B.? n .. ?SNK-O G 13 1.11 IT LI ° CL ILAGIJAN CI I I 1 TL.tiGIVEN OTHE R (SPEC IFY) , .. ! I ?]? I D OIU X I-... NO PF.FlCiS r I I TEST IICIUSrn I :. OT FR (S kC I . _.. 9I cxln? LIt .. -, ., .. _. aI ERVIDf° ^ 0 I EST RESULT ? Z ln I iG GO [ N EINANK 4E Nn. YULIClU ,UIL BVEU CL (OEDLNw INTS 15 IIIIt ATF -73 N ZPE D V j q SI.g CY ATLDf 11tY011! PNPVIUb AIL Ii LLlytl IAUG HO. L 3 S?(?(`,,//\\11 fyrl A???v DN t O .IOIRIITION: ORIGINAL.- LEND IO WAGIHNOlON STATE PAIII(IL -OI,YMI'IA, WASHING I ON E- ' - ' I SC(IYY-IIIPI ICAJECOI Y INVCSTI(SA10111COPY PLICATECOPY: LDCALI.AVIENFOnCTMENTAGCNCY i. I I ` v' ...sa lad ? ?? `. JIATE v) -'sTi7f7L1 MOTOR VEHICLE COLLISION REPORT ?LLq DATE OF COLLISION ?WNOSCOLUSON IV FCOLU505 I Al COO CITYNO s..eH j /? i•CF? D F sA, OM. IM [? COD CIlY, OWN aDx FOw W µnF rM LES N W i ? PM ?? . ?© y'? CEI Y, TOWN AOMCL$ PREFI% rFOa STIME, DODE SECTION A ?' w«x"FrD ChB Il. 3? .EPr •3i3 ©© OF P441- Cfk l% '9-.J I ?f 0 -4 ?IONF1Wi ; 1 ECN E FSTREET,flOAp Ofl HIGH AYpw INTFRSECTWG WITH SiflEET CR ROAD ?°AY'`P' G? f ! _ PREFl% ED M EPOST 1 28 . NOR INTERSECTION kbCATIONOF COW SON MMP DMGRAM DATA A BETWEEN STR?ETANO N _?' / } ?jI EaTDa ET +'r / /?' © wcssrrlcnu tf/?p?y 9 FriiwEiu+wswx uB ?E' NON %RD c _ ?a nlcN' L-/' fFEr lI_J ® DF i ^DN INTTE ER I TEfl CLS. -;T fDCSr O {6v q "?+ fA SKNwroLYFO f--r pvErvKlE.v? pvErv .ac Irr /L-? (? ?. L pVE-CtaF pvFaLF R nyorrvFPlwwRl - e v SPECC OE E K ? LY VFFw.fa Y pvfrvKM PFDES1x AN I]NaNCWUSnvE auN :?.- 1 , DBJECi STRUCK IRAVEILVMED, sTaucµ pNr V OWNER OFOflIECTSNAMEANDADDRESS LOCATION INROAD WA Y F?N © DDDE pFK ' ! + ??LE EET -sky ???kirn • ° F AgaE rrvµH • E Z DRIVERS LAS; NAIVE FIR T lAME.. MIDDLE rwD CAna DRIVERS UST NAME FIRSTNAME ID -... MDLE ea^ nil Ya. STREET ADDRESS ROUTE NO.AND BO%NO. NI ,vq STREET ADDRESS Pn X30 Z WaNS wFPE ROUTE NO AND so%NO. P Fx IINJxFaDSFA P ' , ?' ' -Y CRY STATE ZIPCODE DRIVERS s ? 3 OCCUPATIO N SEPAaA,E CRY STATE -CODE WI'/ERS OCCUPATION cc Co?l< G' 3.s ?x? ?z DD DaDN ORIVEFS LK:ENSE NUMBER STATE 5 % DATE OF BwiM AGE '? ? .I SC ?? ?/? BRNERS UCENSE NUMBER 9TATE SE% OF&R H AGE ? 797c4 fi ? " ` ? i ?E ?i s T DATE VEHICLEYfl M- I. REV DODGEI MOOELINOVA pARTI- BOGY STYLEIZ Wi,) VEHICLEYR. MAKE ICHEV.-DODGEI MOOELINOVADARTI ro BOOYSttLE I20R.) F 3 /NLOIh wt all - ?? p 4 LICENSE PLATENO. STATE _ TRNLERPLATENO. STATE LICENSEPLATENO. STATE TRAILERPIATEND. STATE r y51rf VEHICLE IDENI-ICATIONNC). 11908 MODEL56 NEWERI ODOMETER IMILEAGFI VEHICLE IDENTIFICATION NO. I/r- J 8'?1? `?? / - IIB60MODELSa NEWERI COVETER IMILEAGEI -' REOISTERE ONNEfl-fl M1AST FIRST MIDDLE NPME)-., DRIVERSLICENSENO. PEGISTEREDOWNER (LAST-FIRST-MIDDLENAME) µ gg DRIVERS LICEN SE NO ??pY .. ScGr k/eiZEf fni'?x SG /fG/•EN M/ M O S OwNERSApDRE55 ISTREET,CIT ATE)., DATE OF GIRTH OWNERS ADDRESS E ' ' - ISTflEET.CRY MIOSTATEI ,. GATE OF &flTH- V J? r F70 -3 R 3- 37 MD wY YE 1+5 v? - cvl PAR SOF VEH EDAMAGED FmuATEDCns r i. i?l , . -.; r v LL PARTSOFVERICLEDA I ED D A.rMFIp f.. _ LIABILITY INSURANCE INFORM A71 N•VEHIGLE NO. 1- WAAS.ITIE•REAUroAIDaLE Uaelurr MSURANCE ?y__ COVEPAGEINEFFFCT FORTHISACCIKNTONYOURCAR •?YES ?r,,D - mil NAME AND ALI- OFU 1 M ?I F_ y Orv NAME OF JAWJ}y INSURMJCE COMPANY E NAµ / i• r r z S4?' NAMEAND ADORE55OFUAB UfY Mi'u.-EAGENT Crtv yr IE Sv UA81UTYPOXYNUMMR V Abe. C l'I' ! S 3$ -! O O 5 isr MJLwY .._ ` "GE o wunv. 1N (usFaFPAaArEaErcwrfoa.mnx,xµwualFS AGE ' l ?E I NAME / W Sryi a ( __ SE% AODPESS m6 ssx p ® rua5 /qt ='E. TORI + .' STATUSOF MJtMED MARKF-ONETHATAPPuES p NAr W' NO`H AIxIND WATUSOFINJURED L DwDIMD MMNFIRSI ONE THAT APWES M •4 L 'J ppwEA MVEMICIE - pP SSNCEa ULLED K I -I- p--,. VEH CLE DnADINO ON DnA %•q ?Nwoa FDN EF& 5 r Mwoal couPUHI ASSFNCFa KILLED IN,uar t pMDa O P aFl ssw S Oo'•+.R annf.P: ? 50 B? IIO7QErcI 0...... AN ND - -.. IVE o P Hircl S.IOWRORTHBYARROWMCIRCLE Aa•if 11 ? S? B? 7[:] D MoKA 4H O I x DESCRIBE BELOW WHAT RAPPENED.IREFER TO VEHICLES BY NUMBER) I r;,E 1 .MOIa alN[lr'.IX?MrwivEM.S'DH a L 1 -- ! 51NLIt px'? -: VEHICLESPOSITIONSBEFORECOLLISION 5 M YfraDM f..x%ED w,a INVfsrnlLreD BY t [ Dµ1 ANpNO Mau PAaAe Al - VEHKSF N 9 E W ON STREET OR KGHWAY NAME OR NE) M EWj E v v[ rtlE OCCLOKD N° now ? D ? ? • ND SLY Non 5 Ro ? A,Aa ? ;7, 4 D ? ? Rx D ? 11 ? ? ? ?Dr ?o.ro °^ 6 0000? '- KRRea1 ? 0 0 I} I / '? n1I•SnHU.I 1AEoNa FF, fi10M DIRECTION TO PEDE (DIRECTI r 1 lL T " wm.WAS UDMD ?SNXwALK - z?wAlKwAr NH ON. n 5 '4i1 ? OULOER • D =C fw'. ? lrt b ? cnoiawuK e OTXER / I ^ D - f ('•?' RpAp /AC[ WCAlH01 IIOIHrCONDTIdis S 1 A ?, T t 6 IWU1 TIMiFICCONTR01. K:HIdOH[I TYPEOiROAD DRIVE /V REHK:IEACTKNJS Y ,. {! HrfA1 DU Av vFNKMM f VEwUe I,:NL?II CAf rFKL? f IeNFCP ON UlLtlAE . t 5 d T^ d k . AO I I 1 ON4a? 1 ? DAYLKYIi ? 1 ? SGNALS OI O7 OPXDAEI , 1?J<? v 1 tP ) F]i ?Y ONE WAY ? Odp STRAD T NIEAD y ' W E M?-•F T E DPµMp 7 D DAWN ? 2 ? 57 OP SqN F D TWO WAY C:] T OVFRfAKI1q AND PA9SIN0 6Ea0w - +1 ?N 11 y _' t ] ? SHOWrNO 7 ? [HUSK ? J ? YIELD GqN ? p ? BOAD SIBLF ? ] D ? MAKPJO RIGHT TORN r I Y 1 ! ? s ? • ? rO0 • ? "NT SIpiEt ? • ? iIASHMO RED ? • ? MIEPCH/MOE 1 +} I / ! • KE C) • ? .1-0 LEFT TURN` rr I, L ( .! I{ ? ? b ?OiPrc-I b N t ".,so ET ? b D FLASHING AMRER b ALL EY RAMPI } C, 'l f Y J y D F 0 ol- OAPK.NO ? ? ? 50 MAKING U-TURN IUNO- ° ? 51N(ET l10NIs ? e D RN -AE ? e Yq w.LV. t } 'I 1 , REASON FOR NOI SEI•faoµ.DER 0LfMEBLFN ? b ?DLoYww rr f KT•CLn[DVbbH RfIAAFId,[,<I 7?GPfOry ? 7 ?OffIC[RiIlAOMAN C) -0sv I L f ? STOPPED FOR TnVF.C 1}/'I ?,, SE [ pGNAI S +' .? S I ? ¦ ? 0t ER. SPECIFY 1 E) ? s OR PEn slop SIIF ,v I PARATED DAT 1 J t<i E I NO ? STOPPED M ROADWAY I„ T ' `' " . ° n 4+4wv„? ,(.' "7w. 6 , O R ?rj n ._ f4 ? ID ? TAT"C LN „ -C I ! I !, ?Y?,I,4 f+7sp)p?w lax?ryy? f 1 t'eEf.k"+ rlli a- ,x r',.w ,1 / j I ' 4,Y q° f'?M1 L .TdMr?11 .'}Rn i?L .4 S r? ! 6 t "r Yx t9X 4`' 'w: r r 4 I ,t by ?i ?' 4'I L+i°y %' IIRbT7F?dSJ K C NI?umP D DATE OF CCLUSgN DAYOFCOULSION TIME COUNTY NO. CRY fq. FHWA A MO. DAY Yfl. T E N 1 MON 2 tUES D Y/E A iNUH S FPI B SAi IUSE %00 OVflI } / `? `? ?DRBAN L I J = III / R TE O URAL C Ntt STATEROUTE CWNtt ROAD ? CITY STREET O ADMCLS. PREFIX RLIN-CAGE OU SECTION I ?O NER (SPECIFY) W G S / 0 CITYORTOWN ?IN S W P REFI% E 0. MILEPOST O I ? ?? P w D ) V O D ES L."' O LL NAME ANO.OF STREET Ofl HIGHW Y INTERSECTINGWITH:STREETOR-D R AMP DIA- DATA 4 ON `Fz=-AL k 0 INIERSECRON lIW -NT %RD INTENSE NG ETREE -Al ON REF. O //?P•?? C Q CA ML1GE CLS. 71k ERENCE CTfOF55^+EET 0RR0' 11 N KES? BETWEEN VL? sT TREETARO L- -1 OE7 COTE 11 0 t) DIRECiION FROM REFERENCE Ofl CROSS SIRES AM +} MILES rv 5 E W +!?i!1S S Y' u F PEC( COOING USE ?'• g ?; 1Tti A FEET OF OLD I A E J ti A EI ?HITARUN COLLISION INVOLVED: ? VEHICLE-VEHICLE ?VEHICLE-BICYCLE POTHERIWR RY SEVER NO. KILLED I i? ?VEHIGLEOBJECT ?VENICLEPfl iNAIN lJE OLE ?STOLENVEHICLE TOTALNO. NO.INJUPEO ) ? ) ?• OF VEHICLES `f? ? VEHTCLE.PEOESTRtAN ?NONCOWSION UMAZAROOUSMATE-. PROPERTYOAMAGEONLY tj OBJECT STRUCK (A-9O OF O WEECT STRUCK AN D OWNERS LOCA ON OF O BJECi STRUCK E Si. DAAfAGE fT 1 _ F [ _ ' t I! NCL.E G ?PC-J'NAV C-A FEET?? E El RD EDGE 3 ORNERSNAME LAST FIRST MIDDLE DRIVER'S NAME-ST FIRST MIDDLE -IF NIC,CVS! OR REMSIWM. CnEC+I ?; i R RL ?, R ,. STREET ADDRESS STREET ADDRESS v I v E R. CRY STATE LP CODE PHONE No. E R CRY STATE ZIP COOS PHONE rvO. N D,. OWVERS LICENSE NO. STATE S EA DATE MO. OF BIRTH DAY YR. N 0, DRIVERS LICE-10. STATE SE% DAT MO C OF BIRTH DAY YR. 1 DRIVERS OCCUPATION FWMNAME PHONENO. 2 DRIVERSOCCUr TION FIRMNAME P N N CODES >101 CLASS 1%1 SEATSELT 151 EJECTION CODES > ` -Lka _ CASR 'A1 S, SEATS T EJECTION IWURI HATUREOF NATUR INJURIES - .VE FROMWENEBY: i REMOVED FROMSLENERY TO VEH. VEX. YEAR MANE IDODGECHEV.I MODELIOAflTNOVAI 51YLE12 DR.CONV.) VEX. VEM MAf-ll>DOGECHEVU MOD; yOARTROVAI SttlE12 ORCONV.1 v '6Z VOLVO 7t1'F_ v nZ E=t}-L2 E " WEPT COLOR UC. PLATE N0. OXJ Z87 STATE cv 7 TRAILER PLATE NO. STATE E ", -COLOR UC. PLATE NO. O STATE c TIWLER PLATE NO. STATE (?' VEHI IDENiIFICAII N NUMBER DOMETER C VEHICLE WENTIFCATI N NUMB OOON1EfER Bl 2 5 78 7g3 E 3?oZ c 8 , E PEdsiERED OWNER-- /? FWST MIDDLE RMSTERED 0'MN -LAST FIRST. MI0- o, -cvoo D -F2EA 2 i A , 0. ,; ADdiE99 Of NER ADDRESS O O'h`1ER G! ?? ?f"-?A?50 z NAME ANO AODRES90F WSU CO.OR AGENT NAM DADO-OFMSURANCECO. ORADENT VE?• CHARGE d ANON NO. ENFIXiCE,,, W CHARGE AT ACTIW NAME ADDRESS & INJURIES OF PERSONS INVOLVED CODES T 2 ] 3 , SIX AOE BTATU9 N EJECT: L. NAME: o' K, C ADDREss: U P NATUR EMOVED- PIRJWEB' SCENE BY: TO A NAME: N T ADCAfESS' $ NATURED TO ES' R DFR M SCENERY' W NAME: 1 ADDRESS: N INJURIE SCENE BY'. S NAME S ADCRESS: E S, u u iNJUNI 9 S PWF R I.1 A VS ) A 'JN •. A INJVHJC111 r' n i4 E 2DE J TS RY 5No" " 0 1 T.PED 9 BCVCUST . 1 TOTXER POSITION AD . CENE DOEAO ON ARRIVAL I.SS D I 1EVIOE'. ,JRY• D O 3 2 LL f N P 3 V 1 R DIEDINI10SPIT.AL .. I. POSSIS.E'..JRY E lY .'1TNESS D 1 A OY S G 10 Y rt1 9': J x?A? ?p I rarr&e wz TO AISkAI tlkli 15IElEtigh I, NOT INSTALLED OTEJEC?ED I. NOt.N USE 2TOTALLY _. ECTED USED 0 PAR-LL. EIECTED A UNKNOIt?. A ll'IK•IG.'.•. A 55 EAT BELT rMW,1E EJECTS;, T_ I AA10A A?'rc `SCE] 1ihM A 1 1 * ! 4 i?? ?L I +1?y1 t ^'?Y L - 1 77 1 r?i!n ?? 4 ?i ???'? ! a Li ?t4?ho?r?4fYStlr I, l;tit h7ll Ts'1(r' - 4? ? ?u t1. ? G nom T? 1 ?? i??Y ,.• Y ? } ? I tl 1 1 ? A+ 1? t L 7? I I? f ?. a ?' ? lY I - I l HII r L H < ` rr no br F ? ?jq G?f?+ VEHICLEDAMAQE r.w EACH eoxc cu; THE NUMBEROF EACn DAMAasOARFA a r1RY?,."^"' INSTRUCTIONS: - 2.SHADE MEAOFSEVERESTiMPACT. .... nw •(; ?.? SORAW ARROWISI TO SHOW PR HCiPAIgRECTIQY OFFORCE .. ... '• DAMAGED VEHICLE N0.1 IUSE TH193PACE FOq SHETCwNO DAMApETO7MLLEit{, MOiO{1OyOtFS,ETO.) ® +o ° s rG. Ploaa DAMAGED VEHICLE N0.2 I rnpyr 14. Naor a e ra HPO0 e 7 a Ia. TIwH rt.rbol • k - Ie.umArvPMO, -' a ._ rnl Ia.nunH 9, :Z SEVE 0 DAMAGE. lE N0.1 1).OVaturrl 12 „ , ,° M ° 1 ra.UMe<TARy°e ° IT.Owaan r. ,) t I' IQWSABUNG DAMAGE JQO,HEfl MV. DAMAGE SEVENTY OF DAMAGE:IOTHEfl VEHICLEI SEVEPoTY'OFOAMAGE.VEHICLEN0.2 2 FUNCTIONAL DAMAGE t NO DAMAGE ?g9'18U'a O.V,IApE J?OIHER M.V.OAMAGE I0D NO LSAiw DAMAGE JQ0MERM.V.pM1A0E yL5 / •` TOWED BY JT 2 FUNCTIONAL, DAMAGE t NO DAMAGE 2 FUNOTIDNALOAMADE / NODAMAGE - s j~I i L I 9T DAMAGE TOWEDBV EST CAMjGE TDGY Ear DAMAGE u TO OY E CG• • a LI. ac DIAGRAM OF COLLISION; . TO TO s :r DRAW ARROW SHOWING @"I AOi0p1°PO'Y SPDwr. nANRCT ?. 7" \ ???-c- -?...- ' ?5 7' eeccmnANa i I G! e 1 i -T1- ?LJ`• __? .-r--• NORTH IN CIRCLE ray... _ I d D "a :w`°`.iciwca.xEwlNror -f- a' .A a.?wv[Hidp,PFDE[Rpµ°R t T-?I a '.?f?. • ?PFmw,ER""ca°"?u'"'%?DN°FFO"•? ' - ,---T I ; .:'1--? ?'~-T???' -c ? I _? . I I = I , .. i 7,?[T'?-5 F? I -f I T- I I I K •?, ' I I i r ,., ? hI I t I,= f DESCRIPTION OF'?`? r I ( i COLLISION. (INOICATE VMEWAi PROBABLYVISIBRJiY, CED HAPPPEENEDBEFORE 0URWOANO AFTER THECRASLL BPCMlOE WFORMATIONNOTON DIAORAIA,EO.pNVER r ar d'? - - OL4A&UIV. RDESTRIAN CLOTHING COlp0.C0<SfRUOrpN Oq REPAW WORK,ETC.) t"''1m Lk,, s I No. HEAOEO OR. ON STREETORM AYNi-EORNO. •• •• w?,....,;.. WO?NEOaiEOf10N N SPEEDS HID P i:. 'b D' pRFASINO r- N 3nn Enn W ' PARKED OCCCUP D m )off _. 4?4?L?.-,y l/J n T/'"? C .c . ?C. / ZC ? ? ? ? A 2 ? ? ?-_ ^._ __ MPH YES ND YES FN'O? r 5 ?f-' PED. n MrH'_ I? I X L.In?1 ;LOND OR .-Ay MOmrAY .rEGOMD, r° CpMwinlE,°w,- ?tP? ?• _ PED USRASUSWG. l IsUw dpnnm 1 'en?^'+w.swmAU I7 P°ya 0esaxA _ Y i ROAD OAD SURFACE:;, -WEATHER wMxw _. bi raEPrnnE an+m [°p,r p„q Ip„ ?_Cl1NTRI84LT1N0 CIp?CUMnANCES w •omDl1lbeotcADPOFa_-,.,. No a w i omEn °°`s ? wIR + rNN'-.?. 1 mr 1 I pC1F'?YFwC , j ErwExea ' NQ ' alv°bNOWarrtAH[AD . ' ^ a ,? W[T x n RAePn .. ? --?-• wDERNPLVEHCFOF ? ? TOO. CtC36r J a?w. ? ;` a ?, v?.My?Ip ?? i f• ? ?_ :e.-_ -1-T?%.-___.-_ L_.?_{1 u^+n+ _. _aL l-? °°^TN it ? r. ?a? m a sxow a ? suoES a ` Tm { e r-' uuuro J .. •' ,? r I?t ? .ICE f -1 ra0 r'. ^ uc0'vnrEAa 'i-I L ? s°wu a? v?na<O ??t? MFr?i1MI Ib' ° 1 i bey ?_ j?K r 1 0?'WE°Aro -_ CfFF--------- - ?6? LLrUM< • OIHPr'YEpYI---_ ?_ _ ?..` aICPa DOMOM ? ° ? ewvw I - ? _P°? " ^r2'-l omlEOAn0[rav T^' _- - LIGEITCONDIT10N3 TRARIC CSIITRpL '- I'' eaN<egHU °?. I HoO°O1MaA1°no TTPEOF i?)? mDEP[D Fp1 IeH[a oH?D? _„0.z Vsti4a V[xue ROAD VEHICLE CONDITION SOBRIETY, ;,;,„ n ? iRr'P1C Q, 1'" L.' ? -p J rCrtOf CHE CR Mom) 'V ICw E ,,21,IXL •.. D H:IKCNaYai I • °Mr m°OQw°10N"L a k UYUDIII ' '' ? mmp„ R? a'?? ,w ? MEa°'rve "} reo .; r , Raow"Y a aww ? ? a i r Wn - ? .? ??10? mmMr'am°i u _ - _- l 2 a ou[H ! i '-'I '° { acH.woe -' _- 11fp _._"? :uurm roer?0r'rw r''. - ?' _ Lco. I I wrn°oK'rve a,- .moeaemrv " I , ? ?f Win- ? sr ? E-? ?, ---- _._ YWrt3- - J uM, ?rE? ,W91M?O DNrtlwo _ .,. L . mawoRN aAnc.Tmr[r r M re? wNnon 1 a aq„K rwo Ara[rt aADONO t --?, ..-.-. -...;,, _ ruHV LeNn ,a( 1 m[ewuonrA[u rcwrrn .TEST r-T CNO w _axaaAm _ _ ._ h, :'?; + T ,? -? G ...? x Munn - _ J ,rmanr[x oIHrRIVEt.n ,? .. /1L •. I Cyr '«•f omoen 5 ,. __ Hoof [cro ?. r ° ocRr"''°Ra"° ?, uwnwED._ nw<ileoeciirj' o ?6 % TEST RESULTS 2 w W+E,r10<,.no.rA:eReH ww eAx, I 1 (' ?'wKfrRlivgplPA:[R°HAM[[AAwr^ `_ C ` eP°R[HD ? rSV M1 - ') NReiO? r•"'?? 'M•0°e "NHL 1 ` 7 X .. _ oRo-s L:m • ar[orwwr A cwoer wre -• OrBTRiBUT10NOR10;NAL COPY; SEND T0 WASHINGTON STATE PATROL--0L•u -,!I! j - :/? 7 W PLICATE COPT. LOCAL LA WEN FORCEMENT AOENCY'9 COPY?TNPUCATE COPpAY WVETq Ti0 ?'.COirY { .4 E q,?}?1 A <9 I, ? C? >? I I ?'• a I ,:171 * '; ,-. p, k ! r i J, SI V? 1 ?,? )471) ?, 1,L 4 Ail I '"j` ? a ??Ii?`??? ?r 'kl r?? ? ? "' ?YFF' ? GI4k6 ? Ip.a. d . 1 t c ti.• h i r ?, ?r:r r 71 4? ?', ?t ? r ,?yt r yr 4t.1 v°S` 1 r , twt J??, t I u? A( ? ?Kr P ? DATEOFDOLL N DAYOFCOLL1 510N T1s1E. C OUNTY NO. CRY NO. - FNWA. E _, MO. I SAY YN. L t SUN 1 NpN 2 fUES J WEO ° UP 4 FW 5 SAT Nl (USE 2KOhOl/ Z / ,. III !! ? BAN COUNrv` ( / ??(?]]?[• ?STATE ROUTE COUNTY ROAD ?CITY STEEP W A OMLLS R111M P ROUTE /OR STREET CODE - 5'7 O : S C ON ?OTHERISvEOFY) Lu . (7 CRY OR TOWN P PEFI% E O. ... MILEPOST O C MILES ? 16 8,409, . LUD J U LL _ . ...; ._T. -. Q X70 NAME 8 NO.OFSTfl 0{IWHV ...:..:.: WTERSECTW6 WIM: STREET Cli FpAO L 1. R AMP DIAGRAM DATA 6 1 NONINTEASEC ACCIDENT E -En T If %PO I CLS.. NTERSECTING STREET OR ROAD OR REF. Ef1ENCECPOSS STPEETORROAp N BETWEEN =D' LSTREET.WD AE Z OIStANCE OWECTKIN FROM REFERENCE OR CR !i ? S PECIALCOOIM USE ... - MILES N S. E W L ?- OF D FEET • ug (((??? ?HIT3RUN COLLISION INVOLVED: 9T"ER ?VEHICLE•VEXICLE?VEHICLEBK:YCLE IT?,,?,"?(WRITE) f? M% ? VEHICIE-0BIECT ?VENICLERRTRAIN ?GTOIEN VEXICLE SEVERRY NO. WLLED Q?yV rE? O. TOTAL N.IWURED NOA OFVEHI OF VEHICLES `-f? ?yEMICLE PEDESTRIAN ?NONCOWSION ?HALAROOUSMATENIAL TYDAMPGEONLY AGEO OSIECT UCKINAME OFO Ci SfR UCN LOCAttON OFOBJECT STRUCK .. .._ AGE E ? ? O L6 (.LlCT=_"?? 6•GtJ ?ROADWAY FEET ? S El 1:1 RD. F.OGE S? DRIVERS MIDDLE DRNEP'S NAMEUST FIRST MIDDLE RF DLYCLISTOR PEUE4IPIAN GMECKILA.: ,.. •'.-._-: D I IVT? Ll s/? T. ° A STREET ADDRESS ..., ... -.'.....:... 77 1 ? A STREET ADDRESS .. .. - .., :... ... .. :.. ? V. . 0 L,&,C C. V E R CRY ...,.. ., ...: STATE PRONE NO. E R QfY-.... ,. - STATE.... ZIP CODE .-_,-PHONE 110. . LA-At_9? -W . N ONVERS LICENSE NO. STATE DATE OF & TN N iANER3 LK:ENSE NO. STATE SEX DATE OF &RTH :. 0. ? ,1 , 1 A a MO OAV Y0. 0, MO. DAY Y0. OPIVE UP A T g N FWM NAME ;: . PHONE NO. C 2 CRNERS OCCUPATION' FIRMNNi:: V ... 5 ? . ,? ? ? IIY? FTY?•LyCT ? CO DES >143) CLAUSRT j0I SEAT DELT ?. 151 FJEcrIoN' CODES > 131 Cu& ll i JI SEAT BELT 151 EJECTION NATUREOF INIURIES NATURE NJURIES . V D NE T fP MSC BV• REMOVED ? IA SCEN RT' TD YEH . T E A g. OD EL HEV.) MAKEIO O MODELIDMTigVAi-STYL I3 OILCONV.1 ., .. vEH. YEP0. MAKEI NEV.? MODELIDAFR•NOVAI STYLE1200.COnVJ :.i ._; ? 7 7 ' ' ` ' I , n, E YE H. UG COOLOR ATE TiVLLER MTE N0. STATE ... E YEH COLOR PLATE NO STATE TM'LER PLATE fq STATE ., 1 ? p , ? 6Z) L-I-cJ'T V 5 ?idA. H c vEHK: IoENnFlcwn n NLxa4Ea.. ,. ...: :.:, ouETEn, ?. ..__... C 1R, - YEnK;LE IDEW cen N Nuue ..,..?:.. .. oooMETER .. E _ 23 _ 002 . 7 77 E GISTFAED O RE -LAST._... _.. FR9T :..',:..... ' .. _. LVoDLE : ? _, FIRST I REG YfE OWNER- .. _ ___._. .,.... MIpOIE.. 0.- (_.?,1• I' 1-d.?N6 ?.C° c'?.?DFtb ZM 0. pDOPESS OF OWNER _. ....:....:. .'... _. .u... C AOp SS OF OWNER:.:. ,. ,..::. ' E 'H `- ? 2 ANOADONESSOF MLSU RNCE 01L AGENT ,?,,, _ m wWEANDADORESSOF WSUPMICECO. OR AGENT •LL ?I - i ACTION '. AT N _ ' _..: ...: NAME, ADDRESS & INJURIES OF? I ER . SONS INVOLVED LADES 1 - I J A 5 ,. SE% AOE STATU9 N EIECT,• C NAME: J 11 G z I 3' I f C ADDRESS. . 1.? A . U P. NATURE OF REMOV©FPOM IN%1RIE3' SCENERY' TO A NAME: N T ADOREM 1NATURED UR.3'P 4 ENE ?F TO W NAME: .i ADDRESS: N VINRIFR SCENEB'•' E S NAME: s ADDRESS 51 ;IIfi.R ? •v SCe.1 I it AtUS I Itl SEAL PO I IVN .JIVIJUN! CU.i:. C O T . E .WURY . L O ,ofs - ] Dc,Cusf S A S I 2 T.OIHER POSIflp1 ADDA 2 D SCENE SDEADONAIIIIAL iuN NON019 V IDENTIINJURY 1E E O E OtrIFP SNTTNESS 5 ] IOUSMOtORCYCLEI 5.P0.RRIONUNKNOWN A. DIEDIN HOSFRAL ,4 INJURY W,J' 1,aa -t y en t w.uam pU? 4 y n 1. NOT INSTALLED 1. NOT EJECTED 2.NOTIN USE ].USED 2 TOTALLY EJECTED J PAM "ALLY EJECTED A UNKNOWN 5. SEAT DELT FAILURE A 01 I'D," F EJECTED ?IAw d C ? ? ;1 f l 1 y I t I ? t 1 1 ?1 ? I 4 J ?Y - 1 ? ? 'k 1 p RK 1 A.- HIM, . I FY?+ ro w I ? -.aa VEHICLE DAMAGE EACH .CYICLETHE NUMBEROFEACHOAMAOEDA IIISTRUCTIONS: iU AOEM11AOF1IWe TIMPACTALDiRECTIIXJOFFCRCE. -- ®4 --, ,a , DAMAGED VEHICLE NO.1 /USE THIS SPACEFCRSUE- DAMAGETOTRMLEMA,OrGRCYCLES.ETC.1 DAMAGED VEHICLE NO.2 a x D ? h ,.? 11 HOOx .. n ,SIboG , . s ,+.Rml ,,.Boob 15. TnnK ... , -.... ,S. TAnK . ...._ .. •?.?.. ... - • ,x F IB.UMrcr,Yps c1Y ? ,D ) 10.UMara,uxa a_ IT.Ow,am ' GEVERRYO OAMAOE:VEHICLE .I 1?OLS wwaAMAOE. 3000 ERM.V.OAMAGE' 2 FUNCTIONALDAMAGE ? NODAMAGE SEVENTY OF DAMAGE; (OTHER VEHK:LEI 1ST .AMAGE SQOTHER M. V. DAMAGE x FUNCTIONAI. DAMAGE 4 rn-I wDAMAGE faTYO'OAMAOE: VEHICLE N0.2 1? SEVEDL.ACp DAMAGE 30 OTHER M.V. DAMAGE 2 N.CT9.0 DNAAGE 4 woAMAOE-_ TOYIEOOY1-lUKSu?S E3T•DAMAGE TOWED EST. DAMAGE. TOVIEOSY EST'DAMAGE TO I L.L. (w+,i ,Llc -}C7L s i^'r-N TO \4 3 TO a OIAGRIIAI;O??OLIJSIONyj flku I i I I J !`; , I, I, • r •I '. - DRAW ARROW SHOWING - • ? ". _T NORTH IN CIRCLE nln+.rw , w .y ? ... i i= 4 4 7 - - \. •. I 2 ?DaFRDa ?ER N d - - - I I -??. t I < t n Lk I s.aMNVDaC,Ef4DE8RWld, mEaroarKxaArawACr.. rerancaM1M8.wari 4?„ f"nb '-' . _I" f I I I I I ?` ? I' I I I I I I . "DESCRIPTION QFT Dd° COLUSIOpkk,r ?.r XNV « {;fit RNOIDATE VIIUT MSA&IITY.REW PRGBASLY HAPPENED B60RE WNNGAND AFIEATHECMGH.iNCWDEINFO{11MTgNNQT?aDIAORIAI, E6 OlW V1Sl0rtJfl'. PEDESTRIAN CUDTHIw CCLOR CONSTRUCTION ORREPAI WOFK.ETC.1. ` s I ?E I c c, l - rte u.LD 0 ago ?? , /JE- L 'M;I,I 57 ..?...,:iiGIH{i+Yy M . s:(rarn? - -.. !?Y„?}• Y:0.•w+ ;.it.+?Y.a+n NO.OF ONES S HEADED NCREA EAST p0. ON 9IAEET OfIHGHNAYNAMEOR NO. ClONE00t CDON +mrEO . _ . .. .. •- ... - . N 8 E W '. ? PE S.+C ... UO LEO•V.LY PARKED I P K WASVEH. OCCUPIED . I __1 p? ,N . 'SOLD SfT I/..? t?Y. C_ uw , _ YES - NO YES NO 1 El 7,1 1 PEO. p IJ p L p tOaCCOrWFA! lea J „ gCxOSy,D K C^M .'. ?' ' PED/RICYCUTWASUS ; ?1 ( ( 7 I? ? - Il IsOFwta x? Ar sl' t_ICiu+smuit l J ux n? ciaw?u,a ?I Io,KeR •. JIOAO SURFACE,-. " IcccKORq TW.u ... - .z WEATHM IOf? ae ..-._.. .. _ BU KK " ..__ TIN EGtO CIgCUMSTAljCES DlM?a„ ,,,,g?-.;dc ,- s.• sy>«y. .? ? D'`?„a ® MLYm arRAKwru,uo p=p x ? aN.D . 0_0 COQ C,a? &Er . ?,? [Jap aNOW r C? a. V a? iv-s , ? E? _ ar__._ pap ? Q ?IOn ,al DlA- orD.? "'"' ?,p =TO p,a? , .? .•u L-0 =--P- , E,. ?(',"n..S/n?R. V . ?.?.? ?» .. ?-0 71:a E] DR4RI}R 'R D„•DHaREO'1 ?:_ial-J : p,xp =rD. n,ar ,?„e,,,?M^ ?,? ;a: W^ LIGHTCONDITIONS KNacKaNn . ZUAFRL,LOEIHOG;, Q r? iS°?"+'° I? 1 J =TYPEOF.ROADI ae on wlo " LFCONOITIOR- wcLe . .,a SQ".IETYi:".• -" uD.ae rcKLrx oKD _ ° ?a? aR SQtp°°mr sATDHaaNJL ?a? -A, ?. ? ?xp ?_ ,. a ? ao v _ Dwee?rat r ?'? . ? 1? WAa'rv ? t tJ I_. . - ?J-, IoL?, w D,.va .?lr._? wRN I mw? , } `7 T . 'L•J ww?eYaAaaa ? wnwKra- ? _ rnr .wm' ?11? ' Jp DWM f-1 p.l 1 -. ? `J• ? n M. [??4 ]El M. -- ?Ix? '? uoNn'a I- a n"`D f-?? °LJ ."'Jn- ? m e LEL„l-Maroa?m I NOawKwa @L ?,a? erclun .. a? LaWlab,I pap aKWAL nap ¢MOw,wAUs1Oi ?ap T Y aM CHEM.TEST ,Inx ? r•7 - -. . -t_. ?[j'' ;y?yl s°M"rMara°acHn I .,??? 1 I? m?w? ?• rurm. : , orHel uAao ? ?m• U - pap OrPU `?xp DN9t0 ? ? KD pYN'la ? n 1tlT11LR,alO ?tr. '' ::. ' ,y ii i!. C • '"o„ai re`t+n - a (-I w I PAN x (" .._ I •,? i!!?? +nL , orW.F.-aF, %11 1 % TEST RESULTS ' M , t` u.n.oanwawr.nM.1 ?1.1ZALIC Sc?NcLr wasw <v1Ej .cNeD .aca ??a 11 ?{ GS??„b C:N[:? xoo /-1/Il - uoEO`ea? I.- +r3smMrnarK'ew3Kj.w?ww // aADUNO. Amer (` 77 .LK . %.?.G wraor"T I- 14 71 APFRDY" re -r- DU/IlWTE COPY: LOCALU G /a'h llJ - fs.SRa Y:LOCA.LCWY:SaND,O WASNIHGTD,1 STA,EPA,I,O,- w TO W ENFORCEMENT ADEMCY'S COPY-TPIPUCATETE COPY: COPY: INVF.SiTO F.STIOAIOR'9 COPY ! n ' . I k * I ryryI?g _??1 / f J J ?, _i?l t '.)Iv •.J ?J ?.,,1„?,d; -I t I , }? fll 1, 771 ? I r, + /? STATE O F JJJ J WASHfil1GT0?1JFACE' I 1 TJO 1 t p !?„ ,. UNIFORM POLICE TRAFFIC COLLISION REPORT D ` T C ,?j a? l q ATE OP COt 19 F COlll91 l' Mp OAY D 1F O ION ? '. ll•• I E 'Lirt, ? E 1° ?_-Y n. urv) x ] oNS FgIE IusE xgDO HOURI} .. I fl .t z 01 F C, \ _ T 1/ ?] ,?. 1 T ? OBTATE ROUTE COUNTY HOAD CITY STREET O CL9 / gOUTE O UR N =M J u ?C?1 C/ SLi THER'. EC1GY1 D W STREET CODE E TION 9 ?? ?: 1?E W Iy?ry??IH 'CITY D@rDWN f?? ?PO? O ?: C -?/LjgILNAS ??1 -OF ' WIA WU.I U 4 ME6NO.OP ETD pH?KAV 3/l\ IL,1 I p4I °. T OBI a?^ 1 ?? INTEg9ECTIND WITH:STREETORgOA LL ??? `U^'` (L AOH NONI Tq{{/q)?E?C 1 I`114 N ETWEEH • 1 b ?0?"' P)Aq "DINT P S wD IyTF?q CLS I EFEHENCECR095ETREE EET AN ROAp T. EE ?+ E ?COOE E 7 11 DISTANCF?NU T CI FROM HEFEREN Oq Cq 9 X ?f MILE 9 _!d ® E AL . DD I ? W .1 5 6 <+n- ND 9E -> _ l '(]FEET ILII Dcou,ko? NII?D.IIH COLLISION INVOLVED: ?VEXICIE VEXI lE - ^- ,I VEHIC ECT LE9CL7 ? ?VEHICLE=BICYCLE ME WgITEIPUTS, HUH 6E EflITY ` 11HJ TOTAL NO. VEHICLE O E T VEHI LE RH TRAIN ? STOLEN VEHICLE -??? ENO KILLED M 1, OF ?VENICLE-PEDESTRIAN ?rypN-COLLI ON ?.-ARDOUB MATE RIAL NO,INJ " OBJSTRUCK AME Of OBJECT 9iRUCK qND OWNERS NAMEI l PHOPEflT' F TV OqM 0£ONLV (J -' LOCATION OF OBJECT STRUC tl Al N _$ ` I e• DRIVE 9NAME- q9T /] PI_gST., IODIE OIN 'E IN oADWAY ,D FP6T OO STOE 1--e- CKIJ? ?? A R V i ?uGmur A 14. D wST FI M OLE . ESTRIAN CNECKIQ n. T R 9TREET ADDRESS I.. - R. ,. 1 -... sTREEr woofless_ wTT , E CITY.;, p rw e V R - '-yU ER e'F/¢. Y zlPAeooE...[Q?. D?gg ? E Irr .. _ .'-..... _ µ z ,wT SC ?YcJI? 1 -1 ?OLfU R. IT ArE Pcob P 1 E O 11, N bRIV-LI ENSE NO. N ?? 6" 8TA[ 1 SPFJI 1-N RIVERS ICEN6E N0. ATE OP BIH «<111 I1.1 12 Hii? ,\ STATE flll S Q. DPI EN9000UPATION FI (? "Q N MO. OAY YR. ,L/S,?M NAME I_VERSoCCUPATION. ' I 1ry^?C' I L ? •, w•J ENO. .2 FIq nAME ... .. -. HONE NO. 1 OP JUR?_ _ ql `SEAT BELT 151 J CODES ul EJECTION - CODES L r uy uC I]I CiA95 (a15EAT BELT 151EJECTIO.V LI E O eD l-• P TO S q YEN.Y'AR GE-CHEVI ODELIDAfl-NOVq)STYtE DNV, _ CE - D TO V -f-/! H. YEgq KEIO CHEV, MO EIIOggT-NOVq STYLE Ix pq-_pp ), E vEH. oto ? VIL.LE 6 - V _ fl, ATE HO.. E. flq RPLATENO. STATE. 1 ?P( 1 t LO(/N.?a /)?, -n. 'E'. EH. <OLO -PLATEN.. BTATEr AILERPIATEND STAT { (,' EHICIL\E1.IpY+ENTIPICgT11(OPNIJHUMoeER,JC..•,. ',.Y1,e:Ia? ODO ETERH R!. A L X J (L/I / E CLEIDE , N ER -- w E E V_•.+?•(-1l Q ?3Z1 ?1?q5 ;c = geOISTE E WN/?`R_LA6T .at L._". FIRST;.; -, MIDDLE PISTE PE O ER _LAS ' O N ..... .. l2AP-Y 10 _N WN _ sT DDI.? _ ,? aI+ME s A 9 o E N `. nAME $$ ?.? ? w o DoRE oP HwNpE CO p r,--,, 2 ? 21? ?'%r kt •' ? \ u..rd.-T:V „ _,F AND,A PRESS OF INS ggryCE 00. Oq qG • 4 ' CHARGE -- -? ltl.lfl.. NO .. E PORCE ENT CHARGE., ?„ .. _ J 'o. Cl N AME ADDRESS & IN Cl Ik - ES I 1, ??JT, yC JURIES OF PERSONS INVOLVED a C NAMl. _ SEK ADE STATUS " C N. Lw55 a EJECT. ( - C ODRE39: Yr• :. Q NwTYR¦ OF - % A NAMnF6 sce eav FgOM ro n N. Abo a r .._ .. I T .- o w g - ncE OVeb FHOm W Ilea T I S., IN, °N OP 4'4; '' . E NEMD M _' ? S EE I S INSRIE {tI STATUS ovlpFROM v} Ix) 9EAT YOSI TION Nr TO (,`, ] Y 89EN0[q I]I INJURY CL. ASS IIy MI 6FAT ;81 EJECTION t• v 0 OYE089Tq N q I I. NO INJURY F O A@LINp INIUgY I. NOTITN' ESTALLLPD • NOT EJlCTEO D O WT N@.dT @ T T Fq YOfITION ]. DEAD AT tlC[NEI8 O OI!A@LINO x NOTIN USE E O ISI; ON T UONRONNpYCLEI /.O 1. INH-TA L PO 98Ll INJIURYY SUB KNOWN q. UNKNIDWHIF EJECTED ,4,- _ ..... •_... EJ6CT@O Iyl! < }TJNi I -? - t f r / !Y J A' d l' ? .1 1 4 I 'l ?yt1y4. l k f ? I 1 } I rw }J`l?. rl I'L ?'4 1 1 : ?, it ItV 7 1 ,? I :SAC v f I - t 11? 45 .I .ply,( J 1 1 y h''.+., d p T r -;r ,.t .. .TDNRf' fi.1} I t _.f 3" ft ? ?? I - ?+? ? IAYS ?) .ice L a." . tlFr "IS S?WFYFL bI ^Y >'I'"'".r ?u „A? ` > 1y= y, ? pj H?(I 4 3l A. ^ ? _ 1 yy {( IF i I :I 5 JI xx `?? fI x 1 jl < `1 yy]ya?yy??• t J (' f:I ?f JTh ?I I 1f1 .1 ?YS RS I ?. V W d' ?Y ?1 d r ? SIDE 2: COMPLETE REPORT ON THIS SIDE _^ - -' -- -- "- -- --- - ---t VEHII:I-EDAMAGE 1. IN EACH BOX: CIRCLE THE NUMB I ER OF EACH EAMAGED AHEA. 2. SHADE AREA OF SEVEREST IMPAC ?? E';; Y:Y 5 C, L " TO OF 'a INSTRUCTIONS: 3. ORAW ARROMS11 TO SHOW p RINCIPAL DIRECTION OF FORCE. RIN PA D IEC N ROW'S' To SHOW p IS DAMAGED VEHIC LE 0.1 THAI S _G, -ELTIMS -'All It" 1EY BITIMNIG DAMAGE TO DAMAGED E t ?Ae 't? ..f k' 3 [:]OTHER M.V. OAIAGE I[:] DISABLING DAMAGE .[ I.T... -. DAMAGE 1 ? v G,EO BY NO DAM AGE n ?s i3'. L'In+ A. IITJir: A 1 3 r.,ln " ,, Si A A ?i•1iar?i`., ry 1 r x(_ IV -,,) Ir11L J MOTOR VEHICLE COLLISION REPORT NO. O C ?1 . L ,TIME OF COLLIS :: x x°.a> ???' • IfY n N tt ,- TOW - K,/11 1iJ .• PNEi % wou [aT c° OGLS /V IOn -HIGHWAY '„_ E,?? ixO.L6..• "• PREFIX fi LEPOST TF?L AAk?iF e 1 i N 11TLRSECTION-LOCATION F COLL15101. STREET AND STREET I MP AORAM DATA • • 0? ` ax ?i Ho ?:.aii ?,P atr ?;.s ,r Hn-, ^v ax, uxryc[. a ?DFt rrt?lX o?Cy x??? x, x ? aT I TER I CGS . , >rw s.wan x ux7zo o D- wrc,A v[xrcu i[oa ? „ xtx x /! ? J oxrr xun DDE USE ' AELT ST RSrS.aflw,rrw_ONArcT? I n -IN RO.ADWAY," •_. ?? M r ? 3n ET DRIVE fLS,LA. .x x s C0 ORIVE S LAST NAME C ? 4 ? r[roxo, O 5! vH, mPd a.dL.'.?.+• yl?,;; ?:'?.f R TC N6 AN %. O STgfET OO E 5 : •, ROUTE N fJl BOX Q ., O?•;L -?,aSJ?- _.'.,J?};,??J? .O IVERS O//COUP ON,; CITT;?„- ?_,..'.?.. AE,,.::.,•-.,,,,y [IA LOGE Rrvlft$000UPATJON? Q O'}Cr LORN •• S Eli].,- - - TAT 9EXi O L 'TYH AGE ? y23 - - IVERS IJCENSf NU E 'y ST T SEIC. - r:1? E - .D TE HTNt 1AG8,1 - vax n Fo9D xM00-ELjl?lwov [ BOGY STriH 110n.1 _- ?,_- _X6/il _, _ -, - MOOEL?A;,1xw-uw[l BOOI?YL6?rl;.°? LICEIWH?,?;5 _ T?'fj? ?t<.N £A PI.:!1TE '? , jAyy1STA G? (a :LICENSE P[ATEJIO: y-? 5 . _. • ti T? . 8 ^IK TE N4x ;AjyA?_AFFy^?`.' U .,? lU4 h Y_HF'"''Ie964-tloxL[L-;1 N[wl 00 ETER F 7 VLNIC E PIGTI N ?T N°°.._0. ,1 -OOMFIT[RI _ 5-3 ?? R G[STERCj'?.DAM1OwNN?mauaaN[I' * " z ,?SLiCEM$C:NO_?yy ..•`2E.C,3 Eq EO OWJIER I -- -.,;xlooca' rtl ?y10 [RS,?„ _ N$LN6•.L ... Sc? 5 A rv? ? ow.[ERS' .. _;..Jn'L•.r =:.DwTeoF?sINTN?>, owrNan$??ccA. :? v&'::.? . ?X.!•;-,L!cT? .__ _µ?.r.:sSslws+.'..-?'?4Si419T.±17 SCj h7 PARTS "`^ KiiJiX io:u,Tmma,.../ , . CMTACOR.vENICC4:WMACeO.b.u:..k'r:'.r:.2:u->rn.i?i:...:tY•t`!'9a: o INwi o- .,: ar,NV_MA,TtR.. C S %? S LIABILITY INSURANCE INFORMATION -VEHICLE NO. 1 - Coven GE IN EFFECT FOR THIS ACCrmENTON YOUR CAR YES ? NO nA[?-A,,,M AOn,es ' IrTrn _NSUR-A,NCe puc NOLDUaT, r..... 'r •,w . yy y wywy,,?,ME 1,,LUwILrrt,Nww,,H< .cow Nr., eE.r.k. _ YR,Ancc/ [nTt'J4?M1I::.'fif_::[_2 :?.+ .. ._ . - :tw'V!:J LlweltgT pw l[_ VNou IS.TS?nu v+n .• r:c?'C? :..:•,we; .zHO'IwuRn.....?u..l......tz.o ....._.a :;Yu. w'?R?.i;9xn"x•L'n.'?! Twc?. M6 NAME M F SLA,ltiOr? MN:-!!- r._?.?y?CIM FlH Y ONe TMATAY 1 ST Tt150FINJURFO "" yr -',? _NAR IRSTO-o )N.{T/1?T ' l[?r(.?h, ovs>RCC[ W R l y? 1 R LLE • [I IN I , N V(NICL( p ILLEO ? Or 1 I[[v[wt1 Iwrxowl 1 .•, c.l J u 71, , , s 1? 0 50 0W NOR IR CIRCLE \ 4wa?fx.-,•?.-..r.,[L?.:` 0 I '/ Desenroe 08 NAT HAPPLNtO?.I LFU T !X, L i YJ4Jmo- f' _.,gra Xti _ fo 151 o w o r Ckra%? \ \ WxNa[ A,y awwr ' _ 2. r4 kc.? _ Seca, cd__._ 1,-o cK-_-- Rca r, ?,vo% 5,F%-o Ac .---/.v. \ ? 4 =grorra. Rr,.n.w,Y[L ...w,R,.. Q- n.[.,ywxrRxw,. S a //aw_._c/. ?L, _. !?/!/,c.^c __Gr?hLCt L It1 r VEHICLES POSITIONS BEF Nunm ICL[ 5 F W ?{ ORE COLLISION H ON STREET O GnwnY R NA OR HO •x. ox •• ty [ Ntlt O NO 0 3 INVC$ncAr[o or oTxtw ? r ? 'T ¢? ?'?' }'? 116 1 OIILt.<, i9.'IJ LJ U? r' ', .• Kt J( ... ? ? ? 13 I IHV Ox Fl ? N DI1.[ L U I I ? ? ? L-1 ] C 0 [ [ ? T KO8 TM.-t 4i LE? [J LJ AL OMT.. u.?9: _ ?wOA.INO •,: .. IROM - _ ? r TO, .-..M..'U.-'al4 P[Ur II " _Is Jlj w . >n: xAr 11??1l ALJr 3 (1ja A?y ,,,x[1R8A]IIEN•?r: IIOAOAYNFM'mow wrwvl "I CONORIOHS TRA ON IIIC CT110L It x owl 2 .' TYPL OI RO.D "• vlx rl[ I [ 2 ,.' i.kr• [N/V(MKL[ALTIONF.•,?„r- D^v[x nt 2 cxlc. ov 1 r I? a.a J L J w [ 1 r l nNT J ING 1 rJ DATLIG.. 2 C I OAWN I U SIGNAL. Ll ? 2 ? BT- SIGN on ,.u -,? ? ONE WAY r 2 I? TWO WAY I ? GOING STRAIGHT AHEAD ? 2 ? OVERTAKING AND PASSING ??` "??Yyy W J Jy WIT El SHOWING ( V l 1 Go- n 2 n -L. ETON -- o_I > 0 Nn?nHAIRI[ ? 2 0 MAKING RIGHT TURN I ,., > l .NOW ,[-l YOD w O I[: I( _ I OnLT I 1 a f 1 LJ l.J FLASHING RED ?? . E] ?gARP? LOOP 11 ? . MAKING Lt" TURN ( l 1_? A ?.-? Tr. .l 1SP1 CIp S O1I T ?) , C] iLA3NING AMgf:N 17 , A,.,,., C J 3 ? MAKING U•iUgN ('> > L1:' 1 t I I 1I (? A l._: y--wT[?Ol rCN11 T A Cl RR SIGNAL r LL TI1RY 1AN13 I El A C] SLOWING -- POM ,NOT [ItMO NN48R gLA'vO ?? > 0 nxtC1PT r 1 ?l n ,e-[R/TLA(:.x AH 1 1 T T 1 1 l J ,ryY.-D FOR T.....c .,.,,..,. ..,. r....v.?°....r ---- - ?.? " IL.? ?a:r -T A I T.RAT[G (J II L ? A ? mNAL oRfi 1o oM .- DIVID C 2 L? PG ? S ? ^ STOPP[D iM ROADWAY .T.R TIHG R ,r n AIrIC _. .. L? ? (, 1 Hn vrrrn ? Ip l_' I rR ArrrC LANE. , 3L 1144441111 I t A ` II r ', i k t ????t4g?d?,n nsRSR,w 'lE R 71 D GATE Oi COLLISION Y. M DAV DAY Oc COLL131DI fPI s 'u - TIME IusE +aOO HCUwI J UN TY / C Tv N /,. :- yyN AUnB E ? S T I 1. S m r , Q3 2 CCC../// ,.. U JC.L_LcYC w. / COUNTY ROAD ?CITY STREET ?STATE POUTfi ?OTNEP ISYECIFYI ITY OP iOwN CI y = Y w LS REf1X PEII% E6 ROUTE R TPEET CODE O_ MnE Pmr - L D ? c ??] 1I??yyII IN ?•1 ??1 ?" ILES ? 16J ?? Of- F. ZEZ,/?,__-,_. M V .... ... _ C T NOcD S t??? .. ®3N H?NO. CAST- _ INTHRSECTIN6 WITN:STREETOPROA LL O D w 1 N oN INTERaernaN BETWEEN ?? ?O • STREET wNO SI-i-?,aE -"'s?TPEET M"I'. AN CODE TOP CLl n - srHeEr OPR CHfG.55r HEET,OR ROwU U T(AtI?,ICEI}?[^PyNO DIPECIT-O?H FROM PEFERlNCE OR CPOOS95T,]!ET I l 1 LI EETS L.? ? ? w J?'FF• [ O ,Q F < - IW RITEI VEVEHICLICLE COLLISION INVOLVED: H ?H HICLE -OBJECT E VVE EHICLE-R BIRCTYCLRAIE N' A/TrtiII?_?-,.-?STOLEN VEHICLE TOTAL N0. VEHICLE- S SEVERITY __NO. %ILL£C O.INJUPEO OF VEHICLE ?VENICLE-PEDESTRIAN ?NON-COLLISION ?HA]ARDOUS MATERIAL PROPERTYDAMAOEONLY OBJECT STRUCK INANE Of OHIErr STPU K OOWNE0.5 EI LOCATIONOf OBJE-LICK .. ?RaADw,r FEE, &6? O EDGE EST. OAMAOE.; R OPI V<RSry E_UL4T F RSr NICOLE R -EN'SNAMfi.LAIr FIRS! MIDDLE (1111CICLISTGAFEDESTR 7- L_,,.,;., .STREETA -: STREET AOORESS E R CITY Fes, 21111DE. Q -READ. 'IyJT E CITY STATE - lIY y00E :,.. PNOnI HO _ " o- IvER3 LICENSE MO. L y62DB STATE raA SEX stn OA rE OAHYRTN 3 z " o. Ivl R SLICENSENO. £ D SEX IOOAT@ OF 1HRT9 DAY YR. UPATION RIRN NAME PHONE NO @RS00 0 IVER5000UrwTION FIRM NA F. - PHONE NO. ( ? CODES c-,=' '+1 SEAT BELT Z 151EJEC40N CODES ulc?',yL1"„-r _ I sE.r HELr --- eTle.v __ P SOf N,u /j uRESUC N, OvEO TO M NE BY: i.M IOU SCENE ev: FRO TO EKYEAR MAKEIDOOOE-CEIFKI 67 ai4e-V. OOE1IOART-N?vA13TVLE 1]Ow.-CONY, 0-1H?1/c_ zAR . _ V --AR AKEIDOOO V. MOOEUOAwT-NOVA STYLE I]OR.-COnv.l. E E LO LIC.I`'? O-. ?.. TAi! nAILERPLATENO. STATE- .. E -.H' 1 VeH. COLOR.. IC, e-Nq. STATE MLEPPLATENO STATE.,., C L VEHICLEIOENTIFICATIO!v NYM3EP _ l 36 t77 K Izc 63?... OOONETEP Rb7z8 L EIOENTI TIOn NUMBER -.. YE ODOMETER :, .? E N nEDISTEPlDOYFNER-LwaT,_.,-,,._,___., rIRST ... ,:'. .. _. NICOLE S N?vS S:a - ,.. E:' N REGISTEPEO wnER-LAST .. FIPST...... .. .,. J+IDOLri..:,... O- Don IS or oY/t/MFR .. ..,.... ,_,... p -0• ADDHe- A-- __,-.c-: .....,. ... ?_- ,?.: z..... .-s. r. r3_60 9A 2 NA]E(ANOADCRESSOFINSURAFICE C0. OR AOFHT,. -, .. -. Q.L K I MAN O 1OORE33 OF INSURANCE CO. DR AGENT -, CHANO(?{?\ T`?VLE?ILF ?T?KT[O 5J ENfOPCENEHT ADTIDH .: CHARGE ... eT TmNNO., , INJURIES OF PERSONS INVOLVED NAME ADDRESS CODES I - x O S: , & ex ADE STArvs EJECT: o NAN.: r ?K _ /S z z 7 z / U u"iI"E(a« S e s"GENE BD IRON TO E P '"" N anon: Z3 z / 3 1 z / T s IN, II, RlMOv Ra: -To w T womm uFnuM N E 5 S 5• M ITT ,,.+ u3I tIUN I3.1 N1 RY CL-11 I N)s[AI IIELTTO ISI EJECTION F. NIlASLINa INJUnr r'ND'jNSTAO 1. NOr EJeCTHO L+ },r ENaIN LNIT IN-, ]. TOTALLY FJlCTfO :-ICLU11 + 1 ].OEAO AT 1111E ON-019AHLINa IISELLE D IC CLtfT e ] [.OMIR rOfITION ].OEwOONARNIVA1I r[VIO NTU.N.H.r IA.-LILY D S=. IRV-MOTONCYCLEI +. OIEO IN HOSPI TAL J -.:LE INJURY .g.11NUwN o..., E s. [ss e ] e. roamoN UNXNOwN lAr neu reuune INCiED ?1C y r ??, J' ?Vl' J ,aur V I '. r. l ?? ' f r SIB -',? ,{'7tRm"['1?9%SN'li:;^ r t{ '?J Lr?f 7 T {4 t j;? It V s' I y l y>' ?1 ?l` 2 ? Jd ? ? »]I*+aI t?f r Y I A r l I o Ll y ? p ,? . r ? o L } 3, I J .. , VEHICLE ? NKJARNS 5?1? ?f ,?? ? ?lnl u I?i?Jv£x ? ?O DAMAGE 1. IN EACH BOX. CIRCLE THE NUMBER OF EACH DAMAGED AREA.'"' %A IPLE T-I INSTRUCTIONS: 2. SHADE AREA OF SEVEREST IMPACT. ` D DRAWARHOWISI TOSNCWPNINCIPALDIRECTIONOF FUHCE -DA\1ACEO VEHICLENO 1 I s.nACE FOx,KETCnIIC DAMa4e rp rRA LeNf Mp pccLE...c / •? DAMAGED VEHICLE No.2 IS IS w.I.Frr II ` r T I} Ovnrurn V EN 'v t Of Oa GE VEH CI 0 ur E acE rH I'? OISaBL,NG A GE - SE ITYOfO : E EN VEH QCLEI E ERITY OF DAMAGE. VEHICLE N02 ER - f}? O4 G ) L? NT OE< N. GE I 0 OUNLi Ma AO a =C ?A S]IJ GU ;.Ea OTNM.V _ACE . p VaGE ?y1 O SABL NGORALpAMaO DAMAGEE Ll ?1 ? NCr vAGE ' Y T_ ? i OW .U B EST. CAUAGE ,. TOWED BY E5T.0AMaGF T:gEO BY n? ESI. pAVgGE ..• to j! " a '- Ste ?-„ r ?>c- s .: y.J TD DIAGRAM DF Co___ LDR sHcwIHG R NORTH IN CIR CLE L 1 Ll.owr of _ _ > i'-: / '- - ?...._ •--. _ . _.. .Sy `- ". . reoESl«Iwxo« - f --- -._ O K TJ F vr.? F 'INDICATE WHAT PROS ABLY HUVE EO SE 0 NG gkFTER F A„H INC E O 0 OT ON pIAG AM E G DRIVER osga m , . a ,REpucfp EnalArycw HNwoRK,Ere.l r - - POSITIO HEADED ' NO N BEFORECOLUSION SR E-TOIR INCR ONSTREETORHIGNWAY AMEOHNO. 'IRON OI < 0 S L PESD S -E V 1 .11 HKEO . N S E • EASING OECRfASING ' ?'- - - - PARKED - YES O OCCUVIEO ESQ NO __ ?7 7. Jrb ' PE B C ST WAS SIN ROAD SURFACE C CK ONEI G. 1 E ALK WEATFIN11 ICHEC EI' - 2 KWAV) SHOULDER CO"""' I< IJIMA. OSi A CROSSWALK S TING C ft CUMOq TANCES EC ONE OR E - TE. wq E - BICYC E E} E OTH os Id I I .W, R O ?R E E CR 5 O vER 0. 2 1 \I DH CLEAR. CLOUD 0 RIVER 2 ING Y UNOf FLUENCEOG R V 11 0 . 2 _ F E O ] a. p G G AREA X ' l X 8 0VERCAST O O glC 4 O LOO 0w N 00 LY qry ' D SGI / ] wET 2 R ING p L E GE OG IT O' C11TIR t - A E ILI AiKNG AING [ tFOI'F4 DRUGS ExCEE -EDT - E IA O O SG L MPR LOCAT _ H URN TT ING LEFT T RN EKCEEOINGREAi SAF vR OPEq 4 UI % ER ISVECIi YI O x O /V EFEC TUPN SLOWING ISSIGSASGANDSO x B OTHERI FC 1 SIOPPEfO L.G H TCONDITIONS CREGK ONFI - RAFFIC CONTRO IN0.2 f ClL E E TYPKEO OF ROADE 1 101 IC CNEORMOR VEHICLE CONDITION LAT O VIO SOBRIETY ? T1 TRA C EDAT SIGNAL . GNALS --? ,1 I ONEWAY ? I? I?Q ?C45 E CLE ISaIF'SFiFBUTF01 1 N0.2 ji AN'fFi {E E ICLE IC ECK ONf1 . 1 NO 2 ?O S O SIGN T a p p g N - OA 1 / LGHT - _ .. - SIGN '... ..._- " x/2.1/ ryp-N, -_ -- n A 1 OEf CT E AKEE B BOA LITY : WIAIRtD S Q A Q W AI r Sf T 6 N 10 l 2 O WN .:. ) W ? ELO - S -- I NG i FEVERS L6 %- .'POAD _ -1 NTfN NGL EifL 2 , HEi LG i5 2 : DEFECTIVE . __.__- •. 2 NOTIMPq qED ... w §O ! LANG A l t1 /ARK{MIITT.- -I p --.... CAP- S,I O _. tlGHti ONE ET -..RED . .... „-,--_,.. fAMpIR-- NINO - .. '. 1,? Ob/. P .. _._._ ALIfY .= { ' 77- _ REARLG TS '. ES WOR 1. ONTIR S OOf. _._ \ Iqp NOT ! BEEN pRINKIN4 2 M OIN41[NTLRIN6 TRAFFICI '-'- •-' IS BACKING DARK-WE{T l c -Ori f S G S NNW L[I a: Vk CHEM. TEST D K-NO ?. [fT LIGHTS I NAL... .. }" -?, GLIAN .1LA ??, SE AR Ep ' ? o N TESTO VF L I.S. IYECIFYI -,C I THE „ ..... NVN,R. f /Y rV EGA ^ E..:E I DSS _. ...... _ TEST R{/USED ISTIOAtINOOFFI B LK 2 D E I . ! fi-• I % TEST RESULTS Z - I _ CEgSNAM{t, raANK V TC^? ?, ?' ?T ?/IfJ (•A I TG i BApl1l NO. f' i '%?• IICf UIS/AlCHEO OLILEAfIVEO ^qp VFpryCE FI CFLOw _ w "Ol I???t?. r1% AI ?q !} NRI 1 TNp? MvfOFD '{/ V •J • ~ l-g EICE SHAM Gi NO , fNGY ^rE SPIN UISr A1111 pA 1111 gfvONr OtlY wrLlt rE COPY LOCAL LAW E NFORCi I- TAG ENCWS COPY- TRIPLICATE COPY?INVESTIGq lDWS COPY w rTE F , ?? a ? ? .5 1 I f N j r { jtai e5? ,? 5 v "'+?ti 1 .mot LA e )w ?Wrw ? d T? ?? Tr 1 ?,'.??N?I `gin D DATE OF COLLISION OAV OF COLLISION _ TnAE 5' CO" FHW A pAV x UN i NON 2 tU15 3 wE0 A txUN S FNI B SA1 IDS •lAOD ?4UW J 76 Nl' %N COUNTY/' ? []SIATEROUTE COUNTY ROAD [] CITY STREET W AOMCLS. 11 PREFIN ROUT STREET CODE S ECTION e-f ???p 1 ?OTHEN (SPECIFY) CITYO n T OWN N J W PREFIx EO. MILE POST L N S E W ?IN ??+EtO ''77II 1 r 1 , IJ / ?/? - _ Jt JJII MILES ?JO/ ? ? ®OF_I CJL___?..C?.F?S G!?!V_....___ V LL AGDA T C INTERSECIINGWTH.STREETORROAD SNO.OF SAY N M DA A .-DI T ) (11 N OII? O r +A A ? ACCIDENT " 4 TEflSECTING STREET OR ROAD NEF. C ML LS ERENCEC SSi EET ANO iPEEi ETWEEN CODE .. ...__ B EFERENCE OR CR -11L.11-7N- n-11L.1-11L.11-7N- NOUSE ?1 ?MLES N ?q5 E L'O FEET Q ?? W OF VERIfY EHICLE VEHICLE VEHICLE-BICYCLE []OT ERIWRITEI []HT ARUN _ NO KILLED ? V COLLISION INVOLVED: ?-L.? ? EHICLE-OBJECT []VEHICLE RR TRAIN []STOLEN VEHICLE NO • ly7 . TOTALOF NO VEHICLES []VEHICLE PEOESiRIAN PROPERTY DAMAGE ONLY ?NONCOLLISION ? HA2ARDOVS MATERIAL []PROPEnT FOWECTStRUCKANDOWNERENAMEI LOCATION OF OBJECT STRUCKS' E VY ,. ESi.DAMAGE OWECTSTRUCKINAMEO OF ?EC []ROADWAY FEET ? ? ? ? RD EDGE S F/? ? DRIVERS NAME-LAST,. - ,' FIRST MIDDLE DRIVERS r1AME•LAST FIRST MIDDLE IIf. UICYCLISI OR PEDESTRIAN CHECKI L) ..: R v _ ST T77 -R V, ..... .. .. .... STREET ADDRESS E STATE ZIP LOOS PHONE NO. E LRY STATE. .. , . .." ZIP CODE PHONE NO, R CITY _ rid 3i ??ly-iot y/ ? f FNi 6J R N , ? pWVEPS LICENSE NO. GTATE SEx. DATE OF BS"I" N DRVERS LICENSE NO. STATE SE% DMiOE OFOB^YTH °' LdUEC? S3 /n? C/Ji? /? 01 D% h'7 0. ? DRIVERS OCCUPATION FIRM NAME -. PHONC ND. '1 DRIVLRS OCCUPATION F NAME .. PHONE IRM CODES ?> ID) O RY _ TAI SEAT BELT __ lal. EJECTION CLASS -- CODES > IJI CLASS IA' SEAL BELT ISI EJECTION INJURES . ... C' NAT UREOF R FR MV ENE SV CD Y TO' ' %??. NpMOVED F OMSCENERY DODGECHEV ) KE TD MDDELIDARI-NOVA) - STYLE 12 08 LONV.I VEH. YEAR y??J GGECHEV. MODELIDARTNOVAI ETYLE(2DRCONVI VEH.YEAR. . MA I .. .. T T 7? /'ON _ P? iP17 % V I E COLOR UP UC. PLATE M10. - STATE TRMLER PLATE NO. STATE y VEH.COLOR UG. PLATE NO. STATE. . . 1RAILED PLATE NO STATE ._..._. :, " , cRy ? z??? u?? C .. , AATIG H NUMBER ... VEHICLE. IDENI.FF. ODOMETER ..-. C .. VEHICLE IDENTIFICATION NUMBER _...3 .. , ODOMETER ?: .. . , 7 p G? S / 1 E ,. L E 4 0 TERED OWNER-IAST FIflSi MIDDLE REGI S .- MIDDLE: AEG GTE LD OWNER-LAGI FIRST ( L ? ?. Al1DHE55 : ..?.:.-x.. ADDRESS OF OWNER - ..... . D /d ?3 A%%L E z L NAUEAR ADDRESEOFWSUNANCECO.ORME ... NAME AND ADDRESS OF WSURANLECO. OR AGENT ....-..... .,: . CHARGE :.... .,. ITATIONN .._ ?.. CHARGE CHATIONNO. ENFORCEMENT ACTION - V ED " co ots - 2 D A s ' NAME, ADDRESS & INJURIES OF PERSONS INVOL SEx AGE STATUG EJECT. NAME. C C EDFNGM I HLMO OU R p. V NA I U RE INJUWEG scr Ne nr 10 A NAME N ApOR[SS -- DFHGM °v .. 3• ? in ru scp x QS IF W NAME. A:DPESS. Eft vLU11?OM N uRn scrNE pr TO S H•ME 5 E 5' ADDA[AS RCr:M3VE6FifbE.T__ - vu^ . cINE Dv "L LJI tt ::. RIST rus alam owl%JN NO NNn DI5u1LrNGWJUpv s 2 P•4S[IK,En ? _ to w suTncu IsunawN , I NO T DELI [D 1,07 EJECTED f ID 0 P, q'SON WCYCLISI? D r l A•l I [I IN1.RY 10G 11L E / u A 11 [DOW'1 PAID 4 UNKTOWII IF [C D O 6, ; tl q I'QVi IOn rol l A // N O. I - . 6 SEAT RELY FAILURE EJECTED E 1 . E T 4 V, p a VEHICLE DAMAGE i, o?.w INSTRUCTIONS: J SHA DE ARE A Or 5I VERLS- IMPACT. ?? „rII ` J. DRAY. ARHOWI.SI TO SHOW PN NCIPAL DIRECTION OF FOfICE. UU POSITION BEFORE COLLISION 10 No. N[AD[D REaiIE VUST CR fA Sx4 Dvs>'p H14HwnY NAM[ OR Eo.RFCiION. LEGNKLY wSVE1. S EO 'OCCUPI. '-'' f vE5 NO .Y EL J PE OR LO __ _ G. w M O w D L wA LHEING DUEpFR' ° GSwF ESIG TED _JO ROAD SURFACE ONEI .. YJEAR ONEHEEII K CONTRIBUTEC CIRC CIRCUMSTANCES _ IveT`ttk ACTIONS„ CnECK ONES --- - O _A - i?t D ER E RlvEn E ^ ?1 ' G 4 .] .> > IL ?TRAIGNT AHEAD .. iI ?p c E E DY -. R INFLUENCE 0? ? oLE°wINO [. (,I-'i p[° IVt [? ov I,4 ALQQnQL- '.SOYEBCASI_ I.?.. UNDER f ;,? io05145 Lr J> AND SS,NG . __ > > ?1.PnIN_G I I? DRUGS N ENCE OF IRS ONE C rvTEn '? a E ]rl RIGNTTURN f -_ IIIIE' .._..,? ' O -WING . :... I 1_?.I f D ° rl A G O iC IT ?1 OPEN T? FT J Cf iDG C S_ (" LOCH. ri LE I?KU ---j 17_. I i.. ..N NaxT R. --lo-, u - _n6 7_7ALS. _SEGUV ?sff!'? U RTURN I.f[Clfvl' ONl ER lsv[CIiv1 r Ovl ?STn GO4!1T J -RI I SLOW NG OTHER lGAID No D, 'PEE OrEN 1j- DIG GNA OP EVE I 1 11-i STOPPE FOR LIGHT CONO IE IONS RAFFIC CONTRO Ne PE OF ROAD _ VEHICLE CONDITIIVON SOBRIETY _ TRAIFIL CI1( 1 1rv0.>vESIGNAts 1 D> fCK ONF ORMOREI v'NCLE?ESFvwiEllv[DI [ ICNFCKONEI I..JR? i OA°iDOS ON SIGNAL ! ....... 0'> JHV L10PTo. F 1 IGnT ?>4_ °f L IrJAIflLD_ - ADwnv . ,. R NI STARTING IN . >f O r_ E C 5 f .1. AEHIITI STw511NG INOM HDA IL!, > T G R N4[ f OS IOH AEG LOO RA r HEAR ILIGHTS . .s. J INN4 .. . E . I >?.? T, -11Y A ICI e LEV nA0 _iIS-^ BACKING lUI TSON ?L. AAHU. .. 6 I IN wwv D [kT - ! - L[I1 ,arD Dn o[a CHEM. TEST .4G 50.. ;L-AL .. UNN LAMS S «e ! , 1.,?. ( nK-NO f.. CIR/ EPANArlO -? I [R ISPLCH VI $Rf [ T LrG 15 _. .._ .. _.. OI ntR ILAG"Al TfSTGIVEp T - 1...,__..._... IvipCO NODE ELTS ' If LT R[I U]EU ..I. ' D- ,tH lsvf % % TEST IIESULTS 2 IS G .11 Cl.1 O U.I t O M C - IIT}- r Vl 'HAITI > M IIGAIINGU CE LNAAC u„nls. Al l III yr llUVfU l f M DISTRIBUTION IGINALCG" SE DVPL CAIt CO YILOL'AL IatV[NFUNCCMET A[?[NC ?SCOPY?Tn PLI?gTELCOPYpINVESTIfiAT01]r15 COPY ell 9 t'.6 '/3 :•[m1r5?iM ?t J Il ], ?? s I iP .'"Y` CIA ? VI I P Ty?,l?k ! 4 ?'.t n f 1 J N' Il " 7 A'V21'SY t f ?( L i C A r f , f 1 I r, J 1, u a ,t ? ' 'J k r I DAMAGED VEHICLE N 0.1 "SE THIS aPAlt EON SKEICr . Nc naMACt TO TRAILERS. MOTONCVCLES Elc 1 !R- ° j ^ DAMAGED VEHICLE NO.2 I. ? T O?rE d t] O.r N n 16 ^ FEVER ITV OF OAMAGE: VEN CLE NO. 1 ? OUEAEJ IG DAMAGE > ? FUNCTIONAL DAMAGE ' E > ? o'INER M,v DAMAGE . O No DAMAGE 1 F iv OF DAMAG[ . IOTHER VD, CLFI Ip °ILAaLING DIMAGE l OTHER MV DAMAGE ] 01 FuxcTIDNAL DAA,ACf ? xO DAMACI Or DAMAGE, Vf HICLE NO ] - (E??-pI ULIxc DAMAGE LE pp O M cE I LJ FUNCTIONAL DAMAOF .. ? No AMAD iOWF08Y s . DAMAGE - E TOwEO tlY AGE E To s TO s s io DIAGRAM OF COLLISION OF COLLISION ' DRAW ARROW SHOWING I 7 NORTH IN CIRCLE O T tocAr[rn0eaete ru,xr Ur IMran .__.... I _.._... _ ..- - 1 '] [now ve«et[ rt0[tra,Ax oA .TUN wr .. -?- - ._. _. .. _ , -7 4 + 7 wxrwrrObE/PNI --r- ._ DESCRIPTION OF' '.COLLISION uxo uTE wNAT.notlaev na.v kO OniGO THE cNASn INCLUDE INFORMATION or ON macR Ec On PER DURING AND OLAR LITV,REDU[[DwLtllrtY. 4NCLOTN NGCO nuCT Ox DNpEPaR WORK,E CI - !('. , A.lAI'G, SAL `? i MIW'Li??? L ? ?? I1 IE?,? F; oYL. Lu4"EL? L-1IYYI OF . GIVE NAME OF STREET, ROAD OR HIGHWAY INTERSECTING WITH: STREET OR ROAD YREFI % ED e. MILEPOST. ! c ,? k2- r 0.29 NON INTERSE TION-LOCATION OF COL 510 HA P DIAGRAM DATA . SL-V., STREETAND •? DTI L r STREET BETWEEN E I?t -_ All ?E n" Aau•o do SS" C uILE. IDENrIFlW IMIDMA IK Dl. on t ?N MP IN TEr NTER LS Nr ero i JJWe?cfo c[ x5 rN I ? ? OF ? 47 76O; /?1 wvo nnwn, gLY FI ,L/? r? I] o O I r SPEC. CODE USE ? ? VE r[ • L I io t• Fv[nKIES L ?.E Li xon ?. r (( cal OWNER OF OBJECTS NAME AND ADDRESS LOCA OBJECT STRUCK MA ED OREEOT STFu U IN RO TION ?N [E] to PEPMN owECr WAY,:... O .. $ FEET S W E j-, 11-i MAI n-afffi-11111MIS DRIVERS LAST NAME FIRST NAME MIDDLE IF .-E x c"Po DRIVERS LAST NAME FIRST NAME -MIDDLE C?L??rer JA r ? ? IUO [ Eoya':- STfl ET ADDRESS ROUTE NO. AND BOX NO. MOPE rHAN TWO n STREET ADDRESS .. ROUTE NO. AND BOX NO. r' , fir, ?' fAre?• INFUnEO USEA M G?TY STATE ZIP CODE 1ERS OCCUPATION 1 COIL S .oO. CITY STATE 211 CODE DRIVERS 000UPATION r ?I^' ??? E druL` ?0?0 13 fLc..S PEIOPT FONM DRIVERS LICENSE NUMBER TATE SEX DATE OF BIR T HH AGE DRIVERS LICENSE NUMBER STATE ' X GATE OF BIRTH AOE ?R -%?! J 7 7J?L GL1ir A ? E ?o y"J .36 [ Mo • rEen VEHICLE YR. MAKE ICHEV: DODGE) MODEL (NOVA-DART) BODY ttLE (2 DR.) VEHICLE YR. MAKE (CH EV: DODGE) MODEL (NOVA-DART) BODY STYLE (2 DR.) ICENSE PUTE NO SATE:'- TRAILER PLATE NO. STATE LICENSE PLATE NO. STATE.- TRAILER PLATE NO. .; STATE. k ?-?? RJR. VEHICLE IDENTIFCATION NO. (IM MODELS d NEINERT ODOMETER (MILEAGD - VEHICLE IDENTIFICATION NO. (190 MODELS A NEWER) ODOMETER IMILEAGEI c??ar- !s /0 77 ?a C REGISTERED OWNER (LASTFFIRST,MIDDLE NAME). - DRIVERS LICENSE NO. ' REGISTERED OWNER, (LAST-FIRST-M1 DLE NAME) -DRIVERS LICENSE NO.;-. , SS a n l q /f 0. 64.4 cCCs /-, OWNERS ADDRESS , (STREET GITYAND STATE): AT O OF BIRT,n OWNERS ADDRESS','. .-,..(STREET, CITY AND STATE) .... OAT OFBflEHR -1 3 So i Sf• N :r FDCx ¢E cc CJJ9 o U PARTSrOF VFICLE DAMAGED - " 2Z,.. ..'1A .. Y% L-. f= r r rIQC rTw':,f PARTS OF VEHICLE DAMAGED .... EoTRE4,tp COST WAS THERE AUTOMOBILE LIABILITY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ? NO r,..... NAME AND ADDRESS OFLIABILITYINSURANCE POLICY HOLDER CUr st•tE '•"EIP - NAME OFLIASILM INSURANCE COMPANY /ZA4&'/ZS AJS.4 .qAa- AooN '- NAME AND ADDRESS OF LIABKJfY. INSURANCE AGENT '. -.. Gtr EIAT[" .. :. DP,,:.) UABILITY,POLICY NUMBER ., 1ST INJURY ...:_.:.- - AGE _ •PPrnNU INJURY: :2ND . . .,...._.."`IP .. -... L;i '. :'.: ' ;AGE: NAME TOTAL NAME ADDRESS SEX; UREO ADDRESS SEX: S EEIFSLOCJ!+IV91L E U n _ IaE -_ d * T E Do 1-11S ES aEO T E OOCTO n R STATUS OF I •D ONE IN VEHICLE NARK FIRST ONE THAT APP 'r. II ?nlH,uuv NG S .,B LIES - STATUS OF INJUR OO-ER IN VEHICLE :?MF. r KILLED MARK FIRST IINa E EPF ONE THAT APPLIES '.... NOx?vel E Oq? O PASSENGER IMlxoa E" CI E, l " Pw oE _ ?PASSENGER NO E R ry 1 tt ?O HEERRWRITf..N ? 5? 5? 7 ER WRIr E111 OOH El 50 7? 6[j SHOW NORTH BY ARROW IN CIRCLE DESCRIBE :BELOW,WMAi HAPPENEO:(REFER TO VEHICLES ^ IA -", INdGTE? A . ' WHATH PPE EO u O e ?. ?t Rt?eMS c? Oxw n S "'r ?(({ UST /,1.) JZTA1 /JCFLO tF TaEEt oa HwNW.r -` / FORE COLLISION No of LE HI vErvwl[ vFHlue n vAAK[o WAS INVES110ATED BY VEHICLES POSITIONS BE AGAIN FI•MDwa l[aAILY r•PK[0 V[nKl[ OCC11R[0 .IA" orx[R O P IIbL PD VAY NAME OR NO C! F L, rx -.N Y[a 110 YES ND ES VEHICLE N 5 F W ON SIRFET OR NIGNS !Y1 ODUIR ? ? ? ? ? -',:? ? ?'? ? ? ?. ?rdoUC6 ?O?t NroM1 IOTHEN ? ? ? ? frv[mlr PEDOrN•N ? ? ? ? ALONG ? iF"IODS1No l l FROM DIRECTION '. TO DIRECTION - 1 C 5 ! OINFR PEDESTRIAN WAS USING I f-I SIDEWALK I WALKWAY ] SHOUIOER F " K DRIVEFVVEHICLE ACTIONS ^ ROAD SURFACE WEATHER LIGHT CONDITIONS TRAFFIC CONTROL M.FeKONN TYPE OF ROAD rrv,GIE KHFU ON[011 u0AF1 K `x1 V vLrv,C MI Krvl<A d•II F., ORIC ? O 1 0 o I 1 Y•0 [ vYrvwll CiU,v ,?,{ '•:• I O I 1 prlxtiaw I ij.J DAYLIGHT ? 1 ? SIGNALS C] I C] ONE WAY E ? 601NO STRAIGHT AHEAD ( ? DAWN 2 ? STOP SIGN 2 E] TWO WAY 2 C] OVERTAKING AIED PASSING 1 DAY 20 RAINING 2 L, REVERSIBLE E] ] ? G RIG T TURN MAKIN H 2 El WET 7? 6NOWINO ] E] DUSK ? ] ? YIELD SIGN ] E] -j SHOW K ? FOG [ ? I P/RAMPIE ? K ? MAKING LEFT TURN ONi00i ET ? A ? FLASHING RED ? K ? 1OO . ( I'] LEY OTHER F ? DM' K,5OFF T ? 5 ? FLASNINO AMBER ? S ? AL ? 5 E] MAKING U TURN K ? ICE 5 ? 11 P ?J 5 1:1 fPLC1sY (S S ? BIHf Ei IIGNTS E] 6 ? RR SIGNAL E3 S ?0+7UIIN ? A ? SLOWING RCASOH FOR IIGT SEE1rM DANGER ) ? SPECIFY ? T ? OfFICCNfLAUMAN LANES ? 7 ? STOPPED FOR TRAFFIC .:FeaGUni0 W4.ON d5IPACtxONG. [ICI ?__Y ? S ?OTHER, SPECIFY ? I ?SEPARATED ? S El OR TOP8IOH ORAL S __. E] 2 DIVIDED El ? STOPPED IN ROADWAY __. ? _ STARTING IN OL V NON RIAFf IC ] UNDIVIDED ? 10 ? TRAFFIC LANE _ ADDRESS ,; ." .....BELL-. AGE ? 11 ? PARKED POSITION WITNESS NAME : ' ,. • ,;, -: . ? I2 El EAGI?' (ENTERING /? Y ?{? ewJ F1 c f k (`rSoL +0 + / v l . rl /?/ t 6 (h t ., 7 ? 15 E] BACKING • Ai ?I'!^ .{ ; ? LJ WRONG WAY Ai ,.,, aNNMAhi_fdY: P,zA,r?Sat'Pe;. `7 ' E' v. pI' Y t? „ i l I 1 F '. ?" T ) r I l'? ? r ?t I 1 I - P' ICE *kyfY?. ?1??, ` r I I v ?, rr y •I } S ?'t,,KF've T J i STJ,• 4,? 4 YSM?I, ..' y 2 k V . J3 ?r L J v'? era ?E3 {• {1 'I 1 k 1Y S 1 Y 1 1 H .I r1 r GN .'Ly .y_ euy. G F w'.J; 7T {'7 i I R ?LL TAAwa M WC, vJ 1`'Y?M J MOTOR VEHICLE COLLISION REPORT - ' NO. DATE OF COLLISION DAY OF COLL 6u vex M ISION TIME OF COLLISION 1L 5: Iluu ®A cDUNTy yq, CITY NO. - /___ _ LINTY STY, TOW E ?? CITY, I'll DML A REFIX F xFET CODE " pq S T SECTION W OF Q?W 3 ? w GIVE NAME OF TREET. ROAD R G WAY INTERSECTING WITH: .-ET OR ROAD PREFI% EO MILEPOST J NON INTERSECT10N.Lu9GATION OF 'C/OLLISION "AMP DIAGRAM DATA BETWEEN UGFrL!L'Gl?h!L,?Ur STREET AND STREET Si n oi? rev ry LI' d r eY IxT C. ToxiXRD nE xiseici ss%[ a.o ?4 O OF Y ?UO e1 ? 9 ......wx ,s vosyse -- - V, . SPEC. CODE USE ' ? ? Of vimicv U - OCATI uA, NOO OSi CK -NCTR OWNER OF OBJECTS NAME AND ADDRESS OBJECT STR N N ROAD a oxif 3 U , 4 W a DRIVERS LAST NAME FIRST NAME MIDDLE .w r..' .o '" DRIVERSLASTNAME FIRST NAME MIDDLE UTE NO. AN ROX NO. STREET AD D RESS RO rr" '^ STfl EET ADDRESS ROUTE NO. AND BO%NO. b ' ` CITY STATE 21P CODE DRIVERS OCCUPATION CITY STATE 21P LODE DRIVERS OCCUPATION ORIVEflS LM SE NU BER STATE SE% .T. AGE D OF DRIVERS LICENSE NUMBER STATE SF% DATIOFBIRTM AGE iii6 -UU G 53 7 F I DAY q DAY YEAR .CLE VR . F MAKE I I 'DEL I'll DUN BOGY STYLE E-1.1 R. MAKE rc„[v.-DO- MODEL nR BODYSTYLE U.N., Ct LICENSE PLATE NO. STATE TRAIL RPLATE N STATE LICENSEPLATENO. STATE TRAILERPLATENO, STATE XA/.Z e7 VEHICLE IDENTIFICATION NO. uwvoocss, xswex pOOMF,ER :uRS.eu VEHICLE IDENTIFILATION NO. xsw, uaPlUax,w[nI DODMETER 1.11-11 G C'?1 ? .i 33C1 ? G REGISTERED OWNER as Rns ORIVERSLICENSE NO. REGISTERED OWNER Ilws, FInRJJiool[x.uD DRIVERS LICENSE NO. ua.?G-AS h OWNERS ADD .OtY xp STATE) DATE OF BIRTH 2f'EET II OWNERSADDRESS (STREET, CITY AND STATE) DATE OF BIRTH . YEA M? 11 Y r rEAR .0 PARTS F VEM LlE MAGFD ..ODD _R-PCl LIABILITY INSURANCE INFORMATION•V HICLE N0.1- cove ncE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ?NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPANY NAME E NAM N ADDR LIA IJ INSU A EAG rtY STATE 2IP LIABILITY POLIC NUMBER 1ST INJURY AGE 1N INJURY: (USE SEPARATE REPORT FOR ADDITIONAL INJURIES( AGE ry AME EX T-1 AME N AoORESS SEX AOOgEST I- -1 Q r ' eocrw Y STATUSOF INJURED MARK FIRS T ONE THATAPPLIES STATUS OF INJURED MARK FIRST ONE THAT APPLIES VEHICLE II Mw ?^ IN r KILLED I ' 5 axu^ I ?xiu On cox, i r o P" ? ?.. p1. =N ILLED r ?w?H ?w ?u Cv I m' x P } L?; f1 ry GI ?I rv:Rnr.?' ? 5? 1 7 a : D? w] ? 50 7 Q 6 ? SHOW NORTH BY ARROW IN CIRCLE pK.,[pwixRP?.DA.M „ „ x»ar .a Q\ •\ YpxA EDLN.?x %.w,. wn?„DIN „AI[, Dn rc On PI o_.__ar DESCRIBE. BELOW WHAT HAPPENED: (REFER TO VEHICLESBY NUMBER( (Jehicle-._ho?_r-ow?/_m? Car_/?ev- -... r Y -' / 1- AT o NYLETIB VEHICLES POSITIONS BEFORE COLLISION [II D, VEHICLE NSAD[O ON STREET OR NIGIIWAY NAME OR NO. ?ra ?roLK ND [YWRI ??d¢ I.°.rl"% IIOir.% ri??rc?D ?rorc _„olwv[nICMI ,0_C`•1 I oN W 1 ? ? C] ? ? N r IOTHEAI ? ? ? TD c FROM PEDESTRIAN ..?_,?? 01 ALONG .. I? '• CROSSING T N A ?wF ] ?,•w` A F] ?„ 3 ??n 60p1 NEOCSTFIIHN WAS USING 1 ? - I S L• LI THER GIIT CONDITIONt ROR DfURFACE WE TflA FI fC CONTROL nvu TYPO OF ROAD S, D' c ACTIONS ORIV[R/VFNICLE Ia D„, on ulM, rc I t"ow[I I A ` ,i1? 1?OAYL IGHT ? ,K? UqY ] ?RHINING i ?DHWN ? , ? SIGNALS ^'l S 0STOP SIGN Ox wewl y ?ONE WAY ccc???? I D{I ] ?TWOWAY ? I „?GOING STRAIGHT AHEAD ? t ?OVERTAKING AND PASSING ? WIT ] SNOWING l ?DOSK U `3 ?EV[R SIL[ T ? ?MAKING RIOIIT TURN DAR STRF[T ? T ? SNOW E ?F? A ? LIGHTS ON C] ? ?YIIID SIGN ? a ? I LASHING RED l J ROHD ? a ?;NTLO HANGE [] E ?MAKING LEFT TURN ?A?ICE 10 V[fHr S?OGI(TS OFIFET ?S?ILASHING AIAHER ?B ?ALLEY ?S?MAKING U•TURN ? S ? 911% B ? DAR ITOLIGHTf ? B ?RR SIGNAL C] 6 ?LI I (IAN_N.. C3 B ?SLOWING R[HfAN IOC NOT tLEING DHNG[R T ?i?1Glir E] 1 ?OIFICI,II•FLAGMAN ? T ?STOfeEOFORTRAFFIC - _- ?s `,mil, Q ?V, ?' ? B ?v?Clrr ( ? ?? I IJ SL PAR AICO ? B ?DR 6101 SIGN AT D 'I Y ?CAJ? N?DIVIDFO ??0?bTOPPCDIN (ROADWAY )CI A?701NAF'f f01 1 Tn IV DEC nOnIYIAII CIIHiE ' I ? I' Y2? ,x I?f(. u - ti 3 -fill 4. sF ) d ?' Kr ????f&„u 4i J '. LB?E~.? ?? STATE 6F WASHINGTON PAGE - I a. No ; II UNIFORM POLICE TRAFFIC COLLISION REPORT c0M- NUMBER ^. ,. Cvl a:a(y t v.,t?ynn _ G -. WTEOFLOLLI.SION .,_ MO BAY Y0.• i --. _.. OAY OF COWfigN TIME SUN LI011 iuLS WE I.R 1. BAV WE ]-OUR T 1 Z ] a 6 S ) Y CWNTY NO.' i 1 CRY 110 f.. / .: F.- ? URBAN '. CC7U'NiYI ?STATERWTE ?COUNTY ROAR ?CITYSTREET O .. ? PREFIX NOUTE OR BINEET CODE it BECTION ?OTNERISm' ) W N I ' 50p4`4. ':. y i L ' _ .. S,x NS E ?Fi CITYOfl Tom .. - . U VITI tE PNEFIX EO >Y POST1l: ..;z J 5 J U • MILES 1:1 ? ? c? . , .._ ... ot7 w,u - 3 Q • A.. aNO STR CR NIOWIAY l: .IIRENSECRNO WIM: STREET ORROAO O ,mil RAMP K OIAGRAMDATL:,Y,4 .;+• ?, M••i1-':pryl • NON MFIISECTIDf/ WIER 7 B BTR IXI _ •? , BETWEEN STREETANO STREET ACCIOENf MIlEAOE CODE %qp III((J?ERSE TW AD ON FIC SCLB E/FNCECROSSSIREETON-x A - I "" •. IWANCEANOOWEC ON FROM REFENENCEORC WR4 T MILES N S E W FEET :: OF ?' ! .... _ 1.?•s.. :-_ uA e `? S CA COgNOUSE W ( 'Y FY A.p '? .. ?Hrt ARUM' { t. SEVEANT? rl,i COLLISION INVOLVED: ?VEMICIF.VEHICLE ?VEHICLEBX)YCLE,._ ?OTHER ?YIME) .•:. NO IUl1ED ? , _. ; : F._,. TOTALNO. ?VEMCLEOBIECT ?VEHICLEaiRTRAW % ?STO.EN VEHICLE . O r - OF YENCLE3 ?VEFIK:LEPEOESIIBNI ?NON{OWSgN •. QHA2MOpU9 AUTENAL,x. '?" 1nwF'_? L'J PRCPERTYOAMAGE d4Y? r OBJECTBTNICK(NAME OF OBJECJS/(WCK ANB OWNEflSNAMEi.Y -• ,. , ... LACATIVI{OF C&IECISI!IUCN iC. R,':l, •' -- FgT-pIy ?ROADWAY FEET ? ? ? ? RD EDGE i' ? ? DfOVFH8 k L FRST M +,n P[BYFgT;NAME'LA;;t P?RRiM o-D D RI tL? r V• -" v/ C 1 /' D .n?Y J?^R ? 3r .J " t `T T ?r ?ti ra 1JiY/ /?E ? y t r e a ?etREE3 (?oliEB$ rR 'Lf.Y+sa:?i#rz•ns .c+•. ?-- srn:1^ ?ABr+[? .fu ' q ByRF 6x tl rLL i . . ? Y . „? . . ._ . c.d?. :_r nt V 'E -. nY.^..SUY :..:.:wbTAlE.iri.e..e.?i.:.os. DP 000E,+,ys PI10NF,_NO Ei CRY.iGX+.;lt3-d`=+:.c'1,w._:.ynSTATE•] iiwn.n+A.n L COOEppHE 1 p'3. ? o,. N -ERSLICENSENO? y? 'L ..STATE - SEX.,GATE BBRH N DiWER9 LICENSE NO.^ry y 4 Q1?'L 9_TATfr ..ilE% DATE:Of MO OAY YR O M0 DAY YR i r l - 4 _: ?; - . Sp ? ? ORYERB OCCUPATIOIi F" !IALTC-» DRIVERS OCWPALKNi, ,_ FINMNAM, ems,. . r n ' CODES >1(3) CLtiR& _ _ MI SFATBELT 151 EIECTgN ':':'::` CODES >1(3) wLn9?9 . .41141 SEA (5) EJECTION C TBELT' . . IUTURE -..- ry ....? ?r..? P'?Fa%)IaES .. -._ J 1 :..: ... ` ? l• I LUZS -' .I L L I u A - •?- • BY: •.: TO •. .. £??, REMOyyEE ROM SCF EBY -.' - .. _- "TO •I . VpLYEAP:. AT!Y4EplODDE:GItYJ.:. MDD41BA9I'N9YN S3LE,?,aL•cariVad.:vf Y?YFAE! MAl(E (pOpOE{IIEY.i,u MooEL. DLAiAipV?llx. ?LC??Y r Y 'Hr. VEIL -?' ?S.L7TE hD,+.: STATE-.-TnAnER,?TE L+o.. 7A.tE fE VEJ1. UCSPUTE NO,;. STAIFW 1}PIATE ;->?TE r _ ] L 9 ?. :-- 1 "v a).?au ML ?xEi11E NEry?FICA_"-j I M+Y ME M1 E RasTEAw L•13Tx,.5sma.s:vau.FIRBC.::..Gwa -.•.f:x.=ei NDIXE, ' REG45IEREO OWNED- Ju./11JdL..,cE ..L...:. •T 0 t ;•'fY.,JF .;a1? t3` I> nLltfltJF? AIX%63B of owNFx >,.u/t.Y, ?L a " .P r ,? ADDRESS of uWNE?,?,,..su.e.F mc.Y..ms sar LTa T d? ?' C 'T.V 71;{ ?Cll- C`7.{ J t 5z 1 .. ta:. ; _ HAMEAND OF P SUR41CEf:0 Ofl .Cv.._S _" T NAME AMDADDfiES.Of WSURAIICE CO ? ?'?EMT,.?u.-`V I .x?w { ?..Y' -' ' • # " . G `:.. f.ws.54LY YG2IG ]u>.1 ".r...? CRATgNJlO EIIF ORCEME M.:,+?3'GS? SuL .Sax:.:.._ 9 - ? A .:J/.}.- •a• ' - ' r . ti• T f ;Au.X' "SAY M', n%Y{yM ^RHy7' 4 oRTy.!/,(?f.•TN'YfRIM4 v i! H T MT IvAMN?j DRESS & INJURIES OF PERSON NAME A INVOL D CCCES:.:. 'T 1 _ - 3 J • 4 a 6 ?: . D S VE { Y .i SIX •ADE. STATl18 YLK JECr--: c NAME! .U:'; .p .. 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O 6 16.TnaN d lea; I _. , u i Ie.uroF. - _. . la r m.uroore.mwa P lD P n o..nan Y , r ID P n.aeR?.R & .S BEVERRY OiD e - SEVERRYOFDAMAGE:IOTHERVEHICLE) SEVEPo OFDAMAOE:VEWCMNO.E ?•..-? •? ,O` 1OpSABUNO DAMAGE - OTHER M.V. DAM 10 aSABUNG DAMAGE - 30OTHER M.V. DAMADE -1 O-Aa1NGDAMADE - .3OOTNERM.V.D_. E 2 F NCTIDNAL DAMAGE ,.,• . NO DAMAGE = FUNODONAL DAMAGE A NO DAMAGE 2 NNCTONAL DAMAGE . NODAMAOE a `S' TOWEDBY C_.? E3T.OAMAOE ESI. DAMAGE EST DAMAGE ' TOWED BY TOWED BY W.. n - ITo ' ?''?'. I 130P_AM O?QOLL1 0 IDRANORTN NCSRCLE-' 1 aaRFr ,mwr.FU,wFe _ LLL- uvALEiCJ .. .. - '? .? law rwxAaErawroF f>?i. ".ri ? ? T ? ?:PW, I e !i '= siwrcr K .*..*. . , I .. er,awrr,OOAet vE,KAEOq ._. ? _ aIDRE - ` DESCRIP7TON OF DNDICAIE WHATPROBABLY HAPPENEDBEFORE DURINGANDAFTERTHECRASH IM:WDEINFORMAT10N N0T ON DIAGRMI EO.OWVEI . ?. ,COLL ISION,- .} ? p3AI11tY REDUCED VISiBtUfY,PEDE3TRIANCLOTNINO GOIOR CONSfRUC110N OR REPADt M I / I?:i? r VEHICLE'.`1'upU6Ll` i LJESt OJ `cSWAA?SoJUtt-,_E Co RpJUTJINC? =LDA?6 C'.L)CUG Lb n ,. _ .? Qt_..W1 O--See VEY.'-DE fL.-IrJ fonvww-! Ib?KG-?iHSru--?"?19s?-I:o n 'S??V?EF -'LC?A L,??' cov-i-hor_ we.,. G LL f S c o zoAV 2,1E QJF2Z0.AKTu?-Crar,? o_ v lf, !. RtST'Uri9:-Rt 6•0:-SLOE _ 2 D ITI. _ µ?Y ,I... .?{Y.??r?*+,riw'a'r a9{xAr w>c'B. NO OF IANES SPE VEHIC P T { VEH. HEADED MILEPOBT_D ON STREETMHGHWAYNAME OA NO .O EDBM:CIIGN 1E0A1LY" WAS VE rq_...,___,• _ WCREAYNG DECREA.SP16 ._„ ?.:._..T . -: -?- - D ? P L '. Ya4 . N s...E w - YES 'NO YE9 Ni a H. .. Dw lE .,4?i ' ', -. .. ;YaT^fif. ;?' ' ? ? ? 70 R - ,wan 7 MErwlrn "% PED/BiCVCUST WASUSWD: saewMA ..??wAUOV lo_ '1?CHDD•SSY . 1[7ICRUAMCSSYAa..aoereltm?irt[•..• T9 OnrtA - i - OADSURFACE? y:. WEATHEP' ,.'a., ?yyt?CONTRIBUiWO_CIHCUMSTANCFS "+ e 1 «?:,,ort+gpvRAaEeclDra- "??. N rorc«o+G IAOw ic"""n«m 1 wnm `'+b: '©O L,RADIRMFAD ; `? ? ? ??] a?>oY ?' ?.mD"?EDF ?,?°?al?. p ? wan,?l ??=L7..°?p,?na, ? 2E] Q4F_j 0.11 ., [3a? 3LI ?a? offn- D ?a? -T* ? ? D?R.ARA.a ? , ED Q 1 .S?-J__ e - . _ _ ,.?° ?_. vu.ni a[? sor mDaHr ?,? . ? '? °'°""!D ;T q VF i OTKAIS[tslT O ?, ? r - I1.T? aen(O,? B10P . O 'El lA1Wl?n ? T? -Fd 1G? ?v . N? L?J Lx 1' ):." SDSRIET.Y' ? a+m Tewua ' u p?Agy;,,, rly?, pl;?q UGHTCONDITIONS -TRAFFIC CONTROL M+FaGxJYPE.OEpOAD - lilCLFLCONDITION s1ti1 ? 5 a E] ??Dp yt GLCRaa plpwaNN, Q It EW YxE p:I ', HR=RaMFg Ma.] .. -: -?r??. s a DID V KI rmow" 0, El ? , 0-0 rRA,mz - - ;011[] PAZMPOrM El D . ,n°?nre a°?irn .I.s1??_ ^ _Ll =.t... 1 1.d?? w ? Lfie R . ?:. ,? M ? 0 , ? TM rA, ,u.T .: mcsR.+c.lwcn ? F? D. m.., _ CHEM. T EST a-?--.: .!. :1... ; ?N • : k MOUOm= T ?' ?: U n.°A°"a?uw_ - or.ln ?L J ...... ? ? ! t O wMFi im ??? onnFn..._._. - 'T ? -au ? worsErn ® rFarR[FMxo i T u,wwi+FC t'. r T ? . d 'U +n 'r . o IaYCTM. :. .. - 7 , ^ . u m _...._ ` (F, omFAIa'EDSn .. ....%..% TEST RESULTS ,2i ? . aloA,w rre wAaaA,NA OV`?S.wcr-lYT" _. Ma s- . .......... raze Aramn _.. .. urt. 7,17 .VO ,?canow X wYeliMA waTrxwaNAMt AMrf-.-_. F - MDa[W- ?.. 1e: +=nsix r wr0AT4f.aRT?..- DAny^?^ r y/x/7`8- ;rBD,ion . Mi[ I ?? . DWTVDLMON'Of"ULCOPY:BEIOTOWAS 70N BiATEPArnOI-OLWWA81W10TM-ap WPEIGTECOPYiIOCALIAW ENFORCEMEM AOENGY=COPY?TRE'UCATE COPY:VM91ElATORBCOFM 1 ?1e rM 'i F @ ?? •d , .., , NL `,;,35q _: ..,.o,.M,iL,A„ _...rrorJa. _2CL-?YFJ _ .. __ _ _ _ _ . , _ . 71 ) MOTOR VEHICLE COLLISION REPORT 'TNrTF ? ,' ?? DATE OF COLLISION D yl+?_ F ?'] w.•. Yen n OF CO ruts nto L ISION TI E OF CDLLISON,?.? +ur rn '" U nu [5 - -u - S COU TY CTY NO (?/O/ ?L ' c ( ' • , COUNTY CITY,TOWN = :' MILES O E TOWN AD L VHEFIX A OH Si C t ? C (ON r Er r F +•J w= ?] ''Y 'OF M ? 49.9So GIVE NAME OF STREET,flOAD OH HIGHWAY 1/ INTERSEG ING WITH: STREET Ofl ROAD VREFIX E O MILEPOST.: NOf1 I`ITEflSECTIOfI LOCATION OF COLLISION ON GO. .? _S'tU$JJSTJU V, AM1IP OIAGflAM DATA BETWEEN STREETAND STREET II?T I0? OF I,y/r t? "' ? " L / nr vs c,ss .. i' t o n SP '.CODE USE ,,.. ct llssr an n..o,MS On rrrvn ?• t OBJECT STRUCK .. rxxut Or ouecrsinueM OWNER OF OBJE T M " ... S NA C EANDAODHESS .... LOCATION : ON a IN ROADYIAY " - - er iorirlr?rAOUCi O FF ET W : S "• DRIVERS LAST NAME FIRST NAME M'DOLE Rr3 r IS J.til? ? •• ' DRIVERSLASTNAME FIRST NAME MIDDLE: v - STREETA OHE55,.- ROUTE NO. AND BOX NO. SCEZ '•'"•*r •.. • STREET AODR ESS ROUTE NO. AND BOX NO.. CITE STATE - 211100E DRIVERS OCCU?ATION CITY. STATE 2,P CODE ORIV ERS OCCUPATION ^DRIVERS LICE 1NSE NUM,CBE,Lfl'7/. I ry-I?-S.s '-?cyGy.I LJI STATE SE% DATEOFBIRTH AGE 24 DRIVERS LICENSE NUMBER. STATE M5EX F DATE OF BIRTH AIO DAY YEAN AGES VEHICLE YR MAKE Knpv oeceet MODEL InovAD.An' I BODY STYLE UoAJ P(Ck--?If VEHKLE Y0. MAKE rDrev. OOOCEr MODEL..w vAOAAiI BODY STYLE,.Ixow LICENSE PLATE NO. ,ASTATE TRAILERILATENO: STATE V VI? - LICE NSEPLATENO. STATE - TRAILERPLATE NO. STATE ...,_, VEHICLE IDENTIFICATION NO. rsv Maoeu Anerr6nl - DDOM TE rMltesOEr - VEHICLE IDENTIFICATIONNO ; t.-. W u -,, ODD FTEH IMra:ADrl REGI EKED OWNER rLAnAwsrrroous NAr.H J. ,??_, DRIVERS LICENSE NO. `? a I . flEGISTERED OWNER,,. ewsr.HARA. s_t.:; ;.: IVERS LICENSE NO. DR .-;ya _.. .... DVINERS ADpfl E55 ISTAEET, GTY ANO Sf E 'DATE OF BIRT H.., MO BAY YEAH U` OWNERSADDRESS..r., •. ISlAEET M DSTATFI?n '. DATE IPBIRTH? MC - DAY YEAP PARTS OF VEHICLE DAMAGE _, .:aa.Y_- v. , '. ?.z' . i rexer.rAre3 _ D A HI AM _._. - ..:. 6si rMATeocwTq.- A, oMAYlArDLEa _ 5 AUTOMOBILE LIABILITY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- covIYASERATHER GI E IN EFFECT FORTHISACCIOENTONYOURCAR YES.?NO NAME AND nDOfl E530F 4ABILITY.INSUHANCE.POLICY HOLDER , ,.•:,;4 :*Ej_s,a, .yvi'.-- - C: NAME OF LIABILITY INSURANCE COM_-LJ?:LY?'?y?+•?1 NAME S - D0 IT 1 vp g- V ? ? 00L D -1 U , NAME AND ADD OFLIABIL:TY INSUHANC AGENT '= D t1 LI ILITY POLICY NUMBER _v,.S_: T'.VW(yV'?'. 1ST INJURY '. es _.,:'._.".•...yo,. .._....s...e. :...x..:; '`:. :.AGE. .AHD INJURY +IUS666PARATFAEPOR FOR ?DDfnONAL UUU fs4iS?y`yF;? 'AGE, .., .. .. ....... ..... _._ ...L _.._.__-_.___.. ... ?,.. ....?__.... OGRESS ME%F HE55 SEXY r- F . LL Jl .. mcrwr Q© - STATUSOF INJURED ' -'- MARK FRSTONETHATAPPLIES'. :',STATUSOF INJURE R D .-"MARK FIflSTONETHAT APPLIES.15 ? :..Y J.' TxT ..._ IN VEHICLE sAS U? IN VEHCCLE eLr.wY KILLED KILL ED ( r fiO a N eic . 7w0 •_. ? 50 6? e7 a•, ? .5 O nTH_. .: rl SHOWNORTH BY ARROW NCIRCLE 1 OESCq BE BELOWWHATHAFPENE01(REFER TD,VEMICLES,BYNUMBERip i L --- I 1 'y ._.. ....__... _ ...._ .......................... I VF,/IICLCS POSITIONS BEFORE COL(.ISION INV esnoAifD Er VEHICLE rr.LALeO ?U? A O(NSTIIlE'ET OR HIGHWAY NANIE OR NO .(TOUR( ?L11yyC l_IIV? 1 ? ? ? 0 ? ? SlbArroN • 10t F I r lL?Cii? rzoisrnMri '' ALONG _"?• 1:a:K._ .'dre«+o ].lia.J.a'• -=0o..1kvSrrax:'.. ' ' ? ? ? L-, 1 1 ?v CROSlIN0..I C .. (ROM TO "of.sTRIAN NAB US]VG l ? s.n•r..,a S U...... ] ?s.nwr v.x ? cwr.ssw.ta 5 El rnnuw:sa 60-'. nOAO SUn(ACE WFAlN[R LIGHT CONDITIONS TRAFFIC CONTROL TYPE"2 OF ROAD OHIVlRIyEHICLE ACTIONS 4:'rrf •" r n t] VLIGHI ,l•t?! enH yrLH KneTao v+ct1 KneeX Ore On viwrL I SrGNALS ? I cl ONE WAY ?x F ? ! - L J ? S ? GOING STRAIGHT AHEAD DAY•N ? /0 •?? r J ACT ? I S10r 1, ] ?nUSK Si 01 SIGN ? J J/Y TWO WAV ? 1.??/OVERTAKING ANDFASSINO SIHLB T-1 - C3 J QYIFLOSIGN ? 5 ? FOAO ]•'g AY,INO FIGHT TURN T [J 5::111 s `j IGt: A 'I 0 LVA- ICRI SO, LT J I n i r ?TLAiHIYn (IRO ? i ?INTF RCRANGE ? A? MAKINO LEFT TURN f All ILOOVIRAA•VI Fi r ] ? L.1 L If.r ?5 s)f/ ;,? ,,. + ,.,• r_ LJ 5I]FLA-"It'r-AF.M ? 5 ?ALLLY ? 5 ?MAKING U-TURN iry ' tl CF r Gr•TS 1 n SIGNAL r ?I'A ? p ?? n ?5LDWING err n,AYl Ns - r • _ IMF ASr1. FVR YOT ]EIINIi D?N.Fn ) Js , ? ?•v C) ]1?i,P "c' H,rI Afr,sAN ? l?STOPPED FOR TRAFFIC O A I?•?.,!,i. -77111 AFAif.O ? II ?5TOFF( ATH IGNAL on $10, InG _ ? 1 Y O VI0L0 ? 9 ? STOPPED IN ROAOW Y 1 ?T i '•T j r?nr--,,,c COMTAOL I I ] r JUMDLV OLi ?101-SSTAnTtNO1N TnA1i C1 ANE n""I'1"G?. - 'lam • tl, 71 "In I •... ' ?-. U2- YJ AeY?' Yr 'SL 16 1 A Y Y. 0 lJ4.2 ? V ?{I PAGE / OF NU- POLICE COMPLAWTNUMSEH W e1 - UNIFORM POLICE TRAFFIC COLLISION REPORT „•v_' -, y ?,., .' D DATEOFCOLLISION DAYOFCOWSION TIME , COUNTYNO. CTYN IO.. FHwA. MOI. DAY TR. SUN I MOH NES WEC M N Fpl 9AT IUSE 2gD0 HOUR) } UgBAN I ,.I E A t T 2 ] A° 5 a X n ;?Z / -RURAL LOUNtt/??(( ?STATEROUTE ?Y. COUNTY ROAD ?OTYSTAEET O AD-1-S. PREFIX FQUU{TEORSTREETCOOE CTION -.- • 9 •+'f1V+•• l•a. ?OTHER(SPECIFY) N .? 9 9So ,Ste wx.N L/ IN / CITY OR TOWN PHEFI% EO. MILE FOSf J? ,+{RCS, R O + MILES ? ? ® 91 ©OF /i??? J.:{CZ'Tol U dC7 "?'^ .F CA NAME 6 NO.OFSTREE HIGHWgY IMERSECTINGWITM: STREETORROADLL NAMP DIAGRAM DATA NONINTEPSECTION + ?IEIISE O ACCIDENT Irv TER NT C45 EH NCE cHOOS35TREEf OR ROAD, A .c] MILEAGE / SI Q N BETWEEN STREET- STREET CODE "TAI DISTANCE©MDESCnONFP MEEFERENC RCROSSSTTIEET / unoNLIH3 SPEC MCOOING USE r W OFEET S OF 1- ?/C2 /.lam A, 1 VEHICLE-VEHICLE VEMICLE-BICYCLE OTHER (WHITE) HTdgUN NO. KILLED fur I COLLISION INVOLVED: E] ? ? (3 5EVERIrv TOTAL NO ?VEHICLE-0BIECT ?VEHICLE-RRTRAIN ?STOLENVEHICLE / NOJI RED ,y Y ,1 Or VEHICLES ? VEHICLE-PEOESTRIAN ©NON{OLUSION ?HAZARDOUSMATERIAL ? PROPERTY DAMAGE ONLY IC - mil OBJECTSTHUCHI-EOFOBJECTSTAUCKANDOWNERSNAME) LOCATION OF OBIECT ...... S E W EST.OAMAOE .. - " ? NOa04YAY FEET ? El 1:1 11 RR EDGE S ) LRNEgS NAME-LAST FIRST MIDDLE - DRWER'S NAME-LAST FIRST MIDDLE OF UICYCLIST OR PEDESTRMN CXECaILj R d wN .. ?.:. ?.r R STREET a00RE53 I STREET ADDRESS _ .F RE CITY STATE -:. ZIP CODE E .. I' PHONE NO. CRY STATE LP CODE PHONE NO. .., • C! rr.,•?tY.; n. Cc/?i . ? ?'b!J? ,'S-0,793' fl ., 1?: N ORIVEPS LICENSE N0. , " . STATE SE% GATE OF BIRTH N DRIVERS LICENSE N0. I I STATE SE GATE OF BIRTH - I O, .v s lE•xr'- !> GS//o C?C M S oY O MO. DAY YR. :-? 1 DNrvERS OCCUPATION, FIRM NAME . - ". ,." PHONENO. 2 DRIVERSOCCUPAT10N FIRMNAME t:- CODES > (3) cu°ss G 14) SEATBELT Z IBI UECTIDH / CODES >11 ]I' uVy w) L 53 SEATS T NATURE 15) EJECTION INJURIES f u q" .• ? INJU ES - y "IT I 6CENEDM TO •J t7!e FROM SCENE BY: TO VEH,YFAR MAAEIDODOECXEV.1 MOOELIDART{lOVAI •. LEI30RCONV.) VERYEAR MANEIDODGECHEV.) M OEL(DARiHoVA) STYlE12 DLCONV,)Ly'?• [ E VEN. OR ? ;? , .."('I.AIE NO STATE-. •?? TRAILER_ PIATE NOT STATE:Z-_ E VEH.COLOR ' -C-' LIC.,PLATE W. STATE TR.AILEA PLATE NQ L STATE y " /, PAS zr? H.' i - x O VEX IDENfIFICAT .NUMB -^.. - T;,N? _ a .:......,,,:,. ....,...?...,.., C .:. VEHICLE IDENTIFJCATI II N e R;. ?.A ^i`_a'4"' y,. ODOMETER 5.. ,A,,,,v.., I ` r+ +". Z REGISTERED. OYIN R-LAST;'..,; ,.r r..l.?. FYt4T' .. -. ?..e.F i rH;.u .MIDDLE ., flEDISTETIED OWXEP LAS .. .. FAT":R.aL';LA' i' -^Jn IilfiCE t% AOORE930F OWNER n'u-T..L.'•_?d '.• • ?..?A....:;..NkL].w-.. .:. .1+': .....?a..:L_,.:;>>I'L'. O,ADOPES90F. Efl• P,,, :::.:.,,AJn+':.... ,t...s ..1.,f?'SL•+L'.lYa_.4115:.:..J ?!^ 2 - ^A NAME.WDAppRE _YWJRANCE CA.OR AGENT??•I Jr_ i•,;,?•,•.? _ NM'E DAOOPESSOFINW"A ECO ORAGEM ? .f .. uTt17 L•".?__v.:. ,-.7 C E ACTNYJ ,. ., ?v y c Es ' C ` NuAE NAME ADDRESS & INJURIES OF PERSONS INVOLVED ;, „, sEx?AGE srATUS N LH : ?] EJEG T ?` C ADDRESS: t U NATURE OF EMO ED FROM P IRIUPKS. SCENE Rv: TD Fa S A NAME N I ..1 f , iy. T ADDRESS: U ?I $ IWUPoES' SCENE BY' 'TO» T YJ ; ' EG W NAME. _ 'y{ J•` ADDRESS: NATUREOF N HIUNI 4' Bf M FNF. RY• TO $ NAME: 1 C?u 14, S ADDRESS { Y -'y- V ?• -L. S. IN.NR?tS 1 P.G AY. TO f 5 - ?', Ip"1?' °f yy_ ISi TUS I.I+EArfo to JI NJURYClASS M IRI`SEAt REIf jlllllfclION 1 C dPFCf41HU i R INOINJURY 305ABUTA IIUURY 1. t.Ot InSTALLEO R. NOT EJECTED 4 t ;Y1'EMI 20EADAi SCENE ONONDISASUNO lNOiIN USE D 2. TOTALLY EJECTED ,y Su- t 1 l !{ S', O CCLSi1+ 11 2.OINER MSITION 20FA00„ARNWAL FL10EN111.WURY ]USED ]PARnAILY EJECTED p _{ ,'k? T I 7 SO CYTNEP IRUS MOICACYCLF.1 AO?F.D IN OSWfAL I).POSYBLE -9, . 5UNEAi'ANOBELT wIITAtIUPE A.UNEJECTEDxNOWNIf ,?L I E A Y, Ti:.ESS d ] APOS n. Y uyA1.OwN 3t i. A I l{ ?.. ?L 1 '?.•'Pa"??"? 4 'JC l «S2 k, LC { •> 1i ,TAT I , .,Yp ; f ? ITT• ?? ) t T 1 V ? S ?3 7 I ' f N H P f I i Ryl jl?. QQ??Y u LTG Y `_ ,? I „ lL r? 4R' k P I L?! 1 t. Y ?? 1 ll y 7 1 A? ?? 1 f I s 1 T % 77 A?r; ? I T ? 1 Y 14 ?! Ar, . 1? :. .. F't7I1L,yy,U ppA AYA'? ... qk, VEHICLEDANAGE t. INEACH BOACIRCLE THE NUMBER OF EACHDAMAGED AREA.' FI-ERESTIMPACT AREA Y INSTRUCTIONS: 2.SMADE . O aDRAWARROW(S)TOSHOWPRWCIPALOIRECTIONOFFCRCE / DAMAGED VEHICLE N0.1 NSE THISSPAGE FOR SUETCwNO DAMAGETO TRMLEas. MDTGRGYCLES. ETCt DAMAGED VEHICLE N0 .2 ? EAR ? T r ? ? 1 r?.HOPG 14 Raol 15. Tlk - - • t I 1 r ON r ? R O.IboO- . . ibal 5 TMk - / T re.umercA m.cA I ,t e.umrnrrNC. n ro e e n, a.NwP v . awn.P SEVEfl1TY OF OAMAG :VEMICLENO.t I QDISABUNGDAMAGE 30oTHF-,.DAMADE 2 %FUNCTIONALDAMAOE A NODAMAGE SEVERffVa DAMAGE: IOTMEfl VEHICLE) 10WSAlAMAGE SQOTHERM.V.OIAIAGE 2 FUNCrgNAL DAMAGE NOOAMAGE SEVERITY Of DAMAGE: VEHICLE N0.2 10013ADUNG DAM AGE aQOTHFA M.V. DAMAGE FUNCTION AMAGE 4 NODAMAGE TO-Dal JV EST.DAMAGE TOWED BY ESr.OAMAGE TOWED BY ESi.OAMAGE TO /; i•:. aCyC a?/I. ,? TO t TO t DIAGRAM OF COLLISION r' - I .I ? ??, I I i I I'" II :DRAW ARROWSHOWING NORTH IN CIRCLE ro rowr.FEA r NOAD« , 'I If/ '` ( ! i I® rsimuA'cRls?Rpla w,- . 1I r 11 !,I i I i - T GGH,RONOCnw I ? I EFOwr ale all a 1. 1 I I ICI I I `I_? L ' I I 1 I 1 I I I ? ? WwAfnRC«MVa r l a ' DESCRIPTION OF" 4r ANgCATE WHAT PROBABLY K.E. NAPBEFORE WRING AND AFTER THE CRASH, INCLUDE INFORMAnON NOTONDWOiUM,EG OPoVER "COLLISION, A l U?{. OISABIUT E00 Y.R 0EO VLSISUTY, PEDESTRIAN CLOTHINGCOLOR,CONSTRUCTION OR REPAWWORI(ETG,) . ___ = / JA ? ! / / ?T J ? ?? ? /IAi .i `+ n fy n.• ?.( ?iVM ? / •. + ? )O ? i?SS?YG O .J O ? l7/JC.?al/ tJh . _?_C. US•.t;?(•i... -/0 •c uSG '(`oar Z"/O? n /..O ?i IJ IN4li .'.. ... _ --_. _. .. -.. :~;ros.a, _.. 0 ? VEX. NEAOED MILEP +. 1:O`ry.M?rs •+ ON STPEETORMN)NWAYNAMEORNO NO OF LINES W ONE DIRECTION " S PEEO9 VER 9AfE LEGALLY PM_ I M W VEH c aC DE NO. WCREASW6 DECR E W N EASWG -' ? • v - ? Ems: L nf . ___I___ .._ . '? ?P ?.i- ST•lTf/?/f [Y. .+•? ? AsN ? YES. NO .-YES -.'NO --' PEO. - - ,,. y, m,EEroA r PEec<RNE cm w I PEOYBICrcusrwrsuElND n?DE .. .?wm 'QDwAtR ?n<N °O< ^? „L, .. "?. •s ROAD SURFACE:o CKONO WEATNER?„'4+,_e IaK aD '- CQNJRRIUT ter _ IN4;CIRCUMS,TANCES 4CA ONE EEC ,,YT?+'{; „?I; ' „?•,2' v " 's4.? ' ' ?R x ''cY W pa vFn ` ow FR F: 1 .. I L? Cm -? CCIdID,' . , ?x6l1iO:GEOI r?_r ;? O ?. .:?x?'.%. ANM A 'E? ? ?3?- .. t? %LlMfA fAl-1 W?FEP Y ?R;; ?`?a?,TlmNrrksr,,.:. _u tL? sa« a?aov.a I?la? totnu a.T. _ .?'? mut TO c a?. :? ?-TURN,?F.. -., -El El C.- ? ' ? a (? ° t y oa?ro?MHr :_ , . , ? aoi°Aa°inlrt . _ __ °c"'n k A'J' . -? LJ• omul,FtoPn . __ omwlsFeewl - ?''T PurPOPeR ?°? Aa9we: -. oePtnwoaroP ?1x? 9arap IScwl a u'°? {s./ <.. (?T .maveD OR s -• u ? TRATRC I'? t LIGHT CONDITIONS 't.TRAFFC CDNIROLt ' ? pE.GF ROADI, NK ato R - -'yEHICLE;CONDITION, t ? ' '.. SQBRIETY 4 C C ? ?rewNF . :GNKN aO ... M a V[KIt ?1?61OIIAla N ll ,c O w IG ?1?OKWAY wil I ., N0.t?1.011OaF?CD?. tY E NONO .aL I .. ..pt... __... ,: mpApPFD 1? .? ?... t OArOONf ?IS? Alma ?t? TWO - ;. ,? ? y µp °. ? ? O? ?I ?.'.1mMillClµ{?' _ ?t[] ?_' (' (?'}7 .u-l..t__?® ._ _. -QtrQ-. rmAwlmm°lo wr?.'•'. rutl«o 01-=J "E° exNMat .. ??? Hiecrw.r ., ?a? w°wwMrt f'-a?`Keoowm LJ ?xO,?rwnq r'-,. . _ ___. N.oaor ml.Fl -eNORNK.a :?°? :Y^?:+"?,,, ??? DARK eTren ? _ uaHrao.. I RIINAL LJ SIG ^ T-t rwow.r.uFr nw«IANE, rte,w wwo D- CHEM.TEST _, •_ nLCNn ?r - 5 TuoM.w ? .kN?rwr _ I ;-y U..A-1 ' ._.- ?-ttmorrtN _.. oiN r i ' M r °; I ome orvao ? ? r.ourern tt,rnolueo a •T ' .S e . tM1 :4. I y, ?? t' uwrvwo °' 6r,u,m<m % % TEST RESULTS 2 1 <t tY " , • t / raTi3,FAI Neo Aa,e1 NMWEO +ww,lA"un m.r now fi/ /!Jl! /%/2- x? ./i ?,C SNm ? Nlr ??M« r F o ? r.lon. o•nor Re wrta OO an Mr,wvrc or wn - :ss1 r i-V / DUGLr<ATEICOPY: LOCALUWENiCIICEMFNTAOENCV'9COPY-TRIPLICATE LORY: WVESTIOATOP'9 COPY a +I -- akSf r 1?? ? ? •I 1?' 1P7 <i i n D DATE OfcausloN "--? DA"r or coTLlsioH -?TiMe couNrr NO. clrr NO. wA A M DA MDx wED ixux 5 FRI 1 SVr mis snr 5 oD HOURI } _ ?ugBA11 EI T A 3 A 1 tt O Z URAL C WHTTY ?STAIEROUIE COUNTY ROAD ?CITY STREET Q DM CLS. PgEFI% RWTEORSSi .evcOOE, CTION ?? ? OTHER ISPECIFY) ? CITY ON TOWN PREFIX ED MILEPOST L O N S E W ?,- W f..1 . „ O C ? Of_ .____-.._____ _____.. ___?.__ MILES E3 ? C3 Gr .... . . NAM AND.OF STREET Ofl HIGHWAY INTERSECTINGWTH. SIREETORROAD LL AMP OIAGf1AM DATA ., ??? 'J I I a I 0. NON WTERS H I MILEAGE HIEq ION XcT LS INTERSECTING STREET '.'H IT 0' A 'I ERENLE CROSS STHEET OR ROA ?F N BETWEEN STREET AND iREET CODE " ANDDIflEGi1XT- REFERENCE ON LflOSSS1gEE I H Lts rv I mlrvvaf n SPECIAL CODING USE ®MILES E W ;' 3 ?FEET ? C3 (Z Ej Of CO.b __-- -1 .... . " COLLISION INVOLVED: ? VEHICLE VEHICLE ?VEHICLE-BICYCLE ?OTHER(WRITE) ?HIT A RUN SEVERITY NO. KILLED TOTAL N ®VEHICLE-OBECT ?VEHICLERR TRAIN ?STOLENVENICLE O F_7___j NO IWUPEO OFVEHIC LES ? VEHICLE-PEDESTRIAN ?NONCOLLISION ? HJSARDOUS MAT ERIAL ? PROPERTY DAMAGE ONLY . OWEC1 STRUCK INANE OF OBJECT STRUCK AND OWNERS NAME( .. .. ..... . LOCATIONOFOBJECTSTR CN :. ..:::... .:.... EST..-AGE:., ., S E W N ? OADWAY FEET El 11 El ? RD 01 EDGE 5 OWNERS NAMEiAST I;:; .FIRST MIDDLE •' DRIVER'S NAME-LAST FIRST MIDDLE xi .ICICUSI OR PEDESTRIAN CHECKICI.::. •::: ?.",. R J PL.CkmAsj OD?61 y?S RL-?.Ti t U a STREET STREET ADDRESS ! V E CRY .-: . .. STATE '.... _.. .:ZIP CODE... PHONE NO. E'. CRY..... ... .. „STATE ZIP CODE '.:... PHONE NO. n ReUnc'o tea. `t8oS5 22 ?y?1 A N' DRIVERS LICENSE NO. S1AlE SE% DATE OF BIflM N DRIVERS LICENSE NO. - STATE SEX D ATE OF WRTH . O PG-Ck-CD - P,Ho wn M TAO DAY Yq 7 2c 6ti D, ? M O. DAY . Yq I DRwER50CLUPATION fIRM NAME .. .._ -. ,. PNONE NO. 'j DRIVERS OCCUPATION,.. FIRMNAME .._ ... :; .... _ PnON N . LlZJa of R ?c . ? .CODES > IDI AL SS- TAI SEAT BELT J' 151 ELECTION CODES > IJI C1p5 9 " SEATBELT I+I EJECTION iURE OF INJURIES NATURED INJURES MO SCENE BY TO ia(I..CENE RY. ' TO DG E{HEV.1. VEM. YEAR IDO MO. m"AHT-NOVA)..' SI LEIt DR{ONV.1. E VEH.YEAR MAKEIDWGE-CNCVJ.:. MODELIDART:NOVAI.:, STYLE CZDR{ONVJ_:..., V 1 1 T7. ?F 73 LJ. 7' 7 1)V ?vc v E . P LA TE NO. VEH. COLOR..:. UL STALE. TRAILER PLATE NO. STATE E VEM. COLOR ... _ IK. PLATE NO.... ? STATE . TRAILER PIAIE:NO:. '?.. T - , pet, IJp.ra y? ?A '.:H C VEHICLE 1 ENr1FICAl10N NUMBER DOMETE..,, C VEHICLE IDENIIFICATI N NUMBEfl _...., i , ODOMETER C.:.w?.,...ta-Y;y E. I(l 6 Z 'i 7 9 E :.'': REGSTERED OWN R-UST REGISTERED OWNER -LASTA ...-.: FWST_ :._.._., ...e:,..+,:.• WDDLEJ or P6 CKA4,44 'T. o. ADDRESS OF_OWNEfl:.. - ': :?.._.:. ... __.. OF OADDRESS WHEN .....: ....: ...:. .. ... ..:.._ _. _.?.:..:: ....,:A-. CAI E.- NAME ANOApDr1E550FINSUPFWLk LO.OR AGENT ... -..,./ u _vRwL- D C1 Co, vI Ki?nW c? NAME MIDADDRESSOFINSURANCCCO.GRADIENT ENFORCEMENT HARfE '..,. .. .;..... ,,...,'.. .. ... . CITATION ACTION ADDRESS & INJURIES OF PERSONS INVOLVED NAME • cones T" 5' , SFX AGE STATUS EJECT: C NAME' C ADDRESS' . U F,. NATURE Of RLMOVEO FROM. IWURIES SCf 11E RY TO A NAME N T AODRL55. _ $ : IMUVFOiROM iWNif9 f SICFNFRr TO' W NAME' . T' AE .A -?--TrLM?EO-iTiorn LL N AIOE9 W CF NF pY TO S NAME . S ADDRr.55 ? AI L-jl E w.f f 15fF?(- u S V I Hll.9 Y [rl TO "IS AIUS ITI,IA1 POSITION J WUH CU55 TAI SI Ai REII 6"u-1 C ? P SSENpE T . ?' l . f 1N7 LIRY 5 D :AB O WURY 1 NOT NSTAILCp NOT EJFC EO 0 RIC YCIISi 1 I { A. ?y C G G 1 ITT D T SCENE R i? d OH 5 NON p5 BL11K1 NMNFIN nv { Z NDr 111 USE 5 USD 1 I TOT LLY EECTED D P Rl ALLY FJFC FF.p E D R iNE39 ,_ . FL_ I U. IAOOFI LEI POSITKNIUNKNDWN /J/ A plC OSr `I L 1 'O AUNNOYf.I 6 BCAT RI FARURE A U DOWN Ir EJECTED -4 BY9' I I? ? ra Yi': t A,y I ? Ir}',P?(G ! .?1 }? 1 adl - ?_,..?? x u.ln.rw.w..r,,,,,,A.?l'""i ,.`. 7 1,'L.'A_.?.'.:L ti <r.l ?a•I, All L M1 \ 1 11 F 1 ?,a„flay ?, ?I ? f IY 4 :? A;f?r ?ni A J:; III f +? 1 I 1 I VEHICLE DAMAGE 14KA A:rr INSTRUCTIONS. i 5 AWf RRi WI TDSHOWPRINCIPALOIRECTUNOFFORCE ?r 1 F DAMAGED VEHICLE N O. 1 lust rH s-LE FDR SKEICII.IG DAMAGE TO TRA LENS ITT-ICICLES, ETC,) DAMAGED VEHICLE N O.2 D?4 H sv a Uo:F.,,.F. o.. I) 1ue SEVERDFOAMAGE VEI 5 II DFOAMAGE' IOTA I VE CLE' . CLE NOI I'O GaITYaBI xG DAMAGE JOOT EEIMV DAMAGE IEOpITSAtlLIIG DAMAGE E]?OT.E..Y. 5 ATr OF DAMAGE VDECLE NO .A.A.E 1(1 DISABLING DAMAGE ]DOTE V. DAMAGE y S 'Y )? FRICTIONAL DAMAGE A Q IO DAMAGE 1 ? FUNCTIONAL DAMAGE (ONO DAMAGE ) OFUICi ONAL DAMAGE A O NO DAMAGE E OWED BY {1. Mw OWED tlv EST.DAMA4E TOWED- i DAMAGE 1 _ k 3 TO f . r: ._ -... -?'`"` - •- : DIAGRAM OF COLLISION ... t TU AW ARROW SHOWING DR NORTH IN CIRCLE RI .1 L 7 7 oe w - ' os I ? 4 uilusunvitur. cONO INS i , usE.,ic. cosrAVCr on ' _ ? r .i- ? . DESCRIPTION OF. xNpICATEWHAT VnOBAbtY NAIPINED ecfolE.DUawc AND AF?E D THE CIASI, INCLUDE lIP09MATIOI IOTONDIAGRAM,..G.OIIVEI - COLLISION D's AB LTr, RfpucfD Y" ITY. PEDESISIAI CLOTHING COLOR, CONSTIUCT ION OR REPAIR WORK, ETC.1 - aW - - '; POSITIO IIEAOFO N BEFORE COLLISION MILE I - 5 FET OR NIL WANE On NO ovE olgiciwN IN ppcq iiv AEIG ' E i 10.E s E w REASI CI EAS _ K C CU OP Ep ? :_I 4 I D PED °nD _ _. - - , .EDIBICrcL iwwsus NC. a DeSCrvATFD i MARKED I SIOEwA ) I J ISNOULDER A' s: I Kw _ _ 'CROSSWALK ,[I ;9 CvCLE ROUTE 0 R . T ACE,. R O CD WEATHER ...: .. ....... CONTRIBIC ITiFCK OIC+i onOinoae ANCES i .. .. INO?-1-L E. C, il I ECR Ox E D-IR- ?NOF1 Oa vER D Iat l, r---I I? SORAiGNT AHEAD r^ D CLOU°I I :ADYEfiLAS -1 LUENCE pf OL INF - ,II A ? ? ? I'LL ?j I . yEfL1AKING ASSIIG _ ET _L___N0_ (?! LUExCE OF NO? IxF I 1)' I.DFVGS -- lVl"CENTlF ,- b E v I I? t J T N 3F NOW ) OWING ?? G TO (- 0 PARKING ! r -KING L? j N FO l - G i:1....1 60G919tl- 11 r TURN LEFT -' CF L -FOG 1 EA I SSFD PEN I jl0 p G u.TURN' f-1pr-I 5 r BNO T'q; All I AY DICIEGIID SLOWING _ -DTHER IYECUVI lOiNFIS EC fvt ( '- 0 N L : _-' RELANDS 1 -•- SGNISGNAL - FP ISPtC FY -ER ° IOW ?Br-I SNgFPf °iOR C A' LIGHT CONDITIONS <HfCK OxFI RAFFICCONTRO p)_RGL[ CLt ?. TYPE OFROAD O)' RNECKONEOHMORE VEHICLE CONDITION VEHICLE jj?? ax, AS ? .. SOBRIETY. ,_. [ ICLE ICIIECKO I _ STOIPED GNAL L._7 O OP SIGN L.-.J _ SICIALB r' ONE WAY NO) Q 1ED1 NO) L rJ RO PI. IN DA G I TI . nrvE BR EL D uiv Alnta -_ ?l s x ° ING I E . G _ E I 0 G T ) . A NED I) ? 0i START . DGOSRTIOR O D - - : . . _ NG EHTf WIND 1 J DUI I 11 I G ( AIPGE I1 I J. E A. LGR IJ ETV ?,.JTJ inAF F DA a IT L A I4 SON al -. Asl c j Btn -_.. _._.. B: f ? 1+? _ OH OOI1 HAD o NKINC NFErv R BACKING - .? - I h 1 L _ DA s T i ' AIR - T 1 p - CHEM. TEST t '? I J ? r i 1 s' a IGN B i .^ S N - is TURN LAI IS - - NI '? -_...-... ) I NO L_ , f?A C a F C " nAi?T Tf GvfN O T Hfa ISPF C FYI I ?,? f1 T ?: :J... aINf [I E.G.,, > ! .: . FLAG N E _ ..- .... .. ') -G. __ _. _ J. NODEFECTS ( -.- - iL.l Il USED ', . e1 -OT-U_CR,I K ?l; J DIVIDED - I I _ 'k' TEST RESULTS f % 2 SIT 7 ?• , 11- 1 1^11 All x ILL U vt51G _ ': f '" „i INVIS G 11N4Of (I[II.S IA EA LA E,l NU G ON LICE AINNVED A OW AR.RY[O LL [DEDf ?O 14.1 1?5 n5 NR MN OI.i.A EI[i. D Or RIPUIIT HIO ODV DATE r T DUPLICATE COPYV LOCAL LAIV ENFOIICFMLNT AC,ENCY'S COPY-TnIPLICAT[COPY:, INVESTIGATOR'S COPY IL?