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Home My WebLink AboutReel_0023FAJ OF CO ISI DY EZ?YL DECISION HI A IMN , I } - COUNTY nIT._? CITY no I E ? E C V.,TV Lj STATE -. COUNTY PO.O ?CIiY 3TPEEi V1 t.`.? IJ 10 HR ISPECIFVI O N A3? Wifi OR YiNEET CODE .5 L C 0 1'.?JILE LI LI E u lEl O -.`.??TY 'v ON TOWN .... V_ V % EO. MILE PO i, O. A T NAME lNO.OF STREW ORI Y„-_ ON Cc,JF ?1S !rj? - HTIPSFCTING wI'rH.3TPEETONPOw y ° NN+I GNAY w '::. O. NoN INTEwaECTlo[. *?Z J ? - ? ?cE NOE NT CT G REF E CRO55 E wOnO NI. TwEEN L..?\ - iREETwND ??P ?.I?r+/- a ? STREET C - OOIRECTION ITT REFEPENCE OR CROSS STP[ET / l Irk pFFer ? ? 60 ? a ?('?"l VI/l t f .^ wnllF?f $ IECIAL UOInG LBE -, IliVOLYFD: HICLE-VEHICLE nVE CLE-BICYCLE ITI OtIER I-TEI 0"'TBPDN O sfVEPITY TALNO. uS VEHICLE ? AIN TOLEx P 9 "'NO .I l y O VENICLES VEHICLE-PEDESTRIAN ?rypN-COLt SION ?HAZIFI ATERAL F EIItY DAMAGEONI Y OBJECT STRUCK INANE OF O6IECT STRUCK AHO OwNEg3 ryAMlI '. .. .... .. LOCATIONOFOB .ECTSTPUCK . EST DAMAGE ' • 1r??11 - C ?ROAOwAY ISFEET ? S LI? N EDGE D, . . s ?L_ . R DRIVE N YE-LAST Ig3i ., MIOOIfi "? ?ODK _.:.-?????`( _.? _,. .. _ R D.IIYE,I•S nAME.LA3t ?Ixrt MIGOLE. yF B•L.oLI.I GP PED?srx aH ?NECKIU v 46 r 1 ?C 3 SNI c v TPEET AOO.ESS -. .. .': - .. -.- E CITY.. -, _ STATE,., IF CODE PHONE NO. CI v.,_ ... •. STATE - 21P CODE PHONE NO R . tI'I ULl i l 'liV _ ` R ORIV`ERSLICENEE MO.. ,, ;.•.._,.__. J ? S S? STATE sE% OATEO OIPTH t?f l ' ? OPIVERS LICENSE NO. ,,", ......... STATF. SE% DATE UFY RTH Mo. 0. - OO I . ? Y 't S I i 5 -0. ORIV f2c OCCUPATIOn fIRYN E .,. .. - _„•IHONE O. ."..:. 2 DRIVERS OCCUPw ION, ;:,_FIRY NAPE -,? -_.:,:._..:- PHONE NO. . .... CODES ul euLSY lal SEAT BELT Z IsIEJErnoN -. .'- CODES uI??J,°u" Y 1+I SEAT BELT ISIEJECTIG.v T 9 NE of 'TUU - w neuoYlD K.YEAR Y WOODOE{NEVI O UowRT-NOVAI STYLE I}oR.-CO To Y ,VEARF AKEI OOOGE-CIIEV ELIDJLw T-NOVA STY LE J}DR: CO11.I . E T -2(0 2A?. y H rFL? wl -.; LK FLAT,NO..?. iE...,;. w..ILlRrurego TATE.. ,' E . YeH.GaLOq_- ue.nwTE Nw. S ATe ..: rwwILERFVwTEN r,ErE. :' ir 4?LtA. QA Lid _ - o ; I . (?`... . L_ EHKL Ip-1?IGTIW NU _???; - [132i? cc? OOOYETE 1-7 ( VE ICLE IDENi1FIGTION.NUYe y.-. OOOY! EP '_,?; E , I Z ' ..' REDITIIII -,LAST- F wsT :.:.•._ DoLE ,. E 4 wEGI3TERED 0--LAST.. i:,... , .:. -T .._.,,_ 'oLE Z O.. wm sEwiw .: :_....- MANE ANO AOOwl SS OfI ANCE CO.Ow wOENT, ,.:; S-A(?+I?-2,vLru . - Wulf ANO_wODRESSOF IMURANCE CO, OR AGENT c..-E? - \ V:}-QUIP-C?c'?-?1_.. <ITwTION NO.. 4 I I E YFnT DTIDrI - CHwwGE. ,,. :: -. CITATION NO. NAMEIADDRESS& I NJURIES OF PERSONS INVOLVED coDEa } E% AOE STAM F H } EJECT, N C AEKf . DDwk3t: Iq P- j 3 I z I D SCE O V ED F NOM TO .eaw L A L ' ? OAF O ^ AOcu. t -? j .? t ICJ 5 F . 1 J tc? Jr w J T. Y E S' g•.. lVANNAMI ? 1 fO ..: us .EA rUSIrmN ?1 INJURV CIPES NI SFnf BELT 131 !lECTION C. },IA]SlNGEw 11lOESTwIAN . 1 I. NO INJUNY Y. DISAwLING INJURY I. r10iIN3TALLED I.NOT P.IECi[D - O D. E CYCLIST OlT 6 ] }. OTw[w IOSITION IeUS-uOTORCYGtEI }. O[AO ArsCENE OE ]. AO ON ARPIV ?. DIED IN nOSIIt A wI L eNON-DISABLING I If VIOENTI INJUwY ! IOSSIw LE INJURY E,u ?TDIN UBE ? U OwN },'OMALLY [JFCTEO A TIALLY lJECTED UNKNOWN IE F' E NY33 6 ] E, Os TON I1NKNOwN --- S. SE t ELT PALLURP ---------------- [IFCrED --------- uti;{yq 1.1 tlq ?. ?? ?1 r ?1 fN 1 F? ? r ?uF 9 4 t?"a ,`.{y11+r`'., {1 AIt° t wF et rv r c'• t Y 1 1 ?1 I -. t F t I 1 .+11 1 W Alaw, t? _b ;Fo ei ] !HALL E EY NLSt CT. L I - INS-f RUCT:ONS: ] oH1, 'H? 's psH:;Tr FNIVCIPaL DIN_lr .,•/ I R C r i I DA .IaGEDV HICLE Np. TH S,P Ui .,R SFFrcrNxc pllucE TC uE x I?EPf iCacr. [: cr. OANIAGED VEHICLE NO!2 1 EvE1x ITV DF Da1.IA4E?-111Ex0.1 1 CC1 UISatlLIN411114E l ? DTH1HUV.p-AOE )?[UKCTIONAL Da1AGE a ? NO=.E 1, 111ITYOF011a4E: IOTIENVEH-EI I C1 DISASLInG O4M4GE ] ?-11EN- Cau4GE T E3 FU.YCT:ONAL GAIADE a 0110 L'.1AGE Tv OF pt-E,vEHICLE- [?]] MAG[ UTNEH U.v. GANAGE 3E ?ROU 41ACF , NUp CTI TOWED OV \i I I EST. UANAGf -- EYT. C%J4GE ST. DANA4E T wFO SV TO E RD DIAGRAM OF COLLISION DRAW ARROW SHOWING . ... .. '. '."' ? ?' .. NORTH IN CIRCLE CS ? AS 1 3 alwvFHKU Peoesrxl p`I NO, VEIKtepx e . _./ .' . _. J ? V:?•J t3:'/?C ' ?\ 5 - o AFwIE x !; E . c l DESCRIPTION OF (INDICATE WHAT PIDIARLY NAPIENED EEFORE,DURING TIE CRASFI, INCLUDE INFORMATION NOT ON OIAG-E.G. DRIVER _ COLLISION DWSILIn.PEDUCE0 V15ISIl1,PEOESPIaN CLOTHING COLOR, CCNSTPUCTION OR NEPAIR wOPK,FTCI _ [?£" /c.R L/.Uc' ? 7712E C?c? POSITIO V EN. NEApED W. - N '3 E W N BEFORE COLLISION NILE POST DIR IxCREASING DECPEKINO J, ._.. On STREET OR HIGNW+Y NAME OR NO. . . C? Cam: I' '. xD. DF LANES INONF pIgfC71On .. S I alf ps VENICLE ARKE IFewKEp CIDDL•IE' ' __ •..' •.' '. PED 1E0/BK'L'CLIST WAS NSING:^ KONG .__.. MARKED , EIOEw+IK ]' -111 D SIOULDER, CROSSWALK E CROSSWAI[ E AT OUTE ) OTNE -' HOAOFSUORFACE CKNlI WEATHER OnEI _,CK CONTflIBU 'C -IGCIRCUNISEANCES TI 1ICCK ONE Ox MOx .. "` fC E K•i KnOn3- 'KVlLx E' D O I ^:. DRIVE 'No 2 D D R O) _- ..RAGNT IEI x. _ ?F _ _ -1 T CLF q C 1.-..xb0 E wIMI.YG ) E EMC Al O OL DRUGi NELUExCE Oi ] FO O TO Y B . ?IxE CENTER _. DISH ED vA SGA F TLY 1SLEFP OV N4 ] ) -.. R141T TUPN " ] SNOW - CE A 9 _ OTIiFR (SPECIFY( J SNOWING OG t S. ? OIYtCIFVI I.E. ] EMCEE OINOSTATED 9EE1 LIlxi X._ fAK?ESVItip REAi E S DIDNOTGxANiPw TO V[NIf.IE - NIPONR F E 9 !AILING lO SIGNAL rIOHEN . ,,. TuNN' 'OISREGARU STOFa GUL GNT p15REGANDSTOP SIGN SIGUAL R,TRD [ 1ARKING •IS LCC T O \J p 111 Ifi R TIVE EOVIM •. ., OFF ] 'IS UTN 3 CFY! v16LAT101Y 'A' lA[ING' LEFT TURN ING. S" UTURN -gip' SLOVRR6. -.. _ ,. ?aPP[CFpN. T IGHT CONDITIONS H'CK ONFI RAFFICCONTRO 1H0.]Vf HICLE ' l 61GNAL3 E TYPE OF ROAD ?] ICII ECK ONE OR- ..E .AY VEHICLE CONDITION •VEHICLE F9 No, li tb'N1p17fEDl I SOBRIETY Y ICNfCK ONE(' EIICL! i N0) ' stoPltDAT S1GxgL p OHSTOxSIGN- p 0 , 1. .X WYLIGIT •] CIDN. ?)• ',' -(NAY. OnA SIVF NAN D Ip:. P FFICLAME ]. DAWN • D If LO 61GN _ - ] _. PV+ID NSmI[ ].' DEf EC T NE O L 4NT5 ..: ) NOT 1 A RFD _ -.. 11 ? - VA PTINO FPOu RKED 1031TON ?' iLASNING . 1N11xCN4NGF ).:. ,. I AARCLIGNTS Imo a ..' EHGIxn 1ENTERI. TRA".. E D K-STPF T L c ow n .. a .. "I WANG . _. Au !H t. '.'ALL[ Y Sr .. .1D1f3 vARl f/l .,...ox n alooC Ix FEND ;3~ SACK N6 -? ?: FT a GA NAL .S • 4 TWIN L FLUwI `7 t CHEM. TEST No. ] y RR-MO p • D C[ 'L`IZ-S-?? SIIARAll. - TEST GIVEN OTIfR ISP[C 11Y1 ] ?/ - R ' ON10f0 F 1 ',' TESi Rff USID - ' ?? OTN[R lYlCIFYI ..... )IQ l? L uxDlviDEO 1 i: OT EN 15FECIFV X % TEST RESULTS 2 •? (ftIGAl1MO pFirG[R]N+uFSRAM1K J L ?? A BADGE MV' vOLICE OISxAiwlfp YOLICF ANIIN[O !C Af FIC FxLOW uPl OEO AMNU?3 _ I -3 ¢?Ix ve?TIe+Tlno.o CE/p?3 +Mf ANAIK ', 1 u4E MO. ENCY LYSI.AOl r. Eo efo nHOV?,O pv wTF w 11c? ?? e mill F . SRV .? v?v,....?.,?.. TAIPLICA-E COPY?•INV[STICATOfiS COP Y? - , [HIPLICATE COPY: LOCAL LAYENFORCENENT AGENCY'S f.OPY_ ','#T'ii4aYlan x 4T- 'Y j 1 I 4 } I: t \ r 'rl ?[ L I.. Y .F f E 1 + AF}I fl r l yl 1?1 1 1 f ?N? I 1 ffff ? ' 1 A 1 / t ??,a ,n5?u ? )a tr ?1 t? $ E uY I r, /? I'M I rr?, ?' L; ill ? k W + rI? a itiw; 1F rl-r?"N^?w. ;,.:t,?.,l} M1110'1fM'?:.^!""'°'7}?,^-.r?F? 'an±-! t? <:•,.c:..,,:L 9 ,.,-? ,r+S4i A tj1L?z,. r T ?. I ,/k ? s Fis I'?r r '? 1• 1 ??I . ) r 1 , L FI ? I ) ? T s?.ffYrf I ? I I, E PAG OF P UNIFORM POLICE TRAFFIC COLLISION REPORT OLICE COMPMNTNUMBER ' qW.. ;r •1 D A OATEOFCOWSION M OAT YR OAV OF COWSION SUN MC fI1E5 YIEO R 1 FR G i TIME C OUNTY nq Gry NO, FH t . • I I y 2 a U 3 I B A n jLp 2240DHOUR) / A LT RBAN U ` f NiY C ?STATE POLITE CWNTY A h OM{LS. PPFFIX ROUTE Ofl STREET CODE RAL SECTION ) -fit NA. t - s ® RO D ?GTY STREEt ?OTHERISPECIF'Y) O N -.. per) J "( 5O = ' S L B N E W 1IY OH TOWN C ?IN W P NEFI% E D.? MKE POST ?SFt :,3 ` )) OF T HI ES El El ? ® ER ? U ?la d OY!/ e LL ? d k A l NAMELNO.OFSTREEIORHMaHWAY INTERSECTING WITH: STREETORROAD LL P -F OUGRA. DATA '- a C)? riL ?p O s n O ? NONINTEHSECTK)N _ ACCIDENT IN (ER NOppp??? RD N v £q CLS INTEASE - STREET OR ROAD OR REF ' N, /n BETWEEN D • /• ?^'" ANDCL/I 16O i STREET MILEAGE LOGE , } . , EAENCE ROS93TREEf ORROAD STREET DISTANCE yAVO??DIRECTION FROM flEFERENCE O R CROSS STREE W ". +ILES N G E S S Vntn,irv PECIAICOOING USE - $ - . I[JA IA/ ?FEET OF ? l?• ? ? ? • •,- •Y:e v ' r VEHICIE•VEHmIE VEH CLE BICYCLE OTHER IVIfUTE) ? ? ?MITARUN COLLISION INVOLVED: ? - - SEVERIry NO KILLED t ' 'LA TOTALNO. ?VEHCLE-OEIECT ? VEHICLE-RR TRAIN ?3TOLEN VEHICLE NO.ITUUREO y L ,.I ip, OF VEHmlES ?VEHICLE PEOESTPIAN -, ?NON{OWSION - ZHAZARDDUSMATERIAL ®PROPERTYDPMAGEONLY ORIECT STRUCKINANE OF OBJECT STRUCK AND OWNERS NAME,- LOCATONOF DEJECT STRUCK T. DAMAGE' - -? ?ROADWAY ? ? ? ? t DRIVERS NAIAE-LAST_, FIRST IWWLE pF.-S N FEET RD.EOGE 5 AME--FIRST MIDDLE IIf SmYCLl9T OR PEDESTPoAN -CUj -7 .. „•. -' - A I StREET ADDRESS - R I STREET AWRE53 _ E .. CRY - STAT • V.. E .. Z h E .. , :., 21P CODE .. PHONE NO. R , STATE LP CODE -.,'PHONE NO. N pRNEf13 LICENSE NO. STATE SE% DATE OF BIRTH N DRIVERS LICENSE NO. - STATE SE% pgTE OF B2iTN 0. MO. DAY YP. O. MO. OAY YR YA DRYERS OCCUPATION FIRMNAME- PHO•ENO. 2- DRIVERS OCCUPATON FIRMNSME - P N CODES > ID) ?= 111 SEAT BELT 01 EJECTION CODES > IOl WUURY CUSS lat 3 SEATSELT 11 EJECTION - TUREOF INJURIES NAfU F WURIES FR M6CENE By: TO EMOVED fROM SCENE RV: TO VEH. YEAH MAKEID?OGE'CHEV.I MDDELIDARTNOVAI .. -(-N.-C V.1 VEH.YEAR- MAKEGODGE{C-) MODELWART?gVAI^, STYLEI2CR{ONV.) e G/l? T E H YEN. _COIOR PURE N0...: STATE ,... TRAILER P LATE NO. STATE E VEIT MDR Lm. PLATE NO. STATE. TRAEER PLATE N0. :. STATE.....' - I - i C H .. + O C YENK;LCm mFOAT, nNUMBER+ ... ._ ,., ODOMETER ... -.-._- C VEHICLE IOENPFO gTI NN MB i • ODOMETER - . .- ..,. +--•?, y E E - REGL9TERE0 OWnEA-LAST ?..J. .FW9T .?. :-....MOLE fl N EG491EPED OWNER- FIp9T MmOIE O ' ODRES9 OWNER .. O. _ •. : A DDRESS OF OWNER ... NAMEANOADDRES90F WSUR,VtCECO.ORAOENT ?- N AMEANOAOORESSOF ULWR.WCE CO. OR AGENT - + - •.. Y- CHARGE ... :..... ?'.. ,... .. G TAigNtO. ENFO RCEMEN T' CHARGE CRANON :. V ,'. ACTON NAME, ADDRESS & INJURIES OF PERSONS INVOLVED coDES _ 2 a s SE % AGE STATUS w EJECT. L. NAME: _ C ADDRESS - U N AIUREOF RE EDFROM 4 . P I WUPIFN, SCENE BY TO + Y - N N AME: T A DDRESS: $ N AIURIE9 F IE VEDFROM SCENE RV' T O W N AME: I T A DOAESS. N I V . 'ROM WUR` SCENERY TO E N AME: ?.: S A CCAESS: E 4 y ' S % r ER To y I II5tATU3 121 SEAL POu`ITIOFI IiIFAORY CUSS Ia19EAT BELT ISIUECIION ?? jy ? C ? O O D S E 3 . DAS..ENf ER PEGEGIRIUI UC OUST . oIHER WANE V I 3 2 / OTNEn PQSITION ISUSM ,TwcyCLEl A D S POSITION UNMIIOWN NOIWIIY 3. DEADATRCE E 3 DEADONARRV•U. aDEDIIIHGSRTAL 6DSAOUNGINAIPY SN04019ABUNG I IF`ADENTt WURV 1 SItlL URY INJ I.NOTINSTALWO 2. NOT IN USE ] U,EG 4UNKNOWN .NOTEJECTED 2. TOTALLY EJECTED S. PNmKLYEJECIED I a. U\K`IOVINIF L?}t 'tl? V y ? yy Yn E I - 6 CCAT RELY FAILURE EJECTED -. y ` 0 m t t -:.L I ) Iri 5 r ao-'`'"?4?§ w n '`FE ' 7 , I?Y L I i L I I .tIWS?,YI S Ii Sa?AAC7".L?1? S - pL??` Y'I +k '??qr? I?rA? r LI t r?If'?C Y .A ? ?. - I 1iL. Y .?., D+.u .,» 1 ,S,i.C .95T??• Yla ii..t? }??_K?41 ? I ql ',- ?. + ?S tt? .h1A I k?.,F 'y t r A s t Irl 1 C???r } C IAA ?> I - - SIN Ir _,.. .. swweu?wa'?4k?I :. L.v. INSTRUCTIONS: e!_•a _ -.rn°i?.. w.?:7,.., '.3aw"'_ ???' .c. ? ?? ?, 25HApE APEAOF SEVFRE91'IMP CT. 10PAWMP04i05HOW PNNCP-ECTICNOFFONCE. +' , 11 DAMAGED VEHICLE NO. 1 IuSETH195PAGE FOHSKETCHINO DAMAGE TO rHAHERS,MOroNCrcLES. ETC.) `.. x > tD.tkW DAMAGED VEHICLE N0.2 'f`? a Ip?77 t le ,.. tA.fl°ut ?! is NooJ ?YB. Ix I tl(? IS. TIMIk ? .?yy tl IWArcAItMDe .• • t tl Tnn4 , ii5 X t>.OVFriwP pTEerr+nlW fe 12 SEVENrY OF DAMAGE. VENICIE NO.1 SEVENTY OF OAMAGE:IOfHEfl VEHICLE) SEYEPolYO DAMAGE; vEHICIE!`0.2, t>.aMIFni 1QOISAf%1NG DAMAGE J•?OINEN M.V.OAMADE t[]D4NASLINO DAMAGE - 2 FUNCTIONAL0MM0E A s ? LV.OAMAGE t?FUS TINOOAM AOE - "DDOTNERMV. DAMAGE NODAMAGE 2 NNCitONALOAMAGE 4 N O DAAl DAMAGE TOWED BY T EST.OAMAGE 2 FUNCTIONAL DAMAGE • NOOAMAGE SeeK? TOWEDSY EST.ONAAGE Tp TOWEOBY EST OAAA- ' c70U TO f S '°' DIAGRAIYI.OF C.OLLJSJON.s yv=.i l ! TO FEAT.- ?? I I i ?? _ I t! DflAWAARONSHOWINO rr . A. °? ( 1 ' rCJj r??? _?? I ?-1 I-? r ? NOATH IN CIACLE Ts"?. - / _rnEeracc°N reeii01°"".- _ 1 .L, ! I i ( 1 - n ?. N tCGTE-EPPNlGF ?,- SM v?tF.FE°FmpANpN ! 1 I ?_r-? ? -F- 1 Y a°- t10rl,5 ATIMFACT.. .I ' i ! ! ! ?? ??_ C ? j' ? "F' ?/? I -? ! I I I I -ri 7 'J- ?? DESCRIPTIONOF'?-. 4 " ^+c. I ! ! r i ?- 4 ' CiOLLISION ,..w ? N0&Uh REOUCFRO.ov'I?BYILrty, PEDES R?OA WT C LOfl,CO ONSTPUCTI0N10q UEo NWOfiI(EiC."OroN DlacnAM, E.aoNrvFn +"° ' e/j-77°/ ?d?s S lJcps : a? i ?f v_r 4i1 .p7'??(` tumor fo e/n o?r rl --2._9f+ /`?1-B_ .; 3.yr T` v?'r+/_Cc??J?e? caC ° ?iSJiT GeJ??r 4/iii?Yrc1 oy?P_T?iC cot?X?J!n_e y 3??? +A,<»sva 1 OH. -. qvx T•q VL•r?,.,. NO.OFlANFS SPEEa9 EMIC IF PAPIt .P , HEADED P!C M p DIN, pry STpEEFOq IK.MYAYNAAIEOgr1a ?? WONE OWEcT Pp>TE L Y OuUP EO N ED r?? ?? C - r f cps a[ YF?_ND C A•? YES r ..4 PED.. ? LJ Q AacND - a l ) r?. -1 0 ar•-1 6 a1?' AOAD usnD. 'L.Jw L . 7saunEt,. ' SURFA Q I?mYAIw °n?M1""`m I -J.6c,EPtE°wrE r 11°" _`:c i? "' IcNE«olw rcHE«wNt •- • COM.RIBtI ?CIRWIIiSTAMCE?7: '% + w.rr ?S -,lJ' . .•. • ?`?°?? 1>wFq- nevFA u?EU°wF" '"oPe! Y3 ?_R,? Nn>vFnetl ?n io a°" U "Y ?' eT.wNFANF.o . ?l ,'? ? Mr1OF1.o,De'La ° Q ? TFO°t_o1OM'•i0b. ? ? Qa °saEaMnEOwAna ° L'1J c E ? axQ EI-El Q L_' ? ?D«.ID ??Q7?Q ??,rA,rD ? ? N.Aw?D ?,?: ?: ? r, ,; " ' (? FoD _ _v-l• ? ?"E°e QtDQ TM ,ayvl r'I?"I J a°'Elicmn°EUM.. Q ° Q u" n ? = ? n ?..,De o. ?.?1 UGHTCONDITIOOS E;TAAFpCCOfigOL;, k"vtTeFeai.TYPE OFROADY- T"ioN ?T? m? FDq 1 IGMCN uu Q?DY? tNDx , Rowe on Morci >`?EHICLE? RIO ,fi S:`rS'?N?''{SOBRIETY "t,":r.:3'L3.f QeQ °fO'ar'F0 ,ibNl QTQ DI4 w"Y 1M. ° 01 ICNECTt ONq GII a. .. DDNneeuTEDI x `•J e? "° WA ?? wnN. L]Q_;N - )_? ,wDw,Y Q f j F ENE IQ ,w,,,, , 'a )_ a" ---p - F° WE Q AF?P Q °Q = M„e L >I J --- JY"L ' C] 1'1191 .._.--_. ' l ? ? IN° CIM ?FO?b qM )?•, 1x1 uM°O'^cSO°? ntxQ 0-1mrrrwro eaF ?eQ mwE ?. 1°nuNET ?°? alelnw'?P1cN leD wTrn CHEM. TEST ? ° 1 ?v'°iaRwe '."1;. "1 omce?r ' i? ?-?- > Q• .: . I-7 ?? m? r?1; ? f1 ?? 6F. M?ix? ?' /r' •1 I ?- -r ?TE6i6NFN DMf ?YEGOYt .?} MIN R .,1.._._-.(`?.(?IOFE?. U/_>I__i °•"oF°- ?u_ia lveer° Lr,,,L( TEm nerlnEO 1 =,x'i is 1... I__) mlTMli'0 II??>!_, uawofo --_- `'.v--e?>rtCT'1 1 TEST RESULTS '2 ' .«r9nwTF.DarNCe9ewexIMA.1 eA°De NO. tf w.1 .3 ,X 4 ? Ftt,t IAerM1 o t FDUCEAMreD MAW?E FLOW it ... wn ? J>y? //il ?' ?.°° // 7 >.oo "?? wrap? . , ng, ? Ar •n. e S.F .. 14.,?? ?t r F,i a? '?' y T 11 rr?`I ? t r? a. ,r. orpr r II I . . E ? r MOTOR VEHICLE COLLISION REPORT N.,.. ...?. NO - "` 0 yl µ, ?^ ! ' .=v.}.A;_;CATEOFCOI,L `Adl .,:.: DAY OF CALUYOH. -- TIMEOF,GOUl910aN / (: `"' ? D IHUR rw Y v MxVrf A GO Iv O y C ! - gvn e ??? Lori ? • 1 :OD ' COW „? CITY.T WN 5 u13 9. ?N E ,. CRY.TOWN.i.;( ADMCLS OD PnEFI% Tf ORliP TGWE SECTNJN? •' f, -y AE V rFl .SV I V o RrL vaowW i Q ©DF Il"'n 2T L col ot? -`,>R/!•f O ?' TS-A+., ?Y t 'G4c' y d. GVENAMEOFSTREET.flOADOR II GHWAY.ye WTEPSECW YATH•,ETREET Ofl MAO" F PRFD ro /?t?r .5 I /V o/?>?' PRE EO EPO4i f t t 32 ? - ` a x NON INTERSECTION-ATION OFCOLU50N / MTWEEN STREETAND I /lJ1?L-T/ ?• ST V i RAMP '. R7CO' J, N NW _'^ fOl u'u]r, xYhvED ; U--- ?vEx EaCYCL -flOrxExl-10 J T RG °v[K SPEC.GODE W`E q[. 'N ry ,. lf! .. nYEL??EOElrwA ? nxTx x .., r b y WELT STRUCK xLME CFUwFt19 OWN EROFODIECTSNAMEANDADDRESS ]) LOCAT IN AOAO ION A kr WAV ro iORtvr Ci T .4 "" . THAN -R RSLASTNNA_E RRSTIUAIE MIDDLE OFIVERSLASTNAME • • FINSTNMa WOOLS GYED I I 2Y? S ? ? no /a /?D vi,?7 cowsKN On ROUTENO.ANOROXNO.. Y E HAx TVq , ROUTENO.ANOOXNO.STREEAODRES - '- CRY J/'STA.TE/n, ZIP'JCODE. D/RNE/R?S/O1CCU?P/rA?TbN., /? S= CITY STATE,. DPCODE' ORNERSOCCUPATION, -ENSLX:FNSE STATE SEX, ;ADATE OF&RTM. AOE r// /?i SP- ,7 7 l?q x ` ?: GRNERSUCENSENUMSER.,, ,,, r.. ...,. STATE SpE :.OATS "n M . -AGE 1" I FEAR VEHKLE YR MANE ICHEV: DOG3EI MOOELINOVA-0ARiI ;.-. n ?.? ra DY STYDR.1 ISO, IN 'l VEHKLEYR, MXEICHw.-DODGE) MODEL(OAOART)SODYMLE(2DR.),, . .r LKENSE PLATEND.. 9TATE.A,u: 'TPNLERPtATE NO. '.. '..I- STATE ^ 1 O 1 7 UCEN9EPUtENO.. STATE ; TRNLERPLATENO . .:STATE . :?...;;ia. t ' I vENg?IEIq TIFlCAIgNNO.-::,..:.?I188B MOOELSSNEWERI: i,JIOOLIETMIMILEAGE1 GOt 7 T7 ,-??_,l VEMXXEK)E1LTD'ICATgNN4-:.;;:?; IISBSMOOE44sNEWEAI _:, ETER_lNl "' ? l 3(7 or) o 1 +Wf 1 ' RS Ul yr••r'•/1{ASTFWST/MIIOOLENAMEI .{' D{iNER9lICEN9ENO., Y.'.. -,51) ? T97 W" OW REGSTE RE00"EA. :..IlA4T.FIRST MI00lENM1E1.?::' .: DiWEP9 UCENOENO j° NSRSADpRE39 -J11" EET CITYA D3TATE1 DATEOF &RTN':r:. OWNS ADpRE93•, :.';,;,.,ISTREET,CTN STATEI DATEOPBIRTH P- 0. ? o ; 3 5 o f R , ?D DA YEr '. PMi90F:'FHKLEOMIIgEp ..: ... _,.`, _uw... EsnuMfovE r PARTSOFVE"g I AGED.:.::., T IS. r r -r s - sTq WAS THERE AUTOMOBILEU.0 T WSURNICE LIABILITY INSURANCEINFORMATION VEHICLE NO.t• COVERAGE W EFFECT FOR THIS ACCIDENT ON YOM OAR YES ?NO NAME ANDADGiESSOG W&lIiY WSURANCE POLICYHOLDER .: .:.: :. ... - .... Pip 7-15 .,:'NAME OFIIADILITY WSUEIANGECO ANY ?'n /91110 A14OW 3? pl! 9 /6c f S?3 qA%? rI/ NMI OADDRE590F W&LIfY WSUPNICE ADENT ya !p WV P ? UMSER 2 z,?E-. o ,i?/ 2J?s c,?19 9 3 6 zt '? o G 1.372 '? "" ?.. ? 1ST WL•iY.i..? r...4:: :...»...,.-dWa,'..w» naL1,J,.?i :::r :IRE 2N INJUflY :' lusE vNM FREnanrlDn nx4wNa[W AOE Y. NAME T?ArAi. ..err ?........ ..-. .... .. .....-.. .....-. <i.Ln.•Y eLn SY: .?. _11. ^? - ?. _ eD A NDORMIE AGGRESS •• SEX-. AE55 Y n?war. wYAYeu?N;LE ..,':,1 MAHArPgI LTYETH APPLIES,-. :• .:';y, StATUS OFPUIP'ED" MNIKi PIVEH nOnvLA WVEMIGLE aVxDtP ? NNLED I I?lE N[) I I IlCW QASui r-? KILLED I IsLin[I .,. eLtev/dbtlnul i?x dILwe rxATwn?cii`a< "Tieq Iwlltgweif'Rws a t ew \'??., . E :. oww o`?"PKH?ILae .A"°rwDY.y'w' S Y i n 1 vcnwLtJlv I Jl I BEFO RE COLLISION Mw LAx ! de Y ° LrwLLrp ANS.q V P u L ? a?oc ?i WVf9TgATEO RV +,{ ?VfHKYF N ? L W, ON STNS[! OR Ief W ? AY NAMF 011Iq wIGOY [ tONL i aFO M W . c D [s •TAft ?MIA0. ?iRIGI ,a IYD. ? ? Q ? ?ST Ll, / ? 6s7` ? JRJ O . pGln D«eaR ww??AlDx {, InI YrR •YN• ? ? ? O ? ? ? - ? ? O ? ? ? ? rA?x r r` I w ) : - ? ALaa '• C - FROM DIRECTION TO DIREC710N '. S 1 L L ? lA `iDLSt MAN WAS IISIM t 1 1?fAnC1YNK )? WNKWAY O?Wq LDC. e?CNxiwHA 0? Cwnaw4a s?OTHLN 4 11' Y : ( 4 j?• + L I Ci I L MAP fRrN:E ''' ? ML.LTHLR tY AA EMHICONWIOHS TRAEi1000NTPOL KxIG+dFI . . 1 1 1 M1PE OF ROAD W'efLl ?n14.?1 W 1 M f 1 -ERIVEHK:LE ACOONS v CLl I KHrG'tdt MLaMrI I ' ? .1 1 }r, .. 1 aa + l , 1 " I I ? U+iK ;n I p D t-r I 0-,.,s 0 p I p ONE WAV p 1 p 00I STnAWHT AHEAD y ) I? l { I?I??iiyy '.- .. .Y I, („? I A 1? ? I pIK.Y ?/ 7 pWI T 2 ?i RNNWO 7 0 DAWN 0 2 0 StOP.W? fD F 0 TWO WAV p e p OVCnTAKINOANOPA59W0 1 ?( I / 1 •LYy r_. A T y1 : , ? a ?:MW D?!.NOVAAA 3 01- li p 1 pYKLU EXVL p D pIKYtR4RiE NT J AAN?OMHT TURN I: L I l • plfK, 1 plWlT4 Orl ? L ? FLASHNO RID OCN::GE t p • 0 OOP RAM p g p MAKWO LEFF tunN • TLS ? A ?K[ OTHER a ?{O'.A'1 GFYI a ?OK?H1501, ? a p rlAarWO AMBER , Y M M1 p a p-LY ? 9 ? MAKNOU•TURN ff j r L 71 1 /' I ` / V ;i tFl r ? a ? G?eGrY a nARX q p e p w Kn.L ? ^ ? ? S O ? , n AaON IqR AOT KEwOON E A [R SWell KY1IS i 0f IP E ? Lm n% N LANts a L W.* , I + 1 I 1: I Y _ D nw .cr U :fFGFY E Q O KEPILAGMAH ? ? Y ?al•+ ? / J ? ? = ? / { ? p A OTHPA'DICMY IED Q Stomp AT DDNAL OR STOP ?Y . Y t ' y?S/? E' I?' ` J ? ? l , ' 1 I _ _ ... pp11 UV • ? OTA kK p t ? O D ] ?UNIfO 0 p W IIOADW •, -, ? 10 ? IRN W , y L p1 ..., k I1 ? } ° c FI LN i[ _ ? ? ? ! 7 r ? x a' ?°A,? "?21+.:. ° e?+?I`i +?+...'. ? ?. r?`R ? '? ^"? ".?.y t" ?. .- r'??k d `1-D.{MI•-r'• ('1.&. ? 1 Y?t" 1 JI ? AtF?, . 't7l ' Z n _ y'nw,. f ??. J Al P. A V IlVlalul. ???•?' ^el.? -: 7 ax," I , ! sMOTOR VEHICLE COLLISION REPORTi': o NO. _ _ - L - 0.AtE0 +COLUJOrI rtui :.. ., ., D • AY OFCO WSIpN .,,, ,,..... -NMEOFCOWS10N-,J::-4 NWUrE9 AM ?? I :0(9 PM . t. .v ?}F,ORAL nu E COUNtY,..': ,..•. GTY.T WN .. •,, _y 1,? con"nET t/ 1'FC ',SdIV /'o?rL?olOW nWiYDk Cllr l W aIAA` MILES...: N, -,-... CITY , TOWN J.9 .. ? r)2T L'Vp?OI? O?D OF AOMCLS EFI% ,aix- wrF fr3 :'sy?7J?St7.' ScGTICN' a.r.. RM - OIVE NAMEOFSTFlEET.ROADORHIOHWAY ?4.-..?;' ..sr:. WIERSECTIN WITH: STREET OR ROAO;;? 4 ? r O _-.; PRE[]X : EO MREFgST.: '? 'a+r+;r" RRE o ? ??r S r ? ?• 1 n MN WTERSECnON LOCAiIONOF C OWYON ? P _ i /J --.STREET ANO W ?S V(y L?<'/?• STREET BETWEEN "/ 7 / m Nr rrXICLAHDM,Rx ER XNmE. fin, • y? , 9 '?? INTER No INN Cls. Af EnEf?C[0 - / L / V / © F C f!E ! p ? A .•,$?YYO vOLVFO l OVMIC[EVEHKLE QVV[HICLE-CL F]DrHENlwwrfl T^?U /. l C I K;[ ° nts f 77 '' h SPEC.000EUSE ? . E r ,.ui 0-- 0 ? rmi r11JECI STRUCK PPMl DE GMfersrRUCxI OWNER OFOIUECTS NAME AND ADDRESS LOCAT IN RCAD 1 n J ION WAY }' © SAD E L 7 /? rA / FEET $ OnLVERSUST NAME -..' RNSTNAME MQCL OHE rN.W lwO C'w3 ORIVERELAST NMI. FIRSTNAME .. MI00LE ani0 f/?/: «VfD ?ou?fiIVH00 DR 15fREET ADDRESS ::..., ,,. ROUTENAND BOX NO..... MORErHAN- PER R a A DSUSE STREET ADDRESS. ROUTENo.ANOFlO%N. _ PTY STATE L"coOE _,. ,',... .,.. io?x t ?/? `?33 OHIVERSOCCUPATION„ L,qd. Tr?N C«U:AH 1 CITY STATE L PCODE- OHIVERS OCCUPATION..: .... DRNERSLX:ENSENU -- ... :.-. -. ::'. STATE SEX - lFl.TH, AOE OR IVERSUCENSENUMSEl1.-: STATE SE% GATE OF BIRTH :AGE j7[ rW I-SP- 77 k,, X f n Sr Y/ A VEHICLEYR, M-E(CHEV:000GE). MOOEL(ROY-ART). OOD7TYLE(2DR).; -- VEHICLEYR. MAKE(CHEV:D000E) MOOELINO-DART) _ BOOYSIYLEI20R.);.:::. .5 0 LICENSE PLATEN. STATE -. '. TRAILER PLATE NO., PPFJ 22 o UST -- ,;STATE ... LICENSE PLATEN. :. STATE THAILFJr PLATEN. -.. ,:;.. STATE: ?. :.:. VEHK:LEI tl%ICA r!m NO. •-.:-;,:-(IOBBMom SNEWER),.i::, l r?rloot-2 ODOMETER IMKEAGE) 3a oa o :,- VEHICLEIDENTIFICATKl.NO .;,::. '.(ISBBMODELSANEWER) ., OOMETER LMAEAOEI RfiGI I} T•Fllla^I•MIDOIENAMEI pRIVERS IIG E N SE N . .-.: REOL4TE REOOWNER ?.:,IIASTiIRSTMIODLE NAME) :.. ._:. ORIVERB UCENSENO....:.a:, // ` C / yy 1? .;: , ;` 1 - T ,,DATE-FIRTH , GATE OF BIRTH 3 -7,3 a;Z 0o ? & - " _ ??O?T Alh l?'t-S/n? - /f'?.2 STT I/TNIi.......... "..- .•.. ... .. . SrorcoAwvENC? WAS THERE AUTOMOBILE UAS UTY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ?NO rC. T NAMEANDADOR 0FU!i?IUTY WSIIRANCE POLICY NLOER ,. , :, - ,. NPME OF LIABILITY INSURMICE CO .& ,w fr °°i` ?ox33? Gr. 9r7/6c ?? 5?3? 9? I?R%?? L 4,r/ f -PA NAIAI/E'?/?-y1O?AOORE990f LInAOUEY WSUIWICEAGENT,?. .. ?/J?(], /?1/J ?.}. (j'. ,:JEID ' v L /`L- .?A? %C/T STE ?V L•%• / J?j `•: WdUTY POLICY UMBER ._ Zr1ie o zi ?S =0 ?) 372 INJURY ISE9EPARArEPERDRrFCwAmrpHAl SI 'AO NAME -AL.' NAME ADDRESS - -_ - SE%. D ..HE S -_--_ .--.-._----. SE: ' uerV AH ------ M? F EN' -------- - m AND Y Gr[ 0 ? O - ODFw rgNBV?roCrOM ® DOCIDHS ---?----^ ®? WC DRS ----0, AUUA_ I un SOF44JURED I HAVE M.KFWSTCNEINATAPPLIES STATUSOFINJUREO 0111157 ONE THAT APPLIES ..', N $ ?STATUdmEN - W VE (CIE Dwnrq norl psn un IN VEHICLE IRLVD NONw Aa stiq e ?PA9iINt[R IOllEO 19EVEPfI I.- IMP .-- I ILLED 1 WvEnEI IM,r?Oril? 1 < .•.. ? Hd91RAN Df91mAH OF nA W EiC 011HERwNIE.N ? 50 B? no`r` °;T IT, ? s? Bo ?? ' '3r SHOW NRTNMARRDWWGRCLE \ Cam, : MSCRSERELOW WHATHAPPENED IREFERTO VENICtES OY NUMBER) ^.''• p •` , ' MOCAfIM? C'.. \`J ijryi?i-r ? 1.. L ?NHd?,NME•D?? 0\ ovOr SN9R' _?Ua2v1, FIr G? FoRi2?SXl?i> - j scr?7 Sz [71 7,a iR, ? .,5_.-___ /t ? I ,? (D ---? ,?'r? rl r - C?? lr'vq.D , U'' + /?-;r ?? `•+L J'. 1 l VEHICLES POSITIONS BEFORE COLLISION oY lAr,r LT....L rNn AN PJYEGraen:o nr Ydrt LfD4tr SISX:?x: u0u nnr.lO V rai'L9 (Ktlm{0 L.I 01nl LI 1 • 1 F .1 LC i ; G vTHCLI N S E W DN STRELI 0111X01 RVAY NAME ON IlD d.N - ? ? p ? r sr z OA Clw 1 Aq l3 ? N ? . 9 V«H:E n j o m' I ?sa o o : t °I ! ?,, blmN o o ? ? ? ? ? ? ALaa CT D r , . ? ? ? ? ? ? ? HfM< rNM DIRECTION u" O DIREC O 1.4 W ' ?v ? fJl -;'I? r},. .)LSTRMl WASUSI14 10 MDE-K 20WALAWAI RpAnSVRFACE ]w:Allat. L"lrCONDH.GHS IMFTICCO ioaw T TI N 5?fAKfULOFR .?S?fx . OEl OTNLn -RX cHrAwJ rvVf.UFnOAA V-ill VEHIL'tEACTIONB ,4( b '9,. ?`i:' T ,fFAt,?D1Z upv, ? • 1f`•aN a., I wmcxrrw twwN , LL e„H 1 1 1 -' r ? ? K ?wn aR 011 o 4 tom] r) ?M' ? ""AIS O ?nrFwA1 1 I 01 0--9rn-,c,,t mrAO 5 I; ) ?i IIA.WFD 2 ? I+wN ? I ? , F AfOn%aN r) 2 ? iW0 WAY ? J ? DVEnrANINOANDPAS^IND 'I Fi 1J J I I l Y-? F-1 ( 01 i ? WTI ] yYM ) ? dI.K ? J ? , a ? D ? :MW { ?,w { ? n C) A [j iE' YI:In L•WI ? D ? IYfV SllllE ? ] C] L'A?IN 1114111 TURN 11A1n E !L oval) R[D r'RC C] N ? V KING LLFT(URN ? ' ? Y + . t f I. ) A T t 5 , S 1 , ,? ) 1 ? n l W ICE DtINR DARN SIRIf.i ?, ? nnRR S ? S ? LCwl50FF ? S ? ITA•LC. I RAMnI Pr Il00 ILA .aaYrO AMNFR ? 5 ? ALLEY ? 6 ? MAKYK.U TURN 11 { p . .. t . A IfJ' t J f ": ?! L!' r .'PFGFY S DARKM ? S ? ?S ? IR[ETLG73 N MTSFEM DAMER ?' 1 IVI 317I1µ ? B ?T,Yn WAV• A ?CI.ON'IN L'A'MA AtN 0 14 JL ! - 'N'nQ 1 ? ori,ER ? t ? Kr cL..nMxw tX+n acraN3 LrE1 w nrr orNf rLnM.N ] r4 l} v:J AA „ , ? A ? I L ? t o , OI LR J'iC r ? ) ?:iPARA1fA ? A ?sf EOA A _ a ?CHIT O ? ' r, F ? ' ? /L' r K}I3 < 1?) w / ? 2 e dwLn D ROAnwAY nr 93tt ?? V , ? E ?TI t Y ? r ] ?l- YW R ? )D ? iM%nt ?An¢ C ( ^ I ;1 L Ege y r 1. N.4??'1 VtFra?. .? u???k .:. 1 a ' ?,?.G I I?y'A lr? .?•?! J1 rfr 41 ?r,'. n .. - flR ? . Y, w ?a z l a W? f (')STATE OF W HINGTON .AD! I OF 1 Sp'AN'159 w POLICE TRAFFIC COLLISION REPORT ® TRAFFICWAY `, ...... ., ( RoucF COmqu:NrnuMwe Ej PRIVATE WAY .. opFOlcau N . COILI! n NIV CO ?Jr -7 X% wr u N rp r Yr. c7 71 '8 Will= wOu.I 0o U :T ec? COyNI <ItY NO. 01- QN QE °IN CIIV OR TOWN N -NO OISIR[Ft OR wGNWAY J M,ItS 5 ow D9N L? o"MA&4 ON S"A 4&"v RU gAI A? RWn0951 } rnlFgS[CNNO WiN. Srgt[109 gOAD NONrN1E.5lalp. BO .efl1% [D MLLF WSI ?, Slq(EI{ SlelEl R OrSrANCFf '•E ?lN ?]T 0 rV 1 .C9055rp NlAefSrMltf OS lsvE I ACCIDENT Ui lS N !![r OF 1}`+LA1 MIIFAGE COR M. pAmOIA CIXII$ION INVIXVfO SOrll.Of N1189U. rOIAINO NO ?RiII[D?NO IN-'. ? ? wN.gDi. OF-_ g IN i ' 11 Sr.E IOpgOAD04 glffM.XE IN IMF CIS CR"lOSS SIRI(I00 q0 E ?_ epp , l9rYDAMAG[ONIY ?awlrfD cl .11R, SIp?C[INM.E N O I St9 B IIC C[ ' U NIDOWNE. S NAMfI DAFAAGE / ^S .. ? y S / o S l _49.- I-AI CODING U51 ' UNITNO. 1 Domes NUA. usI NRS m ow UNIT N0.1 ? VEHICLE Q PEDESTRIAN Q PEDALCYCLIST l ,77 Dq E.iNAFAE: sr SreEfl ADD9t55 rWFi ADpef55 SIAEF . D }I oa r.rone` ° Y IAII _ "^o«"ee'.se'"E i9H??E-%T248//nK StAn x D N v IY l IN All Br N « i ... I .. Z OCCU9AIION A«Ff RgNF NO 5 ONI NIONr X XN /$? S-v E .-All- 'IF. 1-1 NO. Ftt5 IONI NEIOMr . Q CHECK(YI :N I V.. A AmorN[o AE : i sn ro CODE5?* ] wu.. ttNlc . 1N:r I " O 5 e °nrv ?- Q CHECK(. veNlaf AS AN Mq ANDINfi t CODES ? ' ] n S 1• K.cu :ii N h ' • j} z IN wlos e x»I r. IN .1 ° ^ tt ?Ye p ° « ° ° 3 :' I ° »M79' ? Q „ eu Q 1.1Y <Sk • 8 '? q/?? aev. moo[ qq?C D^o?y nwAl //y r/ ? / ? }DpWCKl' "Y' E I p Y I AE l ? Y N A ytf•? It. IN?/ 7 sul FAl= sl,u /C H YIN a t f Il e A tl rp 2;IA1%}N NO /I GIL 1u p 71 ? ,3i YlN 1 IU N I r A I N I I EIOrSRHO I+'K?/. SSI/. MrDOIE?/33 ] ? App.1sSN O.YYN. W 00 KSr ,I.51 m1 No. [Z: ZZ7 Q/ QQD eT? ? ll eR / . , . >7dL itJ E NAIf.DD• S ?? lC0 Op AOt NI /i/6mE R n DA«.GDA.1• ' ° cN o . CNA.u - D ?,°EI N ?U-NlD I DIO «De rbi'ono: 5 ` ? •' r" .I WAY • roY o 'o" _ ? f ? "" FJ u _ DIAGRAM OF COlUSION: 5 NoX tNO.rN OESCRIPTIONCP al= COLUSION: Ilneswnema I IsNIHnNRUSSAp I wu B .- II _ `` ff ff /? 47- 1 ? f T o? (LlO? f 1 ! 1 I P 9 4 _ . o?v?nssCaa?e.7a . t i I f ?_ ?_. C1?.?irXoG loid¢. orS??Qt?ooiu?F l?i/i- __ t}-- ( _. I ?.. i Su*?rsfw??? 1 t ,._.I- ( ` [ -. _ 1-4. L Ate tFx?ito.4tns /f.I 7rtuva/No !$ur2r Irv v - IE 1. _r. ! ? .. ?_ ,t? ooar?.9.??rt?j--. zs?soH ??i?f --- ?,. ADDRESS 8 I JURIES OF PERSONS I NVOLVED * CODES 1 , S 6 CL OCCU WANTS /WITNESSES is imr?l.?i.MNi ii -us eci uiu s '«N"D••` .ME_ es Ina «rcr A4 Zv- 'o V, .w OF ; p __........ .......... ...... .... _... _. .. .... .- . I NO . OWI55 N., W N . MDVID I.p« Yurc. Arc Nrcl. YNwl lia- E.DOI O• .cE X. 7" w. CErY DrICI°('Drrr. X a 1 S. wo I... aD D.11-.. 1 .n.ov[o. own ? ,, • S?oS?f ,. ? } -` :?. ,tt4.,ftL xnlY.' 4r. pr4T11 `? 1 VEI • I y; s 2v'n ? i L ? o- ,. ' ?? .?:: x-^?4 .,__ ?r?r.Br,_.??+ffic.R.,>d _. >t. -•- .__a? .d?[_. "• •s x .a n:.rk , "?" A O STATE OF W INGTON No '•., ,_,.^? POLICE TRAFFIC COL L" ION REPORT E]y TRAFFICWAY' Iplceeannurvrrvum v 164 -11 a L-J PRIVATE WAY J' _poDeg?oJ{ciq. ISL. _ l7 bC'/?t10 w 1 I.uis.lw.o._ I ?u;? rl+u lust,I courvrr ;//J / ?L??G`G.•cJO..? mlw.r/rpD 4/ arrw. rmve °. 8 / ?N ?, ?IN CrY IOwN, NAM[I DpSrel[rOxN WIWAY . (puns 3 r G ?.?, Cu.?.e ON - /C5 (Z' l IWnOR IR[ S?'??D S ON .s7 INr[R3tCr ND rAI :3nEl DR WAD NDN Nnvua DN e[nn[N nTi srvm a???Glf?deNe.+Sivtn .Hr1A [D A,—. 5.6 r D • cl aDV roN you RD[vl .cvo3ssrvnloR N[AR[u uu vosl ? rn l3 3 [ W ACCIDENT wu RA"' . (O nn « G ?o3T MILEAGE CODE 7 10- oNlNVav[D uvtRU. rq rlOKlltO?Eq INNR[D? ?SeR1AG[ ?rvlrl RUN .MOIreRe I 7- INRI 43 sntr RoADDR mrlwra g03331W[T«IOM y - gv[Ncus ?vROnarrDArAAC[oNlr ?u-svlnD ?ai D J DBlicr r AM1Or C911113rlUC[ANDOWN(R'3 [I far DAMA« 3e1CW CWING Uhf _ UNIT NO. 1 UNITNO.7 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST .1' s DRNIRS N.,uf//I IASr Asl f ? ? w+?nvsNAUf. usr - C?.L /L ?i' 7 sr ? Ritr AROR[S3 •? fi //s/u?n nv eoof rrIDNe NO. 1% Gl, //?/C 04? ?/ fS S D R cip sure 2 l R 11AIT oe<wuwrr u rvAUf arlrorvl w e IeNI II,DNr G/??E YO E R DeewArloN NAME a.IlOrrf rvo. Ens IRIDIII N Ieln - ?CHECK(?) 'nNKlt AS xrv,N turiv' a AN r ?CHECK wswN Uwiont«w ! ' ? NODES?• ?"'"" r ergo. Ay R•e•cIL S "N • ? nw ?orvc.u. - , CODESP' u ss ! 3u 6i'O,n n wrcs ? / H M s" .D ? ... r RI ? Eb:,r. ? M. ? 14N •• ::' ? A. ND ? u ? M R. ? °i ? ti X p" Ku NrlwR wu IDODCt.cW 1 .ADDtt1DAVI.r+OVAI 3rrLL lx DR.cONV.I D E E nYW I V.1 IIDA•rfq,•w) l a 2 ov If uA AArI ND - ? vtN ca fi NrvKI .rlCArgN rvO :.r4 G isd / ID 7 I.?,2 5?°' /moo L vfNICLL Ip NII1 I I I I I rI u nennetoowr+eR usr nvv ASIDa wloNf NO / EL /? ?L'?w.? ? t ?,.f? O W v nD A++tR. swsr me u ? ^ ADDR[ss«oww• oa L???? w.? E , MrIlAD0RI5301N3URANCi CO gAGtrvr ?? 1 ]] DwACtDARU ' S'e/ "w`o` uAw'o,v[w u cNAVa-D C?P lfXS e-7-711 crv. g • l t ? ov o ul - ? w:v 0- D y.+.7 t er ,L?jIL I QrA c? rovno AWAY er' f a v DIAGRAM OE COLLISION ! ysy""? i 1 I i _-L- ev:vro"O°,v DESCRIPTION OFCOLUSION (us[surnlwMAl LenR Ha3M•+1 .L?_ ?r .r.-? .c,,; @ vcs./i ??r's - NAME, ADDRESS B INJURIES OF PERSONS I NVOLVED O • ! _ 2 3 All 6 OCCUPANTS WITNESSES 1-boulwu"i r?u 1 1 AU v wwlr v r -In- w3n [icE p Arl Awl N ADnD, -...._ ..- NAru d---' «anDrlou? ? ? ?NDr . ... o - No -- DnR ---- 141111 « NA.1. .•. ?ARe ?p.r ?"S R. ?' A- X ?.^ /I f ?? I ? L?SI' M11r lql I?I ?M xmNn R u.'D 4 xm w3 + .11 O/1 ??L /J/ / .7v / ) M ?/ ,! a :e r ?a L 4 v ? . ( Ysry t ?? u a• -> a i4h ? } Ira .? ? , ti< N 1 . M? l ; r la Y ? c ' L Ek 5 i t ,.I t } ? { ^ ter . ' l l ? I E?g X 1 O410wN NNAFBNO 45,911109 MGHWAY pN p[ ?w C" RS / 4WR09 RF ' A y M4ti 3 pW O, ON e. 56990. }, INIE9yCRNG MnI». 3,4t[I OP AD NONIN,fv5fC11pN Cylr?Kr Al; r"sa , _ X Fdr6i74 ensvelN mFIx MI1I 0031 - O 3. C G Di AN f D f CII N cP0 5 5 519111 N[A9tS,M if O M 113' M 5 [ w ACCIDENT MILEAGE RAMV D D A y Rn IT, L $ CODE }} coulsuNlNVgvlD N19 ,. ?v9ipel ?"rte4uN ra No {ulD wwlD m»DnD,. D IMEe css c , vlro.uo94frf9tNCf 4osssmnD94oAD _ . _ lom NO '7? aveH nls 1[J PPOli9ir DNAAGt ONIY o Y[SU1RD ?81°`?lF 700 .J •? Oe11C1S=PVC[IN,Vn{q OBIICr S,PUCa •NDOWNf45 NNA[) IS, DAMAGE 59FCNl CODING I6E ((J( S UNI7 NO.I UNIT NO.2 ?VEHICLE ?PEDESTRIAN 0PEDALCYCLIST D9Nws N.Mo- wt n9v I D4n9s NWAr. IASr I e smw ADD9ess Ell -1. '-' z r IMf :LCO v»oNI NO. D Y un R .--C-N. L Iw, 11 D..I• » I V I UIN N E A E -c-."- M 1N0. [r[3 MWH, KW»I E M-1- II9MN.W.Ie P-1 NO. [YES IGNI r4K:N1 ? R pCHECK(? ++NeMRVr ANOINO 0CHECK( /1 »ttrAS•NCMno 0 • °.in:'" .w.. ??wc.cl CODES ? " S { e i; ss CODES ? * 7 a :u iin;.w' 7 w r D .MN . l ? °t I p EBNI. ? N:a1t p"4vN,. =111' p " p Esc' ? zb ? ? ;D Y " v NM t1?9 MAAI IDODGf LNtv.t { IDA9,.NC AI S,YU I}D9.C ) .) AvOgl ID.w .NbYAI r A9 { L r.tv. 7 ? /Y/LRC. E » N u N 1 rA,t FAIL r4MUP qA,I NO H vI»c e • IfA N. F L _ I vE»iGl IpNUNCA1gN ND i v{»i 111D N l A e, z I I I 1 Ptg3RP1DOWHl9 UEtI rIPSI MiDIXI F- O wNF4. Vel IIP3r iM( W ? ADO4fS3Or OwN14 N ? 71 c ,? p E AMIS•DD915'a1Hw. eeo G9 wlNr T- R ADTNT l s} MIA > ufvµn,WN W JAM-DMGA 5 . ? c.. ?• C»A4G1 ~ _ 910 5 DAMA4?? lS ? ??v ?IIMNNID ?AW" ?--NED i3 ••IA IG ?OifOii 5 : IOMD ev OMD ? AWAY eY. s GLLISIGN s w r"• No¢An NOPI» DESCRIPTION OF COLLISION. llntur-NI&"l„r NICts5A9YI DIAGRAMF , wwq er A99ow _ ' I I r I /T EX i TEi x PELS % __ ,___.. / n II NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ' CODES 1 - Z J I 5 6 OCCUPANTS /WITNESSES IMI wrnlw»ru swn Id ApdNONAI HAW SI - - NM AG! --- IAIU ,awl. ua -..._ »RV' n". n4 /XCl " wl iq ADan, M-1 El IT ? tw, p,l, » . p H tt441. N.MI P.O F -. .. _..- ..-_...._-._.__.. •DDPIf, .,A,l?. W ..._.. , 1"10 AMe p.aKl pMdnr ?w:r ?ri::.M r0 wl r? •lw.n, a,l??i' N IMa ?•Me p•r°,{I pcaR p:° : ' • N% rNlr r.Y151LAIV.D pI<Ir,NAr1.9•N. X r c 9•DD?• h,r N:. u+,10• dn •Dll d qKI DSrAICMG 2 }y?OQ rgKl .P4vlD Z {/DD DAllq 4lrOn Y/ 7 6S ArrIOVID.. n -? DI-A,1 / o, rt W ? a ! . v J, ?X n 91 L? Jd11 `-? ? A ? I d t T 1 i ? ? i ?I A y( ? t f 4 1( 7 t3 l r ry?` M W d ,,I) , ? + 1 - - - WSP wIPN.I.001 J ( , v 9E STATE OF WA INGTON •Gt D. I No 1 ?_ 7 7 S -? s ® POLICE TRAFFIC COLL 'r N REPORT TRAFFICWAY PRIVATE WAY EUICLC vu ,NtNUM0E4 i„?: y , }I yZl q iMt COVNIY DI}Y r0 EMWA _ IVYNDD91 pU90AN zs?s - - a, GPAL SH L } t I] PRIVATE WAY o _ 1, Ar 1 Mt 1-NIT ,.[ Iu.aD ?f' HOURI 2 -- r A o o . pN C];. p( :N n Civ 0910WN MY iNO Of SIPEFi O9 HIGHWAY Cl3 90UIt OR 9f qry MRES s ow j@ 0r ON l? ;•50300 ,NIE95[1IINO'm1H, SIRFEI OR ROAD NON InItPSeCtION ?U iRtr1X - M,lf 8031 x eerwnN A1Ut 'Nod era K Q • 50 01 W 'C+053314 F Nf•vE3 MIl PO M t R M [3 ACCIDENT R Ou RAM W A S ! retr W Or J MILEAGE COll13gNINVO3Vf0 fvl R,IV: CODE 'D'AL NO NO SIIIED??NO.INE09[D?? ?3U,L I ?HIra RUN wn'onoir 'N 'PD CI, IPEFt0+roA009 RItRNtt IMFR ClS CPOSSSIRlRO O C»VInICllS ff p ProRP[Y O•MAGFONEY p ? v[aflf R? OexCi SIREOX INAMf Or OBItC131PUCR N:DOWNER's NAMEI Pf UlrfD ` 3ros tSrOAMAO[ SRCUICODING IDE _ }- I UNITNO.1 DRNtP '3 UNIT pVEHICLE PEDESTRIAN ? PEDALCYCUST 3 NAME: WI ' Nv3 MI 09NER' WANE: NSI r x• ? sl+tfr ADOUe S A'.- ffJ ZJ z D HR 0 t ADD9esa r srAi[ 1 1-DE PHONE W. D Y AIf R -- NERs u<eN n s Arf A .v u N ` l Z /Z r• V Ar DA e n wrB1i a «CUPArgN N to RgN1 NO. Ef5 OHr MEgnr E «UPAIION fI9M NAME IRHONt NO. [r!S' IGNI IEgn aZ p/4- RMp/` ` r -? Jb R ? CHECK (.) ' ' M l vtHIC » A r a A IHfo p CHECK (? s HIM i a N i orHa ANOrHe CODES' D S • i N' S Nrcr,o-,z CODES?* D a f•s AN lMR :;?? » s w r» a .. z .N luR,ES r c t< s x m p fuo?a ct 0 ' n?u p p 4 1 7 r 0 p e + p?8:» M,XEIDDOCE.afv. N F ?r??Kll ?7.°.1,., u iD.ar.r,DY+ sn?elxDR c v v 7 ??? I MODfl IDA9. AI /J J C /Q E N ^d H. surf v ,[P RAIL w. s ru H vw.c R iRF0.RIIZ7 vlHKl[,Otnr»gwigN ND. C H It Denrl Y 91901 9y I E Rec Srt9eoowne+ lASr rl+sr M,DOIew.DNt ND ¢ ADDRessaoW,xR wne+: lur NRSi O MI W . wNe 2 r/.s N NAMIa ADO+us ermw+ANCe co. c. ACeN' E SS•LaF 5G , A R n DAMAO M[LA A / Y•Y L ' ," " cnuC» [) - CH».u• gAMAG •Pu R p t _ / ,t},: 3 ly1 M?o E OAM•? ? i;W; ?91MIUNID ?RnIN ,? . i0r ' Wr.Or ? WAY ?.-INID [yo r D a . C/ ?-,a S/ 12 -ew ? °V' s rirrnu N DIAGRAM OFCOLLISION ?U Nmc•n Nwl« i -'I I I- I ., 1 ,.., tHtlrYHe<1tswry. ' ar +ow DESCRIPTIOO OOF COLLISION: Iust surneM[wusHetrlr Nece35AAr1 TT /9 /YiGN .PLATE- !r .s/?EFJ /vNF 4 / S THE XOAJ STiQ/f!/?./L . /y !?/d T J.s.,ih l _ I_ RQ_. I \ /9?t5 FL/lxi..JL _tbw../ ??C9d Y?c.( .Z32 Pi, ' _ I 1 I NAME,ADDRE5561NJURIESOFPERSONS INVOLVED r OCCUPANTS/ WITNESSES ia: On .IN ? s HEI BODES 1 - Z J S G l D r i N•Ay - 11 all Ac[ NN r!. vAr w wl nuf (XCI wRr ! A - .M. omlp .pa pmt. r n n .. _ N ?IU+ W .. R 'OIfOM pAM1 M [ tOf Eq+ltl tt a ?•MS ?',°"R'piD:H.pw: p:°'Hl. wYUw•r..caECt+sN+Mtat•H. i•OOtC.ACtN C. X 1 act Dsqq.•ratc rolgl .+. DAn a+Eroa •v.rovtoe o•n ?DrC c Dsi" of 2T i ? V " r ( .o?• . no Hfy »// $ f 7 yN 4? ?' t?•n!S I ie ? ?.;` i i ,-S '?, I' ?yl?^'rM1'r?+?.9,1 IE J ? IJ[Y1; wi1'*rC.+'FI((;???..i '!Y!?a' ""Al r ? (fit q?q ?I '.f Y• ? . J _ 1.: k r .. 1 rl?? t/ ? r ? I .k.l ? y .f}II .?• 1 .. r .M'I t f : r , 1 POLICE TRAFFIC COION REPORT XTRAFFICWAY I RAIN x me, tJ <) Rx d+ c r Al PRIVATE WAY y D or<d! couNrr n- err- rw, a N °F ° N .µL,v yo [a srvurogl.cNwAr rd cu p I% R0931Y[F r µ °s °w ON er4.G A .2a 990 I N! Nl9seer NO Vna wear De 9o%D -N wn?<Gloly??C l.. ._.. M%E rpsl? "2 T ? BftNTlN i?jZ %j SIgF[I t /7?'?C%L siq[[r ? - -'f' •NCl eD Vt r IgOM elFiq[ C90335r9[[r NtMfsl Mlll pp5 ACCIDENT Iffl w OF MILEAGE ?_/JS woof I', I / Cam/ l%iY.t'.. /1 cal sqN NvOlvm pup, IOr%t NO NO nl.EO?-.INIU9[pQ? ° Y%lBG! ° N r l qUN wn'pioM Y1 I ^ Nd dVfn Cl[5 pgOgqly DAM%GF DNIY ?f1°s?lr[D °vtp(Lt U ?+ oand slvuc%INAMFd oencr srqucv ANDOwNfv's NAV,[I lst D%MAO[ svfcwc UNIT NO.I UNIT NO.2 0VEHI! LIST .?? ! 09w1vsNNnl Uyr rr??9Sr ` MIDIX Dv v(9's NAMI .I lADDetss ? IRlr %nwrtss ?. I 8 8.30 ?E OX; -oa 8 7 ,a n. coa .NON[- D r srwR r -' "lv /. ZaDLo.J u/? 9&3?rS' 37 R !2 .? _ D9 tesunNV HO srwn/J , N - ' ? a• _SmiT/!'?.3r7 SDK LJ/r ? I I i BI Nst-. a [or - FT7y;+' «? r ?/ goNt- s dN s E «<wANON .?? ?w1 "M rMM[IRKIw[-. [r[S ICM HIdII ? CHECK (?) vEwcir %s.N vrtr? %NOlNw 0 C J. vs. HECK (.? I¢, ?'- _ CODES P ] s rvrcrcn 6 y _ sNnKlr ASAw MM%n[orA rrgq '?' I. CODES ? ] a.u . s.s9. r 5 r%<no-v. 6 y r, !Yqv wn?l. S'°" 1.•eU..,cr KI r.n NOD. I I "tA. °? oaN. ??%,I 4? wYyol ° .,-ou o?B. ?w ???. _ • p?J NI%%l IDDDO(CnlYl %MDDFl 10%91 raDV.1 slrtl l ]D`e.C?'O/N?V/?IJ 1 v.l IIDAqAI K"1 .) . Y 'R••. /I 1K •! S O .Il,9R.1[ I.r[ H 9 ]B y w.. n R rv vtnc t[TE? All pl t'. Cll Df NINKArgN- W ? r- ?wnKll lpNrNl Tel l 9 I - 6!/ i?i / 6? /iOsoiois_SS? E I no ! I I i ?'?. ne snrtnowwe rv F - ' 9. rwsl MKOU: 'T? N? .DOwadoww. ' W ? ?( s?irJC N ?'}. W'.: N ee%Dwfssd lHw.A-r<o eaw ?? E N II+ZS-dPR;ERr- .S??E'LO - . /._.. c?sE....q? R _ S rN%M.clD 9rfA 9N -- t _:Tl c ? ? ...I' s: wra cNUgq ? <nu ? ? 1?"M%oti n9rA ? ?? 'iW I is I?[r r. . ?Aw^r ?gFAwrxo f O.MACI _ ?,? ° " LzwDBr ? ,GGSaJ S Iwiroer 1( DIAGRAM OfC LL1510N' N n NDK%p?NO9r I rniogii `lTw:Nl#' s T.,N?. ` 7 w9euuiivp. _, a ow" EIESCRIPTIONOF COLLISION• Ilbf wFUMlNIN WnNNass9erl _ fJ ! J _ _ I _?._ 1 ? I -' ?_-i? I '- -s°?T/f?_.ao.?c..? .dc??c H_6.J Ti1K ? _/ w - 3 . i _. '? ? ®P? ?? I (i ??'??I ?d??IG?J. ??__13f?-???'o:D !'C?E .,s Zing/ NAME, ADDRESS 8 INJURIES OF PERSONS INVOWED CODES 1 _ 4 3 4 5 6 OCCUPANTS / WITNESSES 1p:o6";0 ""?.NiABM?ii y% r?l - ws9H' -vvr -wv - ` ? HAMF r I. esn fled "'cr. ?f 1,- ,-. , , N.,. AMe Op.1' 0" OM ?11P rgOM 1 'Q HAM r+er OAw °,"'0. 1°:' 1-? 9.YRI ..?+?.c//dy(Lrw / J??J FHler °AMS J _ n Il E' 1 I .Dl,.,n .. .°. H. .. .___ Q7 ? ?I/.$7 N•Me?I ' rlm Nn /(iJ bNO o?? °r: ?10 p ( 1 r I h 4} 'S +4e ra\ - ry`r.?i .'1.173. I '? { 'M 111d tiµ ? r 1 ,r?FJrl? ? ! c r N ? J I W? r ? LBi I i r_ t 1 l ?/ l rNl 4} t t ! ts*? %"' ? ' t r ,?I ?- ?.p 5 ?. TP? STATE OF WAINGTON 9A. 1 Di1 I?1_ .. 7R."R'°° 7 I I. POLICE TRAFFIC COLLISION REPORT RTRAFF1 f - ? 1°? .E V WLKF COMRNNI NUMRf9 7 PRIVATE WAY DA[t Oi IX „ COUNIV ? ? , ] I:,, yl tl,itj?epyR CDV OR TOWN ' [DUN,Y NO CIfV Np. ?i,? - ?N E ?IN NAMe{NO P319tf10v MGnwAY i C I gpUi(OR St C MRts ?w r ON OA K iN[fvY ,iNG w3,n 3[9tf,OV 90Ap NOniNleR5tC1gN 9vtEl[ !O. MRF K151 ' o la RfTw![N (J[_ U S,Rf[ta /AYR Z1vft1 Oi5 ANC[{D R 7.3 9 I HI ,CROSSS,gEF OR NtARt ,Mi ACCIDENT M[[5 I 5 [ w 0 DAIw d 5 MKEAGE iFtt R c 111 NINVIXVFD vt9irv, 11 w10 IDIAI NO NO SiIIfD?Np. iNNRtD,,J? ?Yil[AGf ?NI,I RUN wwowDN d V[NIC [S ® ° iN IN rl IRff vOAD p19D(9ENCE iMf9 CIS Ca03s51H[I RO.O ?] I ?9[OR9iv DAMAGE pAY ?o[5 IllrtO ?vF?'KI[ ODKC1519UC[INAMl Oi 0ahCl SIRIKS ANOOwN[9'S NAMFI E51.DAMAGf SrtCULL CCpv{G1H - lwsr UNIT NO. i v mi IwneR' s NA wE , UNI I;N ? VEHICLE ? PEDESTRIAN ? PEDALC(CLIST ^ , , • LAM Iv[v 3 NAwF: I.•si I s,RtlIAW9F53 I A-7L. 1.11ADD9fs5 -' Art Rircooe [„o.<NO. pCU1o 9X D A 3 GS7-12 DR wsuuN sA R b^PwAs i o WA iz 14"' !y" I V I . " "" - {? w [YCwAlgn IRM [a R.pK NO. fns iGni N[?Gfl, ft ^ M MMI: I E R CUVA1gN fangNf NO. Ens K.111 HICMI ? CHECK (4 NNK[F • A ANOIN nl ? E ? CH (n NNKIE •s AN rMwo e CODES b- s rC,1? s [•cl?o. e IN ,:u ' • ^„n w[w ANO*nf o.c. C ?' s < u • ° s E. rco. n» ' ? cs . a N pI :. •? N.•.? ? N NYfwR M MA[t IDODG[cIAV.f m ' a a rt. ? v.rt ? ??. IDNI.NbvAl 51v11I9DRCOnv .f tie' ? •? ? M& ? MA. 0.1 „ Y - n ?? 1 s1AI [ .I [ pDt]fD [ 1 pI M Yi ? - p tiuREEA11 NO 3,A1 H Nn ` _- NNKI(ID(MrcKA1KN NO. 1I I I I nenrtrt°owNFR w1 n[v MDwe °IID[K •a C L v nq D[N I I VIF I I D S N -AI. w _. W w.eR lASt I MI C 1 a uiJ 2,?, I lo` 116 ? o oir > N *[ at, l ' NAMEaADD.tssvlNSwANCt CO n Gt?c .uN1 I E R v? ? ? ar OWAW MfA se ? Kao.?IJ '- • ARKM?NN lI "?A Cn•RG RE OFF ? [] pAMAGF HN MMAIMD t3 Ir Dib s w• O° R[AV.[xD •?° RED. ? AWAY ] ' I 16iorrS? A f IDwwAtcWY AWAY I DIAGR AM OF COlUS10N: N 1Y ?? NDK n?1n DESCRIPTION OFC 11510N: Ilrst slPwuYNr,N SNfnuEaasuK I r- 1_ ? ?!,' v? ? IS 6 0'1Y. l?WZll__FA115_. 7 t 1 QZl(5 oF?__. RuAt1A?'_ ?u REGIIt .veFL'L_ pi I f .?. +lxl, Aft*ox zlo D s a _ OE..,a _ jl eE m } H . a Nit,.)__-C?_PA?Klufr_LnT,1tCH?LSi1V K_ ?_#:: ?-? !-f { ft Ya?reo f ._+-- dv,p ?y A sNZ 71 : t ? . _..J ?.`- , Yt >_I?+Tn_ IL NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED CODES 1 Z 3 1 S 6 N OCCUPANTS/ WITNESSES ;E?1'a a",°Iaw Mw sw?ls .ME ? x[ Au 1u ""?" -K{? Rlr- I. -- MECr- tlYR tr,a I. • roNU N •[ nd ----- I N ..w aoi.oM?•AU ?R.KI?'?'.,.?,,." ? • w No 3 NF CI • ? :' ?[onls ?"•;Y G +,GG 1 1NAw .DUD. •u N 1 K ?Oy yUOJ'fsp t[d N1U911 /G? A[.[OVID.v pA11 /kl. N Mc'T ? N u'i t?.%;Mhj4 ey???SY`lt?1?1?,,.J,.. k????E??_ . Ir'[In4.Erdt+Erf1Y S'ir, a.[_.. iK P L uy -:_ I, a #R 1 r ?? f ?o- 1 lu f POLICE TRAFFIC COMMON REPORT .I J.IKA""I ZY ' Q PRIVATE WAY 51 DA IXLJ f 1011 HOUR COtWty <rcW. NWA. puteAN o e RAL El ON ( l OR, CllrwtowN NUAEaNOOt5TRLETOR-WAY ao,c?s,t./ qqIT D MLt3 ®,S pw 52., ONO +? JfV INRRSFCI NG VniN S,RIt, OR ROAD NON INtIRStCLNJN ??'D R I% Mot POSF ? 1 SIRItI STRtfT eLTWLFN NA L: , D Arv FaDe [ROSS31Rtf NAVE iMII Mn[S 3 1 L OL tl W 5"z s ACCIDENT MILEAGE E AMP DI AM MIA ' COIL SIGN rvvIXV{D [R ir: Nltt 9UN NO MKllllp NO.INJw[D ?50llAGF ? OIM D IM[0 C13 t RfOADOR RI MNCf QOSSSN(ETOR ROAD PD d VFNICIl3 m Q.?jORR VDAMAG[ONIV ?cFSUIttD ? vtaClf 3. CIO ORJfCT STRUCKINAMf Ot ORJECT a TRUCK AND OWNERS NAM[I 151. DAMAGt : re Fg,,,sos co SKCUI COdNG Ifif UNIT NO. I UNIT NO 2 p VEHICLE ? PEDESTRIAN ? PEDALCYC T DR VIR'S NNAf Wl Rt t CF- DV ORVfRTNAM{. NTT5 7 S,vltt wD t ,BEET ADDVfTT °r xl. coof rwNe NO D I. Ae U134 -I -401 R NER'3 (ILLNY tJO C SIAif ^^ 1.1 I v ll fH A E 1 OCCUPAII fIRM HAMt{PNONf NO. Fr[S ILNi 1EIGM E ocLIJ.ANON LIRM NNAfa PNONt NO. tY[3 IGNI If WHi ?O R ? CHECK (7 AND,NIV ? CHECK (? V w[IF AS AN MR rFO A t vAl WIC CODES ?' ] 5 I w. I e ;; °KC.:?{- T% , CODES I- D i" . ° 5 unaN a ales O illw:gl.D,. p -RA-T ? W' ? ES:H 7 XI, ? °M,. • M ? •., "All ? 81;. ? H ? u Ku ylN rlAR MAAf IDODOF.afvl IUDARL q MY",?- VI t MOWIIDAR. vAl l _ Do()Cc 4DR E m sure nMUR AArt HO v H nN IR o V? - QA - CI - A v3N1[ltIpMIllCwrpN NO Y IIRVH l1 I N - I 8 L - ! I I rIG13RRlDOM+AR W, NRSt Mlpplt rNON{NO I O wN WI rnSl "owl aOVJN1R :3r FL A-s D, r, N E MAIaAOwusalNw.uR[F CO nACfHI R v e- DAMAGI ART. ' •T IU BOO " fare crlAeee ( ?DPI^r -D t o a •el ? AWiv ?.t INID Nii"aNOw lp gAMAG! ARUM L IORIar t 31 Mn U.ll c o IOV?IDRY GLYI •w ? TOWlD RY. AwAY s DIAGRAM OF COIIISI N: NfI wNI N rv. ND2An NpIH w ARROW f i R ns3 DESCRIPTION OF COLLISION: IVSISIPIRIMIMAt ETIFNtGTSARY) NO M Mn ... 1?L ueH'?I S16 aeK Q-.? R0. DRIUa DRims ad.ty . Cw-r(%UL.. 03= SIB S?haJ l HiUt. TRn n?la A c +cH I r l l? N . .. v ?e l ai I N CDMCS .I D. Re bT. _ _ __ E NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED + CODES 1 - Z 4 5 6 OCCUPANTS /WITNESSES .u:aDR?o?1.:I rM.uu ii uK Acl w '; frsu un T0j ?L wl >o ADO.us ili. a YID I. ?AMa 0IO,K1 M";'. ? D» ? ;: ° MI No • Rrs ".??,ti'i3°I s .Ai. ?w? ?°.: ' ? io.?1. ? ::s. X S?o.I..G WIKI•>N• If •N. R ?o• •GI d ?ODir asZtic"l o ?SOti D I .221?g oMR °MI O C 114 h O STATE OF Wt HINGTON 9•`f ? Dr ? ?TRAFFICWAV N19 "f. ' POLICE TRAFFIC COSION REPORT fIXICf COMRIAIM NUMDFP I ( 444 ,`I PRIVATE WAY T ttt pArF Or<IXl1 N UN _ w ?Srr Lr w, a tlmf IUSE x•I%IHOUP C0=rv3Y C'OINItY rq. CIEY NO. iHNA ?UR! _ - , ? N 30 w N 9 CIl Y 0 N ?F 0a f6N00 SIaEf3 HIGHWAY f15 RW1E Oa ?Y? :.A ? ??y J /[ ? ? ? w 1 OE MIt1 1 ?W cr A/W C.IC QNV A h _ m r'; 4 Mfauu NC VnTH. Batt, ov wN Nevuct orv vafriz a Mne you SJ 3 BfTW[!N /?/L''? SSP[[il Q 139f[r T vAMa DIAL -A / p5l•rvC[6D aF?T ON IPON 9rFafN F CvO555Taffl OV YtA f51M.[aUSr FS 5 E AO rtFl Dr ://tn Rtl W ACCIDEN MILEAGE CODE t aaOADDq atifR raCf a I R COII SqN rvvIXV[D fv[a IV HII6 aUrv ?SV IIAGE ? NO INlU9[D rq KIILLD M313N H,HRnDrr N IMEa RR 0 9 C9?3519[FT09 vlr -E? TOIAI NO CY VIHCIFS aaORR1YDAMAGf WIV ?pESUIi[D ?y?IX?rv! 91 OBI[CI SIaUCK INAMf OE OBaICr SI9UCK ANOOWN[R'1 NAMFI f51. DAMAG[ _C_ COD,NGIlSf p3?' yy UNIT NO. 1 UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ,l 3 D91v{a'S NAMF lASi rIa]I MIDDY aw19'S NAMF. I USr rl E Aooatss 5 srvFt ooaess QD JO ON /?D I7o R A I9 COIX aHOrvF NO x CII? S1A3{ D r A,t uc NFN q p 6 Wq /p.?5? 'S ?`S R ASt uz o If 139TH 3 Dv vEas uctNUHO /7R F S6T? uAIE Ul H aD 1 D 23 /5 i V E aIn uurvu An3e°vHONE NO MD i D r ?.. Ens Snlcrrl EaICNT .I ?.l r cuv rloN mNAMts VHOM NO fns WEIGH1 .111 HT N? l2 ?S R . u<cwATlorv N al J.. 87 ?CHECK I?) MHtiEAS:N[MVior forANOIHEe' ?CHECK I/) VFH 115AN-10IEOt ANOTHrn o9c. cu ' " ° 3 3 .:,. x CODES ?' ] 5 ! e s oiox'9„ S 3 . rlN CODES 7 n u ini.N $ N N e 5r ' FIM:.° ?.AA 1 ? " DM A1' ? bnr. Ki ? D v NS ?w °Q ?E8D9 ?h HVtA1Po 1 H v 1 IIDAa .NOVAS x ?: v Y tl 1 z H rtA4 AN ttoooGtcnfv,l SIN C.. V.I srr3l lx Da c El loAar.NOVAI Ca R E p _ g /. IXoa uuNU VIA tN vnATe NO. suf J - - H I vfH Caoa A ° S Wµl CE>vSSb A GA C vtHKIE,DFNIn, A rv ,; MHlnelawDlcArlorv rq 11 P3lS /-'N1151PI 6;F Jr'EI 16!yij L ! I 9lGISR9FDOVYN{a IASI 151 MIDDI[ ngNf NO 0 9 SRP Wrvt9. LASI na5r f OU Z' W A NfR ,. ° 2 A111111 -11 N E ?- wtssamspvArxlco oACENt NAMla.O rx? f R a ro i ? *Rpm i IARV' ? a DAM•cro •RU > p'"'ci'O"" m cHAau cHAac[ o M: o."uRI • s ro s DArAACf Eu ? ADV'AV []rtMUNED ?,°livnsr ?v[MNN[D fu.DAMA t 5 1::ort:' DIAGRAMOFCOLLISION: NAI NDrcArF NOVrr -t--T-1"aflu?tyssunF I e I O ' - DESCRIPTION OF COLLISION Iln[slarnrAUM s3afrrMeessA rl L9 T76771?°._rK/4.. - r ? ! 1 I •? I . I4 N4-7-14 req- /9 (SL/GY?!T ?aW_N..ty1Fl? . ...CUKt/G ? _?T ?O!/J e- /?G /!'1J/d V._ . ? r , T t '' . Las> . _?on.7iYaL -rA!!?/9E7 OFF__.__. _ - ?. .. .., L . .. ... _ , ?Nc> . /PaAO . o? TNC- e? T Sat -- 0 3 5 , 1 l ? ? ff.. ' 3 4 5 e a ' PERSONS NAME, ADDRESS 8 INJURIES OF • S. INVOLVED uI CODES I - Z ? _ luu ntvnn I sw OCCUPANTS/WITNESSES NAw raw ADD r oNU 1 SEK of A rAllrs "., ' ( n11o LAO I .' f-t'+ °! /170SCR /nAA°GA/PET ? ??.5'- 08? .°+0 " " U'1 _ Arts TN/I.lsv/1/ .rA ; ?Ame ?rc. ? ? % I..Yt. ?' 'I I r y Su I M wA.uVto rV v. ?AVA ? ' ?? . ? r ? : r , yr ri i; <?T s ' ! . ,M? ?.^. ? .?..' ?: ci D I W AI P.r3 L? r r.. n. . D sas a P V Of p'4 X f / r ws, xa + "? ?p ? ? D / ? O o.rn Has k 1 ??6? ? 1 1w Sx?, 'ti i !?d ??,T7h 'rl?$gSYI{. b "' ? ARS "., ° " of ,? 'I 3 7 AS T ?tw4v tb P ?royr rt andl cif s?F7 " t rf nkn Z`! t I.r t 1 1• ?ik b S N ?Y 7 ( r f ? ? ?? ??t IJ a J r I :,tt d fiR ? rL ?' E T 1 ? ,,_ I tttt^i 1 ; y tt f? ? ' 1 ? T' d fl{ rt ri, ' M IT,IT ?4 0 his ? " U O I',v Q iO I.:'' N O tII,,, r- LCI M C O O_ ¢¢O K 1 . a .. _. Ah ?VlFY? 'Yr'?' .. I? ??.f / "KS"wl` ? ? ?I('??r;l;; RAGE / O, / I Nn POLICETRAFFIC CO M ION REPORT LN TRAFFICWAY -11 FEAIN,NUVSER I q PRIVATE WAY - p t.GE, z I ZGal LS 8? ..--,. c IU$E 3nXppME HOUR) WAI i p iw T,., /SZD coUNrr f FFFfSDV E6N0 Of S1RFt, OR HIGHWAY A O. 7;* i H.l 5 NOU,F ORS V rHwA ? 4D Ru CIION M ?N C&E (J IN C OR )OWN / Its ?S ?I" RD, Po/T Gudlo3J ON dEJB !3 Pal ? ?l p SO3IPa M E POST INIIRSECTIFRG Wt 1H. 11RIll OR ROAD NONINRRSEC110N n?J?? cc?? BETWEENO"leee-- fo SERFfI B.A•&1 LMS SIR[f, IREFIX f ^/ R D•R? 1 I DI?NCERDIRE ROM Rfr[RENE.CR05551REf10R FA.RiS-u , I mrt[5 S t W FEE, OF D. A ACCIDENT MILEAGE CODE P MARAMDATA T IN _C,_ IN _C,_ RE[IOVp[REf[R[NCf 1 S COLIISIONINVOIVED' LVFRIir: SVRIAGE ?HII6RUN O RED 0 w"alpl" IN 1 x -ER - . INJU - T O XIIIED?N O,AINO O"'Ictfs ? PRORRIYDAMAGEONLY ? -RIT[D ?B[°CIF SD OBJ[CI SEeIICX INNAI Of OBJICI SiRUCX ANDOWNFR'S NAME) f51. DAMAGE SPfCRLL CODING IAE UNIT NO.1 UNITNO.Y M ?VEHICIE ?PEDESTRIAN ?PEDALCYCIIST US1 T- S - DR .Ii NAME: USI tIR51 MI DLf S IVEi L L ; T o IRSNAME: D • , SEREEIADDRESS REEI ADDRESS pL ?Sl RCIA&v OASon CIEY 51AtE 31RED PHON(NO. D IY ,An IF E / or; [ LAJ x/37- 93Z R DRW1RS UIXNU NO IIAII E X I R' L NsE NO An DArt r RHR - L57b LSZSL 06120 ?yR I pA «b - OCCUVAl10.J NAMF6 [NO. tr[s SGHI [SIGH, E EYES IGNI HEIGHT OCCUPATION MNAMEe NONE ND. B z - /u ! R CHECK 11 nHCEEAS:N[mnorfEaANO1HFRAL ?CHECK(/) YfHn[ASANfMnovE[oFANO1H,aAI YEN "'O '731 IS- CODES"' ais . i iii s L oN / 6 "s',° -• N" K o' CODES P' 3 n . i+ 5 u- a s n" . " Z IN, als r N -9 R F 3 =71- 0.,.RM.Mr ? V ? Eg.IR ? ? "p. aor pN ? N NcI O aio ? n,,. ? x:211 ?,A ? Dm vEH YEAR MAXI IDOO<f CHtVI A,ODtLIDAV1.RgvA) 51YU I3DV.CMV1 H[vl MOIXL(DN, rvOVA) YG 1 Yl l «? 1 79 MEee Mo9 ?/De E 6 Y sun mR n .. No - H -11 I H aoR a F7SFF 1T A I A f 6zv K P /S w F I C '° 38 n nlnIXHnNCA,NON o. L YEMUUIXNnII A N I I I I /AJ! 31 L I I I I I I I I I I IXf - RIGISRR[DOVM[R LAST NRSI MIDER, PHOrvl ND. O I wN[R: IASI 11457 MI SAMff w ADOR15saowNlR N fR 31 E ?_'.A.EE_CF'NSUQANCIC0 NAmfeADD MVINSVe-10 OR.Ni O] R Nurwl..F I lea PEcK S£ -. I wA - DAMAGf NIA J- AREA I:.;<d+N CHARGE . D] -- cHNW ,oE •S E31MpAMA41 ill NIN ?eIMNNlO ?AVA'Y'J ?@JMINlO 151. DAmwGt IGiolio? J ' ,ueonoR SYLXID°= {? IOWT.A'fYDer IGIrSONI gfOS. ?:w'A'v BY: S s - = DIAGRAM. OF COELISION: 1 Ew NeCA,Ip IH DESCRIPTION OF COILISION_ IDS, s--NIAL -7 IF NECESSARY) VEIL+._§J®._fliei 3A. 1?1_Vth_k2fT Pd.W. E/8?kfa_ if. ?D : --R ? ?-? - - , , .• I+•.r? ? __d.TLMJ..EJ__.154:._U.U.;T±?s-C__.S?yd+!tl.._ ' - - - 1?/ - ' C-i. t--- A ?.t, vtJ u _W 8.5?,_c}S?e?3?s_. Scpyae ?r, y _ _ ?`` -t LLI 6 sk5 wwl-ro }?Rt„? s?..fder%1?> _ © cnhalo.? ADDRESS 8 INJURIES OF PERSONS NAME "E " INVOLVED CODES 1 - 2 4 5 6 , '" OCCUPANTS / WITNESSES is" l .Eiuu+ASm t ii i iu R t_ i '".,?« uir nsn iJICi o1CY NAVI L Lf L :,o' Y37rj3z9 17 - / , rO . Auw.. NA,DRIa 'T y . _ ... .. ... .. . ADDRUS wroR,a ..._. . 'P• • R mwmERUm -"' MI. .YY Nn. pAMe OT. ? ? . O A ??• Pr n - AMI ? ? EXKI GSVA?CMI DAII b?vl. SNnVE AR.H. BA;?CA OP r . • v . 87 b' rl?j y`,?• - yE R' n? ,T 1 f ??'?Jl E y 1 '7f15,F( n'«.o f 3Rd"? nr"ttfzu ri,x * 'Cy { i l J >' R H ?4?A' ti , 1 .1R J# 4 Y r 1 s lix. k pA?l(y T d r 1l <, hL l.C... +fi: t7 i T y 1. ^,-•?F t ,? ?'r Ili y i J ? 1 1 rI t ly } I u t '';I L° ? I 1 f r f .?s 4 ,.r?).,ayE r f .I1 Iy'ti' p i} ? i H]u ?S 1 j1`. 77, STATE OF WASHINGTON PAGE r GF7 No 1 47 17 7 7 z J` r m q Nv ya: 2 POLICE TRAFFIC CO NREPORT ?TRAFFICWAY out wmi"u eFR uE Orca N ? PRIVATE WAY w''_ - it 1 '[]bDNOue, COUMY COUM CIrv NO. fMYA QURB 2 e 3r [S QS Q Op TOWN N flNOO SivF{r OR MGNWAY M p DF 5 ROUrf OR SIVfF C / U M pN INIfeSF<IING VnrN: STREET OR •D NONINrfRSfnb sGt?.v.?AG oLb G/J? P 1.1 1. 11 pOSi ° BE1Wff ms AN<t r S s+errr a sfR([t r RE R N ' .Ce01551R[tr NEARtsT Mllf ACCIOENi R _ ?. ,. RAMP DIAGRAM IKIA S E W of o/ 3 MILEAGE i FIll COlll$IONINVIXVED tv(RIIY. //??, OTA[NO NO SII [DQ- -I 9[D? 0 Wkll E QMr(aUN ww'd- N1 V IN .0 RSEC+I SR FI RaOAp OR R[fEetNCE IMF C'S IN CIIOSSSRt[i OR roAp ?v O p I Y p VlNICI[S Pv Q F 9fuITED O v[1 CIS 11111T 5 NAMI OF pe (CI SIeVCx ANOOWNE9S S 8'50 _ ? 9 NAMfI [31=µ AGF .?- G/l'Sn..? Co T s SRCIAICOD... 6E ' ] UNIT NO.1 .-P UNIT NO,2 ? VEHICLE Q DESTRIAN ?PEDALCYCLIST 7A SNAME: IASi 1,451 MI E DR,VtR SNAMt U IR sr - - STR[l1 ADDRl51 ?? /J / / G/? S/ca JG= srnrt p D Rttr ADDRt51 ?. :I eou nl a2 C kR'S OCINSt rI STM[v rNOlve NO. n 7 ' " R nr s1ArE E /.? to `K I` ?r.? MD I o.r I V I u -NO. All DA eI n +u i o•r I r. acuvwnoN MNUntsnbNE NO. rts IGNr-GNT E XCUPAlloN mNAMEa PEroM NO s+ X3oEi...)E; u s %o r R . fns IGNi .-T - Q CHECK (?) nN,nfA :NUnPivr vor«[oAl CODES P. 7 A ^ ;;"'LA .c,c(L. AS ' 6 ?CHECK I?) VENICIF ASAN EMriorr{aw m[aA` CODES ?* G? .^ stA n ? ?'' 'n lwrts RI N ro Slid ? M..N I Q N vfN rlAe " MAAf IDOOCt.cnEV I f MOO[lQjOwe?' AO N-11IR . AM 0 r?[AR Q `?C1 v ? V O ? KO O;: n I l r .r+O I A1 O f EN 7 STATE TIAIL11FATE10 STAY H vtN. aoe TR[gsFe-;IT -5TT 7E' ?IJLt C I , VIN It IDEMINCATbNNp C VENICII-11 I A I el N O''o efGlSftat00wN[R NSl IIRSt Mlpgl PrgNE p10 L ? i ?! I I t I I I -' ??E ?? O W D WNI4: fI451 Ml Ml N ADDR{ssaowNee A WTIf N L Nun! a Aoonus a RrwRANC[<o 09AGfNr E .4 •AGf ARlA . - S .J , rTo, aid 695 uS.MmD I ' ?- R D ' b ,I..ao N a w?br°MI g•MAGDMU cNARn - C.A. L A ? t,? 5 t1 DAM ? °SWAi ?RF D D or ? AVGV RIMMNID lsi,o6YACe E nop 5 AW D i AY 1Y f IdiorioY e /lI - a DIAGRAM OF COLLISION. .SNIIF rs IctsaAtrl I a< ff l" DESCRIPTI ON OF COIIISION: lust stAFUMtM SMIIFNln11Aa 1 -_ ,Y / NAME, ADDRESS B INJURIES OF PERSONS I NVOLVED * CODES L - Z 3 OCCUPANTS/WITNESSES Fa AOgib NUU • . - S 6 N l •M[ b s[x ACS teru '" ' nsn fxn " ........ ... .. w A - • N Dan+ O of a .. . MovlO noM QAMe Olo,el Q,r, , O H w. •D Dpl51 N •r .1 r enurw•IwGaPKI.1NArl u•Nr a.DG OE n;,E NC. " ? f l' s rNr s. Q•M.a O -NE Or°:rl (A: ? ' i°" x O o-li i of .3 auD c t0 o sG Eq,cupenD asp G D•na ro•r AnrovtD own /,ti3? E n E,. L" ?, L t r L i, , I, t 77 ll h : r ? T r y 'k,t? r j y r l )1. w POLICE TRAFFIC CO'9ON REPORT LI TRAFFICWAY .?,c AlmwumetR PRIVATE WAY Z D f COIII _ NO i ?... ?. ( : ?PIS.?. I t H.'4I. 1 iM[ (USE ]RN «OURI COUNIY ?2 Ir CItt HO. ,. ': EHWA ?U AN URA ?N ?f OIN c- R1Owrv -1 IF NO Oi5lRftt OR IRGHWAr . M,ITS ?5 ?w Or ON CIC RWIf OR I SFCI n INI-CUNGVeI«: sletll OFF-D -INIE .11ON eLrvnw ?dI ?? srRfei Hx Mnf POST - '? Oi ANCf DR PoMRf f rv t. KRDSSa1etLl NtAVfSI ilt ACCIDENT RAMP. DIAGRAM DAIA Milts , 5 f MILEAGE , ITT' Or CODE ' 1010-NINVOLwD [Rite: TOTAL NO NO nll[D?NO.IN]UR[D? ?SPIIIAOt ?«ile RUN OFIF-CIES FROaRTY-EOMY ?F[SUII[D ?vEOCll r- xD iMtR Cl5 OR V1itRLNCF YLVAD CRO-POM -m-Tv S SD - ']] OelfCI51RUCR INMnIOr Oe][CI SIRUC[NID 01YNf R'S NAMEI LsI.DAMACt l4F Al -I.. __ UNIT NO. I UNIT NO. 2 0 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 3r L DRrvtRS NAmr -1 NRSI MiDae Dervw's N:MF: IAV i l Stet[t ADDV -111 ADD.- sT.Tt Coot r«oN] No. D Y SAL iP N r . S" ay; ;A 28 / R rveesuc rvse NO ' A A I H 11 1. 1 1/0 /O I V U eN No. A e x A f? eiR « , i - _ «CDPAnDN c [•PrIOrvt NO. Wn HlI GHI E OCCUPANON MNAMFf PONE NO. fY[S iG«l IGHI Z S' u ? C E K(? v Haf+ A dANOIM[P l ? CHECK (r) HCl[AS AN Maorff OPA rv OF. yy ` I CODES 7 n.'A + i in S r p eo,°r' CODES 7 ii • i in:."I S fe xIN a v 1O'c'cu .'Y] z : u ° o C) «A ? MIT n Cartl ? r wMy°' ? M ? ro,[I ? zsN ? w ? ?. Ku h« ?1AIF Mwu IDODGF.e«ev.l tI IOARIF-A) SIYILUDR.CONV.I r I NH v.l MOMIIDAR1.NOVA1 l .1 _ m 9 /f E Pen T N ?uR a+n NO sun H vt« A K«IDLEIDtN AIx HD YEHi Lt. N I . A Z i i! t -11111DO-111 IASI nesr MiDDU ?, aroNI NO W W*+ less NRSI MI - a ADDass or OMAR N W].R i E AMe •ADDeaso mwe eo IIGIII DAMAGI ARU R u OF? A-1 A""G' ARG ? 4 ,? RYO. Ibiono:i ° ul. cM..?AU n??N ? ($?RlAwwo ? r ?I-.ID rD.wAT AMw a ? no. rro.; s S r?Der owtD ? AwAr er: s • G?LLISION tl It s lry r+;e uoel DESCRIPTION OF COLLISION; (1,31 P lewrvru S«EE MCl Y Y1, .. ? A 2 a ' O 0 -? ' m - 6 i U6 GCE T 1? , -0,7 ;- r ® I o A,r 4,ay QuAn Dicib OfF -- 0,c o w 41 e ? ' nT. I I .I I I ? I 1 I I D uh'Y . _ A En.6P.? ? E NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES 1 Z 7 3 3 S 6 OCCUPANTS /WITNESSES Ipb0,11ONg H S1 H[ AG/ VAT - wMw R•' - nsn era N+w .Dana °' +M e O W, 0 M . ? H. C.'w +MI ? A eppR151 hAluelp - RMOV10 r•OMO• ?N+tl?,+UN? ?i.?xH 1- b NO . 9 NM.?Iol +tM•I5 .Nnl ?AM ?.D,<. ?[o.a. ?.fL" ?'i Rv . X w.L>I(..r«,D ry.{IRawweR.N. r•ouoa +GI NC. sic•I ac ?'wD ?..?YTD R..la Nro.r A...oaon I 7 _ ]+n«. ].oo ? r 1 7 F P e 1 ,. i:7 R STATE OF WASHINGTON Gf r Dr 7 I RR . N - POLICE TRAFFIC C ION REPORT ?TRAFFICWAY o PRIVATE WAY ru r .z ?'.•' o.rtoteou s?oN _ w. rv rMe eourvrr v; t.. -''r ,; _ aD ? . ?? f v. iN L? IUS!].D7NOV91 NprttY CrY tK3 FHYIA ?? ?;'D c ?- 1 f+ ?N IG• ?IN r09 rOwN ? N {NO O.SmFF109 µGNWA 1' ? ? ?µ ' ?'? ' :: ?T ? 3. y MlfS 5 ? OF ? ON Wrf OR 1 f, t?q0 @ i sml wrevslen"e vArN. ero9 .D Norv Nreese I SG?r?.9G oGb G?? aliwtlN S sr9fcr Nf t rosr s ? ` S s } ? a / Smu t ,° ;, •• ANC Dv d+ 9 [v N ! C9055519t1r OV rv[A«Sr Mnf 5 ACCIOENi RAIN - ?.? } 0 OF caulNVOIVm. Htvf9nr roiAl NO omlro No.lwwtD? ?snn`fACf ?"ra9 ,,,"'p','?o .. .. D sE r9fE 99p.D O9 fafNCf •-5'] f E;r O VtN Clt3 .vOR9ir D.MAGt ONIV ! SrQf ,? ?.FSUIrID ?vFNKIf p3EDr IN Ip.O ' ;. IME9 QS CgpSSSmtROV 9DM - - D ECr Sr9uc9.NDOWNIV'S N.MfI ? ev=A«ACf -? srfew mwNC taE s Dent9sNAMt. UNIT NO. rr9sr M ! UNIT NO.2 De e ?VEHICLE ?PEDESTRIAN O PEDALCYCLIST ..3• wl sNAMe: usr vvtlr.DDeess - o r '- `? c•wc zl. cox 1. NI NO D r ,I . SrAIF I. S R sectNUNO / OCCV.ANON _ ?d/2 MNAMIa ONENO SI.If I Nt TI[:Tti}?ryp ••• .D D9 H? V Arf D. Ew piv ND i _- r[3 IGNS tEIGNI E «cu..nDN MN •Mf a.rgNE Np . Ens IGNI .EIGN - a 73oEi JG u ?o R r - - ?CMECK I/) 'wN2iN a re .N..11I ?CH ECK (,l) a o ' • s r CH 'rt"'cfl.s •N rM. rtt .. CODES?' a ;,"L CODES a s D .c.c? 7 • i s IA u ? - n . e N,uwrts _ ;a M - ? .M.w. ?l ? se<' ? C"& N- ? "..•I ??; pwz:r ? w vlN ? MCI ? ?8m O ? r. , «Aep nlDOZCCwvI MopusDA91...ov.1 sr.u l]o9.cpNVl Ku r 3 l .1 1 vl SIDAe .NOVwI Mo•. y srAre u. n.n NO sl.rt H N a e vtN ulaNrlNC•IKSN NO- C veN? uluN ? I e1WSR9tDOWNt. tASr /I.lr Mippl .MMNO I R t ' I O WNtR: /msi MID NO. s ADD9tss c.-1. OwNty S/ N L NAMIa ADD9tssamsueANa co o o9 AeeNr E e2 01_1-1 r6, R 9 .N N weD •et• as e ' " -- n ' HCio"?' CN..G vEV4mD JAMA4% K ' CN•. rwCMNN ' ID IF ROM > A- ?.1- D ??W;: Drw«Dw: .10. ? y} ?.ewMNto em DAMACI S 1 ?" :... Ibiono: / .w.:e . G C/li .?X-si•? ?w?: ; Er= DIAGRAM OFCOLLISION? <A«Np.rN DESCRIPTION OF COLLISION: 1.1 SIS-Tk 3KIT IF NtassA.rl a9ler ieeii.ir`I a ow _ - - AV,, ex 4AL NAME, ADDRESS 6 INJURIES OF PERSONS INVOLVED + OCCUPANTS/WITNESSES IF-Is "-IN, M?ii' CODES 1 _ - - 2 - 3 '?. _5 6 .Ml Slv •Gf r•i .t Sr. Iscl .Ub15f .rs .t O, A w ? O" 0111 ?M ? • OF o '• . MOVID mpM ?A.. ?.w KI ?.4 . ? N ? n° 0 .MNlf N N•??. p. - N.Ib.G.r.NiDMKI. SN.rr {v. N. ..p p. f r I 3 1Y N s. ?.M{ ? ° l?Cir•r.? wa ?121i1. 'C ..C X . Dji. nir ']?KICS..•C•ID ^OrKI ... MD D.rl Cr I.O.. .rr.OVlDa. D.rl d t i 1? ) s E .4 ? ! I"r, ..J y 1 L ? zu :w Ir ?' i r ,' a A yvs f I. Ir?? 1 cn '1i `-w,RYr r ? ? a .. 'RJR ? ? n ? ? , t T _ ? - f F ra' it •k C??I r 1 I , ? '?"' ?tf141 1? i Ay. 1,:1f 1I I '?? ,? I I ? 7 C 1 f ? A 5 ,T ¢?? r A 'I,r b t' r?' I!1 r 7 ?? 1' ? ANY- C 5 I: 1 I i I ?: r r tit >,' I r ' t t "4r,?. I ? 7 (f( POLICE TRAFFIC CO ON REPORT Lai TRAFFICWAV MiNiNUMBF9 Z C PRIVATE WAY OM C 3'67 IIMf0o j lusfJ ?.I Ai4I :I+,i MO NOU4s ? COUN+v ? ,,, _j eg,-c l I COUN [IIrNO . HWA pr ueeAN DRA i pN f pIN C Ov IOwN (SNO O[SIRtF10RNIGNWAr to (5 ?5 DI ON 16m Cl Ls M gOUtf ORSIY , IN,lRSFCIING SNIN. 51REr1 OR ROAD NONINIER?St/C SE , ON eflw{tN ycF-r[??i? 1.t E{o. ? 1 !O MIlER03, I RM Mu I Rfr(4 N .CR0355ivf[I OV N[AVf51 MR Mots 5 •7 FnI w Or ?, Av. ACCIDENT MILEAGE CODE MR DIAGRAM DATA - CO1115101 INVIXVED v{ N +O,AI NO IIO IL11D_NO. INIURED? ? oItft-t ?NIIt RUN x lx %.RD IMfq. C[5 RS( II OR gOAD04 REItRFNC4 V ROIip CROSSS+Rt[, O CK VlNICI(S prROnvty PAMAG{ONIr ?-11-11D ?Vl.i1N -? I/ r J Q Q 0011C1 SIRDCR INAMEOr Oe1tCI514^UC'%I?NDpOWwN[4'S MANE) fs1.DN ' SRCIAI II--A UNIT NO. 1 UNIT N0.1 ? VEHICLE ? PEDESTRIAN p PEDALCYCLIST > D4lviv's NNAE WI 11431 RWf45NUnl: NSl I MIDDLI 3,4lN wDDRt53 igifl ADDYt35 r '?%L C ?I? ?? coryvy?t NO. R nr A t I DRrvtR'3 VCENYN To 2efgpe-Z SIAM tivA. ? 5 '7/ I V Iv U!N NO. A N R occ?u-;RAf,1o.N NRM rNONE No. tpn?s 1,<wnI .NK T N ?tri/7lZ11ifd7 L1'r, / S E CurAIIDN NRM N•M1a-1 NO Ens Klcrll IGN, CHECK (1, ," iN wriv rM+O A ? CHECK (?) vENI<le AS AN Emrio r No,NfaAl ' CODES ?` D ;,' s [ e u 17 -1 CODES ? T D A; s FA a ,A Y FM carts SS, B -All ? ? a. ? ? r p M t .x 1 ? ea:D. ? " 1.1 ? N ' V(N rEAR [DDDCt.Mtvl 77 .?1T ,,}} I.NGVAI Sl It IJDR. ONV.I O"2/p ?+0'?. E rA I MOt%t1DAR,.NOVA, r I NO"' Je g N. LGI. ua?Nf o p sun Ame nAn NO. lA f H 1 C N vF vtNKlt IDtMU1CAIKIN NO 82to2z8?g1 L vtn Cl( N11 AI Remsnge?ooTw++e4 [ASl r1RS1 oou ?? O% /7V ? rNON(NO O f wNfR. lw ers, MIDat 7 x . V W D ADORtssvowN(R F5' Q P S4??E N INER . i s _/U6C EE AN(a A—- O--All CO OY AGIN, aKr ?? DAMAGI AKtA "w?b`^' [NA.Gt D,..DNDI . . g•MAG( ARtA, aA4G' ? ?Nl "' ,D. 15,. DAMAG(en w'; N as :. ? ? RIMAINID i o 4,D. RI EN (sI. A AAGt ? ^ w•r paMwN(D 10-D o n eY.. (l,?jddJS 5 0 wA, ev: r DIAGRAM Of COllt51 N. ?', u'ilecisw,l evAll-IN - .? - DESCRIPTIONOFCOLL151ON: Ilb(SUrrLLMIMAI SwnnNtaswr) UE?ItQCF?/_ ZUGS754111A/.d(1tJJQ'?le ?.__? ! 7?'._.? ? _,QCV.?1aa? iuro ??vy, ?ocuuG oaf. - vflr .. .CL?/Ud ?n?rs?,?suifs doidG .?-Sr.P,trt? M SU,QE . ?T E •. ,l OG1';iff s , ? , , l?Ca, 7` 1o1rtO L1uG/EA,OUrrocy P/?Oxf?H _ NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED 1 CODES - 2 6 5 IN(slsn(A+tN+usN( OCCUPANTS/ WITNESSES raADDngNU.-I L, ,, S(% AGE IAI x D•,p n5u ?ac? :,°;. NAM{ fl vi95' z ND Odi- 7o/S- 7n z --? Aoo4ES5 ?6 O rla E Al . $' p ^ . C) p :: 'M' 37 zss7 z •DNI53 / d • WvlD rrpM p•Me NI p,vl R ? N ?i.D " b E J?ViJ/ 39 7 CA z •nalx i D .?i,T°l5 sv •M. p'E°'KI ?.'?. ? :1. X rlrLE.uN. 4p•AG[ a3y3 p QJfxT?6 / p D•TI/% •r..o De o±n If W V A 1 P, f x I I L L a? ; I 5 P ? a A? I rr''•_. ro L l- E STATE OF W INGTON OF PAGf POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY L N J U sP PRIVATE WAV .ou[orcau N ilMl: MO D ,.. Y.. qY. El I couNrr ) I• -_ _ alE x 'f•r IUS[xbplwURl ON ®E ?IN CITY -0 WN NAMfaNO. OF STgfElO9 HIGHWAY qQ FALFS 3 pW XOr ON _ PoucE CE..,_N COUNTYNS/?_ O.? aIYNO. iL1 3 ROUtf OR Srgf O [0) 1up AN RAL EEOIIDN ?d INItgSECi NG WITH STRFFIM WAD NON NTERSEa ON nlEFl% EO BE1\VE[N DIS1 . MIIF POST / J? rRFFi igEET 5Lf ANCfaDR MM1[S igOM RfIRE E,CVO533TgffTOR NfARf3TM llf IY13 ACCIDENT RAMP p'AGRM1 Miq •?L «Ei W Or MILEAGE CODE COtUSIONINVavFO .KIN1'. fOi•t NO. NOO ItLED_NO. NNRFp_ ER C11NG rgfF10R ROAOORTdifgENCF ?SPIIUGF ?NTaaUN IuMnO D?n ' IMFa %u a-StraE.-AD aVEM ClE3 N PROrtR1Y DAMAGE ONIV OBdCI31RUC%INAMF Or OBI[R STL- ANOOWHERS NAMFI ?f."FE ED ?bF°'FlF Q ESI DAMAG EE . $ E SnC43CODINGUSE UNIT NO.I DRIVERS NAME: Usr ngsT UNIT NO.R UgHICLE PEDESTRIAN Iptx RWER SNAME ws'? ilg? PEDALCE CLIST - s x R E e l Rtss ? ` l M E "? }? ? O"' SIA1 O ITV COpf sinN pDREU D I PHONE NO -s cl MNfR'3 u<tNEF NO . Y MAN IP F vHONF R ? . IArf E% ?1L ?Z. rr- OA I Wf' lKEN3E Igrf ATE Or eIRIH M D•e .Hrv. V I DAY IYR. OCCUPATION MNAM[ a VHOIIf NO. r EYES GHi KKiHi E OCCUVAIION i q NAE a PHONE N0 EYES WEIG T 1 I H NEIG l O R ? CHECK(,) 'vlH nr qs:N rior AuorHta'u EA 0 CHECK (? A v i O ' CODES?* D n:ss A isn 5 uiel oN EMP o EE OE AN THE A som°e•eu? CODES + v 5 E H p ?'ox.oe np S x IN .1 WWII,- ?.MNA.KI O b:.. ? „^..II ?".° w`E p N KI ? u ? '. v O?HKII ?;:'11 n EqR Y "U1 EI000GE?CHEV.) tll i?NOVAI ?2 FoRn Si lf Ixpa CONV.) YfAR ( Hlv.) 10 i.NOVq) r I V.) E Y IIONSf Vw fN suit [R MTENO Z- H vEH caoR ?" N• . I nlpauaxG Iurlo"rEO. C of c MNUn L P ( 2' RtG ST[R I l ! I I FOOWN[R: IAS1 IIRSI MIDDIL PHON[NO. O Srt [R. IASI NRSI MI aE ADMI350r OANlR W • ER N ` E NAME A ADMESSa INSURANCI CO. OR AGtNI U • R AM-I -It pS•xING ' -? elor ^ wr . CH DcE CIE. [ O momo gNAAG[0 U x ' _ S IO eOTOY l31 DNUO[ ® AWAY ?RtMNN[D K " R(MAN[D AN f31 OAMAGf etOP ______ 3 I f :w vpeY: AWAY per: f I000ri0ii DIAGRAM OF COLl1510N 1 u I sHUIUNEUSAgr) NOR erCAAR eowTH ? DE5CRIPTIONOFCOLLISION; lusESwn[fuNlu swUUNfussARr) • ._ VEN. k..l WA6.-FASTDowaD .: :.. ONR RD- . WkAS J R OEAJ SUMPED ONTO.I-WIL RDPj) - AND NtT THE R 1 SE S g c LG ?T FROtsC_ CGRNrcR oF..U6H.P_- k ? .. . . A 'I ... ._ 'l . VFcN. l...BRR1G60 AND ?.4.GR' o?t RpQR i + -. . , . ._. 20 F'r, or- S1s?nARR?cS E 6uT'. W DS UNPtOL e- llzl ®- ? _..._. ? AWzo -rAe cmLSSSOQr DfAR''r X _ NAME, ADDRESS 6 INJURIES OF PERSONS INVOLVED * CODES 1 2 3 4 5 6 pu" D^ VAN. OCCUPANTS/ WITNESSES ;a,' Y1x , NAME AGE wrus ?E RtsTR. txCl ,; ;p NA EIis qMl i+o NBURI OI " rover. OAM e. ?R1' O "" . ?C.; ?i2',.EI. ADMISS w NMURfa MHE IROM OAMe. ?nAKE (]? . ?M ?jb -11 1 c <IRS HUU aa. egocr or .crrxc. NAIU Rtor EA . ecrw er ?AMI p'c`"KI ??o:n. ? :iJ ?".°„rP X , N- aKEpnrATCwp ?OD?e? ???5 x•m HR p•n ornroal A DAIr to '3o S7 xl kll+J f ?D `Mt U . ?t xe a - I rc{ ?vt I 7 J P;' y,77' n? ?'fs-(.?. , 1 ?L h ? ?,r F 1. ' • pM k.', SyF-+uyµ?-yy1 Y ? r! ?, ? E ) . , 1 I 1 ? 1 v ? 1 5? ?? fr?7^,h ?i Na E U 4m ? ? 1£? ? 1 Sf t ' r D ? I I EPI ' T r - II f ?,' l 1 ?,?? ?: 111 L t! ,s I ?. V L F. 1, F'N I? ' ' I , E I31 Itl y `"? ,?? I) r ? + ?t ? 7 1r 4 , ? r I of t ? a ti r. 1 (T? ? ' L E , G t FL, r k A bL, lvY [ 7 ., 1 1 5; . Nr W? ?? a tp 1? I n ?rw 1 POLICE TRAFFIC C ION REPORT 4TRMFICWAV s' POI; NiNUMBER 4 PRIVATE WAY -PAr L,9I S01Ll wr lwo..I;uH wl9. rL. n.iN tOy I o I ?ME Fv.ouHouR) COUNiv o E? T-vl' s6"3 CgJN1YFA. 'EE?^ CITY NO. iHNA Ou enN wRu jil. pF O'N ercOR lowN N-NOpsr9efr oR nienwAY a Raun oR e•;ti Ml[s ?s ?w oP QN `j 02y0 ..... wIER3FC1 NG Wrln SlRtFrOR RpAp NON;NItRYCi;ON PR[N% MNEIV51 ?? /y. BFIWF[N PRIN. `c "I'll 0 II ??,f r ` pS nNCit09[M? iROM RfNV .CROSS S1Rff10R N[AYLSiMiI[ ACCIDENT ;I[5 3 L W MILEAGE OP CODE P RNApniA - CIXI lOlAl NVgVfO NO SRII[D NO iNJURt ?SP IIAGF ?HxF 9UN IOIAI NO (?'? WvMDi" .... Oi V[nKl[s ?Lj PROM Y OAMAGFON i % w IMFR Cl5 WOSSSTttROR ROIDR O4 nlEnNl1 _?5 Y I ? R[SUIlFO ?vfp<lf ODrtCT SrPUCRINAMF Of fCl RUC=JNp OWN[R's NNnF) E5r.0=AG! is sp, SRCLLL COOING IAf UNIT NO.1 OR VIR SNAMt IA51 LR r IF UNIT N0.2 VEHICLE 0PEDESTRIAN 0PEDALCYCLIST - L TJ jAQ, 9vfR $NAME. Nsl ; , - e SIYIIIA DRE55 ? SrPfFi ORf55 c; OIY 5r/ il SIP CO IX -NI NO D p SrAIF N I G? r ? U L43"i"2.7 Y JAS 1 R 123 5 ? NFf DR rJ K FNSF STAIL n N I FNSf No. V f • - OA[E e cs z M I' I ? MD 3 Y OCCUPAi;ON FeVHON[NO, FVfS R;GH1 E rigt Ea PMCWf NO. FYLS GNI HIGHi to Caakr IJ?I 2' R. M . oA i (o . p CHECK(17 VIH p1 AS:N UUionF OI.NgHFR I CODES ?' a s 1- 1 6 S=4 'L p-CHECK (.r) ?vFn CIf ASAN (MROrfFq At OIHFR•l CODES ?' 7" I x,^, 5 u 6 ;°• p . w.N 1 ? m° p cMm' p „.%T! ,.D.vv M DI DN C] --.NCI p r%CC D O M;.. p T .X"' la e • -- EIDODDGtcn[vr MOOAEII?D`ARr-A) pR•(}^CO[-NV.r Iv lcu- ? ? 1L v) MODEM .NOVnI 1 v.l ? ?'^?n s? Y?- ?? n. NS f VIA $IAIf I-- Mr[NO. sTATE H V qo9 [ G PJ f . C ? H Ll kl - V[HK4;DIMI;GIgNNO. v(n CIF IDFNII{I a. I i ` i F B 3 f-I 3 -1911 1 D Gs R[OOwNLR: W1 N r .-I ADDnssLaLolnFR pgN[ND. _0-bZ O F s [ [R: l 1 11951 Y .. , Ai ZtKM;ODIE ?• 4? ) E .. Moe J MMIaAODRwawwRANCe eo 0o e ' o'%T- R rAHi LF ` DAZMDA lA aHNmO •? ' F lu"crgNU CHAYq ? , DM.PGf ? wirnoMU I AMAg3AREA 4 • O?O D? 5 l51 -.1 . Gf S LLL 1IqqOl .-N nM.MNfO p I IOM D ORMN .- 0.__,D = - - - " l3r. AMA t D OP 5 IU ICfI0ii r e. w A . AY .Y DIAGRAM OFC LLISION: I w ND' •qrn DESCR IPT IONOFCOLLISION: IDSFSwtt[MLNrAI SIR[tx Neeesu9rr NWTA _.sla- a' . _?ir_ ?0 _ Vey ??_n??_N?EIs_afl +- ?- ?-? _ ® _ _ - No . C?a??•L?Lr•x• N1mK,a[r?l-?oa0__lA•JYD731- 12 . Ver} 2 1 5 C+?r± ? )3 SHD?,a• . _ - -_ - __ ? 3 (1-1 l LeFf'l $r o:. OH }l's.,_UPHrc4:_?Gi1F?1R_. t + F I ! •,.+ , t_?_.?J. I 1 _ ?_. _ , 1. ovw ?t o rna -.?.. f1k _ LeIT 5,?. or__LPd.1 $jf`ul); "11Jc_ LPF•r._kP.alz._or.?H+!_1_.!?'S_?y__ NAME. ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES 1 - p J 4 5 6 OCCUPANTS/WITNESSES _ 1•IUS '"„'^" wv,'; '") [a L ?AY Mp ?'? . N D4.n Trr. . .M) G.l 01 ' . n nail. .Me 0M" p";,, per:° 6K.':6v o II L F .. 1? yaw 4an5 tXn ?1 •' ) R1D A7'! 9MOID,ROM N,1; 9, A 111N1 Rr ?•Me p„ plN -11 rIMOT* t r ' 7 N33b I -, ? S b!`E ?<T "?: is°r )14 s.wle: ?•Me ? ,`. ''p?o:? H" X •. v.gr3 rl ... N. ?? p0r? ??, U?1 Ups C«IG S}, IrST4 0.11?? Arr9pvlDpv DAtI L ) I1 1 4 ?:?tt sp 1ti u:+L??+°N^.? r^?hr.e 5.?'' .ilf?+t'??.. .?J r_,a ?x?"'Tt,w>. 'rl. i,tLi1 •'„r,^F4 Y ,}rj, '.' t I ???MjF i + t? t J 41 dj,Gy??Y?' )fir. ?'?Wr , ' h ?:y y r I µ t' i n ND(!? 1? I ?.r 11'i a L I I . "PA STATE OF WASHINGTON w5.159I+N.t.tR) . G( / 012 7 3 I h 7 N -}. p( o. 3 / , (.ql NAM AY c - - POLICE TRAFFIC COLLISION REPORT ti K[ -,A- p(?Irya-- PRIVATE WAY '7 f's Oqf OlI 1 l N nMt COUNrv ??? COU, CITY ._._w_..? .I wlnlhtN.l ii: ILi IU }^` J GG?/? -?I97 pUCly[ FIVW& V ON Qw p N 8 yl[ EE /? ° /34 r«GNwAY µ RwttoR e ."Is p or . t ' . ,l w ON ? IN [v5E<rlNG VntNStREtt OR VOM NON NrERSF<rgN J r+tU attWE[N Siv(tr { /?/nJG(?? STR[Er [?rp? -9 D v ' 'Cµ0555191 r NFARESI MiI v° MILES N S I i / r[E! f gCCIDENT Du v,w MtA MILEAGE Or /` Q.S CO(USpNINVQVtD? vt RNV: ' CODE - r01µNO NO.RII[0_?NO INIUR[D? ? 11 LACE 0Nra RUN OVENICI[S m wrv'pti55 'N INItP C(5 G0555m((t09 ROb ?'?O9 f t ?]l I RRpvf+rv OgMAGl ONIV ?%SUtrlO ?vf?iCl[ S o911 19UC{INAMt Of (Cl sI+VCR.WOOWNt9'S 1 -. 7 . •. Q?LFO --. [?-) 11.0 A -WIICODNGl6+, ,: - . . . .._:., .. UNITNO:1 IR's wMeusr ryr M ?VEHICIE ' ", p PEDESTRIAN-. ?PECALCYCLIST ORNF9'S NAMI : USt 5r9tHADD9t 2i L T ? ? ??? 2,. -1-T _- , gw9tu E _ 2 ?? 3 - ccn- iii2 - sAn :ncoa 9NONE w. D ? 19?5_ 379164 R: V ?as RCeN w 5Ar f Mo ! ? ?7 V l N Mo. I u. ' I ,+. .... ^ «curgNw r a .+M a f No. es 1 roNr E eu9q ION rIRM NAUt a 9NOrve w. Ens eNt N[wNr .2 c ..? /?S R ^ Q CHECK(,,) nN? l ° CODES?* qN mp [1 CHECK (q Ku qs.N non arq ve Rx {EEE 5 .:T . ? n tcrw:. wr .c` y ?N wi t e s' i s rv.. CODES ? * s >w. 1 y u no r, 6 sewn ' S ]> k L ' -i' 0 birr+ Q " M U Q uts "° :' ,yz. N nr a M IOODCtcNtv. E q4 •inul]o?oNVl w 7 Q"w' Q `8.n Q Q„ ?:,;,s, E mOOEII uR ? ? UCIN S1AtE µlt9 wAr[EA. 3 1 P{ N a F4 - ??Y n laNnrw = Krl NO. Cv eN?l N 71 0 3 F ?' / 2 L a %41Swat00WNON Utlt rIR1! MiOIX[ nGNE NO. I I U 5r ( i sr MI ! I .,ry. M 0 D la- ADOYlSS 9 W ?v¢v`' o.J 3 `IS # /? 3. q w" r [7 . i 1 d Z JDLoc J G.S- NM.1 agDO+tu a:NSU+gN<I C G 35 9/ N E f?s/1 ax ? y . G5' ' A ( O. +KrtM ? E qg{m -' wS -R ,':Ma l tik IIO•D p d aa?® 1°Iywoer 91M- LG S DIAGRAMO?F COLLISION: ?I MGEU i " Imlr - AA • i-I _ 1 -1 5 j I (- j l i? i 1. L.A I I 7- I I I i ?-, O~ NAME, ADORE & IN RTES OF PERSONS OCCUPANTS/ WITNESSES is eD''roroMaR?iu"v aao.ES _ . NwMI A -- ....... ...... . .. ACCIETEE NAM[ lji?w w¢s "I alf%-5e' V, Zed- v?/Y.T L?fr Tt? c..f -.1 ? I J 1 4 1 5 1 6 s % ??vgrr ',: r" e r. ?. B u x s'a L ' ?`f? ?,.B'14S g ?:s. R" ? ? 1 ., n , : ,''2+£..R•+ e .( -._ _. W: ,rx -?7 x , . . _ , .-?. .4 . .rl OF SHINGYON D5? • ? WSp T3R 1ev BDI ' 6 _ ??? jjj d No. 3 3 1 6 3 7 POLICETRAFFIC COLLISION REPORT {TRAFFICWgr pa,C[Cy,?A,N. NUMBS "? / • ? PRIVATE WAY - 0• !! f I • v i- ?" Bia lrwnju u9I coo"n {• /f 1 muNn ND anNa, __ .. r"w - . QN Q( QN iy'?C'?3?? 5 QW Of /'?/w- N (aN005f9([f04reGNWAY C- W( Sr [ 9U9A1 `fin A ?.r 11 D . MIE ? OW44Y/SG wrt9xarNCVaE :sr9(noR w tpNlNre9uelon "!roar eenvee ? •? uaeer a ?EA•(FJ sra[Er 9 Dr FaO, .CROSS5r9E NFA9ESr m„ a _S 5 IT ' / l. d oar 3 ACCIDENT MILEAGE coDE DI AMWw - CO'ITS 10N rNVOIV[0 vl R,rr: OiwI NO r10 [llEO?NO.INNR[0? ?Sn?lLlGf ? ? Nii RUN wMCnO RD 9WA009 HffRLNCf rN_ INrt4 Cl3 CIIOSSSISYAORaOAp dvfHIClES Q PROPERTY DAMAGE ONLY Q HSU[TFD Q (( v(aCIT . Il - OBItCIST9UCR INAMld OBItCr SIR....0WNF9'S N"AUI - fSr DAMAGE SRCW COD NG USE - f UNITNO.1 '. '• ,.: NAMDwr R UNIT NO.2 Q VEHICLE PEDESTRIAN ? ? PEDALCVCl15T a. m. - ?2 FEZ ? 9rvE9'S NAME: uSr T,ET . l 1 IS c5 F ADD [ss r srA a n.coa rrroNeNO. D r r wf R ne45uea N . A «D DAr' I "n ! I ? u N A i pAr r I v9 RR. «CUMtrON vM NAMFapwNF NO. ens reNr Le a"r E curA roN rIeM NAM[apNOne NO. fns re"r rewHr R Q CHECK (?) s,[H l • North n: A ? CHECK (?) vlH CIf AS AN rMROr[E d CODES?' D n a i S t e so •v nn xeuoH R,r A D " CODES * no« ,u in: "T An _ a wes - . B 5. IS D M7B .DM ? aA 3 ' 1 ' ? s'?. ? ;u ^ ? wMy;r.D ? m N r ? A1 ii MI ? Z Z , r nth YEAR AN[f I- V.1 (OAAt. AI Sirl! 1104. ,l v I n .L r T. - ryR mD l IDA vwE rto« E l r sa srArF raulFR nwre ro. srA H v 4 1 nH,ele Nr9rurlDN NO. I I I I I I J I I 1 C L v l .o NB r A ,. N "11 I I I I I I I ! %GiSrt91DOWNtF Wr FIRST 001! tlrONT NC, 7..23.?o ?Q G ADD9essdovmfE y w r [9: w Bnt M y 3 G/ ?e '? ? Q G AMea ADO4e v w.Arre[eo aAdnr N E M 8t M e5aw. f?iPS " R n ' wCro vi 4AMAd MUa MM C" a CHAIR w lMw C l t5r .yfr r AW O Ero. 4iorioii oy ? i.'I ?9lAw IS O D ? ?auwNfD rOVAIS HO WAY 0 Ow 5 sI S O Q " e BY; ! AW DIAGRAM Of COLLISION n 1 «H. COpNO"W, r" DESCRIPTION OF COLLISION: lose sutrltM(NrAISKlrnnfduAarl 1. I I. T -- r J L Lrn r+ NAME. ADDRESS 8 INJURIES OF PERSONS INVOWED CODES 1 usurnfwNrust OCCUPANTS /WITNESSES 'u I fn _ _ - Z_ RN... . J .... 3 6 __._.. AOdr,ONy NAM d NAME tfI 319 AG rAN M•r ;.rc. [ISt1 rIMC! A E - ._ .._ ...___ lM l1S N [ d ' ID r9 QAMa Q NRrKI ?ro Mar r "1 ? r.• w l tN9 ar QAMa ? o• •?:1 ? i0 v s 1.1 NAM1 a1AN• a•OW OE AGl K. _V1.1 04 Q<10 LAt[«t0 ta [ r ct ... r.D B. .•... ... .___ _ A. sq?k? , , r A. W' 43"fr" ? bar ,1 7 ?L r ng 1N ? _r I I dry e " l ?'wfi ?r } ? ? It ? "e LT41 Ftrt,r ' 7 f,.. I `.r r l '; f 1 ? 1 'I F y? tip: ?' I ;•f 5. l y?[ LS 11 '. F I c r r '. [Ea?4at - f ft ?•: STATE OF WASHINGTON M.1 10A OTOR VEHICLE COLLISION REP TF 'Drv. ? y NOLL ANN°X o`M f7 ALN M SHOH o??rSpNPN No. f ,OpTDNN ? N NEN DIIR[ET ,.. ?H ? A ? O1 w F DI CT. , ABryy. ...... D,RFDRIREFTD . p •mT . ?E D"DC LilAt<' Sd All ? ? ` .r A" ? ?O ? ?O. , w w e ON rv F p[Ft OR poA N?NrF froN R 5a E ILFNISt wEFN 'Ror c Ni . 11 Not '0 p•LRO.PDpDffNDNL[PnfiPplPENnF,NDL =14.l """ Mn DpMPATA 4DQFT OO BI COLLNION ?? IITAL cl[9YO,VFO'?? QxE MA[o 03[xc [ ?c`p nO n[ ? NOVN[, ? n en L e?AfECt OCnO ]F0 n[ TOA "An ' ` EU" y en c d ? ,pO T r i . OBJECT STRUCK • L (NAME O/OBJECT 9TRVCKI' yMOWNEP OFOBJECTS NAME AND ADDRESS ?uPA xo,rlcT Inc, coo. = O USE IF AIIAI .AN DRIVEq'9 U9IN ME FIRST NAME MIDDLE 0 s DRIVER'S LAST NAME EN 0 FIRST NAME MIDDLE[ N1 0S CO ON OR ?? ` ... p ?, f. ..PE iN AH iwo TREETADDRESS D BOX NO. PERSONS U w[RE TREET ADDRESS flOUTE NO, AND BO%NO 4+n P N -As. LEA N - I L i Dv , CITY STAT f Jy 4 E ZIP CO DRIVER OCCUPATION COLLISION O CITY ? ? ZIP E DRIVE // STATE RSOCCUPATION Y? -IeM1£ ..1+ .'`•S• v + .Y ?' RIVERS LICENSE G FORM L I U D STATE 8E% DATE OF BIRTH AO N NSEN . . TAE B % E F I S 35 C wE, ? F MD DA, R EHICLEYR MAKE (C H EV DOD Y . ? ? ? . OE) MODELINO"'DART) BODY STYLE 12 OR.) VEHICLE Yq. AKE ICHEV. DOE) MOOEL(NOVA•OARTI BODY. LEI DR) viu RC k4l R . Q''l B1 /A IZ A,r" LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE n CEN9E PUTE NO o 8 . STATE TRAILER PUTE NO. STATE VEHICLE IDENTIFICATION NO. VEHICLE I DENTIF :i- rS ICATION NO. 32 2 REOISTEREDO NER (LAST-FIRST-MIDDLE NAME) DRIVER'S LICENSE NO. •., flEGISTERE00WNER (LAST•FIRST•MIODLE NAME) ORIVEq'SLICENSE NO. - OWNER' 'p? '?°' T S ODRESS (gTflEET, CIi NO STA E) GATE OF BIRTH OWNER'S ADDRESS (STREET, CITY ANO STATE ?h u y ) GATE OF BIRTH YA Sc Mo DA ", r J. APTS OFV ICL DAMAO O R FVEH DAMAO LIABILITY INSURANCE INFORMATION-VEHICLE NO.[- WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGEINEFFECT FOP THIS ACCIDENT ON YOUR CAR kL TES ?NOy?l hy ADDRESS OF ' LI BILL I LI A L M L - O A E F IABILI Y IN?URA CE C AN fu -n ?'. AME AB RFg3 CITY J T ..? r E 1 1 ? NAMEA AGGRESS OF LIABILITY INSURANCEApENT . Clrv E A;P 74A P LIABILITYPOLICYNUMSER 1G INJURY E ? CY' OO3 2ND INJURY ILSE 9EPAMTE AUDIT 'on ADDITIONAL INJURIES) AGE n?, AOE D NAME NAME IYxt-T. ADDRESS N ADDRESS EXTENT OF INJURIEg ? DID ? EXTENT OFNJURIE9 ` -+ ?? INJURIES pEOUIRE R EXAMINATION BY A DOCT- Q NAMET" S DID INJURIES REQUIRE ??11 DOCTOR'S STATl15OFINIURED F.XAMI+IA?ICM BY ADOCTOAT ?i? NAME •. ?,?R wve IRST ON?OIo-ye`PPLIF9 STATUS OF INJURED MARK FIRST ONE THAT APPLIES "? Q IN VEHIttE n ro feLE .? ? ,p KILLED IsFp iwwl nq ruNl ?un IN VEHICLE U?q'YIO NoN?v?nL PODSOIfRq N N r• ?axf KILLED n[v[11 IMwoN couruNT 'A UM O µ.E N ? 5 AM 0_ n?REArAr No.__ .. ? B? 7? 0I_' w_, N ? 50 e? Prv70 MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: p' ? HELMET USED ? HELMET NOT USED - s ....w ORt BY ARROW NCIRCLE 11_ I E EL YW -A, ?jNiPPNE gQ? Q Dvle I 7 PPEN[O IREFERTOVENICLESBYNUMBERI A nNr LA.C,? A. ? w_A 8 O \ \ - '?'Y' l? N.S-11E?L,ERL"LAy._WQS ??[FA ... - ' R r.DHa 1 1 On 11D-WN[KLS':n N1, _T h 1+e ?v' e.k r, a U-P ?=?.IrN1??.IV a_[;1v.4.,_e.??rr?-.-r?? l[1 "_Lt C--,.Ld, ' -~? ??- 14i..atpvo.al??Krr}?4?CFn.v v-?w?.?4.vMCk 1 ars h.0.c? S 1. 10 C.cww\_ ?r\_ .o___v_151 v_h Bo ¢ S 1 we. V- e LLn tkx At. (n ?kkk? Y•?A4L.???op? J ? cAVV 2 L?E._O t?? 9M[ P cr o..._ roc NPE t IC?Sfr_uc?`}v4c_ a: Jh_CeKL. +r_o{Lg{'iI?LA?Pev' IvackC--I,,[SbLppAVweIe\?6 ?' LLCCt!NF1ev' LV!4L MMrN+?(.(CLLFg. Y?.? W. 0 Y ?}i V j 5' ?3J.L B 4 >r14L,¢?'C\_wI.¢_o_ I.W_L_Q-"?eLe7?tr_uek .vrx 'tis Wlovlh v_er _ _ TM, Ln ? ? As .. ? r. It. hLU , Y ?' h_ `Mv? W_V.v. I r}cy-l rrTaw _ M J-E-$S_ ?gWCS F-?Y_Ntl?1_L??{'?pc?y. I ?I[ ti s y?fi ?s1\?e_b 4B??r_Ly. >v VEHICLES POSITIONS BEFORE COLLISION MI INV r U1sK NO o .[ ? v[ aY P.x.[u n•s ' VEHICLE iiv fi•M rANn N cu OC<II.FD 'T ILO ?' H g F W ON STREET OR HIGHWAY NAME. OR NO. rtnL - No ` ?.°wr"`Xi ,_ ... J_- nl0[ITNAN OF ? 103 ? ALONG M? ? ? ED] ? ? ? ?wt,rr TKw 1 Hr ti T J' FROM TO PEDESTRIAWPEDAL CYCLIST WAS USING' 1 ?w f ?- ,w. f ?K.?aA L ' Lw0 r?BrN[ r?i:A ? ff 37 J 7 PEDESTRIAN/PEDAL CYCLIST CLOTHING COLOR ?,•?n•„ •1?n .10 1 L. `? ` RDAO BURrA °• .?Mro,rr4elNr WEATHER'" As, LIOIR LA>•JDTTICIA '. `T11A/,rt0 CONTROLt A ??; C * : - DIIIVER/VMICIE ACTIONS WNKMC, aND 1 r 2H[c+ oN ?C TYPE OP ROO^Do I 1e, owe o, uD , K4 CIFA, Q DAYl10NT 1 IM w [ NC TCK fNN[ vlr14lT '?' 1 Y M1[ilAF7.YAI .. I, r 1 ®It ®DpY f ®OMRC.IOIP [ ? DAWN [3 1 [3 SIGNALS ?I1 N?TONEWAYx ?I 1 ?]OOINO STRAIGHT AHEAD yy YII' ?' 13 [ [3 W[T [ ? PAINING ] ? OUSN 13 ] 13 )TOP SIGN C3 [ El TWO WAY [3 [ (3 OVERTAKING AND PASSING t ?' ' J •' ?7 Altni., ] (3 )MOWING DANASiR[[T - ?] 13 SNOW F ? LIONTIpI ? ] ? YIELD SIGN ? ] ? RO OR91AlC E3 1 ? MAN)NORIn-URN T 1 1lyrry, r ?!00 f ? tONT]ORIR 13 F ? /LASHING [3 RBI O ? F IMTO[RHANO [1 c ? _8 ?• ? s MAKING LEFT ooAct I ? a'[IF I ? "LIGHTS ? S ? ILAIIIINO -SER ? I ? AIIEY ? I ? 4AKIN0 U-TURNlrv I ? 91TCIRY ? E ? AN SIGNAL ? I C] LEI ?e U1YiN ? I ? SLOWING ROADWAY CNAPACT[R R„;pNAY 9UnsAC[ T1K ? I ? gcl f-1AOYAN (3 > ? STOPPED IOn '"A. i I••i v??• I`1 ? 11 ) DRIVEWAY SIC 4 I•oux{',, r ??? [Irx[WrF ? M ? [ ? OTKR. SPECIIY 0 S&PAAATI ? I ? $TOpPEO AT IIONAL J • tiLFNi?• r ?•?Wcx Tnr ?f?nsr~I On BfOP SIGN ? I ? STOPPED IN AOADWAY Er4 • H (310 ?r ? nwr, [3 `f `<'Nrrr M ? I .""'o ?,N„« v.•.V ? I ? CON PN%NC ? 1 ? UNDIWDEO 13 10 ? TPA- OL INL r 1 1 i REASON ILM NOi S[[INO OANO[n I DID COLLISION OCCUn IN A CONSTRUCTION ? Y[S ? 11 )TART nOM yr ' J' OR ROAD MAINTENANCE AREA' I/op 11 PARKED P NnORITIOII PWI ' V _ ADDRESS IrM NO ? 11 ? ilriil NGO IENTIRNG 1 IBS 1 B[[ AO[ ? 16 ? BACKING 13 11 I ND WAY ` 4 ? ) ® ® 6KGIRY t ?. r cmrki %V% 1 ? CHECK IA 111 YOU W[ "C DnIVIAO A COM4EgCMl I,CW OEIMITION DI A I...[RCML VEHICLI II ANY YTNNCIf TNF Pn NCInAL UA[ 0I WHILN II TILE inAN1• f ) • VEHNCIr AS AN I4A [[ NOTHER nrNTAHON OI GDYYnDIT IS MIn-ANOIS[. FRORUCI. -fNGHT ANNALA OR FAASrNGrns FOR Hint I - (..- 1 h I N uA C Ir POnT ADDRESS GATE Oi R[I'ORT 1 l ?L'1{I 4I L? x ES 1 ± 11,?'A O ST PUTION 9HElr NO wA I SH, TON STATE PATROA RTIN WAY, MYMn1A, WA MAIN SHEET NO ] TO LOCAL LAW [NIOnff.M[NT AGENCY WIfERF h { A OF COPIES SHIET NO J on[, I!NS NO -',A C Y O I NANCIAL A/AKI [ R "" - OL 4 SN TI r ACCIOF NT OCCUFFrD GTDN MIOF AHECT NO 1 YDUn Copy -Mrv'RRRIfrflXm '? 5n V !^!)" 71I1-' MF n 7n4 ' i ?'TF : NN9 1fM" NrR? y?? _ I Y 1 7"iY' .Y+. JRFtm+fm L 1 '?{' "°.x,0.1 h .ILL6'Id1, . I ? % T ?KitSeRlWd ' J.iiJ.. POLICE TRAFFIC CON REPORT 'XJ TRAFFICWAY Nrw x _ , PRIVATE WAY F ... ..IT Fca r .My . ? o I -... ( • I Couwrr tr c.rrn NWA 4t CI Ov,OWN ? oIN 110N fiNO.aSIVtF10v MOnWAY Mnfs ?s N pw ! of ? W, OM ?'? I a iN1-1IN0vn,n. s,v{fl OV AD "OIP ,ION ,.(mil ?- .T: A NEIDI ""7 .? I DiS ANCt ivfMr M [ .CIpy551eEt1 NtAV[SIMrI[ 2. ?D rt[,5 w •5 t w« ACCIDENT MILEAGE CODE Q^ ealsaNlNVav[D ve1,r a1uN NO.INA1v[D? ?so1l1ADE ?I, NO [tl[D D IIa1 CIS I wet aq•D Oa E C9CR5 SIREETOfgM vF n _ IOTAI NO '. VINC,,, ?rgK01YDAMAGI ONLY ?IYSUI,FD ?bt°'FIE -? 21 q S Oel{CI -- INANIOI CTIEC, SIVUC[ANp_ OWNE V'S Ia.M[I [S,. D' IF 51YCW aNG IRE -- UNIT NO. 1 UNIT NO.2 O VEHICLE ? PEDESTRIAN ? PEDALCYCLIST pvn[aS NAM[ I.vS, rv51 .l?atc??fliPJ T .P G- Dllvtv'S NAMI, lAs, I L --- yl1If1ADD Is OB X53 ?U?r Y? S I {I ADpvlSy Z r n eoa ENO. I A,e ?/?A ns? ??. `+C! R n ueeNx s,AI Ll. DA I OF " o?vm?7??t541 L u?4 18, ° ?5 1 v l !N NO. e MD wr I . • • Z OC yv l?E ,• /??? Y{ /?1 r ' L/ 11 •( IQ E o euvA,lON 'I'M N.WfavWNe NO EY[s IGn, ItIONr I . CHECK (.? IF -A- A-MIRCIA, nc-ANIFNFOII ? •NDINIV 1 ?CHECK (?) NO ^ CODES ®* 5 5 Inlrw 4,16 CODES ? * 7 a 5 u 6 ro 1 wily ,exs 454rs l My;I DM MNA.MI ? m l ? M". „I ? -..45 =W- ? a ? ism ? W ? :° Ku v[n. espopel.e"ev.l ?/ NID?? rn xrle D..eonv.I !20 E I I LIDAI. vws [ l m b r"O G. ?3? yIAA .ArnlN O •- ' H W N. n CE aMIrKAIrw NO ?r . Jr 15 -_T?ctJ /SE 4 -7 1 i vlnl It laNN N l I ! I I I -' IIORnvtDOwN 1 ?IA51 rMU A,— h NI NO Nd(i a"°'??/E O I sAil NRU AID . 2 Agnssaovme• ..?5: 779 (l?p N Z E AMfa•DwnsovoulANCICO DIACINI i(JO,(JE R D•ASA jl •lIA Z -_p AIIEA y r cnAea Grua v i --- IdioiloY s ul. o..wa'A ? Anwmn IEMNNID = ?°e"w ?IFMNN[D w lOVA0 t rn Ilo. S !i 1 0 AW O 1r, Z • nu DIAGRAM OF CgLLISION: n• any ?v ??s1 ,N - ?? DESCRIPTION OF COLLISION: (WISVFLAWAFl•ISFt(IIINT- 11 ?I??ZdLS NND.C?lY?ptlf/ID D.tJ 7/r>?L 77faJ•- _ ? :: PS oe ? x F t r 20 1 ;`, NAME, ADDRESS 8 INJURIES OF PERSONS OCCUPANTS /WITNESSES Ip011„ eooEOrlu r?i+w V ii - Z 3 5 6 u. Act ulu '"„ nsq un :'C7 NAME •Me W' ?^ . O N ? ITA. A WI N W •OD[Iy5 N•,W a IDr•pM ? AMI 'IraKl O,rIL r ? w ? Ii° MI NO .owns «Yls,c ar< N.wa1•nr ?p Iw +cl NC. ""w??5a No-i?iD ca Lly s!.rc.ac pLS •vIO ?•Mi ?'l D '.""?iw - • . ?".° qn. D•n ? X S r161Y/f rLll 7, ; 9 07 C MIN f L ? 1f R ? ,? U "it'1 + r _ 1 j f I r 4 [ I 1 7 l ?r 1 4 ` r r I ? - f ? k r " 11 . If I r( JI ,I ? Y . b POLICE TRAFFIC COLON REPORT LCJ TRAFN(;WAY - ?. PRIVATE WAY n i I iM( 87 4?.a?r ?.IO?a?;IXI oi9'o' CWN,Y JG°FG?so.J ODIlrt1Y f; City ?- NwA ^ ?awt 0. OT rO?IN ;ylrD4{O.rN N F6N Or 51RF1109 G WAY /?LS't7r °°'' 11 ;; ,,L ROUif ? cr ANlfs ?5 ?w ON,:: /Lc:, INT-Cl-.1N.-11-ROAD NON-IU CTON ?/9 J 1S /f LLl pR•Ix O xf 105, . ` Oi 2 .S+//P.. afrvrtrN sratrr ° AQ sr «r L r ?q "' y.f/ .CR0333,4tf N[MlS, Mil IN/ rifts s4 E DJ LG ?OSI ACCIDENT MCODEE DA A CIXl15HIN INVOLVED. v[RNr' Nu6RON NO. INIIW[D? ? SrIIIAGF ? ND 4ilLED N°RIDI IMF e15 O ICk55Y4[n Oe t 4gOADOa nr nNCE -. .77 ? 10- NO tl VfNiCltS ® ? PRGnarY DAMAGI ONLY ?•t3p31f0 ?-'Clf / 4 OBItC15,4tKRINAMEtl O{J[C1514UC4 ANDOVINlR'S NUnfI .1 D•MAG[ SrtCIN CODING l6t UNIT NO. I UNIT NO. 2 ? VEHICLE ? PEDESTRIAN O PEDALCYCLIST Dervles [ LAS, sr Mi 4rvw' N -1. sr I _ 5,4FF1w Dvt53 ?i 4f[I wDDVt55 A,F IIr COOf PHONE NO AE7LcFC/? ?/0 37??9 &za D R IY AF - 17' n A NCtN N ves 5 w1f N M I w SiN N. A f A = ' ns wN, Iea;M occun•ioN e{nro.,e NO. E CUPw ION •M NAw,e{rrlotJl NO. Ens IeN1 NUCNr ? ?1 O CHECK (.? w.,o1NIa -IC • ?CHECK I?) vEN aE ASAN NAnon A I. ,fi CODES P• ` D m S I O y,° 'c'cu- ri? <' I. nin .f3 fifnr N vrv .CU CODES IA , S u 0 5. n I - i? ue111 50, 'o's S N EF 2' ° Nx.MJ ? 3LC' ? F8N a ? K:< ? 4 MN' O -AA--C- ? MC O Cb'. C) ? :° • _ v.1 vIN Y[wv xt IDDDOL c", ILIDA4,. AI Srrlf l2D•. Mw ,lJr 977 = D ? E wl I NV.) LID = 1. a4rt.,[NO a S,w,[ ; H NF« crosrrclT N . dvo J mcp 7-5- C VtN CLI DEMIIKAriOYJ NO. L iLIIDN wI NJ. T CIO 9p I '? nmslenoowlJe4 lu1 n v ev°Dle G Lt/ 2 rNONe NO ?SSYN/ w rnsr M..•,•„ m+f : A' SStl OWwte EMOf C: N•Mf{ADD•nStl nSU•wNCl CO. 04 wGt N, G R n DAwAw •Jlu ' ' 7?' G yAwur Juu v. o? D , . CNUiN Gf a.J IN I 41or - ? ?nAw.Je D ? wAr ?4tAwNEO IbiSni? _ / lovno 1avID AWAY BY AWAY .1 DIAGRAM OF COLLISION. e,wn le'll I .'c [,N DESCRI ION C;, COLLISION _ Ilatsw«wNr seen rNlassARrl AIR ua eru -- 1 I ?duc, ?Zr> rci/ ^i was:3 I i I ? ? I t I I ; v?? c1?,s_?•?_ ra .vre >._ I iG:cwf' I .?. - ^ ;- ..I- 77 sTi ./.Ci6 _7?i/I-E/1i3i9?? c..+?:_d- _. - NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ? CODES 1 - 2 3 , S 6 OCCUPANTS /WITNESSES Ilbf slr'n[wMU sN IM •DDTDNU HAJN ln SI __. 'A. _. - fix Ac! ' •N .. w• u.I .. w ' .11 -_' - . _. +.u. M314 IJfCI N•w7/ / Er No /?6r.5E , _ 37dp •Dwlx po G .../ G?»+ , •[ fA / M e ?iR' O^,• . ?Ci: ?Pu?Y IJ •DD•If1 Nq0• tl --- ID 10AMf OJt.KI?HI•n Oh: ?••n°. AD wl Awns, v:,'a __ N Irner ?AMS ?,val?ao? ?:° ~^ X +vUIGa GaIKPSN wIUN• I• 0• NO AGINC. OJ ptl {DII a21 DO./u/( D d/'IW W raK? y.p ,' D. 4r na ng •rnWtDS i•ll ??u STATE OF WA&HINGTON PAG[ I °f I INn __ 7 n n o A Q POLICE TRAFFIC COLON REPORT ?TRnFFlcwnr IalKt N,NUMBFR` •i PRIVATE WAY -", ..PA.4,9i. 0111. Vl! ?J.? ImE C W+ i -? uIY IB uRl roa ", IY1 1 OUNIV I 1c, M. ' ruRbm ? 1 1 f O Q tZcuJ c,r oe,owrv ?N ?t ?IN AMfBNO p514[F, OR HIGHWAY gmlt 5 ?W Gi N O4 gWif 5 f Sf y m ON a 12 IMt4 CI ,H. 514!(1 OR ROAD Irv,t4SfC1 ON eetE l [ Sb 6 ?5?? ?^ B[M'FLN SIPf[i L 1.11 TS 5,R[[I U MLLf P05, '/ '`/' Q f D1 ,AN<t•DeF 1UN Mvfi[R[ E CR055519IE, NfA4t5, Mllf POS, I ACCIDENT MR[5 S w RAAV A 4AM MIA a P MILEAGE IF[, CODE coulsloNlNVpno. rolenr ,OTAI NO NO.R llfO NO.INNq[D ?SPIIIAGF ?NII.4UN • s 1 INifR CIS d03551R[AORRLApAp fRtI4R eR a vfrfKUS PgoPfq, oAMACL ONIr ? aisullED ?5ioai ?C50 OBJ[C, SIVUCxINM,t Or OBIICI SigUC[ANDOWN[q'B NANtI Efl qG[ 3 SRCNLCODING IRE . Q { UNIT NO. 1 I p U VEHICLE ? PEDESTRIAN ? PEDALCYCLIST Demos NMAf IAS1 Dos, e MI R 0 rvAM s e '--;3?---- -- ? L fiPll, wDOVl55 3osb o Sr GwfO • rr H IIAII l". - D S,PI[, ADD4[SS NOrvt NO SpIJ 42 Z cg_ R , Y qIt IP t DRIVtRSIIClrvYNO. [ x E H I IICFNx r40. A,f DAfp BIV,H 02 fn1 DI °ol r v OCCUOMION 4M N f•hgNt NO. tY[S IGN, NIGNI E OCCUPA,ION t19M NAMFt PHONF NO. IVES IGHI IE1GHi - O ,f bGtA3C 1 R ? CHEEK (V) af. :N Mqo fo ANpNIeA ? CHECK (,I v HlcIf ASAN MR0 ,aANO1Nta I CODES ? * D 5 1 6 [^',° CODES ? * ] ?, • ° S -'-__F6 ' " ° rc s i uv lp f • m o ?.MNq.KI ? ; Kn. Yl6v MAxt IDDWtCN[v.) u II ? a?I. ? ;;x.N ;D. •fAODll10AR, ,qvA) 5,YU 110 ONV.I ?N H ryvll ? zb.1l. ? r 1 MHf v l MOD[I IOARI?NGVA K1 i ?;: r _ Y ow Nur[,E I S,A,t R E H . ) [ x l1 SILV? Rulea6IE NO. s1An Cn - `- I A I nN Cut. eN v[HKtEIIXNAATIfKA,Ip.INO. vIGRRM00WtIxe 1 LAS, I I {IRS ' M?DDIII-11-7, 1 1 ' C L vtHlCIf IIXNNIIA e S u I I ! I1 N l to ?A ADORt53p GWMV ILIE' \ 1,17 O W fR. lA5, fl , MIDIXL I N E A OSYrv AMt9A00 [-1SU-Ci CO OR AGlN IN U I R n DAMACIOARIA wi.N n ' E wOYJNN EHUGt ? CMAP ."„U.<',?N gAMAGf o'Mu IOii f 151,pANAGE AW'wv 0R[MAINID ?AWAY ?efMNN[D 1fO1DAmA t •lDR dior f rDM wTD f D ,ov?Der_ Ioev. f I Aw Aw•v • DIAGRAM OFCOLLISIG su R , Nu NDKqu NO4IN DESCRIP110N OF COLLISION: Iusl SanLMLN,u SH[t, Ir-15SARr1 ._ .. rE er Aqqow __... _ -7- t ; ; - ? .-} 0071 . I i __ IVGS_ ja 1-4 ?L fJ__A7}C?+P?J'a _AVol p ? .I._?51f?IJ .LSo/J 5 . m . '? TT'11 -i... . - -1 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES 1 - 2 3 4 5 6 N lux swnrM[Nm sw OCCUPANTS /WITNESSES fLr •DOnrorvu N.M AMI n lsI ? -?- i[? Aw lA,us . , W S,R. txa , P , • N DNRY K. . N o. ?. AM . e ? F4Cf' ? ,, . •• a. LA.nr w • M•1S5 AMt AMe ? H ? I:° No .. _. ANO.1t, c JN r Of "•"'+s xlNi e. ?•M? ? ' ?<r•l •• A ?". . s NfMl••AN. CI Y e•DCI O• rq W;u,cY 4?sQ arcl DnrAl ?. D I,??? RLr KyI nD /16Jf* 1 . I 9 .PaovfD e out ?L 5? :.,??wrg•4s91t It, °1 -- MOTOR VEHICLE rCOLLISION REPORT o, LL o r « a?DUNT ?•( cor S, o J? p FERO°„ xI N ?," v " ° ° r N N,"E."D DI Tx n LE, D °r n Ao; E °E ° N ? ° AnEn;rv °RR . I J ? 5G 912 n.D n RLEE IDn ?.' o? ?q y No x pp x.nxlocE. Ex ou o?:aK"° ,N. T, A 6 rn T.4 A " I.- no 9 rDIrEP o °o ; r R B <o ao=°. a: ° °,lw a„:`? " / T V " IN, .1.1 P[ <EO 1ROSSESIRES °s?aoA '^O E°nEVs I&W0 OBJECT STRUCK An x to OWNER OF OBJECCTS L NAME AND AADDRESS Is j Dfl1VEq'S LAST NAME FIRST NAME MI()OLE wEgE NVOIVfp OFIYEfl'8.Lf5T NAME...,, - _.,_. _,_.FIRST NAME . MIDDLE , Re , r 119 15 ooTIoN DR BTRE ADDP ROUTE NO. AND BO%NO. ? RR" wERE STflEE1' ADDRESS NO. AND BOX NO. S IN p'l / UF GE, USEA JURED EFARAIl CITY. STATE ZIP CODE OflIVEA OCCUPAT!O Gnc ??R 9 3 ..TV-5 LICENSE NO. STATE SE% DATE OF BIRTH AGE GoF?O5R0N CI TY STATE VERS OCCUPATION on. DRIVER'S LICENSE NO 4 o CCGU// r"r, 3 . SSEX DATE OF BIRTH AGE, 10 D41 1. V ICLE YR. MANE (CHEV. DODGE) MODEL IN A-OAR) LIQOYSTYLE12DR.) .) VEHICLE YR. MAKE (CHEV. DODGE) MODBODY STYLE (2 DR,) , V - T ST 36' A --- LICENSE PLATE NO. STATE STATE TRAILEAPLArENO. VEHICLE IDENTIFICATION NO. VEHICLE IDENTIFICATION NO / G .5=G ? to . - REOISTERE OWNED ILAST-FIflST•MIDDLE NAME) OgIVER'9 LICENSE NO, /_f SGfJ/A _ /Js .9.ear% AEG ISTERED OWNER (LAST-FIRST-MIDDLE NAME) DRIVER'S LICENSE NO. - ?`.L • OWNE,RQ'S ADDRESS. (STREET. CITY AND STATE) _ '" S /Ti L?lJ7 Pry DATEOFBIflTM o R OWNER'SADDRESS (STREET, CITY AND STATE) GATE OF BIRTH A P ''? PARTS OF VEHICLE DAMAGED ?n n? °xRi°?r rO PARTS OF VEHICLE DAMAGED b,"uRx v?n?at ra ` GA/ r v E F / § 3?o s - LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE AUTOMOBILE LIABILITY INSURANCE ? YES ? NO COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR NAIVE AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY !iiSURANCE/fCOMPANY Nr///s ?.O 55 ? r/iCr %l•/GG iG./[ - /r 111 11 NAME AN O AOOgES S OF LIABILITY INSURANCE AGENT CITY. , ? nTAYE SIP LIABILITY POLICY NUMBEfl ? J / / 1ST INJURY AGE 2130 INJURY )USE SEPARATE PEPoPL TOR ADDITIONA. INJURIES) AGE NAM ' yq?p NAME ADDRESS M lu ADDRESS NATURE AND III??? NATURE AND ?? EXTENT OF INJURIES ? ? E TENT OF N DID INJURIES REQUIRE DOCTORS D O l INJURIES fl EOUIPE O DOCTO EXAMINATION BY A DOCTOR' ?O NAME STA AS E% M NATION BY A DOCTORt NAME INJURED MARK FIRST ONE THAT APPLIES STATU90F INJURED MARK FIRST ONE THAT APPLIES S7ATUS OF MARK L _ LR ?opy rNmNO Nos.ru osn sn. rvc rv.os.el usnL ' "rv ? V I KIILFD rI v rv ux?r ?o"vl ? r, ? rA N [n[ ryw xr x KILLED I [ o N4 i O N0. s v o.EOea,?µ .E n or " c" O. ? 5? 6? 7? O ,Inn ? 5O 6? 7 O NR?.. MOTORCYCLE SAFETY! ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HEL.ETUSED ? HELMETNOTUSEO - SHOW NORTH D OW IN CIRCLE -DAY -Ar "b .. "aourlnsfcn DESCRIBE BELOW Ai HAPPENED: IPEfEA TO VEHWL[B BY NUNBFA) 1xrcll INS x rllnr AxRw Rnn, ,n.r tarts !v/t ratJ r?!?'v ¢ / 7G W. All 71- VEHICLES POSITIONS BEFORE COLLISION ox Lw l ` ? n l mvESnapreD Br {??11 'b.MR.A• jF VEHICLE NN S E W ON STREET OR r11GHWAY NAME OR NO. Rourl ? ? ? or 1/Mn ,rM? ?lr E, L w Mat LVr M l: n nu l in v[r ° ?,"^a ?MG l•rI FFTDDDyyY , MM ? ? ? ?? ?iR?tl }vVlir pl F 1 y?,, '' : '? ^ ? ? ? ? ? ? ? ? ? ? ?sr,lx"r ( . rlaLrAMH ? ? ? ? I-MAND FROM TO Cry PEDESTRIAN/PED AL CYCLIST WAS USING ,?u° )x.. xwx J?w" s?s.bU G N, I ,?u L xlx ?or r?n' I?Iro A ^ I' PEDESTRIANJPEDA L CYCLIST CLOT []1 HING COLOR 1 l?IV.„r r?" I?.rrrro xIr i?riWL?sriit x.x" s?:Mii NOAOSURFACE WEATHER LIGHT CONDITIONS TRAFFIC CONTNL TVPF.OF ROA D DRIVENVEHICLE ACTIONS vIr 4 'I''"NLr a" ;.,? ? k:L°' I Qwruma 2 ?wwN u r'"c E.G. 0 1lL?SIGNILE N L f L o , ?rl??IONEWXY-I IF_ wnc. oNL On MOxf ?r NO 1 OOINO STPAIDHT AHEAD % -FF ?2?w[T ?R.i - ! ?IKIBR n [t ? 2 ? $FOREIGN 2 ? TWO WAY ? 2 ? OVf RTAKINO AND PASSING u ?]?]NpY ]?w-I [ ?IIG /60M G f' ? 2 ?vI[IDLWN ? 2 ?qO?p SIIILF ? 2 E] MAKING RIGHT TURN ' ? ?• ? E ? f?fOG ] ?.1"C1,1 S ? GrrISOII E ? 91Rf El?WNTIT ? L ?"ASnn.G AID ? I ? Il-IG "DER ? E ?IN11ROPI[ ? ] [] ALLEY AM C] I ? MAKING LEFT TURN ? E C] MAKING U-fUPN PL s ' DI [ ? ] ? IP[CMr 1 t ?.v I r ? 1 1C Ir ? 1 ? RR IWNAL (UPN ? F ? Lfl ? I ? SIC'WING ^1, /;+q1 I+n? ADWAT T RO IxN' O, r ADWAY OU( ?4MNII jr r?J'. ? r ? OIIIC[RIIAGMAN LANES ? I ?pRIVEwAY ? I [3 SIOPP[D fOI11RAf NC ` LJ - ^• t...sN ?,?w".rn ? ? ' ? I ? OIN[R. LPECIFY ROAD REPARATION ? I YTORP IOn At SIGNAL -A - SIGN w ? o • / ? DWmfD ? • ? s1oPP[o W noADwAr I?-? n ?I?n vy I yv ^ OlR,II IL • ? co. ? 1 ? ND D[0 !1TARTINO rN ? ID ? IP II C L IF Y '? ru 6='}I t Y ff.k J,? /? ?.. T { d TM L Qa Tf-1J 9. (awl?w'; ti [ V L ? F 1I) ?r ?,? if} 5 ` `IW:7 POLICE TRAFFIC CION REPORT KTRAFFICWAY NrrlwABfII .. _ ?n I PRIVATE WAY yP ,' ' gl E A F IXU I g r R. R4. DETIHODRI cSe u l 37;e COUNTY . CIIY NO f A RURAL Or S,eFF, OR HIGHWwr QE 0", CNV 09IOWN N - ICICUL 1 - U.. pOUi! f /NlFS ?5 QW a'I NT I„ 1„) ON L os 01VID ,; 1 1 1 RS'1930 IMF45FCIING SN,N. S,Rff, 0e 90Ap NON iNIF95E000N ..-WORK SIR[EI t I $ Awrl 5 IF".. 111, MILE ROSr .0 r D' wNC Die I Rf .[40555(4[ r rvF•RF iMllt MIL[5 N 5 E ACCIDENft RNA 0 ANM A p IF 10 [I MILEAGE CODE <Ol1t IO,M lOlA NVCRVtD vF41, v. NO RIII[p NO INIURlD ?S4llwGE ?Nit RUN NO pnOIH IM[R CIS CROSSSTF-ROAD OifeE I]] - 03 OF vlHI"i Iep rY DAMAGf ONLY ? YI LIED ?Vf?`Cf Q OB1tCIS,RUCRINAM[OF OD (CIS1eUCRANDOWN(R'S S ES, DAMAGE SRCW COaNG USI 9 61 pp??' Is -0 UNIT NO. I UNIT NO.2 Q VEHICLE Q PEDESTRIAN Q PEDALCYCLIST DNMS i usl iRSI I oRNwsN- uIi FIRST MID.1 ? L-OEj 19tf, ADaF55 aoa C? L Hfl ADD4f35 G,v , f -co a 4HOrvl NO l LU ?/} 7 D R Y Alf 2'? cm Nte'SuCtNYN ' SAf • CIA ( t NSF NO. D A n LO 2 Z V OCCU4w NON N [tMONfNO. lvFS icHl rlwNr E _,R`51* FIRM NAME A RHONE NO. EYLS KiE11 I(IGMi a T e 1 r It R Q CHECK (? I YT C11• : nvr A ANO,NtR A` (NODES ? 7 "'I"" "? a s e "}'•° '<•nL.- NI< Q CHECK (?) Al vIN CIf wS AN fMROV(1 OrA !P Co DES P. * D n 1," uc1wN a }• } rR4M ^5 o Q 0 .R 0 'cl ? c ,11 n x .DM Mn:' ? N Q ",<I c&_ ? KLI Q is «}R 110 v[H As+RUD000Fc "IV.I 1 ,.NOVAE sl l DDR vl 11 l ' V H.r I Hv.E LIO vAl I '1 17 °p'• l l J i(.aEl? ? ?/ aUL E 1 De .? v H S,w,l 14NlIR 0.wlf NO SIA, M vEH. O4 TFTF- lofJ P . 37 WIA '-? _ c nM naNnncAlla«NO RIWSR4t00WN1 L I l Iarvu I A " I I I I IILTI NRSt Mlpa! NgNE NO N6+L 132G-073_7 O I D YMF NRSI I •ooeess ar OWNIR Qyr -71 VA ?CMUfKh L A} ?k r ? E • 2I L HANI&ADDR-O11NSURAKICO O4AGtNr R U DAIA•Ol NlA ":•'?l'O44 cNA;u O1 T SHAOT IN _ gAMAUD.cAA :ARGf E 15 OM1A ? -YEN DIMNHID lu' ? AWAY ? ES ? If04 R[MNNm to i'onoii 5 IOWlDIY ? fOMDpY f DIAGRAMOF COIIISI.IO >4rn NNN NoKAn NOO,H riifin uNeeusun [ARROW ? DESCRIPTION OF COLLISION: (USI-FAT-INN NE-SIARY) _ _ FF 1 S $ SIC Ru 1 t Ot, GLyMFU5 5 VeA _DRlvtt _ o - . H 0 O J'ice 4vHr reeeelx-. %tni / v? ? 1 C1b3e0 lLA"pvMC t ISPNf}' GUen ALJ --- AJ ? S of O&L OF PcAD 1 RolleO VeH4 c J c -- . Ln ?e LQIJu I7 CA^C ?p RRS( (. OLVO NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED + CODES ' - 2 3 S 6 OCCUPANTS/WITNESSES y?yp^fgM,f"N'rN.NSA'?( ' ii SIR AGE rA, [ J '"W" R!: ';I p tsn Encl °1,<;, NAw RHONE . 00.1}5 • Gf Rr •M [1 t 0 E41'(' 0 ^ r OZ., ? CaHS, p " AMI NG • OMli% AN, NA1lAIl01 IPF4 Q•MR ?raKI aHN RQw 0 112 •p • DM15 A f NA •MR Q(•i f ?[rOVrN OH: ?r'Nv IMRr ? ti S111G^ArtiG(grnS(R SNAMISR•Nl X v v-A p•OW OR n/GIN[ rfj W ?L yvyy]NH pr Y ?p' q.LLD2}??SL??C (D '?AnfY bLL K?15?A]pRpyi"ND )W HIS DAIIp RIgR, ? A ROVI D•11 1 ?, EV [a' Il ? ?}S ppyy PY 91' y D ?' ?'"SCI _ POLICE TRAFFIC C ION REPORT KTRAFFICWAY n v I PRIVATE WAY DA,E i IXll N Al III N RWNt NIIMDER I I IMF COUNTY O,. WR VM f. 4t IUSj,]?wOwl C1fY NO INW ? ? Ef ,r '"'11 f?I CZ I ? "ff Ar Oir DO TOWN W" Qt QIN AMF,w d31RfE,OR G Rum pOU(( I -'s 0 3 0W OF IDlse ON (x 0 NIR CNNGNlN-11111 ROAD NON INilR C,ION I 5036 0 9 DEIWf[N sz IV 514(11, KDAf 3T1[fT PR IIA to. MHf RO31 _ f? _ 'd Q`om' 3 D13 AN t O <RO5 3,Rff,OR ,EA4[31 MIlF 1 I MR[S, SR [ ACCIDENT W . R R•MR AM OAIA (11( OF q(2i-u MILEAGE DR " M 1O11-NINVIXVED Vt Rlfv: 0141,0 NO41lllD NO INJURED ?SV11lAGF ?Nn,4UN wNOnoi" IF dV(NICS RRORR OAM•G[ONIr ?p5U11E0 QE-N CIS CA0555 I[t04ROADR?AD04 E NOR Pf ? OBJtC131RUCR INAMFd ODJtCi S,RUC4 AND OWN[R'S NAM[I (Si DAMAGE D SR(C ? . r l J1c51} s UICODINO115E 4NfRsw?M[ ?1 UNIT NO. I UNIT O.2 ' Q VEHICLE Q PEDESTRIAN Q PEPALCYCLIST S Y ? RrvtR S NAMf N51 I I 31 t[t AD04133 1 [, AODRl51 0 Y F D z1R COU RHONE NO v sA1 2,P cm R R rvtR' I-S(N OCCURAIWN FL FNO sun I I N [ 3 G"1 ,(IGNi E OCCURANdJ FAA, I-- 5 IdI, N[IGM r 6 Vi R Q CHECK (.? vtNlcltA. FIaANO1NFaA` 0CHECK L,9 nNlttt AS •N t Rio CODES' O . .a • nD.. naro.. ,v°.K-=- M .t[d•w1Nf CODES ? is snw"' 1roN Mr • u N uRlt"' ti. p. Q .M. , 1 a .r1 Q <s:rt. ? p ° nN uR AMRt OOOOE M ? u 11 RI I Q 'c%', ,1'?"1 ? ?i Q ,M , a D. ? ? :° Ku . I fv.l MOD[l10 ,.NOVA1 3,Y111]DR . ONV.I V l I N V 1 MpOfl 4N.NOVw1 v ' ? _ a E ; VC u w u N s1A,e 71 AAT[w A - H I " aoR W N . 3 nNICI[IDlNniICA1pN NO 3 I? 4 csrt4eoovme4 wf la.?n MldD C L VINIO1-11II A N lt As ME AD II-OFOWNER RwNe O W rt I WNER: IAS, FIRE, M AS Ui N tR •M(a ADD4l3sdINwRANCt co ORAGINI E DAMACto.AU R ( v.cwN c,u? g•M•eeD AREA. cNA4a , IoionGii 1 °A"`A6 •W?i ?R1-1) 2 4w?G, l NOR ? ^OVEN ?RLMAINtD l31 3 WAY I'll s; f ,O ?OfiOY VDr DIAGRAM OF COttlSlO ail wrlu,.eN ,l whin NOR,, DESCR nu NmuA4q rvARNw IPTI ONOFCOLUSI N; (uslslJRrt(MtN,u sfR;nuNeassARrl @ 43 N N?45 ?( < 5 I aio W?7u OF t}?I • ? I Snl KaS ?n1a Tk- ),J)6 LA,- OF- bAse -. Flax fRD NAME, ADDRESS R INJURIES OF PERSONS INVOLVED + CODES 1 OCCUPANTS/WITNESSES 1. AD I-1- - Z 3 5 6 N D .1 •MI ?? I E 111 ,c.51Q, 11 rRJO N. AGI uru 1" MS1R fAC1 M • DDtI15 • d Q AM 5 C, A w -?N 1>S NA,Nd RI.'D" (3- []60 o`.QH+ ?.i:rv Y AD ,O A IwfvISIGAIw4diK1R5N•MI,t•N. ? Ir QAMD ?(i1iI QC1 .Q.i: ?niv. OR AGNK• " w?tllO' _ ? O ° 11 T w 4.,vtD p/_cwD ra .o., •. ov(R D.(ri f , ' /cl• B ,? I ik r u TJ ? ( ' l«N ? 1 l y ? ,ury I uG? ? / 1 EF . "i1 v? f , Y i?S?u ` {C. 1 y ??' i .. 211 j Eyy w ( r Li:.r f? ` I J 1? I 3 .r '? j' L? q I J ?; ? r i. ? y i T y . I r' I s . I , ?r L E J I E ? ?r. . X lrE .I 11 ? ssrtnr= a+? 1._ POLICE TRAFFIC COi SIGN REPORTRAFFlCWAY E 1J LT J Pl%C FWNIN eFR I PRIVATE WAY AE F_ Ou' l COU«n COIJI+r CnNO .. ?•s. J-2 Dual /.. une:n I D i S.I IG( I I iH, o?? / Q . 1 / RI19Al t NO O1 Q F 'QI t Q 3/E?RFF?109 Ni CTLS gW,FOR(?RREE N ?d? / /?/ ? MR$ ?1 Qw 'QOF ? QH 2 - 13 NiF95fC1 NO YA,N. 519EE10990AD NpN N,E95[CI ON -N% tO MR. "I ?Ja/?,?q.-+ (??- ,QD etrwtw s,RFF, I SrRffl ?I D AN E M N RtN .CROSS S,Rff, PNtA9[S,MI ACCIDENT • DIAGRAM DATA ' MIlFS 5 F w ' EAGE i[fl OE /? "' /L? ///. ^l v MIL CODE . CO II To, NVOlVEO Slvtelr: %RO N 4ROADOq gfi[9tNCf ,OVAL NN NO RIIIlp-NO.INJUREO QSPIIAGf ?FII,69UN _R wN'PeiD'i.S 'N 9 9 CIS DR015319FE, i Oq aOb OVIN LIES PgOP[91YDAMAGEONIY QR[SEUIIED Qvfwi[I[ Oe,tC, 3,9UC%INN.S[OF ODJ[ r51g CR ' U ANp OwNfR S NAMn [SI.DAMA(iJb'i SFE-CODING US! STo? siq?.?-s. 057 =JC?FE,?'?o,.i Cc? f /oo 5 UNIT NO. I UNII; NO . 2 Q VEHICLE Q PEDESTRIAN ? REDAICYCUST RIVI5 5 NAME N9l, I D - D9rvlRS E: Gs, I p?•5?.l AM lDOE ? - 2 S,etfl ADDRtSS ??-? ? Pkf, ADDPISS 01 t v DD ONES /Z D C, AR o DR-I NCE NSEN S1AI f R 17- c , ? o VV ? J L?/7 F, "I 1, 4 ?/j ) V I l IN N A TI MD I oA I ?. DECUPAT- 11 MNAmE1PHONINO. s IGNr I{IGNI L'A?Ii?E .SC-.G.G Lm?/u G.7 '9 ?o C E R OCCUPA,ION FIRM -I{PHONE NO. ens -1HIGHT Q CHECK (.1 tNI<i[ A ,wi A H r A r Q CHECK (?) vtNln[ws AN UnriontdA l«tcAl M ° oK CODES *] e:" / 5 I is l w f 0 U y+° CODES " A ,N, s IAaaD N Nn . N J . n ? N a ,,, ,E pM rl °N ? I7 .me .«YI Q b 11 NH rIAR F E u Q ES". Q UZ11 T, y ol. Q Q '9° Q E&m Q r Q a° " 'D.E CNEVI I ?Ji.J ! IDA9r.NOVA) Slrlt lq D9.LONV1 ? E 1 NV.) IEOAgr.NOVAI N I v J vH. ueN uN suu ,gA9tgRAlt NO vA,E H vl«e I F•Ff VIHICItIp MIFICAIION NO. L vI NI It IDEN,III AI 1_ si o??3 ?8 gfGGRq[p OVmf9 IAS, sl IDDI! P«O ' 3 S' ?? ApDRlSS OF OVMIq Nt NO Ss9/nG O W IS D ww,q. FIe31 MI mE Z A Y,N ?? E AMl upDR[ss d msmANCI co. oq gcwl IN u RTJ'GFLB-NiXL[fl _ 157 ? R Do D A0l MG S 4?+? o c N4tj1 CH Dd uN «4 AMK.EDMG N ' O..s DNAa o mG1 ISr., N AGI r'N; • _ , AAUG! plot 1 u (D ^wAVN I5 ? AWAi ? ?REMMN[D /? / ' ° rbioriS? rovrt0 d?y? ,o Alper. ?.G>L{?$O.l? Ar er f Aw r AM DIAGRAM OF COLLISION: NN fu l NDIUn Nw,N DESCRI IONOFCOLLISION: IU5f5WKIMFMISNtII RweessARrl IH ?Y41C l er AIROW ' . . !1_?5. ?, Lam. I 1. Q drtr/ l?i9S - •S/G.._o.J. .SwA..iScwd?6CG._ O'3v`.J ' O SI0 JK4c J _ : I vE/s? Tifrc?..i ?9.J _. G??C/?.._!? ?STav?__ / ?? O ' ? .. . STo? S G?.J .-w/?Ei? . Dr?.JE a_ ?c.Si? - - .GOLCL?-'J OrJ6/L SB`?EJ/ilL. / .MES . . .. .? NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES 1 - Z a 5 6 OCCUPANTS /WITNESSES ,e; Boa o1:iwl:w AMI si al% •ce Inus '"'" : !D . A Don„ N u.ed O « t .Me L Q'" . Q,^t Q A OMISf r d R NIB q 111ON FROM Q p{! ?w • Q ^T Q,i° o ? A NO O Ii?f tiArV150' X v?I GAtMG/{I.SwM111AN• ,A0101 DI N:r ? ?l CIO U l 'D NO ?7 ??/?'? .C ZZ e ? O?? p O /G 7 ' I•v INI e. QAMe Qu{' Q«;:R. N. ? :O1«l1 KI D D.N RI Mi III.OViD1. W,1 / 5? ? .. . , o . • LJS _S C. ,.m•r3 ? . nil Jlpp S / ash ?$€ POLICE TRAFFIMEILLISION REPORT Ln-TRAFFICWAY ,cECwar\ANT NU efR PRIVATE WAY q?1f OF COI I,. _N t1MF T l I vru.v.fl?lur IUSF ]qO NOU41 xi I I ! 3? OUNTr ??rtf YSa 7C- No A p9bAN IT a ry 'UP rpA CITY TOWN'/ as, 09 GH .f 0 A l[5 g5 ?W R+qE GVC r oNE41 Y,;L??e, EC/lf?is. Y M lHl t EREE 52916 , 5lCTrNG WIIn. T9f[T Oe ROAD HONrN,FRSICnON 1 bl,WlFN ?\ LE.E S,4FET 6 ` C STRIE, 44eTI% FO. mrLE iw51 O. Ors ANCIt ,R( melF(el( 1. C40553Te[[ NIA9f3 MN[TK,S[ ` IlfS 5 E ©.,K, ACCIDENT MCODE E 9 ORIG4 DATA COIIISIONINVIXV[D' of 911 v: Tag OIAI NO r10 %Ill[D_NO.INIU9FD - Spil1AGF 0Nl U UN4.141H I'll INTER I ?eD IMf4 Cl5 INIR ZING I.fE,0 -oll RTFf4ENCE C405551R[F1O440A0 1f, 1 OVFNICIfS pR90T491YOwAGf ONtr pFFS[I ?vf?itIT 'c", 9 OB1ECi 5T9 fOi OB![C, S,4UCa ND OWN[9'S NAMFI FSTOwAGF SMCMI COOING VSf t UNIT NO. I UNIT NO.2 p VEHICLE p PEDESTRIAN p PEDALCYCLIST f ?Rrvfe'SNw[ -1 , M1 AR5 Kec?: , , cue L s DRWFe'SNwf: IASI 1 1 lE " Id 3 5TREETAD01E55 C C? I Z 3 i Lc ?L Gar, TRfET AD09F55 sun "TOO a rroNE NO. G. E, I ?? W Cho, 33 3s7--q I4 L Tn. D R r sulE me r `}3 CENY HO ??'113Lt 3'72 SIATf W0. ,M It ? 2 ?n £3 v I r INa AE AFCR erRn IY. 9 cuvAnO N/ MNwt6NgNf NO. Ens wn,-H, E <ueAIION mNwEa REMJNf NO. Ens IW[I rEwM ,Z , ?"\ fX.U 1 j5 S? R ? CHECK (.? N==211T OF ANOTNfeA` vl p CHECK (? VfHlfl[ ASAN TmRlOVlf OF ANOinf,A` "''^ CODES ?' D ' s T e Y MN CODES 0- 3 a s^, s E% e Y }e 2- EY c r M°`iI- p W, 6 ? .": ai p "w'N5. w" "u, w p Ma%M I ? u0 ? M6 p ".MKS p 7.;?. MA%f IDODGf?CNEV.I N19? ?Ku -(DIRK A) SiYlf I4DR.-EGNV.) ?l C E n. vfA 1 Nv.l mODfl IDM1NOVA1 r 1 ) '?" m 6 UClN N S,A,1 A I-AITNO S,AE H In A cj< zz?tsz3 t A C V[NrCIt IOE1CATION NO 1 HIMr1I ICI I loX!61M!010, g12 I ?; L vFnlClf rDENlrr 1 1 1 I I e1Gt511OWNf R: IA31 1I45, M'-' R.pN[NO. PLA crM O W 15 R vmtR: lAST irRSi MIDRF -- 11 ADDRISS OF OWNtR ??++ U b'L...L cc) ctrl L ' Q 44 N E rOVmlY w[a AppRlSSarNwRAHCe eo. aACIM . ? il>\ R r[ .. wMAGID ARtA No ' /f,Z ^"""^"N v ti I?Am9cfDARU cnARU .aw''`c 1o°N a __ a lS1pUAMAGf ?^1NN RfMUNlO o ?DWArN ?9[AWH[O ESI. DAMAGE [ a10. _ roiorTb+ _??, TDVrt br, _ ee ?tL.Ai... ?TOW1DeY; S DIAG R. OFCOLLISION - ' T I T'll , DESCRIF`110Np COLLISION: ' L? N 'A-13 ?tJ,'lie - , ' , I uJ?v ? T.. r T s -S_rr1_`'? = ' ' - -? -I. - ?- -' 7 Y`aq •1?9-r_1c:L??" I=c;r s?/? T ?_ - Se - ?^c.1se?a1?- L- z ?y ht r- j?r_rn D.y?r ?w E- NAME, ADDRESS 8 INJURIES OF P ERSONS I NVOLVED t CODES 1 2 3 S 6 OCCUPANTS WITNESSES Nt Act 'u _ 'NwDw R Es" faa M1WI ADD.DS NAnel a ...._.. ---- ll -y 3 MIT 0 0"11 ON I_ N.M[ ADO.fff wi NATIM (N .-___'? R MOVID TROm 0A.. [0] p a p H O .p N wl N0 ?we 0-."O'M.0W p'.. X rLSro•• r,AMf E...'. OET e. 7 L 1111. W an ", 15 "lD T/ DTs D An 7 A Der Tq own a ' r " I I , - 6r N tF w ,b ,C:- d.....ll ws#? ,,&smn;is`??3.Y,.._ eia,r^'°a? tia^"X.?'k _.???,?''`4?.,e... _ •".a? xn ?<^n° am7 `?'. STATE OF W INGTON RADE t DF 1 WB°"°'° 'O POLICE TRAFFIC COLLISION REPORT [STRAFFICWAY N0' y f \ PoEKf COM%NN[NUMEfq ? - oq EGfcaus N r RM( ? PRIVATE WAY 2 coudrv couNnNO. orvNO. 2 44. NI (°/?j°soR' Te FF HWA e'rs JVI ?UUew kk `' [J ?N ?E ?N C?rVO4 rOWN AM /' MAE6N0.0 SIRFEIORHOHWgY C 40UTEON Sr I 4Al Mnfs [yCS ?w (&or as ICCEt oMOAl?8Ay Rf?. 5? pp0 SECrION ry A5 ?NEFRSECriNG wIH. SIPFfIO4 ApAD NON NEE45EC Y :/f '``.11 W[i1K FO. M?If PoS! ?2 TA BfrWFEN/.lV Fif55N60C 0A!( 3.97 l OBrM,CE 6pR H F fif4E .C4055514FEr RNFARFSiMILE 5 ?J J ( - ' m lES 5 E W ACCIDENT -1 DuG4AM DAfA iiEri D O EEi OF 1 r YTQI ?/ Y$ M EAGE I Coll SpNINVIX [D SEVFRiM _ CODE -UEII CF VENirCil°ES ? °R°4FRE I-.E'ONLY Ep 'lu-p•i?R(?-?'p CIEN wrvowprR iNIER Cl5 CROSSaIYfEIORR AI)R 4°Ap OR Rfif4fNCE l ,u y 9 q OB,FCr SrRUCK(NAMf OF OBJECT Sf4UCK PNp OWNER'S N.MFI '•-U KsUlm lJ 3 SSSSSSSSS ?w.?avAkYnent Si.pAmAOF 54 CA COONOUE Nb"a I UNIT NO.I UNIT N0.2 t vfRs N.MF: lgsr sr _ a 4 RIT NAMF: usr EHICLE ? PEDESTRIAN ? PEDALCYCLIST sr4FFrA IDRL ? O e ss ler 2"oc. vr, M Chell ` - gffr ADDRESS ° ?2 40 Ce , f vt - ; CI? DLX VIA? °X w. RD r su1E iRC N L pRNfR'B UCENSfN SFAIF Ex `? SCH OC TM30yM)3 WA F ?i-2BR,7Q v °4 IKNfND ArE EA ?D,[E-DFB,4H - - J n? SCURAr ON /. f6Wp ENO IYe' { /'I'tld2h"r `t(?Y }, ES GHi MFG E occu4gnoN i1RM NAMf6RHONE NO. LVVS Wcv-vti S&aol +Sf 120 yry R EYES GHI rEiGHi `.y ? CHECK (.? vE,•r EAS:v rmHOVFEaF ANarHFq, pp °_ CODES?+ 3?A1°• •einA".N? 5 [KNON? dy C?KSHEC+C 'CLEISANEM FIOrffoFAraiHF4.l w.N( t4Y Z iN u?FS QC^/0.?E'Y 4uMq ?rv D n A s: a N[CraN d y L I Sy ..? .r vcH rEY.Rmm IDOOpe ? W, :1 cSr:NOVA? Wsnle apR?^ c EV.1 iv, r AR ?... Nc[ ? &%C' ? X0.4. ? N ? °?s.. m ,y y AKF?a rti??ae,,a ?,?, N.frl MpDLfpARr. DVAI E v N Nv1 RoM .,, t } IX lCtNSfM FN SIAM r4wilf4 MFF Np. BtgrE I'I vfHCIXOR !? rh WLX ?z6 WA . - I a N . A vE KEOF tfKAI ON Np, i vFNKIf KfHi rN ??? f-? d' F A, 2,, PI 9' 6 3 8! F H 1 CV D; y 6 RfcisrtREDOwNFR. IASr n.5r MipOIE 4NONE NO. q rsrtRmowr,fR: I ? O VAOvssk'rr usr Ncsr I Moat I I I •. ,3.. SaweS M, N'ENO. ?? A SS CF OWNf. W 4 ??Ea CRc)? Ilvc ?*-a?oc? W r N owNF4 13A,.c'.. NAm!y?•DpRess or wsugANCf eo. o4 AGENr E -r DAmAGro A.4u ;.r,NO ? s ?, ? ?.'. •r4 O. . rKNKrgrvm CNA4Gf CHARGE dLN DANAGEO AAlA I- N TIO.r ESf0. 0AmAG[ ? D1.r. oree tb --"- > ?W'AFY R[AWNlD ? ?R tSr DAMAGE 5 000 OCr °Un ? L C ?o w'.f AwA'!r° -Al rMUNIO f _ ,? ,I >• r. a DIAGRAM OF COLLISION:: Iu N µ IN urz No4rH' By ' Ib. S-Ir FFSVUYf _R ROW D RIPTION OF COLLISION; (USE SUI41EwNrµ SH[Er INFClSSARYI Ve-Vtcb-. Ujs. 5 h? F-- g Qo? A w o,-kt.bo...rl? a: orauBfjY ."R J_ Nf _ ,,[ - - - - - _ _ .< Il d wvv crc ov Y eeF e?1u`itw?110 . ? -, Q Sc(EF 37 f MwKt 1N ALt 2r' lacy: ? CO Tro ?. VQ. ,? a Saiwl.- m'T 43P r Pnces ?' la caE+a-1Dw'liwif4 RR.Ttie.. . o F. a eot V ev1'. ?`3 ra L 1. nVED 1!a(J1' ty.,S 6 a, i `S;x NAME ADDRESS 81NJURIES OF PERSONS INVOLVED CODES I _ [ aW , 1 J k ,. OCCUPANTS /WITNESSES rya1 fV.A/wMµ SNf11 vy q NAw: aAOarKrw NAmesl Act ur`+" ..... mrcr r ? ri tfi+ (LF? r S!r i _ ? ? N; R[sr. E,ea .r n L'F L, Aoo.rss o Dw G,. ;4 D 2 ?. ?a. L r{ 1. „ ,T. ?a Yew _ e FYSI1'H ?c ?"" 4 ,A+FA?, a 0.Y' -4 ITV L..4 t) .. L J NA'IU4f?37 - ? S _ 1 ?i.D_ •. ? ??1?y 1. '11 4 3 g? v FADVrD room ?• M„ • / L° b ?, .. NO r er ? e ? u ?Y .n. ?r?l+ ?n°.vv {?I .1 y? I yV.. 4•nr oAr4.GprA:usN+w a.ANK egpDCla AaNCY o, iNrer, ?Ama ?c';,Kr ?K^t,•,r,?hx ?"::,v ^? t E ::f E rs ,?aT X KfpurArcrgD role A.. vro DgnaEylpr r . t? ? ! u ,v ' w ,.,. rk T,a1C+ l .,w1, tif'4?h'??hlr x + , ? t?W ? K ifs' ' ' ',d,a" ?' ??" r 04th ° ?$*" • ??? " ,? r at L 0 a+.? 1', L? r f, t{ (-7 i? r ??-F r t r , 1. 1 _ f rrl TY1? Y l ?f,' I "!' ,1 ?' A A? Il Y ??5 ?„I ?Y 1 C 1 I i- `I I J 14 Fit ak?li?L'? tfN? ?? I ?? I r1 P "'+'? JIAIL. VI WASHINGTON A G N' F I Oh E NO. 777 III POLICE TRAFFIC COLLISION REPORT III---TRAFFICWAV EOEICfCOMMINtN BfR ' PRIVATE WAY 3 Q t_-COIIIE rv lLl N IIMt COUrvrv TY CIlY NQ {NWA ! ?N °IN CITY OR TOWN NAME6 rv0. Oh3ntf10R MGHy'A?' I• g i 4S• A I 4Wrf RSI t xt WN to w y4ls O3 M, ONa Gait+n er SO D' n INIF4xCI GWtIM SnEET0440AD NO ER3L?Cn1gN `(,? / BE1W[?F` N Sl?vfffr} S R ?LvJ 3IRLFT pv[fl% f0. MIlf Po31 UI ?D / /Yn DISMN FaD4 II CROS33ntEf R AvE3lM IF ltl 4 S4 E © / O Itfi w OI / ACCIDENT MIIEAGE CODE DIAGRAM DArA COll13gNMVOIVfD. NO K4ilIED?NO.INIUR[D? SPIIUG F ?HI rv TOTAL NO ? vk WHDg4r,? M[ R CIS CROSSSnEFtOe gOAD4 ROAp 09 RF{fRErvCE • ° G VEHICLES m IlOpfvrv DAMAGE ONLY M lrf0 ?lf°'Flf O ^ "Il IIIACl3fRUCK IN-1 Of OBIf tSIRU<K ANDOWN[R'1 NAME) [Sr. DAMAGE S 3MbN CODING IAt UNIT NO. 1 UNITNO.2 ? VEHICLE ? PEDESTRIAN ° PEDALCYCLIST 3 DoI Ev'3 NNAF: NSf I.— M RNE4'SNAME: USI (As, ? LRJ L C 0Z SrRFfIAppRF33 ' Ox I , N ' 3 j r FI ADD4E35 1 A 1- SIE NE NO. ,?{.{ CODE D -1 MA f III ` E U P or 77/ ?' R rvt4'3lI<wxN 20-7,5-278 S Ar or d' ND? DA ( V I lI N A occyvNla -oz M.- r FNG fn y l aK Hl E occupwnoN M NAMe s r aNe NO. Ens IeNT aleHl Z 'S I -, A c. l R ? CHECK (.? V[HKIE AS IwIN FMAirIr Mo r AN ?CHECK (r.J eHIGf A3Arv u•pior[[GF ANOrHEVAI CODES ? 7 a ° ! A "3'A° S ? CODES * 9 « a ° S u e v E Z I 8113 ,? ; rK9B,HR. p HAAMI ? VEH v[AR M ue DOD G E CMIV W, ° &.. K ? Z, E DARCrvpvA It A ? A HA. K ? w 'nll ? Sm, ? 21 ? . . .r E 1 ? c)i ED? I I RDV. sYEZ?r.r E v v V.I MOIXIIOART vAl e ro v H [.L.( llrl°u Z SIAI .AIltR 1A1E ND. StAr aT I'1 I VFH.C IA ? VfHKI[IIXHIINGIKN NO. i v LEI-111 I N I I Z I Li isrz I I I I I I I vEG13RRIDOwRIn: Wt MIDIX! r ?q 4 pwNE ND. ? O W I wNER: wl FIRll MI ly., AooaessaovmlR/? E NAMlaA OINwRANCl CO. AGENT -atr YY1 r R I U l D: IC- AMAGI AEEA v CnARGi r _ CHARGE gAMAGFO MG - S l3r. DAMAG! ? w'iy ?ltM.UNlD i ?A= ? l1. DAMAG eEAWN[D : ow[Der: LC.C ??•? fU ?loweoer: s DIAGRAM OF COLLISION: sisuttt?H?MenM fp,eArt NO41H DESCR , Ve1 IPT h IONOFCCLUSION: tlnlslmruM[NI.WIT1 NEass I t i,es?_ d N G rttL V e Fj L4 xL _ I_ I- I-I I I I I 1-f I I I I ?, yT r_z _ _ - e _ . T o caro__S.LIUU?DCAer_ T yt??N i Jt? ? :; ? . `IC fn t.l/l_2_S/?<S VYGLtvt?I?N ? - I T T [.C_L2 -?_ ? T F Se -01.05, tl?. ! I Mg I Ta-,LK _VQ br_f_v,er S,v_eyuL_ y L4LLe r r NAME, ADDRESS 81NJURIES OF PERSONS IN OLVED ^ E " E CODES 1 - Z J 1 5 6 OCCUPANTS /WITNESSES ioi p I q i wwii xK AGt ur -vim "r I rvin txcr "? .Ma ADd1f3 NAI a 0E-------- " Nl eY AM e ?In ? .rl . ?RTiw ?r"Kgw n.M! ADDnss NArtp or- 4 •' I ?Au1 ?;"V ? o . 0 ?r:° e. Hl. •D n.Au °iAHr?m .?w ?ri° .I F{t?}^w{Irf 1Kq + 1 + T1 h? I ?{{,, - ® Y ?yrvT f ? I + 1E ?.l ' y dAit? I ?B , r ?? I.L? I ° 1 t H ? ,r t V y°? ti p t; t I II i E, 1 r t " Ir 3 POLICE TRAFFIWLLISION REPORT LEI TRAFFICWAY Icfc-, N - f PRIVATE WAY D. f rcgll N I lusls'Mf oua[ ?l? t .• w I .I wla.'wit coT F //' C[irNO.. OURAN / I E LY RUTAI'' ;,2 l ?N ?F CIYOR IOWN FtNO Oa «cNWAY U P -C 5X rCl Cls .1 111- - 11 C- r IR(f Cli I .as ?5 ?w O 2T f uA100 ON 9 iNitaSfc-..1«519[[1 OV ROAD NON iNIl95ECNO.NnF? / .' C?S?????/ 5liwfFN ?TTI-LE yYrE[fi t ?•/.Sr/? rv? ?ffjjrl71A. f'CLJ ilf x051 y c YI I ?J - is ANC. D' f [ RFN ,C9055 f1e.tl FAR.51 MRf ACCIDENT SOO Anfs s e w YInAN-r=- L itJE cooiE en, or ', DIA RAm DA1A Cql li VF NO [IIIFD E F ? «ITf RUN NO. iNRUY[D? ? IMFY Cl5 C ROSSSiaFDOR R0A0R? lO TIR ? tl VlMCI[5 1a0If1lY DAM•GI ONIY ? HSUIIlD ??[afl! ?? •V/ •? O511 INArnf OI O51[ 1 IaVCR AND OWN[v'S NAMFI S 111N 1 -.1 DODING .1 __ UNIT NO.1 UNITNO.2 ?VEHICLE ?PEDESTRIAN ?PEDALCYCUST 24 1 IZ bso ?. "n AoDRtss ? I r w yr eoa oNe NO I?okD(fhvD ?U v?8? D Y A F . rvte'SUCtNftN ?1OpQ?TC?l2?A Swlf . ZLX? ?1 IY' I V 11111IUIIN?"O, AE A MD °'I. . ° .2 aeurwnoN /pl[pM?e a?rnoN[ No. . s /CI A?IC?71? iG? [oe? E R oeeu.AnoN m Nun[ t v[gNe No. ens mm F°w«l . _ ? CHECK(,) 'v.Mn1A i o AN ? CHECK W) wnF ASAN aiorf wNOTMC SI a'"; CODES?T 7 • s lA D ?"O CODES ?' 13 c"A"' [-'i NAlDens J ? w.K l ? s' tjn,R DN ? .N• ,.MI ? l ? 1:&- uMy;,pN ?.MX .N ? 86. ? vl.KU ? :.I? _ vtX YEAS {Xfv.I ._ y AI sm (?-C 2) UD r I n.[ Naa[IDAR. vq SIA I. 9AnfvR F AIf u H H . y l.? U/M W/? , ? I F R 1: 1 VIMCI[IDIMIriCAIpN NO. I-3X 1) 13 IZD- I I I i v [Xi if iDlN ii I I I I I I I 111111 l 1-IR ?sfT rnsT MiDDU -1 NO O wl rust W Z ADD11un-11 N Nta E •m. t ADw1fs a ?N>u.ANC[ Co. - INI p R A 1DAAU PAR. V w ? AWAVN [D 4.1A (Ella ??0 OwtD ?lowlDtr A WAY 3 DIAGRAMOFCOLUSION ? 11 1<fiunj I-All P X DESCRIPTIONOFCOLLIVON (US[5-OwN1•lSMtl l[MCIIMIY) - (D\C I >?f31ClAJ7?-?_/?1P1G.Or/l?Orf+?v ?_..R(O i '?1 1 - 6ClTw O?Z/ `..t?I?SS ?•v PA ,. 7 F NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED 1 * CODE5 - Z 3 4 S 6 OCCUPANTS /WITNESSES IwlsWneMFNlu sH rM bDUKfNAI NAm. /l SI ... - sc. AGE 1•tIIS v1.. yam" .... ' " _..-....- :rfer- Mfl1 lllCl ...... «•MI • •DO1ts+ NATURE tl AM S SrI ?"" . ?2 I°(.l. •MI .. FiO 10 •ISS N•IW tl 1 MOVID I9 AMt .... _ _ ND ... • IS1 w,q(( - NAwid? iN s ?•MR ?w, o ?ir° N \? ?rXr Nw .rV w ?.v1f1G.rX.G O.r{1•f..nrwl?l yl•N• X ?! ??7N C? J 1.00101 D NO •GINCr ?? VNXO dSl 1 gL<I°?1r•ICMD i. KA?CI//II?ND /?.Y 5 D•Iltl I /Dp1 AH90v14 RY DA TI` ?' r . r .sr ; IF , t ? p'?a T 1 I ?: i , r r ?rn i`? "? it STATE OF WA NGTON POLICE TRAFFIC COLLISION REPORT 2PRAFFICWAY POLICE COMPIAMI- '1 PRIVATE WAY ?f( DA COLD! ? I _ A }Lr.I p ?wR l ; :lD,?HP.": .I: rIMF IuSF Zbo HOURI COUNlY COl'NY CITY NO. FHWA M O O N I II 0350 FPc2srnJ PoRA CIIV OR TOWN MF6NO Of51RfF10R HIGH WAY N C gWrf 91 ?. Mllfs ?z ?W ®,OF L 7t ON ?A ! IlC_J NI[45fCNNG Wt M: SIVFEiON ROAD NONINlfRS[CEION BFIWfEN 6KIL '/? SrRF[i 6 C I el (&10 $NEEi 01 IAN<f 60 N[ ON IROM NEFFRfN ,CROSS StRFEt OR NfAVf3l Mllf 3 ACCIDENT MIIFS N 5 f MILEAGE iFEi W Of ( CODE R 0 vvffl% E MkIPOSI I ?j ( 3 v v DIA PAM OAIA _. COll13gAINVOIVF0 '. NO.-. KIiIIfD -NO.INJUR[D 06,'L' E DHIrARUN -Al NO '7I rUrM°'v viola N IM EP CLS CII gfFl RvpgDOR Ruff CROSSSrRffiOR PD. L] . OF VEHICLES PROPERIYpPMAGFONIY 04ESUl1fD OvFN N ` 2 -10 r -RCr 3TRIXK WANE OF-11111-1 AND OWNER'5-Me) fSr.DAMAOF SPECw COWNG LRF _ 9 . cPirfec4sc) Co s UNIT NO. I .. UNIT640.2 0 VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST .3! pgNERs NAWE: usr FIPSr -MI SRO RNfgs NAME: wu Fw L SM S-fev-w W srRENADD^Rfss ?1 I,Y tJ tLO sINEEt ADDRESS OY SIAM ZIPCODE ONE NO. tOo?T Tow", SwJ Ws4 83! d 385 7 c D R Y s1AlE IP p ry DRNtR'1 LICENSE 3rwrf y L E% n ( v Iv -t-- NO. 1 DAI 1SIRIYe MD. OCCUPATION fGPNl W. FY[S WFIGMr HflGnl E OC<UVgtIGN FIRM NAME A PFIONE NO. EYES VhIGNr NEIGnr a Mnx e? MAO USA n< I 5' R 0 CHECK(.? 'vFHlflf aSiN fMROVFF Of AfMiOiH[eAl + r 0 CHECK(,') vEnKSEAS AN rMPioYIF Norn[aAl A =°r1° K a CODES ? ] e 5 t oat a a•u CODES ? 'H ] a . i. S N a '3"O j Nl gIE3 c O P 'wporw 0 0 cz., 0 ? ES'a TM V[nIIAR M MAKf DOOGE{HEV EL DARrN N X79' 0 O I 0 Ml:r! 0 ? .1 SrvIE IZOV..CONV.I I I 1 S VI J seoAa aDa E v H .r I nV.l' MOIXI IDARI.NDVAI jtTl.(lDR..CDNV.) ? Y dl LTC[ PV.IE SIAM AIItRRAIF NO. SIAIE H vEN. IXOR AE =U(i9? WFF - - I A V[HKIEIUNIIFIGIgN NO. I $31 1 I I I I I L vFnl EIDENIIfI I I I Nf I I I I 71 RIGISGP[OOWNFR. WI NRSr MIDIXE PHONf NO. r1?c ucrE_ X5-2 o O W v IFVFDOWNFR. f151 M-I 17' ] DoRtssa<ovmtP A SArt o Rs DRLr N E A P awNfR NAMIf AGDRI-ISURANCECO ORAGENI NOA+e R U N I nO O M -7r. rz= ... • r V < iM CHARGE r DAMAG[D A?fA ??MtiP A CMA E E y tat. 0AM OA AtYN 0 i owlo I-? .t-NED ?w'wAV E-IP[MAINtD Fst.DAMaGt IOMD f Q? Ar er $ e f le eN uPIM DIAGRAM OF COLLISION: E' S IR-N[GE ?i ?r v [NOVm DE5CRIPiIONOFCOLLI5ION: Iln[supnEMerywlsMern NatssAPr Her ?o 1 VeH? Sl' 8 s ? N ? a80.-DRwe?_Srn?s?- L ?11 et? VeHE.s tRE Oc?LV ? ?!¢- - _ . _ - Lis [ CG ? Koss ?l_lU S l? ? I _-- _ . E ?. 3e II NAME, ADDRES SBINJURIES OF ERSONSI NVOLVED 'CODES I - 2 3 4 5 6 OCCUPANTS/ WITNESSES ;a,S,IpoufoMNEU sea A0t tAIUS i pvtR A'Ir Rtsl. tJECI ...... N.ME •pemy AM t n e 0M", 0 ,11- 02.1 ? 31- NAM ? . A a3 YMRV 0•Me 0 N"%'OC, •0C. 0 ° m + "'o'- 'D N wN .._...._.._.._._.? .__-..._._-_-_.?___..-.._... ...-._.. vp _.._ 1 • uv Of 'It NnL] A- O'°"I Ot?:n° 0»= ?r:° „ N X NYI /(G+In.G/pf(I.SNAr ef•NK E•OGO. •1G1lr{'',r^. !vY?[Iy?D-?S'P•?r'C'7MO fC_4Yx{I.AfRivlO DeltaPlro AfPROHOpYU o l? COK Io r, W7P 7 r Tr.1HaS ' D.Bo -3.7c '-7 0 -- . lCtFf 4r, ?N '] ?Tp 'n24w. u,N I?y .? t MW.'W'CV wlA R i 4 y S J? ?1 ttj I f Fy ? i 'En° 4• L r` f 1 pA ?My1 ?f 11 7 4. E 2y i r I .I - _ F 1. k I ; ?4 ?p?Yrr 1 o I , f (? L I L I 1v . - 1 + n ? I I I?: GSM } i ? I y ?d??? Nr I n I r,?YYrdyy J?pj', qc elz `! 411 Y ?y+y !? a tr;YF 1 '.r r 7 h' t pTf h? til ;per ` ? 1 ? t Ir I 4 ,, '.. r Pyi '.•1., ? j.r ?Y 14 1E A Y. '{ r?;ry i :I'RS". 11 f ? 5 Y.t I L b3 t`` l ?Sf V t 1 ?? _T. r t. I ?QR IY f -?4'Sc STATE OF WAS IGTON -yDE / OF / LN wNI5YI4EV.1.eDE s? ? POLICETRAFFICCn ! PRIVATE WAY •`•-?,W^•nIX^ nl DA1f Oi_ O ll? N COUNrv f• ? L COUN(Y NO. C" NO. i vIr 5. D.twrE AI ? (f.f. IUSf ]EDD HOU91 02 8 87 I i,[gIA . o CcaSOA7 CITY O T ?UFBA RA N L R pN O 'N OWN rvAVEEN0.0 51111FORTF-AY FCTCU A I ROU(EOR ( E C s F C}pry MEES p I Ow OF C- ON ?, .S699a IN [RSfCf NG wIiH, S(RFEIOR 90ap NOrv NiFR5E0 ON // ?/ ePfFl% [O. MILE POST eEIWffN ?(.??]? 5t9[f(EE.d C?E,?!/Qf5/?E[i Oi?. E? DSfgNEE609Fr wE igOM gfiFR M EN f. CROSS S(RfEi DR NFARfst MILE PO lF5 ACCIDENT RAMP DIA RAM DAfA MILEAGE •? FEfI OF CODE COll31ONINVOIVED: EvERIrY: SN m %.+D O}aI NO. NO.R4EFD??NO, IN=URFD? SP wU IMFIL Cl5 CR Etl04ROADOgPffG[NCE 0 RAGE ? Hre RUN IN RN<TI ORIgIIOAD gHDlx OSSSIq[ET OF-c- pgoeEgiY DAMAGE Orv i II t F] IY ? fSUlrfO ? ICIE •Y/ IFINM OBlFCI51gUC1EOf OBII ISr9UCA ANDOWNER'3 NAM[I ESf.DANAGF SFECWCODINOUSE Z 70 9 - f UNIT NO. I D+wt+s NAM[: -1 U R1 .2 ?VEHICLE [I PEDESTRIAN . p PEDALCYCl15T NR I DOEF N O.1 ! 2V _T_ IASI iIR DUE •?` , b TREf1Ap gESS 5 - (2,9 ?A 9 /o ' / UIY St llE C 5 eLET ME. l 2CA Df O E NO D srAlE G II OC ?/? v eHOrvE ."IF-CE, N T33 4N ?•JL R ST ?iF FMN I. OC<UPAIION rvF NO PHp ATE W % M D o f I W Ra FNSE M7i ss ur E DATFw aI+IH 4D I D I Y. . EYES NtIGHt EfIGHI E CVPAIION NAMEt R-NI NO. a /SGAAlA /yip D R E ES pNl HE-1 Z L7EPLOSYV 1A)" ? CHECK (? vfHlaf As ax iMeiorff A F#!-It Iq:A1 ? CHECK (/) w CODES ?* ] ?;ss' n s FMPirivff .NOrHEUAI vro .cy . / A xr Nt E? D ? CODES ? T G c A i s f y erro Z r !=P M ? . v et , - r °y „I? r•D ? 0". ? ? 4? ? «S .xn yer ? " rrtv A. f IDODOECNfV ? vi:2ii ? "a ' G .I [11DA91.NOVA) SIYI[IRD CONVI BO cHcl-v Ca n7 2tl,p E I I H[Y., E q}.NDYAI Y [] v.) / °O f YH IICENSt nA SfAiE AIEq Mff NO sIAiE H vfH CIXOR ? . )bL Ncv6 G;JA - - I a IT. V[M.11DfN}iIGTION rq. C vEHI IE1111 I " 1 ;P S HIAI 5-IIaISo y i i L I RFG SRRFDOwNF4: St ' V I IA iIR3f MIDDLE P-1 NO. O IS(fR DOwrvf4. WI HRST E NE A God c MI ]' . ADDPESS OF OWNER w w 4 NG N ryuAe a Apoenso msu+ANCE CO. O4 ACI E R DAN DAw.cID ARU 1 _ I31 ~DAMAGf CHARGE /.l1 • CHARGE- r o- nIONN i jAMAG ARG f O?OrIOY . O f G ^RSVI^!yN ? ioSVe D ?R[MAINfO ?.DSWA[YI ?9fMN NED FSI DAMAGE 5 e r DIAGRAM OF COLLISION: IUI - tl I.F. I FI ?olcAl egrvMl H le iorr ? TOME N A.Al f .1, DESCRIPTIONOF COLLISION: 1013WPl[MtN s n NICESSA I F - 9 T (r1r, TUL .LL,N•Q ??XJCt?1N T//cr 1 I f? --? .- ._ _ - - - NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ` OCCUPANTS/WITNESSES°a : ^ E ? R : ,' u' i( COD^5 I f p y 4 5 6 , < f C , - l 1 NANI q NX GI -U' N u t_ - • yn •r _ l.- (• - - •f N9 NECI H Ne. ?" '?:?Kr? ? H ?a ? : F p N uURlb AwE ?AMe p,D,u?o .?"X ?I° 11 IF .,A?r„ .ala• ,R,? ,F" f5D ufxier ?AMe .• X Nrl3t? wi 1 y y / Ip, IDs < D iucE D DanaRlro.r r D [ oils o %Sn C -/ ` / CSU anu neonor IXITRAFFIfWAV "-? I an..- raEmvjs.?4f we 'art -ziw ... WIN 7 G , ..u?Y evATe^c wACMPJr.TnPJ i ? _ r " POLICE TRAFFIC COLLISION REPORT (SI TRAFFICNAY ' puff Cpzz--M'N.a PRIVATE WAY A ! o I a' .. n. R I ur JUST2 ZSi? CF-11 Np. C.- (/I x RwrtoxslR i Cl5 A - ?uwAl sE 1 1'' ?N ?! ?IN CIYORIOwN NAMftNOOf ffrORrRGnWAV 52MI1t5 5 ?w Z-F &/ ON P -Zew" ?i yr 7,`. ,S-idso f MYPOST -T ' NIF95EGiING WfIN: SrRftl OV roAO NONINIFRSECIION W. ? LL /c.?/-/??1(J? W . ?-3/ 6 CF eDw `ONf RfF .CµO......I 9 EARtSr Mllf pSr D AN FI f5 5 f /J ?? / // ??% A?CIDENL tLEAGE My DIAGRAM OAIw ? flFl Or ?A-i?. ?- v/2 R N "NOSRIfr ORROAD-ESE"ENCE f <OllSgN NvIXV[D StVt RIfV: NO. INlURlO? ?SP LLAOf ?nre RD NORIIfD N = S INTR C. CROSSSMEUORWAD ?q ?? -AlNO OVfnictfs ClfS ?PROrferYOAMAGf ONIY ?pSUIIFD ?V?'C! vim _ Q fSr DAMAGE Or OBRICr SIRU`C[,N D/OWNER'SNNnFI OBItCr SHCUI CODING l6t UNIT NO. i UNITN02 MI ME ErVl-.SN--.r ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST USr fI P ORIV(9SNM'.F w1 sl rne Nr.Lrr; ,Qdv? L D /?, - s..UTADORESS S2i/ Et7GLt?7aGY//7JT.?D. L Er ADOREu Z STATE SIPCOw PNOr:F NO. D r Srnrf E UIV ?Hi/n?tau?l ?? 9d3 R I STATE x EI A I ' 11ENSE NO. AIF sf eIn rF B Yv B _ -NIESUctNSFN nra vurD? //dw 4VA, )VI CI v c I ns Ienl MNAi•e•ProNErp NE E nr re GNI C.PAIIDN FllM Ens ez . «cuPAllan R »EVU ? CHECK I?) 'vfNlClf •s:N fMPiv vlf of ANOr ? CHECK(,,) tNOf.s•N IFE ANOrNfRAI ..E l .rv Kr e °A" 5 ' "'O Z' ' ? D c, S r%<Ian u MN CODES P. ? t? CODDUES '. 1 NA-1.1 IL Z S?d INWIFDS trMyY ? ..A ? ?v LJ cg,',,- 2110 ? -11 OARIAI °SlnEIeDR.CONV.I fE M ^ ? E? ? ? sm. ? n ? ?E ewyDIX I V.1 MCIwIIDARt NOVAI %ul D, , MA tI CNFV.I A VEn YfpAR ?I / R i? ?.C(,ev ?x E m Eli O y N fC 52+? 2 STATE 9A lFV-ENO. STATE zu,4 -' H --E- . c ytnl f IwNIRI 3 SE -I.I.."ON NO. p .10121 1212' !B!d'S1I!d!i'OI v NO L I IWI I l o I I R IsrtR o wI rl v Musa I - -- . Rfenrtemowr+eR wI nosr IDDIe ?'- Nurr ,4cd.41D w fR If 7_ •owess ar ?trt<c N E NAMEa ADwE Sa mwuNCeeo aACENT n??LG R DAM.wf MIA d,..,NO ' M`.o? gAMAGED M(A ]5 i rT r n 5 u?DAMAa Awefv ?R M.NNfo ?^RI?eN ?RfmuNtD esr. DAMAG v Borra. - ?M 1-10 r t.9 t ? A AL s DIAGRAM Of CO`I.ISI N: " isl wK.sn NORin DESCRIPTION OF COLLISION: IOSf slrneMfNru SNEEirtweESURrI ALQe''Ci ?tROG?rucr , ' ? '_ ?r?D? ,Cn nii.<r6- m ?GlE-7-lstlvi .FD iPD \ ' ,-_ Srrle .Fr oUeB Goi?clOUFx Brh/. Nic?LS P ? ` = - ? TO.d LG .QoG ?i.li4 - O!/EI?. ?!? 2ty ?? 1 ,.. \ I 1 I NAME, ADDRESS 8 iNJURIESOF PERSONS INV LVED ' CODES 1 - Z 'NNw 'O• 8 4 _- 5 6 "'vl ' OCCUPANTS/ WITNESSES ia:oalEw"Tiu rMiw iii ua •Ge I•N I , RSre NtCt N.w ., ... _- .-. r".:me •Me ?Wl ?..?, ° ?a. ?6RI.v N... owns NO NA!U N_f w"?,ti is°f ___ _. _ rNly ?•.e ?i`"'O?"NE.??E: ??'E°.v,. Ar,.,.nro•1?°.cGN.CH fN•.1 •e•N. ewuw •c(..cv o- 'I r ?1 ir•cM ?K ?•f TwD D.IfjwJR/'Jyp/?,1 •r.rovLD er D•?IL L?GFc:CSC'i/e7 r/ -uJ 3 r3. ?Q r)1L.45 X 7.,T. C , S J7 o$° u ?? ( ,6 ?i ! 1 ? 1 1 1 1 f ? 1 J S ? ? ) t 1 ?1 ?; ? t 1 J 1 I I `. t` ? ?1 e 1 rc.r ? i I r * r 11 ., ,. ,pr X q r . l att ' .. ?? ` Gf WSr 1%IRN.I.BOI • '? ? STATE OF iNA .- NGTON No. POLICE TRAFFIC COLLISION REPORT fp TRAFFICWAY fp,cfcaMRUNr NUrnafR (L'-Jl PRIVATE WAY DuE f . l?N WN. u IuN w wn. R? l 1©?H m L 1 ? couwr ? mu"rr NO. // cnr NO. - sNwA ?UR N / ? ? C??( C ? ( uR•l r gq ?s oCI?DOdClo+r C_d''e.?Ca?i/Z D r s M. RpR8 o0 or rotes5 Dw OM IN[lRSFCTINGYnIN Stettr OR qp•D NON nrf iION "'? . ? pR[f1X [0.:. MIIf POlr / D?SIANCE 6014 CROSS STeffr OR NEARFS M,If pO ACCIDENT RAMP MRFS R ...... RAM OAtA 5 F MILEAGE CODE DDlll$iONINVIXV(D' ER,iY: ?y1 fp INJUREO? ?;I'LIAGf ? wMenoiN '" RROI.DOq Rff9fNCE ?o^ RfFrb. ?r6 RUN RO CR R0355rRfRORRO 101•lN0 Mnllt F q CLS y / OvtN,ClfS ? pPORRTY DAMAG[ONIY ? ttSUInD ?vE EN V NS/O SQ CIE OBJECT 5fRUC[INAMEC-ICrl-CC[ ANDOWNER'S w.wFl f5r.p Mn•Gf ERICIAICODINGIAt 1 _ f S UNIT NO. I UNITNO.2 VEHICLE D PEDESTRIAN D PEDALCYCLIST ORIV[R'3N t' IA3T NRSt 9NER'SN E'. UST ?- R r•DDe[s RbDRf35 DJ O tJ G l6 O j ?? ? SIAIF IIp COOf pNONE NO 9s31,5 D C/Z/ STATE - DRN[e'S CFNSErvO <. 9 ?- U . STATE H ( ICENSF rvO. • f DA BIRIN IT OC?tw? W[E N4wf 6 f N[ NO. // FrtS i2 <.Rrgl??! /Y•..5. -t` IGHr [fIGNr 73 E R OC41p•MN f l p[pNE NO / b21e?2 - ,J S wllLNr IGHr J ? CHECK(?) aNlcil +s:N fmpiV?r a •N T ? CHECK (,l) v[N,a[A3AN D Spion[or ANOrHFam ? CODES ?' ] c • S T e ;,° ?- . CODES T a J X s; s upwN / e u ?- /xR Z_4z IN 3 ?y, ro- .N . XT ? u eMIR D : ? . Lv V[N rfAV [t 10pDGE{NFV 1 t.NpvA Tr f D9<ONV s l ?T? ID „ ? wNA, E ? ?rT ? am. a K v `u v N p . l ? .I 1R E $O l .l O.L?cN V.I( IJDA. NO 8 J. LATE R ER RAZE 3T H vfl._Cggg A E< S -? C GG,oo?O lJ - >o V[N,CIF IDtipN / ? O G G /-//3 (v •?? L r n,<lE lDlntlN 6 o l'0 s ? .3 9'7,7 (?,eilq Rronn•eoowN r Sr .VG- /nG wN RSr mi l- `ElSaA S T Tl 3£{5%1717 7 u .DDReu no«NER W A • 1 N E ?Oa 08 Amf•DDnss?NwRANCeeo oR beNT /?o R IN. GQA?INI I?o.tT ToYru36r? iJ ? C _ ?? ? o.? i O O.N.AGE AJIeA I Pte` n,`" n w "" ° g••SAU AAU 0 ' [ now 13 ?t0Am cH D L 1 < r 11 WAY oll-WES CNARGE _. O.I.M. [D QI A A v c o . . t5a0AMA T _ •f [ fyOGLJ OWE IS OlJ.J EJL W Y ?:owfD /"^ AY f ?? , lu DIAGRAMSOf COLLISION; lute w"uN H+l ND1D•rfNpIN sN[[t<NeeessA•q ow IUS[SVRIM1Ni•tsMern NeussA 1 DESCRIPTION OF COLLISION: ?N ??i I//CC C/ZES ?'OM/ JG ?/7 /1 LL ? $ / . . [ ( // vii/ ? s?AS /¢L o J' 7a /?!L c Z6s7" • ,,? , ., . Tr/ Gc. "? ? T/? /?CC k/ J ? L / ? f[,, G / ?/ E• IA?,+C/ / / R his ?V a < T23 LOGGbE ?o NAME, ADDRESS R INJURIES OF PERSONS I NVOLVED ' CODES I - D I 5 6 OCCUPANTS/ WITNESSES SIR AGE r•ru '" R` N n$u EXCr " ..=TiGW t?"• AL Di .°,0 7 ?' ?CL+ 3 / J - • ew•rs1 .- f 7 • •M e ?R1N' ? " . ?,^I ? u SD AMI ? OL7GL w /.JCi?Cr • ?tff ?. N•Tu•ta L?i S °'y'vsD r•om?M,• ?•ar:T?.T 0 Z., c NAI. ? ? ?: a •cu sN•MI ". •.xNG . x 2 c.l..' .D D Eo Ero A w toe. wn GENC a D' O?? Oc$ • { / + / ,, ? , r " 5•;;,r ...n k1+3i,°.°, 1c:. ;:]w '.v i:;l,..,.. :•.?1.53:K4 E _ a 1 P? 1 [ f 1k . ? 1: W S E afk? ? 1 f 1 ry , c'J I "i3 r < 1 I Tr : 1 L E l 1 ? r PRIVATE WAY - N 99qr r-... 1 1 mE COUrvrr 1 SYwTa ''ul4 .illy IUSE ].W HOURI COU cm NO. FQURem I I• 1 / I crrO row ua.u N AMESN -O- N O OPSfR 01 141[ IN . E10 lRnGHWAY FC/ICES gW1E OR CI p IE95ECtI."n o1 RF 0R OF C Uigg ON P v SOLORJ IA) e_ IN v4fNx E M4EN]51 K? O-UN QqACpMf) SIeEEre J SraFFr Ov?o DISIPNCF60 eF I All- rR M SR NE; CROSSSrRfFr?^R fARESrM lE V05 1'F•?• 1T R DIA M A ' ACCIUG FEE, OF MLEA ? .A.7 CODE IO CIXHSVJN NVIXVfD EVER rY. //yy 101.1 NO. NO. 1IL11 NO. INIURE O O L]SSUGE ?nN6RUN fIN N 'RD IN Rft WAp OIRINCE OR VEHICLES f wMr,owotw3 IME Cli CROE55]R[F104 ROPD ]] veOMRf DAMAGE ONI ? PfSUIRp ? STM CI F R^ OBIfCI SrRUCKIN EOf OBI Cr 5r4UCK INp OWNER'S N0.NFj fS1 . -- = .If .pANAOf SRCLLL CODING Uy eDIAEGC L+tMR ? C a ? S I ? S s UNIII UNIT NO.2 ?VEHICLE Delveas NAME: IASr NR 1 Mma Q PEDESTRIAN Q PEDALCVCIIST RI fas N E AM : ws1 FIR I L _ - ° staler AUDRfss R fl wppRF55 -? - ? _ Y WALE PHONE NO. D ItY SrAIE ' R ER -N-11CE-NO. OCCUPANON AP O FIRM SIA1E A ..A I.IRM I IVE ' 11 N NO. I I ATE OAt OF-T. ?. i a n. 8 . erfs IGHrNE-f E OCCUPATION NRM NM1E 6 Prprvf NO. FYfS IGNT rEIGN I ? R Q CHEC . V l R, -CLFAS 1l u P ANOrHEa Q CHECK (e) DES?* A i vfHKff ASAN CMaoY«GAr 1wFeAl CO 5 1 A CODES + ] n _-°"1" z 5 rn y W e IN P UIF - -, M 1 ' 1 INJJJ I V1N rE?R M Q . MAAN 1 Q rya Q CM- Q ""'.X $ ? ;y 79' ? Q U Q c87tr Q ? ? :° KH MK(IDODGFCHEV.1 AR WVA) Srr'lE I] DR .CON -1. V I ? 7 . . 1 I v.l nfV.l LIpARf.vgVAl SI O _ -? ' V DCEN PIA SrAIE 4AIIIII-Tf NO. 51A« H VIN. CIXOR N IO All A v[FEICIF IDEMINGIgN C EHIClE 1pFNNN I ! 16 191 IQI N 1 RGISReFDO F0: 1A51 FIRS, M10IXF F I -NE NO E 1 R iTlefI 1 I 1 3? K14 L O . wNF4. 1 r1Ra1 MI IX[ F N a ADpel35GOwNf9 W R -HER ?a Se 2 E AME6ADWlSSG1u CO. Oa AGN1 R y AN wMAee ARtA --. CHARGE C.A. lAMAGfDMN L ' xw C y 1 I A L' C) OR es 1 ? R[MNN[0 ? ARrv[N tS11rOMNAG! A.Al WAY ?R[M,UN[D V p 1 ' ° I a _ DIAGRAMOFCOLL -- ? - 10wE0 oiorio S` +• W MN ISIO ICU (u Yl eCAgERO ON DESCRIPTION Of 4OLlI510N: Ilbe surn[MfNrAE SIeE«rMass.KRYI -F- Gr?mNC?:3utir??_Cc?lue?.?. sb ? Q f j? f ? n - !ul._o - }- ..N.is_1LeNlc?c_?L.eE?ille_(?. EIJ "" J ? C ? ? I-t e.. _UCHl!FF11?????? MuelxD__oab_ i?7c.._616?cr -t 1- ,ri= '?f -,- v ]E a ` r - -._ I I?4 `? `-1- - QL I }. 11o?IBM- I(0_orY1a__LL.LAwnL _S[CIKAa( _ RaKE_ THc . DfLIVtL._CeET__'lI?SC? e-. IDR Zb Pulisa Q^^IVJnL „ , I E - -__ - -L. - - f - _ .- .. --- I r I _.. - -------- --- NAME, ADDRESS 8 INJURIES OF PE RSONS INVOLVED F CODES I Z 9 4 OCCUPANTS/WITNESSES 5 6 AMI' sex Act iglus '"„ tvR Ufa s no Ans NO aAmR r. rr o ? r ' 1A ? AM I e+ N e [3 CAP Q 1 . " . ,Y. O H Q :Y4y Hwe gA11LRr G-._ ' ?r ___ .-..___ MOV1orROM nr c) Am, QQ ? ? o • •n Wis. AR ?.___.._._____-_._.. __._.._.__._._.___.____-____.. PTO "'- " ABORII NA11Rt Of NN.?IS NAY ?AMe C]"". DIN 01111- Ki•IwGpPKI. NAY[IIAN. I . ? ADG O AOFrrC? .••• KI D?SV ICNID wxI IVlD DAr(G V11041 A vOVI eY DA« .ow WS O r ?l ,? EL j' . lCf ?yr 4 c F : ?.?1 { L?, Y t+ -? r 14yl? l F Y ,' 'f iv ! I ?; I t, 1 f f T r fj I A. % t ` ? . y ?9i7 ?'I r T T ms Ft? ,11It ? 4 a ?Y ' POLICE TRAFFIC COLLISION REPORT nTRAFFICWAY ( EpICECOmR.UNINUMBER L PRIVATE WAY DArf Uf<IXU5 CO UMf CODNIV IU$f ]bOHOU91 87 . .. ° Ir o o ?c°fFG.?so.j ° CWNIV NO. CITY NO. / QiU BAN `? URA I$N Cir OR Fow 0051NfE10R HIGHWAY (]N pE MnE3 OS ?W ?of N' ,?/ rR RWIEOR Si ( Nsf/3d [1 n , INIFRSECI NG wITH. SrREEl09 ROAD NON NIEVSECIION STREET 6 SEREEI peEEl% f MIIEEOSi ?? ' LLL/!!!- D?SI.NCFa09E IN fPOM etffRENCE. C9053519tfT0R NFARfSTmllf p05r ACCIDENT i MILEAGE ? 2• CO. -C' 3 N S F a Of J C E RAMP RAM WTA IDIAO 1 ,, OIII l101VINVIXVFD uowoi //JJ1 illfO? INX- 1-= ?E.L.I.E ?HIr6 RUN NO RR NO. N0. w O1Al n C 'RD IN R CIIN 39EFI09 RCM.00R R[fERFNCt IN IMFR CLT CRf1SS 51eF[rOR ROAn b VfnlClFS gpEFRTY DAMAGE ON Er ? RFSUliFO ?vF?'Iflf O01[CiSIeUCRIN FOr OBIf rSr9UCn ANOOWNERNAMFI fST. DAMAGE QQZJ SrtCDLL CODING USf _L- l UNIT NO. 1 UNIT NO.1 ? VHICE ? PEDE57RIAN O PEDALCYCLIST •--y 3 D9rvtR'3 NAMF EIR51 Dlt IVERSNAME: iii Sr' MI l n3 3191Er A009t1f oL u /3LJ siREEIADDREM ,Ip[G v u - lJjt?o C J 6S- D R Ir. 51AIF rvER'S UCF SENO SIAff f% DA OiB TH I Iv UCENSf NO. I Af 5f% IEOf BIRTH _DA e ?„/jy<, 'R 1+ApJa9yulo?? Es eHl tcl loY.I E ac[l1pAlION mN.mfapEaNe NO, Erts vnwHr HEICHr - ao s CHECK (?) FHICIE Al Al EMpiorlf OfAt;orHFe AI ?CHECK (?) A . rMpiEi:FE«AN 1 CODES W a i 3 . e s°en 'c`` ' 3 ` CODE$ ? * c 6i . ]] OItS vfH VFwR M Mq.[IDODOt.CnfV l MODFlIDA9f.NOVAI KIE 51. ]OR .CONV K1 0 IN`— r A M . . I I 2 a.2 /9fs t/oLd ? ? E l e An InEV.I IIDAR1.NOVA1 v.l ?__ >a QO : C N plAl O. SrA E eAItF40.Alf NO. S1Alf I'I VFn. CO109 N Il A A f - / ?Tc L.1 So ??/? - H 3 INUrION NO. NEH,[Ili 1 iV,712i20L>1212131 I/ I L raIaFIDENnn I I I I I I i i I I i l t l l l 3 I] e[G?SrtvfDOWNFR? EA31 I ST IOOIE pHONF NO V W 9 GIS(tRFD w fR. tA3 N Sr MIDIXE R DD essaowNFR SF??E N E . OwNfR :21 I.ODRE5-IN5URANCt CO CNI AC r -Al O? AGIOARlA R AN ? f ? Id:'ari:: s o, °YAMiI esl DAM CH ARGE •- DRNIN ?RfMA,NtD D CH.9 IviN FmuNen ?wcI?OV.E DEIV.p21 'esr DAMACt DNAAOlD U '... s ]] oc? MR .. x'77 ;° ' Ie MtN c IF NOeIH DIAGRAMOECOllI510N. I ssAR 1 1 BROW DESCRIPTION OF COLLISION IlbE3110.! (ul3HFEi rNECE33ARr1 ] I N i 1 . . I _ s 4 -a 2d /? / ?? -- fiu? w uoT.? l O T/ZEG 1 . rly . T do .s?f E.. SA ?' Gi3?Z"u ?'c??C. ,of'_ - - . ?i/o a A7 w?-w '.. i.. ;. ?. p..'. 1 11. G= II /?.ST? `..?J?a?.. LOST.. N ._ l a I ? S o J! J E iF R E: cL 9 ?ti /> ?:qGL? I T/4s . _ _ , _. I I .. _. - IR NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED CODES I - Z 3 4 5 6 Imt slnnE.MENru sp OCCUPANTS WITNESSES rov .DDnIGNa NAMt ur sI -su AOE TALUS ?rM w( Ilp9 IIKr ,M;. .VI __. ?N _ ._._. A DDde . NAllbnor un er ?.M e ?RI0 NI_. ODT OI::s. N ME Aml .. - wai i.:°i `N i INfnr' OAUe ? n plc , I .. n.w > .urx+ R!?%?y D F I ;"Om O :° o mer D n X ' 7 ?//? ti ? 'f k PcEEnFf 17 h i e?' d ?Aku Pfd .i.re+ d?<5R : .:+t? I{? R<.,ti ',e t.)''.•?.?-- -l i IL:IV ? .1 ,6.:C y t?tn '6 _ } ,4 ??-4ij jlJylS!I Y?Tf 'f#E RM1 g I f ^ ?R^?'/T l+ C y ?? 1 f 1 ? l . , I•; S ? i1y ? r jc{? ' S ? S fir: s j dl .2 c ! 1 4 ?l ' I r y'? l i?u 1? f ? 1 1 rT t { 1y 1 "ifi ??. °,?r}G x7iks?>ti'rcvaaxsAeax Rvu>?,"v '6i+?r 52 "? ??y ??' l 1 y p- ?. 4"??.i??i.Yu ' wSPI%19FV 1.901 O STATE OF WA NGTON PACE / DE / No , , POLICE TRAFFIC COLLISION REPORT ?TRAFFI--I Evl¢E CamPwnt afa . PRIVATE -Al HWA GOVNTV OIY NO T 3 DAfEI r.CIXV51 ._ nN 7J _ ^ _ 11115 !v Wv'u ?r91f. IvE ., 'r''?Mr TIME 1 IUSE }a00 HOV9) COUNTY 1 -•?^ . U B- Q URT. j Imo/. ?IN Cliv IOwN MllES N of? ^P / "G?--I NO Oi51uEEl OaHGHWAY ON Gad- C r RWTE OaS RFE S/Go0 CI N NTERSfCTING WI-IREfr ORRoAD NON INTER?SEC?TION'" E???2 BfiW[fNC.C%.y?? FfTe / (- PEEr E MILEPOSE. ? ?? D 1 DISlANCf 6DI9 I`OrviRUM eEPERErvCF. CROSSSTREFt OR NEAREST MIlF POST MI f5 5 f ?1 7+? rfEr N C] 0 w OE i ` 2 .?- 1, ACCIDENT MILEAGE CODE P FAM WTA SIRE- ROAD OR R[PfRENCE GOll1510NINVIXVE SEVF H T69U NO. KRLfD?No INIuREPy- ? SP"t'- ? HI rOTnI NO N ". m A' D /p1 Cl5 1 CII 110555?1$/EROa/R'O[JD . 11111ClES PROnaIYDAMADEOrvIY ?cf5Ul1ED ?cIt 1' 9 ORl[CI SIR C%INAME Oa091 (STRUCK PNOOWNERSNAMFI ST OaNAGE S SPECIAL CODING EE UNIT NO. 1 M E UNIT NO.2 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST wsr NR --M1bSE Darv[RS NAME -2 J- 9 L9 IDa DarvE ' E: /S' oL IASI rI a OaCrZ G i.J : /I9 J lE/n -D . ,? G?G?cDi i G (- STREETADDRESSY ' D SlRffr ADDRESS e-- -? 1 'IY STAiF lIPGO ENO. tY STAY -oo. ENO. /7?? //7 S3i R G ,?rs.o 5 732?iz _ ? DVrvr' ICEN5EN0. StAtf '. I? log 1 CFrvSf NO. o r3 TATf % fOPeIR1H -? 9 OCCUPAION N PHONE O. IGHT HfIGHr :_ ' `F ?a /?o?G ,,vg-J E R 'to ,o v. N9M rv-I PHONE NO. vF5 WEIGHT MfIGHi ? `u ?% J. S . , Ad ,; . CHECK( ?) vEHrcif ns AN EMPi" EF nr?IirHEa?l a M ?CHECK(f7 EH1GF ASnN UnPiorf ' A 5 E.I1DH e i°rncrcl? CODES ? K i "'L DES 5 [iee snM N -•-. CODES 1 ci < i+ +u ? m - vI p . t= 11- p .-1 ? ro H rfAV EI E.cHEVd ,n or 1° ? 586. 11 ZKIr r.AH,. ARr.NOVAI vrIF RDR..co"vl ?yor.DM p M,IM.NE! O A I Ev.l VVI, ? 'Nit ? H?K?t .•.NSr MoofIIDARr. I R. ' 1 1=.; ' / E ?U Seri aL=i?E ?i L / 3 V H IICf FvIA StAlf AUFR RAif NO. SLATE i'1 v[H.<a A l " ^? [HIC ICAtKRF I 3 8 '9,GI?!E ?1?193'? L E f tlrl A LIB 11 G/ ;1`1 /$ REGISRR.0-111: IA51 .IRSi '.'.IF PHONE NO. I N IS V DOwNFR: L/3T/? ,?JfIPS/1 MIOaf ?NE/N/O?, U ADDRESSOP Q- N E f ER NAMEEADDRE55aINSURANCECO ORACENt 1C> ' R " ' fi• a%/? u? ..! o/LT /uaL v?EJ I ?? ax DuAACf p?K .. DAMACIOARfA s rnw a;K cHAacr ?! n / GL J cHAacf ?_ wcra"u , ` °RFMAINFD ES°YY ,'w 'VSr". T u.Du 1W?? °RIM4NtD ° C:Ufi?? E ) WID AWA, By ? T W MN AG 111510N N Eu ru e+A Rowm DESCRIPTIO OF COLLISION: (Ines nEMENrAI SH[e11r Nfe[isnR E .? r - - I I, r a? I l I A- I IQ I l / rL ' .4 I? NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED ' CODES 1 - 2 4 5 6 OCCUPANTS WITNESSES _ niu eneu iIn .Dwre ?' - lGO Alu•EO ? K 2'.n. MpAMe?Fn'K'?'A"! N NAM( w ADO•rss _ R MGrID r•rw. »? ' AMe rqI. .-AtCl 'TV ul..E°Er 1.M ?.Me ? ?::" ? ?'anu J ? ".::A. »,vul: .r.arGE•sN.MU.ANr RACCl D• AcfNC• ?..• uD,:r•v.nc Kx41 AuroE 1A0" 5 1 p 5 Dula a.wl Aw•osfoe Dnu i:l. , :r .L. , ?-f I '_P _ r,vun hv?, ti a ry. , ll tsl it d ,?. I I I r : t i ' .1 1?7i? r It '+? S 41 ?? l ?h, f I r ?I? I I ?? 7 I ? s ( 1 1 t , S n l II n? l 7 U L - - I :fIF ,, , } p, l r 1 ??ii y r ' 4 ! l 1r k v I t s` Y (?1^,r A T., H? f? .]Tim: ""p-q, POLICE TRAFFIC CO N REPORT PRIVATE WAY .. u ..I c t wq. ivw ? v l - oin s?w!+tYNO, . r eAN I GO. rJ +uul ? - // pry p[ pIN CI11091pWN ??'?""faNO.Or Si+[,ErOwR ?cnW((??v?? (OMtu s IT pw qW E ,? , mneslc,lNe vn,N sr9[ r oR 9 - . ? oAO NoN lNneuc7lpr? , '?, / ItN/tlN \''YV_R'L? 51,ITT a f-k W vxDU E Mlu rost " 6 01 Rr M C9O555r9f[ NlA9t5 Mll M I'll 5 1 11 re[r'S ACCIDENT MIIFAGE CODE R DIA RAMat Y '' eolusroN wvuveD ve+rr. OIAL NO NO.[ lllD??NO .IN,YRED? ? SVIl1AD[ pnlia RUN m MIT CLt CROSSSIRI RORa0A0R 09 CIE NCE ] S -} ?v5 6VlN Clt3 reOR9rr OAMAO[p,:Y ?i15Ulr(D piEd(N o5neisrRUC.IN,wfor ooner s,ouea ANOO [R s 26 ?? wN H IS' oAMACe sneul mNC IaE r UNIT NO. I Derv195NAMt uusT + l UNIT NO.7 Dervl9s NAMe. ? VEHICLE - p PEDESTRIAN p PEDALCYCLIST usr 21 ??EE ..y'`" . ?, G_ SrelF ADD9t55 831 JAL?KSD,r? ?O rs_1 / ?Y' / tt, ADD9t55 , * r?Sa.?E?? InCODt v ONE T d-G?G??A. 7 n R r A ff 1 -it- rveslclN N A x n q ;2; g4 curAr aN AM[ I V 1 u N N At • n . a R a vrgN[ rlo. r H cni s cn ?1 d E f Occu 11- r11M NAMF a IIgNt NO ms Icn, nronr i.' .w ? CHECK (.? venro A W nvr AHOrntR l CODES 10, * 7 ? A ' ? CHECK(/( uws AN wrioreep wn r1 3,. Z S I cTNw a u a i iv.: IN w1S E n CODES 3 c1,ie . ° S uc IDn p y Nn TT . u n tA9 e V ? Ku p [bm ? W 1 Y ` vl l99? enev.l yyN?++ NOVAr S,ru 1]D9. !aSfO.PO GPA4L ZT E 1 nv.l I. l vAI l No+r ° ( NKIlIgMIr CAI JT, SrA 1941te 0.Arf N0 STATE roN NO. H ? nn v(nl l1DN A J m r L ?? 5' S 1 e1 See sn+[DOwnu- sr IDD 1 I ?;. S AD rrwr+t NO O lYr rr+si Dnus ar oWNU N Iq I ? : ? 1 NAMea ADDRfsso lMUUNee eo aACwr E 5"PAi , ; ?' S• '?? ?.t7E R 11 rfCB? Y ~ '"? . I DUAADID MIA ITO. N BIUC c"A+? enA+m .DRD, gAMAO[ A+u . ? I <21 f ' IOT10? M esO f?[b ? Aw'w: +eMAINID r ?:w:YN pR[.SSAINID AWYA D l5 AMA ' I 10io D ,.,.A'. _ AWAYMr. DIAG P?yN ?)j15J _EJ-,A D't neeusurl die RNOOW.tn y ??Crx DESCR IPTI ? V aY: Z ON OF COLLISION: IlneslaruMeMAL"[71TNeasuRr( _ I ?l j ' ??-?r -? SOnlp -- ? ,!?'???_ - rT- lS ( I ? III y crls?s ' ao , t . ? T'om ? - - '- 1 • I! I I ? I f ? r ? ? . NAME A DDRESS 8 INJURIES OF PERSONS INVOLVED + CODES 1 - p .1 S 6 1 • - N 11lS[slrnfwMU Sl OCCUPANTS/WITNESSES rw ADmuoru NAAN AMI AIr S> ?u+ Ace uTOS r '"?" ° M It sn [ACi :;D;, p'I`.. ,,, 'r ? `: '?• .. , r . oo1(x o, AMe pRLrl p1. .O? p :. Iy., ?L1o` N -E I a DD115f Y +1v1?31rOgr?NO DTNKI/I.''S''N/,MIyS I.N. ^/??/ ? I.DOI O. KrINC• ?D N? ii??' Ynit O. qC ?S. HD rQ ?SCr AI /I ,D D,1 y SlN ?r pAM1 ?ro'A'?fprn• N? ?n,nv K1 A19 n0 DAT I Or Ig9r Ar.10vID1 DArI t i 5` ? ? E t? ? ` ? n9 51 •` Nr N?L/W W/ / J'' O LV Qfl ? ( ? / I ? ].m!15' ? / ?]?0? n ` ? p , y w . l . '(. Y • F,E1a tI F b ,rfi. rt,4hfl ?.:'«a %?u aI' aka A.YA 1 ?tind. IIi it sA ? A h 7 ?' n - ? r l J ? , .. ?+1? -? ? ?'.'F's .? K , '. ,.: e3 ar :1 Jr,,? c`. it .I ' I } 1 n 4 f" V 1`I rt L I ? !1 it J`yl1 v- L? ? ? 1 ? ? LY , r' 1 ! t : , J ', I t J ?F ^ vtnsv ,mv T n . ,. HfP` F` 4°! rAL'.YSvG3:- '?iSirv KSYX.ia6 f xu'? ?'?.. ,. s 4' ?.., .L _. wCE1Mlx}.dM6 _ ,,sT,i?+'d?'L-2S4_ E' t E«s? ?, eu` nY uoa4? di P D •rrU ?' rt. O STATE OF WA INGTON Fy?AGE ? D! ? No. POLICE TRAFFIC COLLhION REPORT 141 TRAFF17AY fNKECannwlm Nr BF4 11 PRIVATE WAY I D fO?GIXI nr I 4x.I ru In.?rvF JuI IUSE]WDNOUVI COUNiv NO. CIrvNO. ?INWw --.e I ? o ?N ?E ?IN CI1v09-N eNO OF 5I4LF1OR NIGNWwY 4URAl ROUTE pE 1 E MIES ''o w of ON p ,3G 9W.0 vllRSECNNG WITH, 51RfETOR-D NONNNESEC"CIN I, PR[!IX M4EP05} ?'o w ?- BFiWFfN 9A-,c u- - r 4 P G. oy OSwNC[e14 N M4Fif9f IT 4 SIREE( C905551EFE1 O4 NEARF Mllf 5 MRES 5 F W ACCIpENi AM DAIw N FEEL OF MILEAGE ,. COD ..... ;-. ' M CIXl ION INVIXVfP TOW NO NO KlllfO NO.INIU FD ? SaILUOE ?N1 a RUN rx I NTF4 C D CRCBS5IREETOR gOdp9 ?? 0EE9ENCt CPVENCLES _w% DAMAGEONLY ?NEE ?vrIXCl I ,,. f ?j -"CT S1RUC1, EOF OBI V^»r1-110 1319UCK AND OWNf9's NAMfI E51. M1wGf SPfCW CODmG USE .. UNIT NO.1 D91Vtq'3 NAME: LASt lE UNI NO.2 ?VEHICIE PEDESTRIAN ? PEDALCYCLIS7 Dglvfv'S NAMF: 51 ? e rI MIDIXI sIR[FI ADD9t3f Slol" 2 5 4111 A.D.E. GIr srwlE :IPCOx D r m P g \ O, C NE43 LICENSE. s A rE I uEN ' ? A V IGNi IE DNi E CUPwtI NqM NAME t PNONf NO . tt3 IGHI HGNI ? CHECK (F7 vEwOFASANr wFMiprN 9 ?'CHECK (r7 VENCtEASAN lMa or CODES?* 7 ss iR Xc1 -7 1 a ° 5 I e, rt1p,°`r? 6 1 [f CODES P- * 9 H _ s; IXA5 a e "y'D " Rd R Nn r 61 Lj I ..I ,N?u 1,2 0' ( Ir U n»eVU»cf ? r4i" ? c"binu O lu Y[AR M VEN "Y' hcl Fu}CI 0 ?i i ?NK M . [IDODGf CNfVI 1lID A.4tNOVA1 STYLE I]D4. CONN.) v UI v N, v 1 1NtV.) AnoflIO NOVAI v (E????• a ' ` H . O4. OLIN PlA SIA14 lE4Mif NO. S(Ar vt .C WA Y[NIOtx IICAl-NO. r 1 I vGSRPED YM[ IATI N95r Mlpp t L v(N <tf lxN r AI Nh C ?. L PNOM F!O. ._EE. or-1. y Q W I1vD WN[4 Lur I4T MDDfE . MG tI (L7r16 .. • N E NAMeEADDRessn mw4.NCf co. o9 ACtNr oAMACt w4EA R Y - CNA4x cNAac[• "wrno a 4AMACtDARu D 14 l pANA ' rUioiroii a ffG ? ?Awwr ?4EMAIMO ??WAV ?4EMNN[C E51. OAMAGt r i 5 ( o ia io _ F l OW'ED' Y 5 t 5 TWA- El DIAGRAM OF COLL151QN: ED ru ti ICAll TN DESCRIPTION OF CppLLISION• Nsfswn[MENrM SNEn rWee35ARrI INIAI k _ 1- - - - Q 1D.?LSti ?.faJLMAI 1FJ_t» 1AFS_ i , R?? 1 L [6 O - _ 1E ? W Eo S __.Lfwc?__ RIVC o6C _I Cbf ? o`r NLS VtHiJ L ' - ?l E t s' k _54? ¢ . _ _ s. _- ? j r T , -- ' _??Wn? e -- e 1 ! _ .. ?_ /_.a -?- +- - l$O CtL?sIEx, {3nc1V aao_(?1 Ie 1 - ? L L c .N -- pNe-4-- Y'I 1 I . (IN4.DD++ B . OvT EiF.;v wN?,r LT i H 4 _ _ _. _?___ I NAME, ADDRE5581N1URIES OF PERSONS INVOLVED CODES I 2 3 4 Nw[ OCCUPANTS/ WITNESSES j°a e owooow"i _ $' F ua Aci r,.iu ysr" wr -,rrt 5 R ei?i Inn 6 $10' ,I. AD e .. ... - _ _ _.. --.... NA1 9 ! •..._? D lff wMl h U 10 N Hf " ? AM Br B Q tY<Yf ? '" • I ? ?i?' C] I'_ NOr V _ . .. ... ... ..... ... ... _. ... .. .. ..-..-_.. ......._?_ Agn4 tUQ _. __ ._ rff A1VV10r 4 °1 M»ID row. ?AMe ?"nal ^'I. p hGC 13• w alf ,M Sr ?AME 0N X Cl rri.nF ? n: ?ni.,v , X EApA U. .o ho LrK D•.Fn1CID /[l.V_e?Od 11 AFV VID DAIrMUIFUgI A v[D BY DAIt e 9 Ea A 123 I E ? B • ? EM 1?::?i ; ? ?? 381 J! ? F J( t E s 1 1 T?• X. c ?1 vF _ ++nl-e.:f:.tr_. STATE OF WASHI `TON GE / or / No. NrTRAFFICWAY vol CEcoMRI - POLICE TRAFFIC COLLISION REPORT Q PRIVATE WAY P .9TNN??A Rfj CW f CIIY NO. ?URBAN OAII O, Olls IUSE IMNOUL ..J C//GE-w/('?`? y y? i1 S 9oDE,„,. tJ IJ f6NO 0is tI OR HIGHW"Y? Ls !- ..?'a.-.? ? ?NwO lRx?T IRI <EE-i09110nNO /t-/ ?Q???? JU r .'Fr.'s M,lts ?s ?E ?oF7 rx/ ON/7i4 27iSC / v9ulx.._ .1.-T ?an: IFRUO NG wIIH: sr9Ftr G9 ROAD NoN INItRSfcl oN o??--?7/ O.O/ SIRIEI a -sT9EO S BfiWFEN ACCIOEN! 9/JA D' ?p"T" - p EaD R.M `ONi 9f .C9osssIRFET RNfA9tslM It MILEAGE %-RD 'j 7s EEis N 9 S E W pi OAS wOS IN I TOR OR FGE NCt 3 TOTAL FvFRDr Sv IIPGE ?N1169UN rurv9wDlx IMF} CM C90151TRFtlO9 .} J x • - I-- NO ?'b N1UV[0-? E Y _J__ T Cdl'? R USt Or V[H CIES D OPERIr DAMAGEONIY eEBUl1EO ? _VfH"L <lE tsf DAMAGE Svf<ML CODING n# N'S OBIECTSTRI$51NNAf Of COIFCf sIRUCV INOOWNFVSNAMEf 6 E VEHICLE ? PEDESTRIAN ? PEDAICYCUST 3T ?¢ ' UNIT NO.1 UNIT NO.2 ? 19 _ x yy.?e.? IRS MI DI 'S NAME: IASI _ D9IVt9s NAME: V•si ..? S E RfFI PDDRf55 J1 . yy,, ? slPffI ADDRE // '' C sIA Ii G/4 nrcou vHONENgfp D Y ur F / / `? ?..., - .?.? R /.J/1 99,0 i V E R 'F R iFis^ : x ' 4. REMAINED E R oi? 'p f a Til t jo r.SJ? 'R NAME, ADDRESS 8 INJURIESEO S yt-l S : CODES µN...... -uR AcE i M OCCUPANTS/WITNESSES 'ra ADOn?a+:?I+ t .HIxI - e .OC.IB, N.W. O, _. -- yi vOV10 ,. ` as". He DAMAeep AREA, a '. h eu ?o-Ac REM.uwD I?s S 5 , AuNIU SEIEII Ir NeeessA9r1 _____ R ft7 ?G.t? Gi0?(d I??.5? r ycu,G: cl?UfJ. _ c/??l D2' oisi9 em! Mmv iAius " ?.MS?i%'?" .?N ?4 '.. NT ?: ° oM ?AMR ?.aK, ?M , ? .? ? r l? ly k se,'°tt" R ,Ilv F?.IYfiU;31.1'NYNN7VRV3:r:.ds4'y?'?'7;l„-',., 1??.•.?1?'ylfF _. 'IRYY? a ?},t?????•" Y s ?, "tG'Ti' ,fit nrSIA wj ??}a+ P I ,? 4? a + I ? a . 1 t 4 d ?I T 4 ?Jl, Q a4 I .. c 4.; a i„? '? .?`° 'G 1 ISIJAIC UPw niN 4 MOTOR VEHICLE COLLISION REPORT COUNTY CITY' No. NO. „[ [ o e N r D ?? TT //1? ? No 7 ' S lS $t . O lJe f e?So . .u.,..: rG , S,[-IN ?[ ?IN ° [s, S ,c m [ nn[D mD! noGTlPn ,IlOA12 K,In ?! . ? Gr ONf FN4 IN,IRS[G,IHGWHHSrR[er...... HONN11n[I.TIEN IN .MFU eG KI[EPDe, ? pAaIAUG [ ?N E SInW Oe[IN° uI[IPGbr Gn IDEH,IrrING (AND IR. VNIGDI. IMAR, n n° ? . ?+I O w /i/llll i' D D ® ?ni I WI1Alue !RA!!IRTA ... qs NGTING STREET OR ROAD ON ?[ °o E B o 8.? Ba: ?? Wo En:...... 1.11FORRGA OBJECT STRUCK - ", OWNFj10 OBJECTS NAME MOjAp011ESS SP[a e°nuee . ,,.,.. I -°!0-°'•-? w ?__;.,.._.,..,_.f.?.Y.._.,_.Y_. ; 6b7WPdFRBerlLT..:._:. S - -? --- - ORE THAN DrytY.E?+'flL•§TNAM?:.__;..;:..:.J.? ; ;f LNAM€ `:?.. '.;.:YIIRPAA: RRUEoc, VEO 1 - ? 0 CDCtAf- C LJ0.1? G-. CDL1HN °N EW OPO ?nGWITOY?E IV(i\LL STREET AODNES9 .._gOUTE NO. AN000K T[Q, -I3q rRy1 o(l .C).80 // SwEnE E A TE _>bTREET ApgRESS.., „ ,,,_; ?• :: ROUTE NO _MD. BOA NO., orv ?8'0 Tf Is CITY, -... .: STATE ,: ,.;ZIP.CQDE_, Dfi1VER9000UPATION.: T T O W N S t N O IA F1. 4 C o1D aq? 1 CO rENMT CITY-: I,? STATE ; ?."'ZIP CODE . Q? l (Ce VI e wk tT DRIVERS OCCUPATION , o N I?YV W U8STATE [LATE OF BIRTH GE r?r?6 G3fNL W 3. q1 .S LCENSE NO. 5TATE SE. 111E OF BIRTH AGE 00 c Iz VEHICLE YR. MAKE (CHEV. 0000) MOO L (N VA•D ) - S ,(] .), 19nh IM14-1 q(I G-?G e2 0a VEHICLE TR, MAKE (CHEV. DODGE) ,M OEL ( OVA-OM J BODY STYLE IZ DR.1 ujj CHUG ()W WM `ldq_Secl( ICENSE PLATE NO. STATE .. _-TRAILER 2HT?E.NO,,,; tk2 l? f} [T STATE,..... lll^^^1~M VY?y ..W 1 .. TRAILER PLAT NO. .,.. ST„ -77 VEHI LE IDENTIFICATION NO.. •,-:,,:,_:, ,....:::...::-, TS sa?37 ", YEHIOLE IDENTIFICATION N0 ,-.;,,,; ,:.:: .:.'.. .. ...:...:..: v k, HEG/I?STEREO OWNER ILAST-FIRST•MIDOLE NAME) ORWER'S LICENSE NO,.: h ? G l REGISTERED OWNER (LAST-FIRST-MIDDLE NAME).: DRIVERS LICENSE NO, e I i--+ C)CA, al'e_. -. SAYA rrs a aor v N k.o uJ OWNEWS ADDRESS -.. .. (STREET, CITY ANOB 7ATE1.-_...-.,,;' aT DOY-SIRTH,;; CWNER'6 AOgflESS ISTREET..GIT AN4 STATE). GATE OF BIRTH - N ' S OJE' f Y}S 4 Y <- u o Y YR PMTSOFVEHICLE DAMJGEOv-??•,_'.?y-ter ?. _,_'..??•-ku [G *IG. PMTSDFVEHICLE OAMADED F? Roar $ $ LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAA YES ? NO NAME AND ADDRESS OF LIABILITY INSUgANCDE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPMY R-?A_ 14 0 f- -t GRElb m e CITY R do v? : A E , F S 7-6,.,,- FAO2 /v1 NAME AND AODRESS,OF LIA LII T INSURANCEAGENT LIABILITYPOLIOY NUMBER 02;0l? 68o,/den-xj 0717 Sr sW P70PtirtNorw*'oas E s -oro-P/?-y? 1ST INJURY AGE ND INJURY -RA E TIORADOITONAI R.RREER AGE ...ti CVL IQ" . GT NNAME l- O IN.NI REO NAME ADDRESS O ADDRESS ^S' NATURE AND M F ???III NATURE AND M F EXTENT OF INJURIES O E StuQ l/•Q AJ ? 1 r 1 EXTENT OF INJURIES ?? Dlp INJUR EXAMINATIOIESNREQBYA DOUIRECTOR+ U- N?MEOR S J •L OS EZ u EXAM NATION BVQA (IRDOC E TOR+ ED 2 NOME R 5 ATVS.PEJNJU® fl 6? NG JWO KILIFD STAM1lSSE RE4??. ...:' .FIRST ONE AT APPLIES _R, a _' ?? NO G[vEn[ INI ltv[n NINGRI °f ? N KILLED el i O o 7 5 ? DF7 Oc ?Obu:«wNn ? ? .1 6D MOTORCYCLE SAFETY: ? HEINETUSED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED 50 NORTH a ARROW IN CIRCLE ??\\ .1.1 1 \I • ERA eNG- sM[[T oA r«oHN„ --- •:: DESCRIBE BELOW WHAT WIpPENED gEIER TOVEMICLEA BY NUMBER) 464'abe , wQs . e!,1; zoAL S/?n,vv_.SLYo,¢s R?,GDUf ly_„AJIa....??n_ .y-T--?.?rt?icl_e 4V IS . _b.r> _ILSlltGla .E?o2(J1GE GLL J? V a ec A Leo ?Aca -,e l Lf AT Y-k e 1?v 6 L --- ....... ---....---- . 4 -- . 4 - .- ... IG p? c? rr_3---h-> (l??[ ?lA_e r / ?1 G a . ? ? I dx_.oP. 9_ - n -. I ? ( ? e ?? / ? / q ? / V F-•.1?../?[144 ? I I? FL I ??/}F M t N _ ! / '? . . ..[.rO/PIV.. V-•..[. ?-? / .. 18a aGe11c. c SJPsc efL t?edC._wPaKlrt?.c?... . t=jC/NS•-(/??z.t?L?s_hel4-_3.Fedvlf5r_L_.d(LI d ( 5 ;• ! ? cclLLid..lc?l-A- sx- I?...o(rtsk /t wt- rt Tet: ? F _ta o? _ a. ..[.,v _ .. s VEHICLES POSITIONS BEFORE COLLISION W VEHICLE N E ON STREET OR HIGHWAY NAME OA NO , ND I.oMN ? 13 ? W Q ?? • I.P «eowu INVE D ATE DY D,«ctoN [ r°[+iI[?? IwnN° I[°uly r.rM[G v[H,gL °cc°n[° I GrN[ i HO r11 NO r[e No . nOIIn ?P e,, ,HA`R ooz ? S utl S/ro2r n . .. ? ? . ?..:I ? ? ? [ «K ? oYi ? ? ? ? ? ? ?PRAIrr wHwAA ? ? ? ? uonG R10N TO PEDESTRIAWPEDAL CYCLIST WAS USING: .?un [?RH a?[• W • w [?AOineeH [?uneN 0.,RAA r?E, •?Ao PEDESTRIANIPEDAL CYCLIST CLOTHING COLOR: .0..- .r a Nucnrl uc, [ ?I«, I ?N,• [ ?«I1 I ? I°u [[ RQAD EURFACE, _ wl _WEATHER . - - ,_31GIITCONDIT10N4 , I j?wYLIDHT .,TRAFFIC CONTROL [•.w? [.nc.GN[I TYPEOFROM ,,.,-.,. r•w. I I 1 AGI.. „-„ p111VERNEMIOLE ACTIONS va«Ka1 IcHIC aN[onunul- .n I ??I) ? [ f+ ,r oH• 0-AWN 0 I 0 81ONAL8 ? I ? ONE WAY ? I ?j OOINO BTRA ONT AHEAD 1 WY ?W!f ! ORAWYq 10,,,a„,, 1 001ISA f ET [ O [3 1 0 STOP SIGN ? 1 0 YI[LUB10H ! TWO WAY V SIBIE 1 ? 0 1 0 OVERTAXING AND PM51NG ?! ?SNoW ON t..TB RK-IlEl DA NO E ? 1 ? MAKING RIGHT WAR 0 [ 0 KE A 0100 pHN'" 1 01 Tll ? 1 ? ILASHP[G AEG ? i ? (L1?RµAQ ? e ? MAKIIJO LEFT TURIN ? 1 ? 1 0 I YI 1 ? IIR[lTlgNit ? L 0 ILASHING _.(FT ? ! 0 ALLEY T O WAY 0 1 C] MAKING U-TURN SKCIFY 0P-I EITHER / IJ wIllY ? 1 ? ARSKNAL W . ? 1 ? µ17URN ? / ? 6LOWIHG - . I I A i•••yr«•r ILR ?` ` R OADWAT SLWACE TYPE.. 0 1 ? OIIK[q:IIAGMAN 0 / O l'ARTS Y ? I [] STOPPED FOR TRAFFIC =a• +r Q'?uwwl[ . ?•?•,<. CT-0-1 0 1 0OTH(A. SPECIFY . ,gE)AD W!AflATIQM,.,.:..:. 1 9lOPPFD AT 61fiNAL ? ?OA STOP 811N ? 1, 5. '' :Ltr y+t'y[7.YN [?'I' ? ? ?? '{ T? J {.. ??J-DJ Y ! f'` F , . .'t•1 t J. ?, .,? P??-Yr 1 ? DIVIDED 1"' l OIWpIO ?:}yv ., `T nw V ?.11J 0 IT 0 STOPPED RI ROADWAY lT 10 Af Np IN . 12 ) r r I w?J? T ? [ I . _ y r? 'u I I I [ `> , 1 S ti r , fj ET N 5?_Y MOTOq VEHICLE COLLISION REPORT °u " " C° CO V uxtlu. NoUNTY. CITY No. If N ME" Y , w n w J:?ruiies ®AU ? F - - - SO I? NDS 7 1 4 ?? E ?N?,[RIM nK1,. ?0[ /c- iq ASFpTIxDNHH•,xll,oR?o ?w ? °FN,w[n5[D, x s?? X [.n IND, O /)r_ F, oS5wao o? 5 w.E A M o DA - -IATI RRIERMEI- E r xATARw1,aw wr TRARwOn w . ?5O a oaE o= " EaENGEMG 10REESTA ETOgno ago e.w e : [ x i • o o OBJECT STRUCK ........cT MnLE., OWNER OF OBJECTS NAME AND ADORESS ?g'nv •R [c. c00[usE "OflIVFRS LAST NAME fIflST NAME MIDDLE • - • y IF MORE THAN WU1E nvOlvEO RI TRS DRIVER'S LAST NAME..'.,, ., .,,;,-w FIfl6T.NAME MIDDLE ' ' 4' I STREET ADDRESS ROUTE N0. ANC DOA Np„- COLLISION OR MORET,-G =.sONS- STljuADDREmss ROUTE NO. AND SOXNO; - • Cot/,?r o BC`'f ?? FUM-UMA SEPARATE , ORIVE!iS_QpG)f,PIjfAN,_ -,U110N CLjY??. ._` ._.y._.: TAIE?_„-?wlL??,(e CODE DRIVERS OCCUP JION DRIVER'SLICENS NO. DATE OF BIRTH AGE W SE% %A - 7li/ 7 i.• STATE Mo ORWER'S LICENSE NO. STATE SEX GATE O DArF BIRTH AGE M I MD. rA ,YEHICL YR, MINE (CH . DO GE) MODEL-(N VAA-OART)_ pqpYlIilyl _ -! 3!4)_ YE"QLE YF, MAKE (CNEY, DODGE) ..MODEL (N VA•OAflT) AGO' STYLE (? PH.), VI? Z6 ? /V 1 LICENSE PLATE NO. 9TATE .. „TRAILER PLATE NO. STATE:; LICENSE PLATE NO.., „9TATE:. TRAILEfl PLATE NO, STATE __ 1 J % J? , : VEIIICLEIDENTIFICATIONNO, -,.-_ k VEHICLE IDENTIFIOATIONNO..:, E015TERED OWNER 1LAST-FIRST•MIDDLE NAMEJ.,--„_, DRIVER'S LICENSE KQy_-?,,,,,,, _,- R&GRSTERED OVINEq (LAST•FIRST-MID-O,L NAMEJ ,:DRIVER'S LICENSE N0.1 ; a1y G . r OW ER5 ADDRESS. ISTREET, CITY AND STATE). - .-_, ............ .DATE O .BIF1 K. i OWNER 'SADDRESS . .:.(STREET, CITY AND. STATE)-,. GATE IFplflT H,. ° I Y . o Q W T ff /n+ A H ,,_ -,,,-,?,.,-? PARTS OF VEHICLE DAMAOEp r r $ $ LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- WAS THERE AUTOMOBILE LIABILITY INSURANCE 1a- COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR CL YES ? NO NAME AND ADDRESS OF LIABILITY.INSURANCE POLICY HOLDER ._ ,;,.._i..r_.,... .. „-•.,;:, .. _..,:NAME.OF„ LIABILITY. INSURANCE COMPANY .,;.:..•,., ADDRESS cir $tATE --2i. NAME ARID.ADDRESS OF LIABILITY. INSUFIMCFAOENI,. ..-....?_x.:.?.'..Gtt- L.•,upTA,,E_,_a_--,., ZIP.. LIASIIIJxPOLICY,RUMBEfl 1ST INJURY -DINJURY IUSE 9EPNUTE DEPORT FOR AOOI,IONAL NJUHIESI AGE NAM TOTAL NAME ADDRESS '-SEA" N'.. ADDR 5-' ESS NATURE AND M F r ?[ NATURE AND M F EXTENT OF INJURIES ? ? 1/Y 1 EXTENT OF INJURIES ? ? EXAINJMINATIO1r ON BY BY'ADOUM CTOR ? 6J NA DOMECTOR'S ?v DID INJURIES KOUIRE EXAMINAT ON BY A DOCTORi OOCMETONS EXA U- NA ' STATVS OP_INJURED ,,,,- JAARN FIRST ONE.jNAT.APP-LIES...:-....:?- :' 9TISTUS9.E.(NJURED -•L[-L:..I.IARK EIRST.ONE THAT APPLIES w Pl rp vaL ? 11 i O IN Y KILLED ron Un ` .._.- ISfv[n[ 1u," pO :Q NO ?P.[s NO KILLED 15[v[xl u,NOn N c PA Oo ? 5? 6? °.T N?[rcl . ?plaN wRnm ? 5? 60 7? MOTORCYCLE SAFETY: ? HELMET USED ? HELMETNOTUSED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SHOW NORTH B ARROW IN CIRCLE 'ww nArclAlep O \ \ I ? 1 " ,, DESCRIBE BELOW WHAT RMPENEIX,fREFER TO OyYMIICLES BY NUMBER) ' .4'1h.J? ??¢c.edt..v_y._4A?hc._7 E. S?c? G1d •'`•. nl?.aclfr F.h.?e?_5-u ?7?oz.NLcO?r.dr5 v.?r.h ? ' mwilDNOrr ?\ ? I •.rll..,•ADw JM tr3-E_ c cy l r r?.d7..e 1_1 .gym 1L, tl?.i des -k' fJ- - `/- r -?? Qom- [ GTi ? '•,H 1., o•x Truk ?,s` F'MAII -F-(?!-e?ty...f?.n-es-PLI?Ja,cited-.aFF ch-c?_?D. -- -.._..._--------- ?w3rS-urfc- ?.alLGOX_..v.h J:oh_w IL; c.y ti cC.a./ed by 1 Nta r? ? .h a11. L;<,-Qr 1.DYE_..Yt_U-,o/1. y_ wcc?`trr _ ed.. h nN..wP.v Fd d?'c-v5 VEHICLES POSITIONS BEFORE COLLISION Al- 17 Mll INVESTIGATED BY J ° 11 0Allr •,uaM VEIIICLE N S E W ON STREET OR HIGHWAY NAME 01 10 r l'OAUr rAIIr[n vlY x%[OCO u' nIxCIX [ rw f NO • ina N ° ? ii ? i41'cl R;',..RDYIIt ? ?.? ? / ...ri.._...-. ..? _ ?ER". ®wi pilrv ? .. Q ...?: ? , ? ,. AI ? ? ? ? .._. . .. _ ., ._.. . _ ? ? ? ? ? ? ?z..., nu1,•,w ? ? ? ? AL- FROM TO ? PEDESTRIANYPEDAL CYCLIST WAS USING' ,?°° r?•M l?M, [w. u • a ??u •?? •?°r r?ml •?An A ' PEDESTRIANIPEDAL CYCLIST CLOTHING COLOR: ?n•A • r ID r•Gwn[c,N[ wA MlHCrwl ..r.A r ?LXr~ 5?N?. •?rl f?::R• 'L ...ROAG WEATHER.. ... C•b ._.00NT.G?ND1TIpH8 ,., TRAFfIC CONTROL _ TYPE Of ROAD 0111V[RA'EHICLE ACTIONS Mr M••R? [u I ?DAYIIDHr RO <r OLIN I[ KAl ICw Lnn•1 1 ?Ylxr'J• ICIHG -1 OR Aqn[ 1 b 1 1 1 ®g1•U.Lt• 1 I ? MY ? OA- ? 1 ? 016NAL6 O ONE WAY 1 ? OOINO STRAIGHT AHEAD ? , ? f ? AUNIAQ [ ? I ?w[l ? M AI, ET ? ] ? E,DP SIGN Q T ? TWO wAY ? 1 ? OVERTAKING AND PASSING T ?D.oMIND 1 ? IAgw ?) ?l?0 I6 pri IINR ? S ? YI[ID EIGN J REVERSIHIE ? ? ROAD ? 1 ? MARINO RIGHT TURN 1 ? !00 1 ? • ?NE ? L.GNI! OFEET DA ? [ ? IL,LSHNO "to ? 1 ? INTE IR [ ILOOPrnuNOPi 4AKIN0 LFfT TURN ? 1 ? ' • CI ?M•ECHYI ?[ ? Zi'lo IIOHTE 0 S C] ILASHINO AMBER ?ATYVO ? 1 ? E ?MAKINf1U•NHN I VEC IY ?esIC IY ? An.-AL 1 7= L ? ? ? 1 ? SLOWING •ruu"I AT •.•, r?? [f,Q ITYM..,.. r MIRY [UN u. [ r ? I ? o"ICEW/LAOMAN INES ? 1 ? DRIVEWAY ? 1 ? STOPPE D(OR THAI FIC . w f u•r. 9P N ? 1 ? oTNIR, EPECIIV NOAD BEPAMTION. ,, ? / ? ETOPII DAT RIGNAL OR SLOP E ?Ip . ???rn1? ?•nul .r. l ® 1 ?[ w -1- . 1y?1sAI i ? DIVIO.p ICY ] ?WIOIwOEp TON ? 1 ? STOPPED N ROAOWAY ? 10 ?STARTNG IN IR Ik LANG f v} - 1" L 77n ";1 aR 4t, a A9 "7 5 ?'fi q r O STATE OF WR INGTON vAGt / OF / PI%19FV LBDI No e J POLICE TRAFFIC COI. ON REPORT aj TRAFFICWAY POIK MHUMBF9 PRIVATE WAY ur wu N .!.• Nfw .?° ...I 'A nme ws[T.DD RI FL[e roAJ mlmtr7( //- a1r NO. FHwA ?upew ?[F Op CTr OR 10wN fNOpp?? a t09HG. Y C1.5 F RWt t 2 / MnFS s w J9OFC Ilr ON6(/LJT(/ALtS 44 (o - Nv3l CLING wt " ltvf IOR rgAD NON NTtP LION PRff1X Maf 90,T / ?? BFIWf[N ffO fi19t[t f 119fF1 ? Ce ROm 9NFVtN F CROSSSTVFti a AeF, 1f 9011 /"J mltl 1 F Ftf1 Of pCCIpENi MILEAGE COpE P RAM DAIA COtII'ONINVOIVlD 11 ?N VFRIFD-NO NIURFD? ?,v II NO AGE ?HIt•RUN a Nrv 1 QFN wv'jgvi" 'N IMF CLS C90S1,IPf[IORRt ?R O4 R[ifH RT ? 1H Cl[ 5 vROPfeir DAMAGf DNIY ? P(SU111D ?-1- 9aoo i /? _/i GBII TSTVUCn ,NAVt Or O`BIt?C1119UC. DOwN[R/yy r/{ tl tS1.0AMAGf L..L! 71TfTf ?(.?,I!/Tlb /?L { ?p E SPfCW COOING Ibf UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCUST E o9rvlas!+ynf us1 "', m? ole J; nfa sNaxc. w,1 Tin, 0.1 Aw i • ,19[11 AOORESS RFtI ADDRfS1 Z 11ATf Nv CODE HOrvt NO D SATF t . o ? Z." Wd J 9dS 7flp R Delvws <FNxN uF F9 y?Uir 7syP? N o?, "I I I V Iv ucFNSF NO Arf DAIf BIRTH ?D D.Y ... pip rlem O?F?N?OH ONt NO !1 ?••jN9f. I Ni rf lGNt E IX<UVAiIUN MNM1l6 PNONf NO [YFS WlIGN1 rEIGNt F% `r 4a ? r 4? 'Old R ? CHECK (?) IN unnorFr a.NOrnreA C] CHECK(,,) ' OFr OfAIDD-1 v CODES ?' D 5 r a„ " I.u s.snv N.+ CODES ? 3 ?, Ste a *.`N`,' .ss s.snv T ? woes 'j s'-I- o .YN I. I ? ro,<t o MIN, ? ? A N .NTI ? N eO V6` ? 1"8:111 ? ? x, o ?11- oDOCF.cHrvr nN rfAe Zpt I FnDAVt NovAr se Ll?f a ca,v r ? fAR 1 r Hfvr nloou IDN+1.NOVAr r 1 yr l 'c'P N tY ? r ? II 1 ? FN A1e AT rRARtR nAte f io H N G GR N l n A N .wtQ u i A - nHKte IarvnNUlaN No. j„ . l i O vFH nF IuN N A I N , . ill I I I I i! I ' 91 DOwrvtR US1 NR1t M1-1 N,ONl N O RF IStF [ wrvl R. 1A51 FIRST .1-1 - ADD9Fssaovm N • owrvtR a ADOR[ss v INS e. n co. OR A-1 ' R FB6ATE N u An _--- ' r v DNBAGt APIA ' p''•'`d ' ? ND 77 CHARW Mf r,!ftAg [A CHARGE a'M?ou"B'Gt DAMAGE [A "p OtlO 1 ' rC ? KMA L ISt ( 1 yl ADWii1V ?pIMNN[D 0 ?Aw?Y ?RIMNNFO I,T DAMAGf I------.• , / ? E7? ? A.-11 ?i,wn?ev. E • r DIAGRAMOFCOLLISION; iiRSlu fxysS.Vii NO9tH ? I DESCRIPTION OF COLLISION: IUStSWft- SHff11FMC-Rr1 wi..c ?euuGeiaC Ma/L rJ?ftiflJ?Q hWhkt•O :fj ? ,,, _ FGJtr> UAL WO-4 /A) MA4 Vbse CA fTAWt O.uTU TNpucHG?? G.ii.v7.O?JF..Q 7/?p!'?,NX . ??? - ? ,sN.o .riTtB.ex rteRa?E s?ira? iii000???sss etsN 7,a ? AN /3 F ee?rc Rt•c 21 , . _ , ? O NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED ' CODES 1 - Z ;1 4 5 6 OCCUPANTS/ WITNESSES Boa wD"la++i lN,:.W i? sra AGf 1A1us ';?" ° s of in Inc, •vl i,0 u910F e n,r w. ? AM B ? t2? ' E D . O ? eVr NO ]0 ? ADI,TS'. of GI ?9 :s ?v'•GM o.NB ? .I o^ . o ? : b Mt • :;a • •`,L?o. ' R .v ?.ue ??"::'D o'"r. Cr 'HS. t ?'+ n•r .l o. wl.:, X ..ow••-NOI,•I.. }?Q S„??D out cl Rlro•1 v?wl..f.a, s ??•.'18'?i6 w....-?ri'?DC.ifsi7.V '?/S ?. ?0 /JL?'.DBr /C6/? oAN O t'?O 2 {? eV 1 ?,? °} Jp FBIfI ?T y/,wl A ! !}? M'r x! Iyvvptlry•Y A ?& h? 51u? " ?' "LYXVP 14v\ P YtAli" XRIRA i. 4.YrsY L l4 LL ( t 1 l i r ._ I ? / 1 ?, ?` I) afd , I } dNy9 S i? f ' r ,},a f I ,- , r al 4r } r y r 'yr t'F?M ( _ ',4l yy MTRAFFICWAY COLLISION REPORT l toucfcoMnAwiNMixR FJ - /`-' J POLICE TRAFFIC [D PRIVATE WAY •'•"? I RHWA arv NO O DA fOfCpll-S N 4 IU ION-.. IUSEDVN HOURI CWNEY r +uvs'rv? r 1D . couNn N . /? URBAN . Zi - v i.: x f F• ;?% wn.,r f ? \ 1 al- f` URAE OR [ stC 7J [' 04 Hi GHW/.Y 51vEfE iN CIIr OR IOW EBNO Of ?N ? .q t L LCI CIs RWTE a ?G99D w , or, I o' MILES ? 5 ? RRfFI% f MIlF fOSt 95ECitNG WIIHstvfFi09 AO NON rNIfRSECII N I I , BEIW 1 I N SIRF[i 8 SiRFfT I 0?5 ANCf60Rt IiON rR MVEffR N<f CROSSS[REEiOR NFAVfsiMilER m ES N 5 f w AC MILEAGE LEAGE A ... RAM DI RAM M ' ?? i[Ft OL MODE R RIf( NCf 'N I23 R ?SRIIIAGF ?N-UN r.IND.Dlw CollSgNr vIXVFD ?R I IME CIS OfC6551RFfiOR ROAD ( [ tU NO, NN l oIAL NO ?F111 D ?III p[vEH-$ ?FROFERIYDAM-ONLY RS NAMEI tSt DAMAGE -1-17W 40d SPECVLL COMNG LSE ,. (1. ? OBiFCt51RUC[INAMFOil?SIRUCV rWD OwNf E UNITNO.1 UNITN0.2 MiDOtF IvFR'S NAME: OSIHICIE ? PEDESTRIAN ?PEDALCYCUST lAVE N I l S FIRII tR'SNAMF: lA/SI/ `' .t ? SS O SIREf A 55 / -. / "? I SivfEt ADDRE NE F / ?J F ]I CII StwlF .000E NON i D IR CITY sIAIE Al SU<tnSfN A Iv l N. NO. All x _DA AY 11 F'ff5 I IErGHI E MNNAE S RHONE NO. EYES IGHI FEIGN -AlloN B ... a<URAi v f RHO ENO. R / ANOIHt+'. ` ?THECK (.01 ltteA : MRi IF A ? CHECK (? v(welf AS AN MEiEirrtaANOiHEaA` g(, e w+ar ' CODE S?' CODES ? . 5 Ix f E N?tRxS Ixt..1OQ ? AM, » I ? uetE ? <s:?. t.NOVAI 1] w4 545 DR..p .1 t IDU [v NATUR [O °? 1 ? ut' ? pbm ? „ ? I:.'Hi. yotb ? H I IDARI. K,1 1 V.1 VA) -I O .l vfN re.v µx.E (DODGE{N ?^ 1 ' .• Rlw SfAI AR[+RAIL NO. - SIAi N vfH A f .? . 1 / 3 ?J? - » /! vE KLL,K-1gAlx%a NO. L YEHCItIDfNII I 3 / / ! R ? MI Nmt: IASi NRSI +fGrSRRtDOMN +'. WI iI+SI MIDDIt .tgNE NO. W OwNr-?--- s ADD+LSSa oi\+!u N -' R N u AN ]] AMt aAOORtssalNwvANCE CO OR AGINt N- ?- "•is c? czfs czJ r rwc OuM p1.MAG;p MLA O4AAG1 M[A dix?r G `I ' ' wCro+ci CHMD CHA+U rw t p. f5 D D f , 5 110. nfr! RtMAIN[D ?OLMNNID 1U ?oTi4? 5 IIIO.'DAMAGI AWAY A Y reiono: S/+ o D ? 12-1 eY: S E ovrt A Br Sseai svAll-1H OE R1., OF COLLISION: lust slmnLM[NIAL SHFEI rrllclssA+r? DIAGRAMOF COLLIS ON: Iu - ? ?o.t}uviR3 _ CoLLJS/o?! F.tJr ?S J _ 41 r IE NAME ADDRE5581NJURIES OF PER "" " S `" SO I S NVOLVED CODES 1 -2 K" 2 M J 4 5 a 6 ,. OCCUPANTS /WITNESSES ;n Ig AD D r iA SI% EGf IIV M n LNCI , N.«f ° ....... .. ......_._.___.___._._.._. . wota _. ._.._. __..__.. w. N . x«e ?F31'?^".?.°iv ?NW-,, ° ? A mn ns NA«F .._......._........_..._......._ SiimRa .. .___. .- .r'trv?DrRO.M?A«E ?1?o'?N: ?7.a.,. A«e "d • A - V 9 iTiB,... rl f !v ^ ?, .S pl ? I ?. 1t$114iM ? 1 rE v 1?(f !? ? Y Y1 , -rfv? r 7 ? li t L ' `` ?(1?' f ; I ,r R 1 ' q Stkd _, .} r STATE OF WA INGTOPN 1AGE > OF WSP 1591RfV. 1.801 No / '•., _ ,: POLICE TRAFFIC COLLISION REPORT CRTRAFFICWAY -111-I'LAINI N1YABEJR .yY/ t'Fl N 0 PRIVATE WAY pAlf fC ll llMf CO4Nrv ?s } l ?Ar YR? wx Rox u, rt H HI t X (USE }-No RI 3Y nr'e;'O 3/ COUNTY NO Clrl'NO. prywA ?u RAl e pN pF pIN CITY Op TOWN E N Of SrREH OR nGHWAY CIS pWrE - gulfs ?s w pof odTA?OLoL.? ON RAa40ISr BA R ,NIERSECr NG . -C,O+ROAD NONNNIAECTIDN cSDK3?D x t MIIf ROSt ?.-f5 (//r. . y _ /7J BETWEEN f Qt A -W A QA)irXA 51 STREET p µCf eplR I ERE C Nf ROSSSIRfft F-MnEI'O ACCIDENT DIA R0.N MIA / TIES I RI E F W IO ME Y iFET OF O A ROAD CODE - CO III.L IN IXVFD' SfvfplY. f wrvD`I R IN %'R0 9 ORW f NCE COVEN NO NO KIIEO_rjLN fD_[}? ? Fl IIAGC E] Hit lTp RUN IMfR S 0!0555 1 OpW O VEHC p prY DPMAGEIXCRILY JIY ?UlrFO ovEIXCE (O/ / d s" 9 I R- OD1ECr STRUCKK INAMFOi OBJECT SrR ANCD OWNER'SNAMEI EST-AGE SpECW COOING USE e o „rr R 04 o ,? c s o -. f _ 3 UNITNO. I UNITNO.2 ? VEHICLE p PEDESTRIAN ? PEDALCYCUST pRIVfR'$NAMf: DST : FIRS, Mwplf p+,vfR'S NAME: Sr . ;. '+ TENiviRMANN HJFR ?z? C ffIADORfu srR a IRfEr ADORfu --- . ^ Pta Brh r, D CIfY E Zip COOC PHONFnq. IrY SAI iP F?? cQfs? 040 66 .y3 IvfR'S UCCNSENO. -If 11 R ' { 393-?8-659 ?„? MD'?AY' 3+ I ? rv IICFN N[i. AIE BI H ND. IMY i... E lCUpu,GH N+M NAMEeRgNENO. fr[S YRIGHr1EIGN E pCUPAI- FIRM AME A PHONE NO / llty /Ja R . EYES IGHT NFIGNL ,• p CHECK (i7 vfN CCF ASnpFmROVFF pAN I M ? CHECK (,F) 1 vFN CIf ASANIMROrfF OrA=C i .pM r CODES ? * 7 ?•cu fl . CODES W 7 n ti a ?; rz,","' S In N [, ?N'°ry .cH clw /n • • N UHE; /?oNE INJ 11- s . M p A E p u 6 '? b ? M K IE . MAKC(WpGFCHEVI ?+ m. 11I DART nOVAI SrvIE E}p+. ONV.I ? -FINANCE ? MCI 0 Mrv- p U- 0 P 1 NfV _ / 19 v E .I MOOEI IOARr NOVwI 1 ,) }B W N PA SrAr PMIFR RAIC rxJ. SIAtE H H vE OR Dtv d v JS7S3OF Lr C NnIR[iOFMifKAtNDN NO. vfH CIEIMrv11 Ai N IJ T C'L 4o' -2 S o RwlsrtxoowNeR: vsr rl+sr miptte L F + ' { " . SA C O RM)HF NO. O , + wNER, lwsr npsr Mi 11 e 65 oo+EUaoA+.e+ W A owrv1R 51 N E N.A.E a App+ESSO IH.-Cf co. OF AGINI VN R n NONI 1 ' ?l CHARGE CHARGE UAMAOE?I AREA ? S tf pAMAGt ? ^W?Y a; IMAINID p AW'IpP[MNNFD ESI DAMAGE ? E ' ! S 000 ?:wv°er D/t f$ (;ARA6jF pnINN. f Idiono DIAGRAM OF COLLISION: -11INECI-111 ev::'v0°Mw'r " DESCRIPTION OF COLLI5ION; IUStslwPtemarAl sHtn li Mttsu+rl ?° DRivc"/t OF- vinyl No / Tv`QNIrD To C , . AVO)n T-a DEZ '7T E % f 4•,-::,? R. N• o/v D AeAJ./$ Tv- RoJAd SNo-`a.oA A WAS So N4RRoW Y=HI, Do•9T Y 7",QAlIC cR C AMEN 7ti ';j j44DnD?$r IIAr Ro Resr I.v T/ve V'rRj' o4£P af7?H. „ 1 . NAME, ADDRESS & INJURIES OF PERSONS INVOLVED r CODES 1 - 2 9 4 5 6 l H lose sl»R[wNtN B OCCUPANTS/ WITNESSES IG+.DOHrDHUNA Ame: m Y HIn ?N Yrx v i.r wsI vx Au TAr : wsr+. eJea , ( ' ? i ?? &At - r ,. a NAAIL.1.1 eY AM e ?'K41"I p '• . 0;;Q' ? C.A{Ar A may k'"ti x twnu Arwr or +MOVIpI C, OWIpRI , p.my pry " D A h I H , xw?a pMIB 51pA1VyOWfR:1+3 hAW{+A 5 '•.v Y. 1M." 'I C°'^•0NrY pn'AA '.? •?' ?. r NE +ApGI O+AGING. n MTe X D, u.l.' 3 53eIRD 7,ff.'s.TD IAII .? !IW45; v.? n r.' ? K•w. . +.!. }. £' H4 m. ' r,..;J.:.. . MI,E H.'I\I1 ;Y Y . R v ? ?.T r 1 P { 1. . \ L'4 ?.. /, ? ) Ih: L,' $??• ?" ?A P; a ?_ -• I y }_, , 7 y 1 ? r? y ?:e E EC F T T 1 ? p' l ' P s ? ? ? ? AL j rh 1 T .yl ? if JJ ,L ' J A 1Pf ? ,' 3 STATE OF WAS NGTON P•Gf I Nn. AI C; 9 ' CJ POLICE TRAFFIC COLLISION REPORT Ky I-TI-Y iOIICE C01«PWNI NUMpFe I Ej PRIVATE WAY 21 Dicau E p.r v ' i ou1 y. urn. DUlt. x,R ?r:l+. Nip H, 00 IUSf Z.Op NOU41 COU- <ouNrr nrvrw. OEUge" 6 OOiS r0" GNWnv 1]N QF ?IN <Ifv09 rOWN «Ilt5 S ?w or /jypLUCK ON ? E 3 t;Zy iCl tt3 40UIf ON 51 f h f?99? NIF45[CIINC WITH Ivtfl04 ROAD NON IrvlfvAs0f?L?11?0N Se???aei pFM'F[NI.(.El UNe BN SIREET B '%Y [Er PRtI1x O. M4f ro1r ?' 7? / 1/I•n DISIANCEA WcIIXUNIRON vFEFRfNCE, C4DSS SI4EFI OR NtARF51 «IIF VOS _.? f5 5 f retr w Of Res AC' (DENT MILEAGE eoDE R DIAGRAM DATA COLL-E.NINVIXV[D EvF91rv. re9 rOIAI NO NO 4IllE0_NO INIVe[D- ?$PIIIAGE ?HI UN .IlrS?N ??"s 1 .aD IMF CLS RWpOR REERFI4CF fAO355rRljElJ lj?? /ZZ 1 Cr uFHIGI[S © PIIORR1Y pAMAGf ONtr ? RSUlrfO ?vFpCIE 3 O v.S' (OJ'J / 9 OBIECT Sr4UC. NAME Of O01ECr SITUCR UlOOWN[- 5 NAME) f51pNAAGf $ r. SRCU COPING USE UNIT NO. I UNIT NO.2 O VEHICLE 0 PEDESTRIAN ? PEDALCYCLIST ! _ DRIVER'S NAME: N31 N9S1 MI Dlf F E? E?6E1U6 6 Iv[45NNAf: IASr IR ? sletFr AOORF STREI AD09f53 Olr 51ATE ZIP CODE PHOrvf NO D 111 $AIE IPC .E / . . 04.,9'5 UC NY Fi?EtEE ?oy6N SIAIF x wA m ?, i ! is?5%u I V E Iv U FN NO. : AN AT IV H iBAr i.. OCCl1PAII- MrvAMEeNgNf NO. EE5 IGHI Hf IGHI 6tuw (/n I I 21 r3[o /BO 6 olf p R CKCUVAN E. PHONE NO. I- IGHI HIGHt CHECK (- rH1a1AS:N 1MViavR AxMiolHf4'"I ?CHECK (?) L111, Pl? NfMRorIFOrANor CODES ? ` D i • s s 1 116 CODES ? * G e. • ,n a Z URit3 Wirnat4w ? A«MA O W' O Cl O w O ? 15'° •t%, O„ O r, NI' vE1000GFMFV1 11A l97 Bw AvOpfIEDAargv 4A1 SrtIEIVD. CR4V.1 RIwEe Z-de• v E I.rA 1 Hfv.1 MOD IDART, 1 Yd 5 ? a A F SrAlt A1l[v RAZE NO SrAft H FH CUOR II A A vtHlClt1-11NCAIIONNO v B v3144 510 ,6i i vFHICIE IDtNI1r, NN 4relsrtRmow,Iw usr n4sr MIDDU E uEEVE RaNE NO O W rsl -NN lASt 11411 MIDae DI Z Apo4Fssa owNee GUS7El1 5T /?A 118?Sy E t4 A«Ie A0DR155 1-TI-EM Do AGINr N R N U AN I a! AMAC1 A4u ., a ° R AGED AILA C_ x! ounAa 1 cHA.D _ - y aEMAINtD cH.4c ? O9EMwINfD ?wiiN _3 Ir e1?oAm"c ? 5 .y E UiOfrO I ?? i /1 i iowD ? S. T w r0«TD v Ar er. s 1 T? DIAG OF COLLISION: 1 l Dc 11 H s ?rNiuSSaar1 a Aeo"o°vi' DESCRIPTION OF COLLISION: IUSf 5UPRIMENIAI-(IT N11.1S.Vrl r IRCCS J ¢e XH V'cINCLE. -m l 7BNuK/rv6 . Noe7?r cN J 04r Erb Rd• LlnAtice= 70 /?660 _ c! ZcFr'~ It. 'v Cueve-, L6F7 7WF E _ c w'rov tv?i? 1E`1++0 cN/g6 70 rZES•7 CN / THE TQEES ON ;`04E eSi,S7 S/UE _ CAK Ga#N9 24.gt) r3AY NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED ' CODES I - 2 3 < 5 6 OCCUPANTS/ WITNESSES sf. Acr urns ':'" ° ns14 IAC, «1 N •DDnss NAIL' 4 Mll 11 --o- TI-ow O"' . O ? :3.,u w xxass u41 of eti sDiPO«OANe C] o-;- O O 0 •Mff155 FIAT' b9ra WV ?s O ?' ' O<d. ? ::'N,. ?a Iw 'n'7 a / J mtlro•t-r Caa.sww erAi.. X L?K //.II ?c e.coro. Z ru.c. IuSP I . ^.. .. >wAhiy Cq4 ?ZOU oraroa :3rao p rc' 232o0 PP o41p DAn ' ,C; 7 °?sh ?? ?SSa`?SYl` , r fIS'"?"i 'Kr. .• i?r I "3r?r, w. iu '. M '? !? . y T v+x ?M NNE 'x`r s Y +?P ?ce^ rf 'M W4YF E)M1 ?$efi, f W R ?' 1 / l? t I1 .dL?? I + E ??lv l II 4 I C? )1}A Sy ? •u a s ? ? i= 0.k '9f y B I. I ? ?1?,. ;f 's E ? f Y11 ?? ? l? t, 5 J? .? tire' q YI I? 1 I ? I?. % R if 6 I u?A I ,,q rS! WlF ?? 5T /?flaLtel p AGt N1 N n.vGt ? n ovn?n f"l vttn.?nto T J IPCCS /3E'o5 4 v UAK t'v?10 \ aaY NAME, ADDRESS & INJURIES OFPnRH nrrti ANTS/WITNESSES 'u-"-'-up E R le • H v n xov n vtn at?txnl,r, nn l!J towto - .. - I $ I ?. e iCRIPTION Of COlLI510N? Itne eumtMtHiu Staer,t ntcess.v 1 vcNrat.?? T2NuEUiu6 NO27d cAJ OaC Y?~YRd• UnA&c 7b /?66aTior? i? LEF rsn??v Guev6'• _ 7 ;rAld: .0 - 70 'IV THE Te6f5 av 7746 6-d7 S.UE -rAr 2vrwj . U. _ 3 4 5 6 LlLa rl 7cla? Z lusP 8 rhP?, P? ° u. au !??? { x Wi1eor 'v?' ti ?HIII:!; hr r r ?„ s. r I ,1 k 11 y j 1}? t ?. ;•? 1 r J ? ?.. ?It 4.t. ,, ? rr 1 5 t t t t ' I ` r ?+ , I t r r .II 1 tit. - lr1 K?? ? I t - "1' • , . 6 LJ ' Ann= T N F d WYISr IRFV. r.•DI 'Ea• STATE OF WASNGTON P Gt Di / N. ' PO LICE TRAFFIC COLLISIO N REPORT ;?JTRAFFIGWAV U. EfxK[caMrulNr NUMeFR-. J •' PRIVATE WAY DArl9 S.. '? :,.? IUSf ]tlO HOUeI CDUN,Y n 1 Irv " pI C9UNfr NO. E:IIYNO. /? °V? _ ? we4w•r H relw IKwnoas e Q[ QIN urroa rowN Amu Na uisret QN /f2Mnt[ s Qw G oN " t3 Me[POs?9?o ,, INneSECUNGw nSrvFftOe9 .D Nrfe ECION [C! ? 9 a Sre[Er U SrP(fr PR IA OP ?? OS.N 60 vt r raO 4tl NC .<POSSS Et O F FSrM.! 5 -11 N I E w ACCIDENT MILEAGE DI RPM MIA ' ffFr Of CODE a OR HiE4f ]] aLPGE 0.11.- IXUS?ON vIXVEO O 4I E0?- INIUafD ? QS NO r vvpeepm S MFR CLS I AO1551RfETOR ROPD L - F _,111 m QPeOt4RTY.- M ON11 ?4FSULrfO ?vlMiCl[ I! • ......SIRKCINM.LOi OBI[CT SraUC[AND OWNt4'S N.MFI tSI. DAMAGE SHtuI COOING IR[ ^ Y S UNIT NO.I UNIT NO.2 ' ?VEHICLE ?PEDESTRIAN ?PEDALCYCLIST St Ne ? y ewte'SNNnf: wr ie5r MID (IVnEa SNA"E: LC Er.DD4f5S STPEfr ADOVlSS ?? - rAlf ZiPCOOf PNONF NO. D Y A ' 14 R "uNO s u< e Sr I4 N I n L N A oA wr' r"a . / `! (4,, I l o . ? O rEgNI GMr tvFS OCPNpry IivN f•RgNt NO. E CUPAIiON N4M NANE•PIONt NO. EYES ?GNI EEIGNi Q CHECK(.) [...... .IMitirNta. QCHECK (?) eN¢u AS.N w.aor[f or.NO `° rpM ]] n 5 I E'(".° nn CODES 0- 113 • :in ,w" CODES ?* 7 n S le 6 s . m • snnM ran arr Z / a a / M l[s iN TfYw°`i4 '°"" .MNA.r<I ? pct .. ? ? 4L>. `Ip- Q NP , ? uS 1 ? *6. ? ? "35n. Su VlN rt.a MA.t IDODGt{NEVI MDD L(DAVnNOV.I Sivn npe. pN.l I v.l .'ODfI IDA VAI l ?Pa 1, d? O E IN 6 N Aaee nwn NO 'v rulF . ' __ H SIAI. N. a flSETDOT . A Z3 t IA I v[niCll lDlNIViMIgN NO. ` viD N I I I .forsnnoovmuuv nesr M?oae MONf Iq. O ? wNt: w] N•v MI W I] ADpelS Cr OWNi• N E wN a p 4. D.i15diNSU•.NClCO O.AGINI K? R INT ]] P 1 DAM.e( uu I I gPMPaeo•.eP? ? , ?;nd .. eNUOe • .p cNA.w s uIIXDAM.eI 'IN .tMUNto W ? iafTDi ? ?D.NeN ?•uwNlo Is'O loiono+ s wwlo AwAr i pm _ .r ar s ?1 o Aw.r - .T - lu u s ul :NOarN SC DIAGRAMOFCOILISION: fu H(C{S54v or •. Ow RIP TION OF COLLLISIO n ?ISWPUM[Nru slRlri/IN(CFSSP.vI h' ?'-??T?LA I . FNI . I _T-; i ADDRESS & INJURI 5OF NAME PERSONS INVOLVED I CODES 1 - 2 J 4 S ($ , IU51f OCCUPANTS /WITNESSES ro.. WA1M[Nr.[S oanoNU NAM NIr tsI AK Ac! TMU _ .41M ?V° a .tr rySM nci I iKr .n. N. rrc.. 5 S N,MI •• .ar.lu _._. __ 4 Movm r•oM Q•Me °.n,cl ??; . ? N ? :° b ,MI CC.Il1 ' bill _... INIVIr ?`?.M. ?? ? •? ? .:i, 1lDL?ey"?{MD n' rfa D ,I/Unt .IrU.I ? IS?F.NS:iiwRweP.IIL?tlA?d?.:TE!M D. ?'.Y9QT? 1.(lf-. y'1 LY]?!L>)9.!..` 0 1 ate: STATE OF WASHINGTON POLICE TRAFFIC COLLUSION REPORT LZA TRAFFICWAY IOIICECX%,7_-EER - PRIVATE WAY 9 D•r[oP COllI SID IAI _ L IoN ,ImE ' IUSF ]X[D I 17?o wr l , iiull.wlo ?wvf lii. ?u1. O O CIIr OR EOWN couNtr N GF/`F?SO..) F6N OR HIGHWAY couNlr NO. Z-_ G orr NO, 9Wrf OR RF r NwA pl ug ?9A1 d, 0. 0, 0IN MR15 5 ?w 10 Ol ?o ws?(,? oN O A .? 9?o [5? qN Fv CIING WtrNS,Pff1099pPD NON INrf 95EC,ION ??JJ//?? ' l BfM'FFN O? n?/?i]S S,R1lr 6 I'LG LN 519EE1 PRFN% MIIf POST ?J ?/ O / D IANCF 6019E I IRON Rtl(R[ f. CROSS I...... ...R(SI MR POST (S 5 f w / O MX ltFi C] A? L OF C "_5 1 ACCIDENT MILEAGE ODE RAMP DIAGRAM DATA 4UN COIII'G,A IIONI V NOOIV[D NO XRiII[D?NO INIUR[D_ ?svIEIAGE ?HIr6 .11.1.1,P- x?RO CIIN REElO ROADOV I3(fvENCt IMf4 ROAp CIS CROSSSIRIFIOR .21 t%V[nlClls PROMRIr DAMAGFONIV. .- p p[Sil pE4 'A U 9 OBIf<l S,RUCX INAM[O1 pBl ,9UCX ANDOWNfRSNAM[I SI DAMAGE 15 f S CULL ODING[AE S UNIT NO. 1 UNITNO.4 VEHICLE p PEDESTRIAN 0 PEDALCYCLIST S DRIVI9'$NAMt: N51 F -,2 ?o EIR i.2- .?DDJE DPIVER'SNAME: Usi PI9 lE /ro-S T cG J .7 en ADDRESS 5/(?/ ?ie,? - _ Z ?/2 ?0 8o a sr9nr ADDREu 3e,X SSs- b7/ wswve/lc Slgl[ SIV CODE PNOHj Gp? -1 D R n DF IF 9.? Pn yJsG J _ / ?/ [RSUeeNSf NO. srAll lF All°11N D V I lx D Ea RI" NG ITITI -- 43ow 12S 7a/? 2 G,//? ? /1 y ??o? ?r83/7S G?r? F %v1 io -n (Xy'? ON/? mNAMf tPHON[NO. IGNi wIGNI E O<CUVAIION mNAMf6 PWNE NO. f S w41GN1 wIGNl ?? Ile 5- ? CHECK (?) v`8 AN.-,Al p CHECK (?) rMVior"t[a ANO,NEVAI Xf?. o CODES P' D a S l ....p°•' CODES ?, 5 l% 4 u °c's[? "]] Nnul(s o =:V- p .MNAA,?F p ru° p c8;- ? ? AmN,,.N(? ? P?,IE[ ? <bm. p ??21i I Vfn YtAR EIDODGf `D/43v t? -113.11-Al -113.11-Al S,rlf1]D C I ? J. U. E IN- o 1 nv.l -11IDAR,.NOVAI I rn. a uuNx PUt u,F ARER PUIe NO surf S H e 9 A n A( l w/ rz i?GSG3 w - - S?1(r? l?=/?2?G W - - ]Y - -Ql lE%MI11U,gN- PIL1 i21J1s,913 /--+-+-?-t- L N =W-1 1 - RIWSRPfDOWN[R uASi nRSI MIDCIF PEgNf NO O W IS1EPfD w(ll R: AS, [1451 MIDDIF N 5 ?/ts Sr9.nv- I] _ !T' ADD 1 OIOW[IIR ?/c E R ?JG LDI NuA!(ADDRUSp n.su9Arlee eD. oR AGINI Ilu o -N, Q' C c5gf /GE R A?C??i1L ?j ?? ?] DAMAGIDAPIA I J Or'tG DAmAGfDARIA D "'O I CH (IIA9U L ?((FL ARGE m M^ P]lar O ?({{,,.? ?L ®Rw?N ?-NED ? W •WA? URLMAINtU elA DO 1V:011: S 'S ld:orio? s 7 lovnD IOWlo , ?0 Br, 00 ? AY Are iJ DIAGRAM FCOIIISION. s,?ly N Sear( ee^rt N[nrn DESCRIPTION OF COIIISION: . lustsw ( [MU igSwer4N(e[s5A9r1 t { - { -y / -? W?P.S n1o Pr f - T _ ???._ _. _ _ ._ O/f G /3i4 j I I 2l I I I I _1/G// 'y/. L(/i05 I?GiA?.JG T/? l?+ i? l F.zS._ Asio/ L ? / G . _Lor. _ 3.4• Y-., ? ? -4 O?i ? /?CG . „? l-,7 ` ? off- .?i - ; L > 5 { ?1 ..1.. _ _.. . r . ? . . . a? _ _.. - , - - ?Y ` ?5 ' _....._.- 1 k .., • .. 1 f ..f._.{ .. I .r NAME, ADDRESS 8INJURIES OF PERSONS I RSO S NVOLVED CODES 1 ' 2 9 4 5 6 /WITNESSES IusESDPnEMwrusw OCCUPANTS N iGP I NONAI n Il -51. .GE IA,US 4` ( .--.. M,c? 9l S1 Illtl •M` C/ /S o of - GD °/S7 837% /o ?- - En.n O L r ?' uRla e. pAM e p(YI°' p I. "' .Y . pN ?C:. ? N.ml ,? rrleAevZc .... S7 83?s! - ' _ _ .. - ._.. Aonn O O . .J -I O ? ' - R MOYID wOM nrv nol s} .n er pAMe p^AK[ pw? p M ? . AMI tin . .... Ir•91XX ... .. • NAiInrM •, s 1N "pAMe p?„I p114.01 p X?M v r•V151 ".•IWGO. S[y.vI EI.N? A R•u?. A , /? D -,i? % ? ICMD v5 D -/? APr vlD er -1 0? DAr! s K7 E1T1A kik. 1 Gl ? A ! ? I t l'r ,: 1 l , 11 (71 I , ? 1 My ` M , YL 1 1' l l ??I 7 I k . I 1 1 1 STATE OF WASHINGTON PAGE DE ?No.~ {t` Ya , 7' ?d 1 ? I POLICE TRAFFIC COON REPORT ISI IRAMPI Ar PIXI E.AIw NUMaEa I 0 PRIVATE WAY V, qO .Y YR ° : wIR ;„., "r 5.1 IIMf (USE].DDNOU R) courv[Y COUNTY NO. / CITY NO. NwA ?1URBAN ? 1 Al 4 ace 20 EFL N / (p eA I Avt[S R TOWN NAME B NO.O StefOR ?N ?E ? N '05 ?W ®Or QZMvAc-Alm HIGHWAY t ON , FCT US RW,E OR 1 SFtfl p NON INIERS[CTION Irv,FRSFC, NG VAIN: SIRtF, O4 ROAD R Efl% EO. MiIf POSt 9V? e[Twt[NC S1RffT n 9 u.E. EEI DISIANCfE 1MDREMI REfEREN .CROSS S,Rff10R NfARFS,MIIF POSE 1E55 F W r[fT OF , ACCIDENT MILEAGE CODE R "p DIAGRAMDATA ] COll15gNINVIXVfD: SFVERIIY: ` ?SPRIAGf ?NII ERUN NO INIUREO Klllfp NO WNp%p1N RO I IMEe CLS C . NlRSEC,I RE OR ROADdlldff4fNCE IgS55iR[FT ORROM - ? ? . . 70 AL NO. -EN "I ® )ffi PRoKRTYDAMAGEGNIY ?uIFSUITFp ?VFnICF a l l FSI. DAMAGE CEACTSTRUCK (N-Of MACI STRUCK AND OWNER 5 N- z SRCIN CODING USE - UNIT NO.I UNIT NO.2 ? VEHICLE ? PEDFSTRIAN ? PEDALCYCLIST S DRIVER S NAME' -1 IIRS, MIDDLE AnA RIVER'SNNAEl N5, NR ?n 5I4FfIA-1. ?• lil iRff, D L PHONE 1 y ]IV CNY SIATf IP O E N END. 1 %W wp" CJ.A m 32- r R - DRIVER'SIKENSFN STAY 5E% I - SU NSF AIf 1l _1 A IF Of".1r. Dnr c wA v . 1 1 - 000UPATION MNAMF ePNONE NO. FYf3 WSIGNI HIGH E CUPA,ION R NAMEE PHONE NO. EYES SYEIGHI IEIGMI 2 R l0 R ? CHECK (?) ANOINF4IA` ? CHECK (?) As AN D OYEFOFAAOTIER 3 A<IDN "_ CODES 0. * 3 5 E e CODES P- * 3 A ?`. 5 I%DN a N 2 ] r 2 IN S AR O 2 7. 0--c' ? u ` ?'g', ? ='?t ? ,-, R ? Ne nVl ? g6R ? K K? ? OI- YEN. MAKF IDODGF CNfV) -79 G MDDFI IDAR1 NOVA) SIYIf E]DR KONV.I Z E ) Y YEAR E f IIDART NOVA) I v.) N. CENY RIn fN A,F RAUFR RA,f NO. 51A1f H nN. aoR fNO. AF l t.K I -101 TER." -NO. L vfNClf DENIIr CA I N T. E R I I I N I I .-TEREDOWNER: -1 1145T MIDIXf 3 MON[NO. 44 O W NO. Pf IS RtDOwrvF4: fl 5, F ?? I] ADD11N 9NFR OwNFR sq?Ac S opm 11 N E NAME a ADDRESS p INSURANCE CO. OR-NT R U N - DAMAG[D M[ ' w°"° 4 "'"?q"N % R i IT. wAr ?n-o ?e[MNN[o -e 6 Iwaper. AwAV - M owtD s Ar ar Aw ... le OF COLLISION: lu u !NM IND CATf NOeIN DI;?GRWA sNtitp NECtSSAeYI ern4apw DESCRIPTION OF COLLISION: IEIEf SUPPIEAUMM EMILIf NECESSARY) E&_ - 4'I' ] ® & gwt> l WAS EATTSO-,3D oN . l/EH. o9tio FgZ(.E,D Ta NEWTZArE A RZGNr CURVE _K. - Sr LeAr rvc ROADLupy, oN THE lt)ESrecU"b r rAEA ANO TRAV6L6D APPe?k• 12SF TJVTNE G ply a-A cHZr TNEAJ FLLPPE0, .CV0r-AJC, ArMOR ]e RPPR01( 2S F? AIJO HsrrZAJC, OAA_7FlE REAR, 1 44%, 11131- ENO, XAJ THE DZMH, MUD 7WETV ROLJ_EO OVER, SAC/! oYVTO 714E 1110 ON ( Ati1E. J/RSUER cT7AT? WNEEtS •tN THE EArreG:.tlliD ? 791 14 B= la NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES 1 - 1 2 3 4 5 6 OCCUPANTS/ WITNESSES i°5[iR sAD?o"INAL nASA. Il sEK AGE .TAT p 5 nsla. fncl ECSL3s?L I RN ' vE ° E .ur ns W '?' IU4 a A NOIJF ..rM n.. ? AM n ? IXI4I ( ] r.II. . ? N.' ? MW ?p NAV! M) . A Ap(IPI fS R p e mOVlD IPOM ?AMa ?? I ?[Nr»nr ? W ?irU u F NO AMirit NATUeRIM IIII /M fir. ?AMn ?MCI afMtr. ?CiJ ?rv I'11I>r X ? enDW pi n ro wSlrKr GSO w KIDM1PAT(MD I ,?12.8 VIKi AR4INO D x/37 nR OrNRMI DAII $ }Iw 33}}{{tt?? y -,y?JJ?'1:?'r?T"i Fwd ICJ ? ??? ?' "? ? a ? ? ? v ? ? v `_ '? d ? _ .,E? ? (?.,og_ ..?.-?'r'TL s?1 rh???6&` `sS4L"' " . STATE OF WA NGTON PAGE ERtV. Op wSPIW1.eD, ;` f 4 5P Ya J f ,' V t ! '`f POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY ?•? fJ I 7 U y PoIN;FCOMR/JNiNUMeFN PRIVATE WAY DATE 11 Cl C l15ON " ON LIME CO " '; /JS) a o UNTY i ^b ID$E DEW HOU9) I: pN. 9I wI I20 6FF N COUNTY NO. CITT NO. iHWA UR&W /lv ? +? ' N ? ?E ?IN CTY 0910WN AME6 NO Oi STRFfIOR HGHwaY RAt RWIt Oq E 5 Epps ?w 9o1 C ON NTERSFCII , l/1000 tN STREEfO ROD NON NTFRSECIION 9FAVER G -PUT E MIUPOSl eFTWffN STRff1 6 F.L.E. St9EEi pSrANfFb DtefC10N E90 RfifRE" CFGSS SIRFEt O /A 73 . R NEAREST Mn[pOSt ACCIDENT N MESS 5 f w MILEAGE NET OF CODE • DIAGRAM MIA Q COll50N NwJIV[D -11.11y; tOTAI NO NO xIIED_NONJUlFQ_ ?SPIIAGE ?MTIRUN CP VENCIfS ?pgpPERTYDAMAGE ONLY ?4ESEUliED ?VEIXH Uf 001FCTSIVUCx INN fOf Opl[Ct StRUCR PNDOwrvERSNAME) IU IH.- .RD If9 CS SE 5 f 9 OR NERENCE C"xOSSSUE ORROAD 9r?/SQ: ST.OAM AIDE E I SPFCW CODMG 5E S E _ 3 UNIT NO.I pRNtR'3 NAME: 0151 IRS, UNITNO.2 ?VEHICLE ?PEDESTREAN ?PEDi.:C CLIST ?•• IDIXE p'? f rvER's NAME: sr - I SUFfTAppeE53 $TPEET pvf55 \vJ1'p, (?1''J?{W? ZI • D P COCF PHONE NO. ' ? R ITT STATE IP I _ NfR 3 uCEN5EN STAfF 1 - `R W EX R I v y uCtNSf N AtF DATE BIRTH DAY 1 2 CCCUPANpR' iMN EYE AME6PNONE NO. S GHtHfIGNT E R N CUVAtION --PHONE NO. EYES 1-1 HEIGHT ? CHECK (Pl) R Q VEHCIF ws wiN M+P'lor[E Oi wuoEHE4?l ? CvAECK (,I') k - z + J i< a R $ T e io ODES ? •,, JKRDN ,fN vEN sax NAx?orEEa THE. lCODES ? * 3n" wb :. s NE a ?„°M11c, 5f ,Ara TqN ? "3n R [DS ? AMNA l ? a VtH rtnR M E(DORADR V ." ?zs.n. ? „ ? r E MUREoF ? M H f ? - ? rs?,P ? n O u .) EIDARr.NOVAI S (lZDR CON- .Y 4 f HEv.) H r.NOVw LI l ) ) ? _ G Z E '3 ?O H. IXW l t"K ICENY PLATEN STATt RMlf9 Hnlf NO. STATE F'I I VfH,CIX04 I D Qi[fF N A VENICU I..R,CANCH NO. ?- _Z REGISN9E0OVME4: UE51 FI C L L DEN rI A N . U RST MIDIX1 PHONE NO. ApD.TSECYOWNty O W NR D N?IER iIRSt MI f A E S GRS '? N OWNER I E AMe a ADDRESS OF u15ueANCt co. 09 AGENT 1J ? DAMAC.! AAE M p ' ' E R u ... -- uwcrgHM CHARD r,• w CN?G 1? IJwU lsr. D• nG! ?wJly ?REMNNID oapno lSr.'DAMAGF E 0^w ?R(MNN[D oiSoTO no AWAY Sr I TOW Awar ev: f Is O V OI GRAMOF COItISIN: I 11 P AR N N No91 SN[[I liNeefun4r) ' ev. ow DESCRID ONOF COLLISION: M, SUVn[M[Nru U." NEcfss,xv 1 3 c9 vew 41 was swrsou"O o" EGG qa jb t Ra. D, qN0 FNtLED M NEG07S.grE R /QT4. r I:LRVE, Zr 46Fr rmoE RogOwAY, ON 7H6 Wesrsouluo EGG AUDI RD• T r Z.DE, ANO 7 QVELE.D AlPRDk. I SF'l Ln/.7we DrrGH. Er 7NCN ALZPPBD, G,UUG A MaR . APPROK 2S• F7: ANo NtrrzAj& Div T 1 IE READ ' ,, Y Y 1511 XAJ 714E DZ:MH,. AMD 7 &Ij AbL•L.EO OVER, GI B v 7S {(?? fxs A f c V70 7140 /CbRp,. CoMTJ.jG 70.R6?T ONSTFt_ bASISCS 'ZJI, 7M4E EFIsT$GLIrUID (AAFE. vAZwR (AA7b NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES t - p 3 4 5 6 31 OCCUPANTS /WITNESSES iC.. NEO " Tii " t s '""" - " r ¢ UATTT N AMi ex Aee uru '^ wJ MTa RE". ITT. 1 l EaN, eaBS NE r I N -1 w w of 9i YID THE BY AMe . ?M, ? "" . ?,^.;y ?vo w T. 4 3G8 .0 AD H Ons3 -I N,1 ?4[or ANTE ? qr?IO' . OCix ? -0 'D NO ' A Malt1 bADGY GR HAn P1oP .ENEer ?nMe ??: "I?M'nEP?M, ?I"rD .Hw Ar r '"• Ev3' 1 r X '? n c. ?l. 7 El .'??HfD luqt ? p oANU nPOgr D.n A DATE _ _ ?1LT ??J JAD H.S 1tlD s 5 M s .:. ,.. "? ... -. 1a dud I +F-aF"u,'<?c'N .. ;:;''?"'°?':'ri!°.;SSE;'?'?t'fF'14'x';•^•,ar+?frfeaf rwE,?Jfn ` 1 a i I7J I t ? I ?i F t?! Akw ? r 1 ,. _.. ..OTV yr . • r .,a LI MOR VEHI „_ _ -Ji CLE COLLISION REPORT ` ` ` Nouerr /?.:. CITY NO, ! E?rruq. o ? • v ? $ NDN ?E? o ?r«, " ?A4 6FF@RSan1 4 _ No. ? ? a U IQ , ?, cL5 AD p s ? ?" ? ° WN ON / ? . [ gOMI[DgAIq[[TC0 pE _? TAS[c, ; Do nT[A[[p, ?6990 _ NA T SHIHITI u ` a LEI [[ p qD,P p oATpR p[NNI,ap ?Tws[px , LE w ? ? W P W p,,. ! }_ b ppLNS p" """ID rMLrAO0113wi egwARjIgO TR!Jy9q!W . u• sa ? L] TO,AL11 ? rI N R Ill*ll C Dl nn [[A L ? ? B B E3 p ., O R a ' OBJECT STRUCK S+lr ) OWNER OFODIECT9 A : ? gift N .... MEIAFIOADORESS ?. ,. _.. .. ........_.. ..-. .. {anEr51 Axcr..?:_ erw coc[uss R [ OflIY_EA'@Lh9T NANE_.,.. ___f1HST_NAME:::.?,.. "..._ ... _._MIII Ig vov[o?BIVFS'rA.l+YELfMM.E.'.:::.:. :..,... •F,IflST NAME MIDDLE IN THIS .' oa ' S { ?' STREET 60D EES flOUTE NO. AND BOX NO,_ 9 TWO Eq .Y r 7 TPEET OREES ROUTE yYl ,-. 4,Y . :.(+ .' .. ??? N, NO AND BO%NO. L? + 9Vl -OLSIA -AITAIS RY-.' STA E 21P CODE DRIVERS OCCUPATION G CITY 1pu\4 V'I al ... .STATE 21P CODE p flIVEHG pC ATION Y IV `ll .70 ` TE D u • . f t ' ORIVEq'S LI STATE E% jATE OF .I n? 537J0 EY A H AGE OflVE95. IGENS ____ ..... SigTE SE% 0 OFUIRiry AGE T l/ M DAY Ya EH CLE YR. MANE (CHEV. DODGE) MODEL INOVA•DART) BODY STYLE5(2 Dq.) ?- VEHICLE YR. MAKE (CHEV. OE) MOOFL (NOVA F flit BOO'! STYLE I2 OflJ 78 DOs? Ya'ToN 0 L .? LICENSE PLATE NO, •gTpTE TggILER PLATE NO. STATE LICENSE PLATE NO. STATE AILER PLATE NO. STATE \ '\LFH1• VEHICLE IDENDFICATION N O `r ` JVIEHICLE IDENTIFICATION NO. . D W ?5 L Q I ` Ae tl flEGISTEflED OWNE LAST. FIgST•MIDOLE NAME) DRIVER'S LICENSE NO. REGISTERED OWNER (LAST FI .MIDDLE NAME) ORIV N LICENSE NO. OWNFA'S ADDRESS STg i ^ C EE ( . CITY ANp STATE) pgTE OF, SIflT11- OWNER'S ADORE^ (ETREET. CITY ANO STATEI TE OF SIPTH TE?I Mo. o,r va Mu o,v L' - ,? ...? vq PARTS OFVEHICLE DAMAGED [ .L 1• EiuG? PART FVEHICLEOMAGED Li?w v IFO - LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1• WAS THEREAUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS .rACCIDENT ON YOUR CAR `fLl YES ? NO NAME AND ADDRESS OF L ABILITY INSURANCE PO ICY HOLDER 3 NA • [.ANA W1TG NAME OF LIABILITY INSURANCE COMPANY `1SHOR WA 9 3sS 7flSR ARM NAME AND ADDRESS OF L +i d°r-A"bV? I BILIT INSURANCE AGENL STATE LIABILITY POLICY NUMBER _ STATE ?AQM `(µ501RAfig? st'f T NSENO WA ISM IS(b3 M ? E5{ ZZ ??? • i?yyOT?- /(/-?.[?• G{. 1ND INJUflY E9EPANAi[P[ Ti0a A0 xa. J Wn 1ilU\ /EO?C'lV S / xJUq E51 AGE IY.r•6o 1 . Il NAM o T 7' . Ep NAME A H a 5 n DDRESS ADDRESS SE NATURE AND ../e S.• . If DID INT OF INJURIES '? IE? III EXTENT OF INJURIES ? EXAMINATION BY ADOCiOq+ N?MEORS L.J OIp INJURIES REQUIRE ?O DOCTOR'S TO Ri DOCTOR STATUS F BYA T E CX ! o O INJURED _ MARK IflST ONE TMA APPLIES E TATUS O E H O 101 IN _u. x' O FI rxa r L-- s[v[a THAT APPLIES AIARKE'HST HE xMHairNO p,.ENICLE KILLED p ?fi?. KILLED V I , ' •"' ' NO pr? ac ? `_ pI ?yE nlnr;A rvr• r F?N 11crr • , 0 E3 6 El 70 MOTORCYCLE SAFETY: ? HELMET USE. ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SOW NORTH BY ARN.. IN CIRCLE DESCRIBE BELOW WHAT MAPPEHED. IREFEfl T0 VEHICLES BY HUMOEq) A . '-?:' rLW[ Trur A[rLlcts .. K [.[...Hxq,. O 0N ra/Z RL5 pR flPP$Ak[ 17EfS A lAR&E 2 ?o NT ' ?, f „.KL[ . p H w (o? I q[prp NIP..a[. ?. - D Ep, .IVMPC-fl 0l{f FROM ;. Me Rl?t$f 518E Of. T+IE imAD H11TIN? L? z Qbb2l rtibS 79kY0'p"^"' •" , M4 TRV-K I.N -(CIE ,gRIL AND SOMMA Z CAME 1•o A OP --- ? Cca w ._ - i ST , , e helm wE N r s SUDS)NI ofF To.10F_ LEf7 Drrcft ??D• K X ._NEAV"1 ..DAMA6E. To..-ME FRONT,AND. 3 1 TIE N QoON?a. COULD bk1y ? GA1 OAK BAy.. i f?Rh> X MH ' ??V? YJENT $MC 't0 iwe al of IMP/X,T ON My ? T! MoUCY SOMNON60 A 54EME MADE A ' _RF t :ff F DFfrufa ID% JO?N50T? I u f 7 T t if PT I 1 _ I.........r . t ? 1 VEHICLES POSITIONS BEFORE COLLISION INVESTIOQED BY r VEHICLE H S l Ll M"E C ? ? T Ya a Wu[O CUn O E W ONSTRFCT OR HIGHWAY NAME OR HO. Ix[cl ? ? ? ? ALONG ? 13 ED ? _ ? ? u I FROM IOR,r 4 ? ^?'.. XEDE57RIAN/PEDAL CYCLIST WAS USINO? I ?A,M I ?wu ?NKX . ? nr [ ?I A ?D, r ? e [ ?I,p dpi?(J • r ?f Ir ) 'EOESTRIAN/PEDAL CYCLIST CLOTHING COLOR' w..?c, •w"???„ nm I?u• NP ,?nrllrpnNLrriwr •""'E'«ICIInI .I""." LI1P` VI -f r ROAD SURFACE WGTIIER LIDNT COHDIIIOH9 "• TRAFFIC CONTROL •N TYFE OF ROAD " TNIIVEWVC/nCLE ACTIONS L ?VEMURCLEA S IC x MUNI, Y I ? ?I A?? ?1' { ? ry rtnh[ [A OrNI ? WYLIONI • •[ Ic.xu uNrl nKA[ ICr oN[4 ? M ?1 I1?SNUA ?•r ?I HE WAY[ pvI RI GOING ST.Aca[u .lr?(ETIpnY 1 a1PU?rr 1?DAY ? IG IOrIi AHEAD L1 j J' R?J W[T 1 ?NANrNG t ?OUlK ? T ? SIOPlIGN TWO WAY [ ? t ? pvCRTAKIHU ANO PASSING 5 `t? C 1? I? ? r I 1 I?SNgxuIG [ ?tOIGr1iSOMLT ? J ?I[IDSON ? J ?qo^p ? ? _ [ C3 nn me T RIGHT TUIIN 1 1 lY• ? ..."a { y? fy^ rpU 5 ? plG.lilOill ? ? FLASWINO IN![NCr1AlIG[ hlI " ?10[ O "c", ND 1 REU '1?•IJ'lhr IUOPr YIA4PI ? [ ? MAKING E[Ii TURN )Tf 1 t 5 ?ISVYI C A ? [ ? 1' 1 I S ? SMEGIIY ?DA ONU NT HIS E] ? ILASnING ALR[q ? 6 ? ALLEY ? 6 E] MAKING U TUTIN ? [ ?HA SIGNAL E Ll OWAY 1L,. IL 7 i "? I ?SPICrIY ? ? 1 T.N ? It [3 SLOWNG ???y? f4 y{ tiW r . "S Jif ? { 1 AGWAY LANE. CI(R ROADWAY5UNIACLTYPE ? I 0011CERILAGMAN ? 1 ?DRIVEWAY ? I ? SIO1PTD1011IHAIIIC P.S'Pll 1' ;.12?d l?. g i ? b ? F • ? . O11M1R ROAD SEPARATION &TOPPEDATSIONAL 1 V W $ ? ? ? ? on Stops 'N 1 f ? n ? T? DIVID[O ? Cl ISTOPPED N NOADwAY -IkO? I M*f ?UNOYDIU ? ['l p si.nle"IuI[ NV JL )? 1 L ? ? ? Y n r A.%? ? i t , r r? 'TP'1 LJ m rt r-, r y,I? I ? r t 1 rr6 ) ?jpA,, ? TY.? ,i : E d pt ? .IE+'? I : ,? T ry+ •Iln?O._il? ,f• r•?? I ; / l? ?¢?'s° ?sr 3i / _ s ? I ? 1" I 1 T^w/II O STATE OF WASNGTON DE ' POLICE TRAFFIC COLLISION REPORT ?KTRA'FlCW,VY I? PRIVATE WAY D® OE O IN 55 TES n5 nW ca OE IfONOZYMPUS 91-VD. E SI4tEt 6 1,Fj 'fA STREET 51 ACCIDENT MILEAG AvF CODE F ? SViIUOf p w'T89UN 4N 14".rrr, m o S D04G-ZRs A E55 S,4tl o 60)( 53 41 SIAIf Zi4CODf 9nONENO D nv S 7-ON GI/'q q g _ R .ENSE NO. BTArF tX I rvl M 251 e II? V Ds EDm 377C? 4^ )N 11- f E MONE NO. F wF Cw wfrcnr E «u V/T• ?j` R 7ECK (.7 w2iE1A ffnRO*OE ANOr1iL2" 5 1 6 COI p ..E MI p o'y91 p z8m. ? K7 ? a;v v+,ee looocE<wfv.r RlOnecrgvq srv¢Iaoecowvr E r ' ? uC NSI YIn s1ArE ,? ?rrF9 RATF NO. SIArE I"I vtw ?Ps? 5/ W I iifICA1KN NO r ?< C GIY6IJISc?5;7;6?9? I I F 5 I%19E . ?.0R1 `?? S ? f No. IOIKFCOMMIN( UMB A. ? mu rr yo. Rtr ra. rsrw?s ? t C ?u4 ? fOlf15 4WIEC0l5 °?? i i b * >l. - . I x 90 044[H4fNCE M CIS C4055SIREROR ROAO SSO 90 woowc USE - i1CI.E p PEDESTRIAN p PEDALCYCLIST SIArF li40 OF 4n N N i?YS J z F 4; ' Y. i b- 0 0 t i ; 7 I _. ?..:. _ -:71 T i ?RSONS INVOLVED '31CODES I - Z 3 4 5 6 seMENm snm _.. T. IrO?NAINAM[SI 1 AD[ IItuS 'N . 5f ti '.NI' 1. EIICI MTi?r y V L?- £ ?' r... e t 2 xf G.?>•. Fr I i 1 `?? ?. Cl?.2f?'•?. Qlsh r?wAiw •,c3 .G 4 r€ r S ?fr1 qA ??v S? 3?F F ; xa E ?.wl 1 .:...,',?, ) sw ,",.. (fjb+.$wryM.r' g r? !1_ L r J?Sl?7 1 'lq)f?FT1t t, Y Y?,: ?'?i a' ) .N, 4 '4Y?? L b r i? r ', Ely _ a s 1r A ;u? , ?t?? 1 I r E L ry t J t? t ?if ' t I a o-i I fi IA r F (??? r.4 c I ? ? rw q ?? E-1 l q?Ef CK ? 1. w r ':' C' STATE OF WASGTON -AGE WSP ISR1gFV. 1.901 1;1G': iJ%1 / oil I 111? i:41 ...... ... •, J POLICE TRAFFIC COLLISION REPORT L4 tR4FICN2AY5 wllcfcoMnAlNrNUM . ? PRIVATE WAY :r paIF OF <OUI IO )USE ]app NOVRI COVNty COUNTY NO. CITY NO. IIVIA 3 ?N QF ?IN CITY OR TOWN NANF eN00. sTREETOR nIGNWar Cl5 RWTF T MRf3 5 ON ucr1NG VA El r?oQ ROADOf EON INrE scro v '/ a 7/? ?Z n / ?P BErwEFEI "A", a STREET DIStANCEbDiRFM IOrv iROM4 if4fN ,' Ss ST4FF OR Nfa4fST MIlEP 51 ES E ACC, ENT w N s MILEAGE Of ODE PREfI MuE ros f( C/ / SO P CIA RAMpATA Ac COll1510NINVOIV[0. SV. i, I , N0O1ILL KIIIFD nIT64UN NO. INIURfp ? SOIIIAGE ? .•,NDeiD,.• NO IN INT R .RO 5R r BROAD O4 RFf FENCE ] _ _ RROP[RTYpAMM E-Y f -'T "YE HCLES ? aF ? vfniC[E OBJECT SrRUCK(NAME OF OBIfCT STRUCK ANOOWNER 'SFAME) EST DAMAGE INTFN, Cls CROSS E,2 C"?r V/ SPFCW COOING IAE I S UNIT NO. i RIVERSN . -1 FIRST MIDIXf UNITNO.Y ORIVtR'S NAME q VEHICLE O PEDESTRIAN ? PEDALCYCUST : Sr {I , l STREET ADORESS STRff r ADUFM 2 i=GG .F. !fc(. r surf IPCODE D ' oNF N u srATJ? n 2 Y/? DaIVER'S11--o R r STATE IP CO R N L . •"? Z X22 ICS I V Iv -,-NO. ArF DaTEa eIRrN Mo 1 D•r Ire q NAm CCCUPMICN FIRM E-ONENO, EYES 111"T 1OnT WGM E OCCUPATION MNAMEa -NE NO. FYfS WEIGHT IEIGNt ? Y ? CHE'K (?) vFnl<E[ASFV S.°nn Mo CODES ? ] ?? ANS T e ' ' ° ?CHECK I?) v[laa[ASAN Emviov[[oFMr or FAR * ? s 6 s • - i z CODES 7 5 [. n i0 n Ir u4,fs Al <E r INI Al o .NN a ?T ? ? t n FEAR AMKf IDODGECNEV. I , ? C9:1l. H Yt^ ? 4 MODfI GART NOVA) 57YLE 12 DR.-CONV.I N N F ? ap' E] Y R K IGGGG E nfv u F' ? <a:N, ? .; ? o° MO IT RoYP ?? E .l OEl1DART NpVAI Y 1Rp VI =m Y Ua. PLATE surf 4aneRlur o STATE H ven.eaoR No A t p 117 Y s3 cvx „ 3 V[ ICIf M IGIIptN NO. !z!OIzI !/i3;/ i?!Zi I I I R[GISTEPlDO' L lF OfNllf A N YEnI 1 "I"? 1 1 1 1 1 1' I I I - wN[R lASI "R51_ MIDDEE IF-NE NO O W RF ISIFRFDOwNFR. la5l IINST MIDDLE Nf rvO. J AGG SSOE OWNER A RE S -1. I iSO F N E L •MEAADDRESS eE lNSURANee CO ORAGENT 'L?INSuE-µZFtS?ACFFT .% / R a DAMAG(DAR tI N 4 ,L7 wcror°iM p DAMAGED ARE ' V °P GeOrt ' T tST? MAGF CNA OG[ '?{ ? aW?v ? FMNN[D tOWFD CNA9G( ? ? AWwv ?4[MAINfD wtn OU4 ES?tO TaMAGt A ,?f ? S !OW [D EFY .••. e DIAGR r MOF OLLISION uMN LATE NO Tn ) ? --I-. sErt[r ENeyssAR E er Ro DESCRIPTION OF COLLISION I- SUPRLE[L SKET IF NECESSARY) ' ] I I ` I 4 .1 . I 1 ., } ? I /V/? OfJ Ocv_ HPJ cOCE. al. bfJ e E c ? ._. .- ii r I ?... . xl SS _.._ot / oST._ G?..-,/T.. !JHlJ_ <usS_._?o .cOC ow. y._GCA*'T .?Y/rwrJ__.. .lf-Wr-. Co/_?r ar'Eo r1loe, d s ? w G :. ;.. , . . `! _. . .. ,_. l ... ,w _ _. . fJ/elu.?v , s.-.Ci Flf/G.. m.-!/c . dox.5 N.E.?D !PO[u.+JG . I I I w NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES I - 2 9 4 5 6 OCCUPANTS/WITNESSES """U".-Al iAnE fd aDDlTpNMr W S, SI _ SFK AGE tatUS " 1TA ° » '.. R[STR I- , .,ATE[' SHA.?, TD79-70's L. o ._ Go,., ' 3 - - . DOre ( , ° f c e p AM e O P6 ? 'A. $1 r ? :21111 r q •DDSIe3 •[ ERIOr R 'e MOVIDrROM ?ANe 0%'.I0tnI •?.i ?,i° p N O al Or I .nOar54 .a .,..c e . .vl .., ' l u -r:uRe. U•Me C] '" ,"..' r ' Q<%I ? ri ? ri T .. .. , . .. :urn • .;r,c, .. x e?D ca.•C,•nD It.,cr .fN.vip /?o/ is?y GAF ?r urPO41 PPR ovlD e wn f f?Yi y' } i i,^ r?, tr 1,[y T `? 4E6R,fR ;'„117.. 1 n4T bs? II A 1 fy n? E,? A ?( I .I:- } E ':1?ri?T I .+Fn. ??(? nn 1jlR?r? )rr 1 S G W H;' 4.?? c r. 1J c 1 7? 1` eyy I?IE i(IL I ! ? 1. } 1 1 >r7 . I 1 4 )kP ?? % I} ?? l f h 1? _I N N^? I F l I r ? IF ? I.7I ° Rt l;? ? Mti (R °y ( ` ? ? ? l ?- I ? 7 .h F ] E , q ? I t _ R ?1 I r Y r f A 1 1 t`-f 2 a t W POLICE TRAFFIC COLLISION REPORT LLJ .......- EDUCE COMRNNTNUMBER PRIVATE WAY ?p Al l ,TEOFCOL N DAY 111 N rME COUNTY COUNRY NO. CIrY NO. fHWA 13 %? 86 T >u. RRR NIS Y,IR DNtS EF 5, ILISE RFDD NOURI 0 030 5c 'Frc e a G ?U48FN RAL ? N Ltv OR TOWN fPNO. Of SIRE R GHWAY AVlfS ? ?s ?W O OF fJ,6,Dcoc , ON. N i??? H lCr CtS ROUIEOR SIR 329/0 I FaiE?`IING WITN: SIRfEl OR PoAO 1- L. V 41J BfrwEEN SIREEr a STREET PREfI% F MRf POST O. DG CEe DIRECT) l REN E. CROSS SIRFFt OR NEARE51Mn-P0 nN mIIES MR 5 E W p PEEi ? OF L U C .1 W, ACCIDENT MILEAGE CODE AMP DIAGRAM MIA R USKIN NVOIVED NFVER rv; RUN TOTAL NO NO. It'_NO, INIURED O ?Sttlt- ?Nte HmOHRrH %RD IMER CIS GIN SREf R-ORREEERENCE CROSS STR[ETORPoAD RD ff OFVEH ClfS Uj ? PMFERTYDAMAGE ONLY ?pF5Ul1ED ?VEHiCEF L M1fl ESi.OAMAGf ftT Si4UCRINAMEOi OBnCT SiRUC% AND R'S N O SHWCODING USE R A NT SNoNE Co QOAD 4NC UNIT NO. I UNITNO.7 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ER'S NAME: USr HR 1 MIDDLE Roo r ,6 RAk D41-E NAME: USI EIR .1 lE ET wooaESS + c o 57" Po.& • /S3 Eft ADDR- S EGoof HONE NO. AD1 O e WA I P ..- D R Y -I zlPc NO. IR'S LICENSE NO. Q op T R / D SIATF w4 A -I. 3 27 v9 I IVER' IICEN NO, STAE SF% DATE OF-l" MD DA JPATION MNAMfe PHONE NO. EYES WEIGMI RIGHT E CUPw1ION MNNAEe PNONE NO EYES IGM HEIGHT fast No?L -Fi4?c' L GF' ?fd2 Jdo (-.?, R ] CHECK(,, M[H of AS:N VAnvN oF, ? CHECK(,') EH <IF AS,7WPr6Vff OFANOTHFUAI 3 JES?* DC As "'Q 51 , 6 CODES" On ePS 5F 6 ` n clfs o 7 ? . E E ? u.LE ? zom. ? . ?I a6 M M ? YR ?F ? n1l ? EB:a. ? ' EAP mA,FID000E{Hfv.1 79 DA;7 fI IDARTNOVAI Sirl r2-WCONV.I ego-Z oQ E r AR ( N V.) Y INODEIIDARI-NONDR. .I = a OR UCENSfPUIE 'Ni?x? u Z-a 75S.' STATE uIFR RwI[NO. SIAM w A H 11-1 l04 iRI"SFDaT A 'N :lf DfNTIiIG1ION W. L vFHICLE ID NUNMI NN e S l 3 0 l O IIfHO DWNER: USr 11- IDDLE PHONE 11 O R t RtOOWNER: IASI NR5T MIDDLE PNONINO. S A ? NONL^' W IEss or OWNER N A R FoWNI. E IEADDR-OF-RANCICO. ORAGINt i? vw&z I R IN U MR TAMALE KFA s.. _ _ CHAR. cIEA4GE T DAMAGFDA.RfA u s IO ?OirO? EsrrnDAMwu ?D-'P ?REmAINm ?DRIVEN ?REmuNfo AWAY Esr DSaAC[ TOWED GRAM OF COLLISION: i«EEr liMCissvir`I INe+AaROwR'" DESCRIPTION OF COLLISION: lusf SUPREM(NTAI Sfan IF NECESSARY) J _ --?-ANNk+YYa? Tyr ORivE? waS CN vKflaMAli-0Y{ b ?? RoraD+ f/E F.gi{,+E'p 7D 5+-ow .s'NOVCN I^oQ ? A T'+sF/T CrARNf°R s 7N£ v?Fl+. 1,EF7'Tfi<• A-4.0D- i y AND SAO-4y RoiJ.FBO oN To o D IT'S TeP. yLvS J N N NAME,ADDRESS& INJURIES OF PERSONS NVOLVED 'CODES 1 - 2 J 4 5 6 OCCUPANTS/ WITNESSES IEp:DpooMrf+:i NUU ii uR AGE rwru ".„, ;, RESn Ena i. i R of ' Am e ? 7A"F ?,^ . ? H o o o P IH UvIOf P (H IOM?AMe ?•.("a?M .?N ?n Sf 4 F rsr.?r M / d° v.. a .. .n fi • Etiifri SkV15R5FRNA' Hall ,.a LL..`unA,R,rt ' POLICE TRAFFIC COLLISON REPORT TRAFFICWAY rolllx cra33PwrgrNUweM PRIVATE WAY -.' ' D FOfCIXI3 P., LO(USION _ COUNJY murJrv NO. CIrv NO. FMNA `_ _ ` r•. q6. rU Ip$f E.Op HOUR O /? ?UReAN RAl 1 ?N ?F ?IN CIIY OR TOWN NN.FE6 O.OF STRFfIOR HIGHWAY W 5 s CIS gOUIEW IRLL ? . -as ® soOf ON ou%emPUK L_VD . INI'll NG Wirth S1REETOR ROAD NoNINrEasfrnoN '54930 BF1W[fN STREET 6 STREET WSJANCEbDJA U REIER • f CROSS STaEET04 NEARfSIMII E f MKE rosr 0? - 3 . ACCIpENr 5 E W OE P3 DJ MILEAGE SO FEfTS RAIAP DIAGNAM wiA NIUS.NINVIXVFD: SFVFPIrv: NOARLED-NO. INJURED_ ?SRIl1AGE ?IIIrb RUN wNIO1RIICNTN3 Torx No. RD IN iP fi 9 ORRNFREN« iN I CIS O'OSSSIRFFTOR ROAD RVf ?PROFaarv AGE OILY OcEl sulr[D ?viwciE OB fCt p 94040 •? q U-f J 31RLCRINANEOf OG-STRUCKANDOWNfR'S NAM E) I DAMAGE E S-AI CODING IRf MS u $ UNIT NO. 1 UNITN0.7 DRIVER'S NMAE: -1 ? VEHICLE ? PEDESTRIAN ? PFpgLCYCLIST ?' N SI if DRNFR'S NAME: LAST Iq Ir L s;? ANNA SrR[fl ADpvESS 3 REtI DRESS [/ 01v S-11 ?rE EIPCODf D I PrgNE NO. -94D3 PYIWSUCENEE R Try SrAt IP - _ wo Lko STATE j., W 1 o rI ?? I v IIttN STATE DATE eIq N Ro. wr r• ?? OCCUPATION 1IgM NAME 6PNONF NO. IGM NE-1 •a-t-.Z Ens E occuPADON E6 PHONE NO. Fns IGNi HEIGHT oR`C 1 R ? CHECK (r7 nwaeas:N A ANOrnev O ?CHECK(7 A ? CODES W * 3 na3• A i.inM" T S Nee1Nr, a i°refOr .eu H aN «wonE NornER CODES + 3 aaiir a ° 5 I% N e 1On •eH ""' SEE INJ N s AN Rs roW C] N ? .? Kn' W' ?R?m• ? Y°0ix?cu ? tuL3r ? Av KI ? ? cbm• ? ii ? IvD . KE H. YEAR IDODGE{HEV.i MODEM PRf -A' SIYIE IEOgCGNVI r 1nfV.l n l(DMt-NOVA) 1 ?' RO P E H Re r ,'... w SrwTE I-IRtore NO, SUE I vFn. «OR 'Al -NO. A WAL C - VFnICIE IDfMIfIUTION NO. FIT'8 l 'S z F UB fn3 RwlsrzxoowNER: IASr Fwsr mIp«E PEIO L YFn CIf-1.1 At N NO/I I I :- S NE NO. O W rsrtafo wN[q IAS1 NRSr N No. ADOmssaEOWm[R N A E NAWEbADOaEssRrNSU. CO. wA Nr R r uA u P p eD Aau -Nn. IWA I 1AWAG[ U e ESrpMAN,rUp CHA•GE a ® AWAY ?INALANED Cn« DaIVFN REARANED ?AWAY _ ESrrDAMAGf D to C !O ]S $ C] T- AWAY eY. ? LOWED eY A f T t e DIAGRAM OF COLLISION: Fu u HA3 INDrcATE NO•rH Sr(fl if NftYSSMY) eY ARROW DESCRIPTION OFCOLUSION: IuseswnEMEMAI SrRR rMRSSCRrI 3 ® ..... _ _ VE/j• P G1Agj A?oeiHBof+A,D OJV OAk 6AV br .. Alvo WE?vr Our OP GOA11-R0 l- f t3N EJu J <RktlaG A RLGHT TYLRJV_ oFVrO oL_YMPLlRS (3(.L,D.. I T T Stxo s'=-?E•wRYS AGRO? T(•IE oAECaL.tcr.(G. Flu ' I ,? (?r?? Ah? Htr rFf£ @A,o of A Oe??yyv6wAy C4C.VEJ2T (Racks RROUAFO 7?1E- CGWERTJ 3e 1 I? '•• NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED + CODES 1 2 3 4 5 6 ? N ILnesaneAUnrusre OCCUPANTS /WITNESSES 10•ADWrrONAI N- AMe: er 31 . . SIR -1 rATU t NHH D n 511, fA R OC,Oojl LA Rhea NO 437- Roo A Da e 1, 'K Hu NA'U, Al [ ? AMe ? ?:f ' O,-. ? M ? ML,. b A DD•ess AWE q lnwr R n'. noM ?AMe. ?racr?T .?^W ?1:° a I NO -lu "iiw?i 01 rNrer OAMe ?r«KI ?'R"om. ?::J ?NI + aRrcfR r . S JAw A eJ,oerw AGeNer rceorsuterKD M]IKx AR•IVTD oAnwnro•r A Dare X r., ? ? ? .:l. .i"'T(ACx!AP .. P? 5 a1d ? ?? 1?.? ,$ tr ?i" • ,, Tt ?..?:IP? Y3a, : Ems' t IMP 1a%' ? ' 1 II I ?? 'F tti.. M 1EAfi&?iR1m'T?' &Y2p?Te9F lAld',L?E,W -,. a. ! 1 1! p 3` ! t .:Ir `I ?? ?* r:?? ,. ., ??. ? ? Syr ? ,. , << .?..?: ? ,: ??_', y .. .. .. .? , , , ... 7 ?.' E I = AY . G POLICE TRAFFIC COLLISION REPORT IN TRAFlgWEtl 1XV, xxcawAlNr rrx PRIVATE war E] [ OAr OE al e v rv IUvi w w 6 elo' rlMf II?S NOU4) Counrc T? (? CItt NO.. - iMYw ?URI -.? [ • ` " )? ? / . F6.OF 84H fiWwY SrRF N E N CIlY 04iOWN ? ? ?I `G 1 40Ur ORS 503Ga ^S1 SE MILES ?5 W O ON 1 aq INIFRSFCIING WtIN. SIgfEEOR ROAD NONINr(??OynE? r r?J-??. BfIWEENV/RVYJI fM1Wi.. NRiUE F, M4EV051 UuIANCE6D14 F 4f .CROV SIREE OR NfARF51M lE Po5r f ACCIgEN RAMP DIA AM MIA .. - MlfS N 5 f W ?/? fi OF/(p F Mll A " V COL11 nVOI [ - SEVfR1YV D NO INIU D SPI UGE ?NIra RU I40 KIllF ? N e31 IN RI SRFEIOR OR RFFFRtNCE IMER qy U10655iREEfOR ROID j I RD f- % To IAI NO 11" UFN RVFHIClES v ? P40PFRtt DAMAOE ONLY ? 4ESUltED ?VFn CEE ` p L ??/ 90 " OBxR 51RVCKIN EOF IFR SigUCR M1DOWNfR'S NAME) FSr. DAMAGE SVF<ULLCODINGIAE UNIT NO. 1 UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST RR 5 DS f:1 IASr F{14\51 MI f •KJ M 1 V?1"EIE ! IVF4'SNWAE: IASi fIR . . SlRtfr ADDRfv ' SiRfFr ADDRESS -. 7-31 l NW iW I UlY SIAIF ZIV CODE PNONE Ix). D r smTE IP f MNERS UCENSE S131)1Z srwrt WA F -1-- D r 143 I V 1v u N fa. wrf FDA RENR OCCUPATION ff.VEgNf NO. EYES IGNi EfIONt E CUVAIION FIRM NAME•PHONE nO. EYES GIE IEIGM t s R ? CHECK (e) 'vENKtFA rf o ANOIN1RI ? CHECK Ill UE ws ANMxo EEawNOr xvN 7 CODES ??' a n x° S e 6 ",',°I?r°r°C CODES ?? 3 a A is 5 ex a w Jn w of M p A^'^?A..xE ? E? w:. iO 1 E ? " '116. ? , DR cEx+v r F Ar. E ? ,,,y°' 1 NV.1 N "E ?ESNE ? MDDEyowq. vwl "3 r. K:ul N I A N. rEAR e1DO9LE<NEVI . FE IDARr.nOVAI si I U .l n J? K d? E - v V LKE U f AIIERMrEERY. E S1A 1 H VfN Il l{J 11G / ' X1 ? yy 7 C Y[nKlEIttNllfxiKtl01. NO. V DtN i I N L PtGRRRf OVMlY: US! NRV MIDDIF .IIONf NO. O MI I WNlq. WI 1-T I) ADD415sC -111 N N E NAMEtADDgIV Dr INSURANCE <O. OgI?fNI /?, 7 L \ R ' ''' . a' PIE V ?L?a ?4 wMAD! AYU • ' CH j CHARGE ° "po S gAAUCE ARU E Ra loii * '' ESL OAMAG A RlMANfO ff ?AWAY ?RlAWNED DAM 11 Ero. IGiOTroii 1 r Ar Ar Aw rovrtD wwr RY w O = I lu, u I AE In sK?lo rN OF COIIISION. +O DIAGRAM .. sfRflu NeassARr) Y'?O9Y DESCRIPTION OF COLLI ION' Iusfswnf-At sNf 1-CessAnY1 . & dV5 NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED f CODES 1 - 2 7 < 5 6 OCCUPANTS /WITNESSES ,a :o?DlAilfuMtl+Yi r?..:w ii si+ Act urns Ins.. ExR :'Yir E NAAv fb ' .cn.EV xr e. AMe ?W, ?" . ?I= ?7a?w NMwI. pIp ? T ADMISV NIU. 10. Y,WYVIDW ?AMR. ?A,Kf?e' .?N ?n ? ? MI 4 77 ?.xx VSa SCI Yr. ? AMw ? 1- 10 w , ? ?i+ ? n.;N ; P•n151?0 1 MM1 IADGW AW NC I.Q U M1JD DALE 0f Y1EW1 IE AP. T2. ?7 95 / t_ 4 F? ? Et.. ..E:n a>' " w N v'al JiwM ACT. I« 1 K '1TLo ?.. '? _,} I E ) f ]i ll?A ri1 + ? _ j1 >J ',tip ?E I I?i }1 f?11 ? ? Y )r S I t? 7 F n I STATE OF WAINGTON PAGE I G° I_ INn- \`7 POLICETRAFFIC COLLI9TON REPORT LLTRAFFICWAY J, I ,won e ,.. ' f LJ. ? PRIVATE WAY RlF LGOIU °i' X95 `i N ?.° ( "' Ill ME ID$[]RODHpDRI 130 cOUrvly EFfa 25on1 7 & Cm iHWA ?U4 Rn _. I' ON CW CITYORTOWN 2 MlES ?5 04 M OPT_ Lot-mg Nwf6NO.Of SIVfEEOR MGNWAy 10N W DfJVILL& K%JIF 3 1si4_lo NllRSfCTIrvG WITH'S1RFE1 OR 40 AO NON INIFVSECiION ``// 0 BETWEEN $PJEFI A PKEI% f .. M4E Po51 / ZD.. OIA Cf60vE 4frf4E f.CVOS55TPEETOR nEA4E5TMlt 51 IIIr o I MlES N s f W R E(Fi OF fle W1. ACCIDENT MCODE RAMP IAGRAN DATA _ D 04 Hff NCE I O ]] I CO ;pNINVOlVfO. ?KVIIfO J?1 JE,y-NO, INJU9 ?SF IIAOE ?Hte4UN OIAI NO dVFNKLES ® PROPERTYDAMAGE_Y ? pFSUlTFO 0 `5/Fw°ilF '40 IMFR C15 R CII I A CROSSSrRfETOR ROM 44?.SO _ - ".I N{ OBJECT Sf-=UCR IN EOF JFCi SiRUCIt IwD OWNER'S NNAFI F... 0-- S SPECI LCOOING US! UNIT NO. 1 UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ?I?- _Z S DvIVF4'SNwf: IAti NRSi if Fr E u AAE: III D - STREET ADDRF i EIAD 4f55 - R 11170 SW SON I LLIF RZAb 2 V STArF IIP CODE ONE NO D slwlF IP o2t D Ll?- 983(?S U R - p11NfR'S lICW5EN0. 51 if Hra MO OAB 1 IKFN rq. All v01A R Y. . W - • ]Tt I I 11 V I - EYES GHi IE GHi OCCUPATION NM1f6agNE NO E OCCUPATION fI PHONE Np. FVfS WEIGtI} IG RM 2 R _ ? CHECK (.? vEH nl AS:N EMav O l 1 'NX ? CHECK (V) yEH nE FFawN HENA1 D 7Jn 11K- A ^rR. _ CODES 0- r ] n , n 1 5 AI• .sR CODES jl? t p ti.ss 16 N a s w .Nrv Ijy , IN n - - N a ' J F tea: °? o AMeUU.NCI o ° ? 86. ? c.»z RIO- o-AAANDI ? REo W6. o H»z[I ?;:wsP v[H ruR M.ulIDODGE.cHFV.I tl1DwR1.NwA1 srvLLl]O4 COrvv.l v r_A. A.l Hv.l IIDUI NOVAI r 1 v.l - 73 OLDS Oh1ECd} 2Dk -? OCF FR HALE NO. LATE SrAT H rv . A 11 .1 II -C- /[ Cr52 {.Ey •' C VFHICIfIDENTIFICA-W. -ICIEIDENIII FJ i 1- 1-1-1 ?Iil;i 171 I' 12 1 I I F I I - E M R USl agNE NO. IRS1 O FIR51 MIDM SFP WNF4. M, D9 I V '~ W ]I 1 [4 4 ]2 ADDIISSOi-1 ' N N AISADD4f3 -N-A-ff CO ORAOENT GQW9 WI?AA?Z; Par s 1 -4 1 R I ?? OwAGE u .1.1 .1 ? "u ]] - DwwGI MtA ] ry:""?o"?N CH ou V • 1 a CHAR o .I RIDE p S E3O 0.vMGF WAV RNWN[ eortaR D AWAY ?RlMNNFD ISi.DAMAGt t rG iGT10? - ?5,A? Do T o AWAY S LI.V er 7 17 To A s r er: 1 1 DIAGRAM Of COLLISION to Ny ti (4 t ecAn TH OESCRIPTIONOFCOLUSION: IU515WaIMfN1Al-H-SIARYI COTMAC?sw 323?uc?a 5w suc?vlu ? oN COTHPASNOtN.9ND...LCx_.I0511?4 SONTL A 6AN- P S _ - L _ L x_ CUT}L 0VE LFAWIN& Vi5_Pa0hM[i _ - I 1 I 1 ?. r_.( I r r t r riJ.Ep 60 Fc?T_STRtWNCr T_umBS _ . .__. _._ - - ----- -- - s I _r , . I? I t - ------- -- _ _ _ - - --- -- - NAME. ADDRESS 8 INJURIES OF PERSONS I NVOLVED CODES 1 - 2 8 < 5 6 OCCUPANTS WITNESSES ii.- lci wl .. N ... ' .? - _ _ - .' - 5 a wl` ?J . I-[- _ A .° Iw Rr •?? . ? N wl ? _ ? - _ -. .? ? - . ?. •Irwn -... _ a,i`L°eiGE Q.Me"1 ? o':?I• ??." ? ^°•?ro .+ iN. ? X wvuwAlR.G VOn+u.A«e A•AE.. eADCIG• ' ' AaNC. 'nn C a l Y ? ? . Ip c . o I`'? D Io%41 roar ? 12185 uP ovm e. 9 D An r' ?ittSa?L.?t.'?? S S M4 H• , x. x r YA. ?3 Kem N vff J Y"4 . S P-7 T 5 Y ?+Y? ?"?.+'a?LYI. 1 s J2 sYl' ,1 r4'is 3 s..r ? z„ ,F `. ? 0?t ,f ¢ {S 1 1 1 R\,sl / k I t { 1 N I I , l 1 f ? , TH ? I? J;s li :7 ys- ?? s? ? 's 1F STATE OF WA INGTON PAGE 1 POLICE TRAFFIC COLLISION REPORT ?TRAFICtW rcaF.00- R . PRIVAVTE W Y " . s 0' i F 4P14 N r ?° lusF ]bOwOUR1 cOVNfY Ilfi ?53` W"(?' "HI"[ 0030 Jefferson *ID 1 - - rvNO. Gimp ? P111VA Q 3 . M QN QE (DIN RION'N N ERNOO OPHIGHWgY S 11 w Us Wl 4 mus M ow yJ OF Ch um ON E4e4NT 7 Rd, INER3ECIING WrrH. snft10R ROAD NON r[RStCIION ?/G DO PREFI% _ / Rf11VF[ srRFfr 6 - 5 OS1ANCti 4 4f 5R N .C SSSIRFErOR RFSrmIIFPo r RC [ MRfIVST. RA F F1 11 CIDENr rlE Cents d MILEAGE CODE 11spN CO M D AM DATA - l INVIX [D ?. [vf 4lrv: r01µ NO O K ll[D--Np IN,UR1 ? SV tiAGf ? NI164UN / y 'iw gVfHID !$ © I'FR II,DrR ? 5 1 R FI (] I 1 ? PROPERTYDAMAG[ONIY ? ED ?VOLENJ ll OB fCi s J tRUCK ENAM R<I SI4UCK ANDOWNE4's NAMFI AGF SRDIN COpNG 115E E UNITNO.I UNITN0.1 DRIVER'S NA,Wt: wl FIF11 M1 lF ' Q VEHICLE PEDESTRIAN ??PEDALCYCLIST:'. ?- ] • Storrs Robert F. O4W[R SNAMf: Us, ?$r? $IREVAWRfss Box 28 Rill AD K. Z Ill slAli ill- PHONE Nq. D Ill ME I _ 1 Unalaska Alaska 68 NA DRwfR's UCEN3fH srAtt AE % R None HI 5 °' 8 ( v ufNS NO. AiE AEOf B14rH e D Y .. " OCCOPJ AM[RPHON[NO, I rs FIRM N IGHI GHl E OC<uPAIION FIRM NAME RPMONF NO z I Fiehe Seli 8 r 7 l 50 R !YES . WEIGHT FEIGHr vEHlttr AS AH A IHE4µ 0 (.1) E AN . Y 11- All ? CHECKV) I wl vIHIa[ASAN EMPioYEEa• Z ,0 w CODES b. as,• D' 1 S ulcH 1 R . NarHt4 CODES P* 7 u D i 5 1.R R 3 " Rw"' N R1. .Gl n IIs and abrasion of head K MvF R E3 .MMA O 51 ? Vim. ? 2.S ? . a AAA%E M7:' 0 W O roE° ? E5m vn ?;' ?io I IDODGt{HLV.1 tl1DARr.NOVA[ sirlE 11 DR.c 1969 Intl Scout 2dr E MODe[IDARr. I r .1 vAl r.l ? I v _ sure i4ARlN rtAll NO. sl•1 H vtH. L „ x23/red QTR 1118 Or. I I'All 'ro 3 Y[HKl[IDtMINGrKN NO. 7 8 2 8 0 7 a 519 2 7 11 HG13rt RlDONNt+' 0311 RRSr MIDIX[ i VfHI lEI N I w PIgNt NO. Cc enhaver James 0 O t WN.4. IAfI FIRs, AM [ NN ADDRtss or oW.4n W 0 SE t h st Newport O E "I NAME aAOwtssalN r. -0 o4AGtN1 Uknown R D " DRAI ARIA R 1.D a 3.R.w ,uHC,KJNN CHARGE CNARG[ µ..AA- IjAAUGEO ARIA . DY I _ 3 131pDNMG1 O A-WKy REMNNID ' ^RIVlN ? .DANAG •lOP O Rn.WN[D Is, lo. D AE [biorro? 3 12$00 kr I wqY p Y., c W a Tow ? f A OWlDB1.. A DIAGRAM OF COLL T ISION: I. ID - N v3 se•IF- DESCRIPTIONOFCOLl1510N: (.1 SU.neMfNlu sHtnnwassARrl e.cle Weat on thg?',gg??? drove?n}?} h , rt?Tt.-ebo ulder--then i,ntn brsadsid"o thalett - - __ - - - S24sging-b.Dth_.lanes.-o.Lrdway-0--Iehicle +a,F3 4_+r -I the_rivht-dtioh-hittinR_dir-t-embankment-and-roll ' " - - - - an, -and-halt-timoa-comirb-to-rest-on-iti-e-top- „B -in-the-cast-bound-lane facing-southwest , {-, - - -I[ - # - _ ------ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES 1 - Z 3 4 N OCCUPANTS /WITNESSES AME Ri sLSI Act 'Al. 13T' ° l m 5 6 xn chard OBIT Buiiil ' 347 P 1 ., .r N on Or, 974 .MI lac head .B R. CT+M R I H p r W.- N I AMe RA. IF AMR . ? x ? r: F .. Dm :NK. A u•_,ra .._.._-.._..- EM e. ?•Me 0[31=1. ?;:m 0,"0..11... vnro•nNG O,I%HSw.Mr u•N. RU41 O. AD EN-. cwD V[D 1, I 1 A...oKEDn DAn NO F 71 1.l ? ! le J.kl9p 1. I! ? 1 t ' ? ? I I Yy. [ ? 7 y? 1.Y 1 7 ' I s ? ; I? ? ' Y Y h I 1 " 1 1 r ,II C 110 r ', 7 F J EE ? ?? •.°" ?:.,....??. ? ? k ? die STATE OF W INGTON RAGE OF WSRIS4IRFV.LBp) ' • •, POLICE TRAFFIC COLLISION REPORT ® TRA1,9- ' Roux coMitArr]r M E 4°fi 3 U r PRIVATE W ' ]I ? ,? " .Zl o . 1 w.. Rn Iwrr bLF re. b.r. msE RIi10Mp Npu41 Ir nrr NO. ?RllwA F O 5 i , ?(. E e oN ON ?f ? N CIV 0910wN E5N0 0 f10RHI GH W AY POU R C%t5 •. iTr ,???v' ! ? to / ? ? l lM 5 ?w ?pi CWlIt/"i.y`.' ON SC ?K.rL VI?OO ky rNEFRSICrING Wr{H. SEREEt O4 A. Npry ry{FpSECipif 'f{?i P ?. - EI% Lt ROST BlrWF[N OAK ?y1QQ SrRFFr F U?EU ? SIR[[{ ?'.?? ?O DSrµCF 60 RF iR r ?j?fJ I M4filRfrv ,(:ROS$SlRffr OR NfAR[Sr MITE Ml[3 N 5 f W Sr ACCIDENT RAM a RAMM A MI EAG 3 1F. R.7'p. L E if Fr pi r E: O DE <Oll 3ION m « 1 ?? v v[D s FR rr. .?M ri i TOTAL NO /'i:?' NO.RIIFO?NO.rNN4[D ?SVILA. ?Ni6 RUN peE?NS rrx i R pP q{Eq{N<f dvfH Cl[ w '. I,NIE/P l]5 UOSSSIR[RORPWD RRORRTYDAMAGE ONLY ? HSUUFD ?SF?iCI l l ]] z ?? . . /" ^ Q ! y 9/ ?? OBIFCI SivV<%IN OBIFCr 51pU<c µDOwNFR'S NAMl1 F pNAGF SRfCW COOING U6t . ;? y {y S ? ? ?? _., ? ` rv[Rs NAMt: _ lASr Nor nlpa[ $- c" T srR[frADDR[u V t/ Lo u o S 1N da LATE zipco a PHONE NO. c =, 9c 7-971 R dw[P < N NO , ArE E% _ N WAL TL T a D R3 aG MN PArID « •MfRPHONENO. - E ? CHECK (.? SN NOrNFV CODES?O , _• p KM Y[AP t10oDGf.CHfV.I t110A4r NOV A1 SrYI{IIOR ?<ONV I /983 L , . ,e E <(v ION IArf WHIM 6'8S n/it/ STATE rRA I .+Ylc1y [40.Alf NO SrArf H I VtNICI11-1CATION No. C ] ,, wpDR[uaONNtR - - ? W `?' ?? FaS TUP 1CN N r? NAME AAOpREUVINwRAAKE0004AG[Nr E cT aJS R DAM•uDARU P NO iV CHARGE N C.A f ? N ,°w? S ; owfD N UAt I `/ SIA AGt Twtl4 . • ..__..._.____.___.__... _.__. ..._... _.___....__ _ MV1t3 ra It . D, h AMI I ? ' 1 RV AMI p .. ? • ___.............._...__.?..._. ...___..._.-__......__... DNISb NO . tD 1. ?AM! r MN NO NL}UR OI I -- hi3{yArryGdr.Elrf rMW FrAN. V NM?t SCIMII. ?•VR X ? ?^ /. ._ IAa:I OF D rq •rAhC. Q^F DrL?CrRD PP ? tif ARO ND 0•rl dR• - w i AS FA D "s`A° cro I ] 7 a KV ?i'SSn4 w ? r . I V; .NOVA) jwy, sY '4v. l A r,?k, , t MIDa -• ,fit . sSO%iNOAGE E{/??gAMAGF?M[A 1-12131417- ? ( ? ? I I ? l iI 111 ? f? 0}?r 1 ? A 1 1 L ? N w Y d L „? ,?f 1t?M A ? rd ? (C ' 1 L v, 1 4 r r ] ??? 1 1 0 r I 1 5 ? e ?4 T # _ r yq "bTATE OF WASHINGTON MOTOR VEHICLE COLLISION REPORT ' ' ' . OArE O • '? a 31' VOLUS10N DA A ,EAR SW Mov Y OF NEb v E TIMEOF LvuV R N y .N M %11 rv !? R ?' Pua OOLNTY CITY TOWN sloE PEE ME ES • r , . .N . OCAGHRM[ E .•. . -All E . CRY.TOWN OF r, / ADM pHEFU- (d I r Ay,{{rEg?iTf!1.??f??fffWJ,i{ ;?4 J,fvl V/?OlT K' t ON YE NAME OF ST ET,R OR HIGH AY SECTWGMTHSTREET Ofl ROAp PREfU(. EO. r Ln1.k7 pJT LNFn µy y k r NOW INTERSE T LOC T • . ¦ n _ - C? g^^N OF ttf ??A pp BETWEEN C P\ RAMP GAOLNA oAU ! 1- U 1 : C 1 F Ee J -r ?V STREETA E ND kt61t) T i ).. uum E DM EE YVx)LAHTUAR+. x ®© tnosswa HiEL[rosrsonniniu rw WIFPak Kw: ( ®® 5ff z . NON %HTO MEfl MER Q8 RASECIPn•mE n.OR IVEInbla,ei RIFF IBM- 3 tE tC. n ? C3 0 ?•?' •Z 'b-i yyJ7vr U E S o Nw E0 1 0 `E°? xr xl rv I 1 ErvR l ?DI,EVNwWrEI ?rvr ...- *Suf + K I /-- ` OSI STRUCHL IHNIf HS OMttr srxVC.l ? n l ? r OWNER OFOBIECTS NAME MID ADOREi? ( c `Ftii; rY?t ? INROAAQYVAY ?® OFpAp aulpEl Z r.. - -? - • • oLwRErrvrN • • 1?. ' "' DPoYERSIADTAAME FW9T NAME _. MIDDLE IwocAxs ORNEf19lA9T NAM FgSTNAYE wYgVEO T,eD)xe.. _ WERE /?(fj$ THw. e^ STREET RO-EEN0._ N^ b ? STREET ADORE33 FiOUEENO.ANDDO%W,. }T GTY STATE TIPCODE IXi1VER9000UPA}gN A CITY STATE IIPCUDE p?VER9000UPATION UCfASENWSER STATE SEK DATE N AGE ORNERS LgENSE NUMBER STATE SEX OFTEOF GYI7M AGE A.N ENKAE YR. MAKE ICNEV OODGEI MODEL IHOVAgART) w BOOYSTVLEI2 DR I, VENgLE YR. MAKEICHEV.OODGEI MODELINOVApART) BODY STYIE I?Dnl::, LK:EHSEPUTE NO. STATE T"LE PLATENO. STATE -ISEFYATENO. STATE TRAILERFLATENE) STATE r r 3v "" _ b VEHICLEWENT6gATONNO. (ISbtl MOOELSSNEWEFl ODOMEIEPIMILE-j VEMFLE IDENTIFICAIgNNO IIBetl MODEISb NEWERI OOMETER{, ^ X SOD i5o c- ' f", r REGISTEREDOWNER (LA9TFMT-DDLEN E) Y 9LICENSE NO. .-TEREDOWNEfl IU9i fIR9T-MgpLENAMEI DRI LICENSE NQ !>ti aRp OWNEr19A00RE98 '1ST ET.GTY AND TE) DATEOF BIRTN OWNEfiSAOLKIESS (STREET, CRY ANDSTATE) GTEOFBWiN. p ?? YF A PAiISOFVEHIG,EDAMAGEO uo r ?. ;?: .a, sn .n vfNExE PARTS OF VEHICLE OAMAGEO TE cWr -$, ?'.,I S'c"f° s:o HEPAn°v0•cLe ..?. LIABILITY INSURANCE INFORMATION-VEHICLE NO. t- WAS THERE AUTWOBILE LIABILITY wSURANCE Y COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ?YES +rtprer? IIMAEANOAOMESSOF LMBIUNWSURANCE POL1CYHOIJER ? NO / NAME OF LIABILITY WSUflANGE COMPANY , m ?, ?la l i r ,n ' ?.! r r • ? - ) IdT. , ? srME? ._r? ; c).?} tr Ire -0?v NMEEANOADDHESSOF NW41%1ANCE T Mr[ UABIMTY PGICYNUMBER W go 7 CoS HST NJUTY .' AGE TNO WA%1Y: IusfavAMIFPFPORTFORAOarKKMI,LAA•fbl NWIE T r?nl? _A? NAME ADD?siO IArF{LUVa si ?? FNID(wAA,E, o Al. gOFNAUPED10x MARFRSTrHA?AwuEe v` WMMMST OVTIUT 9 b'v ?owv NVENgtE IoSVInt STAiIq Of MURED -A Ise I I ? n W VEHHCIE Ao55RIE T. `....,.?1 OHA? -LED jl ?vAbbt w NO KILlEO K?FI ?WN L AMMCH. T. ? ? 5? 6? 7? ? Ax ? 5? 80 70 U SHOW NORTNBY MIgW NCIIgLE DESCRIBE BELOW WHAT HAPPENED. (REFER TO VEH `oNAlxw.H 41 r [ _ n?crsCl f D? I.DHY,A. O o? Veh.-?? w hit L{i ?vr ! oo :'npulc?er ICk-. lok ' J lh ?..?h?irc{ b rest back on µ ' ?; - ? _?1'hort •1•o rRfxWt accident, VEHICLES POSITIONS BEFORE COLLISION Ao EV L.Na ?' ,IAM rAAKeAa WvE9 GATED BY ti ?5 r $ vE oN[ Ltiwi. u?MAYG [nwE . .wetl v P1O 1wW LD N 9 [ w 9I PEEPOIH•GHHWAYNAMEOR NO w<I CAST PAII[.rE/O [ ?I o d p ? a o o A?P_ PA ?? a o Eo° o ?rol6f ?D.,KNYI je, + r.' ?? ? ? ? ? ALDND cADearrtl rnDLL DIRECTION TO - DIRECTION. - IYOE STnAH WAS 1r.,l.D HQSKXWMK T?WMKWAY D?'JK)ULDEII .?[KftiD.l. e?c'=:". a/OTMEn } ? ; 110Ape{)RFAC! wEAINn IKWT OONOIIONS ANC. IYAI TWfq CoNTPOL KNUONFI TYPE OROMw pNV[fl NICI L pD Z 5- L 1 v ,.C H .. r 'S 4 r 1?rP?YTW W[! ?yl c.ru R v11KU r pIv10M1[ .-,fv{IC1E T r~K?<c. DK a?gNl l 74 Yu? ?(W F I ) iLi ? 1 o(O ? Q .alaucisl I ? wrLGNr 1 F NGNAL9 ?r l Q aNL wAr 1 Q DOM STRAIGHT AHEAD ' ?? } 1'( flGfi-2F on, i-f r 1 ? ? (3 MT P ? K"4 J ? DAWN [1 ? ? SIM mv, ? TWO WAY Q ? ? OYERTAKINGAMDPAM,WD T , ,? ? s i ? D ? D.S. Q J Q VELD sca O non S"' ? O ? m"Pon MOT TURN ? a { i ys?UIt 1 I ?{ 1 r.? ? uw H ?F? • ? IlGH1 ON ET O • ? rusHw MO MEncNAaE ! r -:t l', ^ ,! ?D+ {y1 ?( \ g! ? • ?tE OINR pAn S/NELT ? • ?IlOOPVRAMPI ? . ?..m LEFT TURN I 1 .r },(? a,}q °it iTi7n A ONn a ? ISPTCN r) s ? 1-13M ? e ? rtAlYMrp AMBln ? b ? 41.11 ? e ? ..m u TUN. ( T , 7 i1 .? k, ?' ?rl\CIIr t? y ( f eltlEG OWIVI?IK',rIIS ? e QmSK 4 ? tl 0 !? L TM wO w 1111AY. . tl ? SLOWING 1% '. ?1 IrAb11011,pf D[NOen F 01HH(R ? { 1.i7,r: , q(?. a?,[M1[ovwKPl mrlVCrw [IC1 tl[-r y'EY ? r QarK:En.nAIwAI ,AVfe ? r ?STO' DFOI TWrq r, 7(? TYI 1 ? ? e ? ONKR TEOfY ? I ? up-Ito e O o;, (e D AL 1 3 yl?'E El 9 t t1,Iev ?. J ? DINDED ? ? ? STOPPEDNMADWAY r T 1)x'4 f{ ?? ? -1 q 12)3 Q U.UN'gE0 ? 10 O 111Nf1COLAAWE 1?I Y,? - A/'IHnIY Y1 rqe sIMINO flldl y ? ?Ypi t FT 4( Il h' w L fUrR{ Mti.l"v: J'rt• rti? ??'?{. .,Iv`~T z''r,?.,. ,.l, ?i,c. (`. 1. f??A a ! :j ?r Y?Iwyyl?? i I 22 1?'Y7 1 ?? r Ir ' / r f.i d h I?'.,i1T) rf 1 S n y:4 1 .T g tE ? IYU. TRAFFICWAY POLICE TRAFFIC COLLISION REPORT CDIICECOMRA,m NUMBFA E4 ? PRIVATE WAY 1'Mr N1r ir1WA COUNTY NO. Cllrrq. O p OA lO.o p11 1? ?Z. •2. r• •,'w 'u 2IL ? ?F/c E' SOI?J VI ? /LO UAAI 5 AOUTE 095 E 1 Lf L f' ?! ?IN CUr GR fOwv v d"O w. ORµ wryer „ 6 M,I[s s ?w [$o' C 1o/A1 ON tGG?T {lp f ° r1x 3 S/VDU FO -T n e CI,N4w+1»S,V[10R W+.. rlUr, vUVS f11O1, BFI'ntfv S,RI[1 6 5,4![1 vP[ . ?• < 0 U 51AN[I+pefrll N 9 f4l`C 1V115551etF'Ue NlA°FBr «i.F Wyt %nef5 re 5 w ACCIDENT M,IEAGE DIA09AM WTA „y E 2 F o• .C CODE xRO 9 CI E, 99ow O9 A[rFV[r]Cf C0:115ON?r.,vpyfL 5[vf 9N rl 4E '•41NN410? ?`°':A4f ?^'IS 1«0 , w»n°1.- N Mtv CIS CAC6551RfFY0940•D _ ? 101 •: NO 4RONPIVDAw•rif prl+ ?>°I :1f0 ?51FNifil dVi»,C1t5 ? ?5? 1 ?? OBI[C15,4UCxlN0.M1 U°OBrf<, SIRUC°ANDOrm[45 NeMF, S, 0•Mwt D/TcH s ! S4ECIAECOD,NOUSf - UNIT NO. i UNIT N0.7 4s NAM1 ? VEHICLE ? PEDESTRIAN C PEDAICeVCIIST wv N4s M. IX y 4rl9 sNAMo- w1 r.RS1 nnIXF LGCH EnJC3 RG, CH L£ In - - nom m ADDeFSS 2 O G`°?= -N, NO D s19e1 ADD4ISs 51A1t 1- NO .. n4mD1 "" - nrr sun -c- 9Fr3 ZS- ,LION £ R .?. n[45l <FN511,0 Srn1t 1 •• l I vl9 sl Cf rRl NO D IA1( Stx D•1t4^ BPI»° ?" L£ e L 3 T S ?/ nT `6 Jeo !F V B neec4A„oN r c i PW NO. D?,R 9 s «F L»t rc e•n iFR?r 7J-t 9R 2 f WN E R oceu4el oN M Na«e • °»oNl r.,, yr[s wF L»1 rrF a -. Z w C CHECK I?) »c![•s nNf o: a•vo, tc P1 w N ? CHECK (.1) AF ASe `u aorria AHO1wlRA` ° ?•` >« ° CODES ?' a is d in / s ri? CODES 3 i(ii 5 N1c N e ;. 2 IN ufs S? T < < K OT s n C Aw.D1.NCl ? E:a°' C "b:9R ? ° - I. N 1."` ]D4 I J ?v « ° IDUD4tG»FV MUDttICAVt NOVAI 1!1]De-C , ? V xt D !C»FVr f•e W. .Rt w OvAI l I IG7y a 4£ 2 2 M01VAC E » Na 41A lN. i IAn ..nta nM[NO uF H »cpo4 !- Alt NO. A.. o L C 6 w I " c Vt»KLl1Df N11EKwl KIN NO ` vl»?OtIDFN11ri •, N I O Z- •? MOO wpSRRIDp W iiR5 rgNF NO t.15If4[OOwNEe lASi N45T MIDIXt F LEC f/Vbw 7iz-S<7d w ?1 u ADDwma ER D °YjNf° `t 2 Z7Z? N E - oRwm1 INa-?s?czEtN s?sccr„T ]] ADD9tssamsuvNCrco rAM R - ? N ' t •At• t . ?" " O7 ,7 .. '. w< AnuA g :c D a 5, / DAMw y rN ° rn- C +MA-l 4! ly D »•RO[ L - ON ? Awii VIM•INID C»•44f ? iwAtr ?91M+INID t DDwGI 51'D•MnL! 1?5 - IC 1 ??? ? ?y - DIAGRAMOF COLLISION °j AI 1'ic''c ?°'» iw[TU lc SS.SAr1 B Ow ? ? ? L--'-Lr DESCRIPTIONOF COLLISION ,USl SU4vu MtM•: 5»III II NFCl55.91 V£!f/ c<£ ErR GQou E /¢s(,o dtN/J C LcRvC. J S</p ON T/,tt lc£ .a-ND C/}S?' B?c..?D "'• - - ? , .SRn/O.eN Rci3PW?}y C'?J AVP L.ST': ,"N Sr b?r3r7' b`AS srELO w.s-s 7? T D j, iy p .e?vE,c. A f1/lR?x bb .n//t • VLsdCCLL L?vl fic£O iTd P't V W N S f /p 6 'y sN o y; owf of Qyr,N? A•?O dqheK ;-rb P?/TG yi 377C orErOcF C-17N itrvD sp-e/YD° S,,vuL3T/G 141't0 TAf`i17 ?LH/?Gd Set£o "140 7 e O ?N S ADDRESS & INJURIES OF NAME RPERSONS S P INVOLVED 'CODES 1 - 2 3 4 5 6 . s.?°nl«ro++: Sw OCCUPANTS/WITNESSES i L+N•1 N , E rT se. •4! 1„s ` wvR Ina - - K, .Iv 17 IXII- J 1 m <ArCRd EE Niy COS °1p t ianl.cr« p•« B - - .«! YcP '/s .t•,NID ?39t 3Gd7 / Z Im AL 9 TLC G y w. p «v d ] G"'? x' BeLrrv p,-1?WSe?t ? 7 ? 611?FU.f ? I? T o Ile I n STATE OF WASHIN9GTOW / / ,.,..r- - y - ;' S Ill ?bf/A J I F , ,VON ?I PAGE OF ?TRAFFI POLICE TRAFFICCOLLISR No. EPORT •~ p'%KECOA NIWS - / ? PRIVATE AFY D E<IX 1 l n ? / / f ... couNTr WUNtY,.n CITY NYJ. f A RAl O ME N CIT OR TOWN ?E6 rvOEl Oe wGMW Y .I. ?s Ow OF j ON 1K. Y Cl5 RWSEOR 69 / CO vO IF45ECTING WITN11RfFTOk ROAD NINIF9IF ION R fl MIIE POST S yy ?S B[tWE[NOf'R Srgffr6 //?/' 1 OISTANCF6019f 1 iROm REfEREN C4031519k rOR NFARFStm IF MlES N 1 E ACCIDENT w GE DIAGRAM OAYA. fFET OF CIXIISION vIXVfD:. oVFRIlY IOTA NO. KIIIFDn_NO.IN1URfD ?IIIAGE ?NIT6 RUN fiGpgO s SP .ND IN I s4EET 4 OR REffRENCf ?N IMFR ?fy ptO515iRFETORR WD X33 Cf VENIClfS pROPfgrvONAAGFONLY ?tt TUIFED ?vFDIN / aj6O 9 OBIFCT STR KKINNAFOF OB,ECr SrgUCK ONDOWNER'S NAMFI E1T.DAMA1E SPC COOING USE S S UNITNO.I UNIT NO.Y D4NFR'1 NAME: Usr FIRST Q VEHICLE ? PEDESTRIAN O PMALCYCLIST 3R I ??/ MID l T ( F C> ervfk'SNANE: 11 FIRST ?•?l?l f, 19EE1 ADD4 51 15 ? ? -11ADOFE. OF E ZIP CODE HONE NO Qae? r 5 y3? a/8? DeNFN'S IICFNSE NO D R IFY SIArl LIP E . h§41- g STAtf wpm 'I' ( V IV R UENSENO. ATF MDD;1 R Y 0 2 «CUPAIION FIRM NMAF6PNONENO. FTFS IGHt fE1GMr z` l 1 E R «CuPATION f RM NAMES PHONE NO . EYES IGHi NEGNi ? CHECK (e) vfN nEAS nN fMNOrEE OF w CODES D. 3 -AV < i r. ANOrNS 'L- a+ a sYO?ox`c WMCAIOR O CHECK I? AS AN EMNOrEE aFArmrNEU. CODES W G F, A 'M"'R R1O "c•cD ` S uar N ?7"' l n 2 N,DRI rt n s, . 3 ?i o i¢ iaY w ?M O -x<E EE ? [sm4 Li viHK ? "v Gp TN? TNI o ma 0- "ma ? ?sirt. a N ? ?6 V FH F I OIf .) NODFI IUrwr.rgvA) Stvl[130R. <ONV.I r YEAa 1 NEV.1 1. V., STY I VH IX E H j TO E STAFF tR RfR Mrf NO. ? ? STATE C a AFr A ? VEN <IF DfNiRICAr10N - L V ? J Q T 1 $ 41 4 .Z? afGIS1E9fDOwNF9: UST ST IDDIE PEN)NE NO GSIE D- ' 4f . o E9 IAST FIRST ml f ENO. W F? ADDRf15Of DWNER N OYMf9 A f,l L Am E ADDRESS OF INSURAF Cl CO. OR AGENT Gr8 R rN U AN A i D AGEDAaA SAR r?O .w I ' O AwAG(DMFA f lOF I.- CNARG 11 v CHARGE uwiriar iu g L S ' IOlOIfOii EST. RAmAGE 091FIN ?REMAINID A D-N []RWNNED AWAY EsT DAMAGE 1lOP s :w:vonY ? AWAYBY S OFOrtOR R u NDr DIAGRAM OF COLLISION: lu u N <A a'ND9m erAaow _ SEd11R NlClssMYI DESCRIPTIONOF COLLISION: (UI!SWMWNTAl3MltIF1IC-A1 o -MvE-- Veh. had 6s dog JF.I ?aAr._Srs&L Why ?tf C?TA.A? w?na,,?d e? ix.)f `I?L? do , . nb±,+efRd pEOpnq WgLkI L RC 5dG of I / ?ppp ???? 7iJ 7; velt's r?w pfd /L)To. 1 e"VsEsm elross La ti i pp 71! mr` W(Tt- E dsm S nb,W p CPU, eoc Od'h ) o-Aus, ?,c?? i Y&E a ?k q w . 1K13 sack. o0 9A Sr ?oc4ud 43 FFtc e . Al s.4 Itir'o 50S"z C.4m7s bOL1b5R.S F N NAME, ADDRESS S INJURIES OF PERSONS I A,- OCCUPANTS /WITN SS ' NVOLVED t + CODES 1 - Z 1 3 1 4 5 6 E ES j? ?j I µNAMI AMS L T ' SI V S1`4 Ace 'AI . R ESIN. lXR I1L D LE d o 437 aIf FEY - A A DD9ns S ? p'=1 T DIDNR ? IArw' O N AMn. C] FW' O "' . O .'. ? 73„,P i -A URIOr WI•.S FAI 4ENOYro l4ofA AMe. p't°.`NI col;41 G) 04,011. X N o an NnlsrpAF4kD 'i"!iF uINE nr. O AMe ? 'c°.'.a O'c"c'.nF ::: ? r"O...r,. FAN. nAIXAW AGf NOr rCEDD Ovj D?E zy ?? ?? s5 ["iibw 44 ric I l ` 'Y. iN i N?a EVJ'j°F??kG+?"`f 9r i',iaYr`t 5.?e9 ;"4" ?,VV.cF"'r ?YIG2f. l f l ? ? J,? J i? l F fi l r rig ?1 ?'? L .I r r r t ? 0.. 1114 a. STATE OF W INGTON 4aGf .1 pr w5R'M IRIV I N0i 'n POLICETRAFFIC COLLZTSION REPORT 129 TF.5FFlfyrAy .._ pct ,.M ",NU fq .- L \ [:] PRIVATE WAY 21 arl oral . -• G rsoN rMt USE T+D` "OUq cour.r, cour+lrw. cnv Np. E"w I.S .+ A ? UU ml ?t ?I+ ORIOWM1 vt ANO rSIP[t v G"WAV N rC Cl5 gOUrf OR Sr t IX SC- 1 N ?5 ?W 9°° ci8m)'m ON ON Y fn SG/70 ? " ' rRtc .G aRtup41._.u nJN tR?` c?rJ?n_ CE1F15r? '-"' elrWtrn'GFlRp? (3?^i uen , ?Ai ae»+'w e MnffOSr G./8 ' I DSIANC[60ivt?i iON rR M I. C40555rv[fr OV n'lavt5r v?ll vJSr s f w N ACCIDENT R DIA 4.SM WIA D 0gQ4 RD '3'5 rts O MILEAGE fDDE CG«'SVJN iNVOrvlC S[v(gir?.?N ?O+ tN0 NG •illtD?NO ?NlU4[D? ? ? "IT-11 'I'IavV MM" orr ":0.5 : O vgpergiv pa5'.,Gf ONIr ? vI'lC?F N ' I e. If4 ING S14ffi 4gOAp OR HEE4tNCt 'N iM? C?5 CvpS55iNF[r OR gOAp S?? ?O .? OEIt C S AUCn ?rv°vLO OD1EC15_ikUC•aNp OWNFRSruMf: fSI.DaMAGF ? SrtCUL CODwGl6! /_ t0 _. 5 UNIT NO.1 UNIT 110.2 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST C95 L. lE f ; Dgiv[4-S NAMf IaSr iq r r! M V I I 2R K f ' ? ?7 Sl Rfti ADDgf55 C?Z OA0 / 4n 5,A,f CODt R" )m JN D ? -e ,I Latl Y _ // 4 /. J(oELt-S VIA. ? R / CJOF Vq E w C c; Z ?+c ._?7 17- Wr•+f4s4aax r+o sun r o It .. '" ) .v SLaN No R ` vaI t DA ,o a e I , i W m ' . q V / SCS9m"2 A R ' gM n a, F dv "O N N t O r S w M nr f G rt G 4 i.iL i ?N r E r L N1e "ll C No G" , " W tI E 5 12 Z C ti c , ai ? ?ny R r$ M A L T ( .3 R n 57 " ? CHECKI?a A [:1 CHECK I?) MM ras AV EMRIOVrl Or nNr r ?q°1 CODES ? ' ° L/ .".' _ 5 r n 1 D„ + _ CODES ° 2 NjURIB NOJ-E c- l F ? ...., .r,:, ? b - b<, ? E5.,1. ? ",:'.. °.,. P r.0 ? .,+, .,rl ? ?FTS4 ? !, r. ? 110 1 11. tIDODGE C"EV cy v. MCCI: D vr.+pva S, r ll lv D9 COrvv tLCK ?A g H W C r vta D f-C"FV. o MA5 ys' ! pAgl NOVA. v vl It DP C n/4' L '? 2 5" uo SrAI AIfNp "G AfNO t , L " - - I c dd`3 ? ? W? - GAir I"Kltpr, CT1 I O I O L ", EIptNllr Ar „N 3 R Ex F01. .5 c q[G SDRrpowrvty Iws* rmsr M?DDIf C C y CD wNl rvp - W f4E wN lasr n4sr M?DDIE ?M t4 NE NO. I}5 "oD tssa ov.N[4 L yrJ o? . n• ., O x 7- n .. e E owNfv M " rvAMf eaDDg1550 iNSVVANCI CO dAGlrvi l Co. -5E}l77ZC 61./A" R ssTe-zresv A N dh L JN r i?Lc ?N 2?5. ?(??JC LP DaMaGtD ARIA ' -. {.? /? DAMnGf0NN. M ' Y nu 4 • ' E +rwt O ?r ra ?"ARW ? C"ARGI ? 5 o ' MwGI griW?v ?u!M°?NfD ??WAV ?RIMUrvID ISI Unm°t,l R - rU?oiiO+- ' ' s3000U W l:w:.° ° 16 ? A ? er ?:° . e. EI .LYJ ` DIAGRAMOFCOItISIO11: SWII ri wi465agr`I INBC^evb°..rp1M DESCRIPTION OF COLLISION'. ILn[SUOnFMINra15"nrrr N!<tSSARrI 5 CFAzvg7;i2? cE C7UC VE}l.µ 1 k HS SZtfJYFJ3ii?U c^? Rp14L2Ar 2rJ. Po 3 Y }le Slowcn VOar Stow, op. 57Jp.'cv J] ?? - ?raur ) I`))00L GT ANA2Qct? cct„r%/ me., Av 7z' L.cv< • - ?1T bc^TC OV--cv rz- .-e fir, 5. V9I•?+2 /5?6 s ?ISG sotij7/r lj"-9 clti Qv 7C19y 2D?a?J ?ND?1Arp DA , ?71/ST Ca-'E Cax7 Oi,Ae'oxvf+ f16.Ac&11 N2 Gi45 ? CR ?f - ' _ / G C ti?E LGOw,& A7 7?if I O C PGSTS's ?cTNC.ICC: /71D , l A,4s --mvpn-.) Vovet.65 CO zM-D 7-)Fr/ e l£ Iz NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 3 a - • S e OCCUPANTS / WITNESSES -1104"IM"""` s" DD"•:fhat NAMI 1O / S l Slr AGI vl Ste Il l lC ? " J EY2 ON.vi E _ O j FL- • - r s , P Rl,u ili•.ierquvr,,5 n ??. '?."; ?:' ?;c w - .. ,. ??i;` ?IIG" r. _ ..? s _..?- X,'1nn...•n-.??_?_ _ ..'3 . ?,, n r.i TI, H ? E ?f ., '? a k ° 5 io??cf 4w --ft460F"A8NINOTON ` .• "` NO40R VEHICLE COLLISION REPORT NO. 4 . , V •• -.OATEDF COLU"C" :, OAYO .r TIAEOF TFe s MQ X OD'J? ;?: YFA? Sw Mpl NES ,HI nW M ?} I 1?I Rt U W'. J1 ? 1 ? ? [ [-.?[ ?? .? Puce COWTY GTY.iOWN anSnE M8F8 ©© :. GfY. TOWN WKFAL, AOB[ORd11KR000E BE011011 W , Y Y Ao W Oft-EOFSTREET.ROADOR HIGHWAY WEREECTWOWITH:STKF.TORFIOAO PREFTX F A d[IFDOST . . acwio .. ??R 1 V k.. IgNWTEflSECTCNLOCAT NOF COLU510N BETWEEN V 5 C L _ -AND f1A11P OU.6RAdf DATA ? . II, T ®© x.ppp ERp55eo 4p[os, Ox[DExivWnUWU. x NON Xfl0 LATER WT as e•a aK[f IyercNGDaneaa airoo t FcTnn - ©® ? pn,x[n ww[[I curf awv 9 oYYE-LE YE-`E ElYL-E_-ICLE SPER OOOE UBE.. _ K[[5 ? ,aY[ fo s,n „ a ox ?xHAUx 9 OBJECT STRU(* aioBleGr 6,MC%I DWNER OFO BJEDT9 NAME AN DADWiE59 IACATCNY i:. t,.,. ? ?© eIwAIEDtnm IN flOADWA MM tDAEPM OaACi FEET foaE -.. S OWVERSLASi NAME ,ar:1?.-.. ...... RRST NVAE. MIUEE IF -E IYw cols pNVERSLAST NAM ....::I:i.FwB'f IEALIE MIDDLE STREETADDIESS •, ROUTERO. ??-? ?c\Tk ANDBO%NO. nO SI AE STREET AOp1ESS o R, ?fs`? A' CITY STATE ZIP COE ?T lDUl C !r' S ONVERSOCCUPATION .0 'Art 4C1^ rrnr CITY STATE IoFCGOE 1'I Wq 7S.3102f ORNERSOCCUPATION ?r?v<F' 40.71 -c, OPMRSUCERSENLAUER STATE BE% DATE OFBIRiH AOE )%'1 .1 rE' q GaVERBLCENSE NUMBER I STATE SEX M EOF BWTH AOE VER, LEY., MA%EICNEV DODDER MOELIR0-TT) BODY STYLE 12 DR.1 VEHICLE YR. MANEICHEV: OpOEI MODELINDVA DN[R BOOYSTYLE I20R.1 SSA 'h f3c?.1tLE? ' FI•i .C LKENSEPLATERO. STATE i1WlFA w.A ENO. W a STATE UCERSEPLATE NO. STATE liWIER PLATENO. STATE ` 7u U l i fJ 0. VEHICIEIENTIFCATCNNO. 1[880 MODELSd NEWERI OpOMEIER IMILEAGEI VEHCLEIENTIFCATCN NO. IIBBB MOOELSi NEWEfiI O?IETER IM4EAGEI CIo C. REGSTEREDOWNEfl ILASTFUiST MIDDLE NAMEI ORIVEfiSLCENSENO. REGISTEREDOYIHER 'IT FIR4TMOEE NANEI OWNERS - W. I ? ,• ? Ibc'r - C'v..r,.e IiFi ur/J Q- ?"\? ?-c XLn2 O WNERS-E59 ISTREET.CRY ANO STATER 1 ,?. S1?E ti itia• i?.r; ?.,,rS?G[,; DATEOF BIRTH ?? ?" sc? OWNERS ADDRESS ISTMET.C"AHDSTATEI i-'- (-?. ?i °6 i Pof1- i okntir? (,ll, DATE OF BIRTH 4° P MTBOF VEHCIE DAMAEO IS MvEH<u io?v"` P OF VEHIf?yAMAOED $rV•"?:.:.,: :. MED?Le V n s ?? LIABILITY INSURANCE INFORMATION.-VEHICLE NO. I- W-AZEIN EFFFECT FOR MIS ACCTENT OR YOUR CAR .YES ?NO NAM `ANDADORE590F LUJ3UfY wSUMNCE POUCYICLOER NAMEOF WBpNY[LSU{VJICECO4PANY s9 Hl? ,- _ ? I KC', i,-? P 5E-11 O •fY?l M ?isi3.T5-- PL= C WArE MOAOOf1E890FUABA1fY NGUflNJCEAOEM r .. rATE UABIUIYPOLIC,YTAAfBER ?S - ILEA 1. ? eft s Ccc, 1-4 1-3 -O $- ISTwnwY .??,.. AOE 2ND WLVIr: IUSFSFPAMIE P[RWrfOn ADniIDNAI WAAYy. " .. AGE NAME -ESS 3 IDr•L wlDAfo NAME ADDRESS xlo ?/ Sa FF °`nocl[w, r t1OU'O1LS ux ? ...[ • nA _ _ ®©' x Ions ..____ N.f O - STATUS OF WUREO w VEMKIE O pal ?PAS. S -LED MM%FWST D=,r ISIwDiHI WETHATAPPUE •rtlx pSA&Axo lu'R S POSY ' I CR Y ° STATUSOFIY.IUREO O? R IN VEMIGE %ILLED naNli FYI I1 K?RE[ pgAn W 4 IF 'r`n '.' - OH.DE - ? 5? 6O o 7? [ icl ??? r RD O ? 0 I wrn l 6?I oFCO4P rc 117QE` - SHOW NORTH BY ARROW W CIRCLE O -A', Yr TrrS n.GIIN[ ESCRIE BELOW WIIA(HAPPENED WEFPEq;QVLMCLE90YNUMBERI A E C?b?e1a L 40110 r.cqq Lkh!elc 3.. Z. ,_ ,u[Ilon.um UCI'11 iC, 1 J}C:I?J. ?CI'\1t?1? [.? ITCI"j;? I ? ? l 2 n c eh?? e f \ d z f? 1 ~ tt}} VEHICLES POSITIONS BEFORECOLUSION n v[HD'' v M r wlYu[`A LIaRLr d,AMAxD MI.EI ww -4TICATEDUY a a r +?Ti?4•V # ?[? d' °i Y M unADY Ro YEltt[OrL1P<I ?iAT- ?M,Kf V[IVCI[ N 9 E W ON STREET OR I.OHWAY NAME OR W -'I- "° Y 01500 0 O O` 0 4^.0: ;+:0 M"' ®o."" e1 r t D,,A T, O®O? y I . .r . .1 1 r r I I a t? l. a I O? ?? ?? ?a<R. ,e ;i lA4H /'? T d ? ? ? ? ALGro f eAOffn .. 10011 "'DIRECTION TO DIRECTION a - ,yT, ` ?l e F[Ea IAN W ,vr0 I ? U..NA 2 ?.NA.AY ] ? `+rrWlEll • ? ? wRA a ? u• 8 OTHFR S T ' l { 1 h 3 1I x? } r'-+ I 2 f,µ , f I I A al[f E. N[AIHfA LXYITCOVDfIORS YTRICA b •.pI [ ?tlMRbMi R ?OAYIAAIT ?qjR p, TPAFFC CONTROL IgM1t•OrA1 TYPE OF MAD pMNYY[TIGEACTIONB ,YUE cAOM NRp[ ICrIDA dF Q[OI<I ?I IK[ ?SgIIALS 4??ION[WAYM?I ?I R ?ocwD STRAMT AHEAD Iy, yY'J +? 1 ' . ??` j Y! Tf W R W DRY 2 ? AAIYWO ] ? OAVM O ? ? ] ? 810P JION ?ITWO WAY ] OVERIA%Iq AIN iA06w0 F ,1 ,L^ r. q?I ) ] WET J ? YAwvA) ] ? OU8% ? ] ? ANOW . ? D ? , to 5CN ? J ? ROAD, KYTBSIULE ? ] C) MMYq RIOHr TURN ? T 'Y ' . fir . t TT A ?,w . ? a ?•?C[ ? • ? RA.ruA REO ? . wr[11C ANGE ? A ?YA%wOLEFT TURN ,IiNAP OOP L ? i l 4 . . i ORM1R OMRerM[I D11fR 5P[ S?ICUYI LIERT OFF ? d ? I I ? a ? fL-Pq_oTR ? a ? O a ? MA%WOU TERI HLf Y 3-1 a ? SIIK[ IWr19 ? IT ? ftll [r<Al ? a ? TWO T Al ? a ? YOwxfO ^•',., 1 y ? I IKASgHNOY[M„ONYOER -c I ? SV[CIfY r cr ? I ? OIIIC(RIIAfiYW lME9 ? I ? Stavin f01111RMIC ? E O Orr[R J CBY ? I ? YPNRATEO ? It ? STOPMO AT SMALL a L p,, B 1 I ?.,.I I ' fir OPPED w R0A0WAY ?•.. M IRUIC ?--7• ? PY-0 ® B ? ST ? ID ?Br NlrwOw ,? I 1 t R,b f "?i ???1'7.6 , . ? r M? Y ti. 3,rAi?..?'T71Rt1,. ?; v??PM1°"'"'f? ; } .l r.,w L LMHYNtlfO TTMFL.wt 9?"iI?"^^Tfi{•F' ? . ,,.Y, ,. n, Aauuals?1.......,.? r f _• plY. I W?W F i Y ixrNl`'rn1? m ' f ?? R 7E` .n i IRVVr ) ? la' Y- t r^ c- \f7 POLICE TRAFFIC COLLISION REPORT YSITRSFFICVM(AY PRIVATE W Y Ice P -, EQ GQ4l T I ;I ?'?-r-1. . ' tME IU F] HO RI COUNiY CL%M NO. CIiY NO. iMVA pUNB.W - F f p C OR I OwN NAmf6NO. Or51vff10R M0«WAY C]. p s p o Q / M. RW '?.J/¢OU n w tRSfetlNC Wa H.s Eftov aonD NDN wr «? BEMIF SIRfE _ -111 Pweu -61 /VJ- OSr?Cf6D9t rROM 4fif fN CR055514EE109 rvfA4f5r MllF PO31 ' MIfS 5 [ w rE[i OE ACCIOENr ? ?- 'A COIIISpN NVOlvEO'.- vFRrv H116RUN rOfN NO- NO. KIIIfD_NO NIURED-1.1 p SFIUO[ p OrvEH ClES ? PROPERrvOAMAGEONIY ?pE5ulrz0 ?v[H`CIIF ?r` NifE .N ? C, W33i OR Y".Y.U ,( ?- ? f_" t7 1 ' '-' OB Gi5 UCKI Or O01 Cis UC OWNERS EI f51 NAAOF SKCW, ' ?- t :1. K+ - UNIT NO:'fi"-" +; C UNR.N0:2 '.? Nff O VEHICLE ? PEDESTRIAN p PFDALCYCLIST ', R• ?v [R'S NAMF: U51 IRS O NAM[: NSI NR AI l O R _ , C` IREEI ORF55 SIPEft AODR[55 AD Ho' r 5(Art ZIP CODF igNF NO 1-1 NO. v SIA . 1831 37 - A• ° , o9N1R'SUCFNSF StAtE I N N0. Arf 0 t OF BIR H -- ., OCCUPATION IIRM NAME -N[NO. FYFS CRU EEK:Hi ;F.I' CUPAIION NRM NIASE 6 PHONE NO. EYFS WEIGHt HEKSHi . . . •? ,?,? Its 62 ,R; I A p CHECK (V) 'vfHV'IF AS:N fmviv o 1 f A AN :§i p CHECK(/) I ICIf ASAN EU4iorEE Or ANOiHiIiA` 'c E Ho« a °v°rz Y - 5 CODES P 7 a . irsn ;n' yHr CODES 10 7 ?,u . ivin 5 rn 6 2 I URR , "d9. ..,KMA»<I ? W", 11 nk. ? u M MR.- p AR l ? c°36'ct p TSIn. ? n?Klf ?i.Gv vFH YFAR M.vKF IOODOf{,HEIV.1 L.?J ?? Fl10ARrNOVA1 TYIf IZ-c .I ? ?? 1 Y R 1 « 1 MOOtl10ARi.rvOVA1 Y 1 R. 15 vatow UCtN U N SIAr rtv"nFRRAtf v /A - ?' ? vfH. O4 l VIH CIf OENtIfIGrn)N NO. L vfHl IE IDEN III I q, KPILIF11i O 111110151Y101 I I I I I i l! I vfUSRRfDMwNFR'. IAST NR51 mIDgE Rgrvf NO. ,- W I vDOWNERlASt r1R51 MIDOIE I AO tt35Or dhNER N r wN A E4 ` O-M OF INSURANCE CO. OR-IT I R IN U AN ' D 7Z _ -MW 1A SrCeprDi.« CHA?C< ?. lSi.IDAMAOt ?Aw?v" 0 DAMAGE MN? Ot « CHAR 1 DAMAOE WAV Pal-Kwds -M Aw°.Y S u, ,I, ?'OWED DIAORAMOFCOILISION' lu fLL R N l No•c'i°pNO°i" DESCRIPTIONOFCOLLISION: Iu5[SUPREmnrt l3HEer rNtefss 1 V4J1!LEatI?ASW -LI-1- ?0 .L 1 .. _ i 1 _. ANbVIL.t-?I?B9 .. 2w?h- 51?1?5 ?JE' D2vQ? T.d ./ 7155 A D??aa??22 1/?iY.cF ?".L I ? ? i : i 1 _- - ?! ? 1 }2P9Ow91 _O.<} y vk!!?mT ?OLLaJG- 17`5 n t rrr RS3TO ? O ...1._ T-- / - vp2 v? ? 1tiiNG Tb . `" r7 ` ?{4? ?? . cS1l7L}C?FI1 STcS?/9? J2s , r ? _ . ? IZV6?_ ?6 fUs1ED wi13i A??'r?SV?FS _.. I T I f I i NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ` CODES 1 - 2 3 4 4 5 e OCCUPANTS/ WITNESSES I,a:DO"famrti:iN Mi ii stK Ace l.ius 6 _ . . Lla °;°: Aml W I 4 ml ,? ]D .DD•133 - .. .. GAluRld '..... .. '4. vK•OVIDi HA+.I nll? AMl Y•O l n.yls'L.'••G ?'•al•'••+rI.RA•.• A•K .LI•iCl ?11U :rA!r?.IL t.a•D ??N))IrP?•]JVl I"J.IDBr I U 1 le r - 11 T{15 h 77h ..Aa•up?yg.F4A'Y +?' + yM ""fir ,r y y 1 lk'' a, 7 u h ;Ta • " y h ? n? )? Mt• 1( tq!,?•? ?s ' 19t J to p ,^, E l w D ti .I\_ I J SV I ;. `•l rf I t+ ``T ??1k 1"? 3 ( h ;`Y? I rI r? 'S l (( l ' r r? f i, I s l ? jatt ?r'1 I x l F' ?L 1 f ?f' • ? I I ???,}?r EE? +IY'f?` 431 II m I J a . -? ;dram ' t O l ? J POLICE TRAFFIC COLUMN REPORT ZI TRA FIC Y WIKf[U...w NIEN PRIVATE A DATE OEC l '^ COUNTY .•o. Y. w. 1 ?. d Vt". rNt. x 5 IUSf }aO.OUPI ??? Cl1Y fMVA 5 i ?EweAN 1 ?N 0, 0. .-OWN AMFe NO OI S,RIf OR.IC.wAr n RAE Mn[s Xs ?w of p 2 ?yQ00 INIt45[CIING wt IN St-To-lo NONI t45tCrgN }} PRftl% 1v051 mm IRFFte /, -,7O SiAN<fPDltl - -L'. , MP(IU(Nf(.CPOS551Pf , 1A Nr PNA MILE FS S ACCID M,A w IEE ??/ , LC f![r 0 CODE COUIS1oN m IX v V[D 5(v[Rnn M irvx IOIAI NO OYIlIlD?NO.INIURL 0SGIIIAGE 0."... ??F "? }S ? IM[R, CIS pEp}SSTREFfOR RpI•p OV[NICI[5 v4p.EII DAMAGEONIY ? yIRy ?s-N ---1 OBIfCr SIRIKeIN RC, sr4 C ' ? U A NIDOwN[v S NAMFI fSt.ONAAG[ S .OOD-- S-, _ NAMf UNIT NO. I DRIV[P-S : wl IIRS, MI f VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST NOO.2 ? U NIs s . 3r -.1 R4 + -HIADDRESS S,A11 r D 4F[l DRFSS r- EIV— PHONE NO. I Y lA F F O `t'IA?LacK tAxS, $ 3 R Z ..I. 11Cf NSENO 5 [ E I A IV I IN. IAII Sfx All I» F ? S 4 _ mcuPAlloN P»oNEr.•o. Ems ic r •c,cIr E pccuvwrloN NAMf t vINDNF n0 - x R r+ fr[5 wF GHl HIGH I _ ? CHECK (.? c f As 6N un A rr[ AN r ? CHECK (?) Mm ' 'V ' v 1 ? s CODES?* y n ' a ND .cy? ss A .srr ncl ??K v[.1 As AN- 0 YEFOFANOr CODES ? * s" ^ S si Sn Z u fs INI " e i. o .Mw, Kl o ?s ' ? Ee»I. axxr s rfAgDM CNF IWJDGF V M F ? ;o, ? M Mv 1 ?,<I Es:rl. ? ? r.; - .I ODFIIDARrNpvAl Sivlfl>DR CONV.I G fA9 MAe l ..v .1 IDA4InOVAI n'll yl tCENSEP!•lfN S,A,I Itt40.•n xKr AIE H I4A VF.C O4 ?? G l A[ VI»Klf MIIK A1 ON No `. I I 2!! 0!'22 112 I I OFG13nttDOwNE4 Wl NT MIDD1f of»CIt IDFNtI U I I I I I I I ! 1 1 1 1! (E? { O v"O ' - ' 0 w+IFP: wl F1RSr F f m K R s - s ADD4 55 OWNI4 1 - N OwNEV NAMleADDVFSS OF INSURANCt CO OR AGFNr E ? -? R -1 N D An . IA, [SI DGE cNA4 owt-l DAM EDIM[A A 1.1-1 ?AWAY ?PIAN1 ?nwATr fSr. DAMAGE ?RFM•INID S lOwlD • s ev ION'FD WAY AWAY I DIAGRAM OF COLL1510N Iu MN .1 INDICIII DESCRIPTION OF COLLISION; IUfSI RI [ AI SNIEII NEeess•vrl .. ,YYIi nvuss.Rn e F V ' ?E _ + 1 -'O _ EK.3l -taoRtll ON n?sofJV\u._E (ZA . WEwt'?. 7 ' ? ' AR A n ?R . _ _ ,- _? , watU . LGbTRVE-C^Rh4E L9ST ea1J`. - - .4 790 SCRvs.SC SAN nro R.mKT S`AE AuD ... -i _ ;. _?IE41.. Fl\PPE? Iu.SCo 1ZS TcSe • QR\E?, - Sw?roP?L ? _. ` ? rr? ?A5??6?R5 SAL??tiRZ .QRLVER ? .o5tu L•or.SCR?_ .. ^ ? . II 1v NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ?? * CODES l jj OCCUPANTS / WITNESSES Tim ? fto N uu' d .. 2 3 4 5 6 N A c ,A, . pG,_,. AD •ml ??, M. ocslx l 431-Tril 5111 AGf I, tArui '"?Ix nlr M 4[SIR IAC, 5 A • Vim '? Ell \ 1.. \\ eLldly \ Dnlss .P X76$- ?((p(3 •, v c m ?. ? Ame O F1Z ?"' r SS::: I O :4 AMI u M _ . .v Movlo lecw. ? N (]•Me 0^ a - A MVI15 No N•1 o OP L J rr?3 • .A. vfl.. (?? ` eAUW nR • •' • r f 5 • sctN[er 'pvme ?' '?"r; 1r?N ?1: :rr - Y A I 'C rf T \\ ? _ :•NG ? •.1 *'?....I DDS-..x• XiiPpND C•N fY PIVJP, ?. 1t f „kns 4 6,,i1 l LvaTa. ! td '" f! 1 `" ?i t ks Y T 5 nl '. ` i""'?FrXhLq'+r A4k'.R'F'•tir.C,2?f"'saE'.?,?*ST",?, '3?Sd'$/?9 L.. j F t A ' SJIfc, { t ? u ?;? I s yl , r I l l s J -? ' ?? ?? ? ? I r- IE ?? y T 4 Y.. 1 I „ G?ouvA qq ? } ? ..Y 1 L 't r T 1? ? S1.!/ _ I r '? th f '.k I$ i }r1 r r - I I 7s? d I? ? T IT ? I ? ,J _ fY I I }f I r j I S? _ I 1 } I ll '?y" ? E l T ;. Y I p. Fj ?-W 4 R92'x = AR }.. Wev IBOIRfV. I.e01 a I? ',/ ?• J "° '•' STATE OF WASHINGTON RA°f r a I? ° 1 o. N 2 , n1TR FIC y POLICE TRAFFIC COLLISION REPORT •- PRIVATE WAV/ KECOM TA Ir J^ ..• ' .1 F EO{, Q51 .. C R`i ?5 R :o 'I IUS[],OJNOUVI COUNIr /.J ? A :,!_, ?N ?( QN <IIY09IOwN NAMF6N0 °{SIRff,ORM AY :(e 3 i¢ MIEB ?B Dr G c .mil or,w v ?. ., o IEVeFCI NG Wtin. sl9ltl OV VOAD _-11-1c, IGN piUIF WBT y ?O• ? ?~ B[IWFfN SIREFI 6 LLb 519FF1 O AN t6 pf {tR N C905TT RE[ OR NFA9fe1 MILf 90T, lfs N 5 F ` ' rfn W Or ?/ ACCIBE ?MµEpGF G 6 DE M; JJ C0111 N NVIAl., NFVEeI1Y: ? H16RUN IllAGE NO NJUR[D ? I(IIIFD O dd ? [ [SS wNDNRI.s IMf1 p5 CROeeSIRQ10R p0A0 F _ . WIAI NO OV[H Cl[s vRORpIY DAMAG[GNIY ? HSULIFO ?vfaClF . OBJtCI SiRUCFI [M IC15I9UCR ANDOWNl R'T NAM[I III, DAMAGE !.L Lbf UNIT NO. 1 . Z O VEHICLE : O PEDESTRIAN ? PEDALCYCLIST J' s - -?' DRlvw sNAMr.wsl rlvv Mm M o - ?- DRN[R'e NAWI ws1 e S,RfIi AODRl55 . o, X a? [EI ADDREBS Z 1 flRCOOt vtgNE NO D Y ,AIL J ?, VA Ham 3? R DNrv[YSIKtNSt NO. MDNLE 1 G F A T1A wA N I?? 9 1, v 'B lK{NSf NO. SAI{ 1 E B Mo j DA I to NAMf f.RKI JF NO. tvFS GH Gni OCCUVAIrON RM r E CuvA,ION M NAME a P-1 NO. EYfT IGHI HF GHI ?' ' •D JZ MA51hN S AL A R AI H K , I .a.. ? CHECK (? vln ttfA :NVAn vff ANOIHEV EC (, ) O C vfH nE AS AN fMaortt of ANOIHtIi ODES I.- 7 c: = in s , IoN e ° CODES P ii • ° a s ,AC N a °rn 'cu n ! 2 C rts II N ' tY.7:11 O AMBIAJ.Nff ? I.V ? 0m ? .. CS?s. DARI.NOVAI s,vLL 1]DR.CONV.I [E O •^^ ? NV ? Fbm O „ ? C; Nso 1 nvl MODfLIDNt .NOVAI vul vl I n r[AV EIDOOGe.CHtV) `A 2nov cofw 1?7 A f, J° L N B,AIE LF9 M1f N0 i,Alt H vEn. ca CERSF7LRFi3E Il N E `- _ LLJE EAIF9 Wla - - I' C r 3 vtnIRFIDFMI[KAIION NO. I 'DID i3 i S I I I I I . Ja YEnI LLIDfNfl l I I l i l UTl npv MIDDLe RHOtrt NO RfasrtmoowYtt9 O RD wNlR. EAST {IRSI MIDa{ Is _ ADORessa?oWNa ` N Nt, (,lI 's LN16 E - • N IeADDRESSO INSURANCeeo. wAeeNl M.ra. e-,y cn Ns- ..R. bEk[55'LaTRSu-4'D+2 U u DArnwtD A9{. I?AJAACfD t OI t.ow?i clAIGI ^a .D. 151 WMAGI A tT SWAY pFMUNID ptMAIN[D 'w'A -- IG eo110M s ? A Y s 0 0 :wY:r°Ur OA°w`:° s e. DIAGRAMO -- - 111510N: - - ..iwelJrWtyssiprE "e+:IO ow In DESCRIPTION OF COLLISION: Ilnt suvnlMfNl ten tassA ; . I O aa;] F s l?tir15 NOYL'79J3ou '? ocJ _?.77?'E 12IS?? 5) D? ? E}!T?t?` '•. I _ _ -E . - €-Y_E}1?f.1. _?/ElJtcccy?-CAn??7J_r_L?r ol'_z? _zz? i r ''iti NAME, A DDRESS 81NJURIESOF PER S INVOLVED CODES 3 4- 5 6 }'.. OCCUPA NTS/WITNESSES IOR ADD.1 .NAw s, SU ? ADOnss .. "- " .?QJ ??94E. erJl e. ? ADDMSS No • h er ?AMB O.av ?a?. OC.O ? xlJe •..u N? 'n y wg 1 fi ?w 1 Y1 ! p? vt, O STATE OF WASHINGTON += N d 6,3 ,'M uTeE- ?qv ,? 4 :Y C c r_ POLICE TRAFFIC COLLMN REPORT ®TRAFRCVV 1Z --? L. O J 1 PRIVATE WA7 ,-?' _C "T" ? V U ,t ur m:u N 1]I 6` ?8 8 ", ,"' > •' ,•• sj5} o?p co°..r. 5 z 5, On Jefferson couNrr r+o. crtr NO. fNw, ? m6,N 1 ?N ?1 ?w C,v OR IOwrI O Srpfft v fnWAV N?"ai'ad? `s L3nI 1 n CE5 WAE P0U` i dq M,t3 ?s 0,, g]or Port Ludlow e ay H,F9L<t HG Vnln 5,9E[IOq pO,D NON H?fvSFGI ON ] 1 AN<[ :.pFr C90y Bf 551}W[IN Sou,,lfBa 5,9FE, 6 Oak BFL S,gffl f4 p?6Ml 4Ef 9N 9f(, Oe NtApfS pOSt trln t0 MRE,OS, ?i? ? - 6 ' S F CC DENT 1300 TTS J ren r Dt Mile Post 1 DE T ?'" 9AMp pl R l COIT'?ON NKnvEO 5 [q Ir , D,AI NO '• hO vEIfD??rq EENV[D ?SO,TAG[ ?ni3 vuN d VFnflf3 ^, ?pgOVtR,rD, IryiFy' ??y pOp5519[[f o.9pMR ?"G N ]3 ,9 MAGFONV ?MSVlttp ?vFNFF OBE 59uCr.IrvAM ,Po+EC, Si9UGl. ,rvp OWN[9'1 N•5M[I U l?r o V?9/? , ES, DNAAGF SRCW CODING IbE _ UNIT NO.1'. D vfR SNAMI U5, St MD t UNITNO.4 ?VEHICLE ?PEDESIRIAN ? PEDALCVCLIST D ' - Beck Bernard B. Rlvfq S NAMf 3, - 6 SteFFIADpvt15 Box 4'76 rRff, App9f35 Z r 6tAth }Ip COIX Hoff NO p D r "' Port Townsend WA 98368 b_K On ' R 5 A,E pC0 NO. - Nf9 S IICENY NO BECK*BB431MU occurAlloN Mrv,ME av,roHE Na q 3,,lE WA (+ M 3iq n 7 ay 1 v Iv TIC NSf NO. s A,t aBlq,n MD " 9 - _ 2 Er[s wT CNr nfwn, Laborer Port Ludlow Marina Ha 145 5-0 E uc<ue,tlON .NAME 6 prgNt NO EY[S Wf GNI K GN , - ?CHECK (.I vfnae,S,H Unnov[inAHDtn[q°' ?CHECK;V) ' _ r CODE$?' J , 1 1I-•.e. l - 6 5 r,r` ` r[ tt[AS,N EMI>iovr[or,erotNfv CODES ?' 7 ° ' 'S 2 wuole5 ad a d t l I ' < 53 51n 6 y N ° IDK •'• rM > h n erna n uries v[n f,eM MAgEIDODCACntvl RMUDEt DA1-AO n er3[I}D4?CONV Ir ?µ^^-',I ?VVtI ???nip ?H ?t<°v 1 6 1968 Volkswagon Station W .9 Dr ?Gw <nfr, rn 9 INStTLA,EN 1-1 A1.-1INO S,,,E H r to CIX q ' ' ae White YAJ 639 WA ---- __ I T9 A il " " - rI II CIE IIXNI I CAI IXh NO C vFnICEf IGNIINCA N N A )? 6'8 1 6 ;6 - - - - - - - - gFG15rERfDOWNtq IA31 ".I, M ` , Y_ - IpIXf pHONf NO O gG15R9Ep DWNF 1,51 {IRSi MIDp3F NO, I] ADOVf55p CNM[9 VeT W 2 N " O_. N.MtaApDRtssa lNwq.N;ECO w,GEN1 E 4 1 -' D_ K oAMwlo QTFA R 6 85 D N - {v ' A4G - Cn,OGf v S,Y?NG DAM1UGED AREA I } o-l {.'? l5t'C AG! 004lM,IN[D' ?D9IVtN C]RIMAINED ISID'D CNnwGI IS .en f o "w"r 3] - ® w: er All Cit ?:w?:°Br S I , MtH , DIAGRAM OF COIIISION? U T ' N6C,rE rvogtn DESCRIPTION OF COll1510N: Iln[suppSrM[N,AI Sn[[,n NEGss,an S,M1EIRNEGSSAgvI ?ApgpW Vehicle Southbound on Paradise Bay-Road. r } Went into left hand corner, lost.control and - -' , __- went off.roadway.on,right side. .After. going . .__. -down embankment came to rest in ditch 100-feet . off roadway. Vehicle flipped nose to tail_coming..to.rest--.. on it's wheels. - Driver ejected. OHD NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' OCCUPANTS / WITNESSES oN.v ' "' y' CODES I - 2 3 4 5 6 A w .\ N 31. AGI ,AtuS '9 •?? 9(11v (,ICI I , a St W p M M M , Acv ?,AMS ?r., I ?n .?1 0%,11111 ° '.'. \Ar i91 O. 41 vIMO,ID,gOM ?,VA INI X. SSff 13 a11 0*,"n r0 "1 ?x O ap Nlt: Nal r o15„ ... .. I ?•+?o I c 10 of1 //I ,v,1s ?M , $ -,'°WFR3P.?F'^ ?? ?E " ran j " d der "5`9a'C:" " yyA. IDS''" S /qY r = u + ; r N All STATE OF WAS NGTON RAGF 1 of ! ?? NO WSP ISR IREV.I ED) 2 POLICETRAFFICCOLLI REPORT 14T@.FFISAY . 6 4 7 6 PRIVATE WAY/ uAr E coA N I 'y ogcIXl l puI ury.rN H C O9 tIME O u [so", Ho ? cour+rr SEFFFF.RSoN Nrv NO. ?? / Irv /HW ?DR .. a - ??N ?E ? N 11 IMOWN NO.IX SreEEl OR HIGH WAY E?Y ' 15 WLIS lyS ?W tAOF TIA V?S+S. K ON PARADI" BA RD RAI ED9 6o . INrfREECiING WIIN SrR[[t ONIpAp ElO AAi ?i',R pER 7-SASTSRS RD. PltEfl% E ,5Q3 MREPOSt ]] BEr OISINJC DI CI T -F CNOSSSINI.OR NEARISI MILE POS SiPEFr a -Ill 2 M ' y 'M II s s S E # CI lNI AM9 fri Ff,I W OF MI. A ?TjI PI 5 CIX1610N INVO MEA [p; VER IY. IOtAI NO. NO.II[p?N01NIURfO'Q ?SPAIAG[ ?HIr69UN eY V[M CIfS ? ,.IM-KR]YDA-EONIY fl INE.__ I"I SIIXfN C 'ND IN]F? Cls 9f0 WER ]] CROSSSIREFIOR ROAD _,_ _ x?? b rl, SI9Ff(AWRf 162.0 12.1 5-r AVE, S,E- R4,wTOAJ WAE 98055 NONL- I YIICENSf NO. XTE.R5A494Wa (1) 17 o9 SI OCCUPA]I- FIRMNAMF BPNONF NO. I- GNI -., E mZ. wKR TTE'll £Vvlp. &.v 1745// F B EFT C 1f V OR UclNY PU 111 / U flL surf l l 1i A 2 L'DR;q I E WNT• HZ-74o5' WA T Re HArE NO - H I v lnla naN nnu noN NO ? C T 66 11 BB D 53 T WE V I 9[GISRR[DOq ? WN( I 0 T L f- 3 3 "-" 'TOTE.NI E4 V I PMEA.r(' MIp M O I ] ADOREU CS OWNER U N W .? :5000 F,. MARGINAL W E a ADDe S. - SER7 /-j, N E [ss a INwRµxl co. DR AclNr ?. ?RUDEL.rTLAL INS - R STATE III L Alf A, BIR A S rx Ass snN Nxe A sr u 6 y -t' ,en .cu NI- / IDI u'u n.Y A9 I {HEV.I MODEl10AR1.NOVAE ' _ ? NEncaoR l _ _ !Sr MIDIXE I N ? ? of - IUea ?? LS?? AWAr Ir' N[m.Nw° •. ?A;''AYN ?RIMAINFD ESr. pAMAOF f(1'I •rD. y, IowrD ILL$ TDW ?:w:E. De E fd iioii DIAGRAM OF COLLISION: lweau NgCAiE NORin DESCRIPTIONOFCOLLISION: (usESwnEM<Nrµ seen lF NlcESU9rl SMIIY NECISSARYI ARROW tie O veFdlcLr-°rl WAS 'J0KT,31B-1vb on/ '?ARADIsrv yy Rt AT ?S ,',I P, S 1AM" A LARGE ALDER TR£L EEL(. AclZoss TJJE, ROAD, VEHICLE &n) LNTO TREE, Lovic.-4 wAs BLOCIKrNG BOTH I-AN1;.S. I-C, AuORCSJ 81NJURII OCCUPANTS / WITNESSES HAW; C,?/1 ADDRISS ' `O tj E NAW m Amxss NAMI X'WVYJGA,w FKI S BN •/rT/ C ' EcB T pj a S L ,zR _... Aia 'i e ?' ? -.y rr r I WSPIWIREV Iepl STATE OF WASHINGTON 11 AGE Gr / No-Aga I F POLICE TRAFFIC COLON REPORT E9 TRA4IC?Y T ' ' ua AINi IIVAe I ? PRIVATE rAY I qN DAIf Or1 <IXN; ?- C 1 um uD w10 ,Mn I r ul IUSFe mNO- COUNTY ?l+T - YNO. ?, <ITY NO. ? rV N ?? ?N [ ? N Iv IOwN • ' F6N0.0 ,eEF10R «IGN v .wLES ?s pw or?7? L IOIn) ON rs/ CLS lp ROUIf OR SIRFt 1,1-e- G 0 NON ,FeSfG,ING wI1«. >,Rft, GR eGAp SIR?r.[?NDNP?DT ?r1f.?77 ?MV67+ W /D ENI fvfAJT Fvr1/61R[El FI MIIt C,//?? -_ ' OIS,ANC[",.I IS II -FY [ f. CROSS S,Rffl NEAREST MIT[ 51 n[S f w ACCIDENT MIIEAGE R,•IAI DI AM DAfA OF fs ?•? ifFl 1650 _ ' O11150N IXVED. RI IOTAI NO -11111D -"NOINI.II ?SFIIUGF ? / :ro Ift?JlCIS I R GANG SIRFEl OR ROAD 04 ROI.NOE CKOSSSTR[ETORROAp RI VEN,IN OF VEHICLES ? PROV[RTYDAmAGEONIY ?VIIIID 0"'0. N O Sa5'za OB1FC15,RUCK [NAM O{OB1tCI SiPIKK ANOOwNf RSrwAFI fSI. DAMAGE 5 U,ECW C DING I,U _ UNIT NO. I UNIT NO.2 - ? VEHICLE ? PEDESTRIAN ? PEDALCYC'LIST DRWFe'S IAS, F o s RIVER'SNAME: IS, rIR M. l SlefE, p55 ? Y / IR[[, ADpRF55 °a V CI,Y Sr IEw- "PC" P«Oryf NO /,K)/_A,Jly3 [//L,/, R CITY s,A,f ZIP CGpF RgNE SA l '$UEfN 5. 26/ M7aAa qp I v IvIR UCENY NO. IAN 11 Al1111IT« D.r .. e OCCUPA,ION MNAMf eP[gNf NO. EYES IGNI [EIGHT E OCCUPATION FIRM a 1-111 lvES wEIGN, MIGHT ? - b R ? CHECK (.1 -1- AS AN DIPIOWF a AlO,NEV AI 0 CHECK([ " ' v[«ICi[ AsAN EMriorfr Ow,ENEaAI CODES?* G 5 I 6 i'O CODES ?' G A °° 6 1 6 •;r.° ? ter' ? 18.RK ? ? a? ? INNIANO o <.: ' ? b.rl. ? K K ? :°IN O Ae McFIDODGFC«fvl FIIDAe, VAI SIVIE I>DR CONV.I L ?? E « fA. K 1 E.CNFV.I MDDt11DARI NOVAI YUI D v l PU''' Ic Nx PUR N A, AIfR n,n NO s,A,F H vf«.<IXOx l A1NO. IIAII .e? / sl7 ? I saNK1E IDFNnnu,Nx. NO. v FIDENNN I N MGISRHDO U51 IRSI mlDpt[ PM)M NO. O F le: IS, Neet mlpDlE E ? ADDRf [ N F E ADDeESS INSURANee eo. w Ae[NT is ? I u A AMAGlO APtA AN AMAGfD AREA rU"w,•' r CHARGE CHARGE iIrv[Ii[inu ? 5 KID, _ s mM.AU Es ? , I ?Aw':v M"ED I MD REmmNtp r ?nwFw,r ? ? [OWED eY n?DwnAa S PPS ??1___!/ ° DIAGRAMOFCOLUSION: iron 1 RN[uss,orE e5".`.' Du DE RIPTON OF OUSION: IUS[suvq[m[Nlu s«EE, Cl SSARYI n5 7iZAe ll..? ?r? eklolgl 10407-04F 0 r xx? I d X f ? ' Z LIEIt 7?GS 4 s F I d. s Ta d 1r41 D ae e, oc pp U7 S pp ? NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVE ? ' CODES I - z 3 4 5 6 OCCUPANTS/ WITNESSES ioR: anrw'HAiei ii r AK AG( l ? •DeRFss NAI.III . Mn+ m e ?r:1"' ?? : ?R ? :. lD ,ml N M ' ADaess lint Or ll MDwDM ?AMe ?r"". 'O? O? O". 'D wr 'wi No • Dnss N M1Aas°r N xr.n er CJ ?, ? M . ?. NY n ,• •NV .. ,?}yylor?r.ey^{CU NAw uAN. e,ueE GF .Gr r.cF 'lfA.rR A I.I/A .,r..i i011D AC/1 r • KKIp Sn,CMD r .i•lF`•% i1rZi / w,e GlKE UUVIp Dula elNel r? A/ f?.I? Ir'r 1) x ?s , ic-, E.1 40 _ fi .Fy I ? ALY nLl-? ?L STATE OF WASHINGTON uH'• .IfI J O ?' +' j i" MOTOft VEHICLE COLLISION REPO UN tXyNG I No. ? ?w°aYl !!q' syH Ral iaw `??1 "D`sn GPY p m. ,,,,, ,,. Iw)nn pnl ons nFlrwm. etcr ?, I'' ; AFRWAUHU?EO? 1 n,on pw ON05AN[.w F,AtNU1_ w! '?? 5035'!i lr .LAS ACIN. ?w ? H1,rz1s[cnon Pwly w.-.. LXLIFOIR 7 mlw,IHvRCTLAa O O a BW1 HLAI ,A1I,N..11 HI . ON UI I., AlL?„oH JC'• Olv L S L Iu)NOaM WII/"`MMWOl1RAI,BIOR •-+. IHPOA t mmA. I= e ?o e'. 11 ?a A MALI wW .,...OTn(ER,OF 09JECT3 NMAE AND AODRESQ. ON OBJECT STRUCK - $ FMYOONEIHAN 'LAST NAME ? ! j T NAME IT11Dgt@,:, wERE Iva v[p G.R.H. DRIVERS LAST NAME FIRST :.<C: •' ?C I..-. COLLISION wp G T? zl' rG' R t's ROUTE NO. ANo BOA NO. sO?s wUIE STREET ADDRESS E STREET ADDRESS unw ulE E 10 woo Ncpurs p1. A CITY STA CITY STATE ZIP CODE DRI ERSOCCUPATION" afPOaT vqL '•, A1N Tj a I r ApE pP1VEfl5 LICENSE NO. STATE SEA -DATE OF'BIRTN ' AGE. DRIVFA'B LICEN9i N0. Z SIT y MANE IC (Z Y _ oyL v VEHICLE YR. DR.)) L 1 t TE 1 I CA FOIZ b m UE?T' Z D1z S Od' D LICENSE PLATE NO. LICENSE PLATE NO. STATE TRAILER PLATE NOr- "."STATE:. - ¢ AH . VEHICLE IDENTIFICATION N, ., VEHICLE IDENTIFICATION NO. '''^ - 06 0 DRIVERS LICENSE NO T I REGISTERED OWNER (L,VST-fIPST-MIDDLE N MEI OHIVEN4 LICENSE NO. REGIS, E ED OWE ILAT-M1 Q MAMk3LY:C •.. a.f+C 'SADDRE48 l_ GATE OO+BIflrn _ OWN RS ADORERS: ISrREET, CITY AND STATE) ,.. D T OF BIRTH OWNE R IBTREET, CITY AND 4TATEI Y , ! X, .R2 S. b a ?O{r rO { Ci - ?L PARTS OF VEHICLE DAMAGED A141.41%, I PARTS OF VEHICLE DAMAGED , FI vU 4LL' ,O $ - ' ?? -- $ T WAS THERE AUTOMOBILE LIABILITY INSURANCE ®YES ? NO LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR NAME OF LIABILITY INSURANCE COMPANY -; NAME AND ADDRESS OF LIABILITY INSURANCE AOOPE POLICY HOLDER. E TY STATE zIV ' N NYJE ENT CP7 "ATE zIP LIABILITY POLICY. NUMBER .. '+> :V J F P .s" NAME AND ADDRESS OF LIABILITY INSURANCE gG YNDIWURY (USE SEPARATE AEPOATIOR AOdT10 ;INNMIE91 AGE 1ST INJURY .AGE OF ,..•. •, ..~??' .. uUURE ! Im1 p NAME SEA NAM ADORE % o F F ADDRESS NAT AND NATURE AND ?? EE[}}}??^? EAT FIT OF INJURIES t •- EXTENT OF INJURIES pOCTOR'S DID INJUR ES TIEOUIRE 0 ? DOCTOR'S all INJUII ES 1E0U 1.E EXAM NAT ON BY A OOCIOn? NAME E iION Ov A DOCIOR>? M 'NhflR,FaRBT ONE THAT APPLIEb L IHJURPD - .MARK FIRST ON IS TWR'APPLIES,'- 6TATU90FINNURED ` iugW -'.STATUS QT ?Iw KILLED uxO1 1 n U.. .u NOy L KILLED )[[ of 1 ,H E,C I p? QP D p 15r0 6,? OF7,?Oy '... OWPts....S ? 5? B? 7? MOTORCYCLE SAFETY: ? HELMET USED ? HELMET Nor USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED ___ TOO VEHICLCB BY NUMBEflI pESCRIBE BELOW WHAT HA?PEN60' If.!EF4q , ' ` L >` SHOW .111 OY -OW 'N 0 RC E ' .J 41 P- I>..,. N ? ...,...UGH?V?[.. ? WI.Y?? 1 LEI?I?L? w a w^A'° ?67Fr HA DC7 TVIZN vEHIGt E' .w,1.. -U, P Ja 2 HIT' V E 1"F 1 GI.L. +'' 1 m«YC ..Q"- DQ1 V5 A^ , •, Y ? yt L _ ;fit o"r + _ r 1 r? a 1 D / ua?3 1 4x[ INVESTIOATEDBY , , >1 OU. VEHICLES POSITIONS BEFORE COLLISION n a'K a °' '": la`0 ?°,ea ?:«Ki tigy?P? 1 ? I LEI 4' y H S E W ON STREET OR HIGHWAY NAME OP NO ?L W? Ip 1q IgwI,T! ry[ J, ? ?., Il? Iq .?.? W. ? KL WW 1 I ?,IS.E r?'. 0.0 im.E ? a ? ? ? CIS ? Q 6! 4 ? ? Id ? FROM TG 1 t 3 /Ion rti . f ? ? _00 .. .iFN 9 '. 'x. ?-• ala•LRI! ? ?L _ f [cl PED'STRIA WPEDAL CYCLIST WA9 USING ?va '•r?,n r?w. •?xrrAO p iirwLirc 1 "A• 1 I f R' I PEDESTRIAwPCOAL CYCLIST CLOTHING COLOR. w.?n ow. •A "• a Lw TYPC W R0A0 d1WtlWEHICU A'fTIONIF ,rte laluoHaaAUpnN ! 14 nly"i? 1 at K ROAD SURFA_ W[ATNFR ALI!O1N CONDITION _ TRAFFIC CONTROL ro• F '( ` No R, L 1 {I Lu I W (U,YLIm,T ?Y C) MwN wwtl O' ILIGOING 6IPAIONT AHEAD L RJR ?I Tk ki „NC.MI ..Tw ) a>I ?[w?? SIOHALIE•,w Q• ? ONE WAY 591,IV ,? ( L ?'Lf , t I ?c•?w„?~ ) p 9101 lIOH E ! 1WO WAY p F ? OvfniAAIHO AHp PASSING ( T . !r 1Jl f a IK?J[W, ) ? PATH rq ] ? BUS,. C] PF LAS TILE p ] p MAn NO FIGHT TURN „t•J> .?? ? ! p wlT ) N11SIN[tf p ) p 141. lIOH 5 •? IIOAO P• p WUwIHO 1 p l'GnllOH it.-FR E /"fl ! p 4SKINOLEFT TURN ?r IF l1! ! LI i ) •MOW L ?100 > ? DIG .•I"'HIT p , p lLAlHNIO NIU ? K ? IIOOP,PAYPI /? M Y 'Iif ry{ " ? ? EE (IHR1 1.011150 ! SHI.Q.YIIIR p ! p TLLI . ? [ ? YA111N0 U-TURN 11' [3 ! c3 ! ?HJ'l,.,lrl • ? lla.[I _N,, WAY '.• ' {Z" { R Y? ONHR Oln(P ? , ? RRS..., p E p `tµf IUPN ? • p SLOWING I It •+ ? ) ? 1FICIIr • ? >!IC FY El [3 1 pIIV[WAY C] F ? STOPPEp FOn TRAFFIC ' A ,ph A A I,A `. ? F OINCIWIIAOYAN p p ITTTfff? qNMLDFl 15URlACE IYPR SAO P[p Ar SIGNAL AY 1 POADWA p •1 u'f? 4,.LH E ? ONILR.6KC1Y ROAD YEPMADION ? • ?OR/IOPA lJ SIGN h !r ATV ?? y' 4 2 DIVIDED P 'S U•u'~•` p p p S p SIOPPIp,H MOADNAY r( f ? G 51111n5a N a-. 'NO IR !. I n f k ,I tI f ?Iln'?! ?9? Ytkl 1?rt ???I ;I r Y, , ,, r 11 y 1 , , r + I r J _ y? r ?F !T ,:f? ?'?t I i ??' I ^ 2l, a??'?FI ? sir NJ% " P OFFICIAL Uq9 ONLY ? S 0 I ,L ISION RE 00 vEL'A ?' > . x 3 E l- I C' Op nFAVIM VAUEY RA, . . Fr iL ?4 ?fa4YI ? {4 y _ - L A ? x 11 - HM, „jp ' ORIVEflS LAST NAME FIRST NAME MIDDLE'. Rf lrv%",,o DRIVER'S LAST NAME _,. FIRST NAME _. MIDDLE - dfc. „I.A. M _ P-00CH I- PEASCISIDIE STREET ADDRESS - 11E A FAE la Co !JO CITY STATE ZIP n IDRM ¢A it f Y217Irv-,= -r 1A11f. a\ .?LR ?sc ¢ ?pl HALAAIXNAW ceW TAWIfN)Pi[O NoN ' ' l R EfEE0 P i1C CN099EBixfET OA POA r ? ?wE ?p ???°,E B?o???Er;p?l,L B:??o„:°' L3a.oa.?r,.LW°?.,?N o 0 i -o STpUCK ODIECT IN o M-., Rlem OWNED OF, OBJECTS NAME AND ADDRESS 'NIAMPIUCT ' F3 Fc. e LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE AurolAGeuE uneartr INSURANCE ? YES ? NO - /=oQ.C?, ;?OF20 nv _ .. I a i-=07-d r-l L75, Z DE LICENSE PLATE NO. STATE TRAILER PLATE N0. STATE - , LICENSE PLATE NO. SJvfTE TRAILER PLATE NO. STATE RE w v w VEHICLE IDENTIFIC VEHICLE IDENTIFICAT NNO. W Zl[? A Z CQ [p D5 (.? REGISTERED OWNER (LAlT•FIRBT?MIDDLE NAME) DRIVERS LICENSE NO.,: ? flEOISTEflEOOWNE9,1 •FIPST-MIDDLE NA..) "''" ORIVEflSLICENSE NO. L R? E E D OWNEq'S ADOPESS ISTPEET, CITY AND STATEI ... GATE OF BIRTH OWNER'S ADDRESS (STREET. CITY AND STATE ) - OATEO SIRTM - °Ar r ?K•tFJA:t7y W},, SIJ Ir M PAflTS OF VEHICLE DAMAGED rL°,?€ri? r l PARTS OF VEIIILLE DAMAGED ?i?pwy vinruil ru FRo1a`?' t..E'FT s x7Lea A L. - I S COVERAGE IN E FFECT FOR THIS ACCIDENT ON YOUR CAR NAME AND ADDRESS OF LIABILIT Y INSURANCE POLICY HOLDER ,... NAME OF LIABILITY INSURANCE COMPANY ^ rv ? ? I'••• Q Llrv lr,rE Zlr rp_ IS NAME AND ADDRESS OF LIABILITY INSURANCE AGENT GTV STATE EIP LIABILITY POLICY NUMBER 18T INJURY I' 0 50 611 ANN, II VEHICLE M 5 ?EvI W ON BTRCCT OR HIGHWAY NAME OR NO '9TATU90F IWVPED RFInsT GNC THAT ArYlles ' ?px I NI L ?wn?rrrW 1= p,v'nr nr.uM NO 1 NIllEO .:.I.I.f? iu,.rwr r.LArn• MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SNOW NOgfN by MRO W III CIRCLE O F M L..,A D V E 1 1JL ;{ O ='r'St F VEHICLES POSITIONS BEFORE COLLISION uj POUII ? ? JCy ? rDNAP, ? ? 9 ? VEQ MaELtMNF ,?-? ? ? ALDND . PEDESTRIAN/PEDAL CYCLIST WAS USING' ,?.,RL.N. I?wH.v,. .?ow 2ND INJURY IVSF 9EPARwif DEPORT (? nx 1 L J iriAUnio rvlx uiirl iNU?r (? YA NO A KILLED ,aevenN -urwl I AINr CJ.Inw..r L ? 5 ? 61-1 Lr7 eouna ?I MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED ' DESCRIBE OELCNM WMATNNPEN[O.'.(PLFIIIMV[NICLEB BY NVMB[RJ VEHt(..LE A Z was tcFl" 1-1AN17 rC.?EZN VEIi1CLE AI /•JIl1•• VEHIGLC '6'7. l[Mflr [t ANpAVI a Y HwGI O<C CFO ?iiiriw, ?io1K1 r NMCIxw rIf Tpw r1[ ? IA1 ? YfL ?.1_/J' ?roro,t ?MilMllfl ? 64- ? ?I ? 11`dy ?.r. ?rMf rvNl ••^•.._•• OAYI Mr,t r uq rcrwc, PNI uwcll 2N vlxKAl _...___ on un N .? l}I7-Ho. ?rlt ??SgNAL! ?.?f??r•6Nf WAY ?f? ? I ? OO NO Si HA16 IANf AD P _ L1 }? K 1? ) DAWN I I` `?. Wr KRA, F ?RA.N.NR 1 ? W)N ? L ? fTOP 410 N 1 TWO WAY ? f ? OVf RTAMINO AND PAFIINO ?!?W[T J?SMOYV ?Uf.?Ul ONLT ? J ?YLlD OrpN ? ! ?NO%.DSRI[ ? ] ?MANINO 10 Ill TURN -i ' `k(G ?•. ? J ?!bW f ?100 f ? IIUn,rY OIICT ? 1 ? IlAlNINO nIp ? f ? ILOOV RAMNOf ? • X MANINO L[FI IUNH ??I F? ? f ?IC[ f ?oj.f CPilur tlE, ?601t 1v0?'If O f OnIASr, NO AY111R ? I ?DRLV[WAV ? ! Q ELOfvIHD 1URN I?If 4 - f ?fEILUt I ON,1,1 ! RtrGMAI f ? IIf TlA1N J ? ' I ROADWAY WE ROADWAY BUAFAC[ YF i UIIIL[R.IIAGUAN ! fT0%[OI0R TRAFFIC fA 1ALD? , ?f ?] ? ? 1 II tMGIY RO D[[PARAT ON ? f ? lIOM'Ip T610N L J n n DR AIUP RIOM y ,r •y ? ? r3 ? f ? OI DLD ? ! ? f101YN0 W RO [WI Y ? 1 L I_S ?f`a'7Af7f?,,1 J..??Iil?,sl_ """1"`Y"'q' '""'"?" J l^rq'T..^?frFlul.•j 1 °''o. :rR Ir \.t:. -..J 1,?.'. ? Ny •L • }L"." r. / STATE OF WASHINGTON t1FFICMLUSl uar MOTOR VEHICLE COLLISION REPORT p? DATEOFCOUJSION D Fun wY SIII Y AY OF NF9 6AT ., _ T MEOp E9 C AM /? . M 1051 E 1 ?? itiU 7 pM G % v PuiA Wtt CItt.TOYM 11 O g `? / fart raE 114.E8 ® CITY. TOMN. woW fiA V'1M I'S IKMREfAfMEETCO°! BEC,IE%t 7; pN ?? CCunR E .J • '1 MLl © OF '' jj,,,,,, Y75d? ?. 9 w aV AMEOPSi ET, MADOfl NIOHWAY CCALC'CIAI?IRID ?, . C' WTERSECTNOV.IrH:BTREET Dfl ROAD 1 bl 2 IL v TC PREFIX ED AQEPOSr 0 ?.J / NONINTEFlTKIN+I-ATQNOFCOLUSION BETWEEN STREET AND STREET FLWP OIAOflA11 DATA - YXOt © X nb Cn06vi•0 U-iLEStpni fpE X i FVUWIN,°uTnv u°FR a+o°F. NON %flD Jl INTER WTE CLB N <TVq 6m[ETpnrpM On fA DITDe60REFlORIgAO Br6E sFCaw' >fF © h ' E r ? ` ? /; Z ? gv[wcLF ?F°ESllu ?vEmcLf we LE IDc•Inf?X{ °F [ , n ) /f7 X Twl bG r °F:yh S P ''/ c?aNSpn 13 ` BpEG CODE I6E ,, ,.. -f- I.) «Y"i ?. ?.A- I OBJECT STRUCK Inl+rEnmfcia wc ry ONNEROFOWECT t. SNAMEMDADDRESS W??YAY . .. ©© wD FEET OfK%Mmnp[6Cr l: 173 IF t yy ww DNVEfleIAST NAME RRSTNAME Ntpptg.. ?1 LI I wF a -CAns M NIKKwn uvnrr On rAE ORVE119lAST HAM ,. FEiBTIIALIE. _I MnOIE' , •,:. 9 ETADDRE MUTE .AN)wXNO., uOnF NM wIO Snits MBE W STREETApOREBe ... ...:........ .'... ...,,ROufERO.ANDBO%M,, ' ?.P iJ. fDUSfA CITY STATE ZIP "OE DRIVERSOCCUPATgN GTY STATE WP OflNERSCCCIJPATgH . ,`. . - ?-! i• /r fr /<41 ?r S F arr solve DflrvER9 SENUMBEF! STAIF 1, EA f AO!- A gYVFg9 LICENSE NUMBEfl STATE 91, GATEOFBe11N AOE 1 VEHICLE Yfl. MAKE ICHEV. DOWF.1 MODELINOVMOMT) BO0YSrKEt2M) LrS ' V EMKAE Yfl. MAKEICHEV.g000EJ MOOELIMVMDARtI MOYSTYIE (Z 00.) /{ lA1L ?w ?Cco LK:ENSEpLATENO. STATE IMURPLATEM. ..STATE G.l A IN ?? Y -3 MENSLFLATEM. STATE.. TRAAEFI"TENO. STATE , - T; VEHICLE NENTIFK:ATiON M. I.O.NIODELSENEWERI ODOMETER IMILEACEI ?.y?zut z// z G s 3 VEHICLE IOENTIRCATIONM. IIBee MO0E1.9AMYEER) DOMETER IMe FArs REGISTERED OWNER ItAST•FWST MY%.%(E?NA1E1 DRVER9 LICENDENO. U REMISTEREDONNER IWi?-.vDLENAtE) .. DPlVEM14 LICENSEN0. IF, - i \ OwMRe E59 (STMEI,CIIY AN STATE) I ? ? ? < DATEOFBRTH r w OWNERS AODRESS ISREEET.CIIYAND STATEI MIEOF BIfliH uo D?Y rfN1 '? J I?Yf?' /sic r <c 'L.. o(n S YY - P TSOFVEHK:LF OMAAGED z nuATF L`d'EE-?F` t / '. <\- TE v ? A. s ,o °YCO9D? ? pMT80FVEMICtEpNAApEp SiO?ReMwE LIABILITY INSURANCE INFORMATION-VEHICLE N0.1 COVEAAEOE IN EFFECT FOR THIS IDEni M YiOMCM YES ?NO y_. _ N ATM'?E,?//1M1VX/?'1; OF LAO L/IT12 WSURANCE POLN:Y MS/SEDER ap/?a}t It 2_ ?•'/In /Tr?t•w Lk'rvl4 WJ. '?AV•Y?i/Jt... J?{ NAME OFUABIUTY/y/1'$(U/q?µ'?E ANY ?lllF` °.3J ?•-IGI N AIL NIDADMESSOFUABRJTYNSURANCE AGENT pTY tv uAB0.1tt POl1CY NUMBFJI ISTN"Y NAME ADORES FOE E ? IIASE6EPAMTFIfFCRIfaIADprgxKNAAAE& NDE NAM A e _ AO' ® Q ME ? - iWST CNE THAT APPLIS ?uw WVENICLE ry•.n Xp1 a5.eLM PaS.aaLF ?rA ML EO 5[WP[I NFgnYI P? n OufµT w ' STATIISOFWIURED MMKFUISTONETHATAPPLIES ?OwYi WVENICIE bSURNn IgvnGa Pelf (]YAaSE KILLED ISEv[RYI ?'? r ? J,. p f pit Nasl .N ? SQ D? 7[3 Sqw NORTH BY MROW W CIRf•LF ' and ???w'? ".y`n"?H' X?NY,ArX.ML ? ? ? 2 ?uNn'W[N:n?vIHiLI? C! M Einl ' '7? ?pnEE R.w ? 50 60 OESCAID[ BE OW WHAT IIApPENED:IMFFA TO YEHMLIES BYNt1MBER) -\?c??y?r •3.f.?: ?:.?«< wl?-GI?Y.,?C[ ?4 ?? LX•Y.`T ? J.5'A..y?h cr?iy'G S(kL.G S.L. w ?:? /aL •? j?rr.E?cs AGort'A6i I? Qr? T • SIXLEfnn rK:nWEr S ? tY/ Ty.•.:i ?/? /_`? ?.•?? {,\ M ?CC•t?1 H / / C I slimy / . 1 EEE /.- vrhtcr?? wGc<(cf g7k?. } ?._ ?:.G,?,ti vv st <<r.cw s?A,A ,? d :.,.., ??.•,.,.+... Q I _ I?K k,$'t•'L[(u7?..w 'r U v ?Yhl ? l ? u . .._. _ T , VEHICLES POSITIONS BEFORE COLLISION \EIIICI! ? w i 3 nN?r AIEHa•R M MruLLV ru D wvLSrlaerlD Dr aY[OCCLP[n h NI %? N 5 E W ON STREET OFIr! HWAYNAMEOR NO I wr -7 ? ? O ? `? L D et gn ??ifnOl. ?IaV'iKN " 'rv l { ' ' , M ???? / ? ? ? ? ? ? ? ? O ? ?' LICI a ? ? ?errl6rl ? f d1.,?, i'•? 1I, r ,t I. t:I;?ti.,. t.?F.:i` - Nn6IKMA ? ? ? ? AONO cK PE (IESfRWl WA9 USSq 1?SIMWMK 2?WALKWAY 30 s Oxw FROM DIRECTION To DIRECTION Ho LOER I?? iwNA e? sw'KA a OTHER i! f h ?; III ?( 1 MAD SLWIACE KM Fa arr r NEATIEA "TCONOIIgNe QIU TRAFFICCOMROL. --OM r]Yr ri'XDf TYPE W MAO wrKif 2 M'?L°h1rlE DMY/A/VENCLl ACTtlNe will F FNUdf MLIDrEI 1 r i 1 WJ ? 1 ?OPr ? =4M 1 ? OArllfinl 2 ?RAIWq 2 ? DAWN ? 1 ? yry1K9 ? 2 ? sIOP• ? 1 ? ONF WAY I ?1? ? TWO wAY l ? OpNO ST-4T AHEAD g 2 C] DYERT..4ANDpxmNo I 1\ Lyl 1i ',3 T "14J t 1 5 T ? 2 ? NTI 6 ?y qw rO O ,f 53M l ? Ous, oMK WMET ? ] ? YIELD SioN Q D o ? MBE uAKM RgNi rum ? S o .?>?•,']7 !S'? '? . Y,,.L - 1 ? E ? KE ? • ? fiIM, LII1H ON MKI eI (T I ? O S ? [N ? 0 e ? LdIiS OF/ I:PECrrTI M ? A ? FLASIxrq C] e ? IIAYtlq A MO uMR ? I ?M1 Per ? e ? AIIEY TWO WAY- ? A 0 MAMM LEFT TURN ? e ? MAKM UrI%1M . ' JJ 22 MAIOII IOq MOr EE[ R • " "' lIG115 MUNq ? • ? ? ?'u ? • C] 1111 TVIN IQ a ? S p C yt :,. C 9 • KWIELgevXKM allAi [ T OTr1ER rcT1 I I<r ?SMOIY ? F ?OIFKER:IL AGMM LANES ? 2 ?erd'MOF011rMffIC ?? ?e j} [ Y'n? ? l /C 4 ?I.••l•r+? 4 Vr.? 1. ? e ?OTr1EA. OPE CAY ? 1 ?6EPMAIEO ? e ?ST Leo BOA A 1 . I y y {? Y? Y jjA r Jr? ? ` k ? 1 L %?.v I / IY?F, C,E N. "ILIA , I 13 Ml EIIF: ?J; ?OIVIMO ? WOIVIfXO ? • ?Si STOPPE MtNODwMAUWAY 10 ? ? bpM11M ? L ? ? h?{? a 2 J "ld E F E y??q?? LY" S •,.a(b A i. ."--., rvl....c vnr.rrr?a.vl.vlRyPn Rr:rVnE tiq "'...•_••• R OECWNTNUAB[n cal off, 5 $5 D FAIR [I ", ,., za RI [St.FFE12So N couNr an NO. o - ?? [IIr DR rDwN I/ ?N Qf ?N farvOO SrREEr OR HGHWAY 3 yC mlf5 a5 j$w ?DE cNLrhACU1?1 ON WEST VAS RD, [ pOUIEOq CI s?;/i0 „ INIfR5EC11NG VAIH. SIPfn OV ROAD ', f2D• ID 6 -'I¢ f MILLPOSI ?w{??Q ? ? R B[rwtFrv ?519FE1 6 ?w?E'EIr•T?'5TRIII ? O DIStw?Fa iv rMIION JRpm R[rfRfNCE.CP05 EI O R NIAVfStml[R051 ACCIOENi w R DI AMMTA ryA E5 r tl l II.E. POS[' MILEADEGE ,Z EItT CO [Oll I51ON INVavto- lent. NO .IIIfD?NO OrwI NO, INJURED 0 D SRIllAOf OHITa PUK O VFHICIES ID OpOMR1Y DAMAGI ONtr ! ? YESiIIT[D ? V[?iC [? A . INIfR "IS CRC435IRIETO¢POIDP S/7 SO x5 _ A/? . E E .IECr5TRK.IN l[CISIRUCR,WDOwNER'SNAMEI f5i.0MAAGF . SHCW COOING OSE 1 S S UNIT NO. I DRIVEV' -1 ; U IT • 2 _ w VEHICLE 0 PEDESTRIAN 0 PEDAL CLIST xA 1 I St N sl t $l??-IP5 5osae-p A . NO Ur E, IXe 62 51vfET ADDRESS 2(08 o WEST VAU-F-y 2•D , 5T9fEr ADDRESS '? sl a RH U MA01 M W Awrf R?E364 V NI K D R , r surf IR IX NE ' r fN'SN<FnSErv Vj'A 3 g 5 Ru I 8?L SIwiF WA fA m DA 'E, H 2 ` I Iv SIIc-NO. IAIE E DwIfOLBIRIH R. re - _ , it l? 1 V ¢ 2 OCCURANON NAm[a-NENO S GHI HEIGM cFA PO N; ISO1000 E R OCCUVAIIOrv Ill. RHONE NO. EYES IGHI rEIGHI 0CHECK (? «cif+s uRIOEfaANOrHEe OCHECK(?) HICiEASAVmvorfFawuo Pw' Y CODES 1. 3 5 I A lHE CODES ? - - ' 2 INJwNS soar ss r ,.D 5 In 6 , xx 'S ;; ? A»A .HYf 0 r VfH [A9 » EDGl IOO [ CH[v - ," o ra.N. ? ° t, u 5. UARINWA ? w N[I o < a l o om. o ul»I, ? r.° ll 8?t c E ? I rfl)DR <CNV.I I cAMaRa 2-vrt E nnA4 .1nFvl NODfl1DARr?rvOVwl r l l v.l vd" 5 H iZr 4N 6lYg97 SIAIf RNIER RNI NO StwiF wA , vEH. COLOR I IICIIII 11A S- A w AF - [H ICUIDEN tRW' NO IG,?g7G4 Eo oz?q ` v[n Cl[IDN fI wI N L J - P GISRPtOOWN[v S1 Sr MIDDY ,NaNeImER i GARY RHONE NO O IERpOwNFR. 1A51 IIRSI MIDIXf " . , 9, AI OIX EX L614I I?0fe-r TOWNS&V]D N w wNE9 I E NAMI a ADDRESS OF N-ANCE CO d - W65 EXP LS: - F?omE4 SnuTW. _. R IJ '• - I.AD DANSAC[ s.e..° rNNRIIDNN IJON E .R? » w<,?` P"'u 9"""G M [H+RDE :_. [HAp« w ; b E 5 .'% n1 DAMAGI Iy! IW?v DP[MNNIq rowlD ^91VIN pIMNN[D r 'm"Y Is?O+mAee ? ---- ? s 16eunoli WAr Br. E7ZlGSONS To W A owiD AY 11 f R - u u N INUIIC INOVrH DIAGRAMOECOLLISION: S NUI D NIlCE-11I Y AR DESCRIPTION Of COLLISION: IuSE SwellmtrvrAl $HenR NtauARrl \#Al s C E °tI - CI_ .. WA ouTtisou w w WEs r VA11- y ? U ? RVF. A&Q ? Tut. (ZOAD WAY eN TNE. WEST ' v / / a11GJ,-INE. VE{•IIrE-r GOVT//UUSZ AAEb / ? SPvN AkoUND AT LEAST ONC F_ -T-HeJ ,-EFT ?.. ? ,l ? TNEr ROAD wA AND Arr A IE -ZF oti TJNEr .. L S-r D rtC.11 y w au W is • DRI U &Ailns uE. WAS ATTEO1p?lAja TO No C A ? GS 9 - 11 ' uIS V,4 4f. o T BSTA#V7r jATE A M DD ESS 8 INJURIES OF PERSONS I NVOLVED " `CODES 1 - Z 4 6 S -' C su IMINIA UP OCCANTS / WITNESSES 'EO9 wD uorvN AM" a sl G' ? s ¢ AGE ums '" M Pn1R I nn " N - ??CJ?) 1.N NA A MR AI uPlor N r ?Y AMe 0?1 [ ? ":III A NO . oasis ATwEa R NOVID rROM D_EE I]N`R' O,"o.Il. ?.. ? :° ° No . 2 owns - - - w I?a°E e[.1 Rr 0_-EE ?=:;N . J " I Dlsr+rc.RD rES V T; W- AI _ __ R ?R Tw ?? ?`Y?•SS' ??Cn A 07 77W KI +en»sD o+rta MPORI All FAn _ _..? /'YI.E l v, .ti ilin n^AAM1 AI\IT y I? ?l 1 I % 7 •1 4 85OE3lri RON PUTAS 85-0816 Arr.TnvmT NAME 06-25-85 CASE NO 2037 ?E N-4 DATE 016 RAD.MOB.fLM.VILL. TIME 385-6279 AREA HOME ADDRESS PHONE DE HAVEN RECEIVED BY #17 GARDNER BUSINESS ADDRESS NAME PUBLICATION YES PHONE NO DETAILS: WITNESSED AN ACCIDENT ABOUT 3 MILES SOUTH OF CHIMACU14 SCHOOL ON WEST VALLEY RD. SUBJECT CAME AT ME ABOUT 60MPH plu3. HE WENT INTO THE DITCH. I PULLED HIM OUT OF HIS CAR, HE SMELLED OF ALCOHOL. AS I WAS TAKING HIM HOME HE ACCUSED ME OF DRIVING ON THE WRONG SIDE OF THE RD. FORCING HIM OFF THE RD. 2049-JOSEPH BILLUPS 2680 W.VL.RD. WANTS TO REPORT AN ACCIDENT. 10/97=2100 10/98=2ij 7 DETAILS PREPARED BY: ? `•+'?'"? 1'- __.__ FOLLOW UP BY: SIGNATURE SIGNATURE '£ I j h1 I r I ,e J r d. ? ,? Yr?7 i µ. + +At? ? I!a ? Y 71 4 F7 I If , ? Y I..'^:..' . »_. $ Fau^11W ?a ?' ?41+2 •er'F"::. `??pF u'^seP'...:? ?f[N h'i?EXh Ta' m'u li6LQ'D91 e. ^ k F F E AI I r STATE OF WASHINGTON GE 01 ? . , IN IREV v. I.mI 1 ", 1 A. J •i4 POLICE TRAFFIC COLL REPORT MTRAFFIQNA No. ? ;. 4 R F nMf ? PRIVATE _oartyPCal a s.. _. couerr IOIKFC MN !ER a r f I .ry^' 'i7i•.. yy?p O1 GU OS IusE axpp HOURI wr u «lo rwvf 1•? A? LS I-U 'J ?.(P??,C- ,1 (Tc.T ?C.Rval?t NO. nNO. Hww ?um.w gWys"J f/' I 1 C09 TOWN ?E ? ' % fF NO.O 51RFf10R HiGNWAr C pp l rF AI .- 0s 0W KOFCU I WM ??CCt , L ? INIfR5FC11NG WUH. 519ff10R epAD NON tPIrfRSfC110N PRffl% MRF IOSi /+ • -" W'r eEtwfw RNoD DR sreEEr EVAN TRLaAFJ KRAr O5 N? OvE R R r VEN v Oi?J-0 " l , ' f;S N S f .[ y A O.155 iREfr 09 NFARfSt Mll Ni / D D.giA I 0 mER G J k {I COIL SgNINVIXVEO 5[v[xHY. .1,NO A?1 NO x4lED 0 NO. INIURFD ?SPIILAG[ ?N16 RUN V fHICIES LL ?J IMER qy r (ppyy SiR(FTORIKVD'•-.- jJJ .?i '?` n •/? r f , ? P90KRIY0AMAGEOMY ? gfSUIRD OBIICr StvUC%INMAf OF OBI[[I s'RUADOWN9's ?vfCF NAMfI Esi.OM1AGF SKCLAI CODwG USF , 7 ' I E .* s ...... UNIT NO.1 ..'. ' . . nwvER's Nqm[ Iwsl 145 UNITNO.2 D fR's NAmf ? VEHICLE . Cl ..PEDESTRIAN ? PEDALCYCLIST-.?. T • A Y' F_ - PANS? v r -e srgfEl ADOVF : I I ?? S I 6 C. GIaBS 4X. 1ZD- tRfEl qp [si t g OIY STAIE tIP GOOF PHO'I NO D v srAiF IIPC f C{.II/V1AGUM WA 01'93 as 732-`}131 „_ DRNIR-S XIN. WANSLT>k 4 9% KR siAlE + IT Irk s i9 IS i i. IV V fN v AIF OAlfw B IN W I Y I Yv M?S OCCUPATION E 6 PHONf NO. EYfi WEIGHT HgHi E CUPgrION {qMN 6PHONE NO 5'" ', ,?.. ? vNF.MPL, N Q ZOO (rb R EYES N21GHl IfIGH I yyss • As' ? ? CHECK (?) vrN nf.s Ax fmaorffw ANDrHrR.AI ?CHECK(/( rAl of wsA vfH "' O P? m CODES ? a NxA. s l A "° ea.o11 . KT x fmv N DF NorHfl M p ?? rf4 CODES ?' J n x it 5 Ix y u i 'at i. 2 I plp, ?A AIS vFnxY[ t IOODOf CHfv O T 1 fO ry?riv ? vi?C?t ? ru • NOVAI STYLI Ia DR <ON W JIH f ? berev ? vM'-' ? ol- ? 7(P F TAT 1 128 slq• 4-DR e I MWEI f Ri AE i ' . l STAY 1 fe MIE Np stAl( I'1 vfN OR C:F FSFP >a M L 7bl v W L $ QO , W -? l I S 7-11NO, w ? M t .r V(HKIE IOtMIIKAIION NO. I I 2IBA FII ol?i7oo2- -- - HICIf OENNEw L N (j,?R '' ?' PIG?SIFPIOOMMERIASI HRSI IDIXF MgN[NO, I I - I WNtq' I i I r N si m? I r 3?9 ? IYVb?S ..?:, R:'." GMgsopa GA12 UN ?'= la ADORtssoPOW.xq f Z toZ GIa6S LK RD - au IAAC.UN NAml aAOOmss Ci INwRANCE CO. pR ACENr .., :?? ?-IOMtD .CM rT/l-RAT 't'w i.suce.? C:1 ? OAwn IYN ?---D SrAw 1 x rOP 5 '•»(a COLLISION• IusE SUPHewNlu sl[nlr rtttssWYE {D '?1_.wAs £?7Ba_v'Na Q?._EST YALI?-- "'t} 4'f7EC!1?_7?D 7o_._?Go7.f_?T&A_ RLC??- ,?; r AND _? oST .CA?rT?R1-_QE VGNrQLt.--- EJ.1DLa_ v P_1N. NOk7N_.sal"LC?r_?LVf?_ . Rvc1S TNf<_slJLN?NlD_??!IL uls?_.R, DRESS 8 INJURIES OF PERSONS INVOLVED TS/WITNESSES fus/slw FwmusNln ..'?-]Ep?ES 2 3 4 5;1 Id ADp OMAI NAMISI NI?T AGI r lus .. _ AI ...41CY _• {'1 1 4,-M ? "RIM W '?+OF:•i.Ea..l4 i ' q WIT aq _ej l J,:. y f 1 ti?w`q g• I l ;l? R z fSl t , 4 t? t'? 1 I 1 4 _ I 1 ? I 'l? `14$EM ? , j 4a T I I ' 1 p 4, ?T r(.F [ 1 y .f ( d j FJRy ti hk 711 1 t'L t y x +r ? ? t 1' . M1 . n 1 t WSeIW19FV I_?1 STATE OF WASNGTON 1AG1 I D11 INn w POLICE TRAFFIC COLLI$YBN REPORT L2S7 TRAFROWA))? rIX- INEN ev F PRIVATE WAY- / N DpiI OrCOUi <OIU IOn °V I?Mf sf ]KONOURI 03o COUNEV Se>=rEPS ryNJ, tF/C//1 CIFr NO. fN/A ? FUq RA I4LF WAr ?N QF ?iN OR tO'A'N 5 5 ?W In K u ON W c?.G N 6GEei. RRS[CnnGEWI1N ST9tfi Oe 90pDOF rt RSIcN N O wEFI% gWTf 045 rsipza t M4[P05i s ` / BLtW[EN VR11ti ?? 519fft 6 ? STRfEt O' ZO DISTANCt5Di41 ?nION re0MeU5 RF tt. C4C555ivflIFi ``v NfpvtSi MilE O -s I .2. ,TEi W Or ?/E51 tlAllti ICO ACCIDENT MILEA E CODE 4 DIADRAMDAIA rOLU51pNiNVOIV[p Evt 4iiv. TOr,I NO ?}f F'O %IilfD_n0 irvlUq[D- ?SGIIIAG[ ?nii6 RUN •?U Mi yt INTfvCl5 iN v CfING f Off NCE tpOSS STHllOq gO 01 ?5 OrvINiCEfS E11 ?PROK-DAM-ONLY ?LESUITfp ?1,91c" w? l ty?y?D / C? +? O-CT 511-41-DI OBAC151-1-DOWNER'5 NAMEI FSip SMCUL CODING USt $ UNIT NO.1 UNIT NO.4 NPHICLE ? PEDESTRIAN ? PEDAICYCIiST E .24 3 0111195 G f IASr rie i JA-11 L? ISTSR be2i FzAnas p9wf9'SNN.tf. IA i ?NEST? MT _ 5 ST9Etr ApDRlU 916 S. B0 1A?. 577 TRFET ApORf55 z _. 1-11O 'T AM Azi i35z - D R . LiPC of PNONF / ? O4 vtR'Sl Cfrv NO M 38Dy?7 STAif Az. [% M Af B iN 10 07017 I V vFV LCtN5f rv0 tPi( SF% Dprf Of BIRIN B r PIRMNAME A PNONE NO WS OCCUPA OON E[s HIGNI cTtR? BIB 1;0l 511 E R OC CUPATION MN-En LONE NO fvFS WtIGNl F41GN1 ? CHECK(?) vFNlfit ASiN rW.P;orff or,NOTNF4AL W -' a ?' •I ? CHECK (.1) vFNiCIF AS AN W P;p.LL piprv?IHECA' gw CODES ? i 7 iii ( < s` S I cN / 0 tt"A° - .s CODES ? * 7 5 I D 5 ' zi F Ei,uuR?ES A E AJO/L_ ,D ?. I+t+Nnl sn,epM 0+,.BU-, ? %-1- ?ea:,l. ? „ << ; LoI.OM ?M,„,..EI ? <I ? m,R: ?;;.m; ?".vv % EAR pooc CNfvI rlSyDOd E nlDa9t.NO AI s Iz pR.convl OS Ec.TOf 2ZC E rAR 1-1 VI VODEt IDA9Ij O ERVp 81 TRaLrD,laze I p_,qs r 1 DR. v.f 21 Fl. I_ 2 04 a eNSE nA E ,nt4 a,R No v.u S H v N e + L A f A F ' $I ?? BZM z 10 Az I C ?v C y y 1 FlZ 4 V{NKItIq MIEICAtIONNO vfNICEf IDfrvnrl Ai rv X Z v[GISR9100WN[q Wt 1ig55 IDDIf SAME 115 e.?n ??l OIR)Nl NO. - °M REGISR9D WNt9 1A55 55 IDbIF SAttc N Es ADORfssaawNtq A ownfR mil N E AMUADN-OFGIN-?ANU?C"O11ORAG.- ut5.PA, Jf Ln f-riMLO, I X R .N u CE CO OR AG(NT oAMAClD wt ' .:o p•. cN.n TIAMAGtp MA cNA4a ?c°„°°wi D la lwtAw .v1N ?q[MNNro tdiurio? 5 ev u•MAm ?:wveE: [J.1-NI. Do $2000°0 ? :w°t: Der iawtonr 1Z . QW/IEf2 $ Aw,r , Ee 1 M 1. DIAGRAM OF COLLISION: iiuLlu F+iciss.uvl IN pc .. _. ,-.-. DESCRIPTION OF COLLISION: ILntswrRMlNtAl SN[trn MCtss,vrl ._ _.. ^5 - i.{ .. 'k .. .. eh 1..,was_e/b on Rd. with #2 (a trailer) in tow. trailer started to fishtail and eventually.jack- _ E ¢d.' !J. i? Rd knifedblocking entire road. Road is a primat6,9 _ , ravel?Co. Rd. and accicent occured on a steep rade. Dr.#1 stated that as the trailer started o fishtail he reached down to apply the trailer rakes and did. He advised with the road bed of loose gravel(and it is) the trailer totall jack ( y - nifed, Road is a one lane type road. NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 _ Z 3 4 5 6 rox w.nf vfmAl sN OCCUPANTS /WITNESSES roq .DOn,oNU N.M tH UI sfY ,cf Ann ^ P nsu rna ; N,ME GAFF LESSTIC. No '-' y z •m.tx 3Am A ?L I t u4EaN ° [;+v ne B. B ?'. ' ? "' ?N 01•0.5. N ,M! NO v ,m4t.•, N+ru4r O, uL:vfD,goM L.ve ?.,• ,. ?l . ? ;11.1 ? : .D wr No V U.LI; •.1rl y+<E. Navy,+.,• 6+GG11CR WEIR. ,. %?rl m)...cnc rt' n 21 ,-ND D•?^?rsrc.? +?. 4,11 j. rj, S! d Cy L?1!)??fy li'V`L FFII f I V i I 1' >' ? 'r^ 1 {'ITl'{?'A?JIY ?A*IMI + fAx' `? r ?'': ule 1 W i Y Yry? C I' 0 f ?p / 4 I h{ E _ f ?yWA( Il 1 r T' { tL 1 t ,! T 1 U,S Y 1 ? I I ??,fl ? ' r B ?, r .1'? f '' :1 , f r I J by 1w {: ? fie k t ' 1 ? i \ r t ? r v? N A r? •f 1 t l ' ?. 1"? 'I ?1 E t 5 I f? +.n? r F {[ I r- 5 '^ r l i S xJ I i{, rT 1 r 1 , a r? {P9 $ru y I IL ll r I ? t ???' RE ? " =' STATE OF WASHINGTON GI °" ?- No F ) •, .._=' POLICE TRAFFIC COL N REPORT 0 TW8FFICIRAY PoLKf UM 9 " 7 PRIVATE WAY IA 10: ? Ol I P. Fo ca ?- iat N counrv ? .. • . rusr ?.pp"ouer CaNrv NO. arv NO. n A pwew n JQI ? Cr,. D9,DWN f6N0 OFSIDtF, OR HiGHWA. s aS aou 9Al M Es 0{ p po ON G !§D N,F4kCNNG w„H. $,Pft, OV 4D,p NDN N,I4kC, UN L l" 9RIFIR MKt POSI 1 I 9 HlA9f51Mi , .,9[t,6 SnFfi D?S,wN[tAU fMl 4 PF 1. CPOSS SIeFir ?` ' 4 H N 5 ! ACGI AGE vAW D ,A + I w OF ?- MnClll?pAGF Ca ISgNIN O F ! Iv / ` DE IO,AI NO T?F IIED?NO rN,V9fD_! ! pYiFl>GF ?NI,69UN , INIf CLS C4p555TR(F, POAD RV[HK [S II(J /rO, ®vPO4te,v DAMAGt ONLY V OIN OR o. 4 :? ppf 5ul,fp ?V 3 OehCI S,RIK oME Df ,[CI Si9UCa w.DOwN[4'S NAMfi _?- lS,.OPMAG( 59fCUF CODWGIAF s 2 S -- "UNR NO.) UNIT NJO,7, DR sNAME usr Nes, M ^ DervIT [. ' ®VEHICLE p PEDESTRIAN p PEDALCYCLIST 24 3,9[F?DDRt N- W/LL?D G L I_ I a sr PfF1ADDRSS A,E 4<DIX PHDHfND D s,Alf n/ De"eus L<[Hk NO k/ 598 0 7 J-/`/ R WAL-l_ 12 I- -- c wr/ J °•? • V CEN NG R L kn ?pAl pB n . •: . OCCURANDN RM 4N(6"q"t N0 t S WticHl N Ni N E WFl F l3 OCC P.IiON L • ,?- _ U 1AJ/YE' /Q •?.s ? CHECK (A1 ? Al i : o d R N4M NNnF6 IpNF NO EYES WFIGHI HFIGHt ADM" W/14..A WAuA SC N(:O?. ,ST. l.? /OU S'1. 12 ,? vEH C rA Mn .ff ,HO,nfR CODES NO. 0 ' n."ss s I , off 4s"D? p CHECK I?) vENrcf-ANr lffofAlw-ilwie CODES ? * 7 ;ii I n is n'v."' I s In " q x' c' 1 e wF Nlfs AI N HEH YfA9pM f CHIV I I- Moof . I wV,0 s,rl[ 1? ®cwv I .rq Q Q E41c1 M.- ? ?, Ii is r-6.. HHr r°eM p "" n ? 19 Q Cf ANt9 A, L H n v l -1IDA9, NOv,r F I v I a Sled 4 O(2 • N?T ? ? r ,R :. . n e NO AI S ? H ao EI L 9, ?? _ o 3 VtHKIf IIXMINCw,KN NO. lCLI I I? ;'?? SII i I RfaSRR[DDwN[R. LAS, iR51 MIDaF "gN[NO L, R vEHKI(iIXN,IiA SFI"21AI? 5 `11EiFi3i013!. hIU 7c• ?7 M 0 MN L<S, LIDS, MIDa[ .... AM 35 I 55pO ltD A 1N o 2 M E l SA Hunt a ADO4fss a ww9ANa co. ceAG[N, , M R .1 DMAAGEO MEA .5w4 r • - tny F r pLH?HC f"'F CH,.G! _ ra/ CH.:Gt DAMAGEDtA e10. l51 ... wcDCiiu , _.. ---.. f ®a'A: pRi MMNID O,WSV" p? Drq.own DTi r?yW' fit DAM Gl [D ?.. f .e y ,ovnD lnK .., RJ ?;ww[De DIAGRAM OF COLLISION: lu Fu+aets n;o HO°I" DESCRIPTIONOF COLLISION: i-ISLM1 I1-1 1 D.aetsuC. L_r 1 ' { '' O•? VEIIILL[>1 v/?g r yr I t... _ ?EzMc-D ON GOK iY+i ?7., I -I q Z W 5 H D f ( - -6- aRt L .STDPPF?7_.. C?Q- l PI`S &n ?I ! (?N 5 { - ,P` ? G s - v?l.. _srcen_Eaa err nr? ! r 12 . T l .. VC?1reL r u 1 ! e r[N E J? ? r I I . . . ' NAME, A O DRE J1601E ' t puPeDnEHRlpMSHfOM HsNH, S 'n t OkV F As OCCUPANTS /WITNESSES VOLVED Ii, / ' C OD E S I g - 3 4 6 - H A A•! / v S ( A O I 1 . , K ' F W 'Ic v . D »ns r +fa " / / / + w Q HP c- mu y L onnss A Z? I = ? . ???? I? v - - H .D M F E .. 1Y GvDi w AMI 0t.?2 E3jRt. m s ! f "n - a, ?c ' ?` Fuoa?o.9GM Q.?e ?? - - - _ " `o ry r . ../-7t?D A • ?• -, Y e ' , ??:n wai sl:n"e: ?•..e Q 'Qi'-;.. CE:+', 6?'::: , iU yf: X ??ii n ...-. ? ?"\ _ ', r-U _r A•; •If4tH Kl • ..lD CA,t!v e1 ff141 AI rF,..f l'e. . GAIL u ?R w. ? `( P??I M W Off ". qtr & y S(?wn i V /ECr?y., ? • IVU. PPIGNAY POLICETRAFFIC COLLISION REPORT ®_L J' KF N R 1 E) PRIVATE WA < DA f IX Q DO r. suR„ NiS wlp ?u ill. ,YI oR IJC IMf IVSE1M1Wa1 COUNtY CIXMIY NO. / CITY iHW ? upAl i ?N QE ?IN CTY 04 rOWN NNAfeNO.Of SIPE[t O4 MGHWAY % µlES ®s ?W aIDE oL.oe ON 3 t5"69?D.:.. mnRUCrwc vn1H S14fEtoR aoAD NoN IN,f rnoN L? o L.o oakc JTLP,l? 9M. e[,wfEN stRLfl ( S,RfET PIRpu f AS4E roar ..?/. - O151ANCF801 F. CR055314[f NEA4E51MIlE POS E Q? or- a`"fl IS 5 [ W ACCIDENT MIEEAAGG MlA `.'. Of K i[[ 1 h COllISpNINVIXVFD. vfa iY: ILLAGE ?HDBRUN SP R ,I+lfsrrrl VVVrrD» D (p qy C r O4 4F Efl O4 ROAD RRSS1p ED lOtAl NO. Yq Rlll[D_N0I- (YVEHICkf3 ®PtEORPtY DAMAGE ONLY ? HSEUl1E0 ?VF?iCINf // WBSD = --p111 -151-111- OeIECT5T-X AND OWNERS NANE) E11-AG[ S SfKWCODMG l6F UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST D41Vf NAME: -1 r91 if N R DPrvfRSNAMf. IASt fIp r t _ sT4En ADDINss E, yJ ! ` i I1 1-1 1 I PHONE NO. D r Y 5,A,E P "It . N R CI StA[ fx AT- R71 " v 1 U N I f N E Ucc PAEroN E E if 50 C R 7 11 CHECK (.I ?rH Ef AS:N nE aANO1HEanl [I CHECK(,') vfNa CODES jl? * 5 o A i 5 E a "Mt,0,lcr CODES lp- t 7 a AS Ex 6 v " NI 0.111ao3l ? AY.DY ? M" ?, OR ? tL,I,Y Drro 3?YN1 ?'?•' I ? M ? M6 ? H ? Ca„zA Ku ' eDM N. Y[ MApF IDDDGfKn(V.1 EI IDARIIAVA1 51TEE IR DR 1 CM E H.Y 11 IDA41. VAI l De {?1 ., 7 I NSEPU,E SIAi( IR,UlF415A,E NO SCAR FI I Vfn. IXOR N ID p D : .. 1v V[NKIt IDEMIfIGiKN ND. S `f F C I P. i Of 1 I NN I U rIp51 MIDDLE REa5TIREDONER: i .S A w• PEgNF NO. ° W RRD wN[4: T fIRSi MrD0.E I _ D 2 ADD4l35ROW4FER N A f4 _ NAM[e ADDRI35Of INSUPANCI CO. .-I T ND R I V ' , D4 MIA O l BRAS Orw.ACID- "? '""EH0 cHARCI .?? IjAMAUFD aApu .a .DM YG? ?ARIVI?H ?pEMUNFO 3 lSt ?%`AY ?REMNNED FS 1DAMAG[ , 3E C $e 10.vIDR1 : [) romD S DIAGRAM OF COIIISION: yMEIRN ar, IN e+nvpow In DESCRIPTION OF GOtl1510N: IlnE SUpn(ARNTU Sn(lrn rxc[ssAVrl 10 ® VEH, *-I LAS?S NDRTH(jO1.IND ON OAk.6A`IE Aa. AND STRucK A D661Z THAT NAD JuMP6z omm ?._ TTa6 Iv10RTH 80L•IND CANT. E ER NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES l I J [ - Z 3 4 5 6 OCCUPANTS / WITNESSES Irnim^(,rnu wvu s - uR AG( , °': s e Q .DDR(u ?iuR a AMe ?F.A" O e J ?? ADDefss QAA? prolcl? a.R. ?G' ?,. ?' NA. NA, ria nAMe nM, n, .nwa ??6. 7 11 ." rz. } rr a R}, t ,{ T {k„oy 11? i."rv?" I ' a 1?5'?°.8""n1?1'O.f.'A,"ry,y.}yr? 1 r,F"1:+ + ( x , r t ,;lk '? + I t V '? t •. c; 1 N d, ?. rl w 1 I r r l l l{ 1 r L 1 ? 1 + I ??. ? 1' . . I ,S , N c r ? {LI. L F J I r 1 r ;, w _ )1 1 r 4 1 1 p sA 1 i l r ? 1 a. V ' ( T ? R STATE OF WASMNGTON 01 vVI»IRF°.`.BDI IRh m POLICE TRAFFIC COLLIIWN REPORT Qy TRAFFICWAY rotK[c 9 NralR.feER PRIVATE WAY DAIEOrcaus N A N co rv M (f .. wR R ?. IR Iwn Iu w tusl? Hf?I uN ? muN,r NO. /G . NO. r-A pueew URAE I CIV TOWN NAME ON 9E p N OR aNO.Of SIREfi OR HGNWAY qW1 2, MItS ®5 ?W ®Of ION caw- lwy D, 1[RSlCIING w11N S,R[FI OR ROAD fqN N1FR5[C,ION ? .3990 -IX f MRF PO3, ?? BlIW[fN S,RFfI 6 S,RtEI '? DS,ANC[aURECI ROM Rfi(RFN E.CROSSSIRfF, OR NFARFS,M lFPo51 ACCIDENT DIAGRAM DATA Ml[5 E 5 fffIUUU_ LEM MILEAGE l?.lJ rEtt p Of CODE 01 COlIISION INVIXVID SF KP11 v. l %.RD S ROgOON ROfnfXY 11 H O t0 RtD NO INIURED ?SA IIAGE ?M,a RON IuNDf.SiR??. IOIA ?? . ? . I N IM[R CIS CR0655??D Gf VfN OFS m ?RROHRIYDAMAU'f ONLY ?RSUIIfO pStIXEN S(? Q WJ[Cr SIRUC%IN Mf OE OBI[CTS IRUCK ANOOWN[RSNAMEI ESt DAMAGE SnCW COgNO Sf S UNIT NO. I UNIT iR NO. Y p VEHICLE ? PEDESTRIAN p ! D9 V 'k- NAM E: US, 51 MI 'S NNAE 51 "Ol S,RtfI ADDRESS tRFfl DORfsS s i+oalE. DR. Z 60'D- RHONE NO. D I S,AIE ZIR w ?A. 7- ZoD R NER'S IICFNSSIA,f I w U IN. AIF SFl 4 v I MNNAf 6 HE-, E --A- FIR to-INO. R RIF p CHECK 111 HKIE AS !LL FFa?CHECK(,,) 11 WlI A A ' CODES ?' 1 r . w s l a MoiNxr I CODES 1'F 9 i < e v ' rol Z N _FS ;„ p .NRR,.wI p ro, o ? 75,R. ? '.:K° s. ? :.L ARC R H .w.NA C3 MvR , l ,brl ?b:n. O H ? :° n lf IDOOGE Cnfvl AVJplIIDARI WVAI SIYIf I]DR.CONV .I A [ N[v .l 1 r MTINOVAI Y ID l 1 _ E Li r'Q ?. <fnY VIA EN n `l SIAIf MIFRRAIINO S . IAIE H -comp A AF ro Y{ iL ?_ W p C V[H CtFIgMfCA1XXR N0 L 328533 ftG15R4lDOVnXR; EAST FIRST "-I PNONE NO VEHICLEIDfNI-A N I R E r ^ DOWNER: .7 F fIRSt IND. I?LZ NEJ W ADUnssaOWN[R l RT O l-b N NFR , TI 4 L.AN SC+3 E NAMIaADORE530f INwRANCF CO ORAOENI AN FRFiICFR I% ON R DR MIZE. ? f v'u ?_ ° •M•GF ?u 4. D.Gnai , lll.'[NAUL[ CIIARG( ?,DSW??N ?REMAN[D CHg9G ?w41AlN ?RFMMN[D W Y wt o N FSt°.'DAMAGf ] , ,ID -"r o n I : ? fo ^meY er: 1 I l DIAGRAMOf CO LL IS ION: I I-AIF NOR, yjoy - v la sN,ETIiMa n DESCRIPTION OF COLLISION: Iln[suPHIMENrAE SHefr IE NFttssARr1 D ? 5 ? VEIL. '? 1 WAS uo. aNo, ON OAk BAY Ra. Alvn CAST fANTROL &J A II&CHr CURVE Sf =&,& - , , 0ZDC--A`!J OVER A BRfJk E ON -MC, E., &DE, of- F- ROAD, AW RO,1.E.Q OVER ONCE. BCFoR4. - A J _ 4? CON -N& TO R"-r ON S.TS WHEELS . TT(E- VIER. r ODD O Sxt-Luu MS FOR. APPROX. 170 Ft. BEGORo- " BRy . D MWJC- TO A STOP, NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - T 3 4 5 6 OCCUPANTS /WITNESSES III-ION"<Ir•su F 11 I ., AGE ,Alu . H A '" ,? ns,R. [XCT :, Ic, N,M out, :TAME 5 48'1- zoo N° 2 ADOnu NAAu DR1 N Me pPn' p " . p,-r ?191- ? w _ AnoelSS NAIDR a ' ""'-o- M."o,=' uXwlu w nAIX.[ oR .aNC. Ib w• Rla YIN 1. ?AMe p71.1 ? A X 1p Opp2 ``rn RAID n. ??fX I zO o DA II H _I DATE F.m Hn / /O I?•sif -a JS ? f .:?,, Ir LI eN hA fN . SUif N¢a HArf NO. srAl[ H vEN.caoR I D l A " STATE OF VI/A NGTON GF of! No. wiP iM,gEV I BDl kr ? . ' '? sO POLICE TRAFFIC COLLI REPORT ?iRAFFICWAY Pglcfca rNwiwq ,RD,` ?r PRIVATE WAY ] I DAIt OPCIXII COUNty NO. CIIYNO, fHWA Av I IUSF 2.00 MOURI CI fY O // nuFF-AN f.I o 6 qµ F CeYORtOWN feNp.OE 51 EEr RNIGNWpv Cl5 ROUIFON/ F .wFFS ON pw pOl ON C?r/L ??109/? LIDD, --CIING-.ilRFFIORgoAD IANINIERifCIION Mffl% F MYE PO51 -? BEIWE[N -EEL 6 SIR[fr ?? 1 O?IANCf dDIRf ACCIDENT I[fi11 N gPFNI ,CRVOii sO'RIaG?PFil Mllf 5 MCOp[E gAMP DIAGRAM MIA CIXIISIONINVIXVED IV: M.Iirv I qU r4F RROADOR OHHNCE' ]J NOO %FULlLF0_N0. NFURED_ ?:S IIAGF?Nrd qUN IOrpl NO WrvoxRl" IMF Cl5 CRO355@ y?O?D ! Of VFNIClF3 P:_;1 OP[Ir DAMAGE ONLY 0 vFwLIED ? Vf'i'ClF S OB1KriIPUCK INAM[O(_RC NOOWN[a'S NAMEI fSr DAMAGE SPECW CODING tRf % $ P UNIT NO.I UNIT NO.2 0 VEHICLE _? PEDESTRIAN 0 PEDALCYCLIST ]• S DRWLV$NAMF' Nit FIRST MID DRIVER'SNNAE: V151 11q l lit A A V L slRfFt ADO?u RffIADDRI. ^ 4 ..uei CITY $IAtf FIP CODE Prgrvf NO. D r StAIE IP I No, f NIEF-1c, NiF - -9/.7a R /Z ' IIC - N0. ATE AI oOf a Rl., n' A 1. ME ` V 1,5 .F IION 11RMN I.-NI OCCUPATION M NAME I -E NO. % FYfS NEIGNt NE GNI ?- 2 aG,s ear J= asr W l u/ r R OCHECK (?) xrtNKL[AS:N EEaANOrNrR•E ?CHECK (?) IIXRA IAS AN WMMIVIIFIAAAA Z CODES ?' J c A 5 1 6 N° CODES ? t $ A s 5 In p fVo INIW'f, ..b IlcraN i•D.c"cl .u iu.N. I N fDRCrcI FE.I.RE01 IF 0 WE 05,TR x .,vi ? aw>o 0,« F 0 ?yO ? P8d1L ? .?Y 0 O' u vEN vFAR + MA%EIWOG[ CNfV.I f IDMt NOVAI SlrlF 1]D4 CONV.I V V1. -. R ( N V I -11DAR- VAI NI V.1 °a^• 1 1, AGGpL /L E ]q I VFn l[ dNVIICAtgN NO L VEHICLEIDENT111 A 1 _ SMs3 Y6C0`J-7 L R[G4RRl0 DWr+lR USI NRSI MIDIX[ I-No O Isr OwN[R -T {I45r MIDWF I N ? / Ctf Oa(4rL,Q /YJ . ID ADDnu Dr OhNF W LrvNIR P , / LbML N NAMIe ADDRISipINSURAN<!CO YAGf Nr E R IN G A .r• ,] t. FDMIKFO AR[A A Wpm= DANAGFD MIA rA a, b'•u CNMW CHARGE r ['ivlrGiN S D b 151 DAM.SLI =E F` .IM-ID 0AWAY ?P[MAIN[D S?UNAAGf S "1 t i f IOMDer O N IE?O> g f I ??1????11 DIAGRAM OF 41- Fer COLLISION: 1 U 1 urr NOeIN DESCRIPTION OF COLLISION: IUSfSWPLFMFNTNSNEEIEFMC[S]A erl SwUUNI[FSwrl er M.oir j' s,GP/7Le+yf:N The driver stated that she was north boi on Oak bay- at Olele pt rd she slid on Q . C 4 `Z11 the ice, she corrected and the car over , -_? steered and spun out clock wise. The car came to the down embankment and roled >. / over coming to rest against a tree. My investgation indicates that the acoid ent happened just this way. The car in aFGEF? more than likly a total loss. 1e NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED *CODES 1 - 2 9 4 5 6 4 a NMI OCCUPANTS /WITNESSES «tlwur?fA:vsi sr% AG[ TAI ;" R' "!' wsrR fen °' 016 b.a AueNOM"0 OH ?u 9; Tk {fp A- u r or 4 MOnmwM OAMe ?: K' 0^ . 0 M ? .: bTi `Yd? 1 ( ?I p _ r'O ?y-? ! It??? nl{1 1 .DD.rxM "N"wias°F N. e. OAMEF ? 0L]N.• 0 U, AtWOhIAI• A.AN. .AUG[p AGFrK. ?•" I+ ID SPAICEMD RA Kt ArrIND UAl10. M.U.I NL DAII V IR I .a R ?. %N° JCdo lJ S G?!l? /O,? >vf /1- -$r 8 M : i"' } . '7?' . Y: ? n (, STATE OF WAS GTON RAGE I Gr I No 6 ` 'W4S TI.?e . a ?j POLICE TRAFFIC COLLISI REPORT ?JTRA?jFIC"Y Y_ rolKfcoM nnwA E] PRIVATE WA DAIEDrcaus N w rca{ ON I'll COUNTY UI.v 1 lU1FR ?U41 -fc 6 L Y,. I; • ??,N .. ,.. ? ` caurvtr Ea. OIrNO. prErwA 7 Ucil 1 O l? 5 0 ? `65 WRAI rCT ROUIFOR II E [3N 01 prv Crv OR TOWN ^ffrv00r$IRfft GRNGNWAY -7 MIES ?s p ]or .WAZ.LOC f` ON 3"A (3A Ily (L l .TG 990 , iNIFR1ECIING VAIN SIRIft O4 ROPD NON NiFR1[<I ON ?5 ff.1TINEL f1 STREET A FSGAC{I SIRfFI IRFII% E Ml1f 1011 6;174- D I ON °[f R{rv E CROSSSIRft104 rvfwvf5l MbF POSt 1111 OIS :: Rl ACCIOENI R R D RAM MIA ) M LIS N 1 E -'y C2 Ll I0 Or m l Pl / MIST G{? F RE RROAO(MRHRtNCf i w a GDII11aN NVIXVID 5lvtR0v ` 164U IAL NO NO RIUfD NO wLURID?/1`L IO . 0 ff ILL fO ? SJCnfN rv Cr VfNiCI[S ®,? pPRORRIY DAMAGE ONII ?? A'? IN IMF CIS C N Rp11?670 +? OBIECIStRUCY IrvNA[Or ODR(CI STRUCK ANOOwrvf4]w.Mfl tit. DAMAGE SRCW COOING TAE S UNIT NO. 1 UNITN0.2 VEHICLE ? PEDESTRIAN p PEDALCYCLIST ; `? MNtR's NAMf: NSI ri4sl Nor G AIG MF S rvaMF. - D11111 APD--Ks,Q Ames 7 _ j B 11RFEI ADDR[SS 4 / 8 1 r T 'KO ' MUAL IRlft,VID4FS1 (RB I o _0,4 K BA QA ! Z - - Clir AIF Si1COIX 0 TbvLSW U? A 9 -.3'7 v 77' -3'423 D R -c D[ P .. 1.,U-b J.DW W A 9 13 ?s 31 aS7 2 DRNfR'SDaNSE NO NoR-D ?3KF3951--8 1IAIf k= FM l1 w Ofb4N l'j I v V4 OCENSf NO. aN R?L-l?l? Q-7 E WA Sf% /?1 OA EOrBRN 1) z7 12) B 2 OCCUPAIIOn MNAMEBRaNF Ba. YFS -E - a ; Z' ll uNK E R OC<UPAI ON NRM NANfBPNOEIF NO. EYES 145 `/O f! (]V'it 1J J w pCHECK (?) vENClE AS ANfMaonFaAr?omfR'A` ?CHECK(?) FNttEASAN fmviorFEaArmlr'fvw` ! i MN' Inc "` CODES?' 7 ii: `s . 5 . w ( e CODES ? I 4 is 5 F x J e v s b N E 2 U Fs NoAtt N R M OU tl °„oIR p .. uML p wyRL ? pSNI. ? v:K' U 'U"'0- R DRd+V t M IF-,,or. p M BA.xcL ? I CnFV I ND " ? E ? tt IDA 1? VAI 1 N 1 .l IDOCGECNEV I MOOR IOMI NOVwI 1 VFM Y[AR (,(? CNEV ?JIAL, 12-Dr? E ! G/JJC 2 Rip tN EN i(L1A 5 q9 sulF a•neR RAIFfa. slw:E w a - - H I C R --c. 1LV TN 1-/:55 W ven¢ula munon w. i?19,-,- -- 1 3 6' 1'7 6,z l 1 ??• L of wmN TIK 21? y,giJ SI/,?,6 2:3 -I-i-ice 2 D 4EGnnefbow>ru ust msl 1 sAm? rharvE NO W W v unR wrv! uI n4st moat 5 omE - DI u z ADDrnlsa Dw.uv N E wM4 %L n•ME a•DORtsso wsUVANCt co aR •ctNl -.? R IAJ9 powY/.So 0 DAMACI •RU ' En 6 7 IJ AS gAMIGE1r AREAE C . " ^"""°? a o w ' "' wADCt D ASS. cuARCt IJuN o ow fro. ? c? • - - wMAU AHVFN ?vIMUMO 41VfrN OREMAINED esI.DAMAee ioriuii s fst s loud I-ID B r 'gILL15 -row !. ?iaYno OWK.ItA s(Dpp s AwAr Br ,ts If 1 I- AS c.ipo IN DESCRIPTIONOF Olll$ION: IUSE1UPRtM -..KUR.ICES1A4r1 DIAGRAMOFCOUISION. u N ...?.. -•. SrUt Wcs"Yj, A .. VEf//?C£ / u/•ot . A il/c 9au UD au "Q4? BA}' .?: __ as R9. VEtglca a WAs AzL f/hPl/NG . TL[y lvESy _ - ;_ [u aF 0,4 jr BAS' PD R(Qd !/Gd!ic?CS cotuo. _ L. W 504/711 &41" G4. 777-1 ?7-? ,f ADDRE NAME SS R INJURIES OF PERSONS INVOLVED 'CODES I 2 - 4 5 6 . OCCUPANTS/ WITNESSES is :oomon:IrM+•sM fii lJ su -cl uIm ", „ nslR WANE IC 79- 9 KA -7-9--,q83 ?9 9 Aa<! SO G N T 0 D A/ o "" ? B ? r.,?-sR" . p NG 67 1?6k Qy £!L/ . IuRI .. 4 InrROM p.Mf ? . ? . ?" fA _ RnN K N vu ?' - , CSJ a sw i.JO T ?• n ? A v.{ ? 4,. ? N: : . " E.{,. N A L A f ' _ yy o ?•?!; ? p tq { ?D I A •' ?y/y /5/1 6 - ? t4 N ? a? ? ? ?/? ' ? lJ ? .S ?? ?? ?Y ? o .? ?? O ?' i1G? // a' ' 1?Ni'/ /"? / Vlsf? ,,D r R ' + fi .. a 1 i i .? 'ro. Yel G r v i t .r T M?' ! rft.r,Yn fir. flr rr; t Irw s ReJ' k " I tF G? ?. 1, ?? f } r' J I i 1. L I ? _' ?P?fly ?;? j "? rr - r I Ir y. I R FI- rum e - ? ! I r7 -Z - ? 771 1 ' Leal RFV t ;?k ? n . wsR 1591 o 11 X 1A ?r V, STATE OF WASHINGTON R GE OF TRAFF ICI"R/'F cF COM ,ED IuMe t,}`? ii POLICE TRAFFIC COLLISIU REPORT ? / Z R '> PRIVATEWAY; , OUNIY CItY rM). A FFfM d7 , e!° 1 P '.. y. 1" DAIf OfC U f Ll Orv AY rw1 1 u, IU$Et. --URl x RD INI R I 5 A COUNTY ?EEFE ?Sa.) ?. C RCU1EONs OUR RAl - E, 0 1 o 85 CRYO(1 TOWN Fe NO.OFSIRFf 1 ORRGHWAY °N E °N w OF PLU61ow ON OAk BA C' s Kl? ?'G 990 MITE Trost % Ef ^' I ° MILES ? NDfRSECRNG W1111: 51REEI OR ROAD NON MERSECD 011 , (]1_ I1 SsiuER.?a?1 '?? r ,•l `11 519Ef16 PR I DI RAM Soso IN,A Y e 1 D BE1WEfN ISIANC[ADAFCD nIx MRIFFRF FCROSS 519FtiOR nfANFS,M If 5 rv s s F W ACC ENi MILE E co RNAR oR fR /T ' 5 rvl' O of h1 P 1 O IY: ?SpIIUOF ?NIe RUN SFVIR ? iDD Irv 1Nifej / ?IR50 I R CGaaszlRFEroR ROID '09Z 0 $E xp '+ D Dll15AN NVa'I No NO. N, ED ufD__ N ° VtaCIF lO1Al NO ? RRS Y ? Q . r7 U RROFF D-11 ONLY a vtNClfS NtR 51RAMFl FSI DNAAGF SRECIN CODING IRE T 1 { ' a 9 O 9 STRUCK ANDOW BRC, SIRVCR INAW.Of Oe,EcI $ IT N0.1 U ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST / 1r UNIT NO.1 MI DIE N DR sNf.,Af.. st r ` ^' S_ D nfe's wMf: ust rIR 1 R C I U F+= AM6 S5 ?A STREET ADDRESS f ` r ' s IRFFI ADOPf (j9 LID ?FflU -k UA\\f NOrvF NO N ' D nr u1e nEt1 ? j C ? It zIR oce ? ITY ] ??INAC. U 1'•T LOA N l fN..E NO. R IY I Alf R tf OFBRIN NO Wr ? • YS - ? ?, ?` .t D NNfR's UCFn rv C1uFF5R3`196ti3 51A1E WA [z h D., CIA EYES IGntRFIGHI V E OC<URAIION FIRM NIMf 6 KRONE NO s fY[S GRl IfIGHI - _P ?a e? OCCUVAD- r,RMNAw.feRNONENO o 732-49 QW £Y' Stl COF4SZF.EJLTEOn ILL 19S So9 'll K I?) vE AS An FMROYIEOFANO,N11iµ R °CHEC lRCI rD - , x _ ° CHECK (?) rFFa AHOmFa 5 VFN LF TO- ,:N 5 ulo a ;,;err ^M , , a a S T 4 ii M ' aaN CODES ?' 13 i+ 5 u R _ I Yx , . v .FR ` A ? i CODE I 1 TARS F ? <S?I. ° a2., ? WI r DM ° .MRA.NII ° f ° AMRxnrxl v l [girt. ° vNiMSU ° iiui,Y. NOr viD 1Po R Y. ° "MGDEI ° .rvovAl { + Y :o YfA9 MM[IDODGf C-I VFH ? IDARI.NOYAI SIYIEItDR.. X r. - - 1 . 72 GMG DUM i ,E NO G vAI E E A - H a R z• 1 1 R 1 Cln IA TI N S,AII . AItFR RA I .7p c? y k'I c- vRCUIDENin I N vEIMU-If.-FRO Tc 63 w V 5 3 2y `i 3 MIDDLE RgNt NO rIP51 MIDDLE NE IS NEO wNFR: lKl fFq. D SI RfGISRRIDOWrviv. Ulil O Y ?? to? CuSTOE'A go-FiS W owrvfR a I D 2 AIwRESS ON'1LLR L L111??A 18404 -1E? 99 E ND 1 NNAII ADDRfSSO,NSURANCI E ORAGINI R ..i 4 - I pANAGED AREA _ R: tOF , w?<y .irN iEl.'wWMAG! , A , a11ARU . V .L? ?V ?FIMANDD ? ?R nw?i CIIARGI O w • ?AwAY ?RIMNN[0 F51'D D I5 D : i D sl;o? ( ?' I+ L iN Ee:Lrslvl Boos. w:'° ; I.WAY D eY ENtu SNtI IF NLass,lRrl -5 eY , t o cA1.-DR DIAGRAM Of COLLISION: iwet?r NF¢SV;RYI I erAR O", DESCRIPTION OF COLLISION: II15E SnwIR[M V?s1 E.?B OA??n„1 R0, ut?• LE-FT -y R ..Y .• ;; E ? If:j T?Ztif EYE 14 A ? .T : 7I &7 ? i - ?'Cl Q , . ga+uEi.. sNrrto elo5E:n w,,, *'le, f ?w„a RRC4 '?a t E ,m 7zr , r PSA4 . ,` '• ADDRE5581NJURIESOFPERSONS Emu sl NAME INVOLVED 1? aty F CODES x. AGE 1 rAl - s? R N 3 A, 4 5 6 xsn can _ : , OCCUPANTS/WITNESSES 11p USD SUFRIM ,.I X r ?, v J # b VEL..,.....?s? r.. ^.?_. a•:- ... ..?::k..rJ Hn.-?.?SL?vv .. v r ..? .i ''IG'u t ?? 1 ? yy i ESTATE OF WAS NGTON PAGE ? OF ? No O . - _. .. . WSPIWI4EV.I.B01 - . POLICE TRAFFIC COLLIS REPORT ZTRAFFR . W ICEC IN BtR ry ' . I} ]PRIVATE WAY (, .: I - , DAll / OU SqN UAYD OUI N COUrvrv o USE . !"I ? 5 ,RR .. IRIL .1R Iw , .. X I ???'RI v ?F'r>:.i(,5? /v F CIfYNO. COUN HWA pN4 ` URM ' ? <Ity OR TOWN NAMF6N0 Of St4tf10R XIGNWAY C" p N CIS RWIF CMt 4 ;M 2 M ES Ey5 ?W OF HN(ILGC.I? ON Ct.EvELA a sT I _= -E.CTIW. /+f)IfH. 5r4tfl Oe ROAD NON rv1E45[CI ON -Nl( E . MIIf N/TR tl1lWE[N 5lRFffd SIRf[I WSi JJ 0?? `?? °Gu ?' OSIANCf dUP FROM REF RENCf C4051-1 R I,IIARI-ftl ACCIDENT RAM DIA -1. M S" - ? ' S ? p lfS •? MR1 •N F W OF oAK'EA x-D, MI{ff <OLL SgNINVOIVLD Stv IY ?1Piri Rf FE OFI REDREER? RED/D 0v""GF ?nI16RU `?{ IMER Cl5 CRCLSSSIRIETOR ROAD 1 .LIED O NDINJ F N 2D + '. 3 N? U 101AI NO (?7 P40P[Rty DAMAGE ONIY ? FIRE avEn clts ? pv[aCi - 'r6990 y E.? IrFO [ OSIECT 51RUCCINAME OF OtlJECr 51RVC4 AND OWNERS NAM{) -- DAMAGE 5{fC4LL CODING ?- ?. f,. '.' C S ---? C II UNIT NO. I UNITNO.2 0 VEHICLE p PEDESTRIAN p PEDALCYCLIST --- -- - R - .Blurbs NAME usr a MIDDY Fa SHAME: usr FES L,A I s KR 1s s SIRfE1 ADORt55 T ATiiGt _ >^ TREE DDRfsS 17I S Ho rw I?I-L A A ,,qq f'1 ;'.: ,r L <iIY SIAII SIPCOD[ P1 "111 D v -T1 ?-IADL.OC-K W A 3-'S-1034.R 7 2 . D4N{4'S UCFNY NO IAIF tl H 1 I UCE- {c? SUM 33z 1 co ! r 1AIE DAIEOFBRIH ? i ar ?rR I {O v W M oa lb ? _; R OCCUPATION FIRM NAME6-NE NO, f5 WEIGHr 1 H1 E OCCUPATION IIq NAMf6P-1 NO. S1uDES? CNInIRIC-.M N, S, l3 So R EYES 1.1 -GHT i . ! V pCHECK(?) pCHECK (1 E.s nH rMVior"tEa AiIOTHEe? vtweL * vlH AS AN 0" 11 OF 'E ` " ' AM IN L e ,C ? b. - i e CODES b- 13 li 1 5 NfcIID.I 116 CODES ? oA s 13 a:is a s H D 1 _ 6 AFE, tuc row n s uRl?s F- :, p .MN .N F ? s° p C'8"". 11 ? R CI 1. 01;W' c"84". p H ? "X.. ?1e VtH TEAR MA.E IDODGF Cnfv.l IDAeT?NOYAI SIYIf IDDR CONV.I Y YEAR MAx 1 E. nfVl LID I VA) 1 73 cH?V ?joVA-aK E N H l cwsf PUrtNO SrAI[ RAILER RAIE NO. IIAII VIe C- YEL . $UA 552 wa - - I r AILER A N A ' KN CIF IDENriKAIgN Np i VEHICLE I-TIF A NN 5 -+5 4. . lIY1619'F13,L, 1 810, 4151oI-1- - I I I ... .. RfGISRHUOWNFR. U51 FR51 MIDDIF -NE NO ISRRtD wNtR- IIRST 13L.A I S PI RA4/j 3$S-103 c; R . MI F E _, - .. SL E R P Isl. DAMAGE Ino OR,- RtMAINtO 11- 1, tl( (CScw f ?.!.; I i-j.-.{. ?.1.i_I. ?__{__' I-T. VENL"- J_.-.WAS.-SOV7JL82V-ND...ov__CtGYLGAND.? wVE tAr.ID at ? ?RWE(?._W AS.....!?S'C,E.l.E,RAT11.2G_. FRDrSt STDQ._TO_5't?R,I__ -" y i T _ i ., ? ? ?I>r KTO ANA Syll sLDbWAyyS S7R1K11?1fa_ILTB?E,.4? _-, '. '1Nf WEST S{bOLDER. .._ ----- - - -- .1 _;._ '.... NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED L f CODES I - Z 4 5 6 OCCUPANTS /WITNESSES IFu-us`!-`,r'AM, / 1.. 1- ? .?..?ryp Arm ? .: s ? c I NNo C4 11 c,c v M M O 0 CD U O O 1 . o O I ? O ? 1 l1 STATE OF WASMNGTON `eG, D' INn. A? POLICE TRAFFIC COLLISION REPORT NTRAFFICWAY ADUCECOMNAININUMBIV ? PRIVATE WAY I DAII Ur r1n15Or: 3 r'? s' , . • "", ., ,. ? `I' ? ? CUUN1r ? C?letzsa COUN TY /? CITY sos'¢o 9 kOUif OA Sf N ?rUP IRAI 1.1N ?r I?R. -Ilrxu l0wr+ r f4Clb m ?J'?fiTflf7?-. M I IlvvrliNl. AM-, .HI '.•'v, nu N,NNVV1I Ii?Ur1 ??pp11 A I?q?YYYyA.i IAL. ttlaltf wNN I I X tr1 R f POB Mbf /?? r. A l; :I NKt c D.+IA 11l nI.r In•m J,Y4 ! un3' ACCIDENT MILEAGE CODE DIAGe AmpAlA P RD IfNefCi1 BN EI 4PWD0e R[ifHN4 N (Ill(I iON iNVDI v'1r /? ? OPVIIIAGf ?N'-. „OIAI NO r x?UfUyy?NU IN,u4tD? nrtus lD[J,J. wil4cowNn DAmnctoNlr uFw1rcD ?a"N MI: 1. ..=21;:1.. Ir"f? CLS C NOZSSINFfIOa KMU Gaerl,wlxr.lr..mla+o,rrl slau<. ANDOwNIRS NAmf1 F17 D--1 / -? 5 1-coDlNCIAF UNIT NO. I UNITN0.1 ? VEHICLE ? PEDESTRIAN ? PEDAICYCLIST Dvwl x'S wMI If u ? ivfx PNaMf NSI ie I "a t ?t )Nr Nn D N I A.-BB t CNr SIAM tlvG f N0 P!np y?al? v`o:f ?3?1 3??3a R WNI' INy NU {WiflPflCR377D I St. UAIF b r '? 3 31 ?a3 I `/ RIVt4'BI r[rv•A NO AN E% nIfp BININ (IM /[5 ONi Mi x1vNUNIN r v n N • E OCCUPATION MNAMt6 PHONE NO FYES WEIGHT wIGIaI P • OC<,u pp ??• '-' '' ?X Py' i ? tJ (AW 1\T\1/? R ? CHECK I?1 Jr" rA uM N r« RIIIN ar ANOI«te At ? CHECK(V) nN of A F , a ;"; ` 1 P CODES j* : s .. 1D.c.c11 v e I I<I.DN a sP r1. CODES ? " r .s, 1 '- v„ ., D i:H ' 7 7 ?r ?" ? 0 ° .. •s ?wnu.rl 0w ?i ?I . I. ?v DART NOVAE r?111ooN. v., N I ? ,111 IIA ? AxIP%rvAl Nv 1 p N E cNly r r ru4 Y - mo/ v, 1AII +IV WAIT 11 H •tt%UR N t N A AI AfN AIF r DrIND NI,I„3, 3 a a c o C ` v 1lIt i1NNN11 Ali r+N lPpf rve NO. 4fnnnvw rrwm4 c !m, Il?f f Pr ND Nrtxmowrvtx lnsT lINSI ? rtl w A .1bb<trn w4 1 LA ADDn :Bn(,? N Q a `l \ (J?-QC.1L N E AN A AM(AAODxI»r%INSUeANClcO,`R?AC?.FNIO v(J' CY\ R N D n• A I n DASSwfD ARU I-cm nMwtn wlA •~'?? Crrne4' Nn°f;f 1..PUw.r ?P 151 'IwN.AUI ???Nili RI MAINID C• ?AwAiYt ?NIMAINID IPIvUAMAG[ I o?.o?°... a b J x la P'v:lvxow"' DESCRIPT ION OF ColtMON: IIA[SUVVII1IN1A1 valTn Nl4ssAerl DIAGRAM OF COll151 N. ID+I uP LIMN. AI BW IIIr re455warl -t*i1 C.A.-t qo-- a 0AJ-29tA-Lf, ^ R ? 1 r ZTT _?L . .-_ _ YL Y\tifSS Viv\\Vv'hQ.?ix?n? j ???; EAPI.LAF.1.s\?? 0 .^? I\C : 4 n ?:. - _,_._..- -.._ . ? ? 6 ? v\W 9nE7 ?n ?rE'• C/s?Y'S%C? CAV?`.'?FG,I yy EF ?? ?? v ? ? - ?H o1 E .? ((?? .. / L-.'?"• IJ?Yw+C. ? \ht0 L?A W f J ??fx WpEZK \ fsO „ d-t A?A'l NAME, ADDRESS B INJURIES OF PERSONS OCCUPANTS/ WITNESSES rf•ADO"?wA'u1A'M INVOLVED I ?, 'CODES t sfY Are IAlus - Z " ;1111; 9 Td 4 S 6 anla uta IAII MI iu MI i + N r 41 Or A U vl w?v^itlxrAN ?AMP ??. 1?n v??n ?i? °U Nw1 rlnlvNl GP Iwrv UM n ?1•i Yrr11 A+ ?% m1i X *AN E/f` 1. ...v xr.1.,. M1A:.A .! .I•v. . '.•ft na}v?v?I\•Ar ,, DAMN 1:r NN. mJ A1a1ti)vID PI P P ? C STATE OF WASHINGTON PAO[ POLICE TRAFFIC COLLISION REPORT [gTRAFFICWAV wllceeomPl,vNINIJMwN PRIVATE WAY D f IXII OrIrLON IMI or I G try r4n '"I ? ??i y/S-,1 Y CODNIr Ev FI-6.tJvn/ CWNfr w. ?Gi CITY rN). l.WA 0ylrAN MIN noN lowN NAmf Gr-11101-Ar pN pF 1. cfs Pvi I oun o4slRnrt slalor? C, MEfS ?5 ow pa ON wr f?, , INr[RSFCr NG VAtM SLO4 WAp NCN [NS[CIIUr' Q- IRF so:/io 3 1 60INE D1s1AN r EF4ENCf.cvos R filN NEI O4 Ne - -.I PNfirX 0 F i ACCIDENT v uueNAm DArn m f5 F MILEAGE 29) I[ ?] ul /N .-/C S.. /JN CODE CIXlISgNIlrvOIYFD: Sfv ?NI`x. X-ND wl x LCNNL Ix ff UR NUAUON MrE4f r?R'! N mr.r IN IOIAL IJO NO Il Fp,L_rq INJUXrOs?/ LJ :vlli ?NI aFU ?unpHUN? INEFR CIS CNOSS Sikf[ION 40.40 '?. V70//O QVFNIGI[5 © pPWHRrYpAMA.GFONIr I.J xt pyllu[rI u ODIfCf SIRUCN NAMEOi OB [Cr S ' 9 J IRU[A nrvp OWNER I S NAmfI lSr UAmnGF SPfC1.4 CODWG IIS[ S 1 UNIT NO.1 UNIT NO.Z VEHICLE 0PEDESTRIA14 ?PEDALCYE{I5T ONNFYS ruMf. IASt IiN mlpplE Nrvf u'1 NNA[: 51 FIRST MI., L401 cri SfRtfIAINIFE53 H/N co Q Lt %'= dA.•=dA"EG! S X /SAD A L o ? INFft ADDRESS C YY.loiu- FO ' arv JIP rN D IAlf Tou r Y N 2 /? .4rGO Adlrre !n/A .R.'? R .4 0E_0G+c w/F 'LK31y SS"- Y/?-L NtR'S UCENSEN StAI! 1 r, l 1NI I IV R U FNS[NO. N SIAI[ X pAlF Oi tlrNin C L/? L W S`7 /3 V QaN/BS 33" En WA- /, p; IT OCCUPAtrpN iWA- 6PNDNF ?Np fYf$ wFIC.Mr rEIGHI E occuvnllorJ fIRM NAME6PHONf NO. [ FS w GNI r¢IG 4? 'C•F d_ 71-G of ? R p CHECK I.4 clf nsirl i °iio:H Or ANOmCIA' t ? CHECK I?) rn[iF 4WNAD ,T, i»nNniE V" vi x CODES ? ] 1 5 ? j "ss a ,ur CODES ? -. ] » 5 -- aJ:.ca I: ais oN w'14 .p " tgoNC 1 M ? MNA I ? RM V ` ? YI:n ? fi C3 .N r El .. ? s „ pis I V[H. YFA4 NMEIfN.1DOE.cNfvl MfIIDANi lXlvnr rlr lapN Urvvl rr. R NaN 1 f..I A v Y,DIl1UnRl rwVA1 rtE lapN, aav.l 5 _ 3 aLa P N. E o?ic5 Zu{ a" IIATIN. u WHIN NAIL NU AIF H vHC«oN T? A TE?AI1111 n ; ws/ w.Ir b F v7 wA KHICl IXMIIIUrrONlq. L YIR Acl 0 3 t s' L Nr vfHlCl[lu(NnNCAII t 7 y S N 3 G, Y EJ R[GISn4[DOVnNtR: wt r it MlplAf A E N?OrrINO O W R ril EDOWNER. ASr IvSr mlpplE E I'6C/q -NNDAG r r,lNO 3U u ADDREssor owlaa A uvfsluowNFv n N E Alp"te ?1 Ocac:,c Gb('/ ?a' ? T:f9 wvMfaADORfssalnwNAHCRCO.ORN:Hr, ^ N . N oNL R r.3 fn NIGNaw.? ?" oAMAGeowRu ? ! 'rwawru ?•?' 7u? '; DNeia.EO.Nwfn ' loGunLLL'o?: a Esc BIwlAU / Cru4p nw:: m..,arf = vI Aucr ?n u4NUl NFm"INIn AwAr ? N Li?rumm?cl ' m i - `??, 'o i LJJJJ s " D lowfp lou r J. DIAGRAM OF COLLISION: 1 NAI r'Ir„cnN r,wN .. swrnr runmAVrl xr ' UESCRIPTION OF COIL151LIN: lust 1-11"INlnl srnEl 11 Nrcfxnvrl ,s la y r Z I (1) CAR / Ir H ZMl o "el 6 Mrv 24 TH"(r.? dr( A Ah d /{/T C.AR Z Cil n tr/N( // N/,LL y.3 ar I I? r NAME, ADDRESS B INJURIES Of PERSONS INVOLVED ' CODES t - 2 _ •1 5 6 N OCCUPANTS/ WITNESSES 'I''"'Y'" "" aX AGf % :?•" • ... ' n ww (soltoaN A./Y1A/Tt..Ao ?, •I '/SL•tvTL Z 2 L L 1 / - A 11 rv r?1L, ?JrJ:k" faRUS Nwl a ,y xrw' C1 A r p +^n El l". n E N Kr Aw .- ,.r• M E -. ? A pry115 "I.INI (v INfJM -? A`pA- C1":"Cl;",1:.r•?:;?' ??:Y E eu rww ANr x 17",^31, At7?;.. .rn. r.ur "r n al ANnnp a"nave. .NU.funr u.n T r. 9 e'j POLICE TRAFFIC COLLISION REPORT LI TRAFFICWAV wl,ctc TNOMnt¢ PRIVATE WAY DA rcr N ` •e r`° Dn R°r?: N ,r n I,ME u5E)ADnOU41 I.?.. couNIY NO <,rY NO. NWA r IFa 7 ?. ux r.x 4 xr X t / I W ? uURA I ?N ?{ ?In Cdr IOR IOwN N IBNOO SIViIIOV n,GNWAr Mn(s ?3 ?w F67pi W? ON L-2A 2D i<lC v I NWtE 0451 ! cJ 5OZB0 C11 1 rtuSICIIr,G Vnln 3rvFtl OevOnp NOrv N1E95lCIO?Nj nFIWI[N ?`_ SQ SreFfl B ''+rRtfr III VetN% M,1f 1031 O i O rfBD9f ION E90r [Itv{N EC903551Nf[IO4 NFAPlSr M,It VOS lat. nL;-? 3 [ or PAUf1..ttJJ ? D ACCIDENT MILEAGE coDE PAMI DR-A IAG CUUISgN wvOrvED tivfv rr. Orn[NU rO Cll[D_NO ,N)U9f0 ? ?3V,11AG! ?1RT8RU N rNnRwRI" I .RU MF CCS ,rIT(eY 1, 319H09 v0AD OR RIffR{rvCf CROSS SiR[ ( 10990AO ?? p VE»rCIl3 ?VRGPERIYDNnAGFON[r ?gI5U1r[D ?vFaCIf C ? J H^1 /O? 9 OD)tC`S?PUCr,NAMl Oi 4n)fCI SIRUC%,w00WNlR'S NAMEI tar DNnAGE 3VFCLLL COgrq f UNITNO. I UNIT NO. P ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST N{NS IAV ?, rry5 *1111 D1I119sNAMt: - wsr III I I t _ e $IRItI AODxl55 t sTRFFi ADD9F53 2 CITr SIAM [iPCODE PnG D v SIAM L,P[ODF V»ONt G 2ON vJ A 9 L R uvN(NSr¢Irvv NO ssAle f% M DA \ZRY2S I V IVIR a Ervst NO. Iwn NFOP nIRm a2 CC<UVArrOrv l6 NgNf NO fvt5 wtgnl.,GNI I a t Lo z STUD&X SEA I V A t ?toOL? "L.U E R «<DPAtroN MNAMEIPNONf NO. [r(3 WFIGHt fEIG»t ? CHECK (?) wN fM Vrr f A nrvor»EYN • ? CHECK (?) vFn,«F AS AN IMPtONt[ Or ANO r ° 5 I rw 1 e .PO?o"c.cu Z CODES 1. " CODES 1- t ] '" . ?; 5 r 4 a sx°,, 0,, 0 rl g ' E 0 0.11 0111 "1; D vln %EIDODG[MtV.I '74 [iIDARr r vA) I Llf-.Cd 1 M? t 00 Mc E 9.. v.) rtRAR MMI cn V.) xA%uDAN1.NOVA) I » 09 WFA1 unN hAIfN srAlE I(4 nArF NO rA( H C vtn cao9 A A,t A ,o O,mnarvnnurgNw i L4 Z'7 l.Q2i7;Z 2 r L t , OIaN n nl ,A ( i ?- RFGrSRHDOWWR IASI NRSf M,DIXF VrgN(r8J O r ID wNtR. U.51 NR51 MIDIXF T e-k C W 1] ApOe(53 Cr OSM91R N A GWN[N SI AMl B ADDRUSV INwRANCF CO aR AGrNT R rIU N A 1 ?) lrNnncw u,ln '+"'"""' ' v"?r?•• CNARG! gAM%iGtO'ANIA% Cnn1Gt M` w; a. s fslMwnncE cwAN ?RlM.vNlD i ?:wnvN ?11-111D uO1DAMA F oM?tDRr f Aw r ? lOwlpar f Aw•r DIAL qAM .OLUSION ,..,y lu Nit(ssiarl ur ayor» OESCRIPTIONOFCOLUI 1014 IDSe sDPn(MtN1At s»EH,r N{ctssA9r1 p V bl LCl N O zM CaN CC&\1?o ??o?Ltcvc?F PoCty r . PA?iSE'412,Q pV.fAS OWItJ(>L? "''"d?1 g?C:A%tAE ?.3'?NC?I?p LTJ 2?cCZ- y ?? ,w z ? K W` AV4A OF(= aG ' tt ` i 2 Ate? t Rr !c l E NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES I - 2 9 4 5 A OCCUPANTS/ WITNESSES r''OOr'r?NRW MASWN 3I 51% AGI .TAIU' ","" ° Y , I51R lilCl M' F[FtF 2, cwftaD r rU 4o83 sc 1 z , Z ? ft C?A?{TSc_uil Pf tl- q v0314 l o.M ?°. r?w .tt: ?: A Mr r A . ? ? ?l,. ups 0A- ?°. r ?' ,r. c ?; .,. TL A!rv K ' K%rI G I I ri YIIVY rvUVIUNr DAII 1 ®TRAFFICWAY Ira. CE CO-N. N- W I POLICE TRAFFIC COLLISION REPORT POLI ? PRIVATE WAY 13 D" u r rcoulvoN Il of colas r ?' X21 84 N„ 4.,. 1.,.: •rp r.,„ r.? ?? umF wu R.m Nou41 1 couNn 7 n courvrv NO. /? curs. " ? uw e I y(]?H Ol CI Ov IOwrv 6 p 5 ?W 141JPort Ludlow NAmIRNO Ur llxlFl04 nIOr,WAY ONPaxti'dise Bay Rd rtt ClS l % xOU1EON 5,YtE1 (3 ?'C?'?09 CI ?J N11NSlCNNO'MIN 114ltl UN UOAD NOH IH,tx5FC,10N 1 4Rfi1% f MIlf P051 .??? < . 51u1f1 . Boat S t "'w"', \/ 1 11ANC1 sDIN{C,IOrv vOM PNt4FNCt. CN0551IR1t, 0v NEAxlllmilt YOS, D A[[IOENT v OIAONAM D%iA I lAntS 5 200 erl ? ? oi?i 4 Boat Dr.. MIIEAOC eoof HiFRtNCf ,O Po 0O JJ v Iv. L aN50NN-0. ? R yN % ND.IN,UNEO_ SY ILAOt C?S't F ryrvpulp r. O INI[R %LS C S,R[f R A 4 H'='1,RfENOiDR R05551 Po"D ?J I 10,AL N0 _ p ?r ? VNUYF4,v DAM-ONLY ? yf nyEII CI{ Gv[H CI[5 Q r? ?C/??O/ Nl Nl b,[CI SINUC[INMnf Or Obl[CI 11RU<x .wDOWN[R'S NwnFI arl. ESI. DPM"GF tree/dec, poles/Howard Haakensen s 1 000 SPECInI CODINOIbf UNIT NO. I UNIT NO.2 n VEHICLE ? PEDESTRIAN Q PEDALCYCLIST - DJOxlv{RS NAME MIDDU HNS, Randolph H. NtNSNAMl: IASI HR ml aE p2 S,RffIADORF• 3636 Evanston Av e North PNO NI NU O p ElIAD0NF55 1,. StArt 4[DDf 4NDNE NO, 1 tF 114 SIA C Df 6565 Seattle, Wa 98103 789- R ENYNO. 51w1F pAE r IH 1 411L. L11111 NO. SIAIE 5t% AIFGtlIRIN H435QN . III 144 M 11 15 5x7 V E -PAr- HRM NAMEn PrwNE NO 1 D.. IYfs wfwu, NFlan tlz Dccv4AnG, ......... O. F WfICH1 ,<ICNI unkn r5 170 10 R . . n CHECK (?) ? CHECK I?) n[or Arvol NSU'nL .r P. CODES P, T 3; 1 5 ` .1.„r CODES I r J r 5 I a ;` R JR 2 N o n ? ore: :i r o . n N%•Nrl a ? -111.11111 a :Z D « ).b. ?? uw ortvr upu lunxl NOVAI r, qn4 co"vl l 1 N. rf+x .wullwuelu.fv.l euwll In%N1 Navnl IJUx. vl _ 1984 CHEV coupe Camaro E 6 . u uclrvu rwur,o RrtHN a Art H I AIF An No „EaDx Nt IAN rt y silver HPF451 Wa F ICIF IN-fiCAT-NO L FNKIf IDIrv NHCAIIrRNrv n3 E oHI HO - IGSrtREOOwrvw uv N4.r MmaE DHFNO O 4FCISrt NtuowNlx. LAS1 nesl MIDOII . - HERTZ Rental Corr). W L HoRnsaow++I. . 18625 Des I4oines Way S. Seattle, EWa N E NE4 A DRf11GDW 4 E ADDRfss G 11111-Cl CO -ACEN, AMe A N A IN uxAH. N n . -unknown (under HERTZ R i O " Du%rclo %RtA tir;; ° AM aF V u1FA ' ? f 1 ' r r:?. MA tv ..r •w cuYDU ?. rvtN ?YIMUNID urAxrl ?q,"MAY ?R-N[D rrrNbwry 15' DAMACI `?1 IU eo i i0I1 ) f? 'e p ? . ? = -Al Y. /110WID $ ?f `??\111 O{IISION: rvs Ewr,IM NAI • in FNr NFUSSAV.r 'rmK ir.noNH DIAORA OFC DESCRIPTION OF COILISION: I11511IMINIA1 Srni, R Ntussnwl - Vehicle #1 was traveling N/B on the - - / Paridise bay rd. Vehicle N1 was entering J O` _ - _ /TIo -- a heft curve and failed to negotiate sEUn 7- _ n F41 leaving rdy and striking a small tree an some decorative poles. ADDRESS 8 INJURIES OF PERSONS NAME INVOLVED I CODES 1 - 2 J 4 5 6 , OCCUPANTS /WITNESSES 'rcRwD",<w:ir?+Arsni i,l SIx AG ums "L yr~ Y ls,x. 1110 1 NMI ROZNER i L N2{'" none 2 3 -- - us o ?1+ 6 2 Greenwood Av.N. Seattle r9Dnone ?% ?r. 71111 n" ? N AN,•'111 YIG i D CIA ??. Ins •nr ?r? -? H M( , . I+ ?%Mb nr: ' n~ rr. 0' o;:.rr uAn X c 1• `y1+- xN{.??P tl •onK. JCSO Iva uurAl<wD 1, tihr2 Oak,-'. 1kp11 -G4l nl41 4-21- rrwaDeY 4 e3 ? ra b, ?f ?3C4 POLICE TRAFFIC COLLISION REPORT ILY TRAFFICWAY USA` . PoLICf COMHANINDMYfY PRIVATE WAY slon eourvn rea rNWA NO. arr ea. Gounrr $ Fo u uurv Iu n w , Iu11 f+u bUUYI S• ,ux , •I ?FF E. S-3 LL ?/ / /(( ?{'Y? ?UY ON Qf I]IN CIIY OU IOwN J.(o MES DKI ?w pgor cgjI, :A aN00 9fE1 OV NIGNWAY AN nKyok)ur O L LE. rCr RS RWrf ON SINfE IFNSfCiIrvG WIINSI9FlIUU xUAD / L NOrE lnrFggStC1ION [SEAVE.P. Uq(....EY _ 119tE1 Brtwftrv pq SINEFI N Y9ffl% EO. MI(f Sr DISIANC[a DIY[ 1 fNU19flfxf N<F. CNOS111Yt[ION rvFA9t11MII1 VO11 ACCIDENT VAMP DIAGNAM DArA mnE3 5 n[r [] I [) Or r LEAGE MILEAGE CODE 11 COIUSpNINVOlvLO? .NdNUN NO.INIURED ?SaI?IAGF ?r OtxYIItO runDNDlx %'ND I INIf9 5 C N CIING Sixf[IOY GOADOR 9[iFRfNtt 90AD YO• S rxD ? IUTAL nU t%vfNpE11 ? ?YNOVtPIY DAMAGE GNIY I]4F EUtrfD ?Vf?'i<IF ? ? rr _ Q JlCI SINtKxINAM[Of ODJECr SIVUCx ANDOwNF9'S NAmfI / FSI DNAA1f 1/ ? S SRCUt CODING US( UNIT NO. I UNITNO.2 ? VEHICLE ? PEDESTRIAN Q PEDALCYCLIST = Iv[91 NAM[ IASr N911 MIDDIL UI+(vfN'S N-1 USr 11 IAI a Z INtf1AU09F13 ^^ s l,R AIE ' . nt coDF No <ur :n 3" ?l D rNffrA `NESS r sulE ervcoDE YnoN I N N po O` ? R IvL45uCENY NO. D9 PI[ SI IE DI IN I NIVENSII FNSE NO. SIAr( F DAIEq BI07 MD D.r a K) 6 0 D N MD -) V ... 2 1411 NNM IxAIf nYrpIJE NO. FvES WE E 111Nf NO FYES wfIGEIl141GNI «cuYAll 11111 + 2 I R 1 7 0 CHECK (V) AM N 1r C) CHECK(,,) mC 11 s n Are kCIAL 5 CODES ?' a , CODES ? ] i" 111 1 NII 1 a Soa La "I A ' .Malx.n.l ? , x A WW[ UNy ' 4 ? kR: IY ? : MWnIDA911rgVA1 ? Cas. ILI I]Dx -) ? .,. x.nn p YEAH MAIL 1 x.CNFV.I ? {C r•, ? 28.x. O G atIDA9NrpVAI IE Ix D9. OnV.I r - v[N M I 1 . E _ IJ o9 Nsf N(AIE NO SrAJE IxA IIU NnIf NO nlE H I v(n <aox ........... I A An nA FNO AIE - Lk [nlCIf IDENir UIION NO. L vtnKlF DFNIIi <AI NN C O D Pc 0(0 O YNONF NO r NIGISIt9FDOwNlY: IASr iI93t MIDUIL S NO O -ID \ xkG151fxFDOwrvEN. E fIN11 . Il LM DoNF51 Of OWNE9 A W A xF CY OWrvfN 2 N NAMk aADDxlssn mw9ANCf <o oN ACfrJI fl- N R N a IN u9AN u N 7" ' owMO S 1 _ Dv'Np x IS1. pA1.xC.f ?? c. cnAYCE C-I ^xy?1v ?4f mnrNlU a, c VN ?91MMNID ?n ux I I I.D E AGE wu ///???'''''' K I. n``` 1 s u ? [ r E f LJ Y wWAY " wA OWID AWAY bY' s l_. ` •=_ a re EmrYAn rawln DIAGRAMOFCOLUSION: IE Aun1 s flu Nin ssANYI x?Y9 DESCRIPTION OF COLLISION: IwtSUYRlM1NI1 srNNx Ntc(s1.xxY1 VfH. 'LL I FRSLc.n "IV NbL,O"rigr? A ?'.s „ ' SL.SA 191- a"s THE OADWAE( LSfT fGRI.) - I, - Q , oltr (OF- l.O1J'r? L L5TR(.LC.(t A ?LP Of- es Rm> OERRY 1f l A e =J U F c-l* gqy w , w bAL 4o j LAERBE.RR ?v U AD oNTo rrs Ttf- E MA S' - 8 ? T mex> HE THoL.cG W . r H Y NDRI.VE.R E ft, ' ' B - N T a TH LOW ? OLC NAVE HPD A TX-R, ccut , LFT. REAR T.TJ2E. was p L7wwu, BLtiY Z ( NaT Do pmtr-Ne- LF ZT OLC-uRR6.b FA.LOR - -NAW, ADDRESS & INJURIES OF PERSONS INVO VED CODES I - 9 4 5 6 ' SUrnlMI NI1 Sr OCCUPANTS / WITNESSES U.I ,u,auonAUNAl Nll ksl ux Acf um: " Nlrr MI G ?s'st N Y ?Amb o°. ' o nW ll vlVh,,INOM ?AM ?i'i ' ?' ? vi ? ?i b ME i INNN' 'NAl A.. '?IND vE? X w v..uwcErrrcf%>...wn..r.. n-=$ A. =D DAna 91st mnr Den y F !" v? i fY? I ak q 3 ,` A s sF. "Br sa STATE OF WASHINGTON PAGI GI INo POLICE TRAFFIC COLLISION REPORT ?TRAFFICWAY roIICE COmPWNl rvumulx PRIVATE WAY oArE Otc us ND r oar Ecous I „ n :,U "` coum. couNrrw. arr NO. nAA 3 8 Nn R,R N ul EF oE. FJ 1 ?? IC C1.GUAL - N pf pN <IYON IOWrv p 5. (o MlFmlmS ?W r9Gl M FRYCI,NG I SIREEIOR FOAO R 41f10-1-A o ?E I-I M 11 ROWLJtxJJ,Jl?jjyt V? 1 NON IIRSFCI ON g51ANCFaO xI f fiFR ,:? CND Sot tIIOR NfA4111M r , R lN% FO m%[POSI v G, •yu LL . ACCIDENT N MILEAGE i R q /( fi,lp IEfiS J ? L1 CODf ILU `Am-IA ` se Y Cau,aN Nvol uN O NO [IJU4EU? ?? to .I n r ?uMr.yNU',,. -EIL xD v,iFe %li IN N t CIN(G 5rN[f l Ux WM ON vlit4l CRU 51 " 10 NOM ]] _ . DrAL NO. 510rlrv Of V p NO UPMAGEON[Y I f Nl'i,. 0 ?vtn CU J y /? /+i?J?7J R-U OBJtCr SIRIK%NAMf OF OBJECT SINUCF ANU Onrv[uSNNnlI f51.ONnaG[ SP$GWI COO,NG USf j S _ UNIT NO. I UNIT NO.2 p VEHICLE p PEDESTRIAN p PEDALCYCUST 5 DRIVER'S NMAf: 1A51 ,1451 MIUU[I D[L(", SNAIA, U1St NNSI MiDgE 514[HA RE55 $IRIfIA Duf55 VT. A A -C.L:,_TOS D c , v.IGN o 620 N v D VERSl-11 U 51AII - N E occuRAUoN 1 NO 11- R 1 7 o CHECK (?I vrH,<If As wriiMh o A" r ? CHECK (?I Z MI "if iN = -S ? CODES I. t a " s " CODES ?' 2 ,' a r a.°," ' wus ~ xU , VEH Y rM%f IDODGf Cnly l rnUDH 1UARI N[,VA , tUN t v l J1XQ E rfAN n v) n 1 E x qI I- -Al ILL t-1 III -CONV I -x H N HArfr l vn I n[NH,.n NU A An H I 111 caoN N uN A AI nnu NO AI ' r, L V[HKlfl NONUIKJN NO. CO -L C!) O 4? i FHICH UfNI,r CA N vtORlfefOOVM[e: LAST ".I, m-I NI NO 1 SA u a- Am), 0 W .....UO.NEN Nv51 MI VnONf rvO. -? IS ADD4f55O OWN[ qDU t5 O 'y N 7 E NAMfaAOOnFssolNweANCf co lw ACU,I R IN uxrw A Ni DAMIGI vt<ibwu ,n iAAiill,'•"wEn . I • - ^A fSL'pNMW [-1` ,-t nr Av" IS, l l N LJ ! o cr s, I 1 UAmn nq pxlmmNlD p[ +? --`?S War uuo5 i? _ 4 WED rg f Y ` S C:.\. A- .11 ._ Nln DIAGRAM OF COLLISION: ¢raili[ranssi.W.I . ' DESCRIPTION OF COLLISION lusE SUxn[ml"ul snN rlr rnct:snN rl _ ? ?. ? v1rH. Y? l=T•1Z+c^ -IC) IJEfiCTZyT? F ? LEFT TuRF.J, SLxD Ac.RCUS THE KoNOwAY - _ Ol1CC VP COt rM3l STRUC. t A ..,i fP Or- c ? ?J I TO c;Ae4p? W ?F-R a PER R-e w OAC,4oi. &6 ZRY Ltt;yezr RAID x F?OUAb ONTO XTS T'UP- _ 'TO DRZveR S-r Tex HE Tt,o,.w`kT rte. MAY NAv6,HA1 A -TZRE ESL . , OLCT', TFIE C' N p ? ? t FT• RE.AR T7J2e UJIW L)W VfJ, B T Z tcvL'O `? Nor DE RMILfUE. X-r ZT ol'z'ApRI--D I,xoQ ? A UL 'fb_ JPE3-r ors ' _ N , ADDRESS& INJURIES OE PERSONS INVO VED CODES 1 - 4 3 5 6 OCCUPANTS / WITNESSES "'"I s wu •a Inn N AJU N.ca, - _- Ro N _- wl. v r I -f l ?? A - DKISS - -- ,nlr x [A UM 0Al. o,u•' p.n.n, ? .ii 0; ..,. N AM _C_-C . D[+IS4 NIOI r^ WA p,M (•? ...r?u ,[]+? CI li v ? .nnl%,AL,oaNCVS NAw uu.r „?. X ? - •- .nu 17 E na+ e,aD L?`? o%n <;r a,r.,x wo aDU. DAH j . E af? p , : _?.. if i SY End Y [x r'd ?u a y - r ? I;? F k l? -t; ?•J,4 :' 1 I ; c r - t??x aA - r I - IYr?FS ?J POLICE TRAFFIC COLLISION REPORT LJ TRAFFICWAV PIXICF COMgAIN1NUMBER Z PRIVATE WAV DA EOf <Clll N Oq; Oll N IMF COUNTY , ,ID Iw 14 11 usE]DDNOU41 11 11 COUNfYNO CI,v NO. Ifgq ` L3 I 11 26 & x ll3o JtF'Ffrso+? 16 p p AN p4Al pN pL pN Civ OR TOWN 6N0 ft104 HLHwav TCl3 W,f Ok Sf4tf, ZION -1 ps ,MW 1@of Leal u ON SEvAwscyvU,llu Gc? (3 ?57'¢OQ NT[RSFCIING WITH: SIRt[IO4 WPO NON NTE45[CI ON -1 '? ?? f MITE POST ] ` Bf1WFfN 41U L.C UrLll TRIfIALOERn&(- ppPLO . S,4Fl, DISEAN<[60 RfMtlONf ,CROSS STREET OR NFA4f31 MRE W51 pCCIpENI P DIAGRAM Uniq lt5 N 3 E W . MILEAGE rffl Of f"IP 2.. CODE COll41ON NVgVEO' vfRly. L %?RD INI 45fCIING 3 BEET OR ROAD OR 4[ifRfNCE lOIAI NO. NO xltlf0_NO. INIURED ? SPILLAGE ? RUN .,v?o iui?? 'N IN,FR l3 C403331Rfi OP WAD 1 23 a - bv[HIClFS p pWPFRIV DUAAGf ONLY pl$NI,ID ?vFpCIF v??3 ]rQ 9 OBaCISIRI CV INaMf Oi-,Tcl SIPUC%aNOOWNFP'S NAMFI BT DAMaGI SHC AL CODING bE 5 UNIT NO. I UNIT NO. 2 p VEHICLE p PEDESTRIAN p PEDALCYCLIST 3 DRIV Ee'S NgME: IASI i143f MIDOI[ n v R E T IE RCQ 1..E.t L . . A nn IRffI ADDVtss s efo noD4Fas RZ 130o So. ?c Fl lE I °dgel?e Apr T,zly SLATE ZIPCODE 3-1 NO. D CITY -CODE PHONENO. I m?Ev3??1 i wfl 26-vva'6 R slaTE - D fR'3lKFNSE NO . SrA,F !x DA FUF Bi41H I ervf P'S IICLrvSF NO. SIAIF [ Alto ftllRlN ?? ?IERCCA 363bZ, WA 1= 31 9A 6?I V tl OCCUPATION M-F-ONENO. EYES A'E nT NFIGNT E OCCUPATION ........ o 1- WEIGH, HfIGHI ^• 2 $IU Il0 SJ2 R p CHECK I? fNrcIP AS:N fMPior"EP araNO,Nfc'A' 0CHECK I?I tHIaEA,, ANfMPiovfi orA nii:FelAl R CODES ?' ] I I -:sI.M 5 D. •' 1 IR.I? ' ' , 1 q .. CODES P S < 5 , D rpe ;; ;: •, .,?? '° T? Z NL a,51?PLZx? s1Aa.,lac? Cl I p mk. p :PICrC cl ;411I. p ,ANrI C] s ? ?';:R. ? ?° ? r='. v!H N IR , I AE IDDOGELIIfVI f IDAPT NOVA, ST VIl I]U4 ONV I rlne n rEl of CNfv.l AvJD[11Ug4T NOVwI R _ I]D 4 B3 loyo C°£11cA 6T ?-b& E IICEN A,lN SI H lF4 ATF NO vfH COIU4 N ! N A ND AIL Wl?#Ea EyA 388 wA I _ VFNKtF IDlNIINUNON NO C vFH GIIUFNIICaTIONrv ZS L -T T2RA614 CoD6151 30l RfG15RRFDOWN[R. U131 f1RMIDDII R - AME N1NO. O FG STEREOOwrvfR L-1 fIR31 MIUgf HONE NO. N DDmssa owNlR 'M A ut sa-NI I ? N . ? E AGlN, N f ADDRESSOrN-ANCE CO a4 IN u AN A ? FAtb c ^ R- EIL71DO R t DAMAG[D K(A L • lu ac avu ' V'r?ur??iioH -M 'DA IA 3 3 IUi-T10ii ISL. DAMAGL? CH«- p AZ AT e1MAINfp A'?iN !U OrAPG1 p pRfMAIN1U RV,wYN .l nr.I VnwI FSI UAMAGt t ^Ty DIAGRAM OF COLLISION: lull, NEC[SSA1, 1-1-111, wlH le Ito Acl ' - - DESCRIPTION OF COLLISION: lust suwum[NIAE SH[[I Ir NFassavYl 4?1 - ^ - /.ZOT` ?o o vc. W?(3 ih CULue. L)LJa. £XC.cc,-.? 5 LUO 2 l;a ? 3 D R ? J ?I . z 1 srae_ Lq,10I+.4 R. CaR2kLi+d t FLT wl•...1? pLi...,# uL1.. Las,?B- .? L?.?y?? -„ f C:YLJSS ?1 QOT` L,? -0 f $TRAJE ` -?-ccAAL E'`{ ?4111'F10? fWTIIfW = Z..S F1 /O L! !. 1 rtori W 6 1L .1..1?. Tv ;mot o ? iZtsT, NAME, ADDRESS 8 INJURIES OF PER S INVOLVED ' CODES 1 - 2 9 4 5 6 _ OCCUPANTS/ WITNESSES is :oo- ?tir;:IpA'W' eii sev AGf ,,Ann ";;!•' ,; „ wsm lac, NAAV ER , DA{y L L 725-7Z3Z 1 'Z 1 I ADlwu WA $ AI u41 Dr5QtE 8Ac ?AMe p". ' ? ;A . ?? p.4 ?' ADCIISS Uvlp *IN Iv- pAMR pw I p;k r o yr p AEgflii NA,igoJD' I N INI pAMR ? ? ' p"„ r ? H? Ok X yyLUOAT? aIKIRSNAAU a.«,. •1LFFJJMM 1.1?J RAoE?rr.?fw I_ .«'. „?, ?,. 5C.S0 N'S- il<lur.?.RHm ]«JI/«3 YI Ha¢IA vtD IISI ]«u Hvs DA aPWVT n -in a Due d c r !' j,, x ? ?7froR r uYIAY ?a^"&rv L ? I,F,, I ? r 1 I - i L 4}F y'' ? vn5¢ ? '¢m S, x Etf?S ,1¢ ? T ? 7; I ?? 1 ? ?' U 5 - 'J 77 d -nkr' , ?. ? + iJl 'r rM , a 9. "h, 1 ?1 ? ( (1 r 4 ?. ? f ? r?.? 1` 3 r I ,' 1f? 41l ? w Ati v ? , I I ? ' ??r ? ? a?1 h r ? RP I f 3' 9 d I W S { r t,? , 1 " FY? ? 1 lI I t '?? r ,?,1 V + ? Mtiin Ott ' } ?J u l ?, ar = t i l t . I? I t: 6 STATE OF WA.°' IINGTON GF DI pI N 0 o POLICE TRAFFIC COLLISION REPORT IQI iRAfFICWAY IVIIC1.COMMM[NI11111[R PRIVATE WAY Call Al Di 1111- nml CourrtY couNrYNO. CF- vv AIR ,w Ost„1„NOO+K,, _ ?M ON pf ON vCI1IOR tOWN 3iJ ow/?.SYJ? NunrnN S,eiN09 «IC«wn. rcras fox SiviF Mles ? s p or T Lr1 Q JdJ UY /L .(? RS,-l 0 NG WII - 51-1 W 9 CIION - PRlf1% FO M,IF POSr A D C i NieOM R[ ?NFF rFR u " .I I91(I / SrRF11 yl?3 FS S E 511?[/I,p Avt51MI ? CCIDENI ?fH O p ? Wssot4/JCLt4 PN T/.uCCw.'. NCnrA,?E R cRAm onu TOT INO NO 9llFD N0. IN1U9[D? ?SV IIAG[ LV VN lclls PROPf RIYDAMAGf ONLY ?aFEIiFO OBItC1119UCKINNAt Or ODI-SIRUCK /MIG0WN-NAME- ?NItn 4ON RD INI 45FLI,NG SIREF ?SIOILf _ER Cls CRCbSSI`RF[IORRO 51 DMn V ?3 nGf SnCInI CODING WE S [ rOR ROAD O4 RFif4FNCF M O UNIT NO.I D4Nte' N%ME. wI rl4sr at UNIT NO..R sVEHICtE 1 ? w ? PEDESTRIAN ? PEDAICYCLIST ` S u[ rADpvf53 ?J Nu MI 2 °„? rAlf IIR COO NONE NO D III snit RC- / -111 s uC- sIAII R NFNG !% I v4sl cENU NO sF % nDO, Rr:. -C.P 11 I'MA E. F NO I'll G,91 .1. Nl E OCCUVAIION FIRM f n P-N I NO fI[5 •? I K 04 9S0 O R V)f GNr r41GNl p CHECK(? N i o a O e°1 z c t ns AN M vn AN 1N[ CODES ? * 5 Ar" „ ? CHECK (?) CODES ? A Mm Moio:rr o N „r `d. " NJ I ? .AM,A.NCI ? ? b:.,. ? : ? o .A. IDODGF GN[ p .MN , uiY n:"? O ' 0 : ? - V 1 U If?('9, NOVnI Sirlt ,)Ox ONV 1 r? f n fvl I xOIX Nuvnl If I) v t { r ? N o4 ¢e PUIE NO nne4 nnlr NO nIF S H vfNeaoR N In n u[r- F OP6 IVA 1- r NIP- ATI smRA 3 n? __.. U XW^r 2& W.-ID • • • ? o Vlq ?RWNNlD ISI DAMMN Io.on _ S Q ? AW:v°eY ? AWAY Fl n f °O?l RAM OF COLLISION: iw[r lr rxnsit4rl "ecr:avowe1i DESCRIPTION OF COLlI510N: ND15vPMfMtrnnl vrtNU wnssnv.l mA ? O ? 4q'ivc?e STi?rcb S.Yt-- .9?.?r?%pr9?• ?? Ud?//GC6 niPOUN?J c?le f / r a?c?G TiY? ?FQ ctK ly y?'ti y NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED t CODES I - Z 4 5 6 .3 1 OCCUPANTS/ WITNESSES 11 2(. 4 0 6 a 4 P M1 E b° /T}F Y? a7 . wSP ISVINIV. .NUT F _ "?? ?.. STATE OF WASHINGTON 1AGF1 D11 INn_ 7 POLICE TRAFFIC COLLISION REPORT XxJ TRAFFICWAY PIXIE COmVwNT NUmtlEx P 0 PRIVATE WAY ?I DAY 0-1 ION LLOE ouJ 11" IUSE ]uo000R1 co-Y ODUNTY NO. nlrrvo. ? uvx . D? $ x« Nn »,nX" 0710 Jefferson /? xAE 1 ?" ?F ?,N CIIOR TOWN O??NAME SNO Or SWELL IF-WAY 1 AVlES ®5 ?w M.FChimacum ONTorkelson Rd FC't CIS VP(fl% NDUiF Ox SlNftl % ?- mIl[VOSI FO ZION a NTERYCTI--"`:STREET ORIEOAO NON INrfNSECTION R 1 cro llerbach V[fN R[fr 6 / RtF1 5 . O S7 U 1 OISIAN<f?WR , "'U )FEFr RNfANfSIMNf YO51 MM1f3 1 i[fr OF , t R ./ ACCIDENT MILEAGE C ODE RAMP DIAGPAM MIA ? COIIISK,N INVdVfD: IERI, N NO. IN1URfD ?]P IIAGF ? Iq Rtl[D P,,, _N_ v INIFP CLS C , SFCUNG SIY AD NOap GR ROtRFNtF RO S S SIxffIOx ROM ? ? lOlAlNO CA V[NICLLS © ?PRO-YDPMAGEONIY ? NESUIIFD ?V[H'CIf // JJ /??•?l?2A C ?? ,Y O JECISTRUCK(NMIEOF JfCT5TRUCNANDOWNfR'5N t) [SI. DaMAGE SYFCIN COD,NG TAE `III ? UNIT NO. I UNIT NO.2 VEHICLE C1 PEDESTRIAN ? PEDALCYCLIST % q DIWNAAE: -1 NST MLE LAMBERTON Patricia Ann ITV.. MI EE DNNtN's NAML 1 LOCKS Martin Glenn ' A xxfeT ADORess 2 6 Seaview Dr slNltr aouRFSS 621 Torkelson Rd - P "+ OIY IAIE [IVCOCF vnON[NO. D CITY STAY ITV COf V FHD. P Townsend Wa 98368 385-1051 R Chimacum Wa 732-4476 DNNERSUCNSE Ai E A 82N1 SUIt Wa F ewln 8^21 42 I- V E D IVFR uclNx NO. xLOCKEMG392PG «euPalloN Tam NUnE PHONE NO A v4JaalF F M DutaR,xm 10 07 61 ens wElem rElenr R 2 «euvATloN NAMEn PEwNE NO. Ens wflenl r<ICnI r 14 50 R laborer . Gen. Const Co br 135507 ?CHECK(?) Tfaamiol?FVal 1r ;V ?CHECK (/) ' M ovF1r^iI a, aN vf ni , ? CODES I? D a 5 e ;' - M W o D A ` 1 CODES ? 'F n ?„ . 1 6 •',:`? -' - »N n Z „s stated none S ? »mN,,.I«, ? ? S : I. ? 1 ? "0- r ^r ? mA,u,ANTE ? C_ ' ? ? :' ?I! ? %1 N• t Vn' YfAA .I MOOF (aRT.nOVal SYIF IYDx. cONV.I rvOVal N mAR 1 DG cnfvl AVJDIE IUaNI v FA n ItU vl 80 =F .2 E GMC ton 4X Ir b n EIaNU PULE NO srAlE rRMltRftalE lRO. FI v ^ ft Brn HU 12 Wa I silver LG7388 Wa ?p F!3 vlnlClt lDfMlfNiVION NO. I i v FnICIF IDf NIIFIUrI NN O 3 REGISRPEDOVMfR: N51 FIRST MIDDI[ v,N°V,f NO Kurt A. Lambeorton o . I]IExlD OwN[u. WST Flxsl mIDDIF nONEN RFG same as driver , AW ess Of-- L% ,yl Y1 /.DpR,350i pNYR N same as driver same E NAMI.-IUOFI IF-Co. Ga AGIN, ls-- ,ith Pt Towns nd Y a R N A IN wAN N Safco IIricio Balderas Pt. Townsend-A- %'i n N MMA<aO MEA , ,w„ MN <"AR ., <nARCr t,. i N; A"I'A Nfa ? - S ISI.ONA.SGf O ? A WlN f-1 PEnWNFO DRI^N ?N[ aNIU M I]I UaanLl ? ^oK - IUiOTTO? EZSbo-° IOMD nr Etu.Tso-T 3-S nw::° r. Ea.,.Y?M BRor. ?tsoo°- $ ' OIAGRAMOFCOLLISION: :U tuas"5RA'rl eiwv-, 1X DESCRIPTIONOFCOUISION: Tux SUPPNmMIA-11111INlC!1-i j y V ` O ?O d and k ?? T o 306 son r e or vehicle X61 was S/B On !/2 vehicle onto CZ215 Rd nin t „ _ . g was ur was N/B on CZ215 going onto Torkelson Rd - Tat"on pot , both vehicles met head on on curve and _ Gu„A? M both drivers reacted an thier brakes at the same time, leaving same distance of skid marks/ R/O noted that curve isa °TLU minimal visibilty and roadway is narrow. , NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED Y CODES 1 - Z 4 5 6 OCCUPANTS/ WITNESSES AGE wm "' H11. !,!a " k L o t me as Dr#, - e oc 19 Paula J. ,DORI5f a •!IM j,.. ? AMN ? : ' ? ^i: . ? ? x NAw N ,xRnu uTor ?IyLli vIPM,murvw.?Amn ?% '?7: ?? NAw rro » rwl arcua AAAV,xaru. A X jam. Y? A:N:Fw '° 7 ,cu,cY ,.L. JCSO min-2 1 DnrAlc.M1U 0 1 ?%A,?xt KE AR rio 0 25 f?DI?S MNwwlovl 6-8-SY wvovlUn. A _ Mu ' ??... ?.?,ti;r?? •??n rr.? ?a" Nt a rd?i rv... .. Y.. ? , ?u ?:.I?ED'?'I A? i", W PIAIREV tl0 •,e STATE OF WASHINGTON PALL 1 ,'j INTL I% POLICE TRAFFIC COLL-iON REPORT L?TRAFFICWAY 0 PRIVATE WAY POLIO 97., - T DA1E01 causloN $. DAI .? .? IRI, AIR ;N,N, ~. uI I UMI I"t;] a?R, wunlr ?e? o sa couNn NO /6 arrfa. RwA ?`.1.- ?N ?, DIN fiv Ox TOWN RIFT NIGNWAY 3 Aq .IISNIS gw ?GF C 'Vv?T v ON tR CIS 1Rf[ "..S f 110N INIFRS[C1ING VANr: SIHEI?EORPgPU NON TIRYCIION 6EIWEEf15'R ?,o SfRfffd 00 ?1 STRIE' pYEN% f MIlE p051 I /y' NlCEeD NLI R[IfNWCt CRO555IN[E/I?OR?NTjANt5l Mllf P0311?, p--ETA D11 O iE[IS iR N„' S•? E m OF T`E•r^^"'SOX-E?O.iL ?-r ACCIDENT MILEAGE CODE RAMP DI 0.AM WIA COll15KIN INVpvID: Nvx"r _ ? O'G"' E ?NIId RUN 101A1N0. LD ? NO.INIUR(U CP VENICLf3 NO[ ROrtR1Y OHMAGE ONLY ?R""' nV[O1CiE N ,NNUVtuIH INiJJI CIS 1 R NN SIR[FIOR 40ADOR IdiFRENCE CAO5551REEIOR?WPD '5./ a0 OBI(CI UC%INanf f00a CI51R OOWNIR'SNNA[I EST DAMAGE SGECIM COOING ME UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCIIST 3 F 10.51 NHS' f IVER'SNAME: EAST N0. I L slut Dovfu fill C3x3a$i< IE-DRISS c? `Yh1 vie-L, W? ElPCOOf ?y°4,ro R CITY STATE IP ooE PNONE / nfusu?LNSF (uo???? lF?l ll^ I 0. onol elvl? KO- TO I V rvfRsucFNSf NO. SEAT' E onlEaelRl.l R.r n OCCUPAII"' f MN " fvf5 EI NI ISGNI uv, ILj, - I ?_LE ER OCCUPn110N MNPME6 PNONE NO. EYES wDGN11f1°NI ? CHECK (.? Anaxru Al (?) MMINCIAL ? CHECK As AN fA CODES ?+ a w 5 I e • CODES 1. P ?; S Ir 6 ;; ]! 1? 1 V?' w ? ^M N ,I MPLyoDGoI vl .((„fit ..s ll ._ -I, -A) IT y pUR.CONV.) V'q L- L TRY E H -I YEAR M.uEI CN V1 1-(DAR-01A) I I LaDR. V x Y N o N PIwN N cE L 1Suna 1? sln1E AILFR LAN r.o n I (.?? I v N ca°v N LA A AR nnN no A1F ' vfIlKIEIIXNIDIUIION NO. 33s i v(NIOf D[NII CAI Nrv. EasnxfoowN,R sl?p? ?q ?? y MIDULt E 0""L E W' IS?Y`^ pwrv(NO O W RE ISI,W.0-w-WR: last FIRST M-1 .-I N., ] Aoo%fssaowNil- N E A sao«Nex u AMIdADDRL aNI.-CIf°EnAG,NT -0 A- - - 6% n R INUAN CRAGLIT I V Is r AMA I. t 1 ,???IL/?o•oao. u w-w fs1?DAMAR;I . -- CNADCI --- ^(rN ? Aw RIM.TNEO n Cluva ? nwwr AE'N ?NFMNNEO ` oT:rP.! a DAM-01 oAMACE,D AR A t oeurtDll ]] d I .??NOH11I DIAGRAMOFCOIIISION: lu evow sNen liEi[ces5narl OESCRIPTION OF COLLISION: 1.11LA1- SIRNI NICESSA ) p ?' 44' - L.. - ?UMrR Of.. v?? I? R? L} -c )ht0 ?CQE?- Olcl I ?7..J; ,Ona"it ? 6fiRVr? pbwn. po 4?? VU Us E I' NAME, ADDRESS & INJURIES OF PERSONS I OCCUPANTS/ WITNESSES NVOLVED I CODES I u% AG, aAlu 2 '"„ ] p 4 (vR. S 6 u¢I N -1 I-r- UnRTS1 LIVE Of sf[IweY ?AM • ?c-L" O "' OD R' ?":A N AMI A LMM 51 UNIp DfRGM?AMEE ?, " I??i , oa:r ? i aU O? X701 N R'V ?AM ? :" 0I . ?' ? : nAnw uR Ip ? ` ,cr .I .l. f?--+cl?.l ?y_0.craD to V ]•A NR1 w?1 vE?w?° ? 1 lI L? ]bJIWS DuEa nN.wr SUS AwROVIDe• DAu 5 STATE OF WASHINGTON O paOE oI POLICE TRAFFIC COLLISION REPORT Lay TRAFFICWAY OA1f Y oicaus N Oa IU N IrMf ? PRIVATE WAY p . ?N °? 1vs .E n ?f ? N orr ox low IUSF ZxW HOUNI 2 N COUNIV NAMfano. of slRffro?nwgr zf - ? Mnts 5 ?W pq i IaA ?oaE ON Gb dad en X-1 --- 10 ENO. NIURED -AI NO Q ?SViItAOI ?111It RUN r.,rMUOwuirr TCq INifR Cl5 CROSSSIRLEIOR POADR OR REfERENCf '] rR VN CIts ? N Damgcf oMr UbnC151xuCx lNAmf Oi OBlt<151RUCA NIDOWNEVSNaMf) ?viwfrtD 50HCaf f51 DAMAGE .Sf?lf.3l SPECELLWDRIO tAF UNIT NO. I DRrvtR'S NNnf: fl U NISNO.2 MIDIXf 1 ' NNAf: TIE IA DESTRN.'? PEDALCYCLIST ? VEI11ClE. ? IIR NSt ]. xE11ADDRfSS - Rm ABWRI. - - ig1F 2rp CODE ONE nO PH D Ir ' E . R 51,1E ZIP pE10NE LSE 1v151 1INSE NO. 51AIE 3 .2 O Rin I Iv 1CE ri N t°tirq OCCUPAfrON I . 1 N5f NO. V WE DAIf Of01RIH D,. r. rRMNAMf apIrONE NO. Z FYfS WEIONI I[r0H1 E OCCUpA110N M NAMt6 PMONF NO. EYES W[IGHI HIOHI 1 o R ? CHECK ( vrHr1 rAS nN Unpio NoP ANUIMCAE ? CHECK (?) O A r:15 11f CODES?r 7 w InE asAN fMN 'vEH Mw1 5 E 1 n: T y o.c.cu COD * r N ! ES ? ] ri r y:inAn :si I w M • R VfrYtq MAOIDODOr ? O F x ? 'r Y ? x Y ?? I ? NYCI ? CA Y - . V MODFI jDN i NOVAI 7 = ' 51Y1F IZDa CONVI V faR H MM I E HEV.) M ODFl10 e 0p 1 .Gn'fo.v 4 O E z n I NSf hA (n0 SA1f IRAI IR H I H If nO. AIE vtH.CIXOR q ] '. F '.jE _ .: 4 r/ 7 3 5' 6/ -MD a AND1Nre'? r0?vx ?„x Axi.NOVAI KutZ R V.1 ra>M ? All UfN If f -ME NEM]. N M3. /71a.t.A.EP Swp,WEpA To IIu A /<rrrY AavO $c io ,-YO A d/•reH. r"c FAP.,r o r T"r DA pt AAeA°ctz vIo- Y K a -r ote ,6m Mvrn of 'rove, O,rew (=,"Y pp`.yljrt r?Rq (°a.AfS 0 Of" d, e 1=140AY kMd OAiNA CF, EIL M# nre{ fu x ?r =•.fiei.. } v l" I BD _ STATE OF WACHINGTON PAGE i Di / No I -.1 POLICE TRAFFIC COL-10. REPORT ® TRAFFICWAV ?V ,IgAININLLMB`- PRIVATE E WAY I `5" rHww DAN oEC«uYN Imt coumr Y DsfxaWHOuRE lvo. ?URB AN Ru ? RouleoN SIRE sfn N ?f O ?s ?W ?4T6MA7 ON OAKIIa RoA? .SG99o MIIf POST 1H: Slv[Fr OP ROAD ?/ _ M QUV{RR STREET f.CRD-REf OST ACCIDENT MILEAGE Mtq CODE INIFRSE tl SiR{Et OR ROAD OA R[fFRFNCE INIUNRHDIn RED RUN ROAO Gl=SiR[f10R NO INJU ?D PROPFRtT DAMAGE ONL Ov[IFO ?S[«CN SVj "i?7O Y?r -10 SIRUCY INAME"OBJECISrNIK[ONDOWNFP -10 5 •R UNIT N0.4 UNIT NO. I ' ? VEHICLE ? PEDESTRIAN ? PEDALCYCIIST ---- DI ST 3 DvIVlR'S NNAf. VSI Nv51 MI L ONIV[` SNAmf: LA f ACgIt55 SiRf{r ADDRESS 4 SIRt[ O T1o '? i D 7? P!L /3 ?? Sv / SIAIF I CODf PHONE /+ SIAtf IIPCOCE PHOw NO nr 27- ? v+4 R r .?WA-cr WA p?'? 9DDA W ufa BI41H Z ' ..? r r ' N' srAlE E l A v SE FN NO. s E D DA, ? DervEe s IICENSFN s?%56918 C4 r9 m0 Ar / 72? z N ^? // 13 / fY[S IGHt wIGHI f O E CKCUVAIION iIRM NMIfBPHONf NO. ETFS WEIGHT ?GHI B N . OCCUPATION IAPrION l,Rm R a IKi?Rr?JaNGA 1A` r 1 A : alo CHECK Ml+ovEE ai ANOr ? (? v[n ttr AS A /a- 0 ? CHECK (. ANOIHw rft ) NHlnigs N rM m ° NR• ' y i CODES ? + O n Y s. 5 e, 6 is xl I 4 BE j, r CODfS ?+ 5 I 6 j A W Z Kl 1 « e" .` a.IH o.,ra; ?.n ;;rD ?N ? ° ° YY ?u » DODGt CHt V I B[ , ?: ? ?zaPIH HV ,A . NH.,[ a MA I E 73 Z AlE Ml e A NO. Ill uI[NOlemEl R HAT, NO LME F??IAT H I I NN.CIXOR Ht 7 38 r LT Gk Sco _?,? - - C v Uf ID{Nllfl w 1 -.1 IOEMIfIUtKKRNO. 3SZPH D? 3`i L ! 1 t S53 3Sa 2D. •.i lA3i 51 IDDIf NE NO. ISRRtD Fe 4[«SR9tOOwwR- WI 951 MIDDY r Aftovc $ar IF AS PNt NO. W . - ASAM,6 AS ADO?f ? N ?n I ADORessaosYYYR N E AAM. u CO Oe AGt NI R NAME'A-W uM1U-I tv C-- S 4 /;E DwMAUOARU I= ?AM I A I AUOpau a+AHI"c. cng9ct _ IwEIgNN CHAP« DRINN tSrD .1 AMAGt"" ? ^W^!yN ?R-NID AWAr ?REMAINED II^ A 5 131. aOAAIAGF f / a a N? loionb+ ?AloWW?YD BYg S/DOC) • .? Y• :w:v° _ Br fp_ lJ AMOFCOLLISION: [u Nu IwKATt N.1 DESCRIPTIONOF COLLISION: IV.E SUPH{quNru swll lr Ntct35ARr1 SIYINfr FCISSA BYARUOW er DIAGR O[JT or kAkKR23 ' 9 Isf `,p ' ? VE: A/E Nn oN4 &A -/ T 0 + 5%oJ7c f'gRkln6 / oT oNTo rN? r'lakrH Y . . A'q\ El TJo..NO /.ONIC O`^ OArNbA MOAZ" 1 r\ - Il g BOVNO ANG V.[//A ND 2 -4S NOAl srrR,•cJC H./ ON 4,E:Fr P,AR, is~4p, 3R ? vis/oN wAS PwRT.4ar ?$Lr.?.riD l=0. " JQc7`N vtr?Sc%?s l Doc ",o TN c F%/?LScNE:c ' _ DAA psPs, co/ o DLE"v' 1") TA a?.? 4l?IYfILS s roRi AT A k ' NA Ir{ ADDRESS 8 INJURIES OF PERSONS NAME INVOLVED CODES 1 - Z " 3 4 -5 6 , OCCUPANTS/WITNESSES II°ci wwilloNUl ru++ asi sE+ Aa ulm '",,;; I. Nlsw cl [a AMI No1VU1 « F ? AMB ? ii1;EI ? 'aI a ? Hn ?'iu P AO(Wl tt N.,AR.d W, MWIa rNOM °AMB. ?r?"xI ?rrvr + ? n ? i? p ME I * ti-1.1V N.Ew Br. ?AMB ???rl??vIIE ?Hii ?iiA'Nv AIKAI'.s villa KIbI AAICwO I{AKI AR MO DAIIp vI MNI AM4ONDBV DAIi r.YllulAl«f.arruS...A.u..NR B AcFr,cr H nn ? O / 7-16_gl IE ?2 ? /l? ?H9 3 ? S?=o d,IN? X CIr..:c? S {C t WIMP S ?3 `?{ Itrr.I aY s'i[* ,? IifNN _ M AfPLj¢q J?1 F fi[ , V ?' ? ?Qy? 1 _ i I ? ? Y!PA6 ? E f + t _+ 31 , ? 4 I ifJ + R A ll ,7 _ _ u{ ? " 2j ? 5 . ?.r S. ? E ?f ? Y IF 1 1 ' ?• IS, n6 ' CC ' `` J F 1 I )? S i t ? I?,? 1 r r .I I A ) ?i JT ,? 31? ;,1 R 1 1 I. I I f bb ,, f f Y ? N? . 11'. I Z? . ? ? ? .? ?ks ,...: ? l6.N.,, y[.xx?il??r. ysPwr _;i ''r? s+S:?,.. ? . ?'i ?:5- - 1: _...: r - , - - , _ ,,,,,d_?_ -.-•. -.W aw-.ww.WVnf'._..1a e.n?_ NICLECOWSIONRFPORT ..-' •; s LI9X)N DAY OFCOLUSION TIME OF COWSgs AM v AP nUP i 5.1 R eE r W L?lLrylq, DRY NQ N}e,??" [/O / fp+ 5 - PM CI Y TO E -1D M L I { , 1 1 E9 O E CITY. OWN ADM P11EFlX PdPE Wdr11![T[OCF llOT)El! '1Srv OF STREET,.. INTERBECTW O WITH. STREET OR ROAD ?. w? 7 ; ; MRE]oe _ a ry,?il F 2Aq P- I - ? OF OWSION ..,h RAMP: OIAORNA DATA i BETWEEN STR I r E S ?- L r R ? fur n ni E R„NO OCPOSSNO MLf"Udr On MrrrvrPN:a,NnAAnx ,. NON X. NTER T•q [MAaNto D.w.: ??U[K[C[ OGOde1H210R M . b C ?' nrfnsfcrgN: ©® OF WTEfl ? !g J -rv!p f .. T 4 w EM O '//S YwnCLE ?V[. ?DrnfP Wwr[I rcrn 2 ' ? '1 xs r'Y A _ OES P ,- tt[°o[saAN ?- p.wC pnlnrlN y 777 i OBJECT STRUCK KAMEOr Owc-TMICNi OWNEAOFOBJ TS PAND ? © OF W N ? IN ROAD I iY 10 FI,P FEET ,D S A , ^ J •1 P^- • • OPE rnAN • 31 . T DRIVEASLASTNAME """"ME MIODLE W?E,Rd ORIVEFRBIAST N MA MIDDLE BT NAME "? IN ?{ STREET E39 NOUTENO AND BOX . E vA PFPSOR w P STPEETADpiE OMTE NO. AND BOX NO. - y u E E ., `"A E / M ,fa . ]I?i? X/ j?I P?E-.C11 BTATE 1 ZP /?/y??? /• 11 Y'Y+%) l AyK, W Pco?/? ' lroR TIOrM GTY STATE Ilv UDE OriNER9000lPATgN F "? b f I r- A dM i::- 1 JW _I - 11W I AA! -?'Y Lir .r3 /? ... rn n Lw.J --Jrcul I LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- NAME 77 cr7l? NAME AO ss V V l ?x W!w[0 AOdfES4 ...ENTDFNAPKd a 6 f '1 E NRrar w,fd O PASUHClPvENRCLE KILLED rY.KfR Norv a ?a+"ruNl pry, '?'.:, WPq c d5fN0ER 0I'[nsrRNf .. ? 150 B?.I "or?Ouc pP! fdIRMH ._,f SrgWNORTH BY AARpW WCWCLE ? ?????j?r??(F NOrD,?1 oN O L(? MM?Ff1fnO w`A'!` :..' rRlt! TrK W t ?? MCFd w R [ACH?vllw[U[ FHO 9rOw H NO ABEF SEX LE I,3,nr oN P?s,n ?•L! ? 5?FD B?INB I n7aE KILLED rttv[n I iuiRaR E COM AV KINAT HAPPENED IREFER TO WHICLES BY NUMBER) ' -9 2 44 y JsAu sea.,,. ??v v?.?uG? ? s ?za L V[nICIE ON try t?I W NAMEo.NO Dwniar uDMLr ANara dr uOAE L. Anr . !d r[r<f[acwdP ? arn?a ?o%ina `"wp• w IrDw ? ?o ? ? ? ? ? ? ? ??r[!0311 [ ? ? ? ? ? ? ? ? ? ? ?Sn , }-A rj I ' r r ^? - Wnd1R,w ? ? ? ? AE PI'Of.31R,NWbB3Pq ?'YDE- c T?WALKWAY 30 B PD•Ma lKooLmn 10 cr:;;wux FROM DIRECTION To DIRECTION 60 °r 00 OTHER _ . ,. l ? g t ROADSLRFACI Il N [.IWI -THER UONTCONDITIMB TWFCCONTROL KY -11 v, KL! TY'PEOF -IROAD en f [ OfOVER/VEHICLE ACIgr1S v K[ CHTCA UR bI r r ` ,E? Ylin ••1 I 4 'I ?' ` NO~ ! 1 ?OqY © "`"^" 1 OWKN I A N It*naR YYY"'VVV A 1 '? I ?LfjRLLS ?II?ONE WAY? H aM TI ar l ? fANO DTRAIdIT INFAD 1 ' - I [h - 1 1 ? 1 ?WCT K1 J vrnwD ? WN ? D ] DUSK ? ? t ? 31DP • H ] [ D ? ? YI T lY,l'? WAY RE VfRSB! ? t ? OKRfANINO AND PAO:IIq rt T ! i ? ] ?sNow A ? FOO DARN31Rff1 10 [ YON ? w ? fL-A] RED ? ] v ROAD WTFRcNAN5t ? ? ] ? MANWORIOHTTURN A L 4 1 k f. ( }V {T N - I } ? f ? CE S Q oy' '. oN d ? l ai T a` 3 ? ? IF- AMBER d ? ? d ?IlLooo MTN NO LEFT TURN 9 1 r1 Q MA i 1 y 1 i - NM1 t r ' p? 'l'Sj'? ? 3 ? By- dP[EVY YI rt l T` W LJ E KING DTURN . , h ' Y . 5 A ?p`R li RIPAO!lFORNOTSEIINDDANO" • ?6TPEl IOHTS (j • ? mscAk E.F ? d ?L T U1N LAN[6 ? d ? SLOYANO li Fl• ?' ] .. • 1 ..;"') ONYJN Or[tA Kr6H ITC) T?6P[GIY ? ! ? OFFICER.FLAOMW ? ! ? ? FO Y•}, ?I}' ' . ? 'I'- 1 I'. K • d OTNR. R'cc- ? ? ? T ?6CPMA1[0 STOPP[D AI BONAL El d ?0lISTOP DON ! ItTA I". !, I I ?lq 1 . # 1 r ?. ' IRA/IL ? t ?ONOf.O C3 [ ?OwROAOWAY R p( y „I • l MfdNOFO ? IO ? STTRIJNIFTICMLANE AI ) I IOMMR t1C' SEX A0l Ayer T BTMiN[I rT OM i I+{ y R .1 ? 1 L 1i1 + ?f 1 ¦UIr r;? 1 1 r? Yf 'Al .. - il 1 1 1 1 STATE OF WASHINGTON PAGE OF No. I POLICE TRAFFIC COLLISION REPORT ® TRAFFICWAY PIXK'FCLVAHAINI NUMBER ' PRIVATE WAY roN DAIFOi, IXL DAY u¢x Iwi w H 11mE R.W HOU I 2 USf240 RI COUNTY T?-FF2St.'r/ CWNIr NO. //_ [f' CIIr NO. ROUTE OXSIFf OfHWA AN uu¢u / ?. (JE ?1N CIIYOR TOWN -ES as Qw woi / /A OGFC Ea rvO.WSIP[FTOR WGNWAY ON © Ct5 "l°??? MILE POST a¢ INI[RS[CTING wIn: SIR ROAD NOi11rv1fR5[CrION /S ^?S- pp,?, / B[rvYEfN J uN '?EO a KL1 C/PI tIIXO+ PRfP1K ?" O/ I 6 DISTANCE DIR[CIIONi tNCF. CNUSLSIRfEI RNfMF51Mnt PO51 MR 5 N 5 F O Nu 23 w of 1. P. ACCIOENI MIIEAGC coDE RAMP DIAGRAM DATA 5[CTI sl¢EEIORRWD OR RfiERENGf IN .XD aT CIXLISK)N INVCRVfD $frkRIIY: ,- aRtIN NO. KIII[D?NO.INIUP[D? ? YIIUSGF ? 11 ruuwlRlH IN[Ef, C.sT.FE[ORROAD CR IS tOTM NO Cf VFNICl15 PXORRtY DAMAGE ONLY ? RF15UIi[0 ?V[iOlittNF f/ So OBh<I SIRUCKINAMf OF OBI[Ci SiR11CK MXD OWN ER's-11 Esr.OAMAOE SPECUa CODING Ihf 4 $ UNIT NO.1 UNT NO.2 I ? VEHIQE ? PEDESTRIAN ? PEDALCYCLIST - 5 DRIVfRS NAME IASI 1 1 f MI I RIVIR s NAME: IASt mfr ,- (7J ?/ NIS V r-r tE1 wDOXt55 IR 5 SIRtF1 ADDxE55 Z /I /?6 KA! HuL.GC/L ?4 1s Z -c- PHONt slMf . D 11Y s1AIE a1P E PHONE . = N4O L C W R • C KSEKFrvsENO. s1AlF A • B " DRIVER'S 11 NSE NO. tAli SEK DAIF OE BIRTH ND ., r s l m st'r R, c T m ... NP o v - Irr OCCI.VAIION ¢,A NAMEa PIgNF NO. EYES MIGHT iEIGHI E -An RM NAMFa PHONE NO. FYES NRIw11 NkIGNt e 2 -? - G S R ?aF• iz,,24, ? CHECK (?) MHICiE AS AN iMx ANDrweR¢M Mw ? CHECK (.? vFH1Clf ALAN U.:WOYf[O NO 1111 A ' CO DES ? 9 (? 5 t I e ."„°„ in 5 CODES ?* a a iv Ass ` z III--4T Na 71 01 NiFS Y MMM I ? : PS:R. ..°<? ° ? ? lu v Fw NI eM adr" ?" A"sl ? uv ? ? O ° v ll wu , I V[H. YFAR MAKt IDODG[GHfV.) tI IDAxI-AI SIYil Ia DR..CONV.I la VI HfV.I MI%Ifl(DMt NUVAI Y H. FAR 1 O v/N? r o E w i+O, H. J u?INS IPE AIE (A HAIEi slAf H 1 vFN.cwoR A All AtND. AE >9 Clcaw C -T (..1A N J?'O VfHKIF IRMINCAI Nis " L L 1DENDH 1 VEH1- 3 3 R i I: ?s vss Si 11451 MIDIXE NF NO. O FR V ¢EG15DN[DOw1hR: 1,31 PIRSi M1DDtF PHONF NO. U . RE 31f fD WN : A IF 5OOwNFR X w P Vh1ER A 4?I Il z (5 AOD N E oRAwrvr 11 ulANA 1 DR IX NAMea A1X>XESSa INSURANC[co. ?S R- O..d,v R ?AMAG[o,wu u OAASALI Axu : s ` ? s aw N• lsi. DAMAW CHAR 1veN vIMw1NFO ' crlAVw "IIIIIIIIIIIIIIIIIII -VIN 01-N(f) ? "'fd [s OIPAMAGI Rlo 4:O D 5 ' i 1 Idior -R 'w " ? In A- wer eY INOI DIAGRAM OF COLLISION: f-, l c INOVrH er ?[w s NECISSAYYI DESCRIPTIONOFCOLUSION: lus[slrn[MENIU SN[N 11 NlctssAxrt ON OA/< •S.Ik C S 6 /6 S x . 0/A . CA,e / N1A /eD [ ?.?w O.t/d r l D /D /Y?r Sse _? R?O+^Ti" T?•rEe tiNr/L ,y.E was .s'asNr v oN /T, a/e 'rLFI:4 ro in/sr T-aL. . _ ? rwc AnD [.wrrr /N/O 7NC Di1 ?? R -- - y„?a; - - - oti T{fg O/foS/T' S{Oe U?" 7"//C XCD. - N [a5 1° ADDRESS B INJURIES OF PERSONS NAME INVOLVED +CODES 1 - 2 3 56 4 , OCCUPANTSWITNESSES ruiww iii Aw u q 'is'. O ? v,.r0 G A Iwl w AMe ? W, ? "' . ? Ywi ? Cu O APOnss 2 u ' ,tEri f IM Y NAME iiD '• A - ADOna Aluv a v MoMO,.1xoM ?AMe p fu,a ? o ? N CI I: n HAMI Nlo Dx ?„ 1NA,luvu°1?01 sclNl er. ?AMe. ?,%" ?r"a?l. .Dalu DAtI A.AtYq Qii KIP-S NAW a A K • ? M:IKY KI PISIAICN iZ 7. C/s D OAlip •IH)YI AHwOVlD•V a avt X ti Sd Ob O D.m las sRn ws / . G SO l+Y"E + 1 , f ?r7tl^tillb1?61? _ '?.;r IL F d M MRi i. 1' I - 1, :' pe 1?7p? PU STATE OF WASHINGTON D{? No W9Y1VjNfp1tlj R POLICE TRAFFIC COLLISION REPORT Ej TRAFFICWAY s u AE ?` E?EYr r atA?. i a... 75 dr:I- / { POUCF COM{UINI Nl1A5&4 PRIVATE WAY j DAIt UI CORI rv DAr Ou O 1MF CDUNIY COUNTY NO. CITY NO I j? •u wx w w5 wm Inln ?E ul fUSfzun NDU41 iuq A R o NTa?xERSOn1 uRA E N f CIYORIOWN ? ? ? o IN E bNO. 5TRHT0RNG IC/C45 RWIf ON lE 11 MWAY ? 04, -1 N O N?if4scl NCf nt p o{'? Q BAY 1RFF R NON INIERYCIION GJOrJ6 RE WtENUsta 2 T2ialF1A DI I 1TV E -. NIM1tP?. 5 a 6 AN/'CF6D RICI ROF fCP05SIYEfIOR NFARfSIMllF Po51 S^G S ?N ...S F ' ACCIDENT RAAy D MM ° O{ M w ` O /,U Il T J MILEAGE CODC I COIISION NVgVED. 5fVE4IfY: iY •'E? ?yIIAGF ? tOIAI NO ONIL[D??NO INIURtD-L- _ ® Ha RuN ISn N %RD Irvl Yct 51Rff OR ROAD OR IQIERENCE I? nolw IMF$ N 111" ,, C MAD LI "'C 'IS 6Q P40RRIYpAMAG[ONIY ?HSUlUO ? Obi1CI514uCKTNU.Ff Oi OblfCl SlquCA.WDOWNF43 WVnEl r vfpflF ?/ .S7lIQ I;ZT Plov, C FSI DPMAGE Ell I`AECODWG-?- a C- I I^ y UNIT NO. 1 Viv$NAMf: 1.151 ilq UNIT NO. Y ? VEHICLE : '' ? PEDESTRIAN • ? PEDALCYCLIST ?- Y' f (?AQIE {N'S NAME: USI Y? IR MIDDLE -iYREIE $owv I4 5 fflAppRISS TRf[I App4t55 - 2 5?0 zRLOti0A?6 R?• Pi 2 54o -'R.%jr)AL6 RD• ' S1ATt TIPCODF ENO. WDs fX°k g5• Z NSUCEN fNO S1ATE x - ' D ItY IND. R A?wGK w?}, E P N ( IY NSE NO QS33?1 -5• 0 12 ;.I 55 - 2D6 A 6 !q 5 IAtF -E N F Df bIYIN 537 -S£3-56Z( W M 06 OZ 59 R OCCUPATION IIRM NAMF6RN)NE NO. fY[S NSIGHI HEIGHT E OCCUPAI:ON {IRM NAM[ 6 PHONE NO. Ftt5 WE GHI NlIGNI 1_ 2 F,W WE BRL1 S R IA C RN S 6 ?CHECK(?) vFHKif ASweI IMAOVfFC%ANOtH1RIU ?CHECK I/) A Od AI CODES j * ( ; ^IL 5 IT 1CH DH L A V[wClf Aiarv FMPIOYFF E IfAN FR I C r , illy MH ODES EI N Enn.?H " Ap • -Iw FS•.... ... -- - 1 I.ft>F-)6 ? ?," ; ? :v oIN ?--- ? IM" ? zb:N. ? :KH ? r:rvv . r UV AI Sl lf IRDq..-E Q- Ml[4 RAN NO. Ale E H Ax v CgON 1 HEV) A'OD[l CIpA41 rvovAl MERG OU,GA A 1 ..c vI ':=S` 2 DR J NO All I1 ^'` U 3' u .21-4 W A ? {HK IMNIDI FbH93.14637• 5D ?w DUE PHOM NO O N R fD O A ? WNfP: 1A51 {IR 51 MIDDIF NEN '? NONf NO 85-532 b1 2 E®^. 88376 E IDO LA) 1Y H LO q ? R DaAACtpinu 41M"N!D nu4c[ 1f.) IVIN ? AWAY Fp NIMAINfp 151 UAMAG? ? ? Is l,G lOlloS S ' r f0 UERM BQA.UTCWEb 13Y UW(D- AS UEH FMcGav DcwN a W IL' L 0 A --lgap o-URUe M or-IRO PUT g(•zAY-5-D2,u6i.p;urm5&A<s-pert toror-t T'1CIdED UP -P65b •521dNG uEk ® 6&)T kg 0-MIAl WNlcut'InLtca aom uat TO sm2rS6t -z/Az auwa cy. OA)M TA'6;54a 2 UIPW76 M'5540&APP15E < Mr OV70 7W-1 SMx? ejUV.l._UPCvj ;7L,- Dv suoUCt?z tYa?r.?u? v4?mAtc,??.ect zsr6 WAY. uBI®o?ouot-F! sLrsra/UED7awl/wA! NAME. ADDRESS INJURIES Of PERSONS INVOLVED CODES ES 1 - Z 9 4 5 6 OCCUPANTS/WITNESSES ,w emlROU :; n,w•i' u AGI I "RN--- -1_ _ T RFC 385- FE I51 T2 T2 r3-1 i 1 i rlrt= 1 V YAYS• RY?J ??,, <I,? o•Mb ? , ?,.,I. ? tlq"f ° "`' CvIKI?SIMSN Nl tr H.T ? 4AfK1 AUNICY ,«??• `-I - /7 q (? 5 f•t T 1 •• x p i ?Q?14 R+eIU IIW n"RII •MrvYOYIUIY 4Alf fr?1< gf T 7e S0 N 5 R5 E [ Iro5 9 -i7-84 A ? r, L -r('E lj. ?' i aT o " R t~* » n^;gxT - LI E , T f?i? c, I I+,? ? T -? t I ?6h C?}?n ?E ?f 4, I _ 1 T 1? Y 1 iy PAY + s 1y 4 CSIv { ? i v? i r % t ?P STATE OF WASHINGTON POLICE TRAFFIC COLLISION REPORT LJ TRAFFICWAY -a NvNwuR ? PRIVATE WAY Dwnor: a py /V• .. cal N IME ?R:,? AID [?., ,R. uI o4aDlIR, I coun:r counrv ra. arcs. SIR[t u If O? D ?fnwA u SFCION ?N 131 ?I CITOR TOWN NA.Mf6NOOSIq[[,OR [YGryWAY i 3 MIFS ?s ?W ?OI H9 L ON big T!\? Cf 03 . N U S9loo0 IWfRSfCIMG VAIN: SMEI M NON INIERSFC.II?$+N? V/E O O FI, K E1 ?N/ B(IW[ rv fy-f , LT EI 6 V ISINFEI YREN% F MIlFf43t l O Li/Nl of I ECROSSSIRtEIOR MARFSIMNE YOS, 5??????L M 3 E y1."'1{ rEE1Rfs ? ACCIOENI MILEAGE CODE RAND OIAONMIOAIA GSIREEIOR ROAp OR IR[tR[[ICE IE VIXVfO: VERIiv: couj-NIN NO NO.IN1UREO ?SPUTAGf ?HIi6 RUN NIII[D ruNpnDlx %'RD INl[a CLS .IIl CROSS SiR[(IOR ROAD _? . IOIAI NO., E111 ?YROKRIr-GEONIY ? TIRE ?v[niC,( 1 Vf "0. -IECISIRIK%INAMEOP OD ER S,RUCR ANDOWNFRS NAM[I Si DN AGf SPECW CODINGUE / ;)'.. UNIT NO. I MI D UNIT NO.2 DRW SNAMf: ? VEHICLE _ ? PEDESTRIAN ? PEDALCYCUST I MIDIX E IIN DRI?1 IVAM[: IAS`y-y??-?-?. FIRS, S (.?"F-'-R»TC? 1 ? `L'S2 I /w,, ? % ??OYlYe%.? slaEEl fss ® IMF Y,, ? LUIN s l Z71 ,y 1 SIAIE DE R3_fN03 / ^_ t 'I `^ R It ?T SIAIE LI°CWL YrWNE Ww fR 'S l IC C?vppS'a42-P'7 1 f ?? DAf a ?DIRNr? v I II tNSt NO. Rw I:> 5 K S,wi[ ? tf OEbIN M f4 Cp S PAIIp, fIaMNAMF6PNONf NO. ,E.(ES I? ?? Sh1 t; R CVY NNAf 6YNONf NO. EYj3 IGHI rEIGM i? I/V? ??y CHECK (I ? - r •s: M onEa ANOIx[v'A u -bIF CHECK (,l) AN M° onl o dirt l^ ,[A4 A " ' ? MxI "" ?ox.nl CODES 1. 3 =_f 5 1x a ? CODES 1 T D Gl? c?Wx uII. ?c7 ! m ?R IYS 1 I gs MDy" 'D ? a ? D %[ ? cxo:rl" u ? rvDl C RON. Rt NOVA 1 " ? I ? 5 < AA 1 ? ° ? 2 NI. ? „K ?4, 4 '.. I N?vtARM Efv.l D[IIDnR11rvOVAI 1e11 DN.. Y u[ Rg r . MODfI IDA I I , ,y? [{.R M?E ElD0?? <{fV.l [}? ??{•?.?p 1µ`•-P011 TVarY 11TG E ? I J 's NO slAlf SIAIE RAIIfR gA,E CH I 7 STATE(? nn HA, N At 1 N ?/? kAA . NNICI[IIXMIYIGIX]N NO. T3?? PhPSo(n 3g L NKIf IDFNIIfI I?TBiZI10 CSppco$q eNo Reesrt DovnxR: r FIRS, MIDOIE PNoNE NO O mowN r INSI MIDIX[ ° 1 10 W . ADDRt aY N A x s IR JYY'S?.! y? WTR? i E Daa n Iss !+wgAExf c?o N? R N- IL ADDRISS OF IN D AN , . '.nu - o cE 31 DAAtAaE ARU' ? EIOY E IUN[,:ND.G,u lSI.rOAMAOI CIIARU m MAYA iwnY C]. CNARGf R IV [N ?N[MAINfO '• ? D IW^' AMAGI ? Io f Si [G?Or1ou _m4_ ? ?AOwID? ? a + I_]AWArDEY ?LIY ' (IIAGRAMOFCO.ISION: lU.... wIV.IR[rvoRIN ?#3?1p of41c43gfor? 1 Q DESCPIPTION OF COI ISION: lus[SUPPI[MINIAL SNfIIA MC[SSAgr1 #::t IV•?DUht?- pAKBAYRA ln?v? , Jv rt) , r'ki ? ?Kyn ropp 3r3h IL4 n LA-f . ... ^, - •+'" 'ATM a2 `? 1i0V1SYi asn Jl V Sb LL? ipg lbbl hP O _ 5K,4A cCODhtTha 14z tb..t6L 111 83? NAME, ADDRESS 8 INJURIES OF PERSONS ? INVOLVED ' CO S 1 - 7 3 A 5 d OCCUPANTS/WITNESSES 'IC+u,'aNIFR»MrAi i? SIR AGE 1•IUS"?'?? , NISI. IA['t •: nA.w: ?a rn ..- uaRFU I•roN,m " INf nr ?AMe ?". ' ?:' . ? i ?4. p ___ . •[Rw,ss Irl?.Drw,a °' • M?RVfm?uM ?AMb ? ;"1 ?l- . ? n ? :` r r ED NAw ;p [Y tDq,W ;„,br ?AMR n-r"?na?A. ?? ?? WNS ? ? DAN S..Er ?TSy, ??Y Ar ovloer ,nr IIC Nq K.N.cr u[ul .,^P D IaN k r t},, f .tl? y1F ?,Ea?Sr +?Y?Y?, t'a???,}:?va ?i anaxr "?= l? Y:ir:`?>_".3' 9 •. ?i?',? _.'? .,5 h IE E?"?%'asetxI ?[ j >M 5'P tA; 1 jI» ! { ,M,:- h I ') ? 1, I ! rin 11 I ,.` I E (lY s I , u ^1 E A STATE OF WAS,WNGTON 1 1 Ini ,. POLICE TRAFFIC COLLISPi5N REPORT [kj'TRAFFICWAY youa cr mHUMpt4 PRIVATE WAY UA•1 ;II <0.,.;. N DArr .y. [Illlry" COVNtYNO "I'- d??IA IF_ [IN pt ?x, <•IrCV'OAU NAmFn ,. Rvrn, AV ? - iCt Cls AU 5 NM ROUIF DR SiRltlC IX SEC.I JN .`?. < n/5 (]]5_Qw ®:>, \-.,:. i` ;•;.. I_f. __IDN_ (1P ? ` . ? 1, _ r,v,..lw,t. .14f Nw wO ? r,.rv uSI. •u- ?[ t - [i,a FO w. tE pOSt :. r n. Q(??r!'lrt!'< slow bt L„ri,? •Itr ur;,Ar,rl N {UM•,C[.w!•:•, •utfrOU IrA rn.,l I ACCIDEIIf 1 1. a[ FD V .-RAMDAIA ' EAGE GC i ..rrlr CT 0 ? C (,/,.?\! ai1LLA, MiCom OD[ CMUSx)rNNVMVID ?,O ???itU__ wlD -1 ?]rwI` ,! ?,;i H fNU NO .r.IU r ? .•ni..,,•'.. N s1U HIfN 1 I ? uNl w5l<Nrvl: sl4tFIOR FOPU04.11RfNCE C...... 4V IIR0AD f vlrnCfiS © ?pu tv DAn.AG1 Ur.,r ?u!u'11D ?Vf " ` Ss i;:= 0 1 9 .IRUCr.IHAMf CK Oa![Cr sruu! r. A:,UOirn'[wsr,Aml l51 P-1 5 -FAE CODING-1 UNIT NO.I Du,vl WI sNM. UNIT N . 2 EHICLE ? PEDESTRIAN ED PEDALCYCLIST ` t f C:\?`?IUi C ;ter 5141!1 nDD4t SS , IrlvsN'Z? u51 1 Am[ rRlFI AUDU .5 L 7 ;...(i. ?47 f- <It. {r1 1 CuJIJ S ;0 F u:.? /. .. K V?v? ^^ - D R AIE I. ` PFFUNI Nn 17 Z Iw ws u<lNS1 Na s1- 1 UA11 ul n.wu! I ,wl4 sucfrvu NO , 51nIF " DA D.R OC W?AI v Z? Z? oll'. G e rON uvNOrRN. rvts ICIIT NIK,M E -C-11011 FIR' pn lLNQ rrrs wF.cHr Nt. t I I R JN P u..v O CHECK(,') nr i E o'n., I? A? El CHECK (?) v jf AS AN IMRiiivlf ninrY lrfv ` V '1 •"' ' S CODES ? . +,.,.. . . I e .'•:??, " CODES ? ' :"' V :: ' ?1 5 I s 1 AU wrr vl A[IDUDGf'CN[v. ^r!ntIDN,UAR. rs'JVA' rtf /Uw CONV A4YY! n ' V. uv? . - I ??.%•-' t ? • tlF n[vI ou rvn CJll7? MOgEIUAwt NOVA• u vlt G<4<l2• `t l?? C ??" Z v eN., u >An A.uv KAIF NU An H wH?cn q` ,A C ?? C:R2v G vIM,Ut.4NIU,CAIgNIq 1° 9 C? 9 0 L 4 e L4 3 0. clUSl(w L N lrvlw KAll IN G !"I :V, l ci L.? f, - r , 3 lUUwHiR NSI . Sr u.U S}ti1?1 cAT?ay Obf NO O W v s IDOwMw SI IIRII S(v,\s DNII NI.m ADGN»(x OwratR SRti4f N E nUU4t5S WNIR l' Z nIn Dow or lHwawa<o rW AwNI N A I, C in u AN N - DC JvICCi - R U F. AD I n, L4 'l A ?' D fa I(' . f l5 Dan, ? 4w tO nNID `°'_yI f'L«Xi .r?•-:°x.,D, f?.,u ?>.Jti ?,( `w ?xIMA N1U u , ?`_'1 ir: `? t`(,G..>l•.A 5'?.Y:). `? ??'?, c ul r DIAGRAM OF COLLISION' yt.111111111Ar 11' DE5CRIPTIONOFCOLLISION Ills)1FRIP w.INIAI -11 ,IMUSSAw r. U 21 Li?1; G-0ICE i ?Ci .',.U b\f 11.,1 .I\`! _ L ?, I s.t L I 1, lt, \ ,< . ' ,S \<!, 1 IC r\) FJ CaR"PIS F?:.,AJ - 1-T "?"w-"?S1t?C_?-. .j' •?tE'Z. \r; ('f<,.:!•^l J-I) .,.'itk CC..K2. at Z IJ Nor, 5-L-., `%.•I. (?n1: St'r?fCr:f; Ci`:i':: `cJ.6.- S V h,1_f. 'at a,J.1 (""•, .a , . ?L f,-.•P?I 0 NAME, ADDRESSB INJURIES OF PERSONS INVOLVED CODES - 2 9 n 5 e OCCUPANTS/ WITNESSES H , aSI uor. „ .. tA 2-kk I* le Wit, r. kft? ? .. t , II w!n, r? L ] 1 1 ? I-TV I•I/ !c'.t,n ..t v_- Ey.b1E?L?1-?1I?1_`-'S.`.!• 4, ul'?S i G - jW •OV r, . ...?d r_d F' YA+a' ?}yt ?? f ?? W. i Ye, 'x: p ''an yyy?, aS`?a =i5i / i t? C .{4•M?$? d ^?+? 1 ' '?fF' "C^ "'"'•C'L' ?{ ,. I4m<. Flr<.^'„Sk ?"" n 4?.? r N N w a o b Uo o U o o 1 0 a e. I m o .{Mo Arno i 77 t 1 D. ' { n. L"1fTw?Sf'LR rAzEUVF>wd1Ra'?7'fP`S-,i"3ik .y _Y _ ?.- ,_ _ -n''Sf?Wfe Fd?R,? ?.,R?.• -w, R ?J? POLICE TRAFFIC COLLiN REPORT LJ EJU•? k+r iRAFFICWAY 'roLlcEC ININUMbfN S .-DAtE OERCOtI Io PRIV IUSf{] .pp ATE WAY Y,F- 77l TIME COUNT COUNTYNO, CIYNO r ","? I ,Y A•I ? ID. Y iu,, HOUR) iHWA R?W,. .I I,uR11 rE ??? r1 /'..ri •jh11 1. a?. / •. ?UReAN J ?N ?f CHY OR TOWN S.•V URAI ?IN NAMEB OOfS FEIO GHWAY PCICLS W,E SCI H-SEC MITES Os OW [y.DP (`?,•r?, ?.C r,•.Y... ONI.i.Y' I...',.l = 1• L-f2 ft3GA` ;:: r: j?" N1fR5ECTING YATN: STREET RAD NON NTfPSfCI ON wT] , ?, YY pclx f ,v. tf vo5l _ pt? .-LTN STREET 6 4 ?1 p51PNCE6DRf Al10 IRN gFSRF EF, CgOS331REE1 RNFARES1M lEP? STREETD' Q? l W ACCIDENT RAMP, nceAM -IA ?.e ' ?rf_I RE1 COll1510N INVIXVEp: SfVfRIIYI OFC MILEAGE '- d jr+ 11 CODE _ IOIAE??LL NO.F IIFC=-- NJURED? SP IIAGF O'sI E U ruH'ov(pjn ?N E CS 1141.1 Ijf Ei OE' y !DG [ ]] t _E., LES QpROPfRTYD, 1! EDNEY _E ? RS?i,ED-ovnRnp ?, OBJFCt STRUC%I AME Of OS1fCt STRUCK ANp OWNERS NAME) - Rj'?l ?/V ??.3Q??, I ESI DAMAGE 5 (IAL CGD r„ tGf -- s pu ERSNAME: NITNO:IIIRS, :UNITNO.2";-?VEHICLE:, ?PEDESTRIAN ?PEDALCYCLIST{'. MI plE DRIVER'S NAME; 5( -y 31Rt0A00RI •>•e g.J„ I\I!V V L - _ o E V I ,1 '' ?. SIREfi ADDRESS H LI tr Ol 7\E) s.o 1 SIAIE Z PLOpE PHONE NOD HY SIAIE IPC P Nf NO, l 2 q -. DRIV{RSUCLNSE NO 4 SIAIE f% tlIRiH 1 IVfR LI NSE NO. SE% DAIf Of ql I l,l { V ((4 o ,, f V v? ? Il. ?. I (Y?,. V OCCU tON IRMNAME 6PHONFNO EYES WEIGHT HFIGHi E OCCUPAIION FIRM NAME S PHONE NO. 4 _ E'-" N s.,.,T:., '= _ I ? Erfs vrt G 1 HE ceT _ ? CHECK (?) Y ,.. J,/s.• 1.S 3 gyp':; R FH <?PAS?%tMPIN"O.'YEFOFANOI `ER AL ? CHECK(. I vEHCIf AS AN FMHOYFF OFANOIHFR .? CODES + x s 5 uiir rsx "C" CH E .sswlDx.ar CODES ? + D arrNY 5 Ex E J n "y - l 7,: DM ? ANR uN l ? E ? FBpIE. ? H" VE UR MA f :pODGf.CNfV.I IOARt.NOVA) STY f (R C< NI YGRPoM ? --NO ? PGCl C] Cbefta col Ki{ ? ,".°.. ?' DR.O t { •?? ( E NEV.) MOpFI IDARI?NDVA) vu ] :?. (•. HDVU?, ft:,,."sl?M, E r Y 1 RoM H I 1 SIAIE IRAIFR RAIf NO Swif H VEH.CIXOR II `? v„.•T//Y/?. l??-C•?Ib L ?r?1'll 1. - A NO. A 'r..• 1 [ CIF-TIACAIION NG, C „ u ?: IC i !I ?I :ICI ?J `%I ;I 11 L YEHaEroNrF A N yn RGIS1FgfDOWN{R USi r4SI MIDDLE' IPHONE NO I Nf SIFRf If R: lli I fIRISI I I MDpIE I I I NOI I rZ ,, rD wD r5sa0WNER j V w N q, NAMF6A00R[55 MSURANCE CO. CMlAG(NI J { 4` ,..Y? E DAMAGED ARU crop • w`?N"ci CNARG[ CHARGE VNCI ONN DIAASAO[DAREA .3] ?y DR VEN p OROR ? W y ?RFMNN[O 3 ? pI p''? F S IC E.. ? MY-11Y. I IL. T ? AWMYp AWAY ?R[MNN[D (DAMAG _ S DIAGRAM OF COIliS10N I HUT U NLC(SSAYYI Nnc IT a(H nr SI B 40W DESCRIPTION OF COLLISION (USES PREMENTM5HIIIIIf ECFSSARY) y Sr ?1.( li P I 1 ? E' L T-) f !".I?_ I 1 f/,'? Isr i -•QrY [ cI r I / L ,T I?!?` ?'-?.... T.l/_`~--- -•>° '. L I I I I I r ..j 1 . " URIES OF PERSONS INVOLVED + CODES t NAME,ANTS ADDRESS IT INJ NESSES _.- NAMI ioq ioailEOMrRIµ esA3v%rvv(aENrnYACE ?AMe. ?<RE??"..?M.ninO 186E.. ,? ?. -,?J I { o 2 ''1 1 AlRSgne •. - .... r.,N oEA4>rfprR M ?AJAe ate WANT .. r. Y . ??aar ? o':n. "' ? ?k{sue }'? .. ? R? „v RD L IJ?1 ? ' ArcvESS .. .. ... .. rlowtor- '?`` 11? a ?,?y'+R y wv(s(KJArwoarlcErsNAM{eeAN sApGE OR AGE- "JU,•,,,r{ rrx sr ?AMe ??°,AI ?C'ppE?pX ?H.HV le ?',? kr.?` . 'K,?? /? ,?.1 ID r.O ICED SPAICMD MIXKe wR4 hp DAI/p gEkWl ArrgpvTOSr DAIf % ?kry' ! I 1 - J s. 311 A. ! 1.? T' ? JA/ S ;',, ]JpD f ]gprw3 '7 •=,, i I .? t'v , " ?. ? T ,I• ..,Ll !•r \,i,IvtL 5,? .. G J4 ^4' M,. ?k !y?,?' 1 , l 1 LKE", r?d? : ?,{ r,E?l ' IS?f ?iyr qr'?E ? ? fFxr°„'f. 7 ? ??PF % R 1 :d ,<? 7tJ1 Il II ?? ???r?>r:ii71t17 ,(r ? 12" - Z i '•f h r t l I'.' p SJA. . cllv4, r .r .J iJ i - 1 1L + ,J ( r ?4?{y ?'N?ll Y ° 1 IY'(L y a.173s? -11 y f?E[Ei ? E Of '? AUC4 MILEAGE e R.D. CODE 'ISpN NVOtVEU SFVFPIIY. ErvimtiES PIH'vaoPEar or-anncE ONUY EO_ ? cE ncf ? ?Sr gNUN w•lowolw nv. l PintR'S NNnf: VSt NRSr Ulxf laffl?oovfss yL? I sI?2? i1T I C• Sr?rf 11PEOuF PNONE NO. D w' I I` J f? R ansEN SrnrF SEX oaEo NF L y b9 vt 3 (kM /V ? Z? RIN V rcuv?naN MxwME avfroNE NO. fns vrticxr Kiclrt E I-Ut ZI O 511! 1 R Nc saFEroR awooa xfFaENCf ?» P ? ? fl0a PoM a w 1-ria ?. _ [V u ^ jre D • IAGRAM OF COLL .. " I I ? ISION: ... SK[tU KQSLRYI If 0 D E SCRIPI SC ,, V.. 1 1 . ' ; _ i? C?RI o?r 'L K+P? _ I.IC !7? i o P. ? .mv[u 9 •oo[vu • MUP6f _ W., 1s ? F COLLISION: lus[ swnErneKnt sf<n lP KCessE.arf 46 b t3 L 9 T, rt t DT Cr„?coL 6 Gabe . Ur 4 2Ugol iz= F??eA ?-? L.,1?s CL?AeI,°rL? ??e A P,P 4'L;5 Fry4s o rt?? Q wa? ' CODES L z s e - i ?K t r STATE OF WASHINGTON .-I Di 1 No TRAFFICWAY POLICE TRAFFIC COLLISION REPORT Id iLq .E wM15MNi NUMBER 1 PRIVATE WAY SGL36OJ his, DA fUiCIXli qN lbr B NI>uN "" 1R; t^4, I.I DMF y1L7S roDR1 COUNTY Jefferson COUNTYNO /U 1 ND. Illy ?fµ " Al r 1 E CI1vWlOwN U V 214flt OR roL«W Al 2e2Mius ®s ?v g.Port Ludlow ON6R-?/6Aoeoose 1. ADM RWlE OY SIR[ .1 3 SC1UN INllRStC11NG M. Sin NONiN11-11ON / Y,QO BEM'ffN CR #f10 S,4tE, BSo Bay Road vvtNx !O Milf YOSI 8 1 OSIANClaD,Rf MI I4 E cµO5511Ylt l OY NFAVi St MITI ROSI e3 S rffr or CR 1.-0'Cw.r4WY _- p[CIDENI MILEAGE voce Y Y DIAGRAM DATA COLLISKIN NVIXVlD flvl Y,t• °l 1ol-o. NO RIIIIL NO NIUR[D? ?YIAG! ?NI1aRU N w x4D F Cl5 INI SFCiN SiRffl0R 40AD0R R[iFREKf CROSSSTREEiOR ROAD 2 A Or VE«ICEE$ ® ? R40R[Al(yLMAGt ONIY C] Pt5Ul1F0 ?viIIX1IUF A? !?f/Cf/n n V OB1tCi 51eUC[INNnt Of DIIIII 51RUCRnNDOWNIR'SNAMEI F;1.04WAGB $ / SMICiAI CO GUSF UNIT NO. 1 UNIT NO. 2 ? V CE ? PEDESI A ? PEDALCYCUST S ........ M°F. N51 NR 1 M p)t,vf R'S 1:aMf 1, t! 1 9 B HARRIER Harry SMITH (lqiqfkt in g SIRlEI wpOY(SS General Delivery s Rtfl Apo+f 55 41-2 and OA - 2 OIY 1I C!`!f 0 lNO Port Ludlow We. 98365 None D R I Dort Lud ow, W . 65 437ENO9445 2 2 1.5 1 D a '1« D .Y R 1. "u NO Alf s x pATEO Bi- 8 036 AKA 1 19 38 1i V to s ?iY i8 ° , OCCUOAIION IYrn NAMf avMONF NO FYfS E?OrvI wEiGwl E OCCU4Al,ON MNPM[a RigNE NO. F YES wEIGNt ItiG«i 2 2 Not Employeed Ha 16 5- Q 80 -1 Retired ? CMECK (?) E.. ciE a4s °Ir AOrar"ut«E+Al ? CHECK(?I it ASaN BMelorlf Or aNOt«FFAI `« w5.. CODES ?' 7 Ri 5 1 e ; °• + ° CODES ?' J lC w ! c ; ?'" - S N e :,:7'p'^ ; r , T 2 N IK1[1 ..es IT ur ea ? cw.lol.pM ? .wM . 1 ? wL,.f ? M". ? : ? ; ... K " AE,.,.Nll ? ? 8t'.Rl ? malt ? °C1n •° F - VtN. YFAY Mw°f IDODOtC«EV1 1969 adillac [1Cait NOV+, EF ZOe CONY, ldorado 2 Dr. E • u E? vE V.I YDK? GitanE F fIIDARt NOVA) g?`s 44 lZ iv 1°5• l v r t C[Nrt RA E NU •. •! t+ fR.iAIE NO AlE S 1'I vW COlO+ N [A A FATI[ 11 All „' Gold FUB 850 Ore. R49 4047 Ore. I C Green --- vlNKt[ D[M r C41bN NO vErv Clf pENi N a, N N D 3 H 9 2 9 5 3 3 5 E N O N E '3 IG Sti RIDOwN[v. Usr -ST "ID SANDERS Alice L. ?p3J 8247-230 1 V +lu?StfRlDOWNFR Wl N451 MiDME Same N No, 1a2 ADDRlssaowNlR I .D,.Essu ow Nee 28744 Hunter Creek Loop,Gold Beach,0 . . "2 faADD4nsa,NSwANa low ..• .N u .N N American States-Jerry Ross,Brook;ig,§j ?4 •:' q f.a NG +pMAGED'Al.w .'..•: Y'=?i C«Ae , w I-I DRi.(N ?9fMMNED fs10AMw4f AG! Z C)-C)-.-D 0 oaa'S w ? 0 i o r wlu J . f D o n $ RPt. Iudlow Fire $100. l DIAGRAM OF COLLISION: 1 1 '1i i.i[iis:c`r, ' BY ?'?w DESCRIPTION OF COLLISION: ,usr st:RR1EMfNlAl srvtfl.r NlctssAR.l js E ON[a nriG F?.??%r i o?l Vehicle #1 was northbound on CR;i6 and VENU« rr AR2 came up behind a bicyclist. Driver #1 honked his horn but the bicycle did not - , move to the shoulder, vehicle #1 then „ - Ml ;A pulled partially into the southbound lane and started to pass the bicycle. y 6 -? The car had cleared the bicycle when a .de' C4?•..r? vehicle came around the curve, oncoming, T Ar Gr+i?• "' vehicle 41 then swerved back into his . lane and the trailer struck the bic cle. 2 NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 9 1 5 6 OCCUPANTS /WITNESSES ' ?AI?AM aY Ara A N 1. Rfsr. Ina °`. " L7nn C. Hnrrler ((pe) 1:'•'••503-247-23 fi _ w1E1.28744 ]iKnter Crk. L .Co 3 Beach- M?AM R ? ? • ?^ ? ; ? ""'Henry H. i'Iomus 98368g " 437-262 14 6 210 i:e+sle_Ln., Port LL dl ow. W " 1RN.nAMe ?..,1?",';°. ?"; ?:.'l- II. Brian 0. Hiller 437-01:3 M 45? C1'1 ? n-: ,? ?,; ?^__ , .D.1,•.270 Puvet Loop, Port Ludlow, w p p DAn ' X n?noP'.?? i,:••. iW",u Nt7 I •i!r!I-F d'§ aAn, ,.1 .Y.wu ?IE?°•'t? I .Yla eJ/ ?.y Nh ? Y? e ?3 ------ -- -------------- ( `I ' X Ivu. 4 • TRAFFICWAY POLICE TRAFFIC COLLISION REPORT - .. POLICE COMPWJIJT NUMBER RI I PRIVATE WAY .; ?l`QJ7lOQ .UAIEOF.C tll N.. _... 7 ll !_LJ, ...._- Q4 R3 Wdl? I f RIR H Efl E iAl HME IUSf',OONOVY7 AVh S COUNTY -EFFE2SoN COUNTY NO, /G CItY NO. '.. iHWA ??NRHA? IvJ xURAI v qS1 LE " CITYOR TOWN C j/ f51RLF ?N ?E ? r G" D KICIS '? ROUI'FORSN- . SCtI N o , T 1 3 A41E5 S ?W OF . LL.tZ7 LQ (.? O ' c - INIERSfCfING NIfH: LEf OR WAD ApNINffRSERION /]A Al C) H?U eETWFFN B E)fYN `MPH a srRtfr PKfL% F MRE i,05f 1.00 ' O• \L- _ OISIANCE eDl9f ZION R RfIFRfN F. CROSSSIREEI OR NEARESIMIIE VOSI MILES N 5 E Rfr W 01 L) gCCIDENT MILEAGE CODE RAMP pIAGRAM DATA COllI510NINV t 11 lOIAI NO. NO.. KILLE KIllfO-NO.INJURfDy ?SPIl1AGf qqS RUN CFVfHIClfS ? 0 PROFERTYDAMAGEOJLY ? p1I SULIfD ?VfHRtLE Hou[om 0 IN?I/F{f Cf5 • CI IEEE 09 nfJOR I. ftR NCE CNOSS SIU 41 0 f'YU??U uD -- ?. JECt519UCKINAMEOi OBJECT STRUCK ANDOWNER '5 NAME) EAGEQO ? w F? Po c-e t?ISoa PECNI CODING LGE KNIT NO. I' NIT NO. ? VEHICLE ? PEDESTRIAN O PEDALCYCLIST 24 RS NMAe LAST L ?GHi eusr u d INtf1A00RE55 FREE ADDRESS A L S ? OFT' SrAIE EIP CODE YHONENO. D IIY STATE I P N • L J7 GOCJ Gun/ . 365 R E 091vF9'S IICENSE NO. L? L4 LAG T 1-1 % G'j M A H ?3 0? 5 I IV 11 EN ENO. AIE X DA 91P H MD. FRAY IY.. , e y OCCUPAIION fI -ERPHONENO. EYES WEIGHT HEIGHT E CUPAIION FIRM NAME A PHONE NO. EYES W EIGH NEIGNT Z, I?EPu Z -6E?so,l Ld. Sy6g p? ' SL/ R ] CHECK_ _cj ASAN WHOrIF ANOTHER ? CHECK(J sANIM YEE O, AHOTHEIR vf la eLEA CODES?1 3 • 111- 41 5 e IIDH a "1`,°I,°r A SYUOMN 5 ule N 6 sum °C•rn CODES ?ris? r IA 11S11 'A' 'N? I M p ? A RM N<f ? <SaE. ? G ? "0- 0 `M O <°°.Y<E ? n- ? G. Kli ? "'1. _ -1,11AR MAKE IDpDG[CHEV) ?o K? 5I [I IDARI.NDMAI YLf (-R CO ) LTA y .7? E MH. 1 nV.l MODELLDARINOVA) l V.1 A p 4 ClNS PUf SIAI[ N fR MTE NO. SIAIE H VEH.c- G2 ? C 35,G li,.i - - C 50 V{Mlcl[IpENHf1"A"' ?^pp d. !lil / 141 I (7 61 I I I I I I L. VEH -I CIE IDINIIPI A I rv I I i l l l l l l l l l I I ....SRREU OWN{R: USi f195i MIDDLE PHONf NO. FFEPSDJ Co. 5/F.cIFF - ?/ O W RF IS cREO WNfR: l/Si FIRST MIDDIF N - IJ ADDRt55 Cf OWNIR N A R CY OWN(R d >L 2T CE T• w JS O NAME ADORI alrvsuRANee eo. Aarvr F vS E D R NAME A ADDRESS OF rvINSURANCE CO. DR AGENT DM,nGtO ARIA a wc n DAMAGED AREA S, S r r l iM ISI. Tp4NAGl cHAWE A - %,,,N ? R(MNN[D CIIARGF - RIVIN ?REMNNfD A WAY f?d 11 ! CD IO AWWI AYDBY: L LS TO LJ r n) WAY eY: DIAGRAMOFCOLLISION fus NAL NDlCAU NORM eY ARROW ' F E ESAR Y DESCRIPTION OF COLLISION 11J5fSWPlLMEN1Al5N[EiIFN[CESSA Y) ?T le ... "" N CE ) Pose .I ; l f+9 . , ? .. D21vE2 ,q vswnrzl c E?,eieGE7 CALL F/4L,-f TE_. 1acE?AJSE o. _. ? -' pe f f} /tA/JT SE 4?,9y . ?fC 1 G fYT SGE_v4!r ~ __. C;JL.D 4 9y.. LL'. Skl g VOW 4° C f/15 ... v I ?'? lCy. N?J..QEE•J. On/...Gf1'iZE...lt.L7/1Y._ ,H / R'" fi /?srvEtil E.?T Ll N T7 L ltE Go7_ -o.v r( Ae GOtc ?Ty /ZD 7a 6.. EalCUG vTE23t?., 50Y C 6L4 Cf<'. ice JLe S.7- OFr.D L9/?- .. I i ' 19?-?Y 2? E? SL?LJED.CA-ME i.-??..?Nn.?-P.,. f , CF EI V- "f-7- AJ /C NAME, ADDRESS 6INJURIES OF PERSONS INVOLVED i CODES 1 - 2 3 4 5 6 '- OCCUPANTS/ WITNESSES IiLw ioanlL<riu'iJA°Mi sj sEK Ai f rAns °'r REV.. u"n i AME n ? , .. .... AroRESt runlet Or RDR nr. Q AM e. ? n" ?'K"' , ? MY ? `- A(RW14f I NAIDY 01 `ARJVID IYGM ?NAR. ??Kr?[? •?? nW ?N 'p rI HO ? Alv+.nt ... "iRw iO1 urrRnr 0AMR. 0 AE 0 1U. ? MESIK:•Irp?WrKIR 3 NAME 5.ANK eA(wI OY AGINCY ICI ItPAT IRp IrAKI RYIND GAIT Or YENRI APHONO.r/ DATI n ?? !n tit. yr QA .?,i'; 4 t ' ru .•0.E 61Y XT, tKnlP t YF :? a n1 Ik r 1 J ?, ! J fl • l Y , I rr I 1 a .;r ' "'L If?,YN 7 1 ' I s• ti, lE • 1 S e S y ' 4 JI ? 3 I I i t t - gdI r?, 44 . N11' , ? • ? ? .? It ? LAO K^ i., e Y F •..RfYY A. v• YYAA/YY YYVV%Y?./Y?:I }?-?lr D ,I o fir` P ' ' ?YU• r ? k • OLICE TRAFFIC COLLISION REPORT }?1 TRAFICWAY r j - FOIICf COMPWNIN l ot _ { g -RATE DEG ItiS. N o 0"5 AT wln. }? RroR 10 4 N 1 OME (USE R,t10 MOllq) L J PRIVATE WAY COUNTY CpurRtt ' 21 L>?fA?rO? r/ fMy/A ??j***? 5 1 Z I ?IP1io T£JF F?RSoY? /G ?D ' ' 21, LJN QE ow CI,Y OR LOWN NAMF6NO.Of STREET OR NIGH WAY ICr C15 rALFO O, c]W Df ,QRD/SB da0 co.l2a,6 j INIFAS(CIINGWIIH: S,A[CI ROn NON INIfPSFC,ION ) OU E' URAI ( o 51 Rf El sftr N ?G-- 1R , ? r ? S 1??1 E? PRFf%, .--.. 9ERVEfN /? E -E. O ro5i? 3G \? =r ? ' ? a;, Sl NCt60RF FFERFN .CRp5531RFE100. NEARS c.1f POS, , ?? [EIS F W Of N I MILEAGE PAN,C ?. w l t YW ,r 'i" CIXISON INVOLVED. fVfR,Yr NO KI 6 CODE wVl x I w R y ? 1r A ? EF Y TOIAI NO. LEED-NO.INIURED ? 1LLAGE ON, UN OVEHICLES ? 0.F m ? PROPEgiY DAMAGE ONLY FIRE ?` X I/RJ . D rv CLS CR IR"I WAp OR ENfC ]] CSSREEIOP RO.N ?tlFE4 S L ? '? SUliFO FH O01[CI STRUCK INAMFOFODIFCr STRUCK ANDOWNER'S NAME) N6 IJF?IL FSL.DANAGE _ SPECW [oD nc ll•F M?}IL IdeXES Rr 4a _?... 7.r8O l ? " . / -o Y-Y49?.ti s ISo ; ' iT.?Of 3 . ? '. IAS, '' UNITNO. 1 UNIT NO.2 ... D s DRW[R's wvnf:. ? L O VEHICLE PEDESTRIAN ?PEDALCYCUST : g?' ? RryERSNN.IE: UST B1 Rf55 --?-1YI -_ lib ? a L Y f• LL 9 4o ie,41 Al I!SYe E STREETADDRESS '-l ?nzIPC Of oJNE NO??TYC D . .GGca La [v Gu.J X137 SI R IY All IP D P N ?? RIVER'SU Sf NO MAIL % a,-/ eti 'BI H ( V I IICFNSf NO. A,E SE% D IE B RI / ?.,,pr •? a OCCUPATION IRM NAM PHONE NO. 9 IGNI HEIGHT E CUPAIION FIRM NAME6 PHONE N ,y?.SNp /4cjA 71 1 $// R O, .. fns IGHrHECH , ., ' CHECK (.? vEH CiE AS V O AN U+oIO EE fANorHER. CODES?? s n a i 5 EvcrKn µ R r oR:.•.. e i° ? CHECK (?) CODES ?+ 7 -CLI AS AN fAwEOrEF aANOrNEaA - a °i rt WI N ' { IN'. 11 ° ? 4 s 5 In 6 IAFI? H i to tlH9 bkF.4i l+„a egFw,., ARA,,,w ? u ? Eb.rL, ? EA R M1NRF DODGF ?CHf I V ) vC, f110Ag1?NK)VA „R.,l ? i'M;, SFiu veD,N- IN 0 l ? v Cl ? ?riR, E N 0I,A EIT ) ? j ? + A .I ? '7 /-dI?.A[J ,,07• A/ 04 • S,YU O Co.,, E Y R I Nv) mpDEL IDMr.NpvAE L v.) wrn F ICf.N ..P FN WAIF iRAIlFR M S« E54wS l?,F. 1E N0 IAIE H X CQOR I UI NO, Al O FNI E...........pN1? l I iffl?c11Sc7iS I?1317 I l REGISRRED OWNE0.: Wr FIRST MIDOIF ? l i l l PHO E i V[NiCLE IDFHIIfI I 1 1 1 1 1 1 I I I I I I I I I '`I 3? r A _ ? N^ E N NO. O IS,ER[0 WNf4: Ar FIRST MIDDLE N NE NO. '] -' 'vHK+ r ADORF550`OWN[ T W NR 11 ??? 11a N - NAMEaADDR-OF INSURANCECO. OR AGfNI E "_ ' R i7R '^_ 5U3xFff[b-? ,YL'FRI sn it - S I ISl. o-GF In A41•: N. M REAUINm °§ JafP I G.f ? ?? I /I. I - R. ? it ?d;`?q4 LJCCUPANTS/WITNESSES FOR ADD`N0NyUS wMe wY,uoAr..porfcus lAwau K suwf aR AGENCY AMe. B "l 'FIX b 1. ,1 - _ .. _. _ .. ?...,. -. ... '. Sri"!t CL.) RlmAIN[D fet. oAMA 'f TD S .. D E?.r ?>r tie G;•,f?' /LFr?L..? EG _. 721 - ., Ian m Tr1 csc - Ja. sscL.:-_s,9?- P10 49 /C+ALI (Ir h 6-y- PAW M ? E ll.4b - Td Sw.Ea?6? _ ' PAW Y f?/Gl.v ! ff'E 4 b?G /ff /J'??s E.. JURIE5 OF PERSONS INVOLVED + Iuu swPLEMeusNllr -..CODES- _l._ - 6 )Vl 4 %Pj MOTOR VEHICLE COLLISION R EPORT NO. iE om.uNal. Ara A !w 1 f VrtO SAI r caus0 T FMIN 110Vn lN coeJTYNO Grv NO ? / ! J of s0 S WE' & ?N ?E ? W AMELrn.a muET DAR HalwAr PoGn N ON Ao, ' ?`D zs NX ' fi?s 13w 13 Awc ?lA coDE AEG , EMECTI-71 ROAD wiFnSEOTMN yn?EG (PEN rwl sr DR lDexnFrwr.lAxOrAU1x. Iuu cr G sCG FEET ©® GJ/??r ?i?!<Fno FoD I RANA RAM DATA MACOP ?iLbE ?R&.LrED TKAIAORrFOn MLORwE ?OI L>p 2 a «FI' 18--t-E.. NAMEB:M ?RADDADTNEMATENALS w l a??????a OEIECTSTRUCN M/MEOIOARCIQTMICM EANOADDIREW jg'giWCArgct mfG.co??E vGf39Df $ DRNER9lA3f NAA1E .. ... MIDDLE L Lech Pa rick , 11 PIPE THAN Cu19 - DWVERBLA9T MIDDLE .. RGRE NO.ANO EOXNO. STREEET1 AOf1RpE.98 ?! O LJ EONl wT STREET ADDRESS PWMNO.MDWXNO. GTY 9TAT DPCODE E DRIVERS GCCUPATION ZIP CODE CITY STATE ORIVEfl5000lIPAII N I I lp (Jp VUI LO S h DtI\YCE• n[POnIFOR uN ?r Oy\s ( DRNERS LICE2L9EAq. DA O 9 H ME pPoVFJi•9 UCENSENO. 6TATE SF% OAT O & AGE LE-Wt sP- Wa D. io 3! n VEHICLE TIT MAXE R%.r .DODGE) RN ADARR WDYSTYLE12DR.1 VEHICLE Yfl. MN(E ICHEV.DODGE) "No VAD 1 80011TYLE120R1 I I OR( ECano1'n' V Y CI?/INE LICE ,!PL-A1TE NO. BTATE TIWLER RATE NO. STATE -rV I4Z W Q PLAT STATE TRNLER RATE NO. STATE VEHICLE XIEld-IFlCATXXI NO. VEHICEE IOENRFlCAign ND. E14 NBEE 6 1 REGSTERED OWNER ILA9TilP9T#11OIXE NAME) GYVER'S LICENSE NO. REGISTERED OMNER(LAST FIRST-MIDDLE NAME) OWVEfl'SUCENSE NO 5Z E oiTp P ?Fh L oAr - OWN ERs 9S I9TREET, CfTY HTA TEI OATEOFNRTH OWNEA'9ADDflESS (STREET RY APOSTATE( DATE OF pIRfN 1 4 -` PMTS OF VEHICLE OANAGED kbNP F ?T rO pARI90F VEHICLE DAMAGED (P,•Ain vlirlttY he r it Je $ ' Z do s LIABILITY INSURANCE INFORMATION•VEHICLE NO. 1- WAS THERE AUTOMOOLE UA-ITY INSURANCE YES ? NO COVERAGE W EFFECT FOR THIS ACCIDENT ON YOUR CAR HMEE MD 1?ou.? fl NAME OF UANUTY INSURANCE COMPANY wME 'ESy_ crE ne'NT ` ° ' 'T y p lL P f Fre r Jul 'e L' IE STA NAME AND ApENT. GTY TE m UASWfYPO YNUMEER 19T NA1RY NAME on f! AGE INNIT110 2ND INWURY IusElVAM-EREroRr FORAmrlonu VUUnIEEI NAME Q AGE ADDRESS GEX ADDRE95-?-??-? ?SE% NA'.I;` OA`OUVI11E5 r LJ 0 r l 1 !7? I [M EN; OF NIURIFS (A. 0 a IXMINA?TrON EY A DOCfOM ®® DOD TOR TORS u EXAMINUPoIGI GYOAIRDOCTOR) ©® NOAME RS STATUS OFPAM ?OR IN VEHMLE LI Pw N1llE0 MM%FIRS SEVIFU 1 I TONETHATAPPL 'rD'"yu? INwonl IES wvi cart I ' STATUSOFDMURED [IN IN VEHICLE []rA XILLED MARK FIR Si Mini;in"' rsfYUI1 r ONE THAT APPLIES A'P ni•?' •i.in Duman r?.'?• :' 1. uce1M o7 NO HA.,In?AN .? ? ? S? 6c] ? ? S? 6? MOTORCYCLE SAFETY: ? HELMET USED ? NEWS NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HE1ME11101 UlEO SHOW NORIN BY ARRO. W GRCLE DF.SCAIDE DELOW WHAT HAPPENED'. (REFER TO VEHICLES SY NUMGEHI Y„uiH.;rvx°oN"' w! r""`.°E .K » .wD O \1¢lyelle ?•. t.....wolY S?o?pe? iti r: FEE! ID, 1 H uL:? W He L. r\ T n txA 4- °ow I rw,1w.. N.Wn DAR wunw t7 51 ?hE{I ,? M 0 eJ1r eA\PQ E f r. )•., r e HQ ln E?IfC?L rtpolln yE1FK, pnWTt•EI?L?.• In Lr o -. t- ,IrrI,Ilnrr.rArw ? ' r V r FT^ I ?I?IINM CE'I r.L III L"o. RS'k1.1 ---LR pL.mp ? . j kvl"ilohs' whth C'IbLh a Oppe.ah21 t.,.,?e.Q .WL#% chine nyl41 co\Ln1 tr 6 N kELlcc uh L' •w? .. _ -• V A r 4L ' $1?ine rLf. L ,?Trvck E -1h yl^YI -c Con hct i dALxli e. Nn Clelil -ZA-e"ftue 60 FIay1METn i , , dRIA,AAbe -6o crA',e, #2 X (Floyd I.O ,:) r - VEHICLES POSITIONS BEFORE COLLISION -• I On f:NwAr NAMCMNO WST ?- -- 1v1""°N1'""' .i?: r1 '? ?? '•'? ? • ? IJ H v1:IrK;LE N S f W RE ? r.., r _ . r ,R1 ? ? ? ? F? 0 ? 0 U 17 r_]•.-, ' R ? ? ? ? ALOAO 40A•rM PROM t0 PEDESTRIAN ,PEDALCYCLIST WASUSING . 1?E%EwA.. ?nN A .?E.- A?rM.rYINi - ? Iu n?n r?„,. Ar?1. 1 PEOCSTRIANYPEDIIL CYCLIST CLOTHING COLOR 'o... , ? 1- ! ? rA . ? N W r\[c1m ! ? u "' ?+ EIDADIU m °+' YAAn1N1 LIGHT CONDRIONS 1 '?wrLgHr TRAFFIC cONl.OL crPr.. GA. TYPE 0`90AD w,rrl GCIKH A IPOIFAG110Ni „r.rl...n •. r„n. ' I C9OM Vrn 2 0 DAWN ? 1 ? -A,, ? 1 ? ON. Al W ? ? rJNlA'iUWfJ1 MR A•, O 1 MY 70= D ? DUSK C] ] O SI sO, 0 2 N I-Al ? ! O 11-1 . -Nll1•A.'ar.r. ? 2 ?mT D ?sNo`w"G E ? DARK 51W, ? O ? co- ? 1 ? h?H•I"OlF ? I L) MA 1-111011 PIP', ? D C) ' w A ? 1? E ? I IK 11-1 ? \ ? ilA!J1EAl PID ? E ? ILW11tI RAMP( 0 \ ? MAAJ1111111 IHHN ? • ?X:f ! ?11WCV11 A 0' 11-14 CFIpLIfJ 11S ? A ?FlA4aNG A-m ? ! ?AlL1Y ? ! ? MAANNI II IUIIN OIHFR ? A ? 9q.C1FY / ? AMf.11r rF'? 0 A C) WI :YEI14 ? P ? lj O! W ? n ? !A UW1rNi AY CKA ' ?i'?' '?" 1 PACT fl AY •], p.,I, I OfIA:ER Fl ASMAN ? ? I ? DRIVEWAY ? I C) !.I f/'ICI UrO111NAIIII; I r i 11 7.' h?li. 1A}MSi}?4j-.'1 W:'. r J '1 Ti ?1?OGJJNR ?f.L,JWH\ O;?Y ? y. 1 A we ,LR'J'M_ c]Du 1- OIr1E1r. U'[GFY ? . W r urlL MIA •r 11DAD lEIMATION ? 2 ? OMNO. .... ,?']2A.? !"Al ? A ?OII 51(%OFJ u ? S M110 N rUTAI WAl I ?'a??!`. ,. ".:'Y'445r':'?4y_ M 1r r ??I r f r, v t?. pI1n1 -0n r T nXZF ?5 Rr r? ?? y I .) 1 r H ,L A '. l T 1 I,'i I ?!X. i T `. , "I 2 POL16kRAFFIC COLLISION REPORT TRAFFKwAY - PoucE COMpu1N1 NINAeER 5. _ },•• •-'r PRIVATE WAY I ?' DgIE? [COII _ ,_Y jE IIMf COUNTY fdUN1Y NO. CIrr NO. FHWq, I HAT µ Iu. IMI, ID$ER NOURI „III ( I o 3°<<0 tiFF Pe I) _) M21 a ?N ?f ?IN City OR TOWN ASE O `3?RfpiOn"cGCppYY .¢P KTCLS ROUTE OY IR SCIION ?Z .,IS s<lj'ilia- HAbLat,k ON OI?-t=Q-4 ,3 15.Z 7,10 INIFRSfCDHG WI IN: Lt10 NOAD HONIM(RS//LCDDLII/OJ?NQq PNEf1X EO MI[E POST `?/-cr / BfiWfEN L.. K.ICJ E'REEta f.I STREET 1 [IISIANCF 801RfM' 5 iR MRff CROSS STREET RNfARf51 M:1E P051 ACCIDENT RAMP DIAGRAM DAi4 •?Aa a NE W 1 MILEAGE T OO FEFI OF _y .eiaGCic>HIrCODE . r 4 COIIIS ON NVOlVEO EVER IYI ^? EI tuJ aJJ _ a RUN N 0 ER AG Toll NO NO XILLED_NO, INIURFD„J ?SPIL..E ? ?E-?,,55 WIMrDVioM IME. Cls 0.0355 f OR ROTD_? CF VFHItlES © ? pgOPFRIY DAMAGE ONIY ? pE5UL1ED CJ VFaCIF ?I _ACISIRUCRINAMEOf OeI[CT SiRUCN AND OWNER'S NAMEI ESI OPMAGF SPECIAL CODING USC s 13z SI; - - " • UNIT NO. I - UNIT NO. 4 VEHICLE -' ? PEDESTRIAN ' [3 PEDALCYCllST XV N -1: WI DRvER' rvlMf: N51 71 -?" WI (4 MA21AnI1Q tiJMS ouncSs o ?o, 5 - srRfEigoou[ss srREETADDRESS C q?J ?Sy3 Nol cum sJ• clo8 2Z"? CITY SIALC C ONE NO. D ItY STATE P O H NE NO. Pi , IOW?S?C. d (AJr? 9$3? PH - R 'bw WA `1g36a _ OR, R. SIICENSE NO. SiAIF % A BRHI- W LI FNSE NO. AIE E% DAIf B iH y6Cf j- l?l? F MDIs"Y y v S 55zNq 8 zq ys ?., OCCUPATIpJ FIRM NAMCe PHONENO. EYES WEIGHT tIGHI E acuPAnorv FIRM N-1 A PHONE NO. EYES WF GHi HIE-1 ?I b 'y` ?CHECK(,I NMPI Hof ANOIHIR.L ?CHECK(V) iFX.CA"R OR /5' OrEEw ' CODES D n it v!H A, i e e e yp 'c'sL. CODES + N .? I I4 f5 N SCM ( o,•f •{-5 Ar nn?wl D n 4 ii "? I AS Ex T6 En rv SGIt so, ? ? uN ' ? ESHER ? „ nrI 1 xT?rS . ? MS EI ? P°w6a ? ESE (R DG .P.„ / FAY DM MnFf DODGE{NEVI 51" 0 ESHER [01 M. ( F EVI MODEl1DAR1.N VAI 5 rE7y P? Fu? C-1rip, E 6b Fond v!'L F I.ATE N ?? IRAIIfG Rwif NO. SIAIE I'I VEH. CIUR AM 046 WV? N[1 A, . STATE VfIIICIfIIXN11fICAlION NO. C L V(H CIE DFrvI fICAII N! ZO ! I I I I I I l l l l l E I I I I I i l l 1 I' I I I REGORRfDOWNE4: W1 FIRST MIDDLE PHONE NO 4 SIEREDOWNIR: AI lIg51 MIDIX 14N1 NO, ZO - ly 3 _5 AM E O S5W_t s wo4ESSaowrveR W DRF POWNE4 p N IAMEIADRRtS50f INSURANCE CO. WAG[Nr E y, n r?JOL1,} R 7=45 N,T(X.tlIS4?.clDAMAGED AREA L DM:o:rMl tMARGt olw? oD°NOl DAMAGED ARU - CHMGf ,J ..6n 5 [51 DArM-ACi'f .WAV (-1RI-MIT ' ?DRIVIN ?NfMNNEO fSI. DAMAGE I A q o .if5 f?OtVi. IOVxo TOM. A;X er . {'SD r erg P uA' L 'Pli+t:? f2om f ' F COLLISION , lust suPPIEMINrAL Sn(fTlr Et[ssARrl 36 71 DESCRIPTIONO DIAGRAM OF COLLISION LI rvu NDC E NX.TH ? U?k)-I 1 NIs OI[S C.?J'8 ? S e i-r y' I HErfNrassAan AT -- - I II ,l r o- ., uE4 z ?e ELI 7>P'utt, LE?Iu:SF I cFU`..•,rV A80 t S5'?o44r G?r _ IP Q _. I •t'?.R 14sLL $ Swtcu...d Tip q t•.iQ 1. - „ IA-IC. 11, T+-f ` J P-141- 'Ail "sq><uf.L 13 • 'F ..:pl s ? 17776 rd--cr, `I 1 SwvTCa u/ LT.I _ CITY C<veot .pv°wt?o ° I . ri ,.. NAME, ADDRESS & INJURIES OF PERSONS INVOLVED + CODES I - Z 3 4 5 6 ' OCCUPANTS / WITNESSES (,US, A? .ODUf1At NAS E31 $(X AG[ 1 }US -"_ .M Rf$I, EF R Pr .. I u 1r + NAME Fee.! ' ._?. ds Z Z _ ?'?' .nlwns -50 pC 1 N,u,E N p vAr To IaE.Rd xlfrRr- Li AMe. Li F31RI ?%"v.. 171 PIT 4' o HFs W ;dr O - _ - - AoERwu 1 n dl - .. NA1EYlor o ..ia RI - 'S ?AMe. ? KI ?HI. ? -W AT HAMe. SJG1iE7',;f.Aa$' PA n 0012-1 t a Al3ogn5 din h1S'.DItv? H".IUIiI?o! D.•tG Ex v ?AMa ?w?<I?°D?E.?4V B:°.;H. i ? SY?e rr.G cERSNAwa AN. ? eADww AE,ENC 1 oe( HeD ?K ?3 r ? ,„ 1 s I: X ) s c o D n a E I Ar aovtD sr o n IQi' E,? ? ?zy I i ? I 99' ?r t f n ?, x , ,, I! ? ? } i 3?° Nt?a?c^ x ?Iar HewI ?'z try q I r?l r?rT i v • -P _ Y I 1 SLY Jil ( I ?{ z ,r r 1?T?.A ( r , ,' l rr mrL+1 I ?x:1 . ,f E T IT ?r u J,S a _ F, i a HLlt; "`s? l F i STATE OF WASHINGTON RAG OF j --?YWSPISR,R[V LBp, No. POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY -E COAL-NT NUN&q PRIVATE WAY ' t cau N Ar imF /? ?7 83 ? »R» NN AIR 1w1E +. :.. foG3o couNlr P A mlwrr rvo. arr NO. FHWA RAl 1 Na Ok oCNr OR TOWN?,??,?/p F6rv0 CFSflEl109ARGN?A'L 2?NLES S QW OF? ?Lt?AyR oNal GG?x !!// Cl5 W?If-OR pR[F?/; v?yN!/ tl t) IN f91EC1 NG NtiH. qFF 04 nD NONNIERSECt ON OFiWlEN STREET 6 SIREE1 PR[f1% f MllF Po51 O 55- Dj NCE6D 9FFfetNC.CR0555TREE1 RNEIRE-11 vO MnFS 5 F W v ACCIDENT MILEAGE R pIAGRAM DAIA K 2- F[EI OF Q CODE CO(11510N INVOfv[D. v1911v ul IUG! ?M16RUN NO. RiIIFD?NO.IN,U9t0 I TOTAL NO +u'ogoi. INIfR .qD CLS IN g5fC11N FIOR ROAp 05 RfiF4lNC[ CROS551q[li Oq PoAD RS ?? lFS TIRE ?SIIXCI[ m FD -`c pp /'S'l -ICT STRUCK IN-Or OfN I STRUCK AND OWNE9'S NAMFI //^ FSt pNnnGF SNCIAL CODING LbF ???? UNIT NO. 1 UN IT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 21 S D9Nf93 NNnF N51 1 1 If P.1'' o M T eWIRSNMnE Iw51 IR MI OlF 1 519tfiwpD 155 27 IREETADDRESS il4coa F, Al I'V/? D Rn .?? D R Irv SP1E Ir F noNEr f%su sui! H A e+ I .v a ErvsF NO. s AIF DAt ae1RTH ` W3 ldA ? ij S? v o a NAM-ONE NO. FYFS IGHI rE1GNl E CUVANON 111M PHONE NO. fYTS IGM rE+GHi 2 f/ r - - SA. R ? CMEC (FI n :N EMViv vFHICLF •"' ? CHECKW) Ews AN FMRiorEE OF ANOiHI CODES 111, a '""'° s?'N'" ,F< DN $ ! 6 -, ' r ' CODES i * 9 n • ss°v 5 E+ a Z D ? ? WIES T D"4liorro O •,.NAAH O u "' O EBn I ? VEH rEAR M MA[F IDOpODCH[v MOpIL D•RI e NDVA 3 xT?e" ? » ? Call ? 151:11 O ` ? I l . I irlf l40R Cp»v 1 pp V[JkS (WS?z f s Z? E v A 1 t HH v.l IDARI NOVAS 1111LE11DI .. v.I » DFI °aA ,a v JJ ''--ll IF N to 51A1F RA+II. -11 ND Il•I! I'I C vtn CIXOR ...... A +l A E N w ! F NO VF CII IpFMRIUTgrv NO L vIn10FIDtNIFCnII NN r aFG15RRk0 GWNER: -1 fIRSt MIDIXF e()/ 4 71 R, e4, -1 NO O RI ISRVtODWNIR: 10.51 FI431 MIOCIf Nf NO . I? L•- ADD9FSSaoN+vtR N A RtsS wNFa E N-AADDR-OFINSURAN000. -NT , S I _ 131 C! o 1221Z1)/ F293 R IN v AN A N p9 N AMAGlD MfA r» y DAMAGED AEA E ' _ f D °'iM O.",Gi ISl p4A,5G1y ? CHAV v WAS ?gtMA+NID p CHARGE Ar Iv! ?wW N ?REMNNED p olm[ ro+rti tsI. DAMAGI I s b $ 6 :w:v er: vz?/ 44 ?ewmr ev E le A l IN a Alp No41H DIAGRAM Of COLLISION: iFUietNiMasugrl OW R esw lE M w rASSw [r Iy [ ss •Rrs DESCRIPTION OF COIII$ION/?IUS c N ®-- / . , ? / ? ? / ? . , 1 ? fTiF'l cL-fC. / .7Lw/T`7?W.LG^ `y a7I y?c S?%o ? 'L 'Fy 0? ? E /c ?Gl? ??.?? tfic? ?O p ,/ ,?tp / ? / L ? y ? C, NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED F CODES I - z 3 4 5 6 OCCUPANTS WITNESSES Iriweb 11N-1 sf. AGf IAns '" Rum r,lzl ° ANI ZVN . mere uRl nl R ufn?svm F4oM OAMa ?,^: ' O;; . O ; ?{,° FD 1 ? • Dn•u5 HArpgr or ,wu slci 'nr ?AM ? ;"°' ?:?, . O'T ? ." •? RmsNG•u.c In NANS UAN, q•pGl as AGLNC. A -In DISPA "rD FU nI•Rm D•nw 41MRl urrpe? own EST` r 1 YR .kA. I tiY4 AIFI?'1`i5 >'rd7 44`S"SSFFu'AA jd ' ' ? 77 a q ' ?' h F Y 1 1 6 ?'` ` ' l ? 7 ? Y l I rY.. )„? q 4 F i Anp ]+ ?q I i ]Rr{? fr3 A, r " f WS ??` 3 7?Hk f Ins ? I z ,, f ? ? ,? , C s t r I ` f j i T. r ? r.. d f9 YW. { / l 1 S r h ?F ' ' _ a ?? 1 r Y fff???"' a +?? ? S(}5 n1?, 1 I I 4 . jl ]?'Y ?I? I y t P- l ..?, ? 1 f Y Mp 4h'h t }}y j ', 1 P. r ,t Y }? ' ' E , ' F IF t I . , 1 F 4, , r ter r ?'F\ N - 'fir ?r+0 4 {?ll?? 1• r„a It m Y Y '9 N+? 'R ' STATE OF WASHINGTON g 3R No POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY . Pala C-LAININ-M A Iotcwl PRIVATE WAY u 4 TIME COUNTY I al ODUNIY NO ..ry // ?7 p L _) R G 3 n RH I n , R IUSf ],ptIHOURI o6 o p FFrR . ?'° CNY A R p` aAN 11 / ?N pF pIN CITYbTO TOW N - -AY f6NO.OFSIRffIOR HG RWfF URAI wlEps Ow Qof NAT ON u o d IN RSfaINO IH SIRFNOX WAp i?>d ' . N SECT ON eL G PRIIx MU:POS! ]] R .T-IEN /a srRF[I aMAR/N QA -il, DISIANCE6pN[ WMX rL O/ ` ' ? ?gf5 R ` SSSIREf ARISIMIIF 3 E AfC nru. e.u ,._........ ?M n ?, - FF! cau`IONINVavfn: u' OIA NO Q NC tlVfHl lf3 J OBxCI SIRUCq (NAMIa OREECT Y 3 (NENEk3 NNAf: UISt f%') -77-,e staNAOOgfu y Tort Po RT- •7b-,y DRNFkSUaN3E ys ? OCCWAIION rIRM S IT NAME. PRDRRIr DAMAGE QVIY Fi.' A'. "N'" UNIT NO. 1 rIN3 y % mod, 'L >R vnrE zrvcoa v Fxn ?.N 98`x63 ? sl?i[ I-'y S/ V Irv Rao3%T ' NY PIAF SIAfF iRMIfRRAIE NO kt11//o VENKIE IEIf Nll[KAIgNlp. v w,G,G X Z V o 6 RecangroowmR: uXSr rlgsr MIDDEI PNONEI ADOR[uaoWwR Z T4 PORT T Of NSrND NAME a ---co, oRAGENr avAADEO.uu IwAC°in;M cN.xu 3 tSID4NAGF RtANIN[0 rdioTioii ? Aw?nN S/00 iON40ar. CfT wAr 'L DIAGRAMOF C041SION: 1 -1 Nc SNEIIT NEa15AY) I er ARgOY aG qE,., eR1- R o 4,0 - - -- NAME, ADDRESS & INJURIES OF PERSON NMN OCCUPANTS /WITNESSES u+wlu Arc.tu NAw uwnu X .NRf3tGwTNG011KIr3 Pµw auN. gADCNb Af M'• ,-_ ?? c S o CODE 0Ha. RUN ,urver[o,H I IM[ CIS R?S•^I•^-.m3nR OR REEFXFNa raa V r p VINIcif t31.DAMAGE SPECVLLCODINO Uff ]'u nFrsISNAME2 0sVEHICLE Q PEDESTRIAN 0 PEDAL I IRffl ADDRESS ZIPC E PgNE '7- 3 R Y All pb aw .".r.. IR I IKwsE NO. sTAn DATE ;•'J„ IGNI E OCCUPAIIIXJ RRM NM1t a PEEONF NO FYFS IGNI EEIGNI Vv ' 6R a J.. I ILJ?wWr Y ?f I DESCRIPTION OF COLLISION. IUS[ S WRlMENIN sNF[l n N[cfs3ARrl ?ENi ,? WAS S' 7"N DOUN.p 01y 4>14PRr . RO.. 7'N. r>REVL R wGN7 7 ° SA e. - : /rp RAAY /N?o TNT R!s/!) HAND A'Ir"A + CODES 1 4- 3 a U. I A. ..,I . __.. r -... S 0 ? Imo} ? Y 4+ ?? 1 ?;? irT.[?EfN)b7S tr I `? ` Pc1Y.,S+Cti:`?lv?,'?5'f F ? ? h .a) r?} I Y? s- 1 1 Y ? 1 J ? E k 6 } Ip z E -? { u ?^!0 y Tit ?AAy M` r r L Y.w; r I M 1?? ? U§? E r$lt 3 tir 1 Ik r - j IE+nii? . I KL,WiC„k:i:P?IIi?? I / I ?6I,:8? IrxII ATI ? " p , ? C Y"/?,, r., ?. ry. Y ? FM vu M t?PSV•.?? I N ? ? N F L LJ E IN , r rp ONE M ?5 ?w ?aF Ads ON Ovi r 4-k 1 I,F. VlE pn sra Cpp i L. 99a? . .1 c . LPUCI xpwn rpx --? 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MAKE ICHEV OODGEI MOD L ; ;, 010VA-0AITTI_ ... -Do STYLE I]Ofl,l VEHICLE YR. :MAKE ICIIEV OOOOEI: .. MOGFL NOVA DART, .. OODY.S LEI OqA.., '6D Ur,3t31T $E?AI1 ?D? UL' N9 u E .. STATE:.;,;. , -TIAILEfl PLATE NO.'x .STATE. LICENSE PLATE NO... STATE .. _..: ['-_T VEHCLE IDENTIFICATION NO IEIIJ 17 <r 0 '7 8 E O =r-?0 8 7 ICLC IDENTIFICATION ND II[GISTEREU WNEA ILpSTFln9?t^IOOLE NAMEI ,;. OR Vfg9 ICENSE NO, c' 5 i REGISTERED OWNER ILAS-RAST MIDDLE NAME), o"HIEN'5 LICENSENO . J ?o ?vi , JCI?'y ? sl?,? a s lsrrr?- ' ---? DVINEIIS AODHESS ISTflEET CITY ANOSTATEI ., ,. oATE OF BIHTII .. °+Y '? PAlT5 GEO /. T 0FVEHICLEOA Y. OWNER'S AFORE ,., ISTgEEi CITYANO STATEI ., .... OgTE OF 01gTH1 . 17 A0. I DAY YI. n.....: ;+_.:. x ...'.: II Al. i 2 pgni50f VEHICLE DAMAGED - _._.._.. _ _::. REIAPV rx L T a / rn 1 P- lvN7? 5!llELb s s LIABILITY INSURANCE INFORMATION-VEHICLE NO. I. wASTHEREAUTOMOINLEL1A.H.-INSURANCE COVERAGE IN EFFECT FOR INISACCIDENT ON YOUR CAR -©YES ?NO AME ANDADDRESSOFLIABILITYINSUR-C POLICYHOLOEq V U ,. .. T1?? I srprF NAME 011 AWLLITY INSURANCE COMPANY (`IG?I.\yJ f7 ?^ f` N ?'iR 1 1. I - /..C 1IItl. (?I,L4 !lI cl?lll/I ?J .,/? tll;! (!'? - . . 1 AMEp ID ADUIiE• US RANCE AGENT LIAtlILITY POLICY NUMtl N1,? ITY .? re TLV-r_' Jhfi (Ll 31',Iri?z5 1!-? 1ST INJURY - . ,.•'. ; • NAME AGE j IUTAL INJURED ]ND INJURY: t-SLIARAIE atroxi fOXAppIllOxnL lnJUwF51 ... .. ...,.: NAME - - 'AGE .. r` AOOHESS NATHRE SEX ADDRESS E EKTE AIHIES ?? [9 nE O M E%TENTOF IN F JURIES ?? .' IA OC ® O =E .. " C N U p, LTo. N E iAl 9 fINA1NEU Nqq Ifl5i0N APP l > L E I OD .JURIESNED PE " NAME 'DCTORI E%AMINAirONtlYA DOCTOnI ® NAME .. ? NVEHIC LE KIL ED M` Ds,tl H ? D U'Y „ I xu S rossre r iUS Of INJUPFD ? EHICLE HANK FIRS DIS "G , Y T ONE THAT APPLIE 1111ISARLING S F ID ..... L I - Pl pou I of EFc ? N? KILlEO i Is [P[I I rION Ilo s ?- ? 5? 6? 7 O ? ? 5? 60 r 7?Frc MOTORCYCLE SAFETY: ?HELMErusfD ?UELMETNOTUSED MOTORCYCLE SAFETY: ?HELMET USED ?HELMET NOT USED 5 U DII`BY ARgOw IN LIIICLF \ OCSCHIOE DELOWWNATIFAPPENED IHEFEnTUVE1HCLESDYNUMBEn1 ? D,n.'?.?Lr? ??_CeJet<a._,IJrP?4Nr_E'tlac,rr/_ a " { > ' & ;;F ' ? ? "'` i I N,.pI e(JAAA r p ::°? n? >eD i?r e t r s ,yy t I n._v w_r_an_?r_ ally*??Y?- C S ,. a Rurn__btit?cF.?zrl {Ipc / He4,(_" 1 4oa1aL raN?Io ? rahlFdO?Te?C?Y ?i4?ED; I CofX.-Led :ka.{PUb -t LIP. •- S VE'HICESPOSITIONSOEFORECOLLISION Y E?! w V.11-HCU,INVESTIGATEDeY n .NfnF L 0. FY CI ??[lD ' xL' I MI r 11 VEHICLI N s t ON STREET DR HIGHWAY NAME OR NO. xo ulxkcrlen w YF{ 11 AV v1{ xp ?MIxOL ?1- i Cl p 0 11 ?p?? ? ? ? ? ? ? ?...... s p 4 ? ? ? ? ALONG OP LFr0.5rN_G INOM TO PE OCSTFlIAN/PEDALCYCL1ST WAS USING: F ? u ? 1 L57-;--.A- C-1 13 CJ ND. TO m« . 1 C-1 .,.m„m . 13 CJ 1 ? pn ? uss" : ° ?`? A ? p , L . r PEOESTRIANfPEDAL CYCLIST CLOTHING COLOR: CO] [ ,N/?J?M d Mlnr pct, Wl ATHt N 40 t ° rA ?A?iggi ?D ,. . H Co- r10N9 THAfirC CONTHDL TY'I OI No.D u<[twll au - on VLnNC ICLl ACT IONS t 1 D,R r.. r ?Dgruulr " K.wm,nnU w ea °oxn vFxaLl r DNl anvmu l Ki I U Y pr gp{ " ) ? DAnN p I lJ I p 0 , 10 ' r S , . 9 GN+L9 r 4 d ug ?DR, WAY X C]1 E ?oO NGnrnAIGHr AHEAD ORr E?PArNrNG l?prSK ? ? 1 ?FTOr M y A F.1 ? 7 ?wll GN ? TWOwAY ? 1 ? OVERTAKING AND FASSINO l ? SNJMND F ? D I- SpryttT C] 1 ? Wt 7 IO $14v C) 2 of 1 9 OLt _ 1 yNOVf ? 1 C] MAKING IT TURN ; ? ? ? N r 1 qrl [ ? FOG t ? y]JH(I90/ 11f ? 1 ? FL.IIHING p[O Nt"c GI LIFT ? E ?ILl ? ' ? ILW^A-1 ? 1 ? MAKING TURN I?OVIC IYI e?flF[(IrALIGNT{ { FLASHING A..k. ? 1 (1 N I R l (3 C] C] 1 ? ALL/Y ? 1 ? MAKING USURN ? ,f}1 Sri r Tlrq ' ? 11rlClfy ? e ? qa srcNAL a Twu?N R ? I ? LLowINO n Id _ ?OANYw CM,1nACT n Hw01YAr WnrACnrre ? 1 ?mnu nn ? ? i f ' I sP L . n- u AN ?r t w?a ? 1 VtW ? o Ar ? E ? trorFm FOR TRAFFIC ?S . 1 (n1 1 S :tit 1 t ? r, 4 J v7. I ,I t OTNra, YIC Y t ? ? 0 Df[rANAT UN IIOHID T GNAL :+P?-b I?.ti ?'AJI,.l ?v, 171irYa JH ',!a 'IYA"9E.?',.lk?•Xn ?161t r1 't J?.}C' .. . ...?c• I i ,,.- ...DU. _.. ,, ....., ,, .. x,'??l.DA. . k I r f ?I LE ,1 1l,, ? TRAFFICWAY POLICE TR F No. AF IC COLLISION REPORT POLICE COMPLAINT NUMBER PRIVATE' WAY DAIf OfCgll O R1 COUNr O NOU >u I an ituls lA'. II a" [AIDD ? COUNTY NO. CITYFIO. iHWA O URBNI _ ? - ITV / EI?'GURAI ON OE OIN CItTOR 10 N NPMEflNO.OFSIN frON HIGHWAY MILES Os OW 0OF ON .???Q RD INIfNSFCIN PAIN: SIRFfION ROM NON NTERSEg11" 11 11 ADM RWiE OR SIRES SECTION ?3 1S 1v 990 az BETWEEN STREET a STREET PREFI% EO. MILE POSL ?J A TiT¢ R ERENCf. C MRES N 5 E MILEAGE A IEFt o LVED: 5fVERITYt . NO KlllfD-NO.NIUREDOHITA RUN rloRtHS XqD Nr ROMOR R(ifgf [LS [g055SIREROA qOM S PROPERTY DAMAGE ONLY ?RESULTEO ?VFH INMAE Oi OBI[Cf STRUCK PNp1OWNER'S F F? Z h m SPECIAL CODNG U ITN Z ?VEHICLE ?PEDESTRIAN OPEDAIrVCUST 24 N- BBAE usT N qR ? I ST 9", 55 .-H. NAME: .11 J 11 ,, Vs STREET MDRE53 C SrATE AIPCODE PHONE NO^. uQ ' D R CITY SrAIE Z IP PHONE NO, h DRNLR SUCENXN. C H R ISDG -3 SIAtE ?? Sfk gBRIH g I Io I V 4v RSl<ENSE NO, rAlf F% DATE Of BIRTH MO. MY ?T.. ' 26 OCCUPATION FIRM N f fl P ONF NO. FYfS WEIGNr r E OCCUPAI ON FIRM NAME fl PHONE NO EYES WEIGHT I GHI 2 ?"_-- X31 (cb ?-? R . ? CHECK (,I YPN nF AS:N FMV-'NO orauor"[RAT 11- A ? CHECK( P? EHCLE I EMROTEEOfO rl.ERAI 2 M :L Iict riDVCr[rt CODES 1* G O is < iT 5 I 6 st +yyr 5 N u[n TRI CODES P- D c X °sr s° r ec1 H 6 uNIOI ? S v fEw'„r ? .D ,rat ? u OCR"". 9 2S ? C4 wM v v O AMER-O?"N'" ? c8,B. ?v `f O CPDsP. „ A IMAK EIDODGE [HfY.I MOpfIIDA fNOVa) StTIf TAD :CONV.1 VfIT YEAR ? 1 NYFAR 1 E NEVI AgOfLIDARI NOVA1 TLl VI _ I AN 5 Y O IICEr PIA1 NIX SIAIE TRAILER K TE O ww II _ V , X A N . "-r I YDICIXOR N A E V[H Gf DFNI iC roN NO. RE.KURL00 ER. -1 I FIRST IDDLFIPNONE NO i VEHCIE DfN H-H NN R[G SIENfD WNER I . 1° s V `. o W : LgsT FIRS! MIDDIE H NE NO. Mpvf55""IR A DiWNE TI N NM,[ a ADDRL55 q INSURANCE CO. OR A.INI R $5 AN N AA DMAAGI AREA a•NInD ' f - i`f! S o O,"R."1 f51. tDAV.A GE cHaRGE O ?II AYN C1 "A""' auvcE ODRtVFN OYFMMN[0 AsAf IN rUNCirDr°IN [SI'IDAMAG[ r;AMAGE AREA I _ '??, - s E' I f RL+ .W?YD BY? 1 T ?AWAYnV: AWAY E ? ?_ a!l IA L DIAGRAMOFCOLUSION: lu L NAL YµnKAAR PIONHt - RYI eROW s EEruNfasu DESCRIPTION OF COLLISION: IU5ESUPREMENTX 5HEFTIF NECISSARr 1 ` O i I - # 1 F_Tf?^sy' $DUhfR ah OAK6E3X l.q. J AA 1-o?s ?j' NoaltiRS ?STw I -to (mrss A PO Ih' . ?E 1 owoN- a),a---? P ` ••fv - Ir F_ 7R{t?'RDF,r?u.v?r sI-0.11?,?v?[,. ril•?, ..?... tW 0.\ h W pOIA.IP•1r pb C Ga riik m INS AA DB R 1n Qr?? J o t? RO 01 Z uwiky _ IV CD, NAME, ADDRESS B INJURIES OF PERSONS INVOLVED * CODES I - Z J 4 5 6 N OCCUPANTS WITNESSES iGUq eopntloi,:i r?iAM AME iii sE% .cE urus '",,?," „U„+,? I; 1 ResrR. - ANnr L : nrwl 1 A MIV`,S NAHH, d •f1N XT O A Tl ? 1 O'" . ? srvH ? il?irv A] A IRVISy W I NAluv[p Y REWrvID IVOM OgMe. OrCU,KI Oni .,?rss. W -1 RB I o^ wnAe1 ewer ?AMe. ^ KAtrAW Kt ) W {RANK p'AD(Oq AGENCY KI Dr4Al rR0 ill Kl AR OAl10IM 1 AMROVTD eY DAII N I ,.. ., A + S:KT.' eG F: i'' T'...rul Y 1 vU4 ( r 7 5 L >L F ?W ; ddEG ' 'P I ' $J POLICE TRAFFIC COLLISION REPORT lal'RAFFIC'^' InucfcomPlAlm NUMBER ?E - .m RI - I PRIVATE WAY i V "! /? ? ' " DAIf Of I N Z. : ro 1 A yll I Y .. 'Ixuvsl I 1 . IIMf I SE1Wp NOUR) B CC UNIY -SEFFEE COUNTY NO. / I(o CITY NO. M A ?UU AN RAL ! - e O .L'O c Al 1 l CITY OR TOWN NPMf°NO.Of 51FEE10 IGHY.'AY 0. QE N KO f1.4 fCTCLS A 5 ROU`IF ON SEpREEI ? V ?J ?Q SECTION r ?_ ? AvlfS s ?. QOF A?LO C S ON_Ln?Qj>..- Ly 51 1 RROAD NON INIERSfC110N 1 G 1 1-1. ED. MITE POST RR InIFR5FC 1N wI H: O. "'D OQ/( (r:p? BETWEEN SIREfi ° SWEET O / D151ANCf5D E it ER M ENC. CROSS SIREfi OR NIAF.l MI.1 AUl S F W ACCIDENT MILEAGE RAMP DIAGRAM MTA 'H f FELT GP COtL15R)N INVOlVEO: fVERI1YI q. NO. IN,UREDQ- ?SPILLAGF ?NIT6 RUN NO. KILLED SL ION. CODE WHDe1DIH IMER %•RD CLS IN REE POR OR R[fER NCE CROSS SLR[fTOR RO /Zp .f i - R T O. .VEHICLES PROPERTYDAMAGE ONIV ? RESULIFD 13A c¢ ..T?6ELS0 __-_ • OBAC151RLKK IN— OF OB,ECT STRUCK AND OWN-5 NAME) f51,-AWAGE SKOALCODINGLIE ._ ' ? ('44VCt S?A1 . UNIT NO. 1 - UNIT NO. ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 3 DRIVER'S NAME: _T 1- MI-1 DRIVFR'SNAMF: U51 M, DDIL r o TRAG !'lA 1 _ ORfSS I f SIRIEIADDRIII BOX ))C' RFET PD CUY SIAIE ZIP CODE PHONE NO. D IIY SIAIE IP D PH NEN , PoRTL?DLev -N 9836 5 3?-2Y5 R ll % VAIEOFB RIM DRIVERS UCtN5EN0 SIAIE E% iH 'r' 6 ' I V PE IICENSf NO. A W IDAY IY• - .' Zanb ]M3.NtE F S 6 7 EYES WEGH114GH1 - ii,"' B x OCCUPAU.J E[.PHONENO. EYES WF GHT HGNi .7upEn C /MACE, suYee>_ 84+ 115 So ?CHECK(.) nNC"lf Al ANpnPiav"[IOPANOIH[v E R OCCUPATION FIRM NAMEB PNONF NO. ?CHECK (.? n°cIfM AN FMnorEEOFANA4"DIHFR.L IKU v r i V CODES?+ D nuY % i S e e eoKYGI y .in ,r<IgH ? MN1 Cirorv ?n CODES ?+ G n A sv 5 En a "yu ..? / IN U U I ;1o Vln; NE ? N. M E ? p1 ' E6 Ef ? <!F ? C°L ? N c] O u4 ` ? 0"'. ? V UN °PM KEIDODGf CHEVI V[H.YtAR FL(DMi NOVA) VYLF(ZDR.CONV) V.) MODEL(OMT.NOVAI Y R MAK ( N (Z R.C NV) Y Z 10 77 NoNOA GVeo• 1 aeori E y? / 6 4 FNSFPU N S1Aif RMLfR MIf NO. SIAIE H rEN. aoR N . A 9 I Rr -,cll IDENRNUI 267 RDN NO r/ r C EHICIE D[NIIN All N ,9 G S "x . S G'C'3' ?^13191916i ! ! f F I I I I I I PNONE NO. ISRRtDOWNER -1 IIRSI MIDDY Rtf [ VER DOWN[R, UST NRSI MIDpI ....... Y,3 , RbPD o /`R w• /l37-2/S7 W wrvF I ID? ADDRE550r O-fIt N ??•lll o r3?x //o' PbA _,D11-1 NNAf3A0DRlSS.INSURANCE CO. WAGINI R SZ rel. _ E ;,.MAGI MIA N4 iah IGN , omCli gAMAGEI..m » 3 ° N C w I c-GI t. CHARGE p u ? RTDP .EL - Y 3 131. DAMAG[ ? AWW[U ?R[MAINED ?R[MAINED 0AWAY • DNnAGF E51 E 10 OOT1UM 3 Y E S.z00 6 wAY BY: 10W[D ? Aw%Y BY s DIAGRAM OF COI L N 1510 N (HEu nu u NoR1n Ro e EassARr) s R DESCRIP TION OF COLLISION: (USE SVPPIEMEN1Al5N[[i IF NECE55ARr) _ ' + ....: I I I I te / ' O ?N4_ ?o?Y.oN of Ux t)1. No I Ap4o-4eHE " ° .,` ;' I ! J' _ D-n. Ro. /O A'A(o?^N ,pS yARR._N/s.>_ J wN+dN - ER ; A g.AAvFs, SUarACt_y uS .7'tr Gme. I./?x^'. » -..r s .?_?-- a LaF2 ? 44vEL ChNSTRvGTioN• ?£H% / W-0S N6RTH8oVA(/?.?. _ ? ? ? _.. l`.1?....__ /.[D,$T'aoN1'ROL 070 7-H4' G•A4vFL.T 0 SD ' --n THE pb4z> A"b CRO?Lr"D TN < V_ Hr 4> t oN : _.. I I I I , 1° ADDRESS BINJURIES OFPERSONS NAME INVOLVED +CODES 1 - 2 3 " 4 5 6 , OCCUPANTS/WITNESSES IF°Oa b011bW4 N5 " Sf% AG[ IAIUS IN VIA MIM" ^,' R?s1+. e,iCl :'<; y -?? NAMCTRY$A a e'nco" 1. AfRD•1>3 ' ' ' / `? 0 -' 5 NAME NAIUR1 or MovsD rK pAMe Q :;"EO o':n. ?N.' ? :°•vw i0 :) (s d ' ' AnD•ISS ' . r . NAMI. .. _ °p in 1O1 "IA ?AMe. O'r°i<lo"oKl•?NS ?o°;v 1Nt er `• I E },H AnD.ns vav[SIK.AI•,G.EKi•SNAMIERAn• BAOGIO AGIrKY i ° o KID »AICHlO rC . K 'RglvlO wR.REro•i AIroGV[DSY DAII ? N'1 s : 3 ak t .r.+.a.? rL 3t a ?, rf L.a- A" + f ? ? . I Li n V, 1 .l )4r H .- pp lI? ° d C 1 I '? - l } Y ? f 'j • . y : S R L A1a Si A N N t ( r?? ?. h? ?lr ? r tt ? F• 4 i { a o ro ca Q. - ?cxmo . , ' - Vi .. ] UH VCHIL:I_E COLLISIO N DEPORT VU. A GTE OF COIUSION DAY OFCO WSION .. TIME OF COLLISION COUNTY NO CIiY NO i - MO Fes;, 5LH ACN _S _0 D In u 9Ai xW FuNUtES AN PM . . Ike ?`aSlo9 Qy g1 p ?N C COUNTY. - CITY. TOWN .... ,f10UrsoE MILES: QQ .CITY TOWN AOMLLB PREFI% OUTE OASixEEr GOOF SECTION Cwl e." rt "', 5 //r[ F. W W F E !0 ©© DFFlo-_¢L•fI?? GIVE NAMEOF STREET, ROADOA? WAY . .,. - WTERSEGINU WITH: STREET OR ROAD. .'. I??VI.,ON ? [ t ' PNEFI% ED MILEPOST c ccual o ` .,..:.L l' E•j-c_F cL N ON Ni ^TION LOCATION O F OWHION `G_J / RAMP DIAGRAM DATA •A / // BETWEEN /!• l .LlwL STREET AND ( SIAEET WNor - uNOAOCPO=. MniFOST AEEExn wAYµ MBEA SwOOE. A 9 ? NON %RD IN ER xp.0. SxF xE FEPEr.OFOrJi E ODS ; [ASECrKW: 1 w iEE1 T INTER, CLS, ,S Er OAROAO - • co- -.-.. 11 Q VEHCLE VENCLE QVE C E VCLE (? ILL EILWL. (Y'/LL.L." L? ,n.(jr.. i1 ( OIAL"o ?rl QVE OwMr QVE Ei u Q 5 L SEC CODE USE ; •%` „ . P OF VOVCLF4 110 L RIX.R.- QNOxLOL OBJECT SiflUCK -OFONECISIAU:+1 _. ,. OWNEROFOWECTSNAMEMDADDRESS N Q cv ?.? -?. ROAD I . .. ... .,. A. WAY ? _.._ N .o ro AFPMIOw[cr ... FEET [DOE S .......... Maims • • IF MORE TIIM E DRIVERS LAST NAME .. ,.,, FlRST NAME. .. ,MIOOLE ,. wEAFw?NVOLMV[0 OflIVERSLAST NAME ...:.FWSTNAME.. MIDDLE E W,1? r /" IN Tws COIUSCN OA - - STREET ADO flESS,. ROUTENNLLMOBOXF1 . //J / l.T rC.- /7 A. I..w I- PERSONS IWUAEDUSEA STREETAOORESS - .. P } [Y cl - N CITY - STATE . DRlVEfl9000UPAigN ,... ,: "'DO-E SEPARITE C KIN CITY ,'.... STATE :ZIPCUDE,,, ORIVERSOCCUPATION I Y YG r l ? f CC ?Lr " OI[I VE xEPOA FOAM f `. ? , .. NI IO gSLICER SENUMOE ST TATE SE' pTE OF BIflTH. .AGE AA ? 1 ? •P 1 1 % e7 l f(j ? t?'.i M ; ? .23 ) p -9 < E NUMBER _..:'.. _ ?,. STATE. SEX GATEOFBIRTH AGE , MG ... F, M Al DrENI 11 . D , VEHICLEYR. M-AAKE(CNEV:GODOEI MOGEL(NOVADARTJ '. GOOYSTYLEI2DR.1.. VEHICLEYR. MAKEICHEV: DODGE).. MOOELINOVADAFM), BODYSTYLE(2DR1 ' gENSEPUTE Iq.. STATE TflAILEq PLATE NO. STATE Pc?c 3 ! UCENSEPLATENO. STATE W E PUTE NO. STATE L VEHICLEIDENTIFICATIONNO.. (188BM6DELS&NEWERI OOOMETER(MILEAGE) AZl a ens/L i •'r •7 1 -n-E VEHICLEIDENTIFICATIONNO. (,ON MODELSA NEWER). DOMEIER (MILEAGE) „ ?, E - REGISTERED OWNEfI (USTFIRST•MIDOLENAME) .: DRNERTI ICENSENO. REGISTEREOOWNER ILASi•FIRBT•MIDOLENAMEI ,„....,: ._.,.DRIVERS LICENSE NO. . • i? 70 r._ ' ` ^ '° ?p > ADDRESS (SrREET,CIiYMOBTATE) / :; OATEOFSL A y/C /l ?C F : OWNERSAODRE59 (STREE'r.CIYY ANOSTATE) OF TH DATEO SIR u0 A ' _ • jO j, 'r o /C .rL_CL.A,E "J ;Lr y Y rEUL V - PMi50F VEHICLE DAM AGED ESAMNEOCOSL TO -R VEwCLE /J ., PARTS OF VEHCLE DAMAGED EsnMAr[OCOST . y . . .. TO AFPAW VENKLF WA9 THERE AUTOMOBILE UABIUTVINSUflANCE DAD SU N A EHICLE NO. 1• COVERAGE IN EFFECT FOR THIS ACCIOENT ON YOUR CAR yES ?NO ANOADD OFUAEU WSL,R cEPOi: NAI,MµE MAOp1ESS LIABILITY SURM POLICYHOLGEq NAME OFUABIUtt WSUIWECE COMPMY [ ry t NoonE59 `_. arv STATE T. `- . UAMtEANDADORESSOFUAdUTYINSURMCEAGENT att 9TAi[ z UAB UTY POLICY NU BEFi _?-l ._/a l ?J20 -Y3fi ?:/<_, LI ?f7c; 3GJ` ISM // AOE 2NDINJURY J ESEPNUTE.-lOAUfOI TIOrIU.uWWE51 ,SqE - .•.? NAME E /?/ !L t : : I.?, ... ? /, . ! TOT NAME / r NNRE r ADDRESS ADDRESS SEX ? [.` (1lLL<11. e___?__? M F AFMS ., EATI, J Ytf (i YG l XTEN OF ELwe Q ? :?F > k _A . ®Q __?___-_ __. _._. molax• ® arla ( / .eL?-CJ`??_ F AMNA Ez xwF S HtAl U4Of NJUREO MMNFIRST CNE THAT APPLIES M RST ONE iNAT MKFl APPLIES 1WwFx EE VEHICLE plAWNO xdldvOLrA) -NttcIOLF STATUSOFINIURED R IuW'?Oar QOfVVEA IN VEHICLE aAA4 oNO6AhwO POSS,ErE N D 1_1 l E NO KILLED 13EVEHE1 Dal 110 P PEp51 q M01P?M.E LLL??JII 5 CI O ' I i i r x O ? ? A rG l 7 5 5 ? ? ? 8? 7?. SHOW NO ..' ,i RTH DY MROW EE CINCLE i -AIN O ..' I 1 AEO MI DESCRIBE DELOWWHAT HAPPENED: (REFER TO VEHICLES BY NUMBER) NOCAIFp. n,OOAG I ArvL ,. i ihM c ou C nul PErucn ..... - -_ 51 rYyuY[NY,[f Opr1 G nFV S I I iF GV Y+WC7 > ? K r.cLF'wo rAKN[ ` ... V ? L ?L. ?[..?-._ NF-![ ,, _ m[r ANVOV, ?? Q? ? 5 AEnoA Nanw__ .;1.?.C-rte Ems---- //L!y!I/[ / C;,l!? F VEHICLES POSITIONS BEFORE COLLISION NO OF _e nwcu vnAC¢ vI +lO W4 ONESTgATE00Y LIOALLY 6I .Ofq KHg FA L ? t ?? w L LfpNJ.v IAA+lO v[IVCLE OCCIIEO N S [ W ON STREET OR HIGHWAY NAME On NO M[ UN cl [F ND 1. ND L. ND O"P:« 0", h. p ' T v IY A 2 ' I . O ? D O ? ? ? ? ? ? OrCOIIit[ ?O11O lIr NO D ? O ? -11 INfAAIAWMIMPI ? ? ? ? ? ? FG ? ? ? ? ? I IJ t J [ ILOra cpaae.q FROM DIRECTION To DIRECTION IKMSTM1AN WNU^ 2O WALKWAY ]O s,IoL,'"n .D? +nwuf S? ylgyIREC a?oIRE IY1AD WiFKE W1AM[R A_ I ?' ?' I C I1 UGNMCONDITIONS T-FICCONTP01. N ttP R0A0 DRNEq/VEIIgIC ACigN9 --1 VI_UA PEOOF F IG.rcf Me ARiV ICMCa0NE 0n WR[I Iy J?y7 I > OnnOllll I NO> NOI qi I ,Fh?cl>upy 1 DAVLIGNT r9, 1 NOr ? 1 OInY y/ MYrCF r ? ? sIONALS ?I 1 d1[ WAY ? 1 ? GO'NOSTRNGHTNIF.AD r _ t Lh ? [ ? OANN ? 7 STOO SKIN 7 TWO WAY ? T ? OVERTAgIq AND PASSING ` J ? I WlT ] D SIOL[ DUSK ? ] Q YIELD sqN O ] ] ? `NO- ] ' C L• W ?? ] ? MAKING RgNi TURN ? 1 ? • ?D[ E OFOO E 30M [T ? A FlA51WA Rto © GA ? 1 w1ERCHN/0[ ? . C) MAKING LEFT TURN (LOOP/RAMPI FJ I I F 'f g?, 1 .•. 0 RK 5 OtHEq OARItOTPELT ? O ??Y ?[PLU/'Y) Oi1 ? e '"S-.4 AMSLq ? L ALLEY ? S ? MMWOIJ•IUnN I DINER MCNO T 1 ?. ,( l 1011 WO WAY. e ? STREET L101(Te ? e ? M SIGNAL ? O c a C) xoynNo 11EA AN NOT S[[WO "rOq pyYp ? +L •OT.LOr[ ?MrCrfKM C r ? fCifV LEFT TURN ? I OI'rICLR:rLAOMAN LINES ? r ? OTCF+torOR TRAFFIC ' h S At CAL L- LJ A!L•I•'l ? e ? Ollgq SPECIFY O 1 ? BEPMAIlO (? e [(ISIGN J ( / t 1 l « 2 OIWOCO .JR-4-1 ? OOrY[O AGWA . ? :'.?•'?^_. "."'??,: '"'R.41E'T"?-" ..'n[z"??"9SS&eJl{StK2CW?A: r !.pgglrcs"2?. lY'J 1 ) i', tJ :. Ba T .+M. .,L,t<., xwe11?., „?:•- J?NgC•WRA7IW ySyLMYwY 7)tC?? 1 /? ? 1 [1 f 1 i II 1 POLICE TRAFFIC COLLISION REPORT LZTRAFFICWAY POLICE COMPUINI NUMBER - JE ? • PRIVATE WAY DAIEOfmll N D Y CO TIME COUNTY FNWA CITY NO COUNTYNO IL 5 „v H+ O pA? .N z I upr luU...w S. IH?i41. IUSETEOO HOU'1 V E^?? 4 - . /? /LA" . .. .. ?,U/ URA y.JxURAL .. N CITY OR TOWN MILES ?s OW poF ( N-NO151REE-RHIGHWAY ON 111- A M P ROUIEONSIP[FI .3 St -N '• INTERSECT- VAIN: SIREETOrAD NON IN'R5EC110N -???]] BETWEEN tfCIS 9 FFT a RP-AO-14 ft_ FREFIx E MILE PO51 /_-// Vv I DISTANCE eOINf?i MA RN .CROSS SIPffi OR NEALTILMILE LES ••- N S' `[ - W _ ACCIDENT MILEAGE RAMP DIAGRAM MIA A FEET ? ? OF CODE ]] COLLISION INVOLVED: SfVfR IY: L NO %t ED?? NOANJURED<< ?SPAEUGE ?` «NUN TOTAL NO NORio1H5 NTER % AD INIETUCTING STREET OR ROADOR REFEAENCE INTER CIS CROSS SiREETOR ROAD . Of VEHICLE5 ? PROPERTYDAMAGE ONLY ?FIRE D' ?VfHCIf • .S6 ?? ? + W![CI SiNUC%?NAME OFll 51RUC%,WOOWNER'SNAME) FSI,DAMAGE SPFCIAI COOING USf ,_ ? j ' UNIT NO. I ' UNIT NO.2 ? VEHICLE - ? PEDESTRIAN ? PEDALCVCLIST " 3 NWEN S NMIf: IA51 fIP51 MIDDIF D '.l f : 5'-7 QS?1 S NAME: UST FIRS, MIDOtE DNIVER •^/ D SIN[f1A00RE55 • L'.Gn 1R.E1 AO DRESS /-, CITY StAIE TI1- PHONE NO. LOA, I ' D R CITY STATE IP PHONEN . ?.? ORrvtN SI CLNSFNO. r.. MC p I C? SIAI A EX DA I 0 j I "YR 03; ( IV LICENSE NO. ATE FX DATE BIRIN MD. DAY Y.. - I D OCCUPATION nNM AMI a PHONE NO. EYES WF GHt HEGHI E accuPAnON i IRM IJAME 6 PHONE NO. EYES WEIGHI 1IGHI G p R, L • r1 5 J5• R - ? CHECK (rj I PEAS aN IivEF Of Ar?o1NE4. L ? CHECK (V) FH CIE AS AN EMPLOYEE Of ANOIIIER A' CODES ?* 9 % i e I-ON a s. ai CODES P• * D n < is e T - 6 s ii n ]' 2 _ DRIES A Q J EA U „ ::IP ? AMN AHRf ? MTf ? M"'. X ='.V: ? ". OU °L e ? AM - o MIT ? Eb" ? cR K ? MNSP E x R VEHYEAR MA %E D OD GE CN F V.7 I V A) SlYlE 1TDR. CONV.I M fIIDARI?NO H'YEA 1 HME MOOELIDMI,NOVAI STYLE J2 DR.-CONY.) E LD ' / 1 ? ? / { { F ER 4 y L• ? IEIDIJ•mK Diz • E I IT J k V OR U ENS PUI N BRr °. SIAI Ivq IRMLfR 111E NO. IlAlf H C VEH. OIOR I N A '"'? y, N _ V[HICIEIDErIfiCAfION NO. _ si5??' ?'rl! V I E VFHICIE IDtN1iCAlI NN . I I I I I I I I I I I ?D Ag, GISIFP{OOWN[R:. UST FIRS, MIDDIF FNON[NO. ( IJ l 1 O REGISIENtOOWNtN: IASI FIPSI MIDDIF - ........ a 2 DDxtssa owrux -moo o?? 5 N E A wNER - I EA NAME a ADDRESS OF INS 6% URANCE CO. OR AGENT d Ay_ i?Tnp " ""U ' R INSURANCE NAME L APORLSS OF AGENT ]] - - t` DAMAiNt fA ] ) A n i vDrr41 CHA.Cl l3?DAM ALt AWAY C] REMAINED D DAMAGEOMEA CHAAGF o ie ?Uel OP • r" ?AWAY ?RWAINED ESt'D f 1 IQ ODIiOM S ]] ORLL 1 EID AF.. TiE towtDOY ) S?JJ E llJ F ? lowfD Awev Rr I ' DIAGRAM OF COLLISION: L DPIU IIRDIEwTNONIH eY AARON 5 UIIi NfClSSAR 1 -,. DESCRIPTION OF COLLISION: (Ln[suvvuiAENUL SHEET IF NECESSARY) Ie _ I ?ry RNT o- 1 VF. 4 CU.TzAvcw/J& .ATSPD...Wnr; G[LC?SS?U AIJD MY tjo LbEP N6 o v' _ I?) 4 •-1}J/:? I???? ( , 51- U , . GEJ">leQ w v, Po S-)"a?Nl.td v)r SKi5AlZWG OlF A 'PWR A, FbLE (6TT2UCK READ-CI1) CpNn1"G. ?. RES' A SEE FACtraG- SOUTU .. y ED Fr Tai-At-• ., 7F? TO FL4? " DRIUF.R WOUS 2r1U '.?APO SWFT AQD eMLY t 0 3 0L ?J r E u k --? LILCE9 cW LOAS0 `!"46J WIF ). T 1,3D SfCI D MAQIZS ulEkl:r rN cvio s. . r L IA r '? NAME, ADDRESS 81NJURIESOF PERSONS INVOLVED +CODES I 2 3 4 5 6 OCCUPANTS /WITNESSES Liao inDR°IOIIei rMRAa"" iii stx AGE stAlus .,n .° .w'.. . RFS1R.uea ., n .. 1L 1 - d? r1AMl F - J ' ,. }t AI%IDI55. - I OF EN RV ?AM e. ? L ?INw T o arr ?rugV 1 ? IN NA ry,?{g? L%PfET,+M!I,fvn?c H r •DE>atss .. - x iue or ... MnvID rR ?AMe. ?PpKT? n' . O nx ? :° Fo I I ???'rblp`ryMtII ?LA•?" ,uA1: ? + J { a ..4. ?' ? JLi.1 }S.?dY,rviJ{f:tA'..Q . :1`'. .•:.?i .. . ,. .. ?? ? N? ? efY" rS IISr?w +treI mS u lE 1? 'A ,tN rei STAYIE OF WASHINGTON ' rKJ POLICE TRAFFIC COLLISION REPORT C^-7 TRAFFICWAY RIIICECOMRAINT NL '. PRIVATE WAY .. UAl[Oi COINS N AY OFC III ION F-E ,? ?Mr N fIx uDx ND w1R 1NF1s 110060UR1 v Z X COUNTY „T t2,YSU A. Se COUNTY NO. CITY NO. Qfz-R uAN ?yRL ` ON OE ?IN CITY OR TOWN N-FAT.OFSIREEIORHIGXWAT a. MILES @5 ?W G-1 G`, [.e AVn ON Wcx VN11e ,? FCl CL5 ADMa ROUIEORS-11 `3 v'i"" SECTION IERSICTINGWI111: SIR E9QWA0 NONINIFRSfC110N 1 Y,UT r,GS- W -El I Z- +e lk- R?Ra PRlFI% EO. MILEPOST. Z, 30 - FL ANCIADIR[ 110 FNOM PflfafNCE, CROSSSIRfEIOR NFARf51MIlfP 5 D/' Mn[s .-r?-.5_...f...• W `'n Ff[I OF yAy'j- oxFA/ RO ACCIDENT MILEAGE CODE DI RA` P AGRAM DATA COLLISIONINVOIV[0: SfVFP11Y: VN NCIAILLED-NO. INIURFD ?' -A O '' HlnovI01X INFER NON .a0 INTER Cl5 NCR OSSSfC11N TR EIOR ROADOR REifafNCE STREfl OR ROAD 71', -N . E Q IXFN C1'VOIICI(5 l_I' ? PROPERIY DAMAGE ONLY E I .,5-2 Oln? OBI[CI STRUCK(NAMEOFONECTSIRUCKANDOWNER'SNAME) ESI.DAMAGE S SRCIAI CODING US[ UNIT NO.I UNIT NO.2 OVEHICLE ?PEDESTRIAN ?PEDALCYCLIST RI'S NAME UST "'Si MIDDLE WL-S I e M L es DRIVER'S NAME: USI FIR MI l c?erso l/?/i1liaw 1le.wA ?O SIREff ADORE SS 1 66 Ce SAFE TREAT ADDRESS G 1 1 k- R-6 ilAlf IIPCOOF PHONf NO. PO ?T I v wnsc c? W'A 3 35s=z[13z D R I SIAIE 21PCODE 1w41 LI,j) C? ?S3GS 6v '1 T DNIV(R'SIICFN5f N0. E% DAFD 01 BINIX YR ?l)ESTY LM45 C LtIVq M o9 07 sr I V Iv R'?"?C[tN,Sk NO. u? l?W ?F ?}sSSS D AN tPTf Sf% /f'? DAIEWITIRIH oY ;S5- _ IZ B O)CCVPANCN l1RMNNAf 6PHONENO. EYES IGNt YfIGNt > io E R occuPAllor+ {IRM NAME6 PHONE NO. EYES WHGHI HEIGHT ? ECK (?) VENICIE AS AN 1MKO1Ff Of ANOTNERAL ? CHECK (?) YFHInEASANEMROYFf OFANOTXER, NODES ? 7 ) + 5 E +Ia+ a "sA°rz° CODES ? * 7 <i / A is 5 L% a 1O f°L-. " si N . irv ]P TO 2 w warts ". ? AMROIANa ? MCI ? C-Nill B,„„"K;i ? VON1 MI"". E7?;'OF." ? AMPIAAN[E ? f«I<1 p p8:n. 13 ?;'1" . ? V(H. / U / ANKF (DODGE CIREV.) , M ELIDMT-A) 51YL1 Ia Da.CIXRV.I P/k E FAR MAA 1 . EV.1 MODEL( DART NOVA) J_ TY V.1. 5 frv SIAIE IRAILEaRA1FN0. SIAf H vFH. SAD N. Px ?1 I wit ' G T 807 w? (3rT - C ? VIXICIfIDEN11fICA1gNNO. -rz6YRB o,3-7 y e VEHKlE 1DENII All NN 2s H)C S- 32- 3 ......E LAS PIDOWN[T IIRST MIDDLE 7Qf ZT Les-it, PXONENO. 3gs• z43 ° P IilfN[ AS, FIRST MIDDLE ?nr?l,cso Jl s? PH Nf NO. ?az_yy?E ': .. IB E Z ADDNlV O'WNIR /yd Ce?,-rz,"u 54 G8 E A DANER f2t+ I /i a ?l7 ?l Lk<I?owL/ °&3!S' BI ?f N AMI.AODRESSOTINSURANCICD. OR AOINT Wn url,SV'•^ R U E F A ,Q DNL+`.A- .S IT,t ?T'h - (T H, DR T R ?V/.G ZUA - rIn[iOrDiu CNARW wC 0uN 4AMAGE AREA CHARGE ' DI OROrtOkF y o EST'DAMAG e U. -N ? R[MAINID ? AWAY ARIA ?AWAYN ?R[MANlD fsl. uNAACf P ? 2, IGl0110M s3voJ R ioAiDm.. '.ve r / w nY. YF? Try f 3d [O - IAGRAMOFCOLLISION: 11 uP AL INrsiuli NDRIH SNEEI D NiceyS.[RY) A "K.S 4 / DESCRIPTION OF COLLISION: lust SUPREMLNIAL SHEET IF NECESSARY) Vlrh `{''I vliLy ?.Tl Eo• ? o.• Wu'rV. U?y ki. ` C _ 7 JAlll: Iv ? \ ' y 'A'• ' /Chl TNJN Ju• Gf.' Vel,r * wr3 YKyk,?IRY 4 ? ? ? ? • - _ . ? _ - ,•'-..• ??? i?c .: ?v<vY -?•A -?l e..,,,,/ 1• .S IS dY, w. Xy ?AEpp 7 T/1% l ' H ? J ? , _ n • • ..-?,?. C - t ?Y e.l Wei •f/ 2 WLYS . AL v1 'I> VC. . r (I 1 T`I 4+ '._` \ YrAFL•. 1 K u?c .u••+ fu ENt'I. // Vt 4 yr z ec C A l a l ) th - .aD v??„i. i y °•u ? ?'/ I p „ E- $ IAA oY K L,1 .a Mec 1 saw nu- ?' Nx?TI, ?I`.w.f PI.T ' IMP/ CT L 2? ? F st',LA(dtN O ? {- ?lC rVd: VhLcIA-) L•.C of •LVc1d r ". )rf Era i•fn FK: 'LT 1'•.<ra (?r??SILIL ?<<'1. '? Yu Lac f??'E.T. /N TA`s, c. f;,-.,A(c'34a• ' , rNL,'rj rs •71-R. kF-tL L.alKwaa. c.Vt4 2.O -;... [k:,, Z t,.?. wL NAME, ADDRESS 8 INJURIES OF PERSONS f" INVOLVED * CODES I - 2 9 a 5 6 OCCUPANTS /WITNESSES 10 ;ADD-N:I F+u F1 SIX AGE TAIUs I „;;x (ERECT rr NAw r lay-.r WL'S•1- S Inga.i y P ra Z3 f" •L49 Z f Cr.\e..r T Auu 771 rNAtpa LTi •r I Nl nr ?Ar ne. ?ed"' 01. FM ? U.N ? ??( ] Auk JL.IU A/ nJCrs e••s '? "T 3.L'H96 `l 1 ( ALKOIil I . 7 •f' QS N IlM C< N INTEL FN ?AMe. ADD- 1 ? g LY c 1 C?j 1 t i??R? 1 ? ]k1 > F IYU. ` POLICE TRAFFIC COLLISION REPORT ® TRAFFICWAY POIICECOMPIAINI NUMBER 'r/ PRIVATE WAY / DAI 17iII VPy1 [E} `L o O.1101' IIMF wx upx u I,Nr Nl :M9 URI OUNTY C - • . ^..+.•„ COUNTYNO. /& CIITNO. FHWA ?A< 1 QN QL Q N `WE/IIY OR IO ?? ,3.!5 kWL[S S QW SIOF ,3.!5 ONN0.MF6NO.OfIOR NIGNWPY i U Cr CIS AOM RWI 7f?O - 3 SECTIO INI(RSECUNGWIIH:STaff10 AD NON INIERSECLT?IO?[[N??L?' /? / N=EN F4N ll. IZD STREET I Q (BBS W 1i PFIIUL I MIIF POST y, o If 6 DISIANLI&DREG FR M E. ROSSSIREFIOR NEMESr MII PO51 MIlfI N 5 E W ACCIDENT MILEAGE RMV DA GRAN DATA • FEFI Of "' A IC,IJr CDDE RZ COLLISION NVOIV[0. SfVER11T. SION NO. NETK LUD_NO. INJURED- ?SPIIiAGE QH SR TOTAL CR....."' 10 MPROFERTYDAMAGEONIY Q Y'ESUIIED ?Vf'IClE HpH'. BNER no INTER Cl5 C R CI iRf RIIOADOR RfiERfNCF ROSS STRFETOR ROAD 6/7J 0 jY NF O6+(CISIRL KINAN(OFOeI(Ci SIRUCKANDOWNER'S NAME) FSr.DAMAGF E.r= SPECIAL COOING USE UNIT NO. I UNITNO.2 Q VEHICLE ? PEDESTRIAN Q PEDALCYCLIST 5 DRWlR'I NAME: -1 NRSr L O SO?J E2 DRIVfR'SNAMf: UST fIR I Dl 51REEi ADDRESS STRUT ADDRESS SIAIE ZIPCODE PHONFNO. LOA, CM:3 '6' ' R TIT SIAIf ZIPO DE RrvIR'SI CFNSEN SIAIF DA GRIN I IV U ENSENO. SIAiE SfK DAEE OF BIRTH p Ill Ns ca ?a wAR M° 1 R V 9 OCCUPAIIgR FIRM NAME 6PHONf NO. EYES WIGHI GHI E WEIGHT WIGHT CCCUPAIION FIRM NAME a PHONE NO. EYES Q CHECK (,1) Y(wci(ASnN. Y(EO anolHlRU Q CHECK(?) ¢Ef ASaN rmv orE(oFaNOrHEeM Y CODES ? 3 " a 5 F a r6L? CODES P- 0 3 N a 1'"ua + RP ? R I NIURIFS 25 p ? AMe u O WE ? Ebel. ? H at C3 C%'IV M ;S' Q MPA NcF O F N roH' C3 Eb:11. ? G . K? ? Y F 1ZDR.5F Vf fAR` ANR? l 0N) 1 SkA00fl IDMl.?v Fl N CJ/,?`',\I P Awt l FCNFV) rfAR VEH. HADfIIDARI NOVAS 11 LE IZDR. VI. VEH COLOR Iu -1 + r O qq I H R Y H N ATE ?^ YJ VEHICLE IDENTIFICATION W.. M O 1 CW 38 ' i vfHl if lDfN11" N I . V PHONE NO. FEG111ER[DOWNER: SAS, FIRST MIDDLE GA 7 O RE ISTERED OWNER: EAST {IRS, MIDDLE F %L wflsa owNW g _ 666 Mwt)Low UJA? R G5 E owNEa ADDRESS OF '- NAME a ADDRESS OF INSURANCE CO. CR AGENT R ADDRESS NAME I INSURANCE AGENT ero I D SZ DA= AREA ' -,"7lv OFAMAGlOMEA -- FwciiorDiAL CHARGE CHARGE C !SI rOAMA S IS,.10AMAG( ? .-TIN ? RLAWNID ? AWAY ?RlMAINlO AWA T IOW[D IU i'OrTOw T\F S FEd [ ?1F - 1 ? Awer er: $ - DIAGRAM OF COLLISION: Iu nMN INDICwn NORln DESCRIPTION OF COLLISION: Iu5[suattfmLNru SHEET IF NECESSARY) bMRhi N[C[SSMY) (YARROW o V04,50 R{3D r MPU S EO 70py?S A A 1 QWOJiOFOLU FTSHOU DRIUE ? -=° Gc?Ef2-N0 eoMIk6 B "tj (?AUt aj LLr ??u?G uc?r r-afle IWO'r - SPUN A _ D"wAGE 'Di l r AND S WSW, 0j.TO " U9tl iZ)P &j Tp SOx S(L>= Ce9ritlFl 70 i .... _ ..... _ .... • + .. , . - . -- - ? : LAQ;LM DW-U) FAnk)S &YNaNF WAp NAS W 5k0W bbX A PABBIr DID +xT Z: 2WLe .v- • NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES I - 2 3 4 5 6 S OCCUPANTS /WITNESSES liDUR iuaiariu rµR,va iii SIX AGE -U1 ' I" RE. 1 RESTR. IT fa ?1111C.14 NAM AGI NA?gREa TI rWeY ?AM e.0u' ?'" rOR ?Cffi Ar! W j AiWru1 A1URIq R1MOr10 FY(Hx QAM1. QipKFQw1 rQH ??: RD AMe Fw . ADOII 33 ?T L,??Sa INlE+ER f FW r ?AAL/ ?fu' ? OnIP OSIw ?n 10l KI PR NO OANOFEL-1 AIIEONDIY D i! YES r, E K p IADGE OE AGENCY « I R KID, A SP ICWD I ry U Y7?rtk r.1F }y1r '? v aC';,1 irxlri Clr, Kit V R R1 a 11??Nx};?y. ? •+vn ..fl?,. ?fl" '?+ SF!R'?P? I?1 ' f:; r ? R t,d i y J t 40 K 1 R I '?,r ?x fit. ? 71 F 444"' y Imo- . ?U? ' • rf x A STATE OF WASHINGTON WSP ISY(RFY. LeR, qGF GE ? NO. POLIC '" ?n ?.e `? E TRAFFIC COLLISION REPORT ®TRAFFICWAY ? • _w occa Poll PNININ uMefR PRIVATE WAY wcom ' T } . .. it R I Z r N I i IS ?w1p ItHUE31 ("t (USE2=MNO R) Q COUNtt GWNtY N/O. CIIY NO fHWA ?URBAN ` ' ?F OIJ IG J' DN ?F IN CIIY OR TOW ? N . .. N Ee N0 0 StR URAI . EfIOR NIGH WAY 05 M ? ES I ;fyJ MI S ?W OF RWI pSIREEI SF ION ?? C ON a IH:FREECfING WItH: SigEftOR Ap ' 'u ?I'2Op?f N I NONIFRSECIION , PREPI% FO. 1J M FSr Po ! /y LANCE 601 ffR CRp555rR f100. NEAREST MI[F STREET 6 E 3 MILES N ?W FEET 510.fET ACCIDENT DIAGRAM-.A I fi OF COll3gNINVOlVID MILEAGE ( i r NO.fKIUDRllYl //yy --NO.INJURDSP l fLE aCOOE FSi. DAMAGE I N? 4 R(PfRENCE Y? j & .. IASI y i mo[.UNITN0.4 Q VEHICLE Q PEDESTRIAN "" ? PEDALCYCLIST .S1 W^ Cy RrvER'SNAME: Iwsr EI l I l _ ? N T sIR[Er A0DYF55 GRZC ? ?, , - • L? ? ? ? ECQ C H , ?{? ? P ' . REFI ORF55 r ? ' ! IIT SIAIE - LIP CA ?'?S /OEC? RHONE NO. D I StgrE Y ,S Eµb D?NEq's UCEN - p U[ PO rwbN? R P H Y r r TT EKaIT, i1RM NAME tPEgN[NO SrArf Flt B H I I U FN N 01, 1^1 I I Ye. V 5 AIE DAIS B R H I OqY ?YV } p.'^ 'F• p ? O ? 1`• EYES GHr EEIGNI E OgUPAEION PIR E 6 PHONE NO. r T Y1T ' Q CHECK (?) v[HlclEgsW AN Ef O EYES IGH} {(IGHi ,^ ? ? S•Wn` FANOMF Q CHECK (? I u CODES?+ IN uy % SryrtM l Iron yyr VENICI Sq5 fA1ftOYEF OPANOi s e 6'y"O Ox.eu CODES?+ as r I wl 5 <n ? ? " }?I 5 ? ' ' o' oH 6 yrt n s°?JwiY °?' ? ARauANKE " IN RI ro VfH. YEAq ? ?[ ? Cbirte ? vtN `. ? iuHy1 MK ?orroM ?u.J IvU Q ' iEFg c[ eu MARE IDCOGE{HEVI Fl[DARI.NOVA O rb{ ?H I • ^ i :. t I ? V Y 1 SI ]D .CONV.) ( c R m HEV 1 t qRl. VA1 ? [a?Ny cax Y U Y a ' ? E I1 Y.1 : J VEN SIAE lAR tpAllER nArf NO. SIAIE H Ym. 1 ? - •. ' IOFIDEMIFIUnIION NO. I InI I??I ' ??I I I I 1 ` VfHICIF ONII{I R[GISRRFD ? I NN W . ;? ' OWNER. 1. 5i FIRST MIDDLE ; 1 I I I I I I f I RgNF NO 1 5 . O WNFR IASI FIRST MID yp ADDRI53 pOWNFR v? E q . O .., W A NfR N NAMLRA-a$ OF INSURgnee eo. oR Aewr E :. R "sA"o "0 R TO • o N or:RMC[ CIIAFGI • 1 _.. y O ROROir [51. pAAKAGf AR V[n [] CNAAG C) RfAUINfO WAY "y, yNmG OI. UiN.[ ANAL[ U 9 -32 + f ? Al AY S lowEo TOWED AWAY ?RfMN f0 Y B ESr DAAUOE t 1101 _...___ y {' DIAGRAM OF COLL n ISION: LEI AWAY BY: WAY N U Al IND U S oROnol J IR IF NORTH " SHER UALLCLSSMYII .{ RY AeROW DESCRIPTION OF COLLISION: [USE SUPPIIM[NIAI SHF[I FNECF35ARY) T _ ? VEN 1 I E. VIAS .. EA31 Bo.uNn..oi•a _. VAN '1poTAP ? I - AND LOST CoNtiaal ? VAN 7Ru7TAN' ?'REILI youtb?R. .AND Nxr. DR A , • TREE _ y , R '?{ ¢ .. •. ADDRESS S INVO AME FPE INJURIE . LVED O PA & CODES SO n u uvOu ? 3 , ror ACdtaN N usl NAMFD(L AF ci urus DA NH v r ? i Re s R. ?rtn ,6 ?+ , c 7 A . •DDa133 1 I ,9 , NAtuR OF •- ' t I 1, - ,. ti.{i? t' n ."A ..:.?n5?b.f Ff.yERl( _ _ .... ru' -D-r I_er7a fR OAMe. Qr'4Va'? "F .09 Hx ?W.. A 1'rpA Y -+?.? ...}•?i;1 ...... J J J F ,ya I?r? 1?°z°`..F L 1 a wA'F .y ;?. j _.. .IYh ;F, i I et., f, il?Nl ? 1 ` as N r- I c w ? .- d ) ?+ J ,i" Nr a ? r?e / , u 51! " &x f t r 7 S fI T ;'I 1 ? 5 r: ! t ? l 1, 1? I t `, I? I f.. 1 I ? t tt.. r I ? II, t t ? I i.[ 11 F7 jq ? S ? It ( ' T rJ t I Jt' • r v 8 ?. a 1 AX I y - - - - - ' - ' ' ` IVU. POLICE TRAFFIC COLLISION REPORT MITRAPPICWAY •. . PalcfcDMPUINT uMfa 7 7 2 PRIVATE WAY 7 . DATE E ll n. ? . w1M? I4 f ,I IN - ?R„ I Il rA (USF SbOHOUa 2 COUNTY ?F?N?ZSe?J COUNTYNCT C Y /? MY, . ? URB ?,_ pN OE pIN. CIIYORTOWN Ee NO.OFSIRFFTORHIGHWAY^ -ES O 5 WW k;?OF !G//I ON N ?J 1 KICKS A WEO?S XEI 3. a S2 coo sCi ON' R. l-IH SECIINGWITH:5TR OR AD 1 NON INi1R'S/F'CIIO' ''1 9FPNFfNLAV?I / EIREfr &W 6 STREET PREE% EO, - ry OHO/ b 1 Fe DI [?i R REf[RfN ,CROSSSIREEIORR NEEARESTMIF E W ACCIDENT RAM Or l' EE MILEAE CODE - A ION IN ERITYI NO. KILLED-NO. INJURED ? SPIt1AOE ? TOTAL NO run0 - IMER C C ?I CI .? S TEf OX UOM _ A J5551ALE1 OR:9A.?. RS . Cr VEHICLIS p PAOPFRTT DAMAGE ONLY ? R'E'SULTED VfHICtF -????? OBJO ECT S?.tlR4UCK(NPMf Of OBFFCi STRIKK AVOOWNFR'S NAME) EST. DAMAGE cEp,92 7k« s'tumA? 5KCIALCODING1r;E - UNIT NO. I ,UNIT NO.2 . ? VEHICLE .; . .[3 PEDESTRIAN CI PEDALCYCLIST` •. 4 3 RIVER'S E: tASI. HRS ESEL y MW S? 1157l D41vER'SN- III fl t l - - IP{EIaDDRES4 REEi AUDRfSS ' STATE 11P000E HONE NO. ?G[r?/Oly 9AP-5r 3?2,g23 D R CITY OMIT IP D FR'SUCtNSFNO. IwIF a9.S 553 W f% N%j BI IH ?3! I IV LICENSE NO. AE % DATE 1-1. B OCCUPATION fIRM NNAF SPHONENO. ET[5 WEIGHT HEIGHT E CUPAIION f I4M NAMFe PHONE NO. EYES WEIGHT HEIGML 2 R p CHECK (?) HICIf SAN MMOV EOFA OIHFP? ? CHECK (.1) VFHICtE ASAN M Cy",,AC PCIAL CODE S?* 7 n . i S NtCnOx a -,TO ,-c- .x ? + 7 a d is 5 fx D sNOP. 3 N n Z IN NIE, QI 5 t x:. pM 0.Mfy1ANKt ? MCI ? 8- ? =1 ? :,H3. MM- ? AM I o u ? g,6- U IT.. YEM MAKE (DODGE CNFV.I 2 r-J FL (DARi?novAl STYLE IVDU..CONV4 /"CI E H Y A 1 H V.1' -(OMr•NOVA) Y V ) 4 IICF PIA SIAI IRNIER RAlf NO. SfAIE H VEH. CIX l WR `_ I VFNI IE IIXNIIfICAiION NO. - ccF ;?i I ??2068 ` VHICIF ID N111 N R(GI3RP OWNIR: IASi N43I MIDDLE PNONE NO. / O ISt FD WNf R: 1A51 NRSI MI DIF N N . u ADD IuaoWNER ? w N - NAMtaAw4EUCrwwRANCE CO.o u+r _ rm - .tts R SZ41Fi oR DAwv.G[ Avu " 2=1 't;AMACeD AxtA E 3 + CH41G[ CHARGE + '? O eO1T0? 3 If-GF EST. ARwiAYN RfMNNED ? W ? I-1D ORIVtN ? AWAY ?RUWN[D tOWFD t31.DAIMGf RTOr •• IO?OTTON S O wwA ? ww^r er f R DIAGRAM OF COLl151 N; ?u nr NE1USSA-11 Rr wl D r ITn e Dw w DESCRIPTION Of COIlIS10N (USI SUPP1lM1 Tu swnuN[cnsARr) le O 1 i I alf 17 aL)o I. ) ! l Ame - ----------- 10 NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES 1 2 3 4 5 6 OCCUPANTS /WITNESSES Ip AOCIIIONAI NAAV 51 _-..- lATU3 Sf% AGE H1 110 - 1 N -*i, E R fA t.R, ..-.._ FS IJER . MICj' .I Y AME / EY / a d T 8 7? J .Data . NArL?R w --- fM nY - a ?T'4. , ?Md . ?p:Y' [] ft4L. NAME ,N?Nam eatT !? N?86- 378 , wale O ??10 . NArw C'. mr Nr 11i:.rRDM pAUe. p.,.Al ?fo' . ? Ax O.° "q . N M K ?ia b Z 13 71& ADDnSS O . .._ ?°f pwM. ? °: I ? ?P,:,f. ? ?? p 1:??,. K SINi Ed KP'SIMMr ' MD. nEK KIDS C D GIN 1 ?•1?0 " ' ? _S(l a OA ( E G:? Wc' DwllpnnMT A.MOVTDeY •u?'a.,iv... DAI r Tn`5'l'UYIU 1 <' s(.111friLT ? nL•' Yd 1 ;??al Air I.Y? f f1'. 1 If. T.il 1 I POLICE TRAFFIC COLLISION REPORT d'TRAFFICWAY Poucl coMPIAINrnuro.IR PRIVATE WAY pAIFOf ay n A IsI n counIT E 7 ? •x vn uox 1.,-ur (USF 1?.'p 110UR1 ` ', Y VE Ja- C ?Y couNrr NO. cnr NO. ?? ?ENwA U/40AN ? 2 .. v 7 ?N ?f ?IN rYO tOWN E%NO.Of Sru(lI ON N,GHWgY MINS ? 5 IE; w eaf C ON ,1 iCI CES M RONF ON IRE Y,' ELCIIN l . . UHIRS{CIING VAIH: SrRE[IOf(ITOAO NONINrfRSfC ION ` ° I BEIWFtN d Z StREIT 6 ZO -LE P4(f1X E0. Mllf P051 1 "'ANCta DIeEAI FRD REffPEN .CNOSS SI4EFt OR NtARE51 MIlEP 51 IliS N ACCIDENT "E-.-W BOGY RAMP DI AGRAMIATA MILEAGE i[Ft 0 ¢} OF cs ; C OIIISKIN IN- CEV{RIIYI IOIM NO. nO.K D?NO.INIURfD= HUGE SI NN IUtiouiRir, CFVfH O_ RONRIYpAMAGEONLY %. D IN fRSECTIN SlRtfr BROAD OR RFfERENCE IN IE. Cl5 CROS55NREFIOR YOAp /) ENS j?E 091ICI STRUCK NMtf OF ' . ?. sEy?-?zoO - OB1FCI SIRUCXANDOWNER I I SN , 1EF.-AGE SPECUI CODING USE I S S UNITNO, I Ue VlR SNNAE UNITNO.2 LJ VEHICLE ? PEDESTRIAN S G PEDALCYCLIST N' : IASI f Il M ) O IVERSN U oR AME. Sr Hx f Q P. SIRf .YtSS a-, L 2 G3a„ LIo1 R Ste[EI ADDRESS c }? 5AIE 111- PHONE NO. D CITY surf IP ° - i Yj S369 z T TaA VLS 3 R N N . N % 1 3 pRlvt 5 CFNSf NO' rY ?s5a9Rb w? INH M ?z! `o..I YR 1 V ,V R 11 ENSE NO. All E% DAtE b,RIH , DA+ YR. - tl ACCVPPIIW, iIRM E6 ON[NO. (l E} Lf)1 r uI 1 Fs WEIGHT (RIGHT E =UPATION FIRM NANE6 PHONE NO. EYES WEIGIEI HFIGIEt ??. acs y , , u I ? 16 R , ? CHECK I?) lH,aF ASnY iMnn Nu IH A ? CHECK(,,) O O I"l O r Z CODES 1!' D A s S 6 .Ass m I Hn r FIYCH-SANFMR YFF AN mEe CODES ] n < it 5 N 6 :+ss ' ii:"' rcH v I?n rz1e nuns u " I ` „ MANC! I ::rRD MAK?.oocf Vt .cHfv O u nii DI rR PN ? N ooEn I p„ or m s<rm- .D ?Am IANCr ? MIT 13 «Pi1N ? vi,,e ? ..s.. i 2 . J » R1. C1 VAI 5fYlE(N DR.CONV.I WH.rFA HEV.) MOOEC 10AN1NOVA) 11111 IDR:< v.l 1e 1 p4 III PIA F 51AIE AII-A1 rR E N0. S f EN .caoR - V N Il N o) Wp} _ C A RC EE IDENIIfI cAl1_ of rNCIE IDfN1,N AN N . 9 z .a . 6 SIR O; / !5 3 3 L ; 1 , 0 E N(G,SI[Rf00WN[F: tA51 f.... MIDDIE S PNONf NO. O Rt I3-MOWNER: FIRST MID°[E PHONE NO. r° I? ADURES5 p OWNER W N A F WN[R ]I E NAMU ADputsS Or n+suRANCf co. ORALlNI 1 F K. o Qr T Qh ej E.A. 1 7 R T97.MDDR- OF INSURANCE NN 15 NDAMAGH.Anew -°?? /{f- S p I a ??? . nvnwa l51 "WMALI CHARGI ??. CHANO[ (AWAY ? P{MAIrI[O ANIVTN OF-Fill ? !'?IYOW4 ESI'IDAMALE ' Q. 1. MEA IDP • S ! \ _ J/J S W Y Ll?rl c ?lowf° Ar br. 1 Awqr er. ? '0"o E ?IU e'oriom DIAGRAM OF COLLISION: 1 > su 5 ( f 1 I1 Irm cqE noRH' tUNECI-Y b AIINOW e DESCRIPTIONOF COLLISION: IU515U1 M[NIAl3HEEI If N[ct55A4Y 1 / tw G Ate, 0 ? r _ _ _ _. c w u.? L:; A, r/, A.., •r--- -hem N ?a]? w fro// a S/Y rl iA? i7R IYw.Tyr2 R.. Lk.(ZJ NAME,ADDRESS&INJURIESOF PERSONS I NVOLVED `CODES I - 2 3 n 5 6 OCCUPANTS /WITNESSES : °ai ro ei i l N 51 ' o r -) o AMT: SIX AGE z1AlU3 Nn ,IS R [s10. [1[CI i o ' H -H S4 NMU?[OI V/NI NY' ?AMR ?«, . .. ?iyn?r ?ii11el N AI A IXVII51 AMI U AIUR(01 IROk. 1]AMD ?rDi K1 U?1 e:?n ?r? IMI A UAIU U DDI115 41.'V rvl N RI 01 ? w.e ? ?. nl ? ?iwR+ uoulA:AEV.Ga K awmu i 11 A ? w ? n nSr T . R D IcreD la ti X D'O AfAfKY CxL API OWOX/ pAN. N-l u; u`t OAII y. TC Y111Ytt4N.S'I :71 eF' 1 IVO. POLICE TRAFFIC COLLISION REPORT ySJTRAFFICWAY FVtKECOMGUNTNIJMBER i - ... PRIVATE WAY al DAI i ECgf,i N_ re i buff L W C . I IMF IUSE -HOUR) 0/00 OUMIY ,f /LSO COUNTY NO. ? CITY NO, , . iHWA ?URBAN URAI ?N [pE []IN CIIYOR fOWN NAME6N0.051RfEtOR WGHWAY 6 MIES ®'S ?w ?DP hd.mx ON O KT f15 RWi(OX ff 3 .SG 990 SE ax ' gSEC11NG WTIH: 51REEl?OR NON INTERSECTION a? /(, frl Y BfiWEEN SlgfEi 6 SITTTT ,'wix E MITE p031 O-Q? J UUUC UISINICF DIRf IIXJf MR R SIRfEt OR NFMf.. MIIf mRFS N 3 w ?jLYO Q FEET Of , ACCIDENT MILEAGE CODE DIAGRAM MiA CIXIISIONI V lVfO: ERIIYI l?Vy IOtAl NO. NO.KII[FD_NO.I JURED? ?wttt G ?M l¢ wnovfRln RD IMF CIS OR 1¢fFR[NCE WOSSSTREEfORfEOAD - ax ' ` p ?f OFVEMIUES pl[OPFRTY DAMAGE ONLY ? p[SUIfFD ? VFM CIF 'P 'Fie C? ? OBJECT 5IRMK(-1 O{OB- STRUCK AND OWNER '5 F-EI ESr.DANAGL SpECW COOING TAE - " UNITNO. 1 UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST a' IV I VSr l DRIVEMSNNAE; IAST 1 ?MIf ° SIRM -TT ?? ? ADDP 5 ? IY STAi ZIPCOCE PHONE NO 3 f 37-?/S? D R IIY ,TAIE IP E VEN'S UCIN N i-RF-7'- QC/f STA % `YJ D. BAr ?S'6 I V -WITS N N A X A BI H Mo. wY IYK.' D OCCUPATION PIPMNAMF6H10NF NO.. EYFS IGHt WIGHT E CUPATION { IqM NM'.Ee PHONE NO. kYFS VrFIGHi WIGHt _ ? ScLUn Pf L UDG04I i! R CHECK ? L") I yEWUEAS ?NfMDiOYFE O{ANOIWR ? CHECK(,') 1 VEHICtE ASAN fMROYFFO{ANOIHFRµ _ I S CODES 110, a u X w 5 Im- a 'f'O 'K"•?-• CODES ?+ 9 a a ?; s u a 'f'O a, 0 2 17 UR1F5 M ) MnaWD ? M.A wKf ? .IF s: F ? r&_ Y M- ? NNA N I ? MCI ? w:R. ? KD ? "W6. Y[H.YUG f1000"',EVU OARt.NOVAl STYM(TOR.-Y.) H.Y R N V,1 MODfI IDARI- VAJ R, ed 9 C4tac o 2 2 E " z C (NSE STALE iRNiER nAlE NO. 51A1E H YEH. OR P v /1I?2 ?y7 A9- ao ' V[H1UE MI{IGIION NO. Z! 3:7i9 L ;S 0!71/TOTS I I i i VEHIU ID NII I I I I ! 1 1 1 1 1 1 1! REGISTTRII-R; -1 "'T MIDptF PHON(NO. / SiG 3 - O W REGOILREDOINER: 1A51 {IRSf MIDDLE FFYDNE W. IJ % ADOgessaosvNEa " A Wa ^ J- B s- r w E NAM[{ADpPf3501HSURANU CO. OR AGENT R F-1 & AID-5 OF _ I Sx DAmAa Anu ' S DunAGe AXU CIIARGF CHARGE f f ? u IU?O f EST. DAMAGE ?AIAti aLMAINED • ?AWI AY ?TG PJED ISI. DANA 10lOIlOM f § G Tax o AWAY er: GLS ? TODBY: rtvY AwA § R DIA GR AM OF CO41510N• SiHtiv YI _? r?4R?wP1N DESCRIPTICt OF COLLISION; IDSFSEgnEMINTNSWETIPNICI5 Y1 ? / fYUVM Sfans? " Vehicle-wan No bound on Oak. _bay. at-high rate-of. acs speed and eweryed to miss a deer as roported r l 6C/ 3 by driver and lost control. The vehicle appeared _ 1 . -' - to flip"end over end and came t- rest facing the a y other way on its side in the ditch. The driver x left the scene and failed to report the accident The vehicle skidded 135 ft and left the road and continued 69 ft until coming to : rest NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 9 4 5 6 OCCUPANTS/ WITNESSES ,a sfooulHU(p u,?NAVW Ui u% 11 AGe TAT -NJf vesTR exci NAME: -ITS Nufbv oP EWeY. AM e. O51K' OW"' p ?t7S pCBIrf+ F HAAU. A •U .. OOBI H i B d _.. .. .-. . 1 ID,1 ?AMI I]va'Kf ?Wfifle?i' ?ti?i,v A H ?AMB ?µ" ?KOme ?M ?"'.w , fs ..Gar E 5 BAN. 1npa rev'.-?.. •: %? n rIM1 .+1•... '^"'lr ?' .. 1}. -.,. .ur n..re• ?y l ;y n§§ i. b J ? 1 ,?'?? J'C p 4 A E t l 1 1- ¢ .IF-q r 1 p s t ' ? ' , ?? 1[ I ? rl k . i I 1 t ts d f 1 ?aBrw +r ! ?ti ,'? r ! l? Jx PP, A DA ECOII i. I 1 A H1 PoICECOMPWNINUMRER PRIVATE WAY - CO U N S Y { Y+ ? O wlo. iw35I -- COU tY NNO CI1 iH aµ ??T 1I. }5R1 ID$Et pp HO 1 ' ? • ? /d IC/71 S ?l ?tx ' . 1 ?N QF ?IN C1YOR1 WN 0 ry NNAFeN .Oi SiREEI OR HIGH WAY Cl3 N0? fORf qE i 3 l HIES 5 OW Of INI[RSfCiING WI H: SIgff10R AQ NON INIfR5fCr1 N ?_???0 ON • J BFiWf[N O OIStAN Fe Dl4F 11 Nf MRFi Rf PREfI% !O. 3[ O.o SIRFEI 6 "HET N .CROSSSIPEEI RNEARE51Mllf POt',^ MR[5 N 5 f W ACCIDENT RAMP. OIA AM W}A " PFEt pP C l l NINVOIV[0; R fY - MILEAGE - CODE I I IOIAL NO. - . XILLED? NO.INJURED_ -E. 11 C[5 !n I[SIN ? SPIllG1 TER fUNDR1p1H IME CIS CcCSS StP[£i 0?ROADN FUAU F F,-f / q3 PROPERTY DAMGE ONLY OBJECTSIRUCq INANEOf OBJECT SIq X. AND OWNER'S NPME) "? 7y0 _ (( ? RESULIFD ?VkaCtF 151 DAMAGE WCW COOING tGf ' - - I S • ' UNITNO. I DRIVL 'S NAM U31 '• UNITNO. Z •: VEHICLE ' •. ? PEDESTRIAN ? PEDALCYCL vT l ,7 r RR MCA" E U31 t-?'S - SIgFfIAp R ?/ e '. SIRfEt ADDNE55 ? ly STAl1 LIP coot. PHONENO. D Ity ' 1 p4NFR' ICLNSEN - .11 11 D L R PS NEN . ?v ! STATE % RIRH(. IV ll fNSf NO. y Ar V I/ Al f f% OAIEpOf 91R1YR I x0 e. OGCU A ONE N f ES N " I HEIGHT E OCCUPA)ION - {IRA NPME S PHONE NO. EYES '? 11 HI HE- R .? ?-CHECK (? •A M,PiovrfoPANOrHEa v r w A UCHECK (EM) CIf AS AN DM P? Rare r CODES? D % i s 1 IN URIES _ ROYEf O{ANOIHF d s°n •r,[ CODES lw ? ? 0 ° w sr S [% d ? 1L VfnOYEAR? MAnfl µCHfV.? ro lpf <b' IR A :: [rv ifJ ?'W NCE Q PUO' ' ? Cgl- ? HwK[ ? i'uia3r N O ' _ o I SIYIE ILD oNV J I f. HFV.J hW-----ARI-NOVwI Y I DR• J IvOy. H. 4 ' IICf L UFN S1AIF - E _ I4AIlER MIf NO. SIAIE I'( VfK CIX R I A Will if IDE 11F-IION NO. i V(NICIE DENIIFI I ,f.A I i I I I I R[G SRREDO R:" IAfT f I 1 1 f fIRSt "PPE PHONE NO. O R ISIfNFOOWNER: WSi IIgSt MIOIXE ND, .-.30 1 ADDRESS p OWNIR W A WNf R N NAM..-ll.SOFiN$URANcECO. MAGENI E ! I L . _ DAMAGED AP R . •SL x • I CH 5 CHARGE plw', gAMAG16 MFA 33 f f31. pAWApE i cl R[MAINED D AWAY DRIVIN ' ORfMAIH(0 ? LSf, DAMA F 1 RI ?e e S AW?v DIAGRAM OF COLLISION: N u le ' ?.... '1 I r ? sHEetu [USSARYI _. I 1 .4 ND 'RN0Ow- BYN - I ?AWAY $ DESCRIPT OFCOLLISION: IRE SUPPl1M1NIA151E111i maw,,, .. _ _ R CA1 f j..C. I-} i I_ t V I? L. (t?b1?UuuZ1lL.? q tlks ?TleuLK}_ Ffi -E--C3cl?5f .OEb IJGQ.r(?y(.(. J ?j (1? 1 6- I b IeE ?t1? ?. Cb- rtoC l1q , ? ; ? I ? ? , ? ?, "- -- ?cC•!z ?jji? GG?(JT IAJTO.__ 4bcElc?'1.. 6? 1 L r I . j I..: (L, bl (r?r 7a, 6?aizS?Q:- 1 i ! f Iv L.! 1iC1 G14 /•E•a1.? _ L'IJ^'N ._ .0 - - ' NAME,ADDRESS 111111111 F PERSONS I ? NVOLVED +CODES 1 i4 swnlMemµ sPR OCCUPANTS/WITNESSES u AD i WN SK U ...... - . _.._. - 2 - ' 9 " 4 _5 6 . -•_- _ _. DI I I NM,(; P .. ........ .. .. .._..-_ _......._- N I 5!% AG! f O. IAIUS w SEiY iHW In it vii u _ _ Cy" Rl31R. NICI Li Ir NA«t. Srr a Y OAM e. pE2L"' O "'?. O.".x ?C3?,? Afbnu NA NAM r ur pR a AI%"/Sf _. ..... .._. lil IN AJY _jfOP -ly. ?AMe. naa%'1 nwH_. I-I rRn n,rpr A ilim., ? a? ? •u ' .t - da A4 ? 'f? f ? {}0 ? A „ a r l I V 1 ? I Ir,;tk ?w I C tfi . , lNin V11' VV HJ 111 1V l7I QIV PAGE /or i" ? ? u?,.. +s '•• POLICE TRAFFIC COLLISION REPORT RiRAfFICWAY No. ? r.- .. POLICE TRAFFIC COLLISION REPORT NTRAFFICWAY roTlcfcomftarnNUMEER PRIVATE WAY ?L DAII OFCIXIISpe O?. ,(? G DAY i NOlll N wx uRx lull w I,;v NI i>wI? C IuSE Z•IA HOUaI GO COUNIV COUNTY NO, ?G CITY NO. FHwq ?UaOAN uaAl ?N p[ pIN -1--l-WAY OWN AMf6N0, N I- S .- AD % Ur, f)tl) ON INIFRSFCIING WIIN: SIPEf10 NOAO NONINIERS[CTION I 3 y., 69%a ] ? ?? R WEEiB DISTANCE 6DINk 11ON IPOM PtiENEN f ? PREfI% E0. MITE POSE I M C . CROSS SIREEIOq NFAIMI IF I ACCIDENT IllsN S"[ W RAMP DIAGRAM DATA MILEAGE FEFI ? OF I ?. CODE COIlISION INVOIVlD: N vfRI1Y: l 115 TOfAI NO. 0%ILIFD??NO.INIURfD I ?sPIIIAGE ?) uAVN wrµiDnon, a VEHICIES o1 / 1 R C IN siR FTORRWDOk REfFRENfE INIFR. Cl5 @OSSSiREETOR POAD Z] p MK-DAMAGE-Y ? pE5ul1f0 ? Vt CEF OD]EC151RUCK INPME OrWR<151R < ' `? ?O ?J I 1 U K ANDOWNFR S NgME) EST. DPMAGE G)R LE - ? - SPFCIN CODING USF _ L 1 nF 1 $ UNIT NO. I UNITNO. •I ? VEHICLE 0 PEDESTRIAN ? PEDALCYCLIST ]• D NIVfN'S NAMES IA51 flRSl MID if pPIV[R'S NAME: IASI IR MIDDLE 6J . Sil NS?rJ ? STN[fr--ttss S REEL"DRESS ?- - C Alf D n ZIPC ? 1 I ) ?' OOE PRUNE NO. R TTY SIAIE LIP Of PHONE NO. l ?- D Iv[4'S I CENY NU. r. m SrAll A DAZE FbIa1N 0703 . I. V IV R'S LICENSE NO. IpIE f% DAIEOi tlINIH D OCCUPATION F IRM NAf 6PrgNf NO. EYES IGNI MIGHT E OCCUPATION FIRM NAVE 6 PHONE NO . EYES WEIGHT HEIGHT 0 CHECK (? vrNlrN AS:N A°.ftovre nrcANN IHIR. L 0 CHECK (? vEH Cif ASAN rMnEirrro{AN OI Tt0AL CODES ? * ] n;'° R i 5 r e HE CODES 11" ] • i t, a s ° ' S Nl <, • ITT nnrEARwM 0Ae t ?v6' ?pS:il. A"„K ?'r'° I DODGE CHEV I EIIDARTIAVA) SiYIE T R CO H.-R( °„7:' 0AMeIxAH<T0M" 0E9P11K 0v11I' 010- X . I - NY) y {MRC IYIDN'CR II . Ct NSI PLATEN SIAIF E I'1 H .NEVI MODEL IDARNNGVAI Y1 R. v.l m ID I R . ? ? A law l[R ftA -5 . AIE c I y q iI[TRS[FEATERD- H N AE ? VEIRRFIpNHNU1gN NO. L VEHICLE IDEN161 All N F lGI5TF41DOWN14: I KSI . rIRST MiDDIF PNON(NO, '13 7. 21, / O Is tDOWNIq; lwsl FIRST MIDDLE Nf I IS 2 NESS Cy OWN[M ?0t() ( _J W N E UWNf NAMl6 AOIX+ESS-S URANCICO -AG(NI Avu IN u -11 PT 14 MMAG)D M[w s SA w p I N IS - • ? M °. iA ' 1 CHARGE CHARGE wCiiONeN ' iAMAG[DNffA ]] S ' Yow c 0N.NG[ IS' / E] ? RE-11D -I ? AMIN ?R[MNN[D wqr t51.OAAUGt ??A?. , 5 fa...: SIB AL. :w:v°er: Af5 ?iw?fDev: E I •= e DIAGRMAOF COLLISION: lU u tN e asuR CA1l NO41n sr4Enr Ni). ? r Aaaow DESCRIPTION OF COLLISION: ME SUPN... SFReI Ir NtcM...I K • ] - N Vkk CIS TRAU5 /JG A-r 5PD. I JWi , GC (2031-%D2 MAX QM'i? Nv 5110uf DE2 AtJD -" i J ( r F p111 A go' Gmev;,k1/j14i5m ' 016AIMJG OAP A PtJR LE (S (Rl(CK NE11D-GfJ) COe IKE G 'tv A 2c'si ?NJ y ST Fl TREE F-r_trY S©uTw. T ? ' .• IpgP Toro m, ? DRIUFR CUORKS G2/-1Ue: `-IArzb z6IIFT ?AoD R '115IM&E'aS 1DOL / WI'T'ZlJG W ER ORAQGS _ . U)a160 Ti-IE U<AW. LIOAS 00 '-CG,E fZ, SUCILuCEg ? GkID PAARIZ5 u:Ek? IN GUII?E,teC Gx- l i NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED E CODES I 4 8 a 5 6 OCCUPANTS /WITNESSES u"uauiNµi AMl ii Sf% AGE ,AT a(sla. E Icr i , nrvt or pAM u °r w e 073'10 &,. 0= Q WAA - A RrtvISS wl Or N ANAID IP, v pAMe. p wuKl ?M . ? ? n A MPIyS r a l rtrt Ol iAwKS the er OwMe kok R" D T, ? ' ^ wdtl'Y f4 ? ? r ri h 1 r 1 I u,4?1 4` ixfp,L A r LI 9 ti T 1 WA Ai F Z S i E I r 1 ? ' T i,: I > it F ? f l ? ? l I 3 I YI 1. .. 1 i? 1 I..",l P 1 STATE OF WASHINGTON PAGE / W"µ POLICE TRAFFIC COLLISION REPORT ® TRAFFICWAY POLICE COMPIAININUMBfR PRIVATE WAY nll orca+s N oar I N nmE courJrr % p"r . Wx u lull w S Ixy. IH IUSF ]yDO HO q c u rr NO. cnrr+o. I I , . ? ., ur l /33r5y Sii ?i?1°/'SOr/ CIfY OR TO u _ /4a L©Ja(JRAMN &N Qf OIN WN O.-SINLfI. HIGHWAY J, 3MILIS ?S ?w OPT Y cNK ON - A- INIFRSECIING 1MrH: SIRfElO AD NON IN"PSEC110N -5 ADM I NOUtf O451R[E C O! Sf[IION ? s???o a: T SiREEI 14 y1-111 1 ?+ e!SIREfi ...P1% TO. MRE POST _ ?i ?/J 5 REETO , mIlTS OISIANCt6DINf RF ERfN ,CR055rFFt OR NEAR SIMI PO MMES . F' W ACCIDENT RMAP. DIAGRAM DAiq ., . ( "IT Of C IJ MILEAGE COM IXl13. OrE INVIXVfO: VFRIIY: MBIIII, ,.,.No. NO, %IIIED_No. INJURED ?SPILIAGE ?IIi $r q(y''y} - H O-CIES Q lIRI I , I NI p 1 EflOq ADOR ROfRFNCE INrFN? Cl5 @OSSSIPEEiOggflOAD ]] -PERTYDA-GE ONLY ? FD ?V . ? Nj ?p ?p /?Q 1 OB+FCI SIRIK%INAMf Oi OBJfCI51RUC%AND OWNf R'S NAMF) EST. DAMAGE SPECmICODINO UST f TIES, DRN[xs NAmr LAS, UNIT NO.1 UNITN0.2 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST aR _ I , / ? Y 7 DRIVER'SNPMF: U5t TRSI I L SIR{fIADDRt35 ?• 2 ?x y CI T S1AIE D IPffI ADDRESS J ZIPcODE PHONE NO. / yGe/i?/ 3 s . 6-029 R TIT -TE IP I P NEW. 5 Dit 'SICFNSEND. STATE S2 M 8 Al ,% O IRIH MD ° ( V I q' LICENSE NO. SIAIf SE% DAlf Of 81RIN MD .. B ?,fUppNA NAM GcYVL/r F6PHONEw3,q.::-as/8o aa EYES m,DHI HEGHr E CUPANON PRM NAMF6 PHONE NO EYES Wf NI N,,C., l i/v Sna /d oa -3 R ? CHECK (,I .11 iEA A P"iAN mfe'. ? CHECK P E CODES?* D..AI a's.ii 5 ufcra: e 5f Aenv M+ IO.P ASt%R I CODES?+ D? T All 65A ; ? a> I INju / / s en - Es' y'S? nx ULtoF NIII?Ill p C] .M.ulAwil VI. [AN M CM- ? K So CM- J e ? AMMAArNE p x PoM :n. ? Wli,. ? ??2$ ? ?al- J ID (MTV 1 2 EI IDARI?NDYA I StYlfl D iPII V NA4 E( E-CHfVI NODEI I°ARrNOVAI rl I R: V.1 I? z J V lNSf VLAtI 1 E ' 0 sAIf 1RA1lfRMIFNO. "PIE, I I i VEN COLOR I I A IIA N Af 1,1 VENICIF ""I 11C 11N NO, : ' i VFHCLE DENIHCAI N 50 J a ? I fG 51FRfDOWN[R: U51 rIRSr MlDplf P O I I 1 ^ A •• -'! H NE NO. J-?y O ISIt4FD OWN[R: IASf HPEI MIDDII NE NO. I UDRISSp OWN{p ? V? N A S OwNIR ,pl S d / , aQ 3 E. 7 • Amt a ADOVess a n+suRANn eo. aR neeNl 4VA ARIA l r j ° DAmAGIDUrfA 15 ci+iow. r 5 _e i1DM 5 151. DAmAG 0 c..u / ?aA [1 ^ AT o--ED CHARGE - DRIVEN a o, ,u ESI DAMAGT 91°v A -J _ r l TIMED ?R[MAIN[D I 10-D A.AY . I O<4Ja5 er A.Al 1 0 r er: f v "Pirm N INOICAIE NORTH DIAGRAM OF COLIISION• lu //// r Y C- S t[I?1 BY ARR? DESCRIPTION OF COLLISION: ILn[swpumfmuSHEET IP N[c[sSARr) .. e 1, / ? [.-.f' / ? / -7•? ?•h en /?C' /CF> Fi???T T i'r .Q/drd n?"!: J?r A --??-?_ O/i'i ?t/' rt•?d 4 !/qd-1/d i0 Gn.?!/,?/ nP f•?f 17 .. ,. T O z' ?7e I,/ ?P Iv C . .. Jv NAME, ADDRESS B INJURIES OF PERSONS I NVOLVED * CODES 1 - 2 9 4 5 6 N OCCUPANTS/ WITNESSES Eioa ADOV p:;u i+IAiu AM ii W AGE IUS Al IN—_ N";- . -1 1 u[vq tncr NO N ..w s5 NAIURtar w v Am -y e ? 0 P8 '"` . CrIT ? i:Y.,S. A I q -11, NArlwra vMOV[D IROmO ?I rl O'?Y' ? „u Ame Ho ... y A rNVnS iriuvaia +Wt51Ri v.G OV t RsNAwv n INIeY OAme ?p 'AJ',R'O<".n. 0'iJ ?I::;.. E e oww .DING o 0 ra awt . I": D D - lrORl n7 onn } S Na. ??I ?.i.4•; Petil_ _ _p; _ ...,. ,.,, r .. MOTOR VEFIICLE COLLISION REPORT " kUU yxI U N r Wu " _.......-. NO. / V /n ,Y ES OnA FN np P u w E III. iF! ;I -NY N0 CIT'V NO. Qu WA'I F L G ?x ? ?W WTOW.D ET LR Nti /O N E.xD LLD M n E OUIE aR STREEr po 9 s ! .w s?9 3 FO MLEPoyT s., az liLOyi Onf` E li = IMXAN DATA D MRIFORTED V ` SECTWGS, EEi EP O ES L-IE F,E„uE 8CWP05vE Uai nIAMM ? O A<EDCP 57 HE LT i 55 (a REF OWNER F BJ CT9NAMEMOADORESS E l6E My.•,f?,,ryaq-?s1.• • MOVE B AR EE UIUVEq'9 LAST NAME FIST NAM . MIDDLE E S .. ORIVEfl'S LAST NA Tf I •? / EFE IN WLVEO wFPIF W l , FIRST NAM MIDDLE T r w) S c' ' ' ' / Loku ? ?l DP STREET- SS fl TE NO. AND BOX NO. - ..rI vA SW9 K RLLRE 5fA STREET ADOflE59 ROUTE NO. AND BOX NO. I A C•. CITY STATE LP CODE DNVERSOCCUPATION lD r . t:J ?4 s Sr n =T ' I LnTiDn M CITY STATE LPCODE DRIVER'S OCCUPATION ERRVER SUCENSENO. SEAT sex ATEOFDIRTHP AGE ?T ' I S Wvl D RIVER'S UCENSENO. STATE SEX DATE OF &RTH Ace D,Y YII EHICLE YR MANE ICMEV. DGE) AgBEL(rvO ADMT) WOY STYLE (TDR.) V EHICLE YR. MARE (CHEV: WOGEI MODELINOVMOMN WDY STYL (TORT .A ? uCENSE )( PLATE O. STATE TIW PUTE NO. TATE S VEHICLE IOENIIFK:AIN)N NO. / PLATE NO. STATE TRAILER PLATE NO. 9TATE .. ?1/ ?f VE _IDENTIFICATION No gEGITTENEDO ERIL)ST-FIRSTMIOOLENAMEI pyv UCENSENO. g 70 )/v ?.5 r-? le/ E019TERED OWNER ILAST FIRST-MIDDLE NAME) WvER'SUCENSENO. OWNEII'S AWS146y ISTgEET, CITY STATE) DATE OF &RTH OVMER'S ADDRESS iSTREET,CVY AND STATE) OATI OF BIgiH A PMTS Of VENIC OAMAG D AR"'A/kAiuLil tO + ARTS OF VEHICLE DAMAGED Al W. THERE A UTO.AOSILE UA91uTY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- CO VERAGE IN COVERAGE IN (AV EFFECT FOR THIS ACCIDENT ON YOUR CAR MYES ? NO TIAM[MDADDItE590FIWDUTY IN9UNMCE PO YE OLDER - NAMEOFUAN-T INSURANCE COMPANY / - rAl? C 16o NY?C u•r - A } NAE MID ApDgL59 OF UAWUlY IN9UflANCE AGENT L LP AFIIIT POLICY NUM R E• ?/ r Al / i E.'•-_ Eri SC%l? Uiw_ 71 L% r4' -? . I.^.T %AIUNY NAVE •I, ••~ AGE / TNDINJURY' IVEFSCPAIMIE nEPOPt FOPADN1roHAEIxNNtb AGE. L, y .? , V S I IA HIRED NAME •I ADORESRI T - o I )J Y •7 G? SEX ADDFlES9 S[% Atur1E MD ) ,? Mr?FA ATURE AND M F / E%iENTOF INJUNE- F' / - ? L yy ETENTOFINJURIES ? L7 +? f%p IIIJUNE911EOUIliI DUCiURr'- -?-. gDINJURIEG REOUIIiE DOCTOR'S C%AMWATH)N DY ApOCTON> ?O NAME E%AMINARON BY ADOCTOM ? ® NAME S AIU5 OF WJU1ILD ? W MDMOFIq! EE TIXA APPLIES 9iaiU6OF INJUiIEp MANN FIRST ONE THAT aPf•LIES 1r?y`," IrI VF.IIICLE w 'AUl roD.lll y[fI pryvEll IN VEHICLE xsNRIxO Dv NSA Uw6 R-I 1. F HIlLEO I.i[K?I?I luwpl COUiY A.. KILLED II3EV[nF . ni Y[.M? I MiNO i a "'r r Y ^H I.J l I •I 7 c [ rnu NO no I `LI Y lD ., ' O I ? SQ 6Q O 7 a Q SQ 8? MOTORCYCLE SAFETY: ? UELMEr usED ? HELMET NOT USED ;:(IOWNDHNIUYARR NCUICLL MOTORCYCLE SAFETY: Q HELMET USED Q HELMET Nor USED ,I ? DESCRIBE DELOW WHAT HAPPENED: (REFER TO VEHICLES BY HUMDCF, _Va? clF ? .;L..._e /?c>s??l! c 17- Q i7 NrM .. Ol hoed nJ11' -A Ir il?AAr- of ? '* r'd qw w""^v,w ' / T/!l?c.Prl?c ?h r WooK5 c.•.-il c,( P ?i WJn r =I ?f- -?" ' ninon LA„a , P6/G/.ya .1 r RC wQI N.GI ., ? / 7 o C n o h r? Ad ./ j? j n /1 C'alm'/; f J7,7A I/v 1,/q t? c j?/i liT 16d A S/ n // rR W ,'7' h A Ot- ^, 'c 1"u// Ea(-- yo :IrDc _pcLr- DhY/'vr/; / ,/ ._.Q._cMf?'/l'---? D ala/vd...?i'.e. A. n'. /+., 0 "E,d /V VEHICLES POSITIONS ©EFO E E RE COLLISION xo oF lAnre vLr.LU l[6 lr ltA H p v alµ w.n Nv[siaareD Ur HI V HICLE S V L W rr N ? ON STREET OR HIG H WAV NAMEM NO W [ PWtrgx ' 4 wE0 M lEly vrq Vf rtti OCC oltD jiinE ?W% /L1I " CAS Haw 'K ? ? ? e l ^ QI.I f1nn1?. . ? ? ? ? ? ? :;Ln ? n Y i° i 7?? q,NMk ? N ? ? , I , i ? I ID l ? ? ? ? 1_1 ? ?nranr( A +AH ? Q ? ? HO,q 416f.wD FIgM TO PEDESTRAN/PEDAL CYCLIST WAS US ING I?RDe N. w )QwN .?rHwLan .Q W^ uow«N. s??ro+awN°% a?Drnfn rQi;,y nQ mAnw.r PEDESTRIAN/PEDAL CYCLIST CLOTHIN G COLOR 10 1 AAA T?Lr.Ir TQ M.m Q MTADNneclNS a? rU'+an"o°eitc Y°I`E IgAOll1,V N:[ `%tNl w[AWN LKyrT fAN01TON9 IIIAFFIC GONiflOL ?'Y E IfJHCA M+I r nPCOFflOAD URVEH/VLHICLEACTK)ND . ' •Cll Ugll Qatt I QEAA•cA JL?[/GNrr. st T LJ RN4W6 1 Q OX"'WIT T DAWN 4 .V ] L WSM I l WAAL9 ? ? ? T Q ST P r ?H Cr? f Oti( VIHLI[ ICrH LA QI.IH M(IIIII NO I NJ l ONE WAY C) I C] 1 g WING STRAIGHT MICADOi+(., r N Q T QwtT ] QS.IOVA+,R Y / " TIRLET a ? L O ? D Q YIELD SON IIM WAY T OVERTAKING AND PASSING ] AEVERSOIE ? T QWAW r I [Trll ON ET E] ] E] MAKING FIGHT TURN ROPE, ? + Q ?? T W 1.11 ! ?LMT80IE ? a ?FLAW"ND RED EPCrIAHOE ? A Q 1 MARINO LEFT TURN TAMP( OI 41 ? G ?T.,fM ( ? ! ] 4HCY'VI A C) 3 Nf[OAYIT! OI 111 ? ! ? TLASIRNO AMERR E] S Q AILEY 9 (j MAKINGU TURN O , T ? ANf Y E 1 I(VIAI ? C] W AY wO f IOWINa Q S ? II 1%I Q SA 0 S }5'4'x. 4? 1,??'.??i-.. lv .•,lrr. -i+m? vT •py?l ve.1L.'r'' „rla?Rr'v L-., N+ 8 ? , '"T?,i'r??jO f?d ?1R?rJ?',".V!!4EEIlLmlo :., .1.__l:a'_a...- ?- + I,w w'?,I 1 + ? 1R ! v I,•,,l T-11 L 4?1:??? I 1? .._. ,..,_..., ,. .,. ,.h.,....., ?.., ' p I J POLICE TRAFFIC COLLISION REPORT U^.TRAFFICWAY IrU, POIICF COMPWNI NUMBFG I PRIVATE WAY DAZE Of COIII I N ATO 11 ON IIMf COUNTY COUNTY NO. "'Y" iHWq u Ar rR Svx RRx Iu+ wiR TIU SIVI (USE ZxW HOU4) t1 a CY` / ?URBAN I CS '2 C:G d J- ,(SLrN //' ?y ii t ?N ?f ?IN CITY OR TOWN NNAE6N0O.•OOf S f RFEfOR NIPIWAY fCI CIS AM R-TOGS- C .,I- f ? J ,(. ? \ <. MILES n3 ?w ?OP !1,.: (,IC E': Yc ON C .4'I-/? lfRp TG 9?0 C7 INI[RyCr NG N+tH: 51RfEr<OR gOgD NON NTFRS[CIION PRFSI% f0. MIlEP051 / Z D J / / ef1WEFNC'LAJ L%)/. S% IyE?10 L/C,JLII/Ch/JY SAEFF L OISIANCf 60 Rt MRE FRFN CROSSStgffT RNFA4f31 M11 ACCIDENT DAMP DIAGL-A MRFS f W MILEAGE I:... . FE EL Of TI,/»/ ) L<.).40 ON/e /.( !•/ ?J CODE FD' CIXLISK)N NVIXV Stvl RIIY. %RD N IN 5 R ROAD gREfERFNCf TOTAL NO NO Rlll[D??NO.INIUR[0? ? SPILLAGE ? I1 RUN uuoclO?H N INTER [ROSSS NT S ROAD IXV[HCIfS I - ' 'En PROPERTY OHMAGE ONLY ?R fSUIiED I'DiH F AJ`G C?J Ob11C151RUCK INANE Of OBIECT STRUCK PNDOWNFR'S NNAE) FSi.DNAAGE -c-OODINGIAE S UNIT NO. I M51 U41vt G'S NANf: US UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST I l ORIVfq' NAV.f: IA51 IR I Lf ' SIRFE??I ADDRF53 'YG,? v jZ TRFEi P?OGf53 Gtr IAIE D l y/??• ZPCODE PXONf NO. /`' , ?_ t?,1, C,V/? ?C?j/ _ F f6s, DRWF4'S UC[NSEN STATE R IIY STATE IP D 11011 NO, ?r / A I IV U N$ NO. AIF DAT Of BIRTH Si>l /YH G S- R 1? /.I r) OCCUPAIIIXG IIRM NAME ....ENO L.JA M 1 •?,iR 1V L% E V E MD. r YR. . YES Svf GHr HEIGHT C[.. 'i+/-' ?tq 7•/t, ,r, R OCCUPATION FIRM NAMFB PHONE NO. EYES WF GNI HEIGHT _ `? ` µ ? CHECK p1 W vFH <IfA AN LMPIwi pf AN rHER. ? CHECK I?) I yEH ttf AS AN EM%OYfF O q L uw CODES?' 7c"';; <,: ! 5 u a;° - in IG,w "^ rGI i AN iH . CODES s u es ?* D? Ai: sEr""' Ten H A,ry rc+f I"?/ / INLU, ES !);c CKr/S //:/ b S;,roM IN RI 1D) " MN A K1 ? VtH YEAR u ? 01 ? 2f! ? a« Yao, ? Aw N[r ? F ?yRI ? FnR ? Y 9 11 ? ..«v yl . MAKE IDGpcE[HFV.) El10MI?NOVA1 StYIf DDR.[OrvV,) H.YA 1 HEV.1 y E MODELIDARI?JOVAI Y11 pR. V.1 _ ID % :S l't->i fJ '/ ., c; gal !Jc /, E ; x •,. H R U ISfPU N STATE IRALf9RAlFFxO. SfATf I"I VEH. R A}['I 0 --. N STATE t CLI Ip(NIIfIU110N NO. ' C VEHICIf DfN IFI I S(, [GSRRfDOWNER: I.A31 IIgSI Mlpgf PNONf NO. t ISIFRE WNFR. lASr FIR31 MIDOIE NfN i, u Appx13SIX OWN[R FowNfR m t?? 7T E NAMt L.ADDYISSOIINSU1- CO. CRAGINI U , R DR M%AK•?D MfA x irr0 HI I ' S.A.E 1. x IS [H,w?u If tOr G' T 0eO S. 131. -G' C3 I^YN 1? P[MAINtD Dnm,KGE,D Anu CHARGE rrvi rMiclw Al R 4TOP RIVt N FSi IDAM? , DD .?- S'T_.'•)i ? AW YDBY: . ?RfMAINFO E 1 - C3 A 3 WAY ? AWAYD IC OOTlOM eY E . ) Ia DIAGRAM Of COLLISION: rv InDICAIee NORrH SFOfr II NIC[33ARY1 er A9ROW DESCRIPTION OF COLLISION: IUSISUPPIEMFN1Al sNfnnNECE3sARr ) ., L/s N,;:cre. do+. y e?/r / /:; ? 1 < cam)!>P- ?' , r' ` SU I . ,.I.?:?I . ... .. .. .. . ..... _- C i )'I/f CCP L?l i r: J y•?.' ,J /N f i./ tl 7 ? t' NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED CODES - + OCCUPANTS /WITNESSES 1. w "I 1-1 NM I - 2 9 4 5 6 ll {. a P I AMe sF% AGE .rA1.5 „'" R[vR. ufa i. ^ )E 3 NA y A r Y S1f, +I DOgE11 AVI ruv OI q' H AY ?AMB ?EMCH?MI t??Ial- N yA?ay"wwt1? T M A 5 H ' ) OWES N r .? 3 1 !, N i T S AMI WI WI IDH R ? N er. ?AMe. ?.TwK1 ?.HI , C) r ?i°« FD y .I r c ' NO A1 s, '. A 1 M a {y 1 ., BIIRI Wf INes°f EflgAt,.,OpH[I411aAWe eADGq AGIN[ YPxtnr ?AMe. ?io?Kl ??D:n. ?IP? ?i:«v j ? ID F.O K103 ICMD FQKf ARRIVIp UAIIIX RIFO41 AFYRONOeY D Il / ,f Aft, 1 Z? L STATE OF WASHINGTON PAGE DE No. u, POLICE TRAFFIC COLLISION REPORT 0_TRAFFICWAY FOLICECOMPLAINTNUMBER PRIVATE WAY }I 1A N Y 01 CO1,5, N IUSE aWO HOSIRI II COUNIYNO. "Y UR ? ( : r ON KIE n,N Ee NO.OFSTREETOR HIGHWAY 5 ?W Of FCICL5 M 1 SEIIO N: SIRIFIOR NINTERSECHON BETWEEN 5t[ffl6 SiRFfi . IONR RFERROSSSTREIOR NEATI-MILE SI ACDENT Lf5 N W MILEAE ET F CODE COll1510NINVIXVfO: EVERII I IOTAL NO. NO. KIllEO? NO.INJURfD? ?SpIILAGE N 6 NCaLCr, NIwI`i F' IN XRD IN IIN SfRFEi RROAOORREMENCE IN [l.1 CR05551REEf OR ROAD }J K O{VfHIClES 0pROPFRIYDNMGEONIY SULIFp V EW [ 'l N OBrtCI51RUCR ENNAE OE ODJFCI SIRUCK PND OWNER'S NNAEI FSI.DN.IAGE SPECIALCODINGLAE U ,ks SAO UNITNO.I UNIT NO,2 '0 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST }R S DRI1 [R'SNNAF: T I-T IDDL US DRNFR'SNM1E: LAST {I 1 I OFl1 S0 / RZ STREETADpRESS S STREET ADDRESS U1T STATE ZIP CUD NE NO?? Ja D R IY E-E ,P PH N NO. RIVFR'S11CEN EN ANO - WW /Y' STATE Lc1c1 X 1 ? ? ii+ I V UN NO, UMM STATE % DA BIRTH DAr a e OCCUPAIION {IRM NAME APNONL NO. EYES GXI HEIG E OCCUPATION F,RMNAME6 PNONt NO. EYES WFIGH(HEIGHi 2 C c'7_ le f ? R ? CHECK (?J wnl AS aN w.ao:INO E ? CHECK (III) F OK CtjO 1 yEwA ASANFMRLOVEEOFANOTFRfR N CODES JIII? 3 n + i sn: 5 F e y° Ass . CODES 1A 3 « q +sv 5 uTc N H p y ` E ii sn« ry I' }} / ENT Laos F L/- vl- D 1? ( )F;?q,..oM p AAw% [] uV ? Mi N ;„Tg., ,. ? AM1. E O MCI ? Eb:IE ? ?7 ? -1 N ° LlI 1 VLH. YEAR (DODGE.Cn(V.1 MO IDARFNOVAI FI STYIEI}DR. CONV.I 7 i/ H.YFAR 1 HE', MODEl1D- VAI Y R. 1.1 D 7 . rcT /uo L?OC-r c E 6 v OR C[NSEV AiEN. , A'. fRMiFNO. A1E H n.CIXOP N0. AIF ltuF Ps' ' T w I C II VlNKlf 10(NtIIlUt1pN NO. i W -7 S' f0 .L? Is- L V H, 1E IDENTIFICATION NO. I I 1 I I w D YLGISRRlDOWNER: -1 {IRSI M,DpIF 0//tSo/ (' /s W ADDRESSI PHOpNE NO. 38S o /x w f 151EY pOWNfR: UUi FIRST MIDDLE N NO. 31 I-o1R 2r/ /Jc c.cz /)r Mc WS6x1i) c E ADDRESS -NIR 0.NE E ADDRl55 Of INSURANCE CO. OR AGINI N U u R ?} UAMAGE ARIA 'M'wN CHARGE ? ? 1? , ? °P CHARGt' OsAN,ND gAMAG[DMU } 1 33 f ? , Q ? 3 IA. O/A1AGt D IVFN IR?fMf0?41YDN 1 ? ?RFMAINfD DAMAGE I ? AWAYN ?PFMAIN[D f51. --?J f 4 RV ?AYDIY; ?/L[.:S'C+A./S• ? nw1nT° er: S 0 DIAGRAM Of COLLISION: 1111 A IHD,CAIIer NORIXAReow 1mCIMSURr 1 I M[I IF N[ 4 G" ' DESCRIPTION OF COLLISION: (M SUPPLIEWNTAL SKINF N[efsssRrl G I 2 s F&U,EAAN u lefii) j?M Gr 1 vlH/ 6'r0 b /i/i A DAA a S I' g Ay?uu & . *mo ( s-r Cat.-r/w . , t Er7' w. /IriA? GFA:iF•f4 7u /I./1Y? 77-oux 77'I/ 7711&S 0A''/ 0 ? ?/ .?o ... . urn cE'.Ati ?3?,}y - - y v? HiF 3 W? c rwx ?Al IA"1040,01AL-1 A%-LAAb 7111r /Z d Nirzz4.0 r NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED + CODES I - 4 3 A 5 6 IUSl3WMfNININ Y OCCUPANTS /WITNESSES FaRAppmonuNAw QI sl sex Aef urus D '"„°'," A, , REST...RCT i NAw in A _FSS NANR[OI INlnr ?AM e. ?[YY' O wL . ?vNih ?ILiN{A w N, A N ppR11f AME. NAI ld ID1Y ?AM3. ?Api<L?wl a0(?X ?lii Rl p0a15f r)o. AiUEY fF Fw eY. ?AMe ? i " ? ?RV ? 1' 11- fl AIRwG aJ If1 A,Awa N SADq OR AGIfK K1D5/ CMD KJlKL A1RI11p OAllpaltOal APP40V10IY ° I! ~ ? .u._ [,. ...,. M11 .x%I v e i'.? Y•r? a iu??I a r veRmuly Sun ?.. . I mRwV. ..III, .?? its ? ¢ 1 _ f ( 'J 3 .g?1 r qs'?, ?EZN I r. , STATE Ot WASHINGTON / 2 1,1 r. POLICE TRAFFIC COLLISION REPORT ?TRAFFICWAY Ofca nwlNlNwneFR DA?IEOECOU I T PRIVATE WAY o ?w IME COUNIY COVNfY NO, -I ND. w Iuf w (USE DNW HOURI iHWA ' / O 0N ?E ?IN CITY OR TOWN - _ NAMfANO Of SiRfFi OR HIGH WAY /[lam ICE CS PR ?Uq&W RWTE ON SIPFE C SFCR MIEES s ?w_ oi, ON INrfRStCI NG VAIH SIRtE1 R •p NONINItRSEC ION 3 PREFIX EO. M N 5?99'O IIF POSt 0 / ?? BEIWff S OISIANCFAp1gF 1 RlfERf .CROSS SIRffiO NFARESIMitE PO t - Mll[S f w IgEFi yV STREEI ACCIDENT E- OIAGPAM DA ?• ?/ Ip iEFI ? OE COIIISIpNINVIXVEO: EVfRIIY: MILEAGE CODE Wy E? IR EI DRESS I- ZIP COOS PHONE. D Iy SIAI - I'( H N N • f^1 /w L 2 0 / R DR VERSICFN:ENO. SI I A E BI H I W 11 ENS[ NO. SfAtF E% D IE OE BIRTH MD D, / 62 V R. 0 A F OCCUPAr1ON "'EMNAM ENONENO. EYES IGMI HEIGHT E oocumION FIRM E6PHONE NO. Ens wElcHl E wH l 2 f S Q 5 R jA 404 ? CHECK (.? EH <lE ASnN IMR._OE ANOrHEaAI ? CHECK IV) . CODES?r 0 q i VFH ClE aS NFAwEOYEf OFANOIHFRpI ° D iir v yin 5 Nlu oN a ,nnO,H`r YC1e CODES ? ? D a v Ynl 7M" n0 I ' / aro 5 ut N e i s ,n R INI Y MEUUNCt vuI D R fs ' [ EAR MA fIDOWFCHfV.I . FI IDARINOVA? VStTIE IZOa DNVf 1vf ? O?? ? u M x" ? "cb'nfR ? v? ?i P P ri?i 0 n I AR MM HEV I YA E ? q MODEt NovAl a DR. ?1 / V ¦/.?( NtRSfPUIfN //__ hJ R? 2 STnrF ARRPATf NO. SIAIE I"I VEH. CQOR ro l 1R I A ND Al 10 VF"ICFEIDEMINCANONNO. VfHIC E DF UI l ?, I N A l N c u c L Wtsso F " E REGISI DOWN[P: WT FrRSf MIOME PHO ( N NO. IF [DOWNER: ISt O IIRSt MIDDI[ N NO. rt'? I] l ADDRESS aOWNIR W s-- R r (`[ N N LL)r 7 !tA DR[SS tAm TRANCE CO. ORAGem E V R DAMAGED AREA 3E ?ARE.A ( R r? F IS S ='= CNARU CHARGE vgn[il lorDiu DNA.W I T A SJ , E E i L DAMAGI OD.R O,nG D.OIIOY S ISI. rl - AW.Y PEMAINED ?AWARryEY N 151. UAAUGf TOP ? R[MMN[D YL?I S O ? _ 10.1 E IUlOiIOii AWRV S OO Or ?AWAYDBY . DIAGRAM OF COLLISION: iiaelu N[C[StnEirl. IN ev Aluao°vi1M DESCRIPiIONOFCOLL15ION; (USESUPNIMEN1ALSHEEN)NECESSARY) y O->• dtY_3 /, ou,> r uie r CR40614 . cc Lo d aAEr'n9 ckA1dG '< O 6' .` ?iPE?a?p LR'rf Con/.ev/ ?f . Uiyicev AND TYd[ (lc7//C[c•' Cr FJ T//G- ?cac(GC1y? ol,j ?E LGlc?T f S f '° ?? ,b4 Er . acctcL' acv 0e6/ 'ICE P ? ? 4 /U ? 6 1?cua ? NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED OCCUPANTS / WITNESSES CODES 1 - Z 3 4 5 6 _ N ASV Slx AGE um : " RESTR. 1,10 f ALVx11f NO NAI I ID' ? vat- o NO • IAAII;u rEAIW OR, I NO r R -1. )ROM ? -, ?'D'Nl ? o, .^ y w u10.1 ?f ia ,-W vlSln OEE(IR^rFMV aE Y y'?? ` .AOGIW AGINCY _ _ -I IC-11-1Cr.O Kx NE Sr: ?AMO, ?'1Z ORMrI. ON ?` n •Rnlnn n.r,."e. e.e ._.._-. _..__ _.._ tGf Marx ?. , i ? N 0: lq? M 1 J, i E/tUTOR VEHICLE COLLISION REPORT NU. 0 en u,r F cOLU COUN??O. CITY NO. aw p O rWE n M „kjl ® TE, FXI. 9 XOUR 1 bun MON ruEb wF rnuN t AT 1 i'iuFYC ? E L / 7, . 'IW ? AOM CID. Au r HOdIF Oa GTXEEICOOE N N,E NO OF 6THEt W n ? e ?E ? WY Oai I; 3. •? 7.`-f!'? " US w Q aF "" 7 ON ? ' mcwHE HE MLEPo S! _ 9r Rdl roAO ON- IFHEEC r n MlsFmwa xE 4_/w sTHEET eiTwE E srrx Ae a, ML r n ° ° lA TlHHl ` ° tATA P M v un /,+y? j1` sroa Eoiri i.aEro ' I*l ©© -u H111. El-Ane Er I ®®I cF / ??C7i r: ..? / _ .,,.., u...a . .m ?."{4r ii,' ' ... ,,..., . - LOAF EK%uwKKVtO !y a MABLE LI.1. APLawVES ?CHLOaWE OTNFy., ?.,,q. E`E46E fa NSJ El ? ?? I? a iKLfs l? /v. ?ELrEO ?V-E 8`ernHOSrve MMWK lJA MONM ?RIpo ACTrvEM c.. 7567L, IN/ME U'OwECi srnuLel O?E^ OGIE i5 AME AODflESS, ¢ ? ?'lp Jr9O 1?6 ETHAN MID OFVEfl'S LAST NAME LMS DRIVEI'S LAST NAOLE O /, !/ y : /: MOH[ TH I- 5 ETADDRE PE.-WERE 5 '? rU0PE0A EA sF M / ATES CITY TATE LPCOOE DRIVER'S OCCUPATION C..SrJN CITY / ST TE LP CODE DflIVEfl UPATGN HEPo T FLaM r?/ /, 0/ • ?; //?' STATE SE% D OF dfl H AGE F M0. D11 [V? DINNER SIJCE N0. 5 5 DAT OF RTM AGE DRIVER'S `7`1 VEn CLE YR. -Ell EV: W EI OEL INOVA OMT)? BOOY5TYLE[1I-) ICL>E YR. MNLE IC /,f?DODGEI f (NOVMgMT). BOrG-?Y STY E120n.1 ?, `$ - "' ;. LICENSE PLATE NO. ISIfATE TiWLER PLATE NO. .STATE _ L/ NyE PL/ATE NO.. STATET LFA PLATE NO. STATE. VEHIC EIDENTIFICATION NO. ATIONNO, REG STEflE00WNER ILAST•f.1fl5T MIDDLE NAME) r. DRIVER'S LIC SE NO: REGISTERED OWNER (LAST.RflST-MIODLENAME) OWVEfi'SUCENSENO.. lA, 7 '.`? !??? t?.1/ / ?E OF BIRTH WyER'S ORES ISTREET, QTY AND STATEI OAT 0 BInTn INNERS AO DRESS ISTREET.CITY AN TAT 1. ... .. ..r - .. M0. WY vH. R PAHTS OF VEH DAMAGED ?AMi??kH0 c?5lr io PARTS OF VEHICLE DAMAGED.: Nn S INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. T• WAS THERE AGTDMONLEUABI ACCIDENT ON AYES ? NO COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR NAMEAND MDRESSOFUABIUTYINSURANCEPOU?LDER -CITY - NAME OF LIABILITY INSURANCE COMPANY SATE DP NAME ' NMIEANDMDRESSOFUADIUTYWSURANCEAGENT CrrY SrATE .. DI' UAnIUTY POLICY NUMSEfl. ... ' - y ISTWJURY: ,. EP,AATEPfndll FOH AOORGNALINJUwEbI I AGE A ?tltl AGE ]NDINJURY: LEES i NAME N,u1HED NAME SE% SEX ADOnESS M F r? ADDRESS M F NATDNE MO ?? I E E%TENTOFINJUNE9 KjE1jT 0F INJURIES ?? / CIOINJUNEB PEOUIPE DOCIon's CIDINJURIESFEOUIRE ! p OOCTOn'S FJfAMWALION BY ApOCIOR) ©O NAME EXAMINATION BY ADOCTORr © ? NAME h StATUS OFINJURED MARKFASTONETHATAPPUE9 STATUSOF NJMHEO MARK FIRST ONETHAT APPLIES OW,B?wO Na. dbA94v0 FOD qaE ? E INVEHICLE -_F, NWIWU BLWG POS•+OtE I A ?raASxE Naa NNOVEnGLE GLLED IEEKaEI pVWOHYI I?FEOMFU.w( OF EF NO.. KLLEO I.IEREI IMWOFI IIOFP?v FTCM ?aannw Ercl 6 ? 7[3 O ? 513 ? ? 5? 8? 7? E. ?.,,.MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMETNOTUSED PE_ SHOW NORTrI BY MROW IN CIRCLE OESCRIBE_BEL_OW VMAT HAPPENED IREFEfl TO/EHICLES BV /NUMBERI"., LNEO '.'„? /' -1111rn T ucle V ,y ?rJ` C•..l c ?/l till/. e r/ '/)!.! LJ•ly ?; o s H aw ?, L /itCl r?A 'ca E,HtLIA ' ;,: ai!' ¢(l ... ??-r7?/. ,S c c ,l?'i? G r /I r.('/t . ?s .. J2 .r s: ??/ T (./ , . ?olj .jJ P..b a ?,. LCI(Ydfc iEt4? Ll?. ?r?wt/L!1?? N! I /,?: .L 41 ?.'. r// / LJc. .! ll1C l L.?cIL ./G..TD I L'//M ..Crv7f/ t I I ;? I j nt 1. Imo.. uL 1YSC.) L L..IJ _:.C?/J/rJ ;4L'Gt ?Af F ;ll ? ar cL,t/Til•?:c15 .._ ? ! ? c rat. T y ._... . L.1 I I? 31•cae... L 1< .Cl/r IJC. ?. _ ... __ 1 rYT , 1 ?i I < d VEHICLES POSITIONS BEFORE COLLISION Now IMe• vEwcu (wgoo rMKldw,e NiYEBiGATEDBY f m ,.j pN( up,LLr nMnwD ud,uYea VEHCLE EEC W ON 5TREET on HIGHWAY NAMnnetlba NDI I,- O ? 0 ? L' '1 ?.-1 ? ? ? ? 07. A C3 m ? ? ? ?,AA ICJ enlM/ 1 '.? C ? 1 AV r'. irAW ? ? ? ? ALONU ?peyp uD FROM DIRECTION to DIRECTION } tr ni' 11? ?1? 1' I! 1 [ a ypAden .?uoi[wMI (?Gnsiw.ut •?mlxn r?µ`IU i1DUArii sQ ro,DwAY t^ y { PEDESiE.VN_PEDAL CYCLIST WAS USING! 1?-... ?wx"w,r ? PEDESTRIAN/PEDAL CYCUST CLOTHING COLOR: '0 D,nK .0-, a Q u. , Q aRro.....rlve •Q r«iiitinie,irc"At '• J ' 7J i . V , lw ) H II Y t RO.DSURFACt NYATHEN LIGHT CONDITIONS TRAFFIC CONTROL TYPOOF nOAO OIBVEH/VEHGLC ACTIONS 1 / M i , IY Krq Caunel 1DAVl10NT v ?[L[ K.4 f,Aa.tl ' vn:L1 I?If.K W(.lrICU ICnICKONt MMOHfI „ IGA gyp. n' _ ,}? v i t[ Mall I NO a A (ACW®'fl{' $ ??Ey ?r?wfP ?. 1lt ri, ?l 1I 1Lq0 KAiar ]?DAM Q 1 Q:YGNALS ?11 ?ONE WAY ? 1 GOING 8TRNOIIT NI[AD 1 f lI 1`P', • N r A r'T ?jQ C1 ( IJ p'V t Q MINA ] Q DUSK Q [ Q STOP 90N Q 7 Q TWO WAY Q ] OVEnfANWO MOPAeDINO A 1 F. t ? ] QWEI ] YAW(NO "'STREEt ] Q YIELD SIGN ? ROAD ] 501E Q J Q MAKING HOW TURN U 11 J. Y ;. kT IbV ? [ ? LIGHTS ON ? y k ? ] ? -1 ? Too a ? SARF STKET C] fLAS nNG neD [3 E3 M ? . E] MA%1rA LEFT TURN v'}1 A LGHTeoFF C ? ILOOP/RAMPIOE , / F57"y l'a'? ? . Q GE e ? OTIxn DARKNO 13 FLA'?W!O AMDER ! C] ALLEY a MAKING U TURN I 'gy AIt' 4 OTNEn ISrRGirl a 13 91NELl C) a LGHTS ? ? TWO WAY. ? e GLOWING 4al?.? ? SPECIFY [ OTIrfR ? • ? m EtGNAL ? e ? LEFT TURrr 11 ? avilCt TYPt / OrmeR/TLADMAN Q 7 Q STOM'EDron TRAFFIC i ,`rA'??'.y7T , C t ? c r I' r V Y?' ' If I ??\ 5 ..?.,....v. 4-4 1 F1111 I ..A:+ 9I ' I fi 1 u a. mes u n.IU / Ar rlou?wL- -. a? _. _ _. - 0 P) PM ' I I ' , - u+I, r 1 ?rcLS u?E mntEi eo FET ?yH, ue - r ,. ,. pR p p /I ! 1 I; olvC! IRYf`i? 1C1 ?._ ?,-isaa e w p M ES wrHE LraIADD HDHW _ ? ,DILD,IDH °='> : 11 9r FEET UUUM, muba . µ u'K N FILT P ® :ARGIO YMAr[RUxs uEWr c 1 ICI+[IIUE c s er a111OAb E ? N Ol 21 p BLELIWD ? - HH vLlvcLS ? ?i,'E" E ?W° ? MSIVEHM.1 BAH HA ."40',1E. n ? -.v,:ur it.e .c.'>-.L r' E IUECT STRUCK - (HAM 0 oBlECi ern 1 ...JEfl OF OGIECTS NAME MDAOF IE '.•.. I?nei'wllOw cT COOL OCC Ui .. . . . Ie TNAM MIDGE 1-BE 'IAr A S • . ?..1'r F DRVER SASTNPME HN INNLDOLE ?II? ?l l\ 1? a,l /7-' i EO IN I- ow C H LE , O. DDOXNO.. .'. ROUTE N AN BTREETADORESS : AOOflES.r I ROUTE NO. M000X NO STRCET SOrv f M,E .. . CITY ..STATE LP DE. DRIVER'S OCCUPATION 1Nl.cl?.s n-r 1 > 1?Id r t S`u C' ?? l (?t t so" CItY eTATE ZIP CODE DRIVERS OCCUPATIO(' I Jn,r?? TC!_1?rJS. 9'3Cr? I:?nF .. . .- , I EX DATE OF WflTH AGE A O BIRTH . AGE DRIVER'9 UCCNSE NO. ...... STATE SE . F' CHwi'S UCENSEN .. .,. A HO F - VLIIIC )7. MNLE ICHEV,•DOIX+EI MODEL (NOVA OMTI BODY STYLE I2 on.)) r / /? c•' VEHICLE YR. MANE 1IEV:DO- I MODELI OVA,DMTI BODY bTYL 120fl. (I-?f?\? TRNLER PLATE NO .STATE bTATE LICENEE PLATE NO. STATE -.TRAILERPLATENO: STATE 7- : yY.EN PLATE l10;.. ' -' - NO. ... ,:: VEHICIt IDENTIHCATN)N NO. - .-. •-+ VEHICLE IOENRFIC REGISTERED OYMER (LAST-FIRST•MIDDLE NAME) DRIVER'S LICENSE NO. REGISTEAED OVMER ILASTFIPSTMIDDLE NAME) ORIVER9 LICENSE NO.;.:' + Ne,N1?iJf e,r,,) Jirl f1!??1?;? f.AA ME i - _ {STREET, GTY MO STATEI .. .DATE OFBPTH, OWNER'SADORESS :.ISTflEET.CITY MDO AT .ATE DF BIg1H OYMER'D MpiES9 : . 1 l 1 I Jr:? C: ,'1-/1 , (afli_" . 1tI 7r .n : ?'kI'?Nn vS?'TO PARTS OF VEHICLE DAMAGED •_;; ; ,•,_, ';,..._....,.... ."- AM II<? T PMTSOF VE tICLE0AMA0ED . _ ... _?, l Lohnkp? THERE ILI YES ?NO COI DENT ON ON YOUR CAR LIABILITY INSURANCE INFORMATION-VEHICLE NO. T• COVERAGE IN EFFECT FOR T THIHIS ACC ? NAMEOF UABILRY INSURANCE COMPANY .;.: .. .. . - ?-' NAME AND AODRE53OFUMILRY:4SURANCE POLICY HOLD ER arY E T L A P Mr / - CITY ,A m.. 4AB UTY PODGY DER NAMEANDADDRESSOFUAOILITYINSUKANLEPGENT '(r'. in 7 C,9Ir.h? l '5 c7f I FY AGE: . ME 2NDINJURY; IUEESEPNN -FOH KW-IJUNESI-: I'±'E ?pfn LO NAME NAME SEX C 'E ADDRESS ADDRESS sEx to F M F NATURE AND ATURE ANO ? ? ?? I(' -II EXTENTOF .JURIES ?- Exr OIf OFINIURIES DOCTORS L? GD INJURIES REQUIRE L ro DOCTORS © ? - ' GO INJUNIESREOUIRE t• NAME ExAM NATION BY A DOCt01T1 D ?O NAME El-NATION BY A DOCTOR/ MMNFIRST ONETHAT APPUE9 ..,..?. ;,. ` , " J STATUSU-1111ED MARKFIRSTONEiHATMPUES STATUS OF NJURED .,, H. pI L9 PO 1f nOn. HuLE ? IN VEHICLE = ? IN VEHICLE uwu ?iniVR ISCYIPEI IMnIOn MLLCD DISERENe.EIe HwON FvE'H EICIE ? _En KILLED IJO. .. P YI IIOFPO CIT ? n I I` ? ,. ? nA D o nNJ ? ? 7? O 6 ? 6 ? 70 ? 5E] 60 ,. ?.._ I MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: p HELMET USED ? HELMET NOT USED SHOWNORtII BY NIROW UJ GRCLE + 1 DESCiIIiEBtLO,WWHATHMENED_IREFEBTO,EHCLESBYNUMBERI ? ? ..I I 1-.1 ,LGrE t / u„Y.Ir a1 ... w.nH.KS al 1...? ?..:.(??h/??C41 ?? •. ?f ?.C??_._/???/ f ._j..,?.- I.uV111115 I R[r+C1E AR EnOw ] InlHnfllC LL nr NwOw - ; Hn? r'>L (L!_F• _ '?i)??I>r??e• L+_'>r?1'' ?n!_i:o_ ..7fLf--.___S?n?__?r_ c -_7 E9i10AT[D DY II U [ E« ; : C k " ' D 4 ES POSITIONS BEFORE COLLISION LLn:I:r ?:HAEO vE 11 I E HWAY NAME Oil NO Ia ICIKw O SIA O YES to f! RD 0, 1 . ? DEe OR MO [ ?; J, Vf ILLE 1 555 TES W ON STREET ` ?. ..?.. ? ..,L:I. ..?,..,.? ? . RO j1dnR ? G-E. L..1 ? L l A)/) r,7 / ' L Elnl ? ? ? ? ? ? ? S. : s n ? ? r'f ? fIC(f '!/ n??.Il,' .: f1 f1`l / ` A+ mom; DIRECTION To DIRECTION PLIXSInw ? ? ? ? ALAN{ WR ill 1 ? r-T .?HH ? ?' n?o ?u ,M ?NO.- f`CnESTRIANJPEDAL CYCLIST WAS USING', 10 -K IC]- Y ?SHO.Ix EL, lw r DAL CYCLIST CLOT11W0 COLOR: I cc] DMIn n t ? 14+Ir ,? H•[ ? nt rLtcl ? PEOf:STRUNJPF h r•? I ?4_,f„• I"'rl ',': I "y?'° •? Y ,' 1 } ! ,'.N 1? I \;. ll?A 1 C1 A Y . I10AO;JWI FACE MATHER EIGHT CONDITFORS S ?iRAFFIC C O,RNOL'I W,CTYPE OF Nf1A__nEI 1 DR VIfI/ (: fLE ACi 01 '1 ,., lu pul 1 ?OAYLIf?Ir c Icn . E nU vL?CLt c pl MOnll r1 w.L I 1 E-J? M??pE 2 ?DAWN ,?L1 LM? 511NAL5 ?1 E I?2 ONE WAY u 1 ? GOING STRAGNT AHEAD ,,. 1, E E1 BE`Y 2 ?RNRVw1 , ?BUDN ? 2 ? STOP SIGN p, 2 ? TWO WAY ? 2 ? OVERTAKING AND PASSING ? ROAD REVENSIRLE ? 2 gMANINO RIGHT TURN -t G KQi D ?:NOK,RO . ?1 IIB OIE Lr ? ? YIEUD SKIH ? G ? ? t ? ,. , '? t ^1 ( IL-T1' 'N A ?FW 5 ?DMKS"IfeT ? C ? FLAWING RED 0 A ? 0111FCNAIM ? C ? MAKING LEFT TURN O WAV C) 5 ? MANIHGU•TURN 5•, 01 J •r 1 r Lt CD J x.l b ?I.y (Gi YI n ?DTIIIL?Vir117 C) 5 ? FLA.HNO AVIKII C) IT ? ALLEY C3 b OT r T1Aw ? n C) SLOWIrJG Or Fri .1 TVa h I 1 Or?c»' JJy I I IM ' . 1 U b ? w T T U b 1. ) FLIFY E: ? D FA C I ? OT(IC111{ A I. f'T fl ? I ? TOPP KjADWAY EU FA ETYP - t KW Y , T ` 1 Ayyy{42 ", >?. f h 7 L E ? 1.1 AGWY 0IAl1ACT(R ? F? $o.sToOAT UGNDGNAL Y^, Y2' ?yI 2'4F L,J F ` `II-J I L?s,r1•}L T.UEI (•JU '.w1f LUI.?' ? b ? DI Lq 'J`[ Y HGN +11A AtION T BIJ fiTOP tAMI 11.. .. rr tf?PJ k.. u j? IT" +'uh n r_ _ v i r C \' f J z i e 4 I i i N oro ".0 CD. ouo o ? o co mo PP ? 1 C a r 1 ? r? ? r 1 iii Fa 1J ?? ? (p. +? f?; ti f i ti ? "f r ? r. s 1 2 \ i " ti N ff 1 ^wlI y : yt ' iIY ?1 J E.. 11. WE vv/ (I ( ---.?.------- `©• IVU. W TRAFFICWAY POLICE TRAFFIC COLLISION REPORT FOLICECOMPIAINTNUMOER -, , PRIVATE WAY f _ A yi {ux l UNTY NO. N I F N QF ?INI, CtYOR10 ri? CUT S ?W D OflON . : L : STREE 0.ROA0 EFIWfENSTRFET: PPEfI% EO. ES ROMNE ,CROSiR(ETORNEARE5- 5 IDENT RAMP GRAMRSTA OF • ,I EAOF LOGE ODE ,H COtlIS10NINVOLVFD: fVERITYI ? SPRUG{ Il N NO.KRIfO N0. INJURED wlFlp; EuxOV " IMF RI I CLs C N RE 01 ROAD ORAFERENCE ROSSSiRFEiO ROAD R ) R} _ _ IOTAENO. DFVEMCLES H,PROPERTY OPMAGE ONLY ? RESULTED ? FNICIF r ? rS• RC - G? O ?. Qd171,5.T-K INANE Of ODEERSIRUCK ANDOWNER'S NAMfI. f51.13-AGE SFECIALCODINGUSE UNIT NO.I UNIT NO.2 QVEHICLE ? PEDESTRIAN Q PEDALCYCLIST .! - 3 ORWtR'S WVAE: LAST FIRST tE I IV-NAME: IS, _ rl ..S` STREET (!DDRE55 STREET ADDRESS CII[v fAtE ZPCODf PHONE NO D IIY STATE IF D PM N + ?`? . 1 S A ' ^ F{L4i. DR.H-CINSE. . IAIE % R X I Iv D fN NO. A DATEOF BIR H A•O. I IYE. D OCCUPATION fIRMNAME/I—NO. 11115 WEIGH! NEIGHf E CUPArION 1 1RM N-16 PHONE NO. EYE5 WEIGHT NIGHT T 1 " .P .? ? CHECK (,') vEH CIf AS AN-11 of ANOTHER, ? CHECK(?) ' EN CIE AS AN IMnorEE O1ANO f A 1° v CODES ?+ 3 n;' x s° 1.- . 5 NIC1 ON 1 6 ? oYx.cs CODES ? + 3 % iv n.A.N1 5 6 s u - }) a+ ? AMIwuNa Q ' F ° OLcI ? <b6 ? {' "D I YIPFROM Q --LANO ? M" - ? M ? ?cu Q Vel c VfH YfAR MAKE EVI ° ,. 1I • H MODFl E0M1•NOVAI SIYIf }DR CONV ) sr YEAR ( E-HN - vl A .EL OAFT W- . { : " .) ? • E I . Io - .. }e i 5 R ll N FN N STATE LRMIER RAlE NO SLATE H VfH.COLOT A t, C u? V VIGIL IOLNDNGIIDN NO. L VEHICLE IOENII T A I 111111IEDOWNtR: LAST IIRSI• MIDDLE PY.ON[NO. O N ISIFR(DOWNFR: USi 1-1 MIDDIF N NO. L ADDR[S Sp OWNER W ADDRESS OF OWNER ' ° 1, i': 1 ?'.. !;? -,? Cam' L• X : E . . . ..,. NAM[IADDRESSSCPINSURANCECO " -N1 R }} ' I. IAMAGto MU ,jvcioFOiu ?/( dSSNIND -T-lit ED AAG LI CHARGE ; I i OI ; • CHARGE 'v"ia ou I A A I AL }S . - _ . I DM G I 8101 1 1101 3 EST DAMAGE ? AWAY • ? REMNNFD • ? AWAY ?REALAiwo f51.'D I. • Ibiolio? IE oolioi: 3 _ ) : <-a l2•e. - AWAY EY:' < Y i"/T .'n , C.. n l u C) A-1 111: { •.-_ ,. DIAGRAM OF COLLISION: !Nt{LUNE4[SSARr) . _IN erIw oDESCRIPTION OF COLLISION (U•ESUPPLIMENTALSNEII/ ICESSARYI R - s i • I • F ?C' E L'f-' ? ? I .. E ? r I ._ . 5 c . ? IS[ >r r?r • .!'41 I __\? { I.C ?4 1 L't.E 1. 1 h'lE ? I" ? I r I I I. E _?. 7 i 11 v 5 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED +CODES L - 2 3 4 5 6 TOO / WITNESSES IUSF SUP%lMlN1Al5H OR ADDITIONAL N- er S) - -"six " -'o:_ STATUS 'M ?Ix 'v 1 "-- R[fIP. • DER ¢r I 4 YY ` ( / NAME: GL'PIC•1 (.. CI f?S.,[ _.. .-__... .__ ?( °q. ....4 .._._ , I ;Ssf ,,, i ADDRESS C' ;. C?• ,r I,c? r. v i I ./JYI IUR a AM eFle nr e ? ? " . ?MY ? V.1,O. AMf DAMe. OaO' : ?Crx ?.OI N r N. .w C N L A%MS FNF er: QAMe. QuExE QC IE 02. ?101. 1 5' 7 1 ? t I jET ggrr?? T 1 1 111091 AIIROVID Ir DATE .. S' Jh '' y . j:1'. _ ., , ,. ? 'RK 1.>.?:?yrEd.. Ybn ?a wuArx aa.. , ENalzEtrE Clm.? tl V? .J n. I i ..,.a k a aL. R,tz,YYPN^• '/ r n V Lrr R.LL a.ULL .HUII I5L'YUN I R W[ N rk O N O COON T ? ? 6UN. NON IOE9 WFO U FR. eM N OLp OO Ie? . OO ?Q?p? J ?N E [j ? 1 ? "Em W 11 '' ff E] C] L ?Ar (Z w ?? 1 ": M LE9 . . ? a ba Ua Ow ON c=-? ?Ce weEmHO xSrn aiRFm anP wIwT[nFFmwN _ v / ?l EErwEEN -ET A mPFFi X ©® Miw.w cAOSAiw"u i'vosran`w[NnFV'rwiuiiJlwOi.EgrPUNaeP.ewOaE, neECIXW: _ Nn FEFT OF „? -IN„L•ann LlJ uEL Rk ? A u?IN?F; ym K'9 BLAND TNAnsroNrFO: C] .-E TOIKNO. ? t ? LOSIne -E ?..- :.. ? OFVE-S ? ?nRCE BCOPPOSNEUATV- BANNNN ?PARO EuAL11 O y .. &IECT 9iRUCX INNIE OFOaI CTmRUGp OYME OF BIECTSNAMEANDMDRESS Ffflg, rv6.;,.• ?. ... , $ . r .? [ - CRIVEfl'9 LAST NAME .. : • NAM .. MIOIXE MOPE THAN e }f7? DRIVER'S LAST NAMEW I_rr 1?5 Vtc.16 e_ n5 wEPE ww w v[O mwsOX IN ... r ' STF ODPE59 I : S AOUJE N0. AND EIOXNO. ? CT.?.?. IN IRORE wN1 Tlw RE NANT Iwu eE A eVARATE STREET MOflE58. , pry y? ? ..STATE DP CODE P/V jQC)V? DWVEq•9 UCFR N 3 ON VEfl'9000UPANON SPr } s DA F&RTH c_sON ?FrcPTiDA. on, .... .,:' .., .:5 ' ... . AGE N So 3 N I HD. D 3 DWVER SUCENSE NO. .._.: F[ VE? . A?EICHEV.-D000E) MO (PA 1 N „ EODYSTYLE1420R.1':. VEHICLE YP..:, MAHE ICHE4 ' LICENSE PLATE NO. ..SATE,:. G, _118t wry TRAILER (0i BL S I L. ?`l O VEHICLE IDENTIFlCATCN NO 9 REGISTERED OWNER ILAST• dAl00L.E NAME) "' -. OPoVEH'SUCENSENO... '. , HEOISTFREDOWNER(LAST•FlRST-MID ?L R i R Rz tire' y OWNER'S/AODRESS ,..'STREET,pry STATE). DATE OF HIflTH OWNER'SA DDREW (STREET, . .. •.' :5 , PMTS OF VEHICLE DAMMED PMTS OF VEHICLE DAMAGED M-CX (,ol 3no 0 LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE MTOMOaLE WL011Jry INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON O - - Y UR C NAM SAND ADDRESS OF UAEIU INSURANCE POLICY HOLDER NA AOORfSa prvmATE /? v O NAMEAN MpiE530F LIABILITY WSUPANCEADENT,... . prv mAT[ DP - ' '.? ,... .. .. _.:_. ,_:•;.W . .,_ i . .. " IST INJURY: ?N ME 2ND WUflY::,.IUSESEPw NAME Z L- •. _ FO YYNNFF „yILA > - ADDRESS SEX. ADDRESS NATURE AND M F AND EXT C) [D 1 NATURE ENTOFIUURIES STN %- NJIIPIES Fol EXTENT OF I FA[uAX%YPfff A00OCTOR) N! 10 NMIE'e DIDWJUWE5 REQUIRE - E INATIDN BT A DOCTOR( STATUS OFRUURED M Yom! MPFWST ONE THAT APPLIES . ,STATUS OFI WUREO _ ?OPivFP WVEHgLE IOaA&^YO u0rr p9q&n0 BtE ?ORVFn ,IN VENICIE ? AS Ogfn gUEO [nRE - r ?P[D[mPIAV NO..__.._... 1 AA C.C "T ? RAe 11 NI ' NO _ _ ?JNR 1<r!N'? r. ETC( B? ?-STRAN ? S? 7? 1 ? ,nu:N ,vlllre lrl MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: { ; • SHOW NORTH BY ARPpW IN CIRCLE \ V DESCRIBEBELOWWHAI nOCAi[an wgpAOIIMA I ____ YNArHAPP.. O \ \ I11 j Q `nLC ?2 r rw.c[m[anwln Z., on nH ? [TUe on nam:"r[N:10.[i°on ?5 Hwelro ': ? ,. .. ? \ I x wueen eACN rTwa[ AND wow ?L'? Q?"? ? I' 1]rRf[iORr+OnWAr ?___..______.._. _.. __.._'.____ 4. \ I L 1• I ? r NISI I I j12 _._.. _ _..._. nP[[r Dn.wwM ? g (n t , VEHICLES POSITIONS BEFORE COLUSION LAME vr+cu r N0 : ' h : . ? ONF n Ktr [rANDw IaON YEN," H S F w ON STREET DP NORWAY NAMC OR NO, awlrrgY .ra No n[ AO ) . . N flTM Ivdwl ? ? ? ? ?. 1.' ?'. . ar.. 00 01 1 I.:l 5F L s n[[YTRwA ? ? ? ? ALOra .: c:oeMm I 1L S PEDESTRIAN/PEDALCYCUST WASUSUW: rQexwKA [QwKAwA. I?rwuD[n IQcN'wwwKA EQ o '" 1 f - I n; e i PEDESTRIAN/PEDAL CYCLIST CLOTH*4 COLOR: IQwAP IQ thrt ]? l0 10 MROP Y ?yYyM ROM 9UIFMF wFATfIER ?. LIDN tgNOTgNa-. .. iIU/FG CONTROL .. TYPE OF (IOM Hr.[[[ULI n; I[nl<rn,El In16nT pvlHtU T v[K[[ ?nu yly.. P Sµ' ? yL?, r. i f IMG - ?T w M1 t w0 1 b [ ? I Q DRY I ?Onrcul 7 Q DAWN Q i Q SINIKB Q Q ONE WAY E ? RAlwa x Q DUSR Q ? L h x Q e1DP sAON Q TWO WAY ?a ? wLT R [ET T r y F? F ? L'C VI ] Q S O 1OWNG 1 ? Lnnis ? ] Q ,, DSAON Q a Q MAO SIOLI 03 QswW A TRf [T ? roD LOHTs OT O C) A ? MSHVa R:D ? [ Q E ? Ldl?I O FY ? A ? Lt ! T O HER 00P RAM I , ! a ? E TMR C] ISREOIYYI a aiA[[T Leo ? ? /LASHVa Aua[R Q 0 Q ALLFY ? 1 5 1 T Q ORMR Q a Q RnsINAL TVO WAY. IOADNA p1ARM1ER ROADWAYeunrAG Y ? a Qlw[aUR" rrLyry,T 1 ; T t Q I Q OIrICER, BADMAN ? I? DRIVEWAY ? ! -1 t--I L.I[a'OPEII T TIER EP[CIFY I N, b, Ll a ? 1 1 14? I f 1::. Y O ROM P Ai V 1 4 i ItT- _ 77. _I T.. r I kJ . 1. L N .L S C r I IF I Y• ? ? f? , ;;gym t ix ..__kXa?kz'fi /.::. ? r F II..?I IC r n!I r. c p_,I p L, p a^ v ?.1. p i.._. ._.. -,.. u?? • - - - - --..... ..,a. ?.,--L,.? - , ? ,E IRAFFICWAY POLICE TRAFFI No. ` _ C COLLISION REPORT Y POOCECOMHANTNUMBER 1 PRIVATE WAY .1 /MI•,?i?Ol 55 P,x ?u0 I?. FUSET.IODHOUq O-NTY // '.L/ Itr/ IR lixu sl /f :'.: ) .. IC. I IC Cl ill COUNIYNO.O. CITY NO iMWA ?W ?uR AN 1' J• ?N ?E ? GIIYO 10 NAM{ NOO ST 19111 GHWAY t., I 'S I, ,.! ? T ' iCTCS q-Tli OR Ta I , SECTION D "ill p3 ?w 0OFf t..v. ,..,.?.. ?. .,. ON :.Y . INIfRSfC1ING WITH: STRfF 9ROAD NONIN1Fg5fRION' ..S?i05'O c.3 "•]]' r BEM'EFNS f C) STREET6/'?I+. f'?,'., ?•VS?REFT ?Pff!% E MI[f 1051 - On O2. / DISIgNC 6DIR1 igOM PFEERFN .CROSSSIREFI OR NfwgfSIM IE LIEN. M4F5 'f T RwMP DIAGRAM MIA ? T W N.ILEAGE DD ft OF CDDE COLIISIONINVOIVFD: .KItL[: IT N OTA NO NO.KIII[O?NO.INIURfD? ?SpI4AGFUNutOirv Cf VFHIClfS •RD N RS tl SRE Oq ROAD OR AFERENCE Mf C5 CROSSSRFETO ROAD R a] [3 PROFEgiY DAMAGE ONIY ? t45lIt1FD ? FHICIE V J .S T Zl? L+, aD1EC S1gIICKINAME.1Cf1ECTSI.LlCKAN.-NER'SNAME) ESi DAMAGE S-EA[CODD1G., '? UNIT NO. I UNITNO.Z ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ?? S D9IVER'S NAME: Iw51 iIR31 Dl DPIVfR'SNN.1f: IS, il9 • 5TPEE141ODRL55 111 ADDRESS ? • C . CIITV STgIE EIPCOOE PHONE NO. C\V "' r?. ' g .4,r. O ' A D R ITy STATE IpC 0 ?11 NEN ?` gWfa UC[NSE st, s a<a SIATE ?.,? E% r, A N I ; ; I,9, ( v ENSE NO. Atf SE% OAIf OF BIRTH MD i DA Y. B OCCUPATION FIRM NAME6pHONf NO. EYES WEIGHT HE*HT Y vlrt :)'?t< rC 'F's.r ?,d; I/1,z l ?:; ?:Ly/ E R OCCUPATION FIRM NAME E. PHONE NO. EYES WEIGHIHEIGHI ? CHECK (? v(Hlaf ws:N MioYII FwuorH1. ? CHECK(i0 HICEEASANEMROYEFOFANOTHERA T • CODES ?'* 7 a i S yEC a ('•° - iiiY •in NM I ferv r[1t S5Y nMNT „IKY[Il CODES ?' a < is 5 utcn<n a "'O - /]/ ' IN-Ils f ?? • 5 ,, 1 .. r„°. ? MnMAllct ? VEH YEAq M A I„A;[ N ? ? N ? ? qAA N f ? F XH ?oRro Kf ? <snT, ? K ? r.? . Vll , [ F{HEV.1 EL [DARI?NOVA, SIYEE I40R CONV.I 1 E? HfV.) AfO0fl10A9t?NOVAI 1 Ipo+l 0 S Iy 1' Dw,E 51Aif wMlfa0.g1f N0. STATE H vFH.caaP lA N . A C VOICIfIIXMIfIGTION NO. VfHIGf IUfN11FIUIl N ?G [I, ?'i s? `?'?, 1iGI S' L a[GISIFR(DOWNIR: LAST II45T •/? ,I< DDtF PHONE NO. ?\ 151[ FOWNfq: lAST f1451 MIODIE NO. _ ?' wDDGF55q CM.MIa W WN[R ?I NAMEtA0DRF5 50f INSURANCE CO -AG E I< . ENT l n LI R UA CCD LFRT- ]] I. ,, EoAMAGe ARU I A ' I ? / / ' . • ? C ?AMACID AREA IOP I I IOWTOii S OeOUGf [51. DAMAG( CH oG[(E,•'; .V .: .., Y ?AW?YN ,I?R(MAINED,• CHARGE ?AWAY ?P[MNN[0 oVf i Oiuif f511OAMAGf E/???-•?-?I?ry ,? I--••---- S d ]] - f ? , IowEO wY.Y 1 r ( ? ,OWED LJ AW BY s ? `V o DIAGRAM OF COLlI510N: I D . INrec g00,/IH i i i? OESCRIPTIONOF COLLISION: 1-13WKWINT .5WEl I [c[sua I ?I ?.fc f.. r. .-? .1_, _ - ? l r 1 I __ LI I _ ..- "NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED * CODES 1 - Z 3 4 5 6 •» OCCUPANTS/WITNESSES IU51SIi wNIAE5w f.-1101RU rVAM1 ' tr 51 -. ._-...-.... SIK AGE IAtUS .uwl INriH ? .. - ' I• .... ........ RISt9. lXCI Mu+' I _ G. PYf ? : . •' / - ' • A N ISS < • ? 7 ! ir4 IUR or 91 1 ? AM S. ? c?LKf ? H ^ . ? Qii" ? 11ANSP A pp113 Hwl Uaf O/ ' '' "' -' 4 gOVID Ip AMB. . p ...-.. ..... -,- .. ?. A O(LISI P SI I µ ?? IMBV: ?AMp. ?[iK1?("[WILp ?tjV ?IiitiV - GA I gpIK1?7FVEWtpANR pADCAM AGENCY ?( ?• ID.fII a`i•ia IsI OISIAICMD FOtA]AppIND OAIppIW91 APIpOVl00Y MIF ?? ?:'G's.Eel.a. ? s` .a- ? H'. 9? y?'?? .in ,6'??H ' ? N',lr: t•"uv+Y.YA . ??i-`wiwAk r., ?M _ T fYn] IAA • If E ?I TRAFFICWAY' ' . O P E TRAFFIC COLLISION REPORT U POL FCwenaNT-ILM , PRIVATE WAY O C O DA 4• R 44 Wx exup ID Ywn. Is. iul IVSE ?I'DN.OUaI G COUN ? COU . • CITY NO iHWA ? Uae ( J ?? S0v ? RAE ?N ?E ?IN CITY OR OWN?,,,??/? ?NAyMEE B?NO.OFSigfflOR HI?GHryWA/Y [ FWIES 5 nW 0Of . (./Y{•YL) oN VZC7 CI?D?/?/ WIfRSFCIING WII Si gWAD A ROUTE It 1 Sf , 3 sJ?iGJ Q : NON INIFR3EC110N /??/? / (fir BfM'FEN ?? ? ?iPfEt 6 ?{? ? ( (? STREET DIS AN 019 1 R E Ppffl MILLPO31- ? 0?. E .CROSSSIPEft OR N?E^AREST MIME f /?E ACCIDENT C 1; C] sl FE13 W Of rJ? " /.FJ MILEAGE R IA RAM pA1A COUGION IN VED: .YI TOTAL NO NO. KIIlLO-NO.INJURfO? ? SPIIIAGE UN esW s .pD IMEq C45. r 9 BROAD RRfE CNGS$STRffTOR 9OAp ]] - OfVFH1ClL5 ? pROPfg1Y DAAUGE ONIY ? RFSUETfD ?VE?ICIF. .S. Tx Q ' '- ODJECT STRUCK INMAE Of OBJfCI STRUCK M'p OWNERSyg) ESiOAMAGE 7 ?? 9 ?.L?,e y ttlit CG. ! T 7 u t>s?/o l 3D ° SPECIAICODING USE S ?? S - - .' `< UNITNO. L_ - p IVfR' NAME: u31 UNIT NO.2 ? VEHICLE - - ? PEDESTRIAN ? PEDALCYCLIST ' •2A ""' l -taA LLAC?? DRIVfa SNM1F: DART IR I l -- SiREE AD g 5-15 _ 19FEIApDRE55 IY STATE -CO PHONE NO. NEN D IY SAIE P 1 D , DRNER'SICENSEN -cvR LL•R B-T560 STAE YA)A DAII. M 11 ? n I v If'UEN NO. 0 ATI A A-51R Y ill, I ?- 1, Z OCCUPATION fIRMEWAEI PHONE NO. YfS GHI HFG t Cc aI ? E R OCCUPATION fIRM NAME4PHONf NO. FYFS IOM IGM ? CHECK(4 I-A M1HI<LA A ort1a ANOTHER. L CODES ? 7 p ? CHECK( ) VEH I SAN MP OWEO AN-.c. OTHER * ?` r Z I i 5 I a 1 1 Z21 NriNR3 CODES ? 7 a I y 5 ucTroN D y ' ^?] s?IwsLO,gM ? AMINVNCE ? K[ ? ERA, IXi ? T06 10 f MCI ? 8111 ? ? ? vl KH ? iTi.e,SP VW.YLIA9 MAKE !0005-HE1) ART. OVAI S1Tf1]09.Cp V.1 x'14 YVA E v R MOD 110ARi- AI E v., oM ! U PI A S1 A1 IIAIIIIATINI, STATE H 1-011R A ?/ ? I? / ? ?E I ? C . VFHICIE IDtM1fIGl10N NO. SlTT2j21CSIZI I /I?IZ? I • L ID NTI vHi O I I I I I I I I I.. REGISI1,11OWNER: -1 fIRSt MIDpIE PHONENO. J Q f I D fR: LAST fIRSt MIDDLE N W 11? Z ADDRE330l OWNER N N!R E NAME. ADDRESS Of INSURANCE CO. GR AGLNt A A-- Cl v /Y R v ?u Z OMRN6 ,wCDNA rn.,P CHAPGF I , CHARGE a N AMAOF? MG b ' OIOT !Sf pNMGt = D t LD. Y ? REMAIN ? tWAl-l - Q Af?Y ? O A WAY RIVFN ? uMAINFO A"WAY' BY' DTHIIDMDI ESi p f , EIDP luemio? 1- DIAGRAM O{COL SIGN: E INU.YAENORT. 1., ?., .. ISSWTYNECFSSMr7 D Ay OA• /Q. 11 S?i?ol I (IpEq N OESCRIPTI OF COLLISION 1.151flA[MfMAl SHFETI en13SARr 1 ._.._.--._ 7/Et//nC #(-.7? ?sr ?ouND_'a.?J -- -.. E'46l ycf6T74rF-?GlQr/?c..9S.ia = i ? ? . -t- ---ti , _ eq" 5 oSYDE- o} Cefrr?P/1ocJ/lrE7I !C!?-IOr/tiT..___.. ,PaC?/cce/?-s A!STRUC',?.?L>.C-tUA[G. __ o I i ? !? ?~? ? ? .. C (SlOrrioH/1Dl// e?.Ey P ..TYD? s9Hez9.0-?---?G.:.. ? 1 i I • ill , I? I ;.. ?¢ ??.. ,P?o,? .rovur?-,cscz'?rcv _ ._.. v NAME, ADDRESS8INJURIESOFPERSONSI NVOLVED +CODES 1 - 2 .1 A S A OCCUPANTS /WITNESSES IVSE°E'pnEMlNrusHE IOEADONKYEALNAMZ FT SI -------- --- ux c- TAIU ? %siR. lllCi ,n A NAME: . DDEEss N w1uR Or. . '. ..- .. AM 1 xn ?,?KI? e PII • ?WIT' ?i 'B;,Ir A AM . .. .. .... ... .. ..,. .. _ . . Np. .. _.. .. Ss NATURE d . ... ... ...... - E MOVIp ER ?A,Ae. ?HUKI ?To " ? ? li°'N„ 0 N l AN - T A W St A,lIf3 - IH ?AMS ? LLTi ?=,, X WNSiq'WOO, KIISNWZ EI pApGE CIE •sGINCY /KIy 51A1CND EOlKL A1151D a?? / VID Y ?11 a 1 7 1 pp a t4'`^ 'fi'„ 4 k #V IE ! Ili°i' d ,T e - ?' u"? E11? t T ??, .Y.ry2 R gu, a IWO T (ht )? i F? t {r `S I v 9TR? I ,? ?t 1 .n 4 t1,;:R v ? r y ? k s w. a < I ;4 Ip .51.: 1 w E , I,? ? , ?y?. s I S I' l?? ., r i ., ?y , f ! (r ??? ? 1 h 5 f 5 1 (? ?: f ? Y 1 A I ( , i' 1 ' ' L {y 6 ' i . C r iyy Y•r 1 ' 1 1 A,. Y I? { ^P4} S I ? ?? t ? ^ II alErfLrill S fAl E OF WASHINGTON PAGE I Of I N ` POLICE TRAFFIC COLLISION REPORT ® TRAFFICWAY o. POIICf COMPW Ni NUMBER ` PRIVATE WAY pAIE oE ..' , rf5 ?, ". . .. rs N , U t .iwo,'luYj Li uC; - lusFCHOUR) COUNT r I r`f ' muHll- CITYNO. PnwA ` , E y1 •' " p L CIIYOR TOWN pN ' E- E ?DR 1 9 u a ? I I pN NAME 6 NO OF 51REETORMGHWAY tr J ` U N AOUIf OR SI SECN N _ ANLE s pw L.goE j ! IICy• ON .4.' W, •ti .7 NIfR5FC11NGIN5IREETRROAD NpNIN1ER5fCf ON ?' EO. S/O.SO RR Mllf PMi. l'3 J ,: V / gE1WEEN `? •? V+?? 1 EIAEETa?'STU:Tfs+ ETRFfT /, 05IANCE6pR iR M EREN O y.?'' A ' ,CROSS SIPEEI OR NEARESIM Lf POSt YN FEEES N 5 ACCIDENT RAMP D nCl. `1l 1 fFE1 W F ( Kl MILEAGE r RAM 0.0[A - CO 15FLANINVOLVED. SEVfRI Y. CODE . ? IOfAI NO NO KIUfD_NO INJURED ?SPIIUGE ?HIT V .1-1 vIU .. OF-CIEs Q ROPERTY'l-AGEONLY M U ? Vf CN IM? D TIN I I RROADOR AEFERENU RD C15- CRp355TAEEi OR ROAD { - S IiFp NI ?- Ci SIRIIC%INAfd OgJECI SIRUCK ANp OWNER'S NNMEI / - ESL DAMAGE 5RECmLC0D1G LGE REll ADDRESS " n •- fSiAI/E? -vo,,E PHONE NO D IIY 73t i% 7 a AIE IP PHONE NO. I nl.. I//' / 7T[,f//1`Jt 3'tt? LWT ! 3(: DRWfR'1lIC[NSFN SIAIf f% A H ? IV U ENSE NO. Gu) AlF % OA BAY I. T-, V R F l?N? ?3 ?t3 A /OIOL yt? MD. I 3 g q7 IXCUPAIION {IRA NAME{PNONE NO. 1) Lr ?` EYES IGHI HfIGHI E CUPAIION Ft IIRM NAMF 6 PHONE NO. EYIS WEIGH} NEIGH} .. .. E:' ?' !f I S: ?CCi'cL? M}i ]TS ?S' YS R ? CHECK (? I V[NICIEA A 5 ? CHECK Lq M "?° E N VYFF dANOINfR. I CODES?* 9 ?r EM CLF ASAN EMPLOYEE . NInoff CFANOIHER U rinM 5 a NOrn •CU CODES ?+ IuRrY R oI svNxl x y +crcu Dr^ n. • 1 I Cw of •'/lrtAa•.w'AAK ?~"•'- ,v snM SERCIp " VfM YfAN ? ? l ? C84'. ? nxKii ? tutnP Yr}y;' Lp NA -1 p ruoticl I? YI ? iiwY , MAI(F IPO-CHEV) fl lD WvAI' SITIf 13 .CONN.) p aNIR R? /??' E I M V.l MODfI IDARt.NOVA) Uf V.) •D t F ro RE V t UI N SIAIE NIER PUIf NO. STAY I'( VfN.CIX R FPDRFRO. yU[ n,IrE: ?Fl P,jr27/6 ?'A I. N A {ffR V[NI-RENI!"ORt, nNO C I1 l ]9 L VEn CLE IDErv N IS C 3 ?i2!Y'H;JZA,811 I/!QILj r i, ;; I I I I I i I I I I I I I I I ?' RFGIS [DOWNtR, lKt HRll MDplf %IONE NO. IS {D W FR; UCST {IRii MIDDY NO, F o .. j?E f Jfu r(? 732 •4[r77 ?E IG. 'IE L C I?? ApDR[SSd OWPIIR W UI N WNf 3 ?(z f;3G3 i3 r kc? nYw?1 ci,q NAME E . tMDRESSd IN5U9ANCf CO. OA AGENT r? ?)?? IDLY.: 'r R 1 .. YkA 510. S lSl. fiP.M•AG( -._-Dµi^v CHARGE -- hM(IW •••,'-,•?'••.n F ' o fiou ? >?9EAwMD DRIVEN IV •*D• ? AMA F S -. RfMNNtO _____ -_ f 1 PA t•?Cn. -IJIrL- 1--I IOAY BY: WAY s I IOepnoM DIAGRAM OF C041510N -11- -11 1 ? Dclun NONIN DESCRIPTION OF COLLISION (USE SVP%fM[MAI SHF[11f NICE Y) 0 - SHEEP INlClSSINY) SY AgRpW A ...,N ?JC fla i..Jr15 IIGrI `t-llti S?rg. t-h ?G1w? ..._.. 17: ; ;'•-- r :.I ?., _t. i°'1'_.--?...-_k I_ ?f?r t. L}ICL.?? C ?`.. I.JI 3? J }f•f? l! f`?. O i'F < -Fa i S. L l>- -ft_ r d do _ ' St I NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED * CODES 1 OCCUPANTS/ WITNESSES iD?I1 IROVAI NNU rNiue11 I r__ Apgltt - .. HATLP(d _. 094[1 ?wu. • 0.11. flAw: AMa ? I`Jt'J1r Als(Wti _.. .. NAIURId .. -... - . NAxE. I „ 1. RMOV DI9 pAMq. ??Rl?N :?„^x ?1.° r • •i,Y tl"+ 4 Sp? Y M 1r sn i w L I ^'7U? t 1(?... rr Iiv??>f? ?RItT 4? 4?1? 10, ?', Y `+ 6M1 'l,y. 1 e ,.? u'} v< o (i EY ' YS Pal S I `y rf s )H??j ?t Sryi EI I I -I J ???w aF' R 5 J {? , ) ' (yI ) I 31lx??? ,?' Il _ I I + iR N ??? I [ (I F POLICE TRAFFI N0. E C COLLISION REPORT PoUCECOMHNNTN4mBER ' E]PRIVATE IJ PRIVATE WAY TE El 11 ?:.1 /S?O0,9 : •3t y9KGj ll?f1 IIMf COONtY WxIW.Ik (I I r I ? UR) CIX)NIT, NO. [IN rq MWA ryry I / 00 QU RAI Y DITY OR TOWN NAMF6 SiRfEI QN QE QIN O R W GHWAY CIS - R54'f .- ? ' 1 , I , • Alas s QW Q ON Of - U =???Q:- I IEPS[CTING WITH: STREft OR ROAfLu• NONIMERSFCIION ?( Sc/+NSO l//GGC R C 1 2 .E EN STREET It STREET PREFI% E MIIFPo51 ?j TE 2 AN El I I E CIIOSSSIRfEI RNFAR IMIEF ACCIDENT / y Al N. 5 -W ?E UCH U4GLG Y D MILE G IS RAMP OIAG DATq = '' , A E OF -?? CODE CIXIISONINVIXVFO : - A M Y yg NOi[M1IfD_NO.IN i0}Al NO. luREO? Q SPIIUGF 6RUN Hlrlow4m TOTAL N., © XR N 51 f ORROAp RttIfRENCE IMER Cl5 CRO535 POND O4 1n Y Q PROPERTYDAASAGEOI ?GfS life VFNCtE OBl[R SIR 'I-r??-??y???j lJ T J 9 IKKINAME Of OA)ECf SIPLK%AND OWNEkS NAMF) [SI.OMIAGE Y SPFCW COOING IEE ,c.Pt s S . UNIT NO.1 UNITNO.2 : RN NAME: [ASi Q VEHICLE . Q PEDESTRIAN I PEDALCYCLIST. 24 J Ivt NAME: IS, FIRST -- _ StaEEi A0DRf55 V REET AUpRE55 /E ` , Lf STATE ZIP COCf PHONE NO. T 25 S= ZS5 wVfR'S UC1. NOS M•/ X ' IR D R I Y STATE zjP CODE /Z p'L A $ X p H ND ? I- V IICEN. NO. AE % OA BRN b - E -*? S to A ry) I s ?ii 9 MD. (RAY IrA a C[CUP`I?ON, HRMNAME6 %gNElq. EYES IWII IEIGHT TThh R0. E CuPATION FIRM I`-F. PHONE NO. EYES 1-1 EEGH} ,- x a 'JV 3 S- SS A)" /MO•SA R HECK (11 vENKIfA w rofANOm[R. CODES 1W * 7 s excrl 6 v u w CHECK (.? v[N CEF ASANirMnoY[n[oiwnorH[u p croN CODES ? * 7 a + sex E smO..E rLS" J??IR N mIES °" ? AM.mN n Q MIT Q C96. Q ff.VM" ". yD Morro Q A"MAWx% Q MIT 118%. ? 555, Q VfH. YEAR ALIKE IOOWfUIfV.I fE lOARI•NOVA) STYLL ( H V.J 110Mt-NOVA) _ TNKPMPR 2 E R5 G N P SIA[E IeNEFRP, T1 NO. SIA H H. R -yam- STAT 1D HS3 l07 LVAP E :&,, M nHKIllafnnlulaN NO. c Y E N I I A E HI y ' G f+!f lblClpl/ IYi /i/ I! 1 fGISR REDO (R L I I I I I' I I I I I w m WN : WI NRSr MIDM! %q NO. BS- z SS O I t WNF4: bVir 1149 I IS VRY .. - ? ADpafuar ow"rR LL'. Sl O - ft? c41h S+ C W N ,E wneR e11 'f NAMI A ADORt35 d INSURNRCE CO. Or AGINI --t I AD.- OF NSLJR-CE CO. M AGENT MmAf. Aau wAWD ' R " RR 5 R10r ' MONj Y[.? CHMG[ CHARGE ?MgIN ?ROrO+N [jAMAGt AR[A l ' T ' [ I O I*Oii lsf. pAmAGt DRYIN ? WAY 0.1-M ? RIVtN ?RfMNN[O AWAY O t5t,0 ,O! P10r I 5 IONVID t- BY IC 1101TOY R ' DIAGRA FCOlU510N 11 In o" OaNO9v IN ,SHtL1Ir NtC(SSARY) ? DESCRIPTION OF COLLISION: IWE sw%FmEN1AE SHE, W Nra-Y) $ 4 fit..[ , _L I 1-? vvti._ _ 1 wns Ioo K EAI ._ .d L4wn__ T $ i . '. CA _. A. ?:FQ S._ ?ft. ?L.. •!.__ f•/. I .i I I ... L ?.. I I ? WESn'< u?K.S?.. • ._6? ar??+r?_. _. ? . ), ...; , i ; .. ...._._ o p fA.R fl, ? r?Pr?c.._ u ?cn.ban.Kw«.r7f >e rl , I ---- -------- - la ! " "" - . upADDRE55 8 INJURIES OF PERSONS I NVOLVED + CODES 1 - Z 3 < 5 6 " L C : . N `p ANTS /WITNESSES s[D''°D„orl:1 N-1 Aw 1 siR VACi re}uE A, '" _ :J nsn. utn :, :. ( , . . t .. .... .. -. ..... N _... . o a 1 i a _. . r . a AM n A, Owl Q '°?, . O H « Q r 8'NSF ' j Y f M L J-. Y, A Awlu ,x QAMS Q;a%tQrxl:. QH« OI:°`«sr "I"{ } ry S ? w a s To FROM -.- nE Ar QAMA. 0M. Q p0. 0'.. Qnu:v MrMH51aATNOara R 1 ) I nFYM+AUNR y AADOI ENCr d HIKE DnrA1CNlD "'q AE. VI D D•[na nlgl AFrIOV{D. WIE ? ro NO F 7 ? >a ? u ? I -I I: ? a .A•' ? ?h' J ti > ¢I2 „tii k PW-ca?.:,.1I:•. ?e :+', I u,"LRA{, ? II '?.C? ?•??? N'Vkl ,-0? ? 'ri Y y ''N: ..d .4"y.?. I I .xl } Y 'E xl 'E it - r 1 {I I I _ r )? I ,. FY II .T 6r ' ,y+ l' '??y Ar.ArSx • N 'i Y.• 61 STATE OF WASHINGTON PAGE / I/ In1„ ' POLICE TRAFFIC COLLISION REPORT XTRAFFICWAY fOLICECOMAIAININl1MBFR ? PRIVATE WAY DA Fc L rv 4 ,. F uME couryTr D1I7 S W I ' In;;. HOVR) wlR CYORI 0w u= I O ERSOn/ QN NAMf6 E murylY NO. Grv NO. FNyA / I QRURAL A, Q 0. N00 SrR[f104 MGHWAY S AVlfS 5 QW DF A Ct.FM ON I, IN1[RS[CINGWIIH SiREETOR AO NON INRRSf ION R 87r0..1 ?,?E SERI :.,J 12 / 1 n BE(WFEN (,,,, (C„ ?Z STREErd L. ST.- pREfl% EO. MIIf POST `'// DI' ANCF DI4 AlEf N 5 f V N RO RFF RfN E: CR05551Rffr OR NfARfS1MILf 1?egUC ACCIDENL / RAMP DIAGRAM RATA MILEAGE Z FEET CODE CIXIISIONINVIXV[D: Y-.- w..... TOTAL NO NO. KILLFDNJURW ? SPIILAGf ?- "I 4RUN OF VEHIClFS N N X.D R IN 51RE R ORREFEAf INTER [ES CROSSS R RDAD BD -?_. , r Cl pgOngIY DAMAGE ONLY ? FS FUllEO ETV Hc IF1 '. /l'z'-" _l OBJECT 514UCK(NAME OF OBJECT 5TRUCK AND OWNERY NAMEI FST ONAAGE SnCW COOING LISE 3 UNITNO. I . FIRST DIVER' AEAW(: y.,5} UNIT NO. 2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST RE MIDDLE -J? ?Eo .J4 RIVFR'SNMIE: USI T- '- -- ° STREET ADDRESS RT 2 L A StRfFI ADDRESS 2 . o GtY STATE D EIPCOOE PHONE NO. G- W 3 7_ DRIVER '•v LICE- WAT fX R TIT SrAtE IF P N 1 v Nc wA Iq M F mo DAY I r, I IV U ENSENDI AlF DALE BIR1H MD, DAY 1'.. ... B OCCUPATION IIRMNAMEdANONENO. 7Z2Z? EYES IGHi HEIGHT E OCCUPATION FIRM BLAMEd PHONE NO 2 . - S . 1 0 R . -5 WEIGHTMIGHI Q CHECK (141 VFHpFASAN FMPIOYFE OFANOMTa "E Q CHECK .. ? ( Y CODES?* ] aH.r < °s 5 E w e r°sn rtcr I onRCrcu yFHiCLF ASAN [MROYFF DFANOInf j 3 rtMxl Au?Rr crwx for rcu CODES + ? a a i 5 Ex B y-- ,7n z N11iR o, ` Q ? YEN EM n ? 1b`Ir1R s'; Q VON u RTDf Q A,l EY Q 5F, Q B.R. 5.15.15, QC4H,. M f (DODGE{NEVI C 7( (DART NOVAI S1TlF (t DR: c- ,) CHrGP . .Y- ( n Y.l MODfE (DNII.NOVA) Y 1 ,J - o v R aNfPAtEN suT( 04 E I'I Z , AN 739 RATTER (UtE NO. 51AfE wR 1 c H. IXOR VFHICIE IDfNI1fIUTION NO. t IBIO ?llJ- !Y.l:(o l ,10!3 i 4tG15R4f0 DWN14: L VEHICIf IDENIIH I i i i i ' ST MIDDEE -IN., a I f0 WNER: IASr FIRS. MIDDLE N . 1 r 1 I? r ADORE5501OWNER W N A WNER , .I 4I NAME d ADD4155 R IN504ANR CO. 04 AG1Nl E' E o E R " Ds DAMAGED AREA .- Al. N s Iw *= r c..G[ CHARGE Iwtlio rDu E gAMGe EA s ° O ?0110? lfl. DAWAG[ ? R[MAIN[D' AWAY ' ?ARIVEN ?RFMNNfD WAr l FSI. DAMAGE lOA e l s UGORUq $ 00T 1-1. AWAY BY: toW[D ? AwAV eT: s I E DIAGRAM OF COLLISION: ?u u l N Nev ^oeq m r R[I INEC[SSANY) A DESCRIPTIONOFCOUISION: IEJSE I-PEEM1Mµ 5H1tnr NecfssAaq .J '. y! .. ?J .. ,._ ... _... lJE1!• t.EJdS_. LJosr I wt;T Spor RA-Ao S Kcao E-o._._.AIim. A NOCrTf QQFJIC AOd? _ .. q : QanoE: ? I _. 'Tr NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED CODES 1 - 2 9 4 5 6 OCCUPANTS WITNESSES IEFS1sI1rnlMfNUESra TOR ADD'_NAMI N ?1' n fI ...... SF% AG[ IArIJS .NAY. In 1.1 . _ .... . _, .. et ST1, fJIR i . ISS .. - NAME ArCW 0 NAIUR OF n ? AM . ? ' ? A . as ? raN,A )0 NESS N ND µuvw. - ...._. 4 MOVIDFROMQAMe. Q?CLQ?I ,Qa;; Qr.; '0 "DDriff INxNr?f - IM , ?AMe, ??°: E O[OmI QG"d` ? n V x tpAlrq Ofl4lrY naweeAHK BADGE O( AGlNCY IOISAA CHID IOIICl A-.- DAllpngel AMepyEDeY DAR q Q? }I wwrl r IM, ME ? YF yy?y? I 1) I y ?'El J.1raT. 'E.'"YI nt 4 ?b J I ' ?' pRl ' x'+' ? ?(,.?^ 1 1 1 S L '}?'1 ;$ Y } f uu l '? ' I Li ?( " ? ?+E I + I II I F a I ( F I L'•. EI Sr d n ?T POLICETRAFFIC COLLISION REPORT EKTRAFFICWAY oflcFCa.w •NINUr.ERER /G PRIVATE WAY . ( R QII.. - WH iupv l T lme l41 .T l.7 n EesEH0URJ COUNTY 'T s'c?GTi?S0 COUNEYIIJ Y fkWA /lo ?UReA IAI t Yl 0N °E ON CL11--WN _ Na.IEd NO.OFy1R FE l0 HHWAY CIS OOIf ORS F A '' '' // MIU$ 5. QW f S ?!C` /?R/ INI S SI7S"O fRING W1170 NON INifRSECfION OEIVrt[N ?sT da/ / iRFEt 6 AN (DIRE I M EFF .CROSS SIRff TOR NfARESIMR POS I ACCIDENT FOSI ; I?G M ? Ml 5 F W f/- [_(f,/ MILEAGE A GDllIMI VOIVFD: V RIIYI USDl MIA NO NOO xIUED_NO.INJURFD? SpIIIAGE ?HI L N Dnom IN ER CLS CA CSSS fET PO/D ??? E f 5 1, MEHICEEi Q PROKRTYDAMAGEIJFJIY Q pE UITED N OBJICr STRUCK INAME OF OBJECT STRUCK AND OWNER'S NAME - -? ) fSi DAMAGE Spr W IG IC: S. ,..., :.UNIT NO., I.:L: UNIT NO. 2 ;;:_ D IV Uylr' I Q VEHICLE I •rh "Q PEDESTRIAN Q PEDALCYCLIST.!r S' G E O L V : RIVE NAf: Ul Sr I S REEt ApOR DR-?o 0 THE- •?? '? V,' SrAIF CIHIf PHONE NO D TTY IAFE I p O $ FR'I UCENSF NO. STAI[ / - 1 " C NSE M. IA DALE B H - I 1 7 7 1?4.44 e 63 OCCUPATION• iIRM NAMEIP : B,' y NONE NO. EYES WHt HEIGHT .? sC. dql / a E R. DCCUPAIION fIRMNANF6 pMONE NO. FYES IGHL IEIGNI .:;; y, er": Q CHECK (? vrwnF AS-N Du YIV ED ANO HER: CODES?* J n?jyY f ID x rivM 5 1 KRDN a ? CHECK (el VfN w KIE-SAN fMROYfE FAIgiH R. CODE * p/? r a NJU s NU S ? 7 a„ s EJ e E ASS RM DN Ann 'E !3 ??y. PoM Q A-vWNHtf- 4?f ?iRe ?MV•rE , ? Pa Cf RIS { KN. YEAR MAxf ED000f{HFV ) F TN 0.- Q u Q EB: Q ; Q {u ur KU ; . S1 pV 1, YEE l]p¢ VI Y VI MODEM r. VAI ' l4? fJ G? S1AtE IRAIIf?0.AIEN0. StAtf -- H , VfH.CIX R rR FLAT YEHI VDINfRKA w. -1 i 11 21 I I I S A o 1 1 1 REGISRRFOOWNLR: NSI IRSi C. L ' V HI IN I I I I I I I I I I I z •C ID MIDDLE PHONE NO. R/GGEAP v. J2 ApDRl53 OfOWNt9 O W F 11t p Rm: M T fIRSI MIOIXE ' .'„ S D tO .6i R RD EfZ2EiJ???/i?G. NNAf a ADOREss a INSURANCE co DR-INI E, - FR 1' . ?A.wctD ARU SAYIN R uA m -DIIN 4AA1AOfS AafA ?fen61 CHMG! 4 CHARGE DFUVMwI , I I YIDP ITO? a nI. DVM?OI) QAWAY R NED ' ?ARrvtN QpFMNN[D f5.0 y0^bE : WAY 10 1T0 E . OT E WMDeY Y ::. 'I le DIAGRAM OF COIIISION IND G jNol DESCRIPTION OFCOLLISION: (WISUPPR WAESHIIIIFNICISURY) 1 ; r rr- HEIi CISSASY).._I a ARON ... _._ -- V EN Tie.9 ubZ/NG 1 {O dey 3! _ Sl l/ (-" ' _ _ r _ f t _. elf { t , t 1 . _i I t ?G14 S'?6ICfWA1/S LGr T ZlKtd3. ^-- T. I ( !. f ut . /NT77- . I$.AwK Veyil ? f'P?'a o/U 70 o t,d ESZtr Fp I ? ? tI T 11 LF q _ _._ / , , ' NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED * CODES 1 - Z 9 4 5 6 r OCCUPANTS / WITNESSES 4a ?oDillo?NU Fuuwti i - - -' '" sex -1 u wcRH 'ftAr J cY- yo (4, e - _ L Q .. / ._ rUS 1/61 , A RISre. FACT u n u . 'A" NArper F roRns ffGL{ SWE /1'J Gr 2 T r er. -Me. SRI °I.II. F On^R' Qit2lo o . i p q _ x yv - ... ,, A NArUR10l Dd153 u .vgV.: IRpM QAMe OM ? NY • xD xwts aER:En aY NY a °ww OAMe. Oc. IJmR QG"J' Q :Iv WJ. uJCf oR ADINC ' w KIDS (CHID x D yy!!aA. (.y ,,.,EP,,l3' ?yF?EE!JEn ? d' .1. ?iIIT??? (•1fa?R@': -?•R"P':??A Kt ND D-Ilp I1FCRII AMYUVIUYY wll IP-+ ?,µ IpE?,pp??? q ?EpJ S' .T :'7WR'!A /?Y::31':'OJhTi.^7.?YnIF It! ?{ga?? .J9iE7iE ?R? ASFSYE?l? i ?'ll 'i I ?t' I;a I L ?y,y) ?1?T9? I A I ? I F I 1? d l? , V t 1 r j', TIFF I? Imo. - s ? • { E1. . . rY .J?.c?.-._3+1.. .C.a•.I ..ib'r:_.._>•i _,"J?' s - l ?°? ??'+?/ MOTOR VEHICLE COLLISION R ..?_ v. .. ry, ? - / EPORT (,oT causlox o.r of cqusDn r E owsD D v v NO _ ' , l 9?, Dv ruES wEO mun Fw 9AT. naLN INTr C 5 rM WC E COUNTY NO// CITYNO. E N ? ? N' DRE 7 ?x ?E ? W GTYgt IOVM R _ cT CLl P ??ymn .L X i E h 1 ?/, N fR aE ? RFFy DMTEg SrRF T CODE. EECf, ?t EtCTwp nIM ITPELT ?J ??7?j? -' {f •n c p rnEET pT O E AT © )f 1g Owx iw i Ei.n OnwA nNJeER Ew qN,r .. P'RHOM INTEW^fCi ON5*.) )FEET (? ® ??r]>"r?O MILE OTONwEni?Y xO ?J DE I .l J - I? OM-0RW ' t ?, ' - .. - ' e s . ?, T.1-0. wvgvfO wzAnououn u?rrwAL]eEwo mMSPOmEO ., OE'vEwtt14 ? _ _ ? DIME ? ? ... WiER TDTALND 1 iWAMAeIeLgxID FxPL0ENE9 ?Cx E I ? STATED ?YmE BPARnO]NEMATENAL ?M FA ..:_..- BAMMDNM OBIECT '. . ngfRFxC DCM].v Elne(i (A R?oAp J PAgp STflUCK (NAME OFOBIECT BTRMCN) ' '_:.- .. •.FOIUE TS NAME AHD ApDflEBS,... , EMATFN ? 5/¢/O ??rM??R ?r ', aRfc CODE Lae $ I ' gBVEWE LAST NAME „II NAM MO CinM 1 1 v(o s ..... w6 NAM .............. .. IAIOOyE .. n? ?A IV. -. 3 * wr s C V I C C•(f CD TMEw„ p A VTE NO.ANO BO%NO . .. / E o WERE 6TREET AOOflES3 ` 7 / ' ? ...;..t. flOUTE NO. Mf4B %N .. J 'I: r ' I l .. - ..BTATE I - „ ZIP.000E: GAINER 9000UPATK)N. C sEFARATS nN .C17Y: ,...,?- ... ,_.. ..._s / ATE „_.... ZIP CODE NEPOnr FqW GUVEfl'BOCO ' ? f 3 I •. . _ UPAT ,,. ` lS>C"' 'il l: Imo, geVFA'B LICEN6 NI '•v•.. ..,DATEOF eIMH,. AGE, gUVER'B LICENSE NO;._.:.: / . I VTFfT C" U 7 ?;` BTATE SfX. ;LOA & ;.. AOE_ Irt C" .? ci 1 Z ? ?? ' - ?`N YEHICLE.YA 7[ .MAKE CHEV . I OODGEI .MOOFl INOVA OMT)•, `'" n , 7 1 . .: BODY6TYlE120Et1 VEHICIE YR. .MAKE ICXEV.-0000 / M f MO. O.LV vR. i - " C I ' 1I? C ' ^ A•0 ..: ?BODY.BTri 12 DR1.. .. ?. ",s .•.• VEHICLE IOENTIFlCATAN .,; ?I REGBTEgEO ONNERI fl T'MI NAME,,..,: ,, I\ .•" M1 .. NO-:- _ GIRT ED NTI •.•.M. , 11'' I ?r4. 7 K-1 SQL - TV I ~4 I n ..,.. 0 ER ADDRESS ?•?? .. '.:1 BEET qTY ; 0 STATE). ;;:...• ,OAT F BIRTH., '.- . INNERS App _ :tizur.LIBTREET.CRYAND A ... ' 1 lll4•C .? Nr Ci ?'EJC K rnL PMT9ce-0F VEHICLE DMHApED sAr rR. L - ' - ._... _...'•? .'. •.;I ?'.:. wS I?L?,1 ,.. PMTS F.VEHICLE DAMAGED L ?F..j=,,.n1 ?e•:'G,J, ltcil^r,'¢ ?-- _._.?..:L _...._.?L _.<..,. NG u LIABILITY INSURANCE INFORMATION•VEHICLENO. 1• WAB THERE AUTOMOBILE UABILITY IN6URMCE F COVERAGE IN EFFECT FOR THISACCIDEMONYOUR CM ? YES ? NO ??'++`'. '. NMI EMDAODRES7 Of UAp1UTY W6UEWICE POLICY HOLOEfl. ..:. : 'A*'Q ADDRESS •...:'.'. •- (NAME OF LIABILITY INSURANCE COMPMY S . .f NMAE MOIDpgE590F UApUTY INSURANCE AOENi. _§ k I ? a '. R LUBIUTYPOIICY NUMBEq - ?, 1STINJLViY ',. 1 1/?' E.. '..;a - 'AGE 2ND INJURY .. .. j' 1 ?.EPARAT[nF?OI1TFpRApgrpnAL NJ NES) .? r NAME 1 - TpTAL NNAE ADDRESS SEX. INNREO NATURE AND M F ADDRESS &E% E%TFNTOFE LERM NAT „? `rt q0 WJUIT IE9REOUIRE IT??1L ?? U` EMUENT OF RE UREANANp INJURES M F {^ :, EXAMINATION BY ADpCTORT pOCTOR'S ?? ; © L:J NAAMEORS g01NJURIES REOUIRE yy'' SiATUSOFPIJUREO . MMKFIRST.pNE TNATAPPU EKAMINATION BY ADOCTORI ®®NAME ?°A W ERICogze^ D NWqu IDNO pyu U STATU6 OF INJURED -: KFIR CN A MPU:.•4:• Q PAtSGGEA TOLLED J A ? oRNER VEHI W lwG nGVOtMBUVO PW]ILE ?PEGlII NO 1ltVtREI -.1 1[COM IN Q r ?I I• OIPUHETCI 0P'L9 KILLED I EYERp IWNORI 1 eCWOMPWJT ' ++Ir E ? g? 6? ?? ? _.TA N nmW ? 5? 6? o?rrwlErcl rF. I': _jj oDTH(R WR TL IH ? ?;' 'aY MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY; HELM4T U8Ep SNOWNORTH BY MROW WCUICLE ? ? HELMET NOT USED ! woN:AtatWO Mr .10,'1 \\ \ __ OESCgIBE BELOW WHAT HAPPENED'IgEFEq TO VEHICLES BYNUMBEgI - 1 . iNACE [ ET T R I RLCTE Y 'l JL+- tt•MJNxEKKwrIT • t ? on arms H..u`a"con ? -- ._ 0 0 T Er<H vtncLe Mo snow ? ?' ? ? ? ???Ty?-{'IC/I. CC u •-- `14_C.._ ? L L 1 _ a• owfcTgNb TMrTLIr ARRpw. ? ? •• '-'-Q \` ? t[ on.HOn v _.._ C IV lCj_ 1 1 - ?._CL_C_L,_____.__._T___ _.. I _ ameeran HOnWir VEHICLES POSITIONS BEFORE COLLISION a I MGLNxft Y[rvCMl vtnOlt vPMNED WM WVEBTAATEO DY r T rV?fIHHCI( NNE S E W ON STREET OR NAMWAY NMIF OR N0. w WE IEGALLY tIMpNO IADNAr PWED Y[nCLE OCGI.KD 1 ar .+. rOLNE E 010 ? ?r IrL1iS L wucrlw E w rce No w No ?EN& ?roi<i "f 0000 c 1...:: .? rornW ..:? ? .? i Pt0(trmw ? 0 0 + - k ? ? s .t., '- ? ?. ? 1:1 ALONG f -J J t PEDESTRIAN/PEDAL CYCLIST WA$113WD: a°f°N0 I S -SRAM DIRECTION TD" pO(W4N DIRECTION y t? NNwAT 1tMµCEl1 .? ° K! J I 1 - PEOESTRIANYPEDALCYCUST ? 1,. 1? CRDbw4N 10 CRW IWALN -0-- I?MN^RWiO ? CLOTHVtO COLOR ; [r 1 ? MMOR[ILECTA] 1 - LEC1M ( 5 Y ,c,. i 1 ttQCVq I OM ! LNWT ? ( 1 prOWAY ?F MAM(p ' E LIMIT DACONDIAN] r ':.TRATa CONTfl04 v(HCTYPEDFROILVrECNpvI '•' O /VENM:LO ACTMkI] ' t C? l IT F ` L'1 [ 1 ?• YLAH1 ( Xwc, w an F' 111 ?RtM 2 DAWN 1 > p1 uOR(1 W [ ?( ICKKCK OHI q1 MGR[I'•• r t- 1 I I ` f ?. E CDAY Or(R:Allr ? ? ?i •? J t ? I OOING STRAIGHT AHEAD I r 7 t L y Y" t + !1 ? 1. "y Q 7 ? WET t ? AI ] ? D DUSA RN.STPEET ? 2 ? vot, am (?• rl Two WAY 0 ? 2 OVEY TAKWU 1-0 Y1361N0 F i !t J t' 5}1,5, I^ ? ] ypW, ] MG A ? 110N1] ON ? ] ? YIELD e10N REVERSIBLE 1 , J ,YPJ' 1 CJ FOG ] DARK 9TREtT ? J ROAD 0 0 ? LU-Ho AAHr TURN ) '„•l i ?rJ i f '? Loo 0, 0K1 a 01MA ?LIGH1o0/P CJ A ?TLA]HH(E PFD ? 1 ?WiFRCHANG[ A MU(WG LEFT TWIN !` t ( A ;,Y1V`.,:. ] ? OTHER S 01SPlCIFYI ° ? OTRER LAMS ? 1 (j FLASHING AMSFR 0 ] 0 ALLLEE1 ? Y'rPAMPI ?0 ] ? MARINO U-TURN a L *r' 4 'r T J ?i T? YY rv e SIGN, TVA WAY. H • ' VADWAY CHMACTLR ? ? M ? ° ? ? ? ]LOWING ' 1 ?t t T I--Al 6UNAC[1YP T Liµc'URN e I 1 ; L ? ?OIF?[A BADMAN 0 1 ?;WxwAY ? F ? STOPPEDFOR TRAFFIC 1 t / I ' ! A ' 1 I? iw •S ?;' .r 14:... 9 ,-1!A ?. ?I.? ,rl Bfj,T B ? " 1 y.l ? 1 .,fie, ?u ?e ' ? kr•'? ?' I T• I ? ! s E'; s ti+ a ( +w .?yk ? F 'r S I vr" I Y'(t i= rlr 1' L I JI f, 1 1 ? _ T. ? ' , u - . u riJYH a y} " _i 5?• •rs.T.• ..P E a n:?-_.,r tzrT ?,..,, w-. ASS% i".I m 2.?-?•d#'..+a r wF`Dw. s.r. HDw+ Aiwuiis .ln e, Inn ` Ix 3 °- w.)a!t' onl 1 "T, I /G ww - r . : RucE _ QK ?F ? prr oR,owN EAE : " xN.Fl w.asTRE(.a+waww•r .c.. cL PRE[ A ourEan srRELT SEG , H( 1' ? LEA ?5 ?W ? Oh m C(CUM ONnr A C(Y Ik.F',l. 3 . S2?oo - El' NTEPSE OYnrN tiPEET pI POAD 1=77 I&OV 'T I STREET S,RF . it ca.?n of fi PEFlX DD y 1 •' ousEx ©© P.uNa•NCIEIOSS x4MEC1FP04l OP mEVWO uOERexI00F, MIF Z , . ?q E nsECrKW: REe ©® of ? Uu COWSDHwWLVEO ? A ? U OUOUSFNN9 fli ir N . . i F ?E I{ p 1 EYR L OSN (?CHWRw ? 01 FA o[vewciES ? ! %?J 8 fy1 EaE??c FOCr.W.9 ar peAp: . r ? E-TFO ? was ? co Ar NHa ? R.noACr NS sZZ Y . , OBECT STflUCK wWEOP ED PUCKOWNER OOECTS NAMEANDAODREbb §Sp ?sW J CO EC.COce E _. r , c vaP KNI r '. QTT! EM - MIER'S LASTNAFE '" .. /1 Tf AM ., MDME C M WE vO ED OWVER SLA9T.NAME »FW AM R .. .._ MDDE ,'T+'j'Fy „-, r A /so /,j /l L /h = STR ADDRESS :ROUTENO.AND BOX NO - M-R HTM„°D PEASOx9 wFRE STREETAO E69 ROUTENO-MOBO%NO k ?p4 ? 1 ? R t Iv Mt w PI /\ . 6/` IWURED USES CITY :... _,. STAT .-.- .._ P DE.; OWVPJi'B UPATION ,..: COW9XW CITY '....: ;,"._ r.:'B ATE,..., .•LP.000E.) OWVEfl'e OCCUPA N 93 ?5" 5-=& f VER•S LICENSE NO. A S ..-PATE OF&RTH: .'AGE. .. `MVVE1R'?sLCENm N0 . .STATE:.,SEX_:...OAT 11 TH pfl ,,.'AGE t;"'3 t'% R;,rw . R ?,I.L z 1,?i1 P D. ?i ss /Z (VEHICLE YW. ., MIRE ICHEV.•.COWEI ,;,;MOOELINOVA DM?T .:BODY 9TYLE120R1:_ VEHICLE R =E(C"EvQODQE) O ... N%).i ?I A• TL:_ -.BODY. ST 2081:: EPLATE n o d. C e_ cone+ Cusrc ?I ae . LICENSE PLATENO.. STAT ,-,...TRNLEfl PLATE NO.-. :.:;-:...STATE-.:.:..I .:.. tiSTATEiJrs.:._..:TIWLQLPLATE NO»::;, 1..:.5[ATE.:...',. l?(? i S S i /?GL . 4 Ynl 8"/0 VEHICLE IDENTIFICATKKI NO _ . . :. IOENTIFlCATpN NO: w..:.t•„u .. .. ,,....:u... /vaaia Fs41 cl: VEHICLE f Lv14 W i U3? 3 , Po/ F PEGISfEAEOOYMEN (LAST FWST MIDDLE NAME( OWVEq'SLICENSENO RE019TFi1ED,QWNER ILAST:FIRSL•ALDOLE NNAEI -. QF SUCENSE NO U./5 c?AJ LI?R/d v G-- - ni.?iu ::ur,?L .rf ?, rnrs, f3c?- 2P•?AG A? O,/W,NEWS ADO -- (STREET, GTYMD9 1'.;:? -.?.:'yQT &RTH;:,. WN '8 flEn' r:, w,j., . ??'+ p, PMTS OF VENX;IE OAMAGED ARTS OP VEHICLE OAM-ED ..? vU.i_..•.a°.-..L?.a......i..:':.'. WR f?, e ?. f - rrc t_ F/?C12.. $ _?nn A' /? (f r2a r A• tde r -b ?e? = s3 LIABILITY INSURANCE INFORMATION-VEHICLE NO. T• WAS THERE AUTOMOBILE UASIIITY WSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CM 7(YES . ? NO NAMEMDA MESSOFLU UTYWSUMNCEPOLICYHOLDER s:.. NNA FLIABILRY W9URAYCE fAMPMY NAMe. ?p .? LI t? ? D i 'CA/Cn /3 1t rli;, I h :7 /75 Cp NAMEAND E990FLUBNtt wSU EAOENI' :. '. . •..:. e< TE ..:. ,..• .. _ :: .:.: ILMSUJLYPOLK:Y.NUMBEq::: '<.. v..... .. _-.. .:.. I . x I ISTwUURY: .,: AGE. 2NOINJURY 16ESfPA?MFPEPp1T DA ApaRIOH WJWUE91 a--•••,--, AGE. - ,.?` NAME \ WAIREO NAME ` ADDRESS I ""F ' ADDRESS •v -? M F''. ATURE FI rri??? ---TTT VIVO MD ?? EMENT OINJUWE9 ? ?1 1 F WJURIES - 00-VAPESREOUWE x0 DOCTORS u pDINJURIE9 REDO RE p OOCTOR'8 EXAMNATIONBYAD00Tom © ? NM TE EJUM wATIONBYADOCTOM ®? NAME R'?2wI STATUSOFWJUR D MMKFIR9TCNETHA MPU,9TATU5OF DMUflED . ;FIR HA P ?pW[P WVEHICLE D uNO NW lpeUXO PoS4aL[ 1]D VE11 WVEXIC .-DNAELH. NWIO q_ POS4al( PLAUR ?PA TAI[P KILLED Ibfv[Pfl IN N0111 1t0 LA., ? A88ENOER ND.---- - K16E' L•EREI IPWORI IF DM_YY ? PE(ITRAN -AN ? ferPIAH OIPM VC I T ' Q],, r.•,An'L r. ? s? s? 70 D POM 0[E. WNITE IN ? In 60 70 ° MOTORCYCLE SAFETY: ? HELMETUSED ? HELMET NOT WED MOTORCYCLE SAFETY: p HELMET USED ? HELMET NOT USED SHOW NORTH BY ARROW W OACLE , DESCRIBE BELOW WHAT HAPPENED (REFER TO VEHICLES BY NUMBER NDCA[ONK , \\ ?\ ; .(?,1/ly-l'? /Y1cl:rr C? _?t /'??.i!L' ?=G.11"_???_ I'fMCl rnl DUrV.Ct?I t °,(... i°an lw"mw"W.r ANF;D?I O \ \ ; ! UCL1•--crr' C1G2?" rL}(cL{?__t?Gr.!/_?_t_v_c?,?` - PAPAPER wIMKPi j f? ,.Jl ` fe WwsHOw _ LVL {71L1C_(?f (?2 =i?lC(C I? U? 1--- - DPFCroIVmA `• 1 . -??• Qom- ! <,oa?W _.? x IUD a I ' VEHICLES POSITIONS BEFORE COLLISION wor LAxn wwcu wHCM PrAPReD wAS IVEBTXIATED IIY OCCVr10 ?K'IAiI ?OINIP VCNXYC N 9 F W ON 6TREEL7TOR NGNWAY NAME OR ND wOx[ I[[ALLr lMDND MOALLY IAPrAO KYKIAIA DYI[CigN //fi}Lyr a NqqO Y[[ [tMp) HO TP0. ,?•r000[ rp howl ? ?. ?.? C.LSUN^ ! "I1 CLL rl Jli)d /;. iii r,;[gya q. ?..'.UCI. I.?sl?1. ?POUC( ?aolio m• "; mrH1A ?' ? ? ? ? n ) pp- IN c k d. ? ? ? ? ? ? ?1H(Rrr nouquur ? ? ? ? aoAlD wowNO , . -; f `• '•i'-.'FROM7:f DIRECTION io DIRECTION 1M 1 PEDl?TRLW/PlDAL CYCLIST WA9 U91N0: 1?wawAAX (?wAKwAr L?PKKAD(A A? wwuX 1?CAa[wALSA 1?wPao YOV4,..&U, 10 !AWPY VEDESTRIAN/PCOA- CYCLIST CLOTHWO COLOR: rHtAP[n[crm w.rAtu ' 1?aMX [?. 0-.o ?wma,.-C,m e? W01ArAlWFAI,C ROADIRPI/ACE WUTHER LXLITCONOITXRIS. .TRAFR000NIAOL 7YPp Of POAD DRM1M/IYVLHICLC ACTIONS y?A K. -I KLt C tt bM1 VIHXX[ p C ON1- [wp! IC.NCK WI pI MORE, N •, M HKEI 1[? ?? 1 ?DAYlXL11 wA i A W 1 M I p1 1 NO I W 2 1 A P'?OYLKYf 2 ? DAWII ? I ? dDNK! r ? 1 ? CHI WAY ? 1 OOINO /iPNONI MEAD I T i h ?i h' C ? I ? c ILI 2 ? nNN+rD ] ? ousK ? 2 ? STOP sAw ((??{ 2 '10 TWO WAY ? 2 ? OVEI I[INO WD PA55INCI 1 ,K 01 •w {jj4 l / p?:. E• ? 2 pw[? J ?NAWYq A ? DARK TYNET ? 1 ? YIELD WN L-J 2 ? ROM &E EAW-?1L S ? MAKING RIGHT TURN I.L l IGHT A T t Lc Ll-- ? 2 ? Nqw A ? P? S ? ?p111EOn 3IFEET ? I ? /USNPN NCD ? [ ? I OOP/RMIPe 1J A ? MAKAd LEFT TURN V A' 11: C ? A ? 5 ??YEOWI 5 ? D RK NOLgNT! ? 5 ? FLASHING AMBER ? 5 ? ALLEY ? 5 ? MMWOU TUIW '` ' rf 4 ? v `',! '', ty 1 H' ? OTHER 5 ? [PLGIY T ? OrH[ EFT ry ? 5 ? m 510NAL ? 1 ? L[TWO WAY Il TLRN ? 5 ? KONRNO n •1 l LAN!! 0000 !R I, ADWA A 1 , I POIDw AY OHAM T ? I C] OFFICER FLAOMAN ?, / ? d1MWAY ? 2 ? STOPPlD FOR TRAFFIC r? 1 11 1 P I , r ( i'Ph 811..1 d ?Dr.1h ? 1 ? OTN[R 'J'f4/Y ROAD GCPNMTgN ? ! ? o /STEW RON ?µ T y ? 7 pVIGLO ? D ? STOPPED W ROADWAY i? `. >,I /i I i '7r < - i+ .. A?""", ?'., " ,ACI`T t'nr °!r ; 1^?7Lt/?i9.lr!• "r, tR?'^:? 1 ?1A}; W7 1 +.•. +dUk r: MK6b' ?t G?im: y?Y{? I- +'?_-' ?'yhGYr+y?_-.' ?.s? w_ __?_L?_ __.,. .k.'-..... .• _.? .._ ?-.??.e.__, ..`._uarh'.•. ... .. _. -a... _ .,. ,,. IyLY S ' ..: \.l/-mOTOH VEIV CLL- UULLIJIUN HhPOHI . , . .. NO N? . • Dn•e OP CaUMn? TwEOF COUNTYNO AICausION COUxtt CITY 11 NO. 9w. Mpv Oru¢s wEfW. e•r? How P w ;• ?/ ? W HA[E x M. - ??0 ? J+f4. - - ., GttOR TOwx EN ?E ?IN MINE WLE9 ?3 ?W ?pF Oh « N SREErnHpHw.v - cT s REfYt ROUfE OH ElT O00 ECi. 3"' A 42 "b ERCIN EE O Iw.H•TRFROq REEDWx ON Szzoo " ' PREM WLFRp•T h ?1 •E wEEN . d ea L eY d' ST IT yl ? I?MB01,...D. -1 0.06 . FNOT © LEE ..- R„OAOAOCPptLN4MRETP05 OHLNiuYWar IAHWMK NIERSECDd1: F Y T §, 5.r ? 9KwwvaVEO I. ?DF LADE ?ryp NA[MOUOU9 WTERUL9EFW0iIW19'OPTED...:. I 1ALxD a FLwMABtE MOULD EaPIAWEO [f [n pu ..DµH • ---.AT- y O Ew[E9 L ? ??EN0.E B y • EUECT STflUCK IHAM¢ 061ECi 6fwlOp I v ... _ -- AM— ? RAW AC .. O Efl OSJ CTB NAME µDADOgESB„ 5f 4? CJ4F SZZ? -. - FO RFPi?R O6J[LT._. ..:? COR w[ .-. " , DRIVER'S LAST NAME. _ .. PIPER IF MORE :,.? w EO DRIVEfl'6IIeT NM1E _ FIfl9 NAM _..,.. MIDDLE vav ?1 u? 8 rlan STREET ADD ..BOUT9N .M ,..-_ D. BOX NQ,., " [Dw?? DR ?s MORE THAN TVO BT E Di 4 ^ 3oC fl T PERSONS RERE lE58 ' •+ ROUTE .µO80%NO. IWURED UEFA ALL/ ,I E ? 9-6 :. ; ? , p Y ....- '... .. .,•9TATE.: DP CODE. OgIVER'9000UPA110N ? [Owslax CRY ' . a O(/ h ? :; STATE CODE:-: CRIVER'8000UPA REPORT FDrw .. " . _ . • OqI .b N0.', .. AT 8 DATE Oy&Riq ,. '; AGE ` ate. D. B a? c9 OWVEq'S.LICEN9E N0 __E r r 4 I VEHICLE YR MAKE ICryEY.W 1 ,A10DEL INOVhOMR 73 - T DY STYLE lso T.. 1'L2 x Ea vEHICLE,rR:.,AIAKE IC EvDOOOE) MDO IND AoAnn.i. Door. DR 1L " e e0?oneEC AYI . G ?h lA - LICENSE PLATE NO. STATE,.- TMILER.PLATENO : STATE " ? SYN. o "" § VEH IC LE I O ENI I FlCATION NO PLATE NO ': STATE •! TRNLEq PLATE NO? STATE S? ?? : y ? ? / ' I / ? WT7 //?3A 30/8D%'. • N •+Y.•- ' .VEHICLEIDENTIFlDATION Y.. L.. ._, IUUa(f?5I?f2Pr . . • ; FAEO OYMER ILART 1RST•MIODIE NAME) .:._ OPoVEfl $ lKEN9E NO ... _'... gEOKREflED ONNER it RRST.MIDDLE NMIEI E:. DNVER'8.lJCENSE NO. <?• sor oy J 11 / !? ? S' . r VME 'S PES9 I? 1Q3 /-x•N? L!v7 : '.:I9IREET NµDSTATFI:.; DATE OF OflTH .? OWNER'S ADDRESS _,L.M.ISTREEI . CITY.AND TA K?':C.b3 _5?.: E. & I}W `SX -.. PMT90F VEHK:LE A 1 ! '-T • MPJC % t, 'fT n • D M EO ?. t •.... ': ::' .• • i•:-. HnVk?F.`Ylk '.. PMT90F VEHICLE DAMAGED j-i 'C BILITY INSU ANCE INFORMATION-VEHICLE NO. 1- ' - WAS THERE AUToMODIE UABIUTY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT O ? NAMEMOADDRESS 0F UA&UTl,WSU PDY?LDEfl NAME N YOUR CM YE$ ? NO ,. l1ABILliYINSUIWICE.fAMPANY -? . E DAMMEES OF . .. kE. ; UA&LRY a!P....:JILM&UTY POUCYNUMSEfl:._..-' - , 15T INJURY A AME N GE., URY . . :IUSeaV.lMiCiIPM( ...F.Tt IMN wIwiE9J.eu?-"I -.• _. ?.__ .1 ? 4lI URED N NAME NAME Ew NATURE µD IXTEM OF WJUg1E9 DID IWUWEa gEOUWE D T , . SIX.. M F ADDRESS M F ?? MNT OFNURIE ?? E OC ORS o b :? IXAMWATIGV DY A[IOCTOM ® NAME STATUS OF WJUgEO UDWJURIESREDUIIE ,O OOCTOq'S E MwATION aY ADOCTOM ®? NAME N79 -_ MARKFwSr ONE TryATMPIlES ?Mrv[ W VEHICLE OAS+ pINO NONws,mw Py BTAiUSOFINJURED ;;? MMN ONETHATAPPUE9 - , •uVnr ti. OWVER (] IN VEHICLE _0 Ndl p&wO fOaslBlE - p lAasERDE KILLED V E (? 5 EP 19E I ?P qUN ?' ? 5 1— IOi PA ETCI ? A . KILLED IaEVUEPEI IMwOnI OF FAINETC ? 1 0 7C) ?orml err!•rI ? 5? 8? 7? MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED • SHOWNORTH IYMWWNCIRCLE '\ I wW?ewui[.n<o w I 1MACE [OU1tw[T RfELFCI• O \ ! rnw cou,soN scErKlwn, ' I '. DESCRIBE BELOW WIUT XMPENED:IREFERTOVEHICLESSYNUMDERI _ W.VIi?p pp//II -1Y---_? /,??. .I:. ...-I?OSI e.?I.ll _-._hD1.V.C1AliJe s'(*_CJ[i _f llQ T 1 ';' I wD w ? °??? HoHN.T N.M[• w ? ? Nuuu[P E•[H V _91 AND r- ' DRro D •. wD . ??A'Kle325 oV1._-.?k _._?c.+aG(? Gt,?_Q,l?k'Ok _3.1.5 Nq wc, s _ 5 F leu c k.__In vln. L __Rep.L2 Y _ .a `?r ' OlR ' L:.O.?.?? WY`.C7 wSl? ? Ip r -?V=1R-•-{._?LC/._._CL._M1/y . K `Q i 7+[s 1 -; - - In bny?.?L O? _._IL1,?le d.?2t VQ Wc>`y WI /lA.,= u S' % ' - a YtCl._.? L ?CSs_(A V)LCSPole Co- -? • nl?-. oIe_.-.QVbEd--he32_._C?b__?._d<'d_JL!lo•F ? I -- ' ? _ Sec -'-d A- 4"P, 44o-_. L leeeS <1-Jci?C r' ss G> rtE ? ? . ' ___,:.• ? '' ._ . ?` '?„? 8d01¢` ?o?-._c?21.1120001.y'?{=1eoc*d.. ^?_ ! S N EiP1El0AIWr•WAI .__..-._...,....... I VEHICLES POSITIONS BEFORE COLLISION raofwrta reHCU vEHCM MN nK%e w vHVCI, OCtw, ? ? ? ? oL- No AYO[,rww 1:1 ? ?. ? AlOMO.. .. ? , . R •; A9 U9D10: a?wrRw•r M ;DIRECTION To,DIRECTION EDE9TRIANrPEDAL CYCU9T W 1?•D• - a?awaD[R loMnwwALK •?cro• w°K 1?orl.u DE , • ? rolDw•r T ? Aw EDE u 1. d 9TRUN/PEDAL CYCU9T CLO1NW0 COLOR: MrV• LJ C] . OMA a UOIrt RO.D ,M ,?YW A?I G . as ' ? t C:. ...WEATHER; .,. IILWT. COHDTgNa• . - 1 DAY • DAY— I •T •. ,. TRM/q COMROL '...,TYYS 01 AD-'- [• ,.OIYVLR/VFHICLa ACTgNa... • ?v[ C f KaPCAOxw 1wcL "NOI, CIrtCN O l M - G 1 DOILY 1 o~IV yM C ?DAWN 1 Y ., d r =r ? [ 1rL RAP1v.O 3 ? OMSK aT y 1 a 1K11 ra a N MORII MUWUI ? 1 ?SIONAL3 ? 1 ? ONC WAY 1 ? GONO%TRWGHT MEAD ? 1 ? STOP MON 3 ? =WAY ? [ ? OVERTAKING AND PABSINO }I ,1 ?{, j . RC[T ' I„1. 3 J'-- r+ ?3401W;0 / ? IUNTA ON B DMK BTRCET ? ?J WW 66 1 ? LOO ? ` (? ? 3 o W[LD s*N ? 3 ? ROAD BLE ? o S MAKWORKIHTTURJI DUk 07 IMERCHNgC 1O N+YI C 4? C] • ? FLUSHING RE t ?f L' ; ? 1 ?KE CMp LKIMaOf/ A OTH[A 3 ? IVCCUYI 3 0a R[lTLgMT, ? 3 0or." D / ? ? 1 MMWO LEFT TURN 0 3 ? fLASNNOAMaER , (sY RAMPI ? [) ? ? ? C ? MAKNO U-TURN .r?:AAi Y Y T ? OTHER F4rv AO.OW YCHAMCIf ? a ? mmI a *T,% ? ? `TWOEIR ? , ? alOWV1O ROADWAY 6UNAC TYP ?, Y ?r t ?0 r.OE 1 ] 'IOCwCN,f . d! vE (-' f G ? [ ?O/I1CCR fLN1MAN rat f fJ1 1 AVJ ? ) ? 3TOM'EOFOR TRAFFIC a MER ?[ Y LJ W I 1 ? l t L J A ! 7 '?k ../.;l II^f 'Y' N? Y4 -h.11J S .. +, ?'. rM.I. ' ..? '31YTw rr ? A ?I 1 I y- I!I:A ?1 ?O? Y 1f, I r r 'F,. •RD?/. !i t?. •WW' .r .ly Y-t Nr 1 1 f i.? D Al WNM 1?.Yp[!-?1.•STOPP[ f T? ' AA. A f f 3 I i I I F fiAl ?f 1 I V:: e %Y„ E 3 W r ( t 4 ? r ? ?r a l h -r- (9U[!1,? _ ?WOUlA.EE? S't12LGC '° ? ` c !?-=- '..L.c.-.1 1 I I i t?26.5_?U?(L. Qryi QFFNf?r19Eti1 .. I., A- i. ?LtlE2`?TL1 _ •,? ,. .Q NAME, ADDRE5581NJURIESOFPERSONS SE,Sv^rfDMP;uINVOLVED ECODES p OCCUPANTS/ WITNESSES q 5 6 " I - , j All M!. y? 't?'?t? (?, q, .,c?n SEM AG' IAIU • 4AI I. IR'R.SA.4AFL AT f .,w. _-` W iq A.1 Rt51q flitl ;ii ?sW A dql? BEWIfEN ? ?.. I •• ? MIU _ bl - Ncfq I aiEEN ,c4osssrge aNU4ESrMn o11 srcflr! - ? ,_? []MEN f 5 f W OP / ACCIDENt DII. -,A um . ZNINVOEVFD MILEAGE CODN 124111z?. (Y DAMAGEONIY f f SrpIFN D'" INEFR CLS K l,UNlyf 'SIRUCRLNAMFOf OBJfCf5f4UCF ANDOWNIS'$NAMfI pRfSUltFO ?VfNK. ` ?? [Sr.D NAGF SPECULL DING US! ,J -. .. j .,. ?' UNIT NO.7 S t' F UNITNO.2 p VEHICLE ? PEDE J lf..m. MOIX Rv R"SNMA[: V,5(? 7 mRf ? [, 1 X ` Z 9ffl ADD4f53 ??? Srp'4 1iPCODf P1pNI N0. D IY E///'rNNN?...l / d •I o i b R SMrE I FF5,?}(n{{rEf? Eq oA .,;. 2,. DcE (ryy w 4 I D,:' NYq LVf} I D'V U ENS NO. ' 9 l Pk- v l D/C7 _EdPHONf NO S WEIGNf NEIL ( E A CUPw(ION A f? ?%(/ / f PM NAMf 6 P1pNE NO. HECK (,7 ' vE Ic I ED ^ /,/V nJr`-! U O 6 D R .Y ?? D FOfwri?fj'rNFR. ? CHECK Col) A f S e A'NO (11) FH ttE gSwN [MgOYFf OE we Es ®+ 0 n /e]LIM,,-- A? snleuD?on" f°?o.go 0«w cf 0a f pc! M?q,/ONT ?? V' e I f NEYI MODEI IDARr.?_ 's ' 4CtN?E PEAI SIAM Z? E V N I e D . -•?i_?? R tl9 RArf NO. SIAIf H vIN.CIXOR l A KUJ V\fCl I u .Y' WRIUIMDN NO. C ? I i _ L VENT fIDENif UI NN . mores lASr FIRST I I ' ' I I 1 I I ',? .`_ ?????? MIDIXE PNONf NO. I( DOWNfR E, Sr I ' I LW2 .OJ O iIRS( 4. " DWNf4 W ' 6 X?tO? ?f N A NE9 ESSpINSURANCl CO. 04 E N C R I u AA SAxeA CN oa v„ x 5 t31. DAMAGE ? WAN pNARGI ?ANAL I' A kE' n KnWY f y? r ? REMAINED p1OYYD DM,Ap! f 10 L7 HYDE /, IIN? ... WAY [MNNFD [SI. 10 O y? DFCOLLISION: IND UrtNDRrN AWAY eY S yu 11'NfCIitARY}?. a Ag4pW DESCRIPTION OF COLLISION; LOSE SUPRlMfN(µ SN!lTItNK[SSA9 b2D'--10 ? - o>J NCB F3 ,._ , 7 In, ?H 4 y`R IvIUYUrt VtT/1L LL UULLISION NCYUNI NO 1 De rEOfACOLUyOU Ot MO. MOn DAE6WE0 rnuu T- eM NOUq rw W 6 COLU¢610N ?? GOUxrv Ax I O D a Y 6u COUNTY NO. CITYND. PA w E E .So JN ?E ?w Own ` nAME ENO. mPEm OIIWd.WAY N Ru- lCi.C AW.GLB PM gOUlE 1 lr A DAEED G ALES ?° ?w?or OL+Wb,lwj W0. difl GO _ EPfiECrwD mrweTUE! woNwrEg6ECrIw Ao -•'/ J _ 1 f/.C N y e0 m f? emwEEn arPFmL iLe'F/! Vi f la- sxow v I FVwO MBER6R[p¢ STREET P w.pgMl DA A qAV © t=1. ?" gMAObCFJq?aSw"`FO y E 0 iONE oF w ia w v 9 i x ?YyI w l K . ' n6F wx: iEFr •LI ® OP `• W FO x ?r `,,,, ? IMIAnououa MATEPwaeEwo lRAYSrogiED xox VFNV: 1/.' OLFN FLMMAELELIOUD f11n051VEa CILEAWE pOTHM FA WfF p.p. gEfEPENCE0CP09.9mPEm bW gOAp' 8 ? iED ? WaE DdwDEMATER 8 AMMD„M Sg aD mwEMAIFR 6 ? O . YF WEC?T-YS?T•fl!U]CK wM.-MMEmm .1 OWN ROF ECTSNAMEMD MORE35 $iq?7?w r 6PEO,GODE LeE i ! I p.F . • • E IF MOq[ TNNI - a MIVEfl'9 LAST NAME I NAM MIDDLE TAO CMS wEgE wvOLV60 DRWER'S HART NAME .. IflS MIDDLE., Mil V'eSe 11 ' - `lQ V .I.?` GOw Oq ' STREET ADDRESS 9 ORESq IL^.? n v. ..ROUTE NO. HOBO%NO. MD.EMA - Y o eN IWUMEDUSEA STREET AO.. '. EMUgE ..,... -..:. __.flWTEN0. AN080X N0. h - 4 6E- / STATE. 2IP CODE MI SOCCVPAIWry ,_,. COwaGx CRY LLG ?EJi'•] - gErogrFpw STATE..., .-LP CODE DRIVEfl'9000UPA N,.'... L7VBZ / -xw (-,p I - OWVEfl•S l1CEN ENO. .. AE. OF&flTM. ME DNIYER9LICENSE NO. '.. :.. ...'. STATE SE% DA W AOE M r Mo. YP lu CeSe EQ a M p (? z s 4 M F w. VEMILLFV A[ANE 'MEV: DODGE) MODEL IN VA- L - BODY& 12DR.1 VEHICLE YR MAKE ICHEV:DODO I. ..MOD II VA•OMTI.- BOGY 6Tri 120RIX47$ CCCe 4'?P1.9 Q _21 ?!C N9EPLATE NO. HfATE.G..,, .:.. TFWLER FLA NO. fl J'V-7 •( WU7.\ '.:.STATE... EPUTE _ _?STATE_.- -TRAILER PLATE __9TATE.. ... ... VEIIILLE IDENTIFK:APON '. -.=.... iN?7u?C /ZgSYI-f-.. . VEHICLE IDENTIFlCATIONN REGI ER O ( T•FIRLT MIOOLE NAME) _. ?..... DRIVER'B LICENSE NO. REGISTERED OWNER ILAS-FIRST-MID OLE ' 6?e Z 206 S4 -. ONNER'S ADORE STREET,CttMO STA n?/ .-.... .OAT 0 SIRN WNER'9{DDflESS. IS REET,Gtt AN A : . . . .._ . . .? . ; - PMTS OF nEH MAOEO IIiNUGVFRI?kYr r? L S . P .. LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE AUTOMOBILE UABILM INSURANCE COVERAGE W EFFECT FOR THIS ACCIDENT ON YOUR CM t -YES ?NO NAMEMD 0 UMIUry W9UMNCE POLICY HOLOE?. .,. ;. CiT RATE .. _( NAME OF UABfTY WSURANCECOMPMY. :.._.. .. . NME ? Ai L , ,esP l iore_x? ?uc?Iota L[?'L 4r31 I2F?CE; ' NAMEM ADM 990E WttW flANC AGENT..'. -..', QTY. ...., .,. STATE ..:.. '. ?P - LUBIDtt POI?X;p NUMBER-.. _. F ? D • f r . o 1(?ZZ7 UI+t 19TNJMr' ... .. -. AGE,. - 2ND INJURY: 1 6EPAP.ATE PFFGq! ORADdIpnnW,IU E61, I.:... _ AGE NAME ('. C7•{'cyJ .S ... ._.. NAME e /I /WL1 L, v POOPED c ADDRESS U ''T? fNA22n yf? U E . NATIIREMO I M F ADDRESS ?p? I pj/T Cr? U ?U _. AND M E%TENT OFIWUF[E9 C Z ,?U1$(?. ffGlE.[LLy_ CT ? M T ' • , EN OFNJURIES Qj J- IUC? do ? F E WD DMURIEB REDLINE DOCTORS ODINJUTUES REQUIRE 2f.. ENMWATKNL BY ADDCTORi ® NAME CAM YL]?t [ CTOR'9 EXAMWATION BY M ® WNAME wJURE uso FLA ,.? / O MKFWSTON E iMATAPPUE3, y?`?'„?°` MVENI?LE D 0 NpIgSAnaq pOGDBLE STATUS OFIWUREO PUE UREO - KFIR ONETHATM .... .. pmnvEq .. ,. Y G wxlPr WVEHICLE OS avD xOnD - P"", p KDESiPVNP NO. .. WILLED I.- E, WwWI 1EEA M. ?PA59ENmfP WILLED 6FKRD4w01I O NETCI NO l ? ._._. __. QP[ ESPIW t)fPµEtGi ? SE] B R( JT I L hh CC II I ? S ? 60 7? MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMETNOTUSED SHOWNORTHOYMROWWCLRCLE ' E DESCRIBE BELOWWHAT HAPPENED: IREFERTO YEHICLESBVNUMBERI' -TI-fl nM,I wrulHN[D l ? ' N¢nN[ aunIOT Vow eauaax fA. wmwD w . _._ .____ °nu`?AOegs°" wonw.. NAMea aA 'h j • [ wMmP tACN KxG[ ANO aHOw ?.? I ??'? Qom" ` I war ._._._. __.• ___._ -_. .. . >Nx a SwlttTa 'ourA. I . _.__ -. _.. ...-----------------."-_-___ - _ VEHICLES POSITIONS BEFORE COLLISION I " o NvfsrlGa[D BY VEHICLE ONSTREET ON HIGHWAY NAME OR NO mPRw-EEuoAU wc«D MBUir r:PPEO virocu occLVED omu N B E W Cign6 to ? nVES ? wC M rFa M IS N NO ' o Lr°n_ ?Q a route xo ?? ?? O? ? . ?,: ?";' ?. .?_'.:?.'. ?1Q. ?oAiwOEeu roTlaw !,Nj' ;. { t;^ CF ? ? ? ? ? ? NEnrr P.narwwl ? ? ? O ALGND cnoawo > PROM. DIRECTION To DIRECTIO L N PEDESTRWN/PEOAL CYCLIST WAS GSM, 1?ww.Le [?wNKw.r 2 ?KKAO[11 ° _ o s D ?clwuwrA ° ? r ? ma 1f1 Yt r E C) ronw.r u POUE PEDESTRIAN/PEDAL CYCUST CLOTHING COLOR: I ? o.AE [ ? a r ? 6 Mu[0 .? olgE ! [L: AErAOantc a c ? 5l 11 fIf ROAD SURFACE MYATNER waa. to tre. W T 00.01 NB TRAFFIC CdIrROL. KNEA Ox[I Rj _ TYPE OF ?AD 'DRIVER VfNIG „ CTgNB. vE_ME ICHCK Ox[I veK [ - ' ! L l 'OA L Klw ll 1 VLgHT [CK M( !I<U dI LEAEI ttOxt AO W r h I HO i NO I M I MMOAtI w P 1 L' F{ t, ? I ?MY ? ] ? pAWN ? L ? Bg4Iy9 ? 1 ? ONE WAY 1 ? GOING STAAIWT AHEAD I ?RNINA, ] ?OUSK ? 2 ? STOP 1 1?? t J 7 . dh N7 "?• ', 1 6 ? T ?MEf 011 (S I 0 TWO WAY 2 ? OVERTAKING AND PASSING ] FYI ] ?SMOWMO A ? "p' HT3 rON BT ? ] ? YIELD SON ] REVfRbIBIE ? ? E ? i00 B OARKdin[ET ? C) ROAD ? ] [] MAKwo min TURN ? ° ? cc 6 DIIQR C] DLSMHT .MnNOIi C) ? FlA° R[D El A ? M1OOPA wPj ? ? A MANwG LEFT TURN ? F ? b I]PECNVI ° O SST ? iUSHWp -BE. ? b C) ALLEY C) a ? MAKING U-TUAN c) ° ? OTH, REET L Hra Cly Ld,IfT W 4 ? I M BWMK ? a ? ? W ? AY iz C] a ? SLOWING TgA f ? ItlL ? A ? ? DWAY BUMAC YPE VNE9 r[?L 1 [ 1 ? f ?OIIICEPIFLAOMAN !3 T r-1 Mh[\VAY ? I ? aTOI'1'EO FOR TRMFIC _I Ii?vi E L l LJ Ia JT F J fi..?71 a'I.. ' I M ? E v K ? a ? OTI ER..P[C,F NPMATKiry a bTOPPEO AT SIGNAL AD ? ? OR SLOP SIGN A-a-;? .. ,... ,.! ;? :L:1:' .?i.ii-+'rI •'L?s'u°ar_ r P1 Lµy ? „ i i? crG d+J?,, _.:£:ftk.J..I. RT .?_ ! © IVU. TRAFFICWAY POLICE TRAFFIC COLLISION REPORT TM E CO PIwININUmeFR i n f PRIVATE WAY ] ; ',i? AIE i l• • r, Y OA l _ N Wx iNOV ru it lu IE%I. iu IME (US[]b0 "O//UR' COUNTY ? COUNTY NC // ? CIrv NO. r iNWA ? AN ,,) I ?? ! // I f?/C%.f W ( 12,.S fD iI , e V RU4Al. •? L J? ?I! ?E ? N CITYOR TOWN NPM[6 NO.Of SIRfF10R HIGHWAY CI AVIES ?S ?W ?OP i! elz-=7c moo. < /, ,? [„ l., w ON iCi C15 ROU1f OR T EE C 3 ?qo IECIION ]] 1 INTERSECTING AI". SIREf10R NON INIERSECt10N PREFIX f0. LLE POSi,_._' IF \r t' /i.•/ AL BETWEEN STREETA SIR., \ i II N R RE .CW SSiPfEI RNEARfSf MIV:4 i?? ytic4 !i:'?- DISIANCE8014EMIl.[5 F ACCIDENT MILEAGE RAM? DIAGRAM Wi .' `L FfEi Of l1 • , i`'/'??/ CODE ]] ?.' COLUSIONINVOIVED: SIVERIII. NO.KIIIED-NO. INJURED Z ?SPILL%GE ? IA Wh TOTAL NO H+HOVInIn MI IMf ?RO CLS C 1 CIN SRIEIORROAD01,-11ENCE ROSSSMEETORROAD . FY 6VEHICLES © ? PROPERTYDAMAGEONIY ? RESULTED ? E.- p 2 ?^1- -N ZOO OBJEC151RLXK(NAME OF OBJECT STRUCK NVD OWNER-5 NAME) fSi.DAMAGE SnCIM CODING TAE _ $ • UNITNO. 1 UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ' ' 2.4 5 INANE: LAST 1 I I NAM. Wt _ I IV DRIVfq ?r oly,. 4, R J °7 51P[Et ADDRfS. 9-r• L i / S L ?J J C S Cs f. SIRFEI ADORES. . SIA LIPCODE PHONE NO. CITY I A "i a?sl•ro!:/ ??;R, iifl.yl.L?.?cS2f).?•) D R IIY LATE I P N N i { -IR-SICENSENO. STATE 1920, -5.L IT .'?.. :l ?})rJ CJ {Ds La .-: % A -I. iG l // r ?U I V IV II ENSE NO. IAIE DAR Of BIRTH wn.. ( DAT YR A OCCUPATION MNAMEAPIq 1- 4/_Y •721d7 EYES IGHi HfIGHI E OCCUPATION F IRM NOME A PHONE NO. EYES WEIGHT HfIGHI ? CHECK (,1) e,A A oiv Yr o AN I [I CHECK (,? veN nF ASAN wPlorrra ANOrNEa?L r i e e ICIIaN ox.rn . CODES 01 t 7 e.,, (a I X iv . m Ic,roN CODES D q 4 i 5 u O s :is 1. rM"' .rtn o,F, :Z ,y ; / NJURRI ?., . ?. K R J- " .11 t ,,:.D" ? MeA r O u ? ceP,I. H C] C8 M aoIRDM ? A w a ? '. ? iB:RR ? Ku ? r..IN 10 ? VfH YEAR NMfIDODGL CNEy) fI IDARI•NOVAI StTD: (]DR CONVI HEV.1 MOOEI IDART-NOVAI .Y R 1 YLF(] R V.1 I M ? q N U N STAY iRwll[R MIL NO. S,A,, H VEH. COLOR L U N A A [HICIE OENIIi CATION NO. ,? I /I :z!9!$!S` L VEHICLE ID N Ifl A N i I I I I XtGISRR[DOWN[R: LAST FIRST MIDDLE PONE NO H . 0 MIDDLE N f ISRRED WNFR: -1 FIRST 15 ;.r.?.o ifi bnvr' ADDRESSDfOWNtR N WNFR 4' N E NAME t ADGRISS OF INSURANCE CO. OR AGENt I+ R ]] 1 EpM1AG[ MU AwN gAMAGIDAREA HARGE CHARGE , - 5 nl"rxCi oNCi C ai • 'RO elOf• ?) ] A ` S 1 .tOP• ' 151. OVAAGt W^YN aRFMAN(D ?AWAYN ?RIM.VNfO LS1, 0 10 iOTiGH iS iOtIOX !` s / `J„ TOWED TOWED f E• AWAY BY, ? AWAY Br: DIAGRAM OF COLLISION ilnn if NeeESSAXrI. I"ec7i.TeR"E wRI" DESCRIPTION OF COLLISION: Luse suPnEM[NTU SNLEnr Nee[ssARrl °? fEAL ?l"G Ff Y ?- MRS. MOSLEY TURNED AROUND TO_THE.HACK SEAT. ..___ - , ? TO GET HER.PURSE..AND DROVE OFF THE ROAD_..I14TO.1)( THE DITM CAR CAME TO REST AGAINST A_SMALL ___._ =_1 1 / TREE ON.THE.EAST.SIDE OF COUNTY.ROAD_#_10.._- _ L ?? I .I.._ ,._ r.._. .,_., ?.,. .? _. _. _... _. _.. .. _. ___.. ______. ---._.. ._.. x r t ? NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED * CODES 1 Z 3 _ 4 5 6 ? ° l /? uii Six Aee i.rOS N"" M•„ Resle. ena ,. OCCUPANTS WITNESSES ?ueoou wN:ir iu , f HAW: r + r $ I rst 4 AoDerss _ .. INATURI OF R, nr. ?AM e. ?'c`Xscr ?r"I:, R ?C.rY ?C3:.o I ` "" a 1 r v AnnnSS NI pR a gMOVI+IROM ?u%e. ?IaKI ?nNmK ?R? ??oH,. '° 1 ?`"arf ?` r 1? .roerx wfa rrNe 0-- ? :' ? . Ow" ? p , J, F YI W'r 9L q,vISIgA1RA OIIKEe'SN WEe HK I.VDGIW X .r ow AWNC KID SIwiC NI DIQKI ND O wll Ofnroe AMRVVED eY o n w n E N w U s2 PUS(i CY F ti .ps1?I? `' E .) Y .M sM1 ZvN 6?' ?1 r ' S ??>? , ] , t r I ? ? fir. T I . O, J ' y ] 13 1 K• [ ( % f tit r v ?' ?y ) tl +j? JS? ? - ,r t r JS I e I PE t '? 1 l ? ? ? S , J? 1 P a ' `? ? t^ , L, M9 l T 4 f ? J l q . J r. J L ?+` d. I 1 y 4 7 ) ?ni?J?pA, I xr? r ly T err , ' ? ' r. STATE IY RfV 1 R0 ? . f OF WASHINGTON DE ! OF ? . . ) ? , 4 No. POLICE TRAFFIC COLLISION REPORT L.UTRAFFICWAV IollcfcomPlamrNUMef4 Y? 1 N / causroN PRIVATE WAY VU al 7; 1 ,4 . COU N S Y RR ?L Nt w IN S4r IUSE JRDO NOV9 ° COUNfY NO. C IfYNO, ? . f.,•,? ? 1 - I ? DL /.r / J? U J L. FI=f_ LSU/J /? fNWA ?U4eN+ 1" ? ON Of ? N UIY 0416Nrv N 61v0?Jd SrREf10411GNWAY Z.S INlF1 Ids pW ?OF Q(.p ut! ON OA /S A, iNIFRSECr NO WPlN 514kfr0 O -cIS J -11 O/4 5(099V ^ [ . . K$ v NON NI[RSFCEION /? D 1 P4fNx E MKE POSr JJ T }' / BETYftN ?fL, s.E,rI )? BiREFr DISIA[RCE60r 111 -12-'o •?• i'r ? - NC .CNOa514E O4 NEANfSr MIIE 6 MlE1?N E [ W ? ACCIpENi v R pIAORB EEFr OE MILEAGE S- /MGL P I ?f.Jb)< CODE (IXlr$10N IN M DSrw ?f5 ? VIXVfD; TOfAI NO ND O KI. IfD_fL NO.IN1U4fD ?;Al"t Nti6 RVN µ55s'"" S R ruNRwO OF V, 11, p PROPERTYDNAAOf ONLY ? N SU I N iF CIS CROSS115YET ORf1pM NCf' U` ' 11J E lrfO - c C, Oe1KT1fRUCK IN4MfdOB1ECTSIRUCK.WDOWYf4'B NAMF) ESf.DAMAGE SPECI.Y000rNG LEE J ? ??D I C14 S s D4Wf4•s rvAMr. vsr UNITNO.I UNIT NO.2 NRSr ?VEHICLE p PEDESTRIAN ?PEDAICYCIIST t 24 DxN[45NUne WJL 16H1 us1 x FI- -? .. .. . 'T ;s ?a ?Nb I?Td / ? ? I V[ERCIfI MNCATK I J t??l.y } R[OtSRnOOWNL4: .. SA ?,?` ? u Aroaudowrvee Yf A. r +MeaAOweadlN 7 coa PrroNENO. D JLPK 38S-Vod3 R VI M tlp/0 yx Ens Ic"r N[ICNr E 'e-?' !d... ?m L.n R N E R y: 3:113;3; I I ? , r Y t dF?`,;4 FFYY i Dw M • rn o"ONrrDMr cNA4u cNARd . wa""br°w + .. .. ?..w.uD•RU , ? 5 5 1010110 [Sr. WMAO[ 0 -1 El p REMNNFD S ? AW,MY ?R[MMNfD f110IMADt m R '_ 1 STOP " s .y /0o0 a h.eIG SON o [ ?TO-ar: S 1Si orroi: ? T DIAGRAM OF COLLISION r ID AI INDK IfNdr -...ISNEf PN[(ISWIr1 0 PROW 1a f f I I _(- I N DESCRIPTION OF COLLISION: IusesdxEMfNru sNEer D Nf<fsu4r) .. I I 1 WAS N.Aefi /SALC e . 'p e TO... uL'f!4_._ LCPT n,vo _ ._.. ?J .../N rfN ._JEIif eLF _. .7-H ? ._ :_ CNC?PAr rr c_. A5o-.r .uo!.ro do! /.? rsi't' - + _ DRrcNP .- JB a I r NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED ? C (i ' OCCUPANTS/ WITNESSES ; a^ o„ ;' ODES 1 S( - p 3 4 5 6 - ; ., ' „ AMI S. 7'IS GHN/L.t Dona BG sIX w[ alas w ,3B.S-SL7/ 2' ? ':,?" ? MLR I ICr (1Y' i-? . ?ti . F 2 7 . N ruroev _ ,{ ? ? . ?r.Airt/ 1 ) ,.... ..... ... ... .. DM[{1 . Pld . r ' N p f fD I40N0-8 U MKS ? , O ? :, b A {r ra Aawss r Ar nfd .b + rK1?f NA.M1FRANP eAp^AW +Glrx;Y N rp f S iMN" ?.fwe ? u?Mm, .7 0 I tY L 57, D A /3? SC S O ryr D ( ID PER YARRr3D D1110Enro1f ePPROVIDBY DNII ' ? Ey e 1' - ' 1 ?} ? ?? t ? ? 5 JROD NYf i ? ? )- 1 E ?, 4 r. Y 4 (( l r . Y :N7 MI 1 F I ' ^ J+ r . .r .r4?` "arl UlrfR 1'IT t{..yy ? ? t f }1 r S+ I I T8'8 a f r '( N rr n 4, 1 Rk C?ek??``//? c 11 `+4 I??Tl ifYS 'R 1 ?f1?1,? - ? 1 ?? ? 1- lf } {-? ??,' '? . H41 ? I„x? X ' I ? E. 14 ?+` , ? 4 + f l ? 1 ,: ? t 1 ':r rk 1 1 1 1 I ,}I . , . .'.- .'.'. ,' 1. _.? J ?_._..,. A. .. ...e. M1 '...r . ,:, f r: R ? STATE OF WASHINGTON - -Wy PAD, No 4el f ' . POLICE TRAFFIC COLLISION REPORT gTRAFFICWAY EoucfcoMRgmrN IRlBfN 's'J' ' pAlEO II E] PRIVATE WAY f . , v e? O ,,UJ?/ C/?i71 ."`C w" rP?w'S ?n awl (us?:ooiEOUC cou`-Ir munrr N D. alYno. fnwA 6 Sv ?R ?gF g' RP ? ON 01 0, N CIITOR TOWN / l a/-L:lP.TO/l? /(p DUP ( - E f` pL .riE : ?. / NAMfdNO {S RfEl O4 HIGHWAY Cl1 A Mlfs s w of ON ?? ? 13] l/CI /UC/\/ / /D I Z / URAI RWIEONSIREE SFCtI N ? : ,,, .: . _Lf7 !NJ'r/ ? .%).._?C?" J .56990. INI[RSECIING WITN. Sr ROgp NON INifR5FC1 ON ? JR,, - }••D` AA F; - DoEfl%. EO. MHE POSE E - T '' t / OISIANCEEO4E?IES NRESNfNf.CROSSSt ElORNEARfStMIEF 1 STREET, STRFIT SA,Z W ACCIDENT RAMP' DIgGRAM Mtq , i{? 3 ?y? " {E ? Of MILEAGE COllISpNINVpVFD: Vf411Y: ?ODN ? •J ? '? IOTAl NO. NO. KILLED__ NO. INIM._ ? CP SPIIIAGE HIIEpI(DN Hlrvo.tGM IN VEHICLES ® PWMRIYDAMAGFONLY ? 1111' VFd %RO N CI NG tRFFI 4ROADOR RfifRENCE xx INtf Cl$ CROSESM r . , FO IC %? °DIECrSTRUCK(NMIFOF OBJECT SIRUC%"JOOWNER'S NNAF) j / [Sr DPMAGF EPECWI ,OCf,`/`T .fj ?1Q[p?tE+ COD ' {?q +x'{5 ING IAf [NT?? ?S ?Q ?• $ y ? 'S .g • s DRV sNAm. 451 UNITNO.I UNIT NO.2 Fla I MI Dl ? VEHICLE PEDESTRIAN ? pEDALCYCLI3T aN DRI FN'SNPME: LAST {I / 1 L/ ? r ' - EINFE,IA DRf S /?,? e/ 2 /` S RLF DDRESS V Cllr ! f11?.(i'Cx/ Ll/rE zPCOa v„o`f„o. D ITr, ;;. ; `.y R stAlE IPC v NEN . RVER'SIICENSE NO ,? I Sty ? . Stgrf / i 3/ ?/ T It 4 B OCCUPATION iI MN E DA O BIRTH I RvE4 UCFNSF NO. V pjI_ " 5 R7 IAIE SEX IRtH HppiiE O R _ T AMEd PHONE NO. EYES WFIGNL MIOHI E DCCUPAiION i fi?,Il lgM E6 PEN)Nf NO. R EYES -I NEIGNI 0 CHECK (? IyFH CIFASgN FMROYFE OFANOIHFIF.AI CODES ? CHECK (F/J RortfoFANarE4af 2 ?' D e F B n HInEA MHI FECNMI rin rCU iT 5 CODES ? + • V NS " r 1L• /?? ,j 6 ° E ? - ? a , si IN?U„p5 iii u 5 Nt H 6 w?rv ?CLL P flew ROM Awa ? °cAD'hlt iii:et ?1 ri Ur or 5 ? Nal_ FAN VE N PoM ' 4 .,/ O r MA%f IDOOGE;NFV J MOpfI IDARi NOVA' SIYLE Ix DRCONV 1 YEAR O ;HfV.1 0 N/JDf a r fgVA O V „ 0 rwN3P. I 09 CEN RAI SrAIE - '`/ ?7 A? E VEER RAtE NO r f H ? . ,,/ , . VFN. COLOR N l ,. ; :h lHICIf IDfNIIFIUNOryiq 1 C vfMCF DF tfUll NN ? ^? /1.3 5 L 1:, ? R FGIS DOWNER. IASI FRIT MIDDLE PHONE NO. RfG IE4ED OWNER: 1 WI FIRSt i ( I I I ,?` R f1.L75 I MI DIE H NE NO. 0 _ ? ApDR^ssaowNE4 f 5 O WNER n N I NAMES App4E55OI RANCf CO. ORAGFNT E /UN R NUAN C Dx NMIO; AREA D l 3.? 2 / .r:: . L f '7 Iu CM . 5 IS GE 1 In c- 1/'r 1' - n'..A /•AF?rS 1 D4 VIN, CHARGE EI? R nnlii?.. FII gAMAGf AA[A _t .. FCE}SARY) BYAR40W .JJ'f{i l? FL+)T. bn'fu! .,,??y. NAME, ADDRESS & INJURIES OF PERSONS OCCUPANTS/WITNESSES i.sEDa1lEai:u P?ilu NAM4 IJ ) ?. 1 ILJ AWAY BY: I $ )ESCRIPTION OFCOLUSION, (usESuPPItMENiNJHEETIFNEcMw-Y) .Cos Y Ccritho/ 9.:T /'? Jc/F ?/'J 9,v - l ° Yf ` .- ?CFS7 Gl:f.r'4 .. .P? ?i? ??? . • ell r C 3 9 ` C c Al / 7 rr S 7sy. !O ....f! c?1 __ VOLVED + CODES SIX I AEii 1 Z 3 4 5 6 -0. ?F t 5,:-; t S ? F.? r?l? b P,?.: v$ °h?" R.r,U .` ?m?l ? .hl... ? ?• ? 91?dkf"? ,: p ',?.L, A? ,?; tl I t I r ? ? 1 r ViPA9? 1.? ?? 'I?x - f f 11jP7 TV ,?, 1 yr; ' r5P S .? I ? )QIJ ?fY_ ?E y?'UFG,I?'Ita'?"SS?ISS + 4 , Y ?n l E A ? ( 1 ( ?'? 4 1 piL?ll1 ) . f P f b ,??I r fI tip r? ? ? ti T f , r I t; iI?E? u ) f - k2 .U.LLI,$ION. REPORT uI UA U V c NO. `a eql o TMEOFC :oN co "" BO c -S COUN? } J CITYiO .- QOP weo YP". 9W Man y s 9•i. H noLw iW /-' Oi10M 4' S ''8 y: 'X 2 : n n fr on o V z tli HgnWAV Fm.CL I e'FURAL GIY ON TOWN NAMEl M.m6f µR E H. E• W , ? ? ? '? C? YPF3A •00LA. BfPFET f.ODE. ECL GDE AC M «G wHED ML[! ®1 Qw Q m Hn d to c lc ON On k Dn n d y yip ulsEm.w LWTH LTPLEf OP ROY . T PPEM EO 1. N ... ..• one N BrHEET a eiRF.ET 7z _ rNOL ©© '. , fSTw4 DPEgFw ouS?NUU E. PIMP IAONJA OA I enumw 20( DF outh'cnc7 of H1l]cr' ive . T7, _ . . Q a Ny ABIEIaIUWtl ?Yq SFaRt? ? U O. FFTLA CLL', RfiFPDK¢O fA0O8lPEET OHPOM O VfwG A 7i ?L?IAOE Dw B E ? . an B ' aaHroRKMATDW. HENAT D ? H? AMM . ? . o mN[ MATEF M S s SIECi 6TflUCN NAMf KO : ,.. ? IE n N SIN I WN fl F BJ TS NAME AND ADDPES6 ?a PVANP 6P[OC OE Iw Gnrigo - Stbphon ..• Brunotta. Hadloclc s 7 00 r MOH H N OWVER'9 LLRT NAME N A ', M .:MIDDLE IF TYFBcros0 DRIVER'S LAST NAME. ,._ •F STN NOME 1 TNV9 iH Pnr3cor Ben'; Cprigue caMSOxaP - F$. - d7' STREET ADDRESS OUTE NO: AND BO%NO pfa,E50NS w[nE STREETAOGRESS ,„flWTE N0. AND S0%NO. P.O. Box 28 P-.0 nx 2A ' I aE D ." - qtt ATE-...;,. DP pE, DRYC@'8000UPA N CITY 6TAT ,7FFIME DRIVERtSOCC UPA, .. P.TPORT aiM' Port LudlA?+ lln 98?651HetAracl L OWVEA S LN EN A OATEOF ?F H AGE A DR VER 9 UCEN fi A _. - 67..2L' ' .x `STATE' ?6E% DA r' & TH . AGE Pv-EB88 71. ?.4 66., w.' D 'A' -'nCLi' MANE ICNEV.•WWEI' DLINO': A•OAFT):- DY STYLE12OF) KHICLE YR'I' MANE 1-- I <MO LINDA AR ., DY ST (a D0.) ].479 Dodae Omni 4-door I ' V.. ... '' P lIOENSE PLATE NO. STATE TRNLFA PLATE NO.... STATE:. PLATEN :"..STATE .:. ti: TRMLFAPLATENO... ....;.STATE...:.. MIR 308 Yin k VEHICLE MENTIFICATONN0, .". VE ., MICLEIDEFITIFlCAiIONNO, u/44A 0 2444 .:., TiE015fFAED ONNEA ILAST•FlRST-IAIDGE NAMEI ..;. OWNER'S LICENSE NO. FEOLSTER.EDOWNEfl ILAST•FIHST-MIDDLE NAME) ,.a.,, ..,. ,. OWVEq'S IIOENSE NO.. .._ . - 1' P?rkor` Den rn uc PA RK-E -S867. OWNER'S AD DPE ISTREEi, qTY 9TATE1 ....:. DATEOFSIRTH .. WNER'S ADDRESS ... ... ISTREET.GTY ANDSA .,,- •a?4 P.O. Box ?8 Port Ludlow Iq,::. YWRYp., • P VEHCLE ED ' ?wNd D ST?4 AFTS OF VENIC EDAMAGED ' Front s 2, 500 _ ;: ;,,; ''end, Tvindehield s ' WA LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1-' 1%EREAUTOMOSILEUASSITY INSURANCE . . COVERAGEWEFFECT FOR iHl6 ACCIDENT ON YOUR CAR ]YES 0 No NAME AND ADDRESS OF L1.131LFY WSUMNOE - ER _ s• Pnrkor P.O. 28 Port aY1cl].ovr lNfi:TE NAMEOFUABUTYWSUTANCEMAIPANY.:: fig 98565 Colonin] Penn . "WEANDADDNESSOF LAB TY WSURANO.-. AR E 19 ]A pn. LAS- PO_ICYNUNDER '. 11 Co 7.oninl Ponn Insurnncc Co POBor 7 5767 h J 1 • i..' ? 751 86 462-46 ' P^ I6T WJUflY: . ! . U ' ? u , . , ,. • RY uSE EpAPA FREPOH IOIIAOOIpnµ NAME BCn S. Pa rkor 66 NAME wIIwED ADDRESSP. O. Box 28 Port Ludlow yADDRESS , M F NATURE D,' - E%TENT OF•NU 'U'Rl Zut li'p brui°Od PF1i nO NATURE AND U M F ?? NATURE AND ?? GD YUUWES REOUWE yy--?? DOCTORS E%AMWATIDN BYADOCTORI 4.3®NAME m• .OOm Cr gDINJUWE9 REQUIRE OOOTORB EXAMINATION SY NAM A DOCTOM ®® E STATUSOFWJURED MARK FIRST ONE TMATAPPLIES US OFINJURED .. ,.. ' ,..MM FIRST ON&THATAPPLIES yy DLUelwO NONgaAeva STAT DLS Non WABWD POSL E'. q PAWwOEP 1 WILLED p? PE E OP O 16 K 1 Mw I IlOiaPOM I. ?pAlSEH NO.. NILLEG LSE EPFI IMwORI DE pl Nf ?Pf I -T [ - ' .,, ?. DFSTR AN Of PAN EICI ? 5? 8® 70 ?o':.,I,, ,:Lm ? 50 e? 70 MOTORCYCLE SAFETY:' Q HELMETUSED Q HELMET NOT USED MOTORCYCLE SAFETY: Q HELMET USED Q HELMEINOTUMO SNOW NORTH DY MROWWGRCLE ` DESCRWE BELOW WHAT /W+PFNED:IPEFEA T04ENICLE IYNUM-F!)-_` .._-- I TRM:[mp[anLw[ T•OT AFFMOie aunt Or1 NONwivM NAuIO OV . y , 2 MIMe[P [•Cn KwU[ ANa eNOw •:• .. OPaarav OF IPAKLer •PHOw _. _.._ ' ? ??? ?•(-? •,'•' STPEfIOP r.Mw•r .___" -.-_..-_ _____. ..._ _-__..__ ... YI, ji?C'ci' --'---- ?r' I .t - ' "?" 47 ',Y rl A' ENICLES POSITIONS BEFORE COL SIGN ? No vLAN[e Neu rR Dwu INVESTIGATED OY ' OrK U YllAxma MOMLY P•Nr(0 Kwq NCLE H 3 E W J t ON STREET DR NIONWAY AM [OCCV[D yT PJL OlnfA NE OR N0. OYtTgn t , Aq Ke NO rG NO ? I•ITl ? I'IXC[ 4 ? y pDw Ll ? ?'? ].. ?.:: ? ; ? ir? ? '? "$ ?o ?" ° et g , . . D c[ a . w QH(r _ i•I ' ' ; E W,,IwuN ? ? ? ? ALOW FAI DIRECTION to DIRECTION ?D EDESTRhW/PEDA "n(Ir> A L CYCLIST WA9 U3w0: QIDewMP tQwr+wAr DQWOAp[A IQuoLw'i IEl mn[A r?emw IQroADw.r E I T f DESTALIUK pEDAI CYCLIST CLOTHING COLOR: wAA T an mN[P RanLmm r.w u I? ? ,Q- QA Fo-ac- I ? YOtLP RG S 't11 1 7' 1-. h I1 i ? ?.:' ` , AIpwL nC. y13y1FAC4 ,. ,wIAMER UONT EMOTIONS '..' f1C COfIiROL.. ,.. K•'tCA fMQ , RR . :.TYPE Of ROAD'.,, '. ORNER/VEIRCtf AOTN1N3 LINCA1TIK KK1p1 ? 1 Iy DAYLIGHT FO IM, N:HICIi0M.1 •. pKI MI ?I?Ilwt -?vD M2 _ IGNfGl blt 0lIIOMI L V I W ? T r t(q+LP )'4 Y 1 • ? LO 1 IVµ } ? DAWN Q I Q SIGFIALS 1 MOW Y A I Qd1Y O,w ? ? 9"1 Q 00.43TIIMOHT ANEAO DUSK ? RAWINO 3 0 ? 2 Q STOP SIG 1. T y7 ti M Lei :' A ? N 7 Q TWO W t QWET 3 AY 2 Q OVEATAIM0 .40 PA38140 D ARNSTRffT ? RA A ? LOO REV SIflIE ? ] Q mw SIGN ? D y lr J? F C tk M1 F t ?'V ?T+l' L 1''11w. l 3 L 3 ? .Ow S ON Q 2 ? MANPIG RIGHT TURN ? RO AD Q FOG y w. STREET FLAYING RED ? . OWE IICNAOE H Q Ow. ?LOOS OFF A C[ ? A ? . YANYID LEFT TURN y OIIIt11 y ? ISPEC/Y) 3 ? SairMioos ? 3 Q PLA611N0 AMBER f?T y ? 1ALLEY AMPI O A Q MANWO U•TURN ? SPEDMY Q OILIER U 7 { y e RR DfNAL TWN ? e Q SLOWING ? ? e ? NOR T?< L F t 1 '?$?' AGWAY IER Ap r WN ? y ,I A ' II ! Y INIe wAY Ii r G TYPE '}, ?L PPED FOR TRAFFIC ILAOMU/ ? 1 QWIMWAY Q T Q&TTO ji I L fw ULJCONMTit JWK ? e ?OfIKERI ( r I f NC, /I ??T ?j{ ( I.ril 'N ?IiT 4..,•1.,, )i 2 ? p t'iY ', i,{. dr Ad'•I:.` 1 (?" i?lA'd}1 ?:L I;?/LI` .'.t?: ?, :di X. XYNY?71Id T 4. V 7 if?7 r <L ? ? ?Y I l , r1 , r ,.. ?? ` ? , I rrr f' L' MOTOR VEHICLE COLLISION REPORT `---"+ ' UF?Laus4w E1 3 iv ai z ?' 3 5- Teffersarr X" COUNTYM . ? /la CRYNO p'aR'aK ?N?e?irv G(YOa rOwN D LS' MLE. b ? W ®GF N/'OLOC C ,IE.ND.ltF ElpfET OINGHw.'I orY <FfEeSoN PRZ e P,,a Fct.CL HW(Ep1 LTXEETCOD SFC(. XEn mXO•o, /? rlar wrwsfcrr« P;Z ?y GDUA1t / egwEfN crXErt • raErt affq w r? u1w0T ? X•tuOra CIEn?ESVrM wiEFp'WSIO/aiEiOfNilExlwU •xw•R• ?E a --A REECRCN. FEFI OF - CMir5iOx w.G.VO ?yul ?N •l•XD0009MArEW.LDXEUA]1P.w5vOR1FO, (xvFwC?ES ?Z `WE LLELgv10 LOGVE9 AWwE DOrxF R a B B B FA EX C Yq SUpyrnflR ?PoFOIX1 PEFEaE El fp XO.O CDR EIVEM.tEN.L. AMMDxu PApO.GtNEU gNS ?PF ?LE, iciE ? LJ ?Q NEOT bTAVC. p.weOF OErtCrsTUO.I OWNER OF OBJECTS NAM ANC ADORERS ?+Oiwgn? .co E OrIVEP'S LASTNAME EIFSI NAM MIOOIE 0'/aear0 ?CZtI/C/CL <NM,>/ I ITV.u-_-S w[REwuWOt- ea vDxDa pRWER'.LASTNANE •FIRSTNAME MWOIE. L. FI;9ELDV P41111) if/_fFN STFWET ADDRESS ROUTE rq. ARO OO%NO. !D/y'E" Stree.t ?'o- Xfn.50vs wf vE 9EPwuR A STREET ADDRESS y ROUTENO.ANOBO%NO. kT. / BoYI 80-F OTy STATE DP CODE ?rtTwdsand /?a.9Ba6 OPoVER'S UPAnON Stv 2h?' <owsON Ea°"'E°"" GTY BiATE DP CODE post rowntend Wa. 98368 PA 17Z7 ERSIL N0. A MT OF ACE IXCVEA'Et1CETLRE NO. S TA9TE SE% A ACE OffE .A 37665 W/3. M ?( O 7 % iv 63 ? F/DELlJl3 3E7121 HIA. %3 ?% b ? vswCLE YR MA.EICNEV.•WOOFj MWELINOVA•DMn BOGY bTYU:12081 VENICLEYR MAIiEI MO 1 V-D EOCYb (2DR) 77 ?oNTri/C 7RAV5 HN, PL DR. Of/T5b/?l P/GK 0do .2 de,Truck LIENM PLATE NO. STATE ... /////V 831 /v/7. TRAILERPLATE- - STATE Al//F PLATE STATE :TTWLEA TE NO. fJ '.,.STATE N A VEHICLE IDFNRFICAIgN NO. .: VERIGEIDENTiF1GTENf ..... ..:. .. ...:.:. .: .. :'..:.... .:;:. -2V 87K7/V /796 y7 IEGLSTEAEO OWNERILAST.RST.WpLENA.IE1 DRIVER'S LICENSE NO.. flECISTEREDOWNER ILASTiWGTiA100LE NAME):. ... W9 LICENSL o/yearQ roe 'A1,YV) 014"J M4,10 6AliyER CHUCK OWN -' ISTREET• OTY ANO STATEI ..: ': /C/5! 'AStrtet Port T wnsegd V., DATE FBIRTH 3 3o j' OWNERS_ ISfREET•Cfty AND - MATS NN75 6 R v e04T tuULOW w19. BI TN;-. my -TEOF PAW501 VEMICLEDAMADFU. rare /G TS. aumper /If rear yu[tri K. FwiAVLYII(YTkT.iO. s ARTS OF VEHICLE DMLIDED - N RAP/ 70K FH/1V R , g lion T BoMPER, F O 9 s LIABILITY INSURANCE INFORMATION-VEHICLE NO. r- WAS TN ERE AUTOMOBILE UABIUTY ASURANCE COVERAGE N EFFECT FOR THIS ACCLIENT ON YOUR CAR ? YES NO NMEAND AOCRE59OFUABNTTY WSURANCEPOLIGY HOIDER .. INANEOFLIAEIUfYNSURANCE ANY :.,...:..?. xrF.E• ADOaf59 CRY KATE m i NAMEANO ADDREa90F UA&Ll1Y NSURANCE AGENT .. .., .. . !UAB%!TY YNUM¢FA -.. ,: ;..:_:._ -?...;.?:....:ae.,: i ISTNJURY: :'.-. __].ZE 2NON.MY:.. IUSE.FPNN1EAVtlgTWAbarM.NYUU.E91 ::'.ROE.' 3 .. A? ! h T 4. r.? 1 ' r i?O1FO1. O a alA• p' FNOVEHICIE WDC psao...._. BOY• ?O Tc li 0? x i[VEHIfAE IULLED• 5 rx fl 'Iplwo^ IIa! CII.• ! , I, O_- ? D 60 MOTORCYCLESAFETY: D HELMETUSEO ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMLTLIOED D NELMEr NOT'UsEO SNOWNOg SYGA.AROWNCVICLE 1 _OESCNBEBEI-OW WNATIMPPOJEp FEFERT019nQF8EY M1AfEER) I; wlYlNwE i,r4 N•OO..u O .\ ? I ' -_- - '.ir'-, :.'. , ar WanWE lN.r REgeei2" `- - °IX???? W.,.ow \ I ' ?eh[C/e /JO _/_!-hzrXe([ o.r?. ONeWo 'Nw jai a ,nDrrN•Y ,uuls M '? ., 1 j --' "'^ ? . : MAM.ec YE w.WrY __- revers[b/e._dVr..:~ road at..TeFecrna_Co._ ar v y - ?Qen?d,_donie_.4?1?#_-and pLTr..k<a9- I' ?/ ? ; _ t!ehie/e No_?.i, col/oded._,Frcn,_6elFlnd?_ 1 ffLh? .Yeh/cle -nlo.-/ /'n. tl e rear_._ 47 o.VEW9 rF [E ' _. H 4t_.e tlaated..spee2/ ofas.foao._ rr[ ` s .p..l?.__.cSehdr'n IT?G"E aye' ' ? __ T?aw2rtL and n reC, ;'? 4?a/ ct Q. LF u._ ?r I Aol VEHICLES POSITIONS BEFORE COLLISION XO I L•W. r,cu W U rPwIFLDW wvEaT_TfO DY f)?? VEHCLL N S E W d/BTgEET OR NGFIWAY NAME OR IIO. w rCp'EiOi ,rl,.rup.q H,C D Vf DC C- D ?r. ??[ ^° I.RII D9 D D ? I r P r .a / E3' ®; ? ? :a u "oq . w., N ? ? O /a ? ? ? ? ? ? D Mt rr 1 T yr 1, •',? ' , ""'"'M" KI C9 D ? Alorfo / wo1lND nvom DIRECTION To DIRECTION + r ' PEDESTRIAN /PEDAL CYC UST WAS USING'. I?-. .?-., .0-.. .0=Wµ . •?=.- .0... r?s°;l ioni E?roADwAr 1 ?'1 '?'?? ?' ?, E4 7 ! ,'J PEDESTnIAN/PEDALCYCUSTCLOTHNOCOLDR: 1?e.r E?lnR l?LaFIS .?RLYFDMnIC,N. E?:w.. y k t? P(1A04UNIK! ATNfk LIGHT CONOIT 5 M TwFlcc Nl.OI TYPO OIIIOAO „ONVEgf VE1.CtL ACTIONB _ Y N YR ?lf 1 5 F:W<•fFAI vLNtL1 n:Wt. WI H,F4I aoc- Yr,;w ICNFp OW. DI.ONI { ` : ^y4 1' N„CLC 1 D WYLCMT Xn 1 ) O,IU0K1 E )•1 •? '?ajOI, Cq, 1?ul.n.llr P?DAWN ? 1 ?S.PIALS D 1 Da! WAY ? 1 MNO•TRAWNTAIIE.AD wij"I ,t 4111n 1 (N 1 7 DL`R4.-+MFzq_WW ] ?nus. Cl ] ? stoFsnN r((T1 2 ? TWO WAY D 2 ? OVERTANY1oANOPASSING Ir- SY ?' DWCT ] bFkw . DM 'I MET D ] C] OEID SON 63 ] ®q0 EAUR9RL D .T [j MAxmmNT 1URH ?" ,.?• ([ '••? 1??W71 D ] ?"o" . ?,oo a I?A °=iio FLl D • ? Fua. KD ? . ? n ^ ? . ? M"M LEFT TURN ) ID1'ry,,p A .. -cc D>fC ) a /-TI a'FIT tL%WIS ? a ? ILA."Aaq WnIR ? a ? AII.EY D E ? M•U(MU TUIW tl y1Q{Y? •1 1 ?U'i' XF LI• ? s DOMwatn ly T C) oT.In D tl 11 118 bGN4 ? • ? ?j WA?YW. D • D ??p ?a T r I?} III}FFI ff1}}.411{ i 5 1 I RP CIFY ,7' 4 I? rFf /N7 ADwAYCNM T!R IgADWAYIWRI/{}}77,TYPL ? 2 ?a/ICCR.FLAO." C) fllµ[a D 2 ?s"N"n/OR TRMFID L `Y y t '?1 t .h ?J F ""il '? ?tOA[ .n ?] LJfuu.Fl C] • ? OT FR fiFCW NOAD••FAIMno" ? • ? V oAT 9GNAL 1 ; { f on slo, t 9 [? Cd'3. ,,, , C] wWEO •f ® 2 ? Lr?ogP7Nr+OawwROADWAY 1°I.,.I7 . ,:,eano ,l'f?.l) Y?V nit . ? lr: T r°•/.. jf1 y, n v ? t. 'i,f F 1 l j ti i i _ " E l ? I S c: 1 i i i N ? i S LLI ` p 0 0 1 C ? O ¢ cc) 1? ( Y Y ? C F - s- ; "zx f a 4E .' wse rw laty. Lear .?? STATE OF WASHINGTON Df ? OF No. - ?3 .! 4 O POLICE TRAFFIC COLLISION REPORT YJIRAFFICWAV PRIVATE WAY vollcfeomeulNrN eta ? Nw v ns,^7e,L. oI S ???E6NO Or SIRf t N w v N QE ? Ct?v B.eOWN ? - s ?W OF T EJS N 1 L to E PRIOR ROAD NONINIERSEC ON BFtWffN Statfr 6 etafFt iaOM VFIfvtN f. CROSS ervfFt Oe NFA Fer MlFf vOSr ACCIDENT e [ MILEAGE e D OF CODE uVylrv Dr. . o I IMf9 l SFVF$ lll/Df ?NI169UN wrvD rv01uN9F0- ? 11111D NO r . / , ? . IX?E ?tt5 ?e evORely DAM.FOE ONIY V :Oi OBIf IS RUCs AND O'WNF9'S NUAFi fSr. DYNAGf E SeECW CODIN T 1 UN N%! NIT NO HICLE VE . U Dg F t over MI 09_' f: 51 Li wy ^A Iv `. ' ? DORf15 afet A y y? , MK / / IIR COq ENE NO D r VAll 1nlf S 7 '/ 7 W t.rt 0 R ctNSE NO rv tl {? ' ?? 1 ?E >• v ? ? G r I O E noN m NrMF a R cues N 0 ?WFN f 5 `?[ R " lvl:r v?l " ? a i ?CHECK(?) tNlaf . F t `. rMn s u vENrc s A ?w 14 CODES t D cl ] ...wl.NCt ? irYaE ? ?$m. ? : <ii ? rui v On91NOVI.1 Srvlf laD CCa ) nKJOt v - ? ,.,.,l.NCt 1 <Ntv. 11A N I E[ [OOOf.CNfv.l E?"? C E a ?A r fa nwrf NO. sort s? H vfN-Oa I ucfNU ? rtNlclf.o NUrl. SRe DOWNF9: IASr V3r II95r MIDDEF eNONE NO. I W A DwNf9 t'` ' UA y ? „ Adt / E N D .N s INwR.NCECD T R >/- l . ? f5 AMAOtAWAy ? AGRAMOF COLLISION I. D . NDaNE •l INDK.Ie s+ats9wclssM+lT.. , er•9aoW DE PTION OF_C N: Ivseswn[M! AISMFT CISSM+I CK7 _ ? I ' I ? I r - !.ate/ F?•.Lf/EC -.._... V ? ? ? .._ E? L L -- rr , I ? _ Fg-- 1j l - a I-1-, t I c? F 11FRSONS . _ f _ k4lylcR OY' ?o 39- INVOLVED CODES 1 - 2 3 4 5 6 'Iv5 t S 12 . "XV POLICE TRAFFIC CCION REPORT 0 TRAFFICWAY O ai J U I, ...YpnN - ? PRIVATE WAY N OI , JJ CWNrv ryD ?DDN Y s41II j? ,',?"'??y Ip nwnr i. IU3t ].DDN 91 NI. Xll i ?o Cw zZ 2 /`-I I I / s ICCZ/ fFEesafv DIYORID ` 9 WN EANO. d11RUT WGNWAY p - IXfiE dE 9f ! L ?N ?W ?IN ANUS ?5 of . 7uunsrnc? ON CALL` CEOFrnE' • '?0- . Irv1t95EC1 NG WirN3r fF109 PoA0 NON Nit9YCIg /?N //--__ /? MIIf P061 /J UTW-C, PE Irv VJy?1{ (7055 -11, DIS •rvC R f 1 i aF .CROSS 319FII MARf3r MllF ACCIDENT , RAM D•rA - Mll[3 ?!5 f W /l?'f?1{ MILEAGE IEFI Oi SS •'V CODE .. COll15grvIN IX V VlD t9nr: 0 Sf 11 1 RPo.SDOR RIrfpENp IOTAI NO NO S ll[D?NO.INIURFD? ? 44'1- ? HN{ 9UN ?uH'wipiH N w[9 CLS C9p333TP[Ff0 PoAD dV[HICIE3 ?Pp0pt91Y DAm•G[ONIY ?PSUIRD ?VFaCl1 ^?'• o?t?J6D.,",'. Oel[C1319UCp INAMFd031lCr SI9UCp µDOWN[p3NM1E1 11--A01 -C- CODl--. ..,,. 1 I ] - S ?- s UNIT NO.1 DpwEp's NAN[- IA3T Ip sr MI UNIT N0,4 O VEHICLE ?PEDESTRIAN QPEDALCYCLIST Dpl tps --'- '? / / E ///Ae 7• N s NAME: ?3 - SrR[fr ADD9[5S Srp[[I ADDRfi3 a2 990 13ECKE7-7 P7 e,?4, 7; ]Ip COO[ pNDNt 2 P7 Y STAE t ' / 4 98368 3/ SOCEN. SIAI: R 1'. CRfaI?mN 9oyCaF GT7% F i to 0 I v rv l WSE A f 91RIN +7 ou?p•-r?loN f apNONe w. 777/ • - [ns IDNr EagNl E Dc<wAna. npm Nr.NE a vNON[ No. [RS -1 EeIdN ` T Fr.ed< //I,v_Y G ?if77Y'le AL / -7 R via t/ ? CHE+K V) v[HlulA :N A ANO A' CODES ? ] s . i in If 1 5 1 aN a =I 1-11 +E<I N"' IA c ? CNECK (y( V[HlClf •SAN fAWOYFF IAl CODES ? * p ? { K 5 " As eA a s, lyy j A' 6 Nlu l[s E T roYt Lff Yere m7° .DN N p AM1 ? • MApE 1DDDDF.enev.l u • ? 'Cbm1 ? Z Z. S n IL lD.w1.-AI 31r1E 1]OO (*IV I ? M ND O N ? ibm ? N ? ".' w Kl' 7q CNEvY . ZL v pU E 1 NV.I MODtI ID 1. VAI 1 1 >e ' U 31Att RNlf9 Mif N0. llAl[ H vt ors q 1 01 w A - I ] V[NN:I[IDFMINCAIgN NO. ? v WCltl N I I p L'?J I i 1414 IT I? x913 7 'ell R L ? 4 I / ......RFDOWM9 U fT 51 Odf R qM NO fib ?lrov e O --1 11 T I LE \ ADDpt33«OWNER w 2 S ? R NAM[a•oop[ss«INwp.Np co ap ADE E u fy?-?nE? /?! Ur9t - Rob 6 beJe•ri R 71 -[A . cIVNN CNAR« ??? CNN« q.i ] "OMG' 1 rout NIpDAM•Ot • r Sl 1 D 1 ? ADWi SIN ?.[MNN[D ' MIMN [ 1 OflOii ? AWAr ?R[MNNlO ii 3 ' IUiono I AWAY f RY: /roN 7d Y/ ?1-D BY: AWAY a DIAGRAM Of COLLISI N: e1Y a err NOW DESCRIPTION_ OF COLLISION; IUSl SImfMIMN3KrtDMpswvl V6.1, f °.IIQV S?-_?-( GUE57 CA _ ' ?• ?-{ [q? a _ ?e°??15 ??o?nrn Ssrm Y N7K pd \ _ / ?. L I / c mew _a. eG!?.vJJ / NAME, ADDRESS 8 INJURIES OF PE RSONS INVOLVED ' CODES I - 2 3 S N OCCUPANTS/ WITNESSES .Mt up •ee1•i 'IN^'1if -vpr- -+rr- nslp tMCr N,',er • - - • N DDns3 E N.IDR d "' "'-- •M a ? ? ' ? W' . ? ? iL°:,N A • N ... ... .. ... .. DMlfn .-... .. _. ?. wl NAIN d ' KnKI WH L7 •Ma ? C, ? Dnl, ? sus ? r"iD • , .w q ... D MIfh ++OdiK113,HN111•N, e w Nll1f " M N IM{Y ?•N{ ?• uHl W'dn1? w: ?n•.N X 7rcb?r-?C CM•?G'GY , ?C w1 a t'+r &/5 U?f•.ICWD `i/? Kl AppiND p/?plppl? Dp11O RIKM,. Jf].? • "D.r D•n RIA m y 1?? ?' I ?"srr E? ? 3 I r W Y`? r,l 1 r ? iF A ? , f ?I , a '4?' 1 + 'r' I I I - ?L f I -: - I / TS i. r '.[K• l„ N Sab A. kR "- a .Avr POLICE TRAFFIC COLLISION REPORT L?5 TRAFFICWAY EOIICECOMR]uM Bfq. IF ii! !,I 1 ? PRIVATE WAY PA1Epfcau t courvrv (USE b0 OUR, camera. c1n NO. rwwA °Y AN U ?N ?F <yy OR TOWN AMEl NO.W 1PtFFOR I4GHWAV Milfs ?s ?w o r ,/.,f71o ON N - !5 t!v.?rr iCIUS a RWrf OR51 10,3300 -31 1 CtON IrvtFRSECrI.G WIH. S,RF[IORROAD NON mitRS[CRON BFiWEFN DE StR[Ft B / SiPEEi PelFI f AU.- PO51 O. ?/ / DISIANCF BD14F rPoMR[lRfN E. CPOSSSIRfFI OR NtneFSI M?sFV 51 E w 5 / ACC10EN1 MIREAC -P qAM DATA ?' ffr a T! ? fJ/J O[l50N NVIXV[D NvEVUr' s HIT RUN ,OIAI NO O x UED-NO.INIURID ? SRIttAGE ? C OFVFHCIFS ? RPoKRIVDAMAG[ONIr YFSUt ? 11D ?vfa< tF uUSN rUN]we,« IN AD IMF4 CLS CROSCI qEF R O4efrIRENCE SSIy[?? ,. GG (e °BlECt51RUCI[INANE0FOB![CISIRUC[ANDOWNER-EI III DNAAGF 11CIAl0001NG USE UNIT NO.I UNIT NO.I HIDE ?PEDESTRIAN ?PEDALCYCLIST -'? s 9 I4s NAMC vsr Nov t Plvegs NAM[: ust I L S1RtFf ADDRl55 ?J.? ? D tv!l1 ADDRESS ge S/ Oly IT- :IRCO PHON> r7?/- . ?.4 GS f?fli5 s1 'Y ?.',a?v ? P?_ 32? DRNtRS ULI O. ???? / ) stAl fx ?° +I IH D IvF'S/?? ?? ??? OIIF OF B,RIH Y? IF _oV y «? .!?,,??ON NuAF MOM NO eYES GHr HFIGM .. E «<uvARDN eM NnwlE RHOrvE NO. Es wFIGM i rE H r > ? CHECK (.? EAS:NEARior-ANDY.YlA` ' ?CHECK (.? -ICI ASANEMPT-1 A u1C,- a CODES W 3 n s. 5 S;, A CODES {? 3 ?? S rn E. A N]UPIFI ? JP 7" _ ? - ( G V M ? CC ? pb.n. i O ,4'N5. r K S ? i..' O M.", 11 W."'. 0;;. ?e KH YEAR vF IDODOE EV.I CL? tI IDAer.VAI S1YEE ]DR CONV.I E v y? MODfI IDAR1.NOVA ARly TEG/ CSS ?D ,p ?, J YRA 1-1 AUR KALE NIU SIAIE H AF N Al MH COFOR F 2 o 6?/1 - - ZJG l? 137 W -" M A, CII1a M1NC L r AI " 1 19 ?9 I I I ,L I ?0,91?,8 6, I 6f elGISR V[OOWN[P IA51 51 MDDI[ MOM NO L .¢ G (Z S /? 3 S/3 R ISite WNFR ASl FIRSt M1DDlE /n/Ei7n1C2 -JG '??? SA?a6 ] NAMIt ADDRE-INSURANCECO O4AGIN >> 4 C R SURANCECO N 9 %? 5 /? E- C?=A77'IGC DAMAGI APIA i w< CNAIa ?- .CMa AMAGIDAREA CHARGE oi?r°.o ° _ B 131 D ? ?ww ?RFM.uMD ?Gd A°Br: E .w r ?DRlvir. 4EMNM° ?owmer ?Q70 . - - DIAGRAMOF COLLISION: 1 I 1u S LYrI.- Bu` 1 N j I l DESC RI PTION OF COLLI SION: Itnt SUPMIMt r I-11D MCESSARY) _ d?f>/ N? <./i45 ?TC3 vdJ „)?ss.'S_ 1 ? 1- sgsln, a IL I.?. !.I . ??* -- 4 G d y i . F ? ' ? ee T. G7? . <rrvT6rZ / Z) -4 29 B b 95" dpi -?? ?JS, J? d6i? s.._ j. a i?To / dig -cF?.? NAME, ADDRESS & INJURIES OF PERSONS I OCCUPANTS/WITNESSES NVOLVED ' CODES 1 Aa u, 2 3 u 4 wiIi 5 6 1nu .MRr55 - u I sln,l e. AM B ? Ctl"' ? "' . ? O P -I ADMr55 NAru4la ? .rt rDreGM?AM pw.xK1 011.1;,. 0 - N ? .mrru °°i °` i.n.r e. ?ANB p^,*,.r°m:.1.?+'J ?:` , GLA,Ka Ir«vlaR.a. ,DCr o. wna. •r. tD?:PA¢rnc wAKI wnc 1 ovm Br Dxn r?r " R. , d r _ p I.? t. 1 '1 r n ?1i&r 1 br fi x 15 .: «, ? , 1 O , tJ 11 !'! 1 '' F ( ? a µfRf J i {? ` rti r : . f LrF r k ( i ] 1 r r1 I; ? 3 EI ? 1 I ! h ? ? I i l k l r.1? iewnA ? ?,i'V g ` ' { o- mT f I M ?I I r II 5TA1E VI- WA®iINGI VN P"GF <OF No.® POLICE TRAFFIC COLLISION REPORT Ibl'RAFFICWAY -'c"--NTN W PRIVATE WAY ?ySt I"? E Drcou s. rv Fcourl N m, v m .. w i couNlr courvrr arvEa. FNwA DuR URA Z N f DI CIrr OR IOwrv 6 NO Of StetF104 WO A Mlles J$ ?OW QT ON " ' r - t GD/3O C RSt[1 NO WHH e1RFF1 Ov vOAO NONIMfRSICiIOrv e[iWF[N ? e1RF[! 6 e1R[[T PFFfI M"-T" O SrANC160R Al MR(ff Rt NCF CROSS SIBjLI ent ARF51M if GOSr nfe FV F(tr s w Gf 1 ACCIDENT MILEAGE CODE v pl RAM-A C--N-OIVFD lvf v,rr' HIevUN O`AI NO Osrll[D-NONIURID? ?YIIAGE ? OFVFHCI[e QPROFERTYDAMAGtONtr ?pjSV Ov[aClf . xRO IMFR CLS C RFFTOR ROAp OFfRtNCF aCeee [FTOR e0R0 ?e'd$".3? - _ Ogr(Cr 51RUC.yN AMF OF OBItCI51RUC[,wDOWN{eS NAMt1 f5r SHCW CCM?NG IAf Y1. s UNIT NO. I UNIT NO.2 D VEHICLE ? PEDESTRIAN D PEDALCYCLIST ? S W[e'S NAME: V.51 n 111V ,E D vFR'S NNAF Nel I ?T -- - e1vFEtApDRt55 ' reEftA R[SS PHONE NO. If ITV CO D Itr IAIF ,vC NSE N St t Ez DA M Big ?Ryyyy /YS',tp 7 V IvfR' llCfnSf NO. Arf DA E f I DAr°RI .. 1 H,GHI Am PH OnFEq rF5 ,G [e F OCCUPATION NAfe-ENO. [YES WEIGHT fEIOHr ?? 2 ` ' ? 7 D CHECK) H A` :°? AH0111e F? ? CHECK (? vI. A c_ . ODES' 7 „P s E A' .1 ss " r 51.+ c, ss ?.'"' nc N e y ??n rc.e CODE1 Csi (% N - lets ' DM D AM.H. ct ? n ' ? EbNr. D N v,,, .D, ? MN a ? tl S:R. ? :° Rt.. Ku v(H 1 ?}? 1I MODJyD NOO I sl 1 F ? {? E E I t. nfv.l v "n IIDARI NOVAI I .V v.t 'R ,; v f Sf PIA SAf Atl1 q"T;- t e H vl H. CIX R Il A . E t 60 / a C D VIN CIF,IXNt NCATgrv c 'I I I l I i - L E vtHl IE rD[NT , E+ III" ." I RIGISR""W", v Uer 11 1 MIpgF PFgN NO O R! ,STf ID DwNIR: tA5 FIRST l! t - lye ( ADD1111 WNl1 N " R ^ AM111AUDHSSp MS UV,N U Ov AO -? R U + v Dp IDAM/LI AeIA p avA o1MClq r DNA DMEA'' cHUta aA.. µ S Ie? ?AWAY ?.IA1MN(D le(DA1nAGf _ pAMAfI.? io o,NN R(MI.INU rdiorro? OO ''?? T D ? ovn S h Aw er Awerar DIAGRAM OF COLl1510N: 1 u IND r'TeN IH DESCRIPTIONOF COll1S1ON: lust UPnIMf rN Swn F NICISSARYI 4atla HOARY1 - f? - R? T NQ?FiP.? alar ., .? _G' !c-' 1 I I G 3L 10 j ? Lt 37XVis 7XAVr ?/? ?B - --- R NAME. ADDRESS 81NJURIES Of PERSONS INVOLVED ? CODES 1 - 2 3 4 S 6 OCCUPANTS/WITNESSES _ Act -w it- "Y' Pts1R ?ore Mar . N .nn.n+ o Sat a n er D AM e D W" ? e . D C ? "° " M b AM 151 r ???1 OE 'vOVfIp IR DAMe DRw RI ? , c. ?? ?1ti r b ts .r ,nr•1 N "ANY,ts°' `e. ?.Me MI, OYM". ?"= ? ?yD D.Na troRl r or De. D 1 ? ?rgs?a ?? f ••-,f-j ?a• ??Y 7 I \ R E ? 041 t/ e? k ?"? . f R F1R E _ r ?.H¢y e r P I ! L ? - .. ? y tls."N Irwnv l,a i E I r it j1 y ? n 1 ? I I r , ?' - 4i ,.t o - + . n, F ?• - ( , L':: fi ? i t S r u I 7 ? ?1 I 1 ? ?? I I???A : ' 11 ' t f1 h r? ( 1 , 1 ,, 1+ I I } 1 I .I t" F 1 { ? i ? L? r x F . f3 A%? .: AP I Crr k 11U. mw 7, TRAfFICWAY ' A POLICE TRAFFIC COLLISION REPORT RUIICECOMMNNUMetR PRIVATE WAY DAIF iCOll I n ??Eff COUNty /J 6 ?,. ;. ,:I, n ] . C C? e ?pl /r CWN OlY NO. INWA ?u er.AE EAE fi i i ; y ? 1005, RMIGIwwr ? N of ?? a5 ? P4 W ?Mllfs s ?o SC?+ON? 7 I I IQIFRSECt NG WI N: SIR IOV ROAD NON NI[RfI /? .1- 1.11T 6 .j? SSIR[FI RREfI% f MRf POST -7. _ 6 DANCE BO PFMInUN RON vfffPtN< CROSS SIV[f10R rvFARFStM IE ROS ES 5 f J/J? w ?N•Y<.G• O Fr Of 7 ' ACCIDENT MILEAGE CODE R OI RAM OAfA R R OR R(Ef flGt I ' .17 ? COIL SIGN VOIVtO? SEVI Irv: NO.IN1URfD j ?SV.IAO1 0--N N 1.1 ? 'RD FjT]ft_ROA? SR \ Cl5 CROSS e O orroviwcis p.RO.ERrv DAMAGE ONEY ?IIIE fD ?vi EN '- ` - .-C151RUC. I NAME OE OeIEGi St RUC.....NFRSNAMfI Fsr.ONAAGE SFSCW COOING UNIT NO.I UNIT NO.2 v R's NAME ? VEHICLE p PEDESTRIAN ? PEDALCYCUST NSI I I -y 5 V151 rlRSi MIDOIf /?? ' I : F O RfEr AOOVt55 / / D ciTy Al . OOE RNONF ND. SIAiEI ?/ G X5337 R SIAIE ' L NY ? I I l WSf w E % B1 wI NtR ? J/ / y O? I D. I Atl. OAV Iv. ? ? ' ` OCCURAIN]N ? IR.Or+[NO. EIR IGIIMr E I-Tll" ['IFS CURAIION fIRM NAMf 6RnOE1E N0. s _ R p CHECK(?) A ANO1.leAI C] CHECK(.) EN CIE ASAN M orEEaA CODES+ ] n 'c`E-•'° 1 R%. MIL. A O CODES ?+ ] n A ?: 5 In e u ? N6 DEES - U1« t: ? . M A %1 p ? SCI. ? .Dr 9 Cp{y 1 DARi.wJVwl V s1v l D p N ? U°6cE ? S: x. ? l Kll ? ..? +er 1 nEV.I L IOAR1.rEOYAI 1] 1 w .,,? . ? I VEN. YfwR xAaf IOpO/Cf MEV 1 orb SO GI,/! E f r I w srwtt nwrE NO. salt i N. a CF+i. VAII TF4 II . - C VENICIE IOENIIIIUrpN Si 1 'C?IDIS I? L N vmlaelcenll I I 11I I I I I I I I MID a • Rfasn.eD a usr sr OIXE RNOW No Is f0 wrveR: LAS N sr a G L w ] , n 1] DORtuaoAmR N c E cR Ar 1 n . ww.w°DVtssv mswAr+ce co R pAGID AREA j*V1. lNAAGfo ARA ?ilowi o? CNA GF r I CNAR f rOr o S 1111OAW W?V ?Rt [D N N ?/°iWAr ?R[MMN[D t51.0AMAft ICioIIU? ... Ow 1. o" d °N+°er .GL s OwfD A- 111 11 DIAGRAMOFCOLLISION: 1 e'c uaowrN ? 1 Nf4514 1 L C.4 DESCRIPTIONOf COLLISION: lusts MMEN1u S- ttIS5, _- al* A 77 C I ?, I c .. 6?/? - ? ?L s< r I ? r l l I I ? , r _ /? /EJ.__ 1. ADDRESS g INJURIES OF PERSONS NAME INVOLVED `CODES I - Z - 9 - - 4 S ----- A , CC,CUPANTS/W17NESSES .n:o`"o?ItoMrr.:?IM+l ii w -- --- N`^» ifi. Ace urus'.,D INr 5 msn Excr ° ?J ? Are J- , F IW A. AML. ow pNl ? iW,lr AMIIS, ?{ .Ml l S S ?' N, r zo ? ?•? ADDII,• / NAI, Y! I are pru 1? ?' ?„° Nl e N 1 NCl r _.. DD 1, m Ja -- - A S INla. ^ pAMe p alp .'L 0'1: OI I '?.E CI. SE?.Mlf.. r.. ' 151 ,? I.OW OR WI .C ? $yi1D D •If dplv0 A Ov10 eY D I ?? • , X ] S d UM L: a a 7.?:. IS a' f;Skl ? ? 19 5 i TST INJUfl7_ NAM AODRE5S NATURE AND ADDRESS , SEX E%TENT OF INJURIES OIDINJUR E5 EXAM NATION B' A pOLTORI ?EIATUS NAME 1 v r DIO INJURIES REOUIgE ? O DOCTOR'S Ar o .T A--111- o. N A? .010.. .111 KT. 0. o 'RICA 0 .d? num El -'.111D OIL EA Illy— L'p `y915g' _ ?? :WrTS'Nf P c"0-,j MODEL (NOVA BODY,STYkE (2 DR.) E,. igly d & x3. 7 DA E,OFBIRTH IC. JDA DA, "'I m THIS ACCIDENT ON YOUR CAR YES E3 N . ...._...._ ...?.........?.... ... TOTAL YI.AIR[O NAME ?XA •l':' ?'•. ? 1 1 1 NATURE AND 0 0 M F ' REOU RE ED ? DOCTOR'S 1(Y ) 1 E%TENT OF INJURIES ? ? pM NA TION BY A DOCTOfli I' n RF INJURED E% .... ,,.. _MANICF.IBST OME.TMAT APPLIES.. __, s....?....... ... ..-_ NAME -_ .., ? . ' VEHICLE M ON STREET OR HIGH - - - YiMO INVESTIOATEOBY WAY NAME OR NO. onL LLwur (rA„a au WmuLOCaunie Ilan r(( xa (Inl[ . I I MI ? ? ? ® reL rte wo ? YAIA4 ?ia,ce + Tel,::, ? ? ? ® 01::.: _L1..0- ?.: ? ... ? ? ?;aKL ?gv,-,? .. noLL1eM r-] ? ? ? KONG ? ? ? ? ? ? OAnF FROM T 31, PEDESTRIAN/PEDAL CYCLIST WAS USING: 1 ? Fwc u. J ?.w ? RvnrL . ? u 4 ? a • ?oN r ? n 1 PEDESTRIA ? ' x •,4 IX a? " N PCDAL CYCLIST CLOTHING COLOR' ,?rr ,?nA T?x? ? "I n' A ro WY"n II r : . ROAD bWFAC a 5 c. nrl rr+ni WyTnE9.... uDHJ GVPPIJIQ±W... I ?DArLIGNT r ,L . In InoANlFCtn4 i L??. i r T9Mfjx;; qQI,, xRA erl_ ?.?.11511619 __.«..... 01{I.YER/yENj('b4 ? lp w a ?l •n L ?II ?pRY ??,?LIA1 11L7f wI K.I rw L ? DAWN ? I ? SIGNALS [I ?1I ?1 ONE WAY cnL cll o oA W IiC1 L Nax1 ?Ir1 ? GOING STRAIGHT NILAD IllYi l?,,r ? ?T ?w(t 9 ?NUN NO ] ?WSA d ?ENOwING OARA .TN[LT 4 00'. ? L ? d i,-N RRJJII L IA{?T11 TWO WAY ILSI MJ ® ] ? OVERTAKING AND PABdINU .'?{Li,..., ? L ?SNQY llGrrif ON 4?Y ?1-1.01%Lt ? J ? YIEL061GM ? 4 ?lLASHWOPLO ? J ? qD[ ISIS NIERG ? E C] MARINO RIGHT TURN ., ',? .. ? 4 DEC L OiH(q ? ? C ??S1YC?YY1 C ? 61P([1 LIGml6 ? C iLARewO NIGER ? NOC 1 ? ? I100P/RMIPI ? L ?ALLEY ?ij?II ? 4 Yfl MARINO LEFT TURN ? L ? YARINou-m. 9PLCIFY "A ONCII? 1 ? SP[ S 6gNN E) ? RR S IWp WAY a ? LLIT ""' ? 6 ? GLOWING fY l GNRACLW ,. ROADWAY 11WACE TYP{4 . I??+ Ora %J-15PJ4 F' Ai LI Ll C) 1 ? OIHC(AFLAGUAN ? C ? OtNLR LANCS ? 1 ?ONIVCWAY ? i ? SIOPPLD/OR TRAFFIC ,I L ? rl r AV,M ?4?o-r , SPEC, lY •_? ? C ? 05TOPPED AT SIGNAL OII ATOP SIGN ?¢•l!yylI??J J 4 a'? a'n AEI ryI 11? IC t ?MY DlO ? S ? STOPPED IN ROADWAY t} 4 ?' Y.'1 r7 +. 1 Iq 1 O4 9 RT NON ,M 1 !} q? ? 1 ?IM,DYOCD ? ? I III L }4 l/ c ;t.l "'r,h( ; 9 ,..w. !' I 1 N iHi? i,`' E ,;F.J 't CT" 1I w e nl ` 7 rl Mp t T JTe?t I} a91il??k? r} .Ira Q fir, r'?? 171 Siu Yy h } I 1 t - 71s ? 7 l w k ?'r y S L f K I. I ? Mme` .- ryy_?' vtti[ •? I `u '!k+a' a? ?- ,?}q?, ,p qty . ICLE COLLISION REPORT COUNTY CITY F •? ro 'Li •./ N[[ ?N°?[[eO "rR arr on r°w. •rVw «Nrr ..?Q pR rSo +V• NC..'. INO.u. .,? y r IM 7. f e ?e _ 'r'W Q1 • nou L/OP Sr.[.T roo[yN: 5 /? wnH.rN[[roAN°,o w ? R ?•crlo RAR C.CS ON ?D??D «; -?>ZT KyfM m 1V 5C11ON [ O? wHE.N[erlN,[ H°e,N[ErNlw,w, ,M„ `•: /?? O O ..?[. NA «CAYw m COIL sl«N m° ? 4e To' ?FE,. o= e ?:r.ti e.?.o? a:N o N x o °E??ow oA ' a§•'E2fiP!?e!S.?,TY.?:C`...:4"?r.Pde?JLCr ';owNERO?o@a6cr8 FNM"[. )$.rhLW6Pe'rwi,.. c°U[°o[ -_ _ DLO u.. Fl. L ? .ENXL3'§!d?@T,tMl1Fa..i:4. ?..:.:dr4.'la-F oa• ;pyQgb WIrIYDLVED .. :."? 1;4M1fI)Cc+e s;HAP GrJ w[A"TH' L..MIGREf ':' +' BIPE4 AROPESS 9R11TE.NO,NJO BpX NR a EoN ER T Ja3o.? /?. '. x_ * /SV ?L?Ic-•C ,QG /qe. .eOA/> 5A6?rARRPEBR? ,.ae'c BR4.T€NP.?Hx.NQr ro t TE A,,SppJL w!(VEPB000UPATIPN-, C o ISION .Ci.«[a!•.r.?•ro.Ir XPSA7. °> ?,,,.,[? ?P,4ooE. ggy€Ls4ccuegnoN Y ?" rZ)!'T- /•ouivs,d 44 %b3i ?oa6SAG r•+A rAcoiYrq GurFORM u DRIVE LICENEE NO. STATE SEX „DDATE OfiBIRTH' AGE ORIVM LICENSE NO..,. r..q ;,.,STATE B ;, pA EOFBIRTH ..AGE N 7/v 7 uJA ??• S /1.417 w/O+?L VEHICLE Y YRR. . MAKE ------ BE)))) M90 EL INOVA•D._ ). B 5 Y. ,I2. L VEtD EYfI. M 19 9" Of.77S-e1W G1 E(AQEI , P : INPVA-DgRTI .:80PY8TYLE 17 DR) a { LICENSEPUTE NO. STATE TRAILER PLATE. NO. G0.4 'STA;JE -•-•_. ,J,ICP.NSEPLATE NO ,:,:;?..STATE J){AILEfl PLATE Np., pZ- . STATE I -YENIOLE IOENT{FlOAiION.NO. ...._ _ _ -• XEN!O1E.10ENTIfICATK>H?IR,b..r 7,2 02 /:2 ?2 0 ? n ?y iikpISTEREPOWNEB,(LAST-F)fl !I!::: iii NAME)_— OFlIVER'^y_ LICENSE •, ^?- 4AM4TSREPQYIJIEfl ILASL'PIfIST ;MIPPFE NAME) DRIVERS LICENSE NO. A4,41lllrro A+PR GCJ. tiJJq/plt'rYGIJ Yf,J• gig, Kc Y[/Sr/Yp n OWNEfl'BADORESS. ! ESTflEET CITYANOSTATE) ._ -,c' PATE OF91fl ,gGtcL J, lJpKJj / « n R ONriEWSAODflEA4" - GISTREET.SRXAMPSTATI) OQTEOFr .BIPTN PAflTSOF VEHICLE DANACIED. r... _._? r..r IJG•/CAT T- "' D rN ' IS,O? F•yEH h LT?rl?e s, DC s Aer IN $ ° 1 }.?4 • LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THEREAUTOMOeILE LIAMUTY INSURANCE T?• _ rAS COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR .C.J YES ? NO NAME ANO ADOf=SOFLIABILITY.INSLIRANCE POLIOT7IRLREfl._ :-..J ?++w,1a'.c' BILILILINBURANCE,PPgAPANY ... 06ME AND ADDRESS OF t - IST INJURY AGE -' "•'. .. .,-. '..:r..-- ?ltyi A. _Gt•: 2N?INJUIjY "IU5??9LP?.PAT nEPOPT roP A00 ro - r..: $-. r_ NAVIES IWURlD NAME ADDRESS NATURE AND -' r ADDRESS µ :.SEA M F yE EXTENT OF INJURIES ? ? r EXTENT OF INJURIES FIN AND M F A EX M NATI RY A DOCTORT ? Olp NJURIESOEQUIRE n N ME RS DID EXAMINJUA NAT IIES ON RE BY OM DOCTOR? PE Q DOCTOR'S ?? k A STATUS OF INJURED MARK-f EAST. ONE THAT APPLIES, ME ED „'Ip,1J K aNST ONE THAT APPLIES ? IN VEHI w, r.a v.ON.avx w ro s "XAJAMQEIN`UR MAR ? eILLEp IMV(x[ w unr Nw ? v N 1 - ',. ? NO __ w ?? 0°« ?F,u[r,0[N NO KILLED ? nr ? nwuTE nl ? "vUI[ «N°N .^ ,' ? 5? 6CI? w7?c Qom 50 60 or 71O ci' + t MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED El HELMET NOT USED SN.OW`NOR?HSCRCE Ir ,'4fTiw •',':O/KN D. TIUGI{R NUMra QQ\ ?? I Y- r "Z / e -- - - X17 ; 4Y 1 I ? •. .: ; .; .r,m,,.L„,I.. I IVI « --_._., .. .. ___-_._- ..-. ........ .._. / VEHICLES POSITIONS BEFORE COLLISION «W[[ [-,y, ;GATED OY { 41! j VEHICLE N e E W ON STREET OR NIOIIWAY NAME OR HO "?Or°i?ial ` •er,w,r,p `[a,uY.A" ."[[pu INVEST NO, ytiJ?(/{II (1 1lf noun ? ? ? EyGJ? F{r} N° T-1 r-T No ?rSTIG ?iouii I I I r :+J..I ..:.:.? ?. ?cr. ?a: 14W'" E t a.r. , .I ? ? D ? =6 0 u, J? ? ? ? ? 11 ? ? "'-E 3t i? p, ieHI 1 i DA FROM TO + I t {? PEDESTRIAWPEDALCYCLISTWASUSING: r?eYH . .?w« ?INwwN [?u e:N. I?uw?""eaW??,•;r"a„ r,?N,,,W,,, wr .?orH[n , l PEDESTRIAN,PEOAL CYCLIST CLOTHING COLOR UX ?°,I, w"I ?Ia« [? •? [? ' i ROAD SUNyACL WLATNLII„_ LIOHi CQN{NTI eer [e rA,[«r[[,e r,,+??, OF[8... TRAlfl4 GONTRQI,?,..?:. :.. TYPE [ruc,rv[.n,rin H , F r """` wrw•?r" ?.I+?_ I?.'wruGNr " I.cu Nwc oir['I`"?[;;?;.?JYFNVGMC4Rcmllw oll w"[I I r .: j ` q? 1 .'?..F^ L'S,J µyw F ? No ? 1 D SIONµe ?Irl ?[O( ONE VJAY ?r 1 GOING A91RAIONT AHEAD i? I T+t?L?J 7 ,L,J?l WMCr ! ? WIHD J ? WM ? l D SLOP W( 1']I Vf ? J [ .OYLRIAK1-0 AND nM81NO ^4r 'IT t' , D n ea[Lr r rwo ..WAY ? ! ? LI[Ow k ? _- e ? lgH1D ON ? S ? YIELD M.. ? ! ? RCV[ASIBLE dF I ?'j11?4 ih Y ? [ ROApE ? 1 ?4ARIN0 flIOrlr TURN Ti IDIDD 1 ?u[Wte OIF[T ? [ DfIAfHINDR[D A.H , ? [ DICE 1 .,..A DAPX NO ? ? ""ACHMP) 1 ? MAKING LEFT TURN p- 1`` 'vti?yt ) 1 , 1 ? S Or A ISPICNYI [ ?GTN/[r IIONlS ? 1 ? fLAWIWO AMBIA ? 1 ? AlI[r ?? S O MAKING U-TUAN 6E i,.y? 'J ?• {J,? I ? Yn ClnINRP TWO WAY. '4 -' I JJI', fff,,, ? ? 1 C3 ICNY 1 PR egN4 R? ! ? ? lANIS 1 SLOW NO 1 SI {I, _ rWrr AY CTLA gOALIWATLW1FACl TYFL ? r ?OrFK[WIIAGMAN L Yifp4lgg''?? tW?r ?,arawr.Ue LJ,r u.r« ? L ?Ot,KN. wcav, ? ! ?DItNIWAV ? T [3 STOPPED fOR 1RAIfIC (?u'f? T ,'I J 4 v ?e?«I T '4 f? OI?«WIti MPAP AMURN3.... ? ' ? on e?o: e1cSIGNAL T 1 1 P ° t'I' Q ?•(-1' •• ? / f?•-rINVmD ? 1 ? SrowrlONnwrnvAr 1 l-AlI l? NI ` a ` IV 1 ( 4 ?I? M'1} [ AI I'.Y? E s iT['YT fE'- ? U IX -VIDED IS C] ygggs"r . rJ?. ?._ _ MOTOR VEHICLE COLLISION REPORT NcuIW _ /?G x „ o"R RDTL,"?°O ,?ao? y 7 ! rz4 ?[ ON NNE A A RD U" "cM . ?9 ?w Qa RT( L .CL S lAMOTIRDw R TREETOX P NR I [cTXW COUNTY CITY No. D N flalEo R.TR[[ co a G77?a PWu a STREET. D. 5/ ` `It"'a. ?a aRD,TA RITEREEK-N , oo .?10 o, Ea,? ECTIRI ` ?l ° G STREET O ? B "?_ .? B:? Ba. d ? Efl ? ° H4....m."xd.+L ?F? -EST-!Eiw•EpwNE usL . DOD[ Egq?F @ EEE/1..?.?.. Iiwo cnu" T???kk ?? - tlE1 16sei•: , ,G ?v?Lia7ilBl fliH6ME..,.....a_-..:;.:. _?n.94E.',::.: / / v . , _ / ???Y'cGL caulso on ('N/W?t,'N E two ?T(L?d LrBB.R¢Qk ..;v<:'_..._ ',::_:R4llIftIP,dN8.99!L112:.. P RsoNS ERE '... USE ' N UflEE - . EPAMTE &ITY•...-:s_..:' i1P.PPet. RtyA ..(),SIPAT ...: Co I N' :-rye BTATE IP COf1E, SO TION rPORr •• ,.,.....:.:.,3... .P3YFdlw.G.AN.C3._..., :. fl o M OFlIVEq'S LICENSE NO. 3TATE..SEX -.4OATE oOF BIRTM...:AOE -: WYE"LIOENyE STATE 5 X. ,. GATE OF BIRTH. AGE V/9EHICLE YR. M ICHE .DODGE) MODEL INOVA-OAR I ..800Y STYLE,1?0 .), Tflw YR. MAKE.(F11EV. DOE) .MODELINOVA-OAR )a BOGY BTYLE 120q.) 1 7 11 0 .c f• LICENSE PLATE NO. BTATE TRAILER PLATE NO_„ STATE,:_-::... : .61Lt?BE.CLATE NQ,- .STATE TRAILER PLATE NO. STATE to/? ILK/ V ICLE IDENTIFICATION IOENTIFICAiTIpN,NO. '? fo 771,Pa _ • .TEN[D OWNER_IU -FIRST-MIDDLENAMEJDRIVERS LICENSE hpy_//,•..:.:: ((? €?RyNER,(LAST,FIgST?NItIOLE NAME)DRIVER 'S LICENSE kO. , G/(/ (I•?/ ? T S h/J L OWNER'S OORESS ISTA CI AN TAT OAT OF,SytTK„yWRF$'XMD0ESS._, . OTREET. GITYAND STATE). DATE OF BIRTH A, 1. PMTS OF VEHICLE DAMAGED/-,Ml.ecp ,- Klfewti to .' p.ARTQOFVEHICLE DANAOED ,..??Y?«r+o .rnu, ?,l I UR?UnnrvL.c IKY VHMAII(JN-VEHIGLE NO. 1- COVAS THERE AUTOMOBILE LIAERLITY INSURANCE ERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ? YES ? NO NAMEEAND ADDRESS OF LNBILITY.INSUMNGE. PORESS MGT.H04QES, I;i STATE D ,.. •,?.:,x?F- ..; NAyE.pE41ABIL1?'.11lSURANCE COMPANY ., _ u! AD I - NANEAND AppgESS OF LIABILITY,INSURMIOEAP.E<'IT-,,:.__y.•?L,•?rn:, -_.,, aiATE _4-y??_21pw?L?L1TYPQLI UMBER rv^u_R IHA?. FLIES Durt ...+..u4I(dM,S.P.E.IWURED i,W, ..MMgeIgST ONE THAT „APPLIES ... ??DR INY 0DA OK NO NILIED oE:M.S NO. _. _. _._.. XILLID IsAO.R ROS,R ClIKAIRI " a7 R?L*a o ? 5 ? 6 ? 70 cI O oD1IER wAln N E3 5 ? 60 MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SHOW NORTH BY ARAB . CIRCLE l IMIWe(Aea Ixbrw,Y r•IU[1 M \ -__------------ ------ ..___..-_..._......_..... ,... !. MuueN MbI r[uKA[ ,xD UXIw _^ WRInMRw lwr[a er,Wlar M --.-..._._.__........__._.-..... ....... _....__._ erA[n-..-A. __...... VEHICLES POSITIONS BEFORE COLLISION KrRCI[ INVESTIGATED BY VEHICLE N S E W ON STREET OR HIGHWAY NAME OR NO. W [OEH ,AYRRD MYaMYIAR+Dto DCCVn[o ?:: ?iol DuiKtXw `r, Y,r rir[s I IKi I'Q' Irplll ?.? ? ? [ M R RO iIIIp IOIMAI ? ? [3 C3 ?._,.?,.?...?.A? ? .? ?pk1 ?aIM" ? ON. 0.1-1 ? ? ? ? ? ? Ka9r?,R ? ? ? aa1wS. FROM TO PEDESTRIAWPEDALCYCLIST WAS USING: r?Ma A !?Ra ?H.olnaA ,?uawa •?ua .?.7R ,?: ,?. PEDF-STRIARLPEOAL CYCLIST CLOTHING COLOR: wy?e. rR•I?. r r?ur w[ l? r? H IN SURFACE _WEATHER __. EIGHT ;Q TIQNS.... .. TRAFrIC(,WITRPL. TYPE Plfl9M p ae'; d -% 1 Ji;. } rau Mll H 1 I ? ,R ""C", MKg1 •.orlu wl? 'w Wcl[ ,q I c w- 1 RS I MT rI LS I _.. ORI-EIIICLE ACTIONS rIHIGI --- OM OR UDX [I 1l? ' I I b ? 1 l ? DR, I C] p ) ? WwR a rl ? 1 ? 91DMALE ? I C] ONE WAY ? I I ?l GOING STRAIGHT AHEAD !j} I ) I I - J y R 4R. ?) ?w[T E ?0.URVq S ? WSX EEt ? 1 ? STOPS.- ? 1 ? TWO WAY 1 [] ? OVERTAXING ANDPASSING I lM ? l f ? ? 5 6NOW IN6 • ? ?IMITS OrI , ? 100 l ? a ? rI[1091G•_ 1 RlVE ...... ? ? BAD ? 1 ? MAX NO P GIIT TURN T Y r 31 4 I f 7 - ' A V Ik ? 1 ?IC[ 1 ? GIT9011 ? 1 ? NAMR,q RID IIROIANp[ ? ? 1 ? MARINO LEFT TURN III H1 r A k I (? fi % ?• ? C 1 ?16/1 CMYI • ? StnIETlWHi9 ? 1 ? IIASIUNG AMBER ? 1 AILIY ? ? 9 ? 4 AXIN0 U-TURN °MW JI J I { •L ? s" 1 Y Al TER 'I ?4MECN? ? 1 ?RR SXWM 1W0 WAT• ? • ? iµEf MN ? 1 ? LLOW FRG A 1Tt', ,, ??I - ? I !:°.' " I ' • NOAOWAY1WACt rYPE . p,poD,?r:rl ?]?I?r...r. ? ? °1 [] I ? OIIIC[141lAGMAN ? F ? OIHIA. IP[GIY I ?oRVrwAr [3 .,PPAp.N1CANAf1AM ; ? I ? • ? STOMOFOPTRAFFIC 5 TDP rD T S GNAL T ) 1 Ff I I F' 1 1 Y ) Y' . 1' ? , x'ir • • ° ? ? w. „, ... ! ?DIV D[D ? ? e ? OA N TOP 61 0N RIOPP[D IN P DADWAY I ':._ 1 1 ?I . 1 kLL'' ' ` r. tt • r ' rr '? f ; ?r? 7 J RA11K . ? 1 ? MIDI ? 1 ? UNIX OIU ? D ? Bf l TIN 'RA" RC G G IN _ F t t 3 y? I F . : V. H ?t 5 ..x .1 1 0 M R, t(5 ry t .I I I i 1 ?:"I E ?. STATE OF WA GTON RWSP SAIRfv I.qD, `? ' ` E) PAOL Or O POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY No. - I ICKKf COMRAIN} NUM&R ?' All Q1 Al PRIVATE WAY V D Cpl I M_ .. rlmf ( yi F COVNrv IUSE }vW HOUV, COVMY NO._ CIrv Np, ? .?? ?N ?[ Cf O IOWN AMFa NO Or S,RF ?UAaAf! i ? SR ,?!+ EIOV H.-Al Cl5 URµ M EtS ? DO A l.O OI?? r` Rau,E Dq r ?? INrl4slcr NC VnrH s FFro R ROwp MNINrtRSfa h d? eca (7774 yy ,'. Pq[f1R E M4E POSE ' pN .1???1_I. ] OISrANCfM1OVfM 4EAER BfrWf[N?? Sr9Ffra OJ// %%Y;NN%% A 1 .,,' ? I <ROSSSfNffrOR fHwgE3l Mllf Pp3r V?.314EE! 7 Ifs r 3 F W .1?LL ACCIOFNt R Oln Wnpn n 1 rlFr Or MIEEAGE P CMUSIONINVIXVfO. N EVfR,v. E• CODE ?- 4 ?, tH IOtAI NO ® llFO NO. NrU4Ep?? ? SPIIwOF ® Hr m Us N I CEV[HKI[S ®PVpRgrY DAM a Of ONLY e OUN wNRwRlw-y D I r L ROADCW gER9FPECE Oa1FCr3rRUCRINAMFOr OBr[Cr3igUCR ANDOWNFq SNAMfI ?P[iUlrfO Dm", IEEE Cl3 CROSS iR[fl0A RO4p I Q CIF - , 1 F31 D0.NAOf SRGa\I COgNO WE OD M r $ _ UNIT NO. 1 , S DRrvtR3N4mf?! us, nqs' MI a 4PU.EAIS NAOM'FR ?zVEHICLE ? PEDESTRIAN ? REDALCYCLIST ?T ,? >- sr4FfrnooRtss D NR ' ?-mu- ?Sy7 a r s 4M 155RF33 c 2 SrwrE 211 COIXy' • 3' R HONf M. D UY S,Art °Z DgN[R'3lICENSf NO. P R IP N srwrt A Y 'Y mD I 0•r' I NvR I 'v IKIN3f NO. ? V nrf DIEpB4H ?. `. , B «CUPAtION FIRM NMAFa PHONF NO. ? I D.\Y jr9 ? `,-SKI)' 1' CCC FYf3 GHi NFICHi E «CUPA,ION 1I1M N-1 a PHONl NO. fifi?' ?"^ - tnz wEICH, rEroHr - ? CHEC R K vENlafw.A ?rMgv' awryorHEC AE D CHECKW) CODES?• ]due, v s F1- A yolo EN CIfwzANUnaorFFOrArorNEanl . Rn Iwo; '•'s tnrz ?Krclt CODES ? ? 7 M1 yemx.cu r,cE RI '" 5 u N 1} G. =W11- er vfH .Fnqm 0-- D al E ? ?&- ? N..II D por MAaf IDODOI CHf V l EI IDAR, Novwl StvtE l}D4.COVV 1 H?r?AR PO M" H E D Po1E1 D 88'- 0 vewKll ? r:°I.o, r - E y EE''''?? v.l A-(DA gt. q r I p ? ) ,9A 1[R RAr[Pq. SrA,f' H VfH.<pOR M I N e1JQ rE vtH nLloeNrnlurKNRNO. A - W s: 1q 2 2 I E i NEH,af , r A, N vfGRrf9tDOwNf9 UESr r193r I I ' L S I N I I fREDOWNER I 1 I - ' N MDDI[ Sc",f"= O q lw)r l143t I MID L NO _ - . 1] ADp9t53p OWNI /r???O •T W 2GREs7 Ra, N w f DWNtq y2O MooRE 8$= - NrvAfaAOOA[ss ar lNw ANCf co oR AC I E Wig 98,5,39 wMwc?AAU `? R UAJI< PWAJ T CH oGE ?h ) 150,E ? 'Al AW® _ CHARGE ? ? 0•"lNf AAU L D 'I g--T ? 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Air i HIG 7 12'0'2 11-21-71 5O 9rGISIERf00WNFV IASt rIRSI MIDDIt 1 IA vMMNO. - W fG15nRED WHIR. 1151 M11 .1-1 fM. 55 n6a??? 2 OOVf530f " V W ITV 1 I.?W1Yl ?V ti _' • E A GWNIR (JI 7 Amea,DDaessal^su4ANcfco o4 AG??+a? (r`??_ Se lLvla.yr - JfJ1?Kfi'r1Gl SC_O CA. R + I G?,6+?56 Zi?S.?I - C.N. t•Wc.Frt fOM.SAGI ARfA ' Z v, M M fN1a(( ) o.A ,n n ce rw N3 0-M ' gAMAOfO ARtA CH,9GE w<'W.N .' AM? - ° s r . _ II Ids"o o? ?a1mA N[D I Isr o ce ^vrv [:]REMAIN,. 0 WAVlvl REMAIN,. _ OWID ? LOWED 7 JlU BY, DIAGRAM OF COLLISION I u M E _ ev ?a .r- r??[? _+ DESCRIPTION OF COLLISION. IDSE StAft- LSKIT NEC-ItyI _vLy--q LJn6..S'Zn ? - l ` GlEnr 12s1w ? A 1oc6 sl6 v - i ^ -ci? Lf ? ,,ci-ts A. L+ I W t Iv l . ± R . ? : r -` I r_?_ 15- SS Sr, R raC?cw slo? LJZy.-+- pi?ssao._ +?.? ..__ ? `"?'- L' * - . ' r- ?i 1..n5v L ?Ict v? Nb? Slzi:. sc Lahr. ? I I 3ralc.? ? l?s 0 ?a?,? u v IR NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES I - Z 9 4 5 A l WM"`f OCCUPANTS/ WITNESSES luu swvmtN tNA Id ADpt10NA !t SI ... - Slx AW IA1U5 NR yEE_ 'N mIr ...,,n.' R r" __.. ESIR NICt j1Ci NAMI P <? a+ Cam M . = . x 4rl il.t I.;lvd Pf., j?y_._....- ADBn N. "e.Ria r ti .S -.. M na ? v (DM ? B c 'n • ? s i. iN M+' 0 N,Mt lnly .f E 33s•oZ9,o - - - A _. -. r -- -' .ura?n5 ?d.n6 .lytVZ. pl..W N.m4[a _ ,-.. v. R MavlP r9oM .Aar ..,Y sf rnBY ?•MB ?r.. ? m.v. ?arr ?: ANI N No - .Pans -Illfol nvas .INIev ?Ame ?, .. ?aD,.l. ?N• ?.n. • :IrS wMI IRA N. B 1C•Gt OV IPM .vl.KV .?... ;, .E jJ-? CrRO `??? ?Ld[? VtD ?/ ?BRpOr1a5 GAIT n Ir 8 Z1 pAlt 8 J Q ngi ?rv' r I ? IMF' 1 a^r«rw FtNy° { 1 `t r ?-1 1N 4 E t?l I t 4 ? ? N ? 1,tlM yv! I f Ir •F° d ? ? r In r • S r.> t-' 1: T' ' " rr t I i t v ._ I 14 j iM A TRAFFICWAY ? POLICE TRAFFIC COON REPORT ® 1tU 2 = Wu PIARVI NIAMBFR pAIFO {a PRIVATE WAY - 'x o u... - Nmt courvrr ' "w..l ! sE giapeougl G ? (' I J3:20 S2'FFF/?S'aiEJ couryn NO. nn NO. iNWA ?? ?tIRBAN _ ON [IT OP, cTU DR TOWN AN[6N0 Di STRtfTDRNGNWAY iCi 0.s 1 -IEORSIR N s mR[s s ?w 52 OF TeW/dSEEaO ON cc n?Fis fLO. 1NTt RS[CIING mIn51RfEEOR WqD NON INTF45fCfION L3 lp0/20 a BEIwFFN S/F ZQ IIREFl6 pS NCE6p Rl 1I iPOMRfifREN tCRO5551RtfT0R NfAREIs MILE PO tf1X f MIIf WSi ? ES mE s [ w ACCIDENT MI RAMP DIAGRAM MIA rt[r Or / . f LEAGE CODE COINTOTALN OLV[U. NO.R IIFD-•NO.INJUR[D? ?SgR1AGE ?Nre RUN IgI NO. wNOejD?ws F M C!V[NIC FR N FIORWADORgiERFNfE N I MF -RD SS SIREtIOR WqO ?J A I l PROKRTYDWAGEONIV ? MSai[p ?vt«Clf OBJECT SIRUCR NAMTo JECT SrRUC NJDOWNFR' 9SZ ?? __ ? - SNNMEI Is DAMAGE re .uc 1°f/ rr uc r 3@O1-- •AECIALCODINGmt - s ORWERsNA.f: -1 UNIT NO.1 IRST mlpplf 2 UNITITN0. ? VEHICLE ? PEDESTRIAN PEDALCYCl15T -- £O Da NAM: e -?-- a - Z STREETApORf55 Sly SEA/!f D, Clr? SIATF D 1RE[T ApDRE55 _ IP CODE RHONE W. DRNfusIICENe Ns ?tl ? s9.7c? 8fr;z / R GIV SIAF IPC P-NIL ^ t. Ka?t.c s s 7+I I , zJ i/ ° Iv RSllcwsF NO. R IAIE DATE.-PIN Mp ?.° ^ N OCCUPATION 6PNON[NO. EYES WTIGNI MIGHT Z RET/?eEO -- S1J E R CUPAIION .NAME 6 PHONE NO. EVES Vrl1GH1 MIGN I ^ CHECK (?) A OR EAS aN wnorfEw ANOTMe l wlcl QCHECK (,1) AL i I O I J CODESN U 'A,*,' ?? SN . Tin 5 I cT a+ 11 yro?ox.cl? S M v VFN C E AS AN GMR YFF Oi ANOEMY CODES ] ??ss .- •r N ire rc.cl • srSnm NI S EnOw p y h w C 111M p ? AM. AN I IV" ? q:p ? rNl ? INAE IDODGf.CNFV.I Ell A T.NOVAI •KO IRO .COrlv l IN .1 o M o AEI O vi LI e T r NM v R O 1 . ) yY 3 ro XL l k Ce Do 1[NSF PLATE N --PLAT. SLAY E E ° I v.l mOaL1 RI IgOVA1 Buis /1036 - W/3 - IF I' vEN COLOR A N A E - VENICHIDENTINCATIONNO. - ( ITIF I2 - t I IS 919 -41B RtaSRPEDOwrytR: LS1 (1451 MIDD C L. Y-CIEIaNI'll i 1 I' f. I A o LL "NONEND X4"5 /v •? ? O R ISR fD WNFR: LATT NR$1 1 Dlf ?'• ] ADDRE55Of I -I W . A OwERtR ]I AMESADDR-OF wSURANCECO MAGINT E DAMAGID APIA _ rµ [ •• AMAG[ AREA ? pru CNARG D iR . O r CHARGE -Low, •Rip'• 5 151. pAA4Gf C?WtN RtASNNtD 0 ORtMNN[D OTIIIepvOl IIF BOTTOM Otl? I] t51.pNMAGI AWAY w $ OA AiDBr.. ?NW?l El s DIAGRAM OFC I u r Npwpr DES oNlwlN CRIPTIONOF COLLISION. Iwc 5-1-1 SM111i MCESSARrI l ? c ? ??? ?x(O? V£If/c'LL ?1.__ctctsF?A_OUE,t, _CE?v ? T?IC U?v ? R _ _ ?. / ?// WffFfit.O_Bf}cK /N?r?_l•93•TBcu?.?D ?r9-r?£ `I' -- -r a 30, Fr/N RiTr/ / F VE P "I- ; ? ` 5 . , FO?cE S7o TArt P w t . 1/?N1< sc? I r 1 1 '° fbu,`c c*'rW &S OP I ! _ I j I Sa OiPmkrEO /rPP,Co,4 /.D.O_f f._Ff%!c /.cK ._ I - I _r I - - { - NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED 'CODES t Z 3 4 OCCUPANTS /WITNESSES 'usE sutlntwmN s. IEr ADpnoaa NAME m S ... - - N ._ S 6 _... N.w $riq/tlL£ B/re Cl/exe .p R15B - E pRt?aSrS%T/L / sEX AGE TALUS 7/ R n - - RISM - 1-1C1 VTCr - M u N 1N `B. ?AU B p?y110 rA,:I. O? ? ?:9t15. A ASE Es NO NA t un a K RIrADVtIaRwM O.Me ? i I O.o . D G ? -. A Ir vAI.r,G ?vlKle Sr.AMl lRgrlR tlAC GI OI WIrKr Nu PIT of , ??AMB ?~ II I?tM.?w I]Ii ? ? A050 uf-p . p u•.. . Tcsn iU Z pirE DSPAICM4 /3z8 Pa ?Cl ARP VID 1339 IIa DA -REPORT _/8$6 MT! I ?E f$ ?c3t'oero , E, YEc 2 V '??•s POLICE TRAFFIC COLON REPORT TRAFHCWAr rollc 'w NwgazR I / PRIVATE WAY ^^^!!!! DATE OE.cau DArO C1101111 O IO Ul9 sux u D D twRl rE Yr IIMF IDSf RRDDHOURI COUN,Y TC G or OtJ \?(J + W COUNTY NO. I? c_ NO. iHWA ?URDAN AL CiYO i0 N (?AMFOA rv[0.0 S l,R,[,Exr?O<R HIGHWAY '] lE5 ??5 Ow OOF O? owN ItA G GCCYCIO? Cl5 40U,FjW?l??n GG oo VV SfCll CC110N N19SFCr NG YA1H: S1RFfr0R ROAD NON IN1Fe S Dvlula ' %IEPI% Ep. MIlE PO51 ? - ,, tt Vy??c? ??c?r??? BF,WFFN N?t.,..ciVElx+" iREEI A [FT _ ?. ? / ,gNCF DIRf Z OM R111 NCE. CROSS ST9EF10R N[ARF51 MIlF SI D15 MIlFS 5 E W 3OD PFE, ? OF RjLCkL._8&rjy " • -c.. NT MILEAGE BODE a DIAG --A S NFVER,Ir: „- COll15M)N,NVIXVFD'. ?HITARUN TOTAL NO. OKIIIFD?NO. INJURED ?SPIIIAGE OF VIIII-1 ? PROPERtr DAMAGE ONLY ?KSUItfD ?VFpCif " 3°" I I D NITER CJt l5 O NI IT 3r9EF OR AOAD09 Ff+fRtH<C R O53 S1RfFTOR ROM p? 1. { ODJCCT51Rl KIN4EOF°DJCCr57RUCKO DOWNER'5NAMEI fSi.OPMAGE SPFCW COOING IbE 1 E UNIT NO. UNIT N0.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST S RICGVF95EJAMF: I i 1 w ?,/VD(_E,?L MID c / wFRSN_ U5, pE _ A 31 T, STREET -DRE. ??7j L c rcoa oNFNO. Ii-E D . Irr s,ArF , PNONEN FORT TowNSENO WA 9%368 ii! -2ss R D9NtesucEnsrv. VW A SM iTywfie(?aoF sa I l11 0?j' o"(c', 2 I V IvR uansf rvo. ALE 11 _E711 D, DM[d"R D ;r9 , : 9 2 D OCCUVg11pN tRPHONFN FYfS IGH, IEIGHI (Z,-T. fZET is so E R occurA„aN MNAME6PHON[NO. FYfS WFIGNt E[IGHI -7 R Q CHECK (0 vFH nE qs nN UnPiv vt O-R- Ed Al ? CHECK(V) lH of AS AN [Mnor[Ea ANOrHFa. . -Ill Nt 3R> R S l uwI n ODES ? + D • H C sn JI 5Lx N p M A c CO DES?' 3o.ss ssnm ? + s EA) C R, o ROM .wuL.NC, ? U ? EgiiT. ? K?Kii ? iuvv l 1.11 il_jY e"pM El AmE 11 K%1° ? Eom. ? n ? MIN, nL "b III P FIDODGE.CHFV.I ` 1 I C'??V • IDARI.p?AI Sir If IRDR. CON VI j" U V L1- I?LP, ? E FAR 1 FV.1 MODFLIDAe1.NOVAI H v Y IR R. V.I v au !o I rvq l[R ngTE NO. s'n,F , sA H N vN0", L K E AE - $1 ) F- M I I i 7 wA - `- I C I? V[HIOFIptM rIUfION NO CR ? 1, A!825 b IDS 8,- -,-- ` vFHI<IE,D! i<A,I nN . i I ? - 9Cfi15RVEDOWNCR: -1 fIR51 MIDDI! PHONE NO. sm 1 OwbcL -2s3(D w MONf NO. USI EI9s1 MIDMf vFG15RR[D WNFR? - - 1 2 DDetssaoWNEe A N OWNER A 3 sq E ORAGENT NAMtIADDRt55dIN5URANC[<O ?? NT El . uNK. R S. - - ICIIA pANAG[ AxeA ps,w" G s a°.N cHRa ARFA , gM cHARCEbotcr 9 TDR ? S ISIrnDANAGt IV RE-NED ? Aw?r tOROTlO RyYxl1 ?AWAr ?REMRUN[O F51. DAMAGt , IUOOROM TOWED S GG ? %w'v°er AT SCIF-r- ? s AWAY Rr: la DIAGRAMOF COLLISION: lu INOI nOR,H 03; sHtEI,iNC YL. i ^ Z roc. I DESCRIPTION OF COLLISION: (USF SUPPIfAUN1Al sHE[i IP rvECts5ARr1 ... _.._ vE N1? lL WAS W>STBoVND oN G1 p£ GE> RG£ 90 VE>1lcir; ATTEMPTS To MAKE A r TNE s . l -. T J,EF7-14AND Cv2V£. AEAA kc 0 N L 132VS11 1 T £fig wti 0 To 1 I N oADWAy ?R I A GPA^RGE RD ? pE , C^ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES 1 - Z 3 4 5 6 OCCUPANTS /WITNESSES S,,DOil Pa+N- 1) ux AGE zeros '"„"" Ai r RtsrR, UECI tjl A M Aoo.,a r Al.Rtd [ ?AMe. ?ERIK' ? 'K . ?N7 ?itxvv AMI q p 10 ADD%Sf NAIV91d R?p rvUM ?AmA ?,MKI ?,..I. ?x?i+ ?i.?'HV i NAMI NO ADpel35 NAfpefd ti,"I[-JimIR ON?"I.° XINIlr ?AM! ? X iN At.O !EK A 909 AGI KV wvrr ?cSO pN- I K D?}[H!D t.m Hn O ^ RP,VED T.oD HRS. ?V UA,E ?OGG 1 119_ A / 6 44a: ?10 •N" 'tW? vn W NT A T! AC tAS A NOM+A+A T??+ ..,®[- Iv . / Of [ No Ile ' STRAFFICWAY ' ^ . ••. . POLICE TRAFFIC COLLISION REPORT ... Poucfco+nvwNr Df+ ' PRIVATE WAY a _.PA!E ES4SU I N Oar ? 1! 1. M _ IIMf COVNTV CWNIY NO. t CIfY NO. iMYp ?Da+ Fi?igson o URA R (OwN ? ?N ?E ?IN _Dry. ?W Gi NSF /'J RE5 Ws - 0 F6N0 Oi SiRtE1OR NIGNWAY N /7/SLU i'iJY ?4 Q iR05 I gOUIEON STRfE 3 Go/Sa SC . CIIN. WI n: 51EFr OR- . Ti N.A f.NJN INIERJfC110N m ('11-/-CAP .lV Bf M'EEN lrREFI6 llRffr PREfI% F MIIf POii ! O??•AB - IZ 1 DS ANC 111a CII REEERENC . CRO! SNEF OR NEAREST MILE P T MRfS S E fEEI IF ACCIOENi MILEAGE CODE I DIA RAM WIA CONISIONINVOLVFD: SEVERIIV: NO KIl1fD_NO.INNRED Z ?SOIIIAGf ?NITERU TOTAL NO N Z.6101, INRR c9 IN (E 0e a0AD0R WfRENR cR fgISIREETORRROAD JJ _ - F . OFV 1-1 Eg ? PRGPERTYDAMAGEONtY ?HSULT[D ?vF?!ttE Ga2S.30 I .Y l1 OBIECIltRLCFINPMF 0i O01ECt !TRUCK eNDOWNfe'l NAMEI [lr.OAMAGF SRCW CODING USE S UNIT NO. 1 UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCUST I• ! DRIVER-S NMAf: U.ST 11451 MIDDLE DRIVFe'S NAMf: 1 PIe --TAi6ET[- - Z E Sp IN[` l C TC1'P LCO [V /p 1 retET A SIREfIADDRES! ! Z d N 0G- 0ly, D 670 ?L. CC7prpl?V wI IY MAIL IIPCOIX PNONFNO. ?' Tuw?sc-Iv0 -A- `3' 51368 S3o63 R STATE G/',-Roy 9uro2v I ?'/ O+nFR'S IICENSfN 1 1-1 cu n? P //)P w? f% BI n >c i 4L I IC NSE NO. Af DoG[1s cb 6 rL?,9 % AIF Of BIRin i 16 I K1 O C C UPATION -• NAME EPEgNENO, fyE! IGNI fEIGnI 1 E OCCUPATION t[PMNF NO. ! GNT IEIGHf . I ? . f{tS-M /tk2 F/F R /P rTrR /?c0 ?/ ? CHECK(,') ,W, [MOiorFf of Alr'orn c' v[N af A ?CHECK (?) AN FMPIOVFf OP ANpINEAA r CODES ?' ] r ^ s [ e sMO„ CODES ®? ] a ' Z 5 eA b ?„° ` sJ ' (II M Nnwlts - a V ° s F °:oI DM ? MN [ O u1`I ? &,. ? ; Ku 3L x ?or.D ? u lcL ? ES:n. ? K K t ? :A„ P w? VEn. YFAY? R/-'6 IDODGI C-4 tI(DNT-) TYIf It De.,CONV.I 7 f/O r^ P DtE E lIA Ie I fR MTf NO lf Si E n v .. I of moDEl [S..Z vAf -71--l-0/ p - 3 IE - Z L ? ?/r I . A C ?LCO O? 7w/ 6. .^ 11-1-R-1- ISTAN Daf ` 7 6 1141 L7(1,3 V[nKl[IIXMIfIUIgN NO, 114 11 1 ?I Is-l4 I E v[nlClf IXNTInCq NN ! !(,131711 1 L 11 7 6 Z s +fOISReEDOwN[R: Uft 1I95T MIDDY PWNS NO. W 1514fDOwryER: ASI MIOIXf S A-" ST t O Il ADDRESSCF-1. A R OwN[e JI N E N. MtAADDQ-0FlNS-ICO CRAGENT v u .CM C? R F}'f1H Fu l.;_C y t! L7 4)-27-7 1 owweeo Anu `I 41 4LJ W6 _ D.MAeeDIAAu °l;.?cro?A` tN•eu [Hoot[ pi,• 5' ,MWW4 • • , w ! ESr' J IWAI ?aeMUHeD OARIVtN ?RUAAM[D 6 OuxAGk I ,B iallo "Dw+Der, TOWED RY. G C???•? •wA r Ie -DIAGRAM OF COLLISION: lu u ?N SCAIEIN RIPi Pl[ FNTAIS «r [c[ssA+r ? (- - Iu? S?•R •+ DESC ION OF COLLISION IuSESW r 1 i- -}-I--I-C -` ?_.f W_C"•S7' O.v pZ"/'?CO.,a . ??_.._ -._? 1 f 0 zv.. sro? ? ? o s11 A-L . _ }_ _- - _ - ... ... ..._ __.._. __ ...__...-... __.__... ..__ ... r NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED ' CODES I - Z 3 4 5 6 OCCUPANTS/ WITNESSES ,w uoirof[i:iwA:Ai ii -su :ce' uiu: "'' a [sid a 'R n•MI C •DD+nS 3 r1Y•n!' N- N .a IrDr ? •M + ? w ? , ' . .. ? 7, ? RYI,v M n•MI C.t•t NY N- . /n c v.r E?.? ? Pi ._ . ..- .. _ w ' J 64-- '74Y L'T wl s- •DCwItS V RR [.+DE:] WEfii 7A•Pa(feWJ 1 N•Tbat O. ?,e. R`MOVto rPDM .ncl .DI. ..,v. ,wl N[Nf +r ?AMe ?... ? o.n. ? n. ?r..,,a. 'D AMI p 7 - Jr?,T e'S T 1 C X1771 Al rr w ' 9 wFr? fa ` r •G •>• I 4 F rr.[•S$r+-?.?? •I:ooiscr 'n?ilw u M O• R U% ::'?w::u ?:i: ?::... wulq•mA;- .•n a.N• T OSP.e?m la g??to D,fI fi7RIroRT wov[D er '? o•Qn LIF yy +.R e Z ? k? ' i T?./. y4i `+ syy ,ty nRw SE 7 }Zf ,Y 540+'?`r1fi,71'JpRf i ik15A rww 1.,,.- r 11' ?t '(?1WY I '1''1 V r} '? . ??y1 } vl i! ?Itti{IL f ? { I- 1 4t ? - I•.. 1 Y n rll vA}? f Nf 1 l . a t ? ?jC vhf a 1 7. I I ? ff vR - i 1 5 y i I, . ) ! T''4; 0 1 I Y 1 } I 1 P 1 1 I I 4 ' l .I ";1 ® TRAFFICWAY ? v iIXICfCOMRAINiN DER - u a! . ? POLICE TRAFFIC COLLISION REPORT '•. . ..". 1RI E] PRIVATE WAY fM YA C tlMf COUNrv y nv " ' - iF1W0 HOURI ?fl r? ?G wry. (NO x,I,?:IR `w.,i : IE.I 320 T?FF£sZS'oirJ NIG"WAY COON YNO. CITY M. RSAN pU ?lri, u fCT Ci I ROUIE U ?.. ?2 cltrox towrv EErv0.0 Et 09 ON ?f OIN MIEFS pw OF ,G. IDwNSE.Y/O ON 4"' Al i 20. s ;Z l3?i0/ZO l% E MIlI WSI a N:S E RxOAO NONINIfRSfC, ON 110 W1, - /O peff _ ?f BEIWEFN S/e 20 S,RfFr 6 92 WE C .CROSSSteEf, RNfARF51MIlE PO w f A AM A R DIA R 1 L ` l[5 IN 5 OF )elk 0?e / L [Er 7 N 'RO 5 fOp OR AEFfpENCE IN I Zs SfvEe ,v: COEUSION NvOIVFD'. NO.%IIFD?NO. NlUREO? ? sY llAGf ?" OIPI NO. 11I p'M VID 0v CiV[HClES UJ eRORR,Y DAMnGEONIY rA FO1C eUN lE De AG INIF Cl5 CLMSS9REETOR?RAOAD SRCW CADING 1Af ?- 09,fCt SIxUCR INAMEOf ,FCt S,RUCA ANDOWN[RSNNAEI TG NL -? Pf1 tR 4cT FSt M ®O ., UNITNO.1 MIDOIE UNITN0.2 ORNFp'SNNAF: ?VEHICLE 0PEDESTRIAN 0PEDALCYCLIST USS, NR f UR1IRSNAME IASi NR51 - L 60 nhw /JA'K/G , s,REEtnooRlss REE,ADOefss l D -7 / B ^ Z - £ts E h 3 NO PHONE D Y StAIE " Ip . SiA,F Ip COCE g - J X 36 g 23 R t - d _7 dCJNS E % iH I ENSf NO. v U Al OAT pAVeIR Hv Mp ?. DRNfv SUCWSFN L , 7?1 ^ . ! ? v O Kllft S Irv NAtIpr - NRM NAMfEaIONFNO. EYES GH, IfIGNt E OCCUEAt ON MNANEL PHONE NO. Ett5 WEIGHt HEILHt - Z OCC R ET/?£D -'? SI ! 'Al R AE D111 - p'CHECK (I IH ntAS AN MaorIEO nrvo,HFe 0 CHECK IV) [H OE.s:N anNOmle ' CODES * a »inM"? s e% a s"O. ny?t z CODES ^ss , •irz ' ° NfUe F' P"« ? .M. u l v.N Or ul° 0 2b:N. 0 w..cl, 0'191- tllonpI.-A) s,YlE I10R.CONV.1 0 M H , 0 mc, 0 m ? vt I NVI NOOEI EDApr VAI ? 7. y %Nlp vl DN _ a C" NA. EID000f IV,I =0 D 3 icgcu° X4 E - ! 198 EpaA,P S, H H.E«oR 1.: Bl L5H036 pvA4 - - a k6 v[HICIEIPEN,IFICAIIONNO. G L vlHl IF IDEN II n r I fl r I F I S I ;L1 B 5191 91 1 I I I I MIDAE I [°awNfv: vsr nRS, N . RECnrtpmow"fR: EAST nRSr MDD¢ O -- e pmt / fl v i .q s w ? a . ADDeess OF -IR N 1 E i35pESS?rN CZfRfCIcLRTZG m i AMf EnD0el55dlNweANCl CO. DR ACIrvr R -• ? GLn/K/V ocuN. ! DunnetD ASU um"o O ?• . _ oE:FD%" ° DAM.eeo ARU a ' f uKrgNU ff rOAMAL! CHAP t ? ^e,VIV+N ?pIMNNIO CHARGE O-IN WAY QRFMMNtD ?A .L t5110NM [ .TO. ,0?0If0? f I -.- .... o+ Ibior, 5 tso Rr, .1 . TOWED ?;,w:° Er. f _DIAGRAMOF( O EEa ! Es e-c ;tppp iw ?j_. p?" ?73 VISE SUpatMtNUI SH[[r lr rxcESSARrE DESCRIPiIONOF COLL151UN: _V£/f[CLL !kJ_c[otfEA.duLC-G£NT_Et_L!^!£ 4s R 1? E N Y E _ _?fyx?i- ? P? ////,Q.1] / ? /i' /?/ . E_ . ? ._ f:VSTBocc.,?0 oN_ff-eot L?Er}vL9 BACK Lf!!20_?.4ST_Bv?t.J?2?_4NS ?' - Y 'Ro FT -? i - 3 0 4^_ , O ovg_.l.TU p[ZY?/. 7XAclfG£O f}e/ N et sm/?11W1- V0 6E; D 7 "- w? J fi- g - yrriL oo_F ' /ti.. FfNei a o „ D 1 trs• L ti 1 1 1 I 1 C glsa l,g 'tee ,_. o Fr . ?o c_ /_ -. _.. 1' I C 1 1 I ... NAME, ADORE55 81NJURIESOF PERSONS INVOLVED `CODES 1 - 2 J < S_ 6 ';- iia ' i t n u I OCCUPANTS/W ITNESSES j0ii c ur s. , , ?rT--siG/ tq u Aur ?f/!R/GE $/ecNErQ RD Pl li' 1 e3 ?.Me O"Ar'0" .0^ 0:2'Nu e. . A 5 ? rl r: uv[a ;??avm rvOM p.MS 0N%KI p? . O ti ? :" m .prof s "rN're, p...R ?;'O `.0? ? ••?? • .e us .rK ,E Op Dnn '1 m onn orv A X _-t7/tRJSatl1OdPul_y D? TCSO N-Z !i>z9 1339 -/3 86 a r 3+ nr.e? C D s 2' '-C TIF 4 ?N POLICE TRAFFIC COLLISION REPORT VqTRAFFICWAY r gICECC-NTN ETA I PRIVATE WAY - "'77f DnrE Orcau gy?apry/ {., r v U O CilO w. »o li:,. N.I ' IUSE1b0 nouRl T??? OCO. ` U f u' N C /? arc NO. - pruaei9a u f [3N 01 C ]IN NAMEa NO.OFSiRFfrOR HIGHWAY { kl& 3 AHES o5 w pD o2 TowN Et1pE G?cRGt; C- aourF 519 I[95FCrWG1M1H SIREft OR WAD NON INtfR151EC110N1y/???? ?nn?' DE/JF1IS IN BIrWFFN H?FJ..C.?JC.v? iR[f16 + ER ' PRIFI% F MIIFW51_:r • / / DISrANCfe D9F 1 r M EEERlNCE CROMST'Ll R ENfsl MllE $ F W 300 m[[1AES 0 P2 El (3 OF RLLWLE.1?11--l , ACCIDENT FAUAGE' CODE FAMD OIAG9AM DATA D COIISbNINVOLVEO: V[R rvl - pH116RI1N tOtnl NO NO KIIFD?NO.iN1URED psPlltnGF OFYFH ClES [D pPWPE-OAMAGE ONLY p`9t1PSUIl.D pvF°1Clf MIe m w3wD %Rp IMER CLS C C11NG5 RfEl OA WAD.RETIRfNCE ROSSStnffFOa ROAD ??" •" ^Y ? A? Oe1ECT5rRUCKINAM[OFCJECT51RUCRANDOWNER-5NMIEI ESLDAMAGf SRfCIAl CODING Ib! UNIT NO. i 1.11I C l VEHICLE p PEDESTRIAN p PEDALCYCLIST 5 DRrvl9'S rymn I 1A5? D L "M ! T URIVERS-E: ust FIR < 51-TADORES. ? 4 r Nuc.Xl..ti=.gv P[ SREEINDRI. - 2 fSIAIE I CADS HONF NO. 1 c)1n`T ToWNS£ND VGA 9%3(.9 3$S-253 D R t PCB nCrIFN rp- STAr! 1 DRNER'SUCENSF sr%tE I Iv A[ ENSf HD. SITE D r e 9 H 5'MIT?JI?MBC>JO? A 111 0?!oAlDi? HD.i IY. BAY CUPATION Et Rlgrvf NO. EYES 1rENiNi OC E NO. FYFS GHI if GHi IXCUPAIION NAMF6 PHONE - ILAA ? 2 {L? T. R£T Be Is R T pCHECK (?) wafASANmROfEOAHOrHfv ?CHECK(?) CIf ASANMVOr EEaAgtHEN. vfH 3 v ODES D a E nn 5 e eenoH I e 'sA, I , .r D En H 6 sAf'r .eD <no CODES ?° a n ? C ss ('. U LA vlE l D e9 '°" A..«A.N[E ? C] p kTK p ur,i. vo IRD,.I '3 va9 AYIN?f p u ;'a ? Mn. ? ncte p N-v. VFH YFA9 fIDODt'FCH[V.1 go claw. IDA9rAI $lYIf IRDR-<ONV.I >`?II°. a-pR V E ? 1 HEV.1 AgIXIIDNrNOVA) 1 E 1 11112 DR. cONv - -A BOR 1- lCe, ' }{ R-7 AIf MIER Mtf NO. S1Art $IWA 9 - `- H c vFH._R L' N_ FHKIf IOtNi IGIKJN.AJ. CR rY; I A 8 z 5 (DI 6o &-.- -,- L vFHICIE IOFNIIFI I NN . , I - P[GSrtRlDOwNER: Wl FI951 AN-1 sm 1 T14 WENA£ L L PNONE NO. -253(D W I-EDOWNER: UST FIRST MIpOIE NE NO. - .... DDRE55OF-19 A N A E DF OwNE9 3 2 $q E _ HAMEa Aeoneu CS wwRANCf ea. GR AGEHI vNK. R I NZFZb?'x'CFFT' ' - ftAASAGE N[A PON f- I`m?c?nowH CHAOG! Is)oQj NEA .. ?.. DAMAGt CHARGE O awi = IS'. DAA4G! p AW^Y (FANNED I p?TY?Y pa[MAINlO FSI. DAMAGE rG eDI10Y 5 ?. SjOpp 0 IoYiEW Y °er AT $CErVG p roweD S Awer en . DIAGRAM OFCOLLISION: lu u I m N INOr No91H stile nN[ussA rl a ow ?? I x DESCRIPTION OF COLLISION- IUSESNP ANNIAl5MF11I -1-Y) vE,HIC.L.L WAS VZI ST80UND oN QApE 04EPRr-L E - ??• Rb. VEu1C6- ATTF-MFTE.A_ To MAKE A LEFT- NAAID CURVE. AID ?e 1=7 TNr- t 13 S R 2v NF INTo TNT- CIADWAy loo f?? i X G6eRGE RD i NAME, ADDRESS & INJURIES OF PERSONS INVOLVED DE 2 3 4 5 6 OCCUPANTS/WITNESSES n iH- aii m % Ertum A 4 e AM e ?'81K' ?'"' F p + ? HA»E NA14aEO0 DI- 0, p irD,%. C]-;;,. p _BY .,AME No ' .DDEfse Anmra ° ;5 N xiw°nr. ?Ame ?? `M..,E. p rix C-1 ,MM ? 0. Kl ??!! LRD ^%O PIVID DAZE REWR} rta ,{r Y sA1NG .{ e; DGI G. AGiNC. : e,N.-tl :ui?IJHRS/ KLODHIROS (o- 0-?6?A A fh ar' X l/?AyF?VE•lY.wl w.. hG'1 SCSo a r I 're h - R/1 r?y?v?I ? i r, ' "? •r k ti f` 1 I POLICE TRAFFIC COLON REPORT 12SI TRAFFICWAY Ralc V,IM NUMBER ? PRIVATE WAY 1 . -D!_ ISO}p - ,ME cOUNIY COUNTY NO. CIrcNO, mvw J y ? •. ° I ? ,uw w IM, wrtl ? (US[]KDD NOVR) Z2.oo SEPFEasov ' i Q UVnAN - Ru4Al F ? ?f ?JN CIIYORIOWN faNOOSIRFf10R HIGNWAV ?2 ANtFS ?s 0. mc, F• i ON L' iCl ClS AW1E 0951 1p93?/ INI(gHCI NG W11H: SIREf ION _. rqN N1tR5FCf ON B[tWFfN S• 8?Lk bLSIRFIIa S,rLZ,O MEW R[FfIA f MllF A051 ?? • b CF aDIRFCII RoMRiRN ,(gO5551RFFlOq NfARFS1MllF ROS t MRFS 5 F IN R?},J F[f1 OF AfTT?a44 ?• ' ACCIDENT MILEAGE CODE -1. ER AG4AM MIA COL[ISIONINVOTV[ NO. KpEIED?NO.INIURFD_ ?SRRIAGf ?NII6 RUN 10TH 1a0 wNRnR"' INTER ip INRR C15 I FT RRCVLO4 ,SItR[ML... aoss51RfR0R ROAD EZJ OI V.1cl[5 ®RRO%RivDAMAGEONLY ? Y[SUEIED ? VEHICLE I OBJICISIRUCK NPMFOF OnI[CI STRUCK ANDOWNER'S NAMEI PT.•TbanS£ [ ES1. pAMAGf FEAC.E (ZSTT A SM? WifE 1, odu. ZO fol I Alt Is 130°= SFtcuI CODNG LAF ' UNIT NO. 1 UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST DRIV(R'ENAME: -1 IR J MI DLf 111VIR'SNAMF: UslI L C , 1- LB£ ip S,oTf ncNr Z SIENIII p.1. zoo cAJs I P.o.Boc z D SIRF[i ADDRESS UIY S1ATF ZIRC ODF RnONf NO. Cti.Hrtc Fsa wA 983Z5 13JBy-34ky R 111 SAIf I R E "•' NFR3 UC[NSF NO. yIODN s1Ait w? M Eis?Ls+ ?s9 I V ,V V NS[NO. AIE [IIIJ AIE0IBIRIn occw•noN NRM NAME a NrONf No [ns IGNT IRIGNI E cuRAllorv wqm NA•ne a RwNF No. Fns N11GNI r<1GM z u[,E t• g[a 14 sus R ? CHECK (0 vlN nlA N EMn` No A oyll ? CHECK (?) VlNCLFAS•NFMNOY11 ?aC -Z' EC'. CODES ?' G c s 1 0•. ( e i.%m •? °. IA • sn ' :ii s;,', gDx.c1 CODES ? ;'13 a • sK. 5 1A K»I a z wlnrci D ? Aw? WE ?&- ? KM° ?or D C] AMRM•NO ? 'fa ' ? WklK ? H215 ? r,ON EAR Fj,-C"IV.I nos Pi 13 Al (DARI?EJOVSrvIF (JDR.?CONV.I 2'br E N w 1-1 wODF .Y I nfV.) LIDARI-NOVAI I TYIJL (V.) B E SIAIf 4A llq Ml[NO. S1AlE H nn. Q R L S?loSV ?YD 383 Wn V[nltl[IDENDNG1pN NO. vEnl IDtN 11 I Z 15, ,q L 29 z? 8 I i 1 %GISRR[DOYJMR: L51 IIRST TV— 5 as ?r'?t hgNl NO. I O 1 4 WN[R: LAST F1 1 M1 E - -III-IR N A ER al r NAMl E•q pESA+wRANCIC°. aR AGENI R u -NT NU t DAmAUOARfA :n ?. I?AMAUO AVUA ?`%° cNARIx CNARGE ' m r •1oY •lor DAM? tzDw^N ?ftMNN[D ?AWAY ?.-ND [SI.DAMAOI 1 tUiOrtOii f t51. KI 14 ?Oii0ii 5 IMEL -, ? 10- s AY nr Y A ?. DIAGRAM OF COL11510M ID wnly a rn DESCRIPTION OF COLLISION: IWILP'lUMINIAL-11FMCE55AR1) Uf k f Il L _L-?eC- A+A a cm-4 tot i C _ _ g _ _0 - _ _- .3 ---- ----- - 11 Avg. R ti NAME, ADDRESS 8 IN.IURIES OF PERSONS I NVOLVED ' CODES i - 4 3 4 5 6 OCCUPANTS/ WITNESSES I1 XD 1 orMlN ° $ II ' sx Zoi uiliy NVIa 'R. I- -Rrr R esn u([i Q1CV NAMr .fVM15f N•l?R Dr .... __.. .a1 13 AM n0WE0 ?M ?°31,.. A NAw1 _...._.. _. _.-...-'--'-..._-,....._. ._ . rv ° . . . ___...____.-.--___- _ ADfvns j •IteOf f ? ? H` l Aw ? ? ?° w NA l _--_..._-...-___._._....._..__.. __.. _..__.. . No , .- T ... _ . _.__.___. _.-. •m.1x IN ..-? -- N?lQ1 VIN11 + ?•we ?7"'OY'"n..?:+ ?o N +r KIR>r••w1 E X MIOR 1?.n •GImNCC• WO RB=I YAKl03ryra•1^ ?OS!.YS iY EUI K1 r?r: ?107IT5 a .1Id RI MEI ? negOVIDnY DAL! d^?'>ww a ; 1 ? ...? ry, vv?-mow TaR'K•rc,Y ? ,' xr f w 3 ?. Fr? ?> r ? 1f.W 1{ K? Y i ttl .. 4kT 1:'j_i I?. i; f? }i 1 E /I ?I .r 1 L L. ^4 1 r -.?I r O?¢ x 1 v _wq? Vu a=sE, l ?y I R,T . L AM PAGF / GF R f lio 1 O STATE OF WASHINGTON y No I POLICE TRAFFIC COMMON REPORT J& TRAFFICWAY WEK 'ANT NUMIRR PRIVATE WAY . DAIEOECIX ISSN„ _.. P owls oN wED 6 wx.R F I nMF (VSF ].W HOUR) ,1 / co I ?? \ /- IiL?SO.tJ couvTr NO. ?, arr NO. rNWA puR I CITI O O WN j? N.O SiREEI OR HI ON QF pIN MJLES ? s IN 1 ON -7 E 5 wnr CC5 4WIEOR TR ? 2G Z DA I . SCl n INTERSECIINGMIIH:SIP11 ROAD NON INTER-ON eE1WFf? RFfl ? FEi Pnfix . MITE POSt 1Q • °1_6 - DISIANCF601R fERFNCE. CROS>STRFEr OR NARF M11-T MIlfS N S [ W FEFI OE h)l /?> ACCIDENT MILEAGE CODE RAMP DIA RAM DA}A CIX1I510NINVIXV[O: Ev11 C E ? l.Al NO. NO RIILEND.IN - ? rux0.[D1H AD IMER CIS NfRSFCfI SlRffi RROAD041efERfFKE 'OIOS55 QIORRWp T] Y REN F12L CE VEHICli3 p PPO NDAMAGE ONLY LY ? Pf511 p-'CIE SZ DO OeJ[CISIRIJCAINAMIOf OBJ[R SrgUCA PND OWNE4'S-11 fS1.DNAAGE S SnCDVCOOINDUSE UNIT NO.1 UNIT NO.2 0 VEHICLE ? PEDESTRIAN I7 PEDALCYCLIST > DRrvER'S NNA[: IAST IR I ?z IZZL0 WFRSN C -1 MIDIXE - STREET ADORf55 \ /lI}-GCN11 -1-DR- IP CODf -TL Ca)1? P X51 D R IlY STAif IP PNONEN . - L= gtrvfRS UCtNSFN •` /?sulE DAIECfIYRIHF-_ I IVE' 1.11 fN0, fAiF o r aeRIH 17 OCCUPATION .t ON EYES FIRM NIGHT E OCCUPAI.- FIRMN-111HONENO. EYES IGHT r " / R O CHECK(,') DAPiorfl of.EMiorHtv'A' ?CHECK(,') '-CUASANEMHO-CFANDDEEY.AI CODES ?* 1 5 1 a v"'O„1OVC .a rsn 'O' CODES D a A ?; 5 u a Ass inM N Rn - S W F' ?; NH o ?MAHa F ? M.. El Nr1- ? rwH 1. 1 0 ? 0 W' 0 C%'- ? K ? :°N Ku ' VfN T[A4 ^ IDDDIAF.HEV.) L?R?SU? R1FgvAl SiYIEI]DR sDNVI 1?A d? E r R (1111"11,) MDDEIID"-'AI l ; N]V f-. l? f 31 tE IRAHFR ftA1f N0. SIAIt '1111 I"I I C H.CIXOR l N A H CIf IDEMIiICAfgNrq. VtnIREIDENIIfI N REGISR?v[DO?wi\\JFR: r ?''r,Si yFMIDDIF PrgM NGp / W D WNER: UST -FIRST AR.- I] AADRLSSb ?N A WNFq 11 NAMF anDpnss orwwRANnc .a4 AGEN R + + ]] ' DAMAGI AREA ' iAwCigWr°iN CHMTA , gAMAGIO MFA CHARGE wn'iwN ! lSrapAAUG1 ? ?Mti IG4fAWNED Y?? .ID. ?HR H ?REMNNFD tS?UAMAGf 1 - 1 AWAy TOWfD f 6 ? . S -Al en s le RAM OF COLLISION' 1 .SretiV NtCES1JJIr1. a RRwm I 0 PTIONO C ION I [swftf]uFnu SH[[ nN[ctssul (? FL QLLTI/S?yI c_I? ?•••}?7?,? , F W?j? /?lPlzds E l 29 et I '? Cp?S TLarad, ccY? ? ,tJ?o. ??r ... IR NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED i CODES I Z - 3 6 4 5 IustSUr.sewrnuSr OCCUPANTS/ WITNESSES ADUITgNI.E NAMl ra Rfl sI " ux AGE -- TAT , v: ; - CI M nSiP. IJI NA V Np Aqu151 R OR AY IN AM a ??11 ? ?? . pS'?i iY p{'urN NAMI ]0 AJ]an15 AIUR of .7:IDrRDM 0AMe 0 R, ?"` . 0 N 0 n n AW HO A-,,1 "I" aO1 pAMR p^:ql p«:?1. C]'A'? ?? X avl5lquAp a. R .nw o. D AoFNC. a nr ? ? r,5ay?y?FD /` X Y ra19r?? D D N wn a.Tlal ?DAn i?? ?i ..Jl l C RV A ! A J GD ' '1 $?9(;<?1 i1r F! 4?, ?: R C' """M1"AELRtM Y 7Add ?'IS ?i1 SA,FFhn!JM AIF""f4' I?7 .. -. C -. `l. \ ' .'hIY??Ji ? F j l? 4 P l I 1 r t G r? '? {4 ?7 1 I ? ?S r t r{ 1 ! 1 ' Ilr 1 ?,1i 1 F rtiFl?. MIT. ? "H"I ?" " • ? w ?r'n )) T IT d- f. ? T - r 1 I?.y41 ' F . ;. z t b`'y,rf f ? k I fi "' y. Irk A? s ?'y?b??Rt? r y r.. IYU• POLICE TRAFFIC COLLISION REPORT MTRAFFICWAY U RI a POIICFCOMFwNINUAS0E4 / WAY ? DAIf Oi COlUSaN Y OF UMF COuNTY COUNTY NO. c-IRD. {MWA oA+ wx R4 041 Rlxuvl III III IUSE tIWHOUR) ? [v ?URBAN 4? ` ? N ? F N GIY 0910wN MILES ?5 ?W ?OP 51RFEI04 HIGH AY ON aeG?p FCI OS O ROUtE OR IPtE 3 ?4??0 xc110N NIF45EC1 rfG NtIH. WRfE1O1 ROAD r r (.?-.eI4[? BfM'FfF PREN% E MITE POST ? /? f ST ANCEDeE r NE RD 4ffEetN E . ........ FftOR tARfStM IF f O MIES 5 F W FEFI Of ACCIDENT MILEAGE CODE D RAM MIA ' OIIrSIO VIXVEDr SEVE r' l Hr18 RUN ORIIfD NO. NFUPFD ? F. ? O wNOP[DIH MER Cl5 NI4 LING 51REE1 RWAD OR REFERENCE S ??5 F IOIAI N . SIIXFN «VFHClES ® ?PVORPIY DAMAGE ONIY ?4FSUFl[0 ?VfHCFF o ?33 OBIFCt SIRUC%INAMEOi OBIFCI STRUCY PND OWNER'S NAME) ESt. DAMAGE EFECIMCODINGUSE UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST -- 5 OxrvFR'S NAME: -1 IR mlDq F RrvtR'S NAME: USI FIR MI Dlf 1 4FEI ADDRt55 / D SFFI ADDRESS PCODES NE NO 1 R Y STATE EIP CO E PNONENO. CIT ?- DltrvFxSlcEN'i NO. /5? E% oeA D er IH I V E W LICENSE NO. PAtIO a PHONE NO OCC sAIE 11 IATEOP e EYES WEIGHT rEIGHI 9 OCCVPA ION NFNO. EYES S WII If GNI R U N IIRM . ? CHECK (,I R_- AS aN U°Anorff oi:FM,o ?[RAl [I CHECK(F) FH Clf AS AN FMNOVfF OP ArvOMFRAI ? CODES 11 x n"". a i 5 enu a ;,°„°;J'? CODES ?' D a_I a °s+ vM"' s uaoN 6 R1Orv `eD v INIVPRS l IfTr° C3 A.,elR0 ? b ? Eb:rl. I ? C ,. rcE ? AM N:I ? u [3 ES:n. ? I",= u ? a.NS. M EcH V.1 / r I rv DARLJVq lF 11 De.. Nv.l G E HEVd MOMI IDARCNOVA) .r R r p R. v.l lNSE PIAI U 51AIf IIERHAIEN TAIf N VEH.CIXOR STATE Il A N A ` SEH IFIXN11rrCAlr L J L VFHICIEr NN w N efGr IFEEDOWNFR. rI45r Mr00lF OrgNF NO. ? O W ISIERFOOWNfR. lASf FIRST MIDgt NF 1 ADDRl150FDwNF N wNf4 AMeaeoovessom;uvArx eo oR Ar XJta nAMA,r uu r' ' R .. ?, DAMiGEO u "C iON n '"K "' cNA4w ( cHA4GE ' 1 4 A)Cqtl s t51. roA.weE °E"'AT ?RFMAmm ?iww ?REMAINm Fsc DAMAm I 5 f ? IOW[D ? TOWED er. s DIAGRAM OF COLLISION: SMfrli NiCI55ARVlI "ev:eRO 1N DESCRIPTION FCOLLISO lux n[MENIU SH[ET IF ECISSARr) _ lk) Pr 7' S5LOS Sp' { h, G?i4s Sk?cfJt W I A ? 1z c ??S =bE C ?iYA OL o;= C ? 1 , ? pp s D Pt OtL : c bT!rl k l?/cG CRASh, 7%A9? „ JU60 A v_I??7? 5?7e?d Gl» ? Gl?s7C?4uf1I All `iIs ?Z i = I y aoMp r ? Q NAME, ADDRESS 8 INJURIES OF PERSONS OCCUPANTS/ WITNESSES ?oEP;DOr o?.r+:" i;,w INVOLVE * CODES i x% AGE Im - Z '"„Y1" ° 3 4 5 nsr4 enel 6 ,M. AMT. Ir0 ADDNSf V410Y P AM rrcf e ? E'% ? ? ? "V u MF 1U DOe15V IIAIU.1 v MMFOr 0- ?rq%I ? oI e ? NS ??: q rID r ADD41aa NA?erl ?F FI SC MYe Y ? RG4 fN< x¢[ c D w. sA eA ??" wAru ssD DAn« Io4r Ar ° r x p /-< z? I,??Fo ? K F" IIY i MMAt• . h I??? 040,8 4 1086 t ?,L`E'r' 1 :S MN 5 5R ' x. S 4 .r' POLICE TRAFFIC COLLISION REPORT gTRAFFI&AVG MICECw uNIN ER PRIVATE WAY :I OAr[Or Oll .? , S41 ION_r _ u-..o ?•un.- lu. ,.-, o. Tlmk IUS .OD nO RI COUNty E'`?/? O?s CO,- NO 1 O"NO, fHNA E AN u Q ?l or p N CRV ORTORR'N AMFSrvO PFEIO'" IGNWar 200 ?n Y w S l o' ON N R17 RW)F 045 . '> lo0/SD SE 5/ N,IRSICI NGVA1n51e[[, Oe vOAD NON rvtF S[C10N BF,WE[NG 1RF[1 4[fl I PRffl% [O. MILF POSR i D-/D EFL?/ DS nNCt.D.(M ONfRM N tCROS55, Rt[r OR NEAR151 MII8051 [5 RF SVFNE 5-0 c-nuF= W Or RO. ACCIDENT MILEAGE CODE v DIAGRAM DATA vtvllv Coll S10Y NVOIV[D NO ORIIfD-NO INJURED OSGIIIAGE 0-&RG IOTA NDwDIN INNR 0 IMF CLS AOS55 Fj?09NMR NER C""N" ""N" S : Of VEn CUS ® pPROMRTY -AGE ONLY p;?¢D ps,FIXN CI[ 111- IN-1 Of OBI[C, STRUCK ANDOWNIR'S NAAFI Sr.ONAAGF I - MrMA, LJMJ / sJQ00 SvfCW CODING I6E t - UNIT NO.1 UNIT NO.Y VEHICLE 0PEDESTRIAN 0PEDALCYCLIST mvERS NAMr rlRV ml DIF O DRlvfesNAmF: a nx l M _ / LO v Io ADDxfss P.o. 4 e ti RD. DR wlF55.,G„ e,r AE zIP COD[ us A. `18 6S R oNt NO. NoN E R sA,e n 2,P600 Pnorvt WAVLOC?y ' p4NFe'S1 CtN5trv OLFEDwtT .77 51MF A f% M 1 ,114 I RIVE 'SIKENSE NO. C ,A,E W DATEGIBIR11 SI e2 Y I rR «eu4AnoN MNwAFBPrroNE NO. erfs , E «euPA,loN rIRM NAmFB PnoNE NO. er[s MTIGNT fEIGN1 ?Z L " - ND+iPLAY R -- J 135 Q 49. p CHECK_ (?( A Mqv A o •N p CHECK (?) -ASnN-Olf-AIDIIERA' }` I oN J R w Dx.- 5 coDES ?• G n ^ A CODES 1. G R 'y 5 1 B I n 2 uRIES QHIS S 4 IRO .Y.NR.N[r ? 4ti"' ? ?F.,,. p p .NS. 0. o< ePf.o,. p,mN„•NCT p ga <r ? EB.R. p K K .11w l, 7 Ae MARE IDWG(<nfV.l 'D0Dr,Fr MOOFl10Ae,.NOVA, SlrIf IRDRCONVI Pi iO M4Ck E n.r Ae 1 nkVl MUO[I (DART rvOVAI 191.7 COt1G. r l D I LAP ,pV 7. I n aoR ucENSIRU,F Na. Al A,E NO. s,An H 4 , EN It wwa? 1 - - ' h LU k wA - - vtnCllIXNIIlICa1NJN?]N0 Q 1 1 S V I 1 ( i InICFF 1-111-1-1 7! FI IN RIGISRIIDOVmfR -1 IIRST MIDDLt -ENO O t ISR EOOVmFR. lASI rIVST mIDIXE fNO. 7s L •DDRt sof osoNER S N E .DDxe aowntR M p1 4ADDRESSawsURANacO Ov AGINI D I'l R BR wMwID ARU N O CNAVOT pJ iE ?, WME I?M,AGkDAREA• a4 u , cn zzz) S Fsr. WMAQ =AY p Ar UM RIMAINlD ?4MNNl0 151 OO.OD IWAY BY AYVAl f OD f r - R FCOlL1510N._ -??10l1Y? 1, N cA'F OW 1N DESCRIPTION OF CO}LISION: IInESwvl[fuN1•l 5ntfrlr NtclssA rl y+ _I ARR p __ _ ?OL?T}1BOW>Da/? pTSro_ ?y?/, O (/T/}IYS!_J t I i_ 7'._V?7?i \/.Q? r ??FojE_ e P, is>? T I ! 1 AD E)O .LE Y 42Y ?-A T ?? B7lrEMPrm7 . ._ . . . - ! _I VR?S 7?3E SLOW Mov.wr. VD.) -»O_2.yEk- „ - PR,vez PTE77 9 LF P7- 72vv?J?TD fJ 2 J j i?sf?_.L f -I_ . _ vE1v9Y Fl??D.7?36_V.EH.S.COu rmED ?73?tE ?B oRJD8omID. L.iY?E.. 711EIVRWEIQS. D1F5Pj6Rzs ONG+EJ??YIEYZ Vd3•oZ_. ctwNa?-s9y 1WJ))L.4ZD 77)E7?+Rl?. sCS Wm' _ -_ .-- _ .. ?E SLC?Bt? k?B3 U66P 02f?07 - _ OPEOP r f ! ii I I I I i t I i R . M I? NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED *CODES 1 Z 3 4 5 6 OCCUPANTS/ WITNESSES .c[ urus N.,^N -T', R isu 'iacf '•"' M LLOYD E - •M, p:' . ? + >o /h (36L-L, E ... F l N E _ I ? .Dt,.rm -.rr R MtnlO rxoM p.me ??: R' p o p H '° l rnlcooob e .D[WI.1 aC.. ° s° ? `" ? ' p•MB ? "C7 ?r . OD ? ?• NGO••u R, N•w x•. N. e X1 Tpp. M. •-I.- ,, .r.• .5 W_.? Ic ?S^' D ?tTAt,?? owaRkron wovfoer B{? A 39 D•n 3a a r Lr If?1 ? i ` , % 1 11 Ji ' ; + > 1 s ? f s T 1 k? { , I ?r " f a r r ? I t r} 1 F f - l? I t '. } Y ?r c W SP ISV IRfV. I.pl STATE OF WAS INGTON FADE 0 DI I?h POLICE TRAFFIC COLLISION REPORT rsTRAF ?CWCPo POO<F COMRAINI Bf PRIVATE WAY _,4^.IfO COE I, _.N_ T?0 r wlo.r {J ,,. t.Y, IIMF COUNlY w lusF ].po no Rr " COUNEY NO. CIIYNO. ° ? `,_????L?N l 1 b 1 °'w 16 ?u °A1 ? E C1IYOR TOWN AMt6N0 OISIRIt10RHIG"WAY ?N ? ? rN N IUUS RWTt OEt SIREE CII ?[s )? K 00 Co r ON 9 rNT[RStCT,NG Vntn. sT4f[t OR ROAD NON INNREE-N 3 loOiSO n a STREET a m) EN 4 W t9E[1 PREN" MI[FROSt /t DATANCFSpr4tC ION JROMR { RtNCf. C4053519EEt NFwRF511 51 rlF3 ACCIDENT 4 pIA PAM-,A `T S E W IFFT OF E MIEEAGE ODE C COLLISION INVOLVED IVwuY: NO OKIIEED-NO. INJURED ?SYIEIAGE ?HITR RUN wvRHOr" L NM "?4D CII Rf 09 RlM -K- IN IT SV IMFR OVFnICE[3 ® ?PRORRrv DAMAGE ONLY ?p[SUIT[ ?VFaCI[ .--. 1-1 ODJ[CT WANE OF OEIACT STRUCK AND OWNER'S NAMEI EST DMAAGE C905551RE?4, JAD / /? y (O, CODING TAE SPECIAL 3 UNIT NO. I D t4'SNAMt. -1 1451 M UNIT NO.2 ? VEHICEE ? PEDESTRIAN ? PEDALCYCUST IDDLE D E: ST --- FFt 9135 Y STATE ZIP CO D EET RESS UF ONt NO. R CITY E1AI1 ZIP E PNONE NO. -FPSUCFNEENO. STATE EA A Z81 n n mD i I I V It' DCEN NO, ATE All Of 9IRI"° MO' I I OCCUPATION F6OHONt NO Fns WEIGnI .t IG"T E -UPANON FIRM M,f R. PnONE NO. EYES WEIG"1 NE, t ? CHECK(V) "E R VE-1 "Nor-Ee COD t ? CHECK(. swN UnPiov"FtaA"oTnFR"I r ES P D u 5 1 a y.° ca CODES 1? ' 3 Z`, S EII y s. n rts VTDI- IN j [] AURA — ? n YEAR ? rsm. ? ? , e ? ra . Dpm ? --- ? Ott ? zs:n ? H n ? ",.° KLI MAKE IDODOE.C"tV.l NIDALT.NOVA) StYLt E]pv .CONV.I tonfv.l DELIDARt. V., l I Tri-3Tf'2'bNV E m 11 " IN LA N An n AIL19Rq[NO. StAIE H w. cotoR N A L N. A I c z vFwnnaNrmcwTKxJ.a I I I ( i RFGIS1te1DOWNER IAti FIR31 Mr PNONEN L vtnl Euanu I w I I I NI I C I ? ? IS' O O D IR: EAST FIRST MI N NO. W ADDRISS OF _NE A OWNEe pl N E AMFSADDRt530 MSURANCICO. ORAGENI IN ?- R n DAMAGE ARIA CNARGE' AMADF [A C"ARGE Iv.C -AL O y S .ST. UAM.GI CJ .-N ? RtMUMET ? MAY ?R[MAINfO IS11 D- _ IOM6 L $? RY ? OWEDEY f w ? ESCRIPTI DIT GRAM OE CO7111510N F TuaRICSSSAR r F ec Tvao°w°T" 1-7 D ON OF COLLISION lus[SU4n[ E t3n[ITIr MeesswrF - - r11 ?_r - - ----- o .. r T _ . . I t?, f r ? _ ^I . yI 1-I,1 _. ---- _ TV— NAME,ADDRES581NJUAIESOS PnRSONS I NVOLVED 'CODES 1 2 3 4 6 D ? OCCUPANTS /WITNESSES ?awom?J-1 5 .MI PBELL My AM 3= NOT T' !j/'7E Y° 11/Ap7D laE D mi „n D N N E AME n. I.. Y. ?Am e ?LAKL ?'"„' . ?- .. NO ME _ 1 N N • . AME a ??' .A1D91 S a _ R .... k&Y ,. ,.. wa STD I4Dw__?? v[ -?,o?¢T ?m' A ..?. ? :" NEI . :R. YI. .",. D _ N . o j I _ I t ?ra8 .A >, { Cv. nR6w Ir ? u y ,? 1 ) .r 1 ? l I II vr.rt R 5131 }I ??11 J( fE1 t yy ?. ? . , I` ?l J(1t..?1?15f?J $I( INM 1"at.,7. ??? W n,.tiK`v(t I ?r? ??,.?? 1 r S WSP 15R(REV I.eo) STATE OF WAS#fi TON O P GE M No. v POLICE TRAFFIC COLLISION REPORT TRAFFICWAY PollcE COMnAwr NERABFA PRIVATE WAY fs. u0x 'Al ILL' I N DATE OE COlUS N IIMH COUNTY COUNTY NO. CITY NO. ., wID muHS IN USfT 1 wOp OBI /G 0 URNWw 511ti=?5 RAl CIIYOR LO ?N Q( 0IN WN E%NO1S 11IOR"IG"WAY iRCIS 4 H '?j??,A 2 ROUIEOR 1 • (V MLFS :815 W ?OF QNc INTERSECT NG tH W : REE_g0A0 EeSFRIOHN PRf[I% EO. MIIL POSt L( Saen L ?d ' *C9 . r E N s p c ? PHTA Slq[ft Ow C4? I D ISIAN<faDIREMII [ROMRiFefNC CROSS STREET OR NEAVESfMIIF POS LES N 5 E ACCIDENT a DIAGRAM DATA W Elll OE MIEEAGE ILI CO c00 S I S N IL SIONINVOLVID Sfvf RIIY: /? ^^ O. zIIIEDQNO. INLVafeE? SVILIAGF ?""RVN IwIP R yr I" IN z?RD 1 RSFCII E OR ROAp OR RfifafNtE [0 N TOTAL NO. ? MVF"ICIFS P INIFR CIS CROSSSIRLETORI[OAD I ' T] ? PROMRIYDAMAGEOrvLY ? R FSUl1F ?STCRENF ??870 OBIECt STRUC W-1OFOB1FCT STRUCK ANDOWrvfq"SNAASf, EST DAMAGE SMCLLL CODING VSE _ S- DRIVER'S NAME: L'NITNO. I WT FIRST IDUIf UNIiN0.3 ? VEHICLE PEDESTRIAN ? PEDALCVCUST 9WFR'S NAME: IA51 2' 1 EIR 6 SILIll ORE / CITY IAF D STREET ApORE. ZIPCOM ONE NO ? &14 R PC Y STATE N / anfRSUC[nsEN $IAIE f% A pfORN I V Iv SLI INSENO. AIE DAIEMBIRt" AY Y. OCCUPATION MNAMEa P"ONENO. EVES wFIGHi HE "t E OCCUPATION NRM NAMEa PNONF NO a Y? lk a EYES WEIGHT HEIGHT ? CHECK (,I ENC-51IrmvioYNEI of ANOr"[n'.AL CODES' a ws n'.A s Neelw a n "' ° ' °r " ?CHECK (?) [N CIF ASAN UAnorEE OfANDr"EenL + CODE ""•N ° • ' ? ,Z 5 , , P I P 5 ? B ? 5 wren N 6 s Hlox.eu a i. sv, ," ss J}P NI. IS o AWNLANIr ?,CE ? eal:Ir. o IL o M "', IDODGE C"EV,) DEIIDARTNOVA Srv 1 V ,aor ? M N [ ED] o:a. o ct o ;a? Po 8.111. Kie S 19 I IF ITOR CONVI { L E 4 R AR 1 "tvl 1T ngDEL1 ' NOVA) R. v ( °O'A _TB Y u ceysf nA IN vAI RA DR 0.Al N0. SIAIE H vFH CaoR TIAI IIATI ro TEM L A LI AT 3 VEM <IE DfM NCAIIW NO. i - gl LF?32 R__DOW, [R- v"ICl[IDFNt U H1 G J USSt IRSt MIDDLE PHONE NO O W .S PS -ICIIIEPIDOVmI.. LAST iIRS, MID.E N No. ID OnRlss ea A Mrs 1 ? 'o? N 3 H E N to A.DR-IH5URANCECD. GRAGEHr k R DAMAGI AMA xDAI OD IHA CNA9 CHARGE lNAAGED AREA I I -. ii ] [Sr. rDAIMGf ? Z ZiLL'IN ? ? ru ? - s gIMAIN[D ? ^RI^tN RDAUNID fS?IDNAAG wr - ° ° : ? lD 5 ??I^ w:v ?: ? ? ^ ? ev ? .Mr Ill i DI RAMO ` ION; lu NAl NDIc Ar pNOar" DESCRIPTIONOFCOLLISION:l IusFSIwnEMENru 111INICISSARY ? SHLLLT If NlCESSARYI I • o D A Dy . T4. zea cb?s +? why EI?lU c sf- LAP WhE uudt X} (24ws CA ) 8 - Kd ?Z. ,p „ Eo fi7?.P? f?.? .P,OGG/?eJS tW?rL? IR ^ V iYG? o ,?$T O,lJ ?S V `? . ? NAME, ADDRESS & INJURIES OF PERSONS INVOLVED + CODES 1 - 2 4 OCCUPANTS/ WITNESSES asDPnlMIN AE SHE l f1R er ' 5 6 E ApDI 10Nµ NAMf tI r SEX AGI IAN S MSte. NtCI y 1A A H DDRns AAH u.roP SIN eY pAM .1 e ?p1Y" O "' . O? ? i 9N? m A - IS NrM v ??EDruOAS?AM ?r."OF6 .O? ?r: e , n HO.E REp L I p MS ! , . W, D. ?l,w! n r.el n+r ?, - .H.r.o:i1'iir'.._..w• j .?' f_l?..w..t?.'. , t.?'L3?--t?-.Y I-zrw Mcow I'." ?f?momm?mrme?ra nESmBwme?YnP.--?iattaG?ee1+...A..rI 4 1 w 1' 1 E F " 1 I I Sy L ?? 1?aA,? ? { lit ?I 1( I I: It r ! f f M1M?' : im. . l : 1...^ r A r r".I "? . ? ,;. { ,, ??? ? :, k? ? ? _ ? :: ?Y.: ,. ...,-.. %? Y4??????'?,?4, ?At? :.a', ? i ;1 ???.( '.? , ?}.'. 4iYl??('k '?? ??; t?a?.?yr x!?tii A' t4, ,. ?.? r.ih ,Yhh', 'LM MOTO R VEHICLE COLLISION REPORT NDUNTY (loco, VY1/ E MsBa .°N E, w DLL it E.`W" o w Je t o A q N g ?TT ,1t 0-0,0- CHDRIwx x xDDF4,RL[iDRxIDxWAy M ' E EDASx °[ L NO ' ? ?w?a T A) e-?N S. t coJEr -H- T[q Dx RD _ D/Sa R. b /D r?IO3oG Db ii, O As [Ax s o oo? R ONgK. ER.YxORE. RxANP,TA E * TAX. ' E] '10 1115- x0 66NVD?ED ® . ? ? sF 8 cD fl FNB , B q: ? ° x As ES °. 5W q Ix1FR Ix°i C 9.? L ° gEiEREHtEp csOSEEi HEET ON ROM ? G( u ECT 6TRUL?t ,_:._ N w I OWNEROF O&IECTS NAME AND ADDRESS a EPNAO.IL1T.:., L/ sv[c.... VSE n.: .... TNAH . IYERS US7_(lAME ...... „F!flST NAME -_._.-, ?MIDOLE_ W TwFAEo c wsINVOIVEO B@IVEA'S IAST NAMES ?;,???PSJJJAME;..__ MJDDLE ?' AMiGGP. L Lp asc CI LLI:ON OR n MORETHAN Two e- S /C (l: y ?? TDo flEET AOOfl 9 : v '?. ' ES . _„ ROUTE NO.,pNG.50%NO_ PERSONS-E STPEET ADDRESS IN ROUTE NO. AtIp BOYI NO.- . 11 JURED USER '-' i g7? ,S 17ESLG Vls_f /Q 4[PARArz 70 aO Q.BOEJ CODE DRIVERS OCCU,PATIONOOLMSION CITY STATE .. __ 21P CODE OflIVERS OCCUPATION - , . ...__-._.-..._. rT Tu vse M YMq S' 8 Tekm 7eF ORM b48oy wAA rJ? 7 4v(a / / IVEfl•S LI OIRTH ? . ...:.....: STATE SEA DATE OF IRTry„ AGE GcL b o }l7 , OflIYERb LICENSE NO. .....:.-, .:, STATE SE% DATE OF BIfl AGE `Z ... R S 1 IRA ° MO °w O '.•; R X L 9 ( Y oT' FK fNi -h •J/ L.J E•1 ,U" l /Q ryICLEYP MAKE (LHEV DOOOEI MOOEL NOV , I I A-N_). BOY TYL.,,IS. HJ_ VEHICL-YIi. MMLEICrEV?POOAE)fs!ORE?IN. ApAq_T), ,.,BOGY $TYLE(L,Dfl.I. 9& /-0 > Te oe n e - m o 7 Z) /?JeveALk. ICENSE PLATE.NGti .-.. STATE ,...._. TRAILER PLATE NO,,_ LICEN E LATE NO.O „?_$TgjE ,. .,, -,TRAILER PLATE NSTATE 6.7i-RDR WF? - n w Ht3 ? L,,q. .:. 'i HI4LE IDENTIFICATION NO .., .._.. _...: , ?,_ vE 1-!GENTLFILATION N G:._ FHBPlRS G o? ?g p LL E`A)ES fd D19jEiTEO O}YNER (LAST, FIRSi,MI00LE NAME) DRIVER'S LICENSEND. - B491ST_E?EOOSY•NEq,1Lp5T FLRST M!ODLF NAME) OgIVER'S LICENSE NO y „_. •._ L rNtc? NRGCL3in5 LPN f Lth wd oOD - ' NEft B.DDDRES$_.,,_ISTPEET..CITY AND STATEI...... DATE QF_BIRTH__CWIVEN'$AOGRES$___.?l$IPEET. C!T.YANP.$TAIE),_, .0ATE Oy eIPTH.,. T p ' D R. o F• %G wrtLr r ? r .,., " RTg OF VEHICLE DAM=GED LARL?IY?"?,o.. PMTSOf VENICLE.OAMA?nF?. _._....-?_,. _..:.__ .. _:.._..._F?fPpN ru`fLZ. Po- FKD ALT G IV s /SE ?? Pe 5 ABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THEREAUTOMOBILE LIABILITY INSURANCE [A COVERAGE IN EFFECT FOR THIS ACCIDENT ON YO ? .E.A - ? UR CAR YES NO ME AND ADOflE95.OF.UABIL(LY_INSUPANLE POL!CY.RQLOEq,__ TE 9Q36F.-.IN E?F.L)A91LITY INSURANCE COMPANY ..... :. AMI Dmr54 ....?]__- _ AM e L. t 7 S :J s?o uL 2.0 ToAT 'C ?JtuEVC r t+ ) G L?P . ` . , L +- u ME AND MG,fl. ,$OP'.EIABILITYINSURANCE AGENT. ,,,.-_? iy ,,.,, ,--;?,.?y STA,E?? LI LIABILI lj?'POLIC'LNUMBEq LC' SR t I . I • CoGrnaN 62/-5 f YIK N 1ptTTecc1y, ,V l-'Qi1-98368 O rZ3a i?6 8 INJURY AGE ZNOINJUflY I E V E WORT FOq AOORIOxAL WJUq ESI AOE TOTAL ....._ .. .:... __... _ D NAME R IN DRESS N E TORE AND M F ADORES 9 gE%. ,. J ENT Of INJURIES A MINATION UYO?IDOCTGRT DO NOCTOq'g NAME ? ? r NATURE AND E%TENT OF INJURIES OIp INJURIES REQUIRE OR EXAM I TON BY A OOC O O O! T M F ?? I '1 Y $TATV$ OF INJURED MARK FIflST ONE THAT APPLIES dwva INY L u,s.suxa IIJH^iu KILLED ry on 1 6 NAME - $jajyg OF INJURED. P !flST DNE "?- s eLw TNA;&PPLIES ? NL V u r i w1 ND l Pu Y`A ?n°1. 1 w AAA a . NO. ??.. KILLED Is[vine Non a? a NwgIfL ? DNJ(IN r_?< u ? 5? 6? 7? DID oDr Dorn-Iwm.nN ? 5 o s o OTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT M USED OTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED ?? I ? :: IOW NORTH BY MRO N CIRCLE wI1ATrMLIAN.o. O •? ', i w D? 4 L,N L L°1K,Irw,A,Y[L..AAww ? ? -- OESCR tlE OELOW WNAT HAPPENED (gEFkq TO YCXICLES DY NUMOfA) ?V?h S?l?t 'f/i. 2 AP A?.R•f tc. ap ? __Fa ., The I eErL wt"Tq. B?r hT???h$ ---O N, CAr.. rdL?..L__rJE.tf ?v_. GF QoLL„p .IAIL. ...-A, .... a --)Q-T'------ NeLSoms._.4e%nvd!e!f ,. CRr 4-r!RSfe2> e.sLE2_?..?- I b ? ' ? ? (cawase. ... I ?; ! ,• 4 _-_/fLS _enty.JAEe mverheaTec? _tk ?/rf ?I `` ` • a , .. _._.NOD`f- putt 2e_7lrNz side mF._.The l • ' I K __ ..F0L4D. r:..Q T?1_.CRnS _B?+e DP._9?iy!c...... ?,,' HICLES POSITIONS BEFORE COLLISION IC E oI LAx[ P'AA .. w - INVE971ATED BY L 'rn ri 1 [°`? L Lvu Axa av???JJ xMnrvn_! L L L N 4 E W ON STAIETORHIGHWAY NAMEORNO. : .. ? ?Oa Dice, ecr X RIO .' "m„; •s [ v'rW[occ»oO ?'.A ? D 1= L M E ND f D IIK Ki ?.. ? ..? ? .?. ?..,? ?5ak[ 4a, ...l. ) d ? ? , DA a er l o1 O ? ? ? ? ? ?M,xL ± Nw O ? ? ? uo 0 AD FROM TO ? t ,y ' E9TRIAWPED AL CYCLIST WAS USING: ,?„q, a I?M.aA.R L??? , I?wA, ?..,uA • ?mx r?:. I?AO.°w a 4 y Y. ESTRIANJPEDA L CYCLIST CLOTHING COLOR: ??j, ,,a, ,??h r?w? ,?e,l xsr I? u M SURFACL -1. oM WEATHER. LIGHT CONGITIONS TRAFFIC CONTROL TYPO OF ROAO RIVGWE/11CLE ACTIO NS RI fY l a DAYLIGHt ? 1 wL.a.l c ??EI IL? 1Ci? .a c RD D XLaO °.N N L ly?'^^ _Y ?I?wwLL L WAN I._.OVIK.AI' ? I "..A'. ?ON[WAY ? ? ? ? T ?'GDIN091RAIOIIT M,LAO CCJJ ?W[T J ?NAWINO S ?pMs. I LT ? f ? TO. SIGN 2-1 E^IWOWAY ? E ? OVERTARWO AND PASSING ?[AIOW 1?snOWWO L ?1-1 ON OAa31NlLT ? 1 ?YI[LOfWN ? S ?NLOYI(,DAS-K ? S ? MAKWOAIOr1T TURN 0,CE , ?FOO L ? ?l' 14011 ' ? ?FLAYIWO RED ? ?ILOUI?ILAMMIL ? 4 ? MAKING LIFT TURN ? r? 1?If 2 %GIIY/ L 1t A[I I KM, T. ? f ?H.-G AMBIA ? f ?A11(Y ? 1 ?MAKINOU-TURN SP/LIFY 1 ?5P1 GiV ? f ? RA SNWK ? f ? TIT i`VIN ? • ? SIOWWO A AY IA RACIER .. NOAGWAY SURFACE TYPE ¢ $ I ? > ? OIFIC(WFL.GMAH LANES ? E ? DR1v[WAY ? L ? SIOPP(DFOR TAA1(oC ' , ?urMVL LJ LJ 0. ? • ? Of nLA fPfLIIY g0A0 SLIAMTION OPP ? f ? f, FOAT •0NAL ,? [f n n ? , ? E ? M D[D I f1O OI.S ON ? • (?'SI01 P(D W ROAOwAY ?t-Iq? . W y1u ?1 J? w!y?Cjl'? ?T - Y'^`T Y?s.IR K(xrlwe C rLLYf1 YJrT ? h'Iw??`` :: /fi . T•RIII?1 ????N ?4. I N _. f' rT'{ (}iY 'IN ?.?L4:H sT?ti iY r,D 4 L R wZ; In: F STATE OF WASHINGTON 3i Gf / DL .. POLICE TRAFFIC CO 00 N REPORT ?TRAFFICWAV No.. /1 n /. 7 C MNI NUMBf4 PRIVATE WAY +55b DArt oreal N 1Me )' =2 '' /^? i9 wM j rw. ...1H, IVSt3.ODNOwI counrr COVN r on NO. [Nw y{ ' - "a wN , / ?" ?E ? ^ ?p°f?? fano asr9nro91«cNwer ? 5 /,M 90VIf 095rRfF O O??4Al ,t Mles ps w ?'or sr r oN[pa i/J.LLEZ /2? / / d wn9sfer ne vnrN: st9e[rov WOULD NoNmrt45frnoN 10 -.22 G a"x L MILE vosr a[rWF[N 514[lla?+qS//?f?5519ffr 0 © ^?x F}t DISfANC[{D,9 9Erfe N t CR05551R[Fr Oe n..9f51Me.905 ACCIDENT DIAG9AM OAIA ."u,S. Mll[5 ° 3 f g vS'-O IR w Or ?p r ? MILEAGE COLLISION NVIXVfO lVf9 rr ??nt' IOrwI NO NO xeL[D-?NO. IN1lr9fD'? ?souAGt pHit ARUN wNldioi. I" .e0 IfR t 9EFr O4 ROb OR 41l9tNCt ? `f""^ bVfN c" p 940HRIr DMAAGEO 4lSNIY f EIOIN ''Otv Cl5 CROSSSIPIfr OR 'y?55 d ? UliFD ? r / T ??'. OBXCl Sr4LKx [or OBJlC131eVCx MD NEW V[n CL[ /'9 3NAMfr lSr DAMAG[S SRCW COD NG W! Mr) RObvv [ s Delvles NAM, wr UNITNO. In ET M F UNIT NO.a 0SVEHICLE ?PEDESTRIAN [ Dvrvf9's NUwF. ? PEDALCYCLIST .). 5)4tfIADDet55O U 19th ALW- ' a 2 30/ 9 -aa 70 - ?.. / vwrL aecou rNONL NO. D , D Atf ?:t rv?sucwx NO ? ? .`3 R r I su t u I I u eN %?' An a?L/?? r M NAML a 9NONt .??? _ f Ms wn cNr rNr E ac<u.AnoN "1O D r° ° r"t - ? .u MNAMFa vNONe NO. fns IGN1 nwNl DESCHECK?* (?) veNleu A : p CHECK (,l) ,?.,. G c ss awr wrMiS t'[c'"` K FN Of ws AN U.norlf arA .oM COD a u I ^in A ,«ono CODES ? ` a n:is S u u9 [3 oaG' rrw,. rl u ' { s: ??,,,,, A ?IrK.ru ) `. t M7^.oM MApf°ooee.eNty. p `°1`? ?I0 6rY. //p?? ?ir:iE ° ea.?.? MRBq ?'M N ' ? u l[0 86. ? ? :,N[. ?, r7 -o/2f7 A 'E sN Nv.r Novwr [ r ?%Iv ? •?° „ V NS S1All 0.A1F Np • S1A1` H Vf M. L A ?° ?{?? . VINiCIII RICA1pN f1D 2 JS7? L Y-111 DtNN I A 4FIXSn4eoow,rLR LAS1 sr iDIXL IrIONf No -""' N4st WARE W a ADOnua owntu ???"'•$1.r5 $S?17S8 M N ?O / o`z 3 D/G/ ? o?Sr J7 yl^ NAMI?a °°tssa ww4ANCf co o9 ACtN1 E 7rDG.JIiAL _ .yes vi?J R N N p4AAW uu un/owpp.???? eNA.Ge eNwe _ 3-- AAU ,lrr IUtt Orluii 9uD 1W . O°IMMNID +y LS 'nC 1 KLJ"?i AWAY AM., N {LMA NlO - wM N AWAra IDwaO 11 /b.d! DE AWAr°r f f IGi DIAGRAM OF COLLISIO I N: Nstw t .. NDC tF NOV1' Cu 40UP c wutY tcfswn. e Sow DESCRIPTION OF COLLISION: Intsmlwt nu swnnNluswrr o. L NAME, ADDRESS & INJURIES OF PERSONS INVOLVED * CODES 1 t OCCUPANTS/WITNESSES f"Lls" fYWiA[HUCjsI "' - 2 ? I '':. NAAy Nx AOI iwr ?M N+ Y9r' r '-.. Mrr• ?( [ .r . XSta /riCl .r r. * NA !r, 9 4 3 6- 3 (r??'I' ?L .9s:;, uw9lss ? u! a .... Mw[o[. pAw pr?ar p., n. ? .7' ? :O1w ?+ " y Y Af ? " v , -: --. 911x.1..:, nOpl??Kl[s....[a..r, {bu of Acl.a. "..{,i.1'[i °r Irwir ?.MS pbKl ?ro:n. ?`.°?v °' 1•.. ?P ?l ' I :I? / l t ', X M,S .?L ? 7 °NO ' o-u3 OK'??MC O?wj DAna LI9ar An.ovloa y own ! ?:'. c ':ti I I' I Sli L.I INf I '4F? *y? ?• ? ?F? ? ldhi.? M i : ? '?" ? dal ?> ?. w .Ee ?+: i r ? ? ???? s ?11 ??15 U?y T i I L.I '? S t1 1Y, 1 t r } i?a { u i *fi.? l l -ti Y. . r. - Illfff[[[111111???9[? F ,{ -AY AP POLICE TRAFFIC COIJffAON REPORT TRAM ?J 4 RolltE ININUmota,, , s ® PRIVATE WAY DArt orcd . u .. lf? 1 I .' il. •-.. '? J E.I DN t IN [ Y09 rOw IUa "n HOU91 ct? N COUNtY CL-i AM[{NO SrREl10 N CWHtY? CIiY NO. OUR N URAI 9 mGHWAY MR[s Os Dw ?pF /9 ?r? ON ES I Loi2 Ci2 INTIE CIS 4WKOR SFCII ?v D/fY V SIC-D I1H.'TREEr p94p•D NON IHIf vaICnON A ITS, FILE Mllf gOST q '3? aLTN4[N L S-11 a .2 WEE, DIS•NCL1DIe I O. 'y5 /S ls a R t N .C9o5a519U1 H,AQS.RE ACCIDENT O El 5 F EFf w OF S•/?r?? MILEAGE / CODf f All y DIA1411 DA,A - edusaNlNVdveD Evt4nr: OmI NO ND .IIIlD?rq INrU4t? DSPII{AGf DHIra RUN ww'on0?x d VEHltIES PppgglYpANAGt ONE1' D S ?Slaf F "aD I sf I Er eaoAD O4 x[FtRLNCI 'N INfEV Cl5 CROSSSR![IOq YOAp • / Js RL I! l OBHC, a1eUCaINAmF OF OB [CI SrRUC•ANDOWN{R'S NAME) Eat. I-AG[ Y D SFECIAI CODING VSF /j 7 s - e _ UNIT NO.I Dvme's N•Mt: usl FI UNITNO.Z CHICLE DPEDESTRIAN D PEDALCYCLIST -2 q MI ae D4 vlas N•mo- / -vS5 CLOT - G I ?i L J stela wOd9155 2.J surf D _ TRELIADDLIS1 s/ 1 Lcc / 0 03 znc lfiG..1 ' /o D4rvlv'S UCtNYH SrArt ooF? e-1 NO R Alt -oss cM TcJ /? ?° 6 49 ( Iv R' U IN. N L G All DA I 14 n ? A oc ndR NwntaanoNl/NO. rts Gnl-ONE F N ? ?G %/ E R c •1 FIREMNAMEAPNONENO. '/I f//,- / 9C, ?nl R O CHECK (,I v[H n[A w ovf A OF •NO1N[v •t CODES b. * D n D .c < { i 5 I R e is - D CH CK(V) vrN CT[ASAN EmPIOrf[dYAI wNOrnE CODES c * 5 rA N , NU N D ° m o I ?.b. ? 1 VIN FEAR MA{ ?IDpOGENLNFV t r o.>ri pN mH.NDI D ,RI D D h [u I l IDA91. A) SIYIL t 9 ONV?j .1 /? E l 1 N v,l A9r HOVAI n. uc sun 19AREa KATE NO. SATE H TEN l ?cs r,//? - - I ?, - tas3 A / VtNICI[ IDEMIFICAIgN 1 i vInICII IDFNIIH A I s 6911 FGISn9LDOwH a d 31os1/soI l IAyI FIRST MIDDLE M`OM ?NO N ER: 1. }1 a51 /y/N O iD ADDMSSd OANtR W / J / N f9 %?o L r + G DI NAMU AdaeudwwuN U eo. ov Aelm E . cc ? E vG Gam/ !c.9/%la? R -'AG[ !A oia. v? i G 'w c.= CN od 7DC V / MA9G! ?- w 11.1MAGtDMN I Io .? , = - pA? ' IG iOT,CiT a IS ??p ? I,: ? fw//q ED 'w ?RLMAINID ES'F?rA arD. a s ovrto w urioii J tOw:d r e eY Cn •5 ?^ e " ri-/uG l a OEAGRAM OF COLLISION: ¢ 1 N Nov I I 1 NEC sMq sr Row DESCRIPTION OF COLLISION: I-surryEmENtAI-,T N,cI-Y) 5?73°CI?` I. .I _. ?6/1/. .3?_... L?.9y /?GS/_ o?.J rs1GSS 'S_. - ,.. . t e I ' !. _ i j ... -- ' Crd . AS G/9J/.... 4.x.1 .}J65S f.3 ?Az?ilrF? ' 6e,i _ I . s++•fb /J..777 _ I _ T?iY.J /i llo /7i9 OG. -. loT oNii/-bbl c 1 Aet> .? NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED .C D E S 9 OCCUPANTS/WITNESSES ?od?rt,'mr u. 1 3 !, - '" - 5 6 ...-- - N . • l A".7i9.rlS3Sc c,6sSeG/t% o No 31St =/GG•f1 . ? w TAIU u c MU? nsu lr a IN' • N m o oa .C a e. A NSI ?;W' o ,,. 3C ? A Sf NO N AW Y•IVald a MOVl'DI10M DAMa D?nKI Dwl • [] h ? ri° b NO Ap I pal N IU.' OF X la[NAmlaa• DGI OF YANC• a aK Sa•f xl0 rQSKI Afa?NO DQ•m; ??cRKI D(prlr N? ?r?i'"Tr Z G Or-, ?• ND :o1T / s ?tyina_ }T naovlDe. D•R Y t ? 8-3 T.ro a )XD nay // 1 'A i , ? 1 I?f 1? I'? p?7 kt r1 "1) fr?w } RkSlA16 1 "rl?. r?J Pn. ° i l1 . s Kul." H? p,?? OFF Y9?;{? rsr " 7 1 • .° i A , ', +? w r lv?ia St?dq°?^' r ti P ) P Y dlw :A'"'IhSY"t??.YIES.Vr,?l? ? ) t ,?y? ? : F w i,?r 4r?r + I 'I I i 1 , I. r I ?{ , 7 ?+ ',R? ? ? t 1 I {L I .h v. T db??ir f > T A ? I? ! r 41 J 1? I ? 1 1 ,f ?zi A I FLjw I r.;' 1 .f :I I ,' ',`V uu LJ x PA cnP P.u.[.", A, R. P y e r i d 9 c v , n 6 p i[[ O O c „TrASELTIP " wsEaTro ?oss`d,&EE PAP UP rWL+PPPrtl rulEx PA•WPO , } P On µoEfl s NkiFNENC _ .. tou son nrP[v[O ru•E ?-ru ? xn ? 3 [E B ?0 8 "„o„ 8 360 ao?..??°" ^° G?i ' x s,HP o ?E K.[5 ? ?aF ? ? LPP"PETS[ F O&IECTS NAME PNO ADDRESS OWNER $brpl ?'•iT ua N E' U ......, . $ _ l OBJECT STRUCK In[u;P d y) ,. IiNPPETrwI Two GAPS LA9 E ST NAME,-, _.? MIDDLE p?IYEgSEAST (LAME, (JRST NAME, MIOOL ,•wFRE NVpwrp DRIVE RS__LNAM FIP "--^• y?'J COLLISION OR 1 z C (h /f n ?CYk? OP[THANTwD FA.i 4of . e- H UTE NO. AND SO%NO- - -. ROUTE NO, AND BO%NO EASONS wme . POpRESS STfiEEj " ' -. _ - ? ? UPED EA S 7- ?/ ? LF -.ATE, SEPA r d Ya a PYSATE --40 P_ /r/ COLL 5 oN CITY _ .., , STATE_ ZIP CODE DRIVERS OCCUPATION ORIVENS OCCUPATION P CODE STAT . , ,__„ - CITY,,, _-_.. ._'... POPt FORM a L 33 k d °,iIT d o i'3P64r e?? GE OHIVERBL CENSE NO. .. ST/+iE SE GATE OF BIRTH GE DflIVER6 LICENSE STATE ME% PAT Ep F. OIgIR A „ F M. N/J Z /M Tyr e ? ?? - _ICLE YR, MANE(CHEV ,DOD E I, IN VA-pA ) - DY STY ,(Y, Ojt.(_ V IC LE YP: MAN _( „EV ;DOQDEl MODEL IM1OYAOARTI BODY STYLE (ZOR.) . S 2 4?? ?A Stu h?bt! r 8 TE ..TRAILER PLATE NO, - , STATE LICENSE PLATE NO. ,,,-STATE TRAILER PLA, END.,. STA STATE. LICENSE PLATE NO. . .,.. .. wA 1719 91? VEHICLE IDENTIFICATIO NO., VEHICLE IDENTIFICATION No. MEGISTEREDPWNtirl ST-FIRST-MIDDLE N oE) DRIVER'S LICENSE NO. - - _ REGISTERED OWN (LA •FIRST-RIDDLE NAME) DRIVERS LICENSE NO. _... ` lS J G v r-5 -- a?t O+BINpq.. OWNER'S ADDRESS .. ....ISTREET,.CIjV ANO$7ATE1 ,,. ._:_.,.DATED GIRT ATE ADDflESS........15TflEET..CITC ANO STATEI .. _... _. _. .M QWNE ' M ,A , M O . 0 5? PARTS OF VEHICLE DAMAGED ..-. ??P iniIVII. PARTS OF VEHICLE DAMAGED - ......- .._ .. $ riL? s oo ° o n? r y O E LIABILITY INSURANCE ? LIABILITY INSURANCE INFORMATION- HICLE NO. 1- WAS THERE AL TOM L ES NO COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ,TAE COMPANY ' NAME ANDAUD6E55 OF LIABILITY INSURANCE POLICY HOLDEN NAME OFLIABILITYINSURANCE ... . - ... ""' NAM PPPkS? C2 !; NA'MM?E/-ANDR-,ADOLSS OF LIABILITY IN...AANC AGEN _ ° G!iY-_--,,,-TT-,_aT,+rE. _, ,p, }SI?P?[O/LIAB/I?LITY POLICY NUMBER _., ,, 3 Q PO, 13 u ,?? rdw I-~ 1ST INJUR? •?T /NS TCTG?IGO/T7?(i?•'j??j???-?f-??0 OJd?T??(l ;Om nJUNESI AGE ?r_ _.. 1 _.. .- .._ ......, , .. 'r _.... ..-_,. _:_........ _.-_._. ..._--__.._,_._ POE ZNO INJURY _IU ES E i ' ...SL1j- OF INJURED MAgN TIH$7 ON$,THHAT APPLJE9 STATUS OF IN s' ? IN V HI LE NiO "u„a ? n IN.Y 1 LE _u ni w nail `? ? AILLFD r5[v[x[ uNgl PA A ? ?rvP NO NILLEO ,^ T ,:. I J v l O w1TOI NO ?0?onN-T n.J 11 S? 611 p7?P OoDlkP wl lrr lr ? 5? 6? 70 T? ?. ,I J;`:?i MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED ?? SHOW NORTH 0 ARROW W CIRCLE DESC IBE BELOW WHAT HAPPENED. IPEIEA TO VEHICLED OY NOMOEN) -- .. YAUTMAHr[xW ' ?I ' '?`? _??W!}5.__!h71'/1t.ny.A ?'vr.rc /n ?y a//Fof _ L/ pr d uy ,. [ „?Fcft / .T. - e.vry+[/ Ah °4-- ler o. rP..r s.wlxPw tip ?s/Ll. .7JP9.. rA snJY 8d 4. - htal Y.. I o ?txLLT PA,xPNA , w r? -?o a ?- I - - F_cxw7 usa h_TRo nr7 .dX_d f3a rt/.d T l??s o dsc u.r.eA bfy? ^ 1JR_l_!Ry._ YIh[7J I m In _l2LEJ .£e.c• tt7y__Th_L 4 Rcp „1 fh. Vt - b! G4 y " tT_YU,~K..-A?kist?,.7h v it £ _.2b_R.2 d.%?-1ty.d._ r' c - In - / ? ? ... - .. .... .. - EsT aAreo ur r v o n[. nK,. [ [oYs VEHICLES POSITIONS BEFORE COLLISION uo.IL. a.x o L.' :o [; :o I ^ .Are ?MxiA , ytA VEHICLE N s E on No. a :a'orr .u xo ..[ r ? « OI16THEET OR HIGHWAY NAME 41 3 ' K. .. - f3 :1 13 0 1-1 F, 11 ` ^( , wa• ? ? ? ? ALONG FnOM TOAI JL?T i• 1 PEOESTRIAWPEDAL CYCLIST WAS USING' r?[wr [?.^. 'u- 'u, r. 1?C w [?olwA r?n? ?r •?b -?' L a +?A+>«oi?"SMi?:wir,.?.u[, ^P«.• ,r r d 1µ P' PEDESTRIAWPEDAL CYCLIST CLOTHING COLOR I?e•• [?lanr [?" rO 1 ROAD bURlACC., _,WEATHER. l10HT CONDITIONS i RNHC CONTROL TTPE OF ROADA, DnIYENVEN?CLE ACTIONS xuoxc ICAI<.M r r[NU PAN I ?iii Crrl rH4 // ICnIP•OnIP ? j,1 • .v.aL 1 1 ?arlN.rH "« ` giro [ ?11 OO NO [1RAIGNT AHEAD r E '? s{• t "?.a? ?' [ w? OraNAI[ ?I 1 ?('?T ?O/WNLn WAY ?•. "f + {..Ir 1 ? DAY 14? AAW rr6 J ? w,,- ? T ? f10V {ION ? [ l.l. " _ WAY ? [ ? OVERTAXING AND PA{{INO I .'r I I l ' ?? { STPILi I ll0 fKrN S P[VLP{rN[ ? S ? .-N. RIGHT TURN Y h J Y _ C1:_Clw[t._.._ .?[a o ?PIOrS[DN ? ?^ ? ?No. yi y ? [ ?{ DW [ ?!00 ? ?PlGnla OlrEr ? A ?1 f'_.OP[o AMMO, ? [ ? ii00PNnNOIL ? [ ? MAXNOLEFT TURN c] E ?uAAIN0U.1uRN ,A,r IIS P,.' + LASniNO Q?ir. 4 ?' ?K[ {?I is lYl E ?einiri°aNn ? ? L•J f ? S ?rwO -' ,?x T I ? [ ? {KC FY ) OTrrrP [ PP HONK y flit iL•IN ? [ ? {LOW NO {il } TI ?LPIC rY ? ? ?/ ?IANI{ II MT Y ,„ T rM/ ? i ? [10YPE0 FOR IIIL !!7Y ?iL ROADWAY WARACTLA ROADWAY EYN/ACL EYPE ? L-) r OIfK[N[IAOYAN [ ? OIIryrW AY I ` V ? Y f > rn yy..,, ?M1JJ [ TNLA. -c- nOAp [EYKM I - [IOP AT RI. -I , ?r?u... LJ lJ ? (3 O ToN ? l ?O fto, TOP{1a ? i t4, G ? ? ? ? [ ? O oofo ? [ ? {IOIPEB NROADWAY I A v Y' +f I.e t ..ti y -, ? CI ?'$9??} r[y?o 1 r ?cR„ ? r'w r?{?p (rZ. N.? nl?I? r Nn N `L . f /i, f I ,y?f I Tlb rr ? J _•? J { > .4 t ys5 A t 1).lRl? ?1?I POLICE TRAFFIC COLLISION REPORT LXJ TRAFFICWAY POIaalM (NUMBER PRIVATE WAY A w I I ?Vt I_ IUS?Iy Dy0?1 uN /'/??I Y?. V EAt:2a:?J,, ? Oa ION NGNWAY mlmv 5 CITING [ ROU1[0a 51 f I Nw• ?U St<,1 OE CIIYOe,OWN NAME RN ?L7M,E, 2" p ON U ON 1 IM[eStC NG Vn,N'SIRE110e ROAD NON INlf93FC110N 5??IjI?? b ?/J?/? ?? B[TVFFN •' /?I/ SiR[Fl R / ?J' ED. MIIE P05 © ?? 1 OIs AN fR I [ F.CROUSIRItIDON MnLS N v[3 f µ 47 _ L ACCIDENT MILEAGE OB RAMP , DIAGRAM GAIA - R 1l1, O COUI510N IN-10 SfVfN F: N NO [RUO?NO. INIV4[D? O?1(IAGF N -AL NO 01 M =? 'rv IMFa Cl5 I a5f V GS,RFI Oe aOM 09 R,II.Na CR0355TR[[lOR eOADF? VV 9 [[3 ?vF 1< E aVI"LS W ?IRORRIr pAmAGF aEIY f 9 OBJFa S,aVCk INAMt CI S,eUCk 00VJNEe'3 NAME' t31AGL S SMCIAI CODINGU UNIT NO. 1 UNIT NO. 111111INAMI: ? VEHICLE ? PEDESTRIAN ? PEDAICYCl15T u5I Ia T ervte's NAM[: us, nesl MIDDU D lTT6 J?g ; Siel[t wODRt55 ?S DLL ? I? ? P r //?'l^J ,NEtI ADDeF55 - z Y 7 I SIAIt IIP COCI INONF - D - -S? l JR r rvle'SI CINY NO. SIwF D TE 1 1 l tNY All 5q m A v i R Z ONE Bc R E cu,,Mi Ett5 R HEC ?) vNat AS:rvv v AMOrNFewl ?CHECK (/) vNlclt AS ANM NaNfoA' 6 w ` MO -71 d ,n CODES ? ` 3 c S r 6 y,° , v s [R , 3 3 ?, . CODES 1, ss 6' Iw h -11 :° ? ° ° : ? 1&1.D A ">« Ilpeo a v:, N '°'? ? ? Oa.l b ??A, ? ? zI; ? N EIDRDO[ C tN r o , 04T E >a a a vwn RA Uenwn NO salt H vtN 'l . u N.St ? lUl? M Z ?v - I ? ,o VINICI[10l N11LICAIpN NO. i 68 /?6Z I 1 29 8 C ` DINIIfI AI MIDDLE vsl nasnetnovmp E, sr I s+ ?`[ 7?lQOGFdRI GODrfJ /C • rwrn NO O W 1 wNe lws, n 5 ADDnssaov?Nt N A u ..1 J VW • QJ66 E N f R ADD•Llla INweA??/D Va 1????/y???v I J u C? _ 4AIMGED AR LA DAN IA ` X p D I o. i N CNARGE CNAROf m I A O I M N OAMAGI ? AD WM. INID ? ?W?V ?RIIMINID IS I , j01?0? 5 S no :w: °ar R SIGN: NL w•nmLrolcwlfll111ryNNNNNOV,n DESCRIPTIONOF COLLISION: lusesuneMtNrAl sNtnlr Nlaswrl DIAGRAM snf ? Yet//C?l.Ey/ y?,lS ?ST.GR?Gld? O.v ?C111?if7-- me B2vCG?) 770001F.t1D..?B?¢D. _ ADe/llE.? GC LPyO,C ._ . - P I , ^- y h?1? ?,?TIl Q/7? _G !- - .:)`'.G1?'T?: p s . - 7 ? a _.. d lD)'uc7 7/CL1V.fetdiPO NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES 1 - 4 ' s'" D , _S 6 OCCUPANTS/WITNESSES isimn?aMlkr?iw iii u. Aa ?uln „ n31R TAO w• -T- ADatSs N0 D. a AMB ? iYl' ? i$i?v n AD MI33 i? ro• a ° • +?o.?lD roots OAMe ?? o.n• ? ::;v A NO I H •DD•+L5 ?•fl l0' f IM .. ?AMI ?,T I ?('M'1 N• ? :O1rv r + Dell wv0+4Alrq a+(p INAW RUN. RADG O• K.Ur • PK 0 CHD r'O 1 HD DADaq•p• A•nOVIDR O C ? { ?x S 1 f IrS t ; M TRAFFICWAY POLICE TRAFFIC COON REPORT ?K r uMare / ? PRIVATE WAY , PAr orcours - /.? ?• w un .ro .,n. n. ws '?MirouRl Lr? couNTV ?fi?E.?.sCE.? oDUNnrao cnNO. _ p?uuem wu.. Qa' QE C rOV rOWN AMEe NO Oisiv[FIOVNGNWwr a?LES QS Qw ?or Lot ON NES ` ?oi?.:e.2 iCIClS :. v001f Ox 51 t ... 5l r :'' .1? rNn95fCr NG wnN Slvftr OR ROAD NON rN1t95tCIrON /. _? ,, etrvrtlN -? Si•tEl • GAG ?(ry vZ SrvEET ro[ % ( if pl O. ) Drs ANCf •0 v! iON v0 ! .<vO511tvEEr OV NtARf5l NrtE VOe 5 C.? tf13 ! Or ? ?, ?/ ACCIDENr MILEAG CODE R DIAGR pAiw . COlliSgNiNVOLV[O Sfv[•rir: NO iNNI? Q solllAGt ? Nrt6RUN NO EiUED . .RD IMfR CIS rN riN4 nflOV ROAD O4 vfNttNCf ., CeWRSSIV[ROR AD .lJ ? 10,AI NO U vEN10lt5 .0-1-AGE ONtr Q.1-110 ?vlaCl! O y Oa1ICf STVUCR INAaf 01 tC151000[ AND OWNER 'SNwMEI E5I DAMAGE SRCWCOw_.A ' UNIT NO, I UNITNO.2 VEHICLE Q PEDESTRIAN 0 PEDALCYCLIST 1 o•mrs NA.At wr rmv .o a -oss cL ?.- r' M G DOVtv's Naar r =l ci .•r L/ ? Srvtit ADD.t55 9f tt,WDVl33 /?? ? srAle zi•eooe .NONE NO D sur-f?2bSt- DRrvtR's uctNSNO s - cz?5 C ? ? Sc,.1 ? u • eA .RN % G o ? I ? ,vR I uN o?L?JG 570 sAt 4h4 °• l N ? y OC IrON .w NA,nl..NONE NO. rGNTJ;rGNT E R SLPA! N iw NAaea.NONE NO eNr eNr .7/ i??/o .J pG 'o ?+ p CHECK I?) vfNifif AS GNU ROrfIO A OiNf A` Q CH CK I?) vIN aE ASAN Yn.IOr"ff or• r ev ` CODES?` D ? s t e;; - 5 n M1g.... CODES?? e N ?> ro Irens _ p?J (y ! M. or D. p . N,.Mt p royt. Q EB:rr. Q „.KS 4• ~ Q -N" Q V"' Sm. Q Z.1.1^11111 Y eo ° X VlN rlwv wAal IDODGE Nfv.l Av>ptt lD•,veyq•1 SrrY J v•C R nSAx 1 N A w r 1 ••? 3 $S C//bra %?i E 75 lv?ylG ?c ? r sun v eR nwnno surf H vt ea C ' nwa[IUNrnK.noN n6 s L u?DfN aN6 3??s t/sa p eennufoowNfo 1A51 nest wiDDU rNOw NO O W r wNtR: lASi nwsl Mroou / L?4?? a? 2,'_ ?.? IS AoD•tss ar owNU .5-9?7c N E w Le?.?E G NAau wowtslvr«>u•.Nn e° o•AeeNt DAMA(i1D f• N a ? gtNAGfDNU '? = - Id:un:V * Est te ? w.r ? '"' 10 G ? ? Rio. ?efMUHtD w•vN n?D r f .. G I S IOwtDer. V? ? tOV.tD ar. DIAGRAMOFCOIIISION:M l. DTION Of COlLI510UrNruNT•L OESCRI i IS cc?zl!? q GGF 7lll. wT vl //b 41 -- ral? ?1.y? sTv/P? ..-?xG,.+c . o.,.= = 7 - NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED COD S 1 ` _ 7 M 4 S 6 OCCUPANTS/WITNESSES ilnuurnfArtnw tN o•ADOrLONAI N•Ml fn H 3[• GI IAIUS A M 4 ' _ nste Inc' " N. t r???s s? ss?tr Z a d = e o- 2 o ", ' , •oD.nS U Cc5 ? .%°, w e Off" p ° . Q? N .Dan, . .°r?yra • aov"l- QAwe p'1°"I Q n . Q ti Q .oan, +,?'1"s°' ? , INt'S. O.as ?'.:'Q?'o.E. Q:1 ? :° ? L x +. r arju,N.au..r •wu ?..:1 •.c. w ?` ? 7n .a< -tc .a ?u .•..no o.n t y ..nov[oe. °.u a 5.' {E? y €rC _ .... ..?, .I..?.?.E. Ad JKdTRI D,AFFICWAY i IA` POLICE TRAFFIC COL N REPORT No. 3 6 0 0 S 8 O PRIVATE WAY YoIK j _D,n deaD _ nme eouNn u L I SON CO-11 NO OT'NO. FmvA ?DR u4Ae ? ?l {(I er oY iowN laNO. as14lll o4lnenwnr LC is ? s ? or N LOGJC ON N GOILN INFRSECIN..1. S,R11rOR40AD NON INtlRSFCIION rere? F 4W,! , t M3 sc ?R ?^ NeNEe? 3,RfFia MASom D13,ANCfaOIYF ll MYt ER CeOS V ( YH If FO Mlltps, D. 6 A . SSI Ftrp4 Nt,v[S, M?llf ro•?l?J nF5 rE[, w d S ! S MP- R.0 FNr ACID MILEAGE COX 44AY DIA p,rA, - M COtUNOTAL No VfD NO il1ED vt LI /5 ?ylll.GF ?nn6YUN ?LLND INN4[D _Ils AA Ov"C"S ? IME4 '4D W Y 1 YtF, RROM OYgF(NNCF IN I CYO3S5,4([, D4pM 4.. 40g4,YDAMALl ONIY ?gSUI,FD ?Vi,- N M• Oel(dS,RUCR INAM(a ODIC, S,RUC, IND OWNI4 N,Mf 170 3 l ESi.DAMADE D r-rC+H ,- o- SnCMI COMNG USE ' UNIT NO. 1 UNIT N0.7 LR'S NAME 1 55 M ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ?• — . , 5H,12-r's PAUL. WAYrJC D41V(41 i - Ul, NIV - - 1,Yf[,wODRlll GARDOM crr AP-r*I - A su,e D iRFF1IDDgt51 n+eolr P»oN NO& ADL OcJL WAS 9 NC- R Y A ' M .? D4Nf45 UCt NStN S,AII I SH I RTPW 4D2 K 4 WA M 6o „ I l t N ND All A DA e » I i 2 OCCUPA, ION --.-1 NO ?mv. s W {- oK Nod v 8p b E R D«UR,NON FIRM NMI A-E NO. Ens W r cni ? ? CHECK (4 v nIUF.311F, %l f ANO,»le CODES ' Y° ' rI• ? CHECK vFn OFA A fMMOrFFd ,nE 2 ? ] ?, 3 . S roc IRA, e u D.c•r,• nn . S CODES * ] CI,A, Nin: 5 u u» • e n 'cu W ai D ;._ ?M5. , .??,l ?m; ?„,n NDI . - ( n »YIAR IDOOLf{ntvl MA _ (.-I HDrA) S?YI?t] R.<ONV ? ??; ?M . , ?M ?vg_ ?W n K? mq I, 2 DL.D$ U . DELTA. OR. S,AiF MIf N A E H ltD , A) 2 GOLD ln61FIgMDICA, GHC- NS»»O O s, if WA- - - I C nn N -11 11-ATr- L13!9TZM4i?1932' 141 4 ` VEnI EID»II w p esnRloowWeR IA3, v Dole SfkM? AS D2iJ?i2_ »IO.4NO O r rln, r ((Lt?? ,DO4tlsdOWNFY W N ' E DoRnsd WwYAN<l co aAd», N u NoNE. R I MFA o DA4U C.. C d w 1 III. -All 0 . \ ,OSV ' ,O Y., O AW, /V 1 4 ? WAI 5 AWAY er. DIAGRAM OF COLLISION: s! u»u.,N AI No-cAn ND4m I TT"-T_-Ts,uzn.NEasT { ? DESCR V IPTI E ON OFCOLLI510N Iu5lslvn[MZ»rM SntEi4 »lOiSSVr A _ ( PJESS GoR?a RD- {-1 - - ._._ _ ?_o??_-Nes<=coR1?62=Q1?= _ ??-FntrRciRDc?AY__vP ?Rt?NKn , I FILJ4u.YcaMES 7a 72L'! T - E J :..1 ! .. I _i CF1ai:T1?1SY N J_ orJ _p?Crvie 72s SidE.,_ON-_ -rs EnA 60rnlCNtelsr T NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES I Z 9 6 N OCCUPANTS/ WITNESSES id ,a .oo-,Iwue"sl ,M( su`ACi i,i T F; N -; r isu- iei N .MI w ' ? "1i4l ? ? . E_ P 0'.. 0 01-1. 0 N1.1 0 X +, .,.s -F M awed ..I.I N<• _ q, o-u OND i j?' ygC D ? ?,Me I 'R,?"o.,I .»rono ?Q. ?:° o•n ' ? _Tf iod.I.? f/ ?0'?7 - ? ?rw'Tl ZVI w r li y I ? I I t? 1 ?4 ? ) t ' V i. I . 1 - - ??.? 1 M1?? f L 1 ! f 1 f,Y y f fY I f C' Y t 1 I / t IF. - x ,/ J F y 4 ap 5+? STATE OF WA INGTON •?[ D »x sole 1 1 N0. 8-03-7-0577 ?` . POLICE TRAFFIC cOL NREPORT ®TRAFFICWAY 1 PRIVATE WAY _ _ . ? COUNrY ' 21 87 ?? :O,XXTe,.??"?,?? ,•, , 1250 JEFFERSON ? "` " 2 -?, T K•? ? ON O[ ? N array NAFFEa NO. OF MITOe Nw"WAr p iC . 2.4 .,ES o3 )Mw MQr H lock ON 4 Corners Road (d L " ' iN,eexenNC W,lN. sre o eoAD NoN wreexaroN urW[[N SR20 -.Airport CuWf I' ? t?`$ '• °'' 1 AN .C.OSSSe M <s N s [ W ACCIDENT I E M E 3 [< Airport Cutoff Rd. r t C O couis?oNiNVav[D v[mrr: n,w[o_ Osre`,Aee 0-&1,N oru weiueD NO ` wNe.EeN wuSiN . w a roms raragAO }} a veNia ? reonn An,A«oNlr ? iesusn0 Ovi° " / 1 . -TIM uealNANe or aana sreueA,wD OwNUS NA:An esr. D.vnAee w gs: s • UNIT NO.I UNIT NO.2 VEHIQL? O PEDESTRIAN PEDALCYCLIST }• wrv es NAA, ,At Mydland (Dutil), Laurie R. GALLAWAY Gre Allen 5 srnE ADOee o Ess • 8225 Highway k20 30 WT dship ! ane 2 OTY 6'9T68 r ONeno Port Townsend, A WA 385-7297 D R r 'W port ownse d, WA 96'6'8 385-5084 1 2 2 N u EN N A 1 DUTILLR385B9 WA F O1 29 62 V ne M 75 .. 2 ` 000UirA,aN NAA,[ar,.oNENO. [yes ?GNr re- ?? e 1eM 11 E u 77 E [ , ieNr NEK.,r 12 S dr Sel f BLU 135 504 R n AN ? CHECK (7 AN r j ?) r -1 AIA4 A CODES ? ] n S , 1 a "O _ 4 CODES ] n S A ,. - 4L p n 2 /- ? .»..NC[ ®' ? bm• ? M." ? 4 7 My: Rf" » "T°7?' ? O M' O IR,- `?, v!N Pe EIDDDG[CNIVI Io AI snu DD. vI N 1 Nvq DAe . _ 1975 Pontiac 2 DR Gr E 5> j ,' A A An .nwn NO A H vN. Rs 1 blk/mar 704AWD WA - C 3 v[NKl[ IpM5eKArgN W. 2 K 7 S 5 P 1 0 2 2 3 0 L i t ?D N i i w ? 5D nmsnnoosvwEr wr nm u?w,e rNONI NO Ma er. John C O WN j \ 0 . wESS a oWHEe W Same N 2 NM.Ea ADausv msuuNC[co aACar R . 2 me oaAw Ae[A µ _ e gAA,AUDAeu - ,diorioS • ar aw.u ?,N Q ?etAwrxo ia O c»A c[ ?AViir OerAwN[o 11 ? no. u?oi o? s ' 51200. vE ar AWAr WTO Ar rv S r r v A NrHrN DIAGRAM OF COLLISION: a)[,. N?wiin .r .oW DESCR IPT ION OF COLLISION: Iwlsur•uAOMAI PeuPA.aswrl 0 Veh ic le H1 westbound on 4Corners road when pedalcyclist that was eastbound turned crossing - - road in front of vehicle H1, striking vehicle r _ -- --? 4 _ T #1 on left front fender and bumper. NAME, ADDRESS 6 INJURIES OF PERSONS I NVOLVED ' CODES I - Z' 3 •S 6 OCCUPANTS /WITNESSES is i aAru r?.wi ii ue .eE m ns,[ [rer : N .w .o AN. owl O " . 7II:n. 01, , 7 N A» ? 7 1 oD•ns or Owa O.n,t! O"? , O H O; ? No 48 .v r +.vo .r,NG ara.s NA»rauN. X TROOPER D P SUE .o l0e 618 AcrNC• WSP Di '•oir ac os..rc»ED 52 8%3 1 Kr ...?+lo 1m22 o•na nro a ...ro . oan . . E s s 7-22-8 7 ?sx ' We, •. R? k, cr• ? STATE OF WASHINGTON RAGE / DE INn. _ POLICE TRAFFIC COLLI REPORT }KJ'RA'FFICWAr Rouac NUMBER I PRIVATE WAY ' DIEOFLDIU., N OF.,IOSIB _ 51 N wyl"qv I I H.I-71?s.i rlMf IY$f]RDDHOU91 Q3 CDYNIY TEFF6/250N CIrv NO. {RWA ?URBAN RURU , pN pE pN 0]Y04 TOWN faNO.Of 51R[f10R HIGHWAY 2 Avlfs p: jdw ®on orJOb LL 0N4,'.5!°414--n AV CU M ROUIF E7 $d 1 g] 16 MFRS[Lr rIG WITH SrRFEr ORROAO NON INIFRSfR ON r 0lIWFIN •l CUK SrR[[r a CAC ?C 1-1. FD. MIIFpO.ST .J Y' / ' ANCfaDe? tflREN F.CROf55TREFlOR NEARESTM if gOSr .p lt5 f 5 f /'/O ?4 ?L /Y E[fr W Of CIDE ACCIDENT MCONE RAMR DI RAMWrA CO11510NINVOIV[D. lvER ryy, ? ."'.uN FI NO,I-QED OKII[D ? wnoveDl" D IMFI Clf L I r R40AD04 HffR NCf R05551R[RORgOAD _/ 111 ? ? _ rOTAI NO avIn LEES © ? n1oRRrvoAMACfoNly ? aeiurzD ?CLII % OBACr SIRUCK IN- Of OBJECT SrRW_K AND UWN[R'S NAMFI FSR.DNAAG! S fnECW CDDINO IAE UNITNO.I UNIT NO.2 ?VEHICLE ?PEDESTRIAN 0PEDALCYCLIST Gr LSSr fIRSr mi U DRIVt%'3 NAME: /) z omAS DvwfR'S NAmf: I.13i FI MI t G - E.9N -- °2 RF-...1. A 2,3 CLARC-' .9Ut'. RIFT gpDRE f ?s? 0.sre?9Na??Z 1 ISReM fiAif SIR CODE R«ONf Np. rye aAJ GLIf} $3 77/ 07 D R SrAF IRC D HoH .;a P nlc? ?i/f1 °I ?O 7 3- N331 D RNfR'SUCt N5IN0. S1AIF t% n I RIVFR' UCtNS[NO. AIE M DATlp elvin c -4 m MX ''62 ? [ vL ? Lcv lq? -f ltlA P /;( I q OCCURATION MNAMfe Nt NO. [vf5 WEIGHTHF T R E OCCURAIION f MNAMF anHONf NO. FYFS,7 EEIGNI IR 2 ?i]vs lvr7e?Z 41 8o Sv R N f, t3?k /.K S ECK (?) vIHInEASaN MROnEA ANOtHE ?'CHECK I?) EHnf AS N Pi 4 rM vFFaRAN r HF1iA ' o D ° H A °y '"• Q I e v nD«. CODES I! 3 5 / 0 f"'iO. RL.4t? t 5 r n N CODES p 4 S i :1 nu " ' Z' 1 UYIES soERDM D--- ? ,-e° ? I. ? ? 4 D p mR AHK' O M. D ? SmR ? KII ? :. ° MAKE IDODGf LN[V.1 MOptI IDMr?rgJAl SrYEE I]DR.CONVI E n AR MM 1 HEV.1 MODEI(DMT-VAI Ylt l] R 1 >a eao R I Nu RAe sTAle FR RAIF ND. ftMf H aoR IlAll v ?? // 7e 078'60 CYJA G lL-Gls . a2 3r'l W/}' v[wCIF IDENT1111 KJN ND. F131.5 IC IR .),lal I 151 /I 11 I 1 L («ICIfIRNr fI Ti K/I/ZINISI R 3e- I / S S 3 R[G15rIR[DOwNniR µS1 Rfr MIODIF PHON[NO 2G5 T N v2 Co LS N G ° [ ISRRfO wnlR: lAST iIRSr MID F LARSoA/ ?.vn1 F I5 . ADDRESf OE DWNER W A OWN [ ? //' ?/S Nw ew / S N , W' S•/D !cdon/? SPo1C/3?vE (JA• N-1 a ADDllfS Of INSU - CO. OR AOIN AC /nA R 1/0Al& DAMAGEDMEA w ?bw i'wc o ` DM1AG[D wFA N 1 CHARGE LIIARG[ ,? v iN 1 q tft. pAM,SGE AR fit. glMNN[D • 141 AWAY ?IFMNN[D ESi 0AMAG! _ f s- O - IO'MDar. ? rovnD $ /$o0 ° I° DIAISRAMOFCOLUSION. I Al -11 NURT« L ?.-? T?_iT_T [ '"Y 'Yp _ j I Y DESCRIPTION OF COLLISION! WSISIAREMt usEa[Ir MCE53ARYI ?OoTN vF,///ccc3=?vc??Q. s?r1PPa?_- V ?A w ( T/ A ?g N 21 t 1 i I . T . - pa U c N . _i CCO / .. fN r --- . ..Q9c/yc?0.. U? T /l1Af?ir. _ , I _ I ' .gc,rc /raoM rn f".roN'r ,[pa ?,vo __... J ?$ i ?I!'O?? ?? 2 C3?t/iiov (ouc 7 /?aT. J&'zr (/N7? t NAME, ADDRESS S INJURIES OF PERSONS I NVOLVED CODES 1 - 2 3 4 5 6 OCCUPANTS/ WITNESSES Iioo:oo"IKxi:iR?iA'rM S? I,. AGF urns '".,H," -„° e ism bib d`,I AMt ZAN BrYN 7- ?bOy O al O l K .. ADNr.S V ? A a0 N , R I YA/L p u .nJ p- a 0'w' ?'". • ' ? ?iD ""'Srn O ANNA 385.0703 No O _ s-LI -2$ - m , AD;arss w v gr7"S&s'4 AM ' „/.ut; °'MOVID IRDM pAMn p....I p? :` •"' ErOV'Fur , oa T ?d?(O :VuArtr .o ro ' _ - rK r %r ES N . ? ? X nw.T ?pL(u flyMl°e.,.. eAlwl Dl ° ° .cur.. T so `:; . e NA CI wI "2Ry" ?zyy? nenaRr roRl er OPB7 D.n 6 9 8 '. fliiS 4 :MnISM+_e?m... qmW -.?assw. .m ?i - m.. MR _ 3[th4R .... rt... s YE?` t ?I ! F 3 y4 "j? STATE OF V?LASHINGTON LAG[ Gr i i 3 / POLICE TRAFFI LLISION REPORT 21 :AF ` r W.,acax wneE4 -' s PRIVATE Al ul N ?° ll:. I$ti ')"' iI:ID?wE3? ?u IDSt,??DpRI _ ,. I p9 1?? J CO.? C3??CSO ??.: / C IYNO ?EUR!•N pr1 [ 0N p! pIN ?r%/ SoNAMlI O.OE 31 GX Y f Q5 Olllt 5 9URAl y(R.? Mus pA3 pw or oE..lJ _ ON Lri? ' ?? 5 INr SfC11NG VnfN 31R!lr 09 rgAp NO [RSFC110N ?? [rlx - D O ?9 ± CR??C MIIF 405r U yl DI •N MM1lS .C90553191wf1N E ! ,.S Sr9!!f • -G Si [ti T DIl i ? ,r/ M 5 [ w ?j MIIEAGET A R'W'?IA C f ass. t a? rtn N a O? S% -2': .'.. COIISgNI OIVfD- f91vBODE - fOtAINO NO KtI[D?NO_NlU9[D? ?SgUAG[ ?HIa RUN ruND ' IMFO RD ft 9ROADOR RFrl4ENCf _DD O VlX CI[5 e."y O ONLY ? 5 [ q(N CLS CR0555i4( pY epAp_?. _?_ l • f y CnllCT319UCK(NAMt OEEMI[ (l4- K•ND OwNtR3 NAME) 9fUlMD ?V sTE Cl! ?• (/0O^il?/// ?j MT 0M•AGF SHCIAI COD NG IGE [ UNIT NO. ww[es NAMr lASr Isl UNIT NO.] QVEHICIE pPEDESTRIAN QPEDhLCYCLIST -?• Y D4N(e'S NAME. IA31 ?- ' _ ? Sr9(It ADORt35 S ? ? ?? J R(E ADp4f55 E L SAl! EI4CODt 4 D ? 'S UCI N 7 ? SrArt x I ? U fN /, "`FY s m ,S of >y S p7 D' D.. I" V At A 1 a<u4•iIGN M •ME av„or9e NO. ns eXl EcleXr E u4A IoN I r YI O.a.)C ? ? ? ? R rwM NAMt • rXON! No. tns wl EiICXT ?-' Q CHECK (.? ? ? m { •s•v R r No QCHECK (,l CODES?* ?„ „ • iin A A 5 Inclxx. v[X nI.sAN wnor[e orA ? - ° ? N,LVIts p wroa.n<r CODES ? * 5 <ns • s inu" 5 u roN D s"a ry .u 3'T i Corp" Q ? ?,K' ? CRIB. ? a. a ti:' a veX r(Ae MA t (" cXev, I( Ael.rpv) slueaD r4 ? "" ' ? C. ? 18' Q M:KU ? D .c 3 c?1 v.l DA . NDM vSv?M /G l?L/. E X SrArf 19AIlE9 RAr(NO. S,A H vfX ? .,?8 s 7- DIAGRAM OF COlLI510 N t o ? r - eY' f L oeoNOw " DESCRIP I NOF COlL1510N: I., SUrn[xa , LSX[[tnwa5s s9r1 II l A ? v ? ., -' I ? ' ? I -I.. ? _ On,I -DiSCce/Gv? v2? I p '? E `?t ?,?.•? ???? s _ _ . . ` ? ' ? ? ' 7 ! I 1 7 ' _: pi/7/ - __vrrJlJiO..i ? I I , -?'- -! -?- 7 1 ? 1 - iift?:X•?T ___ - ----- c - NAME. ADDRESS INJURIES OF PERSONS INVOLVED 'CODES 1 _ ?- OCCUPANTS/WITNESSESS ?oi 4 9 U' i! '? a ? n I -^ D Dl • o •. 1 +A siii ---- a N,W flx •Gl ,AIUS 'N Vl" : MSrI IMCI ": ,wl N•? : a . I M •Me [? ? K?vl rK4"s. Y :,I .owns L iti1 w .- IMOVIDn QAMI ?N•AI?wr , ?M ?rii •D • +.TVW meWrKP,MMIa1,v I•CGI01 •GI'•C• Vry?1/1p? ._ _-. I H ?•MI Q?:A, on- " ?o yM X ptiaDN CKKID ir•IC ID r0. C1 ••1 D Dxllrllrpr RKIOV10IV •" D•tl . (. { -( i r POLICE TRAFFWOLLISION REPORT 04 Ru• ? ? RAFFICWAY C I E COMRNNrNUw R ,` ED PRIVATE WAY - •. oN q1 Ar ? y _ s orv nN.F couNn Tul (VSf ]bpHO RI CbV iY CIIYNO. ?p I/)y?y fu ??1Nf, wlv.?w.1 ?Bµ 1 eFFe rs" 0 ?N ?E ON CITY O);1'wN NAMf d NO.OE 51RFE109H;AY Ci RWIEOR51 f oUgN 0. 1 Nit55lCi NG.- SIR[[i Oa 90AD NON nR5[CI ON IREII% t AtIIE POST ?theaf dra 0.15 D AN ' 3 IltS " 19Erv E CROSS 1F109 N[Mf51 m1 E9051 ACCIDENT pIAGRAM-A M 5 w /?, ,t MILEAGE r[Er OI trQr.T C tiAA CODE , . COIII ON vOEVEO ' NOIFD KILtID of Rog DR, l-II ?•NO.INIV9ID_ ?SRjUGF ? HIi6 RUN N.I[srv IN IMFR % s CIS RD IM R "?"vRS1H CAOSSSSEC O VtHICIf]R[[IOR RoAp rfJ R L S1IXtN RpOnRIV DAMAGE -Y ?RSVIifD ?VFHKIf - 0' OBRCi51RUE%IN-111 OBltC151RUCK NIDO 4 4 ` WNF95NNAfr t5,.0AMAGE SnCNI COMNG I[if S S 'N"R'SNAMf: LAST UNIT NO. 1 UNIT NO.2 ? VEHICLE ? 9 PEDESTRIAN ? PEDALCYCLIST 1 tJR M IRSI f I-SNANF pR Q 'co 'co ArThur Cs reSe v? ? ? i.l.U MI? ?? 51911 >5 5 R[Fr ADDRESS d i326- 41cvr<-C.TUZ 8 / t 2 -)A-f lIR COM PHONE NO. D 51AIF t Ju j /j- CeeL `1.2 7SF3? R LAkI ? 3 IaN •Z RNiq'S IICtrvY NO Hl C N 7 fY/ ? A ,BIIZ, I SN St NO. / All SfK DAIf O101Rin . S1AIf f% N ...... ?L ° 3 R i 3 ' LO? OCEVV u ? 1 IDN M fdpHGNf NO. FrES G , E H IEIGH, OCCVp-- .r1 r M [ e RHONE NO. 5 WTIGH, ffIGH, L C O R / ? CMECK (?) [HlciIF AS IN omfRAl ?CHECK(?) CODES?* 7 vrH n[ASAN U+Rior[f ofANO1H[AL ,,99aa ""/v A R? A y .. , clroN 1°.c. l J] r o „° CODES ? 7 c a is 5 e x.cn r "' is` sn; , rov ?, n e v c , ,w IS C) N C/ K ??SpRDM ?.. ,rvKr ? Rp./cl ? cS:ne ? ??xt ?,:i:.y x;oI9D„ ?.M9A,rvo SKr "b.aK ? »???? ? ;;L,. [ eHFV1 MOp[l [DARTHW+) sine l]Oe KC5NV.) ryIEVI MO.1 IDA.vyRIOVAE r 1 D L> "^ 97 ! c rc v , 1 1 ( - r a r E ?4-7Z -r, C/? l SiAlt Alf RAIL NO. H H CIXOR A f rv ° ?, ° `PM 962-) 1Jc k LL I 1 KA,pNNp ]p L vFHICIfIMNIII I'3 '7 I S z z o 3 9 31 I i T! I A- ?-{ S 3 Z I 9lG4 e[D OwNt9 V31 IIgSi IDDIt "No. N0 RtG15R . Rfp OWNfR: LAS, (IRSI IOM Z H ND. t c V-e O ` tn^e IR RD-D1 DNN[v IN A YY\ L 44 zCi fv s&- •? N , r Cl ' O ? I I 7C. • NAM f+Dwt55 Oly syaANCf co. oq ACEN, ,` /?,, E / - •Pr I A-6 C R U N •e 3 A DN h 4 ~ . A C M IA , s c CHM? CHARGE ?y w Owj g•MAGfD IA M 1) cLTG EL N E E IO:OO:ii S ryWSAy(j war ?11M.UNED D9nIN RLNAw[D eSL p V Ce ?Aw%r ? ? , w [ ro eorro4 S I ?77Q :vo : , oeY, er?: _ •w DIAGRAM Of COLLISION: lu ix M N -All NORiH DESCRIPTION OF COLLISION: I--MENIAL SMEr IF NECISSARYl e: O ? ?-, - - V_ehlc?e 1- _vor?h-c_v>_ sttt'er . _ T17wfe?I I l_vsr?1??euud u?`?itia?!t?fhemre?rD( - - - =? _a ?r?vY_iV _. • ` _ i _ V ?.1??_C L? 1_N_tJmrL>r _ CQI. rYl.'te 1' ?! 1-_ ? r_1__ -?- ST_c? csWLL.eh.-V?'lTJcl _TL?o._ " " t ' " " '? l I ? - -t-^- 7 Saa iStl F_•l.Yi -_,J.J j ?.r\--I-YS_'E- L:e.-? ?? GIT'? O ? . _ . NAME, ADORE S 8 INJURIES OF PERSONS INVOLVED 'CODES L OCCUPANTS/ WITNESSES ^„ti µ" lol iii `- - 2 3 - - 4 5 '- 6 , N•MI •UD9rSK . Lsa.- NA,p9ra - AGI SIK r NS wvcr en ., na c • n519 UtC? wRr 6 ,? AM ww. ? ? e uYKI ? ? . ?a o su?[. , r ? ' 0 .n v5e nvl Src A-CV.. p1NAMitR+". n„URrf rM e. ?•Me 0rm.u ?ilerm Ori; ? iwV n.r q . ?o wur,. v KI DM1e•K"ID KU KI'A(99?yLD D+narl.ORl i GNp , DAI[ X R I+9 r > S } L 1 rrS•^ 0 n R4 j t :.K, 1 ?j^ rrL -i1. -' .l Ir` 'hJe "t.?iR Ej FI tr J J;l'}I ,?, ?. n y;,d LYr?x a6, 4 :1 r ,r?L s )yyry r < ` ? ? $ r ??y? H w 4 5 I f 'r ( G? 1 J ?? , { A 1 .I rF r; ' p ppyRRK s S I I j ? ? ? r ' 1 1 :r t '? I f r ? L I 1 5 ,N } ,• I -h C tx i I 1 1: f } I a [ ?u I 1? r I J¦q ` ? tf t } lr ?J`y k - - - r m/O1 Y ? POLICE TRAFFIC COLLISION REPORT ?RAFFICWAY vODCECOMPIAIM UM I PRIVATE WAY _D!!E (7 C t _. 4! _ •E.I rr• i ,. TIME IuSf ]•ODHOVR) 00 COUNrr 'h'+e25cr,1 COVN[Y NO. CITY NO. - HWA D eAN ?i uau ?N ?F ? N CITY 09 TOWN NAME6 O.0 siPEFI ORnGMWAY Z LES ?S raGf 14A ux-v, ION ?Ses fOECl3 !? RWTEOR SERE 3aa 5[CI !( SFCr,NG Vnrn: SfR(frOR ROAD NON IrvTE95(CtION T?? vafF'A E Mllf rYlSr O ?? eE1WF[ RfEr 6 Z. iA9ffi • ANCEeO EMI' i iEAfNC[. CROSS 519Ef10R NFARESt MILf v05 IES R ES f Awl REi W Of ) ACCIDENr MIEEAGE CODE R DA RAPADATA CIXUSroNINVIXVEO: NfVE91ty: F rOipl NO. ORIIt[0 NO.INiu,f0? ?svIILAGI ?nae RuN N INTE1 D IMFq, CLS IN TRIETOR ROAD04m RENCE CAOSSStRFEtORROPD _ -?, dVfnKl[5 '90vER DAMAGFONLY ?p?ESUIrED ?I_Il ? 71 o _ L OB1ECr SrRUCR (NAME ....... 1 V<9 ANDOWN[_R'`SNNAfI 11-A AGE YS'QSW $ S- COOING USE UNIT NO. 1 UNIT O.2 ? VEHICLE ? PEDESTRIAN. ? PEDALCYCLIST S _ nER 5 NAAF: usl Nast MIDDLE SY_oT R DRWFR SNAME: IAST N STREET ADDRESS S c ua v pTE COCf O INO, c I M IA, w 13RS- -73a-Iron D R cITY 51AII I DR-SLICENSEN . (r'S?•iw?'fE?w FR S. V 1ILcV' F A O n 10 I G 1. I V IvR a ENSE AIE Dpt dBREn AY OcCUPA110N fI MNAMfevrroNE HO fY[5 YhIGNI IEIGHT E CUPAUOrv MN-VNONE No. EYES W ll"111U.7 WA{('rt55 A-TA gg- ?I+J ( R ?CHECK(•7 y1NnFASnNfMROYfFA ANOrrvEIi ?CHECK (Er( vEn Cif ASA FMROYEEd rNEa?L ° CODES ?] n A° 5 1 C ^'° o9c.c '` ` u ,rtM N q„ .rD CODES ? t ] a A ti 5 N 6 , a N r- r< ? IN R,E; DTr -U-1 D.5 _ [ roM 0 "'IN w Ki[ , n YEA9 MAEfI f<nfV.l Il fIIDAn1 AI U1DOR COrvVI "Y _Y 4 .1 IC-1 DEIIOP.RINOVAI S PY ID9. V) i a 'J Se D ? ?l_DZ E I OR OCErvFVUt AIF 9ARtRRAIENO. SIAIE QA - H I vFn. IXOR N Af tnIGIE KEMIfKAIICN NO. ` W. .I.-IN A NN FIL I 'D ISI I I I I I I I I RE.1-1 OCSSwNEa: usl FI sr M- NE NO. A RL"- O IstER D WNIR: FIRSr mIDaE N No. ADDRessamfR N A o+mE9 -- u51 l ?C ?6 OS IJa c E AMf uoDRtssdlNwRANCtto. aapcwr e R I uA A NAM-A DAMAGID NtA eI' ' nAl. pAMAGfpN enA• E E ' I S t5f. DANAGt D-11. [].Dv- ? ANAGE . rOY RI EN FSt O ?AWAY ?REMAINED IU?oTIOw S tOW[D S 52 if I, -N(, A r s TOWED AWAY 8Y E ? y --llRro RtN OESC DIAGRAM OF COLLISIO : lu RIPTI ONOF COLLISION: IUSESURt INIA-11IIFNECESSARY) 1-41 1 r ? DR C DR G? L e I - __ O A LVALT3 ¢re Tfe`h __ 0 ,ro C,?Ucr?c_GL) __Ve_H' ? ?- - r _ T >T r -S Tue.... UeN, ca.? T1{e?_.Re)ccO -os?o __E?s-tzsp Ne55_000rx?_(RD-_----------------- Iv NAME, ADDRESS B INJURIES OF PERSONS I NVOLVED CODE$ 1 Z 3 4 5 6 OCCUPANTS /WITNESSES ,a S.DO oEi:+:ir?+uA} ii iix gee 1 iue ' x"F R _ 'ESre uea NA w PA N ' AoEVnS ? A M Y ?c' e ? ?EYS .nI . .. ,.W ? W ? va!- AMI N , A _.. _ _._..__-_..... .. _..__., ... ... ..._ _....._..__._...____... _-.... AMe ro; r 0111;? N AMI .___._.. _-_.. _. _. _ . . NO h ?. .. ._ _.. ___. _-....__.__. ......_.....___._ _,. Arc•IS5 NAry9f Of _._._ .......__. ___.. •n N Na?cl?.D m,..n. rn.I. sc1N1 eY. ?AMe ?ur ?•r ? :°. . drKly SEµmr lfAN• X Caj- EAp(A OF AGfrKY • "° lJ5 D?'+IAIC?I. I?L6o5 AQ•RI VQ9KI ?ND I[ DNIS OAtId RIRSRt Z lI ?7 A '1 DAt[ EtlIR'Erh) ERa NN w'?','y,rlrtir <K; n{ 41,14 LLHNtYfa ?"PT .+ IL'll'17, f . ?j Cc?yj 61 1 ?w2? ?'J+ r ;S G ?5YE _• QA c: S b ` Y ? }1 [! I 1f.1 Y,t I I L nFrl ? ILI j _ :1 {tiS4 T y l ?? it E t I 1 + wla ?. 1 ' J 1 _ EIIJ ? 111f A4 . y ' L 1 ;k R y? T :?i Tma?u @ &s 4 . „tea STATE OF WA NGTON PAGE I GF is R F ® ' ` N0. N r AF ICWAY T POLICE TRAFFIC COLLISION REPORT • PpICE COMPWNTN BER ? PRIVATE WAY E iC04lI_ Owv S S ----- 7 I - - 1 r "?? X. (DI. v, MM • IMF IUSE ],W XOV41 COUNTY COUNTY CITY NO. ENWA EU BAN 'V // l I I `I { ?.F? ^? Ru4Al ?E?O4nGMWAY O pf 0I n CIfYOR IOWrv ,S Nunf Brv0 OF 31R wEES ? s Q IgoF r6Ri rb L r-eo ON M 5 RWtE OR$IRf J (o ZS30 NIER-1NOVn1-IRffr OR ROAD NON INTf45FCTtON y BETWEEN 3TREF16 STREET PRFfI% j,- j F MIIFPOS! / S9 ] ? OSIwNCFaD REM i RfN ,CROSS SIREEt OR NFARFSr MItE POS 1F5 F4 3 E W FfET 11 0 OF U ACCIDENT MILEAGE CODE RAMP OIA04AM-A COIISIONINVOIVEO: EvfRIIY. ?SPI F ?XI3 RUN NO.B LIfD NO Nl TOIAINO wN?ORDi. IN %RD NCR CIS IN R II ROR REif NCf TOR ROAD - O10ySSTRFE I]] l LY . OVEHCUS PRORRIYOAMAGE ON ?pfSUllfO []5-F A TOY ??d _ Q l OBJECT SfPUCRINAMEOF OBJFCr SIR 4 DOWNtRSNAMEI EST DAMAGE i 1!? L S SPFCUII COD NOISE UNITNO.1 UNITNO.2 0 VEH:Ct:. ? PEDESTRIAN ? PEDALCYCLIST L RIVER'S NAME: IA51 fIRSf MID lE eoe 41VE4'SN- WST FIRSt l '- SIPFFI wDDRt53 BLA' J IREEI PDO4E35 F s, UIY EIP CODE -NE NO. D Y Al ZIPCODE E {? T 4S &S- I R ? D4rvfR'S U<fNSE NO. 8 SIAIE E% N MI I D,B I2o I D11111 I UENSF NO. SAIIE DAZE OFB RIH I DA. IYA B OCCUPAtION FIRM AMfa PHONE NO. EVfS Wf GHi HEIGHT E OCCUPAIIDN FIRM PL-t&-NE NO. EYES WEIGHT HFIGHt a I ?U R CHECK 11, V CIF ^1 *1 -1-1 OF AFMJO1nFRAl C1 CHECK(/) AsA rMRlorrf aF AFO1HrRAl ° . i 5 1 a s=,v .? CODES t 7 CODES ? 3 C, a ° s D 6 j a DaIfS , _ M il MARE ICDWf CnI1.1 VEHYEAR MODEl1DARtNOVA) SIVlF12DR,.CONV.I .YEAR ( C"IV,l Av 1,DAR1-NOvA1 T l] v.l `Q'O 9 R E ? Y OR lI fNSE PIAI rv . 31AIE RATTER RAIfN SIAIf H v fn CIXON I A N At "'Q-041FIUnON NO. i I I ; I I 1411 I L v N fn<lf IDfN1IFI - 9EG13R4fDOwFJfR: LSI R31 MIDpIf PHONE NO. SRM2 6Z leven ;: O 151FRtDOwNFR: WT FIRST MIDIXF Nf ADDRESS a vAT+fR A fOwNt9 ?I L SS I N rv taADOVESSaI - NI R E -- 79 ? Gr? DAMAG! AREA bu c ? ry I •? . , ? wC - DAMAGED ?[A ?N u CHARGE CHARGE E T r F I DAMAOF 1411VEH ?4lMAINlD 1 'Rl.MAINM SWAY o d DAM ? s t7 1 6 IWAlY 1 C ?:owt er: s 16 DIAGRAM OF COLLISION; - ?I lF I LC r - ? ,,?,,dt ?L Eu ^?91- ??R LNFM INer:'-111 W' r I ?. ? ? DESCRIPTION OF COLLISION IWISUPKIMENTAI SnIIIIFMC(5-Aj VC?}I?la .? L N B- T?o4_?eci_RD PRTUen__ ,; A Arr CfR R S`?1 , , i - p, i• n NeD . R? Aa ?a__ i ILA> G? FL_E t:.u l C ?ueve._..Inr1c-t?ac..__?116__QE-tcH Tl-k. --- 1, I ? -. e"I1(c,-ytr-m-,-._A_..M_At?-Box Cuh J_v_- }a--- l- I I E . _ 1 1._-I j tI I I N I I`. NAME. ADDRESS V INJURIES OF PERSONS I NVOLVED CODES 1 2 J 4 5 6 OCCUPANTS /WITNESSES Ir°w sAENw",EO",F,:i?+AVi SI 5!% AG/ TANS yam' 0?, ??' 4(SIR b/Cln .Mt N a ADD.n3 C] .M e p <21nI ? 'X . O H ? :° . N 1 y ......... ... ... ...__._....._ ._.. _.. ...__._ _.. .DEwns NArwla.. _ _.._.-_..- : ,R , MDVm"0' NF ?•MB p'1°,' I O< . O ? o N AMr ? D(V,lu Fas n, u1N1 e. ?•MB ?. ?F,„FQ.i ?I:",N ? ? X R . +rcAlnca,<IR S..,w af.N. R sADw uR Di0 A'GIN`Cc.( C•a . :. Si.?I pK(l DTn4?AICMO ILL Yf Ic,I FA/pUPR?HD ']Nq`!:' o,na4tUro?R1 a-ll„ / ?? .. mF Br DA1 Y. JvD w -u 2 F.Dan?1Ri ° sr? 12r??, ?^" owl 2y$'`,?aN?da r ?ny1-w , ! ,I r ?i?'7` :YS I?Y ? 1 . 1 a ? I 1 W r ? I I y 1 r ? I / ? 4 r ll ?,V £ J T 7. I t ^' ? % ?L^! I 1 u1( I } I 1 ?r } } k rl 1 t? fry 1?t 1 Js t r1 F y t, , ? I s ' J !P POLICE TRAFFIC COLLISION REPORT TRAFFICWAY FVIICF COm0.NNlNUMBfR PRIVATE WAY DAeF UPCIXLSON 1 rmE co A 101 l IUSE OURI urv r wuNr No. c1n NO. wA '?' QN 0E O 10 OOf SivEFr OR HIGH m s f E w 1 iCi ClS R_"OR SrRFE CIION 0 L o S p o D tX/C ON C.SS Gv.G.Gy NttySF<t rvL LmrH: SivFFr094oAD NON INrt95fClION 300 ? ?7?SCJ??G BEtw[E /??GU r-1 R ll z S1RFEi pyfPl% E Milt POST / 015IANCl e0i9F t?0 iROm vNFRFN<f. CNV035519EEl Oy M Ep05r ACCIDENT mnES 5 E P DIA RICE WIA Of l /!" Cox COLUSIONI IXvtO NFVFRI LED lOIAI NO O. K1 lF?NO.?NIURFOQ-K.?SVnIAGE ?N1!^RU N RD IMFR CI !R(E10R ROADO4 vEffRFNCf IMF p5 CgO5351gfEEOR gOAp `?S CP VfH1Clf5 ROP[R__AGEONLY Cl PILlED ?_N OBRfCt SrRUCK (NAME Of-1FCl STRUCK ANDOWNER'S 1) fSI. DAMAGE SPECIAL CODING EAf S ?- s UNITNO.1 UNITNO.4 I 09IVER3 NAmf: U,S! Sr mI ' KYVEHICLE Q PEDESTRIAN ? PEDALCYCLIST - -- WE SrRFfrAODR[55 s ??? ?J /! 09NER S NAME: °"? o L- NSr $?- /JE 1 Y ?L j/? ?„$ -11 1Pcoce PHONE NO D [f D 55 SIAEE ooE 723 G?LJ -.u LJf1 u JG e J.33 09nf95 UCENSEN 51 f R HaNf / Q L ? ?3• % B H Cull /? .¢ D e,r R? PATION OC [ I Ivf CFNSENO. I?rf % DA E 9 .t/? ?9/1 _ .t? l= X33 ePHONfNO. FS GHt 1GHr T.C sJc.J o E R - ON ? f MN [e vrp ENO. 5 WEGHrHEGHT /irc° a?JC 1 so "A ... Q CHECK (.1 FH CIE AS •N FMHOrFf of.uorHEVAI v IOPE.ATT AL ) F ? CHECK( CODES 1P, ] 14 S ! e S D 'q'?- ?[e, aN E . u"Noy Df ANOEHFC ' +c.`, CODES ? * ] n s u :is i+ e 3n o M N,De ni -cl e ; H _ o V[H V[A9 mA f D m ? TS.n. ? < v Df Dm p M , ANgf ? u ? S[ O er . [ +N [ c.[ : r . OCGfC 1 I ' NL NeF P E (l(DARrNOVA) Srvlf CQVV.I G- a v s R E H f 1 vwl 1i ; r I ? S 6 D? F90.A,E NO. .? S I C vFH.-R L - n ? Rv vEH CIf ?DFNnf UlK>N NO GG'ZI y3' I glGISRRfDOwNER V31 fIg31 MDOI( NgNE NO f L [H1CLOfNIN v F GI[/I !?/%IO;GIL/I d :? l 9 ISEFRfDOw . /f'/?? O N L..Sf SRS! IDDLt ENO. t] ADD9fSS Of OVMtR N E A w"tR NAMe ^ Aoogess a :NwRANC[ eo. as AGUn F ~sus zr ? E DAMAG(o.RU I A 11, P= e' Np Al' CHA.GE CHARGE ?DNnAGFO M[ 1 ?DµDwa i ' q io i'on6'+• ° utn D•M.ce nw.vH ? R(mAIN(D 'av ?° w (m N(D e $ E-? ? ov" EE ? It)_ r, J Ie pIAGRAM OF COIIISION: I u N Nu IND.sArt N- pESCRIPTION OFC ELISION: IUS[s vn(mEN .l w[n rtrrtuss.grl ° >HEElu ruySSANrI. _ e ow ? NAME, ADDRESS S INJURIES OF PERSONS INVOLVED ' CODES I Z 4 5 6 OCCUPANTS/ WITNESSES A, -1 "'m' 111 u% Ace i•rm s '", o" T s r v,su enc? ?'i; Emr w.?ets J ??,3 y ° • nE . o _ N. !D o G ? '?; _ 0 CI AMS p ntE p ,^ R l; AE TZi.] Cho E/? 2 .O ??2 %'oJ _ .Dons •Vi t a _ ,K p fi° M p•mE 0- p n p C ;o N yuN- t w Orr Kl. S.eMl E•.N . e. .r O• P e?DU O .GU.c. . S( s..tewc rc%c .JD o+ rtro A..ROV(DE. o e NO X -3 J ?/ L. ? ? - ? r?a?K3i.' L00 > r W Y M{Ee+ i? • i -f 4 N ' IA?z1 P:+rcclkL,ur ?_(y? t I ?.'.! v ; (? NO7 R VEHICLE (COLLISION RE T iE ° by r VcouNn?- I y r Co.l`uox .wx uii N ° NO. ?N?L i N o(s ?w ? oE a <NM pN A : µ ` :. • . ' NxiERaECnxc mrn aMEETON c Mw.EPSCC.IC.E loL3l N?O `` xnu w A § MOT PE II `?} snow MEApEai w.EAS MO aiPEE. c ? ? n AY IKU ObC IMIIp d,W i1 _ PMLPCAC woEE xa.MaEro..oP l°E,ri(rwo w,or.PP„ US '. ??A, ? COL u xro?EO O uACE ? a?IX a. ; ... ;• !' Y'L z . r E NR ?Nf D ..€.T9flFL?...._..-....:....J,'I'u_...°P4._E.:.N'.5R. B N N B.? S,.E Ba wo 4RGRORii4Ea F^E N?¢ILSTxEEtERAAD r GJ !a. _. a .. rwo E.TYwivW • a 1f'/, .:? C J OL Ec IN, , r .. >.?p11RQl?C... CO - - , ? ?. e :• F7 ,!A-RttErnY 7 _ •ARJLTf.B9. Y•TT O / ( ULISI 0 N ON f? PERSONS ? e rREEr AODR? ? ? r::.. flPILLE.?]a A,dDf10X N0 INJURED USE A y? +y x .' C 1 :J STATE; : D 1 . SEVAITS O L' CO/ . ' P .c_v ; ?T E; &PIYEB?flR COLLISION PE1ORl r „E?e.., .. {?CO[1 IVEOUPgTION ? r • .. ?? ?? D IVFASLIRENSE NO. . .. iATE C'er raLA/ ? 3 q .- ... -- . .. SEA A7ERE 1STH:, AGE. - .,I.:.?..,,• STATE SE%, Nn (rtes?Gyl7MM ?} M I ° Y• I ..? .,:OAi F R elam AaE + Yg d s? YELyCLE yArjE CH Y6 V DO M F a r . . M° o . .. ( . E . DGE( MODEL NOVEY DAq . „? -LL7•• rL ??E???El MRGEL._LNQVA;pt pT1 .,@RDY STYyE,IS.RB I. -, 'NDEdSEPLAi NR 5 ATE ._iRAl4E6P4aTE.tl9. STATE 'LISIfaSERAIE NO. ETAT ' DEG T l €RE&QjVdE _...._. ? %J 4 H 6 . ySSI-F!RSi_MIP.B6E_1i!LM?1?:..: 9BIY€@:5?lf? tlS€ - - ao T n o L . T•F11iST.WOD p61 w ` e s+ EI4IE1._ ..' PATE OF eI TF - '1? '? PARTS OF VEHICL . R L `? ! rd 4Y1S E DAMAGED __.....-. .. ?y,MS yNN PAflTS OF VEHICLE DAMAOEO .... ,. • ..._ .__......_n•.__.....__r.?._...?.r...... _.. JI?2 E IL ? I ' T YD LIABILITY INSURANCE INFORMATION-VEHICLE N0 7 $ ------------------- xI I PM r ...,.- wAS rH R $ l . - "JEAN RARORE559FJ,IA8147YINSVBAdC?P.041CY HOLa RAN, E AUTOMOBILELIADIUTY INSURANCE COVERAGE IN EFFECT FOq THIS ACCI°ENT ON YOUR CAR ? YES ? NO -------------- : - t • DRES 'VIM LWP,-dQPHESS PF;F1ApIyIYJtlSNa?df,FaA NT . ,... .. NAULIF . _ . CITI TE E,1 F.LIABILIII'Jtl511B8bC€R.P.MPAN.IL:. _.__.?„__ ATAiA S e ;}; 15i INJUflY -.... .. ...: .._, .__... :. .: .. : i: YPOLI YflyMOEfL, ! AGE . .i.; - - .? ..• , .u? _..-._ . NAM a ?. :. •.'•,• W PEO 3N0 INJURY .-?, --,?,-(USE 9EPWAiI- O IVONA NJUP ESI AGE NAME •M?" _ ADDRESS O Lg .4. ?. ` 1? ?J NATUREAND EX HE iEOF INJURIES DID INJURIES REQUIRE ?Q DOCTOR'S E%AMINATION BY A DOCTOR NAME M F ? W :LODgE55 SEA- NATURE AND E%'ENT Of INJURIES M F ?? DID INJUPIES REOUIRE DOCTOR' :j SS?a ,J ' i '•. .. _T Ia OF IWV6EG ... uL:.'...?{A61LP OxIYw Mon o MNK x0 Q a S E%AMINATION BY A DOCTOR NAME aeI>IEwu6En ;; BST DN E r . 3 ava `O«AMEwaN NO I _.. %ILLED nErt1D P x Pr Nu MOP ° aL M oN(w BCeuES- xrvPr 00:... u Inc c°I'q RILIEp [n[ ' a lil ? ?. M w 60 60 , Ev °N NO.. ___ IYIHON w70 c1 °O•r „ ? 5?I or r, NITI c 6? $ MOTORCYCLE SAFETY: ? HELMET USED ? HELMET N 7? Oi USED MOTORCYCLE SAFETY: ? HELMET USED ? HELME . ,.. .. MI OW NORTH BY fl00W CIRCLE +z 4?. r,N19°NLEMM{MW M O \ ? E MU... T NOT USED 'y "' IDE lll.REIER ro E-CBYWM ,, .?1 .u?ta_?:?3d plma/ /L-fcG_EEr?al ? 3 Wnns..-JU U..N., F ??? N Wlyt SMD :f I! I'd 'I I Y i --+Fns.--(.b?"a_can:3, ?,e._q.?oL7rL??eyuAU' lr y ? _ ??VV N? L r I .. T ! L F VEHICLES POSITIONS BEFORE COLLISION Z f ?.3 S '? { 'Mvl .1 LJ t;' VEHICLE N 9 E W a E IrAPPlO wA u ,? L1?--11 ((??T ON STREET OR HIGHWAY NAME OR NO. w? pM• vaiA?Iq l.wuYrMrIP°EO vnPga Ixcun?0 INV'9+10ATED poY t 1 E . ?.I«.,.:..L: b•L.f1 ?. ? ..:... aM rta r ? NA IP °IMPI ? ? ? ? _x A . ?U? :i1 i ? MCJ:.:?: Cl ? KE ? DICE a ' I r 1 NSAINA x ? ? ? ? ao.a ? ? ? ? ? ? RAo 2 ? Enl x ?' TArnMPa FROM "N + 7 -LYl1 PEOESTAIAWPEDAL CYCLIST WAS USING' ,OMP, E?ww ? '? 7i dl, t NP .... OMxl.lrPt E aPwiw° V 1 PEOESTRIAWPEDAL CYCLIST CLOTHING COLOR: ?P„r E?Nn ?w.IR M? E?P ??» IIIIIIIIII ?Oro.Ew.r r ^M9 _ 1 v r t?, T' }', ..NBQARFNP(AGt? ._•.YIEAIbtq_.- f,IW1LfA3tQLI .rol ITO - '..? Iw 1919.._ - - W-TDE(LESAlflaol PK. o-ri O l F I Yy Ali. J' YEMtcEEwl I ?DAILIGNI MWrrAE wpwl w. TTy_(.?fg.OAQ.u.4 .y: ORIVCI},?[H!GFE ACTIONS tf 71 yW?? 1 '0[ 1 d*O'C. 'b I IU IrAKGOW pP in?i 1 V } ti fl y ? I SrONM9 EON[ WAY POA b1 'nQl ,'1t S IIA, -.Y 01t ?DRI EKYO.'I ] ?m- ?I ? p 1 rllfiF" [OAANWO ] ?DUSK III OOINO STRAIGHT MEAD ! r F l ff ?; ? ] 0 W[T ? ] 9101910. o l D(TWO WAY { r , 9 I I A Y(' 1 4 ! 1 ] OaP,DwNr.D ' ? ?IOn10 OM [T ? ? IRLLD[ION ? OVERTAKING AND PASSING r I 9 .yT ? ] 0. E ? D STP[[t ? ] ? REVE SIBLE 9 0 MAXINORIO.r IugN ?}1 1 V 1^ ?1 010E ODin(R ] ?llOnia Ol( ? 1 011A""a PLD A WTInMAIp[ 1 MAKING LEFT TURN BMIM P T 1., YI,? 0 [ OCT.. ]?NICW rI a ?fixlEtlNLlltt ? L ?FLASHING AMbLR 0 f ?All[.R'Wpl ? ? .? 1 r YIC.Y [ Ctr,LR ? 0 0 MAM.O U-TURN 1 yd ?bMGll? ? [ OAR Sq.AL f TWO WAY. 9Yff?A.. I 11Y ,?7??I?" 1 H } I E, TLfl..L "]? 1p1,?eITf{.L,. (IOlAILAGMAN ? ?N ? 9 ? 9LOwINO d MPVA,' } ?,',; 0 1 001 L 1,];1?. 4?'J'I, J r...a.r ?'L[E [n'u'l11 LJ?.?wrr ? / 0 UFUVLWAY ? / 0 9101PLD 10N TRAIIII :ffff f i E•w ? L ? OInlR. 91Lt1(Y Sti 4 t I 1^a r ?I?r.N.ro. ?I?Il.r ? f one o1°a1cw GNAL f i r 1 ` ) I1?:j (? E lJ ?r?.., ?•? „w. ? r/ N(1 iN' HIG ? T ? MINCED „ 0 [ 0 STOPPED IN ROADWAY 1 I r?? ?1? ? 1 ,... r I.-. r l 1 y D UNMV I tU STANi ND N "'A':P ! MW ?4- ( 11 1 v1 r IY i.! t tY V -.,Al,? ?. ?.'"IA' g.r ..L °?.1jw.( IF r T v I, I IAL 4?r 1 Y ?N ?.`.f4'9d?,' law L L W` ' J 11'4 ,fQ ti r 1 L.l;. 1 I, ? 7 1 s aI. IL o? INVOSLYDI COLLi5101N OR ORE THAN TWO .. ??,: R WERE sivAn?ieE A wioN - AAy, Y ?w P,TA, ..... :1 ..., nE oRR AO WO R- Fwe?c'"?OQG °R iBTA, TyFtyy,': ?...;-,;;FIR q0 ?flIVER3 gGCyP?z107a.., 1 ?;y?10 I 0 .. _ .... _.. -,__? .....? ¢u PA •yu uca .MY-I:hJNRYft-all .gOATSixIA -P .1: ,SIG€N5EP13TEN0.. .BTAie,.__: ...7MI4ENPMI€Nq,.:, .?"TAM?&ta. '.'..;-'.', .LLS.tlS€C}ATEHO.. vf?^'BTATE „•." a:Z!NUf?P}PJE NO ._ STATE, i. ?Y€IPkIE.IDE31T1FlCATIOfI NO,?.... ...- ..:.-_:i.... .,.:,.._a:..: .. •.(dye,naur,n?.AONNGo.a+'-'lb..:?.. ...,.• I H N BOF.YENICLE DAMAGED lF. vp o.a,o PMT&OF VEHICLE PAYAGE? - - ,; _ ,.?.....'., 4, 1W, I 1 LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ? YES ? NO 1 NAM EANRA00SESS,RE}MBILITy,INBUNN(GEPALIGY21gL0ER.. ,.:,..W? IJAMfi.G6L1AYlLlTYINSURANCE COUV.wv ,,I •..:N" 1,4a ..... + MAN 11NOT GJ(ETIIAIdCPyFB?. ..,w.w BA- -K 0-1 d C3 n LEn NO 50 60 M( MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED S +?^ OW H C NORTH BY ARROW IN CIRCLE ? FASYNBLA NO _. LILLFD aEV[n[ 0 O ."L W ? 5 ?I 6 0 I °a7 El MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED #+ '+ r HI( VEHICLES POSITIONS BEFORE COLLISION .WU Ir ur rAa o INVESTIOATCOBY a 51 [ _.J Cli VEHICLE N S E W ON BTgEET Oq HIGHWAY NAME OR NI WAICTax ra t , 11??11 NKI[ OK10 f 1 1 IL 10 :?1.. IaQ11 ..L:,.. ?.LL?..? - I I ?"I'll ?°HhlNici °I „A ? ?rsDy T? ?..17."?.. ?- ?dT;B lrl nT JI.,rv i 1 ? ?? ?? ??. M. ? ? ? ? ? ? ?.,,w la !( _ ntx •Lr FROM TO I:• r I ..1 0- ,,, EST PEOESTRIAWPEOAL CYCLIST WAS USING: ,?*.°,?Na ? r a?R,BUaINA .?] NA I? ,? .IN { S?"?lh 1r r I 7 t ? ? .NA i° ? vA., STI PEDESTNIAWPEDAL CYCLIST CLOTHING COLOR. ,?°,,,, ,?I?a a? I',, S ,a:? ..J?AQ.BVlf AGF- W(ATLw_ .;. Zion( GNQlTIDN9r. Ttkt(IGLG!ITPOI,,:?t?... TIPF ? Gf9flM.::.. E3 w?P_W4YYfd11QFR.ACTIYN4AYOM t uarrt "a IaRC. orI c w Icwa NN v [ nKal I CAr I I 4 i ,I? t? OI r OIORr , ? w.M0V0iAl°A l ? DAWN ?1 1 ? SIGNALS [3 , I C] ONE WAY ? MI , ?l GOING STRAIGHT AHEAD 11 it l ?RA,N,NO E ?OU[II ? L ? uco MaN L TWO WAY C] I , T'? '•,. EWWO ? A ?W[T 0 [IR[[T ? ? i ? OV[RTAItINp AND PAS/1N0 F t?..( I ? NAM,M a ? E.GNI[0. ? 1 ? 1.1064. , REVERAIBIL IT f K i ?T ? 13 ] El- , ?fOO [ ? ?IGNlf 0lfiT ? I ? ILASHWD KID, - ? A ? NI[ CNANEI[ 0 , a YA[INORpNT TURN Tar, grot s ?. ? L ?IC[ OTHER OARATaO ILOOWRAYPI MAKING LEFT TURN 'L* p D11I[A E ? IM`ICUYI ; ? [TIIELT IIOHTA C] 1 ? 13 ? fIAYRNO AYRLR ? [ ? ALL" WAY. El 1 ? MAKING U-TURN ?al?Jd , 1 t ? 1 LREGrY ? SOI L,iv ? / ? RR 64.M. 1 Y(' ?hh [[ y 4 ? ? ?, pyn? [•.. W+.A .,NDADWUY N ? L ? SLOWING xwACC[Yn LANIG ?' M'f Y, ? 1 [:1 OIFICE L GMAN 11 Y A"5' I ? 1 ?DRIVEWAY ? I ? STOPPED FOR TRAFFIC r hit} ,y N. ...a-„I a c,'?'.. ?,??+,I 1,?a•?. ? L (]ormAmte", ? L [rorolpAr[mNAL 5 Q Q Q Q No nM c ? T? av om 1 1 1; 7 ' }?Ia?j? '(_ry1 f11 ? ? 610PP[D IN nOAOW Y b 4 1 Z #S?F^! -'S' YT"?1Y. I 1 UNOI OL0 0 IRAIf CO N/ tJ J i.11 ,,J.?E 'YN1 .,?§ I rw °y f! ,'.rf ,w.' u: ss?1 "°4°: Y r S ?e rg ILK • , X11 'L , ` 1 E ray a:..'„wr,. _^. ,'Yff,• .- -- Wrc......}iD` _?'i?. ,..E?LFY. ._.. ._ -•..1`L ??4 'i ?/"'? OTON d -" oT GAL US ,onLr ?EIuE COLLISION REPORT n0U-TI G CITY ?ux a '. f s o`? couu - i wE ? ? AH >k.>d w ?x ?fE "ra °w Dwa ' 05 aK ?E.ro EE,ca Nof i* n Z t7 ] OE ?w El ? b ON Ness) D R P H? A "' 3 x G33o0, .e. r„],aEErDR ° xx,rEAEEe, HIEII. .i p E wx Er xDL,a• w.r ../ 42 a6 N p w Y ad ?ac?4F-Pei .5etl z,5 Ea Ea1PDE. caAMD,« ?. `, .. x nv ? ? NMNIBWIIMSi1BIN! e14Yq/AL1 B AuTml 1 m"n OGJE LEB ©.? ? B Ni4 ^s o,crwEU? ? L? NEIEPExCF?CgO53bIPFEI ONPOA E`? ?7. iflUCK" „ . .;.. 1. .,. Duce _ : OWNER PF OBJECTS NAME,ANp.App?E,ySg. fa?N, ' E°eooE USe 4 4d . .P!11YE1'? LAST N -?:.. R Ax Gc ,? ? ' rwra.-..L4.MI9R?€.. E nvOLVED G6IY€Hffi.LC'iLNANg.i.:'-- ,,,_ •, 3 {.. ,?'? : ? ?iNT Jean %?•' c T s PJE§I.NAME .:.. -.MJPDLE .- +' STREET APOP.ESS _ P UjE NO, ANO 60%,upu. swfAE STRE OOp /??• w`Aw r P ? ? STA IP COpDE EzgYVENS OusEA ??- ?"A?? ?-- - ^"UTE NO (IND BO%NO. ` - iPC'? E 1?GX S/ CITY Z QCCUPATION ?]' _I/r- f/J?^` lJ LPogN CITY.,;_ ??/ _,STATE /21P000E DRIVERS OflIVEfl'S LICENSE NO. r/ J 17G OCCUPATION::. ?UA? '11 FORM STATE ?E uo TE.O y. B19TN,. . GE PBIVEfl 5,41pENSE Np ?DAr NTTSG 3 6CA (?/ 3 ?-.•. STATE E OF BIgiH AGE IIOv:UAtJ "' ' ? .VEHICLE YR MAKE (CMEV. OODGEI MODEL (NOVA DM J P4PY .Y1...liJ?dl ' ' yEHI[;?E,Tj), aUIE(:jpHEV1 PO P " ??' Q ?z? ;;! D PQE) MODEL INOVMPART) POOY STYLE I2 OA.) k 3 nn -l e "`•' LICENSE PLATE N0, STATE TRAILER P / 97 ? R TS UIJ U//J?'/lAWA[J //A,EveadAfl 'Y P. LATE N0..;.:::,3}TATE-... : J.ICEMiE.PJaTEpNeOM -:.i. $TA7 `..'. N Q /O ??-_ .,.TNAIEER PLATE NOS STATE.:..i " YEHIPLE IDENTIFICATION 22 x ? 6 Lj ?,j NENIC4E ENTIFI D G.. ,,, .?i' yJ sAn N ?': flEDISTERE U OWNF.(i_IIAST•FIRSr-MIDDLE NAME)' _ OjiIVF{IS LICE / t f /7AC /?Otun? .,y flEf115TEERED Oy/({EItII.AST jIRST-;I?IpR1 ?N/eME1., DRIVERS LICENSE ND. °?: i• . owNER' ADPRess h c 4NT fI P//!ic /lbrcJ iFNDT C Ylge 1!I// -17d41JA.)'. IeTREET, ITY AND $TAT ,.Po TEo FBIRq H,,,.pWT1ES:S C? r 11 AGBE$5..,:.,IBIflEET.GITYAMRATATEI :.: AID TEO yBlq pH_: 1 PARTS OF VEHICLE DAMAGED .. :wl oco EY Reap _;vU GE Aw YSwcL? PART$ OF VEHICLE DAMAGED S?ufl v ° t°(r P . LIABILITY INSURANCE INFORMATI -VEHICLE NO. I. was THERE AUTD«oBlL eulrv WSU ANCE rte/ $ { e57PYe D J'e n 7 q/oyG!/ COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR LJ YES ? NO 3 r °Y NN?EAN flESSo flIABILITY.INSURANCE.POLICY.tlGLOEfl .: w•+,.? •,:UrL,i,. ?mca s x r ADDaESS SC?Q r/?B s •:?•.•• ::Tn9M u^eluTr JN3yR11ryCF.FOMPANY ..;. _.:, rY' NEw&.MD,AQ.PA?$5,OF N-BISITTJN§ SIPIA r 40 W 98/D .. s ..'?.,;,.i :L a TI.?oElcr ryurAeEry...__s..::,A,......? • YST INJURY.;_.. ISLSEPARAE Po - NAM .-.._ •.- __..._.:. .,•.,,-.-•, .?- ITT FORtiDD i1_ NM I—! E51 AGE •? ? ? V4YSNED NAME -.. ADDRESS ,$E?L " NATURE AND M F '' ADDRESS _SEA EKTENTOFINJURIES ?? NATURE AND M F DID INJURIES REDU1PE DOCTOR'S EKTENT OF INJURIES ? ? E M TION BY A DOCTORi D ? N ME DID INJURICS REOURE O ? DOCTOR'S '.,,yrSIAiU90F INJURFi1 E%AMINUNEY DOCTORi N ME k ? ut]r _- E. ... ES..;A.:,,g-„•„ IATJd3yEIN,1uRE0 . MARK BW _ I ronom KFI89LONEItMT1Y2PNE$,.?.... ? NO KILLED Ise eni 'u'? ? p-, ?ro a1n unit x11.1 wuCi T ? x NO ... •_u KILLED O HER wn E I ? 50 60 7 ? ? Dnlen z", IN ?c 5 ?I 1YNOR1 MO '.°un `I* 6 ? ''r;ET O MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SHO NOPTNB RRG CRCLE -. :.tir. nAeluy '? ape :;-C OFS BELOW.Y/HATIWPEWP:, IREFEATOYEHICEES INUMBER? •b xE x01. VF??.fJ.Rf?CLa /sc-_ea-.?_ ?-- ,w ?GCn vex,fil «?IwDw r\ \ ?---_`--- tSyE ' VEHICLES POSITIONS BEFORE COLLISION 1 5 W VEHICLE N S E W ON STREET Oq HIG Y M OR, O ~ w;"oSCeciO INVESi'GAiEO OY 5 !9"??.`?j/' ?5ti ,?i 1 ? ? ? Y.. °"E°" •n °? L ?i.?aa ?.°°'L"I`ci 6 {''t' Y5 ? „ IMI. erg., ? ? IV ? T fit eLSt L ,OwO0 0 ::O ? . ? 09Z.. '?, T .•A,..,..r ? ? ? ALONG ? ? ? ? ?µ«ra -•) 1 , 1 ??.}F I? i V-l PEDESTRIAWPEDAL CYCLIST WAS USING: FROM TO 1"r' r ?J _ EDS. .Dtrr+E1•r. ? rn« ) PEDE$TR1AWPEOAL CYCLIST CLOTHING COLOR: wN• E?W ?i n }I° 1 a ?`'yy,, -ro".? Y/EATNER _ IINtT.GOtm- TWO c ?p } . _li 711odx'4$ r{ y rc.K<. a..r 9 CPNTgoL - ?s14=4 t?{1 1• ?-? ??4 .?AO`ApWftFAC>f.. - u1« wnrGHr r?A.AA. -wl? irAKC. m.i?O rope ? WIri 2AA ..,ulo..E ... EM'E!!!F}F.?CI?o 17 rTP. IWEL +4 ?Y Tt! A wa1 •IV 7?? 11 I` T ? I ? DAr? wlwl°a ] ? awN ? 1 aronue w row ro I ro r j CI ] RurIWO ] ?WSK ? ] ? 8IOM ? 1 ?IOHF TWO WAY ? 1 ? GOING STRAIGHT AHEAD +TOP ryn11 ,1y ?1?^F41 1 ? ] ?Wft ? ? E WAY ? ?eW W PA, ? ] ? OVERTAKING AND FAgSIND I V Y 5 ??Y1'I3e f Fr ] sNe.G 1 ? .. ? ] C] 1 I i ` "J •y'R'-? ] YICL081GN ? ] ? gOIO SILO ? ] YAKINO RIGHT TURN T f 1'!. 1?FOO [ ?IIGHr+DIIT ? 1 ?IlA]nWO N[D 1 WtLRG NOE ? ? 1 ? 'Cl ? ] t?f CArI L OARKNO ? ? ? IIPOPIRAYPI ? 1 ? MAKING LEFT TURN ? ? 1 ;I]??d'fy1111}5fv'? y Ot LR LJ SirvEG LIpn1S S ? ELAsNNG AMBER ? S [3 ALLEY ? F ? 4AKIN0 U•NRN 4 ? - ( I ? F q1 N A p ,fli ?f .t' S V[CW L ? VI[C,IY - ? L ? RR WHµ ? + ? I' MY TN; l J ? ? L? VI' { r fW,{q;IY ynY "v•Viiww'i" AY lu+r AGWAY fY1VACd.7YeL.... / ® OIIKIRILAGMAN LANES ? + ? +LOWIND IJ 5 )f' (( I ' • u.,. • ~. y' E?Il 7 1 j1y ?r 5..,1 (] ? H Q O .ru ? [ ? UfH[q. -CITY T 00 r ? I C] CNIVM'AY + O W gOAOWAY +IOPP DAT BIONAL I.? y 4 NIP hY Il r h{l L. :;' ry.. S '° n ? E ?avw[D oRei?PeIGN F/a er? } tip A t+ ra ? r !`??? S STARTING Z?"Mr ?; l'Y1fo v I ..fi?• o n v tljn% iif?iL Yr rrLr ! I ?" I S+ '? ^ S s I{ I I B k,r) VX»`rL;J@Y,1 I i_ It {5 it r if ! ? S J•.UL ?- rrJ 4 ??., ? E Y t ? I'VI ? p 1? 1 TM1 1 ,i: I e .>? T i ?? QI,J?9 ??llf + ? -? ! 7 1 . 1T ) II r I, ???y§I II - ?I S I { ? j? ay 1 l'q _t '..M I r rl ???1 ..'r ?Y/,/ -- ?? acsf sQ - dYLs 6?6 r ? r ' t ?f ?irf r [?A?r POLICE TRAFFIC COMMON REPORT IU` TRAFFICWAY r a¢ RAwi NUm '. PRIVATE WAY - -" N u cnurvrr NO nrr NO IXV]A / T mf cou /?I r r -:., 9E...o- l?l«lo.? I I I'Lus? Xou91 ??FFEL'SON - ? °°A.+. ?N ?E ?IN arro9ro s.roasrmaoe.9c r ;y Aw ? / N 4 P S N ns 9W,Ep1 ?9/DO OW E S- /957i All- ?E w OF T ON j? Nusfn NC Sm,X: s,9efro9 aowD NoNlNUaseeigN afiwfEN '?-- s,REEr a , s.REfr A f Mlu rosy p ?• ?! / 6 DISrwNCt 1 f. C90S531vf[i NfA9fil Milf 5 Mx[S v N SR OR O! i 1. C.O OO, ZSO lfEt W ACCIDENT MILEAGE CODE a DiAGRwM-'A ] cIXUSgNINVIXVlD KRill[D-NO.INIU9fD? ?SriltAG[ ?MU O,M NO a9UN OV[Xgle3 Q r90RR,rD"AGEO"lY ?RSUIi[D ?vF?i[I[ OrX •'D IN IM[ Cli C f9 1 R a90AD 011 HffRNCf 903351RR,OR ROAD ' FS,.DAmAGF Oe1tn 519UCK I- a OBIICI S,RUU AND -1 -1 5 SRCW CODING IAf UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST Demos NAMe: IASi rI9, ? B2D L(IAl ?/?/1 M?. ?f. NU SNAMt: IAS, ? ? sUfflwoefss 1Rn ADDRss Z PO .Bo fi ?3Z/ 3 - 6 nr -.l ]neon rXONf NO Y/'Fea' "cs !JK 99707 6-3696 D R N N. Ale zw / ..-Ucl-o SrA [ • All D I 1 I N wrf mD D r' :. y 7 y76`1 IBC 6 6i, i Z w-GURATIDN FARgNt NO. Ens GXI ItgNr 4' ' ' BQ P6 W E R CUXAriON MNAMfarIKNtF NO. Fn$ IGN, HIGM ? CHECK (,I I v X a ANOrXfa l ? CMECK (? KXi if o ANOiX eAl A CODES ?' D c J S r a yO ,, a i s 5UE 0 iA° ?" .;r. CODES ?' 7 cIss ]] Z IN wxs cl,T s oa /u,se D 6 @ w ie ° ? A..9 ... UW ? b rt. ? 1.11 4! ? 11&1sF „ MyoF am ? -Von- ' ? w.. ? „gin ? CS n KN rtw9 MAAIIDOOGf.e"eV.l ?/ oJE2GU2Y -11-1 ^' S,rLL 1]DR.. V.I Gy vx Z, o iZ . E Y I .1 NODEIID AI X 1 X. S,AIf Allte 0.A,E NO. o H KX. it /.6/uc 6y2-118 ,9lC• '- - I C QD KXK1F IDiMIlgwigH NO. I IE P S 19Ew(o3o I L v Xi tiMMI I w I I I I RIXSrtnoovnue lASr rwsr MiDOIE Sri svE Rlornw l o W a lASi Nesi s •Dwfssa ??nn. N E av AGw, Ea•Dwfssa mswuxe eo R III ' . iJ S U/ C? - AEU ^ " ^ T?AmAG( AAUP ?? OM" cXr?acE ' NE cX,uGE .rD. ,o •o.•Ge Es?wMACf ?Awm: ?RV.wMO s I ?eviv ?auwMO Es, s coo AM Dar OAI T rti ) ? iowroa s DIAGRAM OF COLL ISION: EE Im"fN e Na ,," DESC RIP TION OFCOLLISION: I-E surruMeMU LlH n NfCI3wrI i Y o N _ - -}.t _ _ ?tyh. <_o_n.?_-1??f R Cakes=J??6 I I 1% N AME, ADD RESS 8 1NJURI ES OF PERSONS INVOLVED ' CODES I - 7 3 4 5 6 O CCUPANTS / WI TNESSES ip wa, oroNU rµi. w" Fii H. AcE r?r I,?" y'? „'T RSIa Eacr 1.i,?; N.mr _ _ . Dwrs r Fa r M ?, - N irwEa - .IrID F.om p• e 0-10.11 ? = ? Ns. ° 1 E#e.3'.- ?MGL??'7+Me4 •e+1 4:T?^NT : L??tiaJ. 1 ?lJ dV d L d4 A dtlAl t >? jy 1?. Ax.rflg4G"F : 1 ? l ? A I ? f NF n11?11.FxAx 'IMP rf I;d Itvv?? I F k L All r PRIVATE WAY p Q3ll '- ?! nMF ? I 0 r• y,, I„1. „ CODNIT Rv WY. u CDIMIY Eq. R w•E IUSf)WDNOURI C1YN0 , / / , x NWA. 20 5? FFEFSO+J ? R•w ?N ?[ ?IN O1Y090 N Ef NO IXSiR[EIOR IRGnWAY I OS Al eWif OA S AUlfs ?5 w or 7UnSr>EC% N ? i95Ti/ugS ON w ly9/00 INr[ekCpNG n: STRtfI OR ROAD NON IN1tR5[CtgN ' eix O. MRFN11 O BliWtfN ?- SiR[[r f n - a 9 / S1REH V / . G DI µCE I I M t .CROSS SIef EI n[ARFSl MIIF ACCIDENT RNAP pIAONAM DATA s N ZSO Nfr 5 f w OF 1 O MCODEm"We Y LO - E CIXl15gNINVIXVtD [R«Y: IN - ,OTAL 0 -11 1. [0? RWMOR4rF NCE DN -E- `NE( No I I I» VvENI Cl5 CROSSSIR .ORROIp S OPl91YDAMAGEONEY 0 RW I[p ?V[aCl"E OBJECT SrvUCk lNVMt OE OBI[Cl SivaR µDOwN[v'S NAMFI ` ?7?? .-AMAGE SPECW CODING USt 3 ...... NWAE: uul UNIT NO. I UNIT NO. Z laVEHICLE ? PEDESTRIAN ? PEDALCYCIIST nRS, E M ). / DR"ERSNAM: E BRD ' tUf/ E/dolt d . Sr. S,RlEIADDRl55 rear Po ADDBEss ? / SrA,F EIP CODt _ENO D / NYfl9i2Q9/eKS 98707 y -3696 R Y AN R"E. CENSE N S y 7 /176'/ aCUVAiION R AM-NINO A f1 K Jy I U tN % D W ?s o V A,F p1R n MD DAY r. . ens Wli KIGHT E CUPAIION FIRM NAME f'NONE NO. 2 U - [ Fs IGNr NE_ B(L P6 •?' R D CHECK(. + w. vlw E A„ Nor«l. ? CHECK (•? EASANI ' la a C r ' A wN ' F", M ODES y 7 Ass J . • 3 s M NomtR 5 1-- a ?vl 711c - CODES ? ) 7_5 1 + ar N 1 AS unro" 6 Nn v Z INE u ue - CJ75 0 {W )] o, „Ay. ,yV Y F .n1 D AuaA1 m? 4. . G M ? AM Ntr Vtn YfAR t " D t'MrnV ? h Ku ? ii .c DODGF«FV I IDARI.NOVAO SIYU (2D.. K?V 1 n Al l Y 1 MOOtI l 9?N /'7?PLti2Y Gvltlx 2!-D12. E slxre mARER nAiE NO. v.n H -c ?•6/ue 642-1/8 /??'. ?- - I ". IATI VINICIf ID[MIIgAIgN NO. i VNI IRAN'.. 40 I E P S 9 E I u G Sol I I I I R RIGISRRIDOWNl µ5i !1451 IWl[ `NON, 7 _ 1A51 I1e31 O ) ADDVtSSOr 01M4e W Z N NAMI E ADDttS3OF INkx1AA4t CO. d AGIN1 E . 3 41 K R .1 MEA ^- o'I"' ow: c«Aeu yC c"ARU ," w [?ro",D„l SA EEA°u / I . 3 s (XiC/ N 1?Ap°SY'AY ?RAW l NID DRIVEN .UNfD AWAY g NF 13.0 •r .tor 3 .I' Aw OrU L 771u s loionnl• e.J ?I.AWA .D•Y. DIAGRAM OF COILIStON: nl N N M • ? u e ussffq - NOC;' F IN sY RDW DESCRIPTION OF COLLISION: lus[surn[A5EI4Al sIanR Nlaswrl 1!E?fiClC?__l 1l?2Tl?000? w a17 1EiTi - - - - ? ? 7b vEE2 7o TAE - J I f -!P._... X01 cb } ? y . lI ITi1 L?6 , / NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 OCCUPANTS /WITNESSES ;p;p,!MAAVSI .Ml N R --... _._._...-_._.._-..__._._..._....___-.._..._._._._..___. __ w _ _ Nw+ v?r _rur. 4 5 6 uR Aa lilus fN ns1R EEIa '?• M11 ADIUHf NAY OF AMR D 2A. D w . ? H ? It4:,• r ? D AM• 0 h11A1 D"o.N. ID ".4 ?I:° °0 At«w 5 - NAIpIfW .... hrIS,GAIryGp KI•SINMIf •Ah• AI•IS G ,pE4. IM nr ?AUr ?^?' ?w. ,w1•?2. Q,•, X ` b/ z ? ,D ? oll ra9wEz ?zDD.11.x.IN«I . t i T yaz ws/ ?N.S )aD .5 z ?a LY rv W I - i IlR l r 'E NoFJ - I? v 0 WE r?W h }1 lr T F ..t - t I ?/Y .. ` P Y . t r ? W I ?l fir . yp com. r ?' [ I ?L ? ryl'! - I I k l l ?{ ' 1 y.?? )S? x ? tae f A S Y 7n ? ?, .: .l ( ,I F ? 1 >', ? y,E? a l?k? I I r ' ? L J '(r? ¦ 14M?w f 1 '' I t7''IT 11 r ? zPl POLICE TRAFFIC COLL NREPORT [,jTRAFFICWAY ? 1 4 - tC I 1B R PRIVATE WAY COUNTY -? ` " E AN NlN F . R• I wn w WO?a10 .. w IV?bO OUR cauPE No ntt w. p{uReA N WAI 99 pF p r,?O4/I? / 6N00 SIRtEtO ?5 { C/C} ROUrE O9 ? E ^ C yyCiC3uC... oOll ?? INIEFSfC1ING SMIH:3r9Efr O4 WAD NON iNif SECTION .lL o?zo eErwEEN Sr9FEI 8 PRfll% E M4E POST - O.Ol? - H SIREf DS ANCF 6DR 1 f MNfiE CRO Sr9Efi 4 FA+ESIM If ACCIDENT MIfS D DA}A _ s iEfl Of /? WL ?`? Q F MCODE E COIUSgNINVOCVFO. SEVEPIiV. OtAI NO N0.xttD_NONJU9ED_ ?SNn AGF ?NIi89UN wRwRIN MER C1 CR YBSRROCNPou OO -ft esvm¢les PWnarr DAZnAC[oNtr ?aesuufD ?-1, FE OB C 510 xINAMED GBJI r tin f95J'^"'F) FSi DAMAGE 1 9.S/7d 3NKIAlCOD NG USE . - 3 - UNITNO.1'" UNITN0.2".' 09rvCR5NAMU Sys 5r i p rHICLE p PEDESTRIAN ? PEDALIX QI$T -. \i IX J-E /M•I/r/ p9rvER'SNAMF: N S FI StRtEt ADDRF 9ffi MpaESS sure nacoof NONE NO . D Y suE I o Nf4S LICENE NO. ?NC SrAr R ' ?• ? ? /J (i ?•jJ• M oAr? I yv l(/' I V I l N AIf Al _ cu-1- N OCCUPATION 9M NAMf6RgNI NO. 3 iGNi GHI E OCCUPATION' {iaM NAA1E6PNONE NO. ETFS IGNi 1E ? 2 a ?xy? _ R IGHl U CHECK( I rt{, cl As AN ANOrNEa l CODES * " A ? CHECK (,I) n EAS AN M NI A P OrFEa r 0- 5 I Iclw., D'sP,D •a? 7 a : . i in a J " 5 E x e u CODES ? * 7 a" a ?3f siineu"' CIWN RM1 rGU ' n - N??MFr IF 4O M E IN .1 ? ? A NRF ? 3 EM.B Vln. v[AN EIOOOGF EV 1 1 ? ?b1.F. ? r;:"" I$? AR O .NOVA Sl t „R p,M r ?'uV" ? Cbdn ? { n ?".R;H. Ku . Yl l CDNVI I Y4 1.1 EIIDARI. vwl l y,l 4w / V ltt SLA,E PMIER HAr[NO. SrAIF H vfN 4 t7CiTF}?- C A W /TE G/ to - - ?? I ,? KtF IDFNNNUINMEN0. c - s i ?fG 7 i VEni DrOtN Or A 8 ?_ 9EC/Srt4rDOwNFR: uur ri+si .-. pol[ -FR:ND. GO?/7 j O r LAMER: r?RSr N . - Cp d/?E ADOnzs ar prmeR W L9 T N wN 9 L O oaJEltc..} AMl8 ADD9t33P?NW+ANCE CO ORAGI , E ' . N ,1C ' R , U I 3 A.3•AGF ARIA p,Ae rD ruxcroNU Q - ' 0 AMAGFO AR[A cNM no I CNAa r i•1 r ? g • 5 `= f? ` %J ? ^. D ? E I roNtO o4AWA Y NTN ?1IMAINID ? n, f5o DI FE , :otlow 3 AY er: ? /G I .J D?J Ar er: f _ DIAGRAM O F COLL ISION: lu eY r'Win DE5CR IP I ON OF COLLISION: J- SWnEMENru SKI TIF NFCISSWr NAME, ADDRESS 8 INJURIES OF PERS ONS I NVOLVED CODES I - 2 3 4 5 6 6 N OCCUPANTS/ WITNESSES ?abo??a AME w a°Rwi i ux Au IArus '"sTM var- NO r mr- R r• -- I514 IACi a rr r . ? ns N •I?9 .?. .- • DO4ru ...... p ArEUla- oNFOrWM aAAE N A N ?v p.Me p p o r ? n. . .. I . p C, ? r"P q ... ..- .. .. .... ... ... F .. . elro{ oars "'A p• e p;; cI p or. p+D INl nr 3 GVrKI+Sr AMI r ? y ? D ,q ? Gr1r IrC O?? ? Y /?? A....... r DT X }aq nRS }Epp nRS o°o ? O ?I1 Ell a U ?. 4 0O a dza V . STATE OF WASHINGTON ?t OF No. WAV I 1 0 0 9 1 ipl inr POLICE TRAFFIC C ION REPORT NU.Meee RIVATE PRIVATE WAY 1 • A .D orcal. ,w riMk 'IVS ]iW UOV41 counrr cwnrrr p i A clr NO. x 4WIE O451a[ iNwA ? C W 1 F.. '" I /? Cirv Oe IOWN rv Oi 11v[tr O4 wONwAV Z(Tyla ?S pw ?oi /?7Xil N O Cl Cl 3 0150 s • .^? „ N1I45ECr1NG Vern. 314[[r Oe ROAD NO ?pSf??C1??N]N ??//?? /y/?f??? BLIWFLS!/1?E??'?MlF-G%r/?r'U' ? FN% </L?'e•?n E MilF V03t. F"1 .-•y .C. I 011 ANCF AD VET 40M eE1F4[ CvO111IVFE100 NfA4f5rM if t[S S f w al IX G?,Qe.l AC IDENT MI EAGE a Me DuG4AM DAlw V NG Iaf ePoAD04 a1EaKF N 4 ] X ?. CIXNSgN1NVIXVEO ?Se IIAOE ?N116 eUN N01N1V4[D p [¢IED w=w ?. s N IMF4 f,13 C40555t4f[i O4 vOM - ? ? n l0]AlNO ?e40a4rvOAMAO[ONIr ?v[SUIrlD ?vla<lf O VlNK FS = O i4 F OSIICi Sr4UC INAMF DF OEIfCr SIeUC[AND OVMFe'S Nnmfl fSr.DAMAGI 1aCi.SI COOING U SE 1 ,., UNIT NO. 1 UNIT NO.7 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 1 - s E 'R 3 DYrvle's llwMt: 1 11451 M10 o4rvf4'S NAMf'. NSI xp; } s1eFU ADD4ess lake ADDVfss ? e 4-7 w Z r e x?. caa p noN[NO D r -'sole c rife i Ov Fv'31 CtN5E NO l'1o5nz SrwtE M I "nvY ?i m al D V U tNSf NO. Ar! _o I FD^ e17 . [ OCCWAOON AME6 NbNf EIO [rFS GNr 1{N:Ni E 5CCV'A110N fI4M NAMEaeNO Nt NO. !r[S GNr ItiGNi .. h-., [I CHECK vfNO As:N fMNV ANOr4fv Al ?CHECK (V) KIE ASAN f.MOior AIgINEMAI 1 • '1p,?' '' - u.. NN .al nc1 CODES?f D? Ai 51 e?; CO E no.. SIA av CODES ? :u b Z es 1 D ...n ..K Kl ? M. ? °. ? P.n. r1f ?14? -M A,A 110000E <Nfvl •.vO0E110A91 WVw) VsIVIE I]De.<IX+vl °:: ? Y,. l N.r I V e E ; ? bm ?„2u ?".01- MOIXl10AY1 NOVA) 1 vl '7O YY1L? YLIOtTr E „ .r ? a. ?CLI• 11 M/f YLIAf.t ?(tL ? SIAI t4 M1wrF NO "L( ] 4 SIAIk H I C NN IX A ?r k ?' . . NNKlE1IXN1VKw11pN NO. L A i1 vfNltl[ DENT I I - ly .? (a?i i 7. ! 1 I I I I I l0 wn 1r I MI I I 1431 A5y7 .. JJ •. - a0i3rta Own1Y 1µf NvSI iDOll (NONE nO ?? O lA . Na ?rf p 'M +g"", Ia7 Aooassar ovmeY 533 7 S, ._>17C1U 4 JA- u V1. s lslwwMACe ? uww ?41MUNm 1°lwwv ?4 MD uI. DAM ! I Ibiorio+ s t .? 1o f . ti ? ilrweD ,_n.n _ _ I-l rowTD_ f ? a2 -frll7dN_.C'itT+ s`r T.L'OG. ?EpCG. NAME, ADDRESS 6 INJURIES OFPERSONSINVOLVED CODES I _ 2 3, '1 5 e ?ij OCCUPANTS( WITNESSES Iusl ,,,.,,NS IN yy"I A01 JAI ''N aK "VII' 4.f" MSIY fACI v,',<r JOY ADp ONN "s, ?? I T xxwg j . z. nl T MOTOR VEHICLE COLLISION REPORT ou"r CITY MELIS$" LIK-RAL P, " oE, "?AM ° D"r ' 2 N2 0 4 F?e syL? I ?N ?E ?Ix clrroN Own - D[xi »AMELNo of 1lIepLr DagnlLL r. us A M Cfa io?f YY1Af ?" ? pqE o {rRElT COO[ Lmr 0. wlES Mato ?5 ?W ?DI RF`I- TowFlsenCl ga[mmaw (n araEEr Dq oA n asfcl n L ON pxE M Not d~ Lx nxe Soo yd O A E a`6 „, ANDMAaA WAOx a A 9. ? d E oL ?. x ? EEr W er?o F .N: » rE DxINVDLYED EL ' / D. usi[LawaMe eE ? W R GLS E ? w RO a E aw Owxe a ?[D CgossU Or O VEn CL15 O AD ?&IL D ?v[?[ LF ?ca ANUO»•E9 OBJECTS ro rl N TRUCK (NAME OF OBJECT STRUCII OWNEfl OF OBJECTS NAME AND ADOgE55 O•ir}?r Tpic -i tI E j PAw "[ $ ,,y r A • • I MD" a DRIVER'S LAST NAME Two C ARS .S 99 FIRST NAME , MIDDLE w1: L' ? - - p111YEfl'b LAST NAME x INVOLV ' I .. .. .. ..... .... _ I ED .. .............FIRST NAME ..-.... ...__..MIDOLE ? THIS I! LL GDLrI= 6 oy STREET ADDRESS ORE THAN TWO ROUTE NO.A?D BOX NO VEAE STREET ADDRESS ROUTE NO. AND BOX NO. INJURED / 2 0o yt . /7/ /Q? C1 /oS EUSE A I IT CITY STATE SIPCODE DRIVERSOCCUPATON __. COLLISION ON CITY STATE 21P CODE DRIVERS OCCUPATION REP IN, .,:? :_. DRIVE '9 LICENSE NOG 7&? 'S ATE SEX DATE OF SIRIM AGE DRIVER ' LICENSE NO. STATE SEX GATE OF BIRTH AGE VE I/CLE YR. MArcE ICH V". 10;E, MODEL INOVA,OAflT) BODYjjYLE 12 Dq.) VEHICLE YR. MAKE ICHEV. DODO MODEL (NOVA-DART) ,BODY STYLE (] DR.) LICEN9' PLATE NO. yTATE TRAILER PLATE NO. STATE LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE Z `/ ?/ VEHICLE IDEN.....TION NO. VEHICLE IGBNrIFICA'IIN NO. REGISTERED OWNER ILAST•FIRST•MIOOLENAMEy„ ORIyER'$,LIGEN$ENO.., _. .. _,,, 5,4,gG /1.B ?? -- REOISjEREO.ON'NEq ILAST!FIRST•MIGO/,ENAMEI,___.- D Eq'$LICENSE OWNEq'SADORESb (bTHEET, CITY AND STATE) DATE OF BIRTH MO DAY vR OWNER'S ADDRESS ISTflEET, CITY AND STATE) PATE OF BIRTH M DA PARTS OF VEHICLE DAMAG,Ey ' 1 I Y PARTS OF VEHICLE OAMAOED o a KL 19 LLB I FST?15 $ 25 op s ny LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1• WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR S ? NO NAME OADORE6 OF LIABILITY INSURANCE POLICY HOLDER " NAME OF LIABILITY INSURANCE MPANY DDR Ar " occ g v?c D??ss:IP //r/sr/ i?t? ]t _ V NA AN pDA_990f LIA81LITY UI,.URANCE AGENT Irv IIATE DP LIABILITY POLICY NUMB{ /'i S /NS NC -Sao Y- 6 ` Su- S?A,?LE f/ s/ •?3S 1ST INJURY AGE ]ND INJUR FUSE aEPAMTE REPORT FOR ADDITIONA I ' L NJURIE91 AGE NAME BURo NAME ADDRESS SEX ADDRESS SEX EXTENT OF INJURIES ?? EXTENT OF NJURIES ?? OUI RE ' EFAMI AT%NfFYA CTOR'I Ej E] DOCOR E MINAT ON p S DINJURIESREOUIRE TOR' D DOCTOR'S OO NAME ? NAME EXAMINATION BY A pOC - ... STATUS OFINJURED MARKFINSr ONE THAT APPLIES HE ? IN yEHIGLEitl no..DS.•L ro Ra[ STATGb OF.INJUflEB ,..__._ ,_'MMKFINST O IHAI APPLIES . „_ VEMICLE I°iw ? "°"Wi D' w0 roS Z FOF N KILIED IKWMI IMOIU CCrrP? w ? KILLED I ?O D M »' NO u a ir w i eie ? ?„eu.. ,H ? 5 ? 6 ? 7 . 7 13 MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SNOW NORTH BY ARROW WCIgCIE MOTORCYCLE SAFETY; ? HELMET USED ? HELMET NOT USED C[ of Wf ??1 ?!N(IL[Clf O \ \\ ? O' WACK[N{ ww A[•r o nw,r NA„!, ON ? OESCRIBEBELOWWHATHAPPENED: IIIEFEHTOVEHICLE$OY NUMDfR) 'ew?? _.oQya%4 x a"rM1,GIL A 1 -? CD D •-- ?, ,? ?. DR NDNw.Y ,??7'2 0 N g?D ??L / i43 -(etcr.E L _ .LN9_?d/Tciv-__ VEHICLESPOSITIONS BEFORE COLLISION of l.nl• ;w rI Ar Dr .11 Muf NvL rq vea"»?c??occ"AL' ICU LrW P w ST o n fo ? VEHICLE N S ppLII W ON STREET On HIG1WAY NAME OR NO Di G , INS ?E ?ip NO IYOVN ? ? ' ? ? ®? Yj IIQ? I LW Qi ? ? W ?pK1 ?arM. IOINTR ? ? ? ? ? ? ? ? ? ? ®aa Nrr NusT- ? ? ? ? ALO D FROM TO PE DESTNIAWPEDAL CYCLIST WASUSING, 1?MR.N• 10-1 '[3- ?w•:: •?c.nAi.:°. •?DrwA r?wir w'?° •?nn•Frwr ?1 PEOESTRIANIPCDA L CYCLIST CLOTHING COLOR ,? c„? r?,rn,r I?N ID . r?Nr.na r [[ H cl;1 ?r..,,Ir L?y????M??? ROAM SURFACE WEATHER LIGHT COI/OIf10N4 TRAFFIC CONTROL TYPE OF ROAD , DRIVER/VEHICLE ACTIONS 'v{ La}Y?'^ J l.,jx {l'"" v{I•VI'Ar"G• DMI O11 OfgY 1 DAYIIGNT. C] I ?o? :X?A ] ?wwN I ? RAIANNO 1 ? pUSK rlrKll KFIC• ON/I ?)1 aLan NALS -. ? ] ? 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IW ' ? ? rRAI NC IANf SiARr I yG In- iFlo -& STATE OF WAS GTOKI ?r s AGi Dr 1 No 1 1 ? 7 7 7 IOT ' . _ RAFFICWAY POLICE TRAFFIC COLLISION REPORT -CF-AININI.WBIl I O PRIVATE WAY e1 D•q Oi<p0 N p I1 DM[ 1.11 1-oa, CODNrr r CnY NO [MVA ?N ?f °IN aiv GW lOwN £!NO Sle!llOe ruGnw•v 3 m,l[s g{s ?w or UwnsE.uo ON G'As ?'o G C12 i/J ?/ t AWlf pl H 2 r IMEeyC11NG Vern SI.III OP b•D M)N INIIeSfCr,ON ?,vck'6 airwliN Qu 6.2 v.m SO/u srem N [ mef PO31 ?1 L/. ' DIZIANCF tOPIM, POm. rieN E. <ROSSZTP(Lr N[ARISTmiIIPOS S NlIS 3 [ w O! A ACCID[NI MCODE E P CYAm D•IA CIXII'gNINVIXV[D NO. el--IYO. INIV.lD? ? YRIAG! ?n1Ta.UN OIAI NO .0 IMl. Cl5 IN PSL II f Hfr DQ HifHNa CKOSSZR[[l Oa bAO _ - VRpg m ?HrDAmAG[Wlr aVWlClli ?YISUR[D ?-1 ?- •/1 (_'{ -T srv«[INAM[ OBlfc sIY«aAND OwMVsNAmfl [siD Acf EC T s sncw coDlNG 4 - UNI7 NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST S 00VIe2![Amt Li1r RRSr ?E77Y L • 00Vlef NAmt u5l Ift 1 l - - Srv[Fr ADDPlSS S f?A HEr ADDH52 2 • tmE.e Zic7 sun OIVCOp PNONI NO r D I SAL C /Lf? ?o:' t Rfi' 3EL5' -7Z/ R Oe Nlv'fiKIN51N -vE1BL 75' Cd SrAr[ A F S A i3 I V -N. NO. AIL M N .' e «CWA110N mNAAn a.•[oNI NO. ins IGNr..., E OCCUPATION IIVm NAMEa VMN[NO. [tt3 IG.[I H[GM 2 t &V /30 S A R ?CHECK(Y) viNni AS.Ni a. •NOl1. ?CHECK(.l) Iventtf AS AN wnorHdANO A[ CODES I' D ?. &1 1 A °,sn S [ e [ KBD CODES I-' 9 v . °sv" M ,w 6 e• ° n 2 NNas av llyn 5 ?:m..K. ?'LU" ?"N ? uN S;v?1 MyorD ?m.. r o mrl sn. ? D o:- AM.f IDODGI{n{v.l A•ODlI M•PI.NOVAI ,y]/Dy CONV) V v A ( V.) IDAYI.MNAI 1- Y ( .) 01.7 1 n SKINL VIA frAil ,TIP RATI NO ZiA11 H Nn pCW AIATI /vE 58 -N 6vA - - I J v[nKIL IDl NLIIIII CAIK2 d 91 ?; I f I I I i vlnlCl ,pN, I A I N I I I 1 I .IClsnnoomw. Vsr sl Hopi P.[OM NO fLirlE ?S 9EDv? Sgn7 O D m+[le. lul Nni m. I W ADDeLSSa oV..u. S E E L - - Uit?,S Amer ADDeiudlNw.A.[ele o. ACiNI IpSi E71L[Rf /90w R 71 pUAGlO ARIA AE7 pyK Dyd ^KTwa ! ' oNAea C.A. Eta, . • P S I3? M/[Gl 1 GI AAWAY" WILY 1f1.0A 70? nmuwo ?eLmNN10 _ s f ioAnosr / Trl1 IowTDaY. WAY f Aw a DIAGRAM Of COLLISION _ DESCRIPTON OF COLLISION Ilnf-ww wwiviFinas vT { yz//C46 '& / ;3 E- ivG .COrLU[L I? I I I I ?I ?_.. . NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES 1 - Z 3 5 6 OCCUPANTS / WITNESSES is sw"Dlov :i NuY h K. AW IAIU MNA _ ,. - [_ ?. H51. flCi Yip rr N.ml •DO.n3 "- OA. . f11K' O "' . n ?.". O tL°.t.A ? Amt ?.[.?,Kr ?=. ? w ? r- I. e. N , . " Nlr I ... ...... _ . . . PMIf3 3 AAXid / IM.v ?AN! ?•[uKr ,;'. ?wr ? = +rv15rK.?vm:drKI.SNAmI t.AM lAMAM AWKv X pKlDfr•rC D RIIKiA .HD DAlld Hrdl DA • s; .?. r Sk> ,w tw,:i ':,,1r ? .. BfA? ..•r. .,. ??W ??:; :.r . :,,, '? z I'' L q? jf[i 4ak W- AV s tl'. _ 6i:'E' d 113' .Nlry Vt" 7WrLq ??.C,Y ,y? STATE OF W INGT®N G! I WSRI3RI4[V I.4Df 1 t` GI ? POLICE No I TRAFFIC COLLISION REPORT "'I' FICWA1 . /IXICF CO _ " . . 'y DM[orcau N ? PRIVATE WAY M4tAIMN 4 - .{ ? If / fu312Z ouRI X" aaC) CO N,Y SE-pfuz so >J COtNrly C In NU. rNW? - p AN ?? 7 W . h + • []N pl CUY 0410WN I / plN NAMfaN0 d314[FIOR WGNWAV 2 M4ls'gJ s pw of {JO27' -ToW NSF. ON CAPS IM[RS[CIMG W.IN S,4 GFSRG': ? ICI GS / RU4M RGUIfo4s r ?? .I , d ... _. IO . [1I0R A NONIN,f4YC,lON I?O1FTU PA- DIS AN ft0R1 ION ellwtlN S ?r41[ra "il Ifvu S1,4[!r I_ T(IMlF3 N Rt/ 4!N'! CROSS Sr4[f ON N(.4[3, Mlt! -__.__ ..._. 22 O 'x y '? OF MRFIOSt ?3 ` K ? _ $ r NO V(N CIFS 061[<131-rUCS II 3 vN1R3 NAM( -URED O ?;4LIAGI ?"I,a4UN wH41.1 p srdrN ?. SNMnr !( 4FSUt IFD pV[N CIF RIx3 1v -AGE E ?- I 2 '+b4• Nwy 101 W. ORT AN COp( Nq D P ?o f,dNVN GEL-ES vWP q%Tc -74, -vq-6S2Z R sun I MWAM+a 4-?OKQ w1a M IS v occul."- r la-GNO fns IcNt rf?cNr Z $-K • SLRV US 11--n-G- SMV E Bt V 14L Soq R p -?' DoDG£ TK r\ ?D Rf-Z L q 11 (, g "? , n RA'l[=0.M( ND S,.,t 'cl p iCA ION NO IT N. I 1 1'9 1-7 111 SR lDOMNrl4. IA3, IIPSt `? rS. A?` DDt! 4Ip1R[NO (udoWN1 SAM f_ sAM E M(a.DOR(ssd lNw4ANC[co OP AGEN1 NoN £ I f 1>I DyuG ?,w'^r ..••? <NUd -' JAMAGlp A4fA ?• olwiew l ,0 i0140ii MMMMD ? -Al 3I O ?oW+AaDer 1C SOIL 7o W low(D uwNeD Is A A., Sio 0 DIAGRAM OF COIIISION- swuu N Nu?u,l NOR,N a _LDESCRIPTION OF CoiIISION: I'h1 su4RUw/nu s141rDlRnswr( -?._i_ _? 7?-T-1 I-7 ssulrs- 9.,wW Nlri£ 7-`AS 150 N dEP£?3EDRrE RD H? L.I. - ?l.J y -- -E;. N,$OUND oN C+AFE._ T -r?, f ?,',_ vcu Iccc s Wc2vtn Zo miss A b I j-?Do" V£NIC,(-£ aReTt'SL?--.Cf'NT_LJf ?1N.E. A1JD_? I ? _._ _, jZo)I£-D o?_ILS R?GNl SLDE_!A! LNb_, ' I i I -- - - ---- ,o NRAME. ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES I OCCUPANTS/WITNESSES ?o::o.a,ll'NoN.rHUSS"'ie? - w 5 6 N.MI W .nDRn3 '1 I E 1 E. FRS "p° O I',o -7/ a, ?•, I,.a f. >o N.MI ?.. RrMicuLS N.wnd anN? - _, a 1 .Me .pax rs;M NnuRld ._..-- ?'WMDIRDM N.MI ?.Me p?.rp ? . p.7 p".° .aM o w f •A... s ?( A'r'^• ? - srMCxlc Nssx?Nrr ??r D D.Ipi OF nro.I "" p n:",• D WSP zio7 221 / w: - a-s- 3 r Era E?yl'{L ? `?" yg!& bar ,M,' !fl - 11 ! ^i - I lr'i !«.?rilSw\73M. ?I.+IS?,r( 't" I ', 4? d vVllY' r,'^' r?..,I 5E+.. .MVi f. 14 I.? 1 [ ! Nil, I 1 p ry cER,,Y t 1; J I M ? ? Y ?l if ?I,yy l t , InR J I iF I , ^ 4 ?F , ? P ? p 4 r 4/ d 1 1 I ? lr I W51 wlRty ,D) STATE OF WAIINGTON GE I OF/ ` Nu• 0 2 7 POL ICE TRAFFIC COLLISION REPORT TRAFFICWAY CICOFN IN-LIM01 ' - PRIVATE WAY -- r I "' f • I r " i t S F1i oi,. 1 rMt D735RI COUNn CgrN TEFFCPSC7iV C WA . Q . .... Q Qt O 'N Cnr OR,OWN NAM - -----y 1 ROM,t S ES ®5 JOW 18D PT Y15LiU? ON D/SIL,UfiPY /9). rMfeSlCIN OR ROAD NON NIFRSEC,rO 1.IIRtt RIIFAL ., N M[N%_ MRF PoST .E W[fNCiSL°FGfDRG t,aDLYII/I°/( 'P.65!! ,3.77 D5 AN t D w ?? F ' W CROSS S,Rf! N[•Rf3, Mil M N • IS NET a[I/S/°? GFG.AGf RD, COl1RpH NVgv[D vtvr,r ASI ACCIDENT Du AM1S O•Iw MCODEE ? S•su l S - t TOTAL NO KIItD?-NO. N-.ED- Q SII`u , QnTI..N DR CES NOIROI[R,rDAMAG[ONIV 0 RESUl1ED 13SVMi wnrDMC?" INTR Cl5 Q065SINFROeyOI?D ?gFE IKE Z^ l ? ? '",?.. I Q 7 i . OG1fC, 31RUCK IHNAFp Ol1tC, 5rPUCR NIOOWNERSIYM[) [31.04w•Ot SRCW CODING t s ? ?}?-; -"r UNIT NO. i na I DR V[e's N•M[ MSS, UNIT7 Q VEHICLE Q FEDE$TRIAN Q PEDALCYCLIST Dvw[R''L F 7T/7fWZZ e!2 /17 ?L£ 19UfUiU£ y 5, " r SIR[Fl wDOR[ D /W /?EWW15 .BLVD I EIADDRFSS N ?' Alt Ii1 COIX InONt NO /-72- ?uiLsfvv /G/2 `/e3zs Bs3/sFr - D R l. rv!e'1 DClH T/rr A t % I N % . MISOW 83?/I/,f F / y 7 V D.. ., acwA,roN MNAMeaHroNe HO. ens wnl ramnr E a<wADDN MNAMea .nWE NO "" '. R Ens rGN, NEwn r _. Q CHECK (V) v[wnrA • AN 1 QCHECK (?) o l r .., ,_. A CODES ?' 7 ?, v' s 1m a ,,,n'°;c? wIe AS•N eMnorl[ .NO,N CODES ?' D ai: • rt ° iv "' ? 6 z INn:?rts s ueroN .• . b unH 7> -.r a . 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L i1 iu? s X1111he" A 7X-f ? r t, ij D%siruhcY NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES I INN? OCCUPANTS / WITNESSES is s ? ?1N Z 3 5 6 AO o -S N•ME I a. Aci 111 u ':' n s,R MIC• IAC1 NO •DO.fss ?,lj? o. H.ME . Ma Q W1 Q wr' . Q a : III"' w: .Dotes ,w a Ay , mI' 0AMR t °.PSI °Nrr , Q az ?,iiW r S , Ih •COtI S "?ivtl Or v ?? I Y .M!?1 b ? fsle.,e.GarKlt sH.Ml at•N. ,ve.fi ' .It A:1 YCr "d i. oi. a< Ic A": G 0..1 ? ?:1 ?V e wto gErQ^o n. a: rno.ID.. DQ h I P ;., , , m _ ral I r . r T I ?4A r. r ( f.?ivJ f Ir J}??: } P ,1 4 I r .a ?: 1 N 0 y ; w a , psi o U O ? O I 0 0 !S W O i a O1 0 . 1 All rdBY .134aG ?'L < kP $f a ?"x ,& TY;t@ W..Ih??«l °?vr ° -" k ? '.l .P .__ ?t. +•._r. .+x ...+,. ..•v v.V I ?A'r?._•? v POLICE TRAFFIC COLLISfiJN? REPORT ..... ... +' TRAFFICWAY .ICU rol cECO wlNUMBIx x Y Y ^?' PRIVATE WAY ,, DAltarou, N f' oq ?L! w un DN Wa qw last Alo IwM ,+ 54 umf courvtr IUSF RMA IIOURI G C_" Y G ri r?tl/E COV I/Y NO. ?cp CIIY NO. {NWA OU9AN ffr? +? L ." k w [IN of ?IN CIIYOMIUWN NwMf4N00 Six[FIOR HO IWAY ALL., ?Oi 'r .?.?M R'C<4 O ?' • ?• w iClfy{t A P NWIEONSIRFE,/C 'V t?TO SFCiION drys tpV A, lrl 5tC11NG WIM?51 NONINIf45MON ! - OfM'FfN - IA 01 ANCf UI L iNOMFRF "Ai Y / SIPfEI ,Cg05551Pff 04 NFAgf51MIlE WS -.s•• Ml,S 1 E W RCN fffl N Of'J jr t'f ACCIDENT MILEAGE cOOE R" OIAGIll DATA ' ..' ?- - CIXLSONINVOIVfO: 00M ) U t01Al NO ?_NO NEUR(0?,. OSPIIUGE ? Q MII LRUN rUNO ao RWADOR R[EfgfNC f CLS climss iRF R E tp ROAp ]] Ci VENCIFS o PROPERnDAM.WEON3Y 0RfSULTIO ? V[O `IN ^- ? ? J ?1 ? ?LVyD or //lT/.2O 1 OB1fCf5IRUCKENAMEOf OBJECT STRUCK ANp OWNER'S NAME) EST D+VAAGF SPECIAL COOING IAf ., ,. ' .: $ UNIT NO. I 4IVfq' N4A[: USf UNITNO, 2 q VEHICLE ? PEDESTRIAN PPEDALCYCLIST ] . ? p I L ' RIVf4'SNPME: N ?B ce>A 514Ef1wDORE55 igffr ADDRESS ?? E CIIY STATE I P OC D I C f PHONF NO. r ? ' R IfY 51AIF I C 1 v r t : , 3 f 9 s l Dqv RS IICENSE NO. St AI F% DA BI n . M 1 U IV LICENSE NO. qif 5 % pAl xIH . I te , . / V R ..o.. i DA .a OCCUPATION fIRIANMtl6PlIO ^^?? c NENO. 'pX lJi? EYES wFlGni HFIGiIT E R CUPAIION IIRMNAEAEIPHONENO. ETES WEIGHT HEIGHT : ?? a , , a' ACHE iK (!? IvFN ICIFASANLMgOYtFOlANO R ` ?CHECK (?) l v 1Hf . CODES 1. 7 nvr su wIp 5 NECrNw e„ THf4A vFH CIEASANfMR(IYfFOLAN5O wcnoN 1;`x-'U CO DES P 7 A t°; a y° » ? r wua /JO ?%/G?/E - 6?n?, 01 S Il l er 4D+t o wwwtwKl W, ? 18.n4 nK Ul o wi+Y Ni li? EAR I AU[F IDDDGEGNEY W fF ,?er[DM ? AM4ULANCt Q 4 tl ? <ii:RV o vin crt a sHf. ? . i 'N jONV.I 1 Al. V VH.Y fAR 1 NEV.) OFl10AR1-N VA l ( K. V.1 PDnt A E qe ,` v IXS>q lI INS I l STAY TRAILER RATE NO. STATE H w A VFM.CIXOR N 1 L A '? '? n & // rr I 3 W11 C1[IDENIIGTION NO. i aye L VFNICIFID N1 fIG(I N! ' ?,: _'_' 1 5D :, 4EG Si[4(DOAM[R. UtSi ilRSr MUOIE PHONE NO. x..5..4.0 OWNfq: SASS IIR51 ..E N N r <y- t f5rd A G7 O 1; ? woogfssn [R W cY Own ` 3 ?// o? r rE4 r E N.WE U4(S]OP INSU4ANC[CO. Oq AOtNT IN V A I -7j< R _ ]] +i eORU? S uI• AGO AWAY F Liti- . ?AWAY ORVRAMID FSI.OMIAOE I I 4101X13 y DKIM. C -D O To- oeono•. j .U w•AY I AWAY 4YI S , DIAGR OF COLLISION: Eu Iii N l IND,cy-Wif EN DESCRIPTION IS 1 B Y OF COLLISION; lustsuxvuMENTq snEnlf NEC[53ARY1 ,- SIIETU NfCFI C GCIVY ARRON - • ; -' _ ;° , yC.1..dS!. t1w?5.7'iyd+v//AAi*.J IJy?::U?r? '-- /P?vK y - yrndN?s'crn./-d:Cc .P?/. SJ o .•en A vu/$? Y' iE /u?/1irl P Jifb?G .cK .._ sB d• U //ivllJ SorE .GX + ,^ w NAME ADDRESS 8 INJURIES OF PERSONS INVOLVED 1 'CODES I - Z 3 4 OCCUPANTS /WITNESSES iai:narllor+f. + EMI - sex AGE STATUS A, RIfIR. [I CI I NwE. ?'?r A1ss ?--?+ r /+ ?? xu,r nY. MpA4e ?r".1' ?"l;1a ?Y"HT O?:Lv f ?;r j v r•'1 p.,. AIYYt3S N.IU41W uvfD IgKYA OAMB. f01 o u., N 1q ' nv ?? ??,{ a4.: v All tsr[ .I •r... ......,. NAB" a u1N o`r OAMS. AKl Oio n O:C„ In :.nv i E; ti. YJ E ?); - - - ffvvII IYU. POLICE TRAFFIC COLLb REPORT TRAFFICWAY LL`I wucfc INi NUMBER t , E] PRIVATE WAY DAI FC N T U'.N i1Mf COUNTY COUNTY NO IR . CITY NO. '-A x`? WN RRx t (USf ab]HOUR) . UUAN AAr 0 I E,-rf_G OIJ - y 7 kg. ?E OIN I CIlT OR TOWN N F6N0.0 SlgEff OR WGHWAI ICICLS A POUIlON 51 C G Ct N "/y MlES ?s;Ow Ho,C ON 1o?3/a ? . MlE wST 5] A D ,? INTERSECT NG VAIH, jR(f10R ROAD NON INI[g5EC110N ?Yl? PRff1Xf0.^ y V BERVEEN SIaEFT1 JR.?`ZQ SIR[ft O/y? :t DI TANCf EDIR f ,CROSSSIRfEtOR NfARE5l Mllf w3T ACCIDENT RMAP DIAGRAM DATA'. p 6 ( MISS N S E W .y / MILEAGE CODE 1 ' T COUISK)N INVO VfO. IYERIIYi _ Mw IOM RD t 5 E R - 04 NEilRtNCE? I]] ?1 ?? - TOT. NO. ? ^K) .KIIROIED_NO INJVRED? ?SPIIUGf ?NII6 WNDx IM'f/R Cl5 CROSSSTRE[TOR wAp crvfwals vPEarvDAMACfoNIY // /,5'/70 ?, ? ?iUIT[D ? vinaE ??? ^ OB1fCI51RIKKINANf Of OSJECI STRUCK INDOWNEq'S NAME) fSI.DaAAGF SKCIAE CODING USE - -??, r'4J' t? $ -UNIT NO. I' UNITNO.R ?VEHICLE ?PEDESTRIAN ? PEDALCYCLIST- Df i *w%f 5 DrvR'S NAM: IAfI II I RIVER'SNAMF: USt {I I' NUU- NOS CC ? £ N '-_ LEe ''' fI?) SIRE! ADDRE IRfEI ODRFSS L IIY O• SIA E SIPCO PHONE NO. D IIY IA E IP PH {` - rz owNs tv lu 2 (a s- R "°? ^ DRrvfRS UCENSFN SIAiE z T1011111" I IV U NSEN I AIF III 1 BRIH L- D "N!?-AxySS1"bICE° 5p?fW!Np F OlI2Y YI. V UsR LE0 MD I I° $ B R7El9Y -)V6RAJ EYES GHI HEIGHT E CUPAf10N NR AME S PHONE NO. lYES WEIGHT HEIGHT It. ? 1 3 2 V f? O$ R k 5 13 _ ? CHECK V) 'N?ciEAS:N wvior"ir of A.MiotHEliµ ? CH ECK(.JJ vHlct SAN V0VEE OEA NHF L - v CODES ?+ G a. it. 5 rrcl oN 6CODES ®+ ] d,uxr xE vAHI 6 cu ?, . z I?JDaOS? ? .,5 fr RM IXKI H . RT,tir. - ? AAWnAKE ? unKl ? ?BkE. ? R?K,? H ? :°HV C] AVnAANCI ?5°4n K8 D? N U ? .. - .f' NH. YEAR MU(E IDOJGf{HfV.) OFIIDM!-NOVAI SIYEEI]DR ONV.1 N YEAR ( fV,) IDMt-NO 1 OR, V.1 ?'.r '"1?,?'.: ''_ys /,. H. O ll N MtfN SIAIE IRAIIfRMtf NO. SIAIE F'I VtH.CIXOR l A Il N SIA N .? A ,( y0.W •^?- ?? NHICIl ID[NIIfIGIION NO. C ? '"?''t vfnlCIF IDENI fI 11 NN . ?3 (12! III7!01 1713 i I I 1 1 I L I MI I I I I I I I ?: I ,D 9EGISRRtDOWNER: IA$! IIg3T DDtE PFIONE NO. O NEGIS lR[O .WNfR. USI fIN51 MIDOI P N I _g X N N ?PIy. ZNDS W - ?: ID Aoovtssa ovmER Nta ]' h, 2 OW EN p, t0g, E NAME 4ADDgISSGPINwRANCe CO 04 AG[M R V ]] )QYt R N COT7 -AD Q,913APA H M._ AMAGID M[ CHMGE • • • OSNCNtIGrDiN gAMAG[ MIA 'd o-i. <roU CHARGE• tl C?ORC? 5 !51 rDA.NAGf ? AP 101 REMAINED - ? AWAY ?RFMNN[D ESI,TD IAMAGE I f TD -• S WlD 1UlO • , BY S TIO rx S ® AWAVDBY: At DIAGRAM OF COLLISION: (U$E U oeMEN At• IND UH oRIH DESCRIPTION OFCOLLISION'_ IUSt SUIPIIMENIAISHEETI)NE-YI K ] ?. .R 1 le ('.. - --13 ILID E[SSMYI .- RYARROW _ FL If ---- ---? L- A_^15..-CT.__..?MBANkMI- NT-,,, ± " rr hlc VrGN. Wq5 FOLWD-hiBRNDCf??D __ OI?I ' ? I I T- B I oKf I , _I_.y. 1 I I__I f._f ERSOTV , 1 1 I I ND v LI I F f I NAME, ADDRESS& INJURIES OF PERSONS INVOLVED +CODES 1 - % 7 4 5 6 J I ?? OCCUPANTS/ WITNESSES -ieX Aci iAIS'"„"" gAr- It TACT ;'K, AMe. o. . N. ._.-. _-' -'---- ... ?n5s N NAm1ea- SCIN nr• ?AMe. ?DR1K1 ?"'l 1 ??i ?Iw _ I .v 1: No ' 0 ?AMI. 0 :"' 01II'l. MIX [1 :°.:IFI ? ? +Jn ,J 1 ADMIN - NA! Ip ' ? ? ? I 1 : i E .ILIA INA? s ....-. . _ . - stlM ev ? AMe ? a: l ? "o""" I O Li; ? i ?, SM, 1 V (EIS ER K RADGI OR AGINCF' d KID5PAICIIID IUKf AR IND OAiIG IIPCMf AIIrONOSY DAII 4 ?L {? i EYf -! !1 ',r ?°L4 s'. `M'f,1?i R,- ,t Js P'? w,u ?K"R'"" 7?:. w 1. 1 !f Fp-T I r ? r I ? 1 ? at T. 1I ' Sn / I .t I f U ty.f t; q J.W r` a ? ??` `-1 I '?r i r z ti yi J ? I t ' I ?} r I ? 1 3 s llJU14 Iii -1?F.,t ? , - ? f l I f1 11; .?ir."L? a F q " DATEOFCOLLISION vx vBA Yu OP„ o "IST." TI ME OJF ?LOtL1510N S P/4 1 COUNTY NO. CITY NO, f1U CITY, T•O,,WN VA !V •r" MILES la? ¢ CITY, TOWN LJ a•J OF ADM{LS J PREFIX ? I x srfl¢Ei cpDF S _ ECTION , G EN EOF STREET ROAD OR HIGHWAY T ?FA INTERSECTING WITH: STREET OR ROAD S PREFIX E O MILEPOST 7 0 , l 21 " x INTERSE IONLOCATION OF COLLISION NON BETWEEN STREET AND STREET RAMP DIAGRAM DATA r OF :?aCoi siri?Lti?uii?rlu n.inri?•?ixs. r. xruouL ® S W ?TER Ki3. wxer.?eA?n ncx AD n c 6 ?vf. xsrr nvxrrN volyfu,-I Lj -1.1 1 SPEC.CODE USE O UO 6 J ?L Dx OBJECT STflUC K Inner OF 0aa1CTSrArKK1 OWN ER OF OBJECTS NAME AND AODflE55 LOCA IN ROA TION N ?E DWAY r•w Pwacr ?f-f) G? RI` r-- cEET S W " I DRIVERS LAST NAME FIRST NAME MIDDLE H L UC?p ?P ? L U/1" "•","" .............. DRIVERS LAST NAME _ FIRST NAME MIDDLE STNEET.F.55 ROUTE NO. AND BO%NO. 2)2!v wL UMV Rol °Y'"'""•O STREET ApOgE55 , ROUTE NO. AND BO%NO. CITY STATE ZIPCODE kJ QS gc, , q? zc, DRIV ERS OCCUPATION ab, x G /Ykim-- CITY. STATE 21PCODE DFU ERSOCCUPATION DRIVERS LICENSE NUMBER STATE SEX DATE OF BIRT" AGE DRIVERS LICENSE NUMBER STATE SEX DATE OF BIRTH AGE • 'IF .1 1 A EAR VEHICt6 vR. %979 MAKE I F"?, 'D MDOEI -f--o EY?CLwl:ve B DY STYLE D vA^i vENiCLE VR. MAKE r 11 MODEL rxsvADnAr BOGY STYLE . LICENSE PLATE NO. STATE TRAILERPLATENO-STATE LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE TF W A. VEHI CLE IOENi1FICATION NO. a ....EETER IMILIAOII VEHICLE IDENTIFICATION NO. NweNPPauAnewarvr OSOMETER rM r t3 8,3 12 I /G / C - REGISTEREDOWNER , ar+riooa n•Mr DRIVES LICENSE NO. F / c REGISTERED OWNER r Rsr+rroPaa rvnrnl DRIVERSLICENSENO.-r -: sh ?v UloWnl/ ,c WN HS ADDRESS all.EET,CITYANDSTATEI DATE OF BIRTH 1 OWN ERS ADDRESS STREET. CITY AND STATE) DATE OF TH Y /EA MIT YEAR Z PARTS/OF pVENICIE MAG uc cL! Y •'rL (?• ... , S THERE AUTOM BILE LIABILITY INSURANCE LIABILITY INSURANCE INFORMATION-V EHICLE N0.1- COVERAGE IN EFFECT FOR THIS ACCIDENTON YOUR CAR ?YES ?NO NAME AND ADDRESSOF LIABILITY INSURANCE POLICY HOLDER STATE NAME OF LIdABILITYINSURANCECOMPANY Mf DPFSS CI Y ilP alb Sheldu? , ?nU cc' rr q ?? v mir 1 r NAME AND ADORE590R LIABILITY INSURANCE AGENT CITY S 0 TATE ilP LIABILITY POLICY NUMBER Re. ISTINJURY- NAME _.._...____._._.....__........-..._.-._.-_.__.._.__.._.__.___.-_.-_-.- ADDRESS AGE 1nlna SEX "A" 2ND INJURY: ILSE SEPARATE REPORT FOR ADDITIONAL INJURIES) '. NAME . ... ..- .._____-?_ ADOR . AOE EX' EA F E] B =r ' r STATUSOFINJUREO MARK FIRST ONE THAT APPL IES , STATUS OPINJURFD MARK FIRST 11411 THAT AMLIES IN VSNICLQ KILLED OM•elUxcr rwx ors+eUnc rxw rnA.nr rOryN a EOV nx r CLE ?wxrP IN VEHI ..rrrxsa. KILLED rs can n s.ae aT urx;unrc nv u rxuxi u aR .?. r_ .• ? NavlnR wrnnx r S? 6? Ir a r D7arcr ?rJrrr" r ? av a 5? 6C] .7 Q?n SHOW NORTH BY ARROW IN CIRCLE •S `?, `+' 1. rL•?>.h? OQSC IBgg,,OQL WWN HAP [NQOr IREFQRTOVQHICLE11YNUMBERI ,...:. ?cts?JGs.P__ ciJ?I>?CUCr'_ TQ4, _aM C _OUtGF_.. RNSij ?Ltv ON? A_ _ p__Rik'(.p.ccfF_.yhlzr_G!9.v_CcwL¢? -'S?(??? • ? -:OML'-_-(3QK$I/-..Ol.IiCI--C1N_?CJP-(1>-'-GL-?'FNA / I, fur - - ---- F VEHICLES POSITIONS BEFOR VEHICLE lADfo E COLLISION RHIGHWAYNAMEORN0 ONSTRllT O rrvow M Or A.IP ai: la arr +wax cwi[ vI (OC R NVltTIGArlD AY ?i o,K ... a ? ?? (YOUR)? . K 3 e.? ? I ? ? I ?L ? Ka ?'brnvIaNAANW OW ^ IOTIIFRI ? Q l_ El l 13 ? ? M .. Pf0lSTRIAN,?:'C?'LJ'D{J?Q ALONO:.w•.'. .-'' .Ja'a/. ?..., XC... _,. ??.. . •?': CgOSLINOr .?. ': -.. .'..v'. -F10M-r?Irii!?ivr ,Tarr::.TO n ?Y Jrili? a?"K.u, P[OESTIIIAN WAS USING 1?un 20wa Hw+aF a"n 2 A D B0mrv1A swuamx cxPHw•ac twwraw•aF TYPE Of ROAD ORIVERNEHICLE ACTIONS fUFIPACE twtH11 LIGHTCONDITIONS TRASPICLONTROL ROAD ,. onar 1 ?DAYLIGHT v a a rrxlaa ux r a KxFKF OnF Ox MOes IT, rr'LLL???III ?"1 ?SIGNALS ?IK?ONEWAY,MM rI r?GOINOLTRAI0"TAIIEAD 11 r1Ax?UHV 2OIAINING 20OAWN 11 ) 20OVQNTAKINO AND PASSING ?a?$TOP 51611 2OTWOWA, ? Ivtr J ?SLUnIN6 l0DUSK E I 2 RL ? 2 ?YIELO SIGN O 0^EOVAO IS C] 30MAKINGRIGH7 TURN AH K STIIEET C] l E] SNOW A E] FOG. "CHANCE ? A O MAKINo LQFT TURN A ? p ? A ? CLASHING RED ? A ? OO" O 1L CIA R I EET D•11K ST 0 A 0Ict S?Srltrrr S LIGsIT30FF ? S OTLASHING AMRlN 0 S GALLEY 0 E ?MAKINO U-TURN DANK MO ? y C-11 n STRf[f LION TS ? A ?RIISIGNAL ? R 011 (TURN LAN 1. ? R OSLOWING of AEON fOw 10Tf DANGER l YFGii? 0 7 OOFFIC[RHFLAGMAN C] 703TOFP[DFOITRAFFIC wew o axHx rr...n...xy s arcr ? 1 ?Ylrrir 1 3[PAPIATLD ? L 001770E ATN SIGNAL -_---_----_? 2 ?UIVID[O 0 00 STOMED IN ROADWAY 10N0 TRAFPIC CONTROL 0 2 ?UNOIVIO[O ?IO? STAAFIN LANE VH1 NfN MAYS ::. ., r. .. ADORl33•- 3[%. 11 bTA RTINO FROM 5 1. 1r y. iF Y - ? ?fANK[DPOSITION r tr`.vTRIRR1krJl?' n-!.-'"If?fl• Ti 'r + '.I ??r `?'L? •?7dlf. -..? .?.?-r,.. 1l1?' ?, Jl??•?? 'f3 POLICE TRAFFIC GOL ON REPORT TRAFFICWAY EvLIC w rNfweEk PRIVATE WAY O / { _OAIE ll _ _ ___ IME CWNfY mlX+rv »o. rvE'o..,. irwA.. to 0 aj ,?X `H ' ?! ': '? OISr [J6DR MESS N R S E WSSSIRfF 4 fStuMll. ?Bf- ACCILIDDEC'NE DuROeNAM 4 -ly 1, •. *. ,. J i![T OF Q 4r Ot7 CODE n5,+r.. r. '-+A x ?{ COLlnE3N INVOLVIP. fRrv: JfO M 4[NQ n ,? ,?p}.1 OVEUEEICI[S NO'RIItFD_NO.INJUR[p ?k+EUC'! ?SiIX[[N US OffD3351RElrOe ROID U. r T .,. rg ar ?•? ,1f.;w . ur. IUS[t.m rauR) / ? (O fe O $ S o ?EP ?eRAµN °E N CiY RrOWN NAME6 31R(fr0-HWAY ICT Z M„ES o3 o°o•P z ON P 3 FI ' INi(RSCCIING YAM: SrRf O ROAD NO INfERkCEWN Pq(NX [MNEt03 ?/7?.00/SE G3.aYrPO 'J BFIVRFN SIREfi 6 S1RfET L? 'Q ? tRORRµ OANAOf ONLY ? pt5 RD ? vfNKU! Au : '!i 1 / ) .. _ OSXOf SrIIUC (NAMlO Dei[QSiRUCR DOWwR•3'+AMH ESr DAMAOf SRONCOORN' 4 4 s K?; c"? a. w.. ??x Egig, l rs. ;.LINErNar Y•.:.: UNIT NO.z.L, ClVEHICLE, z. S oRNf : IA9. ••^ I ..., :. _.r 1. _. N NAMt USi .,,?7nD..0Pccusr- - ;.H 1io'lN e?. D sA m / z:, to A P wR ONRM NAM[E A EYES IOHr HfIGNi R. YEN A n° CHECK(F? C4 A s a „"'O,ar. CODES b3 n • f'RAN.RR4A? m ? Mi. ? ? -11 ? ? i' ? M. ? ? C°:..t. VEDOOGE?JRV.1 t(DANr. ) I$TYLE QDR. r I .1(DART A) 1a SC' anti 4?,r E D ul rRAILfRRAR NO. su1E H N, a e1E47 m veHRaeIDENnrlurwNNO. Y IuNn ?k' iTil 11 ao o,S18Q i NII I i l l l i I I I I I I I F 7 'A RFGSRR[OOWw4:. USi FIRS} M.m' Raw NO. O WNE : USt FIRST ml- ?mJhr! Q J W - IS AODRtS1 OF OMrRff N 31 Z N E wMesADDRw or lNSUeANCfco.wAetNr r r DAMAG! ANfA 4e.?+ao» sro aARU .•,. a„? 4"M"rlrw ??l •s EsT. AY L RuwNro ! D ?iw ?xAwrao 1oi'ono ,.. t?e •r er,F-'IZ L ?n =. ? Aw•r en - S '?"+ p x DIAGRAM OF COLLISION: Au INDlcynu rH DESCRIPHLINOFCOLLISION: IlDfkpnlMewµsreRlFNEmwrl r' ETU faOS5iAY1 n ?pA %77 ,_ s9q T? veh-3-vaa_weet`hound-4572a - .Xudlcw_gdv ilt when-a-deer-juz"d-out._on_iront_of-her Veho -causing--her..to-lose_control I ? - I r t t 1 I Ir, r T ._._ !...,.... -L- L -. .._.. ._ ._.I-_ _.....-_. T 1 I-f I I. NAME, ADDRESS & INJURIES OF PERSONS INVOLVED t CODES _ 1 - 2 9 4 S 6 y r , OCCUPANTS /WITNESSES is r5al'?`w11o u.?iASM"'tsi sla Aef rA 'N `k,r -wi nsre. excr "rT" r t,d ,xt,•%??;1 r w k NIwD w. IG E`< ?? .ooefss NArln of r we . AMe. ?rR. l" °"'" ?YZ"w` i14lr. ?' ./ nnss _._... .. _-.._ -. .._.-.. NAT IM p-- "'DR•'$' ?Awe. ? y` E'41 ° Inl ..n ?nw Kd , -r ?u r.? •ME MH r t a l . _ (t r] 1 •awu _. ?_ niAR?E ?_?---_ rw er• ?Awn °? ° _..._,__ ._-._... _._. _.__. ?p f7 o rcHrD [aSI ARU D D•Ra RIORr "?Arr4DYwer ? ) r c , yf x INrEt ?I..D/?O..ctr3Nwa [•r( a DArow .otNGr nu eaT Z O C J I' + ?` ' 4 g? 1 /O CSO [.m Hn. [.DS INn 6' (e' ?O I . 'I I I I ?,: ,t ? r U7 w9 } .a', _:Js 'mow ?n°%7n LT Ih:. ? 5, .orr I ,_} s w o Iti c., .?' I t a: I f: ?$ I ..?aWWr 'F n _L s } s' - rid •t., v? /p y rdd N C 'v.MI J M i A I u y5?r n r. F }, t? .. ) f l x v 'In T T 1 I i POLICE TRAFFIC COd ON REPORT L TRAFFICWAY rollc „NgWIN- PRIVATE WAY DAt or wu N nm counrv SQ,? la 0? counrvno rv EI ? [yam ,?O Wr • NO rrb nuFl Nrr yr (USE Eb0NWg1 . NO. G NwA ?UR / oN CRE ON CrtyONIOW N O51RFfI0R HIGHWAY IC CU E04 O SCI N -3 RULES Os ' ow oorT3r?Atl to 4/ ON A vWot.E-PA? SlF NI{95fCl NG ?M:; RtElO490AD rvON INTER CIION ??qP?O/SC ?QY Pfj -EN. EO. MITE POii -FIN qQ/ DID STREET e 040 _ IA,C STREET ? • Sl/ 6 'IN Dr IOn R FRf .CROSSSIRFfI YNA9f Mll ACCIDENT `KFS N 5 E W • MILEA E 4 P D:AG9AM pN1w E [f t S- T NO Colt T M pIVEp tglfFrrv. ? NO MI irH E o. T?RUN wrvptprH .INJURIO () OK O T f IN E INf[9 CLS C405SSM ! j] r oW! 0FIRE Al_ NO O ryVfNCtf3 m PtK%l9rvpAMAGEONIY RESFlflif° oVfaC E W / C.JT _. 6 (j OB1tCI3I4UCKINANEOf OpJFCf 51RUCF INp OWNER'S EJNAF) tSI pAMAGE SPECULL COOING U]( - .. -' I Ro SroE T4S^?5 SToTq.F. , r ? . Vag/o - . ] - UNITNO.1 UNITN0.2 Ub kNS 0VEHICLE 0PEDESTRIAN 0PEDALCYCLIST I4 V NAME: UtSf FIRST MI M ?c BNA .? o t S RIVER'S NAME: IS, I fl SIR(E1-1 SlRfff ADDRESS UTY SfAIE 1VCODf PFgH[NO. D Iy lgiF I rucE +rN R 1 MtR'SUCtNSE SATE f% A BI n I Iv 9 U N NO. IA f Mtf 0 &RtH 6 OCCUFA7WN {IRM NAMEB Nf [YES IGN I IlIGNt E CUPANON FIRM NPNfa F-ENO. EYES IGNt IEIGH! 9: GrZ /1B R o CHECK(?) vtN AEA urnuti 'r ANOrNFK 'm IA ? CHECK (? ' wHKIE ASAN FMPIOVEF OFA INeRµ s I.F 6 ]MO{ CODES ?+ D e^[v D a c r CODES ? D n 6 a° 5 eJee . Juvlfs P rr? ix SNOVr•dL?R 1.FP I; ?of,D L- cam- ? o o :, ?- V[N YfAR M E ? a f o al:° a y ? Y. Ku . AS IDpDGfOrtI.) MOD I(pA91.NDVA1 SrvU: i4DN.CpNV.) C0N. Nf ?C IV E .rFA 1 {HEV.) e MODEl1U49f VAI la V.) pM Ee C PN SlAtk AI[FR MtE N°. SigtE H R V n.C N wTF Il N q >tr"E, Y4M3/9_ v~N I h 7 VInICItIIXNpHUlgN NO. i9? A' 69;5 L) 9 ' i vfnICU IDFNHN I I N I I I RGr RRlD OWNFN: UfSI FIRST MIDw! PHONE rIO. $hM< AS 41%lf X65-53 W 4 IS DOWNfN: lASt FIRST MIDDIt NO. ' I? Aop9essry owNeR N q OWNfY T Nwme aADONessrylNwRANa eo.agewr R n AN Z[Tb7Ei, C[RP--• 3] WMAG ,SRtw ?O MKM iM CNARG! /YC CHARG! DAMAGt AAlA ]l ! '-eM 1 !Sl. GtASAG! o y°.VI`YH 0'o--fO ?091VfN OR „J? Awgr tSr,DAMAO! eIOA io» s o o - Slb?4L iwv°er• 41'.2s, C.EC ? Tw?r er: f l r a T. "wm OFCOUISION (u u INEIC F-1 DIAGRAM r DESCRIPTIONOFCOIIISION lose sugnEmewM SllterOnet(SURq _ y T-- IN .. f ? ? I .__.. A DV•??//V6 ?•'A S?` bN_. _ x .Wf. TNF AVID.0'v-,..TO PAA-"'SA°' f3Ay_ ROAD _.- _ 7We RO4.0 rS ..A ?dV+N 6RAgk. A? TN TS ..... .. Tr- l - -... AND slaPSjsar•. AJLCO-'ti` R%Q/H>r FReA?h. .. ' 7 ; . wN44't Tb G.k•T 6N-,-o CCRA-z- -OV4R c a•? 4f. ?Ti?D {•: rTN R?`' S v?J'iira L s s o !o IR s.,1 ws oa c> - _ . _ . _.. _ . I .. . 'o C O AJ?'!? Ott ... .. .... r. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED N CODES I - Z 3 4 6 lust NMnIM/Hw Sf OCCUPANTS/WITNESSES rwsuplrloNM N.M E11 esl uK Act GTUS """" ° . ,. E RtsrR. ercer r N N Aw rr. , DUIU wror xfNTnY AM e ?p1""' U " . O.', o' N N AM N . -Is tN!: R IMOYIOI oAMe ON%KI On-,- QH -11 10 AMI M N MJFIt{ jjiN94/E°r ti<' Nl llr. ?AMe ?J [i'[I ?<Mnt ??,i ?n[. IrbAlsKSryI KIRS 1-1ERAHl nYJf W AGNC, ?I DrSIA1CMp HllrC{AN.Mp OArIp NIRJIr .VfpytO nr pAt( X ND rM1 p }? _ O ? b ~ jrrVH? V ?EIrW3 ???0.61/ ' "?+ y9 yt t. ,1 ? Y ??yy L t ? DAY OFG:WSIGN.,.,....'A .W:u!ODuLSONu_ O NEE wE0 Mux AM PM .a'iI cl{d I} CITY !. Y f, }yp- S{? ST '?•'1 Y, tES'.Y,Ef alG?!;Q?iIT .. U"? •. w..W1Yl Ywea,.vwA.CW TOWN `+T:'?i MXESF:T v+a:; J.A•.. A.CITY•TOYM'•L.e. 2/ ?Of M r © F ?? C R,E/(p EGIATRE COEE' 6E0T L?.S MT{,y '1 ,, ?yy ?iy f pF O<C fP 1 ID EAR , n0.0d1' ..:: i:.':.GNENM1NOPt9o EETLPOApoR. EflSEOTNOMIEM..STRMr OR ROAD. '..': PR El%9', EO' w' MILEPOSTiY® 71'".., y,f? N ON vIN/EflSFCTIAiq OFC M . or C !w r . ?I TS R IY?°? 'F I fS'r Lz F '< DUN]AM DAT - /' ? ~4 A ? wnEETNAD STREET BeTWEEN xE 1. . »Rir /?:ya,, t-'ti eNONI' X•PO 6rKErOR •I. , Ow K , FnosloA WFxwrwa LwwANP ,p? crd//?AEE © we ?f? a KI ®QOM1E 1 L6 INTERI Q$ t <" wvRVEO //-? f vDV<lEVE1,CL[ OvEr4;LEWCYCLE fllEl // vEE+<tE0[VECI Ov? IE.Taw / Cy,.l w°E0 ? C SPEFCDDE ,'.,} >>C YFp.. Y ,? 1 'j"1JA•A}. ?? O ? - !•"xJ ? OWECTSTRUOK .. -.'.VIIMMED`- 3M.cPl OFOMECTSNAAAEANDADDNESS: -..'WROYAi ... ' -, ..??. - d + T ? : M OWAY ., t>: i, '.c QN® w OOEi. ' ', ?; O fPA01 M 08If<'El FEET DPWERSIAST NAME? :r..:..•-.:-5:::.:,wV•I FlRSi NNAE ?.. .':MIDDLE ! vn M E - - MUVFA9UfST./N'N-A'Er.....,;i.... . F?W+S•T?N-A'ME ../»_.?-. MI04£ ,. cJ 1 t 2P cdusa . i L10 ErNNI TWO __ ...,y.;w iIOUTENO. AND90%tq..l: ' STREET -ESS s Po Aox . r? + .-..STATE.?'+un'.u':: [Jy_E CITY - OMVEPSOCCUPAIgN..:, F[d a<PrFDM CrtY.:ahii zJ....A:.ch9TATE .'P: :, ?tC'. LP WCE. CRrvER9000UPATION y, &A re_ wcr GSA w ORIVER945ENSENUM@R;:';y',(?y(iMTIC :STATE:,' 9EE{' bFDATEOFBIRIN ;,. A02 pWEASl1CEN9ENUM9EA f_...... ,.?.:;. STATE. 9E%. F YEOFWRM ?- AOE #!1 T t r- P2 CA I W1-,osF 7P0-D A Vqte IM.. MNIEE r ???A-0MTf BO 1'.OEtk 4195 '. VENIWEYR:. MAKEICN :D000EI .: MODELINOVMD ?._:. SODYSTYLE ROBE '. LKEn9EPUTEtIpr:. :iA:':STAiE ^;{/.' S.:TIWtER?iATE NO.: r +!?+,,. STATE /U l( .. FUTENO ?'4E,}:,. ...T{IARERPLATENQ ,;iJ;-STATE n`" VENKLEIOFNTIfICAT10NHQy :,r;iliEb3MDDEL9iNEY!FA1. 91. ODDMETERI-EAOE) y"g VENgLEgENTIFlCAigNNO, •; $,{ 1112MM LS 111WERIAL ER I. REGSTEREDOWNEli.'?ya{WTdYS, .T?MWLENA4E) :tpRNEA9l1CEN9EN0 .Y, REGL4TEREDOVMER_:,,U,ILA9T.FIRSi.M DOLEEj::.:. .:i,..:DPIYMI ENSENO. e a C Tc KF38.26 - Q (?/ YYt (r h?SaN 77E':'si?,>•..niX.ia8i5TA?T.W?.T r4[AIELYai4_Lli- :x?OAtEOFBWiN.yn 40 rEAR OMMERSAODRE39 /„L- _u..'•.19TPEEf,CRYANOSTATEI..,?..,.:.i.r.;. ;;L;OATEOF,BIATN W yrRJ LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- ?E/nOMOlE390F.UAD1uT' _. A? lDFJ1.4:Yd.^, NAME. W O AD W E93OE W R/Rf iY,,1?V/M9yPAI?EAGENTu,:_.!<FeT.AStiti'.: Isrm,wv.Ew,i''-J''S5..:1?;.:1?•e:3a,if,' ?.: .:?4;..?,?.u NAME - /? ADDRESS (/Ill.//? wu-o 0 ?? OOCrda- __ [ ANYYA OOCTdn N,NE. 5T.LTU90PNRAEO.e.:..Y; ':•Y?f'Aai! "L`.,NMKi313T ORE1 -1]d•rffl - NVEWCIE -.. .,.DAA01w0 4M gllED ,11 [.,N ? 5? 1 SNOWNORRIBYARROWPICIRCIE \ • YaY<A lM O \ va rPlEp wrrowxsrtl? \ ' Dw[CldvIMVR•v? '? Vl n. iiwvEWCIEA ? S ._ YES O I „""".,3 ?r1TL; ' ]Eq WJUHY n pi4+ I .011 KP1AtuuuNE51 i.. -. . f6E .?^.= ...,. ..v..,, n+. NAME /` - -'? ADDRESS /= _ ^SEX 4•w wx x ®0 N lO A __ MARK Rq$T CNE THAT APPLIES L ?±,J, W VENKIE'•: ' Y - NILLFFgE ? .. . ' 4 q . ASEExOER ,IrxOM 1 ) A aP ,. nQ 1? W tl:?a?x nsa,l ? 5? '- E+(vy[-OESCJI?RE BELOW?WI-IA KAPPFNT2M-.-.-LE9 B?NUM9EED :' Q?r1/ S UJ?CS LJL V. . _ VEHICLES POSITIONS BEFORE COLLISION N0 o;,e" Mauivir`,'ADM ¢wiL+:ATn,eD Y[Niu oiei+eD INVESTIDATED BY M ;:I ' I VE KLF N 9 EQW " BEREFT NAME OR NO TWE rAN r[a OT OIPkfl ...w. ... , M rE r['J M ?n:r110E ?.DN<E ., i M l an Q Q. O W7. ?Q? Q ?ipK! ??.E1 ],1EN.. ? ? ? O ?O ? 10' ^'' H 'Q ? ? ? ALoNO - .?„ 1«D ., mom DIRECTION TO DIRECTIO )L FEDFSTMANWASUSA4 1?SOEWALK a?WALKWAY 304 LDER AQ??,A,"°,RN - SQ 4•;"D A?oT FR II01SUI1AiC ntATMTI U ICGIdTION] TRAFFKCONINOL_ 111'-1 1VPwEOf 110!0 DR VER/vENKLE ACLgN9 ? 1 r ? f, 1 Knl<, WI v •C K! vTI+CI! F C, DYE 4140 ?' ,1 YInK1F ttfER l a Iflli??d1F N 1 I M 1 1 W,CAET 1 Q OAYLIGNr QI I I Q SAONALS "I0 . Q MONE WAY Q I 1 'Q MID BTFICNT Al1EA0 C T t I .r1 t 1 "BRY a flM WKl a Q DAwN Q a Q stop SKW I a rwo wlY Q a Q OVFRIAK4q AND PASSING 1 Illfl IM1rfh? ?.r A r '?I I Q 1 ;/Q''?nfiT J 0SwRY ID ] Q OU9N Q ] Q YIELD SIGN Q ] BpM MKE Q .l Q -WO RKIM TURN i ? D ? SNOW A Q FOG A Q DARK STREET Q A Q FLAB ,,Aa RED Q • Q WtFRFNANOF Q A Q MAM4K11 Ffr TURN G RI 1 + `I y?',yyL,? ?> I KE -15 ON OFF 4 7 p4LY?l 1 E) A ? 3 ? OTMR 3 ? LIONt50 ? 6 Q FLASwA A4Bf.R Q ] Q ALLEY ? ] Q MAr1Ey0 U•11MN ?1 f f y ? 3 ? 1 OFY I W.CIFY) 3 STREET WNTS ? ! Q BR - . ? R C] !FE'A'T TURN ? 3 ? m?'Ra AA I ?V r J - { 1 Y MO? 1 Al. i ?N? EW? 1 P VV[D w4DA [Nnl {BOA (OKA , i1'Ah 1 ?o"A Q / Q OFFI'1 /1 O4AN LW E9 SrOr'1'ED FOR TRAFFIO i/ ? Q waly & 'N??'i Y • . i ? ! Q OTNR. SPECrv Q 1 Q S[PMIAIEO ? S ? ON STOPOJCN. L I L 1 '...n .- .._.-.._,... a ?DYK1Fn ? 9 QSTOPPFD RT]OWA Y lY'.?' k f M t fIK RTAHIrKI IN f(( ? ?.y ,L1 1:^I l 3 TLl rrv 0 uNpmnEn ID ? TnAUnE: LA c I.5 II Iti .? IY j. .,r a An le w - Fr De Q n a r?roEmt?N E? r L 1 - 11 L ? Y 4 ?" I -wv? ?? uA?{ a '1.i.. ,+•t . ? ?1 ?r`'?r ?.,: ? T"tlr. /7,XS' ? r '"R"l'T' ? { ? ? ?w, '?1 y - J 1 i? .n.s fi ? '? ? h«EA G ! I 4 d l l r 1? ?.Itkl, ! 4 b;' E f `i,NdiL ' 4?r, ^ +p. IP tt r / ?} i ?. 1 ,? i` 1 _ 1 .I` I I ? ? LI G d } f I t? T` ?"4r' w 1 r I ,y6t - I i ? L,?? ' STATE OF WASHINGTON kw i ' POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY 1?. 14 PRIVATE WAY YI ?..V M. L r? L C C C C DAZE OFC N ? r rv AY e n 40r rve w (USE ]rODNWR) CO NIY R ` J JI QU PAN l C IOwN ON ?L ?IN O F AND. HIGHWAY FC}CU RWI ORSI 3 SCION MR QS ow QGI ON -v tcsr RSIN K1IN SiRfEl O4 ROAD NON NtfRSECtION . pRFfl% f0. MITE POS! G BE-AF StRI(r 6 S(REEI 3 DISfAN E DRKI Mk FEENC ,[RO SfREkI RNEARESf MI p ACCIDFNr RgMp DIA RAM DATA ' Kt3 F N 5 F w "? H4 Y •f' E MIL G A E fEl GP. -L}r- - / CODE causloNlNVavfO. FR rn T .-N NO K llEO E NO.INJURFD ? FIRE E ? UN o O. WNBVem NiE4 US FDEOSSStRfR09 ROADR O4 Rt RtNC FIRE ep-vw ties Q x ° TE TED ?vi P opE4 YDaAACEONLr ? ci( Y ,$'G990 081FC1 STRUCK (NAME Of OBJF rStRUCK ANOOWN[R'S NAME) fSr. DAMAGFCJ SPKULLCOD41G V5E 5 5D._ ' UNIT NO., UNITNO.? ?VEHICLE QPEDESTRIAN QPEDALCYCLIST Dx VFRS NAME: U51 IX r MIDU F D" IASr FI I SIPFtSADDRF SlRtfr ADDRESS 7V rnre zrp eooe? pi < NONENO D r t: L::/!7%/)J ?.;? ??3 l i r R 51Al Ipc E P 5_ Z. V511 D ' FR -ONSEN SfAIE F% BIR H Iv O I V FN N qiL Sf% DAr BI IN i Rm s j??>xl.? j rjI rsT:6 I ?• „ ND { r ?,4 ' OCCVPAlION RM NAMEePNONE NO YE S IGNl-ONE EOCCUPgiION I4MNAME6 PHONENO . EYES -1 ION, R /E ' Q CHECK (?) -O As AN IMVionEOlANOrNEn.AI ? CHECK IFr) NKIF N rMPionE OrANOrn vR 7 F, e CODES ?* 7 s r a ;p CODES ?* O n e <r DN ?r :v + sia«"' s 1% oN aIDr rcu r ? IFUUe%` ' 6Al ' F IN I U. I iT;„gy. Q A.R• -1 Q A' ? co:n• ? .? K?? ? '18L,. ? ? AM f ? M'V'cF ?col M"4k4 ? n U Q Y VEH. FAR w 1 11) v MODEIIDARI.NOVA) SIYlf I4DR. CONV I YAR v . 1 V,1 MODFIIDARrNWAI Yl( R. V.1 MTiMC fill s) f IL E LJ TOrC, > (? lK i.SE S/ti ?f /? MIFRpUIF NO. SrAlf H vEH. CC%OR l l A } Il A N •JL? ?V:7 /1 W11 I ' C V[H CIFICLNfIFK AIKSN NO vEH CEE IDFNNH AU >$9I P ?''31Z 5 L I I I RfG?S 4tO E I R OYMER: IASi IIRSI MIDDL PHONE NO. R I-TOOWN R: IASI 11.1 MIOll NG. MCL '7- 454 w A R -E ADD L C, N. L L N NAM Apyt aINw4.NC[co. GRAD E I AN A R AEUCminu K E, 4 . ,v l E„,,.DRD. CR f eHnxee cAOONN gAiAAee AREw .tD - osort s .DM+ACE w ?EMw ID ElA Vt wgr N ?RfMAIN[D .RMDr FSI. DAMA4 el01 S 1 Gii :45 T ? OWfD W e IOWfO ? Aw r er: f IO ? DI,;AM9FCOLLI510N 1 s AE NDUr(NO4tH .... ?. SN(kI INtC[SLV4Y) B ARP DESCRIPTIONOFCOLUSION: IEn[SUpPI[MSNlAl slrt(ru NEC[ssARr I F am?*11117 cT..,.. .. ._!_ $, _ EuT $1+11J A6N UEN_! . tl.":._?to?eac?tn? S.E,_avauuurHrce._. EeZ ..2r nn?..._Cxeastdt ..stems S//n_cvF ro__. ThE R/cro? _ ._ J JT6.... /} _. DJTCiI _.Aa +L1 _ P?r_rJACLy_-- LAP Tlrf I .I y' Ors SXEas oA[?_Tlte r'?J../9u^._SLr4.t¢ip"°c 3p.. __ .. ,?' .?: 1=L• ... ./N The_. p/TAN. ?sE?aee_. ??r?!2r v6 rzi. __. ? PA4r .. 7:.rr-PiLL . NAME,A )DR SS8INJURIESOFPERSONS INVOLVED I+ CODES 1 - Z 3 4 5 6 OCCUPANTS/ WITNESSES lusuupn(Mwru s ro4 ADDIrK%RAlNw MI' (I eer lsl p -. .. AIR Ac[ tAru .rAr s'w k,i .. R[s14. _., In. XIl rr I ... AI%Nr53 AMe: No NAruR I[or I Q A NR er. Me. Q "2Yc' Q w^` , I] t « ? C.°.Lo No ... Ata4ts ? ruR[a - __ - R Mowm4oM ri my ri to, IIo ADDms NAIV4R41S r - v e e v ?AMe. ?1OiK1 ??'D:n• ?:i« ? n h+. x +rvlsnarv.euycEr?}AaYMFt. e p ..:eNC.s i"'i ui ???nr;-?nD gllO DAIL? ktroRr APVrov(oer oAtF y ? ,? / fp. ?ldl CJ [}S 9' J J 17 J p fi zy{? ?. t F ?f All F.? :wyu?Gu''? a $ f ???q? E YF l ? ? i k _, l ?wl i t t ) l ? -??/? ?J if I I 4 1 L r I s ? ( E `i L r L ? t ? } y}y? t IJ 1 t ,lr? 1 1 1 I r?. ' I.. } ... ? , .V r ... ,. ... ,. ...,... _... .cwt?rs No. IPGLICECOMVNW 1 NUMBER E S/?oo9 ?' COUNTY NO. CNY NO. InWA & c F, (St4 "h ?Y 7 £ $E ?F... , . v Y s? 4 r(? Y, Af • I 4 y??y+ f4tR I ?y?y ,. Iri>?'?I ® IYU, TRAFFICWAY _ POLICE TRAFFIC COLLISION REPORT IpICECOMMININLLMffR E] PRIVATE WAY D vtcou, N O D Y ?Q _ _ i i?• wq ,«rf I • n. V? Xmt IDSE]a]DFg11Rf S'Cl couNrv 1EROOE.? rr NO. ?G un NO. FHwn ?URM1N• Rwf - ON (:]E OIN CtYOR TOWN -,Os ® ®oR ZMAGtx NAMEa"o.aSINFli04 HGHWAY ON LE4 0. - RalrF „ ''3•'/</O n INt[RSfRING SMIH: 31 fi0 NON INIE95ECIMDN PRfX% fQ POST T ef1WEEN SiRFEr { STREET -? ' - 6 (ROSS SIR f OR Sr Irt wN 19 rR ARf ((a.? MaES N 5 E W /1?N0lJ .4. ' FFEr M I ACCIDENT MILEAGE CODE RAMR OIACA OAI - COII.-N NVOlVf1Y Sfvf411Y1 }d RUN NO fIIIFD?NO.INNRED? ?SPRUGE d I TOIAItq RuNRgr M ,•,;?7(OS O ' 04 I6SESTHf1°?W_.U_ ` `h . OVEFRCIlS ®PgOW1IY pwMAGE ONLY ? vFSElrt1FD ? VfKIP Y /? p. zdG - ... ?Y! (Y oeRCrsi4uCR1 On CeER 51WCL NgOOVmFrS t) oX ur.OAMAO2 5-LCDDING USt ) i ' 7 N VSS Lu oW WR. S O ? '; UNITNO.2...- OVEHICLE .0 PEDESTRIAN .' O PEDALCYCUST- S ? DRrvffi NAME. Wf. IR / N O N- LYNN A,I_NAME: W1 I I l SrRf iADD ', 4EF D4f t Z M ASIA R D Orr Sue bP RHONE NO. oRDlgNO S$ S-U82q R OT,r s A DRA/F43 UC N AT I NO. v A E & q;z N6 oD?o2? „ V •Q ( a i ». q Q?URw1jON fIRM NAMfaRq"E Np?p????Q - TEeI a VDJ EYFS GEIi HFIG H r E UPAiION FIRM Ea -- NO. EYFS IGYN IIK,M 'Y 2 W p"5, . N Pqz ( E d R O CHECK( w on a Al O CHECK (.? VEHICI rMx 5 u 6 CODES ?* 7 a 4 ? CODES ?* 3 S Extra 6 3, I' 2 I wu{ N b o •MN•A? t o -vuk O N.. ? v5l:ni ? ::?v .OM Kee, 0- o ? Mi ? =Vll ? 11 nR ! - VtN YFwR MA.l IDODOE{HtV.) fl l0wgt.NOVw) SfYLL ITDR.CONV.I 1 V.) lIDA4 . VAI H Yfw r Io IA. E - H. UCEN PU Si•if RARtR HALF NO SIAiE t H v H.caoR N A - VtNKRFIDENirICAl"N0. i 114 iR: , ,8+ idi2!1 1 I i i i VEH141DfNRX NN i i i i i I E RlC+SRRfDOwNFR: Wr PIRST .1__ XgN[NO. AL NDl NA 8 ' y f3p O W I RF WNF Wr IInT M f R , ADDRt550CMNt9 N A E4 O. o E . fawoo4essar lNwa co. agwuNr ?'`? R- ' L..LS ?OMtJFi. C?MA.??'LC SR owM•Ge wer p"" "O" I g " a o«Dt. cHwnu awRa ? •TOA E te f Tor - 3 fSr.OURwGE WAN R6MM•MO w ?o4NenwwrN ?RtMA1Nf0 !S D :: r ? fo"eoir:r e ::ar I r owYo 5 ? t?voer: Awwr en S www w N rc•rt NO4H DIAGRAM OF COLLISION: - 1 1N0 yw44ow DESCRIPTION OF COLLISION: IIRlSl1PIV.MEHru sXarPNFaSwrt ,- GRAVP L _DRZ._*_ L..!-Cr_ .-l _ jl/AL LE k .RD. __AND. _!-obr GotirROL._TRyxNGr roXD .-fJAF__GOLJ... ZM TNE_ROADWA`L..- , r,_a 1-_aTRUCkstt6 CAw ANOSNEN MEW I C i 1 r!'? _I I ? 22- e,4 rOt l,?esr ? l?lc.cEY IPD Gow _ .._ ? _ ..------- ADDRESS 81NJURIES OF PERSONS NAME INVOLVED * CODES 1 - 2 3 4 5 6 _ , OCCUPANTS /WITNESSES IIu.' aNrio..u _ ui .6, AN ' "Uwt- R cwi 3A. FlR : n? N•MF . ....._ DONAL.D 1311fi .NDL9jIj No. 5""_4 ?. .. C ' ' _ , .. .oeerss Nww° Oi.2 r uvnr, Owre.051'O"':.OC+ """' KL sALLQ fl• a32 4tg3 ..._ .aKt " " ' "O N . _ ,_ .aowss 2 DRI 4 Manor Owrte. O .+?M O o:n. O rH ? t NwMr Ii0 .. ..... .... .. -.. ...... . _...-..... .owls .._ OUO •GI•Kr • v IpAr 3 e NARK OF_... _. --_._. .olLl rHH. NuR? Neon OwMa ?u. Of:E•Hr•OC.".f' On1O.w terRO Tau w4 o was nrwr wrropveoer own 1 D X sr.•ar N R7 ?-? y' . (.,f Q, . E•00Hn. son nos. 0-0 A-ARt I li A, A _?.., r x ?6 Y r? ,DOE POLICE TRAFFIC COLLISION REPORT I?J`TRAFFICWAY PolrcE COmEIAININUmeER I 0 PRIVATE WAY ? oA o?c l _ r NME (USf ]AmHOU9) CWNIr ccuNrv ND. // clrv NO. iNWw oY9 ON OE OIN OIT-TOWN NAME'NOO SrREFl09 HIOHWA? mlfs ?5 ®W poi - , , ON . c En C CS R 9 p DN INTt95ECTINGWIM:519f NONINrtaSfCTgN eEM'E[N 519nT [ 519EEr i4Efl% E M%E POSr P.O9 1 D?I.Wt DIN .C905SST9E 9t5rMl N f W ACCIDENT S 9 JI -1. f OE r' f c? FEET & CODE COll1SgNINN)lV[D: VE / ?SDIIGGE ?HRf 4LYl NO.INJU9FO E NO kaIED ' IuHW[Dm : 9D INR CLS CAOSTSI4 QEEI0ID TE ,_ -? ? . AI NO. rOi O VfHICIFS m QDROPERfYUAAUGEONIY ?fRS lifD ?vfaca - 6/'Y/O _?.. ^^ On1fCt514LCn(NAMFOi On1tCI5iR11Ck ANDOWNfrS NArnfl ESr. DAMAGE SMCW CODING USE UNIT NO. 1 UNIT NO.2 • O VEHICLE - O PEDESTRIAN ? PEDALCYCLIST S? O Iv NAMt I.%51 I rv 4' NAM , m5t iIR -- Z sr4eernDO e 4 °? SSy LIDGDH DRONE NO D s Ano9 I SMTt . 778r.S;) R J? ?. DNWfrS YCff15EN 5 1 DAI X53 D I I I N A I H I DA j D%. ;... p or{yDA-p? NAmLa7-N 1 NO. y. ?A f'/FS IGHI HEWHT E E CUPATIOIr {I9M NIMEf Df10ElE NO. EYES IGNI IfIGNI 2 I Svtir ) R CHKK(dl VFHKIE A IEiN A AuorH O ? CHECK (,l) VP rL ASAU 11 OrHE 2 1, ' CODES 1. * 7 nmY A i'sv S Kr v D NOw° Y f nw im ' S Gt aH p y T°r • e CODES ? 1 13 2 wlt V G SST ' Y D 3 f- o m Y%ANQ B M a El- ? v ? •f•' 6 V o AN H? on" I o MITI• ? H o u Y ? j VW.YfM MAkl IDODGEdHl1) 7 ' lIDA91NOYAj SrYlE 1109.C .) a?S? X /f E ( V.1 Agpfl IDA91A) N ( 1°O.? ]5 t? E G SIAIF a4 fa MIF NO. SIAIE fI V H. O E VtH-GEMIEICAIIdI NO. i VFHICIf IDfNII N elclsrtmoowwR: // µtr Nasl mloaq rnout NO. O W IS wr+f9: Gs! NRSr I I I],` Aoo9essoi owNER A wntx ? ry r_s-Ys?x.s-, ?? , •,?? E NAMea AOOeesscilNweANCfco. oR ACfur R _ i J ' IT. -I T- WM Ar1A I ?. fAYirN6 4 A4G '???••" tiIARG r MA4Gf 'D'%' c- A fTOD I ESI. DAAUG! 10 AWI,N.Y ?4lAWMD ? AWAr ?R-NIED t5 .6 lOiOR ii ' ' ' R`^T 7Ff !H DESCRIPTION OF COLLISION; IDSEwrnEmENUSten lr Nfc[isnxrl DIAGRAMOFC0I115ION- iDTS I I I ' ••. I l I l ,-. Ye !i/.l?.a?s ?Imr?f a? :ca t d.YJtav.En_ L 7/ o Y ! df?' T ?? 'N i ' ? ?f ? ? ? ? I ? t i efr . O _CO / C ] . ?( di _ PAi C;_ l? Y / ? I ? ' ' 'n /YM N,.O tE .../? K??.S .._. ic+ 1 d. "i...? _.._ _. •; .... /; jblrt/I .. i f IJCPY?_S 1'•S /'D//e•c/ :44 / :lC XiF MC 6 C /f ? - rY.r. ., .. i .. _I. .. dn .I... ,. .. 7A Y :.;..: _ __...__ ........ _ _ _.. .. _ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED + CODES 1 - 2 9 4 5 6 OCCUPANTS/ WITNESSES IOrADMr'N]NA NAM( SI Sf% AGf IAIUS " 4NH YA 'Nl AS e. /MR "rtY AM.1+. nr AM n ?' ? • ?w; C3'Nl• f Dww O? O'°I" 0=. 0= O A Amf ,;? H I ?AMS ?- (PS ?;: oD•E%s INN•NS ? p? D r an .. nacATwa+urs NAw a•AHk wucf o. ytq[ayctrD bG?1? Dwna wlr]nr ? 77 b «a ] n Hn C' ??Cr X .1. /?/ %t0 c ' / ]m Ni•L {'v xy` ,duty'. '•. t IYU. I POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY Poucfcom-NTNL To k PRIVATE WAY I>?' DAI OfC N 1,.1 . T uNUN 1 v,? u n I s. 11MF IIJSE ]FDD HOUR) COON FY COUNIT HO. ?G GfY NO. iMNA ?URBAN C A ,, ?frFF c' ?7 uau 1 i kg. QE QIN <tY OR 10WN N AEs"o 51RfETORNGHWAY 7 -0. Y RWtf ON 51 ` ./ TL.1 MILES O5., Q5v HOFC ON ' 'y] Irvrfx5EC1 NG WIIH: iR[ETOR ROAD NON INIf.SECTION ?/ PRffl% F MIIEfOST BEM'EFN SIREET6 SR°2o STRFEI • O/yO '" G E .CROSS SIRfEI OR NEARESiM f 1 DR Cf+ I I Rff m1l[5 N 5 F W OSOy ??' ACCIDENT MILEAGE RNAP DIAGRAM DAtq , ) fEFi Rw OF CODE CQUSIONINWlVEO: SEVEKR TY: TOTAL NO. NO IIIFD?EFOANJURETS QSPILLAGE QNITB Cf VFNICtFS PROifRTY DAMAGE DNty ?RFSUIRD pVfaClE wH410N LIME/R Fv ND Cl5 if Cfl SIRE O4 AD 04 REFfRENCt CROSSSWEETORROAD ?69szoo '.]] _ a OBJECISTRUCKINNAEO OBJECTSTRUCKANDOWNER'SNAMEI f5i.0AMAGE SYEO-DINGUSE - 5 UNI7N0.1'. UNITNO.T QVEHICLE ?PEDESTRIAN QPEDALCYCLIST - 5 ` oRNfR'S NAMH NST HRS MIDIX Nos Ljau E N ER'S NMAf. UST fl 5 1 St4EE Ao09 .. REFi OORE55 9 O. BOY H C7 ' Z IY .SIAIE 21PCODE PHONF NO. D NY STATE IP P TOWN N GD S- R DRNER'S UCENSFN SIAIE % A iBI IN I Iv x R' LICENSE LATE AI BIRfH ^ Z- D-"N-SS F Y I Yv oi?2 Ln `/ v mo i B,Y i B CUPAIION E EYES IGH1 1 R ??E?e NB?1`l7IJVF?2N E OCCUPATION FIR AMF 6 PHONE NO. EYES WtI- HEIGHT - ,Z:. RTEATDE P V ' O S R p CHECK (? ceAS aN im ¢or[fo ANOrHf4u Q CHECK(? vtH1n Mxov[E 24 N[a?l CODES P. * D a + i 5 e a CODES 0- * 3 e vfF 7n 2 Ni mus st : ao,eD ? a ? us E Q zs:a Q K ? Q Q rl." /10 n ? Q ray . U pM KN. YtA4 MMFIOODGFCNEV.I MODEL IDN[I.NOVA1 $YIE 1]DR.;ONV,1 ( UR. V.1 ( NEV.1 (DANI.NOVAI Y .YFAR H NT p E - 6, H. N C N P SIAIE RNLfRftAtf NO. SIAif I I vtH <IX 9 N A aIL N. 'RED C VtHICLE-IFFICATION W. L VEHICLE IDENIH t e IFN.t p i t ! I! ? ? N elGIS1FRfDOWNtR: LAST N951 MIDIXE PHONE NO. NEGISIFRfDOwNE4: IASI FIRST MIDDt f . rD ZND AWRt54 of OVmee W A x OWNER DI 2 W EN E A,mlfA00Ri35pINSURAEFCf CO dA 1 R S AN A ]] CCT7 µ?"f'I p Y nO?" " eH GE eHAeu o F " iC ' - - (3 RtMAINED - ?=AY DREMAINED FSf ONAAGt 1 I4COTTO IO?tITTO? 5 EST, OAMAGE D _ C3P WF S S T°D BY: L r AY eY: w DIAGRAM OF COLLISION I N 11u eNdN DESCRIPTION OF COLLISION (IISE SUPP ENTALSEET Ii NEC[SS RY) .. s FIT N[uSSA.vr1 er RROw ._.... _. = - # / Ca E?. _._V .-- - GRa^x^ o.V&R rHG.?CE+?!r?R= _ i I i ; 1 1 . ?- I I 1 f .. C ENE ,AND 7T1ElU_U6ER? .B9Gtr CrO?NCr _. - ovcp- A ?E1 i i-J I I .._ I Y! I D - _.?E V?kl WRo.._Fdu1?0_ABfjNpCNC?D I . ?' - .._ _ .._ .- I . t- 17 1 ' I I ) ? WDE.ASOrv , G' I I I j I _ NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED * CODES 1 - Z 3 4 S 6 OCCUPANTS /WITNESSES IUSlswftfAVMUSM Id ADbItgNN NAM[ lT S ....... ...._._. IEK AG[ IAIUS as -u??... IN .wi. _,_ R/51R. !MR E NAMt: ?, _._._..__ .ro•fss NAfUR OF ..... INenY AM IT ?'e4l"' O"" • ?Y"i VWNSF Nw 1O p•°K10M11L. OY^tX O:;vo '0 - I N 0 - _................... _ ` ..... ...... ....... .... ..,.. _ .... .... AMft•5S NAllleld ... .... INNR%S NAKE •N ECIM IIY?AMB. QrA ?rMRe ?iI,?T ?ri°x 510AIR. X d Kl?f NMIt RANV eADGed U AGINCY 11 •NI ICE DISFAtC1RD `? NKx:I AeeMO Ol?/ OAlld v11041 AnvOV10 BY DATE /? .C.J, )FNNeS ]q]IIxS ..,:1TLNa? 1 `>i':' ., :1 p F.}PI :. ' 4 tt t 4 h p . gg ( 11 ? Ii.. t. _ _ _ _ OLICE TRAFFIC COLLISION REPORT pITRAFFICWAY IY— . PODCECQNHM141 rvI4Mef4 1; P 3 PRIVATE WAY OAIf Uf Clxt u A Ou0 •uv ... 11. AIR 1wH Il y.1 NMY IUSE]WOIIpUR) COUMV COUNTY NO / OM1 NO {HY/A 9UU N J ;t? G C•le claar "o RAl 1 SNO Of SIREf[OR HOHWAV 9N 9[ 01rR CHI 0. -N '? ? ? H r K Cy5 + ? N P U+ Y 4WIE DN SrRff C Jf A t..?,.3,4p SECIpN ? " . •! rec O r/a•• ' ] . Avtfs. D•IS la?W ?oi I / a7 ]] ING WITH: SIVEFIOV RUAL NON 1N1EV5tC110N 'i{OOY IJR• RT 'LCi •Rt11x ?? f0. MIIF POSE ( DEIWFFN ?? SI9Et16 +?/-2 StREEI ?- CCAD1 [ K)1E 14pN 4Uf9tNU. CROSS SiREEI Ow Nfg4t51 m1lF PUS D ACCIDENT NAMP pIAGRAM IMTA 1. o M4F5 5 f W -^ %` rttr orS? G MILEAGE coDE COEUSION INV0IV[D: lR Tr. IT{RUN ? SP IUGE ? H PFD? NO I I ruMi+o4loiw I 'N U E Ct5 C RS, II0 F R90.5U 09 Rfit9tlKE RO55 . N U -. NO K CIED? Oi VtMIECIIOES © ? PRO•fPTY DAMAGE g1lY ? Rf5iltiFD ?I1.1c. ?^ [++- OR1fCI519U:KINUnEOiOeJ[CIS?RUCKANDONNfR'SNUnfI ESr.DAMAGE SPFCIAICOONGUSf 9SZOO UNIT NO. 1 UNIT N0.2 [ ] VEHICLE ? PEDESTRIAN 0 PEDALCYCLIST RIVf9's NAME: EAST HIS MI UlE DRIVEw'S NPMF: EA51 H4 ID L ? FE STREET ADDRESS 5T '+ !C E PHONENO D IREfI ADDRESS ENE SE . 26 s1Alt IYCOD Urv IAIE ' / • . 21P COD S i'S J R vlvfCENSF NU D All. fx C» H I l1CLN5F NO. DWF IAIE SEx DA YBI41Y ys'13 f?iC u?n +? ° DA1 9 V MD. o R. OCCWAIION HEIG111 ETES WF G NAMfRHgNE NO E OCCUPATION I— NAME a PHOrvE 110. EYES WEIGHT MIGM ,2 17i? 1 . G7f{ R 9 CHECK([? 'vrrRCir AS AN [MP OrFEA AHOT,Ifv t ? CHECK (? H1nFA a OvrF OrAND IE CAE ? CODES ?' J n""1 < i+inm"•'O 5 N b i+ Kr °i; cnoN E, ?' a n n s 5 to 0 'S^O ' :si ?ie?K•?t i] 1NJwln %JOa?/c/C'+vE /sd +[/'t? M o.MNx r ?"41I ?zs:1R ?K NYK; ? N ?AM -,9u ?w:., ? lt ?p,- f c O ? ?y (DODGE CH[V.1 -11DAwr.NOVAI fA4 ?J?U UNV I NEV l MODfI IOARINOVAI ll]DM v.l K ( YFAR / E ]e W tNSf YtAT S1ATf AItfR HATE NO STATE u H . A PIO H COI4 l A A n E. /Y .// 1?,, C av VEH1CR-H11HCATNJN NO. vEH1CtF IIXNDi1 rI NN . 4lG11TtKD0'MNtR: 4St r1R11 I [ • ! iG5/E /9f l/ ' '•' •NONP NO. ?•? O W 151twfD WN[R: WI 11RST M1DIXf 4 N ly, A°n4[ssn ER N E v Uwrvf R N --- wACtNr w9ANCICO S 4 M 1N u AN 'uT ]] lr IN . NAMEEAtx, ES R ]atA r1 A ? •` iVM+?? CHARGE ? r N ,? ? or1VAACto ARtA CHARGE o w o°''vc! 1 RtMAIN[O 151.1DAMAGt I?D _ S EST DANAG[ ?AWAV E`?IRII-NID Y' O1TDv ?AWAY ? ° A Itwv°eY: Dr, $ ?nw v s r- DIAGR OFCOUISION: lu l INO?uN,gRIN S.1 easS Rn erA- ,Lolk? yf ", DESCRIPTION OF COLLISION: IUSE SUPnfMfNTAt SHEET If NEMSARYI yam,, ee:ii ra..d;/•wtJ '?%fr or Tr,'_L'./ ' e ? e //- - IJ .. ? 19 /nom ,li.fn /'l' /'cam/fiif,j• odEOY' Y^'o?tl? s %.qc X A `s / ? / . on ino r/ - NAME, ADDRESS B INJURIES OF PERSONS INVOLVED I CODES 1 - 2 3 4 5 6 _ OCCUPANTS/ WITNESSES ??SAt`?uK11lrtn uiiASU iii SEX Ar1E urns ° wsiR. tna s"". rJ 5 d Jr % iU C`T / %! / .nDwsS Dm' ? N ..Hrlly A.Me 9"11 ?'", 9rN 9 :Z AMI N; u AppR115 N Twra , "I"I IDI4[rA 9wn ?;;"' ?"" 9 q'x 91::11, r H rM Il An[RNn fANt yr or N uiNr 9AMR ?7: 1197`. 1. 9:: 9? •,Nv r ' Dan JfD DAUm•ErR>.1 A me+ u»Al.,earcl• s,•aweeA". eAEK:f oR .qusr w n„ IDn.A1p•lD IIAxl A4v _ Io Nnp `(7 ?' (r /O/.?' /c'.?J'?.t•/? Z 1,? ? ?? X / ?"?tytlrJ_CCO ,i°.[Y, ? s/-_ S' ]•ru HwS ]wn NRS ?ya J" t ?? 1,Tr, [1.!MRF-777,?':!.,'? IE-L i .nr}.Y,: "S i h <' L •? -g xl ?'.i r 1 P ?h STAT.?;OF?WASHINGTON _L0 '• w a? - 'rc 'wt>? ?; - x OR VEHICLECOLLISIOtl l +,. y'' uOliE(XOOUIEWN:iL'".';i?'A l.N:'OAY OF.GOLLL9pIp ...'iWEOF,COW510H?: r RR, WEE R•,P "° 1tYNU. ffP GiYfW;O"'i'?'rFa: aP yyHM'^' m e 5 . :t :%5 yr ?;• ??°€ :?? . wt.._ .,.courtv x.?.N?;crrvaroWx...A...E,. I soE MILEA©,,....,..-.::serrr..rowNtc T r Aor?A(C2ESJ? FeruEh: NO ea/oc? w ©® of z".6LOW b ! $1 V9R a -1 .v ON ., ..N'-,OIMENAMEOPatREET: P.WDOR MOIAYAM'istl.'e.-?: `V.1•'MEREECTNO WTIIRSiREE7:OR ROAD i. _ v- EO''t'. M4 ?•?" 4 ?? a E ! G E NONiNTERSECT IOCA-NOFC`{IXLa EETMEN \_-.?? STflER ANO STRER `.^. LXAOIWAMT CROCE ©© N.uu<noea qu?e?ron`oiHrnrna uNOr+ut•. R' r •+r':.IgN9 ?X-fl Wr[AEEOrwOmY%•On RO'AEUW' Wf ME ??w Ogs3mK Only vFKlEvfKLF ?vN.Cm WCr0. ?OMEPNmrFI- /?Er vErSlEO01FtT ?vE:xCLE rPUN / ? ? 0 I ?C V E SPEC.000E .yt, ,nw- r0 1 •M • v e N. CE Vf LES ® `? ?WTPw J 4/ VFKEErE0E5TPwr ?MNOOw59N . Y i.: 4C ?.' L OWECTS M TY.INNAepCB%Crs PwR .•...-"-;;rh':.n; OYMEA OFOFUECISNAMEANOAOOflE59 '. -...:... ..?.ur ?. LOCAT WRDA OWAV ?::.;+.. •.r.: L'. ?N © OP _ _- - . ION ion.EVAiwm -_ FEET _ 'Ci HOPE t - gitvERStA9TNN%E ....e:.?.-- ,rt:?'.r•FiRSTNHIE_.a::.::.-. ... MIORE'-%. iWa CMS WEPE Wv0.vEo OPoVFRSLtSTNAAIE : .. £•iSTNAME:......:....: MIDDLE. •. ArsoAJ .J ? Musww s ? c StRERAOONESS ?A:?I 'c:.•iAeicYN '"RUMTENaANDBO%NR.'w'. ?• uoRE MM tw0 5tRF.eT,AWRESS.= ._ „y, ....... .....,:,,ROUSE NO.ANO BO%NO...;. " 3 reirsw•v NA A A A CHV .,•? w*.;T:EVt,•iei]TATF?',Eri.Tu::"vwav:?000E:. ` OS%VEASOCMIP T Nlsxc . ST?o - RAw " gUSO ?T ' ?raS3f, Ey2'_ +.tax;_•n=DP,000E:. OIWE OGCUPATgN"...r;: AA*Ot-og-k- It/A/. 99M39 C A, rwTl- -` RWERSLr.FnsENw f%-.ei&t ,gTAR, sE%k COAtEOF emTN:.a pE, ;?... :•. oRrvERSUCEea?EERUAeEA:::::;,.,>rt;;.s;..srATe ..sEX. .„aATeoF?niH.»: eAa, w 7-t.CM3 .ss?sa'p WA 171 Y; S -Er- - w --U2r-A iY z 9, VEHICLE Y0.;. MARE(OSEY,-0000EIi.'. AIOOEI; VhOMTI%F :: YSrYtE(ECRI VEHIMEvSL', m IC vV o-Ei.i MOOEL(NOVA-0MTI:.•i- EOOY STYLEIZOR.1: _. u 7 1 &3 LICENWPLATENQ.V, -4.,3T"egiw -;S,jIJAnF -TE,NOIL^.-,:y;.eTA7F, 1.LJCENSE PLATENM .: :t- `STATE,:::. ,...T A PLATENO.;:..«^.:STAMI. i;:'+. A-7 Q -7 Wn/ vEHNXEIOEEFTmoATIONNO+iitLir._[Eaea M00EL9neEwEn1'T2« OOOMETETj IWRF,AaEI t ? tk9+ VEHICLE WETFIEICATIONNO.?r?.'y':..I1BaaM0OEE36 NENEFt1_:T:;„: [1klER.IMEEIGE L 2/ ?? 7r? P { IS /OSc? o4t REGISTEREOOYMER..x'rn-Lf,MWE54fj.,!E>QtEjUMEL;,'yTYr, OEYVEASEJCENSEtIO-`.r.G AEGL4TFAEDOWNFt1•k?(LASTFlRaT;M _ NALEq:? _ .:i.OPoVERSIICENSENO..;;i?t,>s?i e.ESM - e-?v?•?-NS yweLati(S[REETir-!'HO.STATE)EFµyY`?i.-y f:OATEOF&RfH:a;: OWNEPSAOORfBRfL, r; OWNEf44MORES9?,r ..;;:ar:`:>ISRiEE1:COYAND3TATEl :.."_:;::..i,'l;s.:w u0•TEOPWfill:?y • ? 0 ? /? ? ?r W A I- I D-- AATSOP VENICIEOAYAGED'Liu'FGLE'Y$IRAQ.'S'BF.4nr'.?.'AYiCYAT?a"wa?? :OP.VEHICIE [MF1Fl.FE) .ie...:G.r:'iw:K'-.9eiilaTnNHS:. 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ASEFK[R IMLEO IserFAN w+wm PE Ca.PtANr 0-1 ? •rPUN NO _ _ ,._ osrNNerel ?sEOE or .H nl t ' wM eae ? e? e? ?? y.y r S.IOW NORTH BY MrpW wOWGE ?l [F9p0eESE10W T ENE6 R""EFM 10 Etpm Brmp" 1Jk I f{a I ..P t ri,.?M M«HIIrO?QO•C7P.ln t-n'D_C?:? ?'isv1 ? OnfCrOnCr A. ._ 2 ? ??? Q? arwETOR XUNW I Gk SOC. 1 T / n.r ._.? __ •rwfrr ? / VEHICLES POSITIONS BEFORE COLLISION MOwoN•`M`0 ON STRER OR N1011WAV NAME OR NO 4wcrEw WmclF E R.u+arANNK uaw riuilAe mrla Kf -M o .iHCU OCOanFOetaet[o By NO ??Atigt ?r0•MJC! - ,V'. W N S ? ? 'Q"' ON - orw•r ? ? ? ? . e nw+r•w. .. .'.? ? C3 Ator.o - -•" waun TO mom ': DIRECTION rDI RECTION. . 1 v t;:°4 t ' E?WALI(WAY ]?SINXAOEN YOPaIIV •NwUIIS+q I?SN! AL% - " ?? A M1?=E.OEP R O1HEH ' '- "r _'? , ;i ? r Iv0A091WFACE ..c.cwl " .WEATHER-i .J '. WNTCONM110Ne ?. IRAIIrCCONTR01. rGR0A 0w1 vEKU '. TYPl p/ROAO, '. veKtE ?Ia?. onl 0f•VERNEIKl6 ADt10rE1 T" i fY L vFHXTI IaecROnewuonit lh F. r 1, I , ,E F 1 , „ 1 ? BA,L?.H o t o ?BNw 0, o c e WAY • o' t o B?INB BiRA?,tT AHE;? ? '. c r •L l -knMl? 1 v ' ({/? E p W t Vr MY ] ?RARFW 1 ? O WH ? 1 ? sfO ,ON 1 TYM WAY F MEAS-Ke ? ] ? OKRTAN%O mq PASSM >I• nn -rnt„, b . " 0 ] ? WEr ? a OE W J ? SNOWYU ] ? MU ? NOO ? • ? -A III ET ? ] ? 1TE10 mm • /IAYWaO RED. ? (3 ? .] • MERCNMO! ? ' ? P RAMP O •r ? ? MA%wo LET IURN ? . ? CE a ?Q1H•R a ? 0AAK-11 NER P I ° r rLA9wwtAUx[R E ? ? R / I O C] AL"Y s ? E MAR.auTURN p S /M YI oA RR`b ? a ? srFECUV " 3 am[ET uX s RNOT][[w0 D•rA[n '; nEA50 m IxIN.L e ? 11 e ?untUV1 iMO WAY ? LANEa ... , - ? e'?stawa a nu r tr '•,v L ^? LLLJJJ MOT brRKt T W r ? ooricE ? , ? ` ? erar.EO r r ro I a . '. I` ..w t a I .I n . nnn.se .n.rvrv t•1 f'-1...... .... . 1"1 ('7 WM OAT n6NAL ?. ,(,r JF'.:3 rk?''? .r'Il ' . 1P R ? ) ? ? ? ? ' k N _! i 1 l..i? ! v ' J+vr?'•!t llY1: ?i? ?WE"L'(,??1t;•? '?rn ?i f f?? a .97 POLICE TRAFFIC COLLISION REPORT Ittf'TRAFFICWAV rol¢FCOMnuM NUMnf9 , PRIVATE WAY wt a au Ar rlmF co ir _ I lusE Tloa HOUR) uf r couNlr hq, mNO. FNwA QD4eAH URu Ox CIYO410WN AMFA NO.Oi5t4fF10RHGHW v q ?N Qf ?IN 5 (AvITS ?W QoF LO< IG 10N N IN tRS(CrING N1INSTR R40Ap NDN IMFRSECIION FCTa St E A $?D20 ? ! ? eEtwlFN ?SrRfEre Sr9FfT PRtH% f MIn PMI Q •• r / DI NVCE609 I MRi ,CR0535rR1E 09 N(A9EStmllF r ACCIOENi 5 E W RAMF DIAGRAMMA tt JJ F a y MILEAGE t[r of Y CODE eoulsloN wvaveD: E91m. vf HO. NO. %IILFD?NO.IN1UREp ?? YllµGf pWIN wr'A'i'D'RSro?n rpEN. OF VEHIC{fi © ?PPOPfRTY DAMAGEONLr lmuu iN IM[q CIS Cp?S551NHTOa ROApR ? R'Rf NCt ET' E.I RFSyIrEU OeS TSR V ',r'} ` _ UCRINAMEOhOL[a STRUCK AND OWNEVS NAMEI ESr.ONAAGF I da tl L SPKU4 CODREG 15f _ s rG e., o S UNITN,f UNITNO.2 DaNlR'S w,M IASI E: ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST. N aaF v E Dalvfa N usr il9 AWt. ml E tallIADD4E55 orpu +' 5 sl O• QL><coDE D S REEr ADDFf53 PHOM Np. i `?368 R IY sun IPCOD PHONE I DR R'S OCtNSENO. I L =0 4 62s? 5 Ar W M o° %? ;RYA 1 IV u N fq. AI DA 91 H q D r .. e CCCUPATN]N i?RpM NAMtt PrpNE NO. Ens IGHt NE 7? a [ioY Y f 5 E R OCCUPATION iIRM NAMEe PNDNENO. FYES Mink WIGHT ,. ? CHECK (.O vFnlp A A ^o'It A ANOmER:? ? CHECK (? VEHKEE ASAN fMPIOVff WA Alfa q. CODES ?? p n: " i. 5 e%ergN soNRCYa` , CODES ?'H a:i r < ^sw ' 3 fxa ° rcl% ,bb ulof CA 5 gn a E.N r. N D. M D N1.?°s' ? S:N. ? NRMt ? KH. YFM MAAE IpppGFCNEV.I (DA9iMVA) StYIE IEpR.GONV. J ?A a M E ? ? Ebirt Q - ?Ib ' v H 1 HEV SoV\. i? E .) tIDARI- VAI ( -) (? CEN SfAIF IR.VIfRPUIE NO. 51AtE li vEN. QOR ll RSFV?TF?,'?. ?[•-t ri/ C KHI<lf lp(MUIGitON NO. vf.iCRE lOFN II I rv '? P;LI 1 & i6'6la ! L i i l i l l l l ' 9FG?SRRfDOWNfR: IASi rIRSt MIDpIE PHONF Np. j cse ORVIL LF D. O In9D WW4: µ5r FIRST MIDIXt 15 AOpafssohowrvea?6? 4 co rY q Po 60? , roL f J ww . N E A owNER ANe EADDRessawwRArveeeO. oR AGervr Yw CYT T un[•?. R Ewu R D Y ' N I! T D PDw,Gi CN p CNARU wo V [5'r-fp AAY ?REAUINID i [ST DAMA 1 5 -A D 0 '? Aw A WwAY 5 DIAGRAM OF COLLISION: DESCRIPTIONOFCOLLISION: (WISUFHLW[NTAL5W[TIFNEas5A. ..... 9 K. 0 ,, . o3 dewah i--7 _ D< . .D N ? ? vek Pf - 2 ?? S xce2. a he s.c I NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES 1 2 - 3 S 6 4 OCCUPANTS/WITNESSES is warlfoMrvf uTNw.S'W°ii Kit .oF uro v." e - NI" u excr ? rcr . i9o. 6 N-1 AI NM f[orL r We . A Mf. W, A" 0 ;w-'. 0 ;V V."_ V ADmss . il0 rv.rua a .. RrAwfpraow QAMe ?";K'?"" , Q,^,x ??° a Rio AYwlit NANOIW ? 5 N er?AMe ul KI ??ont. ?U,T ?iivv ' r tgArappfR;IK Lx S NAM[EPAn?a,)?1 µ?E el gip. KIriCY KI DIS.AECWD t'UIKI ARPtIT+yTD DAAll RI APhpVE EOxr Der pA11 SQ ai?tNt ]A'DNat O1iD1 Wf I•<'•/.S 2 POLICE TRAFFIC COLLISION REPORT L?TRAFFICWAY IoucEcoMRUwrNUmBER PRIVATE WAY al OAr 1COlUl ON D.+RO oar c l wxxornTO T»n rn .. nmt c IusE R•oD}RI ouNrr 1 1l?St7 AJ .JC uNrr NO. co 16 1 - fnwA ?u eAN I ?j F 0 CITY ORIUWN NAME&NO 4 -Its OS O OW 001 ' of 4 ON ?- ?--- N iCICLS I STRE .J 56990 "o, Sf ]] 1 INTtNS[C11N t SrRFEIOR ROAD NON INIIRSfC110N "J B[PW(iN SIREEI'G. r ), (/ a WES, vp`fN% Ep. MILE POST ?J •• / v? •OG ` L OISIANCE 6G? MIIIOnr NRE SR E.CROSSSrREEI NEARS>IMIlE W3 Gf? ACCIDENT W M E R V OI"'AM , V O TEE, Of .t A IL - CODE C IISgNINVIXVED: I:O. RRiIIED?NO.INIUR[D? ?SPIIIAGF OHIt? IOTAENO N wNeplGrH INtF 'RO Ct5 51 Rao R NCE CR OEOSSSIREfrOR ROAD ]] . 6VfHIClfS m vRpVt-DAMAGEONEV ?Gf5UlR0 ?vfpiriClE JS'?!r(/ j-? IJi Oe1fCr5TRUC5INP EOFOBIECT5FRUC DOWNEVSW tI fSr.DA'AAGE SMiA1,CODINGUSE _ - UNIT NO. 1 UNITNO.7 ? VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST 21 IV S NAME: ( MI • 1 'iRS} /A s I J SINE(IADORl55 OIT SEATS (Ip COOE P ONENO D STRElr ADDRESS I / Ffir,7 LLJ L V n" . H R Y SIAtE F DRNERS UCFNSEN SIATF BIRIn 1 Iv UCENSENO. ATE OAr OCCUVAlR- 11-INO. ETES IIfIGHr E OCCUVA'.- fIRM NAME A PHONE NO.. EYES Kni HIGMI L L R ? CHECK(/) ' vE -tS, F OF ANDTHER O CHECK(.' _ I ANU ROVE A ' -` A ' F?M r COES 1- 9 5 ° s ° E CODES ? + D a ° 7M L " r Z . y ° D , - - N 5 ? 03 js fL 5 ' w ? W" ?CC% _ o n =1'1O U ? a o 8941 0 r,,Z4 0 ° .. ID, VE-V ? MAKE IDOOCE.CHlV.) MOD EL ;--Al 51111 IROR.- ONV.1 .rJ P i U E ..,fA9 MNC ( HfV.I MODEL IDARrNDVAI v,) ," ? vn. R tICl NSf RA NO. SfAff 1111IRIATINQ_ STATE H N VEM.CIXOR t All . SA , /^? ? ?/? 1 A vEHI0IEIDEN11fIUI NNO. 4 vfnlRElpfN1lNCAl N x[GISTERFD OYmFR: U5r FIRST MIDDLE I to. .Sco E. g O. O I FEREDWER: -1 FIRST MIIX N ri , I] '6]r A ORTSSa OWNER o6 !3 . N E A E OWNER NAME&ADUE-OfINSUR.WCICO. DRAGENr ACIDARNAal'"'ir,D R A'EGTES$' U AN?i T' '- .. MIA V ' O N ]] a r M y CH IX CHARGE r xA i CnO T GF AREA 1 p J] IS ROITO? ° OuAAGE D ? AZAV ?RE AINED ? AWIAY ?RDAAINED E5T°.OAMAG I •TOr 5 IYOOiTG? f T?Oer: /J W OTOVRD Ar Br: f IS P FM NAI NDIUIE NOpm DIAGRAM OF COLLISION: I _. .. 5n[IfR NEC[SS.Un) er ARRtrM DESCRIPTION OF COLLISION: IusF SUVREMtNrAl Sn[Er IFNECESUarI _ _. s vie?a w,?? :PQacrsn a? ..s?• a ??? ?F, ov ," ? 4 „ 'f _ -• - - - _{?• _ I ?r 7Jr6 . onn, sT.???? me Gn.?+r? ? Ld _ biCO Cv(apcE?G-Y -OV .? . OE/) CC-••_. ;t ol- ells /=(YFNG ,cf w ,YV G rL B] IR aRR),/v _. J . . , , 8 Paa;cY uti rJ.e !Cagy.. ]? NAME, ADDRESS 8INJURIES P N NVOLVED * CODES 1 - 2 3 4 5 6 OCCUPANTS/WITNESSES III0 AI NAM fsi Sl% AGt AT 'NNn Rsrt, p(a + AMe: roRrss RE,o NAnsp of q NI e. AM e, 031 l o r..'- ?7. 0 tA;,•I ri r. AMI w A wwtu rupfa R Morro Spa. OAMe. ? ? 0 . O CrS On a0 N AME F • DDMas.. NAnp ra 1 1.°ArOAMB 0'("'Kf ?COHIp ?:i? ?r': N-snoArwp fuv;rRxM a nAaw o. Ar Ncr /y//G?srArelrto PQKj A'?9yaEgo oAlepxfV041 AroIIOVEDer oAn p 0 E rfF, S ..ii 1 '?)?E?.v.A'BaRli? - t'. 'S'.l £ ,Fywfy[ -IIR1 .. J T ? 1 ? "ke ,?{? 7 t S? - r . Ib IF? ?E ' h 1 7? T?? t f tiS e { W . J. 1 1A Rx ' ?•M1 h _: I k r L I? jA ? ? , , 5,?1 { s - 1 I ( t f ? 1 ? f I IT}?? q „,? a 3 N *-4 L? - -. - ... arnrr. Sf IU90F W,IWEO :; FOF.RST ONTHA. MgUE4 ro L?R v ? K SE r.GlA VEHICLE wLLCD IYNFR 1 MwoKl i TIT Q C MOFERP, ?nWSlrvw ? 60 60 ?70 ? RI e \ NL ' SNOW NORTH BY ARROWWGRCLE 'J. Ada AoAMI ?_?1 `Y [ °WGrlialrw wt rtFCIJ •' .? U41 •E[? Ar uAVe! On u•eM? T MiMl Ond mni.?si? S /S Q?_ fnfllOR H?FWw.v 7777 rw.Iar ;: ;-: . M , VEHICLES POSITIONS BEFORE COLLISION ?CfQ,1 VEHICLE N S C W CN STREET OR H WAY NAME OR NO. IroMA ? ? 00 Na 0000 f°< nM,l•:AAAn C) ? ? ? Kam' GDfWNK a?WFLKwAY S?MIDULOCR ,r_ IYDESINw WUl13W(L ? POA051NIKE HEATHEN LIGHT CONGf10rJS rnAf fE:CONTROI KMC•ON[ C?FC•OMI yr H` E ?v1nKlr <.am.Yr IDAYLK?11 ? I ? 5-G!!µ5 ONw AAl ? I 0 DLY p d nw.w a ? ol- C] 7 ? GIIN :JdJ E J T rJG D ? cos. ? O ? YIELD SIGN PMISOF HM.IE DAMAOEO :..: .. .: .... ..,'. ;'?.'- ?;' f•nuArtoGml 'rorE?NRVEIKIL• PMTSOF VEHX:LE DAMAGED ,.. ?... ,. wv,nOlmT •..- .:. •. .. '.:. OrH/MvFfS%E + pA:4. Y,I S , g ' LIABILITY INSURANCE INFORMATION-VEHICLE N0.1• WASWVERAGETHERE W IUTOWEFFECTB LEFORUTMs-ATYINcsoEtlrSURANONCEroDRCM ?YES ? NO '. "'Rq v t? NIME MOADDIE39 QF UAwUTY RANGE EI?UCY {gLOER ?. .. y- NAYE 1 [ ' ,:.;..,... - ._. ...: .., 'NMI EOFUA&UTYPJSURANCEWMP/.. + ...,...,_ Jro AE C- ?'- j4 • -,- ? ?l I ?7J7 /-_ ' NAME DAOpNESSOF WBUTY wSURANCE AGENT oAwuTYPOLK:y NU?? .: S e ?y ISTWJMIV :;.':r `-':: •. .av.»!:.:. «_.,?. .. ..- AGE ...?.-:_ a AROrgNALYWPoF31 . ... SFPMAIEREPOAIIO AOE V ;.•.. DATEOF L`DLlL4f%v{ .:':', W YOFCOl r?..TVAEOF LOlLSg9:- ll901J :er „.r j COW C E P? ? I ??P-..t?. ?rr.?IN ?,?S d'.•i?'. r. :? Id^"'W: ?...:. ; -.'.:.. .. ...G !DINT! -. ,..,I,. E w EIIWirsMnrE r E MAE9^O© "`- ....GTY.TOWN ... L . AOMC45 '.Sr Fl%R J h aORa afTtU9E? SECTgN "o ? A ? ©oF ......•GVEN-EOF TTREET. ROb WAY :. ., ??. INTER.... TH:STREET.ORROAD <. PPEFl% EOq' MKFxPO STV i r?? ? ? Y / ? NONINtERSECigNATIONOF COOL 0 RAM ? OM4RAM OATA'E. g?.?,v' Trµr.:Ai?? { i MrwEEN p. f+F C.. ~ STREET MO STREET , v Y Lkjsl?'r- r79 ?w CO ?2QGk 21 wl WMi MIM•F BwpaE. Nor (®Q?I© I ,'+[r w 'EO ..rIN uxLrostO U'wArIiNPUwx `!rE .irvrNO . 171 NON KPD INTER INTER LA [ RE EO fAOGy ?pN_gJ . E+?r LEY® Oi /'?n. ILA-CIi0N ? y V ? , ?i1.ry1%C+v W/i.; `.<i.?+'.^rRH i! -? ? ?- ?u IvnvrN SPEC c00E7 } „J EV?y2/ Vu r ar LEPfaE.rnAN paLpEbN rNW ' ? Y v . OBJECT STRUCK INAM[aPOSKOrsrMKxl ?. - .- OYfNEROFOBJECTSNAMEANDADDRE53. - LOCAL O .. gN WAY !-... ?N © EE °? O f G ; _-WigA rT PO FEET f -Oe R T • • . . DRWEN5LASTNAME FIRSTJIAME .... .. MIDDLE I'I ' L MORE THw Et voLVEO URIVERSLASTNAME ...... FWSTNAME .... MIDDLE .. : ? ! ? wE {LEFT AO0flE55 .. ..:. .' tE Np.ANDOp%AO.:,. w vq STREEr ADDRESS - .._: ROUTE NO. MID BO%NO. .. ..., _ ??'? is ?s s 3 I ?' ^: GTY STATE LPC D•VERSOCPAT N 7 CEV FA GTY',_.,. '..STALE ... LPWDF,,. OWVEAWOOCUF m. Lam G? 9 2 Gn-SLK:ENSENUMRER STATE SE% DATE OF BIRTH AOE piNEflSl1CFN5ENUMSER: - :. STATE SE% oATEOFeUTM AGE -E b ?l All-P VEHE;LEYR. MANE ICNEV.W I. (NO -0AFiTI .. EIODYSMERGtI J VENICIEYR. MAKEICNEV: WOGE)-. MOpELINOVAAARTi. BODYSTYLEIa OR),::.: 72 ui0 U !r _Aes LICENSE-EW. STATE.'.: TFUA AFLATENO,. ;,.TIITk ,- LI°ENSEPEATENO. STATE :,T{WLFA PLATENO.. ,;•; STATE. _:':' YEHICLOom`IFICATIOM -.;: (I9ESMOD[I9a NEWEfD ,..,. OOOMETFA IMAEADE VEHIGEIOENtIFM:AigNNO. : I19E8 MODELSANEWERI' 'OTOVETER (MAEAGE Sgwo?5- 7 . , REGSTEREDOwNER-..,..;(LAST-F-IIIIEIOLENAME) F' ....DRNEiISI1CEN5EN0 REGLSTEREO OWNER :.., ILASTF4iST MIDDLE NAM0 .-. '.; D(tlVERSLKEHSENO, r,, `i.: =-IFI?WAM ..,., .,.-:ISTNEET, CRYMDSrATEI:. :, ,OATEOF&RTN,; OWNERSAOORESS,. -,_ OTMU.CETYANDSTATEI: 'mTEOFE9RTN' C M° ". NAMEcce --.I p c I TOTAL NMIxe.NO - _??? r +. y .ceu.Flww, ._ a4ir bl.wWa I[a4V NWa VFIVLYa OOOVI[p ?.Aft• ?EE W RfA !II/ - r"611P TIM, [S S NO M• . P ?gl ` ?. C) ? ? ? ? ?ENINI i , ETIOM DIRECTION to DIRECTION •??MVip wVx S? ?rlws'^"iwyx S?OTIIEn I fYF'EOFIgAO OIVVER/VEIPCLEACTIONS C..C.ONF ORSONI i ?i11 4[ wHLFaMa I WHGL V EW?1 E ?DNO BTNWHEAD 0 ?ONf AV PASSING M y, a ? TWO WAY ? ] ???SgIE a ? OVLRTAKVq ANO 0 S 0M.WO TIONT TURN ? MAKSIO LEFT TURN { J / ( y ? a•_WE ] ?YgVA I Oul ? A ? IUSHMINO ? A ?wppPA`jn IE ? A U'TWW r ?1 -I / y ? ] ? SNOw { ? IO(1 ? lGll( SIR9 dlE'Et ? S ? 4AKNO { Tt 5 '1 y ICf. Or rER S DAPK %-F.T 0 E ? FLASH•A A-A ? S ? AIIEY Av?! r IfItc YI ? DNIIIrOIP A ? fEl SKVIAL ? ° ? LAVO WAN (3 S C] FAOVANO ?FY? V r rT y l >;l A ? A ? O11.fA ] 0011." {a L E 1 ! O S c) 5p(CHr S ? Stn{Ef lfrHiS O An MERrfIAV'.4AN LANES ? I ? STC"EGFOO TRMFIC y n1. A50NIOR NOT SEEMO DNIGER I ?fOVf CHY I ? f{ONAL II J '? E r ,1, A ?4n eton GAT EW A4 + j , rtarvwprnu n,rn.crrny 11< ? S 00114. fPECIFY ? I ?MPMAIfO ? STOPPED gM 1 ? a C] D Eno, ? 9 C) SrOPPIO W no OWAr } C I ? ND MOIL ? S ? UNDMDED r3 10 ? ei ron i I S f I r- lr? 3 w \..""•'s}1'1 'ApM[fS « r s...i iYWL1?+P.1$? n"T?1c f"°E=S ? Ia ? iNU ?C?IENTERINO II I t 4l{? X. b,J: ! ap' "r n",?. I'D ,.c R G ?SJ)3 POLICE TRAFFICCOLLI, JNREPORT E2TRAXHCWAr Poflcf1, rNTNwent9 ? PRIVATE WAY 04q C l15 O't? •? OI W "?' I DMf IDSE 2RWHW9) co-lr 1 ?4Fi=L/.s'e 1-A -TyNO. // (C CI1Y N0. iMWA ?U 0.W RIIR.u pN p, Lp. UTY OR TOWN /n'?AMEa NO.Or 51 rDB MGf1?.'AY L ARLfs s _w poi L.? ON I..LJ•P.?.(/E(3 ,gyp fCI C45 RWIE 0451 f .SSG 9l0 ION ,2 INIf95E<IING M+I":S Rftl NAU Npi INIMUCIION BFIWEEN 51RFft 6 'll PRffl% EU. MHE POSI D?SrANC(t DIR I .CR05551Rff NfARfSIMIIF POS MRES R 5 f W iEEr Or E' "G . I ACCIDENT MILEAGE CODE R 1P DIAGRAM DATA COl05KKEINVIX- -1; p=, Hl a 'olAl NO. NO. KILIED?ND. INjultw DFVFXKI[5 I? MPROPERTYDA 01,1IY ?gSEULTED ?VOLIN WNWtDN .QD IME CIS f R ADOR -IlSStMETOR YOAD '' ??-?n?2? ' - __ K OeIECi SI4OCK(NAMl OF OBXKT STRLKK,wDOWNEPSNMnFI LST DAMAGE SRCW CODINGIRF UNIT NO.I UNITNO.2 0VEHICLE ?PEDESTRIAN pPEDALCYCLIST 2R 5 Dt?? : RNfPSNNAE: IASI FIRS I TVII E DRNE9' NAME: USi I I - J SrRfF1ADDRE 9fEI ADDRESS / 51ATF ZIr CODE P"ONENO. D IY SIA r K ,.c,f13 b R E9'S UCEN N Flt= Y All ZJA - BI N v 'B,r !5*'- I V P t NSE AE NYI" MO. BAr .. ' B OCCORAIr4n NRMNAME aPXONEIAI. EYES IG"r HFIGXI E occuPA loN RM NAMEb PlR)NF No. EYcS IGIII IEIGM .? CHECK(r? VEX ICIf,S'NFMPIV'Y[ AN0THfRU pCHECK (? fyf"IUEASANrIOYEEOPANOINER, CODES ?' 7 u v' i+ w 5 In D W D CODES P + D "Ass a isnM ` 5 1.1- 6 yq?. •"E A D 2 I OA M °m1 p AM.M X ?' ? rl. 0= DI,eRIg1YDM p AHEM ?l ? M` ? MA" ?'= p rot- - -IIDODOE.c"n.) o- 111G--w- 11YLE12DR.CONV.1 X75 pG 96pD l?U.2.af,A 2D2 E .Y I EV.1 AgofIIDARr. ( ROY If SIA1F - VENCIX R t A W ({ 1 9 W PL F I ,9 -01--' IUtTr P M,2 1 i5; 2 2.; -L ` ICIF IIXNrIiI N l l! I I I I I 1 1 1 1 tC SRR[DOYMf9:-I 11451 MIDW[ PXONFNO, St-WA rr P?S O y fG,SRR OwrtR: 1IlSI rIR51 MI I ' ADDRESS OiOwM9 N R OWMR - E NAN[tAOD9fSS Or INweANC[CO. C"AGENI ?D I.42S09AA.)ce R INU >2 AGFDARIA N f?AMAOE? IXUR c"MU c"Axcf o-?r ' A " m .PA E I eTOr- f fTOi S t3 ??OMUGE ? DWMN ?9[MMMO ?AWAY ?R[MAINfD lSI.D Ioiof4o: IoioTioii 1560 'w•v°er:r SON P ?'wwA`r°er: s le DIAGRAM OF COLLISION M IAr NoRrn DESCRIPTION OF COLLISION: (Lbe 3[ nerMMU SNF[TVrec[S:ERr1 fltLrv NEa55wr1 ._, a Row ._. _ _. k I t I r I I 1 I LlRC? _ _. VGII " _LW/lr tva<a,+v.__iUacm+_ ouuo?- roora_ a ? c? G jY"? yas.. ov. ?ItAc .. Fea22??_T.RP4J6itt0.. ftyar... IJ . ? _ Ttt.. ? m App: ?f I ' " ' ? ,> }rG G AN?.$? eRpn.!Fe!?er5. ?._, I I I I 1 - ?,y /2_/J1?GHf STRJGF 7 I G ek ^ s? f : .^ __4_ e. iidO .ce,f,mF,9 _ EAu C o_Ft .H?. > `? t L r' D?iueie .. s-nres .iy?w SH¢__$Kame.. er_. 4 ih h fny_-w_ ccvp?6o Guirl?_ Sop"e e.vErr----_ Ca'. RJ ? b ? I 1e NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED * CODES I - 2 3 4 S 6 IUSlfvrtfAUmasfX OCCUPANTS /WITNESSES Ip ADpIKNAI NAMt er lI -- .-OF - -- EAI A XX D - -y,? „T- ,. 1. M fr[ !XR Kiv N E' P _....._.... _.._ ........ .... ... ..._. .- _.... _....._... _...__ ,DOnfs NAru9Fa ..._. .... . ? AM e. ? E7LKl p XAI. I` E 0 CTS NAMe. w 7 A _.. _...._ .. ... _ .. ... AOpll1 NAIW p ._.. ._.. . . R!"OVED IYOM "o eV: pAMB. ?ruKl rRl r ?ti pn, f0 N AMI• No I ,pD4155 I NIwRfii INeerr ?AMe, ?li%'?EDEnr pG?' ?i°, NV X /,I, Mm*, ' EauNK e I IAUGEw -T ?ANCr O o-irial lry .. "1° ^/}VtD DAre Gr REEM; AF9 0110 yZue IAIE I :Ji I .r ...gipp. D ,' II t 4 ;YRV a , 1 ' i6 :? ?w '\.?3 POLICE TRAFFIC COLLISION REPORT I,pI TRAFFICWAY -ICE -IN I NUMBER PRIVATE WAY D T Ui N _ Y Im COUNrv COUNTY NO. CIrv NO. MWA EI iw+ Ixu IEi -yr. (USf ].pOHOURI U F-Lf0 d{O -- O .?NFFF2SaN '' r . I Ru [( ?N ?E ?IN CITY OR rOWN NAMERNO.-REETORHIpHWAY {Cf CLi 1 ROUIEORS •- S .1. Ns ?w zoP f?w Loc. ON. U/lK ? :56990 - INtF45[CTINGYn TOR ROAD NONINTf95ECIXNV PR[Efx f MAEIp3i . BEIVIEW SfREfi 6 Si4EFr '•{/, ?/ ' 1 DISIAN Et IR MRES N 3 E C?SSIR EIOR NGRESfMI S ACCIDENt RAMP pIAG9 OATw M(' - s / MIIFAGE f[ti OF I:OLt1 ToTA VOIVEp: VGlrr: NO. xIUFD0 NO•ENIURFD Q ? EPIE TOIAl NO. EGOf /?IM wwoeeoM ?? IM[R CLf CROSSSIRfFTOR ROM4 NCE ,Q ?? ® p OVfWn.a RRrvpAMAGEOKKr ?H143EIRRD ?VE.1 M1K1 aCIP . HI - OBAC SIRLCR IT+AMtOOeIlCi SIINCKANDOWNfR3 f 1 far DAMAGE SR.CW COpINO USf __._. :+_UNfTN0::1 r;?- _ UNIT NO.f , 3 ?VEHECLE ? PEDESTRIAN ? PEDALCYCUST 3 D fR'NAVFIA5!'i:. IR ''• MI .:...? RNFR'SNAM x. ?° . ?R : IASI y en E?c GS iSGGC /AI L?OoORFJE + JALLS - _ . tr .4 slRf ADOR ? s REfi MDRE55 / Eck 7'C? I Bcx `N- 4 z u . lr [IP a D S %qNF NO. I / P E{ADi oc t fit/ g?? NoNF R is !!/ Gd - 7 7' I ERYUCE - ,- StAI BR ,? x MO i H I IVE' O fN NO. -rE D 1 •? ` ? Lc/ S 9? /n L wA M D7 fs' ?„ E Q o 4714 F % I L o g OCCUPAfICN i14MNAMEePEx){IENp. tTE3 GIEI NEtGHI E CUPAfION NAEe PHONE NO. EY S ?' - { N IGIEl M!rOHt E 1 ,? S'GF a ?B,(S &?a rt //. /.(? -O R .? /[/p ,oy`=` /N A,? d A I ? CHECK (.? vEH An o<ANOrH{R. CI CHECK(. " v ^ a e'M ? r vEHICIE ASAN M rEE wr R o 1HE v CODES 3 n.°.r°y A i S urcrlw S ?:oPCreu ? CODES ? + 7 a^ii 4 °:irt.: l / 5 exellon / 6 s.miOr°e•c -? CNd? ON ? N ? ? ? W E. ? Fsm. n ? a? al ? M.RAANDI O c5 1 ? MI. . we er ? H ? ;°? VE{I YFAR S Y IE . MARE (D(x)(IG{JIFV.) IDARr-Na.AI I EE I]DR{prvll 4 MNf I Fv.) MDDfI IDARI.NOVw1 (]D r.nw -3 0- 1)• ? I I , ? Lpy ? ? R ' l E RAr SIA IRAIlE4 RAlf NO Slnf H vfRt 9 pl Ar ot• A ? I y? /.t/A C /?CK 07G ?A ' vW??unrlRUlaN HO ? i / . vEHlculu N r 3 W' IIt/IBID S;Sj1141D!j !.3 :Z I I L 21P S8;S11'O OISIUIyI I I ( ! 'i REOISrt LO IR• ]D WN UST {I41T MIfMRE PHOw NO. O R DOWNER. I {IRS! MIDDf 3 . ,t'Q Ei 1 ADDRfssorowrlfR W A R z N Z NAMe a Apatssar INw[RAI.Qm. oRAUnr E Nz /VON? R r {I] uMApl AREA wR:IO?H • ' n CHARD - CHMG =.D pwc%PL RiOP - ? lS DAS4GE pRNfN - RIO EO ?OftO? 3 ? AWAY RfMNN[D O41 EN 0REAVEINFD kS1. pAMAGE ? wr r roR E Cp T voer: - iwAEo- E /C jvs E ]yTAf. DIAGRAM OF COLLISION: 3D N M INaewrt wRr DESCRIP ICNOFCOLLISION; (U3r SO REMENTAI SH1eT Ir w[ess^n1 Id IISID NEEZSIMYI er R90W - _-_ _ __-.- _ I l l I /Ilcty-/-N+Af.-S[ow:.[6 gr0__S'r/KYO/? ! T -? --- * -?- } I t _ _L T» _./»AkE .._ ? GEtT-, NA _T_ sQN__/?TO._._ L___DL'tf4/lav -- = - _TO _PRss VEHFLat . -.a/ . N07*_-_4ff'461z1.><6 ,y --_. IR ? ? r H! wAS TuLd-/A? 4 /?? r?loN%' Oac N6.E; I ,. _;._. _? rRo M f? -I , t .SKIO maeks _6? FoEt[? L>•'x FnGT I , 0 ,"4ICCLT..? 2. 4GEC 3J . PAG SS. 1 I I I I .. NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED C(? ' DES 1 - 2 3 4 5 6 OCCUPANTS WITNESSES IUSl3VRlMIN1At31 ipl P[RxrloHU NAw Rir sE - vx _ -- -.wr _- Aw r IRNH - Hn :"i :I "-'-' "" Mrb. RtsIR. run S.IIn 1 17-1 MDMff l , M NAM[ IW IIr?AM e. ??Ar ? NH N'Y ?ri.Hv a fit, +_... m?e?elcs _ __ o N N.?Mss o Lo A rwrOE *-0- ?AMe ?iol?cl ?.rp. ? ? .p ADU N mrsrR:.IAx:o.{SU3NAM R rv ?AMe ? G`E?ro:D.? ?r ??LM . X RIAOw?oR 13 Awr,c Nfi ur SCSO clDn .rCrkD ra 0?1Ls ? R:[A.nY3o OA03 wrea nnpRr /a-1440 AP.rovtoer o•n ?R r i ;1 y??y},y? E f w, 4 G' I rR 1l f T ? r} Y ,CI r Ir 1 t E i? ? ?' Y4'Iq ` d I STATE OF WASHI NGTON n OE POLICE TRAFFIC COLLISION REPORT ED TIZnTT OF IMAY R4 OAI C 11 - all 0 PRIVATE E No. 40lICFCOMgMNINUMbE4 Wsp 159(4(V, .B) - ID ' . 6 . 3 WAY 1 Q Z. w NM1 xr0 ry rir 41 fuu'zNOURI COUNfY O /V courvrr NO, pr ,? .p 4FU'^' B f ?N ?E ?IN CNy O4rOWN O EI? 1: 1 MRIS ?s OW ID 0, N?KO WSrYE OROPONWAV INIFRSECE G ?/ L y Plp CO iCICIS ?i A { - 'F,A ,.1 + INO WItH t4fEl04,lpA0 C• O? R yE ... 'PI 1 / NON INrERSFCEION n. 2I/1. ADM kpUr O45r4 E 2 _? ! yD?p KC ION Rri?s JdlSr..Er. IX! Oi Q(?E rL P TT MIIFAOEi RAMP DIAGRAM DAiw 151// -NO. INNRIO 'OAMAOEONLY L ? SPRIAOF I CODE NIYCR1IN ruN4wDr - I'D y?IRD DOWNER'sN4M[) ?RE H ?siOlfN INrf% [RrpySSrR[EE04RRpgpR?"D O4 gEE[RENCE VIHICIE r T ! ESI. DAMAGE SHCMI COGNG Mil ?G O20 O. 1 5 IR r I "' UNITNO.y ? VEHICLE - DRWERSNAMf: sf ? R PEDESTRIAN O PEDALCYCLIST rRffrwooRESS p EIPC'ppE PMONF NO 1 z No"r- SrAiE Ex D R y sure P DO / I E fBl4 N WA 21 QaA i r I Iv R' UCFNSF NO. R, V ArE Ex arxrN Dw ?Y +4A [rF3 GNr IEIGHr E OCCDPAIION I In. f7O FIRM NAMER PNONE NO. R Yf O"FA-I.I l EYES IcNI ra. lcm lncnw r 5 6MnccD ?CHECK (?) IyIHGIFAS ?N f MOI Al IOY O M FE CODES IF. + ? a P FANOfHE4. sreA if ® ve?r[ii ? tuv e ) ? A 4 iv 5 M srtM CtIDN 6 wm -111 u . r y EL jpA4I.IRpvA 1 stvU IRDR. CONV.J r oso ' ?^M f ?C[ VA 2 E HEyI ? irvovAl ; ? u i4AllfR MIFND. SIAM _ H y V.) EN. CIXOR 1 rv , A I Rt ? 3 lA C 9'7!3!3: VfNICIf IDENrIFlCwlI N L Y N MIDIXE PNO"rE NO! E ! ! I I_ i ! I ! ! I t R GIs RfDOWNE4_ r.. I r E - ?PAAMDf AREA e I R I AN e S` .srD. ? .D«e?, c-, rOiolloii 3 /si. DAMAOf ? A IN c. 'of onA _ S? L OWED ?PIAWN[D p r gAMAOf0 A4N NIAE DIAGRAM OF COLLISION: eYt J N p ar, ?A S Al 1: OF D ?A N WAY ?RF-.ID Is DwM.s e I strop G 7. s'•arrDNletswrll 'N ev arN DESCRIPTION OF COllI510N: loseslrs i'onb ?T J... I ® PIlWNlAISM[I iNfCf53ARY -DRtLtER aStuERV@O-;?: ?. r -f AVosO A D, Q! ?, I If l I I 1/EN. u/ G .-OA, W/E_.I@ogD.?A _ or?..?li r I I 1VorerN9ou4)b DOE DwAY olv.rH1 L_ f , T 7y/g DLYG 9VECGEO .BQpRok,-- ox rcv, I y , cM 3 OCCUPANTDS / W iNESSESES OF PEAD ESS RSONS INVOLVED '- NAME; IUSISVHEMfNIAISMIr }CODES 1 _ 104 Ap01gNµ NAMISI I •DDRISS - ti0. Sfx Gf IAIUS l y 4 S.. d fMCi Nlir NAIWf or .r rr ....... ..... .. . -. r ... IM AV. AM Og'u ?r.rl.. ?M ?%qi- , \NfY113 .. _.. ... _ - e AMID Y I-?AASa . ? x r rsrawf f rsEYJ.rM? AN. _ ialui? °f ra.[ ?ra. ? :P.T ? I".:w,. . ? 411 `f BA[KAb r??_ 3 _ 1 r _ vwskAy. , iyry? t Y ?Tl ...4M L?dR.,+R :any. ? ? I13 I {{ 6+' y r Ly )AAr1 Isv ?jjf'T ? rl.,>,n ?y ? F? f r?N•'3YM!)I y ??' - 7 ?' " `' 1{ p y f u G ( - , 7T ny.y _ -----?.^• v, 1 1 t^ ?+!V 1'V ` y A ,I ? Q ? ' l ` y, ;', 2 l V 0 aiDi (yp ? uTr , i 11 N r I r} ? l I M 11 ' '4NY jl. 1 ? t ! h ' 1 . 1 , ! . l Sy I ? ' al ?lV i x ? ? ?t< i E -r t ?f n l f 1 l? r ?I Ili r.. 1{ ? ? 1 # I'll y>'' .? ! ? 4• t ? S l l Y 1 I f Y l 1 r?lFsa ?1 ?r Si7.IL? '! 1 1 I IL,:r 1 f?{,frw t I ??' fh l?Ea,? 1 J '. ? , V 1 .?'?{ r - - VI 1 { r I rj 4 o0 7 ? T%A(ILO ? p ? S10RPFO NM+OWAY 'i I.t.,.r?1! -1 ,..) •?I ..:Ix,, A" [ 1 EI f ?', MOTOR VEHICLE COLLISION REPOR7?C' s sA-:c ,?.. I 1 T .. NO OATEOFCOLLLSION .OAY OFfAW90N iWEOF CAWSION -- - . CO A 5 N 9wF0 MuR RM SAI R FM P UNTY NO CITY NO - F [O ? AW TY .. .,,.,_ Itt.TOWN FO 11.1 MILES ?© ... ,: CITY.TOWN Hli ICCUnr"ur ,E' SJ nOwi`AA OF AD Kl5 PrEF1% p r plat C SECi1GY IIDA„pv GIVENMI OFSTP Ap OR1110MWAY... WTERSECTINOVATH: STREET OR MAD ACC PREfl% EO MILFPOgi •; IIONINTEfl?S/ECTIONLOCAIIO/NO COLy. Oly,.,.. • I.JJ7/LOG" C?^ D? / `( C) fl.A pA6RAM 0A A S D?. BETWEEN' ST .- ? RNOr /• L7? ?N © R n SE kE W IGHwAr NON % .RD E 1 y5Lpry RSEpKKI' OCj/t%G INlli 7 (-_ WO E INTER I TER CL3. nE NCf Cw]•.s 0 IXU oN WV0.vED NC[E vEnf., ?YEnaIE MCV[tE QOrnEN IwW[FI / UlvFHalES ? L? ? vE ? tH Q SPEC OBOE USE: V t 'I L. 'Y Q l.cLE E RA. ?rKW IXuSaN ?wr ' ? f t OSIECT STRU//CK)) ... INArrE OF WIECistMKx1 OWNER OFOBJECTSNAME ANOADORESS LOCAT V? ?4 Lr ?eJ WROM . -.._ ION WAY .. r ?N ?- 0. 10AERyw° °O L 1 . 0 0 w FEET of S • • MORETnAN ONVERSIASTI-E FWST NAME MN1fAE -CANS pRIVERSUSi NAME [ FIRST NAME MIDDLE W rr.5 - . a L rS - 1?_Mf A ? t LDDSDNaN - SIREETAOON E55 BQUTE tMJ. ANO BO%NO... s10RE THAN TWO SrREETAOORE. ROUTE NO. AND BO%IK). N ONS KERB T TqC Y / D & O• CItY STATE s A 21P000E DRIVERS URA N q CI Y STATE 2JP000E MIVEPSOCCUPAIgN, ; ?(? U ] f ?r FRORTiptM IXII STICENSENUMBER rL STATE SEx .pATEOF f%RTN AGE DRIVERSLKENSENUMBER'.. STATE SE% DATEOFOIRTH.. AGE- v-.41.-F_F 9 Wg - F DAY rEM o VEIICLEYR MAKEIO EV DODGE( M . pDELINOVAOAR):_ BOGY STKE12 pR1"'.. VEHKLEYR MAIEEICXEV •OOOGEI: MOOELINOVA•OART) BODY STY-, ORF I d J o l2 LKErvSEPUtENp. SPATE STATE :. TRAKERF%ATENO, . UCENSEPLATEW STATE TP . ULER PLATE NO.. -STATE / L4/ A CA 1 l-aEIGENTIFKATIONNG-:,, LISADMODEUSANEWERI :.: ODOMETFRIMLEAGEI VEHCLE ENTIFI A CNW. . Ito"WoEL56 NEWER( pOMETER (MILEAGE) REpSIEREDOWNER; (LAST FWST-MCOLE DRIVERSUCENSENO.. REGISTEREDOMER (IAST-FIAST-MIDDLENAME) . ORIVERSUCEMEW . .. .., ..- - OL 73D?LL-EF/! i OWNERSADOHESS -. ISTPEET,GTYMIDSTATE)-?.DATEOF&RTN OWNEIRSADDRESS' I/SJHAJS19tREET,CItt ANOSTATEI pATEOF 018TH DAY Y$AR MD DAr rEAR TOM ' I t AflrSOFVEMK AGED -, pARi OF VEMKLE DAMAGED - Et r? .• _•'- . rERyR VENa[E . _ ?r? fit/ S $ TONRVUME ? Mee LIABILITY INSURANCE INFORMATION-VEHICLENO. I- WAS". E AUTOMOBILE LIABILITY INSURANCE COVERAGEINEFFECT FOR THIS ACCIDENT CN YOUR CAR YES ?NO A N MEMIDACC,Rz 90F11A&UTY WSURANCE WL1CYIgLOEA .. - ... NAME OFLIABIUTY WSU R NA [ J ? ADDR ... .. r+re ANCECOMPANY ' / ` [/ I t ? 1. NAMEANOADX0RM0F 'u" tN511 AGENT.... ,..., stATE P UADILITYPOLK:YNUMBER OM E• 6,G G o S [? /? l 9013) IST WJURY, ;.'. ... : AOE 2ND IWURY: - I- EPARATERFPLYIIfcw AlxtrKWALPMW1ES1 qGE. NAME rOFAL NAME .. .. ... ADOgE53 E _-_ __ . SE%p ADDRESS MAr '." io s ® rocs s - _.. . rv "'" ____. o- O1'` O -- . t.A. µ l CraI• . D ®©NANFO A °uDaClOR+ STAIUSO pENWfD w` MAgNFIHST ONE THAY P A PLlE9 ?'- SUS OFIWUHEO p[vf WVENK%E 06Mxrq l1aN pSAIKVA RM]ntE TAT MARK FIRST ONE THAT APPLIES Q µ CITED.. 1N1' n IHiNOr'N uR ? W N VEHKIE w W+p N4rSRtE ?P !I .. Q 1 K 1'o ^OMRA Q SFrgE KILLED.. IS[vENE1 " u i ? 1 F l NO _ I wp l IE AWI ? TJ? ]'OEr ?lEDEa- O fTCI 60 Q,H't AIUIF ni r.,FR ll.. ri.I r. 6HOW NORTH RI UFTgW WCWCLE ? ?` OESCRI GL WHAT HAPPENED: (REFER TO VEHICLES BY NUMBER) + ? I ? ?[]hGaOJ CL V/a•-.? ?[4IL(?? e/ •t••1? r EOUr (T R M 7;L?C? y? --// McePITi?/VM tL? OR nA1NVA'? OR \?, ?. L ?N.-YnL P? aEaL7 r1IX AMgW¢? ?L ,/ a -,? ?f- lrxefton rtiW / Ll ?-? [ ? d _ L?pI. ']'fv.Y?L ... _._ ' - ?l[rC.r cu ' . : 1 ••'?o ? ? .r.JOC .? `? Opt-'c~i.G . ?u -._.w?7'op•D ,`???// / I? f-+v '?C.?lr?'J?.F>E/Jl?.?s rs..? t ±?lF.±.[.i/?lw?= .-.__ _ ? y ? 4 ? 6 ?r1G-4EAT/K]I%iCGl?f?•-?'-oa[n GIu VE ICLESPOSITIONS BEFORE COLLISION IjOC ?"D//VG pl.NFa Ii. »cIM R! . IAtfo Rr NVesra LV tt V[HK(E ON MAnp•V) [n Attu P V!O verxC r ? • ° I r S[OtCU[h0 ?;r N E 1V WSTREET OIII D-v NAMEMNO i pN 1 i ?OMfn IA t MI IMIq D i ? ? Q ? ? L ? ? ? ?[ M- -A, srt mHKNI ? ? Q'f7 ^ •v 71 ? ? ? ? ? ? o-, nnsn•u ? D ? ? ATO` O K I I I ON /?y A CMOSS"° rrlou DIRECTION TO DIRECTI noeGrrAAN tr+s uswa ?SC[WµK 2?WM.KWAY J?SHOUIpFR 4 0 C ? iti ° ? [ hi oti ? 1 a H iHA S 1l f ?a 0?OTHER LVAD` TAG[ WCATHIfl LKWIC(Wpl10N! IHAi IK CONtIgL IYDE Oi ROAD w*eL'o+r1 gpvFRIVf F•KC 1 C 1 A OVr1 .HKLP. ACfIONJ ;1•tl! Y > V.KI A IL1IC?MI Vu! KN<AOr,lMWRlI A l H , 1! r 1 K 1• A ? att ] 11t ??{ 1 ?;J(Wly9 ? ?T%Ir 1'-•°IErGAa? I?p11Y11(iNT 0 1 D ONE WARY ? I 0 COWES 9IRAgHi A11EA0 • CR Y 1 ? RAI- 2 D DAWN ? ] ? STOP OON ? 2 ? TWO WAY D 2 D cwrn TAKING ANOPASSIND ? 7 ? ] ?ENOVArvO 0 ? BUSK ? I D H(LD :ArI ? J ? ?w'AN[F 0 J ? MANIN6 RIGIR i11RN 03 ? S50W , • ?ibfr E ? MOD ET ? • ? fLASHVKT IILD ? 1 ?YII(I CI AM'f ? ,1 D MAKMO)CFT"'IN I IIIAMR C-1 • D Y I 6 Oi NR s ? 1O`!!C?YI S D i-is 0.1 ? ! ? !l A• axE AMNEN ? s ? I?E ? ? MAKWLIUYURI1 ? A DSrt C1IV OAA K. 1LEt lKiNY9 • IN t'N AL A r WAY. D9 RLA50NFORHOf k EWOD4 . D ? ? ?11VA11URN ? A ?a",IO IfV1M.,hrDwttJY [•.trxAT.IAlfKr [DY'FCNY ? ] DOffcf."'Af,MU1 LNIrS ? ] ? St TRAFFIC o-o., ? A D Dtm. wCIFY ? 1 ?Sf PAN+tfO ? R ? RtIYDP,•:IDN WAL . J ? lM%VGIO ? 10 ? 1 YU F1C LANL 1I16?Irv, .?I1W1?'??p?-. L • ? N1YN 'L L' ?M I fI.1 d PAM"- VlAl nnutl 1 ..•n`+f ? h TTI?' '?li t R? :a : F7 R : kr ° ?saavSSly. i<'s? a _.y __a,,,„, ...^? . _-..1.W.:1. _....? ? •,,,.?a°.a:;:. r STATE OF WASHINGTON I 4 v cE of No O wsrr„,R .r.tDl . ' POLICE TRAFFIC COLLISION REPORT (?TRAFFICWAY POLKECOMq,MNr NUMBER y PRIVATE WAY All .k ' - OLU ?ADY I N Y COUNTY CWNIr NO. ?e e;c . U1Y N0. Y 1 ?N ffiE ?IN CI1Y O4t N NAMESNO.OFSIRurOR HIGHWAY CIS Z •rMLfs pw pOFYA ?r K wA ON ?? NIEASKII 1 M 1 I 7 qWr .J .S"lo 2EL y? O `• p -? $ [f OR ROAp NON NTL SER ON PRfN% / eEiW[fN 3 E Mlll/PO31 ?g C r ? ? ? SlRfti 6 SLREF! / Q,? DI AN< A R I .CROSS SrRL! OR NFMES Mllf R •? ?3 Mlf3 R 5 E W ACCIDENT R Drw 4AM OAlq ib arr?S/r//- MIIfAGE ? ? .?/S//(/y4 - 1 fffr • ???ln? CODE ? - ` COllISgNINVOIVED FR M OF wL° : I TO[AL NO. MUSH IN KIIIFD -W INIURED? ?YIIAGE ?H FUHOnOn, UN i.1 OF VEHKIFS © RR 3 D Pn cm IIITi }?QF ?OSSSIRefrt) wORp yf . ti ?t-F ' F 0 ORRTYDAMAGF ONLY ?[y OBIECTSrRUCRINNAtp OeiECr STRU[R INDOWNfa3 NNAF1 ?SUIiFO E51 DM1AGf SpfLIAI ? COpp O i - - ?? r' ? I L15[ Kee s : , s DWVfII rawt'... .:.: ?T. UNRNO: 1. UNITNO.2 s ? VEHICLE . ? PEDESTRIAN p PEOALCYCUST . aR I I EVRR/S a iQ '.(Ja?f¢tZ I° Find Srwf ADpR[ /rj, - . V ? r I ? 6 ` ? ? ? EF CStAi? ?O 2 P ?? D ?O ? / 1 J ? - -, ??' ': 1 CODE LANE NO. S;1• wA EE36S G4z.a443 R NRrE!/eek A 9839 DRNFxs uc[N 6s3ae2 ? ,I Z Jf ' 1 "C1K.Wbn2GI.. sArE wA M A :? v u iD J°• 70 y .r SE-A9 i 5 wA nf - % is?64 j .? p Tp y qA 4`{ ES- .'H" O' Akiota FA?oa! lr??l EYES WEIGHT EEIGHt E URA ION /IRM L1NAFe PHONE NO. 00 (e FOR !r!S 1 IGHt KL?M _ e ? g 3A ?' ? CHKK(r? vewa A wANOrH[R. . ? CHECK (.r) a ? S? ... _ WHICIE ASAN rMnorf NOrHfR. CODES ? 9 a / . i s u 6 3"1O„ .CODES ? * D "' " Q ` _ >~ ? fwxs u Ass sr nM 5 I%CrION a y,m - a F Wi s. FO 0 A. A Kf ONE- o m,. ? Me N D s ve w AuR[IOODUCH[v.l u1DARr.IVOVA"Ka RD? "e°Alv ^xLwe°r.DM p.m.RANCe 0 uR'a ? "Rb":n+ ? m'KN ?i:,:uA. 1 I DNVI _ ?:?, ? '_; i99y 77,ae L ? 7 Anf P ?d? E /ggRg ?? Er.l BDd? AI a ?' ! ? •? ?7 IZ ? SIAr MfE Np. SrAr[ H wp RAID39e? -A- , r dDR 44914 i ( s fF r? venue DFNruK.Rr O C EHKIf IDfNnN , ui it. TwIS 71Y. l y?.39? L B'L'S: f b!IISI$RfSi$I?I I I ?.. '., ReelSrtmoovmea: IASr Nasr MIDOIE, RHONe NO. O R D fR: usr sr s FA ?( tfi/1 1?I?etze' r ??? t ba ?? ADDwss arowNeR ta 5 N " rP r`F< h- 0. J Q 71 I.- e t A, 0 8 k , „' NAMe 3AOwessalNwaANCECO.wgeeNr E R CO. OQ ,- 66 a ?.g'{? q • av.Areo ARew a3.F...o a e ! 3 Is or».ore eHAee[ eHAau iAM,.e[ ,w[w ..n _ ry? i Lri OFF s rs1. DRAVVee AwWir ? atMwHEO Derv[N ur DAiuee [ ?avwNED `? f ww?voer. ? loweo AWAY ??? 4 DIAGRAM OF COLUSION: Y Iu u N INOKAre PAwr AwAV er: S , I r r 1 ??_ - SLUel lrrur=ssfa 3 erARaoW DESCRIPTION OF COLLISLON (US[SURfteM[MAl steer Nee[SURr, __-_ r? ' L i _.. ,._ 1 .? C !? / d... NF•r?. s y ? u a,L p ?12 4 C k--- ? u and 4 3 a ? ? ._ .. ? •?1 t1 rlr-?e%l Ufl [ i C I eik 'w.io _ _.- NTS URIES OF PERSONSINVOLVED + r L a Nw.r OCCUEPADDRES581NJ? /WITNESSES io?FR ASD'?oli?ow/I.u r"'iA3MMEii _CODES t_ ww FF2r 2 4 _S_ 6 3+? ? )? KR AG! tAl N r iT R[SII. [XCr :rL? ? Y ' - r A '3 Aunwss ?rv ?M. OC.:6L. NAME rNfAn ?AMe. Q 1 ?rru ' ArA 3 yy . ADn'Fss - NAruR a -- - --- _ MwLOLVOM 13 AMe. ucM r O o r ? Q ?;; 'J F • r ?,- ? dl h •I, T a Anr»ru wr"NUR»n O1.... [Neer DAMe. ?[HSI%e ORO:Irr ?Ce?' ?nHV• t I X waaroAUeoarKr s esrAHR eAlx;e Ea .ceNCr IArro KIDiHArCMO R%Kl Aaal o oArtaa[roar ' }?f ? ID NO ml a ar ArrROwoer an ?? '?i,:?'., _. i?E'??.'.. .. ? dW*e /O __'t? 0.. ?r?L?fsb /i??i? 7".j'?' D ? r ?wTu'st(#Ysr"??? •?td,+ ?^' t a i s A 9 ?.fr(ATE OF WASHINGTOtl SAGE. GT No ? 2nor POLICE TRAFFIC COLLISION REPORT P? TRAFFICWAY . RouEtcoM9wHrNUMEx4 ` 11 PRIVATE WAY _. Jr 1' k4ti UAl N A 1Y , w, pNpIN R TOWN p s pW ?( A ON 990' g M: ?t9t?T Iftz a 4, 6 ? ' l M9f 9 95 MII llS ACCIDEN MILER CODE n tD: vERlf/1 lOfAI NO. NO.KMlED?NO. MEIURfD? 0Ynv.Ge pHIt690N OI VFMCEES p pR09E91Y DAMKl ONLY p PfL1lttD ? IuNnrom 4D IMlR OS M CItOSSSiRIlTORRWp I] %? J OBflCTSIRLK:K (NAMl Of ORI[CTSIRUUt.WDOWNFR]NwAfl ' ESf.ONAAGE S9CCDI E.GGNG ! I S ....; - UNITN4'1 - -.iUNITNOL 2;. ,. p VEHKLE . ? PEDESTRIAN' p PEDALCYCLIST rvtkS NwXE: UlSt y? 9 I 1 tic T ?74t?K a Ce Q IV R N- -1 FIRST I s S rRt y r 3a' ` a. 9fE ADDRESS J N StA1F 219 CODE RgNE NO. D I STATE S Qifle_ errs S-)122- R. rvfk U 1 SfA" " '(? I U A 0A M OM ', R O A -T -114 6, 4 ct W F b it 3 I CN9AlpN RM NNAla RgNE NO. FrE3 1GHi HEKA1T E3 AKA I 09w11 i19M NAWE6rRK]Nf N0. lYlS EGER 1lIGlEI ?. r3S 5z ca p CHECK(/) vTH A A ANM p CHECK (? waE wswN ANOr 4 r r C ODES a n . y^ S ACrwN n X10, •6E CODES P- 3 n a y S IACRON A {,,,{r,. n ? NwN? n nee- IN p AMNKAHTT p p m4. ? ;?:,,,. 1 ?? ?of1DM p wNU.Na ? MV ? `6. O = p I., . -EAR ASAKF IDDDGF{HtV.) EIOAR .igVw 3111EEIDR.-r.I V FAR ( .) l(D A) .). IF I r?iro8 Fa.? Cya l ?r oJac E U 9N SrAI! Iw1lE9 MIEtq. SIAt I'I I V NC IT x' OF4X2?(. e.E`7A`r ' ma K 1 •f HKYf IDtNfIIlCwrgN NO. G:IS1R[DOVmf4: 11t:` r ?12!r ;z ?l l IASf {IRSt MIDDI! %qNl NO. i VWICEE.N11F I B i l l I I I V I I I I WNf9: N31 IRS! MI IX wF Imo: O W 1] A DD4ESSV OWNF4 Nt E NA . MeaADDnu or lNwRUgl m. p1AGlNt ` R 18'RSDG r?FCb'.?ER p OAEU4'E ARIA AMiOi ME" E 3 . A' CNNIW CNARG! __ 4 1B:orr:?A' 100D?A?G1 III ?4P1OMD ?D•IVEN ?RIMNNq FSA, E r •t09_ J?, AWAY IO:OTTOK w 1 IJ ?O TOJDS E °N I IDEY: F WA AW.1 r: s .. C 4A i? ? O DESCRIPTION N (usE3u WFTIALSten er Sla ru fmswr _ _ - O ` l 'T i ?! ? r I '' ... J ? _ ?. P _ ?_ I ,. ( I i I I I { , t t 1 I r _ ? ?r __ I - I I 1 ..: _..._. '.. I __... 1 ._ _.i I _. _. _. o- 4 I - NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES 1 - 3 4 5 6 OCCUPANTS WITNESSES Tar, w'rlKwuMNAw'iii 1 '3?>t ece ui 'N"" .E'•; '9ET -°' ---- M4 TAR ii n ' - 10 '? NA __ MI: . _.._ ._ .. _. .._...__-_, w. _. .... -........... M1 l . ADn .EU TEAT n I ELL nr AM e. on- O " ?a7 19'HEs , , Nw AIK M w NrIU tuTUle E1{__.. ___ F YD r• 0AM4 p ;Kr0 oar ?;„A Mill ? 1 NwM I•. No .w•v pAMI. 0M ?r""DAf. par ?'.T.. gRy. rr? X vnrquwGfYWE ?r.wl•u... OIId Au`15 r.m ?T.m?iS?IKD r?S.o6H ?+°?'J rO A9ipvra er DAIe ( ?J • ? , m G 7 ?4 .. 7.... _..- . k'.. W ..In .. '''/; ? . ?7.";T:: _. .., ' . KiE?. . .n ¢ ,. Date Page No STATEMENT OF; •1 t e-T -- --_---- _4 r- 3 - •---- _-- ?_. PAM : Ti", y ? ? t ' .J? r h: ? 1 t .I ? ^ 1 ..t1Y4! f ti i 17}E 17_ ,y * ?f { 1 1 i + U ^ , ? ? ti ? Art - 1 r t t pP ? ? ? ' ? ? ? ? ,?.9' w ?f ' h? ' .fit ' ?t ;?? ?, » ? • •, . )? RS_--_NoRT..HBOUyvp,._O.N.._GR_LO.--E?3 R_/?ZGE/_RBS_E`Q.F __GP_EED _...___V?N,_#..2._.__w.BS._._A.LSO_._.N._o?-rHgouND_?--.oN G?'?7o_?_fLZ?.fL_?S4D.GsW?RRLE. • _.OT.*__?S-'PEEA??LI.OWTN.G R_l-S.N.E.. QF._.1/EH.LGC.E.i_?3k'tL?LUA_:9_?G[P1A__.22'?CtS.K_.-13kxJ?r __T_g??.U.k®.•--_.V ?i{,... #'_`?__-_.WR.$_._S.o..u,T_Fk (3QuN jj 01J ?,$ ? LC?. ._Anr__?NR?e?2•._.- ?oue?v_LRiuE _sr_/?=1?,zn.G?.-1/?.H,_`_? 3_ RCvo_?cla?tr?v_G?_V_EfL °?3__BEZc?w_?s.2?z ._S.rnECNr215._.?rl?P_R.oX .,?n!o.rKE,2 :_7.o-F_r._.._BEFoR? e_vn?r.cvG?._ror2?s_T_._1/?.t?;. •?..'° -_scroPP_R_oX=--!_po_.r.-,._.FRvM _Z?1P?1c7' DF _IiH..x:,_Yh -1JKE?E`?7 -_CRP?.E SD€ of r_rf?_ - - ---------- ?w,?`` ,r<<?. .?°°" SIG '?V( TnR","""y_ D DPIE OF COLUSgA DAY OI COLLISION jIME COUMYNO CITY NC` FHryq A ?? 8 r F suN NDN x lul, wEp° lnuu 5 FRI s .. n y',FWN` j / uHBAN U4 2 1 lW 7 RURAL COUNTY ?ETATEHOUTE .)COUNTY ROAD ?CITY STREET O W ADS"CL° PHEFI% 1 MULE OR &1REEi CODE ....... Jefferson ?OTHENISPECIFY) N J ? S/Q C O L 5 E CRYORIOWN IN N W PHErI% E O. MILE P051 O Ba c er Di 1 ? v p ? C y_-___-___ e ov y_. OF MILES ED CD p TAME NO.OF STREET OR HIGHWAY INTERSECTING WITH. 5TREET OR ROAD EL. flMAP DIAGRAM DATA. T ON lemouat Road S.R. 20 O - O NON UlTERSECTI M A NON TER %RO INTERSECTING SINEET OR-2 AD OR REF. M LLEAGE I 1 CLS. AD ERENCECROS5 STREET OR RO N BETWEEN _.-__-___. STREET AND___. _/STREET :ODE - ' ' S 2 O pISTACEQM ES LIIDrv FROM EEFE0.ENCEORCROSS5TREE1 N V! yr.T INL y S n PECIALCODINGUSE 60 (RFEE1 ? X3 ? OF S'.R. 20 X3 COLLISION INVOLVED. VEHICLE VEHICLE VEHICLE BICYCLE ?OINERIWFTCI ?HIrc RUN ?? ? LED NO KIL . SEVEN— I © VEHICLE OBJECT ?VEHICLE RRTRAIN __-- _ ?STOLEN VEHICLE 70 ALN _ NO.INJUREO FS ? VEMICLEPEDES-AN ?NON COLLISION ?HAZARDOUSMATERIAL F'E? IA PROPERTY DAMAGE ONLY OBJECT STFUCY, INAME OF OSIECT STRUCK MID OWNERS NAME) LOCATIONOFOBJECTSTRUCK EST. DAMAGE ' - "' Enbankment S E ? w ? 20AOWAY FEET [:1 ? ? F1 RD EDGE 5 DRIVERS NAME.-I - FIRST- _ MIDDLE DRIVER '5 1AME-LA51, FIRST MIDDLE JIF BICYCUST OR PEDESTHIAN CHECK) CJ. ... D R GEICK, Kewin Lloyd D R STREET ADDRESS ._ .. .. . .. ..... ....:.. STREET ADDRESS. _. _-... '.: ..: ...... .. V Route 1 Box 749 V E R CITY.... STATE "- - ZIP CODE PHONE NO E R CITY,:,_ - . ... ., .... STATE .. .... ,..;'. _, ZIP CODE . . PHONE NO. Port Ludlow Wn. 98365 437-2104 N OWNERS LICENSE NO.., - STATE - S E% FATE OF HIRTH N DRIVE. LICENSE NO....:. STATE . SE PATE OF BIRTH . . 0' 2193850 Ore $ 12 2'i 57 0' Mo. DAY re DRIERS OCCUPATION FwIA NAME PHONE NO 2 DRIVERS OCCUPATION .. F M ME ...., .. .,, ,. .... ,P HON ENO. Const. Relpe Rick Davis Const. 6o. CODES > IGI CLJ?U55-1- 1AI SEAT BELT. Z SM E ECTION -1__ CODES > 131 LiA55 1°j SEATSELi I51 EJECTION___ NATURE OF DRIES Abrasion»nA_l6 head & lump en-)ma NATURE OF . . IN,uRIEs FROM SCENE BY TO I -E nY O V£M_YEAR MAKEIDOLIGECHEV.11 NODELIDART-NOVA) STYLE IZ DR CONV.) VEH.YEAR MAKEIDODGE-CHEV.I MODELIDARI NOVA -. STYLEIZ pfl: 00NV.) V 1972 Chev Nova tudor V E VEH. COLOR UC. PLATE NO. STATE TRNLER PLATE NO. STATE E vEH COLOR UC. 1111 NO. STATE TRAILER PLATE NO. STATE I waa.y Slv OZJ 887 Yn. . I{ . C VEHICLE I -THICAR.. NUMBER ... ... ..:.. .. O DOMETER C VEHICLE IDENNFICAIION NUMBER"....:. ....: " ..;..:?... ODOMETER'_ E R2L1 1X2 0532 01 0 7 7 7 7 E REGISTERED OMER-EAST FIRST .. MIDDLE REGISTERED OWNER-LA51 - FIRST 1.,,. MIDDLE N. GEICK? Keith A. N 0 , ADDRESS OF OWNER ADDRESS OF OWNER _ POB'449 Radlock, Mn. p NAME ANDADDRESS OF INSURANCE CO. ON AGENT. C A N ANU ADDRESS OF INSLIFMICE CO. OR AGENT Didn't know - .... CT CHARGE ... AIIUN NO E14FORCEIIIT CHAgGE CligllONN .. None ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED CODES Z '.?' S , sE% Apt slATUS eJECr. `. NAME' C ADDRESS. -' u p NATURE OF RCMUVLDINOM NATURE SCf NE nr TO A NAME _ N T ADDRESS. __ S N OF - .,.E S SCFHF nv 10 W NAME: -- ---'- ------'-? I ? T AOp E55' o l xoM _ -? - L?1 _ l_1 _ N rE i sci to S NAME __? ----_-__ - S ADDRESS E 5. H r IAU, _ - - rF r?IGU[p ---' -:Cf AF Nr i'lum '- - 10 ' INStA1115 IZISt •t RO11KYA IJHNnINYCLA55 iAIGEAl tlEl1 ISIEJECIgH C O )PAS^.[NG[n J PI [d SiNMN A naYttrs+ t ?\\ r l S Z N l 1 - I oFUUNY 11 1 NNIEA I n DLA i i DISABLINGINJUIIY ISA1 In N n r s n o a i INDTINSTALLEO U O £ I. NOTEJECTED CU EJECTED O D E _ s R r tnf TNEV ` 1-1 . D _ R IONUr rcw eFor, ruN: OLE IC DIEDrtINwHOoGPl g ro iun m m S lNJU r 7 r 4 IINKNOVIN EAT nrll ruLUN[ CJECIEWR 4EJ EC0 N F?s'r ?I ) 7 VEHICLE DAiviAGE PI,t .1 Ik? IINSTRUCTIONS: - s, a` t-`, c, ?_ ]. Du w R D os w YRINC rAL OntcnoN Or inecE. 61, -A DAMAGE57_VEHICLE NO. 1 .sL .IS S cl . t,n .cnnuNGF 10 TRAIL! s 01011CYCLIS ETC.: _DAMAGED VEHICLE NO 2 IV r u-s - rw•-?? rr uweLC.• ? ? ?? ?-???. I P.. «,rnl S. ?F? r`"s•. SEVERITY OF DAMAGE VE HIC LE HO. E rxT ITV I 1A MAG[IOTHER LEI T O PMAGF. v,,IICLF NO ' 1 0 DISABLING DAMAGE ] ? O V DAMACf "' 1 DuN .FC?COTHEnM V.D M G 0 N NO L^. AGE ; ? N, HE O cE ,?y ] ? FUNCT ONAL DAMAGE 4 ? 0 DAMAGE ? ?? 'R`OE A ? ° 'F''°,"45( TowfD BY EliCkaOII BIOS t51'OAMA UwEDBY<. 5T AGE towLD eYCT en °AMc r to f ` P ° D o ownsen n. 5 0 W t TO DIAGRAM OF COLLiSION_,; ! I ?" •DR W ARROW SHOW RG IRA .___.. i 'cT roir,ro«i., Mi.n•. ' I Y tl , • ANO U,Lx torus ax COLOR, CON5TRUCt50N ORCRF4 R ?NI WOBRa ETfIOT ON p,AGRAM.EGD _ RIVER DESCRIPTION OFF 'IS:eiRY• REDDUCED VISIBILITY. BPEDESTRIAN DURING AND AFTER TIE COLLISION p1 a t r This R/0 and partner came upon the accident and the driver seemed very confused and when ask- t --- ed for his drivers license ran to the front of the vehicle and atteo ted to -o n the hood and when-EUred has.age s id that he ras 21 to 22 and couldri!t even__tell us }?iene?e but -- d?dn!t?s?pear to.be_intoxicatede the driver informed us that he had. had a zeizure some time ' back_but_.didn!t-know i.f_he_ hnd_3ust had another mn- or not. There was no skid marks -before impact nor after_ic n_and due_to the distance after impact'there?dn't appear to be ? !"Iw POSITION BEFORE COLLISION D D LF[Tlox. vR qqA E 1 ^ - No HEADED ..It POST IR. O s T OR H GH N.Nt « N0. 11 ED OCC E - INCREASING DECREASING Y l 5 E u Ju`I vE5 O E r 1' " r. POSarHG- RO o_.-_ --- DESIGNA?Ed? CO lR4L ] ]? _ M,RK WALK 5 KED 6 BCYCLF QUTE L. I It O ,S US" G A -_ EH <.055 -. ALK OTHER ROAD SURFACE WETONR LK EK.. CONTRIBUTING CIRCUMSTANCES ..REC. O R'LFD LEAD?° F< HECK ONE OR .-I I S'?' -N W ° E" DRIVER r 0 OE]J. SOR`A-CIT AHEAD 110.2 ,]qy c EO J ` G - r L -- Ov '' O x R NFLUENCEOi OR, 1 6IIVEBCAST. 00414E i ] 5 G J PASSING ! .,A NDER EOF I B.. O ERC TER J FF APPAREITLI l ] wFT 1 I PAIN xG ] V GS _ ._. _ "A K.1, I R ] 1 HOL ]'r.SNOWING I - ROI'F fiKING T'. 1 G I" ,. 5![EOL LfA',UFINN t? 9PA._P ^ ' CE DG F F - 1 _ n 4 EC E 'S fJ ll•TR G - G SOY _ 4G ... -.. I l Gq 1 t 1 CAR j f 5 SHF ", SOY hfl G .1 Ov105 vI S - < R t `I, r O SPfCIr YI THE. UYE - - G F'G IN LI HT CONDITIONS RAFFIC CONTRO D ] TYPE OF ROAD VEHICLE CONDITION SOB RI N(T P _ 5 0 AT SIGNAL ON STOP IC [CD ICnfCK OIL OPRO RE ?j,9F f(QS 'VEHICLE rr r 1 I No ] VE C EOL?N?A? iEOI 1 ] r KUN'[I 5 E ' I O o _. AIS W., S! N i _• S V xro ._ E AB TV I I" IA" 1 6 ] • A 5 ;? ALD o C Gx ].?I U O ] :SEC TS ..__ ] OT rAB v IREO 4GOSNTION ,I v DOSS rISIIIG INTENCRAIGE ' NND SI ETV ,] ...r AEnGIHG F !RING ] _. _.. [D LUPJLAMP CC F I G TS I _ BACKING 4 1 .., 4 F[ 4. - 5 G llr E5 N0 ?x .. t GN f° .01.5 OUI I EN D KING ! EEY ^g- N En ............. vtn CHEM. TEST RA ZD?T- .. .. w• s7 El- w. 51 ?f • ..?. K -KG 111 Ct - SCv I LIGHTS G L_ .. .. _ .. ST EEI t It R n FU OOLFECT ItS,.,,.I'D _ L ? ,prD _- Y v TEST RESULTS 2 r Houi. Mr IF n 1yC , clluw ,R6 GE N 1.110 D. I- .uI LU.1ANH Y- nNL` .( >4aI ],m IvE" N"1 55 LO uriEpOH.5O VRR. r " eputy_o. Gebhart 04 z8 0455 G4 ,•fr OPV UAIf ? i x I • ? . ®A « ,? JCSO uilcene oh2?79 ? ? v ' r I DISiI11 POTION ORIL NAL CG Y -E .D TO W4514ING1ON -.1 AtE PATIIDL- OIVMY A?IVASH NCi10N 08504 ( UUI'LICATE CORY LOCAL LAWENFORCEMENT AGENCVSCOPY- TNIYLICATECDPY, 14VESTiGA,OR'SCOPV i Al a' ?;. 1 4n., Y a e? t ?? r t t +?5 ' I Y? 0. v ? t I Ir } ; .T4P'1 ETI+. 1 ?. F xl?r _ A+r'•H,r.;l er» e f jCl?{f 71 W., ??#r tiT t II }LStI rA t ? r r" 1r 1 1'. '? ?. 1 k I?S;b?I? E .S1r>YI E Z-A PAOTOR VEHICLE COLLISION REPORT NO. DATE OF COLLISIOrv DA r[a.r sv-r AX" Y OF CO LLISION .. TIME OF COLLISION ? :? - a T m TO LYN TOWN 1LE N F CIT' ? AD-LS IX rOU I¢ OH Si Ei eOO ION SE TION I•« e GIVE NAME OF REST. ROAD OR HIGHWAY x INTERSECTING WITH: STREET OR gOgO PREFIX E D 111LEP05T - NON INTEflS CTION•LOCATION OF COLLI51pN BETWEEN / `J STREET ANO . STREET RA!.LP DIAGRAM DATA ?yMF N -- aAILrIe.IExO et,r,l.r IL.t, r a Lv nF 2Oo ne ` Ne3rRt,;p,xD.e o/Z'3 C)a ?7 Orxtx,nxiiti / vOL?e ? r qv[ . SPEC.C DE SEi ? i 1 ? „ OBJECT STRUCK W.ueer eHtersrRUCM .... . OWNER OF OBJECTS NAME AND ADDRESS' LOCATION - - IN ROADWAY ? Q , 1 rA i 17 FE EF S W 1-1 s [Noll 2.2-10= DRIVERS LAST NAME FIRST NAME MIDDLE •' xA^ xo Y Ia s DRIVERS LASTNAME FIASTNAME.. ...MIDDLE . • GiHEET RESS ROUTE NO.AND DO%N0. "o t mo • "* STREET ADDRESS HOUTENO. ANDBO%N0. CI - STATE 21P CODE ... ORIV ERSOCCUPATION t"•"•rI CITY STATE ZIP CODE DRIVERS OCCUPATION LusQ a 2,?,? ?3 La .? caltua. «Iw•r DRIVERS LICENSE NUMBER STATE SEX •L+ .? O Wf? M DATE BIRTH wGE No 2a y, 3 DRIVERS LICENSE NUMBER STATE SEX DATE OF BIRTH Mo wr 'EA. AGE VEHICLE VR. MAKE ---H -H MODEL INev A BODY STYLE HICLEYR. MAKE Icx _ Oc MODEL BOGY STYLE•I /47 Fo F-Ir- vt LICENSE PLATE NO. STATE TRAILER PLATE NO, STATE 3 w? G AH UOO VEHICLE IDENTIFICATION NO I LICENSEPLATENO. STATE TRAILERPLATEN'o STATE _, T . r tU.ntwtnl. xF.cH . •, OOO.NETER Iu F Sv ca' I4Y s6 NFwEAI'„ VEHICLE IDENTIFICATION NO. ue0ea OOOUETER IwLEACEI R EGISTEREOOWNEq Iu!STyna- uNAUU__'... ?RC . ? DRIV SLICENSENO. .. REGISTEREDOWNER tuaTHRSr-u,DOle mutt DRIVERS LICE ENO.,_, //?? . I Ci0 Cf 4 ?O OWNERSADORES5. ISTREET. CITY AND STwTEI IH fA (p DATEOF BIRTH NO I DAY YEAR .v 20 OWNERSADORESS ISTREET,CITYANDSTATEI .. .. OF DATE I Al 11 Al NO PANTS O1F VEHICLE DAMAGED D „ e r[PCOSr ?LGCN/ sro eicletw NI L ... •. ? ,-?- „ trnnv x AMAGED LIABILITY IN RANC INFORMATION-VE ICLE NO.1- WAS THERE AUTOMOBILE L ABILITY INSUDENT ONRANCEYOURCAR COVERAGE IN EFFECT FOR THIS ACC I ? YES ? NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER - NA ME OFLIABILITYINSUAANCECOMPNY - E AODRCSS CITY '• STATE - - 21P I ' 2 NAME AND ADORE55OF LIABILITY INSURANCE AGENT STATE ZIP LIABILIIT Y POLICY + 1ST INJURY -- .: AGE .2ND INJURY IUSE SEPARATE REPORT FOR AODTDO L.. . NJURIEsk% Av qGE• (JANE _ , . ._ "TIL - - - - C -` -- ----- ApORESS SEX- 'SEX' - ---_ _ _ - - _-__ - ?_O - -_--O- -_---__ F 121 p a •Y STATUS OFINJUAED- MARKFIRST (1 IN VEHICLE •µ nev<w I KILLED T ' II ONETHAr A eNiu N O PPLIE'S rt STATUSOF INJUR EO ? IN VEHICLE ? r - - ::. •• KILLED ' '.1AR Issvtxs nu rNioM r r n I I I L , ?y Na- I r 0 T [ ? N r ^ D l ea . L I ? 9? S? 7? J ? ? T O ? B 6? SHOW NORTH BY ARROW IN CIRCLE ` O?y \ I [-.DESCRIBE, BELOW WHAT HAPPENED: IREFER TO VEHICLES BYNUMOERI;?r _Q?'..Z-_r?EiaQ?.SZ'su O-•/Pi-y.?f??irir o.??ta p NAN ? \\ A :• : ? ? 10' w ? J. olnl N x0,.. \ l.T. .+.,!_s ?i ?9 ?.E?__YfrG._.d.4 a . ??Jl?, CE]\l a t eBgFf/-E•,S.feE./.?P.?_?.TU?.(ic,?•?w.,c-.i? _ i ? . _- - ?.1 /I.?sECQACQ,_.-n?rrt.-_T/ii_ /?a/eFY p?_ 7h{t_ o7_?_.f I IE VEHICLES POSITIONS BEFORE COLLISION I-A vnTlcgrf0 xr VEHICLE yEAO`U ONSTHEETOR HIGHWAY NAMEOn NO. oinscr,n x ?M ?iOUCE L IYOUHI ? ? ? ?- / ? ? sC?NnnvlsrlWll ? ? ? n [ -- ( 1 ? rI IOTNfHI r] ? ? El ? L 1 ? ? ? PEDESTIEIAN. ? ?.? ? ALONG '.. . _. ••.' .. .. '.. . CRORSINO f M rul7• + T0'+SAirdIE[wMAN.i7?:?tla ' O- [ S inIAN WAS USING I ? Pk O[S .r wawa 2 a•• as Axa• ,. •a El xortr.Ia a vswa.a 0 rxt gOAn SUI.FACE WFATNf.R LIGHT CONDITIONS TAFFIC K xai. CONTROL Ir"tI TYPE OF ROAD ORIV EANEHICLE ACTIONS, _ " "`r ICrIt<n OnlwwtxN yr«A I ?N?w;i Ix I ?DAYLIGHI r(?? 7 ?«c;QONEWAYr ue"I r a[ HIT r rC? DHY Z .YUnNO Z ?nAWN ? 1•L`f+ \YL? {JL??/ •/• ? IK?GDIND FTRAIONT AItEAO [?7/?yBTSy1 GI U({TWnwgv ? Z? OVF,RTAKINO AND PASSING ti"•E-.-•? WET I ?YYUAINO :I r K T.IJ'1?IL LS 1 I 'j l IIEVERSIBLE / C'^ OAn%SEREST .?J; L7 i t 11Y ?ROAp vAKINO RIGHT TURN ` -Jy ` )) ITAI L_1 T ?'No. A ?FOG A ? LIGHIS 0!1 7A t L •• IM1Tf.HCHANE R A ?ILOOIIRA 1G ? • ?MA KING LEFT TURN FFFT n'r. { rr L? A r ICE x ?w1C.SY 4 [- r ? LI.11 T9 O 5. 1 ?ALLEY ? S ?MAKINGU•TUAN (•r_}rJ? UU v IPA ! -I y f-1 .:?r N (-1 OAr1K Nn F! 1 WO na? J TR EfiL irt}S {7 r N 0 r ` r A 1. [yyy , (A5L OIMO?SflINC OANffn lL.3SrIT CIIrr t rT?T -y IITrVAYLaNIf ?x?SLOWING . ?(II?` 3 ? AN . ? T?STOPPED FOR TRAFFIC - ! l re ` 1 ?EN ? ( {?'•E J / `` t` 1EPARATlD ? ? on STOP SIGN TSIQAAL, / B `P.1 -n, ? ] ?O V OtD ? .0 STOPPED IN ROADWAY ' T . T? x ' Y NETT YT'CONTROL ?? nlJ OVIOtn n,o nST R/1r16IN . Pl 61 .i MS>.,L4 .+?,1p?,?JEne'l. fir. N tA. I< Vii.. Tnn FFlf, I.ANF , 101I s L 1 ?? I • ? ? ?t I 1 ?'? ?r ?:,?. - f 1 Lr4 ;Y h wTE 0 o 0 oAY o paLUa,oN ,ME T " N unr. Irv rvo C ' Aa? r ] ] E FHI E SA luck yuNl E n r' T O O U ? J UHeA d ,. COU T]f LJ SlwrE ROYTE 000NTY RUwO Q CI TR EET 11 O AOMO IEFIx FUUi ON Siq ET CODE ? O»EN a _j ISRECIFYI ?r W ?v ) ` y I^ 1 0 ?? H E I_I IN CITY ON -N c . ILHAS ?131 cl i O _ ?a cu l S ? ./gjET q IO .. TEPSEC INO I W E0. ,LE P ?? ?? ?' p . .- ... A ? [ W I PFETOR ROw . T V- E7{?iI.L?PoIB-e.? i Ce, rE'?.Nc7• Cd "J I NDN INTERS[CTlolf LL O M ?^t N eeTWEE» S&- z0 srgFfrg ? IINi e ° "elFe.11ce? rgLEEro°n gong Al- 4 JUI,.• u,_ ND oL'fTANCE ANO OIPECTOM FAO TREET REFERENGE OR CPOiS STR E / MILES S o usE No+ON EC,wL COOIHO / ,S ??? OFEET Of ?: J COL I)Fd INVOLVED: ?1:.":C11-1 GENICLE HICLE-9,CVCLE IT IWXI iEI ?NIi6 RUN SEVERITY TOTAL NO. T Illy-IIII LE-OBJECT ? KILLED T-N O VENICLE-RR T_N ?? _ sTOLEN VEHICLE VEN,CLE9 I 1 ? OF IN]UREO V -rEOE3TRrgN Q N_COLLSIOn ?NA]ANOOUS MATERIAL ?? ? rgpFEPTY OA.-EOHLY '\ O CCi STRUCK IRNME p{pyECT STRUCK wNO OWNEgs FIAMEI LOCATION OF 0.-TSi ' P I gUCK. M -LAST FIR LET. O.OAOWAY OFE ,/ V[16 N ET » OOLJ RO EDGE S? ?; D IDOLf .. O qME. LAST c Rat NIOOLE rEOEaf R,q ECKI (?.:. ' R . - STPE ET AO . ? . .G ^; !.' -.I .'._,. . ... ..•. aIREET wOORE55 COOF .. rnpnE»o E. cT y '" . STATE zipcoo :. YHOn EN . R M T} ' ? ' ` ( ! Y . . ORrvEAS ICE N EXO. ,:_ 'fc.-. ;STATE SEx DATE OF e,RTN VEF. LICENSE HO. "o: 0 55 o L• ?- lu R N O RI _ ETATE SEx NDOATE pf GIRTH D Y YR. O ? A 'J ORI TIO VERB OCCU N FIRM A E -.. ... _. ._._... ... ? Onf NO. • IVE OCCU)q LION ?'. Z- R q3 FIRMNwME^ .. FNOnE nO. U_U " . '3 CODES I L LASSY-?. "'SEAreelT A- .1 1]Jetgss I T BELT' ISIEI CTIC H 5 ' Eq •' .•,q, x }t?p'IWN FS::.-' - - `? E EO . ?? ^ TU E pF 4E q' ?J ? N l? [» YEAR Y[I OOE-CN84 T ? . O U P -NOVA STYL R.-CON 1 VEA wKfilOOOOE- MOOELIOAgi-rvpVA STYLEI ? R? t?? OA-CONV,I... "Y^ .µ• ,? L LATE N0. T[ . yLlE o re.._;; E ve c ue rL rF NO TwTE TA ? i . ERR wTEN S wiE _. e C.. ENICLE 10 TI)ICATION Nu H ODOMETE I _ - R i to 1?6?10 31o H CLE IOENT f TIOn NUMBER ?, VE OOMFTER ' kc E? R[OLSTE OYINER- LAST; fl S '' . t . :.... ,: .. ??:I u IeK .E E OWNS.-LAST qE0 fIwST .. ' '. IODLE ' . - N _ ' 1 '. . O: Cga]y Of OW :..' O• q00 3.4 OF OwNfR -•. - O ADORa3 0 CE-ORAO _ t? k AoORESS OF Insugw» ECpo Acfnr ,M p - -_ n,....a._1, .ti •.. -? • T NO. 'e FO C! 4NT CAROF ,, ... _ -.. CITAr1oN NO Cr ON: NAME, ADDRESS & INJURIES OF PERSONS INVOLVED r"?'-... co... ] A . ,, .... Ex AOF lTATUS R Lw3 T CJlCi. S' .C!' past. n;i•., E • P, I w sin eeo fgoM - T- S mow.. M W? OR N ? a vfD rgaM I'M E To S, NA AN 5. r or I Dvep FNOM I II STA IU! • IS[AT rOSItION NV fO E i,, •' ( ]. rAS3ENpfR : FOlSTg1AN 0 0 OTN C CLIaT E lq A s 1 ] ), OlN(N r031 LION 1.,11.1INY CIASS OINIURY ]•Of.•p AT SCl NF ]OlA00N pN-o,a• Ifvl D[ NTI IN E 7 wrgELT ISIVFFA I BCTED T T•LLE1 OT FJOM TIN USE [p ]. TOTAIIV (IFCTID •. , E, F. TN SE .. .. .. a ZEUS-MOTORCVC EI ] a. rOflfION VIf FNO I CIEDIN NOSrIT•L IIINY lrgSlell INFURY K»OwN ])ARTIALLY t]!Oi[O wl O[LT fAILUAE E IFNKNOw»Ir [IFC TEO L LuT ? .Y AFB{. I 4 J 1 :n ? 7 lr I ? f 1 1 lp ' k t Tl,t?r{'ISY ?4 I t i4 1 ? t `?', ? ??? f?•-. •t :.x li,', j. 'I •?r„ ..,,.}.:.. :?,_ ), w...iLU :r. ?N:I.?VtY r : . . ,? ?. , ., J Orr AM I 1' 1 d I Y 'rr { T H ,I LI E Y 9tflf.' ?? F.kfnGn ?AN IVEHICL E DAMAGE " .!INSTRUCTIONS "' " T. IN EACH EO%. CIRCIE TNFN _A AI D FO: =A • -- - IEA ] SNARE ARE4 OF SEVEREST Ci OPA'//AR ] I I - . ROW SIT°SHOIVPq CP LDIRECriV J CE L JJ ? DAHACED VEHALE NO.1 I:sFr»ssa TCE F,JR SCErUr NG U+Ai?V•iorw :-,., nT?.c.Ei DA•.?aGEO VEHICLE 0162 1 Imo,.. n? s r _ ; _. .. r T1 ' '^ .. IC __ IS s WI. ' I' Iu» 6 I a.u .. Y ? v • Sf• E?oTS OF v,MAGE V HICLE NO.1 r I?• E SEV ERwr OF DAMAGE: IOTNER vEnICLFI ']. O.wrv - SEVE.--IIF DAN AGE: VEHICLE NO }' .- ^ I AdLIN00AlAAO - ?{ ] ? OTHER N. O v FUNCTIONAL DAM O i NO DAIIGE F 0 MIAOE .1EAO1 A.IS ING DAMHGE T U F s ?OinERMMAV.GE UNCTIOx,t v:MAOE NO DA . . OnMAGE iA3LIr,G T ? °TNFN M.v.OAMAGE j ?F } i' T - `r ESi.OAMAGE rOwEO BV ?l TOw EO BY Sr DAM..-- L » L NO OA.Vn d5T.0AMAGE TOxfO dv` /! L To I TO S OIA°GRAN OF COLLISION rti.Vic u fy DRAW ARROWLYVING 11 -H 1 111-1 NORTH `N CIRCLE 1. v i - t iJw IX".c N1 4 c»contra IrW -- ? - ? __ -. Lac,rf wDr+ru w. , Vfv'"TIN 0/IIC! fAA, SAOGf NO. OLKI OISPnTCn10 Y+ K t„, r ,T. P v GD IvVEETO IN601 MS/AKLN,M[AII,NK :GINCr X I / E9 Y K /?• 17 OESCRIPTIONOF - INOICATE 0 tl E F E 0 f m E CRASH pE FO N COLLISION:. uewTr.Rfoucfav 9 Y,PEOEST CLOTHINGCOLD ,CON STRCTIONORREPAR-RK•ETCI OTO AGRAAI• E.4 RIVER . - - POSIT O E,0EO "'D N BE FOR COLLISION :;. MILE MST IR. - iNEFT DPH v uE Op nA INO [CTION 51f E O3 y l RKFO ASVER F - E INC. EA3IMG LASING - ': . OCN EO. ALON. Hic, E FL G FWAtK Snau p Ca --E. S OF LK C O3 U ACE RO O WEATHER 3 CONTRIUUTI NG CIRCUMS LK crC L E RC TE p fYM'$l _ IC CAO F U:RFCK ONEI C TANCES IECK ONE OR MOREI" cH V Eruv t» c l - .,.., eR -. rvE EP I. v. I 'LAO E11CA3T O L E .>. E O D EO v D NG Vi wEr 3 INING M }-- E InrLUENCEOi 1. -CE-It I?:.. ArARFNTLr. wnI»G ' •.'?. - NOVnNO ] FA LING SONAI T n IOCATIOx- AR Fl fIG _ - VA E!D ! (? SA 3 ;.eO . NOT NT E T AR. f. RIVE EOU CIfY ..:_ To E f 0 sT 1. ° ° c -t> DS SC ° N nu } IE - ° E° cA f LIGi1T( ON[)[TIONS ' I' RAFFIC CONTRO N }VENICE[ E IGLf (C TYPE TYPE OF ROAD >, ECK ANE OR ORf . VEHICLE CON DIT I N O I E O mUt T SOERIETY F fi cNAL '' '!ICnALS ?t : } o.. ?t [ S q H L!.??TiUTFOI rc •Ifl U{ "O'> ;'O F CIIfCKO 1 } -6 SIO Cx - - o - DA sG TrO 1 anfrECIVF t /? t o t0 n T Er C t i > UA N ] SIW 1i-1 lE E ?._ Nt C TS r > NOi HEO TR EOtO I 3011 T' ? AILASR NG '• ?fY NCt• -- -y ? ]I ° f1C E' - Pf t1G TL } ° EN UNK N NV > E-M G. fRIN° I ! _ DAA EfT ?_?110 nON /IASN xG ?-f?-_AM1tA - - AL 6 { [ IRI30 F SMwOiN ! p11 _ . _ A BEEN DRINKING . T i r^ E RACKING nlET S AA r n LC o y " N Nf3 - a IUI. D„pE? CHEM. TEST _ ?;•-. . , . ° XsiA EfT OaNt3. criiR 1 ?L.f I "i. ?/ ', l QE?, E? I` ..' lsrcrvEh 4' aTH r mfcrn " - } .. E I OTNlP " I} ° IDEO ...: T[LTRfrUSE ? % ' l OTNlA LVtC fVI --- -..:?. }i- NOIV10ED _ Of HLH ISKfCNrI O /I % TEST flESULT3 Z - • {{ y < t ?'^ DISTRIBUTION: CIRIGINALCCPr: SEND TO EYASHINGTON STATEPAT DUP LICATE COPY: LOCAL LAN f.NFORCEMEIIT AGENCY'S COPY-TRIP JPY: INVES'TIGATOR'5COPY ?A •x ' i . - DATEOFCX-SICK DAY OF COLLISION TIME .. ,.Tq }SUN 1 MOH M DAY IUI] WE fRl 'N'R, SAl IU SE W HOUN) C OUNTY NO CRY%.? FNWA, ? 2 } A ] 0 `, S , X I -. ,. URBIW ORAL _ COUNTY ?STATE ROUTE E)COLINTY ROAD ?CITY STREET Q DM CIb PREFIX - NOUTE OH STREET CODE b CIION j •" '? SCf iCrCO:f ?OTHER ISPECRF j - - N ^ 3 - - -- - - - L ?IN LI}Y Oq TOWN N 5 E W W P REFIX EO IL POST ' 1 1 3 C EJ ? ? ? ? U .. : -.. / C ' OF. MILES T - 3};tOr____ ?.__ -__-_--- ----__ LL - NAME 6NO.Of STREET OiI ryHIGHWAY-- INTERiECTINGWITH, STREETOR ROAD i. I H AM DIGAMDATA T /Y/ ON Cr 87- Q NONINTEg5ECT10Nr - ACCIDENT IN TEfl NON %RD iERSECTING TON ROAD ORREF. 0. MIEAGE T G15 ERENCECAOSSSTRE TOR ROAD .. .. N BETWEENiC11tI2_._. STREET AND. ?: _____.- STREET CODE - Q DISTANCE ECTION FROM flEFERENGE Ofl CROSSSTflEET S H ONET,LS E LOU NG USE ' - OMILE . MILES N S E W 7CQ C ? ^• 5 r FEET OF y VEHICLE-VEHICLE ?VEHICLE BICYCLE ?OTHERIWRITEI ?NTd RUN ION INVOLVED: ? SEVERITY ToTA' N VEHJCUE-OBJECT F] VEHICLE AIR N ?STOLENVEHICIE OTALO = O L NOKIED I OFVEHICLES VE HICLE-PEDESTRIAN 3JNON COLLISION ?H-DOUSMAIERIAL PRO PERTY DAMAGE ONLY OBJECT STRUCK (NAME OF OBJECT STRUCK AND OWNERS NAME) LOCANONOFOBIECTSTRUC%-,' _ , _ ESTy DAMAGE .. ,. W B E ? ROAOWAY FEET ? ? ? ? RD EDGE ] --- DRIVERS NAME-LAST ,r ?'- FIRST:--- --- - - MIOpLE ON-. NA.-S, FIR5T M100LE-TV 1-151 OR PERESIflUN CHECKICJ'; R'. Sto.4er.. 1:6 S-ary Loretta I STREET ADDRESS ,: .... ,....... _..._.. -.. .. _ ._ ...... I STREET A...ESS v` 20704 3sd So. E R CRY..: -. ...', _, .. STATE n?ZIP CODE PHONE NO. tt l E e CITY. STATE ?.-:}IP,CODE--.. „ PHONENO. c Ee ttle! a J' y ip ?7 -3575 N -NSE N0. 51ATE EX DATE Of BIgTH N DRIVERS LICENSE NO, STATE SEX' DATE OF.,... 0. ? -VERB S/-yJf? • ' S F 1 O ?Z Y 11R O. , MO. ' DAY YR . DRrvERS OCCUPATION FIRM NAME -.. . PHONE NO' .Z DRIVERS OCCUPATION. IRM NAME - P NEN . i, Eott r- C 5 ?n. inecr w - . . - CODES 01 CwU55? NI SEATSELT_ M) EJECTION _1_ CODES IJI C`u,sY TAI SEAT BELT ?? 151 EJECTION INJURI 5 F CtL-LCCI ROLle - INJURIES F fn6CFNEBY: TO FROM SCFNFBYTp VEM.YEAR MAKEIDODCE{HEV.I MODELIDARiNOVA) STYlE 1}DR-CONVI VEH. YEAR MAKEIDODGECMEV.1 MODEL TOAfliNOVAI STYLE I} DRCONV.) V 7a E?oiz<^e Colt - 2Lir i'4t:r, -V-- -...-.._ :? E _ UG. PLATE N0. VEH. COLOR,.. , STATE TRAILER PLATE NO. STATE - -77 E VEH COLOq LIC. PLATE 'NO. STATE . 1RAILEq PLATE NO. STATE . N J Yellow iv.407 j . . .C. VEHI LE TDENTIfICATION NU BER - _.. ._ ..... _.-_.._.. 00 METEfl -. .. ,... C VEHICLE IDENIIFICATI N.N...EH ET 0[f?3.1 .. E, REGISTERED OWNER-LAST; :. FUibT. - MIDDLE - REGISTERED OWNER-LAST FIRST -.. .. , MIDDLE 0. , Same am driver 0' ..: ADDRESS OF OWNER .:......... ....... ..... i .:_.._.:._.:. .. ADDRESS OF OWNER... .. .. ; ... ., . '.... ,... 1. -.:.:.. : ?.? 2 NAMLANDADONESSOFINSILRMICECO,ORAGENT.. ,, .. ?.. I. NAMEAND ADDRESSOFINSURANCECO. ORAGEN7 t»to Pnra insurance Ss:L4tlo i:n , ' CI Er. i:.-. 1.:. .. CI TAIIONNO. '.ENFORCEMENT. C-Foc '.: ••.' _... .. .. - CIIATI `-. •. _ !Sono ACTION NAME; ADDRESS & INJURIES OF PERSONS INVOLVED' °ODES } ' ' ] SE % AGE STATUS _ EJECi.. C NAME'. C ADDRESS' u p NAIURE OF '" Rl MOVCO FROM uuunas bCINI Hr To A ? NAME' " N T ADOR[SR" 5. / %Il NX IICMDVF OFROM SC.FNF Hr TO .. W NAME .. i Apd1ESS. - N A UA ,S,f .d wn- +u nl c TO 5 NAME' Y .. S E, AIMII[BS r OA nUIIW SCINi nTI-am es TO HISIAIU3 I}I bLA 1`0.41K1N IJI WJURYCLASS 1151AI NLI I SIEJIC 1011 O t PASS[K.ER DI`(Of SINIAN NCYCLTSi - . 1 I 0 ?? > ONt(JI I•f>'?TION 1 NOA .TSC }DLAD AT THE } DEAD b1 ARRIVAL ] OI DLNGIT. H C DI IIL Ib RVIDLNTI IJURY 1 NOT IALLED }NOIMUSf ] USLU T NOT CJ(CTLa fCIrO }IOIALLYI J D PATT ILYLJFCT[O D & OTHER 0 WI1N(SS L - 011'I MDl0 c,cu, [ IVYigN NKNOWII A DICD W PO "IAL } PD SIGLC UURY U NOVRI UN O N1 E L.. ...-.-.. _.. U .? _ .1...-+ ......,..o' ?,. .. f ... ] SOAI OEIA (NLYRE - EI[CTLD . J y MAC .'. Z q \. 'M1N? I ?RLq'S"1FC9Yl R , Si?dllYnwgKLP.Fw.l I 1 4Y1 M ?l^ W'1,°'+W r I 'N^ ?? I IT r I dl ? ?hWmt w 1 11: r, uVJF huL.IIUIVJ: " -' I"I " i.OfIAY(ARROWISI TO SNOW PgINCII CIPAL DIflECTIONOF FORCE. ??"I•Q? ?..?? DAMAGED VEHICLE N 0.1 HIE wsf TNDSPACE,fOq sKErcnINa DAMAGE TD }HAILERS, MOrogcrcus.ETC.I DAMAGED VEHICLE N I T 0.2• c of 1 q f' I X 1 A n 5.ihunY I T.a •W.n ? I ( I a • r a.u S FRITYDF gAMAGE: VEHICLE NO.1 ??-? N DISABLING DAMAGE 1 OTHFP AI.V•DAMAGE ]? FUNCTIONAL DAMAGE . B NO DAMAGE SEVEgI TVOF DAMAGE: IOTHERVF„ICLEI 1 ?DISABLING DAMAGE JQOTHEq M.V. DAMAGE T O -N CT . 0 M. DAMAGE ICi SEVERITY OF DAMAGE: VEHICLE NO,],"""•' f?-EI DISABLING DAMAT•E OTHER M.V.UAMAGE FUNGTIDN } IJ AL : ND DAMAGE ._ DAMAGE TOWEDBY ,.i1. EST. DAMAGE TOWED BV fiT.OAMAGE' A „ TOWED tlY EST. .DAMAGE TO ?'. }-. TO' f TV f .DIAGRAM OF COLLISION.. irv I { I i. I_ .? -1{ I. 1 II OR AW ARROW SHOWING • I--'f "i NO RTHINC IRCLE ? 'IGF1<ia•• L i 1IF _, } T -47 O X DESCR IPTION OF COLLISION I NOICATC WHAT PROBA EO E EO U AITIA CRASH. NCLUOE INFORMALON NOTO DAGP E.0+0 VER RI OSABLITV REDUCEDVS ITY PEDEST A v CLOT I G , , - . H N COLOR,CONST.UCTOROR?REPfMWOgK,ETC,yL.5 LZ '11L1: i i! )' it )f I1 ^t)7 4 i O!] 1'rC )F Tt:l O T'?'1 'Otl ' '1 C ,3.? ,?t^'1 ylt:Lfi l• 1Ci?'.-..0'ZY.O:?. LPL. lA?s ??_T IT?.11G'`....!IIj?n + 1 „ LI „^Y'30 ? clir>< 1. E . . ?f _?.).?rL'OSO?1t'_..C.S.:z2:?.l:lt?_ F,''+11P rlr I?n:?fl 11?1??}'.at?.LM1'_,.1?•?I.?i.J.23ri:,?1 -^" IO BEFORE COLLISION .of LANrs YFFDS vfH CLF D EN + j E -1.1 FPA -? "t• . H IND EOIPEC 10 M Ei 3 v ADED E OS DT DI ECR EAP. ONSTREETORn GHWAYNAMEO O VEHu NO.. INCREASING SING ARKtD GCLUP ED . . „ S . E' w ES NO YES 2. Ej Li r EEO. C_IL nC LON0. CNOSS I 0 x r l A _ FgOtl? ?EF£q ??? FEOISICV SUS NG. SIDEWALK ]f WALKWAY D __'SHOULDER Kr I: CR I CULKS"CPOSSWAIKB CGIETOUTE OTHER ROAD _ SURFACE ,CHECK ONE, -.WEATHER ECK ONE CONTRIBU - IC R TING CIRCUMSTANCES. NECK ONE OR MOPFI Gfl ,.rvEPrvEH¢LE ACTrorvi -' NO. 2 o f DRIVER DRIVER ] DRIVER RIVER ? Ll S N TRAIGT AHEAD 1 DIfY _ 11CLEAR,CLO LYE843SI O UNOfPINfLUENCEOF __L?LOQtlQ r1 oLLDw„G 1J} T QSL95F.4T ?1]?CSINIir,iPOEV •J" - ,J r . [. ]A_y OFNT KNO A D'PF551N0 ]I' WET ] RAINING_? I UNDGE INi LUENCE OF OPU... ._ lu OVERCENTER 1 r, l APARENTLV 141 LJ LEE' -1? AKYl I ' ] - ENOW ?SHOWING _ _ }a V EEDIA•ISTATED r _ I,a VL^DTD _ r?,I-l I dLJ V In ARK NG LOG IO RG N T TURN r.{ MK1NV 1 A ICC Cfi EDING RE AS .'-l L 3 EE YEFD - r . L " q J A- N_-_ I BI-1 O F T L J lJ L[ T- ?? ?l MAKING ??1 l..J M V{? * 1 n0 OIV /W J O E C F . ? I, I OSRfG D f 9 &GOtV - 4rf*jfa GI TORN 7: Eu SLOWING O FP IY(CII [R IYLCIF 1 R (' I O fi. ASSING .. DS GAIII U Y dG [ Oi E IS CIFYI ' TON E]?l.. a OMED FOR ONDITIONS ICN[CK ONFI RAFFIC CONTRO INO.]VEHICLE L E TYPEOFROAD O] '' ICNECK .HE C V 0.EI VEHICLE CONDITION V CLE .'. -SOBRIETY -113A SI T GNAL f JE ' - 1%?I SIGMAS 1 1 1 , . ONE WAY 'N Q C O'} P?CfM'S??9UTI01 [ ICLE ICNFCK ONE, LJ pTOMLD IN J T Ft.I OA tDMT ?] EVD•E ]1 I -WAY V -, f- I?Ai OEFEC VE 8fl KES i1 H SILITY [n 1 JJNU OADWAY DIN L?101 J a1?`wwN ,ll ?. YG„ ? l i ? J flDVDS L ? DEAD LIGHTS Iq ?} LH00AINLITY NLIREV - . TRAFFICLANE ? 11? I PAPKED? 6RiO 1 ?.OUSK - _ _. 1 [ RLD (( ?? ?? L ! LOO R/IMP`F 1J J I I OBINETV' l 0 N ICNTERINO I ON _. _. ' 1 I CAMBER„ . . O ! d`I ALLEY . _ _fl fARLJGHT3 Lf_??THI Il? 00T„. _ EF OT K1N0 TPAIPIGI C16? SACKING DAR. f (1 DAR arRt[i [? Io f aR "" TwowLA'NlLFsr T ,IAIf wNCru a? __DA EYOw„ ,I No rv0 CHEM. TEST . 2 .. . .... ... .. _. ( L...?L,?...__.. 1 DARK-N0 S L_J , , ORL(TLIGHTS O//IC[ ! .FLAG „ . 1?? S 1EQ N i• ?. 1 '-l TIfT GIVEN OTHER IYECIFYI ' }?}-_^ ,..OT„iR IYfCII VI GInIN Y_1; I I ] I D D[D -... L 1 ..__ I ? 1 NOOEFEL'TS f I?? I TEST RLFUf[D--_' I S / rITK 1 K 3 .' UNDIVIDED ''"+5?01„FR IiifCl/YI % TEST RESULTS Z INVISIIWTtN00•/ KlN'3 NAN[SH „K 1ADGE. NO• -111 I P VA 111LD LICf ANHWLU Y I 1 .- AT a 1 1 ,?; a• APR IV E IS m ;;11 ]EDD iMPEDIGx UW 21M 1 `AJ 9 M1 IN X V SID T GUI/I CI 4 [ H OGL MO. AGl„CV UNIT OiT SD.T D EU HLFOrIT M PIIOV[G SV AT f f- T•1 1? T _ ................,.InulUN ronaIR LI ATL COPY: LOCAL LAWCNiOHCCM1,ENT AGENCY SCOPV-TRIPLICATE COPY. INVESTIGATOR'S COPY ^.T?r • 1 ' - OFFICIAL LSE prILY - -' - F N0.av HOUR TIME OF CO ESI310N COUNTY NO.• C TY NO. - 'IN 011, ]Q • P CITY- TOWN ' ADM CLS Pfl EFIX HUUTE OHST CO SECTID ]?G > 6/050 yy lERSECTING WITH: STREET OR RpgD - PREFI% Ep M1ULEPO3T #` `rt'1? r RAMP DIAGRAM DATA . ` 1 I STREET rosT Un:USxrHr xu l.rau.vv. v'vv' •" QIl IHiE CLS. lxlx:nvilH - SPEC.C OE E - t. OBJECTS NAME ANDA.ORE53 LOCATIROADWN IN AY ?N E? a n s Y, is G°Ync FEET S 1V .,. LE_..,,, .RIV E0.5 IAST NAME FIRSTNAME MIDDLE: y1R ' R. F •OX•'"'"r'^O STREET.... 5 gCMTE NO. .BO%NO.. • Z ?c C 7 ION. ! CIiV .. STATE ZI1C00E ORIVERSOCQ?DFJ?TION rA 1 ? rr G4t....?-2-:ti 1.1.• -Xl it l.+L' Y uLtJE.Y ? r AGE ORIVERSLICENSENUMSER STATE SEX -OATS OF BIRTH AGE 1r. ?aoL?- wa M F r0 AY 4A. . vEH CLE.vR. 'A E 15 MODEL". MV,.u+xrl_ BOGY STYLE?:R „ y?Ap LICENSE PLATE NO.STATE . TRAILERPLATENO. STATE c2gy?4 cA,? ? V EHICLEIIDENTIFICATION NO - O ETER r SE NO - REGISTERED OWNER ?..lusr+wyr- InglE nuN.. - .qIV )s°?? 2C'fr soh I"1• W? _E._ LCEN5EN0:••, ^;xy OF BIRTH OwNER3 ADDRESS .T LSTREET. T T4 .. DATE OF BIgTH ji'_ owv YEAR - iY 2z Mo- SAY YEAR s ? uilo WFO Y ? E.,,ILVFHKu YA3 THERE AUTOMOBILE LIABILITY INSURANCE _ COVE RAGEI N EF FECT FOR THIS ACCIDENT ON YOUR CA. YES '.?NO T...E:.:W 17 z t-NAMEOP LIABILITY INSURANCE COMPANY ? "JA 1 '. rw s 4ta _ 9? _. c 1 (? ??lc n ?t e __ `?1wtL cc a, r (? uu,?,3* ua[amFOUCY ume 1a,IF{? w 10? 'CF ^?-ry IZE- 3_.?r st n 'AGE, ]t(p IN)URYy?IUSES M.TT[RFIORT POR AO., ?IONAI?W I131y' .: `-. Z..;', .q EL 1?_'y Tor- E p sex ^';.? -„y STATUS OFINJURED :,......'.MARK CIR3T DNR THAT APPCIR3 L"?C iu?°• IN VEHICLE Islvla IU xOaL'W -T?' N KILLED •? .,v ? S? 6? Tart - "?DDESCRIBCBELOWWHAT,MAIIEN[ IR[FCRTO E ICLE3HYNUDERE JM' ".?C_•_.Z_A7/ fintix?fl.•, - _ _/r2???(J.Fl?'l.t. E.a/'ri ??c_??`?_J 1 ry I l .: 1 . NO. IAIf •[s ? ? ? ? ? 0 0 ?: ? A? F?. ? xa .YL,N ? f 4 '?C r .? ' GRpsSiiFEE aLA:..r,?r:?YAliitr7gtttilgoM{a,.lyF,?E? TpM d, 11 iy ?S'? cc] CONTROL „Il w•r ATYIRO 'ROAD DRIV[RNENICLL ACTIOH3 .sA LA+ 1 I t II L SIGNALS STOP SIf,N T ?TWG WAY ? Z ? OVFRTAKING AND IAS31N0 rlq'1' y 11 .'F Ylf lU 5l f.N ? ] ?RFVCRSI AIE -` tJ ROAD ? ] ?MAK INO R ID IIT TURN '1! (v FLASIHNri HlD ? A ? • rl RCN ANG[ ? A ?MAKING 1.61 TURN +I IILLOY fl.wt N AY4fR (? 5 ALLOY lJ ? ? 3 ?MAKINO U•TURR i? ,, H 4 f F ? ''v ? n n?RWI•IG ? 1 IA' ? t' 114TN"'L C3 R n I ? f] ?z. 4 ' , i ° ?e_? ima' 1. ?© OF ; m A 1 n GO RMMJHWAY I GIVE NAMEOF STREET, T9 WEB s ? &l cat. ;•. t TERSECTWO m- STHEET OR ROAD .. _.< :.N o n e REFI%. O ..; E i I .N)V NTERSEGTION.LOCPTIO!N?OF COLD fS 1 .- nEtWEEN ?EDLf-n? KOG.[I I STREET ANa -I?t7'IOtE.rll? I`)CLICISTREEr NA P DuGRAM DATA •` •. .. " , MIMeER .r'rAt oN © _ p'CUwbCigS.vM Un[voSr OiliofililsnM- + Vn?E - ? NON %RD WTm INTER CI !'?fEriENCep SLHO9isrneEl OnmCn•o ;, Ll ? .?.,mswr«%, I . ^'K, C?3 ® 9f I 0 5'27 800 1Q ? of ' V0.Vf9 Y-. r LE VfrvKLE pVEMKLE-KKVttf rvERlwwrEl /J CJELENO "' I2?LJrf•rCLEOD1fCT pVENK /' SPEC CODE USE .F - ' ? lrsoN oI.oKLES P L_?..p RKIE PEOESrwAn prAN pII .? i . x.- LOC ^ OHJECTSIRUCK (NAME Of 9BIfGTDTAK+I - OWN[ Fo91ECT5 NAMEAND ADDRESS ATION 0? i0 _"vi wOawEti . INROAOWAY C4IJ•I. ?LYIi G[EY' / FEET S 1 C / fas. fi0 ? 4vlbw {r} 1LI:Eb -?'7 C'I'I(Ll? C ?;on . . • I-E I S • FIRSTS MIDDLE ?. FIHSTNAME MIDDLE Tvq cAAS OFIVERSUSTNAME nNVERSLASTNAME nE wvCfvEO 3a_LL M LL_n ?;AnDA _ __h, .. 'aIREEi ADDRESS ROUTE NO. ANDBOY NO.. MON=TVA STREETACDR ... nOUTE NO. ANOSOXNO. . 8 C3?,c G(o PE- u-FE I i26, / Lore 6 /c?L "'CODE Gi SfPCODrE AIE l N -9 ? { DRIVERS OCCUPATION COI Uti cPrnrloAM CH'I STATE (? LOl. .CNODE DC {?L? N>; / ; ?iIUGJ I/ IJ 7[l CHWOOERIISEI000?PATIa. 3?tL?l2r1 !` v M-? (, T : /tA µrJ /-? cr .. V ro R STATE SEX DATEOFBIRIH AOE IORIVEnSUCENSENUMOER ,.: STATE SEX i>au M L ?H - 9z tM WA M P GATE OF SHTH. AGE ,, <<i o"? 7o DRIVERS LICENSE NUMBE S _J Ij PM54021?JV !I ? ` c8 zs IF n c 9 VEHICLEYR. I9, 9 MAKEICNEV.D000EI l?cL?SLLn MOOEL(NOVADART) 5lb BODY STILE 1208.1 4 U'r. VEHICLEYR. 6,9 MAKE(CHEV:DODGE) Che-v MODEL(NOVADPAT) 00DYSTYLE(2DR,1 ',: /c:YrsLUD:ed S'G-f,'0?kEZ.,?n LICENSEPLAT&NO. STATE .;_.. ..TPNLFAPUTENO STATE.. yr q R ?'? 9 W A LICENSE PLATEN,. STATE THAILERPLATEND. STATE :. . YRL 670 WA I19BBMOOEL58 NEWEPI OOOMETm (MILEAGE) IFNICLEIDENTIFlCATIONNO. VEHICLEIDENTIFICATIONNO. (IBBB MODELS, NEWEH) DOMETER IMILEAGE) , . IaL?Io-o?642 eo73) 1(,64-?9GO34-392. o?i'79 PEOI REOOWNEfl ILASI FlRSi MN%1LE NAME( .. ORNERS IICENSEiq. nEGIBTF-.wN- ItAST FIRST• .7 NAME).. DRNERSUCENSENO: .., O-ER9ADORESS . - ,.:. ,. ISTREET..17 NOSTATE), 47 r i r '. DATEOFBIRTH. B OWNERSAD R SS ,, (STREET,CITYANDSTATE) ,. 2L, / $ox 6?01- AL,Z_d1- W.4 ; nATE OF. TH' EM PANTSOF VEKM:LE DAMAGED i4FMPME9C09i? LEE is e_' a `p T50F VEHN;LEDAMAGERJ{r ... ':,". .. :.; .:. ""' ESnMA(E9003r-. s` %oKb L?Cb fwnt { o?^ WAS THERE AUT LIABILITY INSURANCE INFORMATION-VEHICLE NO. i- COVERAGE W E ??? OMOBILE LIABILITY INSURANCE TCS ? NO FFECT FOR adSACDIDENT ON YOUR CAR ELJ' LJ E NAME NiD ADDRESSOFLM&Utt WSURANCE!OLD YfgLOER - NAMEOF/UABlUTY/WSURA/NcEcoMPNiY,:: f.. TsH Ess r?rE>.. 2ro ?? m clCLE ! ' ` .L. 7 a L ?Cf.OJ oT G G.YYL a? GL. J c,f' NAM E0.4DADORESSOFILLPoUtt WSURANCE AGENT.. .,.p V, .; __.„diAIE 2P., UABILRY POLICY NOMBEii:. '?-' I?lL?6ua1 EnAntclaw gnu rT?Law WA 90022. A 31(_ /0 R Y ISTWJU 2ND D,JURY V v • NAME PQL[.. wf1JC ?(?-Y?1 ._ d - O NAME __ADDRESS b W; og , ESS SEX ` Eo10 GI1 a56 3cer-n L Arh O • L_ - nn E. N •w?n°: oeTD ® o9croASD? _ EA-T..BVADOCH- ®© M" SJ/cI nB OFwJURED Q- ENII:LE p PA MDEA -:;C.:., KLIEG MMNf C •O^MwD _. El NE THAI APPL E WvEdsAVUrtl I- 9 E 1 STATUso,"URED pquyEn IN VEHICLE pFADSOATR ILLED '.MMKFlRS uno ISEVEnEI f ONE TMATAPPUE ONp9AN,M0 n IWORI 9 TC O S$f ??J??JJJ " IEC I NU. p nMN vEOfsr FPAw E ( ppw ? 5? 62 70 p n ,.I•. ? 5? 80 T? S10WHORTHBYARNOWINpNQE \ ". DESCRIBE BELOW WHAT NAFPENED (REFER TO VEHM;LES BY NUMBER) _,yj• D"a•? ? 4?? ?yer__O":f v_?h sJe _I I oOkc?l -. _m;k °:c?N._. O c?owrA ll.-? dash. 2n-cl ?_W_h ?h---- 4 , 1 rk E s e NNY \ -she 0 o.c1 -lL f7 --..V_ ?/h c-I, e. --- > 9 - - K v y] s on HCMw WG.S , r)-- O Y' T` Z--. =S?we.r Veal ^?---r_n_ss_-Vc.GF'rrl?. --- - --- ? . ?UE!a VEuI Rd ------ e I j (? - -I - _ d 1 VEHICLES POSITIONS BEFORE COLLISION NO,M?`""ES Aiir""E ;ui:? °n"n"f "'"s INVESigATED Uv [ n OMF O STArAw6 •+ vOKt[OCCMrEO ?/AIPOL ? V[HK:LE N 9 E W O lmEEr On I•GHWAY NAME OR NO DNfCIKw LE IS MO arts FS rA ?r%Kf 14 F o? a En. ? I- ? ? o • 1 I o ? ? Q 0. ? ? T ? ? ? 1[•l?Mf ? ? ? j 10??4nI m ? ? o A I O w folwer ? ? ? ? uOEq CAMSVMD mom DIRECTION TO DIRECTION PEOE]TRA muSI4a 10 SDEWALK 20 WKKWAY 3o MfOULDEH A?cnoc`D.I s? "M ".T. 60 OtHEn HDAD SuHFACE -.E. UU.ICCN-ONS IRAFFICCONTROL IG.Ef+oMO tYPEoFnoA wmEnrvEHICLEACTIONS ' .f alrgrv[I KrAC?6.II v nC vfr•CE[ ?IIfMCO+WL VI-11 KMCAD (v?rvl W 2 1 KA6 'r 1 o DAILKJIT or 1 ' "o SCHALS or l ? E WAY A I ?^ I of '6NO STRAIGHT AHEAD PASOI RT AN NOAN O p T , , I VE D NG WO WAY o 2 o 2 \ Q IY 20_,NG 2o0,- o 2 ?atOFSON 2 U2 ? 2 DWI, ] 0 WXI-4 ] (L DUSK o ] o YIELD SIa4 ? ] ? HEO EJISIHLF o J o MANINa H-t TURN o ] ? Y Ow A o FGG A ? IONtG ON TI o A ? FLA51-O R[D o 1 o INrTRCN J OC o • o MANINO LCfT TURN OOP PAMPI I ONYII tf'11 DdnK 9\PEH I ? 5 o MANU.IaULUIIN C) ? CE d IJ LA.Ili9 OIf ? 5 o rUS•NO AAIHfH o 5 o d o ITMCp Y TWO I OI A.R S ? ? 9Mr.IfY , ?,Inf [I lIf rt, ? d ? Ni:Mr,K ? A ? L iUIN ? A o r o&Nn INAWNiOR IgiSEEIMTOAWlF1 T OT F.1 ? I ?OITcourLADMAN LANE' ? F ? W orT'fo Ton tnmrc r.J 9 (rC ?S'IUIY '"• N M:E AW AM M f r A OTHER. U 'r CIFY 5TI•MATCO ? , o frOM•fD AT DONAL ? ? ? I ? Cr1 BIC, Srv, WOfO ? 9 ? BTOPrED IN MADWAY O ? ., „_.. .. ... ? 2 . , . / r.?9 IN r+iilS +lN FiN: ?] ?//M1INOm0E0 ? \D ? TnArnct. IF I:? _ IAF.FDm%H ADCH[BA oCY AOE o \\ ? PAAFfwA OM w,TMESAMAm[ • ., ME"'Na FNTEnwo !! (/.• .rT t_ FO AG 1t?JJ9 ? ? ra l n E r 1 6+ '] TIIA nn Kn L31. ? ? AGI,ND . ...... -`?_ [ Y E'er ? ? ? r 1' m? w.r s. . •t...u'?I'? $YlA, a ?. ",vl?? . Ar Ar k. rR'?` '?.?59 vk , 'L' {a L,XE 4 nl,Lh L. ,.. I T bi ki -?° w. ??r?y suH uM ? Yt nM? a vM 9 1` _ ? - - WL'MLLES +':GTY TOWN OMC PPEFI• ?'COUNTY-' TTY. TOWN '•t.:: r0® "' s I _ {+ Z Mn If (8 91 OF cI'11 '; c.u .E GIVENAMEOFSTREET.ROAD OnHWNWAY wr. x:,,INTEPSECTWOYAfR. STREET OR POM?•.. VPEFI% E6, MLEPOBIt.' -J..F [ t =0 YP 1 4 V, 1 C MMPC OIAGPMI DATA •? ?' . rI' 4 ix ONINIERSECIION LOCATIONOG COW51 N. :.10"\t N M1hY y71'?-.. ?J /!{ f a 4 STREET MO PsE ^ @fREECTE UETWEEN 114 N %PO P/ G! lrnOba " SHOwAF,Ptsi P[E ctvWSr kEr,PwHw,r.HOU,E ru4EEB Uw NNpp r. FHOt MI) N © PAAPOAO GXlS5w4NtEPOSI OP OkW it'wOIANLw,Px INTER WTEfl CL9. 5f'CO O ¢?t i1 U 1 1 PiIEnsEGWN,/? IEEi E•L® of ?J SPEOCCODE VSE ?!J ?• i001k1^WHw Wn r t® cIE VEr1ECr ? -BCKLE ?OII1ERIwwrE1 _ V.it+'?C A is LOCATION N OCAD n.- cs,,. i qb, 34'I OBJECT STRUCK LLEE OF PFOE9rnDWECrsrPVC OWNER OFOBJECTSNAMEANDADORESS WIgApWAY ?© ^ N_ FEET S E^? vA CIS i •.. MIOOLE' . _C• FSb?SItlSIE?IO[5[mEA IF pRIVERSLAST NAME A FIRST NAME DRWERSLAST NNAE RRSTNMIE .. ,• MIOOLE. wEPE wvaL EO W 1t11a R4 - - E?OwSWI oR _ SOUTE NO. AND BOXNO- - 3TRE[TADDRf.. ROUTE NO.ANOBOX EMAN iwO STREET ADOPESS '' t--1 ,1 ..• PFASOND91PE }b •?. /V +EPMUieOV4' 21PCODE IX}W?EPSOCCUPATIOLN f?Y ???'I'( 1 IN tt C{{Ii??Y r STATE.: LP fAOE ORIVERSOCICUPATION COwsON CRY... ?U?) _ {' •)oy-?' JL?ID ??3m5 S cue PE-TFGw pRIVERSIJCENSE NUMBER STATE `E%. OATEOFBIRM AGE DRNERSUCENSE NUMBER DTiTE SE% ?IEOF &RM? ? E ly{? fir' Sc'IZPI"?zlo?tvs L,'A SI` I o ?9 r 4 LEA VENX;LEYR. MAXEICHEV.-0OOGEI, MOOELINOVA-0MTI_d; ElODY STYLE120P.1: VEHWLEYR.. M.Ell CHEV: OODGEI 1•IOOELINOVADMTI:.' BOGY 91YLE1 DR.1 j; a ?l; Gc,d DSl\J 'D J579 !? n Si0 To .- L%;ENSEPIATENO. STATE..r .:' ...T A EA PN ENO;..:. -.STATE LICY?E•N?SE R`A?TE7NO. STATE .TRAILERMTENO. :::..STATE. }, {+ _ '/EHICLEgFNTIigAT-NO. :-. IIBBBMOOElS4NEWERI_.•_ ODOMETFA_IMKEAOEI VEHK;LEIDENTIFICATgNNO. is .:-;IIOBBMOOEISANEWERI:;:.. pOMETER,IMLLEAGEI tR' `,. , J Z ?44 n9oC3y 92 0917 1 HL JU-b ?l?l UG7 ;""A \ ItEd3TEf1E00WNER.:.•:1[ASi.iNSf;MIDOLENAMEI+.,.:....::?::. DPrvEPSUCEWSE NO-..-.:..: REyISiERE00WNER...--ILASTFIRSriAN1DLENAMEi -_.'.. ... ,..... DWVEflSLX:ENSE NO.,-- r - - r- rwn ;,DATE OF BIRTH ISTREET,CITY MDSTATE) :.. pATEOF BIRTH.. • .'; OWNEfl9 POORESS, - ,.r. {, STRE •GITY ANOSTATEI -. - 40 wr . ? v ?? ,' /? ?'? O L? Eai«ArkocoaT , ? 1AL, $ V ?Ar PnO ? PMt50FVENX;LEDAMAGED - :.. - .. ::••• o vAR VEwctE ?`' ???? ` +rvu rv+..1 RIGA. S A W' WAS TNEREAUTOMOBWE LABILITY INSURMCE YES ? NO t LIABILITY INSURANCE INFORMATION-VEHICLE NO 1 CgvERJwEIN EFFECTFORTHSACCmENr aY YouRcM s 'S ,y Q {I, NAME OF UPBIUTY INSUflMCE COMPANY.. It NAAAEANDADDRESSOG UA8ILITY VIRIJIAiLCE POLAgCCY HULOFA .. L. / o U'.1 ?? ?"?"5:.. t ?E l V L - . n pI. 1 1 1 E 4r.iE 2e• UA&tITY POLICY NUMBER ,. -G NAME OADGGORESSOF UABXIT SURAAICEAGFIJT•?'1 GT,1', : i ?_ :.? .. ._ •AGE 3Np UPY :. ILSE PMME POP ..OB iKMM ET AGE 'C. ? E IN IST WJUnV.. ^7?i??`-?GVC??n_Fr. _ \7 wAw E ?/1?((1 C .V?`I,V n 7 4? ?F N-E SEX q?1t 4aieg( v-1 I A ] q I SE% ADDRESS' CJJ ?I.??. .:_T1 I?U. .ICJ 1-E- M CI ADDRESS M a ?MbN , V'®p °° a?1?.i £-}knee .)ef.-!•5rr? ? PO ;MMKFIRST CNE iHATAPRIES STATUSOFINJURED MMXFIRST ONETHATAPPUES Bt TUSOP WJWED .r:.: «oP4a IAFW -pp. E - ?pmt IN VEHICLE . nU'Y OE:,EEeb t ^ r1Orl?DV16 P wFIE ' A AA O^I P WVEHY:LE WLLEO ? B? ISE?EnEI I,m1O1^ nE CO4PLAHT 0 ? SIT OmP E FA NO OFP,N LI .?PA?ENOfP WLLEO ?ISEII?IVFPfI W?WEW 1 ^L sipw PE '? 5? e? 711 5 7? n LR A -+N r ?:. Hang .t ,J ? ? _ ?' STOW NORMBY ARROW WC ROLE \ \I pESCRIBE BELOW WHAT KAPPENEO (REFER TO VENKLESBY NUMBER( '`. ? e dAGl,.I - V?1c? e ?. _?J2.t?,•i-:as1' aY1?o_.1n `?eh._ .; »E 4 rwwa \ usJON a:? ary.tJ t2"1°V_L •?=16 ?J7st-Y? ??_\Pe• uPA [ACH \Er1newsrXAV ? wQ?. v.??19J? r I i. fC11ONOF iP,V! SIP.EfIDP tK.Pw,r --O_?-'2 ! E -- L y rj, r-- r ._ 1 I bra[iLPr.Lrwlr ; IG -:? - -- . -_y._-------._._ - `{ •, ;, / k 1 F V,PPE n,s WVESTOATED BY I - }} VEHICLESP ITIONG[ BEFORE COLLISION onµ TMLL .PYw n cwo ?°r^?r[ ?P°a,ci r I 1 VCHICIC T3t1 (L W ON 5 RE ET OR IA&IWAY NA E On no pP[ IqN IT ,u ? C r ?o0 4rl P N ?PGLE ,:? ? ? ? ? ??ERF Y I "?' rolraPrs t{ffJ? 10, ? r I 7 ? Q 13 13 A<ono L«ossHO oM DIRECTION To DIRECTION 1 r.: Wu5 A4w rn DEWKX J ? WALKWAY J ? SHOULDER A ? cwi 1-11 4 ? cmil?wtua O ? OTHER $ I PEDE5110AN WASU4Yq 1 pTINERNENICLE ACigH9 I A Evr I J .. R7: UADD '.. WEATHER.. NdT10Ni iRAFM:CONTROL ICPtL+WFI 1VPE OP`OAD Qtr r0«L v'ruCk?s Ic1u<x Oh[b1 WPtl :H .V' rCM[a[Y.EI «,J ?? 9 rI P &C 4 1= r'Ktf t 1 O K,?r 1 Q MYLIfWi Q 1 Q SWIAAIS Q 1 Q ONC WAY 1 OOINO STRMOHf AHEAD } ! r ! 1 ?pflr 7QRAPMq L?DAwN Q x Q510 NOW TWO war ? x QovEnrAXlNO Um PMSNG n? 4 I f I REVEn^JnIC I--1 J ? AAXW6 nXJHT NPN fl I 1iP liy? A14k y ?^ 0, U K[f J Q SJAWL,10 J® OU5K Q J Q V FLD:JON 11 J? fgAO ? I. F •? 3 J .1 4 Jt ] 1 t' It+ A ? LL.115 MNAT9 dl 51MET A FLA5HW0 TIED 1 WTtw...F. Q A Q 4AXFq LEFT TUA4 A 100 IlODP1 RAMV1 ,QE L? d4 ?J ? SNOW ' Q ? ? ? ? 4 Y?I? D ?MAXWBU TUMI 4}` . 1 1: lM I ?A QK'E !?osl'EC?YI OAPK(ttnFET Q y ?TIASIWq A41IER ? S QALLEY ! ? LK f301! ? S ? TV/O WAY, Iri d,ONO Wt ,} Ll, t /Y Jf'r S i o S ? 51'[C1iV 4 ? pmIEIW fR ? 4 ? ^Ai !irGNAL IANESI? A ? H }' 1( 1 .9 pEA50N /p1 NOf iE[Irq pANOER i OTHER ? I ? O/EWER/FLAGMMI ? I ? BfOPYFO FOR TRAFIq t A, yV r } ? STOPPED AT fXYIAL I ? !1} (T(yrr'' \ {1 1MtltA,l0Wwi1 ir1rlr,Lxwt IKl "JrfGf'I E DTHt J'ECIfY^ •+ ? L?IJNOrvXIf DD an sTop 16,01` J gNWAY 1 ryA•, y? • 1,l£'.p + n j ti \t J r ii wwo t J lr n J,?. )d E... rq more l0 1 9 C r 1r ? Q AO@..' 11 0oloW ? F Q BE x !? "^t Wtt Nf11 C.?y 7 J JG.4 AJIt ."1 :.h LS F>, /?[+ ? ? P U1POrNE1IL TERVq \ aL ?? r 13 VY^ ? ?yrA {/'7 /? ? IT ? 1 FWI I I ?. •????Y} .'.1 ??t '? ? Y V / `I,- O .• !'/ ICI r I y ri 6 ;?Yii ?? w J I ;lam 1PI,u ?„•{ ? ? r4s e}.ti?L? .n. u^?:. 4 rv' z xv{ J I 11 ? ?! ?? : ?1 ?? s? ! 'rte ( H ..:,,GP ?s `mavz rahwr? F SJ T. MOTOR VEHICLE COLLISION REPORT NO. TEOF OO ON D AYOFCOW EION TIMEOFCOLUSION COWTY CITYIq. /- Eon 17 DA/ ?`? LATn r NF5 I IS_, Hy HUP FW UTFS AMPM : O ' ?' S?f MI1AK wWu TY CITY. TOWN x?na CA TOU`noE MILES ©® CTY.TOWN.. ., }? 2, Aw PREl. pure dnrpF[TCOp[ S GROH F?n ©©D tire/ ?ti 1. 1 / 4-1 n wNOrp[ gVENAME OFSTREET,ROADORHIOHWAY _._MERSECTNO IT": STREET OR ROAD , PREFLY EO MLEPOST-- D?CCCwwED _Lc .nG 'ZI OO NONINTERSECTKNI-LOCAT*NOFCDt SIO BETWEEN STREETAND STREET WAP • ,:. gAGH DATA:/ u'[qi ®® - xWAIDADCRO55xD.MK pgEN(Y A.DwDDE MTER NON CIS. 0.5EDl10r(: ©® EFEI O,; CCUlSIDNNVgV[D ?vFnKlEeiCnaE ?anERlwprtO ©0 irALND vEHDLEa9IEpR[ ?VEwttF.ia4N SPEC. GODS E r " } a , FwcLF pvT-L-DES'.. ?pdco - ?nr.pu., - . . OBJEGTSTRUCK -,. ...'. ,. I!IAVE.prp9+FCimwKN,.: ..'.-......OYMFA OFOBIECiSNNAEM0A0DgE59 ...:. INROM rAp ip PEVIn WAY ! .. ` ?© °Rp _. -. FEET DRIVEflSlASTN?M/IyE ... aFl/g5/iNM1/.?'/MI/DO/LE // l L> ?% K C/Ili W /"Y IF MDAE MAn ivq CAps FD I"wSgn Op pgWERS UST /N/JAE/n ?).. ..• iIRbT NA?MJE - ':. MIOq.E J/N sv/? Su /?? .AEU-DRESS ;:. ., .... .._ RDUTENO.ANDBD%NO...! -T.-TM STREUADDRE59 ROVTE NO.A DBO%N0. - f Gro/ A? PEpspEO USE pF xR /3n ?D e 7 Lv Goc i CTY r /. ATE ,.-. _wCODE - = DAMRSOCGUPATION ,,,;;,I pauSiOx CRY _::... Z;; ,.,,.: LPCOOE O(i E SOCCUPATON - 9 GS /P?fE c v .v IVERSLICENSE NUMBER "&v b ATF SEA...DATE OF WRM?. AGE-. ? _Li -'ri? U k " r G 7 sue OflWEg9 LICENSE NUMBER, _ '- 11E . SE% DATE OF BIRTH AGE VEHICLE YR MAKE(CHEV:D000EI..: MODELINOVA.ARTI ?:..' W LEl10R.1. ICLE YR. MAXE(C. V.-mw'1.. MODELINDV 1111,:• SOOYSTYLE 12 DRI ;;p -71 LICENSEPUfEN% . STATE.. .TRULFA PUTE NO , J .. ,., .. STATE TENO. STATE• TR/J[FAPUTENO. .. ..STATE / f S / LN _ I5?4 Gv?? ' VEHK E IDENTSK:ATgN NO.., -II966MOpELSA NEWEflI ,: OGOMETETI(MUEAGEI VEHK:LEIDENTIFICARONNO. (1968 MODElbI NEWERI _ DOMETEfl IMLLEAGE d 2 /?E? v5 a5t2c e (9 0 2 7 141 •7 0 RECSTE RAST-FWST- IOOLE NAMU •,;., DRiV IK:ENSE NO.' RECSTEREDOWNER IUST FIRST M10 NAME DRIVERS UCENE,E NO. OWNERSA _MOSTATE)_,,,I- ° OWNERS ADDRESS ?. ,. (STPEET,CRY DSTATE) . .PATE OFBIRTH r 00 -tT 5 /G -70 PMTSOFVEH DAMAGED .. FmuAi[Dpps io VE+.cIE PMTS VEHICLE DAMAGED ? -- : i01"A n°vpAE[F P G s r.[i Pti % S. . LIABILITY INSURANCEINFORMATION•VEHICLE NO I. WAS THERE AUTGMOdLE UAa[TTY MSURMCE COVERAGE IN EFFECT FOR THIS ACCIDENT q+YOURCM [DYES ?NO NAMEMDADDREMOFLlA&LIT -RMCEPOLICYHOMER INWEOF.M-1NWRANCECGNP Y.:. ... NA4I A-E. -' UTV TA1E - IP NAMEMDAOORESSOFUAM1TF b RMCE AGFNr //JJ _ .. GrtY STATE .. [v UA-POUCYNUMBER HST NJUIiY - :' - NNAE -- AGE KAaEO INDSN RY: IUSESFPAPATE pLIronTId AOd+IdALIrtAAPEbI NAME AGE ADDRESS ADDRESS SE% inlNror.uKK[n - .aaa xaioN nr.(OCian ® I [uM puAE W U aM % oM ® i xi aH erA"[ tan " r ©i WAS STATUS OF YAMED ?r%rxc MvENK:LE ULLED MMKFFSI sK ONE THATAPPUE N i B ALE STATUS OF S NRIRED . ,. wVEHICLE MMKFIRSI nro ONE THAT APPLIE .WM N.M S NISSr&E ?PA95F n .?na w41 D+?E•.vmiFN ? II I 5? xa l 80 n?mµ 7? ra ix 0 ?Orn[n wuncN KILLED ? I-El 5? IHAxdI 6? noi.°.x?cl+ 7? IINO W NORTH W AAAOW WIRCLE AA4 DESGiIOE BELOW WHATWPP ENEO IREFER TO VEHICLES BY NUMOERI D,"1 a rwcrs " p _ FClC?-_? ?(1t • L f ?.GJ O {' ?L' O ?S? . - NO .?ia:dmN.InaA? ? I LS -/ . . ) .-- 4 2 1 f_ ? ' wxL. ?? ?r'"' np[[?onn -??':-..r 5/L >? s _ ?L IP?Yla _ - ------- --? --------??- - D - - E., VEHICLES POSITIONS BEFO RE COLLISION - U WnCU mwn AVVEBTMIATEO DV VEHCL[ N, 5 E W dF STREET 011 HONWAY NAME OA HO 9 DSKCi . 04Lr UAKp[q Up41r FAN[D WItL[OLNPED vra [IO ? i?+nOt ?iglc[ bTKA ? o ? a ? ? ? ? ? DKNr 44 ? ? ? ? 4oND _:... '; c .. AOIAw ..,_ ,.,:.FROM DIRECTION' To DIRECTION ROCTHW[ WAII USKO 1 Q b0E WALK 10 WALKWAY' S ? SHOULDER .0= x A S ? 1AOy-rx 1. S ? OTHER AOAOSURFAGE KDIpADpII - M(AINEII -. ...:. LKIN[cmmjl0NS _;.... .IWFI000NIMCX ,•,-IMCKONR .. " H ,TYPEOFROAD,,.. ,....._ D NrKl1 IEnIW d[ IIM-AHICUACTgNB.:'.,__ . VIrKIE K:W<Adl DI UNKI LU"1 ND 1 Q 1 QDIY CWT 1 ? trM1KYt I Q OAYLKWT ' ND ND 1 I ? 1 ? SKWALII I Kp [ OA MAfI y Q I Q ONE WAY ypLry T Ipl 1 Q OgNO STNAKYfr MiAD 7IWAN SIO DAWN 1- Q 1 QIITOP SON ?1 pTwo WAY' Q I Q OKRTAKMANDPASW4 ? 1 ? WIT ] ?NAVMRI S Q OVSK Q D Q wwsoA[ AtWA b 9fel! ? S ? ro Q 1 Q MAKNO RIDHI TURN sNoW ? ? [ ?TOO 4 ? °w-flmE[ C] A ? ILASHMO RED Q A QMERGHY E Q K Q MAKNO LEFT TURN ?E A `OTMR S ? SRCIIY' 10, S ? ?9i'fCIIYL ° ??-1( DeMNKre ai T NO S I T l ? e ?IUanE4A UA ? S ? M NONAL ? ?M1OOPiMUP) S LOOP ? S Q [R W AN S QMAKWOUTURN S ?eIOWYO KAShc1011 NOI6EIN Kf.KLAYD Wvl" MTKA[ O DANDER IKYKI I,H ? . 111 7 K1NT8 1 ? .pry ? ) Q orTK:ER;ILAGMAN L 1 LMCS II? ? IIIMPLD FOR TRAFFIC Q S Q DIRER [P[CUY ? 1 ? UTAPATED ? S ? pl 76FOS TaIbGNAt iq inurK: ? ] QpVN10 7 C S ? IIIOIED.AOADWAY . O 0 a Q1rvg oro - ? ID ? iT 7fi CN ..,.. "" ` .r..?.?e?..e.>;,.®HLIKr.-rv•'..m.. n-.uxm,+,•..-rrr..-.-..•.•eWal?Md:«-n ?A?A:--?e[aF•saeY'•..n r'w?Im re Zr-nxe?emnmalanmMrn?-.ar.l?'•?. D. DATE Or COLLISION A ' DAY OI LOUIS UN 1UI. N(n LIME LUUI+IY NO / MY NO. {HWA- ?V. J ?AY lEE l C I `(` 2 5 WLUA InU S rn L hAI TSUI+1 y1? 'J D. z' // , AOM CLS PR"EFI??% ']NRUA O UU ry Y ?SIAI[HOUIECOUNTY ROAD ?CNTSINEET f O ^ HOUIC Ofl 51hE E1 GOOE SLCTIO {'`a ?O,NERISPECIFYI y l 5 ? 6oc? CITY Ofl TOWN L 0 III O A?N? 5 E W ?MILES LPL ? ? ? LYOF. CQ.1'•1 V?.F_" .._. _._... _ W O PHLlI% CO MILE POS G. A p, rv E•NO.OFSTREEILAHIGHWAY T O'Y 5 INTERSECTINGWIIH. STREET OR ROAD LL RAMP DIAGRAM DATA y*" ONV+ICNSEL O / ACLIpENT MILEAGE INTER N Ni %RO I CLS. E NTERStCiING STREET OH ROAD OR RE t t aq` r 'E RO SST EE ROAD N tit-EE. I STREET AND.. TREET COOS DISTANCE AND DIRECIUHFROM REFERENCE OR CRAOSS SIHEEZ/T.' r'? ?..L? /' I? ALES 3 O O EET N S 'E ISVy • Y \ CD. 1C D Yr / Il] v"wll SPE rAL CODIN.- B VEHICLE•VEHICLE ? VEHICLE BICYCLE ?OTHER(WRRE) O.-Au. COLLISION INVOLVED:. / SEVCRITY "N0. KILLED 1O11LLN0- ?vEH:CLE-..EtT _]VEHICLE AIR TRAIN ?STOLENVENICLE ONO.INJURED OF VE HICIL ?VENtCLE-PEDES,RIAN [].ON-COLLISION. ?HAZARDOUSMAIERIAL ? PROPERTY DAMAGE ONLY ODJECTSIRUCKLNAMEOFOWECTSTRUCKANOOWNERSNAMEI LOCAl10N OF OEUEC15tHUCK EST DAMAGE ?ROAOWAY FEET ? ? ? ? HD EDGE S FIRST MIDDLE ?S NAME tJ?ST UN""?E-'?.f ?' DDNER$NAME'USTf1RTMI0DCPtIF'81C R15TDA FrmuTR;ANcRrc r R ? P .TRCElADDRESS R •? E 1E14J ? • V E yy,, H 111111E PHONENK?p• CRY R ZIP CODE PHONE NO OITY 1 -Al `.3tl N - . r I f ? ?+ ? ' I NO• • • "[?JJ•HS CENSE NO Q?.? I ? US?IIL.A?LIE SE% DA(f1??E OF BIRTH( 1 VD IJ?39 ^'• P- O• U EN5 NO DRIVE E 1 E SEX OAIOE OFD,viN e { ? fl ? DNE S NO STATE !D ? „oNENO. I- z DRIVERS OLGUPA,IW+ FIRM rvAME PHONE NO • _ CODES >1',i. y N CLASS . R - - 'AI SEAT eELT_ '.. IC•I LIECTgN CODES IJr Ct 55 SLATBELT_...: _ 151 EJECTgN _ AlU EOF NAi ED {? ^1 /??y.?? ?pLJ Qty I ?? ; REMOV o FROM SCENE BV TO REMO VED ^ ^' _ FPOM SCENE D+ Q • 10 V VE?YFM NAR[IGV.1 MppELIDARiNOVN S? ? •CONV.1 VE H Y EAR _ MAKEIECH£v.l 57 9 Al ,xLE12LUnV^I f C ? ' V 7 3 c? ? D `• E i DC. PLATE NO.. vEn LOLOf1 U 1D U(a77`T2 STATE (L TRAILER PLATE rv0. _ STATE E i yClOR ICecQ LIC. PLATE NO. STATE TA U R PLATE NO. STATE I ?- (?` D OMET A T1 ON NUN.bER .. O ER YEnICIE WE II+TIF IC(C C VEHICLE WENIIFICARON NUMLIER ODOMETER L ? 7 - y?_? •-•? / , - 7 _-! al-.l 1 / !7 / Iti E R76 153 57( ; REGI; _' OWNER-LAST fUtST MIDDLE L REGISTERED OW14ER-LAST FIRST MIDDLE O.' i Ob -oki l7-y? F O ER D RES O. ADDRESS OF OMER 7 A D S y? t'E" gx(,. 2 ? ry 'J - HAL'.C AnOAWRE550F SURINCE CO.ORAGENT _ rvAME ANOwDORE550f IN5uRANCECO. OR AGENT '?•!F_ r CHARGE ~ CNAT-u. ENFORCEMENT CH"GE ' CITATIONrv . L ^ ^ ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED _ CO SEX DES AGE STATUS x"'Ln "+ I ly ) EJECT. 1Y4, NuAE uhy ?hr~ ayapp W->ae_? 3 3 3 2 a' - p P N Ire OF MDIVED iROM INXIRIr5 `y SCl NE PV TO `k A T N r NAME 0R±[J_GC LC.13$ -7 73 I i v MDnr% SIL ? 13 3 111411 INiI Iu of SCI G?F I.-DIA TO I ; A w 4 NALr A..fi )C- fill LC!tti 3 - -7?t 2 S N ?3 i P t ' . ? . ACDNES} 1 a-6 -t NIuFt R N A SC[NE OY TO + K d S AM[ S •Iwlrss - n E o?RbrT _ Hai?iI i . . S' A sc N IlIS1AlUS 11151 Al P0.1%IIK JIINKINx CLA55 TO 0ElT SI I [JLOIgH 7-1151-1 , C .D iif l'ISf1WfAN ZOIADA SCE NE d ON M50014RY NI NOT OT USE LCD f oALY("C'ro I T OIHERPOSIIgN J OLD.ON ARIIIVAL I ILWDl N111NAIRY HIC.Cl61 0 USED J PA1111N 1Y [J[ LIED ? DIM1R 111US MOIOrICYCICI t DILDIN FIOSIKIAL T POGSIULL WA R }I F . D I Y UNKIIOW^! V UNKNOWN(( 0 VAINl15 A PpYIIWf uNANOWN 6 SCATOLLT fARUIIC T.IFF.IFn 1 .w t; fTF r I '+ W ? r M1'li P! s' ? , ? r ?I q n 1 .+ v h b? J1?1'k,, a ?e+?? I k L? 2 r.64 ? y1?1 ??# ? 51 ) r _ _ ? , I t?? ?jAS I c. I r T kIe 1 t?r A, ht • :YL luil lNls SRACI ro) SKL --I, DA 41 lO rrlAll[rv5. p-11CLt3, 1ICJ On AGED DAMAGED VEHICLE O.1 EHICLC N0.2 [ 4 r I) « I\/?'' ????? Jr. QrI -- fl T O DAUAG[ vkH CLE NO.1 rrrurn 5 uAGf. IO x L[I SEVIPIIY Or OAMAGf: VOrItIE NR ]. "I! _ _ urn 1 ? D D DAMAGE ] ? OIxOHLDPAMMAGV.E OAMAGF Ik ? U AG[i :fO D1 ER M.V OAMADE I O DISABLING 01MAOE a O OTN[P M. [4M4G[ a ? EUNCIIOxAI DAMAGE ] rUx AGf OAMAGE "- ] ? UNCII K? ONALD,M4G[ H NO pAM4V GE TOW[0 By E51. OAMA OW171 ED{Y CT [51.°,M4)G. IORtD EY Cii, OAMAGf rO f 5o tO A L TD 3 I i OIACRAMQ COLLISION 2_>" ^I_DRAW ARROW SHOWING- ; V I , //N6RTTtlH.I..I11,NCIRCLE j _, f"r 14- 'DESCRIPTION OF ! -uxoKAlfwN41.PO34eir N,nENmetwPE. DUawc 4NO.ETEP rNECx4sx.IxcwDE wroPM4TION NOron ol?cnAM,FG oR ER COLLISION _DSADIlr;Y ouCEDlvurerknY,PEDESTRIANCS°TNNGCOLaPCONl1PVCTTNOn 11?rAIR _K. Elc.l.-. -,J ?'. - -_E?ourrQ,FC? ?p_.: - 2 #?Io?HL 6ouha, ?Riuewa?! to_'# un i?a;FO v; 2-?1"tZY?VzQ??4 outo? o s-3, - Rb.-fgnN ums...4ttUak. 13yf.-- _Q . I zt_ ..• b 1V•e #-2 _ uL9s_. il, cstifiRv?1 t2; x} j E S o1. ?11Ipq ?1ZSA:n]?v1Qv_q t.. ?aSC E._ Ot ?t3op ta_L?1O f 1 VSLhiC?¢s_ _Y 1V?v6(-_}? pYD K 1 n,;t21- _?tY11pf L L'p?r? _ ryul TO:.t t _ Vzv%I s.YIFlo- f??ehi-MOV-2cl?-C7' , yk F to . WRt )eau ?._ ;of _ of i esll- POS....NBEFONE COLLISION .ar uxFS LEps emCLE IF PARKED • u E OST Ox 51tl [ OgH-AY nA- A ) . LEGALLY vEN. FrD JIEI•D,ED • R. F f? N°. ONE OINfCTIU w PARKED .-It. Np INCREw51I rOECREASING - - . ?I v? -l G £ 2 ' n - 35 3 IFS ND vFS_ 056, ?°ESIG«AYCp• i)F ? ,. _., ?EpleICVCM5I WAS USING: •ROADSURFACE • KHFCS.oN?1 .,-j pR vFR 2 1 .0 - -M-1. WEATHER I ICNECKO«EI.. F wALKW _._SHOVLD - == t CONTRIBU _ -1 rlC« .OaWER ` `' f .. C10S51ALF CRO TING CIRCUMSTANCESlSW ECK ONE pR UOR[i- r DRIVER -_Ie CVCLF ROUTE OTHE +L .. ... .>, C;?r'S \• ( NIVFR R F N Eal IttkAaT10NS. - IO«O.a DtN2Le •?[A?E NG 4 AHEAD . `-1- r` OnY CLEAR, CLOUDY 1 1 ?r bOYEPCA i? ER IxfLUENCE Of ? ALGO.:D E ; TclIOwINO _O?yQSf L] n F4 gDFO B r f? '.-: Nr3r0 - pV NG L' I] D rASSINO r-t 1 I]I ' wET ] ? RAINr«G __ xDEH NELVENCEOE I] RV [_ I j D (Act- r ie Lr [ r T1J A ASLE.E'TLY• ILL PAK 1- sNaw j1 a I sNOwrNC E STATED ria? SR[[pOINGILMI ; ID I.- °' i _ ?-[l --Ii MP !DEN_IAIIKIM(i -- L? •j,=, . J uklHC- r T ?-r I K[ J..f i0G A ' r--I 1;^KrESVF[pgE/S. CIO J_rP?_f.? ri16r_ ° _0Z[L_rV[s_OUIF. 4A ( IryDq•N• JSL? V.TIInN-'. Ib? . ? ^ l I NOT GRANT PIW ? _O vFNrclf 1 w?E G?nOIGHi r 11i? `{ SLOWrN° ..-_ Oln[R IYf[Ir YI f Olri[P lYftii Yl , r"{, r _G" sr - I ?;1} DISRFGAR . - S THER OPEC ??Te 1 eO VIDLw ' 1 I]?-I IJ ,._f TRan STOVrro ioR c TIGHT CONDITIONS (CHECK O«EI RAFF ICLI.CLE ?CONTROL 1x0 ]VENICE[ IMU IC«E<[oOE OaOAODI ^ VEMICLE CO[NDI'[IQON -_1 I^OC F R?itSi? .` - SOBRIETY..,.. •-, ItLE ICHECKO EI _02 {? STOPPED ATOGNAL OR fIOr fI4N I 11 S4 ALS ONF wAV ?1 O N 1 .• ' ,- ' r Ib ?,f pOApwp N LJ Tr 3 OP,v ?] ,_,6G - ?}•N? a TwO wA? 4.t .L_I 1 wrICTIV[ _ JPA4[S.-._ - '- ?? D ptLlTrt a ?'IMPAInk ' f if4PIINO « •??ro'?JTRAr/IC LANf t o .a1 REVra eu xpAO L wncnvl -], f D 4 ] tcl ITY [n O 1 ,,??Ixc rRpM. a OV 3 K S4 -- y; nlD lM6 - ._ MO y? A LI M]s wrlc-, -??_ xrAn ucrrts T IMPAIR _ I) OSOERH=r. t..uM[: _ ? pl0irll°P i? r? ulPAn4 NC x«iFRlxc +.:.1Y?J. a rrcr ? , r udxif oA L? s. Ji [in c £?s Auer I ij "!.o n _. r• ' ?FfNOninKwe f I`?'baLKl«D • DAnK-sl aEn MGHIT Of `{ 1 SGNA .. {` wo trt Ea yh ..13 Ivn[ 1.•DnNW« ° - o«rvex CHEM. TEST I NO. ] (-1 r?• . I_J t ._ O K_NOAT{ f IM •Z'S Lf. O G ?1 1:. [;;T- -' - p? I••its .Cf? •. C / ? k '? ` •L •?I' -olH tR lS.rc lin - • - - W .E ? HfruSlT ol:'lw ii•laivi ?;e l `,al ID[D •-• or„inisncpn 74 TEST RESULT] Z . '? x, vulK,l Lw ouml f«AMI •rL eeGL114 iNAM[ 77 ,UUI . uwl+ 11Annlvw AMx u Anlc noR 7 »^?Annviu A17 LO 2 2ND 2!I uPfwD D.., 0,1 X l ¢f? 7 `7-7 J Vv•r '; DISIPIIIUl1ON 0111GINAL CI,Pr it NO T115VA5HING11)MSIATI PAIIIOL-OLYMPIA, WASHING ION 00501 WPLICAIE COPY: LOCAL LAW [NI OHC1M[NI AC,I NCYSCOPY-TIIIPCICAli COY1': INV[STIGATON'SCMY IEjyj STATE OF WASHINGTON •-I I1d t`.?l MOTOR VEHICLE COLLISION REPORT NO - 3YL' DATE OF COLLISION OAYO CO ISI n 1 nWR TIME OF COW SIGN - COU h GI NQ I pig f .. .. on rvE Minu,L " E? :'30 q Pi,•.. ?' - »r..cEE COUNTY....... ..CITY. TOWN rw,M,I MILES N??E ;,: ..... CITY, TOWN ApMCLB'? P,R?nE?FI% ygouF PrnEEr cnn[ S cTTinN 1-invt r+ !n GIV A E O STREET, ROAD Ofl IGHW FAx INTERSECTING WITH: STREET OR ROAD PflF.FI% EO,s MILuEP037y?y'YyK >» ,r. R, NON INTEflSECTIONLO ATION OF FO1LL? ON `a_ ,1 /n/_ ?I ?y RqM IAORAM DATq,a y a+y IF 10T r 4BETWEEN O N'L L'EKi R:dO LLE•VLG'TJ PF'L? ¢x"I:C ,r^• ST EC ooLa?i4 ?'J} 1w. k tr [RED] N L ° °cgoss nn M,EEROw OR DE11111 nLANDMARA w uR ,y ANON Xfl0 .REF NG igom anEn b ., t FA NTER, Cl5 !, EyBj )?,+ 4 . ?:. !NTLR5EGTIQN FEE ? r ?S OF Vx,N? x '1+i/1(?l', -., ,y ?n ?vF ?P, ?SPEG. P.I9 Y' TmALNn KEE°w[? x„ OrYE»GEE! x?JNPE,,, OBJECT STRUCK,'.. (NAMEof OWNERO1,08J1CT.,1A.E ANDADDRESS.;;,,, LOCATION •n•^ E! u 1.::. yy P IN RO WAYJI a - OO n JO IED REP GAUWL s'JJ FCC FEET S W FOn[ o" s )t?1+ N DRIVERS LAST NAME v:.:::_.. ... FIRST NAME :,•',:, MIDDLE FEIN 0LVED DRIVERS LAST NAME., }:,.s.,_:ii.FIRST .NAMEW::tunkrk,a,,,.J.,,,,. MIOOLE.s.r. vsM l ,z STREET AODR ROUTE NO. AND BOX N07N T,vO 6TH-- AOpRE55 _"HCUTE NO ANO 007.N0 - AMT 1 mp dOX Z-I b "JURED TATS A $o .. ?3' CITY CODE. DHIVEflB OCCUPATION 9 u bN CITY.?v BTATE 21F'CODE':: ORIVEfl3-pCCUppTION. NJ, Pop 10TH 431x4 S 9931 J {? A DRIVERS LICENSE NUMBER STATE uq uoTE °,r81Rre,n AOE DRIVERS LICENSE NUMBER__. STATE S DATE OP,B tTH ;pGE. N?L " ?p? -Db-L -L39 L- UE S bt 1.7 VEHICLE'". MAKE(CHEV:DODGq" MODEL (NOVA-DART) BODY STYLE (Z OR) VEHICLEY0. MAKE(CHEV"GOOElq . MODEL (NOVA•OARTI BODY STYLED DFL) $^ ?? X04 "Z?'j ln,?CbJCg LICENSE PLATE NO.. STATE:-:,..:._TMILER PLATE NO.:, STATE LICENSE PLATE NO..: . STATE,.:,;. :,;TRAILER PLAT, g, STATS,.,?}. 4 A " VtD177 1J ear ,VEHICLE IDENTIFICATION NO-"_(1068 MODELS. A. NEWER):_,ODOMETER{MLEAGB VEHICLE IDEMIFICATION NO; ,-0088 MODELS B. NEWEIO?• ODOMETER I ILEAGq c2??$z1? s? y77H0 ?'• REGISTERED OWNER ..GAS -FIRST•MIDDLE NAMq - - DRIVERS LICENSE NO. REGISTERED OWNER (LAST-FIRST-MI pLE NAME) DRIVERS LICENSE lllo ; -,_ , . III , , _ - v 9?-lG-Fl23W - F. OWNERS AD E -`, (STREET, CITY AND STATE) ,-AUS OFBRTH .,. OWNERS ADDRESS ;•.::_,.,ISTflEET, CITY. AND STATE);:'.i: OFBRTH.. T I i _F J? ` v YE,R ?b t `f' T ?ra\n'1SL T t u. ` PAWS OF.VEHIGLE DAMAGED _.:: ..v ^• to vE LE; PARTS OF. VEHICLE DMIAGED?? gnEP P Y[N,cIE', u r.' WAS THERE AUTOMOBILE LIABILETY INSURANCE YES ? NO LIABILITY INSURANCE INFORMATION-VEHICLE NO 1 COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER _, `G . ?;.:._.. .„.:.,:NAME OF UABILIT.Y_WSURANC..COMPARY ,,-, .,.E ?.. E. /. ARD NAME AND ADDRESS OF LIABILI INSUMNCE AGEM..... _ J .?. • aD' '_ 'i.,....., 9IATE ,„.?.:..; .._. ?:.::;-.: u 81LITY.PO CY NUMBER:; 1_r +4l .' G::.'.Le?L::r. ' / P,-,Le 14 PO, Re" 7Z& n?f 7c. Fw c A a / PA 6 u AGE 2ND.INJURY. .. _a_..«... 1A!!..,. (D+ ?.._, ....,.,. -n.:,1 AGEr NAME tl? AE• 11 ITORED NAME a ' ADDRESS Rf ` QQCf ?I? I uC? L(.??YtZb' SE%" ADDRESS SEX _G_ZLI C' J r ___ nD R y 11 E'-I liFi4 ?J Fs 1 f _ STATUS OFE ,nRR YO wcloRS MARK FIRST ONE THAT APPLIES,. ?J STATU80F 1 R EHICLE s.,MARK FIRST ONE THAT A ,I•^ IDPq VFn IN VEHICLE xiuii '?ur?JyA OEIE IN V iviunv 'buROiJM E A $: lT KILLED wi v n NoR KILLED s[ I .4 ? SSENDER NO I ?P SE GE NO, MI"Oq `I? ? PEDESIPMN J I ? PEDESTRIAN ?OTM ERVJRIIF IN S?lI 6? 7^x ?OTHER \•JRITEIN ? IS?EI 6? Or7OFlc 1 I SHOW NORTH BY ARROW IN CIRCCE ,.DESCRIBE BELOW WHAT ,HAPPENED, :IREFER TO VEHICLES BY NUMBEW J I.-C ON TNIf DIAG WHAT HAPPENED O ry S( ? ' 1 `? crola^G, ,E. »» lxow UCL?JNPK? .It;,h;Cle AJC?.-CO.aLS! CT , ,p .. l.G» ,ul .,P„°» ? rl' !1 lio NW ?'^'"1 u!c ?Y: LIL qua •,.,LEA Lt 01'Y.[i N '! *V, f VEHICLES POSITIONS BEFORE COLLISION 10 W 1A l YE cu Dw.[ INVESTIGATED BY § I ) (Y V VEHICLE /x ? ? ? ? ON STREET OR HIGHWAY NAY[ Ofl.. NO. "e ^ nuL [0 n,(n nWn[ O qA E ? [tl y 7!a> ? N 8 f w c1Kw F Y[8 NO Yf6 NO Y[S 0 PAIIR ?V NET 1-1 n El d I {„ P[DeftFwN» _r ? ? ? ? u -..?..... CROSSING FROM. DIRECTIOR,:,,;,To' DIRECTION PEDESTRIAN WAS USING 1 IIOEWALIt. ! WALKWAY ) 5-1.111 E =tln• ! I'NMA wi°n ! OINIA ± F f" 1 PN ?' ROAD SURFACE. .. ;WF/1THER .. .LIGHTCONDITIONS.. TRAFFIC CONTROL. -- a4 TYPE OF ROAD DRIVETINEHICLD ACTIOM IEIGLi,.tuf u? f 'F' IcNl4 ON4 ry a oNl INIa[ waI flNl Da Y°nl [ y'?y H' I,ICLE {??+.?? F????Ju???NOf NO14M) nn YORII n0?) , '. f 'n I/ ?Y 1 a `l? I 'YLIOHT ? 1 ? SIGNALS El 1 [3 ONE WAY 1 GOING QrMEDNT AHEAD Vll I ;} rUJ' t MINING F DAWN El F 1:1 S10P SIGN El R) [I TWO WAY ] El OVERTAKING AND PASSING Y ; i [ ? P ? WET S? SNOWING S (yr EUSK ? S ? YIELD SION El 0 ? REVERSIBLE ? I ? MAKING NONE! TURN 1 'I 1 - ? S C] SNOW A ? ? ?IGH}p ONE ? l ? FLASHING RED ? . ? INTERCHANGE . 1 E] ILOOPIRAYPI ? E ? MAK E] LLTUgN IEfT TURN E C3 Ect B OfMER A DARKJIIN[ET OTHER 8 ? 1IGM90FF 6 ? FLASHING ALIBFR ? f ? ALLEY ? MANIN JY' ? ? E6PECIFYI THERI S RKNO M'0 WAY. i,l I T -p ? EIJ ? 0 e1REET LN7N18 C] f [] RR SIGNAL El 8 FFT TURN S Y i v RGSON 8[EWO DANDER ? OTHER ?yL LSE ? BIOWINO I l J 7 t? p CuI,LO YI Mf1A CtgNf. [lGl T SPECIFY ? I ? OFFICENFLAGMAN I/ l t35 ` ? I ? STOPPEDFOR TRAFFIC' r 1 t , /? C S L A Llvf i v i e l,.V Y ? F ? D1NEq SPECIFY ! S[PAMi[D ? 8 STOpPFDATMNAL I ` yyyy???? ? ? ? OR STOP STOPPEDEFDR F IE' r ' '?I ,tM1LCil _ ?) ? DIVIDED (?T 0 C?? W ItlAONAV 1 V C Ll LL ?^- ! 0 iMFFIE n T n ftlV OFD I J 10 I _I 1-n?A+IFM ?A•NN % W A( I pIOSYTW'?) I J e,., , .M?; .'?:,r r 1. ,?ii ,1. I. .f'?F='.--??.,.y•fl'[ »F-? I:trt? ' JT a "; I g 1 r I Yi ?r M g. ,,- -STATEOFWASHINGTON - p EDNLV -?? b •°2^`l MOTOR VEHICLE COLLISIONREPOR7 - NO. I, Y 110[,w a -S-.- nou T E. CrW N? o M I 6 ° UnrY CU ,u•H tL z? . . ?> MI. ' •QI.T...evm).3C ?iv:TaW,tiw9.n._ LES1?Io ' NEF 1 ?5 .,.,• ? ?evn?....LS. 1' S ? F OrT ' J 2Z50 +?EyT-§{¢§?LRQAj]yO,R1JIG_ Y?]y'y,1"„•'.-•?E S[CT NG 1) . TRE6T P.R AO? PREFIX EO MLEPO°T - O VOO ' R f FT, ,)cu ,G. ?- All GRAM DArA' N INTEHEEGTION-LOCATION Oi COJ LISIOrN STREET AND DIA MP . 0 0 [^, I %.HD IN x[nn 1 11 n ? wen Iww [I ............ . ?? NtiO? ;,?ptgq &rGWWgW, .i..0'MNO.ONOGJIVCJ .NAME AND?AO RE - 'N H A's' o's ? FEET R ST tMME \•..d3..r.IM DOLfr;;yS.] r{yJ!{ '':_ -" r"IfLZTrL: MEN-; J-tom I.M LP.tzy w Efl IASLNANE. ..: FJ F? ri f - „ n n l,•?` ?-7? fv?277Y[CY?i f{LGtnl>1, TRE{? _ OUT?E--NO-y,AN6'?OX?{14 .? S,TREET A°OR ° ;Z WjffOUS ANo-:$OAIN°F ry " _ wY lon .. U [c ;_try' ...s...;.JSEv..sT!?,?? J..,e?.:AP GOOE ;ORRf[NS,'OC,OOP 3)OKe C1iL? ? 9?C90E : D9W6R?000UP,ATIONl{ r33 5 d f Lltlm ?m A -7 83 5 --L)2 rm d C_LI rmuc.: LvH . -,. GO _? w ST iE .BCI(' aT4,O RyB RT1f?, BA. ':. - °grvEPiLICEN56N STAB: EK ]6.OS{;_BULTN: ILOFIf Gktc C'!?%l3°5,va wA X a 6, /? t : l C' ej w s?o y r,W.,u?i ? Mp?[Y['ly(.I.w?r?pL" s B•O?DY`?TTIF?.W?1] ?1 w,K[a..111 M1?KC,?,ICx[VVamo[_I MOOQ?Tfrb??,.iulTl BO°N??^(C?12-:u r)?.'1 / Gy Wilds C l s3 2 0 )1/fir YAiy -•.•' ' j 'STP.SQ: CENSP TEiN01 T`j.'-ri'?r sy AIL6R?PLAT.?u? d5 N_E.ieru: :. V F' UTE. ° ,A?TWY t1WlQN P - C110 YIXOz3 LOA s 8&& W ?A14??410'I!II OOON ariRlunnc '. EiN CI„ F TI"?.1°i?'.?lta.fi<{9 9+...-[tz jMWIwI -. 83.§.M'1 _.-. E 1ifGL? bQk?W10AE!? !d - _ , . . 351xg7 212z / brig ! F 5' a 11 d REOeSTt?i IIOI(II[IEC.1 ._- ?_ l:`!F 4 1V[?UC[NE ?1 r"?ie'* r+yRP SZER(O.OWNEftjfWlvrt a.((: Lel ..PR ENS CICEN{, N I L % L ? ' C Ce ? .P E P ? /•^fct.-cam/ C /mar -EE C l? R 6 qDg ..s:;ras P O .Bow 36/ Ck'w4 W X79 (moo BeX 2577 C dlml W14 ? • y ,... ._.. , : ,- ,m..r._ ..wrB:oP_.VeN;zEiDAruc6D.rr<3+:++r.ru;'.4°a ".:'".i-.set::R. e• •• "xul ; - K a S as ear F'v? of ?? S _ s THERE AUTOMOBILE I LIT INSURANCE YES ? NO (MRffiTNSURANCE INFORMATION -VEHICLE NO I OVER aE EFFECT FORT CIDE ON YOUR CAR r-? ??_!!-'??y?? T.'_i!^ -.??3.Ak:4 S NAMCD, F?.LU IL1TT..'IN 4R GO_M A?x`',??? `.. NAM_?!JABILI?Yy'BfBVRANG6`RaL1CY1LOLD-F•N ^ *y F=?e?dt !•{ct7..=( ?iv'ew Pv Ho1c 3•(il .6? rn m IffL 9Y3 ?-s'{ (?'r ,L ?x b•? -^+C-"_ /?SSYt +u!rlY?tl 2i_ . . ?(;O61y? """'- u,r ?? ...:^.... ,? syA?r`+..•'y ??-? •?_ ;ll%) ILITYPOLICT.NUMBER ??' A.,?o,.uet! ,Q o.Ci?>,7zG or'r'Towns?n.a~GlA i)f3cY /?3G.?6•f-.Z, 'LJ . 1ST ? rrir?'?'Atu'i ,wG•c 3ND NJ..q:I.f.I..Si?vc.,uarx1..u..u_+.wwxr ..r..r./..r..ai..µcn? + ? ® -. ? I? ___ ? 0 I Fl I . . oocr ."?O°ooc. L^7 ®«ROC,, L J ^,j BT TI190/INJUR[R J.{.'Lti LSMY`NK F1R3j ONQ TN TAP.PLI '{ Aci'?l i3i,?} .. R[pr?•i L • '^Y."W,RKIIIIS-TON[:TIAT APRL VS511LyyK 3 Il: ?) CCE KILLED Nu 5 ? ILL[D OlwuAV uP 1 K b Y ` I Ov rn,naic l 0 IS [?^[I 601 or7?[ a _y •vIi NOS ? Ic[v[?,r[I ,,,al ,N ND.- 5 6 7[:] ' ?? ? R A.v Nlce.ln ? e Ow NORTH BY ARROW IN LIRCI[ \ I '.?' \ IN „?,,,?.. H,,,, O R : p? •[• .'?:,;?? \ , ? --r',. LEOR H,B[COW W T„?ryAP [N[D1'1 BF[R?^L V[N1C [S Br MUM84R CQC /10 ?.GcXJS.-f,1CIYJLU?II) ?]o!? ?`?/+1/9h. GZJ'1 S?II W 117,.0 r_ 5 i c(f•? __C'.Y]'1;'? _ F}i??t?.IC.?_!"? .-G}jh ra__C0.r-_-_TVO.F2--W45- ? ? " ?Q? .. . .[.T AA wl.w«, I `ti V ?I•L+`a` _Chh ??Cnc?,Y1? Ot.•'?.. c3r_ " ? y -- _._ rE0.C ...__cG.T- _7.?DL l Ir--filgh rr^ der, ------ VEHICLES POSITIONS OEFORE COLLISION ^ [?,77 Nvcsnanr MD nr V .-It ++ '?APF°W O GTR TD NIGNW v ME ON NO V65• IO [re •Q ?I,•'?uoL ?roL[e LITdI'??VISr]??:? .""n. i%..'I` :.,--. ?..:. ? ;,? ?'?::. ? wuc[ 0n°INVr[OUm"N N 10T 000 ? ? ? ? ? 0 ? p ? VEDiSTRNIt?SPv, ?liJ o 1] ? ALONO .? < OS F R'" c A0" PLD[OTRMN WAG UGINO IT] • ]? + )? A ? : [MILL[AG110 ['1' o,!..j I!PAOS[!!MfICSi' lrr[wTNU-;,,,, ,, -mv ED—— YRA7IC COT t„ M,rcX e^u• TYP[OFR p, ON—. rcwrcno 1' lo: ?ivwr 1C ^ 0 SIO .11. ?(?T 1 ? ON[ WAY I lL 1 0 GOING STRAIONT AHEAD KL[) 10 wr•<•U" 1 Y0 OAYLIa NT 11 O WAY 0 3 0 OVERTA"IN° AND PASSING 0 ~ N TW 0 URr 10 NAININO i ? DAWN i 0 6TOP ETON ISI ) 1_I I -VEFI.IRLC ? ) ? MAKING RIGHT TURN ? ] ? WET ,o .-W... ) 0 DU[K 0 ) ? YIELD GIGN ? ) 0 ROAD ('7 fJ S ? GNOW AO FOG A ? LIOHTE TR ET 0 A ? FLASHING RED ? A 0 ILOOPDIRAMRI ? A 0 MAKING L[FT TURN A I<[ A ECI Y ° ? ° 0 FLAGIIIN° ,M 8111 0 ! Lj ALLEY ? S MAKING U-YURN ?j SO O^.ERF I ? LIOHTSO%E! E ' LOWING L" 0 9UPN r 1 "`r'? " 0 ° DOTI [ ? DT RE NO lJ (( ?'I ? RN .LIIr " K lr LIaNfE " AIf.NAL 0 A ,IT r L ? r ? NY 0 ) 0 O111C1N111AGMAN Nr' I J ! 0 6TOPPED FOR TRAFFIC NI OM IOTf9T !RIND Owrq ER„ T 0 EP[c . ° 11 ...... AT maNAL v.?v^.w w•.n,. n:....cno... [TC [3 " [11 nir [R. -?? ? O O O WON _ I r F? 1 ,nRA rl'n ?? -- I s CJ 9 0 STOP -D IN ROADWAY N ) ?? IUFD Jlo f? r r a n nAI r KLAN[ r . . Ay I r . T ' ._ l '?T?«I[F.??, `^7rG l5RP?F@1C7c': ,.:'RtP? ??dT9kR1 ?N":!' Rk6I:Z{L.?1914[,•^^Fa*"^IP?40.'R` ?."AN?S?,Mad:. RT'* .47' r. 5%1. I, 7 ilj- ? ??IN IC'L?1•JY/r1?n11v V1..1. i?•v. ,?, ? %Y4T • - ? - LEI MOTOR VEHICLE COLLISION REPORT - LIABILITY INSURANCE INFORMATION -VEHICLE NO t T E e o LE LI T suR CO E 4EI EF E FORTH C ENTO O RC AR YES ? NO R [ .?. 3 Rn[ CI .. .; .. ./'.1'.sL 4.N?W EyO?'.L A,I..??..rl?,L 3UR NCE Al?'eYjs... er•.. l? Ip. " .?? I GL ' i C l IN" _.NIO rS3_$:YSIiI'iBISrT.?'.Ln`+u9P7.f"-,i'wE» - ::rt ?zu.L - Iw.xF "r'• 'Lf_B Li[1(' LCYLIU BE - ? I{?i iF,? t,? l Th/ l'c f / / CLJA1 SC/?J G( /J yY'lY i O D ?6 'i ;; Ir ST MU RYu"eS°&SriL@A. iA +•-•i . .s'+.KSa a..er"iRoca.,J• s..s'...:..a•I" E xxol uRT ,: I r..o .1.: - m?. yC....1; ic, Aa s Nw ME * k5 ADDRESS 74' AO..... M F [~+fTN MF C - - - ?OP. ?? ?v?°[,'.,.In,r?on .. eeoTO 0®,.,f°.' _ 00 E S L/. T [+T ti.L, ?•,. GIRST E.?e..:i.,-. _ _, LE {ocm?h?,; Ire iTN 7u?? - a e x, ORIVERS_ T,NAME. ? •,,;J?-.E, IH _N E,,..: ,;, ??t .AIDO ••, ? ,1 ' F !¢T ADO E " • - gOUTfi NO.?ANO. BOX NO. ' •' / [• STREET• fl 3 e. ''" ` STA : „:• ?.y ?y,? ., yu .??ZP COOE_. ORIVEP: CCUPATION" c % CITY./ ....?'., ST TE?_?I::?«._?21P CODE ORIYERSOC.CUPIt710N _.. 4 ? 3 j 1-C Flf ? r. oc k W /ti R EAS LICfiNSENUMBER y;t STATE EX. .OATS OF qTH AOE ORIVEAS LICENSE NUM ER STATE •E% DAlE'OF_BIPTN AOE I f'G M KE +I+v? ^[r:.oooc[f MOOEL:'I r? BOOY STYLE?'I -b dG. n: MAKE,w•ICh[upoooal MODE 11, DOOM ?STT'LE: IZ'ulf .l C N _SE:PLA O T »'? AILERPE?TC?O.L 1?::,. STATG:.'.r?v. NSE. LATE N4. ,y?ST• •EVm T(L/uLER PLAT?_?I _. ?c :5 A EJ- - TLFii,OENTIf1eATK)1tflOf.?„•;,(/L(6 oo[y??(j w10^00 ET ILe Q 1 _._ - VEH CLE1 ENT F' TON NU':`!?O(B 'Q w[w[rlf OpOMETE?iI wt f g ?cA.Yr?v »^?Suwnsl ?i 'q [HS•..EIC 5?611A. ?f I' `CT,S ? ?a•J.?A_EW T[ O WNER ,.I Ri ?L2R1!mA!+,!.tl!?1 +:..?9!!!.cPYHS?.i5,p0.-'.. : s •?tl? ? ,use /? s-aP?P ? :RS?AOOR[Si. ?+f?. m?Np?P?[??ariWYti WTE'OR. BIRTR,+, > Dok 37 ?ikock w?1 ?' ,I ? 'PWNER?"AOORE33. Lsl+i?-LYT?ac[°cj2?.:+JI•T. ?••?dwY. OLTEO?B JH" • . "y S?OPa.T.?. JL•'yOANftCEp,;L.`+?::?V?a=; ?aiJ.iSGI•-' E/!J •. n ?!R_OISf ?N FtuD "rt U PBAT??KpVC]iICF.Ec= M94EEjrLQ.ur`.???lJ'•` n ?A?• 9evree% [,+ ??,?w .: i3! P, T 6 g p ? S ??' O OF CO 3 F L TI CO f ?l G / f -- /p r L__ C M T... 5+." LES y.(?OL _ T F1-r_hT5,nj i ?@u? (I// ACC(r? EI r. ox f na,r o T1.1 J r p -;.yw, ?•,E EO STPE?RO(+00•R NIOIIWAY+yyo ? w?TEPS _. ._C WT?,4TREEL,OR, fiO,._„•. ', I ? ? a Eo MILEPOST.. .. Hti ij)6- Sc .tl .14 kF_ ce r ?` d I P 2 d Z n IN CE EC ON.LOGAT OF,EOL S N SET. E STREET A REST ' gAMP .-AM DATA xioc[. r ?E I [, L,u.o cxosNxc, nlLfrv.r ox ?eaxrlr.?wR Lu x. LR .e xw u ` 1 EP INTEIJ C , • ,.. ®i ? = w nu Iw, rcl e. «T [f f, SPEC. COOL USE ? ECi STRUCK4- vn n .t•;.;.:..Iw cs n .,..L.-. ?.? , au ER O BJECT.S NwME -... -•. .. _.. ..AND. AOOR LO ., ?? y nw ru[[ne[R KILL[O ineu,f Ineu, Inlu, [• I,N VLMICLE KILLED RI[,nuxa woii,?L _ NO..._. N [I In :?exr. [Iwf, 1[[v[n[I ( lu u,rl lxe Dryeq Nn TE In ? 3`? 6?.i er7?f. ,Mn Nol___ - ,.E.rR,.,nITEII ? Sn I„osn 0 I I S 7n: 7' J Q_ ATeo DY sT Eero Ar AMeo o ? Le ?;; ?:o c o R - ? nn n" n....... M'..I ??,,??([ ,+ROAO u I c[ wurnr uorlT CO aT T •.. ?, 'FS.KT }SQ• ? } t .?'1 ? P O( T '... U3?4 fnfr.[ ? ...OAILIONT L I4 jR /R:, O4 T OLLB ?p!'Of t T "vhf R [ WAY ?'? M1eNI '(R/V 00 NO?Ei RA1? • ?Y f ?. ?? . 's5A' `f ~,. ? 1 ? I r'.N ren r vlNl trx•• 1 / I, v' ? P A, I [3 T AM[AD I 7 ? 1 ? DRY ] ? RAInIMO ] ? DAWN ? ] C] 6TOP 610N ? ] TWO WAY ] OV[RTA[INO AND /AftINO 1 f I ? ] ?? WlT ]? 4NOwINO ] DD4R ? ] ? YIELD SIGN ? ] ROAOR 41QLt ? ] ? MARI116 RIONT TURN ti ? 1 C, 4NOW 1 ? 104 A IDIGNTl ON (T ? A ? ILARNINO Rro ? l El ILOOP?RAMIt ? A ? I f 'yIv' dINIA ATRICT MAKING L[1T TURN' L r Jl I ? A ?? ICt 3? ISPICIIYI 3 ? LIGNi(OGI 1:1 3 ? PLASHNO AN.. I? ! n ALLY ? 3 ? MAMNO -TURN 1? ' 1 1 M ? 3 ?l°'] [IT 6 ? 9iR]e} LtOni6 ?? A CJ RK SIGN]L ? ( 0 u(O WUNN ? t ? 4LOWIND ' I ? Z f w(A;ON IO NOi 6([VIG OANe[R F ? ]nlElrY ? T ? OF IICFR /Pt AONnN 1..1 N(R T ? STOPR[O GOR TRAFIG l I '4 t Q] uvnl SO n a10? HT,A"rGKL NeROAOW?I? 1) `1 fArrR1 MOTOR VEHICLCOL1 IUN1 HtUH Nlq. IV '" ?" : •, I GATE OF COLLISION ?•?????D?AY OF COLLI50Y I TIAIE OF LISION 4_??l-?iO 7-Z?_L ,•!„ . .15 ve N /S ?AM COU TY Ny Ci NO ?v .xA.< COUNTY CITY, TOIVN ILLS f.'la CIEV, TOWN JJ ADM LS PflEFX x[uiE ONSTNECT C??[ CECTIO N n:f - - - xsa I,L-- ° GIVE NAME OF SI'HcE OADOP HIGHWAY •• INTERSECTI1GWN11:57RECTORHOAD 3 z-7io PREFIX ED M " k y a I x.?..rx ??' /S.(i31 zdf- F>/ LISJVa f0-oJ r..Y ILEYOS T Q. ?^ % NON INTERSECTION•LOCATIOPOF Cl 7 RAMP DIAGRAM DAT. C .Xq x BET` EfN , STREET ID STREET y 1t,v, 1' n xul.• I 1. 'IL Hiee1 7211 EO - t E` D OF 7 i Gve ? ? " e x,ceEUNE<T O 4 O SPEC. O USE fCf ?'. Y _ e ry '- • • ]'° a r, wcv aa_ vew cEe x°o[]ii, •x c vUS,o, E. ES a ?.,rr•l4 ?'' - ' _ Ud.ECT STRULK . ': Iwve or oxHCr sixucxl OVINEfl OF OBJELTS C ? - . , NAME AND AOpRE55 ATKN LO IN ROADWAY He. x °°ie 0 ? 1 l" ET 5 W ? :. DRIVERS U' I Y I.JQ'Ss•e FIRST NAME .... ? .""ILI 1 D \Y ?? .°.u•cwu :` DRIVERSLASTNAME FIRST. ME - .. •. MIDDLE Lw`,\ ??.a I- R•v+uw I , 2 A + 9 m STREET ADDRESS - - ROUTE NO. AND tlO%NO. .o x l -.C )nom .,.., .?•,... • STREET ADDRESS ??^^c ROUTE NO. AND ?{S _ ?-hacll ? ; CI1TY_, STAT.E`` ?'pZ•I'P CODE I O?RIVI HSO U TION. • CI?TY( / STATE -CODE ,... DRIVERS OCCUPATION 4 i - F"YLSN'Ft CV .V / o L) Cv e. Yl 1->. Ac l-0 ..P DRIVERS LICENSE NUMBED STATE SEX DATEOFBIRTH AGE t L-?c I a9/ =° - 117 DRIVERS LICENSE NUMBED STATE SEX PATE OF BIRTR AGE' DAY YEAR MO _ E cv MAKE eY -N MO , v..o+ DO YSTYLE I] I. EHICLE Yn. MAKE v....11 MODEL DARN BOGY STYLE ; F tNCB^S)PL 41E v11(^ [ ST, Tom' _ TPgILENP ATE NO. STATE...... LICENSE PL ATE NO. STATE TRAILERVLATE N O. '.. STATE -: sex .u ---- _------- ^•••^'... vcnla,LE I OENTI11-11OI NO. nswV fLLAxewENr ODOMETEN iN,[[.uc[I "¢.' REGISTENEDO NEH Nloo\[N•NeI DRIVERS LICENSENO. P EG.STE.EDOWNER, Ius'rn`N Dose wNN, DRIPERS LICENSE NO. ^ OWNERS ADDRESS IST EE CTY AN Ei DATE OF BIRTH (/O(/YNEfl4 ADDRESS ^CT.AN T EI /? DATE OFBIRTH OAY YEAR -, Y-i$y T ?L. `V•4 O UAr E 9 ` PARTS OF VEHICLE DAMAGED v - srivwr[p<ar '' A _..... INA epc L ? ? a- LIARILI YINSU RANGE INFORMATION•V EHICLE NO i WAS rHE EAUiOMGallL BILITY INSURANCE COVERAGE IN EFFECT FOR TH SACCIDENTON YOUR CAR YES ?NO ' NAME ANO ADDRESS OFLIABILITY INSURANCE POLICYHOLDER .,,, .. '',1 NAME - ADDRESS CITY , NAME OF LIABILITY INSURANCE COMPANY pr W' NAME AND AODRES50F LIABILITY IHSURAHCEAGENT Cry STATE iLI BILITY POLICY NUMBER L/ • oYY?e r S S r~\ ?h kvl ?a+pr s4 ?oc whx w sa 6 JOY 116 9l rST INJURY r_. -.,_, w- • AGE `ND INJURY:IrEXPARA REPOgTFOR A001 Ox•LINwRIESI AGE , e 1 w C E54 SE% SEX yy?? 0 13 0 J-1 STATUS OF INJURED %MARK FIpSTON?Yn AT A%LIES, ro.ss •..,,.STATUS OF INJUPED ? .,. MApK FINST ONE THAT APPLIES IN VEHICLE fAP\,wo N wx ?`.j • N KILLED Hivtn:l Iv ? IN VEN CLE KILLED • ry co xr ? N or'U' I '. -H J:? ? 5? 6? o?.Nercl ? w". ? ? t E:1 so 6 70 SHOW NORTH OV AgROWINC ROLE _ DESCRIBE,.ELOWWHATHAP ENED:.IHEFEHTOVEHICLESBYHUMNERI ..,; _;l iN ,p . N,p•r... x.xN Ox _w?e,.. _Gw.r-? 2---_ L e? ?_m? ?o ? 1 ,. ? ?% °a:?i,.<xY KL,.xpxi« ? _'C?.ti.._c?E,•.a?---o-??.??n?_tv_? ti 1 . =D::.Q?- [LRLEL2•? =•_ -LcoK_5? °._ZSr_ Cs .^Vti? -- -_?- I 7_7 _. / r ?}6 r { y` VEHICLES POSITIONS BEFORE COLLISION uncAnDUr '' .Cp:?,J+ VFHICLE 1AC10 cu N• .: '1i ..'. ON STREET OR HIGHWAY NAME On NO. v[ 1 Ili ?::1H?s ?ro?K? ?l?' V '? IYOUIII ? ? ? ? ? ? ? ? p ? i ? I r (I t , 17 _ any 1 It 1 P[O[STR[AN ?'..???.? Cl SSIHIS ALONO ..w...y..F_::.?L L:.S#\ i '? IOT [nl U ? LJ ? ri ] !. •.. F ] ror'?.,r<x A ? ? ODM 1]. \, ^:..TO{'? [!f r LA 5 ( 4\ wy ^{e I[OLSTIIIAYYIAS USING, S COD f ?d - C tf Il:'4 I?' { P tTA03U F C[ WFATHFK LIGHT CONDITIONS THE FIC CONTROL iY1E OP POAO ONIVERIVENICLR?ACTIONS_ •1y 4 !I ?I T p1J ] ie I ?t:?i•.mifa I LjE{DAYLIGrIF v •1`• w.e, v N.i Icx40M v wts[ K r<N Ox[nn,[n I' y F >?:Fi._y 31 ^` I\!? CRY ? R-1, NG ]?DAWN ? I ?SIGNALS O I ?ONE WAY I ? GOI,NG STRAIGHT AHEAD 1 1 r 1 C ,?$}"•lr It , ICS t ? 410P SIGH ?2 TWO WAY v FJIVf f.,, tJr,iceluv , ? WET ) ?1•KIWING ] ?DD ? SK O 11f V1.1131p LC r' C] C? _ ?DNER TAKINO AND IASSINO ti ) ,y"1? YY DARK h? C ] C SNOW A ?f0G A ? LGHTS ni Et ? 3 ?YIELD SIGN ? T ?IIQAU J ?MAKINORIOHTTURN ? 1R' ? I,t'V5i6Ll N ,'?-? ? A ?FLASHINGRED ? A ?IN rF Cl IC[ 1 IN S?' D Silll LT ILO011NAMPI IIF S r 1 LJ A ? ? irT rY Lr4HTS 0YP ? JMANINO LEFT TURN ( -v 1 l AI K NO (3 S ?FLASIIIHf, AMNEFI E] N ? ALL[Y [] f 1 7? Y J ,rl ! ? , ? p 5 1 (''MA%INf.IHTURN } CCC [rIR?I T < ?STHLFi LIGHTS IG p I--I I+r'yp, p nn SNAL ?SL ?F,1r1'I{ I W t?a, rtR ? ? ? la iiiru?m LAYe, ?F•OWRIO •/IE 1 'I SOM POH NOT 3lf IhO 0AN01R I L vI?LHY s j 1 :' n 1 v ••r r :. r•; ? T ?O A VAN 1 t r W ? T ?ST0YPF0 FOR TRA//IC L ? ? ;JI 1 DPPATSIGNAL 1 1 y )? , ? ?: L? ??SFY•\IrATFO ?!1 [ O ?U11 so. SIGN 1 {4 In" }ih 1 JI .. .. .......... U ] ? nI V10ln ? 9 ? 9TDPFEO IN ROADWAY ,? „'^"n' ?1 L1 { `t -a ?j t _ KT_ _.-- -- r?NL!•G rl YIC COWAN nl? NnVnfO ?10?STANTI IG IN TR FF f I r F ] 5 T 1 }X,19 I-I-(?1 STAHTIVr1 El01 i ?1 1 Y 1 `^ IIE.•fl y ri ? I?? E 1, wL . n,:1 » ,t J ?? J '1• .lu t ,?"^.'• '^.A..-T -?... ! ! ? I't• ? p ry ? ?: ,r _I'+'' i1 er rJE ^ ^m tr2 R ?I1 t • t:J terra •t raHw?ii ? a ' T V I t ?1;? 1 c L?F ip ? ?l?1+ I J ''t3 IVA, J »a yNM,?JpI MA,1 , ?I, ?NJr.. 4 T( M yy ,, l y t' II' , gg?P6"w°T ? 74 MOTOR'VEHICLE COLLISIOPIiRE PORT INV. GATE OF COLLISION DAY OF COLLISION TIME OF COLLISION CCUNT'i JO CIT'/it.. D T µxW ?.LU ' COUNTY . . _.. CITY,'TCYJN p MILES ?Q CITY, TOYIN AOAICL] PREPI% n(I TnFEI c [?T JII -. a ?•? r' OF c _ 574 a . EOFt STREET, ROAD OR HIGHWAY [RT;E.1 I II T} CH Tt?T} 1 L --' PREFIX E O M1ILEPUST 1 1 ^ NON INTERSECTIONLOCATION OF COLL?$IDN RAMP DIAGRAM DATA BETWEEN (r STREET AND STREETC '•uvn V I _J E ?? x. txo., ?xo.,, x? „tl.nr ?. ?tx?,..,I.? L,I.w.x<. x. „„ ?.•., ??W OF - No is: t t .asxnss INT?EH M y c V + -- „Ex?rvx?rt l o SPEC.C 0 SE - I rt„Ltlr.OtE rv ox 0 I.,oN _ CBJECiSTRUCK .. .,:. uvrq Of OwYn Yi RI ... :..,', OVYNER OF OBJECTS NAME AND ADOH LOCATI N r i ti io p? oET? / f ? IN HOA?WAY n ? u \% O ? l N .o g T ' ' FEET S L T 1 •? ? • 'rv ORIV EqS LA ME MIDDLE ?SYT NAME {y., FIRSTNA SC_ `?C_i ??E? • ^'" ?clua are` ORIV ERS L.ASi NANtE FIRST NAME MIDDLE 5 STflEETAODRE55, ROUTE NO. AND BOX NO. 3YE' . x•xx STNEETAODRESS ROUTE NO. AND BOX NO. a , ^ • CITY, ? STrA?TE -;. ZIP C/O?DE pR(I?V1ER5000UPATI?O{.N • ' CITY STATE ZIP CODE DRIVFflS OCCUPATION ot? RIVERS LICENSE NUMBER STATE SEX F OATEOFOIRTH MO YEA. AGE - DRIVERS LICENSE NUMBER - STATE SEX DATE OFBIRTH DAY YEAn NO O AGE I a M Y EHICLE YR. C? mxEV..mocD MAKE G M Y..P.xR MOOEL,. ? I.w gox.I BODYSTYLE 5+:?? s r[{ ENICLEYR. v MAKE Kx[v. oou uI .!,, or.PAx n . MODEL RRJ BOOY STY LE .O LICENSEPLATENO. ..STATE.,: TRAILER PLATE NO. STATE VEWCLEIDENTIFICATIONNO:-.;;. I?NE NO [wLAI DOONETEn y?U.OEI LICENSEPLATE NO. STATE TRAILERILATENO,' 'STATE VEHICLE IDENTIFICATION NO. IlsRx yoOEUAx[wexl 000METER 11cU1EI REGISTEREDOWNER s-ooL pgIVERSLICENSENO. 2 VC ' REGISTEREDOWNER lu nn+•IOOLLx DRIVERS LICENSE O;EHS AO So ?Tyµ u?El.'????.:MOgTE O0FA 01RTM ?Y!I} YEAR OWNERS ADORES] ,_., gEET.CIIY AN EI - GATE OF BIRTH_ .. _ _•- , .'MO YEAR U PARTS OF VENKLE DAMAGED : -`•v i;wJ.c a? VEHICL DAMAG D ". . !! ;: ; J: f's,w•.*foc0sr S . . „.. ,s ,; v..•.w 1L•._.. LIABILITY INSURANCE INFORMATION-VEHICLE N0.7- COVERAGEI EPFeCT FORTRISACC EioNYoURCAR .YES ?NO-• NAMEAND ADn?[ORES]OF LIABIUTYINSURANCE POLICY H'?Ol_?4??E,,ADD '_.t _... '., l MAMEOFLIABIIITY IN..URANCECOMPANYi 'L -•.: ? AMF ldR [.? S SAD` ?l' l Sa 3?/""v s q?P?3a ( p ?•k ?? s a t . E ? ` [ eye < e NAME ANO AOOgE3]OF IJABIL1Tl?iHSURANCE AGENT iA. ? dtL?il._n TH?J?x :. u'. LIABI{.IiY POL10Y NUNBEA? yat????,?-? ., 1ST INJVRY Waf+.[...v `v,,;,.C.11'r..n ,„'.:..?P-..,.,..y..,.r.t ,? A?G1\E. 3ND INJUAY a ER! O O Ow L 1 4 AGE t° '^LIr? 0 _ rv? [ tx.w m F Q0.;L •r??jJ AL?_ QL? ihl Q?r STAT1?01INRJR[D: ???MAAK FIRn ONE7HAT AHLIES .. ., ,.; STATEJSOFINJUREO •:. y'•?WRKFIAST ONfi THAT'AIPLIFS.??,•,??nn? ? t IN,}'LNICLE L Ne } - IN VEHICLE '? [E-' c KILLED I¢'--w KILLED Ix 1 Nn I <? ?' JTH . ? S ? Ip 48 5 ? 6 ? ? I WRITE IN 6 - 70 OTHER V.fl IN ? ,7 SHOW NORTH nY ARROW IN CIRCLE r.CE.E_LOWEyNAI',NAFIENEO: IREAER TQ,YEHICL&46Y;NUMB[RI S;fl;yt• , rrR'nsl:r?s '?^•'?.A.::a?w`s^ © ?1G?t,-?_?. sfi L! ) 9 ? .2?? wg h ? -? / ,A /? ,? n srM ,° A".A.•r a ?!L ?4-??!1??? ?Il s?OC L ? .] H•?. -[?og E4 .-E".± t',F-?21(?_•Ee? c1` _st i+tClt£S-? ?s r '? S / ?I . Q_ f r r^.?? C?CI ?._ ?.LSiL.L=n fJ t -1 - Qt- m _ejh c nLLLQ3-p .I [?5_ r ??? ?r 4L= VEHICLES POSITIONS BEFORE COLLISION NVFSTIOAt[D FY Nn ar t.w, ? Ir r.n..n uu:I"ri: HIA010 x.ER M VEH CLE N F w ON STREETOR HiGNWAV NAME OR NO F .1 1H ? ,! -13 " R E- •T ? IYOURI ':: ? ? [lfl ';.'.: v wE w.Rlw C'J ? " I ) 1 IOTIIFRI ? El Ej F-1 ? ? ? " C -? If OfRRNNQ??,? ALONO .r.N??. .t.wB,A.„sai S ''.'CII(AS]INO A :,:YN• l ,aA..'S. C FROMl?[.r'Ie;:AA15i,At7.To TOIi9K'VW?M}? I1? ': . -_EOF]TAIAN WAS U]IMO 1 ?s T ?w• O ?,„ d ] ?c. a ?n, L •` r RO!D SU IACH WFATNER! LIONT CONTII1I0115' TAAF FICCONTROL„ TY/E OF ROAD OR IVERNENICLE ACTION]7_. yT 0xtl ^ 2?i cui DAYLIGHT x • c.A 1 I V?]IGNAL] ? I M?ONfW Y x I RI 1f?GOIN6 ]TAA ONT AHEAD X 1?? ORY }RAINING 7 6DAWN ? V ]?STOI SIGN ?t?TWOWAY ?]?OVEATAKINGANDIA"ING 0!?WCT ]?SIAWING ]?DUSK ?' I OAR STREET U ] ?YIEID ]ION U ] ?ROADR]IRl! ? ] ? MAKINO RIGNTTURN_ C] ] [3 SNOW • ?IpG . ? I -' IG iE O ? T ?T . H N / TTINTENCHANOH O IISTRf ET ? A ?PLAEHINO PfO LJ A 1-JIL0011RAMI1 ? A ?MAKINO LFFTTVAN ? A ? ICE S ? ?I ?? ? - V IC LIGx TS a" ? y ?iIASHINO A4H[R 1 S ?ALLEY ? ] ?MAKINOU-TVRN - /T 1 . f if £T LIGHT] C] n ?RR SIGNAL C) H ?T•f?wy LANE[ C3 R ?SLOWING' . REA^ANFOR NOT Ef kIhG DANGER )?? .T• ,.ric Y ? T ?0 Flff R!f LAr,4A4 ? T ?6TOP1C0 FO" TIIAIF L '1 "1'I fdi! ??1Y •1? j 1' J n ? 1 L SEPARATED C] R cla STOPPM AT n STO/S10N ONAL f n ?• W CN I G yT - 02 DOIVIDEO 0 (? ., o STOIPEDINROAOWI t r' z T l.)S[ "Ty L ? y.1' C? d` X % n to fIr f) TROT ? 1 nVN0tV ACA tTAAIN IN G t_ '.. i 1 .... , ?10 ?TR`P Ff LA f 'm?r,?E"•? l?•,r.?.:.Yrl w•-:-.a4ti![BFr»avimt`: -%[inmi]EmY. •Jx.-.^-It-+Y Wav--?...,.. I:.,..-:,.-.-..,...r:.:«?.c•....J,.::,-:..?.__ 4+ T . r ?,{ .IS - ,. , , -. r, y , yc: ?: ?rN "FL".'.t:r t" ? i:i81?''', t ;.I n/,. 'i"K':..? ,r, ni-•-'?6I L ? }?, ! ,S {1 i 1 0 '? h ?M 8 TE VEHICLE COLLISION RE PORT p a DAY 01-1-1- ,yI T1 E \ _O. 'GII ? ?J J1C /TO?N? NAMEO q T ROA?`?GNWAY rvTEH E NG',WITH TFEET OR OAO, LOTION-LOCAT L OL SI L P E a wou,a aaT <ooc PREFIX ED MIL/? OETWEEN BEET A SrD - RA AGRAM DATA NQ <xosHxa 49uraaros) ox rurxr rrrxc ,J.xuu.xK. x, uxruu[. EA I TER CLS x n< . IDS I ? O cu<vHloxrxvo®u-? x r I ry ? o xax Iwxr„I S .CODE USE / L3 x rH I / x Ll x L J ", ? F S NAM o. U I 1 1 t?s `' V I?... _.. I.,.,.W..e.-...: oFE o j? BJECT Z otAD -{' wqr,'°:_?: `5., N Q < xrn a.,. ? ? •) 4 \/ ? - CTt e `. - ot pr3T3!R.T7?'>"&'AC'i7"1`iL71'11? V E SLA_S .....k ?, FIRST N ': w:.?,.'..) DOLE. flvFH3 S .,IE.I,;.« - TREY A E .•_.-, /1 ( T ??.w:nuav.-STATByu,x?n?21 E Oq VEA C ATIO ,, T_?',;'?,_ STA v.n._.... _,_:2. .DE 4 IVEgS.000UP TIO<y R ICENSE NUMBHR ATE 9F% ESIR TN:. AGE O LCE E UMDE ST T E .O E. IgTN 051Fi c * P-F+f< rnr- \ 7 t t7 -7 c) r V , L SE.PLATE 'STATE. TAILER, tF?NO TATE.T` L N PLATE NO. Si ET LER.PLATE ,y("6TA 8.?:. °J V M C E:IOERT IG,jION NO •-_.. o a n[w<wl OOOMETEgIKR[wo[ VEHICLE 'IDEN ON - ,fC .,. .N ,. _ K<vR E PoHIL<wG[ ! ;(3?Gt tcq A ISTE EDOWNBR?fviT-FA uwc.lww 1-: '.OR WE C yw._- -+_ EGIST6REO CENSE O N fl -AOOgtS3..a .-.1 - IE'OFB . Al ; . ,INSURANCE INFORMATION-VEHICLE NO. I. ST E ,CLF KILLED ';? P<° ?rwMx NO _ .- aHluw o 1 ?.roAl rH W D O C RCL6 . \ j .\ I!I CD? VEHICLC5 POSITIONS BEFORE COLLISION >wj ADDRESS .1 B '`A TATU50PINJU [D .'.,Ly (MARNLIIRSI ? I 6 ?`o ILLED NO l% , f ? n ? ANN !O P \ < R v ?iirn•"[ J „A A YES ? NO 4, J 1 t. x 6 M +aY3v?t?..'u-JX..n Sn'1. 'EY C 71 --- ---------- ? LJ ? 0 0 F P[O aT NO A. wx, }? w x <oaK A l xn • S I 1 .r. A A. O 1. ' ! R T, LIGNT CONOITWN! T A%FIC CONTROL TT l0 O D q/[[NrCEACTION , ov lxrf .. ''t<x[ lirrl[. O OT IH 0 11 El 1:1 1•L'OC TR A ?'? ? ? LONE 'AK' :'Y 1 } 'jw? 0.}:<. r, ' E] RAYLIGNT 1 1 EIGNALR ?rhj?1l Ll] H •Y ArI I' °0" OOING BTRAIpHT AN6An 1 { ?'J ?r y - /• r11 ? pMY ]? RAI NINO } n DAWN } C.) STOP SIGN ,\J ] ? TWO AY [j 3 L? OVERTAKING AND PAEI6 yir^SM F I.J ] L? \VHT <L, fHOWINO ) U .USlt ? 1 ? TII. 1 O ? ] MAKING RIGHT TURN' ) 2 ? 1 ? ENCW .? IOG . ?r "(RNr t.T R[CT El } El fLASNING 1![U n J ? NAHOF E] FLASHING GM AunL T OLr lI-?_? ?? ICE S? 6?'I41YYI S 1._)^ OAHKS? r ? f 1--1 O AM F] A ? MAKING LIFT TURN I 'y F tiY 1 O r lI 1 EP ? " n ALL[< ? S n MAKING U•TURN I ! yAf.? {. J r " {t:.Y ?tH ,N rs L ?j HR .INAL f' 1 " 1rf--) \ tl{)? I SLOWING ) F v 1 FA r. w r b[RINO D.NC<w fPICI r "? l j 'f,t1Gx4 yjr .. 4?Vi' ,'r 1..r..:. w.,l Iv ) 1 D r / L AN ?PPrn TRARfIC D NAL AT ?N' JIB}' P I 'A. Fn Dn ?. ' K { N I _? Y 1..? STO opD IN ROADWAY l} (l n b Y E- ? 1 Y -11 1? i t , r:. .. . .. 1. . ... ., ..... -.. - • r:`.: t+ t w6s _ Vigil • _.;L U'?" ,W MOTOR of 1 VEHICLE COLLISION REPORT - - NO. - O IE Oi?OLLI.40N pAY OF CDWSION IIMEOFCO4 SEOH r L'O COUNTYFEp' CI{y N0 4 - r 1 1 p,? NyI 551 nW:/ i PM (/O ? xew hAC[4•Cp iYw CTY TOM( nF AEILEIS/ ®O . TOWN ApMCtS PREFIX DxM MHE aoln wT CF` I wpeMF / E 16rRFL BODE SECe 0 ". SDCCCURBf t, } 1 i'1 raiw FSR ?© OF TV`TI CITY c,? ?., 2l J _ ,4 RO XwN? GIVE NAME OFSTREET.AOAOQq IpHWA INTERSECTING YATN. STREET OR ROAD pREFIy EO fly ONINTERSECI ION LOCATION OF .0 COLLISION t br: PAAr GH DAi `i4e' ?7 BETWEEN STPEEi JD W , NDi 0 © EATNR Da NG xaD t W,ERSFCiXw: FEFi ©® OF ASAADwCRpyWO.MLEFUSrORA%NT1ErwDLwOrAU1A [WTE OR CL„ [ ,WF V F 1 COUnONNVOLVFD &= ELE K[&crc NFR1w 4' ioV5LM0,WE ? n1CLF,quNLE ?O! wTFI SPEC D E ?? ?rh do .tCa.W CF FNCLf4 ?vE FVEDFSrR ? {quSpN ?N,AUN •.. 1 C -?C INPMIEK!OBNCT VC __.• ! :-.. OBJECT Sin UCK 1 OWNEROF' EJECTS NAME AND ADDRESS LOCATION C/7Cl.?Ci/V'j? I / 1? JG{''I t1 `iY {.?5 INROAD AYL w e Q© O TOn [aiFCi'' ) I FEET OOE DRIVEgS$LAEiT NMEE • • rron[iNw -: .' • • f 't4yY:,]• // .-- FIRST NAME. ':.'.... _ MIDDLE ? wvEX acvE ORV bVST NAME "1- I 1 I? e` D NAME MIDDLE sqN( \..-. I CP JS ?/rl . STA15 Au- ROU>TENC,ANDDOXNO,.- •y TSwERE STREt? DIXiEbS I t.:.- '."QUTEA'O AND60X NO I CRY ?? §TATE L.y. L CODE. Df11VERS OCCUP 1qN [vA E /3?''-'?• 77 1¢ CIXUS CITY. STAT / LP ODE DQIVERSOCCUPATIpN I J?-?L 74L C /?/? 41ZC'1 i7C1? ^ ..: ?Df '. 1 OR VERS LKENSENUMBER, -F [' STATE S[X GATE OF&RTH AGE, EG Y/?fE?ti/ L L/ / DAWERb ENS MBEfl 9TATE SEX PATE OF IR[N ?1G / G1-L E -f -j i (/ I„ F 1 l0 5"G 2 3 G -s„J - j M E y4 w}L, r AR J? , VEH%LE? MAK??Vy.4 EI MODELVA DgRI),;,_ BODE' STILE12DR1 VEN Eyq,. MAKEICHEV :C / 'may 1 TC LI ?/ ?JIC f\ C) I/ .DODGE(. MODELINOVA DMTI OOO?YJySTY IR?OTR.I AS ` LK;ENSE PLATE NO. STATE TRNL£q PLATE NO.STATE \ /??/ ?.517i ` - - LICENSE PLATE NO.. SATE {RMLERPLATE NO.. _. _, STATE Y VEHKLE IOENT?•FTTICAATXkINO.; I1186QjtODELSB NEWER( .:. ODOMETER (MILEAGE) VEHICLE IDENTIFICATgN NO. 11968 MODELbd NEWER) DO ER fM,LEAGE GL7L,? ?) flEGISTEREOOWNEfl ?^ C? .3rrE-? S l ?(I,ASiFIRSTMIDDLENAAEEj _ ,T pRNEPS LICENSE NO. < flEGIRE00YMER IUSTFIRST MIDDLEN E L .C S1 j ° •I ? I v I /f ! / '- 1 ? ? A/ h DRIVEg5l1CEN5EN0. OWNERS ADpgES3 ?/ /fN /' L . ' '".ISTPEET,CRY AND STATE .,.. _... r" I :: •?'-- ••- 1 .,_ DATE OF B1fliH OWNEEIS ADDRESS .....ISTREET,CITY•.ANDSTATEI. wr ......DATE OF &RTH '+} n wr r[ul PMTSOF VEHICLE DAMAGED ESn EDWSi PARTSOFVEHICLEDAMAGED,, ,._ STD,X. Am vFNKPE n[uTEDCOSI -...._,. S o tPn vNCa LIARILIT I INSURANCE INFORMATION-VEHICLE NO. T- WASTHEREAUFOMOBILE UABIUTYINSURANCE NAMEAND ADDRESSOFLIAEBLITYWSURANCE POLICY NOIDEq, :,. COVERAGEWE FECTFORTHISACCIDENTGN YOUR.AR E1',.ES ?NO {5 ?y ` vSME SOOn(59 'Orr -... iSTF NAMEOF UABIU{YINSUHANCECO P Y 'SIP A - ' NAME AND ADOgE550FLIABILfTY WSURANCEAGENT,. :GnY_ siSrE iH 1 ,? S'?f?: '" 2P. ,..? LIABILITY POLICY NUMOER i ,. 1STWJURY AGE TNDIWUflY: - NAME lu$F-AN EREP T-ADO,XWSI RUUw[51 4. -,' w?VR[ NMEE .. AGE m ,. ADDRESS - - O .: -,. SEX b - ---.- ADDRESS M - ?•. y F oR w ® ®1 _ ST iUb OF PUUgEO nffj MARKFtlibl ONETHAT APPLIES DarOm 4 O?w'^'E WVEHKYE Dn5R1A•p ror1p55mAq ." D.nn ST Tus OF INJURED MARK F RST ONEiTAPPLIE6 ,T I NILLEO iINH EI N+roRN ? N ICLF SDL POS•i } it? DSG ? w ,CI ?ASSE KILLED ISEHREI 1uNim [w'w" 1 '1 h:: b]OPUwT ?GIR:R WRITDIN ? S? BO °P7O` ? - [n r C .r r` [T; TE 1J ... 0 NORTH BY MROW WCRCLE \ f ? 50 80 DESCnIBERELOWWMATHADPENED:(REFERTOVE ICLESBYNUM..I SPPF ' _ 1. 1 r?CU ?" 5'.-',.SI'?G•?3 :?I 1 ?___I eL? QLJ ( I VEHICLES POSITIONS BEFORE COLLISION I ND n,.wFr Y U --- - •}` HKI.loAA N 9 f W orv STRLCT OR -WA NAME CA NO ExnECN atA110"D upu ? HALO vrNGw OCCVMp INVCSTIOATLD BY ?,??.? ... naLY No ns n] w ?ima ?ro ? iice 1 ,gym. L: ?'..: 3 Ej IDIMNI ? ? ? ? I:?. Q ?. : ??E:.. ? ?1cCmiK[?001,I W pI,AAN t ? LY ? .. R v 0 ' ? ? ? .0,10 y _ CA065H0. .. lJ ?•.T Ir.D[a1 FE,., wA$uvNO E?NDEw., E?wALKw.L1- 3?sHOULDm • El! II U M:-DIRECT(ON OTG MrDIRECTtoN - L h . y go1LODWrACI, w(Al1EER LJfWT CONpr10Nl [ M• s? ixroxw4El AOAD e?OTHER ` v KMUDxrI .. ... STRAifK COHfRpI..._..KWC•WI TYPE Of ' dUVEn XVCNI?LE ACTgNS ?' i ?D, 3. rEKU ?v1nGE .'. ?? F A l 4 i? .. En I Ao r 1 ? or["cu 1 ?DAYLIGNI O 1 ? egNAt9 O ?ar 'M wx?nf wNC p r K wy aw?l rA 1 ?'?r ? tl ` , . 0x(701/ ) ? RIJMA T 0 DAMN 0 ] ? IIIOP WiN 0 t ONE WWAY AY ?r 1 ? GOINO STEUXY T 41EAD 1 ?+ ] 06NOVAAXI ] OOUSM 0 ] C] YIELD SXTN REVCn91BlE ? ) ? OVCATAKp10 AND PASSWO rtft?!1' Y I J J ? ] ? bNOW • ? FOG ? • ? IGHt pL1EET ? • LASNrq R[0 ] ? :10VI ? ] C3 MAR•AI RX,HT TURN i EO•? • ?K! a 0CENT" 6 DARK.BIRFIT ? f C] • ?IWvrRcN JAPI ? • C) MAY,NDI[R TURN r ??} 1ItL ` y,- ``LJ b 06RGVY ISPfCVY) ? ? e 0ILASHWO AMBER ? e O (j 6 0 MAXWCU TUIIN r l r` 1P 4' .c. IR REASON IOR WT6[lPJO DMwI[R e? IMRK NO r GIREET IXMR! ? e ?FMw,F ? IT 0T ALIm EY WAY N}. E O OTNIA L WH ? e ? ]LOWIND tG MIIWFYOYMd DO-,[M IIC1 ;fEGFy ? ) ? OFFKf A.FLADLIML IAWCb ? ) ? STCOID FOR TRAFI$C ,. t /^?? a O OT ER f[CwY ?OC) 1 111YO?? GEPNEAIED OP ON 11 A l`J 'Y?^Drd al?r °[ ..) Y '?,u: lFr, 1 I Lin tr1 1 k , 7, r k 1A ,'kS ? + ?t?_ r r i, li .L, I it f I % M u f it dr ' r f l [ K I 1 .ryti ¢ 7? 1? Il i b i '? ; .1 r 1 5Y `? E,!lv, I ,h 141 ? -??i9f?' .H •_S'? _ "`1ar?L.? . scs.'v`?a"?,msz _r:?Y+z?.t n,: -•? ...?tR'$'v ?0 ? - S'?' , . i?,•,. ?; STATE OF WASHINGTON PAGEOF NO. - ?•V Y l - - POL CE COMPUWTnuMdER Y ? UNIFORM POLICE TRAFFIC COLLISION REPORT D GATE A OF COLLISION OAY OF COLLLSION TIME COUMIY NO. CITY NO. FHWA _I j MO DAY YP SUN MWI zIUES WEO IMIH FRI SAi IUBE 2aC0 HOUfll )- URBAN , E 10 T D s e t)r1 {nf;;';n NRAL fd . , ;. ' Ab Je"1eTsOJ ?OTHER(SPECIFY) LU y n L GITYOR TOWN C] N S E W W nREFI% EO. - MILEPOST t ? C [3 -OF MILES ? Q ?,? LT_OF TTadlock V - f A NAME. NCO:OF?REET OR HIGHWAY INTERSECTING WITH. STREETON ROAD LL ° RAMP DIAGRAM DATA I T ON - A3 6 o tC310 Bari ;"e r Bar i.'7 Rd I NONINTERS-1- ACCIDENT I NTER NCN %RD INT ERSECiwG STREET OR PDAp ORB er ! D MILEAGE C LS. ER CP 'f?S Sf9EETRO ENCE ]Q y N BETWEEN S ND STREET COD E ? ) t/rJ l/? V SA.. CIAILE DISTANCEAND ECRON FROM REFERENCE ORC SSSTRE / ?MILES N S E W i Vnu+ET1U S PECIAICOOWO USE ?t 9 r . .: ^ ?FEET OF F 3 ` COLLISIONINVOLVEO: ?VEHICLEWEHiCLE ?VEHICLE-BICYCLE ?OTHERIWRITEI QHITARUN SEVEPJTY TIO.IULLID y ?"TOTAL NO Q VEHICLE-OBIECT ?VEHICLERRTRAIN ?STOIENVEHICIE NO.INJURED '. ' CFVEHICLES.? ? VEHICLE-PECESTRIAN ?NCNCOWSWN ?HAZARDOUS MATERIAL fl PROPERTY DAMAGE ONLY OWLCT STRUCK (NAME OF OBIECT STRUCK AND OWHERSNAME) LOCATIONOFOB ECTSTRNCK EST. DAMAGE ..:a! 1 no,t $tar_u Gene ir} to Pt LUd lo:r ' S ?ROADWAV S FEET ? ? l3 ? RD EDGE 5 DRIVERS NAME-LAST FIRST MIDDLE ORNER 5 NAME-LAST FIRST MIDDLE (IF BICYCLIST OR PEDESTRIAN CHECKI R ? • D R Thompson, Danny Li D ., STREET a0ORE59. ,. A STREET AGORESS v Ru 2 aoh 524 V E CITY - STATE .. LP CODE PHONE NO. E CITY STATE LP CODE PHONE NO Y- ?• R . -o:msena, :':a 9836 765-391£3 R 4 t N 0 DRIVERS LICENSE NO. STATE SE% DATE OF BIRTH. 1 0 pAX N CRIVERS LICENSE NO. STATE SEX DMOATE OF BIRTH DAY YR '?' . J... 547.01 d TIrA 1.1 ? . ,+J °., . . 'I DR "IRS OCCLIPATON FIgM NAME .. PHONE NO. 'f, DRIVERS OCCUPATION FIRM NAME _ PNONEN . Lopge? 3011ployen „? .. ,. DODES.> IDI'MUS9 D_._ NI SEATSELT 1 151 EJECTION D'x' CODES > Im ?"''« a 141 SEATBEIT 151 EJECNON :' -. - RFMM 6CE1E9 TO FROM 6CENEBV: TO `d .. -YEAR MAKEIDOOGEC EV.I, MOOELIUARTi10VA1 STYLEIIDR.CONV.1 VEH YEAR MAKEIOODGECNEV.I MOOELI.-T-NOVA) STYLE I2DR.CONV.4 x v DK GAR ETT 1 Skidd 'r v H VEH. COLOR ,,;, UC..FLATENO. STATE ., TFWLFA FIAIE NO. 9TATE : ., VEHCOIGR" tlC. PUTE NO. STATE' TPAILERPLATE NO. STATE - . H,. I YE31-1 tint ed Lo P, kid/er I: :.? . C .. VEHICLE 10 EI-Fl N NUMBER ._., - E E FIST. .: ....:._... ...:::... MIDDLE REGISTEREDOWNER-LAST. :.' ,.....'..,FIRST I N N: - ,:- O. O. . :;, ADpPE55 OF 2 ACOIIESSOF OWNER ..'..:. ..::.,N....f.. n. .... .-.... - / kI , NAMEANDAODPESSOFpL91PANCE .ORAGEHT. ... .'..'. ,. NAME ANDADD{iE590F INSURANCECO. ORAGENT, ` CHAl10E .:. .. .- _ .....-. .::. AOONNO. '...- ENFORCEMEM CHAPGE .. CITA ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED " coDES _ 4 5 , - .. AGE STATUS IN EJECT.' 4 NAME: Anders Steins 7ik C ADDRESS: ?.0. Bo:' ;3 i:aaloc? 36 6 U F NATUREOF R MO ED iROM INJURrES: SCENERY: To A NAME: T AoORESS: $ IWUPI SDENFBOFR M T O W NAME: _ ADDRESS: T N M N I rLIUR'F SCENE BV: TO E N M ' rA J ' S A E: ADOFESS. ?r, l J .!. J E $' NA I Ir4nIR.9 SCFNF RV T O 1 f 11151ATUS 121 SEAL 101110N ]IINJLIRv CLASS 141 BEAT BELT ISIEJECTYDN ' 1 D ]'OC Clllf V 1 1 5 2 T. OTHEPPOSRIOr/ I2 OEO?DAT SCENE I. DEAD ON ARRIVAL ( 5 SOS BUNOm IEVIOENTIINJURY 2,NOTIIUSEI.EO ]USED 2 TOTALLY EJECTED ]. PARTIALLY EJECTED D 5.0 tHER IGUS-MOToRCYCLEI R ] / 4. DIEOINHOSPITAL LPOSSIGLEINJURY 4. UIIKNOJIII 4UIOVINIF E O WITnESS APOSIPONUNKNOVM I S . SEATOI FAILURE EJECTED fit - 1 ra '.YG ?? rF`aJ'?` TRVi?" - r? +m i' 1^rlr? ? L t '1 1 L ? wt hn• Yt i:? N + 'i F - V 4 T 1. { ? N 'YB T flu', ) J ??ki IJ r }A. , a ry'h.°[M. a ,kaki :? -y ,.'.,:.. S Y. __ . _ " -. _ .. ,?n.'r ^..,v. w`i?e `• ".] ?6S' uai.. E%AMPLE ° . y VEHICLEDAMAGE 1.IN EACX 80lL CWCLETHE NUMBER OF EACH DAMAGED AREA ° T 6? ,. r , s y F INSTRUCTIONS: ao n WMOWJS)TOSHOW PRINLIPLLDNECTIONOFFORCE (? 1 Y k 3'e ]osv y F ? it DAMAGED'!°HICLE N0.1 IJ IIOOO (USE THIS SPACE FOfl SKETGHWDDAMAGE TO TRAILERS.MUTOPCYCLES. ETC.) E DAMAGED VEHICLE N 0.2 IJ - rttv,i_ /w(Ap 1 to P°ol 5. TnvJ, Ffl4^? ? ,4. Po°L. 13. Ttink Ix (?_ T I O. Urtl«c«r4°° IT.a«,Mw ..... ? I ' I I IB.vM«urlM°° ITKivMUm u_VEflITY OF DAMAGE: VEHICLE N0.1 1?OISAWNO DAMAGE JQOTHER M.V.OAMAGE x FUNCTIONAL DAMAGE 4 gDAMAGE EVE."j. F DAMAGE: (OTHEfl VEHICLE) SEVERITY OF DPMAOE: VEHICLE NO.x 10DJI:O DAMAGE 3QOTrIERM,V.DAMAGE IQMAMWDAMAGE pQOTfERM.V.DAMAOE 2 FUN110NAI, DAMAGE A NODWAGE x FUNCTIONAL DAMAGE 4 '- -AGE TCWEDBY ES<'DAMAGE TOWEDBY EST. DAMAGE TOWEDSY EST, DAMAGE TO a TO a TO , DIAGRAM OF COWS{ON °F I c I ? - i_L_ I ' h- I', I f I I j 'DRAWAR NORT ROWSHOWING H IN CIRCLE : wpwrFUTUIwa t I .'i' i 1 1 I I I I I I I I I I I R FwD ° awa ; t KI . aP ; . " ' ! j ' I i I I i i ' E.a?wCOM81P1Ni°0N .LOO MPHOll-EF-GF - ; I I - q'.Tll'n Xr5' i I ( i I ; I I I I I ?? EwCrPOlIROH] ?rw:D:' E+,D«Fgpa.eAEVF,ACLEDR I _ I i l I I I i ?;=1 _ C I n5f _ --hfo'yl To CIeIO I n?l.?.? Cdi I 11 1- FT '- I i t ' I I ' I r DESCRIPTION OF DNDICATEWH AT PROBABLYHAPPENEOBEFOREWRIWMDAFTERTHECRASH.INCWDEINFORMAn WTONDIAGRAM,EG.DRNM . COLLISION;: cm'e't{+r4. _ OLSA&UTY,RE WCEDVLSMB .PEOEST&AHCLOTHINGCOLOR,CONSTRUCRON ORREPAWWORILETC.) r ohicle 1 was eastbound on Bay ;"dy Road when vehicle lost Centrol et-intersect At that point the vehicle left roadway striking a 12T covered. mailbox stand - ?he ar ver and vehicle a skidder laft scene-.. It zv: s.- later deterained that .:s. Thompson was the operator of the Vehicle throuP,h_a ejitness'Anders Steinvi? Steinsv k stated that Thompson=,as onarating the shidder iaffront of his 'and to ' the braes-oa sate. 3 3 SDencer talked with tronuson and he stasod to ni:as that ha was driving the vehicle. As of 11 1 77 TiLOnpscr_ has nade.no .effort: to conta this office or repair t he stand. Kit HAYLS 1 1-7 SCSO VEH. HEADED MLEFOST.A. X- tryaR,}.k.?+„ys Np.OFUwE9 ONS-rREETORHgHWAY NAME OR NO. WOffE DIRECTgH SPEE0.4 VEH I P D . eAeE LEGALLY' WAS VE fq. VICe1EA51n6 REASINO _ '' w _ ? - -• • -.. (FAS5664 } Bay Pray Rd y 1 PARKED OCCUPIED ? ? ? 7n.- 30 YES W YES' NO -- E w ? ? ? Aa ,N RHDww E rDaEE?«I r w PED/BxYCt13T WAS USVq J -_ :_1- x a wAIKwAr __ . N.w? wMAP I Alx '... cTgss T .pMM KB, ° DI?DNA?D wAUt .e,erCLERDUre .? Ome ;° . •:?' - n:.. ... ROAD RF°ACEa , ,;; FATHER-66 7,.??,.CONTRlBI1 TING ANC l G O w it,. '" tAy a:S6. n .?, z'? .biuowhnnalnEACnan al» ? a n l o MDw 1 HM 2 F ^ _ c 1 a °? fxF.wroTCa:av I ? ] f unlwnsTUacEDe . ?l o ALDDIIDL ? -r c ?? ? ? Dw.? ?x ? ,ter 91I?° : ?x? wFr - ] n nAlma ?x? ??,KTMDwxa. !^,(1cDRa LJ L-d- f-L.i1 nY L, LJ . ?°? RTnAN ?]?...,IDw x? ]AO».eo .... ?=?=?L,,,TlIA1E°. ?o? FOIOw?OK TO ?°? I?OU;gN •MxMO . ,. ? .L1' : ?TiURI ? I? ? s - .?I? _ ?EFWnPEM- ?II?FWIWFn ?°?_ U1WfN° .. ( ? ?a` j ue ?h?^?-_ °Cl-- - , .. r ?`DRKrww; _? ,°_ ? ? _ ; e - ?!? ,awD; '. OMFN 1]PLCAw, Op,ewla4C°T I0!El p°n D1? apni5!Owl°t°r ? , ( LJ'°I J iU Vgt'A?11°? T? r°rpK Ipl ? LIGHT CONORIONS II.HECItOMI 'j„TIUFRC,COIIILOL.a M ] VleY't wnElgjITYPE OF ROADS AO ] K:HtGe Ml OR Mpml ,VEMICLECONDITIONr: w 1 Y $OSRIETY'64'Z, 4,y?'r?E.fi 'M' . ?"? aroweDAr sorlu' ?B . .:., ? r ? enMra ? . ? r ? Drew°r . I N0. ] A?04V °Vp [n .. P COffIRw°rtR Da4, M I .. _ DPffDN ? ? ? napwnY .:. i w uan . ] ° ° L?-4 n DwAY I ? o EC E . , .. ? ? "° AMCI : °. ;: ? ?in? °Re M ]; Lawn 1..L--. _ - y ??__:_ ??_-._. ?zLJ wrwP"^m?? L..:.'I? AR?vmnoN .. ] L L' . _. - ? L4? neo `° ?4? u .. pU[CrM :1 = == ?,'-TiaoENATr -_.. ..-. LJ ?„? MlAOIq IIXTOm10 a« f-- ^ ?'?91OOM_ ° ?UIawP.O- - ?1°? -aAwp ':; °? ? °?w,w. E1.171 11wY1wiAAie`m ?°? M-- 'MCrm CHEM.TEST 12 0 0 -.. '._ ... LI LJ __ °I,,,,?m°?`Eer'iOUDIm q- ? Ir?°Irvu«?'•n_ II? °er'iaunpp 0w? ?mm?NER' - ? o lerca n, .. T, omen O?•? r-- I ?]?.7 PNDlD - _- ? ? M)DVELTa n n rEarnllG]]a t . ?, , v „? o^wnlRc" % % TEST PESULTS , NVeaPYr],ODlIK2warwMe ]Awf rU1 1-ATVZS DEPM laDwlb. 7 IpLCl NKYeeD AKCE P.n 10°1.1471 0948 ° °° loco , !° Amin ur wArID ILOw YreDlD X ]nwAl t DEPUTY ef°Deeo. ,`7 . AGeM;r ._ Sheriff oar eD]r, DN#7 nar roar w10/1LA/77 AAHKIW an // WVIJDiiiE COPY:IOC?L IAW ENFOflCEMENt ?GENCY9 COPY-TRiPLCATE COPY:INVESiTOATORSCOPY ."i s ? rp Y 11 1 lF't^f"f'F`.` ^R=°°r= ?T Iza. 4 Y 1 r'1 ? t r ?? I'? ?N A .. ? 1r tl2C ?' ? ' 'S . n S 1 •,AV?'I,A M? E OF IVU. .- , } t YE?G ?'a -_; ', ???.-_ __. .. UNIFORM POLICE TRAFFIC COLLISION REPORT .-. PIXICE CGMPUkIT NUMEEq ? ;-, .?l z, l ry a GATE OF CUWSION DAY OF COWSION TIME COUNTY NO CIIYNO. . TE ON H A ' P AE? - i ST EETCOOE . - I I . O THEq ISPECIFYI Jefferson ? N 6990 L p y N 5 E W L?pIN CITY Oq TOVIN vREFI% EO. MRE POST MILES ? ? ? ? ?OFPort Ludlow ?? 8O • TIC I A a-? NAME bNO.OFSTREET ORHIGHWAY INTER5ECi1N01'ATH: STREET OR ROAD LL RAMF q.MigAIA DATA N T ®IY C, 10 O 1 NO-TER- ' j 0 I N ETYIEEN STREET AND SIPEET DISTPNGE AND OIRECTIDN FROM REFERENCE Ofl CR0559TR ET ACCIDENT MIL[AGE CODE ..,.a .. NTE „? ... O IN R . ....... %0 CLS .. .... ?EflSE TR STPE Al -IF EPENCE CROSSSTREETOR ROAD ,/yI S?l'• ? a NN G ,;J'1y?? .AQ?'•AN ?' r .. ?MILES 5 E W FEET C3 ED C3 Q OF COLUSION INVOLVED: - ? VEHICLE?VENCLE 'I TOt,LNO. ?VEHICLE-0&IECT -1EHICIES ® ? VEHICLE-PEDESTRIAN OD,IECT STRUCK INAME OFO&IECi STRUCK ANOOWNERS Telephone phone pole OiiIVERS NAME{AST FIRST D MC MILIZN, Jerry Lee I STREET ADDRESS - E Route 2 Box 814 ,R R CRY STATE Cuilcene, Wn. 98376 732 N OR VERS LICENSE NO, STATE O tICI•;ILYL401DW IYn< t DR ERS OCCUPATION FWM NAME Student 'C'h' Junior e' V 1970 Chev . E YEH. C LK:. FLATE No. STA E A H I thLi Grn L 6 I Wn C VEHICLE 10 TI, I NUM L E CE140Z126-6 g - p, flEGL3TERED WNER-UST f Mc Millen LPE, ADDRESS OF OWNER ???'?'.:'. Route 2 Box 814 Quilcen NAMEANDAWRESS[u uAV IR..Ir rnrn cnc VEHICLERRTRAIN NON-COWSION ? HA]AROOUS MATERIAL School D R I V o. A N 0. 2 V E H I C L E N 0. z or in Possession GTA KN NO. ENFORCEMENT CHAR E ACT" NAME, ADDRESS & INJURIES OF PERSONS INVOLVED L. NAME: C AOOFESS: U NATUREOF INJURIES: R MOVED FR M A A NAME: SCENES' N T ADDRESS; $ NA R D FROM SLEN W NAME: ADDRESS N I N. URE OF M V FROM E RC NE / S NAME: S "RESS. E. L 'L . S SCF, N'E d% • 5-.S ISISCAI PGSIIrorI .i.JUnYCU50 I C ]PASSENGER J P!'ESiRIAN A I NOYVJURY 2 S D61AOLIHOINJURY 1 1 N D RC/CUST ! O' 4Eq 3 ] 1 0TNERFOSNION I DEIOAT SCENE ]DEAD O'.RRIVAL ANON 0 . NO S 11.061, 111-14Y E Tr •E55 3 ] POSIRUSINOr1 UNIlN MOTOIICYCLEOWN) E . EON HOSPITAL PO SOLE YUURY HITARUN J NO. ONLY MADE known ,i„, PNON NO. 1 iLT I31 ELECTION - '. ?NOVAI STYLE I2 OR.40-1 'Iw tc." TRAILER PLATE NO. STALE ODOMETER L,?. r? MIDpLE ? 4{ - TA I CODE5 I I 1 - 1 ] 1 D1 . NOTVLSTALLED NOTEJECTED 2 NOTINUSE 2. TOTALLYEJECTEO D USED 3 PARTIALLYEJECTEO WN IP 3 SEAT UAT GRE'.Ii'c;LURE E UNKJECIIOTED L S ? ? j : Y 7 ::._ ?riEG_ • . '?''I ?,.irof.? VEHICLE DAMAGE IN EACH OOX CaiCIE TNEHUMBER OF EACH O-A WA ^°^ INSTRUCTIONS: 10 AAw wo WISIT06HON PNNCIPAL NRECTION OF FORCE, t , DAMAGEDVEHICLENO.7' FUMT SSFACEFORSKETCHINaDAMAGETDTRM-.MOTGP W-$.ETC) DA AGEDVEHICLENO.2 a IG Hoo° H. Roal 15.T-n , 14. Rao! a 6,a 16: T1Gn4 - ({„ > ° M.rtsn lAa -.- i , 19.UnawerluG SEVE OFDWAGE: VEMICIE NO.1 SEVEWIYOFDAI E:IOTHERVEHICLEI SEVEPott DAMAGE: VEHICLEl10.2 '. ._'? 1 ISABUNG OA D QOTHERM.V. DWAOE 10 SAMW DAMAGE DQOMERMV.D WAGE , QDLSAIlUWPAMAG G? OTHERMV.DAMAGE MA O E' ' WAGE 4 NO DA G 2 FUNCTONAL 2 FUNCPONALOM,AGE A NODANAGE = FVNC110NALDWAOE A NO-AGE EST: DAMAGE RY '. EST. DAMAGE TOWED BY B,iU=g .Garly ESTDWAGE TOWED BY T""O S TO Mn. S TO °1 000'' To - RAM DIAGRAM OF OFC OW%,.. I DRAW AflflOW SHOWING i- NORTHINCIRCLE. .aowrFTA - 7 °B °N PD DH aidl { drivel ray to Portl - m - I clKW R= 3 . Fire Pg=tmen!t '. M Frae.aLERM1DF i ?- .- I i -t 1 1 I ?? I.C I i' I I I .I 1 I' aHDwoEHK.u.o 'I I I r 1.1 F0.411IX1a ACT: i i. , r I I' 1 f (_ , •a I I ,?.? + L : 14•- ? - SHDLwF„oe.aLE R,. -1 ? I ". --. -I-I?.TM`I r? i? t T ?T!' f I r,.i i I 1 1 I l '. S I. i 1 1 } 6 I LL DESCRIPTION OF':; ;. DNDICATE VMAT PROBABLY HAPPENED BEFORE.DURINGMlDAFMSR,ECRASH.INCLUOEINFORMATIONNOTON OIADRMA.EOORlVEIi CG SiRUCTION OR REPAW WOHI(ETCI WG COLOR PEDESTRIW CLOT KJ COLLISION ' ? ? - H . qSA&IJTY,REWCEDVERB tt. R/0 tYlat he Yas R/B on C.R: 10 l!i 1. a deer. E3teped bato' A the, roadsa.Y. Driver informed this miss it and due. to `the xet road started sliding and leYt',the'roadoxy t and he_ weed o - - - - . - - - strikin3._a telenhone,_pole and'_the enbaaloaent ^,_ r - 4 .. NO.OFLANE9 SPEE0.9 EH •-. •.. KED 77, POSITION VEM NEAOED ? MILE POST qR ON 97REETOf1 HIGMWAYNAME OR NO. B WONE DWECT,ON GAFF LEOALL WAS VEH O OCCUPED PMKE NO. '. WCREA5W0 DECR . . E EASING F ... !J G `•. N S W -40 f3O C.R. 10 1YES No.YE9':°„ No - r ' - - - - o° v - a . PED h--? t t n l on arATAT Ar a (? >V-. C , ° S PD. &GTGUSTWABUSWG . 54RW I 1 AR GRRR Ra5 I-pgG3 tI nDxM8wm I a>tOUDa], L..1c- ROAD SURFACE) .. plEtx aND . „L WEATHFA , -. icIIET+r CNB CONFRIBUT ,cx MYIER ': INGCIRCUMSTANCES ECx aNE aR i•,DAR CIaVER AJS"? ?r ClR91 ' •: ri.'? - mxp.:vjbn uDnD ?? aIRAAMAMFI:D - .. EA ?l? .-? 1 ,?- O?.a? °Y ? ~t ?FALUFNCEb ? ?. 1000ID6E-r_-- ?J a?W?i lq = ?, . '?y{?. u-? FARQFAa4a1G c. . J a ? bqw a C!', B.Ow.Ia I (/?? E? R 1FD I I ° O ' ? G -_ ? -14^•s10cY AnwR,Pfquq:'1. .:' .I?A?y?,. ?J.. '_. LJ' ?-, .ICE LI FOO _ - +? WC9fEG?. iw- ... C °l?n ?0? xFOO?"icmc roMP ?. t,p? uMUTMn.?o r• ' - E. s KmaPmr f . a nlR ?Ljdeer in ro_nd ?° vww". : TYPE OF ROAD VEHICLE CONDITION ,°nuTfFAiaAmN°F^. - SO RIETY'r` ' i • ?E (J °mn °gN1°'• QfO°°= UGHT CONDITIONS .`,TRARIC CWMIX. V .nt Yei.DS - Cx o.E aA Mp1a1 , W a IC1 I ;,, VfWC18 rcRFCx ONE OA :L.I.. A w.cu ... ICRECK ONE) , rl aR a1DP - ICREU aND Fi rlo ? ?, U• EEH43 . 1 •(-,, LI CN WAr = '':D °EDNiga?Il [=N °C = .,. ?Y? AYN - o•ruc,rt . IJ= a.w ? ? ?I t. rwo °? ?4° axxicElaNa ? i 'Q HEDI°IT• `. "°D C °'.`? m.R1w°wr "?4 I I : ? , wwH ?a N .. I sa I ?= ro .o : wnw n ? ar A+w J N ioR .lw m rov ? ^ a drNR. ?;a ??_' .,A??G 1 a' I N11Y ?, ?.? OR' °M - A .'aLVIDiMOq n16'? MCItND ° _ Lwnn L_I ° axuw I -. M-0 L. ? 7^A CHEM. TE5T , w r .? .: Cj/ eliding ?' _ ... O r^ 't M D T^ 1Ea t ?: ' oMUpnvil J6 '. ff. .. ;.:.. •? rnrwnc '' »_... l_1 '.. olnQtli[CVVI ? . I ? TEESST % RESULTS , .m,roArwoarrcLAaN.Ma FxANx Deputy N.C. Gebhart ..ooeND 6 1 a A1cHeD Aae Aw..eD AAn"NL`o '! MRU Low D .E 1428 2123 «N° 2144 = 0° on SCenel? X '?U1GiMCFIKf°a aIDGIRO 6 . ACWC I JCSO .- OT.:ET Lruilceao -OA AargR 122877 AIF,K]NO ar DA1E '' FR X ? t ?, µryWATE CGPV.LOCALUWLMFORCEMENT AOENCYS COPY-TRIPUCATFCVV WVESTIOATOII'SCOPY ,,•'. , Or, 1 yt I?? lyl F, ???V moor, . P mr! F -D DATE OFCOLLISION pAY IFCOILISION TIME C OUNTY NO. CITYNO. I..A I IlQ 3? DA 79 YH. UO ? SUfI 1 MM 2 IDES ,,WEp 4 FRU1 S FX B SAT IUzZ <DO HOUR) J / ?UROAN COL'::1Y ?STATEROUTE COUNTY ROAD ?CITY STREET O A DMCLS. PREFIX ROUTE STREET CODE FUR SECTION j Jefferson ?OTHERISPEf,IFVI UUU! ) S 56980 N S E W N CITYONTOWN W P REFI% E O. MILEPOST O MILES ? ? ?OF Port Ludlow O p / O . CR A T I N EAI O.OF STREET OR HIGHWAY ON C R. 10 INTERSECTING WITH STREETORROAD 111. O R AMP DIAGRAM DATA - O NONINTEIISEGTLQN ACI:IOENT IN TEII ON A %HD R CLS INTERSECTING STREET OR ROAD OR REPv N BETWEEN STREETAND STREET MILEAGE WOE . ERENCECROSSSTREETORROAD DISTMICE AND OMECTION FROM REFERENCE ORCRO STREET / E?119 S UM XI PECIAL CODING USE ,?]MILEs N 9 E W ( 2 FEET ? OF Rock Quarry Road ? COLLISION INVOLVED: VEHICLE-VEHICLE [3VEHICLEDICYCLE ?OTHER(WRITE) ]NIT a RUN EVERITY KILLES NO TOTAL NO. ? VEHICLE-OGJECT ?VEHICLE-RRTRAIN ?STOLEN VEHICLE 1 . NO.INJUREO OF VEHICLES ? VEHICLE-PEDESTRIAN ?NON-COLUSION ?HAZARDOUS MATERIAL ? PROPERTY DAMAGE ONLY OBJECT STRUCK INAME OF OBJECT STRUCK ANUOWNEHSNAME) LOCATIONOFOBJECTSTRNCKS E W EST. DAMAGE Embankment ?ROADWAY FEET ? ? ? 1:1 OF EDGE 5 DRIVERS NAME LAST FIRST MIDDLE DRIVER'. NAME-ST FIRST MIDDLE IIF NrCYCLI>T UR PEDiSNIIAN CHECKIu D CHRISTIANSENt Richard Scott D R A STREET ADDRESS _ STREET ADDRESS V 3 Blks No. PO. POB 40 V E R CRY - STATE LP CODE PHONE NO. E CITY STATE 21P CODE PHONE NO, Port Ludlow, Wn. 98365 437^2319 R N ONVERS IK:ENSE NO. STATE SEA DATE OF I.T. U N DRIVERS UCENEE NO. STATE SEX DATE OF BIRTH 0' CHRISRS40ORL Wn. M I .0. DAY 1 2 13 4C 0 O. AY YR 1 DRIVERS CCCUPATIDH FIRM NAME PHONE NO. 2 DRIVERS OCCUPATION FIRM NME 11-E NO Cook Harbor Raster Port Ludlow Wn CODES >1(31 cNUS , o S fj MI SEATBELT 2 TAI EJECTION 1 CODES >1,,R IN URY CL S4 III SEATBELTSI EJECON NATUREOF DuuwES Lacerated lips and loose tenth NATURE F -DRIES FR MSCENEBY:Port Ludlow Amb. TO Jeff. Genle HOS FROMSCENE BY TO VEILYEAR MAKE IDODGECHEV) MOOEL(DART-NOVA) STnEI2DR.,CONV.I VEH.YEAR MANEIDODGE-CHEV.) MODELIDART STYLE ONV.) VV 1966 Chevrolet tudor V E VEF. COLOR 11C. PLATE NO. STATE TRNLFA PLATE NO. STATE E VEH. COLOR UC, PLATE NO. STATE T TE OWS 601 Wno H t C VEHICLE T IDA I NUMBER E 1381762105557 o5o24 E REGISTERED .11-UST FWST MIDDLE R EGISTERED OWNER-LAST FIRST MIDDLE N D. Same as Driver N C. ADDRESS OF OWNER ?- ?- A DDRESS OF OWNER y 2 IIAM ANDADDNESS INSURAR CO. OF AGENT N AMEANDAOOPESS OF INSURANCE CO. OR AGENT Farmers Port Townsend, Wn. CHARGE CI ATIDN ND. ENFORCEMENT CHAR E CI ATI NN . None at present ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED cones _ ? s , ' _ 9E % AGE GTATU9 N , EJECT, C NAME WESFELT, Carl Vestal C ADDRESS POB 117 Port Ludlow, n. TX -2 1 M . 66 6 UU NA UNE OF I:MOVLDiROM W XIIME9' SCENE BY TO A NAME: Y annet May T F "E RtlC1L1:.CT_B_III.AD_3.t7].HRLL.f(adlockt,_W11 16 2 1 2 6 2 1 S LM v D H M nPPlrs Scrapes and brusiea "".Y Port Ludlow Ambu lance , Jef f G unl Hos in, W N AME. T Aonnfss N AATUNLOF PE.Oly" M To S' gn-E59 _ ,F .•l,+ r¢. wA,. oLU•. IS1A111111 lY;LJLCIIWI c ? P S l IGI"P ; ] f(! _ 1.1) IN. U1 1 \ ! T 5 D '1A 't WNY IKUII1 1 IIRI 1N.LCR NOT EJFCiEO D N 11C1C f ti _. SUIIL S. D F unlnlnD:JTXW J Dl UON-111.l a NO41 ULx4D ( U U, JRY .Tf 4U.L ? IOTAt LT' "'Cr. J U I.[ ] 1'AN1IM 6 "'Cr. CI CG L OHNR nl't 4010r1OYClT1 ADItU!l1NOSIITAL / f,.:wlnI PT IRIY . I UIFNM.N (IIVR`rOWNR ?M; nW .. ,... . .? F 4 TN _ ?VS w f TF n R 40, + .r r x?.. Ak VEHICLEDAMAGE 1.l1EACHDo%, CiROIE THE NUMBEROF EACH DAMAGEDAREA E%AMPIE , _ R 11 p,f HADE AREA OF 9EVEREDT IMPACT. INSTRUCTIONS: S.4UW ARROW(S) TO !HON PRINCIPAL DIREOPON OF FORCE. •? ©/. •,o e - ° IISSPACE FORSKETCHING DAMAGETO TBMLERS•MOTOHCYC 'CI DAMAGED VEHICLE NO.2 DAMAGED VEHICLE NO.t I b f a IS.IboO -? - I a A i IGl 2 1 3 4 5 n d 1STrW, Trunk 4 2 30 umwurn.o. E. IT.OrwNn . . 1 11'. SEVEWtt OF DAMAGE: VEWCLENO.t , ODIUWNODMIAGE 30ODIERM.V.DAMADE Z FUNCTIONALDAMAGE A NO DAMAGE 9EVEWtt 0IX.. GE:10 INEfl VEHICLE) fOgSABUNG DAMAGE GOOWEfl M.V.DPAIAGE 2 FUNCTIONAL DAMAGE { 171 NO DAMAGE BEVEflItt OF DAMAGE: VEHICLE NO.Y 10015ADUNO DAMAGE 30OTHERM.V.DAMAGE 2 FtINCRONAL 0AMA0E t No DmM TOWED BY Bill, S aruge EST.DAMAOE TOWEDDY EST.OAMAOE FST.OAMAG E TOWED BY TO Chm-acUm° , n• s 1AL I TO S To $ DIAGRAM OF COLLISION - - - -r- -I--'- -- - - ':DRAW ARROW SHOWING NORTH IN CIRCLE r, aPOWY.rFAlDAf9 K 4 # / 9 O?nIEF IgADWA Y - _ r / J TRN ?CdRnp. - - - ?? , inEAa, CI PttasrAUa?Crlw x LOGlE wIGeABLEPdVlGr ' _? .. ?- __ - _ _ _ __ _ ?_ MPAGl. ? ? 'ry a K??oen wTtlOn I I I -1 ? I ` i ,. arwWmoNAxevu.c,xon ANOArlFACpD4pi OPf -l'}I 'DESCRIPTION OF ? 1N O ICA Q TEWNATPROBAB LYHAPPENEDBEFOREDUMNOANDAF TERMECR ASH.INCLUD EINFOR MAT IONN OTONDUORAKEMDRNER . ?. COLLISION„ ? ? dSA&U TY,REWCEO VIS IBILItt, PEDESTRANCLOTIIINOCOL00. CONSTRUO TITjOR?I PARYVO RKf E TOJ Driver informed this R/O that he had just pulled out of the parking lot of Spark's store ' and fell in behind this slow moving vehicle and he pulled out to pasa'the•vehi le an when he acdelerated he started fish tailing lost contro of t -e veFiic e s r aniy e enbankment causi the vehicle to flip en-Tc ovar end. ?Ftese-taas4 no^colimlonx'?Tt - to • - vehicle thT t he was attempting to pass. P.-.. BEFORE I l.:j AY "un..: 5'....u..-YsW?6 '::••. •'. STREETOfl Ofl NO. KK HEADED MILE PASTDIR. - ON HIGHWAY'NAME NO.OFLAN E9 OfOIEDIRECTION, N roa .oSPE C . . nASt VE PAua?y RIQ':D P D WOCCI w. NO. xICHEASIr10 DECREABING .. . ... . . . . 0 0 El El .4:`1 _ L.1_ C.R. 10 n YEB No YEH No n PED. l n ? L_ . cno°A.,n-_- n " MF-GaNnER ne. slerowl µOND _ KD,8ICY0JSTWASUSW O: rn[Dew F'? oz xI.. IWAUw ?',JuqulnER ,L_Jcnostw °l..!cnoss'wii% °nM?L'1'GI!!R?dlr?: ROAD SURFACE.,' J?-xt. THER;,,x '? GCCKO tL' t.;.CONTH_BUTINO CIRCUMSTANCES-". =' • 1 #„I> F,IEO, aNl On alCNt ? ""' /??Cgllcgq?;t5? I-1p Yl?tGl$ ' FHFGR wG N.VCR W I 1 ' LR? nTwl La"L4 OrMA OP MOEI ' ? t n?NWON<M D, ? E1 tu.,,wG.,a1DY NO, n, I-1 tHCtOF C1D9E_ ??? LLYY WNN 1 J?7 _°O 4 n_,rvDrwm ` 1 .' - l?? - =_- p =?` J-?-- / . __ O," _ ?° .. =?..LDtHGtor I-1, f-1 ?RGF?IZR nl,?;mu?s?• L 1 L J •, t ? n ?. w,rTUx, 11 wow l.J n? aHavw a ? ?n VFCT dNO•r-- f""l a ? _ ro 4 J ?I e? LounoHr o ?' ? IarW1O'Oilw, . F ^,?, LJ ca • ? roo - Q.-? aretaHeon? - _ ? IO ?°rm10°t^ a o°°txrzernTNOizol». ??? aiwn, R j ! O -707 7 _ _?°?V RIY/ `(,??T ? ""A-- ?l .• ? n ? T ' ?° ? +eIAO h EDAA. ?ran ooniebr„L r ???111 omenIYCWYI i l_.Jt° ('''T ? 7 .1OMNIQI -,{.. FT L1,` rrwroO.. LIGHT CONDITIONS :TRAFFIC CONTROL; " F.w•ge S.TYPF OF ROAD.; rarY a M ',VEHICLEC?O NDITIONi ? ';;%;C . L-'PPRIETY;•,,,,,-,r? Kr.C18 ICKLN aNV ?n? w AreauA IGNtaK ONq 1 xo t KI.MI U ^ r,E • N? t ICNECN l Cl ? o E wAY ?? Y HdMMf Ll 1 Na , CpvlM1d Rq I NO, ? n ? nor.?tDYM wuo C:ltr J I 21 C , NMAtr ? 0 A~_' .c" •: ?1 ?,D? ?. _ S _wmloxnsi-=-- nal. .J --- ( .1:.4J ? ? I fA ? I Aar.; ? I woe u• r]a (-1 crI•n a J J 'L°oMm ? u" ?a ?1J? q iwo Ot"''n°iw? t . ?. ° t ? .`d1. - 1 _.__ woon _ ?,- 'J _ ,.._.: -._ y 1 nWOn : ? wr"n ? • a _ r-1 n'b °r . rureD 'ew ?°? CHEM TEST -7 mi, nr L'_ ° YwR T, P r r 1 o nn "----- . , l 1 f Nf W a a Av 1 w I r`?yy L r rtnrOMN onnn lMG?1'1 .. ones r r. 1 taweo (? ? wareem r rurl,vusto t - orHe nllne..I V yt' ormnn...._... ,.r...•,,.r?ETMxnlreenn % % TEST RESULTS 2 , f.'• .. r.atrrlca.ar.w••w. - U1311AFT Willinm 0. Deputy w.oew 6 aloe .,r,r l.o r«at A....a Mo a o,rt I o81311 7' 2241 tHM 2251Fa 00A rwrao•aoW 10 , w ynw !J 7,7',71J tuatw 6 rar JC::O wrap T•PFr. D,ra nrvrorrt 071?tl' ArwKMOnr fwn F ? i p t ? ' L' k ??- 1 w ?' IA+ L YJ ' o ' < I „ t ' at>; , U?•' vV/\i\711 ll?d PAGE OF - -_. ?' dJe: .. _ f ., rOLIC E COMPLANTNUAIBER , . 5 p .:3 UNIFORM POLICE TRAFFIC COLLISION REPORT !T ' 1 tl sO DATEOFCOLUSION OAVOFCOLLISION TIME COUNTY IXI. / CITYNO. FHWA E7E7E7q Al DAY- YR a1, C i SUrv upn 2 IULS S wE0 (11TH > Flil p SAt IUGF nOD 110UR1 } J / f/Yn RBAN RURAL OUNTY ?STATE NO E R(COUNTY ROAD ?CITYSTREET O All CLS. PREFIX ROUTE ORSigEET CODE Ci10 Te.rFe ?OTHER(SPEGIFYI N 3 9 6 ! CITTYORTOWN PREFIX EO MIL POST L NN S E W ?IN 1 W .. O A MILES Y51 ? ? ? 'Raw -- 1l Q 1 Q ? - - , O /? V A _ (LAME&NO OF STREET R MWAY INIERSECi1NG WI 111: 51FEE7ORROAD LL RAMP DIAGRAM DATA T 0 0 '1 O N NONINIERSE iION [ // sETYIEEN 1ej?" EETAND STREET MC.. IOENI EAGE E NTERSECINGSTfl ORROAORRE RENf1O5S STgEET?IgOAp L/! TSSSSTTREE A n+el 5 E W . Of ? COLLISION INVOLVED: ?VEHICLE-VEHICLE ?VEHICLE-DICYCLE ?OMEnIWFITEI ?HNARUN SEVERITY NO. KILLED TOTALNO. S VEIIICLE OWECi ?VEHICLE•Rfl TRAIN ?SfDLEN VEHICLE OFVEInCLES? ?NO.IWURED ? VEHICLEPEDESTRIAN ?NON COLLISION ?HAZARDOUS MATERIAL _ _ PROPERTY DAMAGE ONLY. O W ECT STRUCCKINAMEOF OWECTSTRUC ANDOWNERSNAMEI LOCA110NOFOD1ECi S1RUGK - ESi.OAMAGE ` ?'' T ? E W iS-? p A ( FEE ? U'OI ? R0. S - DPoYFHS NA ELAST FIflST • fAIDO?E - T FI ORIVEflS NAME?tA51 FIRST MIDOIE F(rCVLU5I OH VEUESTSIHI Po4M1 CHECKICJ D R ' 13(anc[1r G?'C11 ,`` R D SIRE ADDRESS ,.... ... .. I STREET ADDRESS v LLJC F.J C?SSf V' E R CITY :STAtE 21P CODE ':-,:PHONE NO. 1 • E R CITY :. .. ,. .STATE.. ., .. 21P000E :_.. PHONENO. .. Zcl 'OW (?? 07- 2522 f N DATE OF OIRtH N DFIVERSUCENSENO. ... .:.- .STATE SEX O ATE.OF BIRTH ? - O•' `I O 2 RE Y 96 . O M D AY YR. O. 'JO L L•F r J Z 1 : DRIVERS OCCUPATION .. FIRM NAME...,,..: -... ;: ... ., .:.:..... '. PHONENO. Z DRIVERS OCCUPATION FIRM NAME,... CODES 7131 L"L 5V_ _IAI SEAT DELT._.._ ISI EJECTION.- CODES IJ1 IWq R C 55 Y ---- lu1 SEAT BEIT?..-._ 151 E ECTION___ . NATURE OF - INJURIES NATURE F INJURIES - FR M6CENE YEH. FAq 0' M MODELID NOVA) 1, IJ. CONV.1 FROMSCENE RV TO VEH. YEAR MAKEIDODGECHEVJ. MODEL IOART-NgVAI STYLET2DR-COVV3 1- v' / 1 ?/o(Vo 1 2d r `28 v „ r VEH. C R UO PIATE NO. : STATE TMILER PLATE NO.- STATE E VEH.COLOR. LIC. PLATE NO,. -:. STATE TRAILER PLATE NO.. STATE j t yt C '. VEHICLE IDENTIFICATION NUMB R C VEHICLE IOENRFICATION NUMBER ...... .......... ... ODOMETEfl .; .;: E` 1423 y y/ o Q212 / k L. lntl . REOISTENED ER -lAS .:, FIRST -:.:'-... 11 DOLE REGISTERE00 NER-USTFIST.. f •.0. - 0. " ADDgE890F OWNER .:. '...: .. ._,,. :..... :. ADOHE55 OF OWNER ... Z,6 mu CA z NAMEANOApORE55 WSUNAnLE CO.ORAOENT .: .. .. ., _ . NAM EANDADDRESSOFINSUHANCECO. ORAGENT. ._ ..: _..: .,_,, ,.•„-,,.,-. VI'I G?C'S ? 1 ?•:cl'LP? ? GNARGE - ..... ..:. ..... _...:. „„ CITARONNO, ENFORCEMENT CIUHGE .. ., ITATI ....: J ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED LODES , SEX AGE STATUS RN % Vu. WEGT. `. E] NAME' ' F 2V ) .? 6 C AOpgE99 I O Cr U P.-; u NATURl OF IIEMOVEO Ff10A 0UME5 SCLNE RV L'1' T nin 1 A' NAME N. 'T A DORES!: S . N A UK IEIA VLOfRUAI ' /.. I WUIKES ALENFM TO A? ,W tiStF°>. k' ? .: V W. DDRESS' T A M M LU n fl N.. WIURIF. S' Sff NF o TO IIAMF ' 5.. AUDNFS!' W I IinF Y g x f. i?, J S lf,FNF 11 Sf I1IHIAIU> IIIStAT MA%IllOrl MIVOUNV U'IAGS 10 EL ISIfJECIK3l1 1115! AI IT 'L l' L. 2PASsfNGfn INO NNRI 501HAUlINO -"Y 3Pf Of51HIAN i 2Df.ApA15CFIE O. NON 011111111o O 1 nCTCUSI I t F MLTgN S Dt-CNA IIVAL I RVTGrN111NJUnY 1 1NOINSt T AllFO I.NOf EJED1En 2. NOTKI USE 2TUTMLYfJECTEp 1 USLD 3 PARTIALLY rice En ? yj y f ;ly p - RUS D 5OtNfn lI. d 3 IuS MOlORCYCtEl 4 DIED IN HO.MTAL F POSSIBLE INJURY E n LWTRf Ss 5 PERON UN%NOWN 4 UNKNOVI.1 4 U-10111,I1 > SEAT RELY FAILURE EJECIID . l Y 11 AN Jvu 1A dim ? T I I ? ? ?j pp F ? _ f - I ? T - • S j F ' ? { 1 , 1 t 1 t I L.: y r ? I 1 A J f h JT i N J - t _ t d " i y q r , ?• 1 C i"?,t? x 1? / h41 WAt l1 f yl ' ,L ti s I , 1 yY 14 ?? i 1 ?1` ${ ? rj. vJl ? ...llir'"Mx.p?,p,?q?l?C",*pRRPlflry;^R-f•'?yly7^T"q_ Y`*?' '?"', ^B, G" lF ?a+.L V !'IT +R ftl{i'JI v+ V/gwwa?l'j ?,e?.?. -?,- y Y' ,• '1? I ? F I • P f ( I L y ' Y . 4 9 r, )?? iAI ? J ? ? ? _ . I r ` I' .M1I ?' al P. t . _. ? '. .. '.:.1!M1'#:D! d6TfJ ' 'E ,.e n. '.Ci.As„uZM?? A::. .... _. • Hf ' VEHICLEDAMAGF I. INEACH BOX, CIRCLE THE NUMBER OF EACH DAMAGO AREA.y -zAMPI y ?+ '1 INSTRUCTIONS: 2. SHADE AREA OF SEVEREST IMPACT. ( . [_. Y • µ, rAV ",1, t7j-" t. ]. DRAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE. Q? I iy'.n. OAMAGEDVEHICLEN O.T IUSETHISSIA-1.11S KEICAIINGDAMAGETOTRAILEHS,MOfOHCYCLES,CTC.1 DAMAGED VEHICLE N O.2 t". G rPPI ,a IF ? IE T.= R , r f. •,.YF Orr•"•'•' 1 D ,. S€ EHITY OF DAMAGE: VEHICLE NO, I CLEI SEVEHITYOFDAMAGE IOTHENVEHI IITYOFDAMAGE EH CLE NO. T - E T FUN TIONAL DAM GE T O'EAM GE AMAGE { ? NOD I, I B ?I NO NCT ONAO OVAMAGE 01_I DOIl1AMAOE DAMAGE 1 , -?, Iy I yat NTIONAL DAMAGE A LJ "1 DAMAGEOAMwGE TOWED DY I S ESl. DAMAGE TOWED DY kl f.OAAIAGE TOWED by EST. DAMAGE D ?_ DIAGRAM OF COLLISION f r?+DL? TD S G f DflAWARROW SH . .i OWING --' NORTH IN C _ ArAnowr FE.runLl IRCLE ._ . owlaFr aOADwAr cONTAOLS i?ifur CDN IT DNB _ I t_ ) I 1 I I IC • ? ACE IAICxci onsrnuclox 1.p . : 1 I oe nlros ioni°..srnux BH Mr AV „ ?,/1 V ? .i. ... ... 1.... . -. I I - 4, 0 1 RO4 RLtVI 10I OG i ' - lS r . ll El . LT DESCRIPTION OF (I DICATE WHAT Fn-BwBLY HAPPENED BEFORE, D68ING AND AFTER THE CRASH. INCLUDE INFORMATION NOT ON DAACFM, E -.OnrvER -COLLISION ; DISABILITY, REDUCED VISIBILITY, PEDESTRIAN CLOTHING COLOR, CONSTRUCTIONOR REPAIR WORK, E79.1 i 1 ?' gC( Fla i ell ? ` e q S?W'--?- CA.VL.C/ ? c . _ pEaJ CL•L+c_L.?? ? ? Y Ce.K?I-er:_Ifne f--Ve-?nfttEf? _c.nln?..?.[Je? fov_?I?oLF_5---%.oo-F-f--?k _ w-EONy ? lonl_ 6afDYe_-- teovTrL ofA LA.Sca rxtl k ? Jf? ? y e . .. Vc(I.clc -ti,e L. •t SvolleJ coF ?-r vc -C? ?s? __ , - . ? ,r.__ o -r or 1 oe-1 ' ?r POSITIO E HEADED N0 N BEFORE COLLISION LGLE POSf OAR INCREASING OECREASINO - ,. G , W - ON GTREET OR HIGHWAY NAME OR NO. D. of LANES IN ONE DIRECTION -ED S VEHICLE pEGALL ARKED Ir r E P F1. OLC [O EL c. 7 So E! mo? A, -' 1 P- ', ALONG - D I PE / C L T WAS NG- 21 11 K IUNLX Si WAr OSSw ErI E 'c E F( I D II ISOEWALK S? f[ 1 f E 'fiDNF ? ROADSURFACE. IC CK ONEI WEATHER (CHEC O I , CONTRIBU N NG CIfl U OSTANCE '... . O E iq e E IS IY'zA DA E I NO 2 K NE IC DRIVER N0.2 ECKONE q oRI0 E2 ER DRIVER 1 0 3 IN . IH r? ?? LL I?, GOIN6 AHl? L?I?.e-I STRAIGHT AHEAD ..j. ,. _?? f DH •&CLIFRCAELY ( L 1. ?LL9B.OINFLUENCE OF FI I FOLD NG Df?IpEFA= ]? L.? %nFG DEO WARN.• I rl 2'1 OVERTAKING L C. A D AS91NG - ] $ + N] `117- WE ]L SNOW 2 I ?RAAHIHG _ ,5 OW a _ I2r ORUOS INFLUENCE 0 t?]?_ EE EO NG ST T OVER ?.r? -Z, L. G TO l06 SIGNAL F P _ ENT Y - LI SLEEP RKINO L 1 n LOC 01 r.iS I M K NO ONT TURN L Izn AK IN- L 1 •' l ' '' ,Ar CE I I r FOG Ste- _ E EztEEO G 1. ?SAPC SPEE I 1 ? f I D E .. . r OPERATING I?B OEFE T OU LFF TT URN ?JS?' LLTURN ?7 l .15x..1 S I.? ( ( ? DNTIR :E TGF fW Imo.: 1 1TO 15 S EGG 00 i ' )r? Elf 0 SLOWING. . }r - OTIIER ISAECif Y1 OTNEn ISPFCIFYI . . .- - r 1 It PgOPEN L PASSING. I f DISREGAR D S TOP ITt J SIGNIBIGNAL -_-. I ( O TH FC 1 BI NO VID ON 1 r ?lC, STOPPED 1.11 , L GHT CONDITIONS ICHECKONEI TRAFFIC CONTRO VIEHICLE v E,:..TYPE OF ROAD (CIIELK ONE On MORE NOi . VEHICLE CONDITION N AL ? „, SOBRIETY, _::. C ICK O + 1 TRAFFIC STONED ATSIGNAL IB? ? AT fIGNAlS 1 J I ONE WAY ? A?? k QQ 'Ai VEHICLE IFOLONl?N DI l N0 1 1'f' H NEI O]E I ... OR ST r -? J Ip?? 6TOMED IM LLL JJJ ", Y 1 ' µ L ' r _71'? I DAYLIG ! I ' ,- _ "I .111 S N'T -(\]' I TWO V r1 l ?.. ??: DnAKE51.E _• I ?''? +7 L J t J ITY ,.IMPAIREQ_,_- l _ -. ROADWAY ? ?IUi - STAFARTINOIN twx¢ T•? TgFIC } i 2 '• 2 DAWN. .?.-;. j GF D -- L .L--. S : REVERSIBLE - ID ,L! L 1 DAD ,_ T DE ICT L..IIE OL GMi3.: I I Ip DEBILITY S /-r-ROTIMPAOLED ?_-?_ r , 1 6TARTIM-FROM 1 l 1 PAgKFO POSITION 1 ''7 r 1 OW K.,, A„J RED .?c 1INT[RC ANGF _L.. LOO?HAMP -_.-... OE EC Vk 1B J 1.4REAR U-HTS.__ NBO SOBRIEIr 1 IO 1..J-, ...Ll1NK 1 EN-IN6 IENTFRINO ?121J TRAFPICI 4 •. 4 O K f!T ) LIG TSBO ON z I FLASHING J 4 Bi. -G LIE f 1 sL.. [f 1 I O11 SMOOTH J -?- , rIG .i , H-T I BEAR-MKIN- 16? BACKING. y i` - , (I s uariri oipE SIGNAL. B iun WineiFT Lnro IN, CHEM. TEST j ' ?;+ t tii," •;"? . ^ Dinicr umITS I... f D IICEH/ _! AN ePAAG 1m TESTS. 01111. IA[e 1fY1 1 I.• /J _ _f ;I T B' OT FN . T DVIO[D NO DEFECTS - _ ? TEST REF41SED' (• ? I ' 1 { •+ 4 OT kR SPEC IIF If - if 'GH O L - - '- u DUDE- Of'fI115PFCIFYI _ ._, % TEST RESULTS 2 f t 0 NUO < EA 11. U[NU POLICE 0 I.11 . PUUCt AIIA VED AMU ACE I 1C FLOW ?P __ • _ '/?J2 !A kI nArr g°1q: 9 X1.35-,,Go AnnivkD" arA"0 rot-N 11 S e • _ L1• ' M h GDIO F fl [I UUIN ALLNCr uNA OASI.A Uti RATE OF ll[POAA1 APFllov[u NY OAIt ') AA,Yn sN f` &N..- ; -TION OR VI BAAL CGPV GEN T BTAT E YMPIA, .I A - - R 11 TE COPY: LOCAL LAW ENFORCEMEMIENT ENT AGENCY'S 'S COPY =TRRIPLPLICATE ATE COPY: INVESNVESTITO A GAT011' 5 COPY 1 ?y; n ?wL 1 6 PLIC . T ] _ =f Y OH ! V.' POLICE COMPWNT NUMBEI T'L?1i r}!'Ii 1 Xfl: L +rNA1Aa?IFORM OLI_vtlAS??'iJ`A'N rncE oF.: ??D - !,. ?..;.. ETRAFFIC ,COLLISION REPORTr;- - ir.Tr;• "sm,M3.iiF'y`JZi'aDaaTF¢"msL i DAY OFCIXLSION }? TIME ?.• CPUNi ll0 G?•.Ll?i C 'S .EH'!r DATE OF COLLISION /// U O .. D Y ] SUN 1 'o Z IUfs B WED 111NN 6 FPI 6 SA II E 400 O RI J .??? ! ?' i ?... y ?' URAL { 1. A Ej GO 3 .? O EFI Q- TRWTE ?. Y1GfO IRE DE' LOFT t , . -un O N_tt=•_? ?STATE flOUTECOUNTY ROAD ?CITY STREET DIACL4 R S,.E SPECIFYI -- -- '---,- _ _ _ W , _ .EFA EQ l MIEPOSTC D J'Y2611 IN I. S YORIOVM W A VL Yp+ _.r- / 95?- UJV7p,,,,{{{{ JE?p?il f/?? L Gl ?fJatJ t} s T Jb A i C MILES ' N ? ? ? - LJ OF • ???? ? ? r RAMP" D GRAM DATA - I S JJJJ A I_ AME .yO.OF ST EETOR HM,HWAY- •1 MTER6ECTINO WIIM 6TPEET OR ROAD' LL- ] S+ F T _ O _ _ ACC GENT MTEN _« X RD.. TERSECI to TFILLT ON ROAD O REF• 70lITWADI.G +i F{DN PQEA G . e MLEAGE T C15.. EPENCE C.,.o. TPEE, . ?N•`_ BETWEE __ ._ STREET ANDNd A,nfA1REET - LOGE 1:. it I"_ J• + . 11? SPECIALCOD NO VSE 5'' 1 FWZ{'S Y"st RRR JY1J 1J( X WL'` ,?? I DISTANCE AND DIRELTIONFNo ?''7EFERENCE RCROSSSTFIEE I .'. ?FEET??_VEHl?l ?' OF AIZIII?fI ?TY.._ ?. ?--^? SE ERRT j NO xILLEO CIEWEMCIET - ?VCH EBICYCLE ?OTHER(W TEI E] T B PUN COLLISIONINVOCVED. ? VEHICLE RR TRAIN - ?STOtENYF MlE'- / NO.INlURED Pik bN J VEHI 1 6 CLE?OWECT TOTAL NO. '.'.. PROPCfltt OAIAAGEONLY OF VEHICLES Q VEH CIEPE0E5TNAN ? ON COLLISION/ ?MA2 ROOU5M TEPoAL S OBJECT 6TRUCRINAME OF OBIEC STPVCP ANOOWNFRSNAIAEI t _ - LOCATION OF OBIECT STRNCNS ,i- w .k..w. E6kpN^Ap ?*1 • ' ?ROAOWAY FEET ? ? 181 ? PD EDGE IpR DRNEL9 NAME _y[ j i^?? DDE? ORIVE{$ NAME VST fl MDOLEV BOTCL6I YCL p Jl HE?JO`I y D D: J t l4L)12L1SCD .STAN ? E " • .. L R STflEET? DHE55 -. ?.? ..f? .., ?"- ... I, 6Ti DORE..S- ? J.. '{; . STATE.>.::....?.?.+.? 21P. CODE StnTE.? -YIP. au[_i .... PHONE NO. ..PJIONE ND,? U 1? R R - 51 TE SEx DATE OF BMTM N DflNER6 LICE 5 O .. •. .. STA E SEx DATE OF BMTH Y' I .,.F. T p x N UWVERS LICE SE NO.:.- 1• " " /^? MO D Y R Q '- O AY fl _ Z A ... ,?.? MY1 DPMO EN I Er60CLVPAI .. F AME'.:'...u-••-, __ PMO ENO Z DR EPS OCCUPAI ON. FIflM NAIAE CODES_> LDI cLwss- !I SEAT BELT 151 EJELTIO" CODEcS> ul CLASS-. 141 SEAT BELT ISI EJECTION 1 i NATURE OF - 1 ,V JU ES .• T"= "`T" IWMRIVS - p I r I S 1 FEOOSGEP I'- FR EHEB T TO L .. YEH.YEAR M EI HE J.. M ELIDARTNOVAI. STYLE I2 fl.{ONYJ VEH YEM EIDOOGE{NEVI DELI ART OV SttLE 12 DRGONVJ I 3 x i TAA LER E Oq UC,.PLATE fYJ 7 6TATE RAIIEP:PLATE.NO.. WATEv VEH .DOLOR iJC PLATE ND STATE_ P? LATE NO STATE',,. 55'V,? H, p?j M a _ ?A ETER.iYn C VEICLEIOEMIIFICAT ON.]VMOEP t: ODOMETER 1JYDf0'A3? YtiT1T I I, OAiN 32 UAUR -0 (" YEMICtE I FC IOH FIU DFR . •: _,.J?JnY _.: - - - . .?iY ... , .:- :.,. _.,., __ •_._ •3 1P-LYE E- IH.I:,, •'t _ L , Z .. ?. E ,.p MODE E REG IEPE00 NEP tA51 {W. ..F RSi -ui'ID.4'TJ iMIDOLE l •O. AORES6 DF OWNER i.+-.. .t ?T ?... AD DF.OWNER 4 v.A w].: :•A -.2 1 }Y{ y Y ON?" ' ?F NAME ANO ADO ESS OFINSUPANCE CO.OR AGENT - ] a k NAM ANO ADDRESS OF NSUPANLEC OT AGENT •• .... b -.C S r•. t r_ CHAi1GE CITATION _" CHAPDE .:.. CIT 110 N0._ ACTON. 1111 J it IJ F -0 TL - VLr V•YJ V'Y10'S JJIN3J 1 O W LSP 3Y5 COOS r .? L 1 .,'p j 5 C NAMEIADDRESS & INJURIES OF PERSONS INVOi VED ^ sEx AcE sT?rus EJECT d t (,` ADDRESS EMOVCUFROM •? >' U-NTURE OF V SCENCDY TO 1•. ryry p - uutlPl[S . . PP A A NAGE• ..w d ?:?' :. i. . T AOOf1FBS'? ..", I.M v[r?`IA TD f. 1 3 II ? ' iLnlmE9 __ ,' Af ???111 1(r ;1'' ^W NA4C:.:. r. _ _ _ .OJT JJMt] '}C ...+ - .... SS TO . ;... 1 e .. ?.. } .I ADDRE' I L u lE 3v[UT9? .. .._. 1 .._ RcFNE Rr L? 5-.i NAME 1 .. ... - ? 1 S ADDRESS •, - i0 - e. 6 AWI S. SO1 Nr Iiy, : _ 1 1 ? , k I11SiAtU6 1]ISLAl POL411ON Ijl xillJRYGU55 EAT BELT 151 iNO ION I 0pLqCE M I3WRY.:G 6 DI6 RL NDINIVRV NOI MSTALlCO 1 NOI EJCC/ED Pf Dl51R141 1 2ENE UNONOS MNO 2 INU?C 1.1AILYLJECTCM FI _ V . D 2 A-NOrR t No IDDW1I-ll Ri(NIO?VHIFJCTCD ] 01 5R OIONICLIFI? PsDWhTAµL 1rOOYD ENJURV 4 VNOIKi D 6 Nii NiSfl?, ] B 1`QYTIONU a f+l , L:_._..__ _, SJi AT BrLT?LUIBE . EJCCrto T .' r ,1 r,? I l?l 11 .;? J ? t 1 ? `4? I Y ? 'lf _ I 1 _ S t I I ; ?? 1 ,r T! f , t i i 111 J 'YY' ...I - S 11 7 I Yi- m.Y 1-; 1 ''? ' ? 'i.4 to 'w ' i x hT F 1 r tiI +? I ? ? N ? 1 Nt t' 1 I Y n'J? ?f z , b 1? ?1 ?'4?''?t?'f`?r?' ""`" R ?' ?`G?Sh?"43?OA'?",-, °1y'-?3,,. ^ae?a$' • F '?S.^,z 'r°S; 1^;',?j0?,',',rc"'1?5,:,i ?,"g I 1 t? ' r (?? .,r?,. ,?„ ,fin ? 1 .K? /i I f v tl ? A J r J - " . mall IICt r, ? Stir ?. ty`, I .y Nab Fp ? '? 1 Sai c U .H? ?L • DISTnIBuT10H..ORIGR1ALCfA' V. sr NO TOWASIIRGTON51-11 .. INVESTIGATOR'SCOPV DUII.ICAT E COPY• LOCAL IAW[Hf OI1CCM[NT AGCNCY's COPY-iNIPLICATL COPY:- , f' E•. •-'`???-r VEHICLE DAMAGE 1. IN EACH BOX. CIRCLE THE NUMBER C•` EACH DAMAGED ARE S[A SHADE AREA OF SEVEREST iMIACT L Y " ` ' 1 x 0` i ? . INSTRUCTIONS. j i. DRAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE. O/ x .'. '.: . . 1 _, DAMAGED VEHICLE NO T Ise THIS SPACE FOR SKETCHI ETOr .MOTOR<CLEE. ETCH DAMAGED VEHICLE NO. R fV - I L C I H. °° „ N w X , mm?,A •W r E M y TV DF DAMAGE; I- l SE EAtTY F GE 10 ?C EI C •JIO ? -•%'?\, y o 6EV EqT Oi0 M.\Gf VENC O T E DAMAGE I A GE ] DTM GE pE GE ? ? ? DI J ??,y{?O F+TP' O .V i 0 EARL G DAMAGE S L DA PGE GE x ] O • [I ?LGE. L AGGE - E I? FUNCTIONAL D GE A C ONwL 10 E T OAM G % ? . • DAM E E EST. . 0Y :_ D E E ' D ED Br S TOWED BY D - G To G IC?\ _ IDfjA}N ARROW SHOWING - J NORTH IN CIRCLE,' 1 ?;OIAGRAM OF COLLISION- -•-r : ? a \ . '? ? It .? _ F^?jY?1 ? \ Y3?^ .? - ? I y O ?J Imo.. _. _ I L -,DESCRIPTION OF UrvDICATE WHAT PRO0A0Lr HAPPENCDBEf-DURGArvO ARTER THE CRASH.IrvOqLAUDE wfOgAlwT Ok rvOT ONO _GRAM.EG, npuR _ REDUCED VISIB LIivP DESTNIANCLOTINN6CUL?GOxSTRUC;O PAIRIORK,EtCT?-,?{'.Vf DISABILITY J _ ."COLLISION , ? ' ? ' ? '• a ?r Tr3 3.>:r•YA _:?\ -.--???--El s 1,.?`• - __ __ ' ??` - h _ . __ 77 7 PA ED VEHICLE I ' . S R R? E POSOITION BEFO RE pCOLLISION v_ NAME a _, ` Lo PEwEE[i C { 1>• ONE Q q 5J u MILE P ER-.' OR Eli: SIR ET OR I ` F L c En G p NCRE G CR V •. J.X I .` \ - ` / I V n E LD E IDLE TD x to E R ]??.. - - .,. - F IL EO ? B RATED l0 -1 E MARKED rT G w } LE. I I C U LK 0 WA K 5 UjR..7 ? [ ]IJ` ' FR TE W PE IT C . CONTRIBUTING CIRC MOSTANCES n ?`,v YNp ri{ .ECK6Ht OR -11 c ,RDA OSKONEACE ?WNE TOER IC T. ER .. fI?J RGA. ... J. R I D .,DPI ER O O O] ] / 6.2 .T-J Gn. SRfG t?, -I,, 1j1A-O Efl 0 u O CLEAR. E OUDY NOfR NFLUENCE Of T Y G N IR J\ N zi-E U-s G ri ? _ DRY II ^ISILLVERCAS. f_ALCOHO - M?.N-TUON R J ] INING ^]I pgUGS ENCE OF nBnu oR rJ LJ sLgE WG? -• J T LI. _ ..././ T SNbn ] ? ? SNOWING I EXCEED G ED ' ?G G n _ AC 4. 1(1x4. ?1_I t TURN '- 1 [fOL T .. 1 1 C f T _ PKI - (l1 KCf G s.? J J G "? " EC-fFODIP. rB.'.. .. _. TUP E F t • p 1 ANT RAY r? {? 7 JB? S NO OxOT GR IT1 OQ 4.41. I CLf L_ fl i _ __ [ p E 1 LCN I OTNE CCIFYI pP R 5 N^ J O N F S PE OR RAFI f c.. .T F1 i sNC L ?P ?'? ? O -. I I SGNAL RIETY PPE LI HT?ONOITIONS RAFFIG CONT Cl n 1 o,at.I, TYPE OF R.A. VEHICLE CONDITION-. SOB . ICHEC%ox0 ?_?B? RElD sGN CIE '- [CKONfI HIT LE (CHECK ONF OR ORE E I'LL ??IJ?C {{?? E ? _ D ?I$' R}IAu{EOM ] Lr 0 OE DY" I NO .2 ONE WAY ] IF FIA STAR iCLANE J 1 MY 11EO _fO? I SOP w0 Ar BgAKES Vf _. 1{ t ONT ?] _ 1 Y ,) D v 1 G q D if E 1 N ?11 SITON V RS RILE K A I F ] i 1 J ) O)1 P RCD 7 -? N ] N AD 4 i _ 0 L__. SG -_ -?. ROA N00 sOBRl[iV r r 11AfHNG ILNIERINO , Lw5 G r NT 1 D I T f I J'i' L - .C T T l . . ] DUSK P r-REAR LlcllTS_ FRED _... <_ OO IEI AEK ING ' WMIt-SI LE -`• Ln NG ALL 1 - 1RISw0NN I AE xOnT 5 I 1 IKING DtlXp4l L IEI I _ _l.Ll En_ -.. __ ID E CHLM T EST I LIWTSAN _ E ' 11} Sy LG {%f .I -i??l. G L. 0 1 CGiTf1-ES-? , o __. .'-I lF O [PIPEC 1 / _' { P ! fiRELI?IG TS I OF CER/ E .:? _ .._.. (.( __.__... ._ .{_' G N .?. - 71 t NO DEf ELTS 1FST RCPUSFD - -F G. °fA ' TI I . S_J I ] Ov [ LJ 94 TEST RESULTS 1 [C YI - 4JIl.. ] uNR fD ILUY Cf i wM .g [AAN% ESNGwlINGO PIC[l6 NwM 11 INy Bw4G1 NO PUL,f.L' Y CHEU u LI[t ARIHVFD VLO MPFOlD gI RHS I v[S1MwT IHfN LIE •RANK. BADG{NO ?G{NCY II nx OST RRLT. RLPORT OwIi OI y APPROVf00Y GATE PATIIOL-OLYMIIIA W ASHINGTON9050E 1 f,',`i n 777 it g?yyp'/..f .UNIFORM POLICE TRAFFIC COLLISION REPORT - .LC?OM,?P,UWTNUTABER !?, 1„FT .117;11.1 3V . _ DATE - IA Y DAYOF COLLISION ': '. Mp lut5 WEB t SUN / Z O S RI S At -. jIME Z R? - '). Y na o COVNIYTaO/ 1 {!) J Lfl D 1 "f(' r _ QA • NTY "_G: ?STATE ROUTE COUNTY ROAD ?CITYSTREET .l ?OTHERISPECIFYI--- -- - O N T,T• EFW. ROUTE Oq $iflEE7 CODE_ CT -l J ( / 9Q. C E W '?IN .. CI ORTOWN -,. 5 MLES El 11 ? ? OF -:_ __ -Eh T W U . . (?, - .f f1EFU{y E6 d tp Ar1WST 9P'T y'GC 'Y! n rl }"' ?) - rtd., - ©%? ^ • : 1Lf--r NAME NO.OFSTREETOFiH%IHWAY 7!..,. WTER$ECTINO-111 STREETORROAD .. LLLL •r a . N ? RAMP' DIAGPAMDATA "?t ly z? ? ? ?•? 1 'I -?T.r , S Y, j Y f ".. i r?{?.( Q NON WTER$EC I ACCDENT MILE G LATER NON %RD WTERSE T O sI61FEEREE O FIOAD OR RFF I E ClS ERENCECROSS BT EF A p `•• TQ? N} BETWEEN RFET E CODE ? _y . ,f s -d'? ' y.?(aYFT L,,' gS?µC AND DIRECTION iflOM DEFERENCE Ofl LRO iRE 7'I 1E5 N S E W ••• 77[[/ N „x . y I G EC?L CO INOUS v, !Yy,? N_S .lI I/ b L '?S P 7 , ? ET OF ? i U G..r_ 3L, Y ) ? y?y lr j 4 . - ri I ?Y. ; K Y h `,cY!,tf??i? !r L X{ COL . LISION vEHICLE'VENCLE•_ ? ., VEHICLE BICYCLE ?OINERIWRrtEI ?HIi RUN I VERITY INVOLVEO- ? TOTA OFV i ONLlFO L NO O VEMICLEOBIECT ?VEIIICLE flR TRAIN { ?S10LEN VEHICLE NNO.INJURED EHCLE .-[?V . 0VE CE PEDESTRIAN -jQ ONCO SON r ?HAZ DOUS ATERAL _ ?PROPEflTY OAMAGEONLY OUJECTSTRUCKINAMEOF OWECTSTRUCK ANOQIyNERS AME7 L- - .c''L_. LOCATION OF OGIECT$jflNCKs?. E„ y 5:.1. ]!µ110E " N ?No BY, Y FEET ? O ? ? OF T EDGE'' S ' `D . "^T?? C MOp,E D [ ? OR VEgS NA E.USL FRRTMDDLE?K BprCI,$IyR PEOESTRLAb CjrECKIR„ - „ t ?fy Sl CEl AODRE99 F+f, +L, V Z.L.-?. A l:!!w { J:• Si) t t ZIP PNONE O RE ,,. CITY STATE f IJ ;t ZPCOpEk4 ?: PHONF•? N 1. .. r ?7 ^ ? l xJ 17 C" 1 1 D E ENSE No., ..... STA 5 D TE OF Lun IM N DflIVFflS UCENsE STATE _SEX! DATE OF BIfITH:: r: - O AY r A . ? Q MO DAl Z OfWEn S OCCUPATION..:. FIRMN E., rA V_ mpi - CODES -> 1?I. Cu S TAI SEATD LT 1'r [JECTICN CQDE$ ?>I]I CIHUVRY, SS SEATRElT ISI EJECTION T.FEC,, N F ;.... :,.. I-ES -UNITS :• ... ..- •' NTv SCENE Br TO EOOACE E V .,v . O VEH.YEAfl. MANEI C U' LIDAflTNOVAI?: LE L2 R.CONVA -' VEHVEAfl. MAKEI(OOGE-CHEVI_ MODELIDMTNov" STYLEI3DR.CONV]:) - -- n. _E N., i l1C _PLATE AA STAT E E%? Tf1NLEfl PLATE NO . STAlIE 1 l • _." EH. COLOq:_ .., LTC. PULE NO , _ STAT&, - TMILERPLATENO.- STATE"*a!4` M _C V LL IT NUNBEfl.AC - Y ._ O IEM i.. (?` ; E M.SE 1DE"IIFILAT ON NUMBEfl _ OrDOMETEfl[ALtli?littii^_i .,r _-?;: .I"( . _ - .._?J..•lt It I21 b?-- - ;L ` ' `Eu ,. , ; A . , F , .I /T! y I:.v RAJ (i ,,, '.t.. ry) ;a OVNER lA5 •'•.ssfS6i A>i.•aB•: ..._. MIDpIE ! REGISTERED OWNER NSTf' C t FIflST i.W?,.. EI_AVpptE V 7 Q ; I Oti I ! V 1 A 5 r1ER' r 1 + '\ ' • 1 ' . ... L r , OOR 55 OF OWNER S:4: b, ...A' Y 3 1• YL ..??? NAME DADDHE OFI CE LO AGENT..,. NAME ANDAODRESS OF INSURANCE CO OH AGENT:.. _,.I.J ;_ ?? CHARGE 'i - CII TION O EIFOf CMEN cNAR ai- TATK)N Li 1 r OTPIIjt .. . G u ADD Y !' ,•7'- ?m.S!'4 if, 7 7? Y 1K( fM1 f iC ?'?. S CODES II 7 `.1 -:lw NAME ADDRESS & INJURIES OF PERSONS IN?OLVED .• •. 'C SE% AGE, $tATUS rv w .EJECT .. •..1T•ui:.tiN.St, \ wr-?'-/?. ?. Don[ss, 'r ; U t -..P I ' 1 o URE Of, --7r ~" u=13.?'!!_ NJURt[9 ` ...: SCENE TO .... :'.h .,A ,T 4 NAME•T ., ? ADDRESS A . q •.: 7 ?! ADDRESS' '., . eo N .' ... A7wE n 5 ... ... ... Sr.FN[BV . , TD I x , 6 _ I 'S a ^. ?, ar?Gy u !? ' ' I• I r 5 .. J u'TNr Br To INt IUS 1)ISL.T19511DH - J tlA lR C st I Iy;,W . C D I 1l I a tl BEAT n(lT : I[I[JECTgN F I P ,sr. Nar. I NO JUfIY I5 'a All r10 Wlun Kll $TALLED• NOI FJ[CTCD f 21 3 CCTCU " Ot LR ' Tt ? 1 4 NIY Or t D . E, KIVS VOIORC OLEj SA r ` ., tl0 ... ! M +S A I!?N UI. NOWN A, D POY Vm?j p"If 1+ J ST II( iT t . a . T . L M NN 1 a ? I'r 1 Ali f N wrrcr A 5 k wr Y'" 1 I?.,I fi1 r t ,? ? ? ?u1 1 I L,,^ I r _AI'o-r r ? ?n l[ F j. f ) .• IL?? fi? ??I.wY ??FA?CIfiCfLaL TI? L7TCYF?J?.?U/MA4F.l1 A'FI'EAT L?X?? I • ]. SHADE AREA OF SEVEHEST IMPACT. O% SOL• + INSTRUCTIONS. J. DRAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF ED E _ DAMAGED VEHICLE NO. 1 IUSE THIS SPACE FOR SKETCHING DAMAGE TO mwLERS, MOioncvCLE...- I DAMAGED VEHICLE NO.2 Y - .. 1 Roof 0 H CL ?I Of DAMFGE EH ClE NO.•f.. T 0. W SEVF OFD GE -H-1 SEVERITY EI / Tv O O GE. E 5N-'-? E ? B GU MAGE G ? T E V.D MAGE 1 ? p GD AGF : DAMAGE 1]EHHpu AD GE" ] OTHER GE DISA F ] ? L 0 DA Ofi t ? 0 D GE 1 ? FUNCT ONw OA LLLJJJ NCT 00 E ^ A -E SS T DAM GE EOAMAGE TOWED eY G[' AMAG Y I L? A.. WED BY OWEp Y rvt e 1 S ITO T ??,? To ?. ! , a G b1. AGRAM OF COLLISION` ',}y- I- ?:r '? 1 -'?-:?---flNOR HRIN CIRCLEING - ( ! l r?ill --_ 1 1 ° FAY l 77j --F F 3 ---IImo;-c ? ?? ?7'r3?" =a. L^ilA1 & t i I - - 1 ?-rdt KLp,L bN 1 r l 1 1 I -171-17-1-7 1 N ' l DESCRIPTION OF _ of Lr. ouce° Irr,PF° NcL° _FCC°°EOR,aonsq0c?, °N}t/?i`.eA ?R ??1 { 4 TO., e 1 4 er \ i1. b n'Y. CSC, 51 Il' _` .d=? ' ° VIA ?3t?t`?v ?yz?r s _ =? ?1 _lt.r Id ay)y Q Ja 1^ ,L, _- _ All, - 4e, • POSITION BEFORE COLLISION "'' NA O n .•. .. p °FIL o !D- A-.- E d F7 lj I_ L Sof 1 G V I ?E oC 10 -El MONEAOEO INCRF G CREASING rREEi y OE S W A r _? t _ M ao f_° ' ?- C?CI?I DNG ??1 }FA .F PED. YIGG 1--I SIDEIMLK ]?_? J.? 1 UL n E M.FGA? -WA 0 ED 6'? 1_JD E ?... S-A PED C LIST SU EAC L',.• yyy .,flOAD SURFACE WEATHER CONTRIBICTING CIROCUMSE ANCES ..•? 1 OEn E I, rw 1 ECKONEI NEC EI FNYER RIVER ] ,°N0 T AHEAD iim Ny D LE O 1 110 1 CE OF ICI LL G p SOE JFr1T G - !? .' + pqY YOYEACAST- V UND.El ha NFLUEN CLO v LGN, J N' 4,0 t t 1 L? O ]]n wET ]?Rn G I] 1UNOFR rvFLUFNCEOF n..n YFF! ?F? MfT', ]?} { N I r]? ` SNOW J1 1?1 E+CEED NG STATED. `IN LIe© nPE OCAT e ?.f?. A_ G .?.. - PAOFK71G F 1URN f IIMI wI? •? AKI r D HDE D_ Jfl U C OG )j FE EErvGDRE N ._- I 4 i F FC YEIVIP g -lJ f? sL? r? n ° ILiEA TR=? Di °GV 1G- ` } _ I_Ie? sow G OIAEO 1 ?T? STO E F i j - O [ I C I f C 1- er' OFq DE] O ElSIGN/SIGIIL 510 [7,E] NGTH OV I TRAFFIC IP LI HTCONDI710N5 TRAFFIC CONTROL .v L-E TYPE OF ROAD VEHICLE CONDITION_,_.. SOBRIETY' : ??n?,sD n SIGNAL IT Y IC O EI O SvF E O] 1 ECKONEGRMORE E CL '{S I??PAp Q V C E '. - fC O El STOP S r' G r ° E A ] 'TCO{{+/?il?{Yk?^1 y/.O T y?a.?SnT?eO fEAIN DEFL .7?jCAH NG IN ,, . ' ` ? ft°f r, ITrL' TWO L?".r ++---yYYf RAf FIC LANE 1?° +t r? Fui_ a\ ! ? 1]rco'? 8fE T7\ ??J? oir? - L.I?Y'?? ?ihl? ? )IITi.nKFDIO5 T1oN r. - TE GfiG NATEAINO NO n[ G[ ] 4FF T E `]]? DSO a - unK___..- L-1 RED. _ _.? ...._. .__ _ FEAR c u . ?. J .- I L.SHTS ON EE u?! ._ A EII G .Let.,. v. - - 01 5 ODJH - , -! CENN T G [ e? _ CKING ; r"' S gEfT TwOw Ert CHEM - f 4 ={ L TEST - K-rw r' snc L sr r - r\ .. \a? i? rESrG E OTHER N l-1• I ! ... 1ITHEET LIGHTS. _• `._) G N .- - '- _.- _._ L.-. -_ _. _ { :11 IJ, ; } T "' ' et- T E J p I NO DEFECTS TEST REFUSED 1 orHER laffclF 1 rK - .°}N I5 FL r - 2 - - ' 1 >-1 „ .T } If1 CpN+.ol ?..] vNDWIDEO - % TEST RESULTS ` I E~:IC ARNWED MRULOCt. I Dfp OW T nx. IS ,DAIINGO CE SNAUL.HAN FUGI NO -C N,Y ]FHO T t , .?K1 L E?l t} P JU f?E+ 1 "(;,r.„? ]oo jE'. Nns NN HI'S -S .cwt S .al '. ++ L" N NfO LATM44 Cl HAMEe NK `'A eADGf NO Cr 1 nit 18'41:1-1 DATED I,D.. IIIOVLDAY UATI E OISTRIBUTION. ORIGINALCG'Y, SEND TO WASHINGTON STATE PATROL-OLYMPIA, WASHINGTON D85N DUPLI;ATf COPY' LOCAL LAW ENFORCEMENT AGENCY'S COPY-TRIPLICATE COPY: INVESTIGATOR'SCOPY S dI 11 ? •?? ?`Y` "-1?,{13 ?j ?? I .l 'ircr??u5y '? ,+ y, .? ? t a k t tjy4 ",.?.??n'Y'FPN; 1 i?Y: FI ' ?" .a 1 i >ei P9 µNfk ?'r + r -77 A1. ad •F L `-? ..'?. t '?1 . '. I •.??.' 77 iwdl r y i •. I H I G V N PAGE . OF NO { j f f POLICE COMPLAINT NU BER V UNIFORM POLICE TRAFFIC COLLISION REPORT A .. DATEOFCOlLIS10N ` DAY OF COLUSION TIME COUNT NO GR NO fHWA M?.I h T SUN 1 Mpl 2 IUIS ] + InUN 5 FRI SSA} IUGE'?I ?Bj1R1 ' ET J '/ ? T' DURBAN OWNCTY - 1 ?KC? ?STATE ROUTE XLOUNTY HOAO ?C ITIWTE ET [:]OTHER ISPECIFYI --- O - DM CLB PflEFX t ROUTEORS1flEETCODE I _ 5 ?.? q Q^ TKW O N 3 E ?IN CITY ORIOWH MILE. ? -?_ OF??AJ ?ocGi -.-.? U 1 PREFIX i t EO, Y MIE POST aG (-i C -. . -?. -I AM B MO OF STREET NGHWAY INTERSECI WGWifN: dTREETOR ROAD-• L'L RAMP DIAGRAM D ATA i ,{ ON ON [rIO H T O? NON - ACCIDENT C NIER 'NON %AD WTNG STRE A..OR qE OROf p? E CIS : ERENCE CR OAD SSTP ,r ' N'• ' . rt ??JJ (1 (J BETWEEN.- - .. ??_ -_ Y -_.j.OL. STREET ANO r STREET M GE CODE . { P !- _ C p O_ pISYiMIC ANO DIflECTIOfI iROM REFERENCE OR n?CHO'SS STflEET_ 3 : N E W , SPEC 4CD NO (U'SE J --.. ?,.ny lyU...ifi 1 n / , OF Jf(7I /?Y EE, }?7?I ?:M . uDM l ?:I [] VEHICLE-VEHICLE ?VEHICLE-BICYCIE ?OTHER(WRITE) ?HIT6RUN' CO LLISIONINVOLVED: SE EHT ' No IuE. ? } 'o-No. ffVEH6CIE-OBJECT, ?VEHICLE-RRTRAW _ ?STOLENVE-I-E OFVEHICUS T _ NOANJURED LJVEHICLE PEDESTRIAN ?NONCMUSION ?HAZMDOUSMATEFIAI. PROPERTY DAMAGEONLY . , ?ECTSTHUCK IN?IAE OF OBJECT STRUCK AND-Efi3 NAME) v i_+ - ,I :I ".' LOCATIONOFOWECTSTRN CK ?,,,. J:STJJ.. AMMaE.:%. i IN OF / ?ROADWA FEET ? RO.EDGE S •'- NS T, --_- '--FWST?,T-- -_,'„? N%ILE rER B : Ej1 -FIRST' MIDOLE>IIfpIQYCU51. A(iCNECK) ?g,_.s?"'p$ .D.. , R7 STREET CF?A2 S.E. f . ' -v . RE. STAT J,.,.. ,-•.ZIP CODE:.._. PHONE NO } ?40LUCk tjlq V 7 `/31 28 R_ CTY.: ?..w ;:.:,..._ "-,'STATE'.:, , ZIP CODE ::..... PHONE NOS N' DiWER9 LICENSE NO.... _...:•....1 ._.:. .:STATE-... SE X DATE.OFSIRTH__, '. N DRIVERS LICENSE N0_- ..' .:..:. _.,. .STATE •.. .BE%:_ DATE OF bWTH_'.?.I °' ? ? Cak)Tf Of//(381JA wA / ? J -1 ;Al YR Q•' MO. DAY Yfl.: ? , MNERS OCCUPATION,. iWM NAME..:' .._:. ::.... ..-..•.-- _ "NONE NO. DRIVERS OCCUPATION •. . FIRM NAME . - . _.-.._.. ?..._,...... P N ., CODES (!)SEAT BELT ISIEJECTION . .CODES >13I L115 5 1!I. SEAT 15) ILIECTION lion NJURIES 6CFNEBr?_ T -7777 ili0u 6CENE BV TO VEH.YEM. N IDOOGE CH Vle' MODELIGAflTiNOVAI : , i STTTE I[ 0.COlN1 _ VEH. YEM , MAKEIDODGELNEVJ,J. MODELIDMT DVAI:i: STYLEIZDRCONVJ.,r ?' 77 rvT =- '44 d S w - -- ----- E " H. C TE I:O. l LZ9 STATE . C O TRAILER PUTS. NO. STATE ' E ' VEKCOLOR ., . LIC PLATE:NO_. STATE. TM I.E. PLATEN. STA ' I ,. y f E '" . C D NRFICAigN NU [N:fl „•.? ?-'. OD METEfl:c -..C VE ICLE.IDENTN'K:ATXTN NUMbEH .A:+ '" ODDMETFA sLLRG1Ytp3g1 " RE IER[p LAS( ST.• „xc;,C?_,J IDME,. 4 iJ. REGISTERED OWNER- s HQ •;:FELRT ',:'G 3.+tr?n ":LLAMOME' o ` ,.?F, .CaFfo?, F?,(>~c eisis o ? . '; .?• ADOIIE55 aE? NER.--+77« ., - / ..... Y.l_v, . D..lS?jC? GO? Id'[HOC?Q.'?J (,JAQ .'2 ADOflE55 OF OWNER . . L3 .. ?? w' 9en ti:?'!Y.:r?f1x . .I .-L ANO ADDHESSOFN3 RANCECO. ORAGENi.;..,.• 1 .' C ....:?1 .. ..- CRA ION NO..:?• ENF ORCEME NT,. C• ?_ 1. .._. •.:..rJJ" J..' NAME ADDRESS A INJURIES OF PERSONS INVOLVED'I -COPES ..':: Z J A'..• :N:btJt i ::.f1L•.. (.?. ^ . ` BEX AGE SIATTLS EJECT: C. NAME: - C •' ADDRESS I U p" NALURE OF IIL MO LOFROM . NJURIES- SLf N[nv TO A ., NAME .. .. T ADDRCSS. S . NATURE MOVEpFHf%A ES SGf NE RY TO .I / '. W NAME: .. -- I T •... ADDLEM r r D RoM - . 'N'' IRlA . eci [n N T O - - S A ntes[ W , $' MCI` = ,I of HY 1c TO 1 116 AIUi ITI SIAI rOY1XW IJI WJUHYCUSS I-1-IBELT 151 [JFDIIOM D J YM INp N OfvCpLAI 11?T1 L T OTICn rD!i14]N 1 NO .1u., ] MAD 15.... AL ] M OOH I 5 DIGADL NO INJUR A ON S TINNRV '_- I OT NSIALLED r Oi fI USE ] U [0 I NOTEJECIED TED [ IOIALLYEJEO ] PAn -Y EJECTED , E _. .. YA1N[S5 ._ .... ?. ..-.? ' .-_ ,. _^. RUS MOIOHCVCIFI S ] _ SP051IgN UNANOWN DEDMIgSAtA` 1 ?. T Pp5JBlC IJUH UHOVI:I _ 5 BEAT BELT FAILURE UNKN UNKNOW NIf.- _ I EJECTED A y I .fI t k ? L y. _,,, it 1 ; 41• ? r ^} ,L?,C,Fw-.. ?.rz »PV°v!!'Iy'..,:_, P. m,?!93E1Rva5tmmrcuq -?IDW^ '?iGPdS5?5.+m"+ '"R,-.'?!wt! ?n I,vf--?i?`?'"?' fl r t`''., 41 I , $NMS ?? fl„1 R`.e_^T.lw .._.. E 1. IRCLE THE NUM ER OF EACH DAMAGED AREA. INSTRUCTIONS: ]. SIIADE REA OSEVEREST IMPACT. i :k ]. DRAWARROWISITOSHOWPHINCIPAL DIRECTION OF ORCE. r6tm DAMAGED VEHICLE NIUSE THISSFACE FORSKETC.'H..ANAGE I_l.MLEHS,MOTOHCYCLES, ETC.I I I ly N„a DAMAGED VEHICLE NO. Z ' f 71(r !°p:l r • .JPR- 15. tlIL ' • a 'Mi I??t S ` /' [. Orrrrv.nrl+a eZ I 1B I I \ 1 I I• ,_ 11 ? SE VERITY OF DAMAGE! EHFCL N' 5E VERITY OF DAMAGE. IOTHER Vk[]NCLEI F Yw G D ] ? OT SE pwA1pGE E C E N0. ? U 5 BL G D GE 0 TNER M V. DAMAGE ? pISABLIN AMAGE T ]•Q UNCT N AL GE ? N E ] ? UN NDAMgFRM.OVEDAMAGE t CJR`uSwB'o GgpgO G GE 1 ? OTHEN MV AGED GE • ND ? ? 0 ?.( 7• OWEp .jr `Y•?! EST. DAMA OWED DY CT D AGk TO WED BY \_ Ei D AGE ° r N.Y ; To ??. . ry [w It L , I OIACREUA OF COLLISION i .I i 1 EE? w 1( I NORTH IN CIRCLE RCLE ,q -? _,i ..._ - IYy I O O iI. NF f _ `I -?- - 1 t li 1 DESCRIPTIONOF T IIND LATE WHAT PROBABLYN ff COLLISION DISABILITY, REDUCEDVISIeII T EE T DN DURINGANDAI OT ING COLTIjiF uc L SIN T O 01 DIAGRAM. EG. DRERE _ > c mN OH-VE?F?I TCI H ] - )L? v:-J ,.r1 1__L..t, I_ \. I ?-? ?-- :t _?_r? fem. 1, .i?` l? c;•, i,.?x ' -' POSITION BEFORE COLLISION ( VEH. 0 E E . .. ? C GODECRN I .x 5 E T GR NIGNW J NAME OT NO. ... D EC ION i wu P F ,yf0 AG ED .aC S.. YA r x 5 E IT N. NG .. 11 • Y C . t ED LJ E .0E C .? L.7 '? [E LO ^-'? 551NG?_ A Y U N `K'O { E CYCLISTw C: 1 I -]i -I] I SHOULDER •?,I CIDSSIA SI1CROSSWALK ED' ESC O E (?E ON?,t_???- F 5 t J CTNER R AD SUfl FACE WEATHER K L i 1_ I B CrCLE FORT DRI ?1.,4? Y L SI•? DRIVER OF 0 ; ... E? ._. ..: 0 ] E Z y PA. DBUGS ` I (, fl LY J i +Af. elr. IC ECK ONE) IC O I "?? CONTflIB C TINGGCI ORUi.IR{ANCES-.. r` IpU. Erq'/FVI?xFI EL/E? - l } n M7:T ! ?Y1 ER UY UNDER l EO rl=?, ] n ING n]n UN INFLUENCE T f0 NGY O CENTER 0 ] ?dG EL EU P 1! .`1 S FE?n l_l 5 R 0 AMEAO rfl] ^o?oq ,?ilNO J ] ENpv ] - 5 O ET B p E AIPA E --- A R 0 NN R TED. w O ] WLEDL.. J ? 5G GTO GIS -jMPR I TI _ S LEFT O lJ OO E%[f D G [ CE I AS E.SPE.E 6 m D E D f - 0 Of....NG - LI 1 0(F FC[IV F.." [/?} L (? fK OJ'? OF O q MFE M[R IY(CIFYI _ I FVI ?- TOP?1 NT GQ1 I •]I ? 7 . LIR LO WIND (7 I J L-.BL.? SS NG 1 HT , (? IITLr:] GNfS LN?L T? I r I l fBu ON OLAI F 1 ID. I-1]O O ED FOR 1 STPP U ONDITIONS HAFFIC CONTRO E }t YPE OFR4AD IC NFCK ON l1 INO.]VENICLE INO] E OR ICNECKDN ORE ,_VEHICLE CONDITION: y FN CLE ?? xE? QR - SOBRIE Ey- '+-?1?: I i C E-? 5 ED qT ONAL ?0? ? 1 n i GNALS r ONE AY 1 UO ] ITs rflii t?Dl N. CK ONF CLE IC , ] 0 ' RST0161GN .' . IE rr ? ?. .GNT I ]n 3?GN_. _r?]I-.1 I> ORAKLS E !-? . I IC . RTA .H MOO iO _La p U L????6N -n gFY A IF WS -__ E? 7 I-I _-. _j , I]l GEFECR T II gUI NORED MU-1 T MFAIBE TR C LANE L JII? ^ KEDI°LNITION - • FEO 1 N0 ?p N R E- n% J 1. ?EARCT.V, ]?,NO I.-TY'-?-• ; . -I?-II]I 1 BF.-IC-11UNE LJ iJ ,GEH, OF- DEL _tjL_1 --O SMODTH L] IIRE11.RN II ? , ?, wD E ED AC ° KK 61 -BI-ET 7 _:L 416NT19tt_ ?!? RR 70 TWOWAY-LOT .36NAL':_ TURN IAN,, - _ , - r- ^T _ 0" I Nnls.uxclvNto w._ _rw I nn D CHEM ? TEST R 1 NO. - DANK-NO I N B i1 !lT.LIG Ii. All I eF N L_?__w ^- -- a fi vEN IFYI FRI F ;? 1 .. EI 'EOTN[A IVIGFYI r_/"I .. _y-,:?.? DWD[D ... ?I I f,p pEFECTS _ t .-? T[sT R(FUSFD N / 1 IF K I l UND DFO NvtS110ANNG O••IC1 'S NAULARwNK IUD.. NO FO I "-'..._.OT f I ISP(CIFYI - % TEST RESULTS - + s - w r •'f: - E •r IiTIGATINGO IICINI NA t RA.1 I CF OIBIATCHED OL Cf ANII VED f. FLOW NR A°NCE DATE ]Rp0 l ..'( ]•00 A IV f 2- f0E0 R NPR ?? M IN X NO Af.INCY 01 '11.6 PEI. pwTL OII [F UNIT ORT NIOVLOD DATE ' ' I I 41 ,.4,•._-„-`^-..----'__-----•'LOCAL LAW[NFOIICfMENi AGENCV•S COPV?TII?!PLICATE COPY: INVtSTI(iATOR'S COPY 1 Ir KKvv ' r 9 X? 1 y T(Lus,1 77 Aga R I+? 1 ,r ?l Yrtf, T h l '1 wt A¢r; w°r KIWK' 7;''. . 1 4? tl z, ZC f?* ' + IIIk w r 7 ?t+ •, r ,?,. 1 r I q Iii...:' ._ ..: _,. . " ...,.... 'err O "DA(E OG COLLISION DAY OF COLLISION TIME COUNTY NO. CITY NO. FHWA '• ?URBAN N AAAA/Y UN MOH -. WEDA IIIUN FN SAT J,5 Fl- I 2 D ! 8 (U5E 2A00 HOUR) > Q I OPAL COUNTY ?STATE ROUTE L?CGINTY ROAD ?CITY STREET O AUMClS. PREFIX flOUfE STHEfjCOOE S TON , 5 9C /Ael' vh ?OTHERISPECIFYI / ED % EQ. MILE PoST ?./CI(YOR TOVIN ? I N ??O W C '•? (Q? F p? ? /. 73MILE. ? L_ ? L`Y'F-•''?- /!/?__._..-. ...._ U U . RMP DIAGRAM DATA N NO.OFSTREETORHNHWAY EERSECrINo VATH'. STREETORn- T L?, ?Itl ? o R ROAD OR fl F EE - r _ • NON INTEPSEC . T O E STR INTER NUN %RU INTERSECTING ACCIDENT T CLS. ERENCEC SS STREET OR ROAD I. _ P L? ..-/ TS pI/J /? ed ,p MILEAGE •-? ?STHEEi LODE O ` d /t N , STREET ANR N DETWEEN DISTANCE AND DIRECTION FROM NEFERENCE OR CROSS INE .. , RlwuiEm! SPECIALC INDUS USE ?MKES N 5 E W ?FEET BEVENIIY (gVEHICLE-VEHICLE []VEHICLE-HICYCLE ?OTHEAIWRITE) ?HITARUN NO.KKLE I COLLISION INVOLVED: ? VEHICLE-OBJECT ?VEHICLE-RRTRAIN i STOLEN VEHICLE 311O.IWURED _.,-.,-.„ I TOTAL NO OFVENICLES E= ?VEHICLE-PEDESTRIAN ?NONCOLLISION ?HAZAPOOUS C•ATENAL _ _ _ ___ __ ?FflOPERtt DAMAOEONLY OBJECTSIRUCKINMEOF00.1ECTSTnUCKANDOWMER NME1..... LOCAtIOHOFOP:ECTSIIU KS ..E, W EST.DMAG N OF ?flOADWAY FEET ? ? ? ? RD. EDGE S °NME•AST FSL9T. MIDDLE GrvE DRIVER'S -E-LAST FIRST MIDDE'IIF UILICIfI ONPkUtSIHIA CnECKI ? R . STRE ADDRESS.. , ... ..r .:. r l FE.T ADORE53::. _ ..:.., ..: :.: '. ::: ,..?, ......... s r V d ePf/? , 3 D so c/. v- E ..: STATE :.?., -...:.ZIPCODE,, ,. PHONENO .. . Gtt 'E R . . . .. :.. . /? /r /c5 37 /D D T > Go d wn 8//D3 Y7a 75- N?, O / o DRN LICENSE NO STATE. % DAIEOFDIRIH ,.,.., M0. OAY YR N , OWNERS RLENSE NO.: ..+-...- . STATE. SE% DATE OF BWIH--. 0, J.• MO. OAY .A 7 .. jll? t > r . . ::•... PHONE HO ORrvER3 OCCUPAT ON FNM NME,. _.. 2DRI ERs OC ATION ..: NWAE 11 . S a , Z Fi^ o cN. iii 101 SEAT BELT.- t ECRON _ __ CODES ___J14) R U •, CODES > IJI CL?53- TAI sEAi BELT 1 1 UECTKIN - • NATURE OF IURIES 1? sG I VLURIVS 4 EMOVED R TO ENE VEM.YBAR BY: TO IAAKEIDOOOECHEVJ IACOELIDARTNOVA1 STYCEI2DR.CONV.1 : R FROM SCENE BY EVI VEH. YEAR NAKEIDOOGECH.. tJOVA)? - SlYtE 12 DRCONV.1 MOOELIOART V' C? ? el l? _l/ :V,+, N l adfP O . E. • e VIEW COLOR PIATE w...:.- L STATE, -. IflNLER TE NO. STATE .. E .. ENCOLOR LIG PLATE NO. STATE.: TRALLENPLATENO. STATE T)e)c d H: . I erOnJ dG77S` 4Js c. A ID I CA NNUMSER.:. ._.. __. .::•.:::..: DOMETER....... •.. . C': VEHICLE. WEHTKIG111 NUMB .... .,': ODOMETER- '?_. . '? ??? 8 cX 8 S 3 9! S L /Yll ?/?S' S' Ls' D2s9 E s flEObT OWNFA LAST O. ADDRESS OF wNEq .'::'-...::•. ..... _ ..,-_. ADDRESS OF OWNER-: ...:... ,. .:..: .. :, NMEAND NlURANCE C0. EM .,. v . ... .... - NNAEANOADDIIESSOFNSURANCECO. ORAOENT. :.. _ . J/j{ r "' r / STv!/Z•° /dlorrrcf , , '.. .. .. .::. A .. '. .. : . CIUROE : C ..?. ..-..i;:., _:...;:. GTATION NO. .:.'.:,... ENFORCEMENT.. , .: . ., . pll?g .., ACTION;l`' i /Jye E co DES _ ' s D NAME, ADDRESS & INJURIES OF PERSONS INVOLV -' 9EX AGE STATUS •. . UE CT• C pp NMe- O w/ C ADONeS9 Y / O nl U P NAT... NJUPIFS REMOVEDFROM SCENE BY. T O A NwF / e ?' <n '1 3 a T /J" S=" ryco d ADDRESS. !Pl, r e M V DFR M 5 NAI E IN,U SCFNf RY TO NI NME: ^ .G7/ T253 /J u nn O ? /A O 7 ) 1 J 1 1 - H e. ADORE y T N ar *S' FNEPY M TO SC S NN= : S ADMESS . F E w i o se Nina. o TO S. 9 J l III lIAIU. 121sLA V SIIKKI IJI _R, CUSS Y 12I NEAT UCLT NOTINSTALLCD I I1I CJECI%1N IIOT EJECTED I O P PASSCIgER i 11 rCLIS1 M /.OIIIERP031TKK! ! 2 NONJURY 2. DEAD AT SCENE - 3mAOONARIBVAI l06MLIND nOUR a NON-GSABUNO 11EVIDENTIINJURY TPOS`PLE NJURY . 2.NOTIN U SE ]USED . 1 TOTALLY UFCIED O. PARTIALLY EJECTED NIF A l OTllfq o"' RUS MOTORCYCLE1 a 7 !i'OSIrKw UNKNOWN ADIEDIN HO SPITµ I BEAT EC LT FAILURE U[CtED E e. S , e r ".111W M«N F1 C 1 ±f I ) V ,J J1? C:h "h { A1+ ,I ??,?' x 5 5? ?IY1.?UI"' ?r'J •t. ?f" it lu / - .JI ?IdI ? I ` lF?S1 t ? .. M . i 1 :. ...T?-:•..>?I4?52nK?. - ' I .-. VEHICLE DAMAGE 1. IN EACH BO%, CIRCLE THE NUMBER OF _ALH DAMAGED AREA. INSTRUCTIONS: 2. SHADEAREAOFSEVEREST IMPACT. ,,, M LE , `-- y- .I l? wi? E Y 3. DRAW AHROW(SI TO SHOW PRINCIPAL DIRECTION OF FORCE. ra O E 3. • F I DAMAGED VEHICLE NO. 1 IUSENHSSPACE FUNSKEiCHING DAMAGE TO TRALLIIS,MOTOIECYCl.. ETC.1 ? DAMAGED VEHICLE N0.2 r? °?gIE. ,' r HE UW ] G ,s T f 3 T? -i I v. D rNlurn OurNPm - t ^ Y ?r Is IY?E U li OrDAMAGE; VEHICLE NO.1 IrJn DAMAGE ]6Z OTHER I.1 V.0ANAGE T CI NCTIONAL DAMAGE . U NO GARAGE GE IOTHEn VEHICLE) N ABL NG DAMAGE 1 OTHER MV DAMAGE ]E F ITOY A AL DAMAGE A ?NO MACE SEVENM S ] ??U V OF DAMAGE' VEIN- NO) ABLING DAMAGE ]R :NIFRMv RANaGt nCRUNAL 6AMAGt t [? N TON'EO. OY /E , jgIC• EFT.OAMAGE TO-., EST.OAMAGE TOWED BY,?) r IfT. DAMAC.S >5 4 S ,)? ? TO T. I TD DIAGRAM OF COLLISION / DRAW ARROWSHOWI-NG -;?c/[s? ,E FL i/'jG•i+?G NORTH IN CIRCLE , wr fewrunE4 r oiiAOw,r i. .. ?• T-11C .. n r AV ,n Ncl C-11-11 AN_ [ SNB..YL,HaE.P,DESTRAN°, . DY,[DrPBNRDN4.TrYP.K, _ ? R1_11111w'All YfPraE OR DESCRIPTION OF IINDICATEWNAT PROBABLY HAPPENED BEFORE.DURING ANDAFTER THE CRASH. INCLUDE INFORMATION IIUTON OIAGRAM,E.O. DrHvEn COLLISION DISABILITY,gcouCEDVISIRIU7Y.PEDESnDAI1 CLOTHINGCDLDR,CONSnwCTION OR REPAIR WORK, ETC.1 Y?>d- /?t/ric%s ?t?ae .Sadr/. .';??o/ dP/•_"pii_A?."', IS>,j d srl° inY?ssdi!/S. <o__7'diW /izTo. T/rr_o?iis•e o,?oii GJ?crr?. _ -.YDi]i.i%pi' ???_. d o;T'i _ob s ai•/.,? ?i,o/, c_??! . s. rno? ?.y-- owe.. T_e _d.: ?? cr>i/e _i`? ?/` ..--- ' ? ' /.9//: S_dnd_.s/is.?.?.a r1rF_._/?? ?? o? !'pl •. ?-_Tile _x`L?a?r /..:fifTs .vf?//?7 ?'r?.. ; r POSITION BEFORE COLLISION Np aF LANES SPEEDS -1- IF 'A111 HIGH. D NECTION rOSItO zwrE LEGALLY WASE V ND. RE.- INCREAMILE SMGOECREASING ON STREETO HIGNWAYxgME OR xO. PpflKED N E OCCUPIC IN I ,IX ` - / - I I I 1 r / {?J/yj// l PI ?? LF MP ES - NO E5 MPH.rO wI. l PFD 1-II n n ._ m N n. 1f _ _ NO.. Ross 0 _ FROM __ TO_ro:_ PF B CN iED OIBICYC115T WAS USIrvG 1410 )? IWA ]t W 31 I? A KED IS OULDER ALK FO.WALK BICYCLE ROU F I. .OTHER ROAD SUHFAE WEATHER _ -,. CONTRIBUTINGCIRCUMSTANCES- FRYE VE CIE- 3. ICHECK ONEI DIIEC 0 1 'HECK ONE ON NO— I NO 1C y .JSF •,I O ROE] OE) 1N0 A1 3 ^.rr.?E SIR0NT AHEAD fTr OLD Y -- 1 UNOEq INF WFNCE Of )I OLLOW G 10 EOA OE )I? ANDRTAKINO I)a.r U Y 1 RCA T L-. JJTLCOHOL L .? 00_10.5E. __ . NtSC -_-._-L_J _t IASSIN6 ' Ixc E CF 0 I CE E 'I [NT ] H Grli T ] ET_ ] IN 1 ]LI DIU 4.... iL EE --... UIIN Ir _, ILI ..] T SOW ] ... SNOWI O I I] 5P EDLINi T -_--_ E BI 0 CIS OCATIUNC.. IN. _ATED ...-....I_- _.._ __. _.._ L? ?.... ....4 AL NG . T _ - - I I LEFT iURN i I. _.. 1 .. -. _ G E I 1 OP X OPERATING VE AKIN I I I IG[ -- _,FOG„ I? 15CESED I.- T ANT pREC V °... _.I 6I I 0 f 1 U OT W (? I D SREGG D ll "' - --- r U TURN I t 1 Isi Tor E C G ?, r D?I SLOWING •?OTIIER ISPECIf VI OTNFN IYFCf I ( gOPEN OS E, Si yy O E ISPEC VI t I X61 a4BIN0 ] J SGIIISIGNAL I!VI NO VIDLAl.. ]LJ THAIFI FOq LI H CONDITIONS ICNtCKONEI RAFFICCONTRO v rcLE .TYPE OF ROAD ENO . ] I<RICK ONE O.?GE VEHICLE N I O N CCO DD TII SOBRIETY .' , C StOPPEDAr SIGNAL I ENO ]VFH CLE .rr f.0NAl4 [ • 11 ONE WAY Q p vQ 1F SS ?I?L ? 0.2 -11CLE NEW N 01 VI NO ]E ICNECKOHE STOP SIGN •. {0; STOPPED IN ROADWAY A ONT. ITI fT0 - 1 IJ('T.? TWO WAY DEFCCi E ITI ; NBO PHIL— 3.1 fTANTING IN ' •I. ] ..I-•! ?..N _ S W YE O 1)I I 1. SGN...-_ _0__ II N IO RS BLE Imo. NGAO __.----- _ _BNAKES ] DEFECI k ?.. HEAD LIGI TS_._ IM11PAIfItD._y. -._._ 190 ABILITY ) -.._I_' j NOT IMPAIRED -------- _= TRAFFICLAN[ aranTlNC FROM I L-. IARKEO POSITION . ]ri DUSK ...?.. --.-.... ._. _. I FLASHING ?.. ALAI -? - FrrI NTENCNA GE LOOt NAMI ?J 4? ] EFECTIVE .,, 1 X REAR LIGHTS I- IT I IIBnSOBH ETY 1 UN K . ..ITOI MCIIGING (ENTERING J .J TFAFFICI . 4?..LIO IS ON EEi.• . .-,?._ ?.. AM...... . . . ... El'2.. ALLEY.^_... .. . .." . (_:.--IyIEM00 .: •.. .-. _ _. .._._. _._.... _._- X?' K' ItE E NNDnrNA I N G CIS I BiICKIN6 . _ B;r I DARK-SRIEer ......• La TnoFr--,- DONAL... owar-LEFT '° nN Laves .? rycrVHlD a IVEli CHEM. TEST • DARK-NO -' O CEn/ : K N - r-i T G OTH ER ISPFC IFYI STIICET LIGHTS _I '.. ILAGNA4 1 NODEFECTS EST IVLN TEST REFUSED .., -_.. ,.... .. I .?L..___. __.. - .:!1i Ot k IYECI?VI INNY111.0AINYO OFF 1 . D. K 11N'SNAM[ S IANKI I}?]. urvnWlolD E-NO. DUCE II - UTrIkiI1WECIFVI ISIM1.-ED I Y EST RESULTS pI.ICl AIn11VlU ••. YC[ 2 T IInFFiO FLOW until l-I uw. Q X ?Sf 8- 4 9 ? 1 I j".7 f, .. DISTnHI TION. OIIIGINALCGPY: SEND TOWASHINGTON STATE PATROL.- OLVMPIA,WASIHNGTON 01150, DO LICATECOPY•: LOCAL LAW ENFORCEMENT AGENCY'S CONY-III PLICATF. COPY' INVESTIGATOII'SCOPY ! w S S STA O?7'? • ?S H„ V M? rr 9p( PAGE OF V O " UNIFORM . POLIDCCOMHLAINTNUM BEg POLICE TRAFFIC COLLISION REPORT 9 ft' RD M DATE OFCOLlISION DAYOF COWSIOx T ?+ P Tq. r SUN i MS•I % IUES S WE04 I 5 FRI SAT _ r TIME COUNTY IrO. CITY NO. (USF 1400 HOUg1 } FHWA ? ` . .. S E COU N TY ?URBAN .. ( _ T ?STATEROUTE JgCOUNTV ROAD Je• Q?Son ? OTHER ISPECIFYI ?CITY STREET O aOM CLS. PgEfl% ROUi[Oq ST R EETCOOE NeRURAL ? ? L (? ( ? N 3 J ? J lD ? + .l I1tlqq? S E 4Y ? IN CITYORTOWN 11 C MILES .C1+ ? ? 11 D OF LL A PHEFI% EO. MILE PORT [ .h , U o :.J 6 NO.OFSTREETORHIGHWAY LL 2- A ON - ,F` INlEAEECIINOWIU1: 'IF\/- lO 51REEFOR ROAD O gpMP DIAGRAM DATA I NON WTER9 KYL.. O N BETWEEN /a STREEE., ACCIDENT INTER NON XRO INTEq M ROAD OR REF ORROAD E CTWN O CO D T ILw NG USE 02 FEEOF Ce ,- 1 a'I {'l -- 7 COLLISION INVOLVED: ?VEHICLENEMOU, ? VEHICLE-BICYCLE ?OTHERRVRITE) ?HITARUN ERITY TOfALNO. ?%-1 ?VENICLE-0EUECT ?VEHICLE?RRTRAIN OF VENK:lE9 VEH:CE-PEOESTNAN ?STOLEN VEHICLE ?HAZaR0005 MATERIAL , 1P CSTRUCKLNAAIEOFOWECTST'UCKANDOWNERSNAME) LOCATION OFOBJECi STRUCK D 0 MAOEONLY WAGEONLY S, - ^ I ?? DRNEA9 NAME IAST IRST ?FDA- I FEET ? ? ? ? PD EDGE EST.DAMAGE S MIDDLE 1 ,F OflIVER'S NAME LAST FIRSTMIODLEPf1-GLISF OR PEDESIRMNCIIE CW R V\? 1 STREE R ESS C R { ? ^ {{C E L2?. C p IDZ STREET ApOHE55 V . e R CITY STATE ZIP CODE PHONE NO. E CITY STATE - X /4 QUIOCGC R ZIP CODE PHONE ND. N D U -2Aro O.. ER Iv R?4akP {STAT?E?.} ySTE%%i ?J 111 7 r 1 DATE OF BIRTH y Y MO ?A, 6 N DRIVERS UCEIISENO. . O STATE SE% pATE OF GIRT H MO DAY YR O OHNER9000UPATION FWM NAME S . . PHOrvE NO. OPIVERS OCCUPATWN FIRM NAME ' PHON NO. tTr. CODES > 131 Cry 141 SEAT BELT 151 EIECTION NAT R CODES J 101 C F39 141 . U E OF "; INJURIES CIC?K'Q'?'L?Ot VE L ATURE SEAT BELT 151 EJECRON INJURIES 1 n• n ENFBV: VEH MANE(DOOOECN 1 ?'(e.lT MOD L(DAflTNOVA) ' CN C? STVLE REMOVEp FROMSCENEBY: TO .,) - { v' ? 12 pR.-CONVJ VEH.YEAR MAKEIOOOGEC1fEV) MODEL IORRTNOVA) STYLE 12 D0.?CONVJ ` d o S E t>`G z flr. V VEM. LIC. PLATE NO. u 9TATE TgAILER PLATE NO. STATE E H VEH.COLOR IIC. PLATE NO. STATE 1RAILER PLATE N0. STATE ' C VELLIEI J? Np?R L?Tt 6 ?J METEfl L ,d ' i VEHICLE WENNFC ATI NNUMBEH ODOMETER w - 1' ? E E S 7S E , : .. REOISTEflEU WNER-LAST FIRST N MIDDLE Osi'h-t ?u?-D? REGISTERED OWNER-LAST FIRST MIDDLE -:+ O. a A00y?,SS OF OWNER O• AOORE59 w0.$oxZ2f C112,1Z c"' OF OWNER 2 ?1 rn . N EANO IN911 E O. ADEN I JL_ .. tA..AKha rn. NAME ANU ADORF590FINSURANCE CO. OH AGENT ` w 40.. I L , --"' `A CTATIONN6 ENFORCEMENT CHAR E I A I NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES _ 1 0 5 A SE% AGE STATUS W EJECT L. N ME . C Anc ixw: U NA U OF P -..Fs , II.MOVEDFROM NAME, - - iO M cely T ADDRESS, ''PoPop + A `It r S WJLIr+Il B: M V 0111 M t ?? W Sc!'NE RY. TO ) "I NAME. 1 AOMES4 N E. m R sc_Y rfGTF6?---- y I. rD S. NAME' 5 ADORE34 E V I IAIV1 IlI Y! I'UYIAIV TO ( F { ? ? !: C E. 55[NOER .I WAI IY pLASS II:II AI IILLI I••i LJLC tIpN ? ? A ! 1i1 ]IYDL41111W ? ?? 1 UNUR/ 5gv'LIILINR I!III111Y L^.fALlfp I.NOT EJffT[U y ALyI(? W O y (uCYClr41\T t Ik l Sf.EIC N., IN O NON W51tllwIR +. l1f111N U;? ; Olµ{YEJkf.fEO '$V,11 C ?N 7 ,r%h (1110.'-ri' i. D SOlrllll ! ) I.OfN[nIY14f:Y1 .1 pC RlN Ann JAI IENITNRNIURY .l UrfU f CL w1'.ilt1IS3 1 l 1 MUfUR^,YCILI M Ol IO..IT AL /. P(1 Ill f.IrMUNY Irrl!fW1 I fIM MIIY [.If Cll'J 1I., jf(I '4j 2 A1..IIIOIIU •J.OWrI 4 IPPJIDWN I ?. 54NEAnpnFAnNRC rn.cnn r fi 4 M I - t ? L.. ti Ff d? !x 11 I ?? L J?f J4) 'J r r1 t ! 11 r Ir In c.1 ? 0. 'rl( 1 l Yf'.; k tY I A mta. 1 VEHICLEDAMAGE. NEACH W%,CIRC ETHENUMBER OF FACH DAMAGED AREA EMV PE + r.dn? +b y' IMPAC 2. SHADE Al1EAOFSEVEREST T. INSTRUCTIONS: 1DMWARROWISITOSHOWPRNC"P URECTIONOFFOKF DAMAGED VEHICLE NO.1 (USETHISSPACE FOR SKETCHING DAMAGE TOTiWLERS, MOTORCYCLES ETC.) DAMAGED VEHICLE NO .2 + 13.HOIX, 1A. POOI ] 1 f D. HOOd M rb°I R?p+r ? ' I6. Trunk rnOrl 1 S.TWnk t] ?p ° I ] 10. UiMermrrl+0e IT.OVMUm n T I tt 10 F ? ° ' 1 O. UnEercaMie T.OVMUn 5 VERRYOF GANAGE: VEHIClEN0.1 1DISASUNCOAMAOE 3QOTHERM.V. DAMAGE 2 FUNCCONAl0AMA0E a NODMIAGE SEVERTYOFCAMACE:IOTHER VEHICLE) IQOISAfKINO DAMAGE 3? OTHER M.V.DAMAOE 2 FUNCTIONAL DMIAOE A No0AMAGE SEVERTY OF DAMAGE: VEMIClE N0.2. 1QDISADUNOOAMAOE OQOTHERM.V.OMIROE 2 FUNCTIONAL DAMAGE a NO DAMAGE ` TOWED RY, II',j Y. •L,;i„• + EST. DAMAGE TO WEOBY EST. AM DAGE TOWEDDY EST. DAMAGE II 11,.,,1_t. TO : ay' 1...l TO a TO a DIAORAMOF,COLLISION' '? I - + - 'DR AW N AR ORT RO HI W N C SHOWING IRCLE ''noA°'v rAv nowr,rtAruAEa ` RoAnwAY. ' I -_ .J., s Y Y• a •? S r ne?cm- ? ? • I ? i ?r?caSrnCONpic u° r; - - ? nFFO°ADL-OF WPACT. s.awvo«?PeoearwAHar't a " _ • . EORPOY A. ATWPK,T. `Ntl MERO3 l15'Oi0i1F? ?9 ? f: - - .-- - _ - _ _ DESCRIPTION OF,? - ?INOICAT EWHAT PRODAB PENED BEFCR LY ED URING ANOAF TERIH E CRASN,INCW OE WFO RMATON NOT pi01A0RAM,EQOFWER '. COLLISION, , dSAU1R Y,.EDU CEDVIS . IDIUIY,PEOEST RAHC LOT NWCCOLOR CONSR iUCRON OR RE PAIR WO RK ETC.) 1 ? Ot,. ., A a - r 1C7-/--w-,-•-c..:- _ te 4t__ '? I C ye_4? • YK'-Ar--r r,??c r-<' __S rc- G?_r+ te k` a r ? ? 1L_ r.Pt( JCI ?N t-rnYTh OJFtt l'_-? r? SI_rJ?C 2 fL ?C? f C L r __-, .... • ?- ) C <, II l1 JrA c o1Q r•a, Jit ,?Y.. , UCH- J c o - 'E "? ?.• S ?*.. Wcr , - S -?c L~a >. ?J _I AL c ! nte!::._'% ... B 4f: ":f C.. ..•...7r _V: i.'y., s.+nY'Y .4sJ io9 n:bSC VEH HEADED --EMILEPOSTDIRON STt1EETOR HIGHWAY NAMEOR NO. WOE WECTII tD ?? eAE PO P ED HO. ?'.I WCREASPIO OEDREASWO (/? '• 5? S'G ? ? YES NO ---- ? ? OCCU I YES No - 2 _o ? ? -- - ^_ r? PEO. ? L.l L.. r- 1 F-.,, °+"rtTO" ___. PAEC wlDl ro rG°*oeT wf _ PED,DICYCNSTWASUSMI M F71-- ] WAGIwAY i?eNO111DFA Al-_l Cr'A?oSwAUt el._.IClassWroW( .. ?9CVCiE'Oi OW I! Ot![n - ROADSIIRFACE.A IcHECxaNel r•,„.:,WEATHER:,X N]+EOK ONEI 5;,;;CONiHIBUT -1Gt INGCIRCUMSTANCES- FGf oNe cn MD^D• a OmeA ? ? n , ON+En ' ..;_ .4Ae4ki'? O1MR Q t ? em°O°O.wInA1FAn If u _ 4•a?_ ]Y U_ _ - NW[HCED. _C?2? f?7a(?=GMF11 L ? L ,rJ (C??I-El ?APART IE L ?.1-Ae ?f L O°? a mM)w - _ a r'1 WowF u_ _ ?a f fln °nn0 ? y ro : t o ? ? ? ° ?PA^kwo r_'7 ?J ?-n unrum ? ? IGa ._L . J A C? IOO _? _ L-?.?? V 9/J°_ I?PPW OtUn A n I? O_Fr[Gnr"?B FOUF? 1 c I °0 U.rYnr -- `? f( ?1 ._1-..!_°°_lJ._._- -?.?.__-____.- _0 e_L?_!?-wcu . WHr? -J= .1 .J L ?r ?It .1 '? _ . .??- ?'? a'pNM OIHLn1aFTQIYI D1K°RFffiTl r-l°f--n . - 0 n '] n rca°^ f- L -1 "1-1i°fl__I r°.o"attinw OTQD wH LIOHTCONDITIONS TRAFFIC CONTROL: : .. - (.weaa-.TYPE OFROAD;, = -TYPE VEHICLECONDMON-I M ONI OII K G[ M 4 1 G'?":SOBRIETY,.- - K1Y[ ' LN[Ln pN ~:; ?a? o Iurta OH[I NO ] KHIX] u 1 90NAt° ND tp[I 1 W w^v H (?. ?, 1 nD. f ,H- M . I l t ND. ] ? e °p?yy?^KD HAY i aruan I V i J] r LSL] n me A r ? -7 ?' LJ rt EU O' ? ! ? ] aN _ ?3r? ° ?]C l ^` _ -_ , '? " _ C1C1_r^o n„? °f w°o m°qn ° ...... _.._ ^3-.iJ k?,._ .._ . -- l 7 _1_aOb Mw _ __ . __ .?J'? R Odra ..__ _^_ .'? J Uw aMM1ETY _..__._. 1?1]l.? MwRHII YNO o°A""nria er -is( ILA4M le AaEY oitiuoo'_- '?.? jF?l u0rgr eernwNMro I (-+ ?fs, ( eAtlua ?tnn a r•-.a;- J Hoar . - '? -w+Aiarrr : awncrurto l la?? onuwm _ ?__ °+^+^ CHEM. TEST t ra ] II I L? h rA?.i NO : a cis- K+a AoAat ? (( 1 ?-I rta orve ort.nlanrnl 1 r 'e, ? orran_ ]; ? aAUO .? ? j Nou m ?_? r-1 rtatn]ruuo 1 '. . . ' O K IaIYCYTI AO AAf ItC . canrHOa ? - .. -.. ?]: I LAk11NWO. - Wi O ?YIPIYI... - • ? TEST RESULTS 2 K % F.Yr o+nroo. KT i II Y o 437' L1zl Yfo uFmo ° a:%po 1ON' °° zl33 ° a I ..( lV4 LY ?' AIrr „ ; :? tM + tatOA YV1prC Ki AArM WIaF HO ? Cro IAArpt Of}.e Dlt. nAte pAn OI larOnr _ c AMNgveO nl ` i e .? ? . ?pS t ) ?1 'P. tlrn .A i B 5 ,y 3f , ,yhl STTTTTTT ?TE O WASI ?I 1 LAGE or POLICE 00 U NUMBER '. UNIFORM POLICE TRAFFIC COLLISION REPORT s S2 DATE OF COLLISION DAY OF COLLIYON TIME (AUNTY NO. CITY NO. •, a FH GA BUN Mp1 IUI. E HIUP fR aAT DpQUPI !• _ - 'gy`p COUNTY z AGMCLS. PREFIX ROUTE OR 6TPEET CODE...,. S CTION Jai FAA' ?? ?STATE ROUTE N]COUNTY ROAD ?CITYSTREEI O \ J {ig•6c ?OIHERISPECIFYI y 3 Ls?o, 990 ?' '? % 1-51 5 ! N CITY OR TOWN O PREFI%; EO MIIE POST ) _ 7 I f O : MMES ? ? V ? F [ll lr'tl'__? .., 2 ?S? _ .,. a y n INTERSECTINGW A. ..-. NAME BNO.OF S1riEE RHI NWAY • --..'.- ITH. STREET OR ROAD LLWO RAMP-. _ DIAGflw DATA T : ON.' Co C "I NQry!ME116ECTK7N. ACCIDENT NfER %PD INTERSE TIND SIRE OR AD OR NEF - 0 - - MILEAGE I CLS ERENCEC(1055 aTREETORPOAIt , Y rr ?N BETWEEN_- STREETANO_._._____ ___STREET CODE i _ S O)STANCEANDOIRECTIONfrEREFEREWNCEOHCROSSSTRECT, H ,? SPEC WO SE •? ?MILES N b ?FEEi OF .__ LL ,r• L}_ N)q V LVED. ?J-1 VEIIICLE-VEHICLE ?VENICLEDICYCLE ?OTHERIWRITE) ?HITARUN COLLISION IN NO KLLED 'L1 TOTALNO. .? L1 vEHICLEObIECT ?VENICLERR TRAIN ?STOLEN EHICLE NO INJURED OFVEHICLEa ?VE ca-FEDE..AN ?NONCOLLISION ?HATARDOUSMATERIM PROPERTYDAMAGEONLY y + -ECTSTRUCKI wEOFOBJECTSTRUCKANDO ERSNwEI I .LOCATION OF OBJECT STRUCKS E., :W. ,.', ,.. EST DAMAGE..., 1 d OIN OF FEET ? ? ? ? PD EDGE a •-D&VFRS NAME nT -""MIDDLE --- GWER'SNAME-LAST FIRST MI.-1-Claw an PEDESTRIAN CHECKI C7'. STREET R STREET ApORE55'- V -I . (3X lx T E .. "r F E C : STATE IIP CODE PHONE N0. R CITY : STATE ... IP CODE• .. PHONE NO R Leg VA" N p&v fi5 ULE STA SEX DATE OF T. N DRIVERS LICENSE NO, I '.,STATE SEX . DATE OF &RTH D NSE NO. 0• ?? fAO. DAY YR. Q, MO.' DAY. YR 11 1 'I WEBS OCCUPATION NA` l S PHONE NO. 2 DRIVERG OCCUPAIgN iIRM NAME N N I-IO - ODE W -,u M SEAT BELT I, EIwi1ON_ CODES > I]I IwA Rr w n CL SS SEATDELTISI UECTION___.__ !DOE,?$7 NATURE OF HA URE OF '!IYGa - WUfllES RE UP ES B FP SCENE BY TO - FROOSCENE BY TO VEH.YEAfl MAKE IDOOGECHEVJ -, MDOELIDARiNOVAI STYLE O- NV) VE YEAR MAKEIDODGECMEV.1 MOOELIDART-NOVAI. STYLE IT DRGONV.I yY v 'v(y` R Fr. A E M.? PUTE 1?A. STATE T RNIFR PUl NO. STATE E VEH COLOR IIC PLATE NO. STATE TRAILER PLATE NO. STATE C YE TIFICAT NUMBER _. OOOME ER ._ ..,, , D VE ICLEADENTIFICATI NNUMBE :. REGSI RED TER -IAST, W.ai MWOIE .. RE&SIEREO OWNED- . I , FIRST I . . MmOIE • ADDRESS GF OWNEA ..'. .. _- _.. ., ___. AOOFlESS.OF,OWNEfl. - .... .r:: . .; 2 e .I OREa50F 415URANCECO. ORAGENi 1 ". ¢ - ?D ? FWSVMNCF COON AGENT :., ENFORCEMENwEANDAO ., . '.L .,• . n G - OMAN ..... GTA I N . C ^. 4 CTION ;j?., :. ,.. r.. .::.. .• 1? CODES - ° a NAME; ADDRESS & INJURIES OF PERSONS INVOLVED 1 SEX SAGE STATUS +I EJECT .. `.... NAME', 4F ?. R U.. NATURE OF SCE Dv FROM TO 15 'e P... 4UlIPoES A NAME - ?l T ADOF!E94'. A' - g N4UURrt9'. SCf NE IT fl 'TO .W'. NAME: - ._. ,. •T, .ADDRESS' M''. D .. - ?1 1 1 v •: .i.N NI!ME .. SLFNE BV' TO '. i 8 AGORE", ?.. . I E NA SCLNE RY TO C .1 Y I7 s :,B' 4113 e'. - 1° 113rATUa 1]ISEAI POSIIKIN I]14UUHr CLASa HI6OT IYA ISIUE)C1gmr t v D 7 PER- A 1 T DEAD A, SCENE I O NON BINNG T NCOITT W UTU LED I IOIx IL YCf. 01D'... I. B 5 0" t aCYCl6T - { 7 T.ORI[R IDNPOSrtMJrI :DEAD ON ARRIVAL ICVW[HTIIHAMIV ] USCD ] PARIMLLYUECICO d? Wlint. { 7' :.a IDU& IMANONN YCIEI_ gCDNN051'RAL T.PO59BlC NAXM; UNKNOWN AUNKNOVlNIf B 5EATBfLTFAKURE ' UCCIED , r t}ar v 1 ? .. ,Y?TRW% r7gWl?'BF7uN .. .., .. • r. .. , M ... • wn .. n. r S..i. nA . ,, u _ e..H.. ..... ..x _ !vA ??? h. 0° ; VEHICLE DAMAGE NEAGH BOX CRCIE THE MDC O ?, SHADE NPEA OF SEVE EST !.,ACT. INSTRUCTIONS: G. DPAW APROWISI TO SHOW PRINCIPAL DIRECTIONOO UHE SIES ETCI DAMAGED VEHI DAMAGED VEHICLE NO. 1 IUSF 1x15 SPACE FOP sKFi[NNIG DAMAG! T° TPAILEPS, M 14. RIMI E5. Y I sE rt n n 1 IF ' E low rl, ,? l 11 YOF DA GE VEHICLE NO, _ •p E TY OF DAMAGE IOTHER V EIICLEI GE 1 OlswOtl ° DA GE I, O ER M DAMAGE F?EIIITY OF pAMAGEA YE GCE 0:1 M GE ? pu5tlL xG DAMAGE S ? N IEAB T E V ° = AOE ? GE _ ? OT E A ? O 6 D UNC EST. DAMAG 1 LJ DLINGDAMA „ ? AGE = fsT. DAMAG {y OeY Tl A _{? FU CTIONAL DAMAGE DAMAGE DAMAGE TOWED BY CT10 •, :` . f I"Et TOWE4 Y S iO I s I / ! RAW ARflOW NORTH SHOWING / TO I I (_ 11-I CIRCLO To. DI(LGRAM OP COLLISION r -?"-T I I 1 - 1 - p 171. ? t. ! 0.Y D 7 Y V. UF GY- GY- i _lf .U- A .! .? I -_ y .._? t -I -T ? - I I -f •. 1 I ?I j -I 1?_ ;. ?:. -- ` r _ ?I ' rKO. R. IT .1 I LIM n : ? ?- _ DL ,IN Ko N , I { C II I I CLUOE INFORMATITC DURING AN. AFIER OT ON pIr-AWAAI c O Iv R N Ow REe1 wo F.N? DESCRIPTION OF' pN01CArEwRiouceuVISIB Lrcl. IE.,STRIAECL.-NGE-U.. gD,XHE SR cn CRPSN Q6 DISAELLITY, ' 'COLLISION ! IFPARAED r? 10.01 LANUS PARKED I OUT OR NO .. E IP TLP LG L ^CUP ED POSITION BEFORE COLLISION o nEE N G W 7 : l ?ul , Ll IJ C n .. Ne D n G EAS N E _ I. ? Es NO, rds r *n{ 1 H r r w xcrl C '.:/rv It? iJ =Cl??? J -1? I DR -- rat V`J D,v I?LIL II CR_DM?xGS A _ 9 5?p GN TE 'L _ cL Et AcT ° D LK <nossw "R rn ° pR yrvEM P ?s LK =? ?SnOULOFR Af ?M. M K DN rtDlelcrcusr wwsu Na. WEATHER • 'CONTRIBIUNENK One OR MOne1ANCESr, 7T T AREA ' ROAD SURFACE "- (CHECK ONE) ^ N4 IC ECK pNEI p NOEq 0 110.2 OI ST..'. ' ER IN I NO. n 1 ISRE ED WARN ..©/ O T ° 54 ° D Of=. DDDY NO. EP INSLUENCE,OF-??0O?_FLV 5 x ° I•?J -0 (-1 G R n APPARENTLY IJ A T.R. C=LEANIC?SI_ a,[2_ NGL:?Z-'NG[DF 1--;,y--? n. I1.? GYEEG E ?°[l-DRUGS. I ( °PER PARKING r?"J LEFT TURN .?g rI a. WFT = R ?-I EKCEEOING STATED G ° f? LOCHTJO , , ?5? FT .I. JAL I? n PE G f«"• - J_ SNOWING SSAO. PEED g Fl EKCE 'G E S ?ll r T H E -? a`{CI VE Ff°,UIP _ ATI 1 _ E NG .??A? L: °_.E 1?-OG ?_ _`. p D O EG° T PIW FF?-?? I D S fG D? i 1 R .. r 6 TOyE C E .6'..-."JI.?(",-$ ° 6 GO S I I en e - IITL J D E o 1 o E FYI IMIn PfP ` V TR° FICfO BIT r if. IYfc fri SIO nI L IT ISP Ci 1 CeL7 PASSING sIGxISIGH L. _-, _ C? o STOPPED-El SGN L_ LJ F cE• TVPE OF ROAD VEHICLE CONDITION. E c.F ' ° STOP SIGN SORReHECK7Y pNEI ,-,tlr?,PE°IN CCKNDO ITIONS RAFFICCH IT,_ NO1 ICHECKONFORMORE 1NO1 end F 5, p, I J R °WAY IENExlI INO.]VEILLE (--I O NE WAY DI STAR TI N NG FR I DAYLIGHT 11 J C Lf r D C l ND L?Y 1 STARTICL t E ES ?I 'Ttl? ,ARKCp P051°N • ? -' V R[ rw0[ I I LG i5_ ? _ 1 IIBOGBO ABILITY i?l ER6 NG 1[NTERI LE ( I DT.IMPAIALD_-«-- - 1 -1-lY _ _. - J1U TRAFFICI I 51r { D YN ?_ S GL ND r? O TF C ANGf 1 ?.. EM LJ°E 5. l ! r^?-INK. ODIif •''.[ i 0? FLA DUSK` -L<1 f REDS.. 1 (C1, (?(1? LOOP.HPML-_... ( nF r REEN°PINKNp ?Iir? B?CKINO N M. 'i Kr PARK-t1REET -le 'LALIER?a Ejl:..J-,ALLEY L IA .OIL SM00iJ1 _.. L TEST (? ? OTrILP , `. II JJIAWDl ON._.-.: Al f-"15. 'I rwO wAr-LErt s-) D. ° 1 E IurclFr L ? (1 PARK-STREET ne' ' 6GNAL TV LS y?_ I 1f5TGl E _J•?•4GNl/OF} ?. '?-F7.`ITS'Ff \ I t .. }..J._ -. .....-. - f-- f CLPI i sC I TESTREFURD 41P LGHTf. ._.:- TH[R ( "1] NO OEf 1. ! [ET _o1Hw ISP[cELTS 1. yo TEST RESULTS le 'i??H[A YPIC frI --/« - rrK r ai ° Ol POLICE AHIHVED AMBULANCE INAII. FLDW. - `` lE l I KDxmD UU7 NO. 1- n! ANRIYEO ; nlp efnwl Go < s L 1. ATE. i . ' >•DO /'. r "?} ' . Ems - r,n.VE r owr ",d V" ` eADGf xD. .GLNC Iron Dfl.AD[r. Dwr[onrt ,onT Invuvc lncorFx:[ns IJRANK• I t X S „ DISTRIpUTION! ORIGINAL C[fY: SCNO TO WASHINGTON STATE PATROL-OLYMPIP, WASHINGTON BSSOC•x..,5 } 'DUPLICATE COPY: LOCAL LAVFENr ORCCM ENT AGENCY'SCOPY-TRIPLICATE COPY: INVESTIGATOR'S COPY J. N? 1 t 1\ Ra?• / '?fh -1r1'E°,[ :Md ?.`G•: A U r 1 1 T< k pr1YJST1lJ•w 6 r } ,p'. Iltr Y v .dA°' ro'y( 9(?'f . ? .? 1 V ` L L?1 ?? ? r `_• 1 I ? I r;1' i•. n M 4?5T .,? I r r ?? r L??y /, .a I r 1 ^ •t 3rd / LICE GOM LAINT NUMtlkN -?? fP` . ??)?? ..UNIFORM POLICE TRAFFIC COLLI2IO73 REPORT G .9S i' a F a 1 f cmuSmY T.. i ? 73 oart ?of cc L 1.v='L I]TtD n41uN+Ply Bsat n,rE Ius?Ti`0 ;touRl cuunr/rf?.r un No L?. .. gYll 1 ?nunAr l' x w ?tl 1 v? 1 .? 4 ' I ??- STATE ROUTE JLJr COUNTY NOAO " LJ CITY STnEFT •' ' S+LT"V?? ri O TNEn ISPEC.FYI • V 01 N L - ?? ?C { 1 '` (-1111 CITY Of•10 LJ L f L ? Y {IEFIX EO.. • MILt/Y47: T/ I DF ti .41:) CtC !!?? J U G r NNW ... 1• I. •?:,? L \ .O G TNttfC '' IN NSECTI IT flFETO OA 0• MY _-A IA A : ., T `ova o :. ?? fC AC<lotrrt FPCf r Nr A G.1 LS. . I Nli'II ECTINO STNEET OR NOAO UX T OR nOnO 1111ENCE CR055+iREES I - i.; T,;tip N °cint ho3d 4TpPETANDIr lts 1. !ET CnOF /? i ?zJ? n I ' )',y1?^, .,,? C OY PNOM NFFtREnCc OH CH055STREET f Iii + N=647" ALCOOINO UGE 1• ' OF 01ele Point F ad' [ • FNICLE-V'FNIClB ,T VEHICLE-BICYCLE '?OTNER IW RITE' ?HIT°HUN ICLE O°IECT ?VENICLE RR TNAIN ? 4 PO. K'LLEONT • vEN • - i r ETOLEN Yt Itl CLE ' - ' ' ` 0 r?O. IellunEO : - , r Y I I IND. .. __-,_ I-?V[H'Clt-PEDLSt P'AN COLLISICN f l -ZANDOUSMATLnIAI + I I _Fs I1TY 0AMAIA ONLY T+?7TiiTXKrNwE OF OB,ECT5TRUCK AND OWNERS NAME) K EST.OAIAAGE LLOOCAT16N OFOOIECTSTRUUC ' " l' Y I • r • ?I E I I I_INnn nY:nr' Ff PT ??O? nO.EDGE S 1 PIRST 100 .n VZ'i•ENw M T E O I rtnC+cn:f-PT .q^T-MiOOLE?•?IIFPCOESTn IAH•CNECKI (" ( t ;Hnurr;t.` nrzrsln D. ''O Orcodt 4'.oi-man L? I ' GTNFfT ADORE55 .. I '.rr REL A00HLSS _ I ? t v :t 2?ox ^2l V" 22617 87th Pl. 4Je&;t ?_ CRT STATE ZIP GOOF PHONE NO. -AIL Y :• ATt .11101E PrIONf NO T R - :d3on :'in. 93:65 732 4V20 ? R Edc:ands an. 98020 77C OS 36 Ivt NE.L.Ct r EAO. _ STATE Wn 5E1 DE EOFY BInTH Y nILEPIS I.C-SE NO. - 0 8221YI STATE Y °EK bS TE OA-TN M$ ? 0. n o 7 ' t rINMY E IHON[No. On'VLA9 OCCUTATION . . FIIIM NAME ONL YO r ak 2 dl: 46- LODES attr S r' Sl AT BELT' E ON l C >1 nSS 2 1.. 4 2 Y SEST qE LT •? f1ECriI.v i ?__.° s Iw ?ecerntion ui s es pnLnT I ;v:?;i: :I.i•.,? y •LiiT6a^-Pt. "owns ? VA C`=.Nd',t. Lud o••. ',iE1 ,C•:^-Pt. To r3en-I n rt _ r l.V•Ivu.?O ?. •CntvI MOO LIOAR}-f iOVAI STYLE I]ON.-CO\V.1 VE . TEAN MAKEIOOOCE-GREY. VOUFLIUaNi •IIOVA Sf-&I'D. Gu- v ( err. !,Ic - ' ? (:atali,zs 4dr tt;i V 71 DoLi,•e r c Cora^e / y F .? •t•. ? 1 ?i ATC S RAILigFLATEFIO STATE E 741 COLOR LIC PLATE NO. Si ATC. IHAILEHItATEN wrl 1 ( j= %:^71 YIr.. H .3ro•rn llJJ 267 ;7r.. i G. .t C ?+r•GY Y..v.LN OOOM[TEn C VEN?LL IOLNTI I'CATION ..1- - E A - UME N YD E C_2 11757 lOSSI] 6.,1 G12 4123. 76279 NI'N5Tr w10t +Lw-lUt •rgST u100L1 E NE0r5TEPEDCV:NER• LAST PIRST MIOOtt N L^`'P Carl,?ro:ert D. N. Sstle 0• On i Cwal.. • ,- ,. 0• AOo..-FOWNER ' ' 2 I 1 4F I•. •. En L G3 4? f.Y - NAMt ANM ?LTS NAM. ANOA...ESS OF INSURANCE CO. OR AOFNT. . .. .: CHAnU? .. rnnoH NO.. cHAnee CITAI-C! NO, )._n1- .ACTION- Crone J . , NAME ADDRESS 6 INJURIES OF P cools r , 4 ERSONS INVOLVED SEE AGE ]TwrVS . it ?? c ICI • 1E D C ?C 1 rl I.ri i t'' th c 15 1' L,tT. Sw, CLle 4 47 6 p ice i nY° rNO,r To T t• '13 "' 115ti: r,Pr.lttla 171 6 ^I' C L• _ y vtn FY`_o•A _ wn.nm+r __ I E 5' dI•'i'r nFMevtu .ImM ,• tr rn (, N55lbO1N ' I•'' ..ryq lNlunV '••. I° uN :IN vI nILT<i?°:u?w. i. ani ivii c?uo i'iniucv iE ronvn _ nor.rnr.X T•T?-R1 .... ...... IN 1 g'al m 4? 77 a?i r \ EHIC LE DAIVIA E ). IN EACH BOX, CIRCLE THE NUMBER OF EACH DAMAGED ANEA?- 3P SH AREA OF EREST 3. T` -y AWAFASO S SEV SHOW IMPACT)I r. `L(Co •,?+? t f JSt17 V]''ulI ONS• 2.D DRAW AH RUWI) TO SHOW PRINCIPAL DIRECTION OF FORCE rn • e9 E . [ . " DAMAGED VEHICLE NO.1 ggTHIS-CE 1,CVCLE6 ETCI ° AGE DAMAGED VEHICLE NO.2 t •, S r rnun ` S ' t R.. I ? p• p 'r 1 _ ] 1 ? Vn UTJ `5??• F IE u , S - . j ??? i:ll? o i r 3 i u 1?•c. I"'?? i?rC. •• r T'. _ ? r? • I r .. J r?•? Mao[ of rr CLl 40., N EOTHERI S( NIr O(UAMwOE. V gOISABL NO OAMAG[ ']?O,H(n [n V. DAMwGf ,[?DISa°LINO OANaOE THf]? M.V Da AAGf 1?. OISneLING UAMAGE CLL NDn OTHEOM V. DAMAGE t ry?. ,U4f.rniNAL nn AOC + Nn GAMAOE ' . ) I] r UNCi I...I.AMAO[ C]-..A- ] FUNCTIONAL DAMAC.E .?NO OAMAO[ •. r I .v fry?,q? I 7 711,1 ?L?:7LgP'Srl TO,YEO BV E.I, OnMAGfi TOIYEOOy[y ,cj ow n,r ,411 E',LE , ? 9 ` SS 11 m Cn i';nc: - 2000 . o s ro _IT.R CUtR s3Q7 J. n. :$ r " `• AGRAMOF 09LUStON ••f DRAW ARROWSHOWING ' i J " . T NO IN CIRCLE' G 6nONr. FEA,URf3 _ r.y, I. ' •? ? , O q" r rl dT? >O!'ic - r ? / . G nf l LOwDwA. iPA(1 C C • "All wp[AV'Y.TOI ONS 1 •.' , !: .i %./ ;. Loc•?i nroe.FLC foIN, °F _ _ , ESCRIPTIONOF HNDCATFWHATPROBABLV•HAr eFEp BEFORE -TERTHSCRASHINCLUOEINFD A NNOTONDIAORAM,EG ORIVFq °SADILITY RF OUCEO VUIBIU,r P PEDESTRIAN CLOTHING COLOR CONSTRUCTION OR REPAIR WORK E'7OI . , , , OLLISIDN ' .. :kVei"-101A1 was south onthe' Bak $a?•:tosd rounding a 'curve' 'to the riSYit + ,: g f''3-Jd' slut t ung-ade. • Vehicle P1- was over the. centerline onto the northbound 4 lould er. Vehicle > was north on ;the OEik.3Dy Hoad vrert into a skid , , sl_ldlm,:broadside- and slightly across the, centerline.. Vehicle 11 wes . - ' re Far ;r' to thn centerl=ne and struck vehicle #2 in ttre ri;,?Jt side then.. 1O vehicles struck r zht side to'left side and vehicle xl went off tre -rest side o_' -: e road o into t_le ditc '111cle l'2 sru do ^letelg °__ T1 l ' # , ran p?., , went-off Rat'stie o Fj n d::R;( di ,. POSITION BEFORE COLLISION u.! rmBEF ToIR IOU SIN[EI OH mcnwwr nAM[oR NO olnicnoN ' u "L ;i I Q NCR(ASINf. Of CnlsS,4G s, ?MM 1 50 50 11 ? O®O? ?`n . ? Oni< "1F y fioJld J?l??? Q.e e ? Oak Ry caJ] o' M.H ? ? ? E ( ???? • • OR • B RIFT OR HIGHWA, IN [. CORNER tOBF. CORNER OMO .OO)BINO r r..N TO ,p:ror-K :?wA ]?s DUS°E. .p.uRKED<ROSSWALK B? RXIOCnosswALK e?UT-ER r D - AUAD SURFACE WEATHER . ._ CONTRIBUTING CIRCUMSTANCES ° IVLRr VfHICtE ACTIOrIS I f • ICHICK ONkI I..... ON 11 ICH[CKON[ORMORfI V[IMICLE ICH\CK ONE OR MOREL In ' I. O] I I. On en OqI V ?« ' rv O u N x ,TO., x QI ?AOINU Sr [. r 4 ' ?o- ,?cL[.R ?,' , ?N°.ynNrfufNC[°r . .I NC,oa Q,> DlSgf can°[° WwRN. EAU ' gtH,LV AIL[[. ?x? 1A g6GK O U 0x?nl xp RAr4IN. ?>pg„??9INr WINC(Or r3S ?in[R CEN,lR ? 1•p ?..a LL }} " Q r ?IUGruTAI[O S?f I il, iNO II [].SE]- H IH ?]? , n U ?)?SM ]?SNprvrNG pJ ?Sr?fI 'w '.?P[ •f F ? • ? 1 INO L[rT ?. ??[E • v(?.[?e" ?10?IMFAOFIR,UnN ?1.[3 F R11 ?S??° ?IIp Or3nLGnnU 4TOr ?II? 01C] NAKMGUTURN rN p[? S? l o/•-r-LD ., uH•un r n ?e ?L.•.noPr N vwn,IHO (L 4.rr'nn Nr a: o:'n niD6 ?e? a[owlNn: IR , r' . GHTCOr I1 I- TRAFFICCONTROL 4-1CLL TYPE OF ROAD VEHICLE CONDITION SOOHIETYI . ?,? wr T i QUR TY nnArm '• m acA w[, VE,nrlxa ,NU w ( M,uIfI vl Hc luau oN[UR _HC,l jJ 1 n , ? N.t MnnF OrrlL'IS IP ,NOJ p.? An SfOi[G G L fnN,nNIUI[n, r 10DAr,r ?, ?- w\S ©] U - p ninrr[n P ¦1 pnIrICNVr ntl•• ®, plnln A... rMrnNl,n D ? DWA n I•Nn,? ? • ?. ? VII JnrLI Il Inn > r3n l Nn C] '] ? ? ? r ' ?' ' T^ , . , rr n I. ? nl 0<:) 1-I.-Hr 1 ? ,],-.,LN ? . p r .':; NI:I ? ? IrDI,:,rIIrrII I II? ; ? ' ? ? •, o„ iAii,?Irir?r• v ,N+ N ' ,,rr rlN,,., ? ? ? • ?r, ? .r.4LI ? k ? L ?, ? •' ' r[nll NrN6 .n; ° ? . , ?I) ? ( .ICI 0 ?r.Nr4 f ?^??11?1,7?w"•r:,Hn[n rr.r rnB• U TEST AG .. 1 • :, 3 r r ?1.? H (IN•. 19 ?I ,,,r, p ? cowow wnr ,r a J ,U ? U ?]pD nrD ? cnoYrn ? p SID: ,r„r , .r.L rrr.I rv INI NN., rI I•,.I rrf,l i) A4 .a, I r TESTnESULTS ? ? , nI• IrI I 11 ' ' :; _f; t ,-, 4 Nv,S ,IL AIrwNA rIII ICI Arrrlr,rU UV\NY MLI UISYn,CIrr 11 w L,I L r r ' : JA YLO(D x,BO ' 2 5 : 776 2100 2110 ".' d1 1:n R a l ?oncr } D w,\ HH[ M a n m r d „ r ts e rnn RmrA u+rcr NU s A eancr An on s, n. DAn orgvmu rv\DU rnla JAP no x i F p ? YISP 0-3 5-0-76 w+ } { v5 ?ri q$(fj'l(Gy? p?? r 70 ,? , IT Ts7`°. r>,.srT T z•, h ir?l ?,KF,w'f ,4l H' „?I(1!!r „ to ?, - R?'I? ??. Jcti ? fi• I," ,,x?l Inter-Office Communication Jrt. aro: •n Y'4i'.1.-..n. v7f To: •Fr.,ennt C. J ioyit n, Port An -?lesDate: From: "•rt•oner Port An ?e7 es File: Subject: '•,tal Collsio- !teport t.G:-ns.n j: 1aril:: O.^.odt Driver #1 - - - - - - Pobert D. Lopeman, E,•e 19 aoute 1, Bo:: 621 . . _....., _ k'ort Ludlos, ';es•st lncton ` ll;i55 Pontiac k:nrdtcr, Fie;.,T279 Norren L. Omodt,.!Lre 5S . v 2i87th Place Weft -7 d IcT:d=., S asklin..,tor 2971 Dod ce "s to tion wL, :ron, DJ,_ 2o7 (!tilled instantly) Passon.•er Vohicle !r :? lvn 14:I OmodL, It_re $2 7 87th P1uce -.ant - nds, Vissk in?-ton F d on arrival) (D DI:TE TISIE and LUCF,'f_--- r11::rrt" u?? l`t IS hay 7, 1975, occurred 8:30 Pr;ri., 5.2 miles south of Hadlock, Oa,k Bay hoad, Jefrerson Counter. hrrived upor. scene '9:10 P.;d. e , SYNOPSi1. Investi••stlon of tt.e pl.ysical damtirre of tl-.F. tiro vek-Jeles t S revealed tl e 1965 Pontiac hscd struck the 1971 Dodr;e ir_ I tl e r Yr.t side. DSTA-LS Upon arrival nt tie rcene, Deputies Thurn,:+on, Booth And i:Ay^.e.^ o: 'ate dnrl'erao:: County :;!,crlfT1s ot'1'Ice ')dviged r V, at t•e:o k:•.d died in a Iioare sto.sion ,.9!Ton. Tt.e crSver of the otl Fr ve: icle r;n? iniurAn on! nil bi'd 1, een :a orted to ,Tef'i'Jrs.,n tlrrer41 iios^itul in ?pr` 2'or:nrend, Rank Signature Date ve. -,?o Remarks - - Captain - vuton:mt T.i _ Sergeant _ Suprrri.or -- - WSI• Itr,•. 1.61 i- e Bare Drg i Dusk I . nlt t? Do ted 50mrh Pole kSl R F 5.2 Sou t,!-. of ',,tclluck Oa It Bay Boyd 1 ( ! 1 eorurernrnt ldentllJ cstIen p_10?24n is-17'10° C-11444" RR #2 to fop; line D-3 133" 4r12 to fog line 8-217;1" R Pl to fog line F'-819" LF #1 to i'o_r• line G-2514" 4R --1 to -ou_e mark .. 1.- 0 41t r; _rol mract point I-651^0" RR -skid 'roa I:? J-100111"BB' said 'frcn IC-7414" LR •_.cid t'rar.Y'2 y L-8017" :.F' skid from .02 1--316" from tog line k-1110" W. wi:eel r2 over cent?rl! 0-3110" Lo p2 over centerll P-116 1 speed snt:fL' ='1 4-21 and of nouff from foe, line; H-1281S" nol.c to RF wheel imr."ct o f Shoulder F Lev A 1 vP 1 i #2 r USTATLnOUIE ?000NTY ROAp L7 D M C LS FREIIA Rou1CONSI TRET000E son LU I • . J •? ?J . ? N E W IN n ? ? ® ? 91 or Hadlock _ lJ,88 AME A NO.OF STREET OR HIGHWAY ak Day Road CR#10 n INIETISECIINGWITH: STREETORROAD LL 0 nAMI• DIAGRAM DATA TION Hadlock M ,"•No %RO W CLS TEHSECING TREET OR ROAD [R[NCT TOR AND Pt. Ludlki 4 EAGE CODE O -IJ__p._.__ IREL110N FROM R EPCCIAL COO LCS N 5 E W a ING USE ET ? OF, _ County Road „ 18 COLLISIONINVOLVED' ? VEHICLENEHICLE ? VEHICLE-BICYCLE ®OI fril-HET ?HITARUN SEVERITY 1 tOTK NO. ? VENICLE-ODJECT OF VEHICLES ? VCEBCLE FR TRAIN Power. Pole __._ ?GTOIENVEHICLE *IO , ED - N INJURED ? vEHICIEPEDESIRIAN COILISION ? NOR . ? HAIARUOUSMATEAIAL ?PROPERTV ODJECI SIPUCK (NAME OF OlUECT STnuCN AND OYI NEflS NAME) OAMAGC ONLY p IS A NAME !:CI'HC NV 10 N T ADDRESS $ waI1rE11kR --------- .TT LV SCI N[IIY ' W NAME TD -) .-CES '` Ti MovkDrnuM E NAME 5 Rrl Nf nr 10 Apry1I E5 E A S• iuw rl'aW6TP ?- r •.r.nv:+I,w `r t0 C aFASrJ HI:rn LT. .u 1N.,nu.I Sr• Hlcl At Ur LI :cuorr "I"' n lx In I NDnuullr i III AIIAI .".CrNf. 5 D?A111 P1011MLIRY DIIIW UISAnIIIJp NOI INSTALL CO ir LNOr 1CC1ED D SD11411 + f NH ? T 011rrIPnrltxw • Ot(xlf-YClrl 1 om DUI AHIIHaIWNK I AD4DWNOSINTK IVlnl rllllNJURY T POSNII lOI WUS[ SfO "' ?lolAll rf JLCIrD IRA, , D PARTIAL lY1JIC1F0 ' - ,gss E - -• -.-' • . A1 ' lroN UrvuwWW • . I[INJUIIY UHKNr s eul ufu rAlwnE /. ukmcD _ Power Pole/ Puget Power LOCA110NOF OAJECT SIRN CKS E W •.. I" EST. DAMAGE 14>( 1 RS AMElAS q L 0A0WAY 15 fFEi ? Pj ? ? or ? n. RD EDGE S 755.00 .. D GP IMELL JOHN RICHMD DRIVkgSNA1AE lA51,FIRST MIDDLE ITT BICYCLIST OIIM.IHMNCHf CKILJ, . , R D TREET ADDRESS R v 2524 Sherman St. v R rtY - STATE .21p CODE PHONE NO. Port Townsend, Wa. 98368 RE CR Y STATE .. ZIP CODE .. PHONE NO. I "- " N RIVERS LICENSE H'O. STATE SEX DATE OF BIRTH M D• 396 of ° L N DRIVERS LICENSE NO. , , __ .... - • STIFF-7 EA pAIE OF BWIH •' ? l'J a. m 1Y 6? O• MO. DAY YR. 1 WERSOCcER_I10N FWMNAVL; - PHDNENO. Stud t t 2 DRIVERS OCCUPA71014 FINMtIAAE T i _ PH li .__.._ en ? .?Tormsend H.S. CODES >'-•I LLISS 2.. :SEAT BELT., 2.. ISI EIEC1ICN l CODES >IJI C U S _. _.._. LURE Oi INULVR ?• ' S ._. •I G AELT- SISEJECTION _..?_ OF EED. R MiCFNE VEH YE A Y• 3 BY 04 nd h efferson Gcn rl. INJUn ES F- SLErvE VI 1 . A MAKEI000GE.CHEV.1 MODEL IOAR}?NOVAI E l l CE IZORCONV.1 N VEM. YEAR V. AKE 100 E MOOELIOAgiwOVAs \ ;TYLE I2 DR.CONVI v V{! sedan 2dr/ht v ? E VEH. COLOR H LTC. PLATE M1O. STATE TRAILER PLATE NO. STATE E VEH. COLOR . PLATE NO. v. t STATE AMIi PULE NO. STATE org. kim 156 I-Ia. H ?? C VEHI LE L. ITER ATI N NUMBER 000ME7EN w L 1342675995 48352 C VEHICLE IDENI.I.-ON NUMDER }? ? 00o ETER E REGISTERED OWNER-LAST FuLST MIDDLE N a 5 REGISI FRED OWNER- EAST FU15T j.. -. MOOLE _ HiltonA Karen S. a N . f ADDRESS OF O'WiJER 2968 Laurel Rd., Longview, Washington 0 2 ADDflESS OF OWNER NAME MID ADDRESS OF BISURANCE CO.OR AGEER ! dk NAME M,DAODRESS OF INSURANCE CO. OR AGENT CHARGE N/A EN RCEMENT CHARGE - A 1011 h II b . CT10N Nf? l ??3"gT1?j7FTfES OFPEASZSN5INVOLVED CODES _ a a SEK AGE STATUS N EJECT. L• NAME: C' ADDRESS U WJIJIBEOF EMOVEDfnOM • A. }'dASY • rr ??RpOF 0.%s r Z ;?-l6 II F77 1 J?,y"'"Tf,'?Ir?'.'hA"P"^y?Lfq??,Nyy =-npr; P ?+'s I I 1 r- ?t,,?VLL '1 f if ! - ?1 Lx !.: Y LT Y'^A` ,<.t ?N%4. I'- l J tl.?v .?'?r 1 . ? •>f Y Ir'` ' ?' 'I x ? J IMF ??K?4,;xP+ s, UI:d ryl ; al w Icy ) ? ? 1 7 3Jt 1 1 I ? N I1 ? ? I ??J k I ??1 I ti?ti H M y??µ 4 ? ? e?i ;r:,? yi •.. ?. .,x•44 ?5. ..,, °? -;;t1 r DAMAG D .?.. i.,1 IS r I _ -?mitl%T'G"r r -nICL:d i.F.'Id -: a/! ?Er+ ,,ttom? A l ? ? VLII ICLC NO 1 I ar L ? Nc .AMAUI '677" n I OUII<vLL[5, [ UAMAGED VEIIICLC NO 3 Sy?-. ,L; Z YQA?!- I ? I m1 T I T • - y . n } t D S! CI1 O DA GE: FHILLL O UYOY GE IU1NL'r 1 fl 1 DIS4111 IN INN L Y - A ~ . ) Cl 1AL AGE ] ? 1 O Ors 1.1 DAMAGE [ r ]CSI OIHFN M.V OwMAG[ I ? E 0 Cq vlrxCLE N; > O L GE col O Ew G p E > ? IuN AL DAMAGE ? GU GE I ? OINEq M. Y-OAMAGE a o A ? N AM > xt g vDN ? 1T CI L uAMAG,[ Dqu 1 ] No wca DAMwcc .. 1 La'lnq lsT. 5 U^ weE TOwEOBr i 10 •..i TOwE.BY 'C _-? iC•l. E' GSr..AMAGC ID tf To s L6,. tvj<3 r'. DIAGRAM OF COLLISION DRAWARROWSHOWING s I j _ I I . I. I F 'I r:r j?\0 NI UjTH IN`VLE 17 i i I_ ?-I" -T-.r.•?I I I 1 1•T.•1 I -,..,.`{ 1_?_.? ART, !? 1 ?•-j I I ' 1•?I ,- ' ?. .,r,lA[_l[n,_H -.? : ? =• -?_?_7 , 1 I .:.? Ir??,?!dsy,Po?o 71--; ? I -?- DESCRIPTION OF L - I Dm F WHAT PROBABLY HAPPENED BEFORE. DURING AND All. THE C-N. NCL DE INFOnMATIpNNOIONDIAGRAM EG DgrvEn COLLISION .,rfoucfO YaBV5.ID 57RIANaoTNw000LOR,CONSTnucl10NOn nEIA won K, ErC.I _Vehicle i3orthgeat_orl QEk 1ar__,^_oad in cveyc to righ_. Vehicle fmlcdao ne+,otiate " . - -- --- - _ curve _al d ran off loft shoulder_arriover i7an4, Struck uo: rer pole bro -dD_de __ to leSt_llriver apn?rently fell asle_ep. - PQSITION BEFOR E COLLISION HAOEO O E O O R ON STREET OR N GHwq NAVE OR NO - •- IN OxE DlrtiFCTION . Ixt I G DECREwsING lr rA Oak Hay Road l ?) 0 ,- - YES 11 E 4 _ D. ALONG- _ ' ] ) . 1. Do I" __ OSTrNt. _ _ __ _ _ r GUen?e.n - Ow TO h AFDBrCV'CL IST WAS USIxG - SIDEwA 1 Y r ISau H IRIB ROAD 11" 4111 MATHEfl CONTRIBU n E ,w S 'CRryM^qK[O 6 OESG }f j Oll SS AL moss LK D BICYCLE ROUTE 0 H TIN En - ECK DNFI Inl EI I< : FR ONENEOA NfOSTANCESl N FCK 'CL Cl G E I 11's O.j U ff O> ?• Ca L/± [ C O , N INrIUENCE OF uJ• [.CASE- _.dEC9_01-_- r Dn vfn - IN'OE>_ OwrNG 1-. n > SRIC.Agp[D EARN "'•I ovsl2. s _ cyrsc '"i- .N. ?In GO= . NERD I >;_ ? ? ND LuEH[E 01 w[T ) i R G Lt1?_pRDGSRwr f } r.. vE E A FA?f N?Lr tiSEr PASSING ?-? n. G ].:J c T RN J a HO ) CE EOINC ITAl Ep SHOWING J .3^fFp l.. .l - ['' F C I IOC f C G -? , I T B ?..J OCATI AnKING ??__ r1 "I ROPER _ q E U N 1 , , !5? ?-1 C- 1 p OT "NT T nqv ' pgERATING 4E4*w_mw r M ( ISI u URN I` f, , f ! E Isrfc Fr- to nrid r[arn ? --A BD - slgrB CO 'j.- - L o -?BI? s wn.c ` [ oG IN CH Li COND T • -_ iicir s??w,DLiT.r I T DvEintsrfprF Vl - ) AIIDN STOrgf FDo 0,0 ?1 I IONS iflAFFI( CONTRO r TYPE OE HOOD lE > IC C O VEHICLE CO N D ITI ON SOBgIETY . RAFSrc i ( i I I 2: a. y BF I E : J 5G LS O Ew I - f 1 Q U1 0) ?.CiUNltlitl?t€01 NU )( ICNfCK ONfI {}vGIx4? R SO cscNAL 1 J ? S D G _ - _ J i DAYLIGHT > 1 STM y) ; TWOw r A D C i IEGTIYE. ?1 .ABILITY bl `Kt' .- ,- i vAIR . tD .?, N Y 1 JIO?J TNAFFIC LANE ]. C U E ? I .._- ? SG )L Wf G R GE-- I> IT --_ ] AfR1 1 lA.l..... S_ NOT IBEU - - _ 11TC NG IRON VM K[ llllllIDN 11 ' D OOEN DARK ST [[i LLfY N LCTIVE ] SOBnfTY E I1 C 1 ? ME BOING IENI(nIN6 TnAFFICI ' I I Ia0 (q n[Lt H O.U. N U T rI NKIxG N [E 15r BACKING • • It" Lc a01 r- 5 ,,: 54 L. 5 TURN IS " CHEM, TEST NO - J E Jt „ q !.' X an (NOa Ts o r . AEi -N, c N , I I I T sr mvEq Hnurrurn IE ?',' _ r ?` A T > __... ___ _. ... ..._ .-_.. .. .. } . -ICE. „ O OCFEOIS 1ISl-[1-13 r; ' ^> ."UH-E. It I C AlY IIAW:t HO ulrCI IN ' OrNnlr A', % TEST RESULTS M•AICrrL15 rLl nrn 2 ? ` ?, nr 1 t 11tFr3cLLTidt G17 , In 3 yir U.IM I'll AH11 1 2D 9 0700 ]'.' ^r- 072^•_8 • ( r w u 1' I iN.-II.. ?D M MIN • Sr. / r n ? ?c.? '', n.nuxunnN nuu.ruAr rr. ls .... 1. Nl I DI r B/8^ 1/20/'!9 ._... __.. _- MF' .I?jll I? iAll I a rM Lr..,LrA Uq.Y __ _...._ .... ........ ..... ON Un:+M • UIIOI M[NI AG[NCY'S OOPV THIPLICAiI CUIY., UIVI STIGAIUN S COPY 1' "{ Eq t T? Tf pl ?F E( ,53 °k 1 t? n ?I }r'? +r ? ,7y?y a p yk{ tl LI }x k I I , k? ?p'1/ 7 t.,pr? r r ? 1 'X ?? ,;k?d.?T?L 1 4 r .. k•1i 1 d,y 1 y I I- yt?V I } ?? ?'?19rE}?? ? #a?` ' w R r 1 '' I, , ( r ' LI XuIS •dr ?r T I • , - , - + ?. f E?? t•}L } Y?Y???? ' '- 1 I 'Y, . STATE OF WASHINGTON FACE OF UNIFORM POLICE TRAFFIC COLLISION REPORT DATE OF COLLISgN DAY OF COLLIS ION LIME c.ullrYNO CITYNO. FNWA FA AIO •Ei I?.1 -7- i SUN I MGII Ufl1 / YJ ?UBA RURAL COUNTY ?STATE ROUTE COUNTY ROAD ?CITY STNEET O ADM CLS. PREFIX ROUT/E OR STR EET CODE SECTION 36- N ^^ L O N 5 E W ? CIIYONTOWN R?.- ( / .cIY• V M/' ILES ? ? El JCLOF J"T(?'?I.LAC F U PIIEFI% EO I AILE POST y 7. U C ANO. OF STREET ONIIKHWAY INTERSECTINGWITH: STREETORNOAD LL O RAMP DIAGRAM DATA T Cr ON , _ , . " '.T " I NON INTERSEC?IN ACCIDEIIi I NIEIIINON . XHD I NTER CLS. E NTER5ECTINU STHEOF ROAD ON HEF• RENCE CROSS STREETOR ROAD Q N: _ BETWEEN STREET AND 'STREET MILEAGE COOS I\- 57 DISTANCE AND DIRECTION FROM REF RENCEOR CROSS STREET ! u es HS 0 SPECUL COUIrvG USE ?LJILES N S E VI I.'.. t . OF OA- y CRVENICLE-VEHICU ?VEHICLERICYCLE ?OTIERIVRITEI ?HRARUN COLLISION INVOLVED: ?SIOLEN VEHICLE RTMIN .NO S KILLEDEVERITY _ ? ?VEHICLEOBIECT ?VEIIICLE-R TOTAL NO NO.IrJJURED . OFVENIC S LD ? VEHICLE PEDESTRIAN- ?NON COLLISION ?HAZARDOU5MATERIAL .. ROPERIY DAMAGE ONLY ...,OBJECT STRUCK(NAMEOF ODIECT StRUCKANQOWNEH3 NAMEi LOLAIIOrv OFOOJEGT STRNCKS E' W .. EST. DAMAGE ?ROADWAY FEET ? ? ? ? RD EDGE S DRYERS NAME UST. , FIRST MIDDLE DRIVERSNAMELASI FIRSTMIDOLE(IF UICYCLIST OHPLOESTRIANCNEC..u R R STNEET AOOPESS T' "- v 51,t E ZIP. CODE .....',PHONE NO. E ' R CITY '.. STALE ,'.. ,- ZIP CODE PHONE NO. R rJl..Clc_ Alrr <? ° 3"'' i • 7 r' f? ./ L-c=YL,? r:-T G; N . .. .., DRYERS LICENSE NO. - • .STATE % D O GI rH N IVEHS LICENSE NO. STATE SE% DA OF BIRnI Cl Q. '' 1. M Ofi Y ; O• 1 -7 I MO. DA1 ] ?( • ?, 0 fl3 LUPATION F AME... ... ., ....PRONE U Z" PI EN DRIVERS OCCUPATION FIRMNAME .. CODES >1-3) EEATSELT Z_ I'•I EJECTION _ _. __... CODES >J.,,, I.... _. 'AI SEATDELT__ __ ISI EJECTION ..I__._ NATUREOF _.ES -.. NAUVRERTES I J FROM ESCENE BY TO REMOVED FROM SCENERY: TO v VEH.YEM ?? MAKE[OOOOELHEV.I- H^ MODELIDARI NOVA1 v STYLERDR CONV.1 v VEH YEAH 6'c MAKEIDODGECNEVJ C &v MOOELIDART NOVAI STYLE[2DR-CONY) SfC c> E . COLOR VEH LTC. RATE NO.: •. STATE TRAILER PLATE NO. STATE E' VEH. COLOR '. UC PLATE NO. STATE TRAILER TEND . STATE ± C VENT LE ID Nil A 107 NUMBER . O MEIER . : .. C V RICLE IDENfIFICAIION NUMBER ODOMETER .,. E 7-C4F Z F'?.? E 'J..'.'- ?Li -•`? C'C ^rdJ.? IIEGLSTERED OWNER-UST .. FIRST ... MIOULE REGISTERED OWNER-LA5i FRISt. '.. MIDDLE N Q r} I / I'!C'/t??LL Q• N <?sNn ! _f ' XOORE35 G owNkfl _. ,:. : , , ADDRESS OF OWNER i. 'LJ=J_.AAA.C Gl !?,•v L? S"1 ? ?2 r. om? . Z'/ !7),(L Nom./""r(,_kv!A/?C•n J. NAM rJSURANCE COON AOENi .... ..- . •.. ?4 A n?mA??e NAMEANUADpRESSOF SU ANCECO, OR AGEIIT ..._.-. ,. (1L'K CIW1G... CITAT 0 ENF ONCENE CNAHGE. - ITAII H .. NT . LL?L.C ?A (C'i` /Ir UAT / -l /Y F?_ AL10N CIN CCC??_ SONS INVOLVED LO BES NAME, ADDRESS & INJURIES OF PER rE% ADE STATUS EJECT. NAME' C C ADORES.. U P NAIUHCOF SCFIIf tZM TO INJUIIIES A NAME T S AD[JIERS I:A 1_. r&J [f.W NO MGM IO y. ? 5rki Z 2 tT a av+ y r. I W NA.F. N lIn ti n'I llv In k ?'''?..q RA,??Qud1 ,. ! E .?._..In__. kge;•v?• Y''' I S vs 2FSnIr•D.Alev, II II I I nl sl ule v L' ?% IiY II? Mk. OL, v ...LNNII _ I NI A I w. D 'i I1M Nrl !I lLLD I Non fc11U A',i? • Y. '4 ?I?I D N _ iI 1 _ .? 2D{ FI At r )N 1 ( 2 JI 111 C [Ali 111, 11! 10 S rO 1 rUr EI ire r oL 011 I 1 [LIT au r rAl I1 4{. ! f?*?'•yJ '1 .rt o?L LOrU T AnlO T wt aTAL r n I II J I uN" v 1 Ij_ k S? 4.A, AEI .,y`" Sy ?3., 5 yI k W ?nPo, p ' 1_. p a " h it T 1 ?!r t - 1 _ F rI i fl e ?Y 1.. 1' ? !Y1 3 s?4 I 3 1'F ? ? J ? { , ti F S ?? .4t:nl tY I A ? J, `Y ? I -[ r r,f L ??y 'I I • i {? L F }r I { S c 'ri 1 Ifn??"r"'? c ;1 I r IC'I'. VEHICLE V v? ]• SHADEAREAOFSEVEREST -ACT. INSTRUCTIONS: ] DRAW i r , OC . ARROWISI TOSHOWeRINCIPAL DIRECTION OF FORCE. '0' ? r DAMAGEDVEHICLENO.1 lu6E TINS SPACE FOR SKEICIING DAMAGE TO THAILEII6, MOTORCYCLES, ETC.( DAMAGED VEHICLE NO, ff H,.ra I.. A R r I6. Unu..u»?wR 1>. Orllluln O . err, ' 1a { 0 SEVEIIIrv OFDAMAGE: VEHICLE No.I IQ DISABLIAMAGE AhIA > FUNCTIONAL DAMAGE , Q NO DAMAGE SE gITY OF OgMAGE: OtHEq VHHCID -AOLINOUANIAOE I IDAMAGE RN.V. AMAGE > ? FUNCTIONAL DAa1AGE S?t?VT'E•ITYOF DAMAGVEIIICE NO. > AIIA.E }LJDFU AL YSN ISA IONGDpAMAGf NOOAMAGE AAGE TOWED BY .DgMAGC TO t['?5n TOWED OY FSl. DAMAGE ? T01YED nY fST. DAMAGE QG ' TD S • TD t ? DIAGRAM OF COLLISION r mENnev -, : ; ...DRAWAflflOWSHOWING- - .... .'. :. '. ..., : . . xe,o-N,va ROwr, ve»rafF .kelsrxuxs ou[ors DN•orr no i:roriaKDxineas . _... .. NORTH IN CIRCLE ?' - ' 4 ? Row.xoa+sl[vwrc 0A NDFyrAM.,.,rxyFLF I i !. i f r ? 111 r e,rr[ y,er PcoLar ? f __ ?: , 1 i - I I r r -I_. Ii t I ?_ _ .1. <Y6M'._I.. DESCRIPTION OF COLLISION. (INDICATE WHAT PROBASLY HAPIENEDBEFOREDUHINO AND AFTER THE CHASH,INCLUDE INPOnMATION NOT ON OIgOPAM, E.O.OnIVER DISABILITY, REDUCEOVSIBLITY, PEDESTRIAN CLOTHING COLOR, CONSTRUCTION OR REPAIR WORK, ETC.1 LP! ?./Q _...tJGN.I;.Z.. Pnlns_ TUiLV?N. _t? :_LGrT F _ ?'= I - - _ _ ?. r/?pu.. ?.s. ?.._h???-?-..iC _ /_.: /?C?rtt I1- .. S//JL__Pc? v??H ?.:L._-ST.t'. Lr.C1!?'.11.G-.fa? '- VOSI ION BEFORE COL ISION - - - F xts SPEE0.5 No D LA E V NICIE IF PARKED GNt NO. HEADED M" 'T ON STREET OP HIGHWAY NAME OR NO IN DI RECTION gyro sAre LEGALLY WAIVER INCREASING DECREASING ` -.to - 1.1 0 ? , (r' N r . w, r 1 L1 U LJ r 1 ! YES_O YES RO I i ) ? I MP _ _ ? rtp. 1 1F?•- x x H?».A .ou eonxe L? ...M G _ ?- FPdA_ TO ICLIST WAS USING, ` ISIOFWA ]I WALK A S?..I61°ULOER "L IM E`ALK S 'CU N '!..T.2 ? `°N Tf° •1 41 ARK itP 5 A K CLERWTE 10 [R R AD SUR AC FATHER .. .CONTgIElU7 NG CIRCUMSTANCES ` vfgNE, GL Ac ONS?.;.,-; IC EF O NET ICIlCK ONE( ICIIECKONlO 0 EI • { ?`,? • O <eEpJ}I ' }vlN CL[ o- . Drr FFr--- DRIVER O ER •OF.- DRIV[n ? 1 tea, GOINQ O. ] NO. ] NO' ] MO } 1 I!1 STR G T AI HT AHEAD ya tAH, Ol?lw j' UNOfR INILU.CIOF I ??I1 TOLL OWING I T pi fG 0lO YNRN. -1 OVDET KIMO !`I? ?_ J.pYiNBr1iT. LIL...LALCOlOL_•-_..?I?.L.J-IQQQLQFE4 .C%•.! 7GNIfIG ?•. N0 9 ' __ . A 1. 3 ] LT } ( R4 G I ]I-- ORUO] INFLUENCE OF {t 0 CENTEN r Ilyi AMAPI TLY , MAKING D N UR 6N0 ] 1.. M O?_ I 'S? f kED °STA}[D -I? F L GTO ISf? LOCALONIARKIrq ?I MAKING LIFT RN ? r - I ?F%C[E GNf S ?)IOI I 1 ROE ( ?B( I ICE A OQ r ) ptfe T 0 1 I "AKIN° SA SP ED 4 N L I •L 3? F fT ![ UII - _ . - _? Q Y 1 l _ OIU NOT GRAN R 1 -? 'TURN It. S SI r 1 0 FGARO r-I (- 'rl uSu SLOWING y ?LD [ CL[ } ? - - _. '• .ESD.•GONG S ??__ : OIII[H IYECIFYI 1 [AI !CP I "_ I L I [ °a i }` I ilo°i°c" °o vmi?i of l El D BTDMeD}oR GUO t ) - . _ e g L Ii7F,1 C N'3 p?ilOryg iggFFIC CONTRO e ° TRAIIIC TYPE Of ROAD VEHICLE CONDITION ., .SOBRIET I' '??11 ICMICK ONE( NO IVEIICLE 0]E IC EC 0lOII ORF V I.._JBLJ STOPPED AT SIGNAL SIGN _ _ Vf Nltlf ??{{'1 ``?CQQ33 V[HICIt ICNECK ON[I r ' ? ? r j WAY JI IRUtFOI I NO ] '- ?-I j G HE ED ENO } I ucxut o o LJ RO DWAY` A 'X] IIX -LIGHT .. a Twaw Y_.. .Cnn[uvf. II!_..?_iurAlrilO'Y ! m TRAP ICLAMF - ` I L? _.... } I YrflO ,' } PAWN : . { O[VF S Ol` .. N n A f -)>___I .1113-1.111 tw I?11? trARnxo FROM } FLAOLIGIItf NOT IMP 1 AIREU.- J FIAR-PoSETION -1K - NLAH NO I IN L ANOE ' 1} DEFLCTWf IInD SOSP IF ir -FIGING E. - _.... _ I : LOG.IIAMP nlAR LIGHTS IS UNK...,_ TnAFICI IENTIRING - -- r• } I ASH NO A-1 , i niS WUHN NOT ll(MT10N1[T S HAI .. Mn[rl ..- .... ...: 011 u•IOOIH P.[N pIIINKING I IB•_,.,.I S?CKIMO ` ?ri Hisoritt` t iiixAa IWYIwgr lrll n VMY11M4 xl 1NO[? CHEM. TES 1 - i : "1 T nAr K ll. El 6FT1 Nn pncYlp ElIAl1A I ? 1ES1GIVIN OTII[R IN[CIIYI r CII CGrrt} F I G • r LA MAN URre S H } -.01U xx NO DE F L L' TS . LEST REIUStD !, T OIHrII rVf Clrl ?:., .^h N(rlvr Rr»E 1, iweeH rl rk rj TEST RESMIT y S - rr IIH,,IrNG rr rCIH yNAVI trrAAK rr u x u LiCI. IN>r,rE»lu HV IIIAI IIL'r LOW LIf.L ED AN AIIiNV10 L` IMIEntD Ir",. yrry r 2iA.,71 H, InS IN IA Ir Url ui r AHI 1 A11 nrrI W E ! . . H MI / C?,/M /?q IEI P• K S1l_LI STA iE OF WA NGTO PA., OF . POLICE COMP A Il M9ER UNIFORM POLICE TRAFFIC COLLISION REPORT E - D... DATEOFCOLLISION DAY OF COtLIGON TIME COUNTY NO. CRY p, -- fHWA ; A i MO `I 7 I D Y(1, / -7 T t1N 1 M9N n IUfS ] WE A iN11N S FH S SAl IUS?)' Q ?I J = ? DM.C RF% R ?' URAL . COUNTY ?STAIEROUTE XCOUNTY ROAD ?CITY SIREET O . O UTEORSTREETC_ OOE TO - xe Z R 1 A ?OTHERISPECIFYI N ? O L'. N S E W CITY OR TOWN ?IN W PREFI% EO. _ MIE SI 0'. / MILE. ? ? ?OF_Il_?>?JO_G (?._ W?_.? 2 ?L, NMIE NO IF GTREET OR HIGHWAY. .--; I INTEFLSECTINOWITH STREET011010 LL RAMP DIAGRAM DATA. : I ' 'O NONwTERSEC ACCIDENT MILEAGE NTER ,PO %RD CLR INTERSECT NG STREET OR-ROAD ORREF EI NCECROSSSTREETORPOAD N BETWEEN .__- GSTANCErrAVNNrD DIRE( A p ., Fs //? FEET COLLISION INVOLVED: TTAL NO Of VEHCLES OBJECT STRUCKINM .inLV Vac ??q. HIT[RUN SEVERITY -., LOPROPERTY KIU.ED STOLENVEHICLE IDAMAGE ONLY 1 CTSTRUCK EST DAMAGE ? ROADWAY FEET ? ? ? ? RD EDGE 5 .,MIDDLE.. DRIVERS NAME-STHFIST MIDDLE. RF BICYCLIST OR PEDESTRIAN CHECK$0 ..'-?'.; . A/OuG ?l?a WI «i/F o/? e D • R STREET ADDRESS _.. .:'. .::.- ...... :. -:._.. .: :':: ?, R .. STREET ADDRESS ....:^ .... v, E .. „?'•,.,;:; .. .. STATE :. :'..+. .. -. ZIP CODE: '. PHONE NO. CRY ....... -:.. E R CITY.. -..:..- ... _. _..'; :STATE '._?.:•_. TIP CODE t: ., PHONE NO. R; Se ?m C'tl A ci 63 ? - • f N ..... ., ?.-- STATE. W VEfiS LILENGE N O D SE% DATE OF BIRTN . N DRIVERS LICENSE NO.....'. S1ATE.. SEX. DATE OF 8IRTH D• / J ' E a r•' yCU -?S /? Iu3 ??. N1 [? ZS '1fl D; MO. I DAY 69NERS000UPAR FWM NAME... . ... -. .. .. ... _ '_.. PHONE NO. y DRIVERSOCCUPATION -. FIRM NAME .. PH NE NO. CODES > 13I cuss= IJI SEAT BELT ISI EJECTION CODES >1131 CLASS' IEI GEAT OELT_ I51 EJECTION NATURE OF, NIURIES NATURE F INJURIES - ? M FR SCENE BV. TO FROM SCENE By TO ' - VEH.YEAR. MAKEI130DGEJ:HE11: MODE5I TNOVN : '. STYLEIZDR-Cprv.l--.: VEH YEAR MAKEIOODGE CHEV.1_: MODELIDMT-NpVAI.. STVLE12MR ONVJ.,_ V /9C5 ea ?ronE ?dK O /q VEH. COL STATE..:. THJJLEti P UTS NO. STATE ...: ,; E H VEH COLOR UC PLATE AD- STATE: ..• IRAILER PLATE NO. ? STATE •riJar .H ?• Q?4 E. ._ .(.' VEHI lE.1DENTifX:ATION NUMBER.' ::...u .,.-- ._: ODOMETER ?. n _ ..C VEMICLE.IDENTnIC AT10N NUMBER -.? .. . ._.. :. . ODOMETFA E' /336..? S8 :J b' 31 B E , ' . ,. _..: zlyG 3 A .. REGLSTERED OWIIEq,y LAST .....'.-+?.:.;;,iIRST.. i.'-..;•: _.; :. MIDDLE ".._., REGISTERED OWNER- AST.:;.-:. :-- ..FIRST.. o = S ' i3 o : ame a s ? . ADDRESS Of. OWNER=,.... ._." '.L.,._...._ ?. : .: _... .,_....;...._.:?. ADDRESS OF.OWNER . ..... ... ..:.. ._.:.,i .... ?.....:. ?.:..... -'.:%M.u.l.,. NAME AND ADDRESS Of INSURANCE CO, OR AGENT..,. .......... .... •, NAMEANDADDRESSOF SURANCECO. ORAGENT' - CN . .......--. ... .,... .., i :_ ... C NAIKIN NO ,.,.,,_ 'ENF ORCEME NT CHARGE..: ''.: ... . '.. ?: . ... :_. . G1ATI N :,...A..r.' ". ACTION coom NAME, ADDRESS & INJURIES OF PERSONS INVOLVED N SE% - AGE STATUS EJEC 0 C NAME: 7 C' ADDRESS'. U P NAIUNE OF, NJURIES. - _ R[MOVEDFROM SCENE BV TO A. NAME' T ADDRESS'. FN R E DfiIOM TO RCFN 5., I JU R R - W •, NAME'. r 'T•, ;.. ADDRESS' NATURE ! ?[M-?lu7_l nulJg¢sI SC[NF Dr. _ To - + S E NAME' 7 7 ApDgE DS {Qfi.___' xb rnGwi'-- i S• nlw s To C O 11191AIUS I ]PAkK[ApFq ;Pl D[91 RMN NCYCILRi IIIIIAl P0911- IE?' 1 1 6 7 I.OTHFq I'CSRUII I INJURYLlAS3 NO INJURY 3DEADAi SCENE ] Df AD ON ARRNAL I 5D11111 A6 1 NJUR 0 C D BUNG IF 11110 UgY ICI AI BELT .NOT INSTALLED T. NOTIIIUSE ] US[0 ISI CJECIKri .NOTE.IECIr.D t Ol :VFECIEO ] P R EJECTED D SDTH[R O wIl NE99 L BU•v R MOIORC r'NYCLCI [ ] YCGINON UNONT .OfDIN Q tiPITAI T. MSSIIIE MJUNY UNKIIOVIN O 'FA-ELT FAILURE U OVM If EJECTED • f fir. '?? r Ir'? 4rIF Y F ? *•? ? z?? z` 0 ?,Y3 p VEHICLE DAMA - :'`T?YLEA'"!11 EIR[t??rakY? 7?m? ``11 ?. - `I § AREA OF SEVERES IMPACT. INSTRUCTIONS: J. DRAWEARROWISI TO SHUWIPRINCIIPAL IEGIRAN OF CfIUrc ?-;' IF ?T??UL_? ?n...N'd.ye ,"5 Ve_hFcle ND _?c;h 6?Ak/ hf_ A?eacP_ ct -7 0 ._ V r h l c t o _. (a-`? 9-1] q o CI Vh Q R 04 ' POSITION BEFORE COLLISION - - NO. LwFlfb NO,. ABED CRF ILEPOT q5 O EET Av NAM NEoF I ON 76-'R IN I ?..^xlr it Ir_I I L?-L N:Tn -` DAMAGED VEHICLE N 0.1 IS r wsE IRIS sPgct FOR sKE, DAMAGE lD s, MDTORCrcL[s. [,c.l -- DAMAGED VEIIICLE N - - 0.2 13 1. _ n I. IT I INN, 17. 0-1- IT O. n.c E EVERITY OF DAMAGE. VEHICLE NO.I DISABLING OAMgGE ] ? iUNCT10NA L DAMAGE . O V. DAMAGE ER M N GE YOr DAMAGE IDTRER VERI-I [IE ?NpISABLIrvG DAMAGE EITER NA ? rUNC, ZONAL bAMAGE ?MAG ? Tr OF DAMAGE: VEHICLE ND.] IE RIRSq L ING AMAGE ] 13 OTNEHMV. DAMwG[ 4 ? ND DAMAGE 'UN CTI TOWED BY T 04MAGC EST 7OWFGEY -F. AMAGE 1D 000, to B Tp E DIAGRAM OF COLLISION- .L :DRAW ARROW SHOWING NORTH IN CIRCLE ] 1 .._ ---- . EHDW.«p.,ELLVtHTLLDP ' f[DtE,«,.«P,TN,.frD«[ DESCRIPTION OF COLLISION PER CArEWHATPROBABLr HAPPENED EEFOHE. DUHxG AID AFTER THE CRASH. INCLUDE INFORMATION o oNp AGnAM E..OR-. DISABILITY. REDUCED VRIBLI I. PEDESTRIAN CLOaHpGCDton,eoNSTRUCnDN OR REPAIR WORK. ETCL- - rt0 J ALONG . PEDRI SUSING! 'EI ]I. I ?SHOULOER4 CPOSSwgLK S' nLK° T - CLE R ._J OTNE E ROAD SURFACE CHECK ONE, INEAKHER ... .. CONTRIBU TING CI FICUrn IS AMES p\ ]xi`„ f 11"IlK III O U 11.7 DnI_ IER IN L 1. 2 pR IN- YEN x , SO I: 1 (v/ -DNY-- _h- -fl N_SL EOr 4COh9},___ . tOOLQ, Gv - I - IyJ YISGC OED wAN L L `7. A Pa551NG A T ] I A WING ----- NDERIN r _I Of r .L '._I._DRUGb j OvERCE SF- 7 NIE. ENily ^Pl SLEEV ' n]. R GH U - I_- T ] SNOWING 7 E.El I-!J 5 E..4.ML 'N?G TD. - n DLn . - -' OSATIO . T T RN S RN O_c I "I" novEH A T: h t c _ 1 IOlrlfn ISPECii YI - SPEC FYI - IR'N", GRANT RUN IS O L OISFE STAP&POILIPW T _ _ I _ nrv E I SLOW NG G _ SIDEPED FOR ' LIGHT CONDITIONS ICNCCK ONE(. RAFFIC CONTRO d. I FN C C H t TYf•E OF flOAD N ] EC ON DR MONF VEHICLE CONrP DQQIjTjIQQON v t SOBg1ETY _, 3 SIGNAL OPPEDAT IGNALS r I I E NO AA ] 4. tfx'9 i AE01 t 1,E1.1111.1 (CHECK ONE( ON O T __ _ I x D G 1 l STOP s X .. - 1..-. > ` DAwN s cn ] ENS tl E _° o -- A B 11 1Y sTAnimcf n . _ _ ]' p s _ -... ._ r ING . D.. A NLgDL F ft ' T 1 .. NOT o. MPn I TI . - PANKFOrosmD N t .t1 .'• .. HEO ' ' ' OO.RAI n I,, .rL n G l ] Onl El ] L ENTFnING inAFAFFIGI j . biN[ET . O r •-?- I,xO x GOT". 11 1 "U1311 __ 0. ... HAD NOT - BEEN UR NK INC I BACKING 111. j _btREfl IIIIIIL." S -Al !6 S Ru oND.] CHEM. TEST '-? - b 3 -IT 1. TS O C[ rNLMAn - - ' 3 A RD?-. - _' - t GIVEN OTH E. ISP[C IFl . ] . E ] O 0[O NO OEF FLTS \ fST NfFV fD ? - •? ' O C NvtING 11N40 I 2 <lN 6ENAMI A HANK ' t SPt Clrvl -- - 'b .7o TEST RESULTS -- 2 NAME E NAME A NAOK En UV1 NO O: Cl 111. EU UL CL ANN vt0 I,? L 1 nIVfU NAFI C HIRE _ , g 0 ; „ "N' T f 1 M • O P frCA `•?. RUNR5, AI 11 Ur I .U hv? UA,f 1 I( DISTRIBUTION OHGI P JALCG SENDTOWASIIINGTONSTAIEPATftOLOLYMPIAWA SIIINGIONDR104 OUPLICATECOPY, LOCAL LAWtNF011CEMf NT AGENC, SCOPY_THWLIrAlt COPY, INVESTIGATORSCOPY ?e'A ? -r Ts b / 1 M1? _? MOTOR VEHICLE COLLISION REPORT - x ra NO. O T c COLLI F - u OaL , 1 SO 7? c x /n AM 7x 00 ® PIM Y CITY rv /?° p/ S? AVn.I CO - T Tp WN o , MILES: O? TOWN ADM.CL5 VHEFI% xouT[en s [T 5E oN i, T r r w 4s4? F Hadloclc (!A (, / 9 -,,. ENAME ST EET_RO OR HGHWAY I NT P C ING.W_-11 .. STREET O R D : _ - .. .. _. , ..... _ _ ._ - PREFIX EO MILEPOST T ? :. COUNTY R OAD D 10 p i NG N IN HSECTIONLOCATION OF COLLI]/ON TE r MP DIAGRAM OAFA ayl B E TW E EN cotmt Rd. 18 / STREET AND t4ats Mats Bar Road STREET - ;ix............ .?L[xe.r ox i.-TNn.. IA....... aN. Knle.a. r l.7 ?? rER N IN cLSp I.T[x Ine .Tx[ ,.. e n./cxa I [r .R. 18 OF ? 45 'D S 3 -'-, - N n.x Iwxir[I ®?-2 o aA L SPED. USE x .a e n n o O TST U<K aci,T 1-J,;ra ;?._OWNEfl F,OBJECTS NAM£AND ADD S:;A:?L.,; LOC ... .. .i.n _ ar .. _.. ... _. _. . - IN RO ATIOn ...-.. I:'If=1 eF aaTl•r AOWAY. "'• -_. lJ LI a In oeJ FEET ? R` - O IV£RS L F FIRST NAMEr?.? - DRIVERS LAST' ,w.. ,..,.. -: F1P _. - E:sLW.......- ?._. ,.- GA_TZNEY Marion Ann e 11 5 REF.T.AD RE - - ROUTE NO. .rv [ _.. .. _.__._.. ,,..:?iw.L.aliv_.'S _.?..:._.,..OK•HO. - [ STREET Rfi55 - .. .ROUTE NO.,A DBOX„NO: ..-- [.LL n Star Rt. 1 Box 495 N 'YJv'i lLrpvln?>LSTA????yA?21P CODE ORIVfiR3 OCCUP I CITYi:.. ... ',?.,... .. T,,;,r?.. y,;,, ,w:.II.P CODE DRIVERS OCGU A Port Ludlow 11A 8 6 Retired '?"nPIVER9'LICENSE:NU? STATE SEK DATE OF RTH AGE DRIVE LICE Erv R 3 ATE SELL EOF BIRTH AGES GARH"6IA 2468 WA X 2 28 08 ,}[: MAKE; Icn[v •.ezal MODEL' IxwA.9.Ai1 DY STYLE . 12Pw_I to ANE.Slcxav • OOEL.' IH. .A I BODY STY E,' Y' 73 chew S/W 4 Dr. LICENSE PLA E O '.:::$T? ..:? TRAILER PPL:wTE. ? ,STATE' LIC NSE PLATE NO„ ]T T .? t AILER PL ENO ,:?:?T, TE???v' YAH 65 WA na VEHICLE IDERT,I,FIGATJOJI O??..:119SB' Q' RI ODOM ETEF K aweal -.1- 1 IF lE3 H 242 0 O ' EO TERED NE '1 .AFT-Kr..,FA •_ Iwr DRIVERS LICEN E..NO ?F_, s..'_.i: EGI ER OW P,,, sT.HrOq' 1 ;:rsD VERS-LICEN E NOi S*A•M"E OWNERS'ADORESS „..... 'IaA[[r`OT, : .DATED TN OWNEPSA E5,-.. y., '1 Iti`y;, _...- OATEO IRTN" _._....__ -r...VwL._ _._. -4 _... •- .6 IAI P SOFVE _C ERAMAGE i.`e ..vA_vA-:d 1.1;zlc. ,,:?i. ve .?n v[sr ART OF VEH 4E, AMAGE v..-.,J,;, "awwvG... ,»_.yi :•• •Iw a J __. > 2 ?, s Cf -- OLLin ?- I E L SURANCE T LIABILITY INSURANCE INFORMATION VEHICLE NO 1 STNERE ... Go fl GE EFFECT FOR THIS CC NTON YOUR CAR YES ? NO NAME AND ADDRESS OF LIARV URA CEPS CFUHO DE 'Y YAY '? ] vrl F '' t?ME F'LI B I INSUR CE CO ?Ei, A t S , J E NO' ESS OF IA MSL RA CE AO T- ^ f- 66 .ITllt!=`.6.wa;011Fw•'.xsJiia(1.ed?Ll' ,^h(.%u:3.e:?iv?Y?l+f1.•.u.'.:da C. 2N•w:.N.J_UwY.- ??u..v_'A'w.+:<._.:.vur -v .a ..,r...xv.nh.-.[R[%? a At.- 1 NANE L NAM ??-_ x[ - ADDRESS E%. '. ..- ADDRESS _..SEX. . M F mlil -------- ----- [ T.wr • v I [w.xlnn,ien xv . uo Tox)F ® S TUSOFI JUR.o EO CLE MARK FIRST ONE THAT ES E K LLEO r MAeI.RlnrvKiu. [FwnlIRI e STONE THAT AFP' S STATUS OF JN UP "'JII L S G II?l'"' na l ILLE Ix 'X lN r T I^ H x.n , a aLrc ? ? f ? IS[ [A[r e: [.1 . _ I RO H 7 L - l 6? u' ? X 0 ? 6 5[D _iN I [] U SHOW NORTH ARROW C ROLE '\ ESGRIBE BELOWWN T HAP C CB-IRFFE TO_VF CLE6 Y NUMYBERI '."',..L 7t,: :P z p rQ__cuit? v.+-(c?? -- ,[[Tien ?? Q._ [...Pxl.nw,._ChQSSEl7 Ci?cJJ_p _LlU? . Ffic1n?D___ A "A 4 .?FI_.rnJ n?rar,_r3UaYtpr.?. c+Fus' r?_ QOUNL'Y FZCt?(?' ?-l _ (?(D I`J v7" :?';2T p _ _ _ I+f T _ °t- ?2 (-(N r VEHICLES POSITIONS nEFORE COLLISION INV[anGwrcG DY NCADLO [ „w[B y. . EN L t (RSg? E W ON STREET F.ON/HIGHWAY NAM! GR NO. pEy?1 No _ ? .L 1--1 ro`l`l NI IrouRl ,.`. ? IEY ? ? LL 4 ... ? ICS Y? .. ? ? Ic ? NO I.Nfar oArl ox I Iqq oT. CNI IN ? ? El ? ? ? , PCOtSTIVAM ? ? ? ? ALONG CHOS NO '- V O . ' TO . . - . : ? •Y *?. .]? ? PTO[iTq N WAS USING 10 H L. . , 1? n.u . ? S ? S? RO U U CR: WLATHtR LIGHT CONDIrIO E TP IPICC TR L 1 rw,l TY LO PO O. OR f CN CLC TIOM :- •'?'..,:? .. .rN .. v'nrYl[ I •f [n[ v Icxatx on[On •aA[I : 1 = Ow l 111???JJJ111' [ 1 1 A 1 ? DAYLIGHT ? 1 El SIGNAL. ? 1 L? ONE WAYuo,I M GOIND STRAIGHT AIIEAO 1 DRY l? IIAI IRO ! ? DAWH ? ] ? GTOP SI GN X I TWO WAY ? 3 OVERTAKING AND PASSING R M1IDL[ -1 ? i WET S? SNOWING J ? DUSK ? i ? C TI LO SIGN El ] El NOAD ] ? MAKING RIGHT TURN E3 J I 1-1 M1HGW FOG FLASHING RED ? A MAKING LEFT TURN ? ? A? A E] LBIGIITS ON E] A ? A ? ILOOP?HAM ? P? OT IIT.N `IARFSTgf.[r r, ICf. ] [] r9P[CII YI ] ? IGNTS OF, ? ] ?. FL ASHINO AMRPR Fj ] r] ALLOY ? ] 0 MAKING U-TURN ? A ( 0 S ?DIfC n, 9TRI ,r LIONr9 ? A ? RII SIGNAL El A El LWO?WAY,'N ?A n- SLOWING NI ' R ( CON FOR NOT G pAHOtR T 6j,??IFy ? T ? Oi'1'ICI'.11 /ILAGMAN El T ? STOPPED FOR TRAFFIC "" I ? ?? O.N-ra :u.ru vr...r, cn.na.Ir<I El S (_J 41•CCI , f' ? -? I. _J H ? OR M1TGI'90nip NAL ...... -- I ? 4F 1•AIIATFD r . I L ? ? STOPP[D IN ROADWAY tyI C] 9 I] GIVN FD yV CI'D IC ? ] ?? UIIOI VIpFp ?I ? ','A IIIC LI H[ ??T•???[F ryHFF yy??LL¢¢'? D IROM/ ??.aYS.t Yir',I .? .tv .4 w,-.'Nw - ,1 ??:'. ..w .-h._(?? T,--[',.i^ ? .viSfGl•'.?;?vr I . - ... v? F ?. a L e p NO OR E lU OL fJ FT - i O TE,O ."..I AY-op I 'TIME •COLLI H co cT PM w.• C U ILE Y - ADM-CLS PREFIX urc on nin coon SECTION ON 0' +wa. ' . . "-°??itrrre-?scr? tLSlrrtnl /??d?.u.r 3 699a " • ,,,,n G. C'. E.-F,_1[EET_R9AD OR.NIGN Y,?v.:•-?,-N EA ECT sT EE ROAD, - PREfIA EO LEP 7 UN INTER .CTION'L/OCAT, ON OF DOLL /y] / `? 1 •/ ell WEL'N (/•[[YV ?I ' STREET ANO/%fJ(/S J?/]•(} RAMP AGRAM DATA D ?? y: P<n [ ;,??a nNF.xnL. »www. an.°A.°°[. `"` 1 5 NOn RD I ER I TER CLS. w No ` ="7S "oo n - DOE DF 1-? ? „rxen Iwxiiel / C vo? ? v /` SPEC. CODE USE .. - v ` v[......... wlwx -Pun A VSJ CTTRYCRI#y. rlniwf off' wuc[I„•,•^,?a w?::, O j, (t OF'.OBJECTS-NAMFA ADORES AT -,?...; ".,.?„ Q E? °r- ?" ? FEET Dfl IV LASTJMAME, Z; U,t ,; IIRS„NAME -,,, ,MHO LE,.iu.. w IV En9 LAST N E..,..e,,.I-....-.f..FIRST,:Nw s r? NpA[,xw»iwo xusoxswu[ -- $TRE ADDRESS fr ^'r. --... ROU HNO _... ? _ _ -.r1.F:x'G..'laY?..a:GwSL3._-.. .- iANP3 jl• O ',..:' IN,uw[oua[w _ T F OOP :n.:Fjw-_.?.e._v;:.::.iwf'. OUTfi HO.fN Jc•[O.; .. :.Y: 000 c s T rowTF<w IF » ?CITY l.• ?w?? STATE',]; ;, ZIP CODE _gRrvERS_-000U .ION;,; I C -_ ?? -, ,?•fT. T-Ey---„ .3.'J.,.•ZiP,CODE ;OgIVERV4---QCCUPA TION'? ] ?.:u:. _K • L -!?S, FAN -, -.,;LLy. • STATE S K - 'OF BI(1T , 1 SAGE _ -DRIVERS LICENSE NU ER., a1 ,k ST TE S- •OATE *'I"!' V[xi MANE+y?•d[ay,p°o°[I MODEL +Inw BOGY STYLf:12on:1 _'? MA Eryl„1 -`oo I ?OOELlxovw-wwTI U00%iSL }',t?ywl 1 ?3 ?oi2d -29 ?e ± LICEN5E YLAT?NO W?STATE.?y? ?RAILER?LATE rO__ •y??STAT-?,j?;. ? ' LCE 5E T ?_ StATE?^• AI, E PLATE NO;w a?:' _ATE"-^ nL/7.3?1o G lfl - !•. P},Ls s'j,lv![wl ODOMETEMr,{L4oe VEHICLE.IDENT,IFI IVIDNTN0;'{jj,•yj)908 : ': _'_ . • EM(, _E,IOENTIFICAjION NO,';??'1t93 a s x[w[wl OOOMETCI(IMI?eAa[ r T REOISTEflED OWNE[(W1,vr4;JRST,-,.-, •AV aI;y ORV S?ICENSE NO :...u?tREOISTERED OWNER.laws?-iI_ p-...... u[ I,;j4DH ERS_LIC6N,$&sN,O.;Jw' OWNERS ADORES-1 (?R :?In[i?^-: -'S[,_ ,??HZ•j,a! OATP OF,B ERS AODR_SJS t [nA 7T_- ?rSl- TEOFOIRT, PARTS OF, _V ENIC?EPAMAGED<iesuv-3YG:A+^s[ .YL'tao „ , o con r IVAO CIA PARTS OF-VEMLCLE:OA OE ?s•sx....Jx.:,eL.. ?"._.:.r"S._''X+ii.:a,:Y .v, ?n < ryI IT LIABILITY INSURANCE INFORMATION -VEHICLE NO. 1 - coven AGE NEFFFECCT FORTHISACCIDEnr ONYOUR CAR ? YES ? N NAME AND ADDRESS OFD NGILrTY RCAJRANCE PoLIGY?OLDER ?) " ..v u [ OF LIABILITY INSURANCC CO ? I,_ IFTAI. NAM-A _ODRESS•,,.Q(-LIABIIIg,I.l]RAN-CfIAGENT',?y'j?j"„_[{r '' 2r ? ? Ar?-C, 3 / l / FEc?r1?? -.?.?fL• Ci,; (?.u ry? ? ? Cd ??•?u b 1?T iNJURY??i'h?rS?-?i1yq ?Yi.?.?iSL.A •]? A..OE JURY -:I ..ow4 1. F 1 '?ACEI NAME E ADDgfiss F ADDRES F nu A . -- BTAr lO N H lkIARK FIRST O NE TH`. P - ATUSO IN O jUR FIR f.T YH MARI< PL NETkAT.P IE§, U P; I E GL Q, [ ] N LLEO • a a I I lu novel I °' ? ry NO E C H _ N LLED I•[ [I ix IM Ii 1 ' Fw c.l ' N L , ? ??n, S a ? 6? ?a ' _ ? SQ 6 0 7Q HO NORTH U ARROW CIRCLE O \ ..- OESC E DC OW NAT XAPPH ED REFER TO VLH CLE -BY-'r1...HR = !3?.ss Su???euv? NI y ' [ p09 ^ 4 _ !4[?9--. , krF9d-c:yj iAv_,.7.0 n. wwwpw. a? _ .,near p wnlp«w.. n ?_ rte! . - - ---- --- ---- - G _. -.. / a ?? • ??? ""? ? ` / w s ) u i ?f >c'i _ ?? 1 / VEHICLES POSITIONS DEF 11[ADCO ORE COLLISION NI NO N STRCCT OR a11.Y.1. .1•.MC On o iN oIw v[« IF r i oA,L, [x [ o INVESTIG.ATHD RY I[w ? I^wr[ ? ro rwol lIC• NO: [ O 1 '1 _ a o.. , - b . a ? • [ <:,. ? np IxYf.N°.,IpN NO nT ICnI ???? ? E] L 1:1 El `.. S P[0lSTR "':.???O ALO O".. 1 :.'.•-' :..: C 0551NG ... ., ..PROM '. TO.:. J I.?•.`?.:;:...:. PEO[SfRIAN WA9 U11NG I? • ]? w p, wllw ]? • Aa[w•r «outolw ? 1 ? [ wo D?o xn••w•lw [x[w NUAOQURFACf,;I LIGHT CONDITIONS, TTAFIICCOHrROL. TYPE OI l I AILIOIIT ? SIGNALS ?PONC 0 DOING I.AH311T AHEAD l? DRY .A 2 AWN ? ] F3 STOP SIGN WO OVCNTARIO AND ? ] ? L E] WCT W Sn DUSK a ^N[ET A ? El l C] Y IELD SIGN ? A ? [LASHING nr D IFFILC c' C ? r MANINO RIGHT TURN E] 1 L''?? L1?? MAKING LEPT TURN ? [ r'SNO Lj ICC r LIGHT r 1 I_3 LIGNTYOFIBT , ? s E] FLASHING AMIICR A MP 1 CIS ? ALIi-Y r_' LJ u 5 ? MAKING U-TURN ( OrNCM F? 1 L ? 'ECIIY 'A RK NO S ln[CT 11G11T• 1 1''T 1'I LJ S C? AA SIGNAL f'"T TWO WAYU LJ IF 11 FFT TRHI LINES _ A [:LOWING i RC ASOR FOR NpT S[[INO OA.GlI m•rwA<rlow•. 1IC. Io•MU+,P rI•?ox k T ] RFl. C T 1.7 OFI'IC[N/F LAOMAry ? T ? STOPPI.G FOFT TRAFFIC GIGNAL ToPPE Ar - , 1.? A I I Sf [C IY ' I I S ? O O [j 1 n Gf.PANATI p 0 S SIOPPtD IN ROADWAY 1 1 1 IC _I 2 DIVIDVD L-710 r7 lJ LJ .No TRAFrIC LAN[ IF Cl 2_ 1 . L ] ? IIMDI VID[O ry11 L1 TAR" FIND. - 'r I PARK l.J l J Rlnernn l' 1F P J 1. ?? ? >' ppgypE??pv??t tyI ?,? n C 3 py L Y1' Tb E w MOTOR VEHICLE COLLISION REPORT N0. GATE OF COW50N DAY OF COLUBON TIMEOFCOWSON AM ' COLINTx NO. / CRV NO ONMn ES .FAn rvES A'. I.D. t•I n LwD e 1979 X 5; 30 PM rV•2 Febrt 6 T ? , E MLEB OO CITY.IOYM CCUniY CITY. TOWN D - ADM CLS PREFI% nDUlE Ofl 6rnffl COD[ SEC •% 1'S ®© of Hadlock Occc?rc Jefferson ?w - wTERSECIWG WITH: STAEETOFROAD BVENAMEOFSTAEET, ROAD OR HIGHWAY PREFI% EO MILEPOST ° y Oak Ha It ? MMP DIAGRAM DATA ION COLLI NONINTERSECTIONLOCATgN OF STREET Hadlock BTREETMD Port Ludlow ETWEEN ' O ?F ° B n R DI %NDi DN © N•aAOADCAD55wG. uAfnp5l OngEnNrrplD LAnouwn. [R bwoOL' NON %'RO ?FNOCLYOI EiIR OF . D89 wiER I ER CLS ? B nrrFns[n 1' mlEn ®® DF Hadlock ? v C E SPEC _ ®EHCIE VEncfE p O.-R-11. T F C D 0,, CI ,E7 pwi nun -7- H ? EnEDEB1wAn ? OBJECT STRUCK InAMF D' P- OWNER OFOWECTS NAME AND ADDRESS LOGAICN ?N © n0 DINEC IN ROADWAY FEET t OMVERSLAST NWAE IFASTNMIE MIDDLE u. PE -1. DRIVERSLASTNAME E FIRST NAME MIDDLE Smith Agatha Ledwich Stewart m1oko ANDtb%NO. ROUTE NO STREET ADDRESS ROUTE NO. AND BOX NO. rnDAE 1nAN 1W0 nFn ,ws WE . STREET ADDRESS Lane iner 55 R -'D A 1000 "G" Street a CITY STATE. LP CDOE DRIVERS OCCUPATION DOWSd CRY STATE YJPCDDE OnIVEFRSOCCUPAT10N Port Ludlow Wn. 98365 Housewife " Port Townsend. Wn. 983 8 IJaitress H AGE DnNERS LCENSE NUMBER STATE SE% TE OF BATH AGE MRIVERSMENSENUMBEll STATE Sex DATEOFBIRT M T DAx rEAn SVJ-IT-HA-L870Rr Wn M F WJ? A 13 65 ST-EW-AM-H702RA Wn VENgLE YR. MAREICHEV.-OOWEI MODELINOVADARTI BODY STYLEI2 Mfl.l VENgLE Yfl. MAKE I——--.' MODELINOVAAMIi. BODY STYLE (2 MRI 1979 Mercur rand tsar is Cdr 1970 Illercury Marquis 2dr BTATE TAMER PLATENO. STATE AT NO LICENSEPLATE NO. STATE 1RAILERPUTENO. STATE . LICENSE PL E I Wn ORD 437 YAl•f 634 Wn. 119M MODELS. NEWER) ODOMETER (MILEAGE) VEHgU:IDENTIFICATgN NO. II9G0 MOOEL58 NEWER) DOMETER IM%EAGE) d VEHKLEIOENTIFICATCNNO. OD64D1541280 9Z66F6032)6 ENAME) DRIVERS LICENSE NO. VST-FAST'MDOI REGISTERED OWNER ILAST FIASi'MgDLE NAME) DRIVERS ICENSE NO . PEBSTERF,OOVMFA. ( S??nEi?-TUalas A. SPf-IT-HA-L870 Stewart Mioko ST-E{4-AN,-H702 OF BATH OWHENSADDREOH (STREET, CRY AND STATE; DATEOFBATH OWNERSADORE59 ISTREET.CIIY AND STATE), DATE W 1000 "G" Port Townsend, 41n. n. P.O. Box 427, Hadlock * AMAGED PMTSOfvEMgUS DAMAGED r O , rl a 5.510 ..{{sll ppiF ycfoysl y? SJ? 4 V V V PMTBOFVEHCLE D r•vAn 510 P T-. ri r7 WASTH!RE AUTOMOBILE UABILITY WSURMCE DYES DNO CTrA6 IAMCE INFORMATION-VEHICLE NO. I- COVERAGE IN EFFECT FOR THIS ACCIDENT ONxoUFE Y ,... NAMEAND ADDRESS OF UABUTY INSURANCE POL?ssLDER Tr E NAMEOFUABUTYINSURANCECOMPAN 1 t D Wn. 98339 Hadlock Sa 0 ougl s Smith P.O. Box 427, ER NAMEANDADDRESS OF UABII/TY INSURANCE AGE, qrv Si•iF ZP WB,YPOLCYNUMB H509251 Homer Smith Agency, Port Townsend, Wn. ISTli AGE 2NDINJURY: NSEGE,•RAIE AErORIFDA ADdlgnunMUwEHI AGE IOT.L NAME NAME -.EO SEX AOME55 SEI, ADDRESS. M : -.-__ M F EM O ENB •DOC00 .MF MARK FIRST ONE THAT ES TATUSOFINJURED • ONE MANN FASTTHAT AFFU ? p,ASSLM><R FHCIE glLED ISM EI N OW ES mSVnIL WNAH Twuc "a S I%SANwo Wob•N PDav9H VEHCLE 00 duK I ULLED M,tmu1 i.EHnEI IuIHMI? IIOE W?E?? i p,° 60 70 pnoctlwN D 50 SD 7 D 50 G IN p ,,: nF SHOW NORTH DY MROW CRCLE wDO E01 \ I w OEBCRiBE BELOW NNATHMPENEO.IREFER TO VEHCLES BY NUMDEIB vehicle #1_w4s going- up hill., heading- i #1 [a? \I F,„;;?v N9wY, cle Road Veh south on Oak Hay began to fish tall on Ice -- -- ? M,Nw[A (ADIR EN«[ w.D M.D., i 9N[aIDnD.IA.ELnAw%N. \ i -- --- '-- Vehicle. #2 heading_north on Oak Bay -+? 2? ----'-" -` --' ' ©i -- _ i road__caught the rear_warter _Qf---_- Vehxr_le #1 and. through it_into _ _- rest off .th_- to #l came Vehicle s i ) -- -'-` f I _ - __- _ _ . n_. p I _ r-gad on the onposrte_, side of the -load- l behind Vehicle #2 y J r 1' 'Y INV(eTgam u YEHCU ENCU • - * n LrrAA.En D VEHICLES POSITIONS BEFORE COLLISION wM [ t - 1 VENIf.LN OH BIREET OA HCIIWAY NAME d ? D «D. Oo"' R = 13 oa ? ®? O ak Ba D D D D?? Oak Ha ad Front DIRECTION TD DIRECTION. ^a*'"°"' D D D D wa+D cnotun w0 10 SIDEWAA% 2Dw.LFWAY DD MOULDER A??,pywN, B? wA"'o"Aw""vL[iA SOD HER M D[BTPoAN WA1uB ICAp B,il ACE wE•1HER UONTCO+BTIOfS TRMf1000NinOL, pt<+[AII TT'PEDFroM OBVERMHgL[ACI)oNH NCFAOF ID?IlE?OM/'ORHOIIEI vlnA>( KxCai IOnuCDAMiF V ?T I Kw C•LMI p NO I K.K,'CL T 1 ?dAVM 1 D DAECHT D 1 D BgrfAU ?1 1 ? ONE WAY ® 1 (Z) GOING STRAIGHT ANCAD DAVl11 ? 2 ? 9rOP GION ® 2 TWO WAY ? 2 ? OVERTAKINGANDPAISFNO ? ?' ?MY 1 ?-NM 2 ? p ? , ? WtT , ?NNOW , N DAR LA D 2 D Yilw SION D 0 D )IOM 4D F ? , DMA%NO flgM TURN ® SNOw D INA. SINEi LT ? t D -,N,,, RED D , D n 71KNIINGE D 1 E) MA%INOLCFI TURN LFGH15 O 11 A-1 ? ° ? uA%NOU TURN NE. ° ? LDIAFJRK IRW C] B D ILASNwD AMR(R ? ° ? A ®" 09,11 ° D w•v I LEFT.- D B D BLOWPID ? IMRCE-FSIHTH D E D ""(,OVAL TWO.- ? t ?o"N`# E ? B R(ABONIORNOTSEI pAAglR T 1 ? r D OFFCERIFLAGMM LANES ? T ? STOPPED FOR TRAFFIC Al DOi `F .(wrnwPMMr. IKIAKrOM,1C1 MD E DOA STOP,WAI l - Y D E ?Oln[R fPCCIrv 1 0 ' NDID D D Blo"(DIN.OADWAY 7 1 0 ,.. F-?l. .t Ail,n•F 14 Fn I A1 LL 11, , Y l I q ' ' , . _.? .•r .•, n 1 s . 7-17 r L 1 Iria tit 4 '` t?5 4 r ?y ? ?? 1 msl, 11 fI I s -_ y$f?g?9l(?' 4?1' i^ r li 1 YIJF,(( IJl I ' 11?' lf' 1 1j. ,iM f?lf ?` pg??, fit, r ?.1E ?,.I .y... ?. a ...,.. wit'•scY?%re. r 1d 'a?,.swt7 •',x....._._... _..,? ..r.J.?..,?...:? -'? '? '? '... a vJaa'?.P, I?? r ? ?, MOTOR VEHICLE COLLISION REPORT ,,. .a..,.a...... NO. '(ATE OF CALUYDN D AY OF COL LISION RME OF COWYON AM COUNiv Giv NO. ?'?°NRDAH w. w sv. .Kn FL:bruar 2, 1979E rv!s wfD INUx Iw 6. HwR MnulES X 6:30 1 PM PwiAC[ COUNTY CRV.TON?I do µ; MILES OO GTY.TOWN L6 PREFIx R A IRLEic 5 TA]N rt ? Jefferson ?w 1? ®© GF Hadlock ? ?? GVENAME Of STPEET,ROADORHIGHWAY WTER6ELIWGYATH. 61nEET OR ROAD PREFI% EO MILEPOST D•?ccw iD Oak Ha Road NONINTERSECTM]N?LOCATKIN OF COLIIYON MMP DIAGRAM MTA BETWEEN Hadlock STREET MID Port Lud lOW 61REET IF Mi ] 1?© AROADCHOSSrK MIElPO6i ORIDENNFVUK IANpJARA. uofR.DwDDE. ® HadlockR ;`RRSEDIIDH:?? RItLT ® %IiEfl ? 1 CLS. HEf FPENt N05inOS551w"E11pi p"gwpAp 1 q <OwYONnvdvED ?! Ly VEN°LE ?wGE ?vEnKLE6KrttF QOIHERIWNIEI SPEC.C D OFO1f KL[b ? ?QvEr.CtFObIFCi ?vFHOLE iRAw QVEIUDLFP[d61NNl ?141<OLLI6gN ?NR-RUN 061ECi SiRULH (NAME aOB1FCI61PUCN OWNER OFOBIECTS NAME AND ADDRESS LOCA IN POA TION OWAY FEET ?N © n? EPAR O6IEC OWVER6LAST NMIE EfIRST NAME MIDOIE NI DRIVERSLAST NAME E FIRST NAME MIDDLE Smith Agath Ledw?ich D Finch STREETADDRE56 ROUIENO.ANO BO%NO. w0 STREET ADDRESS ROUTE NO.ANDBO%TIO- 55 Rainer Lane P[REON6wl I A U P.O. Box 83 CRY STATE 21P LADE ORNER6000UPAIION _ Dpws %W CITY. STATE ZIPCOOE CANER6000UP:.iLY.I Port Ludlow, Wn. 98365 Housewife °OniONM Hadlock, Wn. 98339 retired DWVERSLILENSE NUMBER 6TATE SE% DATE OF EYRTH AGE DRIVERS LICENSE NUMBER .. STATE SEX M GATE OF BIRTH AGE rFM Sh1-IT-HA-L870RF ion M? 12 0 rE3 65 ? F -N -HJ-K6 5 M n YEMICtE YR. MARE ICMEV: OODGEI MOOELINOVNDAIm BODY STVLEI2 DR.1 VEHICLE YR. MAHEICHEV.?DDDGEI MODELINOVA?DARTI . BODY STYLE I2 Dlf.1 1979 Afercury Grand ldar is 4dr 1975 Fori3 Pinto SW-2dr NO. STATE, TRNLER PLATE NO. STATE _L!C[N6EPI?T ` LICENSE PLAtE NO. STATE TRNIER PIATENO.. 6TATE ? n (YLDJ ,,yyFF Wn . ' YAJ 478 SQn . VEHICLE IDENIIfICATKW NO. 11868 MOOEL6b HEWER(. OOOMETEq (MILEAGE) VEHICLE IDENTIFICATgNNO. IIBBB MOOELSB NEWER( OOMETER (MILEAGE) 9Z66F603206 SX12Y204342 52556 REOSTERED OWNER ILAST?FIH6T?MIDpLE NAME( DNVER6LN:EN6E NO. REG16TEPEOOVMER ILAST?FIR6TMIOOLE NAAIEI DRIVERS LICENSE NO. Douglas A. Smith SAf-IT-HA-L870RF FI-NC-HJ-K615 OYMER6 ADDRESS ISIREET.CITY AND 6TATE) - GATE Uf&RTH OWNERS ADDRESS ISTPEET.CRY AND SLATE) .. DATE OF BIRTH P.O. Box 427 Hadlock Wn. 983 9 2r 3? 3 P.O. Box 83 Hadlock Wn PAg150F VEHICLE DAMAGED rOO , rivers 51 e. rear door, both rear quarters, s?-`4"'?'b PARi60FVEHICLE DAMAGED. rtPAw VDT Hood Grill Front Fender sTO6 WASTHERE AUT LIABILRYINSURANCEINFORMATION?VEHICLE N0.1• CAVERAGEw E OMOBILE LIABILITY INSURNVCE FFEa FOR rH15 ACUDENT aN rouR LN+ ?YES ?NO AME AVD ADORES60F LVBILRY WWRANLE POl1CYHOLOEIi - NNAEOF LIABILITY WSURINCE COMPANY TP N DOUOlas A. Smith P.O.?Box 427, Port Townsend, PJn. ? SafeCo NAME AYDADMESSOFUA&UTY Ri$URANCE AGEM O'rv biAl 2P LIABILITY POUCYNUMBER „? E . ? H509251 Homer Smith Aoency, Inc. Port Townsend, Wn TST NRIRY NNAE - -__. -_._ AGE nNnfD 2ND INJURY: NDE 6EPARATE REPONifd+ApnlgNAt RUUnIESI NNAE ___.___._.?._.__?-._.___.____.__..._.- AGE _____..____- ADDPE59 SE%F M O O r , AODRE56 ?E SE% O ? YD,-FARE o _-.'®_? DDBoA. _-__-_ __,___ _ _ u _ __ _ ._ ®® n.Mi°"' __-_.._...__-__. . 6lAl US OF NJURED Q pwIR WVEHILIE MMNFWSi De.mnO "` ONE THAT APPLIE NDn D6ADI,+O S 6TATU60FINJUREO QpHVFH WVEHKLE- ? MARK FIRS -D6ADErq P` N" T ONE THAT APPLIE n°nD?&M 6 O R U ?vAYSFNG(R NO KILLED IY KREI NnONI OF CdAPWIi OFPAN EiCI QPA]MNDFA ? KILLED I y ER[I IMn°nl R ni IIF C OF P/n ETC( Q AO[,iN..H 0:?.., I. •.?.onlnN ? 5? 6? ?? QrtDE91PIAN DTnfr.. v: Rla.l„ ? 5? 6? T? SHOW NORTH BV ARROWWGfECLE pESLR BE BELOW WHAT HAPPENED:IREfERTOI£HIClE90YNUMBERI \ ^I°E„„., „r,L?D ..' O ___ Vehicle #kl was stopped off the ? ? `:"o E4« ?.`??K'.?':b; \ - left hand side of the road (when 'Nw ?R;'E AMlb DN ? I NUWHIACH VFndE ANO Yqw \ '"'°°i0'"•?`°"'"°'" - _ _ facing south) after a prevxous__._ collision __ Vehicle ,T2 came_around_ - ,?? Qf-- ,?lAl \ I _ _.ya.__courner,..a_short_dys.tance_from_ ^__ __ _ _ _ _ 1 - , • .__ the.. spot where_ Vehic],e_Clumber_.l_. I ? "-------??--'/-•- ;- l l: was.parlced WhenlVehicle ,?2 __ ,applied thm?r brakes they beaan__ i to sliab and slide off to the side --- / ?? /! ?? / 1 of the road and hit Vehicle ?1 ?_,__ th F i ht e .,g ? g in e r r ar _ - / I ? >r p ' iIAETOHHmIwN / ? VEHICLES POSITIONS BEFORE COLLISION ON 6fRFFT OIt HIWIWAY NAME OR AV C ww UM6 vLHCLw v[NKO r.H.lD w.L INVE6TgMED BY r ? LfD.u.b I.K IEn.Gr PERAD v[.KLL DCCEPLD Ap OiiinOL ?ip G[ ?E VEHI LE H s [ W "° IYwN O ? ? O oak Batr Road 1 M l ® ? O ? O ? , ? aKf ?a I?'t1' '°J HPwA O O O O Oak Ha Road 1 ?? O O O? ®,KRIr d,nw ? ? ? ? ada u°bwD IRDM DIRECTION ro DIRECTION AD1 argAN wAS LnWa T?YDEwu% 2?wAalEwAr ]? 61gUL0f.R A??ross:MP a? °ROi:S,°% a?orHw RDAD SUHrACC wLATHtn uartcGlolnow TlwfacoNTRa K.Na orl rvPE OF ROAD. Dmm?.vEHICLE ACTIONS KNC"MI vlHtll vfnG! QED%dE I'D" vEHCEf KNUONl I111.Wt1 HKIE HO I M, dEU 1 ? NK? 1 ? DAYINIT b. wi ? 1 ? SgNALb R bI J ? 1 ? ONE WAY bI MI! ? 1 ®Od1q bIRNGHT MEAD ? I ? f1RY O ] ? RAIEIHA E ? DAW+I ? J ? B10P YON ® t ®TwO WAY ? 3 ? OvCRTA%IND AND PA6YN0 M6T ? 2 ? ] ?6NONWD ] ? I%14R ? ] ? YIf LO SIGN ? ] ? Pob 'ILL ? ] ? L'ANMID RIDNI TURN qq II ®] {LV llgw ! ?IOD ! ? l10ARGM?l OM LT ? • ? ILAYI++EI REO ? . ? WTIPCHANGE P ? A ? MA%MD Llfi TURN KF ?! ? OMR b I ? DMHl1 H[ET ] ?tf+Lib OI( ? b ?Itw•JIWD AMBER (LOOP/RAN I ? b ?ML[Y ? b ? MA%WO UITUIIN OIEIIH ? b ? bA CMY IYLG YI L 8! TP rt ` `O ? b ? PR SIGNAI ? b ? Ltfbl lL,1N ? b ? 6lOWW6 HEA]ON IOIIA016fL W0 pwID[H IKJIDnHM PLtAA[I%, %E C b ![ t Lb b I ?. ?[GfV ? J ? OIIA;[HiILAOMAN lAN[b ? I ? bip`PfD f011 TIWfIC . A I ? b ? DINLfl :A`f GfY ? 1 ? Sf PARM[D ? a ? OR STOP YdI ?`µ sev .r-? cars por T?t? ??i?kfRrs on ?T d, ?ntADfo O . ? bTOnPLDnIHO•DwAv ? ID O °?` n??c N I Q ] F,71P.?Y„Dlo J I- ,, A IL , I, 7Gt]IEfE7?77^y°.7'f.76E¢R. .. ., ..- w"'y '.+,ea"'^':?rr i? ?..I .. , ?,. ,.... ?..,.. T [Mn !rT NO .-. ..,._ ?• OAIEOF COLLISION DAY OF OOLLISIW TIMEOFCOWEION -ES AM COUNIT Y GTY fJO ? ?'.' _ ? __ DAV _ ?A rirv uDV ryES wfD nuN F W c. u0 : V PM I - '` qAF Fry COWTY CITY, TOM OUiSUE MI(ES CITY. TOM lE bllinfEICODE dE lON Zu dl. aCwR n??l% E PflEF N .E[_ I ?' I N OF O U) ?,! t( GIVE NAME OF STREET, ROAD OR HIGHWAY MERSECTINGWITH.STREETOT[FOAO FIRE- E0 MILEPOST a Y - I KGWRfo Q. - FF - Y_P. [ NON INTERSECTIONiOCAi NOF OLUSIO MMP gAGRAMDATA '/ R BETWEEN STREET AND EATR!ITE Y INDt . NON RD w ?ano.Ntn065wau tCFPpSraH nEniivwGiwtpsE?WUO . IxiElttECipn: FEEL ©® P1TEfl 'C Z7L ?MIT Z n Cn ROAU C i I c°wsw NVDWD ?vE uv?n<u OvEnKYk.aC?raclE ?? o CC4 OtnEKlwreeEl b 'L OYIE SPEC CODE lflE p, OMLxOvenclts ! •6µw. a IJ-JO N OsIEi ?vnar<awsox ?nn mm ?- d - _ .'?Y tttybbb ct r}I OBJECT STRUCK _ AuEE FDESCTain A3.12 k a y .. OWNEfl OFOOIECTd NAMf ANOADDRE59 IN OCAO ATION WAY ?1=1 ff•[[•FFF???[Wggq FEET fDOE 8 Y ' ' V uanE iKAV ®• 4 t $ OWVERSLAST NAME .. IRST NAME. .. MIDDLE rvN CAn9 DRIVERSLASTNAME RflST NAME MIDDLE wEnE 'wDLVED All coILVWOR fir` 1 STgEETA ORE53 J 1[OUTE NO.ANDBO%NO. WRE vq STREETAD.ESS ROUTE NO. AND BOX NO. GTY STATE-.. ZP'ODE D VER3000UPAM. sEPM AIE /1 -- C-N CRY,; STATE ZIP CODE,. CA. ERSOCCUPATION l!..L G? C? REPOni FDwl-1 a 'r OflIVERSLCENSE NUMBER?j,,,,,,,,,,,,, STAT SEX DATEOFBIRTH E OPIVERSLICENEENUMBEq ,.. 6TATE SEX DATE OF BIRTH AGE R _ _VOo7?' M F Zo u F u0 DAV rE R VEHK:LEYfl. MAKE ICHEV DDEI. MOCELINOVA-)._'. BODYSTYLEIt M.1 VEHICLE YR. MMEICHEV:D000EI MODELINOVA-DMTI.., SODYSTYLEIt DRI - Eo fni2 cL ?C-O ?-f D fZ ? IIGEnSEPUTENO.. STATE 1pWLER PLATE NO. STATE LICENSE PLATE NO. STATE TRWLERPWTENO. STATE - . el VEHICLEIDENTIFK;ATgNNO IIGES.CCELSINEWERI. ODOMETER MILEAGE) VEHICLEIDENTIRCATK)NNO.. 0...ODELSLNEWERI DOMETER (MILEAGE REDSTEREDOWNER IIAST'FIRST-MIDDLENAMEI. DRIVERSLX:ENEENO. FEGISTEREDOWNER ILABT•FmT.MIDDLENAMEI DRIVEfl9 LICENSE NO. '?, Boy" &m6-ss R-Gic-TPm 12D OWNERSAOOREBS, (STREET,CRYANDSTATEI 1ATEOF9111 H OWNERS ADDRE59 ISTREF Cf DD STATE) RIT101`1111 v A W nArA 'e. UL RE[AP,? PMTSOF VEMK;LE OAMAOFD ._:. - EOCOSi PMTSOFVEHICLEDAMAGED FsHUM[o C09 24,NK LLM .!2 - 2 S NAYEMCIE dTDAE.NAVFHCLE '. LIABILITY INSURANCEINFORIUATION-VEHICLE NO. 1- WAS THERE AUTOMOBILE UMILITYINSURMCE COVERAGE IN EFFECT FOR THIS ACCIDENT OV YOUR CAR YES ?NO NAMEwEANOADDgE990F UAB RYPSU LWCE POL CY VO DER 9iwTE NAMEOFUAIIIUTY WSUFLWCECO PANY H woDnESS b[v .. ... SP , Rm? e? 1 Re4,Le-a ? NAME.WDADORESSOFUAEDLfTY'INSURANCEAG NT DAY arATE SP UADUtY POLICY NUMBER Lo E ee e ? r -? eti c??L ? l4D?S'/2 . Y 1ST NJW _ _ _ AGE INS INJURY: I-111MATEBFFgIYFORAD 1-INAKEESI /JJE N E L NAME TOTA DDVESS SE) ADDRESS SE% l?rtn?e 2 .. Q HAiuAC AND -_- - x HAgR9 EM[xt OFnMUE4- Pa I MT _" DD[ K•ta DaBE oD T?Aa ---- -...__ o ? u.HMw"'APr[XI •. A DDCTOm E.Arwx.Tbx•r ATncTO ®© •,,. STATUS OF VMMEO MMKFWST ONE iHATAPPLIE3 NwF NON OiSA& STATUS OFWJ D NY MMKRRSTCHETMATMFUES wvj OwNF NvEHK:IE ?? IxevEA as.eulD IN V ?PASyffl lDLLED EHICLE nONgTVID PY 0 'Y SHOW ?ww°T rx'.n °x[DRCLE ? 15?vI 60 Ioru v ...-nD No KILLED 'nil wn OF 7? V°.nficl 1 EJ ? 5? 6?I DE.,CRIBEBELOWWHATHAPPENED REFERTOVEHICLESBYNUMBERI - t TAK[in[blTUr[ R ciaO -/J [ ??.!/_1?- ?!L?- ?lV./N n^'. M a K b"aFnE H jg--civi Lo vi _l I '{o .S 12,0eA _1d.4- D:MCT"DN`dT:Kb s Qn2_ D?? 7y_ K- o7sY? fli -?? Qf- Ll!a=ny-j _ u7'i pN ?'?o acZ- r V VEHICLES POSITIONS BEFORE COLLISION DuNU wnrcU: WraCl[ •P.n.E WVESTq[iED BY VEIIIGLE M d E W ON STREET OR -WAY NAME OR Rpe HON Ua4lV sl[NO[q UnuA AR.FD of r[Cll OCCwIKO R OMEK "° ? ? ? ? No n[ Y o • No ?v TACI ?-1 I ITblO r ? ? ? ? ? ? ? OVC[ ?O q4R 1 IDirtA ? 1000 l ED ? ? ALa1JO ? ? ? ? ? ? ?IrIFIMI rtusrWANwAdIRINO 1?ODEwaK t F"a0['0 TAO- DIRECTION TO DIRECTION J _ ROADdWPACE wcATHER ? WALKWAY 7 ? •u1bUlDCR • ? cNUp[.I.., a ? c'io?i[wiD. d Q OTHER l 5 I? JI,... WrK.c. Wl ;-. CO N T F`DCO MTROL. p[CAW[I TYPE OF ROAD YLIGHT ?T I Q m ts 1 E WAY I? BiRAIGNT MIEAp .' .-? 5 { h .,r! fI - rt t t Q DA Q t Q ATOP aIGN t4 TWO -v ? t Q OVERTAKINOANDPAS&NO ? '? tit 41 Fv 1? I ' 1 ?I FF?IDD??yy?. ll???? S K i Q W Q t Q WELD SIGN Q t r] EgiM Q 30 -.43 FIGHT TURN I r + V J1 i ? D(JQJ? • ? [ ?LIG[II/ ? • Q FLASHWD RED Q ? A ?MERCHRAMPAIbIE ? A MAKING LEFT TUR . ? r 7. -4m i ;'J ? A' w- a CWI ?LIM[I6 afT Q a ROOP N I O d (3 a ? IIAAIRVO AMBER Q µl[V Q d Q 4AKW0 UTURN ? I y ? a FC IOTUa[[MOMDE•R a ? nlAEii°aHTS ? a ? m NGNAL ? a 13 NZ, YH MAdp(F ) {TK 1 E.i J ! { ?NrOp OT QR ? r • ? GFK[RiILAGMAN LMEd ? a ? BLOYANO I ! ?1 I Y? •S'I J T L: i?D'CGIY ? r ? slomlo FOR 7M110 jI 1G '. yt 4i ?1 Q 1 ? H[R fP . [DIY ? T ? 1 ? ! dTROG Po AT 'LL { ( Sr.PMATED Q yq+ ! 71v lJ ... .. ? 7 QDNaD ? 0. d Q dTDPrrDIN l[oADwAV ? I ., r ° Y_[°DLFIG ? t Q uHIYVIDm ? a? en°ii°DJDU.r r 1 ? I 11 r ?Ne a,y r ?? ? ? C?RRpp;; y? .r A ? r G? r1 t r .GM ' ' !, {? ? JP. ? l y,TA;N J { <b' ux.,? M' 1 '.F.. J "AT? - .xr?.I+?1 I? d, LI y Ui{,(.b? ^ {. ?llrT lf.. J -J t I t i Y ?t y yt LOir?PW ?q ` ?' I y TA?r ^? 'r L .9t4riS.?J I T1? ?J?'V^??Y ?? i 9C?AAi. «TtUuA'. n. d _ o r s -E OF ASHiNGOPds - 'D POLICE ... ; N1 NUMtlEfl. 1V ! i UNIFORM POLICE TRAFFIC COLLISION REPORT COMPU • ' : . . -Gh dL W t aD.Arr as v DATEOFCOWSION DAY OF COLLISION TIME COUMY C HO h? -; _ e- MO p YR Y i M'Jn 2 IYFS WE • tllUll SiRl p 5 T IUSE 4A00 HOURI J r . H `- ?r Oq 'a r 4 ?1 `r . PRE I% ROUTE OA ' : ?„ CWlltt ?STAIEflOUTE ?COUNtt ROAD ?CITY STREET O STREET CODE S CTIOl1 ,G ?yy"^^? OIA 5"G 99. '4 4• A j F?,? e N'.' ?OTHER ISPECIFYI -'"' - - -' - W n • • I .JB?• L"+ CITY OR TOWN N S E W []IN ?) /? -? ?/ - F/??G+c ?? '... MILES ? ? ? OF F W '? 'HEF % EO t T t M LE POST /t/ ,f TJ r ?1 11 I I r A? i `Z J y C. A.„ 1dJ i :NAME p NO OF,ST REET CIR HIOHWAY '. INTERSECT NG WITM bTREET OR ROAD LL U. " 4 V YD RAMPS U RAMD T I t p '_ 1 1? 1v O ;= TJ :sM :xT7 ?? t mc., V O NONINTER+ .J - - ACCIDENT SECTWOSSTflEEI OA RO OOP REF NtER IN N QO E? R I'll" d i N. BETWEENL.c.lJ.-Lia?JC -_ ,J BEET ANO. iREET DISTANCE AND DIRECTION FROM RE ERENCE OR CROSS STNEE MILEAGE CODE S I E E ?,? c !K' J '.. F P COD US []MILES ppYT 5 E W l .1 S FEET 13J??? OI?.?LfJ._?Art Il+- E f O._ H J ' E_v..?? I}? f?yTl ?. ty? j f ? J11 :.N7?l:iil.CtJ:..LL il:? .r.? = r$LYI? ?^ ? VEHIC-ENICLE ? EHICE-BICYCLE ?OTHERIWRITEI .. .. ?HITIINUN COLLISION INVOLVED: SEVTV :. ?;, NO KILLED ? TOTAL NO VEHICLE OBJECT ?VEHICU:flRTRMN: ?STOLENVEHICLE --' OF VEHICLES 3NO.INJUREO -, ?yEHICLEPEDESrRIAN NON COLLISION ?HACARWUSMATERIAL N e? ?PHOPEATY DAMAGE ONLY OBJECT STRUCK INAME OF OBJECT STRUCK,wDOWN ,-LOCATION OF.OBECT SI UCKt.E^ESiDAMAGE:;,•1 B Y _N ?ROADWAY FEET ? ? ? ? Np EWE 3 DRIVERS.NAMEiAST -?•---?--•-- _FWST MWLE Ofl EAS NAME lA5I PR5i MODLE Ii DICYCL570R PEDE51N 13C EC Icy { D R_ %qA I1 7 s. I : T : [ I rl t''' J ., ? i ..._.-.,.v_..._....-....?_ ._...F 4 A STR TADDRESS,. ....._.?.. .._.. ,._?..,. .,... 1 _ _I^ 7 E 7 Cs V'' ':l . •' R. CRY..,:...'_.. ..f..:i„u. STATE.'_.:.::?:a'.,... ZIP.CODE.:.:... PHONE NO E R CITY. TAT ': .: .. _;-. ....:.....,,...SE •..'.,, .+i .. ZPCODE:._...-PRONE NQ . i : r N O.' DINNERS UCENNO w:.:w _.w. ??.: STATE: 'SE% DATEOFBIRTH_ MO I DAY VR . IVA ,ryLI[ti-tP/ .74 7 N O .' _ DRIVERSUCENSE .. _ -: :......,_.,.p... STATE :SE%'. ?ATE DAY MODF BIRTH:::; YR L 'N'or. q piWERS OCCUPATION F M M-_'.,.•_I '.?.^':.?:.... ..PHONE D '1 URrvCRS OLCpPAIIDN FIRM NAME N NO L A Imo . '' .• e ? . ?. ODES.>131 cuss LIRY `I SEAT BELT-. EJECTION _.I NAT N F t CODES J 131 ??URY- "4 I S - °4 ASS EAi BELT I>I EJECTION •? "' ' ?. -' • .. E.'a. U „ EO INJURIES E D .,. i I INJURES ..... r.. ..: -. ::_. ....: !,. ._:a ..J_ ,.-. FR SCENE VEH TEAR BV I - MAKEtDODGE{NEVJ:,. TD MWELIOMT OVAI STYIEIr OR.{ONV.1 REMOVED FROM SCE E VE YEM B ` NEIWWE{nEV.1, TO ^{' M DELIDART-NOVAI. STYLEIrW{ONVJ?1:; ' s- • E_ N , YEH COL - UO PP LATE %0.- - 5 RE ..,.. TRAILER PLATE NO STAI • .- E N__ VEH COLOR _ W PLATE NO.STATE - t• Y TRAILER PUlE NO. STATE _ 1 G E o2S A 1 CL f..+ LE E BC T BEN wCLE ID IFT__. IUENIIFICAi ON NUMBEfl ::. J OW El EflO T • ' • E - S 5 E i EnZ E J .. 9R t If E N - T:. ?i .J.. fiRST... ..MIDDLE_ .S,; REGISTERED OWNER IASi.x+•14 .. FWST?r MIDDLE. o. i? ra IVO/E?A?rI .T O ylry ?fll?Ew.OF OWNER _-_: .._.. _.: • ,'. _- RD?nESS OF OWNEfl NAMCAND S50 SURANCE CO (Ni GEM -,• NAME D ODAESSOF SURPHCECOORAGENT - - r .... CH ANZE'l J. ..... _.I ,, GTAIIOV NO -• .'.... .,. .. _- .. :. E F ORCEME CH G Nr;, _:.i_„_ .... I ..... ... GTAN NN _.e NAMEADDRESS & INJURIES OFTPERSONS INVOLVED ' copes ::" .,. ?"I '[r_- SE% A 5 ATLAS N ?' - s. FJF Ci' 1 ' C NAME _ IL I ? ? ? 1 r, I U ry ,F ,,.?? . NW ..OF /V C LII 10 o i ' p P RE5 ?IYr - SCFHE Dr ?, T f'F. .. I A NAME L?LL? EL D!Cvill/cr ?` 6 T _ __ _ _ /_ S i111N?• 33 .Z .3 7 .2 ;' Dwtss 8 TI/-7G G Z?/.)LP l i? S f. __ N F F HFNSVLOf HD MIUPofS rr T SCl Nt Nr N / /1-j 4,4 TO ' - & ? _:v - . 1? ?r N' I A U(C5i _.- HLMOVFDf HOM ?- ' I v.ruR s -' - srn:t Br TO i .- S H . AMF . 1 7:. E o S HAIbi- F[viTv(biti -"'-- -- __ ___ r _'.?1 uuos T :T NY 1 4S1ANS IrISUiPOSIIK]N ILNNRrCU55 O I>......Kkl I IL ?_ IAISE.ATIIFLT nA R G T l J O. O D SS N F _. Al On+JRY 1 511 G NRY I NOT INSTALLED I IaO1 CJ(CICD 1 `. J pI[l? n.AN A 1 r DI. AD ti IC O BLNO T IIDI II URF C 1 c M GIALI?IJ(CrLO Sf > r \ T D ODUOV PAL f ( UnY D U.'•CD ] F n Ll CILCITO SO fR I? ?/] K I' CUO ' r , 4W • ;:: . ? .'.. E .. - ?I D1411 TAL PO :1 t NJURY UNANOV, U OV J F 4 :I, L > T LS5 a (solo', U'.•.NUnTI .._.:. I ?, __. ..... '.. eslu uutie%unE clcnp :. ?._.. Nj.- k' 3a ? L.1 J ' t r F r ;? T k? I TZV . ;3 I ?Ii ` Fi Yn r J' S ,+` p r. X r 1 dd k L?' --iLL F ? „?i: t fn Ml?r h1Ai?`T?1?t .t ?•• ?i4t. !: I ;} J J S k ft T T ' ?i{It'F,tbEa IP v'.: 4 7 a' G r ',',?da n ?n t n? ^p { r r 1 .v w? [ d.• 1.-+,: 11 u'w _ 5 i_" ? ?L r :; ?J ?r,?.? t1 4 ? y rr+?:' I? t v trv tid y.. ;? r a , r1 W ?? ? I ?I ?N rl' .. / ... ...I ...". Y ,„. .. • .. .. ? n . w ., 4... ,. «......... 1 i..,G%"Wf11'd'IiL VEHII:LE UAMAGE s IN IN:?.`I tc b as t3 +t e. }Jr y 3 INSTRUCTIONS 1. N LACK LOX. CIHCLL TI E NU tlE. Di LAC pA .IAGED AREA rLXA%LE 2. SIfAOE AREA Of SEVEREST IM ACT. DAMAGED VEHICLE NO.1 . pflAW ARROWISI TO JNOW PRINCIPAL DIRECTION OF fORCE. / IUSf 11I5E1gcE COx s%ETCx NG pAMAGE TO TRgILFRS MOIDRCrttES.ETC.I DAMAGED VEHICLE N0.2x T Z, Une _ is. UMx?e 11. O lA S[VERITYOf DAMAGE E CLE NO.1 SEVE.ITV OF UAMAGE (OTHER VENICE EEVfRITVOFDAMAOE VENCLERD j FUN <TIO DAM ° C J O OTHER M.CE MAGE OHA A ? DAMA , ; Q OISAtlLING DAMAGE g 3 OTHER LI V. FUNCi ONALD MA.E A A E AS, y ,I} LIAI T IN. V. oI D ] JO N TOWEDB f'h-l•,? st ) 6T, DAMAGE 1!irLi !, f /•,,.L-'+• :?=v ?,1 No DAMAGE . TOWEo UV _ Esi. DAMAGE J xC TIONA L DAMAGE LJ O D A °AMAGE No TOWED BY'...__-.A :. ,. IA -DAMAGE ? TO ,.;_ //•.?/IJ C/}.n _ JicT?? T To f '_.OIaGRAM OF COLLISION'S CZE IE11RN=N ?.OL;- ,. H"•I T t : I 1 y I-_ _. ?. I t? _ i I 1 1 771-T- ) 1 y' `NAW'ARROW SHOWING !f1 1 NORTH IN CIRCLE .'.' -11 --5 "P '-1 nA F RAE I , DESCRIPTION OF? • COLLISION m VE' E r.o E DIAGRAM EG E sDJ L iY REDUCE E LItY YxEDESTPIAN CLOTHNCODR E x O , . , I °NS \ C ETC.I s.C C \ 1, `\ , P -1 J - / :--- - ?:„ POSITION BEFORE COLLISION ssffos VEHICLE 1.1 AA RKEO LLY . .• .ONE D.Ec ?VEx.? HEADED MILEPOSTOIp' ONSTREET HIGHWAY LAxfs NAiAE OR MO. N roilEO LEGA YEN. NO. INCREASING DECREAS NG -E. ". OCCUPIED N S E W - - ?•I 1 1 I I - _ lni-. ES D ES NO DTI - '7.J J. -f r 1J: r-i , PLO. ALONG rED/RICVCtISi wAS US G _ C OS qLK G I C Yf o U %???. T !1 SIDEWALK 21--lWALKWAY MOULDER 7 SL LAP V f f=COTn ROAD SURFACE W EATHER .,. ,. CONTRIBU TING CIRCUMSTANCES •-. p C NEI _ ..O F-K C E I ONE 08 MORE( '. t-' + - 0 { fl? ?cTIL(p. D DN E .] D E N o ?ER IN I O ?LXX EAL ri OR - .11A., 1..4E1lERCAWOV - ICE OF PICDHDL E ?• , ?.?9Ji r r G IGG A'RC' J T S AND -ING r 1 f ? .-ING (?' F ' DROCRIN NCE O 1 C E T• I r?' - M SOW -..?,I ?' Ow I IN G ] ] J A L N T 1E0 M i . \ E'. I nL E -1 OPEP A KING I s TIDN - N J L { ( j ?. rcE r I oc 4_. E f' DPE r ATI- .11 ° EECTI E[ L RN 1 M LInN- U ? J / -} T F VI s I OIMEI IY si I Dc cLE T --- IIIIIA"D @ICIA& G ?_ SwWINC r GR SG I"A". -! E s I OLA r T R L_ L I LIGHIICONDITIONS CK O.EI ? RAFFICCONTHO I No ]VENC E H f TYPE OF ROAD iN0]" EC OuE OR MORE( VEHICLE CONDITION ?$,Q Qy Vi O -1E ?CO? ?EC -, SOBRIETY ENO _: I C ° 1:: . . ON ??BI? S G AL SO . ?J s J EAv fA IF I I S ? D 1?+'1 D T. ], 510 s AY ??ti? „'? O itCT 1 f DARIIYf .? '? -ADWA f a\: TTxA' `.IN' . ] D IN ] Yt S4N !O LRSIEL L..... y,?l.. O ..?. .d efl KFJ [ fit' b: CT E .. IG 5 :- WAIRLD • OADIL - D _ 1 M A ED n FIC AxE f I-STAIITING FROM P ARKEOPOSIi10N 1 ] DVJ t.. S ° RED. A F I ,. OW 4M .._ -- BL S U KU01 ETY . , L1>' Mn R`I Li ICNI IHNG '? D 31HFET ?LG ..... - F ..A LI G . _- , - . 1 ?_ENOIIINKING .- . A F b_-1;-CKING . ,_}. OG.7lJ LET S OFF 6 :. SG L FS 6 0 ? -_ I._s ?xLVm. CHEM. JEST ". •? NLI E l-. J Nett upnrJ _ O C F G t NA II u 0' G .- 1 xvA • NO OF (YL is A,: - ', a IT ryeN Tt I O .' - - J ilsT nFFUS[D ti . r ? pil r l. 11F. -I ! 1 ] % ? TEST RESULTS 2 tl 40 Nj?iE RV NS K .. • 0 fU t A U A J v[0 CL ? F C OW t S ?t0 D l T 1 G41 C SPANK rl uD tutu - Ii ON r AOI.T Ail. Rl. - "IN llo"U DY AIE - ? .. ....... N............_........_.......,.._........ DUPLICATE COPY 1 .OCAl I. AW 1•.iOItCI AIEf AGENCY'S COVY-1111VLICATE COPY: INVk SiIGAI DR'S LOPY D DATE OF COLLIS DN .4YUf COLLIS OY RME COUNTY NO CITY 110 f.Y ? T E M ? I?YAr nq cou rtF v Z'{-- T UN ? •r•, Z TNS 3 EDED?tI-tHJx S FIH e?SAt _J_LJ1_.i I Si: ]nUU HO11N1 1??0? Y Z , ADM Ls PR F ' ?UgDAN L ••T?•f11 /r`(/^.? ??,C.,?? Y ROAD ?STg1E ROUTE COUNTY ROAD ?CITYSTHE[T O E IX HUIEORSTNEETCODE SEG,. SECT ON ?OTHENISPE-YI U) $ 990 L OTY OH TOWN 4 N 5 E W ? 1N I? ' P NEFIx EO. fA?LE POST / n C. 4 A n Qo AIILES ?. ? ? OF l-a ?.4 t=.1? .. .. .. LL CO +G? A - N 6!)1J OF STHEEi OR HIGHWAY INTERSECTING WITH' STREET ORAOAD LL R MIP pUGRAM DATA T t o ON O NONINT F.RB ECTION^?^" ACCIDENT IN TER NON xRD INFERS CI1NO BTRE OR ROAD OR REF. N ? n y r.??•?J? 4 MLEAG E INTE CLS. ERENCE Co RROA° ? OETWEE `• AND. _._ . .. ... .........+.. tF.IT .111T - COM ???O D I TANCE A S NOORIECT1OW M REFERENCE ORCHOS S S I R ET FSO S PECIAL COOING USE. g pyI / j p IS ? ? A S HS LJFEEi ICI ? ? OF - L'J? ' COLLISIONINVOLVEO: ? VEHICLE-VEHICLE ?VEHICLE-BICYCLE 0 HERIVIRITEI ?HITp qUN SEVERITY mTALNo ?VEHICLE-OMECT ?VEHICLE-AR TRAIN r? STOLENVEHICLE _ OFVLHCLES •---- "-- .- -' ? I NO.NILLED NO. INJURED ?VEHICLE PEDESTRIAN ?NONCOLUSION ? HAZARDOUS MATERIAL ? PROPETYDAMAGEONLY 00JECt STRUCKINAME OF OBJECT BTPUCK AND OLVNERS NAME) , _ ,:,, .. -. , _ LOCAt10N OF OB ECT STRNCK J EST IAMRGE:. ,:. S E . W . ?? rr , ?ROADWAY?"'FEET ®? ? ? NO EDGE S `•" pR1vER3 NAME LAST: -, ?: r FIRST .. ..:. "DOLE t C° - J - ,.. DRIVER'S NAME LAST FIRST M100LE I" -1-St OR REOES-AM CRECK)L7 D R L nAu? EVE l/ ?l2ts D . . STREETADDHESS .. -: ,, v ?-? tBX 5osn? ?: E R L1TY.r.- :.: . STATE.: - .ZIP CODE. PHONE NO TACI(?GB?c7 ?(i1A. q?3? E R . CITY : :. ... .,. •.-.:,;.:. STATE ._.:.. 21P CODE .:, PHONE fA. 'N O OWVERS UCESB NO. ... .: ?F gq g Pg STAT//??E. 5 DAT''E??LLOFl111.1. z i° N 0: URNERSLICENSE NO. STATE SEX. GATE OF 81 T4 4,0 DAY YR r - /Y• U ?L? (J ?J Dfl ERs OCCUPATION FWM NAME PHONENO I - 2 DRIVERS OCCUPATION FIRM NAME =COM _ ln) SEATS LT-?_ 1SI EJECTION CODES >113, CUA4- - (AI SEAT BELT._- IS) EJECTION _ TURE F a `NJ URIES H O VED F SCENE BV: T M F OIASCENE DY: TO VEH.YEAR A MMECHEV.I. MOOELIOAArNOVAI.• . STYL 1(2 DR-CONVI ? VEH YEAR MAKEI D MEV.) MODEL IOAgT NgVA1 STYLE It DRCONV.1 v 18 TL at, ? h.1 v 1 E 1. VEM. Wq LIC. PLATE A0. STATE ., iRNIER PLATE RD. STATE E . H VEH COLOR, ". C. LATE N0. STATE - TRAILER PLATE NO.. STATE.,::... .. :.. N = ?G 1 3 A I - . C VEH W NTIFK:AIR N NUMBER :_:: , ,: r ; ,..... ) MtfER :... (•` VEHICLE IOENTII ATION NUMB R e A155Q 6 1 / 55 L' '. A 7 q- ZZ o E N' flEGLRTER OWNER- t - ..'.., .. FIfISi .::... - ???q1 ',11 pp ?I MtOOLE R WNER-U I. FIRST _ ,•., MIDDLE L 0• / ADO. SS UP OWNER ... :.......:...... •_ ... ,..-..: .. ,'. ?. - S-S AWNEN- ... ., . ...... ...:... ... .. : . ;.: : :a ? 1 2 . . . .. . .. , .. NAAIEANOADORMO RAN E RAGENT. ,:. .. :... ... -.... I ... -. NAMEMIDAOORF.SSOFINSURANCECO. ORAGENt ,.. ,.., , : : :.: ? i)ooe ... ... . . : CHA E. ,, ... - C ITATI ON ENFOHC[MENT CHAHGE NTI NT u E V ACTION { U IES OF PERSONS INVOLVED L°DEG - z y S E% ACE sTAtIIG + vl ?? w n[if EJECt. c c NALIE: _S E Lk J- ADDRESS 1 L4.(/S./ - 39 1 -2 I 3 t Z 1 U P- NATURED' RL MOVLUrnoM .? M-F., FA:E[DV TO A NAME N T ADDRESS i S SCMOV Olfll3M -- TO I A111 FA F W r NAME -Es ' N N TITMI}VL ?110M w Alm Rcl NF u+ T o 5 S A UMFAS 61 rN N"riluliltr.Ul.-_.-.---------tiNT V?Ei)IriIT-- -- -- -- 1 LYTA1.3 : 14+11O ,A,pr AINA r S 1 ILL If A1TIRlV C D ]Pir.(511.11JN - 1_ - \ ' I OltUll SI. RL ..11.1.1 1 UI AUAI A:11•C i I AIIfD )T C INOTUCCrCD f TOTAL tY IJLDTfD g D Ci1IrIILnt s lfITHrRTrrl AT1011 .vOrURGrDUI aI ; 61 b Of 11VAL I ; fIIN11RY NT UCUV I U R :I PAR Y Elcira AL /PL U .ILL M:Jrir INA.GV.N . U1;1gMYr + s ,. nom.. u i D GATE OF COLUSIOII DAY 11111 Ll510N LIME COUNTY NO. GTY NO. FMWA' T. O. DAY M i SUN) NON 2 IDES ] WED J JINX 5 FRI B BAt IUS[ JQD HOURI } _ BAN ?,?UJp, E J S Z PA I(./11VL SECTION COUNTY ?STATEROUTE COUNTY ROAD ?GTYSTREET O AOM.CLS. 2 P-IX ROUTEORSTRE11TCODE ?L,,r /JCf/Z ? OTHERISPECIFY) I 19 J f5?70 L ?IN CRYORTOWN W P REFIX EO. MILEPOST . 'O q N ((??Sii 1C 1A.LES ? IC! LI^? ?oF ?//??c/G?L?I_ ___ _.. V - , C N 6NO.OF 9TflEETORHIGHWAY WTERSECTINGWITH: STREET OR.15D LL H AMP 01AGNAMDATA .. ' NONINTERS ' ACCIDENT IN TER N J %RD ERS CTING STRE i ROAD OR HCE. O ? , , ? MILEAGE INTE CLS. E RENCE CBOSSSTREET OR ROAD _ N _'STPEET / IA STREET ANJO •?.,/ %. ^A' ._ BETWEEN GV ?.. ?H COOS 1tp OO 5 - OMEEFE? NCEUR CRO55 TREE GSTANCE CTI NN Ffl 0 S PECIALCOOINGUSE S OMwES 4 4 , ), ,-,s S-_ FEET OF C//1JE'S. / _ ?VEHICLE-VEHICLE ?VEHICLE-SCYCLE ,®OTHEH ILYPITEI ?MBE RUN SEVERITY NO KILLED COLLISION INVOLVED: ?VEHICLE-0BJECT ?VEHICLE.nRTRAIN ?TOEEN VEHICLE ... . NOAWURED TOTAL NO. OFVEHICLES ? VEHICLE PEDESTRIAN ?NONCOLUSION ?HAZARDOUS MATERIAL _ 1/ PROPERTY DAMAGE ONLY LOGliK1NOF OB)ECTSTRNCKS - T STRUCK ANDOWNERS NAMEI .....,: ,,.,,,.:. ."...._, -.:.. . T RUCKENMAE OF,OBIEC OBJECT S T ? ( I ? -ell ?EJ • -7D Io sew ~ { (riY/JZ iL1 ROADWAY FEET ? El ? [3 .MEDGE S V P ?? OPNEPS NAME IAST -_ ._ST.;'.-,;V;S•;;:•?MOOLE •. '; DRNER'SNAME-LAST FIRST MHIOLE, RF BICYCDSt OR FEDESIWMI C HL CK) -?,,,.", D D_ R STREET AD 53 - ....-^.. . _. ... ...: _ ... _..?,: -..... ' STREET ADDRESS, '.. ....... v- r/ .60x s9-s E E CRY :....... ... STATE. .:..; .. NO, .: DP CODE. :?...... PHONE R /s s. (u5 .$? r . - N - ..: ,. ,. ... Dn E?rl . ATE•, S E% OAT N .. N DRIVERS LICENSE NO.. ....:.: .. STATE SE% DACE OF BWTH: , °- Gas .a ? 8 a 0. MO. DAY: YR ORNERS OCCU_Ci. FIRM NAME. .s •?r??T' ss 5 e . ? h ro co--- 1]I C.,ASS._1 I41 SEATOELT_ - 151 EJECTION _J CODES IDI CI A95??_ IJI SEAT BELT_ 151 EJECTION „ • NATUREOF WJUHES NATURE IWUBIF.S F M ENF. DY' TO F-VED OM SCENE RY' TO VEH.YEAR MAREIDOODECHEV,1 MOOELIDNiT NOVA I:- STYLE (Z DR CONV.1 VENYEAR,. MABEIOODOECNEV.1. MOOELIDkRT.NOVAI STYLEIYDRCONV.)•. -, V to v N Nr? v `. E VE., OR UO PLATE h0.:.. STATE.. TRMLER HATE NO_. STATE E YEN, COLOR . LTC. PLATE N0.. STATE _ TRMLER PLATE NO. STATE -: .. . 1{ P, dN' t!D'Y I 'd "1: 1 C VE N K NUMBER. _ .._... .....,....:.. ME ER..:. ... - C VEHICLE IDENTIFICA I N NUMBER L E'- . H 11E D -ER REGISTERED OWNER-LA ....-.:.. FIRST,...........,. .o:.L.MIDOIE.: O GtIX?C'. .0.". ?. . p "R :. i :.. .. ........::. ..:..:..... ,.. .: ........ .:-?....... ADOBESS OP OWNER . ? w...-..... ,.,..:1... -.......?.-. fa.va. ?.r.. OR NT... -.....,. ?.. r........:_a,.L._I-7 a?N T/d ? .• ? ? ... .. . ... GIA .•: .. ... CHAT ,. -..... ... ENFORCEMENT N ... ..,..,. .., .. f.. ..,-'.:... .. I.:..... A ..:.? ACPON LVED NV co DES O NAME; ADDRESS & INJURIES OF PERSONS I T SE% ApE 9TAN9 N LT EJECT: C NAME C ADDnESS' U P NMUNE SClIrIE HO POM TO WAIHIFR A NMAF.. { T ADDnESS _ S LIRE ! WHO. TO Y1111111ES SCrNf W 1 T N E S S E S. N NOI . lcli0 p D NI O.WiAL I Y POSYOLEWW Un YY l SEAiPf Li rAnlmE I i UEjTcIED yy 1 I ? '?'. J J L ? I .T F -' ? 1f II AY '. C Jr? g p11. 2 k. y ? I` I 9CY' ?,?: , h ?8?'?ilr! t ) t f ( Y ?I I ? '' 1 1 ?? 1 c. ? TS\} t I. F N dP 2? 1 : I t ? atir ? ' f?' rl ? (i t t lr: 4 f?T? ?? r}???hhrrl?? yip r41". r?. ( 1,. Y N DATE OF COLLLSION DAV OF COLLISION ` TIME COUNTY NO. Csv NO. _ FHWA 9 r? SUN 1114 WE TMF FRI SAT T 2 ] 9 B IU9 O n 6) Z 76 - ? COI/flV _/ ? ? ?STATE ROUTE COUNTY ROAD ?CIT-BEET Q ADMCLS PREFIX HOUIEOfl 91REETCODE. CTION - (• f?? ?/y. ?OTHERISPECIFVI LU 3 - / /? /? C/IT OR TOWN ? ? ? NE_ E D 0. C , // ?QL_/L OF_ ,y MILES ? 1 ? ? U _ N E A NO.OF STREETO ,HWAY • ; ? ;•,. INTERSECTING WITH: STREETORROAD LL RAMP. DIAGRAM DATA T ON .s?. /®E o - ?- NON IMERSECigN. ACCIDENT I NTEH OH I % D CLS INTCRSECTING SiflEET Oq ROAD OR REF. : 'N - - BETWEEN. --... _ S1RE[T ANO___ _STREET MILEAGE CODE .. . ERENCE CROSSST EETO?ROAD (/O V - EE 0f9lANLEANIj OIESCTpNFROMFEiVAENLEORC OSS STREET/ _ ? y 2 HS SPECIAL COOT GU9E /{ 1 / _ /D FEET ? 0 -?5N ??V.?J___ •• y ? COLLISION INVOLVED: VEHICLE-VEHICLE F] VEHICLE BICYCLE ?OIERIWRITEI ?HITARUN nSEVERITY NILLED NO TOTAL NO. ?VEHICLE OOIECT ?vEHtLLE RR TRAIN ?S70LENVEHICLE OF VEHICLES . O.INJURED ? VEHICLE PEDESTRIAN ?NON COLLISION ?HAZ RDOUSMATERIAL PROPERTY DAMAGE ONLY OBJECi ST HUCKINAM OF O D/IECT SIRUC%ANOOwNERS NAME] - - E% t J LOCATIONOFOBJECTSTRUC ,'_"-; EST;DN.tAGE , R / ? / ? J/ "' ??? ••??? V ?ROADWAY FEE ? ?? ? HD. EDGE S - DRYERS NAMEAAST -;-- --?-- FIRST --- _ ---- M DDLE . -• DRIVER'S NAMEUS? 11- MIUOLE -IIF BILVCUSI.OR PEDESTRIAN C ECNI U D R ???wsd,? p' ' STREET ADDPE59 ' .-.'?.j? ?.J. .•...-: ..-.: .. _-.' _ . _ ._. .. STREET ADORE99 _ E N CRY ". - .... ATE .. ZIP CODE PHONE NO. ' E A CITY STATE - ZIP CODE PHONE NO ?LG(?/f Lr/i? ?N f?A! N CE NO. DNVERE LLI NSSE AiE SEA DATE OF p I H TH. N DRIVERS LICENSE NO. . STATE - 9E%. DATE OF BIRTH . . U. ?// / E? E G??lY •' (/? / U ?(J{? ? p ? ? • ? O% ?• . MO, DAY .YR. NO. n e / Z DRIVERS OCCUPATION FIRM NAME ,• _.,. PHCB ENO. CODES >1131 cuNSRS MI SEAT BELT EECTION Z CODES IJI CLASS SEAT PELTS) EJECTION NAUHIES F - : _ NATU RE OF NJURIES M;M ENE BV: TO -MOVED FROMSCENE flv? - VEH.YEAR MA%EIOOWE CNEV.1 IOAATiJOVAI S TYLE I2 DR CONV.I VEH. YEAR. MARE IDDOGE-CHEV.1. MODEL IDMT NQVA1.'. 9ivll12 pR.LONV.1 ._ .. v QYQTA l i?c ?iq iuQ v E VE C ?L7OII._ • LIC. PLATE NO. ST TRNLFR PLATE NO. STATE E VEH COLOR UC. PLATE NO I.. STATE TRAILER PLATE NO.. STATE...: ?[? ?fF177 /tI H,. _C VEH? DENTLFICAT NUMBER CDOMETER,S-' C. VEHICLE,IDEMIFICATION. NUMBER ODOMETER E: E` HE RED OVER-IAST- :. FIRST. MIDDLE " REGISTERED OWNER -AST„•'n , FD9TMDOE , o. ? o. ADDRESS __N ..... '. _._' _? •...:: .:. _-. .._ _...• ADDRESS OF OWNER.- .. I ...: ;-, .. 2 NAMEANDADOHESS tWSUNANCECO AGENT.. .'+?•.:: Iv/. 1317p,1114 iy/Ifio d iNG-alf -? NAME ANDADDRESSOFINSURANCECO. OHAGENT CI ::I, 1 .:.,:• .. .. CIT?110N NO.-^?•???? 'EIJF ENi CHARGE- CILIATION .,;.. /FF O?? AC71ON ACl10N .. .. NAME; ADDRESS& INJURIES OF PERSONS,INVOLVED CODES SE% AGE'. STATUS EJECT.; `, NAME. C. ADDRESS' U P NATURE Of- NLMOVEUfHOM BOU-5 SCf Nl RV TO A NAME' N IN ADDRESS. s NAtUkIE OF f F UOfnOM f .. r I Nm C N TO F d? i w 1 HAML: DCPE&S' - T N M INJUR 7TrbvnY noM TO E S NAME: S ADDRf.55. i E. NPillu?gt.9 SCENFVY0R? _ TO _ 1,ISIAIU9 141SLAI 0SI1IpN IJIPUUHY CUSS TAI SE AT BELT 191EJECTION C ] F 211 NGLR IMA - , M.-B, DIS B IN6INJURY , NOIFV9IALLCO NOT CJLCTFD D ,pTA InC CL61 6 T 0 [H POS IIp 0(0.1 SCIt ] OL OOIA nWAL' I 8VO •JAOL IIG IC UENTIINJURY 21101111USE ] U: 270TALLVFJECTFD V T " D Till fR E INI SS ] U• RMDIO I C -r) BPO IONU IIOVl11 DI[U NHOSPITAL POSSIBLE MJURY ,[D IUNKNOWN ARIAELYI lC ] C O IUNKNOWIi E. 95CAl tlEIT FA IUHC fJECIkD ^t t y - ? 1? 1 L- 1 L ti? j I ?+y fy ANj ? ? yy 1 r 5 ccr? .: '?? ;u? 1.+ 1 .I„ V? 1 -Z-•4 nMr 1>vrtww `W"r•J ,PM J D.q,.l? 1 I 1 i 1 1 !Y ! I, 17 i. t ] DRAROW fVH c P? •YJ ], DRAW W AHIiROWtS I5110 SNOW PRINCIPAL DIRECTION OF FORCE. OO ,P h• b DAMAGED VEHIr•LE NO. I IUSE TNISEPACE FOR SKETCHING OAMAGEIO TRAILEns, MOipncYCLES. ETC.I DAMAGED VEHICLE NO. 2 ^:[v - i 'A. x _• 114 1E TruY ` I II r 1•f 6.T•un '?{? ... 1 IB U ' 11 11 16.YmrNnrrBq ?" +Y ]. O.wI M^ruq 1 I] 0. ? S. .lw• EE g1TY O O E' VEN CLE 1 1SE E TY OF DAMAGEI IOTNER VEH [LEI EE EN iv pF DAMAGE: VEHICLE n0 PIP .? I ? OIE BL G D AGE ] ? OT E V. DAMAGE ? DISABLING DAMAGE ; ? OTHER M V, DARN E I •? O SAPL NO DAMAGE ) ? HER M DAMAGE ] ? FU ct 0 L AMAGE ? AGE ? FUN __AMA. E ? ND pAMAG O= E • ' S •] FUNCTIONAL DAMAGE \ ? , S f Vi, TOWFD BY EST DAMAGE TOwEO BY CT EST DAMAGE TI E51. YAMAOE 't TO LT... O D L. _L I f`-? \ ER . DIAGRAM OF COLLISION ? '' i '. 1 I DRAW ARROW SHOWING 1•. ?A I ! I 4 NORTH IN CIRCLE n, i O t. AD.AY 1 -i • ; I ? _ t 'r ? 1 1 i T- M `? - ° fR[all5p T 8C i DESCRIPTION OF IINOICATEWHAT PROBABLY HAPPENED BE O E DURING p AFTER THECRASH. INCLUDE INFOKMATIDN NOTO IAERA E.G D E : COLLISION DISABILITY. , REDUCED VISIBILITY. PEDESTRIAN CLOTHINGCOLOR. CON.TRUC.DN 4R REPAIRYpRK ETC.1 [, Y1. r POSITIO : N BEFORE COLLISION - F LANES E D VEHICLE IFIARK ? zA •, .HEaDFp D PC IF I I .. T C SING AIN SG A ON STREET OR Al NAME No ED EC ON LEGALLY PARKED, EH P OCC ED . LJ C f ED 5 ES PEG. ?{ ? O ''' . Na - t o?R _ I?RRM '7 - ro I (( ISIOEwaLK )L??wA rED1BICY L SNG. { ( 7 ],. ISN ICR AFKB. E{. 1 AL L. EHOuTE L O H i DISTRIBUTION. ORICHMILCGPV: SEND TOWASNINGTONSTATE PATnOL-OLYMPIA WASHING TON DBSOE DUMMATECOPY, LOCAL LAW ENF ORCEMENT AG ENCY'S COPY-TRIPLICATE COPY: INVESTIGATOR'S COPY +.--`^_-- ROAD SURFACE. ,CHECK O.R WEATHER ICHE<K ONEI C6NTRIBU C I TINGCIHCUMS7AfCES HEC KONE OR MOR[I ?, ? - yam:/ DRIYERfn CLq AClIOxB : lN<,3 vLy2tll I?xF? 1L DRIVER o DRIVER _ . ORI E .. ... x V - 7 L1 HEAD DRV ,C OUDY 40YLRLASL NOER..FLUENCEOF LGO HO L?! 19i145E}OWIN EOw -I rl DIGII A" c c )? . _y_ - A NERT I A55O n ,] WET ] RAINING r ,n UNDER INFLUENCE OF S_ _ B R GEN CIYR I I E ? ExTLY n FE OE! K -N E.T ] I ] SNOW - I SxOw NC - F%CEEDINGSTATED, ` ] SPEED.tI.J7 LILGTO _ „ IIPIIIE" PARKING IJ BiJ__LOC57107L'_ .? rl M I A -A.-RN ? 0 4 J A A ? . nC-7 EzCEEDING R ?.1E?.1_SAF[ EFEEP. _ '1? r OPEP ?-I ? (1 OPE C'T IYF FOJP Ds A S`•1\U•TUHN-.< _._ - __ - . B1 1 _ 6t?: _ I S pD O LEANT RAV To E Ir OvA G AO No LaT I.- I,? - nBU SLOWING M IDP-111 . - OTHER iv[clvn _ o R LIBL^ P SNO DISK (-? f n STOP SIGN/SIGN L ? OTHER IsrfclFw I_. ,BL I N VOCATION I-- ?? TN?f fE CfOR LIGHT CONDITIONS ICHECKONFI RAFFIC CONT00 1 o, ] V lNICLE vEll«E. TYPE OF ROAD O•] [CHfCKONEORMORE ;_VEHICLE CONDITION. VEHICLE ''SS I{€II??pp jj QQ@ ? r .:. SOBRIETY VEHICLE . ICNFCK ONE sNOS EO is10NAl: l lJ i05G ? ? r In pAE.AY '- O.) T k 51ED A 1 I np? ....E IN OADWAY t 0AILIGNi B W 3iGx ,I l? ?,I fFCCTIVC YnAKES ''I 1.?. , -1 NBp ABILITY 1 LAPAUI I? I,pf -' ST RT G N L lJ R C E _ YIF .L?I? SIGN _._ . [ E LL ROAO... _ _ p[FFCTWF II_ IKD LIGHI S._ HBOABILTYFAINL O___ NOT IM . III[' L ?. V...C 1POSIIi ON ]1-1 DI13K r fLASHING nED -. ?E[ II I.-C.-ID, %-'II)~ -i LIf EFECLITIVGNET9 NATI I ?]i 1 NtlUN050BR1[TY _ -. _?._ ...._ _.- K I RGI NG IFNTFRING _ _ TRAFF II]r ICI E DAPK-B1R[ST. ., ..??U . 'f?B•-- FLASHING .._...Z ?.AMBEn.,. r IS ALLFY ( ?E I inES wOR O.[.SMOOTA !_KF-I HAD NOT GF.ENDRINKING I 116 B'ACKIN6 n oARK-SI6lR EFT 4._i LIGHIEOFt_ ? I ?BJ BIG A '-" TwOwar-L[FT BI- lUnN LANFS PYxclv?Ile 1_, I rnvw..-.. ... .. b Dx VER CF FM. TEST 1 NO ] ._.... .. 1 1-l, 1._.1 . . - DARK R[-NIGNl3 ?{T %LA'C i ] I II11 S[PM1N_l[O _ yl _.. i 1 if[iC VfN . ? DTI[ ISPEC IFYI l - •? . OTHf B' J 11 I D IDED _ _.. .... ( •F NO DEFECTS l .._. .. .. ___-_. j I TEST EFUSEp 1 '• _.S.____ _ -olw uPeelrr? _._. B n I F 1 .. _ .... i? ?il I u [O GL J. wen lsdfcur! % TEST RESULTS 2 . xK ITINO ON KEN'S NAMFA A -EST GA 7 ... '::t ..(/. ,., L' BAI>GF NO i POLICE OIYATCNfp J _ 1._'I??. IVED PI ICFLOW. Lr[EA UVH) Ant[ l1OFED •- r' )FW )EGO IM X M BTIOATINOgH-1ENAM[AHANK- vf I Ii F pGL NO GINCY RD15T.sp[l. I[Of NlPORI PHOV[OBY OAT! zap SSAE U WASHING -G, OF No. -__-- PO CE COIAYL uMUEN UNIFORM POLICE TRAFFIC COLLISION REPORT - - - F = ' COUNTY NO CIT Y ND D DATE OF COLLIS ON pdv OFOF LOLL GION IIML /? . N' J A ]e0 H URI J RU M. ' A M DAY i SUN 1 Mql z LUIS ] V.ED A ZRM MI y B SA1 USE EEL Y /Y ?J Z ADMLLS PREFIX ROUTE ORSTREET CODE ECIION COUNTY ?STATE ROUTECOUNTY ROAD ?CITY STREET CI ( 1 fCC0F, ?OTHERISPECIFYI M tJ 1y !: J PREFIX EO LT O TOWN MiLE POST Lj IN ?? ? ./Y'I? /?? C MILES N S ? ? IIWIOF L _J-O.F-Y U L.EJlJ1?. u D _ nAIAP DIAGRAM DATA OR HIGHWAY REPSELI O - - { §; AME O.OF STREET NG WITN: S1PEEi OP ROAD ._ N T O ACCIDENT INTER NON %fl0 NTEPSECt NG STREET R OAD OR REF. y "- I NW-3- INI CLS EPENCfyR TR OR ROAD ` 0 MILEAGE N BETWEEN _..-.._ ..-... _.. B-0 B REEL CODE DE J - OISTANLE .DIRECT ON FR OMREFERENLEORCR.SSBlBEEt =01M SPECIAL CODING USE +R ,E ! 1 ®MILES H17D? ?.?------ ... , 1i ' 6x ?FEET ? ®) ? OF _ SEVEPITV !Y VEHICLE-VEHICLE VEHICLE-BICYCLE ?OIHERIWRTEI ?HIid RUN _, NO KILLED ? EHICLE COLLISION INVOLVED: _ t _ NO INJURED TOTALNO ( .2 ? VEHICLE OBJECT ? VEHICLE PR TRAIN STOLEN V -_- ?PROPERtY DAMAGE ONLY OF VEHICLPS C] ?VEHICLE PEDESIRIAN NO" COLLISION ?HAZARDOUS MATERIAL ' - OBJECT STRUCK INAME OFOWECTSTRUCHAND OVJNENSNAMEI : .CATION OFOWECT STPUCK ESi.DAMAGE 4 ?ROADWAY FEET ? ? ? ? RD EDGE FIRST MIDDLE DRIVER'S NAMELISi FIRST MIDDLE Pf dILVClIS10R PEDESIRIANCHECKIU _ :P Rte DRIVERS NAME?LAST -. ' D' - D 57Z-cvA?z< 1 ioKo tloSoD(? R STREET ApDPESS . - - :-- STREET _-RE- V, .'.. .. - Po. ?4 ' ?. L Gox '73-7 v /aao ?. ?_rr E CRY- STALE ZIP CODE PHONENO R CITY ... STATE ZIP CODE _: PHONE NO. ry I. R w ? . 3 CITY 9a 3 &E8 'IH-A•'.•(,..L' St ATE SEx. OATS Of BIR1H .. 1 N ONVERS LICErvSE NO dTAiE SE% DAtE OF OIR1H N DRIVERS uCENSE NO... -- /? t+ . MO DAY YR. 0• I I ?Q/J O /1 I- ^T1r ?O / V I« o. l_67r? RF w A F z I ri L f P:A A.E. L.ON-. ` DRIVEILSOCLuPATION FIRMNAME PHO.vE r10, DRVERS OCCUPATIOON N tL??r?css ??hlzn?T -P.tl LE,dL0,0 CODES J 131 CLASS _-. 11, SEAT BELT IF'I EJECTION _-_ _ CODES 7 IJI C1A55- TAI SEAT BELT ISF EJECTION- . NATURE OF1 TORE OF INJURIES '. INJURIES ROrOA UEN[BV. TO : VEH YEAR MAKE IDODGE CMEVI MOOEI DART-NOVA), . STYURDR-CONVI - , F MSCENE BY TO VEH.YEAR MAKEIDODGELHLVI MOOELOART NOVAI, STYLE IZ OP CONV.1 ` v ly?`T M ac! r1aR?uls Dk V 19-)c meaC. Maa ci?'s tiDe VEH. COLOR .C. PLATEN.. STATE TRAILER PLATE NO... STATE.... a? ?I y TPNLER PLATE NO. STATE E r. - - E _ VEH. COLOR UC. PLATE NO.. STATE C VEHICLE IDENIIFICAt1ON NUMBER •.. .. - -, ODOMETER a.r ?. ton ' C _ VEHICLE IDENTIFICATION NUMBER - ODOMETER lOO?Ooa L `! Z CG6 P Co32oG 3281 L' b7 fo' INS'?//?$o PEGISTEPEO OWNER-UST.. . fIPST .. MIDDLE PEGIStERED OWNER LAST _ - FIRST MDDLE "' o.. s2hiE p," .. z AooRESS .F OwrvER _.. .. . ADpREES LIF OWNER ..- _. A . +. 4 NAME AND AODPE55OF :SARAN fCO OR AGENT. NAME AND ADDRESS. NSURANCE CO. OR AGENT. ?FECO HOMC-(L,5)-1 9OCEl.ozAxr`? SAFECOHon?2 fi ITH- PenTIOWNSL?+> ! 1 --- CITATION O C MGE :.:.. .. CIIAII NN a CHMGE.. :. E -CEMENT I A, ... ACTION 1 - CODES _ C ] S `t - eECr. NAME,'ADDRESS & INJURIES OF PERSONS INVOLVED skx AGE lulus - TAUS C AuDRFSS I GL?.]G- PibUE F??°5--1-?u' neX+oveofHoM U NATURE OF SCENE IIY TO LQ IM-) P JURIES r?o? A M E: 7y N - ;9r1 ks M T AA URE?Of -._- 1MU [O fHOM 10 J."% .tx 1 Q!4 1 Tf M kr, Lr S INIUfRES _NE BY ADDRESS' --- -- LMbVf:U1R M N -5 scLFrz BY To E NMIE EI ADLIRESS' S Ci F Y S 111S1A1U5 I]ISLAT PQSR M)N I:II MAIN CL S I,1 SCAl I1LL1 IRI[JELIgN 4 lL DKAD OI EJECt Etl ?{?'V ' A.SEFgCR 1 NJUR A -All JURY 11 1 GTAIIC. t TO ALLY FJk CIEp ', 5. r 1 P • T C1. C R p! gBAMING t r O1 IN USE F _.. r. O :ncF:c Ml -b ] >.D1N[RP.BITION ]Df AD ON AnnIVAI IFV OFN11 INJURY ]U [D ]I nRAIIY fJLC1f0 , R O1HCR nU:iMO1pRCYClE1 A OFOIN H051KTAL 1 POBYOLL MJURY d U Ovf.! N NOWHIf tl LT FAILURE LJkC1ID I p r rJ D I] 0 POSItKlrl uNKNOYM I 5 AT 4 R YNN[SS 4 S ? 5D1.? gpV?. 1 ? V F11 ICLE DAMAGE '• INSTRUCTIONS: ] s OF RL p E E L +-ACT I J parr Ir> ip FINr IPAL pIILCi nN DF FORCE QDiVl'. I _ DAMAGED VEHICLE N0.7 sUSI IIUSSPACL "IN SrEr n G[ •GE TD Tr.a Lns, rnDrnncruE>. IT ti DAMAGEU VEHICLE 1402 I ? J D 1] W.Ir n DISABLING VEIICL[ NO.t II OInIx ^ OTIfP VFIICLEI 5[ IRY OF DAMAGE. vFIICLE NO ] SF ERITY OF pAMAGE .N.,AL GA 1 ? DAMAGE E3 J DTIERM V.ENIM SE? DisAnrLNLpaMAGE 3 ?OTIUAMALRMV DAMAGE I BLING DAMAGE I}''GI OTI1EnM.v. DwMgGE ]] O • lJ ND CT DAMwGE a NO GE TIONA ? - FUIC L ]? FUNCTIDNAL DAMAGE A ? NO DAMAGE ] AMAGE OPMA -T' E tOwED BV 1 DAMa IOwED tlY. TO ------------------------------- AWED BV TD TO 3 DRAW ARROW SHOWING DIAGRAM OF COLLISION , _.? ...- NORTH IN CIRCLE 1 IoL xn I '.. ?. I ' 1xAFFrccaxlnDls I CS IATCn. 10.11 11 Ox } rxpe aLDR o ei[Yt -^- ' x sn w . renfslxuNrAlns eernRt _} ? ___:.- _? I DESCRIPTION OF ICATE II AT PRUBABLY-11tNtD BEFORE. pun NG AND AFTER TIE CRASn NCLU L IIFOIMATON NOTO DIAORAN, G, DRIVER _ PEDESTRANnmImD COLOR. C015TIUCTON OR Riga R IYORKNEMI REDUCED VSBILITV DSABILITY COLLISION,:, , , 1 -I POSITION BEFORE COLLISION IN O STREET OR NGnwav L OR IO. NAR M ND. DIRE II ONF L CTION I tPD S Ly PARKED I 1A IN.C" II OCCU6 TEA FD ° E . D Y'L E POST As Inc as - .. -j r- 1 - vES 0 ;YES M 71: - int. r x ...wA. Ixt r Mlxtn last COx rv.I. R ADSURfACE N:J EL D WEATHER ICIIE CK ONE E - CDNTRIBU _ C TIN CURCLIINISTA'NCES K F --'III-II}1 E I ' I DOING .. .OPT E O -IINO, ] " Y ? CA C O Uoy O LBC SL - LICE OF -IE ALCOnOA NO , ? :-1 f' LOWEN 'T qSLQ;E1Y. -- L? O I I - EG RD R - G. ` I. Ew0 ?] 0 E NG DAss NG - ._ ... _.. _.. ?I .11 nAINNG 2 RU 1 ]^t FLULNCE OF IBI CFN E LIEtl ENTLY St te E MAN I I Xlcnl TURN _ :) ENOw N I3 EICEEDINGS-ED . E _ 5 GTO l9I _ PEOPERPANKNG ! R5?.-? L.,QN - - AKING LCFTTURrr , ?? ,.LV n._._ IG - IL YE E !`-__. aKINL' UTUIm -. - 6 5 I -r ., DID NOT GRANT m Ovirl ClE 'Si R GGUO G ..? _. . 'll _.r I ._..__-...__..._ ._. _' SLOWING '?-- OTIEn 151 LCI{VI , OTIEN ?S F[ _ __, . -_-' OPER P __. ._ _ .. . .. .-_.II] DSNfLAN SGNrS GNAL VI - Otntn lAl ClF I e 510 mEO fan .1 .PITY CONDITIONS - 1CNIC EI TRAFFIC CONTRO D?VEHICLE HYPE OF ROAD 1 O^ N ONF OR MORE " VEHICLE ??FNDITION - v pp FF,,ppee SF hid 7ti IN D O . SOBRIETY iHU Er ICnf CK ONEI > I pH S O SAG III " -N- 71 ? oNE wqr II t w cUN r . noanwn v . 1 D PIT } DAWN 3 .. SIG D ] • 4 f SWE _ _ O o _.1 iAKL5?1 T A V fl D AR NED At, _ T Ep T' n AFll C LANE f - S AnIINGiPOx KED POSUON S DUSK - L4 Irvc Il CUN LOOP M-1 _ .. LC V ) ...: AR LAC5 DSO E H - ] ERGI NG If NTEP Nc ..;' TRA CI e IF A iREET 5 1 ?6 [ I 'e 0 00 R.. NOT f DIIINKINp 5 BACKING _ ,. _ rvu.r xI r CHEM. TEST i 3 L 50 [[ : "'N.' IN L s TURN I A - .6 swan Np. > _ .. . _.. ngnK-ND .. _ Or Xr prIF= 1 sfvAnAll[r --VIN DT Isrtc UVl 6 STX[rt I.IGIIA = N iNIR V UfO D NO 01111:13 4T nfF US[n O t[Ii vi It I I iv10ln UrxlnI C rI -- TEST RESULTS 2 w L 4gIIN40r? 1 Art I .UI 1 fNAMI AnAwa U. tI[f U3 CI'U I -- IIfI A1111111 ] II VfO IMAIpI LOw ' W ?4? _ Is K a )I NN CuI nX M G. D.I D t 4. DUPLICAI[COPYLOCAL LAW t'110RCEMI Nl nG1:NCV'GCOPY- TNIVLI[Arf COPY, UIVESIIGAlOf.5C0XV 1 I is?` r?r s I 1` .. _. .. ,, ., . ..? ...__ ... e.... L. ? .. ?..__,a- .. . a, ,.. ..1_.r. F .,Irv,.. _... ii=,.., x as F... : ' FATE 1 S PAGE G; o UNIFORM POLICE TRAFFIC COLLISION REPORT HDUCE cDLmL:„- E, - -- T 'D D - -_- - _- -_-- - A EOFCOLUSON DAVOFCOLIISION ??R T SUH T Mpx > 'VIS D CD A IHUN > ?l?l U SA1 5 THE ip01JL1YR1 J COUMI NO J CITY ND C URBAN 1 COUNTCY•{/?'r(.? ?SIATE ROUTE If?I000NIV ROAp CITY SI FEET SE (, O D 'CLS. /PREFIX ROUTE OR STREET CODE SECTION •\SO? OTHERISPECIFYI W N S( / Q ?V L N CBI E W LjIN CITY OR TOWN H W q /JJ PREFIX ED NILE POST. C MILES f11 a 0 ®GF__ Fl?kYJc.h-.------_.._ ---._ J 5 T 8 ON O OF STREET ORHG14WAY INTERSECTING WITH, STREETORROAD C I??.io U. RAMP DIAGRAM DATA -77 I O NONINTE CTIg1. ACCIDENT INTER NON XflO TERSEST O STREET • OAU ORREF. 11 IXi N. BETWEEN FEET DISTANCE AND R 5 FI MLE GE CODE 1 CLB. ERE CR/re- THE ORROAD L Q VVV ECT1 D N F M E ERENCE OR CROSS STREET / MILES Hunlr,e lH.. V 5 ECALC NGUSE ry E? .. AAj))_/'?/ C.k }4? ? C]I Imp of __ ((pp COLLISION INVOLVED: (RVE ICLFVEHICLE ?VEHCLE-BICYCLE UOl ERIWRITEI HIT A RUN SEVERITY TOTALNO ?VEHCLEOSIECT C]VEn CLE RR TRAIN H LLED _ STOLEN VEHICLE NO O INJUFED OF VEHICLES VEHICLE-PEOESIRIAN [DNON COLLISION [DHAZARDOUSMATERAL PROPERTY DAMAGF. ONLY OBJECT STRUCK)NA%!E OF OBJECT STPUCN,WD OWNERS NAME) _ —LOCATION OF OFUfCl S1RUCN EST.DAMAGE W ROADWAY FEET IF E DE O O ? O ? DRIVERS NAMEiAST -,. - FIRST MIDDLE D 1 ?/ v N DRv-N AME--BT FIRST MIDDLE I L i 111 S CHECHIL] i c .iAMeS D R s f-t i i tf A G ?T ? G F _ STREET ADDRESS R V ` i?33 v STREET ADDRESS : - ' - ,. E ?Un A7 ?7 CRY STATE .. ,. ZIP CODE .. PHONE NO. E R i-lfl e?c O/ GvR ? R CRY STATE. ZIP CODE PHONE NO. -, ... - . , ,? F i Y??G 9 N NAj>ZC ?, Q 33? DRIVERS -NSE NO. STALE SE% DA 10 1 TE OF BIRTH N o. Ise/? at-i 4JA 1-t 1=l 3F o. DRIVERS LICENSE NO. STATE. SE%:.. DATE OF BIRTH,: , ' Y Z F WA 'r 870,t %3 ORIERswcul ATIIN FIRM NAME PHONE NO Z pPIVER50CLUPATION FIRM NAME NZ, i J I CODES > ID, CU55__ TAI SEATBELT.-_- uI EJECTION IN URIES F CODES > IBI cross AI SEAT BELT- I51 N TUBE F EJECTION J -TIES VED FR MSCENE VEH YFM EVI EIDODGECHEV TO D FRDISCE OMSCENE MR TO . ` I MO EL IDMT-NOVAI TY 1 SLE IZ DR CONVI EH. YEAH HEIDODGE CHEW MoDELIOAATNOVAI STYLEISDRLONV) v" IQ 7 S FORD /7? tro Si04(5 - v 19 74 M &-a c f 1 a Q Ur s '?(?] 2 E VEH. COLOR UC. PUTE nD. - STATE TFAILER PLATE NO. STATE E VEH COLOR C PLAlF NO STATE. TRAILER. PLATE NO. STATE.. I 11. 1;1 C VEHICLE IDENTIFICATION NUMBER . .... ... ODOMETER-. .a .:, C VEHICLE IDENTIFICATION NUMB P E i25S (, E q ZL?F(?o32oG 328/ REGISTERED OWNER-LAST ._ ,.. 1-1 , ??. ., .. MIODLE R EGISTERED OWNER-LAST: .,,...: .. :FIRST _.:?:. ,: _ "• MIDDLE o. / -/A_cy/ v4? ? K ao?r ?E ? " .. S M I i x bout ?s R ADWE55 OF.OWNER . 2 A . DDRESS OF OWNER . MG S .. ... .. 6laPtiE NAMEADADORESSOF INSURANCE LO.ORAGE T_ ..,,-. Coui ?Mpi?Y?Fs c fidA N - AME AND ADD..-INSURA CE CO OR AGENT 5AF - - o, l" 1 cCo NoM?-2 5kiTR Pot [ to SUS A CHARGE. ENF ORCEMEN T CMAFGE .:._ CITATIONN ... A CTION NAME,ADDRESS &INJURIES OF PERSONS INVOLVED Co." _ > s s SEX AGE STATUS EJECT. C NAME.. C ADDRESS' - U NATURE OT _ o ED fMOV(D i MO Fn P ' ILLT- S V INI OM TO A NAME " T ADDFESS NAIUNF.OF ------- DF S-- N ?M I-TVES Sf.F rR TO Y? NAME: I T ADDRESS NA u RE3--- -- -- L L L I N r,D URE NJ urNF Rr ROM TO _ E S NAME S ADIMEss E . I iiJLIwrB srnir ev In nrsuros ul>ul rovllo., JIINJUn+eless I AISEAT UfLI I ISIWFC}pN C D PI SSSTRILAN nt.CUST A OInfF T^1 1 1 TD I )O1nERPOSI n 5 I NOINJUFY >DC ADAI SCENE >DE Ap DN ARRIVAL 11 5015 001GINJURY BNDNUNTONU Ir VInf NTlnuOnY OTINSi LLFD j uStD USF DUSE 1 OIEJCCIfO 1101ALLY(JiC1f0 To, IL ( PARTIALLY L JELlfO E d AI L J , U MD101CYCLFI S > A MLirW UN%NOWM A VI-nOMwTAL ) POSSIBLE PIJUFY UNIWOWIJ 5 SCAT DELI Aitunx OWN I F EJECTED G Qtd yA, Ax ? ,?N EFA INV I ? ?x5 n=z v .#y?; l R V %%n '.VEHICLE DAMAGE T Eac BoA,(RCfE Un NUrnmgD F c OnN+AGCOARCq-""•1" INSTRUCTIONS: I Of AREA Df 5" r.'Sl ""'AC'T 3 DRAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE DAMAGED VEHICLE NO. i IUS+ THSSPACE IGH-TCH Nc DAMAGE'(. TNA LFll m-._cE-irL -- DAMAGED VEHICLE NO.4 _ 3 H P T, - n sfvERrtY Of DAMAGE 1EIRILl NO•T I ? DISABLING DAMAGE 5[ it IUTHER E r HITr Or DAMAG[:OVEkH CLF NO.Z IYrx r.Ys .ONTHfgM V.oAMACE +ODUx ,AC[ vE0 O1U1fnM V.D MA ?_jursasurvc oA :Or CTOHn[DAMgcE 3 O OTHER M V oar.aD I AL -E F To'EUB, EST. A TOIEDr.1 a1 ST. 'A - FuN MACE O HoDAMA TO OE- TOWED Brci Esr. oAMAGE _ -E s f N 0 DIAGRAM OF COLLISION pggW.gqqOW SHOWING6 NORTH IN CIRCLE TCH. II O IlcI -' Fc oRNOxs.T M.An. .. r ... ' DESCRIPTION OF D o On ven COLLISION _ nsan uir ?niouc eI E sR NcLOTR OLON, CR 5TAUCTONan REARR,ONK,ETC1 ' FOSI T[ON BEFORE COLLISION H STREET rcgwav rPEEOS HnLLV s IWA e.o! HAM[ oR No O ornici oN R RE vEilD INCREASING EASING + HS F PARKED OCCUPIED YES ES_. No _-PED ALONG _R K IV DI C < T SUS C O . DiSWALR BICYCLE ROUTE PEROAO EK SURFACE WEATHER - CONTRIHUTI G CIRCUMSTANCES ORkI CHECK -ACTIONS -1c I I, vfI R E O h i t oO 7 '.* l D O C H r EAI '"""R 0. i N '. 0.FRCA3 ALCO. ON NCB REF [n wnR T.' Of G'..?L ,:. G. ] F IN RI rv[C OF O [ -?---- 1 G 8 .N[ n APPARENTLY 0 MIKIIG Dw •- - . " I qN OW 5 (p M ,I E? 0 )' LOC 19H PARKING ...I L T t _ A ? E 1 NO tA5 -- APROP l E FOG C ! _- J ,_,. ,__... .._.... 'A' OPE ![ : ,16 F(FCTI. O6OUIP 1, 11 -G Oi-nH ! > ?`Pµ An ,. O EO I SLOWING 1 Ol 3 f YI OTRER ISrEC FYI r .,f D x vI i -PPE LIGHT CONDITIONS TRAFFIC CONTRO L r - Ai IN r' iI E L __ A1112"' LIGHT No vvEH ENO ]E TE RE OF ROAD VEHICLE CONDITION SOBRIETY S GHALS - [H <K OHF OR MOH[I V+EOE ?,,[[?xxppr p I.CIE -REK.REI Ifl ST CrvAI N] dhr.`fk ju+sim oR Sloe srcrv I DR, -1 No I BSTOPPED 1vH + GHT I ..-i Y O r LITY O - C .R, ] O .] [ Y .? .. iC f ] R. L• All' RED.___..._? D TIA T G . __.... ..._SG NOT InRKfUPOS TION O HLAU Lr4 . MPAI I(p l • F G C NA ICE - ... - - - UN' IT -_ ' 00•' AM _ HE E ' T I BKS.ERR 112' I M wG I(NT(H NO AR IRS L413... y.._ r G '6 AILEV TNC, w( N An HOT .. ?.-. ._ 1.0 J n 0 iR f' HDRINKING BACKING D 41REF1 .._ y tl E AH(s rT u« v 4 r, 0!r, 3 sirvAL B .T CHEM. TEST SIR,(,M04HTS ° C 1 11 IT DR,— I ObO II-ERYI 1 T 6 ] n U '. NO DE Fk TS '.. IST nI WSrU 7 , ..:qj d? Ty ut C 1 .. IL s c NG Of G g ' u ?oeD oTHU1e 1- ?, rksr nesuus 2 i{ .1 A11111.1 a mviua osu ?? N (s w.Tw,. oll =.v(. PR, 7 TAE?L ]?Br c ? T - - x[rrT> i4 ) T 1' d OISTRIREON OrLLCOP\'. f Itr.+Eo ASH NCTON Siglt PAINOI-OLYR+PA µAS111NGlON RNV(N 1 S [)UPLICq TE[ COPY LOCAL LAN CNI ORGI E11 qGI NCI"+COPY-TRIP LICATk COPY INVESTIGA1011.5 COPY Ppy ,pp, I D a E f L a O C A T I 0 N ,y OATEOFCOLLISION M0 OY YR Z OAYOFCOWS SUN 011 IUES IEGa ] 1 'N 2 S Y WN PIUP FRI SAT S 8 TIME IVSE2JCOMOVRI , T z COUNTY NOXJ/r- / CITYNO. FnW UREIL URAL 17 COUNtt ?STATE ROUTE COUNTY ROAD ?CITY STREET Q ADM CLS. PREFIA RE ET 000E SECTION ? OTHER (SPECIFY) N O CITY OR TOWN W P.F. E0. IN ? U-ADLt ? ? ? OF G r- U 2 7 MILES AY STREETORROAD I AGRA P pp?? Q14 O N IN R TI N ACCIDENT WiER ,ON A RSTR E OR ROAD OR REF ET A o O( ON TE SEC o P M I?EE ( : Y 5 I C4 S Te A ''( AND `l. J W tJ DISTANCEANOOIHECTION FROM REFEgENCEORCROSSSTREET 32m, SPECwLC DWG USE ?1 MILES N S E ? W E * (L ?J {J . 1 FEET OF SEVERITY *' +I ?VEM?I.E:?l?iCCE i COLLISION INVOLVED: ?VEN)CLE-BICYCLE ?OT IWRNE) ?HITARUN NO, ra IED L •.?,' yPJ.,'. - Q?t®STOLENVEHICLE '1?0 IfUUREO .um+ ].,, TOTALNO ?VEHICLEOBJECT ?vEHICLERR TRAIN ?r..? OFVEHICIESQ? ?VEHICLE-PEDESTRIAN ?NOIl COWSICN ?-ADOUE MA ERML T. a OBJECTRTRUCKINAMEOF 0EUECj?,ETRUC1K AND OWNERS NAME( LOCATIOrv OF OeJec STRUCK ?ROAOWAY 041ET ? ? E D DRIVERS NAMELAST FIRST MIDDLE LEZaTIS pA1(1p ?• D ORfIER'S NAMELAST FIRST MIOOLE {ff UiCrCLISI tEZt)tSa?/k2t? R V SIREET A 'aE53 * EX-9 79 O B I R W . STREET P; I E R . ZIP CODE -NE NO. 6TA E CRY 9A D co eK -,w A. S 33 1 CrtY /!I/ SATE I`?A D u: c? GA%A. N o. DRIVERS UCENSE NO. n 5z p5 9 STATE ScA DATE 0- BIgiH A_ IM iD0 DAY 5 0 CRNERS UCENSE NO 5 14 1 9 ATION FIRM NAME PHONE NO. DR 'J, ' Eq9 OCCUPATION FIRM NAME ZhC 11aEC 2. ia,crunn nnf FC 7 OI !N U Y A I SPAT BET ?l S' EIECRON I / CODES >11L CF0j AI SEATE VEH.YEAR MAKEICODOECHEV. ARTlJOVAl STYLEI2O-014 I VEH.YEAq Kt IUUUMC.:ncv.l V L65 e EY MV L ztpP- v E J . PLATE M1O. vEH COLOR UC M TRAILER PLATE NO. STATE E •/EH.COL UC. PLATE NO. ", . . uA. Cz " NUMBER V HtCIE I viIFICA CCCMETEq vENICLE IOENTFKATI uAIdER L E 16???5 L z14 LI &I 1?15g? I I N REGISTERED OVMER-LAST FIRST MIDOIE LE7.C11?J LIAVID ?f N 0 REGISTERED OWNER- O .. 1 ADDRESS OWNFA 6 3 N? ?k . z AODRE55 OF OWNER NAMEANOADDR -NisURNJCE fA.OR AGENT NAME NOADORESSOFINSURANCEC I D: K /A'1.T?]- C NAROE I?.I? W A 1 E fTAiKIN NO. 5? G 1 50 ENFORCEMEM AC110N NAflOE? F ? L ? f S CODE NAME, ADDRESS & INJURIES OF PERSONS INVOLVED s.- AGE C C ADDRESS NA URE OF MOVEDFgOM P INJURIES, SCENE BY. A NAME' N T ADDRESS OFP M INJURIES , SCEN aY W NAME. T ADORE59 i N INJUP.iE dCF11E9• M E NAME S Or,REss E e ; ,ni??i` ECS.?E5 ,A IIISEAI PUNNCVi J?IUUa C 51 I F 5 E DER M1E PUUR S A NE O DL PUUR'I tiE TS A "a q O I T DE ES S IVJURY A, Y 5; T O Spy J 7 DE400 I R Y UU K .OµE' I A DCO spill. T OS.AD E D O f 6 7 PJ 9Y E ....,, E A . .zsJ PHOPERTYOAMAGEONLY arv,a Esr.DAMACe F WRTH ? 1 428 1 NOT N4IA,AEO .NOTEJECTED 2 NOT N VSC 2. TOTAtLr EJECTED ?M 7 NE0 0 PARTIALLY E.IECIED a UM1KNOW'I a. UNKNO:.NIP I SEAT BELT FALUaE EJECtEO _ 1.1. A 1 All h I 6, I y-. .F?? r?l } t I E A J ?,'? m ?? h-yE?`^>?j?F?*^?r ? irlh} I ?. III - ?' 1 ? /?'. i b A ? .? M r •-alli .P . ,T II is r T L?,;1 !-ll; ? 5 t LaK I 41 1 ,`'.k1 ?ej 1 V N VEHICLE DAMAGE Ls .. 11N EACH BO%,CwCIE rNENUMBEfl OFEACq pM1AGED MEAxu INSTRU 3 CTIONS: 2.SHApE AREAOF EEVERESTIMPACT. ` q.(( -I? 1!'Y„ .OPAW IN AflROWISITOSlpWPgWOIpAy gRECiION OFFORCE DAMAGED VEHICLE NO.1 IUSE Im-FACEFOrISHETCHWODAMAGE TOTRALEFM-TORCYCEMETO.1 1 ' ' x A7 > 11H DAMAGED VEHICLE i l rq rya I&Trun 1T- 7 i ? ? ? 10 ,A a •1 .. k ?l 'r' ? x i 11 ibo0 [ , 11 e ? ,7^ IB. UnEaruwleae -' _ ._._. ' n a 1.'° ! 3, 15. Trunk I i.OYMUm L 18. UnancewMp° VERITY OF DAMAO :VENICLENO. I tT " ' 1T.Orrlum '^ s IOOLSABUNODAMAGE 1110. 0 OAMAGE.IOTHER VE--0- aOOTHERM.V.OAMAOE gSABUNO pAMAOE y SEVEWTYOF pAMApE: VEHICLEN0.2 - P { 2 FUNCTONALOAMAGE -----E ?OIHEq M.V OAMApE f O06ASOHp DAMAGE yOOTHEfl M.V. pAMAOE ]r TOWEDBY l It?S EET.DAMAGE _ FUNCTONAL DAMAGE . NOOAMAGE 2 FUI TIONAL pAM WE / NOONAAGE TOWED BY EST. DAMAGE I TOWEO 01 EST.DAMAOE p i 10 FI..I ;i:\ y DIAGRpIA OF COWSION Tc To s .iuHluy _ I i I ? I e R?oax? xv,Yy.sEAnnEy l I -! -?'---? t w1.1??!?/ev (DRAW ARROW SHOWING Y? r a I r I ? ?I -.1 J NOA IN CIRCLE ,.. mFE` AY I -I?rL it -iI I I I ?. ?, L , u.M Av ? . k i ri x?TEHPOV?ixrw'?Aru""iAAAHU'v01 I 1 j . I...ri? T- ?? =?.1 I I ? t , ?r,? .. v,owwneAeEev[wclEOA _ r-^ _ l I -(T'I'•:-'i t'-f.-G._ ;_...( ?_.},_r1.u??ap t '".-.-,')5;`. Rn°E.n DESCRIPTION OF ENOM;ATE MATPROEAELY HAPPENED BEFORE WRINGANp AFTERTHECMEH,INCUlOEI PAINFORMATION OgWEq COLLISION qSA&Uil',gEWCEON51EHgy, FEOESTRIW CLOIHWOCOIOR, CONSIRUCRONOR gER NOTON pM0fIM1, E.Q •x 17 cc? Y?,_/r•e?ii <z ?. 7. Ga J,[L 4v.-, ^ L .?`t??T i , t L• ?- 1's^,V!__.,- f r!_?_5 -__c r?l?. ? ?-' - U ?/ ? t. i?. .t . rLl -.Lr__ _? !' r' •z-L'c1.r._? u.+f ,:u :<,?,??F?T>• ,„ '.?d M'LEPOST q0. :Li -?I NO.OFUNES SFE V s NO N BAOEp .WWCREA.ANO ??? CN 6TREET Ofl NEIMYAYNAMEOR NO. -' WOKE WiECT10N R.Fe py WA9 VEH. >'F°0; S I OCCU%EO f1+ r r1 r 1 1 ? ((??7 C (I_?? (? 1 I? I ` u? -- Yes NO YES NO PED. - LJ ` J L 1 ( uIX_n-. _ mREEr wan - -- _ d G ` PED/EICYCUSfWASUSErIl: '^. Iya[.w,u,l a Raeewa wA ` ROAD SURFACE. c l st_.Islanml [L Ica sw.u nmwm L.-fn'maRE r .. «.$ WEATHER,aat u,`..CONiIUeUiiNQ CIRMACUMS TANCES- ?aMR 5 ..,:•• s f.r aHFI.. KIr Onq ?? rc CR ONEIOgD - L Sr...i:?. 'r 1 1p??IpW yp°pLACipwl.,, ?( ?- oR 1 uxWAaaov -' ,r? r ..--oF ? ,a °M1'p .. tL?j 1(/y eln°0°1°MaNrAHw J - ImE?r ;-7 r0 mERrAK.a r x C weT _ r nM+nD L IS i?r [ 1 -- Ux? ewuM¢[oF (-T o cv.ren •? - El -'woF sw _ a ewow ] ? 9gwp , 3-f?IFD - FA-TO {^. .HUW ?. 1 R T` _? n IJJ Wanf -- ? ?' » n R _ a.En wa C C 1°R. TOYEwCO1LAWrn/W 10? D>bMq .. n , OM fAt?.» OIwTq I7KTy --- 1 "-- -----. _.-- -- 1!? ? [ ......A oEwEauo maw ° U13MCONDM NS ,:TRAFRC Flo-, .. 1 I scw.aq.MA I ?"(? w°^1°'.wIA±IOx IT`-1: erowEOSan I . ISnfGt o?w (??Na a exwgc ,? pr,E 'I COMDfOL; wp c TYPEOF ROAD, ; YnnLE ICcalnnE alN I -.:u 505RIETY "' ?1 °L rwvrc ^„ }:. j aE WAY 1 HO. x ;OnE O[FECn 2 rcn¢CK Crp °x 0 uruonr x t i. I ^`? _ I LJ rNE??n .-L Q Hoar+r? i w J Ia. ,.vacae '_x --mFECIrv>e - -.?' °'-° APIm ?- 10J mvroM'° a _ Doak I^Ie ° N - C L t ? LJ InF ?r'.,o I r?rwcwwoe L,,,,?... _. _ ->)°J.. ' wr uNO C'I marRRmoFrl?M. .;R . _ '[`I I[IOP _ _ ;rI??1 RNUGHn.. _ _ux?a0[M1x}Y Hx'? MDIOWIpRD1WI _. ??-2 A.e1rR _ hl4_._• wOMO _ CI ,IIIfRCI rieelRCn rJ s _. -__ •-? ?' ' ar I e. ^n , ..Twn Ar EErr C °_.I eclna . _ tuAn vuza ?e? Wen!enxcTUn[o ;? .TEST e °y -°`7'?` ' amcu:' 'I IcnECx art1 L on sown lJ .. OM[n . ... _ ___?.._ rxyi6rRN OMEAI3AEOAYI OMwIYYCMrI .. .. .. -. -.. .._.-. LA i rO O[I[Cn , ? Ixm AENYO 1 :?' ?. :. ? !° nOlnAirC _ . 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Fr [ Ir?uorL I. {al Iro?s? 1 .UiiwAirN lLnrn T oa CNLIt TEY ?"'i ?.?.rr _ _.Ii n[r {f 1 •.'_ Irmknol I ,.,o rtwrs[rnvl ?• I ;'? ??r Y i rI ° {t. =C ?° U t 1 Ww,PI$ L+Tnc or + k?" ?•I c n u a .. 1°R - rmbia.: f~ . a ircarn I 1 ` ST G , MA % TEST IIC ULTO 41 ,vr c t ( f t re A/. i u3'- cru I .aK uu w:eJ oW r 14 3t ?I91Z1 Q? ?? ?r t .. ?j ?? yatiela ; w[ .. u rd r o:il y o recr r aoY n/ctgv[ 30 ; h t d 1_7 I 1 rrnl•+mlGrl oR.°rnLCCnr •lunrolusN Naramrnn rem?L Ob11IA. wnu nNar Non..o1 't 'y II ,"'! y r ! ,k ,/('UCA+L OgYLOCALLAYJCM1f C1rIGCNCrirA?LNCY 8C0.Y TI IPUCAIECOnY tuvrgrl?/n OrIUCOPYI , r l^1 l nF_ N, 1?` ns 1/yI VAT ? U.S ?' 3?Vwu - . x - ?',.4 .' - 4b ai F+fF' 7. T P? 'R?%T Sribvxof?"? ' w ^'F? ' ? •z I ?., ° i STATE OF WASHINGTON PAGE OF _s,? , i , e„_¢ No. ' t UNIFORM POLICE TRAFFIC COLLISION REPORT POLICE COIAPU Ni NUMdEP ---_-? F ?' ._. y ,,. D DATE OF LOILIS ON OAY OF LOLLIS ON TIME COUIRY NO CR NO FHWA (i1 ALO/ Lly 7Y ? ) BI 1 MOx = THIS D wED A TIIUx 5 FRI B 5Ai IU`??...URI (' j - Fa N t ??_ COUNTY ?STAtE ROUIF ®LODNTT fl0A0 ?CIlY STREET O AD CLS REFI% : RD TEOR 6TAEET COPE ,- RURAL 5 LRON JSF/'[.eS CUW ?OTHER(SPECIFYI W 2 J ? I IOV/N LITYO R (, Q - P.M. EO MI E P L O C? N 5 [F'E'Q? W (????N 1 1 / S ???ULOC [EDW W U '' l . 051 ^? ..? MILES Ll'uF- .1? --___-__- LL I G? ? A E! OOF STREET OR HIGHWAY.„ NTERSECTING VIITH. STREETORROAD I Y. RAMP DIAGRAM DATA O NON WIEfiSECTI E^ ` rE?i S? - - ? ^ GC DE T TER IHO %F p CLS INTERSECTI G 5 ?[ ERENCE RO TREE OAU N, ? [? (7?/ ppp . ( OETWEEN. Vr?_ _W Ay L?CJ / FA? _-STREET ANO._- _ _. ST EET M EAGE CODE ? DISTANC ANDDRECTION FROM REFERENCEOR OR=STREET NUrvwEI SPECIALC D GUSE i - - ?MILES N S FFED? W 0 . e .. 1._ _.M1O -__ ?GC?FEET L} OF. V?. _. L?Ir . . -:. / ... . ?VEHICLE-VEHICLE ?VEHICLE-BICYCLE ?OTHEFIWRITEI ?NRARUN COLLISIONINVOLVEO: SEVERITY NO KILLED TOTAL NO ?VEHICLEOBJECT ?VENICLERR TRAIN - ?STOLENVEHICLE F 1.N0. INJURED OF VEHICLES ? VEHICLE PEDESTRMN ?NONCOLLISION ?HQARCOUSMATENMI % C&PROPERTYOAMAGEONLY .. ::-_-OBJECT STRUCK(NAME OF OBJECT STRUCK AND OWNERS IAMVI -..: ::'.... .-.. .-.., ,' LOCATION OF OB,IECTSTRUCN - EST,PAMAGE..::-: L? - ? ROADWAY FEET ? [9 ? RD EDGE f - UFIIVERS "E•UST_,.,,,., ;,: _ ;, ;.- FIRST -- ?.: _,- MIOOLE , ?- DRIVERS NAME'UST FIRST MDDLE OF BICYCLIST OR Pt CHEC lO - i :':? R . , L I'f? 1 GvGle GVwrs R.. _ :. -EET ADDRESS. ::.:' :_ , ..: ..'.: .:.:' I ,' STREET ADDRESS/ C. -,;:.. ::„?. _:, :.:..:.•::c. .. ... E R C y .. , .-'.STAT E : .. .. - 21P CODE - PHONE NO. C E R CRY .. _. . ....,. • - STATE :..:_..:'.. --'.. LP CODE ;y ?, ,PHONE NO. ' 1 r. { Lud?bLj ?1? 7936? :'.N DRYERS LICENSEE NO. ': .. ,. STATE , 5E% DATEOFBIRTm N DRIVERS LICENSE NO. ... ':'.... ... .:.. .STATE.:. SE%:. DATE OF BIRTH ...-- ° 3 [ 2 Y3 L ) w.? M MP P` 63 O. MO DAY YR. DRNERSOCCUPA110H. FIRM NAME....-.--.. :: :.. •. _. ,. PHONENO. 'j DRIVERS OCCUPATION _. FIRMNAME .,. _..: .- :.....:...: .-... HONE NO. C ''````??__ CODES > IJI.?uU _ TAI. SEAT OELT 151 EJECTION CODES > Ial CLAS S AI SEAT BELT 151 EJECTION C ._.Es Gig G. aF. - "NUB'S OF NJIU"I G FROM SCENE BY' iVATE•' O C.S, S?LC>: GFOM SLENE BY TO VEH. YEAR- MN(EI DGECHEY.1 .'. MODELIDARTilOVAI: STYLE 12 ORCONVI. VEH.YEAR. MAKE IOODGE CHEV.1 ..: MODEL IDAflT N0VA1 _.'.: STYLE GI-GNVJ-., ;';., " E . VEK R.:. IK:. PUTE NG. STATE-:_:. TPAILER PUTE NO. STATE : E VEH. CULOfl ::- UC. PLATE NO. ,: STAIE._. t TflA_ PUTE NO..: STATE....,.:( ?v?ui CM,Py37 Wv? N C VEHICLE IDEMIFK;A q.V NUMBEfl ;,:e.. ODOMETEfl..:. ;....- C.' - VEHglE.l0ENi1FICAlION NUMB _.Y?_i :. , ?. CDDMEIEfl \?,::It.y_,: .. ... . E . - . ...,.E -. REGISTERED OWNER-UST-:.•. ...::.:.:...FIRST ...:...:„_:-.'?:.._. MIDDLE •.:::. '.. REGISTERED OMER-LAST..i-'n.,+ '...iIRBT ?.. ,,,L.:.. MIDDLE.l O. O. - ADDRESS OF. OWNER:. .....,I ?.. _ ..: ,._. '. .. :. .. -. ..... .. __:.. ADDRESS OF OWNER .... _.?.:,,.._ __...:... ?.. , ti.. L....,.:ice. ..??.:: ?.. :,. ' 2'. , . NAME.VIDACoRREESSOFINSUHANCECO.ORAGENI.....,.., _.. ..,.- AME ANOAOURESS OF INSURANCE CO. OR AGENT ., ,s,.. ,.y... w,_, T:S, CHARD :::.:e:. :. ..: .:'. ,- CI _-:..' .: _ /`{ TATgN NO ";. ENFURCEMEN ?' ACTION 1 ? CHARGE:.:.. '. - CITATI NN .. ....: ,. : .I•i:: -_ :.'? ?: '- NAME ADDRESS& INJURIES OF PERSOlN- INVOLVED CODES .. u - _ ' , , SE% AGE STATUS N A EJECT. C.,:. NAME: C" ADDRESS: :.U : 'P. I NA UREOF REMOVEOiROM NJURIES SCf NF flv TO A ?. NAME,. N'. T ApO11E55 I M -cs 5C[NE RY FROM TD W .( S Al)DRES9. N- NJIIRICS' E NAME S " AGB.ESS $'! N _ ITISIATU5 Ii C - 2. PASSE NEER P[DW.- ° BICYCLL51 D e OTHER E , E -NESS .0 a p tl P0$igN UN OvMI S UEONNO N)AL I) V.S.IIEtl'JURYV I S SC?AIUV TI [A ULURE I A UNI 0DY[JUEL[CO 1 1 ? rt+; "Fr .. ti ????' `?1 ,;,? ;n,1-A tYl `??'T1i' ),C ? ?`: t ?'?:N rc, ' °w y •? yy,, r I g _' r I u lY t? r1 ?I'{. ?y?t ? ? ??p. ? ??' - >, x v rS % ¢ lti4?: v ^ [. 1 t 1 c 1 JI I: '/ , I;h? d 11 (Y i l' 1: ll? 1 Y 1 P '1F '.? 'Ft2f .1?? f 4 ? - rr ,? ? • ? ? J S H FI AHEAD, E E a c, INSTRUCTIONS: G. DIiAIY- S I,OSMOw PRINCIPAL URi CE, ! G DAMEGED VEH 7 I v?v? GE"I ILE1C P . ICLE NO.1 Ius[iHSw+ce iin snEicHINC DAMAGE ,D ,na ns,M 1 oncrC?FS,E cl - ? ] DAMAGED VEHICLE N0, 2 'F ! /tl--1 Jt I T ?-7n f nm ?? , G ??•r, Ful lf 4 (I?'' ?_y 6 7-1 16 U- SE ERIT OF Y D GE ENICLf I Q DISAp LING 0 F J ? ''E CI o Y L ,nERVERCLCI E: E C E O r N N. DAMAGE ] ? -C. M.v. DAMAGE i El ] ? FUNCTIONA EOg UISq BLIrv4M AM DAMAGE ? 0 AOTIERM. 0 G M E ] ? FUNC,ONA GE J O N OqugG AGE K ? En M V , _ F NO DAMAGE FUN CIAMAOE O ED RV _1 • (, .y. T, E DAMA OWED BY ESi OgMAGE C, ONAL E ? NO . i ,OWED BY E51 ..AGE DIAGRAM OF COLLISION -. . ' o - DRAW AflflOW SHOWING rFA,uRFL ' "'-- •? - - NORTH IN CIRCLE No CRAY IC-T - - -- "ANDAFreN tali RM --.-- . N 7 77-1- -YY L I 7 - DESCRIPTION OF I iNO LATE wqa R D ,O PENFO4EFONE.CURING T NOT ON DIAGRAM IT THECRAS INCLUDE INFORMATION COLLISION sae urY.pE UCVI _T1PEDESTnq C_THING CO _G DRIVE C , LOq; STRUCTIONO REPAIR WORK, E7C - , i i I. _. " ' ^• POSITION BEFORE COLLISION _ -? HEADED O MILE YOST D R Sip OH HlGnwgv AME Oa HC. N OrvF 0 E V RANKED L -1 PE EIGFREASIIG AS - RKED OCCUYEN. z [ _7 a YES N MR. ED YES NO I- I LON ON UP. w - - G JM _ r_ P ST W4 G 4DF WALK !WALKWAY J E ' 4 .. OULOE,i Al. CROSSW)CROSSWa !_., ONEI H C NECK ONE OR MOREI -FIR ,ROAD SU RFACE .. WEATHER :' ... CONTRIBUT BICYCLE ROUTE OTHER C ING CIRCUMSTANCES' ER C I E C s5ue?L, •' -9MFS ' L OR OE O .. '.. DRIVER F // r C. INI LUEICI 01 N Ot T y, LI R T AHEAD ?60YE S OFIR 0 EL', RC L pNC OHO EGAID'D MAR uJi O'. "TAKING E N I ?O r N ' D ' __/ T A D I-NO p AIR, ( qCF fn -' v .. ca ' APPARENTLY ? ? BOGS 77 - . . MAKING 11 ° 1 ? SN ?" - M A J ED ED C MAKING Ipr? L F _ I F G I E'111 S. I ; v EFT TURN - - QLRAT NG 77 . 7 GRANT 0 - R - O[F CCTIVE rOUM_-_ E,71 NN DID NO Hi- T G - ,g O Rfp Sr[Clf vl - - E S.G ` NG PER T ISRf GARU 510r THE ISV R FC FY LIGHTHFGOR arvE710N5 RAFFIC CONTR Nc SIG N'S C11- D p O A FFO FOR O I D J TYPE OF ROAD J VEHICLE CONDITION SODRIETY O, } VENICLF IC IECK ONE Op MORE t I Q i BID! OvYF T SIGNAL GN I E W JbCO If?Ct? .. y i L 01 E? 1 -I no OWN M I 0 GIIi J. ?T 1 ,? W C -J -•-_.. __ - a ABILITY G - - - tl KL5 ? : R M R ° ]r 0 C F Lt?• t . '-,- .. . __.. 2 NFID A Iiv ' NOA O .... ' TI IT, ? 77 NEgOC GHis > G FnOM S W 41 nG I -- NpT IMPgIN[U_____. A K [D POSITION L ?, ( F -11 AMP,-, .. 'FC ] D50 A D ARK-STREET 11 Gt 5 NK,_ Y, -..._. _: t G TH GI CG I[NTFR NG ALLEY n A ° oT ?M1 NG BACKING , y ""RE is oF S OLI T _._ LcyE 4` D b , I.? RAIN D CHEM. TEST E J ND - A , . •+ I ,.. ,'. TES, GIMFN ,FNISVICHYI } '. -.. ... OlvlpFU - - J N0DEF NO ? -- ? ECTS TES, R[F U..[D UR SP _..... .. '... ? / IF a ER wGCr , C . IF 2 % G % TEST RESULTS ATING --N-- E I r LGI II NLIL`1=C i ? ml4 OE IIOw `l't 1'1 ? IJ tl.v 4 I. F• `lu > GF ? A y, .? _ I C ? ` lac lrw_" .N.A U ins 71- F L / ??? ? R 7 1 o i,i n 1 DII /" R, 111-1n BY X I f I?.41t r `j c. 7 r t t DISI HIO ITiONt On IGNAL C" 'Y Er y NG10N 51A11 1 T OL-OL M YASIiINGION GB50E UUPLICAIf COPY LF:ICAL LAW ENFCRFC[MENT AG ENCYSCOPY.. TRIPIICATECO Y INVEST G - . I ATOR SCORY z A».,e. 'W UwNIT uSTATE ROUTE i •M ??_/?`,r,?sry.? ?OTHER ISPECIFYI y.T ...' H L O _ N b E V! ?w , I MILES ? ? ? ? OF ' / C AMEA NOOFSTPEET OR HIGHWAY I .T. ON d ?. NONINTEflSEDifQN?. O N OEmEE. Nav J.DGY STREE DISTANCE AND DIRECTPON FROM REFERENCE ORLrROS OMIIES ?FEET ? ? ? ? OF .S?'JJ7 NEHICLE VEHICLE COLLISION INVOLVED: ? 77 TOTAL NO. 1- 1? W?HICLE-0BJECT .r I OFVEHCLES LL rf VEHICLE-PCDESTRIAN D R E I v R E N' c 0. ?E A T v E: T H / C 1 L E F N O. x P A N T S W 1 N N E S 5 E 'iT?Js3?y? ?4tttF? s 'ADORE95 7 Z3aX ? P STATE . psr?lC NIV 9000UPATION-CE ryIA CIS '? nl 0 SAT - l 40011011 J Z ROAD ?CITYSTREET O W to OR FOWN ? W U CHNGWITH: STREET ORROAD LL 0 D G R V ZIP CODE '. PHONE NO. E R SE% GATE OF BIRTH N ? M0. 1D3 AY YR. O, THON NO. 2 OTHERIWRITEI = 5,-- 'w IFI% EO. MILEPOST JP DIAGRAM DATA Pvr. ,eo .. .? , y' :R NON %-RD NTERSECTINOSTREE OR-1? ROADORREF• INTER CIS. ERENCECROSSSTREETORROAD :CIAL000INUUSE ]HIT8RUN SEVENTY NO. KILLED JSTOLENVEHICLE NO.INJURED _ ? PROPERTY DWAGE ONLY UECTSTRUCK EST. DAMAGE ., N It E W FEET ? ?? ? RD. EDGE MIDDLE III BCYCLISI OR PEDEStH?AN CHECNI CITY STATE ZIP CODE PHONE NO. DRIVERS LICENSE NO. STATE SEX DATE OF BIRTH MO. DAY Yfl. ORIVERSOCCUPATION FIRMNAME PHONEN . r C. E9 F NATUR INJURIES ? V L A/ Y REMOVED FROMSCENERV: T (: Ab N EAfl ' B MAX IDOOGEGI V.1 MODELIDARNOVAI SIYLEI?ORCONV.1 ., VEH. YEAR. MAKE IOOBOE-0HEV) MODELfOARTN0VA1 STYlEf200.-00NV.) PLATE AO STATE TRAILER PLATE STATE H VEH. COLOR. Lt. P-TPLATENO. . STATE TRAILERPLATE NO. STATE ,. . N wN 3a IlE DENT A NNUMB .. .. ....:. U MET R .. .,. I C. L VEHICLE IDENRFIf:AII NN MI R. _.,,: ..... OM R .. ET / E 1 .... ...FIRST MIDDLE PED NER- REGISTERED OWNER- FIRST MIDDLE .; N " ADDRESS OF OWNER.... .;:;..-, ',. .. :.... .: Z AND AODR A N _. .. ,. NAME ANDAOORE990FINSURAHCE CO. OR AGENT _ t ?^^^r• I A C"A"GE " C1TA1 ENFORCEMENT ?N G'• ACTION F s t _ z s Dooe .• NAME, ADDRESS & INJURIES OF PERSONS INVOLVED 'S E% EJECT. AOE STATU9 w ?jyT?? 1 TI D IAS.(!»fn - 1FRtw xln BD Alul ) XNIY 'N' 111 ALIro LN J f• I C ; 11.OIA111 1 CT J DkAO AI ST'F E D NRM TN H NO NL 1 U E TOIAl1.YF FCII O ?'n i 7.On f11 POJiKW JIXAD O'1 trvVAL INDI NII NJIPy 11PF0 PAIIIIALLYE A A ?_ KIU U FI DCT P! C IAL If0 ! FPJUNV LN AU NH?J:i4 1 Y 6 F4 D Sjjj l?jBTW1 Ft. 53 s ? s a rr ?.r ? r,ARit x.,,12)zw,? lFr?tZ vAt?..?,til+ ? •? ?' ??'?0 ?" r' ?'- ? ? dA aY ??wy. ?' ? n Y ) If If l ? ey n •` ?Tr&ti aJl?t > ? ? ? f ?? w?Rya??e° s r ? ?1 ) s.?L I i T t r'. 1 'JC- I 1 .! rYt 1NL f 1 4 1* R4 - VEHICLE DAMAGE TIN EACH DD[,CIRCUS THENUMBER OFEACHDAMAGED AREA. I ©? INSTRUCTIONS: 3. UNAW ARREOWISITO SHOW PRINCIPAL OIRECTIONOF FORCE. DAMAGED VEHICLE NO. T IUSE THISSPACE FOR SKETCHING DAMAOETOTRMLEFI% MOTORCYCLES, ETC.) DAMAGED VEHICLE NO.2 a HOad - . a IG.IboO = a IA,ROOI IS Rool U?? 13. Trunk FngntEw IS. Trunk r ? • ` ? J ? [ Ie. una«crrwa - Ix T la.um«[«nw• la , ° n.a.H«n ?., 1 1. lD n.am«R BEVERITY OF DAMAGE: VFHICUF NO.1 SEVEROYOFDAMAOE:IOTIiER VEHICU:1 I ODISASUNGDM M G[]OTHERM.V. DAMAGE II]gSABUNO DAMApE ??OTHER 2 FUNCTIONALOAMAGE 4 NOOA M.V.DAMAGE MAGE SEVERITYOF IDDISABUNO 2 FUNESE 1.2 300THEA M.V.DAMAGE _ E ? NOOAMAOE 2 FUNCRONALDAMAGE 6 NODAMAGE TOWEDBY ESi. DAMAGE TOWEDBY EST.DAMAOE TOWE09y If EST-DAMAGE I TO ?'b7'iAJ? TO a Y . a -DIAGRAM F--COLUSIONL ft?s I O - - _ r -? DRAW ARROW SHOWING NORTH IN CIRCLE I IODm Ro.Ow rsapwv.FeATURla F .-??0. ? • E ?9 uu O a I ?IX uC?K aF POWNY IKE?COnPTMlC _ _ J - ?. _' -T FAR EIDI PRCBAPLEPVNTM I - _ __ ? I WvA T P Iw W J. vfwLTE EOEY . CTPt6TIKHeATR«ACT _ - ? I ' • i+w?F- «" n PcauivDH°wO" -- - . . ;COLLISIONaIY+e?:xA' 'V ,?. ppNpICAI bISABW S WHAT TY.REW PflOBAB CEDVIS LY HAPPENE IBNITY. PE0E D BE 5TW FOR AN E O CLOT UMNG ANDOA HIN000L RFTERTHEC CONST[1UC MSH,INCWOE INFIXiMATI WOIIL E TION ORREPAIR ON TOI NOTON OIAGIIAM.EA DRIVER •. Y? Cl_tc J L?-r S-S? ?°'!^!d-- ?? A ?l V_!? ?C -13A v? ?D xc CAR N AVgc ti_< ! 1711€-S.LiN e? F_.???5_fZ c7 n p =- ?vc?EdS saw 6t c A R ?O ?.v.y_e?uax?lx_nX?J_.?rrJ?` Ac ;E'iNG . 6„t,t.r h n1A?_A1J GSM -._ . . I. r'I'irx+Kl.YAfyrSw`'ea tiKaT Ji f> Ak, LGSmt.?J posmol ... NO OF LANES W OKE DIflECTKNI S PEED S aArC LEGALLY I AS D' WAS ON STREETOP HpHWAy NAME OR NO MPOSr OR WH. HEADED IU: NO. - - INCREASING pECPEASINO - i. V PARKED PIE OCCUPIED io ;??? ??rF c?_ caa Na Xt! No. NO PED ? l._I ? [ ALOM ?? r OA -_-_?_ fAgB..nO E? ''' J i 61FFET OR H [mu • DEaDNATFD •'•: T •• fl Pl O .1 m I -? ? ? .• . • . PED/BICYCLIST WA9 USIN (1 77 L...76AlEWNK ' G - ? I uurt ?1--.1wuKwAr ?vau1D[n ?CrtlS,wv+N 1. ..lcrossw mAlA L' JJKYCI[POU1E ? milF n . ROAD SURFACE;;; CHECK ONO Sw„:,WEATHER + KJ?[CK CneI ;=it,,.;wt.4:5?CONTRIBUTINO ICIKCK OH[On MOPD , pQ •- ?I t Aa =- pt MCRH ( q pRNTA .. NO, I I NO,p ? aIANWRNHI? NO x X o"r xo+[RC.+r ! I/_N N.CGwgL u[nceoP rl, 4 l g°i?im[LY _ ??L? ?_ , J L F u.=? w?ugm ww[E _- ?.-AwPAa[Ino-, - _ _ ? wn . _ _ ? •? _ a ? CBIfOI ?_ ? calOfAC wwFHtecF frl A4FEi M1Y . . ? ? 1 ? M f I'- i _ ? a . Mqw _ a ? 6npwna 1-- -- ff ?) ? adyF[DUi.r[TArto ?[ ?la?? IOCATICN nAlou ? A ? ?A? K[ '?FOD ?_? a°.r?e ?'Ewo?d QI°L..,? ^_'.s?oP[" _4,J?s1 IXF[c'N11N°n[ar, ?[? 'y I-rJ _ ° ?____ _ _ ('-? r-? mwraAwrvw ( onP[pAro ._t?.J a_L.J.°`?"[? ) ?? movf DOUart _ T .. - ?•? alpwfp __ - ORI[RIJKCV'R DIHwIY[C+YI n•n w"aP[A nI= eDnralawY ?T, (_J'[? IgiDTMr IX".9" ??Q,; TPMq LIGHT CONDITIONS ,.TRAR?QCDRTRDLI. ,...W?xa,ay,TYPEOF,ROAD; DITION:; O N VEHICLE C - ".I: g?r„SOBRIETTiir.6HL•yti c..ON 1 Q[? qR ,CHI_ -N MD x Vlw4e ? ? [ANAL6 HO a KPaCA Cr.[aP LgMI -?I ? MWAr I IgCn Hl! GG VfwC11 4pM OV?ECOJ NO [ VCOHII[eullDl D [GE I Y[ 1 NQ x ?°?. a?I rWF[OM _J wnnHr ? ?=nom s_I=E t =^r - ?I?-q[mixo?° al?iv,w[°ic^ ?la?'.il awaI _ _ ? ° . ?? i.-J ? - LJ'?? - _"O"Owu ___ _. _ - °? wieua la_. - L:,! Ho Mrto ?M? iuwm roalnN. . . x ? : . r?aA>-q r_? ? P!HAHp'_--. .? * P[MW?a ?I=? I-HD . ._ _.,._ _ . .[ 1 oe.: wIH"np ?la? eACK.n f wH aa? J l 1rm..L ?.• 1 ram In[SRP,clurro ?[?? qR Oaam I-Y CHEM.TEST = ? ? .-.. . r K On! I- T[aTGMH OR"AN[CIPYI t 1T J - J' 1 r[D_ '_..- 0?--._. -?_ _._.-- ° ? I =' '1 ? oMCFp L) H00!/[CIf I l r I nat"VU[[o ;: '.: ' ' OH"PI?C?Yl _...._. t l 1.. IXiI qLK - ?_ l Ifi ? ._-. ... ___ YO"Nxo I ,y. `.7f DlieR lviNl ? % % TEST RESULTS 2 - a n.rranrKLPfHAMe lAUR no IwK[ AInaP iwce M+.Ym RS IPn r U[I plKlPfnAMkfPw1 WMIM IMOJr LOII. pkl[C=PlWHt pEY DAIe WPLIC ..,....... ......._._.. _ - ATC COPY.IOCAI LAW CO-; EN/OHC[MENTAOENCY9COPY-TRV[1CATEWVf91IO1iM'9 P srrzzis?: - R- 3 Ed Y k a t s ?` x r? ? »?i, ? STATE OF WASHINGTON PAGE / OF No. POLICC' COMPLA lIT l1UMtlER _ 7- y 9 UNIFORM POLICE TRAFFIC COLLISION REPORT A GATE OF COLL44GN DAYOFCOLUSION TIME COUNTY NO CI YNO n5' I . FHWA MO. DAY YR. SUN IfUU IUkS WEU NIUU FHI ?i!0}I E p > I 2 J < 5 8 A IUS?V /1 -i - 11?'R(1RAL COUN ?STATEROUTE (MCOUNTY ROAM ?CITYSTREET O ADM CIS. PflEFI% ROUTE OI 3IA EET CO DE SECTION X R .v /J O ?OTHERISPECIFYI N 3 5? / 7O - - CII1YYORTOWN Fite'.. EO. MILE POS?TJ / p? .y ... / -. C 2 MILES 11 I 1pI p El 11 V •' _, G .'LO OF .___... y Ir'•?'i., g . _.__ . . NAME NO, OFSTPE GIIWAY NTERSECTINO WITH STREET OR ROAD LL MMP DIAGRAM DATA T ON i oath o ?. ' ' I NON WTERSECRON . O N rJ I,?D-,.?v Irk ?k1.\ (jI?C?. P? OETWEEnIyVV?L?• J N.F.- 9ETANO..._..__OCGXL _G.F FjZ.YYEI DISTANCE ANDDWECRON FROM REF R ACCIDENT MILEAGE CODE 11 I NON X-HD IN(ERSECTI G STR E OR Unp 011 REF. WTER CTS. EREHOED R095 STREETORROnp 36 r . ' E ENCEOR C^HO^SSSTREET T W NILES O 3 H? Elwy 5 F IALCOONGUSL , E OF \.?8 FEET 91 ci El COLUSION INVOLVED: ? VEHICLE-VEHICLE ? VEHICLE DICYCLE OTHER IWWWWWiEI ?HITARUN SEVERITY NO KILLED t f1 . ?? ? ?VEICLEOBJECT ?VEIICLEgRTRAIN FFFddddCCCC 1 7IT7V StOLENVEHCLE , q , NOIWURED OF VEN COTES ?yEHICLE -PEDESTRIAN ?NONCOUSION _.a IN g+i < nlp ?HAZARDO SMATERIAL ERTY DAMAGE ONLY OBJECT STPIICKINAMEOFOBIECTSTRUCK 11 LOCATION OF OB EC TR YYY9k?@@NUUU I TS UCK- ES.. DnMAGE;, -` n r ! ?ROADWAY FEET a o o W RD. EDGE S 4 . DRIVERS NAME IAST. ,, FW5( ,MIDpIE .' -1N I NAME LAST FNiST MIDDLE IIF BCYCU5I. OR YEDESIPIAN CMEC 1? _ 9MylOAVl? QO ? 4 E l°F ' L VA o i (a .. -;v3 ...?. N ;' ...,_ STREETADDRESS :?::.:.....- .R. SiBEETADDRESS . , . ... ::. '.:.... 1 -7 io9 ?.9yTovAv. :.fiigvyY.c '.. - E CITY..' . ........ ....'..., STATE .; : ; ZIP CODE PHONE CITY ' S j . . , ...., .:. ......,, .STATE ....?; ,,. 'P CODE ,?... PHONE.NO. R ?rrz ? s i4 9??0 3 . A f A t ` , N DPoVERS LICENSE NO.. OF BIR O• (. ,. N DRIVERS LICENSE NO.. _.: :...... .. ,.:. :,-STATE:. .6E%, DATE OF BIRTH .: O. MO. DAY YR M q :. .. w f NI Y.-. ? OCCUPATT--ION ., - DRIVER FWM NNAE .., .: $ N 'j pRIVERS OCCUPATION FIRM NAME.. ....,.??:„ a _ ___ .. ..._..._...v,....« N N ?/4>UO7D FiLi/T S!'>-I?Y/ri? Zf- w. J CODE S IUI CLASS-j- 1AI SEAT OELT_L ISI EJECTION _, _ CODES 71JI CUSS IWURY_- I - NCODEP ?I SEAT BEIT__ 151 EJECTION- NA ' VOUHTUREOF - FR MSC -E- TO FR MM SCENE RY' TO VEN. YEAR MMEIye? {HEV.1:.. MOOEIIDARTNOVAI STYLE IZ DR: CONV.1. VEH YEAR.. MAKEIDODGECNEVI- MODEL IDART•NGVAI.. STYLEIZDRCONVI .::.... / 5 2 / v 0 D I v t? E VEH. C LIG TEE NO. STATE.' TRA1LEfl PLATE NO ST tE. , E - VEH. COLOR LID. PLATE NO.'. STATE: _: 1MI1ER PLATE NO.. STATE .:?_... R .74s?/ ? ,¢ • , . 1 . VEH I N IFI A I N NUMBE C ` - .....,....:. -... . OOMEIER :... ,_• , (? . VEHICLE IDENIIFICATI N iUMBE R L` T/(oJ'?GG6z73 55 8 L; ' E NEOISTERED OWNER LAST E .. .FIRST ,. M DJ E gEG*TERED OWNER-LAST. :FWST MIOpLF. II O, Ap g F ? E . 1'- p fS40 OWHER......., ".. . .a....l..?_ ..: ..,. ,... .ADDRESS OF OWNER. .., ... c...., .._:....w:-... .,... . A?.,.r.-.,wa.,.cA.:.'bL, .Z. -;. '? , ----------------- - . NAME AAKIADDRE530 WSURFNCfCQ 011A ENT:. NAMEUIDAODRESSOFWSURANCECO..ORAGE .,..: .• .:::,... _...'-:_.c.:......?.:,„.- tiowlvE ,., ..: , f '? CIIAA?//E¢?'... _.:...:.. . /.', .. :. ...'. ..:s;...:. ?J N`O ENFORCEMENT . CHAPGE • ? I ? ? /. •/G FFi K.SE ?C.1???0 ACTION - '• al s ., NAME;ADDRESS & INJURIES OF PERSONS INVOLVED C00E8 •. 1 \ ?c+ ..:.:. .. .. .. 5E% .AGE STATUS HV NAME ?.fI A rl- EJECT. L. ' i?GE NFfC(?? T I J hi [ (( ?F C AppRESV- T F F- U ry WA 'IgE O .111 IES /UQ?E IIEMOVLD fHr1M P SCFNE BY. Tp 1` } A NAME' T ADDRESS GY D 11 M i. S ' n .gry 5 Bc t 1 ' WU ' 9 SCr TO I ( W N ML. . 11 T r ?. 1!Al? 1 h I+ ' r•, ?u{ IPI!!L' ?I _ T ADOHf^.5 .. N rvxr.. 1F - VISTN<fAl? C fFNF 11Y TO IN r r µ i Y E MUM?`- rns+_. _ 1 NAn -si ?Hr TO J 1IWJi4N 1 IFUa M T I1 )' ?' ulufcla.i C I Pf Uf1IIO ?n A 1 NI.IIIIURY SM514 MHA1RY f NOI tl151A11E0 INOI EJfCiF.M A KJN M.LI NM NOT IYr ZD1.A0 T SCEI:E E 1 IUse Z IOTALLY FJEcurt O ABK' C Jpt IRPM !F'Y! JDf AD S I A I ? -(• I'" 1 A M Y ! PT „ i i I D N ] L IFWIF N I 1 IV I D II Ri1M LYf J[CIED D 11 ?/' M LOIOIM,YC TI p UVI K)S IAl T (Y) t LWKIF UNKNOWN UNKiOWNIF 7SL 1NLLTTMUR! LJLCiLp 1 I ! f 5 ? f?r I q t' (?. 1 ?fi L Y 5 h' S? A' ? ?, ' ?? ? ??b . v ? 1 Y Y ? A f r l ? 0 L @lh?yy.. 1 1 °' ?' t 1: y I 5 ?? r F?1 g 1 4y ?`?YW -I - t lli 1 v f . sl 41r I ; ) f ? I r x'11 DIAGRAM OF COLLISION t TD k .FTxrvxn DRASV ARROW SHOWING I NURTH IN CIRCLE I J E _- E .r xo,ow,r h /r ._ )LI_,r i I .T_I I I I ..CnNSrtroxs tlcr !.._ ? i t? I .r`? ? - t I L } L 1- ' +rx ?KOx L oLL _ f I < ( f_ 1 i, __ .I I 11 I i i i I F ?r -?_ ( I 1 DESCRIPTI ON OF ':.COLLISION IINO LATE WHgTPROBgtlLY HAVPENE00EFOHE,DUPING 0 } q}gip 015A.,,.TY,gE000CD VISIeILIiY, IEOfSTRIANCr OTn OCOLOR, CONSTRUCTION UP PE RI-lAT6 ET0N TON OIAGrIgM,k G. OHIVER WORK. IN ?I%fU L /i?? : ?? l l . 7 1 r 71.'f J L _.._L? i Y I . •y ? _ , Fir _L_ < ?,'' .......' :.G. IJL.' _....?? _C ,_ - a'-'?L <<.' C r/ / ??n --G ?` 3 -? POSITION B FORE COLLISION _ 1O NEAOfO MILE POITO N. 04D E RfT ON nIGNWAYNAM OPNO ?' ED IC R' FA-D. .NO NONE OIgE<T ON INCREAS OECHF P IN ASING . r E LEG LET OWN. E ED FED. n l HONG Ul. ES NO OR MPH J J J L ' [DIR ST WAS US N6 1 SIOf I U CIIO55 [OX IrvN _ _ fR0 1 w.l > L' WAL L Y]I O k ? D ?--ID-E-1-1 -1 N _-_ S L- I I g ^i , ? AD AD SUR AC - WEAT HER ¢NEDK OF., ICRECKO EI CN 1 .- OSS W L. K .•• ^ ^ •--^ CONTRIBUTINGCIRCUMSTANCES., :Y ino E I...I on1ER ' NO f> D RNa > CIIECOK„ON E)IOR MONEI' - OHI f O) \ RrvRNICLE ACnorvf. , J NO ] V(P CLt IoHLwpl"j' . I , OOIN D C v ID ORY CLfAR,CLO ----?.-__ °OVFPCASL I1 , _ StgA ' I j UNOCR.ALCONOINFLU[NCf OF II- -1 -FOLLOW N IGHT AHEAD ' J L (' EO r A wgAN _, L-____ ?OOsLOSEL ! I] 01 a L i OVEER?KIN f E UNDER 1 I}? INFLUENCEOP I G I I ? ^ ENE ? J rK A PF DRUDS E NrLY Nf 1. ? L 1 !°I O 1 ] SNOW ]J?S OWING _ . t ff C f ((L-- ?? CE a1Np SrATED E FRONT TURN b(EOLNI? I I ? ?F NK ? .i_?_"' ` 7 3 SfIS M OC NO IJAI? MAKING P 111 1 LEFT TU - ???i I S CE Eg E L I O E I 1 S I Y ' _ j ..I JS OTNf11 IfIEC f Y{-'- S EED I giNO . UN 18 I . I 0 OiG ANT rN 1 ( _ __. 0, _.4F E 0. _?_ L. L..I UTURN CLF f r ?? ! T E ? f I OtIIEN fYEC 1 . 3T9 WGAL 0II /! ` 1) r I SLOWING (' i I ' ? D fll -'l - '- ?'. ? / NDIT ONS RAFFIC CONTRO "INIC . 1 vS.C L sNa ,1) s E iN[ sro I rR j Nl/ a iLC t ) FOA - r TYPE •STO F D KONU ND >vENC 1 I,_.,SIG ALL L ,J INO.)' OFROAD , VEHICLE ?cCONDITION '. SIGNAL DD SOBRIETY I " TOPFE ICR ICKONE GNMORE VEI C E 6V 5,fy744EF??9Q5 I NCLr ICNEC ONi.I r- R 1 B AT , E' ON D- SIGN r j1 r DNE WAY I NO > f CIINAIAUTLDI O) r_ KI:-0 r G 1> I `. ) , Tro W nono EnYN . i J I O N .._ ?] .1 YIE O ..... -...... 30 , t O FCT t A ( (y "L. / RIAKES -. I I..IM ARID t STAR T OIN It I Ll 3 -'? TRAFFIC LAND S ;) 1 U! C L r ... ] (WNK .. II1 AS f 11 0 r RRlllT*,. 1 ?? Np O p ,' IE 1 Lt Ili .,. ). NOI M,' STARTING FNOM I -- -.... FAIiK[D FOf111UN I LOOP11l1N I] n S j NC E I I D NK-Srgf E1 1 ^ L CNr/ON ... 1. FLAN Nf. b N `•• r ,_ . I NIFI .. EA I G TS --. > Menawa rzgrfmnD ,5 •.. A .. UNK .. .- ._-.. 1 vuvvlm L I f N DIOI )?i rT L. ff . J U U r ILNI)II NKINa t R.LCKING 1-1- ' I U -DANn.NO scN NN1 G I L l 5 Y Is '? '0 'ID 'vLn CHEM. TEST - CZTT-. I Pl+mx I NO.) - y + .: 5E 1 LIGNIB RAG N I lygl q .. -. ?. Tf. GRVIN nU1 PN ISPrCI)YI - OtIIfE1IYlCII YI I+X I >? nIVRN. J NU DEF tl Is I rttl III USrO I _ 1 - IV 1U 11.11 Z "111, N la ?. FKIn'LNAUt RS IInNK -"?- 0 III 111, - TFST NESULT9 2 - L UI+r r/) 1°. IX. ,.n. -a' v?L -. -? w r rlc mr l.?`. v.ff(WEW? I J I rI )Lw LI 1 rota L. .. Ur I L TjI- A l M N _ 11j? F h4L'1 ,. __ OsrH DLI[N OIu Ac's sr 1 LA w,. n}, .rnr[rnl DL u n n, Ivr,?u) IR;u __?I- J.-= I;?1 r.' ? 1?'Ft r t . I of w F ?? x &e P?dKf& ." JiM 17 1 i J a- ?I?+ r / r, I , ) , r _ I ?A fn?r lX t a c ?.?FF L t r •t ?? T ?k1• } , L ,H ,rti?L 1 V 1 L .' } 1 - ???? rn. I - t ? alEe ff t t R hr 1 l? R }1 .. ..•, `,. ? ? ?.?.. '.. _.,. ?.t..A - ,1u?,. VISA, ,rte f ? ,:4 I OF 113; POLICE ..,.i.r F UNIFORM POLICE TRAFFIC COLLISION REPORT COMPUN!NUMUER r D GATE OFCOIDBION hIU OA CS JON ?7 DAY OFCOWSION ^UN I.IOrr IUES WED NIUP FRI SAT Z 1 2 J A 5 e TIME IUSF. $AOU MOURI j COUMYNO. CITY NO. ? . FNW ?URBAN ttt COUNTY. AD OS PR E ORAL QSfATE fIOUTE ?,000NfY NUAU [:]CITY STREET O ?? EFIX ROUT OR STREET CODE ECTgN ..J l:/•F(:•,S ?C D/1/ ?OTNER ISPECIFYI y J -5-g3 L?r o L S E W ?IN CIlYORTOWN / NN W P REFIX EO. MILE LOST C • ? TT MILES ? ? ? LF IY'(.C fy0. il?zJ D? - LL -- ?r T NAME d NO. OF STREE gMIfJItWAY INTERSEC(INGI411M GTnllTORNOAO ®?CL\SI /M JiR rill? LL R MIP DAORAM DAtA I _ NON IIRE115ECTION L _ • ACCIpENi IN M:LEaGE TER 1111 X... INTERSECIIM1G STIIE UR ROAD OR REF . i CLS. ERENCECO SD STREl ROAD • N OEIYJEEN STREET ANpC, STREET i CODE ? S ?10 p D S/) 0.11E ECp Ffl OMfl EFEPEWC EF RC fl O?BI /? ?MILES N 5 E W l TIIS S unoNt PECIALCOOiNG USE , ^ ? ? ?OAIU /, Q O FEET COLLISION INVOLVED: ? VEHICLEVEHICLE ?VEHICLE BICYCLE ?OTHERIWIIITEI ?HITARUN BEVERNY NO. PILL EO iOTALNQ QVEHICLE OGIECT QVEHICLERHTRnIN ?SiOIENYEfIICLE No INJURED OF VEHICLES Q VEHICLE PEDESTRIAN RNON COLLISION ?HAZARDOUSMATERIAI ? PROPERIYDAMAGE ONLY OEVECT STRUCK (NAME OF OBJECT STRUCKANDOWNERSNAMEI LOCATION OF 061ECT SI RUCK EST.OAMAGE vl ? ROADWAY FEET ? Q ? ? . DRIVEfl9 NAME•L0.ST: ... FIRST .. .. MIpOLE _ RD EDGE . pRIVER'S NAMEIABi FIRSTMIDDLE rI: UrC+CIrSi CFI PLU[SIHIANCHECKIIJ R -:I STREET AODREBS. ... . .,.:. ^. ,... ...: .:...... :.. .... . .. .:. R, STREET.ADDRESS..rv .. :.. ,....,.. E. 1.: 4•R1Z 120th . 'y. CRY ::.... .: ....: .... ': STATE . .:: -.: ZIP CORE. . ,.. PAUWE E' ? CITY ., :.. STATE .. : LIP LOBE ,..., PHONE H Nnr? s /vJ wt? R • N O DRIVERS LICENSE NO. .- .. .. .. ' SiaiE,. SE% DATE MO OF BIgTN DAY R N DRIVERS LICENSE NO STATE SE% DATE OF BIHTN -.. . _ Y O• MO. DAY YR. ?, DRIVERS OCCUPATION FIRM NAME..1 ....... .. ....•.. .. -.. ..--PHONENO. 2 DHIVERBCCCUPATION. IHMNAM CODES > IJI CV35.__. 1AI SEAT BELT __? I:'I EJECTION _.__ CODES >1131 CLnSS .?.-._ 1Ar SEATBELT.___ I51 EJECTION NATURED INJURIES V D NJU E gE ' iR M;ATENE BV: TO WE FROMM SCENE IIY: TO VEH.YEAR MAREIBODGELHEV.I .: MOOEI.IDARTNOVAI;, STYLE(.DR-CONV.) VEH.YEAR MANE IDDDGELHEV.I, MODEL IDART-NQVAI. _ STYLE (2 pR•CONVI . :V 46 .bo1DC c V•SAN V'4" !J . E -' H VEN. LOL ., UG PLATE NO._ STATE TfWLER PLATE O. STATE... E.' VEH.COLOR UC.PUTE NO. STATE TMILERPUTE NO. STATE B P, 'C VEN LE I EN ICAT N NUMBER .: -.:: ,.: .. '.:.::. . OOOMEfEq .. •.:' C.'. VEHICLE IDENTIFICATI N NUMBER, .: :. OOOMET fl - - - OO .. . ,.: , REGISTERED OWNER-LAST:.. . ..w?.. ; FIRST .... .:.::.:.::.: .. MIDDLE REGISTERED OWNER-UST FIRST .. MIDpIE 5 , 0• <W.c a v p• ? ADDRESS OF OWNER .:...:, 2 . NAMEANOADOHESS FINSIRANCEC .ORAGENT ...: :..:...:.- ,.,.: NAM-DATORESSOFINSURANCECO. ORAGENT CHARGE, ,:...r. .. .: :: .. .. . .... ... :.+.. CITATION'!O ENfORCEMENT CHARGE . . .: . AT N . :.. ,. ,_. .. .,....,.. co s ? NAME; ADDRESS & INJURIES OF PERSONS INVOLVED ne irF / 5 B EX AGE S .f• EJECT. C NAME: C ADDRESS: l" U P.. NAT.R'C` WJUfuES SC 11EE RMNEOVEYO FROM . A NAME: I? Jill `S / WUNIE9F IIEMOVf D FROM SCFNF RV' TO T ADDRESS' .\?rJ // ,_' ^ '), i. 'N' L?MSVE-dfll M 1 I N f NJIJRI R' SC TO S NAME: S A ODNES1: r•. ? NJURRS. BfFNf nr _ TO INS-- ' IZISlAI WSIIpN IJIVWIIYCUS3 TAI SEAT RELI (WEJLCIKJN ` J. N(fER 1 1 1. NOIWURY S DISAUIING INJURY NOT INDIAII[G I.NOi EJECIEp J PEOf-AN O I 1 CLAF T OIIJER OSIIWN ]DEAD At SCENE J UEA)ONARIUVAI ANON DISMIUNO f V10[N} ?. NOT IN USE 'l. TOTALLYEJFCTED .11,1 D . 5 011 IT 6YAlllF 33 y T . S J 1OUS MOIORCYGIEI 51'0511% A qEU PINOSIYTAL I (INJURY I T POSSIBLE4WURY J USf.D A UNKNOW:J J PARTIALLYEJECTED A UNNNOWNIF E, 1N UNKNOWN 5 SEAT UELTFAILUE EJECTED 4 4i? A .Yq H! N?__'9N<, moo. ?r•EO r-.ON ..Ell S1_...MAG,!gpF.AS.T oAV?C cRO..:: CaN.. S??cRV',la S?Jav'_"' ,_^ DRX G2....JtaS?._4DnTP.D1.. 02DUc pl?l3cN1r•O ..?..?15??= ? ? -Y<N? ?n'_/y-7AN.c`?_____..-'-I --- - POSITION BE OR COLLISION LANES SPEEDS VEHICLE IF IA IER. DECREASING q EADED MILE ISTn q. ON.FEET OP .IGNWAY N NCf A FOR NO. IN IR NO ECTION raF r pFGALLY WAS 'EH. E E 1 N E, W 1 NG E I ..I AR Or El OCCU E r'AS? l?fAjgRo,A'S' 41 ?/ INh L I,.l! 11 ? 1 I - - ? I J No r E E .. R G----- ..___ ----- CND]SING _ I[DlaicvcusT wgsuslNC: 'II -ISIOEWALK ti Iw KWRY 3! (SHOULDER RL 1 MARKED I al cn"o AI LK A RED a?-'DfslcNgrfo )" I -' p-- ` ROAD UR ACE ,.WEATHER -ICHE[K ONFI WRECK.- ... CONTRIB I .. S UTINGCIHCUMSTANCES CHECKONEOn MOREI ICICV L F OUTE . ER DRIVE wvEwcLEAC IR TIons DRIVE IO DRIVER Ir- DRIVER O.] D FR A NOt DRIVE I NO ( V{n E rr L J GHT?? CL X D Y EH1VFRCAST.. -'° LII ? UNDER ONFLUENCEO `?T ? iOLLOW NG TOP409u . , 1 f OIS ScR Owq.N "] MG I - STRAI NT A.-. L It:J-ANDR?A S N 1 ] WE ) 1 I N 6 _ - - )LTI I UNDER INFLUENCE O OP O5. .? x I 0 CE T E l._L E _ _ _ T I APPAgENL J ASE. _ S O -1 ygKING RIGHT TURN I 1 3 _l:_s DE D ...? ,? -° ---- TEO ;.>>Ll _Y C- NO o---- I Ig? LNG O .. L _ . -- I IM 0 ERP RKIN i •E 1. LOC T D 7 MAKING I?•? CE I C FOG -.._ .. Y KCEE S CE F' REAS ? 'a E 1 I IMPROPER -- 0 p EfF NO _ LEFT TUR MA INS 'a, N 1 6 y/ 1 T CN OPECIFYI - ?.OTiE Y [C fYI . 1 IgI I OD OTC HT PAY TO VE C E _._ - 1 10 f0 J $ O G.T C IO EOU l(( I I-.. , . I UTURN r-- L ?BLJ ]LOWING P OPEq gI I Itr A SOHEGARO`TOP I 18I ! OT ER ECON I rI 1 STOPFEO fOR IT RA AFFIC ONTRO CINOI E CLE E tLE TYPE OF ROAD NO) tCHECK ONE OR NOgE VEHIC I Tq FF IG ST OME DATSIONAL I1 L? f 6NAL5 ONE WAY VEHICLE NO ] O VEHICLE RCHECK ONE( Oa STOP SIGN l - . 7 l?` I SGwN__.... J_ AKFS VE.. MIAIk1Y TPAffIC LANE SI 1 ELO ?.!_ 6GN .. I R[V[ SIE A0 II Ef Etilvf kIE1 Ti NOT STARING iR ? "A. R I_??.'REUa N6 INTERCHANGE 1] ME ] IOSITION C FLASHING _'!i`l AMmit _f ALLEY -N IONTS . TnEa ORN j_ IW DRS GOT I K_.._- 1 ! 4 "AD NO SF MPNKIN6 TRAF DECKING DAnK-SI 8ET - qq S IrONT30/ IGNAL _. ' _ 1 I•i .1 Tun I NFLEFr _. 15 .. I 1 I c uRIR ... .... ...-H CHEM.TES _.I ...-? DARK-NO S 1); {TREITLFG TS OFFFGMAN L%T_L-I SFPAN Tl0 R t-- - _ R ?.? .I TESTGIVEN - THlR RWIC IYI T OT ER ? ?? .. OT FN I Dlv pep _N - - -- I:. -.. .1 ... ._... i[ST NFFUS[p .I ; - II IHEC FYI rrK •i N ? ( .l - I E unprvmED - OfH[AI.....l vl x yL TEST nesuLTE 2 ... -, Nv[sr?oqunG Orntkn RNA Aa N K useE o no route m sFArcnE roucEJwuvko ARIU - MIfCi? ?NarrPso? 3 All ` A I M .All. FLOW .EDED X Vf3110AlING prIIClr1Y NANEEIIANR AApGr NO AGf NGY IN IL OR OI ST. EDL T. ATE DI"'PONT AP FNOVEHAS DATE iIN SV _ ? 3 c S _•v ' I , DISTRIBUTION- IPLICATE COPY?LOCAL LAW ENFORCE ENT AGENCYO'SC=TRPLCA E COPY ?•INVESTCATOI/S Copy r. , - .., _ ? rv{k gasEl?Eo . ":'a F r 1 . +1 ? . ? ' _ ..-- ,"'"s. •'>r va?__- "?' y' .,? ? ?7t>1 ?rs?u eta fp,: VEHICLE DAMAGE INSTRUCTIONS: 1. IN-EACH DOK, CIRCLE THE NUMIEI: JF EACH DAMAGEDAREA. s• SHADE AREA OF SEVEREST IMPACT. 3. ORAWAHROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE E%AMVLE .^Qr Q L aA y DAMAGED VEMICLEN O.t , RUSE TI-FACE FOR SKETCHING OAMALE TO TRAILEIS.MOTORCYCLES, ETC I ? DAMAGED VEHICLE NO.2 ?? y ? .. ?• i.qur T•?1 IF rC,,P , v,- IU R8. T'_ 8. UMxc 11 R TrvAv I +I F F .1 1 ). O. t x i6. uMxc II N E IT ) O I? t " ITV OF DAMAGE: -111"LE NO,I TY Of DAMAGE?IO THE. VEHICLE', . .xru n SEVCRHY OF D GE - ? ` DuSNOLINGDgMAA ?y OTHER M.V. DAMAGE CTIDNRL DAMAGE' 1 8 NODAMAOE IUW'EO M GE E yI IS LINGOPVaGE ]fLy?OI ERNIV DAMAGE T LI FuNCTIOrvAL OAN AGE F LJ NG.A.-i A AMA , 'CIRCLE NO. I I C!OISgBLIIIC DAMAGE 0 OTNIN M.V,DAMAGE 1 [! fUNCr1pNAL RAiugGE IIii A LI FIO DAEAnOE eY ?axs 6.a 2A6-s- ST. DA A TOWED DY ESL, OAIAAGf DA OWED ev MADE EST. i _p CNiMACJ i 37ai?L T T TO 3 DIAGflAMOFCOLLISION... I 'DRAW ARROW SHOLYING ILS . NORTH IN CIRCLE G s ?. AA, 1 .. ' noeweLE n+IC.E Oa HMN.AmsefroAE i ? I _.._- -. .:... I.. •. i DESCRIPTION OF COLLISION 1 OC T WHAT PHOBwOLY II E OE FORE, DURING qND AFTE EC I C E FOnA1gT10N NOT On DI G AM, E.G. O.IVEN DISgB LITY REDUCEO VIS , BIL TV, IEOESTRIANCLOININGCOLOR, CO SiquCTION GA PEPA NWORK.ETC.I - } Ids D GATE Of COLUSION DAYOFCOLUSON TIME COUNTY ND. GTY NO. .1-o' iHWA T SUN i UvV 2 IIIfS ]'IIEUA t11VI S FNI D SAT IUGF 2ADONOUn1 J . ?UR9AN CUUNfY 'I Z ' 6E Ca ?STATE NOUIE ®COUNTY ROAD ?CITYSEET O OM;CLS PREF. I R Yi UflBCTNE ET O CtON r rrL ?t 5./j ?OTHER ISPEOFYI LU - te , CITY O T OWN ' PREFIX EO MILEPOST L N S E W ?IN ?••IFFI ?t , 1 ?Ga{ l E ?• / L ) t - ? ? ? . _ Z AGD ?( C , . OF ( . . MILES L , • ,. 0, A AME NO.OFSTAEEl DAMMsHWAY IENY?RIG?C ET OAA1610 cJ".f' O RAAIY gAGAAM DATA L ?,C? C 2 ,.. .. . 1 ..NN INTERSEDDOtL- ACCIDENT INTER NON X U INTERSECTING ORE OR ROAD OR REF D MILEAGE INTEL CLS. EPENCECfloss51 E OSy0A0 N BETWEEN ... STREETAND --:STREET CODE (J DISTANCE-1DIRECTION FROM REFERENCE OR CROSS STRE ;?? 9ARLES N S E W ORFInS nul?E SPECIAL COO IrG USE 6 ? OF COVN I I(J.... l Z b.'f ?FEET 0 El ,-. /.; '. .. .. COLLISION INVOLVED: r] VEHICLE-VEHICLE ?VEHICLEDICVCLE ?OTHERIWRITEI ?HITSRUN OEVERRY NO KILLED - TOTAL NO HVEHICLE OBJECT [:]VEHICLE RR TRAIN .__-_ ?STOLEN VEHICLE = NO.INJURED OF VEHICLES ?VEHICLE-PEOESTAIAN ?NONCOLLISION ?HAZARDOUSMATERIAL OPNOPERN DAMAGE ONLY OWECTSTRVCKINAMEOFOWECTSTRUCKMUOWNERSNAMEI LOCANONOFOD ECTSN LICK - EST, DAMAGE ...:: ?fl0A.VVAV FEET ? ? ? ? RD.EDGE 5 DRIVERSNAMEdASi, ;•; FIRST „-, ... MIDDLE- DRNER'SNAME.LAST FIRST MIDDLE -BICYCLISTO FEDESfPoAN CNECK)? %'- D R MO IJ 20 E- EQl D R . STREET AOgiE55-, r:'. '. ..::.; ....... .. ......... .. STREETADDRESO. .. ... _..... .. .. _.._. •....:?... V: 123 A klak 2d I V . q.': CITY. ... ti... .'..,. .',..... STATE...:::. ..._.:,. ZIP CODE .. PHONE NO. CITY. ..:. .. ;... -:... .. STATE. ._,'.:..:-..,.':• ZIP COOE_ ... . PHONE NO. I R . . .. . . .. Se&)o A WA 983SO 653-ySY . N DRIVERS LICENSE NO UATEO &RTH„ N DRIVERS LICENSE. NO. STATE .. :SEX DATE OF BIRTH: . .. O• DAY Yfl 0. MO OAT YR. yyZ !J 3 MON 20E 1•Af ?. h fr .13 S6 DRIVERSOCCUPATION FIRMNAME :.? . ::. ... ...:: .... .. :... FHONENO. •j DRIVERS CCCUPAiION FINM NAME ..." ..a.,•: CODES >1]I L ? g_.IAI SEATDELT_-1. EJECTK)N CODES -, INJURT CUSS lal --- SEAT BELT- ISI EJECTION IUTUREOF INJURIES NATURE , INJURIES FROM SC NE BY: TO .: -WISCE NERY: TO VEH, YEAR. MAXEIOODGECHEVJ„ MODELIOARTNOVAI . . STYL 12DR.CONV) VEH. YEAR MAKEIDODGECHEV.I -. MODELIDAflTNOVAI STYLE I2 DRCONVI:,:. v 76 votks 2Ab a Dz v E VEH..C R UG PLATE NO.. STATE. - TRAILER PLATE NO. STATE E VEN.COLOR .: t,C. P-TE .o. OTATE - TIIAILERPLATE NO. STATE .:, . H.. -rnRl CMN 064 wk H.: C YEH lE IOENR ICADON NUMBER ,...-.? .:..: .. .. ..:. ETER •.. ...,". .. C VEHICLE IDENTIFR:ATI N "U11 1" ODOMETER i ..,..;... ,/.., E- 1-773 09a /0 0 7s4s..7 E,' REGSTEREO OWNER-LAST .__'..:.,-...FIRST .?. ,..,.. ?.. :..... .. Mo.E. •. .. REGISTERED OWNER- T, ...•_ N Ro r C.t"d &6 21 t.l..a2c/ O. ADDRESS OF OWNER.:.. ..:.' ..... .. ..:..... _ :.: _'.... .. _,...:.J... ADDRESS OF OWNER .:... ...,. ,.: .::.-.- :.: .' -.:;....:._ ..,.,...u.:.,.:: 1 . 21• (0 x1037 2` NAME ANDA ESS WOU ECO.OR AGENT NAMEANDADDRESSOFIN-RANCECO.OIIADENT.,..' CHANO _.:,.....: :.. ... ..... ...:.: ...:.: ... C HAT NHO.. :..:, ENFORCEMENT: CHAR B •.:': .. ......;::..:, .. ,:::1.:....:.... G A .l,.n'...r. ACTION ADDRESS & INJURIES OF PERSONS NAME INVOLVED COOED 2 ] 5 , SE% AGE STATUS EJECT C NAME: C ADDRESS. U N P AIUIIE OG HEMOVfDiNOM -TIES SCENE PY To A N AME. N T A DDRESS S i nv nOM iA u t aw n x s cc F TO ? ? ? CI 1? A w ? .1.,.,. Y.L. ?77 In 1 T rJ,?:(" ? ? N I?,tSfG?F1Y--__ urtLDtlvirll M ? to +f' 1Ie 1 5 !mw S .0-ISS xil E rl if b? ii77?vEpTIIOIA i ? G? i scfNE W TO I S J 1. ....IKYI JI INNHV flA1'1 IAI SE AI IIELI ISI IJLCIION C Il A: FOCR O..UuH1 AMSAnIINO1NNnY INOT INSTALLED INOTCJECiCD Y f?l? FSIHIAN 1 2DI ADAI StfIIE ANUr l GSAIIIIIq 2NUTNUSE 2 IOIAILYEJfCILD 1r O A 1 C 15! \ T DTIItR POLIII V ] of ADO NAHRVAL ILV MININJUIIY :USED J FAN1MlLVEJCCIEO D G „T (11 - EJ Jl? 11115A101011C\CIEI Aof I.-,HO:NIAL I Tosv Il E Ir11URT 101111 AUrIK110.11IF .1 I ?5 „n.l? N A 1 (At f???/// AIN]`f 1101. UNAr1UwN S SEA f UELIFAILURE EJLCILO r11ti y J J _ i ,,t44?y?? 1 1 I' I d t?NV`r7 u /y r'? ?1h I rl If a Ir ? 1 ?5f : s ? yI'a tl 1 t t ,I { 4A 41 ? P f rl tr. .? ?A•J1 •(1 6E I 1 !!! II W[ ;L ; f• ,? 1 tf .? I ''FFCChh 5! i ?4 i l Yf ,z°5`??t. O!N& o . h . T mr E%AMYLE ? 1.INCA'CIRCLE THE NU-EH .FEACIIOAMAUEOAREA. VEHICLE DAMAGE r ]. SHAUE AnEA AREA OF SEVEREST INTACT, , ?? c 0? • IN5IFSUl:11UN5; }. Dngrl AAUCE m rnmuN Moi0nc5 ctus. Ertl cFraiil ? V'•,V•• DAMAGED VEHICLE N - 0 D{1MAGED'VEHILE NO.1 l , .K RISE THIS ETCNNGD _ 4 AocA N r ` IT. 11. O..HU.?• LIIITY OF nAA1AGE: VEHICLE NO.I SlV OAMAGE t ? OTH UIF V 5[ EN'TY OBCDPPAIAGE: IOTNEF VFIII o?N MV DAMAGE GOANAGC ] O I CI A E I TY OF DILIAGE: VEHICLE NO t I E0 DISABLING DAMAGE A] B OIHERAI.V.OAMACE L'( qGE I Q . I (] OIS I-HO DAMAGC 2 F.'- IOMAL DAMAGE ? AU -Al' ` I AD .I O II (?' UA ESr, DAV AGE ] ? CT t U EST.OpMAOE T0CT DWE By f.ST. D I.WEDBY ToWEDBr S S To ---- s goo TO To DRAW ARROW SHOWING DIAGRAM OF COLLISION I CIRCLE NORTH N - 1 .. I - I _ ; i ? - C T O 1 1 ? I uxVw[ur[vr.tDxD ON, rwrcN coxsrHUn on InE lrcl I ?!' 1 W j- '--f .? I.. - t 1 „ E,Flero?n D ? ? ¢ -1. t 'l. L?? ?- J 1 1 ,_ I I 1 - ITO 1 1 -L Z, I, f I .1- I o,[KmIIFOn A;- . DESCRIPTION OF NOT ON OIAGRAM1LE G.OnIVER _ IINDCATE WHAT PROBABLY RAPVENEOBEFOREOURING AN AFTER THE CnASH•IICLUDE INFORMATON REDUCED VISIDLITY PEDESTRIAN CLOTHING COLOR, CO STRUCT1ONORREPq RWORK,ETC.1 1.113-UTY 1 COLLISION, . <//. NTERt4!S-' A---Se-OLCS_--°F_?5,. FlPPRofrrn.n..T.G-.--S?E=_0 ._.e.G_SO_ ?!'±P!i_.-w?.?_?!.__V.EN!.cl? d_o!1'7_c.0... TO The-sAO.V.LL?E,e O_es,;l s Pl N ;5 LC1 D A N H .. .. _ eN -TA - GILS__ T N E__OOa9-. d-..QOF.v E.-/!-_ CoS7 ._GO.u.T Kr L ?_:V.L M?kC ._! 7J VGA GIE <] t/ S I _ _ E_r 5_,_ J EQrC iAJ_fv._ Th}E___QlT<. -_.oM_TM?-.__EnSi_-_d0 d__SAouL, ?c CS raerNS---JI'o'l ?. _, b[.ock i.._ry-,. a _wr P Irs . _ T /le57. _. DA n _So?^.PL?cTt 9?.!hco..ma.Fuq--° - NDrtE DzIVE? ?i,qo L/Eh V6 /Cc FRO- A cc/DENT /7c nRrOA d0 OFF/CE?S / SPEE05 CLE I[EO ' M LANE E DwfcnoN I '. I' WAS E IieD occuiEEli ON '. - IN POSITIO OEFORE COLLISI NO E OR VUI. HEADED MILEPOST DIR. ON STREET OR HIGHWAY NAM . 1_J IEl -No ING DECREASING El 0 N S E •4D MPNyD Y S NO E NO IF / _ I Ell ? DA?E l L II D G .. - FROM_.--..-?- TO ED. I lON -- -- } I < SED EK i IV R 41 1C ? , TI l E EHO U I OT ER t? 1 .. WAL SN OnIVERIVENIC FA TO Ptoralcrc sr wwsusiHC I ISIGEW L :_CONTRIBU,TING CIRCUMSTANCES .1 L No.tvLxale ry Dgel` A SUfl ACE.". .WEATN R... ?.. .--- Ic ECK ONE Un MOnkl r ICN ECK OHEI xH:CK ON 1 "• - c DN E I SrRAIGNT AHEAD III I n E O . t NU I. 1 } DRIVER DRIVE 1 NO 1 ND] t D PASSG (" , UNF ROED WARN. L_ CLOU" ?t O IN -J 1? 1 -1 I _ r 1 AND PASSIM. II' ULCOlW4FL E < O I ?J? r C1.R L S7 O RY ? _ .? ?_ I GA i :?L?(_ FLUFCE 0 IJRE r APPARENTLY } ._.._ I EII IN I BI E SS[E __ n GIIT TURN ..U GS t-LI-.? }I Wer ] N6 = r C f _ ] I , A NC t ( CR ANKING I r. l r G TO FC0 ?0 T F JOI I SG. l ?S?? IOCAf ON-._?_._ _- - LEFT TURN i? 6 Ow ]?? S OW 6 I??I"?I EP I.? MAKINO LJ ` - r F 0 JJ++-- C VN TURN ' r E D I E .. -_ I PEED F , L00NOT 01 T I I I DS G RIW S?, I Iy1 E G [ S nP GO {. GIS -1 1 LO ,6? EON . L _ _ , _ .L ? 1 S-S. _ T T F 1 I ]? J TRAFFIC ' 1 O ill t O sP[CIFrT O NFR (SPEC YI I n I B' I OLAT I ? f I ' ONIFII I : S CN ?N 3 ORAL t AT N SUtlHC IT1 O N D -VEHICLE CO ' I -S D n C Y STOP SIGN _ On i(anii H C C NDITIONS RAFFIf. CONTR. rc ..'TYPE OF ROAD QQ 44 €€ l! ICNECK OMEI 1 0. ] VFHICLI VI NO ] ' IC HECK ONF O I HONE VI NO ] Ij'fFbc N }I b f[m VI I IC. )E OI IU STOPPED IN Y ' _j ROADWA 111 O F Y ( 1 NON L6 v D UNHNGIN ?D A E ? N TRAFFIC L . i. 1111A EMD T S D LIOHI il O1 /2 I O I D IAKL5 1 ?] 1 II - _ _ TIP ARKEO PO J DAWN ] YI( D OAII.SIBLI t I RLAIiLIV ITS ?? NOI AIMED I J P C N B ET - ] _ Mf ONf. ILNTFIIINO SIGN - -- IW 11 5 G K. I LOO 11-1 NO! ] EAILG T '] IK ...! 1N fIICI 1 WSK 0 .. ,. I w H6 O K-SimeT E L G 6 ALLEI D I. O If IN INn S . TEST 1 .. Lwlr1E DN AMBe - - , -- n, .II r v CHEM E Ovf I S n mA 1 NO. Orlrtn ISPEtIFrI S DANK-Si NLlT K II f` . EDn .:. cm L um. --?F? 1 cwEN nwnK Fa 1 Dric4Hl S , SINIf1 LIGHTS UfA / 11-11SFI ' HI r1 °• 1 GTS U IIEFI' . OlI 1. S } U I.... Ir?- TFSr RE411LT5 2 - - I M F 1 tCNVI /? _ /] vIN1Ir A. ' ' M Wi - ' ,?-- ], ( A II:I II J NU IN.IU Vr. 4FFNi.O IN O IINU UEr?L FI,wVLPwNA , n, E I --•NI_ „- ?s_at 1pL,1 ,! Liss J INI,i I s? MICROFILM CERTIFICATE COUNTY OF KING STATE OF WASHINGTON The papers and documents appearing on this roll of film were photographed by your affiant and that said papers and documents are true and correct copies of the originals thereof as the same appeared on record in the custody of the Jefferson County Clerk. The microfilming of the papers and documents as aforesaid was done in the pursuance of, and in conform- ance with provisions of the statutes in these cases made and provided for as they appear in Title 40, of the Revised Code of Washington. I, the undersigned, do hereby certify, under penalty of perjury, that the above statement is true and correct. S gnat4 Date Northwest Center Industries Micrographics Department ?r„r, ? Ts?,? a1 r I d h F ??J+ i IJ l ; J ? i '? X11 ?1f. t 1 ? i y 4 ' ` r