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Home My WebLink AboutReel_0024A fix` h , i ,a `: _'s4 ?Et3 ..rne AaSYL' „.pgT:-s- , , av .. .gy .u a 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- ante 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. C? gna i e Date Northwest Center Industries Micrographics Department 1 ! M k Ld? ??i1' "f +t.^ ?d 3 S i1 ?? 1 1 . Y exi?, NI f,lt_ 1f k ?y a I, N%OTOR VEHICLE COLLISION REPORT NO DATrvc OF- COLLISION DAY C OLLISION TIME OF COLLISION U/•?Aj ?r HOUR MINUTES ? M _ /?,i C) E}•T'rl • . UNTY O. CITY NO •?+? i? ? }?, ) i7 ?1. an 1< UR COUNTY CITY. TOWN MILES Nou: u E CITY, TOWN E'F/-" t5n%? J; .` 6 0 or /? E - ' oM P c5 L nE.IX - .-?- N? ?UNI o N E - ? D GIVE NAME OF STREET. ROAD OR HIGHWAY INTERSECTING WNtI: SI REIEST T OR OH ROAD PREFIX Pi EO IAILEPOST NON INJERSECTION-LOCATION OF COLLISION BETW BEN STREET AND STREET RAMP DIAGRAM DATA ".1 ,. ° Lxono enoa.rno p L[roai on oen. .. no Lxno en. un °c. ??,,,,,II ETI? I;:IIoF N y / ' FT InrER " eLS perexerve[o <n°sa arpeer op noa P L / ? LC ? o ncx Iwp:rD orVL co Q v ' C] v y 9 s LLL?? PEC. CODE USE rv ncoLp lon BJECT STRUC q0 X OWNER OF OB? ' r S AME ' ? ' J [ AND ADDRESS LO CATION CZ? [ ? ? ? A/1?l+ 'Unc"?G?<rCf'T F' 4•(/"r f- i '. IN ROADWAY B^/C TEET ? LI o T-"- a "I. ou A 511 • -If"'c'!- .?/r h 11/FF. ET 1_J auac ? ?O ? ORIVE.R. FIRST NAME• MIDDLE 2rcl fle h ?'C3nr ?E• - - ;; DRIVERS LAST NAME • FIRST NI ME MIDDLE n r0 UY/11 yt?i it/?f e l 't, ii ET ADDRESS r-.AOUiE NO. AND BOX NO. ? I ? roar" u STREET ADDRESS ROUTE NO. AND BOX ND. ?/ '?Jl 1/1 (( r w6-w-C, aShiAJ[, CITYY r STATE C2IP CODE oRlvcpS /P On ? I +UO?I/l/?Cl• C.J? i? / ?e?WfS.St)' / ?0 -?? a _ CITY STATTE I(P? CODE ppWERS ACC"i an /? BE' c-?C:C??-ZV/S C -??.O ;!?L:EI ?2 r.?hn ?l U"RIVER•: L.ICEN SE `QdER',-? ST E MEF Oho oAV BIRTH AOE DRIVERS LICENSE NUMBER STATE SE% DATE OF BIRTH AGF3 ` J f •or-C6 v N o ?? ? O M F AR , Br-n Lnl-Nleh? /G>_n ? z? ?l e .. INO n•DARri BODY STYLE lx VEHICLE YEAR MAKE . Ien 7 DEL ? 9 = E7 Y OP yEH ICLE .YEAR MAKE IEREV GDOGEI MODEL (NOVA DARTI BOGY STYLE I. . /? v .Cl?-LI nr . /9?8 •Sib•ATGvo ,t-or LICENSE PLATE NO. STATE TRAILER, PLATE NO. STATE 2, lcya vY?tsh• LICENSE PLATE NO. STATE TRAILER PLATE NO.. STATE. el &L' NON VEHICLE II IN TIFI C ATION NI.II?BB MODfiLS a NEwEn1 DOOM ETER I EAGEI L yEHICLE IDENTIFICATION NO. N9bE MODELS, NEWER; ODOMETER, IMILEAGEI /9G9' G i o %G l/?V? Ala CL REGISTERED OWNER ILAST.F?gSi.MIODLE 14AMEI DATE OF BIRTH REGISTERED OWNER ILAET.FIPST MIDDLE NAME;,: .,. GATE OF BIRTH shall e ii as ii" MO JDATIYEAR OWNERS ADDRESS ,.. ,. ,5A All e- I ,DRIVERS LICENSE NO. , OWNERS.ADDRESS ., .., „? DRIVERS LIC ENSE.NO...;. PARTS OF VEHICLE DAMAGED - [srIn ATEB COar PARTS OF VEHICLE DAMAGED TEP?E?T n (Jr-51 ve- - P,e ? u P.- IV' /X-r r aE $? 50• LIABILITY INSURANCE INFORMATION - VEHICLE NO. 7 " cOY`n"O YES No NAME ANp ADORF.SS OF LIABILITY INSURANCE POLI N CY HOLDER c r[c TA "." NAME OF LIABILITY INSURANCE COMPANY., CITY r AME OGRESS T 21 !?/vfCv 3:7 r-?rr?alrc!rirc•? SeaT!/C ,e? %a?oP NAME AND ADDRESS -LIABILITY INSURANCE STATE ..:. ... ZIP, LIABILITY POLICY NUMBER. „,.-- ? ?1• ?? ) e T TG R Y r:l b9 Lqq)) .......,.-? vN n .. ,yl A r: rs ' lA ?? ?A {{ W r DA _D ATF.OFCOLLISICI DA YOFCOLU SIOI TIME G OUNIY lO Or111O. F"A ? MO DAY _2g,, . T SUN I NWI 2 iUES T'.YED A lMUP S FaI DSAt IU:K'2A Dr O URI J r / cl FOR, : COU" Y ? Y? IJ/LV :RUFpI ? "'COUNTY ROAD ?CIIYSTREET LJ S n W A DM?CLS. PREFI% ROUTEOIISTREETCODE CT ION ^`1 C l-f•S C1V ? L THER SPECIFY' M 3 !5- 0 N 5 E W ?IN CRY OR TOWN '• - W P HEFIA EO. IE POST - 0 InILEs ? .Q ? OF W?A0L(I;tt ( 1, )o ' A NAME tN OF EETORHIy Al IN tERSECTING WITH. STREET ORHOAU LL g AM1iP GIAOflAM DATA T /? ON ILJ O O Gt.!/TcR _ NONINTEHSECTION I TEG ON MD t R t v/1G G O • ACCIDENT I E SFL ING STHEEl ORRO OAD OR REF. q. CLS. ERENCE TE CCTOSSSIREET ORAD I"T I N Cy.e BETWEEN •?? I? STREET lWO ?L- MI GE CODE , / EC ? % /sd a 015lANCEFNODIHECTIOrvfflOMflEFEHENGEOR CROSS STREEt T M1 LES 5 E 1'I R ' ? n r?iyS NS S - 1 ' VICIALCOOIN6USE Ui rW l / ?) ? :? I Z FEET ? ? OF 1 I .. ._ .. LJ v ? ? HITARUN LLISION INVOLVED; f{ VEHICLENEHICLE ?VEHICLE BICYCLE ®OTH?jy.;11??? ?IWHITE) ? TO ((?? ?VENICLEODJECT / SEVERITY NO. NILLED ?VEHlCLE-PR TRAIN L.iWK TOTALNO V ITCC II ?STOLENVEHICLE OF VEHICLES ? VEHICLE-PEDESTRIAN ?NON'COI.LIS:ON ?HA2ARDOUSNIATERIAL ?NO.INJURED ?PflOPEflTY OAMpOEONLY OBJECTSTRUCK INAME OFOd1 EC T STRUCK-1}jJ?? NERSNAMEI LOCATION OF OBJECT STRUCK 9 YI ES.DAMAGE E fd/, ?' ry ? ?V'-?Wpv ID cEET ? ? 211 ? F00 EO1E 0 DRIVERS NAMELASi FIRST MIDDLE -YER SIIAIac..lEt fIgST IAOOLE fb.?r.-.Si ON P'.IL•r 11 - Ur.LL, L1164 D STREET FDDHESS ? R I STREET ADDPESS V E Tz ?X SJ6 V A CITY STATE ZIP CODE PHONE N0. ? - ` E R CITY STATE 2IP CODE PHONE p0. t!/C C•c .vE a? 376 N D DRIVERS UCEENNSE NO. STATE Sc E OF GIRTH D!A N FRNERS Lic-c ND- 5 ATE 5E% DATE OF DIRIH • *-I6I C -)7?? ]p / O. MO. DAY YR le :15000UP FIRM NAME ORIV1 PHONE NO. AR.N J 2 CRIVERSOCC-101 111mNAME PIIJNEfFJ. PA } ? {•? ICTL ` ' O IIV .1J • CODES > IJI c sT ? '1 I SEAT CELT Q EI EJECTION „J CODES > ?' CiaSS o ' SEAT BELT Is' GECTION NiYA.1uR1E. P NATURE F !!??"" n S E INJURIES _y REM1fOVED FR M NE BY: LLIA.1 TO • TfTI-A. FRONT SC[N E qv TO VEN.YEPA ' A1AK DODGECHEV.I MOOELI0ART-NOVA1 STYLE 120R?CONV.) VEH.YEAR MAKEIDOOGECH MOD'L10ARTNOVAI STYLE120R.CONV.1 v 7 D?? ?/LIOUAC' 6.. v E VEH. COLOR Mc. iE NO. Si TE TflAILEfl PLATE NO. STATE E VEH.COLOfl VC. PLATE NO. STATE TRNLEfl PLATE NO. STATE C VEHICLE IDENTIFICATION N UMBEfl ODOMETER C VEHICLE IOENTIFICATIOe' NUMBEfl OOOMETEfl E NU ^ r // ?CJy Yf L7 /T D d r Y'G / n (G E ®`` PEGISTF.flED OWNER-LAST FIRST MIDDLE flEGISi'cREO OYIN R-LAST FIRST M;ODLE N z ? N Or r/I E J?/ D ADDRESS OF OWNER . AODNESS OF OWNER ? Z NAMEANDADDRESSOFINSUPANCECO.ORAGEert NAME OAGORESSOF rNSUHANCE CO. ORAGENT CHARGE C ITATIONNO. ENFORCEMENT CHARGE CITATIONN . ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED eaoes _ c w 5 SE% AGE STATUS IH opA ei L,SV N[AT EJECT. c ,I p RAMS: C A DORESS'. .d+TryFE T 6el I 5 2 L 1 U N P I ATURE OF L EMOVED FRO.N NJURIES. PCA'I h1T A' CK ?I LIME BY A N AME.: N T A S N DDRESS FROM11 UUg 9OF 1 N E ?v: •FF l TO •I T ADDRESS' N., -- N "NIT nED VRD'HUM E S ADOR-Ss E NA M?It s: - - 1r L3ta?rtal? --- s• 1• r 'r . ' C 'O TC E1 (?7 '. +t .. O J`r U d. T0. D fC :l, DSO. '. JUn'/ Jlis G S Ui C A. E I1 tF-s z D O P T .'MC DTill r u?D n10 TfPi I T rG uC _' iunr E ' 1.1 tNF A ..:i 1 __` S 9 U 'U rGA . . I NOTN'TTALLCO NOT EJECTED 2 NOTIV USE 2 TOTµLY EJECTED D USER O. NARALLYCJECTED A UNKNC'Y.N U IILY01 RIF S GFAt ULLT FALURE EJECTED G°fi I f t"N? ,..:. k ?a ne F x 'a Ye ?? ivuom ? x I kxrt?• NEI 'VEHICLE DAMAGE cHnox 'iCLTHENIMBEHOFEACH INSTRUCTIONS: EAflEApF,.EYERENT vAGI. - DAMAGED VEHICLE NO OAMACEDAgFA E:E FM -oWISI TO$H0 FRNCPAE tFF5GIGN OFlollm ? t DAM.1 IUSE! IS SPACE FORSKETCHINGOAMAGE TO igAKEP5. MU10HGYCLESEICI O? •• - Ipool 1 DAMAGED VE-HICLE HO. 2 d ?? •1?a+I?/JI-; 'C((p'? 10N y rUi 5, Trent '1 'o-Y "?-? E? I- IS 1boU 5 T Ysf.'f?ILNrr) ! 19. UrC rI Hool ?, N ..fP`'" wcunnae ! ?U1 E•" I5. )rust 4? s`t3F _ SEVEfl TY OF UPAIAGE: VEHICLE NO: rl Ovwrum , t i 1-?"?-?j'? > rB Ur.fwrrr "Y IQDISAPLING DAMAGE SEVERITY OFO AGE. 10lHEN VEMICLEI IY.O.MVn ?k1 r ? • ;+ ( Z FUNCTIONAL pAMAGE pQOTHEgM V.pAAIAGE 1?DISABLI:O DAM AGE 3 SF?./ERITYOF DAMAGE: VEHICLE NUZ !!'a '. <?HODAMAGE Z FUNCTIONALpAA1AGE A?NOOAMAr AMAGE I pISABUNGOAMAGE 30OMEAM.V. DAMAGE TOWEp BY 1 .. - EST pAMAGE _ 21-I FUNCTIONAL pAMArv I I I I I I AW ARRO DR lc NORTMINc -I 1 11 w p FAO ow.r _ .. u COrvmlcrlab"''I x O I ` - I 1 .- "- _ A r ? C>G - ? C nrroe EPdMCn S SHD FE ern DUfeCrEDSPD„„rlMwµAC°° °q ,?I t r ? I + 1 I ,; __ i- r r - 'l 1 T ! -?- - r 1 I , i_n CauroutiwE DES DES ` x `?- -- ?- _. y_--- CRlP7ION OF" C / + I I I I I IINOICATE IVHAT PgpA' B I OLLISION +." DIGA&UIY.RE000EO VIS S I HBlllW.APPENPrDESBHIAN CLgTH Np COLOfl CON9TPICICRONIOa EP j OTONDIAURAM,EG.GRrVER I W A R OgK ETC. ? r K r1 ---- - VEH.??-' MEADEDITION BEFOAE CO LI510 ;?; , - - x PED YES WASUGWG: I .NDEW,;rc •,f I ,.-? -.-. .. __.-.- .FPoM____._w.??•N TOt Owl ROAD SUAFACE. WEATFIEA-18MO11LD4i 'ems Mx _. icrosag 1 °E "" I?O IGIECrc G+4 :.. CONTRIB U71N0 CIRCUMSTANCES N01tE rHEn G4YrNx 1 E CN4 dNEn.. 1 GE NE on,rogEl ::. ...:,:r-WwEN,£gIGe AOTpy, . 10 EAx Eq. x YFgIGtE - MP9°ng [_l,'1 l ?'?7 on 4 - nr l <tG ° xx? NO -x -.L AECGIOF 4.CEq' _V L-1 8r°pWpW.IOMNIEAD wer E L uND ,!-'t uN ?uIFwENC ?? 00 LosELr ;°L1 ? Exi wMw , I?? aWnAwnG l ?- LJJ ovE cE,r En r; .._._._ .:mr No .14 AFF-111 5 »c 5 r- T .1 AStEFP ' a- npwE D- I'° - -. 5? srw ° ` Fqo --- ?- ? l_ J 1 MFn (-'- E E - LJ A ?-, EE?ONM C-./3 1 a m or J _ l J DE o f L'd-: LLNM°N°mr 0 E IS GFYI OVE lE OP OOllogr { ' 1 f('?-? _..OR 1 !C M "? .gMfA - .. 1 r0. ?.d.r r__- `I ° L SLOWPq uu x EIGHTCONOITIONS TRAFRC CONTRDt P .aruL '° E"l'•`elen ICNEG<ONE ° Ye?X:u vEwc¢';. TYPE OF ROAD VEHICLE COND o "10L`n r?! f OwEO FOR S BA <°N. Tl o IETY. .! 1 S,prwe x? otE w,oNE DH MO.4 vfNGE ITION NO x l+° F fEDr° I1q. ] C tCrc ON.1 ? ° ?,j CN lr?oP Sq?'4 Y °° rF51 ? - ArLIG -1 r ] f ? i1Y0 " F rIVE ° l-: n?Ob?WAy W I ?' { •' aa. ?,?_R InE c ?- _ 1.. .. ... ??10?.i rsrnuA^^RO Lwe 2 -J, ewx 1 r ^owD grH,wE ; r ci- Lws..w ..'..? ..') .. ° .... ..-.. , I?l IENFEm.o x ? EA e °ror o i rWO E.r •_ 1 w°°"'m _ Noy x ar vaeNn.ns a I U 4 . NAN I f9 NCNREp •?-• - DMew , _: on CHEM. TEST .-- „' rRFl UGM9 rK?, y' •..I rcI°C40nEI ... :-1 ._ ... emAwrto .._ _ E ° Or-ER ._'. - ... l__ n orveN omegISEEGm rc nrsECSrn - j rau Ena -' TES r uD 1 k . ar ?C uuwyED m?nl5nlty».. wV.Srf}Srr,OEA.rIGq-S N,ME.nwc lvc w:er6.r.lo?ro % TESTRESULTS 2 Ani,IV'io ° fwrv w erullw0ar? p eZ-7E°lu.•.t OaENO -lM.r --?-•. uMralhu%' x?OE'o Mw o-s•sxr roof nlrogr /!~IUVnort°er / HM•-_ wre 71 _ nsrn:BUrIGN GmEVVU rrw « ....... .... ........ . _ n••ilY? - 'V FrN ? lf?l 211 i2. 4444 I`?TE` L N 4 1 4 S. y^nrd - .•. Na 7 I s a? R ?vr f? ?.u x a? C ) kw , pp l n I?? 1,T1 i t? e co s I II of us3o LM Is clTr N LO r n- r PrGFe 71 c n "Y ?? TY .T W M IL4j 42S ENE OF i ?,,. E,?I_-E TREETC p0?60r?H W-fwx??l-...-„"?",SEGTLtrG,? --?_?.-A_EEG OP ,_••- R FI% F0 L P J I NIN INTERSECTION-LOCATION • C7LL3SIGA BETWEEN { REET STREET AID ST AM OATA r Q E? nNLxv.u cnvaal,w „Lro,r ox ?ue,tln ,v uxv..... aw. vx.vva. I IN I NTFP C13. _ [[ • • ^' , IN [c OO ? ? m 3wn..c1 C ODE USC Iu[ V -. [.¢va x- BJECT STR C ?.? {. _ ,_ e"i[cr _ -?? _., )VNER yE O_ 9 r E AN O _, v R GWAY,j -` . - ?? ? FEET ... .. w -: MIDDLE. , DRIVERS AST IVE }AST NAMEs..u,..?.:.:o.IF,IR9T';JIAME..:;. ..e ° torr wx.w,axa __ TR ELr e_s-,_ -.....:+. ... ..'„ ou a AnD' x no I.. _ r?n.rcc. STREET' O R_ESS,„t..?,i-r ur?.1..lw.:i:?RGOTLin t P ?o ¢c 3G roar.ww ]"T?.:::. •rWy-sT TEJ ...•.._,h ?Z1F Gaoe O VE 'OCGUPATIOH CITY;e,y{?,?:?..-jy aT..Te .-,L.yl;;-:;a«',zPR CQCIE ,OAn(EAS:?C4UPwTlo . ORrv• E _R9 CENSE?I?MBEIi ti?y?a STA?? SR IO.SjE_Ofq I_R.TH EC '..y ORIVEPSy1CEN5E.?MpfiRy ST_ - aEk :OA?EOF BIRTH, ;A06 1 -Y - L- 7 7R N ? cxNit.Tw MA. ?(, r.•vvov[I M'006?'il ?r-vw^rl BOnY^LTYLE?{ 1 _ . ["rcccrw_ MANLy2(w[v??vvva[ MoOEty;liav, o l 900Y'S?.??2 "' SEPLAiE N0. - [4?'y1TA-iEti,^:% •T-?SAILER-FLATE'NO:+ Amy wU_-- Y :3. _._. _.,?u E:? - wiS:.'`ZATE'.,?:..av .._-...:P E. 4. Ar5„-.TAj. '. S 5? VENKIE IrlENT1F.?!?ION XO..?ij„p0' .,_d w"!Y?!1 OOOMETCRL '._ -... €)BCI:E WFNTIFKATION,R_:?J, M1B--, ..??x[rtPl •OOMETEAIMiiEn°[ T-•Ilno¢l`"MV,I?,}'T., OR RS:CKENSEN '. 1'. _ PEGISi[AEO.OWN[N'ri1+AwT.1 ° - _::;REG)STEw[?WIj-ERr.I _?ludx[?l v'?^ORIVRIf?LICLPNS ` / ae lar Lfi ?- L-0/ 7 41 lar4 . GwNEw?ooww?l.t..N?-_;I.°.rAn{«?,+,?..;.-., •.y.? .ow?Ens_nowaassi..R ? (1 e o i03?/wrx rn l ° n. .a. .. :o?.v5}!1G¢F+.'B0.!iiSFf"-•-. • n 3`:i , A.., :,rte [a cmn..:... Mw?rulfet .:£C5Lp?4FJ!En1445.AAw?GEw...-,.- c r 'tr,_sE,.!ucriB_ F,p 'IC. $ ra nT t r am LIT LI BI TY i SUR CE INFORMATION • VEHICLE NO. 7 - COVERAGE IN EFFECT FOR TH SACCIOCNTON YOURCAR YES ? ,NO t AND/ID ES'3tN,rV BILTRIW?SUwANC Y -IC_YNOL .MW"- FLIAEII [TIY NSUPANCC CO-rM?PAN?T^+, ^yy..? • _ - - i .v n[ai Cit[ sr.T[ Nn I b ^? ? r7T }c ? I? P F. AMO ADOwL^y6,?,,,•?UAB[IdSY.INSU? IWfLiAGE O[Y.':?i:•V•C3YL? SI.?s .Ssa+3J.?aY- g'+{'r-LEU[BIGT%-GOYIFrX'N--".I?ER-:h -. '( 376 5 ut ? ? T I tSc?? ?? 1 1, Ta?or_ rr r f aS Utai ? "? { Y AGE 2ND. rIJU? "e iail• P_. rY=N'? ? i ?O- -.?j ...AGiil'.rut "'d iE.:l.' ...,..+_ .'-:Aakr.NUCxrt. .smc+mv.?.'_ril?r3iS.iwn[L ME ?- ?? NAME ? ADOwfss j ,!-F i-4 AoORE33 M x..v.f ..A ? .u 1- A.. _ ?? { ST iM1SINwlRSDr. vv[ t75 : } a.wLN l"?.J .??5 a.1 6 O1 p7 Q` ??iH[wrovrrT[ IN LIFE ?irsiA US RFC Cw G MARK ORI S{S?ra T ?f[.IESI - o I?u 15 O[,. 6O1 O HBTARROW E y.° g N.w,.n. ... O\ a6 'DESCRIBaABµOVFW"AT?"^AP EOu-WRLiER YDYVL?ISC{E B S-I ItlP?R?-i ti'n' l7v f?D-I-n Fpa a-- _ LtL? C?_a - q (1d=Chera_-.L _ SG7erve ]. nNw w . [N .w[L[ J ... 0- CEI_ A— A. , 2 -?Ji-- . . T T? \L VEIi ICLES POSITIONS BEFORE COLLISION INVESTIGATED BY Ht OS 6t O O Y RARE O" ¢[? ac °roU,Na[a" Y El [ LlC N S V x f5 Q `` 1 rvoun, ????? f r•'Yf'." ?z ,{" - ?. .? s ?."t? ?ww ?wRl .r R" Drxt , .EDt=t. •.AOO?.? CON n. 4...:. . ?.. .Cw..IL. .CPOFMMG Qc FROM:y? IYTO _1• ;°.. a x ?_,I" ntDE"I?I,NW,tI„I"G n. . '? ]? ]d, A?[: _ nO.OSUwFALE „y`wt T LW TGONM ,QrIS.; T uiLL wTwoL I TM1 •..._" nrE Or noA?" x[c.ex? ° 4iwliLi? ?c?c'?cTla e'L:i^??I.ow. . vIxIKI' f ? -? o _ ? ?11 ? ONE WAT„I ?'I ? GOING f,,AIOHT AREA O, Y.r ]•? I ?l a 1 ? O YLIOHT ? ?]pIGNALS ?, ? OR? }n NU ] ? O AWN ? ? STOP SIGN © ] ? TWO WAY ? ] ? OVERTAXING ANO PASSING 1 ^R VIR4IRLE C.I El wIT TC, SNOWInG ] ? O ?j ? IN—. SIGN ?] ? OAO ? ] ? MAXINO NIGHT TURN r n i"IEt r_? CIS" NO RID :"L""'N ANDf NAMING IEVT'TURN _I SNOW , n FOO " ? nN ?? a I _l F ? a E] OOIIRAMn3 C] " ? l [ L r (' ? S 11.SIING ? S ? ALLEY ? S El NA"INO U-TURN IC7 1.,? GC S? S?,tCIITI S ? O 1111I.T C pLOw3no C'? A 1. " ? " ? LN, rl E] A C] rt J l .I. " ? • ° cN _ I N+n j %TDnPtD FOR TNAF/IC +4ON ro j'ftll OnAN4lR^ } ? fn 3/• `_] 1 [-] of r3rcN /II ROMAN ? T [ c ..?..... .. e.,...c. n,. Lr I ?.] " ? i,Y,".r- C] " ? onsrnn alaam, L -------- [] I 0 av,w,Ttn f , r f7 • ? STOPPED IN RO OW U } l? OVIOCO ^ 6TA TI OM J ( IG? _.-_.. .-? - ' 1 LANs f 33 .°?v nrn 3' ('-I fn I +I-mRA ? T-1,: ?'?NRR!0.E..M.IPYAM1P?pawQW4?MPIR;.SttNkIKNT'f??'?+9F1R :.-n9?f'.?T. A1" •r, v'M'MI':l`}, .N?r.MRfil'P4 .IIIYFMSA,CW'M .. ... ARiR.,FN,. AM?SRARRWRS.M?YIM? G .? 'Bosom rt3• 3 STATE OF WASHINGTON PAGE UNIFORM POLICE TRAFFIC COLLISION REPORT of No y f .L CECDIU•uNn.wnBfN ---`- - J T•R. A OAI EOF COIUSION p4 0l LL I SON- - ? -_- - I - _ - COUNTY NNO / CItYNO - _.riyyA € O 5 EU M Sill? p,Y MY R rH IUSL9a GDr.UPI L.BN,Y 36 ]\Y 1,nEP? ?SIATI POUTS RC.UN TY NOMAD II II?CITY GI BEET Z O N ADM CLS. PREFIX E OR 5I REET CODE [?RIUT ..? A:L S.C NON (5 ??II L O C ?C YOPTOWN J' MILE ? N ? N OF. }t _ _. - _ LU ED USI 0 7 3 A NAM I NO.OF STBIET..HIGHWAY I TEPSELIINGWI,H. 111111ORPOAD TELL- .AMP MERAAA DATA T ON 10 . . ° NONIM1'TERSECTIOII ACCIDENT b +lE. NO CTS 'NEN? TINGSSTPEET T CH .ROAD OR REF: ° N IT-EEH 5IREETwD }BEET MILEAGE CODE DE ? sz s o DIST,ANCEANDDIREC O I'll-REFERENCE ENCE ORCHOSSSIREET ? S SVECIAL COOING USE -DOFEEI ?omo .fH ?ek- Iht-Ar-Qc roh , ? VEHICLE VEHICLE ?VEHICLE 81-CIE ?OTHER IVIRREI ?nIl6 RUN COLLISION INVOLVED: SEVERITY NO. KILLED TOI AL NO ?VEHICLE .ELECT [:]VEHICLE HR TRAIN ?STDLEN VEHICLE OFVER,C ES 1:-? .. NO INJURED L ?VEHICLEPEDESTRIAN IS NOR COLLISION ?RQAROOUSMA,ER14L ? PROPERTY DAMAGE ONLY OBJECT STRUCK (NAME OF-ECT STRUCK AND OWNERS NAME) OCAII.N OF OELLCT SiHUCK EST. DAMAGE S E ?ROAp\YAY FEEt ? [) 1:1 El .D. EDGE S DPIVERS NAME LAST FIRST --- - MIDDLE DRIVERS NAME.V,SiFIRST MIDDLE br BICYCLIST ORPERLSIHIAN CHECKIG STREET AOpHE53 11.',`x'' - C I STREET ADDRESS E Y `` STATE ZIP CODE PHONE NO. ? E CITY STATE. 21P CODE'PHONE NO N O, DRIVERS 4C O, STATE S ` , K EX DALE r( f l^1 ( O N O DRIVERS LICENSE NO. STATE SE% .ATE OP BIRTH MO DAv DRI4EPS OCCUPAII.N FIRMNAME PH.M1 E ND. C?ri< uti'S?LE\ `JL, 'Z .-ER5000UPARON FIRM NAME ., PH NE NO. C CODES > I]l CLn55--- 1AI SEAT.ELT_ I`-'I EJECTION CODES > JI Cin5 5-- 1°' SEAT OELI_ I!I EJECTON -___ IrLUP ES F? , C JURIES F EO MM SCENE RY'. TO LMOVED FIROM ECE NE BY TO VEH yEytl I GECHFV.1 D M(IE IDIO MODELIDP R i N OVAI STYLE I3yD?RCONV.I VEH YEAR MAKE (DODGE CHEV.) MODEL IpARINOVAI STYLE IZ DR.LONV.I . V A r ` • t.Y y ? ? ? ca. Iiwh o ?J V E ?EAH?COL LTC. ?/A?,E N0. STATE TRAILER PLATE N.. STATE E VEH. COLOR UC PLATE NO. STATE 1RAILEIT PLANE NO. STATE C E VEHL IGENIIFICANON/NUMBER ;.... ... - ??/-• I L 6110 L nICIE IOENTIFCATION NUMBER ODOMETER ,. ,... .. N. :RE OWNER-LIST FIRST MIDDLE H N RENSTEHED OWNER-:AST. _ FIPST .. .. MIDOIE ' A?•OFl CB - ??(??`?_. 2 ADDRESS OF OWNER NAMEAND-CRESSOF INSURMCE CD. OR AGENT VOA AMt ANUADDRESSOF NSURANCECG ORAGENT ... ,.. CHARGE CIT ATION N0 ENFORCEMENT CIIAHGE CIT?N NO. M. ACTION ADDRESS & INJURIES OF PERSONS INVOLVED NAME coas ' D , SLY. AGE STATUS ? { EJECT. _ CTA C ADDRESS u r . r+ ILRL OF ??•- EMO Ln FnoM - -_ DRYS?? ir, ?.tthSSGC? <yss2.LEN HY ,D NAME T ADDRESS' -- $ NJI NfS? `R'.fl Nf TfO ff10M i0 N W AME T T T ADDUEss I N {noEn }o uRrts _N, BY S NAME S ADURlSS E I IS NXIZLL?i N_ t o ISIA,US H ]I SL AT r•OSrI qN JIINJURYCLASS JAI S[AI UBLI ISI[Jf CIKJN C Z PAS..^.f-(R ] Pi D, SNKw A RCYCI ST I s j JOT ( O TION R OINJURY I Uf 15C[ C ] CIA. ON AIR L S DIIAULING INJURY NOT IN51ALLED I N0Ol EJECT FD I: N(1r+pSAIIL NG t r10f III USE 91 I'L J[Ci[O IIWUf N111NJURY ] US[O D P Ri..I fJECTfD D E nfR 50 b.114sS I U O Olclc,EI bV0-tON KHONN LCD IOSRII L I POSSULE.N- A LINK NOW:+ l HOW1111 SR[ATIf 11 FAILURE LECIED 4 Y 1 5 +ASF(r ti ?fp? d ,Y?? 5 I- f-.C VEHICLE DAMAGE INSTRUCTIONS: ' ' [ EAO sr r [sl c I ` I1? .I ] IT- ARROW b lOS.DW vlurvCv C"AL U f1EClIUn OF FWiCL-_ ('? ?iL«. -.-r DAMAGED VEHICLE NO. 1 us[,H SSPACI wa s+ll DAN- I. TUw-S ° „nCr«FS [,c OAM11AGEO VEHICLE NO Y [°( 0 L 5 T UrT ANNIQ VFHIC E tIO-AGE 5AO 1 DA' . ouxClLO .OOp BLInG DC GLF OH UP-, 1 -1 AGE TOWED EOp DAMP pAMAG[ s I ` DIAGRAM OF COLLISION. -DRAW ARROW SHOWING I -- -I? ^:-- ) . NORTH IN CIRCLE .,. -.l«.,E.Ap..Slr.nA, Dr prnn.ps r . ,AD...AR..aIYf.alpP _ _i :.f ? ?,?` :_. __-_ _ - i •? ?? D.r,LATpLH.DN _ T- t c A DESCRIPTION OF IN E EICATEW vx E 'p E c Ar H .L f M ° u D ;cpwvut, COLLISION s [TV, R EDUCE D s IL $TV. PE s ANCLOT" COLOR. ?A cos c G D E o" I JT'Cf _ _ S ?, + 1 t ! ' t e bhp E `. ty p ._.__ L\. I? t>? I. T ti I11 t -Ara ` - - tl, xo POSITION BE CORE CO t R E,sION IN eII NA NoN uyr re ICEF I WAS _ E DED ,nE OH NO ^^?Y E nc ED OCCUPIED 5 E. -_ ? ,FJw I w 9 ' - aD Y Up, 1EI C? NO y9y ? / ED CROMAR[ •L tt?om?', 0 L_' YJq.}(?' - ^A4 SIAl. 3, Fit EIST AS USING' C SHOULO[R r? CROSSw 4 E ° ]r _D • ?' " °t H CDSKOANFACE WEAT DER. .. ... CONTRIBUTING CIRCUMSTANCES: J lDN ,E n-I C.- AE, p.- x oREI r o - V[?w,4iLEAc ? Eq ° « I? , ` Loup CLEAR o - 'Eo UNDER I A I LJ ° s E D G pnr _.- -' J o 9LASL_ ALCDHOL _ 3}.L45E.4_. D is c L_ b ? { 'x ]L. K vasslrvG I 0 G5 f 1 , 1 ( ? - pl i - '. ?`_xOw I ?I O ixc -_ - 1 D W FED G ..._ 1 ?? d O PARR NG LO ?-1 G nN h cfT - J 'T . uR . . - a - -- F C D -. QUIP Q IP - r- - . - _, I N 1 3 'N "G11 S SOW xG L_ 6 -I NF O 1 A,FIrIPCA P ] GN.•IGNAI O NOVOLANON YI. ' .1."] 'rlCr LIGHT CONDITIONS RAhFICCONTRO TYPE OF ROAD O ]C - VEHICLE CONDITION SOOfl1ETY. D 5 GNA t CNFCA ONF ,MO- ICLC , . EC °NfOR MORf V E QQff 1 N0. ]EkCU?III??UtLDI FNO ] F ICH[Cr Ox[ . 01 STDP SN n S, ?, - I YsDI i SicNAlS ii S JNa __ : f ONE 'AY ..iwU -.4 9 ASL t7 Hb. /1 .I P IRk0. w i ."PC. S x rYDT Y AFI L C r " ] D wN L0 1 n F .A .?I] -_ . V 01 _ ..- [ D GM S tY N TIMVAIIIFO „1 M YfD?US 1- -.A D -.. AS.RNC N . _ . T - DE resrvF _.... . '} r Nao'soAA I*r F c c [Fl ' -; N N .IG ALIP_.,- IE , rY ..., ...,..-IIL,II LIfn15 - wonN .VH - ? ' ' T nrl'ICI ? i GHno .. En _._ La ._. .-.... V . 1001" ._ _- O N n f ,6 RA<NIND ? u M. 0 CHEM TEST ] '.,' , a\ °r«i i s nn'?[- _.: .... I I 1. 0TIIE1 .... n rs h'AK s E s t ] in N 5 .. .. DvlucO .. N OF k T :. "E I ,. `. O S ' I[I V.lp \ ] N Is•I Crr TEST RESULTS 2 E514 O J I1 - O llcl n+ vI"cl A Iv E? IVLIU C[ D C r LUw R. vrsTlr NcD N. F c P , [ Uu, na a T i -? ITI? 1 Yr ? ^' DISTIiIUIHIUN. OIIIGINAI CC" 1-1 IO WASHINGTON STA T CPATFIUL -OLYMPIA, WASHINGTON IIRSW DUPI.ICAIL COPY LOCAI AWfN10RrEMErIT AG[NCY'S COPY-Tf11 PLICATE COPY: IrIVESIIGAIOR'S COPY. I d ?? R a m ? ". ? XS??1 f ?v,? t,l{rfl• ?}_ (?'7lwvr?A,?y?,"h"' I .`r 4 1"dJI ? t 7.J q 4#?•p. ?l. ?, _ Iet. _ ,I f t ,t f I ?? la y 31 ??? r 1?Z Y I I '' " R f 'I 1 : 4 L ISIDR T / ! - L L J J L b PM -.._-.- OUR t NO w? `- // G / G C T . L? r ,TT, {f1 U I_c^ -._//-- ? ESN Ic! \CrcG CA lG/ 1 _ cos }; AV- Aj p ,!To U!01T O . 4 iE S R H G T.? -., r ER G w1TH OR AO C? PR Ix EO ILEpOSi r - ?' GNINrE AID ° DL , ? _ DETwEEN a c ,,,__?RA" ANDI? ? ,Arl'' Ft- g? l s n j ? RANP ALRAH DArA _! ? ON .„ -- - OF 7-LIZ PI,,c c 4 jflrc.[ 5 C] a u•, r cWr'? E[ o ? INIE. ? ••? N1_ n BLS: d -?^ : [..K , ?? ® ? « va,aoP[o??*, EC.LO ?» BI>.K I >r• bj/,1r?_ uEE ?„ •b...,K oleo a --"-? DT RUG ?_' / 1 W DF CT 4 ND WHORE _ HR LJ H l`J I r a J L5 ` L n n w g? . DRI E LAS NAMb•.y - ..? Fl W •. ",? Gill E_ J O IVEHS LAS E _-. - IDCL_ e. Ef'' C'!' I??V n N E k: REET AODH ,wla: ,? - O E!' UO O. } 1 TREETA O E « [ro»,,.H /J pp E, coo o v.. NOCCIIFAT Rs occunATlcar; - ?- n RIVER. CENSEHUMSER. TE ° A fi Eq Eq DF' S " 7TLR-1?9 16 ar 74 S3 ' _ AXE ' 1wRV: soot 1 MODEi- BO Y E' IT a ,I ..r ..,...-?S.•..L?.r..? ., -. 4 PEATE TAT T ER' PLATE _NO_ t T4.:_L. - E E PLA E ATE 4" '?'(RAILER?LATE•NO? _ ?5 3E/ ? VE EIDfN R: TIO,. MO I _ _,-HO,x _.,.. 1 O ETEftl«I•.• [ - ?- VEN EfOE T ATION.NO _?,_ eB b sw[w ODO.ET_,-. ?• 035?.Y Wr .«1_ 1D '-.1,.?/¢.• .Y:. I- RE TEAED° ?( K«,••aJ 1.! ? , ?' , /? ? _ - RIy9 ? 6• ? .«.owc.•ury[I ,uLfDRNE • LIG_F_N5E JiV}!I Do c -'. REOISTEREO IKA TG e!' a er 1,'e.v./v O R DOR ..,uG; farR[[r..On ,atf•tiiart?: WTE OF' TH'f: OWNCR AODRE53 DATEOFBNf--ii+ p?+ ) R ••A * PA 01 VRiI LC .. ED _?.? _ , 1CgR:¢ >. : ,o ,... w v R R. VEHICLE fiO:, e. oTb os INs R 5 I LIABI L IT'll liRANCE INFORMATION VEHICLE NO 1 COVERAGE] R N T L FOR LA- Y ??? NAME ANO ADDRESS OF LIABI4 TY UR H CI E TON YOUR CAR YES ? hO GE .. PoI-IGYNG "t ?`I? ,EOF LIADICRY U NCEGO (} _.. y c er= Y? er 33 NoY[ a x?l LLe?srt 7l6,rF j7ha HCe 9r?n? Go ' N n nRESSOr 4ueiurrH RA cE E " ,T raj _1 L BL*? 1 Vancov-vex r ? rs NJIJn "rL'.zr.-v''aP-,Y..,_- I?$o-.Yr.'iI^w_.31e:5.a.t.?ct.-t '?eE z .u n •I q, A [JO?,p/?.3_?TTOIQ 11145 1 Yti M 9E% O FE9L __-_ _. ------ -- cu - .: ES -w$u,m on /7.eo?J..?i,7?'/i+xQ -1 Kc "fir J . , c D,i H -- 'Y' TVS.Of.11UU D',• M Rf01 TOXET T PPLf4 _- TA 50 INJURED ?© MAN. ..' - - FIR T TH BAPPL Es - ! - Y M L X LLED lu IIILF',JJyJ • 1 Iwt« I r: o LED ?;y? .N •+ GH O HOr ARROW IN CIRCLE •-. .D R EBELO MATHAPPfi EO.n[FEnT .VEX LES -I .-..:.. .. _..... .._.......? . ue[R t t - .!.; , i e<'f - MI. O I I . VCy IP rR?/.I.tJ Os _'}?I.0.Vt ?( ry SO.LK.-/`j O/1( t I ?°f w r• a y - .l?r .?.. .[ .».,:".9; •11 .? n Gons?,.T DnS? oaM ..i! o ?w ? ' e?.ees on .r;fgk.. s_de e Tree? Rob s ?r per o c -- ddl..a SW efu<._'y"oh L. /-7-o OL 'o rCO )/S+e.?i ! ?y'y1 w fh.?E c...GUh1QI /Wet've ti ?'f/Y7 .7_'__w4S_.M._!.•?'... •.J1 ,T, < " <1 :. ',.' ._.. •7C i i? LErT1.It .'n.e .f.r-Ac ??nuj Ill _.G. A? ?"'?' ,. t ? AU? L?^ ( ?yI J h C r_coo% •t12 x, s ay' R17! .? I T l.?` fo N?e 1. / Rand' SILY N".OT O W a- t ?•, a rya .•..[.,,..,[,.???J?? ??ec , !' P^?en?anr{rN. KemN ?ooferndanxme f-??I ?R??z rl.; /?tbE (\ n ---? ?1, rA VEHICLES POSITIONS BEFORE COLLISION INV CSTIGA TL-O DY { Vco c4c 1H[y1u?o''cIO DN srnccr OR 3 El 4 h NO I ° HI r ? Ill 1L-?1 ? • NAM= D[. N?.l oi.? c?.. viw? ? ?,. ? ro? rnil[r [. naa •?1 1{ Al'?•i ? ?' d (( ril T ? ? ? ? L 'b .... i?? 1-r?J, L 1 l^JI ? ; FF. VVAS wtIn N o RO CC DRIVER ACry4v,1?^ MU 1 - r , C Y ' J I ? a1cvV, o• 1 ? —LIGHT U 1 ? TB GNALO ? II f] ONE WAY,cI II ? GOING STNA GHi ANrna ? r r ?y9 , t ?" ? nor T NA NIYO T L, OAVVN ? T CJ 5r01. 51GN J ? TWO WAY 11 T Q 0-1A.... AND PASEIRHL , i r:. J 0 wEr oE] s wlnc T [] nu R ? 'i 13 nc4n s cN ? T ? nrvrnn[ E r ROAD ? T ? MAKING RIGHT TURN L? S l? b OW rl I°O o r' .LA [HIND R[D -1 INifnf l• NGE - {? .?. C , (`R ?.?Cj1.?I 14 O .H `S ?'i? ?J 1 ? A ?? ILO°nIrt AHPI [j A ? MARINO LER TURN LIAR I, J ?J L f lvR f l ! ? ALL ? ET I E] MAKING 11•IURM ' i IN 11X4Te,?, n ri° Y rj I ° r?<<? •?n ?A?11 rn rGIN Y-: V1Y•, ,... `"' +wOT Bird«l o'NaER rL?.';i,`_i. [ ?? ""r./LACwA r,' r.? •LOw ND I f L I l_ rD von TWA FriC `. I 'yk I,> I j L. ', I I [ 1 . - RArrn - ? R ? DN 1 nee o AI. r t'.-}r s C: nro ro IN gofow J G nrn _j t rr?1 , i r? RD .-r ?? nvlDrn ?1O? nHr ?, It ., r rw 71177 `91%al7M. .? ,.1 ¢y x 1Y"i?t1 . . mT??/t5 4? F 1'4v ,t - i i` Ui L't (a1A? t i U I UtV ,AGE DF IVU. 1 a UNIFORM POLICE TRAFFIC COLLISION REPORT "01GE `0"' nDmDEn - P " -DAfE Of cou s,oN j7 c(Y. oNNlL .D Ho.., ? F o IE COUNTY RAD IT 01,YI Y iRFET O LEE N ACAA{? R TE ORU.o StCiION _ I C OH i0 N S FF W ? IN f {LL IX , l U ry L?J O ., 0 A? mow/ Y MILES ? ? 0 Q 93 OF HA /J CI W cD MILE ai :, C T . NAME INO OF $i A RHIGHWAY --- --- _ tFR$ELiINGW IN. bI(Cel OR ROAD ON c y - l[. O P' 1 D GRAMD TA - - NON INtEASELnON J -- + 0.1 N .n U .o BETWEEN _. C FC-?O sl EETANp C_F` ID 05TANCE AND D R T O FR 5 EE "CC""' LE GE CODE TER D X-RD INTE i EC/ G STREET OR HOAD ON (EF. CS ENCNCE CROSS STREET OR gOAD I I EC N O REFERENCE CRC 0555TREC1 [] ?MEETLES 0o(_J_L ?F ^?/'• Y F Y ? , uvp LlHs 5 ECI LCOD GUSE CO LLISION INVOLVED: ?VENCIEVEHICLE ? E CEBC GLE ?Vkrl Clc -Cl -_? 0 RI WRITE) - ?HI1 qUN DCVER TY N IOT OF ?VCHCLEFAIRAN ALIIO VEHICLES ?VLII,CLE PFDCSIRAN O MILLED ? tO EIVENICLE NOINNRED ?NONCOLLSON ? HA2 UO SMATER L PR 08JELI EIPUKIWFOF O WkCT 51R1LM ANU 9 O ENS IAMEj __ _ ? OPERTY DAMA GC ONLY LO`A` NOFOb1LC15TFFCM '.?:-.. GSiOAMAGE '- OWVERS NAME LAST- - - - FIRST .. i ?ROADWAY FEE ? ? ? ? OD ;, MIWLE EDGE 3 U aEn'S NANEwLAST FIfi$f MGDIE-IT BICYCl15TpRPEDCSIRIAN CHECMTL R • ... . . LTREEi DdVESS -.,_ .. .:. .. -'?'. R .. .. _ STREET AD.RE55 V E I V R GTY .. .... :. slATE- ZIP C'OOE PNODE NO. a ??? E R cRY STATE 21P c E.... PHONE NO N O DRIVER L STATE E% GATE OF b R Try N pq'.IERS LICENSE NO ST - • , AY IR Q l A . ATE ,EX PATE ?FBI TH YET MO. DAY P iOlNE E N N D iIYEH OCCUPAi flgM r1AME O Z pR VER50L000AI ON . iIR a1 MAMF ' ...Pn NEN, CODES > IaI c ss. S._. MI SEAT BELT I'I EJECT ION ____.__. T FF CODES > ID, nu Hr Nr S CIA T OFOF U IILURIES -d ul + L F _ ._.. CA ELT.-__, . 151 EJECTION..- _ I1 FI E k OVCD D SCENE S [/z/?rtr 10_ ` E YEAR M EIDDUGEL Evl MDOEL IDARTNOVM VILE {ONV.1 s RCOED F O CFN-y VE EAR MAMEIOCDOE ?11EVI ODEIIDARTTOOVAI STYLE 12 Un.COYVA . - C VEH. LOLOR UC PLATE 1.0 $S ATE TRAILER RLA.IE NO. STALE 11 EH LE DENTFA;ATION NUMBER - : - ODpMEI E R - -- VEH COLOR LIC PLATE N STATE IF lEH PLATE NO. STATE - L, ,. .. a7 B ? 74 °2 Y LR- ..., -C :. L VEH GLE pENI1FICAIDNI ER InUER " ODOMETER V;• E s 2a 4 / 00.7 ~ N 0 P.EGEU c REDO'WNEF--LAST MID . r FIRST- 1 DLE F E. PEGISTCRED OWE USi ... FIRST. MIDDLE AOOHE55 OF 4'/-NER - ----- 0. _ S 2 'L-I . - , _ C AV?FDDFIE O uHU+CEGO.ORaGENi - - E O JRESS Ur PiSUP4N0t LO OF+AGErvI ., C APGE ... .-- CIi ATIO O. - - L'EO CC+.CN L AiVGE _--- -'- T -- - + - -o-NAME, ADDRESS & INJURIES OF PERSONS I NVO LVED CoDES -- 5 C E.It CT: 0 C?HF55 U F IUF OF - "--" "- CS f F `EG TH, A TO ._._ _.._ . T O S .._ fp' i S J-....1.--. _._ _ W \[ 10 S _ N' y ... _ ..._ ._.. ,rsGr._ I?r - .. iu,v -97- E E I r S d... _ _ .. - - - To J I y . r $ L- --- H - .. ... ._.._ '1 ! 1 . ICY IJN C D C I A.• T t ..r C Iy I` \{ U OF T U iY I t \(` ILD?L PILL LD Lip _HV . .. .. - ... rul"T rL irlE IJI Clip I ?L `TI I Y - { F- u H5 I• t ae tN I r1 .I 5 ]NJ'I?'-: 1 PULR pF LACHDAMAGE D A.- VLHIGLE DAMAGE HARE AREA OF SE E! E ACT 2 u A Al I Q? . INSTRUCTIONS a. DIAINARROWI51TO5 Ov NCIPAEDIRECTONOFFORCE p, • DAMAGED VEHICLE NO. I 'I SE Tn, sri[ ?? snt n, NC p Act TD THA"IR.. rnu1DNCYCL15 ErC.I ' a rel, _ DAMAGED VEHICLE NO. 2 1 a Hxw 16 1 - • 5 OF DAMAU[ vLH CLF xO.f IEOHDT54BL I: E ] OTHER M 0 MADE ITY Or DAM IHER VEHCLEI 1[I-I pIF c AAIEAG IOF a n OTHER M V DAMAD, L ITI .1 AM. VEHICLE NO.] '-: Q DAMAGE a ? ONERM V. p""" a [] -N-DIIAL MALE F I] ND ?ONA. DI.AlL A ? NODAMAGE. ]] Q FU_ ] ? A [] NGDA-E (OwEp BY I A I --"- -- TO 'Ip F .PAGE r0 -- .? S F DIAGRAM OF COLLISION - 1 ( DRAW ARROW SHOWING I_- NORTH IN CIRCLE L NVSV,I ,Lr„ coxp noes _ i - _ -' u I ct P„cx coxs,xuciloN ] LDC„t(xpn,nttro xT Or - i I I i I :tan v(x cLf. n[p[:,n ,N aP- ,,, - _ .a[a,R.x..Tx,nllpxl _ ? t r I I i I ION OF ION NOT ON DIAGRAM, E.G. DRIVER BEFORE. DU"rNG AND AFTER IHLCIASH, INCLUD AT LT eoueEU Vaveaiir vi ° osnln AIR WORK COLLISION COLLISION a ' ETRInv ctoTV?NGco-, o,5Txua?pv.on Rrv _ , ETC.) POSITION BEFORE COLLISION E ED nT .FADED .11C POST "II'EA5ING N sl EET ON n GHwAY N E OA NO O s,FT EGALLY E INCREASING DEC IT F w I .. ..___ ...: _.. _..... i..._. _ '. ?. PH ..?. ES NO YES ND xTv ,o..r. KED. AL.N ___ _.. .. _-. .... C N .. ROj -_.. TO ___. ' E PEDxCY'CLST /AS USING, 'SIDEWALK 11-AV SNOV DER - -twALKF ClOSI.ALK . ----E I0T ` ROAD SURFACE ICNCCK ONEI WEATH ER CRECK ONE' - CONTRIBU IC TING OCIRCUMSTANCES, ,J NE y D, E .I Ilt-1 , ' n0: , NO ] - -NO rvE. N0. ] _ ? ?l I Y a, c' _ T Rv '' I FYET ' .. 6Ot LACAST ] FAKI NG IR INIIVE .-' COHOE. ] .EP nFLUt OF 'ING '' ..4CL 05Etr, .E CF UTE ND [D V. _5 IA r A Ar nG AND PASS NC ', - AKINO I INC. ...-__. A' ICE ] SA-1. .. ... . FOG ( G5 TFO i]' -- G [ 5. ••',A SAIL sP[fp. V IRAN . A 1 'IN, -_ 1D GNAL 0 OPER .{ .. E.v..___ IMPROPER PARKING LOCAT, OH G... 0 TrvL Ivt ..., _-I ... RIG.T TURN r.ING ' LEFT TURN 5c U-TURN --I stovhxc "di.an'sPtcan .-. -- LIGNT CONDITIONS Io.tGK DNEI -O,- .[.Irn TNAFFIf CO NTAO L . LE D ] L T.11 ci i _. - ER L F.,,S nc 1,1 CC LC TYFC OFO OoD " STOr N[.D°cI.T '..••--::. 'D.TU ,] GN'S G•InL VEHICLE CON DITIOY PC> )?o` 4165?@DI n .. ie_ NOV101 TON -S08RIETCY pNEI .. No [ IEHt r„EO.oFI TRAFr IC I,. A D yap°?H cNA -I DAV ULHI a wN S, off .l . DwA- ). _ ' . U RCT v[ E 11. 11 11 I ..,N15 ?' ._. .. I IxD Axnr.Y N41; . vA[ D p. Ao°A?v°." _ RA,CLANE O 1C I D 1 DUSK 04 Sln[FT A LI. 1F ON. e SNDr tT K ICD xvG :.tiI tt: A'Clx RR l ., I„InR EJ 5 AIt[? L T - - _ itI - T GNT5. A V,R V e "' 'a •IVU'UUw fiv N K IC A , No. ] _ CHEM. TEST C INF. [r,:IN NG .. rr I I I C ACKING S _ (- 1 -' 1 7 ..-? FVI t 6 4 S,nE N Alc 111- IT 1, 1. 143 DI: 1. I;TI L E 1. IT Rl I 1111. - 7 x c :1,1.1, F i _ I 1I -- 1 1 I _2 D n 7a A I _ _GI, R?AEUIIT - ,E {'. Ifs E•..FV I, L ., ,i, , ?. ., t"E?FY,?PVlSi GAtU'TtfOYV 'S v,. } ?L73Si?su' Qa. '+LF tia eSR a u ,ry . - ??9 f - ML s G vli`ur 4?{iJl'lf l?u{t.11 PAG[ of IYU 5 } PoucE co ulNi DtR I Kro ! UNIFORM POLICE TRAFFIC COLLISION REPORT t 4 COUNTY ?STATC ROME :E COUNTY NOAD ?LIiY SIHLEi O ApA4LS PREF% I'll OP STREET CODE. FL110N t ' $$ . 45ikS3X ?: 5 + LC .. DATE OfcausloN - DAYD cal or+ __ - i_E - ? 3 ? sw, 1 uoP 2 m s D ? .? m e sa 1 ? oo HouR, r _. cou Tr ND c] uo L?%wn ? r (' ImAH J1 - r nunA '. - ?OIHERISI'EC lYI -- f - ? D Q CITY ...... rv / H ?/ / PRL I% EO ?• - ILE .-i - , O MILE? ? 00 ®OF_ ? _ W O ' V ' .• d G/. U' NAME S NO OF ST c R WGHWAY . 1CHSECT I!i WITH. STREET Ofl N°AD LL RA f' 04TH - - ON ?Ry - _ o :. Oy llllERSECTION CC E T N'ER 0 D TER ECTINGS EE IOHHOAD OHf ER. Q lE E LLS CRENCECROSS STREETORROAD C - " N BETWEEN 51CET 0 C !t 6 __ S-fil CODE IS SSTLE ANCEAND TION FROM REFERENCE OR CFO ' R ' D T DI EC EC GOD GV'=S= E -'- ' 80MILES N S E K11 8 ..1 0 ET El SEVERITY COLLISION INVOLVED CLEVEHCIE ?Y£RICL£B,c,.E [DO R(:1'RITEI El,-,,R- HILLED - EVEHCLEODJECT ?VEHCLE RRTRAIN ?SOLE VEHCLE TOTAL NO I? NO INJURED OFtFH,CLEs LLB ?VEH CLE-PCDr.STRIAN ?NON COLLISION ? HAZARDOUS 'A TE L ? PROPERTY DAMAGE ONLY OBIEClS RU_K INAM[Of OfilEt`SIRUCK ANUUY.YER5 NAME) Q NONOFOIUEC STRUC%S' ESI+DAMAGE ? E ROAOWAY FEET ? ? ? ? RO EDGE S .- DRIVERS EWT, FRSi -?-- - ODiE DRIVER 'SN C1A5 F- DDLEI .11CL151 on PEDESIRINCEGKT R M. R . ' ' ... _.. . . .. . _ -. -... STREET ADD ESS - R CRY... STATE - ZIP CODE PHONE NO. ER LITY STATE ZIP C E ?_. . PHONE NO. N URIV[HS L,CENSE ND. . STATE SEM .ATE O! BIRTH N DRIVERS IICCNSE NO. __ STATE X DATE OF BIRTH Q, /J ? ? l- Mo Dn1 vn Q, MO ' DAY TR. _.VERS OCCUPATIO FIRMN_E HONE NO. 'j DRIVERS OCCUPATION. nl NAME - - PH NEN CODES >113) cNJURu ,al SEAT EJECTION _ ss -+r_ SEAT ELT.`_ 151 EJECTION.._ INURIESOF ` ? UHEOP INJURIES SCENE VEH.YEAR •?2 l0 Y?E/ BV'. MAKEIOJDGEC E 1 NDGSLIDART NOVAI LE 12 DR CONV.I HOMSGCNE 'EH YEAR BY -E COCGE CHEV.I TO ... IDARTNOVA) STYLE 11112 DR .1 v bc2 Clrr :/ c?cw 11r v E P VEH. COLOR UC PLATE NO " r1 tE? iRNIER PV.IE NO SLATE E - vEH COLOR UC. PUtE N STATE IRAIIER PLATE NO. SIAiE . . I R E,?o 0 - I C E: VEH tE ,OENfjAiION NUMBER - ..? - OOOMEIR C IEH,GIE IDE ,IIFICAIIOH f DER .:.:...• ODO ETER ? i .+. ?/ 8 /7L-2? a 4Y/ 0 600,7 E _ RE.11E.Eo OWNER -LAST.- 1. _ FIRST ... f MIDDLE REGISi r.RED 0IOVINE LAST, ,.....:. fRlsT,'. .. ;. MOOLE 0. 2. .. ADCas O• of owvEn`-_-.-_--- -.- Aconis5 0E -,il?R--. • 1 2 NAME AND AOxE?S GFE:?JRAVCE LO ??4GE.N _ 5,E AID LDELS.S OI INStIRA,.CE CO G5 AGE1,1 ... CNAFG?-_ __ . crt TDrY xB -, ?II E FoncL arvr .. .. I'- ACTON ' - - - conrs 2 s NAME ADDRESS & INJURIES OF PERSONS INVOLVED - , saws E.IECl: C .nt- U p .__ NAT-URk Of o''loll-----? - s r f P . - - - ------ N D t 5 S ,L of -- ' 'S t RY O 10 f-, f " F W E 1 [ Rt55 M R D _ 5 F _ l= f C-i _ s? G 1 C ?.L Sy To J ITT Lt i LepH C ?- _-?) f T 1111 lCi'ON O E ci7•or A T 8J 4 M 1 R d Ari . Y 1,ttnnp 1? 16 i 121 11 "" J'}4?, L?:;'q +'+""-V'..yW ImLnoE !J L ZTt/'? „4 " m Y A: IkY Y14YG7? SGTi1L0.4L'1 Jr T,II..•" 1t: ?,£ ,, AaY III L?? T. L7 ;.•r ,. - 1 9? Ii ,"'A Y I V TV, L rv 1 ? Vky'' u ?u "Ii. D DALE OF COLLISION DAY OF COLLIS ON TIME COUNTY NO. CITV NO. FHWA AA AIO DAY ?[ ? 1 1 'rN• 2 IU[S O LVF.n A UrUr S FHI ASAP IUSE 2400 IIOURI T 1 , .- ? UTij1AN ` ' COON Y ) •?LOU"IfY ROAD ?GIIY STREET 0 STATE N AOMCLS. PREFIX BOUTE ORSTREETCODE BECTON ?r•!J -l.(f rI? ECIFYI 0 O CITYORTLWN PNEFI% EO MILEPOST + J ' b . ?_ m O "•r?. L? C,-'\ _._.__ ...... _ ? Z] OF •' .1A LES 3,0 -7 ? l V ?• A Ny?E NO.OFSTHEEJ Ofl HIGHWAY 1NTEflSECTINOWITH SlAE R : ETOAOAD AAA1P DIAGRAM DATA- - N ACCIDENT T NT R NON %HD TERS TING STREE OR ROAD OR HER. O N o N . A,. BETWEE J. ?'°•Y?G' ?•? STREETANDLL`,PlA. :r .a'aL /"? .. -STREET MLEAGE CODE I TER CLIT CE EREN CROESSTPEET ORROAD 3-7 6Q. DISTANCE AND DIRECTION FROM REFERENCE OR CROuSSTREEi' sw S NFlNS PECIAL CODING USE [ , ' LED 3/` ? EET d S LJ W OF CJ.. !-(•? `.I !? •'1'? r ' COLLISION INVOLVED: ? VEHICLE-•VEHICLE ? VEHICLE BICYCLE OTHER (WRITE) ?HITARUN ' 1 NO. KILLESEVERITY D N TOFALNO ?(?I ?VEHICLE-OIUECT ?VEHICLE-ARTRAIN /? )?•'•C !? ?STOLEN VEHICLE NO IWURED OF VEHK:LES I?f?f ?yE11CLE PEDESTRIAN ?NCNCOLLISION ?NALAHDOUS MATERIAL ?PflOPEHTY DAMAGE ONLY OBJECT STRUCKINAME OF OBJECT STRUCK AND OWNERS NAME) LOCATIONOOBJECTSTR CK E ST. DAMAGE N S E V! I ROADWAY FEET ? ? ? ? np EDGE 5 ? DANERSNAME-AST- :. - FIRST ?: -- --MOOLE - -•-• DRIVERS NAME-LAST FIRST MIDDLE. nF BICYCLIST OR PEDESIRI NCHECK)?):,v .-....:.:r D R J /rn • - D' R . STREET ADDRESS .. •. :. STREET ADDRESS ,-. _'_. .:'.:.:.. ..•:.:. '. " . E '. LItY-.;y. r_.a •`\- ._.?\ STATE, 21PCODE.. -..PHONENO. E CITY-_ STATE LPCoDE .,.:.PHONE NO. R ... ? R _tl 1. 7 CN.A d " BIRTH D N CRIERS LICENSE NO. .STATE SE% DAT T E OF BIRTH - , O MDAY YR 6 m O, M DAY Gk'•:LGb t S 1 2AY -O DRNEAS OCCURATON -NENO. 2 DRIVERS OCCUPATION -: FIHMNAME' ...•. _.. : , .,:.,, P N . D Sl C (? s J 3e _ CODES > IDI cuss--,_ 11I SEAT pEIT..? 151 EJECTION __ -_ : CODESi rJl CU99 1°r SEAT BELT. 151 EJECTION--. .!MORES P IMIURIFS F FR MSCENE BY: TO - FAOMSCENE By TO VEN. YEM N EV.);' MA KE IDOOGEC MODELMARTNOVA): STYLE I2DRCO-I VE-EAR MAKEIDDOGE,CHEV.).- MODELIDARTigVA) . STYLEI2DR.CONV) ? + ? /N / E PLATE NO.. STATE TRAILER PLATE NO. STATE E VEH.COLOR r' TIC. PLATE NO. STATE TRACER PLATE NO.. STATE... •,. " FH d ° "= 1 C ... ,. V n LEI NTIFK:ATK%N NUMBER.. . ".. ....A.:.. O ETEA ... v C VEHICLE lOENIIFICA I NUMBER,.._: :..... .. ?ci •. , .- . ODOME ER : :.,.,:. ..xx ., E' J bC?o4:2 y l8.? E' - EGISTERED OWNER-UST .... -„ FIRST .... .:. MDDLE. •+ REGISTERED OANER-LAST MIDDLE AGGRESS OWNER , -. .. '_.. ADDRESS OF, OW ER .x.?.•..... w._., _. .. ..:?. .? 2`;. NAMEANOA E FWSURANCECO.ORAGENT ...,. _.., .,. .. : .--. ..-... NAMEANDAODRESSOF WSURANCECO. OR EN .i....:r. ...,w... eu• . _ .:. •.:. C ITA ION NO. ?. ENFORCEMENT GUAR E ...:. :: ..,. ._:. ;. :.: •..:... A .,; ,,?.,Y;,-: ,ll•i ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED Gooes _ 2 5 , SEX AGE STATUS °° A i L wiY p "t EJECT: C NAME C ADDRESS. U P I NATURE OF NEMOVBEDFROM NJURIES sCENE Y To A NAME T A DDRESS r? Y A LIRE i { MO D{I1 M nFS RCI NF nY To NI NAME ?I i T AmE ADDRESS p+,V N n(s 9CENF PV In M TO ?N S E 77 ADnnFSs _ E. u'I Ife RcLNr.1 5 To . d •!I Y[{I I(4.r 11UY JIrvAI Ir CIAS:• rA10LAr n[LI 51EJFCIION '' O IrC GllStn 5 / IDI EBIY)' or l0Ot Or C11VAL S ILAf[N Mx Gqr ]N(oiCO USk LCD ]Poll `11 ll. L'D BI 1 IILLI'. rAOlpil(-Yfl4 °flln.nlA" I. Pos.ol DIJUIIr AulInWD 1 ALIT KNOVINIF ? •Wl yI? (.wY ? `. y y S ? fF Q 1 t J :irF A M ? y t •' :. Iv A t A1A tN[5. _ IIIOJIKW UN"NOWI L' 1wi m" It .AI ELTI IF. EJECIID 1 ? T / MG 1 y1 j 4 Ir 'µ7^Y I{ t' ? ? t ! F ?1 ,A .r >st ? x.x m ' r ?. J } T+ r'I y .' VEHICLE DAMAGE 1. INEACH RE UMBEfl Of [ACII DgMAGEOAREA. >. A AREA OF IN SEVEREST NIPACT. INSTRUCTIONS: ], DRAIN AIROWASN,OWI5I TO SHOW II I'HINCIPAL DIRECTION Of FORCE. EXAMPLE ?°°L I • Qr ?•,, . e - ??'' t 0; MA GEDVEIIILLE N OI IOSE THISFYACEEDNSKETCHNGLIMAGE TO TRAILERS,MOTO-CLL;ETC.I DAMAGED VEHICLE N O. 25 rrrrr F. U-1 I ' RI 1-1 T. aHl+. I _ rr na. Hr.R GE IIIACLI IkF 1111ARLI D - N I O O,NCR LI.V DMIAGE S[VFR'I OE nArnwGE' IOTHERVEINCLTJ CJ D SASLINC+OAnIAGE ]OOTIIPR I.IV OAMwGE 1 EVEHITY OFOAMAGE. vEH [ T?IF S LINGDAA,AOE LE rsOJ 3Q OTHER LTV. DAMAGE > I FUNCTIONAL DAUAG_ . ? ...A ... k , Fu'CT ORAL oAMAGE , ? rlU DAMAGE ? , wM cro U E TEDDY ?y?? kq Es jJ.•''IG'Yr, s rowED BV s,. oAMACE s TOWED Br ESr,oA.MACe s rn/' yl , J}L TO TO DIAGRAM OF COLLISION DRAW ARROW SHOWING I IDENr F V FE.TBnr, -" - l: ? ?Il/ ' NURTHINCI RCLE - . E ,-; I ; ? T?..?K(Dx,RnL3 fKIRN,xFL . . DN.r. R TD ] , D +Y ,, T xD x Kr.,IrII GDxnII LIrDY ADw utr , I r `?.. . 2 o. I R r aE,BLeFaH, ` 1 .,r j j 1 f a ? i I? I .DOxLAr IY,T IRA, ATA, k 1 _ . _ I L I AxD arLH COUnnN _ Vq ?' _i..gYi•"._ J Y_c I- _ _ r _ ..?_? DESCRIPTION OF IINOICATEwXATFROSABLY HAFFENEOBEFORE DURING AND AFTER THE CRASH. IN CLUDE INFORMATION N OT ON DIAGRAM. EG. DRIVEN COLLISION Ds LITY.REDUCED VISHALITY. PEDESTRIAN C COLOR. CONSTRUCTION OREPAIR ORK ETC.) - EXIg Sr'r ? Jlrv ? ?P z r M i 7 - _ aF ?/ H-- -? ---./l?G .G:JtYL. VD-.??I l'... _GC'r ?.? /,d?Gr!!C .rJCt_ ??? hucs<..E-. G? '?a°?•;cT r t:' •- Clutn /t ?'?!'?' G CK.umc ? 1'%C-ice [(' _?al/ ?i.. ...C",+ul?r [.V /.?S_J?? '•r .+r','. D __ _ --- --- - -- -4 PAN a ?. POSITION BEFORE COLLISION 1.1 NAME GANG . N ONE O RFCTION ross,U E O IA"lr ON Ne LEGALLY F S E+ '. SS -EO NI EFOSIO S TFREET OR PgNKED ED IYA Y n sfV+?,? 0. "CREASING OEC EASING HIGHWAY Ys L" El 3 O IYES I 'NC +N uQ s rRL rHH.•rrr. w?N I. ",; A. ..r .,x - 1 ON • I A PED .ALOxa-_-___ _ _.-._--CnOSSING _ _?- _ --.:-- rwON._ T •. + 11 I ] --1 , MAZST SI IUNMA E b ',0E54 E t I PfOIBICYCLIfT AS f• SIDEWALK WALKWAY IfNOULDEH 'CROSWAIK CnOSS K SC C E OUTE 1-JOTAFR O NI•]••µ. -?) 'W R AD SUR ACE .... WEATHER =... CONTRIBUTING CIRCUMSTANCES. E CL ACTIONS ICIIFCK ONEI (CHECK OPOA ICI FCKONE On .0110 I IMO G Irk, '9 DRW ER OIVEN .-F. NIEN P q 1 O) O.} jNO.] O> 1111 l I"AIG"T 1 FAD WF=___. ;BCAET ?' _?RUGf INFLUENCE 11 r (BJ- Qtf CASE N- C AG EFP NTLYD [ ?]I MIGNTTU MG U v __ J _ T ,•• `!-D SNON NL-- MI?6TATfO_ S G?I.4 _ GOC?TION IRK---- r?, ] LE TI TURN . 1- 1 .. f K G E I I O 1 I O t G _, '', M-KIN 4 ?. I ..I -ICE -I N E S E _ 4 ?_Of FCl f FO. ._- I-. S I: TIS Y 5 6I 1 I OI TG N T 6 ISY RY E1-.--- I la 6L0 NO TOP. F OI(N ECIFVI DR.- Y[LIi VI \?M OI (H f.. A I SSNFaA RSTI I 1 D IINER ISP[CIF I !- i P v? ', Y r',?, I ?7 6TOYIka FOH _ ' +I ''b PA f,NG > sn:NrL GN At EI .I r_O OLAI GVY >• 1 " LIGHT CONDITION' RAFFIC CONTROL I CLE TYPED ROAD VEHICLE CONDIjTIIQOSNnI I SOBRIET TRAFFIC ON II ST ED IsrcNAL ICIILCK ONEI IMO )VENICE[ 1 NO. ICIIFCK ONE On MORE ICE! 740IyQi) SJtC VENDC F ICS,CCK ONEI L l O 6T0 SIGN E II-All i1 tt . 6TOHFD IN ' ?II ALS , ONF I NO r-IVIJ PAD-1 rs 1 T OAYINt T > i ] TWO 1 -.. of Ficil v[ I IRAII LRI ....,1 `...I STARI N Ixf.w DRAKES -AIIIlD.._. • 1NAFFICLANE 1 .S t „ I_._.AwM_ c.... _ __ _.. _ x , un AP'IAL r'lll'-i STARTING FROM •• r V.• > ] E n m salt ] n. r f 5 • ND N 1 D ! OF (C`IYF ] 'I) I ME AGING RENTER- P ?pp [0 10 A HE TOUTS U A -1. K T fF CI CHEM. TEST 1 vvosrtloN '. I S ITDWAr..lrF 1. onllvYnorr lSllr OT 111. ALL" IL f3fTNE.5 FNNU 115, t BACKING IIICT •• b L I nr +A•. I NO - l4 64 I f b. v rr 1 'L a • `cT---Er- nNl I51'r Elf rl r ;I ION I I ( 1 ? IrsI GIVEN !II ? •"' 3,11(Ii O ( it Ct L NAN T UOIIn -> TAYI.IO NO BE F LC IS ?Sr Iq FU510 I _ Ut Mitt CNrI I Iv NLN ON11x .Y [CU /7 INTEST RESULTS 2 T 1 ?. A if Vlx I J?+rIM/ -?? N'I?? I-1+sv. [t?-? Ilr iVlri IPIII[OI LIA r +f r yrl 1 F. _ !5?1a(? s/UrL.T -1L1i?f1l1_?i? ?! ....... AIR' r ?Kr s: 0 rt vdl----NIHUtIR )Ill( ....lsrv rNlIli':\I..Ii1,1.l rtr PANIUI ULrLI+'IA sVA.NINGIIIN NN rn1Ti ;Fq dkV? e ?rc FNi xBIAkF? ?:? y,5 kN1 4 D DATE Of COLLISION DAY OF COLLISION TIME MO 0 Y T SUN 1 pr 2 RUES B WE IHUN FPI SAT IUS DO HOUnI y COUNTY NO. CRY NO. FNWA L ' K ! a Ct^ - CO UN TY ?STATE ROUTE COUNTY ROAD ?CITYSTREET 5 UPBAN PUPAL AOM{L5. HIEFI% RO TEOR STREET CODE. 'SECTION efl yf ( Arty 1 -- I? 7???G°/iS ?Yn ?OTHEfl ISPEC, I 1 3 4 6• P •?? . ':Wi N CITYORTOWN W LN S ?E ? IN {. PNEFIX EO M.LG Po51 ,. ' / / F 1 O IO MILES ? ? ? L'7UF. L,,//, g C _ NAME6N0.0 SIRE Ofl HIGHWAY NTERREC(ING WRH: EETO R ROAD ILLY a flA P GGRAM DATA - ON T D NON WTE115EC710N, O MACCIDENT LEAOE y TE O X flD INTERSE TING STREET OH flOAp OR REF. CLS EflEN CFCROSS STREF,T Ofi ROAD µ STREET AN. (/_O __ STREET CODE UISTANCEANOOIgECTIO FROM REF REN v i N E CE OR C55 STREETT N5 S E W SPE TALC NO USE -, L ? J ry ?O nFEET ? ? OF CO f COLLISION INVOLVED: ?VEHICLE-VEHICLE ?VENCLE BICYCLE OTHERIWR TEI - BEVEn Y ?N116 RUN ' r 4 ®VEHI CLE -OBIECT ?VEHICLE flRTRAIN TOTAL NO ? NO K LL _ D ?STOLENVENCLE NO INJUERED n 'r VE LE S ?y OF NICPEOESTRIAN EHIC LE ?NON COLLISION ?HA=ARDOUSMATERIAL PROPERTY DAMAGE ONLY A OBJ E C T STgUCKENAME OF OBJECT STRUCK AND OWNERS NAMEI .-.. '.. ,,, LOCATIONOFOBIECTSTRUCK -: •,I DAMAGE • ; -. ORrvEflS NNAE-LAST - ?POaOWAY N S. ,E V FEET ? ? ? ? RD EDGE S ly DRIVER S NAMELPST FI RST MIDDLE BF BICYCLIST; CR PEDESIRAN CHECIG R. STREEt ACORES3 .. .: :..'.:'. _ ....... ,... _..-. R.- STREET ADDRESS.., I E crtr. ?..:... r R ... :. -.STATE :'.,. ,.. „21P CODE PHONE NO, E.. CRY,. ___.-. a. . ... '. STATE PG y N DRIVERS LICENSE NO... .. STATE SE% DATE OF BIfliH H. DRIVERS LICENSE NO. 0. MO DAY YR O STATE SEX . MO GATE OF DAY YR eEr ` I`y ??}f P INirvEflS OCCUPATION FIRM NAME .'. _ :_: PHONE NO 2 DRIVERS OCCUPATION, . . FIRMNAME. '.. .., PM NEN . - .... F . - A . I CODES > ul U55-'A1 SEAT BELT 151 EJECTION CODES > IGI 'NIU.1 CLASS 41 SEAT BELT 15) EJE T P TUBE OF wuwes NAUURE F --... ION C ,p 7 w mes FROM SCENE BY TO FROIOi GCENE By TO VEH.YEAfA MAKEIDDpGE{HEV.I MOOELIDAfl'W0VA1 'TYLE E,20/RJCONV.I VEH, YEAR MAKEI-ME•C.EV.1 MODEL IDARTNOVAI _, STY LEI3DR.CONV.H,.-- fy E V EH. LOLOfl UG PLATE NO. STATE TRALER PLATE NO. STATE 'E YEN. COLOR LK:. PUTE NO. STATE ... TRAILER PLATE H iPl/r1/7 LiJn ?' ?t O VEHIC I-TIf ATION NUMBER ... .... DOMETER C VEHICLE IBLITIFICATI N NUMBEfl ... .'-. E ? ? l REGISi ' E OWNEP-VST ? E / . FIRST -.: MIOpIE ' REGISTERED OWNER -LAST... ?. • ,_ FIRST.. .. .._'.....-,. MIDDLE.: ?S T H ? OrJ O. d/7 / dPrJ ,G ApD EES Df OWNER O.. ADDRESS OF OWNER ;. rfVMs r 2 NAME AND ADDRE590FINSUHANCE CO.OR AGENT,. NAME AND ADDRESS OF N SURANCE CO. OR AGENT E CHM ,,.,_.. ...... T . .... . .. .....:..... GTATION HO .. ENFORCEMENT CHARGE--' . ... .. --. ., GTATIONN ^Af `•' 1 ?Ayp p ACTION . .. ,# LN i ? .,, -,,:. ..- _ .. .. NAM ..., E, ADDRESS & INJURIES OF PERSONS INVOLVED CGS 3 . . ? .. , SE% ABC STATUS EJECT, '"S # ` NAME' G C ADDnEb!- RO ? ' P M INJIIRIES SCENE f1v F TO I ? -E: t , ? Y T S ADDRESS. N y "E r- j , U NL MOVEOff10M SCFNEPV TO 1 pz$ W NAME' I ADDRESS N It N WJUPrtS Scrll'-.VjZpFP M TO f ,? , 1 $' NAME y, S n E? E N •. u aP S. " 'I'an' 9 atr NF qY TO' I IISIATU3 2 PAA srN E 1 l JIINJURYCLASS MSEAT BELL j?IEJECRC14 C O D p (R -cUSI lONIER 11 ! 1 ) J TOtMCR POSINON ? O-.1 t OCAD iSCCNE 3BUD ON -RIVAL I E DSADLNG NJUnr fl NON DISABLING BVIDENTIINJURY NOT INSTALLED }.NOT INUSE JUSEB j I NOIEJECIED ?TOTALLY EJECTED D PARTIALLY EJECTED ? IA' F• e miMfS4 • 3 I TLS MOIORCYCLEI 5 e POVGONUNKNOWN - A LIEDNHOSPITAL T. POSSIBLE INJURY A. UNKNOVNI 5 SEAT BELT TABU . A UNMNOWNIF EJECTED - 4 v imam fT vim} ?? } S L Y I t8, ' 1a^s,L_:?- ?cY,tG'ixuaaraxa '.. .?.. e[Rnc ,a "Z4HU - TA'FA (,Y3.. "lau: t E CLE DAMAGE N EA JX 1 E T E NUMOER OF EACN OAMPGEO AREA. yR?? INSTRUCTIONS: i olnawn now sl TO SHOW PRINCIPAL OIR ECTION OF F GnCE. y O/' r 3}? DAMAGED VEHICLE NO.1 rvsF,Hls srACL FDn aK[rc.INCDAMACt TD TxaILH/s, MOroncrcLES, Erc.I DAMAGED VEHICLE ND.2 -A _ SEVERITY OF DAMAGE VEHICLE NO I 1 SEVENTY OF DAMACE IOTHEH Vr LEI E n iv OF OnMADE VEHICLE NO.? $1 °sneL xc nAMACE 3 O o v DAMAGE ? ? °rsA L"c I_ae af7c°THEN MV DAMAGE , Dls^aunc DA-' 3 O o IER M.v °+MACE ?- e- U ru"cT 0"Ai DAMACE- . O n Mnc? MACE . O"o DAMAGE 2 UFUN . I] No DAMACE ' 9 2 F T. DAMA Tow N r DAMACE Toweo xrcT EsT. DAMACE N wp -A TOWEOSY DoT cT t .-'. TO , is E TO [ 1 ORAW ARROW SNOWING DIAGRAM OF COLLISION NORTH IN CIRCLE T P s I` 41, r s 0511C ON=AD CC, a I 1 _ ?_? I ?1 t- i- `A ?rTPT,?,DN DN AREA,E Rp I - _ .I_, I 1= rr rRpaAPLE.D x, DT i IT ITHILANIA-51F08L "el DESCRIPTION OF /DICA EwNATP oe ULY HAPPENED BEFORE DURING AND i THE CRASH INCLUDE N AT NNDT ONGIAGRAM,EG RIVER L a}y IT ITY,.E000EO V.,_ITv,PEDESTRIAN CLOTHING COLOR. CONSTRUCTION OH-AIn WORK. ETeI COLLISION - r; Ip ycil _j/%_.f/?As_._?Jr s=_._d.r G'n • r.°?_/_ _ /'dsi orS? dp.";- - ?L J Pq ' , I '' ` _ T12e_.rfodo?u/dy_. ul?i.r do tin_ c, tea' don/l_,S'r/'u?/f _ ? ? jG/+ dar?d 11 ONE 11HECT11 N Pe 1"i POSITION BEFORE COLLISION DN Stn EEr On LEGALLY IDCWAS - GUrEEO F V r` - HEADED G% DIR w NAME 01 -N - I CI i o f NO. -E / Itl YES 69.1 .. L.I 11 EV. L.j L j Li I OR D _ o _ D. c _- --cnoss xc - s, FFOHEICYCLIST WAS USING SIDEWALK 2.._ WALKWAY a_- (SHOULDER I. CnOS_K ° C a DU rJ IER .. A- } pOAD SUR FACE. WEATHER CONTRIBUTIN orCIRCMM§TANCES a r IC (cKO"FI (CHECK ONEI LCIEC, n.En O E I R T T RIVER '?1 Rya D. T` AH _°?_ " ^ O-1 02 w G ! jI NO , aI o D - 1TU N TAKING 'a I_ AYEHC y?ALCOH .S44.SSL r j x 2 wET 2 r I R c_ C2? -oPUC"s wFLU cE F I l ar N7E" IN ?CLK_ I HT TURN E c EDINCS IAIE. -r-Dr-' - c, I.Irs? IMPROPER PARKING 1 hJ. _OVEH SIGNAL SIN ED LMT - I _-= _ARC ?•4N.- MEiT TUnN ?_.K ' E ; 1 OL- IS. FEAS N E OIERATING j FO_ _._a. u-RN I ?.._?._. i l , •. 8 1 -? .. - orc A m c Iw 'r? SLOWING DISFI I- rA v`f!p'F -?sI ns? E (1 s OTNCR ISPECIFYI - 1 - EaJ l OIS` RDSTOP -p`PEO FOR _,°? sGnrs (:NAL L 0'.! NO IDLAT ?T FIG '/' H3N IGHT CONDITIONS TRAFFIC CONTRO I ° TYPE OF ROAD VEHICLE CONDI TION SOBRIETY HECK ONE( 1 0. 2 VEHICLE ,,,El ICNGNAL F,r h IMO' (CHECK ONEO DIE I CQ - ' CHEC OiEFI ,,y.(? SIGNALS 1 ONI.Al TN10] t'b?a iU{krill ENO2 Ig? n PPE^YN NO I TWO DETECTIVE a IPUR :7 1 I ." "L Y_ J i iiCUHE / r\ GHT SG /t 2, K 5. T r - 1 ' 13- YIELD FlVl.EI.LE ' DUSK SFLASHING IG ^.r CMAn '.) E OS...IETr O L12J M[nGN IE NO F ' x 2'' REG. LN IT 0 (AMP. E L° 1 ..I ?._.. '..U X____. __.__ r- AFFICI A. H - STRl FT - Y .E 0 IS( .w .. _ _ DVE'... EST SON DO w[rl [ NG JE [[x CHEM T _ ACK NG -T 4 r xxlnWM U ° DARK- S,Rf IT LANE SOFT .., _ SIG Al E TUHN ..,I5 NO THE. ISPECIFV PARK-AO DI CL / c -NTH - T! rOIVEN I. SIIAHAII. .. _ _._ _...._.. . _ ._ _.. ._ _ ... 1 " 'IT s1H[rI UGIITS T rL GMAN .... - Ur ) DIV.. Vlom /,. NO.EFELTS ? ? lxCFUSfO ?. r orHfR lv[urri R'- ,o r.c'/? ,+ Hn 2 A ' .. NOIVIOtD TEST nE5ULT3 I' R r G+TInG Orr 1111111"1 AI A NK Lltt TCrIFU LI VIVID AFF FLUw P 1111A CFA AMUULA rMPEDEO AnR_ ?.IS I d PHIL o M N 1 r -,F?, `' mcA,INCUn m[H aNAU AHAN r °AT[°I lnarorl, Fuv[°ar +L ? A:+L DISTIIIRUT,ON ORIGIN ALCGPY'. SEND 10 WASHINGTON STATE PAT HOL-OLYMPIA, WASHINGTON DEISM i - w' DUPLICATECOPY LOCAL LAW ENT ORCE MENT AGENCY'S COPY -THIPL ICATE COPY: I NVESTIGATORSCOPY ..fir. .?`'xw,• '' t' , L ?_..V "l ?tL-b- CSH1Nutu"t PAGE OF ti r. f?? U NIFORM POLICE TRAFFIC COLLISION REPORT POLICE COMPLAINT NUMBER pW U DATEOFCOLLISION DAY OF COLLISION LIME CITY NO. COUNTY NO iHWA SUN ] MDN ] 1VE5 D `E a N'UN S FRI s SAi IUSE 2a DOHOURI >. = / Y - 65, -y DAN • r + ,. COUNTY -STATE ROUTE JS?OUNTY ROAD ?CITYSIREET ? OTHER (SPECIFY) O N OM CLS. PREFIX A .•__ ROUTE OR STREET CODE ...?.. z SE TION 1? 5 ?. _ ".. r. - ?'h "AT u :° L A T N 5 E W ?IN /CITY OR TOWN / MILES ? ? ? OF NAMEANO.OF STREET NIG Y -. INTERSECTING WITH'. STREET OP ROAD O N o/ W LL o % E PREF OV M EPO i // RAMP O GR DATA - ,. ? 9 I 0: N'. NON IERSECiION:. - - _ )((?? , _ DEIWEEN H^kz:.C.?•y. /NIA STREET AND JIVo•_/,5{.)NJ igEET -ACC DEAR E E CODE TEfl ON •, X S 11I11 Cl NO STREET OR OAD Cn REF CL. I_E OS TR ET OR ROAQ (J?"' ^,C? - ^g', { DISTANCE AND DIRECTION FROM REFERENCE OR CNOSSSTRE ET - / MILES G FEAT W [J FEET ? C9 OF _ rL.G 0 D C.I I' C 1 S•L'CU ,IS _ 5 EC L GOING USE. ... : ., I,y YF' .{( 4F ] CYCLE []O HERIWRITEI HITBRUN ? VEHICLE VEHICLE []VE CLE?BI ? COLLISIONlNVOLVEO: TOTAL NO ?VEHICL[-OBJECT 0VEHICLE SH TRAIN __ -STOLEN VEHICLE OFVEHICLES ? VEHICLEPEDESTRIAN -NON COLLISION []HAZARDOUS MATERIAL SEVhN11 NO KILLED NO IN URED []PROPERTY DAMAGE ONLY 1 y , '.. [?[??{{'pp'' ORIECT STRUCK (NAME OF OGIECT STRUCK AND OWNERS NAME)" %A% LOOATION OFOLUECT STRUCK ,'. W JJ:._._... EST,OAMAOE N S E IN OF ? ROADWAY FEET ? ? ? ? RO EDGE 5 +?! "1 ` 1 \B"? A v ` M - -' Y" _ - R DRIVERS NAME-LA5T ..; - -,. FIRST MIDDLE" ....... f'6e• ANN Se,NN - R DRIVER'S NAME-ST FIRST MDDLE IR SIC YOUST. ON PL DE SIMAN CHECKI(3 .-.;:. .._.: W<,R3'vaY?6•/f!N QA E" - ??°u ' •'. STREET ADOHESS V -.' JF/-I'.c rl$a9N CC•+ 5,44 ;rF O A V r- nx 5. ' L ?? E R CITY... ZIP CODE .- .PHONE NO. N N 3 •' ?3 t 1 Tow R" E R LIT CODE.,-.PHONE NO K Ar \ F N DRIVERS UCEN. E NO.. .. - ....... STATE SEX DATE OF DIRTH N DRIVERS LICENSE NO :... ..STATE SEl(. DMO OFDAYiN Yq. y, 1 F?,S S, ?- DRIVERS OCCUPATION FINN NNAE ": - ONENO. _riic i F c?L. ? c SP/ _2 DRIVERS OCCUPAT ON FI MNAME _,_ _ PH NE NO }3,•?? V-•r1•A: CRe -°/,+ Z' urr;&ACy zz?' ? CODES > IJI LA55, _ Ial SEATBELT?.._ 1.1 EJE-ON_ _ 1 '4 CODES >113 ?Lg55-? la' SEAT SELT_ 151 EJECTION >Yf+?M 1 IEWURIES F l NJUR ESOF - '?^! Yr FPM SCENE SY: TO FROM SCFNE 9v' TO + VEH.YEAR MAKEIDOOCC-CHEV.) MODEI.IDAgiNOVAI STYLE IZ DR CONV.I VEH YEAR MAKEIDODGE"CHEM., MODELIDARTNOVA) STYLE I3 DR.CONV) (Z E H VEH. COLOR UC. PLATE NO..- - C o?9977 STATE TRAILER PLATE NO. STATE E H VEH COLOR LTC. PLATE NO. STATE TPAII£q PLATE NO. STATE a, I T n r' C E VEH1IC?LE IDENTIFICATION NUMBER .......+ . ..:. G' I L ~ d ODOMETER ... C E VEHICLE IOENirF CAl UN NUMUEfl:. ?. _.„..... - ETER'..,.?._ y?2+, T -- ? ?? • o•` FIRST REGISTERED WNER-LAST NIGGLE a?l.F?ss<? r.7r°rTj _s ara?r•/ ?%= - o. NEGISIERED OWJrvER-LAST... _.. FIRST ...."?MDDLE _ 4 ?( ?• ADDRESS OF OWNE. ADDRESS OF OWNEq .,, ..._ 'Z NAMENEDADDRESS OFINSURANCE CO OR AGENT NFMF 4rvp ADDRESS OFINSURANCE CO. OR AGENT lI+ --? ? A $.?'S y CHARGE -? LIi Ai DN HO- I[ ENFGHCC MENT CHARGE .. .. L ACTION ?FtiTt?lI.CY? `?_fL. rl .i? I S . ,. CITATION N P.. i Fu _7 e r ADDRESS & INJURIES OF PERSONS INVOLVED NAME CODES ] - Z u S a , REx AGE STANS _ r EJECT. , ` 'F C NAMEJ? r.:AT(r-? {.? ?`^?F3N•? SS ijZ U T- ./ ' ? d. "p p NATURE OF HENRIES SCENE BY TO y+ ?+. A NAME: A T DD ESS --- 1 S R A rTfiitivco rnoM MES F TO u 1 Sf.ENE RV^_ LI W NAME ?: i T OD Ess ?3?Eb rgoM . To I. ' S NAUE. eR ?( 10 "t{ nlsuw ul5e r'o-IILw CLASS I L Info uu ECT ON R` Y ' C O ) PASS!N^+ER PI OI'+1 R'A1 NEC\CL '1 -T11 ?S I 11? I OInFn O 1 0.11- 11-D E JGL D 'Al n EEG '1JUNY C'.ON 111 114 f'J :.f Yi,'IJUNY NOT NSTAI LED 1 NOUN USE ;USfD NO""CiF0 T.101 L F fCitD JPA 1 ILYEJ1:CiED ILLYE - .; ,. D •. OTHER dWTINl55 RJ:.A L C F J /)I/ a FPri+'G: u:+'EUIYN TAl a fllV :n05 ) r.7„ nl[IN, URY UNKNOVlII s SEAT HfLTFANURE • U .N EJECIED . bt 9AT ' ` 1l pI vll '; r t ?'1 s Tam ??aL-?q?? e a l `Y n L K??? I 'I IwwYir J???? , :• L.-a _..._.._._.. .+.. ,. . • ?..J ... n.. .. A I.* ., .. _,...e s.. ?raaA -1y ;+ r r< 1 L , .;. 1 , 777 •I e " VEHICLE + M A_.d -11 D SHADE AREA OF SEVE VEST IMPACT,I.. INSTRUCTIONS: ]. DRAW-.OV0(.To SHOWPRI-F.l DIRE CTION OF FORCE 6j Ole • DAMAGED VEHICLE N O. 1 IUEE tHISSALE FOR SKFrcll xc aAMAG[rD TRA LEns, MDiDRCrttFS, ETU DA M AGEDVEHICLENO .2 r FQ• J 1 O.•r?n '? ]. U+.luln - SEVERITr OF DAMAGE: VEHICLE NO.I I?DISABLING° M GE ] ? OTIIEn M.V DAMAGE ] FUNCTIONAL D.IMAGE . ? NO DAMAGE E IITY OF DAMAGE IOiHER VEnICLEI I? OSn BL nG DPMAGF J ?OTHENMV DAMAGE xD DAMAGC ] O FUNCTIOxnI DAMAGE . ? II Tr OF DAMAGE VEHICLE N° ] - I ] v. r DISABLING DAMAGE J C? O ° IaAGE - FUNCTIONAL -AGE . ? x DAMAGE TOW ED BV•E??L 7br?A EST DAMAGE TDWEO BY sT DA„PGE E . VA IAGE TOWf B JAL • .ARJAQ= CST T ov' Irv ?oTAI_ TO J ` _ TOCNJ]Ls.oC? f.OL DIAGRAM OF COLLISION F-1- A - - I _ DRf.W ARROW SHOWING y NORTH IN CIRCLE ` C UNUw,uieVr Bono rroxs r ?w4QT JtI 1 YIS ._?_? ..I ._ _ I -?- .. _ .J_ `-? -^k rwun I c,X.1tc CO. ,RI•A -. !. Lx,re.ROe,eLt rpwr of I 1 . s. saaw vEH nL FLDTSIRwwoA Uencr.UMNONS,T IVr•Ci. . .NDe,AL,NFwrLEDR --? - A"PC?n 1 . _. __. __ .__,- I - RDrJbTN 3 o _-- I = D.FTFRLDLLnDN DESCRIPTION OF vFNED BEFORE.DURINC AID AFTER THE CRASNINCLUDE INFORMATIOIIDTON RAM, E.U DR VEH COLLISIONS .. ITY.IEDE IINCL IIIi,GCOLOH,CONSTRUCTIOIORREPAIRW9RK EtC.I - 0 T TJa a '' F? - i' < o E c . E __, RarS or _ c _ _ _ .. _Ro.,.. To_. oF___IA F<.15EJx?-, S?SP< - f L /i P R PT rJVI ?G vres _THd_.S?S tO_T_? Yvo.G-h T_H?-0a _A 0 F,.?i ..C A.JrE o F TR9.Vcc. - v c N _a+o..a___tl AD - Ay.?o A .L <-HJOJ-c v'T i '.Qr_:IC?.4aF.,A4._Y?SJJD_J??_)y J-?'!?`?1-JG.?L/o ?T?.-?-?G?•l dV0!? jl_.Gp?zf?iary.. _ ?.lva ?_ 5?Y3.??k. _Na J 1•J __R.R pTgE_ Pn?+K'z. S?iX!JrG. TJ!C P??Rot. LJwJT .?1Jo°.?!•'O_ Jh GV EJ1+G:. I_T_Wr SI'. _A PR O)f_, 5dJ ._h'O.-_?_?,GdJ.I A.. / o?R c$%? .q !?(?a N'? Jao' R?sTTH? Pz- pF Gah cT, ??%J.ST THc-•.!2%aHl' G RQ HG -- ROSITION iIEADED No. S BEFORE COLLISION -E rosr CREASING DECREASING - DISTNEET OH IFE-Al NAME Oa NO. iI arDiE ulncciioN If r EGALLY 'ARKED D^ E IF PAnKEO M.H _CUPIED I-I PnRr,47 ! __ F. YES D ES !LO __ ' E °se. a [.cowl A.O CICLST IA_ USING rFIOI . - ]' J" SHOULDER R ED ESIGNATE CROSSWALK CR D E WAEKwAr CYCLER-TE 'LJ DINE OSSWAL R ROAD SUONII ICHFCK ONF WEATHHER ICn ECK OIEI ..' CONTRITRIRV TI C_CRCUMSTANCES N HMOREI ... - ERrvEH CLE ACTION wCUE .K.t?oF T INOF] INO k] IvE] 'T'I\ STRAIGHT AHEAD URr ' CL DDDV s0 EBC ST.__ - '. UNDEn VFNCE OF .L. ALOOI Ot FOLLOWING O_ to SS. DISREGARDED IAR I .? icxislG. '. All pPp SK NO I.- _' SNc ] wEl H .;' rvDGn CE OF OnuS v ER R yE -1-INTLY A51FEP r i?J AKIN mart TURN snow. ,_-___ _. J G-Wllc ?..-:__ _.__ r I E ED TSTATEO __-.__• _ I 11 NG REAS. sm c .- -,_. __._ MP OPFH s? MPR aK Ic - __ LOCA Q. _ .-Al... arc LEFTtURN - G CE FO 11 r4Ni T Fo F UR D :_ of EOUIP. I U U 6_ I SLOWING '!I ,ECIFVT oiilEi 5FC it-' D[R, ' NG UP 015 s UTHfRrsPECIFV X STTW`E FOR LIGHT E N ITIONS TRAEF IC c E TYPE ROAD VEHICLE CONDITION SOBRIETY . OM FD AT vcxgl NO] r • 0 C El ICLE NE f '[[ INO.]v A -_ OPSGn CHEC nMOREI rC TE TA FUIf01 E CHECK ONEI -11 SIGNALS ONE WAY D. B STOPPED IN AY T -LIGHT ) N. _ _ ?]X TWO— ,_. BHA [S _ -. ...-1. AIRtO Tr 1., (- STARTIGIN s- Tn AF FIC LANf . . I r-? .._ •--. 111t0 _..•Jr -' 1-ISIRLE .. cT • rI START Y 1 IVT Imow I Tv xcFROM )? _ D. ° _ D,wn s?cN noon _ 1.u uans NoTI AIRE._. .... ? rARKE°rosrt on w NO nT[H Hn NGf MER • '' S pM lCirvf HD 509H.- GING EIrI LING ] DUSK . I] RED OOP L.GH tnAFFICI U I. .. MYAn e 0 -STREET S FL,fH r,G n 4l lir HLS wCRN yy - 11 --N HNU°RTxK NCs .? D'ncKlNc ALmEn -siactT n Lwow rI v n CHEM.TEST S TIN ?E IL In, r u w •r "D OFF...- ._. FT rw. DIIOt) ..... ...- IcHtcKDSCI- ST ..IS IIST I_P-YIIr.I_ _) 0 D J? 00[ Eus Usfo I sFc_ 1111 IT I n 1/ J Csr TEST nCSUtrs Z - r I I X .t H,N raT tl \. ^11 6nnNK -- C II LD r nICE (, rF L OW 7 i.-.r NEI LU F ?IV C) J. -UpLIV`t0 )R?vivl DforL 1 X1/Jrc- TJT•OJ•f Pcov ,kiF ?J/7 002A? M I 1L .11, N _ _ NYl,ncauN s «ITu I•NK L. ,x1.1 '- - Nor Is T AlIH-1 D RATE - X•C? -S,c_ -A- I T _? ?_1 ? 6 7 J B OUYLICAtC C01•Y l1'1C 411AI... ?ICF!'1'.Inl•fIC.`'?SfUPV IPLIf.IrTEuCOPYr'IN'Jf GiIGATOfi?SCORY €? 2 U 1?Y + Eye 4 `, a ` G f U • 4 . f . E y. . ?Iik dryry` ,J?a}}TT??. iAL.Tc T'C1??ub? ?' • < SLR YF:T ,.ter 4: swe : of ?? R 7 :. a?i ?9T'Y&diV 9?'6°?.EU;• rY '?,? ? Ilk rp cl,:?•.I m..?M r T,-:,?... ?.,k ????' t??5?4?`?3111??a?h"?r T AFT 4 tt ?I Et! d ee IF A NPY 11 l 1 I j' I A e' r, OEM" ?a ;` i' 1 L`0t VhNSHl ' 1 - Imp V PALL Df No tJ^? S UNIFORM POLICE TRAFFIC COLLISION REPORT PoucLCOMPUwINU DEP D OATEOFCOLUSION DAYOF COLLISION DIME COUNTYNO CITY .0 FHWA •,•' A 'b' M ,A? ^ R T SUN T MW Z IBIS ] `E A tNUH S iNI B SAl IUSE 3A0U HWRI ' / V` Q UI IN RAL O STATE ROUTE tSFOUNTY ROAD ?CITY STREET FQ ApM CLS. F'RE-INA ROUTE OR STREET CODE 5ErBO. ?tt' ?c/•?t.=RS ?N DINER ,SPECIFY) W L' ;r flf }p L N 5 E W ?IN CITY OR TOWN PREFIX EO MILEPOST W '.: O /?NNMILES ED ? El OF. HAO?I .i_C/- .__._-_--.___._ T bNWE STREET ?IGH Y.. ,....._ INTERSECTING VAIN: STREETORROAD OILEAGE HEIR NO DACDMDA'EnCE O???i!'t Ei On POAD OIf+CF w¢§ N. BETWEEN d?A31y.G.?-/T )QI-4 SIREETANp !Y/J../S{ /NJ ??. iflEEi CODE } - [ Y -r DISTANCE AND DIRECTION FROM REFERENCE OR CROSS STREET y A S SPEC H AL O.-USE Z'CFI C .- 11 •. 4 4?' s LJf EEiS ? 5 E W OF_R4I?w VEHICLEVEHICLE ?VEHICLE BICYCLE ?OINEPIWPItEI ?HITd RUN SE ER IY LE I. COLLISION INVOLVED. _NO NILLED •? R VE-1-IF DJECT VEHICLE RR TRAIN STOLEN VEHICLE 'N NO TOTAL . ? ? - - - - -- _ ? NO INJURED k yYy OF VEHICLES ® ? VEHICLE PEDESTRIAN L] L] ON COLLISION ? HAZARDOUS MATERIAL ? PROPERTY DAMAGE ONLY J f: •? OBJECT STRUCKINAME OF OBJECT STRUCII OOWIIERS NAME) LOGAIION 0111 ECTSTRUCK ESI.DAMAOE N 5 E w ?. ? ROADWAY FEET ? ? ? ? PO EDGE 5 I. . -- y DNPIERS N -E LAST: .:.:, FIRS! M DOLE DRIVERS NAME-LAST FIRST MIDDLE I f BICYCLISI.OR PEDES JAN N CHECK,Q t-- .., _ Pet, v 2, 1 F)" R - STREET ADDRESS fl ,i. D I'?Fe F'A4!? St•H/Y - D MAX V DRESS -c vAll AAA, E' ZT irlAF S ANN c v 5 r/S P'm a lF, P n r ;? -_ :.. :... Si TF. .v.._._ ZIP CODE PHONE NO. E CITY 51 E.'. .ZIP.CODE .._.__.PHONE NO h 'r rwa R c q 1 T? w ,? /r 38 - ?3 / R j r r? ray ??Ew t '1 Y w; N DWVEPS LICENSE NO. SLATE SI% DAtE OF B RTM .: N -V ENS LICENSE O ...:. , ? w X ST TE.. SEX.. DATE OF BIRTH T i. O• M0. DAY Yfl. O• MO 0 Y YR r l ":f: ,[ P_ /? M'/? ' /S -s A, N4.E 7? N 7 fit'•X,•f ' 'I DRIVERS OCCUPATION IHM NAME ,._ PRO END. 2 DRIVERS OCCUPAI ON FRM NAME .,.i ._ P NENO <ii,F % F C.^L. '? C Y3i1t „%..r/,•c CRO -N Z Al ifi.$]dCH I s..?: qty •5; t -. CODES >1I31 ciUss _/_ al SEAT BE T__ ISI EJECTION CODES > 13CF55-? - 'SEAT BELT_ __ 51 E(ECTIONJ"T+. Hf IrUU ES F N+TFES F tT ?,. FICKA SCENE BY TO FROM SCENE BY TO c VEH.YEAR MAKEIDOpGE-CHEV.I MODELIDARINOVAI STYLE12 R CONVA VEN YEAR MAKE I000GE•CNEVI-, MOOEL10ARi NOVN STYLEREIR CONV) , w. A, V 7n pa ?L•q"?t7 v b0,a v _ E VEN COLOR . C PLATE M1D. STATE TRAILER PLATE NO. STATE E VEH. COLOR LTC. PLATE NO.. STATE TRAILER PLATE NO.. STATE 5 •j. A At ' i C VEHICLE IOENTIfICAT1O•! NUMBER .. . .:.. .:.. OCgMEIER (•' VEHICLE IDENTIFICATION NUMBER . •...... ?,?I000METEP ,..,, A _6 REGISTERED OWNER- FIRST MIDDLE REGISTERED OWNER- LAST,. FIRST LAST - O. JcjF Scrr r•u1wT _34.zg;r-- " I " . may' AOORE55 OF OWNER _ ?. O ADDRESS OF OWNER • YiY _ <irn • 1! • ' ?Z•??? A C --- 2 NAME AND ADDRESS OF M1SUPANCE CO. OR AGENT R. NAME AHO ADORE550F V+SURANCE COOP AGENT M t CnAROE - CITATION nO- Er+O CE E i CHARGE CiI?TATID.N . •? - - T FACTION Q jr .'r 7 3 4 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED -coots _ y+ 5, 5E% AGE STATUS EJECT. 1 C oDPFSS L4 mil- G'13?S.F1,C0-- -??!J 4 fi_ G no u A UPF OF nMp"4- OM NJURICS [CE NE BY TO - - .N P A NAME. T AOORESS. - U ES F NJ H 10 W NAME I AOCAE55' R _ H NK M BY iCU ? to E NAME __ _. ._-_-.-_._....._.__..____. S ADDRESS S, INnlwcs scc NE n. to rASCENCFP i no lNJUnr S r:AD.?yc uuunr Nm N; TAItm I NOTFJECIED ]S1RAN I(rII Ir ICaD aI FCi NE .L?NUCr PI "XI Tr,O1 NUS[ Z.IOtALLV EJECTED ifCL JFCIED I AyOA'H +CIFU CnOLIR.IALL )!.t„4BlC INJURY S SCAT BELT FAII.UPC A CJICIEDN R pµ t,[51 1. ?51T??? !f0`CiiO-lo T e ] __ 7111 I L Ail TEL ti J: 1, tl rti .. 1 i?,,, ! I ?- !rJ11"r"g-F? „t, lrr,'^nt t•?l ,? J! ?. +.? &1?, " -f wr E -d' hl P,2. t N"?'7S' A"5 lr !'ti' DATEOFCOLUSIOl1 DAV OF COLLISION MO Y yR. T - 1 M(yl 2 IDES ] WE A Ixllq SAT (USE TIME MQ FPo n G COUNTY Np. CRY NO.. / FH. 6 B 111 X COUNTY J ?J ?URBAN 7 ` STATE ROUTE ?'COUNtt ROAD CRY fiREET J ? p Q ADMCLS. PgEFUI ROUTE OR STflEETCOOE ECTION E ?C CJO?L lOTIIERISPECIFY) W ?r1 0 C ITYOfl TOWN I" pp ? W W PREFIX EO. MILEPOST I i c q • MIlES ? yl ? OF ?A4LDeIC ED _ p.Lo T NAME SNO.OF EET RHIGHWAY ON 6AC? INTERSECTING WITH: STflEET OR flOAO O RAMP DIAGRAM DATA NON WTERSECTgN CC OUTER NON X-RD EgSECTW STREE 011 ROAD Ofl qEF. N BETWEEN O TR / T"9VE ' C EAG E I R CLS. CLS'. ERENCECRQSSSiREET OIIROAp S EET AND -G L!/i ? wbTANCE AN S CIINN F50M EEFE RENC ORCR059 STP ?DE EI W F HuxFS SPEC CODING USE O . 1SION INVOLVED: ®VEHICLE-VEHICLE OVEHICLE-BICYCLE I OTHERIWRITE) MHR6gUN BE ' VERRY ? OF..,C. © f? U I VEHICL-FEDESTRIAN "NEHICIE Rq TRAIN NOE gg ?STOLENVEHK:LE NO.I-ED Q , . O 11 Aa R e m v R s,.n N O. E c E N A y y o. ONCOLLISION ]BIECTSTRUCK(NAME OF OSIECT STRUCK AND O WNEflb NMIEI [] HAZARDOUSMATERIAL PROPERTYD - LOCATION OFOBJECT STRUCK AMAGECNLY EST DAMAG `rh': C. OP:VERS NAME / FIRST `'?' 'MIDDLE ?flOAOWAY FEET oooo RD. EDGE ' . E E ? /CO/SLF 7?/Di9?.4S D ORIVEfl b NAME ,AST FIRST MIDDLE :IF B-CLIS OR PEDESTRIAN CHE II A ^S S uLCiVA .. t CK, Y' STREET ADpgE 1 ? t R v J V oiJry S TREET ADORE f v 6 4 T # Z a z6 =y Y STATE LP CODE HONE NO. E K CRY -???vc'sD v d36 %eVEflS LICENSE NO. STAT SEX GAT STATE ZIP CODE PIRONE NO. TL?ra cv?D ?tvA. (, E OF BIRTH y N 0. CRIVERS UCENDE NO. ATE SEX DATE OFCIAYTH R , WN O?CC?UP?AT,IO,N7 FWM NAME ,' I. ?f/I/I ?P7HOON+E/NO. 2 DRIV SOCCUPATION FIRM NAME CODES > IJI cubs TAI SEATBELT 161 EJECTION I IATUREOF P - CODES > 131 CLASS sEAT.ELT EJECTIGN ' Q UMRIES N F DRIES of SCENERY: TO OMSCE EH-YEAR MAKEIDODTECHEV.1 MOOEL(D TNOVA SttLE 12 DR-CONV.1 ?? T Ef ?? FR NEBV' N. YEAR MAKE IDOOGECHEV.I MOOEL(DARTNOVA) S I-EI2 CONY) D a EH v ? 72 QF/Ey ? ? ? r UC. PLATE No. STATE TRUIER PLATE NO. STATE ?? 3 E " R COLOR UC. P UTE NO. STATE TMIIER PIATE Np. E U , EH ? IFICATIO • ?HS I ODOMETER N NUMBER 1S ?'t e... ? z z-77 ` ? C VEHICLE IDEMIFN;AT pN NUM R - I eeLSrERED OW N i MIDDE /c??sLE. AitG N REGISTERED OWNER- T FIRST MIDIXE SucuvA? B?ssr E ? ] - IORESR OF OWN Efl3 ? JAE ANDADDRESSOF w4ulUHCE f`.O, /E??44,?E 7_v , ADDRESi OF gWNEfl ? -7/'& 60/`%l _ ENFOnCEMENT ACTgN U iwM ITAB .t/CIS L???i- >?J.C? ViN 9 0 % /3 ?? NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES a J y SEX AGE BTAl N NE EJECT. - L. NAME: IV,, ?_ -. • C ADDRESS. ').: ` i U NATURE OF P INJUPoED REMOVED iNOM _ A I? NAME SCENE BY: TO T ADO RESS'.' I u FTIOM KIIIfakS SCENE BY TO 'P N/ NAME: T A ODRESs: N $ E N v n AME SCFNFRY-. TO '.. Ip'I• : ` E A DDRESS `... $. Y lA)Po 6 u NE qY' -. . L C . TD y I ISIAIUS 121SEA1 POSHX;IN 01 INJURY CURS IAISEAT BELT ( T,PAASENOER 161 EJECIgN - - { ? 3"msTRWJ A 1 R.ND WJURY 6. wSABUNOIfUIm I.NOTWSTALLEp 1. NOT UECTED T OEAD AI6CENF Q 6 . BX:vCUJi . e. NONwJApUND T. NOTWUSE a.TOTALLYElEC1ED f? 0THlR 6 T 1.OTHCR POSRM)11 JOEAp ON ARRNAL IEVIDENIIWNm J USED )EC E e . D.P.NRAL TED WTTNEJ3 e ] e IDU6rIMD011U0NRCD l ADEpWMOSPITAL T.POSDpIE `.U." ' UNNNOWNIF yJ IN A . :SEAT - 6.6EAt BELT FAILURE EJECTED y =1.1.1 'l l"i °'7f 7?) <w?? r g+l 113TRU(.TIONS: aoruw ARnowrolmSHOW vmnc7PAL dnacnoH OF FORCE DAMAGED VEHICLE N0.1 NsE THIS SPACE fOIi sAErcwND OAMADE TD Tfluu[fls.MOtoRCrctES,Erc.I DAMAGED VEHICLE N0.1IaH,wa Ia HOOa a 51;71 11 4?' • ° • u.Pa.a ° • u.laor 1 t. .. IS:T,unx ... le 15. Tnnx 14. UntlacSMe•,L IS.UMrwr,•2• 1T.Owman `,? SEYEPott DNA E: VEHIC NO.I 9EVEPoIY OFDAMAOE:IOTHER VEHICIEI SEVE OAMAOE:VEHICLEN0 ` 2 FU14CUNODMIAOE BQOTHEPM.VE UNODAMAGE J QOtHER M.V. DAMAGE 1 = FUN UNO DAMADE 3 S rl DWA.V.DAMADE 2 r ` FUNC710NALOAMAGE { NODAMAGE 2 2 H FUNC FUNCTIONN.OAMAGE { NODAMADE 2 n NNCRDNALDAMAOE { NO NO DAMAGE TOWEDSY .. I_1 L` KS(.SI. • ESi.DAAUOE TOWED BI( EST. DAMADE TOWED BY '/ ESR DAMAGE TD fd!! _.MSIGOWSION d 2, 'DRAW ARROW SHOWING r ''InwAD,r sAnrowr.ru T;k NORTH IN CIRCLE - PDierNNt9 J^ +?X? I , IGDW girl, aIMDr..P.cimo•ASIEPD+wv = ?2 _ - ? ? aow°N?ECi°°eroe„dvnmAm,awT ., ^. _ - _ - ,`q = ms`s DESCRIPTdll OF „?.`??4yy'VF , MCAWE TPRWABLYHN+PENED BEFORE OUP'W-DAFTERTHECn .INCWW FORMAT WTONDIAORMI,EMDM ?' fxi 5 Y' OkSABLLrry.REWCEOVISIOIUTY,PEDESTRIANCWA INOCOIOR,CON MC) O WNRWORKETO) _ y COLLIPIO sl rt . ?.t•r '??rf/C/! E ? / ' -u-r/.r^r'{` t-'./?i% D.Ci 1?.4?C ?t / .?G' tr/!C LE -^-. ?C T?7.E6 r,?lD _ O.v Jf ;rc' GF? //I .rr?r L•/1J? Jcr. PC .. _ - ,. l1v . ?OSIY L _ ?1. .: _.... x.t.. .. NO.OF IANES EPEE ENIC I PARK I BEFORE L VEl° HFADEU MILE yt a E PICREASIHDP0.ST dR. ON STflEE(Ofl HIDHWAYN FOR NO e10NEDIPECnON rEp tEONLY ASVEH.-?w NO. DECPEASPq PNiNEO OCCUPIED 7 x E W / l ? ?? ? _ ;?[ YES NO YES NO si • ?y?F 2 0 ? ? - n Wit;..: ?,,?I r;,?. ? ? r? .MPH ?- n n DP M Ddeu, I D ? ? ? ND D °?T D 1? -1 a3Dd. )Ow s PED/SICYCLL4f WASUSIND Ia9oEV, ' ) °?6qU L_iCMnp sv °I_I °n u:Pp,TE 1...1 Plfi, '?• ;, ROAQ SOU gAQE_; yz,,;,_WEAT? „{,t,._?CQHTHIBUTINOEIRRCUMSTANCES ,;.?? .:-.w.rrRrvoxlc.cmNa w°cu Szl ow. , orarFR - cHdavEn ucRC oRVEH L i caw __J a u Y 1. ODrcED ?,? .«ADwwD C=? °'"°'?E° ""_ ?'? °?OOs ?s°''.. a n 2 ? p ??0 wum wD¢sa ?e?- ?u ?..? AvcE°mY- ?a? oH°r1Oiurr. ??.? I ) ?a?. arcw a? sxowxo: ?a?'? srArfn '?eT? sa,u? f-?.pr1 IMaenm?AroRruwa.. '?e? ?sw.'°r,ulw .?? ? ?`.? ?? ?. ? ? rDD ?. ? ; ,PPf u C ?J . A L? eLnJ DEG ?dP.. ? ° ? , u ;a ° NO?On/.YIMV mdViEa -- ^1,? DIHD119PFCW1 Dnfilar/.CSYI El d9PEB?AIQ eRM ff? 10 H0D E31a)FC•xl 1 ".w T s T'. .y LIOFNT ?NDITIOfIS >TRARIC CONTRDL. '?vD.dc ?,TYPEOF ROAD, VEHICLE CONDITION ?:;.SOBHIETY ? (?°? oR810°°FSroP°uondiON°? ,?'?, nYi Ho "K?.dE w rcHFa dvE os wa: .. ,v.dE ?o?e or°T"E ; rcHErx aNq `"' ?, ? aGHN, ?, ? OK Al Hn ? a ? H ? 17? A an,olw ?r? noH°P -- tJe? )wow' ? ? u .- , «MmxR"B1EO ?,o n"°ix 1 : wwH I-? (? a rva { El"D d a? ??I'''?T _._?4InJ _n? L?-.47! wNre ??Q_umc-°°encn ____ CI)? rfl°v°rla lx.rw"° u J.??„ °4a1__N^°sox^•°r __4.4J N=A,^..__.?Ln SJ°LJ-s°TM- .?°u °onraw ?,°?nvxNO y4 Y • ? ornsai ? ? m..._ ?•? nrzVOiww? r ?e? ?msd wuo CHEM.TEST r , r1 ?, .r 4 L _LrT'-r-T • `"Q"i'^= TL!_a?A? . ?.L1.vs.wreoI-- -LJ-"?' - -- ?_? ? IsfEam,`y? I .?'r V!TS ,N )? ' DED A?Ic F 1(t-.J? ormco © ^? woEFECa ?1 rrsrn?usao ' y{, 5y] r Nr¢ f41a1 .1 urDMDm i1.i? AY?{fomeewP[nm y t. L, S - •1 lV ooxrwl 11 x,11 1.1 % % TEST RESULTS .IWar:u-?rcua H erm. w. Pdc ueo ..ar.)o cnav { ' ail O/ clCt? ?'? °? /}f:J I.•.."`r<°,+J%f? 2.oD J y ¢ ii1 13 ` ? msnu.r..oa.ex.a a ? F.ooew wr pII[rORr, APrRD.som rz ? ° { ?I r , el,r Jn Y ? 77{{ '?'k'}4M• as, iu J A `C4 fl OF_. OATEOFCOLLIGION OAt Oi COLlISOii _ ME CGUNTY NO. /? CRY NO RBAH 1 SUN MON II LS (yLO IW iN SAl ] 1 2 5 6 IUSE %<(roNWRI a ?? 2 ? RURAL I E - ROAD ? CITY STREET COUNTY O ADM CLS. PHEFI% POLITE OR STPEET CODE SECTION STATE ROUTE VZ&C p ? } t? 3EFF?R ?OIHERISPECIFY) j -R. FD MILEPOST ?IN CIiV OR TOWN 3 N W 0 75 0 O O N OF._HAO)....0 G /H MILES LL PAAIy DIAGRAM - DATA C AME ROOF STREET OR HIGHWAY iCHSELTING WITN' STPCEi OH gOAD Q A T w1 o1V D d(REF ?O ACL OENi A INTER HON %RO INTEflSECTIHG STREE EREN^EC TPFEi ON ROAD INL CLS O N NdI1NTEPSE BETW STREET AND EPT EEN - - - -- ----- MLEAGE LODE Pk(?r. . ? SPEC L -HULILE HUNDAOns ENLE OR CROSS Si.VEEI EF P OM E P ANDORECT ON F DISTANCE I p ?'1 ' Wry ROAD #1 O ROAD S I f ? L6_J 19' OF -C01A SEVERITY D_? EET EHCLE-VE-LE ?VEHCLE-PICYCLE ?OTHERIWRITEI ?HIT6PUI: NO KILLED '100 ?V _ STOLEN VEHICLE _ COLLISION INVOLVED: VEHCLE?ORIECI ?VEHICLE RR TRAIN _ NO INJURED ? TOTAL NO ?? J ?VEN CLE PEDESTRIAN ®N-COLLISION ?HAZ DOU MATERIAL _______ ?_ ? PROPERTY DAMAGE ONLY TO VEHICLES L J _ ? EST, DFNAGE LOCATON OF OBJECT STR CK M EI S E W OBJECT STRUCK NAME OF OBJECT STRUCK AND OWNERS N ?ROPOWAY FEET ? ? ? ? RD EDGE S MIDDLE DRIVER S NAME LAST FIRST MIDDLE Ir NCYCLISi pR PlOE 51 NIAN Cn[CnIQ DRIVERi NAMENST ... FIRST _ ... 'D D y y raM E? T R - : R .. I STREET ADDRESS _:,. .. ..:? . ODIIE55 STPEET A v oX.. X02 E CITY STATE 21P CODE PHONE NO E CITY - STALE 21P CODE PHONE NO R R ATE OF BIRTH J 9 O N DRIVERS LICENSE NO. STATE SE% D iH . &R SI,ATE SE% D^ (E OF MO. DAY rP N DRYERS LICENSE JdLd R D Y O o. s69a f P EN O / PHONE No. •j OPrvERS OCCUPATION FIRM NAME FWM Nw pgIVER5000UA1 SQL gtfpLOYEO VI <fO PA BLLE o)i F5 At ?NTFR OR NJ Y Pr i - 14' SEAT SECT I51 EJECTION LASS CODES > o, COLAU.45 --' 14' SEAT PELT EJECTION._I CODES > ID C NAIUREOF AT REOF IWUR ES UR ES ED RgOMOME TD F M M SCENE Pv: TO -CONN.1 STYLE I)OR VEn. YEAR MAKE IOODGE CHEV.I.. MODELIOARL-NpVN SIVlE 12 DRCOrN.) VEH,YEAR MAKEIDODGE-EV.1 MODEL (DART NOVAI . /Z TON V E. CV• E VEM.CWOR - LTC. PLATE NO. STATE. TRAILER PLATE NO. STATE STATE -. N VEH. COLOR .: l1G PLATE W..- SLATE TRNLEP PLATE NO. N ` I bOZ I ._ VEHICLE IDENIIFICATI N NUMBE .. - ODOMETER _..r _..:- :w,: wll L CATIDN 1NMPEP ODOMETER C .... ,.. i F (+ C L. .. I I DEN V K: E' ?1L1 5 5 1115q u E E REGISTERED OWNER-LAST ,. FIRST .•• ?.MIODLE . FWSi MIDDL REGISTERED OWNED-LAST .. :. .... .... ?. . N N r . ?G AS RUV V V O• S OF OWNER ', ... '..-:' - ..+?•:.. 0. ADDRES ADDRESS OF OWNER .. .. .. . .. . Z ' NAME AN DADDRESSOFNSURINCE GO OR AGENT .... ., NAMEANDAoORESSOFINSUNANCECO.ORAGENT , ? _ ?QQ? 55 (LN?( ? Q?PGEAIT9 750N NO. ENFORCEMENT CHARGE GRAN 5T ? Lr E ACTION ;..: s ( ) G lECt ADDRESS & INJURIES OF PERSONS INVOLVED T S S " .. E sex AGE TA U ? R T , NAM -6 - NAME SAOAdS _EI?ELZf??.01 c25. I ' p 3c z 2 6 JY It c 1 ADORECS RT 0?' _33 P -5_T__7'?IJ?NS.HN ?fu?vBE D`f no ?t7.?0>:1--. L ^ D F K RATLINE OF .^J W O. N E t N SCENE HY UrnFS A NAME -- N T 5 ADDr+ESS N IURf OF-?-J_. "c?OVk?D ?NpA To l LINES fiC IN, RYr Ifi JU --- to NE 5 NwE S To - E S, . cn i xr w iurrD? AWN,(5 A!S AI SfAl I4 Ll SlJEGIgN III Si AIDS JINNRV CI 1115E AIrgSrlpN 1 ' OT G/ S DISARIING INJURY IOTxISTALLCD NOT EJECTED C O N STAYER OINJII IV IIAIL EJECTED T{ ) PCDl51PIW ] OtnEI+P05111ON J DEAD ON•AAnIIVAt A NFVI(OLNTI NIJU r D USED USE G ;AN OWNIF A prG rCllSi +C CLLI ° DICD IrI HOSPITAL ) PO`.SIRLE INJURY A UN-CYN A UNNI 1 6 El .a D E . 0 _ S SEAT RELT FAILURE EJECTED l PUS O 50inEN bPSuSM I U E WHNF55 _1 _..,. G 1. v A iw ?'S i?ktS. f ? _ 41i rvR7 ?. ?J= PT? I??"!?.?f ?? ?';? ??+ 'l?x?j?Doh ^,P" s 7` ; • _ 'l t.`? ??' syph ` ; + lye-?,' A pP. i r >•If? a l- oFE c L .a E PRE.. )1I?'?M1? - VEHICLE DAMAGE +. IN E ac RG C"' ACT. E !s SHAOL La ] 1 . ,1 o Pal ForaE N( INSTRUCTIONS: ] Dnaw an nowa rc o En oDE _ DAMAGED VEHICLE NO. 1 j USE 1.15 SPACI DF VK!) DaMACi 1u iRell EXS MD o c[ ...{{{_ O/AMAGED VEHICLE NO.7 SEVERITY OF DAMAGE. 11RICLE NO. 3I LA OISPSLING DAMAGE ]pD1Nffl M.v.DAMAGF SE pXOIEAbELIr,G OAMAGE)XEF'E??O,"ERMV. DAMAGE c Tv Or DaMFGE v(NCLE NO.x SEp RUrSAbL Dar.IaGE ppG)RERM V.OFMFGt rNG ]? FuNCTIONAL DAMAGE . p %7-ACE NO DAMA GE x ? I Cl DNAI DAMAGE . ? ,t o.MAm . ? rm DAMAGE ] ,unn roN ? T MA TOIED T. DFMA.E lowfD ar DAME E Da -7- TO DIAGRAM OF COLLISION i ro[«r Fr. - DRAWARROW SHOWING NORTH IN CIRCLE ' _i ? / - Fo,on,rA ow FL iuNLe u.,¢n Ox orr bo.ow,r _ e l/ E 1 -?.- .. J "-' -'- «[ / DPRL, DT1IIGN,.,r «,L, DESCRIPTION OF urvpICATE WNATPRObAELY RAPPENEDBEFOOE,DURINGArvO AFTER-ECFAS".1111-EI-FMATIDNFOTONUTAORAM.EG. ORIVEn OR REPAIR wOR» ESr c COLLISION . DNSipucrlox 11AElulv,R,EouCED VISrb?Lnr,PEDESm AN <1.1-IN coloR, .L.__ POSITIO `O N BEFORE COLLISION O STREET IG"WAV NAME OR NO. 11 I" IN plr[IECT uN ? -Ally C wPA Vi?D P O C D.. w CREASING DECREASING E C U IED _ 'p 1 NO vFs ND ?. x a ,G IL p ?- 'ED C ST wA U NG. n S OR ]_ XOULOER C D C RK 6 G E LK ] 1 w L E TE 0 E '11OADSURFACE WEATHER -EI CONTR IBU I TI NG CIRCUMSTANCES .. OR MORE . of ACTION5 . C CKONE E ICXEC O ] x _ I " GOING x STRAIGHT READ NO. CLEAR. CLODUr 6DYFRGAST NO 1 - lNOERINFll ENCE OF ?._ALC4rlL . G FLLOw NG 000145[t _ Drs ED ] ... 'G rG AnN _ an'D PASSING - '""- wET _..... ._. _"...._._. - A KING ?...I _.. _. LVENCE D UND _ I O rvT[R ''yy 0, t _. .-.. APP [ Tlv FSL _" ? 1 AKINT ] M RIG"i uRN - ,] SNOW ] SNDwrNG EMCEED s iED ._...... y. 5 vA_G TO .. I IMPROPER PARK xG LOCATION Nu '4 LE TT RN IC OG CKC F s' rMr NOPER )URN " D G vF EOU P. DTIECTI 'E MAKING I-' s ' - GTR[N ISPICE vI E. ' ' -OTNfR SPELItvI - .-Cl 4R ART R/w G; rcu TO V( ! ' IMPX P UISrIC4Anp II rioPRGD.,LIq"_ ?.." r._ U2`t 4PIFO STOP IT ilt 1 N ELOwrNG 6 51UPPC0 FOR y LIGHT CONDI710N5 CNIMTII RAFFICCONTRO NO_ . IC ONT smNALS vlt-oce TYPE OF RGAO CFCK ONE OR MORE _ DNEC wAY VEHICLE CONDITION Nott[ p E I" :c E 4k°??1DI SOBRIETY . ICNF CK DNE, INO i` lbl S-PPED ATEIGNAL _ TT PSIGN --I O'er T PPE°t iIO?Dw,r" IIGNT 12:, CFECxyr xD A IL R r U V-NDr1 p . / R L d,AD.-. T RAFFm LAFE •. . ] DAwx .- Lp rIl R.. rat. F.A. .?..L??.RO v1 ] "Xp AN t it rv01 MPAIIIEU__ FROM -1-14. - • PARKED POS i10N DUSK _. .... _ . IAS"IHC __ ._ -1 INI AN4[ D[!LC'r V[ NLAn LIGRtS ......... \ "NU RrCTV UNR -_. ... MIRGINGRN,EXING I]. . ."_ TnAFFCI O -SL f " NG I 1 EN DN xKINC ACKINO '' R Sl LE t . r rI io[x CHEM. TE _ / LONTSO s 54 AL ... TVN ;IrI« Lm» -_. r _• slRlll lr4RTf OPFICT ') ILAGMA N N I SIP llns? . _ - I, i15r cIV EN . OTRF R ISPIC IrvI : v C ND El 1,05 1 1151r1CruSED _ . O IRi1r(< [ ..• ...._ PI ?.-._-. .....- .x] uND OrP _.....11- '. SPEC FrI ___ % TEST RESULTS - T FFI V.U ^NN A ow S I 40 C N eAUG NO l t 1.14 EO L` L X A Fnovme I I.- NO vrsl w, caPFK(XSN MU RANK -- ? -_aXly DUPLICAI[COPV LOCAL LAW[Nf ORCI MIf Ni AGENCY'S COPY-TRIPLICATE COPY' INV ESTIGATON'S COPY N E ,< vas ?AFA , >ae [ ?, EY p t T" - v ,a!°la ? Yil ffi? a. c' Y " r r UV t AA.1 "tl tlUi fJy J UNIFORM POLICE TRAFFIC COLLISION REPORT "D.-. 1 toL II Ui[,rlor-_ -_ ---nnroF COl uslov' iME .. cou Milo-- -_cN7No r A I Ni DU• ??IJll?svL-I,?-(i-w ( .• nn llOUnl T• / q u /? ?1 snarl A t? 7 DAY _1! I' I I' I?1?11_L rEE II'I CUU111v ?SIAIE Do. rC ?COU11TY H.1D ?EDY-s,nLLT O ADM _Y -(A Ellx II??F ' I LCT GDDE ? cnoFl F ?r 'r ?o111EnISVECIFr1 St L?_ n v .; ' r G OHIO J -- -r 'U. to IL ('(ISI C ._. A1LE5 o g o ?El I', or oF IiRDLOCI? o ` r•?' ?- NAK1F.ANOoFTDILT0)?DItJ/AY IE I'LCI GINITII. STDLETONIIDI.O LIE'. NAMn UTAE 1 TA B T -?-- u / Olr1iflnsrcr o•i / -- --- --occuEr+T 'N?EiI NorTx nD Incn'stcl n[ur Dn nono on r`eF. ?y 0 M FALL 1'tfl FIILIICI.C 10 Sr6jlF Oil/nOAD \ qn 1 Y t?' N DET1 F. +if EET AND S1Hf.[t CUUL !/V =??s / T C_J ISTNEA DIECIONFFIOMIII:FEIL [OfICr10LSh LLf / # uru 111 Sr•I CIALGO.Irf('ll .l: •Y „ ? 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UECDEAI NG ON EiI E[i Un 11 GN11AV NAn.E O,, IU IN buRODIR[cilOr+ r ,I r in'11%tr E5 O .1 I 111E. WAS VE" U 1 - YES NO T I I I . lr„r1 uS,-?i D L G , 1u.r.r 11DIDICVC111TWASUSND IIOAO SUFI FACE ,CHECK OV I 1DEUA1K ...'YEAKI?NR rl 1.KNA . 5 IDD Y CONT I ILI SW TING UI(tCUMSTANCES A. r.O +G 01t1U 1[I ICYCLEr10U1E ALK ;1 UH ? i O D p z i NET I alU ' 1+ , ICE I Iy ??. OT11[ 11. C .6YI CLEnrl cfoouv . AOVLrICAST . .. `:.I JOIY rvo _.. [UG ..I OilID 1S.-I YI I ... o ?., I UNn rwrrvcl. Or LCU o INn .n1JTt U(, [ nu Crl E I AS. .LS to 01V. C.' t? 1 rn - „ TD CLO n - C N11rr a L 5 I1 I rr D 1m cD; $lDl'N nOL 4nT ",Sn[UU'1'''rt c? c r 1 rr..1ENTLY L II .. IG DC .._ a I nI1 G C' I rUU P..... .I a _ r TON 1 _ IEAD D 11NIGHT n DIAKIN. I• rt n c - 1 Gi : M1IAK'+G PASSI N , O L T IN UTNnil '- a '? ES, j S-11lc DII - LI FIf UUKIJI TI ONS T RAFFIr•CUN T ER01 T wll ND. . u I v 1 u 51 CAA SIGNAL UF ROAD VEHICLE CONDITION OOIII%TY I TYPI IC1tLeONEONAIDIN. ar' ( [pr _I 11,1 rcK UNk1 1 I'i.. 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'y TRAFFIC COLLISION REPORT - UNIFORM POLICE r A V * L 2y3 a n tz 35. r a_ j .? _a ;. GATE OFOCOLUS10N ..t SUN \ 4DNI ] Of50]FWOL LIStON • 1 p 5n1 n? TIMDEyw? RI _ COUM?'Jq I CITY NOS, '. 5' f !. ;il1YrA[ 7.7 I lr7 "^ T i y? :. cD rJ V Z • n /{'/E'? '?"?'?' ?STATE POUTE CWNTY ROAD ?CiY STREET ?M'?LS "P E % ,i nOtrflp? CTIpN Y"gC•?+[?1I> ?O HERISPEGFY) - IW 3 A -SJ} L ^ - ? N.. {T? /.?. FITY??OyLy TOWN W PREFI% EO.' MLE C,. MIL'..:-N 0 E. ?W OF ?? 1 , P!' Y O 1 (rt J )'Ti _NAM d O.OF 6TREET OR ryIG 1W/.Y,=-M. . INTCflSFCTING WIIH_6TREEt OR POAO LL J' RAMP DIAGRAM OA A i` A 1 7 -ti-T p ON o x ) p _? (•., NONIMEFISEFTpryi ?_ ? .-_ .. ? - - ? ('?^? N Jt /? 4+e. - ACCIDENT MEP ON •, %flD INTERSECTI NG TR E Ap , f)OSS SjgEFST POAD I°?d -, ° • MLEAGE I TEA pB N'E' (N- pEiwtEN_ S11LEEl µD __ ,S EET CODE r Y 1 GSTANCEANDDIRECIIONFROMREFERENCEO?CR055Sl RGET: y [? L- • ?MILES N G E W .. flvA'G+[ixa• C CO I E Y?y I S'v >.-- FEET OF ___ __ ?• ?. Z.rM. vnI uYti?J.l.# f3 1 - mVCHILIEVEM CIE _, ? VEHICLE BICYCLE ?OTHER(WRTC) TtRUN { SEVEflITy COLLISION INVOLVED: VEnICMOG1ECT C] L ICLERR TRAIN N NO NLLED - Q 6TOLE TOTAL FVEHIO VEHICLE Cxy,? O - NO WURED' V ?? OF VEHICLES I " J? I ? C) VEHICLE-PEDESTRIRN f3 NON COLLISION ?-AROOUS ATE ALL . ?pPOPERTY 0µ1AGE ONLY A ' OeIECT SIPUCKINAME OF OBJECTSTRUCK µDOWNERS NAMq_ :: :'...... ,, LOCATgry OF OBJECTSTPUCK -? E$T 9AM GE. N S E W'OF ?RO DWAV FEET ? ? ? ? RD EDGE S•?? r. „ • OWVERS NA E_I/u(? -+••:.!••Jt!:?.-• FWST?S«-.t-"-«'?•r• ODLE_ IVEq$ AMCiAST F II?T MIDDIE J F d? CL a7 pt' alP1AN CMECIU[f,? •, A ?' strPLEr - _ ?.. ,. R sl D E? ?-?Jf ?D .x N E Y J.. y-/:.•:.tr aY. ST iE.G"..•. ZIP CODE)... O . E CRY?.,Y a.A..... -GTATE . zr coDE Q w 'ENO. ' N ORVENS LICENSE NO.,.. •_. ?:- STATE .SC%.OROV dWIH N R IV UCENSE ... .. ._._ .^ 'STATE.. DATE OF pgTH: DA °- V'FL.lFC? O. AY YI]'if0 lbl i 0 +?+T31 •'lA 1q\ § RS OCCUPATION FW NAME ?...v_ ?.,.??... PHONENO 'j`, O1WERS OCCUPATION... FIRM JIAME.: .. _ . S/ .._. 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I.?. 71OYf fA C:n111 ilT"" CODES " !d;ry -?' ( o How ESS NAME ADDRESS & INJURIE50F PERSO SLINV0LVEO sta AGE s1ATUS ] s s A uECT.) vs "sci«E nr FRDM .. TO'?ru flq,, II}} eq?? y.J r . . . I A, tyJ??)..'^u F r. r fY fY. y. ADDRESS. F MA URE Of 17 rAdVCD FIIOM b n^'R' V y 1 A G 12 S YiRIWEa SCFNF qY T6 .1 ^. J (F n fIM1 NI' NAME J lJ r 9 e' 'T M ycW+ E.T MAm/s - "?.cr NT nr n .. A To 4YJ?,',i J A K I `. E NAME `1 A I s ADORtSa y ??Fkr'Ey i B NF.F scLNr 'fT"Tgis..t To y',, ' ? u iua u1sEAl rosioH IaIwAIRYCUss i. • j A1 PFlT ISICJLCIIOH'h,A C ) IASY HGIP - 1 NO MJIIRr 4 4 gSMN.INO MJURY T NA1ALLED NOT [JCCIEO ?' n-- (? fµ D It Cf N111AA ) Of AD AI SCI C Ip Nq O`A p1111G I 0I USC ] TOTALLY CJlCRO N 1 ) d A I, t ) ) 1O ER 0.v aM ?O!A AL 1 Ilv10f 11 JURY' ED E ]GRTIMtYEJFLICO n ry } '? Fn•MSSi• •?? _ •Ipy11G.U N+CI UCOMNOSPITµ !)P04SIi0.[rpAlllnT 4rINLISE Tyr NOWNIf 'F !' {i \, 5'I • ] ...._. 7K%J._. _ y....l«_ «...4? 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O R C GE: W.'f TOWED BY WEDGY ST DA AGE TO WED GY ? , ESi O GE N'l TD i' ?. jE fE' .}I,.. : I ti^? i UTAGflAM Of COLLISION I I i 1 :11 I. !( 1 I I ( I :I_ DRAW ARROW SHOWING 1 .1 -I II I t ?- NORTH IN CIflCL? - O tr?' L rDIN,D } I i I I . J '4 i ? ?L?_l? I I' I ? I `r_-? j=: 1 1< ( .1 (•L, I _ '? ° y; lR.6'I AV 1 ? 3 "101w I I". tad t Ir_ ?`i -?--rte r!{ t r ; - f -7? :? . usCFR . I c oR .?- ,. (. _ ( I I I m I t ) DESCR PTION OF `r 1 EwN rNA a D E n c G n DI,?ALvc-117 T IN ;I.. COLE-1?lON ?os a u?ZyrsEy>LFYbyr tiles E E RIA c o Nc coL Ar?tD .eo R tEP?T n?i9?Eig " "'`?r?n3lr J? 1 STRU( " q-m vi '74 i } A I TAYti ?-iv n .? 4 Y t ` J N", P ' lUIECTEI DST D"' POSITION BEFORECOLLISION _ ON I% O .DS oP.ys EELVEHICLE,. 'W II ?!P? Dk y cq NO W G CR G STREET. l.A _.. n M[. O 5 '{y ^L •1.? .?A. I ? -fir, E_t? '' a•? '? , I`4 r' .v ? i 1 ....t_ 1 ? S ',_J_ r? luo s ilo vs r ¢ -RH C?CL ST. To G-EW .?_ T Pc a 17 ^L I f C" 1?- v Ci E 1. WA OFA CROSSWALK ' ? fY _ fl0 ?O SUP A6E t . .. Y[yECTONeRIa voWRI;OTI?NC CIR n MM??ArV? r' Lv t? 1 t N?ZA N E T DRIVER G. f 1 o R .?_. t •1 ' t : ?i?'. Al T ( clE d c r n u p f LD,E } ° °`r r1G•ED TRfr y? ?}- p K c ?. _ Tl?Y[AGST_ xz='i u ' ?C?Y"sG 5! ?Y EHL?17 (''? 1. Au c f '.Tj7/, WFT .L?_L l?r _NPYGj. INFLUENCED, UNDER f I E n i.l Az4E. 1_JDI.. G T° N •? P- p rte } I k OW I C I ..1I? EEOI TA ?} ?I_ 5 G O 7 ?..LNOC o 4N ° • °E? n RAL AS ! - -. L rF r.x ifE 5rtE "i.J 0nE F3°-I r ... PE F D .. ?5?.1 A eRx>4k £. uar? e 10 T rv?, L E ? P +•, r, - ? T \ 61_ rvnW I rvm -' 8 O 0 .. O t I Lti 1 ; _ AI P O F ?I s c 0 ,I R Es cxu }L i c ( h I °D" ON STOPPED FOn S I). GHT CQNDITIONS C ONfI RAF FIC CONTROL NO } VEHICLE 1 E TYI E OE ROAO NO } 1 . OR NORE VEHICLE CONDITION r C pQ?I E t ? SOBRIETY - `s 1 - T ...1+ sq T Al IGxak - y L I9CO s 0 E n ". ? { ( E fl 'f FDI ° '-LIr+,1 O N E - I V I E' RYAY cI EURNN III - V_ > IN L ` U L.'E' .J_IMP nkLlT- HBO ABILIT TT L 1rDL ANE ST RT G ,o Y I :,nor -AIRED A IN FnOM l9 (] PAn[En rbsmoxY. ] W A( c E G r c rk._ LOU nAM? 11 t I_n r Ts .E E .. 11x1(- .. U bE ON GN[n NG '' '}0 T r c G S [Ei LG TS ON Is n[0" rJ J.-L E L.. -0I3 OOC[ I\ [° mNAwG qN0' 0110 ° -STREET ° E ('? rNN CHEM. TEST LIGHTS 0 E I . s a AL.-. -'?5?- e I r b L? ? s ntnMOC c1Ai1 ' .. -. ' _.-. ITGIVIIN J ?' R __ f IsEC I U ,. ' A 11 • -+ } brv D _ (\I Icy NO DEFECTS ? I (J Tlfi n[rus[D SI O nrR Mi[Clrvl ^ K T- ..._NM- l\. 'y'"OSrvEN ISrEC?r vI NEST RESI/LT6 ' 2 ? :1 a1wAT Nc or RAIK u ND DI « IR SPAICIRD POI. 'Cl .R v[D 4NhILANCE c Dw ikA3 b O NVlT K4 )NCO fIGIPl NAVI ARAr A Duf NO AG[NCV 14 iTON . s UfI AD[ At"" T X ?s O lC0 On xnvtDRr DATE ?R Y 1 /; • I 11 ? . /. L1 "1 i r N. • 151R RUT 0 OFIGINALCC Y, SEND TO WA5HINGTON STATE PATI OL OLYMPIA, WAS IINGTON9054PI WPL CAt1: CORY. LOCALE W[Nr ONLl M[rT AGENCY'S COPY TN PLICATE COPY' INVESTIGATOR SCOPY ?? t EA A? y INVMa}i `?.. ",I%: ?U.'lG 7 r ? . . CG •? . c.?ydiX'Y?"J ? .. '--- ?: _ ` ' j Q n - _ STATE OF WASHING TON PAGE I UNIFORM POLICE TRAFFIC COLLISION REPORT ,id._.l ??{ _ Oi _ _a_?x ..ill. _iSGYGlfll cQuv..uu'3vv9 .7 i43i.. t ? I LAY Y 1 ? 3 i 2.4 21 J a.... k.1n } V"iS ?? l .yy D DATE OFCOLL .- BAY OF COlL510f1 TIME C W1Y NO • .. OUNTY NO rHwA M??Ey ? ' A MO. OAY YR B T SUN 1 Mp1 E IUES D WE A IxYN S fnl SAi IUSE 2100 H OURI / ?UR?µ 2LR µ E J CN" O ?STATE ROUTE COUNTY ROAD ?CITY STREET Z O A D C15. PPE RSIREEI CODE SECTION 4 6 ?OTHEflIF`10FYI y R ?, ? ? 1 U ,Y JSL ORVORTOWN P POST EO : REFIX I 0 •JMRES ? ? E ? ® -.--?.l-4ClJ_O C,(. _____. ____ IN ° , - ': C/? JV fY M C ',. NAME LNO OFSTREET OR INTERSECTINGW'ITH. STREETORROAD FR M. O11"A" OATA - S 5" ?$ HONINTETISECJKN. ACCIDENT TER NON %RO NTEASECIING STREET OA ROAD OR RE' T QR RO Cl9 ERENCE ROS TR Ff ?•]!f Q' Q MILEAGE MILEAGE O ?,S f. ? j 7 ` . 3 N . J0.. STREET BETWEEN_ „ GTREEi D. .,_.C Y CODE (LJ • 7 - .. 1 E OISTAHCEANDOIRECTON F FROM REFERENCE OR CRO555JPE Mxrsw S H PECALCOOINGUSE - { ? j MILES N S E W R IB /? ? C A ?FEET- ? i? OF ERITY ?VEHICLEWEHICLE ? VEHICLE BICYCLE ?OTXERIw-EI ?Mi]RUN N0'D" _ . R 1 • L LURE COLLISION INVOLVED: VEHICLE OBJECT ?VEHICLERR TRAIN ?STOLEN VEHICLE NO.INJURfD TALNO Ly . TO OF VEHICLES ll? ? VEHICLE PEDESTRIAN ?NON COLLISION ?-ARDOUSMATERIAL ? PROPERTY DAMAGE ONLY B , OBJECT SIPULRINAMEOG ODJECI STRUCK ANDOWNERSNAME) ST. DAMAGE ?ROADWAY FEET ? ? ? ? OF EDGE S . ? - FIRST-- MIDOLE- DRrvERS NAMELAST - " DRIVERS NAME LAST, FIRST MIDDLE Ill bICrCLIS1 OR PEDESTRIAN CHEC )U D ? -n?/OTS- JJto C R. _.>_ _ •._...._. ____..._ _ _ snEEr ADDREss -- R S1HEEi DURESS .. v G s7 • v T E CITY STATE TIP CODE PHONE NO. E CITY STATE 21 CODE PHONE No r '•` R o J ? R >? N n a - flNERS LCENSE NO. % SIAI % OAIE OF BIflRI I AY VR N Q DRIVERS LICENSE NO STATE SE% DATE OF BIRTH MO ' DAY Vfl. a ?i ! O I n ' ? III'•LLL? IIII • ? ( PHOnE NO. PAR ON FIHM NA E DRIVERS OCCU - '1 OCLUPATION DRIVERS FIRMNAME .. . PHONEN . - ?j CODES 101 uss _X? 111 SEAT BELT.- 151 EJECTION CODES > IJI CLASS-- X11 SE BELT-- 151 EJECTION w,3?YY S TUREOF ? ? TURF F JURIES 1 NJUPIES bCF EI,j yJ 0 _5 O • REMOVED NE INC. VEH YEAH BY: MA IDOOGEOHEVJ DA.IN. Al : TYLEIRDR CONY.) MO.E? VEH YEAR MANEIDODGECHEV.1 OOELIDARTNOVAI. STYLE I2 DR CONVI V Q E VEX COLOR ' UC. PIATE.FO. STATE TR LER PLATE NO. STALE .. N E VEX. COLOR LTC. PLATE NO STATE TRAILER PLATE NO.. GTAIE . (i'Y . . ;?X6 -72 f, 14 H 1. R Y • (•' VEHICLE IUEXtIFKATION fNMBER,'. ::.? f... ... ODOMETEfl . _ T..... C . VEXKLE. DENIIFICAII N NU ER _.... .- - : ODOMETE :. .. _ ,' . A _ 'L E (COQ A991 7G i2, E. ; ,_ • . .. .. MIDDLE .:.' FVi51 .• , Mi DLE AISE- :- . REGISTERED OWNER- ST.. -.;. FIRST 4 N' ', F • N' o ... .:. .. °• OWNER Y PlL :.... ......:.. .,... ._.. ADURE55 OF • .. . ADDRESS OF DWN . F oS 9 T4 ?7 -pa.E?wnsr?yfi 2 NCECO ORAGLW : q NAIAEANDADDRESSOF INSU -CO OR AGENT .. - .. ? ,. .. ..-. - . NXMEANDAU ESSOFINSUHA CHARGE:...: :'..: '. T. ._ ... or%IIDN NO. BEN ORCEIAENT C -C f ACTION ? ' D N S INVOLVE NAME, ADDRESS & INJURIES OF PERSO ' SEX AGE STATUS °' EJECT. . NAME: U V RE OF nEMO EUFnOM HAAtU PIES To A N NAME' ADDRESS Ofn M OV GI S ? To ru OF SCf RON / . W NAME'. - , T ADUr1ESS -'- Rfii110M V f N IAU:.FR scrNE nY To S MME S _Orncv __-- , 5• wAiN ] SLf Nf rlv I TO IIISIAfVS I]I'u[M P0.511KN IJ)NJUR. CUSS mm-v I]I GECTION C' C PXSSINGEN ; rLMSIr A OKYCUST t D IOr CnPOSIIKH ( ? O "IURY 5 DY,ARUNG INJURY DL DAT SC( NE 0 NON DIDADLI- 3 ]OE OONA iIµ IEVILRH111NJURY rOS91 cINJUnr ? l 1 NOT INSTALLED A NOr WUSL ;USCD NOI EICC I I f ] 101 L J CIF.D . DP IIMLV r. LCILD "Ir , 4 , D ]oTHLR I SFOSSTIpiT?RXNO C, 666?:?...??i ? Dt[OWNUSRJAL- ;II. SEAT DO FWURC uic°u E O?WIIHL55 111 -.. ...a.?:.a .... _... .+e ..?. .. _ -.. ... ?. .. t .. .._ . e 1 f t Yi f ??6 oz r , arse F? I? ?Y 5+E i ? 3 .. .+?'?s.'S..i?'r?'uIaVLU,uYeLhVP.L. ....-,.... ... ..rti.. +auwmnl_ _r.. ...__..._.?v?....w.._. waY6.fuo.u .n. ... _•1??"S"^_?' e? ?Y?' --5' f^"?I ? -??- "V' JiI.UW «IIINUIYALUIHECIIUNOF FDMCE. ? ? "? w'?Y., ( DAMAGED VEHICLE NO.1 SE THIS-CL FOH SKErcNlnc°AMACE ??'/ n •? 's -' M I] N.a,l ro TnAHERS, uorONCr LES Erc.l U.ihIAGED VEHICLE NO 2 I _ i ,? s. L O F 5 (, •x. E.E.. - A, a n^.Iw c n a P Y '^ u. u^u..F,.,.,, (p? ' I Y FO LAGS: EI DLE NO`N ITYOFOAMAGE IOTN V CLFI 1.U.rNU,^ p` : I,?OS L a DAMA A ? OTHENMV DAMAGE IEOq msADLNG DAMAGE Eq}E?NO eEVFNITY °FIO °E' VExtt ' L, f,L I• ] U aL ? 4GE ] ? FUrr,T 11AL DAMAGE ? TOFAMAG OAMAG[ I ? GHASLING DAMAGE } I N M1V G 5 TOWEOB T GE , T- A. ] n FUNC ? MACE U FIAiw[s OWED TOWED SY TO E A E OOAM GE A TO t TO S To F,T.OAM, ??6 3 - ( DIAGRAM OF COLLISION I I f I 1-L 3 i' -- - i i W ARROW SHOWING w ?,? ?sAa[crxuw? ?, r -IDRNOflTH IN CIRCLE a!,[fit.w,aFFRa,DWAr i'. t `?_ f f{' I I frq ' ,TKMGTIa?' I ?- 7 ?i? ?1 r ~' ? i 1 I + r ,. fwawYIH?LIP:DKSiAANa i I r ? ? I w? b FSi1 f warrrto.,'AT vIN CL. uR ?`Ef"7 _ _ ?' r ,waAf„R aw I _ _ ?? -? I ,? DDLL, I ? ?f _ "? i- DESCRIPTION OF DISAWLTEV REDUCE Y._1,.AFPENED BE f COLLISION maAeulr NFDUC[D Vlsla urr, IEOfsrglaN ttorN xc cofOR eonsrquci orv oe n[v ipfo ManoN nor ax ,EO, ogNEq - - " 'T - `won.. ETC.I _? A ary.D ? ? _- 1 'T ? ... - Q ?Fh tr+. K' ?? r I?A ?; a - .`-. F/F G.-. r(: T_.y' N...? Cis __ ? y '; 0 /__ l+tG.S4`?4 ?,JesLTrul.Y.L 1 1i - 4N'7 if ': 0. ( I { [.: /"' IUN e R COLLI ION Lx1 - \ EAOfD 0 O Es y ?,,:? f; 0 MLEPO Ok O rHEIT ONH° \ EEOS L. 1 f\'(y p,? I S, f Il --I INCREASING °EC AEING EOq ?y,L IHO LION ?,,` 'LC°ALLY S EN° MI ir? 'Iqa 3!MVY. i 1 (?? ?.'.? rJ_ i? L^ }NAM` L ` ` , V / 1\' - / / , t4P7 .FOpI ?O{CSC P Fp ?: ,[ Y' u 4y I. . } L..1 ? `\ ` I E: Cl it 1 I +%?` k? 9 ?; Eo. C_j?,nf A, OxG_ o slNa -- - IIw, ?i A.,RISI I - - EmSICYtI ST WAS mINO }? } P E --"I Up ALK S. _ D_ 6 q'' I AD SURFACE ` Is«ouLOER I.. cans [ j Esc E r( ?A'L"'•"'I 1: !V I;,?N>` ' WEATHER LK _ cvcLE gOUrE Eq :'.,., KHE<.O FI cNECK OnfI .CONTRIBUTING CIRCUMSTANCES i DRIVES EHF. ONE ON MO 1 DN E F Cl AC D E ?, ! IND.} NGE? OqI E OER 1 ?0 YNI xUn 7' NC. } ?I? OqY [ I ICLEAq, CLO x Eq INFIUENCEOF T'-I OLIOW NG O}'I S NGHT AHEAD f I?} T(''7 RLASI :LGOOLf L1 I 1 o GqH {/{ i (--. - a2CLGSTti_ S,?_ N I-' OV[Oq? a Na " d ??}. >??L"?T? t ?LgAINING }01CP GLINFLUENCEO IBI J ER 1BEN L - t , ASLING. j'`?W (-' S aav S r SNOWING E EE Gs T D ?' .ESIFE DS ING ^C.EA f S` _???'1-? _T}I^ fE L 1L j_S I,,,?, s° b IM O E P qK G - s L?I NIG T TURN ?} IC! . OO y [ 1 E CE G E sfOC_O - f J LE TU ., ew ?Er, . (? I?f ESF E i i J IV I?SC 0 EELT VE EOU?- S TNG RN '.?' ?. .+I e. Y." ki. f1.-I _ __ _l. l JS?? 00 OTC qY 1, 1: I s GaAO ,-'L E. C_? ?_ U.TURN ?A?Z'. DTNLR IYECIi11 O FC YI - ._ V ONIf GOL 4 I i I - - ?•u SIOWINO S I r' BT S°.4 }4. S fGARA Li i OTHER ILIECIFYI I v CONDI710N RAFFIC COYTRO ENO. TYPEOFR4AD VEHICLE CONDITION NOVOLATION [lT? TOPIEO FOR _"'S";L } ICNFCK ONEI OIVfNICLE IND.] ICHECK OnE OR OREI SGeflIETY TRAfFIC EH v S 4 E ICLE.HISPSJCQ?DI NO.] C,B? STOPPE°AT 9IGNALI I Y I' r- ??? J SIGNALS ??Ii_ ONE WAY NOt `? "IM1-gl,t CLE ICNICK ONEI rr OR STOISIGN ?" 1 DA G T P .n ?- .. 1-?lL? g0FPED IN 1-_-Y - :IGN_ V } SWAY . DEf ECTWE NSO AS LITr ?I_r I .p Y I t I,' T OMAN l - I YH - -_ I •.-..?.-BRAKEf.._ ._ r:? I °L_ A A DWA w _"< 1 ' 'I , 'I"--'? DLI WtK LDL. Sal _ 'ICJ R.O.S. f INO ('I I--1 --? I L I I OEuwTIVF. -... NLAO LIGIITS? -IafNfl[n }I .i...NDT A"'AIII[II f'' TRgfFIC UNE. C III ) F R ,?tJ ?` DARK , REO IJ L..?-L00 RAM °E ''-' - Ii I OfFf<IIVE L _ I} 'I-HBD SOSgIFTV- PggK DPOt Ii1ON 1 1' ' T [ , f [!T ONT90N. - - I S«INO Sr ALLEY' L ? Bf L ? - .. REM UGIITS SWORN 1 ??NK•?- .____ MFROINa IENifRIHG ( Itl ? -J TRAif ICI Yl - , F". ' DARK S [ET. ° ua«rs . R U ,... - --'-- Two w,r-Lffr I ! ? u ? -OILSrv1DOTN. _. - HAD NOT I Bf FN OIiINKINO niSr? EXCKINO L }} .1 %v 9fE DARK o •. e T r , S I SN t' I I 2 ° NOf 7 - CHEM. TEST - 1 { ?I L ( " J STRLET GNTf I .CI ?_[ fLAG'M fE i[O OT f "- ' - i I TEf GVEN . J... .. .. OWHN IY VI ?.a l'+'41 '. • '?' 1 I OtNln Iv[C Ey ! TI I D 0[D - -. . O DEFECTS I _ ._.... _. I I I TILT R[fUl I 1 1 . . " S" fl U 0 O O OTHfN YfClf rl "' SO 1 Nvfs Tla o C L 'f t nAUU NU I % TEST flESULT3 Z E f E - . C 1 U E YID AMU LA GE AIIRIVED M o[ofoFLDW ? E M lfL6 Y 00 C R'f NAME •RANK, <N O TT ? eA [ N ,c ^ I, w . t ? _ ? r/. y. , ,1 _ l NCr • r•- t mr nn m ar gofr nvmlT . AtI Ir - ? unL RIOVL OArE L' ? .A: '.. U llI0UTION ODIGI NALCUIY "END TO DUIIICA LE COPY. L OCA L LAWENFOHCEME "ALIIIhUTON STATL PgtHOI-OLYMPIA,4Y NrAGFNC O COZYE PATROLAOCOPYA IOIY ASIHNGTUN DR4(M I` Y' ? ^'^"^^?^? ?_.-.?,_--_._....-_. _._.-.?_. L?._...J?v??_ - . INVESTIGATOR'S COPY _ rte.--r.T.R'SCo-?. ?-..-.?.?.-.ter. -- 1 T 11 4 1 1 ?I ? I r -v 1Y R?? i?.1 ?' 7 MOTOR VEHICLE COLLISION REPORT NU. PATE OF COLLISION DA Y OF COL LISION TIME OF COLLIHUn COUNTY CITY NO. CIuNAAx COUNTY CITY, TOWN Ief,--ersoh iAncam 'v 1••, MILES ON E CITY, TOWN C' `'' OF AOIA{LS 3 PREFIX 8 GIVE NAMEOFSTREET,ROADORHUHlAY INTERSECTINGWITH:STREETOHRUAO v.v v} e7T Co. r-0a l2. ff?lcck-C'c,nter R11 + PREFIX EG MILEPOST ? - ?/ r?C INTEHSECTION-LOCATION OF CO LISI N %ON BETWEEN STREET ND STREET RAMP OIAGRAMDATA O ?• N?/-- (] YI of r LT 1,?k- e ZeYsyy Oac( NTN ? "5: r[xL"C[DCxOasrR[fr ax nD. °"? wer ol.? sPEa c o sE I ax OWNER OF OBJECTS NAME AND ADDRESS LOCA ON Q OBJECT STRUCK YwforoARCrsrRVCA IN ROADWAY P..f ??QLILN DEFT s W Fiem GLYf'?. SNhW 4i: 'If v 'DRIVERS LAST NAME FIRST NAME MIDDLE E Ic.scN, PCLrT -,I C<zlverY , •' 'r `:. ", WJ4'INA-' J, DRIVERS LAST NAME •FIRST NAME MIDDLE AND BOR NO. STREET ADDRESS ROUTE NO E ' •'"v STREET ADDRESS ROUTE NO. AND BOX NO. , / B ET ,GIGS,/? St. •• •• CITY STATE ZIP CODE ORIVERSOCCUPATION '•' CITY STATE ]IPCODE DRIVERS OCCUPATION FD-ItTo?;lisCrd, ?JQ, cIF34 hrtir?. DRIVERS LICENSE NUMBER ?9C'C' 59-10-5 -c 7 W STAATE ' Y SE% F DQATEOF BIRTH I 1/ vv vEAn 63 / AGE r4 OR IVERS LICENSE NUMBER STATE SEX DATE OF BIRTH MO DAY YEAR AGE VEH CLE YA /973 MAKE Icxev Do II I= xov. o•xn IAOOE L LTptfr BOGY STYLE -, r yDR VEHICLE 1R. N AKE lcx[v. °°oe M OOEL wOV. v.xr BOGY STYLE II.R LICENSE PLATE NO. STATE r?KP ?i21? V?a. TRAILERPLATENO. - STATE - LICENSE PLATENO. STATE TRAILERPLATENO. STATE VEHICLE IDENTIFICATIONNO. H-111.t[SAxfw[RI CODMETER VEHICLE IDENTIFICATION NO. "aE VCOfLSANfw[M DDOMETFn IUn1.DEr :3 p G6 A 1 f ( 7H8 34, dcb 521: fNAHU DRIVERS LICEN N0. REGISTEREDOWNER LaiTr xsrvl [ I REGISTERED OWNER )_111 urooMxAV[r DRIVERS LICENSE NO, \ 1 LL bJVPJ I 54H'(e RS •x HG v? l?I?IVGr OWNERS ADDRESS ISTREET,c[TYANOSTATEI GATE OF BIRTH MO EAR SatLee as above OW.EFSADDIESS (STREET, CITY AND STATE) OATEOFBIRTH EAR DAY Il PARTS OF VFHICLF,OAMAG • {1 SEC' eCN.IAr[NY J-C i[DC°s ?[LE aM ? R1 PARTS A A [rw xv[xKl C1 C Scr c e<lfro)L E Ip? LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- COVE AGEWEFFECT FOLIABILITY IIDENT ON YOUR CAR 9YES ?NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAMc OF LIABILITY INSURANCEACOMPANY S N f % fo A ?S IP? ? ? O nl ts t, ?c erv eeSiyu • e r? 4h 1 e P © 7l12 NAME AND ADDRE F LIABILITY INSURANCE AGENT I TATS ]IP LIABILITY POLICY NUMBER l?om, o Ide U ?Ohio X; 79 - 3S . 0.0 6'8' 82W 7101 6 SES R-1"llRT FOR ADOTD LNAIR ESI AGE Y U ISTINJURY AGE 2ND INJUR E NOWT K: oru E.- .. DO 1. SEX 1UAfD ADDRESS SEX - . .. -. __. M F . rvrr uP STATUS OF INJURlD (•'.••"cr. IN VlHICL! ` ry KILLED MARKFRUM Diiv n r c ONETHATAPPL "??,'P. IES c 4:L 7 IIO SRATUSOF-URED • IN VEHICLE Na d KILLED MAR: FIRST ONE THAT ANI1111`..' OgVac Hilir?on rcow•uI o: 1' " ??q No. ___ r{YC126 Ly ? Jl ? 5 l G C3 r 7 Q c . ? 7 n 6c] SHOW NORTH BY ARROW IN CIRCLE w ww.. xW. ®• ` ??°" a LTw.f, coq j + i DESCRIBE,BELOWWHAT yAPPENEO[IREFCfl TO V EHICLES BY NUMil RI. .,- DYi?I' 2? snts,? h e q,fexl fJirvLtt H°cewn DK CGLU,It Ile?c{?``CZ.1¢?CrQYD.?S{y? n't e y C 2. ? s l7c 4f /C i"O e /f ?l Y[ AxD :. f.cx xrc11 xnw T. r o a. C z a [ - 1 Ia° // r 11 11 cr oN o. rP.YU ...A D,AL '? i v •? Q2 F U T[•110 o w•• y, ? dPtec? zv).cjr- -.C[9 n?.. L C ? -i ? Ce, ?[?. Is ¢NCE>_ q 1 }(aY fNL.. L ? Ch.. SQ.W !hc•1'BaSQr??et car aH brL 2 ?ppcc Y.3 2¢r L _. yC .c °t%ri? __ ra E+ I ...' --_• - p VeCr r -('lipo-] rkl (-•:!` ?e_..le{'lLrLt'hrte.---`t- -- _./2LQQ / ?!0. !1( 4.1Y. ?:[SrLC/•1?3Z0r1`• c?a_l.?j.? ..a-.?G r ry E] a (?e Y l • ? ` y y} C tl.r?JC S Cr •C rQQSI ?QuQ/M •I or C Y 4 =1J C y a • , / , IT C - G. C I 1L)t A ... _ %t!i HW:C 21! '?ICN F (V 'IL??L6( Q.( J I^ SIr?Z1LC -0 [( - I' a f, . : . ,. C . l . 5/ . ah YL?( E°.s?LL ,. AfG•-??l1:1?•,71 f';?.ka?• r,? i ., Mid cr mcH c?reYe T b,! fe re e...•.144IHre B.Llc tr. 0 - c Y•'e r'? Ney? r*-ss e! : t+?• .SltrrfCC VEHICLES POSITIONS BEFOR f V ENICLE 'IADID E COLLISION NAME OR NO. ONSTREfTOPI"O"WAY D•ICrO L•ran II [A l IX xr•A wrE NYESN 1.1, Y ?? ?r0 IVOVRI ''? ? ? ? ? ? ? 'NV[frxsAlro ?°Hr.c ?xD ^ • IOTIIERI O L_1 ? ? u ? ? Cj `•rx FEDCSTRIAN ? ? ? ? To ...• ALONG CROSSING PROM PEDESTRIAN WAS USING B?nrx[n ????.in:: 10"Iw1• ]?••••w.. l?r-w.vl+ A V..?.iw+Ix S [ SVRFAC! WEATHER LICH T CONDIT IONS POA "AF:I r' 3f:1??..v oA VLrO"i -L? ?v ]?nAIN"[G 1?GAwN On ">` 1 ? C., ) ? fnOWUIG ? DUST[ 0 _ T I • TRAP FICCONTROI oxlr x,vl .I ? l ?91GNALS ? ] J STOP SIGN ? D ? 111,D SIGN OF ROAD TYF! v"?'-. C] ONE [ wAY 1+:°r+Ir Y n A ? RTWO EVERSIBLE ? J ? REVS o,o Oy1?R IT,V ERNE HICLC ACTIONS ME 1? 1M?GOIN4 STRAIGHT AHEAD ? ] ?OVERTAKINO AND PASSING ? 0 ?MAKINO RIGHT TURN ,-j l ? SNOw A ?fOG A ? Or "f3 OV E ? A UfLASHING n(D ? A ?: N? FC-.`GE C] A C] MAKING LEFT TURN A L ICI y ?'.Ii1 ?1,?, y LCAR' 14 11 OFfEi ? y ? y ?fI.ASHINO AMBER ? I ? ALLEY ? •J ?MAKING U•TURN (??I ( y A _ ..J DiI•R(EI LIGHTS ?A ?n111'L11AL E ? ?L1111 TI1RN LAMS 6LOwINO [) ? A[.SON FOR NOl SE E1NG DANGER /U;,?, r'. • C) ] ?CIr Ill ILAGAIAN C] ]? STOPPED FOR TRAFFIC ?,y{ y1 j I.y {, I ' M P ? B ? SEPARATED ? B ? CHOSTOP SIGN SIGNAL N L 1 k I' ',IYr. 'H[Ir?r.'ri ? ] ?OIVIOlD ? 0? STOPPE O IN ROADWAY ( 1 J •. ?1 IC17 ,?,P X1 9 NOI l fill CONTROL ?.I ?UNDIVIDtO ?I0?START IND 111 TRAFFCLANE l?""?'"" wPpF mfm,' 3??)F?9' ts+ ` f cWI 7 I t ? ; ,? .Hr 1 12 ,spy {i x,4, ?• 3 D Y .i Il t + BSI S.kRL ?T£W B M'f3L, +vf: ?ELOLC , 1 l.1 ff 1 / i'E?Oa, 1 I f{AµFPPp'" rr I I ? d 1? SFE ?? G ,??, 1 r t ? Wit: a ? ,? 4 k ? '? • i A 1 I .. c EN IA A. r DATE OFCOLLISION-.. DAY No ` OF COLL ISION' +.,.. TIME OF COLLISION ffA ... nux ra H UR MI IUT ES COUNTY.NO CITY NO / 7 JCl- ); RPM C I /t O COUNTY " CITY, TOWN MILES CI T Y,.TOWN A s o acur sr f r coot JEFrcR?N - CN/n7?CC//n xO ?W OF (/Y1 C[lm ?aVV A GIVE NAME OF STREET. ROAD OR HIGH wY INTERSECTING WITH: STREET OR ROAD PRFFI% ED MILEPOST NON IN TERSECTION,LOCATION OF COLLISION BETWEEN STREET AND STREET RAMP DIAGRAM DATA yI w???n?ii rvc, rr acwir an°6ti{rYliglnc i?'no.laiiri u ..rote N ?E ?a - - T Ir n ni E C 30 f .-I.. PE TIM ? OF/ ; IIE ? . ? r HO SPEC.CO EUSE OBJECT STRUCK NAME OF OBJECT SraLCNS XOWNZOFOBJECTI NAME AND ADDRESS LOC N ATIO ?';? r..+roc IN ROADWAY L`l ? CL V^/ ? pm , r??l • '!//r1/9C'U//'? Y s r x . DRIVERS LAST NAME ... FIRST NAME.,:: MIDDLE '. ..... pPIVE.S LAST NAME FIRSTNAME MIDDLE s;c?n?aA? T)AV1 T L ROUTE NO ND BO NO eLV,o r"rxn nlA.r. ADOR5SS .A X . STREET ADORE55 .. .... ROUTE NO. AND BOX NO. CITY .. STATE, ZIP CODE :.: oRIVERSOCCUrA ..Arf CITY' ...: STATE :_. ZIP CODE DRIVERS OCCIIATION DRIVERS LICENSE NUMBER... STATE SE% DATE OF BIRTH AGE DRIVERS LICENSE NUMBER STATE SE% DATEOFBIRTH AGE ST?OU•DD-TS?iR r7 F Z. y? 7-7 m F DAY Y[A .71- t w. MAKE Ev.DDIXRD MODEL INO ARTI:., RODYSTYLE:.:DOR.1 VEHICLE YR, MAKE.:'. ICIEYDODGEI M ODEL: NOVA-DART) BODYSTYLE_ODTI JCL 7 0/ P C( !/z TOA/ LICENSEPLATENO. :.STATE,..' TRAILERPLATENO,.: .. -, STATE ' . LICENSE PLATE NO. . STATE ,.. _TRAILERPLATENO.: .::..STATE_._. use v A. VEHICLE IDENTIFICATION NO,..:,IISDlMOUELS&NEWERI',,o, ODOMETERIIILEAGEI 9 8' ? VEHICLE IDENTIFICATION NO.., . HPE[MOOELS.NE...1, OOOMETEPIMREAGEI REGISTERED OWNER ILAlT.PrRST MIOOLE EI-;; ,;, ,. DRIVERS LILENSENO.. • REGISTEREDOWNER:. IL111IPSiAnOnLE HAMEI:.... DRIVERS LICENSE.NO.:..:, S?D?a D D9J D JoFc s -w-AD--/!5 ymr OWNERS ADDRESS :::.•, :_::., (STREET. CITY AND STATEI :.:;.. DATE OF BIRTH OWNERSADORESS ?._ISTREET. CITY ANDSTATE). UATEOFBIRTH,. ZD7Z3 / St`r'/SE-/« ?• ?yz8 ys [AR PARTS OF VEHICLE DAMAGED :,o of rw fw caa P/955. S/DE F, AWC< $/cO T ? """"" oa.rwrw v[xrcaa ?7 LIABILITY INSURANCE INFORMATION-VEHICLE NO 1- cC1VERNGEEIN CFOF ECTIGt) LTHRIS TTY IDS NR ON EO AR X1 YEs ? NO . ..:..,. NAME AND ADDRESS OF LIABILITY INSURANCE POLICYHOLDER - "CITY STATE ZIP "-J,NAME OF LIABILITY INSURANCE COMPANY— DcVID J • S' ?ilH?D- ZO?Z3 /OS "P/S? K!_) l tJq. q8d?/ S/Gn1AL .:. .. NAME AND ADDRESS OF LIABILITY INSURANCE AGENT. . CITY.. ZIP'. LIABILITYFULILy NU-R . :. . STATE. . . ..: . . .. . . .. . .. . . .. .... . mlLi N /_ao z35? Ste{ JF5. 4j10y- A771f, Caa. 98l/%l ,q 1-d v4z0 T+ I, --- NAFtE A E 7_7 "?" ... A HADDITI NAL INJURIES) NAME A DDRESS ZC7Z3 /0 5 'l")P/S(c / ?"/ I_GJ/? SEX, pDDRE55 - -- __ SEX -11 !! n E l 5ti z " i S ^ •r TA . TUSOF INJURED . w rr P,fr l oVENICLE , KILLED MARK FIRSTONE THAT APP ° ?iV . ... ;. , LIES "N"Id" 'oi A irc STATUS OF INJURED ? r,P„rAr . IN VEHICL No. . MARK FIRST O oHA[IIr KILLE I? IrA' e 16 NE THAT APPLIES . &a 'ro'f. e,l.a ?` ti r0f C I F: •. NR I"i.•I'•! ?OTN^ El ?jI 5? 6I? 7 O ?t1THF P'.•:ISITF.N. ? O 5 ? 6 7 ?r- SHOW NORTH BY ARROW IN CIRCI CO o? r.a , r.P„. N DPaEa.LHDaa,LE;; rrwl ?;aln Ir .a rvr x. a . D ,a,F, Da a MA X TO VEMICLC56Y NUMBC RI.. . oa1wNC ?UiOr7R? rv/aiacu?_- i'OM t1Ct7D CAAJ.9? _ f GO ynaF._,9?/SCE aP..... .°a[La 1L[I rFrvr[LL .aD fxDY, caws EET [ STR = HIGHWAY Lfl?'._ /.//P_ST_ COcJ -OAJ A?'A•9.?r,.?E??QEi?_,? ---- slfDE-- of T?C4CCK flNyfJOCJ,---- / u / D [ _. H _ --- - W _ 5111. [1 Vq rofamAY [ VE H:CLCS POy1 TIONS OEH'ORE G LL ISION NO OF LANEs varu cLW ? wA D WAS IN VESTID TEO DY YC II•CLC FIEADCD ON STREET OiI HIGH WAY NAME OR NO. In on[ [TID-H ? oIw •;° I,OUN ? ? ? ?? 7 L[c LLL+r. c[P v[HICL[OCCOUPI[C r[9 MO Y[S N ? ? I ? ? o ? A,L ? ro JA c[ L ?} ? :Data YSlao rnvurro.no .-_ _ 40 IDnlcm ? ? ? ? ? ? ? ? ? axaarrr F -?? .. ,r:IT nr A•; ? L ? (,Intnvfi I F"cl,t TO . J C O L OIIrAOI ??CA .Jn[r IIR TI __ " IF o"U, U f111 FII/V CIE AC J T-? . • < 5YE cA. it ?]n IL.H. n cr .I Ir ,c o:iM' I. •e real errt.n onr. Dn PDn*I rr c r wlor .oA I no L `j yr ri ?I r?'.IpNnas nl nNC. WAY I(?GO NG 1 I.AQIIT AHEAD ` I-?. • I C I U. ?? p ? .T.q ?? (, , vn W A ( J L,JOVI N1AY. fi'i Alm PASSIrlO (? u (] : (1 I u •. : r ( 'I i ] f ] r YI „AIJIL [) ? vA.um II GNT Tu", f r .. r.r H 1 t r ?? i ( f .1 M1 ?I.rAMINf? I. F.I T TIIPN C_J A rJ ? ?? - . r l J I I', 'I • f l: r1 'I f r . ul. ar J r? I'L. Is I? (? rA.ItIGI TUIIN II 1 ? r J LI •• r ] rJr. ....•.., r? E ?.LOV(Ir,: LI I. r ,II iN L I.rllr ? ,. Al OF` g x?d `{(f ` STATE UI' WASHINGTON MOTOR VEHICLE COLLISION REPORT NO.aLLJ Y p?t(` DATE OF COLLISION -T[O DAY O GI, L1510 N TIME OF COLLISION COUNTY N / CIT'"o . rr +:' All '7 •' r [ / •u /? n'7 .UO uirvulfs PM L7 n.,. CP (^„ COUNTY CITY, TOWNSU 111-11111 o MILES ?ND CITY, TOWN ADMI$ PREFI%O nUO SECTION T :Hrm 'IALi "°w CS7O of P , rF ^ GIVE NAME OF STREET. flOAD O[: HIGHWAY`,. INTERSECTING WITH: STREET OR ROAD PREFIX ED MILEPOST C ti[n cuvn?!' 4 0 NON INTERSECTION-LOCATION F CO LISION RAMP DIAGRAM OATH STR...... STREET v BETWEEN Ec, NC , c rocE I N E /n+ 1? l w. q M,I R.E.11-L uM: II . Elon RO. t f• FNOi !N ?? OF I ICI I.LZ IY._ ? ?oNFf L x RA INTER IN?ER Cl5 ib2? ? N11fR5FLN0 FFi S W N IPLYO RsJNI? CSI OFA tT ? ?-? ? c ?? v I]v[ .1„w.N - T,pgY?pC? (;lflV SPED COO uSE -- .:K IrvTD®L n o ?rv ZII OWECC?T??STRUCK RR-OF Oe,ltT S,PU<.1 Men OWNER OF OBJECTS NAME AND ADDRESS LOCATION N E 0 LSTCO LLnID IN RO WAY ?? Tao FP. OlNfu E.. k. FEET S W lKo E ?RIYERS LAST NAME IF .01E N FIRST NAME MIDDLE WERE .1 S DRIVERS USi NAME E FIRST NAME OMIDDLE _ I /.. . C {.. N 010 STREET ADDRESS ROUTE NO. AND BOX NO. .PE I R_ w0 STREET ADDRESS ROUTE NO. AND BOX NO. w;P R_EATE Pf 4r z CI STATE ZIP CODE DRWERS CCUPATIO A CITY STATE ZIP [ROE OflIVEPS OCCUPATION E A C S ?? FPORI [oR. q? DRIVERS LICENSE NUMBER STATE SE% DATE OFVBIRTMR AGE DRIVERS LICENSE NUMBER STATE M F DATE OF BIRTH ACE Fr•IeIQ * -A - .-L_ WA M M ? ,E, 2 M YEAR t. s- VEHICLE YR MANE (CHEV: DODGE) MODEL (NOVA-DART) BODY STYLE [100.) VEHICLE Y0. MAKE (CMEV: DODGE) MODEL (NOVADART) O, BODY SttLE R DR) °''. 97G a?-surJ PE:k-LL , Rya" k P LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE VEHICLE IDENTIFICATION. NO. TI- MODELS S NEWER) ODO ETER IMILEAGEI VEHICLE IDENTIFICATION N0. (1958 MODELS 8 NEWER) ODOMETER 1111.111D p( ' ° r G 20- 8 '2 . 306 S.is 9.2 REGISTERED OWNER (LASTTIRST-MIDDLE NAME) OR LICENSE NO. REGISTERED OWNER (LAST-FIRST•MI DLE NAMD DRIVERS LICENSE NO. 8 OWNERS Ap E55 ISTREET, CITY AND STATE) OAT OF 8 RTH OWNERS ADDRESS... (STREET, CITY AND STATE) ..:; DAT OF B RTH r u - ,e ! 2 L PARTS F VEHICLE DAMAGED . C v ioin -iEDFeSCfE PARTS OF VEHICLE DAMAGED F cosy . ..., SoRIPMRVFncLE .. - LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1• WCOVERAGE AS THERE INE FECT IFOLIABILITY HICIDENT oN YOUR CAP W YES ? NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPANY, . . uF F r nfss f 4n rv La_ P. SMIE I t Cpa tu' NAME O ADDRESS OF LMBIUTY INSURAN^ AGENT s,AIE pP LIABILItt POLICY NUM DER, ' .-n .. - ,ux:v...[,Ero,I +cn,PP ,R,uHER y.. •, `z _ AGE !; tST INJURY ..., AGE 21,10 INJURY: I ?._.? , NAME NJDUPEO NAME ':4s ADDRESS SEX I ADDRESS y?SEX ?5Y EriE'LSLLkNniFf___._ -. ?? S+IEnLOi iHl4n,f,5_._. _ LI Tk E eEW,RE F MT, dD rR,un fS nvW RF n E OOC EOP .y? ?H STATUS OF N "R MARK FIRST ONE THAT APPLIES fr•STATUS OF INJ PE' rv.u MARK FIRST ONE THAT APPLIES ".?ijYM1 -? OA SE KILLED Dixiuln' "0"d5 Iros RoRdvq IN VEHICLE 10 ,01 etE ?pglvER IN VEHICLE DrI.EVn un'i0 ? ros KILLED y PASSE IND Isly R[I IM r?iOfi rq COU ?PASSEN[ RFI MNOgIrRD AD FRNj.Fl Ou ?.? 7'r{ w ,1 ? Ee?S'Y f ?PEDESTRIAN E rAEiLI ? PEDESTRIAN NG' [:1 5F] SkAw, v' ,.. ?Ot,'IFAW IE IN ? 5E 6.? Rfi?Ar ?0 NER WRME IN u BY ARROW IN I.L. C/ DESCRIBE BELOW WHAT HlAPPENED IREFEll TO VEHICLES BY NUMSEFIT `? d kr .;5 SHOW NORTH E ON pC HAT TP[ ED PAM O \ \ I _Y. 1- ??(?Q._.1x c 1f70_??374'h='9-YLJ Q f4 A * c5 s+ VEHICLES POSITIONS BEFORE COLLISION RD N[ v[ncfE vtN OF FP.P Dw. INVESTIGATED OY VEHICLE W R Ofl STREET OR HIGIIWAY HAMS OP 10. MR OR[ S LEOx.E, sl.RdRO O,L ..R.[D v n,qF ocdAV 11[ /' O ?ii RM ?PO cl N b E IRICtwx YLS 0 fl [SFT 0 '6 F[ O? vE? LIMPID ? ? ? ?I ? o 0 0 [? ? ?WlK[ ?O,I,Ow it "<. 101NE10 ? ? ? ? A,IMF, '*: PLOenbuN ? El 1:1 ? ALOpn onosLlNd FROM DIRECTION. TG FDIRECTION 1 [i ?' ^ M1 PEDESTRIAN WAS USING dD[w HK E WE-AI 1 SnOYLDfP . °'"i;w ! Pa 1 wio, a DINED ROAD SURFACE WEATHER LIGHT CONDITIONS TRAFFIC CONTROL K.j C.0Rt1 TYPE OF ROAD. DRIVERNEHICLE ACTIONK.IS t . 4 IG•IC, ORII CC,,,,•• vn V[nKXM [ o.![u DR, ?V1n,U?E NCA ORI OP MOREL REM RP[ IF 4q" l1, [ W E R •'{71 ?Ki31 1 1? DAYLIGHT ? I ? SIGNALS ?r 1 ? ONE WAY ? 1 ? GOING STIIAIDHT AHEAD D 1 1 ,. I ? DRY 1 ?r WINING 7 FLF?''' GAWH ? 1 ? STOP SIGN ?( 7 ? TWO WAY ? 7 ? OVERTAKING AND PASSING b ? 7 ? WET 7 L.? SNDWING 7 l MISK 1:1 7 El YIELD INCH l3 7 -1 ROA0151pt[ ? 7 ? MAKING RIGHT TURN Ftvll ^ ' l l 7 ? $NOW A f-'1 FOG A 0 DAPK.G..EET ? ? f'-1 E-1 INTERC 1 NG ?f ? $N lJ UTNLR L t R,b ON ET E FEASHINO P[D 0 E IJ (IW ? E El MAKINO LEFT TURN LyyO??E ICE OTHER 5 ? ISP[GFYT 5 ? LIGHTri OfF 5 ? FLASHING AMBER E] e ??-T ALLEPIYRAMP ? S ? MAKING U It DAPK qqyyM" E99 L ??!8yt ,' ?5 SPLCIFY E ? bTREET?IGNi6 ? E ? RR SIGNAL ? It LJ LTW0T WARN ? b ? SLOWING q-,EFY;, R71p' REASON FOR NOT SEEING DANGER F ? OTHER -I IF 'ilv N S. 1 I- 0 STOPPED fO R R TRAFFIC V +REAONvIA:NY SEEING l,D [ECI SPECIF E] Y / ?OF/ICf NFLAGMAN E- S AT 1, SIO[P SIGNIONAL , r i 1 :1 ,' ? b ? OTH[R SPECIFY ? I ? 5[P0RATED ? E ? O ?? } ? OI W0E0 ? E ? STOPPED IN ROADWAY L? E~d f l ND IR.IfIC E [-I D 10 SIIITING IN ----_____ Y f-1 11•,olvnl ?7 ?7 11-fECUIrc ;'' 1a k -0-A IL UNIFORM POLICE TRAFFIC COLLISION REPORT NQMHEH I ? ? 1f k ?y & -; i u ' H ? r ? YYY111jjj. h i f {I a, a ?SWYc vm M 3aia r E ArEn iv U Y qYn. , 90 75 ? ^UN E T IUSF 2AtA NOUAI r J -_ _ _ nunrr ,n / r N u ? 0 un O 1 ST TE ?? Ou TY AOAU [j C.T, r N1EFi O ? ??/? /?? ? PIi 11-E'r-uE LJ A kTR T A I 1 }" I J OlHEN I?PFCIFVI UJ ? LTV r-J? ?? T-?-? ' L W ? IN c,rY D a E EF " _ LE _ r.1u ? ®?(-] ? [}', pf Ch?,rlaciup s NAMEb IIOMT ?E TOflHIOHWgY V3 i.4TE NSECTING YBTM-STIIEEtOH110A u Mr aLHAM UAq .? T (? I NOH INTE '-" ' Q , '1) O !\? N' TtiECTIOH TAFEN S•aansrJnville Ro act STnEE'i nND eilnt RO.'1ft 18 STIIEEI MI LEA1E C 50 " T fESpC Q?E Ei I> OR °Q_ L nC L:3 NO DIRECTION FgUM nEfEgENCE OH CR WS ?NicET ILES ??11 ?J . ECI O Inq I1SE F EET ? ? 1 ? ' Hur U,f IH l.? L,SJ pF (, tlLttacun intersection COLLISII.YJ INVOLVED. "VEHICLE-VEHICLE nVEHICLE-OICYCLE T IW TEI "NIT. R.. SF VERITY TOTAL NO. LVEHICLE OOJECT "VEHICLE-AR TRAIN Culvert -..NO. %ILLED ED STYLE EIICLE 2 V © EHICLES "VEH ?_.._... . NO.INIDREO CLE-PE OESTRIAN nNON COLLISION CI HA AHDOUS MATERIAL ?- ^. ? p OPERTY.....EOHLY -ECT STRUCK NAM ^ R I E OF OOJECTSTRUCK ANOOWNEg3 NAME1 LOCwTION OF OOJECT3T CK EST OAMAOE . ?AOAOwA ? AD. E Uq D RIVERS rvAME-LAST FIflST IOU ""1 1 M LE ' i E ` YInYEN9NAME-LAST In9T E nEEnl [:J MUJL I Andersen Richard T D . sTnfeTAODRESS V 19 Atkins Drive STREET DA ogfss . E CITY STATE ' R EIP,000F _ PHONE NO. .. ,. _. Bremerton 1*1 98310 692-8515 E R CITY .. .. Tn lE . .. ... ZIP CODE' .. I E N o. ORIVEAS LI CEME .. 4299 STATE, 4n I SEX '1 vrgOTE OOA?HTH 16Y 56 N pAIVER4 LICENSE NO. .. .... . . STATE SE% pATf uF yH[H OgIVEHS OCCUpgTION FIHMN ME Q' -„ IHDNE NO. DIJIVERS UCCUPgTIONfIFIJ NAME„ PHONE NU Electrical w rker PS NSY Bremerton 478-713 2 . COD I" I ES sGrDEU IsI EJECnaN IAI CODES LTic?'159r _ InI SEAT III T 1 IE LRE En ...._ JECTICV _ ullE OF - U?OV FBO-B 70 '0 FB SCE V VEH. YEgR MAKE OOOOE-CHEV.I MOOELiOAgT-NpvAIS YLE I30R.nCOn V.1 BY: OI KEIDODOE- R E T. CIEV. MODEL(FA_ -NOVA STYLE IX DR.-CO-.. 97' door \f i rEH.COI H L nlpiE NO, 11 TE.. _.. . AILERPLATENO. TATE _ E vEH. COIV LIC.P LATENU. 1L AIL- LATEN Q A 3 1 p 9 L. FI (?`. VEHICLE IOENi1F1GTION nUMOf - 0- xER. -VBC NTi GICgTION NUMOFR OUOMf TF.R, E I q! 2 L BE STEREO WN L0.5T, IOOLE E REGISiE REO OWrvE A-LAST FIHSi MIDn LE N Same N Q, ADDRESS Of OWNER O' AUURESS OF OWNEq Z 133. O 2 ADDREA OF INSURANCE CO. OR ACEN! DR CNwgOE YAME AID ADDRESS OF INSURANCE CO.OR ACCrr! _ ": "" "' ii one CItATION N O• U EMFNT ENNC F cTIOM IIAIICF LITAlION NO, NANIF, ADDRESS E INJURIES OF PERSONS INVOLVED LD"[9 q SF.% AOE STATUS 7NBO _U9T LA[. UFI ELECT. AME r C : l1C.enFfl T• ~ u DnRE:3aF7? 1 rth n,>•rl - nr.? N ?h RT, 7 . P A .uuR?rR 'FHE nv FnoM R rt nc. send Nn N D Av Rf h3 S N of HoM T , _GHfgs: Ynf of M E LSGS:e?_._ c 1 3 BIT- .?.. r..'n r.Dn rll lnr pln~Yiv, IInM IAI 's) zPw39Enoni D. wll, ?ni erlpN ]. P(D[sTHIAN + 1 p n • OI^ANLINO IL IURr NOrii r..nLLER 1 I 1CCTF0 PICYCLIST 3 ) ) T11[N -'T 4ION IREE nOR OrI^inNIOVnt, A. YD 11I[Ni11INIUCY I,OE?iNN USF. ]rAnnl. L.Y EJLLTEU 1Fi'T- SUS-M r011LYpl E1 'D E wiie I ' I D IN 11011-1 39I iln NSNOWrv 1I lu i e, ov NON UN%NOwq J. OLE INJUnr s. 9inr ni rawnE F of crr:D f , 1 a ke ,1. rt ', J Pon" t. , ? ism k `w }? stix ti .. `?'' « ? fl - ? ? z ? Ej y`?``,,;I,P ra. ° `ss'cvt`-u ?'?,°k?c?b"r"c??a,T??,e5u93FJ°? ?mue .,.,...:., d?,+ __. [3? !?' ,,, INSTf UCTIOIW: a Deno. N ? ?" r t , I _ ___ rr _. { 2vas,,, rL? ? ? h--_ c zt ceot rucfinD i - -N..T,.,-.-- , . , r,c.,, .LTp •+ , c L E-f--- --? I-- -' „? - L,y °, ? "-' - -- -. .. ?..1 .. T. __-UAf?.:GED LCiIICLE N02? y ?? { t'- u ? I fi ?, Gt' EE' r 0 E V L°r E C ?•Jr T?-] #? " y CLU OVG 0 _ ?? O !N OE r C]NO 0 ] C f I O.. ) LLII rraGE ) ?I ru ? 'U ?. N] C7 4TH[n LLV GavaLE [ _ ..[ rl,'.p .,r.r.' {; NCB 'f ,?. ? E:TV• LUAraa `?iU ?- ° n'. E f{d?P .1Ck"? TOVre a -rI 'O n4rraG CST p°•,rAGE Y ( :._ ..+ trl.j'ya ll - S C? - U S ?? ? DIAGRAAOF COLLISION D „y l;„O DRAIY,ARflON/SHON/ING ?Y;L ti Tvy-0I$ ,'4 .ES ^.? !1 [ii ?:.?_ ???? /? -___.__ NOHTH IN C1fiCLE ?'. `i6? -* cLA. c "" ,... ?I ?-?-r DESCR.P710N OF Are ? ;T I r•\ COLLISION ? sAKU ,nfou_FDVSISI4TV?pEDEStn ArvECLOTNI NG C+ULOHr LOI STI VTi50 nEYa gw01nK.ETC'INpT ONO GRANr,EG UnIVEn •'"4•; y? T.rt, T 1 ? .' L]v. cu_ i2aacr:C?] r:.i'.^.`t• x..l't l::e? r-. +n? _ f° '? „ + -,- ... ;. •ti -• ' ? ca,. z ? ?I:; .9i?rrT ,_, 2! ? ,n:n ??ic:; n cLl,_L. ,.: a __--- ? - .. ,_ 1?.1 ., T _ .. .._. .. .. .+i M1EM. EaAFO U L N FOSITIOY BEFOFlE CDIIISION Nsrn[ir on nr..rn?v DNE Dtnkn o. r J1dtt O. NCNEwS NG UECREaSrrvG '+w4E On NO GALLr 1 9 ' S F w r Al OARKED OC p.ED y y ? t 1j } I ' ? i:'.•1: Camav f.o i :`i2 g, c _ ? n i ) ?G ,N SO r[s? No YES rco a I E r:G f $IDLI'/wLK ) ] ° F45[.u0 Nrn:.RNEU G DFS GNATEO 0' ? "7O rp •r• t,? RUAU `14 FACE LVEATHER ALK svouto•n inossEVgLKS CnoSSVAI ECVCI[nc4TF T UTnEa • •.il ICarECK ONEI CONTRIOIJTICJ, a?[unUA151 ANCE5 o.r J vG N? a U n ? .Gn[r N L E r ?? UE] f NOF) nt p NlO E) t NO°! E D YG o e E `r C Can CLOUDV G T EAU " t+ I Dnv f 60VCNCAEi + nLCOnOLELUENCt OF ) 0 O E p ) l•[l ) nawwr, a uNpLn r+ELUfneF a. f p st en '] - s [e nN ?) n° o Ass ric 1 EvOt•I n ENOwrNG ] +T[U ? E ' ] ' ?rNl t ?. • n L Y ??55 [ETU r.f ST P K+NC• T Uir { ,I-"• d r_F "'?FUC. ° kP'rEFU+•.t. piAS ?,IpvU IS rOCnt UN P.r ? d L[iTr TURNV .1}T 6 S y 0 rANi Nw E O UTUf?N O fFC trl OTNFI EP[CIi VI f II L I fJ E: SLU,IINO E r I) CG l 5 r S CN vl StOppEO FUTf ?LII HT U]inIT10NS TRAFFICCONTRU T7VPE OF IiDAD? -' D ) TnniilC trn_snvt. rNO )vtrncL[ D. iE Ttr WnmEOn N10N[ VEFIICLE LOVDI710N P rSORRIETYY IOPP[o Ar SrGNAL ?] :io iF ?foSf t rcNm. orvn ° arslopsmN I s crvus oN[ waY s co•:4?A'E5??m vl°?o >f 4A.L u+T ) S pN I Y D n4?U Y4YN ?? ) ? o+iaKnrvE rL r. slniluncw fl': ') D •:•I ; Y Sr4NU d F?OAUn:rPLE ) nrl .I?Lr Orr T nDf ,ersi?+ IJ InnNT Cl4Nf ,iW? rN0 illOtr ??qq .Y ] U11f< 5 r,G IVT[IrCUa•rLF IS '• [O Pw11 p,E0 r'OSIIrOY ;y n,NKf?FeET O lUOa NA••p ] rD1CAELll4nt5 ] EOPrr ft, f] rnL'IN01[YffnrNG ?,! ° L 4rrt9 Dr, e L L r.p y d I,Irnlr; nK. TNAFi LI l IFS .?,? ALL[ nn + t y UAF<.STnF[T .... Or15'.:U •A ;, I'E[NfOn NrrNG BACK NO u+Yr uG.rls oPE t ] i L P rv LT .• I. r. v..r " f rvnii CHEtA. TEST .- i •?? V I % .'. ilp[fl lrU.rTf b f ifn. I _ 5?-??TT- +I f 1'T+ T[Si LrvEN Tlrirl I•.vECri rl I I I OirrErr-LFE+i YI ] OrvrOlU TFSI niTUFtD ??1 ? 4 Uvrtrlu f+? 9•, ".o TEST RCSULTS 2 ?? ??? y'--- ?? UHF Nn .rGrrD I ? I fl., r.nuE wl; n;r5 -?f -rLL nNfnvln In4 tk rJVf UFPiIUW I ? `+"^O.GUn.:'rTa ?I1nnu,?r r. ] oT?r??T? I?rusr cun?lEO:7?llv.._.._ °°i'? .? LnN 7 `, • .rG 4+ . ? •? ??L?._ L? L?6. ? al4 Hr rnUAiF P ? fll osla ouTrcr. onrmNnL COpr: srrro TD;us NernN .ranrnnun-Dl.vunla lens Incr4 Dusea ? -.3? 95 pUPL+CA1000pY luCAl lnYrINFONCI'+tNiaCiCNCY SCt)+v-Tn14L CATF COpY?rNVC.TICATfIH'SCO+V }}r?? -A r _ { f J15 i ! & L 1'S fY L ` ffl-to 4 pr?'ZI """?sw-y' 4Elmi..:?.__U72:W•S«iC.L'J?s:•:_._u.......,w,a.9?i`uGT? ?r:4....,:15am1sR.h.•......?__..5.,?,L1"?. x ,..?.Ilui. .. .?2`uc'. ?i_ daa 5-w rr:,e9LEe?^ . STATE OF WASHINGTON ? SFB}I.AIREVII?I 4 PAGE _._/. OF_?_ F1Mo• y;w UNIFORM POLICE TRAFFIC COLLISION REPORT POLICE COMPLAINT NUMBER - -'-' C r DA F COLLISIDH ? ,py}'? _ ? ,0 I,?v SUN fll TIM?S/O HOUR) }COU/?ICITY NO. DURBAN BP RR pAL 1 -. ?STATE ROUTE LdJ I• J CL??TREEIR-F6UTEF!!R-SF- I ? r_, COUNTY ROAD ?CITY STREET ECTI W J? l ?OTFI(NSPECIFYI 10 N LEE I-W CITY OR TOWN yPgEFI% MILE POS 5 F J MILES _ LJ IJ OF L'HI/Jr//57 Q?/jil W II O .?q _ { TRFEYaN HIGH WA I NTE S C IN WITH:STREET fl A. C) q P ?1 I P .; y{S _7 iz ?. C N 0.C - R IN R RR LTVJ( rc,;? _ .? 1 BETWEEN NON INT EOC SS q AO . ;'CIS AN AND IRECTION FROM pEFERENCE OR STREETCROSSAND STREET ----STREET p STREET Dq r MILES E W - .. fr` A FEET ? IJ ? ? OF C./C A9 O T U dL? ? ?c I Ar, F"THICLES LISION INVOLVED: ?yEHILLE-VEHICLE VEHICLE-BICYCLE SEVERITY ^?•"??, ~'? NO. HITA RUN ? OTHER IWRITEI NO/ VEIIICLE pOJECT VEHICLE-pp TRAIN n?'I STOLEN VEHICLE _ N?yEHICLE-PEOESTp1AN NONCOLLISION Lj HAZARDOUS MATERIAL PROPEpTY DAMAGEONLY rc?r OBJECT STRUCK INAME OF OBJECT STRUCENOOWNEgS NAMEI COCA NION OF OBJECT STRUCK. EST. DAMAGE , # NON ) (?C?](?[J °F L -? DRIVERS NAME LAST FIRST ?ROADWAY -..FEET RO. EDGE 5 MIDDLE DRIVERS NAME-LAST .FIRST MIDDLE (IF PEDESTRIAN, CHECK J • ?rsErl-?c?GiYc ?C awls n ciE y?l FS ••? ,t 5 TA OR SS 7003 ???2A ,Q,Za , M AT ZIP OD PH NE NO.?' CI "' / A? ?? ??}/ IP O PION NO. ?; OgI`VEgS LICl!ENSE N°. ` STATE BE/%'' I?,f}DDATE OF BIRTH DAY SE F -URIV c PATION FIRM NAME DRIV 'VERB LICENSE NO, STATE. ;o]A EOF BIRTH OAV Yq. ; PHONE NO. CECKEXT?.L°S 'ORAL! O,C {/ CODES (3) ASS a (4) EAT E T (5) .f' NAIUq INJURIES f' /YQ 7 UHIV RSOLCUPATION FIRMNAME PHONE NO. CODES 3 C ASS___ _ 4 A ELT - 5 EJECTION... N7TDR . _._ /y? REMOVED i ERDNJ3CFNE Y• -: VEH.YEAR MAKE1 LE CHE VJ MODEL' ggi_rvova j STVLEI}pq, Coxv.j E?7 INJURIES RO _ Irm SCEN BY_-_. T VEH.YEAq MAK IE000E-cNEV j N O a L'eyN 2? [nKyT41'dE /96G 7ylFieL? EN. OLOq LIC FLATS NO. STATE TRAILER PLATE NO. STATE ENICIE IDENTIFICATION NUMBER DOM ?R o? /of/D/r,, p'5769 650 9B O REGISTERED U'NNER-LAST FIRST MIDOL . o qT-xoVAI YLE }pq.yroxV. VEH. COLOR LIC. PLATEN STAT TRAILER PLAT NO. 5 ATE VEMI R I T W t ' Eh R. E „ • . Iq ??? yo??? C%?.?.erc? r " ADDRESS OF O.YNER ?• N T .EL' ? _ 3? A`v AfN/ ?cu/ uGRl,4?J, ' S NAME Af10 ADDRESS OF INSURANCE OR AGENT " NAM ND ADDRESS OF INSURANCE CO.OR AGENT v "° 4 f s CHARGE ?f ? b? ? , ? n CITATION N0. CHARGE • Tg U ' L,F/tr?eF ?o OB >y/.? rd/? ?S?S?427 ah+lTu CITATION " £; 0 3 GaL, J NAME, ADDRESS & INJURIES OF PERSONS INVOLVED confs 1 _ 2 3 4 S E? SE% AGE STAN6 NVOI KO NAME: lA?/`L ? S C? 9 + DECT. L ,ee. •. .. I. ? Donn -?.Y _G?.- if L.70.C! // "//,4 Q If :S v •P -, I / 161 / 1.21 1 1 . . ? `?. ? I? ? F 6 R . + i , REMOVEOTIIO IJ1 7. FASIfNGFR I ]. PfD[57tlIAN /.OTHER POSITION I. NO INJURY IBUS-MOTOpCYCLE f. DISABLING INJURY 1. NOT INSTALLED I.NOT EJEL'TEO S, f } O K. tlICYCL157 tl I }.DEAD AT 6CENE tl, I•pSIT10H UNKNOWN ] OEA00 AD RIVAL tl, NONDISAOlIN6 E }. NOT IN USE 7. TOTALLY EJECTED ? HER E. W. RE ] V tl. WITNESS , : A, OLEOIH IIOYITAL I I VIOENTjINJURY 7.10551BLf INJVRV ].USED E, UNKNOWN ]. PARTIALLY FICTF D %:UNKNOWN IF B. UN%JJ0IVI IF MaU11ED f. SEA1PLLT fNL1AE EJECTED F , ? 1 4 I } Q a I + ,? 1 ? L TA h YI ? f I ?. J y`, .?. h I,?.: •.?'?`' ?, c.vh*+.I'.^ ? 1 ?.1'..:' AIIEC?n,'....-?q? ?;:,?E1 AxY-1.^:?{ I r .'-?'? f ( 11 '' ? ? Y J +J IJII!f 'A9•? t?,.' '. ?? 1 ?I ? ¦q I r rl DATE 11 COLLI610N AV i C ION TIMF -1 E MO: O UN I S cnl 8 6 T 1 A IUSE 21001N, ql COUNT' j C!TY NO up BAN UNTY . ? STATE ROUTE 000NTY FORD ? CITYSTREET AD LS N O CODE B IT.-T E CT ON V 1 ? OTHER ISPECIFYI LU N L ? clfr On TOW /^ O S N FIX W Ea. MIL E P03T ?j I ( !/ MILES ? ? J^I OF ?-//•/!/ cum c A F TMEE T 6 , NAME OIOI INTERSECTING ITl 6 TORROA LL T ? T NON 1 o 0 INTERSECTIO N BETw J /Yf.?(• (!>N qN0 f •/( STREET CIDEUN? MCODE [ DISTANCE AND OI ECTION iR0 FNCE OR CR 645 NFET /{ ?MILE9 N S E n W E 11 IN NYNB[[IM! t p FEEr OF COLLISION INVOLVED: ?VEHICLE-VEHICLE VEHICLE-OICYCL{ I ?OTHER IWRI re) HIT R, RUN Slll"ITI TOTAL NO. ?J?? ?VEHICLE-OBJECT VEHICLE1Rn TRAIN OF VEHICLE.[ I ..O.., f NO INJURED ?VE NICLE-PEDESTRIAN ?NON-COLLISION ?NAZAROOUS MATERIAL . OBJECT STRUCK INAME OP O.JECTITRUCK AND OWNS RS NAMEI LOCATION Of OBJECT STRUCK Br..A'All N ? ONIVEHS NAME-La4T FIRST 1 DOLE ROAOWAV D ?? DPIV... NAME-LAST FIRST IMID. (IF PEDESTRIAN. CHECKID cs TA.) R f D E R .tI1EET ADDRESS l 6ilICEiA D E6 E p Tr T I CODE PHONE NO, R 1?.i ;ci!/E• / `"4/ /D?%''Ui - ?. • E cllY Z R 0 IP CODE PHONE po'z 2 Zpl A OnIVE RS LICF NSF NO. N ATE SE% DATE BIRTH )AY N NO. DRIVE P9 LI CENSE STAT . 0 E ' lo Do^.lj IF IRRITPF. DRIVERS OCCUPA ION FIRM NAME DRIVERS OCCUPATION .JF 2 S 'NJUnr 1 1 LA$$ 11 SEAT BELT 51 EJECT ON CODES. I21 CLNl?sR 3 S F ATURE,0 FJU O N E.1AK• AR EIOODOE- RR VAI ST FROM OENE AIt GillT/ VEN. YEAR MODE ART-N pSTYLE I,-CO V,1 V f LOR LI LAT TEN VEH.COLOR LIC.PLAT TE IDS FITIFICATION NUMBE OME I VENICE IOFNTif ICATIN NU BEfl . .T R RED OWNER-LAST REGISTERED PIRIi w F N OF OWNED O• AODRE.4OF OWNER .... 2 .. NAME AND ADORES. Of INS CE C .OR AGENT Sr •rt .? r G AM6 AND ADDRESS OF INSURANCE CO. OR AGENT CNAROe CITATION O. EN?ORCEMENi CHARGE C ITATION NO. ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED coDEl sex ABE /rgrus ms's Elecr. nfim I ovfio fn P RI FB BCE O NE BY TO A NAME: !! r T A DnP u ? d 2 ? C i ' ? r OF R ! [ . S I 6LEN lV^O PPOM ,n.. w -• D. 1 - t T nEm ovEn nm E " ;Wl ro 5 S " / vAlwn O EM S' D i to O / ? TO .. III ITAIUS C L.PAIIINFER III B9AT POSITION IN 'DI INJURJUYRCLASS .NO Y I. OIIAILINF INJURY I NON-DIIA/LIMO IEI SEAT EFLT 1 N T M yl [J[CTION O : IIclcL. IAN IICYCLI/T 1 THER TION E. DR AD AT ICIHI L. DIAD OM ARRIV(IL . 11 VIDE NTI INJURY • T IO/IIILI INJURY , O I ITALLID [, NOT IN UII 2 UEID i I,NOT IJICTID TOTALLY IIICTlb P ? O AwTrN.„ IU/-MOTORSYCL/I N.-R, NIINRMOWN 1. OII IS IN NORFI TAL , /, UNKNOWN IF INJUAIO , 1. UNKNOWN , ARTIALLY IJICTID (.UNKNOWN IF AILURI ¦IECTlD % ;i 1t?w TI Iif k J• ? bJ I . •. 1,... l.A3T. i,^ Y Y t I. W? A a SY54A i ?d I I Wl 7 1 . I I .. DATE OF COLLISION.. : DAYOF COl11910N TIME COUNTY DRy Np -... . 5 MQ DAY YR T SUN I AIDI T IIIE5 WE 1 115185 FN-[6[MT] (Ul TIOO HOUR) ?• ,? _ FHWA T ?9TATE f10UTE QCOUNTY ROAD ?CITYSTREET O ADM4L9 PREFIX ROUT Oil CODE CTtON T ; v ?OTHER(SPEOFIR N 1 ?' "'r S { 0 N 6 E W ?W CITY OR TOWN W ,? i PREFI% EJ,? CA MIE POST MILES t.c NO.OFBDiEETOR H%+NVIAY - WfERSF1:IWO WRH:'STREETORROAD. LL RAMP gAORMa T - S.-..c-' Nq1 / AccID -CECT - STREET MM ORF 'O ?, r MBEAOE ':: . CL4? ERENCEG116993TREETORFKIAD F ` ?'..1'Ip. N BETWEEN ... i . l" !..' STREETANO _ .? '/ ; / TREET CODE /icl„ 1 W. y2 4 .,m• •yl?i'ri•Dy.( ' DIyTANCE NlO TgNFyOAI REFE Ofl . BT y0'? ?MN Ca N 8 E W .. .. YIHB LLLMLCOOWGI1SE?t?>` 4 f";1^-4'. ? ?•/..T / •:': ; FEET I-Y DF .,a l .. ./.. , _ _ ",+ ''?1T t-Ll?te rm tx +. - .a? COLUSIONINVOLVED: LIVEHICLL:NEIUOE ?VEHIOE.BICYCLE ?OTHER(WRITEI _ ?HR6RUH. : SEVENTY _ .. ? TOTAL NO. OF VEHICIE3 I- ?? ? EEC ?µ EI-m- N ?HATARDOUS MATENAL.._. ?STOLEN VEHIOE NO,WIUREO d ? _ ?PROPERTY DAMAGE ONLY -&• ,OBIECT 81(it1f;1((NAME OF.ODIECi STRUCKANUOWNEgSNAMFJ ,y r„ y„'. _LOCATIOIIOFOBJECT STRUCK ?, w W N 9.-.E W(....+ ES IY 4 ? ? ? ? RO a TDAMAGE * ?ROADWAY FEET EDGE res ? ... •••.•ilEL?YL.-J-NpOLF ?'.' DRNERS NAMEiASi. AV BN'iYCM_$LRHP P' H . J/l L/ . T Y J //-7t L ?cDS C. ^1r r???.: L:L/7 Flip ! - T '..1U.' I7 M dn.LbCw" 6EC., yi BTRE1=. Gy.1,.G:?L7, .•; s.c? . _? IT,? ?<. .' n A 1.C+A.rrsy,?z _...., .. tsiATEa...N.d:+v..a.aP CODE :RIONEj10? E > arY y?/ //!/?A :: 1 Tl('JL /, x• F Mfr - r / . R ? F'rl .•..w.,,v,. BTATE.+,+lro...-w..n.+ LP CODEy,?._ FtIDNE H_O Dom, D&RTH YR .N DRNEn9 LICENSE,NO w..:..? -..:.(....STATE.., ._BFX.: DATE OfpIRTLIJ I v _ O . l Mo. DAY Y_R Dwff.R.S000LPA •..: FWM E. illy '.1 4ru?.?,u d yir7v.._..ssa:..t?.aPNONE Z.. DRIVERSOCCUAT !FIRM GHQ !^1 ''.2C --.:..OODES r7 JI uqS ! It 1 1 1 SEATBELT 151 FjECT%k! - / CODES >(m Ct UW ..'!. NI SEAT SELT 151 FjECT10N wu-s°F ISw:;. NATD , 777, ruuc D R?EMOyyEED SCENE BY: T OM SCENE BY - VEII.YEAH: MNRNODOESIEY.1... MODEL(O/_ATTIJOYN .:.: STYIEU?R+00011Yr1 :... VER YEM _. ANE(TAOOECFEV.1.,,. MOOEL(f)ART?NOY??. BTY.IE (3 _DRSONV?a... ?, IY f•E MlE NO BiATE .., TRNLEFI RATE N0- STATE z."„ VFH.COIOR UC; PLA1E Np gTATE_, X11 PLATE N0. a/STIR/TIE/,, N LAN%Jc J Iv ? - . L. ' N Y-; ""' A - Nu ti . ,- C VEHICLE LL)ENTIFIG n N ! M0 OD M R?yt _:' - '.: REOSTF.PEO -UL4T_,r.r::. FatST ..::.r:-:.-.:. .-.? MIDDLE ., '';'REGISTERED OWNED l',. - FaL9T ". MIDDLE 0. N i - AO _iJ r!"" •.. DRE990F OWNER- ... r NAME IND OF 4UIWICE OR .. -EANDAODRM O-SURANCECO. ORADENT ACTION _..} ?. r^ '% NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES SO1 AGE STATUS n vp. r EIFOT v wlw. T `., NAME: P.. NATO F RSCFNE BYFROM J 3 .. ?• `?'1. PU RKB: A NAME: TO N.. r T NANAADM?I!SS: .L { r l 8 PAR110E B: SCENE nDFROA TO • ?' .. W : HwuF: ?' t .:TADDRESS: ,$ .. SCENEnr:F I TO J"i.7I•.,, C E NAW: .uRy-1? ,..E AMRESS. Rom _B PUU S: r FNE BY TO 11)'JTATU3 IlI SEAT POSlIgN II. PAAIRYCLA55 IIISFATM.. LT 151 EJECTgN r 1, •O' 3PEDCBiHNMI NOWJURY B1C 13T ] DEADATSCENE 6gSABLINOIFUURY I .NOTNDTWNSTALLED 1. NOT EkCIED' Y . SNONDISAD4N6 T.TOTALLYEJECTED yy?? ONE • T.OTITERPOBRION D.OCADON AFINVAL I IEVI-DENTI IFIIY ID. OSED . PARTIALLY EJECTED ,F U•1J D 60 DIEDN S W99 • ] a. POSIIgN M I. IIOLITAL 7.P05NBLE I1ANi1' UN%NONM I. UNIWOWNR 9 I ?U"' t .E _ S. SEAT BELT FAXLInE .EJECTED f rya . fa''",; r . •,'"r ?s^,, .~?41?-' ?, '? r, ?!fit""'"''"," •. ?,?„ Sr??"t9?S7#?"' `O f-?r?„?''?1, gil?,+C,? I is P 1 . ?` 2A VM' 7711, - ?1L li 7 w n? 4 k y m t .l I l 7 per, ra r " IN DAMAGE ,. IN EACH BOA. CIRCLE THE NUMBEp OF EACHDAMAGEOAREA » ° 2. SHADE AREA OF SEVEq STIMPACT. INSTRUCTIONS: aD WMROVVEI TOBNMPgW ALWECr OF'FOACE DAMAGED VEHICLE NO.1 NBE 7EIIB WP EFDRB CWWDANADETDnw.EFt%gTDRCYCLEB. ETC.) DAMAGED VEHICLE NO.2 Noo° a ..• a is Hoof ,A ? .Raul ?rbol ? ? ? ? 7p ''?? + ?`- -? ,B.UmbaapNpA 18.,IkNrrrNp ,T. a.ra.o > ,T,owNm ° r BEVEPITY OFD AGE: EMICIE NOII ,QDIBABUNODAMAOE OQOTHERM.V.DAMAOE 2 FU nONALDAMAGE 4 NO DAMAGE SEVEWIY OFDAMAGE:IOTHER VEHICIEI ,QGBABUNGDAMAOE 'BQOTHEq M.V. DAMAGE Z FVNCgO DAMAGE A NO DANIME 6EVERITY OFOMIAGE'VEHICIE NO.E - - , QD,SADLINODAMAOE -' -- 30OTHERM.V.DAMAOE 2 FUNCiI(MIALDAMAGE NODAI TOWEDBY. EST. DAMAGE TOWEDBY EST.DNAAIX .. Eb^. DAMAGE TOWED BY '^+ AQRAM Of_COLLISI DRAW ARROW SHOWING - ?wnivA ,G' a NORTH IN CIRCLE I' bmrANMe brNnDAP Caxonla .. - _ - . e ICEPArIXCGCTWafDN , ? .. .- _. ?. El ?larpmAiEEPNfaF .+j:,:t ? _ I I I ?. ? _ _ a -rw.Gevmcsmw PCbT,OMAr MPACf EPOIVaEVDACtEOp ?? _ rl I _ - S s , , ArOMOr Cp Aia?? ` ? pp?, yy f A, DESCRIPTIONO T'4' T"+?t,COLLISIQ •yy? pNCiCA1 ?„?` ? DLSA&LI E WHAT PROBAB ,YgEWCEDVIS . LY H +BEI APPENED BEFO,IE WRNDANOAF TYPEDESTPUNCLOTMNOGpIOIL TERTH CONST ECRASN,INCLUDE WFOR gUC110NORREPAIRW O mj OTON DIAOMAI EG. o1,R.FB AK g1LETCJ.J ... ` T `, ..o Jtrt. #_." w w/ zz. ;?jt_y Cq HIOHWAYNAMEORNO NO + HEADED- NO.OF LANE9. SP V IFPNiNEO. - WONE WI IEPam PAP U 7GEj;; N S E (1 9 111 4i U NO __ NC, 2. 90 _ 1 PEA ? ? ? _ _ HT .. E R Wa Eo?eLLlr wA&usb ? ^^?? -I A o:.... LIbuE.. a?.vAUwAti- t?biouraEn`?e"m'?D°swNA -IJebn vrix ?0 b°ECre9ON'iA1°Aalre" `r r,E ` Jr w ?• . ROAD SURFACE, parECx aHG ... LL_WEATNEf, --? ? CONJRIBUTINOCIHCUMSTANCES" 3-# ;3 ,. "?!.`c..4 ,pecp orrD ICNECN aHE Op uprG ?3YfP - prmB -_' s ..;? . _?_ b•vETI ''G- NO a . :aeS.IaELTRrvgbxEA c ,. NO wecle M J?Ky,. DpNa -.- t?! NFA° l - . pp?? I-I n -3 __- 'OLD 4! L?__ - ?' 0 b°oHV"ma.°Fp . wv ?f? P u' . ?_? E _ - ? ?_ ..? DKEDr ?,? TT7 ?+A? r ?,?_ .. ?a? ENDb a? b?wa -- ? ?EmAEa ?, r? ` G^©;°Ppx.p -. ?A? =reAp wrROaEn = - p aF I? ' le+. °f-1 _ ??_.-- - -? ?;rUifJE ^^M- ? , W U' .:. ._. _.. ?,?. bp,b10 -., _ , orreB?Eprn omEA aPEOrYT 1 r J ? P ?,a? ameP ? ? WD,IA ? r ? Epp UGHTCONDITIONS ,T4AFA000NTR8L ' :wecz!UT.YPE OF ROAD .?VXHIILE CONDITIO ' _SOBRIETY TgW„t "+ DID a"may bore ? ? ,prI.AIB- ONEWAY ? ? NO a. a - bITEq a .: ._. ? ° ? pmf M rl TMU,r +__ ?N J (?-1 .. \ ,-?T -?- pCl?(I Two - ?+?_ .._.. ? ? MIbDP AmRY :_ ;. .?,p? ,°1PM?IC IANE Ar.rm Pena _ ?_?- _ - L]40_^ i.?,?_ .R:w -_ ? p Ml 1^.?. + ? ? EaolaET'- -- ....- 1RArllp ° _3111 ??_ `^°"I°°"° ???_= ( ? L..7 ? ? - ? ?-L.,J_ ?-? _ r ?? m"A°u+mrN..u ?,e? eACxio?" °? w avr° ? ? EoHU rf r; r,'Y'Oimwi" m aw•r nNen ? °? CHEM b .TEST ? . e i_ "' 13Vi `Amur' u 1 sE' ?.!° r i_ ? LJ lJ. .. . ?_.? Trm IINEN o mcv. I D 0.0-" .. ammo U X-1 ? w ECTE F . TEa,pwap.--- r { Y ;7L q „ E T !/J oa¢ 3 . ^j uv"°p ar?n_ 96 % .. -TEST RESULTS T 4 ?' ...iEnw nrrrAN°NAUCAprw aroocw ASaTEMTw rlmwsN.uL ww... .... .- - F.naEw ArceD .. ApcE UVp.TO .. ? _. ?r?nwv. 1-1 ar .. a.m .. a.AO ... o wu vx ADENar _,_._:_ .- .. wropm,.AOn__..... DAreartrom .... AsvnoAYn ..._._ wn., y .?• ..,,.. .r<?. -., 'A ,,y:.-j kYx?f. gq<al ..a..?.i.-,. .aE' ?4.i}7'N s.?'S{??3'. .. f f?? ..t ST 4T F11S?INGTOhI ! N ? ? ?'? ? ? PAGE DF / o. POLICE COMVtAYITINMBER ` _ UNIFORM POLICE TRAFFIC COLLISION REPORT ?. nI L m p DATE OF COLLISION DAYOFCOLLISWN TIME COUNTY NO, CITYNO. FHWA' n GGG2 ? OAY Yfr C T SUN 1 MW 2 N!5 D WED A NUP S FPo S S i IUSE ?aQO OURI s? ). . ?UpBM /riRVRAt G NIY ?STATENOUTE RCOUNTV ROAD ?CItYSTREET ZO AUM{LS- PREFUI nOUTE On STREET CODE SECTION AAff _ r „UrI ?OTHER(SPECIFYI W o??,f?,( L CITY OR TOWN W ?IN N B EE W VNEFM E0. MILEPOST - .C V. /j S?T 1? II I•? ?OFCr/?1?G<1/? FLEE ? ILY l/ I ( 0 A _ ___________ _ N . NO.OF STREET OR HIGHWAY _...., wTERSECRNO VATH: STREETOR ROAD LL LL : . J NAMP DIAGRAM DATA T ' ON C j ? NON wtERS CIDENT INTEN C OR REF. S O •< '/ E WTE 19 . EPENC E CROSS TNFET OR PO_ N . BETIYEEN B A .. _.STREET Mp 9? f.-? STREET COOE S?(p QQ - I DISI- AND OIRECTON FNOM REFERENCEOfi CE1099 IR ?MILES N S E 4V IurMF jIM - CMLCOOw6 US . '. - ! 4 _ I _ FEET ? OF OY/ 6'SJ 1 S•IC?% <?.SCJ .. _. E?( • COLLISION INVOLVED: ? VEHICLE-VEHICLE ? VEHICLE BICYCLE ?OT ERIWRITEI ?IIITARUN SEVERtt NO WILLE D ?STOLENVEHICLE TIlAIN - TOL N , O O FVEHICES? ?VEHICLEAEOESTPIM ?NON{OLIJSION ROPER .?©;O US?NTENIK N pAA1A0E ONLY Cl' ECTSTflUCK IHAMEOF 08JEC :.:OBJ SDiUCKMDOWNEil4 NAME/- .... tJe • . LOGATgNOFOBIECt 9iRUC% .: FST.OAMAOE f Q [ ti ?? ?? cro QT S? ?EJ ?/O?h If ?y { E R Y F T ? ? !S ? ? OADWA <,rt Ip EE RD EDGE S « D NE SnAME.IAST:..r_. _ _ iWSt, .a -:.. t, L;a .?MIDpLE pnryER'S NAME ASS FRST MIOO {_I. BCrCU510A EOES. !u _G .(Cnl Y. ? ° !JS vi `c.? e T D' :' R STREET ADpiESSm.....-.v- ..s.r?..-?.._.uc_?-u.uvua.x:u•rw's._[ :. R • STREET ADOnESS..i.iw_u r?? :n_ti,>r..?.n• u __......?,__;_..=:v:rw.:?s•.c.u I I: T/ BOXY DJ IVY E NO i CRY •L.:.. .: STATEr .-..,: .._ ,_ ZW CODE r EN0 , " , . R ; . R . or ?uu1 a 8 ?S S - N DNNER 9 lIG NO -.. :,_ '.?.::?.r ..ST ATE. -SE% DA t F B 01 H .,.. N-? DRYERS LICENSE NO.. STATE. SE% GATE OF Bwm .. •.. ..._• ) 1 MO. DAY. .VR /J ,[ / ? J 0: t(J GYJ' ? /./ O 7Y Y? O_ p I.YY ' J.I .:. ,.,.Y `?: -. _. E O Z'? 'I OM/ERS OCCUPATION. FNM NMIE .....? DRIVERS OCCUPATION . RRMNANI_ 2 . 'CODES > nI INJUflr _ C1A55-1 141 SEAT BELT •_ ISI EJECTgN _? CODES >P- 'CNJ?unr?e__ I I SEAT BELT IS! E,IEtTipl NATURE Of PLIU.,RIE9 Y NATURE R URIE. wgpa=v F SCEnE V' O O VE EMOVEO FROAISC BV TO VEN. vEM MANEIOODOE{HEVI MODELIOMtilOVN..: STYlE1300.{DNVI YEN. YEAR MA%EIDODOE'CHEV I.. MOOELIOMTigVAI•-,. STYLE 1300.{ONV.) A E D. .. IIC. RATE AO. .. STATE TRNLER RATE RO,. STATE E VEN COLOR...... LA:: PLATE NCL STATE .. TRAILER PLATE NO. STATE _ H ..,Q BN 1/d9 lC? ? H (.' ..a. '.C•' VEH DONE • C ? - ?0 9 ., E 1 REGUITE D wNE11 -lw$ i T•.:,+n..r?_...:, .e. ' ..I'..:.• FWST WTEREBQWNER-LA!IT I N N C H .. .r ,::. ?. ...... ....:.,_. D A 'ENFORCEMFNT- _...-.......__..:. ..... .... A ....-.: r?._: . " NAME 'ADDRESS & INJURIES OF PERSO NS INVOLVED -.•,= CODES - 3 ' ' ' , ' . _..: .. •.•. SEX AGE STATUS ?• EJECT. N C AME o. d6• r ? c A DDAE9s o ' _f rr ,Z? i1SEt?. U N TI Y AIURFDf H AIOYED MOM UURIkS SCENE., TO A N 4ME N T A DDRESS S n 4 t;. IMOV D R l.9 Sff NF NY TO W N AME T A CORESA NDM u D? N f tD s iHr nr $ N AME A DDRESS `' I. ATtf?r??_ Sf,CHt Ilr ??- TO I 1 1!I Sl AI V0.111(n, Hr CIASS 1 If41 {RLI IS I ISILJECHON `. ' PA V.f NFJA I Ilo.lRr I IMRINC6._RY 1 gtINSTALLEO I NOT EJECTFO . O I rrn, t.11YAV tiYCl15t )OIHlR W'JTNYf DT-115CENE 4 q 411 3 O A AIH]N D154RUIdi 1NOTw USE IDE F Y I 310TALLY EJECifO D l O r4f, ! ) LEI 'e' j- M i n O , HN f L A DLO DSRTAL V NRINIUN ;US D I / PONYME INJURY l DPARTIALLV EJECTED NIF 4 A `e O RU TbN u NO siAT uli r FAll UnE [RCIt D ?i iT ,Y Ji1 z? y r? Tw d of a ff E I' x!x. U 31 X41 1, - : k 1 E%gMYLE? EA OF SE CIRCLE THE NUMBER OF EACH DAMAGED AREA. •'-0r`•J'l(? 1 VEHICLE DAMAGE I. SIN EACH HADE BOX. CI INSTRUCTIONS: ]. DRAW ARROWS) TO SHOW PRINCIPAL DIRECTION OF FORCE. Q/ ?, r, r r ?• i r DAMAGELIVEHICLE M0.7 IUSF.I... 3PACEFmJ,KErC»NGDAMAGETOTHAIINB,MaIO1111CLEGETCI DAMAGED VEHICLE N0.2 - -?1 lz' IG U nnwrn, f t _ IEVER OF DAM ICE: IL 1IC E O.1 SEVFRRY OF'AMAGE IOTHERVEIJCLEI SE EIIIIYOFUAMAGE, VHJ CL[NO] 3 tlLIVG OAM40L ] OTNE V DAMAGE I ? DISANLINO DAMAGE ] CI OTREn M.V. DAMAGE HSABLING DAMAGE ] 0 OTIJFn M.V. DAMAGE ) 7S I C IONAL DAMAGE LJ x0 C ] CJ rUNCi pxAL DAMAGE , L7 IODAMAG. ] C3 FlICTONAL DAMAGE 4 C] NO DAMAGE [[ lbNEDBY EST OAMAGE T OaY T.OAMAGE TOWEOOr Ea1,DAMAGE Y., TO TO ?? F s _ ,H, NV TO CO.- flOWRC ^A f. - -DRAW AR WING' 1 } ' ' I DRAW ' DIAGRAM Oe COLe1SIION ORTH IN CIRCLE '<)sOxofr NOAOwA t I I I I'?+ 'pka rNC COxrIrDU `. I__ ?_ I. _ _ _?. _.. F? f. +_.i qLC{ DSY,L,rtM.lDNDIN9», _ _ - - ?. Y,TK,.KaN,rKMDi4N f ? rHr,Llia, - -- - _ - T B„lLE.pIyIDr _ 3pl ® -? Qo ry t ?_? I I ? ' ? +' V. C, DESCRIPTION OF 11 ICAIE WHAT PROBABLY HAPPENED BEPORECURNG AND AFTER THE CRASH,INCLUOE NP.-TION NOT ON DIAGRAM, E.C.DRIVER N4 COLLISION DISABILITY. REDUCED VISIBILITY, PEDESTRIAN LOTHNG COLOR, CONSTRUCTION ON REPAIR WORK, ETC I - - z" yo%_!_lrla5^gs?,ur_un _G?o . it J•.jf/a/ oGs???d ca, afsE -- ,Hr.A? .:? ?erfac%K?f+Y,_..Smze"L -xe _ S'YruciC p+it / i% ?mac . /c?is e• ° . c Tie oiS? n9?T_ouY at' d - 7z"y ?o/nSC/i.?dTNJy .Y'' ?. se rr Tile __ e", -4G!_6 ice Y_T.Jr./ a i1_???id,?t,i,J. a _ - - -- ------ - ROSITION B FQR COLL SIGN .. WORE OfRECiION r reo i,sF LEG LV S_. CDfD 1EIOSTOON 5! FEET ON HIGH AY EOA A NO. ! OCC PED n NC ASnG OEC EA9 NG MN t E I I l?--'? o ?NAM? UMrG ., NO E 40??.. )1 CHD55Wa __ - 00 rn _. ..-._70 _ 'b°,•a ]f- LKwA i AI MARKE S,- jUNM KED a -10 0 ED ]ri fl. ; ^ A ICDInICVCLI3I ww3 USIxG. `SIDEWALK »OULOE II I CROSSWALK CND LK ff F D TF O ER -I r?'(( (E4 BE . ZVAO SURFACE ,.. WEATHE .R .. .....CONTRIBUTING CIRCUMSTANCES ..,. DNWawsve»rcL y?YLL IGO CK ON., ICHECK ONEI I<HFCKONF ON MOREI • IRO. L J pr al !' t ,Ty . {,S,,t VIR EN m"I 1 A 6/? n r rKJ J "h 1 p !A CL_R•T-ii glJt FR D 1 i... ey 4 ,/I O) ,I ^ rO.], LLOINI- O . A POHT _AD A N• NiIUf NCFO rQLLOWING 1 EIV F W Z] O ASN° A CASs U I NOONOL-_ _ J ° ASSING?!'b +n h^I r 1 )5 "f ' ER OF A OINEER CFN'!N APPARENTLY _ MaKIx6 5 EDS 69 PFD L !T? L E I ..IT T RN lY f- #r !T [ N CEE TA IT 771 f i TO `I 1 MPROP -KING I r- R C) 1 S Ow 6 O N6 I] C r ..?. G i-_LOCA. ION A_-' LJEPT TURN '° C Jf/? i fp S ni I.. I ._.._ I 16 FACEE ICE 00 r? UGEN ED tI NAY 1'..FI V CC I nGL._ 1?1/TILT TOP paS '..._/._i A.oLIa» .__ .. __ -,af uow NC ,4 YA I 1 Dii.lRISPFCIivI -?TIORISPFCIFYI- DSNEGA"A STO OTNFX ISIICIIY1 ?__• r 6fOP1lOfOR IY ,. B .ASSr»c ) .. 1 RGN1. cNL X BI J Nu v DLAI ON . )I mwrnc I STOPPEDATSICNAL t 1 114 %T Gb-DIIIONS RAFFIC CONTROL TV ] e eE ! [ FE OF ROAD •.VEHICLE CONDITION r:. _.SOBRIETY ' IS ' ',.. OnEI '1 O.) IC lCK ONE OR MDR! VHIICL! I?p QfR [ ICLE tC11EaKGRII I I._J OR STOPS GN ! JNO,: Ij'f{bLr TFi6 fID1 NO, 6.; t -11 c u r-,. rI ON' PMY IB nTAO IN ...u '1 '?. ,1 . •^ i OAYL G I)')O OnAf LS '. + .IMIAII?kD TY TSTARTING IN T FFIL LANG -' 1?5VCAr ly 1.111I 11 R - `: ] - ...N )] SGN 0 TV S f ]. ) DLACTIV OT RAIRLD_ PSTART KfD 109n1TOlON ry F IGI 1 - T ! 1 SOP u ] r% K t r V 1 ' I] f 0 a IfNTRR Na Y LO M1G ._..? 100111 • r. IIEA 11 G IS ..UO K IRA f CI 1' Y 1 J S . UAIIK STN!!T f IRO 6' "'.2 ID I. BACKING Illy -111 M. NK N6 no t T ° .. SIGNAL L:fIEM. TEST 1 i nnHN .,rt Clrrl i1 l.'. " i'Gri B M I. 4l 0 nwy ...... rL9T GIVIN f 4.$,'`y m JJet1 a S G .r" ! "YI ;X b1 K MO -- Un. IJ K4+ ?Y; i, III .. - IT )? D 10 X 1 FOOEFCCI9 LSI HFFIISfO - 1„I., or». ISItC 1 /y\t • r N KS U U ILIU UIH1iI JJ.Cr 7iT J iESE RLSU„TS 21- 1 11 11 1 t. KD ,, riG U [ iNA 1 A K u t' ) Ai IU r I rlv 1 AHI D IMrED[OJI '' i,S?f n' _. 4???r224Ar71?'t1L?. `Y' f-3 :Ll_%J'? ???ec?: -?'??oSJI:II DEC •-- PHI, MI °. ISt.GArr w.t ,AAM <r , PAII LI'IILHO11t vlU BY U4 E N x - w. IH i, I.S 7? r1-1,g_ S T/?7?Y^ij? i I . \ ZA> t ). s L•f/ I •t [111111x111 )4 O r N L - S-1 O Cif rAT1 YAfIlf -OLYMPIA, L Nr1O`J DA.OA ,C$J ? f?ItnA, ?yM» ? I! ra Il':$?C??B 1 ) { `si T ? „ ',A'1 l ??? Fw1 _Ii ? ??7 e¦¦d l_ y?ryy lµ? 1: r tI v 1 I Jr siI J. s _-?.n+rA?/'e6?s? {w-a?-L,?..'15??,?SK?'?{r ,1 }_keJWa ).. IL?.V ,...?a diY?..._..N,:__.. _,.?_'._ _....`r??t....,`Ji?1.-- Arw 3?a?,?:' '@Fy,,,xy? '"1•u.. ? r f f yli. tIA I Y.. Vf Y V A V! i li`i U I V PAGE OF 140- ! POUCECCMPLANTN-.. . UNIFORM POLICE TRAFFIC COLLISION REPORT ' L t I p F Q DATE OFCOLLb ON DAYOFCOLLIS ON TIME C OUNT/y !?' CITV NO. FHWA A MO. 04 R. T SU!i ! E, 2 fUEi J WED A RI IF E FRI R 5Af (USE j.M1GO HOl1Rl - J / C gBAN r /C Z A DM CLS PREFIX ^VI RURAL . COUNTY ?STATEROUTE IICOUNTY ROAD ?CITYSTREET ' O 3 E OR GTREETCOOE C10N G? ) i'E1?il:%1. ? OTHERISPECIFY) ., ;` w , L CITYOR 1011N IN ? W P REFIX ED. MIIE FOST C ? /I N 5 E F . 1 \ E? .?.4•. MILES ? ? ? LrAOF 1'?1l\/LL)???\ ly ?T .? 1 A EE ORHIGHWAY INTERSECTING 1I1H: STREETOfl I10A0 TR NAME 8 NO. OIS O R AMP DIAGRAM DATA T . ? ., Q-y V ',''(•7 NON INTERSECTION W ACCIDENT rER NGN X HO 1 " - OR REF. 4TEASE riNG StREE OR ROAD O MILEAGE CLS, E • PEr.CF. Cfl055 STREET OR ROAD N. OETWEEN STREET AND STREET CODE •-s Q DISTANCE AND DIRECTION FPOM REFERENCE Ofl CH0595TREET NURETgS 5 V PECIA L CODING USE ?MILE$ N 5 E YI r ' ,. r .?., ?FEET OFf•If tvL C. ? -• COLLISION INVOLVEO: ? VEHICLE-VEHICLE ? VEHICLE BICYCLE ?OTHERIWRITE) ?HIT "U1 NO. KILLED SEVERITY ?STOLEri VEHICLE IN O ' O ? I OF EHIC ? HAZARDOUS MATERIAL LES ?VEHICLE- E ESTRIAN ?NON COLUSION © ERTYDAMAGEONLY Q OBJECT STRUCK (NAME OF OBJECT STRUCK AND OWNERS NAMIN LOCATION OFOWECr STRUCK U. DAMAGE S E ?nOADYIAY FEET ? ? ? ? RD ECGE 5 DRIVERS NAME--T FIRST MNOLC- DRIVER5 NAMELASI FIRST NIGGLE I" WGYCUST OR PEDESIAIAN CkleCRILJ' D r)A!C:M EXc t/ x - D R STREET AOOPESS R STREET ADDRESS E CITY STATE IF CODE PHONE NO. E CITY STATE LP CODE PHONE NO. R K G.-,A, ie 3F' N!/Ltc R N . DRIVERS uCENSE N0. STATE SE% DATE OF UIRIH N DRIVERS LICENSE NO. STATE SE% GATE OF BIRTH D• IAO. DAY YR O• MO. DAY YR. DRIVERS OCCUPATION FIRMNAME 1HU-1 2 DRIVERS OCCUPATION FIRM NAME --U. )' ,, l liG 4 IA,.i ;t:, i) ,:. CODES > IN cuss 1AI SEAT BELT ISI EJECTION CODES >10) coos IAI SEAT BELT 15) EJECTION AtURE OF IH UNIES NATURE OF NJUR CS FROM SC NE By TO FROMS ENE By T VEH. YEAR MAKEIDODGE CHEVJ MODEL(DARt NOVA) STYLE I2 OR-CONVJ VEH, YEAR MAKEIDODGE?CHEV.I MODELIDART-NOVA) STYLE I20R.-.1 1 v E VEH. COLOR uC. PIAfE NO. STATE TgAILEfl P-1 NO. STATE E VEH.COLOR UC. PLATE NO. STATE TRAILER PLATE NO. STATE. I ?uL9 f.Ei?C:i? H L` HI LE IOENTIFK:ATION NUMBER ODOMETER C VEHICLE IDENTIFICATION NUMtlER OOOMETEfl E ? cc-S:14f IIL ``IS??LI `iL%(.:I( rs L E REGISTERED OWNER-LAS1 FIflST MIDDLE REGISTERED OWNER-LAST FIRST -OLE N /'/NCH }AOOIL-,D T BfGGM Y, 0. . ADDRESS OF OWNER ADDRESS OF OWNER Y.i \ 160'j. Ay S4r "1,1; 2 -A ANOADORESSOFINSURANCECO DRAG T NAME AN0 ..RESSOFINSURANCECO. OR AGENT AJ CHARGE CHATIONNO. I ENFORCEMENT HAflGE CiTA I NN . ACTION F PERSONS INVOLVED cones I 2 µ , s NAME, ADDRESS & INJURIES O SE% AGE T, STA9 A EJECT. `. NAME: C ADDRESS U P NAIUREOF REMOVED FROM INNRIE9, SCENE BY. TO A NAME: N T ADDRESS 6 NAIUREOF NLIAOV OFHOM VLURIFS' MR. TO W NAPE' T H DRESS: Af 7{F' v DFRDM N %ES uses sceNE nr IF S ADORESG __ - "- - E n iuit?.'?'F-' _^ -'-_ _ r7^r),"FA7 ? IS TUS 1-'I? +0 TK J. C 5 O ; `A?_C MCN I 1 I ' ` 1 / ? t ' I IO f OLAU I ISLE :( n! .' ' I, PiO ?v EL lOrlY 5 0 D S IE U.'IIr11NJURv T DS :ruE ruugr a? lt• Ek S 6 ]_ ^ l: MJr C FI l A u PU: ro ul J.?N I O, L M1UEU . . . . ..1 . „ . I NOT NSTAL:iD %!Or EJECTED .If N U ?C " OT EJECT ECTED 3 Loco l'IN11ALLY EJECTED IOY(N 3 VYKNONY IF , SEALOELTI`A. t EJECTED df BSg kA, nr MA'1.TF_ .. A >` 1 P I v T Yk I F ? t y r y .. I A ? G - ' d S 2 ! f i>r r4PYLCil? VEHICLE DAMAGE Ex P r 1.INEACHBOK,CflCLE MPEROFEELIIDAMPGEDAHEA _ INSTRUCTIONS: AEGTl l 2. SHADEAREA IS SE SHOW PRiACr 6 1 G.OPA•N PRPO WISI109n0 W PR NC PPL JPELiiGN OF FORCE. DAMAGED VEHICLE N0.1 J IwEr-i+IS SPACE FOR SKETCHING DAMACE TO rPPIWPS,MOroHCrcLes DAMAGED V_NICLE N0.2 1 a INIaJ l? .Rml rnr= t ]Hood a a.ib41 lk- r a bE•R is rrwl+ TM = + ' oW,i wnN„e U y la uw .-t LIMTY•DFDAMAGE:VEN CIE NO.t GEVEPITYOFDO-AC 0fMEH VEHICL I EI SEVERITY UNGDADCVENICtE N0.2 UrUNCTONALONAIDUANODPMV, DAMAGE t? Jr+GDAMAGE SQOTIERM.V. DAMAGE t IONALDA O Q NO DAhU OTHERIAV DAMAGE = fUNCAMA G 4 4EINODPMAf.E FU.C Z FUNCTOIIALDAMAGE a NODAMAGE C]rUN 2 UNCTONPLAMAGE 4 NO TOWEDRY L: KIGY SO?.) ESL DAMAGE TOWED RY ESr.DWAGE OWEDBY EST.OAMAGE TO f•-?1 1'J J. f.F^TV SJCT:4. TO S TO a DIAGAAM OF COLLtSlON..- '? ' no e ?? / ? - .. .L. o ?`? : I , DgAW ARROW SHOWING I } NORTH IN CIRCLE . ow v owv rE.PiuAEa ?fusoFlCr"scr,orFAD•DNPY u J : I?- _ . VsuPVrE cMn arlutpNa - j --j 1 _I_-..,1-- r.r..y 77?-? ----10P " _ , I I a.=TTn4,E,._SPNDR M'ECLnOYrKNS MPPCf. I r t . t 1 _ i . a.Kw PAD- D EE OR NEDES-mPn D ONE PND..,EA D,DS,D ..: I( 7._l i _ +--- i ( f T j DESCRIPTIOT}OF (INDICATE WHAT PROBABLY HAPPENED BEFORE DURING AND AFTERTHECRASH INCWDE INFORMATION NOT ON DIAGRAM . COLLISION _ . , E.G,DUVER DSAB 1.7Y REDUCED VISIBILITY. PEDESTRIAN CLOTHING COLOR CONSTRUCTION ORNEPAIS WORK, ETC) J !?ta s--n _"}v HJ cl-4 Jr•Y )?Uf . nt7 i'? I,> ?/ J -t-F 1?dQ/•/iF GVK.U E /?c- L ?l iii ! rN :r r 7/ ( rti L6 L,-) c+? c-0 r -p -t.? r ft I IJJA >v i P IT O VH HEDED N8?0 €?4TDR. GN IIEPSDIR ,• _:;.,', .. ON SiflEET OR HGHWAY NNAE OR NO. .. ,,:: NO.OP lPNE9 N E DflCON rED PEE0 9 -E LEGALLY GALLY WASVEH NO INCPENG OECREA91NG ?_`) F `P I- 1 17 YES NO WA PI`' YES fNC }? ' J --- - I, PED I j? I? I OR EET ose coA M rOwl ,caosN - r JPO+• .__ _ 4 PEDrEUCVCUSnvnsusl G ? DoEV+ , ? w I. ?ssauLOfA cNassw•LK An E .IK I °re rnE r ROADSURFACE-• WEATHER -.,,-CONTRIBU TINO CIRCUMSIMNCES ? -y ? ,...uwwvTHlcleACl a Na - ICHfCKONEI Dv £ IORECxONO X E K ONE OR-11 • • I C? OR Ie o ni VD? t A I NO I rlp NO. 2 ^+ ? 6?iPP9MPHfAD ,?. w+,• J _ I_1_iwiNw . ..i ! (.l a"A„L` - T .._? 1.>J..c`"`c 1 °( i #: ED "" 1 ?=LJ' w - Ja wEr ..... a }}? F_ .. ..., ?irrr ervceor r I .. ,'- ,f--? LorR CDT A -fIY R- __ ' ' MNw RIOHr iVRI ' fl It C fDMa F '- r11uW iD ? PPO PA _ J r J nEA nD -I'D. ; e L Cie w E LI l rEC'.'° l I ,I? u U. " oiHENlvec,rrt oMENise<wi N.?H ?. ? -? ? .n anon ?1 l 1 Na EvA"urwN`YI '--T DroA A LIGHT CONDITIONS I:HecK ONeI TRAFRC CONTROL Oa v[HCEe vEMA! TYPEOFROAD r G2l'K ONE Oq INYe VEHICLE CONDITION V GF ,. .. SOBRIETY E P ocrf°•r arNUL , c-1 IJ OP—SDx ., f CK W,[ON SO L_ "CT,; Vk Itt 'c"CK NeI t o•.uoHr ..: J SL IT -. _a ...AY .. D?rECim _.., nNDPw Urr SID - r k o.wn _: _.. ') wrv - .a owAvue .. .. I D EcrnE _ ,?( 1' ain M ? rPDM rl PWMtm FD91ROH a wsK I n`i'y' I . '_ LOp'°Awo ° a Ne.+wciaH`'ra _ ? -a I , S0° rrr ,_.•li" ? iliurKl PN1FRMa _ .. PP ?s .Pun .. rn<swoAN '..... oN SUOOm H.owr -- '? tr.Irvalw. r+n :te'? IucNrA i nmr=r -Ay", mAN U.LN ? rPLSnwAruAEO _ ._..: rn rowrv CHEM. TEST + w a --' '-? : ? , ° sr.emwRS , :_: rL+nv+n t arnPn.rro ? r rear DlvfN . _ r , ' olrven a mor0 ._ , I rA Cerzers ' Eerner°aro 1 osFSn,wo,n wn c y;, UM%N0E° : :'or+•en,wre.n 9F 95 TEST RESULTS wa1?4. rAOrI'YN • aw -E• r ' [..S r N•r<n+0 -'r' IP,a+IYEO ? uuwrioNCE "lo M+ KrlGw wALOreo I NAfvrCEA aA•ME AA.n,+ •U rM¢ ?AGl r. DPIF Or NtPLNr PP +,•JVrO nY I DPIe pUM1Ci.r[LCW'% IQ:PLi.AW Lrvi OgCEI?i.N'r%OENCV SCCPt'i n,PUCAfE CCDV ?InvESrMAIORSLOPY rb '?i ?.:9 wAx '? •. ?1 't ?• ? . r ta't? r ?m5 r .wl &v? '' iSr F r r 'rl prVbt:r ?lu.,?d I r; i w zv . R9> )p.. t?Lr5J1.."+fu l p\11 Iu LY 61 G I N R E P O R I ONTHISSIDE. ANSWERALL OUES11ON51O1HE BC510F YOUR KNDVILEUGE 11HEH INFORMAl10N IE NOT AVAILABLE 70 ANSWER AOUESl10N NARK I I DK IDON'7 KNOWI STATE OF WASHINGTON PAGE wSP,C1IHEY.,,111 No. T PULILI CUTANLF rll NUMBER q4 1 UNIFORM POLICE TRAFFIC COLLISION REPORT 1 + f ^i ?F k ,1 F O DAlE DALE OF COLDS ON j DAV O/cOII ISION I E COUN1v N0 CITY NO. ..'Y.r I L 1 % - / O??7SR T SUN I I, yl ] LUIS D WE INUP 5 fRl G S41 IU{5 .J/tJOUR)?J? Y./ 1 A / l?f?) I?R?B tiary i. ?. .? . Ix . .?. J c ,T\ USIAIE ROUTE ?COUNIY ROAD ?CITYSIHEET O -" "nA•I •- ?_ +?° J .y W ?OIHERISPECFYIr S" y L c 5 E W ?1 CITYORIOWN,I W n fIA EO. MRC PO51 4 C :2 "SMILE. ? ® ? ? ®A 0-tua 1_.- NAME AND OF STREET OR HIGHWAY INTERSECTING WRH. STREET OR ROAD LL DIAGRAM DATA G. T ON C& iz ° RA I MONINfEHSECiICN fy+CC[ IN)ER NO/f XHD +MfRSkCTING 5TREEl OR DAO OR REy p C STSEEIORRD D CLS ERFNCEGROSS N BEIw•EEN STREET AND -!'?••""C?'L'???Y ILSI T Olp C, Nl ±iX?? ?• Y Ui51ANCEkAr+DONECI UN FROM RCftNENCE OR CNOGS StREETI 15 S11CA1 COON. USE --l l7'MRES S ZbfF) OF, HKLE•vEHICIE ? VEHICLE BICYCLE ?DTHERIIVRREI `- No ARUN SEVERITY COLLISIONINVOLVED: F ? NO KILLED ){ 107ALN0 Vf NKI[•OBJECT ?VEH CLC RRIRAIN ?SIOLEN VEHICLE NO INJURED L-j OF VEMCLE51-/ J 0 VEHICLE PEDESTRIAN NON COLLISION ?HF]AR-SMAIERIAL PROPERTY DAMAGE ONLY - j t . At D R I V E R N 0. E H I O VEHcu E Rtelme N 0• ADr is 1 IRUCKINAME OF DEJECT 5I RUCK AND O'NNEHS NAME) IOLAl10N Of O&IkC151RULK E5T DAMAGE •?IF,' S E IN OF ? Y ? ? f A • ' ?POADWAY FEET ? ? ? ? RD E WE 5 ' NFME lAST FIRST MIDDLE DRIVERS NAME7I FIRST MIDDLE III bICVC-:OR PEDESTRIAN CHECKIU R D - AXf436 -7 - AX f436 7 51HEEl ADDRESS - .. 7 7 • a RE I. SIF1E ZIP CyDE PNONE NO ffriYJACJ !i?/ ?S-?<<j C• ?U? E R .. CITY STALE ]IP CODE. I - T• let.O G!-t•..: Y??F: ??:??-SI. _ . - ? / BIRTH ?- 4 T ULE VSf NO. SI AIE SEF DATE OF BIRTH N °" UPNtR5 U-1+5E NO 5 ?z ?? STATE s:A. SEX stir DA E O i? i,1 ? OCCUPATION AME PNOr+E ND. IIR N '1 DRI LRS OCCUPF1rON u . ME D E I L T.?? ?T ?a EZv c, ,FW CeC? :S >1,31 C?^$5_ .J- rAr SEAT BELT- _ i1 EJECTION _ _ rt' CODES >'DI C A S -/-- 1 SEAT DELI-_ _ 15I EjECIION__I?m-a 116 Df mwJL RE Of A.1 C.CiC 111 r iNE BV lD RII.ovED F DN. SLI NE Br Io -ONV R LAG KE OODGE.CNEV.) c 95 MODEL IDART-NOVAI ?2? ?' 51 ILE 1]DR CONV.I 9 VEH YLAR 7 I Mw EIDODGE CHEV.T /cY ? MODELIDARI-NDVA) STYLEI]D I _ Cl-? o /1rr?sP / V I f T ' ? .OR LIC PLATE M10. Er• r/Ar??! SIwTE 1? TR4LER PLATE NO. St ATE E " vkH LDLOR I n fl F IIf. PLATE N0. G n !i7 STATE 1RAIlER PLATE NO. TE STA E - R ' ' -NIIT rCATKN NUMBER 34/2m, E/2 zd'"? 3? ODOMEtER G?lRd (?` E vLHKIE OENtfKATI N •.BER -??31P IZZS? ? OCOM , t .R I ?7? :,I _ y c Dl TED OWI/cR-LAST 11851e MIDDLE •?•J/,'Tit:c i? /JD??NiCA N °• REG151E LD OtNr ST FI/RST. /? E I •JEt>C?F1.'/Njt1 /Y?'7L'A?J FClct 7- .•11 y . i OF r+ER - -iCT / /SY Ve7J 41H, t 4 -171; z , ADDR[CS`/? OZ+nEP /"TI T e<?USE-/?d IN OR AGENT N i D AUJTi[55 OF INSURANCE CO CW E?GENT qk,v r ANCE CO mr5U r+ArAE ANO FDDRF550 •? ACTION `'- NAME, ADDRESS & INJURIES OF PERSONS INVOLVED co St. .fs AGE S1wiUS -~ 1 I I Z 3 r Ir / I C ADOR[ss -7_ Z U NI MOVLOrNUM u m[ ???: x1NL er To s T : DRE 55n1/?. _?L._!lL/'•; Ii ?.?(. --- A?7J :-- S D ? ' = ;DVk ?f NDU 1D NAxIi(} ?__.t ;"• tGI Nf OY { I ??? .L,f - - . ( N N o^Dllrss I -- urar ---- t BGrr'IDM C"ll 1f BY To E NIL 4 uAt 5 E s. LD Rf S BILL V To At- ? Iy 4!¦ rcl ri A T•IEi?:i r ? r : "'ter ?! ,??. ;ts ? ` f {° v nip kam"W_ au SIDE 2: COMPLETE REPORT ON THIS SIDE; v '-----'-r ' VEHICLE DAMAGE IN EACNBOX. CIRCE E THE NUMBE R OF E ACH DAIBAGE D AREA LAAMrc_i, tl 21 EHADE ARLAOF SEVER[ST IMPACT. vJ INSTRUCTIONS: D On--OWISI TO SHOW PRINCIPAL DIECTIONOF PURCE ?i r I 'I, , r DAMAGED VCMIC LE NO.1- _ I1sI,R:s srwcl FOR S.I tcR rv4 DAMwG[lo T PAMIRS, 1OHCYOLES ETC.1 - DAMAGED VEHICLE NO Z • E '4E7 o-•?-,n?LS' to ° •N?.'1.. n. o.•n..n D?.o? _,l 5lvfnITYDPwG[:ofRICL[ND.1 5[v[R,IYOFDAMAGC -RE v[ CLEI vffllTYOfp,MA4C:vFN[L[NO.]I 1NfRMVDAMAGF P - t 0 OSABI tv4 OAMADE > ? OTHER M.V. DwMAGE 1 ? O M,GE R] CI OTHER M.V. O,MaG[ ny SN BL,xG O,Mw4[ - NODAMA.1 7 > ru«a:oNAL DAMAGE < Q No DAMAGE > O IUNCI.OIAL MACE I O No DAMAGE a u -CT-A, UAMAGE IsT. D,M 4 :' " ul. DAM.ee s1. DAINwcs lOwm BV jlP 1VABL-Cr A 10 TOWt T , DIAGRAM OF COLLISION S U?`? _ - __ _- - sE- I 'TDI -- -DRAW ARROW SHOWING [I+E. --J NURTM IN CIRCLE •'? „?+°4' to a; . a R1<, DN - --- - IQ Q - -- -- ----- --- - p1 I" V, 11 osn l I I I ? ' ? I-- ? zV p? r "` .NB.r,In<DLI L,DN I _- - - -- -- - I -- -!©J :-i- I • -- '?" ? . - _ ??#. o t l R xD 11 E s, ?S oN DUC1wM c.O 6 ' AND DESCRIPTION OF LATE WHAI PROBABLY RAPPEILO BEfDRC.ov1,«c I ' ?'oRK fo? NOT COLLISION ns-LY, -U- 1:5,.11.11Y, rmEST1Ax oLOI"ING pOLADn?GONl1E pRw1uc15o 111c.A,Nw t _ c'c'N!C•.[E ? ? (?.dui:"? ?u? ?1?'?L ? 2c;???/Crt•'L_rc?_%,1P_cyJ. __CCi/.>C??l /?rl?' ,,d' ?/p -Boo /SlYCl-,^ -ID Ce 66 rs rciJ, ND Or 1.«E5 .:? PDS. T ION OEFORE LOI LISION E ov s, RR14R,.AVN IN PNi D11l Ct,ON , ?tG"1Kir WASV 4 EN. IADCD uILa POSiD 1Ff10 AIA OR NO. (O OCCVr 10. 11CR[ASING CECn EAS ros t L I4=w ' R?? '- A- N _ YF5 __ y cbr l (1 I Z ?? M .-?-'I P[0 --- Ov4? ------ _ ING---- - „. DM- RtU'_ ht ___•l s'-wa. R.fD s. Is,cHATe° RIR <Icnl<ao CIaR+lK _'cNCES R0 _ cYGLE 1017E II_ 011 E1 [HIC L °NS ; rI „. -1-11ST HAS URFACE VS«c t--sD[ WEATHER? wu ]! >--s CON, ...... ROAO SK BU7INGCUMSTASt - { P ,yI - • ICn[CK DNfI ICHFCK OVEI • I__ ON[ O1 MOAE1 ]yP E o.IUCw I , U D [1.I I ?s 5l1wOiGRi AR I vER 'N ORo1.E, R E HDE^ y U A ' G I ?;fy +t ORV -^ 1A[1 S0 4 I '11D[1I«F LUf OF 77 "R O.+N4 - I> - p .SIGnD[Dw? -].- O^{ORi ,y NG '# a MF-?. Ov. __..Alcoyol £ P - 1f v ,Klvc 1N _. _r] >x wEl- >1___ G__ _ ?]r-- D[1 INCE or r B ° , I r1 n ---- ?/ M,K RIGHT lu - [ DIrr45,A1f0 - y EL '1I. ,? ' a wow a' s«ow_xc i I??:[e[ollwT_ ? •1.+:i TO I PC.LOHr-aLNC _ MD'I IURH < . rh't - I Ief-_ -. fa s Ea eCP-. I ?L v9"-- ?-sgyvE Eomr °L- L° INH ? l' r I •; Br=.-' s I^?- f 0«m c1, 1 ?'-' O tw DlI>`? - _srl s w.N° r, P1R[R lsrlCilY- nlliS"e, YI A lOr i ref ? PTNI115/f CIFYI CI>J 1.A,,,o fOR r[ 5f5 GNAL _ ._ HOV DlAl10N 0 v i?IBr-1 I? 51o15tD1Pl Or D 5 AT 510 4N LIGM7 CONDITIONS TflAFFIC COFJ7R0 TVPEUOF ROAD VERILLE CO[NII??jDj??I71QQ0N SOBRIETY NI -1 - NO Itnf CK Ox[I` JBr;- ,RU I J?Y?1 ROAOwAY 1,%t DAYL WHT. ] I } Otr lCTrv[ -_ -j nnO wBllliV -ItOJ STAR,I«G IH , (r1.£ ./ 1PAr FIC .. [LO RIOVfRi e1.[ > B 'KCt - ?I>. ?J IAI eIDITV ?ARKt°POS IF M. sGN _ n AN` ollinrs o ,vAIR[D-t C-I F.Lnuvc n«l S p1. -NG _LO[)r Rau Gf U RL I1C]IG IIS _ I e D-BnI[t _ _. '?I>.` u - F', D.R. isowln L RII c - -- 'L I.;"o°D:K .. 1 1( N°°?INnIN4 In d.C.INC N CIIEM TCST -I 1-I 'yl I I_ „N Ilv s NR -? v.llrT -, D NO i I J 1r4R1t O,I _ -_ E Gv,l _ .-l OIRIR ItrLCI 'a s -F-SN(- nn c vl« ? E u.ai"ocNTS ! IN 'I Y E._. .?1, J? > O x NO DEf LCT4 ,n 1 -- II slo OIHIM Orlbra_ . ]k na°RImD Olrill nrFUr YI =AEll RESULTS z u r,..,nol 1 1014 - wN1,vaD .,,e •. «.FUrc,,,N4a?.clR Sr: :ni« N. n,DCI ND roue uara<NID H i. rI DED AA I tD iv ,u>1 u 21GO RRE?qq ... .. I _ .... _.. - ...... ..,- n.om Nfrn11 AnnOVID EY OAl[ . d . qE'a I 14 ) ? ?f ?r 7 Y Ili ty S:1. .. 1 rii„YT"i'"}',I•Kr Y ?MIDeF ,.w (wb! F -"b "b'" i ?vly,rWlPt k '? i '^? r „ t, 1 ? f LIy 7? 11# I F 1 i I ?E? ?S ,- I ; .f .. ST ATE UP E OF WASHINGTON NO ,Y$1 MOTOR VEHICLE COLLISION REPORT W „ •. DATE TIME OF GOLUSION CMINTY NO GTY NO DAY O R ISI N E OF COWSION _P sun uox uES wtn rxuR fat s•r HWn xu cs AM D,.,, , 3 } tu% COUNTY- CITY.TOWN ... a a MILES OO CIlY, 70WN AD LS PRCFI% [b11IE Oq6 AEET roof ECTION_ ?iP x° OC] pF ? Y?? E/ • ccmext Li:Fa ''' _ 'GIVE NAME OF 61 ROAD OR HIGHWAY INTERSECTING WITH: STREET Ofl ROAD PPE I% EO MILEPOBT?, tiA S(7 •I. NQN INT€RSECTIONLOCATIO OF LLIS/I1ON [, MMP i" DIAGRAM DAT/? IYx EY,(J+ i/O-(• I?IM[L ?•LIS'(? STREET L?, 4,?"-.Y1m r."`4 Y•.t'r. BETWEEU'N CS EELS 6ErAEO FR as DGE REFEPE? GPmoq",Ea'ST "ONOM r ??E R?SRO ocnossq?iTl?iiro niNlf?iirv •nA :NON %RO , INTEiI M CLS /y1 yy..?? AT ?$ W? • LI I OG Du ? S• Y Y/'M *"?•+ .Ao7 ' ?rvlEP5FLt0 IEEE OF 1 -C ' Itoll sorv rv WED ?v(aLFVEx?CLE ? e• ? .(a PVwru J ¢PEG TDML xo. N.,uewrLr ? et J(t??^ Y ???'SS... :n. ?!?"eW. OF VEwCLES ® ? vtxwLt ntxetw ? C9N ? wx IxwMEOFOa.fci tuclN" OWNER OF OBJECTS NAME AND ADDRESS ,._ LOCATION y?•;, QQ TIN 9 , OBJECT STRUCK IN PO AY..:,v.?? • i0 RvuR Oal(CT.' BJEC ti /;-IY iIr ?-/ ('} FEET S W UDE' DPIVEflS UST NAME .; ?. ... .:.. - FIRST NAME -- . • • MIDDLE -. wFaE?rvv "I DflIV ERB LAST NAME ..:.. .: FIRST NAME,'???..n.-, M ILO; // ,/ xrnL ^ .. o. /71C\11!JT•_ ? usox Da )??.:r -? ?•-C V STREET ADDRESS .. .: - ROUTE NO. ANO DO%N. wEn[ 5`TREET ADDRESS ,., ROU ENO. AND_ _BO% NO. r CITY •_ STATE ...ZIP CODE DRIVERS OCC?TIDN FaORr [OR CITY--•-?•- STATE ZIP CODE, DRIVERS OCCUPATION Wa- 1 I 3 '.,DATE OFBIRTH:,. AGE DRIVERS LICENSE NUMBER;.... STATE SE%- DATE OF BIRTH AGE D0.1VER5 UCENSE NUMBER STATE 5 nF-!VZ F ND D,: YEAR (CMEV; DpDGq MODEL (NOVAIOART)_ BODY STYLE (} DflJ " VEHICLE YR MAKE VEHICLE YR MAKE (CHEV: DODGE ODEL (NOVA-DARTf BODY STYLE 12 D ) /9I3 /I/y'lLt Ffr: H/, -In...ly <,'l nr.;}n I k UCENSE PLATE NO. STATE . -: TRAILER PLATE NO. STATE. LICENSE PLATE N0. STATE TMILER PLATE NO.'« :STATE:u- ._ I I" VEHICLE IDENTIFICATION NO... ,.11861 MODELS 6 NEWLR)., O[MMETER IMILEAGD VEHICLE IDENTIFICATION NO... _11963 MODELS A NEWEM.- ODOMETEIi.IMILFAUE REGISTERED OWNER (LAST.FIRST-MIDDLE NAME , DRIVERS LICENSE NO. REGISTERED OWNER; (LAST.FIRST-MI DLE NAME • :DRIVERS UCENSE NO.-_ a OWNERS ADDRESS (STREET, GTY ND STATE AT OO.r0 PITH OWNERS ADDRESS :,...:: (STREET., ITY AND STATE DA OF B R1Hr( TE,R- eeo r R _ ,F • PARIS OF VEHICLE DAMAGED:' - iOTF[v?INYitcLF- PARIS OF.VEHICLE DAMAGED ......n.-, .:Y• .-a. +•'S iuT /r) S J •,A' {ri J,.r:?. IL..I r.. r.-'? _ ..TORE E: WAS THERE A TO,AOBILE LIABILITY INSURANCE 'IJI YES ? NO Yl'4 LIABILITY INSURANCE INFORMATION-VEHICLE NO T• COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR 9 NAME F LIABIU UflAN : •c•'. ,,;;.? ,1, - NAME AND ADDRESS OF LIABIUTY,INSURANCE PoUCY HOLOEfI •... ,QDRE55 IL •? r ^.?I " ?lM?r+:.r TI i? r ?d•' ?T?-l'e. I'tl'I r G- / 1 I "'1?L1 !'I/! //IGLxC 0.L.. NAME AND ADDRESS OF LIABI- INSURANCE AGENT .. - •?? a +. LIABILITY POLICY NUMBER „?,-, ;,_, .. - ry F• 1< ?. h(I I,i ti-, ?q 15TINJUPY. AGE 2ND INJURY .;.?:.:c,?.'.. LV..-.v.a«?,... ....A?...r_a:PSE., .. NAME /i L r+.r s. TOTAL NAME %'I C'' ) i• EO SEX - ADDRESS SEX ADDRESS Ate. T oCNL E .II ?. ? oFN?Q_ q Ewl x( irvt at3 aEW?RF DoE oas iox pr, DOf* a+ " O i.u rv.r r Rr L txKtoar Y. STATUS DF IN R MARK FIRST ONE THAT APPLIES E STANS OF INJURED ;,.. - M-u" PKFIRST ONE TN uT APPUB.,.,_,:,_, - ? OPoYEq iN VEHICLE os ??aIy Noa ? OP ER IN VEHICLE %ILLED ASSENGER ?nZ KILLED S,R (F ?P SSENGEN ND. D'' NOx -- • r r? + EVE [? V EIE.I aL r [TG ? EDCSTRIw 7? ? EDESTPUN ? 5? 8? D7 ?mnENWwTFIN ? 50 6[:] _I} ?OWNER WP IEIN ,1 SNOW NORTH BY ARROW IN CIRCLE OESCyIBE BELOW WHAT HAPPENED: (REFER TO VEHICLES BY, NUNBEIp INgr?1E ON TNIb dwOMY O\ I C4"..?_3 M,Ics ?•?Cylmlt4m on S?aJO AfY T AT HAPPENED I? _ ?! ! V t. 17 rn $•fArTL L_p..ps. /tfb 1? S M e i5 ?( .cxv..r x.uef D. I ver.Y 1L,0.??????J?(?.,,'n.? s[atC E1M ? ?u ?('[. rv ;`?? rvi"•rwm:o°M _?caf'LSf'S•11P?ai6 Err 1-TI d L1 Y r?rk )1M/j S16. d ? y<I?o?;.:+Q? cnw r ?_t»Y?c??{n{...c]?T-T? .$ a nd _1??[fsELttz? I'? ??.' 1 /? OJ>DJJbLC _i S?.a? o l // S o N' ?? •?LEYAI>IJ 7 -7 Cher UI(mK<un;L ,cy„_ i!? 4FS!cQta'?- sp?rznee?.S.s• hr?,T t ,?_ ["??y-=--fir- aI i t?. nf,y"?`,?.:.? •S:i p: $h? TD Q.I?O?_Way bnr k men doyD, a Qrjv/ r. 1 H Cat by 6inr4_7/f sriz[?lzt? e ' tt • R_?trs.ICS! ?r_r?es.Sd s =ts. / Q41 ?• 1 A?'"y b Q11u1•_w?1L.r?? -54, S. ?,? dr, k z a } ?e..lc4?melLAlc?hol wT[Cn?cns ; (tt w.x ?vri- LAC w 1r SD IaY "fD rC' S fxKl[ Edo .L I)J? 5 :./ Yy VEHICLES POSITIONS BEFORE COLLISION f wwt ro:n BY t , ?. L,f b r "xDwO ,f OA[DW1Rwu O tt• INVEST[TIOAT 4 tt NOI 13"'.& ?OPMIICf v T YNA ME ON N0. DwfCtgN b -YE NO E6 NO YES )I y A (C 4 NOHI plYalq ..,.. ? ? ? ? ON STR[ET O R HIGHWA .. •..• cEpbSlxO 11 O .. 0 OROU OREO N 010 O DIRECTION- P'PjJr A L ;..! } ??L7? F E 'kY ' nOESIMAN El ? ? 11 ,I ONp L "iL...::w uF•,u.. w. • *? ` E PfDE31R1AN AS USING bIDEWLA [ W,L - ] s.1ODLDER •E [ Ax(D A DINER TRAFFIC CONTROL 9.M- Gnu TYPE Of ROAD ORIVERNEHICLE ACTIONS Y rlnKL? pHl. b} ?[ ?V1xKl t]QA dI[d1 MOR[I K ROAD SURFACE WEATHER LIGHT CONDITIONS rl 1q A// Kxf .ox4 ll 4Y ut y 4 NOrE y[ f 1 r. T-.. ?spt 1 ? DAYLIGHT ? 1 ? SIGNALS ? 1 ? ONE WAY ® 1 ? ODINO STRAIGHT AHEAD r7"• ?1'? W or y ?1, II F ©1 ? DRY } ? gAINgO } E] DAWN ? } ? STOP SIGN ? 7 ? TWO WAY El 2 ? OVERTAKING AND PASSING P ? } ? WEl ] ? SHOW HO ] ? DUSK ? 7 ? YIELD SIGN ? ] ? ROAODLf ? ] ? MAKING 1YGN} TURN, V F T DARK SIPF.EI INTERCNANDE + S -? ?I ? ] ? SHOW 1 ? FO6 1 El LIGHTO ON ? 1 E] FLABIIINII PEO ? / El RppPgUYP ? 1 ? MAKING LEFT TURN ? 5 ? MAKING LLTYRN I IF :.j' L;n 11, t It'q" ? 1 U a S ? (OSOCfJFYI S El LLIiGHTSTOFFT ? 6 ? FLASHING AMBER U 6 ? ALLEY •. LI.. u6 ' T.ER 1 ? DARK NO El ? fV.O WAY. 0 ? SLOWING QY /+I) STREET LIGHTS ? 1 ? RR SIGNAL E LER TURN ? S? 6 I.'(:F rt)\ li HEN L (}.. y r.: REASON FOR NOT SCCWD DANGER } ? 2p"," ? I ? OFFICERIFLAGMAN LANES } ? STOPPED ld11MrMIC V, p1fCUA1D nbV."' df1A•LI MNb 11cI C3 1 ? OTH[I' SPECIFY STOPPED Al WNA: I ?g ? 1 ? SEPARATED 1 OR STOP tdI AY f? I]7Y J ? 7 ? DIVIDED ? 8 ? STOPPED N ROADWAY ST ARf IC 1ANE Iqi M"" N F`IC , } I V RFD I .J '., rr: ,.: nI. U!-M, e ?ja s r ;mod uSEVr`. OF ..1ppl,,?1Y./} ,'p ?7,L1 •? 11111 ?./? PAGE ! l I A IYU MM K ,. ,' POLICE COMPLAINT NUMBER - - ?S xav UNIFORM POLICE TRAFFIC COLLISION REPORT • 'E L °OUNRYNO. CITYNO. FHWA F. 0 DATE OF LOLLIS ON DAY Of COLLIS ON LIME i' [ M Y ^ jSi SIIN 1 2 IULS G WEDA I- E TM JD SAI IUtiE aa00oHOUR1 J ?UflBAN ?' 7E / j! Z - IIISSS/// URAL ; --4 RbyfqCA COUNTY ?STATE ROUTE ?LOVNTY ROAD ?CITY STREET Q AOM CLS PREFI% SiHE b CiION .?? 7 ? OTHER ISPECIFYI NY4y'i CITY OR TOWN PREFIX EO M FO$T ow 0 ? iF a •'F"} C NAME 6ND- STR TOR II GHWAY.,. INTERSECTINGWITH: STREET OR ROAD LL RAMP DI HA" 11TA WX "T O N • ?`" NTER ON %'RD EFr $ELl NG STREET IoA II H - x L;'. + NON WTEN$ECTIdI. ACCIDENT I i CLS .C (; IOS,? hEEi Ori ROAD LE GE /s rY Ha. ?H'.j?+1 ?? y y - (M?j`.v 'rAy?i N., BETWEEN STREET CODE o-ES E / N. SPECIAL c00NG USE LSJj qj 1 SYW' GSTANLE nrvo DIRECTlO FROM REFERENCE OR//CROSS STREET O ?fEET El ? W OFij>1 C.` HV ?d SEVERITY M COLLISION INVOLVED : ? VEHICLE-VEHICLE ? E CLE-BICYCLE ?OTIEHWRREI HITRU NO. LED v r ;h D TOTALNO • ?VEHICLE G.ECT - ?VEHICLE PR TRAIN ?SIOLEN VEHICLE NOINJURED b AZAPDOUS MATERIAL PROPERTYTY OHMAGE ONLY OF VEHICLES ? VEHICLE PEDESTRIAN NON COLLISION H _. ? EST. DAMAGE .? OWECT STRUCK (NAME OF OGIELT STRUCK AND OWNERS NAMEI 77 LOCATION OF OSIECi Sq T NCKS.. E:: ....: _.- r W ?POAOWAY FEET ? ? ? ? RD EDGE f J iC .' ONNER$NAMELAST ,,. MIDDLE. - DRNERSNPME-uSI FIHSI MIDDLE IIF CYCLIST OR PEDESTRIAN CHELKLQ.._.:.'.,.. D ..... _ L .... TNYr'"?' F . R SIPEET ADDRESS -? R STREET ADDRESS . ....... .. .s, - ... .. n13xR." _ I. I v zoo } V: - E qTY _ Sl'Al ZI CODE PHONE NO. E C rY STATL _ 21P CODE PHONE NO. •. $ R. R >7' + Y `i N ORNERS LICENSE NO . STATE SEX GATE OF BIRTH N FIVERS LICENSE NO. STATE SE% OMTOE OF0011" YR_. • it 7 °AY? o. 0 DRIVERS LCCUPATI FIRM NAME ... PHONE ND. '( DRIVERS OCCUPATION I.H. NAME CODES J 101 CLASS AI SEAT BELT_ 51 EIECi ON CODES IJI CLASS- AI SEAT BELT_? 151 EJECTION ___ ''fie } _ NATURE F - 1 Sl ,. JL NIHNHIES F .+ r?OE?drr?Y?%On ' ?AM/A i D_/1.I.LA[/ MJURrES _ a ?y RMOVE NE RV' TO FIT 6CENE BY. TO fgOMSCE S VE 'EM MAKEI DGE-EV.1 MODEL MARI NOVAYLE 120R CONLr.I. VEH.YEAfl MAKEIDODGECHEVI MODEL (DART NOVN STYLE I2 OR -CO-) E VEH COLOR. uc, N0. STATE TPLER FLAIE N0. STATE H VEH COLOR. UC. PLATE NO. STATE TRAILER PLATE NO. STALE Jill H 'p c VEH LEI NTIF LION NUMBER ..._.... _ .. _ ODOMETER C VEHICLE IDENTIFICATI N NUMBER .. '.,: .... '.-'... .ODOMETER...; i , : T, ' Y L y o? 37f?s` 3 i? 3 e EREGSSTERED OWNER-LAST - FIRST - MIDDLE REGISTERED OWNER-l. Si FIRST .. MIDDLE. E 1' N ?Y N / l/1/I __? •S ?r 0. O ADUgess Gf -ER 4,1 ADDRESS OF OYME tl' NiM[ AND ADDRESS Of rtuSURANCF CO. OR AGENT NAME DADDRE[S OF wSURnNCE CO OP nGErvI CHARGE T1GIn?lON NO ENFONCEMfNi CHARGE GlAl10NN . T• /'- p^-- ACTION CODED 1 _ a O 1} NAME, ADDRESS & INJURIES OF PERSONS INVOLVED EJECT E s YES SEX AGE S1niU5 r tt?A . I NAME p A NAME ? ______-_.._._._.._ .___..__..____.--_._--__ N T _ ADDRESS -- S NAOf rlC.nrt`nv To W NAME T N M1T 5?___ 1vcl R TO E E m:nr?sf __ gA p M6,EDItiSI-____. . S' ry ti DISI US (: St 1 o,I IXFN CU ws rN Stet B[Ll ISI[Jl C11ON O 2 PAS.I f[R : n'c cISTAN ("7 I t ? r 0 I'E L[ C nrA T I L'?4 G UIY '- D L n r lo? r uim NO 145TAIIED Ol RUSE ° o NOTE FCTED V [Jr CiED a Oi FL N IFJ[C1CD 0 s d ?,_ .°.u o : e oo? 1 N , .. . iiinwn[ n s sr? F J[CIID E . . xw.', y p r ?? ? TYrLIk? wriq r? '' { t?• 1 r ] y, xY I l __ OVA . T ENh^Zt 1 ! s CH LEA? J ?ti?"?? .: KL I L ]. GRACE AREA OF SEVERE ST IMPACT. -6.) INSTRUCTIONS: ] ORAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE O / . ?? • _ DAMAGED VEHICLE NO.1 IDSE,nrs srAC[GDn sK[,cHIxc DAMAGE,. TNARERS, 101ORCYCLES C-11 DAMAGED VEHICLE NO. 2 1y,^ 1 ' SE ITY.P OAMwG[: VEHICLE N., 1 I.E. OMV....A.E 1 g.SA-AG.AMAGE J ITY.F pAMAGE'IOIREH VEnICLEI AMAGE E. M.N DAMAGE IND B IS L D E ? o HLExOJ E NTY OF DAMAGE. VE ,C LING DAMAGE : I? "RERMV. DAMAGE , ?O SA ? J D FUNCrIONPLDAMAGE NDOAMAGE N.DAMADE T u CTIOUnDAMAGE . L LJ I MADE ?? I C'I T.WED er ..? ^ Ei. DA AGE s M OwE. BY EST.OA.A.E AGE ,DWED SY EST.DA To J 'DIAGgAM OF COLLISION s % r. f TO I _:.-?1 r?.. .- j?' J,( i DRAW ARROW - NORTH IN CIRCLEING L ,HO 3 d - 7 All, 2 °r,AR.3 AL„LM. cD 3 I = - - Dxu D NP„IPNS "T I T L.<m[ 11 ...A,., -- - ?1 1 HrAN04 S,ow YC.,a11E .,..,c:, ,.,. ., ,. , A 7 .. SxDw.RD..[L,UI.,aLDA - rw,SU,NrA,esbvuu ^ ems; /r'd •. i(>•. DESCRIPTION OF . INCLUDE INFORMATIONxOTONDIAGRAM. EG. DI-1. PADIASLI APIENED IEFORE, OUTING AND Al- 1NEC LATE WI N ,H a o on eons c E o ETCI COLLISION 0 R c rtr,rE Nno f T DR R m d?-- ._ - dT!=._T?G Zeei7?..f/-dr . - POSITION BEFORE COLLISION T - - - - On STRfE NnIGwwAr t nMF Oa t?O ONF .,-VD.. u CLE A ,F pAnKED S.V NEO H HEADED 3 E MILE POS ?nF INCREASING oE ASING . . R I PARKED I OCCUPIED _x SI C _. "/ _ / /C r 1 M, s? 5 N ` IEEE _ . / -_ PIED, PEOeCCOST 115 USING x D IL ,. W IOPiG -ALKJ 0 ERE. O ALD 35W ROADSURFACE WETT HER - CONTRIBU E gTANCE5 TING C1 oCUtoEI OOJ1, C t o Ei 1 ICHECAONEI p ICNEc xE1 D p H X L J S . AeG A RT AH E _? '. pRr xcL/ F - _, ' RCASS -. RINFLDENCf.P _ CD. OL _- D, - s x. ? J }.?E As rvc NORPA S NG , _, . J NET _ x RA _- _ D Gs ?+ 1 : M ° II CHiiunN w .. ] IN fU ED 9 CIL 11 PCE PARKING LEFT I.R. A ICE __ _._. O 'LF"PECEYI A FOG -.... __... - b1kI4 SPCCIFYI 1KC[E G RAs SAES" .. -: p,pnorcn,NTTw. T. yDxCL, - r[ S NGN I,p P rURN Pul .: °rsR`RO__- I ST-E&GO LIGRT _ IIIIIIA"' P -lb [NA ?_ nU CC EfOIIIV..- . - IT Vt 'A L" C 5 _UTUnH .-'Ni- nowmc Sr qrP F1IC FOR v _ SOBRIETY LIG H T CONDITIONS RAFFICCONTRO vE [ MCP F. OF ROAD VEHICLE COCNDITION E.0 -11-C D C KONE OR MOREI E Sf?rIICV pNF pR VEn CLE ICn1.CK UNLI LHECA vcrvALS ._ .. _. .NE WAY i No ] IF ronRtli4uiEm I No J 1 STOPPED ATSIGMA L OT SLOP TIGN I-PPEOIx - RDw.w,r r'x ruGNT x Tw.w I Dln.cnvl rA '- NIInKES PA ILED .... ..- . .._. _?._. SIGN J .. -._. STARTING.. -- lnnF, C C LANE -t __ ^ Y,[lD 7 Di, ZCT ,r ..R. J. rmeo ANLI mAnL Uns ° N.nm AUa. - -_. ._ 3G• -- F NNO SOLAR IE,v _... -. rv4 F 1 c I ] 1'- STAR,VGGROM rARKEDPasmorv :I} MERGING IEN,ERING A SNI ] WSK E 0 LLIV?NnS,v UrIK. T NEA,? L GNTS _ H E - GAP -S,AEfT AS N4 5 Altlr ,NIISwI.HN E r,nU NOI LIGHTS .N AL= .._ _ .II S' Opin n31N CHEM. NG I, CHEM. TEST ,wD WAV L I - rAAFFICI - ?Ip BACKING .. . GAP K-S,.11T S 6 G TS OII _.4... _'. S,Gx AL ,L RN InNI: n,. xl ,w+ - l - O -IR .. -R SPECIFYI IF lE l4 s 4 N ] E I r x NO OEl. CIS ES b ccl. - X X R ti 5T RESULTS - _. ._ .. - 2 - ID ? . •, U -NVL3?I..A1 NI. uIIRIRirIArA1 SR,NK - I .. i /?2LirJ3#1?11?a? 1/' 3 "%O 1 ?? ?DHI f u„ „YL ,r4„I,LG.r.L,N:, ML ,r sn 7 4 D 3, 3La_ r 4ry E , r ?rl OUNI ICq IL L.Gr'v L.r, ., nw l „I,:%•.,I .l nr.I'rl'? LI?-1 IN,PIICASE COPY IVI'.IIGAl011'5CGPY if?t !r jrttll??f?yv r 5 '? ? ? -fKi ^1?yN ? (??I`? 1 ^E?p?p?r+ RAT DES 1 rr t,r a F? I EJ A 3J't ?" •FiI` t e crrr rrln '^ 1.-EF°L'r ?'+.'', '?^Y •I?4 r,.WYY'?rv.E R`,?'. 1 f'1 II " I CC?1 ? °?, !1 1 LIN? t L; i T•RtT rT I T,A ?F4{- L..1 .,+..,..'?_ ,..tiNi S A 1 L.. 1 tl¦ ?11'?Y t.L 1 V?9 rAGE Or IYU. E 'mow P0.IGE COMIryA NT UMBER UNIFORM PO LICE TRAFFIC COLLISION REPORT `, ?2¢M?A?JI DATEOFCOLLISION OAYOFCOLLSION TIME COUNTYNO CITY NO. f,1WA Lr0 YN•r'. r 1". `i Yi i4 A M OAY T SUN 1 Z LUIS ] WLD A RIUN 5 FNI D 5AT IU5 TIME W.1 Z / 1 OuRum 6If N .Y?' i CWN Y u---HE iRICOUNIY ROAD ?CI:I557REET O ADM. PREFI% ROUT S RE TCOOE- E LTION _ F• Y OTIIERISPECIFY) ED ??7? IY l ? IN •O Cli Ofl O N W REFI% EO. MLLE MIST L p U' • ;.• , C- 5 MILES N? S O W Oi..?...?.,? L"'•?.V M -- LL . L C 6N0 OF TREE WAY IIIi""'IT"'WIT". STREETORROAD LL RPA • B.. LHI x T Off! ? NAMEK_ % + y'k' ! I NpI WTERSELTION. -ACCIDENT TEH i0 XRO tE SLCI GSIREEi ROAD ON REP. j 1 j p. R °- ,^ n k? p Y= NY Cl5 ERENCECROSS STREET OR ROAD DETWEE STPEEI AND MILEAGE CODE- OISIMLE AND OIPECTIUN FROM REFERENCE OR CROSS SIRE 1 H Et SPECI CO INS USE r+uNlw[ MILES N 5 E W w? ,/? rH5 FEET ? OFC .. L i_.L. KG V r .\. - _ . __. G f?i ..• j '°' u9E!'"r "{ , ® VENH;LENEHICLE ? VEHICLE BICYCLE OTHER(WRRE) ?"1, ARUN ?NO. KILLED SEVERITY COLLISION INVOLVED: --- ?VEHICLE-OWECT ? VEHICLE RR TRAIN ?STOLEN VEHICLE NO.INJURED TAL NO OF VEHICLES ® ? VEHICLE PEDESTRIAN ?NONCOLLSION ?14-000SMATERAL PROPERTY DAMAGE ONLY G '• ODJECT STRUCNINAME Of O[UECT STPUCK MOOWNERS NAMEI .LOCATION OF OILECT STPNCNS ,E. 1Y EST.DAMAGE?' < F? ?gOADWAY' FEET ? ? ? ? RD EDGE 5 _ DRIVERS NAME-LAST. -- -' ' - - FIRST --- - ' -' MIDDLE" DRIVERS NAME-LAST FIRST MIDDLE-lI' KICYCUSI OR PLDESTPoAN CHECKI [J ' D 11u &2114?? JOY/) °' C 21c?E . ?An( r??1nK1 ni p RN K,h R STREET ADDRESS_ `T R _ STREET ADORE55 T? y^'• RE STALE ZIP" PHONE NO. A CRY C1. STATE ZIP CODE PHONE NO. ?J I 3?0 377-52 CkI(11Acum uJf 983zs NavE a " N DNIVERS LICENSE NO. STATE SEF GATE OF BIRTH N DRIVERS LICENSE NO s1ATE SE% DATE OF BIRTH \ 0 \ '? X ° y2309 t oW M q 1 1Y YR o. F 773 N S (,JFI h( ? QY DRIVER5000UPATION FIRM NAME PH I:E NO. ?' "'?r .1 T': ORNERS OCCUPATIOtI FIRM NAME PHONE NO. 2 .c. CODES > IDI'q- _`_ MI SEATSELT_ 4_ 151 EJECTION ?_ CODES > I]I CLF55_C- - IfI SfAT DELT._ ___ 151 EJECTION _. _-__ k NATUREOF STAT?? INJUR ESF -,?O?rc N4C WJ ? -? URES No !V FROM SCENE DY' TO -LI SCENE BY TO } _ ry VEH YEM MAKLIDODGE.CHEVI MOUELIOMT.NOVA1 .STYLE I3 DN.CO.) VEH. YEAR AKEIDODGE'CNEV.I MOZAFIT.NGVA STYLEI% RCONV.) a {+ 20? V 6 Fb2 %T P v d. E VEH. COLOR LICTE IA STATE THAIIER PLATE NO. ST AIE E VEH COLORPUTE NO. STATE 1RA LER "LATE NO. STATE ;. r " U_ N WA si WA ... H (?'.. VEnICIL IDENIIFILAIWN NUMDEfl :. ODOMETER •.._.-, C VEHICLE IOEN MDER ODOMETER? ' ell L , E - E .. T .. . N REGISTERED OWNER-UST....... ... FIRST MIDDLE A .' . REGISIERED OWNER-LAST FIRST //. -MIDDLE Cr`12 GF CAI d . . O C O. N • A SS OF OWNER S(?*nt As ??C 2 ADDRESS OF OWN R.,. Rf If & 329-A C'ti.MALVty w _ NN.IEMDAUDRE:S Or INSUTTMNLE VVIC - , o F NAM EMDADDRESSDFINSURMLECO. OR AGENT N CIAT NN CNANGE' T t k -A I TIOHN . ENF CHARGE- +. .. ORCEMEM ACTION N111. TAerz"+ A n d A ?'1 i Goofs " , _ S PERSONS INVOLVED NAME, ADDRESS& INJURIESOF - 5[% AGC STATUS rv I EJECT.' d NAME ?n r3n n (ice vg? r 4 8 Z >, ° IN - NAWUN55 p,?-?. G6?z--- EOF \ I 1 LMOVEOFROrn .? ; -• - _ 'i DEAD .1 1• i RLY5MG4o.C L FI I4 OR OJt OCM1AL PoSNION 1 ?OSYIoll IBE IiJVIh' I?6? 7a? A IP -o 1 NOIINSIALLED 1 NOT UFCrEU T NOY IN USE 2TOY H.YIJFCIED ] USED ] PADIIALLY rJR1C0 UNLIIOVIN D Ir SsCAi UIIT FAILURE f. JrCJfCi[ TED !y 5 ku ? ' 4 ?• • r T S i'£,1 1 {rye t' IL T. 77Y4 - .C,.. .? b$Tm"71 ' j, I. % T F.'. !t :'iYn f F? i } A?'i'$" TyP 1 1m- ?I n 4MI. f ?xn eTC.I DAMAGED VEHICLE NO 2 NOTOPCVt f GE f0 TPAILFR3 DAMAGED VEHICLE NO, t . . vit iNIS'J`Y[ rOR fKETCHING DAMA r._gat I/ ' .Hl;" 15?1r nL Itl U .. 1 i I L4 S f+ EP 0 . -I 11. 0. j VE ICLE Ox A , SEVfJFITY OF DAMAGk. EICk 0.'I E. IOTHEP VF LEI YOLOANAGE IA. 1 GFSADL NO DAM E ` NSEPMV O C1I GD MADE ; ?CYiNFR O AOE ;E IU5Atl ING M GE ] O OfNEq [I GEC E p l NCi (I 0. o NO DA OT A UAM I u FUNCTIONAL DC.IALR?? A LJ I TOWED fir ,'•4:' AGE C? 1UNCTIONAL AGE AG EST. DAMAGE T C..A OWCD DV MACE TOWED tlY ',Y et.•' 3. _? r _ ES f i0 ,.: TO f NO DIAGRAM OF COLLISION I . I + DRAW ARROW SHOWI I_ 1 I_ 1 1. tt 1 7 yL••?F j NORTH IN CIRCLE 1 R?r { S Y1 f,PNt,IDN A_ T - U..1«1 DF A .N . 1 1 r I ? T 1 j -' ? _, ? ?G-•_ _. ? l. I I"TT11 t -a-?-} - 'I 7.?. r { T r I E •NDA rf c LfO«. -. ? L- ?'F" -r- I`: 11 1 . Al " DESCRIPTION OF ,Ono uTC WHAT PROBABLY HAPPENED BEFOAE.DUn NGANOAFTERTHE CRASH, INCLUDE PDR A NNO 0 Df GRJAM. BG DRIVER- - CONSTRUC!-.P.EPA _ K.?.TC.I . ETP ANCIaTNINGCOLOP ' COLLISIOIVI j , . PEDE OISAOILItY, DEDUCED VIS B3LIli S _(,+L?1`;Fa= 'i:La:_-L_i.)/ 51.1- •- .. •le...?.1?K_?.if (5 ??.•:.i.y l?J??. Il !-SJ??Vr..l n rz ?,.1 'y 4± ' -- ? ; cam - - C Y --- S,PEE + . O E LECTIO vgGA LLY W SpEH? -P TI E HE O u510 - _ VEN. HEADED ILE POST DIR. STREET OR NIG.WAl NAME OR NO NO INCREASING OECPEASNG ff RKED DC E0 YE, NO N R 5 G ' ATE I /' EO 5 U nKEO 8 OT. ' ] I SIOEw•LK PEDIBICYCLISr wAS USING'. 8IC - .8C a0 i SHOULDER CROSSWALK OS•wA E < l ACTI-S ° ,'ROA SURFACE WEATHER .... ,. CONTRIO. NTINK CIRCUMSTANCES [ ONE on MOHEI NO iviH ii ECK ONII ICH DRIVER NOx I CHECK -1 a E O I NO 1 OR VER Ox - IINy, _ Un 1 O G 1 r _ L 1 I ST GM A EA` 1 O EMAKI 6 1 I ( Onv CLEAR, ClOUOi s9YEnGVi z . N ER INFLUENCE OF I ALCUnGI I FOLL 44Gl9iEl.- T t fi ARUED •-?] gy-3N - / PASSING (? Y i 1x - _. _ RAN. G x __ r F I PRUGSI CEO B O FR E Lv I 3 FEP 1 1 AK 1 III T U .N Ij IJ] .i RIG L..., T- '. 3L tNOW A r ] WOW NG C E GS .D II G. 9Ef t I LI L GnA ., WE PARK G u OCATIOIL - , I i G :.., I-•1' ..4 LET TURN 1 II-- Cl .FOG 1 E Cf 4F,t AS 3APS SPEED \ HOPED I J T OPfiR i 1 ( I IrFFL, lY/ 13 10 'F VT fl y 1 ?I I6 -- 3 ?' -- - Y - I 'I D or ca rh ?IS? 1 E C E ( I RI!. ECGD D LIGHT II E?D 1 ,--I ]s1 J ot0 NOt 1YECIF YI OTNln DTHffl ISrEtIF VI OPCn -- ISREG 10 $lOP 0 FII ISPECIPVI r' 1 B N Y rGLj fTOPIED POR J TMFF C ONDITIONS TRAFFIC CONTROL I TYPE OF ROAD ] OHf I D Ix SIGN S UNAL VEHICLE CONDITION V Dl 10 ATIO SOBRIETY =, E C El.. EI I ? ?.]B? no ED r3IGrv:. , On.1.1 SIGN, ICNLCK ONE. INO.I VEHICLE ' fCK ONE ON M l y'Nlttk IT kL(M?IEUT OI O x IT h?AUt P VI O } Pi' -1] - cnr I , ? { I I?-MONALS - ?x1 srn y I'. O E WAY '- - Alx rw0 A• 1r' 1 PE t f I I KES 6 L E IIa AO I. 1Y? - I t) ONAIHtO PO 0 AY f l KT NG N -' J' Ta DF n cunE,.- , . _.:. _ AWN xl O _ .J _ GN Lxl j SGN __ PC DSIDII.) I .. BM - i IDI[AO LIGEI3 _ _ .. ELI .1 -? HOtIW InED '??- rTi•-STAai NO qON"' l? PA KED POSI TION: 'I ? 3' ( W3 ..._ . I I -? f S G REO _. _- i? , .I Nr <I G OUP HA ' ] DEFECTIVE .J MLGHTS Pf I BON 'I ? iJ ILNTFnI N I MERGING G rn FPICI ?Ix .S _ OM R [lT I Sf , fl G $ALLEY L ? !S O on s DO7 NO T KIN?G D BAC G I tJ 1 I f NCNTSOn f o t1. 14, r r P 1? ;• _ AMBCO ...A l I CH CHAL - -. f WO L T LA. f O CHE T ST 0 x l- I ] Sr[.IfVI . K N B I O ] N" wri - TEST O fN 1 4 1 - _ tl !l1 LION f L 11-AN . - OtNln -. -' ' ...Y TS . _,._ ..-.. _._.. TEST FMFUSKC. ' { j _. 1 •_... x. OIV IO[D I I I NO DEFEC _ -- ' I , ". .. OMf Wltllrl ,'. o' ] Iv,G!O NEP IYf<Ilvl i. O1 - - % TEST RESULTS 2 NAME I I '. 't 1 LATI O r.e NU POLICE O,v U I L I1 r .x?a0 AnR 1111 « POLICE ARP lD LE NPIOED }"1 I 1 x aG t„ --_-- xEHOSD ] - N NYtlTIrE•rme onlCEPS N•uaAnA«A PAUCt r, unrt ml DUT AOer. ATEOnIEroaT oere rnovto lr y A / ?,. .............. ?................. .............._........_ . _... ' OUPLIW if C01'Y LUCAL.LAW[Nr ONCIM[NT AG[NCY'S CUPY-iNIPLICAIE COPY: INVf511GATOR uCOPV , SV: ?. f I 7 ?r ' 10 !P ^ ro ? ?? ? ,f?N-.?i lei'N'ray'"!?..".m9.?,.pn,KKnm,?D>t?P?IEPIM.+ f . .?' ? •. ?u , aK ""eT.'?..., rrj? .''?'r 'h,,: ?, 3 4??. ,Iq '' sl ?? ?'' , fdwtw "lSs" _ Hv,.u2 ?sisnt ,:... n r STAI E OF WASH INGI ON PAGE OF No t i?r POLIC. E COMPLA INT NUMBER t}fYY UNIFORM POLICE TRAFFIC COLLISION REPORT A F DATE OFCdATSION DAYOFCOWSION TIME COUMrNp J - CITYNo fMWA ({. y' ?., ,{AQ 1?Y YR T SUN 1 431 IULS 3 WE + ),UN 5 FRI a SAT IU,SSF^PzHOURI j / ?URBAN ^ PSq^' COUNTY ?SIATEROUIE ' COUNTY ROAD ?CITY STREET O DMOLS. PREFI1 RODUT.. CODE SELT?IpN .. , §???g p Je:°a won ?OIHFRISPECIFYI Y. L: ?IN OITY qi TOWN W PREFI% EO?. III POST d + V -'? O N 5 E W f $ g.?. C I: MMES ? ? ©OF. .?_ .. LL r A _.:'.' NAM NO.OF 6TREET OP WGHWAY ^ INTERSECIWG WITH: ETREETORflOA[I- LL RAMP A. DATA WTER F AJCL DENT D TERSECTIND STREET OR ROAD OR REF. MILEAGE IN CLS ERENCECRO55 STR ET CRflCAD BETWEEN- STREET ANO_ _ TREET CODE OO ..Y - OLSTANCEANDOIHECTION FROM REFERENCE OR CgO55 STRE i {111$ SPECI LCOOI.VG USE CY[y,' p ( --. ?MLES N S E W a} E } a OFEET El E3 b _-_ ___. _ :. •: SE ERITY COLLISION INVOLVED, ?VEHICLE-VERGE ?VEXCLEBC CLE ?OT ERnYn1TE1 ?IRTdRUN NO NILLEp W ?j OF VEHICLE'OBJECT ?VENICLF flgi N OSTOLENVEHICLE µ TOTAL O. - _ ------ y NO WDRED Y, .ft :, VE CLES ©? ?yE CLE-PEOE51RIµ ? GNCOLLIS ON _ QM 1Afl0005 MATERIAL ?PROPERTYO AGE ONLY 5. OBIEGT STflUC%(NAME OFgBJEC[STAUCK µ00WNEfl5 NAME) LOCATION OF OBJECT S"'No`5 E W EST.DAMAGE . t"A 'ZvJ? OS?-Q nC ?J.?. <t-11.0^.x.-0:1 ?II ?l f03. ?C-C?1L.3CL.ir1 ?POADWAY El 00 RO EDGE SC.. k DRn/ERS NM,E{AST,-? E -- fIRST - MIDIXF ORNERSN EUST'FIRS? (DOLE iIt•. BICxGUSr ORPERE5IW CHEC.jLj eF k Z '.yF' R pa *t J,,.,e"J3 1'1 er D f•,,y ehr '11 I sTREEr FDD I:ss... : a STREET ADD Ess F A ~µ ` ?E1Y.Af f .. "' E _ 4or, e 2 Eox I SI - ?V . r R CRY-: STATE- -I 11P CODE PHONE Np -RE CRY -T:, C iATE ,y'1P CODE a_. RHONE N'O P •?? { ,t Fort r..se l . d O DWVER9l1LE SE NO. - ;STR{E.: SEA DAIOE OFD YTH YR.- ,.O•;, OPNEfl5]LICENSE NO. re? - • - STATE.- .SE%„ DATE BIRTN DRIVERS 000UPATION FIflM NAME PHONE NO. 'j CRNERS OCCUPATION iIRMNAME ? '?-PM N N , Y cs; enter EeIN en 1a?ed LEA a ?fe.. .CODES ,> Ipl C ASS TI SEAT BELT- 151 EJECTION _L _ CODES IJI C SS ITT SEAT BELT. 151 EJECTION NATURE OF AUREOF ` i UUURIES Legit Knee INJURIES FR SCENEBYO:L r ,1.C A 11111RnCfToJe£f Gail. Gosv RE-EFNEflr To s M VEM. YEM MA%EIDpDGEtNEV I-- MODEL:DAIjTNOVAI STrLE 1t 0RCONVI VEH YEAR NEIDOOGE CHEV.1 MODEL IDANT-NOVAI STYLEIPON CONVJ v Tog ELne tv':or _V _ .- I.. ?. I 1 E - VEM. COLOR -.: LR:. FMTE NO.. STATE... TRAILER PULE NO STATE . _ H VEH. COLOR UC. PLATE,NO. STATE.. TPULER PLATE NO... STATE H I" B1Tie I3B ?1h n .-I C YFNICLC OE TIFIWTIDN NUMBER ., .-„ OCDMETLq C VEHJCLE IDENNFICAiION NUMBER ODOMEiEq-: { ,ARP '-.fp e' RFGLSTERED OWNED ?1-AST FIRST MIDDLE REGIS,ERED OWNER-LA 1 J^•FWST IODIE , F of 0... F.s TirivEir ?' - ADaless a ovmER p, ° ADDRESS OF,OWNER .. .. _' Y L 'n NAMEANDADDFESS.1 WS-CE-OR.GENT NAMEANDADORESSOFWSURANCECO. ORAGEHT._ Stated ne nova ' GHMiGE CiAIION NO.,:' CHARGE ,-\I CIiAI _ ENFORCEMENT ACTION :. .15 NAME ADDRESS & INJURIES OF PERSONS INVOLVED GDDES 1 y e - SE% AGE STATUS EJECT. ?s I s.D4 U: NATURE OF REMOVED FROM P IHJURIE6 SCENERY TO A NAME. N r S ADDRESS FROM N I s F x JJUR E SCFUFN To W . NAME' 1 ADDRESS' .. •- - . N NUURE sT'c Sno FROM TO S. NAME' . S ADCftSS . 51 S uuIMS SCEN[VUY- TO .. A IIISIATUS 11r5EA11gSI,IpN IJIeUURY LlASG I4I5LAT BELT ISICJECTg11 C Y S HWp ? ! '-" W O ? ] S DO i D 5 I ORY U LED NET + : [D C m'cm T 1 DI A II T SEEN[ 1 N ^ 1L H E I iH U.S ,,OIALLYE fLTEO D 6opIER - DUB A IO LYLIEI I O AID JDEAOONAn 4 q[D NHO^fMTAL AI IEVIDCNTI INJURY iros9nl[JNJUnY .. rnr usE p rEJCC,CO PAT AUN%IJO.L D E EIYTI Nf55 , ! I e 0511 MYJJOWN 65CAt Bf 11 FA%URE . ECTCO EJ £ .. .. Y 1EG v E?i77.IN t INSTRUCTIONS: ?i- Nj xLN bbKtc tint rtFdF?MO no° EACHMDD,r"c? HLA: 2, SHADE AREAOF SEVEREST IMPgCT. ]. DRAW ARROWMI TO SHOW PRINCIPAL DIRECTION OF FORCE. °L -" r z 8 l?I1? rr - T?F C t. DAMAGED VEHICLE N O. 1 IUSE THIS SPACE FOR SKETCHING DA.AGETOTNAILERS.MOTORCYG-.ETC.1 •f 1] IPP l' '°.' • • ' iS t o. Iulx Sf VERITY OF DAMAGE. LIEN L`LFNO1 t DISABLING DAMAGE ] ? .-P.M.- ... E ITYOFDAMAGE IOTHER fCLEI It ?gDISABLING DAMAGE ]13OTHER M V DAMAGE SEVER iY OF DAMAGE'VEH CLExO ]I?' - D SABLING DAMAGE S 11 OTHER M V DAMAGE ] FUNCIIONA L OAMAGE , ? NO DAMAGE 2 ? FUNCTIONA_°_AMAGE A O NO DAMAGE . . } ] LJ FUNCTIONAL I E] NO pAMAGE ? • TO WED BY. Hidl?a C58.r8 ST.OAMAGE E TOWtU bT F4T. A AG6• ` TOWED BYF i wMAGE 5 TO Chimacum Yn. S 111 TD 3 - TD 3 ' DIAGRAM OFCOLLISION OHAW ARHOW SHOWING j I NORTH IN CIRCLE " I I I rt I I _7 I 1 1 -T ? I ? ' M KDxP TInNS ilex caxsmpeT ax -' --- ' - I_.% - _ I I -- - - ! '77-7-r-I T77: - mrw DeutE rD NTa r I ': ? 1 I I ? I j_? ._?_ I I I ( ? I 1 I 1 IT I Mn.x ?- rbedvTlre Fend -I { hdl b I i T i t ? 7 7 _ _?- ra a vo a -t Dri9 r ' 1 " : ' ? ' I r l a n,r{ - ! I I I I? ! I I I 1 - = f : • DESCRIPTION OF " INOCATE WHAT PROBABLY HAPPENED BEFORE.DLRI- AN. A' TER THE CRASH INCLUDE INFORMATION G. DRIVER COLLISION DISABILITY. REDDCEDVSOLTV, FD.-FANGLDTIING COLD ,CONSTRUCTION ON REPAIR wof!, I '• 2 q __ ,•cA'N?9117 a _ ryfC• ?.1 3val found driver inned under the vehicle with 1-W -upper pO _ rtioi.of hie bod r' -- - r ...y...r 16_vahiele..__While?raiting-for the toa.truek the. driver informed me that he had ?` too_faBt..aad_rheu he.-rounded -the slight cemms:he loat_partial control l)ecause,:, K le_ateering.-Hetween.tho_txo_arroi>e the vehicle vap'airbora_e for epproximate7_T - -- -- --tom ?L T _ E IF PARKE • .??e'•', , ^ )SITION BEFORE COLLISION - - - IN O?°FE o D AIES FD EEOSS p^O GE RK, WAS VEH. EO AHLI POST R DR. ING TRECT ON 11G11AY NAME R NO. Ost R EO OC CUPIED E PF r C.E. 32 1 % SD M.H k5_ YEE - f NO YES NO uLl '?T1r 5 xx, xx.. °gosslNG Li ONI - I >F? Y 1SEOUL... " OSS NG YC OTHER SIDEWALK IG?C a6swe I-Ic w c° E1 °TF EI? i WEATHER-, .. -' CONTRIBUTING CIRCUMSTANCES._ Iv N E C s ( . IC ECK ONEI ICNECKUNE°n NO I C,_ /? SSxM 'tE Ivfn DRrvEq En SRA c O2 ] ] HT AHEAD -, ^nL°EIAIEECLOD°Y ?N n?NFI°FNCFOF n fOOCLOSj p? 5G ° ',g]G•gNO PASSINO I n rI . ?'?• aFxn _ ] aFAI_ NG__ ' n ?NDGS IN' L D s fE T ?5PEN,EY CJS? NGHIT TDnN '? ,i }y i k. LIN ] ?1 NOW?N. - ]?y%C NGSTATED _ 0 5? IMPROPER PARKING ?Kr' A I G ` s. 4EQ.L. L[__-_ LOCATION_ _ J MFIT TURN 4 ']:fF SnFFi o I-'? I?.? PEE AS. I. I?Un n I .° CTIVE EO°IP D AKING 'QYl ?LLrw F.. AN. I ST9a[!GO ll rli 1J jl]? spetsdiM L16U 'SLOWINO .. o . ?-O I1211PO OETOP :,1>l_I uGNIbGNAI r tt'' L?hBL? THEq ISPFCIf Y1 NOVIOLATION "•? I•'-I IJII- OPPED FDA TRAFFIC VEHICLECONI D I T I ON :.- SOBRIETY....; ICHECK O EI'-' I ooPPEOAT SIGNAL A Q f f QQ VIIN. )[' ?ll? ?{Ii i15{AOI VI 1 ]E N ?BL7 OETOPSIGN OG^GWEDIN _ j ,_.. DEFECiIV[ • 7 xBD ABNRY EjNSD ST..TINGIN tlIMES_-._._ ?? ..J YY T;) . N L'ti L?GI`[3.__ _. _ NOT MYNH[ ? L_III'..J AFf IC LANE FwPC[U:[611O GN ] r'° DEFECTIVE ....?.. 'D'EFECTIVE'S .. ... __. ,- I... SOB.IETY U NK-.__ _ .. M[OOINp I[N}EgINp TgAFFI[I _ ) - I lIO[S wO11N D/L3MOOTIL _l:_ ?' ?l N; , IIAfONNOT [ - LIm? awcKING _ _ IS'' I ir::ilw v Iux.n .. --l- I NIL ] . CHEM,.TEST _ ., . Ej [71 LJ LJ .... . . ? ?.E., •. _. atee 11 j, __? ,..1. _TfiF OIVfN - 1 pNI E. ISFFC IifI I I NO DEFEL'TS I I I ,l ST.CFUS[D . -'?" - IINIIssECIF % TEST RESULTS 2 -Deputes Y.C. Oebh;,M I 6 ID_ 10 191A 2356 .TI 2358 ,^?IA.R?15 ]xrollMo ED.x. o .....IL"?t ?1? " DISTI • OUPLI Quilcene :n. I .`'. d r' i i IC l,i it v v dl+J rl i I L Z7 I L) i v ?acc ! i v } I C ..• UNIFORM POLICE TRAFFIC COLLISION REPORT Hf. { Fk 411, 1 Vill,! -1 IN,. I _.TALLY JECTID .4 r.cgNw "I NOTINUSE r3 Ull* o.. IIIIACTUD -IIAO. ANM.IAL 1. 3: 3. 1619-0-CYCLE) 4. DIffo IN H .1 1-. 4. UNK a K. Rr r1 `J t ?? JY J !'? hr ?pp?F? I (.'rAAP4?1 M/A1um ' ?tl W l""R"`f1?:T?"'B r 'S 'II'?T?^ ?.'WMAR G 77 7 ", 7-: 7 F?'7? ???Mr ? I i VEHICLE DAMAGE CIRCLE THE NUMBER OF EACH DAMAGED AREA. EXAtAPLE -r- E 1. IN EACH BOX NSTRUC Yl L INSTRUCTIONS: , 2, SHADE AREA OF SEVEREST SHOW IMPACT. - 3. DRAW ARROW(S) TO SHOW PRINCIPAL DIRECTION OF FORCE. O ? +A 0 . l0 e DAMAGED VEHICLE NO.7 DAMAGED VEHICLE NO.2 ' 1 I 1 A- EIE 1S Trvn1E - _ _ O I1 ti Trvnl? U` I ? una.ru I n } y P o" IEaOI9 eLINODAMAGE IL]QOTMeRM. v.OalxaGE cl.m +QpIEAEIInG OAMgG6 TNE]?OTxlwM.V. DAMAGE s wrcYOr OAMACE: v, «ICLF nO.x 10 OEAElINO DAMAGE ]?OT«ERM.V, °AMAOEI , a CTIOIaIDAMAGE - A0 GE nCT ON AGE 3 NCTtONALO MACE AQNO OHMAGE ' , OWED nv T ETGN J9E TOWE°EY ` ET. DaMAGF TOWEOOY EET ,OAMq°E O F /. LCIGUMI t ?J i? TD , f DIAGRAMOFCOLLISION, S I "I' I( I I I- F i' V I I I DRAWARRO WSHOWING Y. FlATURE A' I ' I ,' 1 i ,.. ?.-l,•,,t ?„ 1 l_ I I I NORTH IN. CIRCLE I t __ 091ECTS ON/0- R WAY` _- ;E.:P ?o? T DI GnETwGLTIGNDNE ,ICE : E " 3 L Q 1. L-Al. qAELE POINT OF- f'1 I' I [•j.?- 4 I.,I?I\ -j-I I I ''I :??_ I \ PEDESTRIAN ?X? I' I i I ?1 P? ? I { D e,ELT POEITIaiMrAT HOW PRO " " I ' ? . I I 11- I , . \ S PENAT«EO EFORE oATEw PCOLLIE n. '? - I I I ??C$?? I I{ I I I I 1 I I .?. }f YI I -r-i f•' I 1 I 1 - \ DESCRIPTION OF' °Yi» f DD-T P ATP^ E $ DIAIIO AID N I u E INI-A D GN IAGRAM I E E HAPP N CT 2YM COLLISIONi?r..a,. o R , D D .G.-D v R . E gN ED CON?TR LTION OR REPAIR WORK Gl y, .` Y, EOUClO vli El LlTV `r°LI , ?. -- I k a?F t X N r Rq l?erf.?ic / LlJos ! o >? on l'e cNTTo?1dd d ce 2? oc`lq C_d1Pye To-_A s are e f Y T blCG ??T ' 1 \ ? ' a F "...r ?. POSITIOMBEFOBEICOELISI,!0 ? E oeo cgeAS E 1. ONE 'LE.A"LL61 .. 7VT- NO r s t?'. r. ) t a i FED. ???? ROSE lK p p ? p ` W At- ' W RAN wAE US O I F T PEDCR WA OE -? IEIIA oEE l ?J OT Eq'+? A . 1? ' -' ROAD UR ACEE WEA fIjER:jI NFRIBUTIjfC=g RCUMSTANC Carr yr,.•y K' ?? ERt 11 r?°jlo ,yy? 1 !I IC« EI IC 8C 1 w`''?' ??E7'Llff'A?IS?bq 1fA8f` .. ?"? 4 " ?'°G t N d IA. DR., [Hc? ° LO T FOLI r ?] Oh flO ?,.?'. DEG! AO ? ? e a?qA - ? ? q F Eo ?F???.e E Te ?,. pgF'.,q rr.Y.s<9 tr ? ? r? cE u ? 4X r`1 x? .?: ?`?aRs J f 71Fn D- EFI ..... ;N nF. ne-._ -._ _ nlln°--.-._RTOP, C?IR SIT- n„nD .. O11 ?T y I-ICI-I:MAK+NGwTMaN 'it ? f A1j . r c ?,r ' 1q??s } f k r ??y l?Yi6111/\LJ L, L.Ji, Ydi. - •-.•-...,. ? 87D.. ?IaE31?`.?.. ? _•£ _ ,- JSLI .:.: ? ? F A INSTRUCTIONS: DAMAGED VEHICLE NO 1 y J u1nOL nn LAO slvulESl cT - ]. DRAW ARROW 51 TO SNOW YRINC 'Al DINECTION OF FORCE ; . .S . IusE TNU sxgct r0H sK[lcHING DAMAGE TO TRA L-NRIoRCYafs, [!C I DAMAGED VEHICLE NO 2 -."; ?- '.E ERITY Of DAMAGE VEHICLE NO ! I] OrnN n . „ --fir ,. 0 r 1 .mpr -17 IG (r T 5- SEVERiY OF DAMAGE. IOix EN VEN CLFI 1 ? VISA bIING DAMAGE ] OTNEDMV DAMAGE 1 ? DISABLIND DAMAGE J ?OIn ENMV.DAMAGE IE QN-ABLNG .=E ; O [N M.v a ? FUNCTIONAL DAMAGE A ? ND DAMAGE J FUNCi ONPL DAMAGE NOpA.AGE DAMAGF TOwFb BY Esi pgMAG J ? FUN Ate[] N EST.DAMAGE' MwGE ' F T Y C! f TO OW ED O TO S TOWED bY EST7 AMgGE TO r DIAGRAM OF COLLISION s . '? ra " • I, m[NUrx' Axowr x4•PA nMUxss - - ? _ RAW ARROW SHOWING - 1 t. , . IF vewnfs _ .. I ' NORTH IN CIRCLE E k oe.tns 4n.orr n4AOx•v lx•rr c c4xlwoLS s n o s __ _ - - .. T lcl 1. AT. . ' u r01 1 _ ._.. 7 7 ,. ?: -' xax w CT. A o w Ds I IT VI-11M. . _ I ? I. __,RP Alxs eI Rx[ AxP Ar cours DN. _ ..... ' - - DESCRIPTION OF (INDICATE W COLLISION DISABILITY. n[DUCED VBS RLITV PEDESTRIAN CLOTHING COLOR, CONSTRUCT ONNC UDE WORK,ETC.INOTO DIAGRAM. E.G. DRIVEN ] t POSITION BEFORE COLLISION VEN.. HEADED SING IT C N0. . REA REASING ON STREET OR HIGHWAY NAME OT rvO. f VEHICLE FO ONE ORkCiiON EEDS AL k VEN f F = PA KD OCCUPIED . .I .. _? _ T.. ?. I MPN _ NO S S _ x0 f t 7? ea 11D. O_ FF DIBICYCLIST S w xn r OF __... __ IHG __ TO r ED S ' " l WqS USING. ROAD SURFACE WEATHER ALK SNOUL 'C DER . CHOSSIA D D'CYCL I _ 'Ti tox EN , ECK ONEI CHECK ONEI v En D CONTRIBUTING CIRCU SEANCES E 1 DRIVEFHVE 0. N C\E ACTIO S f h _ N o. J. l `-" - 4 wM DAY I OFVEn N DRIVE NO. Nof] r;lifi -' uxDER vr S D STRAIGHT EAD r7 ON. DVERCAST S . wfvcf ALCO OL .,-. I -, ` _ L 5 G a EST EGARDEDV I'"?SIGN I. E L7 -HEARING ?? P WET RAIIfN. __- - +- - a N.E. INFLUENCE OF 1 OVER CENTE LINE AND A X ` s a I wxc EPCIEGNI DI FAILING TO SP[EDL IT 4TED I r I ] L IB ASLE11. SLEIP. "HO RI I 1 PARK RN ING ' A'1 ICE AOG _. _._ _. . .. . SIGNAL - D NC FIAI Sgctrff PED4 AT 1 AAK.. N EF T OPERATING « I T [i r _ .._ OTNtN 15 fCirrl -- URN S .!_ O C - O Q r - ( AK rviEOu ;S: B' J G I " IGHTCONDITIONS RAFFIf CON THO ICRT CK ONEI IMPROPER O la, G /SIGNAL O I ICI E G TYPE OF ROAD VEHICLE CONDITION .G HER I _- ???!}}} FED FOR EPA C q I D ] VEHICLE SIGNALS 1 D ] CNE<K ONL OR MORFI CLE rN I EN nnCIf l?b?ff SPiR€ , , r_ Z SOBRIETY D PFD AT Srcrvgt IC NECK ONE I... OR>14x arGN ?I -LIGHT , DI I E NV e f y .,-- - HO x SIGN )r DAW ] F ..- •..- SON D USK nG TWO ] -J OAO J UEF[C! v[ I CRAKES rr[I'D NL A4lINlS AG' - II I S A T D -il TRAFFIC LANE jj? TINGPIOM I TR fO O ON T _ HE I E NG . LIGHTS 0 ET -- Ffl IJ RFfCTWF 1AMP LOOP r ^'IS LIGHTS ALLEY s-.? _ - O 0 t I S fNTfRINO } K... IIJ RAFf CI NOT S RK S [ f O G -_.? x 0 -- OII VU ..__ rnrnuwx' 'B T N[s s I xD ) C UNCT_'_ - x[N ON NKING I BACKING CHEM. TEST -) .... ,I .. ,.ITT lGrFTS 1 t GIIn q SE ![D .. . IEST.-A OTHER ISPICIFYI ? S r -R?U ] .. OTnEM If CIF I.E. NO bE FELTS 1.1IUSED I 5 ti t .," . L x?., }'-. t - F YI r[ rNm.x.?? ,,.............. .. .... J uxDlvrntp prl.lx sxlc lrl % A IEST RESULTS 21 1 _.. ... .? .. KADG No AGING. - u[.n Rrr p15,-- DAIl 4. ;I.1 APPRDV IRS x - I ADL! : DI---?-ED Y i A,t DISTRIII UTICA]' onIGINgL CDPV !EN0101VASHINf,TON STATE PAIRDL' OLVMPI A,IVASRINGTONDNSOA OIIPL ICAI[ COPY' LCCAILAWtNFOHCEMf NIAG.ENCV'SCOPY-I1[InLICA1ECOPY. I NVESTIIATOH-S COPY rte ?Lp PAGE OF I T J' POLICE COMPIAINT NUMVER .? UNIFORM POLICE TRAFFIC COLLISION REPORT u' D DAIEOFC-SIGN DAY OF COLL IISIOII TIME COUNTYND. / L11Y N0. FHWA a }EA' M ?(1PY3 YP Vo"I'IE IULS G 1 VED } URAN URAL COUNTY ROUTE ? LOUNIY ROAD CIIYSigEET O DM CL5PREFI% ROUTE OR STREET CODE 113?HERISPECIFYI ww N V IL JJ 'd'-5 $5`'I ?IN CITY OR TOWN W PREFI% EO Ml POST 'p O O MILES ?C1 ? ? OF.. .-1ne l.H.I rV?/? [AQt( LL 6,pO t Y. M C^ NAME ANO.OF STREETOn HIGHWAY INTERSECTING WI TH. STREET ORROAD U, RAMP DIAGRAM DATA ?? tz ° T ON I "-INTERSECTION ^ ACCIDENT INTER NON X RD INTEHSECTING 57REE1 OR ROAD OR REF O '1 `Vr ?Q MILEAGE I i CLS. EPENCE CR0555 REEL OR ROAD r N BETWEEN O(, -i O ry?-- STREET AND l?I? C7. ...STREET CODE , DIST//AA//NRCEANDDIHECTIONFROM REFERENCED CP0555tRFET urvCn[In5 SPECIALCOUING USE ?? II Z MILER F(NS?I B E \V !J IL? •_?- D FEET IN 1:1 OF C- V- ALc.c,- \ ? VEHICLE VEHICLE ?VEHCLE BICYCLE ?OTHERIWRIEI MHITARUN SEVCRIIY COLLISION INVOLVED: NO KILLED \ TOTALNO. ?VF ^EOBIECT ?VEMICLF RgTRAIN FN VEHCt ..v ", OF VEHICLE.. VEt1ICLE PEDESt RIAN NCOLl151 ?HAZANOOUS MATERIAL PROPERTY DAMAGE ONLY D --...,1-Iii-P116C l` Cl l1??? n D R 57REET ADDRESS R STREET ADDRESS v Is 3I tlEUb,_ICAt?S V SLATE ZIP CODE PNO E NOS I? CITY STATE 21P CODE PHONE NC E "Y N pRIVEREL LICENSE NO. STATE SEffx OAI E OF DINTR N DRIVERS LICENSE NO. STATE 5E% ATE OF BIRTH 0. a L`ZL l If O. NO DAY vP. '; DRNER5000UPAIION FIRMNAME PHONENO. 2 GAINERS OCCUPATION FIRM NAME PHONE NC 1LtG:?. ?7i tau>?_ - ??T? -- CODES >1131 [,X!E; TAI SEAT BELT ..Z. EJECTION _.l CODES > I]I CLNSS--- --- TAI SEATB _.__ ISI EJECTIO V ?l-7 ?Zi-I 1) v •? E 0 . VIA CCA.. l,C LATE N STATE iRMLER PLATE NO. STATE E VIA COLOR IC, PLAIE NO SLATE TRAILER PLATE NO. STATE ` R 1 , 6U(E?5`i?3Q- ZGI? R F C M E R IO NU B N VEHIC DENLIFICAT ODOMETER VEHICLE IOENTIFICAIION I MBEN ODOMETER A p? ?n 7 /? p ? / L E fIRSi MIO LE REGISTERED OWNER-UST REWSTERED OWN -LAST FIRST MIDOIE N ?-"? SAM O. 0. ADDRESS OF OWNER ADpHESS O OWNER 3 1 Z -a- OAWHESS OFMSU'CE CO. OR AGENT (? - ?'T _`I E-ei'/J?'t_ >,.; S`l7ll? `l7i lZ-i?1 ' NAM IDADDRESSOF INSURANCECO ORAGENT - _ Z RGE NN O ligiIIO ENFORCEMENI CHARGE CNATI AND J /}??!\ -/. NO ALIIGN P S NS INVOLVED cones _ 5 ER O 4q ADDRESS & INJURIES OF Sx AGE STATUS y" W I S y. AS AT n EJFC ((?? //?? NAME ___ LJ- E1_ti i_ ( Ac Jd. r C 'l (? Z s k G- 11 VLURIE.S F 1 SCFN[r OV VM TO A NAME -- --- T ADIME55 W _ $ n S? Z RL MOVED IR SCFN(A, TO I L W NAME' I T AGCAE55 - ` ----HCMZIVf DIIIOM `- N IqN E SCFN[ny TO E S NAME O ? S E ApDn[59 A lbt- -- ?HTRDu- sclRr nv tD S' ItI51AtUS P0511NY1 L A 1 :I + I . JIINJUIIY CIAS: TAISLATPELT ISIf C ° ] P(DF SAM (AN PICYCLISI E - T - I 1 I L i .OIHLH PO:ngN t DOADJATPSCENE JOF AP ON ARRWAI P NIpI Ulti%niiilonv I[VIOENIIINJIIRY R ] NOUN V5EItD 3US[D UN%NON'! O T EJECTED 2 PAR YCE CCl(D ]PAnTIALL Y (JECIEO A UIIKIIOWNIf D 301HfN I I DUSMOIOIICYCLEI AYOSINON UN%NOW+F A DIED IN HOSPITAL 1 POSSIGLC INJU Y l6CAi ntli iMLUHE CJECICD E GWIINf55 - - - °x'? n ql T "''^y ar I' a d J If 8 Ml ? ? °?F n AIL, SI? k Tr 3. , ., I ? 771 • r..YOf`Sil v I 11 .1 ) __ ,.L Snr!!r {?IS'EYR%f'CIY.'?erYt,..'rT1., u .sbLa.?? O Wei 1y4'L_ ?•?'. A b _ INSTRUCTIONS: ]. Dk AH[AO __VEH I I.'ACT. ST 3. DRAW ARRON SI TD SHOW PPINCIPAL DIRECTION DF FORCE I n?? er i r. ?..^I . s K JY E 1 1 1 nI y t. a Ft ? na P f I DAMAGED VEHIC E 1 O * j LASE TNISSPACI I S.ETCNING DAMAGE TO TRA LERS,MOTORCYCR(S, ET C.I DAMAGED VEHICLE N 0.7 ?' L L T ,I , ; l rr M ?5 i ?_? ro 1 I I 10 Ur W rur u ?;?? rt • (?j U e?:? r 17. SEVER tY OF DAMAGE VEHICLE N0.1 SEVEgIIY OF pAMAGE. IpTHERvE CLEI I ? DSABLING DAMAGE ] OTHERMV DAMAGE I ? pSgtlI NO DAMAGE ] ?OT P DAMAGE ? FUxCT ONAL OAUgOE }OwEO gY Hill r6 Gara C' N MAGEST DAMAGE TOODFRYCT HAL DAMAGE A xO AM T DAM E. D ESG ITV Or DAMAGE VEHICLE NO. F, I EOPD U SA LINGDAMAGE G ] ? O'rNER M.V MAE K ?? CT MADE AD NO DAMAGE Y ' To Driven awa '3$0.00 TD g OWEO RY E s1, DAMAGE TO I DIAGRAM OFCOLLISION, Enbankmeat ? IDRAW.ARROW SHOWING ° e I I I I NORTH IN CIRCLE e WOLF j - (\?Q(?\?] s..rcH. con [ s [ cI , - Ar[rx0en ` MI ro xs IN— [ v[NKLL ND[MnA m cr rpsnwxsgr ur. ),. I I •.. t 7 '? _- •'-• I _ ,_l._ ?_:.. [ _ - j 1 I _ NrADegeL[v[x cfe aR . IT A .nD DESCRIPTION OF COLLISION ONDICATEwNATPRORARLY HAPP-DREFOAI DURNC ANDA E THE CHAS". INCLUDE o ONNDTON D E.G.Dn IV-ER D5AG UTY•nEDUCEDVISmu)Y,PEDESTRIANnOTHwc COLOR. CONSTRDmIO OR NfPAIRwO N[ >TI .: ,? j., - - r •d'E' ? r al ?v r p 3 3$r}` 1 L Driver_inforred__this_R/0 thst_hewas_N/H on C.-R,_12- and when he _rounded the.curvelthere vas - - [ ,I' s S/B logging truck and a portioa_of_the truck was over the center line. He swerved to miss 4 x hitting the -logGng.truck and lost control of the vehicle causing him to_strike?the enbankcientl Driver_caid_that _the_logging truck_was-blue-in _cglor,but that he didalt get an Wares off Of the-door- so fast he didnrt have time is get it. He di$n?t? n n. r ? collide-with-the-trucIc-but_did hit_the-enbanlmenta_,-___?._. - D D O _POSIiIW N BEFORE COCOLESION ox EET ON AME ON xo. r F RACES 7EI "L 11 1^11EI C O T R SxE DIRECTION N E IS, -'V `L rI _ _ C.R. 12 ,E ?LI MPS .N Dnnfn - ---OaD,31NG G eo )n DM?« rD I M, 1EH)1RN%LK .WA I ISNODLO O ED SL 'C M ' kl• CLIST SING 1e ROUTE n0TNCq CONTRIDUTI S- .. oR E r A ROAD SURFACE WEATHER CK OFCIRCU-.TAN E a C AO 3 n5 .d pi 1 EC. ONEI KOxEI E FA - NO D EP 0 v _ ?? P6n W I.' EP N ) D O() VJ' I O .'NIGHT E ' 1/_y_O`-_W_-_ a 1 N=IOU_ ] p 0 ONOEr t •A Y 1. DRY . f:yYEBC.I3L L? a uLC NO I ) q "LL C1A5?1? S ] R5 0/1R f WAmI-. f {ZI? pNfRTAK G I f? I^ ??'IF NfLUENC -I CR CENTER u OP0.i5 O r Y A x ,a L1_LLOgDG3_ .r LINE A, T n]r-MINDS I I.?,). K? _ S ??.N,S E?IEYI - ? LV oc s [p FY,- ?.-....._s FFO'ED. 3 DID D 11 T EE P I 1 So`nDL=G )? ScxiS CNAt p LIGWICONDITIONS [CN ONfI RAFFIC CONTRO [ TYKOOF ROAD INO VEHICLE CONDITION .] VEHICLE 1 N0 a G A f L2, ? ICHE FOR N- o E r?j F ff??If,PCQ y'NOICLai2 ?Ifl U{ DI V AYLG T. . ... L J i I] I N _ I ? ? ??-- r ,??OFl EC11VE OnAN LJ S wM aL D _.. ?ST sc ..__ r ] _ m [ -_ -i. RO ]I, 1 [: WE I L O L OHi3 1 ]?_ DUSK -"'-' _ HEOSrIIN r EC_.100 H My G[ - -._ ?)r- I fC vE RE L GNIS ON eEt ,?3 .. AMBER ?O -._ ?.•I ALL LIGHTS, y115MSWO 001N l10HIf OFF _._ ?... I L. 1unN[A.11 .. rurNU . E. DARK-N .__ .' f1P([iiGHTf OFlIC[N iLAGMAN _ II 3 ?[7- 1 S[FAIIA I[O T ] DIV ID[U : ... . NU DEftLTS OTNl=1Y1C IYI - IIAo4 In° ! V• O[D R, UNOIV-. - - OINFn ISrf C1I VI !! jj fM OPEK;ANAINC S?Sn OGALQN - ( I?K U .. o _-___ I'-' ERATING L _ --T .-? L T RN g IB I OErE,grvEEDSr-::_ g J MA I .u u ISD SLOWING ?rl ND?IpL.TIDHYI TC1 STOPPE FOR $OBRIE IT EnIGIE C nNEI y ? f ig s 1 1 I ! STOPPEDAT RwNAL ON ITOI SIG •, 1 Hp.a - _ ego N Ao,ow,,IN J Rw ri[u TY I'O ' J S TNG IIN HOT I-AIREO .- . 77 I IIIrJ ( % O i ._ -- I , UHA,SORIIIE iY 1 Ilal? w [ rDSI ON TIERGIICI(ENTERING _ ni[H OIiIN.ING I]IST] RwCKINO I.Ei CHEM. TEST j j 1. I':j ![fT OR,- T611 HIFUS[D C IFYI % TEST RESULTS 2 . 6 1 JCSO _ J quilcona 09277E U RIBUTION. ONG )UV INAICWY SEND TOWASIIINGTONSTATF''PATROL-OLYMPIA.WASIIINGTON CATECOPY' LOCAL LAW [NI'OHCEMENT AG(NCY'SCOPV-TRIPLICATE COPY. INVESTIGATOP 0 r I ..J ' .VIA _ Vh r. P OY I'lV \I[b`?., I:GDIV PArY GL O ' POLICE COMP-T-EIEq r +r uE ' ? UNIFORM POLICE TRAFFIC COLLISION REPORT S' g GATE OF COLLISION OAY OF COLLIS ON Fql SAi NIUx SUN t WE MON 5 A COUNTY NO CITY NO {I,WA LIME ? IUSE ]ADO NOUHI } /? URBA N a? p - i 5 6 1 ?` = ] A M[J? DAY YR T 7? l ?O ? ?'.• J ,, URAL ,} L B ' tte CWNTV . ?STATE POLITE COUNTY ROAD SEC ZION U E CODE E P?51fl ?CITY STREET O ApACL6 PREFIX RO ?I/E O yi L 1?1 ' AT:i I+.:3?)Y ?DTHffl ISPECIFYI , R, q l A ? [ / N L N S E W ? CNI'CRIOWN N W PREFIX EO MILEPOST .. Y O : ? © ? ? v OF { .. MILES O T HK IWAY INTERSECTING WITH S F STRE YREETORNDAD LL RAMP. OIAGRAMDATA - - , NAME GNO.O E - T ON I N ONYREASECTION- ACCIDENT INTER NON %flU mTER5ECTING STREET OR ROAD OR REF I 1 CIS ERENCE CROSSS FEET OIi POAO ' .A y O., ? MILEAGE • N? BEIwEEN STREET AND - .- __.__ _ DISTANCE AND gHECiION FROM REFCRENCE OR CROSS STREET STREET COOS ASS O - Mt 5 ECALC NO USE Y .• NDat '' "' ]P" ?MILES N. 5 E W .. J _ rA nV nJ' FEET Q OF ?VEHK;LEVEHICLE'/M l VE CtEOICVCIE COLLISION INVOLVED: P' T1 - ?OTHERIwRITEI ?HNT RUN _NO.%ILLEDEVERITY N VEHICLE TOL ERIC flR TRAIN TOTAL NO __ _ _ ? S E NO INJURED . = OVENICIEPEDESTRMN ?NONZOLLISION OF VEHICLES ?TI-RDOUSMAIERAL O PROPERTY DAMAGE ONLY OBJECT ST...XT.AMEOF OBJECT SI.-ANOOWNERSNAMEI'^-?'"'-^_..._...?_..__?__,_.. ... LOCATION0111E1-IRNCKS"'.E IN •••: ..= ESTDAMAGE a7} , :;:rent i:n*:; S ?HOADWAY FEET ? ? ? ? NC tP . ORE`S.-E. ST FIRST ,-- -'"'-'--- MIDDLE TS ^-' DRIVER SNAME UST FIRST 1 IDOLE-11I tlICYCIISI Q. rEDCSIPoAN CNELKI[];"'.' k D ILSCtiIT J_ltcr ?ictoi p: R Y R STREETADDRE55. _': ...:_ ._.- __.,. .. .. - ... ... .. ... 6IFEETADDRESS :'. ..... - -. .. :... ... {3 " { E CITY. ZIP CODE.. .. PHONE NO. u! RE., CRY ,: .. •,. ...••I: STATE.....:. -IIPCODE PHONt NO ? twJ aIO P}C 5' J .e lnlanc n.-S N DRIVERS LICE SE NO.. 6 IE SE D lE OF B RIH Y R ... ... 0 D N OHNERS LICENSE NO SE% DALE OF B qiH STALE O. OAY YR O IAR°Y?y` vyw, „ -: ' y J . L 1 O 1 9 Y Fi S . n . 3 PHONE NO : J., CU ATION• FWM rvNAE'?: - .. 2 ORNERS OCCUR LIONFIgM ME PH NENO . ^. DRIVERS OC •' e.s cSt;Jte .rt• WerterL Y•A4inG a LOen .., .. .; _ . 1 -CODES > IOI CUES-1 TAI SEAT8ELT - 15I EJECTION CODES >1431 CLASS-,-- AI SEAT BELT-- 151 EJECTION _nl• - NATUREOF - I_LRY.S NATURE F INJURIES REMO TO FROM 6CENE BY' ROMSLENEBY TO F L VEH. YEAR MAKE IDOOFECNEVI . MODELIOARI STYLE IT ORCONVJ VEn. YEAR MANE IBOOGECHEV.1 MODEL IDAgt-NOVN -STYLET t CIF-VA V 196° Fora -. rr,%Er^.Oor E VEH. CMOR :. LJC. PLATE W.' STATE TRNLER PLATE NO. STATE VEH COLOR _ LIC. FE ll,NO..-. STATE .: TRACER PLATE NO. STALE , _.. ", L }J. _Y_/Grn 5.17ri?LA Wn. H. ..': _ C VE LE IDENTIFICANON HUMS ER ', - . .... ,- . - ODpIAETER .,.... C. VEHICLE IDEJITIFICATION NUMBER ODOMETER- -L E E T F MIDDLE R ' REGISTERED OWNCR'\T FIRS1 MIDDLE, N ( I ST -- REGISTERED GYMER-LAS o :>ca, si r Ts r oti7er) ? 0. . ADDRESG OF O AR.. •....•.... • -.'. ..-_.. _ ..... . ADURE55 OF OwNEit.. ... .': r .... ... :: 1.. ,,.I, ,.; Vn. g ill 23rd Ave. SO. Seattle 2_ r . NAME AND ADOM OFIW§FMCE CO OR AGENT NAMEANOAODRESSOFINSURANCECO OR AG ENT .4erlers lz= Sertttle, `'n. CHARGE..-:. u. CIIARON NO. ENFORC[MENi CNAHGE .. .. 1 .. IFATI NN ( •,? V ACTION T ADDRESS & INJURIES OF PERSONS INVOLVED NAME CODES r A' c , sE% AGE sraus N 9, E < r : , r C NAME ?. .s ? C ADDRESS n NAIUNE Of FROM 10 P UPoES l NfFl SCHf nv V A NAME. T AD(K,ESS 9 vJA 5 A UHEO?- u S (IY FNOM CCNF , TO ( . UUHE S •? W . NAME' ?_ _ T ADDRESS ---- -- [M v(T LDIPOM SCFNF IIY TO 't ' N .-THE-1 y E s = s s E. tm "MM, __ Maccernarf? ld uEHF rW. 1 r p, f.?"gti a 111W.1US ITISIAI MSHIOFJ IJIWJURYCLASS 1!1 [ IBCL7 I5I EJECTION 1 I H l E I[D ' L ? 1 C O 4 NOT w5 CO O [J C ] PASSLHGER 1.' r10 wJUI1Y S DIS.nI NG INJUnY 1 (I? ±Pf IM 61R AN - ZDCADAI S`- DNON DIS.PtIIKi )NOT WUSf 2. TOTALLY E,FL To nc,c.SI , ) T.OtILEn rOSRIdJ ] DIADONARPNAI Ir VIDCN Ti itUURV ] USED l - ] PAR TALL I CG rm ?IF % ? + ! " i Z r!i D NYL ?) A wCDmIIO 5 01 HfR j' i 1 L ??? .PPRAL 1 rO551nLC PINKY 5 SE A1 OELIFMLURC CJ[CIfD F ` E lUN -WHAT SS , O 1.. UYK 1111 ? 1111 °. i. -.I ;,. • • 1 (i: 4 y}?,?9 I T f ?qF 'f. 1„I 1,? I r 37'\•Y' Y n." ? ? n7141 i1\ w. ,? ?'S•'..'P' .'?.,-??f ?1. .? ? I. n?,.F,' m,!W,?J.,,,? ? T, ti ?,J?.oA h', S.' L 7" Yr`?? , I 1 Jf 4 MOTOR VEHICLE COLLISION REPORT NO. TG,O COL SAO, : Alp 21 7' L :. T ME OG. 1? // / PM U ?+ N! TY NO. - RLF ra o co DI E w^' A I ea" .Q2IPTP!¢T.YROAD,ON_H16NwAY.??iy „WINTER,EEGTINO. wIiH43TRFZET,ORgOAD Yft.TNL . e- vHEFIA EO MILEPQOSIT iNOI INTEHSELTION.L CATIONORC O IUETWEEN /Qf?2u ?r (Gf ' REE-I ar w?LC17- 1 ,- BEET AND MP AGgAM DATA ?+ wM[,o,o cwoar,c ?u?ii?ro<i aM ?oiHrininc u»o»,x,. [w. eroc[. r INTER I GLS , r..? .... [now o+A U? " `r . w?o / PAI'f.? OOE USE 'N? n i - 8T _ -. _. 8rwuca4 'L f0. F'OBJEOTS NAME AN M ES;, I LROPT.'AY PEE . - a Ls :::; CR F,RSLwSFNhM??,[I;yy.,y..-. PIRBT;,N,IM6 •w, -. ,:,;...NIO LE-.._:.^' RIVCRS ?NAME •.wil.MWaL4i II D -T. LG/7 c 22 , . I / xao»aw<,[ OUTE; ?ETR,ET ADOR - `>JSC''1Z.h "e@k„?})a0U LMO.."CI.O -'"'r Ixlux[°ua<, STREW ADORE35 - NO.?AN -' , eOE,NO:; ....a... r...,?_R j _. <<LLalex 7 ' Fit/? L//? ....... w[ x CITY.- _v+'F1)s•?,#T?1TC?w4fy ^.yLP, _COOg, 'DRIYERB•OC U ATIGNI; CIT 'w., -.:: ".: ...STATG_a -?iJ ,Lp CODE DRIVEAS,000UPATIOW, DgNERB3.?CEN NIIMO ST, 3!%: GAT B RCN AOE; VERSU<E MBfR--yv ElG E F IRTH AGL? .......-.._. E NU AT. OAT T MA ! r-lor NE .[n.ue,q ..... ?_ .?OpBLjFluarA o?,A-rl BoOY sTYLL'yTlmw,? _ .iwe. MA -.I v.oooo<I MOOEL,?INw±o.wTl B DY?STYLE,312(Owa _ n? ' T?yo7 cFt /cA . rlr, - LI_C_ENSE ?f y'a?q ??STATfiyF _NT.ERypL.l ELip„, ypu3T T£'..:_?. .. -: LIOENEC PLATE NO. ?.?_9TTE,;? ;ZRNLES PLATE,NO' - ?STf?TCV-'. y-L / "A VEHICLCIO!!>]1RIC?TpM:-KO$js?LL3B6',},owu'sN[MO1000M8TEPorN[uf '. ...? VENI<LE.IDEHTIFICATION I'?O? ??L, 960?NOO[u,E "aw[AI OpGMBTERIrI _. , /2 /s zoo 25 ?>? Ig /73? IREDI?E[L[6?,?_AnT?my,?IrrF1?IVLRSLICEN3E N0 :._REWSTBRFD WNERtu[T- ,!'17?- "r°°A..N^!' 1 .^.;OPN6RS.L1C6115E-t!q.,asi .4/.>'?2I<t/ :-A2Ry 2AY i.O?Z??A?9?P" OWNERS•ApORp!" Y?^? ?,?!?'Awn. ... ?..:iiiLi.?.aa.. GATE _OPBIRTN-?, OwNER3 REEE`,,,,y? ;.Tnw[ uOJT - .nAI ..,tiN: uuwli -OIVL F;B RTN., •73 7 f2 Cnii« /? !°o!!T o w/s<.r io ^z l PANTII;OIKa rLY""-.:,<,i}[,;. -:(,?:w F,. M ... PARTS.OF.Vl1MIGLE:DAMAGEO?:w,,,?pyyu;l._:.?eA::la?!,I-.:.._.rx? ?%c.F rr?0 fea.?T fT FE Ofl aP?. 5 b : "" a`. ° S',.: A. _ h LIAR (LITY INSURANCE INFORMATION-VEHICLE NO. 1 • covr .E ne FECT FORLTHISA ACCIDENT ON YOUR CAR ® YES ? NO 1NAME'w?R ?O??S0F1MY.lRY?019WANCEPoLKY HOLDER _n.a?l?rx_ _ _ . 6' LRY aM4_URANGC`GO A?Y? jr. ?.: .•?..ti ` " y ` v? /? ? ?°.CD lr ,C mi r '7 /;'Fr.,e N???-c>6? C-R?r?GE ?i?s; .IS S ,s; fa?T 6/// FjJ ' y AMFyANdZ1D{L{C$j OfEC]AIIIL.T'(: AGENC-,,.--' •+. ^'. .. -. 'PO IGT U fR ZYD /? 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L:C»7,rJl•. ?./lEsT..._. l75 TOF.__&f:1,Ct_ZEO SrvnC:_. - j ' -.12 fCz X L L lverrr < r r_ wX/S , VEHICLE_^a POSITIONS FI B COLLISION ORE INVE[rlullrlD ur V6,ICLl IIeAOW w ON STNLET OR NIONWAY N E OR NO. AM . o n:N, ' "' "? NO Yes Arr ? ?? ? rn N ?, rouRl r Q? ? ? g I ? . ? ? ? in ? P. ? ... rro or . ?CJ?? ? ? ? n R.».,.. 10 P rn srnMn wAS uvlNC ?) .: >[? w ]? , e 1 .C?" C c w?e , P - HOA[ UXfACI;;,; ' '>?,rrrArrq, LIOHT CORO,TIONS TRAFnOGON ROL rl ] a TYPE OF ROAD » PW(R/'[HICIL ACTIDNion •o;r'?r' ; "I 'I '[ > I LI ?' • 1 ? DAYI.IG HT ? , B I F.NALS l roJ ?>O 6 W Y l J II I OiGOING STRAIGHT AHEAD 1 CJ . C? nHr qA, WING > n DAWN (? > ?? STOP SIGN l l ] ? TWO WAY ? > ? OVER TAKING AND PASSING '? ] r ) W[i ]r) SNOWING ] OIIAA 1 rJ ] ?J YI[LU FIGN L ] ? RD'DNeIAI[ I"1 ] I LJ MARINO RIGHT TURN E-1, n SNOW [r., FOG f•I`n 5Tw[eT A)-] 1. Hi3 aN 1'? FLA 9NIN0 NrD L 1 A r.-) _ f0.CNANRf ? [ ? OP.gAMIa MAEIHa ? '' ? LEFT TURN r.I .[ IEE SC7 f?[L^r,l S lNwrv OF?[T n 1 ' ? I , ? FLASN 1— AMNE„ L_ r] , ? ALLET ? S ? MAEING U.TURN 1_1 8 r-R.Z.,r I /? ° U ( 7 cJ NN RIGNAL El o r_) L ,' 1 nN ? ° n FLOWING .'w :DR Tjnr BELU.n n.NDIR T L? svru:r [l ' [_) D, rlECnn[A .M.N LAN.- ?? T r:? SrorrPD roR TRAFFIC ,.... e,o•+...a, r.. ...,rr:u,. ..r - r ! ° ? ST ,rNr N ._.-..?? 1- G-1 E O AT EV.N.IL ? ° l? g 3ro -- ? ? ' r tiTPA NArcn _ r ? ? )? a rn n IN In oCl SrDIn no[nwAr F BlReel?ermamneEr^°.?-.-:n'.-^?>:-n-T.? m~ •.:gmxmm,NrmaFr...'r-a mo',<F.Pw..'.,.?.?..:.I,:`..::.'. °.,.::...,,.,... J:?!;....:.r : LANe ' ] 1 P?,x ' ? MIAI T AN - 4 y ^•.I kII . . DAMAGED VEHICLE N O, I wstT AcEron sKFC IND DAMAGE TO TPwnt9S,M°)pxcrcLES.Ercl v, DAMAGED VEHICLE N O.2 R?1 •Lt• IS. TrvnL RAOI ? • 1).0. ww.n I r I IP r IS. 6. MIW`u , . 1). p• E En111 OF UAF- VEHICLE NOI fFVEPITY Oi pAMAGE' 1 — CLT. ME 1 plagxllNG DAMAGE O=G V. DAMAGE 1 ? DISABLING OAMAGFT ] SE VE R ITY OF DAMAO E. VEH CLE'NO ] • - ]? FU CT ONAL DaAIgGE A 8 NE ] C] ... • ®OTNFP M,V DAMAGE 1 ?DISABLIxG DAMAGE aRI DINEfl M. V. pAM GE ? NO DA T FACE t ??1-11 NAL DAMAGE A ? NO pAMAGE-?. -- OWED BY?'P/,?d EST. DAMAGE T %Ol.LJ O OWEDRY ST. °AMAGE TOWEOB CT DAMAGE 4 SES P f A? TO TO I ?p - . ' DIAGRAM OF DRAW ARROW SHOWING _ NORTH IN CIRCLE AA r 1_ r a IM.A I 1 _ { { !--r-r-'i- Tj_-T-II ?- j 771 T-T Oi-I .I I I ITI .? j I I I I I I I. f i i I -I- I I ??I j I { { DESCRIPTION OF INDICATE WHAT Lr NAFFENEOBEFOflE, DURING AND AFT THE CPASN'INCLUDf INFORMAT ON NOT ONDIA M,EG.ORIVER' _COLLIS10?11 Drapaln,nt srPw Dtsrn ANC o COL Rc STRUCTIpN OR AIR n.ETC.I , G P? ? Co__.Fd _ `" 0'?_. 4 6 5?%vc? d _CfC/l- r/_ uld S 4?? Jii?P 1 p+/aJ d/y w' n ,_' RG4/a? To _ _ . d v_o? d 77.c f ?d?` escc? _Cu1/iS/!J/l d??_.v/v_s Ti7?r_ f5>i!?e? C!LT fC _'_ - _ ? . _ --------- ------ POSITION GEFOREC ELISION VEH. IT., Mll O S E RHIG wA AMF OR NO O N E P E° _SAIN _SAIN Cn ING f E w -7 -1 G L M ? OCC PIED ED ?-L rEO re LISTW US" -AO G: ISINTEWALK I i - Ixc_ _ O R'MARKE S? ?UNMw L ? n ED G ED rp R AD SR RFA E CMEC O E WEATHER - LOER CONTRIOU - - - C S SV LK . CPOGf ANCES . TII CI Un HOU w TE - " + ' ER ' - N I. OR vFP 1 FC O ? HE, EP E .. „; ,? •. 2 ' o s t` E pnS E .,1 K VoR'I x IX 1 D r ; N RIxF LUENCEO O ER NO] FOLLOWIIG x GTHVER ] y I? W LEIL•Cl OVE A AHEAD NF . W CPS u Y y _I SIG G p ° O r? R I ,(.1]? l N L 7 [[[ T ] ING . - -R- I ] ITS ENCfO ^ t l CENTER OVER EL n r"' Ex 5 E AUL$RR A . _ K H6.. I--t i-, ual { aNpw G I l vFE T T I I 5 I TD AL ..{ ING 1{ PPllQ OG p P ?Au IAIIU NS Rx CE I I, DG I i aazs PESO 0 NOT GRANT IM 'I T p 11. 1 O I E ° I E T G '-1 S1 LE G V I . - O N 1 _.. 1 OTw C-ivl V C LE - - 5 S ` 1-S d.. pos „ DA?4?1/!1Q s 6W c U0? LI MPRo L. PASSING T AFF- I ] I c /f GNAL I ?1 IX? OO IA o E' DR ? c NT CONDITIONS n I, RAFFIC CONTRD VEHICLE Y E NO ] TYPE OF ROAD ¢ -K ONE OP MnnE VEHICLE CON6I1 ION IjQ?{F Q(I :. IIj9?{F CLE Q(I ->• :, :SOBRIETY - E ' T (r' 1 (n? D IGNAL R \ T SIGN— pxF waY C a C '] DI VE CLE ICNECK ON I NIT, I_1 l_I OR Rid SIGN 1 /\ 0 L .N ] I fT ?' X Wp C t tCr vk ' d OIIAK f "? rY -T ° ° ] ° . '-. '] fGN,._._ ??._ ) I Fvt LE W _ _ L _ ___ ] , OF FICTIVE LAp LIWITa . ?J. IMWnEO bOA ) I PLRr ? I L? TPAif :Cl .rI f1AP IN E P 1 a Wa ING ITS. r? IMT NG[ l -1 t AMp )- -' pFFFCTIVE n - '"DT (MEAN 1 a xeo SpexlETr ARK . . .11p11 t -' MENDNGRxi[nwG ?g I I D RK-fT F L I GNTf0 C IS• FR HIN _. ' .. 1 Al- ... - ' - ..1_ EU mrrs TI [ WORx _ ?ti3MO0Tx '•--A I?uA°NK-?-.. -?- ? 1 PEP DRINKING L I_I TRAFFKI T- 716 J PACKING S "G. 11 Tso p L f IwD fF T uFl z ??- e. I oN .N. ° ot? CHEM. TEST f l 1 ` ... K RP{QAEI-Ti °LFp µ ^-u lr i its We» nxRIsim vl H T#.: F - K ] DIV 1 k XI. NO DEFEI r l j TEfr N[ruStp S, SIFOwI NG dI AC.f K•N'S xgM1 eHAMK ?kl MNU D[ MULL NO V I FOI Kt 'T•- '1 CI/YI CIxD TEST RESULTS Z r I ESTHS11-01 I KERl AMEARwR ? ' POLICE A.U VLD rLOVI A AT Ar191 ?d DJ Ida VLtD ] MPFOED " 91 I M1N? X U[ r NO w I OR GIST UEr rt Or RE 0 t0 er IpUAll N ps?° 8- 3 ?8 ^ 9 I E? Vo W? O STATE PATROL-OLYMPIA, WASHINGTON 885M DUPIICATF COPY IOCAI L AW ENronCf AIENTAGENCY'SCOPY_TNIPLICATE COPY: INVESTIGATDR'SCOPY r At t .r T,se ) PY ? W Y M• I' 11 ?,T{y gg ?- I?t', 'w? yykYdO? agwlf ? L ? L+ I ?r y .?1 \. . ... -, T All STATE Or WASHINGTON PAGE / DF !' W No POUCE COMPLAINT NUMBER t? UNIFORM POLICE TRAFFIC COLLISION REPORT tit; AY OF COWSION TIME COUNTY NO CITY,ND DATEOFCDLUSKw ,T FH A A INUR 3 FRI B S IUSE jdWoHOVRI J Y/? L • O Rom pAY BUN I MOx D ] IULS ] WE T J' !J Z AD LIS PPEFI ,ROUTE Ofl 6TREETCWEG CTION SIF'y?t z 9! OUNTY ROAD ?CITY STREET O f GWNTY ?STATEROUTE k1c • ?./'SO ? OTHER ISPECIFYI N L' N S E W ?IN " CITY OP TOWN W PREF% EO MIE PORT r I _?` RAM ?OF _/c ., 3 A' r...r,I M,LES ? ? AMDATA N AME NO.OF 6rFUZIE qH GHWAY?;->.:._- INTERSECTWG VRTH. bTPEET OR ROAD. U. C .ZZ o?n I r'?'T 1' .tT ?• WIER NOII %RD iEflSECT NG TREE O V)AT-DON I I w •:1 NON1ryT E /J ACC DENT CLS ILEA MCODE E NCCFIO Ej olj OAD p ER 6 OETWEENb GC L .-USE STREET 4^•.. D4`ITMILE ANO DIRECTION FROM EEF YRENCE OR Cfl035p REEi: - .( 4VI E S ® OF • SEVERITY jy •COLLISIONINVOLVEO: ®VEHIIXEWEHICIE ? VEHICLE BICYCLE ?OTHERIWRITE) ?HITBPUN NO KILLED 1-1 VEHICLE-OBJECT ?VE CLEnRTRAIN ?STOLEN VEHICLE fJ-NO WUREO TOTALNO VEHICLE OFVEHICLES® ? -PEDESTRIAN ? COLLISION []HAZ RUOUSMATE AL ?PPOPERtt DAMAGE ONLY NO OEIECT GTRUCK t ,._OBJECT STRUCKSNAMEOFDEIECTSTRUCKANDOWN ERSNAMO :_ LOCATO EST DAMAGE N 5 E W ? OF JJ'wnV ' ' RNO O AY FEET ? ? ? ? RD E.H. 3 r _ MIVERENAMERAST_;?_,A "gt.....F ?L.•?T.-A•+'1•.•- MOULE,?: DRIVERS AMEU i,tIIL"T M.nDIEJIf BICYCUS7_ON PEDES7PMN CXECKIO ^?' •`??_._ ? R. D S G i D L Si11` l7JP d ,. , R I ss _ ??I STIIEET?UDnEES- +`-..-• L ... .-?+- -.: SiflEET AODPE ?.., -'?y: ..•-..+wZaS1J...`brLf.:FL..= tY _ Jf- o? NO, ` ''Mr•' R. 90 = d J a d d N DFWFAS ENSE NO. ST TE SEX DATE OF BIRTH: e.. N IXiIVERS LICENSE NO.....' _. _ST TE vSEX?. OMTE OFDBwiH lyf _ .. AA F V _ O /? 7 i YTAg',F?''? g 0• J /J / ?/A? "n ... M3. o. D Y vR. J H n ?y? '? DnNEgS OCCUPATIOrI FIRM NAME PMO ENO. 'j, OREF150LCUPATION 5? _ ? `I, r dP /? %?... _/( ./Atop N• S_, ?% rv CODES 71] CuSS_ AI SEAT BELT 131 EIECTNVi t ?, , gv CODES I]1 Crig55 I I SEATBELT, I31 ELECTION t' OF NATURE U' r INJURIES INJURIES Li° RpMO EDP Sfiy? - FROAL 6ELENE BV C TO ?l1 Gl OD OM SCENE PY TO ?i • VEH. TEAR MAN 11X1DCE CHEVJ MODELIOAflT-NOVA) `'. STYLE I3DR?CONVJ.::.. VEH.YEAR, MAKEIUDOGE'LHEVA- MODELLDART•NOVAI STYLEIZURCONVI . „ aT v v C:v?? 6 DEC' E VEN. COLON. UG PLATE AXI.,:: STA TRAILER PLATE NO. STATE •... E: VEH.COLERw IJC. FLATE-. STATE '-'PLATE.NO.,. STATE •? i W H" -+ i? 1 C - Nr.1ETER C VEHICLE IDENTIFK:ATICN NUMBER rAi? .a,,,.,•i :u:--..::: DOOMETER.,ncl. • "5 • - lF ¦ {TIFLCA 1r1 NIIMBER?«:.• _..,?a._. r ...••_ REGISTERED OWNER-UST ..., FIfIST :.. :.. MIDDLE. - REGISTERED-11 LAST .._ FRiSi MIpDLE N, v N .,; `. roA 1 yK 0.' 55 OF OWNER.. .,.:.:a ....-.. '...? .... ADORE IT L-6- AME ANOADDRE55OF WSUIMNLUENT ' NAMEANp RDDRE55OFWSURANCECO OR PGENi. ....... 7 /mod/d" J S ?a//y/Ci? CHAPGE K/r .y ?.. ?.?r.._ CI ATgN ENFORCEMENT 4 n I >.,yrv 7 ACTION .CODES L'I ?'? 11 y q e.." ". NAME, ADDRESS & INJURIES OF PERSONS INVOLVED - ' 3 A Si•'+? SEX AOE STATUS nvl -M y AST EJECT.. + 1 S,i k. C ADDREss /ovEDFROM y x?l . _ wJU FESDF ?• • / . 9.5? BCFNE m To 1. T' / .t Bird '. I ,y 1 yL A NAME -_T-, J$ 2f -:..1? G 3 , 1 I. "+Gl 4 +'9 T ADd+Ess. d7 ,?//'.1• C'r REMOVI:OCnoM To C M'ri r 4 S "euuyES Q seENF nv W NAME $ 1 1 . I ADDRESS' / U !1 a,?F cb Pi/ 3 :H rUlK4ER OVEDFN 6CFNF DY TD ?i19.°: A f, E P ,. 9 KAF S S '.S a ADORE E s FNEYRr TO S• F1A S w -- IJIINAIRY CLASS IPrBEAl P09110N ITI SEAT BELT IWEVHON I;?ar J INS R HOPUURY SDISAnlIN01WI1RY 1. NOT INUSE N I SE 1NOT EJECTED TOTALLY EJECTED Z ' ?+ PA95[NGE c ] i niC EROM 3 DEAD AI SCENE IOTHCn POSrtxYI :DEADDN UI- A ION DISAOLING IEVIOENT)IHIURY URY ] O w 3. USED UN.NOYYN ? . 3PAnT-LYEJECTEO NIF A ' P D 3011?N 3 ] TION LINKY II DEDINHOSITAL 3 ] IP T.P0.SLNLE INJ bSEAT D[LT iAAU11E EJEC TEO ' f • / vniNESS e E A E4 _ r? 6h%r t 4 ? n ? Ip ;? 'I i w,?N w10 S• ;•'a .. ??,AR?J?S}?.9aDM1' Iw J N ?• rlv 1 urt VEIlICLE COLLISION REPORT .GATE OF LOLLI30 _ NO. DAY OF CULLISIO? I _ TIME OG -COLLISION COUNT N C TV PAY uux C o ,/' l Gln ro N a D D a C Tf`- ?? CITY FTOLVN ?- AOnIC45 Y{l Ef l.X cs x eEl l UE SECTIJ `- ti S ?7 C GI NAME OFSiflEET•HUR HIAy `??UF 'l•--T §•? INTERSECTIfIG WITIi'STREET OH ROAD PRE•I% EO MLEPOST `/ ?? JD,V INIE3ISEC:1 N- GATIONOFCOLLIE. N ?v t HAM, DIAGRAM OA FA fpt RTTWEFN ?Ir. r STREET AN rt- S41REEi r' , EEJ . kV y :: .n.. G3." v .m . ... ?•., ,. x .,• .- %.xu r Gx xR.o• d u• xrFE, n a ter; ;vL ,z? L, r,rJ GL3. 3 z s rxE. ax" 'ILI 1 D I / ? ? G'? H.••C 1-'U'w! fJ /?Jr / )dp? SPEC. CODE USE )?r?oao ? ?I " I .uuu ? c x 11.i OBJECT STRUCK ?, I? ? ?CuY' r EoF Ox.ECrS a ,, OWNER OF OBJECTS NAME ANOADDRESS LOCATION :J L`lo Pwx [ 1 7-!w W ..AY T1 • V(61.. DNDE.. AST'N ME'•',_,I'.., .??IR T Azlti_ MIDDLE DRIVERS LAST NAME+ GIO FIRST NAME :,J IL`l rurMIDDLE CT ?r * ?' `` ^•' U , N SLY TGII:ETAOOpE55 (ROUTE N(O'.ANOrHH kN0 " "•^r STREET ADDRESS _ ROUTE NO. AND 80%NO. - Vr • STATE ZIP CODE DRIVEN OCC ATI7 xr•x, r. yy CITY STATE 21P CODE DRIVERS OCCUPATION k,, DRIVRS LICENSE NUM ERSEX DATEOFBIHAGE ORIVERSLICENSE NUMBER STATE SEX 1 DATE QF BIRTH DAY A RSODYSTYLE Y EHICLEYR. MAKE -GN MODEL R y '1 (- REV I r.? y3 t LICENSEPL.ATENG,. ATE TRAILER PLAT ENO. " STA yE (' J ^- LICENSE PLATE NO. STATE. TRAILER PLATE NO. STATE O0. ' 5•'" i'r -? : $ _ <TrX ?S4G, r .- VEHICLEIDENTIFICATID NO xl OOOME,ER U VEHICLE IDENTIFICATIONNO. -G)19- _ r. uPE1FAnln[xl CODMETE ?G•I {"y,?y - T:. 21tf1••6 .¢ ?-G)19- OGWNER..?- - )ry ooE I_ ;: OflIVERSLICENSE N0. R EGISTEREDOWNER - AIT?r.-II"n DRIVERSLICEr SEND. ? ' : YA? " CI STgTEI ??TE ClBIRTH OWNERS ADDRESS' +4 iT ^ r J' E CITY AND S AiEI DATE OF BIRTH DAY _ 11 YART30 V ICLE DAMAGE J '? r F k ?- I• t /, .•:.^ ^•-.;._•:`- ."':+--.. xGE PARTS OF VEHICLE DAMAGED ,.... .. ., .... I_IACiI CITY INSURANCEANFORN7A-fION-VEHICLE NO 1 - wgOVE GsT EREEIN AUErComo FECT e LEORUATMBISUrvACCIIVSDEVUHANCE E CTONYOURCAN YES NO NAMEANO DRESS OF LI tlLTY INSURANCE POLICY HOLDER C ITV N IA81LIn INSURANCEC MPANY M '. " M 4 - ri L r, PT)1J("'4l ? ? ? r / lrP A..S .S NAM AND QORESS F .ABILITY. Ufl CEAOENT, Cl,y : _ - ,.. ... _ _ ? _.. .. ... ,:.: 4TF ....: _.. LIABILITY POLIO rNUh1BEfl F tl IT IJIJLNY S -- AGE _ o-2.1.11 URY: IV;E SEPARATE PORT FCR 0 LINJU I AGE A 6 u . SEX n- L r - ..-- - -_-pEQ w' • P ?? :, STA NS OFINJURED MARK FIRST ONE THAT gPPLlE3. STATUSOF INJURED i° • A $ ? NI"" r•.oYN MNRX FIRST ONE THAOi APPLIES.` IY --E S ? - e?Ir rr.l 7 ? N ?-? 5e?u Ir.uvG ?.?r?7? IrI a 9Y KILIED ? IN VEHICLE L {1G A ? ?? CI KILLED ? Tc 11, ? " x 41 1 I XGd' J ?2 ;? .. O Cr il• tYbv 2 310 IORTH RV HPOW I CIRCLE L ------ I ,1: ES r •, }h ?, \ ?' i DESCRIBE, BELOW WHAT HAPPENED: (REFER TO VEHICLES BY NUMBER) I r O 1 ? rx1 r a • xxt l`"" u .G ?/?/ ('tiA?/ ? _ ? L !. ?///? _ _ .(SA'q. . _rcT?x.r??- ---- t??J-Y?!<'Grur x ?ysS I.Y=.f_ sf .f ._-?- . ____-_.- /!? _ J'JlJ C/!•(!. /-/.-IV LF/ ?IcL. /F IJ /!ll .__ 41 Jr-u e- (i. • - I . ,/ ? ; ? -Of 'Y"?_.... Cl4J ?. i .._ ?f "`'S" ? .<Lr [/ CG. J.J/ r. y? ? ?a 1? a //: /4 1 ? I ?/I PJ$ '? (/ --- It1 r VCHILLES POSITIONS BEFORE COLLISION I x INVCSIICA,IU Uv xvlxl E x,lo •II VEHICLE IAUEO ON STiI F.Fi OR HIOIIWAYNAVE. OII NO. rrl• vIx'alI L ?Clx w) nr• IVOU 1 ? ? ? ?' nL gin ? iArx?rl ? nri ?i p 7J? I ) IOT CTI f ]?.1 C117 ? ?n ?HUCF ?M.rHV...... Un I(. 1. --- N?1•?`JICJ?-T.O IJ (^? ? ALONO ? C 1 1 ? ? " - 1?, ., -` M J 1 u ,R,N[[NR??DD?f '1 EIITST I NWASU : I, ) ]C.l.•ixx I_J I" " •.._w .0 V•' ••.J. ti? gBiy? ?..* ?.. i. IQ OSI Nf ACC.. WEAINFR IONS R FF 11T CONDIT IC COP, TOOL TV EUF IIOAU ?? -?J 1IG NCIIIf,LF. f'TtOlf3 J? A G', •I •'•• T-? 1r.?J . ..v -I OR VE{I DA'D ?' _ •,I ;. ?? `?w[If T SN IW NC ]UDUS NGIIT A"I tTJ ^;xvlflU31f'N , ?] 7NFVIF,A,,ILE r ? r 2`p OVFITAKI.IYO AND PASSNGI 1 'I 1 1 (T-- U TT TT--?T r-? s y ;.•. 'r., .1 r? SNOw a ?i<w; ,I Lr?L G %{r'NEI! ? LI Ll LJ {.DAD ? ] El MAKINGRIGIITTURN J ° ?` nJl._i NT ,?::•?,,. SL.?? 9J tET I 1 NL IiGD ?AnGHKNGIEPT,UiN Iri yy, h a ) G (- I N L? ?. LIT. hO AVHEp ?ALLEY (T'-T)M KNCu run4 :? eC! 0. (•-'?IS, "I II.H,3 IF G ? f ,AL 1-10. / Y' ??ii?r it rN l.n!\ ?? `' lDVnhf'• J ?: M1 1 ' I T .. -131,111, M Or J'1 "[] "rr r[I ILAC-1 _ _____ ___ f'?'II J 1 1•r0{DII ITIAFVIC J Y '1 ?? I ?? Y1GPPtn AT SI.NAL 11 f C.J "I JOR3TOA SV.. n Ito ? )?sTLYYEDINROADWAY I' Y IrI IJ _ ?J. (? r.-nc u I n I G?1 ?? w Ion D?? Tnn ,,IJ t c 1 J r w w! '"'A"'°'l,96141? .?n '? Tx "14t?f d ??? M} kl L I" {I y1?' : r r ( ,C*" . t_ . J ? ?' #t , J I {^71 1 M ^q ??{ 1e I }r ' 4 I J!1y If/ I ?1 ? J • :.vJ yy fHr' I 1 I 41 k R I _.- ._..-.••..... ..L,.n.r A,wnaurrvptoN Un0w _ - Y LOCAL LAW FIFF O-__ : __ NCr"SCOP Y_1111PL IC ATE COPY I ____ GATOH SCOPY _ HCLE THL NUMBER OF GACH DAMAGED AREA,?? E%AMP INSTRUCTIONS; 2. SHAOE AR EA OF SEVEREST IMPACT.' OAF a DAMAGE ]. DRAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FO CE. Q / P D VEHICLE NO.1 IUSE TNIS3PACf FOf+BKETCHING DAMAGE TO A N TRAILERB,MOi0nCYCLEB.ETC.1 DAMAGED VEHICLE N0.2F I a oNJ l N I A arorrl I r r l S. u F Fla ,L,F 16 T,..P ` I n • FK E H I r I'. ? vrFFrr•pa t• (n E. T .. wr 1 vrrurn I U r BE RITY OF DA L MAGE. VEHICLE NO 1 2 ? °I SN BUNG °A M ISXN NA[?E ] O °THERMV DAMAGE SOR° aABLING VENIILEI ICNER M. OgMAGE IS O BIT . ILIA MEgGEEHICL y? ? F CTIDNAL DA 6 , ? NO DAMAGE ) ? FUNCT OxAL DAMAGE H *NO DgMADEV- > OAMAGE ? FU " C I 8 . T E . TOWED NO °AtiAGE 1 ? w. (F a EST. DAMAGE -ED BY -EBT DP.AGE' 1 OWEO°Y to Driven n away - 11200 r° s ro DIAGflAM OF COLLISION - - i • 1 `' - -^ r - I ?_ 1 I ! I DRAW ARROW SHOWING EAFr 3 ?? _-t-J---' __I_ I. t -tl--r?I -y- I+ 1 I +-1 _NORTH INCIRCLE ' F I I I I I i i I I I I •{ ^ I .I 47 XNI - 1 1 1 . 1 ( I I I I -?i !, rl ,? . T v I I 1 J I I I- Ii' ?'-I I-1'I 4 P1"1C^`,pALT",,l. AT 41 i { ' i {Dt -, ? - ^ I r • f r ^ f _f-? DESCRIPTION OF IIND CgTEw rPR + i ` OBABLY Avv kNED BEFORE Oi ONO G EO ,DUB NG CRnaH,INCLUDE INFORM 'COLL ISION AND q DRVEq Dlsnmurv.REpuc[DPED[sTRlgNC WS alulr, wrNWC COLD eo sERDC " T oN REVAI Dx Drive r-i^vorded thie_?/0 thxt he was dri_ing_slov account of the heavy snowfall and than-: . S _sluch ori_the_roadvay_when he hit the small dip_ia the roadway by _the Beavery Valley store h j a 4e t at_Yor no_apparent reason fiis vehicle started slldinglout Dt controllaad h_ . _ into- thditch and _rolled over hitting -POSITION BEFORE COON F AOEO LLISI _-. .._ MILE p TR E .. ow EU I I' EE r M DIRECT DN NAY ' N GN •O J 2 Err "G L .... DECRE IN 4 KE u Eri L ? ? ? ??lL (?I I? C.R. 12 /? L. 2 1 J ES 0 NO O F'? u ? r E ?n L.2 DG ' St .. ) r I ] r OA _ I Imo' E C t AB G: E WALKWAY t ..?SHOpLOE I_Ir'aO55wgLK SC ICNOS E E GPOr'1 CYCLE RO E ?-- ? ] . . . . AD ?K RFACE.. A WN ` ' pTHCR ... 'CONTRIBUTI ONERCUMSTANCES O - E O I F E .' +C ECK On MDREI - - NO IvEl C4. CiO a - ' n DgvER . ER ? IN O] O.) DRIVER TV : {t -l t. Lv o oA % xo ] r G HEwD - ? « JI ? I O ? Eqq «OUOY f? UNDER INFLUENCE OF L owI I?'? I-', C -? ?27 DXER L.I I gLLco NFLU T4Z?.SLL LAP SAD q .0; c..O fP Q NG `E u -T F? [NCEO 0 _-TIR I_? A_ EF T nlC O I) CLG3.__ T RIGHT TURN' f SNON NG O xG STATED - FAILING r, 0 CED la? I OPE G.. O, II u ,oD Fom CE [ j E DING E I O _ L9CA N PAREIS TU LEF } ° ? ?' ?-, l s. [p y!° T • L? NG T _ D NOT . s o :T 4 . IEI? .. a Dp c _ rR(w _E 7 DISFEEAP. ?I LQ`-r G. la T4 [ I 1 SI 1.L 4..1[C 1 ?. O GG}1 I? u yi L •-? C ? C . TO;pn icNEGA" i TO' lY e? °p To 1 ?tO ?> r CONDITIONS sAFFICCONTRO v HBr-] [R IcNLCK DxU - o ] vENlc4E ' i No) 'NECPiEE OF R MAD Vt. ?GO ICLE?{{CONxDj?IT IOQON.. ,SODRIETY '?..?: (( s ° ED Ars c AL - ONE OR ORE ?1? O I E F I C ICHfCK NEr , ' L ORSTOParc INO ) 1( SIGN— J iT? 'i?I iIt 01 i O] (71(- oxE wqr ?°? STOPPED IN _ uc J STHOADWAY --11I lo. )WO -_ ..' OFFECI VE Ell ((''? 77 ARTING HOD ABILITY I ID BI . ? _ IIED I MPA ]G ELD SIGN . _. p O _O ?L pFF ECTIVE L)? .Rp TY BY FI I O p MPA (?? (-?? _ HLAOL GII)3_ a K? ? I 1 J ..R FTY N I?' IN 0 G L_..L ?. AMP C[_._ C I)L_I E GF DOE T RIND LIGHTO. _ I I NFIGGO ... .. EFT i 1!I I r - ? I I L 7 44GRMTB ON ? Tlri B DIIN - nAO OT ? MBER?.` ? E V _- 16? B KI ACNG-- 7 1- L: _ oR s oot +_ ! B[NNnnI.KIN. t TI AO 7 6 [ - . ° L- L U ! . a_.T2 r I IR CHEM. TEST rr ? 7 G J BG L ?- l .__.. ._ 0 2 ?6 H " I /T IHIAIIAIID I GNTf _?? . G N lES lRYIN O BF VI :B i I) I pW ?L [p _ i?j 1 NO DEFECTS F T[EI REFUS[D OIHkR IYICIFVI -' - 1.- 1 - . ?? 7 'I Dl0 ". NIRN isviG Fv1 74 - % TEST RESULTS •2 E[IGAHAD OFaICIraNAnEAngxK UcE NO ? LI Ck plslAiCHIU vOLIC[ARHwIU ?ANIH ULAN11 TimAFNC FLOW r I f N, O , `N JC? D."TIN "I AOIT. ATe°.RSI°xl PNp Hio RY HoATS M /Y D Quiloens 1;);, - DISTRIBUTION ORIGINAL C- SINN Tn weL.mn.,....... ........ _. ___.- _ ' x S V 9J 5 kW G: '? c .?,Fr at ?R Rn Tr _ oaB : ?G ?. .._uGiL•1. i?..a... i?w5...?,.u+•+..? Y'.{il'F'1 :5?. 6. . -LGFw4.. .v?ur•5. iifv-ia?.+:'.Jd'q}f. _ ? ?A? Ai? /p STATE OF WASHINGTON PAGE OF , Jy[LJ" POLICE COM LAWT NUMBER ???!!! UNIFORM POLICE TRAFFIC COLLISION REPORT - - _ I .. . .. OATEOFCOLLGION' DAYOFCOLL-. TIME COUNT NO CITY NO HWA ry ,, _ ylp ,jyY YR i SUN r Mp1 Z IIIIS 3 WA A InuN 6 inl D SAt ILA gO NOURI >. _ _ RBAN •L /O J J RUPK _ CNTY E) ® = ACM LLS PREfDf fl TAE CTION STATE ROUTE COUNTY ROAD ?CITY STREET O 9U I-- Jefferson ?OTHERiSPECIFYI ?- - - - N . . y ?I _ LI. 'N 6 E W MIN .. CITY Oq IOW PREF EO y MIE POST l r w A r? i O ML¢r_ ? ?...?of Beaver Y.,]1e3_ U ' -f ;. , ?i ?i."•yy. EIZI C '.-N E-3 Of4TREETOPMGHWAY INIEPSECTWG WITH. STREET ORROAD:- LLLj, RAMP OAGMMOATA A o?. r f _i. L{ i. 1?•'AfA - _L of i.. B't^ n, s, ;I T.. ON-c R.:u --.. .. I- -_._--- -- -- - --- - .. M. 71 ^- NOII PriEFi5EC1. - ACC DENT WIER ON. kJiO EflSECTWO STPEE T OR R0 AD LIEF. - J; INT P -. JAILEAGE_ '• C ERENCE 55 (PEST ROADMrJ 5y:, dam- N BETWEEN STREET AND CREST CODE i t t Q M11, IdHl • pLSTANCE AND LIES ON FROM NEFERENCEOR CROSS STREET: EC CODWG USE y,, . a ? .. ?MILES-. C 3k`rr .... FEET OF _ .? F tl ?., •= k g C04ISI VE ICLE•VEWCLE ?EHICLE'OICYCLE ?OTHERIWfl TEI ?.RUN SEVERITY QN?yV OLVED? _? _•__- -- NO.N llEO TOTANO Q7EHIC7LE'00.1ECT ?VEI CIE RRTRAN SpLENVEHCLE No I.. -OFVEHCLES= ?VEWCIEPEOESTRIAN„ _ ? ON COLLISION `•?MA2MDOU$?AATEPIAL _ ,J i' ©PROPERTY DAMAGEONLY O ECTWHUCKINAMEOFOEIECCTTPUCKANDOWNERSNAME) _ --. +•,?. ;^LOC TON OF OBJECT SIRN CKl. E..W ,w E$T,(}AMAGE C`ja.• 55 Smll trees in the ditch ?RO D AY FEET ? 11 El C1 RO EDGE 3 ? ? F 0`L,LUS NAME tASi. -.?•? FWST - -?-- ?•.-?MUOLE •-- -ER 5 NAMElh3Tf R3TM OV.EY BM, C41S1'OR Pf-PUAN CHECIt1GT.1? J??. •. Q JOf$f SY eneri c4 t Q 5 R_ iREEi.ADDRE39? .?-? ^? _ _-R S< FET 'O ESS T t - -" X V'. 7:56:k. Street <V•t ,+ O? c ..-_ :1.•J vfi -' "?, E CR _.. - .?.L. STATE - ., 1.. ZW CG?EO is Pl10NEN0 L. CTY' ., b 3 3 Y STATE •I 1 trSO i21P000¢'TO ..PHONE O R 4omsDIId R Fo:t kA. 0368 35-2217 r o ` Y, N OIUVERS LICENSE NO.:' SATE. SEA.DAIEOFOIRTH. I,NRNEA3MENSE •..SjATe?'bE .. GATE OF BIHT ..-r. ,. 0. MO OAY 0- PA . OAY YR. ' JQI•'ii..70%s09 l:n. ;A 09 29 30 -.. .?.DRNERS UIION FWM NAME .".'i... PrgNE NO. ,Z DRIVERSOCCUPATION7" M NAME..... . P N yy` Teacher art To-.rnrJen3 High School l CU IA1 I31 R55 1 + QQES_ IJI ILA SEAT BELT_ EJECTION '- ICODSS >113, C I SEAT BELT_ISIEJECTION C -il y I NATUREOF .... ;'. 'NuDRIES Stated DOIIe - ••: _ - "'7 SCENERY: O SIAM6 FNC TO q AyKE IOOOGE'CME .1 .: MO.EL(DARTNQ1,V STYLEI?DfL•GONV I.IIJ -Y.. MANEIOODGE CHE J . MODELIDAFIT-NOVAI STYLE13-ZNWI t.-E V 1977 Dat.•-= B-210 tvdor.. -- --vE PLATE KO... STATE TRAILER PLATE NoE LOfi m. PLATENO.:SATE!: •. TIUBIERFIATENO.?: STATE:.uai:.. I952 Wn EHCLE IDS NFC.TI N NU BEfl : C JDENIIFICATI NJYUA BER LE, REOISTEHED OWNED FWST : '..u- IDIXE REDO ER -.LASO. • $af![e 85 above i.. I I i ADDRESS OF OWNER .,J y .. DDPESS.OF O Efl _._s. , . . l-?.:.?. -r' f•a?w+At ',,,Nn y}y?,, ?Jr SY y 2 ? , AaD NAMEANDAOORESSo SURANCE CO DR AOEM - NAME AND AODRCSS Of SUNCE CO. OPAGENT .}A } •3 M P?Jm Seattle$ khy -at q cHA I_ ._..._:, ..:.. : ..•.,._: cITAn N s..a..,ac x IyS . ,? iUff1d .. ENFORCEMENT_ ., •#'. C 1 CODES ..:.?. 1 l t c ADDnESn NAMEr ADDRESS & INJURIES OF PERSONS INVOLVED' SE AGE sraus ) d' o NAME. s y. U. NATURE OF RI MOVED FROM 1 tlfl y?, y 5y9 .L' M1rfYi( IT -TES - SCENE OY TO Sr -T ADDRESS.. .. 111].f M• 1 J'' Y T',4 ,TS<1 .S IrwnlES aciNr FROM To I `. J ?/: NAME: T MDHE59 To "+ kTZ N WJwDrA scfNFnY. ANw- ..r 1? 6.'NAMe V T. L ?¢rrt JI Y I 6,., VWM.3 SCNE nY E TO' ,• •...I ,'? (•,- 1115 AIUS 1)1A[AI EOYTCN IJI WJURYCLA53 TAISLAIDIEL I31[JECiCN-• '• ' PASSENOCN - HOVIJURY GOSAIR Hf IN,NRY NOrINDTALZLO I`NOT EJEOfCD? ^'i 11 O J ftt31R,AM I1I? "''"`I, )DIAbA15CINC NONU BLIND )NOi VILrE I-? ).lOlAl1VE ECTED N X I' • 9. - • D SOIH nL6T _- `? \ ) . POSIilOr1 UNHANOWN JOCO W HOSPITAL I1 RO SIOLC INJURY E r, rnfraa. J S.UN-o L•T rNlI1NL EJECTED _... .. _ ._.1 -?, ,t?ey ? J?rS i I M ?S+i rlo .,, p I?? zlp-stn, .rM Y :T,77`77 .+n7A•'?D I 75ir "p, m7vc - t,. -.'• F- A J .?. IF i 1 I 'r v ?sJ? f: U ?L B xR ? u . h 99 yy ` ??? . f? t C"S I ?? 1f 1 ? i+ -T P J ? I f t Y{0 I\? VEHICLE N O. 1 1USE THIS YACL FOR SKErCHINCDAMAGE 1'a TRAILERS.MaTDP<YCLEt, ETCJ -DAMAGED VEHICLE NO : T -'v 1 I L u n HE, VEH CLE NU 1 111-1111 E THtr' . DAMAGE GE VFRIiv OF DAMAGE IOTH O IASLING DAMAGE ER VF3 CI CLEI OTHER MV. AMAGE CTO RAL DAMAGE . [] n0 AMgGE .] SEVE0 TY9AOdL DAMfl 0C E •O ?? MAGE OA UNC ? O DAMAGE 0 ED Y E ED BY T W MAG S t T DIAGRV OF COLLISION wv re+ruAt, FOA - - 1 I 1A' 1 1 - I ?? l 1 (DRAW ARROIN SHOWING j } I NOflTH IN CIRCLE wAY t 1 T 1 ? .'L? 'h rl` Li ?< i- -- i - i I Lr lad I ;-- - - ,I A,IMP.. ANDA.TtAtOLMMDN I DESCRIPTION OF E ATPROBABLY H E o E "UPIND AND AFTER E CRASH c OE o i ' COLLISION . N r l INFORMATION DIAGRAM. EGA DSABILITY, REDUCED VISBILTY, PEDESTRIAN CLOTHING COLOR. CONSTRUCT- O REPAIR WORK ETC.I O RIVEN - _.. _______ -____..C,f.L?. 1. _-? __ _ ![ I.GII. !_ ?)i[.? i:) _ ff'_L! / 7A ?.?:! 11L-?.? -?^_ ? J / ??._._ 7?!/ /1? t?' ? /i/J/I 5?-?. s?.? ? /! F:6 •: 'c " ' C H 'f L SJ ? T ? _ r ^.1 ? - L -..._I .?.J . i.--r :_ ? •/ ......K?C ??I.J'1L?.r_r 7.J c i 3 .Jl%-//_E ..C!!.:...' !''_KG _Y./?. ?•?- _? _ 3l`-.?/5..?V[•"'fi '-r` ? nli/'i _ 'f/' ? ` ? . - •:_'-. [H %IlH3 BEFORE OLLISION - .Cc fib(-4 npie RE<?IO IPE F FD FAR ` w. NFAOEG FR E IOST DIR. ON STREET 0 HIGHWAY NAME OR NO oat W t NCREASNO OECRE.H. OCC ED L S IJ . 14- I I y rE? ?I ? I : ALONG }I f _.-L `n SING T .. HR o PEOIBICVCI ST AS USIN G . S E 1 ] ] HOULDE I.... MARKED S,- UNM C OS ALK ED B. ES r T ] - n I 1 TO .ROAD SURE ICNECKOFFAC EI WEATHER ICHECK ONE) CONTRIBU CROSS TING CIRCUMSTANCES : A D C C E ROUTE OTH ER NE CL CT ND DR VlR " HE CKON EORMOREI I .] Kd?n`w cI+ N 0.] CINDE OF ' IN ] DE - GO - I i ORY ?CLEAR.CLOUD La.ADYERCAST UNDER INFLUENCED AlCO. OL OOSka°ELy EISG ED WAgN3 j, r l $ . [3]0 NG t 1] ?J WET ] rI RANIN. R a5 E C _ _ LIVNEER C N ° - i AN A59 IS ? IFMT. A r ? I I]I. I w.v.[ __ ] U SN OWM' EXCEED I I]? Y ED G3 D G DI O -- SG L -I E KIN4 I a I IE( ? RAK NOH 1 IE k 1 _ _L..?F? ~. EIIII l °A fYEFG E I A 1 I O [ ^ O J r ,° (" LE MAKIN. q"I r L I - - - 11'' °1...l - .. ... t Isi I DID O O m TH F c E .I __ .I _ DI ?.. G DO a T .-. Df [CTL k P v i 1 '. TUNN E: . ?leU no IRa Or R EC VT Y or SPECIf YI - P _ - ° PA5 OC . - - ' 1] 3 S w t I - ° E IS 3 IYI ND Ln °N ,. ?]? 970 PED FOq 1 TR F N C NDITIONS GHLCK ON[ RAFFIC CONTRO ND] F c O,] TYPE OF ROAD ICHECK ONE OR MOgP VEHICLE C O N DITION y CLF I CN Q? SODRIETY ,:. A FIC... 0 AT . IN I U t a 1 ... S 6NA 5 ONE AY ' N NO { R5 µ I E IC FCKONFI IN. ] L ON 17OI SION L } Io owsrN ' DAYLID T ] STOP .??? ? SGN._ TWO . ..... _ r f DEFECT VE 1 -.c °RAKES ?I.. r IiBD AB LITr - , I 0o TARTI ]j I DAWN " ' f?? I-SGLD ?.._ ] 1 FHSIBLE _ .. ] j DEIECr Vk' Hf AO LIGIIrS WPAIRLD 1]' I NP ABILITY Vii. NOTIMPAIflEO CLA T ?It III I.NOrRO ST IXIfR A NC ANf.E I __ ) OFfFCTIVE -__ N ARKEDPOSTIOF _.. I DARK . PCD - t 1 '. LOO PA I -- . , REAR 4GHTS... B OSOBflST . I .DNK.- MERGINOIENTF Na I I.,..JI'1 TRAFFICI A 1 -1TRlI - _...L 4MT10 nG AMEg ' ALLfY -_,°_- _-._.. T R WORN I?IF OH.SMOOTH.. AP NNOnINKINf. ACK 116. B dACKING 0 ARX- l[ ° L6 r60 P -°. SIGNAL Y Lfir ° Up l N[t , Aa-A ° off D OF] CHEM. TEST 1 -; ?i•I IF DAK-NO IR ELrL0 S -i A 1LA S A N SFV tD ._. _.. ..-. ?• j l TIS 6V[N _ - f PI ° . T ' ----- -.[ DT ER ] L_DIVDID ... 1 /I NODEFECTS .. _-.. r r T[SPfTUSlD - 1 ( 1 f I 0THCR IY[GIIY1 IN ItN .• ° ' 'l? UNOWIDEa 'OHIEFIIYFCIIYI % TEST RESULTS 2 V 4A1 0o CFH IN K ., _. SAIF. _ LC[ < D 1..- i VNM Ce aNNNt4 CE li ILOW 11J J t0 M D[D s ]Ani X vtsn<A teN SNAME ? Du N] u¢ r utT r r ovfDB In9^ i t r _ DUPOCATC COPY LOCAL LAW ENf ONL-EMCNT AGENCY'SCOPY-fHIPLICATC?OOPV?INVCSTIGATOflJ3 COPY t H -!? i.G ` "Ili' ?V ?N, g 5 ry Vii . ? [ YA. r t L JTW. • ?, n ,r -An' 1?y I Tj L 1 y /? L ` 0 ... ._.(?Y'w?'iv a'i*ua " ?7I?PAGC 1 /'Y?G Z IY?. o FORM POLICE TRAFFIC COLISION REPORT POLCE COMPLAINT NUMBEn V SION COUNTYNO / CIIYNO T SUN / n RBAN * YYYC/// URAL ?STATE ROUTE CONTY RCItY STRET y ADMCLS. PREFIX POLITE OR STREET CODE sC110N y/? ? OTHER ISPECIFYI 2 3 E W ?/?L?CITY OR TOWN ? ? OF l%. lui .._ 8 _.. IL) EFI% EO. N OF STREET OR HIGHWAY INTERSECTING WITH: SIREETo 0 ?z ROAD LL RAMP DIAGRAM DATA I. !L?) r I NON INTERSECIIO ,^J(^- o ? ACCIDENT PRUEAGE INTER 10 %PD INTERSECTIG STREET OR POAO ORHEF- IT LLS. EPENCECRO SiPEETOR ROAD 1 .` ' N BETWEEN. STREET AND - .. TREET CODE A "'41 015y+ C[ANp DIRECTION FROM REFERENCEDq`?, RODS STREET }(2? FEET [NOD D ? OF 3 UNaIttN SPECI L COUING USE COLLISION INVOLVED. 131 VEHICLE:VEHICLE ? VEHICLE BICYCLE ?O H THERIN'RREI ? BIT 6 UN SEVERITY NO. KILLED j w ' TOTA L J VEHICLE OBJECT ? VEHICLE RR TRAIN ?5 OLEN VEHICLE 1 NO INJURED r ' y(?. OFVENICLEG © ?VEHICLE PEDESTRIAN ?NON-COLLISION ?1ARDOUG AIFRAL ?PROPERTY DAMAGE ONLY 9 ODJECT STRUCKINAME OF OBJECT STRUCK ANO OWNEflS NAME( LOCATION OFOBJ1--UCKS E EST. DAMAGE C, „11,, ? ROAR.AV FEET ? ? ? ? RD. EDGE p! (A /1 MIDDLE DRIVERS NAIVE ?34T /FIRST LZ a ? % )J D DR-13 S NAME EAST FIRST MIDDLE IIF BICYCLIST OR PEDESTRIAN CHELKI ? - 71 a t D l I,- . A iiA VI !L V R l A STREET ADDRESS. A / STREET ADDRESS Ny ? E ! In E R SLATE 21P LODE PHONE N CITY /? ? r. (c<IaLIj?CIL? L 11.1_ r: E R CRY STATE ZIP CODE HONE NO S!- =`1 I -c(Jt?• IC?i?? - N 0. DRIVERS LICENSE NO. I/ y1,1 G7]??-C??" ' SLATE VA. SEM ?u OAIE OF BIHI ?D Z Y Y N o. 5 ERS LICENSE N0. 1L1 3?7 STATE tI yB?E%? DATE OF B \V4 ?I DAY R_ ri ? ' V i DRISOCCUPAt10N FIRM NAME PHONE NO. "t.c7?L S 1"?'E?sc7? 1?iAsi l 2 --SocCUPATION IRM NAME PNONF NO. C'mii)?Jr (?rUiY, liflSfllJ? ?t . A .. CODES >]l CUSRS IAI SEATBELT__`-. 1.53 EJECTION. ___ CODES 131 ICNU55 -1-_-- TAI SEATBELT_.Z_ ISI EJECTION ' ill T T Uf ?, ?. (r ,`? /1! I L D INJURIEORES ?-r OF c- INJURIES ' qM ED F OM SCENE BY: TO R OVED FROM =CEHE RY' TO M ? . c v VEH.YEM A75 MAKEIDOWELNEVI 11?J MODELIDARTNOVAI (115 STYLEI]OR CONV3 Z v VEN YEAR 7Z IAA EIDODGE-CIIEVI Qi\T. 1 OOE11 AgT NOVA( STYLEI]OR CON') Zf?tJc - U a E " EN COLD lK. PLA E NO. S14-l ? ?.1??5 STATE <vA (HAILER PLATE NO . STATE E " EN COLOR S(c f3u UL P TE NO : STATE TRA LER PLATE NO. STATE ? I O E VEHICLE TOEc 1 FN;ATIQY NUMBER 7 ? ?7?/ ODO,M`ET,ERI C UMBEfl VENICfE AIENIIFCATION N?( ?L53c?' ?J 15? ODOMETER l-F?`J Z ' [J ?i - E T _ REG151ERF^ . .RNIF ,. I ISTEREO .. -EAST . FIRST AGERE.SS OF OWNER c i . .,? J ?rAAAI,L NAM[ ND ADDRESS OFIHSUHAEI 00n AGENT ??LI-S,rA c---_V. rYZI O ADpRES5? 2 CRAIIONN ] A = R ?EJECT. ENFOHCEMENi I' "' NAME, ADDRESS & INJURIES OF PERSONS INVOLVED INVOLVED ° C NAME '. -11_ C C, c 1s?_I__1 - ? 1 I l? Z z i C AOnE5. N NATURED INJUnES - {??(: r?E NCMOVkD FROM sr.EHUlY TO J AP ': :? p a N HAMS ( ><EJ?, i_'l• r c T ADDRESS Az $ W i?UUniE= r SCENf OY FIIOM i0 N-E. 1 T ADDRESS. HA U ? 1110M •.? N ., SCFNI Irv TO ..,I 5 AME S ApDNE pS . - . . E JiU. .1 D A ?Mb p - TO r t { j tI31A1U9 I 1]I =1:AI POSNKY„ J -IYCLA33 II =CAI BE LT 11 31 [JECIION I C :PI = SAN BE 1(--1 { I )OTNLnPOS 1 ON ]DIOAD OHAAf ARRIVAL B NON I CNINJIY U`aC NU CLLD D OY LLYrJfCHD CCI[D Pi ALLY a 1 p = WS fRDI I I 1 f b j 1 V .NOWN S 1U A DCD IIHOSPIIAI ] POS=PLC '_N, I S OW N IF E E e IIN[SS 11 ..ll _ B O i110N H S FAILURF CAT DEL O JEC " a3? e sssr;?B]sw.YAxeaw, A G 1. IN [ C O C 1 LLf I - UM 1 O[ EACH D MAGf.O AR R. ---? -- J. SHADE AREA OF SEVEREST ACT RAW INSTRUCTIONS: ],D OWISI TO SHOW PRINCIPAL DIRECTION OF FORCE k...: ,2 11 Imo( aL DAMAGED VEHICLE Nu.1 Ws[ ss ACC IDn [TCrrvG DAMwc[ta T,+ArLtns MaiDncrcLES,Eicl DAMA IC L ENO.P E H GED V r Pq,??y Tuo 9 ? '! t3 T I] Yr ru^ A V ? HI J '!r n-?""u'?z-T DAMAGE, VEHICLE NO. I WITYGf I OISA BLIND DAMAGE ]OOTNEq M.V. DAMAGE ) ? FUNCTIONAL DAMAGE A ? NO DAMAGE -TTY OF DAMAGE:OTNER VEICLEI I?DISABLINGOAMAGF ]?DTNER M.V. DAMAGE ] FUNCTIONAL DAMAGE A ? NO DAMAGE SEVFnriYOF DAMAGE. VNI F SLING DAMAGE CLE N] OTHER MV. DAMAGE ) iOUN . ? NO DAMAGE L A, trr T.-BY 5 fI-AMAGE cn -WE O OY FST.DAMAGE ESi.,.AMAGE TOWEDBV L OF y 3 (?FQ T. S TO 3 DIAGRAM OF COLLISION D W ARROW SHOWING ORTH IN CIRCLE 061ICTIG Uxoiu.M,fM. [OND,roxs = J - - i . -- . D 1.3,6.ElEEM 4 S=0 L ,RD.I,LAKDLLr3rDN -- - Do ? _ ']_._I. r I 1 1I I I DESCRIPTION OF TORE, DUnrvc AND ATER THE CRASe INFO..AnDNNOTONOIAGRAM EC OmVER NCLVD[ COLLISION , , DTI-1.11Y, REDUCED VR ,LIT r.Pto[sT LOTH. R. C...TnucT R WORK. ETC.I RE.A .._.W/f?'iJ.._i.C/_? . POSITIO V1. HE AGE. 5 F N BEFORE COLLISION MILE 210'" . INCREASINGPOOECREAS NG - ONE Eft OR NIGH A ANEORNO v n NO. 'A"" DIRECTION IN ONE S sTL IIIE DS r ,L VEHICLE PARKED 1 L. IF PARK wC?PEH r 1 I L _?L-l /? / / YES D -1 PRE -T L -I S rI i L1 r LA [D. oM :_ O /B CYCLIST h NC LK J I C 0 K CRO E 1 J O E ROAD SUfl FACE IL EC,O EI WEATHER (CRECK -1 .. CON TRIOU (C TING CIRCUMSTANCES U +MSSTANCES HECK 0 N R E E NO. x [ J R n GOING AD _? (- '- 6lEARSLOU 6 CASL O R NFLUIxC .,_. etcDOnuf,_ awl xG s1.45 l O EO FO wwnN. 1 IS c ELI 1-' T ING c u AND PASSING 2" t CRAINING 2 L DRUG LUFNCE I-, I T .! FH APPARENTLY F7j,,M FIGHT ;UqN ?L;] SNOW ] jaN ,.G '11CEJE [ I1g11TATE I I - G AGIO PFn rnn xc I I ?, Maa r-TAI A I V "-1 X' .,_ FOG _.._ X 5[ f S • -- 1 ... 1 T _ OR - PEnwTIHG l __IT IEC qvl_ - -- IFFT TURN I5 VIN. I Ur R PEC I ' IO I C 1 16 I D O TN ,O D G RD T.1 I ?/. _. 40, 5!GH J_. _ ,el I Sl.w xO' CIN-S IFY I [R ISPF IFYI ( I 16. PASSING SRFGARD STO ] ssmN VENAL N Clivl 1 ' I B-1-FOR >L TRAFFIC LldH? EONDITIONS DN(I RAFFICCONTRO NO iVEHICLE E TYPE OF ROAD I O)1L ONFOR MORE VEHICLE CONDITION -SOBRIE7V-' ' r ? OPPEOAT SIGNAL 1 Bit . 1 SIGNALS ONE Al W 17. fl C It 1SbKfl?J IDI I NO ) T YF SUj CY: ONF 1 NO)E IC . OR 5TOPSGN . ?BP OWAYN LIGHT . . I OR G x) I vA UtFEC,IV[ BIIAK[S 'GB ABLITV J IMrARE ? STARTING IN FO+- RAFFIC LANE )t I 0 N _.._ [ GAO U[FFtirvf HtAOLIG- r+n0 MPA TY NOS qf. .I SAPNT-FROM -J F EOFOSIt10N WSK ' RFLASrNN [D. Ll' ' INikRCHANGE L00 RAMP - ] ""C "M L TS . HOO SOB. [TY l)r? Mp BIN. IENTE.ING T AFFICI ` OAq[UONT{O f[ - ILASHING -SL..?.A Bfq _ .__. ' -. AtLI1 I -:. II AR L GIF . SMOOII+. _ .. / REHAD F DRINKING - I-j13 PACKING DARK 17.111 t r I+GHTtO RN 6 '. -AL "' FT ^A U L N[S r,r4 ruu ru u - .L .t xnrwn Orr +f CHEM. TEST OfJ I N ? I J I-1 I _, DARK-NO .... STNElt GHTS F OF=A ........ 11 CMAN -- ED SLPAn A,[D OIVI OLP O OF FELTS "--' tESI GIV[N TS, RfFUSfO OT+rF H ISPFCIf v 1 xs ] -F!. - n)nIH IsVeer % % TEST RESULTS 121 1 NVIS R,-NG.-c-SNA lB-K hvl3l ?GA,rxu Orl?CIHLNA Lr[I UW - l1Ck ANU O LOW PyySHI,°? .?I_o` MPfID[ F ..E I N M X ., ND NC, I ,,p I lfJ S J NI I ullyr5g. t, 11AIL 11 r?T ?B APPHl ?r Y // p i •i ''' DUPLICATE CCMYV LOCAL LAW [Nf UIICf ME NT AGf NC V'S CDPV ?l11IYLICAT ,1"."""I pI NVEST IGAT Uf195 Co" 4 ' m r ti _.. "1C? 3 [eTr '?,fidfE? 1(ir "i sw T L 4 $ KI .N n ' ?E 1 wit, F?? V1?H f I fV 1a4 1 U iV :,G f .,oF / No. POUGECOMPLANTNUMBER T UNIFORM POLICE TRAFFIC COLLISION REPORT Y ?eee T ?V, R W" In Tb? . t J rlE. . ry 4 ( ra •xer+'+rdnd-Ba-:' ?, ? Nz+E , J - w D DATEOFCOLLISION DAV OF COLLISION TIME COUNTY NO CRY NO. FNWA A L MO OAY ' i SUN 1 MGN % 1 5 3 WED Fw,, S FRI B BAT I SE 1aB 1 '• J ?L ? EE COUNTY S H 5 STI EETGOIIE RUR ?STATE ROUTE gCOUNTY ROAD ?CITY STREET Q AOMSLS. PREFI% / E 5 TION P SQ/! ?OTNEfl INPEOFVI N l.^/ S 9 L N 5 E W ?IN CNY OR TOWN W PREFM EO. MILEPOST O ? T LA?w PA ? ® ? ? Q •r/)/ C - _._._ .-.-.___ MILES OF_ . LL / 50 NAME ANO.OF STfl TO HIGHWAY INTERSECTING WITH, STREET OR ROAD I Y RAMP DIAGRAM pATA- T ON , f:W Q NONINTERSECTION pCLIOENT I NTER ON X RU HTEPSECTING STREET OIT flOAD OR REF (` I? /J ? E M I I CLS. ERENCE CR SSSTREETOR OAD'. N BETY115- ,J. ? _ STREET AND.! ?' ?_!E- ? STREET C)DE 5551REET DLST CE AND DWECTION FPOM REFERENCE OR CR O S PECIALC IHO USE ?/ ? ^ ?FEETS ? 5 ? W OF TI ERJINFTEJ ?HITA RUN COWSION INVOLVED: ?VEHIC-VEHICLE ?VEHCLE-BICYCLE SEVERITY NO. KILLED ! R iOTALNO ?VEHICL£00.1ECT ?VEHICLERPTRAIN '??/[:]STOLEN VEHICLE . _NO.INJURED OFVEHICLES ? VEHICLE;PEDESTRIAN ?NON.COLLISION ? HAZARDOUS MATERIAL PROPERTY DAMAGE ONLY OBJECT STRUCK (NAME OF OBJECT STRUCK-.OWNER. NAME) __ _, ... LOCATIONOFOB.IECTSTRUCK ;, ....-... EST,DAMAGE ? ROADWAY FEET ? ? ? ? 0. EDGE I _ DRIVERS NAME IAST FIRST MIDDLE DKIVERS NAME-LAST FIRST MIDDLE I FBICTCL SI99 PEOESIR AN CHECK)? ' R ^ / A ? I I .... J STRE 1 ADDRESS _. - Tiri s/' STREET ADDRESS ... ......... .._ _, .::. -... .-' ..: . V , / ! // - V E R CRY STATE, . ZIP COOS .. PHONE NO, E R LITY '•. .. STATE..... ;. _ -ZIP. CODE PHONE NO. d/ a>n 837/ Sf?"' /?ys E . " . , N .. _. STATE DN RS LICENS SE% GATE OF DIgiH N DRIVERS LICENSE NO. .: . .. : .STATE . SEA- DATE OF BIRTH 0. p q/S i!Jn MO. OAY R S /D O O• MO. DAY YR. DRGjRS OCCUPATION. FWM NAME PHONE NO. 'f, DRIVERS OCCUPATION FIRMNAME .... .. .. P EN . /?Gy [l S-'o qT S'3 1 i Jr y T T G ^ . . A ` Pf w . n CODES >113) C _j 1,H SEAT BELT_6_ 111 EJECTION CODES >1131 AL al SEAT BELT_ I51 EJECTION NATURE OF WURIES TIE RES FROM SCERE BY: TO 00 SCENE BY TO VEH. YEAR ARE(DOWE-CHEV.) MODEL(DART NOVA) STYLEIZDR-CONY.) EM. YEAR MAKEIDODGE-CHEV.1 MODEL IDART-NOVA) .. STYLEIZDRJCONVJ ,. V % O oL a5,,,g4wc:4 !1 P • v E VIN. COLOR LK: PLAT E F:O. STATE TRAILER PLATE W. STATE E VEH. COLOR LIC. PLATE NO. STATE TRAILER PLATE NO.. STATE .:_..`.. H 71 C/?3 H C -R.1 IOENTIFK:AlKAN L.IIIMBER.. .. - ODOMETEfl - :.. .. C VEHK:LE IDENIIFK:ATI N NUMBER E. S LT > E REGISTERED OWNER-LAST FIRST .. MIDDLE REGISTERED OWNER-LAT.,., ,.,. I.S ,.:. ... _, ...: MIDDLE N N O: O ADDRESS OF OWRER - ADDRESS 01 DINNER. I NAAIEANDADORESSOI wSU- HMECO.OR AGENT ., NAME AND ADDRESS OF INSURANCE CO. OR AGENT ENFOflOF..CNi CNARG .... CITAT N .. ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED cop'S _ z 5 SE% AGE STATUS L?q B EJECT: L• NAME' • .s /! • /F .CI 4 ?/ /? - ^ > 1 3 ' / C ...E55. S^JM , 0/ U P I NAlF --7BCEN[pNFROM TO DgES R,I I -- r NAME' T N T __ ADDRESS I i $ INJl1UESF HE RYfHOM TO N LAE ADORE SS F N NA R Vf NIVRN IOM $ NAME S ADDR ESS S, l? AWUR:fA SCI NE_ 11161 AI VS IJISf AT POYT%JN JIwAJRY CLANS I C y PASSENDEA E? I NOINIURY 5 DIs,Bl,Na.NJURY D PFCIBIRIW T I ' tDEADAI SCENE i " 1 T? n NON DISABLING PO [ 1U E O. Ni1KSS - 1 ` { _J E 1 I OOy pON INK lµ„1 EHRI O M L I. w S BL RY T NOT INSTALLED 1 NOTEJECIED ] NOT IN USE S TOTALLYEJECTED D UNKNO S PAR IFJEOifD 6 Sf AT BC WLTN FNLURE A UNKNOWNI EJECTED l ?f V=IQLIC LIAMAGE 11NEACHNOKCACLz THE NUMBER CF EACH DAMAGED AREA E%AAIPLE ° I1?[ ?1 I RU CTIONS: 2. ti11ACE Arvc4 OF SEYERESI IMPALT r J DIIgYI AAROWIS)TO5,1CW PHNCIPAL DIRECTION OF FORCE , DAMAGED VEHICLEN ; CE sPa O.1 _ I.G rRI - FaHSkFTCH t:G DAMAGE TDTRn LEµ;.MUrparva[s. ETC.) DAMAGED VEHICLc N0.2 JI U s 1- 1 r > -/??T..'.....?? -. ' a How r/?`-? r,?i-=gin 5ROOI II 111 U 11 ? 15.Trv 4 -"'? _, Id U wcer nwe _- ` ? T d 18. UMwcar rm0+ 1l Ovwwm __ ° .' , n. G.wlwn 10GEEMICLENU.1 rYN-INGD 10 THIN VE U DZYOFDAMACE:VEMICLE N0.2 IQDI3ABUNO ADUNODAMAAMAGE 30OTHER M V. DAMAGE 1 L? LI ID'' pSARUNGA- FIAGE :IQHICL[I Oi11EFlM V.DPMPGE I 00bARLIN60AMPGE JQOFHER M. V. DAMAGE 2 NUNCRCNA60AlAAGE 0 NODAMAGE 2_ rUNCTIONAL DAMAGE. 4FINDDAMAGE 2 F Q UNCTIONAL DAMAGE G(1 NODAMACE TOWEDDY !LCS ... EST.DAMPGE TOWEDBY EST. DAMAGE TOWEDRY EST.DAMAGE TO ':U A, LL:,,I ,L\ S Gr TO S S DIAGRAM OF COLLISION TO tt. Imo, 1 f_/ 1ORAW ARROW 5H OWING [now . f[ATUn[s NOATH IN CIRCLE DDS _ ' IL7-- ' I Llu TEMP Dn,.DInD.? Frciorsrw,cnaw t I _ ? i 7 - r i t F ? _ _ r T ? _ ; , I-W ..yLiIOar.ENrw,srM"RA'"c°fl _ _ I) Li 1}- ?- PrwMMnLEYExxa[Ox - _. r • _ DESCRIPTION OF -COLLISION - INDICATE WHAT PRORABLYHAPPENE..EFORE.DURNG ANDAFTERTHECHASH.(NCLDDE INFORMATION ROTOR DIAGRAM. EO.DRIVEN 615AR4TY REWGED VU BUTY PEOESTRIAN L , , C UTHIND COLOR,CONSTRUCTION OR REPAIR WORK, ETC.) - ?Ct _2 - s4 y f//r ?tir ??? i c ?, Q 11J cN X-. C/ c 7tL ---- -T? -?? L• L ?'_C.?,.?7i?1.6_E_CUl ?J.l? Sro i r ? i' ?:.Gr? ;alb t?._._ ----r--_?__--- - ~ o HEADE No. 19N BEFOM L SIO DECRE REAS NO D INCrtE 1 A5+:0 DE C ONSTREFTORH[OMVgYNAME ORNO NO.OFlANE3 INONEDIRECTION SPEED.4 ?E n VEHC LEGALLY ' IF PARKED WASEH r'?7 r ?. r{_I 1 i ' L j L _ O 51) PMKE?D 7 ? - Ll OCCUPtEO a. S -_ Y Y NO - PEO .) J r ? Now _ __ s ,Y --- 1 - Q -.-N. - F! I wt PED/RICYcUSr WASUSN G: Ir190Ew41t >I? A.Lltw ;ygyUJER I rgyg iyCV 6.10ZTF Tt t N .._ ?? ?ROAD SURFACE 1 E <A.FI '?WEATHEA.,.? ICx ONfj ?, „y?r_. CONTRIBU IC TING CIRCUMSTANCES. Mf 0 0 ; xy,y _._ ;onvETl,ve ,w w °" "FLU a nE cw F bc Ew ILS L + L1 _.. Nn _ .. _- Al ? T Lc ' DC] r°.i.° rl > LJ N°wvA;vlN rwOxi w[ rnU Y VF ( 1 FR .. R,ONrrurw _ - F - o _ AOaxo MgKwO ? r ' Cf f l° f00 r t E MH, .- w -, anon[ l I ti 'L.J y J Ox A, _ -- . ? ° ` J OrxFR1Y[OfYI t ° ?OMFnI C?iYI ? ???t .. _ . W M ? k t„??,??v! { ' °? I I l vllfAtx ,N,N T w roR swN so I OixFR ctifYT'-CI ?TL -f wwou oN T-- ! CiTED FdF l? Jr TFAfNC LIGHT CONDITIONS ..,.A VNIN ,.TAAFRC CBMTROI > F .. w.n[: TYPE OF ROAD - IVrvfC -W MOrIEr VEHI CLE CONDITION. VENC ICx Oq' :.,, SOBRIE TY GN , L 1 , .N1L9 - ! I J rJ °''ew > -T r[o FHK? CHECK Ef "o 2 [ 0 li ro1YN + I xr : I w ... _ ! f e 1 II J, tieo l . I . RIVING W1E Ll . RAVI wN q [ J,i _ y /\ [ wu U f ? L__ AA- p ,AK M f'" _... A r fAnCb > ?' , 1 UNA. - f IUITeI[ra t I>? INAFfrCI W °M N `-w ". N l[Y ..•. s I xE° m:..oo " . . ?. [alxanr ----- _ 4Mn,n ?ISn wC trt s( l y u I TMd u r giros runfo r CHEM. TEST - I--'? I _ Fl-AN ONnI ?/ ( /T Q t !? TF-vrx orNenlfa'FC ran oo-uM Drrlcen I I i ..._.. 1 h C, X> u- DrrvF 1[ 1.TEST RESULTS % w /.?/.(' -?. ?L/ fl-?nG JGiwp K ?- - [cY.CE MIS C IO.Kf urw.TO -I Frce/ waro[o LOw nMi II `/ w K:r ORD ?. [[f r, Miep Poor 0 D Y MTe .?•-.???.?,+r.[wwc M..wcxr Unce[rENr AGENCY'S COPY-TRIPUCAIE CCPY:NVEST:GAICFf!COPY ? d pt.G A ?IFCI. 1S _ J P a s i R t . F t , t k >? k '??ET w R.??.?-B'c'?c.firwr?„wa..?. L.>r"w?'4,19 ,.,k•„1... ..,?5.?,...-.. iL'?...:u^dir;r3...-.. ,.,?"f?N.=e..?, .«?c+: _,-," J ? :.?i WSP?1391REV. 31131 1 ( A ' ' - E "Jz _ n [ F? ?y I? ?J ?J .'rte S.'? VV ?j ???TC?V?JJY Yitl PAGE OF ' STATE ?)/ L ` I 1?f JO. F'Ul10E COMPU nT NI.Mdkfl -? :.r iq N fi ? UNIFORM POLICE TRAFFIC COLLISION REPORT 7 r. D. OATECFCOWSION DAY OF COLLISION TIIAE C OUNTYNO. CITY NO. 6PR A M DA YR. 5UN 1 MDN HIES WEO (1 UP FRI T Il °E 0 -OUNI / _ 04PB.V1 COUN COUNTY ROAD ?CITYSTREET ?STATEROUIE ;I Q AOM{Ly, PREFIX ROUTE OR STPEE[000E SECTION ?:C 'T"?f x-1? } V ?OTHEHISPECIFYI y 7 J rrY J lJ i - C T R TO N P REFIX EO V, MIL POST L" I Y U W N S E W ? IN W . C 1 l MILES El © ? ? OF T_.?' !iV A.) EjE_ Pl LL NAME SNO. REET.DRIIKJHYYA J INTERSECTING WITH: STREET OPROAD LL o R AMP OIAGHAM OAfA T Cn uu ttt i' ?inJ ON _ I O NONINTEIIJECTION 1 O?? ACCOENT I IAREAGE NTER ON IN 5R I %:RD I Cl, NTERSECTING STRE CNROAOORNEF- ERENCECROSS11FIETORfl0- N'• 1J . .ERVEEn ? 04 STREET AND STREET WOE _ J ( J` DISTANCE AND DIRECTON FROM REFERENCEOR CROSS STREET S V, FECIALC.DING USE MILES N G E S?' _60 FEET n CID Of / ? -• ?Illie FlUN COLLISION INVOLVED: ?VEHIC-EHLLE ?VEHICLE BICYCLE OTHER(WRITE) ?StOLENVEMICLE VEHICLE-OWECT ?VEHICLE-RPTRAIN ? SEVERITY NO KILLED . ( NIURED ,I?1? TOTALNO ? ? NO. t PROPERTY OAMAGEONLY r OFVEHICIES ? VEHICLE-PEDESTRIAN ?NON COLLISION ?HALARDOUSMATEIIAL U OWECT5TRUCKINAMEOFOWECTSTRUCKAN.OWNER5NAMEJ CTSTRUCK LOCATION OF OBJE EST.OAAlAGE ? I , ?1 o 4- .I?'LY O. EDGE ? ROAOV/AY-kEEi' ? ? ISI ? 5- MIDDLE .RIVERS NAME-LAST FIRS T RIVER'S NAME if S[ FIRST MIDDLE Ill B. CYCLISIORFEDE5THIANCHECXI T 4?/ f? STREET ADOREfi$ I STREET ADDRESS .. v C, 014 v E pyE/`IO_ CITY.. STATE -. ... . .LP CODE PH E CRY. .STATE/., LIP CODE PHONE NO. R 7 R N " C ENSE NO. GAINERS U STATE 'SE% DAtE OF BIHTH N DRNEPS LICENSE NO.. - ? STATE SEX GATE OF BIfliM 0. {(4 L f \ I ?1\ - ?l?Q. 12 I jY 7R O. ? 410. OAY YR. ORIVERSOCCUPATON. FIRM NAME ,' .. ....... ... PHONE NO. •1 .RIVERS OCCUPATION FIRM NA E PN NE NO. CODES >)] I CLASS A) SEAT BELT .Z 51 EJECTON CODES SI easy ,, <) SEAT.- SI EJECTION " NATUREOF INIum's ! A p ?.? I? N.IURI SOf ?. FROMSC VERY: 1A,.l: C +`' IAM TS A'L:? fFOLUi FCENF.Y: TO • VEH.YEAR MAKEI ECHEV.J CONV.J - (DART NOVA) STYLE I2 DH ( VEH. YEAR .E-CHEV.I MAKE( i MODEL(OART-NOVA1 STYES/2UR.LONV) - V, (pa /-K. ? p t ZNK. 1T V V E' VEH. C -1- .' STATE,.- iPAILER PUTS NO., STATE - ;- E VEH.COLOR C. PLATE NO, -' STATE TRAILED PLATE NO. STATE .. H '.. b UZ rj4 1 H C - L E . VEPC E.1 ITIF:CATI ?? _ 6q b t36`tZ6 I ?? C E VEHICLE IOEt .ICA 16N NUMBER, „. ...._ ,. ODOMETER .. REGISTERED OWNER-LAST ......:.,..,„:..FIRST. ... ,::... IODLE REGISTE DOWNER-LAS[ ..:. FIRST _ MIGOLE N OJ N O. ADDRESS OF OWNER . .^. ?...`... .•. ;. . .,. A00 SS OF OWNER .... .:... .. .. ... 1 K ? ? OFINSUR.WGECO O flAGENT NAME ANDAUI NAME AND ADDRESS OF INSURANCE CO., OR AGENT- .: CH E ..... ....:... .. . ORATION NO. -. . ENFORCEMENT CHANGE .. GTRT N .:... Oi..A ,t s. ? I' - ACTION LVED GDDES - ' 5 ' NAME, ADDRESS & INJURIES OF PERSONS INVO SEX ADE STATUS N N EJECT. O NAME: ??' (I l ?? I A - . C ADDRESS' D P NATURE OF REMOVE.FROM UURIES', SCENERY' TO A NAME: T ADDRESS' S eAI?I E F F ,IIDFIOM .NGUNIiFS S-0 RY: TO HF NAME'. I ADDRESS' NATGAk R M V N SffNE R . S NAME S ADDRESS E v11J I..'S ' .:i FI?Y? TitOCI 0151AIUS ivn , " 1 iIO ln G NE E ] 6 NON ?VSBUND O CLIOT RAR OTHTR P041fKIN U9 MO11CYCLEJ R n A E OD0 ARRIVAL D OINHWItAL ? IEVIOEfII,-n, 3. POSSIBLE INJURY E e. MIll'SS e ] ,UNYNOWN el' - A iT '? yy x_66 h` h YT S' 9 x T we "l?A.. 6i? 4 1 S f WS W Cl44I .? t L T }J? • ,?q T ? 1 ?;F1 1 I.NOTINSTALLED -NOT E:ECYLIfCD t.NOTI-SE i TOIALLECTED D USED ] PARD4LYEECTEO A UNKNOVIN 3 Uf-MN IF C SEAT UkLT FMLURE FJECIED P ;L VEHICLE DAMAGE 1. IN EACH BOK, CIRCLE THE NUMBER OF EACII DAMAGED AREA. E ].SHADEAREAOFSEVERESTIMPACT. %AMYLE { y_ t W INSTRUCTIONS: G. DRAW ARROW(S) TO SHOW PRINCIPAL. DIRECTION OF FORCE. i / I 6-Q I .. • DAPAAGED VEHICLE N O. 1 _ ruse rfNs SPACE FOR SKE TC. NG UAIAGE TO TRAILERS, MOTOHCYCL[S, ETC.I DAMA GED VEHICLE NO .2 ? ` 1) I.n - O O VnlYn 5E MACE. VEHILLENO 1 IC7o15AUL1uG DAMAGE ] OTHFII M.v nMIAGE E 11,1 11 AM1IA F'. IOiIIEx Cl[I 1 E 1[7 OSAtlLINOPAMAGE OnIFRMVO MACE SEVkx IY OFUAMAGE' VEIICLENV 2 DISABLING DAMAGE ] El OINEGM.NDANAGE ]?FUNCTIUNAL nAMAGE A LI I.I O UAMAGE ] F El ONAL DAMAGE .LI NO DAMAGE.,; ] lJ l'UNCiIONAI ^AUAGE < (] NUDANAGE DWEU UY ST.OARIAGE E iOlvEO BY Yi.O-A- E TOWEDBY j ,1„ EST.DAMACE f0 S I TO S TO e f i RAMOFCOLLISION DIA G .. i ' ; DRAW ARROW SHOWING I FI Hr,fr, Irxwxff HGAD...rAaD..Y NORTH IN CIRCLE oN°crr or mnloKOr•[r uII IenvmOLS i .•. .•?1- t unuw.wrlMr coron vs _ . .-. '? -• -•1-- 1 ?-? __ •_" J-- CVA ['r<ONS)xu[vOn ANw ,. ? , ,I -1 I • 1 iI ] L?Ar?.ADF.ILL.DIHrUr ,MrADr L J --- I I <I :; . _ .-_ _ _ - - F FxUWYf KLf.NUESTH,ANMH 77 ,- _ _ : L Axv AlrfxcG Ls,oY. ° I < I . __ I Ir t I . DESCRIPTIDNOF FIND-CAT-WHAT PGO.ABLY1fAPPEIEO BEFORE, DURING AND AFTER THE CRASH, INCLUDE INFORMATION NOTON DMERIAN,EG. ORVER COLLISION' ,1 DISABILITY.,Epucco VISIBILITY, PEDESTRIAN CLOTHING COLOR, CONSTRUCTION OR REPAIR WORK, ETC.I. - Ii r (Ty / 1 - 1 -- r A '-oOSIT10 N BEFUq COL ION '. o. of LANES PtE DS VENI<LE IF FO IT NE1. -A.- O. FMSt pIN INCREAS NG OECRE431NG ONSTREETOR NGIWAYNAMEORNG. - IN ONE I .Ell ON LEGALLY ARKEC AS EN. OCLV SE° N 5 E w '.J LJ -? I I_J I (? IF ' ES NO - ES NO ] l ' ...x 1 I_ I ) _l I- f r _. I L l l AL O N ? ___ _ _ _ a , H . rM=E fnHNLHI_I _ _ DYr.I -To-. - '- P( IS CYCLIST WAS US NO. _ 1. ] ] ED 5I IU N HK 8 ESIG A ° ) I fl? -.l W I ' C SNA 1 CYD lD xY K W RDA G SuR ACE, ICIRCKONM ..•WEATHER GN_ONE. - . ^ NTRIBU - IC T NGCIR UMSFANCES • RECKONE ONMO 1 • .. I "pNWFHr HI LeACnons< nEM n e O.]v[Hlek! It °I YEN RIVER . I ORIVFx DNIVER O M ry DO G „ 1 O] 1 1 I LFAR,CLO ? AS VDY I O.] ( UNDER ,Nf LUENCEOF ND ] I TOLLOWINf. JAL J O I j D'.F -WAFN 1' I IN El 11.CQ Si11A10NT Al1EA° I] c;vcnTAKINL . WE .OYFHC I ] I H?MIHG _ ALCAMOL__...... ] UxDE111NFLUENC.0 DRUG' *o . _-04CL0 ELY ,. AKING IS I Ov Cl T 11 LINE 5 --q,___- 1 AHENTLY 5! IFP ?I L-.fA 551NO M !? I SxOW - • - SNOW MG ----- [KCEFGSIAtEO ?]? I _41L IL_ _ -._.-._ EALING I° I_J..- J.. InNAL_ _.,.__:.- _ , 1 '1 PiIOPEGYARKING y I? !. LOCAT N. RIGHT TURN l? LEFT'IURN l L CE E f00 L I I F I CE[D °! S. (sA FYF( 1 ILO M 0 U N \B EI A N ;f C YE€WP 151 "AK11 1 I' ISL . I _ S I -_ - __ I I °D F TC\[ NT Lz I 1. GU t F ll (.. . LLTUNi ) SLOWING 1 6I . , OTHER 1vEC11Y1 OIN[RI ICIYY (,' _ _ S ( 11 I .sNlf t ' ) ( O1GN 5 G Al TUY I Tillf I C I ( 1 ID TU)N _ I_..I iMYEO fOP L Tn P C f 11 H CO DITIONS TRAFFIC CONTR ICIIELKO H . OL <f 1 D] TYPEOFROAD VEHICLE CONOI EION SOBRIETY 1 LEI j ST EDATSIGNAL I NO fNICLk 1'' 1 sIGNAI 1 IC F<K ONC OR NORFI . IFSf ,}f65?@DI ]E ICIIf CK ONE, I I ° H.T. SIGN Il ON 'NO] I NO Y j1t1Y DI[ C WAY 1 i . IBrI R-1E IN `• I \ 1 Ir T I 1 rur L _-- ._ OADINAY '.I Y'' nfl ECrWE Hnn An leer°'' v nro .10 1 T 1 \_._,_... .. ... I H __ > DAWN ] RLD _..- 1.. ... __ • Ux l3. -IMPA NED _ .. ..: -111.1-1 ]. nk.E ] C W1 ) lllip Y ? V 1 • STAIITINGfHO'A SIIN ] W,SK 1 ILASNI --_- I I 1 .-. NOAD LGNtS NOI IAlI11R .... -_ - PAIIKkDP0S1110N NL P • Nlr HfrlAVG1 it .... ctWE - T Y ILNIEIIIN(1 INS 1lA%UNG IIAMI AN LIG1115 LINK_ .'., ._ 1.AffCI H UARKSIRf [T "IF - ILASraM1G •' NIIF WU,111 1 IIAD 101 I AIILY tIGH II On 'F AMSLr1 6 115 n.lCN1N6 'I , rul sNmm? xl IN nn xKlNn I ' ' nARK-SLF.... n0 rl lf r F .... ?__ • nM WAr -lIl'1 CHEM. TEST Iv[n -- . TEST f x, F• Ar 1 Nn ) H O ... SIGNAL R aiiir`li uOHT{ ICI ' L. .. . I n' xlPwl;eltlr7ZfArI-' rnTCmrN mnnn lx?TxlFn AN _ '• " mnln Rrlr.H •' S •, i - i Y ] 1 Nl0 NO lltFl. 1 .... H[I UKID I --- " WNID ^ r TEST RISIILTS 2 ' - - _ ( Gorr ? r r NA 1 IV VII,CIx f NAk nM,K I -=NUVIN Nvr xV 'JA U_R, II1Ifj _ :11 MV . : r n _' f _--I_ P . dla'???i?M \ •;tr ?v P a?' I 1 0?0 xi Eb+ C STATE OF WASHINGTON PAG t OF f No. ??FY J7?' UNIFORM POLICE TRAFFIC COLLISION REPORT POLICE COMHLAIN(NUMBEA ri 'V 1 1 ? i ' ? t r :: K TIME COUNtYNO. CITY NO. FIIWA i D AL DATEOFCOLLISION Mo D YN IN I DAY OF COWS MaU hies ED uNn (91 sAi T aUl 1 2 ] 5 J` fi N F ONquRI r Z 0 FAN F? FAIL IE. I COUNTY ?STATE ROUTE COUNTY ROAD ?CITY STREET _ Q ADM CLS. PREFIX ROUTE OR STREET CODE SECTION ?/SO I 11 3 ? OTHER (SPECIFY) N C.7 LEPOST M Q i0Y/N CITY OR 1. f MILES N KI ? ? ? OF I PREFIX ED. //27 C' TAM ANO.OF STflEETOR HIGHWAY INIERS[CTINO WITH: STREETOR ROAD LL -AMP OIAGRAMDATA T ON R AD OR REF I O NON WTE0.9EC / //// a? V'? ?? ACCIDENT MLEAGE LODE O N ER xRD INTERSECTING STRE OR T C. EPENCE CAR0595TPEETOfl ROAD . LA ER LT 703 0 N /aiREEi . DMIEEN STREET ANO.`' F S SPECIA L COUINGUSE REFERENCE OR CR05SSTRE T UISiANCElAqNID OIPECRON FROM I,??--7?- e.D LJFEET ? S E W OF _..N lX/??U.../Yl Urv S ND R FIN EVERITY ? ® VEHICLENEHICLE VEHICLE BICYLLE ?OT HER(WR TE) ?HIi6RUN ..NO KILLED COLL ISION INVOLVED: I VEHICLE OBJECT ? VEHICLE-Aft TRAIN ( ?STOLENVEHCLE No-RED TOTA OF VE I J LNO HICLES © ?VEIIICLE-PEDESTRIAN ?NON COLLISION ?HA Z RDOUSMATERIAL PROPERTY DAM GE ONLY T STR CK ' OWECTSTRUCKINAMEOFOBJECT STPUGN ANDOWNEf1S NAME) _,. _ N S E.: W :.. LOCARO OF OSJEC ? ROADW Y FEET ? ? ? ? RD EDGE 9 D DRIVERS NAMEIAST :-.. FIRST MIDDLE An-vr14 A <ucLt - D DRIVER'S NAMELASi FRST MIDOLC IF bICVCL15t OR PEDESIPo CNECKIO B2o u I LLe T7 e R , - R v STREET ADOPESS '.::.:. , S AP 3 g r 50o m Le E CRY STATE ... BPP?COODDEE PHONE NO. `[6560 E R CITY. : - : - STATE :.. ZIP CODDE ,OPHONE NO. 5ESV' '. "( 00 N 1 DRWER.9 LICENSE NO.. - STATE SE% DATEOF BwTH. DAY R N DRWER9 LICENSE NO J STATE AA SE% DATE OF BIfl1H Y 0. 53ZfU1 GCJA . Ca O. ? I ITV YCJ/1 _t S 31. DRIVERS OCCUPADON FIRM NAME ... - _.. '_PHONE NO. C? 7 M Aa,7.Lxt ? FbW C R? p 'j DRIVERS OCCUPAi p•?tV ?e ? -r 6A S . .. ?,,? 5 CODES > w ^L SS___, TAI SEAT BELT.___.. 1'I EJECtgN F 1 EJEC110N_ CODES J IJ cuss-I_1AI SEAT BELT I DRIEOF AJQ A' R E WJURIES T 6C EMO E `RO. XCE OMSCENE flY TO NE FA VEN.YEAR RY' MAKEIDODDES El" MODELIOARTNOVAI STYLEIZaR CONVI u ' YEN YEAR. 6 MAKF;:IODGE C"cV.l C G MODEL (OAATNGVA) STYLEIZDR.CONV.1 >K ` -7 zixr6_9A1A 0 U (?a v 3 nn n4/ v E 9 VEH. COL UG PLATE NO. STATE TRAILER PLATE N0. STATE E VEH. COLOR LID, PLATE NO Gv3 ?5 STATE A TMILER PLATE NO. STATE U ' ; w1?. 1 Q L ` _ V H I 1 M O0.-MILER DOgZ2?N??oS?o DOOM H..... ?Zo?o C `E VEHICLE IOENIIFICAiI t-AL4•DO4G2583s t°? E ?' •- " FIRST ..MIDDLE .'.. REGISTERED WNER-l t N n . * LM REGISTERED WNER-LAVT ... M A lt'M SC of * 0 O E ? S? O t L. I A7L1 D• T . - , ADOA 99 OWNER ... ....... .. ._.. 0(o0'tj_1nAAa,Gtiin S@ . .' Z ADORES OF OWNER ._ _. .. ?..., ...... ZAZ7 51LV&IU E`GVA NAA OApORE59 SU C CO.OR AOE T .:._' .:• NAME AND AODRE590F INSURANC'CO ORADENT ... ..,.. . UI A N :.....•. :.:.. HM CHARGE..... .. ....., GItATION EN FORCEM ACTION . n ., ENT ti ?v l.c'? _ Iv lu i 5 _ D CO DES , - g 5 NAME, ADDRESS & INJURIES OF PERSONS INVOLVE SEX AGE STATl15 EJ ECT. NAME 7 5 ?t1-SQ ?ut?so (0 2 1 I f C ADDRESS -Dc?-2?7--.,?,.a.eu/'` IICMOVEDFR M U p HAI W+E OF .CFNE BY TO vJURIFs A NAVE LJLLL?I/u?.I? -- / L f I f N Anrn[55?? w I I T S E S' 6 T iF 'tV, D T £AI„ir'i A lll >ai $ Ix Y ?:u ? h M1 t( t (d ti jp +eFI?I?1E? YIeP'b, lord ,r -"sF l _ ' J _ .yam ] MCI] ( F ?t J("/aU •.-.-.L?.-4>tir.- ?•" ?p ' MPACC"ti _,.w:_7? 2. SNADEARCA OF SEV ENEST IMPACT. - Y INSTRUCTIONS: DNAWARROWISITOSHOWPRINCIPALUHECTIONOFFORCE O/ I G I DAMAGED VEHICLE N0.2 DAMAGED VEHICLE NO.T usE TNIS SPA E FOR sKETc cDAMncE TDT ILERS. n Es ETG i'33a; N7 1 a IF Rte, " _ ,; A, y Amv s} .0! IS. T.u _ MOT, G I 6 T B k NI. ?KtJ I .1 11 0. ri - r ` ( 3 M SEVEHITr OF DAM GE. IOTIER ENICLEI SF EnT OF OE' E IC 62 ; y ND ' ] ? ? O DE O aGE Mm° O AMAGE 10 DISABLING DAMAGE K? OT DAMAGE 1? DISABLING DAMAGE ]? O OTHER M.V DAMAGE c NCTIONAL I ? urvCT ONAL DAMAGE ( ? N DAMAGE a ] - '. 2 ? FUNCTIONAL DAMAGE ` NO DAMAGE [3 TOW N n 1 TOWED BY E E BY. EST vAM vF TOWED w ih o MAC [ s 5 TD To4/e TO ..yy o Y•5 \ ?A7J1 I DIAGRAM OF COLLISION y' I i i i. - - ,CS DRt%W HI HIli CIRCLE r* ? -3._ ? ?#.! ! II } ? ? I?/I?-'' •?I I %ut P(DEf I D.,tG,f DN ,KwrF4 , .KIDM,R4 K y NNfOw }, g I i 1 ? I I a a G"K' y DF,LG DM,DNa T .?.\, 1 AN FaIrE? ..__ - are u R RE R .Y•_,t-- V I-r-r 74Qe?, Hi, J h M DESCRIPTION OF No GATE WHAT PROBABLY E E ec Dunwo Ar ?E ECRASH, INCLUDE o 0 o AGRAM. EG. Q RIVER D E F RAN CLOTHI ic; O. G? RUCT ON Uq E 1? ??.ETCI y a p, COLLISION DISAB,] TY. NEDUCE Y S B \\ ?5 MR.`Heclg? wcis f('(titi0/ir29_ gaKfd on?? R;_/8 El?}ec--tK?n9 Y § ?X? }JFe_CTUR.v?-/Je-/ost___?onf/Co/ oF`..?tis __vc/(i.c/e? Hi:S e4/g _ ?SYA ; !`he_-_iKOad __eh fle east a<il?e o e K"rib C?irL rr?¢?_ks w?eKFC%?ab n {'ox ?iv4y T/,e-_X" 0'-...cea c- 9(?cAcl`e'•c Px.,e ? / the , fi¢'c :.G 'i I{ 64*-v_ittee,-- he__C.gFi?. 'C?o ?,,,,?,,, - i •F' e- . 9 a i s7` a.n.oJl'l, ea_?-.?' G 2 `??. a one ?s /e__? aio/ . b ? ...? EPEl.S PAR. POSITION BEFORE COLLISION "I' NONE DIIECTION LEGA o N GM a -' a PO51E ¢C oc[ YNAIEOINO. SAFE E E yy?Jd` UP, t}? HEADED INCREASING DECREASINO p 7,' /'L . O - - - { n yESFNO ., NP. PEO. 77 L77 LAMA r ' , c Lsr O 1 E 'I i Ar ]L: SHOULDER Llcgossw°, t I o PIKE B7 ¢r TouTE 1. EA2 _ N SS FIE K r-J l- ROAD NO., SURFACE G•EI "?tn$ . ?.... WEATHER =- CONTRIBUNECKOrvioCU pST?NCES , CXECKONO ? T T , '' ¢ oNEI ° c p.A - `` `?"??? DRY R Z", R j • • 'D DR VDEj E T ^ 1 ST E o. a ° 02 [-j G EAR RtR1C/ AR O T O ND , NO UIDLRIIFLUEI ? n OXr ! x?irW"Sf15L It?1 1?1 uMGQr? CE F ?U=oaS-445FSr - I.zJr=G GG. E Lr ? y+? ^ , m" ?. 12,E NET 2 1--1j Rw NING_ ] DRU°5. CEO n••n_ _ R_? S ESE' T 0;? G G EIGEEDIIED ROPER pC L CSA f?;_B ;` D O IG?J O[CEC ?Ef-I?G ?5 i SE TI GN ?7GVI i (. SIGNAL- d X r 1-I I c G `S ' ._S[ ] I 1 G_ - rill S ?IC RANE > A ( 1J6I 1 I IS DoOE G RIW l_-I r_I 5 SIGNO. UD G.. I - uB,__'i I F it tt' i 1FII T E f clfvl? Ol SP If 1 DE: f 54 P r I O EC L. C iq%F, fIO FO +•T ( .ITIHE" . J 4 '? .Ilan , NAL _ I1 -. AIDN LI HTC NDI710N5 RAFFIC CON7R0 G E. TYPE OF ROAD VEHICLE CONDITION. SODRIETI( I )BCG ovP[o ATSA FAI' M ONE Es1F4Rr5?im O4I I<HEcK Onn oi+sTw slc r,ry C ECKON 1. N 2 E C E 02 CHE D °HF I O.} ;55J ( _.. 1 r s 1 - 5? 't I 1" o.'- - .. _ InDAn urr 0 El ST...D E. IN •Ln' ,J LANE ` rUG I) Two 1610PAIIIEQ. - c l 1 x ° Bnn EL _ 1 [ 5 B -' E H U AXILIT ^ I Jl ` I ST 0 Fq0 >;* I I l AWN ] SIGN v _ ?, D L I5 _ -NOT IMPgIR;p__ ED P° T°N E f I E flCl lE E IN r"i - '•-( HIND r NlC , NBO S° J a nYGE , •_. DOECTIanrs °,.. _.UNK l T F •• ;nt K RED 0o R , n[• N r AD nar ._.__ r? ._, A. HE t IJ.IO Tb UN. ET j6 NNERNO ° _ _'_OII SMOOTHM v1 BEEN OgINKINC L._?16 .J. KIM6 dpi r TS t( 1 sePAnw,[Ut .r.. - yc,? In NO CNEM. TEST i 5 01116 1 ° sD L -? N o f Iv Pn ``s J ARK- O +F C[ 1 TG bME[ 0179 - ' I T CIA J f-_i D D o0[FECTS - Itit X(FUS[D _ ,? v ". O IY C - a .a ... • "u ° 'Ew % TEST RESULTS i 2 ED 'A.NClL I (frlO lrNGO FIGFN'b w4 ANK E.- NO oLDt AIIIII r -- DED fTIGAlIN4O(Fr<[Nf /•11ANKNCI N., III Dul% o on novE a RDa E i f I DISTRIBUTION OICL SEND IINGTON TAT- PATROL-OLYMPIA. G pII TORS PLICA I E COPY ' LOCAL LAW f NF OROEULMtN NT T AGENCYS COPV-Tf11PLIf.ATE COPY. ' INVEST INVESTI GATOR'S CO OPY ? AN ova pj? I 't l ."JM19r - I1' "•...Ewy?,. A•,?'^z"'k ;St Fr°, Na+' ._I I 1 1 P i ) I ! p, I I i. I A I _ ?? 1 nk ?J'M?i ? 1 } a . IM ??i?7v a?" '' e? ? V ti,"s ,j ? a ?iY . JG]? '? ???'a ?:' ? ? ?4 ? ? r w ±??'• ?. ? '? i ' I ¢ r _ 11 e ' ,:,.,' ,- i ," SD :'y ..., .tgvl B?«,_ tY_•.w. .t.i .s-d'..*, t ?z - i : u...:. A ? : '' r_ . IR . CH BOA, E T IS N IABCR OF EACH DAMAGED AREA. 2 SHADE . ....... MvLE EAA - INSTRUCTIONS: F E . AREA S. OR DRAWWARPOWISI TO SHO P a [ •• C DAMAGED VEHICLE N 0.1 W R NCIPAL DIRECTION OF FORCE. USETN-ACE FOR SIIETCx NGVAMAGE t°inq Lens, MDionncLES. Elc1 DAM Q / a • AGED VEHICLE N0 2 f ,? - 1 ]M ' r lI' '1 N R. P r I5 am oo v of . ] Noce qm a { ? u ] ?, .:. 1 ( U^ri. w .r dI 16 Tru 4 •I? $ 'N3 3 SEVERITYOF DAMAGE. VEHICLE ° SE VERITY OF DAMAGE I ` , u , [ 1 • ! IT. Ca -N 1 r ' : DTNE VENCLEI 1 DISABLING DAMAGE 1 ]LJ FUNCTION L Ems', g Enq D AGE I ?pISABLING OHMAGE O'=V. G •??`.1, NDD G ? g1TY OF DAMAGE V CLE NO!' DISABLING DAMAGE GE M ER ] fk ' " I Sl 11 ?' TO D J'? ` I P k ] F UNCTIONAL DAMA GE A LI NO GE A i17NCTIONgL DAMA GE AGE ? S O t •, •. ? 1 J TO '- \ ?/ C. e DAMAGE' WED BY v\ S l I O . S T TOWE 0 /1 EST.. MA b Y E ?^ t'4 ' a•. L1, ] DIAGRAM OF COLLISION ,. j:. ( -'1 ,__._ '{ rl r _.? 'L ?_.. II _ ?. I. 1, 1. 1 G'I.IDfIAW /IRROW SHOWING I. +`y'• '?'-- -' NORTH IN CIRCLE ? Y 0 J AAIAEATCJ .1 . DF .. I r_I _. -- I ? g _:r1Y. Ox TINr $.MY' Le 'ED I .? I I I I ?._i? 1?•"'_:' L ?? i + , z 'v'r. ' - _i ICI I 4 ~ ''I'? v g DESCRIPTION OF COLLISION IINDICATE WNAT Nw ED TIE UHNNG AND AFTER F} /.1 TIONN ONGn `OnIVER Dlsge urY bri REO CEO E pF ITY EE m AT ' . . STH qN CLOT Na COLOR. CO R CL 47- µ q e G Il E i iT?rj M AX L i'1»'sl E ..?nl PDSI71ON BNFO xE D E COL LIMN : LAI NA? ' .. , vE ? .. ? y y } IN EASING ECREA R wN _ NO. " E I WwY M FOR oNE .'.EC..-,. IN Tao q P[ AS ED OCCUPIED ,, ` C 4 5 S, IN . y , FD OLEJ- DR S xc • f ? L7 [ 5, $p Er D D G. wqs I]SIDEWALK E w _ ? / qo ? - 1 E F J 1 LDEN'??ROSSWALA Si- `1 5G 4 CRD-K k' ROAD SUR FACE WEATHER IC EC. I ILNE BICYC CONTRIBUTINK CIRCUMSTANCES _ OT ROUTE E . - grvE I • 't ' D o;... FC ONE OR X 1 pRIVER F -- I NO tv[ { .I y , ?-'• '. ? G,VSF EA .C _LGE LOILIG) 1 N R INFLIENCEOF nN ? TELL' NGV (? 1 • F W P G E Dn -?5 ;? OIT I vI Aq ®'r_ E '32 Z t. Wh7^.° - RH ] 'IT ] NING -? -- p ?+ S _ NOT, LUFNCE°1 f-? n]n HV.. nBn A LNT[v LIx[ 1 A ° ?]? NO U t ] SNOW ]n SNOWING _. 1 sECEED NO TAT" f ML GTD - OPERPARA xG 0 v n? ... f ,•I.E LJ4 CE oO . EFD L f[ 'N E R I- aAI14H.. I• CEE° G E 5 ?1 '- I v 'I I I I aA? LE R LJ D 1 " q , I r • G ??F?EC VI ?ER - i i•IOF 3 _ Un I_? DE FfycTI [ODU FE TgA'I ^' ) TO , III I -RE ' S C[ ;LmP GGQ LST I?IB? G IOD S G ?y^ xr ? ° I [ 1 HT CONDIT CI.. 1 U' GMSG SIG, I h r l LA I L 11) 51O 0 ? 11 IONS RAFFIC CONTRO EC[OxEI INO.]V[IIICLE ? vE E TYPE OF RMAD ,. VEHICLE CONDITION :SOBfliEiY ? ] ICNFCAO [OR Oqf. V Q? Ir CIF 1{ x(r , TRAFFIC .. DE E] ATSIGN L ? +p " .' . .. • I SIGNALS ? e ' 1 1 ONIEWAY NO] N•I?rMBMr( 0 E IC ONE) ?. DR STOPS GN 'x ° ° A e _ { \ Ldlln cNT1 -._?_' 11 O- -. I O _ _ ?.? orlV -mod] Y _7 I' _. I" r?. slinl(CS E ?J IdEAUI E`L?r 1 S ? W 11] ROAD a-iJ? I?-10rrJ•L'RAFT C LM1E ' . 1, ?• 1 t ?! Ir. SGN G . LURED ?U r ].---a.. LxU G IS_ ? NOII vA1RLE1? OB O ` (( C [J11 'PSAAFT..SIiDN r"1 J I . . .. - D I[T S ? f I eE UG RCTY LOOP RAMP _..._ J PEAH _ IG S _f.. I .-N I I F ES OT 1 ' I 1] F .11-RG TFA LLJJ fLLLL?uJJJJ?1 F pl AEI 16 N. d I F.ET I 5? ,..v 0i_ L : I ? CHEM. TEST I s IT s? G R 0 ?, 1 e MO E - io I L ? G r sT EET ucxt: "Al 1 sLrARA i[Si GW[N . _ ., ? f OT FR ISVE CIFYI Ni . _E.._ " - _. ._.... .^ +-, . -'_. ..I Drvmtn ]I 1 NO U[FELTS I TCST nrruSED ? ? 1 ::: :_ _ 1 r+ ' ,•`: t f Vry _ G r fi . 1 lxeN IVeCIF VI - ..,_ J, ?.I. I . J A ] JIOO '- fR lwfC iv I r • C ul A _ / , . F x° POLICE UIY C i k 9L TEST AFSULTS ' LIEl " A.-A-1 A U rv[D 1IVEp f0 p , A :L ISl A?NDOV CCNSN.MEE ANA X t .1 NO C ~ '- ? I^ r]Dp •? 1/ > A E UAIlO T ]m ?? APNIOV[U BY AlE L' 1 v. E A? i ? ALC •• DUILC.TECCFYO LOCAL LAWENf ORCEMf NI Af fNCTVO'S COPY ETPIFL CA nVAINVESTN6A ?OfiS OPY BI •, L'' L ?? R 1P '??? ? 1 ?R (1 J 4 1 1 IY -1 1, 1 TA ,E I t U ,U't 1 ply M tr '" ? t? I t fA 1 ti L y ,+ ' , ;, ? ... V'._ ' ' rc.P L°I z ,. > ? „I, ?T?f E , . Y E ?y +fyJ +S?(IfM1 N .IF . 1 M.'????I.i :t k ; .n ? n ; y g ;J.? ,, -?.? F.',ww??rxxm. 'LQ7,., •79 .L 7. .,. ? Y 4" (?.;:I r F 11 ,, ,I ? , CENw F< M??r s ? GATE OF COLLISION OAYOG COLLISION TIME C OUNT CITY NQ.-:. .?. 0`fIBAN -- Mo. OAr SUN MCN I E t pR FRI SA1 I S A OHOUNI ) T 2 J W 5 s ?- PURAL ? NTY C . ?STATE ROUTE X COUNTY ROAD ?CITV $LREEi Y _ O OMLLS PREFI ,POLITE OR SIflEET CODE 5 CTION .. Fit {C ... :. ._.. -.- .. -: .•-J IETC?SaIV ?OTMER (BPEGFY) ? N ..7. '' :^ _ .. __9-?f D r ..u.• ?? . L ? CITY OR TOWN .. .. ... - IN W PEF% EO ILE POST : 1 /. H? N' S E W O ??: ? C bHWAY NTEnSECTIHGW TH: STREETOR POAD • LL R AMP OIAGn MDATA 'A ; E ND. USTPEET OH H .? :.. ?? r• ay -T ON _ , NON wr.M ACCIDENT I MILE GE TEIT NOH %fl0 NTERSECTI 6 STREE OR WAD ON flE, CtS. ERENCECRO.SSTP E OR ROAD 4l P OETWEEN STREET AND_ THEET CODE Q 5 : OSTANCEANDDINECIION FgOM REFEREnCEORCgOSSSTREE-. '"^ NHS EGL WIVOUBE br F . ?MILES N S E W ? _ ?-rT' yH r . ' {ir?wa 1N .'... OFEET OF ` ' V i M1 SEVEPITY VEHICLE-VEHICLE ?VENCLE-GICYCLE ?OTHERIWRITEI ?HITLRUN ? NO.Ktt1ED ' ,INVOLVED:._ - .. _ COLLISION T -TOTAALLNO ND ^I ' I VEHICLE-OSIECT ?VEMICLERfl TRAIN _ ?STOLEN VE ICLE OFVEHICLES VEHICLE PEDESTRINI ?NONCOLUSK)N ? HQAROOUS MATERIAL NO NJ RED ?P OPERTY DAMAGEONLY .,:..' OWECT STRUCKINMIE OF OBIECI STPUCK ANOOWNERS..NAME) .. .' ...' '.. ..:' LOCATION OF OB1ECi STRN CKS^.E;;LW ?':?.; c,a? EST,pAMAGE .. .-._._.?_.?-.. _ .. .. .. _ __ __ _ ____ ?ROADWAY FEET ? ? ? ? PO. EDGE s __ FWSi.-. ter-'-MIOOLE. NE 'NAMEiASi-• . , -+- [MLNER SNAME-LAST FIRST MIDDLE'TF._BIqYCLIS' ORPEDES'TRIAH CHECNl C3 "??Yr D : • . -, _ . UST?I?I TNA _A v STREET ADDRESS' ..• `":- 103 IAn l L ^v'C / OJ Tito R : STREET ADDRESS ... '- ... - .. ?'_ • • . E E -HE NO. CRY .. . -STATE ._::. ....IIRCODE-._'-- PHE NO, A . . . • : O ?11? 'IOInJ :: ... N -' 1 E DRIVERS LICENSE ND.. :..... -... STATE SEX DATE OF BIRTH N OWNERS LICENSE NO.. ..:.. -.' STATE.... ..5E%: OMTOE OFBIRTH YR 1 Ay o __ 711 Wl9 t1 .R O. I .,? DgNETi5000UPATIIXi FIRM NAME ..:..: ... :. :.: -PHONCNO. R "1 DRIVERSOCCUPK-H f fIRJ. CODES/ lOl CUU MI SEAT BELT_51 EJECTION _ CODES >1.21 LAU III SEAT BELTSL. EJECTION . NATURE OF -- - - . .. 1_ NATURE INJURIES .. , • ''I" f INJURIES 6cENE VEH.YEAR TO 8Y: DOELHEVI:MOOELIDARTNOVAI .. 1 ST,rIEITOR:CONVJ MAKEIDO REMOVED N- VEX YEAR 1 MAKEIDODGE CHEVI TO MOOELIDART NOVA), STYLEIRDRCOIIV.7, . C O STATE - ER PLATE NO TRAI .. STALE [ 1 E VEH. COL 'R UC. PLATE !.O STATE TR LER PLATE NO. STATE H VE COLOR !N L . _ _. E IC ATION NUMBEn OOOMETER E>? L13' Y9 i C ODOMETEq '.1.. roE TI ICA VE C E ICLE. O . . ' REGISTEPED OWNER-LAST: .. .: _:..: FMT -111.1•F'-... MOLE. .•. REG*TERED OW ER-LASTS':.a FIRST -J - ? AVODLELI .?... N O - .. '... _i I 'O• -Y- .. a..:... ...... .+.? 1.. u_. :.•GZA.a•1 ADORESSOF:OWNEfl ADDRESS NANEANDAODPE.S FINSUnANCE CO OR GEM r:! ..-! ., NAEANOAOORESSOF SURANCECO ORAGEM .I.v+. 1s <iJN i::,l. } O '•, /..:? CITAT 1.1A .tI . CHAA ?' , . .1' . f.: xr ....,.•. _- _._ _..: ,. L i L C CGATIDNN ,.a ENFORCEMENT,. .... . . . . ... ..ACTION r A R V ` CO DES .1. .'L ' 7 a s r, ! Ei s J OLVED '• ; SONS IN r-,. T. NAME, ADDRESS & INJURIES OF PE .. SE% AGE ST US EJECT. AME' riry C ADDIIESS FI R U.: p OM NATUREW SL FlOr F IFUUNES d h C CFNt n TO N •. AME: ,T "•S AOORE95 EMOVf DFNOM NUHEW SCf NFn 'TD T `8 .... NAME' - - 'S ADOTIESS - ' E : uiHF n TO s . I f MISIATD9 1]151 Al Pp.Y1KYJ IJIINJURr c,A% HI SEAS NCIT 151lJECTIdJ 1 1 PASSf .R N1.11 N t D( 0 T CENC 5 DISABLING INJUTY AgL 10 6 NGI DI T INSTALLED ] 01 N USC 1 OT CJECIED c1CD V TOl "I y O " NCYCIL^i.+ % I ! Oi11Cn Ppp,,,?DgH ( Y ; DEADO ngNAL YI OSITTAL IEDI N ICNM TI J n ] POSSDLC NN V .. , ]U CD U NIOVR! r JCClCO D. PAnt NL N IF A LINK D CC 5 01HfR -. EWIT?ESS 4 OTILYCIfI . HR IA J 9POSIi1CM UNAHOWN _ . D 59EAT DFLT fA LUn[ ED EJ(CT rpr ?, k t r[ F4F f f1 _ .lE ?? !r«• ry ? 't J Fl IT ?' ? P 44 W?i , b ? 1. h i i r w''JJ PJIOTOR VEHICLE[OLLISIO J.7 PORT I: r A, CEFLIS"N lel - . o>A -- fv -- -.. I II IN fE,i E Ni •T'. Eer Oil OAD NE OF ETr 11UAD HIONwaY HGrI% EO - T A..P aM O ,MP arA O I - LOCn'r f N OI COLL LION Hr - ? - I xo,P - ?Irr se'r GJ'r„x °?LCJ 1L I' ?l ? Y ? 'L _I _ L1 x rxlwrNl uu - . CT s K I n sT L WNF.H OF. OJECr+ NaMC TND AUIJPESS IH i f T ?I? [, •„ rx?xer -- I y rj? NAME ?N IE MIUOLE wrxc rvvI cn DH ERd LAST NAME FIRST NA IE ...... MIUDLF UHIVE iS LAaT . , _ `x+ siNEET A PE SS TE rl AND d NO.. ROUTE NO A!T BO% N SrREE-r DDRESS A Iv CODE DRIVERS OCCUPA'f C TY TATE 2IP COUE D cRE OCCUPATION ION E ZIP CITY. A? car>.,E, Pc?rl'StirscNlS - Md E ,TER A E A :E EHS LICENSE NU ?T TE T A ' aEtl 3ss L L TY LE .x; M -°° rl MoaEL n,xa D LE. Iz PL 6e1.r, ! ? STAr L Er ..SST ?Ey TRA E N E ..e NSE PLATE NO. T E ., E E NO- - STATES I I ATIO NO - I fi n[we ODOMETER x n VEHICLE JDENT FICA 19 " [ OOMETERI O CE ' OP GENE O }eRE wNER u I ,. , 5rn? , , 5-ADO 55 ,,r. Ire -., DATE OF, NTH O NE A RE ARTS,OF'V H E MAFEe cs P O. 1 G .,.. ... .. " ?°??°?4jS (7 s 5 WAS THERE ' LIABILITY INSURANCE INFORMATION • VEHICLE NO. 1 COVERAOE IN EFFECT voa DENT -YOUR YES NO THIS SURANC C M Y,?: A RAND ADO 5 AD RA GE OLICY HO R NAIE OF -ILITY D O SOFLA INSURANCE AGENT L 1 P, C U . ,. IS .(Jy??Y/?{?\ •,{yGG ! -. i GE [n [v x+r Crox(. ?no /? Pxl /[ N El'1V•_•TT P'?CL QLS ?.IL___. ?A? -__. .... iwc° -.. Nr /L?Fy??y.2?'J ?1?Jy/1?0?/ ). _s.?..!?/ lL.' '/'-7??1IYt ..., ryIE ADDPES Gj`? ?-1L?..471U 12t, .J , -_.. _. _....I N7EF R GC?LS1 Vqq•/LLI? r/'`'?? t_IJ?I•I r C , •9?f?/.(J.?.•LS _... ?l LAYS t=5 .. [? ^•1 n,u ¢. Sc/ ?fn - nauY d?Pn •a'LJ .°? MST' ?y'"f? Gi l1S .LSP ?f.?l r.,.ll„°I( •' MARK 11 F P LIF ' ' ATUS OF UR O T FIRST ONE THAT L ES EI C F D CLE ? ° I KIO I., _ RT l ?. x1 °. o[I fi r K 6 l ? ?r? 5HDW 140RT11 D A [ \ OE IRE, U LO V,WMAT H PCNF.O: Iftf_ ER O VEHICLES Y NY !111"J / .. .. ' O c7d'iG?HJ? 70 ?? ?cx?L? 9lC OF 1 ? , :,rR[,Pxx:nxw„ Ivu pa?riz9 GWr -C?P P_00.C) FLEW -?? (?? R BA-19V- 4NO 5 i'-"c_k A 'Z of DIP "\)c QE,4i IPAt r- eow-1-..... 1 -- ., IVp.PQAl;1..e`•NL So.W4S.CZGILVC? , I ? i Vr ' 1? x - -- K VLIIICLES POSITIONS BEFORE COLLISION IT r, II r - -: - -- INw:cTIIGATED . ? ..,'•.r n• or r. rmu < vuuur: r w oN LTnrcr i m,ruvnr IuMr. on NO ( No. ?.[IH, LI Ej L-1 P.<, nrvn Nrrnirn.N N; wi rl: DaaTn??N -'.[_] r? (j [-j ALOaO nus rno.l to 11-1.1111A. WAS rRUADSUPFUa .:, wumm? i.lcr•rcodonu,' rurFlc conuioL c Tn•I: Dr uGAU oiwAr rvrrdci.c ACnoNs r; -c F-1 oAn lOllr I I 1 ?- Ja HDRA- i•^I I I ONF AY 11 L]'r.0 NO nnnl r nHr nO r ' r y' r rN Uqr r( r.I .-H r I] r 1 N l W At (J Z(-, GVLNTAK NG AND I ASTINO FII ?El .vr r r •.rw r] r? '( I r r I 11 (I Q MAKING N RHT TURN l D J NNO I r I F r I rn c i r 1 M,. ( r I A INO 1 AFI' TURN R r.1 i I ) r J l_ 11C r I ^. rr Vi r, J ( I A I 1 1 A 1111 [j J I] L I Y L I I MAKING 1 -URN (1 l I ?: Cl ^•r?' (7 11' ) (1 AO,YIND rLn'i.A<opr : [Al rr I,iTI.-I 1/I' 6M+N - I.l I ] T7 frlJ OR T,1rrIC .:r .,. .r,.. - l1 I'1I-A 1, 11 OR 1, "1" rl I I I :, , .:n I f Dwnr I rl A a vI T rI .Inn.Y"IPY'!i?nlq:.-,!<!w.[!I"?"1@Mn!I!w°H.gAP?'IX14M:*rF.417P>IE90^r-: ?11?`.?.-?0".T"O -.rr'1".IIT?I9?IR6'iPOPiI[IDpprP[91. .... :.. ...?'i-':? lull : m p a T>'? ?'r c C ? T ?x HrE ?? mW 1& ? M1b ?? ? r' _ _?•? ' fi Jd 4 1 ' r 1 ,?, Ir' T?"H - 1' -?Ar?re. .. r ? }r}4 •H7if' ?hY..' Jr?.i,Y Ir?1r}? 4 x J :j Jr'.''X Mil Al, 7 i N Yy;'l ;=x2 l Jy, ll J ,; 1, I? ? f K Y' tl -jh 8 Cz:, ?v IYyA,. - ?/ f.. _16Yy1NdYJ' I .? U' 4{r f Y .lu D tl '??p?1 1 rf } 4': 4n rl' '_' 4 .??' 1aiS+,._?Yi4 .....?'tt'Jii..-LIS....p.. .1k4+Ua_ .1".S.£._ . _._.c- lli"ur -•. - .ZS a MOT _OR VEHICLE COLION REPORT S. 'nil':uwv.:.. _.___?>- -_.tP+cne_.u vr.. P?7. .DAY OF COLLISION RLME OF COLLISION ?,M .ATE OF CO ELISION COUNTY NQ. CITY NO• oM^? . OU SI 1.11 n E CITY, TOWN MILES N' OLYN COUNTY CITY, ADMLLS VREFI% HOUlE OH STREE TCOOE SECTION ? r n / m 51.''..OF Iv?LA.,ILCVVC'_ C ? Sa ' SON - ,• INTEASECTINQWITH:STREETORROA. ru `• GIVE NAME OF STflEET,R. DOR HIGHWAY PREFIX ED MILEPOST e. " INTERSECTI-LO ATI OF COLLISION NON BETWEEN STREET AND STREET flANIP DIAGRAM DATA O n.c .o, E u -°L.JSSI.c nlwr ..- .• x. ?? t. Ir INTE ILL LEO ET.. 1OF 5' 7522 r n• L SPEC.CODE USE Ov` C O t OWNER OF OBJECTS NAME AN. ADDRESS N LOCA OATI N ?E o ral.oex 11 IIIICT ;T7 III OBJECT STRU K I e RDWAY r FEET b .rYll .n, OR • FIT NAME MIDDLE OR I V ERE LAST NAM E __ r . . DRIVERSLAST NAME FIRSSTTjNAME MIDDLE \ ?CY !2S L L d /j LL r, f STRE ADDRESS ROUTE N.. AND SOX STRE i...F E55 POLITE N0. AND BOX N0. ODE DRIVERSOCCUPATIOV P 1 CITY, STATE 2 C " CITY STATE ZIPCOOE DRIVERS OCCUPATION + y r f t I t G 1 a. ?I d .J - C t-'L. S LL' P ?` LL .. DRIVERS LICEPISE MBER STATE SEX DATED IRTH E DRIVERS LICENSE NUMBEfl STATE SEX DATE OF SIREN AGE F NO DAY Y L Le L J MO O+v YEAR 48 E 1 -1 L- MAKE o0oell MODEL I....A,, BOOYSTYL oR 1 .111 vEH:CLE VR. MAKE Knev, NOtwI MODEL IxOV, P+ BODYSTYLE ? x LICENSE PLATE NO. STATE TRAILERPLATENO. STATE LIC ENSEPLATE NO. STATE TRAILERPLATE NO. STATE X, V el 3& W w EA VEHICLE IDENTIFICATION NO. Ua[uootu,xtnlR DOOMETEN uRU:EI VEHICLE IDENTIFICATION NO. IIPeE wOeu+.tnE,I OOOLIETER uI REGI STERED OWNER Iusrl Nn+I you rv+un DRIVERS LICENSE NO. REGISTERED OWNER w,srllN .........n OR IVERS LICENSENO. 0. 7C," SCIS Lc CITY ANOSTATEI OWNESIEAODRESS 'ETREET TE OF BIRTH D OWNERS ADDRESS ISlREET. CI A STwTE1 P, U , Lea 3 ?/ ?cor? wu DATE OF BIRTH MO DAY YEAR . MAR 1 1^1 O rn wvexre PARTS OF VFHICLE.AMAGED ! L A ICLE oR?.A°Y Le D.t A a•P•aL L e'?T re?? p R. _ S YIAS THEREAUTOMOBILE LIABILITY INSURANCE YES ?NO LIABILITYINSURANCE INFORMATION-VEHICLE NO.1- covERACE IN FFPecT FOR TNISaccmENTONYOURCAR NAMEANDADDRESS OF LIA8I LITY INSURANCE POLICY HOLDER NAMEOF LIABILITY INSURANCE COMPANY AME wODRE55 CITY STATE ZIP C rel / LL G - ./? 3 - U-I ?CLIa e '4 e >r -e a • N Y• r NAME AND ADDRESS OF LIABIU INSURANCE AGEN CITY ATE ZIP LIABILITY POLICY NUMBER „ `" -o Rd- 5-7- PD A& a• 2 ea t?JL 1ST INJURY AGE ZNO INJU IUSE SEPARATE REPORT FOR ADDITIONAL INAKIIE51.. AGE, SEX SEX ADDRESS .... _ .__ .--._... M F -... -..-_-_. __..... M F • •v STATUS OF INJURED MARK FIRST ONE THAT APPL IES -TVs OF INJURED MARK FIRST ONE THAT APPLIES s e e w? 1NOVB111CLE KILLED .. ? FV n `o"''Vi ? E ? :. ; ?wrL? ?ia IN VEHICLE w;ir, No. KILLED ? w s n 5 Q °Bo?L xe 7 O°? [v nw tirrvonl ?o nU ?o? SHOW NORTH BY ARRO W IN CIRCLE i DESCRIBE, BELOW WHAT NAPICNED: (RCFEp TO VCIIICLES BY NUMBEpI .,.. DI„ :I >. ?? PxucnYn.cLe ,.P srK.r Dlwt .e ^°^ \\ ? -?? Q~• y A _ "- Cr vSiJtL.ti U?2 GY+.Z ? ?!'??? ask. ? cffto? ?..---- .. L:r•. P L'CL?c'...'4.. r--. r-j-_ _ rrr!f ` ! P-o I `w CL?" ya' s ? /+-c?lr•.nL ;' C?K-s..w L . . , 7 ', L6 A L..., e?-Y C ? : t I ' E y . ,. _-... L r w. CY-wcar-c•/ .i AT•c t/?E-t. ( /LG.? E ; ,i A.r G,/LAL CL ..;:, __L4 G-GI - C.tr•Fr / ' / J VEHICLES POSITIONS BEFOR HEADED E COLLISION WA NAM ON NO I, -•ICr:o '.t L[ Nr.P N.Ir wvesnewnD rv 0 i• ?% LJ HCLE S E wnI 61 Y E ON 51"11T OR HIGH 1 ? ? ? ? ?ro.u ?MO OTmFAl 54 ? ? ? L_ ? ? ? PEDESTRIAN ? ? ? ? ALONG CNOSSIND FROM - PEOESTRI AN W AS USING : 6[]uI.NI 1?L.L.In.s. 2?n•L. n.r )?:.:..:.. -Q I^ ]¦?:uiyn RDAD SURFACE A THEN WII LIGHTCONOITIONS TA.FFIC CONTROL o.[ n TYPEOF ROAD `• + ORIVER/VENICLE ACTIONS o,l ox nowlr Kw1< •I ' I I ?f:1:??,IV I ? DAYLIGHT ' Sls:r•ALS ? 1 un , ? I •?ONEWAY ? Wj I ?GOIrO STRAIGHT AHEAD ? V UN - 2 ? nAINING Z []O1WN ;, STOI SIG.: ? J I ? rj2 []TWO., n 2 ? OV IR IA K ING AN D PASSING ?ryET ' )?SNOWINf. )[]DUSK TREET ,,,, ? ) :::1 YIELD SIGN SIBI! nEVPN ? ) ? nOAa )[]MAKING RIGHT TURN LJ ? "?.Y?. SNOw +?10. O+ S +[]LIGHTS ON ?1 'LAS-IC RED ?.?ILO"CANGE ? A 0 MAKING LEFT TURN J . ,k ICE ! ? Y?6iY ] ? °iGwif O%El ? ] []IL ASH !;G ASB [N C] ] []ALLEY C] ] []MAKING UTURN ?T ?i...... 1H11 ? p 5I11.1 J ? 6 ? ?iiiuaN UN1E ? C]SLO,AING ntA30NIDR NOT i t LINO GANGER IGyL';LI ?I[]0111CEN ILAGV,Y ?Y[]STOPPEOF011 TRAFFIC •. I ,x , y C3 K J , r..I' 1 SEPAIIATPD STOP ED AT ? B ?OR STOP SIGN SIGNAL 2 []DIVIDED ? ? 0 ?STO/PEO IN FOAOWAY I, ITPOL f?I N J []UNOIVIDEO ?10[]1,A/F CLAMP ---`- "? ar• ,?.JN.SL>.?r1.AAJhesewlIWaa[r--.,rL+LnnIRYa+lem?nafraS:UF.+(Ln1m? reelMl.nrlPMfiNL91flAl7L2RS -'s--?+Re. !!BP?fTBIdS .1.?t?B. ", I..r. R?-T VII FnDM?L+_.p?I6A?g?. .... LJ ? . N' B M C4 v ' ?M fl c T g .} ?1 g .tA g tA M1 ti kE,% 'HAUL F C Uh L. t.IFD DRAW AR FiUW ISISTO SLHESHUW T PAC PI+VPAC T. DIRECTION 9F FDACE. INSTRUCTIONS: CE ?f,e tr _ DAMAGED VEHICLE N 0.1 IJ nrb A,x I, IllrG ORSKETCHnc D-ACETD TRAtER5UO7D-CLFE. tTC,I DAh7AGED VEHICLE N O.T -y N IT D• -- A aAGC. vI"ICLI H0, 31 1FI]OIy4ELIFIG pAA1AGE 11u1 OTN NAGF J ? FUNCTION4lOAAfacE L] N GE DA TmvfDBy ii J AtsT DunacE " V n E ITVOr OA4AGE UT, RRV[HCLE 1EE B?]uinlMN InAG I[QNO G E +L]OIHEHrA V.O rNNGE ] L] '..N _AG' No o4elAe . I] NO Da•nN4EDN [ J L] C L _GAHAGE ?? t Si. P4uAG A 111, IAV ro aF -B1 .. F r ED .Y d , 1 } _ ? r - " To - J ? s? C . To O DIAGflAM OF COLLISION .. s N ?/ RAW ARIjOW SHOWING _ Y/'.°FS ^-? NORTH IN CIRCLE ` ' ' " ?..-- AREA. ITII YifESS : J M o •HOwvF. cLl .mum .N Ua ,. . - ? ti. .tmsrN ,v..,,s neaoA ?v? ct , r rr, ? t DESCRIPTION OF PENED BEFORE. DURENG AND AFTER THE CRASH. INCLUDE FNIOHHa N NOT ON DIAGRAM, E.G. DRIVER ., COLLISION OlsaBUTVntOUCfD VLnILITY. PEntsTRIAN CLOTHING COLON. CONyiPUCi O.. oR RCIAINr,a Fw w Ev- a C?Jr??e :? r/,c /Efr ?v/F?_?dr/? ?. ?•/ sG_ d ??rl?/_? ?J.• _ - C?4 _ _C.f .i/,et /2?dF?c .?r eJnF? S';/UC'/<...lT?t EN Sr?? /•.°n S . 44' Fi.i ??iTG6 O7!' _ Eo rr CPS S/d L' 5/?•'?' !/ /L dS _/itd Jl<. °/ - _ __._ } r i ?> - POSITION BEFORE COLLISION NO. 1 1 A111 . ' E LEGALLY cnWAr l aN Si N[Er OFF N4A,t off NO ntc A pcEo v o.. NEAD[O REAi NC oT RD- -H EnsN 'RE c ..._. s IEB F. /CVt` _ _ Lw TV A., .. .,ED ALONG ......-__CH III FHO O___ AT ;•r ? FE O E _011 C aEUyG. SI LN w [R O R OAD SOflNACE W IARHER CONTRIBOTINGCIRC IFASTANCES v[ C 0 ..J ..d 04 yam, . C F fl , H F E ON[I v R L DOING DN Di D R nw - J 11212" a RAGHT AHEAD R ^i. ``II?/?.???p _ ,. ._ ,A" A? X DAY, n Or N wENC[OF Uo CI lr GNS10 WARN OvW,nz NG amo rASS NG J v.FT ^ Haiti NG Nn[N IN LU[N[E Of 'B OvN [RCFNTCR GH UG S E yFEFeNiLY J'. N.aN,r:G ' ... ... ... [ q Gnl TURN T -.. svow sNOw NC IHCA+n1ED uac TO y Orl ...c 'NAANic .. ,. _ ..__ .._.. _... _,..:. co .nT acNAL ocATw _._. LEFT IIAN [ .E H(A5. NHUr[R aTING .._• LIANI - " ?• - -. f . I[f L FOG .,F(yrFFU - .... .. _.. ,vnN EffCT1 OUII. ..... ... UiUR. OOr,Di CHANT N;W --_? -??-B y y.. 104tH EL[ ,I O[,U[ ...+> I ,..1 yLOwING _.. _ :... n n .. .. -. c I.. DIFFER iiF c [H .. - rc 'vrP X - '' zior rfu FOR n. L v oL:Im.F,n f TH FF CO M ' Y H - ' 'i - . 1.14 TCONOITIOfJS IRA I N O YC OF ROAD VE T ICLE CONDITION SOBRIETY H OFOrFEOATS,GNAL 11 IEnELr UNFI ,O JAIn n[CN ....... , p Ln,[L[ ICn[CN DrvEI UA LTO •. GN O t fDd ?? SiiD No J -Al N F 1 X FF TARTar DAYLIGHT J GN X -0 - _ M ,. , Hto ?Y /'? _ B innf FlC In NE J A?GND tll[ „ F J r - J An' NG FHHM MIDU rny,+ON F N„ .n...,.L C .. n„aa B ?,[P'., • I..: ,._.r y .I I , ! 1J rr. Fire ,.,t HiYG 11 r d a • I • D T s [ T N c G EN• ,y .i+ . .-'El fr 11 [ ..-,.w I No. ] 64M17, TEST B FIT- 1 1 11 N it - 1 J 11 y '.iI f : +, _ ul. r e ;< Nc Dt Us yy y lSt ll UIS ..... ? , ___ _ 111 's c rug r `?V,}?f? `? 1I'? i??NrtT - Tu: ••In", Y „'I { '..I? ' ?A ?,ry Y 1? 1 1 { J ??4Fd: tt} qtr t ,S 1 S fL. 'Y T ? Y?Yf• ? s " . -n ?...wi Y ...;,`.:i ?1¢?+ _ X14.. 4 J F;' SW ?? Ay O STATE OF WASHINGTON PAGE DF i No. ----? Y fi M?, - ,+" •; ' UNIFORM POLICE TRAFFIC COLLISION REPORT POUC C IA rJi n,PfbEn ?- ` $ CY.y DAYOFCO io uJ, NNI lots WED HN inI s I,ti Ff^ o D ). /?-. ?uRGAN J F < ? M i E D F yl* • '. r I - T COUNTY ?STATE ROUTE g000NTY ROAD ?CITYSI BEET - ??a? ?OTHERISPECIFYI GLSI fHl l% HOU t0 iN E1 LO E SECTION 0 C W III ?? ?SQ N S yyyy ;.? L C N 5 E IN ?r 01t OR iO S'?'?M LES ® ? ? ®OF. NAME dNO FS PEF OR HIGNWAY NLEHSECT VG STPEETORFOAD N' ? PREFI%EO MILEPOST Q 4! LOB: RAMP OFGI DATA ' ' r Vt ^ T ' ... - I WIT . ON LL o , T y •! .1r C I O ON TETUION //1 ACCIDENT ME OE INTEF ON TE SECJ G5J EEI OR Poz OH flEF. I Ms, STREET OR POAO [PENCE CROSS i' ..A: { N BE WEEN TJ IGO d f /.1 rE-_?_ ?•JCi 1 f( L Li EE S-ET BETVV CODE - p ? /•? ?,J? sll i4Y 1 II'' m • Y 'CE A?LESCIION FRSO E_E'ERENLE OR CR FF?N /C ?FEET l7 OF M H- S SPECIAL GOO NG USE ? I"'+ '. E LL VEHICLE ?EHCLE BCYCIE ?O EROI EI T RLN COLLISIONINyOLVED. ? ?r' 0 SEYEPITY NILLED ? -0 i y J ?^y ( (yy TOTAL NO V.J` E L EORJECT ?AEH CLEHH THAW ?5 O ENVCHICLE Oi :Cw CLES ? E C E EDESIR AN ?NON COlU510N ? DOUSI,IAIEH L _ IS NO NJURED ffyPAOPERTYOAMAGEONIY AA %i '? Y I • CHJeCI STPVC (NJJA[OiOWEC STRUC .AVDO ?IEPS NAME) -- lOC IIONOr OBJECT SIP Cx EST. DAIAAGE N 5 E W Oi + , c , r A MIDDLE OR:EH'S DPIV ERS NAME-LAST. ".. ., .. -FIRST ", . ? RO ST -Al FIRST FEET ? ? ? ? nD EOGE 5 _ Nq,AE V.SI FIRST M pDaE .11 HYCYCli11 OR T EDESIRiAY CnELA?[] ,:.:iy p .I E?'1 j^ ^ ? - ` yDy D R / STREET AD R STREET ADDRESS DRESS 'i JJa?Jra" E. ? V IgPg CITY SiglE' Z CODE PHONE RD: E CITY STATE, 2R CODE PHO,JE rvO. E? H R N OR ES ICENSE ND STATE SE% DRTE OF BPTN N UWI-LILEr.5E N0 SIAIE BE% DATE OF BIRTH -. ODY O• Mo OAY YR F• tiRIVEPS OCCUPATIDfi FPM NAME ? PND JE NO. DHr:ENS OCLUCFTION FIRMNFME PHONE NO. ^?;G, '?T.. CODES > IJ! ClsSS - rAI AT BELT v? 1'I EJECHION _ CODES > 3r CLg55 _ ITI SEATBELT-._._ I5t EJECDON._. _. f V NATUREO JURIE,+:•?r??J_/ JI MJUR ES F ?} NpMOVEO d P SCENE BY CJ J• - /J• , TO /? DR--C.NV.1 / F DMSCENE BY- TO } S VEH YEAR Mq E'HIUGE CHEV It• ?,UUEl10AFT NOJAI , STYLE I2 DR ONV.1 I'll YEAR. M.AAEIDODGE CHEV.) MODELIDART-NOVAI 5TYLTOR-CWV1 gyp. A= S E % Cp'.OR LJC PLATE M1O S1ATE TPMLER PLATE N0. 5TAIE _ E 'JEH COOP uC -E NO. STATE TR LER PLATE NO STATE H a' H t aiS "rF _ .? :n. 'Til 1 'I; a C VEHrC IOENi f1CAlION HuMUEfl . . OpOMETEP .. C VEHICLE IOEEJIIFICATIDN NUMBER ODOMETER E E r a - NF/G?S E.E. O ER -LAST FIRST IDLE 1-51-B OIYNER-LAST FIRST MIDDLE ? _?• e cl-?11 14 0. Ess GP oaT:EP DeR?ss Di O'•rt•LR +4n'?'?r. N r.YE MJG ADDFE SO nSUncNCE LO OR ALENi - E U ppPE65 Ur rlSUFnr'Cl CO OP AGENT cntiT I'D!, Ho NAME, ADDRESS & INJURIES OF PERSONS INVOLVED LDDrs , RE% CE .y5iaiuS - _ EJECT. E' Axr F n "G'f.?n - C RFU_S 3 / ?L' / u 0, I J P N?l.J ? i reoF/ a!c_n. ._.. _L/ Pct J 5 I RES TO. T Gi c E _ . __..?.. -.. ... _. .. $ ! A To .. ,TL ?, I t T i 'ril % ? ' CJs` C E 1 ..ST T....T AIJ?f /? P fI nL ':f .,r InI1. Li ra-.IPE I:J 011E _;VO 1 ?yA{, d• m VEHICLE DAMAGE IN EACH DO%, CIRCLE THE NUMtlE? OF EACH DAMAGED AREA. E%AMVLE INSTRUCTIONS: ]. SHADE AREA OF SEVEREST IMPACT. ]. DRAW ARHOWISI TO SHOW PRINCIPAL DIRECTION OF FORC Q? ' VEHICLE NO.t DAMAGED HISSPACEFOR SKETCNNGDAMAGETOTHALERS,MaroncvcL, C. DAMAGEDVEHICLEN0.2• •? •ry4r r?___'ly 101 . , 1Er• 14U 1) On 'nrl- ,r• IS..T?nt Ua? le. una .•LUIn. ) n ,I E I MAGE. VEHICLE NO 1 .. MAGE AMAGE O O H A SEVERITY OF DAMAGE. IOTHERVEHICLEI HER DIS D DAMAGE 1:1 O < ] SEVERITY OF DAMAGE. VEHICLE NO. 1 J ? OT V.DAMAGE R O ]I]F UNCTIU NAL OwMAG E A O DA GE C T ONn L OAM AGE NO DAMAGE ) E l OA A NO LJ EUIC HONA I OAMAOE I E ? UwB.., 0 ST.OAMAGE ° I T WEDGY - EST. DAMAGE T. 111-AIAII . TOWED RY TO _. _ S ... DIAGRAM OF COLLISION - i__I - 1 'DRAW ARROW SHOWING ATU _ I f-0 v? NORTH IN CIRCLE SNNA" I I _ 111-0.1-1 ER M11 f I 1,FD,MrEH. <D,OHrO , R<.PaKH.<ONSTnN<WD AHALtT<I :. ... ... I - ( sTy i "t- 1. -I_.1 i.f L.A:1 .0...LF.ONTDI T DNr1",[ LE.110r.TRrAN 77 T. Tii --? ' '-?- 4-L-1 II'f( Ili;llilillilliflllii.111 .DESCRIPTION OF IINDICATEWHATP-11ABLYHAPPENEDBEFOREOVRINO AND AFTER THE CRASH. INCLUDE INFORMATION NOTONDIAGRAM, e.O.DRIVER DISABILTY REDUCEII SIe1LITY PEDESTRIAN CLOTHI G CO OR STR CO E C - COLLISION . , N L ; N U T OH OR R PAIR WORK, ETC.) Vehicle $I vea treveling_PiB an-_CS_18 tollotidng_the tag line. lost control of his" :?; ?-- sehicle?slid.tor_93. .teet_aTd_otertoraed_in_the.: ditch_ot_Dsbob Box road.--- `: ;. -POSITIO • N BEFORE COLLISION Zz. S N LA INANE DIRECTIO v N cLf IF PARK e 0 NEADEO NO. M EPOSTO _EHASING DECREASING OH STREET OR AY NAME OR NO R N LEGALLY EC AS V[N OCCUPIER 1 o L7 ? ?? 1 r _-_,A_.?11 ..'rl 1 ,>x - YES` NO YES NO ( 1 fD. L_j_l1 JL ALONG- __. . OR caosswG_-- IoM ]! R , FRED B OESIGNA ) NNCYCLISTWAS USING: ISIDfWALK I WALKWAY J SHOULDER AI-1 CROSSW 47 PE CEG EWALK ?BICYC LE ROUTE ! 7 0 HFR y ROAD SUR A E.. ICIIECKO II -.WEATHER ._ 1 FC O EI - :. CONTRIBU (C TING CRCUMS ANC S- HECK ONE OR ORE( T..- Y +• oR eR qu wcr ow NO] N 1?T?LII?EA'" A IVtR' 0 IVE R ONVf DR ER .w r LI J CO N4 1 ,Ir I DRY CLOU r^C •?YLRCAS DY l 1 f- UL COHOLNFLUFN<EO OLLO G I T04tLO5kL= ]I? OS 5 110tD wARN S ? ?]I'?I 0 BHT. I _ i lT _ ANG _ - OF N1111"CEOP ) OROGSf_-_- E OVER CENTER LINE- _`- _ C I r'7 = I-)-A'L-S- TI A D Pw.. - ... °I D C?I ? O ITTVNV 1 SNOW J C? Uw N6 - 11CEEDIN6 SfATCD J _SPEfOt MIL - f GTD GN L °_S r' kr-I••IM ROPER IARISIN J. LOCATLON.' ? -. - LfiITYU1.N 1 Ai(yftONtAi - _ , 1 LV PER t T G FWP T E I KIND ?B? 1 161 - ! I EAHi RIW. I j6E1 }O f TC . I?11 D _ I YII I _ VTURN 'I a FLOwINa . L? GRIINisPf Ill OTHERI-Cir Yl _ L Y fl IMPROP[N PASSINr. . .. sL0 6 GO LIC.ML ( ?I7(_.I llGrni_RD T01 - - _ I71°I ?I ! I OTHER(SPECIE YI No (o. TRAFFI C rOR. TRAFFIC LTT CONDITIONS DNLCN ONFI TRAFFIC CONTROL O )VFINCIt v ICte . TYPE OF ROAD IfNO.] ICRfCKON[ORMORE r-VEHICLE N I I O D T O N; XCX A SOBRIETY. E T TOHfi AT E10NAl fi . r r? € I? fS xx PP eR ? < Q vI NO] (fo<ONTA?lcQL01 CKONFI VI N. L]E CII 1"IT011IGN tIGHALS ANE WAY 1 II' ?M? R :Z ROADWAY DYLIGN i) i6 E ° x;11 Of I BI 3 rl ( ? WfAHI OT_ L IO _ DAWN N S TJ_ I, SIGN rv GAD SBLF AKL . .. . ...._ IKt 1 11LJ-ALA. LIG IfS__ . _ L _.-- _l IJ?. 1-_NOTIMPAIRLO.- _ `-• TFAFl.LANE . J If PASTA RKEDPOTpTON ] OU -A !V EILAHIHNG 1 ( j LOO. IA? c S "? - .- uN O SORIHFTV I I]' 1 NC IFNTIRING ]( J P U N 1 !!T L G Ts D B -rLAMN%R R . .. 6 AL LE Y UGNT .... RW A WDIIN I 1" oIt I L „ „ . I I HAD OT BEEN DRINKING TRA r !- l?ld _1 BACKING . 101 Sa I GN L IS IWOWev L1Fr mI r ANDS - IV... ^• DIII Hf CHEM,TEST I Nu ] I_? ? I ..I 0 -NO flnl[i L<IIt ....1 1LAGM?IN Al ??FZITONEI ' arm R (srFC On -EN ) niv IDFO K NO DE rECTS I I I 11 11 n(r VSlN UIII.N ISP(CIrr1 - ?,• K 1 .? -?[IlnHilSPlCIIY1 % X TEST RESULTS 2 N S M ?1 ESNG 1 .rici AUI T-.- NF ILV IrG? . •IJ? own V /TC - Uw Nn - O - v v v I L01% ATCrn1U UI _1A IIIRVIO AMnuLANtF IIIAFI IC I LOW p n O o IL AnnrvfO IrArtne DAII n `? obi "" ° )" )A°° O IIRT O MIN , : TSNG,1 Di P1<IA-N c1 APANK AI;IIrt. nI101.I A0)T WD? ?KY DArt OUnIICATI'EOVY LOEAL LAtY I.PdoutEVFHTncfNGr••orv_r1uPLlcnrE COnrDwf:ncwiDN•SCnrr flee x ?i P f ^w N ' { ?,i^u w '?. L"' U u?.9L:ifl:, L"M.'-`1,.,""-.. i'?il tl . 4.:., _"',•"9t?aw_...3f _*? _._-._ILYLSe?:_Iri'.'4?}???_ y _ ,$c I ? .?? _ .. .... _ . WSP.159(REV 51)61 µ ? STATE OF WASHINGTON PAGE OF I . No. fi qn PM ? l per.}f iPOLILE GOMPIAINT-.EA UNIFORM POLICE TRAk COLLISION REPORT =R?`}dZi",y t? Vl 9 A 'b4XrRi I. +?. D DATEOFCOLUSION DAYOFCOLLISION LIME C OUNTY tlO. CITY NO. FHWA '( p' t.l(J.? OAY? Vj(' f SUN 1 M0.'! IUFS D V!E A RNLI S FHI B j?( IUSE 2A001(OURI /? >. URBAN UR L E ? (J 7 c-LRY ?STATEflOUTC NC OUNfY ROAD ?GTY S TREET Z O A REET CODE UM{L5. PI FIX ROUTE OR S T SECTION • ? OTHER(SPECIFY) )A'( .? • ?j 'lkz's l CITY OR TOWN P REFIX EO MILEPOST L [:)IN E W S N ILI ?? O ?? ? OF 41 L MILES ® ? U C NAME S NO OFSTREEID.NIGH Y INfEHSECTING WITH. STNEET OR ROAD V LL. AMP DIAGRAM DATA 1 NON WTERSECTION . ACCIDENT I NTER NON/ %RD INTERSEC MG STR E OAR AD OR REF. INiGR CLS ERENCE CRO TREETORROAO S S N BETWEEN STREETAND_. ..STREET ILEAG .S? f . CODE .. DISTANC ?NDa-TION FROM REFERENCEORCROS48TREET HH w S , -:. PECIAL COO OUSE. _ :.. [?u N pS1 E W 5./ FEERTES ?3'?I ? OF. p-_. ZSY. ( .. ._ ..., ..... . ? VEHICLE NEHICLE ?VEHCLE BCYCLE DI ER RTEl ?11R&FIUN SEVERITY KILLED N0 COLLISION INVOLVED: ( ?VEHICLE-ONECT ?VEMCLERR TRAIN .?`J =C 41 ?STOLEN VEHCLE ._ . No.. RED TOTAL NO. OFVEHICLES D ? VEHICLE PEDESTRIAN ?NON COLLISION ?H-000S MATERIAL PROPERTY DAMAGE ONLY OBJECT STRUCK(NAME OF OBJECT STRUCK AVDOWNERS NAME) , LOCAT ON OF OSIECT STRUCK'-'_• _" .. EST. DAMAGE ?flOAOWAY FEET o 0 o a RO EDGE 5 DRIVERSNAMC•LAST FIRST .•;-. `.. .::.'.'.MIDDLE: OHIVERS-E=IABTFIRSTM1- -CLISTOR EDESRIANCNECKID '. :,: A ' STHEET?DDRE58 _:.. R STREET ADDRESS '.... . Q E' DE .,.-. •: _PHONE N0. ?..,.._ ....:, ZI C O E.: CiY .:::. •...,. .. '._..'.. .:STATE .. .:..'s.,.:. .LP CODE.. _:s.?PHONE NO. R R ,? ••?? MVV SLICEIISE NO. Si TE p ATE "" IN N DHNERS LICENSE NO. STATE SEX DATE OF BIRIM . N O ti V AR O 1 DAY YR M R O• MO DAY YR - _.PHONE NO. ORIVEIIS OCCUPATION FIRM NAME 2 DRIVERS OCCUPATION. FIRM NAME ,, :. ... ... :. : .....:.. PHONE NO. CODES > IJI CUV TAI SEATDELT ------T(5) F ECTION ---------- CODES 14, C?Lq55__,__ TAI SEAT BELT-_ !51 EJECTION ------ ;- NATUREOF BLURIFS INJ NATURE F URIES FP MSC NE AY; TO REMOVE. FROM SCENE RY' TO VEH.YEAR' MAKEIDODOE{NEVI MOOELIOART=NOVAI STYLE T2 DR CONII VEH YEAR MAKE IDODGE=CHEV.1 MODELIOART NOVAI,.. STYLEI3D-ONV.T-... v 97 z 1 pfi DK ply V E VEH.COLOR UG PIAIE NO. STAIE. ,. TRAILER PLATE NO. STATE .. E VEN.COLOR UC. PLATE NO. STATE TRAILER PLATE NO. STATE :.._., H H 1 " Karen MT3laZ 6ae t C V H I N I N RUMBEfl I..,._... _.: _,_.. O METER ..:.:. C VEHICLE IOENIIFICAII N L E ' 111 Gl 64y 8G3 ?, f3 E REDLRf HED WNERlABT... ...?,.,,..... FIRST .. ?:?. -•. ...,. MIDDLE : REGISTERED OWNERLA51 -51 • MIDDLE.. N O N . z ADDRESS OF OWNER..... .i .:, ... .. . _..... ... ,:s. -. NAM AHD ADDR SSOF WSIIR [ G7( NAME AND ADDRESS 01 INSURNILE CO OH AGENT.. : .:.. ... .......... I+ CHApG GI NO. ..,. ,.. VED i CODES = ' ry ' INJURIES OF PERSONS] NVO L NAME ADDRESS GEr. AGE BIARJ I oai . EJECT. O NAME; _ C ADORESI U P NATuR o ICT •rAV'/E<If10A To A NAME T AUDRI''SS' " - A V ?TIf 71010 IDr HO%I 1D 51 xL9 I .ff N[V HY UUI `rf RAME. H wTUnrcA ?a aF nY S NAUF __ _ _ _ _ ___. _.- S AnnnFgA S I TI:•LU IVrJ DIn HrcL ?° u .. r M-I.R - T J 1 I1?. I _ _ lff TKI l. om uu! ? 0 i ,t T ( n rnlnnrv O l(Nlf TI rIi 111Y D 1111 . I -R I ? f /] UI(N r LI l ' Uc'U11 11 O +fA f •?I 1: 'lIVI1V E O YAINT'R _ ` yy ?/ Rr O Jt O.l U4 -I;1hY 1 UI v roll L'U LNOi fJECTFD f f Sf. .1 IOTA lr EJTCIfO 1 OC LNfIY( VN `JCf. rfD i 511 AT III : I 1 fA'IU'If I IFO 10 eV z 9 ??? • F n. e+t( 5 R ? T 4 m ra sr, P? _..._L134H1 ,...• V . DAMAGED VEHICLE N O.1 f 11°Y'ACt I'ONS1FrCNINGOg4gGF rO tNgILFN5,M0lOHCYCi( c DAMAG D VEHICLE N O 2• E . F ,ccJf ? I4. t F EVENITVOFDn11GE' VEHICLEROA t ? OISAE LOIGOAMAGE J CI OTNEN AI. V, DAMAGE )U iUNt t AMgAMAGE S""'Y OF OArnAGF. IOTNERVENCIEI 1 ? OISAOLINGOAM1IAGF ] CI OTHER MV DAMAGE ) pFUNCi ONAI DAAInGF K[]NOUAMAGE SEVFRITYOFOAMAGE: VENICLENO.] ' I CIOSAPING DAMAGE J C7 Oi11En MV.OAMgLE ],?FUNCTIONAL DnrAAGE NO DAMAGE T ? OWED PV MnGF TOWE05Y ST. OPMA . TOWED DY MAGE 4ToA T o r u Wv TD S f TO DIAGRAM OF COLLISION A RO SH ''+s nxmv. ,,A...... NORTH N CLE ILrs .. _ .. r ._. _. cDNtxP AFFIA ? ci0"stxuerlox J ... .? ?- ] aocATF xIIOeAPLI Va Nr OF ] NlowvUl us. 11-11IAN Dq pP,eu.os uDNSU Iv.ACr ...'._ R ... .... ?.._ I , L el?oW rxos+uE vDI cu orI . GNU:°i nco:i"i o`.roxF / DESCRIPTION OF I CA F 'HAT P DUR NG AFTE THE AS O T COLLISION II ION 0 0 OIAG -FI VEN ISAULITY.FIEDUCEOVSIBILITV, PEDESTRIAN CLOT IINGCOLOR,CN.TRUCTIOPION FARWORK, ETSI Vehicle A was Northbound on C.R. 18 and was just about to enter the curve _when ,he ..,..•. observed- BF,Southbound.logging. truck. in his-lane of traffics he too]c the only course open to him.was_to hit the-ditch..-The logging truck-laid down a strip of rubber but_dzda't stop. There_uas..no contact. with either vehicle - - - ------ ---------- POSITIO VIN. PEACE N BEFORE COLL SIGN MILE POST OIN ON STR EE On N GHWAY NAME On NO. IN ONE wrli[ciloN v0errn vE IF P E 0 E f IPC.EASN6 DECREASING aA gKEO C_7 OCC J G V - -- - -- C.R. 18 1 50 50 ES FP O ] I ?I I UP. I I L I - J Eo I r f j PFOIB CYCLIST W45USING: o D to c __. _ no _ KED 7ED I (SIDEWALK ]r AL%WAY] _:4110ULDER ICROSSWAIK 'CROSSWALK iOICVCIE IIOUTE I...iOTIFER 'ROAD SURFACE ICNECN ONE( WEATHER ICNECKONEI CONTRIBU C I TING C IRCUMSTANCES. HECK ONE ON MONEI ..... NRIEN/vE .,, NlctEnCnons S )v [N CIL IO j . D V _jN O EN A. pHIOVFF Gn N (? GOING STRAIGHT AHEAD Icy Icy ONY 1 ? EVERCAST 'UNDER INFLUENCE OF I J J FOLLOWING DOS OS j I , 5 NEG f1 V RNJ E;IV I? O n A G . .. .. t ? .1 '' FAHLUUFPCE OF GIVE. ?E EN APPARENTLY I U NO T I]Ir - MAKING . ] l SNO ] 15NOw NG I]u E%C[DE TATEO SEE L_.. ._. 1p( I r G 5LF . I 1 I I nWfW .._ R FR TURN Fr: I N . -l f _ I I I I... ICS f 0 .__ (- I CE D G I .S. I.4 (. E 1 . IMPHOILD l f _ _LOCATION___ 11 OYk IIATNG -- I OIF EC f R LEFTT {IN ` ( I ?° ? I .L IS I N G r RN JO [ ur ?ISI I _ (- I GII D o T ? aT9 I. LIE. .. SLOWING OINEP ISA[CIF I _. OT„FN IYELIFYI _ _ . . . ._ ._ 1. - ROE SING . ) CH f ,5101 SiG SGNAI -I P I OI IE L FYI N L ??-'? SIDPPFOF L I L I 1R F[ 'pN L M CONDITIONS ICFI[LK ONE( RAFFIC CONTRO c TYPE OF ROAD IRO) VEHICLE CONDITION ETY - SOUR I . A C STOPPED OR ? 1 O.]vf,11CLE 1 SIGNALS I , IC ECK OF OR MONEI N L]1'7 ONE WAY ? A VIE g, CLE C[?I ?arJ 1PI ?? jy? F?4 1`C f$r+Shl {l'DI - ECKDNH EHIC LF. ICN ] AL I°L_I ONSTOP SIGN lD!-I cTOPreON FICA A 1 LGNT .... ,] IGil _ S SIGN ..? TWO _ 1 E DIIAK(S 1 1 ?p? R ST/1 RTING IN D TRAFF )I I A. I - 1?I I I'D ND IIDnO d ° I] 1 ,IlAO GNtS I O IC LANE TA TG FnOM P U ] I W Rt05 G __.... LOOP f NGE ..__.. I] ., ?DIEFECTIV1i5.. M E...... . ....NU E Y I .? DlON'? ANKE POSIT ON J]I ,-. J 1RAFFICI ILNTERINO A HARK-ONEE .- !S?' l NNf. ?.. _ nE 1 .. 1 _ , uu IA,LamI ._• TFISWVIIN oI. cMOOm ... I .. .. AU OT I PlfN ml NKINC ;'""1 , ...I nncKlNa s IK•sUE .I l6 ISOf ° . nn _... 1.. SGNAL I. twow 1 Lgv ILFt 0Y s' I n:.. NctvNlP N ilrio[> CIIEM. TEST -.1 ° O IT I [ TLGNR LAG. ? AN tL70NT-- 111AFAI EO 1 I[51 GIVEN GT C R ISP[C IfY1 F . _.? EFPFN E' ... i ? DIV ID[D - .._ _. ? I NO OCF[t TS I 1 LEST nli uSLp aIFItN IY[C?FVI I -- uNnrvipED ,I N SPlC1, RS TEST IICSULTS 2 X IV[SNOAI. GV,FICIN'SNAMEA NANK De ut WN G 0ebhart eves ?_ ?I__ I, FIfO I ., znAAII NA ?G NA.G1 NO. 6 ADGI N•, 6 OLICE 111.APAICI 0 LICF null IIU Ar rT l' Luw vtl, eYy Fnnnlvfo ce iiiprDF M A„ rer06 .1 ! In PDO 9 p ),a., I 0 FRO su I . ND, uNI, RN DI., n RIT. I,PT Dr IIL II APNID?I [ ru nY [1- JCSO Quilcene 061579 i DUPLICATCCOPY' LOCAL LAIYE N,oRcr..MCNT AGf.NCY'S COxV iRll`LICATC COIN ••INV[^T `•, ?.•?. :.o:nrr? ,Cq TOI1'5 COPY y ? A91W'.?', 1 CE A 'a 6 JN' ; ?I T .?1 rM .. , _.? •. ax Tx T ? t re 79 ,,. E / - ryyr«. 4' ?y G?'S?b-?Y:uf'a A? Ks?• a.:`L"'- z:. Aaw ??m.r.:auu°,.c?.vertar?a?Trsc>a. kW?zoi - `?' 'mss 1? 1 L?J E vb r-? ,r E Pe F`? ? E v • n ?' . ? 0 • I ]! ,UC[CO VIAW iNUMUE ., .,. ?ay .p' UNIFORM POLICE TRAF( COLLISION REPORT [ A ga" ? 5 w? N4 N ? I. •? y D DATE OF LOLLISKJN DAY OF COUISION TIME C OUNTY NO. CITYNO. FM 'NA T MO DAY YR. O/ 1 ] SUN I V01 P IUFS D WEDA tIIV11 3 VIII 9 SAi IUSE 2A00MWR) .}.1 ' ?UPBMT URPL E' CDUNTY ?STATE ROUTE FK] COUNTY ROAD ?CI TY STREET Z O A DM CLS RERx. :ROUTE OR STREET 000E SECTION i OTHER PECIFY ? ODaJ /?? aL S ) Jefferson []W Grr oRTO N W P N,,I% LO. M ILEPOST O ... ..... C nter 1 ? a 11 El noF 3 O O 4 C - _ ..... __ e . MILES NG NITH'STREETOR ROAD E T ILL R AMP DIAGRAM DA TA - A T.. NAME SNO.OFS Er OR HIGHWAY ON C.R. 18 I INTERS C A. I O ACCIDENT N TER SON %HD LS NTERSEC ING STflE TOAD OR REF. D MILEAGE . E IA F C nU. , T Q00 N 6Ei1'/EEN STREET AND STREET CODE 1 . U LKSTANCEANODIHECiION FAOMIIEFEAENCE OACROSSSTREET NVYLwtTNS SPFCIALCO INOUSE MILES N 5 E W n '. .2 FEET Of S.R. 104 _ _ VERITY ?VEHICLF VEHICLE ?VEHICLE-BICYCLE ?OTHER(WPTE) ?HIISRUN NO. KILLED COLLISION INVOLVED: [33 VEH:CLEOBIECT ?VEIIICLE-RR TRAIN - _.., C] STOLEN VEHICLE NO.INJURED TOTAL NO I? OF VEHICLES ? VEHICLE PEDESTRIAN ?NONCMUSION ?,AZAR000SMATE.IAL PROPERTY DAMAGE ONLY OBJECT STRUCK (NAME OF OBJECT 5IRUCK AN DOWNERS NAMEI LOCATONOFOBJECTSTR CKS E W EST.OAMAGE Ditch ?ROApWAV FEET ? C3 C] ? .D EDGE 5 DRIVERS NAME-LAST „ FIRST _ .DOLE DRIVER'S NAMIt-1 FIRST MIDOL 111 1 OR PEDESTRIAN CNECKI D LESTER Jerry R D R , . STREET ADDRESS R STREET ADDRESS 23520 94th Ave. Eu V E _ .-STATE .. 11P CODE.: .: PHONE NO ' .. GTY , .. ,' .. •. EE CITY: STATE. :.::..•?. •,.. LP CODE -,PH R ., . . . . , 847-1968 Oraharo Wn N . ?:... 77 ORVERS LICENSE TO STATE - SE% DATE OFpATH - N DRNERSUCENSE NO..c...,, ?.. ...::,.: STATE.... SE%- DATE OF BIRTH,... O .. [ MO DAY IS • R636RH Mn. H 12 08 37 ORNERS OCCUPATION FIRM NAME ..... : ...._.: . . PHONENO Z DRIVERS OCCOPATION .FIRM NAME PH N NO, t Tacoma Nn C n T C t . o s onnesen on e CODES >P, ICBJUU?55-_1•. TAI SEAT BELT_2_ (SI EJECTION I CODES > IJI CLA55--- NI SEATOELT_ 151 EJECTION. • NATURE E3 F Stated none NATURE F WURTES S E REMOVE. FR MSC NE BY' TO M F VEH.YEAR R,: TO MAKE(DCIDGECHEV.1. MOOELIDARTMOVA) STYLE(3DR.C0N11 VEH.YEAR MAKEIDOOGECHEV1 . MOOS (DART•NOVA) STYLE120R4ONV1 . V 1978 Ford 1 Ton utility V, E vEH. OR UO RATE NO.... STATE . TROLLER PLATE NO. STATE E ' VEH.COLOR :. LTC. PLATE.NO.' STATE.. i THMLER-NO.. STATE . .:... H 1 R hi TH 3194 W Wn. (?` VEHICLE ID N IFICA- NUMBER - .: ODOMETER (,' VEHICLE ,OENIIFK:ATI N. NUMBER L; E E REGSTERED OWNER-LAST. ;.... FIRST MIDDLE REGSTERED OWNER -LAST.:" .:.'.FIRST"._.;-. MIDDLE N Tome an Construction N 0. 0, ADDRESS of OWNER. :..... .. ADDRESS OF OWNER .... ... .. .. " .? .. ...'. .......... 021 Waller Road Tacoma, Wn p NAMEANOADDRESSOFRISURANCECO.ORAGENT. .. ?..... '. NAME ANOADORESS OF WSURANCE CO.OiI ADENT.. .: .. •... ,,...:...--:.. C CHA E.... :. - ... ITATION NO. .. ENFORCEMENT CHAR E...:..' _..... ...??......,.... ... N .. ..: . .: ,.. None ACTION D V C C O DES 2 ]' A 3 E NAME, ADDRESS $ INJURIES OF PERSONS INVOL 5 AGE survs EJECT. L. NAME C ADDRESS'. U. P NATURE OF REMOVEDFROM TO WNRIES' SCENERY A NAME' N ADDRESS R M O S , IVLU E3 SCFNF q TO W NAME I ADDRESS' N NAIORIF.' SCENE qY' 1 M 10 E NAME' S AD(MESS'. E 5• N I'IIF9 ITISIAIUS I]IS[AIIOSItxAN RCFNFIiY. I RY SpSABLINOIUU.Y JINJUIIV CLASS 10 MI SEAT IIELT NOTWSTALLEO T SIfJECIKJN T. NOTEJECTED L. ?. PASSENG[R P[UF 5'.MN uT OC OT D D I.NO WJU ]DEA.ATSCENE e. N?EEONUSABLINO YDIE)INBJJURY PO ?L i N N . 2NOT IN USE l U 2 TOTALLY EJECTED NIf ECTED A3 PAR D TEll 5 I ! ERONUIIKNOWNI I , DSTIT T. pEDI ifA.URE CA"DEl 6 EJ[C EO WNIESS e H P 9 r 9l1? . A I A I Esdtid - & 1 F ?i FATE OF WASH INGTON i7 - -- Of FIC1ALLSE ONLY - NIOTOR VEHICLE COLLISION REPORT OATEUFCOLLISION DAY OF COLLISION - TIME F NO, -- -- --- -- __- . xnr p O COLLISION • T COUNTYN CITY NO. ?' n CITV, T COUNTY CVIN MILES S rr (('`?? N E OWN CIT Ii , ApMLLS PREf1X RO O D ?OP SiPE E T C E SEC ION / • ,• ? . / / ' - • y ? G VE NAME OF STREET RUAD OR HIGHWAY .. -: INTERSECTING WItN: STREET Ofl ROAD PREFIXI EO MILEPOST 1 NON 9Az'. INTERSECTIONLOCATION OF CO`LISION BETVIEEN STREET III STREET RAMP DIAGRAM DATA _ ff?? OO H E nssmc.mnvnsr 1, ' x oc of .rrr xc t.rmm.x, "'""'b r ER RO xrew Ex oc CL spiixesrgrr na cro4 r L T O I? OF ? fl r oL tt OIntR x HHEr I ? ? ? oa v[?r colts s / "I'll D USE OBIECT STflUCK Q xANEw outct RR 4 ? VCM. _, ....-.-. 0WNEfl OF OBJEC TS.A.E,-ADORES.S -'., ::-.. . ..._:`.. IN ROA OWAY .': _ FJ ? TIM rn RO _ ,E 1 C 7 FEET 3 W R S ' DRIVERSLAST NAME.. FIRST NAME .. MIDDLE' OHIVERSLAST NAME , U Q , FIRSTNAME -. MIDDLE ... • ? a STH EET AODgE55 .• ...--,.. ._'ROUTE NO. AND BO%rv0._ 5L 19 ? l I awe n ? CITY .: STATE ZIP - "°'••"•^^`° ?..°°•.. r7r r n ` `-+C STREET .R. fl0 TE NO, AND 80%NO.: Q l rl ! ? .. ,-, ., CODE DRIVERS OCCUPATION o ' 1? ST 1e ? er..xerr s°u u°wxrw"r CITY .. ,STATE 21PC DE DRIVERSOCCUPATION ? •?: I R h N U DRIVERS LICENSE NUMBER STA n, 5 L { Se. c ?m 1 In l TE SEX DATEOFBIRTH AGE M F M YE Tr r- R t W DRIVER ICENSE NUMBER _: STATE SEX DATE OF BIR H AGE 1 ME 2? A vEl ICLE rq MAKE K:x YauOCSE MODEL rnOVA.OAAR BODYSTYL D f5 ^ i P °AX 5 as s L N E R 1S TI.,,;L P;akL. VEHICLEYR. MAKE CCOCEI MODEL. n I BODYSTYLE RP T) G1 LICENSE PLATE NO STATE - ,PL? Ca aiG2 u ^ . _ TRAILER PLATE NO. '. STATE: r• ?4 VEHICLE IDENTIF CATION LICENSE PLATE NO. .STATE - ;- TRAILER PLATE NO.. STATE T NO., ._ 000 TEP rttAGE R LI^ VEHICLE IDENTIFICATION NO VANE"EAI .. ODOMETER:-ffACN _ n REGISTERED OWNER . rsarfsrA ou n.Mtl ?DflIVER3 LICENSE NO Nf L 2f 1 . OWNERSAOOflE55, . IS E U ND E s . . I 'DATE OFB RT REGISTERED OWrvER sr;Mnsr sruu.l ;.., DRIVERS LICENSE NO. , ,. 0 DAY I ' C- .. S h R r 1 I H .OWNERS ADDRESS ISTREE C V1H sTATEI DATE OF 88RTH YEAR 1 .. - ..., '._ MO VEAA UAY ' t t O V H ICLED PAgTSO EAMAGED :.:. ezr PART Ofv HICLEDAMAG ..N (•' _ ?. .'. Q.x..vf DB"S;«x KtE ...-...5 e.a ' 98101 sa*n?:a..'Kt< LQ7 Ct R • c p A 4 S . . . LIABI I • ` ST IEH E I L TY INSURANC NFO R M A T I O N- VEHICLE NO. 1- IN EFFECT FOR EFFECTFOR L THIS LITY ACCI INSURANCE OYES QNO COV ERAGE DENT ON YOUR CAR NAME AND ADDRES S OF LIABILITY INSURANCE POLICY NOLDEfl aME ADOPtxe CITY NAMEOF LIABILITY INSURANCE COMPANY .r STATE . ,.. zip I .. NAME ANO ADDRESS OF LIAR CITY INSURANCE AGENT ' - ? .11 LIMB CITY POLICY NUMBER ISTINJURY -. AGE NAME 'zNDINJURY: IUSES ARATERFYO TFO DDITIO RIEST- AGE .. .. .._ DOgE33 SEX -_ ADD RE _-SE% . STATUS OP INJURED ? ? MAR .•. A.. ? K FIRST ONE THAT APPLIES STATUS OF INJURED MARK nFit. RST ONE TN AT APPLIES IN V[H CL[ rwn PH.I .?"r IN VEHICLE C ,LKILLED stvln iu vrr Fr i ?r KILLED I .. Ml Yix o w t T ?xtsc 6? . ? S? r. ?( - ,.AN: ? 5? D? 7Ocr SNOWNOHTH BV RROWINCIRCLE /DESCR B[,BELOW WHAT NAPPLNE0. 11gEr([R TO VEHICLESBYNUMBERI _ 1 ?t ?1?ET CSC Il.? fuar.??Nna}r? CRC rFl-.${8t?-?DAtLIQ?Q O?? cD Ry__??_la_RpPcD•'Lmr?tly?thl_k} E;c?t,_n4lnte4t ?? F o. .? -,1eda?.c l 2. U_) rrr.. C,?Tt? --nPPnDR --rq-turzue-Ly p ?ht la aa [ a'} E l I / / ,x?x Q`- ? , pp al ?, . .1 E ? 1 ` f ? l 'L?1C_CU.LL ?)AN?-O.C_}%IC.-..CLIRNID J 115_cIS.k1 LIQ,j)_J_ ,P?1I AGE ••t ' . 4Le._cwave„-_ i?s_dR? u?en_?Pw-.veh.cleS?,?-cwpidl atelti q "t ,? r ( Ike fiRME-C LR 11e _LR am t^Or?lZp ct:EL2c?ior i _wiTL.P. ?iSl+-tnllil?c? MO.Et-DAL+'_ A 01-w -}t ,q :4EI? C.1RL°. P..U?.?S,::Cspaoperilnly? whela_?eh;c lZl?l Al <! } , l T _n1eRacprt,p?zt?DrJ o? ?h?cun,Ie E BaLr?LfS diacC4iDA! J i - -' S 1? ? /' , . _ T Fnom_{hti rA5 EL la,rJE 4 ;h Cuaw& caoc 3 _.c?' Ai:wL 1111 L t _bth c1?L1)_;ra.t?,n _SLd: a? ? ? CI A!- .DF d -I°T ? / / - o r nE :w C E l VEHICLES POSITIONS DEFOHE COLLISION o VEHICLE HEAPED It? s ON STREET OR IIIGNWAY NAME OR NO. N •"? IVOUIII 0 ? 0 ?W i^ IOTNFRI c? •• EGi? i'n. :,cix fug! xV FSTIGAIFD Pr r o srr M"FCr'o ?inxr ?:prci ? 13 Q ? ? ? ?:? ? o PEDESTRIAN ' ? [j ? ? Al a ? n ? L-) . ,. oh . •..^ PEDESTRIAN -S USING 1 a.r. ? ur t?nr.•nAr 3 ? CROSSING: '.. .. ,..,,,.. PRDM.. TO - ?'1 •?.} M.V ^?'? v..v.n.w •+ fa l t RO*DSUNFACt W EATHEN LIGHt CONDIT IONS TRAF FICCONTR : ,•s t hHA IJ <n H.xHe OL TYPt OFROAD DR (' ?ZZ%f'r^ 1 DAYLIGHT Yr r • ? I ?&' ^ 11 ? ^ Sw . IVERNEHICLEADTIUNS o^.r rcwrcK fwErw wPr f y w E ? ?S14NA I ?,? DNI' IQIt A I ' ING l ?DAWN ? I .1 ?wa WAY L3 ? I ©COINO STRAIGHT AHEAD ICJ ?r? J ?j? W[1 O SNOW 1114 l ? 1 ?$To'S ? ?DUSK IC." 31 j IVIO WAY C] I ?OVER TAKING AND PASSING ET ? D ?IIELU •,-? J G SNfIW A ?FpG A ? 1" T F-? SIGN ? 0 L J IIOA"S" C 3 J ? MAKING RIGHT TURN SnI S ET ? A ?ILASH J H C ICE S ?nr``rM S DARK IRY V C3 H IJ rr •• TT INOIIEO ? A JIIIRICI I.AAMI f L A pMAKIAOLEFT TURN LI1 tS DIY ? h ?,w.,H o J •, • N 1 Nf. -ER '' ? ALLEY C] ? 1, OMAKINO U4UHN S t lIGH 15 r ? h ?r" "co hTAiO O NOi SFt hO Oa NGFq ?. ? N f?1 r - ? Ir ?sii0rvt r,wNr Axlr 4J? A ono-O ,,,,, • ..•, .•. ,,,, ?? r? rfl „v E .. L hr [,? rr IL-11 _ ? 10jTOPAFDFOR1RAFFIC e13k PnRq fEO StOMFO Ai SIGNAL ?: `•s,? lJ LJ r,.?r. •• T II?v?Is, C rsl ,n, h , T STOP ll?Il?OVIRFD ?B? AJ y wnq:? - ??'." ??"'?'rNi' .F?'aL. +Y3f ? S O" F IN L? q GTOHFD IN IIOARWAY ? T +F1fIJ , \qll• r S AO? GF f • ?" ? 4?:1: ?1 I + M? ?Z' n:Yv 4 ?Y ' r X F?Y sT J. .F y 2 w; ` r t r ?? yy4 1 }- 1 yI ?, 1 ? Ij h` I 1 I 1,7kpp, '0 II 2 t{ P I Z ti < z -177 A' a? w VEHICLE DAMAGE NUMNEPDF 1.MEACH BOfLGBICIE rHEIMPACT a,SNApE AREA OF SEVEREST INSTRUCTIONS: . SpgAW AggOWIS1TO5HOW PPV.C PAL pRECDON OF FORCE O ' ' DAMAGED VEHICLE NO. T (USE TNISSgACEFORSNETCHINGDAMAGE TOTRAILERS. MOICPCYCLES, ETC.) DAMAGEDVEHICLENO.Y ??! `J? IJ.Fwaa e lA Pool mq..?, IA ( rs t3 TnnM .._ ? r• ibol j '; rs. TnuM x ] ie.uw:wrwwl.ae .. - ?j ? ' le.umrrilra. SEV OF pAMwGE':T'EWClEN0.1 SEVE.3AS DAMAGE:(OTMEq VEHICLE) GEVElbTYO DAMAGE: VEHICLE N0.2 i ?DISAfil1NG DAMAGE S OTHER M.V.DAMAGE' 1QDISABILKL pAMAGE DQOTHE AINV AMAOE 1EjMABUNGOAMAGE DQOTHERM.V.DAMAGE 2 FUNCTIONAL DAMAGE ? NO DAMAGE ] FUND DMIEE • NODAMAGE 2 FUNCTIONrY DM1AGE < NO DAMAGE TOWED BY ndYS EST. DAMAGE TOWED BY EST. DAMMiE TO -Y ? EST•DAMAGE 'R ro * G ew O 3?aU ro - Is TO x il DIAGRAM_._CQLLISION;(, i"A ! I !! I I I I I I I ! I DRAW ARROWSHOWING Rawr rE,Pm,3 -'?• ? I ! LF ; • - I ! I ! I1 I NORTHINCIRCLE - . . ' I fw+. 1TPrcp"ulwlcrah -• i I'I I•I I I i l l ?- ! I i I lI? I T? I _.fi ;l4 i I I I I b_? ! I ! I `?;/ 7 -1 T ! - EFOwrv ,HOwuTNCLr: Pf9, "' oH ! I I li 1 t r,. .; . ,• I I ! ? ? j I ? I ? ? I 1{ - ?I I A ?wwA c auw ''' ' ! ' ' i I I h - + •HDw FAAN VTNIaE? ArLR ? _y_ ! I I I I I i I I _ I I I??!??_ ?! P Q ?/ d I ICO-?-id-S? ?! ! ! •DESCAIPTION OF?wI. ',.'. COLLISION Jvx `S 'i _..._ C,+', (INDICATE WNATPRpBABLY HAPPENED BEFORE DURV AN. AIM TH PISA&U]Y, REWCED VISIBMY, PEOES]RWI CLO H e q COIAR,CONSi E CRASH,INC-EINFOPMAUON NOTON DMpgAM EG.D5IVER RUC110N Oq PEPAP WOg11 ETC) T '' '' ?? p _yeP/j. ??_Fivo_ls S'OG1? O? ?+?.0 • ?t? - ?i .._?5?? Ol????`- S_, . . .. I ^VEH. HEACED NLE PO,igR. Ydl„IR+N: NO:OFLANES SPEE ON STREETORHIGMYAYNAME ORNO. INONEDIRE-ON Posle OSEM 11 PARK LEGALLY WASVEN NO YVCRF.A3nuG Avv.tttS4q PAANED MCIyIEO J? I C O .S YES NO YES NO 2 p" PED - n u l_I ? - - « bmEE] r `L I Se iOw.l RED/BN:Yf,LISf WA9 USP q L• ISFw•vit x .1 xn SrWlMq •[j-IIO. 'Fin 04. n P?OIIn nOTN -.` . AOpO SURFACE,, z cA a.D tii WEATHSL' ICH[cF an -'iMn.-_.? CON7R18U ic 'TINGCIRCUMSTANCES. NLCR W,y,a,5„ IJ`? w amYe1.YD.asisacwrra ? w '? _ N _ q... ? .", i• DRNw r ?? NO, x vcPICLE ry, _ n' °r' ?- ? _ q ?_ _D 4: , ?. Gti ?-? sDN„? AAA _ - LCu:L•- AND . r 7 Al J x' J '''n a "'v."° ` J a ? orwow n ?e rl wegcoPm ? .-. ?.1-i Aw.eTim I I ..? L?l ? ? -- = 0 °"a""B ? ? ? ,rA,? ? - ?, ? ? C„I ? Tx:noN ? ? Q urwn'°r - j I? :Sc' I . FOO p_ ?Ar li O PI ?D?Eq - ED ?-cl J - -SUE ' OA.fA eyr ..l 1:.L I . ly l = = Ov ? I _ u p,E . rwnk F« LIGHToNaITION.4 TRARTC COYIk?G 'vsm;jGYYPE OF..ROAD.;L a?a a<« Ma? yVEHICLECONDITION « U:r„?SOBRIETY ? IAL ? Q, El ^ - o ae_w.Y _ HD ?D came cq « . N0 a ?,? ro.oO°?Dr I ,? MrtIDHf C,? lx?.rl !]e•x? TWO WA Y aFaE . MDw° ni3_? '`' 41x E- wl^,_ I a ? aL'rvwm ?110 v.-roNioN a L? oorL ? wo !-J. L Lm A.w .. "n uD 10 n ?! A,oeP?n E],2r-.l w.D _ _ .__ • `'?._Das aw neI _ I l? ec"a4fNNOa«nwa 0-13 e.aon °? °In1e".n°naicr°i J,n L ??en rw RIAM, r.;Ur Ce? w191Y naw roACD orAWP CHEM.TEST I NO ! ? (-7 ?. ... I ?e T emcrtiwgn I r_n?wrcfA, f -" aenAA:im' n 1 naDne .. 1 G e n(,cECVn r I^ i _? n,f l DrHew r ` f? Dn+tAD C'] L. Na DFFCCn f1 -l xngvlMEO --- l A e I w„ - _,'(., I IAaase p °T?^Ix°s?Tq % % TEST RESULTS 2 f . Nvemwr.uar? swwe,lw /'IlllM/?, !/'01, /L - p. ?'? 7-?O ro,s,avrcHCO . Iwse.HwveLn/ A., c n I ! T aHU /?,•aa now x.oa MP""EOio Mw " X w.e,roArrny ,EnaHwe,n w? ,.ooaw p,],D,r. ttarHerom Mvwortoor a; ? A,-/ k 3 //9 -I PUCAfE COPY: LDCAL lA W ENFOACEMEM ADENCY'S COPY-igIPUCATE COPY:INVESTIOATOq'SCOPY F gig ; 'k ' ; •ula EfI.?. Y ?. Y tT° w -? S , tl ?pp 'kI > a? TOE. •':2R ,fl J?T l r D OATEOFCOLLISION DA'OFC-ION TIME COUNTY NO. CRY NO. FHWA RSM A M? OjY ?R. ( T SUN 1 NON Z NEi i WEO y INIIH 5 FPf tl SAT (US UPI J COUNTY ( ?STATE ROVTECOUNTY ROAD ?CITY ETRE_R Q {L5. PREFIX AO M OP 9tAEET CODE RWlE S CTK1N p?s'Q? ? OTHER(SPECIFY) N ? -Y ? 1 ?`? /?O ` ?IN CITY OR TOWN W PPEFl% EO. M ILEPOST L N tippSlI E IN TDt ? ? ? I U ,? C MILES 1!]I . NAME d NO.OFSTPE R HWAY -" INIEflSE0Tw0 WITH: STREET Ofl ROAD O RAMP OMGRAMDATA N P NON INTEHSECIIMJ A CCIDENT EF TNT NOW %'RO TEPSECTIN6 GTRE OR ROAD O EM yR01`SSI TER C15 O N , M-EEN?T Q STREEiM d9/P O r STREET M ILEAGE CODE . / M SK DDIPECTION FROM REFEPENCE OR CROSS STP ET. CST - 16? SPECIALCOOINGUSE. •..JLES N 5 E W 6 A IO . D ?FEET OF SEVERITY ?VEHICLENEHICLE ?VEHICLEBK;YCLE ZOTHEP(WRRE) ?14Td RUN NO. KILLED COLLISION INVOLVED: ?STOLEN VEHICLE I IN R I PERTY DAMAGE ONLY U& O - AZMDOUSMRTFWAL SKKA ?NON{OW OF EVEV MCL'S ?VEH CLEiEDESTflIM ONECTSTRUCKINMEOFOEUECTSTRUCKMOOWNERSNAME) ..,.. ,. LOCAARONOFOBIECTSTRUCK EST.OAMAGE ? ROaOWav W EDGE 5 FE ORIVEflS NAME•IASi FIRST .. MIDDLE C-ER'SNAME-FIRST AYCLISt ORPEOESTPIM CHEI'KI ....,....- D D R STRE T AOLRESS ... ":.. R STREET ADDRESS E CITY STATE.. •. -.. .,....DPCODE '... PHONENO. R CRY ....'... .. STATE Y, ... LP CODE. .PHONE NO. R .S,39d ?GE v° /Y TATE N DH?lERS LICENSE NO. STATE SE% DATE OF DIRTN N CiWEflS LICENSE NO.. STATE SE% DATE OF BWTM 1RT. DAY MO I . MO OAY VR. C• O• 7 G !? A DHNERS DCCUPARON FIfl1A NAME - : PHONE NO. 2 CRNER9000UPATION FIRM NAME : ,. P NENO /rJdB?> exe e CODES J IOI -R MI SEAT BELT 151 EJECT IIXJ CODES J 13I c'ayy 101 BEAT DELT 151 EJECTION NATURE OF NATURE 01 II WURIES INJURES FP MSG NE VEN YEM MY' O HOVN ST1'LEI2ORLONV.) AKEIOODOEGIEV.1 OvEO OM SCENE VEM YEAR tlv: MAKEIDODOE{NEV.1 TO MOOELIDMTNOVA1 BTYLEI]ORGONV.1 7y od9e 1 224 Z/ y COlD1A UU PLATE NO. SLATE - TTIIREA PuTE.NR STATEN-.. E VEM.COLOR ., - PLATE NO. - STATE ' TTWLEN PLATE N0.. STATE rH 1 VEH ID RFlCAT DER E PEGASTE O FA-IAST_...?_..._.. N J rA 41 O C' ' 0 ADCRE55 OF OWNER .. ...... - . .a;.. . ADDRE59 OF OWNER . .. ... .::,;A ...:..: .. ?d?s 2 NAMEMDADORESS Fw CA}Op AGEM NAM EMDADORESSOFINSURMCECO. ORAGENi s a . ITA - CHARGE - CHMGE. ,.: :..... .. .... : .... - .. .. T JTA MQ ..,' ENFORCEMEM ..: .. t7 ?`O ACTION co o'S - 5 ADDRESS & INJURIES OF PERSONS INVOLVED NAME u EJECT , SIX AGE STATUS . C NAME: D P uRIE5OF REMOVEDFPOM NATURE By w1: SCENE TO A NAME N 1 ADORESS: HMO EDFROM ' TO E A $ tlV IURIES. Sf.EN IeL by NAME: ADORESS' T N 1WURIF SCENF9 M 5 NAME' S AGGRESS F• Hw N E 9C.CNF AY' ni . IIIr SlAIVS IJISEA}POSO%w IJI INJURY CLASS C 3 PASSErIGEP A 1 I.NO INJURY OEAD AI SCENT 1 5 OISaRL1r101NNRY d Nt1ND15APUN0 D ? PEC?SLRIAN B{rCLIST d ) ).OTHER POSITION . D DEAU ON AHRwAL 1EYIOElITIIWURY ItlLE PUURY p D y0}NpH E T IDVSMO UpRCYCLEI a RDSmoN KNOWN ADIED IN HOSPITAL OSS p E N WRNE49 1 NOTDISTALLED I OT EJECTED _ 1. N'OTIt USE TALLYEJECTEO a USED ?. PARIIALLYEJECTED 5 SEATRELTPAILURE A FICC EDNIP ry. ?L Y? tl n4.i ? fbk :!t 3 1 r' w4 r m , ' lx4?- ?G y Y A ? F'I+ u ,n : x p1 yy2?y , 1 1 (? ! ) ? r r, T c?Jllot "?:r 7-1 VEHICLE DAMAGE E. IN EACH pO%, CIRCLE THE NUMSEROF EACH OAMAU61JREA EA p( 2. SHADE AREA OF SEVERESTIMPACT. INSTRUCTIONS: LES, MPLO / r• r• - 'l. ] . DRAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FO CFICE. DAMAGED VEHICLE NO. 1 IUSE THIS 6PACE FOP sx Ercx NG DAMAGE TO THAI erC., DAMAGED VEHICLE NO.2 1 y, + ) f I ??p? E IF N A.'?` E flITY OF9A AG 'EH CAE NO.1 1) .Frlur^ ?? DAMAGE. . I.T.E. V1.1-1 IEOnpISABL NG OAGF ?E^0 ]?'.? O T A. •A j ??. 1 OISAOLNODAMAGE ] ? OTNFflMV DAMAGE I OISAOL xG OaMgGf ] urn T ? FuxcnbNAFDANAC • ? NO UAmgcE A ERMV.pq•N A E M GE oA . T O Fux<T AGE riOVAM 0 au NF E OS ESyT.OAMA IOWFO BY EaGE . • ll,O MgGE T - F 0 GE zs?.o A to aWAS?H 37ofA? L4 s TO DIAGflAM OF COLLISIDN i ? E cE TI 4. . J_ _ I DR WA ROWSHOWING - @F. i .SNP Q F'? Ed I 1 1 ?_I I 1? ' ` -1? NOflTH IN CIRCLE T-111-TIOLI -7 T -(- FIR N -:N I DESCRIPTION OF. Y I (-° 9'A) -,V l OLLISION',\ ` olsaelLiTY.R o cE vs bu.,* Fofs rlnN G,ANpA N _ \.?45G dONS pN'ppECJE1LU°E ??yy5? N orpN°Ac .c. °R v!n elf. POSITION BE QRE C IISION xp ° IrvcnEASrw° Tcn"fAS NG °N ` 4 '?f ±Q as) L c*`^ T 1 r n R WAA FOfl nO. i rr- E A N1 y? T N; E w Tl , ^R _M E N f r^ ^, ``???/ _ EV1E,y ?O u ?y! T"r VILJ ay nd Fc°. ??? ALOxc-. \ .rP rr.rn 170 ALI ^T nf I M?? __? d.??•? w y?yYa . w G SIDEW 7. 'f _ ]? ouL°eR- l 1 s ' ` ?`? E+C?TRt .?Y` AOAD SUN ACE WEATMEq I LK < EI_IO 1 t*' "" ru r i ICE OxEI EKE ONEI "? CONTRIBUTING CIEflCUMOSTANCES w ?e,_ f?( F En E. A _a7 FOL ER L An.isr L?I..,ALC4tl LUENC V.2 G 037 DISREGARDED A• 45y G bING FI EA /E - 1 . -; l?Ow ;C SxOWIN° AVE S°?G R[A3.0i111?_4'? APPAR n IIO??]C?? NTI-.N ?a Y r . y, i '_ _ G O OC1llIMPROPER PAflA NG 0.[] INK.N. LEF TURN 2 11, 1f 61 1 7' Tts ?3_? 11Sf ECTIVF FOUIF. ??3? T nGI ?1? •7 .Ii -TH p,A f 4TN[N ISiFClrrl-?? pN,ErISPELIlrI ??( 0 O[n lAxr R,w ?11r FL PF CO LL4!. I??t"I ? F E _ ?(a? s° xra '. ?. 1¢0h" N?. ?, ?1, T$?'. J1ffff - E I_61? N!. ?']i.J SlGrnulSGiGNA'L TOP I r I 1 O C 1 ?)? TROP OR ?h A ',?{ GH ca oxiTIONS RAFFIC CONTIT - OF ROAD I_1 O A O _ AFFC- .? 9p N$p jlpOry: SOBRIETY ??ly NO. , E LEnT I[MfCKO oR M4 MICL 5 4 t II!J11, LS 1ry ' ONE 'AY Ilo ! IssEf K?'#s9m o.2 1 c fl_ LJ9? o !•I 10 1 GN L Y1 T??` t 1 ° Ercxr _ ??J. ^ r. .l Twpw I j oFF t _ (_?.i)of- o ?n T 1• ?i1 5? ttf ]1 1 . rneniriea?r I -i -•? .._. VELD- _ J- _- +' 12i^ OFFl CTIVT ?'-.'- TRAFFIC LANE - '? 1. ' t ?(L-? -_ ?] R __ !-?.L..J OO A IE_. EFF OErS ^. ?. O O E I- SE O OO T ° ; FROM L ]1+L--? WSWS I? G N F NG )NO. G D.NOA IILD ?16? SACKIN°I TI N rl PAIUISDP TF! F- \ i .I S R[[ T y ?l,. "1 IxG s 1 [A G i3 I -. IS P __11?LIGNr3ON r L ,5` 1 .. ._ MSLfl L_ LJ. OIn,M DEN F sf1cN13%L a l SE w LEn ?s .r fl G F,,I 1, I. 4 aRA-x4 ) 3? LA--IN DEFECTS Esl CMEM 4 TEST -' L \ .. ?[ I II • ;OfI?1 f3T_ 1??7 nI54,c1 1 ' b ^ fTRfil 10 Tf .•^ C rK ] _.. '( ; Ir. 1, l_?° I L 1 I I {?i eg t. ..? r I 1 b X i x rvr lCH : ?} . j NvIOIW TIbG 011 I<IxiNw1? NK' Tlrl OuCIU MAI<xEU , , L4 u %NVID TEST R?ALTS . 2- ................ :n?• 'H .. _.4?`i vl At PIG ?.%Y I nruaTlNC Orr Kfxs NAME AxANA uxc'? ,'? O .-LR D 2 no .-__ ,^?? (?,tl 'u. 'N n• flN • ,. urr nR OIft fUbr UAlf Net." ?-- oAl -961 AUIt L 11 OISTHI,,-1 ORIGINAL Lf Y SEND TO WASHINGTON STTE PATRDL-OLYMPIA, WASHINGTONpflSM hv-I 4 S ?+ \ OUFIICACd'Y LOCAL LAW TO nCCHENS AGE.CV'SCDPAV-Tl1IPL ICAT[COPY, INVGSTIGATOR'S COPY ' I ? 71 E *?p ?; s E ?I F ;' I I .li 1 4? r lUYy?gpe?e,E??py Y1gY?-.•-+ 1 ? 11 }' i'EV'J?1 ;¦ , ??tr??",•'5fC?[3"'?... ,Z"I?'l. ??xe°,".`°T'7'".•??rT7m'TY ;'.. 'Rb ?.'xi'3° Yr'l%?''r:'S"" -e e r ?I rJ l I r , r ,. 1 r?' ?I S A u ., q .. A1? 3.. a -- -- ----? v.•v.?rwVC .. VY SJJs j A r 19U POUCECOMPLAINTNUMBER y ••,. UNIFORM POLICE TRAFFIC COLLISION REPORT .. DATE OF COLLISION DAYOFCOLUSIDN TIME MO 0^Y SUrv 1 MON 2 D WE A Ixq 5 FRI B SA1 u' 2 DO?OURI J ' COUNTYNO G NO I H A Q RBAN ?SIATEflOUIE COUNTY ROAD ?CITY STREET O RUML AGACLS P EF gOUTE OA STREET GOD 5 TION -- 3el rCI?S Oh ?OT.EB(SPECIFY) - - y ` _: ??? ? / y ? /? ( L9. 'N', S E W ?IN ?!V• LII?Y OAR/TOWN W EF% EO MILE r09 1 ... A :.. -? ? 9 " ex ?- MILES I / ?OFi eI ? C ' t^-^: E NO.OF 6TREETOq N10F1WA-'1Q- ,' .- IMERSECTNG WIT -STREET OR ROAD- LL R GAGRAM TA A . 7 t ON ° : - Ei1?O t BCTWEEN -STREET SIREET DISTANCE _5 E ...wy F 'L .- FEE ? J O ` ;P h•?-`r. vrp' ..rq DT.?1'wL-. J ..??r`?_?__? -4 COLLISION INVOLVED: •..?VEnICLFtVEnICLE ?VEMICLEBICTULC ?.?OTNERIWRIIFy ?nTapUN SE ERNY TOTAL NO. VEHICLE O&IECT ?VE CLE RRTR N NO KILLED -. ?STOLENVEHICLE' / NoA uRED OF4[NICLE6-{ j?•_ f? r ? , OYERICLE-PEDEBTRI?.?.?,.. NOHCOLLISHXJ .{?NAZARDDUBMATIRML' "' U L.J \ ? PROP RTY DAMAGE ONLY' '. OBJECt STFUCKINAMEOFOBJECTSTPUC%M'OOW LOCATION OF OQ.IECT SjAUC1 { _., ?„---.-w ,y:.•AO,,.a a.. fST,.oan? A GE r , [ -- 11 I1 Q ? oADWA OAFEET ?r I E ? R TO?4I I ' _ O.EDGE l OR V_EHS MAEMBI ? -,•., FgST ??--MDDLE-.. - NEfl 9YIAMEtA9,7-FIRST MOOLE11F; BIDTCLtRtbFIVEPESIFAAN CNECFFCIT«'-: ' u_... _«....._... 1:.:.YT.. :. 1 , .. .u.,r. tit RE _, . crtY:•,._ .:._:_? '? FTbTE' 4 `1=..?...zmcw ' pNE+lo E STATgv. - '..:z1P000E.u' . PnoNE NO eG WA• to +A - , . (? f??.. ApI•• )t r i N O DFIVER511CE DATE OF-BIRIN - -N ' ORIVEflS LICENSE N . , ..., 6TATE :- .:SEX ' DAIE.OF EURTH... .. UO. BAY YR cuq 'lTl O•,. .... .. MD. DAY YR DRIVERS OCCVPAIION._: __.......-,...--PHONE-0. 'j OgNER5000UPATION.:.. n NAM ,:i...._...?:,_.?-' .J. ?.:........P NEN , 11 CODES >1101, S AI SEAT DOLT I51 EJECTION ' NATUR Of _ ' - CODES. > o, CL SS F 151 EJECTION AiuR OF LASS IAI'SEAT B .., JI °-S 7 I-RIES -,5A-i 4j I:.J I UR EB.. ,... .. .. I FROM RCENEBY. SA Q7 TO • ' ' F OSCENE ff - VER YEAR MA%EI EVI.,. MODELIOARTyDYil_ 1 5 YlE 12 . - TO Nft YEAR; A F?pODOCLIBVJ. M E AR NO AI' STYLEIt Dfl.SANV 1aY... / T S E VEn ,_.LIC. PIwTE NO:._„- STATE"::. TNNLEfl PLATE NO. STATE E VEN.COLOFf .. lN:. PLATENO STATE.y...?T LER PLATE NO.u STATE.:•.A;:i'.J A 9% /7 WA C vE IcLE:IOEnIVICwTIONIIUMBEq..Ax .v,.q. •?. (,' MLEUDENTIFIC AN NJ IBER - - ? ? OOMETE S1S:Y L ..- +7:Le U... - a A al CFl i. REGSTERED OWN RASTyd.Jy FWST Yl.. < 1...' -:-MDDLE b R EOSTERED OWN -LFSTJY JFRST o - r F. : T . ? 0. ADOpEbO OF OYMER _: ' . . ., , V: ,, ? ..?_, ,..._.•,uu _.:?,.c:r::. _:.. t u:_.ti? r A DDRESS O WNE9.:'«..?U: ..:.1,_e:T..?_- ?.....«a.:l"•e. MIfJ.. vc.?,t1,.+d ' NAM AND OF INSURANCE CA.ORApENI - 1- ., N AMF DADDRESSOF INSURANCE CO.On AGENT •_. 1 M1? C Jwla'.:L:' GTANONN ..ENFOnCEM CN ll, ACT '1 nTL' ?;u _u NAME 'ADDRESS & INJURES OF PE RSONS INVO n T•.,. S "-:` . coofs LVED ^D ' ` I ?n.t..u•? .! ,u SEX AGE STAtUS EJECT.1 `. NAME' I.'C coDBEs9: :U' TURFI - REMO F - 'p VE. .W wufl¢s - FCFNFDY 'TO - "A ' N NAME' ' T b ADDRESZI . 11, IEB - sciN° n FnoM TO W.. NAME: I ' ABEI T `N .., NATUREGF A MCTV DAM ?_? SCENE m TO E E Avcw- .. B C i C NFn TO I C ' D Im lus DP(pCB1 lAN O f LIST olsw rovloM F Cn¢nnosrtloN 1 ??\ - UIPLAIB c1ASA z InJA ENE' ~ 1 D nE DO NM A11 v8ZOUN. -11 -A", If vIO[M NIUR IgsuiBEU •J '!O}Wu,j, .,. .? V MEJECTION NC7EJfCkG- '7 5IE ]iOACTED Qik E 1 B eWATMB6 Y B D BUS MOjpriCYCtEII nPpBIi ON UNxr10NN AGCUINOBATM I Y 11 PQ.SR LE INJURY J SCD UNxNOWI! D rAn iv FJCCYFD UN%NDWNF 11 B 5E AT BELT TALUNF EJECTED j}. J :SN D' ?f ' g { ?TYT I ' 3 ? { )Rt I J ?I M T{ :d:T?'Pf Pf ?ffiW ? tl p >iV Y N G b m r. i9i ?`C. . ... 1 r I 5 ` INSTRUCTIONS: >SHADE AREA OF SEVEREST IMPACT DRAW ARROWISI TOSHOW PRINCIPAL DIRECTION OF FORCE. 'C DAMAGED VEHICLE ND. 1 IUSETHIS SPACE FORSKETCIINGDAMADE TO 1Rw1-MOTORCYCLC5•E1 C.I DAMAGED VEHECLE N0.2 ,( ^-=" } `? (j??I7'/?I U Hwe SfVEHITY OF DAMAGE; VEHICLE ND J SEVERITY .F DAMAGE- THER VEHICLE, SE ? VERITY Or DAMAGE: VEHICLE x0 ] - IrvG AGE ? EpwMAGE 1 ? 0 AG "I.E. E I.E. M.V. MADE I D SABL NG DAMAGE OTHER DAMAGE EFF IN fONAL DAMAGE a ? NO DAM G ] ? FUNCi . U NO HAG[ > C) FuvOTIONAL DAMAGE a rvO DAMAGE.. I {Y D ,f OwEDBV' ;J (T?"`T?)I l"",A aMaGE TOwE00Y OA EST.DaMAGF TOWECBY EST. DAMAGE '?" • • (V \r'4.n L )?Z a? OL7v To s - ys, • ? I y'' • DIAGflAM OF,COLLISION I J I _. 1___ I .: I tDRAW ARROW SHOWING Y E, Pt NORTH IN CIRCLE * e ??tt -7777 .1 M I, A ' •" P .:FLfTnN DS I I 1-V' I ICI I?I??(?' is ;?. •{Ta `.y5 L S Lrcl rcn,,, 7 o Ee0 T I?IT I? j 11 Tj, , I ! '?' ]. EUCA,L.A 4 ''4 fa.,, - •S. s.OwYF. T,L .LBSSTR .N Dn __. I- _ I? ?- I _? r? .aS,IDrvs A, ..AaT--^ ,' Ir r--- .TJ GA,,.ALDLL,D, E_ _-? sl i- ! '? I •I ,T -? -I ..R r ___ T, 1 I r A , f3 _ •.?• DESCRIPTION OF INDICATE WHAT PROBABLY HAPPENED BEFORE. DURNGANO AFTER TIE CFASH,INCLUDE INFORMATION NOT ON DIAGRAM. E.G. DhIVIFt COLLISION DISABILITY. REDUCED VISIBILITY, PEDESTRIAN CLOTRING COLOR CONSTRUCTIDN OR REPAIR WOnK. ETCI •' rP • "y •7 - • ?. - ' 4. _._L'Si?=?-?)? __ °/ (rte ?L'6.?M __ /4i _LP rJL_ L'+-i ?/C: ?/?•c:' ?" w a r /r r r F' _ (cam. tt ` CJ r P .-_ - -r ! POSITION BEFORE COLLISION - IO. CC LANES ED E ED NO..NEwDEO gEASI Cq EASING ONSIRI ONHIGHWAY NAME OR NO. IN OrvE RECT ON N Y If 5 " WA YEN. ILEP111 IF p OCC EO y i sE BY 51 NO YES A 71 4 J w. .T . , OR ?_JAL FROM- To MARKED ALK s E TE E T-? ,. ' I ICYCL15f WAS USING . K ] I L Ar DI ?SHOULOFR AI ICROS II)CYCLE FAA- -_cgo,. NE i E '*S I.t ROADSURFACE WEATHER :.... CONTRIBUTING CIRCUMSTANCES "" OTHER - DRNO, , 7 I-- ONFI CHECK ONEI ICHEC N On 10RF3 } I - ] L Sun (, . 0 HO ER _ ER - DR IE? ER W Y?.. I'.!?l n G G qpc :Y ] 0. 0.] lJ STRAIGHT IEAD - ^S• - u E fNCE _LO FOLLOWING E ED wA OVERTAXING F_11 -NO _L1`_ DAY 0 ERC41 __ L a_ALGQROL _ F ^-1 ?1..? . C14F T A: 6 :U OVER ' I]^ IT PAN \• xIT r ]rl INFLUENCE OF ' IB? ER APPARENTLY O ,1t5• OR L UG E _ L I _a I_J R14xT TURN T 1 I G > E CE D:AT ED BI- IRI'L ING 10 0 E 'ARKNG AI KINV ' _..._ _...-_.. _...-.. ...___. - sr[[D IT j::1 ..?._. AL L J..1OCR QN___ E-'J '-) i'EiiT FN ,.,. 5 rG nEAS. 1 --' T O". 1NG C 1. E F .. :. i..I a ....... _ _....?_.?. [ .. _. -? -_, I. 'B . I6 A n I ,'r. YI Sr 1 1 I ! °4_ E D r nv , DISIF O EG OG l 'D OL _ E F OuIP SLDW NG _ ` IT OMER IS:Enrn OnE lsP aw r I FR B MPNo ) ?? ?I-J'11 slOPrmF I I r .11EHISI.CIFY L DLAT)DN J ]t_, TRAFFIC fL ASSING r LI HT CONDITIONS ERAFFIC CONTPO -I CL ...HYPE OF ROAD VEHICLE CONDITION 508RIETY..: _ ( aPeED AT LGrvAI CHICK UxEI NO.]vEN CI[ rN ] C fCK ONE OR MDRE VEHICLE g YWItLF ICNECK ON[I I-IB? On STIX'SIGN B1.111. N _ SIGNALS TtOACY^Y n sBIE NO] ] IIAFI IC LAN IARTNGiNOM L I NO _.I AKII IMPAIRED_ L am.. _ __ L s « . r Ap D l cFn l "D A MPAH)m_ }}D ff , ITT POSR ON E J"I 5 > IGND ] > LASHING -. I HCHANGE p(FFC1W( ) HPO SUBII EiY I] J ,F, 4 `ARAf FNC I-IFFINO Y I l iK 11 IF T n TS _ - ...r No, 1 LIQM1. E! 5 FP"G 5 "ON ALFBi f :I O -INFIFY. UO II f LlCEM. TEST -115 I AcKINC F `'v 5 OGvrf pRE D lT SIGNAL ' 5 1 L J 4 2-b r- 'B. D A O O EP a- ' '6 G CN OivER ISPICITYI -RARE T ,• E s xca 4 Ts :_._ cMA _ _ M1 ]-J ,Fq ...'-...DV?DE I N 1 a NO Of FLLTS TESL REIUSSD A r /. • ] nEU % 76 TEST RESULTS 21 I i JFNI , 60 rILIHf NAMEA A N Isn TCI E ARRIVED IIIIIIOflO uIIG _ nI? ) I I. 1 I 11 i•' ?1. ATr E,nI / ].mA >.m IMF.' . N- I IN Yvlrt AWA'I I .Z3 ) ewNOY ) UNIOnOSIAGE' ED OxFROVLDBY J RASE ' DISTRIBUTION O)RGINALCCRY . SEND TO WASHINGTON STATE PATROL-OLYMPIA. WASHINGTON 985N CRI tICATt COPY LOCAL LAW I Nf ONCf MENT A.ENCYS COY-TRIPLICATE COPY INVEST GAJOR'S COPY .?i dI" 1w v_- i S r 'at fir,, «. ? r ? a I I t'1 I, r L r??'. EL,$ ,• A ? ? v I, a ?'-' ?r'(? I ". - >?"""^E1?sN""' ? ri . •?•• . I:r?' ?- +`F 't ' +? 4t F L „ I> r 1 r I. l p91E,¶? _ ?C? WN Arl a-, DATE OF COWSIOIJ DAY OF COLLISION TIME COUNIYNO. Cli O ' E?FtY .i} F SUN t MOx Z IUfi S W A (HUH 5 FNI D SAl IU2a (I?HOUIi) ?b /? i - - CO`1U?cN`T{Y!'E, y?.??? ?STATE ROUTE r•11000NTY ROAD ?CITYSTREET - ? OT R O LU URAL ApM LLS. PREFIX flOUTE OR STREET CODE b TON . . yL,` `Y?.yy HE (SPECIFY, , / - L" CITY OR TOWN N S ? ? C W REF% EO M EFO$ ,IOC E 9 ? ? OF .. MILES ? - A '- ! O- A A .:?.- MES O:OF STREET Oq IGIIWAY.. INTERSECTING WITH-STREET OR ROAD. ItLL. HINIP AG -- ON tiZ? 1Q - O N NONN%TERSECT p L BETWEEN ?J ACCIpENT MILEAGE TER X F' i[H.:EC IIEF. NUN C E FI+CEG S SiI?T?O O ?i " _,_ - STREET-. _ yJ' `IJLJ VJ Y - REET OIGTANCE ANO DIRECTIO FROM REFERENCEOR CRcOSS(SJTREET, ( CODE Ei O GPE LCOOINA E L COLLISION INVOLVED: ? VEHICLEVEHICLE ?VEHICLEBICYCLE ?O NE.RN.TEI ? HITARUN SE LRIIY C L' p+, - . TOTALING VEHICLE-OBJECT ?VEHICLE NR IRAN ?STOLENVEHCLE r NO KILLED _ F :?.N 2 L' ' OF VEHICLES ?yEH CLEPEDESiPIAN ?rlONCOLLSON ?HAS RDOUS MATERIAL _NOINJURED PROPERTY DAMAGE ONLY p` s x OBJECT STRUCK (NAME OF OBJECT STRUCK AND OWNERS NAMFj _ _ ` :. - J ?•` ^p r ^ .... ., :. LOCATIOrJ OF O01ECT5THUCK ,..'. V! , ¢ '. •..,;; ?. ESTDAMAGE _ R '!fY tT IFCC. ] ` ?FOADWAY/F T ??? R v ;fll Ny -; OHIVERSNAME- AST ? .? Luc ::. MIDDLE -. ' D EE RIVER'S NAME--T FIRST MIDDLE, III BICYCLIST ON. O.EDG S IAN CHEM -?- F x,AY,?'` f u ?; . I ET A : t t l R c V N DavERSL IV 0 I DRNE0.5 C CODE A UPE O INJUNES . FROM SCE VEH,YEM V t E H at w E, . E '. . i N REGbiE11E _ ? 'M I. 0. ADDR? 1eY J '. fiD; ,LAdL-E4 A ?• o: ? AME AVD ,.,.,. . ,. ,.. _ . . rass:. .,_. : R , : . . ... gc,? 32 l ??- Z`I S£ flv;?c s v ` .STATE _. ? ZIP CODE PHONE N0. zI C ENSE EX OATH ft. N Di A P ? oar ?f D. :U-AIION.-. FWMRAME .. _: .... .. : .. .. PHONENO. Z DI ? IJ CU S AI SEAT BELT _ 151 EJECTION tsu Kv*-E _ ? ? -? o _ N, o tats 1 _ o- k TO M ... ELIDAHT N O 1 DR ? ? ` W. STATE'^ TRAILER PLATE NO. E Vf N?'871 WI ' - viIFK:ATWN NU BER...U..,u Aan .•. . ODOMETER ..'.. ,. C Vf L; E OWNER LAST .... _.FWST ... .. ... IDDLE AF b^ L C., " ?• OWNER •.. ..., .... .. AL La+Ur ??5? P47C .L Svc XS'CPA lF, Ca9? II CN RGC ,? N w C. LION NO ENFACTI NEM "' ? ACI ON let 5 ?. .5 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED 'S NAM€_ AZ A cc C G oci,a p yAK S A NAME N T ADDRESS S N TUAEOF I -Afs W NAME I ADmw T N i. sw- S NAME 9 AGORfSS E NA1'" '2-1 ) $. INANel4 IIISI IU! Al S 0 HK : SffNE Ilr 10 ., ,t C EP1S5f NCJ.R F l. I I t 5 JIMNPNClA55 NOIIUUHY bDISAIIL ING RUUHY II SEA'DELT NOI INSTALLED ISI[JECIION ( NOT E TE E U „04t u I 41'x'1 IY 0 D Pfgb11UAN dLlLtbt 6 W1ITNE 1 1OTHERIW,IKn pHINYLtFI ! 1 P JULADATSCf NE ]DEAD ONARRNµ A pF.DM RUSPITAL RNON D15AOL 110 E DENIHNJURY ) PVIDELE PIJURY 1. NOi.USE DUCEO UNKNDWII . J C D t.TOIALLYCJCC1f.0 DPARIIALLYEJECTEO A UNKHOWNIf ¢ { } r Y E SS - M1 OSITION OONWMN 5 b[AI BCLI FAILURC EJECi[O ' '? yyN ',, '' I? t? I .I Y r tY?_1 A ? 1 tl* I S 'r d' ,fl r P YN 5 141 Y N(t )1 T: ??VWNA?'•11 I . l ,i1 7.II ? R/RA!n1?cv . I , Ir ' ?. 't . • t ?$ +°'"P>,yy,'m"" u a81? ... '",'iPo,'... Y?i, a ;:' ?7 ..: rte`'-. p°f`?, =ry' ; ?'t la;F."?grr• "fr-''r' I ,. ?+ ! ;.. I z; it • 7 E Lam..... -, .. .. . _ ...w,.,. , I r i Jr DAMAGED VEHICLE l a s NO. 1 IUSETHLR SPACE FCR SNETC- DAMAW TO TRALLERS. MOTORCYCLES. ETC.1 DAMAGED VEHICLE N • O.2 ]. HOaa ?'1 I It a I' ' EYn ? 1, runk .. - a I O I ti f 4 R-1 Ie.T- t V VVV tT ? T e ndaruvrW:t t3 tt1 o 1 f o IB.UMUVrrpx 5EVEPotV OF DANAGE: EHiCLE NO.t I?DOASUNGOAMACE D?OTHERM.V.D-AGE 2 FGNCRONAL DAMAGE, ! NOOAMAGE SEVERITY OF OAMAGE:IOIHER VFMICtE) I?NSASIYq DAMAGE DQOTHERMN.DM.tAGE 2 -ucm1ALDAMAGE t t10DAMAGE SEV Pott OI.-AG&VEHIC-11-2 I?DLRA&1NGDAMAGE DQOf VKV.OAMAGE ] Nu CTIONN. DAMAGE ! NODAMAGE _, TOWEDSY :-f-i •- -? ESi,OAMAGE ? TOWED EY EST.OAMAGE TOWEDSY EST.DAMAGE TO ,I I lL`::.. E Dv '? S TO S TO S DIAGRAM OF COLLISION _ - I ! -r DRAW ARROW SHOWING --r NORTH IN CIRCLE F c sua I I ?--- ?I I t-1_.. I rD.v uwancws - _ - 4 IacnEAt°"°". eTC COr:TmucroH : - ? r ? I ` xlDtt,revRDeraLEwwror ADr YTavclEVExsrR,rl aR _ 1..?-_ ? * ?--? L r-, ^ _ ?T.._? t -- i , -.i I i <rvonwN+AnMAC ° OnE vhfM I ?y I 41 F- r - ! ! V T I? FA _ - -r F-((_ ( r I I . .fir i1 e"!' 1. ! I 1 l DESCRIPTIONOF IINOICATEWHAT PAOSASI.YiIAPPENEDSEFORE.WPoN(f ANO AFTER TNECRASH.INCLUOEWFORMATON NOTON 04ARAM, E.QOPoVEA ' ..COLLISION ,: LREOUCEDVISIBklfY,REDESTRIINCIATMUq COLOR CONSOIUCT ORREPAWWORICETC.1 DISASIIfT , ?rLC_ ? ?L1.•..rscr.:? ii.!J i?C ~/r. ?T '.i L. a:7,(f .iC1 _ .. POSTTIC, MI...HEADED BEFORE ,.:.. .: ..: ... ... ,.... .?..r"- MILE POST D.R - ON STREET OR HpHYYAY NAME OR NO NO.OF LINES IN ONE DWECDON S POeI]O P fArS VEXIC LEU U D W ? U K NO r . . DI CREASWO DECREASING /-Y i r _ , . / i7 -- PAR 1tE ? 11 O C C f` ? C t r! _ -s J.W -? F_ ? <•r: ?- C:.?!I? / TES Ro res No 2 ^E] "[] i- n -MFH t_ I ? ? - PEG. ? r L I I. aivEE'toA Af pat "IOND._.-._._.?_ ______. _Cb55ND_ _ _ COIWFATOBECOnaNa1 T Yrl ?]O_? PEO/SICYCUST WA.9 DSWO. t!^.sofwux I 1 iswlmt " cNOSSwux ^CROSSw® "P?plrt r OiR N -flOAD SURFACE IaE«oND WEATH19T:;;; IuEaf anD CONTRIBU .. Iu TING CIRCUMSTANCES; a« aL OA UOIw - , - ?; j tl DRF?eslxaxAelcas rln-x vorAE: ?MOr? ` ORVEf nNErr ? ' rl ? Dm.Dt - ..,'A , 1 arMNMRAHHO <_.I ._l °? ,JY 1%. arm I .swveear ,l !' . l #AW U. °A+wOa ._._? L wfr 71 - 71 O?T,D,,.rMENCEOf - I • { 'ar a? emrA J DIE, :n nA,Fn °s°fEDUar ,'^.uwTO p- -?,r-7. ,_ IcD:rnX PMnq ?•?Munrom Imru _ _ _.:. _..• . ._... • r I. ron_ _ _. _ J_ wFx?®.anErs _. _ O° x n?1e?J c Carviro. -7 wu OR.. ? ° O ?eL e; t i?J__r^-,__DO anwrni- sl DrD.ef<_ t. Drxaem _ sro-.oouDlrr -t? - I--1,? mqt ' .J oINEArofain oTHfArneon - jf? ."? " `-_u: ? f'w - ^ w?vuur?Owin ?T? rt ?Dru LIGNTCONDITIONS TRAFFIC CONTROL.. -i TYPE OF ROAD a w VEHICLE CONDIITON. _ _ .'y,>'w:J,L",=,'; SOBRIETY i -w o z` ?f? o-?,°?„TyONu Iaa«ar.D w veRnx r?_I ?_., t U lNW! tw.x NPeu .e oA M q L:] 1 ? oaww vEfFrAE on cairn ? 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L Al I X «asra,rwoarcenaN.Mf IA.,., x.oce vo .sAVC• uXroaoartuT wreararcar urwvTSev - care OUWCATEIrY LCC?t Uw ENFONCEMErR?AOfNCr'S CVYlfAAJCAtE COSY. WVESTIOATOR'SGOPY rr.4? I )(? t ? I {J ^I r ''l :,f.'0. .. }?'?.'• GNi'rsLL.n'.'"N. ?'- , d°.1 ?'n^ .. !? ... iRMSwN.^"nT?!P?" 1 C ?l ?"tL ? ?+r t S ?yI4 ' ?i 4 ?t J ? ta y ??S ? s i 7 r t ?r t 1 .r 1 of r?J, 1 f ? ( ? D?E?1tEr?j I ?k`7e ^ } ? lI In s I I D DATE OF COLLISION OAV OF COWSION TIME COUNTY FA/ GffY NO. FNWA ?U 'I, A MO y;VY - - R. " Y SUN I MDx 2 - 0 W; A R.15 FRI B SAT 11 ILL ?.yG0?MD11R1 % , Z UgAL i E Z 1 -j G-TI TREETT COUNIT ROAD ?CITYY SS TEROUTE O AOMSL9 PREFIx CODE ROUTE OH STREET CTION . [• JE?se OQ ?STA ?OTHER(WECM ?IN CITYORTOWN W M4LE POET r7 S O of UILe` 3 ®??? v ,/ C , MILES NAMEANO.OF STREET OIjnIGXWAY INTERSECT NG WITM: 9TREETCRROAO O RAMP DIAGflAMOATA ON 16 T IDENT x•RD "TEPSECTIN69RL E OR ROAD OR REF• I- NCN INTERSECTION "?-- ACC MILEAGE I _ CIS. EPENCECPOSSSIAEETOPROAD O 1 N `DZ It LE PD. Si^L?G tG i CODE BE'.VEEN ,CE ANOOIPELRON FROM REFERENCE.ORCPOSS STP Z OI.ST M N S E W l ' V SPECIALGOOINGUSE OF 5? ID [ ?? .J T E? ERIrv SEV VEHICLEBILYCLE ?OTMEPIWRITEI ?HIiS RUN NO. KILLED ? VEHICLENEHICLE ? COLUSIONINVOLVED: 'TD ?VEHICLE-OBJECT ? VEHICLE-RR TRAIN Ec ?STOL4 VEHICLE PROPEUREO ?ROPERTYDMLAGEONLY _^ A L O 51_I J ? VEHICLE PEDESTRIAN ?NONCOW410N ?X:SARDOUS MATERIAL • DAMAGE O&IECi-uDKS f F T STRUCK ANOOwNERSNAME) LOCRTION O F p 9 JEC O OBJECT STRUCK(NAME ' .F / _ - ? L J . ? V =>< ?ROADW/W OFEET ? ? ? V EDGE S DRIVERS NAMED FIRST MIDDLE ORIVEH'SNAMELAST FIRST MIDDLE ;F en: rC.•>T CH FEDESIP4t. LHECKI:.. D D g • D , i P?= R STREET Ao w, R STREET ADDRESS v 08 15 v E PI,ONE NO . ' E CITY STATE LP CODE PHONE NO. A CITY STATE ZIP COD R KI ua s?l-D,v -w?. T F BtRTH EO YRL DAY N DPI'. EPS U6" SE CIO. STATE SEX O'TOE OF SIRYTH N. DRIVERS LICENSE fro. STATE SE% oMO. A O. •A. Ok V 10 p NO. - -. I DRIVERS OCCUPATION FIPM NAME PHONENO. 'J. DRIVERS OCCUPATION 1-1-e ? ODES >'=''D"•IL?ss III SEATSELT ISI EJECTKIN'. >111 IDUHS I41 SEAT BELT IS' EJECTIon C CODES NATI.PE OF ,,..1 ??[L :A L F{( TU NA INJURI E S IWUalES .Y- E" . . ('L Y p U EM SBRPEBV TO ENE BY: VEH vEAR MAN ESHEV.1 T MODELIDARTiIOVAI 5 LEI (tCONV.I VEH. YEAR MAKEIDODGECHEVj MOOELIOMT-NOVAI STYLEIEDaLONY.) ?loz Lk VAL pdZ. v v E . LATE No. R LID. P STATE , TRACER PLATE NO. STATE E VEH.COLOR ua. FLATE NO. STATE TRAILER PUTS NO. STATE _ ( ? C YETI LE ID TIFN:Ai NUMBER DOOM E (.• VEHICLE IDE ITIFICAII N NUMBER ME ER L IIS-LS-7 2- E E PEGASTERED OWNER-lA9T FWST MIDDLE MIDDLE REGISTERED OWNER- ?T N ..,R-?IA?, JEf41 i-,A N O D* ADDRESS OF OWNER o t E. LKUtJ I Srrcr ,-cv . .z ADDRESS OF OWNER - R AGEFR' O L NAAM.OADDRESS OF RAN NAME AND ADDRESS FINSURANCE CO. OR AGENT ) ? Z? C GtAM1N NO. EN FORCEM ENT CnAROE ,_.. 01.9E ACTION DO c OE9 I - 1 S d DRESS & INJURIES OF PERSONS INVOLVED NAME, AD EX GE TATUS p - c NAME' rvl rO AOOPE99'. FROM 7 -1 V R MOVEO SCENE BV To A F P BS' irUL: A NAME T NcOPESS o $ uU?f 9l, NE BV TO I W N.ME ADV,e44. N H M ^' B SCENE By TO E VAMP . 5 s ?A^'aE44 A E Y y 5 ? SCFI.- J,xJUH.LASS . if.IDEL' n, EJEDrION , .. L. a SSf NG[R f MP .e.l wvlKr. I NOINJURY S GIS.BLING:'IJURY DEAD AT %lunl -E T No, ?E O •A 17T M5TA?E0 ?S? J??N 3 ? To EJECTED i UN IOViN i ECTED ! A S T 'O :?LE B ' 5 ` I ?iURY V P SYB i OED IHO ai O AT BE: •A'LMFE $P EJECTED . 'iE49 I rJ ? ? S o 6 ) . 0 , { .4Lut n crY F5'Il1fF0N y My9! %•?? I`IA.AS ?` ? M L , ? r ( ?Y k ? O 1 - J l I C _ ea ?SA E• ? ? Iun ? T ,Jn. - / l ?L•=, S MLE f ? ?Z)T O ? wGIUfl l-T- ? ' ? ELi IC, PNEflx _ ING T _L ?LS O ,.. ' , ' - 7 ? MILEf PN ,x ED ?-F/- ?' -i Y.:.] , , \ I?,_?•.y ?. ^ L._C?. t^__?:,: - -- --' I Er .LTIDN LnLAr °N °r L y?IDN NAMF DIACRaM Dwi GTHELT - RD K. » e. -_ I;. Po A.,;Ii. e:o .. »..a.oa• o» I .». ,, »-.., II» f ILwI ` - Rn --7 ao; .-E. n °E CL4 2t i0 EL. LnDE .SE ? OUJEGTSNwME RAND-.ADORE I AY ••?? ? a»co «Y V: RJEC TN O I eu xl.,, ....OWt ER, i r. -rY- ?W e I R ?• [J 1 r \ r.-.\ f. o.? fir' M ? ?i\II\1e?r? ANDD sKA s r M & THE T ° OOx EET ORES : ° _1_2'T.. re -1 1 - n on IVERS C A ION ?? E ? k I ,ry ? E ? - OOE O E .... T N' CITY, DE • 1 " OH kH4 LtC E ER-,•_ ATE A F B T AGE: r? M P LE » S.l.. •) E Iaevl.POaoal M DE I»ww ? B DY 5 20 .I • v .. a .n MA`K .... .. I OOEL`I ... h_y ICE LA _E;NO ?\STPT4:, .. FiN 5 tE L :P - ?- R g DOM CR 4 V L NO.: „,y ?L VEMI LE,.IOgNTJFiCAT10NN , .11, OD E R D ' RI-GI j P OWNE ..t :' O _ E Iv :.. •.RE E OWNER n J' ' T y r F..IR r NER DDn -, T »osrs E, s Dce L? ?u- }. 1r? I n-. C -??j 1c,nn E?SUIILS? w DA. TYI „*? T F V£N10 EDAM 'OTl?w * /Kw• w,:.h - v ••^ n ve» cxc - S AN S 4n5 - L u c "? LIABILITY INSURANCE INFORMATION-VEHICLE NO 1 co E E O •?. ISA L ° YES NO M SAD RE:.S -L SU PO YN OE f . - F L L L/4 `? (II? N?LGJlY1 14 c E Y M l C+ YI. 1 a O E 4 GY1)tY?LC..?' ` - __ No t- -I KE ea ?iJ'1 ?? F y P uoc 1 - o ' E T ST UE F E TA US N U ED L1H5 O a- N HI E EO 1 ' VEHICLE LL a I - 1 r' rl KIO 5? 6r, I 7r SO 6? I 7 u Nq lJ, OFS E, OCLOW W T NAPPE FO flEFENT EH Ea, N4NRkR -•,? 1 vrl SY I. n O ', r?7 .\i' I i \L \t0.:l.C1t ?..\•(? -F`(GC\t . ?, In.?Nn A......, 2'_ J I ( t c.T ?Y y ct7 Ct?i\c? Cc?S1r?_ J 1. u LSI?-` BEFORE COLLISION VHIL. I T OSITIONS N fl ??? u '` ,???? ?1 ?r••r? I"-? rln. 11 ti , ; ° INoIJ oL.r.LA.`L i;-S:\ a?LJ n n i_ r? r? r? r? ?1 r F .n U?on0r o L r' i 1 .. o»n TYPfA , D T IDLE fOTO % ? T y? ,- r ri,pa ar.? 1', n m cr T?ir oonunL», r L.o r o ° ?! I n I ) DOING sTf C11T ANI.An J I?J? r S, [,n I? [1 I r WAY :I ,,r.'WNGIIr A ; IA. Sr Nf. J ( , -1 T O r? ! E-FIT-11 ND 4 [ 1 I [..? _ xNU -.1 TUnN I? R ( n slcN [ 1 r`? n M i. li"_l fl ET [] w° Li MAKING LEFT TURN 1 ' ` Y I I G U•TUnII 1 I J ° [ AK N I[ 1 I J r I i , I WING (I [ I I [ , I I i 7 I l - . ' ? I o r.n rON TflnFIIC h ?, ? •..,• l.__.? -._.. __.__._ ?.I ?" 1..-? I [ 1 Jen ?[ I n [.J roP o IN nonnwnr - ? k.? , I }r Ii C.I I l D ?JI°I1: .q,r P ?l T 'ti ?,? I I . ( I Ir n ' -I 1 .,r I• , I Y y , N (t y , S r? SS 1i ) i 4 g4:I - 4 t. u F i - 1f AU'n:..c?,aw-.uws,ayyrl.? aY3'-.-- =Fswr. -:1 INSTRUCTIOMS 3 o t u Iron o f Lr I f,r?I CL . 1 . U ks I d` U'r" 1 ro 1 ??.kw r.YS n __ ( \ 1,1f ED V.. PILL ND I rn•s waLE rcq ,+ n na-E r- - T ?°' •., N,., 4IVa LE ...u Dnl. •.L -- - = ? '-.!-° j 1 Dl IA_GED /E h11CLE N0 2 r i o° ??'',V I ? ° n 4 U _I __ VI CGRAMU COLLISION u_nl s - DHA /I AiTRUI 11 SHOWING NORTH IN CIRCLE r (.ter n - rur ... ?E ION OF 5?ro?all l LUSIO o isaelii xlGnbl nGN moro COLLISION HtO Tv,UcED VrSIaIIYEpEUESiHr.t.rcLOiHINGCIDLUN',LUNSrFr;CIIONOHENenalq wUlr K,E1C.r n nucra.•tl.EGc _ ,_R - 116J,?,C?E / ?/b2THPA(t?uc> _ 0.111 QFS?/? - iR G? D ZEf f ... - .. -- POSIT(ONEEFORE COLLISION - „ - - - E OEO Ea q s •r4 U C [.:SrxG 1 v r 1 s - NM h Ox NO O 4°? E W .... .'. v AIOIG OR EO OC ED NET YES n0 . EO•blLVC TrA UK 51UFWAt pr K UN Iu NKEO F '- pESrux4iED I CLE IIOUTE r OT— RO CHAOt URFACE NG W r.E'rTHER COIVTfl1UTlT1>vNECU IF TAN(:F. S?^ CV ,1 EI 0 ° ° xot) ON, I ] O OUDV - I 1 vCOHOLS LUFNCE OF OLLCO:.NG Irl OFU WAf+ J N_ OW 11 G r?) Ei ) rM1G O E C C G ING 3 C C ID Ell L;N IT , 1 -TO )vegtrLj LEA GOING GN E D A C ASSING AK.N GUIx 10't EOr. A E E a5 5 O - q ' ! sa CllUHt 1O 14 rl'/E EOUIV 3 ANt q;w f SNYY Oi HErl rSaECIEYI = ! UT11EH iSatClcW _ -NOT rE 11 SiG4IS COOL IGr1i .1RER 11-11Y. I T- fCOT1DITI TRA CONTRO( TYVE OF NO.l? VEHICLE (.ONOITkIq U V' SOEHIETYr 'i 4nEr C f 'E ONE1 LEST TUNN 0 T T SLOWrNG STONFE I FOR G T I 0 E v I IN* E 4aWN YIF L' T C E ) U. r U R- I K-SiEEAII LIOHts K 1 -T LIGHTS OV ANTlp !EYN St'i t]gr1 Uu1K STHtfi -._.. ON S•t0011I E. U1.rKIVG S lr'+I r. Cif E 5!GNAt Tw01.Ar LEST a li DHElII, TEST. t DANK 1+ -- -- T-?-ar- -11T L.4- 'I 'A TO ' 5 T A S Tr?A1-1 !ACKING ] E U( r 1 E N ) U .. i r.. ' T L' C 1 K L TC5r 1". LTS 2 X OS1NryUTION ! Ute ,., ...• .. .. ......... ._.._._? --l ?a..I.J ?V I? •. ......rr ..U r. LuLnL 1..1W tN fNCl r.IFNl ,1irL1,CY'S r()I•'I: illD'l1CATF COI?I'•'INV h..:IIG4l (1f1?5 f:fIPV l bs .' •kxH'F?'RLHa . . S r 1 l . e` . ?L 1 r??V ?, i'Tll ?t, L µS I i ? Yr t? y5 h ? N? -I ?k?o?{pP yI ?y? M1 I E 1 t I l( . i?' ?. t' ? 8 4 m? GJ s r f Ea T , A ti YP. y l y_ -G T _- owr o OLL - u tEO • N.. Frvl sw ,M Al IusE 7yoo ry ' cuunr /? L rY N I '. avH ?unoaN E ?7 / !-/ E 1-I tom. l fRal ' G '?Gffc PS?? L pgGGnNr r -A. [] G TY STgf T ?D EAISPEGFYI iN CIrY OF iOwn v w N ? v ?? nEG, HEFI%E2 Er cooE o MILE Vt?- ,: on -_-- L T NAME a NO. T HHIG ,/ L? rA/ O / ON n?EG 1x6 wI TH:Si HEE rDgrlOwc M. OlwGn wA, Dwla , I INTEPS CTIO ?- NCN ' ?G`f I.pN ?.,,XP C ? I TERSECTING STREET On AO Pf FEREnCE CNO55 .:TREEt OH RU AD G GTn kTANn ??( A•rwfEN E ?Tq.Er ? GDt ? ?O /O An INECTron FNOM REFERENCE OP CHOS33TNEET / D • F k1' nilS rN ECIA OO,nO USE N COLLISION INVOL ?Vk ICLE- YCLE E]Or'EAIWHITEI ?e11iNRU EI E-VEHICLE J V EU: ff--IIV FVk AI tY LEO -LE, `STOLEN VEVE=iCLE - AIN TOTAL ? ~ ^ C : 'C (- A NO. NJ U F VEH [ E . LJ -S yE HICIk-PEOC3i R,AN nnON <OLLIS ON kAl l p, AADaU3 MAT y? INAMEO JECTSTRUCrtA UWNEPS NAME LGCArIONOF OBJECT STqut% -1STAU P RTY MADE OILY EST M D E ?p? ? 7c UC?c-- /?-Li.QfGaG C/ c63,?3 ?h°rirln I ?Ir6a6wwYFEETCJCIL?CI EDGE . A AG :`O yE I AME ,?_L IR \ mole r Onwen 3 NAME, LAST Inv M ouL p „r"crcusr OR+to?srwAH CHkcu. D r ? --- R AE wDaRESS !ll R -Er AOOHE53 V V E O,TV STATE 21P.CGUE -, PHONE Na. E Y ATE 21P CODE ,. ONE 10, R R N ' LICENSE NO. STATE +EX OATS OF SIRTH Mo. OA N IVEP^. LICENSE NO. TAT SEX SIATH Mo TE A rA. O. O. 7 RIVE AS OCCU.ATION FRM NAME PNONEN p 11-SOCCUPAr ON FIHMNAME PHONE ND. CODES IDI CLAS"-,Y IAI SEwr nELr I51EJECr10N CODES >In'ns"sY IA SEAT E ECT,+ NATU END. x O YD A% IDOOGE-CHEVI n MODE LIDAR r-NOVA) STYLE 2 DA.-CONV.1 n ?Ar H YE 'EIOOOCE-CHFy. MOOEl iY lnwnr-NOVAS LFI>OA..conv.l H 1 E7 ?L'1-?. P RO. Uii 'L A A LERPLAT o. Sf iJl?. E .. E H 1 N cokoA I'll, STATE TAILERPLATE NO . STATE _ (,` L- VEn,CLE IDENTIFICATION NUMBER •.,- ;_..,_.. :3v?!'35n tz - 6 0 7- OOOMElER ?f5f 5 L VEHICLE IDENTIFICATION NUMBER- . .. OOUMETEft .. - E HEGI STEREO OWVE1A-LAST FIRS MI LE b p C ? Ll{? E G..TEgED OWNER-LAST FIRST MIDDLE. N I 1 w, 1 l-7cZL N Q, OOq O OwNEH{F?,?- 1? D • ...... S OF Ow.E. 2 AMF ANO AODAj?ESS OF INSUHANOE C . OR AO_NT ? _k. ME IN' ADORE SS OF INSUNANCE CO. OR AGENT q.E. CITATION NO. ENFOIICEMENr AC r... CHANGE ANON NO. ,. NAME ADDRESS & INJURIES OF PERSONS INVOLVED coD¢3 , nUE STATUS I P ST EJECT. C (•` ONE33. D Y --- EMOV tO GNOM O 1l3 A AME T Neu: _ S d _ Hef OF .1 M-G y, wME. -- - -?J-?I-L N E 5 4 5 S' . C > n ,.. ,.I • o A r.m r. °nr ' Inr L,-o L T itcr Q U F Yc Sr w 11 1 > I ? i???? : i On slr.o ar.rEn N Y I n x M l.... Ell n r In NO.,r I n.v v x F t L EJ :Tt'n uerrrn n IF AU E r. 3. ^ n oE,noN UncHnwn A rFnauNt GCrtn Isr?i " , x l ?? ^. ??, f?3, r? ?pp11 ?? TCTIJ l 1 ,cv :,F Er r?r - ' !1 [*-? --0:,'.1.11;Ef1 VEHICLE P10.2 ITT I.E. R _ ' O r.l OUIEn rAV vALlnu[ I [] O15e lD GAUAOE I,Ir N] El GT O M,-h - - ``GE r. NO Gn.. ,:=_ ] u r r. aov4l [,A•.,.,:, _? rIG'?„'a?E a DRAIV ARROWSHO'NING NORTH IN CIRCLE a C7/ RLY avPEl ED ER-f, INCwOF I160R ulOr Orv UTACNa61.E.O.ORNER S,_ ,TV,- FRAN CLOTRI.NG COLOR. CONSTRUCTION OII RVE,%-A -14. LTC.' - 7 i'/SL ?:i.°n 6' .iA•%-/ l7iJ Gn,]7-.?S J'/rJ :?:. .__.?. _... - - RE.lAY F,..vE IT NO. ,m.[mn[cno. i EG s vn°iKaE io Iv¢i ocC."E. n1.<iiaisiv°.uK_ i iouT[ F .. r SS J TRIUU [NC[ [NCF fa I[N TMGCICIRCI/•`.1STANCE S 1 T, ] IOUClO,E ] tl .. -TR R U __ SIGNIKR[OAR U[O RAi1N' ,] ':IG. - + Lv I., A IS ATION PART. a nCTIUr,s V 1 GOIIwiGFIT[Al1EA0 > ANORTAKINC. PASSING ] IGKIf TUI1N { KING i1N t..5 'T A'r 11OA11- ILI N 1, ? 11111 -V[IIICLC COfNDppITIQqON vl No) ?i CSd?ithlbiitf 0l 14 OPERnTU(C. OFF[C f'v[ [<IUI'•. '1 EYE F50U1'LILTYN--- N(il) CNLL'r. UN[, ' L I.IAKINO UTUIIN L ? INf ' ?,6pp, C TRAFFI A[SwnAl R SIGN S,OPPFUIN 0 I. n(1( ] Fr [cTIY['S ?, nnluT. HRDA T, NIUETV . nOAUWAY t(? PTn IIA'FIC L:,CLw IANE 11 pTA'TINOFR051 uF11( ; (ENTERING NEAR LIGNIG IA 0•: IF YIf ,N [r+(GIINr:ryG -- E EC 111ArIC1 11 nACKING I- CI IEM, F S F OIIIL'I InP[CIFYI i[Sr GIVfN M111'f I'US(U , -- - - nnl:.rl nl Y. RE TLSr ncsuus 2 A"iiivll! r.lLl?rv°ipio'Irn?G s N ?I..IA?[rl,a'.INL.Y'S C?iI•V?TIIII.1 ICn1E?flIYY•'?INV [.:rl(iAiU11'4?COYV '+v?t ??'r9'S^^?""%{ !' ,'•'°pt' , : `Iry'°p'M ?i ?'ii . ?' : ?: ,i(,. ,'? say 1 r f ? (fir; ti .- _. I?z? ? _,?E_,__IUI, ` ru '?..>iu _raa?^d'-.....`''•°?"' °?"?`" ''?y;,:"`,yNi.,,.--aE?;F._ra.?'.':??•. ?_.?'-?.?° . STA a E `JF V?JS??r ?9?? 7 Ja 9HAGE 1 D.' / _-_--- y ? ? uNIFpAnI pol_ICa TnAFFIr. COLLISION TEPORT rrMHLF .I- EL 1 -n -17 F, r 1: t a IUN rY J ITAr i DUNTY IDA i IcI IYs n1E n DTllF1ILPLLIEY' -._ ---elrr Dt• to IvN O ?? -__. r c -T H. - o ?: _? SoE MILE-IT t[i eD , L E vt ? IN nF CG'i? G' cY rx? 6 n r n - A ca I -- C ? ry `? <_ . C I _ ME'_N.OFST TOH f.'11 rNTE.CTNI4WIYII:SiREEiONNO w L. L ,IV n4NAM[A ° A T _ I r J? U . FCYING STNEET OA NOaO UR - fu t I O n D I EHSF.CT 011 jq1, ° R nNnr-. ?1? ? OUI ?C I1 f HOM 1I Ef EgENL:F ONLEROSS LrHEE? ?? I 1 ? actin EM' /1 J1 c -ENCE? r?' rHLr oR RonD l nLXXEaD-.E ? i.l I beer ' YERIrv ( ) T. ]VEHICLE-VEHICLE El-HICLE-nlCV K.I OTNEN I.vRIiEI ?,II N IDN INVOLVED: L-ULLI ' E KILLED NO, _ . . E I+ICLe N s HIGLE-HH Tnn1 [j VE oiALHO. I_.IYL cLE-DHJECr I-j (?(' ? O 1 JUnFD I OE ONLY AL OF VCMICLES LIVTNICLE PEUESf RIaN rI COLLISION LIN OUS MATEi1I N ON 11D PDOP A PAOP EnTYD E F 48.JEC2 STRUCKK (NAME-CJF OBJECTSTRUCK AND D-1ENS NAMEI UCK CATION OF 01UEO R O L DAMAO T f f'11- r-i ?? -- II l_1RUAOwnv F ?O[?[On D ORI VEPS NAME-LA+r FIPST ANODLF ?' ?~?', D D1RVLIISNAYL LA',T 1.1- N1111- R REEF ADU E^S f STREET AUUHESS I V ow, ? - E rare [IFCODE v CITY E Ai zlv cook vnDF1Et ITY N En-CE-ND. L nHI .37i7i' " STATE !fi? SE% FO'I N lS7 ?•?' f D 7 r? 0. IVEHS LICLNSE NO. 0 ATE SEX TE OOF RIRTH nio. Yn. O• N . IVEriS OC N FIPM NAME ENO. IV EHY OCCU VATION 1 ONE 110. HM Nn.IF vrI ` CODES f1 C'sEY SEAT DELI ?' 1`''EJECnoN L CODES 1msEAr nce.r . _ I F NA ILD1 .1 - V E O 0 n u F[lN TO LAR FM KEIDUOGE-CHEMI MUOELIDART NOVAI ST IV UR.-f. JN V.1 VEIL. vEnRE nKF.IDODGE GHEV U!L{OngT_ Sf YLE IT DN.-CON- NOVA _ o V vE11 CO NOH LIE.. PLATE NO. S E I.A.--A-1 SLnTE ?J E YH COLOR LI-LATEND. -ATE AILS PLATE NO STa fE H li ?sL J•S' LGf/J OMETEII NICLE IDEN TIFICATION NUMAEq C, , VEHICLE IDENTIFI T10N NUMBEq . ODOMETEfl oo C L? L E- ^' L - 41srERVnownEH-Lnsr wR,r moL EC•ISTEHEOOnNFR-LAST ' RSf, MIDDLE N O, n of O• naonE,R Or owmen D A OREY1 OF I.vSUNA N<E CO,HAOR AGENT D AUGHF.SS O +Ni SDHnNCE COON nGENt ? CNn -i• CITR IT Oti NO. LNFORCEMENi 1AR4?---- CITATION I+. 2/1 /c' A.-N ES C - II OD - 1 sc..*e2 a1 1 -- NAME, ADDRESS & INJURIES OF PERSONS INVOLVED _-? AOE DYATUS I -` I_, -- NEtz[ EJECT. c C DDRESSO U r A n un sloe nY o :ES NAME ? R T -- - DO-, 1?1 nuc' N T N unnL _ wntH % C D D ecgncn ?. FI CYCLIST H D Prll •"•''v,-'.,ID.J I.O (?' 6'- E i w rgfss . n. iOVnuv1 ._ TNCa'L, .. . L ?qME Y 1 1 i r t S t t '?, ? i . ? r y1. ., .:a aT ?*> t7*?Ya? 1 tl?il a• - . u i ?- ar t r x?j ""?+ R 'I"t 'a t61 1 7 'Al w? IVE IN: jSEV[I I "Di.E I'G DI I ? l r- I vE I i , I IF ICED 0 I RO ? o l1 1 -- I of I 4X, r D DATEOFCMUSKIN DAY OFLOLLSION TIME C OUNTY NO. L'TY NU. V /q FH { ?1 7 MP^ P? -717 1 T S . 1 /1JN 2 lots J We0 J Ipux 5 FRI 5 SAIr IU 10 11 1 1 I Z / ? 9 B ?`? rAL E C01UN" ?CNYSTREFT ?STATEROUTE ZCOUrIrY ROAD O g CLS PREFUL ROUTE ORSTREEI CODE D M SECTION p P LF MU ?OTHER(S E Y) - P MILEPOST RE! IX EO ]IN ?CIIWN [ 5 . O ? ? OF MILES El LL AMr 6NOOFSTREE11RHIGIIWAV INTERSECTINGYII,M. Si1EE10Fl ROAD R AMP OIAGRA11DATA 0 1 NON WTERS ACC DENT IN TER l C S OR PEF. v1 ?/? y.AY/^ ?../1 /? ? M LEAGE V TE L E RFNCEC?R-O•ESSIRlEE-T OR PDAD ?? N . BETWEEN /mJfEIT AND ?,STREEI CODE ? ? DISTANCE AN DIRECTION FpOM REFERENCE OR CNOSSS,REET Hox HS SPECIALCODINGUSE IOI MILES N 5 E W/O COLLISION INVOLVED: ? VEHICLE-VEHICLE ? VEHICLE-RICYCLE ?OTHERIWRITEI ?IIHARUN SEVENITY NO. KIUEO "' " ?STOLENVEHICLE VEHICLE OBJECT ?V C NO -URED N R ON OLLISI N ? 0 A VEHICLEPEOESTRIAN ONCOLLISIO HA2M0005 MATERIAL PROPERTY DAMAGE ONLY C ES= 0 N OOJECT STRUCK (NAME OF TR UCK ANDOWNERSN E) ECT S O? . } LOCATION TOBJECTSTRUCK E ST.DAMAGE:.:. ? ( / ? ( ) ' ?' • ?? ? RD EDGE ?ROADWAY l VFEET ? ? DpIVEfl9 •UST f IFISi - MIDDLE DRIVER'S NAME LAST FIRST MIDDLE Ill .1 1111 1H -DE $ IR-I CHECK) U , R STREETADD ESS R STREET ADDRESS V 'e- A?j(23 v E GTY -D STATE ZIP CODE PHONE NO. .: E CITY STATE ZIP CODE PHONE NO. R / T 7'rRul?'?E7llQ R N DRIVERS LICENSE NO. STATE SE% DATE OF BIRTH N DRIVERS LICENSE NO. STATE SE% DATE OF DIRTH M DAY YR 0. ! No a YR O, . O. FEVA NAME PHONE NO. DRIVERS OCCUPATION 2 DRIVERS OCCUI'gilON FIRM NAM PHONE, N, 7?iiCK I V c-? VLURY CODES > DI .- CU55 _I-- IAI SEAT RELT.. III EJECTION ?. t NURY mI51 EJECTION____._ ?. _._.... _.. _. CODES 7'J' CLAS,a S 60F DMUP E90F Q?f'E NATURE INJURES FROM SCENE BY TO RFOM SCENE RV TO VEH.YEAR MAKE IOODGE{HEYI IAODELIDARTNOVAI STYLEI2DR..UJ VEH.YEAR NIAKEIDODGECHEV) M ELIDARTNOVAI STYLE I2ORCONV.1) V 'S8 tiLlA01 -tfin. V ? E YEN. COLOR UC PLATE AO. STATE i mLER PLATE NO. STATE E VEH COLOR UC. PLA NO STATE IRMIER PLATE NO. STAT E I I C VEHI IOENIIFX:ATgN NUM ER ?? MEIER O VEHICLE IDENTIFICATION ' MBER .. ODOMEIEfl ..,. E °JS j??5 pp E MIDDLE REGSTER D WR A Fl RSi ST _LL p^ REGISTEREDOY,NF -LA T FIRST MIDDLE 0 ^ r T'^ ?p ' A , `/^??? ( 0. t ' ADDRESS O E o6 (73J yp T z ADDRESS O OWNER NAME MDWSUNAN T M E ASEN L NAM NO ADDRESSOFINSURANCECO ORAGENT ?.. A ` UA ?, CIIARG .. CI igT10N NO CIIFURCEMENT CIIARG CI TALI R N .. "'?? ACTION L coal _ r w 5 VED NAME, ADDRESS & INJURIES OF PERSONS INVO S[% AGE STA,U9 " EJECT. b' NAME C ADDRESS' U p NATUNEOF? I11'AIOVEO if101A TO ou -s srn.r nr A r.AME' N ADUtI[59 $ AXIS II.IrN?1Uf11UM TO W NAML' T ApDRFS4 N HI ,IN9" - UfI1DM _11 TO S NAME __ _ S ARO R CS9 Sr L ,• n iTh 9 ;!l'[4arrslA - TO IVa IT Ai I'UYIKAY JI/UVnICIq!r;. AI Sr AT ALIT IsuJIC11W1 PA" C 1Y N V 1[A f A fR M i 1 lCO 1 N II j Inl X11 VCTJC If D (IHM1IAN J 1' O AIIK:YCIIDT 1? Ij \ "?I ? I ? 2i, 1U , I i T{f NE ION 1 0 J 1 iOTHU1nU'AIxYI 1 WAL10'I AlII1.VAl ILmrN'IN,uH, UrtY r11FIY P 'i` ! ' ' U U11 3U';rU Ur --1 . _ C DPAIMIALI.YCJI:'lIR A ll!Ir(NO'.YN If 1 I E O 1TIHf[55 1 / J l Ir At O 3 A IV`JIgN ?II?iI1 JK11 A I41.D PINO vS[A IRE,,! AI, URF CJf CILO r - r I t I.} ?(?J ...? IP • r L} nY ra nFFK 4? ?L 1 Z r Y tt P c5???• 4I??y..; s ?r MOTOR VEHICLErCOLLIStON REPORT - NO. :.-rATE OFCOLLI510H -. p II ''DFV.°F COL 6 29 9 - E°F COLLISIOH• 1??? g0 -' COUn? ? CIT NO Z L? r. L ...[ c n L .c .? 1 r?Bd? .. c TY T-., _ ADM.aS PREF I r? 5 Jefferson Ouilcene 4 ?CI uxlcene J w uvfi yl et„ _oR . ?lssi ___ °S. ...-__.aT ?.._ L?'AD PRFFx eD. Posr w :.' C R @ T N INTERS N.LOGATION OF COLLISION MP ACwwM OATw ETWEEN S.R. 104 i .1MEETA.. S.H. 101 TREET Ax 1 14:Lle ®n ° ".w.o .°.a »c. xrl[ro., °x r°.nnx.r M LAn°..x. .x. xxrvc[. ER 1 grew cls. • a , Dabob Road ? r[I c. CUOE usE \ OBE UC ?t '- 1 i xwucw ?.L.? c{,O OB _CTS MAY AMO• eSS 1 D a1Si.:xw ?? Cw DEER ? J I ? ? ....•r,n,,..110U1 .... i,•,.F13T.N _•? F IuMGr,yN?-,??y-- °OLC???S SULST. AM[,?..? MU?S, r.,-.» O ._ JO&YSON BE WY JANE ° STREET ADOR[S {Df•A;,y,•?,?,:+-,. _,,,e;?w .?RO[c2EiM0- X '..;: EET .ROUTE-NO.. AH°B NOS:.. Star Rt. 2 Box 627 •;,II?000C _, HERS _CU_ TIOw1 n?yu;?yj4y?, ., sTwte„t'?y;?',,y_ZIP COOED Y[lIS«GL.; [.T1oHy Port Townsend WA 98368 Real Estate Sale ORERLICEHSCNUMO. y„O:,'3. TC &1.. ATE,Oi. WTN- K.F,. _ ...-RWERS IJ°EN?S„[.NYM/fR„? ST 4TC- GE.O RTN-AGE H ° ^ ? 4 2 4 ? x 11 OD WA y a w: lu_ KE:?f?o,ar MOOLLµ?w.wn1 BODY;.'?TT:Syn(Sxl ?„_- MA/4'•s'.......?...._. ?f',w.?_.._... :. amS?, sT„LL?IS_. -?P.. ~ µ MATSW 4 DR 10 4 MATA LIC .PLATE N0. ?,x, TATE.L TRAILERP42E.IlOS, ...ST t?c,?y. Y<ENBE:PLA EN4 .'.+ E :T E LAT?RO SJ TE-?. - IGL 236 WA f VEN LE EHTF(CAT1O ,-MO '?,,,,1-i9o ._. La ?. .., 100° ETEMxrNin.ti O1,_LC IO[NTIF _ ,,, ?fLB BjYaea 1 YyTE A4A18 N4 81 1 90.000 REG E !D O NLRrj,.alG.si,;,ne.nwwe.c:c„rr.1 LNaPI!IVIRS [Cfic[iE?J.O.?.?.y:. ?-? T .. U1 _.y. . H.oAi P-.--, ?y?DlflY -CR:EI.St, :. f.ti SAME AS ABOVE O,?IERS °Dwesa_„{fir ...L °2 '?` u,ti...:. 'oA ror ewnn. aw±[ws o/os?na_ f .. cL+2_ .!• .s'?a.Vx..A.. Rc PA, SOP.,VE111CCEiF!!i.AO[a,iriiwYS•+:i:tGiSa>4i.TxSLu"ric."•Ji2?:w. re wvrw' ??'ain7??I.l[.?E:al!FMO,EG'S.,'..?.?'::'.L:IltI'.C:G1.kStr?54n>34r'i]'.=? Iwm<o.rv. saP•P?:EaKAs FRONT END S S E UTO OS LE Lt INSURANCE ® ? LIABILITY INSURANCE INFORMATION -VEHICLE NO I • CO E GE EFFECT FOR THIS -ID ON YOUR YES NO oRµ:E?NOEDII[??W'I?r?a?,yy r+l l ?,:?_M1 <>'.?4C?E i.LM/LrFCR"InY EYyYRAryGErG,Ow,Ab,,?F;'?'.^,?Y? NA EA D?ADDC1[S6wN L;/IYTT YCO, • o Robert/Batt n, Sta Rt Box - P T t[WA 9898 1 STATE FARM INSURANCE CO. N_A _ONES40T,LUUIIfJ[Y IHSURAAKE?,OAT...+iY3C:6?.'?"k:6YShJwiw.6f,::.3.Sf.?Y..vi??..A'ar.-ue....r,:?LLIMILITj':POLIC'!?.UY/tle„ti. %`Pg(jy? BRICIO BALDERAS 2174 Sims Way Port T.Amsend WA 28368 1 -r lT wuwr,.:.:.Jt?^?i°C'?^'L..:-3.?.?s'L?. Ytw`.T'-•'••?1 anDFwuRrTil .... n'LI..?.rn1>T 'AGTy' E A E N _ _ A 6E% DO E _- ?S ADDRESS M F __. ____-____ _?? Tiiii 0 . ST TUS W RED `: .a??. 'bMKIWSTOMCTNATA ?LI[S•, Y'}, .. y.? T[190P. ItcU ° y....j,y..,M RK TntlT ONP.T AT ?j,t.' - nr ..v.....wU »on ...... : !P ._. IH Cb h l cr xrn ?? 1 cl oxl n a li NO ? ?U . SE] _5 6 7 .u SHOW NORTH GY ARROW IN CIRCLE -O[SCRI/E BELOW-. L PKNL "fR[P Tk0 VINKLE6 p,Y MU „sER.H,?e .1.. : O`1 .? ?' 9 aHr[La w.. o: o:r,.FFI.. \ it ) ??? --- ?f..1 ?//•sV-?CJ// ._1U.^V'J.. Lj._Oh_CCt1RT. 1?-47-5 M?,H• tl 1 )-JI:, .r u ?'nlr^`./`-I.' l y 7l I /} LFfl J ?f C 9 l T/ ? ? y ? c pV Of r _ 7 i x?V9 _!n_ O I. ?... -- 10 . .... _... _.__.._ ' ...... H. • VEHICLES POSITIONS BEF NuDL° v[ cLe L W, ORE COLLISION Mc IN no on sr Lrro NtG x[ °;. v.x o , ° INV[STIOATEO DY ? Af. of .outs N? TDD 1 0 ? ? No ore ? [j ? : ,. t .. o ? ? ? ? ? ? ? N PEDESTRIAN ???? ALOra _ '.. cnolslH 1R.. ? TD ., ..".,. ?4 PEDESTRIAN WAS U SING tn 1? . ? . F? f T A L_.l c ? L l r ^? ? HGADSURFACR y„WEATRLR, M I GHTCONaTIONf, L TK FP¢CO n L, d_.n oNU TYPEOrn D. l OwvnL ?f, LNI°LL ACnON>h,,w.AY f•?}F [n <.['.1 1 [.wv., n RAININ } ? ? x 1 IJV1 ° LIGMT ° ] CJO WN rr,' ?_I 2S NALB ! LI OTOP SIGN 1 O Y Y P OtNO STRAIGHT AHEAD 1 ? G ? OVEHTAKIMO AN° SSI O r ] [-j WET ]? SNOWIN G 1 D ]K E] ^ I 1 RO O E i ? ] ? HARING n16NT TURN ] ? SNOW A_I f00 OAll S1RFEr A ? LIEII,S ON 04 0 ? FLASHING RFD wCl.ANO E] [ InLorEIR% ,E A MARINO LEFTTURN A IC! ? O,n[w ^ ? I[P[Er. S o l I.N L 1J.E.ET .R rS 1._j 3 ? FLASHING AMDFR C, S El ALL[Y ?? [ l] MARINO U-TURN (' ? ^ l lwo-cR GFr nANF to A ? E[wrrc LlGN fw A R SIGNAL ? ? WD Y WA o A ? Ayr iu?n SLOWING ? ^ E] - R[AwGN /AA RGY IMNO O?NGFI r . .,. I T ?, [f. Fx C.? , I l O FIYUIIrL A°MAN Han - ?Y _j BTOPPEO FOR TRAFPIC ,tOPFFO Ai SIGNAL 1„ . n, wvunvv.HOn v?trna ? n U °xI CI.v -`? - ' ? ^ ? °w Brnnn _^'_V D 1 [? Sc nAHA r[n ?? ^ ?, BrOPPFn D OWAT O [II nlvmlr° r-TID? I /T:: nci ! ' 1; I OL IC L.,J ) ?J unO Vln O ?Jt ..... . S 3P9C'...,,77R5Y' t . 5 . . ;. ., I. t A 5 Fit I pZ Y [ ., •? ?FxE•V je 44^ Ip'? r: ?A 1 / _ 1 t t s K k_. a?? all, 4 J y 'tYtij . t p r r ! , nl `'Ip ? E 4 I I 1 { 4'tl' 1 .1 t ?,d Hf` _ I by n ?? tl?? a i v^ ,.. ?a1 w re,. - rr FAU C - H nUA - L - rHE NQAI3FH-QF?A-,"Ffl1ACi'A Ell' A -- - .-FRNW _ IISISTR UCTIONS - 1 SHADE ARFA O($E ER ST IAIPACI.- ?I(r Lllr l+ .] OR— HROV I I TO S O VHINCIPAL OIREC 0 OF FCIIC / ??`?.a.? r ( O/ OAtEAGEONEHICLE NO. i E AEitxrve DALUGE iD THn?-1- , nipHLreL F- ? ] cE F Ert b I OAMAGEO V E HICLE N0 2 I T,- ((((((???? rr ' L UUU ?`4 - I6. pn1u . TFH LE NO. E F o. O r ?? DA EA-A.E CI u?C G GAA0IGE LIIIGAUAUAGE HLH ]Er?LDFHEHNV DAUAGE I ?OIS B : p Fuxcr DxAE DA.ucE G p A TOWED tly OiAGRAM OF COLLISION -?,)?J? - DRAW AHHOW SHOWING r?D.uw..a °w ii i %ii y NORTH IN CIRCLE ` r E l ws cen?rs o.Or. H1u IPAF.w co.rAnu - r 1 l? -?? `-dry, .,.i-•?^V-G?YJI? __-- / cE.+rc..caHSrRyrnow ? 2.1 ,`::d; Hlo..bLF.D wTDF 1 ? ` _ _ ? ?. .._ . wa.r PE.Ia[.PExsrR ANw - . -, ._ - J•K " ? - ?.. .Iknrmlr.ro?,Arlrl.wcr DDw 9N+LrNEwK?DR r ? ?iC /OI sn 7 -7 DESCRIPTION OF 11 DICATE INHAr.ND9AaE E L COLLISION ., EEIGNE. DURING AND AITER THE ` H. N LGGE INFDH Gr ON DIAGRAM. E.G. DRIVER r P. D,valu vHEDUCEO Vrs D Ana°rHlr.c co x.mvsinucr D.NIGR HEFAIRrmHK. Ere.l L iC ! ------------ , V[1SITIO HEADED q 1 N BEFORE COLLISION CREASIF In ... Ox TREFi OH,NGHwAV NAVE ON NO. 1 IN ORE DIHECTIOH asrrD EE r aA e LE L-11 AVEH N 5 E w NG D[OIEALNG - .. _. - .. •- ` - PA . OCCUDIED -Al _ i a NO O T... ?.?rl 1. . _ ... ..: .._. ..._ .. .. '. _. .. -- .:. • F b VCL Si AS USIN G E ,K .r wA ] LKw s NDVL DR C .... N K I- E. Cx [ t« I e -? .. ROAD SURFACE .H'cK ONFI WEATHER H cK nNEI _ _ CONTRIBU 5 cN TING CIRCUTANCES. ONE murx,Er TALK D — E .. .. ._.. R EH jLE ACr m1.s ° W.1 I' F CLDVD I DRNER ,NO.> V ALDER INFLVENCC OC IvEH VO. ]' - - p DRIVER IN O, r \ G' AH AD; ' - •-_ Y ] t'i - SNpv ] O E CA, ] IVO 1 ngvlN6 1 _.._ALCONCL ] DE E FOF All. E E ] ] rDO CLOScty .. C p Sp D ARV' E ? OVER A NG NO ' TV KE ..? G .. _. T E C E IT , IT 9 5G O TURIN T LOCATION N G \( Et I\ D E U p LEFT— l R IS C IL? N 'LS( `MY ?O O S OTH{FI ISPFCIFV ' DID S T F OE TH ..T r OS E ° n b YF I'D x N NO G O . N ITICNS K HECK ONO RAFFIf CUNTROI NO ItEf KL E fYFE OF flOAO NO] VE HICLE CONDITION SOBRIETY - FIC . .... '. SIGNALS ICN[CK OxE DH AIO _ ,.I 0 E AY yF CLf H? HrO ONQrIQSn ND.J IFC PI ST?OI VEH CIE ICnECK ONff SNO] OH 6rOISICNG AL -.-' .. .. 1 /{..OAVI •HT .r. a nAwN E2: ELD 1 x .. TwD Ar ] _. - >: , DEf k<rIVE bnAKU ] f ...? -r1eDAU irtY -... ._.. AY . - I mNG Ix THAI 1 IwnE - D prSK .: Lcni a+F WH -STxfIT ALrING :_ . -. A nin 1 .IOW pE - E AL- - -_- - ] DEAR GrT/I .?+-.__al sou .1"ice -. ....- NOT E) - ] U [ UNK. HAD 14'•. ?_ . fF DH NKING 1 I HK[D POSHITION ] ?'T,GFICI IENi[PING E _. 1 HACKING - L IIGN SOFT . __E EIGNAI. E TO FIT rwrSH••.1 r..«,U S - ul wl ow+. UHrv Hi CHEAT. TFST IND. ] nE U S EF TS _ OlnG ruV ._I.?---?r$r- I ISi ti v N :. ' nrHlH CIFYI _ IT UTHIR _. ] ., , S r.? ? 1 nlr.FU wen.o .... Iy1ncD - rrs n F%Lsm 1_ . oTHHI ?nft F Y x TEST NFGUL rs 2 _ ? 1 !?, 7 .C?n \,y? III 1 : K ' laC P FN xN ?t',</cy' v nNrv 1gn%r••r•, D AHRI, n i ?? a.,00 ?n ?E nfT J .,NE '.HT . 1. AT, / D-D /'% .o IN. / r _ / ,: . v1 A r UINT nINI T ? Ir A DUPLIG\TICOPY LOCHI LCO ?r f L NU rn 1Yi5IR 116TO.V :rATE PA IRTI -OLYNIPIA, INAiHi,VOTON R1- L g11f:F!f NT Af?E NCY'SCOPV- I NIPLICATFCOPV. I NVESTIDAT(IR'S COPY -. ??,L'-"'•'? I . . A I„'-"4?1716k1.^"'"?,'.!?,?• ?R£"- 'F±F','fliYAR!`x".Tir°"?1? ... _i. 1'?F5'?' l,?n Ttm^?! I 'a r 7?,:'.1 t I _ r ?clEni? W ' pA P, . ? 1 F 1 3 Y (L , ?"1TT"' it I L F COLLISION J [ o r P D:.Y OF COLLI^. Un sA H Ly. urv E IuaG y.:u I p j uNTV Nq. / D // / _ CITY n0 N ?uH E am ! L'?? A A 2 , T ?j50 Z J 1 .J Pat uUN %/ LINTYHUAU ?[I HFEi E W I-s vREFIx Drk RE C aS `T CQOOE 1 a 7. ?? O d FY1 70THENISHF.C LJ /J FF^^?1 ^^ I N ... /.ILES 1 ??''(_Gl\ LI LJ 'K?\ V ?•? O _W ._ J ? Try FET p Y w WITn.5TP[GTON NOP CTINp 1N U- O / ..r. JF !l ? Lwl.1.LAr?/^?4 ?1 ? ?'7 ON ? N INTERSECTION ?t ?t J EN s RkET wno o M u Ni H C INp STREET OH NOPO ON . FE.E ?Ck CHO3. STNE[TCN NOAO wnCE AnO OI RECTIOn FROM HFFE HENCE OH CNOS5-REET o; j :EF;S C 3 0 ? DF oc r /o? I N a ;L? fj' U_ ECI L co In T WNITEI ?HlTw nun COLL151041NVOLVED: LJ Vk HICLF-VkHICtE ?VEHI<LE-BICYCLE ...... ?xTh/ _ EJ STOLEH VEHICLE ? HICLF-Op![CT VEHICLE-RH THAIn TOTAL NO - 'LE?RI Y _ry0. NIIIREOT . (?r OF Vk HICLES ?VE«ICLF.-HEDESTPIAn NnN-(:OLL1510N L 1 HA.Anoous- HIAt ____.-? ^ PRDVk HTr O.LMwce oNLv U CK AND OwNEPS HAMEI CATION OF OHIk CTSTR T SiH U <K Ou EC STPUCK (NAME OF OBJGC O«MACE EST. ^ r I ? ? J ` /E{-//?-f??? ?noAOwwY?Q FEkT 1_i?IE L1=o. Et GF [ ST R T - I.n OLE RS- FI HIV NI. rvAMC L.uT FHI>! uukE ,Fall LH FLOE?P«..N LHECKI Lr. D 74; AL?tiL'T - TQ o R R v REET .DORE hJ? Y0.6 I v srREEr AOpnESS F C .21P COO. PHONE NO. CITY STATE - E LI _PHOnENO, Ci(r srATE -CODE , ??i/ceccJS zc?SF ?B37G R P r? ? DRIVERS LICENSE nO. c S3:L o8 9iATE ..vA. SEx 7:> OwrE OF BIRiH M ?? .R. .o. RIVEnS LICEnCF nO. D STA % ATE OF pI RTn, A H. 7 ' ENO. OHIVf RS OCCUPATION FI M ? ? NwM ?- Z IVGRS OCCUPA lIO fIRMN vNOn LAME II EnO. /may LADES. ?11nJAUssR u'sEwr eku Z. 181EJECncN CODES u _ _ _ E o Uc / V VEO ER YF.wH Y............. O -On V.1 7 -7-5 .J E DYAI ST ? „ V I'-E BKl.ol E HYEAH 4 IDOOOF-<HE E ?,, 'To V.M DELIOw IT-NOVA STYLF 120w,_COnV.I E ER L ATE LEnILATFNO A -- ?E VEH. COLON... yt. wiE NO. SLATE AII.EnPLATENO 3iATE '-, W C EnICLE IDERTIFICATIOn Mp! - . - _ . -^ O ETER ' C _ ICtE IDEN/ICICATION NUMeEn oDO ETEn E ,... FIRS ..,..'....MIDDLE D wNEN-LAST REDL.iEHE 'E- R[pl5r £D OwNEn-tASr,- -,fIRSi. -... ... .. MIDDLE.. IN N ? O. 'oD"Hess ov owNEH. O• AoDREL'cF OwnEn NAME w.NO A..... OPINSU CL CO.OR AOFN ;_ 3 - 7?Gc/.CJSEI NAME wnD wpORE55D1lnsunANCE000RAOENT ... ...L ..,- ?ON? ._ ENFOPCCMENT ADTIDN GRANDE ',, ...: _ ?...: .,.;. CITATION NO_• ' ` V F conE3 _ w ° PERSONS IN OLVED NAME, ADDRESS & INJURIES O ,. , _ ,.. EX AGE STATUS ry4 s ' T LYLS ElCCT. - c C l DRl A: D «<OI ttF NFVn IIDM 7 A T S ovm FRnM • W NALIF, ?? uow ss I M N E S' S .?re nesrnw?+ J I i; ne.ri nr ccknF pRr(<^gr ° 2, Rru+l nn« tulin q«A«.nv. O Hesv / Ti«us?MUro«rrrt..l I. I «m.Irwl O wIr ? e ? i \ R. Po51 rInN uNKNUwN r:• ?s NU!cnoN u nlrrsr u!n I. or uECT.D .N.ot mus.. ,ttlrAlty £IEm.n s u irANrlwwNV F.JrcTrn sr:ineti FAn.DRF'el-Ten Ir EF, '?M"ty?1.TT H z ?L P _Sh ?I 1 pan { I I y Y y Y D I f r N l I I ] S ASa ' I DAMAGED VEHICLE N O.1 IuSE qs YwcE faR SKETCHIrvc oAMwc rn+ILERS OTORCYCLES. CI DAMAGED VEHICLE NO.2r I]. HSr•5. I \ . ? r aoS ` yN_ (.. r ] fi Uw `] •Y, C\? ? ..... .. ? i -' J ll rr? ?r MI, Iu, Y. O? n ti\ T ? ? I . .. 1 ]. Ov ^ SEVERTY OF OAMAGf'VEHKE[h0.1 1 ? —AILING AGE ] CI OTHER M.V DAMAGE SEVERITY OF UAMAGE:IOTHER VEHICLE] S IIITY OF DAMAGE VEHICLE rv01 I ? LISABLING OAMAGf ] OTHER M V. DAMAGE, E p15A0L NG DAMAGE Iy-yI OT E DAMAGE ? ]?fUNCiq DAMAGE l ? NO DAMAGE } ?FVNLTONAL DA MIGE M GE J FUN a LJ NO OAMAGEi CT TOWEDBY EST. DAMAGE TOWED BV E i UAMAGE ES r UAMA E TOW ED BY TO S !O S TO S DIAGRAMOF.COWSION Y + 1 AWARROW WSHOWING NORTH IN CIRCLE Ar L- - A wALReM. <DNPI,mN, A,cH.cmllrnucnSN e+s ercl GSAeLfroIN,Dr . r_ :-? 1 i 1 ., ' ? _ _ i ? . _1 ? I - f-1 - _ '- ?-I?,? G : - C]'Y`71, - ? .I ? I I 1 1 I ?I _ .i ' I I I I 1 r r ? _ r e ?_I 1 I? _ ?-r I - I AND.r,lAGDLLIe L 1-? --h_ I DESCRIPTION OF IINDICATE WHAT IROBABLY HAYPENEO BEFORE. DORINGANU.AFTER THE CRASH. INCLUDE INFOn TO NOT OND GRA51`E.G. DRIVER , ET OISABLITY REDUCED VISIBILITY PEDESTHIA CLOT J G CO HEJ COLLISION C . ? N RUCTISq, A`H WORK, IS ?N ,H c ?r cow ' _ as POCHTHD N BEFORE OLLISION + HEAOtD u EPOST DIR ON STNEET OR HIGHWAY NAME OR NO ?• VEN ^ o ONE ECTION S , PEE D, Eq LY ED . . NCPfASING DECREASING IN' KE?O? I- OCCU IEII L Ir F r n%i -I]Q v'1 ? ES Q ES PFD. O'G - -1 } DEWALK 1E6/OICYClI3T WA9U)INO. 5 -- - CNOM .G. _?? J_IHGM^A5 r,10_?w_. . T - ED ;UNMARKCO 5 ;BEBIG NATEO ` I r ' WALKWAY LK I ISIIOULDER KI ICrAAOSSWALKS CROSSWA CYCLEROUTf POTHER _ROAD SURFACE 'CHECK ONE] .WEATHER . ICHECK ONE] . ... .::: .:.. CONTRIBU TING CIRCUMSTANCES CK ONE On MORE] 1 ? DRIVE RRIDICL[AGSIGNS O.]venlttl J,IrySUP, - pR ER 1N0.} I.E. OII O.} DRIVER ,NO I A r OIfIO lEl r r??' GOING STRAIGHT AHEAD DRY _ 1CLlAR,CLOUDY ILADYEHGST_ I DER INFLUENCE OF .L:? LJ_ALCOHUL__- _ _ -1 OLLOWiNG LJ.?I?.=QOSLD3S.L? r •REGAROEUWARN. I J" ZIG IS Q OVERTAKING IJ}LJ AND PASSING G A] I FIUENCEO UND ER C]I i OVER CENTER LINE I1 ? APPARENTLY I?]?,?•M ] SNOW __- J SNOWING ------^- - ' „ . _OR G ] E CEE ING STATED u .'IT - 'S? FAI NGVO -LM OOCASEgNEAR _RING IGHT TURN ... _;?ILI KINO M LEFT TURN ICC f r) _ 1 1 I F? CKCEEDIND REAS AFE YFEO 1 I OPER -iUR ..,_ - i f T NO I?BI QEFECT, EFWy- u f j S MAAKING I^ UTURN r' i-l J ( lJ l I l (f1 L L If 5?-1 DD OTCGfAxT RIW .- i.II I DSRfGwnD sInP .. r ?,I I .. _ GiSu 1LOWING .. -.,___ ».. _ OTN(R IYECI/YI OTNLR IY(CIFYI _ ( ; IMPROPER E PASSIfm _. __ DI)REGAHOSTOP SIGN. SIGNAL _ _ IS, I OTHER ]SPECIFY] ....: NovwLAnON I-'I ITOP1. fOn I, mwrnc LIGHIT CONDITIONS CNIUC. 0NE1 RAFFICCONTRO INo 7VENICLE VEHICLE TYPE OF ROAD r 0.} RH". ONE ON MORE] _ 6 VEHICLE CONDITION VEHICLE TS INO J } ?S • SOBRIETT . _ VEHICLE ]CHECK ONLI r? 1N0 2 STOPPCOATSIQNAL I :::)ED On fTG SIGN 1 ONITOP . 1 1? ININALi ON(WAY 11 _-__ . DI I C f iE 1 f . B? IN J I ROADWAY y I .DAVE OHT : IJr I fTOP SIGN ]' lIVO WAr i, _t-L. AKESV? -._. '; 111_IJNCtiRLOTY STAR N IN I I?IOI-1 TRAFFIICLANE .._.._..-.. syll. ._ 11 -L. +?? . '?•'?J no1o3151e (_,.J1 „HEAOLIGHi3,?. "ED AIR J''. ?._NOT IM[AlflEn ARTING FROM L11El PARKED POSITION i?_WIK _ _ 1 'el Ir. R[OJNING IICNANOE - [rI..IL-?... LOW.PAMP._- ] DEFECTIVE .;]_..__.-1 LIGHTS. I]l?'NOO SOIRILIY' "' ....._?J.JlN• ?- 't"11-1, ?I NIRGIN6IfNTERINO •LJ TPAif ICI f{ 1? LETEIlt ( ([ FLA)q"c t-Y L AMBER r.JE f _: . ALLEY _-?._'_ L .I?A. ?. oN 6Maorn ._ F?l?. ..' H DNOr .11N OR NKING i Jl[r] ?ACKINO f I DAAK-sine.,. E.L. pan ort_-. I...' nn .._' ....I TWO WAY-Lt Ii TURN UNIS -- vAre uH vfn CHEM. TEST - ,1-fmui uGHr} _ L OMAN r I u na ED " rte GWE« Dru In lYE Urw J . . EI O lR - ]' D IOtO I.--I NO DEFECTS 111TREFUSED ? 1 _ • CTN.RIY.CIFYI - «D,SAMK FI ' S -' ]' RrIDEn '.-'-. "_•OINER IYECIFYI ._ % TEST RESVLTS 2 FvIfHGwrING Or rrLLRSNAUi A1IIH K ` ...T./ ewVGE HO Dr v mHto Lr[E A 'i c•.:, '/•T, IRS N POLICl AHIIIVt4 -- L ! vieroiorLOW - nlveo AMA NBe N NNN NR r ? X I •SOG+pN40r H1[tN>xAUfi RANK a+DGf.NO I CY IT OR pIif.Spf 1. DAIt Or RPONI WIUV[p fr UwrE pI.PLICAIC COY VV'LfKAI LAW lNf ONCEM[NTPAGENCY $COYY? iIIIPLICAiCNCOPY?INVCST10A1U11?5 COPV • t stir G• 7-wy E" 07,_7 1? ? n )nmr annkT+ yr ^+v, ,?rYp R , a I?Py Il+lt"I " I - I9N; T 0 AI,ry •. I ! 1 J IY: ? ti, ? ATS ? >P k ?- A DATE OF COLLISION pAV OF COLLISION TIME COUMYNO CITY NO. rgwA 1A MO. DAY YR r SUN 1 MpN E 1U15 ] WEDA LMUP 6 FPI 6 CAI (USE 2aD0H RI [ >. QU C_ NTY ?STATE PDUTE ®C)UNTY ROAD f ?CITY STREET 0 ADM CLS. PREfI% RW I E OR STP Ll C• SECTION - ... .BE . .. JC ?PpSOAa ?OTHERISPECIFYI ..... J I ?% ? ? /SO YOPIOwN CI x 5 E W ? IN ,V, 4C (24 © LET / PREFI% EO. MILE VOSI C ! MRES ? ? [9OF_.___ ? A - NAME 6 NO.OFSTRE Y-, INTER5E1TINGWITH 6TFEETORRDAD LL RAMP DIAGRAM OAIA- .. . = ON o O NCN IM--, IC T LE GE INTE IN' E %•q0 CL5 I EPSELIIfq SiflEET OR HOR OPREF. ERENCE CRO STREET Ofl ROAD N BETWEEN SE<'Io. I _ _.. . STREET ANp , OISTANCE Li1 NN FS MEEF FENCE OR LROSS STREET SPECIAL COD NGu C ?MI E6 HuNOKL InS ? VEHICLE-VEHICLE ? VEHICLE BICYCLE ?OTHERIWRITEI HIT B RUN SEVERITY A' _Y COLLISION INVOLVED. ? ?. NO. KILLED TORAL OF VEHICLES = O VEHICLE-OBJECT nVEHICLE flR TRAIN ?H_ ?SIOLENVEHICLE NO INJU .RED p,- VEHICLE-PEDESTRIAN NON COLLISION g2ARD0U5MATERIAL gpROPERTY DAMAGE ONLY "'?,,1 _ a'Y5 y OBJECTSTRUCKINAMEOFOBJELTSTRUCKMIDOWNEHSNAMEI LOCATIONOF OBJECT STRUCKF- EST. DAMAGE d IN N T ?ROADWAY FEET ? ? ? ? RD EDGE •- S TI 1 DRIVERS NAME--LAST - FIRST --, MOO E DHIVEq'6 GT - NAME 5T DOLE FW6T ' tlICYC 151.OR PE[45 P CHECK( CJ. '.-" E OLIM T ?C OD D E 177 Z PCODEPHONE NO. E STATEZDP CODE pNE NO. j.N,E"RS'LnENSE SSSiPEET Ap0PE590 NO.OF0 IIYT DRNERS CENSE NO. S 00 39 SOY .?! '1 M DAr ORiERS CUPATION N?NIIe 131 ?uU_! JAI SEAT BELT_ I'I FJECTIOH CODES IJ CLASS lal SEAL BELT-- ISI EJECTION __--? ?- "LA555 - MATURE OF Al E F - J ,R INJURIES JUREB EM VED E MVED -y FROM SCENERY: - TO +1?• •? VEH. YEAR MAKE DODGE-CH V.I. MODEL IDMLT NOVA STYLE I2 DR -CONV.) E .YEAR SCEIEAKE (DODGE{HEVJ ,. MOOELIOARTO VAI .STYLE I]pR.CpIVI ?K E VEH. COLOR VC. PLATE NO. . STATE -1114 -1114 PLATE NO. STATE E VEIL COLOR IIC..PLATE NO. STATE (MILER PLATE NO.. STATE H yx/- 10 Yy ? I C VEHICLE IOENIIFICAT N NUMBED ?:, OpOMETEfl. :. I VEHICLE IOENNFICATION NUMDER ate.E!CCN+b b s r- E REGISTEPE OWNEfl-LAST ....: .:'J .I ... '.. FIRST MIDDLE -'. RE.Mlf.ED .iRE, I :x-. MIDME.: '*' a O. ADp m OF OWNER-- f ... ?' O. D - ADDRESS OF OWNER_ .-.. ..t. ..., .. .1 ... -.._ ' '?`"•. NAME ANDADOPE55Of WSUgNICE LO ON AGENT AME ANp ADDRESS OF. URANCE CO. OR AGENT . ...., - .? CHM10Ee?,. ENFORCCNENI I NAME, ADDRESS I& INJURIES OF PERSONS INVOWED coD[s SEX AGE STATUS A- A, - ' EJECT. C NAME C ADDRESS'. -_ U p HiMOV[D fnoM ' wAT..ES F SLCNE BY TO A NAME' T ApDR[56' - S INJURES LM EDfRDM SCr NF nY TO I NAME: I T 1 ADDRESS' 1 E Tii'i?vtpinoM Arbr WJURIE6 SC[NF IIY TO 5 NAME- S ADDRESS E S. HALM B Rci'Sn1 TO `` O 1IAlu, 1" ; nASSr NGCn A nOrCV31µ 1 O1H[q POS 1qN UpNARrC456 HI•+EAT BELT ISICJECTIOK 1 No. JURr 5 0. AD Np NNO I NDT INSTALLED I Noturc T[p }n1 AD Al SCENE DH'W DEAD S PL NO D OI IIUSC ]LOINEYCJ[CifD ] N AR D LL bO1NfP b WIINf Sb S ] ? ? i nUSMOIOnLYClE1 E ] E PO IIpq V!FNOWN O nMAI IE OCNTI NJURY ] UCD ] P nRALtr ' MMHOSniM IOSS,ME NJUNY u110WN AI NOWNI EJC bCA I O 1 pCLTf L • a '.S __IVa...._?. ? ? -.?_.-?i? --.a ?. S Y.. J . `F . F L ,[JCCIED ._..1.:_. _ ._?.- '•??. _. ?'?. 4 INSTRUCTIONS: n NVL a -_ DAMAGED VE 11CLEN01 - t.IN EACHECXCIRCIETHENUAMBEROFEACH O?MAGEO APFJI ^ ?.SHADE AREACFSEVERESTI VACT. - "3.CRAWAHROWIEITOSHO PRINCIPALCNECiIOHOF FORCE (USE mIS SPACE FOR SKETCHI aCAMACE rornutERS,MOTOgcrctES, Eicd _ '; IEAAMPLE®/ '. DAMAGEDVEHICLEN0.2.- 4- r t x ft (?I ? try???ar y ' h . ?JI Ilr 1 rE ? ?V p 3 A A, OF. ??.??;4? 0 9 JIM I C yr VvfA0nIIMl3 %JIV PAGE 14U. '? .. .'A '. ?j ... - '-•.. P UNIFORM POLICE TRAFFIC COLLISION REPORT:" OLICE CO FWNTNUMEfER O' _ OAIEOFCOLLWON -OAYOFCOWSION TIME C OVNI NO. -F HWA A 10 BAY R. SUti V(N IUES 3WED TNU Ffll SAi ) t z A 5 B IoE2A00y UPI D.. ' - ) . :1 ?? Q VRBAN E 7 ? { J _ . RAl CWtltt TY ROAD CRY STREET E] SU [3 TEROUTE COUN A . h- ''' A OMCS PflEFIX_ POLIE OR 9IAEET COO TON ???• .1 E].R ?/ / - / .. ?IC7OTY ?OIHERISPECIFYI .. .. - N L ° CITY OR TOWN S E W ?IN N . " W EFI% ED - _ - MRE POST V •OTT dtli?.•_ Q 8 - ? C . / MILE El ? F (, 5 _ CA U . - . " 9 vY• 3Vr .R ' T V NAME No. CF STREETORHA3HWAY --.-i TE CNX-WLTH. STREuo.R- LL R . AMP DMGiLVA DATA T ON 1 O NOY WTEPSECTIp1 -? ` ? ( ACCOENT MIEAGE -TEA NON X IHiERSECTWG STP Ap flREP .•?c EJaF1CECA SRi CAfjCNP - N- . BETWEEN STREET M. I2 P I STREET CODE S ":• = ?J? ., ?d + PEC C OMG U ' DSANCEANO DVEO0NfPu REFERENCE OR CROSS SREE. MILES - l1 5 E W /'J Ylny O SE; • y ryei.NUU•916 FEET OF S. '. 'e C-] VEHIOLENEHICLE []VEXICLE-BICYCLE 0OTHER(WRRE E]IITIRUN SEVE'1RY N)NI:; COLLISION INVOLVED: VEHICLE-0BJECT CIVEHICLE-RRTRMN E]STOLENVEHICLE T T NO INJVRED ; AL NO. O `•Q•FVEHICLES = E3 VEHICLE-PEGESTRMN []NONCOLLZION []R-RB0USMATERIPL PROPERTY DAMAGE ONLY O:lJECT5Tf1UCKINPMEOFODIECTSTH-ANDOWNERSHWEt ;. •... .. .... - IDCARON OF OBJECT StHUCK •'• • Y µA P? F. •N S - ?ROADWAY FEETEl Q ? ? RD EDGE - 6,. ORNERS NAMELAST FIRST :-, ,?. _.,,MDOLE ^ ORNER'S NAME-LIST FWST MIOOIEI -. „,__. _.,. - rL?y cG1L) aC IV R- _ R D STREET ADDFESS R . R10NE N0. ._.._... IIP CAOE?.. C -: . .P.: STA F_ >•_. w E'•.. . : .._.,- , . ._. - T ^+__ R . ?- :-••? ATE. - ` IL TE O BWiX .: N DRNEIS LICENSE NO,,^,..•. .? STATE SF]L. DATE OF BWTM _ --+ T ? (?. ` - L ca-T F MOB DAY YR DAY YR. FF W WWE„:..-_-._ Z -_ `^ -y U E /• ,CODES':?/ 13F CW99-- ___ HI SEATBEL X "' (51 EJEDTIO,i - --:"I COOES-'113) C - • (sl SEAT BEI.T:q ANRE _ .AmFE _ FA SCENE BY: TO FPEOM 9LE NE BV: TO - I YFN?YFAIL AkAnE1DGSOECtEY,.LC MODEL IDMTNOVN.:.,: STYLEI2 DItCONV T* MN(F?IDODC{'CMEV I.' VEHYEM- MODELIDART{q AI':. SiVLEIZOfi.COI1V)arv3 v,. , cr F_`V __. v- _t.. ,1--.. ? - - _ E VFN: C040 IiC¢YF/ITENNOC,?- _ TA.. .. ,)LFA,PLlE: C10^ STATE'--r+- E- VFl[COCOR- 11G'PCATE NO- STATE_ TRAREIiPUTENO:= STATES .,..C T H Hcn .. .._ a .C .O Ap ILTIpIBF?y.. ?r - DOIAETEF7__;?i- ri.' EHIC4E IQENTIFICATI M. R.a.?.`?'?-?' OWN_' J`" , REGpIE Z ', fIfLST I '_MODEE yr PEdSTERED.OWN LAS 'tfu FT...K.kG.. SNr1?.FiA?-?PR?i.?i. ' ACNVF99- O ':-1.-?' 1>._m1.V s IW, t '; AODRE89:OFOWN?P '?T I. I J.,D4MA GJ•,G i :SCdFAfLlf A LLl An 430 so Aim- t 1 ME AHO DORFSSO, E ORAOENT^?,,. . ,? ,,,, ? ),,:.a:.e .'? NAM ANOAUDRE'JS-O yl SUTUNCECOI OR AOENi ?: - ?.ii ::LG?1?.:t': V ... 1 .-. __ ... CRAT10NH0.. ENF ORCEME NT . HAl16E % ?c? ACTION t '1{ . ? _lY •Un..?i. .. X'.V:1f iM t.s ADDRESS & INJURIES OF PERSONS INVOLVED NA E COOE9 ?.... ??I D.. .??w ? ;rte „N M ,. SEx AcE srATas PJECL O NAME:"• I _ I .LVq ?. _.._. • C ADDRESS'-• U'. .. P - OFHOM ^ NATURE RE OVE Tp WUNE3•... SCENE flY:w... A NAME: $ :... ...'Tp •J -? tLII EOF 1CFNf BY' W 1 ADOREi9' I M .. .. N To '•.. ACTNF RY. iNXIRI s' - 1 E S NAME: .. _. -. ..:- :_.. _._ .._. u AODRFS' -• I S• ?IiAI Rh S' - -'. PCENE BY _ .. _. ._ro.. _ _ •.,.'?_.. _._.... I Ifi lVS !ti+F-k '? 4:'lY . ?J Ufrv CLI:J_ •+tA , L A 1 ' ' 11• I?` bTP E ??I C O J. PA SCNNE? J%Ok S11H PO '... A y 1 \ iPTMFR POSfnON NOINJURY 2DFAD AT SCFNE 3. DEAD ON ARRNAL SMABLIMI1- A,gIFDA9ANUM 11F.VIOFNij IIVUfW T.TIV I LLED NOT WUSP T- .I VSFD I.h JCCT D• T. TpTAILYIJECTED '? 3.-TIALLIILIC.ED O E DT 1 I, VTtlIE.'.S F J US4OIORCYCLEI- AT?vTIbN J.ANDNN A DIED. ROSPAAL T IW>4RLE INJURY • UNKNOWN S. SEAT BELT FMWRE {. VI OWN P EJECiCD _ m k : ? 1 rj?j pp 31 )}^ Y Jnf: • ?mrb i I ?? I S ? W I ` ?? ;"?sn?u - "7;i•,^ ) nk f;5 4v1" ui:'" ?1?v r 1I °?"nr• .,.1 _ G `( M? DANIAGEDVEHICL EN I O. 1 I]. H IUSE}IU?ACFFORYKET[HING DAMAGE TO IRAILERS,MOTORCYCLEl. SIC I DA ED v/VEHICLEYA,N0"I 2--- . Y eEwt r ?1- +'7--?i E E E I+ S. u E Tm..+., ). o..,I... Iw. r .... .. H. n I., T _w'.ff-JU.-.,-,L/?_I•I? '+V+ 1) ' M l V RITY OF DAMAGE: VEHICLE NO I a'U...IN°OAMAOE ] o iUNCIONAL DAMAGE .I ] 0OTNER M, V. pAMAGF + xO Ogf.IAf,E . ° . i rlu•n SEVfnITV OF DAMAGE: IOTHER VFNICLfI SEVERITY OF DAMAGE: o I IOOIYnBLINGDAMgGE ]I]OTNER MY.OAMAGE 111OIABL NG DAMAGVEERICLE NI 4O TNEIIM.DAMAGE ] iux MAGF + Q x0 MADE ] Q FUNCTIONAL DAMAGE + LJ LTI NO DAM DA TOWED BY Sand so Chevror_ EST. DAMAGE AGE TOWE09Y ESi. DAMAGE TOWED BY EST To Quilcene VF. YTOfhL . D MA TG s rD t •DIAGRoM O. COLLISION . aD+ V,..CW pE Duff I DRAWAR _ ROW SHOWING NORT THIN CIRCLE ' 1 ,? I ? ! THAI-IoNTROLr nucr ory] U ? I ? 1-?_ _ I` -? ? I 1 I I f I III ' Kl meuIFLE.mNTnF ). LL°nCA f f 1 _L ! L -I I _I I j 77- 'I 1HDWYln GLnDM1Y "OE1TRMN.,KTDX DNftLD„TIAT M • .111 DLL. DN r 5Y' .D . s ra ? } , f T DESC E P„ .P y P `J 1 [ I RIPTION OF IINDCATEWHATIRGBAFILYNAIPCNED BEFOPE DUnINO AND AFTER RE CRASH, INCLUDE INFORMATION NOTO D GAM, E.G. ORIVEfl - -COLLISION DSA(ILITV,gEOVCEDV SIBILITY,PEOESTRIAxCLOTNNG COLOR CONSTRUCTION On REPAR U 3 F ..!J- I , W K.ETC.I '- ' K Driver informed this R/0 that he was NIB and due to the wet road for some unknown reason , s - -- - -- ---- his vehicle started fish tailing and he lost control of same. This R/0 be]?@ves that the a ? o-3.W Y kif __ ._ is was over loaded with weigh t and when ho s rted into t curve the vehi le Vy f c - with the over weight started to sway and he lost co tr . a. - n -- TI NaEFORE COLLISION - E TM1 f Power dole' ??t-'; -- H ±w "HEADE D MILE I ST O SING DEC IR, ON Sinf ET OR HIGH WA EASIN Y NAME OR NO. OF AM 4. . PEEO - INONEDIRECTION OsrEO S R DALLY F WAS VKErI. A RKEO OCCUPIED El L - CR 18 O_ MPN O S ONG_ OR LRIH ;77 AS L'SIx O.. IYIDEW ALK -'WALKWAY SHOULDER A -.A ,__ ? MARKED S--UNMA gKED ! 1OESIGNgTD ) ° TO AD SUgFACE IMECK OMEI WEATHER ICNECK OnEI cgasswqu CROSS - -""' NTRI[1UTING IgCUMSTANCES ICHECK ONE O•l MOnEI wgLKO evCLE ROUTE .OTHE •.- R onrvwr I NO.2 V ' vENlttEncT10Ns CLl I oNf OIIIVFfl IRO.] r? CLEAR CIC 0 O D NO, O.) DNVER 1 02 T ' - N DPIV D ] ( X I.V1 ?.. U GO G STR GNT EAD DRY -?--__ . L1?i?YfIICAIT V R NEL fN EO r ALCOttOI_ FOLLOWING J'.`TgQOL4£Ek f p 5° ED wARN ° _ T] E D 21j I WLT T ) I R IND_ AIR ?- UNDER I •)I DPU451NELUEn EO ?Sj Nf CENTCq ? lALi NTY $L[€ (? r I t]L M N AK PASSING NG I] SNOW 1- n r ] 1I SMOKING --?L ' I 2 CEf NO STATED -U. VEFDL f . ? gII NG TO I S L L, ? ___ --E R R A KIN ° J?1 - J n A r RIGHT TURN MAKING ..I K! ?JAL A OG SA° DG EA EfF I rU FR i r? f,gl aq? NG rfCT F ` . II L MAKNGRN OTHER 1Vlt1rY1- --?OTHEq IVECIf YI 1 NO GRANT J M 0 C F - ._ STOP. ° ° I GO G - IV E4UII E J ? IS UTUNN SLOWIN° ND ' 1 I R IGD r _ _ '1] DICNFSIGNgL5 TO a x4 VIOLATION YI I ?+ i I)? STOPPED FOq 1 N IaICK DNEI RAFFIC CONTRO INO.]vNICLE Vg-7, TYPE OFRMODRE D.IcHECKONE DIT •-- VEHICLE CON DITION VEHICLE ''{{NN x?Ljj?? QQ(l SOBRIETY -.. VEnICLE MHFCK ONfI L__J g CI TRAFFIC {TGrr[D Ar SIGNAL 1 i SIGNALS I I ( : WAY 1 N0. ]o•1}Ei?}DI 1 NO. ] OR STOP SIGN -101". IN I LLT_.DAVLO T - J ?Lj 1 SIB it TWO TY . '] r[] A. Al STARTING ] DAWN ---- 1J ( ]I I.SGN L OV[OS LF L 2? If ' ° _WPNIILO ?] ,o ANE TART ]? DV{K YN G r X . ]E(? NTF KNGC 1 . k OLIGHiY_ I -' J, !-, NOt ^M(AIHEO_-- -? ?11? P INGrn.. ARKED POSITION _ . r D ARK {T LET L... flCD --- tJ L00 flA I,- ] DF([ETWF _J_HlAnUGHT3 I )r NS°SOBRIETY q MERGING IFNTNINO LIGHTS". .. ( rLASHI o u.' l AN![q FI L., I11 It L?ul J•? YMOOTM r -' pf NNDINKIHG L-?15? (ACKINO DARK- {i•_ LIGHTS Or(.- .. _I Slcgµ ( ISTUR V°NLANi T . . .._ Y-?1 Vcrv+[ DwN I Dn vin CHEM. TEST I NO 1 )) t I ? f GAHR_NO IS l f1-1 LIDHt{ r FI ,_-- 0 OMAN H I 111,2.3 LIO ;... . _ _ . l TlSTGIV[N _ ..1. OTIItn IV[EIIYI ?Ct ....- __ U •? 1 DI OFD NOOEFECTS LA , TlllFllUi(D_ f I I tMIn O RI(tIIY I / wuL K V --- - y + WIDFD -O iV(C rvl - NVItt IGANMC Or IrCl R1 NK Al M1O TEST RESULTS Z Doter W.C. Gobhart NVturc.NNOO.nnHS MFnnA K 6 L Ct OIS D ATF ? YA CnlO 1 0 rD EULIGI alllllv[O :xo """vio"`] 18 0 0 .. ??ro Loon 0 O X / N n+OCE NO. clN.r N II U/SLA Ul I. pAIf O1OVpnT AP N No— .1 H MIN 6 JCSO Quil cene 090778 - • P 5 Y z ••?•••?••.?•'•. a. rvU pUP L IU -ASIA N O TON S rA T E PATROL-OLYMPIA,WAYIIINGTOFI OX:AI tt l.• ICAT[CO Y. LOCAL LAW[NFOgCEMENI AGENCY SCOPY-iqI ILICATf COPY, INVESTIGATOR'SCOPY S IJ I P, •?4 ? 1 L ? I r„ `I I Y 71 1 s PAGE., Y IIF NIJ1 fi?l? 1'li` OF T,f.F t a I?U• POLICE COMP UNTNUMUER ; ( f '•? UNIFORM POLICE TRAFFIC COLLISION REPORT . , C A., 1 t[ I -DATE OF COLLISION MO. I DAY YR. I IR.FCOLLISION T SUrv I M0Y Y - 0 WED T I. S FRI B SAT TIME NU E 2400 HOUR) > COUNTY NO./ CITY NO. fHWA OBRBAN COUNTY ?STATEROUTE ,?COUNTY ROAD ?LITY STREET Q ADMCLI, PREFI% ROUTE ORSTREET000E GE TON -• ?BTHEfl IUPECIFYI • N ? L S E W ?IN CRY OR TOWN N PREF. ED. MILE POS C T MILES E3 ? ? ? .?OF- .--____..__.._ ?__ U '. .. ' A NAME 6 NOOFSTREETOR NGHWAY -:- IMERSECTING WITH:LTREETORROAO LL RAMP DIAGRAM DATA -T ON .? N NDN DRERSECTION, • - - - - ACCIDENT MILEAGE INTER %-RU INTERSECTING STREET OR R AD OR HEF• ??]I CLS. EREN CR .IETORROAD ` . BETWEEN STREET NID. _ DISTANCE ANDD RECTION FROM REFER N CR S ST T _-... _.. STREET CODE S - O S E CE OR REE Z]MILES N S E W 7 uAfa uldR[IHS SPECIALLODING USE OF..T - ? VEHICLE-VEHICLE ? VEHICLE BICYCLE ?OTHERIWRITEI COLJSION INVOLVED: ? NT6 RUN SEVERITY _ N0. KILLED OF TOTALNO. 1?I ? VEHICLE OBJECT []VEHICLE RATRAIN __ ?STOIEN VEHICLE NO, INJURED F VEHICLES u ? VEHICLE PEDESTRIAN ?NONCOLLISION ?HA2ARDOUS MATERIAL - ?pgppERTY DAMAGE ONLY OBJECT STRUCK (NAME OF OBJECT STRUCK ANDOWNERS NAM!) LOCATION OFOBJECTSTRUCK I?„YI '. ? . •. ... .. IN N S.'E_. W. -. ED.E G. EST. DAMAGE „? "C ? --- ..'. FEET ? ? ? ? TO. - FEW L 4 ll 5 -.- r v sy• ,7 VEHICLE DAMAGE '.IN EACH BOX. CIRCLE THE NUMBER OF EACH DAMAGED AREA, ]^^'"?? NSTA UCTIONS: z. SHADE AREA OF sevERtsr IMPACT. ' O.ORAWARROWIS) TOSHOWPRINCIPAL CIPECTONOF FORCE. (?,?-Y w DAMACEDV2.ICLE NO. 1 [USE THIS SPACE FOR SKCTCIINGDAMAGE TO TRAILERS, MOTORCYCLES, ETC 1 O/ ] ! 7 ] ] ID EHOa DAMAGED VEHICLE ND.2 Fs10n ? ''?'= 1 Ibar ,D NpoG- '? f' / 1 nI'w 1E Trunk -¢i A. P_1 § \ i9 Unc«avrlape IS TnInk k .. T.a«R.nr ?i???FM IT.a«k.R +a. "x'§' SEVERI I UDISAOFBU ODAMAGE:OgMAOE VB CLE NO.I 3 SEVERITYOFDAMAGE:(OTHERV'_HICf!•.) UOTHERM.V DAMAGE I GEVERITY OF OAEHCL W.D2 _ "/ 2 FUNGRONALOAMAGE 4 NODAMAGE UWSABUNGOAMAGE DUpTNER1A.V.pAMAGE EUpIGABUEl AM GE:N DAMAGE FUNCTIONALDNAAGE UORfER M.V. DAMAGE •'4 F1 N 2 NO DAMAGE 2. FUNCTIONAL DAMAGE 4 NODAMAGE ( A TOWEDBY ( C ESi.OAMAGE TOWDBY - EST. DAMAGE f TOWEDBY EST. DAMAGE E DIAGRAM OF COLLISION I TO s rµ 1as RH i I O-ARROWS HOWING T "yha y,. w?a:e ]ROwr RLr,IAES ?_I I ! I f I NORTHINCIRCIL z Pfp[srm?ks .? ONECTRONrpERR„AmrnY ? I I ??-t i/ fPIFFlCCONTR0.9 - 1 ?? u uEMU"u:'E«P coNi.rkpas ,i }T' . , _ i i L I i ??Y r ?I 71 A O +, (.' I "ereiwsrwcnon j? _.. 7 r ws.. '. ? oc i WroaA&EPOwTOF !?'. L ? I I ' ? --7""'r_ _ '4 ? +?? I f' I - r 1 y 4..-IFE w.NPArH? "«(aRI ` r. i a .? ?, aRDw Rpa.alE pR(pRa 1 ? 1 I 1 I I `_ I ? -C ` _ ANpAFfERLOwLOn --i ?- I I r t 451 5 DESCRIPTION OF ' ?q? COLLISION Iws°Aelu v,RE UC DVIS BNTY PEDESTRIAN CLOTIIIINOCOLOR CONSTRUCTIONION EPAIIR WORK ETGj Or ON RU%M O.O;VER k ?? c _- ?!?/I5 G./JS /ru>z cCL O/J / :J O 'n`?C J S ? Ir?_u_27?. -' O 7t<. y_!t?'CctJ-G -.--P0 ITION HE ORE LLI ON - - HEADED MILEWPOSTDIR 'o, 01 SrREEiOR HIGIIWgYNAME OR NO. INONE DIRECT E NO. ION PoarEn REE05 V HIC I. PARKED NO. WCREASO DECREASING a LEGAU.Y WAS VEH. N S E W - PPAKEO OCCUPIED w 9 *I 2 I`?,1_? I I l_ 1 I 1 ' _ -` YES (NOD (YE?S_(N?O .,OS FED ( I .? [ OR m a _- o"i 1 I '...1 ( +'r 1• . LLaka ..____. __._ ."_-_. .cMM9W ... a O ? ? .C CMWEAr S EM IG iO >T 9 ?tin PED/RICYCUSTWASUSWG: w[ t I• wAVC 1 'a R p 6 .- _ m )'pM --____,_.rp -'. ROADSURFACE WEATHER.. Ra swu ROKfw L 50c Dore 'F7_ o _ Icxtcx onR =" IDlECx are! - -' ,.CONTRIBUTING CIRCUMSTANCES .r L,f-1 . OrYJFP I ON OA MORI ".:r,ORIY y41(1.{L+AO,Iq[a 'IS '?•' E ? ?? NO 3 OravE' ? 3 VEWCIE OcR ?bL ta•J; ? ... r ?l 7-7 i • WOY 1. (? fM N [O ] Gd10W I C _ - L i. 1 L u_ aaL _ I I w laa sn GLY _ .131 9q E AWl ? ! UHRE wFI , C MER "' ?._._ L- -- ?'L ? OW,E _r4 (? 4E ""'Y ]r Akp PAa9Hp AAR _IIARE. _HT. aP( P.. r-'! 3 PROPfRP «o _N1NO "". 1 \ a i_= ( -....- A 1 s°c -LJ C?I) Loc ?y? iesi rW°uRH .t? tWy+. --- Ar '.;- 1 , T,AN __?? [ I?DER rMf. ?__ ?a,C LLtUIWq. .: ? , wra RAn - , q OIHERINKCSR OMtAI3Kd1Yl __.. ? rOre . ".___ ....J_ __ Ow]a LI r'^ Y ? T ? PA0.ti MMA I ?,]. I s?cHESa iron ( ?1 om E IM ? a? , GHT CONDITIO n NS (TRIIFHC CON NaA TROL was ;-TYPE OF ROAD VEHICLE CONDITION L mamEO r,m r Y I XI e. p rLaHr! L , 3 _]i rpwta-- : L? 3 [ ok oA -L, ale awi q 1 No. SODRIETY wij'..'• _ canofe 1 _ Vua--t;;. 3 I R rKm _ _Ap J - ] - ffL Ak _ °1R a_ of a AA M0 W n a K e P uoao a j ?? ] "r- m C11 -XiT ( i a ) pIIElt ?'0 .r0 1 + IOOi I CUq ?, ' PAMt a!IjIW pA - [ ',y f /lA.4Arq [' wu4 _.. I Mre r ORK.aOe r l ti'? if l(HTFPoIa ' 0 ?-T L?A' : _ A«MR AuM 1 f bi(woom .(\ [I ti?Axw _.. ' !,!. . ri 6W lrHE --I M W lrrt E ?ra aAtlpnO ` Iy ' p.i 3 aaNLL ? NrN LwE] Ha M:NkEO .y CHEM. TEST ' " pIP[EN,OIaHia [ IIMwN KHICR OrEI _ '1 Hp ] T OR4R ._J bEPAM}lp ?. TFina Om(RIIP(c'" O-D M]L( fC a V OTM CUrI I PO TIC 1 i Rai R[NHp 1 r I CtriiRpl UNpIyyO O+EI[ Y(PM _. narair l'z?r ,.w nwMl % % TESTRESULTS 2 3 aALxye,a. roxE aw --D -i.. . u .? 1 I :mwp ( row., 4 „+ I 1 ra.rna u. r.( ?«E.I4Ml NO pw, l.r EI. 7'... ! ].ao 1 -_! ]boo : ?? ].m IuPiao L k? •I' ...t ... _.. 0 p I DAT]an1.1 11 J APlMaVEO ar I RL J W L '4.! ', hl?1 , I " n.oce Ac a Aoa _ i__ r ? ..?? •K- 9 >yl' ?. MSTRARUTIWr ORKLNAIA(WV SEND TO WA SH'WOTONSTATE PA}RL-OLYMRA, WA.^uI MITON DEIpA I (: yy{{yy 1 DUPUL TE LOPY IOCAL I. IY tAfpRC[MFIIr AGENCY'S COFY-TRIPOUCATE COPY IIIVESrIDATOR9 COPY YYal1 ?,'I 1' ??{ T I ? S. 1 ??I r 7 ?? I Yi y..•. v- 4 jl 1 H ,I ,r Ci w ! 1 I I ? . i 1 ht a } : ?. -. e ? I ??rIP E i ? ,'a?p?r?..ar,-rtr?•-. .p'g? '7?".,..7?? d1? ' ,?i4 t I '? .i { 1 D' UATEO c-SION OAVOFCOLLISION FIVE COUNTY l+O CITY NO. FHWA A MO. OAY YH. SUN VIYj IUSS Y/EDA IF FIII SAi 1 2 G 5 0 IUSE' Dn• I) ^UPBAN £ ' Z 714 ) ?G? PUSAL N COO ?SrATEflOUTE rlI ICOUNTY ROAD ?CITV STREET YY?I++ UU DMLLS. PHEFI% ROUTE OR STREEi000E G C:K1H V?LZ`'CIL?O/? ?OTHERISPECIFYI C'I y C ?? Q ?IN CITYONTOWN ''] W P REFIX E 0. MILEPOST 'J `? !? ry1 1 LAILES ? ly ? ? ® OF T?.li ?N 4J V NAME ANO.OF STflEEf{.OP HIGHWAY INTEHSECLINGWITH:STEETORROAD LL R AMF CIAGRAMDATA A !C ,J NONINTERSECTION 1 ACCIDENT " CN 'ER %RD IERSECIING STREET OR ROAD ORHEF. RETIYEEN -A. •" ? ? L? SrRSET MILEAGE CODE IA ` CLS. EHENCECP SSSr EETORROAD J ? ?aTi/ ? /T - T 1? _ DISTA NCEANDDOIREL fION FROM gEFEPENCE ORCROSS STREET S N / S S PECIAL COO?NGUSE AN ? ? ? OF ?? I G C? 1c? • 3 EET VEHICLEWEHICLE VEHICLE-BICYCLE pp;;C HEHI'.VRIIE Illrb RUl: SEVERITY COLLISION INVOLVED: ? ? W ) ? NO. KILLED O m ?VEHICLEOWECT ? VEHICLERR FRAIN ? T(? ?c ?STOLEN VEHICLE ?)IO.IN UPEO rA O - ? VEHICLE PEDESTRIAN ?NONCOLUSION ?H:SRRDOUSMATERIAL PROPERTY DAMAGE ONLY HI OBJECTSTRUCKINWEOFOWECTSIRUCNAYOOWNERSNAMEI LOCATIONOFOk""TSTgIICK EST.OAMAGE / ??? ?ROAOWA k FEET ? ? ? I/ RO. EDGE 5 DaIVEHS NA1f.E LAST FIRST' - - MIDDLE ORI'IERSNAMELAST FIHSTIAIOOLE f C+G111 IcFPE?%IINA'. GrI ! Gnl'.; R CYeG'Gr=`K/ /tGAg D _ _ I STREET ADDRESS I STREET ADDRESS v i3 oz-z5? v E CITY STATE IIP CODE PHONE N. E CRY STATE LIP CODE PHONE 111. // -- oo pO N DRIVERS UCENSE NO STATE SE GALE OF OIHIH N CRIVEHS UCENSE NO. yy$??lATE SE% DATE OF bIRiM n G/? ^? ?n, !T MD. OAY YH. O z D, DAY YR.' o c C UPAIION FIRM" P HONE NO. DRIVERS AAME 2 DRIVERS OCCUPATION FIRM ;",E NO. , / ? / '? ryczee S !/-,- 1v CODES > °' CLASS I`I SEAT BELT ISI EJECTION CODES > Ipl CLFS, L SI AI SEAT BELT I51 EJECTION US E, NATURE OF NATURE OF INJURIES c FP" OMSCE SCE NE RY' TO El.IOVED FROM SLENE BV'. TO VS -EAR MAKEIDODGECHEV.) OOEL IDART NOVAI SIYLEI2 OR CONV.I VEH.YEAP MANE ECt V.) MODEL(DARTNOVAI SW EI20-CYFV.) v `-73 Ocos. G?trz/4ss zo v E VEM. COLOR VC. PLATE NO. STATE TRAILER PIII NO. STATE E VEH. COLOR LC. TE NO. STATE TPAILER PLATE NO. STATE H y2 NQ.C i /? . (• VEMI LE IpENRFICAT10N NUMBEfl ODOMETER D VEHICLE IDENTIFIC I N NUMBER ODOMEEfl 3 T5?K3 ? 412 935' E E cr5?? SS REGLRTEPED OWNE/R'-LgST FIRST MIDDLE REGISTERED INER-LAST FIRST -CUE O. ADDRESS OF OWNER ADORES OF OWNER ?.., 2 C R AGENT NAME AND ADDHESSOF INSURANCES CO. O NAMEANDADORESSOFINSURANCECO. ORAGENT ' / A-?• CHARGE Cl fAiION NO. ENFORCEMENT CHARGE OITATI NN NO, ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED CODE5 I - 2 S L sex AGE crams +• EJECT. NAME /I/ I/. '?V;e 1 C ADDRESS- C 6 Z l 3 1 --.3 1 U p NATURED REMOV"cDiROM D:JUPoES. _ scfNE O! TO A NAME' N T AOORESS. S ivJJRR Sa S?.EOVgUfRUM TO W T. ADDRESS' N DRIPS' Sf.[N?RY S JNR. __ S AmFfsS E n; DTf Za'--' -R. mra Ar e I 10" __ IUY JI?fA J ' • . . C D I E I I 'u--,LvIER "NIAN 1 _L 'C 151 Tr )O111-1'iO T.1,/L'19 HF.11-NU NONE. ' 2Ti UI E F O' UEU NHO..PI _ 1, ENON O!S aUNGR1 IEVf.EVT Ulli! TP:JSS IItE NIVRY r C.f 1 NOT INSTALLEO 1 NOT[JECTED ":OIVIU:F 2. TOTNLY FJECTED J USED G PA- LLV EJECrEp ?KNOW:I A O PNOIVNIF S S[AL OELTI AI:URE FJECTED _ 1]L r I r rl r , I J MOTOR VEHICLE COLLISION REPORT F COLLISION COUNTY N ITV NO pAY OF COL . DATE, OP C .?• rcan'" +ux Nox a LISION ...xc4n TIME O wx rn +.r » ^ -rc '?• PM I un W C % { WN • CLS PREF I% x rwaai coo[ 9EGTION c I. L COUNTY .CITY. TOWN.. °x ;.f c??? t/ c`cClUr ,e.`; o: . CITY. T O MILES ?? %5 DF ' . >ctC G?Q/v EGTING WITN? STREET OR ROAD EFI P IT INTEPS •. GIVB HAM! OR BTRECT.,POAD OR HIGHWAY KxR» ?Uc/ UGtlt3' ?Or4? MP IAGRA M DATA NON INTERSECTIOK-AlION OF COLLISION' STREET A STREET O %ftD a WEEK w xloo[ r ®O R ow NcAn[ raw+ criNC on io[x*• x.^o^xnn. " o Nil???a? +i I + I ? N I T CLS. To " a tRa n n cwoss OO ° G ?uJ / AY,Y/ O w? S/J'?/L EC. S CO E l'SE / 1 ® N " ? OF OBJECTS NAME AND A°°RESS ?N 'IC 1 OBJECT T CNy R w,ow+[ Rwuul WNER ADWA , - ,I • Ql7Zh` /rc%/% wax rFEET n.. 'jl! - x ?c:xvo - RIVERS LAST NAME •_ FIRST NAME S. I S, ?,MIDOLE ? ?. .. L.[. D _ F 1 p;' flIVERS LAST NAM4-. -: PRT NAME .. •• [*r^I+. x.x- - J?/A +4xa.,..[ I%X? STRE6T,A OR _. OUTfiNO AN 00 NO n[o u+[• 15TREET ADDRESS. ..'.. ROUTl.NO. AND BOA. E+O• - _ rAnwr[ LL HOx I _Ih ?,,, ''<_• //? crfciE Eli rt/?T=G/T%iv`? nr.°x. CITY,{; ...i.•SA STA 6 L:?.:.:; ZIP CODE ,ORIY[RS °GGUPA'T/ION rY .. ST ! ". ?.LP COOE ORI EftS..,000UPAlIOW? ? ?,y DRIVERS LIGENSiN Efi•r,,,- STATE SE% DATE O. BI TX AGE, sa! GRIVER LICENSE B[R ?:: STATfi Sfi% .OATL OP DI.TN ^ t GE N .yy 4A, ry '`i .? "/ !? '9{C•' G? lu -Sr/ MAKC.. I e4ow1 ooe " I.wv.. I oar ssvyc IL [wl °?r yARE??0•?ar __1 MODE .IwoVAu ,1 BOGY STYLE IC°R.I v[NicLC •w. ..? _.. M .. -. T AILER PLATC NO. ,y TATL .f. •r LICENS "puxTE N4 STATE, :. TRAILER,PLATC.NO. .. „.-AT. LICENSE PLATE NO ST TG J ?G `7 Jdr, /v C! r 1 9 s.Mm.u_ _ I opowrce .. ?" VENICL610[MTMICATION.NO.?+,?I196B Pooau O xaw[RI OOOMETEiN LWa ? - VEXICLE tOENTIPICA OH T C'`%S /%/y??J r`r ' tl r REGISTERBQ.OWMiR_ IuRS-/Mrtl wooL% 1:. ORNLRS VCEN N REGISTERfiD OWNS Mm FNU•sl °RE 3LIC{NSE 0.,... $ ? O!• Axo nAr .?;;.: WTe F B TH OWNCAS ADORE35 ... , aT .GATE OP RTH; Y? '. •x o NlAS ADDR[s9?;:.._apa._.. oA• .[ Mp t A 7X'A I ? ?• PM TS OF VEHICLE DAMA ED _ ...... , -. 77,77- M 3 DP VLNNa.E"DAMA68Ot._ :.-..... L,GI?' S a' P '/ ?/ / g T"ZG WA 7 TNEREAU'ONOBILELI AR LITY INSURANCE YES NO ? (('? LIABILITY INSURANCE INFORMATION VEHICLE NO I COVERAGE E••ECT R H S CC EN ON OUR CA LI J.IN• NA EOF LIA NG6 CO L= yy NY I N CAHGAOORESS OP VABIL[TY MSURANCB POLICY NOLOE.. j1 ,.. _Y INSURA M AN „ s • • ??' ._ on .. v LUI .LITY PO IOY.NU BER '° .. r.? I [A RQD?R[ssor LIAOR.ITTI%5UR Nee AaeNLJ t J A pZ ,¢JC NE?,C/LYd 6?GLt?'i95 L/7 <G1?' IILNSO??Cult %?s?b l?7 9 ? ". - , AOE LND IHUflY?54? AGFa. $ I IT 11: -.F.7.Sf ?? HA .x • , }' NAME rF ., ? ? ,., 36J[, : AO]4E5S " DRESB M F -n[ ,8TAT1`16 oI pNR® M•ow+MARR FIRST ONC THAT II(?LILS LJ ST ATUS Or INJURED - l:i ?. oNxauxo x.o+AR w„+I? IN VLNIGLL of"?uwro ?J KILLED wuwT ;?•°w ??^ E oPTwuN N? KLLLEDbrva N IN °?? I clr r:: BL(PKT .K o.? ? 5[] wfi?':w lo:7 aa+c ?„ 3 1j LJ HoC ,w:_ ESCgIBE. BELOW.WNAT MAPPENlD IIEF[R TO VLN CLCS BY NYMSERI?"... SNOW NORTH BY ARwOW IN CIw CLF \ - / ? NP9w 9LLI+. Ar S A ??, ? xlF I a O? % R.NUM.+waa[ww La`. ., rAtl87NJlR YEN-' a No. LOUR, N[ IOIN[NI a OF I PcD[fTRU.H ? ? rmwtftuN wws uuga • cI[ [aI ICI m e• 1 ? DAYLIGHT `??'}Ir^C, OR, l?11 w.1rHIN0 ) ? DAWN lJ T Cl WaT JF4 b11owIND , DUfK 1'? R , ? pARA .T Now Cj Poo[ IONt. ON N ? . ? CJ °Orr? O LY wCASON IM Aq1 f[LINO WNO[R P[ I;VLLI?IVn ON bT?R?[y[T OR?INIONW AY NA/M•[ OR NO. ?fIJGA • lloa ? Glr°b J III --- r•w wAS T",111111 TIED "I I 0 n +»aaI . Iw[..NNNaw 71 IIC caw rftoL tM•.[o 4.a rrr[ of RowD DwrvrvvLN¢L[ AcrloNf ox[ on w. ti ?q III?ISIONALS CliI ONE WAYn 1[ ?11 ?xOO1N6 STRAIGHT AHEAD 1 [ 5TOP S a4 ] ? TWO WAY ? I C] OVCRTARINO AND PASSING a fS I O ?IILD S v•. Y r? R[VIR, OL[ ] E] MAKING Ro'r TURN •? C] . u ILOOP°/RAMn? O A C? MAKING LEFT TURN A C]ILASHINT. •[_ r11 b ! J ILAeNING .VS19 FLl 5 n ALLEY C] S C']} MAKING U-TURN • ??i ?:, L 6LOWINa ?. A ?(''? PP LONAI E_J A ? I. [ATUON ? . (Cr]' / LJ OIIICLR ? 1 ? 6TOPPED POR TRAPnc {?? V l.J w Si ICHr ^ 0 e ? OK STOP SIONIGNAL 1?' Il ;4_ 1 LJ bCPAHATED 9 f'l STOPPED IN ROADWAY lJ r [ D DIVIDED nI0 n A." I""' ur ` '.. .,.:,'`... j LA . ?j k w r T irk 4"?k fr AF?iY"i ? . u . Y MGi9.Si? }'s1S6sLTFtitiA ?K VEHICLEINSTHU 14 F L` C fiF' IS.TnuIA 1B ee Q leenr Un '?-' 12 eDN i tB.DINw[erIW4. D •' F;l I;?LC'f ;L'h1ttZ'.' SEVER tt CF M • I OA AGE. VEHICLENG1 u.i,il,i SEVER ttOF DAMAGE: (OTH RVEH?CLE) SEVERITY OF DAMAGE: VEHN:tE N0.2 IQOISABUNG DAMAGE C] OTHER M.V, DAMAGE 1QDISA&JhGDAMN? Q OTHERM.V.DAMAGE IQDISABLING OAMAG ,rporHER DVM SAGE 2 FUNCNONALDAMAGE AQNO DAMAGE 2 FUNCTIONAL DAMAGE N DAMAGE?AG_ 2 EUNCTNXIACOAMAGE 1 NODAMAGE TOW'DBY ESi DAM GE _ESLOAMAGE - y_ EST.DAMAGE I'r`I;I??IC .•TOWEDBY ?_ row3Dav - S l Cic = TO----_-..__. a TO - TO - ; •-_- DIAGRAMOFCOLLISION ,DtNner IDRA W ?RRON MOWING S - . aRdvr rFAnxfa xPFrK W E-C- N N O H CI RCLE , •- ?- O ? Aa.ET?I -- 17 xTEPPOBAOLEPUNTOF TWWVEHCLE.PFOE: NC?eFR ApE°voE'A"cxaw'X'daJ I??` I? -_ I I \ 1L t".'? ? .1 7 JI E i 1 I ? L ? 7 I -IL I'?1 i E _ J. L G{._. r >. r f - _ DESCRIPTIONOF' IINDICATE WHAT PROBABLY HAPPENED BEFORE DURING ANOAFTERTHE CRASH INCWOE INF COLI.I$ION., , ORMATION NOTON DIAGRAM, E.O.ORIVEfl N WORK. ETC) DISABILITY, REDUCED VISBUTY PEDESTRIAN CLOTH NG COLORCONSTRUCTION OR REPA I A J /' ?F/!C(?- /?-!7!(+J-!/n??' ..L__. l/r : ? _ .. ...._. __ 7°_t_'/Lc(C .1 ?","Y/J -,fc! 7i /r A,/,J .U..°i/'Ji? ! >__ ?P .__- -------- --- - PO TIO N BE O OLU ION ., NO.OF VwES S PEED S VEHIC PPSIK VEH. HFADED NO. MILE POST qR INCREAIING DECREASING ONSTREET ORHIGHWAYNAMEoRNO IN ONEDIRECTON POaTED FE LEEGALLY PARKE D WAS OCCUPIED E N S rE /z I I ? u Y E 9 NO ? ? C NO 'EES - N ( - ? ( I _ l? ( ? PEG, rl I? f ? r Carw Owtpl IerOwl: ow _ _ .. illoSVND __ Smt 0 wcnwA C,. TW,I _ - PED?BK;YCUStYIASUSD:G _ -J("'j? -_ al-•ngier'?`+ut fl: I -_-_a - I ?aroeN'u -, wAUCw r l uxP r cR?05K6wN.s D Te m ROAD SURFACE,, ICNtCK O!,el WEATHER ` I<NECN DNN '. CONTRIBU .. _-... IC TING CIRCUMSTANCES XE'CK OnF OR NGE - , .:: - NE F 0. U O,WFR NO i fWNER NO dfYF N .R > N t SR OR? 'E`er"]-?/• ' IJVEX dTiiNQNTAXEAO ?, 1 Dxr CCt ??DIJ ?-- RwPWFKECF 1I_ O W <LOYL ar E 0 NIN r,ar ftvEnE?A ywO IJ . ; a` Ei W Ia tRV WE OE 0 C iF -NT 5 I E LY ?JU PKIHt IURN 1 IJr ! v ... > SMwwO _i .' dM ST a ?r0 - a?:-7 P,R,IWO ? ?r L i LEFTT.RN ?, KE ( r Ex EYEEORW 1. t0 nFND"ER aI I Ovt EOU P. r Aye , j a r M " ' y r KLE l I OP K r . 0 60wfp . O !a<tA ERI 1 0 ISPtCIrYI ,fl pq AIDIBOP OP 'la . E NONumll- iii 1 rE'T?OwFD FpI LIGHT CONDITIONS plrt«anel TRAFFIC CORTRDL no nX ?e vt TYPEOFROAD KOne oR NONfI a i VEHICLE CONDITION NFNKfE K..ecxaNE O SOBRIETY ... sf'1J s? agN,l aron SUN 1 DoNw T jlaxF ,r _ R 1 Iw a DeRE DErfera r<onlNxurew I NOIT Ienurtwt; NG a r1Pi ? aroPPEOw `..1 ?. Ro,owAr I`, 1N6Nr a . o,rm L ° > ...\ rPar \(?>I TwO W,Y w ynlE > ,n f EEIECrrvI ... a i I M NBDAdvIY > 10 `? N.f'wIM. L/NNE _ r- .- ? 'w > ..ouyn . .._.. ... N , IOM o :. TDCx.nce oYuuP AD IG a _. c Itcrwe J' xunNm NO MP.NNID .. 1- Np inowcrr >I una APo (eo PdaR 1 R I 1 uuawDlDnemNo -B" T>W . -,A _ •. ALLEr _ Ce +MOON y-. ...._"_ .__. ... _ND -I ? i duN+WO ,- r I _la^ -K- a Dla.iisaiT NA a .. ; wn,L 'e n `err 111 atNCnAfo a '- dNSTn CHEM.TEST NO I - T '. DTW.N dVIMU _ .p,f lCOla IT.TdreN TE.TII[N'A.0 1 mntRlssEC On .1-1-c- ? r IC Cb?ixM'.M - OMiPI".'fCD'D % % TEST RESULTS 2 ?K•.1 - Ifnw mra No .... . WtvJ ODSP?MD vnM;f :,K?Il4n ??I NmJ __ . ..-L NO DUPUC?tECOPV. LCCµ UM EIIFOHCEMENi ?GCi,CY 3 C? L r.,.,.n.-v,....,n, nw:vnnu,un :,naua O+V-iRIPUCAtE GOP'I.INVESTIOAtOA'GL'OT'Y s? uL X91 4r .F ?J r t d?. f S r L? 1 fn'. if, c I ?.. 4 1 I j I r yv 1 1 _ 1 I I I Y I v I lFii VLt I ?,T d -?' S SI f°1S I ! ?n 1aOl? 1 A? «deR YDD 'rhk I ' / illl?A.I 1$ y y+t t:. I d' d CTIONS: DA??tAGE I . IN EACH BOX. CIRCLE THE NUMBER OF EACH DAMAGEO AREA E AMAGED VEHICLE N O.1 G.ORAW AXR'H SITO SHOW HIriCIPAL gRECAON OF FORCE?'•r (USE THISSPACEfOfl15NETCbp:GOAMADETO TiVA LEAS A??IiORCyCL :9, ETC) .., AA, . 1 J ' 1 L A r I c G DAMAGED VEHICLE N 0,2 - wt ? 1 ?% - iJ. HOaU 14. fYi01 E . . ? .J . l. , Q I n \' ? - ? "'? ? ? I I `=ti'_,•;`? ? I]. D F E{ J N s M' r Y Y Y )? .:: gYAM lvry`I?A?•nyc?P._?: J:v. ?.^?.itl+l?A'PlAlt.. n. u. _.. __.....-_ 41 _._.__ _ _ ?syr YI 41. ?'"? A STATE OF WASHINGTON FACE ? OF ? No. WGP159(HEY:S,)E, p M1 "yq yy C ?'` UNIFORM POLICE TRAFFIC COLLISION REPORT PpLICeLDM,'uNrNUMeER 91 {1 tJl") ? OATEOFCOLLJSION DAY OF COLLISION TIME COUNTY 110. CITY NO. ?U FHWA I !L µ' ?T MO D YR. GUN '.IGN 1 E FRI SAT IU 2aCO N0Ugl } ' .C ft k T I Y ) 1 2]VIED IMUfl a 5 9 BUT J RABAN ' ORAL ^' y. E COII/IiY ?STATEROUTE COUNTY ROAD ?CITY STREET O AO?CLG. REFIX ROUTE OR STREET CODE bLTION p4tp 1 ??` •-??•? ? OTHER ISPECIFYI y 1A Q N ^ E 1Y ?I'V CItt OR iT+OWN W PgEF E0. MILEPOST GG'+ILES ? ?'_? ®OF •r'°TC-CU.L:S Chi ?Q U I ?V V ff rrF;T? I Q NAIAE BNOOFS EETORNIGNWAY INTEHSEC)WGYIITH: STREET ONHOAD LL 41 AM DATA T NONIYTERGECiION AC NT U INTERSELTING GTREEL OR {VOAD OR qEF. r Q U ENENCECGS STREETOR ROAD N D -EEIY C ?F STREETAND Dc.D c c ?? GREET VC OE . , _Q I CIaTA1LEANUDIRECTIONFROM RcFERENLEORCRO555THPEi //?? V E.? SFECIALLOO NG USE T, ? •H7 J n MILES N S E W ?. {{L?.?. ll- l? / .?_: . • . -? OF N\ FEET 000 d OLVED: ?VEHICLE-VEHICLE ?VEN-E?DICYCIE ?OTHERIWRITEI COLLISION NV ?HITA RUN SEVERITY I NO. KILLED " ss •' +'{ To rAL NO ?VEHICLE-OBJECT ?VEIICLE.AR'RAIY ?GTOLErv VEII CLE NO.INJUEU V OFVEH,CLES? ?yENICLEPF.DESTRIAY, IX?NONCOLU50•: ?HAZARDOUGM-E='AL PROPER OAMAGEONLV MiC S -0ET STRL'CKINAME OF OWECT STRUCK AND OWNERSNAMErrI i..__-: vnF na Fr`T I^ AF. T -?1 \ r_ DH VERG YAMELAST FIRST M10pLF OR ` ER'G ?F:+OVJ FEET ? ? ? ? RO EDGE 5 N V R ?. ? lA . Yet I L 4 _. I J ; LAST FI FIRST ST MIDDLE IF B:CYCLIGT OR PEDESIR AN C'fECKI ? D rv N A ?kLi L V D R STREET AD SS STREET ADOAESS PC, V E CITY (1 STATE ZIP CODE PHONE NO. E CITY GTATE ZIP CODE PNOIiE NO. R YEsuLSA? Lill. cT?70 A7 a?- R 1 Y .k 6 N Q. DRIVERS LICENSE NO.. (T GTATII''E GE% DJAT?E OF e:q H p ZC L?, !R. ?L? 1P Y:.L 9 N Q. ORNERG LICENSE No. L GTATE \ GE% DATE OF BIRTH MO. OAY YA. M1 '. ? DRIVERG OCCUPATION 1-11AE PNOnE'NO. p?.lV? Gr-° r tJ S.C?c-cL1 T(LA,tGI`=,1 2 DRIVERS OCR+ATIO'I IA!A NAM 1 P N NO ? t a " S ,- A CODES > 101 CLASS II, ]i WJUR CLASS Y I AI SEAT BELT 151 EJECTION pp? JK "T"' OF IWURES 0'0's INATURC ^ JUR FG ?( l.eTKK'. FRM SCENERY: TO HE0091ENE er ' b r3 V EN YE.UI AAKEIDODGECHEV.1 j i L. MOOELIDARiF:OVAI r?f1Q STYLE IT GUnv.l L V VEH YEAR / AEIDODGECHEV.I I1 MODELIDARTNOVA) 3TYLEI20R-CONv.1 h z%? $ . S I H VEH/CO OR UZ)r UC. P ATE KO. K35'1 LT ATE .? TRA LER Py j?( O; uA. I ak T 1,-715 H r VEM COLOR UC. P ATErNO. o IJa ct •t STATE Z2 TRANER PLATE N0. WA STATE k µ5 Q VEN:CLE IDENl FIGgtION NUNSER O METER Q VEHILLE IOEN'F:CATI N NUMBER ODOMETER E zzq 4-7 L0 ofr3i0433 264 E - ' N REGIS FO OWNER-LAST FIRST MIDDLE C ' REGISTERED CANER LAST FIRST MIDDLE - . ? r L?scct k a_ lp+-cL?INI N Q ApOP.ESS OF OIVNER AODREGG OF OW.VEq Y 8 1 NAMEANDADOAESSOFINSIRANCECO,ORAGENT NAMEANDALC-EGGOFINSURANCECO.ORAGENT ll/` J CHARGE C ITATI NNO. ENFORCEMENT CNAROC ITATIONN . S J` ACT104 J CODES NAME, ADDRESS & INJURIES OF PERSONS INVOLVED _ _,- 1 __ - _ • „?? R ,?•, D ,,,, t 5 ? ,;, .• C AW.E55 U _ NAIUFEOF HEM01ED1110.M P IWURES SCEe.'=_RV. TO A HAVE' N T ADDRESS S hill aR 9 S NFn rgo'J TC W NAv T ADCRESG N IN U fE'Of Iit1fUVE rl __ vn: To `G I S wvE _._ . II _ .-- E ^ To :.YEgT •• C E ICLI IlI LJECiIpN (^• ?. O ! '; 1 4 \ ) I S E r Tr ?S ) Of - OS q J E O I I U 3 N 119'1 ( 3-".C F .IJY I NOT Y TALLER ! Or N USC 1 u.'M 1 NOT EJECICO ] TOTALLY FJECIII G PARDAELY EJECTED E I 'Epl ?l"J..I A r IL lI-;DO?Ci1G YE 10..._.!'..1R I D i ' .UNIT ,IF T _ . ISEA T IE i I AIIUHE l)L atom It ' r yam, P4 t'LYdtf'F?"CTLra.._._-.3aa?.._._.,?.. 'I '.y+lk'(Ai ':'r8t y ? + EA OF SEVERE INIIAC. INSTRUCTIONS. ]D DRR ] AAWW ARROA2'OWIS I T TOO S-O SNOWSrP-RINCIINCIr O II 0L. i PAL DIRECTION OF FORCE ITl?l, i -DAMAGED VEHICLE N0.1 'USE THIS SPACE FOR SKETCHING DAMAGETO TRAILERS, MOTOnCYCL S.ETC.1 c DAMAGED VEHICAl $? p me I. F,.. 11FDAMAGE^VE ICLE-, 5E ITY OF DAMAGE I.-R-1-1 O'SAOLINL DAMGE GTHER MV.°AMALE I 0 DSABLING DAMAGE ]Q.aMAGE UNCTIOrvwL DAMAGE- . ? NO OAMAOE C3 ) -Cl ONAI OAM AOE ([] NO MACE C' UNCTIONAL DAMAGE ? ry r' TDWEDSr Erickson Bron EST DAMAGE TOWED Sr T DAMAGE rowtD ar DA DAMAGE - *.Fort Townsend flap [20000 TO -- - (ES x w°isT. p DIAGRAM OF COLLISION 1 I I ! t I _I I , _-.HAW ARROW SHOWING T I_ t I l?-? I-I j NOflTH IN CIRCLE i IN J AT Door do tr MRVCTD» $?, iA4o'I _LcV Ac..r .1 M1?Y I--.: .. r, M o ,. ,? i T-1 i, ; f I -} -f E I f I f,` I I? 1 -„ •F IsA Mi E ED V U.... AND All sTRUC FFHVE "HV FT EDUC ;C n N ed_thie R/0_that heraa_Northbound on CORD 1out in Yrogtp! ed_to.nvoid_the_colliaioa with the=door-and lost control oY the vehicle cousinaidoraye.168_teeb-than going backward down thq?_anban=ent'?trilcU2r a manner-.as:-to.cave-in_a portion-of-the- roof sad undercarriage dEmaga t b POSITION BEFOR COLLISION N VSH. E AD SFEEDS I IF -KID FD CREwSI G OECPEASIrvG ONSTREETOnI G WA NAME FIND - INO E SA{ p gAKID OCC PICA }e}v .T+ n„ C B 10 $0 o C ? l _ OF, ?. -LJ a k47 D ELL) g F?o ED D ___ - (? r ED ARKED a OE ?1 '-{) > CYC 5'T-1,11Ha i DFWA ]i -I WALK ]^?SNOULDFF AI. _I CROSSWALK [7' CnO55WA IOICYCLE nO En , flO CHECK SURFACE. WMATHECONTRIBUTING CIRCUMSTAN 5_..K y d { i wAY HECKONEORMOREI .-0 b., NCB 1O L S F Wp rc NV En > °n'vER °n'VE U E> Iyl?l GI, NO 2,E] f?T 1 NO) O> O LJ L.J STIM'L z 1i I On_ CLOUDY- n N ENCF Of IQ-r aL I-j T-j p EL °FD AqN ?7' Q OSHA} f G fV. IOLLOWHIG --s'GVENGASL _SIGOtlOLFw ,??I? ?J^_s sa DE LTANO rwsSINC ,? I ] WET G ) PU ? N ? } I °GS INFLUENCE Of ?1 3 C E] S E E TLY I" i , MAK FIGHT NG YUR h i N _LNOVHS. IT .A I [ C- I?-71 ]I? SNOW ]Jj ?_ ]n uE EEC G TC° n_n SG L OF f?3? OP' -.KING {? r LE TTNc 4I As L OCALOL 1_ I L? "^ ',T. Ic( a 0 L U 0 I PE 3 ?-I S`E. E __ Ste' r?ID E S,4 E Iv 167 NM 4 1. 14, ,' °I ,] =L l ?E EET1 .-1 Rm' l i 5 6c oo a (ol ){E 1 ; .: OTN[R IYEtIiYI - - E?--r f 1 TOP q (./_ '_I OWING •? '. I F_sl, ML JI)rL- SIONESGN?? TO, 11 aL I v A n , _ ?NDITIDNS RAFFIC CONTROL VEHIC -AR %T"SPECIF RIETY.. CSO O STOPreCI 'CNE LE .TYPE OF ROAD VEHICLE CONDITION J N I. i CKONFI 1H0}VEHICLE I NO]'ICNECKON. GRMOR[ VEHIC SOB AT IGNAL , I-1 f{ I-, , f 4 M„ I I T? SILNA i i I1 E ONE WAY I N°.] R? ? ?? pI I VE. NO jE ICNE ONEI- ?-.l7 UH STOP SIGN 1 a#' oAr a r ], o. LJ_v Two WAY Duarv( R 'urr 1'I ROADWAY ACN -61 1 ? I ?y ??-ORAK[5 _. J IMPAUItn TRArrtC LANE w I I. Sp I ?] L ? O LF>I I FCT'ILVFHr3 ?I NEO AR LITr I'7?1pL??j SAgRT' Lf 0 dI? - j¢ A LET ASNiNG ---Lot AG _NOiIMPAIRL° `-IIEIJ F KED ° 1 N DAR tT LLT L C? 1 SHE KS A ] 1 nE R°T F NO.) NL_ AIETr }L Gf IC I[ T RING +f Y 1 ]WfK .. IAL [0. ..?_l?_l1. ^OfIFYAMP4_ E, lj.O. EF1 LI 75. ?DIIV[ni EFFNDRINKING ?ll v. EN O ^?7I31 ?_ 1 76 II C IN° r ' F I. s l? IS aNMOAEt_ 1 s c At IS _WA LErr -:I, .. I ruNFO CHEM. TEST _ ? F{ -QIN ' 'CARAN EHMV f .:» s a ncm) ,1 ,. I F AHrto ObrtR v Pw u?_ E Tc I.V T E. , r D D D - 1_I 1 NO DEFECTS ?. _f r sr Fo TEST RESULTS G v? 'nn wMF UU»K ? eaucE NDED m n»c on f ~ 1; EH c I ... - SPATCHID I uct A'HVED -__ -_ uurFlu ww u.,.,A a ?.r ... -- ..--. •• •^_ .AOC(ND Act NCr uaralDm Sou GA'[O _ X ntroRT ovtUSr Arc JC30 Quilcene 10 14 78 A AN 013TH UTION OIiIGINAL aePY skNO TD WASI'INGTON STATE PATROL .n run's wnK..:unrnu.... t' T w? N` 9 t• 4 ` p C"Tr tf 1?4' ?. J 4 Wd 4 '-ly .Y ....r Z .C?u1 B,M;>< t3:il.uJa 1 4Ti?' " S ''T' '" £ . n - b b'a "1 ? % - , : . , STATE OF WASHINGTON 6cd :. :i+ :Yip.•-...: $Y .T,d - t • •r PAGE OF No. 1_ POLICE CdAF•4WT NUMUEII - UNIFORM POLICE TRAFFIC COLLISION REPO RT OATEDFCOLLJSION DAYOFCOLLISION TIME COU iY NO. LITY NO tnwA DY YR. ] SUN I MUN ] IULS D WE A IINN 5 FNS%T I ) 1 IUSE ZLDD N%RI J/ a ? RBAN ] l 1 CW L U RAL N NTY ?SfATE ROUTE 0LWNtt fl0A0 , C15 PREFI% ROUTEOR STREET CDOE 5 TIO ?CITV STREET Q ADM Jefferson ?OTHERISPECIFYI ? {rl CITY OR TOWN ER=t Li]CC].Dil N ? ? ? ? IN Q W PREFIX EO ..-s . _ Z z / __i_ OF_ - c MILES R T -L--? LL ' ; A .- ( " ` y. EE A ..I ,- E NO.OF ST OR WGHWAV;--- -,. INTERSECTING VAT.. STREET OR ROAD LL RAMP DIAGRAM DATA ,. f ` ,.. 10 Q R ' Qi?I 'T ' ?J. , d , . . ' I NONINtERSE Q- N. BETWEEN. ---STREET AND ACCIDENT INTER %ii0 iEflSECTING STREET OR ROAD OR flEF E III ERENC RD STREET OR ROAD ?,_. MILEAGE s qEE CODE .tau "t I _;, ' DISTANCENDqADWECIT FROM IT FERENCED R CPO55 STREET __. _ S SPEC AL CO OUSE . ` `A ?, ys 12MILES N•V S E w ' O . E . _ X I 2 FEET OF - ^ O SE ERItY T l • ' ? VEHICUNEHICLE' ?VEHICLEDCYCLE COLLISION INVOLVED: C3.114611011-1 ?HR.RUN _NO. %ILLED n s%B ^ -. TOTAL NO. ®VENICLEOBJECT ?VEH CLE Pfl TP N 1 ?STOLENVEWCLE _.NO.INJURED '•• - .OFVEHICLES - ? VEHICLE'PEDESTRIA - --?NONCOLLLRON - ?HA2 DOUSM TEq L' © PROPERTY DAMAGE ONLY ?( OB ECTS RUCN INAME OF OD ECT S1flnCK ANOOVMEF SN ME _ .w f LOCATIONOFODJECTIR'N CK5 E EST. pAMAGE T_... Floe "treC ONNER5 NAMEiA3(„ ;-; --.- FIRST ---- : •- - MDOLE , ?ROADWAY15 FEET ? ? ? © TOLD EDGE SL Cr': O ' R5 NAME-LAST fl-I MXilPF' BICYCLIST DRIVF Oq PE M5 TRIM CHECAI[I - - - L, , , ,. _. . D .I:?iC D] ran Su.:ene , , R. STREET V ::L.a 13 E R STRF ET ADO E55 .,.. ... -: - PS CRY... STATE .. ..-.J^. ZIP CODE. .:"PIONE.rvO. R E CRY.•.,?? nr ..e••• .a. STATE ?.• LP CODE .71P .. E nO. fY R . ?ort .Lvf?lar l n F'g55: '.'3?-22^? _ ' .. ' N DRIVERS LICENS€NO..•. ....: •..--:. .'STATE•- 5E%. GATE OF &qTn-. :. DAY vR' Q O .N..,, ?gNERS UCE SE Iq:•._... ...?... .'... STALE' .SE%? DAlE11F BWTH..?..k - ' -' MO' `OAY VR ' ': •_ :F ?i • V ' . z2(,.&: gyp.:: Vn. i4 07 16 GO ORIL•ERS OCCUPATION FWMNAME PHONE NO O, . E 2 DRIVERSOCLUPATION ; -FIHMNAM " ..-i v C . . . . Cock if-r!.,or 1:_';Ccr Port LuJloz ' CODES. IJI ?? SS IAI SEAT BELT '1 I'I EJECTwN I CODES > IJI C",LASS I41 SEAT BELT- 151 EJECTION??? A .'Y NAT- NJURIESOF rA A l - Al- U E5 F .t • EM VED SCENE BY: TO - NE BV TO 0-7 .. VEH YEAR MAEIDODGECHEV.1 MODELIDARTIOVAI STYLEI2O-C-.I - EH. YEAR, MANEIOODGE CIIEV.1.: MOOELIOAINOVN STYLEI2ORLONVI „T "- • ' _ j V 72 L'od;_et ^vJor % 1 V E '. VEn. c LIC. PLATE NO.: - STATE .' TRNLER PLATE NO. STATE E VEH.COLOR LIC. PLATE.NO.: STATE 1RMLERPLATE NO. STATE ._ '.l H c'1 /E'11 GTt i7 inn. C VE -1-TOR NUMBER .. ... -..... OOOMEIER H .C VEHICLE.IDENI-ATIH NUMBER E 3G3L16 5 l p ,2 E. is • •? gEGISIEflEO OVINER7LAST FIRST MIDDLE e as driver REGISTERED OWNER-LAST, -,. - FWST AV.- - \\ 0 ADOIIESS OF OWNER - .._. : .. ._. ,. ' ADDRESS OF OWNER, .._ T3 2 - NAMEADADME550F INSURANCE CO, OR AGENT.. - ,. >. ... . ._ -_. ... Ln .. NAM[AND ADDRESS OF OlGURANCE CO. OR AGEM _•,•p .,,? , . p LNMGEu_ - I , .... NAME, C ADDRESS U NATURED- p nuuRlE" A NAME' N ADDRESS T NAIU €Df N111E5 NI NAME I ... AnOR[as T NA WJU1IFs E S NAME 5 ADDRESS S. IuYui- 11131AIU5 C 2 PASSIND[R Pf Ot SIRAN T 0 nr.Yc, E YOYII MESS P 10P IIVrv NV. ENFORCEMENT GH-1. & INJURIES OF PERSONS INVOLVED` ' coD[s _ 1_2 3 5 SE% AGE STATUS EJECT, v FRS O V l1 6Cf N F TO F MOV[DfnoM SCf NF DY TO DTn A'31 11 C ? ?I i 1 5C Nf DY . TO f v - SCf NF ?6l'RDT r'te' . 70 • o UI --c.Sl .. 1AISEATBELI - 151 [JECtX]N _ • OWJURY ]DIADAT SCCN[ S' DISARI ING PWuRV EN 1 DIRIG NOTWSTAAEO S 2NOTI1I USC ` I.NOIEJECTEO IJ .] TDTALLYCCifO V 1 DTH[R POSIIWN IFIVS IJ T ; IXADON ARRNAL MCDlry N05AfAL 1 0INT 11IINJURY TT•OSSIBLL IIIJURY 2 USED l fAlluNE CAlJ [ 5 PATIAIIV TJCCTCD N [DNIF A LCIEC U IANOW B POSIIWN 5. S O L I ? 11l? 41yJ h 1rJ; Y{'? c / ?fS 1 t+ < I I # I?? I{ I DAMAGED VEHICLE N O. T IUSE I ISSPACE FOR 0 ETC G DAMAGE TO TRAILERS. MOTORCYCLES, ETC.) DAMAGED VEHICLE N O.2 ' "?N 1] HP?E nI EE%! u ?4A! li I' ' . IB. Trust 10. U.er M•HFE. n a.NYrP _ T Fei.r/mil "T ?a F-r F 1 •E ! , UF, r IF:.Tr E IB U n. O...mr. 'P• 111 OAMAGF 11"111E "I, O EARL NG DAMAGE ]OOTHERMV. DAMAGE ]FUNCTIONAL DAMAGE ?E ? N DAMAGE F DAMAGE; IOTHER VEHICLE) SEVERITY OF DAMAGE: VEHICLE NO. f-` SEVEPITYOL DISABING DAMAGE J? OTHER M.V DAMAGE 10 DISABLING DAMAGE Q OTHERM.V. DAMAGE ] FUNCTIONAL DAMAGE . ?NO OAMAG&.' , i[].FUNCT1OH4 DAMAGE E U N DAMAGE TOWED BY -' EST. DAMAGE T E T 51. DAAIAGF TOWED tlY - EST. DAMAGE TUWE t TO B .DkAq AM OF COLLISION _Y _ II I I t -DRAW AA ROW SHOWING -i? ! +' 1__+? F -i _ - _q .. NORTH IN CIRCLE II rX -I 111 _?. .R MIA ArcN mN o 'A" 2. LC&TI GF ;.LE PpINr G , I I I -i - --r= I L ANDAF,EREDLLSIB" ' _, _ \ 77-1 r DESCRIPTION OF COLLISION 11 DICATE WHAT PROBABLY HAPPENED BEFORE, DURING AND AFTER THE CRASH. INCLUDE INFORMATION NOT ON DIAGRAM. E.G. DRIVER DISABILITY, EDUCED VISIBILITY. PEDESTRIAN COTHING COLOR. CONSTRUCTION OR REPA;(]WORK.ETEB.. - Fr*r- i N/8 vehicle that had Driver informed tR/0 that as she round the slight curve -there was a `I T . - _ . _ his bright-liter on. and_they_blinded_hery_she said that ahe lost ooatrol of the vehicle _in ` I _ -the -curve and_when_her- - 'ght rear vheal,_got into the grasaie area the vehicle 19tarted,to ice ? (' slid tovara the.dr*p -off- and she-turned .the_wheel to avoid going over the enbankment and in f X dbing_co_she._over_correeted_and_loat control oP khe wehicleo .] _• r. n F + B f POSITIO E HEADED N BEFORE OLLISION gR >E M SE105 - - ON STREET OR HiG"w YNAMEOR NO D.D E INON N E PG j WALL APRKED YEN. INS OCCUPIED FrVr FS"°. N n C INtn EAING F.AS NG : i rr _Q ?I In ?1 _1 C.R. 10 PH 50 C? E9 O Sr O F Fri f '• , >P RI -. 5 _ ?_" FRD SD M10 FED. ICI !. ALONG _ _<nRD55 N K F7.1RKED DESIGNATED ]] MAR PEDIBICY[LIST AS U51"G. 1! ISIDFWALK 51. WALKWAY J(.-SHOULDER AI. ICR°SSWDL BCR°SSwALK BL. IBICYCLFH°UTE LIOTNER ;. T - ,•'yy, .flOADSURFACE.. IC ECK ONE) D VER 17 Dflv f. ??]L ? WET i-]n SMDW ] I ?. ?I ICE f 1 B("l i x' ..Urv I N I°ICNECK OxE OnOiAONEI- IECK ONE) 0.] INC.' E?,L-]j QNR LGLFL OF rl_o_3G1?51 CFrv RING ,] HOER INFLUENCED IT _ _ C?RVGB ?I] L GSTAlEO L I SPEE L My nn_ -G FOG '" 11 .. C. . Ho??R SPF,C LSA ?.?_. 4 N,.._ C EC D I NO 2 VEHICLE I a l -LIGHT ] 1 , C AWN IS L° _. ] L WSK _ . / GN _.r F BRING I VDARK-STfl/ET IIGrITOOFE____ CI E: NC AMBEII GFMI s DARK _ o J_/T [ET LIGHTS. 1 D N P H R IF " ER O.] ?,, ter. DISREGARDED WARN, . '2 IC EC OI'oPUO E M E ? VE ICHECR ONEI-- O F pl I O ] WE jf} ND] J L AY 4 VL ?nITV - Q -- ,.L BRA ES CH ECLG111._ - _- .IMPAIN NOT.IMPAIEiLO RANGE ] l p HIECTR01 G TS () HBD SOBRIETY C AuEY N[M LI H - Fs N L JOH; oDTH__ nADNDTNKINc FN DR r-I TAY- EIT FS 1 ?) L' P.u 1 . NO ] CH EM, TEST .. s-_ o'6'D-- I A V 7 ` _F6T -IVFP _ f DIVIDED _ - . ? Nu DIWDFp HI,PECIF % % TEST RESULTS ERrv HCLEACTO $ LJ' Q °IS c FAO Old, OVFATAKI G AND PAESIN° - F7 *MAKING RIGHT TURN 1Ir-j AHU" LJAr LEFT TURN y3sE= 1-7 RO Si:. ORN!' GWIND L16 !' STOPPED FOR C 1/Q ON STOPS aN DNAL Qti] 11.11E. IN OAG r?IG I ? SP FIC L E ? `v ( ' QIII ? START G POSIT P iON 1ENTERING LJC IREFC, C1 [_]IEQ BhCKwa I A I JCSO I Quilcene 1101778 GIST JU71ON. ORIGINALCOPY: Sr NO TO WASHINGTON STATE PATROL-OLYMPIA WASHINGTON DRUM pp GUPLI TE COPY. LOCALLAWENF ORCE RENT AGENCY'S COPY -TRIPL ICAT&COPY. INVESTIGATOIVS COPY M 7kle, { I 1?4gPP ,'??? Ai 1 i, ?1 ?') }?SJI }j 99 r? r ,11-7F.,_....` .L'Pl?iii +.''.1r,'biMO. !..? '' ri...T^ J'?{ Y IT, s I > - 1? Q j- 1 .,. ?:r?".'?"`..++```-:II?- __ ?}''T{+,if-e. ?u.?'L.iSk: ?:_,:+L?NrW4'fii'1-. '?•°?.sr±.1,"ts .: ?. ..NIbL.....+K+' G - STATE OF WASHINGTON N ???Y"? , AE or ' ' o. F POLICE COMPWNT NUMBER : UNIFORM POLICE TRAFFIC COLLISION REPORT ,.,. 5? py r ?b f "'?'TIysS n 4 h 4 T rb Q; xwy ?AflT J Y , N2 } tl f3 Eh N C ? _ v Y I . w NAMES . ..._........-.__ ? I T ADDRESS ___ . E ., %HMA R[ Sea S NAME'. G S A GAI.. . I 8 ULI s"NNI I I 1 115 AIU] IJI Sl Al POSITIW - tJI IAWRVGUS] ' O D vA9][ q[R DILY'ECUSi O1NlR D I 1 ( A e- 1 ^ ).OT . M t NO 3 DC DEAD D AT AI SCENE ADON ARD RIVAL ] WIIH[56 ` US 07ol 'US Ol011CYCl CI A POSOK*UNKNOWN 4 R DKDINH06s7IAL D GATE OFCOLLISgN DAYOFCOLUSnkI TIME COUMYNO. / LITY N O. fNWA. T A Yfl p A SUN T MD1 2 LUIS ] WE A INDN 5 ifll SAl OHWflI ? ?) , x ?UflBAH E Y .• 10 17 ] l? - N. I YYY(/// h Y UnAI CWNTY ?STATE ROUTE COUNTY ROAD ?CITY STREET z ADM.CLS P E11K POUTE OR STREET Wf CTION ' L;$?CerL06 ?OTHERISPECIFYI - - - W H -' : 4040 - , L S ® CITYORIOWN ' W PNEFI% EO - MLF i ? .. MILES ? ? ? ?OF Fo,•t Ludlo•_ C N ' LL A ..,----- ]N OFSTPEETOfl HIGHWAY---:;? INTERa ELIING WITH. BiflEEi ORROAD LL MMP WAGR DATA - 'I • 10 q '. ?- Np11NlERSECT ACCIDENT WTER NON %flD INlERSECTIN35iNEEI Ofl "D i •N_. ... BETWEEN_ 6TREETAND STREET .MILE GE_. LOGE ' CLS ERENCE RO65 /BEET Ofl ROAD •' ___ .. ...- _ DISTANCE AND DIRECTION FROM REFERENCE OR CROSS6FIEET / Q 6PE I L GUSE . r 2 QFEET OF LE .3.,L'?;v*l3$ EUCd __ •-._ ., . VERCLE-VEHICU II--RI VEHICLE BICYCLE OTHERIvYp TEI LRU ?HIT COLLLSIONINVOLVED: ? __ iJ -•? •' 6EVER- NO. ILLED 1 _ ?VE ICURRTRAIN' ?STOLENVENICLE TOTALNO VEHCL-OWECT F V 3. N0. INJURED . O E CLES ayEH CLE PEDESTRIAN ?NoNCOLLS10N E] HAZARDOUS MATERIAL ®PROFEPTY DAMAGE ONLY J IOWECT STRUCKINAME OF OWECT STRUCK ANDOWNERSNAMEI LOCAT ON OFOWECl S1HUCK - EST,DAMAGL F v0 ^O•nt/A-A ve icle rolle4 Over ? 6 E IN N IN ROADWAY FEET OF ? ? ? ? RO EDGE $ OR VEPSN EAST -,- -. -FIRST - MDDLE DRIVER'S NAME-LAST FIRST Ml- JBICYCLIEI OR PEDESIRNCECKI -.L D R o ass ? r. 3 Irene in L' s e E STREET ApDRESS v P O.I3 r v "'` E CRY.: .., IT ATE '.- zAcooe - PHONEN I. in E CRY _T J :. SLATE n -ZIP LODE PHONEN NO. N DRIVERS LICENSE NO '..•.:`, .._ SLATE'. 6E% ORTE OFBIfliH i N ORIVERS LICE N6EH0 -• STATE SE% . DATE OF 81fliX RT O ? 's T 'JiJ: t'n. F MO, DAY YR 5' 15 O,' " MO DA DRIVERSOCCUPATION FIRM NAME ... PHONE NO. y DRYERS OCCUPATION. NAME PHONE N, 3 r Ck J d b F • .. ,. re? eac .:zm u pas ort . ounsend CODES o, CUSS IAN SUNBELT 7 I5I EJECTION-],- CODES.>IJI, ??? IRI 6EAT BELT- 151 EJECTION--- MJURIESOF 5t!, f, QI Sore NATUR 0 INJURIES RREM ECENE VEX. YEAR A. B n'.• MAKEIDODGE CHEVJ. MO TO { •OOELIOMiNOV/U ';' Genl. ZZ.OfO - STYLEIZ DR CONY.) ROVED FgOMM SCENE VEH YEAR BY TO MAKE TDODGE-CHEVI MODELIDART-NOVM SYYT EI]UR LONVJ V 1=171 T,,mte I Corolla ltm;;-n - -`V : . .. -- , ._ - . . , '` ,H , VEX. COLOR .. PUTE O. STALE TRAILER PUTS NO. STATE H _ VEH COLOR LX:. PLATE.NO STATE TRAILEfl PLATE NO STATE ... I I ^ C ENN:IE IDENI Of% MIETEfl C VEHICLE IDENTIFICATIN.NUMBEP t..:I:? . ;:ODOMETER '.::, • ,L .. _ T ... E S5 1A A7 E PEGLSTEPED OWNER •+.LASi _ IN. MIDDLE . REGISTEREDOWNEfl- T-: •vI .,.. FIRST MIpIXE ; O Sx:e c driver - 0. ADDPES6 OF OWNER :. .. _._ ..-.. ADDRESS OF. OWNER .. . .. - I.. .. .... NAME ANOAoORESS OF INSURANCE COLOR AGENT. ,, _... ,.. .. NAMEANDADDRESSOFMSURANCECO.ORAGENi ?, .: :, ... ..... ..... Sf1 tec. none I C IIATIO O.r E ORCEMENi CH E'.. .. .:: '.I - _, C TAII N 0230 1 ACTION - ;? , - NAME ADDRESS & INJURIES OF PERSONS rINVOLVED " - • CODES t ; ' S , SEX AGE. STATUS y EJECT L N AME' , C A DDRESS - ? O' I p NJURIES NEMOVIO FPgA SCENE nY To A N AME: T A T DDRESS: _.S VR +rM v6ufn M _ %IM s . / : scrNE Rr To TD ?A ` % IAI6lAI BELT I5IEJECTION 5 DISAUIINGINJURY IT NON UISABUIO NOT IN57ALLEp ZNOI IN USE NOTEJECTED 2TOIALLI EJECT IENOCNTIINJURY PO,,VGLE INJURY ] US D A UNKNOVRI O PARIIALLYEJEC UNKNOWN IF S SCAT OtLT TAIII'll EJECTED N^ p v 1 yt c t ? 4 ? Lf r I E< ? p . i• - t t ?? }r 4 r 3 t I Irwin :' r' i v n , ` fix. yI-- V 9JMOTOR VEHICLE COLLISION REPORT NO. ' f f W DATE OF COLLISION OAYOFCOLUSONTIME OF COWSION / COWTYNO? GTY NO 'Ell Sux -11-1 M M S N CITY TOWN ApAyyS PREFIx « wrF OnEi LOOf SEOigN p,2A ?' -{`N quL • COUV•]TY Ell Y. OWN pNil1, RE lz f Se fi r o L ©DF GL'i 19 t-6 Lo GIVE NAME OF STREET. ROAD OR HIGHWAY WIERSECTWG WTTN STREET OR ROAD PREFIX EQ 111,011 LRY,0,K1? b wt i 411 NON INTERSECNON-LOCATIONOF L? RAMP pAGRAM DATA . f BETWEEN STREET AND gSTREETTF Q© RALRabaaSSw4.MItL%5r OR Mx,r= LAx W,Aq WTEfl NOH CLS q5E aa556TRE DE,b nW ' wrw - ?NEEI E ®EF-vOExCFF ?vExKLEE 1.- -6LrIX x?Orx[R wPo,O ? /? SPC DE [[ ?y b• s.' orve`wcEESKK?6 L-1 _? r3- ?VII ON— Dlu- 0 11"I /'+? L, ' 1 I'.ju .N t? /i STRUCK . Ax LS 4I4 OWNEROFOBIECTSNAMEANDADDRESS LOCATION A F INROADWAI O© R EORERAri -ECr qd-yf f-. FEET F0b OGE y -.J.d!, :{N'.r DRIVEPSUST NAME `FIRSTNAAIE MIDDLE v.OCN,S[ pRIVERSUST NAME ` FIRST NAME MIDDLE Z -" WE. a:t 1 u aM TMWD uTe NOl,P. qo._ •? {??x? U.Eb SEA CC ., L?O{??E- ?W??ERS OCLU ATION STATE LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- COYE.iGEWEFFECTFOfl THISACGDENT 6VroUR CAT RrYES ?NO AMEAND_MESSOFUABIUTYWSUfUNCEFOUCY__N ?.? NMIEOFLIABRFTYINSVRANCECOMPANY -I ST JURY - AGE D NJURY INSESEP FORACa, s, AGE E rOTAI N E ADORE55 SEX DD ESS SEX D M F M _U r ?On- ®? x,ME "5 STATUSOFFUURED I MANKFIRST CNE THAT APPLIES STATUSOFINJURED MARKF1I STONETHAT-LIES ne AN4 xOx aSnpuxO wyE ?Pw NVENCE a5 aW4 Ox aS,WN ?46? E ? x4Fq IOLLEO la[MVF. Iw?YI CCMPIW ?PASS[ wLLEO Is?EVEnE IWNMOfi E r , ? NO r I ?FE arglAY NO ? ,1 W,1,I P• ? 80 e? Po7OESr ?,n,.r:R ,.s.E.:N ? 60 I e? D7? SHOWHORTHBYARROWWCIRCLE \ ' I ME RIBEBELOWWNATN ENED.IREFERTOWHICLESBYNUMMAI R ra?iC? 1 -H. 1? Qf-- ? I s,Rrr Ar -- -- - I r a ngEnoR..ix...r I KHCLF u0 ROW ? ? ? ? "j a,Ngl ? ? ? ? .. N W MFUx ? ? ? ? AiDra W LA7NEIT '?' K.raarl C ` E MH NOT ! 1 ? O'N4,'c?.s? ? 1 ? aY 7 ? R4,wA -'JNC4.',' p'N ? E ?- a ?SNO- ?S?EAIOW E?FOO ? a ?O,T`f cir IY`t GFY; 7 a w ASON roR NLtr u Eno oAA.GeK 'I I b KwgEln D...rw a5 R.A.rn t,cl ON STREET OR IAGHWAY NWE On NO I ? DAYLIDHE 2 ? .- S ? DUSK ' ?--11 DG KSTAILET T DARK SIFfif LcuHs?l DARK No S ? TinFEE LIGHTS T ? OTN1T o- Zy agio-: ua`aErsnow un6LrFNO ------- -------- RAen wFa INVESTIGATED BY «cw%D ?:?Ta ? xo . =1 ? ? ?LH,A, ?o ianxeN ? ? ? MEIN, DIRECTION To DIRECTION NAl%WAY ] I__I SHOULDER A U CgJiiwuq a U [,aci iiF a U OTHER rnAFrtC CONTROL RH[U n,ll v w[LE TYPE Or ROAD YYwaE rtH ATxIF 1 pOVER/VEIIICIE ACT101q K.u Ir:w?+ovErn AOgEi ?I 1 ? SI .s No ?I 1 ?`ONE WAY ?`E ND I ?' 1 ? GOING STRAIONT AHEAD ? T ?woTS ? 2 ?TWO WAY ? t ? OKRTAKNG AND PASYNO ? S ? YItLO SIGN ? G ? LOAD SIIXf ? S ? -LNG ROI ELFIN ? A ?fLA-GRED ? 4 ?ILT?GRAROE ? A ?MAKING LEFT "N ? S ? rLASNWG AMOTP ? a ? ALLEY ? a ? MAKNBU4UAN ? e ? M TiNIAI ? E ? lf? lur. ? 6 ? noWla ? T ? OATICtR FLAGMAN LARE! ? 1 ? STOIMED to. TNAJrc ? F ? Otn[n. tT[GFY ? 1 ? NPARAEEo ? e . ? OR 5E0P o0N ?N' • ? ] ?o-E, ? .0 STOPPED W ROADWAY ? . n;.o,aFD n , nuND H0 ? la n s: ^: arc. .?s Ti ??F J ." a K v S vt '? ?u A a VEHICLE DAMAGE 1. IN EACH BOx CIRCLE HE NUMBER OF EACH D AGED AREA- . OGAREAOfJEVERVEHESPRPACT. / INSTRUCTIONS T A O DR SHAWARROWISI wPR INCIPAL pREGT10N OFFORCE h DAMAGEDVEHICLENO. [USE THIS SPACE FOR SNETCHINGDAMAGE TOTBA1-% MOICHCYGiES.ETO) DAMAGED VEHICLE NO 2 .R la Hpq 1 N°oU 14 7 7 H?Nc1R 15TN?.A s. F h SA... 'z P`ra le.una«carlIac+ = e. une«Pm.De .y I 1 v or.?n,N,? = a«,wN . . 12 EEVEf11TYOFSPMAGE: VEMICU:N0.1 1SEVEHITYOFDAMAOE:IOTHERVEHICLEI SEVEHITYOFUAMAGE: VEHICLE N0.2 - 1 QDISABUNG DAMAGE G QOMER M.V. DAMAGE 1001SABUNG DAMAGE SQOTHERM.V.DAMAGE 1LI-QLINGDAMAGE JQOTHERMN-AGE 7 FUNCTIONAL SAMAOE 4 NOOAMAGE 2 FUNCTIONALDAMAGE 4 NOD-AGE T FUNCTIONAL DAMAGE 4 NODAMAGE 'C y TOWEDBY? 4 ?/I ./S- /L-s-- I EST. SAME TOWEDBY EST. DUAAGE TOWED BY EST DAMAGE A To _ s TO. s '?1 w x { DIAGRAM OF-0OLLISION I 1 _ / _ I_ I I DRAW ARROW SHOWING a: Fu[uN[s I !-'-" _7 i T NORTHINCIRCLE ?,, ,. rrovn I I , I Ir,r- at T FT _ uwP.ci°fueAeLFwwr I i ? 1_I i,_) a.'?rEI°E°E off y-. _? " iF F7_I I '- I I__ •!? II(???'?f i t-I Lre-.-' ?`1 ,. tiG h 6 Fx ChY51YT. F' Z_D F? d DESCRIPTION OF UNDICATEWHATPROBABLYHAPPENED BEFORE DURING ANDAF ER THE CRASH, INCWDEINFOflMARONNOTON pIAGRAM EA ORWER i - COLLISION _ ;,,?y.; qSP&UTY,REWCEDVLRIBIUTY,PEpESTAIAN CLOTHINGCOLOiiCONSTRUCTON OR REPAIRWUHK EfC.) Ica L1 F- ':,r..° r 5T l..a?Ti;.?! o? _C„cl£_ Sr ,t l.r .Gur1-r (?,4.? ( Uz• ?. If i I ?,iao??4 _ I i' r: Zvu ?1 o Ooy.{_> y. { rn• P N R O r s y oH. HEADED..... O MB_E DECREASIfq TREET Oq HI(iMM .WE DR NO. y)?ON SPEE0.4 PMI 'J El OCCUPIED •! h N 1-[???W l.C:. '/S I? y?Eg ?NO YES s T ??? n MFRV ? PED. ? ? ? Nba= a? "MG \ v eECD1W0ry IE A? F iol PED/&CYCLL4T WA9 USWO -•1?bOFw ??w ? II.JsWLDFA -'•?[n64s AUt 1_l 1 CLE/q 11E r-IOTNFR V t?C R'av, .,ROAD SURFACE, yg,,;WEATHEi[,a'$x QNTRIBUTINOCIRCUMSTANCE _ s+Y 1 ', t 1 -IS IP.EcA ONO _. IcHE aA ) ? 1'"",.K'' r Ra rrTwclE.,? ': I Drvv[R - aavm -DmrtA -. rnim r r s (J'?{ I'''?? = _ - N NO x U)??fR.V01RAHU t '' wk M-M El- E ]? Lr. e•RUDCE E n CFNfEA ,. ' ?' IT 1F 6hn+e J ai. :f 1 ?-7 SEE I MN? =r ? anOw =LJ.9WW_«0 ? ? lwiu"ir LFD ? L?31 ?U"°.'° ?':._I i«ATgN1° - ? ?: ;6; `S Alf H pa? s ? °_ t' I- LI OTNE Vn O1NFA 9FECIIT I '? N°`"OrrouiaN°fj y ?I?.?«mArs?x wR .2b? b C, f 5:: , t: l1C.HTCRMMRI[,YA .:TVACA'vT•m[mn[. C'-_.vnvn n.•.... _•.vu a......... ?:..... ..---!•__.__.._....__ IJLf.:{J.,1•,.? `' '_S. -1... I?5 arun L_jx 1a Duel -{T - 1 ! L°.r n - F?, 1 ° ,- DAinuarts r PIwEAIYffJfvl......•- rr'E>:oA rK[narwe- NwTa[AylApar?T,raNAH X ?r ? a 3 . I ?1 ? aNEwAr I , NO 2 -DF ?_ ?x? lwaw•r ?C,? d??rvE ROAD _a•n. 7- ?e0 n'"'OAeI Lm r?,? a[ H,NBIMAED '-r.uMe -? D-D a L i FT i17 AM.'r J,71 [ CHEM.TEST "qT C ? rtn pNFN % TEST RESULTS 21_v N ORPS[.•CET u y w[ x / 61 A i E.. U1' VVHQY"1liiI%.A 1 U1V PAGE} OF _ Iru. } - POUCE CO l"LMT NUMDE UNIFORM POLICE TRAFFIC COLLISION REPORT _; • -r CUUNtt J C O' % BPR .^ D GATE OF COUI'JON- OAYOF COWSION TIME J ? N^ a M ? DA FYH. T UN I MpN 2 DAY 5 WED A RHIP S FRI SSAi 1 5 21(? UR) J /r+/?C/O ?qAL 6 2 ACM-0L9. PRER% ROUTE ORSRLEET 000E C%lFl GOUNTY STATE ROUTE LaCOUNTY ROAD ?CT'STREET O ,? ILI ?FFFtt50F'1 ?OTHER(SPECIFY) N??? T uS.Y? ?N CRl'ORTOWN PPS". lea. MILEPOST •'TY FF????,?? HWAt C ACC: L`? LL G x. ```[ O 2I M -m,uS ? ICl ? ? QOF CI•. INTERSECDNO WITH:STREETOfl RO 0 RAMP OAGRAMOAiA 1' ,.?; x ON NAME 6NO.OFS HKiY AD T ON ? ? I ? WTER NON %HD iEP5EC0 OSTfl fl AD P I NONINTERSECTION ACCIDENT I TF CL9. ERFNCE 039imEETOR ROAD ON c r I O 52 ID?I STREET M? E BE OISTANCE ANCE E CMLCODWG USE Q OWECTgNFROM flEFEPENC ST REETANO E OR CR?O•SISSTPEET: VRa,FTR /AND QFEETS N 5 E W OF \ h I O . J.ry?';' _? ' SEVERITY COLLISION INVOLVED: ?VEHICLEWEHCLE ?VEHICLE DIGTCLE ?OTHER (WRITE) ?MITA RUN NO, KILLED 1 ?. VEHICLE-0OJECi ?VEHICIEAR TRAIN ?STOLENVEHICLE TOT-10 NO IWURED -:1 OFVCHICLES D ?VEHICLE-PEDESTRIAN ?NON?COWSION ?-ROOUSMATEMAL ? PROPERTY DAMAGE ONLY KANDO S .;E E9T.OAMAGE T• WNERSNAMEI .. .. : LOCATIONOF OSIECTSTPNCK O gqB?J?E^CT,.SiRUCN FNnAM/ELOF O1BIECT/9/7pUCC , / Y F "'a 4r- "SAN' ,?? GIV ITT L. 1C `/\lY \/Al?• ?FIC/?EIJt. ??? ?ROAOWAY 2FEET ? ?Kb RD EOC EUv?KCV ? N DNIVENS NAME (AST _.__._ .FIRST„_, __ NIIODL'c ONVER'S NAMF,A FIRST MIDDLE I'' 1 ` • y. D C 2 0 ~1,9,1•1 /4 L, f T- D }J ' y I: R STREET ADDRESS R STREET ADDRESS - .... ". • f F -J rT_ w 702 3 L,rt fE ©F? KFS V , w >r -W E CITY PRONE NO. STATE -..;Aw..e".:.: 21PCOOE, _J,n, .PHONE NO. R. _.. STAT...: R ,M4 7Ac'c'r-j WA 9E3goR 97y17zs Ofl - DATE OF BWTN N jIV?ER9 LICENSE NO STATE SE% DATE 71 RTH N DRIVERS LICENSE NO '..STATE SEX _O_ G /R O. MO DAY V0. Tim,.i _k A PHONE N0. ,2.., OWVERSOCCUPATON.., FIflMNAME DRrvfFiS OCCUPARON,_ FIRM NAME ?/ L 4Sop? An4 c . CAkC, VA I HoS {{{ Y V CODES J SI Cu55 RI SEAT BELT 51 EJECTAN I :. CODES J DI cuuss' ..... AI SEATSELT SI EJECTION A-EOF c ATU E . y. MJ "•• ` Iwua ES A7FQ HO?? iwURES - EMOV O IE-V I-Ef000GECHEV.r: MODELIDAflTt10 AI.•':r. STTLE l20R.CON_V .S"_.i: y? VEH,YEAflN MA%E E-0XEV.I-t MOOELIOART NOVA(:•.: STYLE I2 DHCGNVI VEM. YEARS-.E S [ f Alf V .a ?, • 'E VEX' R:p;j. -PLATE NO :r? STATE;,'f.:: Ti WLEFEP,L!ITE,N0.- STATE„ E VFH,GOI,Ofl,,,.-.: uc:PLn?E;Jro .,_ TA. TRULWu7E.tta!; srATE{?V^.??J F`-yI ? ?' C ? VEHICLE10 ITIFIGTI N NUMB .a:z?i:t:,ti.'JIAL:S6iLYi1 ETEBe,>C:`s.•i C _ _ WENfIFK:A NU ,r...x«afert:Cdt'liR2JC OQNfTFA}A N'/. „{>) f ? > PEO49TEAED OWNER-LAST; (L'_L> _TSA FYi9T .c+MIDOIE ? flEGLSfERE00WNER.,• ??v r'` .....rroB11iJI '?3SLCJ°IStrv+Eu I??' ? ,41 ?^.J C` AOORESN •OWNER•Aa••'tiJ_ W+i'.r.•ww4.ibNl,..«.I...vrq....s?w..x.iYSIW?..A.. ADORES:L.OF_OV•'NER.iO??:.A:,. A1:GA.6t?111_?s.a:Jx:S%4??r195 Y OR AO ..d•"..6'?7i4A:?E%+.u1:3 WM.19 7A'" y , AND SS OF WSUPNJCEC0.0fl AGENT, NAME INO,.__._ESS"F INSURANCE M wLyl(,EJ` !' /big Y'°f Lco Sf CANT/E (JA CHAR" n 'r+.h ENFOO ' .. .. CC {'.' J _ CRAIJON NO..l.Axr t Y• `'. `n..'CODES INJURIES _.. tr.a431. G!+' •I ; { ND NAME, ADDRESS & OF PERSONS INVOLVED A .I FhCfj M C ADDRESS YA`"I.Y t•1 - ,JA:. U "NAM P .. INJURIES: A NAME: N'. T ADDRESS' - IS "AURIes? . ?y NAME: I ADORE59: N "uuAles' E NAME- S IS ADDRESS E $. YJU'? y'.? IN GTA NS 12154'1'OYTgN O DB CISµ 5 ) D S O1 HEP S- E n w TIf W. Il ORAIURV S O4ADUNOINJURV 2. DFADATSCENE S NON OISAeUNO XI OTHER -11- aDEAOO`I -- EY2)Elr 1,1-RY A US'OOUORC,CLE11 JOEDINXOSPITAL T.POSSBLEINJURY 2- 1 r' TO TO ?r 1. NOT INSTALLED 1.NOT EJECTED 2. NOT IN USE 2. TOTAILYEJ1 OTE ;y L ,y ,.USED D. PARTIALLY EJECTED 1 t?y6y,1, 65F.AT BELT FAILURE AF.JECTOFDN IF Y r 4•': 1 1 1 ' i? r ?1 d I A , ? f T E ?yl?? J } l ? I ! ?1 If V ? I T y ? 5 ,'1 A ®r, ; .?RL , Y F 1 f 1 s?` I } ? {!? aA ,ndSF,Frr-'• T t?tttp• qtr ? ?.l '' ?I ''?_?# Sr'?!._t(?{*fa,d?k IQ._'dL9 r"i?.-rx?I:-_Tllr .. £..s+m°L^Y^Y4{ .?-_314d?_-SL"?Cb G. ww:: _+.:L?:SYei6?i§au °"_.c..as.•v?"°itt__.. y_ VEHI.LE DAMAGE EnC1100x,"I'LL I UE NUMDER 01 EACII DAI AGE. ARIA LxnrAPL[ SIIAOE nREA Or SEVFII CST IMPACT. rOWED RUCTIONS: ]. DRAW AIIRDWIS, TO SIIOW PRINCIPAL DIIIECTION OF FORCE OAMAGEU VEHICLE NO. 7 'Q ?'aQ??? •? ) V ,,S CL fun SE-11 11CA.-L lP r• ] OAAIAGEO VEHICLE NO.2 11 N- IF- 1 1G' 11 A.All; -N11E I Or DAMAGE1 T'I LEI Y Of paAGE' E II: .r. AYLING DAMAGE ) ? U M.V.PAMAGE .1. 1..POwMA[ ^I DIAL NC,IP AL pnMAOE AMCJ fuE EnECAGE GY G I-. BY CI E5TDAMAVE r0 tP [tI. DAMAGE (C U 1 .:•l i. ((, i rt t 5?'-:O u E row urcr oxwL o o pA s a.: I TO 'TO DIAGRAM OF COLLISION - J_ f __ _r I 1 I ,DRAWARROW S ROWING ?Y _ .s anm...IfAIDnE{ I I I I - ?I 1 /1? I 1 I t NORTH IN CIRCLE >! ILI_ ,,,` I AY I 'f I I L... I I I I I I _f_r _-r avKr , //F" I I _ I i I I j Z-?--7EF ?? I x + MIA r. - ?-1-=?_?-Cy??_ I I '?I?? -?---I • , I -1-I! J • ..r.. ?«.'¢ •._?? pLLSp« ` -- I. I`.i,_? _' j_( ? f--I':i- ?_?-- -?-*???r-?-•?•-:.-+-?'. 7, _}? DESCRIPTION OF NDCATIw«A AIT _` I1 'COLLISION Dl:wpa,Tr, I¢ u ousp, I u srnl+N Cio Lon. Coisi UCnONO Fvf.ID WORK, ETC.INOT ucn u, [.c. pnrvER • ?? _'?/E'n!/?]Gc aft- /JO,PT,^.Qiu/U CifJ (JT /?-] /D• A ___L _Q._ ? ? C/,ccSSeO k'oAALuL1y z0 ?cf?_?1/Lccnl- s _?LlIG C/•'m?Zd1'E>! ?OR? vcc'sJJi15l-/, .Oi.°? vF-,fs o ¢ j POSITION BEFORE COLLISION On wO, Ix oluvE Onit?pn - V CLE vAnK[O OL NEApEP MLI rOGT 01n. ON SIR-On N,ONWA NAME 0. Ixcn Ea5 N4 11Cn EASING 1 IanKEO 'VIIS 11 IE NO No NO .?El No 11 iV rtp. i ALONG- OR Nc _;I?EngA?E«t 0 rE-1-c-wA,.11- E- •SIOEwaK )1- )? ISNOULOEner-OCROSSW L E "'lALK.Al O jf nKE Cvc TE E fl0?0 EKG CE KIEIF ionil L CONTRIBUTING CIflCUMSTA NCES W OTHE A pnlvE rvFN CLE N_ 01 F $ACT,oxs QT ,. IE On MOnU _ .. ('? O.)r(nrcu I NO`, O NXf] nnl FA . -::. ?E6`on°t7` y n c AR CLOUOr j ' .-T W1-FICE OI O ] O I J.IT L--• i°N'Alc«f anEwO . pnr Y..L_ -1 au0.4LoWlNC n p GxitnESG OVfn ;" If GAnpfO.wA TAK l? IJ-?'.6D SNLASL _1_ALGONOL _ ••y„-OSElv,_ I ) I?]U INO WET )?yI x0 ? ] I NOEN,NI"EN"T (-I Ov ER CENiEn ANOPwS51NG ._ L1DnuGt I _}' SL.. i_JO! gICHIT ?uRx _ I '•L I s«av ] r?snpsnnc I-? ]LI sxctE s rwt«c T° ` pc?iioyrAnKN iJA? u rN EE „y_SUaryAL r• N n 1CF FO! 1 , 1%CE n G S r1 - rF I_ Or[nAT NO LEFT TURN .. lrr.?,,L r..._-?... J(?-?_ rE D 1 I TunN 6 ?S? u KING Er TIVf FOUIv __V s1 S 1.-( tap 9[o c E plsnmanp - _tG u Tun N o l eciFri-- of«tN -crv) M --m- net en llenr _ __- Le? sIDw,Np I YI , --NO ] I O.N'GCN; srOr o «[n LS.eclFrl ROIPEO FOR NO TRAF LIGHT CONDITIONS TRAFFIC CONTRO I TY4E O F ItOAO VENICE[CONOI }iIQON R v'o wrloN sr F,D CMCK ONE, IA..I VEIII11E vI NO ] ICn I CK ONt On MORFI ON t to SOBRIETY - '? OrrED AT SIGNAL _ LE ?bl1f ?f C E«IC11 ICNtCKONEI - I__!•Lr pw.101 SIGN r s14NAlf ?. ONE w+v 1w_--_....-_ _. 0.l U C N !n u OF A NO) 11 ?E?GL S.IEJ%?!(?CI r °? -11E.vx D IIGIIT I t`D N _ ?)' . ...X ] 1 OWA' I LYE AKtS V` Yp TV. ! jlO`? T nA i AH IG - - 1?°.L? 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J5? nil, /P DAIL/ti/iyi?h n 111 ` ;KY PAIL ' RISIIRIIIIIIDN U1bul11nl ffN'Y •I NO II, WASIIINGl ON 51A1 E lPNnillDt OLrNP1n, WASIIIr11ilUN OEi4M Y'dl Y ? I V 1 Sys p ? ?} v. ,? NO e F PAGE I OF I 5 AS . PULICECOMPLAININUMRER fit, i "t Y ICE TRAFFIC COLLISION REPORT • ?i? IY UNIFORM POL DATE OF CDAY OF COLLSON A S B SAT IUSE 1400 NOUR1 CITYW FH DU N B- ?N • ROUTE OR STREET CODE EC11ON ?STATE ROUTE ?COUNIY ROAD ?LITY STREET O 50 00 `S ?OTHERISPECIFYI L 5 E ? IN CITY OR TOWN v W MILE ST - ' ' Z o MILES DIv I ? C NAME ANO.OF5 HWAY INIENSECDNG . M D ATA A I A T o I ERSECIIN65I.EE OR ROAD Ofl REF FR CDCNT M D . ERENCE CROSSSTREETOR ROAD. N A4Z STREET ANO -A/J ?SiHEET OE SE ^ • ?FEET ? .? OF _ _. SEVERITY n p 4 E:DCYCLE ?OTHERIWRITEI '? EHICLE-VEHICLE ?VEHCL LVED: COLLISION INVO ?VEHCLE RRTRAIN ?=L. ? KILLED INJUREO n ^ TOTALNO/a VEHICLEOWECT AN - ?NONCOLLISION ?-ARDOUS MATERIAL T ? OPERTY DAMAGE ONLY RI OFVEHICLES ?VEH CLE-TES DAMAGE EST y 5'? OBJECT STRUCNINAMEOFOfl T51RUCKANDOWNERSNAME) LOCAIONO . FO&IECT fiTRUCK .. .. .. N 5 EW F .: '' r T i a C % •C 1 // C° - ?r d DRIVERS NAMELASi. FWST ,. -' MIDDLE ?F yG 9ti/ DRIVER'S D. EDGE S Go ROADWAY 3FEET ? ? ? ® NAMELASi FIRST MIODIE IIF,eKYC4510R PEDESIflIAN CHECNI? ) ) 1 ,e($"FY' I'Gk D R STREET ADDRESS R STREET ADDRESS. ---- ' '4, V V • 1 E ....STATE . LP CODE PHONE NO. CRY E ,. CRY _ STATE. ZIP CODE PHONE O a l qv R . R q v . e '' N DRIVERS IR:ENSE Np. -. - STATE SE% DATE OF BIRTR N DRrvEflS LICENSE N0. ? STATE SEX ONE MO. OF BIRTH DAY YR '_ ' .. MO. DAY YH. Q, DRIVERS OCCUPATION FIRM NAME '.... PHONE NO. 2 DRIVERS OCCUPATION FIRM NAME. ... P NEN F' h N ? "I I gUR?nT IAI SEAT BELT151 EJECTION CODES > _ CODES > IDI LL F A55 IAI SEAT DELI 151 EJECTION-- k .? • TUBE OF ,. JU ES N d{ ?f• RTES T i 2 REMOVED F OM SCENE RV'. TO NE 5 • YEAR D, : MANEIDODGF{HEV.1 TO MODELIDARiNOVAI , STYLE I2 DR•CONV.I VEN YEAR MANE IOOOGE{IIEV.I MODEL IDARiNUVNE STYLEII DR.{DNV.) y #. a? r- T? 'V . • ` ? - E H VEN. COL UC. PLATE W. STATE TRNLER PLATE N0. STATE H VEH. COLOR LIC. PLATE N0. . STATE (HAILER PLATE NO. STATE . 3 9 _?. > L 2 1 S WW . ? I ?1 AMI 1 a IBEfl .. ODOMETER C VEHICLE IOENTIFICAII N NUMBER . .. ..... . : -E.. FIRST MIDDLE REGISTERED OWNER-LAST - FIRST N' tlc/d d J? o. . . .. ADDRESS OF OWNER :... ?. ..:. ... 2 NAME ANOAODRESSOF INSURANCE CO. OR PGENT ANLECO. RACEtIT. -.. ..... :••.. NF ... ..: - I ENFORCEMENT ACTN)N NAME, ADDRESS & INJURIES OF PERSONS INVOLVED .TER MIDDLE A N N AME A DDRESS. (ROM $ w TO A R SCF Fnv uRles / W N AME' I A DDRESS lit -..' N N A U E DCFNf nY. TO Res $ AMC' S A DDR[ss M S i U SCENE Nr TD • N M A uu 151AfU5 111 SLAT roSNION IUI NNRYcu55 "' DLAI OT.LT 151 f C PASSENDfR NOINJURY ] 5015APMNG PIJURY NOT 11 tNOTINUSE 40T"'C To XLYEIE 101ALL[JECtf.O t .AN D( f S , p,A.A15LENC AL HE" NABLING EVIOC"'WRY USED 1 ; PARTIALLY EJCLfEO 0 : D S C ^ c L DI S 1 T.OtH'SRgN AZ`HTRpPO1YOCAVEII DEDAD ON IN HOSRIV I UIIIOIN IR)SMIAL )POSSIBLE MJUM ; 65EAf p[Lt FAILURE F.JECIf ONIF UNKNOVV E a ' wR N[ss - L s - ?'?I !f4 I ? ? T ?? STS r',- 1 I% I411?y} t `I I I L l I l?? I 'ice' FIS rr ? 1 ? ?>rT '., A? i1 ' _ f L1 ?[I ? ??f DAMAGED VEHICLE NO. 1 ILEE TNIL SPACE FOR FKETCHnG DAMAGE TD Tnq LERS. MOTORCYCLES. ETC. 1 D AMAG EDVEHICLENO.2 r? xoyyr B. TuP (x'xr II f. 6. Truce R `. }+ I F E fpAMAGE VEH CLE N0.1 FEVEPTYOI GE NvEH CLE E TY OF DAMAGE: VEHICLE NO Y e s - . ?•D 6ABL NG DAMAGE ] OTNFR M V.OAMAGE 1 ? pIFACTBLING DAMAGE 1}?, M. V, DAMAGE ? FA MADE ]LJ I??{I OTHERM V.OAM GE ? L ) FUNCTIONALDAMAGE ? NO DAMAGE ) QFUNIOxAL DAMAGE • LJ NO .AGE ] DAMAGE • NO DAMAGE' O DA L CT , M J r + EFT: pA.... O MADE EGT. TOWED BY E T DAMAGE S , TO FD DY TOwEDBY 1V ? ? , TO [ L. TO E O 3 - n7 r C)a 9 4 DIAGRAMOFCOLLISION I .DRAW ARflOW SHOWING NORTH IN CIRCLE ;P I I T L-A LIT I 'I 110/IP6?-_ + _ ' s4; r ? I?? -~ I i. lr+ 1, LOCA =111-OF - rMPA ^? sn?yr??? / - ,1a 11CISTFIAN 1-5 xAfr 17 . - DESCRIPTION OF nmc AND AFTR n+E CRASH, wcwpF lnloRMAnoH NOT ONDA- °" COLLISION. OsABa1TY. FED.Cl._RRLITY EOESTRI THw COLOR.C-STHUCTONGR REPA nwORK, F.tCI - is?} - I.,? y/1• ?/. ?dS source on_ G'o ?E oK+d_ r?/a Fx? ?, ?,..9 a_r?-s?t:?. cv/?_ r -LlJ/J4'Ii /C_ilFjfiG/C' ,?/?oA efi?..JifC' .?Je)sT r dG of._.T6 ?e'.,Adu ,rye sT/rc e?I " L j _! rj? p POSITION BEFORE COLLISION - O E F P t 'C ,. IN ONE DIIECTI LALLY -V MILE POST Nf TOnH HWAY AuEORNO. , E n oC u 1[ 1{ R P E .,. ' N K O x0. EALING O CREASwG N S L _ _ if J . YES NO YE: . - r ? ? 1 Lam' 'J .?I y . - IL A OnG_ r wwA Ntq rO I>Ilr I --CnOFFING. t r • t F CvCLIFT wA[U]w4. LN I ALKwgv I HOULD[R4 AIAPK NrAAR F E& EFO T 1. IFIDEWA )( CROF]WED AL IGROSSw L . 1C I ?O E ROAOSURFACE. WEATM NR CONTRIBUTING CIRCUMSTANCES vE rv E iO O 2 L M w L ICHECK -1 ICHfC EI IC ORMOn EI. VOEj IvOR HOE] - O O LSr L I G . EAD I 'N I . IT IOOLLOwING 1 -l r ) I A' RTAKING I ? I DRY LO+1DY F ENCEO AST- .LL?tLQ4 L _j PASSING I - _ _I r APPARENTLY J]f' T .11 1 i al- UN W[xcEO r' G ] I _ E ASl E G F om{ - EK EEO GFTATED GTO 1 b?I u O PARKING R MAKING ![ ]Gw -3PEF0. ..? L-_.EOcA_TION - ^? LEFT TU _ _, RN .-1 1 EKCf NG REAS IOVEn ? OPERATING uAKINO X I CE OG ` C PEE O SCTIVE -1 ___? F 'J, .TURN I_ F , np OTC I((I I AvG NU_ S .. J 9 Slow NG ! O E -__- O •tN Y[CIlYI OI FN S?[ClFvl ` Q?' P SOPGn Jso'STOPPED FOR 10 Lr TRAFFIC FIGN/SGGNnITOV 01.1. ISPIDINYI PA- LIGH IT ICONDITIONS RAFFICCONTRO E TYPE OF ROAD VEHICLE CONDITION SOBRIETY... ?' OtvEDATSiGNAL C.ICK.11, 1No.2 v-.lC C'2 ICHfCK DNL ON MORE VEHICLE ?gq[[[FC UFO Q ; ol[ -, ICHECK OHEI OR 11.1SIGN . ... ,: '.1 •Lf ( jr^:, ON[WAY HO.) `ar, 11,sijDl N .) rIG F,DPPtD IN ?.J ?. _ ._ D _ DFSECTIVE -'. S. AN-11 I A" TNiN lIG i I] 61G r . . tl AKE M A I tD I E r _ .. [ Lt r 1 I I; f p B GFROM ,Y c I _ Vn1 .) _. O ` T ' i O ' N 1-4 ?, LASrNNG KEO .IETV _ II) W K TnFIif ci IEN RII H E AM:GE ] ? I? .. nr P iicnls k {, - ... _ .u ... , - _ . A [T " AN. D ; FLISIONG TIIIESWORN LL O d_. 0.1CKIH6 L D ON A BE .O I S 00 1 NKING - N K- mO E II CHEM. TEST (" B Iww O ) rv, 1 ." I-Al L I E- ... ' ' 1[ H I IF N, OINFP IFP [IlYI O RK'NO sTPen c n O'A B .. _. . __ A O l HH NO DEf EL TS T Rf luFED I. D WID[D ) It 6 S [ _ _' ,..., y OMEN ITIICI r+ XE ^ )' IYIDED OTn[N IF11C., 11 ?. I %I TEST RESULTS 2 a s NO r 'I w rcA, NG O.rl n a.Mt.1-K ?y -,+I?/ Nvar cA,rx p.nuH 'A T nAI `[a0 A r43 U VAIICIII. PuucE A/n?nrv/E AMn CL 1 unc Fapw POL CE IN n`Tr ??JN _(?/O ),M Ow J?)Aa ANnvio HNBO MPeOfonE/C? A IN V ul?mFl C - rr -- , ' X , r . L wm+r APPn7, DAR ?j ,, u /. / ,p `' ? ? ...e GL/ S/ u 6 r 0 / o? 1 r i: i :,/ :gy y p - IXrPLICAi[COPY LOCAL LAw,NlDIC[MINT AGr NCV'B COnV•1HIPlIC ATE COPY: INV GTONBH.M EST IGATOR'S COPY '' Is f rh A 14'9 ,?: 7 - v n.i; ).1 ,.,.rEnT 3.Ti ::'•1WA' r' ?'?„', f,.-.'`?, '?i.. r '?? dltP $(F T. -?? p 1 P, } . t ?R .. .... m.vo r n? x A hkE . • " r Y w {? L - t. M ' ? AYR , STATE OF WASHINGTON PAGE i OF No. POLICE TRAFFIC COLLISION REPORT IFOR POLICE COMPLAINT NUMOEII t UN M D DATE OF COLLIS ON DAY OF COLLISION TIME COUNTYNO. / CITY NO. F WA ' yA e: . MO. ,, OAY fl. T SUN T MIN V 1115 D W p < R"F 5 Fill B SAT ID$E PaDOHQUfII r ??? DURBAN Tl} 1 b- Z t tttt d J 111 FI% ROUTE OR STREET CODE PURAL ECNON ° • ' CITY ?STATEROUTE EJCOUNTY ROAD ?CITY STREET O AOMLLS. PRE 7 - Lcs OOIISQ?? ?OTHERISPECIFYI W O ?-IN? CITY OR TOWN MILES ? ? ? ? .Ea'- dGLJ/1J W O PREFI% EO. MILE POST A 7 IIT A _.,. NAME S NO.OF STREET flHtC/HWAY ;. .. INTENSECTINOWITH: STREET O81011 LL ' RAMP DIAGRAM DATA T-? ' ON O - '- O: Y • . NON WTERSECIION_ ACCIDENT O NO %-RD INTERSEC-STSRETORROAO OIIREF• INTER LLS ERENCFROSS TEFTO DAD. i - r TSB' I - 'O, N' /? S-,? /d STREET AND ?' REET ?• ? G'a T MILEAGE LOOE 1 I - - ,,. ? - --_..... BETWEEN _ / _ OLSTANLE ANO DIRECTION FROMHEFERENCE OR CR0555iREET N S E W I R S VrWr HM SPf.C AL COD NO USE .' { ;-- T V • : Ft --/ MILES "OF R%U ? OF J.-?_ /Q-_-_ ^rl - A? 1 ? VEHICLE-VEHICLEYENCLE BICYCLE I ?OIER IV/RITEI COLLISION INVOLVED: ?VENICLEOPJECT ?VEHICLERR TRAIN ??? ? Y•? ?HIT6RUN ?STOLEN VEHICLE _-NO.KILLEOVERITY I N I I I ' ( T OT A ,_ _ 0 A NO L I? _NO INJURED N Y . F ? ICLE OF VEN S ? VEHICLE PEOESTRIAFI ?NO„CDLi1SIDN ..?HAZARDOUS ATERIAL ? PROPERTY DAMAGC O L • T 1 OBJECT STRUGKINAMEOf OBJECTSTRUCNANOOWNERS NAME) LOCATION0 10DIEC15TflNCKS E W EST..-AGE f {Yy I ? ROADWAY FEET ? ? ? ? RD. EDGE 5 I DRIVERS NAMEAAST-._,--- • ._., FIRST,:.: MIDDLE _. DRIVER'S NAME•LAST, FIRST MIDDLE,IIF BICYCLIST OR PE DESTRIAN CHECKIU D D: . ST A STREET ADDRESS ' .... ..:.._. - . ....- - a.zsYS_ v ? E CRY . •_ .. STATE ]IP co- PHONE. NO. E STATE... ?'-CODE _ ... ?. PHONE NO. ' y ? r ' r N ENSE NO.. DRIVERS . STATE 5E% AT OF DIRin N DRIVERS LICENSE N0. - STATE SEX DATE OF BIRTH Y ITT o. ?o ? yap ? 1 4111 SAY YR ?j O Z/ 5? O • MO. DA Y ' DRIVERSOCCUPATION. FIRM NAME . ....w j d A?? -All . 2 DRIVERS OCCUPATION FIRMNAME - ., - ... P E 0. .. 2•Tr _'; ?` b CODES NATURE OF IWURIES - FRTURSCENI v VEH.YEAfl 77 c E H I VEn. LOL c L E VEnIC .IDE -' N D• REGSTEREO d• . Y ADDRESS 01 . '„ _ NAME AND Ai v JC. PLATE N0. STATE TRAILER PLATE NO. STATE E VEH.COLOR LIC. PLATE NO. ?Gss L/? H ATIN NUMOEfl .. . . .. ..... ., -. ODOMETERS C - VEHICLE IDENTIFICATION NUMBER. 7 /S'/ S%lv S9y? LI` E R-LAST.. FIRST .. .. DOLE.. REGISTERED OWNER -LAST. ,.... f?_ N O E .... ... ,. ADDRESS OF OWNER 2 - i OF INSURANCE CO. ON AGENT NAME AND AODRESSO INSURANCE CO. Srdf 6 - .l?oTirdrr % d F CHAA(IE e..: CITATION NO.. ENFORCEMENT CHARGE - f ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED cools - LeN r ODOMETER ^MC . _ ...... n x IAGENT .. CITATI NN NO. 1 ] D 5' ?Y cim, :s S• nIhIM 9 SCEHI HV •?Vm TO IN51MU9 I]ISEAI PpytKYl RYLUSS IR St/T DFLI 151[JECTgH E fLLtT? ?_IT e S USE ] ?? A IRUS (0 0M Owill ] OIO IOSIInTEAL > POS OlC11N .R1Y 6 55[b0 11 rMwnE D uPARTIAY NKNOWN FDLCi[D fJECTED ? rR L ] r Ir }u 41 I N4' IY Y j- t 1 1 ?t T ' Jlfl a 11 > - ll I - ' f A t 4 I ..r 1 ! 1 h 4 1 F t y f h t ,? rm V"YI'M1I Y,l' 1 JWL 1 ••I 7, '4 ? , v ^-M •. Cr ISM 1 I T '.I 1 F?i •y I t ?' ._ ,. _. .. -. _ .._ ., ,.. ... .-..-. .... .??'. -'III aA. IY 1 'A r l y M n l , I ,F { MOTOR VEHICLE COLLISION REPORT NO. OAIEOFCOLUSION DA YOF COL USION TIME CF COLLISION COUNTYN / CITYNO. BFA S C D,.2 tr? x ; wOl vM • /? j RvRN. CE COUNTY CITY, TOWN xRAirfRF Po%7 T , .+?r» $ ro L? O L FOUTSOF H IowMF' : W CITY,TO' ALES QQ of .PVM p J L T TO 1 0 AOM 6 PflEFI% POLITE w91?L0DE SECTION GIVE NAME OF STREET. ROAD RHIGHWAY MM K r0 1 P 30-T-SL,1 ?O w -?- INTERSECTING WI TH. STREET OR ROAD ?VD 1 „ L". PREFN( EO MILEPOS` N NONNTERSECTION LOCATIONOF OO(L/L15l) GETVIEEN \ STREET ANO STREET RAMP DIAGRAMDATA 5FCr4%N. Q®iro5i onnE»l rrlrwiGiµrv prsinn. Ex. erumE. F EE T a INTER NON %flD I E CLS ER9EC cs F O AD OR D RpAO clE VEwCLF O MR-ER(AWIC) SPAN N ?'r Owi%n>IVd V[D ?- I ? F SPEC. OE ?? v rv ? ? ? 5 ® LJ._J OvEwcLEV[ceSrRIAH ?-COt?vo» ?rvr.RUN FV - ECTJGyUJ) IHAU KI O NEROFOBlECTS EANDADDRESS LOCAT O 1 VI IR',v IN ROA ?O C. AT E V 1 ION © n DWAY ??F FEET Q EOfE L/ A. 4 ERS LAST NAME FIRST NAME MIDDLE W CAR FIRST NAME MIDDIE DRIVERS LASTNAME e P?ee?YS N .p Sr EET AppR 55 TE NO.ANOBO%N . } 3 ?0 5 S70 F:::- wrv.O -f IR' o_A ROME NO.ANO W%ND. STREET AD— CO" STATE ZIPCODE ORIVERSOCCUPATION ARATI CRY STATE ZIPCODE' 111ERS000UPATION P J N- L, C EPDRrFw DRIVERSLICENSE MBER ?? JNL ' ' -VERS LICENSE NUMBER ST ATE T WT VEHICLEYR. MAKEICHEV.-CODOEI MO BODYSTYLE120R) VEHICLEYR MAKE(CHEV:DODGEI MODELINOVADART) 19 7 ' P O STATE. E NOSTATE ..IE R T SEPLATENO UCENSEPLATENO. STATE TRALERPLATENO. STATE . 3 X171 , ? VEHICLE ID T.FICATION NO. (1988 MOOEL56 NEWER( OOOMEIERIMILEAGEI VEHICLE IDENTIFICATION NO. (IDS. MODELBINEWER( DOMETER (MILEAGE AI S 13 EGISTEREDOWNER (LAST-FIRST MIDCLENAMEI DRNERS ICENSENO. REGISTEREDOWNER (LAST FIRST DME NAME) DF-FISUCENSENO OYAVERS AOIXiE55 (STREET. TTY AND STATEI 4ts-Y3o 7 Ll DATE OF BIRTH 8 OWNERS ADDRESS (STREET, CRY AND STATE) DATE OF GIRTH PMTSOF VEHICLE DAMAGED ,iF000SF V r PARTBOFVEHICLEDAMAGED Si0 » WAS THERE AUTOMOBILE LIABILITY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. I• COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ER?YES ?NO AND ADDRESS OF UABIUTY INSURANCE PoLICY,gLOER NAM E OF LIABILITY INSURANCE COMPANY O art s I NAMES 1 IATf R I I C r• A r•t- ?J L7 V"C_? 1,110 NOADORESSOFVA&LITVINSUPANCE AGENT prr 51ML EP VABIUTV POLICY NUMBER CO e- CI}-0773o6 -O` -30 15I AA AGE 9[P,n,rf PFPCnr FOn 4Awf5. ABE 2 D URY 1 NAME rOlAt NAME pD11E5S SE% M DDESB _% M 0.6 BBC, " noN,"`9r=fwclaP El , H .ME°NS off Or,nocrpm ®E' H,Mf SIAIUSOFINJURED MMKFIRS TONE THATAPPLE S STATUS OF INJURED MARKFNST CHE THATAPP.I . O 1%uvER W VENICIE nnD •.A,Rr vxm wvL ._VEHICLE. D OS,NwO P09Ywx+E x O "D KILTED Yv[HO rCO"P I g EL OP 1 1 - R _1 v n FI H 8[ CPIAnI or P.NEr.I ?Man ? sD ?D M T ? s? 60 70 S,,C NOIIIH D\' ARROWINCIRCLE ?\ n I DESCRIGEBELOWWHATHAPPENED'. IREFERTOVEHICLESBYNUMSERI wa„°wN?F.oR.M •? ?s ?? _ w?.<h . [.palyt? --_+?<..._b X-1.--?'°-- E FpRIHF 1,MlFF'9 ry r rtk Y? tsa S ?DV I 1 JAI `- " 'K ` 31N[E, ? A j.. L /? 1 .cr w,:: »,r:9 w , F I ,..fr .. 0.3._ HwxlRa \ ?IT,.KLA S? 1•I'1Z5.1/?.. a•ti.Y,.._._ vrpW ' ` ....I >wunA[Kw vTrrtE,rq) IK,NL14n o. m.„L.. A1xOW ; ? ? "IC ...vcYl ..-_'?o ..-1-?t_ v._i• l?T o cs __. _.._ _.._..... ,.. j ... _ _ ...- __ .. Y - srwrlorNPVrHAr ?? I r__... _. ...-. _ .. .. ... __... _ _.. _...... ....-_ VEHIQLES POSITIONS RC-FORE COLLISION rq21D;,?'"s r•c'grED Y i«om"?%:e ST.ATro By [r «0 HO?.. v[NCt N B E W f1N 61RrET OR ,NrGNWAY HAMF OR NO ORIc, ?YINVE? ? 0 ? D ?LKK ?-111.. NOF•» D D? D l „r •. DD?O D D D ? ? D LMa1KaN D ? ? D AoND cAOSS•ND mom DIRECTION To DIRECTION PFDFSTFANWASUSING 1?KIM— 70-KWAr J?b.OULMR 4?C='WA 90 c eDOTHER No AD FKE N[AIN[II 110HICONw'CN3 IRMFICCONIROL cH C- TYPE OF ROAD ORIVLRNEHKIEACTIOF15 .NEL IYKI v1 r•CNI F V1rKU Kr4CA OVf tlr bOll[I I[ rr0 r M) > 4x NORl1 y0 ) ttK[ ? 54NAL9 0, D ONF WAY 1 ? DOINO STRAIGHT AHEAD rp r M 1 1 OiKMiA 1OAYIGNR ?' 1 ? 1 CRV J J{a RNNINNG J D DAMN 0 J D'o,' M jp_ J D lwfl WAY D 2 ? OVLR IAMNO AND PA NO J WEt J D Swow,rA 2 Dw9K [3 D D "1 LD IAN D O ? IIDAD SIR([ C] O C) M.IUNG pn.7 TURN INTFI4 NAN E D ? MAKING MIT TURN E'S vow D ' [' 4 ? 4 D FlA! nr101,[0 ? ? A ? TOO N ? f"liB aH HOOP; R,MPI ' Cr O1 GAR ST f[t -El D e ?MAKND ViVRN 1NR ?1C soR, ? e ?I1A!nmG AMH[R ? 6 (J 1 ?0 ' ? A 1 (GFYI 1 D1.0 H. IF ? µ0_N0 D 6rtCVr a ? ii ifNOLG T$ ? A ? RR fNAL ? e D lff UWAI 11(ABON FOA N0191[MO DAArGLR i `-N ? r ?p11C1 N.Il Af.MAN LANES ? 1 ? ST(X'1rofoG TRAFFIC SPITFY U•rcl s ± v lt v-.urn wM . R , . l l (3 IT ? ONrtR VN OFr 0,0 a[PARnro ? e D 61MP[ S70IPfO AMT 7 !ANAL D J D DwD[D D c D sloITED RDAOWAr (? > f-1 n IrMNt E-Y 1 n 1 10 ?-19l All wOw ? l J Drv'1 D AF 1 C I. C N • '?y 1 J r. u .?..r ? M`y12' f"!"•-Q1175@:f.r.}._,'b ..',. Is' 7 ]AIKp A _'I" a -.7. T F} j_ y r qj!??J I rk , ' 1 M ? tl ? ; j .'f i. F ,? I IM1Ir N 3 m An7, 1vp? N Vj Y4 t d b'L - + Aas } ? l VCHIC GE INSTRUCTIONSCTIONS: IAN EACH "C""" NUMBERO IM EACH OAMAGEOAREA E p? F 2. GHADEAREAO REAOFSE SNEST IMPACT. ACT. - _F ia ;. S DMW ARflOW19J TO SHOW PRINCIPAL DIRECTION OFFORCE DAMAGED VEHICLE NO.1 F----- IJ 1 . --IUSE DRSSVacEFGflsKETCHINa OAMAGEioirlAlu:ps,MOiopcrcLES, Eial DAMAGED VEHICLE NO. - e Nr /I..-.+ Lnptr_.71, 12 I S. A-I 4 T-k ?° Fmx.. n Ns. u 13 H? 15. Trunk v. o il ,e. wa°r°,rreo. mrn,rn EEVEHITY OF DAMAGE: VEHK;LENO. , 1 T.0- 1QDISARIJ.VGDAMAGE LEYEIRTY OF DAMAGE:IOTMER VEHICLE) SEVERITY OF DAMAGE: VEHICLE N0.2 ?OTHERMV,pAMAG.E IQDISASUW-AGE G? OTHER M.V.OAMAGE iL1DMAOUNODAMAGE SQOiHER M.V.OgA,AGE 2 FUNCRONALOAMAGE NOOAMAGE 2 FUNCRONALDAMAGE 4 NO.-AG TOWED BY 1-"L,-'C.Sj. .! E 2 FUNCRONAL DAMAGE NOD-AGE E9T.OMIA(iE TOWED BY ESi.0AMA0E, i,wEOOY - EST.OAMAGE TO `:. t 1 `r S To -.._ = TO 5 DIAGRAM OFCOLLISION T? ,L,r?c?abrtloru 21 ra PnOxA[L[RH1DF I I I - -- I ? _ L_ I ? ? I ' I DRAWARROWSHOWING 1 NORTH INCIRCLE = T b . r_ _ _ . ? I .- ,1 _, . F ..u uu v °fSOxE _ - _ ?? l + rtnc °u alo,l -??? ` r DESCRIPTION OF3' 1 RNO ICATE WHAT PROOAO ,'--COLLISION' H ^. OIS LYHAPP A&UIY,REWEO VISISRITY, P C ENED NEFORE,OU EOESTRIANCLOT pINGANDAFTEg HING COLOR, CO TH NST ECRASN,INC RUCTION OR UIDE INFORAUTION I:OTONDMGpAM,EQORIVEq HEPAIRWORILETC.J - 7 r tc- VEH. IIFAOE? I NO. 6._ WLE POST OF. INCREASWG oECpEASM'O ?+NSTA G' w...a!'?:.'..y? tyeV:.??,r':•i:,:y:;u'. ON S1pEETOR HgHWAYNAME OR NO NO.OFUNE9 WONE OIflECTION SPEEDS S,F[ HICLE I PMK LEGALLY WAS VEH. I ?? C? C? C ? 0 C gcc _ .? ,? PARKED OCCUPIED ? ? ? ? _ 2 ? - _ YES ??NO YES NO PED. C I I_.) L J l._ Or rR St -- -- Dnjpgy„° 5rnu1 x l .«fxAY [. C«w. M n OS >I .,G Vr.I ry q w ( ? i l ? ^''7 ( ' ? PECl YCL13l WASDS°q: 1. ImoewAFK n Av 5i SHWND, RD4TV,tK .. 1 -- n e- ???mss F l 1 IEn1Eau ?; ?C?W ?-'"TO . ROAD SURFACE: WEgTHER~ >jp. ,,;t,?„(ej? CONTiiIBUTINO CIRCUMSTANCES' ,ri .:,,„iwLt ,;; / s •. °n'rtvtawno ACr :: 1pIFCKM 1 -" K:MFCR GNII IFNTx ? ,, k On[«, HDxI . ^.•ji1YOi: fT/ ?Ha1G?ONe «wen - ow?nn «uvFn' ? I ?? «,r _ rr w^AC.w_ nn ? ' L ? J.,J ?_=""-°` wFNCa « ?- j, ou" a • "". . •awu ? 'v w 1r ?T -+i3f ] o[ ? ]?-OUHDFi4MnviWNCa GF (-1 ICI O E C E 'f ll., 1I I j I ??IJ PI°H Tllpt f .l (-.d IT J L ? -_ n T rNOw ?? ? 5 C, MAYMM ° _ _ ??? .[ o«xnSMrto a _ , ?1 ( ? , SMI"D ' L? wC?nMi PNl,cwD ?.O iERnIFFI L LJ r 7 r 1 u . J Pao 1 I r - ... _?J4? 0.0 u -' . 11 -- LI 1-1 Li o enINM1'G omi IRNt?n n° E J I - Pn, A f1 ,? ? [n"n° DP C J 1 r°.ai I r am ? T J orvm FOn I- -1 inNIIC ' lIOHT CONDITIONS TRAFFID CONTROL W KHICK an , ' Yn,Clt -KNC,.c ATYPEOF ROAD %VENICLE CONDITION [ KxFDK «,F M °ID'°FI D ? ° C- °NW° J ?-J ? I - 2 =. R S,OP D=.-,, ! -1K ONn l_.1 ? C.J Dnl W,r NJ r °?-- ^H 1 RAruDHr - J - ?? tno ?, L e5r^'C a rNOw . t a P xx 4 J aw .. _ ,'.L a' 4._: AWtFD O J i J ?'. ?? l ? ? .'".. P NIKW - .. J J f? la'wae r 1 K nx,arnra ? « ' u ? f , 1 ? G . [ . _ H°r.xxwn ._. - 1 „:F °'GX1^ [ , ° mFA .. CHEM. TEST '° i I n:rv,A'+i'T ...? «Ilvuwx iO1°0 j I av,P?w I .,w u K curl I .I - r_ - r• ., .. I ... DmrnlvnRlnl ? a I° .. '[I _? Iwq f 1? ? Nod 5 I I' rtnnaauSFO I D 1 n, v = Mt, i 1M4A _i 7e °A TEST RESULTS 2 R C xlxw IwIMM1.- rWnDO I Mrl. nAt rKW p,Y'KN rOnr. Dr0 At NO O I 1 AIPOI-<L P W Nrr R AF ruvLrc , cGn, Lar.ALUwr «I,ICF TN Gcr.Drsco r r vtxn[m eNVI. nr onncav 7 A 'c 3-°r STATE OF WASHINGTON PAGE OF No. I ] UNIFORM POLICE TRAFFIC COLLISION REPORT POLICE COMPLAINTIIUMBEfl y ro t? Y R cf r 1 D DATEOFCOWSION DAYOFCOLUSION TIME CCITY NO, FN A URBAN O AY 2 TuES ] I2 E STATE ROUTE PJCCUNTY ROAD ?CITYSTREET W FOUtE ON STREET CODE SECTION ?OTHERISPECIFYI CITY OR TOWN 3I c"L ? N U LEPOST C OF I MILE? ? QOF STREETORHIGHWAY TORROAD O A T ?L O N CJ ' NON INTERS 1 ACCIDENT H ROAD OR REP. TERSECTIrvO STREE WTER CIS. EflENCECR059 STREETQFROAD 0 /?i. `y mq STREET MILEAGE CODE 9.5/70 i N STREETAND BETWEEN SSTREE 9 NOOIREGPON FROM REFERENCE OR CR0 DIST A NCE A NOFEMR SPECIALCODINOUSE F g T S [ W y ? // (( OF '1 L,JFEE SEVENItt VEHICLENEHICLE ?VEHICLE-BICYCLE OTHER IWRITEI ?HIT&RUN N VEHICIE,OBJECT ?VEMICLE-RRTMIN ?STOLEN VEHICLE NO.INJUflED TOTAL NO NO. . OF VEHICLES IO VENICLE-PEDESTRIAN ?NONCOWSION ?HA2AR000S MATERIAL PROPERtt OAMAGEONLY OBJECiSTRUCK INAMEOFOBJECT STRUCK ANOOWNERSNAMEI LOCATION OFOBJE TSTRNCKS E W ES .DAMAGE PD. EDGE 5 ?ROADWAY FEET El ? El 11 MIDDLE ORNEflS NAME LAST FIRST DRIVER'SNAME-sl FINST MIDDLE IIF UrCYLl191 UH PEDESTRIAN CMELKI .... D 'r L1?1lAJ`?N L1?W'?'-f.1? d\ C]L' D R STREET ADORE A STREET ADORE - ' 2F t ?t? E COD PNOnE NO. STATE b P E CRY STATE ZIP CODE PHONE NO. R IT30 ll L R N uo px DRIYERS UCENSE NO. STATE SEX DATE OF BIRTH =ATE OF BIRTH N DflNER9 UCEN9E NO. STATE MO. DAY -YR 0. r MO. DAY Y0. C L1,00 N WA M I [ O, DNNERS OCCUPATION FWM NAME PHONENO. 2 DRIVERS OCCUPATION FIRMNAME P N CODES > 01 CI u- IA1 SEAT BELT 151 EJECTION CODES >p. CUURY ICI SFATBELT 01 ELECTION b NATU OF f ,.. t ,,: NATILR NIURIES WNPIES R M ENE N .YEN1 VE w L ?V BY' TO C6E?CHEV.1 MODEL(DART?`JN 9TYLG(2OR.CONV.1 M REMOVED . FROMSCENE nY VEN.YEM MAKEIOODGE-CHEV.1 T O MOO LIOMTNOVAI SlYlE12 DiLSONV.1. V ? / Z O aL ..LL K1'Ays_y(2"J[?_ V E / C L .... . PLATE N0. U C STATE TRAILER PLATE NO. STATE E VEH.COLOR UC. PLATE NO. BTATE _ TILVLER PUTE NO. STALE „ H ?J Y VG?l? iZ L.?A H C VEH LEIDENTIFICATION NUMBER OD ME ER ... C VEHICLE IDENTIFIOA L N NUM „_.. ....... ... L L E E REGISTERED ER-UST FIRST WODLE REGISTERED OWNER- FIRST ,.. MIDDLE N J? NO 0. ADOflE99 OF OnNER : _. .. ADDRESS OF OWNER .. ::.'_ •... '.. .. :....r . T 2 NA EANDADONE WSURAN JOENT NAMEANDADDRESSOFWSURANCECO.ORAOENT ... ... ..,'.. 14A-044 t?f 4SI? Mc? ?4. Nn LTJU G/ N GTAT NO. ENFORCEMENT HAR - -' ACTION CO OE9 1 - T ] A 5 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED SEX woe 31 1 " EECr. c NAME: , ?' L S O r( 7 Z l 3 Z- L C AIXMFU' U P NA UMk OF INIURi9 ()k O? IIkAIOVF.DFROM SCENE nY: T O A N NAME' ALA L?InLF1 VN - F Z I ? r V t T $ ADOnEi9 MJU Ufs A .JkZ,-V- O? A?L-? VE F M 9CFNe m. To W T PAS'?1 N0[n T tAD A ',K: 1FNP A Na pNATI1W ?fiY I, FIOT W U EICD TOTALLY UECFO NOT I i1 DVLiIrUN 1 T+i \ 10THTnM '.NKn 1DFADONARNIYAL IFVIDEN1HNNn P04!'' IIV JUSFO ].PMIIALLY [JECIED ALEJECDO li OrI.LH I 1 I--?I ?? nllS VOIOnGYCtiI AL?'LDI'lIK)'.RIAL IILWJU(IY 6 AT BELT FNLUNE T T N E S E S' V j • -•K " ' ? St ,.D t A f h t DAMAGED VEHICLE NO.Y (USE THIS SPACE FOR SKETCHIf10 DAMAGE TO TRAILERS. MOTORCYCLES. ETC) -11-T IO a - DAMAGEDVEHICLE NO 2 , -RHRUU iK. f ERR 15 TRIRK ..I r BG I I .Fool irr:RR > t0 UnOerCerrlaCF ' I 0 r II 1. 18 UMe.crrMUrr 1 T.OvMVm ` a SE V'E?fTY OF O iMAGE: VEHK:l ? • it OrFRMn E NO1 SEVERITY OFDAMAGE:(OTHER VEHICLE) 1I;/OtSABUNG DAMAGE OQOTHERMV.DAMAGE I? DISABUNODAMACE D SEVEWTYOF DAMAGE: VEFiCLE N0.2 OAMAGE 1Q CW AMAGE 2 FUt1CTiOM1AL DAMAGE 4 NODAMAGE 2 FUNCTIONALDAMAGE ? NOO . V. D N ON E TOWED BY }?es Carats V ? AMAGE O N DAMAGE { ODAM A EST.OAMAGE TOWED BY EST.UMIAOE• TO NEDBY - ESi OpMAGE To Chicuicum. Tin. . 5].200 O o 5 S DIAGRAM OF COLLISION 'ro e I .?._ E I' 'r. t_. __.. 4 ?,. ?DRAW ARROW SHOWING D -" ? f Aax r Llvwr.FEArvRES PEMSnnwv : 1 NORTH IN CIRCLE f ,!Polo Palo!. -? - -,?-- uNUSNV"i.`yrEUP carOngNB ' p in'?EAxiTCCw?mucrwH : w0 ?,?rr I,gEAeLFI?NrDF NOwvFwCLG VEUFSrMMr OR IHPACT. '1 _ a I t - __f I 1 ? ? I I i - p L VFHidEOR 5laµl' pIfORE AxOIiTER CIXL510N ' i ? J-. -. ? .. I I I 1 I 1?' r t I 1 1 DESCRIPTION OF 1 . -lr N I - COLLISION I D ATE WHATPROBABLv HAPPENEDBEFORE OURNOANDAFrERTHE CRASH IYCLUOEINFORIAATH)N NOTON DIAGRAM aSABlu"'REDUCEOVI5IBIUTY E.O ORNER pEOESTRIANC RfA A , . , LOTHINo COLOR, CONSTRUCTIONOR REPMRNa L TCI; ---?ver..in-tormed this .3/0_ that_ he- raas__t•i/B ng. C.R, 12__arrl, appzr_ent1?_ the right front tiro • t '-_-- b1 .out ca sib hici to lose control of_fkte va}i c?a Tt'rilang tF.e telspl'- poI FtA-'-- th9 EBrbanh D+?te oderate damagge to tho vehicles , --"---- -- - y - :: PO TOMB OR LLI ION BPEa- VEHICLE P vEH. HFAOED MILE POS NO TOIR.- ON ST REETORHKIMNAYNAME OR NO.?-- INONEDIRECTION roai¢0 v,FE - IWA9 VEN. WCREASwO DECPEg51N0 LEGALLY .. I? Y E W ? + - PARKED OCCUPIED . ('? ((?? 7 ? I_ R 12 C _ - 'I x J? I J? ( 1 . . 1 50 u 70. YES NO YES NO r __ f? • c _ , PED __ :. o I sTn - n s ' r.. PED/BICYCV A9 VSIN I?SIOCw r I ;3ROw0EA __ CR059M _ 3 F Cc l __ E$q ?_TM WrE caw e COR M IE w.i -'-rD - _ RF RO FACE I.,CNE.K K AY O -WEATHER 1 FCK -.. .CONTRIBU .. TING CIRCUMSTANCC F ? - .. pRIVDIx L -Apr 1 ?tL!NlLIaO K 010 ? C ON 1 OmVE ' ' IOC CORN OV! ri?'?J S,RAaNr _._ ._ WFT Ltd !ovE _ x I I RLVILOFRCFOF _ J a_«A f- n a "' I ir ? .TOO.?wsE 4- _ L s'o ESa - - J - rp0) ow+r.KVa .uwPACaw, tv_ .. ? MMM _ _ D+ce t mciw o 1 .. f ; l AFR IF LJ L J E - --- ucrnr ^ Ja . SNTr aL7 6NOwIq FFO 5 I J LJ OC ..p IC! I? 100 f_. CF aM W iJ (•,...Nan0m . TAN OMEnlarlWY " _ fL. OWM LIGHT CONDI l ' 1 w R r-^ xl d5A[ 9 0A (. CKIN/5?i0rR1iALT OMfA YECYFY) __-__ rq Vr;uDON T ET - GT FM I TIONS ICNICKONFI TRAFRC CORIRDL . ;YEI,a.e -;. vEP.cL! TYPE OFflO AD I q I Ka. MORN .VEHICLE CONDITION YwucLE IcNFCK t SOBRIETY.-- H A-AL oO 1' r ? L aqN a C '? L? °? E W IECK ONE) M .J s sqN ? I ?, o„ - ..- al I D, ( I 1 i „ Y I Nn ue IAFEC lJ F9 ?^? U F o J 1•a- -' r It wIH ;' l - i aPSK .- ' . i_ I r I •aILM J ::; fKaruO! OOPMNR O 4J .u - .. wEn x i : __ -_ aUSC am iMioroRrFMYr r ? qH - l . y Rtfi . . -? y I FwwM . .- - . /il YMWMS ' y t>A `. ,a 1 U *. .__ I ?I j uEROw0llHrxpM FR/sFIGI IJ L v er 1 , L aA T - r . H l J Ia a BGRA, Lro Fr rwww.e ?L cR niax N o DR CHEM. TEST ,, I Iq x '_... . . r MEN ) oMlnls.EClm J I x aVEVO I MOFIf OM IrT !A Lara,MnyRKr+ c: t{.C ? M ra cor a aN.veANwl ._Gab rt .Or0 AoelM raK:Er,w b 'TF rO ? OM RIYICUrI _. ' ,r r; o lti of 7d 0031 r ? Wr, ru 7x TEST RESULTS Kl ArwIrEO .? p;n;o`cE 0044 '„„ 0 2 „ . noW O 15 M " ?„ -?.' /.l(? 7,+/? 6 JC5 0 ,IE 1 .???R P1r Y IA E Tr 1 ? I Y 1 ? 1 ?L R? I 1' • I 1, A'1 { I P 'ti ? d ? ? f l_ r ) 4 1 ' I y ? e ? l ? ?*F .'i T'a:'41'VN`"''??'°i fl ""yyP,A" "BtD'+•'. .',? 'I' T } e ,? ) x Y? 4y L .e V r . N 1 _ I 1 - - Ar ? • ' l T,? IA, Af r . , ),? L ? IV, r ? Ifl It l 1. ?.' I f Il '? J t Y { e . APPROVeasroI_ o . M1F.O.R.CE.AIE.N..f ._/i.OE..N- CY'9CO?Y-TRIP-UD- CAoI?-E ?r.L6 LO? wPrY. ". 00"ieGa 10?AS °f6Lr'ro"O7R? a?NwrM RrIr IHl:M .r'v.RLOteG., AL.r U w . w E f A g" ? '? „ au y • -J A'k r 1JYYIG Vf- Vrl YlJdLlltl?:il VlV PaGE pP 11 Iru m , ' r ,j. UNIFORM POLICE TRAFFIC COLLISION REPORT IOLIGECOMVLAINiNUMBER - r fY C? r5 * '• ,r 4" D DATE OF CDLUSICN DA Yq DAY OFDOILIS ON S I.rLx UN rLEE wED INIIF 4q i'ME cOUNIY rlO. rNO. FHW , k $ o 6 T E ? . 05 % M51 E I T a S SA! % E A IUSE:iCO HOUflI 00 20 ?UPD tvk '. L COUNTY JEJi=Crs on N S E W ?STATEROUTE COUNTY ROAD ?CITYS'FEET ?OTHERISPECIFYI ? IN CITYOR TOWN Q W ADNICLS. PREFIX PNEFI% EU. RJ..- OR STREET CODE ??-/rY•/+, IA LE /,'T ? LJ ORAL 5 RAL "? ' ',_ ' fs 1 MILES El ® El Q ®OF Beavar Valle ?J P ' C T , NAME B NO. OFSTREE/ RHIGHWAY ®N INTERSECTING WITH STREETCRROAO O RAMP OIAGRAAI DATA r I C.R. 12 t 1 a NONI........ ION ACCIDENT E M1 INIEP NON 1 E X RD CLS. INTcgr_CTING STREET OH N AD OR PEF ERENC-OROSS STREET CH ROAD . ' Y n '' ' N F DETYJEEN STREETAND STREET DISTANCE AND DIRECTION FROM1IREFERENCE OgeROS5 STREET 5TREET 1V ?MILES N S E CODE GOOE u WEI YECIALCOp?. USE O C C ' T . r I.. I? .., ?Fc ET ? OF r P ~ y COL VEHICLE VEHICLE VEHICLE BICYCLE O'PEfl RTE LISION INVOLVED' ? ? (.Y I EHICLEOp1ECT _. .. ? HIT I RUN SEVERITY NO. KILLED , F - ,?A _1 , [jf/ [)VEHICLE-RRTRAN TOTAL NO. Y OF VEHICLES O n VEHICLE-PEDESTRIAN I-IuDrv.rn Il:nu 1-r.,.. ....... ... ....?. .. STOLEN VEHICLE ? I_?O.IWURED F '•'.= f O R P' i% tLIIr,James 1.iichacl O I STREET ADDRESS R v 6266 Brandon Street v RE CITY STATE zIPCOOE PHONE NO. E Seattle Yin. 98100 R02-6588 R N DRIVERS LICENSE NU. STATE SEk GATE CF BIgiH N 0. FI:P,LT?E5LE2Kh Y•!n. M MO GAY Yfl, 0 5 A 6 0, 'I DRIVERS OCCUPATION FIRM NAME PHONE NO. 'j Y E Fe a L D n r M= VEH COLOR UC %ATE NO. H I Green DXX 322 1 STA E Tin. TgAllEfl PLATE NO SiO TE E N C VEHICLE IOENIIFICATION NUMBER pDOMEi[R C E 83777.0 L E flEGISTERED OWNER-LAST FIRST MIDDLE •' O, Samo as dx'ivar N O ADpRE55 OF OWNER • 2 NAMEANDADDRESSOFINSURANCECO ORAGENT t ?. Farmers Insurance Tukl'J911.. 1.7TT DAY I YR ENFORCEMENT CITATI n - ?I lone ACTION I I NAME, ADDRESS & INJURIES OF PERSONS INVOLVED eopea _ s X s --s Ola Gaa le, :'33 cart sc n'e ei. H NAME: Fl; X11, :, I LiattllCiJ B. 1 ADDRESS 3 to Orcas Soattlo Wn. r I.Q.T "Laceration of the, lc:eor chin aren r•'02 FROM 3 NAVE0 ADORE'JS I .9r. DER EM •E? S^f4E c,r M NAME- A-ESS e .'[ POSIT NI N P C y T P 4 L 0 R 10 R \ \ r , fi 0 S .' 4'Ulil !AD v t 1I 11 1 I x ? CR T ? I I / ) 11 N[ 5 tl a rrO LIED I A. / 4^ ? UIU cycl. PO IALE IIIRMY j! .• I.w l S VUir U ? t- .: T 'X(l? S 'Ik r? y? t? ?H JAI' I aA ?= r Ty 1 ? F1? ? r? I 'FAY !tJ Ti; 1 a ]s T} k a 4T1 lr 6 +(} I L ` T ' ' L) r '1 ?+n ?; JS 1 f f SI I>? t+l J...' `?, - t "'1 '•' - WAKAR r..'y e•"-1+rrr..nnu'?51;r,.?ty a j A- _-r r t Sr r I. NOT NSrnLLEO I 2 NOTEJFC•TED CH '111SE TOTALLYEJECTED USED PAR rIALLV EJECTED j U4XM10:/'! 4 Ur:-OINIF ' SEATRLLTFAI'=E [JECTED - F r INSTRUCT DAMA4 O I r O 5 IITV AAI OL N6 I U ?un<noryau rDIFDBrC La ?. TO 7 C g i DIACflAM OF I. I T aura ztr?, - o ? A 3" s? H .E4.,;h .. •a RC, RFACE WEATHER ICNECK ONfI -. ..., .:. ..CONTRIBU _. ._ TING CIRCUMSTANCES ._.. .. n :..,. cn RrvegrvEHN:LE AC (CHECK ONE) OR VER IC NECKONE MOREI r• \ % nOxS ;; r 1 O 2rlxr[ILEovH NO) vE)N NO. DR VER INO.] 0 ER O ) ? T ( f I U T A GIG X C E CLO I OR 1-?AOVERCP37 aJll I_ALCOHOL_OP FOLLOWING ?_J>U T0441.QSFS,Y_ , ( EGAR D I ?] SG .N _ S R ONT AHEAD ?)? ^IVIERTAKING DF SS I ] E ] J I A G,._ IrrI'' rr ll .L1]J.L.ORUGS, - L E LE OF O E CENtE JI.E I J i r I T I S EEPNT A ING U]C l 4 OW I 5 Ow G _ SPEEDL T iaiE= LI] I?? S r , FAILING TO ` f IN6 r I16 ? I RIGHT TURN I?If? O .i CC E.I? .. I. r??r?L ALEYEfG FAS J I u?IO• _3?URN PER LOCAON. ( ? ?I I ?BI.-_I P. 9FFECTIVE EOU N L 14 MAKING i 6 S I l _ OTNEH IYFCIFYI -- O ?SI? 0 OTGE _ T- , '_,iO E?G.. 41 , T_ _ I C I ?B LOWINO'. ER IS EC YI L T I O ER r ?BI S G ? f 5 O - I SIGx15 GNAT V f OTHER I EC FYI I/? B -VIOLATION I ? L? STOY l PEO FOR I GR CONDITIONS RAFFI O ) E ILtE CONTRO ICN{CK ONEI E, 1. NFCKTYPE ON OFOR ROAD O ] E O 1 VEHICLE CONDITION VEHICLE IS xQI Q E SOBRIETV "?' L ICNECK O E - TRAFFIC B ITT`— DATSIGMAI I C " -lljGNALS GNEWA= _ ? i. I 1 I NO) {{?? 'ff?llti??E?1}?}}F N I j HO ] _I OR STOP SIGN ('? ( fE E E AV If t O TOP L - - 1WD WA ?.I RARES. ASIL.TV gOAOW AY r_ I I f i 2 1 DAWN 1 7]I I Yf 0 - L. 34N r ]rl fVENSB E (? RO 0 r )I iFCTIVF 1 HBO AS CITY TgA FI C NE ?II? 6TARTIN6UFgON .. ]I WSK 1 1 _ L NI O 1 E'D' 0. I Q _LOO _L.J_LDG RA P_.- HE_LGHiS DEIIFECTIVE ?. FAR LIGHTS _ ._NOT IMPAIREO_.?_ 11 1 11 gIETV ?x L UNI( PAgKIDFOSITION ?JI1I 61FNTERIIK ? FLASHING O AFK L ?.. IIGNt90ryfEt `?. 1. A IS LT All[--. i I U..OH. SMOOi I. -- . .? f=, A I BEENOR?NKING ? iRA i C 116i r BACKING lran E[ r 8. qq B Wkl 30 F ._ t. I ,S GN L - Tyro WAr-ufr S LIFFILANES -- N[rNNL oNioEj CHEM. TEST _ ,. S OABK-.O I C[ / x 4AF I EAN LIGHTS Tlp L ]{ 1... j Tl S T GIVFN OTHfR ISPECIPVI 1 B ] ? . OVIO[0 I ] i I NO UEFELTS 11 ( TCST nEf i I S ? ? • . ..._. -._ .. irr[R IYFCIF VI - ,,,.. I.. . ,. . 11. U [O , U ? I UNOIVIOFU OIHLII ISPFCiFVI TEST RESULTS T I rEH,AV'ifH,,,G11ATIHf?G,?Offl/CII /x'A??Mlww6NANK 1' I I LJ?GS?SI. CA N)u n ? BAUGFN?4 LICE UIIYAI[NkU?Y YOLICf AN'I. ID AMU NCf THAFFICFLOW I3 it I z "j O )fM ARHIVEO 24M IMPEDED rrl I OT _ WII ING qrf li N'S?( X ? r N l 9 Nn3. MIN AGINLV• uN OII UISr.A Uf r. VATS Of NIPOIIT APYIIOVIUUY UATF pnGf•IL?NU _Ic( vCIUPLICATE COPY. LOCAL LA\V ENFONCCMENi AOf.NCV'S COPY T{11PLICATE COPV?•INVESTIGATOfI'4 COPY ? ?It a? a; 7 F^h• '?jfY t I Tk>j:7 , I Crv .? ?elnllt?K! , 11j1 .. a?? ? t "" d MEN= J - L yy i k I 8. I STATE OF WAStixifVG7ON rncr ' of 9I P v ?'. UNIFORM POLICE TRAFFIC COLLISION REPORT vpur,ECOMruwrlluMBER €• %w r ? F D A OAtE OF COLLISION PAY OF COLLISION TIIAE COUNTY NO_ CITYFO „FHWA y I U V VII. (' i `:U i MUY 2 IUfS U WED 4 IIIUU S FFI IU3E 140(1 J L RBAN t `j _ K RURAL COUNTY STATE ROUTE ®COUNTY ROAD ?CIIYSTREET Q A .S. PNEFI% -ROUTED 9fREk fyDE J 1 C 6i iION 1 'I'F ,uN ?Oi11ER (SPECIFY) W N J j 9 .V ) C L N S E W ?IN CITY OR TOWN W PNEFI% EO. MILE POST Q MILES ? 0 ? ? (] CNIIn ACU!11 (? rZ J O C Ax, _ LL . . . A NAME ANO. OF SIIEETObHI7AY INTERSECTING WITH: STREETOBHOAU L i. .-I DIAGRAMOATA ON Ceun{s11 o Q NONINTFRSECTION \??,•,.. ACCIDENT I NLER NOF M ECR F.13 SiflEE OR ROAD OP REF R CLS • ^ ? I•{ n pETWEEN l'N jE{? •V ' LI UAi C A :J ?t ' M1 MILEAGE CODE . FFE RENCE LRTR/EFf +R/O-G?p ? r j? ` V .. AioGti: rwO l• h 1 .SX I GSTANCE M1D OIflECIFONFROMREFERENCEOT l E S , S ! HS unU?Et /? V SPED LCG wO USE ' ?V C 1 LJFEET ® ? ? ? OF aLf]VCR •.'. ijx- ? VEHICLENEIIICLE ? VEHICLE 8ICYCLE ?OTHERIWRITEI ?IIIT AflUN OLLI610N INVOLVED. SEVERI(Y NO. KItI[0 T TOTAL NO ?VEHICLEODJECT ?VFHICLERR TRAIN ?STOLEN VEHICLE NO INJURED OFVEHICLES ?VEHICLE.PEDESrnM ?NON COLLISION '[3-ARDOUSMATEMAL ?PROPEITTY DAMAGEONLY OLMECT STRUC K INAME OF OBJECT STRUCK AND OWNERSNAMEI ' LOCATION OF OIMECi StflNCK 'T .O-AGE / - 4vLVCR 1 J?tu I ? ? S F WTI 1 ROAOIVAY 3 FEET ? ? ? /J RO EDGE : DRIVERS NWE-LAST FIRST MIDDLE DRIVER'S NAME-Sr FIIIST MIDDLE IIF H-CLIS1 OR PEHESINIAN CHECKIU R •? _GtR~rc'nl P?('S?EL'C LEE R STREET AOpRESS "':. I STREET ADDRESS '. ...... . ,.. _. Un • RE GTY .! .. •.J, STATE. .. .. .. •.:Zlr GOOE PHONENO. .R CRY. .. ... •STATE, _, •.,. ZIP CODE ,,,-_ NO. -ONE 3 (n "In 5 N Q, DRYERS LICENSE NO. 6tATE . SE% DATE OF BIRTH M D V YP N Q, .• DRIVERS UCEN l NO. : - 611E "I PATE OF TM.' . . MO. OAYBIR YP h' 1 1Y ? ? Ofl IVERSOCCUPATION FIRM NAME , ., ., .: PHONE NO 2 DRIVERS OCCUPATION FIRM NAME -.. ... ,:.:... P N NO. ' N 3, s i CO k EC uLM-F( CODES S IJrUSS __,._141 SEAT BELT.. .If''IE'Ci"N" CODES 7rJr CLa5 5-14' SEAT BELT.?___ I:rl EIECTrON __, U,VEOi - I ES NATURE F INJURIES .. FR V. NE BY: TO : FROM SCENE By TO VEH,YEM MAKE (O ODGECHEV.1 : . MO ELIDARTNOVA) STY E(2 DR: CONY.) VEH. YEAR MAKEIOODGECHEV.1 MODEL(DART-NOVAI STYLE(-.RCONV) V . 60 ` j CFi E Y Mqfzn :Z oo V. E v6X, a UC, PLATE NO.:.. STATE TRAILER. PLATE NO. STATE E VEH. COLOR UC. PLATE NO. STATE TRAILER PLATE NO.- STATE . H H Q VEHICLE IDENTIFICATWN NUMBER . ,.. .. •-.. .:. OOOOMEtEH ., .,. Q. VEHICLE IDENTIFICATION NUMBER E JI7J ?z Q (5' 'E? . flEGLSTERED O FR T .. .... _FIRST . .?.. -. .. MIDDLE REGISTERED OWNER-US MIDDLE.;, 0, G. R EN Fr t ; N . OR OWNER .. :.:.. ;..... ,._ .. MOREBB OF OWNER ..: .. ... .::, -.._. _... ,.-. r( So, 2 NAMEANOADDR'E9SOE1.FINSCU,RANCCECC,, 17GGENT?( ".: ? - L.1 N.L V 1?>7!N/ ?C_Y= ,Lm I --a , NAME ANDACDHESS OF INSURANCE W. OR AGENT „_,'„_ ....: ..... ...: ..: CHANGE .... ... ... ..., .,. G IATION HO. ENGORGEMENT. CHANGE ... GTATI NN .. ..-' ...... MINE ACTION NAME ADDRESS & INJURIES OF PERSONS INVOLVED CODES _ E S , SE% AGE sT?M. N EJECT. `. NAME: C ADORE. D P NAIUFIEOF NCMOVEO Ff10M PUUWE9 SLF.NF. R'/. TO A NAME. N T A pORE59. S 3W 101A 0 NA 11 tE / Y 1 1 i iJJ A Sf,E TO '3¦ ; ?( ?{YV„,.r, -r.rRidDl": ..? ??I?. ?. .,.1:?ft?71!'°`„'S"'.'04M1 ??1 "^"".,,'IIrtANRt ?+P11P"F^!rHX.??' ,1, .., 4-+V"J.l'?WI ?AT'44"M? rr]3fr Aire. . - I ?w.dPi 1 f ??R ?RI 111 ?y ?, 1 1 Li 55 2 x?. I 1 2PF l . mh 0.1 W? T ? A P 3 •? I t VEHICLE DAMAGE INSTRUCTIONS: 1. IN EACH BOX, CIRCLE THENUMOEROFEACH DAMAGED AREA. EXAMPLE 0 2 SHADE AREA OF SEVEREST IMPACT. •• _ 3.-IAW AnROWI51TO SHOWPHINCIPAL DIRECTION OF FDRCE- Q/ I DAMAGED VEHICLE NO.1 _ US SPACE FOn SKETCH Nc DAMAGE TG TRAILEIIS,.OTDRCrCL G.I DAMAGED VEHICLE NO.2 E!P!! I A' S. T nIL1 • 1 1 R 72 ITS t]. -+I .•IUm ^ r 1 1 ^ SEVEnITY aF DAMAGE; VEHICLE N01 ._. 1 E OSABL OOAM 2 OTHE ,MADE ? fUNCT 2 b L' AGD ? N SE VERTY OF DAMAGE. IOTHEnvExbLEI 1 OO$ABLING DAMAGE O'I]OTHEn MV. DAMAGE 2 FUNCT ONAL DAMAGE • ? N O wM p TY OF DAMAG E. VEH CLE NO:2 •. : 1 0. IE?HOU ABL xG -AGE 2 ? T.E. ,DAMAGE D ? N t ? GE A E 1 \ TO f' I T E p AGE 4 s E l0 FO OY _ .. FE ...... T f - EST TOWED t /'?: f,F,I ... DIAGRAM OF COLD °" s'-• PK. '• ?: I I I --. _ ??-?! 7 1 I I RNORTH I SHOWING E?o, NORTH IN N CIRCLE Et C_N 'T.I ?- -I _ - _ _ rI i_ -.DESCRIPTION OF COLLISION UNO¢ATE wNwTPnoewetr HAPPENED °EFOREDn NG AND AFTER THE CpASH.N 11PIN O NOT ON TGOAM,ER ?VER? osgealTY.REDUC vSBIIT r,PEDESTRAN CLOTHING CgLOR, OO?ISTNUCTIOx ontnEAF, go'. ETC, t- I I1 I EL ' I i 9 t 4 iC L1 c,. t r K 1 ,T?11? Cy)LVG 1 oLiJ ' \? ? _ t?? .J 'Y o E .nts I ,?'S -IN } C=iLO? i 1 LJJ ?. ?RPtl xc oROSSIlG_ ] LDER qL IIAKED LISS l : l ES G .TE .II-1 - CYCLIST S E n SHOU L? t o ROAD SURFEACE c.,. WATOr ].-..: CONTRIBUTFNK CIflCUM?TANC O ES ` ••• ' .` j?2? q (?gryE1r ER. ) s n? ICNECK 1 El M ONEOR 0E11 L?f Kai TtCLE AFTIO •-fC omii ?[; 2R D - DRIVER F} wloER oE F-1, CT G A E ?, r 1 I\.. VEBCASL ?I U1CNDER FLUENCE I ? ooc6 Ol},'SG P ED a F(;) r?2? RT KING .' on, I- AN. P}? ] nuxlnc } uN ufxcE OF n ;RF0 E E TER f?g1"1 N]LY Lff L a-: WE r_• UGS l? ISLE EPp ?hv.-lam a TE{q ! ' IN IN "R.{LJ_ SNOW ]n SnOW NG Ll0 l" CE EPEE 0 TSi T O IF 1.FI.N 'AN . a -?I5? LOC IRJ_ GAf T G .} ?. .?A ICE A A Ev ONG ONE'S ???r I -- ?+r ' k FOp E?S OfOYJ:E _4___ D E ve EOJ'a. r ` I 6 ? U nN N . +- M• FFCr 7?! OTHER IYfCIEYIwEli lsiEClf YI ?S(?1 v G- AY G41G I?e0 SLOW NG a._ D y'y'}Et. CC NG IY ° fEGiGxgL ??--''I, rr II ONE ISPECIFYI STAFPEDFOR 'ASS J aN J l? L_.1 Ov10 LATION LID C IHECl DITIONS TRAFFIC CONTRO E. ,NFpE OF ROAD _ VEHICLE I CONDITIONP _;,SOBRIETY,.C ._,.y is O? OPPLOAT c L It f[K Oxtl tN02VEHI LE 1 02 IC CKONEOA 'ORE) I E - O-CLE 1LC1 ry[ 'j,Q Q5 IC NEI OR STOP SIG r-1J SIGNALS [7j r ONE WAY O] If?Cti•fF1?1E01 O.] ?o STOPPED 0 0 N I e I D I] S } }?. .E TWG-A- I I— Al-HT O E snn[ - N D TV .. 1 (• ^Sp -IIV? .J L T 41 l j--17- ecs_ LANE START ]Ll ??II SGt (?, qO a E_ - ? ] ,.J t 0 GEi..- ? NOT IMPA BE? = DID .. E.-I ON L I }n EI RLAIIIINI C -r TWE I]' 1 NRD EORR FTV rl?]? , F ING IE TERINO _.. 1.1L00 IIA P__ :j] FEC .;,1 E _ EET nEAR.LIOGNTS .. ! ..JJ N tJ L_1 TRAFFIV - 1 , ;r 1 - - ISr NO p i i .NOINKING _ .y ! IS c Na '' ? ?t GBTS ON pi N Dnl 0 ? -s °4 .LO nc -_ ° I.scxnt' sT[wPo A?:nost " f-j °?-_ ?t CHEM.TEST 21. z-er clvEn rr_ -- ?5 :; .. r n"ie]NOCnis __'. i • I - ru ._.._-. _ i tR lertem tt ' i L f... L- jl my o J. r? NO OE FECTS L} if STF. I.E[0 MT1 ' 1i i T 1 orNtR isP'ECIr YF `f I 7 uxp vlprD >_""'O [ is>EClfri '. l It. { TEST RESULTS i VEfTIGA Gorr ICIN iHAMI •N.SNKI eA(Kt xO lbf OlSPgiCxtp OL Ct IONV[D bU cE r CfLOW !t? 1_ 1 ? (. i- ATE /; ('L:?i •. >rDR ]FO° ANnI t ] oo I:iifoEO s I I? EfIIGA OrrlClnYN l1NwNA X -1 No 1Gf NC UNli nnO Sl.6 pFT. oATE41RFIFP9"T PnUVED III riATE M ; A ( IN .. 7C ll I"t..) ll L:. IL ?[.'t J-; ? °va ?, 7 ?I DISTRIBUTION . ORIGINAL COPEA SEND TO WASHINGTON STATE PATROL- OLYMPIA, WASHINGTON OBEDII t ATE COPY LOCAL LAW ENFORCEMENT AGENCY'S -COPY-TRIPL CATE ICATE COPY:-INV'ESTIGATOWS TOR'SCOPY ---`-___-- T N d' _... -......?-._.-._. ._.-•_. DUPLIC 7C r Ef6?x9P R ?, JI.11J?Y ?5 1, ?_ 6 4 r ? A", L _ . a J1-?vI.L Cir LV A 1- dla"I-Ulm-AD FY -[_.. _o :_. [N6. _ ., I UNIFORM POLICETRAf -'COLLISION REPORT ('""'GEpOMPUINrNU BER ?4 _DATE OF COWSION A `µl t . DAY OF COWSION TIME COUNTY NO .,9 µ I.1 ?,i' ] SUN i Mq1 ] 111!5 INIIP FRI SA1 IUS 2+ DN q GTY NO ? FNWA Y C/WNtt L ] + 5 B ? i j /. .I.i. J(. • Ounsm ?STATE ROUTE COUNTY flOAO ?CITY STREET Q ADM CLS P E %- ROUTE OP GTRECT CEDE 6E TO E ;'Q Ov, - ' ?OTNEfl ISPECIFYI N _ ? ? ? ,I _ 4 5 AL L 2- ?IN CITY OR TOWN PEF EO MILE PA ST Q N S E W RULES ? ? ?-U` OF?C/?/EI•l .. (Wj J _ }--? H ,,S)i • 1 A ._-=-•: AME ENO.OF STREET OR HIGHWAY -.-r: i. INTERSECTVIGWITH:. STREET OR ROAD- LL- _ • - fv?yy w'.: T Ow - LL RAM DAGflAM DATA y 1`I ? I• ? q -, ?,'.??'??.8 ..... __..__. ?.. ... O C J T NON BVTENS .... •.I. In .H,-;'[ 1n l ':: J.d Q y ACCIDENT V lER N 7x-nu- -- INTERSECTING STREE OR flOAp ORp _ ' A J• YN DETWEEN MILEAGE -. GS ERENCE_C 59 STREETORI RpAp„u ,. 51 dJ! DISTANC C E R S D E AND DIRE TIONFROMREFERENCOCR S !ITRE - STREET CODE : I Cl? 1 N yyF OMILES N 5 E W S SPEC COD rypU OO FEET ? p ?.. 1.?y P Y A J.I '1 E_Qv V nL I iI OF _I - - VENOIEVENICLE COLLISION INVOLVED: ?VEHICLE-BCYCLE ?OTHERIWRNEI ?HT6RUN SEVERITY L?•. ? . ',,, 1 VEHICLE-oBJECT ?VEHICLE-R"T"N NO K%LEO W ?V--? Cj VEHICLE PEDESTRIAN. NON-LISOH ONO.INJURED y }' d, y E OBECT STRUCK I AME OFOWECTSTRUCK ANDOWNELSNAAEJ Oc VEHICLES? . LOCAION OF aECT S7RUCK r,ES ,DAONLY TOTALNO , STOLEN VEHICLE ? ? AZAflDpUS MATERIAL C-/VVV1 PROPERTY DAMAGE ONLY t O C N IS & t Pc U3 L! T " T ? cF EDGE F RD t Y? --- GVYVERSN ELASr -FtliST - ?RO OW YIS FEET ? ?T?pJ V E- -_ _. ..... ."MIDDLE -- p"ryEflBNAME STFPST MIDDLEIIF_PICYCLIf10"PEDE9IRIA CFCKI[] P1 ?. D .,SMITH LAIS MAQiC o:y _R. 5 r s ••J'- A GTY.'i.,: STATE_ E. CRY.. F - .n . •--" -.... STATE.::.. ZIP CODE PHONE NO. r Al rl • A VICE tJC L1?1+ `l / i" S ?J Ib ••..': -4•.. T`9 N DUVERSL E SE - 3?? JIC R / b O• - STATE. SE GATE OFSRIM N DRIVERS LICENSE ...- P O. ,STATE.. ,SE%. OAiE-0F ?IIRiH I . Sri- I"T-NL• hb52$PI L 3 A . DAY YS MO DAY YR •?? sy.. ?'? OWNERS OCCUPATION FIRM NAME. P ONENO Z_ DRIVERS OCCUPATION.. ,. FIPMNAAAE ,. All r t P4or_4')'j to ro I-) cA SVVE UI?t 'GCw ET PN N y? ,l L ?,.. CODES > IDI CLASS HI SEAT BELT PI „ ' EJECTION CODES .> IGI CLA55 I+I SEAT BELT__ 151 EJEC110N D WIUWES. INJURES (T tY`.. T FP b-ENE BY: O u "aOM VED ...-r r + VEN.YEAq. MANEIDODGELNEVJ , MODELIO R NOVAI : STYLE 12 I H,cONVI F SCENE BY M MANEIO ODGE?CHEV ?.?T, ?f G DFi? L _. T ._ STYLE 120RCCWVJ LJ •' - „ ?q . y ? IQ72 DoD6L: - [` - L R_ VEM YE- -. --. 1 MODEL IDAgi NOVA) IICPLATE Y,O. SFATE-- TgNLER PLATE NO. STALE E • '+P.A°P _.E VEH. NO. ?? • V COLOfl.,, lX:. PLATE NO., -STATE 1gA1LER PIATENO STATE._ •+ ' :"' LIVE c IW`Z7 W-9 I . _ C VE LE IDLNTIFICATION.NUMEER .u OOOMEIFA D ?/ C : ENICLE IOENIIFICAEI N.NUMDER ?? L L111- / ODOMETER tv, L C,2R-.? S Y t e s ?/3 /v/E,r cel REG4IEREOOWNEA 1.-.'•'_..MDDLE REGISTERED OW ER T, 1FRKi .n•..y.'c..l.xeu..,., 1N.FAIOpLE S?ryf? `' O• CcALG/Jri CO. ?UV Etv/l L' COJe% N• ' Q'(dl, ,. -. -.. ADDRESS OF OWUER ar..!'. .q.:. •. --- O•. 1 1 GJ+ T... [. ?o .Box 34? p; ?F - ?.' LiL / •,•_ ADORE. - • .. ?.Jb:;c+at k.»L, Z c NAME AND ADORE OF WSII OR AGE T -. u.._... U• ?OF OWNEfl ? w. MNCE D I'-• -- •A .NAME ANO AODgLSSOFINSURANCE CO OR AGEM ilj... `.,,? ?v5' A K ?, CITATION NO ENGORCENENT CN PGE .. -,v.: J ..... 1 ATl NN 5 1'r,•'1•[ 1•: G,1tff : NAME ADDRESS & INJURIES OF PERS CODES ONS INVOLVED :. SEX AGEI STATUS W L. NAME: ` U JAUv L) c ARE S- 7 Z EJECT.I L ADDRE59 >'T!d F SS - -'-'rEMDrFRFR,,.. e Lv un"Gx? - A NAME v.rn?B? TO . ? r ADDRESS. - S N JU E 9 / I"MOVCDf ROM SCFNFNr TO •. I ADIXRF55-' _ - G P ROM f E S „NAME: SLf N P TO S _Em _ E, miJU 5 bTAW i nl ATU. I ........ NDBIrgN RcrN n. To C ] r SSFNGER ) IDCSIFN_ , IJ HNR C1A55 Non Jun r I n 5pl NU 6 I 1 L TDCLT CJ[C1gN " ' • D rIo COST D • T OMER POS1gN EM Dl ap ISGi L ] DLAO GI R 1 AL p NON D SA pLIIq ICNOC i1 1N 7 INSTAL USF LED J I N J O AILYC EJCO CTE D 6 Nt11jF55 • ) ?. IPUS AIOtOnC Clfl p} . I•ILION UN. aNN O[DW DSPIT L JURY 1 ) I05Sf1 LWJURY L ) 1 CD ^:' uNIU OVrI n1 PA ALLY C CCI A LM K lOI• f X -.._. ... __ ,.... .-_.: .....:.. '..._-... .- _.._?L__......:? _...?'.:1 ....I. SDAi RESi•FMLURE "., G.-::. 1. _.. IMI E tED .-_- ...a ._...--_.?.1 _ .._ J I - ?I it k .. +1:?•:";..-.wstrsesm._._ ?;. '"',;sS" '"z ? ; =:za: :d --' ^'^ .,.•,? ari MOTOR VEHICLE COLLISION REPORT -- - -- -- u-.- _ r -°- - -_ . _ . - % - DAIEOPCOLUSION '. .il:::. r.:. :_D fAR AY OFGOL wf0 USION.'. .' ...iWEOFCOLUS%IN ?. .-.' .... fnu F9 AM COUNTY N'T CITY NO: ? / _ CAa1TY-.. _. •...GTY,i x' = effe z SUE MKES ?. O© /,7• ;:. S ©® DFl GTYN :.,. AOM CLS PPEFl% •' wr lrRffi COR °9950 x GIVE.-E 9TREET.ROADORHIOHWAY n N WTERSECTWOYATN:STREETORROAD: FREFI% EO , I.9LEP09T ? }•y fERSECTIONA ATIONOFGOLU510N No BETWEEN 1 STREET- STREET s? O w e A fl ft MMP NON aAGR -A - - %AD d ? ? m ? 1 HHH (y ' r N?© E R O D C n.swacE ?SNSeerwoi 0nfo[xi-1.1 ia- » I? Z ?® ? WTEfl WTE C44 n aO ia RE TO f Nafa 3%SO' - ,EEi D oFL lOnwwLV[D QvEHKLEY-e v.:c amtt mNEAlwnrn [v?C [,AA ?j.a ?j4:? QrEn LE-1 - t mAr o I.aKNaLE f M E SPEGCODE LLSE K? mKn [5 ? 0-F. = K _?_r? E aLE w QMN<auma ,. ? ?, f :'. DRJE?LTHUCK ?, - IaANEd OeAKTTrKt z ??OF?9IECTSNAMEANOADORESS CC J L e C a i 0 n LCCA CH ..:. ?N ©. ar fOPlPM WIfa FEET faat M , " ? ri ? - GTY ORIVER [E; 71 15L ????gg?? IK:FA A C• I A H F 1 -.....MIDDLE ASi NAME FlRSTNAME TN'OCAR! DRIVER9fART NAME . FE[SI NAME MIOOLE r P ?/7` /`IOf?JGS G owea'on (DRESS. .:.. .r.,..., .- ROUTE NO.ANO90% ND..r' ?. '•? / r rh ?, W PE N AE Imm TVq R- wfAE AIRED Dsf A STREETADa1ESS,. . ,. LF CODE STATE lto IUD. 258 ?1 OfcVER9 CCCUPATION ?.uEk Di-I E.fe- o SEPRTE cttLUloa f tlRT raPM GTY :. .: : ..STATE. ...... : ?.:. Z?.000E: G9VER9000UPAT%1N ICENSE NUMBER - STATE SE% DATE OF &RTII AGE a WERSUCEN9ENUMSER. WATE SE% [IATEOFFWItM:._ AGE _ v F ?(? P1r g y M F a r r ; q. MAILEICHEV.-0ODGE1 MoDELINOVADARn .:,. ?p Y9TYLE120R.1 VEHICLE YR. MAKEIGIEV: OOOGEI MODELINOVA-0AATI - BOGY STYlE12 DRI y„ ?nrtio?•r C'o nueAmG/N/ , -TEND... STATE ,_ : .: IflAKERPLATE NO. STATE LICENSEPUITE NO. ...STATE:; :. :. ,TRAILEI[PUTE NO. ..:.STATE s 7. l?H { IENT)FK;ATKWHO -. 119BSMO' CE-EWERI ODDMEiER IMILEADEI VENKAEIDENTIFICAt4AA N0. .. ,.' 1;2,amODELSBNEWERI D OMETER,IMY.EAGE) r ) OWNER ILASi.F1RST MMIGENP,AFj DRWERSUCENSENO REGSTE REOOWNER.-.. 1[A9T FMT.M0[ILENNAEI DRRTRSUCENSENO,;; Y"4's A.V ,OTTYAND9TATE1 :.:.,.... . ;DATEOFaeRH OWNER9ADDRE9S .. ISTREET,CnY ANDSfATEI. ..'?.:: ..... OATEOF BIRTH ,• '[' • A,D wv vF AR ND pAV FWI r •, ? N%:LE OAMK E - : ' - ' ElnMMeDCASi •,.., PARTSOF VEHK'LE DAMAGED . - 1 ? FrMAKOCWI At lr' - a - ....... ,I A,q . _ •? :.'.' . TD rEPAwvENC1 Y ... . .:. . -. . ..,....:.. . rgpFVAM VNFCL9, " WASTNERE Y INSURANCEINFORMATbN•VEHICLE NOI GJVERAGEIN E LRANCE FFECT FOR FOR TH( THISACCIDEACCIDENT ON YOUR CAR ?YES ?NO A A-RES50FUA9UTYY!]URM{EPO HOLDER I -.cL•i;•L•: ./v-',LDDAEV. //?!' :!•YA .nA NNAEOFUA&UTY WSUMNCECOMFIxY i<-.,, . ,. ..L I!A /. r)??.iT ?'!. ,,//?'//,,./r ?,, ^R• -i'r<' :; AOORESSORUA9L[TYNSIMANCE AGENT. :'.. ,' .. IT- .. :.. Fn UASILATYroUCY {Y ADDRESS e. ,. .?...? .. .- ..I I AGE 2ND WJURY RASE N / amrAwaa, • m NAME - ADDRESS 'SE% • q Y _ ___ yC., k J ® 1 NA1.E + I 9TAIUSOF WJU NEO MARK FlR W ONETHATAPFUE S ? try ? ' pAKA W VENK%E DSADV,a r[O,RNOn?A111A,D PM. Mt j , KIL LED ISLYFPEI IAAVpe 1 ? e N l' 1- 13" !1 AN O 60 P0 7 ? OESCRISE BEIdWWMATIWIPENED:IRE /pVEHKAEO RRWI,RPo .._. •,, Q SEX QOrw'R. NVENK%E ?ANAr i Q R ILLED 9lK.REI1 NO Q?MJ,n7?...+N ? 5O SHOWNOnTHSYARRO-CIRCLE \ NDCAw?M[fHA?w[Ae © 1\ ?[O aL I?idar?A?O ?] ds ?\ ,,\ I. 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DAAK sH,lET ? ! ? fLAYI,ND AWHR I ? s ? ALLEr ? 6 ? ..m u NRN I \ ?? Ala•, s ? Bry MR GIr ? ( ! O 111 MILT lgNis ? ! ? M MGNK ? E ? IriT fUWAY fN D E ? mo-4 ' ,t 1 . A, 4{ 1i l'? I I ' Rf A50N aDR NOT ]lFNO pWffifl i?Y'l GFY O ! ?O„K:rRFLACMAN LANES ? i ?woM'FD eon TR-Fx: ?? A l : 11 ; . rrgDr+{. [nrAAtrpn frCl ? A ? of F A'fCI,Y ? 1 ? TLRMAffO ? R ? onsacwD AT AL ? ! , 1 • .__..._._. ? 2 ?OrNOEp ? 0 ? STORPF15NRfOAXWAV Ita - I o'' y p I ? e ? TPU,IC ? ] ?LMWIMO D ro ? Tnmm NIR BIf ? + p p P D ? u%' '; 'M ?TAA?nfNO illo4 yR nDroDraN ? i 4.l? - 1 " 7 .. 1 ? __ , l,', 'r41f? ;'. `:j ? 1 I? a ?I 7 ON 0" y % • m"b'1 ?''?. ATE f WASHINGTON OT AJY?T T Y b t ?i 7 `F T k!f ? L. yL.. x" yaaj`?i / • 1 . i w. I r ? ?r r c ?,rE t a ry''i'{A t IL. u ' , 1 1 i` l 1'%RFiN, ? Y:., '•„ "?? I?? 1 ?1C ":'„""' I f "S+I?c++?, . , .•7.1?ir'S'. ?, 1"'Il","?" ., r?.,i ? .I - ` ?S I. a rl , ? f. Now, I 1 ?J MOTOR VEHICLE COLLISION REPORT NO .PATE LSION UqY OF COLLISION T OF O ?. Lit Cc 1 T C TOWN. - _. !-?F=1 GI T -?? TT. -H T?' ? r?Yi .?w • C?Lci ? I rn tk? t.i ?"?? nT CUUY NU. G G rY NO PREF % „cv.. uv w[e, [ . SE . 11 a? _ 9?P/5 o PP T ..o GI Ov.3T EETT OwOO IIOHwAY, , - ERSE ITH?STREETOR gDAO ING T PREFIX EO MILEPOST No- !C ^ -?- •• ?` IUI COLLISION --1 s STREET- i \ l I U A- T MP :e TrvT? i'lilA aDj ? » -F- fu? Q a T PEC. USE rv+ C [ cle e M ^ / ?J `tie0 EC UC ,•a nuc OWNER OP O r5 NAME wN0 ADDRESS Y .... .. .. IOw ... ?? [..Iq a ;-r? ? ? C-l? `°?' fIh Lri: j?O -l/ !-f - ¢rh ? . _ a "I LAM 41M. MGM= °=' q?rrraTrrscsr?Tr - a DRIVERS LAS NAME N F - ?, UULE TREtT,ADDRES S jI : 90 E ANDO N :. 3 E ADO 5 - -ROUTE-,A OD O. C TY .... ST E, I. RHEA iION;:, C T ? ?„ '„-, ....,./y.. A. E,u,,,, _ rv,,:: COPE _ORIV CCUPATIO[v ?t?.,•-'1*^p,:.l•a',(:n(i l9,-<1 9$'Sb : Ff?ll Wc?-kt(' .. DRIVERS- LICENSE UH ER - T S% - q H E _ru L,ti l3rc ?r? i T U E % O T OF R EA'E y / x 3, [ v KE If M DE ?1 _ OD T E-..r .1 1 -, rH, MA%E-1 I POE- L C E LATE O ' . -'STATE TR ILEq. L TE' U ,?,? T I V - LICE EE PLAT ?F ? 5 TE :.-,,,, ?, T AILER?LATE N - ??STATE il.?? FT Wc, VEHI L ,IpENTI. .. TI „N .;, 9 ,eneu 8. 1000 ETER kucel? a ?Iz`IC_t,Cil?l? V C,EIOENT CATIO.N,.[Ipa„I„ O T R_RIL • e 1 11l RE EHED OW R Iucr-Pla x[MCl .w -O IVEq LICENSE'.N M a E ^+TEREO usi- 'MIPOLE„R• [I DRIVER GENSE NO.C•.y OW E ApDHE55? Is DATE F BIRTH }_ _ ?4 1 Go 1 ie It 5 ! ? VYn S D q 33: [ I 1 E FBA NB r l A. / r o ser o a PAR 5 O ?VENIC £ D AGEO•. yyv.rv PARTS a ICLE :._ _ TcTn? L? ! Sr?c S S LIABILITY INSURANCE IN ORMATION VEHICLE NO 1 W B'R" GH F CT FELT S CC EU O Y YES ? No NAME O 1 _E OF L ABILITY SU..{H? N LOL/E_-: ME O L b TY U Cfiµ'.COH ANA -»,?? I?- •icl I»I ^ ?Mfo_.f ICI- 1 El'i.?2k^fL r'ji.a._?s n. U.. CI ,. __ .-... Nw D H Fill LIAR.ILITY Y,NU 19 )NO U R Vv MI r E. - T, R'TT L ( AME MC\v-L, s CLf s:Y?S Al __ I ME?b Vh( 1(l (?? ^G SE% ADDRESS ?? + DORE 1 Ll C.lr- ZI ?? IU /ltl s'V? ?!1- M F A / ' Ce • f? FeT nNj IC - -- p ... !<,E HA-I•t .LIN J t,llY[T aul•-.. t._ f9'Q a Irv.uA Ys A.ao Pc ? N -..__ __ _ • U H S TUS N KFIRGTO TNAT L NVC CLL .rvn ro 1 (?? as J ED f ,•.u no I »r Irv AI ? ST T 1 R --.•• M RNPR FIRST ONE THAT AFPLIES,?,.n-? E E u - KILLED ? G ? S v ?? ? No. o.7. O ? 5?n IE 7Oo o SH W NOIITH nY A ROW IN CIRCLE I O 1OE CRIDE,.BELOW .tWNAT HAPPENED. IRBF[R TO [I ICLES BI U OFRI : 4'. j " I i ` ` ./V N. ?•J /-( I'?':._ r(rliilRry' Y ctt [7!I/ _____ ( s [»o[»o. t rl i 3f.ue.- A•r.C c...•/ JF Y CAF C:a r•?/ I ,P % % y o + 6: VLNICLC9 NO,.ITIONS DEFORE COLLISION ^ ?•!? - INVertn?e7A, En ur E Ct [ N 5 D W ON . R 1 OR 1 1 R.- OR NU ER[ Irv' ? r:rn s ? ro.IC[ t ?o?I0 c g El ? Yo r g -1 ?, .[ ?NnINY.,na,r 10 n 1.0111 1 1 Ej EH 11 F it - P...STR.•. ? L] ? PLpTn,I,I,N,YA3N3RlG n .?.. ? ?,,,.Y..I. ,L? ^f, A? .: _ I?OAD:V MIAC[ WH?niCn II [ ^: , ucnl co OmONS n pA LIGHT iMni I y? r cc0 nJ I?J'BIOnALS P U .n lo[ I ? I J OHC W Y ER ICLE A.,. I :o x I rvi o, MOnl ?? 1 GOING SrR,IGHT AHEAD n l C1 f IY 11 I f 1 1 AWN .. rJ) CI StOI. SIGN J ft I T U 1. I 1 i LJ -;J TA O AND PAS^ING r j R W hG f .I f i V T [ 1 -.1- r 1: f 1 YIELN .^. N I-? , I l 1 E 1, 1 [J KI , ,TIGHT TURN I ? L J OW I. 1 OG t l 3 f Ll vl A:H 1116 HI'n 1,J A L I C A Do' f? A I IAMINT -FT TURN _ 1 « f] [J l J S 11 f R LA. JCR I I S l _1 F E j S 17 I T I a rJ .-ING U-TURN ra i IJ T [ ' ..•., f { Cl 1' < h f , A f ] N f ] n C:; ILO-11, o NI/d<dNn o•Hae + [J an 1. rr I 1 I I u - T(.u ArLAG.•AN LA ,IS LJ T r_] RTOI•PPn Fnn n„FnC l-J p ° T •? GNAL iJA S I-1 J f 1 D n gp,DWAY O 9 Ll B,D 1 IN 1 l e ORA 5 A 0 5 lU SHOW RlIINC PAL D HECT ON OF FORCE DDAMAGED VEHICLE NO.1 IDSI .SSP+cI IOr snf,cHlNC DarA,cE TO TRaLERS. saOio"crttfs. nC:l - DAMACE'D VEHICLE NO IS T-1 4 a sfE-Tr OF OA.- VWICLF NO I NOArnA'E DAUncf } -AILI 1A I DAMAGE A N sfvEPTY OI DAMAGEI OIHENVENCLEI i ou NGTI.N Dnra- EVI O) Q,DlEABLINGDAIAGE D AVAIE C . O 4 _? FDbr a w _ ST..D.rv.OE ? AGE TDwfD PY G ) U- D rvGE - NOD+ra+ E nu,- ?S1 -, To ? ecnl' Rl o . To ., s To . . ?• DIAGRAM OF COL, ISION ...-, DRAW ARflOW SHOWING '? . 'Demo r ?, URT CI N IN E - I• c .LUIS '.._... ? O° S - 11 1- IT AK A l,Dr ? EnD«YLr,ELI FIDE:,Kr.ND.- '. r,lo<D,LrF,p, .wee .. - .._ -? },. , DESCRIPTION OF IINDICATE H+PLV PAPPEI EDPEFOAF. DUN NG AND aPTfN tH[OI45H NCUDE INFORMATION NDAGD ELEG -fi. L COLLISION . t 'IY.' Ds+P UrI ReOOCeoucED VlsPU[otsrR AN aDTH NC CO[oR. EOnsi"ucnaw UR -AIR woHKf - - , ..... .. s ? V . + 4 x I POSITION BEFORE COLLISION HICLf PKED l O O. ... • i E 'E ,A 9 ? 1 voH. HEADED K.I PD INCREASING D E ? NSINEET Ol IG.w,r rvaWEDR N n rr E S VfH uEV ECREASING AgN - iFIP OCCUPIED •.p.. ./ V O T L_ I_ ?.4RSOh APP fZd J. YES YES i, ,. , x _ P r. ,.n,• - , La rp PEM ` -- s c a ED DlsrcN+rED xrnnSrws usxc. f , 5w° E ROUTE I NEN PE LK 55 9 ' ' s RODSURFACE N CK ONEI P N G WEE TONR CONTRIBU IC TING OECIRCUMSTANCES: NE n - IrvIHIL ?'`ry0 it EAR E .dx, G O 0.} DNIIV ER 0.} . - O.VE2 DRIVER _ ? XI rGHT AHFAO Ate" Y iT9R Dr OYEPC ST._ uuDE nrlcl : 1LL40 OL_.- i o G .J_ SA Sl_ D .wfw"DE - -VERTAK PASS UG y -11 x xG F?• S ON ON G fNCF rP. [R S , a NEN}LV L I a J U-PING f_ V 1 A ...?_ _..... ?.-}. 5 OW J -WIND _ _. __ -_ - - .._... FE. EDrNO 0 I li Y .. _ GTO 1'' ._'.. j _ ,S _ 5 M PKING __?.. SOC , rV rv .. EE TURN - .. A 1 C FOG 0 G E 5 ? S o 1 r 4° ° G . ONc .v. 1 E. CL o I DSREGARO - __. ?. -_: N SLOWING 7TH[P ?Sr[CIi VI- -' IKr OF P' vASS nC A IS } S GN S G TO . .. .- Do ? vl "- 5 GIVE D FOR LI HTCONDITIONS CK ONE RAFFIC.C ONTRO TYPE OF ROAD NO I VEHICLE CON D I T ION SOBRIETY oP E srcNAL I 1N0 ivFH CIF rCHECK ON[DR UDREI ?a j' j ? y E[o 1 NO M r 'l I ?t Y? y? ICHfCK ONEI NOJE r N I OR i O G SIGNALS 1 v l . DI [ I I D DG ST"m ) TWO WAV ' Of rtC, yF I NnO,tlILIIVI"- T' STARTING ID } SIGN - '} L GN S . [ 5" R. N C C ..., bllAnES - ) D 1 I _• VPA HED'? '_ ' N Oi t O a IOAF[rCLANE 111' S PAKKEDPOSIIION D _ ._ D -f .. .4 [ P b ARRN '.. G C . L00 RAMC _.. AL J 1 . !Cl I _ NEAUI O aNOO,N. ., . J yP OP l - .11. D"rNKING ) 1 IF ERINO C, :I6 J ACKING I .. . DANK-5 P 4cHT50 P DARK-NO RItl L6 TS .? SG ) _ +GKtAN TUW Fs -N' A 'NT SE ? . .c„,EC 5 v -. - NO (DRIVEN CHEM. TEST - -. tEST GIVEN N.FP I5.I CIEY, . Vl 1141 A OlwlR P l n,.r [ DIVIDED - N NODEFECTS 4.[1..1 "'- 11 .. H-- ,f Il UElD 1 L DIV,OtD . % TE57 NESULTS Yn Z Nv[GrIGAr,E r ul, A+rvN ? IAIPO I. xO X11,.1 ND " -.1 tD ul rH VED Ar u IC .C NN EEa N N r'.t a.PO A", TV", ).al 111 ero ;FC ' D 5 PHNyED PYO " glOrv " ,a X -- - ?Cl!°u!-'' -- /O 1 ? u I ? ? o?•?FO3?n SAr ? ??_?/ .?,7 DUPLICATECOPY,LOCAL LAW ENFOIICI PJc NT AfiFNCY'S COPY TRIPLICATE COPYp•1N VESTIGAlUR,S ?COI`Y 6A T f ' ??-TTT ^E T vwA J. i pp??yu.w?vh -? I A'. e F T ?e r 71T "WI °y , I. J, t 5?, rI"u.: j,°m??'?y4pI" M(e C? rhC?m??tiy'i 4 011 11. YV' Al L'1 ??/I 1 ? IL - f: 5 1 I 1 1 t I I 1rI' 1 r I O GATE Oi'CO SON - -- OPYOfOLL SS•ON -E?- _-- COVNIY fI // CI1r N0. nW A L T SUN 1 Jn 2 IUI S ] wED A inuuB SAl uS? fr?Ul? UVI I'I M 'C Z _J / ^ ?URBPN URAL IFR E r( EFI% AOy CLS PR ROUTE OR BtREET 000E ELTIOv COUNTY ?SIATEROUTE XCOJNTY ROAD ?LIYSI.EET O LU 3 5 0 ?OIHERISPECIFYI 1/•f µI CITYORTOWN N ? K 4 W PREFIR EO MILEPOST I ?- D - ?Y= I ?®? ?Of--`l N I_ MILES LL 7 `-? C NAME NO OF STREET OR NIG I WAY INTERSECTIrvGWT STREET OR ROAD LL RAMP DAGRAM DATA :-- O RS ACCIDENT INTER N TRE ET ORROAOORACF NlERSECTIN O NONINTE M LEAGE CLS ERENCE LROS B N ?? - N II-EEN STREET AND. -X BEET CODE S7AEET DISTANCE AND DIRE N TIOFROM REFCRENCE OR CROSSS SPECIA.-DING USE AILES L O 'El SEVLRNY ?VENCLE VEHICLE ?VEHCLE-BICYCLE ?OTNERIVIRIT£) ?HIT]PUN NO. KILL CD COLLISION INVOLVED: IN VEHICLE OBJECT ?VEHICLE-nRiRAW _ ?STOLCN VEHICLE 2 NO .INJURED IOTALNO OF VEHICLES ? VEHICLE PEDESTRIAN ?NON COLLISION ?HAZA DO 5 1ERIAL 13 PROPERTY DAMAGE DNLY CKS E „W EST. DAMAGE OBJECT ST R U f OBJECT STRUCK (NAME OF OWECT STflUCKANDOViNERS NAMEi ... LOCATION O I I?? TT ++ II ?IFOAD'.AWa I FEET IpI ? ? ? RD EDGE $ DRIVERS NAME LAST . . FIRST MIDDLE DRIVER'S NAME LAST FIRST MIDDLE NF UK:rCOS1 0H PkDE"NIAN CHLCNI LI D V /Jhm C.7nR QOiI D R STREET ADDRESS .. . ..R STREET ADDRESS .A-? x I V V p o o r P E NV HON E Orly STALE "P CURE PNOVE rv0. R CITY _.... '.6TATE 21P CODE ZI R ?. r/ ?A 6 C `? - N DRIVERS LICENSE NO STATE SEA DATE OF BIRTH IH SEX ORi E or SE NO N PrvERS LICEN. M0. OAY YR 1 O r? A Yl 0. M 1 O ORvER5000UPANDN RRAINAME PHONEN - -- _ - N0. //o?T GGoi oS - 11, CLURY III SEAT BELT__. .? 151 EJECTION CODES > lal CLn55 ---- (ul SEATBELT____ 15) EJECTION.---- CODES F ' NATUREOF F IN'U- O NAT. rvJURIES NJMRES i F _ e S + TO 6C F FROM OM S CF CFNf er TO EVE R M VEM YEM' MY EIDODGECHEV) __ MOOELIDRT OVA) STYLE I20fl LONV.I VH YLAR MAKEIDODGE-LIJ MODELIOART?NOVA1 Ely E12 DR-CONV.) 77 Ch r2 ?AndcG o(? V E COLOR 11C. P E NO VEH STATE TRAILER PLATE NO. StAfE VEH -.R UG. PLATE NO. STATE TRAILER PLATE NO. STATE . YALGCZ w? H I C VrLE IOENi61CATION NUMBER. ODOMETER O VEHICLE IDENTIFICATION NUMBER ODOMETEfl. 55?zN?i???v?zy Rf(cct;? E E REGISTERED OWNER-LAST FIRST MIDDLE . REGISTERED OWNER-LAST. FIRST MIDDLE N © /es NAT[ p o. . c AGORE:S DF OWNEN ADDRESS OF OWNER _ . fJ_p_ oX 15 ?8 ??E4?m wA 2 NAME ANUADDRCSSOF'INSUNANCECO. OR AGENT , NAMC AND RD[HiC OFINSURavCECO ORAGENI ? ?iLys 8 z CHARGE - LII Ai10rl rvD. EN FORCEM _ _ ENT CHARGE . ClrgiIDNN .. ALt10N CO DES I - 2 5 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED sEA Ar.E sums 3 T. C - C ADDRESS. /5_Sk _-_--- _ " G.:3-9- OM - r U P R NscIMr NOF VCROr tD l i-LI u ?o I:LAIUIiE a !? A NAME' N ADDRE99'I' To S All, F W NAME: T N ODRESG ---__?..._?.--_ FI MJVEUfIiSM T 0 N Rt al„--?-? GCE NI ny s E uwE NAME S E S. ADCV1[SS -'--- R[u5Jfi04 5?6T-"-___-____..?._. ;! F to PTA'111 rs J IN Ia .. ro- xr IrIS1AlUS 11151 AI f`OYIKn Ir t1.AEu I INSTT CD l1I.0Ol 1 t UICTED AlIlMGINJURY NO OT ,USE LYEJl 2P rSf NGEn r I, 011Als 5f19 J6 12 O1wU5E 2 iNt ALlEJ1.CIED G NUN DIN 'DEAOCI'Nf au5[D oP?muuY Ultl[D L 1 O IIN I ourt.n POSma! iDE AO aI UIRrva nvul[Nn INJURY A I l j` 151 iBC VC ID MUtURCYCI EI A DIF.DIN IIC`+PIIAI i POS•.?IOI[ INJURY UNKNOW:1 K lOWNn D 5 rry[R Ot l 'r 55 6 ] A POSATICN UNr NOwN 5 SEAT Bf II FAILURE fJ[GIED 5 W E - t fR?ty, '" ,??.q °tc? "as,r•__,.,,?_,,.-:.-i .ss. .Y-? .? G _. +,_. O B !? I `,J MOTOR VEHICLE COLLISION REPORT NO - y GATE OF COLLISION D Y OF COLLISION II TIME OF COLLISION -? LOU TY/yo CITY NO ° i'L t. _ D.Y < L,?! ? ?(? E C} 1 M 1J n.L a; } N ?- ,,.?? COUNTY CITY, 1111 an MILES !! a t? ES CITY, TOWN Ai? LS VREFIA n -ET CODE SECTION - Gam. `o JLI OF C.CI J urE OH??O u G IV E NAM E OF STR E ET, ROAD OR HIGHWAY rr•Y IN rER SECTING WI TH: STIR E ET OR ROAD PREFIX ED r ILEPOST rP 3` ?-2 N rT? CZ i? 2Cl? Iff 11G 3. 3 !!ON INTEPSECTION?LOffCV?ATION OF COLLISION Ii Al.IY URAM DATA BETWEEN ?dr r C STREETANO STREET ?' - E- ni_ucr oas nu.n„irusru?o.nr rr r,cr•.u r+.rx rn orn• rrEr E 7 ^ lN u ¦ EOF c, , r o NDN 9s/°ss aEoD E orrnn rrx... SPEC.C OE USE. LIT. I Z 5 / °°° ?rrrrrr,Y v OBJECT STRUCK AND ADOAESS LOCATION f:1 O J wuEO oweeis %r CY OVINE.- OBJECTSNAME IN ROADWAY J ra ??yN FEET 5 VI ' SR -? DRIVERS LAST NAME FIRST NAME MIDDLE Ya ro^ DRIVERS LAST NAME FIRST NAME MIDDLE a T til nt l? /S A? - STREET ADDRESS. ROUTE NO. ANO BO%NO. nAr"^T"Oa STREETADDRESS ROUTE NO. AND Box NO. w 7 ?C /I'/Sn (JrZY JC R VE CITY S'.'ATE IF COOS DRIVE RS DLCUPATION •? CITY STATE 21P CODE DR[VERB OCCUPATION u ?EiW lSc ll? ILA, Or 'a-3"6 8- l?'I?cKAN/G 1 DRIVERS LICENSE NUMBER STA1TE SEX GATE OF BIRTH AGE DRIVERS LICENSE NUMBER STATE SEX DATE OF BIRTH AGE 5 vle IU A. yl_ . Av Yt: / OAY YEAR VEHICLE; MAKE. .maR MODEL r ++i' BOOYSTYLE Non. HICLEYR.MAKE r REV. Door. MODEL SODYSTYLE r. r , _ •' C IE? -n?lzl ? Er rND..F+HTr x LICENSEPLATENO. STATE TRAILERPLATENO. STATE LICErvSE PLATE NO. STATE TRAILER PLATE NO. STATE l G h/3U IN ., ELSa newe ODOMETER MrM+c VEHICLE IDENTIFICATION NO. MoOE Ln[nr ODOMETER I.-GU {VE VEHICLE IDENTIFICATION NO. uoo + ?f ?-/sBe nr • n' / ?- "'/ •? rusisrnsiJ, msL wuEr DRIV ERS LICEN ENO. .. w ., ?, • REGISTERED OWNER ruse Nnsi-N OOUNAMU DRIVERS LICENSE NO. REGISTERED OWNER ?•J.. C -7_ IS x OWNERSAODRESS ISTREET,CITYANDSTATEI DA IEOF BIRTH OWNERB ADDRESS TPEEi,CRY AND STATE! DATE OF BIRTH. ?3 ,5 / G •(? 0 DAY YEAR DAY YEAR MO I PARTS OF VEHICLE DAMAGED EsriM,reocmr AR .VEHICLE DAMA D ToKErMn viRr?LE' dC-7 - WAS THERE AUTOMOB LE L B L TY INSURANCE LIABI LITYI SURA CE INFOR ATION•VEHICLE N0.1- COVER GEIN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ?NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER - NAME OF LIABILITY INSURANCECOMFANY;;',:?; NAME ADDRESS ITY.?. :...STATE : 2rP / S I t .+ 7EIG ` !7t -UD .. NAME ANDADORESSOF LIABILITY INSURANCE AGENT--;.. CITY ' _ _.: ST - - 21P....?LIABILITY.POLICY NUMBER ; .=, fa L 23g T ,lo ?s T Lavso?cD QA gJ3? J ST INJURY - AGE ]NC INJUFl Y:. 1 SEEPARATEREPORTfORAOO YO ALIWUR E41 -'' r'; AGE' .. .. .. .. TOTAL _!Al! L4 6 Ai s -Tc -,Y SEX' O F 7 XI?1 _.MGti?'?! (.A•L/C rI 7W?fl M F - ES t? r'Fl SEX - Nth ?S aUt_CJII?LdSvY- :' DfJ ? r/ -I a1u STATUS OFINJUPEO' me :? ARK FIRST THATAPPIIII I ' STATUS OF INJUPEO MARK FIRSI ONE THAT PPUEB.-:- M p l'. ? IN lHHCL! KILLED 'S x.u? ? IN VEHICLE uH n, - fi 1 N• ?j?nv h u' ^a rr r ? " KILLED stv ru,.,o. co ?? ? 5 ?. v. 6 ?rvir rro7 Qic ? , .n T•... ? '1 6 ?r noc7 ?enr fE l ?? SHOWNORTH BY ARROW IN CIRCLE Iyl'S' •\ DESCRIMBELOWWHAT HAFFENEO. IREFER TOYIHICLESSY, NUMBERI',? „' ? R .; 4?Ett.c..r_ _(=D?L,u-Alltl6-/`?- Cl-LC?tlr??c_ ? 1 O ? ? GJUeoeLJvTtKal?_ /ec._.L?iiv_rlf r I " i ,. ' N.I t • °' \ S[J? .. S/va rnl9-ss_--??? -- ,. x. nr,,.Mn LEn YfHKaE .,, E"Prr _TzE/9-D - Pn.EimnDrrn.YEL...nnDn _7Ho ?[roA• p . I r---4v6zV eEY `? u7;Jr?0,•' j I g - ;Ii{ + VEHICLES POSITIONS BEFORE COLLISION ' IE PrrtcrD r ^vfsr cAHDKi al If) o?i ".?--- .r c.e Liii ?i' ?oonrn ?1 VEHICLE rtr,OEO ON ?STfIEET OR HIGH-A' Y NAMED NO. ? ? a IYOURI ? ? VJ ? YS?Y_GL? -? / aI? ? ? ? ? i r x ?rM wvnnOUr ?:5 , Mrs ' ? n D, ;i IOTHLRI C7 ? r r_.i 1 OR TO !'JN •I r .: PEDESTRIAN ,..? ? 10:1 ? ALONG FROM ,? PE OFSTIII AN WAS USING 1 ?suu,aA ]" •r..n.. _] ns?'n,. .+ A J r. :s: G ? " I ROAD SUrFACt WEA T11E1 LIGHT CONDITIONS TRAFFIC CONTROL cnfr TVF OF IIOAD DRIV l?NEHICIE ACTIONS'. onE On wxR. • f nr r r.r'y;i:, i?a•v , ?pAYLICNi f'rTH^x ?-T CNALS ? M?UNE WAY;, r,r r, ?GOING STRAIGHT AHEAN "r7 ? 6"Y tLlN .NING ? DAWN 1~?51 _ _!-T ? ?7 Sr0P SIGN ,f?? 2 ? T\YO WAY El _ ?UV ENTr\KINO AND PASSING L ISNII.E ? ] MAKING RIGHT TURN Lf i1I1 •.? J C? P: 1 L._J \rOAr•l0 .1 CEO K ? D ?YIELDS61,I U T 0IIOAD -J A ? D t ft! INTF RCHANGF lJ t- ?'` ; J J? SV JW. ")G f . U A ?fI.ASrrIVG HIED ? A OILGDP/RAMPI C3 a ?MAKIN6 LEFT TURN 1 L 141- -} CJ J` CE ?r •?1 IS( ?t1 fLA'.HIN(. A-FR ? ??ALLCY E] 50 MAKING OTURI, k 1 ?) ? ^ ? I ±? I,Y` rl ??.? :.V .I ` 1W ' IN -R K 1 •HTS ?? A ?IRr SrGN AL ? A ?rt/TYIU?,IANEI ? A ?SLDWIHD I ti I T(; f?, 1 ff_? 4 j 1 f •)^I(E ON Of SEE GO G.. Fq T ?, -.rt r (?-7S x L?) { CI R. FL Af,V All C3 T ?7TOPPED FOR TRAFf IG 11 A, N STOPP fIARAfFO ? B ?OR TO'SGN SIGNAL ?1 1 47,-, ?OIVIOED ? D ?STO"FOINROAOWAYf if O STARTINGIN ?1I 1 t Fl!r?fpP OI E(y'7' 1 IV DiG b f ,f /t •? :?' ++. NV. ?• :in. u-9. tlrl^F' I;?: ! 51 rM' S G; rr+ a i,,., SI ' i.34 '1 r y I 6 r Y ''$? K= - -a) J#zm.. _.,..1]:.,,L?. VEHICLE AM ADEN f CH RO% CIC L THE NUMBER OF EACH DAIAAGCD AREA 9 °x , . INSTRUCTIONS: 2 SHADE AREA OF SE k VEST IMPACT. DRAW ARROWISI TO SHOW PRINCIPAL DIRE F T ON DAMAGED VEHICLE N O. i C I O FORD ID,E TH SS.ncE roR sKETGHINC pAMac[ l0 TNMLEN3, MptDRtvtt ES ETC .1 DAM IH! AGED VEHICLE N0 2 • ' "J? % d3 I LM! ' E ; ao 'J I q SfE N I) "? U. W G S , I 1 E) N.n ? e. a ? SEVE 1-11 DAMAGE V'"111 .1 1 I ? DISABLING DAMAGE ? OIHEg N.V. DA MAGE ? SEVFq iv OG DAMAGE ? OISAtl LING DAMAGE R .1 DAMAGE SEVERITY Or pAMAGE' VEHICLE NO ] MAGE M v Da G ? IO k P } FUNCTIO DAMAGE ? AGE TGWED r• Ei : 8 } ? F CT GNAL DAMAGE D AMAGE , } OTN[n ,G UN Ll ? F NO pAMA O D AN D BY i{{ MAGE OWED BY SO TAMAGE E ! T E ESI E I TOWED ( .• DIAGRAM OF COLLISION 1 L ' • _ LLEL __ ( I DRAW ARROW SHOWING NORTH IN CIRCLE r ............ xDwDNA1 -7- 'PNCH.N 77 ) rxAn rP oe,e[ero N)or . a - ? __ _ ._ IF• Imo.^ r.r,i -_ C _. / _ =1 I T?k .. . L.on.xoe,nr.Irr ne on I '` ? ' ,. noetrnuxn)w3«)anr ,NO UI[n c0urupw .. , ,•... I??. 4 ( ? ,.. 1 -. 76 I I I I I I ( I I I .?! DESCRIPTION OF COLLISION WHAT nA Dugmc AND Arr n ToNOACq M,EC. _ DISABLITI, REDUCED VISIBILITY PEDESTRIAN CLOTHING COLOR GO E Y ' IC . . ONO E ORK,E LI E 4-7 - . ' Y r I r f a'.. iyyt..' u 1 POSITION B FORE COLLISION A'FO MLF --- 170 OF n K D '^+ +5 •, PO NO. INCREASING ST OR, DECREASING ON STREET ORNGNWAV NAMEOR NO ONE DI FCT ON T ME LEGALLY EO N UCCU E W 77 LY `E :: YES D Es o J l r1 Pf0 LONC _ nI OS - ro W.l ? . __ _ CIMS, o "EET PEmtl¢YCL 3T WAKDSING, 1SCEwaLK ] WALKWAY ] I u Di ER cgos3wAL E MARK o ee°KrLE nouTE) FaDM I.E. o ROAD W ATNER Y C.Ic. RI D E w ECK ONE( CONTRIE1 1 IV D ING CIRCUMSTANCES . C E OR MORE. .. v DRIVER ACTIONS "P oQ?Fi D CI C O E E O R } I NO. DHG f] - ul ` n? a A '- I OR L UD '• FRC \ INFLUENCE OF Y . __ r0 S G 1 I I?r tfG F I }J ` ? wE 1 q I r L.1 D UNDER UGB INFLUENCE Of _ 1 OIEER q 1 IB( ^ L E NTLY J r],'-I T. L N? I P ] SNO 1 ?3O G I ] F CFEOING STATED i F[DLMIT f Gip SIGNAL 1( PARKING I ?I G $`,?... ?IS>A FOG 1 I KCEEDNGREAS FE SPEED _ O 1 IM T .. L o f DG--?' FIA- G CI E U . -- - A 3 H N ! . ', - OTHER ISPFCrFYI 'N glsrfuin- OT f 'vENOT GIANrRm a HICLt - D 0 Gx6 c'L HT • 1 ^- e I SLOW NG . ' IGHT CONDITI NS R 'G. HLq SR =AL' O GN P B THE { IS .)':?, 1RAFFEC FOR , IC O C ONE, AFFIC CONiRO NO.} C E TYPE OF ROAD O ] 'CH ECK ON-EDFIE VEHICLE CONDITION C' r SOBRIETY SIGNAL L I IB SIGNAL. r r ONE WAY O E L jfgJ FRIDI N M1 AuI E F ICHECKONEI INC., . DR STOP SIGN I J - - _ T t O DW l 1177 I D LIGHT 5EOP } i3v0 _ OF FCi v[ I NB6 Aell TY P J A ryY r lry T } OAWn ] O t ]; ELp 3 LN. FLISIPNG } l nrve a 1'0" E . T HL SO IIGn _ TS M AFLO__.__ neD ANL i IRED_ ._. F IL LANE nA E TwRr xc FnOM I n PANNED POSITION -- RC NTF C GC L ..POOP AMf OEr LCTIV[ ... RLM LILHIt ] I 0 OB f U K I I 1 Mn RfING (ENTERING lJ} A CI ` . t A DwRK fTq ET ,.? LIGNl3 ON 16 rLASHING BEH - III AILS L-..... Tin[3 EVDHN (? ON SMOOTH , NAD BEEN C.-HP. B I J16 BACKING P . Iwqi%oiffr s _ s _ __ L SIGN A - TWO WAY-LEFT Nn [3 71 N?NSnrvc.w.ln RN P. a.A DHip[a CHEM.TEST I f ! ,•N? e N? FICEnI Of NEq ISP - ECIFYI fl1 G t MAN v, A7 I N Lf rESTG i ` t 1 AI .,. D i.. fiIL„AT. N GO, B lxO. K K I SHAM NA NDI O p wDCENO. POLICID I O O ilia C Fr1 I iFBI REFUSED % TEST RESULTS vlD POLICE ANNUL A NCE Z C' OW I y $M ?I ,F I I i` 1 I' d4 ? • AARIVEO AT i xgOO _ j f G,NN C n f N,MC NK BAUOI NO ,GI NLY E Oa"a [.Dni < y ( ''; ' DIST RIB ON O 11 T Ay:. T LOCH L CGPY. SEND TO WASHINGTON tATC OOIROL, OLYMPIIA, WA511 i GTON DflSd (? DUPLICATE COPY LOCA L LAW[NFORCEMr NT AGFNrvK rneV r r ??JJ?? ?t Wo= r '4 a??t ?. ><J ?? :t } g F 3. vyi?H C iJ"{IVH3t7jTNtxm PAGE 0!y UNIFORM POLICE TRAFFIC COLLISION REPORT POLICE cpMPLAINUIUMBEn 77 q. Mo OAIE OF COLISION _4ESE iC?[ OAY OlCIXLISION IS S WEO A UWNS FRI SAt U HOUR) COUNTY NO FHW T ICY _C ••// ?STATE ROUTUNUCOUNTY RDA?CITYSTREET OTHEISPE"" N DM CLSIEORSIREE,ETCDOE 3 7 4_ /J bE ON ??// CITYORTOWN IIKILES N S ? E V1 ? ? Of__ W PREFI% EOMIL POST ?+?] 6 2 N 6MO.OF SLREEt ORMIONWAY INTERSECTING WIiM bTNEETORPOAD ON / Cve Irt'lz NON WTERSELTq LL O L V , - PAMP DIAGRAM DATA ''// ?ATT BETWEEN STREETAND .-.._ llld_ S/L._I YiPEET gSTANCEO SETS ANOOWE0CTIDNFROMREFERENCEOF__OPCROSSSIflEOL/J1 55 b E w /[ `O ACCIDENT LEAG MCOOEE Htiriol?j INTER L %-RD INTERSECTING STREET OR ROAD OFREF Oi CLS. ERENCE O t E SPECIALc INGUSE 9, P. .Ya'wC• F.. COLUSIONINVOLVEO: VEHICLE-VEHICLE ? VEHICLE-BICYCLE ?OTHERIWRITEI ?H116RUN SEVERITY NO KILLEDR VE T TOTUNO. ..? NrCIE OBJEC ?VEHCLE FR TRAIN [:]STOLEN VEHICLE NO. INJURED OF VEIIICLES ?yE NICLEPEOESTRIAN ?NON "COLLISION ? HAZARDOUS MATERIAL __ ? PROPERTY DAMAGE ONLY OWEK STRUCK INAME OF OBJECTSTRUCK ANOO HERS NAME). OCATIONOF OW0TSTRUCK E SpAMAGE ROADWAY FEET RO EDGE S RNAME LAST, `:_';,FURST DRIVERS NAME-L, FI-STL.E(A. p: . STREET ADORE I _. ' 2S - 1 / 7 5 C4 37- 5 < STATE t NO(24t>ti'tACttrv1 A• Lq NSE NO. - GATE OF BIRTH N DRIVERS LICENSE SEX DATE OF = y zz 7 c..Ll °' -°-1 e5i'7 i? OCCUPA?+ n!1 PHOE NO. 2 CCUPATION FNC -a 6u DLL bc.?2L?- A.;- c? S J IDI CLASS - TAI SEATBELTEJECTION CLASS-IAI SEAT DELI F S BP-u Is '-s ENE Y V TO - GgOM SCE V M . VE ? 7r, E A'j MOOED/D OVA1 .. bTY??? ,) V NE DY TO VEH YEA6:5 7 H MAKEIIp?dV.) MODE??OVN STYLE IZDR•CONV.) C E " VEH. OR _ UC PLATE NO... STATE . TRALER PLATE NO.. STATE E VEH cCA GGE C)U. ??r?/? 0 2F/ H . L UC. PLATE NO. Tt/.EQ T 5"7? SfAIE ._ Rl TRAILER PULE NO.. . STATE (.• VI:HgLE q I-ON NUMBER ... ..,;. ODOMETER ( ' , VEHICLE IDENTIFICATI N NUMBER E, G(,/006?OQo . E: . /002 /D-54e A 9 /75 REGSTERED WER-AST p ?M1pOLE FIRST/i>UCTD /TL k?GILSC-7V C D ? N REGbiERE00WNER-Ub - FWST .. - ....:. :.. :...:...:. MIDGE.. s? Or' V CtJ / ? o S c- . ADDRESS OF EP :.-._ . ...:. ?.: , ..,.' _ .:. -:. . A z ODNE55,pF OWNE9 //L[ST//TE S,cATTGE NAME ANDADpRE59 FwSURANCE CO.Oq AGEM .. .. 4AAeY(?yuD -?FeL?b1EX'7D.U CHARGE . GtAT10N NO N AME AND ADDRESS OF INSURANCE CO. OR AGENT ., ......:; ?, . . ENFO . A RCEMEN CI ON T CHM GE /? CITAT L(?/„t 95q574: NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODE _ a • e _ SEX AGE STATUS W NnH a A EJECT. C C NAME -bc 1 IS? 2 - UU - ADDRESS . ?-JtAr- NATURE Of Z - 4 7 z f LI AT? SCLOVCDOfgOM NJURIEG }0 A NAME. LVr AEI' E V T T ADDRESS I 131-71 2 I S / X"N ESIX Ll T ± E tO FROM _ U-r )At SCFNF RY ?'L TO 4. 67 1 W N AME ',I ADDRaE=SSAd-7-LS' G((CG(CV_-. )"1 3 V N NAIRK RcF f E S N N nv TO _ AMT.' S A DDRESS- FF S 1 1L, 11 b I I] A qN IJI PINNY CLA551 C O D D S T P 95fNOFR ?PLGSi R,AFI BILYCLgi M1?M[ ) >. DINER POLTgN IBUSMOTOPCYCLEI 3 DEADJDRV ZOi.AO AT SCENE ]GAD ON ARNNU A DICO I S D AB SABLING eN ON DISABLING ILYIDENIIINJURY IAI bf AT pf l1 I NOT UN LCD ZNOTIN USE USE J USED I]I [JkCTgN NOl EJECTED 2.IOTULYEJFCIED ] A E - { B E POSIfK)N UNKNOWN . WNOSPITAL i. POSSIBLE INJURY UNKNOWN a SEAT OELTFAILURE AUNKNOWNIF EJECTED y+ r' ?L r -e L• •A . L L 4 II I t ?`i ?+ (r, V.. "N? VA Z b. d 4J MOTOR VEHICLE COLLISION•REPORT;."' - -= DATE OF COLLISION ..DAY O COL LISION TIME OF DOLL SIGN .: 77 COUNry NQt CITY! O:- r COUNTY. CI TY, TOWN 111LE5 O? CITY,.TOWN AUTALLS PREFIX EE W L T On 4Ff'. G"/..raccln ,' GDFC/ia KE c .30 3 9L}I5 GIVE NAME OF STREET, ROAD OR HIGHWAY . INTERSECTINGWITH:STREETORROAD PREFI% EO MILEPOST:e, .,-,. " r NTERSCCTION-LOCA r10N? C?LLISION NON I FsllEEN STREET AND STREET PAMP DIAGRAM DATA. r ? LV OF r,•iana+o.xussiwu, .•?ser.sro .,iw.. as •uva.ra. Ix•iuc[• ' i T?FR CLt. , xtai n0 [wi ??fo ?C=i , Ij SPEC. CODE USE ox 09JECT STRUCK rxnul a. ovtci SrxVCxr OWNER OF OBJECTS NAME AND ADDRESS INII LOCATOAOIOWN a ? '"" -- - AY o x +aC FEET S y,! : S DRIVERS LAST NAME .. FIRSTNAME '. MIDDLE.. 57 VANS %MsR F. •••" r DRIVERS LASTNAME FIHSTN ME ... MIDDLI G z u K ?F TcK »7 _ STREETADOR ESS - :. ROUTE 10,101 NO.. -)?rE'. ?A.Q.4ow'? c?.vo. vON1'"•'"'O STREET ADDRESS ROUTE NO, AND BO% N0:• s34a w r -!?d CITY ,• STATE ZIP CODE / TC??AE?o/ GG?N /?'js DRIVERSOCCUPATION Bits D4/VCR CITY STATE 21P CODE Sr IN %&'!07 ORIVERSOCCUPATION . DRIVERS LICENSE NUMBER. 'fuBe.F (: Y•J D STATE WV SEX iZ f nOATIEfOQF BIRTH AOE c-1 LSE rE?' DRIVERS LICENSE NUMBER STATE GAt:12O i" S4 G.I Iti SE% DATE OF BIRTH No DAY v AGE v¢HICLE VR. / % MAKE. 1<n[v.coxlr - 22?v. curh MOOEU".rxo-oAxir Vo .a ?Ea BODY STYLE rL OAI Vr7.? VEHICLE YR. 1969 MAKE Kx[v. xxal M ?o ODEL'IxovAO.sxn BODY STYLE noxJ=- f?c o LICENSE PLATENO. : STATE' TRAILERPLATENO. STATE'. LICE NSEPpLA?TE NO. STATE TRAILER PLATE NO. • STATE VEHICLE IOENTIfICATION NO.rsM woeex3 Lwex+_ •'3C7 E /3 O EE wr.t•eLl VEHICLE IDENTIFICATIONNO..: ,_. rrstew xlnexl -..:- OOMETER wrL@•etr Fas2V c/ /044 REG15TEREDOWNEq ,".: IUn+. Lc x•u[ _ : .:DRIVEFIS LICENSE ND. R EG.STEREDOWNER;.: ..rusTrM at n•..tr .. _ ',- DRIVERS UCENSENO STEVEN'S C?n76r? F• CkEAiOOK7/y)a i . C r CWNERSADORESS -;: .. „ISTPEET CIT NO Tq 1-:.'-,," 'y?.'DATEOf'B IRTH.- OWNERSA°DRESS STREET Crtv ANGST ttTt 'DATEOFBIRTHA _ ° A a84o W q 5t o o ? ° E R P RTS O VFHICLE DAMAGED ^ • l_e. "•..:.r u•r F °Aax. aa V ICLE AMA - ? osT.- .._ ..._ . , L Z7 '?ROAVT CeR 5 rox .RY KEE L£Gr .lS9R um v LIABILITY INSURANCE INFORMATION-VEHICLE NO. 7 COVEflAGEU IN FFECTFORTHIS ACCIDENT ONYOUR CAR `. JZ?YES ? NO" NAME AND ADORESSOF LIABILITYINSURANCEPOLICY HOLDER --?;s,? : _„y_-' :NAME OF LIABILITY INSUPANCECOMPANY .. yt: NAME ODREtt C - E T R tNUg7ff ?AtR/ - ' ?LL E/l77 ER Irl rEvevn ,. O' Q1/ - 6(/N gFl3S&I MLJ><dAL D NAME AND ADDRE SS OFLIABILITYNSUQANCEAGENTC iY:,.F.wT... _v H.N.n?E.. _:.r,:}_2 Pmm?.eLIABILITY POL C.,Y•NUMBERf'?y,•??ty ?. , _... T cSE oin G???• ? - vhc%/s EA/ EPOgf TE F °P AOl1fTJORAt. NJUP!Eti'w.3yf•?HY?nf„(SGEI` ISTINJURY:,-..,._.Kruv.+T..?-..n,-2:-: INOINAJRY'i9•. IUSE tEFAPA P •?- ? / ? , U ADDEF55 ?__-`_ ALT Y•J li ?__. ??. F AD°EE55 ,/v r__V _ i EL c M F - - I U .- 2 ED 5TATUSOFINJUR@O- -- MARK FIRST ONE THAT APPLIES . .OATUS OF,I U %: -. MAR K FIRST, ONE THAT ?L lp N VEHICLE KILLED iiin ny FIc 11 1 LIP rcr ? o M VENICLE ???? [] KILLED I . ui ? 5? 6? 7 a LJ .. RITE.H! ? 5? 6? . .7 ? SHOW BY ARRON IN CIRCLE I _ DESCRIBE, BELOW WHAT NAPPENEDe IREPEQrTO VEHICLES BY NUMB@Rly.+l,,,?„fA2=' -,uro?n..Q? ?? I.J dL°?n" -GieYd_/I??L__Sf-ey ..?iy-.?.?-S CJ•' Y f r ,.r. I... 1 Ir VEHICLES POSITIONS DEFORE COLLISION Nvesr nArto er On wCrnt:LC HaADEO ON STREETORNIDHWAVNAMEOR NO, .:rscr s:ii ??• :,r ??o• r? t o tp ( ?r?srt ? X f / ? ?.... . ? ? e• r n IYOIIPI ' SiJ ?? J l E ? 10 D!EIU L ! N?J ?? J'?J C.') t._J ? ? ? E-1 ItOk TR AN '. (3 E_ J ? C) ' ". ALONG .,.. ,:.. '. " CnO331N4•I.Y ::•:. .. I?. L' 1' FROM '.a7_t'IS. .Y.::TO L?i?? ?Jr},u E ST III USING ?? I ' T T-1 =?J ?" A ? ;' B ?< G ??s `J+ - n•IAp.VRFACE WtATHER ? - LIGHT CONDITIONS TRAFFIC CONTROL = TYPEOF ROAD DRIVERIVEHICLE ACTIONS •.•••. s ?.: r ?IrAr1.IC,HT ('T ?"IL •1J 31"NAIL .a ,? DNEWAY•M 0. r,a KnLC+onrwww k IK?GOING STRAIGHT AHEAD .t ? r1 HAIIr N J U UA'nN [3 2 ?Ct02 s- ^ ?2 ER -a WAY ? 2 E) OVERTAKING AND PASSING Y ,It V ! 1 ? SIHIE _ _ F n •T ? T (?Yr[tD :IGY ?_? O ?n"o ? 3 ?MAKINGRIGHT TURN ?.:Yrrvv f,O A JE '' •? Grwr1 11rf'1 1, a Sr11NG rIEO u ?fEn ? :' ?I'a 1 , AA?PIE ?A?LIAKINO LEFT TURN ,, 1. 11 S L.1 x??.+,.. S I r ? LIGHV1.90i iET ? y ?FI f .1MAf.H ? 5 ?,ALLEV ? 5 ?MAKING U.TIIRN y nTS n t. r rf rAl. ? H ?1 1I•r uxY l•Yt'Y A SLOWING ? ? • "MI r 1x01 Tv _.. tE GD+NI:EN (": T L,0 fH ILAfu AY ? 70 STOFIEO FOR TRA FFIC" G 9 01 SEPARATED $TM ? e?OR STPOP SIGN (jNAL _ .,. _, ..., ? 2 ?DIVICE. C] O?STOMto IN RDA, AY ? W ?,, -ly?. r yf Tpp? A r? l Vw l l f, (:r NTROI. -`m1Et .. 71f TuNAIV10r0 y > r STARTING II ?••II O (A-' ?? -')' I•+i, (.1 F' MI ^' rKd ! VAR, F p 3, ?-?k,MaTu y 1 l as ,!Ff,RY,R H ?' •,'Q•4jIR "a+7YI",!I('iVS - _ . r1 n Irl ,! • 1. EI?t I f .1 , ? 11 ry n y nd ' r P, It, J)a - ?? wJ ih a Y 1 NE CH 90%.C HCL THE NUMBER OF Of E, EACH LHJ AG1 GED' .? DAMAG IT- 1111, ? L 2b „E CF E F5f - C 7N3TAUCTIONS.D.DHAV O Isl o ow f LDH6e1G eE p/•?,w.te?--?. - -- DAMAGED /.HIC LE NO I JUNE THIS SPACE FCR..KZTCHNGDAMACE TO rRAILERO-TCHGVCLZE.ETC7 DAM AGED VEHICLEH0_2 II3 I J. HCCJ Y (??. "?? C L I E S M I i _/?? ^ F j Peel rr l Ir P.L }} ? Y?-? e ? rt r?Pya -c ? ra CP rY FD 4F F L 10.1 iF.•JEHITY CF OAMT4E OI EH EII CLE) E ryJ U G ICE O. TCr I LoOSdI MAGE 30OTHERMV.OAMAGE ?DSABL.nU DAMAGE r-JOt 'H '/DPAI4L:F. [A'USPAUM1GO.MAGC ]QOIHEflMV DAMAGE ;U C 'V lOAI G ca]N. ?[7NfICTCr COA4 GEIJU ^E ?FUNCi,UI'MI U-MAGE a NOOAMA:.E ? ?L'O ED ,,,? , ?" I EST DI" E5f JAM CE I( rO eD B, TO' cO r1Y FSr OAM1tiF.? LT? rN G[ I S To DIAGRAM OF COLLISION - j. - -- __ _ DRAW ARROW SMOWIt.G_ ? - r FkArUF.e NORTH IN CIRCLE / wroJJlw.r ? ' ._ .PD,Nrw , .r N w m ' ccH. _ .. _ P.OP. AG MNDN I rl r = DESCRIPTION OF (INDICATE WHAT PHOD BLYH PPRNFDBEFOHE DURING AND AFTEiIT ECR; FI IIJCWOE VlFCRMAT ON NOTON DIAGNAM .' COLLISION I , . . , EG.ORIYER JISABIUTY, REDUCED VISDUTY,PSE-RIAN CLOTHING COLOR C-,LCj!CN OR REPAIR WORK, ETC.I Al?!=-(1J /_f././Z (?/?c-[?..- _.1 r '? C ':•,PITIONPEFOR OLLISION ;• ? • - -. / _ nO. of uNES SPEEDS MK:LE IFP,wKEJ V£H XFAOED ALE POSiD H. O STREET OR HIGHWAY NA BONING' - IN ONE DIHtGiION FG+'Ee LEGALLY WAS VEH. .:A.E FVCRE Su NG I'm KED OCCUP No G DECREAS - . I IED . N 9 E W I? C . V /p / 7r9 _ t (-1 I T YES NO YES No r v[JL r i M n( o -`Ei DRH-WAr fn ,.EEC M 1 • wj i`EU [.j ? ? ` 1 CIttx49r0 _._ . PEG/Hh CUSTWAE USING l._IY°Err LK -xl "I • ?ISr'rNIDER 1-1CIw( .,;ROAD SURFACE ONjr,15U T CIRCUMSTANCES N I, A x I CK wN '. C.PVF.H A C GN EI ;E„?CtE A N ( k - „ Na ^'xl J v¢r !nu. r.r HiN f `._ (? n, Eof IJ M ACwrcH Py ?. -. UVTST IJ L n, HN 1 rcF l on D «L HE•3 " i -DEER r2 a -J°?? Iu.o ?lcS ? '.. I_ 4 l_..I _ ? K l 1 o: L I 7_1e?l vnwNa O CHIwGfn . CIFENI'+i YI - ( I .? R f' x' N!u s - m Fr, 1,. Itj -1_ -F F°K UGH7 CONOIT70N5 TTATFlC CONTROL K cL>: .TYPE OF ROAD.. VEHICLE CONDITION -SOBRIETY -I e C t?D •L TCHFCa w'U 3 L Ira x -Ic.F ,, CW MMTI Vk ICHICK F F -' IC C<K °„E - e M r j I C., i r R. .rNOI x?l w RDARIAY J er? Pe L."We J e E ! '? I 1 sr .. _ x' .. ' n'M4° c 00'•1?'u' ° __.x. Ah Lin?ro ?..i o Seri Tr ?. rlwfK(IEnrunn ° ... R ,.__ °_.. J. 1tY I ...? uK;Wmm eLkNN°D'?WKRn ' e1 I aeKFn L. _. -_.. - ' ' A .. e._ - c ask.v '--- ... r•R ._.• . _ rmnMm nm ornvFn CHEM. TEST - - rswA r r..,r r . ro"u?r.Fen - ??' 1 Ka+I __. ._ uPleRFe rn ° 6nM.r1 °r n•RUr ilf i% ram. :? J .. , , .. • _.... ° r.EN ... x; ..I ... fY, 111FV Ee I 1 OrM fAlG 1..... /oNI k< c rm x f. % S TEST RESULTS 7 No. i sq r/ J /- IIwr•J f A AF to I I ?- r Afw N •c CUPI?CAICCOPY.LOCALUWFlNOPCFA'F Nt AGENCY'GCOPY-rNU'11CAfE CU'Y ?INVE$TIDATOfI'D COPY ? ?P NOW J }!'VIII i? kF - -IeFn+.F '"naeyp?+' ( 'Arl 1( b II, u" ` D GATE OFCCWSICII' OAY OF COLUS ON T'M! LOUrITY NO CIT'V NJ - E N C '. IAJ?... ? YII. ? U? ?? T T SUri 14'n V rUIS D WlC A rFU+ S FHI R SAf ` I?E ?+.n G?NI (J C z / _ Lll.?l% P LAEEi CODE UTE OA L UAN SE T ON ?( COUN Y ` ?j }YCOUrviY POAD ?]aTV Srr1EEr ? O A I OMLLS. " PREF.% S C ? . \\ Z?J.L V?? ?OTHERIS EC FVI OII ? vN CN Y O' W . ? .....% E O L MILE FiSr L . ? t•Y S E W --?? N /I ? •J u . ? .: Q / ? '? -,qT I . yT IIB? A ?IFILES ? Wl ? ? Ly OF ?`1 (/'AN V'Ltiv V I ..? Q' NAMEn NO. OF STREET C??HUih•WAY INTERSECTING WITN: STREETCNROAD LL R AMP pIPGNAM pAIA '. T i I NS O I O NC'N TERSECTION I 1' - FC I If EAO NTER NON/ -RO I'N CLS. E A TPSECTING SIPFE Cn REF. C PENCE LROSSSTPEETORROAO. N U I 7 ?? DE YEEN ITFEEIANO V ^ COO. J ?? I S O iPE ET A Q FiREFErENCEORG NO&S SS LISTAnC'c .AND DIRECTION F // IIIES I ! ? ? TRy S ??`nr PECULCODING USE Iy . ? ? ? ? 1 r?.?/ ^/? ? y t 1 L ..? ? Y11 ? ? OF liib'L-ZN (-? IY?'ITLI ,LP r [IFEET VCf11TY ? VEHIC(E-VF.HICIE !D VEHICLE BICYCLE ?GTHEH(WHITE) ?HITBNUN y0.%LLED 1JNINVOLVEO: QTALO F? ?VEH CLC-0AIeCT ? VEIIICLE-RRTHAIN ?STOLEN VEIrICLE 2„101. TOTPLN 4 OF VEH GLES ? L I ?yFHICLE PFOESTR AN `iONCOLUSIGN ?HAIAROOUSMATER AL ?PRGPENTY DAI.IACE ONLY • -OEUECTSTNUCXINAMEOFOWECTSTFUORANDOWNERSNMIEI LCCATONOFOWECTSTFIUCK - EST.DAMAGE ?FOADMAY FEET ? ? ? ? n0 ECGE 3? ' ORVEAS NAME-1-AST ©© iPSr MI..LE 'IOG3Y?TI PEBFSTWMV YHLI.R ., DRIVERS NAVE UTFPSTMOOLE 11F3C D SLDTT, I?11-RJ?-rJ?.r??-(' D A STREET A11111 -"... 1 STREET AGGRESS V 1-77--7 OV-7 58 V E - STATE LP CODE . ,i ,10. E CITY ' STATE TIP DE , ._ PH(:NE NO. R S-AI_rZ_e --OA. R u'l N . CWVF A S UGENSE N 0. STATE : SEX " BIRTH ` N .-ERS UCE.vSE NO . - [ {t SE% $_A,T GATE OF IT 1 YR 1 Ay 0. , / ` '? ?1 •jr ?1 1 CAY 411114, O ? ? f I . 0. I . 'f . PHONENO. pNWEflS OCCUPATION FIRM NA E Z DRIVERS OCNPATION FIRMN-E - PHGNENO. M g FaC'Y?. 551 Tr LCl 7tT"?' ? ... [ I4) SEAT 9ELT ,Z TION CODES (D1 CUU55 "I •'?` ? Ctn$S (A) NEATULT (St EJECTION ? NJUR ES F 'LLN '( .0 ?IJUHESO + ? PE .-EBV: TO GRpM SCENE AY: TO V€H YEAR i(E IDOOOESHEV.I MAe 1 MOOELIDAPT NOVA) -. 6ttLVIp CONV.) ?IA ) -YEAH g1AKEI000GE- E V MOOEL(DARi-NOVAI STYLE I20RLONV.1 . K V E' VEH. CCLOR. llC. NUR AO. STATE..:' TRAILEJi P4.L NO. STATE E VEH.COLUR -'. LTC. PI,RE NO.. STATE iAIJLER PUTS NO. SiAT£., H 411. C B I Lt i}. H //I Q, ClE IO.MIFICAi ON NUMHER ?. .,"_; Y :. "I 1i OfAMETEA.., .. -Q VEH%:LE.IDEMIFICA' NU rI - ::.? .::....: CCOMETER, ,. ` ` E `CCi?I l5 i ?FI1 4r?z 54z2- L , PEGIST ED OWNER-UST FIRST MIOLE REfTEREO INER-UST.FIRST FIICCE: o t?? Coy>l?'Ci T17°?Qi k4. 012 `+??3?tr L o: ADORE OF OWNER. .. ..: .. 6-I S 633 z L? ' 2 - o ack (AJ Luco? .-S .-Ss. ?iN$URANCECO.OR AGENT „ „ NA tF-ACORE:SOFINSUAANCECO. ORAGENT CHARGE ? CI fAPON NO. ENFCRLfMEM CHARGE '. _. "... CAA IONT?„ IJ- (,Q? Z ? ? 7 AcroN ' ADDRESS & INJURIES OF PERSONS INVOLVED E N conED a a ± s , AM SGT( AOE STATUS q e,• EJECT. 5 NAME: Y?? ' Q 1 ??I' ?' I ^_ PMRES4: In 'Q? ls:!-lj(.LV ? A p OM f DF NJUP ES Y I GCFnf TO A NAMF: T _ ADrness' ? ? a ? - '- !- 9 __ __ __ _ eLI:;'. rIJ' Rte- ?7"H p FNO TO ',AA TIP 3 I'.Cr AP Pr ' 1C>! tl y N/ NAME: +•=U M I M N N. Uri nnun.F.R r FHO ? I' erIF PY TO S NWF'. ApnR: r:: _ 10 j SEAIfU}:KYI ig1V(S 1:J nuytlY GLAb3, I 1 rna Y .:LL a ..yN 1 F O V1 NO NJIlIIY 5 I O 1.01 El O I AN C { J ? AI?UIF, j . (111.1 T ' LCT FJEO E O 4 O _ BY,m."D B MJJIT?ON UnK?WIV!i "Ur A U G0 Fl, NJURV ). URf AL10111 FAIL 6 ? E 4 „C 0AI' _" Fa ?ft A , I.rf ax t t? MOTOR VEHICLE COLLISION REPORT NO. DATE OF COLLISION M YOFCO Nls wm W$ION .HS MEOFCOMNWSION EA, T HuA r no CITY NO: COUNTYNO Mr.- . y ?PM 4 IRAL Puf E COW Tv CITY.TOWN D JE- SON 'E W,SDk ?W MLES ®O CITY.TOWN /3 0© GF L' " - ADMCIS' PREFIX .? ROLE Oq 51R??O 94 ZION nObW GIVE NAME OF STREET, ROAD OR HIGHWAY WTEPSE iwG WITH. Si REEi Ofl ROAD .C = C a PgEFI% EO MILEPOST 3 NONINTERSECTION IOCATIONOFCOLLISION RAMP DIAGRANGATA BETWEEN ...TAN. STREET - AP x,ERIF-51 EE "'C"w,r nWSF O© R, NO pcRO55xO UEEPOS, OR NRNt Frlxa -w ml NO N XRD as n ©® , N [NS[ INTER I E CLS." R RO C NN. FEET ? ?? /? a ?Kx? EI / -S-YED j CLE ED, N : [U D 0 sPee eool E ,, . S OtFS ? I-I xM0 OFS w 0 E ?n,.xVrj' ?L 2. 0 - , ;:, OBJECT' UCN I OGECt6i I ,.,, .. OWNER OF OWECTS NAME AND ADDRESS IN ROA ? © P DWAY FEET O O EP,x puEGi "I AT • • - - pRl NAME MIDDLE T IF MORE I.. twO CNIS DRIVERS LAST NAME FIRSTNAME - MIDDLE _ o J C ;; M E E. e N .e O oWHSNNOR SIPEET ADDRESS :. _._ TNO.ANO DOX NO. ??a c u ;o/v MORETHw,vq WARE wWREpaA STREET ADORE POUIENO.ANOBO%NO CI „; _: ATE ,., LPCOpE DRIVERSOCCUPANON "-_ SEPAPAtF FEPd1 IM CITY ... STATE - ZIPLOOE- CRNERSOLCUPATIGN - BRIVERSLICENSENUMBER / STATE SE% So 6 e,- b/? GATE OF BIRTH 07 3 AGE DRIVERS LICENSE NUMBER STATE SEX , DATEOFBIRTH AGE VENH:tEY R. ' MANE ICHEV,OODGEI OOELAOMn 7 ? 7A71 MN;LE YR. MANEICHEVDODGEI MO DELINGVApMT) BODYSTYLE I)pfl.) ., 7S F Foe r? 0 - U? E`NSE PLATE NO. STATE I'b 3 UIP.?" z/?s? TRAILERPLATENO. STATE LICENSE PLATE NO. STATE TRAILERPLATENO. STATE Il7 OOELSa NEWER( VEEH EIDEN11F4ATOIIIdaG? LNnaS OOOMETERIMILEAGEI 6Af ? y VEHICLE IDENTIFICATONNO. II16BMODELSSNEWERI DOMETER IMILEAGE REGSTEREOOWi1FA ...(LAST FIRST-MIDDLE NAME)_. ,. DRIVERSUCEj5E110. J P6 78/ J REGLSTEREOOWHER ILAST,FIRST"MIDDLE NAME( 0111FISLICEN1ENO. ASE ?.Vo/L/ o n OWNERSADORESS ,,pp (STREET,,CJ?j?TY ?f?LATE). ... ?B ? ? DATEOFDIRTH fo ? OWNE.EAOD.ESS. (STREET. CITY AND STATE).. DATEOF&RTH V6UES3o V Vau so U( t ? 5 l PMT OFVEHK EDAMAGE ,,: :.... SS^ • G PMTSOFVEHOLEDAMAGED ,. FS, vA,EDCOS* WAS THERE AUTOMOBILE LIABILITY INSURANCE LIA6ILITY NSURANCEINFORMATION-VEHICLE NO. 1- VERAGE IN EFFECT FOR THIS ACCIDENT GH YOUR CM ?YES ?NO NAME DADOgE530F U K/ AD'!{TY NSURMCE PO OEH` c 1 iTpLp1;FU INSURANCE COMPMY.__. " N im f Y ? NAME ANDADOiE550F UA&UTY NSU CE AGENT .. ....".. Ot STATE zm LIABILITY POLICY NUMBER ISTNJIIRY AGE YND IRIURY: NSE SEFAIU,E.E-1 FOR AmIgx,llxNwE51 AGE NAME _ _ _-_--_ vwTOTAL nEO NAME -- DDRESS SE% -___---- DIGRESS SOE x Ns M ? ?. MN„nx mclpH ME STATMOFIDGIED _.. . MMNFNST CNETHATAPPUES STATUSOFINJURED MANN FIRST ONE THAT APPLIE S . DIWVT NVEHICIE Q D I,sYNaEN MLLED a IYYERFI FIW gIa•Ia YE PaaIOR I I [ l O M IN VEHN:IE 0 NLLEO IaS,IUWa Ix[ EREI -- IvixdO rE o pnxstwx, p ot??cn wnne.N ? 50 rP.w iG 60 7? pPEpfnw -11 a-n tE l•; ? 50 6 ? 7f Pax F,Gl ? SHOW NORTH BY MROWINCRCLE \ I xDN:AdAm a 1 ,A¢erNfWnxnxM EED.S O '• ? aN w a M.N N NtM•tw9 DESCRIBEBELOW NTHAiNMPENf.D.(REFER LO VEHICLES BY NUMBEpI ---y??S r0--Oe!N /[-CE -- - VENCI 1u,W R EKx KNCr[ x10 xIM dNTC,N%Ip,RAKI eF AnI10K. ...._. --------- ..._ - - ----- - ----------- - - - - ! - - I - __ ----- t I _ i VEHICLES POSITIONS BEFO RE COLLISION HIS "" ii s l e Viu u i c? « a INVESTIGATED BY VEHICLE N S [ W W STR[CT -HIGHWAY NAME OR RD DNfCIIOH IFaa r a "0 un _ v L M l e 0 NM Ka j?- ?= ? ROW 13 ? ? ? ? ? ? ? ? ? ?Pp1t[ ?"-at1 b p,aw ? ? o a ? ? ? ? ? C] ?..<RII ' ? ? ? ? -ONO cE RIlawla FROM DIRECTION TO DIRECTION ROESIRM WAS 1a1n0 1 ? 30EWAlR 1 ? WALKWAY ] ? SHOULDER 1 ? caroroi'rn,La 5E] cZr wfapa S ? OTHER MAD SURFACE W[ATH[R LIGH oONDITION5 T-FI000NTIOIL pRp a4 TVPEOFROAO DR IVIE / NculcIONS NR•IC,MI KKLI V KL L b i 1-11 Kn O udll f N I WfwCLa ICMCNONk ONMSAM b 1 W t E,N 1 ? MICAIM 1 ? DAYLIGHT ? 1 ? SIGHALS I t ? 1 An? OtIE WAY ? ) T M 1 ? GOING STRAIGHT MEAD ? 1 ?DRY '0 RAMNG t ?DAWN ? ) ?STOP SIGN ? 2 ? IYAWAY ? t ? OVER TANINGANDPASSING ? a ? -' ] ? SNOIVRNG ] ? WSI ? ] ? YIELD som ? ] ? MMR40LE ? ] ? L•ANNO RIGHT TURN ? ] ? SNOW 1 ? FOG 1 ? IIGHtS M ET ? 1 ? r45H+A RED ? 1 ? =-c H=E ? 1 ? 4ANM0lEiT T N ? 1 ?Ict OTHIE. S ? a-VRr ET S ? I F! O/I ? S ? FLASInv0 AMBER (ALLEY AMP( ? a ? ALLEY ? S ? MANGO U TURN ? ? w1ER Kc., S Y [C NI • ? Bl' Zt? 1 ? S ? RR SIGNAL ? a ? ? in TLR a ? SLOWING IIEASON LOLL NOT SE[x. DANBCA N•IKWDVN,:N p•1A,OtNwSF cI IGH 3 F ?OICR 'to, ? F ?OrmER"LAG4M l N LANES ? F ? STOPPED FOR TRAFFIC 0 a ? Dank R. wcav ? 1 ? SCPMATED ? IS ? SOIROS EED6 AT SIGNAL OPGN _. _ _.- ? a ?DIVIDED ? a p STO"EDVIMADWAY _ A IRAr11L Y ?ff'HtFl-_ _ r'•? 1.J ] ?I _,oto ? •uRi1IGN TO ?HF,rNr IMIF - y .1 9 Y. a? np{" ry ' k a r al U KIM ?j"? `lptK.?9W . . V / I I ; I I? I t ? ' , 'S ;i r r„ L 7 ' '? H+h r ?o, -il Y Y 'S v N. P ]" f nSY 3, ?P ERI wy s "a:? 3r?nA'?1?Y ??3 ... `;? fi Y ] { d . ,t t try ?y for VEHICLE DAMAG E z sr IE„READ SE ERE ST RT (7i (? INSTRUCTIONS. G. DRAW .RnowallD SROw Pn nr 'AL mRELn ND FORCE. DAMAGED VEHICLES N I O s + 51-ACE F ON SKE,LI+NG DAMAGE I. s.A.,,., Mol pncr?LE c I DAMAGED VEHICLE N O.2 y -- . e I] F r 'l tr n r k Q E I1 O..,lu,n uW ??3 p. .a.lurn O ? qy A- SFVFN11a'OFDAMADCAv[RICLCNDI I D SA LING OAMAGI ] (] OTNENM V DAMAGE DAMAGE ] ? FUNCT ORAL L7 N GE E ELVERITV OF DAMAGE. IDIRER VEr+CLEI C, , ? UIS LING DAMAGE E ] ? pT0 MA ] C) FU+ rL o T sI. UAM E $EVERIIY DF DAMAGE. V EIICLE r O D SApL NO DAMAGE ] O M.`EOAMAGC CT .1. 11 UN - A MAGE T D LT S iOWEOBY Bill"S aara a ESl,OArApG TOwEDpY Y( Y ? A.? O ED pv w ' TO Chimacum VII. 11000 TO TO Srvv. FWfn . DIAGRAM OF COLLISION • DRAW ARROW SHOWING NURiH IN CIRCLE . R v° I s I Nn unuwAUrzwcoxP, ct.A,cR.cpn Antas E,cl ., ? ?? ? .? qq r s. swoNVexleu .toea,m,now oelEnrD;ImnsAl N..n. AILE YIn cLL n 40 -' -. _.... ?...' -- :?•? -I .v--_. • 0 . sn- n°u,n1...,,ns.11DA , -. Fence two- strnn DESCRIPTION OF COLLISION [INDICATE wRAT PnOBABIV RA EKED UEFOnE. DURING AND AFTER THE CRASH INCLUDE NFOIIMATIOR NOT PV ° G AM•C.c. DRIVER _ DISAau7Y,R DUGEDyrslaur:. PEDESTRIAN CLOUImG COLOR. C.L.-U.-N 09 PEPAnwORro..ETC 9. Rx6 spoke with driver of.•Veh Aland she informed me that a bee flew in the window and,was -'" f _ the„VOH- her face and she vas swattinE at it [ind apparently lost contfol o flying around ' . Veh???l.-__. crossing into the.-S/B lane and Veh 02 ,was unable to to avoid being etck?y - • r - ? e f 1 ' POSITION RE FORE COLLISION "' - AME O NO. O IGNwgYN ° TREE +O. o LANs IN ONE D BELT ON I ...D S LEGALLY ED NON. REAOED / I EASING INCREASING OT CRI . - _ C.R. 18 1 C P „ 6 .. - PAR ED - Es L a ISO s , - ' - L ; R. is n..l 50 -- ?;1Dn .I W„ -I t Dnx+ n.0 xEnl_ lE .D A n PED. .. cICLIST WAS USING. _ 0 'OLSIG RTED ) ?SIDEWA ] LKW v .. -- SROU S ...'. n '.. C GLF=FE I ER ••. SJ „ ROIt?[IL U ONEpCE WEATONRI, 'G. CK CONTRIBU TING GRCUMSTANCES .. D ? } E DR ER C . AREA. G a Ir DRY Y ] '/ ' CLO r D -",tiNUER INFLUE 9} LCD ] I Y q£ .I 2 I I G A A. E NG - ' - ^ ET :y _AAYEBGAS RA WING L « , A ]? T urv DER NFLUE DRUGS , -- E L, D' IVI?" 1111 - ltv IL - [- M NO TURN FRINI 7 1FVc 3. o W "- SIONY,NG ' FICEED IGSIA E -1 SPEED , TO IIE" LI ARKING IL11.11 E" L Zei _ OPEFIA7 NO KG - _7 .-N N '.' D - _- t r-`-... A, D DEFECTIVE Eapj _ N $ ? I piri[ii I.PELifvl -Oi;an1S1'LC IY EI-" I - I _ I__ 3G AR . GNIS G+At l/ TI 11 ,eI 1 NO V11 OLAIrpN 1 S .FOR ` I C a LIGHT CONDITIONS CNLGKON TRAFFIC CONTRO O] CLL E ?TVP OOED O ROA FDE O.J ICRFCK ^ VEHI CLE CONDITION R NO JE ?f?[ hibUi SOBRI ICrIETCK Y iNOC]C F ONEI p - T AT SIGNAL OP SIGN OF SI (-- J 1 X T NA ',41E WAY E . FDI dn 'EC ... Vl I E -PE IO O ° N ADWAY 5TARI N , pwvLIGNT ] SIM - I 1'_ v " ..pN K[S _ 1..=...__EO_._.._. °. J iIIAFIIC IA +E -^ 51 R M AWN D _:... -.. DUSK ] VI[tU LAS c tEU ] •91.[ Gr a LUO.N v nElfCl VE ]' __2 . . ,..:] FEAR LLGHTS I+T A MPeII.L RV[D OT SORRCFY °.:......._uNK._ __._ .. _._ - O rpRI POEDPOSI TION nGfrvc R.TINING L. T A CI _ DA S FCT I O S FLAS .PL S Al ll'? TNli wOnN ?A 0 A +AO NOT eF[NOLINKIN[. _ '+- ACKI.. • I _ l G tET A ISO _ °r . _ CGVp _ .. - -- - =- " - ,. _ nrl w. .. _ Notn CHEM TEST . I '? l- OTNn F, . nA ICI K Ff TS y NU O F tsT n[IUS[D .} pllitR lniGii vl +v c L ?? -DIVIDED i aT IE ........ v % TEST RESULTS Z ICI AIIILIVIP NCE A I FLOW 11 IGl U. LI I ATING.111C1R'Y A,Mte FICNK o.TCI1 lb 1245 PpLlz48 pD "nMNI bAD R? APr?CO `15 '?i 0ffiIIAFQ. Nilliam C. 6 "I _ u, rw N X vtsl,? <w:ryclrNCY Nn na U.,n 1 rr I InuYrOUY /?? T g N_? I N -_!!?d 6 JCuO --- QuilcaaenL C71C79 T -_l-F k i in" 1... V DUPLICATE CDVy LOCAL L All i NFONCEMF NI A6CNC9"ti CORY- TRIPLICATE COPY'. INVESTIGATOR'S COPY a uv 3A.? v F in w ? f o E OF WASHINGTON '. ., f PAGE O STAT D • LOMPLA nI NU BLR _-J +rouc . UNIFORM POLICE TRAFFIC COLLISION REPORT A ?6 ?,?4 I ' D A ATE OFCOLLISION MO DAY YR - DAY OG COIL SION- FR-Ip SAT EOA 4pn ) I t5 3 w T6 S T SUN 1 - TIM[NOUP IUSE ]<DO I J CITY NO. CWNi ND / Y / 1^ [FF-C --??? nWA ? UNRAN URAL , '? ?" EI lO 0 7 CWNTY ?SIAIE ROUIEC 'COUNTY ROAD ?CIIYST„EET o DM CIS. PREFI% C ROUTE OR SWEET CODE- / 0 6 GOON 5 y 's,1Q Jefferson ? OTHER ISPECIFYI CITYORTOWN N PREFIX ED, M 5 ILEPOST } L N 6 E W ?IN _ _ l i w U 3 Z ( ) D' . _ . maCllm-___.__.-.- 2.%n' >nILES ? ® ? ®OF.....C l LL NAP DIAGRAM DA TA C NAME SNO.OFSTP 'i HIGHWAY INTERSECTING WITH S1REEi OR ROAD LL 0 .. .. - T U ON C.R. 18 D OR OR RO 1Y ( ' I N A NON X-RD NI ENS ECTING 57HEET A REF. LATER EFENCE CROSS STREET OR ROAD I T CIS ' -. ? ' N NONINTERSECTIO BETWEEN S111CE7 AND __.STREET DISTANCE AND OWECllO1i FPO REFEPENCEOPCROSSSTREEi- rAILE GE LODE uA,Ax Kuxur+ElnS . SPECIAL C LING USE k ? } I 4 I ? ?yt a ::MM ?MLES N S E W T ? ? ? OF ? .Y,SL ',:y ?„ i "^^I iWwe 1j ?1 FEE ?VEHCL-EHCLE ?vEHC1E &CVLIE ?OTNERIwaiEl ?RIF ARUrv COLLISION INVOLVED: ?SIOLE. VEHICLE SEVERITY _NO RULED NO INJURED i G x .- -- VEHICLE-OBJECT ?VEH CLERR TRAN PROPERTY DAMAGE ONLY i p !f- I'? TOTALND FVEn CLES ?VEHCLE-PEDESTRIAN ?NORCOLLISION ?HAZARDOUS :: E " M 1ERIAL ATIONOFOBJECT STPNCK -l ? EST. DAMAGE - . Y q?]Y ?? ) "` - I .. OBJECTSTPUCKINAME OFOBJECI STRUCK AND OWNERS NAM 7 S E W OF ? ' ? ROADWAY FEET? ? ? ? RD EDGE S i TA` ' 4- n w"? DRIVERS NAME MIDDLE DRIVERS NPMEUST GIRSi MIDDLE OF BCYCLISI OR P[DESIHIAN CHECKICJ :...., }'L' '' ? - .- -: D` DYKE Caroline Eva a si PEETKER, Rose A. TRAC ADGRE S TN C'- u R. _. . .._ GIPEEI AUORE55-....: I V 108 Marine Plaza 4 V 1636 Hi11 St. ZIP WDE PHONE NO. E C iV ... STATE .: .. ..:..21P CODE ....., PHONE NO. ; E " CITY.: STATE - ., . 98368 315-0624 d w p.. Port Townsend Wn. 98 8 8 4l , ; n. Port Townsen STATE 5E% BIYiN DAl E OF N DRIVERS LICENSE NO. - STATE. SEX'. DATE OFD BIRTH YR MD 1 N 0• DRYERS LICENSE NO. - W F D YR O 08 23 12 A904DK Wn. F 03 12 10 _ u n. E88 N3 P„ONEND. DflNEPS OCCUPATION FIRM NAME z RM NAME PH EN . DRIVERS OCCUPATION Hsewife + y ? • - Hsewife CODES IJI ?wUSG_?_ I.1 SEAT BELT.2 ISI EJECTION ?. CODEOS 13 LIAOSS_],_- la, SEAT BELTIZ._ ISI EJECTION ___1- NATURE ' 4 K Y NATURE OF NJUPIES az,Qd_ noII JURIES atgd no E fly TO RNOM SCE - " w 36 w ED O SGFNE VEH YEAR By MAKEIDODGECHEV.I t MODEL(DAfliNOVAI STYLE I)DP:GONVJ N VEH YEAR MAKE IDOOGECHEV.1 MODEL IDAHTNOVA) :. STYLE I)DR;CON 1. f, }"' I I + V 1977 Cry Cordoba tudor v 1966 Ply Val tudo r ? E VEH CWOR LJC, PUTS NO. STATE -.R P LATE NO. STATE E VEM.COLOfl llC. PLATE NO. STATE - IRAILER PLATE NO., STATE , I H Grn iw 055 NUMBER Wn. -.. ODOMETER I C Maroon VEHICLE 0.11FIC cis 617 AIIUH NU BER. Wn. . ,..L x? ail C L.. VEHCLE IDENi1fCAUON ?. ... -E' 1 RR, E REGISTERED OWNER-LAST... FIRST MIDDLE N REGISTEHEDOWNER-UST ,. FIRST NODLE 1.A?. § '+ N Same aB driver 0• Same Els iver dr . Ld D. ADDRESS OF OWNER 2 ADDRESS OF OWNER ! ., I? NAME AND ApORE550F w5URANCE CO.OR AGENT NAME AYO ADDRESS OF CE CO OR AGENT. "..:.. ... a - 3 Safeo Everett Wn. Homer Smith Port Townsend. Wn. TATIONN I > % cRATIONNJ. ENFORCEMENT CHARGE CI uP1 CHARGE Hone Ac oN None C NAME, ADDRESS & INJURIES OF PERSONS INVOLVED O E. DES AGE STATUS ) J 3 E ECT. `n I C NAME C AADRE;S - REMOVEDf11pM U V A TUNEON SCEN[BY wuacs NAME: 10 i N T pORESS - RF MUVEO GNO n? TO S 1i IE OF SLfNF RV IHJUPIFS •II / W ` N VEDIIIom y To ] E I I 5 AME H '-' K'. S ADDG+ISS TO 1 E S NAIF?I I?ISIAIUS 1]111 Al FoS 1CN - SCI E BY J AI CLASS "o'"'" V S D`+ U G NJURY B HISLAI BELT NOlIN51ALLE0 USE R,') ILC110H NOT I [JECIfD EJECTED (. C ,Pf PASSI F I F IPO51110N ' ' I I I DON A J II Y IE VIIIC 3 USED )I I CLIF.D U A N-KtIOVRF OWNIF _ D ll3t E 01Nf RSVCR I 6 . ? ) ) U G. 5,Ap1pNLYLICI A P05lION UNKNOWN SP TA IV i OICD IN H01'IAL NlU ] P05 UL NJUNV ( 4 UNNNOWII S SE At BELT FAIL URC [JLLI[U E eWnHESS . .. _.._ ._._. a J JI. nr ? ? F It ra ? '1 ???I ` • 1 FF . , I , L W _t f S pq 1 k, 1 d ?+ ] p ''. I1 4 t 4r 1 ? , ? t A i `` Fl 2 '+_ ?f«A?Y I I w s X u 41 ?,}? .? ? F i.--?.?'?w7':h'?'fA?'A4A iu l'o %? S A 1 p 1 I v Iq . ST ,? .W 1 I I a. t J 7 Die 1T l 7 1 L f .,7n : k I 1 1 4? j t ! r L 4 J l t?d l hliA61m;lw 1- ?? r bb y I R P s° M1l. Y N ii F J +a ' ?9 MOTOR VEHICLE COLLISION REPORT - ..w ? P NO - -. N - - O O . O s t LET ih N 0?7" 2a 77 / CITY 11 ••. a.?! T.TyzLftVR T .'•„?„ es.. r7 Gn ro, rl ? u ' ' „? LG PNLF ? . -- .T i vA;$c[ r 3 ?'Ll CrI ic?,vC L M / - YERGECTI G W ('I .xGTRE T.OR ROAO._,. PR A EO MILEPO N In iE rlOn LOCwTIOn OF COLLISIOn BETWEEN f ?• STREET AND MP wGRwM OAT RA - r SO ~w•? wa enazR cxoaNnu n ?exazr en IParv. nine uxonann [ ex oc[. I N % R° rfwvee nrcn ?? u NTER T E CLS, [rtxtncze oa w ww SL/J walrtl O / x ?L®r I?I v[nlcu arq•w La o c ?' .noa o "? 1, ? `i I /( GPE E SE R xun a OwHCrT?-?srwuc • " ' ? BA4R?!_ .: iFTlly[a[IL:1/Yyw`.Z.OWNjMJ OP OBJ¢CT9•NANE;µ°;AD°q EGEti LOG 7 f I / S p AT N. (1O O ou WA ?` LJ M // f•' S ?t / "?+ L .i,N,oG Kan CC ? - Oq ELM.^530(jj{{}iV:$,;f,1R$F: ML U„•-T,.,l,? .,,, HI ° E' -__ DRIVEII- LA? _ NANE:.?;y-,r;?1,f IRST.;ryA E_, . ?MIOOL6„' 7 67 S R[EEIeAOgf-- :RODTH-NOLLANC41bX O. REET•A E ?:•FOUTE O:a1NO B0 - _ ._ _ _.. Y3 ' . , mLLaon P/r/ 4 i ronT.Rw x[ " -• CI ?,.?•- - - ??Op4 ORf1IERS?000UPAT101•a;y STATEiy-,w?_.,]v:•LPC °Y ?DIItVEgi'-OC44PATIp- -, v [ _ :: a _,,HR._s` srAre s A,rc-oF IRrN s? - D L E 5 Y- wT? se - !"A_ 9 I T Aas: I-00-Y/y-lJ'67 JG St/If n a ?.7 i/ 6 3 Y / DAY ." I O L oo?s --e .lroi. C,1 /,=Ma?iY ?iP /yoYcR/1?I?IE O Q3 ?Ta- !S _ TRwe?RPc TCe of .. Rrwre..::Y L . s?,r w c..O. yeY_ rnu E uFE N y srwt a?3 ^d?G GG sr//f OOO4ETEM wo . I<LE IOEN FICATI NO? t9G8 moo i n[wawl ODO ETEAIN - ? _ 38/%yzz s 77 1 REGISTFA®1 ?? {ft'?ONrvlg9lnGE r10 uT:S Rl4BTERH7 Eq / - •- ?-_ -}} _._ .,_ -,::.: luar. cnwoO,F_Nw_1 yc ORIV _ SLICliN?SE,?,- .,.• OvmE? -_?. .iLf.1.-A 8!I?ILTa¢.'?6r ATE OF;BWTN ;? ONMOI4ADORE?Sy? •-IaYw ' PA FrS+PP1.. 411?!? - v' • Ji"w.Y1SiI?a a.rr..no ?.?. PwRTSPl..veIICL. Aa[A°ED,Lx?.ts...i!Ei.Y.Ii?.Y??l:sik•i-vll+fJ.`3: •KI6•fr'f /,?Y% Y- S/DE 5? 'a Gam' .'N°lr`inr u 5 LIABILITY INSURANCE INFORMATION-VEHICLE NO.I - Cove AGE IN EFFECTFOR TNasACC ? DENT ON YOUR CAR ® YES ? NO M w Ey?` /Wlplk^kIO1f ?Ot?OpzplR. F•LW" _ie6A.? .N E:O.,-L LI'?K In3URANCC:•COIM •Y!.. - ? AG.. ?'e:._v: ,]ad!:r-[ld.-G a!Nt. YYwv.vil.[: ? Ll LLTY L?..GY.NH BGAyxdl.Y ??F/Ira.P/?( Eh'.?3 oG,? /?/?. 'U-v7-s"T87y7 ?-f' ct!• . / I?'xRy ASE. '2N0? URY•. '. ' wr ll. A>vTik'YMhw.r v... ' _:A?YI4 r.[Sr f NE AME RESG SIX-- R[ - F °rn a lwnaw: T A1 }?-? -iia watwl - Innaau.' ? - wA ?w,noN n A P`txrow °OL1 n:nor' w. w ooc r - Eel ® •• ?.?Q? ._.. M!U1tElIRSTp11CT AT K CS -. 91 T OFI RCO y'( V'M N.fIR1TONf,'TNAT? Pclgy? ..? wrvtwr? #- MILEp w az I VR CLC e.. I}ny Rwu<xaw ® 1 Yw? In xow co.r ILLEO L n I no. wr a l w ? xxix 1 nonl wn I ? _ ? 5? 6? ']-PEgww TE IN 7? ' ? . , LI . . ? 5[:] 6E] 7Q G O Tn YµROWINCIgCLE :.. OE q8e BCLOW TX P ENlD glFCRyPVtIOLEG,BYy4NOMB.. \ I •.-_. r ,.y ua??D,,.-• R?,s.?ir? vr? O` cow cyrl hl?hls%gy f??Ly?7 _ _ xwnvwr xu•la w \ \ /YrrRr3?1t/ LF• •VE o6SC ??kED 6Y /f__.6 csh esr D. "' . •[aEMn..•a,. ' 'f' i5' u i7"Sr%fuck /Pl l-fltc 4E r Y / C R / '? w f , ! ?? . _ % i v r . o.:?? ? y i -- , C e:, uwo Q I Frvv_.Rc!/cd_F,/ol?_y?e s/de. Coln--D/cat -__-' r -_CuWS _auiYGR «///S__SI?f15. RE E_. Gv/ioSe jffRD ?e ClrMc. RbNif /N? . ?: ^ f,? /t0 6 t e J! AS r..r J"EYE ('/f/ /to SRS (" i» C+? /, , N.^6[,<ly.,.f/ciJc• .X. P,? 'Tf1I.`L6 ?LC/DCkS'•. Z s1imr?;Jcf C?Yacr ff p / 6R t , _ • ? - I,w•x„„ / ___._/ fr'/Sc `?lrA'.=? Jo?f• ?'F_J?Ie Y195` f-1Fi1:/i?_ -'- a 177 3 ' VEHICLES POSITIONS OEFORE COLLISION 11 A INVESTIGATED Br L t "[•f° xx •? r••• r?? a e• fO V lll le O STREET NIaNWA [OR rb N r w nAN Nox R Yes No ??a?eoe ??o 1Cw F o a El .0 1.... '1 ? IROM ' O . T __ M1`.I USING ? a ]F 1 w ]n u0lS1N0 Pf OLS1RIAN WAS lJJ 1 ..la ..aw.• L, u. .a ??. , 'El 0? xvw , TIOA0,411gIAQ •nhYRA?r[I?••; ... bNT <ONDITbNf rgAII1C CONTROL I.."on iY O w0 1 [ VE C tACT ON! r 1[, wl I[xlfn0 v nett Icxacw unl ow NOA•1-la txczt :' rl I II [ y I n ,. rH I `p OATII°NT ? I ? GIG NAL3 ? I ? ONH WAY I ? GOING --NT A-A. 1 ] 1 f_j '.C.V-y7 DIIT ] ? H,ININO ] L? DAWN C_, ] ? GTOP aION ] ? TWO WAY ? I E] OV[DTANINC AND PARSING r U ] n WfT .lL GNOWINC ] pj E] DUGK ] ? YI f.LD SIGN L, ] ? NOVplf lql[ ? ] ? MA.1NO IIIDNT TURN C1 ] ? GNOw .r? Foa . ? NrlnOn,nc ?ONrM1 OnErT ? y ? ILAHNIN° RC° ? MAIN. LEFT TURN _ I OOPr r1AMPIe.? ? E] " ? ' _ I?I F f Cl a El ICC S? ORTC?I YI G L I l GN T1.11 T ? ] ? ILA-1- A.- n S I J A LEY 1:1 G C? A%INO U•TURN T? M ci lA-??WNa V? w ? ° pq M° N ...NAL <I LION rS ?I (? R ? M1 ? N ? E ? 4LO WING I^NASON rOn Iy??E. ncO pa?r°!q T ? :;recl:r ?_,{ ' L- DrncrN/rLACHAN L? UR ? q ?? GTOPPF-D FOR TAPfIC • c v. .. [ -_ C7 ^ ? ? ITa,-.,,[,IGn.L R : nN •?•1 . ." a se PAn ATED - // r F lJ ?? fD `? O ? i0 PD IN ROA°WAY L • • E J 4 A } _ 11D r7 A"" QAN ?rl i ? c ? >L ? i ? ? ° OFD L J arnnN _ srd d'"IV'.. ,. ?... 1 I - { ua ?l IN , flelall" .i . 1 INSTRUCTIONS: 2. SHADEAREAOF SCVFNESi I-AD, -- ?- © j1-1a?,•+ ]URAw MRpwISIiO SHOW PRINCIPAL gRECTIq.OF FORCE ? '-'t ? h ? - DAMAGED VEHICLE NO.T ,USE THIS SPACE FMi SKETC-HING DAMAGE TO TRAILERS.MOTORCYCLES. ETC, DAMAGED VEHICLE O 2 2 : a ? . ' . ° t° Rao ... _ta ,. ,Sr ^?^16.TMh H t .pool IoN, T h I' , IS . nn I B, UnOmuorle2e 18.UM-D. t2 SEVERITY OFOAMADE V C ° : EHI LE N0.1 SEVERITY OF DAMAGE!(OTHER VEHICLE, SFVEWTV OF-AGE: VENICLEN0.2 I QOISABUNGDANADE 30 OTHERM.V.DAMAGE I O DSABUNGDAMAGE 3 Q OTHER M.V. DAMAGE IQ DISABLING DAMAGE 30ORIERM V. DAMAGE 2 FUNCTIONAL DAMAGE A NO DMIAGE 2 FUNCTIONAL DAMAGE NODAMAGE 2 FUNCTIONAL DAMAG 0ME E MAGE TOWED BY ESSSTT,DWAO" TOWED BY EST.DAMAGE TOWEDBY EST.DAMAGE TO c!rl Il?I il(?(.rtM ° 11)rr/.jo IS TO 3 ?. DIAGRAM OF COLLISION_ - r-?7,- I-}--I{--r)-}f-LI I I{--If I ! I I I !DRAWARROW SHOWING Irv R nsG_ Q?I? I I I I f -ram-r-1?7I I y,•.,I' - I NORTH IN CIRCLE RLDE. wrc arrbna"s°"DV'Ar _ ?. I I I I I I I ! ' I-` ; 1- ° I - .. I Ti E.rc _ I I? sM?r 1.f ^t ! I I I I _i_ ICI PAr I CasTw`?,c"rc,wHrc ? I T I-r I _ ?W ? . , I -1 ?_._ a_?I TS ,,_ ?T? I'1 ?rw PBDRAA?EPDNrb I I l ? T-t ,? ' : ?, 'I v^ I f I I TAI ( I-I? ? ?-'---?-?--j L T---- I i a D E nDEaRR HDA - 1 PDVKaAlwPAC. r - TY ?.Ir _.,-jam I / s,rowPnoeAm rettx« r- ' r2 T2'? `r I _?I ITIiIII?? C?-I!Fl r. III DESCRIPTION OF DNDICAlCATE WHAT PRDDABLY HAP PENEOBEFORE DRWG AND AFTER-CRASH WHAT PROD MI \\ U . . INCLUDE INFDRMATION NOT ON DUDRAM.-E.G DRNER COLLISION gS PEDESTRIAN CLO NGCMOR.CGNSRVUCTIONORREPAIRWCRK ETCJ' - 2 , 77, 70. ice-. P IT D VEN Kkmo- NO. NB fl C LI tE DECREASING WCREASING DECRE - -- NO OF LW ES W 0 EDIRECTION, SPEEDS VEHICLE IF PARKED roS,LEGALLY ; N E W L PARKED - ' YES NO YES - NO FED. CIDD µ a G - ?iKS9m 1P r M E 4pwFAl IETOwI PED Bn,YCUSf WASUSW 6 ?lJ aumw ? :I_I wuA I + C ?_r Au [-I IE RnDOUrE 1 IoiHF D a R ;,. ROA ' SUR rcnEFACE « DHD WEATHER-„•;, HE« ONO ,:,;_,.,_- _: L-CONTRIBU TING CIRCUMSTANCES! « ORO - o NO, O ' . r - AHEAD NO. vFRICIE E r45 t ruuHr nJ L V? ? m _7 -ccDyDr - O ?DHD ° D Cam- Cr D a Rl ,? O (? O wEl ,D A..ND - D2?R N -- DeC R E -- C - . DaD O Dew C o Dlo ?? n R. AK D D AAT- Rlve?wn'-' . . o i __ I vE..c _E-' -. I__r_L! DeD we.D . Zv n C PRDNA n m ? E] D „KK,,Ptpr, ? ?FDR D LIGHT CONDITIONS ,rmu arm .TRAFHC,CONTROL- rz„pi ?cHnE. .TYPE OF ROAD rc . aE « M«q VEHICLE CONDITION- rTHrcaE c J:SDDRIETY -..:±.Yd k f J-,O qm -D AsIawL. i f ' , LC p«^ 4 D, m u ? D,n ° RTo- N t wrlloNr C 1 D wK ??ol I ,, ?` ? vro r j lI !1 EnlrE - Aom ------ rAr R?rrc AK ! a J_ a r Y ° -- =ED NOT Dtt? P rc ^°?__ C'I L 1_ ( ? en,RC wqE ?AL _DmAM - n ? a , ' u 4? N ,D M NTH, ? rRAFfi Asa ° AS.oq LJ_l,i _ !°?_ _ ._ - - n Cyl .?"°TM . ri,.( - - MW T D10D eAc D b an?a r rNV E::r ? ^ ,VRCG bf CHEM, TEST , e ? l:? T Ir . R L L 1 ? fro?N -o w c:---- LJ I_-7.IDw U L-l _ _ _f • y-. ECn 1.. IJ t'- esTADVIID , Aw+ wX61WnAlbr rw Ao?lwrc `AOmo O iza -. oNeRlrF % % TEST RESULTS 2 •1 eM.f,pAthpb. U.f :7 t rI IgKA DS P.,C D ... ` . L.., fl.1- 'y. pAn bgpRT ZI/7 er Ml7si ?/ _ ?. !?,? ? ? !fit ;:.,.?a r.-,,....,' --?+?tA :?>.°a?a •? ? >I ', ?S ??ry E{nj T? „r,R- 1 41 sIt T T k° Y r ka 1 g Y' .A Y My?+? ? n£A SFaE D A DATE OF COWSION M 0AV ?N. DAY OF COLLIS ON TIME T SUN I MpN IUfS G WED IIUP F I SAi IBS(. %pO NOURI y COUNTY NO / CIiv NO /I? FNWA URBAN EE1 COU 5 7 q D ? L = AB Y OMCLS. PNEFYI% ROUTE OR 6THEET CODE uRAl S CTION 1 L L ?STATE ROUTE OCWNtt ROAD ?CITY STREET ?Jl•?L./? ?OTMER SPEC-) N ' L ?IN CITYORiOWN W FkF1X EO MILEPOST o N S E W CN A? C L rvt ? ? ? QOF MILES ttit 8, . A bN00F ST EI Oq HIGHWAY IMERSECTIN6 WITH. STREET OR ROAD LL NAMP DIAGRAM DATA T ON C, NON INTF 'ECTgN ACCIDENT I NTE R NON %RU INTERSECTING STPEEI OR ROAD 01111. N" n 1 /? BETWEEN I/?LF\l? 91 MEET ANO (,• - -HHP 'ILIA E CODEG 1 E. CtS. EPENCE CROSS STREET OR ROAD ?? O INSTANCE NID gNECIION FROM H[FERENCE ORC OSSSTPEET N 5 E W 5 S PEC AL CODING USE ?J MILES A' Z- FEEL 4? ? OF P A _ ?VEHICLE-VEHICLE ?VEHICLEBICYCLE ®OTHERIWNITEI ?"IT"UN COLLISION INVOLVED: SEVERITY N0. KILLED E]VEHICLE-OWECT ?STOLEN VEHICLE TOTAL NO. ?V IV ? NEIURE. OF VEHICLE E EDESTRIMN Oi S [D VENIC ?av-CN O U K;W ?HAZAH ERIAL ? PE RTY DAMAGE ONLY PRO OBJECT STRUCK INAME OF OBJECT STRUCK AND OWNERS HAMEI LOCATION OF OBJECT STRUCK - EST. DAMAGE ?ROAOW.AY Lt FEET ? S ? ? PD EDGE S-&-- OPIVENS NA 1 FIRST MIDDLE DRIVER'S NAME?LAST FIRST MIDDLE 1" BICYCLIST OR PEDESIRIAN CHECKIy D U i?1 S, R 1 CN-A 1) C, D STREET ADDRESS T ? L 3A "P STREET ADDRESS E 6 T _ X R CITY STATE 21P CODE PHONE NO. E A CITY STATE LP CODE PHONE NO. Qu ? ?erti? N O•, UNNERS LICENSE NO STATE SE% DATE OF BIRTH DA Y N O. DRIVERS UCENSE NO. MATE / SEX DATE OF BIRTH MO. DAY YR. DRYERS OCCUPATION FIRI, AME ONE NO. '1 DRIVERS OCCUPATION FIFIA NAME _ PHONE NO. ) QC- c V 1AI SEATO T T IL EJECTION CODES > IGI C AS S CODES >11]1 CuUU 141 SEAT BELT 151 EJECTION n /Y P.A.FI SOF (4. LJ/1' t NJURI S F C FROM SCENE BY W - TO -C- Fn000NE BY, TO VEH.YEAR 11 IDOOGEC EV.1 MODE IOMTNOVAI Si Ib DR CO I VEIN YEAR MaKEIDODGSC - 1 MODELIDANTNOVA) STYLE It ORLONV.I H E OLOfl Y UC PLATE NO. SLATE iRA1lER PLATE NO. STATE E VIN. COLOR LIC, f ATE NO. C STATE TRAILER PLATE NO. STATE -?LAC DFVti J I C VEHICLE IDFNTIFICgi10N FIUMBER ODO MEIEN C VEHICLE IDENTIFICA 1 i NUMBER ODOMETEfl E CC lq4 r S r' p E /q ,J REGISTERED OWNER-LAST FIRST MIDDLE REGISTERED NNER-LAST FIRST MIDDLE 0 0. ADDRESS OF OWNER ADORE OF OWNER 2 NAME AND ADDRESS OF INSUR-CE CO OR AGENT , P\1 NAME AND ADDPESSOFINSURANCE CO. ORAGENT CI CHARGE IATIONNO. ENFONCEM. CHARGE CITATION NO. ACTION ADDRESS & INJURIES OF PERSONS INVOLVED NAME CODES _ 2 3 y I sz( AGE STATUS EJECT. O NAME: C ADDRESS- U P NATURE F SCE E DY FROM TO A NAME: N T ADDRESS $ NAUP EbOF GI" vll.FRM TO r W NAME ---- T ADDRESS COVED WHOM NA TURE OF N - JR-F.S BLFNE RY. TO S NAME' S ADDRESS-, 5. _ MA NE- P.CFNOF T O AISIA1U5 I>)5LA1 POSITION .91IN.IUNYCUSS IUCLI 151EJECIgN C µ 61N J I E' E LE[I 2 11 RY T U N O ? E O 1 I'EDf BICYCLIST 1_ OIHCR POSNION i D A.Al SCENE 0 DFADONABRIVAL OI DIS- 1. S TAI L V. HO CTED YCJ iN I IE-ENTI INJURY ] US D U PARTIALLY EJECTED D 5OTHER . ! 6 I.US MOfOHCYCIEI AO[DIN HOSPITAL N T.POSBRLL INJURY NOWN 4UNKNOWNIF E 6 WITNESS if PO RCHUNKNOWN 5 SEAT BELT FAILURE EJECTED NQ NuA G 1 r I' fi I? ll ° ' rl Y At; JIl ?"2Nrr Ifi.: :.?, It'YI ?. 1 KL 1' 71 1 ., r iI?'fT a ti q yy Iw, I ? I h hl t ' ?` ? ?M,? ,, ''!' 1n1 I' 1 ,,F ! .YI 1 V f 7777 K ?1 J '1?'1 I I., r i J ? R 1 1 ?r 5 yl? LIB' iI .?.{ I Y itf - ., I .IxL.,L.r.NN...In?LAIHRNU.•.INRNU.1 -- -,.-- (. mMIGLEDAMAGE . T E AREA OF SEVER T P T ` .-- I, + fL 1 SHAD .I . . ES I. AC INSTRUCTIONS: ] OR AVt ANROWIV TO SHOW PAINCIPAL DIRE IU DF VN.-E C DAMAGED VEHICLE M 0.7 -E 1- svnce noR;SEr[NiNG --c TD TH.iLEg1-C-1-5 E+..r DAM _ VEHICLE NO AGED EHI .Z - -? mA. - ]. Nwu I IJ_ ? + ? d uwx..•rnv t ?+ +?•, , 13. Unexwrr.ya DAnuOf: VlreCIe NOJ • NEH:rv OF L LI CISAetING DaMAGE OTHER N V.OAMAGE sEVE"ITI OF DAMAGE'. 10iN ''E - r1 LIAGE: vE"C_E 1O.) ,oD LNYG OANU10e?Ca - V Ma :.. 0i5s??°?OAarAGE 1}'1; OTNERNV.?-All A l T[,'I'l-TICIIAL OANAGE ; N RIAGE [:IGrrAt OALIAG- NaOE ) F NCT K ?Y tAGE FU . Li r i= .OANAGE To.-.1 _-?,: LrF S, S E i0wE0a EST. OaiVAGE IST. DA.A.E IT-E. .1 ++ ro - '-T., : , • TS. - :+? S 1.0' LG s s DI AG RA M OF COLLISION :. I. IOI?Y Amcwl.lnowt nuunel •+;%'.'%rlC.!'?/ .%•\=- DRAW ARROW SHOWING -' Q/" NORTH IN CIRCLE A?/7"' %I ?'? ?? ?LPS*. ANa OP .Dw rrDAOnav - - __ - C' is =wisN:RGU 1 1 1 ______ . -!.. \ z, - A. I'll AT.. ILFC :-7. NDwYENRLE ILD[:* Np, : - --? - -li,?"r ._ -- HIGH. DESCRIPTION OF IINp.CAT.w11ATPROe.-HAPPEN EDdIFONE....MG AND AFTER THE CRATN,xCLUGE.11.-AT-4 NOT ON DVG-.E-G. DRIVER _ COLLISION p154eILITY, REDUCED VISt-ITY, PEDESTRIAx CLOTHING COLOR. CONSTRUCTION OR REIAIR'WORK,ETG, ..A ' ??..-t cC_C--. E: ?! -^. cr-!-!_i.: i?:''OGi.UD .GiJ .!?'- /c i fiu G L'/?/_" .`.'iJ!/.L.?G'.?. .------------ //// ?11 4JjJ!F Gam. - .C?'.:? c t.r`+?!!. /.$ ?eJ.?JEi<:.. _ - h E"?Gtic/i/. ?._../,Ci ..?? 7 , ? POSITIO V EH. IIEAGE. NS FOfl COLLISION HLE POST.- On STREET OR HIGN-Y NAME ON xO w. P AN IYCVE DIRECTION ? ? v CLE LEGALLY P ED IPV to WAS VFH. PIED OCC NO. x d E INCREASING ECREASIHG .1: 'Y H ARK S NO U E NO I. ? '., - ... .. MIN .. -_.: _ . IED. ,. r rr •.."w r n+ruH caxn< nI ALONG CPoss.NG ", .... ... FPUrt _:.._ O:, ...-?,. - IED: SICYCLSTwA3 USING : ] a RKED S UNMARKED G DESIGNATED t' SI OFwHR ] SNOULCER CROTT 1 CROSSYEAL CLEROUTE T OT HER ROAD SURFACE CIIFCK ONFI WEATHER CNf<K ONEr CONTRIBU C TING CIRCUMSTANCES "ECKONE OR I N ' C F R C OpE ,. DE INFLUENCE pI .VE1 0 OWING SREGARDE STRAIGHT OVERTAKING AHEAD OV .. .. Y 1 /L ] W OVER AS ) RAHI- ALCOHOL NEI OF •) DRUGS V--- . EzCFE DING STATED T CLOSELY O ERCENTER ia1LING iO NSG. AR'NTL A SLEE IF IVIROPERP KING p ] NG NO ] =T TURN - NgKIxG J SNOW • C! y ] SNOWING ?v/ ..... _. K I^ IGG y i SPE[OIINIT -Ya Uzi ElOINGH "ED y, pIO NOT RA .1 .YE TO VfHItIE H SIGNAL 0 iUN OIfN DISREGARD srCHFOO G id LOCALON IS GFERAi NG fF ECIIVEE `, / ?j SIT t??I? J LEFT TURY MAK O , TU ?X1 <6N6 OTHFH IflECIFYI IUIWGITL'ONDITIONS TN[R IV[CN YI RAFFIL CONTRO IpOIfR E IASSIYG NI TYPE OF ROAD t EIAR t] S usRN SIGNAL VEHICLE CONDITION VEC Y T a UU VEiOIAi ON I ' SOBRIETY STD ED IOn ) -' 1-11C STO FDAra GNAL ICNEtzON[I f O)ViNItl6 SIGNALS NO. IC ECRO4l0 NOREI I. O F WAY I.- f I NO.) C YRIb1T{E01 "rCl! I<IIEC ONES: IO ] • } y .'ORSTOP SIGN y STOI EISN ROAD A DAYtIGNT t ] D ] ff? dl 111 L0 ]TWO X p! f S L[ t D. ECIIVF LS ] 0 EC11V! 11 TY 4 IRED N O Itr t A 6 N TRAFFIC LANE TA TING ROu AWN 1 DUSK r' [ 0 K-6TR!!T LIGHT— ON ] D NG .. y'. JZAS ] PO ? INTERCHANGE .. LOOP nANr 'd ALLEY GN IS pf fffv[ - ] PLUIt GNTd IA T E ONN _OF -.I, r• ) ;LIP NOT PAIAINCD HEDSOSRI[ Y - U - a xao NOT dE[N DRINKING p 11, t0 01ITION T MERGING IENTERNG - TngFIIC1 - OFCKING 15 _ y. OAPR-SIRF[!T F .. p LGNAL A-ti[rl AYNF V I ' . .: y rrn[f n,Nr ,unlN Ox Merv. DR VEN CHEM.TES t NO.) - r DAIK-NO. y OA K- 3Tfl[HT LIGKtd [ LA - pI GNAN L -TFL'i'ES fr- S. SErARAi(O O 1`• I V TEST GI LN OTHER IVEC IrvI T N _ U ? t .-M. TEST OtrNFD OIN/A IVICIr YI -..- a y] UNOIV iDEO T OMEN GYFCN YI .. TEST RESULTS 2 VEItnIGA[INO `OFIICFN-i NAMt?R M1 T ApG[NO LKI OIV NFD L?:7r')tArA"' IuLItE AHNiv6U <F I ICrL?W ?Y. _ ?r : ?';1 °p?l`?•?.? A gip, iN&Q ? ? Ivv[yTIOANNGOlP 4'L '; ;i t .7q t?l '?"? OEnO ?i? l +GSYL'r . !). r? U•HI OH DrT r. g ODE ArEOrN Nr 11 v API nV[O er OAi! 7R i OVFLIC.Aji'COPY?`LOCAL LA/Y FNf ORCE?VE NIAGENCY'^.+CCP V'TRi PLICATELCOPY"INVE 3TIOA"INSCOPY . 1 r 1f?1 '.-.?1 , ?Z!`? T1kt?Y+ 4 µryu.ntli' .gab silo +f+ 1 Ad6t : '¢,nlt- ,.I ?ti .? j 13,,L ?.? N w r k M1 J S7'A?fE OF WASHINGTON-. ? i D+IrulNrnul.BEq - - -- -- -F GLG , p? UNIFORM POLICE TRAFFIC COLLISION REPORT , _ ?FCr rl] DATE OFCOLLISION M OF COLLISION DA TIME ' CITY HO T . D 2 COUN TY O STATE LINTY ROAD ° CIiY STREET ? OTHERISFECIFYI GO CITY ON TO.N O NOUTE ST L E _A q NIG w OBI ? l8 H ERSECTING wITH:STREET ORROA T W ? ? l T111T A RE FERENCEC 0334flEET OH ROAD ? Q ' N ',M'RGCZ AND STREET RETLVEEN ??T •l l? DISTANCE"" DIRECTION GNOM gEfER[M<60R CgOS514.FTREET FECIwIC IRO USE ICLE-VEHICLE VEHICLE-tllGr<LE COLLISION INVOLVED: ?`?'J--?I? Eq iw (J 1 °HIT6 RUN ? VVEEH ?3TOLEN VEHICLE HICLF-OBJECT UjVFHICLE-RN TRAIN { Lµr?{V V Fv ERITY _- O. KILLED ., . {?. JTOTALND, 1?' ' OF VEHICLES `-F-? ? VEHICLE-FEOEEr RIAN ° NON-COLLISION HAZARPOU51ATERIAL - -?....... '. _.._. ,NO.INJURED PROPERTY DAMAGE ONLY ? OBJECT STRUCK (NAME OF OS TSTRUCK AND OWNERS NAME) ) LOCATIONOFOBJECTSTRUCK EST.OAMAGE j '' ? VP11%-J L/\ ?ROAOwwY 12- FEET ?? E ? RO. EOOE S 6 IVERS NAME-LAST FIRST ,...OLE SNAKE-LAST IF-T NOOLE U ..YLLIST OR PEDESTRIAN CNECKIU R , S EETADDRESS v I v E CITY .. ..., __ STATE ,:ZIFCD E PHONENO. E . G _. .. ,. .... u.•.ZII CODE PHONE NO. R R N DRIVERS LICENSENO. - - STATE 111 OATS OF BIRTH MO. DAY N' O RIVERS LICENSE NO. STATE 3E% DATE OO?OIRlH MO. YR. 0. O: OR.-OCCUPATION FIq-A¢ .-„ ONE NO. RIVERS OCCUPATION AME ., PHONE NO. CODES ISI CLJULSRSY IJI SEAT BELT 'EJECTION CODES IJI<LJAssr TAI SEAT BELT fE'EJEGTIG.N . AJUNIRFS F TO '' FRO. SCN IV: TO E F v YEAR MA%EI000GE-CHE11 VEH. `7-7 L`tt'q. OOELIIAR-NOVA)3TYL - l 11 t?i?c,oN z v, V.I. YE A R AKEIDOOGE-CIE'. MOOFLIDART-NOV A STV LE IF DR._CONV.I f EM. <O L 4G PLATE M4 TA Rwltfi RP TEN .STATE re I E.- VEH. <OLOfl LTC. PLATE NO., STATE.. . tRMLERPLATE NO 9twTE l ? p ` ?? ?:?7vt 1J0 EZLJ Q,a4{Z Z' H:': `• VEHICLE IOENi1FICwiION 1; zz -1 1 -Cl' L VEHICLE IO¢NTIPIGTION NUM f -,?;;,, : ODOMETER E RE IST ¢D OVMER-LAST ,T-.. _. .,. .FIR,S/T? /?MIODL¢- ' 2 E., REGISTERED-ER-LAST.: FIRS' MIDDLE. N ?aLVJJze%,th f•trm ( 1T T*- N O; ODREm of .. ... -.. .: jsS ?D - O• - WOO-. of awN[R, ...:.. ... raw i em _. 2 M(EwNOA00NE550 INSnVNANCF CO ON AGENT _, ... ... .- R?kL 11PAE AND ADDRESS OF INSURANCE CO, 01 AGENT. ? I CITITIONNO. FNiORCEM¢NT wCr ION CHARGE '... .., _ CITATIONNO. NAME ADDRESS& INJURIES OF PERSONS INVOLVED cDDE3 , E% AGE 37A- el[CT. C wME: N C DOHES3: D NATURE OF SCVNl qD FROM To T A N oRCV: S uxE Or ss"cF-e 6vH FNOM jV '? ? I gtA Xg Z M},r ?>f4 e t 3 . MIA U • l I k? L d '? 1t Y. ?, IW ? 1 t ) E? Maw ` 1 • . • ?J MOTOfl VEHICLE COLDI jbAl REPORT NO. GATE OF COLIISIUN D AY OF COL Y LISION? TIME OFrCOLLISION, ail rt1-1 rx • COUNTY NEy. CITY NO. COUNTY CITY, TOWN rA r M1IILES 110 -. CITY, TOWN; ADMCL S -111. n EO Si 11LITON GIV-rNNAME OF STREET. IEOADOR HIGHWAY. A. r', r (6 lYl . ' - 1I1TER1E1TINGWITII: STREETOI? R?OAD //?? ClrMArw ", r•V1 /?LC PREFI% ISO MILEPOST ?j ??Z NON INTERSECTION-LOCATION O OLLISION j BETWEEN STREETAND STREET RAMP DIAGRAM DATA I OT["' O"'^/ (O ® J OF C I / ?Oix?ao ?r [w l u r.r s....arvau..li' u wE IN Q HTE CLE. xEEr c/ / O . O.yeo r evex c.e .e orx x wxrrEr o. 1 a o [oa,E?. ? a ? BPEC. LODE SE ?, .? wE[r r.rv oxrx a OBJECT STRUCK..,+-r OWNER OF OBJECTS NAME AND ADDRESS%, LOCATIN S? -..• IN ROADWAY, ... ... N ar 0 [ A aou[cT. a i FEET S ,,y •"• ORINERSLASTNAME. ?;- .. ClIRSTNAIIE " MIDDLE:., nrn? • ..? DRIVERS LASTNA„E - FIRST NAME j MIDDLE-:. H;ch4Le 7'- STREETAODRE53 ;.. ;,-.;. ROUTE NO_AND BO%NO..- 52E/G? C I 1O"E r"•"r"O STgE ADDRESS ....: ROUTE NO, AND BOX NO.. 7' 9 1?!` ^ I / CITY .STATE IPCOOE ,. LS 7" C a ?a C? 9SG G 'O RIVERSOCCUPATION- ?ac{?' is7` w.. CITY ., .., STATE. ZIP CODE Sr?,Tflr Wa 9?f168 DRIVERS OCCUPATION, DRIVERS LICENSE NUMBER r .?_ STATE N 9 o s 5-7? SE% DATE OF BIRTH AGE 33 DRIVERSUCEN11-11ER:-.-.. STATE #0 e -tn-PKyYli NA SE% DATE oFBIRTH vp ?a YES AGE vEHICl6 vq 6 6 MAKE- xav.0oowr G M C MODEL ,.Iwvauar?, BODY STYLE P1'ck U VEHICLE Yq. MAKE cxev. OOmO MODEL I vrmwU,; BODY STYLE now 5Z On leg LICENSE PLATE NO. STATE'.: TRAILER PLATE NO_ .STATE LICENSEPLATENO. 'STATRAIL ER PLATE NO STATE 08365 L?a Aeon A . OZ89G? WA Affl4c TION NO. as .. OODLIETEq wnuCU VEHICLE IDENTIFIC -15o _ f3 75757 EE M VEHICLE IDENTIFICATION NO [ar -:.,, qDq ER. wr.E A A REGIST ER ED OWNER I-Asr -x.uH, ,.: DRIVERS LICENSE NO. T3aurlu llrssie M WA73 8.1x' REGISTERED OWNER -usiPra.Tw wEE ._•.w, DRIVERS LICENSE NQ-„ OWNERSADORE55? GTPE[T GIY TATEI ,_. OATEOF BIRTH r•? T[ 'Z [' d C ,V VV i/`l ?P ??Hll[Gbll9 R... rt •A0141 OWNERSADDRESS (STREET CTY gs/ATEI __?. DATE OF BIRTH ... - _. '0 DAY YEAR PARTS OF VEHICLE DAMAGED... L I N R OBFORL aTHISLIrYACCIOsu cE COVSERAGETHEREINUTOEFFECTI LIABILITY INSURANCE INFORMATION•V EHICLE NO 1 4 EI , ENTONYOURCAR YES ?NO NAME AND ADORES OF lIAB1UTY INSURANCE POLICY NOLOBFi NAMEOFLIABILITYINSURANCECOMP NY NAME f( Y3 a >G T3Ch ci+ F RPM e / PS fe oLtlna G L, Tfac 3 :A]aL a ?3Z5 ?r"erv ?ns Co e » /n NAME AND ADDRESS 9R LIABILITY IM3UIEANCE ENT„? ST iE 2 PLIABILITY POLICY NUMBER 5, :-.. . /?? r. 17`73*M 12 3S J?a6e f' ('ljr, ? h j'or9- r wn ,,d Wa 'ISTINJURY '.W:?..?'?Sx.?•wxr n, v.?_:. ..-..n Vie..-. ..]...?? AGE 1HD INJURY (USE EE ARATE REM on Agmnq L U IE I•+• • AGE AM AME ADDRESS EEx ADO. E. SEX M F M F 101 S F1 ?STATUSOf INJUR[O"' ?WIFKFIRSE DNE TMATAP)LIES .TTTS'''IIITATUSOF INJURED MARK IIEE_Sr ill NF THAT LIES VEHICLE ? . .. I ..?-r r~ N VEHICLE ev a wrr~ioa KILLED XI LL EO wiu •. E J v n I x I ' I L+? [] 7 re ? ? I I 7 ? ? S THErt v;RIT I;r E 6 ?] ?rc O HEA IrH.T[IN ? 5? ? SILO NORTH BY ARROW IN CIRCLE _.; OESCRISE. BELOW WHAT HAPPENED, IREFER TD VEHICLES BY MUMN CJ11;.« w! P ®. n; -Veh/c/.c_#OryE kJ Slop r _. , a s7' [cl. 7? zYyf ro ?71- Pa n ? .Y. T f a a Sa.cl? O?_?Oac?v?JiTF j7 oic1L ? . E - s ? O - ... -- GY $70C 1?1N ??Pre)l y2Tp? Of 77L arm[ P3arEn l?o.?tCE AL JE 5r 4-; 7 = ChIC ?'?y?'One_l,EI rG Q^+ f/.TC/c/p,h_ '? F' Fa [ C 7 D ' • I ? j(t-yl s S uO F c .r?_INv T .[nN r e iITYI-r Cy _Vch i-C !r<°. 7. t?Q??/-7/P r0ac e?t e'CI Y.. t ZI= l...orrn.730gc?.n ,/Ie IVCr_ j?oy.E ?•. An.`?. ? g Ji f7E UYXCIP r; 041 +` _ - v; ? ? G- SLOW; t0 Or 57W,-F'u.; M VEHICLES POSITIONS BEFORE COLLISION YS N v INY[1TIW rlE BY ivr rr rax^EO lADfq y • EET A HIGHWAY NAME OR NO. w+ attfEKCUriP ,IA,E ar la VEHICLE R T OONN S ? Ll ? ? aT r? IVOUIII C: 0 ?I wn -- - iL ? 0 M T `° 10 TH[HI IN ? ? ? Cd[r /f CN rn y !, CI ? ? i1 yf. ? . _ _. ? PEOESTRIAN?..:..,'? ? ? ? 2,, '... AIONb •..'a.rv -...a .?'... . ?.'. '.: CgO.ZSIN6 .,,.':.FRO T0... . .nAAwWr:rxM;rJ n, P[OESTRIAN'NAS USING 1 ,•0[w^ . t ?w..rwAr ] s•• sw[r. S El a E ?OTxln ` wL ROAD SURFACE c. n•rEr E ? I ,? DRY [3 1 ? WeI WEATHER ) I ?d:i.?:['{a 20RAINING ;10 N -' LIGHT CONDITIONS I ?DAYUCHT ] ?DAWN ] ?o- TRA CP`C CONTROL ox,r ? 1 ?SIGN ALS ? ] ?STOP SIGN TY EOP ROAD rx µ ?"I C] ONE WAY w" ® E ?TWO WAY SIRLE D IVlRNEHICLE ACTIONS -,., v .[ I aroma[ cxlta wrfO ? IK CR GOING STRAIGHT AHEAD ? 1 ?OVERTAKINO AND PASSING . ? ] ? SNOW . ?:DG TAET A ? DI K ? ] UVIEID SIGN ? ] ?ROAD NI[RCNANfE C:] ] ?MAKINO RIGHT TURN [ S ET A' C] A ?FLA1HrNG qFO ? A ? ILOOPIIIAMPI C] . C] MAKING LEFT TURN v ICE E S?NE< r?. S?o TS Of F ? 5 ?[IA SrE NG AVBEII ? 5 ?ALLEY ? 5 ?MAKING U-TURN T?? E???v S l_J Sr (p DIE NO A?STRIf TL141r 11 r1 Ti ?R.SGNAL ? A ?LIMI (unN lAwS ? S ?11.0-NIS R(A5ON,04 NOT S. i.HV..•rn. t rv . .... •. ....... i ?)?CF/C[R.IIAGMAN ?1?STgPPf,OFOR TRAFFIC --- ? ?"', xr -?srPARATEG ? . C] STOTOFS14N11AL -_. .-.-..,, __._ ? l ?DIVIDED 0? STOPPED IN ROADWAY ?''69H0"RE'„b ...';lb O ??VO IR "C CONTROL mmpEmn ] ?UNDIVIDFD F.rrYeRWUUmea.-.I T-?ID STAN TING IN I •.,. J+ r.JSL4Af&JGld7t: K, 5 5 i T F - j] Y 6 . r J ? i i• y $$ y : M1 ggyygy??W 5 ? d t yy #.. ?, 171 ?t F A ?y?E L f.qy 14e E Pr 4" ? ? ? T P • 1 ?• A fS - r V ? f - ? ? Ydn?" f.*" 14V pig , ?,t ? 4• J!I 1 1 15.? ..rra. r...r .....+....._._.. MOTOR VEHICLE COLLISION REPORT .,. __ NO .- r couNTV H OF s D COL .. LISION - x - c r tJ?y y (/v n ' Y .-? N / E^y E@ TY O. / C EF r c° c ?0 a TION d / •r / /i ,. f ?' .!' Sc /li Y r1L? Ci/ r ? - E OF-.STREE ?,POADO HWAY..•?... ?ti ,.E <T OW)TH_• fl RPOAD M •o ox _+-,.,.GIVE / .. ... .. _. _ PP % LO M CPOST / , / L? A G M O A IA NON INTERSECTI N -LOCATION OF COG?LLISIO //•/ ? ?' P IA R M D ..ET ET A '? uETwE En- --El - NON % RD nra.x[.T xa O?1 L:d. hR4 Aaac`io ar o[ni ar xc unuwaxx a, oca. ; .ca x fr x R CLS ER INlE "T L a.• ? s, -z./ 'D P El USE a - ELT STR ;fir IKA .,n .. "_...).,4:.-.._.... EN'O •. COTS, NAM D ADORE .- _..? IN R _ Karxa ai L"1 E? WAY"'" ..'` T _ f 11 1 ?L?S i 0 E SC TN E ,,, ? 1R5T ':.. LE UJ `ER S,Lt3 NAME__%-.:'.- RS .N ... ..._.-. ... IIOO E .fin. A5 ? ' C f / Nd /' /?/?or? C REy* O.- ".,PO TE. E N TREETQ 3 -;-? 0.,U :NO .......... T R. / U /i?x ? < axTra \ 1 .' E ...21 COD ORIyE 5 C TION: CTY _•„ : STA - .,,., Z CODE OR E OCCUPAT E ERS LCE SE TATE E TE PT AGE E U E0. TE %, E F. DIR A ' Tux ' Gi/[U/L / 6J 71 f ?3 ? - .i. Li-/7 ODE +l _ AxYI DY STYL a!2'..•• I 1 r M NE M EIL'- 1 DORY STYLE IS R ' ' ?• - . u w M ? f rv. /7 Jy SE PLAT f -... . i - T ATE.N ! .. TE+ x. E TE OI E_`;_ .TR LER PLA-SEM C L_ f X/31? fi 7 r IDE OTIONN 4 100 TE EN CLE TI TION NO I D w[1 OETENI .aa V H LE ; ? ? HECI ER IYE t _ 3 L SF ,11E TfiR O ER.IU ORI ,LCE SE NO?y ; N 5 SS -.?J ,? :' O.. _T F O O ._-ORC 3 ,,. :., - ,J T OF IRT RTSO V IGLP?DAM. E „?_...?'.K^ __ .. s.ll.. x.+,.. . PA T F VEHICLE.DAMAOED '., -" Jle'..._.-_:.« nwi ?eae 5 HERE U 06 LIABILITY INSURANCE yE5 ? NO LIABILITY INSURANCE INFORMATION VEHICLE NO .'l COVERAGE EFFECT FOR -15 ACCIDENT O OUR CAR III??? -. /? r NCE < M A ADC ES D ITV 19U E V OLDER N - /. '?• E t o 7'?Yn IS ?? ? ^ `` :Z: ZEE n . A i2u+ertD t gut NIA AMe AHO ?D oP,l.,IA . .NSU ec ul.:ca•w.. :.e,• .. ... _-. , °uc- NY ER..<.:. .......s:.::.? (/V t/V I V ry INSV LquL .LSC' G CTM Sr f3 LZO 4 f l,J Alsd rTy G An" RARE . IL CLJxtd? M _ ADORE F F• ;:' A 1rJT/ I? `? - M 7' A US O '.RE D ST; No" rLLE L? xa I ' ' F, .? rR / 'L[71 ° KILLED ? JAAgK TO arfA.uxa rx.uxr 1rvaxal 5 ? NE THAT AP . I ° x°,I 0 ES "o`7.rx Lrar T T ED - VE C E x o ?.. H 7' LED "? M HK FIRST O E TNAT APPL ^?' 5E y? IES _ ?a*c.lr 7 SNOW NOR IN nY ARROW IN OIRCLC I , DEL W T HA PE Or IpEFE TO -CH OLES O NU DEPT);} OESCRI E ?, 1 I K axw.r nA as n e\? ? ( l F? I I ` C Y 711¢ Lr!? ! /44N0 uf-_YIfG° 1Zaf6r N..$ZOtF - p LR.. L?U:-?l7 trJ D.1/rC /-.'t ht WI. 'J 1. /yy p. ()N TG_INt_.__. ' . UG Z. xu•Yi xf?wcn rcla ,x fxow ' .xxaw gr: ? en° ;;. 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IISIVG 11.7• )?w l?, •1 ~r Trtf OF ROAD D IVRR`VEHICLC AOTI --- rAO[ -ATN LIGHI COHMlrONf IrG COi.THOL IN f lM1AI 1" n1c,PxrO uax11?'• " r • I GOING Tp AIDHT All[AO rl 1 1-? O C WAY IS 1 1, Ell ...... II ' y r?.r?f. 1 ?? DAYLIGHT ? \ - I ? TWO WAY T OV F.p TAKiNn ANn PAM1SINO 1 nAWH CJ ?I S101' S G 1 ? L I 1 r}?IIRT JL1 HAINN.O ! 1 f r -. 5 5 T 1 l(.. I} l MAKING IIIGN, TURN 1. I J L-? WLT 11_1 ENOWINO 1 I t_ I ?? YIFLD 1: DN I. . . 1 7 t1E.ur&,-r f .1 MAKING LPiT I.Q. A 1 NG RED 1 1_ 11 a GI f r I" I r r , 1 . I CI A J L, 1 I G FOO A r 1 OP r AMPI l I I f 1 1 GL ?'1 Otrl)II 5 I7 1, .1 5 1 1 L INO AMrIEP 1_7 , 5 1_l --Y r_1 n El MAKING U-TURN l 1 1 Ior•ICrF? 1 - r I L? GLOWING I E " IlY' r ra ?...? " (.? "L I? " ? D r r I ? _ . III / 1 1 fi01rP[O hnq TAAFFIL I U f G''I /FI AOM AM AN t 1 • 1 I AO O I . GER 1 t. I r ( , r . - ( A 1,1 PrlrrY E- IJ I I r PPrD ,rKGNAL 1Prn I RoAnwar r.I t I ) I 1 A rI T rl I I L L ? I' L y r q , UI a* : L 17 f s5 f f't V+r U + N . r A ? f A pi, Y l I ?a f: r Ir a?YS lyy, !I 1 YL 1_ 1 7 U 114iAY t'CIN..:i?I 1NuiUN. v ??L j ?J OTOR VEHICLE COLLISION REPORT NO. x? L _ DATE OF-COLLISION DAY OF COLLISION TIME OF COLLISION ? AM COUNTY f/U CITY NO. D ? 1«, 2 ?? 7x7 L,ar? Iyx ,. , I., n I•„ ? t6`s T COUNTY CITY,TGWN NIL S rlf?r CITY, TOWN AD CL PNEFIX tl , ?EE/r?COLE SEC7 ?LL.'11 ?`CJJ OF lG / ?i J L /?? yy D •v. y GIVE NAME OF STREET, ROAD ONHGHW Y,,1+.. INTERSECTINGWITH:STHEETORAOAD PREFIX ED MILEPOST C a b'. q <...,;. AEAP LIAGH AM OATH NON INTERSEECCtT N-LOL'ATIONOFCOLLISION / fl BETL'IEEN C3 ?G Y 'REETA O STR'EET ??E DE C frnanc a r[ T ? L'J OF Pa Lnu> Ln..,..xx. Lux..... I? C AY 1 ?i ?. - vEx iLr . ?c.xEx ."x ,EI SEC. CODE USE C vEx? Lsc ? a \v OBJECT STRUCK vEx it+ Sinvcwt ER OF 00JECCTTS INAME AND AOONE55 LOCATION Oa 1 O G /? / / IN ROADWAY' % /-DL° yj 5 .a, ? • DRIVERS LAST NAME ... FIRSTNAME .?:.IODLE DRIVERS LIST NA.:IE FIHSTNAME MIDDLE- +' 4E2 R/A'N FeAtl Tof-(6tiSoN x - STREET ADDRESS ,;ly,- ',_FlOUTENO,11OBO%N0. STREETADDHESS ROUTE NO. AND BOX NO. - ' " f © / D?? ...rx. CITY STATE ,,;IPCODE JORIVERSOCCUPwTION CITY STATE „,.. 21PCODE DRIVERS OCCUPATIA,. S ' '" E° f E WU ?3,E ! 4t,/z PX , M r?ARr/E S DRIVERS LICENSE NUMBER,. STATE SEX GATE OF BIRTH GE DRIVERS LICENSE NUMBER 5TATE SEX DATE OF BIRTH YEA 3 ?iI'J sVN `/'" F " t is A -A-L- b OC L(.3t M Mo 3 N. MAKE I MODEL. BODY STYLE VEHICLE YR. MAKE Ix I MODEL BODY STYLE n VEHCLEY Gxav. cap.Er rgvx4axrl 10x.1 c Ev-000DE OaxU 0xJ ? 5 G .Z .? N V lk 67 F'o R p 64,- L LICENSE PLATE NO. .STATE TRAILER PLATE NO. ,.,.STATE ;.`' LICENSE PLATE NO. STATE - TRAILER PLATE NO. ,-,STATE E L-134. LUIj 600 9°Z w J .. VEHICLE IDDENTIFICATIONSNO nl-, „ . DIN]MkTER irnuGH VEHICLE IDENTIFICATION NO Ext. DOOM TER. ???LL' _. REC.STERE00WNENy ?I!A0!??u x!. _...OR/?5`'L CENSE NO. REGISTEREDOWNER., ."_IUSr +fl0osaxwk DRIVERS LICENSENO. f Y" 1 :,?y?(?c mi OWNERS ORE55 ,?IETPk T Ar ST pE 0 TE OF BIRTH OWNEn5 A00HE55 IT TYAxO 1 DATE OF BIRTH DAV Q +C"g p' (L / Z7 L-I AJCcL A! L-It AN L rEFN YE.gA ,ft? :fir ' A "E "' AR Of EHICLE AREA E , ?{Vy PArIT FVFI?ICLE DAMAGED er. :: _- .. .. ..: sTxM,eDCasr'yy'T f(L -'•,'.'_ .. .. _ u,Elx Va - ? 7C i ? S i? F , . , STD E.a,x Y<x.L ' WA5 ........ WE LIABILITY INSURANCE ' - .` " LIABILI Y INSURANCE INFORMATION•VEHICLENO1 COVERAGE IN EFFECT FORTIS ACCIDENT ON YOUR CAR YYES []NO - NAME ,ANA)D..A/D_DFlESSj?FFLUBIUTV INSURANCE POLICY HOLDER ?; -1.NAME OF LIABILITY INSURANCE COMPANY:- l+ - tEAME Y / T /-r F/1NETT? n C C r " NAMEA_NDAOORESSOFLI-LITYINSU NCE AGENJT_ ^? CITY- :.,? ST TE ' Z ;i_LIABILITY POLICY NUMBER: ••? ?.n i,i? ' .. .. .. ...._ .. ..uu _....? _._a _. _ .- .+In C C IST INJURY - AGE 2N0INJURY: I SE PATE REPORT PoR wD TO L NX1 1 AGE. NIX, E E gm -- --- '- n:: '------'-------- f.'''' SEX D EST _ OD ETS - M F ?- "? h bTATUSOF INJURED MARK FIRST ONE THAT APPLIES IV Imo., STATUS OF IWUREO WRK PURONE THATAPPLIES `E JN' .... ....x Ywx.`Ix4 d' ! NVEHYL! A °?ufL nr n?s.e IN VEHICLE S' fi µr? ne ixxiox? p^N 3im Y9 KILLED Iiiinie FT + -_ KILLED FIfF{yj0: r %' V.I ?C.IIL-H4 TNr-.'1 ? 5? :Oxl xe7 QiC 0H--- H-7,77, . N,: .1I .._ ? 5,0 6„ ? f710 ?•N."A:. µt 4 41 DESCRIBE, BELOW WHAT HAPPENED,IREIER TO VEMICLES,BY NIMPBERI #?,A,-;._,Y _, g ?{' Mr. s iiT HOW NORTH BY ARROW IN CIRCLE « O I a1ND a T .r.L ... z 4 r a ?I VEHICLES POSITIONS OEFORE COLLISION ?P. unar?D B^ - f I VEHICLE x[wO?A ONSTREET011HIGIWAVNAMEORNO. °'xicic DL w e1 °?" 1 ro YOUHI 9 0 ? o C. -mrx P. /s ? ? ? o a ? ?M';:kM i -1 Ec^ r_' r--? A?1 (OTHER) r? l J ? u»?.r 13 L 1 ? ? :GI f I t E[ODkSSTT RIANW..AS .U? HNG ?.O.? ALORG _.? .?... -? , ii????c77n1111"ostlNa+.r 1. -- : '.. xn FNOM- - u . T. TO x +aT 1n 1 ???5 i I n..Dla...- 2 ? ) 1 1__mu. , . O? ?: E ? APr[Ew uw. yy 1 TYPE Of NOAD DRIVERNEHICLE ACTIONS ?p ROAD SURFACE WEATHER LIGHT CONDITIONS TRAFFIC CONTROL I ® OAYLIGNr Dx ,+I . +KE .a 'Y a[ Get' i v xn.f ? ?TGYALS C] I ?ONE WAY O 1 ?GOING STRAIGHT AH EAD NE •? lr.?nfly 2?i:AI-INf. 1?OAWN I.S m.'?. ? 2 ?LtOP •.ICN 159 ?TWo WAY ? 2 ?OVERTAKING AND PASSIPINII n IINESIRLE (L/.I: T? Wff t?TADf\ING J?OEI1S ? 1 ?vIf LO SIGN f._?1 ? gn f''?r l F?F??1 MA'(ING RIGHT TUNHI. 1 .'' 1-? 3 ?u• AL]Ftl(i A ? 1111K tOY LT ? A ?ILASHI NGHro ? A ?:Rrr.lln NVE LIJJ A IFJ MAKING LEFT TURN IT ?{E I .4vvt a' ? I J k yIJ IYIC`.r T?lf JJFfEr ny? GAMMfp ?S?1ALLEV ?3?MAK NGU. RINN (I ?:v J' D 1IC IEr GET r?Ta0 SG ? 11 CJ ?Il???rl wNEE ?tl?SLOWING 1 If SUY YD MTMEING OANGrR C L-? r (?. f „rl fLALtlay C? E ?STOPPEDFOH TRAFFIC " A? TTDPVfDAT SIGNAL 1 p n` _ ? C] B?OH STOP SIGN LL 1 ?.J Ll CJ -71 P AH A r_ED a I 1l1 r t ? F3, ?D Vmm ? O ?STOPPED IN ROADWAY a : ?L,.,. 'n f TIWy?.?? q AST t a1f'r r NL ] rI vInnt DS START f I I ? r I1 1?9?. X14 L 1?WMLEI?4 .W.'_.._7?^Grv i r M., r L '_?P!°. -'. Y ?•??f ?,. ^l y K 1 t• 1 5 4 K+?m 1V,? G f Y V1 ^Fi 3 IV. 'r x }}y' VEHICLE O,GMAGE I. IN EACH pO%CIflCLE THE NUMBEfl OF EACH OAMgGEOgHEq E '{ yY ,. INSTRUCTIONS: > SHADE ARLA OF SEVEREST IMPAC r ]. DRgW ARRUWI5I TOSIOWPi C ALE RFCTfON OF FUHCE {ir a DAMAGED V6HICL: ND, 1 lust -S-CC ELI)sKE C I NG pAMwGE TO 1n AlLCnS, I.IOiOR..YCLFS, ETC.1 ?ls/Jlj )].Imwl Sc DAMAGED VENICLE)N0.2 r??i r IA n ( eoI • - I?i'-?f.. IS n„nL R u nv. Pt] f vfrllGlE NO.1 iT U•r'u ?" ,- Tr^a j ID. D D G rn 1), 0.. turn `'Y LI S L 0 ][} OTH[PE.t V. nA, ;EVL-fl{Illvpc pAMACE Ip IHEP V[HICLEI X YOF D-E; ENICLE NO.)' !+'? J LI DNA MADE A OHO UAMAG[ `+ LING OAM1IwGE ] ?OTIIEEI M. pAMAGF SF II F Ayy-4' OEfDpYLTI.. ._ > FFUNCi V pNglnwMAGE aI]Np gMgGE jOF LGDAMgE >n0f R 'DAMAGE O cE p Dr fs pL M1 cE r Wkp6 s rPrNror. A o ssr,D DIAGRAM OF COLLISION. ......F I I s o- _ DRAW ARflOW SHOWING 'AGE "c',? I r I _ NURTH IN CIRCLE ; F vcnpN - 1 1 0. j i IMA .11 o="Hq DILrLp ( _ 1 i i I i I k R' DESCRIPTION OF- "'I-T.. ATPPDBAeLYRAPPE E e o p H-ANDAFTER TIECnASR, INCLUDE wFOHMgrION NOT ON DIgGRgM,EG.pRIVER COLLISION .-T plsgenlTV, nfoucfD WS Blurr. PE E$TRIAN CLOTM NG CULOP, CONSrn ASHOH HEPAIq wOHK, FTCI 5 d?4 t _ - c I p r x1 ) r w ' E 1 d -POSITION BEFOR DECISION Mz1K,+ °S HO HEAD(O INCPF SEG O LLISSNa .0 5 nEEi IGHWAr IIw EOH NO. ' -' - L AP E fl} - S E IN pNE DIRfC ION PO it ??G L ASVk ' HKED OCCUII D e?': ES NO HO 4 .M I ' I I i I '. ,' rep. r IL.r ir_i rya IoHDSS aG _.. __ ! IRr PIO(MVCLIST WAS USRD: E )1 f ) IARKII A SUR A WALKWAY I6 O DE" 4 K' .. iCg 055WALK Si. C S AL p .IUp G pE )'. T 4V E p{pE O (F y ICEIFEK OxfI : , W ATHER CONTRIBUTING CIRCUMSTANCCS K k?'Y-' 'OI ICIIECKO 1 lar[CK Dq MOREI ?,..'.( • rye e e ACTIONS INOF] ONVfR ONEUPIVfR ! p _ ` f NO ] E ] v ' d' qiY' t u if I ?_r? pqr-- sflvvlcnir '.I I i nta.,R.NFLOCEDE r NDf 1 p c n D q, LbI it aDxp G-r FOLLOW G I STgAIOHT ANfAD g ..?] WET ] I INNO? N f IN E C O '-f ffiELCLOffIT I ) FG 7a U]? OVFR}AK Np ^ OPVGS_.. I?IPf Of NF ?? 1 S?NTLY Ir- ARO PASSING E 1 +-L.L I S ' >?WO!T' _?L.>?..Y FD EXCE&O-STATED Af D AE I•L I, T I IIIN r F `(?"?> 1 RGHTUPN 1 ?4 ! ?? 1 CF - I I, (_ OF I - IS[ LOCA ON K a _ LJ J MAiT TURN I - OG 1 S ( ?(ID LA I. I OPl a , 1 S ! b i. 1 Ibr I O G f. IU. I R; ES LVf FD I m6. J NO ,yy OTN(q ISI[C YID-- OlrifN lYfCIFVI •I. 'I. ICLS_ I D [f. ?? + E UIUNN r E !- sl o fH .c'" 5I0 .cot 4 i (( I 1 A. f{ 1 6 1 aLOwlxp i:1 + >, ic O 1,41P .I N! E ISPFC YIrJ). i} IR MaIr9NONIEIIONS RAFFIC CON 7RO Hoc E Ill 'A 1 .I 1 TroMep FOR TYPE'OF ROAD 11 L ,, L >VFIE C N.> VENICLE CONDITION Dv RLAID AEFIC r 1 CRICK OONE N oRE Vf SOBRIE7V , .. i..f GN IS i.I O f C 1c4?ECas01 Vlrrl< E ICrIlCK ONE}.: I I ST '? FD AIS GNAL .. ., I ) UtF INp.I .I pq TO GN , i 11 `1'0 , F. .T ] SI _ . ac rr, „ A II iD. ......... !A fl A Lf V I, 11 _ . I Ta ^mILxa IN S f t - I A AIRLU f 1 - IA.F LANE Y t_. V 11 ) _. pf r,Af S I: wnRAM. U.. l nl IS .,? I Nr M--. 11 D E 111 .-. 1 STAINING IIrOM iIEEfE t4, PA11 P05 iIUN 1 1? AI DAR RI ri f I) U U IEKF ' u rf oN L s ! uc rs n0 NIFm Ir. '?y i. u6 Aulr y --_. _ q Area rA? ?IL1 If MR ,? u W? n L L s i?.? F ?? e_ I-- L _ 5 ..r ,.. n Il u:cKlNr. 'I n i CHEM. TS C'T A P `f + tl'T • IF 'IS' 'ryy I r• SI IEI IGNL i'IRAy I LI.AIi?T??-_ rl) nl t:•i 17 'A" Ulrrl ! NO DkFI, CIS I I FR I L ; 1 } I uNnrvrnrP rE1J ' L 1 r,? ??.._. '• T- rxe ur •Me n. ... ._a__. a I irn - ? , fF T IIESULTS N? on L.HAa IRUnD ??I ??n' lira It 1 A AL rrr f 4I'? ?llpy A? C IX A I, r ;. T F 1 $I1+ ' 1? r ??IVE, Si r?rRTn: rd N11 t 4 IH III (IIIV Y •rglq 11 ? 4'?q A• /I ?f•? 3?? 4'""L ?X .... il._ } E'+. t .?I4 r`. 1 - - T 4 Y yr?E1 r ,m R ? rW x •x Y? ? $ L S I J? k D DATEOFCOLUSION DAYOFCO LLISKIN TIME COUNIYNO. CITYNO. FNWA A VII. T SUN I VON Z IDES ] WED A INUB 5 FPI B $AT IU?E)000 f(}jWl MO 1 ?xOA+Yx i ' ` x,11 fy J WIGAN URBAL E / L--?= f- TTTnnn COUNTY ?STATEROUIECOUNTY ROAD ?CITYSTREET Z O AOMCLS. PREFIX ROUTE OR STREET CODE SECTION z 9 ?/ D 3`.f. X'N ? OT HER (SPECIFY) y t/ -' - J CITY OH TOWN W " / v PREFIX Ed MILE I /2.O to ; ° ?IJ LU LJ[?.. ... .. _._____-._ MILES ? ? ? ? Oi..._./, C F! T ETORHiGHWAY DITERSECT"6 WITH: STREETORPOAD U. RA P DIAGR MOATA- T W N1 & O 16 m. O , NON INTERSE .' 1 kJ /.1AY/? j/?, /?• !f- ACCIDENT MLLEADE D iER No" CIS.. E (? PEf.CE C ""'E" OR ORRa. OAI Fo POSS 3 N r/ BETWEEN STREET AND L?\_- .( _ -VREET ODE COOE f? , C ANOdRECDONFPOM REFERENCE Ofl CROSSSTRFET/,. /T D L9 T A N N E W ? MNNApl+E Txiq - SPECALC USE ' •• , / / I ? I/ OF /' ?O M?C(/L1 C _ _ ... /GI FEET E ?VEHCLE BICYCLE ?OTHERIWPTEI ?HITARU SEVE.1 VEHICLE•VEHILL NO KILLED ? COLLISION Tor-O INVOLVED: VEHICLE OWEC ? VEHICLE RR TRAIN ?StOLFN EHK;LE NOIWURED T n OFVEHICLED ? VEHICLE PEDESTRIAN ?NONCOLUSION ?HAZARDOUS ATERML 5?PROPERTYDAMAGEONLY OBJECTSiRUCKINAMEOFOBIECTSTRUCKANDOWNERSNAMEI., ., ..... .. .... ......, .. -:. .. LOCARON OFO&lECT5iN 5 '•?J??"? T, DAMAGE*'. QROADWAY FEET ? ? ? ? RO EDGE 5 DRIVERS NAME USi FIRST ODLE ORIVEfl3 NAME ASI FlPSTM OGLE KBN CL Si;OR PEOESTR .CNECKI?A ?D ?LVI LLr ° ' _ R E CITY ?.. ...:_ ....:. .......STATE .::.. . . ZIP CODE...... ;e,PHONE NO ..,. :. STATE. .. ,... .:__ZI .000E -..._PHONENO E CITY:: :: ? __ . R n-7 W1 taw LtJ aZ? YRTH N DRIVERS UCEN5E W. .. : .STATE SE% DATE OP ORTH: B STATE. SE% DA E OFp N DRNERS LICENSE NO Tp yI { ? I • ? ° C s AORW SOCCUPATHIFIRMNAME D t NN Y CODES J IJI ILA 14I SEAT DELT_ IL'I EJECTOR _ _. _ CODES >p, CLASS- IxI SEAT OELT_ 151 EJECTION __?_ C SS-- -- ' ' NAtuREO ? RI S NMR"I I . INJU E FIIOMV NE VEN. YEAR RY TO MAKEIDODCECHEV.I MOUELIDARTNOVAT -.. STYLE(ZDR-COW), '; E.OVE REMOVED fPOM SCCNF RiAYI{E IDODGECnEV,I ,. VEH YEAR, MODELIDARi NQVAI .. STYLE( CONVIi'. _:: V DCcF - V., 3 -T.v(1 I I,os -rmo_r E YEN UC. PLAIE AO STATE TRAILER PLATE.NO uiATE E ' VE N COLOR LJC PLATE 1?a, STATE. T R PLATE NO.. STATE ,:. ?.. + " . ?. U Wf C" C 0 ?G17 i Q LJ jjgg? ; I ZC?I? G C V N N f A N NUMB H •+ I.++ . .:. ZZ.AE3 111q`79 ME ER .:: gM4 C Vt VEHICLE IOENIIFI ATI N N R ..,:-:.?+..... „_ t--4zo loio • OMET .:. L:Fx:.. E .. REGISTERED nER-LAST . ,....._ iBiST . .,.,.., ...?..,,. MIOOLE •. REGISTERED.OWNEP-L T...::...... ?...iRL4T ... .... . ......1V.MDME?? N C N'' E .O. ...-.:.,.::«.: ADDRESS OF OWNER 4... O;' ADWESS OF OWNER:..._ ... .. ......:...v.-.v,.:..r+.?:.. -:.r.::w+ix.:. .2...?; HAM DADORE WSURANCECO. RAGEnT .. '.'::... .... ...11, ,,C;, NAMEN ODRE690RINSURM E l OR AG NT.:. _.:.:..._ ?.e•aAi...?.inv!. A f ` - Ttu lS rati ,t)G (S4 0 ?? : A N • ENFORCEMENT. H E ::.:::.... ::..._ .....N. .,,...... ... ...., . .:.., . ' ACTION ,,.1.. L RC"7a i[YSe V f?;, n '- fx D CO DES _ ] ] e OWE ADDRESS & INJURIES OF PERSONS IN AMEE, N _., ,. _ sE% AGE suius N met. C ( y - / c [ N ME+ LIA YL ?- N I .?y? A 32 Z I 3 12 BS ? ? S? f' ADM (21&5.4h- ' P , - 1 10 FDFRDM N A n,(40F SCFNf IfY TO A I E_ T UMES5 _ $ h t,R,IL. 1F?- SCFHYn01f10M 10 771, 11 Di All a3+t1 ...?ys aJL.`PF x?. • W ¢ .. .!L C r ?'YUat ?. +. P ?YtT<V C A4 f •?[R lI51AI IV: +'x" _ 1 NWARfI CIM:'• NC. MVr1r )OI AU AT I Cf NF SdSAUUNO WNRV elIONNAIRINB INOI IHSIAfIfO PNGI"USE nOI kJf CiCO 7 lUfxILV(JfC110 ?+??PL MPK YI ) T !:il D D ll'I I T 4 [ 5 ( /ONU RPO"IxY1 IRU'• AIOIURC1C11I . JDi A(10'r AAlu/AL [ {Af 11 W r10.111A1 If ND(r TIINJIJIll 11'OS NI K( N,LRY ;U5[D tr x IOW'1 SSf AI DIL11AILURf D PARIMLLYFJECTIFD A NKIIONNIF CJfCIED I ! J •'. 1 ?? I? T S } '1 A 3 / ' AI`OJIgeIU•1r 11'M1•r il ? t --nn+xart4 i 7?r h T 11 1 I W ? I f A LrJL. . „ . JJfxII?? p YYIl?? I ?, ( Imi, ! t H b k JY? NX R?a ,I gA ?? 4 Yk°, a4 rJ- r c F, A 4 ' Il , 41 1 bw , 1 p Ah S?5 k r ? LEI. r: ?j ? Y.} !j . ! WE" ' I r e t. _ .. ,. r i 1 r . r, ?? "M"GR: I 1 ? ., 1 ` '" •; `I I I x14 r ?rxeu; @',°r• ZI;R,!'"."'..`?,. P",.., '..' Ir"Y'' '•,^?p?"nt Y? ?'; a ?, Ati4 °? a, ^z ?' Xt f•k"" I -?? MUIUK VEHICLE COLLISION REPORT NO - - DATE•O O C 1 _ sYx ?' , T L Co /- /i'??F--cod - L ?/ µJL\ .7c)r L7 rn yC? » E . Q C __ N- OMCLS PRLS x r ca SECT go-„ LGL ism o. f ST E p DU ?_ -I TRPI ITHr, ST T HROAD PREFIX ED MILEY T ON INtCRSECT C 3 A/ s8 ATION OF COLLLIO" MP ACpAM D TA DETWEEN STREET AN A I ? OO s y c,xasr sx cyx s- x?c rwiunox.xx a E• N U T»x s, rrer pr 1, .s Ss.ix`m:.iL a?`o /C-?v »/E OR NTIF CS n,7n7?C .... x orr`.? HMO ??n -!?: x L7 - o'xcx wx?ral 4-? SPEC. D us E E JBJ CT ,ca ucKr xuN T. E 5 ON °? O O OBJ C . ?,l fLlU2 ?? _1/??/CLiL_ Fl ?iJ ./D,?s /•C?S .... ._ -. ? ., cT: ?1 x i?31?f fi?3717r79P9 DRW TNE - IjST E L sn. xvoaYro ° 5T I S. ML _....? DD H"IRI /$? JJLG./? - =- c... m._" STgE T _,E,•Su • w OU E ADO E;G UTF yANO O r 77 coLlls?ox ? ?/ E y .. .? wx, non ?? ^ZIP CO dOFII qS OCC A N: V R COUP TIO D M L e ?j aG / K- _ 1 2C YI rc.- '.::. R CE'? NI GG K TE y 13? [/ -_. E .. C,.. U E ?T T E T£•O 0 " A E Ic AKL L pE 1 D ST '12 -v MAKE'-1 a O EL Ix rl BO LG 7 ?h /oo [U>D 1 ICE E L N E T RG E -U T I LCE £P-? O ?TE -T ER NO' S Dz U s GG VEH C E IDE TIFIGT N N 1 9 - 1 W TERI I yE IC IOE TI A O y?l 0 I OROMETE L ?19 - r k :STEP ` NER ARaI D VERS 1 NO R ISTERED OW ly,ar N,n E,x,M%I D ER,SLIC S NO„Fr CRS A / C/ m- r o sTe 7 D O D / PAF OF ERICLE D M O. w ?_a.l. '? r 1 T...,::... cR rani PARTS OF, IC pA E L1.4 ILIT IINSURANCEINF? ,,,ORMATION VEHICLE NO I rHE CO RACE FE E 5 ACCIDENT OLDURC YES ? NO E AMD RE SOP' CE PO CV LDE / L IN U _ 1> ;.'4 B YIrNSU A ECOMP Nry -,?? 1 l G!t [l/ ?irrrP[t /?(? ??.C?DY r1r/?c /[,f.C '?/l-l??C? 7, q.E p s F Ae 1 VR c iwe r ,y z P? ° Sp 1 e- u7t?er^ Tn /boo ST NJU F ,. Y... ?+. L . t. E- URY 1 r s' .LOC N E .. ... .n _r A RE O ! E% D RESO - - o0 o .r DR n. , Yo<ra e 0 T U O J [ M KPR!T ONE N APPLIES TU O I V ED A (FIRST O ETHAT ' APPLIES, j.• 1 ('LW'1i1 ni vlx :. ry?? ny use N.VkMC [ LL[O sun x:vn coxr N C E :c IM ono c.l 6? 6? 7 ? fZT LLI! ? ? 6? 7L 1 W T D AR U C CLE I I OESCR 0 [LOW WN N [ 1 PEq Tp C CLES Y:NU pER Af..l ?'r I 1 1-4 I I R • -?? Cl?- ? ?? •e?/ c ?e- ?/ _ w /z ?L/ w-mss -- ,• , II VE/IICLEG NO ;ITIOA 5 BEFORE COLLISION ---- - IllvesTlrgreD nY VCO01°L Ne OEp ON ITR[- T OR rl err WAr AM[ OR NU. -_ ' ar•VOC _ . ND for If. ? ---- ( U........ E7J n : rc I'4 DFHTR4N ??? ALONO -..-' .Rp4. , rYOr'S I1tIA4 WAS USISI I?.,l.c • r-1 r ^ ROSSIw'O TO' ., _.-.. HUM)NI MI, L[L[ wYAiIrY LIONT?CONprtIOMS sTR?TPIC COMTROt?lcwec?Rxa [ O1.6 p ORIVIRr Ye HILL[ CTIOH?. •?-? xr. la Hlrw 7 ,?I'r: n?rr I'sll • I 1 Urt [-1 U.1 r N- Q 1 n f 1 1 L L L? r^7, 001110 STRAIGHT AHYAR 1 DIY Il-.? R 4`M O T ! r,? > (r( 1[ t I Sli.••~ []) r, T O Iw V rrJ [_I OVENTAPIN° AND A-INO I' Jr'? 3 n r'[ ? 1.? Y U [ [? [ 1 C[ MA-0 RIRr TURN L [ I [ GNOW t[ [ 100 [ ll 1 O t ( l [ 4A 1 r [ [-1 I < AMnI r r] IAAAI Nf. 4f.YT Tllp11 I [ I, i l A[? GN,I L I T l.? r.[ A!tll NR AMHI.N [ l ?..I Al LI..Y [, [ [ I FIA KING U•TIIRN r i I7 ' r ] ,?„ !") [ I ?rl,l r., 1 rJ I IND L [ [ r [ ( .LfrW ,.1 ? SY n ,» r7 f I f l ,I,n ALwr,., L. 1 [ [ r ,? HTD'r r n Dn TRArPrc I ? ' I orylnrn n u Ur R IN NO AOWAI r AI VEHICLE'DAMAGE HmMai." E c n u PB1 :f?. llb vau yn,::. 'vcLN r ] 3 E AREA Ur E NEST v T INSTRUCTIONS ). O HAW N owls 10 ow RINLPHL OI ECTO or FORCE ?- 7 4MA EED VEHICLEN 6 O.1 iu.t ,Hlss>aF n[*c+wG OAMACE TD ixut[aS.MOipacvcLrs. Fltl pAMA GED VEHICLE NO .2 / ?T ( L I L.. MA '6 U f ! ??I1 E or,?1 S'c'r IS ,6. u EVERETY OF DA GE: VEHICLE NO. I :OD INapAMACE J ? oTHEnM.v.DANAGE 1 EV61I1101DAM AGE TH [ 5 I ? D IxGD,MACE JT7oTrTEM.V.D MACE. A Fv ERITYDIDAn1A0E.v HC , [IpISADIIN EE LE N0.9 ) ? pTHtRM.V.DaMAGG ] ? F.RCTH.NAL DAMAGE . [I ND DAMAGE ] E3 F.HIGlICNAL DAMAGE .011. DAMAGE l ] o Nu6TOH MnGF . NO DAMAGE\. Ow- EST.DAMAGE T EST:OAMA4E T LST.bAMAGE' 10 -1 SI%?a To tiI• S 7- 7; DIAGRAM OF COLLISION . ?. ,. DR'AW ARROW SHOWING ' x r Is l _ .___ - NORTH IN CIRCLE xm11" D.Dw A. DAA jl ,xArr EEDN,xpEl 3x DM.RKF IO , S M1 - -? •-._ ?- 1. ---_ T O VxV N .A,LH LDxs,x„a-CGHS1-Z CEIDH ] - .. ] SHD«Ylxral rrDInH .N Ox ? -, :?or:.;?A"ro.41. o?rUar DESCRIPTION OF CATE WHAT PROBABLY HAPPENED BEFORE, DUNICANDAITERTHE CRASU.INC LOS INFORMAIIONNO a,5 TONOIAGRAM,E G, UHrofR COLLISION ABNITV,A.EDUCEDVISIBILITY.PLUESTNIAII LOTHRac COLOR. CONSTRUCT 101 On REPAIR WORK. ETCH - POSITIO VU, HEADED N BEFORE COLLISION IR. 'ILE T - O STREET ON HIGHWAY NAME OR NO. ND. or LANs INONE OIRECTON S r , lEE. C r HrCLE ANK Ir F ' KED VAVH, PEIE NO. 5 INCREASING DECREASING ED J OCCU D Ll _ YES _nES-_ NO H _ vtD. D181CYCL13T SDSING PE OR cnosARKED R.AL____________. SHDUL [N 6 Oly CtFROUTE ) LOT > SSw L ,aSllD""rxrelF.,Dw.I ROADSUREACE HCK ONI WEATHER CNICK ONEI CONTRIBU TING CIRCUMSTANCES ONE OR MOHEI H ILLS Np ] [ DRIVER I NO OnIVER I'D 2 ONO F] D r , w.?xu GOINGiGU AHEAD v - ` ? &DUICACL N GEn INFLUEHC ._ALCDaDL_ - LNG J..I2?.P5EL I HEGAn DED wqa J? slGnrSlc x > A55 _ xc ; E _ .. ... ._,. .._._.. I r-. .. _ ...__.Ixc __ _ _ r r r NFLU[NGED _DRUG E ._. - ?_.. [ CENTER ._. .9...?.? .. ... _. .. HE LY f-._, -7 IG J RIGHT URN _- -' - > Now . _..a_ -------- 3 - SHOWING EICEURIGIITATED 1...5 o MIi. - ,c TD 4 ._ !-I IMPROPER PARKING PN _.. ` - LEFTTURN -c. , C .-_.1 . I.P. E cREAS rn ? lD _?. nn R T,r 'III , e' vEw fOU LNG UTURN 3r'7 .. 5 Si-_..I iO VFOrHCL[ I ... II 510 A40 L14 T .-1 SLOwrNO • OTnENISFECoYE -? OTHER S-IC! _ L-- - -- L_ x -' O To' SIG IGN.Ll [] - I lo N -; T 1 s iwc FOR '- LIGHT xCONDITIONS ONEI RAFFICCONTRO ,NO.>v[HICLF YENI-lE TYPE OF ROAD 1N0.]ICNECK UNE DR MONE VEHICLE CONDITION v H Cl[ p p ? SOBRIETY _ ILHFCK ONEI' vi E _ STOPPEDATSIGNAL I._...18L?1 ON STOP SIGN SIGNALS ?II ONE WAr - . 1 O 5 ?U€?Fri ??{EOI N '] .. .. NOL ] ' ? 19? _ STOVVEDIN OAr IcHT _,. '._.-. _ ._. DAW _ > oP ...-...__..SGN_ If LD go-, -WA. .. '.... _.. _.._._._? [ IRS PL[ D. nvE -I,.._.,B AnlS DU E[TVE • I HBDAB I V RED AR Urv I. RTNOIN TRAFFIC LANE _ LIT 11 NDrROM PARK E vnnKDPDEIT I ON S ..? ?3 1111"I NI RED I HANGS ,) Df rECTVt RLARLGx15 D O UE'lr . NK RI r?2 IF OCINa ILHTENG •-- -J 1n+FFICI J n.n 3 P[T LIGHTSD ... ,... .. ASw BEN ,_.., ll[r __ ?_ .. ..__.._ Den _4 OOT.!.. ,_ .____,.. _.. - uwO NDT ?' " n[[N UN NK N4 j15 ,_I BLACKING DARK lTRrer ! . l10HTt 0!r lwo w+r-LLrI A FS - HEIU.. ( IvE,r CHEM,TEST .2 ,. . -- E 1 N vt 1 ? ISPF - IFV I .-STV rFT?i4Hi3 1 ' fLAGA i M _.. UIO 'I NO DEf El:TS . I IIS, rUSfD r !, li HV14[O U Eiisc{clrvl yE 9; TEST RESULTS Z - X ITaATIHGwrrtlH'>NAMI AHANK ?- -- ATG aOrIICIH 4PINK J e,OpI MO UIDGC NO L.CE UI. - 1111.11L AIHNVID FLOW 0 nY[D CE t D NN! N IS IRS > ?« A > AW C RD[i NV TIOVfU D DUPLICATE CDHY' L[ICAL LAw[Nr0lICk MFNi AGENCY'S COVY-TRIPLICATE LOPVINV FSTIGATOR'S COPY A v? ? En YnVL7eyf{?(S?GIYII I 7 ? lh? a r T 3 ey-(??`' t Ram Yd/gy _ Rd6GUr_ ? .?.A t /1 f lJC' YVg6l-1Ir`Jla 1 iJl\ PAGE / UI J NO -- UNIFORM POLICE TRAFFIC COLLISION REPORT EU: et eoMr-u,a NuMxe'R- o rE OFCausla• DAroF COU SS OS - - __ C m" D Y SUN EIE - LIME EDUNTY 11 O ? -? ua: um. AT cNY NO MINI` 3; L 't A.S "L--IJ T 1 % YL . s FN 6 Incylounl J uRRAN Y UHAL x' COUNTY ?STATEROUTE COUNTY ROAD ?Clv .i.JU ApA.CLS 111.11A ROUIEOHSTNEEI CODE -CllO ' S1NEEi O C f-/_j f0• ?? ?GIHEHISPECIFYI LU N } '- L /?Q N S E IN - CIir OR TOWN LU C POST ? ? .2OF-..---.-.. A/1L?Gf, U PNtFI O. MILE Y." A AME NO OF 5 19, T ON ???///F flSE QG K1Tn sT [E1yItA0A0 LL RAMP .-AM DATA v p DI. < N_ F4 p 1 ' I NON INTEAS6cna` -? / ?+?mT-?L 7z . ACCIDENT INTER NON %RO INIERSECTING STREET OR NOAp OR REF. ` O I HE CLS ERENCE ROSS STRE ROAD N N MLEAGE DISTAN S i - REN STREEIA --/TD EEi CODE I DISTANCE ANO CT ION FROM REFERENCE OP CROS66TgEET Ei - a MILE$ ? N 5 E IW 6PkCIAI CODING USE ?FEET V???-y?? COLLISION INVOLVED AGJ ' VEn CIE'VEN CLE ? E IC LE BICYCLE ?OT ERI gTEI ?-11D N, 6EVE.UY OVEHICLEQWECT VEHICLE TOTAL NO OFVEHICLE6 ?VENILLE PEDESTRIAN ?NON COLLISION TRAIN ----- ?STOLENVEHICLE NO NIJURED ?NA:AROpUS MATERIAL MEG, STRUCK INAME OF PROPERTY DAM AGE ONLY e+ ! ` '? p' k ODIECTSTRUCK ANOOWNE0.5NAMEI - ` ` LOCATION OF OFiIECi STRUGKS E ESI. DAMAGE T a h lr ? OHI EfiS NAMElAST FIRST ..MIDDLE OAOWAY FEET ? ? ? ? AD EDGE 3 ??, DRIVERS flAFIE [< TFIKRi MIppLE Il DICrCUSI OR PLDLSINANCNELKI PAX w ??ct . T t ?C v? S r: t r ; y K? n 1 k 1 ?.p . . ' , G ?'?{?1 1 7 i ? ? 1 , . r.l,L?t-.`?,Lb'"i? ? . Y6.v '? ?-•_ 'L? ...,._ naY'S+a p 1 =: i5"3` :rig' •. LI , INSTRUCTIONS: ° '?`?'; _ M ' , } ? or o s l s L IR c D TD'o cE. I _ s?( ' . ,? :' DAMAGED VEIIICLE NO.1 ust ,N]s .SV,Ct t, l,r«rvct M,pl i?,n «s MD,O SCrcL --"- - • tlL DAMAGED VEHICLE NO Y ' 1 ..? r y... R rr Dr DAM,cE vLN cLI No. I ,v or DAMACE to tix Of cLE No r- - l«ER,`?` `o Ule,xt NO D. ? ; ax ir L ` x , ] o,«ERMV DAACE Dls,xLrNG DAMAGk i IER M. V. D,M,GF ' ( [] `D!N ` G -AGE ) ? OlRE11MV 01 AGE ? EUNCnON,I DAMAGE . ? NO CArngGE' ) o NNC, DN,L DAMAGE t ? NO D.MA., ? ny. ;owfDxv f Bi1lIs Garage D.MA 3 E 3 I-' + F 3 Chimacum wn. STotal To DIAGRAM OF COLLISION s DRAW.AggpW SHOWING [ NORTH IN CIRCLE a xb,f [,z On?Orr xO,pw,x r Y I IOCw,[rxae,ntt rn R, 01 ? - - /- ' -- - - y z§,= .• l i«owxw?ai NO,3„.x DR Duln.DSn,Ors., w.wc, .... __. _ ._ / r E rem s,«,xr„xs Irant - _. 4 IJ DESCRIPTION OF LLIS CO ION NDIC TEw«AT R AF TFR,nE [RAS« RCLUDE F-TION DAGRAM•E DISASILITr, 11AIIINE. ,N BEFORE, C?OTV r4iG COLOR otoF corvslnua]Drv OxREPi ETG - - b . . .r : E -. _ , _ U _ Driver, wp unable to explain to me what happened. upon my arrival the driver had ran from • r, - - _ the scene but came back a little later to check on the iafured passenger- and le was t7fen - uDl f , I _. - _ placed under urreat.ior DWI He still didn3t remember vnat had happened to cause ts?e accident - a - -- - '- POSITION BEFORE COLLISION - r M NICLE xE'A" El p. NEADEO enEASlxco cniASlrve orI STREET Ox wNw?rxAUL OR ND. IT Dmterln e,i5 s "I IN f S - C.R. 18 1 L rJ 'I N Y No Q _ r`. ' D. w m. CROSS11G .. .EO-c - E sNC sIDE A )' a « I 11FRI OILDEI -? x CR- L , ,' ROADSURFACE.. WHAT oER CONTRIBUTING CIRCUMSTANCES ONE DI?Eq ?'sy€o-4 c f tc N E ORE] F J ?' 'N .gyp / D / STRA FAO ,EJ y , I FOLLOWING - _ __ 60VfRC Si N<0«OL- a "...y_ .9.4185E nDEO M - A«D T- a 1 . x I! c« _ - a . . O 3 OW a SNOWIIG ?- N, R5 So _ LEFT IAK N r...0.CrlvE"E. 3 u IN. 6 .. ,. 1 3 I ] i, -REGARD . -•JTrrfRleYfClFri_.. Ol«fR a1 _.. D .•-?- S. l'4 ?---. NG , .N 3 C I _ ` T ON LIG T CONDITIONS RAFFIC CONTRO t TYPE OF ROAD - VEHICLE CONDITION : RRL4NONII ,ND )vE«r [ o. clt oREO A SOBRIETY U 11DAISN S . vfn t c« c flfl QSS r O -? SIGNAI I I. E V D INOJ If rv?p? {FD IND. J` ] `r IN I ON I . Y o. L ..C Ax L.1 rWRC IR - - -'T ]MPA FLU Y r 3 ' n rv sr )1' sw C r '• H .. .:t....__. .. _p •_ q IFOVONOON L? S • r.. Dl. UJ) -- _ 'J ) EM .-. fl i G '_ 1 t T1 •. ] _-.. ..RED ._I. DU H ?4 U fR N IENTER]ND L 411 A C ?I) D -STNIET _ M ._ A «nc 1 LIV wun - ° I , - _LG SON __ _ D.sMDat«. ? i NaINC 'ro e:c.INa - xnA O 3 DARA-STRIfT ... , CII[M. TEST 6 AR 5......L14«r{Off SIGNAL' .. '4 lv rN 1, ItS 3 111- NO j • - % ' - ` .. . / ISYt c]EVI x bixl[1N?GnT3, ffICERr ] -1 YIN AG.AN ?_ I I • NODL LCTS t f ' n` t P,n C / rK vIDID ......:... " u«l Fie / USE= I c«vI % m TEST N[SULTS Z - r . .. { ?INDelputy C. Gebhart 6 Ol 19!7A 1644 ,TL13.646A,1o) p 1?s6 Y«DYLDxr??o[n ?' lrv I P rl ?( '_ iT _6 N - JC50 _ Quilcene 011979 ? St1irRUT10N ORIGINAL C4PV sf D To WASH NGTON F-1 PA ' [ L M •IA, IVASNINGTON 4F1. M DUILICATr COPT IMALLAYl". IMINTA4f NCYSCOPV iRR'LICATEC01'Y INVESTIGATOR 'I COPY A LTtL 1?1??jy7lJ ? 1?+R4??i..' C fLJ ., jam} pj''^n"4A„'r` ?pi? ?`'^ } f?' y/t,'1? 61 ?}?Y?r.4?"Y'? ( 'f ] '19W. ] 1 r+?'?!'_?nxMAVxI].1x,'^' ?!?.?'tl}f x `?..ywnrw.w??;?Bl Y}f •11 t 'T ?j i 7L. r,; 1 A 11 ILI t . TAI I E OF WAONGTO I PAGE -JI ?' Li J UNIFORM POLICE TRAFFIC COLLISION REPORT T'ol cE coM ANntuMBLH -- d. ^'c Y. t - A - ui.rE Opcausory o DAr 5" OF COLlivo ---co r f. 5, - lQ 79 YN isuN+ Moq IIUIS?wcDA IHU sv: Lsal T...I C O uar NO .... Iul p,IP,O HOURI clTr NO b44 nwA £ '.. co uNl Y ?STATE ROUTE ?COUNTY ROAD ?CHYSTREET Q DMCLS. FgEFIA ROUTE Oq STR CODE SPECIFp EET fHRI Jefferson ? URBAN S CNO-Xt ry x ' N ® • L N S E W CI D TOWN j fyl W PREFIX ED MILEP - C MILER ? C3 ?OF.Irondalf - 6 OOF STREET -. N E Ofl HIGHWgy A 7 ._._-... INT ' T N • ERSECT NO WIL)1. STREET OR ROAD RAMP DI O AGnAM OAIA is I ONI - T '? m q. N ERSEC f l ACC PENT INTER NON %NU INI ER ECTING STREET OR FUAD On REF. N BETWEEN I E CLS MLE _ .. AGE EflENCE CROSSSTREETOR gOAp LT. E -E- Sr EEi CODE Ylf,T DISTANCEANDOIRECT ONF OM gEFEPENLE OR CROSSSTR _r Sz. /p B LE Y '• F MI S E W yyE1n5 SPEC qLC OtNG USE ?' ?1 ® ???? of _ C. R. 12, J c„ COLLISION INVOLVED: ? VEHCLE'VEHICLE ?VCHICLE BICYCLE ?OTHERIVI E) ?HTL RUN - SEVERITY - 1 ©VEH CLEOLLIECT ? TOTAL NO I y EqICLE RTNAIN _ OF VEHICLES ? SIOLEI VEH CLE NO K LLED ? VEHCLE-PEOESIRIAN ? _ _OUS__ _aTfRAL NON COLLISION HA2APD 1 OINJURED T OWECI STRUCK (NAME OF OBJECI STRUCK AND OWNERS NAME) ? _ ? PROPERTY DAMAGE ONLY . ^A M .IV... hone ale DRIVERS NFME LAST FIRST LOCATION OF UDIECI SIRUC ESL. DAMAGE ? ? or ROADWAY FEET ??? s r t MIDDLE D - pRIVERS PPO EDGE 5 Teta2 NAMflA51 FIRST MIUOIE Uf UICVCUSi OH P EDESIHIAN CHECXICI.: Jr. BRO'dN, Dwane David D - R STREET ADDRESS --- R C' .-.. - i - I BTREET aDDRE55 V Route 1 Box 201 ', . T. y RE CRY STATE .TIP CODE -. PHONE NO. E [ITV - Port Townsend[ Wn. 98368 385-4454 R STATE zIP CODE PHaRE ND. _ N ORIV- LILENSE NO. 0 GTATE SE% DATE OF DIRTH N DRIVERS . BRO1.00D4-7PT WE, ]; ULENSE NO. 0 DAY R O 10 30 57 STATE SEX DATE OF BIRTH Mo pqY r : URNERS OCCUPATION FIRM NAME ONE NO. T DNIVENS OCCUPATION F . R e Laborer Griffith Shorts Farms Chi IRM NAME PHONE". # macum CODES >IDI 01455.__L IXI SEAT BELT .Z ILL EJECTION_ . - CODES > 13 NATURE OF LF 5 I IIl C 5 _ +I GEAT BELt 51 ..} JURIES eyed non[ At RE OF F.JECIIDN^„__ I NLpG. } . n[ FROM SCENE B UP"s , wY A TO VEH. YEAR. M KEIDOOGECNEV) MODELIDARI NOVA). [ROMLGf N ST'ILEI30R CONVI VEH F PV TO vguS T x' V. 1 6 Ponti9s GTO YEAR t d MAY.E IpODGECHEV.I MODEL IDARTNOVAI STYLE I2 OR.CONV.) AAT Sa q 11 H. VEH. COLOR 110. PLATE NO. STATE TRAILER PL u or v ATE NO. STATE E E N 1 Burlrund KXD 47 WX. ' V H CULOP R UC. PLATE NO. STALE TgMLEq PlA1E NO. StgTE . ST p (, VENtCIL IDENTIFICATION NUMBER L 0 METER L' VENICLE IDE ? NIIFICAiI ON NUM E 24 123D78 ODOMETER f F a O REGISTER4D TENED OWNER-LAST FINSi E MIDDLE RHEO OWNER ON JOHNSON, Roger W. N EGISiF -LAST ' FIRST .._..._ MIDDLE., ADDRESS OF OWNER ?- O. [ yy '.. .. <DDPE55 OF UIVNE u l Box 660 Port Ludlow k'n, 2 - NANE ME AND ADDRESS OF UISURN?ICE CO.Oq AGENT. 1IAMC qYU AOURE SSOf nlSUggiKECO OF AGENT DK n I A"°"+*L?' CnAgGE } DWI GiATION NO EII(ONCC !ENT CHARGE C ITATI NN ' 0744 AC1 oN CODES NAME, ADDRESS & INJURIES OF PERSONS INVOLVED a C NAME JCNIISON„ Roger W -- SEA AGE GlAms , _rr ?^ 5L u S x EJECT „ ? • C AC TAIL --- o_'Q7<_, _.D . 6_fip Port LudloriL:n . 1 p I"Iilu?t. SFtovrDFNOM Ra a 2 1 3 5 2 1. y i ? r 01v•mnic A N NAME - mbulan ce T o Jeff. Genl . H osv T ADDRESS S MIUR fESOF ------ -_._?-_?_ __ lMOVEp ?ROAI IN SCENf R NAME T D T ADDRESS "IPIES E m t SICi S NAME TO #. I 5 Dngess ---- - E ti sr0,- 1- US IIISIAI nOVigN CNr f1Y I iD C iAl IF JI-NUUNICIASS .) I Ai PELT f 1EbIR Ic,CI OI ? L 1 , N MISANII .GINBY II DD IAC(N[ L 'ON_ P % + OI14STALI CD I O 1101 [ TINE E . , ;DE DO RnNAt _B"T IWUnv I 'USC ?A1ETEp OIURCVCLCI U EUYnOSPIIAI N P T osNU ENJUnr Novrial urrcrvowry j I ' ` F'' ra( _ L bf A ; -I pILI ALLUHr ' FJCLiCD +s ? N t _ I T 9?rI r a l E h ?? „ p ) X k ?' ' ? IJ11i" f Y p., ;. r n 9" T Y1 4 1 -7 "IT ? I I 1 1 ', II I N?? ? I VEHICLEDAMAGE I.INEACII00%,C+RCLETHENUAIBEfl OF EACHOPAIAOEO AREA E%AMPL INSTRUCTIONS: 2.SHADE AREA OFSEVERESTIMPACT. ,," J DRAW APgOWI31i05HOW PRINCIPAL DWECRON OF FORCE 1° DAMAGED VEHICLE NO. 1 (USE THIS SPACE FORSRETCHINO DAMAGE TO TRpILEHS,MOTORCYClE3. ETC.) O' 1O Y + x D a ° " IJ Nagl DAMAGED VEHICLE N0.2 14 ° IA R°al 13. HOP0 nr?"111^^I5 , Trunk ., 11. ROd 41 - 4---? T IBUnEmcwrtpe FrIS. Trunk +y IT GVMUm Ix Id.Urdwrm?pa ,w DNy SEVERITY OFDAMAGE. VEHICLENO.1 SEVEDlryO OISABUMODAGE,IOTHERVEHICIEI SEVERITY OFDAMAGE:VEHICLEN0.2 12 ?°^V^ Y'''r W `y 11]pISABUNOOAMAGE 300THERM.V. DAMAGE IQN DAMAGE JQOTIIERM.V. DAMAGE 1001SABUNOAO J QOTHEqM.V.DAMAGE 2 FUNCTIONALDAMAGE A NODAMAGE 2 FUNCRONALDAMAGE J NODAMAGE 2 FUACBIO NALAM OOAMAE , A NODAMAV' r TOWEDBY lti I(? (j F, Y'JC EST. DAMAG< TOWEDBY EGT DAMAGE TO ^)? TO TOWED BY PC L s JJ EST.OAMAGE `r s r- r, s DIAGRAMOFCOLLISION •°°^ TO s nr I I I_ I I ?..1 I ;1; I I I 1 ! !D RAW AR ROW SHOWING ++ I.` dDL ow PDwY FEARIRFS I I ? T .:J r I _ - NORTH IN CIRCLE J' c? D«,r 1 1 1 !? I i L `' ?; onBr rlD.r ? j ? ; ?--I _ ` ? I - T i --?• - ? „? "? ' ? a<'PM1OOABIEPpNTOF 1 TJ;+r ?T r,-; I . 1 i -` -1. ?Z1_ i I ? I-1 - tu;? n I vY2? TW VENICtF.PEOEmnAnw _ ; y -I ! _ " r _. l"- ! r -owcARDB.aL-vur MAA p .r rce"Pe -- T -L? { j T I 1 T 1 i 1 I I I r'A , }I y4 AnnBA?[ c^aws°iDn^? ?? A ? ; ?.I I I i i f I r!Ft?,t,- 2 TiTr <jIL I II I, I -1 '? - ' "' DESCRIPTION DF ?-' &!} ly' . - PENE COLLISION IDaA&LlTEYWREWCEDVI"^usIBYIRY, PECESBAIAN CEDTNINa COLOR CQV3TFICIC O IO REPAIq WOflKTETCJ?TOY DIAGRAM,EQORNEq A _ s _ J pr G?_<v. 13 0_? S1_"L!5=± KoI I?Lerh r w :._)? fJE E,J !? +/LI?S? .J-?rF'_ < L.D..Z_ ?,1..RiGli __.1fLL2+J ? f Y V L 1+ C V V E.C k! ? J ? r , _ _, _ _ r {A I V <-, 1 T , J_Ff I N i 11 CL S rl,_C i Z.J i.f._w >, ?l,;,A?!S)LI_ ?S? c,J IJEr ?_ SC, ORLEy 'G _-E- _CO:T_v G 7o r:EyJ- /IJ 7h _sJ.CG+ n >]ti v< r p - ? ; _I k " ,y+POSIT NB $ID VEH."-' HEAD ED NO. MILE PO WCREASWG ST p R. DECREASWO ON STREET Oq E NO Al.- HIGNWOR aO.OF LA11E9 ONEOW W E CRON S AOS PEE 0.Y_ VENIC LEDALF•y I P KE 14A$V GGG PAANEO OCCURED 2 LJ ? ? L L J I _ - - --- YES NO YES 'NO r , PED. 1.1 l__1 ? L_. .L6A] C On nw °?^ ro>ECpWep E PEO/BICY ASUSW ADSU R SU F ?-; O I_ _qpE yN... n ny apSirq A OA?Pr$? °f -lt i Ep T?-T '? T 1 J -. :_ O ... : "' ' 't? ` R O R ACE, I F«a„G-'. a Z;?gWEATHER,^• .u@i Ic„FCx D»EI T' 3?'xn>A?vtya•?'CONTAIBU Ic TNO CIRCUMSTANCES Lx a„E Cw MOnp .. _ E I lornw - ..?4?: atw?r ?t ???,? _ • . , .. .. stbeDmrtnnoecrM lora?,?. ?. Ll MTr 1 ? ttouw :DeE^.xAST DNER u„DEa,nEwFncccP [? ?J _A`°°"a DWEa n ? e*? Lp?Lr Da FR C id E° .a°°° AaN rai I sc I-I bm L.J ? ? srRAUHT.V,FAp ? x ? 7 _ j? ( J ? _?U°64Ir=LUg40F L ' ?- y? CEH*Fn s° _._ n _Q !3FEV rtr _ ? ?PAa w , AkwO . _ ?'? Po _LJ ? B _..? ? iArE ? _? drTIUIN E T UM lJ, FOG . -_-_. L 1 ?- _CEfow pRfA9_ J _ IwgHa _I_TUiw ?PD L OF CIMEWY?_?_ ? _ ?°? l0. onrtal sHECarI •-•!___._.._ orn nIEPECSn ,?{o.T„cre _ ?'7 ?.,:_y-., nonsa Orwnr ?__-. un,mw.: " LIGHT CONDITIONS „ U 7TRARaC CURTAOC ; I J ASN^ vualE' TYPE OF ROAD' Cf+'? J bGnE Ap LVEHICLE CONDITION? 1 r0i0TMNOlA °° m T- -• ?,? ? EW ? - '. F rc I , nD vz m ` Icr+EaoneonMOAEI Ej D rt , VEeAE rc < R - 2 COnrw < aE % - T,,.SOBRI rc„ETY...,2; ?^?-s?ro°PV?ED Ar?sorr.L " was l:l ' s c ? 0 =u- ro v . D S rtA5„M gw F -?__ ?= '_-_ I'L I -. ? E P A^^^?gYr?i -u? ?11 a ° I I. iT G ? pGP ? , IYEEEIrvE 1 PEAAdp n • o50B a[ 1Y ' ? ' Oy aD.,o B on oMe< ? a un ° 11 AJLE ? `A 'T ( a rn 1 eFr`?DnNOOaTI . ue .rt oF ^i `* i . opnAL I> B' + _! ? a I< aMl C ° oawpr"w+ci ruaeD .•-?- --- wi CHEM.TEST ? CJ ,. H E arrs .. ..n ?..-.- _... ? I sea ? '7 _.-, ,.. _ rEttpNFn ? orReaiAPE Fn' OmInIYEC?VI .. lH'.. ? ° I c ' _? MiOC _ ( M IlCt9 a - ' , IF9r nENXO I• w .j1 .i. ? i'? }rMlrq VMtnf 1 : moi EJ ,(J. namxD rRK Ovi ix<avj • „en 6 % TEST R ESULTS 2 '?• n?/i, ?• sr.1. .a YceAn Nwe.nu , ogre rIXKF.FANEO W X r wro°nD _ °; Nrononr.orr. wracA AFADnT 1 «n .PNmFDBY arc N - J- - 15-??? I 1 I OUPUCATE COPY. LCCAL LAW ENlOH(:EMENT AOF.1,(:Y'9COPY-fRIPUClTE COP Y: IHVF5T10Ai0R'nC PV I r F I 4 4 d .' I ATE F A ST O li11.4SHINGTONd ( - PAGE OF No {'CLICE COMPL -MM-1 r UNiFORM POLICE TRAFFIC COLLISION REPO RT _ ry f? F' Q p4iECF COWSION OA/OFCOLUSION - GV )CUES ) !• 04 IMVP 5 FRI fl ]AF € / 7T TIME / 7`J HOURI J CCUNfY M1'O. / CITY NO. FHWA r^ (]URDAH i< ?+e + - 5 1 ` COUNTY ?STATEROUTE WCOUNTY ROAD ?CITY STREET Q AGM CW^. PREFIX HOU lEORSTREET CODE S.NCN C j T1. ?c 6 IZ5 O0 ?OTHER (SPECIFY) U L N 5 E W ?Q IN CI TV OR TOWN PRE- t0 MILE PoST { . muss/® ? ? ? ?GF C l/NIl?<CJM O W v Z I `h C a? N BNO OFSTREETOfl MIGHWgY INfERSECTIIIG WITH. SiflEEi ORROAD U. , RTMP OIAL'.flAM DATA 1- _ y ,,, 'T I NONI!IlEflSE ' f I O ACCIOEhT IA LEAGE NiER ?N??O?N? %-RD '^?'j^` Cli. iERSECHNG SiREE OR A AD OR REF. ERENLE CROSS STREETOR ROAD S W$k ? V DISTANCE STREET4NDBMVEEN DISTANCE AND DIRECTION FROM REFERENCE OR CRO555TRE T STREET LODE /?, P 70 ? ? y 5j ' x ?MILES N 5 E Vf' _ r r v+t.R*n5 J S ECIAL COO NG USE .. . •? K?' la 1k. Il ©FEET OF CO?O7I '•I' ?'L ?C?? _, I y COLUSIONINVOLVEO: ?VEHICLE VEHILL ?VFHICLE.A;vCfE ?ORIERIWRNEI ?rlli6 RUN NO KILL "EVER"" ED I p1R311' TOTAL NO. ®VEHN;LE-0BIECT ?VcHICLEPR THAN OFVEHICLESO . ?SIOLENVEHICLE NO.INIURED ?VEHICLE-PEDESTRIAN ?NON-COLL'SION ?H:ZAR000SMq'ERIAL ZPROPERTYDAMAGEONLY r .. iryY• ' Od.ECT STRUCK (NAME OF GMECT STHUC%ANDOWNERS NAM E) (?/? CK6 1-7012S111-1U- /-G.??2?[?- LOCATIO!I OF ?RCAO:/AV OGi STRUCHS E V/ EST. DAMAGE FEET o???A NV ]' GRNERS NAMCI.AST _ FIRST (RIDDLE O ORNER'S NAME LAST FIRST MIDDLE HF OICYCl6i OR PEDESTPoAN CNECKI :j ' o ?fOL7? Q ?F1 MG-S G/IFJ r C R n R FE F ' ?? a „I, u {s STREET ADDRESS I E ST.21. K /S MILES L.JE? I THEET ADDRESS ? Y T i CITY STATE )IPCODE PHONE NO E R r /k) FiCLtum LJA, . 59/3E3 R rr N O DRIVEN. LICE.vSE NO. STATE SEx PATE Of E:fliH MO OAY YR N _ . -• N a-L.Z-ES-F.SG-3 NJ LL)A 1'L'I• . ? 11 +l O. I OTHIERSOCCLIPARON FIRMNAME PNONEND, 2 V : E H C p ij L E Mq.. N 0.1 1 a AJ (,,)A '12 CH6V ? f1' 1ri DZ v COLOR ,. - PLATE NO. STATE TR.VLEP TIE NO. STATE . E I '/2L-r) GVV 114, WA H 1 CLE IOENTIFICA ION Hu BEfl ...?. ODOMETER _. ,.,...:... C L E 3TEPED OWNEfl-LAST FflST _. .. .. ...... MIOq.E ShMt N E.S OF DWNEA :... :. ..__ .':::_... ... N• 2 iAHD ADORE590F WSUIUNCECO. OR AG t 13eR_jj -Ab Prc-2cC- CS?o?Aa? LHAR06?`•x?? _„1 .. , . ICITAHON NO. ENFORCEMENT CHA UW 1 0130 ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED S Nn nESF W NAME' ADDRESS NE U N uRIFS S AME' S ALONEGR E N iuls2'„'T- S I•:m•xcs MSTAr" C ) T`Assc•ALN VZ(iF STN:MI CL T O M1 OrHrq E •. 1r,E SS SIRTH DAY 1 '" NUM ..:? '. UOOMETER - ' -(AST ... ...'. FIRST .. .....: ........ ?AUDDLE IF IHSUIUNCECO. CRAGENT - _ - }.... _ CURT CODES , SE% 'DE TANS IN EJECT.; TO l 11011 RY 5 DISADUNG HLLPY I. NOT INSTALLED ?NOf EJECTED S _ >OTHEH-SIT ON ).DEADAi SCCNE DNOrFp15+?uvG )NOiINUSE I ), TOTALLYEJECTED ) II D DEA00 AHHI'I AL IEVOEN 1, •N 'UHY .l USED D PARRALLY EJECTED EUSMOIOHCYM1GA>I CLEI) DIEDIN !I OS TAIL ). POS.'Y.IE:hNRY A. I.NM1!IOYIN A4fA.NO'WNIF tl PL;IT,O•, UhA S SEAL RELt FAILURE EJECTED ." .. ?. -. - rQr ?+Y - Y I 1 I 1? ?Iti'.tr ? T J.Y. I 1 MyI J??' (NIS ? ? 1 1 t3T I„ +? 1 ON, ?,ms :GS,^ K3 } ? 6 ry Tµ ytT'-i4 T b 019 'S li C?Ix J rrx ? -I a 2.SHADEAHEAOFEEVERETIMPACT. . •.. IN$TRUCTION$: - 1 DRAWMROW(5ITOSHOWPNNCIPKO ECnO FORCE. DAMAGED VEHICLE N O. 1 iusE THISSPACEFCRSNETGIaNooIJAAGE TO TRAILERS,MGTOncrCLES, ETC.) -DAMAGEDVEHICLE N O.2 a ° ta. HOaJ tA,ROEI a a ° O.IUOe u Bow T • te.uM>mIIW. Ell, _ 12 x tOLaOrunW. ?EBtTY OF DAM NO.t i (.j M31BUM ONAKiE JQOIHEBM.V.ONA/LE FU2CitgUL NOOMIAGE SEVEMYOF DAMAGE:IOTHERVEHICIEi 1QD18ABtWODAMAOE iOOmEB M.V.0NAA0E 2 F1INC710WAEDMIAOE I NODAMAGE 9EVEPoTY OF DAMAGE: VEMClE N0.2 ..-.qy.?"`.a-, D19ABUNO DAMAGE 9QOlHEBML.DMIAGE 10 2 FUNCTIONALDAMAOE NODAMAGE ` e_ OWEDBY - GAZA . EST'OMIAGE tOWEDBY EST.DAMA.. .. '10`FEOBY '?` ESi. DAMAGE - o Chimacum Wn. . s TOTAL To s To ' _ G.jMAME MUNO11.•. u, R4V BROW SHOWING - 1 ?Ft?Y: ° T16RTH IN CIRCLE 1 . .• . , I•AASU?°w'u?i,Dr co'ana,a ,.• ti tom P till nceasrawrar .a asNDw.o.asAmurr..won y ': .. '.. ; ... .• I I aarerloa,veaA.ACr. ?` . „ ? ,_ RIP OF Tk arCOLLIDESCSIOTNION s + K .. a uN01CATEWHAT DISH&UIY, RECU PROBAB CEOKY LYlIAPPENED eEFOBE.WNNOAND AF &uTV,PEDESTBWICLOTMINGCOLOR IEBTHECMSH.INCIUC INFORMATION NO ON pAOBM1 EO 01a CONSTPIICTION ORREPANFOR.A? 1 T ' Y? SM ' ) y,? . j y , .K: . ..t T.Ti n :. .;. vsr_appa"ntiy didn't realize that the alight curve is the roadway was coming up and i did. " s ?h?tht-curve and struck the corner of the -house.-,.. -T ' .??. :....•n.G TIG. B ... -.. _ _. ... ..N.++.M a.?r.F :?In.t?a'R ., a.•.r, s'e: NO OF LANE9. .SPEE0.5 F 9?DA11Yr_ . WAS VEH. VEH. HEAOED ?MtLE POST DR ONSTREETCRHIOHWAY NAMEOR NO. WONEDIREOTION E OPA[U(ED OCCWIED W ""¢ - N0. J1 1 CBEASWO DECREA.SWO o C.R. l8 YES No YES NO 'Ji' 1 v R4' 'loub-ltlo _ V'TTfT_ C^"- _ ? ff,?7 I f?k ? PEG. ??? FpliOw DaECgaEW vmIE TO Wa AU}A _ ?/I:'1, U1G ?' ' S D/SCYCUST WA9 USw ? T-''T 0. ?NaW f J a?snDUtnN, ?r?vw.ux ? rmix L J TFDI?1 Fr"' ?' ? i IlOE L?:. G _ ROAD SURFACE_ KLtEGn ohG A -y WEATHER rcHEC owel -?. j.COtjTpIDUT ,/. ? 'rc ifig?CIRCUMSTANCES- [on wow t :' i b ° ,r•.Tn ? awvFn , _. -.. i . .F - x I>?'EA . © . wand n /; '?J slw,otrtN,E.n s"- -' ?_??- - „,,,ND uwenNaDDCeaE INaBNFwDCeaE F«aowa.s ?1? rooacaelr __ ?en wwaDrtm _ . ? ? musaci uw. rno.aY ?.i? :AVSA"w°NO : , _ ? O. ?p . ? ? ? _ (tea?. exow ?.? eNaw•.D ?a? acETnwusrArtn eeeeolnvr EManro ? ?. soau_ "B ??.°irvra'a':. ? ? ` I rocA ? -. ? ?iu?*?{' ? ° C ;. ?.? A? ? ? aEenED ? Q n 4? I aF F aAFF ?a? G„U,C fElrl OHTCONDITIONS CO ° ?_ RPE<.Yt yTS?FRC CDRTSOL -. ?? ? ? w•qc. ' -vine Asw?F5w0" 7YPEOFROAD, v off... ? 211 L HICLECONDITION ; _ - -+ _ rfFpT l Q yEl- L. -11. S08 I y, „ ?;y,, a. ivywu slaNAl - p 1 .4 a OxD I eF , wo. : IuECA awe on wow , , ,T, .ela orlon ? . .aw + F = I T . PE - :, sxdL a LF?Eleit. TnT'I .. t11i - 1 ?= ° ? ?uo°nwn,aors ° °YM ?°? mxAl ° _m rt=uuns x r unu.H ?.. ... ?°?.amen... Daml XlZ . ., WPUCATE ? ore;wer ? , HD : olsecrs •CM,nartEal , na x - - .. ? o ? srofOPr«°F°Arw ? rwo _ - - f"""i r? orarocrnr: F 1 ? I 1 rm .`.3 .? ,?w?:. ?mnFnc ww.e nDV? r' ? '.i ? 1- ` ? ? ?-?'+ - -? ? ,.baa?a,,f?-:? r ,? ??. IDn N, .! L. -??,? _ _?__ I?I - - ..L.I_?-.°"°° __ - -'?1 eeeN Onnl•.HO Uu?'IMCAND.... .: °f"wAra T .. LLJJ ?"?..?rma:o - tars CHEM.TEST . L-.?..?, " nI a o*Hiriisrtum avuuIx D a ? atom _. ? w IrTeora 1 1 Trarwvexo .. 1 ::'. .? o: 'J> Y , 'Y o a,iW % _K ...TEST RESULTS 2 ?, . 1*I 4w ' eAOaE ro. _. - 6 wuce lA'rA,u.EO _..__ .... ._ _... .. east N•wTO .... Awwwu .. a,n . 04 i 03. 014 -ate Ol a wox rBVraFww ...., 0 ' O M. 1 1 -6- Aoucr ... _..._ ,TC IAaTal oau on....... _, Quilcene ogre o• .... „ 0403y " .morTn•r ...',aTe., .. DUTIDN:ORI(iNALCOPY: BENDT0 WA5NHDTDNSTATE PATPOL-OLYMPIA,WASHINGTONtIB60? T ,'. COPY: LOCALUW[NFdICEMENt AGENCY!ICOPY-TfuPLICATECOPY: WVESMUTON'S COPY ' ?k e ?Tu ? T(F , ? a f { ?. ? •, ? T Po P: 'a . .4; ::.aat t " -- DATEOFCOLLISKW ... :- .. - OFD loll TYRE - COUN,r NO. CRYfq_ ?. +fHWA _ _ M 17 Yq. T SIIN i •YN 2 TOES O WE , INJN 6 FRI 6 SAT ,USE 2A(!0 HWRI CW lY ?STATE ROUTE ?CWNTY ROAD ?CITY STREET O A-LS PREFIX ROUTE OR STREET OOOE CTION - Tr ....q^Ar'1l ?OTHERISPEOFY) N ., - a .. ".` /¢/ SQi..^. S,+•. L O. N ?N CITY OR TOWN . MLLES ? 6 ?OF '.: _GCI7 W V - PRE EO i y IE POST/ Q ?'J W } . A.: ... -..•NAME6 .OF EETOR HIOINWAY.'." f - .. ON a.p. iN1ERSECRNO NTM:6MEET Oq POAD 'L LL , RAMP pAORAM DATA Cs ??? O NpT Y+TER6EC?IOtI. .- ACCIDENT W EN NON %fl0 NTER ECPN BTBEE q fgAD OflgcF. Yt? E R CLS E EcigSy STREETDfl ROM N- BETWEEN 9111EEhN7D STREET MIIEAOE CODE y . /\ I L.??T. xly '1 DWANCEANODIR F(IOMREFEfiENCE ORCROSS - N YCIAL OpNO SE I W ?MLLF9 N_B .E. ` '.x r! ;: .tea fnI FEEL OF t...:• -_ - .. ? .. y.A.. .u.g ??f T'f- ._ ) VEHCLENEHIpE VEH!cM-BICYCIE ERMWEI HR6RUN SEVEWTY COLLISION INVOLVED: ? ? ?OM ? _ NO WUED ; TOTALNO . ?VEHICLE ECT - ?VEHICLE-ART1WN ....... .. ?STOLEN VEHICLE ?!. NO.INIUgEO-,.r.,'.. •. .. O OFVEHICLES ?VEHCLE-0EDESTRUN ?NplCOL%" ?IW ADWSMATERMI ?PflOPEHTY OAMAOE ONLY .. .._. _ _. ., N . ' CD1ECf.SfRUCK(NMIEOF.OBIECi STRUCK ANDOVNERSjIAMFj., _..... '.wJ..L ...... ,. LOCATION OFOBIECT SfBUCI((' ?r;,?„a. _`. E$tDAMgOE....? ? " -e .. "I K• Z:: T TY'Y 020-All FEET ?' ? ? ? PD EDDE T W, . $ pYVERSNNAEiA6 a.ar?r.a?....v ?E_W$I::_+._.11_. Diu" ,I fi.: NML-WTf--STMIDDLE-_..-..._..__?__ L+DRIVER a d .. ... Z - H .`.. a r:. ' 6iiiEE'T AOagESei?Y• Cs . ...r.....a?... I.. STREETADDR :.E-' OISC.u...A«y:b'? .a:.. •.r.«..._.SfATE . ::..-.u-.... .., LP CODE;;:.... PHONE NO. E C_RY ?_ :.. : : STATE Z1P CODE r- ,::. _ PHONENOI R,, B _... _...... ... _. _..,. _ , !y n,Cl- ry f.TC N ; OWNERS l1CEN5E N0. Q yr. .:... STATE FF]{_ GATE OF BIRTH .. :. N OF ORrvERS LK:FNSENO.......... . ... . DATE DAY BIll .. • -.:.??. MO DAY YR O• MO. YW Nil. . J' r-ne T CM.Efl9 OOpMATgN FYiM NAME - PE.. 2 DgNERS OCCUPATION ,.?-FIRM NAM All >1(3) CLASB,y_ _ 114) 6EATBELT' 7 161 EJECTgN 1.. CODES J 121 2UVRY . (11 CLASS SEAT BELT: .. D'1 EIECTIDN i T ..! muRlFB F? -•'C^ .{' I":toc NJUWE9 SCENE BY.TT C C'TO T ?.- T SCE FROM WC EBY TO . •. VEr MAIIEIDODGEGHEVJ.. NODELIDARTIgVN STYLE12 O0.LONV I.. ?. VEH YEM MAKEIOODOE CHEV) - MWEL,DAFR•NOVf?. STYLEI2 DRCptVI?„ A ? , VE1E ? ... PLATE NO.,', STATE -. TII!uIEB PLATE NO., STATE .__:. -. YEHCOIOR.. LTC. PURE-NO__? STATE. TRNLEfl {KATE -STATE Y' : N..: e 1 C Nu .-:.4,.?_?-,,..?»..? •.: ODOMETEq .?,,V_.i .: C., t' n • LS, E' '.'' REfL$IEl1ED.OYAVEA., LASf....y.,_e..: :.:. FNST_,.,-. - .. .... MIOIXE.; .'; .::., gEOLSTEflED OWNER- ` • ADOgE89 DF OWNER «_..»:.. _,, _._ 'L:.. _... ..::._ ...._.i is _._ • : ADDRESS. OF OWNEFtA.. .,, .....N'- _ _._, .t..-•IS _ NAME ANDAOpiESSOFNSURANCE CO WAOEM •? ? NAME ANDADDRESSOFINSUflANCE CO. OR AOCNT p I v_.. ENFORCEMENT ?. 1 r n t• ', i, ACTION •,?J NAME ADDRESS & INJURIES OF PERSONS INVOLVED CODF' ' ' ' ' 6 - : SE% AOE 8TAT19 , EIECi.. F L. NAME \ •, •` U. P:. NAiIIRE OF REMOVEDFROM, %tANtlES:T C^••. ?: ,.•.} ?. SCENE BY: •-.'. f• - '."r•• i0 A -' NAMe aF N S lWORESS NA E VEOf S SCFNEBY: O - q ) I a $ y W.. NAPE: i4 1 r >T AOORE'.?., , 1l • N " SCENERY: TO f , rIN i E' NAYF• , ? . ? I ." S ' ADp1EEK. . E . SI' .au S' .. NE., . TO ... w N ;.: IN6TATVB 1116EAT F'O6lf10N I31 1 YCLA99 I -1 -1 ,., 1 I P . C. O 2. PA6SEN0[R ]PEDESIRMN . 1 Fosrtm, • ; 1.1K1 YLIU1IY 2. DEADAt BC[NE ? i K I 6, pS.WUNOYWRY A.Hpi d9ABLMO 11'T - ? 1. NOTPISTALIED 2.NOtMU4E ' UNEN 1.NOf EJECTED `. 2. TOTHLY LKCTED .. YP CfCD 4 P I ?, E t 1 e POBRM)N UN s of DN NO6PIt T PO141.Y ilRY E N . OMI i 6 SEAT BELT FAIW . UMNOWN p + . . . RE EJCCIED '^ V ry„ \T w , alkti ?t 4,1 -:/ MU I Ult VtMI'LE COLLISION REPORT DATE OFCOLUSION NO. DAYOF "o SON TIMEOFCOLIJSIOry 'T "D uwU,E9 •J C? n ?/ vFAA aun L•ON IyIF w 'xun F 6., i 'KJS' AM PM COLMY1q. . CITY NO .: -' ? u F -•? COINTY CITY. TOWN of MILES ?oTO n CITY.TOWN n dC w WO ?J.?i D R/' le]I© OF /''.•'11 ApA CL6 PREFIX RdlIE OR6TREET000E cilON 0 d 3T ETOR GVEN AME OF ST REET,ROADOR HIGHWAY NTERSECTNG YATH. STREET OR RpME, b • T cccE°n°1'un ac/ he rE de le /&04 k - 1 OC NON INTERSECTION LOCATION OF.: N PREFl% EO ; MILEPOS}. ..,? -. . / 1 BETWEEN STRET ANO STREET RAMP '. DIA-1 DATA N ©© ON)[nObY.?Gnu tEIVOINn55pgEOE.N vl, j a?NUMOEn.luuoGE. N NON ? rvC ? I I N rFP6EC,ION. FFEr ©® OF 1n ft?,r?o //4?!/a/??//?v s/ Tan NTER ( FV E ' O,•p o E ? , gvEICIE V?NC ? ?D,NEPIwwiEl / F RAw E „ci ?D ? w / S SPCCOD IISE '• «wE ES 1 ! ?rENCLEpEaES,PoM p ?NT LSKH( wN ODIECT STRU C K - (NAME OFOWECT 6inVDIn OWNEROFOBIECTSNAMEANDADDRESS LOCAT / ? IN ROAD ?4 ?/ /! ION WAY ?N © dF id PEVAN p?eJECi FEET EDGE .. • • IF-TIM DRIVERLASTNAME FIRSTNAME WOO E -M - • D - / Sa'u Sus ?i? ?l?arl aim q STREETbOR[55. ROUTENO AND BOA NO pgIVER3 LAST NAME - FIRSTNAME MIDDLE c//c/, Sus.9i/ . . E A I STREET bORE53 ROUTE NO. AND DO%N0. S ?? ? ? 7 GTY - sEVAAA E ATE ZI ODE DPI EPSOCCUPATION . CauSpN RT 'r ( " l ' r l J ? d G ? ? ' GTY - ... STATE. : ZIPCODE GiIVER5000UpAigN -TFDnM .c j(, / F ,I;f- • ?. . j .? cs- wlr@in?, DRVERS LICENSE NWADEfl ,_.. .. STATE SE` SATE OF BIRTH AGE GiIVERS UC -tic-VS Sa7/v" lil? .77 ENSE NUMBER. STATE SE% GATE OF BIRTH AGE YEAR 7 YR, MAKEICHEV:DODGEI MODELINOVADART) ., UOOYSTVLERDR.1 e, s 1/1? VEHICLE YR. MAKEICNEV: DODGE( MODEL (NOVA OAgTI.: BODY STYLE (2 DR.) l LICENSEPLATENO. STATE TRAILER PLATE NO STATE ,.. DP? S23 CENSEPLATENO. STATE TRALER-TEND- :-_ STATE Lt/n G x -?5 "sV3 &A-7. VEHICLEWENTIFICATgN NO. (I9WM(XOELSANEWER) ODOMETERIMILEAGEl V EHICLE IDENTIFICATION NO. 09MMODELSa NEWER) DOMETER(MILEAGE REGISTEflED OWNER (LAST FIR$T MNOLE NAME) ORIVERSIJCENSE NO. pEGISTER E / /' ?S'S : E ? ' EDOWNER (LAST FIRST-MID IXE NAME( DRIVERS MCENSENO. rr / _ / N n ! - /S SSJ7N9 OYNERSb ESS (STREET GTYANDSTATE ,. . , ) ? y OATEOFWRTH. OYMERSA ?, ?c Uclf?' r uc/?A/ 41n. ND D. EM PARIS OF VEHICLE DAMAGED ?:P OOgEw (STREET, CITYANDSTATE) .:, DATE OF MKII Mp MY YER ... •. SiO rtny?v[HIaE PARTSO?-,NK:LE DAMADED hpCygr LIABILITY INSURANCE INFORMATION•VEHICLE NO 1- WAS THERE AUTO MOBILE U%eNir INSURANCE COVERAGEINEFFECTFORTHIS ACCIDENT ON YOURCM ®YES ?NO HA EHID bONESS OF LM&LRY NSUgANCE POLICY( DER ' 6TATE NAMEOFMABILITIWSURANCECOMPANY _/ _' :.. a rru . E ?7i Qr e as li ba i/e Tlp I r?hry?i,/? ..iSr-cs-enc•t NAME HID ADDgE530F l1ABILITY NSURANCE M f?GG C/??/P/? PcrfTc.?•i1Rr,Lf gcf,) uABI1NYpoucvquMBER rICrS j l/G ' £ s ' / / A,{c;rTt/rc • G o ii S krGc/ 1 J,/ /L'.., ;LB 77 ?S ISi N,ItAiY ,E - NAME //,/G l?(! 1?'7 f ADORE 55 ? ilArun ---_-- AGE I GE% wA -L REO 2ND INJURY: I A,E PE rKW al - NAME I&I -- ?JIJ - _. i7 (_e?S ADDRESS AGE EX FnENr M .Mm DDCrom ® I DNDµcFals ? M ?-_- - ___.. _-._.__ -_- .. ?. i ."""IF STAIUSOFNJUREO ®©' x , Mx ,ON nr ADDCTDn+ AuE MARKFNSTONETHATAMIES ? NVENICLE USAIKwD I+DN dsAN ? STAIU90F INJURED MMKflgST ONE THAT APPLIES a [ ? NDF KILLED I"I"vE"nFl N I ?-A IN VEHICLE -MIND xOnw qNM PIF ""l d N I N RAN FDWp ? FTC'' ? I:u; TT.w ? 5? 8Q no7? _ 0--A KIIIED I l ?P[DC - NO v rl E?e'' SHOW NORTH UY ARFIOW N CIRCLE ? ? 5? 8? DESCRIDE OELOW WHAT ILNPENE O: IpEFEfl TO YEHICLE9 BY U _ e?aanwEIHA A ew \ REFr MIN N a ? / , N MBER( S-_-._?tTT r N?a/cc F_-Itc Tora1 .Poo4_ itL • p• wMac E r?ACN KI. ?:.Rro°:°"' H -- ? -ry4ar/<•!r? Sfk'r!!c ?2?-Lc/?G/7 .Sq l / -?? Qt•-? \ I I JaT ?C Z ? ri h a ,2.__CC/'-../"r `Ge /l•2y ?/-G/rj?? 4°: •e /7 F C t4,zd /Of.E - Js?r / _ 6 ?r? n.?- 7 Fem uv /c/ yr? . NaL//c 4L?/7/t?C.7e'!1. ?ru k ufli/Q_!?T_e?// VEHICLESPOSITIONS BEFORECOLLISION Nool".Nn ve cl[ v[NICE NVL91'OQED GY I VCIaOLE w F IIDNI?INNU.o !M14 r [P V[rtE[00 Lr 0U•i0 W N 8 F ON STREET OR IYDEIWAY NAME OH NO a1 DICTIdv L T n na RD • b O iiiMl ?p d E"iDf "° (wA., ? D ? il:keze /n ?.rn><F1 I ? ? D ? Q ? , ?`DmFE C ;I"d ail KIINLN O 61 O D / - n Q ? ? ? O ? ?M•IV1 „ NnE?.N ? D ? ? "OHO cnoaE.IO moM DIRECTION To DIRECTION E rFOr6rWAN WAS UNIEb 10 m0e.4K J?wALILWAY T?SglILOER A?erin•'iwN. a??",gASI"w...', S OTHER rUbBWIFACE -AlHER LEbRCONOrT10N3 iMFIK: OMI vEIIFNCLIM COMROI 'MCKCNR v'r•CL[ TYPE OF RO b wr+hl xl OIYVER/VEHICLE ACTgN] ?II ?MY _AA ?' ? MT M ? 1 O s10NALS w AEn OII DI I Q ONE WAY vE•CEI ICMCKWEOE-I ?1 1 ?] GGNG STHdO AHEAD i Q 7 r] T gNNNp T 001- wLN ? ? CWT WAY ? T w ? J _?vOKRTANNO AND PASSING u Q ] Q ))Now ] ?9Yo M ] Q OM, DHLK STR ] "LD rX r( O D YI RSMC 0 w D ] ? ROAD D ] ? MAALNO ROM TURN D E ??E FOO DI ? EET twSON • ? D A ? IUY,NO KD ? A ? UPj ? E Q -...LFrT TURN "1 ? / ? TERIC C. • I.C•IER -l ? E ?Ej? DARDANKK NO ){rMFET • ? a D rIAYwO AMO[p A ILOOAi11A Q 6 ? "LEY w Q F Q MAANG V TWIN RE A90N 10/1 NOT S[[NOOHQER lO?]1REll'CHIS n DDIEAL ? a C) 13 ? A LF R f1.FIN ? A ? OLOwANO AwECUNDYHAY. mr .cruN• I c 1 T 0DY E. ? / Q OrrICE-t ADMAN lHl[ . k ...• ? r Q arorr•m FOR Trwrlc fJ I L? S N C (?rv/l; rN ? • ? OT"- .?•ICIIr ? I Q UFMAIID Q • Q ST a"tO• AtbONAI ? J 0O.U.0 Q • ? STOFProNRObWAY _.-_.-.__..-?_._.._ ___...,,_._.__.___"'_ Q • ??. ?1 inA t ? ] QdNDMOrO ? Io ?51- . 1• r Q: w aE A D_ 1. ? Y u o a 'N ^ t N u }y..I -YI .. 1_ 'M.7An ':--?e.yw.?I ?'b?? y'"'TALI'.? J,^MU •I Y? t' .. - F - , t14J'(?y,RBE ,.....- stai39. ` ? y S I A E OF WASHING ON PAGE D 0 NO ?. " UNIFORM POLICE TRAFFIC COLLISION REPORT 1 I cplAruHY rlurABin '-"'-- ,+,? . A D TAT DATEOFCO_LISON NO DA, YR --DAY OF COLLISION -t-ME T SUN 1 MON Z IVtS . WEDA 1NVNiNUN 5 fRl a SA1 [USE 2400 HOUR) y - LCUNTY NO CITY NO. FHYVA ?URBAN { y Z RURAL v LO NTY L]STATEROUIE OLOUNTY ROAD ?CITYSTREEI O ADM'r 5 PITEFI% ROUTE OR STREET CODE C110N . _ J ZS 1 I OOTHERISPECIFYI N ?O A L S E W M n_ nn GTYORIoWN ? ? ? ? ? P EFTA E D. MILE PO..T C LJ OF. _._. MILES ."G] IV EI LL'. .. I` T O? N E?NO.OFSiREET O(INGHWAY R I NTERSELTING WITH: STpEEi OR ROAD U. O RAMP DIAGRAM Al. D Al 1 N-HNTERSECM(Yi S? O F L- ? 7?U ?5 AL CIDENT I NTER NO NN %RD CLS INNERECTING STREET OR ROAD OR REF. ERENCE RE O T T O gp- e I l vc.•• N Q /A ML .??f F"T _ .. STREE T AN D.-C a D[tWEEN ?_I-l STREET MILEAGE CODE yE / / ?o$ OI Y? 1 . a A ....__.... _._. .- OISTANCEAND DINECTION FROM EEFWENLE OR CRO555TREET ? w,lsw ?AiH SPE IAL DINOUS E A 7(?)) _ OFFET E-1 [j C3 0 VEHCLE-VEHILLE ? VEHICLE BICYCLE ?Oi ERIWRREI ?MiARN COLLISION INVOLVED: U ? SEVERITY NO RIltEO ' T _ " F? ??..??II TOTM NO ?y VENICLE'O1ECT [3 VEHICLE FIR TRAIN ?SIOLE VEHICLE OFVEHICLES ?yEH CLE-PEDESTRIAN ?NON COLLISION ?HAZARDOUSMATER L ..__ . _ NOINJ..ED +C?A PROPERTYOAMAGEONLY wl '1 r7 y Ec OBJECT STPUCNINAME OF UBJECT STRUCK ANpOWNERS NAME) . LOCATION Of OBJECT SIRUC% ESI.DAMAGE r i 17I? ??r? N G E ? ?? ? O D S DRWNMItIAST fRSTMIDDLE DRIVERS - ME LAST FIRST MIDDLE 1 i P E'ES fNNN CHECNIU S D R 1 , D R n STREET ADDRESS. .. STREET ADDRESS ,. .. ? .- w _ ` V V js4 E R CRY STATE ZIP CODE PHONE NO. E R CRY STATE 21p CODE , . PHONE NO. ik t N DRIVERS LICENSE ND STATE SE% DATE Of BIRTH N DRIVERS LICENSE NO, . STATE SE% DATE OF BIRTH l 0. MO DAY YR O. MO. DAY YR DRIVERS OCCUPATION FIRM NAME PHONE NO. 2 DRIVERS OLCUPA110N fIRMNAM PH NEN 4 $,J CODES > 101 CLt I., SEAT BELT EJECTION CODES > I]I CLAS TAI SEAT DELT 151 EJECTION S V `W ATU ES F R A , ?_ _ -? NATURE OF ,•_E REMOVED FROM SCENE BY. TO RI-ED F OMSCE NERY. TO 'L VE-EM- MAMEIDODGE-CHEV.) MODEL (DART-NOVAE STYLL-H LONV.I VEH YEAR MANEIOOOGE-CHEV.) MODEL (DART NOVAE STYLE I2 DR CO V.1 wM E H VEH COL LIC. PLATE NO. STATE TRAILEa PLATE NO. STATE E VEH.COLOR UC PLATE NO. STATE TRAILER PLATE NO., STATE ~ • C VEHIC IDENTI C A ION NUMB R ODOMETER . ! i I J 31 - C E VEHICLE 0EN11FICAT10N NUMBER :. . .. . . ODOMETER E C_ 6 9 7 3 1 REGISTERED OWN fl-LAST. FIRST MIDDLE REGISIE REDOWNER-LAST FIRST.. . . MIDDLE. N N AOOK55 OF O !E C ADDRESS Of OWNER J ) I) o 1?//y?J/J??-.1?__? ` Z r ` N ME MID AOFINS)O. Dq AGENT NAME AND ADDRESS Of MSURANLF CO. OR AGENT e CHARGE C ?CJT?LJIU C ILATIUN NO ErIFORCEMENI ACTION CHANGE Cligil NH ?. -___ .. NAME, ADDRESS & INJURIES OF PERSONS INVOLVED oDES Lc---11 1- _ sE% ALE STATUS W - EJECT `. NAME 00 U p N luaE OF ntmOVCO FROM VIES scff+r nv to y } A NAME T ADDRESS 'I S NATURE & l D FR M IR 'f I CFN E T O i• ' ? W 1 T NAME. ADDREss , !; : N URIF.S SCFHF BY TO E NAME 15A S A DDRCSS 'IfN - y . g I SI lul 12151' roYIpN J c s io I f IDEA 1 51CJEClION i.Y' C O P 5?[rµiCP OP[DI I-AN IICYCLIST - I r I • ' 1 ) OtnINP05NgN P O 1 )DEAD 'CONE J Uf DONA IR.1 SDOADIINO .1-1 ONON U9AlIL NG ICY DCNiRNJURY 1 NOi SIALLED 2. NOt USE J U ED 1 NOTEJECTED 210tALlYCJfL1ED D PARTIALLY [Jf LTCD ' 'ya ?:p D 50I I[R 0 in[53 L?l 1 A I IILS MOTORCYCLCI PFO-HU-NOWN I -DI'l HQSWIAL 7POSSIDr-ITY UN%r OWN 5 SEAT DFLT FAILURE %rlUWlllf tJCCiOp f p,, S 4' f r >'' 1 ? ? ? ti ;; I FY L t? ?1 L L k Y;^.LRfi19'.SI91C' i ? sIMP ••ndxrn geew v t e - -..ua.. ;wxd.uuYdAYL . rN'-rdlCvNiCLf?rT'r"Oy""I°CI"%L'PF''E-`- VEHICLE DAMAGE Sr AUE VFA OF SE Et[ST MP CT M1?fl ?L INSTRUCTIONS: D. oRAVA HOW IS) osD PH c LDIRECTION OocEQ?E3'• DAMAGED VEHICLE N O.1 IusE THlSSracl curl sxt,cH NC U+MAC[TO ,nA L[ns,MO,DHtrcLES.E1c., DA GEDVEHiCLENO ,2 _ j u R.- U D.• IT ry x 7 rr SEVEFRT F AMAOE: VEHICLE VD 1 1 ?. ABLINGO MACE 5 ? pTRER..V. DAMAGE )? F UNCTIDNAL DAMAGE A ? Np DAVAGE SE V""" OF DAMAGE. 10THR LE , ? DIRAn L IN. DAMAGE L ? NEH M.V. A MA . I ) O FUNCTIONAL OAMACE . ?NO DAMAGED RriY OF DAI= vEIRCLE ND. ) , DtSA BLIND DAMAGE ) 11 0711ER M.V. DAMAGE ) ? rUNCTIONAL DAMAGE . p No DAMAGE i OW ED BY? 1 .. DAMAG TO Eoly 5 EST. DAMAGE -EO B DIAGRAMOF COLLISION DRAW ARROW SHOWING ORTIN CIgCL D ?I y tD L rIGL.,aa ? xf,LMTHnH _ 1 .? , xsA cur =M"" I ` ? ? _ _1? I I DESCRIPTION OF cAr[w"AT PROnaB[r"A [O Bft " uu"INC AND AFT THE CHAS", Nc UO OnMAnIN NOr OH RIAURAM, EC DRIVER A rvw ran T 1 - COLLISION - 'A DR B Urr.n[ouc[° Vrv° u m[sTR NCwTHNG COLD.. TRU-.. O. HE TCI . __?Elf-- 1-.W/?S-71L?1?ELlN6._.N0?7118ou 1A- ON-C2 18 GUNEN W-WeR._GOST CaNT2o4.oF.....-__ VENICCE._oN_A_ C0AJ-iErL-3-C Mss£D _ _SNE. Pogo .H tT_ TNE. SourN?uyP__AI7cFJF _ 7l? °uEcEA_. n1ox?G-.p1TUl--Arp1LOX '75_Fec7r 1 wsSGO_SNE .Fb?P NGN.t u -/In?p GAr c _ro _- _IZ.ES7_:.(y-!7q EIVd-.-_! tLI_TI?L HErD1SIT10 N BEFORE COLLISION oN 11HEET OR HIGHWAINAME OR NO UNO 11 HF D.HECT10N , s YEEp s r VEHICLE LIIALL, wCS V- . E IN "p L u - r p P. IES o Y F Np PEO n. Ir cowl Pf-CYCUSTw.SUSINC, r sm[wAL1c °I iwAlnwA _sI.OUIDE C-10SKSUALK E?a+oSSrALIL • 1BCrCLEAT UTE . _I ROADSURFACE f CA ONEI 10,2 x^ WEATHER . -CK HE, X cIEAR,c[ouD CONTRIBU U D' w[NCf TIN8 CIRCUMSTANCES . R r- . l LOWING .. D"T" . - D A AC) ONS ` N u DRO' H AREA. 1 ?noG51NFLUENGE 1 I - ..J L, ; le -' [ NTER ) A .1" Ya__?..__ AEL. . ) AND PASSING ,BI T URN W M...-... _ _ -,N ._ •.,? 'Zl -J. 3 MrT- FIIING TO ZONAL "- I "PROPER Annuc " _J_ t LOC .10N ?_ f AIAK- LEFT TURN -i GE ... ... ... .... I! _., _-_._.._ I EPC[rO NC. nInS. ESPFIO ..-.._. sA1 I RDYEn F I° N - l r-- p TrNE VF fOU Y. _. - K ._'.S- I U-TUHC J..... -_ISt DID HOT GIANT AM ,o Vt.RCtE _ ... O of rcH -.. ) 1 _ - - ,_ Bi -.I SLOWING - - pTMfHISPf Ilvl OiHLN15PECUYI ?' YNDYf 6 r 1 O B OTH[t IT V 1. L'IPTE"N -- 'J )i_.? rRAFfK FOR LIGHT r CONDITIONS TRAFFIC CONTROL TYPLE OF ROAD VEHICLE CONDITION SOBRIETYA ((--TT 'TOPPED AT NGN L fC ONE UII MOnE CAOHf IN..I VEHICLE ,NO. )F IC" V LE 1??1 Y?i?pQ irQS VEHICLE IC.,.ONEI 15TOPSrG 1 IE"107ti? l? v i tl F.01 °. I s N 1 o Ar SIGNALS noauw?r ? ;.. , r, mrfcn°E _l unD an u,v '..110. arnnnncw o L-"r a_ i,oY ). IMPAII_..-_...., 1-1 CIANE _ ' ^ ? p I C HELD ). n LE i OU fCLV[ II1? P^nNTINGrnOM AWN ') N o0- LA SIGN D HEA T ITY TIN. IIDN _ .?.. .... _. ..- _ ... ..... . m[u_ _._._. -K rmOS..NIETY I)._ [WINC IENTERINO :-... AvNNC I ) D[FICnV[ ). M I LoOY IUMP _.. 1HArf IG1 . .. _.. -.-..-: Pf O.. .. _?.'. -. NRAIT LOO UNK. _.. - ...! OAn[ T.11 T ..._ .. r. ,. ALLEY rln[S wONN .I HA a G, ';IS' .-I P?[A1NG DI RSIOOIH .. 1HENOn NA1NG 1f.NIfO .__.. ?._.'..-... AMB[nN.c 7 6. .. ... .. ?_. _? _ nx 61n[[i nn I TwU wnr- LtFr - ,uxln nnIVHI CHEM. TEST ?. SG l 1VnN LAx[5 I S`. N0.) i..? .._? IIGHl60 .. _ X OAHA O -'?O Er O11IEn 15FECIFY, ° / ?S1R!!Tl G r5. ..._ AOq AN ,. ..., SIPANA,[n x UN 1L T.I I,VIr I[ST GIVEN II T e UIVIDI. NO DEFECTS 1151 rIlFUSLD 1 O IIRilC ... Y UIR TO rvl--T Z EST RESULTS HH ? A 'irNt?u VIf,iG O{IIL It NAME enAN[ BA Lr C. LIrU IN , FI Ow A ?°^ M:LDI'nB ?---F#?3 ___ „1J =`EO°E FJ`Q' V All w M MHI,p- I bR ., ; HD -LH- 1 D t H S nM - A Grl Ac --,u 1 DLT s ^ n - 7 uc uNGa vm Br -S CAR, T 1 ?N a a. x w:LICATE ICpIYH LOCAL I.AW FNTOItCtMENT AGI.NCA COPY''TNIPI.,CATELCOPY+I NVESTIOATO`WSCOrY IF -r, ? ri"i }y 'n r- r n VFL W 1 ?lyiA 1 1 { + f C. ?'t? t f 1 I Y?, + 7 N t 5 I Q? ?i -,v E ?L??>d Yr u,u.. J?r?? '','--?"., rr.i"--' ;71.. _ I >??.-i t?H*-1' r, i ! } ,?? • 1 I ri Tp?j ? ft"'. 1 I'. r1 .? tr , ci v t p _ - 3 5 % c ? , B ? ? a nlnFa?e-? A °---?•?-?"?2c r,?L ..t;E?E?'Y'n rr?lvcr'?i ?r''e ;>.?,Y/'a'at+?w:?.nr?'.?. '"?..?s?,r...,,w:? ?? i,?.,M . 2. SIIAUEAIIEAUI SCVE [sr Ac T. I Fl?? ?'• a PIONS: O. Drlnw nnnorrlsl TOU Ow I NCIrAL 11111ECTION OF FOII(.C. 1--- Q? P+. ,af---a-c 9L, ]y$ _ kE ter _rJAMVO [IIICLINOI IUSE 11115 nriluxs ICIIIIIG DAMAGE TO 7IIAILl11.,MU1UI1CNC-.I.1C.I DMAAGED VIIIICLE NO. 2• L vE«I? `? E umvol oAU.uu mr«ulvn cw s[vuD,r Or onon "^^ LLE NO ] ?'x_ ?? ? P,r` Vt u +u o.enm a ("1 o I v urunncE i (] u:. mDmm?aF a l-J Oran 11 v.-1- C'l uunuuac DA f a I7 Irn v MA11 ?) `,a;;. 1. f r. ce . ? NO nA u P !l nrN . Cl N-Arln_DE Dnr n - L]_n mrnl. u . U N •nMAGVn E rn cL EsI, unl WEOBVCI OWLOBY A4 1 . rlLS?e4? nMACE O no IL I SE 3 y i, To :•fC?G.i?? ?uJ ?? No DIAL lZ OF COLLISIOrJ ?? .'OF1AW AHNOW SFI tw. ,. InNnxr -' " _ f" NUFITIi IN CIRCLE t ? ?r,,?„n.INM..rrA,u?IEL t t?c1 .C r I in??nlKFw,xn.s ?V IY/CS i`.. ? `\' I i 1 L ? O ? PAT_ -- F I' I V 1 01x[IE.LnrGrA'A.rn,; L? i I I pad - <: QxAfr..L„.n„f„nP.Lr. .1 I i /N?s r v . sxoW.RO.,ne vu„uon J - I 1 -?._ I mod. °.. °._° ...° °i O u c? V .. nuanlANr„xanroRE . ?,? •, ANG,"I«cuuxmN , -;-?.---..--__._SmaN,r/cP?ry•S'efid.6s' DESCRIPTION OF 11 DCATE WHAT PROOAPLY.IAPP114CO OEPOAt. OUnING AM. All TNF MnT1 CxAS«. NLWUr MEOR0N NOT ON I AcRAM11, E.a. OnIVCA EJ COLLISION olLnoxlTV, NCUUCE[Ivslvu,v,PEU(srA nx aom NC Cawn.[onsnwa,oe on n[r:.m wo oLl •, j. _ ? ? + . /G r / A? i'/rQ dc,?. ?1dti d SS!' c2r ?D ,?£ ..//er! '/e rr/ dddi rrc.vvsl.::?' // Y.J v.? Co• T'" ? /r r dncT!?r t/C err c% /n Td . r? /E/T .C?rdC , //?iSY frt/ dfe?,... e xr Ti?f, y 7i(? ... -.. A. Gd/ d e S/ ?? °?/ /%f c_ 6i 5rt S. ?? of T>r c . ram dd??; srruirrr i»esGGradS ? ?' M .Sr?dr/,_.i/:rps g.Sc•i;ciGSr /.'a//L?d ddF/'. dT.?c=d5? ?iE? ?. %rJ>'t?S dX? ?' -•u . GdrAr rLS /'c 5 ors r'r'S .u?.rcn S. , . ,?/jB ?r/.?Nl' ul?S /Od/ET/i>i/?_ syNCr '..,r . .. ;? ? ul/??1 i/i E' ?G/cc/G,.,i?a//?'e!. 0.7%-?. /ii?._ iifr-.s :/oT.r//y_ _----- POSITION BF.FOTIECOLLISION -t POST ON Noe Di [GLOP seEs LEGALLY q p. OFU OIO STREET ONx LMVIAr OAAE OR NO >HI trCREAENG nECAEASx1G - E I [CC '. N E L w _ 1 '+. r J.- ; X .I X. :?? Jll4 ?? O? •I ?NP SL E9 O Cs _?. I ? k Ll- rfu. ?-. oR .x uAL.cunxu .x m i r O _E3G 3170 rr0 C CI1ST wAS-ll I EK 'MA-F. 3 -D A Kf '- O T[ d,1 SNOUIOITI C SSN C OCSW,I BCYCLEROUIE T ?OTHEn ,uhf TAU SUNFACE fNEATNE(i CONTRIBUTING CUICUMSTANLES 0r11VFINVF«ILLEAC 0 PJ -C., 0,41 '•ICxECN.NCr COCCKAll. OI, MQAEI Ixa, VlxKE3 aElS3?IP + ' n FN or .I. -In i 1l I'• I aolNa j ' ? I'-¢ L I? 1 NO ] - bTnA,arlT AHEAD Y h I1?1 VV Inx O a ll VNO[ UENCCD ! LOV c OSREOAROFO W wN-A.DIO ?/L nHY 1 ~ AfT„Y ^. ALCQNn _ iT I OL OE' Y a SIGN/sl(j.?___ /\2?_a PrASSIN6 LL I k 8 ]L ... Enr ] I_ j .AMNWa____ h]I_J_UNUL3, h UENCF B O E -E tE0_ _ 1ALPLEFINTLY _ !" AKINQ URH - B ^ S FAILING T O • • Y-: a` -3 O 1 S O _..N. [C3 T ,IOCA E SrR r gPARKIN I- -I?1 LEPi iU Ax I XJ j_ 101(- _i B 4 _ I IA'I IKCI[ N s- a IRS 10 T O r ' MAK INO uTunx 1 Ae SPILEO Ilo I_ u e I .-I c coo Pa u oxoTC n Ec o I I 1Dr. f I•.. 3 L1o L c F NT 1-STa c c, ]-ra?? sLOxINa °rl_ I 1.:H[n 1VECIPYI 0111[1115PFC0'YI I' O -or'r1 xY ? [ [ n310 B ' Nn VFI YFCIIYI ?? I]? 1 lTOrl'Ea POn OIAI nN 1-.. J -FFIC LICTfCONUIIIIUNs TNAMI;G;uNTnOL vl .1 E TYPE 0FIIUAD VEHICLECONUIIION SOUFIIETV I Torr[nATSrcNAL 1 IGUI CK UNU INO ] [ C L 1 ] I [C ONlOUAO ,FI VL01LL[ € U Ir`(3 VN•ICEC ICrI ECK ON[I W.TOr SIaN i` 'I •. ; 1 I s c s I OWE Ar _-__. I NO ] ?tl i11U{L'nl I NO) ` ar ? NOA6WOSY- 1 oAYUa ?] ow• x] Two i (Icnvl: I Hno ANUtr I I._ { _ .. _ 1 aTAATINa rlr 1 - p GN .-.r IAO[5 JMlAOnU-.._... r la I .Al rICIANE 1 1 A- ] u 'a YI(ln ] OAI F I] ] 1 o f 111 ET NIIN. 111" ..? .. f LN [? 1 t 1 i ] . fA f 1 A I O N111 .. q] IIX.Tf S l ''. A 'A Ir _ 1 AIr ICIO NT[a111NG kr j? IArICl1l,1NIS !.UNKL P ITY L M I rIASIr NF AN,.[ ]I IL lA. I- II F'. B. Alllr . LIIISWUON , I 'All T •16{ I,dACKINO Lr1 l,- " _ i on xnmm R n 1 - T , Z .1 H1, O rl „M WAY ISIrI n, 1rNV !CliF ,?T, TEST Y } ? nmr SIGN rl I _'l _j i. ,x m. Nu i M? I j e1 tIa y{er,, E rL. I nu ?c•nf r oi?in°? T??uriEl-- one E ?' ?t1.rvLN rrrw`C? i" s, v i hf -.5:, I .1 P ] Inv UER X NO UEI I'.LiG I IIfr IIIr IISIn 1 P :% I T IIrNI«1:+11:11YI r/ III:I•IC. ^JJ-L JL k [, TcaT n[su iius i I - --- «taa'.. .„o."-^-'---K. l.. I. g ?_ I 11` ?r l^ N 1 I+/ .y.. t.• s rl^t ., ``..PJ.?:,I , .. ° 7 '?:_.. ,!- V I n!'??'1 p???? •??' -I "r Illu??ul,r rn ILAf ?N r{ ,?'^' I 1y ,?, ft l-- _I-... _..l a>!?5/ OVA ;a?0 ?/ I ? ' C I.T:In IM1 _ -- - ?•--- _._ _ 1 11 Irl I Al I I i l N 1 All- 1% 1 Ill A L•I 1 II. 1 I V 1? ,rS• I I,- yll - Y l t' 1 1 ,11 1 11- otiv ? !! a k d`f AItt15? u , ah? t ,a;ti ?; Y?iada ?C'? "?C .I 1..5'1' sssr I ?' •' ? I { 1?+k+'tk ? '??. s [?: ? 4 g rr .rl,.'. 1 1 I - I 4T ? 1} ?l.? 1 ' S 1 h L ? 1 ! I I l ??? F 1 ? I ?:{ s k 1 ell rr jt ry; n F!{ r /979 r.#r.•. ..::.Y a L a ? ?w •l?Lsm i u"" 's SA ?'xx,11' 'r j`gY ... Dr , :.r ,.,?. 'y ra i, ,? .:, r ?" ?` IMAIIGI LfJ JI'U n!lULN I11?? r, UNIFORM POLICE TRAFFIC COLLISION REPORT f rL e ^ t21f C(Al i•i,_- O (UI 0 _-- THEU.lf!'/1lG---- f,ITY I.UNWA: N U s ?'? -' I r I i n m? nl? nl;t.: u'nno m Y ^7 u:mAr! rr jl? - . II 'CIS IIIL NR f.ilUl(U SIIIEC l4U:%I: GFGNUN 1' 'Y j g>f U1.11 11' fATC10Ull nLOL VlY "a'. DLIr+51NEEi F p 61 I /'/ Otlrf Nl.+r_CIFYI' __ L 11 E Ay ?IN ? ? CIiV011,Ui,r" O O orI f /? rs? a' ?t C - IIPM.CdrlO-UFSIiICCTOrIInU'IIWAY IN rEnSCCTINn rY11H. '.'. T ??• -?'L4 ?_ 1 NO!l I.YlL115tC1?0': ^-N DLTV¢n1 1e, ,/la? • /.? ?,r„,,.,,,. ??tl • '??? ?- &OLLISION INVOLVED, UVt'NICLE-vullcE LJVErrICLL-OICYCLE TAI 0, VCISLES [31EIICLE-PEDESTPIAN ONONCOLUSION -FIRTHAIN I sinert Anr,1{rss ' ? Y Y Sr.AiE 1 ' IU•CO N [i(I EPS LL"K?:ENSL NR 550/\1E 5t% 0' 9 6% is? asst _ .VEi.._.:_ EJFCi:ON . !11 l 1011 UC. Y:?TE 1 LIAR g/!JC ` PX w G evn TPAILEII 1'LM1I E' NO. 5' C - ' YT1%L UENIIFI„I.iWN nVMUEP 6fi OMt1E11 L E ntc SlEnt:u ncmEfl-LACr rmsl N Sf</ '? G?1Aar/? s ?ooiw5s ur oFN?n " - IrNIt VOAD[,RCI..'iOFLISU?I/NNGE CO Un.1GCH1 '---? D I I '. L sln[Ei V E cnY, ' N omYEr s O GIU CI1S V E li I C L E N 0. 2 _.-.._. (.111 OrICEN(NI -- RCIIUN NAME, ADDRESS t INJURIES OF PERSONS INVOLVED RLCIUCNI NUAO Ofl1'EF. ¢ •MLCAGE 'ICn CLS [1,L lCY. CIIOGS S111ELi Of111UAp Bp CODE I 6 3 8 3 4 ?x?lr !.I'ECIAL COD NG U.aE - LYEf111Y A i[1 ?rUiARUV ' lIO. KILLLU s /`STOLEN'/EIIICLE. -fJN01NJURED f IEPoAL _ oPf10uERTY DAMhGE ONLY LrFhIONOF(rDJECT5TfTU-C9r--i1 E1.YI LST. UAMAOE ?I10 DvAY f[ET?LJ?0.0 Lt{'? SfAiE SE% UAIE JF Enlll MO DAY vn h? E PI NE CATCELT.___ InODF.L IUAnI•IIOV/1 TYlE I2 DI1:cOrIV.1 <• riArrcE CO on AGCm .. .,, cYA?laarlr- coDES__ _ oA D _ A n ?EI1- - % ARE IAIIIS _ _ E.I(OT. ?T 13^L it "t' J?L_ _ c a 1 ?3 ?Z ARMIfS ?;Yj?/C?I.J(_tiJ?? ?IJ._.Tlr7s lY:-- Yf F 1! _ __.__-_-.__.__.___.-. t I 1'iJ rs _ A r L A, I J • VI}? •' i•,I -t 5 Ihn (u I? ( ¢ ` 1 ? ?T _ ._._._- o?. ?.1___. _'_- _T_ 1 ?.- A V ?. ?'1 A''A rNJ 11 ' ' _--_-__ II I .r 11 1 YI ,A{1111 „Il lll. Lr I, '- ! Y`- 1 1 ll I 11 A ]1 I/11 I II'Iln / ( J { ?al 1 ??/ 1 I IIir.AII 1'L? IJb 111 ,eY1 IRVI 11 1{I(I,? 1, 1 4! 1-II' IAI 11111 1 III I:IIN - L f ) r A,? die 1Y?_ / rlo f!•,f` L wM ?! 1 J rla ,1 ? I ? L I II? rllT? r ? r , t I 1:4 t , 1 V . v r rJ{ 1 ,. I ^A ? Y? (1 i ?Trr!? . v a - UHIYIHIiL .. ??. cncnuUA,pln— THE NUMBER OF EACH DAMAGED AREA. -?--ILC?" ? • INSTRUCTIONS: 2. SHADE AREA OF SEVEREST IMPACT. ], DRAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE. , DAMAGED VEHICLE NO IusF Tnls SPAEL FOR SKETCHING DAMAGE lDTHAILENS, MOTORC GLEY. ETeI N_ DAMAGED VEHICLE NO 2 . J ?-..•? ?Truna w., ,1 , m r e. U t I? ? rT • I F I `•, , Fw F,FINSUN I B LNAMAOAFpc EHICLE NO. I > UN<TION't E DAMAGE 1 l O NTHER ER M V. DAMAGE . ? DAMAGE Q SEVERITYOF DAMAGE, 10 CLEI r O p FABLING DAMAGETHE 2 ? FUNCT,.NAL°A,`AGE R;EM'N00 M GF°AMADE SEVERITY OF OAMAOF VEHICLE x02 Ey-?I G pAMAGE 2 Ex'I OTHER MV, ppMAGE "I ] LJ su CT TOWEDBr t1C.?4.1 EST. DAMAL.E TpWEG EST. DAMAGE I DNAI DAMAGE . LJ ND AMAGE TOWED ET To ,-TCc.,:N.?SCJAdI G.]F4 3'rulAl ro , BY . DAMAGE To 5 DIAGRAM OF COLLISION I m[N??rr nD.DwArA Dw vD. cle, D..ED„DNIDrrRBAp NND,,,.LRt?.t^NDN p - ._..:. -__.; . DRAW ARROW SHOWING NORTH IN CIRCLE - -- ._ ? I N: L p ,,.ND MPA ,uu rDNTD ?_ Q??£ I - t I a Dwvu?aE.rEDnmIAN ^a I - --? - ti ? _ i --I L ?I I III -: T, I I __ _ I I IT I I i DESCRIPTION OF COLLISION IINOICATE H ENEOBEFORE. DURING AND AFTER THE GNASH c ar oN ,ED. DRIVER DISABILITY, REDUCED WSIBLITY, PEDESTRIAN CLOTHING COLOR, CONSTRUCT ION DR FICPA In WORK, ETC IN R _ Vi1._?1. ?.cyi?d__$ C3 _JJ f?.4 Q4?_yrc .SPz?h VG4 C2c:54d ?'cc iwa l(E, fAR.tic ?( Lv -_.- _..P.\..L.? STK.,L IL _FlG9Ci o?_? TC?F.? ?. (yP O .. J?WIdLL U F ?6.L?9-s L.?_? ?2` SFc1u....__ 2CT` .hiE--cam ?15E.._I?olt_?? u?l._ T!?4-. T2F'\E.c,?Zd iL1'?i o.>.?SLd' L« n \ q 53_` _L ^ "AdL--?1= ?I, I _ Rol l u Feo F vc l c - - 5 A_(!t+?± AF1e,e. ?.ot-,Flt1 a? of ,$k:ta?l _o,n _HI?Fo •:. wlcC\5_CoL?,.,.?_,TL? CSLsT Lr '?2E_v_iL? _"y?¢,.?cy..ru.?• o. POSITION MILE COLLISION -- oF LANES Y. I.AAK E N.w H E ADED INCREASING DECREASING ON STREET OR HIGHWAY NAME Oq rvO. - Ix ONDE OIRE[i10N [ SPEEDS INCREASIxG EC EAY NG G IT nX?-1? -1? 213 -5 D E NO ?r?-JT.(L.. _? Li r-I + L YES 1 AEG. LL'.-_JE-N^ OA aNH -W L ? J J I cnosslNc l• ?W C Al I Q w+ W t •fuh G L 'y(1 .. ! i` I I r.A d I 4 z '3 .. _ ' 2w?Awc .? I oArucxr ...._ , ) acP ^ >, rvro IN— . .I UEF[<TIV[ :J UItAKLS l MODA I LITY J I -- I Ile ROADWAY 6T D >I I O WN - _ I][ LD ,?. ]GN ) ! R i f I . _ __, Dt Ff I )J II CllvF LAD LIGNiS , IMPAII LO ?) ? s ?IIr? ITIN STR I ] r DUSK ..? HfOFLASHING r ?_ ? 1. l ll MNOE . _l -l q '- M . NOl MCA Rf1L_ ._- n C" - ?f RED D U If MIRING j: :- D RK S EET X LIGHT SON _ I LSj L1eAL I A efn? _. A . . T5 WOIIN I - ? "A. NOT TRNi 11CI .-- " DIFK_3rR(fr . ? _. . f .OII SLIOOIN .-. B[[N ONINKINO II16?? _ e?CKINO L L Ef . L. TWO IEII ie r s , y, I Rldvx I CHEM.TEST DI VI" NO.) --. A-.- ( STN[(Irvt°GNTS ? OFFICE N[ I I '' 3. FO UAL, -" -i _" OTIIfN IYLEH VI - I ) U O[O iE3i 61v FN ?. .... ..... 1 - Dim Iw 3Afeurl - L, _ _. Xy_ NO OEFEC TS I iEYT N[i USFO ! " r UNEH LD orxea srieNr ? lfllO NNDO IK A NA K fN0 YOLK( 1Y +, DISrAICIIEU ` % TEST RESULTS rUIK[ ANIVLD NC N N pIVLD R 2 t rM 1 1 r IC( lOW' Pf D[0 y[ HANA I ISl10A,IM1U O((C YNAUE N[40 1oN)Ff„ N 2 GAI to 23 n! ?x 2 IF, '- y A IA e AOGf NO . AG[NGr ?,T(n' .fit IST. Dt T. D T[Oi [AORI A .NUV[o er r / NN3 uNi I r ( r 1 ' wli?IrAiil?^uy0F11GINAL CGPY. SFNO TO WA5111NGTON STATE PATROL-OLYMPIA. WASINNOTONn AS USIx (FAC G: ALK WALKWAY SIGN agKEO 5 jUNMw p$$W ,.. CROSS q KED - DESIGNATED WALK a Ie E OUTS )( OTH I U-? ER E NEI ....WEATHER. CHECK -1 CONTRIBU C TING CIRCUMSTANCES E. E ONO ONEI . j DND N EnC RY - _ LEAR.OL000> A i?YARGAaf oNOE> - ENC O L 1-. 1 U 1.J AICONOL GFIVIFR 'D 199 FOLLOWING I? cLOiS ONDVER I DISREGARDED 1]r'. I GO 0 ° OVERTAKING f ° WET ] I I RAINING - I] 1 DRUGS CF n, ° E NTER 1 ?c ^tE(?, APPARENT n ^ ND SSING SNOW ] ' _ s ow NG T[ I a X L:. S E[ L N T . -. y` ° A KIND ?J ? uqn ,r-1 AlmRa MA N E CE - 4 FOG ? . ^ i [ [f50EE Fn5 , NE . I I V - fR OC OPE 6ri pE ESTII IpyN FOUIP . LEFT A TURN _ , U y? K NO I IfY1 ? ( L, OTHFILISPEGFVI- ^ I NIT I" I SI T O E C EN _ Tn (( III' I_OS FGARD 9 nO Qn, ?_?ll ^.1 TU RN ?. L-e? SLOWING TION f j I ?'SSmo A ' A :.. I']r_i s°icrRi s?c.::iTOP - I NOvnOL lsvfclrn _...EL AHON C?Ln TOPIC °FOn S R RAFFIC CONTRO Ixo.)v-CLC v CLE TYPEOFROAD I NO . ] " 'ICNICK ONE OR MORE ,VEH ICLE CONDITION v F N OBRIETY F TRnrflt STOPPED ATb10NAl 5 7- f ?11 = SIGNALS -- - E - - I - t II' j` ONE WAY I NO. ) C ONEI YI MO ]F ICxL L J L j On STOP SIGN Yj STOPPLDIN J .G I • y1cI,?EIw Y e [7El' ' ? ? ,l'• E, A "LA GATE OF COLLISION DAY OF COLLISION TIME COUNTY NO CRY NO F M ,DAY Z SUN I MUx = IUCS O WEDA I(11)v 5 FRI A SA1 IUSE 2ADONWRI J? :4 y /? . fNWA gBA N ?? i cpugn J _ ?STATE ROUTE WCOUNTY ROAD ?CITY STREET ° RURA ADM..". PREFIX ROUTE OR STREET CODE EGib L N 4c GIti ?OTHER(SPECIFYI IW 'O L N S E W C?pIN /? CiY 0Ri0WN HF IOL? OF ? AL 1 5 ® ? ? m - PREFIX EO. MILER ST Q C MILES ._ _ .o E IO. _.. W2_ 2 • /O NAME aNO. OFS TOR HIGHWAY INTERSECTINGWITH: STREETORPOAD U, RAMP DIAGRAM DATA T A N O NONIMEflSEDT10N INTER {E ?? \\ , CC j RQ t ACCIDENT MLEAGP NON X.RD INTERSECTING STREET OR OAD OR RE IN E CLS. ERE-CE CpO55STPEETOR ROAD f- ' N , DETWEEN CIv ?` ....SYP(Zt __ _. STREET AND. _C S`.'...__.._..__ _ STREET COOL 6 0 '. DISTANCE ANDDINECTION FROM REFERENCE OR CROSSSTREEI N B E W ? ?riWlL N O SPECIN. CUpINO USE , MILE6FEET 2AO ? OFX-9.1.1OA\C.. COLLI SION INVOLVED: ? VEHICLE-VEHIGE ?V[NICLE GICYCIE ?DiMERIWRITEI ?HITagUN SEVERITY TOTAL NO ®VENICLE061ECT ?VENICLERq TRAIN ND XIILED ?STOLEN VEHICLE I S , NO -U RED OF VEHICLE ? VEHICLE-PEDESTRIAN ?NON COLLISION ? HAZARDOUS MATERIAL ?PPOPEPTV DAMAGE ONLY 1 BJECT 6TPIJCK(NAME OF OSIEC O T STR1ICK MID OWNERS NAMEI LOCAT ON OF 041ECi SiR UCN ? I S (?pE ? EST.DAMAGE Y CC 1 (?? 1/Vp ?OL.:.Z `C G Ll IK T ?k[v V V F v frN w . .. . . LL . c• OAOWAY EET??Ill?RD.EDOE S ORIV RS NAM LAST FIRST MIDDLE -REFS NAME LAST FIRST MIDDLE IIf BICYCLIST OR PL IAN CMECNI [J +{w( P F. f?' yj.. ?, D . VJ?Z?NG%t=0Y2.? LTrr1LT\\ d I ., S STREET AOpflESS • R R Y STREET ADDRESS _v (Z4 Z 836 v ? ?I E CITY - STATE ZIP CODE PHONE NO. E CRY .., STATE 21P CODE PHONE N R HH Iit.T ' U - .. O R ?+:1C 96'bZb 7 32-'113 . + N DRIVERS 4CENSE STATE !EX DATE Of GIRTH . N. DRIVERS LICENSE NO. STATE SEX DATE OF BIRTH : o. Y Pc T ,k ( sc; D, MO. DAY YR e4 LA 2 K fa ?? Us I it E Dgrv RS OCCUPATION IPM NAME E . HONENO. 'j ORNERB OCCUPATION FIRM NAME _ _ .. .. PN N N FIVE + ? +t9 'iNIYV+ . ``1, 1 1 C ' I, (?. T C.? f"r IV 1141FQ ??'1c 1. `DLJ.'1? A ' OI Iwuar CODES >10) cuss-- __ TAI SEATDELT.. IFJ E,IECT.ON I CODES >1- In - - l SEAT BELT?_ 151 EJECTION NATURE Of CLASG-- NATURED F +. WURIES L? T FRMM 6L NE BY' • i?Q O t"MS .IF [Lr LOLTIJ LTO .If FF Cc I WURES Rgp O SC N VEH.YEAR MAR IDOOGEHEV.1 C MODELIDART-NOVAI STYLEI DgdONV.I l i ENERY ' TO VIE" YEAR MANE IDODGE-CHEW MODELIDART NOVAI STYLE I2 DRCONV 1 - v 77 cWLv CAi"A¢e Z2 TL ' v . ., 4 r E VEH. COLOR LTC. PLATE AO. O STATE TRAILER PLATE NO. TATE E VEN. COLOR UC. PLATE NO. STATE TRAILER PLATE NO. STATE 422 " ?? 227 WA I ? C VEHICLE IDENIIGN:ATI N NUMBEfl .. .. ODOMETER % C VEHICLE IpENTIFICAiI N NUMBED DDOMEI R - ry A E ?Q87L7LST2 Z6 24 7SZ.2 E REGSTERED OWNEfl-LAST ..FIRST.. MIDDLE R EGISTERED OWNER-LA TFIRST- MIppLE r. N O: N . ADpflE53 OF OWNER A DDRESS OF OWNER. .. J ' 2 ... d , F? NAMC.WDADDRESS FWSURANCE CO.ORAGENT _ N AJAE ANDAD PE S IF j - C INSURANCECO. ORAGENT. (?1 vA uA V AA eC E ?uu h l? u r ' .J t CHAR G ATIONN ... ENFORCEMENT CHARGE ITATI N ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES ' , SEX AGE STATUS FJECi, y c T NAME' (J,j '21A/1 ? (? ? 1() I0 So S 1 S ? 5 C 1 ?'! "n AODREGS. G I ?lv-YI?LCYC K? /YT F \ 17 § ? ? U P NATURE OF RE101EDF10M WJURIES SCENERY TO S v + j N NAME: S } ? ?"7 , T ADDRESS' A Y ? S WIURI S EMOVEOFR M II 9 'f RcfgE BY TD W N N AME'. AM a T ES _d l ' t N WJUPo ECFNERV NOM To i E S N AME: h S A E ODREGS L' M S u WWC NE Br 10 V ISIAIUG 121SP Tr`O SItxYI IJIINJUr1rCU5S HI SC AT DELT I EJECTION 15 I C :P IST 1 2 0EADADATATS S S O I. NOTWGTALLCD NOtEJECTED , D CYCLriT G%:YC O q O Y' C PA GN ON M IWISADUNG UNG 2.NOT IN USE 3 USED 2TOTALLYEJ[CTEO 3 PAI TI D E G ? GUS oT0C Lfl G PQrIVON UNKNOWN % N DIF.DI HOSMTAI ). Pos.LE WJURY AUNKNOWN U " !?. F ' e. SCAT DELTFARUPE WCCTE o W pp titA??S'- :?1 !dF?; VEHICLE DAMAGE 1. II. LALIIB %, CINLLET IL NUAIUCI OFL CII OA .LO/. IEA. W)( ?L a. A AREAOF S EV ERESTIMPACT. -- ?- INSTRUCTIONS: ]. DRAW W RROWISI TO SNOW'PRINGIPAL DIRECTION OF rOPCE • T DAMAGED VEHICLE N O USE TN-ACE-( SKEICIINGDA1-1D I.AIIFP5.MO1DncrcLls liC.I OAIA AGEDV EHICLE NO. Z 1... 1n1 . 14 Ft?l RI. 1]. O.rllu,n N H Q 1]. U _ .. 1 urn 1], M.rlr I SEVERITY OF ABLA-E 11 DIS SEVEI41TY OF DAMAGE: IOTNER VErr?H?I1CLE( OAMAGE 1 CI ISABL ING DAMAGE 3 n SFV1ITY OF DAMAGE: VEHICLE N0.1 AMAGE I H O ] _ ' I ..G 9;7m ?? O DA A GE J } ? FUNCTIONAL DAMAGE L G p 11 AMAGE UN DAMAG E CTI F LJ OWEOBY T .OAMAGF TOWEDBY TOWEDBV TO 1, .'-. _ TO S TO 2 f RROW SHVYN DRAW A NG DIAGRAM OF COLLISION : L_ NOPTH IN CIRCLE IP[HH i -' - -- r l.M cmrvixDL. aA BMAxAS ? - I I I __. _ . .; ?. UNVNLU1LMr. LD»INT DNS uI^T` ONSinvaT Ox 1 T / I r A»DNITLxiDL.LMN - _. ._ r I - OES.RIPTI.NOF' INDCATE WHAT PROBABLY( f F OPC DURING AN. pE NFOHM ON NOT OND L c. DOIVEn _ JELO CLOTHING COLD CD 5 CTION On a EPA n}VMK/E CI COLLISION OISABILITV, nEDUCEDV SBI i F - --- __ _-------- - ------ POSITION BEFORE COLL ISION OR NO ONE IN EC?ION T LEGALLY nKeo IA E I IN [ueE o O VFFEN. HEADED . MILE INCREASING DECREASING DIn.SNG . 01I STREET On HIGHWAY NANE F OC ILJ - P, YES NO YES - rE0 C O .? .. _. ] OR IT G . -. . F I FIE- MARK ED i ' xB »IxI> D -.-._._ _. TO PEDIEICYCLIS WASUSING ROAD SURFACE. T . S K W E [ T oEE i E CONTRIBU St .-L! 1 I[ nOSSw 5 TI?K OrC+e ORUrtonEIANCES F I f at K BCYCLE HOUiE T On ACTlclHl 1NO E ?i ECK FeEI KH FR Dn I i[ I c DRIVER vEn o N. FIVE. L a y.I .I GO G NT AHD EA C^ ?11 OqY - EAR. CLOU 1 60VFRCAST 1 E Hn IL NFLUENCE Oi -.i .? L[OO-_-- A N0 T I CLD S .,IT . .. ?•. ) S1Grnu 5GG,-p_-_ W - - _ a SfiFNIG A - 1--I2 ~ ET , y T ?- RAKING DHV 5 NFLU[N n pf NTER APPA"INILI I i r7 I KIND MIGHT'DAN _ 3 SNOW I ... ...__-._ ] NOwING .. ?..F?_-. - I:.?TI 5p OL MIT TAI nFaf I .. _ !... SIGNAL TO HOPFn l? PAFK G J,SI LOCA. 0 ._..- ?r OPE ING -' E AKI TI.RN O ,SJ . C - SEEO T J 'UPH :. VE EOUI._-.__ I U ' -_ SLOW G I b S p -VINE L D T IN E - 7TN[RISPEGFYI ONE (SPEC i Ov[R 1 81 ... SING f P s 1T, _ SIGN I ISPECiiv IB.- (VIOLATION ow CFOR I 1.1.: I. TP f ITIONS LIGH CO N CONTRO TRAFFIC CLL TYPE OF ROAD VEHICLE CONDITION - SO 11(ETV KN CKDNEI ' I STOIIEDAT SIGNAL J ORSTDPSIGN TN ?F D l EHICLE NO 2 O.] ICHECK ONE DR MORE I ) .._ NO , VEHICLE 11?ACS I???Aflfl [j?Caa(L11 I - t.?I:ON{F1r^VICDI E VE r H11 ]E (--- 1 ?To, IT-E N ,. SIGNALS > v., ONE WAY 1 ] TWD ' - - ErkCT Vk I ( HBD. LITY i RDADWAY :..! TIICGINF T Ar F LAN 1 DAYLIGHT T .I PAWN SK GND. LASH 6 _ _ RIVE ]'.._ - 0 D T [IIwNGE TAMP OO NAKLS DEIIII [ PL VHis' ?]-- DEi[<TWL REAR LIGHTS MPA _ IRt O._.. a _ NOT MI A6HEO. ] ',. 111"11TY -I 1. I Si EI.-R.ON I la - THAiF?C1 1ENlEq HO FE w S PfD. . - ALLEY • , I. SM001N H?AE N."TNK ING '15' ACKINO . -? IO 60 DAN iFF LIOH b Bfq Iln SIGNAL D Ltrr [ - ,b NN rv!O n CNEM. TEST . ] ` ."1 l L JJ ' I .. .. "-- - 6in[EINLGnTS . - KEHI OI?iN AN LrIE 1 ,. SEPAInATFO _ ; ., FECTS 1[Si GIVEN - i[Sl n!F I USfO I aNI C1116v[C IPV .i '-' OtHlN ISPICifYI E "' '" B rK DIVIDED - -' ] ' !U I NO DE ONILH ISPICIFYI % % LEST RESULTS 2 - f3i(GATING O111<FN irvALN AIiArvK IN. ? r ? N U XA (L f 1ICt I.I t n+'Almlo? .. ] W, LILf I, vfO A1INIV[D CE IM..... .D] P Tw - IS, nnin lns wnu o HsnAXl Anwr'- - T _ - ?D-iD?L'ATE si nn. of lu r0H1 X _ MILICATE COPY LOCAL LAW[NTONCFEILN1 AGENCY'SCOPV- IRIPLICAIE COPY' INVESIIGATOfi'F COPY a trv r a j al ?F 1 t-ll ` - II. uJ/:. ? l?la OF I I 1 l= Uf , POI GL OMI LAVll II COLLISION REPORT UMDED - ~ UNIFORM POLICE TRAFFIC D DATE OF COLLISION AYOCCOLLSIONTIME COUNTY NO DI ! WED INI1N FRI SAi U' 1 OO HOIN E CITY NONWA Y p S D ; . .ONy i SUN 1 Mp: E I I M E J / C` , UUflSAN X AL - ? ' EEET ?STATEROUTE ?GOVNTY ROAD ?CITYYSI R CO 1NTY( C O,HERISPECIFYI • J S c 5c.d ? ?F>: ° AOM CIS. PREFI DUIEOR SiflEE1000E SECTION J ANN O E . CITY OR TOWN IN ? MILES ? S 1:1 ? Of...-.. IY !. 1.V.ICX.- y ? W LL I PI -FI% EO ? ?? MILE Pp T ?} Lr'* u. C E NO OF STREET OR HIGHWAY INTERSECTNGWITH'. STREETONROAD LL RAMP DIAGRAM DATA a'JF11an} ' i T ? - .T T ON C I¢.. 119 * N o NON WIERSE ` ? ' ACCIDENT MILEAGE NTEIR ON %CD IN I.S OR REF. IN CECTING STREET ON ROAD OR ROAD EREECROSS STREET N I::..YF ,,,,? 11p? l ?L'1"%.'. SN ?`5 61iT "'L STREET ANO -.9TREEi OETWEEN . CODE .5 . ?* DISTANCE AN?N DIRECTIONfROM REFERENCE ORCROSSSTPEET N 'S E w 1 nunrnLlns --Al CO IMO USE L '!,•?d IjjNJILES f. ?y? ?. 1 OF .`F•I?C.?{..?F_l.- ST IIIN. .- _.. FEET 910 N ? VEHICLE-HICLE ?VEHIC-ICYCLE ?OTHERIWRITE) ?HITEAUN COLLISION INVOLVED: EJ VEHICLE-OBIECT ? VEHICLE-RR TRAIN ?STOLENVEHICLE SEVERITY NO MILLED NO INJURE O : ,, r J TOTAL NO TO VENICE9 ?vEHILLEPEDESTAMN ?NON COLLISION ?HAZANpOUG MATERIAL _ _..- ROPERTYDAMAGE ONLY v • . N D O W N E ii S NAMEI OBIECTSTRUCKWAMEOF OBIECT STRUCK A I i ? P)q Li G ?? U LOCATION OF OBIECT STRUCK / N S E I O ? O - ESi.DAMAGE W F' ,g i ` MIDDLE IRS ` - ApwAV ST ON PLD EDGE 3 DR VERS N AMEOA`T FIRST MIDDLE O OCLI NCHECR ? y . ,T ? ( R / ERS N U??S??fC L( .^ n J ? L - G ?O S 1 G. C LYL?S ? DD R I {L f $ J , 5? ? C peC r \ I Sig EET A.... SS ..:.:.. E? _ : ' ry - ' E R CITY STATE. -. 2IP CODE .PHONE NO. ?? R CRY STATE ..:.ZIP CODE .... ..PHONE NO. ` . a ! 3 1' ele WA + N OA E113lKENSE IAp. STALE SE% D4 Of BIRTH N ° DRIVERS LICENSE NO. - STATE SEX DATE MO. OF BWTH .. OAY YR. j:u+ 8 b F4 . °• (? S20J$ ?,fj Z"l ? ? 0 . ;? ' S DER,I?V?ERS OCCUPATION FIRM NAME PHONE NO. E ILII l>cci? 2vi? c?"???ht:II..I,Cc;l/OL $ DRIVERS OCCUPATION FIRM NAME .. PHONE NO. - CODES > IDI CU%_ _ MI SEATBELT y- IS) EJECTION.- __ y CODES > 1'3' CL>u_._ MI SEAT BELT___ ISI EJECTION.-. _._ I_ F b. ' NATURE OF C ttaIURIE [J% ???Q NO1? NATURE F I ..FIE - sf E FROM SCENE BV: TO D cROM SCENE DV: TO I VEH. YEAR MANEI DGECHEV.1 MODELI MTNOVAI STYLE R DR CONV.1 VEX. YEAR MAAEIDODGE-CHEV.) MODEL(DARTNOVAI STY LE I2ORCONVJ +' V 7 3 ?7LcLi (?i9 n V. E H VEH??`COLOR LxK/F C. PATE M1O. Gl t 736E STATE CA A?1 iRMLER PATE NO, STALE H VIEW COOR C. PATE NO. STATE AIEq PLATE NO STATE '] o- - C VEH LE IDENTIFICATION NUMOEfl ,. ,:. DDOMEIER (.` VEHICLE IDENiIFILAT10N NUMBER OOOMEIER .. . REGISTERED OWNER -LAST FIRST MIOIXE REGISTERED OWNER-LAST iWBT .... . MIDDLE .,,..', N O - N O. ?.a . .. . ADDRESS OF OWNER ... ADDRESS OF OWNER .. .:.... .... .::. h NAME ANDADDRESS OFWSURANCE COLOR AGENT ..... NAMEANDADDRESSOFINSURAHCECO ORAGENT ...,. ISP A (>vlrvtow,r 'jo J7<lvct? Y CHAINGE C ITA,ION NO / ENFORCEME NT CHARGE CITATION A / V` ACDDH NAME, ADDRESS & INJURIES OF PERSONS INVOLVED copes _ 'p s P _ A NAME ! T ADDRESS' IS NA LIFE W R.MOVFOf HOM SC(NF RV TO I, WO ED W T N 2A IwuWE -.'- ?IC.6 p in?IA - SCENEDY To IS NAME. S ADDRESS E NAri ?CM RCENE RY TO S` IZIbEAT P0.4rgN WIWNRYCU55 HI SLAT DELI 15 1EJECTION C 4. PASSR 1 NO INJURY S Du•AWPIO IIIGRY NOT INSTALLED 1 NOTEJECTED ?Tµ H Ti or AD 014 A J l O YOi I USED 1 PARTIALLY E JCCTED , D I LR S O 1 -- p ul o' M N O EDINHOSMTA L P NJURY E UNKP IIURE ,IF N U U-NO E e WIIHE.4A III J O NR OY 'J e S SEAT DEL A p ? 1 `? 13 IJ? ? 41 ? 'E'° f 9-i4 ?l I 1 Y ) 1 I T r 1 '. )fir I t. i u ? 1 - T YZ Ir - - - . 'd t 111', ... - ? old ?:nzr?N - ilM'ftiJ Y { OF C I I I I{ - D-F I. l ON. LLL ! L? _ I ? ?C? 1.. fJ LL 1 CO. C.-I CITY. TOWN IL-l CITY. T.- PRL- -111 L UI 1 =/IL vo EL IDh F LJ 4r c IS C7 IGCII 11 HSk 5T E A - G VE 1.O +TREET R OR MIG L EU 1 11 - l OA ' I - - -L A OCIpN OF GRLLI :: Drl N : GTlDN. ADRwM A D nE W C? ?11R??iJ% CJ 2J hvs. ux rv[nr rune t,nuu+ Nvx [x. unrcce. kR NTEN C c %rn[[ ?'°: tt . r p. ?JCJ ?1t S: ' 11 r NSE ` " /. IAI I- ? P ' c ? n • v nu - F UH EGT NAM.. AND ApORTI5 1 El «e ?? ? `5 0t: ^ _ _ D E S LAST NAM FIRST NA ? ` -' E ME DLE prrlV C S.LAS,T NAN Nq ,,tr, v .1•«? .fxannFwtxY? STREET .ORES. ., ROUTE NO. ANp % NO. ....... u[cw STREET ADLESTr ROUTE ANO % NO ' NO , , , . ., , [ ,J=130 ?t1 t,. Sc-,j r? .. nnxrFnx - _. . xt M CI'f T E ZIP 000UP CODE 6 . H5 ATION CITY. STATE 11, CODE II VERS OCCUPwTION 3 . Y, fst.r _ DRIVERS LICENSE NUMBER TATE GE% S?V-51 C??-3?ill? tll1X x DATE OF IRTH It IT far pGE I7 H VERS LICF 5F' NUMBE STATE E% RATE OF D RTH AGE veP MAKE .-ooue[ f?rCcJ Ij??1<tie OOEL Ixv xY1 ChD,,'E ?,? BOGY STYLE. 13Px,1 7. a? - nece [x. MAKE '... ev: vo ec l MO' BOpY ....... t Pw.1 LIC 5E PLq FE O STArF - TRAILER PLATE NO. TATE.. ., LICENSE PLATE NO. ... ST E.,.' ... , A ER PLATE NO ':.. :.5..TATE.,. , .:..': t'EN C E IU737, N NU.,.', 198 vtta xtwexl ODO T R L¢+ee S 7 fEl7-J- K 2 2!;'q"' VEHICLE IDEN 1FIC^ N NO :I SBBNC a «cw«x l O O :Rl Mruue[ H_EOI TEREO OWN : rwxr-FI, otc N-0 RL ?c,? 3CV4r nV1 URIV.. LICENSE NO. ?Ir°Sr FJ??6 r!'j? REG STEREO EH ILAXrf Pv«¢'M+x[I .,pRl 'H LICENSE ND. OW ADORES 1 T crir wxv wr[I TE OFB RTX I 1IN111 p ,:ICT«¢ TE OU^RIRT lElS rr•? `2 A. .I M l i r? ? RJtn S W ?, JG C' ACAGED ED ..rn.,. PA HTS,OF VEHICLE DAM . ....; o xevwrv vew c PAR VEHICLE.. MgGEU - - s j?'_' f _??.f::n?.-s3117<•cr tlfa_ le. S,.n??C:.,_G'??? -Ss T-!? LIABILITY INSURANCE INFORMATION • VEHICLE NO. 1 co?irr^cc lrAi c'r°ECTFOHTHIISACCIIDENTONYOUR CAR {xyl YES ? N % NA WAND ADORE F ABILITY INSURANCE POLICY HOLDER NAME O DI T rtf (. .. __??r ? Y N - ..lf ?. GSJI? 2'pt?? I\$-nC ?J4Jtt1 ?,`.y1 ISJ i.? 1,~11V MV f?,L,ll,? E!L-,:.)L •.,tx ??. A AF FLIABILIT UHANCEAGENNT 11-11T I?AND OGRE N A P ICY NU E , c? f? lo'wCio 3: an ?ca?s it TLt s;r+.S Uc?a? p>A AGE U 2ND N rM E NA J_U_1 M ADDRESS ME%F ADDRESS A1EF.. rt ? ? 1 +rr. r or rv.ux [v ? ? x n " .. . - • -- • _ .... • ....• ." * ? .. u [s neourna fT--?I uo nu 1 rave u vrn n 11 r «I?L7n rwnP A vc AM [??x II T TU URER'- [] UENILLE IL••-,Jyj7 K FIRST ONE THAT APPLIES ':- .rnc nvn.u an KILLED «r rx,u Ie[v[nel In T x ? 5? ?cln' n[70 STATUS OF INJURE p (-1.. TILL-.-fJll NO. :. .. .. KILL[D ? MARK FIRST nleM.l nc In,urn Icrvenel 5? ONE APPL THIT tl r Iw nonl 6? ':. IES . ? t ENO Y ARROW CIRCLE DES E. DELOW W HAPPk Ifl FER T EH CLES p 1 U RE it % / . - ? Yv he. 04?.'<u cauv.? 1?oc.c? 1S ) l t1 xrn [tcn v ,. vnn Frrow ,? ... u1«r [rron or rn,vtL Ar Anxow -?_ . ? ? . n rrrrur. r n x VEHICLES POSITIONS OCFORE COLLISION INVFSTICATEn V NY `j- x ,t. v,«xro vrx I[o TTT 11CC .°W MI ETRFFT Olt 111GHWAY I11ML'Mi1D I A Nn Y n ut ? I l 0 ?? O [-J f7 ? rn,nnn 10. pI R, [7 G`9 n Cl c '• ??il:_?? _Lv LIN LI [ I1 [? ? I 1.7 (_? n El IJf I 1.1 N M1rnuN D Ll 0 LI PLOLSiIU ?, _, . )rl'"' l[. I ° A rl i 1-1 t r_l n n.,,.w.1, A I. -?--- - wrwn[Yri" -""ucMT rnNRnlor;«'" rnwvnm cu%+iirpl. Io-,u on.I rrA¢Dr nu,n np,on ... 'I J \ir. n) mr vrx: m:r[r. [.«[n. r,nn. i r'r.:r[e ) Ir .l n.I r.[? I ?_l NAIL r4rIT ?n111 1rl.1 LIC.IIAI. r: LI 1 [-l ONF t•IAY«r [_rl 1 ral OOlllf. UTIIAIRNT A114:AD . [ 1 I-, DIIY Jr I NAIHnIR ) [..1 pAVIN U J LI ErDP SIGN I ) n TWA AT ?J) rJ OV NTAKINO ANO PAS51N° AJ ( i J [-_l W[T [[__I rNO WING Y I.._I NDSK I,.,i l [_l IITI.D LION !.1 [.J A I_ I IIDwn 1UL f. l f p I_ l -KIND. nl.MT III— ( 1 :MO L I f (?. FY I A I j1 , [.?2 11 r: 4 .D [.. l A [ I - A+ A Ll AIAKINr: I.TF4 TIIHN [,.l [ 1 ITC 2 l [ I I_..11' . MII"1 (.-l u rJ Y 11 I - ? A R I-TARN IJ rl 1 ??1t,? [.? ° r.n. [ l r.l N c tt L_l •' 1 I IuH I I-? - n rc ..nMrtK .ci I.?.l ,rrYUr [J I_I°'I lrI ULMAN 1A.rN [.l IJ 4p ron rnAVrID v r v. I .D r .a, r•r.I r. ..+,.•.r r, .rx.:......ror mro 11 n scrTrl. _..__.. _.__.___ Ci rr C1 •,I•rrr'T f I I L l - I I Cl ., Lr - l r V "I fi T; N I-AlW,Y r. 11J I) 1 l_ li[r n[ d ' . . k ,4n ':r Y xL IihACi E r •f',` & 1' ?•., UL -[n'bT L Ylalrnl Kx.f .ova-. -..W: &a c yi15.?!'°'. - u ] s D[ L sk 1 _ "?fy NSl RUf f10fJS: I ] DRAW ARROWS i0SHOW PR NC AL DIRE E t t rya [ O UI OflCE i 1 ' 1 •v Y t c[ ro sKkrcH N G UPMACt TD TIU [ENS MDrGHC VDAMAGED VELN? P ? _DAMAGED VEHICLE Nc r•.w sfVEPRY pFDAMAOE: VEHCLE NO., ttr OFD i'I I P IT O•mmn I ?'OTSABlING 04MAGE a ? OI HE.AE-AMA.E tE ORDISABL INCFD.MAO[in ER ]EOCNiO M.V. OAM.Gf SEQRDISA BLI I+G'DAMIgGE[NrCLF N' I]x?t OINERMV ] ? FUNCTIONAL DAMAGE A ? N O D PMgGF T ? {uNC,rON.L DAMAGE ? EAMAGE ] O PuitCi10NPl uAMAG . LJ NO DAMAGE DAMAGE OWED BY +/l/+ MAG s1. DAMAGE I E DWEDS Y EST D 5T . M P q TOWtO B GE TO f [jO ? O 3 T 17o ._DIAGRAM OF COLLISION t DgAW ARROW SHOWING nD.Dw.r AROwr I[ s I ^ NORTH IN CI gCLE ."ONs oulc,s xrorr xogo x,rr Nusu,Lntr.. mxD Nz rcc rxrcx coxs,xuc w . -- I ' --^ ?- _ - our[ rxo rxrA ?. pwYlNa[.[PLf,H . Pw, fE,N,LIroNS,TIU.,CC (?? ?GLY_72% - - -- -_ Ow.AquPLrvfx u[an [s,AMxrN,xs en UAL . I _. __ __ fl JIJ FC. - . _• ... r L = DESCRIPTION OF ImDICATEWNAT PROBABLY HA " f COLLISION N NOT ON DIAGRAM. E.G Dgrv[q DISABILET REDUCED VrsleRlrv P oiiieu?,ECioiHli'c co[on,tor'isieocT F eo OAN¢ A N P IN- c UL - POSITION BEFORE COLLISION HIGLE NIGMw4 YNAMEORNO. INOIOFEOIPECT ON NO. H[ADED HEASFG DECREASING O ET OR i P EGALLY S" Ho KED [ 3 E w _ a? - D -' x'rl IT - ES NO "S NO ALONG - OR -- - x,OS(fOx Dw.l - r!D cxoss Nc "x t,ra rc . ( IEDIBICYCLST WAS USIxG: i OkwaLK SNOUL pEA I Cn05 B ROUTE T -OTHER ROADSURFACE WEATHER. CONTRIBOTINK OUi H c[EACTiDxs oAUOg1ANCE3 CHECK ONEI CHECK ONEI - vluoxiil NO IvF ] R E? O TR vfN DOING . ''' yyy 0 ] ll"AI GNT A EAD '- c OHV CLEAR CLO UNDER INFLUENCE 0 LOwING_ _ G ROED w S N _ .? 6?YERCA37 `---- ] SIGN+SO. CO O p p FE NEly UN N INFLUENCE [ NTEN An N,,y 45. . . ?I2? MAKING - _ O I][ STATE s A, ON ] t 1 9~ O _I 0 PPRK G k ED ?IGNXL L'N' A.M. ON I 4 _ . M EKTURN -- .?, ICE A F_ f[D NG REAS 'p" ..._+. .. .?.. _... .._... _ _.. sAK[cf YE[D_ U_. O C N ._. ... - _ ,- VF EOII URN I51 1 3 . DIU NOi Gfl,Nlfl - ? - .b FC rYI O,irEPISPECIFYI r 10 vEHcl[ SIOPb GOLD +_. _ I -WrNG p HfR IY ._-. - B uPH'PER _ S11-ANAIS` B C rl 0 DFONGV R NOT A LIGHT CONDITIONS CHICK EE RAFFIC CONTFE INO.]V(H CLE NILE TYPE.' OR ROAD OF N0.] ICH[C OU E K VEHICLE CONDITION " C IOL TION SOBRIETY... T FAII IC S (O TBIGNAL B I --^•..._ ?- GAS WAY I ,,(( 9 C{5 I HO .)` uitb 51, ,`ND. ]E IGH(CK DN i iJ DR TOPf GN D I DAYLIGHT N _ D 1. W- ,I. _. Dn ICTIVI '. HBD ABnrtr ROADWAY - 1 .I O a T 0 I ] CA ... O ? . - [ , :• -B A Ls _ _. MPA iIE? . I FA' F; LANE W I DUSK ] I'LASHI G A' I -IRS-1 I INII.CNXFG a ] - t n GIr13 r ? NOT IMPA REO r._ A7A.1 J ° KED!O Op I - - - ! - o - sHI G ° l ( t_.._ LOO-IIAMr el ... ALL[r - IT .. REANCLONTf '.I wORN ] E?ERGING APF CII xTf RING . GIGN 50 - ...? '._ . AMBER - _ -_ -' O 3 00 NKING BACKING 1 pANK 3 RF[T ° IcH o D,RK_N1. iRll1LIGHt6 ? 1 q NNAI - .. CfRI A _B TYO WAY-L[fT 1nHN Lgxls - uric. N _ s[rAHA,[D 1-' IO s- OIN VO fT CHEM. TEST + 1lB, GIVEN ___ -- r i iHFIr ISPECIFYI O + _ NO DEF[C15 i P ? r o nprD unto % TEST RESULTS 2 GO FI ( • 1 I l LER ! HANK ??: _ ' UGf Ap? L FO ? OLICI ANNrvEU A. /H TAtb NW1D CFL OW uPEOED ] N? I X NV STIGA,INGOIrICfR MAUt ARANK - DGI+IO °. .1-1 - r < VN r, ON IT ACT, . DAI f01 nEPON, DG 3a ?y Ax PROV[OBV I ?ROPt! ilx DUPLICATE COPY LOCAL LAW FIFtORCk MENT AGENCY'S COPV? ?IrrUL ? PI .WgSIIINGI ON OBSOA TRIPLICATE COPY INVESTIGATOR'S COPY rr I « I'I 4 F' ?f9?d F ?l W, r. ?wn:a ?4 f? asgs+v 7?FWiJ?TA? ,P FA r' w-' yd S tl'?? IK f I l - I LI i?1?', Jr I /f I. E i i .;I f' PAGE -+ OF NO t POLICE E--, NuMBEB w,- UNIFORM POLICE TRAFFIC COLLISION REPORT _ _ _____ __ d. S>•f shN.?r D GATE OFCOLLISION OAY OF COLLISK)N THE COUNTY ND CITY NO, F WA H ) A M - Y YR_ SUN MpV TAILS WEDA NII FRI SAi ISE]aODH01(HI J ?.: 'i' Gl C l 1 2 D U 5 6 ;? L / RURAL V Jp} y 'fit C=U?ry ?STATE ROUIF COUNTY ROAD ?CIIYSTREEi O ADM.CLS. PREFIX RDUTEORSTREETCODE 5 CIION IS E !°i9' p ` n ?OTHERISPECIFY) W /C O y EM C7YORTOWN W PREFI% EO. MILE-51 0 MILES ? ? ? ?J oF-?I_7-C_J_J??LL? _ ___.___ - ° /? ,?, a sa I i.'I 1 A ANJME ANO, OF flEEI 1HIGHWAY INTEREECTINGWITH. STREETDRROAD LL NAMP DIAGRAMDATA - TON i? 2 f 1.. I NON rtDERSECTION ACCIDENT NTER NON LS ERSEGTING STREET OR ROAD OR REF ' ° MILEAGE 1 C15. FAIENCE RSTRE TOFROOAD N BETWEEN STREET AND _..-___---.-STREET CODE 99 __ ?. ..1.. ._. _-_ - DISTANCE AND DIRECTION FROM REFERENCE OR CR055 STREET GPECIAL CODING USE nuNLOnE1n5+. (]MILES N 5 E W ?FEET ? OF - a Y I ? COLLISION INVOLVED: VEHICLE-VEHICLE ?VEHCLEBCYCLE ?OTHER(WRTEI ?HIT BRUN SEVERITY M NO NaLED to ALNO ORVEHICLE OSIECT ? VEHICLE RNTRAW ?STOLENVEHICLE NO. INJURED OF VEHICLES ? VEHICLE PEDESIBIAN ?NOI-COLLISON ? HAZARDOUS MATERIAL __ T7I PROPERTY DAMAGEONLY OWECTSTRUCKINAMEOFOBJECT5TRUCKANDOW ERS AME) .LOCATION OFODIECi STRN ?CKS E WEST.OAJAAGE V1_ 4) 7 ? NO WAY FEET ? ? ? RD. EDGE S DRIVERS NAME-LAST FIRST_ -_ MIDDLE, DRIVER'SNA 1, FIRST MIDDLE III BICVLLISICRPl DESTRIANCHECKIO. R. STREET ADDRESS R I •p STREET ADDRESS .... p V V.:6 E Crtv STATE ZIP CODE R PHONE ND. E R CITY STATE _ ZIP CODE PHONE NO. ?I N DRNERS LM:015E 110. STATE 11 DATE OF BIRTH . . N i DRIVERS LICENSE NO ^^ • -. - STATE SEX DATE OF BIRTH: 0, MO OAY YR. 0. MO. DAY YR. ORNERS OCCUPATION FIRM NAME _ PHONE NO. p DRIVERS OCCUPATION FIRM NAME . ,, p N CODES >1',i, CAS In1 SEAT BELT__ ISI EJECTION---- CODES J 131 INJURY Imo'. 'J g?yp??1 N?IURE OF NATURE OF CLASS Al SEAT BELT 151 EJECTgN,., wit + - rS F. n9J ?. REUNVED NJURIES i FR MSCENEBY: TO RgMOVED w, F OM SCENE BY TO VEH. YEAR MANEIDODGECHEVJ MODELIDARTNDVAI STYLE I2 DRCONV.1 VEH. YEAR MAKEIDOGGE-CHEV.1 MODELIDART•NOVAI,... STYLE IZ pRCONy.1. dYh V V E VE .COLG PLATEE NO.:. STATE TRAILER PLATE NO.: STATE E VEH.COLOR tIC. PLATE N0. STATE TRAILER PUTS NO.. STATE N rE ?3 .? .J -I' -. C VEHIC 1D NTIHICAT- NUMBEfl DOMETEfl c VEHICLE IDENTIFICATION NUMB R 511?2 ;7 ODOMETER.. L.: s3/ E'.:. E', > REGISTERED OWNER -LAST.. FIRST .. - MIDDLE REGISTERED OWNER-LAST' ... FIRST .... DOIf .R N; WY GLa N a. 'AS t ADDRESS _ t OF er OWNER ADDRESS 0 NAME AND ADDR OFIYSU O.ORAGENT I A. r .. I AA B_ :( CHANGE.. -NATION NO. ENFORCEMEM CnARGE - ITATIONN T • by r. _ NAME, ADDRESS -& INJURIES OF PERS Coo,S ONS INVOLVED ' 2 5;( 67. AGE STATUS R EJECT. C NAME C ADDRESS' UP TURF OF --_ SC[NE BV FNS TO u uRIEs N NAME E T AADREss II lW S N -Eo EMO EDFROM r URIES RCt NE pY. TO J uAE. W I ADOHESS' _A N NATUR OF A M3vlolnpA - - `:: 'C?' NJU SL[NE BV TO I' E NAME. s - 3 $' iFLAF f - _- -- SCl NF flr FIT 1 p1SIAluS IZISE AT POSITION I]VIIURYcU55 II)SEAI BELT PI CJLCiKIN C : PC?[GTnIU11 I oINIUR! SDDARLNGIN-1 I NOT INSTALLED 1 Dl [JECIED NJ.n T 2 DEADAICFNC AlNORD RLINC. E. NOUN U5E NA LYEJECIED E Z T PQ4110N J pE ADONINAL IEVIDENT)INJURY D USCD D PARNALLYEJICTED ., N E E O1nER - IIU5 MO1pPCTtlf.1 A VIEDINHOSPITgL 1 POSSIBLE HJURV. A UNKNOWN A UNKNOWN IF 159T I 1 a s ONI[ I 0 E ol, POSIIKYI UNKNOWN E ASUTRELi FMLURE O EJECTED ' Q. J t J • y? )i?F ??. J. 1 JI' t I I' Y k s i'I J;+r,Y. 1?•, mrdr t'.a,P^ m..?n 77 '?7 I -I 1 i I EI.? _ I ,rr p v,. T', " m r , £4. r" lW-rQ OR V iICLE COami N REPOR 14J 1 Al .1 TE O C LLI O O COLLISION LL a M J ya 7 1 l L ,a.? o o I L Cb Y, MILES. f?('1 TY. TOwN 5- t uVr U LS P I xaac o, 9kCilUn INTERSECTING WITH STHEET Oq a0A0 OAD OR HIGHWAY PREFNt EO MILEPOST ,. ;? ,.: .n.n, ex IVE^NAMEOF STREET. R NON II: 1.11 -TON LyO?-TION OF 15I0N RETWlEH STREET MP Aa.iIAM OA Tw 11 NOT woo ' IN o, I.ER «5: w.::Q:arv x N W N wnr,[I ? ?- ........ E USE ?x » [cL ass uAr[P cost. ..-T S UGN -. NA-E r e[ a U ADDRESS wa R -E. JECTS NAME AND LgONOWwY ?N_ L' ° ^--?T ••'..?? _.-e .••... IN '' To nawra coat[ IclEPkJNt TC.??.. 7 YGfAa'£I ? • ' DRIVERS LAST NAME - FIRS A.. ?.^ _ MIDDLE HNci? ?IL_FFil..t ?a?1 wocaxa [InvaLV[n r»Arv two a .,;. -._: MIOGI.L: , , DRIVERS LAST NAME ...,.::: FRIGT NAME STREET AD E S :.' T NO ANO BOX. NO . m_ . .. _ - - iZt a l .?,(..?..? I? -II- °n,19x x,. x STREET A..RESS, UTE.NO.AN. UOX.NO. CITY, ETA E ]IP COD[ ?-rzt' "??L *ssL:N 1 rJA_ jg.sESS .RIVERS OCCUPATION L 2(L CITY.:.,,, TE,:;;;,; :. ZIY CODE . . O RIVERS OCCUPATION'. O E G E U BE STATE YH ., C 1?, 47 ?L W It EX z A H [AG E CA 53 D?23 DRIVERS SE NU R STATE X E O T- [ Yw. E -1 1 MODE DOD T LE S 1 .- c[c M E tc 9o°c MO EL. 1 o I TY E 12 n L CENSE Y TE NO. .-t T.... ,? .0... ER PLATE ,O ..ETA _ LICENSE PLATE NO. JPTATE_..,.;.. / h..RAILER rPL T,E NO.; ,;.?ETAT2; d5?4 ?JP VEHICLE: IO ICATION, 0,??, 968, [ Ii a 1 O.OMETE0.1 ruwo[1 : VEHICLE IDENTIFICAT NU :a,:,l l9 E u @:x w[nl ODOMET REGISTERE O ER wlus,Frn•nHroOLa 1,M; ORIVERE LICE E NO. ?EFF t+t,cic TH Ac-KT X47.) REGIST 0.ED OWNER Flnvnx o NAMtI .,:..;,FOR RS,LICENEE.NO... IERSA O EES...s.; ', "x« e[i:c .?. [.:. ,,„oTE... A. [ OF _1:iL? 6 1,.- OF GIRTH ?. A ,CL l Cott' t l..uS 60i a J% G 3 PARTS OF VEHI,GLE OAM c an _.. PARTS OF„VEHICLE DAMAGE P. ; ?t 1A . - LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1 W.AIETRIAI.REIAITI..T.ILELIA..LI YINSURANCE IDEN YOUR CAR 00 YES E] NO V NAVEAND O L tT I E R EPO CJr OLDER .,, _ AME O I BI IT R NCE O ?? NAMEANDAD . RESS OF LIABILITY _ ... ?..... ... ... ... _ I LI Y POLICY .-. i. .._ ._ ....... r u. ST J A 2 1 1 I A E N E NONE :?.- ': ^ NA E :_; ..? ..::. - .. _. _ X :' EES E El El 013 1x, Ii? E TV O JUR D N VEHICL O ?r[ . t, H LLEO :,-.1:..T - 1 NE N T. L I T TI OF ED VEIIICLE N LLED . MAR F R T le<vex[I ONE THAT APPL olwtxo"I IES . . ? SO 5DZ _ 60 7 O R I I '-E '?` O ° x,°rvw.r n n \^ I U\F.. a.[x Y.xr[E. A w ! ??a\?'P ' O +CRIOE. ELOWVMAT N PPE YtEtER, TO VEMG E Y NUM E ... CAR I [acne aCt crF con,?Ro 5}Zgc_y _ R pole 9I,a n VEHICLES POSITIONS OEFORE COLLISION xa L[ `v INVi.LT Ow}ED RY = INC. t lIf[wO{{fD ON STRCTUR GNWAYbp FO1R NO. x. e, aeE vL• Ann Y cuO c NO ITOUer `vJ ? ?l? ? 1RCA? CJAIe. ..FCY+Cl ?'.`o ° ??«o °? ;, r c,; IrNT..rA,,, :[. P Rrv IuTllflrtl ? ? ? ? ? ? n ? M x», PEn..TRIAN '. ? ? ? LI ALONG ..,; ....." ... IROS INOM .., :.... T._:.: .. ... SnG P-11RIANW 9U911. 1?. 2?wA no• Any ,f. Nn? Ir [iwU4URIACF, W1AtH1R LIONT GONRI}IONS TRA COI Ti R'OL-? c[°nEl 111101 ROAD I .. V..I C HICLE ACTIONS.; ..' .. 1 GHT LIA L ^ T rl ??t WA-1 2 I b`G.NG STRAIGHT ' AO N L T DRi 20 RAINING 2 RAW t ? 1,[I WF 2r-) SHOW- D [_i rio- ,OF S- Y I.' t SIGN ? Q TWD[RE IIY ] 2 IJ IIOAD ? 2 ? OVERTAKING, AND PASSING 2 ? MAKING RIGHT TURN 'T ( CJ O I 1 611W Ar] III A Ii?l LIG Y4 `PIeT 1 , J ILAYIU NG Nf0 INC.HA.- CJ • ? ILUTI' ROP/BAFI ? r A I ] MAKING LEFT TURN If SC1 ?„tf?r r, S ? .] LI'I'Ntxf• I.J A n ?.? S r_] FLASNIrIG AMIIER u S C, ALLOY U S _1 MAKING U•TURN ?J ( ' L_J K pIrTCCrR. A C? t INL{In` HTS C_J ? 11.1 SIGNAL J 0 E El w n Lf i TUNN T `,.1 R ? SLOWING NTA YQN IOa NOT SE [rHO OANOIw' ) LJ SP[C?T T? ( [ ( 1_) ) 1..1 OvflCl R/II AG MAN LANLU f-1 l i C? GrOPPCD FOR TNAFFIC I.,vn..r..?••nn c••,.r...„• •., r ----_------ II ?_ ..iN.n I_J L.1 r.Flr. ., r '7 -1 4f PAR?TCp 1 1-) ( ? 4TOYPICI A S..HAI. R ? T OR ST01 C GN . [j I J RIVIDLU [_1 9 ? STOPPED IN ROADWAY r.NT c NI InL . ? IN DWIPID 0 1nGL - E:1 n ll n RtINO IRGM ao' Fps RZ ' n q, I ? I L IF X ' ?I 44 4 ?AF?r a tie L71fnHL _ UO%•CIRCLE TILE NUMBER OF EACH DAMAGED AREA. EXAMPLE s I,J• INSTRUCTIONS: )• SHADE AREA OF SEV E REST IMPACT. O? L Uri r , r'? ] RAAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE <52. DAMAGED VEHICLE NO. i NI! SYACk fON SKf 1cN xc DAMAGE TD INAILERS. MOTOncVC Tp DAMAGED VEHIc LE N0.2 , e :.lip D ;IT '?y ?gM? ' ? , n I r r I F !r ,fi. UnJnun rpP ID? U?o• ? RRjl SEVEHITV MADE VEHICLE Np •, " u" r"?r•lr• 11.0. urn L.p K I , DISABLING DAMAGE ] ? OTHERM.V DA 'E§IIT- OAMAOE I.E. En VF?CLEI [HICLE THE A R 'EVE ITUN II y4'j ) FUNCTIONAL DAMAGE, ISABUNGDAMAGE MAOF ] O 'E O No DAMAGE MAGE FUELCT DAMAGE 2 O F ?OISABLIxO'AEAAGF N] ) NODAMAOAMA < I TOwEO BY k ?') EST DAMAGE • ? N GF V °MAGE EA L TOWEDbY. S DAMAGE NAL DAMAGE t ? GE I I TO A T WEO BYCT E !!. °AMA°E ?"f Ix I??/'V L. TO O ! P ! ;.DIAGRAM OF COLLISION v ? _ ? 1 .I I I ? WAHROW SHOW v, d c 'r-'L-7--. I . I DRA INC NORTH IN CIRCLE I Al ,, I --r 1 "?",fv f I.All qK L- I /? IN"A De INTOf 'G ( f I JJ--?? CT, L DN r _ .-_j I { I L ; I_ =i;INo^.o 1i DESCRIPTION OF I 1 I Fo 7M PAic?' v?llp?.-c-I-3 £ `- ?-? -r w T COLLISION IISnaiiT: "Eouc[TPROBABLY NA VEVFO[sT oPEC`uR NC THE NCUIOE foRMAnoN NOT ON OIACRAM_EG i ° v sIB ur q A orR Nc R, COxsTRUCT oR REPAw IR wo K, ETC I. vfn ? f D 1-yi a!" 41 ',e'1 c 1 ? ? ? lr! A-_DO_?n+._C]3a?_ J`•... .. ?N ? e/Z c? Aa ???_???-fl__?r c ci g4?i ax tD ?? H ><[3rD CfJ?L - - riN_73?1.c->ki ?l Cie 2S G o _ r.p.• J R bI A tTi c /S'?P _ Dr I_.N F i 1'Jc. ?- '?'r^'LY` VC? uClC?liP 1,1,1 G '?s „e FOSITION 6EFOgE COLLISION- , oNF In IT o i VEI O'. A° CREASING D CREAS gEEi OR IGHw YNAME OR o:: EC ES Sv EEDS `Ly )Y _; ! E ros ro E KEO OC S PFFf , PAR - = n r ? C.J xG ee l..? Aaa ?I / N `La APN!a'n 10 - ---------------------- =70E ol - ' i t c ?nI°E " cD L. t g ?`r GYD ST LING 1 SIDEIALK I A 21 SHOULDER <RDFSWALK 5 ?< B?? ? FROM A _ TO RO?DCK gFACE, nEiECITCOrE,R L -C ON TRIRU71N oHIRCUMSTANCES _ E our OTHER OxEI FOR ZREI N CLE L RrvEq 0 I -'C CLEAR. I i ?VF? TOLLO Ix RIVER DRY CLOUDY L??L-(_A ? INFLUENCE O O _ °I?)'? Oo S dT6iR-.-kFE'AlG i ; . kDYEFICBSU_ 1. ?I )I D DED PNINN. ? . OVEER NG I,?)^ ?ING ?) UNOCR NFLUExCE OF EwiER G /SIG )o n .I?vFR ASSING .:: = A[ ANEni[v n.Lj n+iCF i]I((L-- lNOw ] SNOW Nc- [a3_0 YF D[. TS ATFO I!7 ° O ?y( r I5'!? CE 1 p G O E r, ? LGS1 OIL KING Y - t .L.2 J-...J ?[ __ FD`O E G _EA=_ n DU. 1 )? TIN°FOUv. oTH[R lu[clsr, sP[cUrT io vEHCLE I n A UDA4 r _ 5 . (-6?? OvEn ?.v[-1 O EWn0510P I? f Imo..... _ I NO ] V[nltlE - ' I I I ^ cNA -- I -LIGHT D ... A _ ; -. X ry I O ]I A _ ^ ] L L I -: YmD N DU K . _ _ ED_ n EIAIIIING ,J L:..LBN. O. ET I 16 lr N AMBEq G f-lE 11 LL Y ! T _ L G Tso i.FT _ t O °InEET I LB, 2 Nn ? 1 FORA fI[[ P GNT! ] - OIIIfP lt+[clrYl _ LA AN Fr - v[snc.nxc Of [mFRs NAME • N.NK x eiT I'll GAIINOD'[ ICE n'l NAU(A /? Ur li nANK "n C O EO O F :.SOBRIETY-: ONE NOI IOdrr? Dtl C4? I E OCLTE C CKONEI WAY I ""C GATUL ?_ I... I .tlRAKEE F ?', IMP.URtnITY ° R! BLE 1 E B ABILITY NDTAMPAIEY T tHANG[ ^I - of C I t5_ °_- T LOO RAMP- ._! REW SLIGII T! I I H SOBr NK N LEr I- oRs -..-II z, ncFH On?nKINC -PAY-1. LAN , v CHEM. TEST D - -_L I TESTGIVEN NO OE FECiS f TnErusEO uxmvmm -- LIx:F x0 POLICE DISYA TEST RESULTS cHLO F rv[o ][BB .ANNINE E3 c` C UNIT OII DISrA DIT LATE D'?EPGnT ??JT71 Sc? E 10-?7??b AL C W Y, SEND i0 WT eN CNGTON STAL E PATROL _OLYMPIA, WASHINGTON DRMM L LAW CNf OR[EAIrN ._. FIG. IT TURN ? ? LE T Ti°,nN r!!!-- 'D LB? T RN BLUNRNO ?2? TOVYEO FOR TRAFFIC ? ?I B ST. R STOP SIGNIGNAL ' O n-,I IC ? P.-AYN i F IOL TRAFFIC LANE 'T-TI STARTING FROM U ] I u GING IENTERING ? M TRA FICI ?rID BACKING y OCHE FY Cl I I i T A J? I It ., wrs ?x?i Yh . D DATE OF COLl13K1N DAY OF COW610N TIME ..' 'GLINT NO. CRY NO. fNnA _ 7p ?O. DAY YR. i SUN I 2 IL'S S ,ED A iMIIN p FRI IT 6Ai 1 SE 2AOG H-QIIJ } " QURBAN t - 1 ? ' . E 1 w' C IC' CD `T 'J •: P . . ". COUNTY ?STATE ROUTE ?O000Ntt ROAD ?CIIY STREET O D/MJCLS, 18EFI% ROWEORSTREETCODE- SECTI • AL ON - ? OTHERISPECIFYI \ N ^•"' 3-- - -O - - , L 5 E ??-W ?IN, CIIYORTOWN W PREP%: EO MILE PO6T C.' -?1' ' . ?; l n ' Al I l 1 / U j! O , '•( , . J ! F . MI 3 ? ? .}J ? DF 1 C LL I 9 ,NAME ANO.OF 6TREET OR HIGHWAY - INTERSECTING WITH: STREET OR ROAD I " ' Y DI I V :TiON ..:MY?AFAM.""TM\. -; • NIXi'N"EPSECiIONI. ENT WTER ON %RD IMERSECTINGSTREETORI{OMONF T p p ADAO CIS' ERENOE S E ' O• > •L M GE / ' J BETWEEN STREET AND r' lf? `rSi ? STREET CODE ,_ _. DLSTANCEANDDIRECTION ffl gENLE OfI0R053 STRE - -- 1 3 E SE •• L ({ ?' ?MILE6 N W ? C) FEET ! OF T l'S 1 _ • +. L - t•? r. 1 I" QgG VEHK;LEV V NICLE BLYCIE 1 RITE) ITERUN SE ERIIY COLUSIONINVOIV - _NO KILLED OVEHI .OBIECT ?E?112'(EA11 A WIN? ' ENV E L1'. d L E ICLE _NO INJURED TOTAL NO. HICLEPEDESTIIIAN ?NO COLLISION ?HAIARDOUSMA.T PROPERTY DAMAGE ONLY k -;, OLL6CT 6TflUCK IH OF OBJECT STRUCK AND OWNENS NAME] O ALON ECT, STRUCKS 3.E ,.-? ,"m1Y.-;, EST DAMAGE.,. T W Y L•.I/^ ` PYS 1L OADWAY FE ? ? ? U RD EDGE S - ?_;, OnIVERS.NAME LA6i _ _ •_-5,^:, ...:'.FWST„? ,_..........,?. .. .. MIDD{l: -• DRIERS NAME-LAST, FIRST MIDDLE, II,D,cnl ISL DN PEOE6iWAN LNECp? ;ti.. .; - '. R_ 1 -SYREETAGER ES----7 . _ ...'. ..I...-.??..-....,.vim . ; ? _ V F o T e"x s a FDJC: i TarF<,'r\ R? ? •. v: ? ' GTY .:...._..?_a.. '., ,..A... ... STATE ...t .....DP CODE :. ;-,PNONE N4 E 'E NO. .. CRY _.:• :...:.. .....:. :t:. .STAM.-,: L. .-..r.•:,.ZLP CODE. -, PHONE . . . : R R LoFZlJ.? r Jrn ti,,,r N GARNERS, LICENSE No.,., '.. ., STATE. SEX UATE OF BIRIn N CRIERS LICENSE NO ,,. STATE 6EX GATE OF IuRTH..:.. • MO. DAY YR O .. MO DAY Y 0.. R DRIERSOCLUPATION.. FIRM NAME .. ..-.... ...?.. END. DRIVERECCCUPAIION.FIRMNAM CODES 5+31 {j"RY -- NI SEAT BELT - 151 EJECTION- r CODES >113J GLASS' IAI.SEAT BELT I51'EJECT%]N .'YFY Y NATUREOF NATURED F NUR ES NA JVL ' NJURIES ' ,hK kq,. FR SCENE BY: TO LPOM6CENERY TO - '- VEH.YEAR. MAILEIDOOOECHEYJ .: MOGEWDARTNOVAI.'.. STYLE12.R..ON1) VEN YEAR AUKEIDODGECHEV.) MG-Ll.ART-NOVN.l 6ttLE 12 D•tCOFJ ! v e, fl, v .1 E' VEH.,COLOR , - ITC, PLATE W. STATE TRAILER PLATE NO.. STATE E VEH. COLOR LTC. PLATE NO., STATE::.e. TRAILER PLATE NO: - ..H? H-: "- - -•__ -' " ' ETER.:ly" •:c (.` VEH IENTI X:ATION NUMBER :::..l?l • NIETEfl C VEHICLE IDEMIFICATI NNUMBER:: -Dom ..; T '- :1r a MIDDLE 'I REGISTERED .OWNER LAST .::,;..:. ... ... F BIT / ' 1 I ' I? . I F C 14 nN - Iy t. !? L E. J?i• I: '0.? O: AOORESS.OF OYmEfl. A....,: _.....?..___. .. ADDRESS. OF. OWNER J1? Y n? /v nA.J N 2? NAMEANDADIEFLESS NSU E CO.ORAGENT._... .... ... .,•... . NAME AND ADDRESS UFINSIJflANCE CO Ofl AGENT:_:.. ,c...{??'.'.:.v..u.H.¢wG?. .J ? AG1 - Y ?_? e•:. .:.:...:..... CITATION NO ?.':^_'?.:. 'ENFORCEMENT CHARGE . :.:: ....' • ?.._. ... I AT .1 wa..tc v r ? . i. , • ? ¢ ± ' ? ACTION - NAME, ADDRESS &I JURIES OF PERSONS INVOLVED ) CODES C , . SEX AM STATUS N IE EJEC T T, ?• I I `. NAME: 4? ?W C ADDRESS. Y !d U,'. NAIURECF RENO EOFROM T - L i Yi ? „P,. A W_ES SCONE BY O NAME: l T ADDRESS: - 6 T I, F [9 SCENf ROFP M IWU TO W NAME' A ` ADDRESfi. .. - ' A N " M vEDTnCI MJUR 6 SCFNP nr TO { n E ' S..' S - NAMr Anpless ... b ' F? ' ' . . I n S' NnS S V ?6 cENF . To . • _ ) F, C INSTAIUS 2 PASSENotR I2IMAI POyI10N IJINJUR CUSS .. O NJURY 5 DISABLING IIUUnY 11111AT13EIT 1 NOT INSTALLED - 151EJECTION I.NOTEJECTED ^ T. IX O n ?a[O VINOSPR?L II NP0690iE JURV 1 OL Ly ,r FJCCTEO iE }•? E laT FES ( p fbSR10N UH S 3 S pSE M?fiE fFNLURE . L . a .', '.." 1. :t.. I 1 S^ gat {K. lYct? .? ( VEHICLE DAMAGE _`"N ti r d rYd?f at ?44 ?2 `ka s°•` . °" {5? p s of L o sr L r rT. ?: .? ...,, ' IINSTR UCTIONS: T DN r A40 s TOSNOWVrINr PALDIntCT1ONOFfDHCE. N. ' -- -- - • ' DAMAGED VEHICLE NO. 1 lus. sv+,[ ruw s.[*c• N.:",mAO[ ,o TNA tFns nrowcv t l _ DAMAGED VEHICLE N0 7 TY Oi DA . k'I C [ iv DS UAm+cE. DTNF VE LEI -- Am-VFN LLE HD] f? D B+BL nc pAmncE D C1 OTHEH cE ?I] O SARLnaO D,m.cF ?? aT. N V p A O u s+RUUC DAMAGE O B O O m V. oA.AC[ , v`p PUrva Gl-L DAm+cE A ? NO GA.- P El oNAL nAIAAr.[ ONO DA oL7 EUrvcnoNALD_ : ? NO pA c`- fi -T '.,`? f si OAm>eE r DAmA 7ow[o Dr uANACe 4p ARROW SHOWING NO DIAGRAM OF COLLISION R NU "-'- T RTM IN CIRCLE i. loc,.L.NDP,RLt.o x, or _ -? ",? , [„DN.[„cLL.P[D[3,„,NON _ ..:_ - .. ... _ ??? ??? IoN• LRO,'3D ... s. ?-?- O.,[L,.DSItDNS„m.PLT. . LNNw.Nr..NI[rL:L.[ON ""' .ND.PT,AKD.LHDx _ Tom'. DESCRIPTION OF BEc<. uvN N4AIIO,,ETENTHE CNASN. NC.uuL wfONmA NNO, On oIACNAm E.c onw[N N - NlsOAL AVB COLLISION ID I.CA1, T cmDS L ,nE PEOnn ANLLOTNINGCOL CORSinuR 1.0-1 _ - [ I• -?V-SO?ht?-._ol? co I? Dloh Ro?`?D o RMaGv?15?i?k ?? -,,•_ „ : : .... _.?Sn?(T.TN?.'f?-o1l-R?-Cit1.51?9.1 ... ?r w - -- -- 'r7'????__? -V-)-r',IX-eiX ?-Avl_ _.Ykl'NA -- l ?? o p ? o (?4V O l y?__ p 15 io _ vp- SVL SVL Js POSITION BEFORE COLLISION Dr LArv[s-_- ''' NI,.... MILEPOST 01 STIEE, ON 11-Al NAmf OR NO. OUF ORECTIO rpSR FEEDS r LLALLv AS VL NO' NCNTAS NO E , F PAN-D u NC. _ E IN 0 li, ITS .6 ISS NO ED. CNOSS Hr [ _ AN N -_ D M ORCYCLISTW Sus NG 11DFwA l SNOVLOFII , CND. OTHER v[R OICDtcK_E, I__U„R CONTRIBUTINGCl RqU STANCES `LE ?r$o«ir -E I J D IV K , NVI w I i I GOII GHi AHEAD IN. 3 .+. E' ?___ !'1 0 Et C?sL nt D4BQ?PLIIEu ;., 9GS -r It _ G G ED w.ANN D Ass N. AN. I LNC Ri RCENIEN TLY r c L _ 'z ET > c RIGHT RN S-I .9 C s. 1 MAKING .. vm o-? T c I I TURN I. n N A C , 10G O. B .1 LE ST., . GO OC..TO.N 45'S ?,+ D DD NOTCn+NTNm ,11 -NIGANLI I onlE Fc r - - -. o _ J I l SLOlIlG }' ? mNli cN+i i I DTDHIE? 11 ISi oN II CAPON .: A SIN.-, 1 LIGII7 CONDITIONS RAFFIC CONTRO IoLLE NypE OF ROAD VEHICLE CONDITION SOBRIETY V[ILL[ N ILrIECK ONEI _ S O?SIGN SIGNAL ppi?pp 1 I} ! ICIIIDKO CI D L-1.1 tN P IC ECK ONF ON ...T: N r-. ON[wAr ,NOP 1F51SNhSASflm ,NOi Pml NA t' oA ucnT w `.T.?`1 Es - \_?.r- .. HUD ARUTr .H ILL 3 , _ D .. 'VAIHLG_ ._ _ I L. . DAWN Si4N DOAD BL[ - - -,> GN,S N011m1'A NCU N. OSrtlpll ,NG[ ._ 1 oLrccnvE ;o Nnn soomnv EP ITS i uFNCIPNrznIHc •.:. 3 wsK Lwsl - ' ntAN LGUTS I'HK,-..... mA n ?. -:. . N. - DA f[i [ IN AD NOT ? ? L14 TS S _ _ _ 0 0 H TN On NKInr 5 BACKING N ? II s [[i'. G' - NN "' [ orN CHEM. TEST .- L14 A Iw P, I, I 5 OA O I-Ll ? N ..1 '"'M E\-STI kE, ?C•NTS rLAGNAN I Si P?n.A .. _, \' t S GIYFH [ , i >' U,Hlll > NU OEEf CTS' qam fSi NEl uSlp .O,Hr,wlC- p r NO D..'?y ..Iwe.. 9;11 T[ST RESULTS 2 pf LOw G?, E N V S y?-211cQ E `l o?r[ h 1' 1) r -Lam` -? [? o= All G14 D 6Al.?•lj ,.[K, ° f?[ G f t- - BADI. N. A IYI° NLYrDDY ry a 1.4[C, O ?DNn t.. DL' a I _?? A A,E?AN I --- UI511„TIUTIUH J111L NAL CDP S[ND TO I'IA.-INGTON STAT[ I'All HOL- OLYFII A, WA`,H INGI ON HAS 1 v Ee . Ol1PLICATECOPY LOCAL LAW [IONC-ENT AA[NCY-SCONY-TRIPS ICATI.COPY INVESTIGATOR'SCoPY 1.- 4 f fz ti; ?f11 flaE O "d L p, J1?? SPIN p y Il.? 1 h n w IL 1 :f J jY I AGE ? -? r?, F X4' J- '..{ I No. --A CJ. VLA nNUrmkn •• '(p• i ?+ ? UNIFORM POLICE TRAFFIC COLLISION REPORT F + _ _ .._ s - "-'"----' YNO CITY r10. fHY+A 9 .; D DTE OFCOLLISION---- --pF'OF COL O IME- - -CWNtjs A FY R U LMLN IUIS YEp I PI SAt IUSE]n^Hf1UR1 y ]URBAN E ] 2 3 4 HUBS 6 ?'? _ /? URAL COUNTY ?Si AtF ROUTE .?000NIV ROAD ?CNY STREET Q FEQ-E UTE ORSTREETCOOE S 11.1 { [FN?•` TAEe e 1 ¢/So j s SAV+TI?tm ? OTHER ISPECIFYI ! $ N d C111 OP TOVIN ?- POST ` Q O I MILES N S LL /J d'C AME NOINTER. GSTREET OR ROAD A N - T ACCOENT SE•'T G STREET R ROAD OR REi. Q MLEAGE CEL: ''STREET OR ROAD ' _ _.STREET --I IREET CODE 7D N BETWEEN UN U'?mS SPCCMLCOIXN6USE _ FROM REFEREN EOPCRO55 STREET 1,1 V `??'^ DISi CE ANDOWECTION ffff//// 6 ` ?MlES W e _ FEET ??LZ_?j O_. __ _.. .. LPUN ONILLEO ERITY :a 5. E ?VEHICLEVEHICIE ?VEHCLE BCYCLE ?OTHERIW TEI SEV NO COLLISION INVOLVED ? STOLEN vEH 'LE r 1 - ? VEHICLE OBJECT ? VENICLORn iRAiN _ _ NO.IWURED ? ,J Q TO EH LLES L_..j.J ?VEHICLE-PEDESTRAN ?NON COLLISION ?-ARDO B E L ? PROPERTY DAMAGE ONLY y? 6 _ OC tON OF OBJECT STPUCNS E? EST DAMAGE ^* OWECTSTRUCNINAMEOFSI RUCKANDOwNERSNAMEI ? N W Yxxf ?' . ' F?POADWAY FEET ? ? ? RD EDGE S A { D ESI N CHICHI CI D MIDDLE III UH:YCUS1 ON PkU -i ' t 1 .? _ ... ... pP' RS NAME-LAST FIRST V ST IV ET PISS ADOMELASi 11-1 STREET ADOBE'S _ MIDDLE IV Gr ?• o R 71 V, E CITY . - STATE -'ZIP LODE .:.. PHONE NO. yi++ tl E STATE ZIP CODE PHONE NO. - ?__ - R R `TOT-? ?O?wnJ?WO ?Igg? 11 4 N DRVE LICE EE N0 -.. _ SLATE SEX. DAIL 9-RTH YP N DRIVERS LICENSE NO. _ STATE SEA- DATE OF BIRTH A? yJ?5 , 1* f r A e L N - C MO. OAY YR. '.,1. C• 1 p Z DRIVERS OCCUPATION FIRM NAME : 1 T DRIVERS OCCUPATION 1- NAME .. _ PH NE NO. 1'? ?' 1 COD > n...... TAI SEAT BELT 1•vI EJECTION CODES >11], CIPSS Tar SEAT BELT- ISI EJECTION ASS- LURE OF MXIE F - N UNVS EG I NkRMOVEO t.? SECENE BY 10 F DM SC F.' i. ?a2 < FR N H V AH EIDOOGELMEV.1 MODELIDAfl OVA). STYLEI]DR-CONV.I VIM. YEPP MAREIDODGE CIIEV.1 MODEL (DAR T gVPI bTYLE12D-ONVJ - t v ?D ?7N F-x,611 _ E _ VEH. COLOR _ UC PLATE NO.. STATE 1HMLER.PUTE NO. STATE H ON COLOR LTC. PLATE NO. STATE TRAILER PLATE NO.. bTATF . q •z L t _ -54 EI [B - # ?' ., >. C VEH? ??IFICAIIOY VUAI ER .... .. ODOMETER. .... C VEHICLE IOENIIFILATI NNUMBER :ODOMETER._.... r (p 001?1 ." E E ... t ., REGISTERED OWNER-LAST fIRST. MIODIE REGISTERED OIYNEP-LAST FIRS, MIDDLE N ` n?c. (3 6L?2 0. ,Cy„?' ADDRESS OF OWNEn 0.., ApOREbG DF OwNEH _.. ..: .. _. ..... .. _. .. .. + AEI R' 7 ?)???5 19fd6YR Z NAME/JiDAD0IIESSOF INSURANCE CO.OR AGENT NAME ANOADDPESSOFINSURANCECOOR AGENT 1' T LI}ATIDNN I* r..? C?AR'E CIA ONQNO E[FpRCE .ENT L RGE t L: ?' I? .., `? I ?V C.O'h W hVT?? rb U ?? ACTION T[ ..: .:. ,. CODES ? 0 5 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED A .A. _. _ SEX AGE STATUS EJECT: ._ p. NN.IE OF scF.?r nv r„gym TO A NAME - B N T ADDRESS. -[nr DvkoTnoM TO S SOF ISCFNf nv t ? ) ? T F ` ADOBE'S YEinSv[D n10A--- T ?A I units •- O E S NAME' -- ' `Y S ADPRESS M vZISP[i6'____ TO ' Sr 11 5 ]I`.LAI""0' nv J rl IN, JUN, c'S 1 n Dl f UURY R I 141 `+[AI BELT UT TALI ED ISIEJECTON 1 NOIEJECIEO C C ] P C4,InER P[D[•1NI AN .? IclRt ` f- 6-; IOIHCP I.OSNIgI MOTORC11 Y I NOIN IU IXS PLn ^Df AOAt SCENE B 01 K JDEAD ON ANTI VAL 1I NDf II,JUNV A OED II-SPIIAL I POSL LC URY ] OTI VBC ]USED 4 OWN TOTALLY EJECTED D1AnN-1 I JILTED A UNKNOWN IF D x O1HER I RU' xPosYTOH UNANO S CAI BELT f,VUJHC EIECrkD E xWI1Nf SE 4 141, STATE OF W INGTON rADt /.. Dr pry No. 1 7 0 0 5 5 A's c?' M y: t???`3c D a air, . Mh? ? r e ? k TI?I t 7 POLICE TRAFFIC COLLISION REPORT ?TRAFFICWAY * wllCE-KAIN,NUMdv .,, PRIVATE WAY _DA,t O.(dIIS_. L I j- I gg ti DSR McDDPI <OUN s Ir C(,?/^ YyO. CnY ND. fMV °.D RU a 1 DI DN CrrOR,OWN N t6N0 pS,eYrOR MGHwAr P" Nlts D1 Dw D' n oN I? Ip Cl3 x RWrl ORSINE 9335L SFCI lNIIeYCIING.1. S-El DV AD NDNIN,FRYCriDN RnwttN T11 vtF, a r0 smty PMNK [O MetPMf Q . I O?S,ANfFa D•t {FV t. C•OSSSivIiIOR NtA•tS,MIF S, Mnls 5 ] w ACCIDENT P dAGRAM OAIA MILEAGE CODE causroN wvdvtd vtem PUN lO1N r10 NO VIIItD NO NIUR[D ? C3 A.1 0-I upi ruo?xf N %RD IMfq. Cl5 ue _ I IIND SIRItI RROAD Oe MMMM] CROSS"' ?]] dvw eles °rROfeR, DAMAFa oNI. ?wwutn Dvi°cli Y/ ? D 1, Denel srPlc.IN.i..F OB][Cr SIRUC[.NDOwNtRT-11 es, DAMACt RSaAl C s .g- srtcw eowNC lrsr. -? UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST S, Iv l L A -- DRnte sNANU: us, I i--Till 1 P , 1 U){. _ l 7 0., s,eul ADDVe IMeIADDMSs 1 .( c r seen :Ircad rHONF NO L r D 'r ,A,I v? t ?3 R DRNiv'S IKINY NO Inn, S,A,t X A F !I N kk-r M I V R u fN rvp All occuP 1- NAMF I PNONI ND s wr lea„ E -P-- r RM NAMI a -1 No. -S Ic{Ir Ka{R a 4QA kL (?. Pj ZIO (, R D CHECK (?) 'nHKi1AS:N IMAV'r No " l D CHECK({.) 'vrH aF ASAN U.nonF wNOr{.v? ° CODES? *] I e i° s CODES ? a D ?, ,s . ° 5 ra e y a INI I o m", D1b.,1 ,?i:Kii ? ?',,. • w Y V 0-- 1 ? :' D c"8- D 0m, Ar DOWFCHivl 1???13 nlDAVI I SrrD 1]OR CONVI a>7e E Y HI MDdIIDARI NOVAr RA uaNY AF un s AuR MAre NO vAV H nH I RS/O. B1, w- ' ` W I C ]v HHKII IduI l cA,-Np VI-11 N I A l r I l_I I! i L 't i a l i ndsneloowvt• uASI rev Mlddt E HONI NO ?d5-2frJ? CI W I, tR. l nv I 1 Rt u ?- O DZILKA E rt•ADDRrssa NweANCt co oR ACINr ? ? R -- AGFD MIA ' ' O AMAC DARu l O1 -01 CHAYtA _ d 3 ISl DAM.? Fb ? ww?r MMUMD rowLO ? •lAA]vN;D ? A= ,on]D lsl. _ E r A. sv s ? DIAGRA L } M F COLLISION' O I ' . H ti s?Ar ? ,H (L?.,?O._; ??b? 1 11 / DESCRIPTION OF COLLISION 1-fti-Al vad Ma-1 Ve?}Ft _E?6Roaon(?_RD"?DRtvez_11 leep ¢r Cark 0b s5 a v -711 t pioT ? 6 i ; 1 I ; /..j ! . S e ._ o riFl? . a nE nu _SirvLx -- A fly - Ut L to 1 (dolt t _.on! ° / fCP y cnMe . N PsT _LJ?J IDF, Lila s1b u c 1 p 4.-An w. ,A F-1 NAME. ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES I - 2 3 5 6 IIM su.nlwNru fw OCCUPANTS /WITNESSES r w IoNAI NAM l, nI u?...?ci ui- wKHv.r- -Nr „sn un R .AU r . no.ns Fr Aw s D.:.i" D " . O: OIw w 1D __....... -..... ... NO MRI Sn "rU•Id ... •._ y •AM?O{•OM DAMI DrcaAr D"d.R•Dw ?i' N Awl rQ A «s Nnu.?d "" s < A•"'D °• D= r ° D X 1•nN.wla•ANr ADCIa Au... IHrD {KA Ki .? vFO i DAI ianlo. f F' z-I ?.n n ' m q - 4 d L s ?I 1` t {'?' ? X It - I KI I J7 _ . F?? ?71 J 1 L' PRIVATE WAY •M?.. c,r..nn,n, NUmuv - D•,F ca ?s Imt lnD. ,.! 1 st>.ap nouRl Cou couJrr NO. F crr No e.u ? ? ?IN c IOwrv aNO IXSreenoR -".AY N as u ewlf o9s n[ p [5 S ?. 1& F ON E'n e j SO ,[ CING IN S,REEIOR-D -H 111951c-A n _ FN l0. A,u(rcril rlONr IRW[W srPllra srPEFt O9 D15t• NCF apvl RFFl9f ?? A F O55 CP S1PIt TOR N[•lsrMlf WS Rl5 5 f r- ACCIDENT R - pwfAwM Owiw MILEAGE ntr pr 47V L, Lj Call•.grv vpvm vl ??_??_//////,,.??. CODE 101.4 NO ® NO nIIfNO NNRED ., IN R ?YllwGl ?Hr{9Urv Mf0 CIS CROSSSnIf(IOa PJ.NR'ro°DOP WFIn"tl .VFHIC1f5 PRp D•/%wG[PVIY ?r `. ?gil,ED ?3f°f ORJE<t sIPIJC[,N•w4IX CIS IK[NJp ONN[RS NN°[I FSI DA„•G[ SnC . 94 Co.- I6E 5 UNIT NO. I pPN19 > '3 NU•a Iw,t x451 A,IDD UNIT NO T VEHICLE [D PEDESTRIAN ? PEDALCYClIST t S,RFtI ss I D9 vl9 sNMx: Sr ??,? ' ? •? _ I- ° /C. ,nFI.IDpRFSS 1 101 f?e LIAY, RCOU rHONf NO n D a TIRNFR3Dr NPom - o arZ r?s R % o ?Yix, 3 T 1 - i,>4 m eat D..'ic;8 v IP I Np [ F Dw DeRIH ? I ` prtu¢? •,N eTtl WliT a,J °J•Fa P.gNlw ens wrrtgHr E 2 occuvnoN IIRM N•mFaelJONl Np Y l L J 170 (o R ? ?CHECK (.G A i 1 Io. __ / n H,c E.,.niJ•a No CODES 10. T oi c w, a ' J ?CHECK (.? 'vlHrcir •swrv lAwonrawwlHER' D 'Ac- • l e '•4'" p w w p°" ..w.N l ? •pPI IDODC CHF V.I H 0 91 ? bHl. ? h.K l aL •: •IWLLID•vl nOwl s,nt pp CWV : µyot« w.N .N I ? p ? bm. ? „ Ke 1 ! S 2?Icr a I E l• ! vl PwlptI IDMF Vwl ! ,) II98 ) a Fq?,. m t, I S vFHK l I..nDIU. ` uuNSe awn _"S25 ,D •, FR as=,IW -T H O C oR -M ? vl Hl nlp N, I ? r n _ I S'D ` TR ` 3 ! J ! IC! , n.snnoowwle , sr JNpgl rNO No TI IK!Ni i4 ?I I ! I I I I I pl nn 385 b9 ° FD !R ,ur nr •, rJne S/}/he AS D V •DDn 30 (MnMR C KI - w c I ' wppRlsa I wewrvcFCO ovwlN, E As A )i jw I/ R R ,Ltaelz lr?tl?. TRI - DV oM,.clo.RU a,. D r e rLL)AI_ 1)1?tlf*W U tM1KAD M[A n% C . CHAP. ?? 'i a 'D"Na b • 3' R w r ro' rnmD ?e1J.w m = ? i?pw9,.w era. A.Al .1 s ?• IDepnD.F ?Ip ? er. DIgG'RAM iCOlL151ON M! • ?? - snul u5s?fi7., eC:?eowl" DESCRIPi10NOF COLL151.O_N IcaeswumF uslRll reuswrl ...? -Qw? 1?_I•. a I J_., ' ?_ --V1 "I w l6: :-SRJay 8e7 ( vrp Vh! ? R? _. Ve14±z__?:75_BeSVU?_ vmk ?Dy L NL G Tu - - ?I I ® { i 510 VAI VeNal Crb55zs ?C ? ?... NAME, ADDRESS 81NJURI ES OF PERSONS INVOLVED 'CODES I 3 5 6 CKCUPANTS/WITNESSES "'----'--- wr---- rn.oo?,gN.IN.uESI v. .. r. , wve 1•cr N.•v I Ne . eara.xR q ,r, .2 -- .MVI„ .... N°tUn U. A ` NS " . w. ? •re ? 1 ' O . ? N, 4 Y E?n? ? ?+H3" 770v " MW f . -?__ ? S rU .?M D r pM 73? 4 vsl ._ D. ,, P. ?•re ?,a,.F ?,.? , asa fJ)r,rC? .lM x " / _ Pw. o..el "-u., c S,Fy;Rn cwp .q ,rD Dena nlwl .R.wrsos " wn M•w V , l s ? 1 S`.I, I ?^ L3 ' ?.fs 7 rk Ek "U E S, t AW. , a h ? ?, M 4 s i I T.Yrt ?."C r?rr .,,wJ r, MOTOR VEHICLE rCOLLISION REPORT cauN???., oYL cHroR,O«N fs ?s ?w ? ON ON ?%•iU?E.E'11/1«., rte, Y?Js [ . ? ,EOne?? of D,ta,nRNe,x DR P NIn,1A.....N ,?? e Nt[ ?.,w[[N I NA oe?E s 11. PRO, oo .,„R.n[AA [. RM, a,a n rff Q or O O •?' /9 nN,P aN,MD„A o1PAN1•PAT\O a vo.v! 'C - a ? Pu,S[ a*o / I snci"cnoxEE, oRHO•D Oa SS STPfET ON ROA I R C RE 0 ? rx[ 1 ?.fe?,Ha ?rEn B M.,[".. 8 Bn fIII- ED tIJECT STRUCK' 1 Icr e,n. ,.Ny OWNER OF OBJT N AME ANDADO RESS ?fG PFMPNA G[_::.. :v u. ' • • O= vm8 LAST ALf€: pql- -d .. ..... ...,.:. IH _.. ?-.?MIO[IEE_ FMORE-N AERWOLe TIO wER IN THISvEO TN _ .. FIRBr NAME .......... .. ..... MIDDLE_. H cows oN OR xERETN Two N STREET ApOflESS-„- ;., ,,,. ,. RpUyENG.AND BO%NQ;,, . ,.._.. ?-?__. PERSONS wfPE _ ._ STREET,ADD B ROUTENO. ANDBO%.NO. ,.._... .. O / O 7 NJUREO sEPAnATUSEA E STATE 21P CODE ZIP f]f11VEfl5 GGCUPATION._, cOLL SIOx CITY _ .., • STATE ,,. „ _, ZIP CODE DRIVERS OCCUPA,1 M, " ORIVEfl'S LI ENBE NO. STATE SEX z ws? 1, GATE OF BIRTH AGE vi a VRIYEH-9 LICENSE NO. TE SE% NIN/ r,41 l DATE OF BIRTH AGE NO A, VEHICLE R. MAKE (CHAFV. O DOE) MODEL (NOVA-DAR) BOOM STYLE 1] ON.) 7 C?iE? /' Tom/ TQUC? VEHICLE YR. MANE (CHEV, DODGE) D L (NOVA?DART) BODY STYLE, (2 OR ) LICENSE PLATE NO. STATE TflAILER PLATE NO. a 14101 STATE STATE T ILERPLATE NO. STATE LICENSE PLATE NO, VEHICLE IDENTIFICATION rv0. .. .. Cc -17 4a ;rL/ VEHICLE IDENTIFICATION NO. REGISTERED OWNED (LAST•FIRST•MIODLE NAME). DRIVER'S LICENSE NO. REGISTERED OWNER (LASTFIRST•MIDOLE NAME) OgIVEgS CENSE NO. • SEA z OWNER'S AOOflE35 (STREET. CITY AND STATE) - GATE OF BIRTH OWNER'S ADDRESS (STREET, CITY AND STATE) D E OF BIRTH a' /? a s?'. N,t '? D a PART OF EHICLE DAMAGED ??i?nV[.1cY2"U PARTS OF VEHICLE DAMAGED dv}a?n ?fw`tx 'f° LIABI CITY INSURANCE IN FORMATION-VEHICLE NO. 1- WAS THERE AUTO MOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUq CAR YES ? NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER ??S•Fl?Y??..? . ?-CESS I NAME OF LIABILITY INSURANCE COMPANY ^ rr aYA'Fr 5, AME AND ADO 'S F LIADILITY INSURANCE ADEHT GTY STATE LIABILITY POLICY NUMBER ZIP 4'PG" b4; %e //39 O 105 8 G> UqY AGE p INJURY (USE SEPARATE REPORT FOR ADDITION,. INJURIES) NAME AGE ADDRESS 5E%, M F ADDRESS 9E% M F I ? ? r EXTENT OF NJURIES ? ? S REGUI DID INJURIES RI IDMINAT O REQUIRE DO 5 E%AINi ON BY A DOCTOR' '?O lD NAME DID NJUR EB REOU RE I+ NAME "S E%AMINATION RY A DOCTOR? ? STATUS PI iNJUREp ,,, MARK fl E THAT APP LIES _,... SIATVS OF INJURED - .• - ? MNIK FIRS THAT APPLIE9 _ER IN VEItI LE KILIFD Ii[ uniu u, 1x [au 1 O of IN.V HI PA LL KIED 15[v[xN "gi n u ?x u earl ND Pe pcu??.RO.1(.11 El f 51 6? 7" ND OfDOrP«1 ,. ? 5? PA 6? 7Nt SHOW NORTH BY ANNOW IN CIRCLE IxOKA,1 On ,w\N•al.w I ? _DE5CRIDEBFLOWWHAT HAPPENED: IREIER 1OVEHICLE801 NUMBER; ? w [ a?,? LEU «A1 na n TT war«... n..11e DN \;/ n A1r « , Ff ? cAai?E.. /1ao AE/y l?i/Qc?s?ya¢aN?YY/NASl% Ti3E ,?wsu w,,c ,awr,.pw &ofa oti Bowe ? ? y 2 8 I ,r ?i G FA/IFA? U/A/?f/AP/ /r /J?q'/ AD. !? j ?A T /l ? ? ? ( I i ? ?F' , rr loY i9vnAVD 7f ?i lFT/./?f j AifnP/h er??y'yAw I.?lwto ?V- D?.?ir C?.ffer OvP y 71ic ?F//sL .f.??Tj?ijN uvp Yifc .?cY1D.J+vy ?/is!/j d,/JE?T/Yv ]-.rir//ofe/y /cslt/E,x. I ,? ?/lviaA+L /UPS Sb C/ose ?o.?/s/.',ei/cF Ix?s'N,u I [! E ToTppi 7•Vt . I?%T(r?i Ao%?/?l b% SElitiax 1 l AeZ e 0 45 VEHICLES POSITIONS BE FORE COLLISION ? r ? INVESTIGATED BY VEHICLE N S E W ON STREET OR HIG HWAY NAME OR NO wlt, Frlf' n0 x0 T?` n0 D le I ??? ? r RD,AI n ? ? ? ? ? ? ? ? ? ?:a ? ?D:,?I a,1A. ? ? ? ? ? ? ? ? ? ? ? ,Ar, `" ? ? ? ? ALONG FROM TO ru Y ^• 1 ROAD SURFACE NLATNER LIGHT CONDITIONS TRAFFIC CONTROL TYPE OF ROAD D RI EIVVEHICLE ACTIONS rlK a«c•`?` 'I I n DAIEGHF r,11u 1<,•EU U1.F I?`wt rmue 1 O J ?r1 YI fn,u-1 OR I.1 I 1 ? -N 1 LI I ? OIGNUS ? 1 ? ORE.., 1 00NG 5TNAGH1 A READ n [3 DR, IN rrI] I P ] 0-. ? 1 0STOP SIGN 'A'AJ ?1W0 .Al ? ? ) ?OVINTAX NO ANO 1A85 HO ] ?WEf I ?ypn?lp I ??IGHTS ON Fi [] ] ?,,,,o E- n ] ?"1IVI SIRLE ? ] [] MAXINU RIG IT TURN ., C) ] ? MWW • ? HOG S ? ?, IHr50riFf ? E C] IIA111MU RED ? I ? ILOOnIH NOF C] I C] MAM NO LEFT TURN 0. [3ICE I n Dr111R SPlC1r Yl DAN. NO \TRttf 15 L-11 Ayr ? [ ?f[ nxO AMG[P ? S ?ALLfY iWOwAV- A ? ] ?MXNOU•iURN \ ?"C., C] V[CIIY o?nlA R TGFY ? I C] RN-N., ? e F] tFA"SU"" ? \ n :10 HIT RUADNAT CHN I?in ' ffT-??AT]TCiW ROADWAY 6UIN¢AC}L?TTPE Q ? 1 ?Orl1CER.HLAGMAN n ] ?pNlv[wAY ? i ? 5101'PfD rOR fIHFIC P 1 I ' F L,J 1 (?. H...rH LJ LJ 1r1 n I ? 01n[R SPEL rY ROAD SEPARATI ON P[D A 6IONAL 0 ? [ ? 5 p" STOP O ON t F ? ? - a ??YY ? ] O V M.O " ? E ? SID ION RO pVr ' 1 [ J -T J ? ? U ? « ? 10 C 1 OL L l ?? 1 ? OW OLD n IN n 10 n Sl AT I 1 CG NE ., - .....1. ' 1. h ... - r : 1 ^^ff mtl1..+s,vlnmrV .Umm?•?laavu+. pn C?p q .1 P'R.A6•?? A 1I ...,. -? ? .Y ( I h: ] '? ?8 tX ( T?R r ak 3? XI A R11 °I T;? < f A J POLICE TRAFFIC CO ION REPORT Wl'""?"""IAT nIX RNNI NUNGR PRIVATE WAY "Wi DAZE Or<IXIIS A c I 1iMF lose ltlD nouRi 11 COUNIy? GOUNIr cltt NO. ?FMVA I '? , C ORlow 1a NO p51Rf ?yr WG«'WAV 6 ryoL- ON °?w °f., a4unA&tm ON 1WIf fM t Cl _ I YCDNG w11« 51nFl OR ROAD NON iN1tR CIKN N - NMiIN A sa??l L OA t-- 1n11% E NRF 1051 t II 051AN[I aDV toN rWmnHn .ceo55sInUOR Nt t tROSI ,1. t5 3 F ?77 ?^ ?Z Ilfl w - r N r??• ACC ENr MILEAGE CODE R D-AAL MIA { p ' •' Flo CIXInpNINVIXV[D YvtR 1? lOINNO NO %Rl[C?NO NIVR[D? ?S1l1AG[ ?«1a11N %- D IMF1 l5 vY InFI R10ADORIRFFnHCE UOSS11RROV nJAp / 11 ~ - IXV!«cl[5 m 1ROnvlvDANAGI ONIY ?YI-Ill ?vtNiCll By 8 t51 DN .GI OBACi SrRUC%IN-1 C10 /E -1. -1) SnCW COgNGUE UNIT NO.I UNIT NO 2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST - F.?'. vles NRS1 i p° ?u I enty sNANe IAS! IR 31nR ADORISS [1 ADDn55 9l? '? ?J 6Z / /! - ?d /. S+ D I ? 5IA11 Ii1CODt FnCNF NO C r 2414. x/78 772-Z?Z R SIAIf OervlR'SIKINYN 2vfi`nT.o/J? 5c? SrAn ?I/4 NPl r7o SV I v rvF UtNY NO Ai[ F MRn ND R . .R 17 occwA+wN y, tar.oNe ND ns ? 1 a«+ SIQLcs RM1a sQ![U?IStXiIlT I?S? E R occu.A+oN MNAA.talwNF no [ns rn1 ,4K.M ?,:3 - ?CHECK (V) A,A o AN 1 N ?CHECK I? 'nNKI[ASANU.RIOn Nolrrtv 1- rR "iO CODES' „ A n '?'•' ev,$? vZ r 6 CODES 0- 3 ai 5 6, ,, C ] a 5 r w1s ? ..,,%..%r ° SKI ? m'. .iK" ? "%°.1,3. R MO An NWA •Sr. co«v DF e : o M • ?.,+ .NCr urc' ? ',%'- ? .i da ?.4.n. , DMTNOVAI l 1 M R 1 11, J '•O"•' .: fi '? r1q /.v,5{IDOtGe <«tvl M . I . l l ? 111 ?l ( ] / E : 1 '6 . . q Ke Sl.le rvAUR «A1e ND 1-1 H n«c I .R LI u '?•? u FA-7 MRK R r-A S'4 I Z, Ei1 o11 81 ,$:5 i l0t IgN1? A i i i i i I i N q ncrsnnoow.rtl IAcI?? rase Nloge R.a«I NO O 1 n wl nnl r•? w. 5.p .I,.' 4' Z. ADDnuo ovmee E NA%.t DDnssq INSURA«ct co uACtNI 1Esu S - -tu K40ILLA W E R • owNtR - ? l u p - 4" ; ,.?:,; ' DAMAC1o A%u ?w..`o:r; i 1 D . AO! F 1 DAN tjM3ACtDA11A ID. a `•y : 5 F1p N , 1 DUnAG ta NN IAWNID T " MM ?.1- ? NID . alfOrr w. k x 77 :P DI RAM OE COUI $I?NI ?vY11111LLUS Il1 1 ?ND1KRAn -1. ARROW DESCRIPTION I?SION Iust nDG$?_._ IE Tic--t'C1C_L Pa?ownc E5 oaccAv7tr2tD VALk F ik` F ltd 4 - _ j - ? Stc ? ??L p 4e f - ' ?F { - . 6 ,7 fir- , •. , bt ucl oT A D? P_t?t1 _(4u 5ljt W o i 1 A'tLra ?`oe Zt) OSTiA7k GFV .._ w lI A& A I T l?'7 t ° ONS NAME, ADDRESSBI JURIES OFwnPERS w OCCUPANTS/WITNESSES "''43 'rp SAppi pNAI NAM1 INVO VED ° 5 • CODES S AGI 1 IAIU• - Z Y.1 'N ?' 3 Nr ,. , 5 6 R MS 1 1 CI , at ,a. ..'w ? 0' .. OW o5 •,- N r ? lwra _ .rN OV?Dnoa. ?A%s ?N:%'?'R ?R ? :° h ` ? W ---. 15 N- M 1 l. . . ;,a i Agwr53 v,°i?11Fr as 'N sgNrR. ?•M ?`."'?^,., ? : e ? " ?.•,. ?j p, ?r?{? F I?..?.N. a,.'IF S.ww a1.N. F ?oF A171 p .u c aKl .1R hD ru.1 ' A...ovFDn D+n I ? RRIK 'v=.?"I`.lt .Y. .I1 {a+r. :.?r* ,.. ;JR:. It 4 1.y}??5 y1 1FUiA n- 7w. 77T [n q? 7 q 1 1 MLI y r? L z? O STATE OF WA INGTON •GF l DE / "?R"R'"° " (? POLICE TRAFFIC COLLISION REPORT 21TRAFFICWAV nxKFCaxruiNrNw,ceel "n PRIVATE WAY DATtorca - ,,? u DAts .. ?. wv. • u ,lo rvH ?.. ID x.oo NOUeI 1.11 O7/O ? COU h E /? cm NO F q ?' pIH nrr oR rowN rNles p CIE ' WI(? tgs w R NAMvr. asIRFFTOerReHw,sr rci Rare ORST¢Ff wRAl 7 . p O Y31 Q ON [/iQll ItRRCDNG wrM SRfFT OR ROAD N E ??? ?V y 5 * I" NDIf IN1fR Cria N ?/S /?,S OA EN ??? ,n E /nRF KAf 1 ,JR , ? ? /Y`e fGCa Ta OSIAN(la DV MTyON et5 E.CROSSSTR ES f5r fPoS ACCIDENT N • t ? ^ ' yf ?• 'J•+? ?? I fEN °v OI ` MILEAGE ?rq r CODE 4 'y ? 'f CIXU'gN NVOtVFD v Ruv II.N NO RII[D?NO NA).I.- 0 ElnGf ?Hr6 RUN OI•l N0 bv(NKIf3 eROnOTV DAMAGE DNIV E SIIXFN wN? IN OBIlCr sr AND OVM[R'S NAMlI pnSU1TFD owl= 8 OaKGr SIP«RI f r O ? O15 l RFI q•,)pp pp R{EIgH(E l :eCtRSSiRFiORRpRD r' ( ? ?}?, ?"&i y . / ?? 1 r--' ? [SI. D.wAD[ SnCW COMW lEE ? _ _ TR - Nr NO. s DRNte sNwaE UNITNO. I NRSI ? VEHICLE ? PEDESTRIAN DRrveal's NAA,!? p PEDALCYCLIST S _ sTner AODRess Utt nFI AOOREU /7 SIATE nR OIX lv3 NC[NY r / Y I - _ ,hS • _ SIAIE Sr?-EZ a ?l9 ?as?R rvl t NO. D..' 1. MD ; AR W a a,e MD L ?fil « DN NAM[ yy^+? t"o. r s un reaHr E «cuRAnoN RM HAMla Rr,oNF w. Z CIY!/?I? LCI BfU ' , !ns w i KR r § : i ?Z G ?Ed R IV, ? CHECK (.7 v ? : ? _ IHK F •s N p CHECK (,l) Enrla'v T CODES ? * ] o1N1V •NS , A veNKIf ASwN MEgo e CODES ? ? ] <.v pAs r, a ;? Ix> nqH v `a , u Ri H MA,e I• ,c cr.ev r I IOAer wvAl O p A....,,o wb,Rt• c'S." I. O .^I ? °..w. E Ku -: •VR LI . r CORV) l I rrse RU 'All Ante I'All H veHe x° M •.r IIDENTUICATIDH fvO C ' HiUFI H 8 !2?SIS:R o'o'o:518121 L I I I' .Y.'r I I ! I I I I I nesnITITIO Nte Inr MIDpIF rfoEaHO ..• *CI ynV ` AnonuaoMmu W ( lr ti 4 ? ? r.u„ .....`.•r• vr.vrv,ySllJlyry: IV3151nlFWNN f IINQSSAa I ? v C?-Y' bPap ?c,,D ,ot?l- per' GP9.a?oL-_ ? / i3G!fil?!/seE ~?snUGOiJ?i 1 1- 1 2 1 3 1 4 -5 r X J, MVP k ?I ?a POLICE TRAFFIC COLLISION REPORT LA?TRAFFICWAV rol¢moAUwrvrNllMeta ' PRIVATE WAY _ ]I. +8 _o cow 1 j o I?: n Q?_ D 0, n:iAlq iwel u. IS•,. K i I uMf IUIID to RI to 40 courvrv SEFFrP5oti1 couNrr NO, arr no. .? rrtwA ou UqA ?N of Irv C1r [w 10Wrv NAMf6NO.Or Sratf109 WGNWAY R I gW1f STRff (p Mles 5 ?W RIDte )rnaeum ON Q£AVU2 VAL_LF- 9S1150 lqE¢, NC SMm vem oR ROwD Norv lmfgsealorv !!iW[FN ?2SON "-S REr S EM6&b/ rC!/-,L, Wfex III, Mlle rosr ('.Z0 7 1 rt DiSlwrvCt 6DRIMICX+PoMgFe[ FCgO]SS,Rt[IOR NtwRtSIM It ROS e Z IES E W itfl OE MILE Pas-r ?0 ACCIDENT MILEAGE CODE R DI qNA pA,A COIISgrvINVIXVfD fvlgnr: > 'T RUN O,AENO Oxll[D rvO. NrUVlO ?SVM1IAG[ ? Evmnls rx PR-Ty vMAGfONEr ?aiunm ??.'- N .aD IlrEq CLS I CI fEl OR RDAD Oa FIifRENO: [RO155,af[rOa ROAD n2- FO D - ' OB)fCl s,vlKx INAMI OI OBT[C1 S1RUCV AND OWNrRSNnMeI f51.DUAAGF SRfCIN CODING USt UNIT NO.I UNIT NO.4 VEHICLE 0PEDESTRIAN 0PEOALCYCLIST z' S DRlvigs NwMl: u.S V t" MI Dtt mE RT Z CTo2 A VIR Srv Sr fl F L lnl K\e- P ?- 51gEGADa I O P-ZAVe1Z vAlr 20, D 31.11 RL. 1°I o l w101LLb # 8? O Y lAif IIRCOCt ntlnlI No. 'Po2 WbLDW WA g631S X32-4L) R _ c r IAH -UElri a WA gE31o 37;7-gy51 12 'L , Iwrytq'$ uC(NY MtRTZVA s43NZ Srw,t WA . n IA o8 jog ILND I V Wt U rvO. UILLI-LOP 36L PF A,l Z D 1F tl n 10 IO(o ?loy wcugA MNwM[1 -1 NO ens enl HIGNI q E CKCURAI ON MNAM(A RMTNF NO . Wt GHI IfIGNi ?2 2 7 ?K ?3Ro Ib s? 0,K R pK DK Isss o ? CHECK (?J vFnlal AS.N No A r ? CHECK (.1) cD AS AN rMROVfr Al C:wN0lnro I '" NoR.rD_ CODES ?` ]? Ay r 6y,° IK s CODES?+ DPI 4 S ) 44 il:"' u b„ 0]"D_ . 2 IN,?aS oNE nLaur * Mao,p" o o L l t o Mk. ? ? --.'KI on" ? cg;". ? =X: s? p VIN rlAa ANA a tDOD(t Cntv.) 1978 Gmc_ Z--178 IIDARr NOVA) MIL IRDA CONV.I P,u. E n r w 1 nfv.I MOIXI IDARI NOVA, 10,-79 ?oDCe CoL-y t v.) ?J ryov. A IKf NS RE S,Af wllq RAl(rv0. s1w1t H nl. caoq a .? MaRooFl pS r6346 w h - - 7P? WQDog(n lJ/l `- N 5 < rVInIiCIKI Ip l NI rl;CAZrp1N 4rv0 181z51219.04161--I-- L 'fC1lt MIM1N2UI RG1311gtDOVAVIR -1 11951 MIDDY SAMZ R1S lANME O t I Eal fq. -1 1.- M1 SAME SArnF-- Z SAME E --I. SAME 2 RADDetss or lNwgwrvu co oq AClrvl rv p f-p CO I4JSokA0GE R No 7NSVRAN C T pyAAGI MIA N6 ' ^??°"" eNweel ??ou • a ... gAMAGr ARLA? CNA-Gr• 7tq S w ?o`N ! r " ] . wlsv 0 R1MA'NID ISiSrio? u1 Lloo 1oerDFr E ueACe to o lx? Aw^r ?REMAwtD rovrto f 1 000 ..Al 11Y DIAGRAM OF COLL ' ISION - F All oq L u , DESC RIP7 ION OF COLLISION. fuses Rr wsnll c rI ;? . _ tvtwdy - -Ii ) T_ • ? I I ? I ? ? ? ? ? -- I ? I Vui7eL.iE. ?`! NAS S8_?u 8u±v_cIt vAL.LE.? RD ? Sic_' AN TVANGj) RIGK1 1FYTa Nts fl(L\VE,uh? D .. , _ , ' _ 111 ?.. i uk , _ - VcNlcx-_?` 1 S Ses_. s arL._EicnvcR vnuGy Ru ! j c A 1 13 RCA(. STRVtK VCUTC4C ANU . .-{ ... ' . . ., __ .. WAS_ ALSv _ SS OIJ -BCA?/£R ,_. .."b ? j /r? ?_ ,sKIDE'-'-LsI- I, VAL.LLy 2DSl•.AutK VCNICLG. A IN. ..---- • Ly ! 7NL REAR - -' - - NAME, ADDRESSR INJURIES OF PERSONS I NVOLVED +CODES I - 2 3 5 6 OCCUPANTS/ WITNESSES N . , ' : -- "'cV N.MI ATR,L??? ? T?ct\ ;K, " (09?,-4oaq M ?. - ADM1]] 111-7 NE Ib7+h - S[ATT/ f "y?.r NoFJL a"e. MO•" e OfhIO " i:w ? SR _. - -. _ .. I1q pl . R SvvtDiq;rA Ai. u.,l • t01N - 411N1 pr 0- ? 0 q"oIZUnN y hl ,(?h11,. yhl a{?/ ^ „ 7Ar ? I l05 rn ? IDe A DA11 SO ? ` rOI 1f /^? E?R? I. rl. -T ..r._ SQ s I .-,. ... 1 J4 . . .. . [a 7 ;' j V 77 t' , WNW r, .xD z Df ? ATE OF WA INGTON Wt..At. No C t' POLICE TRAFFIC COLLISON REPORT ®TRAFFICWAY . rolxa coMVwNrN Itv' J '; -PRIVATE WAY A? au r?Mt - r- .. Nouvl YI INn.L o.I I f? f Ih O caunrr couNrr NO rr NO. OfuoeAN aU.. o ON Ol 0.N crrcerowN NxMlaNO asrvarov ltONwxv Mus S OW OF C,AI AW ON gej f. , 41-1-£ wcu; vswnce t uc aN rl iNnvxc_?NO MUN VVttrav voxD-q RSON KAKE QI? eeimtN '4vm a EMO Dy ?v N x fo Muvosr .. ,? P F ,r ? s ' 7 Des w t DP MNtl Y iv f <NO55 SrNltr N(Mitsr Mxl YOS N W . MILE tlfr Of MILE SST D vtv r. cau ACCIDENT MCIODEE ' M excexM wrA vx . srn l v t v n 5 .r -a 4 I ''' i 101AI -? IN uvm D O SV- O N a vuN roulra NotufD b r wNV :tDrNS t voADce vt fx cl iNrto a sD aosssratnov vow _ aver cas Q ®vvottvrr DxMACe o.n. 0Vl'-U ?s1atN __ - ) p =?E' oexcr uvucv,N.Mta oexcrxvuct xno owNees Nxxal tsr DNau;f sncw c owND UU " . _ ? .f w cat„' UNIT NO. UNIT NO.2 O VEHICLE O PEDESTRIAN O PEDALCYCLIST ! DvnlY-S NAMt Iwsr NY '?` NA65 EIJ W 11.-1-IAM M ?- NmNSNNAI: u5r i - 2 5 2 ACM v3v3 %,jcKL.I0 AILL- Kb rttfr WHM sun IIr CADI hgNttq. 51LV[JL'DAL f- wA OK _3( D IR i VAR w I mvalCINS IaAGCNwL 14200 R sun wa Y11 II A s% V N xn D N MD I Dr (. a 2 oc<wxsw.. M NxM .NONE No. tns is r NtN;Nr U5N fvVSf1 BRO Ilq S(0 E R occurxrwN NAME a NIpNf No. tns cNr fxwnr ( T n CHECK f.I, • w w? • w I.NG r? Cufr-r , n N ,wu Y :7 _N?`' ' S ? S ? K S e ` a a iA 0 %-1 0 M6 MID- ' ?' `S •fi NO ^11 9 I ' ZK IN Dll,\ -1 NO p '• ,Y { ` j1 p. Jr A i? e, to ?? f: t f ' n L ? I .ro e? : j 1'_ Ir .a ?ASxrw-t #?' S I O ` F rvuION TAT S A MOTOR VEHICLE COLLISION REPORT I «n. / C CITY °o "T LP NO 0F._ " le, En. ` - V11111 , N Q 9 0 d 3 2 ? : ° o.u ITFF bZ o. ?N ?E ?:N Oll I.." D, , Ae0 E 000E R R ? a ? ? „ oN =eDNDR C E N W °E< 3 3 ? R <R?^r,,R ?R?,° R IR,Ee,° -MET N, Oa,O8 I E_0 RDAD Dan,ND N,EPME,OR :-E, N. ...N°.,. E, 0 o ? r Et ? D:R Doun ,ERIALn R , eR,E , `P EOLL -0, I, E, DR R DR S5 « : o D, ER ; F ?aE;; o ?V.<< aOMY w°E.AL B.-Fwo .°° B:.oe^A?,IrE ,,E. , o ?7a"ao OBJECT STIR UCX T n,AU OWNER Oi OBJECTS N AME AND ADD RESS {?'"'"'EDp Ot, c ceDE usE PRE11,1111iiiiii EOCNODA/11A MIDDLE DRIVER'S LAST NAME FIRST NAME IF MORE 71M oIVED DRIVER'S LAST NAME FIRST NAME MIDDLE • 'I?E ,-?1? 1 S ,s 4 , !e-NE79j IN T.IS ? STREET ADDRESS R .TE NO. AND BO%NO. O PERSONS E STREET ADDRESS ROUTE NO. AND BOX NO. I .` CEPARA A CITY $TA E ZIPCO E DRIVERS OCCUPATION COLLISION CITY STATE ZIP CODE OFU E 5 OCCUPA TION /PEFi?-r EPOR DRIVERS LICENSE NO. STAT SEX DATE OF BIRTH AGE DRIVER'SLICENSE NO.. STATE SE% BIRTH AGE DAT cl E S? iz N 0? Z13 M F '' MD DAY YR VEHICLE Y1'. MARE (CMEV. DODGE) MDDEL INDVA-PART) B OY YLE (2 Dq.l 86 NEV CAInERAZ- CalLAE VEHICLE Yfl. MAKE ICMEV. DODGE) MODEL (N VA-DA T) BODY STYLE (2 DflJ LICENSE PLATE NO. STATE TRAILER PLATE NO. .STATE LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE 7 AHE VEHICLE IDENTIFICATION NO. VEHICLE IDENTIiICATION N0. !GlFP 7H4G? l!o/z. 0 REGISTERED OWNER(HST-fIRST•MIpOLE NAMEI DRIVERS LICENSE NO. REGISTERED OWNER (UST-FIRST-MIDDLE NAME) DRIVERS LICENSE NO. G,?r?s Tlrom?.s Nr OWNER'S ADDRESS IBTREET, CITY AND STATE) DATE F BIRTH OWNER'S ADDRESS (STREET, CITY AND STATE) DATE OF B RT H T?ONDfIL E 16ADU fk11F (010 ov ?? R PARTS OF VEHICLE OAMAOED All N" o r o PARTS OF VEHICLE DAMAGED _ _ {IPAw III? &i*,o E e s LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- WAS THERE AUTOMOBILE LIABILITY INSURANCE DYES ?NO COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPANY N , D,Y ` ? Aec.r D EaR /?IC ? =N COOL l 1) S 6to AN NAME AND ADDRESS OF LI -'TY INSURANCE AGENT OILY aIA,E ZIP LIABILITY POLICY NUMBER 14o in Sm17-H P.o ND. 9 6P o 804 1ST INJURY - C AGpE ]NOINJURY USE SEPARATE REPORT FOR AO ll RESI AGE M 116 J ?V IN UIRED T NAME ADDRESS 1 ' - M F ADDRESS E MF NATURE AND EXTENT OF INJUPIES / I?TI "-` ? I NATURE AND EXTENT OF INJURIES ? ? DID INJIIHIES REOUIP[ E.A. NATION DY A DOCTOR, O DOCTORS NA/F J31 NAME h DID INJUR INJURIES REOUIPE Oa OOCTOflS EXAMINATION BY A DOCTOR> NAME STATUS OF INJII-M MA FIRST ONE THAT APPLIE S STATUS OF INJURED MAPIX FIRST ONE THAT APPLIES DtEM_ 1 Y HI L n P.. NO D_,in° wR D:s,N •G P FILLED I:."«L ?4 tea, ro...p l ? M,r,x HI L pa,Ot uO AOH.D?S.E, x0 rosam q EDeN. ? , ? XRLED , ,;;«( ?? ??; ?DEC,A '4, 1 i na ?HDEF?AN ?:,,r.,. R'..,1 :'. ? 5 ? 6 ? NO ir, ?rEDIaNN,N rA 7 ? 7cl ? Ol?rl 1, v.RI,I I.: ? 5 ? 6 ? MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SHOPNORTH BVAI IN CIPLIE S.T.• OESCP BE BELOW WHAT IN PPCNED.IREFERTOVEHICLESBYN MEI Pn.AiHArNAto ?.eCIF O 1 Hu[?F fOW CW.P•t 1 yr ._ ... .. ^. _..- _ _. _ _ _. _ _. ? _._ ____ ) 9 AS 06 & °^ O •:u u)A .-Teo1upp4, C6#7 Ily ,F N..,AE. •p; L.ERV/NG.fASSHOPRrT? P.OG. Rai _OIL7 ./N.FRDA/T_UFO)t _ .. --- ) IB-SAKEI?.tFND./L1 L?--C/}2WEN7./NTQ_. -. ___ ? t. vt , /O?EWifNTNE_kEAee.dFA1 CAE ..... -__- y 71 ST. f , =RONDAL E' MJ VEHICLES POSITIONS BEFORE COLLISION WVCsNOAIEDOY 'IRE E _IF :_I El I A?, 4. p I 1 I Y5 ? ' M1 H - C5; YY ? ynY ?I 1 11 ?t. M r t Ar N . ' a ? ?? I4 _ ,. e ikt t . 1 q ??Yk P OLICE TRAFFIC CCrAI0N REPORT ® TRAFFICWAY ?7 III iJ U 6 4 2 L 101 IM Nr NUmBFv ED PRIVATE WAY . o {orcau . court 'w p ... !u, Iu?F Imt c1 ' ; .« la crtr No 6 (// pN pf p DI IGV IO^wINI F ND GSrvtlr Oe wGnwwr 1[s s pw Gr (]7vi ON L? wnesrcr NC wln s =xnroe w.° NoN iN a nwN ROUrt OR Sr ? 9•Y/50 Cr RA « ? D sl.NCe aD et r eFIwR (?a Dam _ 1 v{ItvF t CvOS151R!{ o rl. mxe POlr?.?O RNUR{ A CIDFNT 3 Mx[5 1{r p MI{EAGE .3 N 5 [ so r? L,LI ?D. w CODE R P .m D,I, cw15KN N .L Vt hrr. 71 Oro.10 NO hll{D?NO INIUR[D ?SPrII.G[ ?nrra 4UN f . R-R N INF 900.0 pR VtrFRIKt RS I Z a Vln Cl 0PRO -D4m.G10NlY ?pR,w1r[D ?vFp[t[ o.xGr SrRUC[IN.m[GOeltGr v uc[.no OwNFR SN.mH 7 Cl5 Cvp1}Slq[r OR q.p •50300 = {saL,.o?,.ft snow-DR-US[ UNIT NO. I UNIT NO. Z p VEHICLE p PEDESTRIAN PEDlLLCYCLIST s s Do Nes NNAI meow DRrvtR'SN.v,.t ? srtttl.We155 ?? [/? ?J vttr /.pDRt3s /1 '?/ c"l n surf :?.c G .noN{ D I r set Z ,SICFNYNO v ?/ { N P A n IKeNL w .R tw ei n i9r?s?n2sA_ Sow 9 z? I!;/,fb V - - ac rKN a °Nt^ Z ? s c«r a Gnr E Dcc-11- =!'f7p? s m1 IarGnl z 770'?'?7S 2U?fSf/--1T. S /z R l0ftA -E91'TNC . p CHECK (? Nn.siNU by .NOlnl.' C CU p HECK( I I R p?1 r^ t.S.N lm Orrr OI.NOrI.{ , .(II NnC Z IN CODES` ] it , N' D a• 5 I c ro p o CODE ? S * ] u' ,° 5 r,owN A y Ow lDeos ? otl?R« DR ^°"? c« ro l ":t: o . mm.Ml o ? arn. ? =X; p M. ? a x. :K1 ? :s? c .1 IDOOf Cnivl {1 NO ? u w V,I - (, Wvl vl Mog11D vw, I , 77 Td a. ?o/en. E '? }?{71A7 z /i I D " KI h. 3r R N n ? 3r.r FI N 11eMrtNO I [[R$E?[l?? _- --II ?X ge Vy/I7 NNKIFIgMIIK.rrON NO C R 1F wNli i EI 1 1 IS I I I I I I I L nl i hD.V.? I I I I I nGrf R.IDOwMP Wr IrRlr MrDwl AIpM NO r RD 1 .DOnfs / ?Er Z v owN.R y{ N Nwla.DOnfsv ..NClco a E DA«.cl. r R Z R cN..q D,...w S ..u M.RG i 'i a 1>I DAm.G r,r ' Or ?.ImANID l rnw R«c ISr D l ? ?w:: ImmmD S ?:+°er DIA a GRAM Oi COllIS10N NI N.«N. r, I - i 1. NlGss hi .. i:?v.owlN #? X190 -ey- el? RvIYE ?VActr ,Pa 6+61 IowRD eC ? w.r ar t??, DESCRIPTION OF COt ISION IusE3anem{Nru t I a3w. _ U?cl---AJOkrE1:b;JAVi?:.I-l-, ? i I t *z -1U0 .vA-40 9r, - e GUS S Nyy O *Z.: b ?A'Ttl ? 9:40 -7- , IL ? Ue'tIQT?_?jN NAME. ADDRESS IT INJURIES OF PE ONS OCCUPANTS /WITNESSES IN L D x 3 6 E 1 Z N.«I ?? -- r.IUS r« MIC.' 1 1'?r ., X11. {xCl r. N «I ua v v' p.«e ? «.yr p..,r p r.w p. (ryL OH D.. D.II M" C I.1 xk' ..e Y 4&w' ' EI i ?4R!asYk?Yl".We4?n'?tJ'?M1tTh...n? : ... T,?iy :E ? R 4? 1 E1? ;r ??W??k66AA77TTT" r obi .fin II POLICE TRAFFIC COLLISION REPORT p1lRArrlcv?Ar lout! camn,um NU uR _ PRIVATE WAY t _pw,F???{{`C`yqr??J?j ., ,L N VTi10 W ;i :IwlD. r.un .-'u?. I ??'UUU555 n /q? TT ` Vf vEyJ? ? COUNI - J?GN-•?_ CvuNY ? CIn NO. Envn °UURAI Y09 !OWN 6N0 Oi 51?Fft?` GnW ?N DF ? mus 's ?w or m ON NAM[?1ZY ?_1 rC1.Cl5 _ I 1 OR 51 fl - S0 L Ivlf S[C,rNG wUrv 5,4([, O4 w0 Nit .A B[IWE[ 14HT S,Rftl Y4(il% t MIlE W51 V/j? • l rI / a to 60vt GN IP R[ CR0555,41,1 Fyl E, L NDl -ILE;E N AGE i M CODE 4 DUG-DATA CGIISIOIINV.VFD NtV rtY /1 n,6RUN ,GAL NO O .LLED_J -N- N1U41O e'-) ? SvRI+GF ? 0 V1.1I[S M4tY DAMAGE-11 ? p113 l,[D ?VFIXCIF NuNdlDirr tN IMf CLS C 410"' [O ROHR ?'?? ? D 5 OBIlC15,4UC41NANl Oi ODI[CI S,U AND 0wNt45 NAME) [S, 1 AM11 S SrfCW CODING IE! UNIT NO.1 UNIT NO.2 %VEHICLE ?PEDESTRIAN ?PEDALCYCLIST F' rvtvSN+mE wl N451 "IDle .. rzi o 15 O4rv14'S NNAF S, a LL ?1 L? L / - ° 51 [f,A D 55 vc?L F[ ADDRESS 1?6 .rvGNzy 23 R ?ls 4 85 0 r O Slmk d% I ICt N. NO DA,FP BIRIn OCCWANON I 'll .I 6" N, NO. Ens IGn, H , E OCCUYANON MNAml I"", NO. [n5 WlIGNT NIGni ?! s R 81 ?CHECK (?) ?vt."MMAN rho A CHECK (VI, v"f1FASANDNnov[i GAr o,N[eAl 1 5 l e CODES ? ` 7c" • ° CODES ? i 7 "; • ° S IA e y - ST Uv RS C 5 M ? ANN .rv41 0 ? gym. o a rs K y;t ? m N .„ t o W, ? M",, ? ;o " 'l _ nn HAR tIDGDGLrvlV.1 l,D TIgVA) Slrtfl CONV.1 E n[V.) A'OIXIID"' - 17 v r R `V I?IIV Y V1 l -7 ufN vAl AneRnA,e ND. s,+u H weao4 A n'FI N. / 3t?F c VlniCll IXMiNCAI TKI L A vlrv Clf IXNN d r IZI D J I 1 ?I 4ro?snnoowNt4 wl rmv mma[ --NO O rs Rfu wRRe4 wl n4s ?Dae D AODVI55 G OwNlt N A OvA E ? ????? ?• y un °A00415sb rNiO•ANCl C. __N, R L"60v AGLN 1WTON D•MAGD MIA 4 , • "_ ?torv gAMAGD MtA CHARGF 1] mAGI iwYW.i Q RFmA Nm M RIVl 131 DAM1 °'._ S 4muwD OY ?DAwArH . -Al lY DIAGRAMOF COLLISION - - E EuRx N Nev?o'o"O°w ° DE RPTION OF COIII ION. IViF SU•neAnN,4s s5AVr1 i- zl?!Io?k ?ry_ T I f -,- rr "- / X146 7a ?-m --+--T ® 1 , ? 53-5-41 ' v L _ ? p,- -- - - e_ TIFF, .16T/5?ttti'' f,5 tYZ ?/T?U ? ,rJ.aL. . ,..., 1 T ._ l I o I a _W. _?i? 1"FaJeN?i T?STaP r_ IM 00,6 4.WA . .. _ ? _ J ._ . - NAME, ADDRESS & INJURIESOF PER INVOLVED 4 CODES 1 - 2 J 4 5 6 OCCUPANTS / WITNESSES -1 i.wi "X' "iS is I. .....c' i:'n• - -. .. N+tO41 (N - rN(rvlD ivW „N nrn •p Z", N i Lx E y1 owlH R IYE Li r 4 rv F r?. s? F°u ?F' "ki 8 . "Zo EEr\7ow" ???P.+++G777I I OF I TRAFFICWAY No. 0 4 0 1 3 0 Z • POLICE TRAFFIC COLLI. REPORT N IOIKm Numxe - ' PRIVATE WAY b ?2&ToN F counrr _u.Facal hh $a R; w ., w Iy5(2O?sa CSC V COIMir NO nrr NO 1 w ?rNw Z Cn+09 TOWN f NO p e N 19 1 9V9N t si l1109M ?N ?F ?IN ?? w !s s ? W or L?f?t/H/?UlC N RW1f 0!11/5 '7 (? nI1RYCI1NG Ynin Siel[I OR ROwD MXI Mf9y5l C-IKW? ??? ?? 0lIWfINOYC? 519[11 M !O MRF ROlI S ? O TLTFTI-+ / P DISIwNCl aD PIROM-1 C9055 9( F. 5I9( OR NlwR15IMl FKIS ACCIDENT I Ma(5 5 ! MILEAGE r1fl a L k7 -9W CODE R DI w.M pwrw , 0.11-11 wxvm ?''I vvtvn.. NlavuN IO1N OF NO ti..I NO aDIID_NO INIURID_ ?YRIwGf ? VInKl15 eeOR9rv DwMwGl ONLY ? 9l SUIilO 05?b1N INTIFF ID Mf CIS OSSftOV ep.p9 ?'aftR(NCF CP"' SIe( .Vold OaACISMUCa INwM(OF DBI CI SI9VCa H.D NH'S NNn[I [Si.DNnAG! _ S SRCW COMNG Ib! UNIT NO. I UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 3 pRW1R'3 NwM! Sr MiDIX TSAz I?,??r L. DRN1R'SNNnt USI ??? - z S(RHNaN33 Ivor wDD9F53 ,I.ODy? IN U1• D .1 3 T.`r3•cc?i17S?JA •1 09MIe1VCtN5t NO z SDP SINI x i N . na ibA i' V i a U n(N ••- wt lx ?! n «5yvN1oN 9noNe s MNw+y.y ' . CH CK Iwl Mani E oc-11- M NAV1 a vr1o.11 NO (ns Ierll Mlw(I HEC ? C s:N ror.NOIMVN K(/) ? CHECK M nla•NOIMawI w CODES 1. 3° f° s! e u CODES ?' 3 c', f s s u a 3'°.w z wwas ? H Mr N rlsq Mk CMV l ?bn. ?N:K° l IDwRrnOVN -.1 ONV I ( ? ?Si. ? Y 1 Mil MOCtI IDAR1 Vwl ?r°D aNi) ' ' ? Uyy E Te 0 " n IIaNV . Nl wl uwwie NO s1Nl H n N oa w R4 Z7 w I C NNK 1 IKAIKN NO 3 i l l oiS L v1n1 IIIIXN l w TI 1 nenn.lDOVmly IMi sI MID(x! waNF NO -TS0 go-7-w, O R I n !D Wri IASI nesl Mlrou wDDnua oW.aa W N w My 6 E NwMF aw9Dn .wNCI<o awNi ' R WWK DM(A Syny Vxioor b CNNW CnwaW R== I r;AMM.Ca.SRfA o I31 D9Mw01 N N ? MMMD ? wWw+ ?MMNMIF 91M ICIGIIOi? S f I-D A r/ AW.Y ` ? IOW1DaY A F - a DIAG -- RAM O F COLL -- ISION: - N3 LVffY l415Ui1 _ fl -- IS. Nbc nNOaiN DESCRIPTION OF COLLISION: lust Sl/(I(wN sMnlrMaSW+I ROW .. I.ri7r?- { -}} -- 774 ua ? ? iv 1l 4 o z ' - 4E-- J ,-. sT 0 r o-tom ) a f I -f - ri - -_1 I t t i - . NAME, ADDRESS 8 INJURIES OF PERSONS INVOLV 'CODES 1 - Z 3 5 6 OCCUPANTS/ WITNESSES ?a se'?D^„'o"'„"N? sA Au uro R1VfN Y.r -ql MS R l1fCl 11? i1o ` • N w(a N,v i iM . .we OFi1" O" 0 72, ME- FD / A ds sosB - " ll A ? oF.9.? ??;I? .. .Ma DM. O w .w ? X w I ..I.,ca1aM.....1 a.. N. ?f, L.yDCI Or wN?(A. ??((,/?.(.??{f'l'?? MEND D .vwbvlDa wn I R'. M y s ty !S:If., G my ? ?e rr,?»t??`4?`dflth :IBS 21A IM Q I I r PRIVATE WAY D.r(DI COIF D r? tiMt couNn , .. . . . - /i cvEx+rr w? I i _- I •?o iw i 'u. ID3E ].OO,gURI ??C c1'LJ ? nn w. pEMVA y px p c Y-M rover. EaE+o auxHOVfwnwnr fcr s R11xµ .5 Eps ?w or 9b?oc.G? ON H xctlr.c r uvl[ ov voAO r,oM mnvuctror. noun ov rHE ly/o cr s L?/uE/L fwf eerwerr?" 9 ?F?"?u ! ` rosr ? . ama .g? cr/ a rv[er 03ru,C[aDa H>H voM ttnM EcG0533rR{F Da Ntwv[3r Mxe .S? ' / F ACCIDENT auM M Es s w T / / G 11[r « .? ?TLJ MILEAGE S/ pD c verve w H «ragnlr,votvtD v[vnr oruw fa anuo_no u,uveD? ?vuwc[ ?xra vu. w..vnoo.s r" IHr[ avwnes ? p cii onsssremc. vnvo vowae POEOr{E fn .DDnvtraw.c[awr ?aiwEno ?viau ? aexcrsty«vIxAMEa oaxcl uvucs ,vE,DOVmEVSwwE ? I' I _ esr oi.w[ srtcwcooa.¢ 9 u;E 7 UNIT NO,I NITN0.4 VEHICLE Dvwu U _ swwt ?r ,a„ M ? ?eElx sTR IAi? alsr x snAM x5r ? ? stnErnoovEss 2 tneH,.novEss _- :I. EDDE xD D r 3ret[ - R DeNte3 DC1Nx /r 3ratE rD . , r rVS ( ME NO ar OrN r, - «cw.t vM.+.we a Enw,t w. ens I x+n Irelwr E ...•rroN i i 2 rM AME a Mq.e No Ens c e c R ' ? CHECK" vrfl ,r A wv uwNr ?.3r+Onxv? ? CHECK (n i . CODES W 3 ?. S r w'.M ,w s /boas AGE •cr _ a =7.o' v.xKtr ASxr. tMr on[o rfav ? ..E",.., ?oc.DE CODES ? * 3 ?, 3 ucror. y a w x. . .,t s- o G a 2v n l.. I ,. C rM ?n.KU vr ,ID•vl.wvI snu °'^` ? uw,. aov convl yD"° ? ^.?+u.r+ ? u: ' ?n?.iu ?u::u nr I I . ? ?` ? hy_ ?j /E/ rlw urr f nv y E l Me . µ 1Q an nwn no S G/ - v.n _ H ax C a ` k ?i nxKUlw•rxww 4111 C / O / 3v i „ I Ia rxI o q Z 4 nasnnoovnxa usr sr Dpi mo re uo ?n wsr l ] l : "m .o9,.J`". Vt, i . gyn .... A ?, i r ..?RYeiy ?''AA 44f ?rve nYS??`np n P?. T a? n CODES 1 - Z 3 S b E5-:;.? ?,' 0.11 00 ON El a- 4 j y- iL4.y ' ...-. POLICE TRAFFIC COLLISION REPORT ??? 9uvz.?,_al".. ?'?"?? '?'1°''"'` ? ? ,•^= T/? R IO. J O . O / TRAFFICIVAY [O, ee eOMRA Nr NuMBEV N .. ?ry va'a'kPRIVATE WAY o•rF Orcqus t couwrr ?N ?1 ?IN Z Q •vn3 ?w Dr Iw (9kC,ING Wlrw 3r9t[rOe [O,D Clrrw rOwN AMl.N0 p3r9ftr GHW,r eNTm,4p?,>M oN ? (?q?, NONINI[43tCIlON C,3 eU4At 400rf09 [ D S Stn fN [ rl t0 mll[WS1 I ,NCFt tM^ON 19pM el a 3 t l.?90333r9{[104 NFA9lSI MIIt 6 1 3 Q ACCIDENT MI r m OIAG4AM D•!A CIXII ION IN IEA E CODE ' VIXVID vt41,r bA, nrO NO [ItlF0? D, VfwlCll3 ?P90n4rr , N01NAJ.ID? ?-IAGt 21!! puA,G[ONIr Q ? w s W 1 11 R::: x' K fl WMO4grF91KF I cR CN()SR {[EppR Ira ?FFf IrlO Uv C A Do Rs --AE T_E bynecysr9D 9 oe r c sr D•MAGt S? srtc A c G1 ?Q? ' ( l owNC s UNIT NO.I UNIT N0 s wwtv' 2 ?VEHI s NAMF ?, rks' M . t D-I..iaM'T' CIE ?PEDfSTRIAN us, ? GEDALCYCLIST s. G?Ge vem ADDVlu v ' 24 I .11- Y. ?GJ ? ? WAIT N2EiL7TLE _ 1 . 6 s Are ' n! '3OCINY NO R 39 u?t 'YJ+ I FNU NO s 8 ?di V A x w. be w MD 19[.... e a??J?^AnoN nvm NUnlafwow NO . fns Iew, new, E aeu9AnoN r wm NAmta9rloNe NO IT A, AN (IR ECK = A, - , 3 IT i i f I. .. ` T STITI .t? Fly, 5 1 NT- -TY IC c k'? J r , l u 1 d r ? a r +??'f: f r a o- a rT?} E tfi ? J IumAGlo.ru OD n om C]' ew,9b „r! g,wreouu 3 {s pmAb WN oD9 ;k? gelMUNfO ?D IvtN ?.{m4Nt s D•M,we D S Ar S •w•r ?:°?Dfr R, -, R,AMOFCOLLISION a I'M .11 cqn w f +4-- I "I1TvrSe1, ss.,.n l._ er,[e4ow UESCRIPTIONOF COLLISION IusFSwnmlNru sl.noraasw.r i ? I UCThQCE'?? ___ ?rX?IKf I I I I T??rGA?t11.E???v? of ____ 3 77T-, -77i 777 I ?I_I RfJ?do 1 T J .. f f i C 11,4 .3 _ sriee . ?.tB3( - -- ?I f Q?vrraG? "Mme qViR/?,es ? ?SJ ?Bw c a ? ' , 7 ED q { ?P31 1Vt? 1?r ?, ; i j G2J 3{t: /?SGN?/ u S LO.S?iI?-,y/?,ve /•u ? ? rlQCr? 1 + b i4ai f.CGasl?/.u! /.t?1??71?i A NAME, ADDRESS 8 INJURIES OF PERSONS OCCUPAN TS/WITNESSES n:oo^ I M I„' ;w INVOLVED i? CODES I 2 J S 6 . . . - , O , ,, wr R[' N v. •oi i^ wwM eiio iMa m 4 ' )) N.rlMlb - IT f,NJVtOlepm ?qMe ON[cl? o Mw. ?^ X o D o.? IR M R51E5' V11,7 .a., , M. e' La I; / ! f9 Y Iba r? laif? cRJ+ f r ! C r tij,?{ ? 1 r I r , V ??y??{ ? , ' r , yJ) I I° b' &e-p, ry q r x U', '- `W h + r 4i a :'IS@ ¢Wi 1 Y f. ,,h?" t? j $. 1 r nh y ? ? q f " ? Gf.) { 1' ry 4 ? t' h,?1 r ? 4' Yx ?aa MOTOfl VEHICLE COLLISION REP RT "' COUNTY CITY AI No No loll uson „. oA. o. wu van B A4n 4oN r4[F wED InNP 1 1.'w.. ;ES" ? ; nrp q 7 7 2 e e :w . ? ?n ?E ? oxr x EAno rn[n own ?ryJ w % c.s uu r?s c ou ax srx " "2?oE ?w?or(Z} , t ON G GL i oLx?o 11 4 Erosl 6•.- N ? ? 1 ` unC?h iir?oi'1 lrryuo InrExsECnOn HII Or •' r' uP Ouw40ArA Or"[11 " Nc[o CNo Ernk FiUaluinoA F vE El N2LI11" x E ) v cl 114911 u n F.CT STRU K Ear OINNER OF OBJECTS NAME AND ADDRESS tBrAirNAO Ec c00E usE ' ??C9? _ S IS?IL $ DRIVER'S EAST NAME FIRST NAME MIDDLE vOLVEn DRIVER'S LAST NAME .FIRST NAME MIDDLE MQ c Ulo...DI gEEr ADORES 1GD' rL NO. AND BOX NO. E STREET ADDRESS ROUTE NO. AND BOX NO. 'NI 1.%L?yl i '1 STATE Z(I,P CODE DRIVERS OCCUPATION CNY STATE 21P CODE DRIVERS OCCUPATION C O LA I V DRIVERSLICENSE NO. STATE B 1 DATEOFBIRTH y AGE DRIVER'S LICENSE NO. STATE SEX DATEOF BIRTH AGE VEHICLE R. MA E ICHEV, 0 OEI ODEL (NOVA-O RTI B IYLE (X DR.1 S VEHICLE YR. MAKE (CHEV. DODGE) MODEL (NOVA-DART) BOGY STYLE (2 Ofl.l '' LICENSE PLATE NO. ^^STATE TgABER ATE NO. 5? l STATE LICENSE PLATE ND. STATE TRAILERPLATENO. STATE No VEHICLE IDENTIFICATION N0 . VEHICLE IDENTIFICATION NO. A? S' •Jj REGISTERED OWNER(L Si-FIRST-AHDDL A E) OR ER' LICENSE NO. REGISTERED OWNER (LAST-FIRST-MIDDLE NAME) ORIIERS LICENSE NO. iL 1 ^ ERs ADD E' q]R ET. CITY ANDST=EI DATE OF BIRTH,' <?NER'S ADDRESS (STREET, CITY AND STATE) DATE OF BIRTH ` PARTS OF VEHICLE DAMAGED ?30n ig? siCx? - k1'ErAwvw..u o°O PARTS OF VEHICLE DAMAGED 1 nkl? n v lc? ' Tu $ -- LIABILITY INSURANCE INFORMATION-VEHICLE NO I- AS THERE AUTOMOBILE LIABILITY INSURANCE fIA.?y?/(1I COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR r \ YES ? NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPANY 4 Klj mrrX(?JII?,L?hON EIil,nniSa1 ??:nd•_id'1i?ASh 1?I?La? W ytc1a1?s N DRESS OF ME AND AD LIABILITY INSURE CE A NT TAE TIP LIABIL POL L NUM ER o kg Les H _ ?/. IsT INJURY NAME AGE OTA IN 1NDI JURY IusE SEPANATE KEPOAT FOA AD01T10nA;In1UBESI L NAA.E AGE ADDRESS M F ?BORESS E NATURE AND EXTENT OF INJURIES ? ? K F M NATURE AND EXTENT OF INJUnIES ? ? EXAMINATION BYOA IDOCIOHP ?'? NAMEORS r EXAM1NNATONBYOA IO OCTOR.?n?' NAME ORS STATU9 OF INJURED ? w IN VEHICLE KILLED MARK FIRST ?s ni rr ,uvixe.l ONE THAT APP o vlu iuiwW, LIES w sibr ur?A 0 STATUS OF INJURED o MI L ? KILLED MARK FIRST O ?5 b.ix Ifev[i1[i NE THAT APPL O s.u[ IMirvoni IES 0 ann ' ur? xl ' ` x Or[ NO ,. O nsra?ti . ? 5 ? 60 r ; ?r[ N EI 1 n m?ti,..,? „ ? 51-1 5 ? ^ 0c o .7 MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SHOW NORTH BY ARROW N L IICLE x °? _, ».. x•41X 14w DESCRIBE BELOW WHAT HAPPENED. (REFER TO VEHICLES aY NUMBER) 1 .. .. to CIRf w'n .._?IEIi?CIf' ItiD. I c? wEsf 0n crap e_UJR eo%mA l em auf c1? t11? CC2 1e` , a;?x:"i?.- ,d [roan Qe-f F 1'S h -ICI rUK Cx OU. /OCR E 'E a nd /- P nd e.cf r'n I I ve &k; tt t ^ ? a clIn f a' stun J'xs?1 S c,l/+s ' ? V ? 'r I t f ` y - _ I? u .. } CL I J Q JCLI E o 17f 1 /l .S FR )I& /Z Qt /l ? i ? ] E 7 _ L tr i rn 3 7 4 . VEHICLES POSITIONS BEFO RE COLLISION .• Bw Lx[s .oxnL YDxc,[ br.xMO wA. rovesnGATEO Br -' YE E l N !i E W ouAl I ? ? ? ON STREET OR HIGHWAY NAM[ OR NO ` onl lax [c '?1.E ?"R 'H E' ANO HO rr 11o HeE AINO vE??EOt? Es Ono 0 11 ?S 1? 1 ?PM Ca I SA-J. ' ," x T ? • , ? 11 ? ? µ 0N0 FNOM TO PEDESTRIANIPEDALCYCLIST WAS USING ?A,P 10n.. 10.11.111- •??? '?i-.il .?Br ,?t, ?nn PEDESTRIAN/PEDAL CYCLIST CLOTHING COLOR ?,... 1111.,1.r . 111 41 u . 0.1 1:11- s?+ xl' 1no x1l1:11- on n r•IC 1 n ,rr r. ROAD SURFACE WEAINER LIGHT CONDITIONS _ TRAFFIC CONTROL TYPE OF ROAD ORIVERNEHICLE ACTIONS Wn•.ucnr ,cxlc. oaF1 ;'• ? 1 I ?c ?? I1 n > •1' xm.[ alna n.n cx 4cml ? ? I ?rOAV 1 ;??rO Ml? J ?DAWN ? 5111-IS O 1 I O O ONE WAY 4J1 I IJ1 1 O GOING W.AIGN, AHEAD ---••• YYY I ? xbN• . ? UUS" ? : ? 1104 S10N / . I ? I -Al ? r ? -)III a N. ANO PASSnm [) : ? wr r J ? wa LNG ? 11 it o E' ? J E] n.o smN ? J ? nlo:onslmE ? J 11 DAKINO R1onr runty El ? s sNOw Ar? I 4 ?IC( E ?rp0 ouuyllru s ?HOUIS OIr ? ' ? gASnINO RIO n rruur.nnr ? ' ?I109P.NAmy ? ' ? WKINO I[Ir 1UAH . f ?°IIUIT A ?Ytnl E'1'UGnrs ? s ? RA51-G ALBIN ? S ? All[Y ? y ? uAAMD U.runN ?A?'Wc Ir r ?°nici. ? L ?Nn1 1 ? ° ?itriw1M ? n ?SD.- ROAOWAYDEWUDILR RO ADWAY SURFAC}}E11,,TYPE ? 1 ?OIYICIYITABMAn ? I ?UNIVIWAY ? F ?SIOPPEO run T.-R; ? n n LI •• n E]- 'N R? ' nn... 1' ? E ? f 1 rR SPE(11 ROAD REPARATION ? I ?IVOIO ? E ? 410P1•[n AT 'I NAL nRroPBGN ? E ? TOPPED IN ROADWAY 0 0 ='. ,v H ND G Fr k 1P;cv1*J ?N fly r` C'. I1 . J °6 a yp?9 f e-? ?f POLICE TRAFFIC COLLISION REPORT ILV TRAFFICW3.Y 5 rolKECOAIBNMNUAI . PRIVATE WAY y _ _D?r ! dU.A.. N _ _ l Dmf couNrv 12 I r0? M) of nlq "JrE ??-Ty.? IUSE a40D HOV41 G 1235 EG E 50 11 muNnpD. Irv NO. IA (/O ? uReAN AL IO ?N?E [:]IN -I TOWN NAM OOSIPEIONIGNWAY SFILES ?3 ®w 6a OC ON epui'P, )ZD ROO}OR 03304. ' iNTFRSfCIIN4 W In: yTRfft09 WAp NON NTHSfCI ON qRE E AVl[GOSE I(J l SIRFEI6 StgFft BftWFFN f / ?/ DIyTANCE60 PFM lFyI M4lVF4fN .CVOySyiRFfIOV NFARESr MILE q03 D ACCIDENT N s E w MILEAGE 1-1 OIA RAM MtA / . i? ?^AJ'tt] OF i[fI COD O LL IW _ / E CQLLl-NINVIXVED fRTY: O KIILEO No.N_ ?souAGE ? NI+gUN uI'3 TOIAI NO [?? ? w"° RROAppR HiCRfryIX %9D C65 INTEL ClS CRSIRfETOR POM ) 4 /E II .E O VFN CLf3 %?f ?RPoq[RIV DAMAGEONLY ? IIFD ? [ Clf OBJECi SroUCRIN FOf IfCi 31RUCa MJDOWNER 5 w1M[I F3r.D0.NAGEI / Y ' CDY SRCIN COOING TAE ... _ UNIT NO. 1 UNIT NO.2 Dq vlRSNM1t ASI ® VEHICLE ? PEDESTRIAN ? PEDALCYCLIST _?4 I NRSr MI Ol vF4$NAmf' NIT r ON O A TE25oN MICHELE 8L& SrREE DDRFyS E ffr+DORE55 R 2 I QI BI UDAP, / PO. 60K 153 STATE -co gNONENO. NA-DLO WA 95339 12 D ORNERS CEN5EN0 D R II STATE P E LOC14 A q9339 395 5132 J , 2 U 0 72N.T SIAM WA. s M RIB116 ( v Nf' I<EN ENO. AA5 MM334 PD AtE A A F OA}EwRIRIN l0 y ` I e OC-ATION M I.-NENO. (YES 14NT HIGNi E OCCURA(ION {IRM N-11 NONE NO. 385•S S ErfS d1IH14N[ - 2 E E ILO R WAITRESS ZII S (u 130 5LXo - °n ? CHECK (,A,) ofNCS[A i FMIM1V'rfdANOTNFR.AS C ODS a ? . ? s I erw ( 6 k1O, - .ys J' ? CHECK (.? I VEN CIE ASAN GIROVFF Oi ANUtNF9A e CODES ? ^'D .... 7 c"I +'mwv"' 2 s e. N a I ° s L L 1 S = y , ?° M ? ro8° ??8?1. ? „°„v ? vF rfAR MAR IDDI%,E <NEV.1 FL Ip ARNNDVA IT-11.1-IONVI yDrro,. ? .MN,I.NCe ? ? o. NO 171 M.6. IC R° IEA 0 Nv Ku ° elfev eNE LE 2-b E . 1 l MOCfl10ARI.NGVAI l l b Foo-Pu TK ,. ldNx qU yIATE RAIIfRIUrf NO SIATF 51? I?J239 WA - - H vkN CIXO4 t , W I 1P7330 WA - - 3 V{HCL[IOEMINGIIONNO. ( Ir121 I I I 511 191-311 L vF CIf IDENIi A I 151 RIG I 4 3 - - Rf SAME Eq RIYE21#} MIpOIE ONNG w ^M rERfDOWNESoNu 7ANlCE MIp% 385-5132 a- Appgessa OwNtR ?? E wfJeR -- (all t?tD? H'A•DLOCK A 98339 m' ? NAME IADORl3ygIN5URANC[CO OR AGENT SAFEC'O• E 1 • P T TCk, W END• R N STATE rAPA; L R .N DXXIDUJU I 77 ' _ V REIxsAKnowa AGtO AFlA Or Iuvcrovu CNARGt I O W CHARGE I to 1 ° r -? - 1 . ((?? W RrD. ,..., a lyl DAMw4[ ? °iEVN ?R[AWNFD LCL,°SWIVI AV ?GE EIT DAMAGE _ I?_ s Ocs ALL LITY W ? To te s2 ?? ° iv° le e w er DIAGRAM Of COLLISION Iu InDGrtNO4IN DESCRIPTIONOFCOLLISION IEntswnlm[Nr ISH[r INlCFSSARYI + T- r " vt er A4ROw Q?t 11EHI.c?E I tA4T(3??vNO,o?sFIDV?I?'Q? Ca?!e"?.. -i- r f I i I_ _? _}f ? ] ?. SIGNRU.ING Lt ft TD Z CRP55 RnAR 1L?( U? - ' - ?- " . ? ? _ - ? ? .. _ ____ _ f _ r ? f - - ' I I I I I- .,F?•SfgOUND_NESS.CD.a.N?72.RA ..y?(_CLE L?UY4IIE/ fr . _,_. CINTO RO/Y A•Y.-IN FRONT Of VEt+1G?L Z? ?cZ+? C `-1 4, - - NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED ' CODES I 2 D 4 5 6 ... OCCUPANTS/WITNESSES wDnfor'.:i NAM 'e V -styecti?rus 'w6°' uici :;,,Y. N +w. Si I DI NNE ZID - Io373 F 42 I - N o 8 3 , MI .; SRI GT 055 WEAD P ; ?+Me ? R1A' ?.R . (71 a rrs',,. _ >a TdlyrR5,NITA ' 3185 - 6254 " : 3 1 . AMI - uRI . IGVfO 4oM "° - , .. - • - : covrn _ .L .r of - w,v Q.Me ? ut' ? o:.. ? H2 ? ::' Y vnlc NEFIn++ a .,.. O4IO +uNCE uc ps am Iu KI vlo wlw IIggI Af w IDe D+n ? WTI X _c$Ek N T 0 cR 56 1A15/? 9 3 1>2?'?" I L?? 12 2• gS ,? -? _>L3_ yl , TS` MOTOfl VEHICLE COLLISION REPORT - -° la DDpN wt " AD "^' TY - u ? ws sp NnN E, N ; R SRI. Nn olEa dl S ? ° ° $ EAJ o a/ i ? b b 2 .= ?I nlr wN NNE.xo.1-1E1DR1° r ?" ?[ ?? TwYrenL/ ,..,. _. 111.19. Z. ? ON tai/?%/ on. ?..iJ.ii ?? ,,? [c ? Co96Go ? crwew,rN SrRFFron D ? RsF x xl - ?y»z ? eo ? ..,.. ,.uf PNor aOwnn rxlFxs[cr No [n Rx ooF, + 0?E xNtnoAn woss xo uurosron o[xr sr NOIANOMn VAT A .,FNS[DrDx tEtl O D Dl .. _. 'I v - cmubox nvo[vt° ?? ruEt nu• 1W:rADOq Wt[RIAU KWa tAAN•rogi•n of v[N ttF Su-- xo5 v[u,tRl A[ s S t-• ?nc F ?v? BCm B,,u 8?? x ! u c [u,l rv [xN lO SI-T t EIEPEpLROS9STREET ON POw x1 OWNER OF OBJECT A k OBJECT.ETfiULK S ME AND ADO_ RESS )ar w?? o .. n[A / a ' ' [c coot usF So ,. KAY.YiA . p 7Co bMC A T... TnWMi1 s rd. ! $7 '' • iMORE,NAN wuo[.v[p U A ? VOi MJTB Ai LTO NiNs coLL S ON oR MORE rNAN Two VT ID U (P HaN IJ Ap.T- ??, STREET,ADDRES6 .. ,. .,.:.. ROUTE NO.. AND BOX NO.. / HASoN IN A STREET ADDRESS.- _ ,. ROUTENO, MO BO NO. ? WA 5u-42Arc sEP: !7D t l ma f RD / _ J hs CITY STATE ZIP CODE. ?.. ?Ar .?s Lvod. wy4A DRIVERS OCCUPAT .LJLIIN.. CDLI s o CITY ZIP LODE _.. ) 9&JIPb',. lSAr /aWnrh D ERS OCCUPATION _.?._ . ^ .... OR1VER'SLIC SE NO, STATE SEX DATEOFBIRTH pGE O ' RIVER'SLICENSENO, STATE X DATE OF BIRTH PGE_ JONNSmF S?3 7N WJ-u it 'j . i5 47 3Y /0 Y F Mo. owr rR UDULN BD 90gSPIL" alnriy (.,yM Y VEHICLE YR. MAKE ICHEV. DODGE) MOOEL (N VA•DM 1, B DY STYLE IZ pH.l V EHICLE YR. MAKE ICJIEV. p000E1 NO L(NOVA-GMT) BODY STYLE (Z Oq.) _ )974 6snC T... TAUCY TL.[11 VA-. I97y C/teu, Y'I CAnN.o ?s[Kv LICENSE PLATE NO. STATE .. TRAILER PLAT O.. STATE LICENSE PLATE NO. STA TRAILER PLATE NO STATE ' a ?'i= v/3? LLAJM, N/6 rv/L - . VEHICLE IDENTIFICATION NO. VEHICLE IDENTIFICATION .- ,• ... _... ,- .. .. . 1J.T, REGISTERED OWNER (LAST-F T•MIDOLE NAME) ORIV? ICENSE N'O. ? REOISTE[ED OY(NEP 1-5 .. IR$T-MIDDLE NAME) DRIVERS LICENSE NO. .. . L6 CC /L /L ?1J ? CL. 1-? V?llbMDi. NOR ?. OWNER'S ADDRESS (STREET. CITY 7STATE). / ; S Y ? DATE OF BIRTH DAY YN OWNER'S ADDRESS IS- ET,CITYAND§1ATEJ.,, PATE OF pIRTM AY rn "o u[s no J %r AA AL, WASS ' " IUD b A. F ?D ?aL I I ,? E, PART90F VEHICLE pAM?GEp -. ?klww YlE4AP?.i?R PMTS OF VE LE OMIAOED - ,., ?- „-- . _; .,. , (ly o T?ots?r ro , ?. R ha R.o { Fn1,F 3E... P,A. s , . ,-. . _ Fet..a oJHbW. nit w-l _ LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- WAS THERE AUTOMOBILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ?NO • _PTA NAMEMQ//JARED$.Of.L1ABILITY'INSURANCEPOLIOT HOLDER.-:. ;..... .-_.,. .'::--...:_Ziv._• NAME-OFUABWTY-INBURANt"OMPMY AM[ ADglESa Cliv ETATE i ?."... .I- NAMEANG(IGGPESS OF LIAB!?ITY INSURANCP,AGENT.':-+,__....,.a.: GTL.:.I....uv....'a,c 0i?J5v...;._.:i .:ZIP..;....?LARJNT.T.E$LLScYNI/MBEq. ..-:i !'.'?. :w •.':•.i?.i:l 1STINJURY ApE ENO INJURY (USE eEPAPATE RFYOPifoRAODGIOxAt NNgIF91 AGE - 1. NAM ._ ..,.. .. TOTAL 0 NAME SEX. ADDRESS ?. - ' N Ap 5..0 NATURE AND M F M F EXTENT OF INJURIES ? ? EXTENT OF INJURIES ? ? vP. EX-NAT ON DID INJURIES BYOA IDOCTORT '?' ?w NAME AS EXAMN?TION BYDA IDOCTORn? O DOCTOR'S N .: - 'S ', 11ATUS OF INJURED MARKF1HSTONET'.HAT.APPLE$ yTAJJI Of INJURED .::. JMAR - $ -,,,- K.HR$T ONE THAT APPLJE9 l a ? IN. 1 ND vw rosin ?DRwFn txD KILLED urvr KILLED x[v[xi uxn• "urv ? r I" I ' I" .. AssewFx N NO. _ o17 CI 1 El ? 7 ? Oil [R WRITE Ill El 5 ? IN ? ??OTNIR WNNf N. B El B ? !\I MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SNOW NORTH B ARROW C ClE E IpE P P. PFTA VEHIC4. F93j B%L- ... -W -' ? ] wue t vM'UF uD Srgw ? r ? ? \ _ __ L 0 -- ------------ „ ... FPri ? NIi) ? /' / All ------- - ----- \ r L ` 1 s , Ep - 15 _ VEHICLES POSITIONS BEF ORE COLLISION null F ; HN,CLM .xAAlnw11 • INV[STIGATED BY - + ?6 VEHI lE N 5 E W ? ®? ? ON STREET OR HIGHWAY NAME OR NO. I/ J D. OeK% ?Nn A°i ? M ID w[ t;?r l& r i?[«CMN[D D ? ? ?:;'^p ?iplFCf ?:6K[ ?w ? 910 ? ? ° ? ? _ ? C) : . . ? ? ,IpN ?.AAN. ' ,t ` ?. ? ? a MO40 OL• FRDM TO _ , r •' PEOESTRIAWPEDAL CYCLIST WAS USING: 1 ? Fw 10--l 10 twy -1. 1 ?u u'i f ?am r ? a F ? nn 1:1 N• w n y t Lt! PEOESTRIAN/PEDAL CYCLIST CLOTHING COLOR ?o, ,?„r,,,, x. 1? ., •?ne .o Fo ALAI .?woi: ::•iuiiiir Y?nt' ) ' 1 ? ,,,,RW000RfAC[._ <.[wI W[ATNM1. LIyTT,OpN01TI0NS- TRMFIC CONTROL„ -._ TYPEDLA PAD . _ ORIV yyyeHILLE eTioIS " -:, '' L '_? r Iy Y ,-' F .? v^,/,f S+F ?' K T :.1 Ia '1?(u? '? " sf•xui 1 ?I' ? DAY E n W[T ? I ? ?1 xcp5M I ? MIN?W 1 (2- I ? (Mrua,/ F ? BAWN S ? oU5% ET .r [..[. wN ?I 1M ? LM:NwL3 c] J ? S10P SION I[ O S G ? 1 ? .o.ct[ o: NOAU n I nE ONE WM c• lid f tY'J WA1' 41BL[ ON wAu tl' • C [ 1 a DOING STPAIGHT MEAD ? 1 ?f OVERTAXING AND PASSING Fr ?? • I ?,T r J1 I.NOW ? ! II ] • ? -110 ON ET I 1 I N 1 ? RSAO HA E ? J ? MA-1 MIGHT TURN ? / ' I 1 , ``( A . - IC[ ® • . ?I00 D ° L ?116Ni{OI I • ? TLA{n NO.10 ? 1 ? ILOOP, V ? • ? 4A.'NO LEFT TURN ` : I E' ! W ? E ? { ? SP<C 'I rl I a ? 61NML11161118 ? a C] 11.111N0 AAAEA C) 1 ? ALLEY ? { ? YAXIIIO U-TURN 6PtCRY r ? Liffl%Y ? L ? RR 61GNAl ? a ? `I11T TURN f ? SLOWING ? b ) T R DADW?Y BW•yF?ACAITYPI..- ? ?OfI LEWILAOUwN ? T ?pRIVM,AY rA L{1 I ?SIOPPE o'TRMr'C + ITS ? FL H i I-J ? ? N I.J LJ •N rw (? ? W n F Ot fP 6 lC 1Y ? ? . , ROApOBEPAWAT1,,I .:. ? j/ T? J OIV DED stop I SIGNAL ? E ? OB A R PPE AT N E ? ? S10PP[D IN AOADWAY ?tiMtt, 1.? 1 - F 1 1 -1 o LLlllAlllflYtiC?-_ ` wA?tu,?W,Nrx , ` a m a iTYR,^,TJIS ? Y r? r77, N. _- 4ac dun ..5.. - f2 T Y h CYA$HINGTGN F y ,. OFF LI L USE ONLY EHICLE COLLISION REPORT NouNr ( clTr "? _ NoX OILS wY [ "?.N HO GM°A. °` E ?" I, - ON MiI,IX? o ? A. [ W?9P6?°` x N ?XE ° ?''? EO YL[ ? X s NOT ? ? ? xi ° PL° O •OE° O /?? ?iaGa f[ .w x0 ETREET ON ROnD OR •, IXAYEI. //GG ?jliLC?V IQ E IIFf{e3Ejy-g3 BTXEEi OXROA Y2y.. arnuc r DoDEIm A ' 7,S,m•a.'?.E185.TtlaMF4 ?:, Mlgpl, ? E •y, A a 2 I ?^ ?}'( .?.? MILTON -jrluJ57aA1 J? ,; f ?. T[IEET aODRE@a..:...;.; ? yyy?' .? ? r . i ITY ? ?, ?I? SASE •, F - Tk. ?? Vim. - OflIVFIfIB OCCUPA[ION M, C' ,N 't, x RIVER' F ? W4'Jl1 ??Y xm.+?YARV ? ?• 3 ? t1uR. 6 u MM "nnwf.rpwuL3 ° ? A,, ON STREET OR IGHWAY NAME OR NO? ? ? ? ? ? ? ? TRI WPEDAL CYCLIST WAS USING: :STRIAN/PEDAL CYCLIST CLOTHING COLOR.1AT LE YR. MAN ICHEV UDGE) DE ) iICLES POSITIONS BEF RE COL ISION OEN9EPLATE`NOTATETggILEq PLATE NO. STATE ENSE PLATE NO.9TATTRAILER PLATE NO: STATE T 1 AION NO. V `{ EHICLE IDEN[IF IST Eo o NF-FIRST-MIDDLE NAM DRIVERS LICNO. TERED OWNER ( ST-FIR$T-MIDDLE NAME) VE S IEga rYer LICENSE NO ApDAES9(9TREET. CITY pNDSTATEI D ATE OFBIMOWNERS AODR ISTAEET; CITY ANSJATE) -0 DAY N PATE OF BIRTH Ho T;A A TI. BILITY INSURANCE INFORMATION-VEHICLE NO. t- was THERE AUTOMOBILE LIABILITY INSURANCE [? '" $ COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR ?ES NO OLI ---- I R[s s /?? DID' - ?N AME OF LIABILURANCE C AD ESS OF L ILITY INSU CE ADE T c, CITY CO' V yl ,3 ?? AGE1 °[ D NAME AOE ES6 RE AND ADDR sex ATURE D ? M F E%TENT ENT FINJURIES DID INJURIES REQUI RE DOCTORS EXAMINATION D ? ? STATUSOF.D 1 MABFI R9T ONEiMAT APP D Y A O TOR LIES STAT49 Of INJVRED NAME Ifl9TO ? I Q KILLED =11. 0 MILLED K[ ' =y l , NE T4 ATAPPIE XoX 9 [3 O ? ORCYCLE SAFETY: ? EL.ETUSED DY ARROW IH CIRCLE .• f EwIWS S ? HELMET NOT USED MOTORCYCLE SAFETY: ELMET USED ? ELMET NOT USED ?,Y/J ' " C"ISCRIBEBELOW C •..^ .- -A •ti,. CrxaxB G+HEQ .. trbA>d" a brJq_zw 7 1 Ueh Nod PakmQ:: fl.t?lAm'I rc,Lluaa_.r.51?d r ? ?? ?' > . tc-Lt Uh&.c ? ?-a.Q IN Cc Vth W2 ?'7 Vekgau3*vne oettl? L*?QV.VEt WW 7- -as?aaY_L+at4AE_Ve1r? ?r?en?'IO.wO. L.n?,.E? 10+•? t,,?? ?`?DeAt-C_cLi6.. oPE(?i?r.?vxC?4% II ?!? ?? IUo s•. vSivf trageLur TnuRCll? Y IUATED BY '13 - iaAfAl3 .TROY TO I I Id ? Li°?? W..di [??I o.I i?Q?•oAri uNl.. - .., .c.?.?.....,.. uo.l, -. ... . rroe er nDAO r ...?RaryEIWEnIC?R WDi.lwn on L y?1Prs r ?_,. °' ' 1 Q paY 1 ? 4wL? I ? [MWH Q' 1 ? SIONAlS Q _?I ONE WAY L^ 1 Q DOING nrM10NT ANFAD ?n H"". l? {17 5 I. JJ????$}'? I QRAIN,NO E'1X13% Q i Q BIOPSION t OYEflIAX NO AND OA PA$SINO r IPI•- !Q??y I?nN°v0"It 1 ?LIOI?Ie d1f1 ? E ? rI[LD SON ? x NIVI SOI[ ? ? 1 ?? r gpf `„ 1 ?FOO L QCAR. OIIEr ? 1 ? IIASNW0 af0 W!! CN NOE ? 1 Q MARINO aION1 lURN 1 ' 1 / i 1 ?N;{ 1 OvHIP ryP DANAWD ? A ? IL"AYPI ? 1 Q MA%WD LE IT TURN 1 ,- ? SPlC[IA /Y ?13 tOrlll EI wCQ i atiYIPf( IfII Y LgH13 ? ? 1 1 ? QAIlA AS3IHGWNAO IAYBLR ? 3 ? IMO fY WAY ? O C? 1 Q MARINO U•1UHN / 1 II III ? E ? `Ell IlN1N {?I 3 Q SIOWINO Y N, 1 7 ROApWA BIMVAC[ YPe. ? I ? OII I[f RIIAOYAN _a T C ? I ?an rcwAY ? Iswrr[D ron mA? INI. WC." I? i I ( +? ? F ? ?N ? / ? fue ? o° R ro 'TOPPED RN nOAIXIAY kB '. tli ° A7Lt ?1, ND IAUIIL ,? ?.: 1 - 1,s•u ^1. J ' nragl N? N i[H? •'r I I . ? "S as 1 l / ?? _- _... 'J J ?CrCwsvury NUMM[N a4 w -1 -? ? PRIVATE WAY DA f or ow ro N Aro[o, [N D ? I Mt oUNrr couN cln NO. ryryry OOO lust )dop Nouul . r. wv Non ??ls rs ,• s' rww ` , / ir1 r ??? f/// i/?/ IY ?I / ? ? r ? Q UPBA N - ON Qf Q,rv C1r Oa rowN [ rSrR[l10R NiGNWgv s NAm dN00 r Rg 11f 0451 s W po' Mats p SFC O ION / 5 r ON `-3300 , fx5[CUNG wrIN (Rt(IOV VOgp NNrlvSICr ON Milf POir 93 I n ' LI- N /, / 5mt11 d 5 tfr 4, I D>IgrvctnDxl l QU rvoMRtrlR[NC[.c slelfr ov Nrgvlsl M U ., y M lt s[ ncc DENr w Ducxun- N r[Ir Or Mt. (N.. .. 7.. „[. ME , CODE DE avlU. OU N • -Al NO r vnxtllp r rq NIVRFD / QSp , pNldeU , d?RD TIR CIN SrRF[IOR 4pnp OR Rrtxt NCf N nr.s'nU?s i( 7' • N y Cl5 DIM ST PF[tOR MAO dvfN Clts O QvNORV1YD4MAG[ONIr ?ef ?•fNCi{ ?' O ¢S l0 / O,[CI STRUCdINaMf Or OBltCr SIRUC6 ANp UwN1R'SNZil [Sr DAA1pLE SRC AI COD NG US! - /1. S s ( UNIT NO I DR Vtxs NU.rt usr nvs' DIIl[ UNIT NO. Q VEHICLE ? PEDESTRIAN Q PEDALCYCLIST Dxwws Nnmt usr R )' / '7 /7J ?J•iC//. J.•1!r rF?r ? i S mi m1 / 5r9ff1AD0Rt25 1. {.A ., r)C. Nj'l G1 n xts5 r ^ L'..: !•,. , ' ? ! sort ! ? :IRCOpE o o D t '_ r. .? YI J c ' / ` RIR,IUNSF NO ic' t 51ATF ! R srArl vcopf e,.oNt No / I uSUCf O q1[ O p e r IN d ac<uxgrwN M . eNONf No r {s m Nr E occuvAl oN qM! a RroNt No. curs w(,cm .N cr[1 /mo ? CHECK (,1 nH FMR N -VI q[ 4"s r °u CHECK (,l) < i n n vo 'i ' I ~ ? s •• / e s^ CODES' ] ??? fN l N lMVl s x i l ' / N i NOII ?] o D 'v r ' ? °` Nr x dl IODWt Cnfvl. -EL IDAar NOVAI 51.1[1. px.fOnv? Ytge ° Nfv ^ N ° ; NOV °•? tt °: 1? ul '%i L 1 l W J 'di r / Optl R q 1)U v / N oR 11- A 1 lN s1. qR[R RUt NO AIt " H i N vt pace O L ? C r_•^, r• y.r I C )' r': m1 Rq IN n NKIf ?wNnnc4n orv NO vFHKll iotnliNU i N (j r L `D RlGiSRe1DOWrvIR sAST NRST' MiDDIf ONI NO e , G"J 7: f f. r' ?_: •.'? O 1Gi51fvfDOwN[R lASr NvSr m?pplf ONt No ?r s 1 nooPtsSn owNtR W OwNL. N N-d ADOR—INSURA 1 oe ACtN1 E /r t• ri r' R ? I -A C. CQ N p) DAMACI ARIA / a d, S lssorµrr nvor <eAVD( J '[ ., /;.: CNAYGI v ; :G ?!)CIA 1 ... D •Aw4Gt u ",NNe , Li etmAlNrD C i0'p ° 1) W N RtM4wtD tsr. DAMA I ° ?: ? 5 d ... )rL,. ?.w;.0r7rta 1 . C \ • ?awY: A , . _ Y , ?, r NORIr,.., nr L ?., DIAGRAMOf COlllS N: 5 sU"` "• "IV 'U INO'c DESCR PTI r 16 I 5Nf11 it N(CI554er1 B? R ON OF COLLISION: I[nE SUPRIMINi4t sNltr.r Ntcfssge+, Ow NAME, E558INJURIES OF PERSONS INVOLVED ' Of CUP /WITNESSES li e'- M MIS CODES 1 - 2 3 C 5 6 110 c NA .Nl j r sr. Acr zero s ", " „ R srx uru , Anwud r t . rv. uuta rr r i7r,. _ Krr,l`n.. ?AMb 0,^A" ?r, d"N Duos, ; l : . Nl w w 5` eMOVro rxDN ?AMb Q.i ?'??? r ?.1 ?ri' 60 UU ? trw N?INRI OI >IOA +n•rY • ? ^^^ 'IS xl Ntrv ) N KIAbr ?AMb ??r:?r,rr ?ii T ° i• ' " X 4?rC L ru r . Kt AxwNU U 1! vRI RIxr nP_lI- pAl! . •,• ., I •r 'r Ir. 1 I I h S? 5L 1 tS .?n t l r m 3T T #;' .: r-pns 'Swr=-'r[- A E I n ?' s V J? t. *rs y yt S u s v,. (fa -y?q ` T , ' FyG`n{ih ve'S,F i'? w'?+LgY ' °'au,"i??i/,. Ja 3.r t°"m r.r n C .[„r t ?e&? u, Elr??F L I ;f?r :e % ¢ ? v? ?! 1/ } ?, y r r ' ? ,, r 1 r tg1gLry1 '. f Y?f ?t L _ T67 L I 1 r n ?.r t ? I 1 - rlfir ??? n ytlt ? ,' ?.-, 1k ? t am 0 3Rr z a NJ E %. Y ( I 1 1 fl POLICE TRAFFIC COLLt.N REPORT 1251 TRAFFICWAY "u. p5WE 7"u. PRIVATE WAY DA1FM I?Z "d LUIS RID Iwn I NALL (USEtbp NOURI 020 CAUNTY 11 tJ -NET. ? ?? GlY FHWA I]URSAN Ru OITON TOWN •MFa NO,dSi%EIOR NtiHWAY 1/MITS ?1 C3W gd QPJ N -', 1 7, /E Ep ??2L? n ..-SE.-WIH: 511fEFIdE1K1AD NON IM[RSFCIION BfiMRfN SrRlEI a 51Rffr POfIK MYE ?` O VV, 4 AN Di E CROS 51%Et NEAP Si Mi E D' 5 f W Q '111 T' N OF ACCIDENT MILEAGE CODE :. '.I O r fDllISgNINVOIVFD. vFRllr: /1 LOIN NO. NO KM1IID_NO NIUR[Dy ?sP U1Gt ? It UN d .1c"S [D 0 PRD-DAm.,ONLY ? pES.11ED ? VFd N9an Hf fltf INN CIS OS58T%FIOR ROAD OYlEC1519UCK tNAMEd Oa1ER SIPUCK •NOOWNf-Tj Lf F 151. DAMAGE ? C1µ -G _ v $200 ;,..°'UNITNO.1 ?.UN(TNOlr3., k ?VEHICLE PEDESTRUW..O.PEDALCYCLIST R' S - DRrvERS L 51 NANF: IR rvtR'S NAMF: IASi I 1 _ ?? Si%EI ADORfit Eye PO 2 9 ?? A M <? Sl:, ' iREfl %55 1 SIRE PNONF NO. fiPCOIX Cipaig O' D R Iiv SA V _ 5A R OD 30 .. 5 V STATE A N%Y DA. r _ ° ???'T'?'1 NM NAW,Ea%aNENO?85'3131 erES d1i if GNi E WAIroN AMEa P1aNE NO. ttts wHI HEK:Hr ?" E RRa41 ?: '- ? CHECK (0 N mla. f• • A ? CHECK(/) MNK EM%OWE DF-TWIT AS 11 CODES 1. D a s .sn ° s 5 1 a s''?O.nl. ' N N CODES O f a 5 A a s'MO•n •ss s. nN n n "R DI ? NN .M1 log I ? ,"am. ? -V., 11 VOW :R-.V- C] -- o 7s° 71 ?m • ? z .a ? u H. YEAR MA tIDODGF{H[V.1 CNGV MCIXIID•91 NpvAl SIYIF LRD° -c-) 2 TV -W 1 IDM. AI l R °D'Y' H SfAI iPNtfR 0.AIE NO. ST A H' VFH 1 .? RN 2 W I C VEHKI[IIXMIfI(:AiION NO, L. V IIXN i I " 10,5 5 3 4: I r R(dST%OOWMf. WI liYii MIDDLE PE10El N0. 0 IIR51 I v ?, ADD%udoxrx9 G N A Wert Nw..l EnoD9u5diNw9NCF CD DR F.cIM V?? W P, R: co-ENT S i MIA ND 11 "Ci0"" o 11C, IwanNN D -1 J?N ! ' cNMd ND cN d I = - S {SI. DR/.fAGI W ?ffMNNfO ?AWAY OPfAWNID DAMAGE [SI ITT. DIAGRAM OF COLLISION: il°IruE?clss1RY) .? evAfR?w l" DE,RIPTIONOFCOLLISION; IIA[SlA%[MINiN SMeNF Nlc[uARrl - I vc" b WAS p ?. 3m,. ON Foap. CORNS . I O-Cr OF WWI TROL- AFTER MFI ??1G 1J F FR W SR2o '?'/ A t? ?1? -- \t3 2 FT T OF OM . N t eza SS?DE.WRY . o"ro R P&zvAre LgwN, J T g ? ( ._ ?? ? , Cr Cx? ??9 C E MU6 T Tpp yU Hti(. COM i/UG ?b A •'?' O LiVKS? 77??/1? FJp z vi9r? D&LVE-WOW. rJE¢zv?R of Vb/? >?t/ THE+J/ OR&D UP, KAnCRXA.)G. DOZ A c?tGV i ?EWA.ILAJC, E LCrF/ 06AITM6 A) 1- 1 q NAME, ADDRESS B INJURIES OF PERSONS I NVOLVED f CODES 1 - Z E J 1 4 5 6 OCCUPANTS/ WITNESSES IrGY °AI?wlilfdMlFAMi rNiAiw ii ST. AG f um '" S , 1 1 , % . 119. txn N,MI f,cu a asE . ,8s-048 Q 2 - , •DDnu K- AT.. E ti? AM S B'EW" 0 ,.n . ?a. ?i'9.I,v NAAN U F AI ,OII>s NA1U9 S. P MOMDLYON ?AMS ? IgKI ?rn . ? „ ? .. b " , NO AfKW l N°?U? IM ar, ?AMa w9.I ?rKrwn. ?RR ? n ? X >IK.• d.l,1R N 5 N L.DfAa /GfNd q?? In IV-2 K?I}?ICIfD R mI,P1 O&? i11WD SER5H9f D•IIQ MMRI A Y DIALiI?{ l a t - i??ly'eL A a ? 9?¢ e b il CI ny Y • k i gr?,rp hb' K4 -0.K ?! ? ? `f' f N i h I ?/r ?{R[?;?, ? U 1 H ?W r.l; n? ?L A ? I 1 ^1?' r, ITT ldg c s POP--- Tocvu t--Nb (l?A 4836 8 f Q, I 0 DRAW DIAGRAM OF COItISION SCENE IN REASONABLE PROPORTIONS. PROPE4Y IDENTIFY VEHKUS AND HIGHWAYS SNOW SKID MARKS ANO OTHEN `AYASUREMENTS ` ---r-.-... pr I I'll F., to - , ' t lER AM ' q r. MDG:j?* AGTNCY UNIT/MST Di T. AFPIIOVED BY PALE W REI'OAI ?y? i d 1ri! r i is rw I .-rr?. to POLICE TRA FFIC COLLISION REPORT WTOFFIOVAY/-- N 9.-r r PRIVATE W Y _ -- N riME couNrv ml1EErv NO rv c .yA OI a 1 J a ° iNI, - : 1 0 oG9 11 a T£?cF£ CS o . - ( 0 , _.. o. ao - ?N ?E ?'N C1YOR10WN N Fe NOO<SIRfIIOR?IG?WAY Mnfs QS ?W M.F S ON ?fcodE .CL -:G ?.`?n0/SO iN,HStCIivG VA1H 519lfi OV 4DA0 NONINFF95F<i ON III-E. SIRF[i I 519ffi MRFI% MILF P031 ? ?/ ? ' 1 piS ANCFeDRF ti iROM FR NCf CROSSSiRitlOV N[APFSt MiIF S FI N QQ ![5 5 F W OP RG £ L ACCIDENt MILEAGE R AM _TA - IT 1-1-N-VfD SfvfR iv: NOOfM1,ED?IVO.IN)UV[D?YiIUGf ?nR69UN lOI " my I p5 W 1p/(} O555 `?'O ) AI p V[nIC 5 E(? f ?vvOHR1V 0AMAGF ONIY y9"5ULiFD ?VEa<lI (YZ 9 f--- 1e11CI51vUC91NAMEO. 111T 51-1 -N11 1 -11 11 i. DAMAGI E SPtCW CODDiG t .? UNIT NO.1 UNIT N0.4 VEHICLE ?PEDESTRIAN ? PEDALCYCLIST:.. S Ovrv[R'IN-1 IASi .95 M. F DR?r?? J /I?9X1lSFrfyN N 6- 9 o LOC!(£ x/ e. GG ocvte . ADD9lss eter ADD9tss ° Co. R0. FA' 5 5-4-z KK 9 LCCir7$ L 51Aif IiPCODF PHONF NO IIY C /MAcu?N W 1`'ff3-ZS 732-h//5! Y R, P I SrA1E w w 8'368 3?S-Sza !z Z IVIR SI <tvY NO /LL ;rv* He G z C S1Alf F% MD .J, V i LKfNY NO. RD£cFSo B 2 Aif A F ?DAit°AYe 9.n ! az 1b .At ON MNUAf ePHOH NU. [v{5 HIGHt 000U i ' E OCCUPATION 1111 N-1I PIgN[NO [Yf5 GHI HIGni IL ¢Q R K T tlto,v Co . R /7 (r R sb?R£ £,?v77ie R de l3a Scy ?CHECK 1!2 INHK fAS ?N AEMiD,Hfc ?CHECK(?) -gLf As AN DMNOOYf-AN01NfvAL CODES ?' 7 0 / 5 1 e y CODES 10- ' 7 n <Ib „ N1URR5 <a I S I.UL cK- c ? a"'.A`7? ..AMA ? 2- 61' ? bm ? : %T' t y MIJDP ? rof° ? 8m ? H ?..° Ku ? ' vtH rEA9 f 100DGf M[v.l 7y Fn eo IIDR. v.l l IDA91? AI Joo P u n v.1 -11 IDARrVAI A 6 / UGC eliJSSie l I/ .? ° L N PU SIATf MIty PUtF ND. iAl A vfn. IX - S l l el A S w/,A? S3J2S WAS} C` /C£O £/L/SG9 w/? StnKl[IIYNIIEKAigN NO ? Y n It DENt AI I o Rrzl /oo I ! c S/?/9?J5' I i l l i WG15RV(DOM++l9 WI N051 MiDIXt LL hEOH NO. Z- 2Go I IS D wNt9. LAST NRSI MiDCIf F GOT L GhIAFe?tS . "? ADD9Fa ar oM«e9 BoX 2?1o GH?.nHCVr? w.9-, e9 /015-0 CfO ?T Towysra0?w/f - _, Jy faADD 1. INw9 Eco ao AGFNI I fir NS/F IGO ns/ R No nJ £ A 4 g AGE APtMu DAMAG[D A.tA o 25'8' ' (If fS • [LCe Cnn9OE ON e'"?i:o+w 1s Io ? D-N ? nww?mo [] ?°1??" ?9t Awto ul AMAa 5 " - ' ;Vo dionb? W ?? 1'=Der. LLs F' t Der /G OAVS f,3 oo0 DIAGRAMOFCOILISION: Iu t N NDKA,p IH DESCRIPTION OF COLLISION; Ius1-t.FN... s.""Nta5s I ?u.A_D!?s1 S?cEGew.?lNf ,.mac/K/N6.? -' T,rtc?eiisc S1P?_DE Vf/t2 wig <tff __ ?su?fP_Ee_W_F1N?1ie_s_P Y !EJ_ fleotiJ7 S c ? _ O£B.41.£_?i.C41J_foCLLS/_412. w.lefl ?'? ¢<tly?__ '. ? 1 0_?o LerszE_._.TN/O.,r/rSRKf_.FRo.•?__!/ff1.---1"Lg? 8 - -,- _ T .. _.r_ - _ _ _ .- wns_ Fetecyi,v?c .A.,,,v 7U FGeo,t r2-r- tt s'?oA? _ NAME, ADDRE SS & INJURIES OF PERSONS INVOLVED CODES t - Z 4 OCCUPANTS/ WI TNESSES jp tEVM°iYw%w fl U u: M" N.Mf _. _-- - ' AoES9I' Aft, ! H 9. •M e ? (QI ' ? "' . ? N ? N,E It: y 9 C? i' f ? AI F 1,11 , c -tn a ,,m tu -. - Legs t et't.L 2? ? ? o?i?u ?? ? Gf ? ' ' - • -f2?C?ln ._Oja- i ['__? -??--- e?,,_pt_?L _? ?lzz- PAG 5lRIAL UNIT INVESTIGATING OFFICER 1 I / PPROVCD BY, r OF Z TrL 3r ..:.' z?i F t i C?^d+t 6Y5fJ' 1k^ iA9ttl,,,x"^I,;v AY P ryA .+a ?4. _?;J'Pk?la, ,V" rkFw'W'n.r;wls" 'Em 104 1 FfMNi14' w I WJiY +I `x G v 1 ? 1I A a n h d ? , l` y F {{ t I i I IL . .&EASON COUNTY SHERIFF'S DEPARTMENT g 5 ADDITIONAL INFORMATION SHEET/OFFICER'S REPORT , STATE OF WASHINGTON ' . ^.;,.. ,• - _.._,, . M IAOTORVEHICLE COLL ?' - _. - ISION RtlP . aL N ° „p ER .1 S11 u., D (r 1 ' F°N E x dr+1? ti ' ,^ rtF ,rY n x -I NO 11 E xc, . ,„ : •.IF (.I. ?N ?E ?W Amomn'. ? C F .I ILL,IJ`n 1C ON ' ?L C L i l i {?• v I ? „N w nxOAO x E N BE,N °_ ' 0o PN,I.,N°LNBMPR . xBNE P?oQs ouE°to :?'.L , 0 i.'I- L ICII.. ,,.I wA iRy+Rt' ?A?Jd 41rx y„'?•;?,' "7 OR ri 1 c OL 1 I N,NY 01. oL OF I ??g?? i .-.xs? 616:: mOA,ecrEl n ?.. y F.gEJECIBN?¢1WP(?f?1tEE 461?r?7"?I?T'.f' , "':; .+r ` 7^, g .?, ;.. t 4 • '?,.>IF MORE THIN • x ARE f A$KSFis:LhiTNAWF._,i„-:r i'r5nCL`P.lfLEWW r-''• 1 w OL ED Z ..MR?NAMg'' .off • u.., ` iiirn I' C I: I , J c l'? J , t?j T.. ON . . ONE THAN TwO RTREST:AOpREEg a .,... : ::?,.R4VTEtl41 EltLll yi,' ?L!!EET_ , PERSONS Q RESS .,. ., wENE D i.yltE:l:st-. SEA a A . GELY ,,,?xBiAT? ZIP.GOILE . Is O Z g TN T ? ilt- is 3 C L r, s ?' r / CENSE2 OTATP :p E RDERB LIDENS€NO:' 77 'C F ,kY? 1 y 7 11 0 N, [ Mo A y IDLE Yr. MAKE (CN OpEL 1 ,; C -J,i1!iS 2 611" I• \ s 1 LICENSE PLATE NO: .'::. 6TATE.:;. S" ?. TRAILER L/Qg,{t."j• A Qf[LI?::.W ?.; jLAENS€PLATE NO.. ;a+L`. 1 - TR I ?I I 1??? EEIIGLE.IQJE TIFICAT1ON No q ,":. -- fr6d ik # ?, '? 7!fdflpLEtDENTIFICATI , ,? ?ti 1 ?C? 7? ai.::::kTA ,2::' '•' ' ITEIR 0VINER IE/lsT_ FNAMF! MINOR Ilm 2Ul JIG.QNI@FSEA,kWNER IEAST:FII{6T-M L IL ]i / , I ?'). LIA1E? N1 I Sc G , ORIVE}? . O 1SODRESS. ' t AE ANDSTATELSr4 RI . V - OWNER'SADORESS.. /,R,• ! 'l /'•?? L1?/I" Y vN.?r A YP ' u.O V < f l r! r L 1 1 "i I I , l Gl I I.: ? i r „? - _ .?I I- t d 1 LIABILITY INSURANCE INFORMATION-VEHICLE NO.1- WASTHERE AUTOMOBILE LIABILITY INSURANCE COVERAGE N EFFECT FORT IS ACCIDENT ON YOUR CAR YES ? NO AND ADORES.S DF, IASILETT.IEJEURANCE (:.. LEI DOMES; sX '! t': L?Q - ?Vrc?ILltl1 ??iL??Q{ll MA., .. :? , 01w) If ILI 1l>ti1,(1lxC NAM= NAME I NAME ADDRESS .?'r. ADD I 54, '.. . NATURE AND M F , URIES ?? /l N T OAND EXTENT OF INJ EXTE INJURES DID INJURIES REQUIRE DOCTOR' 4.' IM F ?? S IRE DID INJURIES ON OR BY A EXAMINATON DOCTOR, NAME E%AMINATON DY A GOCTORT NAMEB ? ® sAe NONd w•vM ?'.M; p IMO ? O XM1IfD .,.,?rOq•R,., NIELm lyA No ? d ? : r • . INS PI[ nr r wNOPI RNNr -? . ?. t„. . , ' ??., .. ? 50 6 ? 7 ? O ?I , 5 ? G4 6 Q• T.Q.. MOTORCYCLE SAFETY: 0 HELMET USED 0 HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOTUSED SHOW NORTH R ARROW IN CIRCLE • rxNU L p£,I•?y ?Lr I I 1i, n tu+, L f ' L a. T . - w , 1 1; 1k C. 1 1 iv Ir'r•? r VEHICLES POSITIONS BEFORE COLLISION wa. LA.u N 4 E W ..cL.n.NO.n xlww. r1AREEO NAF INV[Sl10ATE0 OOY1?,1 M[41Y .LYAw? OBLYIMO ? n.n ? « V E ON BTRfEi 011 HIGHWAY E OR NO. OwcrION _41 ,n p .f' IgJ7 j^,VO Np P ? °ra a ? MO r rtN ? ? 0 ? ? ? 0 ?' e L NXI ? QrXAPI PFDESTRIAWPEOALCYCLI5EWASUSING' ?Nmw 1r].NX. ION.wA ,0x"10 10M= I?m.n r?:: 1?PO.PW.r A PEDESTRIAWPEOAL CYCLIST CLOTHING COLOR , ?OMw r ?INrN I ?w. . ?v,INS • ? fR.lr wAPw ESIrmv. axti -c' A ' "" ? w.ua.r I H ?1 El1 OAY I YA4i.iAU•i J ? MAN •F vn.rA a.,O.O.N, .I wMalli ? 1 ?? [gNAt3 r'1' 1 A? ONE WAY . Y J Y'°bF IwaOIN OPIIOPD ?1.1,'1? 001N0[TRANWANEAD wT E ? R.INWO ] IQy WSII ?) FF?-- J ?^? ? t r [T ? J ? [iOP SIGN • ?yy rW0 WAY Y ,7E? ` IM [ •i E] ' ' pY[RTAXINO AND PA[[IND 1 gnl3 ON ? 1 ? Sew' r ? S ? nllO [IOM S E,J POA O . C] . [ ? MAXINGRIONTNRN 10100 E ? L-13011 ?, ?Kl O B ? E ? ILASHMO xED ? 1 ? IN ?.W I[ ? E. ? MAN1N0 Lf/T TURN f?I M'EC " It ?SIPIL 1,GHTR ? • ? ? f ?II ASH140 AMBER ? f ?ALLEY W 0 ? [ ? MA%ING U-IIMN C r ? EINCNY ? It ? RR .DMAI ? 1 ? l' 1 T IL•1N 1 NI[ E) [ ? kIOWINO kC1,:??I.. .[! J A.. r (mot ^?, ?? {{ ? ,7E (? r ?OIIICINIlAOYAN ? / ? MWEw AY [ OnI MTCIF'I r ?O Qr ? ? ? { ? ? It ? TO%fO Fd1 lRA/rg1 OR TPOP RDNµ 1 1 E ITY y „ ?a EO ?P F+ 'r ? [ ? 110PI•fp IN RDApWAY f (l u ! .MT ., MM^?Y'!; _ ..__..,.?. . M.I"I IARIINO 6 ?I Y (f eR n ? A __ W A- G POLICE TRAFFIC COLLISION REPORT X 4FF[bVAY gxKEC N e 1 C PRIVATE rC t 1 D Al E, couNl v _ .., D $ ? fur. ID w , ?- IUQSE a:oo M n OE? r E CDUV fq. (/p I 0URRtLARN civoR,owN ON QF Qw NO.d5mtF,O-G-Ar QE 3. { ARIES O 3 w 8!D ON N IN IRSFC11NG wtrH S,Rttr O4 PoAD NON NrfRSFCr ON Cls /1 p (?ZZKT D e[ Si4[Et E S 4ffr 00. A RRFfix ARAR-l _4 1:? [/ N<(BD,t ,CeOSSa,4ff1 NtAVf3rMRf PoSI ACCIDENT Ml[5 N SR F w MILEAGE DATA p {[Fr IR,ONINVgV[D ,,p K411lFD?NO NIUeI ?aVM1IAGE 0 HI164 DIAL NO u ?'7M!Wl ha d N IMFR pt CROSylIeE[1041pAD . VEHICI[3 Q RROgR1Y DANAGF GNIY ? wwlnD 0 EaCtf OB1fClSm t[ ' 1 u INAMFp OBI[CI l,R=KN100WNF4 SNNA[I E51=AMAGf 3gCW CODMG ' UNIT NO. 1 UNIT N0.2 oa e's NAMe: wr ,eu ? VEHICLE Q PEDESTRIAN Q PED COST "I M, F RL L DR,vIR SNAMt s, , l,qE, ADD.R[ -IT A-1. - Lt L r , rt RO D D OI RHONt No .4553 R sun ,R l NFR3lICENStN r,F .B 'H I I NSFNO. At BIRIX re D I ( V w ?• bra __ . NTNP OCcu.,ON ANFf ggNl NO. I". GM NIGHT N E -PAT- { 4M NAMf 6 RHONF NO. [rf5 IGHt H G i ? Z l2S 5rZ A Q CHECK R N i ?- l ( v H<uA A pANO,N[Y Q CHECK(,,) nt A CODES?' ] a 5 I e i° _? .v , ~fn nc. w "ox S AN MgorF CODES P- * ] ?? 5 In N e MO A •ss " R "K•<u 'i 1E 77 z. Iwlxlos y u M r. p,, 6 ? tea. RN.. KI 0 4411 0 ct- Q „°.^ Q 4 V[H Y[Il IDDDU CHFV,I -(DART NOVAE SIru IR DR {GNV) r. R, ? ? q ? ? :° R EI llr R H . 1 t(OARr. AI Y l .1 l I S1A ry MIEe qA,F NC! f A F H. VEH. ?? ? '' VtHKI[ dMM1KAigN NO. lIE AIRIP SILtZIBIW.lIfol3i IneangD a w? rlRSr C L VFNKIE IOfN ,N I N l i l MIDDLE rNOM NO O m P, R svM lASr MI N931 . ADdRllad w FR / 3I N 3 wn E NAMI.ADDRF3[ weANcl CO APENT IN u AN DANM:ID NEA , w R - ( ?D 'uW CHAR.[ DANA.[ AREA, ;:N e1N ? nD Uionoii•a ES UNID p1 ' '\ D-- -? w . DAAUGf , [JRFMMNID Is I]. S Ip/? Ow10 10 -D ' I?a 0W gp C] ONWA ev er S DIAGRAM OF COLLISION PIT NA ac Ieow W", DESCRIPTION I T .S{Y{ 4e4ssuvl - OF COLLISION: Ilnt SlgglM! to sHFllrMCesvRrl O VEN?e l c ST BOU 1D O, ? ? AQ G ,_. w _o a _ ppp E . E 1. 1 !O3A[?IEa6D _ ve..ANd WENT _ I UNTTo A Sk D i ? ? _ _ _ ._,_. t ? I i i I I -f._ .? - yE1ALCLE k->`PS ? SI ` __ - .- _ .Tnti. pE.L.w L5_ENA._WEi1T? ! , - i -I [ ?.._ ? t .? , ? I.__ _1rf. ?EZO ?RLCAE. ?R-.?FSIAE.s`t-CAU.EO.S41ERlE?.Y 1 NAME. ADDRESS INJURIES OF PERSONS INVOLVED 'CODES I Y 3 4 5 6 OCCUPANTS /WITNESSES E_-::?^,EOMr1+uEN+AM A„H rii? AGE uK urus , „ "'^" D" ' rur, HnR lx[I ; ?[;. .... .. A N DDREaI AM NANJ. OI r Q AM r e Q9cI Q ??:.. ?::vM N AME ?ANB QKAKI ? ?? . Q H ?MI, m ._. ,n.... E^rnI nw, r, n,r r?wn Ik??' 1 I ? 2 , L4? 1 PP ?IZ+` ? 4aTn', ?? AGE 'VM?) ?r •. ni n ?.- I c+x I' L? J POLICE TRAFFIC COLLRON REPORT ,Yff8AFFSwAY Il-J?I PRIVATE WAY - ,? NiN xR ?.. I 1 .. ! ,WE <OVNrr to c N '1-im..? Oil IUS[]•op nou4l 0 25.8 D 20 E . ivln) "l- iHNA / (O O p ueu 01 1!}1NO Of f ?IN C ,OWN .11 3 0, 01 >7 oN Gcar?rr 11 C1} I ROU, Oq3 Gam ?o [R Cr rv4 r Sr4[[(Oa vO.D EqN NltRS(Ci ON BfrNT[ ref[r QIP(lflain RE! t 1- 1 -?1-4141 / / DS .rvC[ URE r1 4tl(R[NC CROSS S1R11, OV t•vFSr MITI POS, ACCIOEN( RAM p.rw Ml[3 r 3 F W E ? Oi p' MILEAGE ItEr COIl13K)N NvIXVFD vGnr' C 4Z? .4 pEE[ pp grRCf ? rOr.I NO NO RII(D?rvO NlU4[D? ?3>llA4f ?nr}vUN yyl IMER CIS gp35 3 ,R!(IOR eO•D ( / ? J CRV[nlClf} PPORe,YpANA4f ONlr ?RfSplr(D ?SfoICF OBIICr Sr4UC.Irv.M( ItCr lPUCe ANDOWN(4SNAMII !SID AOF SMCUICOgNO IbF - ! UNIT NO. I UNIT NO.2 0 VEHICLE 0 PEDESTRIAN [] PEDALCVCLIST fR'3 rvAM[: -I I , MIDDLE 'S NamE Si I l 3,41[r.pOV(SS ,REf D04f SS ?? SI.IF TIP CODE Nf NO P D v rA,f ZIP E I Nl4-s!K(N f rv 6 8`S R - P t. Gr/.9 M 16 i8 v I ucFN E Ar! OArf OI BIRrn cuP.noN AM(BPIroNt NO fns Icnr «(wn, E oc 1-10rv NAMt}P-ENO (r[s w(IC t rnlc Z ?c?°ti5 Q R n( nr [}?.CAECK ('') v[n¢FAA .NOinrPAl ?CHECK (?I vtn AsANUnnor[[a.rvO,R eA! CODES ?' ] V' ' • nn+. I s uKr D ^'D?ox.c f CODES ? ' ] n":ii' • ?" NI S Ix<rbN B r^`? ox.cu m Nr . x> z IMLr F M A, m p. N I. I? 0 ES- Iff H 2 ? ^3 Nn. r[Ae MA•[IDODGf <nEV I MODFIID.vr ngv. •Srv [ D y ? yM O'Nov" O zs:R. 04.Z; 0 :. v . ???y FOJ?d l l COrvv I '" ap'e H I lEA 4 ( nfVl MIIDARr.NOVAI Yll vl ! I U Sas SrArE wd ?xc ? 4' 'e Y(N? D I\ 1 1. Il A , . V[nKIIIWMIIICArgN IFp ?1?/631y l1918?3I?^ V -LIl N,I I A 1 1 i 1 u eeelsneepoM]+eR t I s, MIDDI( noNe NO ?ieD oF? B 697?70a ADDRFSSaovm! O W I (FD w,+lR. lur N45, ml ,..- / I6[E+ 3 1 ? o•!J 6 O N Eu ? }ADDRlSSOINSU4.NC[m. De A4tM F Q IN }pAM.WDMIA e, CNMO! Cn...I =4.1. DAM- G rn?w•Rwa -yy } } vlv(N (? OIr••Oy01 ? D.Ww LJ III-MD : ?^wMN ?e[MMNlO t3r.DAMAG( DYrtp 1 ' - r B ,oW s/?0 foev f w ? 1 DIAGRAM-FCOLL i -(- - 1_. I ISION: Ip '(AI IN is NORtn DESCRIPTIONOFCOLLISION• IUSFSURE FMAISMft N[C(s RY! {..? _ _I ? ,O UGriV G/AS_LV?r'.vIJ _4N A ?Oc+r?NH j/ __- I 4 -I i I ?FT J?1? _ Oa oAL . 77/E` ?-NT -- - •- { - 1 .. ' el.N uP__ ?9 _?a+?rf? _ !? //e rJLI c?2. pw __ _ JI.j_. ?T? , ' -' .1 ! f .l , A i E - ?'/ _.O.Yyr- ?S?O _ ?GQ•J y?tiJrq ', z" . l ; NAME, ADDRESS IS INJURIES OF PERSONS INVOLVED ' CODES I 2 3 d 5 6 OCCUPANTS/ WITNESSES IA .MI 11 s(i ":![ t nvR !na -MKv . 00•HS Na qd S, ?AMB ? iL•' ?°' . []r . ._.. DGHS .Mr .rUBld IM lDO w'Q.MB ?nArOn •0e ?u, ... No - ' sun w+ ?•Me ? ?,[ : .Ir n'' (KL P?"/Y??D:Irv Rr wP? .'TTvr....r,T , 1 1 11-7, 1 .aa.s -c I.- - - --I !ill /A •F'7 nil r : Y pry 3 rt? K 0 I i 1 J: N WSR Sv lRfv?.a01 ??) '? :- STATE OF WAS INGTON ;??, ? RAGf ? pr r No. ? s {": O POLICE TRAFFIC COLLI. REPORT ATRAFgCW; ^? / eIXICF C NT UMB[ ^ ? I rar ? PRIVATE WAYl q- w:l pr <tN+15? N A.O Cp::?50.: COUnr, ' v . v. ?::. . v .. ... L5t •JCC HOER. COUNIY NO CDV NO iNWA ' ?/ ?? ?U BAN '. ?N ?f ?N C+.pR rOwN NNn[euO MSrv lr OR nGnwwr Cl1 ROUIf 5 BURAI r- ,5 ?w Dr j ON Gw SrRtt•?eR ,? Dr, NrERSr<Ip.: MItfPoS, ; N} i stnvfl AST o? srvar QiSCO..C?_ ei1„ 71S'Z •? Yk `2 -? DSIANCl 6U REY+?UN rROV R[r[Rf NCt CROSt5ra1l+OR •.!•Rt5•v:t ep5• ACCIDENr AM pA,A ;FJ4i M:[5 i ! W R R oe MILEAGE t N tol+l? NwrvtD ine CODE P cy fprAl NU t,[D_?NO N,vR[D? ?. lt•LE ?wt4RU I [ Cl5 CRC5151RFLT0RR?RROADOR R[ifRFrKE /]S f. OvFn<US ®, ? e4pry Rir LnMAGF pNIr -- - ? vt5u: ?lD ?vlp Cir ' ^B.tC15•vuCv:NAMtpeOli[C?a•R AGI W R? ? lUU a,D OwntvS VAMI ? 1007gD ..? SRCIAI CODING IAC s UNIT NO.1 UNIT NO.Y ,?T s - D I [ u.s+ r?RSI mo:! ?v -s NUM[ ? CHICLE ? PEDESTRIAN ? PEDALCYCLIST : ' . ` 9 Rt55 S 'v - IE DRt?` T;v ???+.L? I, >^a?. G? C SIw,E lIe COD[ e?,DNF NO D y? O IIe< l r I zU 5 7-71 R (6RI-?ouJJ IcJA 3?8 RCS Rf,w RS z N ND ?' D t<rB .n L 3?i? /,??, s? tel.. Q Dwre a B R,n '.,fit', ? I C E (.7 ?/? s? //{ ?r c o%, v V v L?c?i ? I ? ,nl I- ? p / ` .Y. ocnl.A .w 1 B enoN! Np fs wscnr H cn, E pcw w rIvM AM n enoN[ No Q a/ t C)Epw pp Z ?DOP? M/5(1,p B jj` 0 (? R j r _ t.fs wtcnr c?1nr -- ? CHECK I?) , /V]AL) L I.C . 601• y y s< r`AUOr?IQ ?CHECK (?) yr lnr•swN [Mnu?rl or.°5 irnrRw'} 5;i "LI CODES ? ' ] n a s e vo o"5•? CODES ?' ] ?i' r' u, riR a 45 Ns e:iir.• Inc r 16- 1 1. "' I v?„ ,. ?t lDOOC[ cnfv ? ? mwtG Fol., Rw s . n>DR?cc"v ? ?I s"nReyM ? „Sw.n°I w? `"'?? 0 2b:vR p? ?i?Q i ? ? ;`vs. D ? '_ - d„ NN. 9"' vJMA. f nFV.I NC,Dfl IDARTNOVAI vlfl DR??yy?? V1 t' ?, 1 y1 ' N i.. MA'ClNSf elver t wIlla qwr[ SrnN IEI ? V 1? ??Y. i VVV N<CkGR nl -,No Af M Aib NpH/ s uJ4 N,r ArK?9a9 wA 3 3? L ?''? • RienrtRtoowT,ty wl ?RS ? SS,DDIf e•roNl No vj, rlveDr?Nlvr ppN ? a ml- .. 1 O ?R IRS, F NO. 3? 53'ty?. S: ly Ao-1-0-A. I . ! wNfR } T p, O? 7 NAMfa+DDRUSw mwv.NCf co wwctN, IN ?ct-- A?i c`.AI@Ri4L. S !U$ H ;sr- (D Q u SFsp S0.'f.rr J? s?.i l •::+? oo"ti p f ? . ,I ' • CNADG[, ., "o1•N rvc S-11DARIA l11Of... . Is?D+N,.cE vvEN cnwvcl D?r:o°wr ???? 1'' +B BOYIOR s ? Aw•r RIM. CU D BV ?:w v ?91Mw NID 111 OAMAG! 11 / f DIAGRAMOFCOLLISION RWAr . u e +: <w,t NOVfn DESCRIP 1 GE s ' i !1 LuDU M433ARr e+RRWw ' ONOFCOLIISION, Iust suvvuMfNUlsrNn rN¢¢SeRr t? I O i?w/1 4 GG"SY/ CoLxoc of his Vshr WhlL4. ['ouL?l C-UXVP. oi) W"_TnRV&w,-W4- /a,tkf r P, c1u£ TO /?FlGd T!?' CA l?suu 111 v . Tb'coss -?-Q on). '?elh. 22 Staid D???Xoss /?71 t1 ouCemtrJ?'T?c,! 1h, 2 ?TeucJ i 0 Thy } hoar-IEF F?',ud8Z R,W i (LL. -hEX) 5 IJ 19ROUA.6/illbl 6-jk C,c a ' / rc &? 7 ,QEA q-lk-pf3A1EL. -DisRbIiFL i III ? , NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES I ' OCCUPANTS i'rVI1NES5E5 .vrt,ul•.fv, s?fl? r Z 3 4 6 I Mr _. slv Rc[ na '." _.. .r. r. .... 1 .. t. r;:i' J: r'• d PRIVATE : WAY w t. E I t ME co rr . . . urv RI IUSE ]fin lgURl !?-ArZ r. RIR ?I ruD. o_rw ? ul IZ.l?7 Ct-f'W?W 4 /\ f A 0 ? •••• .... ?N ?E ?Iry CNTd IOWN'' rr NAME{NO.O S gfF10R nn//AY Al ES ?s of (D4Nl$7...d ON 620 Al R , FOUr FD . . . IMERSEO Wlln: SIREfI OR ROAD NON IMFRYjCIId?I{J sT -EEN / / / dNE SrRffl 6 (J?FZ77 // Stgffl ZZ Rl PMI ? ?? . I D IAN aDI f FFffP[ .CROSS SIRFFI ORN ESIMII[ gfCIDENI ISO IM N 5 I w Of sr N /??? 6d MILEAGE CODE - _ . COllI510NINVOIVED: fR tY. TOINNO ?JVO CIIILD?Np INJU D ?SpIIUGF ?HII{RUN g.- F V[H IClf3 O '?pROpFRTY DAMAGE-1 ?gSUETED ?VfHICIf OBACi STRUCK INANE Of STRUCK AND OWNFCS NMUI I HfESN? FST _ CLS AO55/frttE[i OR ROAD - (O ?1^E? ? -- DAMAGE Sp $ fCIPI OJDIHO - ... :: • .. --.. UNIT NO.I ., .` UNIT NO. ? VENIC4E-.PEDESTRIAN CYCIISTw, FR' NAMfVRSI it i . r? ' ,S { ? O VfR'SNE: IAtt 1 / ?' r ? ?E ••. SIRfETADptF I ` . ? gFEI ADDRESS ? pfgNf -O? ° IIY 9 SIATF I I:.. . ? NEq'S UQ SIA I E N / e- 2ZD? GJiA /! 3!oq '6 ? MD°9ENY0In q OCCUTATMJN IIRMNAMI { NgNf NO. FTFS Gn HIG r E? CUPATgN FIRM .Z UL]l' 14 ?V M R NAME {PHONE NO. EYES IGIIT 1EIf.111 1:? m FFFe@ ?CHECK (,') vEnIC11 aANOrH[v. r ?CHECK (f') IVFn C F e? CODES ?'H 3 5 [ 6 x l CRC ur ?in { U E wSANFMAOYEE OfANOirrt .` CODES + 3 a { i. sew y y » yr Sn uNl clgrv qDF rc 6M1 2 IN 45 -. I` ae p- ? Mq Kr ? VFM YfAR MAC E D OOG u 1 ? am. ? - , w o,M[ A r ? pav ? ra:R. ? K?KD ? ray . `? I I , 'nFVJ ?v'?d? DEDMiNOVA) SOS . T DR.coN ) N L H 1 .) AV'AEI IDAg1. VAJ E ,D ? .61 NSf PIw J"Z 67 Srgf Rp or UIF NO SIAff H'vLH. t.; ? V[HICIEIgMIfICwI - M}u NO. ? C6SSoK 0381 Rfusrt 0; nl fIDEN11 I - _ ' vfaow??//MIV. IAti HRS//I 77 M" ?S L ?./c '- AD Or1r, Mw ER: 1A51 FIR51 I- W .. 1.' . `f Y,r 1 ?15 f DMStu Z'. ySS' 44"444 iWiS p4,, N wl4q 1 r r' w ?d w! NAAV aADaRessulNw{ANCeeo wAGf I E o ? . ICO a { N I E /1 .A r ' • i .?.? 1 ' . ON OF COLLISI?O.NS? IUEE SIPIEEMEN111 L4fi INtU55MY) _ r?y. f 6 (? L Is. k P ?.._ s18 Ew.MVI Sl'K.4tk. DIE Sn __ J3' t,' .ai -l,c.d (oo Fiw?t k E Zi ° k 11 p n? Ys;- aV_ ;Y t l ',.p ??f POLICE TRAFFIC COLLISIC.TREPORT L,2I TRAFFXMAV- .vplcfc '.:a1N ew ?. PRIVATE W(IY? ? -?? .c _ w+ For wl ? of ' I. ,.I S MF 11.1 (l,lF> NOtIYI S COUNTY ? ? ? UNIV ryp 1 / Y GIY OiMVA U ENI RA I CITY ON TOWN EaNO.plIPFETURnGnwnv ? ?E ?IN / ON AulfSS cr RIT e--1A iCTG A RW Ep1 O G ZZP NIERxCTiNG W1 SIFEIORROAD NO D 111S[CTON aA??E'? ?("(,!/ ? FE16Y`?+ SflW fM EO . MMF PO51? Z? L UiSIANCta D4[MT `ON IROM RFIFNENF .CROSSSTFftI OR NklLM IE SI f5 / N S ACCIDENT E RAMP IA(irtnM MIA - V ? •l ?j ? OF .-7 S CDDE CIXIISpNIrv V[D?? xvFNT TaR tIAGE ? N U I? TOTAL NO. E/, NO. K l FD?NO NEURFD ? lP N u _N F.I. 11D R C IM15 W R RfIERNCf 0. -1-0.- El v[nlflf5 /PRpPEPiv DAMAGE ONIY S?IXfN ? RSUIIFO CIF GZ.3>o 001[ CI STRUCK INAME I O11fCI STRUCK AND OWNER'S NAMEI [lE DNAAGF E SPECWCODINGIbE UNIT NO.1 O.2 UNII ? VEHICLE ? PEDESTRIAN PEDALCYCLIST . ! WErrs NAME vsI rIRS iD F av --s l oR TN U it STWF A 21 IREETADDFFSS ?J STATE EGI% P DNt NO d T ?a? ss?1a?s' A- 17 D R Y STATE IP E [R'S LICENSE 'n STATE n % 2 1 A ? ? I V v R ICENx NO STATE 11 DAIfIRIR11M OC UYANON M NM1f 6 ENO. frf! F I Nl E IXCUPAI ON M NAMF 6 PHONE NO. fYF! IGNT EfIGNI 2 »Y aFc /? S R ? CHECK (.? 1-N[MR Orll OF -IFIR:M ? CHECK(,') [NaE ASAN UwoYFF OF ANOIIUC? ppIR? CODES ' w. % ?inM 5 1 a ;'M°{R°`?°1 11, S e I? x.cl CODES P- D 5 c N * nni A sIrsieMN l% a T US uv / DI'w.:'°OM ?.NN„MI C] 7": 1 C] 78m. ? %VMii ? r.:,.,v ?AVNxANCI ? w, ? 126.nF ? vl„Ki ? I HN YTAV MAKE ID CFFEV.I /??? n L ARTI+OVAI 5TYLE(D.00NV,) ?N rt E 'ilk (E)OLOC N¢I -11DUT-VAT r I .I $ v ? xvl s E RAnIR NAIr NO sl H vFn.cpoN F4 A N kid ?YGS75 Cdf? VEERCII iUFNI NC 1-NO BCS 0 C6l 3731 3 L L V n 1 IN I lA I N REGIlRR[DOwM R. USI PIRSI MiDIX[ PIgIENp IS lD wrvf R.. 1A51 FIRST MiDOIE f Y 1'„ %t A1wNtsspo«NER O .? erT PT. Rd 7° T E [N : 7 NAAUaAD ssp nawewnco wACINI ? ? R m u 21 •?? \ C s ry " ?? OAMAU eA g?g1F??,! IV ?in:?r,o.1 ul. : EST. MM•ct oa U rvIN ? ?°IAwNTD CNARG[ T vi ?nwAFN ?REAwNED .. ... _ SLUA WIl rjAWAGE? u for I s I- •w•r o =I" OIAGRAMOFCOtLISION cATARIROW ? w[11 YI ' er p /? O DESCRIPTION OF COLLISION: Iusl suPnfwNTm lI.nIF-SSARYI I/?cd; s Fo?wi?G- ?Rt/o7 V './ $? T C Aw 1&- Cu IYc-v vim/! 4-A S7err6v Fe2 eJeeit f I On! Tiff / og c0 J16,W AOS 7 OL? a,116 07L) 7W- G[1 ?Y ?OQ CI %?A?/-ER? K Turw cv NAME, ADDRESS & INJURIES OF PERSONS INVOLVED l F CODES I - 2 J 4 1 1 5 6 OCCUPANTS/ WITNESSES '?u:Darp::u HAS!" ' l AM ums 'R}1"' !!"' ,?, 1 .(SIR "IC M. N Aw ? • DORI!! NAIUNIp ROM IMKV AM R ?A?aI Ml;- ?h„ ?r .v AMI , • (RKNSS --f OF , °IM(nID I—Q ?AA ?r' NS ?I: WY :'? ! ":Era Rr ?AMa ?" ??FrI. u,Y ?:.11x sc rR PNIlI?!• UIICI.I. /// LG ?.C RA[%Aq 1 ro A.G,- V cso K%95;3 AD E mrNCn ?Y ?I3 ?ll?l 2m3wsd D.IIg,- A- T t? c3 Wa aE+ I h ?C Y; ,RIX 1 ,, v i 1,>nYp F w E F?. I t S 1 II t Jy. ., ? 4.A rh. ,wen_?pp ?;I a ... Ls I? tf TS 4". I? ii-p I A C n d ' .e J r/ i POLICE TRAFFIC COLLISION REPORT N TRAFFIOAY!), Ro- --NN)N , PRIVATE WAY -' DME F II N OZ z,. 8o DAr 431 N w. NoI rms TIN c rn w IWf C (USE )nDNOVRI JO OUNTY - ?P E.R6 COl1NR ryp. (/J_ CIn NO. fHwA ?UR&W --- ' N ?N ?f ?rN 1VOA TOWN s AmE6NOOF11vFf10RHIGNWAY C ROUIE0R 11R 2 Mlfs [?s ®W ®of ow ,z ON (oZS.3/ 1fR <NnG iMTH. 11v![1 Ow ROAD NON Ni[ SECT ON GJ. oc.a nzscov?eY BE1wfEN 'r .JGr frR srv[fl fAffl% f0. M%EN11 . /.? ? "- ANCF AD Rf ION FROM xtflxfNtf. CN0511TRFf10R NfARflt MrtE {011 D11T M f5 FFFI s ? Of ;LN W ACCIDENT MIFEAGE cou RMAR DIAGRAM DATA CO1110N SfvE 1 TOTAfNVOSVfDNO O[IIfD_NO. INIURF ?YIIAGf ?Hr6RUN us rVNOH f•s rN I %.RD N1fR Cl1 i N r 11RFF OR ROADOR NfFEXFNCE . pt0555)R Ffl OR ROAD ')) . RVFH <Iti ? P-RTYOA FONLY ? ptwlTfO ?VFHCI( (• / (Y?/OO •? OBJECT 11RUCN Il-E--lIll 111-1-10WNER 1-11 151. DMA_9U 1- CODING l6[ E UNIT NO.I UNIT NO.2 ?VEHICLE ?PEDESTRIAN ?PEDALCYCLIST 2- m- FI F r I 1 ADDVl15 -Ell EN -Mp.T_t_5 IRV 11eEfl DDRE51 srAlf llp-. 1-1 NO. Ow 38 -4 M.Q D R I'll surf rR f ORtV RS 41INif 11A F % BI H MD w. r. I V IV R' IKEN. \ IAif DA11 BIRTH Mo wr r.. _ «cwA1wN MNAmEavHOfJf NO. as G-f'IZ fns IGHi HIC4r - E «cwAUaN NcMr ARHONF NO. Ins WiIGHT rEICm E - s A wirtgEsn R ? ? CHECK (V) "XIM ASeN mR OrF[a ANOw[cµ ? CHECK(?) Hn A AN [mnortlo A CODES ? \ ] ." S I e"; CODES ? ] e w )) p(- ? f NV MV ?rv u V IDOD V.I rt Rf Wf LO Ppx CO mODH IDAYL AI S Y1 .I E r r A4 f .I r lIDAR1 ovAl p R ; -ie r v H. GR T frwNURlwn ?` - suu I ATE 19AREY nAie NO . EV. / H I 11" Caox I N I N / A 1 _ VEHKIlIMNINGigrJINO i VFH If ID NI UI NN Yo Ly O 0 J -3 -7 RIGRDYtDOWN[R -1 FIRM M'-I HgN[NO O R ISI f OWNER: I.- MIDDI( 1-1 ?AIA!L P,5 A VE W 2 ADDRessaoWNeR A NIR E NAMe BATE W1V NURAll co ro-1I 1 laN• R u A - / ") AmACEDMIA a i - t d.N CHAVU S tSI r[umA(.yq. ? AA.AY ? RtMNNtO v r,n IAN DIARU CNAR rwceN%MI D?f ? AWn\r ?YIMNNfO 11O1OMNGI jOiiDir n 10Wi^Br y.. p IorrtDBr f ...- OFCOIIISION: -B ^1RERtORT DIAGRAM 1. 11 R MCI St,RYI e H DESCRIPTION OF COLLISIONS IustswKjWNrM-TIFN[CISSARYI 1-11=4404 ® 1 1_? ? - \)II 'I' I LVRs Sc. $ND. ON 3.4c-oo r?E.?t.A_Ej;4 RD AND VEs6Rfz xjjTo-r"F-Dx-rc-- A . ZT THE.N cAme. -- • SWf-TLV•LNCf Owr of BAck ONTO TFIE- POADLOR4 ` ? , C oNTROL. AND ROI.1 1 - W& FLaST ONTO SXS 71 - .TACM 74a nll-W C4h%rN v TO RE.6T ON THE. 0RZVtR AND . fE•ICI:f.E.JR. ? • S.N T c. or-lrc•1.1 01JTWC- fAbT iiT.OE OF THfL RA• H L'' ? ? ? ?DRT. SN OZTc-H - APPROX. ISO FT• DssT. SWe:Ft I O ?T or, Ccxo molr ow Tkik. ApPOWR`f IappROK. 1l45 FT• I? NAME, ADDRESS R INJURIES OF PERSONS INVOLVED f CODES I - 2 3 4 5 6 OCCUPANTS/ WITNESSES ';E:;oworHTIIGM.tN:I NA Mlµ31 I'' SIR Ace 1 2r• "I (Act ...... H Aw ifo A pplis NAIURI01 Br ? ^, • ? ? ri?ni H AAN ? A Dpftil NA TUPIq M'rviY lR(%M?AMB ?tixl ?irv.?In ?Ii• b AMI NO A D(Rr1\\ / NIIUR fa Sc.IN Or ?AM 0 I0 1=11.0 M1 ?r? rrl.• rA? µr ,«AOR ?ANCr D1IFAICHI I AVE'n 02 U DAIIq%Ipl DAII 228 )mws 7 yci _ f? -0 s 1,) ),BSI A ? at '? z ,,ar ?4 s ??r I 1? ?t a lA•cPFRq :,kn. , I T ? 1 y ? ;;? A ` an k T f. a ?'* Nx POLICE TRAFFIC COLLI , REPORT ICI TRAFFIQN 10 lalclc NzN B!R ? PRIVATE Ay M1E0{cols DA o cots _ 1mf courvrr t IUSf R1(b -OU41 1 11 w muNly rvo. arv ND. HwA U ? r5 r ca v +( Q ? p RR,AN URAI / pN pl pw cllroa lowN o "I Al c aauF a M TES S P 1 3 It SKIING Vn1H 31vf 1 . •D NON INt[RSICI ION -IN -III 6 sN, I% Mttl IO31 D• ?/ / I D vC 6D4FC1'Urv IROMR N_C[. CRO55SIVtFi fARFSIm1lF PO,I m [5 5 1 w gCCIDEN! I EAG RM1 D AM MIA wF1 or rr• S L E LODE M l1 qNOIAINVOlvtp SE Vf41r ?/j?f1 NO O%U[D NO NNREDyj OYIUGE 0-N-RU N Amgwo?"5 °f RD IMfR CLS 1 F q lM 6lfRENCE C9C.S sS ORRD•D /]a --C [3 PPOttP1r pAM•G[ONIY 0cF5V OVfMiC'i / 10900 q 00,fC1 SIRU %INANLO OB CI SI4UCR AND-111 SNAMFI AOF _ SRCU ODMO AE s UNIT NO. I UNITNO.7 0 VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST - FF1 ADDRESS sAfF :mcoIX PHONE NO D r SIAH zlPC RHONE p ?36 ? 8' R SIAi[ ,dk fI F MD°i?GP ( ? Iv I Frv NO. AIf S!% OAIF CV BIRTH " ` . PHONE NO. EY[5 1GNI -FILM! E CKCUVANON {IRM NANf 6 PHONE NO FYFS wFIGHi If1GH1 ?? / I EAS:NEMNar[IO AHOi-tau ? CHECKI? aNVVOVl[arAltifRA1 vl-clfA CODES' a< 4a 5N1cra+ p.ieleRrc a s(oM"' SNICrN ewrearol CODES 0? Dn"ii b 1? LA IN vl' RE 3 t ? .MN A KI p W YEAR MA [IDODGf'C-FVr <I ? e 1R p rs "-L(DARENOVAI rlFfa 4CONY1 :e' 0 AMN%A-cl 0 fAR DM 1 CH V 1 c, ? zs.uR 0,=Z! 0 . MUDfI(DARINOVA UrrEUT. D.. i m E . . 1 1 ^? N pp v ,e rvse P,Al su¢ -1111ANNa 5zu1 H vln. CaoR l l A n AF AE I C -1.11IXNI I CATION V EH Clf 1IXNI i A I NN wG3 aF0 IR' UASr Sf MrDIXI PHO11 NO ' O IERFD WNtR lASi (1931 MI IXF ND. ?'? .. a S Apoalssa OMNIR ?- W N A wNFa '. ?1 ' IaAOpwsaal uRANaw-I R jNUAr CO OR-INT- zz DAa•GFOAae• D/JAAG[ M[A A°W C-ARG1 15 -AVA ?;W?i. OulM„?r.lU ?A..I ?R-NID ISI'pAmAGI 10r oii S O?Ol ' i = 1-.DRr. .I1 ?IOA•eper. S ww q _ ( FCOLLISION 1 Fu uatAR 1 eiAlfn ^ CO_LIISION: sw SHtt 11r N1ctssARrl Sf+I ?ESyC?RIPTION OF Imo[ n[M[rvI•l I I ?" .. _. lilUl?'c+4 _. FLM'1?/1CiR QI.Q?. I I I _L. 30 C y1Yit 2??Tc?/?& /L!O_.SG?__. - ? . •: i , ' ? S/cal - ?G -?-%? r -.• NAME, ADDRESS B INJURIESOF PERSONS I 1 s f I NVOLVED l l 1u OD ` s , ? a 4 ?5 a OCCUPANTS/ WITNESSES n , vDO%?of :iA:nii .: G' ` u " - 1 R LR I 1 t,1C M r r r .w,w n was ?'r lrv +..nlcAr.-, 'na nr p.Ma ?•":.",l'p %%,. pl: " ?,• au HA.F?1?(A•'?Ylu nul?r wlvRl, A , D•n r 3 ? x 'T _ ?T z•p 2 ?%N33.H,T? I ? ?Yp y tr+3:' CA ' 9 d A ! B r ai a T 1 q. iu .vbnm T7 y. .. ?u:K(s?_ .. a4 STATE OF WASHINGTON MOTOR VEHICLE COLLISION REPORT ..' DATEOFCOUIS" OAYOF EOF COLMSIOfI '.5 ITY MO IMr .E.x sM. n rR s•1 My 19 ? COUNT CITY, IOVM D« ` ?1P-Ft=RSON, PonT jowu nE Mp.E9 ©® Z ` COY, TOWN .'. DF 1'oY?t ?t71AiNsr,D ApA1CtS pIFFp,', ROUTE wETRVTCOpE SECi1CN -/> 275 ONE NAMEOF STREET. ROAOOR HIGHWAY wola TTIO WITH: mm" on R0Ao PRfru EO ME.EPOOT NlDb1 l± r01W1- RUBrD NON INTE-CT-1 LOCATION OF OD-R DETWEEN STREETARD TREET y O ??? DLAO{I,W DATA .. © © - nCfxlVV?x3lAx[YAnn n6IE99E. ,NOfI AO n 6 T n T A E E MroM p (%9. nTE p [ p 9 `!/:VI.RE?pIRp10: y( /p / ? rtr ? TLT FAl NVRV[0 - METE ?V?CIEmCrttF A?nlrvFn WNrEI ?•?,I/? UM,AA,??-FyI 1.11L. T? 1 z N snI ?.FOx A9x CA40_ ,rJIvh" 6PEO.E?OEL6E? pa? wr E1 DrvD.cus > ? . AxW?NOx ? °;u 1? y'li' , OSIECT97RUCIT NA.IE VDp.ECl Lr AI c OWNER OF OSIEGTSNAME ANOIDORE59 1„iIOAOWAY 1.!' .In.[I- ?© «oae ip"Mm r xmw}?.Ai IP?•I? FEEi 9 .r .0 5 • • LAI-E FUTST NAME ( OPoVERS LAST -1-tJ C•{I1?IV/'ilr Wc{'1 VV EN D] ROU TENO.AIID %NO,. SOIEETE39 _AR SLATE COY STATE, av.+= WA_ 9?j STATE SE% DATE OwF&RTOT9VEflSLCENSE NUMBER STATE. SE% DATE OFRRTH J ?LCi@ DIti481 b oh WA4 y t g A I EAR / ADE S4 VEHICLE YR MANE ICHEV: OODOEI MODEL INOVADAflil BOGY SivLE l?pll VEHICLE YR. MANEICHEV.•000GE), JMODELINDVAOAIOI IBO /96l lOh'Dk R1R? 'omz- 1 70550 SOY STYLE 12 DR.1 ki I° LICENSE PLAIENO STATE igAILER PUTE NO STATE LICENSE PLATENO. STATE. TRAILEq PLATENO. STATE 11 , u v?} VEHICLE IDENTIFICATION NO 11896 MODELSANEWERI ODOMETEn -Ell I VEHICLEIDENTIFICATIONNO. I1B66MOUELSSNEWE13I -METER IMEEAGE) ._? y st*zpNolo?BSt?14?9 1z HI .WA 1 REGSTEREDOWNER 1LASTFIRST uODLE NAMEI DRNERSLCENSE NO REGISTEREDOWNER MAST FIflST MIDDLE NAME) ORIVEgS LCENSE NO d?1Ge at(Uts SkIhN f?SVIw -IE'c'F_ 81 M yx . OWNERSAODRESS 0 (STREET. CITY-'STATEI OATEOF TH"OWNEPS ADGIE59 ISTREET,CRYANDSTATEI OITE OF RflTH -` _ 771 AK•t?,olkwl=sT'Po?rtow sewn w' r` "'° •E• '? €? PMTS OF VENCLE DAMAGED _ .- Pr PARTSOFVENA:LEDAMAGED - i RFVUN VEI CrLE" 1 G 'N yWAS THERE AUTOMORLELIA6 LITY AN CE s D! LIABILITY INSURANCE INFORMATION VEHICLE NO R . 1 pr_,Y COVERAGE WEFFECT FOR THIS ACC W. DENi CW YOIM CM yy YE$ ?NO x ' A NAME ANDAWHE590F UNLUTY81611nANCE POLICY HOIOER N-EOFLII91ftYLVSURANCE CO.., rn y? b ` PdJ Jul l???ftU1S 777wRC"o, W. Ft9PTtlv1 0"RUh4 y3G+ PR061??55tU GoKVALTy r NAME AND AOOElE590FllARUTYr49LWANCE AGENT - •iA tP UARFITYPOIJCYNUMBFA FIcW1E1L SMIT+fi 1?5? , PJo, boy -f/, PoWTOWOU ISTNJURY gFUrn, Wk 983?fl MC D -!O }], (?? /-Cp. AOF TNO MJUgY: IUY6V RPVDIRfOn ADprgNALWArEER ,ME k4 r??, " NAME V?/\W V riV VF11VA6tA NAME ^ \ DD[IE 5 VTOTL 1 77(hnlik W. ,PeFT mw'N%SFO,;p sE% ADpnEssD. SEX 1, '`? fi1N?51 r ? aD.m ESYInc. F,?,?. ?.?.a o ? L. I U I DU I ° TU ?__ - 101 5? 1 B? I T?-_. [THDY, ROWWCIRCLE DESCRIM SELOViA l` HAPPENED. DIFFER TO VEHICLES ITYNUMSERI OC Ed IA.MYI?DN ® wRs fr"e!l? I onOe_ ri hfsi -K ? road 6n rNa•lorsXE: ?tv?lu, 'd1? m?Ni? A«o M.oW ?No 1? , C?r- LmGl ro ctSc{ a ,u{ ?J mi ddl, 10.42- 4c ®.- I.I,x ,a t krz . NEIn _ S+ruak YA- s we rou Kdcta eurve• ?.1? -tom roacP. 1 E5R ?h .., I ? DA.Lr•O 40-, , ? D.WN 3 0 %,o rA J mix". , ? roD L ? D.R. 1 -Rl Ir,HS Iw A ? 0". l"-YI A ? DAPA SIP[[1 I d H p r A NO w I A ? IpNAY .rL L I A I IA Ir AIih [ ? SI I I ORMA Irl DUr wIAA_I?I??.aI ?r?,Rll ? I QrnlwaTRNEUrt Nam ? ) ? OVTnIA%WD AND PASRNO ? .l ?MAAVM RIO 1t TURN ? t ?YAANOIEF1 TURN ? A ?- OU TWIN ? A ?'I #o ? [ ? STO[Y•FD FOR tWFC ? A ? RTGIND AT RONAL 011 STOP fLON ? • ? 51014FDNIIOADWAY ID ? 6TMIw IN IRNII'IANf !_v I dG _"'W" ti wANUw. rlE1L1 _ } 11 'jYgy17}lk?].I7' ' A 61 1 N. 'tidy . All" I POLICE TRAFFIC COLLCjION REPORT •. / PRIVATE WAY I rollcf cys u rNUMluv f f . oAn a al san co I s oN ' couw. 1 ' M r V coi ,a,, arr no. I»wn Ig El n , , oux 07 ZS 85 N„ 2222 ??FSO/J n ?DReAN ?n ?l CIr OV IOwN , 00 v G»wxv ?s ?w ?ol NADLDC? ON N??S Sco2r?R M . f<l Cl m OU1IOV51I, 'r GG 5[CI Orv , Nnxuo ax-,» awu GR ROAD F INt uo?oN N MAxNIc WALL,RD•n ZRDNmr C RDf r ' veer Fo. mnf POx O. GD ` I RR 7 ? C't1 D'MIfSO,;,MVlES xtNf1.C U55 1T0x?Nr?<,vfODke AD51M,1/[???5 r?? Orn-W I ?IOV,. [] ? . ACC DENT MILEAGE L DE O e v DIAGxAM WIA cOISON NvOlvtC ',IV Ir y , _? IN IOIA+NO rRIIFO?_NO vnx U p, Sv l?^GI I ?:+;Tr'••S ' xeU IN MFR Cl5 CROS SIREE,ORVeO OR ??°04 %ifRENC[ J pv!»;IfS © C]I "xGN C,r CAIN51 IS ? SI Ilp ?vtrpiKE .. . +N.'FCI OB,Ir, S•vOCV Ar.DOwrvIR3 NAMr. 51 pAMnGf S (- v 3 .J ?? SRCNI <ODING USt I _ UNIT NO.1 UNIT NO.2 Dv?vtvs NAVE VEHICLE ?PEDESTRIAN ?PEDALCYCLIST ux?vlxs NAml l us R s,RII, DE AN AU- N (C,14 ru x soN MICuAE.L A .2 208F?1NS TLD, tE DDxt55 370 Sj 1 2pNDAL.E. RD 1y 5„It N?RDLaND WA ClS p P S LdL4y o R -H H GOOF P»p Nf NO. W H L Z DRIVFesu<tN NO ADLOLK, OA 9 o ? uNE KE, . 2 DEAN*A(-' 4OSK3 WA M DAlwexl» os z3 (.C ) I 'V x x,l?S V00- At M A Y ? 2 a e2 ONE NO .»iN cuxl< TRADE;I&-L- - P.T. -6w I vAti(G»i E R --AI ON N.. N f A P»ONI NO ? wt GN , GNl 5isp RniN LINK . I?0 SD? 3 x ? CHECK IV) N ^ CODES P ov A.M,Si: A ? CHECK (,I) "rF of Ari»Fx AI CODES ? '- 7 ; 5 , ° ^•" wS . ? PIS NONE +::,,,:,?._? ? ,..„ ...I " " 5 ON '; . •,3 . ? . rt»?uP .I DDD M ? L. ? n R ? ? "o ' ? ,.SIP ? : "' n, ce •P 1 ' „ ' GI<»w CHE.1/ 74 M. De vA s a vox Irv IrVVN 2-D(Z E A I al,Dnm NOVn coNV. v;Ld SnIERCIVl NG -DR 7 e v[ Nu PIAII NG A MItx A, 5 tNO H v»ca AIN2 S N `3 WF11TL (3S 3L}BD WA - - I C WA - - KB807 BLV H "Z INICEfIpfNIiNCArpNr:O CLA/ 143$21 Zo5g - -- e[GISrtWDOwN R , L l p(N,INCAII 8 N l 135°L (36o- -- -- 5 2 [ 1A5 "'0"I PrbN[NO SEA r 1 A LLy51? w et ILIV10OwNtR 1x51 rle5 Dlf NO mECuALCsotj M IGAALL A P»WIN& S? I° ODel SSp OwNfR A f55p Ownfx I 2 SAME N E SAM£. 4: aAO.1-iNSCRANCIC. Ox ACINI N-1 I N A Z SfAflr (A2M- L NrJWOODTWA R Z N?N C - DAM.wo.etA o5:?„- N ?. . 1 ""<'°"•' c»A no e I51^DAMAGI hft Ipl ?+ ?REMAiNFC ' C ] 1 -LII 7 7 .. °;vn"a.`?.I jAmACr,D'AVIA CNAOGf p l NL7 o- ?N ?APlvt ?R[MAINID [S r'•,AMAGf r ` s 000 :w::° ? wv A«A:° . $ILL?S To W a?rjo000-°D? a DIAGRAM OF COIISION us l NAI IN nv e» PARKt uG enT s'enuN¢tssnxn ow' DESCRIPTION OF COLLISIONS IDS[SUPPUmirvIM S»urII NtC155Axrl # VEIIICLL 1 WAS EAS•T$ouk)D oN Nf_SS' carWER R•D, _ d V 1 VENICL,L *2 WAS ALSo EASTSoUND ;i&PIIJp V"ILLf, 1 a ?iCYa ?W16RR 7/ -01 o ti N *L V841 o ?•iO5 c4 2 o - EAK f?AR of- 41. IWoc.Ki. LNG 'aI Ac.R AclySS IuTo ?NEL- ?l T RDAD LNTo A PARTING f.O-r. 4z ccorwue.D wT'LFIOVT si'D Dln;c ??. p . 1 R °rxp SmtTTy s SFbT R AVE C°f 2 was ARRLSTLZ fo K UW Z 7p-\N W, 1_I0- RLVOIC#.D 174,St&-r Akgt," Amp Orr -40D Ro u pmfLtJlLp , GA _ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED I ' i CODES - Z J 4 5 6 ',°u s°"nlwNal s."" OCCUPANTS / WITNESSES wAnu,uoNa wMfsi sIe act nn " ,. wslu Inrl 5 u Nwlu JSE nA OVl or 0 C " AMe ?.". ' ?r„ .?:i W 0R15 I SNGIC L' - - - - - A Dr?al ? VJ S UvIM 00 vf,vIU IRO M?AMe ?^ r ? .? ?: RTiVE. &tL.DERA5 W-7- ' ?3O2 3 - ? - "_ ^ A ro W 1] SEuA ur+n: ooRT "? ?°Etol N oAr` . s6r. e r ?AMe ? F": ' ?,^.':,r. O :+:° ? G::,,. / / . l ' 1?, a s? ?z fir= I s • _ 1 ?r f ?YTU. '.y?iL Y1r 9 R [Y, z N ) S fix ' ?. €c R %i ,?t POLICE TRAFFIC COLLISION REPORT ?23TRAFFICWAY PIXKfCOM1PLAINr NUMfFA PRIVATE WAY DANOi Cdll I xo 04r " Av IXrueSN w. ww rv4 xrR r. , • IME c lusF HOUR, ? ounty - _ I- ND, /? LIIY A'O. NWA OTURR,w QAl I N p[ ? N Civ OPI N 6N0. d519FE1 OR HGNWAV MlES 05 ?W 0.1 ON N Cl5 pWTF ?%30D N INIFxSFCr NG Vn IH. 51R[fr OR ROAp ZION Nt[RSFCI ON Pgff1X E MRf PO51 BfIWf[N SiRfFr 6 SiPEfr /9 I5IANCF 60wFMl IROM RfIlgtNCt CPo55 SIP[[rW EARFSiM It YO51 lF5 5 F ACCIDENT MILEAGE P DIAGRAM DATA O OE ' O O dl15gn1 VIXVfp 5[v[x tv i01Al NO NO xll[DQNO IN1UV[p-? ?SP INGE ?Nr6RU N N NI i ruN4vlpr" X. IMtR CLS of CAOS55[RFflJ. ROAp ]] / d VfNCI(5 ?PPoP[RIVpPMAGF ONLY ?pFSUlltp ?VFpCIE / 0-05-INN^ OBnC1519IKX Anp ER'$NAMFI •MAG[ SPFCw CODING IEE UNIT NO. 1 UNIT NO.2 ? VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST 091VE95 NAM f' S1 Nv MI a G D-R'EN-E - I l SIRI -F ?) ?.? o(r ..?iv _ zIPCO[?c vP?rwNE NO D iRfft AppRF55 n. ulf 79 . 'll A?` M ? R ORNEF'S pCEH5f n0 VF7 51A1E /yX? /•ci rv BIRNr 4 ? I V r W. lKFn5f N0. IAIf Sfx p^tf B .q. DA. v.. P oN r CU N KRIf IIO ItgHr s E MGVANCxV M N-16 P-1 NO. EYES IGHr IfIGHr ? ? 6? ? R ?CHECK(?) vrN OEAS:NrMnon ^ANOiNfeA1 ?CHECK (.1) 11 v(N ^l clf A4$AN EMNpvft d AIT,INI CODES v J e ll? CODES 1- J • i 51n p Nlwlrs rnOH ? .wx J? e NN.YlA. HAXFIM[V, " ? E ? vt R? u .RMUU[l Ip•el?A, `i 5 v A" t ? r AR ^MF u ? ? ==l' ? is wj NOO °NOV aDr cvt? E . 1 VI A, I fIIDARt 6 1. ILpir® "I" m lt9{u1FIIO. ll Aft--- H vfN. m. A I I cu -.1. 1-1- NO ? vm nF anll uI n RtG15RRiDOWNf e. S IwOr MIpIXf PNOHF NO. O I RtU WNly, 1A51 NRSr MrDgF W JI Il ADDef53d OANER N E e DDRtssdl Eeo wAdNl? ?? R SDIFwCE I ]] 10 /?L r N DAMAw ARU 7, s .'?;,""" 1514 wMAd cHARru ? mlwN Awrtp ,=D cHARGr ?eww ?eEMLp+lD ' Es1.pAMAGE 1 ?Mw,FO j ° S Ar nv W AY Xv ? f 1N DIAGRAM Of COLLISION: I sl+nuwussARrl I ^r 11RO.v DESCRIPTION OF COLLISION: (U5l slmNEMENrAI SN[HI{Mns5ARr1 ?? 0. ( S ?GIC'rG ??ol CUoEw"5 5 f ! ??S .Ua?: ? d o F ? NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED f ODES 1 - Z 4 5 6 OCCUPANTS /WITNESSES 1. s,p''tp 1-Al ? A- ) 11. AGr um• ;' R ESn Lxn Y • LA nn.re Am d a AM e .r^1ti 0 1 . 0 H ? it ? . owns _ lwEd []M OAMA ?,^,X10'"4..0.^+ ?r: • D4.rn "?nI,RU°ia ?AMa 0i. 0'..r. O»" n X +.Gd.ctvs r,AUI-All X.zX;f GR ^ rD GIrK. _ CXK{???p Y[w Kef ./X'66 DAN d+EIr].I a DArE ? ?S ? Br :vJa ,Gu T Ii r ?f POLICE TRAFFIC COLLISION REPORT M TRAFf)CW r"D ICE COMp , IR E) PRIVATE V? D, 10!<IXlI s OIS N ? COVNIr ,AINi BE4 -_ / X, I. S.I - IUSE].Wf.OVRI / WW! N0. CITr NO. iHWA ?uR 20 .r £FFteso.E? u.. , UN p[ ?'N cl*. o4lowN oot sTetHO4.RCNwA. ,s 4ouTE as m"S OS ?w UOF iFpLOC ON SoN tr¢riT I OR R A ' IFRSECr NGVn157QE 1p37BD O E D NON IMfRS[C110N rUE mix F M«E IOSF Bf M'fEN pg(j sTR[fi 6 STREET J OLD ^ ' DS ANCt 0?9 MI R i3 etNCF <e055 STREET rvFAVfSiMrtF /sVUE w ACCIDENT BFS F DI RAN MTA a. FEET OF C _ AG CIXII'roN NvOlv[D FRItr- l ? E ? ... I r * R -AL NO OPLIED-NOINJURED U SPI.AGF UNT64UN OF VEN CllS R e "" a6f Nd IMfR' CIS Ca0555RFflOR a0AD4 I # O U p [RIr D-1 DNIY U RE5i1liFD U IT OBlICI SivuCRlNgmF O Te F V (p j 7 /U / , B1 Cl S VCR ANDOwNFR SNANfI EST D.mAG! SPECUI COMNG IlSE NoA/£ S -.-? - ! UNIT NO.'1 {lest : UNITN0.2 DRIVER'S NAME LAST ? U VEHICLE U PEDESTRIAN U PEDALCYCLIST - I IX[ DRNEV'S NAME S I n IR[n ADDRtss S P,o. Box 332 4Fft ADDRESS - 2- , Cllr STALE ZIp CO D IX RHONE Np Go w g7_,2(/y F R Ilv SIAIf ZIpc NFrv I - DRNtR'SI CINYN -TE • I. V S" 'N-- All uO sv z 3 th/.g /3? / 2 S6 ? D ' _ _ FIRM occup.uoN EnpNONt NO Ens cnt HE- INO/TIN rJL.NO ?A?29j E occupAllorv FIRM -1 n PHONE NO. Ens wllGNl HIG 2 9 AV.ui 385 0100 a !60 8 ` R ` ? CHECK IV) 1.1111 saw Mnr rpr oFANO1NFRA' UCHECK (4 FOff Nn dgrvolrvdAl v CODES?' ] u: . 3 •••,• O s In< ?. a .s •51 ' CODES 10- Z N.WIfS .G £fT 11, N lf' '?M - Ao6t. ?n O,?C IN III '.ID- [0. IDDDW CN[vI mODfI (DART-11I 5 "IF IRDO d:v. 1tIAR Rtl CfI( f /97v TO oTS? R 0o uaNY VIA s l20tiq nAI STATE H . v mUOEI DART ND v41 IF f4D vI rv l A vtN CaoR III NO _? w ? 32 w,q c I A - -- L ATIONNO ? N fNICIFIMNTF N R!T 91Si0 l0 of !z of V I I I RFWS« ' I I I I I I I , REDOwNl R U,ST 1I45T MIDIXI pNONF NO LuOwT E['C?7 Y O I IV. IASt FIRST MI IXF { . N rv , ADDnssd owNfR W q wN R x /rfS3 ?oYE ? vF A a rr? E AMISA W[SS d INSUR"cl CO OR AGtM U AN A R n Dun.GtD. 1. Rn.u..c NV T ?. ' " CXARGE' d G ii gAmAG[DAREA ^ I _ 3 fSt DAMw4f 52000 ;Wii 0 vIMAINlO U AWA,N ' n RFm ANED w I5f DAM.,Gf I 3 Aw :. .4LL G(T s U mo: DIAGRAM OF COLL DIAGRAM _F - ISION: I TRS.le #ssnHA1 a I oIU« No4lN r?D DESCRIPTIONOF COLLISION: IusFSWnFMfN1AIs-i N{cessAerl .. -. _ r J ?I tti f G uP( L_ _ } T _1 SEt S4?i°GEn?c?ri7 -_ ?_ NAME, ADORE5581NJURIESOF PERSONS I NVOLVED ? ' CODES 1 2 3 4 5 6 OCCUPANTS /WITNESSES ADD,- . ;'M C ? D "' " 1 I t SIp AGI Tu3 R ISIR IIICT MILV A W DMI„ I.A! • ?AN B U;ti' ? "' . 1Z .i ?,ii 4{ 44135 u11 OI d l l r Est ? "+ ? T ? 03 f' E: rz ??, z 4 r ?@c a S STATE OF WASHINGTON SUPPLEMEN Y POLICE TRA FIB COLLISIO EP R 7AGE; .z4 of z ENTIFICATION O C LLISION "? - CASE NO ?m, ` SEVERITY OF COLLISION ? FATALITY INJURY ? PROPERTY DAMAGE ONLY SNIP ROAD NUMBER OR NAME . . , DATE Of MO. DAY YR. COUNTY CITY LOCATION Tff? CoulsloN ] //( /?s-- ,titsoiJ /.?i90Gouf N1AroN ... i .1 .; _ - NAME NAM[ NAME DRIVERS YS Y5 /PoBfe7- lA -''i .u C ??i DESCRIPTION'OF.,COLLISION,,.;::; n. I OCCUPANT NAME R R' • , S IVE (USE FOR ADDITIONAL INFORMATION WHEN SPACE 15 NOT ADEQUATE ON ORIGINAL REPORT OR AS A SUPPLEMENTARY INFORMATION SHEET TO CORRECT D LOCATION OR ANY DATA NOT KNOWN AT THE TIME THE ORIGINAL REPORT WAS COMPIETED.) . ?. LCtpaA/? .cif/U/N4 tvoreTN $o..oA?P oiv GtOi4iP TK.en/tD ea.tiutO /}-T .e F, . 5'/-vt0 O.Vro !r/9soN -9rfef7, ko"XIS7' ?3gr? ?o ..17.f/diNG RrN7 oF ff/GeY ? . _ _.. -. r •.:• ' J;o C,q-,ee, . wLST 60,, .1,0 aN mi}soi?..i?T AEA H1r.H 5e-e Oitovt oFF' - t . R:. Pw,-, rur owrw R/6ttT S4,o-4Plie ,_evegwcE.-, Oi-ce di?T- /?•9uEinE?+!7-, ?. ? ?t Imo. I 77.1-44 awlo _R14617' 5110utPB•e AGT/t??F/, (3.5c.r o.al 4* ••eNT, 771E o ., c uEQ ...ONTO - <£FT._$HoccGS> cic A GitfrvcL , SL/D .S!D£ w.hy6 ig.v0 .PolLCm/j®NTcv A _.Tb/ ? y. I 477 '• . fV" q "'F ?. .'.ffy?,k ENfORCEMENT"/?QiJO?/ N/.tVr`4 .YjY„"' ?. SOlltIETY 'HAD BEEN DRINKH I (CHECN) s, pRIVE nro o :r : P D STRIA NAME ! ".. '- F a o A ?E E ? J F LHARG n J" ,r cITATIpN NO m . 4lMAYED T lM/- . .. P.] .tk?ah"s r.?n ar.<. .a 9.,:•;, ?,r. ,. ,.._,?rJl.n a.w.,;,.. .. .... ,ALCO of T?poAgEO . <. . . ? ? %' LttOw/G EcNPEe /'vmej 6s77wu ReBFitT D 4 , ? ? o/ i ? ? g, A, ft%L' r S .. ,.:,:DIAGRAM OFSCOLLISION ...:':'" , JrA J." . , c •, .,.. ' DRAW DIAGRAM OF COHISION SCENE IN REASONABLE PROPORTIONS PROPERLY IDENTIFY VEHICLES AND H C.WAYS SHOW SKIP MARKS AND OTHER MEASUREMENTS !J,. /V#'r 7b VC-94 w,lO 4 ._. _. __t.. ' .t ? .asp/ x Afox /Fro ... Yt '. - p 5 0 ?s INVESTIGATING OFTICER'S NAME AND RANK BADGE NO AGIFICY UNIT DIST DET DATE d REPORT L. A v v A a D" .TiT llei??w/ OfPuTb J, 7CS O tl/- Z eE,A 3? ., ? r, .. ' @ ' ? ,r kiG+ 7f' w? 1'r?A?n?YL3 7nr ?;l . Y;:! Nt ''? 6PhFt?lr r ° ?.L?t ?'r. &`"Lw"(??, 3,4Y.kj: 1 b " T5 } 1 t'4< hT 1 t; !? A ! I ? -i ! PLRA,F :'?). (l f f 'S 4;y q } ?f N L I' El , , P L. ? . T r 1 x r , s ! 4 , h? fi ?- 03 t T_T/tZR? WI?Lllip out.. _774??T - - oT N S .. /° Llll_ h/ID --r&_ 7S' .. ?J _O TI - T lItJ1L-_Sh`L_Zi L ..: ,??z [ fi ? ?,.?1?.;?L C-"?C??----7?. Sh`.??CL`-F- s-12Fj-? c £ . DsP/US.e _ - AMVE _ ---- _.... PAGE INV ESTIOMMO OFFICER UNIT PROVE O BYI OF C.102 wi, r +? Ell i "ddiw'. p , :>1 p d ?x• v 5^°' a Q11 k l A? "?",c7,?'CG 710 3;T I tP zl .t _.{vd I? 11y E rt 1?n'/R??+} Ct l? - k , }t ? a yr ',?, t ` it?fYil r UF-0?p 5? ? { New.'. :'[7 3 O STATE OF WAS INGTON .LE / pr / wsplw,R[v.lep, N ?k y,4 POLICE TRAFFIC COLLI MIS! REPORT ® TOFIC,qAV No, I / rCFC N PRIVATE WAY( ii ...?A Er rC l N D CO?Nr N_ IU$f )EM NDUgI rY CIrY A,, ?a .; id7 pF ow c nro?rDwN En„o gslRNro „c„war p El. raE' '•R' RW E ?.f. ,. o,? Mnes s Ow or ON ?• rNr[SfCi NG WI,H. SiRFfrOR pap NON N,FRSFC• 8. ,ION op060 ???? % ! M4[p51 _ y ?' % OiS aNCf 6p9 r pMR rF fNCf.CR0555r104 NFR ES M7pS) 7WRra Pr tft I(? M1E5 N E w ACCIDENE RANp Piwf pgiA ,CS 64 a, y? f[[t ?v[R Ir pr MI SAGE ryya 7f Cql 110N NVgvfO ar / -'} prat NO RrIIED??,NO NN4FD'?? ? SP IIaLF ?„r6RU ' DS Y.7 ^? .a°" pV[„ClfS I )?pppFRIY DUAALf ONLY lJ Seq[NN IMf CIS OkOe551R[[rOR pAfI _ 3j• oencr sr4uc.IN,vn pefLCl srRUC. ANpowNFRs NAA,EI ? °fwufD ?v[„clE 1.79/0 ?..,`.?r ?y?y'. + _ !A fSr.ONnALF SrfCUE CODING -- UNITNO.I UNIT NO,2 d +: q } s mlv,R 5 NANi'. IASr l,q5, 0 VEHICLE p PEDESTRIAN ? PEDALCYCLIST ) F, ! R FR SNNAf', l _ S ~ Sr ftADDRi35 - - ! q? ? ,,. ?.?XGC IR[[ DDRf35 S44 COtt StAIF S'3 8sf sa 6 R p f 1. DRNIR'S IICFHY Sr f% I rv D NSf p D I Aif DA E B 4 Y V ArD I wr bra: ?,' ° b ? ?_I . «cupuKx[ NA3 Q erfs °t ?Hr E «wRADON r J NANF 6 °kgNE NO. I "* w r, ..T• U kk) SCS 0 R EYES o„, fEK: rsSE . p CHE«(? °H CiFA ANU riv eFO :NOrHE ? CHECK (?) lµ CODES?* 2 ? . s s r cr,DN FNC Al- w%%rff as ? .,l 1w45 6 v n tl ? «p pro ? ? e. a '? 6 .„», t v nH re.q MARE looopE.c-, ° I AI srri?uDR.coNVy „.w.,Rrro pAVRAAN ? cbmf p??.Kr? ?..„s. l?+'. k v.I IDARLNOVAI 1 , syy E , R H 'r ° eNSf la surf tRArlt4 RArf NO. SGIF H vE„. qo4 ?' r Yf„rfl[IIXM NUIKk1Np _ C t„rtlt OtN r M 3k Lu• (?i I ? L v I A I A ! Rlgsn4fpowm4 I wr rwsr ?MrDIXf'? I ! i ' I l ! ?1p?'a RgpNf NO. O R D tR: lasr IIg3r MI „P' r ApORf53q OVM14 as`?! 6 W N R 3 vt/ieUC '? N EaADDR[ssq rNwgANCt co oR ALI„r E tidi"orib? s „„ r,N.r,? M, p Rif:.uMO ? 5-R rrx.oMi - -i0A! C3, AWAI ST ONM1D L pWID pRtMAwm s.-01 AMOF COUISION? I it r1 _ e v aqk l rer: f DESCRIPTION OF-1-10N IUN -TnLolu s„t NeeessAR , 'SA ; O 'Y !/m:i/ c?asT kSvo•...o-- ,J - 1 - .- . : , E. r ??..I I•!.'?ry G.?C?vT iwT? /_Y?: yamgil?..(?1? ?- c, AsuuRtaa 6 INJURIES OF PERntMFMU SONS INVOLV CODES Dt-," IVSi Sw Sarl E • OCCUPANTS/WITNESSES ? 'E w 5 1 . N.Mf roR ADp „o,.,,, Naws, ( Ji, vq ALe IAT rDp nisi ei 4r- p N M1 ??? - ?A a eY U. ? 0"a- • yr, a? ss - I?YfI,'?' rr ioprq ? ° ? Mrl NoM pave ??: . ? ° ?.:° ? . I N nM ?11 '\' JfL? W ? Y f wF$ y ? .d F 5 g IV w .?,RT• ?'+e I .i POLICE TRAFFIC COIII REPORT TRAFT W iN UR . PRIVATE It OTYNO. f'WA !O <G NS pA D O oOll IiME SF xKOHOVRI 113o COVN ?. 11 3 b A ESLRfEiORw pOv l 7 ?-q CItYOatOWN NPMf6N0O I/GM,fs11g1 pW ?oF?o2T Towels ON L IZ? MIU RO51 Q NIF XCt NG NTiN. STREt109 vOAD NON MFVSt<i ON BELW![N 1IVFFI6 ID?MIU .. O•? J l I DS ANt'Fq .Ci CNfROMVIFFP NCf.CR05551vflLOR NGRt11MIf-51 aS12 OF 1?2 ¢ s a 0 A D p R ru.DOR RENO! a E `a D xx ' coQ STUN NVavLO 1vER IY: O D§ UAGE 0R7 a RUN H RI o tttD aausmETOa ? AO INrfR ns SR rv _ v Al iO1NO SIIX[N -- CI p RORRLYD OEO !v ? HF SUtLFD ?VFn OE OF VAN G t. E SRECW OOUR- •? E ORACI SI.UC. IOf ODI(Cl tivtK..NDOwrvtvS NAMfI E51 DAMA w I UNIT NO UNIT N0.2. VEHICLE ?PEDESTRIAN pPEDALCYCUST . T evil MiDDI DRVIR NAM 3 Q f LAS DRYERBu L GA(C L• ` seN?cK ?' "I°A? s. NNEL , IvffT AppRf15 5LRtfi ADD-111 13 5•f.. CORA 22 I(D6a $??LEVIEW °2 sTgiE ??3 Gv ?aniD o2 "` ° 1 q ? fR9q ,, ? R R rERvltti; Ca. ct3aS7 1-2Li 0 ER sL <ANSf NO 11 ??055 OR. 1. M 1 / 09 yL v t IN NO. Fbs ? L?3 o AiI x n'1 DAlfaemTn ol io 1?3 fS HIGn Ez R Z OCOURq[ON vM NNAEARIONE NO..cTr IVES Gnl GHT ?RK D!d/R• owroER W^I-uF1t 81, ho 600 E OCEUVAIiON fIRM NANf 6RtbNE NO EY nZK 1211R. sdLh1 tRuCKIN(b J ?x4 » CHECK I? ' rla A.MiomlvAt CODES` cuss vIHICIFA agsovvtN nrirA ] ;°iRK.Otp 5 A e CHECK (.1) Iv1HCtFAS A-ROY-ANOiHIR CODES P' ]?: s° .is 51a a "" cU0 ' .NnI C1iON •fln ?R i3 2 ? GNrr R. afl.R; NoN .». A. I O ? bHI. ? » ro 4 7RF p W N .NL1 ? w ? S.II. ? n K i $I x r » • NA.flnooGlcHty I-At s?nElxov coNV n« rnv, 7 WlJ1TE MoonIJaC4CDARL1A1? -MvcK?I E H L nvI MooEtloARiNOVAI L d .?s 1N?EKN L• 772UCI? .l-D/2 R 3 \yl ST v n oR s uNSE RuiF slAlt RAZE NO. ALE g L \J yD f l O R R'ly;o os o(Z - ca ??.1 J< r__ Vt/ X10152 CR N 3D vtnKtt f,N[ NUIgN W -+ C A 2 1;3 N; V o119 ;RI 14 9,-1-I- L N 13 O S I` fr1 i1 fU lR: IAlI E R5L M DCl[ 3 Rf I 1 ,/SI NRSI MIDDLE RHONL NO ?+ R YEeuvER v N l W ; s E y N v nl ?( e u? A sser oYnxR FbQ7GdIN ?QE P012T£QVV?cTcaLl? •Z • E NAA.fawDRlsalNw.gNCE CO oA wfNL R I=K =MA - PQl1l?ti? Com A "Iff)c S. uAwL AMU m " ° LL'x • w `ro ?N i . v.MwlD'wu s...?NC • cH. , , 1, UANA4l ?DR'N ?YfMNNID ?A?y.?',,I/ ?RIMNNtD <' _??a 1 iOVRD y yl / 5 N L T A gl'IZJ.h .w'9w CR"OAJ rGW Rr N 1 DIAGRAM OF COUISION I U swr ND. NovIH DESCR....- OFCOLL151ON 1.1 It -NTAI SnEIT rNEDfs5A -r-T - .)-.I ._ .-ISHf 1 1 .. e ow v6'ICL.E.2...WAS WESTBoVND oN (!11LL, 2D AND - -.. .1_.. .. ?- I Q 'PAW4.d7 1jE,NV1.E.' 3 wNLCN. WAS 5?AU* IN -; .. IPF-ROAOWA . VE411CLT.'* I WAS EAST 80vu3) 1T AVOID c-qu4mo N ' 'D 14 ` A D ,I 5 .. LJ , ' ? ` 1 ' L.n. _. _ _ .... _.._ W ??.t? Ufla.lG{-E y I ? NAME, ADDRESS 81NJURIES OF PERSONS OCCUPANTS/WITNESSES'?Lw:i9o°owi???eM INVOLVED in U! J 'CODES 1 .re utus - 2 '".`:".°, 3 s < 6 fslR nu .M1 = - y? '3 AAC S( NEC {b tU EVtE r0 lLt I °O c n,e. AMS ?R1 p^ »DWtr ? 4(o-k4SN ?? 1 I O o ,o oaruy soE•DE.C.S wA g(• t)R V4NC,y . QF w a1MG»l0 tA Q.MA p?..l ? ? . a ? p :° Y NO n;" ?. R 0 ..10 " per ?" ' } "' ._?IND D.It (Y HKMI Dq'! t[y/? 1 ///j(j//?' ?/y ? ? 4U ?. » Lr,L •?f ?R./1n.A/JACI ?7LLJE.E?`•?/ _ .ET<.SC -1 ???U f/rYn7n ??S IA 5-. M ? G ry e r 1 9 H K1: rn ?? v ,. lol AT .r --C I KArrII. IULLI]Ii94 KCYVKI Irv RpEKfC rN NR PRIVATE WA PRIVATE WAY WN AA s ?W 0ol TDWNSLND ON NF'I[I? 3 ROU l ......ECING VA IM14..1 SIT"Ll CEe IRFiACCIDEN DENT PAM D DALA MCODEE COIIISIDN INVOIV[p NO.INEURlD IOIPI O vEH CllS ® p P-Ty DAMAGEONEr p q[SUIIED VfCE I,Rl L'IS CRD635lRfE[DR ROAD %^ E CIBEECr SIRUC%(NAME OI OBIECI SiRUC%AN00WNEVSNAMFI ESLDAMAG' I _ SKCWCDgNG USE I s - UNIT N U NITNO.2 .':' ' ' p VEHICLE ? PEDESTRIAN 0 PEDALCYCLIST 3 DvntR S NAME'. f1q I (%f 'SNAMF: I ASI TE31-- ' - _- t35 53F N.F, 50?? c' QzLs- -1)p" 1C)8 ? S RfEr ADDRESS / pp .n VHNcOV ?Vh• ?As. oijK OLVf N4U L IN D, IY AE lw"te'S UC[NSE NO SIAEf III !Yl A N 0 3 : z 7 ,?9 I N AIf Mo AiE,.vIR1 H Y, OCCUPANON HeM NAMFePHON NO. EYES W[ nI 11-1 E CKCUPATICIN MNAMtI PHONE NO. EYES11-1 MIGHT ?N'fNL_ ; LST. Co. F2?. lg5 ll R 2-CHECK (?) ev s: [Mrivlr F ? ANo eA' A I ? CHECK (4? ANDAPiorFEa ANOrn[aA' 2 CODES 'A'IS°' IkfID,,. e Au ?H"71 S ?' Da s CODES?* Da SII es; 1 naffs NoN F- w7ol D p. 0 W, CbeR'"O.„ K4 63 :° vln YFAR M t - - O-NCI O ',06C O ES:II ? W KI i ? :Y' u 1 , C"Ev I 7 9Nr. I vAi Sirl! Ia DR - Y b T2'vcK' 2DR v H Y ( HEV.1 MOOf l10ARtVAI I V.) Rorn -sa 6 vn 1CENSf PfAlt SIAIE la NO SIAEf H OR A N " . ae?1 LNR4?e i wA c9L4 off. :r C NnKEE 1D[NE111CAIgN NO • ' L` CEE IDfNL1IU I ANN YEn1 38 7 2,1 1- 7 F, 6 A I I 18 10 1 6 2 3 1 1 RtG15RRlDO MR 1 I i l l I l f l f l I W wl NRSi .10011 -.1 NO ?nrr?, aLSTE CA , Z_g744 0. 13f t0 WNfR: LA51 NR51 MlDplf E IRS, 333 N ADORliSO DWNIR W z 'rAcom4 I WA_ r N A-RI. OF fR ' DoRlssa l -.ANCI CO MAGINT R. 1 ft3ZR1 R'{FT- NBANNON SNS. SR DAMAGD MIA o r4 ' r;AMAOIOAREw A I; C N. __ _ _ :; ~:';" ' H cNARGE 111 ?u wty ?RFMMND 1"I OgMN ?RIMAINeD Es11.-A.1 .: EClorinir•R ES '' LJ AWAY fNONL ;D S R o er $ OV S er ?:wv DIAG1RAM OF COll1510N SINFI{ DESCRIPTION OF COLLISION IDS. SUPPUMtMAlSMEII{MCESSAR 1 PAGE AGE- . I I. __ __. NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ' CODES I - 2 3 a 5 6 OCCUPANTS WITNESSES is sD`?Da a:a?u;u i? - iu' Ail feLUS "`^" ° - I Resl6 ?ncL ,:'°;. AMI in . wwn5 q a , q. NI er O •Me ? R,Er NE. L O" . O^r ? ' aI . x+rn NO•mRa ..-..... _.' s,Y,? __ eMOVEOM N4%l ,?o- I er. OA Me Oc. Ocn . O 141 ?i° - n F T DlM "arD` .71Z',"eY Mp.Me p•" .'."I O.^?:n.O ? O,:` P?SIAICM E. I aR?v)0 TIM HKWI AnprlUer D 1 y s ,I QQ T ,? [ iM1` 1 _ urx R; F .o u I ki:h" a r y,?,7}?L r-+ r ,Trs i E G aaT ? h)vgi atlo a 7 117 f r c ? ? ? ?, ; ?rN •' ?'k' T A ?, i 141Sfjj 5.? ll f '.'k p n? '? l ? 1 I } 1 l 1 l Py ' ?f? L I c 'SIN P PVEIP?I ?61'I - - t I ?I I d 4) }? r L L E Y- ? ?'ll ' ?? ? I • I I 1 t (T ?' 1S 9TH ?? T P} ` ? ?1, I rl9y 't rl F 4 t Al t J t i 1} y `? ` + M1, 5Iy y J ? L'?t? 4 7? J ? 'k n' ? i i pgV?1 yI h: 1' I ',o yy av ?sf POLICE TRAFFIC COLLISION REPORT Kj TRAFFICWAY rollcfcanxwNr NIYABfR ?'` v". PRtVAff WAY 2' r ' .I 12 o f `s ? 9 Dnltoiyyc??a"l rv v ?H o ,.u.f Nl uM! co Nrr muNn rq. arvlEO. fHwn ?„gl 'pw "i >s4 ?'•• 05 l?l • »" RY • • IUSf D,W HWRI OUReAN ?H ?J OI L?EFF?RSON /lv R. ? +,1.., - ,{?+ /»• .04 ON IdE OIN 111 TOWN NAM NO U]IRffrO D WA OS ROUIf ON ]r fEr secs it vYA 13041 EREEL. -UE, as ?w 0°E -c6pkjERS ON C (v0/Zo „?. J x' +? wtERSlnINC Wr oR wAD NoN NIERS(a oN we{Ix f Mlu POST- `? ?} -„,fir Q n) 11 "N 1 ° bFiwflN3 ?'J[.Q ]IRE' 6 RI4OD D EIRE.. O• °. LSI OI]IANC[a Dx CI ON ix RFi(PFNCE, CROS]]txffl RNGRF]IMb[POSr ` I f ACCIDENT DAtn V OM s „ N ] MILEAGE xy if[I w Oi 5 CODE ?y. L? y CCR-N-R.. ]f vfvNY. =REED" ?RD 'rl EIRtE OR DRRLUEU E Rb l YGFs,R! -A NO. KIlliO NO NJURD ? ]YVIAOt ?Hra RUN " IMUf cL5 (pO35IT -EOl- .. - r ??,, FE tiVfN C[s O PNOHRIY DAMAGE ONLY ?gwE1ED ?v[M'<lF 3rQ ZO ?i If ° , .rtra. Q UC[INN+.t O{ OYICRHv ANOowrvfR-1 WJCeQ- f]r.DAMAGF SiFCWCCgwOIFN: I?.DIE- 6ET t.EDE Co f Q° s!r .+??''a• UNIT NO. 1 UNIT NO.2 0 VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST Nl[: VSr IIRS MI pR VfR SNNAE. UASr f1R "n'^'? f sIR(HADUREss xEEr ADDxtss a (g,! 3R Ave W. 8 ? 2 DIY ]IAIE -COU ONENO. D RY ] AIf PCOD PiK Nf - WASH. ! 19 382- 02 R ArF l2 -11 tv']UCFNY NO. AIF x el H I lK[N]F NO. DIE BRIH ? .' -? BREl7- E M-r W]IA M 07A S0 63 -U- RM NAMfEPHONE NO EY(] IWIrEIGHt E OCCUYANON {IRM NAME{PHONE NO. Fttb IGHr iEaHr - ' 2 X x 1 5 R O CHECK (4 a O CHECK 'WIRCAMR WAN "M OFAN01MRµ ??W.. ACO Sr v2 CODES 1. 2 c AN5 t i 6 ',+,° - CODES NO- * 7 AMss•a as 5 1. N 6 'M r ?. . clwN°n loxcr u pl J NOQF- F w so1.D» O A»v - ? uo ' O 8 RR O H«2 O C4 N O » O U." O 811- ? NH YfM f IDODOE CHEV.1 EIDAUI'ONOVAI ].rill R CONY ) V 1-1 1 MEV.) A1Wfl IDARI? vwI STILE 1 DR .I E n A n?.? 'cV ..s r' 12D A?-IGIERMil? u]Init H NHGx a DK.5Lu a6G27 WA• bA . { r 4E' - VEHKI. IDEMIIICAI-NO i v(n Clf lDfrv f 1 N J 50 R' { 1 C YFW]IIVIDOwNiv IA51 rINSi PHDNF NO F RR( WNty: 1A51 11- MIDOEE If '. 'rl 4 385-850 ° Agw x r v IE mUOVnRR W A wMY ??' '? xy 9 J 2 ME= E E 3 ti?` w "' NAMEAOOwssaEWwRArvc R oNE R N u AN E` pNAIDID LAG x e " JAAV4E0 ARU 3 Y "o. r KCVK CHARD CiIARGt u ?• _]J 1 A .? X ' , Fsr DAMAC ? + i I., l]. NGI ,°]wiv URINN Nw?l ? e ?YIMNNIU M ?AWAY ?Y(MUNID D""ND .p -?•- f _E IW ,7! t I-D ", ? Er ID DIAGRAM OF COLLISION: lu INDKAiI NDYm DESCRIPTION OF COLLISION: Ilal surnEweNru sHtHUMCFSSAxrI f sMtru M s•.Anvl er ARROw Pole DwRI VFH. W. 50. Alf. 'M MAZE A KT: TURN INTO DRIUE A y " rlsbli ?L WAY, SKIDDED PAST-, FLIT 5HOU O62, 5PVP AQOLLgD a '1 e AMD 0UM-ELLRW60 cute 17-5 SIDE OFACIO& W-r) B? Ctxuu A A' DeAt~ DfTON CaMLA])C.r m RE6T AG+AINSI ? ..... 3 . , _ . .. A 31w= sEf2UftE PUCE[' PWR. Ft - - D(21UER 461 T E b"oE1.= Auo AvO1DCD wunor PASS6F.IGER. sAID.ne Y DQIU60L (A MINOR) mD eezw D121ukIN6 BLIr LE AS NOT In" ruldATGD Vm4. PF"jmw sur WAS •rowao AF[E ^ I Ill uF LT! L6Fr 546A)6• NAME, ADDRESS S INJURIES OF PERSONS INVOLVED "CODES I - 2 J < S 6 OCCUPANTS/ WITNESSES iw sAD?ai?w ut rMiA+s.N'"ii w Acl .um• „"" ,411" vlvR. NIO :, N °?R N ?RRY BRM& ID c'1f3S• 3999 I I - t n Co go. p N blaNr AURIa AME ?,"A" 0".11'- 0..' O lH Yf ' I b" ISS .1 0 + f6p(z+t .rrwN r:llwla Yl.vr+m rYO^A O O? ' ?".` 4 YM Iat ??' 1 1 15, E `1 N r '.AN i" irl ii .rvv ?A}I? ?`E 4 Y M?SU IM Yr fJAME ?:'ii' O;"„rI1Y OGtr O ni?av ` r Nvl]IA]+IrF.lvrK1Y 1+NW{ ADOI Z-'.' K011111 IU IU AYYIN YOY O DAi1U YII M•YYOVIUYr DAL! I 7 r, r 1. XI] G.?I u •ID,?» L 4?9.`? 5a4 „"(Pgyp I J?-. (Ati 1 Ar ..d4) % 4^ E 1 J 1 k ?R I 1 S .` Af r` 1 J( 41 ? 114 (,Jq???yfS I J t fxYT 1 rrl a, r {?l ?' s J 71 ti+°Y.57r'" ??& ...aa ,flit' 91Y O STATE OF WA9''INGTON OF ) No 1 w v?P:4 e 710 ? t g' WSPI%IRFV Leal POLICE TRAFFIC COLLISION REPORT TRAFfICWAV l alcECOMMIw NIJMBFR 2 PRIVATE WAY DAIF Of Qlr N "'O ° tux uvw uH *ID r.u s„. s. IMf ID$[DIw HOUV, OVNIY COUNTY /0 CITY rq. A plJ AN RoR u 3 d .2315 JG FFE' R _ G fOa 51 f[t - D , YCI / R „ p[ p N CITY ORI N feN00 1 flr Oa II GHWnY Wrv p KI GS ?o?So 3 3 B N x?sraucrL R Mlls pw OF , n O a , NIfRSECI NG wsrH SIr(?[ R _N INIfv5FCNON aa[?JJ BETVJt, SIG(Ef 6 1 [I P"N. EO. W[F P01t ?? J/ / Cf 6UVfM QUf ttPf NC. CRO5551vLF10R tIp51 USµ f5 S E ACCIENI MIIf AGE CODE F-1 -- -IA FJ 3 Or - 5[vIPIIY YR[FIOR ROM OR R[iERENCE R.R. N LING : 0N rvv0[V[D. psP IIAGE pH16 RUrv COIl11 rION INV. NO."tIFD?NO.INJURFD? Cr VEN & -RI R.r DAMAGE ONLY ? vESUIIFU ?vfw<If w„PHVru IMER C!S C ROSSSTRIfIOR POAD BQ 9 OBJtDr SIRUC[INAME OF OBJECT STRUCK AND OWNER'S NAMF) -.1 ?J S SPfCIM CODING TAE UNIT NO i UNIT NO.2 p VEHICLE ? PEDESTRIAN ? PEDALCYCLIST s NAMB IASI Has M,oole sNAmt. usr To m, l 1IPf ADDVf ? SrRtfl 5 :,PCom PHONE NO. slnrt D r IP ooE PHONt No ITAII r ,,pp 03C3 ?53?/ y R DRNIRSHCFNYEJ SIAM [ H U DA I R1ER'SI "LICE III NO lrnlf sE. DAr[a e,a[r w v SP' A V OCCUPATION NAMf x PHONt w0 F is WE -1 1O'tl OCCUPATION I- E . ErfS Yrt,GHT MIGHt CKCUPAI ON M f 6 PHONE NO B ? / Il R I p CHECK r? iH "N un for nrM p CHECK v (?I fHrti[n n rFV r ' N nr n I. . VI ` r e S 6 :`'ii Nr CODES ? * J ww + " ;" 5 r .+ a ll 1 < CODES ? [ :1 ;:A1 1 f " V ; w p. Nw. l p p 7U:rl ? t, IDODGI OBy MOON al nlwn °'. nI,JU niw R e ? E p [ ? [I YA p: ? p I r I I r rf AR rf H v al U H M ?.-. B a /b'fJ U EG a / All LTinu mR AI 2 u PIAn NU RHnn NO _ ?v Ly Naa s-qq BI-I _ IQ 1A H c „c ov N N 0 HraE drvINCANONw 77 2? 2?1 PP L t Ef DIN11EA1GNrv v H sl r,RSI M,oDlf NE rvo. R R OwN a vfclsnwoo sl sr cool! oNf NO O I sn lD [ u W AND Iss. -NI. la_ ADOwssaowmR N R IN u AN MAtAAODRUSa msuRAN<e eo wAGENE ?Q ?ys %TlkTIGN DM.,netD ARu w.MAeeD ARU E ' (? _' , I `ni°'""" MMw cl ul cHARC[ wR,vf ? / -A"D - ouaa ? ?ww ?RIMAINIO st ro.JnAC•f eOn s p ??i no+ <y-'o r ff fvDy } q ? WA' ?IOAVO Aw Br. s r ?Y. Bs M All IH DIAGRAM OF COLLISION: 1Mlrn MUSSARrI + ow B "O '?- l DESCRIPTIONOFCOLL15ION: IEAt su"ntmnnAl sHnl H NIL11- er. He,;,f TQE •dLcJV'L'clj- R$.EU1N ?ss J/17 S1SY?J? v/'/ucx2 Lust ConJ?roL U S??N ClKouNrJ Qxcc ci•cr/ /n ! 0TYrr _ U,L/,d i.v?v ?3A?usH dae. '? ??OWALI ClGra? ADDRESS LIINJURIES OF PERSONS NAME INVOLVED 'CODES T - Z 9 5 6 , OCCUPANTS/ WITNESSES Imr urnlMnnu GN U sE. Acr [.Iln ' Rc,lu [ea . u .Ia C3. F ?,^. ' p'7 i0 ?i911r ? n ?vta MJ,vtnNUM pAM ??,:.°r p;' p:: ?.. .o -Mt, 01T, " +,rISI,GA1 rK1P 5•wlx EAr, .uArw A. ,n. V.?!I I?i??.w '?!C-x'?? UA;? ulNwl o?Afll? ".D W)J N s.fr / rIO X TGSO n j I 'k h c i 99F A u CUIIS rv UA u CIX f N I MI C uNIY O COUNTY NO. C ItY NO. N M(?? ?rH V 4 ?('? IVSI I+w nOU4r •ux uw n • rv /t ?.?]60 L NI'. ?(? C' Ppux u ' M L]N Q[ UIN Vr- CrIV Ox TOWN p [ Or 5141 ?M At\ w I 3 APNS O s ?? l iounl ON rl 5c,ou Kd INIIVV tuNI vn D, 10 O CI US AOM 1 RIXl.E O451NE[ SfCIHON ,3 ?OiSO • 11 K).UI NON r+11R5,CVON , . - f gI-EN , sl4nl n P CIKvIIh p C C ]u,tl OU NtAR[sl M v I ss Pv(INf f MuEP051 . V> l, ACCDENI M[µ _' 1 ? MI ycA: o, A.Og E k,. l _ COM ODE R DAGRAM OeIA .x)N rnVOIVtD I 1 1 ?]5>nAG( ?I &(WV AI NO O ED_NO. INIUR[D L 0 r•. r, +r"uxrnll? N %X INIF Cl5 D NI R4CIrN SI4EflOq 4OAU Oq R[rFPNGI CROSSSIPffIOq ROAD ' ?, AcF our LI Ov(nc .r lO?ZB? ' n.I I000. INN' OI OIfuCI5I4UC, AN-NIP 'S-11 SI. pAMAG1 $ 1 SMC44 CODING USf UNIT NO. 1 Dv rtv:. r+AM, Iul rlRSl Mmul UNIT NO, 2 ? VEHICLE ? PEDESTRIAN 0 PEDALCYCLIST ogrvlasrvpMF usr Nx ml Dl 1 T?-1UMAS Q.ivitlA C.Lvt.sC?nc 514[f.ADDU6] s REEI AUOx[ss _ on IIAl ..N N 1li?lu [ LJ,4 -co. c-T8339 nf; -szsY D R r s.AIE (IR oDF vrIONF No Iv 45 uC[NY NO DC S-sLDi IAIt („)A f= 3A3ux67 I v VFR $IICINSF NO .ATE OAIE OrB Rin D,,. .. I%-All- FIW NAME A PHONE NO [rE: 1 l E ocCUPAUON N4MNAME6 -L NO. [YES WEIGH. IfrGNI jr o c Cl-w_+A,. Lk.S. dl? ?ZO sog R ? CHECK (.I N As AH Aw,on'or ANO gRFCIAL ? CHECK (?) w vrE OrAN`iiiilivAl A A CODES ? * ] """'• a „^,"' 1 5 me W •f 1 ? Y 5 , D w Ir CODES No- + ] .:; " . ""•` I ..'se d,r.•:sas AM1.,S LCr . r ?A ? .? . I?Kw, unv „ ?: ?i ?MODU IUA41?WVA D4 rmr N <hm ? ? ?'r ? ?it , p • ne O 7Sl?A?su s l u lP .w yr 2_p 2 E u e I ! n[v_I Moon lDn4f N VAI lPOR - vvlA lNO >IAIE An4NME r,,, An H NcEND4 .. a A II 4PA AE W ENo (JjIUE ir°,Z.NOI E] l..)A I nNnl DENT rKA.roN NO I o 6o 3 M L 6z 1 063 E vFN CIF IUFNIrI ANC NN . 4 tP A iD if Y I I,I'1G1E0edwl 1?tloE?ks ,DDV S a ONE NO O W RLC SIlv(DOwrvtR. U51 11- MIDDFF PHONE NO > owm4 SY1E !?S ?L? ( E A ux. aowN[R n 1, 7Z a AME DlNnssarrvsue cECO. oe AC[Nr k w:dc ?3? ?kl, UA R c IEUAN E ?MMw,D wu E ' " (y "P>Aa ND oAmaeeo'inu RY' „: „ ,;.; ISI Ol cNAUU AwAYN ?NfMAIN1U .omo - cnAVr., AWVfN ?R[M,UNID rto wpr ro rlNar?DNw f]t'DAMAGF __ __ y?f on ?,.?rSO-Y ?M1oS' 'wAr nY- v ? a ? _ ENM Innlcprt NORlr, DIAGRAM Of COLLISION: 3r4Olf NEUSSAy SYAUROW ? DESCRIPTION OF COLLISION: IGS[swNEMervru sltEtN NeassAgrl ve Ut 4. S Wetua? L L Jl6 ?i O ? y r ?Lfa[' is AQ :.l sits LA-c-: To o ?il+t„ l.1kw'.. 11,M Q i? tea. ? Ou..C•EAc.?..? 9 VIS.. Lt.G? Z?? (.,?(/S l,.i..i 'GOB NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES 1 - 2 9 4 S 6 OCCUPANTS/ WITNESSES ,I ,. R ISrP HfCI M RAs u._ rt,r+l It? 1 2-1 1 AN. 0- i n,uy A ? r ?vr <N P A•OVID rvU,A ?AMA ?n I ??irrN Q ?ii? ?I. ?'..:v is llrx(EN SAM ?s, ' n~ . oax ?,: ??EY].+ > ?C+o N'1 Z _ •r rr - DAN Ivonv. ? ;uf? Lill 13 r-- L-- F-- %v 161-:1 ^a 1 tN, I 3]] J 'P° w ! ? ! 6 ?r? k. v ??? IC ? ' ,??4'4'MRf ^ R1 r ' y"? \ ? I ' ( ?T s 1 fSM ;I l t t u 4 ?.[ ? C I I ! , J r r nor I L a rA c r r .F . 77,7"T ?? `Ili': w n.. t'ai Jul sr{`r t 1 J y YY^^ 'y { POLICE TRAFFIC COLLITTN REPORT p(tJ TRAFFICWAY r ,,CEC ;NrNWwbE9 I PRIVATE WAY OICIXn ? ?n ?!]( DAV , N W+ u,n rurl "... I.?e• re nml C u,f e?O U9. UUNrr Te L 1rerSon COUrv,r Hn // (v C„r NO. iNWn URAI I Ox IOwN UN ??w ! Q, mHS ?o„+ f j Cllor SC?W / ON rv tLo NoU? lEl Jx ixOrvwond ? ICI CIa R % xOU1E 0951Rf[ C DE ?O/SO J SE IrON ,N fYFC,luc. mrH ARFIIOR9oAD NW;iNII'9t?r,/rigrv ( wilrl?°?S LdL? ?H v??µ? bfir ° fir% r EO e%LLf Y0,1 L. Z.S? r N la rR l 19om RfffxtrKF. CRJ4: :IRttro9 r;laErl,r vilE .'far / Sln C IflFn,_-_N , h GI Nei 'w S I ndI (IL?1 ACCIDENT mCODE! > 9Am DATA Ortl'1oN irvvOlvtO rNJ %YtIID?rb rNluxlD?, ?5n -,I U.11axu NO -Al n I- N?•' INif 'Ills, CRID,,,,Rff10RPoADR ROAD090if9fi9CF JU bvlw,R[5 ?r •. DAmAGI Urar ?v RC ?vl ?% 070 1 ,19uc.1NAmt of.11cl sr9uc%ANDOwNt9s .uml, sl uamnci sx<,AI COD-USE UNIT NO. I UNIT N .2 VEHICLE ? PEDESTRIAN ? PEDALCYCUST 9 a ? R,v,9s NAml. us, ?RSI n?Dmt D u IPA?ro L. I lulus 7, 51 I,v m1 Drf Z ,IREErADDRIaa 846 S6-K+ STReE? D ,IRttI ADDxIa, r 1 n w No rf ToLi?[1 clA wq_ 4836 - y? R <ur All DN b vNtxslmfNSt NO D t I wlvsl¢tNa NO x vAll DAnwnlRlrr ? a z 7? M ?i z8 61 v R...R N nrv.unN mNAmlanmw NO r r E r r?rlnmv, mNAml%vr9rNE N.. rcm 2_ R ? CHECK (?1 'A AN rv ? CHECK I?) "? r rY CODES ?' 3 : 5 e " CODES ? ' ] iiM A tcY! v m n rr .EAR yr m.% %IIDODCd crrfvl NovA, m,nu m.xl r. 11 11 DR <orxr, mr sv, raAR r1 fsr9vl rxloulunRl .wva IEI N c vl reov D X47 iZc U E rota 2 n n G uee ?O?S rNl•r C n RHAIINO Sun rl H vU.1- if N l m n not nnllNO A of nr'trgNInICAIroN NO i i%r1 iUl Nlni(A,ii rrN w? S S ! '7 2. 14 P eDD 91CUSif eEDOWirt9 L%„ ',%1 ra T 1-I NO O W „C.1,II RIUOWNIR 1- -1. .1-1 , NI NU IJ_ Z ADD9t5aWNr9 nDURI,SU UwNIx r aurnd E NA--llSURANCICO near VAKAoaw R A 1m u AN I c n, N r ? " %mw?D.nu DQ". a nvu IL'W AUI ' n ,? nr,,.e ' wl,nn?n,u ,i unmAO o%?i i?rIA cEO I _?, yy « oE.4) u ° D GRAMOF COLLISION: i?9tl rirri<%s+9rl IN n?::lu rlr ' D RIPTIONOF COLLISION. luusurvrrmHx........ lUmull- ?? + mide (sfa/ Jo &(401 (fit to?ery kt/ DDursueea(( 7P rte? Quo 0 b ° Avf `7b ? U/JE s. T/? rcrQ w dow»?n2 {? u/??ti? of a/' `adal a'K dom. " „ o? NAME, ADD S & INJURIES OF PERSONS ' INVOLVED ' CODES 1 - Z J 4 6 1 OCCUPANTS WITNESSES ' ..?„ ;!, ,% .r, •x ,. a•a u fn :r.r. m, a dlhec "OAkN pr.. rC.. .L7: ?I. X ?lr•iQ?L.r?(e(ai?°?l{ ???SP ?? ? S' io-z ? % ????? ?7 D ____ > „ i _ al: r " ITw "' am s , eL.? ¢¢ E dv??? , M ??yN L 1 .4; , ? I R F? ?n A? 5 t n t y ?q s? ?l f '- d ( All f? .183k .i`A.{!&4l? ? ?iN59Ct ?P. iwAIr40vlDw DAR v '- d ?i } ' yyO?SrA,O4p rUKi(y/A477NMD DARdeen 6v, .'n? /?it6 hS 0l Zl r fl .,E E POLICE TRAFFIC COLLISION REPORT J& TRAFFICWAY Pouac um NUAExR r PRIVATE WAY l .ATE OF N A. O/ '2, ^ I N r + mn nm ,wn II w. TIME C IUSE RMD NOURI O UN(Y_F OE fOUNry ND. /? CITY fMNA Q 1 N CRYOR IOwN NAfe NO.IXSrRFEEOR bGHwwY N QE C].. Aif Q5 811 WDE ON &.s - ON a 3 lv0/Sd y ERSEC, NG ff10R- ?A "T! 11- PPEfDt MAl Ir Y BFIWEFN sr4ff, 6 R? DiSrANCFeDIV ? ROM RfEFPFNC[. CROSS SINff RHEA ESIM IF PO / ACCIDENT ?i iFP.°X dp RAMP D OAEA 6 I Ft5 N 5 f W Of R. Zo /NT - CW MILEAGE CODE CIXO'G'. NO vfp. NO RRiIIED?Q?NO NlURFO ? Sr llAGf ? NONI6 RUN tOF. ?, ® f ' R wnlpxolN I ml4 p6 AD C4dS551RFE[/Op RO? .E?t . O VNI C[FS PROPERTY DAMAGE ONLY ? S RF UI,fD ?v[pCIE J ?o2Sl.3O _ ODl[CF SIRVCA(NAME OR ODE CI SIRUC[IIND OWNERS NAME, /( -.-E SPLCW m0410IRf UNIT NO.I UNIT NO.2 ?VEHIQE ?PEDESTRIPN. 'Q pEDALCYCl15L'- 3 DRIVER'S NAME: USI NRSI m-E DRIVER-SNAME. NSt I A/ L &.) = v :re. e ,L 6L1 WRIE(ADDREss - REEF ADDRESS A'-1 s / O LS 'S /N cN . A,[ ZIPCOM RHONE NO. D owN - O bvA 98368 S- J8 R 8S-oo96 .. 04NFR'S D<[NSfN StetF FX A MD DAY ' .Q4N - - ?? v Mm wA o' / 3 V N cc Q2 16" A M 1 Y ITr 0S o? 6 IXCUPAIION R M NAMFeRgrvE NO. ftt5 Gfl r[iGNI E OCCUPAEION FIRM NANEi PEgNF NO. ftt5 IGm 1EID11r ,? ScC T e r .v m 'ro/ oo QE. -02 R . Q CHECK I? N FASAHr or FOrARfdNla yr n 0CHECK( r? V SXFASANFMttOVFFOrANO- / N I/ s l e y CODES, 0" I' CODES l* 9 u +^ s d 6 y, G Z o Q ? i Q M MA ? , "AK ? Is:+ A n VLL Y r eoM Q AMN , Q ,E ? 1:86 M Am. X A v Kp i° I [[IDWE%E.Cr EY., N >PE'Ar ..../ IIDAR1 OV . A, SI r IZDR.C D iY; -' .Z?.f E . I .) MDdIID.w .NwA) l 8/ UotK.t EQA t/r 2,0t '° ' Y N. pC P ! S,A,F NR IAR NO INI H wN. R 'ft-ii c?A C' C A4 2 wq lo NMKlFIp[MRICwtgN ND rN r If v S X 17 B z .0"4 L Y . I I - v we Bi tl is-is IVIIf ?I3131¢f' IS RFWSRR{p OVMIR. NS! -1 MIDDI! PNON4 NO. H A/ G Lzr 4,j ADOR[ssa ovmlR Q W R: Uft fIR51 MI A 6aJl-/ "r IV - 64/ ?o Ea Dl Z N µ 43 " .v -I - E /vo v6 L1cw'1 LA^v ,? Pi'. Tow S- NAMf a AEwelss d mwRANCE co. d AuNt Ama m /--s. PT, R r S A?'L= h /N A. ' DAMAGID ARG 5 !Sr'DAMA,:f w: Y O-NID [NARd Del N _ Dw D iOpMr ESI MEM'[DMfA RIOr Ci0 ' DD ?-A ,Owl Der glel SaVN AOS A." ? RfAI/NN[D -Y ? 1°MD Aver Br . f _- rG ?OTTOEr 1e DIAGRAM OF COLLISION: I I?CUr NOR(n SWIIUHCESUYYI Rr WW DESCRIPTION OF COLLISION: IDSF SUrneMlmu swnurxass+nr, . _.. ... _. 9LLo"A.4 ro OoLdviroe ot,.. "'E-,2 .6NO. A),rX&A ROB/NSc- CA6 / WAS 20 7/FC -lw CNT /AOSTLS' oN rYe S//ON.cd,re 4_3 /F.s !A0aA/-. AS GAL Z A/PARAUIea GAEL V 7 YA-vAfAL " L ., . , v /?! r=Ao/vr- vh' CA4.2 » CAlt z left' AOIK 37 rsrr of AEcor $'*Ad. MA,trK+ FAam DNB nae nor ALL Fi2gc, ... o. Orw?srt I $A/O SHE H4a rwtu WLtJ f/6 D4?F-AT, . y_. _ , DAjage 2 1;/4y3 $N[ 41/0 N077 NAME, ADDRESS BINJURIES OF PERSONS INVOLVED CODES 1 - 2 3 4 5 6 OCCUPANTS /WITNESSES ;n:oa", a rNiivi ii ux AGr urns ° ; n sn. !4a M Y NAMr C,Eyrt m W//I7NEY rf?'"Do9L N° a 9 2 2 ? A[Kwllt yo Rl IW er AM 6 Q IYf ' Q "' . ? N» rs:Ae n NA N .turns wrd MERVlprvoM QAw Q1O1rQ»nr Q?3 QI:° i y n .v c C HAACaS V. /PO SE SON 0'S- Z 7 d 2 H & f -1 -? ? ArKa•. la riurls LA7 wRr?AMn ?;;'r ??r:n. QG"S Qn:+. Rrv,11WA,wIG lvral+•NMN rrehr x IAWA OR Iq A(:FrKx rrnl /g 1 h ?? ??.??..? ....... ......rr.v,?nrvrvnr _.._....• R%KEl_,.WMNINIMA - PRIVATE WAY 'Lj DA EOFCausroN we courtY wl%+n w. uTr A / g'.,; '• J ? .o« wf w,D muX IN IN rX,uR, / ON DF D ')jj<I VOe v aHI:NO.OFSrREtIOR HIGHWAY 5 .-.-"w Ow ?a ? ji ON 75 Go?sr? n IMfRStCiING Wr NSrAjf10R 40A0 NON INtERSfCitON RRfFI% MREM1Si ?7 1 B[rW(tN SIRFErd $IRFfI Y? Sets iSIANtFe DRfM rv Rf[R[ fCRO555rv[EION NFARfSrMllf 8051 N 0.f 5 E W ACCIDENT DAEA ,IFfEi Of MILEAGE CON .- 1-11-NINY-D N StVERIir - wrMiogp?N N D '? Ff971 x 0 N E OR RfEf IOIAI NO NO aIIIFDi"N SRIUGf ?HIid RUN IMfR ty CRO$SSiR[ROR ROAD Qf VFH CIES pRRORFRrr DAMANAGE ONLY Ir ?NFSUIr[D DviO1?i IvZZ?O y,A.,, WI[CI SIRV[0.1r1µ,(p{tMl[Cr SrRUC[M100WNfP5 NNAFl f51, DAMAGE SHGW COORG - 5 UNIT NO.I UNIT 7N0.F2 D VEHICLE D PEDESTRUW D PEDALCI' T D' DRrv IASo M ? DRIV[R'SN. VSr ?- I _ A(`AI?L /yWe1 V?/r 1 ? . wi?? 51'FiIAD?f55 `?N? ???? REEr ADDRESS , V )t ?rt wIX RHONE NO. R r srAlf iR f "? \wt?i I J Kg U"C" Bi f N IV 'S IKENSF NO. Alf DAZE OFB R X 0$ ND R Y In. FFS iGHi N:iGHI E CURANON NAFAEB RNONf NO. EYES IGHr HIGIII MNAM ? / d' Ee-NENO. R M T D CHECK(,) ANOI"FCAI 0CHECK(?) ttE ASAN FMROWE awwrri[¢M •se ? R CODES ?' 2 w s I <I a e ',',°,;,° CODES ? t G % sin:." S I% N B y n •? t o Iuelfs r, vr r. ? N?irD2$AtR ?„, S D"u w7Y.DN D ..MAMt MBx Nt ?Wl D_1,1,,. roKKt' DIM H. ?/' // 1D000[.cHFVI IDARI NOVAI Brrlt lTDR.cp+v.1 I N ., MODtl10AR l 0 H. YEAR .Dw E m " ru ANR XArf NO AIF H viH CaoR ucl I.et (YJ?HIGLlIIXNrIISI 7 i v("Itlt DEn r ?j r S 3 3 3 I tM ,? •je RFmsnutoowNrR: IASr 1111 IDDIE PROM rxJ. ISRRED WNtR: IASr /IRS! MIODtf i u S i?rl a? ?E30 V ° w ,. ?,. ADwrcu tow,rfRp 1 l N ER t Y •. r ! dp, IF Ar p ?' _1suRAVO ? AGtNr 1 ? y( R 5'it ? H ` IY2J TV (wAAGtD ARG d we ' ' R `D y, _ rw['roNU I:NAR? CHARGE w ?E1 ?U' IN. 0.Y `?'•: o' f'Z*//r- Q AWVv REMUNt? ?DRINN ?REAWNEO n1w D. , tDR l f I s ?LLJJJ f`rJ4. 1-Der, /A T ? -ID AWAY ro:oTl .. A. r WAY eY. DIAGRAM Of CO LISION: siReru MU-Y) ' eYA.RO r" DESCRIPTION OF COLLISION: fOSESUPN[MFNrAI SN_[nlFMnssARr) `CNl-'? O *?1. N' ?'ooh&cr o+, cal ay Rdl_ 'is?'i ¢r 'Pucov??,c Fj? - ? _ ^ ? ??5 ?'??a???• Goa ?, ??fo _._ _ HV-I ?`1auvF a ° Rte C6??G?? . _.^? P+ r NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED I+ _ CODES I - 3 1 5 6 ,l OCCUPANTS /WITNESSES 'iouRn?raul'iiAw'{si u% Au ur ?_ ? R a „ WN sr I NA.w ? REST.. a%tx " M Hfl.'I, .Nwx 1'7 , V Br. AMe D FhA1 D" . D C. ? iC.„u I nYiE :$ Amex fwl or .+Y>tiOrRa. u- DrY.AA<'D"Dn. DH D".T- A-1 'D y r: 15 N.fru?M 1 "'T 1?''. l :?, yctRnrwu F.AN. e+Dw aR acct-N?C1r? ?tI.I yl?.llljwG q..'.n?II Yy?D DDAMe D?:Amanonr 11 :9S D RI a . X ~ ? ID f+o J?+.7?r'n JOV / 6 V PIt .1.,I ?i 1? T.ro n o.n ws I '` t ' M; I i p E r ? - ,u• ? Try r ,(,T,ur I k .Jr 7 J' to h, ?wf a M ( et x cuN' K 7. 3 :} 7T a5 ,h ? ?r J?,"SM919MOOMm, 'J-4 ? Wacwyc•?ry ?:. 34&3 - l ' d L : I J R r c b r v ' POLI CETRAfFIC COLLISION REPORT ?TRAFFICWAY " I. U. roE CFCOmnunrrvlRAwu Ip r ' •^ PRIVATE WAY INY, Of CN00.11 COUnIr G1L5 DIf OE DA , w°NV IuSf ]:W ?.OURI ,,, r LL. »?. » COUNTY NO. CITY NO ,RAE ?' A l T - E.rrL?.L y u o y 4 I Ferv00 tfr09 HIGHWAY l ICr CLS 5 % NDUIE OR SIGFtIC SfC,ION I CIiv OR IOwN O N 01 O N G O/so mtf5 5 OW ?0[ NStNLO ON AS ?V P¢EFI% f0. f ]R IFPS[CIIrvG W1I IRf[r Oe RVJAU NOrv NIFI t 71 N N LS l?`•" / R ` b[IWFfN..x{ICO - 51R[FIe Stut[I P RAM MIA DIAG Cf vL U f`FUtNCI x051 SivfF ION N1AN11IM If PU51 ACCIDENT MIIEAGE O v C VAM 6 w OFF l7 J J?? µDDH ?/J FILT [I I NItR C, nG 51N[IIORRO%D ORR [FRENCE IN f[rOV ¢OM ?]] <Ollliq N S[OVIRM IV O IoVfNIruGL Sa1lUGF NI r++N¢NUrN © _ _NO.IN,u4to_ ILL R FS Ro -AGE ONLY ? f ?SIIXt"rv [51 OPMA0L ' N INIF Cl5 CROSS 5,9 G.9??8D SiFCUI CODING Ibf SlwMfl ANDOWN!¢ OBIfCT 5-4INAFA- CIB1f<151RUC% Ri 1 UNIT NO.2 0 VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST 21 UNIT NO. flRSl MIDaf 09WIR'S NANf: IASr ONYIR SNAmE wsI Nxsl aE ao acK - ^' AUORl55 FN SIPEtl ADO9t55 1QD J M AOL' flvcow PHONE No D cllr self cIP COOP NI No. IAIt o r,?M 4P3rP i=39A' mf R I Y SIAIt 5[z DAIF Of BIRiN DR NSL CtN5f rv0 UCtN5E N0. tRi F W4 AfOfb9N rnn Ar v Z4 60 V . wq 0wr rv Y BtNO frts YnILN, lc..N, E «cuvAl a+ INm N.MEa-NE No I- WN.N1 ,<qnr Z 111 NON n ... o OV lo I N aN ro1wN K,11 u N, ?t 0 N 0 CHECK (?I CFASANU V f A a;;; "`rcl Er 5 ? Ai: ?r _ CODES ? +y-M.' I s r N CODES D- 3 f Z N F5 2' ? r....>w >fl?i N LC%NV OV I h ? ? r r.c vM fn. r r4 0 mANII Nfv.l YEAx R ." O 2dPrr. 0 ?i 0 i.:t.w F'i" c 1 IDA41 NUVAI wODlI ' ?'iIl ?,D.. . . NOYAI NIR F IDGOGI CrBVI FLIDARI t s w E ? to 76 7b Yo Ta Q LIA H oR N A AN nwILN TAI Z N Ale ,. l IN O. If IFFAILILF-1 'All Y ?L.F.LOw L 70 5WA 1KAt NO 1 I C L Nca YlNIallo[NmK" NN F ? LL 9G• vlNKlf IlKN 1 I / O 6 L? ?^:r 3 -1 NO &"- RcrSiFxlO wNFR. Lwsr I-T mlDUtf NF"O. . .OWM. IASI N45I MIDDY 9? 91LI O ASE W wrvtR A DR o of U AuoxlssaowrNl¢ N Z E IN D,AN L N AMfaADORIUaINwNANC[c0 dwG[NI R N h4 R./vl LCI 1N ` /I+.N (;NAAGI?IN[A • ' ' • V ? . H.i ApfA •?wmi nP:'. e'??? ? M? r«Ir%,r,a CNAVG. CNA4Gf 151,IU/VAAGf , DNMU ? ?N[MMNIV vrrtn 00IFF-AD AWAY FS1 . iOflOii S ? ^ LU ? OW D WAY by nwA - f OT,d? : u GS eY' oNO4tN Br DESCRIPTION OF COIIISION: IusF SUVnlmINIAL SNLU4 ..-Y) Iu MfN nu ]5 oW DIAGRAM OF COLLISION: ssARn srBltur DEC.C ON THE 1W 40 Ap7FA l[./LyfT/"rQ n .. t'I Jl ti L 021 a,,e TAI A'O Y» A?oA 0 dh l NrL< G(6 i/ t}rr- D?Tc? RICO dq N.. AN.O 40G LO TJtt Ca4 0 ?F< 40- Gr Db NAME, ADDRESS I INJURIE10 I PEIRISONSINVOLVED ' CODES 1 - 2 3 4 5 6 IRa L... 41" , OCCUPANTS/W ITNESSES 'Fox ALwnIoNAL Nwm sT% Au A, r. NAw un °Ato4f a srlNr° ? w n 0 "A ' 0" . 0 6 0'.WN ? AOORrsS II,Rrw MUYIDIR M ?wm« o :-' 011".1. L) ? w(gvlii Amt " , N " ? 1,11°f p s?IV+1 n. 4A O AMB f l C7 ""». ... O '+2 0 ' uwn 1 rKr v .AI p15PwIORD Kl wvnNU 1.11 OF .1 O.c71t?i - OVA 'L OX I ?` 1 /J• I e). / .IL '_ NA?,$ IJ,:I '? I r +i Y ?.b m s ?a 3 Mild Y r d ? y STS' R n 1 A3.L+ h\FW+,I 9':'eecd9hTFrr??? _ Y III Jt 1 : f Y rJ ? S- . ,Y { 3 T Iv r ?IL(? Ft _ ' Irk; ?k I I b r J MOTOR VEHICLE COLLISION REPORT O• u`i DATEOFCOLLLSION M fLp? DAr Af?.n, YY YOF ON TNIEOFCOLLsS MNU,ES I nun f n v PN NO GTY NO. G ? _ Ow' QI.%lAL r l ??`' • ,E -TY CRY /T?WN ".. O?c W .Ly,-r i. A ?? / T E p MnE9 ©Q CITY. TOM I © OF J E7 ?L? C? AQMCLB'•' PAEPpI ' i.? •.. lp/m anlTREETCtt°E CO ZZBO SEc"m t NS1 yf T" GVEN ElNlET,ROADOR...WAY On TER CTNG WITH. STREET OR IgAO PREFIX: EO MILEPOST Y ? ?- A. NON INTERSECTI OCAi lCOLDS FJEIWEEN STREET AND CSIflEET RAMP DIADRNA DATA ?N © nns , En D .6^«,ur;. •, CITFA AiTE $ PEfFRFKED fAW95-ETT-- ? , ©® DF (? n Q (/870.. ?? "F ?YI IN m,E 8'EG 000I{IIBE OBJECT STUCK I caECrb,PUC•I OWNER OFOWECTSNAME AND ACORESS LOCAT IN AO jNKO gN N 1a DBpAD 10 PFP"rAn[0?' WA E EET EDDE f OR nfEERSLASTNAME •FIRSTNAME AR-E • I A DRNERS LASiNMI FIRST NAME MIOOLE < / .vE 'F° STREETMtliEb9. ,..' ROI1rENO.AND00%NO. w wJUnrD uY STREE ADDRE99 i[OUfE NO,ANOBO%NO. Gir r? STATE ZIP CODE DNVERS OCCUPANON e fi courlgx EP?ATf STATE 41>•`Y. ....-:r.?.r. _.......... LP CNDE L(AVERS.000UPATION. W17? 98 ? re `rlY. ERS Lq R I 11fG STALE SE% I DATE OF 91RfH AGE E I pDVFA5l1CENSE NUMBEfl STATE SE% M [ DATE OF&flTH OAr 'El AOE - VEHICLE TR. 75 MAKE ICNEV: EI MODELINOVADMTI ! vbac -Odd BODY STYLE I2 ORI ?/ - VEHICLE Yfl. MAKEICNEV: oOOGE) MOOELINOVADARTI BOGY STYLE 12 DrI.I STATE TflNLER PLATE NO. LICENSEPLA STATE LCEWSEPLATENO. STATE TRNLERPLATENO STATE 7 7 W,17 7 ay 9 I$. VEHICLE-1-AigNNO 119SB MODEl9l NEWERI ODOMETER IMIIEAOEI VEMOtElOENTIFILAigN NO IIBSB MOOEL9A NEWERI OOMETER IMAEAGE sSoa o j PEdSTEfl OWN 1[A4TF AMEI OFIVERELICENSENO RE[DSTEREDOWNER )LAST-FIRSTJ.IgOLENAME) dNVERS LICENSE NO. " oh '{ OVM 9 ESS (STREET R STATE r I DATEOF BIRTH N OWNERSAOORE95 )STREET, GTYAND STATEI OATEOF&f(fH ND Y YEAR L' • 6/ P' e 5 Y 1N- ?' W,{Fye ,I ? ?? ro " PAIII9 VEHMAE DAMAGED ttYUn e05, ?J`u P ?PEdr r /??? s ?o YENN? PARTSOFVEMgLE DAMAGED KY'F W!f s DoT N?WHInE i . C ^p WASTIIEREAUTI)W-ELIABILITYINSURANCE ,,??// EILITYI CE AEHICLENO.1 LOVERACE IN EFFECT FOR THIS ACCIDENT CN YOURCAR KITES QNO ?`t x ES&O N-R NAAIM[ANDADO flE550F LMBIUttNSIJRIHCE POLIPOLtCY1wL[IEfl Ir y]O r.M` -11 OF UA&UTY WSURANCE COMPNJY r L ,IP 1 lem, B - ( NAME MID AOd1E5SOF lMBIIIiY NSURANCE AGENT /+??p ?? 9,MF !P UABILRYPOLICYNUMSER l ? J > ,S rfJtlRY`M1' r AGE 2NO-LIRY: lulFIEVNIA,[REPM,fM MU,10NUihnrrlEM AOE NNAE ? n ?.. N%%IE..S un SE% o ? [D AOOnE55 SEX G %w I,T¢x.,aR © OOC MARK FAS A? U T ^ dn_ ®O pNOC LY SIAIUS Of VMUREO ? WVEHICLE PAANwD ONE THAT APPLIES r•M p5AI4M v?.. STATWOF WJUREO MARNFlRSi ONE THAT APPLIES DMi?,vn bl?i PD ?q WVEIIILLE : " ? ".. -TO -FILL ? 5? N ?/ Ctw I " n«7QIm B MILL 3P QEI+?N .m. NO ED -1N. rrAwOn Ircw ] no °` ' ? IL1 7 ? BE Q 5? rM]W NOnr R NIrgW WGNCLE H4.,KD O NNY,.r.,mrML„ CESCRIBEDEL WRATH ENEO. IREFER TO VEN%:LES nY NUMBER) !/ehlsle' J yV?7S Qirlg P/JU&I was e/- i e •rDrI,LIN[ WN,..Dw ?N.ArNN,? ri a e/wo Curve <yl t h /- Pit d ' ' JNr..rAIKrYYrrK.r..rDMMM„ .N ,b a R.,LIn4A N s an l h a` ed in / / gf/ G EJC4bl ?/' //J h p o h?s /y f rf da d ht b e? ! lde11's r 8 n r / d V d iS //7A; ; e ?je ? ' F f?? o lt?dy S?`ec ? an ? a?a' ` ? ? ed agf- o''n r? h?` o Paf }? _ •i I , =? ! ! '*Yr VEHICLES POSITIONS BEFORE COLLISION NVESTgA1ED r1Y w? ": r K' r ±I E r E 1 c N V[HCIF dI BINEEi dI H YVAV NAME UNM Dr•c,gM 'HlL r " ?°iliM'}. ?i« 5 C KI I a L,> Ua O O O •N O ?C." 0.= O Q ? ? ? o O Cc] ? 11 o ? ? ? ? o 1 M1 4 ? ? ? ? aaa <[rnAaD , :. )TOLL DIFIEMION To IMECTION ,:: R1 ' IN Ol Y1MAN WA, l11M1 IQ.SKY w4M ]0_':NAY lc)!NdAMII AQ !? uy»:°. n OfHEn ? I ?SiTF rr. ,niRrACE •-.Arran LfalTCOnan t•ty. M [w% rrurrgcunrMa ruerwoJU TYrF Or RDAD drvEnrv[IncLL,crIDN• •( NIKI q AaN YKI uNU nNIUMOII[I t 1 I t ? ;t' T /A DA ?7 r ??y ?r ' fllrl,i ?i^ , Q SAY,-, Q F fr' W h f w « ?• I Q GdM ST-1-T NlrAD Y? :JGN43 ,. Q, I Q OM1[ WAY Q' 1 I W ) Q LArMAI 2 Q OA- Q ] ? N X.N Q 2 Q IMV WAY ? 2 Q OVLNt-INGANOPASSINO ? ' O WI1 1 Q "/M)'rYYrY3 J PP.. Q En R E Q 1 ? IlI !AiN ? 2 ? E? 4 ? D ? 4AXN0 Want INnN - ? ( Q ' Q -w ' Qrm • LJ lYGrllS w• I' ? i Q IIA•JYNG PfD Q A QrIIIRCIIM,OE Q . Q MAMYK{LUIIUNN ROMII4AAM P t I ' 1 ?'?Kf A?IOY[wr1 °?LiYIis OII Q S QMAMFIOII IIJRN Er O, ?IIASYNE?-AlR Q, Q ? t 1 Q 1 ? sI?C?. ° ®elMRli 1 IKDrt! ? A ? lII LHU ? ° ? Lilf ." TVIN ? ° Q 'InN,Nn MASON IOIIrON MO DAMYA INY[B : ? H • r [ ? SPCCNY ? ! ? dflCin /CABMAN Q T Q fl10MTR f011IMf/IC O A ? D1.- •/NCMY ? 1 Q r;PARATEO ? ° ? d OF SOON L ?T L 0 2 ?DYLOED ? r Q 510- NIIOADWAY y f f !1 iI _ _T1IY ? M QNy! IIC Q A QIWrfIM(KD ? ID O1n./CINIE IFISqn• 4f -A" 7 TN? r C • 2 ak .A: ?aYiL,iYb ?,? s I I , r? I J? r1 L K. ) 4 11jI r. I? s G . to I ? h ; STATE OF WA INOTON w""°IR6V ?_ aGE Df z I.?I ry No. POLICE TRAFFIC COLLISION REPORT tn??Aau TRAffICWAV , t oalFOrcou PRIVATE WAYCOMgAINrNWA&R - 31L'T.'e 3' / ?f 7S IX?I uox IuN .N .3 Ir ]IippMNOUR) (.I CouNIY COUNtY ^ / 7 CItY Np, fMYA ' 1 ; • _ N ' Of SIN Cn YOR tDW N TiTT IZ «? N0.Nf eN0 Of Srq[fiOa NGNWA QDR UR AE {{. ? ,. - o » I !-. 45 gOUiE OR St nVIF N ?W pr O I cnlvc N: Sivffl pe AD F+ NpN Nnq,Ep,IDN 6zz8a r r f tCi+ '"'.`FAA `'V,/1 T PttNZ E MnEPOSr ` ?v? % OISIUJCFA ?1 RFNCt CRUSSSIREF fpe NEARESIMIIFPo, SlRfflf SrgE(T 6 lE f aES [ S ` - P w ACCIDENT 01 RAN OarA rfE, ... Or MILEAGE [3 cl _ s ' ? * gIISrorvINVIXVFO Nv[e Ir CODE qlt? , r IOIAI NO. O R NO.N eFD ?spllaGr ?N16RUN wr.uxln x. q VFN CIEs ? v ORq,Y -AGE ONLY ? p[S ? SIIXfN x NFER CLS N 5(CI sIREF10R ROAppq pfrFRENCf Of OSSSrR[fiORppAp TZ Ii '!r . e 19" ) ' I3 } ?2 ? ,? ?{ ?? . ; UIIrD ORNCI SIRIx:R ENAMf p{OBrEC, srRUCR ANDOWNfRSNAMfI VfN OF FSI. DAMAGE sRCW CODING Ibf /ONTO !? _I1 ': T , ] i + . - ` UNITNO. I DR VERB NA UNIT N0 YF ME: LAS, 1 .2 O VEHICLE ? PEDESTRIAN rle pgrvEesNAME sr OPEDALIX YCLIST M >. N 5 ? - s !? slefEr ADpRf ss ( L 7F ?-?// J? slaED nuoaESS G Ii CI -. S? E y ZIPCOOF' PHONE NO. D R Y su,E IPC E peW?as ucfNUN s1Alf A LEI { xtit 009 a «cwA,w f F No ?x.' LICENSE N0 O? IA1 sF% DAIfD.1 RI1. ?+ .. .• - 5 5r • --E- .w'? fYfs r E. GN! E UCCUVaI ON ?- E qM NAME 6 PEgNE NO. EYES WEIGNI EEIGN, I l_.xfCJ ?L( {j ? CHECK (P? vr ? io a q ? } ? v'iyl 'r . h ,` rvfmR ANSr, vr Co] CHECK (?) CODES?*GNS• ?AE < 'nN If asANrrn O o o I VL Q s R nf rnn Nr Ee io.crcl vRD T xclxtu C ODES ? h 3 i,?si 4 iv 5 rx Q uo , c rv ?fZ ?. -: eI? E i VaNNN" u O •mewuKl w I ?o'°oM ? U ? N VtN. YIAVp MAa1DODGF. c-, ?MODfI?jUAR1INpyAO M O r I , ,.4 o vtf It Dg G l.r AR f E I NEVI Mopes EDngl NOVAI O CI E.V s,z :i:ele ?:°H; ?tiAws . a?: DR ICEN P srAlF 1=11C 7- fa RAlf NO. 1 E H rellcIXOe J Z z.?'? { ?. ,?? r •^wu +.? ? R '?.3?&? 'v ?{'?. n VI"l IF DENN A I RfgSnRIDOWMq. LAS, rlRSr Obi LL. )n.i ?i ...?..?_mloaF PEIONF NO. n Is eq wNEe EAS, ngsr Mmaf I w. 7 V7 r??. 5. ?:- . 'R .. «. E R L°,- - ql°d_'?. 'yt' / ^+.•••.. .. E pr wORVpw ?-Vr-LISION: IUSISWRtmtNlwt sNtlt It MCESSnarl }?? I $?J 6d ' 70 7J7€ oleir?S+ :: :: ? - - - - - - - - - - 9` -£s?s.etEyr?. ?' ?ercE•eJ kf,Jf nrlvEt?sk ?. 'a.,'^ caa 6 IN.IURIE5 OF PERSONS INVOLVED OCCUPANTS / WITNE SES rvM sISREmn -NXI Aoo E ° CAE. CODES 1 2 J 4 5 6 Ji J %h.J s'G40a v su Acl anu. ' N„' :.t.. NsI. E?<r , D R , u, a? ?y? •roN:v Ti t/t w 5?6q. n 6q AMR ? : ' O^ q 0^ t t, .. :ITL' NAM •DDErl3 N? Iwla ?mov, rROW ,w,R ??x,r ?...» hJ i E T rw:r p s?r.o ?D•-w nroRl J I T bl; - - A % i t l Y ` STATE OF W S A OFF 0,01 HINGTON ® REPOR SUPPLEME RY POLICE TRAFFIC COLLISI a u r{. A rt E T PAGE o1 - OF IDENTIFICATION F . `+ _. :!2, (3iz C0ILISIQ(Mg ,? „„„ . CAI y . S EVERITY OF COLLISION ? FATALITY INJURY ? PROPERTY DAMAGE ONLY " DATE OF MO. DAY YR. COUNTY city STREET, ROAD NUMBER OR NAME COllI510N IOCAIIONQI??.,?r,_C T7 '7 - d :.: .. .. ' NAME NAME N(1ME DRIVERS ,, J, XkA vs t as :DESCRIPTION Of C4Lll$I N O :.:a<,-..: LOU FOR ADDITIONAL INFORMATION WHEN SPACE 15 NOT ADEQUATE ON ORIGINAL REPORT OR A$ A SUPPLFMENIARY INFORMATION SHEET TO CORRECT DRIVERS NAME OCCUPANT 1 , LOCATION OR ANY DATA NOT KNOWN AT THE TIME THE ORIGINAL REPORT WAS COMPLEIED. L ?r2ll?zx C rht` ??h•, kc?I?TKaEJSkr? ?(?IL?C To k;tE?07rA_ __776 GuT?c.L ` ?? t' C!? ?r?oR? ?' IE?.sL?r,;c f . ?vI-? ocd ?I SccxV ? ?y ?? ? ?' • C'cA-7wouEd 6o To ShoF.Ecdsx-, o F -//,,6 400? ? .?R .+` -• A ?o,'D-TF.?vz?a? ?osp? s?.d .?iaz.v.? W,r?s __ . `'? .Q? iJ.1?f ?/•OTe??.r.?S? ?43 i?/ •?pie ?U/.tfz 1???6` z G O 4X DRrIVEuPEDESTRIAN NAME - ENFO ? 'i ,? ,w, ti39 JGaMARWNRM.Ru_r IC-m. ` .4'A or TROao..... AYUYY ? -. .. CRTIITION MO ? T , fllApfi6?c:6rJ? "•IsY??p'T ? i _ , , , , ? i. kln)rEar-kau?s/o, Gsra• ?p?TE ?cJ.L ??9 ? -/3 ? ? 1 v 3At ? v. ? -UTAGRAM'0[t?9LLISION :.; .':!'; ,. :: Y , '•"-'ww?Nq??{a5 ::aadi?[t URA. UI.Y:RAM OF CCaIi:,I ( ll kEAS R .ABI( PROTOR110145 . KOPEkLY IDENIIEY V(JIICLES AND HIGHWAYS. SIIOW 5410 MARK5 AND OTHER MEASUREMENT... I r I l R? . ' , m + xR r Iusf RUn nou I ( •v? •ux v, n rv, f. ? GF6KSUN OITORIOWN f arc ND. Q{? A /? gURAL S []N QF P4- 6rv0. p{SIRFFI ON H IGHWAY mlf5 Q55 OW Q I ON GES? rNl{RS[Cr N4WrN. IREIr OR ROA NON INTERSECT N Cl5 RWIf OR IRfF SF 'NON 300 Q I A {I,' ) PRffl% F MILE POSE /? Bf1WFF s 51?e / / T 4. T C I UsIANCE %D Vl AI ON Eapm RE[FUE Kt CNOS551RFF10R A Srmlt { ACCIDENT RAMP DI MIA 5 F rDO Ef[r [] O{ MCODG taus orv rvvrnnn YEVERU RD IN CLING OR StItF RR(HDOR REffRfNCF IOIAINO NO VIIlD?NO. NIURFD ?SPIIAGE ?NI6pUN rumr,oxoiX IMER 0. CNOS.f STR[£I ROM IX C © { VEn IIS Q PROPFR1YDAlAMfON[V Q SUItfD ? V[rn<IE a,S,32 9D OnIFC151PIK A +IN Mt OE WItCl 51R-,-OWNER 5 N-El FSI DAMM[ SPfCW CODING Ibf 5 UNIT NO I UNITN0.2 ?VEHICIE QPEDESTRIAN ? pEDALCYCUST V{VS rvAMI. IASI NR51 IDOEf R'SNAMf SI SS -- 1F' T M F /?cr? N / N17 r ci' L rrv N SlRftI AOOPf55 INfEr -R- /I 5/SL' r[ (EAt? !?/? 3 / E ?NE ST OIY SlwrE EIP CODE NONE NO. D SIAIF -c P P L kv /dry' ?Sb S-3 7? R rvRS UCfrvY NO. SIAIF F E ALL//i? Cr/A Sel Z ?3 % OA BINin ( R' lKfNSE NO. J IAIE SfA ... DAZE BIRTH OCCU A1N PrgvEE NO. EYES WFIGnI HGIEI E E OCCUPAIIMI {IRM NAME6 PHONE NO F FS t G 2 K? O R C Y N I HI EfIGH L 20 Slli I ? CHECK(?) : FASN UAPiovtE O{ANDrHIIiA' Q CHECK(,,) mMEa IA l FA A on O CODES?* D ,r r ; 5 r e u ' . S F {Ae Ix R ' Au, CODES b- * 2 n ?; w WS. .r„.,.NEI Q WH. rtAa 11(000410-, uR" ? ?6.rIR ? r.r ? Cu MOpfIIDUII NOVA) SlvIt IRDR CONV rM er ,n:,DrrDM AMEN, E ? ue" ? ES.H. Q „?c` ? ;.;,:. R? HK 6£ Ch'?V / . ) /iii .?v E .1 MODfl10ARl. ( 95 /Y1q?U/TT vAl yU LG V H NC{N- I N slAlf 1-1 NO V- H .CC%Op IL AF ro s/ du, Hsvya Gr/ra _. -- R vtHlDlfrMNrINMIrorv / 9 3 L NiG1511v(DOWNtN N51 Sr IDpt! PI D IXICIF rOtNtIN A Jnn E3 X21 9? 7 i35^ SRR ? I NF NO 0 UC yy uno O WNFR: Uc51 Sr mrpgF ENO. ??/C d!%/V?I /?? E /S ''?/i u ADDRe wNtR N . . . owrvw SDI rvAMFe DORtSS R E " IX INw ANr.1 tp WAGErvI / R / ? f'• ;!RTIZS'&TRFFT- ?TS?T?rrv ? / .vs +/1 Urr.? rJ EIMMAGfDK{A ' `rvsAN?Hr. DAmAGFO'ARu cnADCt OAmA4! Q=Y QvIMMNID oIARG{ Q?q!??N ?RIMAINID l51'ONAAGI ?5 1+° DIAGRAM OF COLLISION: SEYUVIV[CISUPrI H nr I DESCRIPTION OF COLLISION: J.slpPllmlN Ul srrfrHNecnsARrl S T L 46W, ,'-'rkf• E/?'STE(jOl(.tJe? t!/f/E.V NAME. ADDRESS 81NJURIES OF PERSONS INVOLVED " CODES 1 - Z 3 4 5 6 wn su'n1Ly MA, sHfn OCCUPANTS/ WITNESSES rEw ArIDHKVw rwuss v+ Acr .IAlus "` ,. ResIN fact " a? z3 r No z 141 z +uDRm 7" .? 1fG , uar or S Mn xx „ Q r. ' Q . . o as ? ::? A N Mt 7yy r a , .l Ra? ??G? v? ?? •Y uRwlss 4411 uvl Nwlu lvaM QAMe Q": ' Q?7;. x L3•:? Q ;` o w A I 1,Nld 5 •Ir" r e ?AMe ?" ."."Quin+Q t;,., Qn X +• ?rs,•,A ry;"µ • .? / ??//? ?1+ ??f? - ?_?i `?cw ,< Ncr E D T I Tcsri . X 2• ,D,}ruurD /7Yv E. Nn ,! ^ K'.rcf Yp? /7 TI Tmw_ Mwroar O(l3b PwovlDer AN STATE OF WASHINGTON AG / OF ? No. I '•.O POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAV'••" IIXKfcONRNNTNIYABfR Er.W. ;N, PRIVATE WAY I 'J W? Ar OE COl115 M, OAY I ON COUNTY WWi1T NO.• ...GR. ?. Irk . W r gN, 74 4' .Nr.7.v?`usS..,??((",?*'-.. ?r??.?e-r.¢;. n ;.. Ik ,{?Et? 2.Kts. ,,er sr?-fP'?;,'lu•- ?3.. ?:. ,F .:.. 3x ;. .. ?,..2 POLICE TRAFFIC COLLISION REPORT LY,) 1RAFFICWAY IgIICf COmwunlNUMBFR I ? PRIVATE WAY Inn lnt OU N ? 8, Dare [OIESON ,. .•,...1: ,Wr ,., ,.1 IM! C 1111! ?wuErxwURi 073L? OUNIr 4.??tlo.'1 COUNTY NO. /? <IIYNO. H WA D'URBRAN I ( OIV OV IOW'rv O slwlfl ON 1.1-WAY l n: oW °? Piiansc?l ON ?-Al/ kJ CIGS 90UI( IRE( jlll ?o9A?o LION I(x.ACUNG N'II ): Ixtf rWN ap NINIIe1fCiION mfix F MICE"' I 1 IR1(1, sIR[(I E E f Or1..s?3 I Ikf f I D111ANCf MxrS 'V'u lS xlNCl. CRDSS S OR WaNtll Mltl x011 ?o L41 CDV?, YDO ° nEl n n n o sT So. W ( ACCgENI MILEAGE coDE NAMP OIAORAM DAEA C011I'iuNlNVtN Vfb 1ivlwllr: rq AIIIIO?NO INEUR[0_ ?1vItlaGt ?N116 NUN ww?uii?wl Nr r' m u Q eRD N CI SNEf10R ROADOR R[itxfKE W INIFP CIS CAOS151N[FIOR ROP? ? IRU rq l ? NNOHRn Damacf - ? u 1tCI51RUCCINAMf OI CRNECI SIeuCK Iwp OWNf R'SNAMfI E1f.DANaG( 5 Qlo 97/O SPfCW COOWGIbE - UNIT NO. I UNITNO.2 D VEHICLE D PEDESTRIAN D PEDALCYCLIST f Usl l-T MI U11 RA?,dD., ?b ?, pRrv(e'sNNAF: U51 1-1 -- SIN(EI ADpRf51 lI (F 71.7 5o L S i 11R[ft ADpef51 - [_ 1ra1[ tIRCOIX 111N NO D 1 Y 11AfF IA CODE NrgNf NO I IIq MIA,LJA y$y R _ nlx'1 tICFNY NO slalf fA ANbF-R-RC7`l8M1 LJA I 7a21'R26 I v IvfR' IKfN1[NO. IAIf OAIf Oi BIRIN Na. rw . NRM (q.,<.a..,,,?uit Ens w[ICKr ialGNI E accuxnnoN NRM NaM(a NrgNf NO. fns wfgrn rlElcrn 2 STfFufFce Ckcn cwL ])Re?w R CHECK (?) Mviortl or,rvalNfelA( F r IK ? CHECK (?) NµilvII Ni vA1 Gr AS,NFMNiliniw A " 7 r ?; I _ CODES? "" 5 CODES 1. T 5 E i A i 1 e v R' Z 3 " n• D nn: C1-IL` l Mr` ' 0----o "DE DD1. W "i Z fAe WWI Cr1ty) t l 19P?PfLK UA41 NOVwl I Mot-1o2 11vt[1=UR 1 E vaR Me l G1fV.1 v MOO 11DAN1 NOVn1 l R °N xB 10 r U?'EE 1<wseNW llN bZZ33l of A. Au Np n. 10R Roooy/( D/' H I nN <aoR N I r"..... _ „ 113 V(NIG(IUENIIEICAIq - L VtnKlt,DtN1IN A NN ` \7 Z GlsnNloowNtw. IASI sly O Mlppll s vFrEe (ft B.ctc?a[ ?. xwwNO z?a-a/a W rsERiD wnfR: WI 1 i'i app 1S R ? CL? -?.4 Z?Q E le ApOCl1SOf IN1UNANCf CO ORAOINI ?- „) R I EounAao calla ?ti? ' `a 1M DAM1,tc ?DI:RIA 'LL ?O?e Or171 Eu onM.su nFN ? AWAr ?RIMNNEO Ri-D Aw.vN ev?DUnnc? 1 1L 11DlOT \\ f 10 ?1D ? e. ?IDW(U f ( Ind D (MNw Ir er.luoOWollr IAGRAM Of COIIISIUN• i 1rr11 U NLGSIAYY I o ds /So' Q? N DESCRIPTION OF COLLISION: nnf suwnlMaNw aRGUNIGSS.aRrI vCl. ?I E>? (3 M', I I lU WGvn L L.F(" f2.Ad(any s s.., so, . ,u-?.u oilr,a? u,?? t `tA-.,L k ON UL1' W" .rn ?oAdWA? S°? yL ?c $Crnd.rt? S-Kl.i?l•.t, 21 ?° c1 1. ' NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES I - 2 3 45 6 OCCUPANTS WITNESSES ((.. ,,po,rNlN."; r,AM Eei a. ncr ulu. ' w lvR. ulo. I v?R. 1 vu'e L] (:, 11.1; 11 . I na 0 „ P AI A rr,rr ss ,xla ??nprROM CAMS •D". ' D" . D as D": A 1 ' i.:lr lr.AW RrAr.r R,UG 1fv w., •e"r .... - U,1ra1 ',R(. Ki 0 p ';AlA 8, ,wrwpvEUBr 0,11 8 1L,? '.k, . I`Ki.M..... t 9 STATE OF WASHINGTON IgAGE DF No. O WSr s EMI POLICE TRAFFIC COLLISION REPORT IoI TRAFFICWAY PgICf COMPEAININWnBFR PRIVATE WAY . y ? 4 _ (?? oECaE, N F r .v Uaro x,r gun I w„ " USf ];RI;, caurvtr courvrr NO. an NO. ` -~ i u . N 1 _ . ,.I I Cluxl 25 O I ?? ? UY `R R E. N Cir UN IOWN [0] °t Naf {N f SIREF Ox NGHWA, rCl Cl AVIfS 5 N ? ?w ?ROND(a ON N E ROUIl O 3 N SIRE! CO SfGI N x 7' l '?, l E = IlxsFONC VAIH sTREll ox ROAD Norv NIENSfcnoN G 3sGo t aA IWFEN Y?E ? PREfla EQ. mll[v051 O I? ?? -SC iSIN,C[{DIRECI f USS SINIFIOR NFAef Srm l[v Fl FW M ES ` ei ES RIN N 051 SlNtfl ACCIDENT RAMP OIaGNAm OAIa - O - Q FE ' ? MtEAGE OIIISION NVOIVID: SO RUII(D?NO INIUNED? ?SYRIAGF CODE w"S" IN 11 1 U II ECING SIRfEIONIgAU OR HifxlNCE VS I STIIIIl I m -NG 4 ?. ' ' 1-1 - D 3 R .Al v DES ALICHI HIIGHI E w i I.A6 c? R x* g K ,? `1 FS r,aca'S" axa ? ..'?9HxAPtw 3 Y N Rb1:1FEf? E IssaINwRAN<rco aacENt A.Ea R "aF6.80 }IOME.R f`AZ'T?1 RT 3 ] S ' wil?:_+, CG ESL DAMAGI q/1 ^wwN ?eFM.a p1ARGl' .?.? R'VEN N(? M Y N"'wtN Ishlunma{;I I IN 1Q `A• X31 J L s 1=11. ? ?REMAwI? IOWID It]I W {I 1 nY El ? AWAY nr. X cot ISION: ii,1i11iWCisiAPr'I 'r'luv:ucow"' OESCRIPTIONOF COLLISION: IUStSWNIMEN1aISInIt Ii NICtS5ARrl 1 (''DRL VER a'/ LOPS RsDZF.,E; N MOroRCYCC.E EJD• R f J Nb. ON A TRALE- AC20 3 PrXvATE. MoPFRTV. HE. FAzLeZ TO STOP, wNER6_ TNE- TRaLI. EUIERa6 I ST• p,`I FT. $stos NTO F AT'rxDON Sl•? AND W6fvr .LNTO nif- PArH F DRLv6R *;R . viem A. * 2 WAS co. $Nb, _ ON ATrrsoAu FSr.. C ' E? IDPXVE.R "I" k C1 ktL N•LS SAAKIS FPXL.C-D Vf.w.*I F HOWEVE.Rr X CHECKED AND FOUI.Ib So-rH FRo NT A ANb REAR BP.FIkLS WHERE ZN PROPE.R OPE.R- wo a'"'U M Ur• rcffOUrNO OCCUPANTS/WITNESSES INVULNtU I. CODES I UX Act ulus - 2 3 4 xtsrx - 5 6 Enct E QSmG.R :.-WA R• aa7Rl 1 2f?? N F' rFRr rb x ti37' R(.+'1$ DPE a ? AMe ? p. ? ? n _ ,Y rlr?Z Ea?C W ..wE mDrRON ?M, ? : u ??", . ? YI ? :' fio .away a Au,c r 'A.,u°RN?°E scan e: ?AMn ?," . I?N.. ? rY.. ?: a ,A.y,A UN. X 9a?...^y. n Du ...ar.c. ,.. ,? rcMV nA Kr HD pnnaNNCwI P pvioe. uan - 1 b y ?R4Y? t ? fr q x 9 y { N { 'fq .U0 .. UO Cl n ? m0 ' I ... l HON 0 ( , t yn ib s '?{ ?i s r i Et ! 4 p W t J. I i? ? I? t ?,¢? aJr:9^y'p a It 11.. ,I 'arc POLICE TRAFFIC COLLISION REPORT I71 TRAEXICWHT R%ICECOMPWNt N4MDFN PRIVATE WAY .rya . IFO c« arv F v .s r . 4.1 A N y Pny Ps .IR f Iv 5.1 IMH (VSf axpO OUeI 1 1 U r"! courvrr 1, I, I K. r N cnurvrrNO. ? /61 curs. _ (O / E ?r nN f,RAI / I ?N IN nrr oR lowN NAmEaNO as,RFEl oRncnwAT ?E ? YZAVEIS $ ?W ?O,rE1fAT taus RoD I ?/FR?Y5 GWIIH sivEEI UR D NOrv INIEeYCI ON C10"? ?.f 4 .E1wefN s1RFF1. s,Ra, PRfNA MRf POS, - RG a 3 SIAHCL.O Rt x[,fetrlCf CvOS551eff10R rvFARFSI MiIE POS, 5 [ ?(/ D j1/ J m' l Fs CCU 0, CC r• I ! e ACCIDENT MILEAGE CODE DIAGRAM DATA I Inft R OR RErfnrvCf R I VII CpU$aNINV[D: YvfR TY: --7 xIED?NO.INlUVEO_ ?SVxULF ?H a VEHICLE$ PRONRITOAMAGE DNIY ?pESIIFD [?'C [rv ??Ilsrv ,•IyDwDI, IN INIfR Cl5 N YC I CROSS$TxfEtOe eOAO ,s. UI OBJECTSTRUCKIN"EOPODIEC,$IRUCK, DOWNERSN EI [s1.DUAAUF $ $nCW al-11E . LINITNO. I UNIT No.2 ?VEHICLE ? PEDESTRIAN ? PEDALCVCLIST riR I f DRrvfR'S NNAE: NPST maIX[ vF-IAST I<' r A wER'$NPMf: USI $,xlFT AODRFS$ Mr. 0 S 6 V z c 14 L Pk P [F, ADDRf S$ Z , . . . iv PHONE ZAP CODE rvO $,AIF C D PcoDE Nf rr . r -T1 . l A. ?"eT3 'i ,Vcnr W R /-7 NW, c x AIE r l frvY>ID AIF x: Y. <? l I T I: s n 1V A M 4r 9 V ? MD OCCUPAIUN MNAME. PHUrvf rvO. fvF$ aHi 1(aX, E KGHT UcCUPAI ON MNAN.E.PWM rvO. EYES W-T I ? CHECK I,7 yEXIC^l AS fw.N rM IOYE o, AfMiomrRAl ? CHECK(?) ciF ASAN FMnoYEE OfANO X1 ieal ' ! 2 . IwH irn CODES ? 7 n"ii I S I a "s".° ' v iv nm"• claw wn .c l CODES ?, 7 n 5 rK e y S n ? I WD? D p MN I ? bklR l$ Kii ? i.°. .CONV I SIYU:Ia DR DAR1 NOVA f M ? wv .:A, ? YtAR 1 CXEV.) rH u. l ? oam ? H ? Ii°.;v. mOD[LIDARIINOVAI K1fIt OR. 1 n>u I D . . ) YFAe MA EIDDDLfCnFVI II Mlri?4 P(YM V/lLCr' G1Y E ? n. ««+ LICENSE nAif rv S,AIF Art@ RMF NO. s,A1( H vEn. C«OR N A R A, NO. 11AIE s31wE CMwbol L?rr I 1 vEXRDf ICfMVaA,gN N« i vEnaEFIarv1IN AV Nrv C 4'G! /3 3o- - RwartnoowNER IASI 1.- 1 PHONE rvo O I eDOwNER: lASI nRSr miDDlf R a v ca s r? (? a t' W / I a> ADDefssaoWwe o+mfR • N - NAME.ADORESSa INwxANaco oR ALENI R AN as s.>,I . N as K ' DAMA?wDARU ARU? g x,EO s ..... fsrpwmAee ? i^r 0-- ?AWAYN ?RDMUNro tsr. DAMAGE Tb'tA v :wMDSY. ?"R 2C So ?:w:'.°er $ DIAGRAM OF COLLISIOnfaasuxrl I"ev:IVew'H ._. DESCRIPTION OF COLLISION: IU$E SUPPIfADN1Al u.nu Nfc[ssARrl w. \ S Q@- v N. K1 WAS e-t T. N. 1130•.ALD . -k 010 E Q X'S c. r:VEIC.N Kn. hArJ-E.D ro VG>•ic? du qVG WAS at -"NIrnP. DEFT. E H[,r A, /m ` _ Foti elo F' THEN 5TAkcIC ?. 'rACC ._ - GAME TO Ei r.ST N THE $..lf?T'H' a. . .. / BorlND LANE/ FACI NG_EAi : n ?rV Dtkv.v EAYY R4, , ' 1 NAME, ADDRESS 8 INJURIES OF PERSOWS INVOLVED ' CODES t 2 - 3 4 5 6 OCCUPANTS/ WITNESSES ,n sinp?liwuA'w.sw? ii vx All, r.,t nsrx. Exa .i7 N- is .cr.rss uxEa xr. 0.M. ?11'?N,. ?R ? NO 'Wo Am.as nfJxra DIxoM?? O:.KI?p??Nf. ti. 'V t rwra rAa.r ?A", Om110"r'o".:I. OG." O- Aartt aMNxr A.IgV10.JN .•,N ?' tlGSlxq«IKIx$NAV...... A Aa:INCr KI DM1PAI41I r R NO All IfI., "3d'?/ r. L a R I r'L ? ? ? ..TCSC. ?I!?°.:i r.4n.E NC ?f X ? !C p, 'L'?a?FI _, e T i41.{l ?. 1` - -•7.'i? `.,f ., h 'hY'?.? I? ??? 1 ? yf?!N? .v'rJ'. ? :[7F?L?w h 1% f" x„t L .a L, E rl ?? x 6 f ?? 5 ,t I .fws ! 1 tltrM' "? 31 I RLr 1.`?? 1 i ,lC? I `,? t f I S. Too - 4, y kill y f JIHIC Vr YYMJnrnAaU VrY _ MOTOR VEHICLE COLLISION REPORT NO. SUN arr oi uiE6 ?AA xT7 COUNTY NO CITV NO. ? /? ?U9EM. l ?,. • V • Or SIPEH iRI{WWM F[ ?A QE ?w Ow - ?I MLER ?:. W ?? . 1•(Dr.7N ),,t;' 1 ON ?!L- l FO1.C PREFM 3? rgU,EORMrKEt OODE 1v087O [AREnrwwm sPEFr ?,o, wl[RS[m y ?LG'!Li7L1IL'IYI?? mvM eo M.BOm /if/aCTc37. ii.U.O 11-111, NRrnPOGE aM.P -1A w LF, D - ?MW?OR1EOo N11E "KUw a °? AN ; R ° a ?: ? [REH? o , ` ? B H W-ETIB o ? wE s E3 5i OBIECTSTRLICK INWJE OF OBrEC19TKUCN WN F BJE iB NAME AND ADOflE9914f11'OMFOT 9•[D.WKUSE J V $ DRNER8lA4f NAME - _. :E F MIODIE ?z l i? i f? t:vh:; Y's• rS co- ORTVEA'SLAST NM E E MNOIE f n' L c'? ll I-tS1ri'I?. ` STREETA E55 _ ROUTENO.ANDBO%N0. ,•,L rT/',. lLG '.E STREETADOHE89 ' flOUTE NO. AND 00%NO. %3C' AKJ-r I I CITY STATE DPCOE +EI: r, ?.l `%,il'? DRIVERSCCCUPATON ,-I/ EPD RTFDRM CITY STATE LP COLE Pr, lL.1,:18;1c? OPIVEH'8000UPA rL??;l?:. OPoVER'S DENSE NO. A GATE OF BRTN AOE DRIVER'SIICENSENO. STATE SEX GATE N M AGE VEHICLE Y.- AIIJ[E (CHEV. DOOOEI AODELINCVA-DART( BODY SttL (-1 VEHICLEYR. MAKEICMEV.0ODGEI MO L( M 1 BODY StYI 11 Dfl,1 <?'= hh?tT. r.aLu 5 ii , TCYcGGsI zdr LICENSEFUTE SFATE TiWLEA PLATE ND. STATE SH L ' vu PLATE STATE TIUJLFRPLATENO. STATE L oIZ LLC+. VEHICLE IDEMIRCATON HO. VEHICLE WEHTIFICATION NO. REGISTERED OWNER (LAST-FIRST MIODLE NAME) OFBVER 5 LICENSE NO. REGISTERED OWNER BAST-FIRST MIDDLE NAME) DPoVER'S LICENSE NO. OWNER'S ADORERS (STREET. CITY STATE) DAI-I, BIRTH .Itl OWNERS ADD[IEBS (STREET, CITY AND STATE) GATE OF BIRTH ? PAFTSOFVEHrCLEOAMAOED {FBVrmin f?C „ PANTSOF VEHIC-AMAGED Nf r LITY LIABILITY INSURANCEINFORMATION,VEHICLE NO. 1- COVERAGE m EFFECTOR TM IS ACC ENT Off YOUR CAR AYES C3 NO NOLER -E AND ADIXiESS OF LUDIUTY WSURANCF PO=Y NAME OF UADIUTY INSURANCE COMPANY E NAIE tliY JAL r'V`Q-- lt, RATE , d G ,,... il TY NAMEANDADEESBOFLIAWLIYWSURANCEAOENT ATE Sa LIADIUTY POLICY NUMBER q }cws?tcur'Yl.cc>??T.tf ?'L C11t. ?KPlt j Lr LV(•, S% 7t ,STNAIRY NAME AGE ? EO 2ND- 11' IUSESCPAAMERU-T ORArnTDNU-11 NAME AGE ADDRESS MEF ? ADORERS MEF NATURE AND EXTENT OF (MURDER ? ? ATURE ANO E%TENT OF NJURIES ? ? -N.AfTIEONBYA000TOW O NW?.IE RB EIUMNA} ON 8YOA D0CTOM ? ® MTOHS STATUSOFWJURED ? Ori, W VEHX:IE O PAVI ? ILLED MARK FIRS ?nwm IREVLPO P T LIRE THAT APPL Ill A! "O'"'r .u `, IES ',i h STATUSOFINJURED I nn IN VEHICLE Clr•A LI.EO K MARI[FIRST .rY'I. ,xvUni ONE THAT Al AN i.i- RsQ POSxN COMP o nwMA,H.N ? eQ sn 'o", NO (H,1 .... p 50 F 7 MOTORCYCLE SAFETY: Q HELMET USED p HELMM NOT USED MOTORCYCLE SAFETY: Q HELMET USED (3 HELMET NOT USED SHOW NORTH BY AHIIO W W CIRCLE DESCRIBE BELOW WHAT HAPPENED: REFER TO VEHICLES BY NUMBERI Nam[ W M„.. NAM „ ar O M Yr . 10A11Y1?? 14.) -Q1,, 1 d, LJ-l l ? I. Llb V`L "vl Gt \lit U•CL' .'-I!'alu(, ?- Wa ? L?YI 1 "'Lc( Y?[l:i /_; j 1cL??P='t cE?il? n F K 11;;;, : A LLL'L(CI (v c- (.L I1 CIL°L?L_CL . Hrc h u ? sl f ? ? Er a r c y L.ds Ls.i 7uwccn A M_Lad lY A?4LLt?w?,<,(, T CULW Y101- • 5'kP?L?L/K b?Fli(.(.Lsk ? :/11:L 1+ :L.?, I.L;I•v rZ:r ?? r ? It? c(?;; ,.?u T ?tc•t,l=e-eI ;,r-x wL: L+..FL.:..{?-s , TG.? o-?Y•:.?Cr~Jti ec..Yll.J /,-i 7 /U l'J%•L•t. L tcl(Z)L!,. tLf a?1 Lx t-uU./L. 1EI i . G1'S .Y.Lt?, Ll.?n rL•i? L?•l L?-..In1 ?vV?-t( Lt ?I.L:T' Ad- VEHICLES POSITIONS BEFO KwRE R [ w RE COLLISION 1Y WOnWAY RAMC OH NO ON r v? H,zll"; • N?•? u.AP mveblwATED BY ?r?:i ?h ? rurci pow m ? ? ? = ? ? J ? ? ? ? ? 14Mr ? wROY Sn M- ? ? ? d ? ? ? ? ? ? ?MnrK. -1- ? ? ? ? ALMA FROM f0 PEDESTRIAN/PEDAL CYC LIST WAS USING' r0_w kQwN JQErorA .c] AQ ONnN Ip n;e rouii n?roFOwAr PEDESTRIAN/PEDAL CYCLIST CLOTHING COLOR. r c] 0,-, E] -- .0-Ro-H.H. C] ROACSAFFAC[ W[ATHERI LONE CCOYtON] T-11 C[WTROL TYPEOF HOAR M n,YEKICLEACTIONS NAr I Q DAYIfi.T ' KrK L' . tW,r . / Vr YUKII. ICIKCF UN[MIMpVI ' r r p :1iN':::' ) C) a.- Q , p -.,a p , ? ONC Al W Q U ? 1'L)INO STRMOIN MIEAO I ?[E.Y ? i QIlAF4.G D QOUR. Q p SrO NGII Q D Q TWOWAY Q T Q OVERIAKINO AND PASNNG ? k ? N41 ? T cl- J p RHCMNO • ? lO•)1M1 ON f r 0AR. fr I Q 1 Q vlT lO SK.N " 4BIF W S G P f?•1 J Q MAKmO PLIGHT TURN F CFOO ! ? 1F , Q ? F FLASn KD 0 IJ A ?I OOP RWP I J A ?~INGLOFTTURN ? F _"ICE E ??YYCMY) A ? BIREE Ip." ? f ? Fl A"- AMN[R Q E QAILEY ? p ? M -G,11URN ? ! ? SRFCYY F ? OR fR _01Y ? A Q Rn SON. ? A Q t- I AYN tf, ? e Q si. 1N0 At AICTIA E ROADWAY pMV TYPt r D ? r g - Q / Q MFKER•F LAOMW I Q WHWAY I C] ? / ? Sl awto FOn TnA i.C SIOF DAT :NWAI lr, Fns Ear+fY Ry'.Qir lY ? { P ?COKA1 E W ?[7{ FlG ? ,[ OA Ll lJ C'1 w Q A Q UM[N !A`E CIFY ,p?TpN ? i ? LINED TF N N ? ? ST fl rv 6 M'CU W I.OADWAY ? D Q I 7 ,l!tid .it w ?# AA ,•t'Y, ! M 4 var., t- .?•. T_... ll II M Ix1IOI,F?rf+T ?^D' < trD1DH%j."r?"'1Y ,. 4,/ 1^V +W K I ! , r?? "M 1NM1 ?I ,,?rt,4''??n?y-..;?,rf:. G .: ? 1- Ni ' PA Y •'I NrAk t r "? T i'? ', y r )- P -?1 ] ' J l Y ?r7 J?.( RAM SlAltvr vv^4movVIVIV RA DI No. ®E k^ g _ a ?s J'R 7, m S 4 POLICE TRAFFIC COLLISION REPORT TRAFFICWAY ?' nhKE COmPU,Ni NUMBlR - PRIVATE WAY oi AlE pcou l umf couNrr D N unr w - RI b o ? IDSE NpI NOVA 3 Iaa . "' 23? 5 f sa.n Ob 2-1 8 . cnr NO.. r 4 u [R eAN /4 ? RAI ON Of 0IN CIT-116NO Of 5rR[Ei Oa nGHWAY /'5 I'? /?I lA Wl[5 ?5 mW MOF ?, /c1JASeIJ ON N ? I C_ P\' O'Cl Ni[aSfCnNGVrtfN. Srgfft0 AD ,gNINi[RSFC?ON -Cls RWIF045 RE / SECT ON 3 61750 BFrvRF[N CR ye SIREft 6 ? 51R[Fr !f EO M,lE R05r `/ ? EY l0 U SfANCF 6D RFC IFgfN / l MRls I CR055 514lfr OR NEARE51 m,lE 5 ACCIDENr M E P DIAGRAM DATA Of 2 LE/ O CODE MIISw IN COIIISgNINVIXV Iv 5ECr1 1 Ff10R ROAD OR nrERENCE t0}µ NO. Np.4llED?NO.INIUR[D? ? 1, IIAGF Hr6RUN rUVOwDIV IMFR? Cl5 CROSSSIR[fTOR RpAD ?I? p V[N,ClfS PROnRIY DAMAGE ONIY ?Y[SIIED fNiCIE / GO6?O OBJ[<I SiRIKRINAMFOr OeI[Ci SrRUCRIwDOWNFR S NNAF) ?" ESr DAMAGE SnCW CODMGIAf ? ?p G 2 Q . ? S4CF may. ?.N ,.144.cr' S / E?i/LVI 5 UNIT NO. I UNITNO.2 O VEHICLE ? PEDESTRIAN ? PEDALCYCUST IvfR'S NAMF: USr n mIDDIE R r VERSNAmF. ,ASr NR ,D ! v. iE nzL) HEP-?,a, Si4FF1ADDRt55 Bc( o P FFr ADDRESS z , . 1 lAi[ RHONF NO ??a? L DuIC W A q(b2,3a<O3lDt Zz sr D R II SfAIF IRC f FNO _ fgfrvFRSUCFNSEN V 56o 5IAIL WA Fx w M o3A23 tia ( V R-AR't ENSf NO. Ale F DAI ope4ln MD '° e, 2 OCCWAEIpE f6ngNF NO. ErE$ N4 -1 11"1 L,a-l?xcc RA CCrw V Imo., PA, 8f) I ?° E R . EYES VRf GNI MGnr OCCUaAIION MNAMf 6aIKIN... C] CHECK (e) vFn,ci[AS AN rmRiorEF OE ANOfHFe AI * ? CHECK(, yfnKIF ASAN lMROr[f OFANOrMQAI Z CODES ? 7 5 r e sMO,, - CODES * a < is S Ix a "iO ' gn Mx5 J agfb D ? u ? Ebkly ? H u u v VF fA4 M MARE DUDpKnCV A f • eul p p MCI ? <orI1R ? „ I ? ".D v " M f . ( ) r I ID aINOVAI rIE IR OR?CONV) ?£.J o,ek 5r ZtDC, E v n rFAR 1 n(v 1 MODFl IDA4I NOVAI Ylf l vl vwr ? CJ . R No. R sraf a pnAIE NO Arz H vEn.c oR N l A n A No Al 8eE? Ai o.3 Z w? ' c . K KIE IDEM gAEIpN NO. -1 vfnKlf lDlNI rAI NN / - 1 I - J R[GISRREDOVM[R: IT 11451 IDIXF argM NO. l! ER?r- M 385 2zs ? O W 5 R!D wnf9 1A51 I,RSr M,DDIF F . I I:. _ A pjp/p/??y 0? fR // N DWN[R 5I I !4 W E NASEe a•Dlsetss 1NwRAEECe co oR AeeNi 6 PT TOw/G4 J Wf4 R tiro rr° EET-- uAJAACEOARU R a CNMp a.aa _ g;w.ACEO'AVU 1 ' aG w w/rAU? ? Darvw C] nMNNm e ?R[MUm ? nwv a r. DAm.Ge S aD. d:ob? ' s? I- iwYAr fir.4YSON fQx{]S. ?AwDev E ° •?•• le DIAGRAM OF COLLISION; I n IND,?CA lNORm -. ) .... ....sMCtrMQSSA1v) er ARROw T- T D1^ESCIRIPTION OF OLUSION: IVSFSpn[M[Nlµ SM rn NEees5Agr1 LN? . 8 d4 u P1 R? WL Ss F ?l?q ' ?o L ? V ,?/• L- v,L-G c-L?. Wf1}} Rk) dU.;A rL $tIRJ c.?L L(J-'U• 21 I .. lJU ?• Sr?c-c? Cosh 1^ls ha.odcc c _ . 21 / Se y ;i I I' E r .' NAME, ADDRESS 81NJURIES OF PERSONS I R sunlwNw B a NVOLVED n + CODES I - 2 3 d 5 6 K OCCUPANTS /WITNESSES 1 la AOal,oNU NAM[ sl sEll AcE u1 MK. nsu. EJECT NAw: N ADD•E15 N A Aluvlp AM e. QFh' ? M1 . ?wiE Q A ? , I b ? AppRfte N AIIRld u Mp OAMe ?rpKl Qvlr ° O h n-. "l- p N.NV A(Raltt •rvingAli,G rK1•'lNwle•Ar,l ADClp N AW NCr allpfp AIRRS S I CIM•r. R ?AMe ? rCpi I ??iirn• ?Hw ?'°.M. KI O,YA CM rpU A eIHO OArIp nlWl A.r•p er DAII der 1- rtW al.Y 1 Na. x?`"E2' " 1 F ? r. 1 h ? r ?z a } dpt ?W a - - - ?? IW. .. POLICETRAFFIC COLLISION REPORT I?LTRAFFICWAY Wllcf caMPwNr NlunluR PRIVATE WAY DwtE Of COIIr DAY Z""- F CO rr muNtr N0. CIfY NO. inWw 110 rUD,`.r.r li?"?'? J?{??-SO?2 /?' ? ?NRPAN / CTgN I "C"I -: 1 ON ON C YORLr N f6rv0 Of S1R[[TORnGnWAY iCl Cls '-I OXSIxtfTCO 'rL' ° nines OOWE OoP \> ON f _,D IcGG AG as ?R+ SM1 NERSFCIIrvG WIIa $IeFNOR WAO NON I . f.SEC.ION PR[f1% E TIE PoSt r ? nFIW[FN sIRF[1 6 SrRF[1 M O D? CF 6Or IIpEiWMRfi[Rf-,CROSS S1eftF51?0v4'??NfAREST./.LLf PoSr gCCIDENI R "D -LEAMWIA / Ml[S N SS? f W OPW 1]}S?W` MILEAGE c1`44 r4?k'Y CODE ??. IISIONINVIXVtO lv[RII: INTI. H=DN rw RD 11NIERHCIINGSI4Ff10RR CAREJERENCE 101M.EO. NO.n NFO?NO,INIURED_ WIIAGf ? NtB RUN NlfeC45 climsTREETCR WAD -.101 s PWPERIYll-ONlr ?aesDlTfD C]II CIf lv G'l'?RZ? OBrtct STe ANf Of OBACI-R MID-NFRS 1IAAIEI D MAG SPfCNICODINGUSf l` S 'o i H .. UNIT NO. 1 UNIT NO.2 O VEHICLE O PEDESTRIAN O PEDALCYCLIST a'. S ORNl45 US1 IRSI MI pf DR -11D I N-1 All ?5 R n S •„= sreNT ADDRIRF, SrftET ADDRESS I? V?h s1A1E I,- D r srA1E nP COM E . y NCd.Q L'1 l R SF rvO srATF A f EI DI I ,vF4 SU FNS[NO SIAIf ER DAllD. BIxr. O1CCCCCUPAIION NRMNAmf.-ENO. EYES rGnI HK.HI E OCCUPATION MNAMF6 PNONE NO. EYES WFIGIIt Et IGNf R UO CHECK vtnKN ASiN 1Ma ANOm1wAI ? CHECK(,') t ASwrv fMIV11GA AEI?IRCIA1 e r 5 . a ""' '' ?aa - CODES 0. w CODES 1. 6 DyRI ? S:II ?- O" O M O" O 1.-0 ? - 1-1 VFn?m V?fCnEV.I /roDNIOI?NOVAI slary+ZONV•1 rFAe I f vl AgDFIIDnRItEOVnI 1511LE12Ck vl 'DI\! E }:.. ?/NSe aAt STAIF M1FR 0.A1[NO. srwiF H vfn COLOR Il A NO. SAIf BL LJ )lf?b?6l kU- I ut K[IIXNIIfKAIIO.EW _R C VEHICLE rIXrvNNCAT NI L is I ISORFD WrvfR. LAST Nest M-1 NONE NO vl-TIEDIDOWNER: -1 .IRSrr qNF NO R R 6b5 Le v1 ml- a-5.4ON A 7 N_ AmRessa QVNFR ?S ??T.CyI R? Pmt l> 3t^a E ;. EzAIXNft alNweMKe oe weEN1 uwN Da S Co a S r 1 1 R ImMAGIDAAIA 1. AGED-A 1"S • 0vlmA NfD A-.1 tf- ?IOW[D WAY s I OeON' S ' DIAGRAM OF COLLISION: fwwrl AL IroKAn NOerN DESCRIPTION OF COLLISION: luseSW0.1MFNrwlswHn weessw4rl E ??`?'r ]s I 16 SHLI Ii WCfSURrI 'y 9w ' O f3nunQ o v\ ¢ Geo { Cho trnmL r ?$ld??'? '-? it-, o cuRwa_. !-vs't' ca"~G?a'?, (?tR. O ?-??• 4? ROnf1t 5 L11? ?. ?R\_Oro 51d?2 U 79 ? zc r- ?-•- C. S ?.ti0 p h ??iSS 1 51 XO , o h 5•+ E NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 J 4 5 6 OCCUPANTS /WITNESSES II I- AOOrIDURI bN w AAVSI snFV 9. Act u1115 "„, u a ,Y IN .? AD".." ° Rro. nRn+ OwaAe .Orr. ?7H ??`a,. 1 Y Ic A-. A oAIURl CR .eMnvfD 'O^ OM O%'I.•. utl- QAI-Q .q ? I Amnu "i:`wRECR` =14 OAm. OO1iwrr. o' Oi".ir,v r fl t.K IY. vs NAw t.wNA enA YW v fr .ur ° D ?Sr(I I?vnO UwNf w. vYONDer v Dwll 8 +N!P 1 ^l?" 7,rf -. D o J L.Y(fCl h /?? ` 1?:. ??.?F?. Yl/<.h ? h V-. ` M .2 In }1 ! e I N ?.t 't y 1 ? I ?. Y h?N'J i ?.I _ Iy r 1 } Sf?1. ??q(s irk f ,j T -,NRr jI 1 `_ LTG ,? F L '? ,? L f IL rl(r= r w• j? 11.' -'••'/7,I'Y° RI IOp IIRLLiw10. II 'rlu rLl. I IUSE3WJ NOUR) COVN,T COUNIYNO CITY NO„ iNWA a(? 3. ? ?URBAN pN pE pIN CiYOP TOWN ?/ 3 M NPMEdNO OFE,PFE,OP HIGH WAY "Cl' CIS ?HTURAL' ROVE P E CTI N EIIFIE / IlFS 5 QW p Of ON 3 ? 8O 6 I IFXSfR NG WIIry: STP[ AOAO NON IN....FRION PREFIX f0 1+f. .IE roSt BETWEEN STREET e STREET DISIANCf OR it f f. CROSS SIREEi O4 NEARfSTMIIF M ' / IlFS S F W ! pLFt Op (?' ,Q j"(fl ACCIDENT MILEAG E RAMP OA G-[win COIIITNVIXVfD: I L CODE L S . NOO NO, R TOTAL NO INAJRE0 IClF3 O V[H ? SPI V.GE [I H R WRORIOIHS IN,F D CIS rv S v vEEtOa W Cv ffvEr+ CROSE 1A OX v0A0 " HT P OK- p gpRRTY OAMAGE AMAGEONty IY u OBJECT 5IR UCK[NMAEOF OBlER 51RUCKANDOWNFR'SNMIL) ? RESULTED ? V N, IT . T: . !J`/' O 4 d SA y ?i I ESI.OMIA SRCIALCODNGUSE x. UNITNO.I :mss B. D Nu NAM! UNIT NO, Z ? VEHICLE '.'• }fir //?F ? PEDESTRIAN ? pEDALCYCL15T r i 24 9' ' / G2i / •, R Y[ NA11 : IAB, F ?U H ?{•, ? STREET ADDRESS ? ? r 'Z4' PFEr ADDRESS I 'SS 7 ;? I T -Y!.. r`? CITY S,A?IE?l? ",CO., PHONE NO. Kiv POA SIB L(J R Y S,AIE IP N! ! t ,'.f +c"', • OR 5 CFNSfN ` ti 'KS f f% BI N I V LICENSE NO. ATE D CK qIH ' 027 45- 3 Lryf fYl % ? V 101Y IYR. OCCUPATION NRM NAM[{PryONF NO. EYES W?'fIGN,I GHr E OCCUPAr DN FIRM NAMEd PHONE NO EYES WL GHI HEIG 1? QCHECK (? Pivf AI R IOAANIMoF OF ANOTHER QCHECK (?J : .. { CODES?* D n 4 i 5 ! e','w° CODES VFHC'IEASAN DARDYHOPA Ert? .? ?7 sIR P+ D a 4 sv 5 < EO R !" ? v ` vE reAR M MARE (DODCf.a ? Ral `NI E? ART. R „? ? r iEY° BDIRDM ? --ANCT Q SG ee ? 21111 ? I'll B ? I ''cARY 1 I NOVA) SIYIf 11DR.C V.1 n.Y R I V.1 ? -11(DARI.N VA 3° f : G S S ' R ll FNSL PEAT N STATE ? IRNI`FR RA,F NO. ?BIAif H VLH. IXOR I N •I ???/ Kw 86b' Gc10' ?' '??0i I ?A A sC [ CA?L DFNiF CATKIN NO CI VfH CIF IDENIi NN U" *'? ? r° ?1q( ' REOOISIFGtD /WN?? ?• I I gyr?I I MID ? I PHONE NO ` R 5 FR DO fR UST. I. iIRISI I I MII 0 Dlf I I I NO. I q` 'y ? I?? ADOPFSS Oro- W -ER •.> E 31l ! NAM[{ADDPt55pINSURANCL CO. 04 AGENT r R A DAME ARlA Iwt Oxil CHARGE CHARD[ •• '. GXN Na 3A*A"? AREA p I• I,Or ° O1M° .. 1 Ii Orna L V `? / ! .. i Efl DVAAG[ D ^N Om yl Y ` 10 ?OTIOU ( ? AW Y ?R[M'UN(D -1 PV[N ?pfAWNFO ESI DMAA 1 10 f ^ Al AYDeY C/r ?AWAYD BY IJ AWAY S lalOilOU 3 k'l ( 7 }} '. E F ! . ISION. 11u E A ND CALF NORM I { {+<E _ ; IYA4R0 DESCRIPTONOF COILSI ON ID$F eUPPI(M[NT ISHL[TIINFCt55ARY)I' SH[FIR N(CFSSARY) I " A AGRAM OF P?..l....l_? L..L. I I_?_.: I , -. __ .. .__ _..-__ ?,•;I ,. '£ `EV N - d Thecar was-east-bound . on_Cape -George r i I and appears to.have_driv.in_on_theshould t which is Solid, and drove ._.for._.approx 72_. I I 1 +, - r- feet then veered_sharp.ly__to the._r.ig.ht,,--- hitting the power- pole__Speed.est_.4.0_to. „ I F I . 7 y MPH. The pole was. the.-only..object__on_tha side of theroad for several--100 ft. vMIT AME ADORESSS Driver unable totalk at scene or-hospit 1 N I` INJURIES OF PERSONS INVOLVED + a OCCUPANTS/ WITNESSES ';a IA,E CODES I _IH R2 3 .4 5 6 ?? ? HAMl SCR AG[ IAIUS y R[SIR [!R ?iV y? `y ., E AMVlS3 .. -. Np1UR101 .. ? kTY -.. ?Y14' ?? NAMI. r INI AY AMe. ? ?L4 ? ° ? hX" ? IP.NV 1-0 A 1 '?ISS - r?Ampra .. ?AryovmlROM pAMe. plo?K!?o?1P ?Q?' ?:°.Ls. 'D ??{g r ??u ADryI3rv111D - tiAwMt O, aE M AY ?AMB. pFIC!?cMnP ??iX ?nqv + L ,rt A ?r°yG SNwEf uNE FADGiw AGlnt• E=/ /H: s. rcraD [IXI( ?nD ?-1[w[!roR[ ATINY DeY out 1 1 ` 1 }E dKr?? `? O 1,.- ? I'yl i YIY L, r ' Xt ? .["" n.o d t_uvK ;i 1d..a. 4? v:M d? I ? s R??k'CrIA .? E{;? ? ws,p ? ? .v4 ? ,? ?jt ,. '( '?+ a .Ir BM1 ,? !r :;iPB ' p! v i A I ''? r ? ,1 I I S ? 1 t 1.: L ? _{ }Ai _ +. EGFCOLUS ON I.. DAYOFCpLUSON TIMEOF COLLIE ON .. .EAn COUNTY NO. CI !O• ? xYn 5A ' Yx . a o IE5 AM • PM ?? ,, „ INUE ??81`+"ED U 7Y ..CIT. WN I MILE9 ::OO .. .:-.. C17Y. TOWN_.: .._ P41 YH ? ? ' ? F ? ? ? UIn CLS Prv nWi?a -icex[' SECTION n ? . .. m ©GF 1 } To ? A ? l ZZ PD r , (• w?tn µ E?9TPEEJ, pADOfl HIGHWAY:.'. __,_INTERSECTINP{NTH:.SiREET Ofl.RDM ....?L ? PCrx EO. uLEROST .: O CCU xEO NONINIEflSE f / ?/I?G/?rl?h? CTI ON.YTIONOFCO SIGN.: - BETWEEN STREET AND ' Fx01 /ui EET ®161. OW xFAPFSr NIEgSFCIwO SIHFEr nb PIE. E. DO ud PAIINOi.E Cn05.4xO M LEPO Sr OnwErvT r µ NON' %RD 0 • EIESkCIgN. 1 / ?{ L F Er ©® • y?lf Vr O INTER INTER CL$ aclafi POAOr ? ? lI NO wW?0 1 ?'-?OVEMCIE V EnICLE ?vFn CIE NCYhE ?OrnEgIWWfE1 rorAL I •IBvExwc[a O F 1nAw DrrDrcEES ? ? SPEC COpEUSE - OBJECT STRUCK I - o( pvEnwEFV " .x wx .nrnux COLUSION !I !-.. ? r? •.- { '?: ?`;,. j' OWNER OFOGIECTSNPME AND p0ORE39; - _ ?K LOCAT ION - .'. ? Ey I .. INHOADWAY -? ? ?? E E?OeJFC T f rK. r tl FEET FO ' ,? OnIVERSLASTNAME ^ n • ? - _. FIPSTNAME MIDDLE ......, ... P I` Tx.n T- WO CAxs ¦??????F??.ryr???? wENE wvav[o DRIYERSLAST NNAE " r _ FIRBi NAME '?.'' Q ? ???? ' AA?n ' xitits _• .... _ MIDDLE _• - I STHEETAODnE35 .:.........:...POUTE.ND,MDSO%NO_ ' COWvOx On MoxE InAx = a Jn] ??y i'Y W .. .. Iwo 9TREEY gDORE99 E „Q C _ d . • ':. A .. m w , CITY STAT r 21P COO D E A A IWURED S s !E •'I' m ... • ' E,. RIVERS OCCUPATION - n /ES 1?A lS3E end/E f 1/ nEPD swrv CITY :. .. :.STATE ORIVERS000UPATION,?„- nrPD M Y DRIVERS LICENSE LIMBER,., E•r.. ,..,•,; •.. STATE' SEX,. •..DATEOFBIRTH . AGE. LAn PHGRyyyP Ae W M F 'EAR DRIVERS LICENSE NUMBER;.,..,. ;., _,-- STATE. SEX ;DATEOPBIRTH„ ;AOE. _ VEHICLEYR. MARE (CHEV: OOOGEI. 2 : MOpEI(NOVA DART):... ppD -/?912DR1.,.. Hdn g Civic 5L :j-91208J_ , TJ?2. UO A - VEHICLE YR. MAKEICHEV:DODGEI_; MODEL(NOVA DNITT:.;. BODY STYLE IZPH.)__, UCENSEP D51NO STATE ,•,,:,, :, TRAILER PLATE NOi.,,-. STATE ,. IA Ga o5 eq LICENSEPLATENO.:. ?.'.-STATE .;,... .;-TRAILERPLATENO„., - $TATE;:;, VEICLE IOENIIFICATK/N NO. ,,,, RpQQ MOpELSQNEWERI ,_ OpOMETER(MILEgGE) r 0 4 .4 J/ Y797? C VEHICLE IDENTIFICATION NO, ..-v:.-IIBSS MODELSd NEWER) _,_- DOMETER.(MILEgOE) REGISTEREDOWNER _ ; ILA-W-ST•MIODLENAM., .,. ;-_•ORryERSUCENSENO._, an F{!F r-? REGISTEREDOWNER ILA$LPIRST•MIOOLE NAME)-:. ___,DRIVERS LICENSE n M V11Y7 3 OWNERS ADDRESS-•,w ISTFlEET,CITYAND STATE)-„-,: ' - ; .. DATE 01 BIflTM 1. OWIIERS ADD , . _ $,? S G /1 E- ILn `?S . Yr PT Ff Way RESS .,: .;ISiREEi,CRY AND STATE) :.,. :MTEOFBIRTH - 2 PM lSOF VEHICLE DAMAGED , i;..;._.- , .. _ -.... YEAn P RTSOFVE y •EFv ® srD nEPNxvEnuE HICLE DAMAGED...,...... ?y A55. .. „ 5 OPEPN11 v[nCLF i n WAS THERE AUTOMOBILE LIADILITV INSURAN ?F>? ,f LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- COVE RACE INEFFECT GM.-IIL'A' CE NTON YOUR CAR YES ? NO ?` NNAE ANDADOflE55OF LIABILITY MSUjel,Iy EUDEfl . . MANE urr ... slue NMIEOFLIABIUTy INSURANCE COMPANY NNAE IMOIDDIIE590F LIABILITY %JSUPANGE AGENT- Oiv SIATE iv LIABILITY POLICY NUMBER ??,"j IST wJURY 4 : AGE' I 2ND INJUflV 5 iE P[ ! RADpign FS Y$. NAME .. .. .. AGE 0 AL NAME -- ADDRESS U M SS SEX -'SAAR [? nT arwNn[5 ADORE 00 L MF .AMU SlNAT uSOF oFw2UR < r NA. o- D.U -oocrons" - .._? r DU-E S1 _. .r r,N x..r.Y,,,., Gd FT1 ..... •„ ' ER . IN fn VENICLE MARKFWST -06AInw0 ON i` ? SLIG[R TOLL ED IV[REI N loc. '. ,1.. ? 5? B OWNGRTNBYAROwI CNCL E \ rll tl I r nw ® \ 1\ \ ,Mr xlwm re `, Ox[DrMNDrw rMwOW - J? ' 511ALrDA ?,7„ ? I Iwru PLA ?? NVENICLE w0 E .PASS En NO NIlLEO ISEV[n[I OM 11CIr o ?? O ArlI .I.N ? 50 DESCRIBE BELOW WHAT HAPPENED: (REFER TO WH T cka a.o! y!_ eo rRLE,oP? -o'F-CA.C.._--?2eom r. • _- ------- .0. N S E W ON STREET On IYGFI WAY NAME .,HD Crwx o » ? ? ? ? .?'I. + µ wArx ? ? ? ? 4O - ?? \ r,•' , •I_ xYDk S11LAN WAS USNG u",wJ ` 1 ? yKWµK 2 ? Wµ%WAY ] ? SIIOUL0111 rY]AO MAIPKC WEAfnCq 1JP11T C011WI1ON3 TRAHHCCoNNIOI IGr IC•nrt'I •?' ,tlL y •R EI,r1?? M1111 ?I(JnY I W U,rKU? 1 ? DAYLpEIT p' 1 'p lnWlN9 t f.,_ it '- r , ?2?WEi 2 ? n4NANG 2 ? oAwN ? 2 ?siW `fLY y?`( I • ? ' •h - ? ] ? SNOW ] ?'YOWW3 ] c] Dus,, ? J ? N[lD SIGN p O'cl ? , ? too Er (? (IfLLr9 oN o fLA51rvM RCO ? r ? o n[R ? 5 ?H." S ? (LVYI v"s0/% S tl ?' ? 6 ? I'l ASrwIG AMIICR ' Y !1[A!Ntl rLlll W1 pI OM%AIO tl1E51lTR(IT 161119 ? 0 ?!w Y[%lµ ? f2{Nj !} ??4'.. ,?*.. 5[E .r.ErgKY. ufrn YW DNrO[q K lu f rr ).SOP CIY ? I ?GlrKfn?ILA,MAN ? , I YMLXS .. ? r? _ ? ,. .. =^rkN?fyyl?!'Y? ------------ - ? tl ? ONICR !PlL'l1Y [5 s la EE xo ?: iea ?iouce _? ? ? ? ? ? ? S,KAII r ?[u 5sw..r R1oM DIRECTION_;. TO DIRECTION 5? - 60 OTHER TYreoFlroAO., T auvEn2voIwLE ACrav,? v[rACM. ICrYL ONE bI Wn I 1 ? D"ll WAY UOn ? r I C M W I 1 W?I GOnq STANCH, AHEAD ? TY try 20 TWO WAY ? 2 ? OVEATAKINOANOPASSU,IG ? ] ? ?V?n3nle ? ] ? MAKw0 FIGHT TURN ? r ? AU° ? "oov`n ? A.? MAKYIB LEFT TURN n A a ? tl ? -EY ? 5 ? MAKYIO U-TURN ? tl ? l W ,IN ? tl ? SLOYANO MY ? / ? STOPPED FOR TRAFFIC T5 --? LEPMIATED ? s ? SoO mo. T GGNAL 0 IE ri Il 7QE O u1 i'- --SAr r--?-- Iv ' a aN t CUVN(Y NO. CITY NO. ?uN Jr : p rM Jet"I`2V`,,l ?lP ?N ?E ?IN ani wx N it [[, an lxc ^ N [s aa,, "w. "Y POUT[ t o[ 3 ;; L r r?wF- ?.?iorv V ?W ?DF G,; , m ;h IIIIIIICT WRII 7T P G I,Wcr r1. b.Alw ?'?"5!rP?2r f?Orl'r?IA?E?r'?'? T " Wo N[AP[ rviEns NasiR c N "+ N n, tnDAD CnossINC.M t[.DSroPu. FV NC U xoMAxK. r , AK cR smte [[ ? ?W „i[x N a nvOlvfO © ? iu ? l.T., H I T OL E ° ? AZ OWSM A $: yaBM FTtD? 8 L' 8 Ixi[n Ir"NFR cii ocn Er n[ncE on naA V E .C o F s ? w ? N IA P I-AIS 11LV ?J > ? 7O ,; ,.. OBJECTSTflUCK ,. ,__.t .,..? -... OWNEfl OFOBJECrSNAMEANO AODRE55 14 Ki--. ow cT FC cDOF US[ _ DRIVER'S LAST NAME .... .: .:',_.. FIRST NAIVE. .,-,..... .. ...?.. MIDDLE,, Man[ WAN two c,ns DRIVERS LASTNAME....,. ..FIflST,NAME ,-__... MIDDLE. - 1 t t I?t y / GL- uan[ lx.N,wc 41 'f ?I t ec ' - SipfET pODRE55 ROUTE NO. AND Box NO.. cr i r f. I[ns0x)Wfnt STREET AO.RE55 ,. ......: . __i.::. POVTE NO.AND.BOp NO.,:. .'?.. - ? 3 60 /6 . - CITY .... -.. STATE. ....ZIPCDOEDpIVEg5000UPATION.., DP. CITY :...... STATE -ZIP000E. OflIV fl'S OCCUPATION ..,_ !93,4 5 Dn VEN'SLICENSENO, _ ., STATE, 5E% , DATEOF BIRTH. AGE " DRIVER'SLICEN5EN01 STATE ME%., gTEOF.BIRTH ? ,_ ..AGE.:. KID; G p q F aAY Y$ 3 I yo R - VENICE YR. MAKE IC EV: DODGEI. MODELINOVA*OARTI.. ...BODY STYLE IZ DR.) VEHICLE Yfl. MAKE ICMEV: DODGEI- - MODELINOVA-DART_ _ BODY. STYLE.IZ. DOJ- 72- C. G u ` LK n5E EATEN .. STATE ., .. TflAILEfl PLATE NO.. .... ATE .. - LI ENS LAT NO... _STATE ... _:.THAI-IPLATENO.__. .-_5TATE- ?+ KLU15TERLD OWNE - VEHICLE IDENTIFICATION NO.... -.-_...: .. „ .,.:,_. ,..:.-:..?:.a..?- R ILAST FIPSTMIDDLE NAME) .., ,.... DRIVER SLICE ENO. REGISTERED OWNER ILAST-FIRSTMIDDLE NAME)..... :....,_- DRIYER'B LICENSE NO.W?_..._.:.. f , ? pp °. OWNER'S AUOnS ISTP ET.[ITY AIID STATEI ... .... ,.. .. DATE OFBIRTN , OWNER'SADDRESS ISTREET,CITYANDSTATEI _., DATE OF BIRTH PANTS OF VEHICLE DAMAGED PARTS OF VEHICLE DAMAGED ? .??I LF $ 300 ?L f, SlL?T ' ,T Is .{ LIABILITY INSURANCE INFORMATION-VEHICLE NO. t- WASTHERE AUIOMOBILE LABILITY INSURANCE EKES 8P COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOURCAR I? ?NO SAN NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER cl,v - (II:.... NAME OF LIABILITY INSUflANCF L..'ANY.,,.-.. -:..., ADDRFss si,iE . I. Y F'ttllF'?i 4' okavdrrl7`Y ?NSU aucP P? /z4:2 ? ` 2 NAM All AD PE LIABILITY.... RANGE AGE T .. LI ILITY POLICY NUMB P ..... .., .:, cliv ?!llr7 Lv o.8 G x/07 t hi` Sivl V DPA y6 SOOg7 6-Z- :, - IST INNpY: f`??yy• NAME AGE TOTAL TOTAL ZNO INNRY: REHNIT FOR NAME AGF ...., F AODNFSS `E BE M F ADDRESS SE% M F _ TUREANO E%TENi OF INNRIES ? ? E%T[NTOF INlUF E5 NATURE AND ? ? ENAFI NAIT ON"0 Y?'OOCTOflP ® NPME°flS ENAM?110N BYA°OCTORi E .ACT R5 5TAIUS DF INNRFD IN VEHICLE ?D" []r,3 ILLED MARK FIRS OHJUn Iuv[AN Y T ONE THAT APPL NON O? et Nc I 1 IN rvonl IES Ilrvsi?n IONr o " STATUS OF NJUREO ?On IN VEHICLE 0rA ILLED MARK FIRS O'_F Olv[R[I Y T ONE THAT APPLIE NN.., Na IU1IiDnIx S. I w O p?r.ou,?„ ? 50 60 I i70 i?c N ?I .??x„x ? 511 60 I I m70n?" - 1 MOTORCYCLE SAFETY: ?HELMETUSED ?HELMET NOT USED MOTORCYCLE SAFETY: ?HELMETUSED ?HELMETNOTUSED 4110W NOntll BY ARROW IN CInCLE OESCPI BE BELOW WHAT HAPPENED: INEFFR TO VEHICLES BY NUMIE91 `.' m:'coi:nlo'NUNF oA -' IW[Ir »ICHw`;3 A.JIi?DI;r elffLIC / tiejlke 'u c l?/r •-f'f V 1 »? n[ r. NPWIx [. x N,NKL{ .It,? c,m RA . _ o n-I' Ga 6[av e ' / =? ? ?._ rR[[rax c -.7"/!cl ri?I.C.._ LO h}sK.S_ 7.N_•PfL_H1h ?Ci. Vel+rde wed:1-to `Ti` J ., ___--------- -' . ._Arrrewu ubvu7- 1 _Q .Fls_a"fYYrr_,%c[7e.4) ? } q, i 4 ?" ._Lu?at G?oNye R _?r_k! ale-'? ?-?- F I th j ? I : . _.Sr?Fles Vel+Fif.p ?_L_wlr;lt IrLflew L?y_? T _ _?'?d551..T PIIYlY bClSY_k?'I_uh7i?/?s.h Tr°" _ - ! t O 1 ; 2 The ti(va__l o0? s_(p e{0ee `. I VEHICLES POSITIONS BEFORE COLLISION DIVESnOpnDBr "'I i : : ' I t 1Y VWKtI N S 1 W ONSTA11TORRIGHWAYNAMf ORN° ' . , r a: o»c a .no cuoccunD n n.pUO cA r[t L NO `.It vl xo v`rl) No ?i:i:ot ?iairci C R wi 1 na+I ? ? ? ? Ildp-.e ea e ? ? ? ? ? ?. ?:B'ivn ?1AT. I?a1, i ; 1 Mlwl,l ? ? ? ? + ? ? ? ? ? ? ?WIRIII y 'A PI11+`.R ? ? ? ? (: ! r l ALONG C x'OSSINO FROM TO ':1 t I PEDESTRIAN/PED AL CYCLIST WAS USING: 10 I-IR.- I ? ......r s ? wwsW+ . ? ° ,mi,°,[, I ? ?,"M'";,?[; t ? or»[A r ? i°.i°+aii: ? PEDESTRIAN/PED ? 1' rT AL CYCLIST CLOT HING COLOR. 10 D . 'o-, ? .vo ? ..... .IFUC, [n . [?cwa t.iii aL. ?` T" RO?O WMYACI? I [»I[. PVn L h i Ih 1 Y f vl•xctl 41 ' ,r4 7" ?{' m l7 1 L7°"Y !y ' f fl W(AtnLR ?/ 1 I.I fi?Y<P"S YR r ? RA .IMO llGni GONO1t10"5 1 E-oA......T ! ?OAwn r ? WSK InpFFIC <ONInOI 1 [ r[ ONL x+ ?rI1Kw0 SIGNALS ? 1 ? {tq {14N 71.E OI ROAD K [ r rrP 1' .O.t o •r0+n II ONE wprtr? ? ? ] 1WO WAr ."HV[MVENICLE ACTIONS n 1 K«ICK O»[OR KOn[I ? 1 ? Omxa srRAlan NlspD ? r I°VFRTAKINGANDPASSING ?1 ? i ?wif i ! ?°?crD« I f S?WOWINO [?rDD t ?cIfi.. $1 16, {?°cNio ili l1 ? S ?Y.[,o E.G. K ILASHIN°RED O ? S f-SI•LE ? ??o.° 11 AND ? 1 ? I 1 ? ] C) MAKING MIGIlTtUPN / L7 1 ? MAKIN°1111 TURN J f h C.-, ? t ?- I ? ? t?jy`' tY'} 1 VIC Y ' AC T Y ? 1?MI1 IIYI I 1 ?SiREIT°LI°Mi1 I ? -.1Y ? 1 ?IIAWlhO-A ? 1 ? ""MGNAL - P IAMI LOO ? 1 ? tALLLLElYY ? { ? TRI rV11N L 1 ? 1 C) MAKINGUTURN ? F ? SLOWIND nr ?I?{ ROApAA1 MARII :JXAAAJS?Al?.»?..-, f ?K? 1?fVVIAI` R J- 1{LL„ OADWAY {URIyA?[?I?I?YII I T ?01lIC(R/1LAOM,N ? ? RIVEEWAY ! D ? (j ? 1 (3 TOPPED FOR TRAFFIC qA '+.,?'S? -.rs rmy! n,7rlYrlty]y?.} 9?'ird?b x iB:1 N+ I '.i?µ R ?' b m15 P I'Ia lA My 14 c1 '? I r! nsN, ':iP- .-4 _ ,I .iJ1: :T . I .: )+IL I:. a, S 114 N fn. GI s R .. '? l I "? . 1 I L P0 AI r 11 r Y cn D a. STATE OF WASHINGTON PAG[ J GF y -•` POLICE NO. ; P!Y .v. . t TRAFFIC COLLISION REPORT II®-?1 TRAFFICWAY POUCf compu ?s "' h pA FGF<af LJ PRIVATE WAY ,' ? ?: %0'83 DT ? I"` Ufa Ipsfa.po?Gp4, ? G , ?F, - [. ?N ?E ?IN CIY OR IOW N N f s .p ? OF Cq E Gr?F20k ON C . INIfR0FC1 NG IH fPFEt0 KTATT NON INIFRSECI ON 1 . J eERVEEN C Aev CNAti D/ CE AIT iON iR yyU?pfNf f. CRO555tpfEl OR FARESIM LE pOit SIREI M • f c ° op PE 6.- O T-F RE CU;l lVFO ` TOTAL KILLID OfAI NO NO. tED? INJE[RfO? ?sPIUGE bVfII CIFS ? _ tfE?dS , n ppOPf4tYOAMAG AGf ONLY ?'UT'L, FC alb Op1fCI51RUC[ENANE OF OB FCi ? , I 5t911C[ANp OW1JF4'S NAME) J UNITN 1.1 / IV[k'°NAMF: U°t F { « '? IR°t st^r?n ow ss-RS V'Y V, 'y cT 5 if ZIP CODE PHONE NO . . Pr?YZi ToE ?rAs, Nv wN 9$363 -a56 p4rvlR'OIICENY NO 1r , . . Va2 OCCUPAtIpq {IR fOPHO SIAIE f,( A BI ., ? f EN EYES FIGNII X S?rFE•asaAV co. ca4FCi N 1 S ? CMEiK(P7 CiE ASnN Unnov[ dAL o Ai - 73d? ? E C iwn rHl ry NODES? 7 y IR Nr / S 1 DH / n ,lu ° ? o?o«c.c -` N,u (r`s ? ' j Ce v PDM 0 NNOYEAR MANE IDODGE.cNEV?u6" e '9' 0 v Yl[ s ? ONV p/ 76 l jp A I]Dk . .C PoNT rg 4 SAS. f.•fn IICENS t EN S1AIf ?.k L. ?o l^N qA tf4 kAlf NO. MAIL }r { tl Cff.1 NllNCAtIONNO. ?.c -7.7L2'61u,s+ 313, RIGISIIR[DOWM4. USI St M-E P O i? .. « _.... 1 SAML AS Ad 61t` H NE NO so._-1 e R toP .?•••.. wcr ... A I "1'Iirio? [ nr. w.mAC[ AA??[f DAWV VN ? R(MAIN[D $ TQL. IA to o ?AF Ocrat, DIAGRAM OF COLLISION: W 3 I11'.C.n NO. -.s [[i rNiciSURYI eY ARPO r P6" b/i JH P4 GTnj? PaS: AriE,2lhn?e7•.? i? _... JISC(JFA °t4EEt ` w? SZ A CIDENi RAMP DIAGRAM MIA MILEAGE icM CODE RUN wN pIH NRD N[f F TIT FI R DO4 REFERENCE [R Os CROSS SiN[CTORROAO lot bOG F°I DAMAGE SPECIAL COD NG IAE D R I V E R E H I C L E R U AW'A'Y' DESCRIPTIONOFCOLUSION, fpsf SUPPIEMFNfAtsHEEIIFNEC[SSA4r) vc/dA No J -AZ TA4lX4i.va / Ro nEC/f?7J P-e"T JqR<=A T4 d4 LQ r 7N /T ?eess.r AbAT o ArrL O_TH r c ?['NTE? $.?N+c.,_A N,.Nir - A Pow,Rl? Po dH ifJ• d!'oS ATE Sp,D THE r"Ao .. .. JVOLVED CODES I 2 J 4 5 6 $IA 1 AGl 11-11 '•!.m u.r •w .. . C .. N a dsi? r J I NY[A 10 ?q KrA SI,AMf/ NE J, ? f l..IR fh BNI:IG ( Y Y ??AMe ?µ ? ? Y -. rGS )b t lpgqgyy{?, b ?k 4- u ? A 71?) E H? ? 1 } , ??? t ' >v <H 6"»'i`4' ' Py ? ,r ? i 1A A W .,Fi ,x ?. k r, ?{6 •^ fd?"n n ? ,? + . jl arx ? _ ? , k ? .I I?, I W?g l i)! I J' F ?,1 hl ,l J , JE'a N- P h ? t ,? A +Y h 1 I t ,- P ? S s1 "{ - .. _ - 1'. r : 3 - . ,? ?aSTATE OF WASHINGTON . . .._ . y.. --'sl-- .-1--..•+::.':,....k. u u . N MOTOR VEHICLE COLLISION REPORT NO»IKW? ,?1 + wrE Al ?N r } s w 9Ar nur sun ON U wfOIBu ? N,, COUNlY NO CITY NO. ' ?4 a ? W AI E Q N M n /' /Ep LrJJL%rM K e E RDD DR H REE DDDF r D f ' ? a O ? 4 N D 9rRE w,ER Dr x I _. nErw EF• MLFPDSr Q.?') /7G/B/triyliilz : r+ %11 ? ® ', .pro°r dRo:n"F; 3 k r P Ml o.r , r w? D o p o® Q n. HMDR - oR SeEND R n R?Rr ??LL ° ? 1 E ? X,ED ? E 8ILn ?YnA,reK . »nEA .ECL. A o AqD.D h ?n OBIECT BTflUCN IIMMEOFOBIFGl STIeICAI OWNER F W CT NAMEANDADDRESS crrv? FVw aca°i?Fci Q .co E " v ; 4? $ E Y `? OPNEITB LASTIIAAIE e a tty xJ?T(EO 'g'• , rwD MIDDLE CARS 'ERE N D NERSLASl NA MDD E , ' xo T F '?' RourE nD. AND SOx ND. STREET ADDRE59 ROUTE NO. ANO BOX NO. , } :. STATE 2]P LACE DWVERS OCCUPATION y rl CITY SL ATE 21P CODF. DNVEPS OCCUPA N ? _ qN F C Bl1C NO. DATE OFB H AOE w , DRIVEq'S UOENSE NO. STALE SE% OAlEO GIRT AGE -, ? yp ' NS ` EICHEV. 1 MODE! VADJ n 80 El DIL VEIIICLE YR. MAKE ICHEV; DODGE) MODEL INOVADART Yn aAr wr 1 BOGY STYLE 12 pq.1 ry" ' ? TE STATE i RATENO. STATE EPLATE NO STATE TNNLEfl RATE NO. STAT ? E - VEEeCIE IDErtTIF1CAl10N NO. T ? O VEHICLE IDENTIFICATON NO ? J' - ? gEOIST61ED0 ER IlAS'! gSTMI NAME) -YEN LICENSE NO. REGISTERED ONNEq ILASi FIR-MIOD LENAME ' I ` ` 1 ailVEfl S SEND. OWNEfl' S9 (STREET. OlY AND STATE( GATE OF BIRTH OYMER'S ADDRESS (STREET, CITY AND STATE( TE OF BIRTH _ g . , - .i;.. , ;. ».Y m qN_ LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- 'WAS THERE AUTOMOBILE LIABILITY INS-N- --I Q YES Q NO A •'NY r I ADE P i 2NDINJURY Ul-IA ?rk nFroR, OR Appr NAME M RTV Irwi FSr ADE F -T- nN WvEHICIE I!;?nlrv na+Or+?-wr. I 'iq- DEHCLE tt ON! to LES o 'r,w?;1 No ED :KBE wr:'R, ?,? n LL 1 ?,,. u ? sQ RQI ?Q n ' N? s?] s I ?n'r MOTORCYCLE SAFETY: Q r f.LMR ustn (, rlEl..n 1 Ncrl u,Ln MOTORCYCLE SAFETY: IIeLMET Ixnu ??-LL_ C7 ? Ha nEr NOi useD ti11L1VIrANirr HY NIIIOW M('JIICrL 1 1 -- Dt SCIBIX BELOW WHATHAPPLNLD INEFEH TO YEHICLLS BY NUMBER, 2 hl r..Hw.rn,..sa O ? ? aGfc c¢_ ?,v???f??'f/vLp'??/•y,,? -fw»r111?,m LW?l-- s? i.n.I,rrrrrr.?.r.. _ 9"8c{' 'Xir/? /TnJWrI? VEHICLES POSITIONS BEFORE COLLISION - - - -- - - - If.'CtE w. INVF. ilOA?i[T N S L nu ON sm, Oli r»t.roVAr NAM(: Un NO N•• r::, .'_r_ r'", ?,:, ?&r? ?, O o,. NI „rA ? ? ? k 1'wp PECESTRIAN/PEDAL CYCLISTWASUSMG r?r FRD+ FI10M rQnaw..r :QwN, 1QNUUUn TO L"" ,,,?+vy ?, 'r'I yR*«*'h rEces1RIAN,vEOALC YCUST CLOTHING COLOR .,, '?w„S».u. '?aro nw... ^[, O„'In ?. ?NEwOI.O T r P'?'' AD 1:ct we Arrr[n rQn C r?`"rrR Qrra» t nuu un rQ Ytq 1 A, S IGrIT (AN6TgN3 f' 1 E (s DAYII(UrT INAFIcFIC CON [R nLr hPt Ol ROAD LY En VEHM:IE ACiaNry } J 1I} Mr .r»•l I/-L•IH ?uM 2 IJ ..rr??--?' f 4D rwl cw wnl v w r '. rM[xal ':\ xr t NI r 'l ^` Y [} , . f ?..L DAWN (? •. , Qw I Q (xNI ? I r ,N? £, f i` r, 1 fYI MY 2 ?ny? ' _l WAr L• I nO NR 31nMOHI AHEAD +( 1 l: K f i7 wtt ? ? I S1,V ON J (WO-1 "IN 2 . ; ?? +.or Q NI Yl Q 1 ! 7 ' ? J El NNow A J M.-O moo r 'I T ( M o 1-11 'No IT 1-1 - s unrr f a r *' ?I:eK[?Y• A AN. NOIK?I.tt a A LJ QQ t'Alv'u?{Hnn A ,I NGHI,UrrOf U.+L Ov[RIAR NO AND FAYSINO TI ,. 11 1° A MA%Nn LOITTUMI 1 II r Ifr U'W I - ? . ? ICE O,.R AN. ? ?_? (rOP .MI•I ? ? MAnI I` DO JtIN[ r lS ? Q l l l-.-1.11 t} 12 ? rv ? ?I C?Y F ? Y ir U rv ? Mr'AlN4 ? s ?' W( W 1 v NN Q s NO II rLINN ]Ark ?y S(1 ' K L.1 ? 111 „ Q LAONa Ay E ,ti?71b L t AY WWA C fY/! Q QDFFICERF-AN 1),, t r fl7 a;? vy? ? F QDRww Y ? F Q SIOPPED'OnInAFIIC i FA ?P +y f+F ! +I?K cDncwnDOr vE ? e QONFn 'LCrrv 310INRD AI FAfMIAL U A}},?? SI 4? PAC$7 F OFD O LCCJJ'' nooserAnnnw ? e ? DnaTOn ue w JI +rl d?. ,? 1 r "'6pS ^Z1r [J fT (? 2 ? WwD (? o Q BlolrrDwlwADwer''r.Y Ikq ?dV , AIM i 1n>t f r - ruarxr,q r I 1 ???r I f Y ,. C I a y A Fit ? YTr 7 ? u c r!;?I m l ?. t ? "? ,? ? I ( 1 t .? ?NCi?? `'r?t?' r iTi? ? IFtlr1 t. y.yt7 5r, R 1 IN' b Y F } ? I: 4 A. I I"1 POLICE TRAFFIC COLLISION REPORT L-10 TRAFFICWAY Inucf coMPUwrrvuMBfx J [] PRIVATE WAY R DA toTCOUI II. rHS R 3 D r o ' ISAI. I pN 11N I ! II' I umE IUSE }1 -U. RI Cdr courvrr +TC fYG!Snn 1 coueTY rvo. cnr NO f.WA URBAN ° ?N f ?IN CITY OR IOWN E6NO. `O/StRlfl OR tRGNWAY Lp MGS ? ®oP ,/? ON 6A/Q 7 iCIClS M NOUIFONS RF SECII.. UN ?3 ;'!03300 ItR CI NG WIVE: IPfEIOR ROap,/ NON INIfR.... ON IN / BFPNFf /t s/ SiRFEI 6 d $ SIR[EI pxffl% [O /AIIf POSI- / /' ? •?"/ n. 1-- / ' ' OISIANCf 6D19 MIIO ifRENCf, CROSS SIRFf10R NFARf51MIlFP01 Il[5 [ N ACCIDENT RAMP DIAGFAM DATA W 5 y ??J lEfi [] Of ?' aS ?•?? MILEAGE CODE COILSONNVOLVED: SvER IYI UrrSN TOTAL NO. NOKRUD_?NO. INJURED ?SVILLAGE ?HTLRUN uxORTVIx d VfNICIES ICJ' PROKATY DAMAGE ONLY "IT 5 M N %.Rp IN $IRELIOR ROADOXInrEX[NCF NlF?/ Cl] Q.551RfETORRU,D ZT C ? ? LTED ? Y WClE ESU GBJtGISTRUCKINAMEOFOBJECTSTRI KANDOWNER'SNAME) 111DAMAGf ]KCIAICOpNGUSE S UNIT NO. I UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST Z" ?? Nwlx>rIM1f ? Ins, L I RSr oR VtN NAME: usr I I L .? - - S G' r Nifi/ %?7 iuf(t a... Ell IRftI ADDRESS n ? CIY SIA1 ZIPCODE PEIUNF NO. D IIY SIAIE 1111111 N N n oar ., J S 7. ?7 ' R ? 2 U Nl S ULI-NO SIAIF E% DA URiN I 0 VEx 1l-lE NO IAIE OA Of BIRI ??'?? 6? syz ., a 30? R CKCUPaIION FIRM NAME LPIIONf NO. EYES WNGHI NFIGHI E OCCUPATION fIRM NME. HNE NO. EYS v/EIGHt nEIGN / Z / ?Ail n9aC.dn 1 / 6 5 b R oa 8P' D- ? CHECK(? Hat as AN IM ov[P OEA?oIHIR: ? CHECK (?) CIF AS AU MROVfEO DI F m CODES?"' 7 Ii 5E 7T6-,;-,--'1 CODES I!T 7R; qi; 5 ey° / 71 2 rn uns s I 7 ;ra:?"°? MN . Kr ? uya ? BnI. ? 7xKli ? NS6v D ? MN x r ? u: ' ? britP ? ? I.A- ITILIT211, 1GN1.1 R % 1 HEV.1. MODFII OVA) Yl Ix V.j "" V Ox UCtrv3 PLAT N S1Alf RAIL11 RAIL NO. S1Aif H vFH.C OR SA 1FID lAi NO. AI ,c= /V 4e h ? 6 ` vDUCIIIMNNNU IGN NO. YEH CIE p[N11 AI N El > 1 s, L, .0 s71 .00 L J6i 3!NIl i/13;3"i7181 I I I GISIINIDOwrvIR: IASI IIRSI MIDMf NE Q / ?//1 ? PrgNENO. II x! ISItN DOwNEx: lASt {IN]t MIDDI[ H O. O/7 / /? 5? Ir}; . ADDxISSaovnrtR W o> . i r?D? D ' uuF s-owNw ' . L ' J J / EAU X ?Qf ?f-? t• n:dAd P?,c? E M C y AMtaappxessawsuRANCEC .oR ACH /sFrs R 55 IN _ccco A •? S Si, S r r -'`ter, s a?'r?- , "b"' A AR! N D D '77 rNxclwxM 611.Nx,0 AGEOr",Arw" uar ? 1 I] __ cHARCf r • Cdr / /n ] 1]IO. rDAAUGf I. NlMNN{D I? r0Y0 5 x 1 tL•R 10 A— IOwID •/I S TH.'SJ Y' n f D/E ol?°o."Kr ' - ?URI^!N ?AtMAINEO ESI.DAMAGf W Y 0DODTIOM IOW[D BY: t• I / ./OLf? AWAY]L r2 IE ull DIAGRAAIOF COLLISION I ND UIt ,- s ll,lP rtcl SSAR 1. BYA I" MINIM SN[ll1-E11ARY) DESCRIPTION OF COLLISION: (USE SUPPIE . _.... •- I !. ..F////A'1?' / / / yG'I/G/L: /?I GL:yS (jfYSlp , i? ° ndr,i'./Cin_9 •?no'?c as/n9 d on Go, /ETnn . N ? / <- E ? - - ? ._ . _ _ _ ...; ? n.,co?,!/:,tj <J.-sr?r??P/ ?e•/,/c/<..f?2 _ ,- NAME, ADDRESS 8INJURIES OF PERSONS INVOLVED CODES 1 - Z J 4 5 6 ~ OCCUPANTS/WITNESSES jiUlJrIM NAM" t11 slA Ace s?ATUS „"" U Y ilIR U?CI ;;<; ARE„ /-A . -o . s r, . P.Y? /J N IwP,Gr vir%Ar. AMR ?rn°' ? ?a, ? T/o.»i'san _ ens hl A':'cK r/PJ ROM ?AMB ?"_=' ??! . O mr L __ «I ' Irr NIS YfEi1 A'?. ?AMB. m Nr l1 LAIAR G.KIPSNAMI LIANA I.UC{OOR A • LIKY Dx.•'y' KI}I./trrNO N KIKI ARRrND OAI!(%RlpRi AMYOVID DAII h. ?FRr :S:i •un• .., f{(t ny'I ` r 't y.µ :a1, .mr I ?? y1 I G 5 oil 4 AF ? _ rTF:.. 1 L S'. Yfi ' POLICE TRAFFIC COLLISIO 1 / IVU. N REPORT ®BAFFICWAY PIX Cf DOMPU Nr NUMDty ,}y ? PRIVATE WAY pl y?, DAZE Orcaus N ? DAi E ou soN o Y COUNT CaI NIYIq iv W ? .P p n / b J / w. wr .a u wl t r. ul IUSf It Y' . 1xODNOU91 ?4V N?? .?F: Cf't' 101 " . rNWA ?UR AN ?N ?f ?IN CIIV04IOw N AM1. NO Of srgFFr OR NCNWAY f<r Cls PWIE OM SrgiE URA. ?? Mls ?s ?w E IN (gsECDNG VA N SIPIf O StRK N 6 ?. . R NON NIF45[CI ON D eG ;? , pRFflz [p. MIIfPD,1 NCF6pR roNr R[t9FN aosssluro u °i , C Siq[Ft6 STREET DI ro R NFAgesrM / Ml fs [ s W lE rosr P ACCIDENT 4, D IAGgAM DATA - a t[Fr 1 Of ?/ L• K-, CIXISgN NvIXVED: 1 MItEAGE / MILEA E N I F fOrAFYq. O,N'lL'D l[D_NO N,V9f0 C1-'Ws ? pro-YDAMAGE ONIV ?SpII AGE ? 4U IUNRp4?.? 4[ Nrf ?RD P CIS I[RS(CtN srRFE r OR WAD09 RF1f9(NCE.? CR055519[fr OP NOAD t 1 1 091fCt sI9UCZINAME Of GWIECi siRUCS AND OWN[9's YtAMFI q ? qf ulr(D ?v(N CI[ [sf DAMAGE sPECUI COD NGfSE G ?•?. R _ S F w, UNIT NO. 1 s_ Rrvt9s NAME: usr rIRS[ D UNIT NO. 2 ? VEHICLE ? PEDESTRIAN ? PEDALCVCLIST MI f gsNf ° % 1 /' l 9 M C /Y [,E O F s f' l.? l' 9E55 , / '? ui, , 1RU' MI ME `? 2 n cn 1 SI RFEIADDRtss S U C i r-% lA)e I eP : -1 t s t zlpcoDE PNONF No. D y? /? sIAI( tvcODf PNONE NO. /"c•r t 'z 1 Ct.E: i1SY>i, z•1 Lc. _ DRNF9's DCfryY NO. y %f srAl[ 34 t x F ;i f35'.5 J6I. R lr)f fr :LC E. spt wN n ? Ep_? .' i3-?• yr A /.Z .p ? • /b/G/G occupAtwN S H -;'A'L L C M F' I YEq I<ENS[Np. ' Rs? V G MO DA. e,,3 T3 -• E LLI7/ Sfx F DArtaegrNR z ?/ ? 2 PN o Es cNrfacNr E occupAloN E ry / P qNf NO. , lo w? r[s cnr N GNr / f r. "? ? - CHECK D NcA ? ('? v[.1 l-s:s iMno [?o [ A * Y r I R E/N /L /` ? CHECK (/) /3/E FNC IS r l nl FASA " io o o ' _ Iq, ` . ' ) ' '? ' . .N 9 ?/ CODES? ?? N '"' f S 2 ' _ N rMp v F[ f Ar tNfa e x?owR.cu CODES xis ' EP s fx / ' + r A C1Q t 9, n "A ?s.m, •'h y 7 S? (I u Ric K c e : /YC:t N • f p .R.n%' • . ? :°.,v eD' ? xMaxA.?cl ? ro;cF ? fib: r. v[ FA.pM w OIDUDGF.CNIV.I? uvMODF? ARr NwAI rKiE ? ?i?Kii D1 ?v vl 9 D4 C f ; n, .• '' f ,5?? /9b'v To Yo r° ONV.I N 1 EAR 1 CN[V.1 -LIDARINOVAI l RDq -:2 E / /t EL r rt ! i . .. slA Agf40.A1FNp sfArF II FN CIX09 4 sTTn /Q N u? ?11?CY H )E/ 1 0 4 I `' A f 3 ?: . nNKU ID[NIII-1 IN NO Y ?PP- C .s 1 A S.i 'z'F1 IJ-t /1 - ' . sL . J O O i ? x! // arc nafDUWN[9: IASr I sr R L aE am r u N . y ySP T el r s H y sR° . ' ? .: ' , :• MIDDU ' ngN[NO . qt s RtoowrywIASr MID F 951 N a ? - E3 , . r , a S¢rAx P. c't ?t ?r?v1 __ AppplSSp ONNfR O 3f/..°-5:6z '6c- e a w S YZ be, I.•f•' NO. 6O '?"P!.-...H, :. ., . ^ 5 ?/l ?Tvu-tT:[ I.a R h'ttr/C!r? /Oi`/c??• 1? /'iVt'. Ach,?IF c cE c1EA9c[ t'11wtInNN oAMAGE• .-... -.,, Ca, Rfd . %{ deb. sr? W-t5 nnS'fR•`Irq,'(' "'.' lt, nr( "9 /71 Al( in' 9i (e P" hr111 ,1 ?UK /I. VeD h, w / u¢S rJ R•'/F'E$ ?'v /oafs "'n 1`tie `•h IeleK /Io?iceeQ fw'c bie7e12.s r pF1°?11 7 c. . `• - - - - SiIPEElclf_'.Yt:E ca M•C hack In'I'? 'F1Ye fail' / _ bf •:ns( faESF TLn ;f/t { cK Vr.h. '"2 in the tie•T at, WX I AGI X1JN?K r IM•2 1 11174 1 / II-12121415 ?e'`f -F'--Y'^ ,..Taef r Pi 1J? 3'IJJ r, s)?" iC ? Y ! ? F 1 ?S is y ? k ?`IV Oqv I`? Wx ?uMy-FD. Swei(le rNF IUSE ].IW NOU_gl COQ' J? O J Je CSO f? IDUNEY NO. CIEYNO ?? FU?A++ ?N ?E ?IN CIIY OR TOWN AA- ?3 sii, a-F k 6NO.O SIREft ON «GNWAT N IR C43 R ROUIEOk SIRFE SECT ON , Ni[NSE ON Eur t3 (o37/O CT N G1WIIH 519 ORR?p NONINi.....110N ?/ PNEfI% EO MBE POSE _ TL?? BEIWFfN D SIREft 0 SiRFfI oA ?`? ' Ds1ANCE 60 REC11 IgOMREifgF CROSSSIRffIOR NfARESi MIIf MESS yF 1 ACCIDENT RAMP DIAGRAM Miq fEFI pF MILEAGE .- COIIISK)N MVED: 5 CODE t01A1N0 NO. KIII[O??NO INEURFD? IXVENCIES ? PRORRNDAMAGF ONLY ?SPIIUGf ?H116 RUN WNDV(OM f E B I. N .RD R IN 1R iORFVAD O INI[ CU CROSSSIRfFfO ROAD 44lEE9EnCf OBIFCI 11- INAMEOF OBIECISIRUCK ANp OWNER'S NAME) ? Rf3UltfD ? HICFf 6 % E • E-AFAAGE S«CUZCODING L6E -- ? ', - Q ?+ - UNIT NO.1 UNIT NO.2 ?VEHICLE' EDESTRIAN ? PEDALCYCLIST ?? )3 Si', S/„ D4 VER'S NANE? USI Iq 7 ? Q\`'? I NIVfR'BN W,E: USf I ?? REErgpoatss l ?'1 A lc M ? ? I??h C.? 1. ?y?r '•3 SIRE« ADDRESS .11, E-1 ZIPCODE PHONE NO. W 983Nr U I vERICENU HO D R `„??-rJ?OCk srf.vJ? P 8S'31'=-5 .? . SIAiE 0,011fl70319 Wf? OCCUP 11ON I E% F BRN I GIVE' l[FNSENO. IME v - Cr'" DAIF B IH "M o303 T`16 -'I = R&A-0, 6PHONF NO EYES GIII HIGHi E OCCUPAl1pN f RM NM1F P PHO E NO '? _ LiOS-16 B? t . EYE -N1 S Ni HE GX R t ? CHECK ( 17 yFNICif ASSN VAMOrff of AFMipmfRAl CODES * • Ili- 2 i s uECr av •c • S I ? CHECK VfH flF A54rv FM IOYFF OFaNpIHf9?3 * _ a Imlf s y CODES ? 3 a 1% :: s u e DMl ooN - {r s F"5poi DM ? AM. N r ? ?ycF NRIIF e r l VEH. YfAR? MAKE BODGE{HFV.) Dr ? 8,6. Q KN ? C N MOOEI IDARI.NOVAISIYIE IRDR.{ONyI a Df (0] AM AN, ? u N.Y FA4?M 1 .CNfV.I x IT 103 EBkE. ?s?W„2 ? 4? AvODEl10A4t.NOVA) Y ( Dq. V,I ON iwc ON L aEAs S ??JD E 3n UC(N If VA N VEHICLE ID 111CAIION ND. SI1AIF/ 19AIlf4 RAtE NO. -IT W H vEH.CIX R I A A O. A E 5i 16131`/18151 71 I I i VtHICIE IDFNII{I II NN I k[G131FNEDOWN[R: N31 IIRSr DIXf PHONE NO l I I I I I I I R . C,\ C, fle v. W, 3*5-2k4 y ISIFN WN[P: 1A51 {IRSI IDDIE Nf EKD. -RE wNER W A ll RtF Qa 4 6 N r NAMItADD9t5501INSURANCE CO WAGlNI E . ra T, 0 Act ARU 2 lEN - ?- R u DR _.- R I c cl a CHARGE - a'?In"vN AAAACE .wu ' rDP D,xLDMDI , oFAecf ro 9 u I ^ S l DIM1fcl ?D ' ?RIAUIN[O ?AWAAY 0JREMNNED ESID AOt , Br f ??D to d' O ? B ,.1 ?$OAWAY WEDer f I DIAGRAM OF COLLISION: II D A INDlurroowln DESCRIPTIONOF COLLISION: IlnfsurvlemfNrAls «rr [c[ss,wrl _. In SNEITII .Ect Y) ._I BY _ ; ( I I ? I f 1 I iC).. py5 v.?Yk ... C?.1e r M S .1 6o J E, Cam.. I 4fSTsiJc .o ? SY1.. . h "tT 1 I. ? ? _.. ? ;. ( c.r`(1t4.,a...1. wx_C??o.. x . ...rt7.x p .•rp4,.. ' ? , I ] ` . a I ?? , ? ? ,y L 9 " f lV•C ?I'• Ih ETIGAK I. 4? WM?OIIS`.Y CM 1G ?f?., i p ?1w r. l t- . Fru•eF a 3 i' ? ? . I rr`ti r+- ST° b ?afw o •'•- 1 t - !•A-E aac ... uP _aK _...t'oa3•f_., _... ? 4, c. r NAME, NAME ADDRESS INJURIES PERSONS INVOLVED * CODES 1 - 2 3 4 /? p 1 ANTS/WI TNESSES inpiu(iv u x?i- . r 5 6 ^ AVf Ell; _.L ?H o' ?32-Y932 w+RFU INNta ) ? se K A ,l R[stR. Erta wr0. . c NAM `_ . n nr 0 - ?C'%` Q `. ?^fx ?i'7'Nw A 1 4pD.1ff y Fq 1 Nwl NIURIO w MU IpM DIR ?AMB ?wKI?a1 v? ?v D _. ., No ArwO 33 NArw?a - l ex 1 AV KI INAVIBI N BOipq AffAC Pf I ?AMB ? ?lD ?N ? A .1Y Kf S. IC ND IGLU Ilp lro 1 N.BOViO IY T- DAII A ? lY " t [ h r f,(4 1. ? ?? 7 rY Y4? t . 1 f m { ? .J Sr Sri ? ? i t 1 z. P r a r F j 1 O a ' a r, • U O hoax E o ? O O CIO S m. U 7 a)F '. +? ,ra sa r- 1" ?"Rt ?`?{x+' + ,? U F t i yip l rVt` + t + i r yt+R, J ti t 7 r' h 1' _ r rti y"I 4 rv i1 ?f YY L?m,t frr,.?k s -??1Ji dY[ .Yi ? .. p -i 1 ?rl? ?11 Ii?r 4 y AR, J POLICETRAFFIC COLLISION REPORT L'S•TRAFFICWAV FOIICF COMMINI NUMBER DRIVATE WAY r" f pwl OLLI N p?MEYQ? COUNTY 2 82 f6l7 1Rl t?I=FFgQ$013 IN CI ORIOWN AMf(NO ?N Of St4EE l0 E COUNfY NO. GIIYNO. iNWA 16, pDReAN . Q ? Q ?4? ?MGf]H?WAhYw 3.5 -'s 05 []. 40F 04U ONCR• FCl 4 EA9 ED INrfRSfCr NO 1N M. WKE}OR \ ...... Ec"- FRQS AD. O Df- 'co .3 = 'co ION x E•] 1 BEIw'fEN • SiRfE16 S!?"' R Rf u Ct D { .CROSSSiREE OR NfARfsfM LF 5 "1H, R4EIIK EO. M,LE pOSt x/? -&7 I? I J'`J R I t•' W ??// MA[5 X0.7 {Ffr Of R - ' ACCIDEN MILEAGE CODE ewM p•IA COtUSX)N INVOLVED. V ?.(? tOTµ NO NO'Au KIllfO NO.INNR[03[? QYKIAGE ? I IuNIDitDm b VFNIC ES N O NG L}OR ROAp OR RtFERLNCS N INIF4 CIS gO55SRfFiOe POM n I QpppISR1Y DAMAGEONIY QOfSUL}EO VEH,Ct E (?•?f,J (/ 9S/-J LI OBXCISieIKKINAMEq Oe.RS(RUCK ANDOWNERS NAMf) fsI DAMAGE 53CW CODINOl6( _ - '. UNITNQI UNITNO. T.' uRlvEVSNMSf: W?.... M IRV ' - QVEHICIE PEDESTRIAN 0 QPEDALCYCLIST ? - p41vER SNNAE: U51 iiE;E • , - SreEET Y r 4ff1 ADDRESS ?? ( E+(?IRCODt RHONE NO. WA, AX ES IM36 W6 R SIAr r,2 f4'3 UC SIAIE ILIA MD D,r Y2 I V Iv ll tN ' WE MO.b BIRI r l I OCCWAtION FIRM NAMl.R9Nf NO. EYES ONI .*"T E CUFwiION FIRM NAMfe RHON[NO i 2 BW 160 6 a2 R . EYES IGHr ION Q CHECK IQ v H G w u ANOrHea. * O CHECK I?2 H A E W AN- - Or gANOtHEa" L CODE5 No. 7 a.... a °in ?I r 5 Exc a "s'olory c IKaI CODES 1. * 7 a, i`sr .I srz"wi w S I.rnw 0 N r i URNS 5K-: a r Qmi. Q-A ? ? . . DI a =W.- 0A.eKAN4 Q? 0MAI. ?K Qr.HA N?I[ ,? ..Y . MA410ODG({NEV.) 110A41-.K]Vw) SirlE lx OR: .1 HOI DA C.S?.3Jr? u r s E H I I .) MODEL IDM I-NOVA) I _ x r ryry--f}?? ?, ?. e^AA KF? ? {.? m IERnwr(NO. srAl I N R A ..-. ' VFNKll1DEM.IUIKrENO. i vW gNIII ° 50 E5350! !O'3 ! I I I ! ! I I I I I RfW11FMDOWNFR: WT IIRSi MIDDY T9NFN0. O Rf WNfR USI IIRSr ,ODI( •?• I] ADpetV bOwwFR W E NER Ill NwMl eADp V-ANCTCO. M4 N1 ,N R n oAwu A.u va t ' ( j cN , -cE {ajAM,?Ip N gAMAGEOAaa Rf eTw • N ? .I. DAMwG( AWMN ?eEM4NfO. .-N "D?I .TO. fSL ... .i- '1 0??rTVTrO loweo "w"v ?RF•W'NEO IOi"arrow s I er C Ll I ? •wA Aw f C4 Ar ev: f DIAGRAM OFCOLLISION: r? tfAlp NOerN DESCRIPr10N OF COLLISION: El+s[sbn[MEfnAt sle(r FNece55ARVl J-T T'Tr7--1 1 ! ...I I __.. '®.'•1 1PCErD .?c?..U?b6- 1 ?E_1? ._A`FT!_ Ik6 v ?. } ri , -00 7A?KI11G 0Z _ I.o51DRCO or-m c WA _ s - Zuwt? nG A FX 26 u7 M/C..X30u?LIG?Y3A6o?iG ` -? 'Q..z •36'e.© x I t 03 .as_FiAIAG_PostTS.. ---- ---- ? I -1 - _ - --- F .....?. ? ?__- ^-•-_1e I I ESOFPE RSOM Sw P %S NVOLVED 'CODES 1 Z 3 4 S 0 -,.. rMe OCCU ANTS WTNESSES Id ADpIK)N•l N•AN OC SI S[l AGI IAN xlh Mi'- . •,.- ?_ N51. [1[R utn .u 'I' IW/? NAME:. TLJOItEI'M . RI.?Wf•.r7 ... .. _ ° _.__._............... AWeliS AMI N N•tVeld I 47Y AM S Q Eil ? "' Q W NAIN •oonu „ td" N u _ MroOM QAMe Q?oIKI Or"'t0N ?I? _ . _.-... ._..._ ..... .. ... ._ ... _... _.. N•IEnrd _. _. I ' "? wElwH v rc n N•w ee a e•ODE Oe AuN • rr'', W16- rNr tY 0 e_O I= .OC."A' 0...:s. ? ' C crD e••.HEO I? X Bwl1 y :a?x5so owr(b niter •rreowoer pAif ( [.oDHRS {{ Tro•E rws 31 9 Mkt Y 1< ??. E: r t §f ??,hqt ?rw: r ?I l i l7t r s ,n IM M YK R ' 1 + ?` yy k -AE _J>_ .I .. ... , ..- _.. - .. . v K Y Ii. V '.? e POLICE TRAFFIC COLLISION REPORTTRAFPICWAY rood coMVlgINr NUmaEu ' I ? PRIVATE WAY UPIl O,COlII N qT a H COUNTY J wuN1YN0. G CIIYNO. b o L <C 7 • ?N ?f °IN tYUR TOWN EANOOYSIREETONHGHWAY Ra ? 5 l l Ow /tS INIlNS[CIING YAtII: STPEI NOA NON I[RS[ CN O FCICU ROUTEON SIR 00 6arCn K .' • ?.- I . IN N E!ELCC,, ryry ,?OO B[iWfFN 1?1?.?0 STNtEIe .I t7N NCL(L t UISIA D YNEH% Ep. MILF POD I Yi ,• + A L N[E 6 PFMIION IG rfNO5551RfElOR NFARESfMIIE 1 ACCT nL5 5 [ W ' " NAMP OIAGRpM WIA I S 7 c^( f[ft n cl Al ? Of k)2,-,;A LV MCODEE ' CO 50 A ? ll1 N INVOIV[D. VEX IY. NO K IIED-NO.INIUNED? ? SP LUGE ? n fl TOTAL NO Cf V[H CI[5 ? PROPERIYDAMAGEONLY ?RESULTED ? ,urISN ,NNP...rHS rv HD NIF/R [L5 INTER SLIN SIREEIOR ApOR R[IERfNCf CR0555TPFET04 ROAD 71, s..• ? i rIFCI STRIKKINAMf Oi OBI[CI STRUCK AEND ERS NAME) r? 7 ,l1 ?l 1w"i. ?il Nf. 7? Sr DAMAGE Is SYFCIAICODNG IAF ""' ,: s UNIT O. I oryw4s IASr f UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST -24 , ! IR L aN VfR'sNUnE: wsT Ius mI Ol ... .Y SIRfE 1 pDUNfI SS [-fi ?r ,l Y, O r- I _Ll`ti Ikf [t ADaN[55 4 - . <Ir SIAIE LIP<OCf PHONE NO D IY Surf TIP DE PH NE L : } 1 yNG ?'? ?j •` S G {t5IR DRrvtu51iCENSErvO ` ?C ? R N . ' j SC ?•• F 1AIE E% AEOf ORIH r0 O,r vx I VER 5NENSE NO. U SIAIE SF% DAtEO BIRTH "5"4Pr k e? .C -fY _ ?? I 6a s V r.•n. I Al Y. OC CUY A HON MNAMfSPHONf NO. - FYES WF . KtGHl E UCCUPAIION fIRM NPMf6PHONE NO. EYES WEIG T NE G ~ p _ - T L / V - H ISS S? R H I NI °C ECK (V) FAS:NIM ffof AHOrHfaM? "M vfH c 4 o s . o CODES 0+ p ° °crd ?CHECK(/) E AS AN FMNOYffof ANTHEagI 11 + „ , vFH n Nr C •? p n e ? „ ; n A S - 55 A is s u N e m4crc ODES 1. p 1±. ra rIn 1 ( T ,*j v( ' rs - c ' M - LfU1D iCGiiL`CC= J ? Hr . eS MA AY.mA r<! ? rv" ? ?&IR ? B•I HS. K DODGE1Cf FV MUDf e.;o,RD C] RMemIr. ? ' ? co4im ° vi i?l ?14w ? I , I b chti? D StYIF .CONY) z'A IfA( , "I' gV P? J E . IN YtAN I E? nfVl MODEL IDARINOVAI Y l] rvV.l - ? ]B . OR [NSf PIAIIN SIAIE IRAIII-All NO. Sipit I'I EH CGION N E I Il l NO.- F XO-7 I Ib WN c A f 4 :'i vErunLa IrICAHON NO 3 ?h`o1o?016? 12? N 51[ [DOWNIN: USt FIRSr IiDDLf PHONE NU e vEH aF DFNTf AI Rf 51 N1-NER I? ? . ADDNISSa OWNIN '" ; IAST fIRSf MIDIXE N NO. 1 { N A f. wN[R 4 iL IOW' AMU eo ' . E I ? DRISSOIHSU4ArsECO. A 11 14N 1 -N D ?•? R IN UA f AN^G1D ANlA _ _ •,N rl IT GtO AREA a Nx.K RNA. CIU.4GF C r iunCi pUR !•,•MA ? ANWly1 E !D 1511UAMAGf mwrrv I I{/.U eDt10I+ 5 I T ? AWAYN ?R(hU1NFD I r - ?N ?S ]] I n? f O I 1WWLD • QQ DXt - Ar nr: C V y,PC? ? gwAY BY S r , - S f 4. • le a DIAGRAM OF COLLISION 1 UrLMEN ,a cgrr NpNNI 4NKFy1AyTj?-?B pw DESCRIPIIONOF COLLISION: IUSFSUPPIEMFNIAI SIR[I fN[Cf55ANY) To`;pli ?L7r_o ?C UF a'\ ? C l ea cl Z ?E _ K . co ? f?>weNU h-LOJt,r,; IG 1 PI IZOIZ ?a'.. ?..`l11'T 4.7 NG c-l. Us_eL,S!V?' [ c a NAME, ADDRESS S INJURIES OF PERSONS INVOLVED E CODE S i 2 3 4 5 6 1 OCCUPANTS / WITNESSES IFiv' o?lu,AT Nl:MU SIR AG 1 srA ros " Rim ., "Hc ° qvL A . ^ r, DIMiE• S RI Of ? ? aa° 0 11 . ? tl a ? 9 r '? }' ?iallM I s AM R ? ? `1"rlPri°IRCU, °•wn ?Rarl ?1"'.,I. ? ?.Y ? ?.':1?? f t V r w . , P?? ? t f.SI... Amnia I I.A (AIA; .SNAVf A *--NB ?AMR ? ? .? x ?.: r,W . ? Y y X y , ? N ? nmX? w,fr?l rv?psr.srrwD '`> J ? l 1• ? ? ? t Z n. C(A'R YED DATfr^! rr pvfpe? Dnli l 1 to ? • : ?_ x . lyrt Erru? a '', ?9T?ti :II;e A ,, i r ??6f1 S r ' SR A } ? ? r.7R " tai r { r: ,? _ r f4. I Yr. ? v 2r ?A1 E q 1 ? 1. P 1 I 1 tl ! L ^ , I` f i, Y Er> 4 < r W STATE OF WASHINGTON AGE Di / ` No. J POLICE TRAFFIC COLLISION REPORT Co TRAFFICWAY wllcE COMnAwrNUmeR Lu y ` PRIVATE WAY [U l r + N DAVOr O ION ImE COVNir ES R I I ? . uux Iui wIO IaPI NI L! /USE ZEDJHDURI ? L ? ??{ ? COUN(Y NO. CITY NO. F WA _ URBAN /?+ [ / / J 2 '' ° ? '` C (Y 091UWN ?N E lam ` ' ?' , p ? N - f.- ISIREE-H.- hT CLS ADM 5 ROUIF ORRSREEI OUE SECTION. ?`` s pW ?oP I7lY ON 6L,) l2 NIfR >' _laui -o SF(1 IE109-OD NON EREECI,ON J PREi1% f0 MIE POii Ji f IV^ ! N'EI $N. BFEWEFN SIR[Fi 8 SRFFi D grvc J > l U ,ROM RIr[klNCf CgO155RfE10R NFARf51 f 1- Z? - 7 r I ( S. s y -;' j! r 1/ lE , MIl PO51 ACCIDENT 5 E quaP D49PM DATA y LOUs MILEAGE ? Of CODE <OlN 'gN O D' EEV[R IY. II " NO.K IIfD Olq II NONIUR[D ?SPIItAGE C16 RUN wN"De aI t0 ! IN N z.RD IER CLING TREEI REC-RREFERENCE 1 _ - 0 VE (E RO PRRIY OAMPGf ONIV ? I T11 -ICIT l UIND ?v[O N -D, CIS c.-S. `ORROA (?DyO/ 1 E -.(,,..I,K,N.IIIOUlfC15TRUCK. DOWNNER'SNNAE) ISI DPMgGF SPEC AE CODING USF _ - `A 1- /d -r /A7 ' L $ - 1 ,ryf UNIT NO.I DxnRs NAmf usl rR11 MIDDtf UNIT N0.2 ?VEHICIE PEDESTRIAN ? ? PEDALCYCLIST ' JE E i? d R/S .?.!/ ?/? EIFItIg ORIVER E NOME: V,ST 11 MI M[ ? UUxt RfEl PD09f53 EZ S?l6/1/p 23/7 (I T SIAiE ZIP CODF PHONE NO. D IIY SIAIE Z % IC1?tk/Sfa/D ')-?G YG xn(x yL <fNEf NO. ? SIAIE ° R IP ODE PNONEHO. > - ' R A f% r I IH q OCCUPANON E 6HpNf NO ASN I RW l<ENSE NO. qiF F% nn LEO RIIHR ?1 E` . ETFS WE GHl MIGHT E OCCUPATION AME 6 PNONE NO. M N EYFS WE GHt HEIGH T ry' l' CM[C R .( 'vJ c v Z ? K (?) ?ENCI Ar?olMa CODES?t 7 . i Iii 1°M". s r nxrl a 'O R I "wPC.cI I i a p CHECK (?) vfwnF AS AN EmnovFFOPANIHERUI CODES ? * M,I n cE ° kr TO o ,s ^ j K!§ Y+ •;•? u' gI N?f V[' YFn4roM M ?EIDODGF(HEY O ??hK%Jf DPRIt p O N . ? of EMJDI?M ? yM I 0 a.' ? ?a:RE o ?° ? ??„, H1 Y " 4 ' - ' L j A SIYI1IZDR CONV ) ?2- / /'Lt P ) NODEt,DnR, NOYq) ,1 Y) Y rov ,N 1'? G v OR C[N [N E IT lo I 0.AIF NO. SIAIf k?CR 772 SIAItA- P.VEfq H VfH.COIOa I v P l AI N Af I -110EVDENIR U"o"NO C '• ' 1 3 F o -ECLEIcew iCAl NN . l a ? RrG11If RIDGWNIR - u sI - P`n IDDEE tel.. PHONE NO 0 xt Islf oowNER: IS, NRSI MIDDLE NENO. L ']_ ATHR,...OWIIER W R OWNER Z .I t/?S to S?E"i47TC I N 3 NAMEEADDU[sscr lNSUxnNee co oR nl:t E y i; QgMACf D uu R u AN A µpON"' c Agee oN"al DPMgeeR qRu T10v 1 [SI. DAMAGf ? A??fN ?R[MNNfO TOP I' L '°? J D A f ? ?RIMAIN[D AWAY FS WAV ELY . DIAGRAMOF COLLISION sIV, nl v,RnINecr o9IH DESCRIPTIONCF COLLISION: Eus[suaal[MrNlu srlaNE N[eessnRrl r9nnNEas °eow " )vtk[0 Ec_ O The vehicle was south on Old Discovery rd at ' I ?/' CEP approx 55 to 65 and driver misjudged the corner and lost control and skidded onto the shoulder Ue then traveled accross the road and hit the bank 1 5 and the car turned and hit the bank on the righ rear courned then bounced onto the road and ato pped then parked on the side of the road and xi tt .went for help with the car. w--.H., .,,.,., --._...__.,.,,,, ,. .,? cwLla lrvvvwcu y - - _ OCCUPANTS /WITNESSES S"EI CODES 1 ... -,... _4 2. 9 __ 4 5 C ,( (at, gM .,,;,. ata y ?. iq `M(?s? t..1 ,?NMHd'9 d- IF. ry ? ? ?I d rur 0 i' f `Rh,... 4' W YH M C'1 'rr ! .r f r7J?' Y Y E ? 1 l4# 1 rya f j ? . ?? ? ? ? 1 I ?' ? 1 tit c 1 f }} . I I ?j?q t '? _ .?yi•.i T r TE t ?,, y4t?? r J I I [I r { '. > t I i ? I ?' r' y,'• ' l Jrt ?>r f ?3i:L;awb'?43+ h:? P :z PRIVATE WAY OATEOLCOl I3 1 ° ..I Iwro. w I. IsMr I TIME MUSE ].ODHOUR? (? COUNTY COUNTY NO. /?:.. CIYNO. .: , fHWA ?.-.U/RB/J{ LAfnuRAl / ?N OE ?IN CIY OR TOWN NAMEa N0.0 SIPFELOR HIGHWAY ? f CU'. ROUTE OR SIP SERMON ON E M1ULFS $ of - ?Z.S30 IN FRSERNOSWIH; IR[E1 RPOAO NON INTERSECTION 1110/.g ( BETVEE rV f / STREET A SIT EEl PPff1X. FO, MILE P051 O O ¢ ! ' d 6 DIS CEa DI FCII° OM REffRE .CROSSSiPff10R NEAPE51 HEPOSI EF N S E W A - ACCIII T MILEAGE °AMP . ETACIT- A AE fFEi, [( O Oi YJ CODE COllISIONI VOIVFD: ERIN: SPI E NIIa RUN NO INJURFD NO KUED M«SIN IrvoREDIH 'NEE. p 0 IMFR CIS C 51REEIO+INaDO SE ROSSSIPEEEO4 ROAD ! _ . _ TOTAL NO. Of VfNICIES 0 PPOPFRIY DAMAGFONIY ?RESULTED 'OSEMICIE IOZ (v lJO -- OBiSiRUCK (NAME OfO RSTRUCK AND OWN ) EST. DAMAGE SPFCIALCODINGUSE $ u - - UNIT NO. I UNIT NO.2 O VEHICLE," ? PEDESTRIAN : O PEDALCYCLIST:'. R S , / DRnfp'SNAV.E: -1 NITET MI E DRIVER' AYIE: LAST ". STREfi ADDR155 RfEi AODPf UfY STATE IIPCODE pHONF NO D IIY 5LAIE DpCOCE' PMONENCT. R 041VEV'SLCENSE NO. STALE fX A M° 1 DA B "'HYR. I V IV R' LICENSE NO. Alf f% D T O RfN I Cup- NR? AMEa PHONE NO. EYES -I1HI YFGHT E OCCUPATION 1 NT 111 HONE NO. EYES i MGM 2 1 R O CHECK(F7 vFH CEE AS AN fMHOnfaANOTHER: O CHECK (? I vEH aE ASAN V'YEEOFA OT E9. -/ v n c K.KD CODES ? ] ?; i:sn` 5 e iKN 0 is In HI. D CODES P D Ass ivm 5 uEK H 6 .,?°r "cu /iT Q NJ I K Dr flrvl.r, " o AMF AN E o pct ? b:nR ? K O ;;fDM (3 AwEM.HR C] MCE 866 ? h ? T,1 N Y I VD1YEA.R Z a M1V,Kf DOOGf,CHEV) 'C fl lDM....I[[NOVA1 SIYLE14oR. CONV.I -17 ? E 7 EAR 1-1 l f HEV.) MODEILD ?NUVA) '"""C"', B 6 n CEN fp F SIATf IRAILfRM1EN0 STAIF H 11 N. VEHCOOR' 11 AI G AN3G GvA -- --- I C 7 VFHICIE IDfM1117CAtION NO. We ,6 ,,, 1 {015;313; I L H CIf DFNI lI NN VE! I i I I i I I I I I I I I pEG1 RIOOWNER: LAST ! SL MIDDLE PHONE NO. O RF wNF VSf FIRST MIDD M E au W I.1? % ADDRESS ER N ADDRESS OTOWNER . FF 9 AMEaA D E1 INS RANGE CO. oR-TNT - R N u CO. OR AGIN, 44 .AMAGfDZIfA i?o ° v ON I E 1w iwc wu TA 4AMAGfON. l " r iu ,[ ' CHARGE CHARGE l N A u P IO iDIIOw S 151. DAw.Gf ?N ? ? Y KREAWNED ?' RIVEN ? ,NAY ?pFMAJNED 1 FSI'OAIM F TDP S LO ?O1TUii s 0 AWAY BY A WAY ?IOVEFDLY. $ F " DIAGRAMOFCOLLISION. J El UPMW TAll CA"ll RIH IO,la?j'* (?laTa4mr !4b DESCRIPTION OF COLLISION (WESUTP,IA NNXSHIETIFNICES3ARrl :.- ve7! r___? f2osa.wA - %J (0 A12 Z 7SFC749 1T nrcr 4?eiv? avanobb ` ? NAME, ADDRESS B INJURIES OF PERSONS INVOLVED CODES 1 - 2 3 4 S 6 5. OCCUPANTS /WITNESSES 4t.5'D•IIONAL NAM 11 ES) etA AGE TANS IN M 'Ar "1HI- MSIP. EJfR uE NAMI SzoK? 47" COI '.D IFS-0-ni - - .. .DORISE 7? _.. ( HAIUR W n eY AM e.pWI O "°„P OG. O v"o AMk N ' n,f. Aooplss NAEUR Or PMKrvfor4oM pAMe ?MR:I Or" FOB O:° Al N ra A 51 NANs, n "Me"', ?AMe o K1 n D n. oc. n.° N° v wh11IIG Ill N. A EAOOIW AGIr I III, F o^?S (.ICIdD ?C? UuEA? D DAllp nrONl APTIOVIDOY ItTt I ?' sm Hn sfm ws u F g T pp ?Y rglg Y1 1 1 map lrAia'' e - , ?' < I = ??{ lM1 A A 4' . p `E % ?r zrl aN K. STATE OF WASHINGTON sO No 0 POLICE TRAFFIC COLLISION REPORT ;ZTRAFFICWAY . PRIVATE WAY MICECOM-NIN-R RI E I A 1. ^}D v .l Wx. u ?Iw33i lrl rMr. IUSFIWDHOUR, <OyNIY J ? COUNTY NO. CTYNO. I- .. o ? ;. ?uR- pN pf ?IN GIrY OR rOWN AMf6 .Of SIRtETOR HIU'HWAY iCl ClS AL gOUtEON rREf 3EC NN V 1'' I Mufs ps 54w pof C1N INILRSFCtING WITH; STREET ORW NO V 3 6Z 8iO.. :., , ? * NINIERSFCTION VRtfU{ yf EO. MIlFPOSi- - _ ¢p 015 Cf OIN BETWEEN STREET a R I STREET O. C/O ?? CC V RF ' {, I LES SSSIRfFI RNfARE51 MIl M 5 E W Z ACCIDENT RAMS DIAGRAM DATA -Y ;' {+: i[FT OF CdlI OtvfO: ER IY MILEAGE CODE TOT&N , iOIAI NO. NO. RILLED__NO. INJURED ? mil GE [I dVLNICIES RUN WrMiOXDix3 k?RO INlfgr Cl5 IN LEI RROADORREEEIfNCE RS R CR0555iR r % ? v YROVERtY pMMGF ONLY ? iI4F °/` OSACiSIR«R(NMAf Of OBEFCI SiRUCKANDOWNFR'SNY RESULTED V [I 5r D ON, ?//?O _ V "rv Ee. L Yexr . M3AGF SRECw COOING TAI u + s ' - UNITNO. 1. DRW f: U61 FIRST - i - UNIT NO. NAMF 2 04NER pSVEHICLE ? R. PEDESTRIAN ? PEDAICYCLIST •4 ?I " f A I L 9 kic?(T I SrRLLTA pivcft o7T Srgffi ADDRESS T/ QaX ,2S/ ° UIY /?QJ 79 S( Si t A F /? EIPCODE YHONE NO. r?y? D IIY ?53 3??( // Per /( (AWj W? G r J3 O R F ??^j.I'll r?`aD V ppppNE ' DR.WSUCENSEN I 57vNO d x:s-,-Z SrAr EA M U EN ENO ,12 Y I . At k D?I DA eI lY q «cuY L Q 5?'C/7 &4 V fIRM /N 2 7' -G (? l 3v'i/L 11A 1AI ??? EYES WEIGNr HEI?t E R «CUVA110N FIRM NAME 6VHONE NO, FYfS 11 HT EIGH ) T /Z ? C ECK VfNI gVI O Uf ASAN EM YFF EANO1HU `, p CHECK (?) MHICIF AS AN FMAOYLf OFANOIMEPµ CODES ?+ D a TION Y"7 I 5 6 CODES ?* 9 a . i`. 5 [x D L U41F5 rl `{ i r 1 1 x " ?M Vf H..TFAR MAaIDODGf{NfV. 1 - ?iALY pAM E ??,ya ?8". MDOfIpDAAtIr ? 2. ?v? ?PR°I,Y. 1 NOVA) EJ YY lf (i DR.CDNV ) x '?r HY . r ( HV.I l V MODFLLD-1-NOVA) .? y l ? •y F ? N V R LIGf YlA N SIAIE . IMIIfR RArf NO. ` ' IC SIAIE H V H D ? U U G 3J , I,. F S N A vfnID.LIDl nHU1roNNO. C . Z n I fHICL[IDfNlll I •? F:7? ?! 1?171F1 I I L r-? /L I?171z15/I?? R[GISRRtO OWNER: I -1 NgSt MIDDLE PN ONENO. O IStEREO WNfR: 1A51 fIRSI IDq I5. ApdR 'r W Hn 383'-.t-?I?l J s N Zb)Eq E 9 si N.w.tlAOOxud msuR.wcf co, oR AGfrRr /a/tQ•'/?//?Q R ? ?c DA51ACt Aq[A +(n J 3 RTOY r CHARGE CNARG( R.w ,rp D(AMAG[ ARG A f IO iOfloii r ISL. DAMAGI '?f{ s 'i I7??, ? AWAY ?R(AWN[D , 10WFD JI?WAY ? ^pyAYDe , J" R[MNNFD ; lSr IDAMA [ eIOY I IO i01TOM 3 DIAGRAM OF COLL le ISION: Y 1u KC ?AWAY BY: I D NogrH H/ErUN[ DESCRIPTIONOF SCIS5ARY ? COLLISIO f S . IS IA 1 ROw Q \\ N: (USE SUYYLEMwru sMfr.NtcessARq Both vehicles were on E middle Pt rd headed in opPisite directions on a gravel rd with n w n ° o ar aigw and marked soo The road,inst,wide enough for two care to pass without one_ pulling off the , / . road. The cars came together.on a_turn that , niether.car could see around and both at a safe y L R/1 ? speed and collided on the turn A/i _ NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED + CODES 1 OCCUPANTS /WITNESSES [I-.' SUrpIMEN1Al SMIr Qo--M.N. 2 3 4 - S 6 - NAAV31 NAMI. Np , .. - SLx AOf lAruSm YAf RISIR. NfCI n AKUHSS AtUR p .. N+'AI A ? R IM IIr ?AMe ?uRLI?`K r?N? ?{+r?uY H AOKIif .... NArG1 d.. .... AMI ?LAY DIYOM ?A/AI. prPKl xN r ?Ii0 LL C1 ? 1iY 1 H .x31 .0 Aplvff5 NAttM d •,vl 'x3.A qdr IIAA? uIAA?S ,, A.3:., IMF. {1911'196i?. 'f.?Irm...,I?t?YMln'?13.MlAU,xAp 4v - AMe M, xn I M!? p ? 5? LE 0 GW p_ ,rAr.mull ,. J- t w' .t - '`Xti ) PAY ?? 6Ux MOx RIq_ uq FN. SAT. HOW, rWEO ?C ?S5 Z v COUNTYNO CITY NO. Ppx f I ' ? /r, 82 /o r?r-,,?T??aµ C EE UU ?H ?E ??OA ipwN • AMEE NO.OF 3rPEET FR.C ?.••E 7- t / g PPERX L IIOVTE Oa 61PEETCOpE eER. CC 0'"T aM nNGlwrN SrwlES ?? ?w EPSeer 'v fC ON /y;;,,r?v x,36 G0 / PasR.x. EG MLEAOSr /f ?.f eiPCC. 6L`? 1, E[alcci O. // IF No IHrFHSEcT-, ?j FE F. .-o.n_1EFN M LEPOSTORIUExTeYwOLIN °E rvMPEA. E p T - - ©LLJJ OF v J oMMrc /_ A n OMLNO wp '7 2EUOLSMATERALSEEINOIIVNEPGKi ? y RVFNx:UB ?G IM1JIr ?RE ?N. I ?Nii .4ELI000 L ? .. 3P J 6ilrE0 ? L°f<IaECE BL `M OPMEIVE -EMI AM ON GQ GLONwf ?"" a aEEFf°AIFNCE?Epp ETgt? gq?pAp ' OBJECT STRUCK Mox flAGO KrrvE MATFNAL9 INAMEOPOSIEGietAUCIH., VmE OF EJECT NAM AND ApOflESB ?gtT?T-.. SPEG.CDOE IGE '. _ DOVER'S LAST NAME ! e MORE rN.N $ ?ee, IRS NAM.,.MIDGE c.ns OTWEfl'9 LAST NAME.. ° E EWVOLKO FIR TNMI- ,:,, MIOpLE ,. T.IE yr -_ fr'?1 ?? .[/ J t a;; rf STREET ..wE NO AND BD%NO E swME ... OflP.59.:.'.., NO.ANO BO%N0, . Box - tr? GT STATE PCODE OgIVEg9 UPATM*N awsgx A CRY / 7 _ 2 C ? 2- J J 1 y / ,t G I ' SEP X? ?. `?" ??f/UV ??Et. ?O JL) .? ?..u,,NuL? TPOaM ?/ ,• .: -.9TA? - _..LP CO ., DWYEA'9000UPATI N.:-.. ? ,?, 9 _ OHIVERS UCEN9E N0. A S MOpATEO,r BIRTH AOE ` ¢y ? ''??, _ /`'? F yR DINNER SUCENSE NO....: .. :. BTATE SE%.....D U ApE. J' - VEHICLE YR MANE ICHEV. DOOGEI _.MODEL( VMDMi),. BODY STYLE 130fl •?'? 6C- -(? f ?' Wv Ya. Tf ?? _ ' ,n? ? ? j ? ? ?E Z r• ) MIC Y AKE ICHEV. W00 IN VA DM DY. ST 12 R. '?s 'y VE R. -M I. .. MO BO 0 1,. LICENSE PLATE NO. STATE ° V„ TRNLEq PLATE NO NO., '2 / :STATE . LAT N .:.. , BATE •• [??, N? -S Z [,J L(/ TRNIER PLATE NO.?? S sG •' VEHICLE IDENRFlCATIOtI NO. . . AF y ?^ yy .. .. VEHICLE IDENTIFlCATION PEOISTERE.OYMERILAST•FIRSTMDDLENAME) DRIVER 9LICENSE NO,. gE019TEfl ONNEq ILAST•FIR9THAIpOLE NAMEI -; G .. S - JJ / OVMFA' ApDflES9 RE ,Gtt N1p, TATEI? °? I G?.1. •?,. N?E? .r ? S uut? S - - Ai OFBflTH OVMEq'9 ADORES ^,:.: :. I— ET•C17YANC. A.1 ?OF.&TM :.? Y' M0. Wv YP. 'a L r O / Id/. I, PA PMT90F VEHK;LE DAMAGED G• ? P ,/?1J E - An iio. PMTS OF VEHICLE OAMKIED :. ?' - CC - Gf, d A $ p 7?'J/? J1.2 C'/' !sV E.JrNY? S O `? ? ?? R ?"a LIASIL INSURANCE INFORMATION-VEHICLE NO. I- WAS THERE AuioMOWLE UABILRYINbuRMCE / - YR'S COVERAOEIN EFFECT FOR THIS ACCIDENTON YOUR CAR V } .. Y '. N-EEMD AGWESS OF.UASIUTY WSUgMCE pOLK:V OLDER, RYES C3 NO • .. ?..., 59 s /_ ry R iE ..::. >rP .... U UTY INSUMNCE COMPMY.'{7` l/ L .NAMED /pB.I Y 27. :? I'K - _ NAME GPDDRE590 IMTY IN9U EADENT •. I`S p?j ?L( tSTATE. ..r [r •? I //-1/0/'' ?iLlf/?iPiG/Hi h:...•.• -E `-i i.. .•/.'•.vc: .... - ? rl.. .. ?? C' ...:)LUSIUTY POLIC 1 ... __- , ISTINJUAY- ?'• ??? / G } '-. r .. :.. NAME AGE NAME ]ND INJURY: -^1 SE]EPM iEaEVONrfOa ADGrtgN LWAN°E51.'. AGE y LJiYi J G ... _.- .. •... ...._ - "EfIFL',.6 ? AOpRESS LUiuaE M F ADDAESS.. s NATURE AND Cr? E%TENT OFINIURIES SEX Q Q // r? NATUflE AND DDINJUAIEb flEOUWE A? E%TENT J I OF ES INJURIES - E%AMWATKIN BYADOCTO ©® NI AIAOR 9 Do INJUR M F REQUIRE ?Q .y OR ICI S li STATU90F WJUflE D MMKFIRSi O 00 NE THA MPUE EYAMWATION t. ?DWEa STATUS OFMY A IN,IUDOCTOIYI ©® NAME C3 AssENG[R IN VENK:LE pLLEO Od,BUVG Hpv? NO rob9q Le ?ONV[A ... - M fIRSTONE THA MPU S ... Y° ?+ ? FD[RRAN ??' IEIVkPEI IMwgy E CMPLYANT NVEHI G9ABLM0 ,HOiIOd,eLNO PDS40lE y ?S Pf. I ?.': II .:?1t I•. ? $? 6Q ."MR-1 0 pEOFSia,N1UN. N0 KILLED IYVEnfl IMw0a1 ID VALvIeiC IT y? 0 a u[HI ? SQ s? 70 a. MOTORCYCLE SAFETY: ? HELMET WED ? HELMET NOT USED MOTORCYCLE SAFETY: Q HELMET USED I 1i' ? HELMETNOTUSED 'Q SHO W NOgiH BY ARROW IN CIRCLE J _- DEbCRIBEBFIOW WHAT HAPPENED ItEFERID VEH CLE90YNUMBERi F NE ?IM? oAµ G r a i KEN°Cw?iC.ln°NwEATtELi;Oi. • \ .\ 1 ... _._ .. __._ P fc?g ?. ..,[ -- ° i. fKN KMKIEEYANO ;: DaIfEG-tbN-a?1P.KLM ? ., ? ? ?,•Yh o., f? E isT ?LJ 2 nEEr? y[ o..n v ?C[._ o r,Jr S c ele -re - O -- C/-Lf^faJ-/ •?'' ? I / ..I ? ?IJA .ljs v -v.C?/?P1L?.e_- -..br/elts__.L./? ,;??,C J /l+ ?j?, /'E?.r,o A'n /?'Y'?? -/t/c._ ??_,.?(_'_ ?T?-?--YICf?iG?_17.•4+a rj,._ -vi_. r {? 4 I VEHICLES POSITION. BEFORE COLLISION w Of uNES _ r r VEHICLE iN ONF UDAIU ]TL PO1F.- Uo.uLV pMwfn V[wcII OCCwKO INSVESTIOATED UY .?rc 7 F ? ? ?? ON STREET OR WGIWAY NAME OR NO [L'IxIN r[[ NO Ks NO KE M ?IAtaOL ?IOpMjtE[ •'n L IM* - 4nrv 1 'j n1rMPl ? C3 ?., Q.. ,.:?...: ??: ? roc uc[ ?u,IOIQ1 Ki ' 11 I yN f. ? ? ?MIRIP 1 ''S rl mMN a ? ? ? A101q % I // ? PEDESTRIAN/PEDAL CYCLIST ? WA9 USW0: Ro°°NG ' PTO' DIRECTION fR 4 ?Ay.. ;? P 1?SpwAM [?wNKw,Y iQM1A[fA ?GgfO°w4 E0 u,;,;W4A IQ o,_ NONAi[p`{.R!rr. ?• Yr PEDESTRIAN/PEDAL CYCLIST CLOTHWO COLOR DIREC , ? oM ' O NY Aou E E ? roAGw,r r CON ON RO ]? x[O E?--miRECTM E? NMNAi14A POAGbpfl/K! NEAIHER LIGHT CONGTIOH9 A ]? DAYLMUIi iCIM[L, .I IT K:W GDKI vTRMIIC COxH. HEIYP¢OP ROAp 1 !r"n n1 + 1 rt..t,1 1 ?' v ?HtCE?EAON! vD NOI Iq! IDKCNOME011 AKINI ':'.fi PI INp'D'Ir ? 1 ?.. ]KiNAl9 0T1 ?oNL WAY ? 1 ? GOING SinAIONt AHEAD j1 I?T 7 ? WET ? ASK ? ] ? 9TOP SKID a rdTuv. KAV ? ? OVERTAKWO AND PA3 ? br, OW . ? r h C3 &NO S I ?n ?lf? &Qll J \ ] Q Yglwq , ? ?OHr? ON LT ? ] Q vlflD bqN ] ? ?-'AD BIBLE ? ] ? OMMAXING TARIGHT TURN ? { G I ?yY7A•'? 1 I Q ] E lrt?yyy?y }y"' 1 A ??! ? rp0 ! ? O DMKARK sTNOFfAFE, A ? TUSHV.D RED C) ? ? E ? IWOOPCRAMO? ? , C) t ?IyYjgy p•d?, E OTN(R MAKWO LEFT TURN 1 1 1 ? ° ?O CVY IFACCMY) ?pO}R[^T UNITS C] S Q/LASHWO AMb[R C:] E ?ALLEY ? 6 13 MAKING U•IURN '?' t rl ; 1 *l '. j IQ { f T w f fr S M NN AL ° ,,,,,,,,,,,,yyyyyygg?? Y ? ? M UIM 1 r I AGWAY Cn TEA AOA[WIAY SLAP [TYPE ? ? t, [ r 1 ?y,T ° [, ?. r° 'JK ? I ? OIFC[ LA6 N LAN!! ? ° ? OlOV0 ?t"+SSN'PI I Y I rfi [ ? STOPPED FOR TRAFFIC 1 r t I A :4? I 4.I }fMlv+- TyAAfJ.I ? 7 ? DLVEWAY J ?5 I :L ??rY L ..k 17a1Yi 1 Y„ .?L..? BTOPP{DAT GWNAL It 1 4 T? i.;*:I ? MY 1w J A? j { L f I I T day `? etY'f 4 p F ?K ? ??asad i4 <. STATE OF WASHINGTON PAGE Of ®TRAFFICWAY NO. POLICE TRAFFIC COLLISION REPORT fOIICE COMFUINI NUMBER PRIVATE WAY gl UATF OiCdI rv UAT F Oll Orv ?ME Co. Nn 03 D O ""• WR Ra, I9N n(R IwN /eI EusF 24W NOIJR) !c 2 30 TEFFGIPSORA1 COUNIY NO. CIb NO. ?Heq r-r qrv 16 fEiJJ R?u'R'gl 3 W ?N ?E ?N CIITOR TO N NAMEaNOOFETREETORHIGHWAY Kt ClS ADM 4 PREFIX ROTI E O R ETREEICO SECTION . / MILES S ?W ?Of ??Q ?/r QN AII? NIFRYCTING 1 5 pROAD NONNTERSfCi ON 2 IE . Vl (O-/.J?? fit] ' 1?,,YY '? BErW[fN - µJ RE[r IS AQ Y- 14 O7T2 S TREE1 PREFIX El, MIlFPOST - O 17 / / ArvCf AUIRIMTlf51ROM REfENFFKE.CROSSSTR[ET ORNEARE FMILEP051 ACCIDENT • [ W • M E RAMP DIA RAM-lA V O ? OF C? ? COD E COLLISION NVOlVIO. SFVfR11Y. MUS« NO KllFO_NO INJURED- ?SPLIAGF ??Te RUN w«pR[pT« IOU- N0. IN 0 IR RROf R ROAD 09 REFERENCE INIfR CROSS SIRfL IOR Clf AD /2l OFVEIICtFS ULJ ?PROK9IYON.IAGFONIY ?QESUIr[D ?Iv[FO`iICIE Gy7KJO 9 OeJ[CT STRIKKENAMf OF OBIfCt STRUCK PNDOWNER'S NAMFI ESIDMIAGE TM / ES > SPEC AI COD NG USE - UNIT NO, I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST - NIV[N'SNAME: UST FIRS I - R - G/9r - RIVER'S NAME: LAS, IIR Dl slxfugoo4E s A3 x 5, A S 0, tl • - s - LItY SIwI 21P CODE PHONE NO. D TTY STATE IP DF PN NFN I (d ho c?? -339 R - 9Ntx'S UCENSEN SAIf Oqr A l N n V DRIVER'S LICENSE NO. ATE SEX DAM BIRII - R OCCUPATION NRM NAMEEPHONENO. EYFS I(: 1 HEIGHT E l3RVPA- FIRM NAAEe PNONENO. EYES WE GHI FrtIGNI 2 ONn $ R - ? CHEF+K I? M fH al Ai nrv FMAOrft OF ANDTH[a Al '" ? CHECK(?) FR TO Vf HICIf ASwrv fMKOVF,OF ANOrHfNp ''?'• CODES ? a , a i 5 f <rw« a's',°IF° CO DES ? * a a":r°sr < iv :"' S NfcD« a s^•a?ox.c L L lP ?a W ro ? u H'rtPR M MAKEEDO-CHE ? Is:rl ? vMO ' ? q ? OM oavll ? s>I,. ? t u ? r.? - V.) Foie DtL(VARI-NOVA) StrlE1/1?0R.CONV.1 /, E N. YEAR CHEVI MODELEDARI?NOVAI ( F Ylf E2D V.1 2B 4 H C O I -ISEPIAT[ N STATE TR ER I O H _ AIL E N . STATE F-11 vEH CaoR AI N . wiF - C ?3 - - 2 3 UI CIf IDfNf11.CA NNO. FI 3 23 So R[GISRVF OW«[4 USI 11951 IDDIt PHO E NO L EHICIE DENT IILATI N V RISi N DOWNER N W : UST FIRST MIDDLE PX N NO. W-5 OWNIN E Nwpgrvcl w. OR -IN, IN A' T, OR -IN. R l2 f D -11,O ARIA N M.x LN.u -.- , EST. DAMAGE %hH ? ? REMAINED ' 01i ?P' i Ni ' rOURi«O LjAMAGfp AREA CNAYGE eor."iir 'C oi RIOP ? AD"l- ?REMAINED LSI.'DAM.rGf WAY oeono s /y o O - Ar er: >' ?IOWED Ar er S - DIA GRAM Of COIIISION', lu u eMNAI KAn NO4rH slums N[ctssr 1 er ARROW DE5CRIPTIONOF COLLISION: (ME SUPPIIMENIAL SIE[I IF NECESS•Rrl v - - • . : L-O ew. cosscz, 7 4°vrzw ref' 11,6 , - - - - ; ?; .y; 4 r - - ? ,? K 4 vo c-w4deo U/0 rvo s 4- avtv.v ' G5 a ildosT crvrnG , NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES 1 - Z J 4 S 6 S OCCUPANTS /WITNESSES fio?R ioDi?a urMiAVi ii uK AGE urus '„n" " Rf IT " ` Ecv EGG oN E f! tb 85- x38'6 - NAME ID R -PAYS On" 0 ' N Qua ay Feu e 3 5•S ,t0 8 , AIxwI5.5 AMt I luR a w P R M, Y rroM ?AMR. ?rrwRr ?•"' . ? i7x '° g DM55 a -Ole, , uEn ?AAe ?Y: ? u?GT CI Y IYk-?. wVI SIKS r10 CIKIY'S IMMl1 R•DG•0 WIFK , i..l'i`.'?i•;i: ,?p'+:5`3I:'I Y!.,7L \tYIhE?.?` ..n. 1 s AICH ?!. KAKI N D•1101 !ro f An0OY10 RJ DATI • -d br i l A T. 'I AvA?_: !f1 ' i R? rs. , I s;. , ,yt ??rxNVYwO - S:S? ly A " ? rE'`'• w,yp 47i^AT ? ? ' ?? ?' A ? ? I p?'SL,?i: ?it1i •7m- '?d ?'n ! ' ,, NOTE ' ? k ]uk. ; ` & .. .? .-.v++ti?. - " 6 ? ?.F n.'tY?c ,,... ° . . ? 9?. ., ?T ? STATE OF WASHINGTON PAGE / Gi/ . '? ' ' ' No. f: . •: ! l? POLICE TRAFFIC COLLISION REPORT l•Lf TRAFFICWAY .. n IOIICF COMPIAIMNUMbER / PRIVATE WAY `TT pA FOr<au rv I /YS R rvn wrR l.wv v, ( IMF Wrv +DV I+Y IISON +I IUBF ]RUJ HOU4J couiErr // courvrr NO. cnr NO. iNWA OUR ? ?N CITY OP TOWN E UTIAI / T' a [] 1 n ± J_I NpMF4N0•?E SIpfEi ORHGHWpY W 1- C']IIN S / iCI CIS ROUtE OR tREEt Sf II ON •' ' ITS ? [3 .. .'pF °jT /[ '> •./ ON ? NN9IECI NO SMIM SIRFErO ROA . / 3 l0 1860 ' ' ° <I ON, _ BE1M'E /`/S/; SI fFI6•?J, /? / C 554EFt USIANCf ADpE rr ............ pPEil% f0. Mllf Po51 ?J _/ O L J (rv{ 0? q?}Wy, Ip5 ' Yt ryrypp 4F• m • . < ROMp ROSSSIRfEr OR NfARfll MllF p05 MlfS S f W ?J /•?,:" FEET OF r S %IJ• /? I N ACCIDENT RAMP pIAG4AM DAIp M MAGI Y YY - '? . J DDIII NVIXVfp VfR IY. A CODE ' `'. " TOTAL 10(At NO NO [tIEO?•-NO INI 052411E ?HIi[RUN y CEVFHiCIFS ?D90RRIY DAMAGE RE SIXFN Y 'v 155H ruNRwprH S I IMER D Cl5 1 SCAN SIREEi R pOApORRFFE9ENCE CROSSSfREROR ROpEI ]D ?' V ON' I ? 9i S UlrF O ? VEHI CIf ICISr E OB R,K91NMAEOF 001FCISFPUCK ANp OWNIR'S NAMFJ fSt. DAMAGE pECW CODING AE ??J 7O M _ E tl +' QOM{ !y nS4riN4 ?1.-:. ?. S 54n1F-E Iw51 UNIT NO.1 R l _ _ ?? ./ UNIT NO.4 WER'SNAMF: ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST USI 1 FIRST iv 'KAf .. M aK wr- JIM 'A ISIA(F EII CODE ?i PHONE NO. D IAIE I ?j Y :/ %..:/ ///? /j J:• .. rY ?TiPZbEF PH N N/ tl'Y IYE9'S UCF R:N R {[ (AIf I IV EI NSf N0. A f % D 1 O tlIRIIHI ?} Mp X.'` bJ) a?E?IfYI// IRM NM1E6P1gNF`N0 • EYES wEIGNI HEIGNi E CUPAION FIRM NANE6PNONE L ! ;. J?,+•• ?/: ?; / 1J •/ f/ J.%/ R EYES WEIGHT HEIGHT - 4 i ? CHECK I- FAA N R Iwlµ H CODES ? * ] + ? CHECK (?) AN r,,p' N r R regq rwei; • J A sr f D„ % e'S"°>nFCro CODES ? * S n Ae i AS fncnDH a f+ lF 1 L. y s „, asp ?IDDOGE Cµf V. %F F0onR9w °OM INI 11 YA0 s ` ' O 4 ° e ? FM-cl p SMIT ? zs:rlP ? H ? C°„v. r ? ? `' Hw?R ( NEVI MOL;t LDpRr.NDVpf YUL4DR. V,) Rp^S b' = -G// / r' Ar<, ..Yid E OR II FNS 1 N StAiF 0.A?l)E NO. PAT, H vtµ OI04 LFFSF1wTF>Ji:- it IT If Y S SINtIl CANON NO'^/ , - /!15 t .......... + I L V[ n lE N .p I NC .'ty ? I I I RfG SNRE00WNfR'. IA$( F1951 Mlpplf PHON[NO. ^ IF D WNkR. 1A51 FIRST MIDpIE „yRp , I PHONE NO. E a ADp9(uor INwRA.,cE co. oR AGwI E - •'ii? R I D A F -1A _ iron "«q c I.. •' • r w J-G(DIAR[A 1 CHARCE S ISr.'pAMAG[ ^W^rN FSI.IOCAMAGE S rG OA •. •?? ?9[MNrv(0 ' ?^WAY RIVEN ?R[MAIN(0 RIOP R5 ???LLLLJIIJJJ f?.?. ?D?•Y?'?O ,.? ?AWAYD BY $ IO iOTTO:i DIAGRAM OPCOll1510N: ID l ~INman NOR[H SHF[I N[Cf DESCRIPiIONOFCOLLISION; Luse supplmFNUISH[enF N[e[ssA9q /?? ??•?Ir 55ARr1 er ARR ?/ J/ ;Ole ?` `YI?'. r. [FAw i \T/5??? "['i/:/ /ii %•,/%S t/ i :••f//? !• ?i: e' <1:aI e'ejJ ?+' 1\\\\222...`1' 1? C .•?- Jl/:?''iil??j•?: ?•??/?:'/.?i•IA%; /%/%' ,J%ir. rvAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + _ OCCUPANTS/WITNESSES liEii bDlilfoMNfu iEAieiii _ _ CODESTI Z 7 4 5 6 7 M tn?UlC e,hx ., r°•'{? / ?, .._ T,•.,:,, ,.?ly.? z,Np„N.w, ,Atilt \.l?" AI•I'. {irl J+W'}ypy3i r" t ?nGIrI Lr I? ??'"1 ! L'j;M' F :71;yeq 't I?[Ir .f%r??,?; L&?, 14?, 'I RI Ilr? ?s rt 4 IJJ} f 1 ??y?G 39 `J?•??i tf E ':1 j7 ? I,? Iy Aje,?ai !!?v I a l f l u 1 fo NI 1?77(?Y}q 1 v - ? ?. 1 T y T?Il, ?? F\ - y J I Y - ) fy A l E %q, II4EI?V l ) I yJ I ?r { ? J L ? / ? 5' Fop t r I 1 ?.,,f? } 7'r a, I nF ?._ 'Lv'.9RM 9ie' 7'41$1 f C a ?' v" It ? - f .11 L; vv /%A)YlflVl'LY1'U'IV 'u r (o .?q D. ; No. v •.-? I POLICE TRAFFIC COLLISION REPORT ErTRAFFICWAY pppCECOMPIAININUMBFN I u ? PRIVATE WAY a u. 1 4 .DAi OECOID .._. P? Yd i R)7I P w"IX Iwm. i`uF1I -?twl" lus{iiaoHOURI courvrr couilrr NO. a1Y NO. Fnw \ ( ? 4 ??.la µp?.? '. ?N ?f ?IN 'g CITY OR 10 RURAL ! „ h. . S- ') NAMf6NO.0istR{FIORHGHWAY F C12 O ROUTEOY rR SECTI N. fls, o NG F :TT EWNC Y ON e? 3 (a 98(00 t ,gy m INIFRSECI W1rM SiR[ErOV 0 NO NIFRYCrIpy Th (y, `? PR JI% E mRP0,51 / r iUR?I' +?.? ?S / 6ET4'EN ,•x II`C:s Siq[Ei 6 sIRFFt •? ZJ -, DIS ANCF6DIR rlONiq gEPfq, .CROSS STRFE OR NFAR[SfMICE PO$ 1 ,; }? Rf,, MRFS W, ACCIDENT pIAGRAM DATA `3} ?. +ffT OF • i • 1 i MILEAGE - CIXIISgNINVIXVFD: EVER rY: CODE `' TOTAL NO. Nr?Oar?KIrLLED_NO,INJURED_ SPILLAG WNRwDM •RD 1 SFEO ORVUFFFNCE Ix] ..ryl aW.CL t [S OPERTYDAMAGEONLY NRE SiIX[rv .wL[sN INl CLS CROSSS1AFf{OA//ROAD f0?5 70 .k 1 r 9 ......... INNAf OF OeIFC STRUCK AND OWNERSNAMf) ESI.DAMAGF ----- CODING AF }• R - S UNIT NO.I UNIT N0.4 Dalv{rR_'1NAME: IASr Rsr ? VEHICLE • ? PEDESTRIAN' x { ccpp _ . it ?PEDALCYCLIST.. w ::en. .. .. Y ?,Y `1 ??1 C. \ MI J 4 R's NNAE: Sr ( .. •a J ) R STREET ADDNFSS OI r17 RELT ADDRESS 1 Pw ?` i:1 i Z orr ` /?? su{f ?y"D zlPCOce PHONE NO. D Ir S c- et W ? V I?) - SrAIF P :j R Rlv[R'S UCENSEN 5 A f G , _ /r-V N NO I ?r???As116s-z AE % E BNM OCCUPATION HRM NMIE6PHONE NO. EYf3 WFIGHr HEIGHT E OCCUPATION FIRM NAME a PHONE NO. /? S/ R Fns wElcnr HEICHl :_ ( ? CHECK(4. EH CLf •s:N DANOrfE OF APMiorHER."L ? CHECK(, CODES N. 3 A ss A sin vE R LE ASAN FmPLOrFF GFANDrHER. °°?' - . v O 5 u{<lw a MDF Ncru CODES ?+ 3 ?,H1Pr Nn PA NI S I%c H 6 sA ['Si N-c o' Ass Assn. ^° Im cu ? FINNY 4O ? WA [3 Wl ? E.rIP 0 „WAI ? nor `oI D/ vw rlARM MA.E{D?DCFCH{v.E FLIDARr.NwAI srru xDR.corul?l ?A'" NA AN C{?ouoyc{ ?:R4 ??I".°,.Nv>X: E sc { HEVi MODEL EDARI-NOVAI Y'[Ix DR- ) 4DA1 ..! IICEN PlA1EN S1A1F t4aLLRPUIE NO. SrA1E H - Y{H.caoR M???) S??.P2 (v/? I N . 111 Clf pEN//ilf UIION NO. C v nICLf IDEN F A I N A i -r ?'. L F: R(GSRP[DOWNF,R?,,, U.SI FIRS! MIDDLE p,ONf NO. ISR (DOW FR I LAST I flgli I I .15- I. I I I I$I•'1 NS A _ .qa s., 4 yq,7 MV' IJrvAADMl a•ODDFROfWss NoEr R lrvw4Aiia co. wACwr W N A OWNER ] 2 - ----- E DAMACfo"au " R A ]x I F.r i ?? t m-ARU CHARGE rwcnD"?A DPMAC ?p.wu ?? e o. DF EEEE ?AWAY ?R[MNN[D SSIID'V•MOI I '!; ?, '.' r' il0 S SZ{ ?IOWED ?RLAWN[D ?AWAY BY 10- A.Al . eY DIAGRAM OF COLLISION: , •- 10 ,,{ /S,a ?, ?.-3 lEfU NfCESSARYI, _..? OY F40WtH DESCRIPTION OF COLLISION: _ IUSfSDPHLMFNI.LL BX[FTfNfCISURYI 1 1 t»i j r n. ^Sc1 Q _ - .-_ __ 1 /1/erth,?oµ,l---- L?1t..TDY - 16 ;Clr? Core (ZKl r s3 I /i. eJG V¢_ EYLla_: Ye(1_ J„cr -?-s-. .n",,. I ; I , h :. I ..?/: oti.e_.. c ! ?h,... E-j•.e. PGI'?f I ,. r - ] I 6 NAME, ADDRESS I OCCUPANTS/ NJURIES OF PERSONS INVOLVED + CODES 1 2 J 4 5 6 WITNESSES iLw:sYD'aDUIEOrMEiilreuiswii +?i u% AcE t•rus '"„WH 'vu_ _ .. _.. .. .. c . , -?J r .- __.. .. _ _... .- ::o. .{ RESn. ena s"nd ?'i -. .• T ,?. _,lL 6? 1,??? _ .. NAluE101 ._. , rf A{Y»ISS NF AMe R Movro r4 ,,, ,ilT ` nADD,.nu ,'fib .. ..... HAr?R a ? ? p.n.? px ?C.°:I p a.,t tiY -F" NO T -R1 .np.w _. ...."iiw?n !tiler ?AMe. ?u.'c{ ?c'dn. ?:?S ?n ?v 149r 1 ]Iau«G a,cfrs NAMe eeAN% sADCE Or wL.Kr K! s'AlcwD roL •!; tv4'• yD I ,(^?;_ )( I?NO T,•,J / / X{,•Z InD ?AROr eEro41 ArrROVEDfr DAR , k.u_ [ ?d G076 I ? of ?. ,? ?ti ,(I Y T ? r ? ? -? I ? f D I ' brt n1f , ? T 1 yi4 J i An,i h ? f '?_....'z'. ?y,: ?.;` ?j• `.,`"z,,+s x+55.7. A" 104 T" s,c b ? > i r?lt . 1 } 1 N u a ! 'x u M •.1 O li C, El .q e F. I i" ? w 'tii • I. f 1K' al^:? sd ?. . tsi S} ASS t "A?• 4 ! I ? y ,v _._._-_.. _. ?.. rvuu clpMI1NNINUMBEq PRIVATE WAY ? ' °q 1 E U N_... P CHk _ IMN [OUNir mUNry NO CIfYNO fMyA Jy I i wl0. JAI.E{ rMr. ID$f R OU91 7 $ f "1 RRq IrDE 1 ?D [J- ?E ?IN CIIYGq TOWN NAMEa 11055W)i}gq XIGNWgY OS U?[./SAO gOUIE ORS 5 N 5 J .,IS , OW 0- de - ON 46J ? O /zO INIFRSFCIING PATH: STREET NON INI[RSFCIION pp[fUf E MITE POST/l -Q OFIWFEN SIPIET a ST ST DI CF DIR R M f C OSSSrR[Ef O ? R NEARf5l Mllf ACCIDENT P DI RM MTA MIIFl 1 IEfi Op MILEAGE I CIXLI10, NO. fRI I BODE fO1Al NO. NO XILLfD-NO.INIURED.!_ ? S`XI E FIT WNORfoH ' XTD SiR 4ROAD 00. REPERfNCE OFI, at, IM CLS CROSSSIREfl RROAD ® ? PROPFRIY DAMgGE ONLY ?FFSU ". ?VE ? SD .. I "CIE _ OaIFCI SiRIKRINAME OP OBJICI STRUCE AND OWNER'S NAME) ESI.DAMAGE SP[CW CODING USf - UNIT NO.1 9 pglV[R' NAML IASI FIR i I Dl UNIT NO.2 ?VEHICLE ?PEDESTRIAN ?-PEDALCYCUST ORIVfR SNAMF . - : SI , STREET AODRf55 7 REf ADDRESS ? /? •? .. IY J Q /as SIA F D TE ? ? ZIp COIX PHONE NO. ItY ATE N S s R Z S,Ic EN . SIAiE I r Ind ag EN NO 12 j YY• V o •IAr .3? /? I ? OCCVPAfION . Arf DAIFO 1 IH MO ? ? DAY 3 2 RM NAMLI/XONE NOM /?/ EYES WEIGHT EIGMT E UPAt N NqM NANEf PHONE NO. EES IGNi HEIGN f ? HE (,I vEHKI w on OPANOIXlR. R_, CODES?+ auY A iiv°M 5 exe,wH q wm • s cu J ? CHECK (vl) I I vEH IE ASAN rfworEEOIA rHER. + j slum CODES ? 3 xrue " ? • , ( . NuIGu i L N n q A a s e%e,w D s AN 1J - RIN,y9 '°'" AM.MA.K[ ? MCI ? m'. ? K Y,x ? H VtH. YtAR MA[EIDODGECHFV.1 fLIDMINWAI, SEYIEIRORONV I IN zn?ao, . ? M ? M,:- ? 7s1x. ? KH r? HY . I 4/QL / n YO ' E ( N .) MOIXI(DARrNOVA) ( S ec/° S ) GBH /Sp sur tt DFd'W !1/N W LLq flAlf NO. SrglF H I I N. aoR si C ay LFt N '°; V[NICItIIXNiIIIG1lON NO nClf 10 NIII xv Y l i7Y3ir/i7 h? ` REGISRRtD OWNt R: IASI IIRST M D 6 8'13131 /I 11 1 1 1 1 1 1 I I I DLE PHONE NO. O Nis, MI DIE I [ D WNF4; 1A51 Q gODRf53 OP OWN I W B/J r N NfR H51 p NAMeaq°DRtuar INSURANCE Co. 011 IN, E ' yy?? IG ? T dA? .NnI R' ARU 5....D r J ?GCD i`'T T T? EDAa? 7 T ,v.c _ ' CN oo r AR i/ cXA4cr / r°vlufCRNi,°.N g"'W'`IXDPxu IU?OTIOii 1 OPMAGt_ lll. MM f2 ? ^YN ?P-NED Il?I AW W ° • Iq X9MN. ?4[MNN[D J9 WAY tST.t[I •o , •TDI a dd0 111 ?w Y pr I A! IS DIAGRAM OF COLLISION rn a Hftl NLCt 1. u 35AAY1 I 9 I 1 I F s DaDTr ?AwA VSY DESCRIPTION OF COLLISION (WE A. PIT 11 SMfTIf NtCE35ARY) _ __ _ / Y I > ( r -r?P lr.?dCrE E/G e ? v? Ldd 5 _ Qodc? ? ?dSTO2.T1,6!. _C6i.oe/'$ ` .. , J/Yen_d . Tdi'r? -- [ AnESd?nJ.+ J/i5 .fTtuc ? .. r , J7c /-0,/, r . add ?: PAW, .W/' 9r , f _ . rF ? e /O //OKJ/i•A.y i/Gw./E4yyt>'!NG a7i5Ti!.i6a y _.. .... frPo M. 6e/a..J 171[11 i??'{a+(%o!T o,GSEsrua+ ?'?? ., NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED OCCUPANTS / WITNESSES (w S RIIIN P 5. 1 CODES 1 2 3 4 5 6 - - -_" NAw:`S cxev 0;o T vrH Na SIX Ace urns IN ":I nsn. [xa ., A ' N1U rU AR T ' fD HAM . y[1? IR ?AM\. ? ? ..? Nil ? IiiwV b ... AEX)f11 IHM11a i aY ?AM-. ? m" OH' T" ? n.:,V X IStq 1 P.0014. fS MVE[tAn. aADAp gplrKY KiglS.grfnp 4 ?[. D DAllp.[gI O L Y pATI ° NO /D 15? ?y N[ ,,.p n 11 ?,p I mlAm-•r?. [.. ;/J/7 7!?.? 1LIL ? 1 . .?i .??uA ... ., .. 7W! . f{ _-_ A ? f {{ 14 4y1 p I ? nK?'4??1Xw Y !!?' , aL s ,. rc u ',L , AP a , f ' ? 1 ?ry' R ? q A I I K.; , A. L?wrN 1; 7 ? ? k "k-It d_1 a.u IviUllf 11 VIII IIL:LI_ L.ULLISIUIJ Ittl'UI/1 IVU. `fl. p,3AYARU9Kn r Of 00.usgN IME Of C GJUNIY Man NE9 WEO rxuP Tw NOW9gN OUP ANA COUNTY NO., CITY NO. ?URUNI i ?x ?E ?IN G?TTY -ORTOLAN • xAMEtrq Of YTREU GHYGHWAY f(.T.C fOll. pPEF . POUF On sTPFET WCE f tl, p tm„OwT?aTETaGn?a W E? c u 1 ON l7't 1 e? e T f? l? ?GL9 `E/ NGI«T • PPEfu EO ?t\?at-'"f EErWEEHSrGrlox arnEEi. M ?/Y??. ,?:, ?'s ?' ?1 ,. Na .5•?.G f?A?E i er¢ wcnoss"wtu"M [cE'vasronio'vir16r"war eP eP?o?eE?,? RAM.•. oPnx wwTA KI£ VOL EP fE'r ?F LOF ?nnL PMgpU9 MMOVfLS EE NOIPAN9tlniED A j,$.'e: X41 PvEN s ? ?'L. ?f ?R0.EN B I.VJ A9LE tgUtO OEWUJSNES QcxLG9wE ?orNEnfA??Mtt[P RUE FHC yCR099 Bf?.O1 ?A0 J -L. vEHCLE TgsNE MATEAK ANMONIA PAdO ACiNE IUiEWfLS '['-? fO//? / 5 OSIECi STRUCK INAMEOF O.IECT IXTRU0q _ NN R W T NAME AND AD DRESS. FISru pN? sr O.COce UBE uMZ' !?LV'.•' D ?TJI w MVER'9 LIST NAME 'F., NAM ® efPS• e[Y?E a .< A MIOf%E w[x wvgv[o OWVFA'9 LAST NAME ,,FW NAM MIDDLE r p 1aak / I. _ wives COW9Kw Ya ? .: Si E ADOflES9 J 1 ROUTE - MO ETHNI iwOdi HD ESS Kathleen C?• 1 E7Yf _ X,J -S WEnE SiflEET ADNESS _. flOUTc NO. AND BO%N0. NO. AND BO% NO. . ,. ?,. 13 T?fcM.?r staEAne'EA Rt 1 BOX 6`" OCCUPARON qTY ,STATE LP DE OTIIVER S cOwsXW CRY -. STATE -LP CODE. DRIVER'S. OCCUPATION .i:.. ? n. )C , C. C7 • ? REroPr FGRM G y., ., ONVER' LN:FNSEN A DATECOYSIfl vn AOE 8 z Yak` DNYER'9 UCEN$E NO. WA STATE NE% p(OA RTTHH, I AGE. dt ILA SCI ( M No 0 3J O 22 b Nygp YZ VEHICLE Yfl. MAKE(CHEV.•000GEI MODELINOVA-OAflR rB00Y9'T. 1208) VEHICLEYR MAKE(CHEV: DOEI :MODE ( VA-DART), ;BOOYSTYL (208) tfFF `' 7.5 - h i%TS %J l !3 / I ?F 00 q LINCOLN CONT 4 DR f t +S. LICENSE PLATE rIO. NO .:STATE.. TRAILERPLATENO: STATE.:. PLATEN 'STATE :. TRAILER RATE NO... ...,STATE ENSE { 1>1?C:{,? C??Sr/, Lim G., P1G CA ^ VEHICLE IOEMIFICATgN . VEHICLE IDENTIFICATION NO. C, --V4 '7Y82 pJ PEOISTFflED -I IFIRST-MIDDLE NAME) .. DNYER•SUCENSEN0. RE0191EREDONNERILABT•FIR -MD NAME) CWVER'$LICEN9 N L i C.Ya?C CrJOC_!? T OWNER'S ACONESS (STREET, qTY AND 9TATEI DATE OF ..T. OA ADORES9 15TAEET,CITY ANO A 1 T FBI TH .A /C'T l'CU Y 4 ULU 7 < <? `P' .. v q T PMi90F VENK:LE DAMAOEO - N? wr ATlrsoFVEHICLEDAMAGED.d B asadena anizer's . + $ low-& " r LIABILITY INSURANCEINFORMATION-VEHICLENO. 1- WAS THERE AUrOMGDILOERUASj1S YIISURANCE , COVERAGE IN EFFECT F THIS ACCIDENT ON YOUR CAR YES El NO 5• NAME AND ADDRESS OF LIABILITY WSURANCE POLICY HOLDER . i- HAfE, flan .. - ". E Di - NAMEOFUABILRYW$U L.71ceCOMPANY.:- f y ,? R?1`Dt CC1' c-.PY? .S' ?'\' 1:`'I ST I AEy Lv ?/ -31-S, ...- $ 1 NAME AND ADONE$S OF UASIUTY INSURANCE AGENT GTV ATE : m,. „-LTTYPOUCYNUM0Ew..,:. ? .}GiESA w- oC ?Lr ?. L?Cc?LSpIk1 L? ?S?E. l? 2 ( i) 4 9 L Y Isr wJlAir: ] yy?gg ' AGE 2NDIWURY:uSE9FP iEPFOP}FG MCTgN WUWE 1 AGE' '?T .. k NAME .. ... ... >T'S ?J vY0WIF0 NAME Tryy." f L SEF ADDRESS .SE%. v?` hY y'1 .1 5 EXTENT O".UNE9 ?C-L 7Y 7 '] f J M F NATURE AND M F ''? OID INJURIES REOUWOE ? EXTENT OF IWURIE9 CIO - FXAMWATgN BY AOCTON \E ® N/AJ.IiE R , % t• (? `-_ gDIWURIES REOUINE 1 STATUS OF WJIMEO E%AMWATIQV BY ADOCiORI ® ?A jTE R9 I MANKFAST ONET TAPPUES STATUS OFIWUOEO.. '. M KFIR ONE THA APPUS W VEHICLE OWM&MO NONYWnAFWO PCS .LL ?omYER AA>SENMEp IN VEHICLE OIGifJ?UY KILLED O KGpYpi9p&w0 P09 OL[' rc , Q ,1 KILLED IsEJVFNEI pfPKM1 E OMP4Nr PASSFNGEP 1? D - ?P[O[eipN1 ? 6? BE] OFFPOETCI O? P1EDEaiNAN NO. _ (-11) IuIN(%p 110-ETCI -. .. ,...r ,. ? 6? s? 7? MOTORCYCLE SAFETY: ? HELMETMO ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED C:1 HELMETNOTUSED f' SHOWNOATH"ARROwwCnCLE 9 ___,_--DESCRIBE BELOW YMAT HAPPENED,(flEfFR TO VEHICLES BY NUMBER). wucAt TN Twufuuf NxYNlO .. T,c[TNt GMnP,t iHMmPLLae IIi0I7E?iL Vohiola ?l_was traveling-Weat..on _..._.__ wa a 9b sctNC wG? O\ . aA I.Gxw.r :tea _ Discovery.Rd.._Vehicle_#2 _was_%_oroeaing__ Neim a . ?a??; sE _Discovery Rd. on-Jacob NAtLr .N 1Dw _S'. F ET?p A __to..atop at.the_stop_sign.and.collided..with--. ( _... _ ?C. --vehicle #l-,__ / Q 7 _ 7 Y ,fie J nlKna .r ! _ _ r r ( ) H11 LES POSITIONS BEFORE COLLISION Ae wVESiK1ATE0 DY 1 k VE11Clf N a E W BIREkT OH WAY NAME OR NO Y'O"[ LL04AV erANbq LLOALLY F.Vwf0 vkfKIE OCMtO 11 Ot In 1 t MO Ir011% ??? CIX OWtTtn la M Yl0 IM Y[a NO ?iiln0. ?POUC( + 111kC 1 lq?? ? . ?....?.:?. ?:...? ?olrr( ?osrl°N,alen 9 l e1, "° ronan, ? ? ? ? g ,'? r k r Ir ?5,, 1 5 ` nnanMfx ? ? ? ? a ? ? ? ? ? ?. sx(fvF ._ + ?., , . ?L. uoawu o moM OIRECTIO io DIRECTION iJtAk"i'{ Jf?.-??NAAS 1 L PEDESTNAT!/PEDAL CYCLIST WAS USIN01 I ? Iw...,.IA E?w-?_nrAr ? I e YCMOfn .0 LM4wµX [ ? ebf^°n (? a x T ? bu E ? roAUw.1r t PEDESTRIAN/PEDAL CYCLIST LYO7T11IV0 DOLOR: 1 cc] Ivan a Q rq[f Anxr 9 ? 1x. 1 ? A/rPOanectlrs (? / t'.. - n ais wrAn[u , T L 11 I 1 , "OAUSUR,.CE m-EN -T CON011CFfa [0 rtKCA IX<1 TRAFFIC COMROL IYPE W ROAD ( rt.eGl X:M[F (a.t1 vtlKll CX OYI Y-L( WUVER/VEIIICLE ACTIONS ? ?, ( ? fK%[ C t[.K?v I?DAYIIGNT My [ b 1 On Agnl, ICrMGX Gn/a MDNI r '? L W [ if l f LI ,,?-{/1,1 t q1Y 2 ? DAWH ? 1 SbNµ/ I ?[ONC WAY 1 001-11TRAf-1-EAO f y -i'1 J }' [ f } q?"A y / ` t [? laQA1Z^ ] ? DUSK E] yn ? 7 WLi t STOP SIGN ] TWO WAY 1 2 /OVERT KING AND PASSING 1 .. Ln'C ?- 1 D VILO SIGN ] RCVCR]19LE 1 ] ? S40rVAA7 ( ? IG TS ON CT ? CL?1 ? Ln0A6 ? ] MAKNq n10Ni TURN , r 'f L ''? 1 t 1 ? ] ?SNOw A C) FOG / [] DARK80FIET C] A C] FASHAFO RCD A ERC, "VE C] ? ? 1 {l '( T f ?. ?[:E a OTHER C] ? ?T A ? MAKING LEFT TURN AMP) -? y rl l;1 " C3 / OAR / FLASHNG / IALLEY '?JJ". OTH[q ISPEgFYI ? tt 1 pFET A 10 LA1Ta ? ? AVB1, ? ? E MAKING UfURH 'ti I y 'Y b ? E ? SPECIFY F 0 OTHUI ? e M ? WONAe, ? IS TWO WAY. C] ? 1 I r) 7?J1,' lJ ? LEFT TURN ? / C) BLOWING a? 't f } u J p0/OWAYC M 1(A AO-AY 9URIA0 h9! I OTFICEA iIAGMµ LANES 1 ? V I. S 7r?'"' , ' ' ? ? ? f C1 DRR4WA ? F ? STOPPED FOR TRAFFIC Y?l " ( ,?tt 1 T y ,q.{ S,yy 'EP R n I-1 srorrrO AT SIGNAL L I +I ? .. f q ,nM1l°V Ll. +R'"'?, y 5 1 9?Lq_.A' 1"",'Tlr-?'?S- {aPgDary? .1 IJ } Yi tk } r • ? p A '1 , _,' ! ,gip h . f 1 I X44) .^",. ,kIL ? mdxtri ... r"spi r1woI OR VEHICLE COLLISION REPORT °"?^L ?"?• '- aM o NO. sw MON "U, MEOF00w?gN . 9 wED RR R.. • WFS µ COUNTYNO. J sAT EOUxrv CITYNO. ? ?N ?E ? W CI 0 O !,j u1IEAN - ?. N EAMw E wIPONWAY AMA CII. ?'PWK C J MLLB 8 ?w rvr AM R M ROUlEw 9rPFEt CCOE eFGT. ,. N.JL7•Co ERSEm YnrxsrREEr aRDAD x .wrEnsE 0 IY C a PR ?, ?\ C.h ?, eflWFEN ^ Br0 E EF E° MLEPo.Yr.I Nir 9rPEFF ?.TJO m FrA. h ffA't PEE ION EET © ©. OF RANOAn?CPO55FiGNU [EPO YxOlul M °JP RRM DMD`MM / +5 - IE C "L ?ER.-B ?WSi 1u3AP0WV9 Frv BFU.0 TRW5MnTE°? xR V/C3 RROO..pp .1 I '1 ?PE9ELXIED ?Hw0.E BCCgro F>vN BAMMOnuEe ?.AoACTMEMATERAOTHER UB :. •.. W® O CL6 PEPEPDjC?9g?m?ETViroi.O ?j: :70BJEDT 9TRUC% I EDFaOJECT..E !,, ?rll- , Y:. • J n WTI O DI T•R+,EE[ DADDA 39 FnNP OeI bPEC.000E IHE. h ' VER'SLASTNAME IF MORE THAN ' I N ..MIDDLE TWO CRTS DRIVER'S LAST NAME • • ® y wE vOLVEp FW T A MIDDLE . . S x REET AMRE55 COWMD ROUT . NO. AND -RE THAN I SOX NO. 3 + - sON MPE Si D[TE39 '" `. .. A usEA 9046cvg TE NO. AND %NO.:<? :S iY (. STATE DPCgDE DRIVEq'9000UPATION Ou19pN CIS y 1 J? 55,,, '?' • fi 1V LO PEPORTFaw ' ...-??. STATE Dp.VER.S Q /? LP CODE fYO E7 cu TI N ? VER'9 LICENSE NO. ?• 1N" GI mr "' V * ATE SEX DATE OFBIRiM... ACE 0 SE E yy ••LA ,,` I ODEL VEg9 ENSE NO.. STATE. SEX +.OAi O . . x S ICLE YR MAKE (C EV.•i I'EL( N0u1 I ?`'• 4 pgye AGE +p ?•? 8 , ?I', M F uo DAY p000E1 MAgTI. , BOGY STYLE [DRl 1Q? "K yam. JEI, :MOO `` ( VEHICLE YR MANE R.-DO D 7 ENSE P E T tD 'F gOOr l?ia?S ?vapngn., .aopY9r zDR1 Y' LICLATE NO: STATE $ r YV? V 2 a TFWLEA PLATE NO... LC ` EP LATE - TTLVLER.PLATENO. ....STATE.., - NC...,.STRTE..•.. Pv WCLE IDENRFlCARON NO., F5 (? W /aT 1C( VEHICLE IDENTIFl ......9 CATON Np: CM9T EOOVAVE (LAST.FlRSTi.11DptE NAMEI LICENSE NO... J .. .- .. Ir ? RE0197FAE0 WI i.M NAME1. & ''?, ' 0 `jT? er p :.. .. DNYEfl'9 UCEN9E N0.... y? -N'b +? ? A.Y" •: q3 AGGRESS (STREET, YANG STATEI , 1 .• ) . .. ATEO pgiN_. OWNEq'S ESS ? JS 62 •L F.•y I?.iVa D M0. wr rP. ISTflEET,CITY TR I.'.. .r:... lfYg? L3 ? ? ., TS OF VEHOLE DAMAGED - ', •?gq Bo coy.. oY?'. 'y ! i ?NgrTO PAgTS OF VEHICLE DAMAGED ,'H onf ? BTGi l_' Sx BILITY INSURANCE INFORMATION-VEHICLE NO. I- WAS THERE AUTOMOBILE UA COVERAGEIN eISLRV EFFECTFORTH WSURANCE . ACCIDENT ON YOUR CAR F EAND ADOflE59 OF LIABILITYWSURANCE POLICY HOLDER .... -e - AME YES .r r r Ess °'n•.. E3 NO .STATE NAAIEOFUABILJfY WSUNANCECOMPANY 'n ,Z _ 'At O ADOgE3S OF TY WSU E AOEHT Q O Sl r e W ,?Jy,, /'! /???UUAAABBBI!!!LLLLLL ('? ?--? ` 4 4LS S ' YM? •.? •? C V 1-`,1??_? ? /l .0 ? .srATE aP UABI[UTYPOl1CY NUMSEfl r r ?i< `•i ?. Y k. w.IUgr: .( 11+\I? I 1A T I; 139 08y+ , rJ F? E ' - : 7 AGE 2ND WJURV: •? IDSE6EPN41EPEPORiFO1ApMrpxAL WJUWE91 ?• ?p t0r o NAME ?E .. '?' JNE55 INJURE ?, / • I LIRE AND e MEF ADDRESS xf 4 I ENTOFINIURIn NATURE " WATIC EIYAEDOCTORT NAME • ? EATFNT OF NJURIES • M F SIATUI7U9 011, O ?. I ® 9 pD WJURIE9 flE0UtPE ?" ? > URED MAH%FWST PVE THAT AP1 UE9 ;' yR "v '' • e'. O R W VE ICLE oGAwmO Mv.bsADUrq POisIP E ? 9 ATU90FWJUDOCTOM '9 N°OnMe M % r o W e. LLED ' "Y Auunr RNUn Dw.2P M FRS ON THATAPPLI I: IO I rhW NO .... ISE4LREI M.OgI [ cpAr4AIxT (lTJMSSEROEP IN VEHICLE p9Aew6 BuxO 1034 .,. :I..I I.. .n OFPNxE CI ?REDESt- L N0. OLEO ISELNEnil x IMrIaRj !Ep 1! T• ? 5? B? 7? OoN LT .v b'L IOl PaAW'"E4CIr q, v IF r TORCYCLESAFETY: ? HELMET USED ? s? B@? 7? pCL`Y C3 g; (- HELMET NOT USED '14 MOTORCYCLE SAFETY; ? HELMET USEDI WNORTN BY ARf1pWINC ROLE ? HELMET NOT USED W CA1EM xrq I DESCRIBE BELOW __ED: REFER TO YEHICLEB BV NUMOERI ' ?Y .. rrMDe rnE DJRWE rnAr aEn[er• ' row DauaXw xf Ewwr•aW . _._. .._, ----_ ? ? ? 1 ' ?', ? ? Ernf[r OR npxw.v xuN:e CA .. - ...-. . NMDRe X45.... Gross?hq Qn. Ln ( e?ja 1 'LL, I(= .4_ _._ + naroR w w.Y OSS.- 3 I I) ,/S-?j?j?rrSGL.'frl9 rY?.t7) Ip ° j Lo eLs 0)3e- cc e- L-oa, n-? P _ ? ? 2_heaer saw. --_ R ;• e...u..h•k f . IL7 en r_ iew. »1LPVzpr_ 'ETG,- LE ION _ I I ICLESPOSITIONS BEFORE COLLIS .1.1 N B [ W ON NREET OR IEOHWAY NAME OR ND. ? lv I.-DID L[DAUY IAAAED VEWp[ApCU.-, WVEBTOATeO DY IrpPI mfaXW E -?>.. ?..?? ?.. ? o'YUCI ?xD.MerF•_ Tf w ? ? ? ? 40N0 \ 0 C) C] ? ? ? "AMI sTR1AN/pEOAL CYCLIST wA9 LJ81N0; r(]eXxWMA E?wR °"O06M0 .FT1pM DIRECTION' TO DIR J? ECTION --A ( TL STRUNAPEDAL CYCLIST CLOTNLJO COLOII: AWAr A?uosew.a X •?nTOeiwN°. •?mnrn r [° •?ro,nw.lr 711bI - -1 1.11. • -ATFLECIM O"l cr yy "AMER fAWTON3 TRAFFIC CONTROL 9? w.[0 ? +? LI LIC ARW Its gyyyyyyyyy(??'??' LIGHT . - LL .fy f YI ,t ; P E 1 ?Mn%iHf :OtL[ TYpe OF ROAD ' KwECF wD YMKIE R.". WUVENEHICLEACTIONS y t t ,f M r?Y , r?t p,, ,'w 7 ? DAWN r MO W E ?l11l ?VLnCLE. .. tcnE -ORM0ni 1 e ? fI1 A J? 1 rmE? ? 1 ? sR:nALS ? 1 ? ONE WAY E I F If y 'IIM'. ?W[r [ w1tl'L'O ] Y-T DUSK fLA ? ? 8t?? ? 1 ff DOMSTRNDHT AHEAD 1 .r kl, , ?BIJOW ' ?3N0?"`O e ? Lg11160H l1 ? D C] YIEID BOY m O El RLW'VEP90L[ ? E OVERTANNICIANDPASSIM d + }/tl e ?/00 B OM%.[TP[Ei .0,13 C3 3 ? M.A%WD ROH7 TURN ?XC ?LnHUOrr ? e ?rLAeNWDa[o a ? B ?OTMCR OMIE.Np [ 13 IMERCHµO[ J k '4i uA%WOUrrTURN dLpT - t .` ? SRO/Y IswOFYI B ? STIL[Lf u0N78 ? B C) /L.%." AMBER ? B ? ALODI/RA 11 ? ? j I 1 .' v r, H S I / ? on b Y e ? WAY. ? B ? M4fW0 UTIMN ,F .0-o Cr ? RRNON4 uMLI[N ? r-1 ? B ? MV LINR TURN ? e ?BLOWINO(yl?l¢?ji 1 ,M+Y 1 T, .T T rofAOwAr euw E rrpe r I A , TZ OIFTOfR IIAD AN re I t ati N .R I? !'b 1°[r k",(. A?x' Y)r. .e4 ty,'.?',- I 1E r YU t, ? ?9N ?E... A' r y 1JY? >. 1 J , f Y F Iw'Pµ..xYAE' T rtt'. PRIVATE WAY ' - DA , . Y pE al D [ N TIME COuNrY I? sux?l Mex IwtR. Mlesi ', ( {? (USE] HOUR) / COUNTY NO CIIYNO. iMWA ?1Q l A 2 , ( P( G°OU 7Je ?i esrt s.oq ??( ?rJ ?ti7 - Quueu 91 QN QE QN CIIYOR TOWN EBNO.OFSIRrrORSGWOHWAY m e....... 1 I n OUt ' Q Oi / ' X / I r O [E , i M ce l ON /[.E ,Y I .{ '? .'. If RNG WIIH: SrRfEI OR kO NONINI[RYC11p 11 (q? N PFFFU( f0 MIIiPoSI. ?J?r/ -] `O H ?' e• .t s? ' BETYEEN STREET a DI51 sigEET 1?.• F / L6 CFl ?x q?r Al s { N P f N .D40 S}R{E/10OER N[ATIESIM11-1 ACCIDENT RAMP DIAGRAM MIA .? L iFEl ' MILEAGE ? + G . OF l, G e l-l'lf_<' K CODE COY ISR)N INVOLVED: SEV[RIIY: %RU SE IINGSR[ 9 OR ER TOTAL NO. NO. xIlUPE_HO. lUREP ?SPIUGE [l [4 Q 6 wNeH°m IMf/gr S 0555YREFlOR RO+O dVFMICIFS m Q PROPfRTYDAMAGE ON(Y Q FURE DUE ? ]] .j- IL}EO VE Y 9 OSFECr S}RUCI[INMAEOFOe1EC1yiRUCRMIOOWNER'SINMEI zz SI.DN AGE SPECW CODING USE UNIT NO. I UNIT NO.2 :Q VEHICLE' El PEDESTRIAN. Q PEDALCYCUST S D4rvfR' NPME: IASIFIRS! MI DIE DRrvER'SNAWE: u5i IR Sief IAOOR 'Lz G1Y ST R E A ORf55 "' _ ATE ZIPCOM PHONENO. D CITY STATE IF 0 P NF Da aiucN N'at•n £cw,F 1.1 'v'%. R • surf eIR n I' Y D N NO. A!E DA B 1 e OCCUPATION i1gM NIVAf6PHONE NO. EYES WEIGHT Cfjll E OCCUPA[ION FIRM NAWF(PHONENO. Y EYES GHI hFIGNi Q CHECK (.? L OV N VEHIC E AS AN fMp EEd ANOIHER Q CHECK (,I CODES ?? cssY F ox Nv vEH nEAS AN MPLOYEEO A D}HER. wr 5 utclwN 6 5 Ycq CODES Do- ] n nvvawr ID te < r rr+P 5 [tt 6 s 2 INFIm os Ass sRM RDx i n .1 U o i ? . MFUMK o o ante nYN[ o r? Q A -cE o ?s Q Cs H. c K NtRr Kn. T[AR MARE I-,{HfV o o r.. 8 S „ Y .I fl IOA4i.NOVAI 1YY I]DR: CONV ) YEAR ( E V.) MOOELID-'- VAI 0 . /9 53 + P N c .l /« [ (? E u 5 DGEN P L GGsw Su1E IRNIFRMIE NO. STATE H V[H GOIOR wA Al ? VEHICI[ NIIFIGIK)N NO. i VEHICLE IDENI F G I N L I AlC ibl??. ?! I f I I l I l l l l l RfGLSRREOOWNfR: u5} Flgyi MIDOIf PHONE 10 W4 ' it "c Net R " NO. O 0- II MY FIRST MIODIf - E N . ' { I]_ ADDR[Syd ONNER W WNE4 ' J A ,]I .? h ;Z r f1 r E NAM _ J2` [ (AODRW d INSURANCE CO. p AGtN! A N R ]] 4OMSAGfO ARIA IwKrRH,N u CH,wGE uNING DAMAG[DMfA CHARGE I M1! rnxt. DUit 'v I - y EST.DAMAG E] t OAWAY N 10 ON AWAY ?REMAINED ?ORIV[N ? fSr. DAMAG[ FtOF RfAU FO " p O f oiroii eY / I E ? TOWED 1oi f G Ii A- AWAY BY AV DIAGRAMOFCOUISION I I I^y 4 In DESCRIPTIONOF COLLISION: IUSE-PYAUNIUS [Erlf ECISEARYI IQ? _ SW[IIi N[QSSARY ` , 1 -... . _. _ I ,.. T ...: E - :...? ... .. V`t •[ .... M Z -..1•_j' r /',I.F_ /L 7 -.V YI F'IC ? I I ? I ,_ r ; f F . b - ?. ? ? Wen s . oa xz$ '?? +sLA I 1 ..F r .. _ ? ENV. _ .. 1. i ? &h f,:•i0. ...m n Lrs S 7r'ar s jE. F _.__ _--- F r r . X NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ? lust surnIMEN1u sH[tr OCCUPANTS/WITNESSES CODES 1 - 2 8 4 5 6 ip ApglKkIA, NAMESI NAME: ? a'•1 d C P [, q r F ux AGE um ,. M RESre. enn ., r. . . ADdtfSS - .__._ ._Illq(OI-' ,4 NAM At- 4 ulrn er QAMe ?'f$LKE 0-4.01":r oruwY. ADOetyf NATURFd .. ....... q upvlDlfdA QAAU. QFaK[ Q egmq' Q Nx Q MI.. AMeI M1 .. NAfNfd.. H vI3IIGA1NpdIKIR'S MAVf (fANx NgRq X .p.M1 .. _ - RADGIp AOIFKY ___ Kt DISFAICH/0 K1 [ tY: QAMe xn.Q EQKt QHOm[?L?'i' Q1F'f0 1KE A.RIV1e n rvn .......____ _. ; •" N NLLM ER PRIVATE WAY 17 - OA R? p A OLL N w? w 1. l -.t (USE EtDO HOUR COVNtT ? COUNtY NO. ChNO. IMWA I S U21 J W w1o. iw UL? F h?vo EJO ?C) ?URI.U CllyQgEOVN ?N RM E ?E ?IN NAMf8NOO 5IREEIOR WGHWA CLS. AQUlF SIRE CI MILES ?s w of J 7° } INtER5fC11NG WIIN IOR ROAD NONNfCaJ RR ,. ??? 1% EO pR[£ AVIFVOSi BFrlVffr?, I C ? NFEIe 7. 7115 T ?%? 7.5?. DIS IA l+ 801 R Rf CROSSSIPFf10RNWf5t ?• ` 1 . ItE '',E ACCIDENT RAMP -, IAGRAM DATA, '' 11 Vti(J . [ETB S E W OP l G TG9S1? MILEAGE M E CODE COllISMJNINVOIVfD: IRIlY 1 ! ,? e : N .RD R OR REIfRN TOM N0. NO.KIILED??N .INIUAEO_ ? 5PIl1AGE HI b N IMNDHDIH IM[ 015• CROS55 FETOA AD,?-_ ^M1 OP VEHICLES p?OpERIy DAMAOEONLY ? FUSULT[D St HICLE L?V Ea - ) : C OBJECt 51RUCKINM11O1 OB1ECTSIRUCKANDOWNER-51-E) fSi.D"AGE SPECDLL CODRJG USE ( ?- A{5 .. ? ! UNIT NO.1 IV[R'S NNAF: -T { UNITNO.2 ?VEHICLE .? PEDESTRIAN ._?.PEDALC YCl157 a , { .. l DRIVLP NM1E I . IA51 'E$T??' l I b •?i. e SlRfft ADDRESS IRfEI ADDRESS ? 2[i , tY STATE ZIPCOOE PHONE NO. D g y E1Alf Ip p IVER'S UCEN fN SIAIE R % MDA D H IV ll NSENO. A F E% OwIE I t I YV I 1 OCCUPATION fII1M NAMEbN10NF NO. EYE5 IGMI WIGNi E' CUPAIION FIRM NN.1fb PHONE NO. AYAB I WII IGNt R' ' ? CHECK (P7 VEN.I?tl?j %s n p .. :'u ffiA - y N rASa oc b .... A ys,R IDxrcD CODES 0- J ai ? CHECK (?) VfHCLEASAND OWFOIANDT- i ''9 Y z s 5 urc,wN e - N rsrz W CODES ? +' D n sir + i.° a En<M1H snMw' b .croe ie ^4 ? t ..`E 3 .KN, Ff ; IN IO; r ° ? AVVUw,ct ? KH YEAR MME n 1l ? 8%, ? y-Alf ? r.O,_ suMD SRfvO M ?'u`euAr,Rf ? WE ? c?vnv ? n»I[u ? N?H ubE 0 q lJ . I d.HEV.) ri 7 L r flIDN1 .N WA) SiYIE II DR. 1 sr ?/ I F Q V, I Hl M F VAI voM ' S ou " U N PUE . c / / SIMf iR E H za MIfR RAZE NO. $IAIE VEN OLOR '?qI VEHKIf IDEN1111CA1 gN NO C V ' . REG.ETEMO-El: IASI Nn, MIpO E VfH CIE IDENIII I s I I PHONE NO. IS R 0 WNER; IA51 iIRSI MID ! la ADDRtSSa OWNER W N NE w R I ''. NAMV BADORM$aINSURANCICO 09 AG EM E Y . R A i QAMAGI Mu n yy ?fw ?'1 CHMOI ? P'0HN gAMAGF MIA - //(( [HARD[ 31 y ' ? :( OmrveVOr SLOP DfO•fTGii f [51. OAMAGt DR VEN A , ? AW ? EMNNED ?AR AYN ?REMN lD f51.DMUGF ? ! f t:Jl 10/`HEDB .. ? IOWFOB S O rt0ii AWAY .. ' 1 0 DIAGRAMOFCOUISION U INDC ENORIN _ B RR DESCRIPTION OF 1011.1510N IIJSE S-LIMFMAI I-T.1 NECE55AA1) WEE IF C[55ARY G (JC.? L G r E? f O G IGA C% _?• uu CJ '? ti v _: 0 /! .T /4Q/f0[?9 oN 11 s/..Jf ?tGic•.. /.7? ?/?/. ?Y(/1L/ 0 n ? /La?l . 77 --- ------ -------- 11006r oruv-dx afi. (JGY-/IupGw./3td.4= NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES OCCUPANTS/ WITNESSES )vi I N I p . - - 3 - 4 S. 6 N a AOpIR l AMt 1, S I SI% AGI TALUS w I 4 'H n NJ A w ISif. Ina :,c iv ? . . .. .... .. .. .... .... .. N O - s, + xfESS iuR a R, nr E AMB. ? W, O"' . O R» O CS:n. IL p N O. ? A " pMISf N AML' iURfa ... _ ... p MN•t01R 0 0W ?ttimv ? Na'' ?-1 N Y• b J+ r " Y Y ?1 z ., r NPO ,oafs ' ... r.Ja... . ul AY ?AMB. p? IKI Oro:HP (DTX O vw151 AI pl[IrlNAWf NI 8w0 ( A aa AGtNCY / / D I!A?an1 KIDSIAICWD Iq Ka MAMD DAllp vllOVl APHOnDBY DAII h tK, El roF7YI ! A ?E S ?..'UfL ._ p YOi Col S0 x xqx I ?_ IUSE TRDp HOUgJ COUNTY -/ ? CO TYNO CITY NO. - ; iNWA ? rO R O N 0. 04 Q N ?^ MLEE s pw oF NAME6 N0 fSrRfFTOR WGHWAY fCTC3 z 1 ROUIF OR i f 5 CIgN w 1 F 5 .."REECTI V.1 .STgfEi Oq p NON Irv1fR5fC10 ONO /SC'. -)Z 3 07P, PREFI% f MIlf PO51 OSIANCE6D FM1 Ni M fiq 9ETVffN .CROSS SrPEEt R NfARE51 MILE SlgfFl6 StRFFr ?J? 3??? ? l[5 N 5 F OF (? IEFt Of a" ACCIDENT MILEAGE DIA RAM CO lI5gN1 VgIVED: SfVfRHYI CES TOIAI NO m NO. KILIFDNO.INIURFD? Of VF 41C F CODE ?SPIIIAGE HI WNDREDM Nif R/ ES CROSssi'IT 110AOR OR R[fERE E . 1 5 PROPERIYDAMMSAGEONLY ?y OBEFCiSTRUCKINAMfOiO01Cr51RPERtY AGESNAAEJ ?R'N`LJL p ?VfaCINE 1,"/ .?- 6 YO TT AEG .1R { fST. DAMAGF SPECIAL CODING USf > 4r UNI7NO. Y UNITNO.2 p VEHICLE ? PEDESTRIAN ? PEV, LCYCLIST TN s D Neq's NAM usr F?@E T pRIVfR'SNAM : IASi 1 \ ?/i /'mil •C. _ [[ i ?( ,t + STREET AOpNE55 5 RFFI ADDRESS r ?% _ M y: krT?Yy;, t ( 51ATf ` FIPCODE PHONFE O. R SAIL E% Af BRN .0 AY M1NANf sPH LNO -GHT HF?HT E iHlnf 'SAN EMa.11, oFANOTHfR. A Ml.- 6 w wAANCt? ? p Cbnef ~ep ?,?"'E paHD? )WFLHf .) RT.NOVA). StYIFITOqgNVY I PN ?N SIAIE EE TRMI.- ENo, STATE H ? CL1A i C ?Y 5/ATE IV U ENSE NO. OCCUPAtION FIRM NAME s -NE NO IP PH TAIF f% OAiEw BIRIHR o. Y Y. . Q CHECK(V) I VEHCIf ASANE=e y" AE ` ^ o n LYFS WEIGHT fEIGHI CODES ? + uAys s'vivrA."I F f o . IHE 5 tuawN fi ,CaNE ?IFW pAMRA a p 1 i H Y R ( MEV 1 A10DE pM"m 0Mlrc ?11.0.sf IIOARI-NOVA) VEH. IXOR VHIGf ID N I l N A _?IT? I r5? IIRSr /J/,/yip/Q/?)?!1 PHONE NO, O I IfREp ER. UIST fIR51 MIDISE H N N 'pDq. OCC1 O F- J I N ? ?.' NCE CO. DR AUNT E Sy. T c R n R VNCIOr TI . DAMAGt CXAR ? ^WwY f L/') ?C ?r9fMNN[D I CXARG! . DRIVE riAU HD IH le oiq lSI D t Q •"?F AREA Ss f . l , "L ' TOWFD OWID ?AWAr I ?RfMA N[D , AMAG I plOiiUM 3 AWAY 5 A ?. Tp N[GSSARrI. I Br APR "?nnlrl yr rtJV''_ . yTiJ?1- iLoe? fi AL <L7'?c ,CUr`GJYL?V 11? R * CODES 1 3 4 S 6 *sIx I AG/ um nH u,r :: or... ...: MICY NAf.C `` , ,1_. 4; N 5? ! V ? 'Y T CP D TwEOf OMMW4x? vP Mp [s wED rHp Fn s DAY. T ? U u COUNTYNO. CITY NO. ?BP ? C 3 ® ?e FFe • a n / /C? w'4 x rv ?H ?E ? vriEPE I Oq iOwx AMEf M.OF TPftl CA wOHYY AY x DR 6TPEET CODE u PD IT irED wLES ?s w?oF wr sE ...T.STREET ADN wrEpseer UIW nSY•«.Q ON ?F rv. /TO c? 3 lo 22Sl? -. BE" F[x IF HOT f iPFFT STREET E wLrPOSr ER /rl/sr?FFici?niT E E. RNAP DAORnA p,iA PA+RDMLFM91,5HN4MLFPOSIppF OEHl FruYO tArioMAPA WTEPEELTIOn: ffEi ©® ? ?PUx IARp»NSMAiWKBBFUq IpAN9ORfEO' H• TELND WvOL D j +1 EveivdE MAptEUbJO E9 L PE E%nOEW A IT x ?O ' ? I pL UF v ruCLES ? «IXE ? cLs 'R099 BTRf iEPENC q PDAO ? . 8 ED RXIYEAA- B AMMDNM L L ACTWE MATENDUe?. O. 061ECT5TRUCK IxN,e Of OBIECl siPUCxI E ?fu 5T OWN R F OSIECTSNAMEANDAOOFESS T?nEPNq W?JKr sPEC.CODE USE • DBVEfl•S LAST NAME I S NAM MIDDLE F MORE TRAP • *?? TwOC.w3 WERE --D DRIVER'SLASTNAME. flq NAM .. :... MOLE . Jo lvGJt J d N r 'OPEi ? - 9TREET .. : ROUT E NO. AND BO%NO.. • TWO EPSON WEPE STREET ADDRESS C / WUPEDUSEA B GTY. _ STATE LP CODE DRIVER'S OCCUPATON CO.— 5r]H CITY . .. STATE .. -, LP CODE : DRYER'S OCCUPAIT PFPOprfopM Q T sr OfBVEq'S l1CENSE A E% / /? -DATE OF BIRTH ' a- .SJ• g M f AIDE DY R ; Sy ORIVER S UCENSE NO. BTATE SE% OAT tlI AGE M DAr YP f o VEHICLE YR MAKEICNEV: DODOEI .MODEL INOV -DAFT) So YSTYLE12DR1 d as ? VEHICLEYR. FAM.1 HEV:OODOE) MODELINOVA- ,. BODY STYL (2DR.),. _on ,- UCENSEPLATE NO. ..STATE :.. .. TRNI.Ef{PLATENO... '. STATE : AJAs PLATE NO... STATE: -:..: ;_TPNLEfl.MTENO.,:.. 61ATE_:'.... VEHICLE IDENTIFICATION NO. .. .. ... Fass C vyae VEHICLE IOENTIFlCATCN NO.. .. REGISTEREA OMER I-RST-OP_ENAMEI .:, Je Ne OflIVEq'S LICENSE NO. flFAISTFAED OWNER ILASTFlgST MIDDIE NAMEI' :. .. •. ORVEfl'9 LICENSE NO. ._. _ o- • -N -SJ-R IF ae/ ER s ADDRESS IS flEET, QTY AHD 9TATE1. PATE OF BRTH P WNER'S ADDRESS _ (WREET,GTYA SAT I; _ . .... .: ..:. ..... A OF BgTM . D ORt OW?Sr Yi %y % (. An. b,r YP . PARTS OF VEHCLE DAMAGED ..' '.. .. ?wAY iO ARTS OF VEHICLE DAMAGED. ' , ? $ .. SwF LIABILITY INSURANCE INFORMATION-VEHICLE NO. I• WAS THERE AUTOMOBILE UABILT INSURANCE - COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOURCAR ?YES ?NO NAMEAND AD ESSQFU UTY INSURANCE POSY HOLDER. x«A!• y ? Es9 AQ?riI V?Y O/JI TQ USTATE? //IKlrpp NMIEOFUMUTY WSUMNCE COMPANY e:...:__:... '.._. John /J NAME AND ADDELESS OF LIABILITY wgURANCE ADEN h Dtt Per B &.4 -f 7- 41- ? JLS . AB ILITY POLICY NUMBER _,..:... . IfJfK4T[eHC! ldgS.N-..i ISTBlJUgY:, ,. :.. AGE 7 2Np INJUflY: jUBEBfPAM EPINRTFORAarrvJ WIMBE91 : : . 'AGE NAME w W1ED , ,. .•. . NAME ADDRESS SE%. NATURE AND WENT OFINJURES M F ADDRESS SE% M F ? ? ATURE N D AN GOIWUREB REQUIRE DOCTOR'S E%AAAW ION BY A DOCTOR'! ©® NAME E%TENT OF INJURIES - ?? GDINJURES PEOUIRE EpGTO ftg E%AMWATIONBVADOCTORT STATUSOFA` URED MN WFIHSTONETHATAPPLIES NMAAK FIRST ONE THAT APPLIES o O xMOls,eva STATUS OF wJUNED E ?MWTA R" " ET , I.- A N M4 D POBSBE IgEVfNFI .) H F-UH ? ? S? B O IM. IIOF OMA,Qj s? S? B? 7? MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMETNOTUSED SHOW NORTH BY ARRDW w CInCIE wbCArf WTHabATn«A Hp[r Dr`F"Fp O Lwe rH,r nnfcn "T., HC vnArwB W -U- ?: OF r+ONw,. H.M[s bP ? , __, DESCf IBEBELOWWHATHAPPENED'REFERTRVE CLESBYNUMOERI /?//ll... d{'.._..LEnlenj H O/II - - __.._.- _ / M ,V7 uc.d a /?<./.? ..GL Yl r//2_G h f.r_..-_h oo : N,MBEA [ADH YE«DL[ .Hp BHDw wrrcTlDN ar mANL•r APRDw. \ 1 -..-?YS ._/--L,I G.b---RI t TN ?.hl._/`._/A O,`f...w -?? Qa-- BrnErro wAY _._._ -?y ?tic ?[_mt . ,I I • -- VEHICLES POSITIONS BEFORE COLLISION w of ¢ - uN[• wG¢ INVESTCAIED BY EON r,H .[ VENKLE N ON STREET On VErtIA Pc o L L ? ? ? ? IrGI\ w HE, E, H, HIGHWAY NAME OR NO rtCTlfn of w n• w ? IiinOL ? OrfaifcF[ O i lonaw ? ? 11 ? :. . ? ? ? ?.... ?.. ? " 1 ? GADra-- nmmw ? ? ? ? r,oNG ? ? ? ? ? ? ?[.Awr [w CA_ - ,, TRIP- . DIRECTION To DIRECTION PEOESTRLW/PEDK CYC LIST WAS USDLO: .?aroewNA 2?vA . 2?[wuax E? p unD +W A LIUS A • ? C N+ • ? OrrMR r ? M i DDDiu. • ? ro,Ow,r w + PEDESTRIAN/PEDAL CYCLJST CLOTNWO COL OR. w rVo.A+ •?LDH a?MDip f,lcTM MPARA E?MrPOnMCTM I ? ?ii EgA08t%1/ACE tAr11U LIGIET CONCE IG-1C+Mr1 ? DAVLIpHi NKII DLE r ?rl ? ? wH rant nc. RN TRAFFIC CONTROL rNACL[ K,•rL?ON[I N,+CIl PE OY TIO.AO , [ci OHt v[raC1L 'AMR/VEME AECCAONS Mpnl 1 ND> M 1 b t OR MOA[I ? ? 1 ? WE WAY ? OOINO BTRAIG11T M1C AD ? 2 ? ANG 7 ? DUSA OW,HG ? 2 ? STOP SON ? 2 ? TWO WAY 2 ? OVERTAKING AND PASSING A ? ? ? D ? TIELD SIGN ? ? ROAD REYEASIBLE ? D ? MAIfwO RCMT TURN H ? °ro T30FFFFET ? • ? iLASHWO nfD ? E ? mucHANGf ? E ? MAKING LEFT TURN . RANP ? K ? I I I ncVYI e ? S HE%L'TlgnTO ? 6 ? TLAbaNO AMOER S AL LLY/ ? S ?? ? ? 6 C:] MAKWO UfURN l WAY• ? OT OTH[R ER ? • ? ITN BIDNAL ? ! ? TWO ? l[Fl rIRN S ? BLOWING SUI A E TTP LAMES AY ? T ? arFKCR /IADAEAN 1 O E ?Rf '/S? yE ?9?, y,Lf n ! n MMWAY ? F ? STOPPED FOR TRAFFK ,rT?), yf, LJ L.Iro*CMrE L1 Llo'MNI A OTHf U`EC IY STOPPED Al BfWAL f.,r I •13 ... J r f 3 , S ?Kt- .cl 111 t+lulul-1 VLI Na:LC L,uf-LISIUN tcL'ruHl It D.op wLUV q u F cow N IV V. - ?{A?f. Un MC'N, rUE3 7 1 1WE0 un?lJr[60N C?LITY ll /J / NOUq Qµ COUNTY NO CITY NO , pN pE pw ' F•ND st DRN 1-1 T _ S ?W ?? Fc7•tt PREFUI roUIE OP SIPEET (AOE BECr '..A r c?ND Vnm.1M Er DRr AD / r ON /'?'(' [?• - E..p = .?{ ?ta raG"'280 '. ILA' /?•/TAJ.• Yd ExP A'f' C.',+M1 [.E f%r?t N??S ar??/-/f.[lli:l., ED M(Frrosr,r "T" err f ' powAC si xlERS(crwDr rAf? a wA NDCn wsrnEEr ?i J'F' < Lvf FEET © ® DF EA xpsswp.MRfPDS DR rirwD ":J Mlr DoR wrA_.. - -' I -A". . p -I ? ?wIMYAD NJDFUgF%Pt &K1PTE ?,? E P I ESE EN FIAM ADL ,uE9 ? C LCRwE AL L ?w q:iFPEN DCP0a96PEETERnOAp OBIECT SIII E] TED ? W LE BOOR Srv AifnAL AM ? PADq ACr ? UCK S',? apY ?,'INWAE OF DSJ(GT uCW, ,.. .... WTI R F BIB TB NAM AND ADDRESS rvEE9r [? S? EpE .cOce Lp G/d7D . tttr E ! • - `L' [RIVEfl'9 LMTNAME FIH NA FI?PEi .n' ,3 ! 1[Ji/ wvALVED DRNEfl9` THANE • IRS N e" 7"m All pLE _ ?*1 MIDDLE CARS -hu At TH, yy??TT I? ? 5 }y4 A _ ^ STPEET ADDRESS : .. : ROUTE N0. AND BOX NO. AN ia'JJ ?` ?, "33JI`y I sCn xEPE SiREETA0DRE53 ... CI J 1 of .f_lUL e-USEA / .. .... ... ..POLITE NO. DBO%NO. . - OTY 9iAT LP CODE. ptIVER'S OCCUPATION I L^ / '+ I wSON CITY p .BTATE -: .. ?tl EPaPT LP Co.." DRIVERS OCCUPATION G//[ LIW U i '? ?.:1 , '?.: Fpw :.. .. .. " 1. DfUVERBLN:ENSEN r L ? 'Lr. /? 'J ,?rr // :OATEO F&R yp. AOE VER'9 LICENSE NO:: - - :.., BTATE SE%. DAT -1Z AOE y P 2 ? ?ICLE YR. MN(EICMEV. ROODOE) `EL'1N VMOARTI` BODY.STYLEIYOR.,/ (••/? u ?, pAV ?f. _',ly k?:yl I " i r., VEHICLE YR. .;MAKE ICMEV 001 .:MOD IN VNOi Ti'. -BODY STYL 1 Ofl.l L A L LICENSE RATENO.BTATE .; ,TRNLFA PLATENO., ,; :.STATE (rIOQ(,AY j,,, VEHICLE IDENTIFICATION NO. VEHICLE IDENTIFlCATON NO L J I. - Ife? RE ISTERED OWNER ILAST•FIg3T MIppLE NAMEI.., DRIVER9MCCNSE NO. gE049TFAE00WNER ILA97•FIRSTMIpOIE NAME) '_:. ... DRIVEq'9 MCENSE NO._..,......_... '/! J FCE OYMER'9 AODR .. ISf ET. TY AND STATE) - •ISt CITY AN s FI, .. &flTH OWN?'9 ADORE r So i+ f oA.A c? %o?r F Dr Am, ?,y f. PARTS OF VEHCLE DAMAGED ? S) 1, :: .. - f !?/ Ara 1 z@& _? .. - .:._.., N? ?SLi iO. PµiS OF VEHICLE OAMAOED. L[ / & TH •? ,td uT G? ti, _ -./ B oG.61 -_ 40 14. s.?w i.-.. E; Y LIABILITY INSURANCE INFORMATION-VEHICLE NO. WAS THERE AUTOECTWLEUABIUir INSURANCE ''sjtj• ?'- COVERAGE IN EFFECT FORTNIS AC INSURANCE YOUR CAR AYES AT CIDENT ON +??• ' NAME AND ADDRESBOFUI-:RYINSURANCEPoLIG OLDER .... .. -CRv O STATE ID NMIEOFLIA UR`FWSURANCECOMPANY ,._ N NAME MID ADDRESS OF LI/AJ&UTY/INSURANC AAOENT L?•t tt. , /` / /, T ?/SAE Dv.C ?IUBIDY POLCY NUMBER 5TNJURY: nT'I O ?? - - .. ...;.::.. .•.. , .::. ......... AGE. ]NO WJURY:. IA - , NAME '.. ,. , 1 SESFPAMTE PEPoRTF HEST, AOE. 1 ADDRESS SE (p NAME A t NATURE AND M F ADDRESS 6E% ED UIRFINJURIES ?? E%TFlIT OFNJURES DID ;,_N N OU RE © ® DOCE R ?? EXAM NAESTK)N R BY pDCTORa M F A S / DD INJURIES REOU flE W SiAiUS OFW URED . MARK FWST ONE TMATA U 9 ..MINA IONBYADOCTOM ® [B NAIMEOR'S OFI ?<RIWR IN VENgLE GSAUEIWO AONdM•UNO FOSSE ? NJUflEO .. IBtJ7 IL'THAT AP q - a^. .?-.?,, Y • i. ?PASSENDER KILLED LSE Afl wJWr WuRy IF !R IN VEM ,[.. DSABLWO HOx WA•IWp EB ..-P0.A4RrF N ?PED[SIPWI NO '" IuwORI Ci FA$$f DEP KILLED ERE IM NORI 11l ElYT N1 ?t ?, tl. :.,;, .i ? 5p 6p OFaELI .. ? O EDE.p.li, iL' N0. ... 151YI OF ETCI 11, ? Sp ep 70 . MOTORCYCLE SAFETY: p HELMET USED -? - ? HELMET NOT USED MOTORCYCLE SAFETY; NORTHOVAAgOWWDNCLE ? HELMET USED 1 ,n p H[LMETNOT USED 9NOW i?N h OE -? " wpOAlla muuACnAU ?? I SCflIBEBELOWWHATHAP wn•rN PENED.IgEFEfl TO VEHIGLE9 BYNUMOERI v[ ttp 6 ra• : '^ J pN[CrgMUM.,, AA"ww° w? } '. ? GJarNr -_ /:/ c a •/ C. vL:_._ /,-/?i' A".__5 s C ? r? , ?P ""•?? ?<"' C;. I]rwr oR ? /1/itl. _S?'in(?s-s/ C?r-riue (/ /fCf?o . / '-, I '. !/' WeTL.t_ . 6Pl15p Kw[l__tJNL. .._IStuc? J - / GNI?C OFF Thr' T I, T r?accrc?N- ? eft Cr?rL G? _" .wt '• Jl'c l2krJ 1 le- I __t}_t td Sty !r E/ /// E/ y!uN l ? ' - ? E -em'u' R' VEHICLES POSITIONS BEFORE COLLISION of LANes ,} ?,; VEHICLE r ve X 0 WAa WWSTOATED BY - N S E W ON STREET W[ 1•DHWAY NAME OR NO. w ONr pD eLr Si nOrKl UNIAIA A(D YNA<LF OCCIFKp Irh4n ? ?.? ? Ow[Ctgn rIO r[S NO M ??Atnp ?PqK[ } ,5 -,Ir t r A4 IDrNIRI ? ? ? ? ,. _ ? ? ? ? ....?..:?.0, . Ow., ?09r- Fix g y rto ar wA ? Li Li ? Li p ? e tnrr & ?• W ? ? ? ? µ FROM DIRECTION TO 0111ECTION asw[w? "I v,t-•, sj, % PEDESTRIAN/PEOALCYCUSTWASUSINID: Tp aw•LA I?wALArr•r ap It PEDESTRAN/PEDAL CYCL[ST CLOTMWO COLOR: aoLAOLA i ? cPOmpw.A" [ ? enp•swupK [ ? orNU r ? °t[i0"AreD +s elrwie ? romw•r ,/ ROAOSURfAG[ ' ? oAn a p [drt a ? uuD . p A[Tron[IUCtrve • D [n R 1 / r '1 Iwcx oN[I WFAfHFS (-Lgrrrt CONprgNSRARFq Conrnot nr[ornoAD - rnrvFn/venlcLE ACTIONS } ' L Wr,O,t 1 L:T4?rLIWIr r ,tree, oxli -nrnDlL„[?tvrti t: .. vLNCU ^ f. p I hfAR a N0 a ItnICXONF bluggl rh + H 41r pr S Y r ?OVlrD,.ocyl ] p PAWN 1 O SIGNALS ?' 1 p ONE WAY %IT.. NIM T 7l 1 1 ? 1 p RAMq ] p DUSK p [ p SLOP 6N)rr p ?IVAp WAY` (l :f ? F WET J ? • C3 I. STREET C] ] p YIELD CADN J REVFR90LE ? [ E) OVERIANINO ANp PAASIND e li V C) J 3.0. • ? I0p S OARK.SiREEr ? ? ROAD ? ] p MAKNO RIGHT TURN I ,ry 1 ?... y I 1 N ? • pICE ? LOrSTSOIF ? A ? FL No RED ? 1 pIlOO NIENCIRNANAMOEPI A R,9JY fG'r 5 'w 1 I Ty r?R S DARK FIG ? C3 • MAIINOLEFT TURN } 1 L ? S ? 61ST SPY ISPEOSYI S ? STPEET UONTS ? 1 C) ILASNWO -DER C3 S p ALLEY C) S p MAKNOU•TURN 7 1 (f 3 ?td 4/1r ~l i p FPTfC fY ? S ? M• IAL ? S p LTER TII/1N p S p 6-0 M 1 7 1{ r ADwAY i(n IgADWAY WW [ IY p 1 p OfIICLRJ FLApMAH _111 7 •? r l FI -.•. r r. A r r <dCArrl OAAN 1 C] 7 ?OAVEWAr ? T? STOPPED FDA TRAFFIC r l J _(r I 1 h is / .-. I r R`H EC l,vY AnA STOPPf D?A?i 610NAI + J SI f`r I J , 1 "'' i (r t . rr T I 1 NIOWH Wilil LE COLL1,61UN Jjj;jlUHr y COUNTYNO CIT,No - Ael U! 2i ...... 10 N CO. 7a M-STOR A -1-IN -A E3! TO TED. UIS HE 'IT m SNEMATEN OWE TSTR A Ic 2 .. - Y-Pit" UcUEqTS NAME AN ADQREs 03 , I : L. ' I I I /7 75 DRIVER'SLASTNAME MIDDLE N DRIV il w- 111- N MIDDLE STRE T ADD Ew -K T- T_ ADDRESS XNO _ A UTY .TATE_ Z, C I L .p. OUDE -TA UNIVEH'IS UCEN,SE W. Vcmci.ii Yft - I ... V., - v 11 ON -TEND ?TRVLERPLATENO _, : ee, STATE ) i ! - - EPLATE ?ICLEJDENT VENIGM I TION EFED 'LAST'ANS DFUMM WO-ER(LAST.- . DFUVER'SUCENSENM? IS ADORE- L 'IS C AT .1 LJ ' Om 1'5 M LIABILITY INSURANCE IN OORE r.111 FORMATION-VEHICLE NO 1. WA l AUT INSURAN E E` T`Z O-OPILE -A 8 1M . W FA. I 4 ACCIDENTO YOURCM -_?E-Iw- OF LUIGI NEFFECTFORTH ` 61y &rATE w AGE, AD. 0 DA- 11A 1-1 -THATAFPUE `IAME -La 5TATUSOF 1 0 _- IOLLED _0 0 P" WEA 0 5 OFl"cTC'l' 0 . ISTIII. =1 ..ED I ISEVOTO (1c T 70 C) 0,,- , IT 0 60 70 MOTORCYCLE SAFETY: HELMET USED IN eD, MOTORCYCLE SAFETY: S-O-NORT..yAFROWINCjFaE 1 0 HELMET USED 0 HEINIET.OT USED - - - - - - - !W?OtVj!A?HAJ?PctED IRE _FlqTI)LVEHCLEELSYNUMWFLI.,,____ A-- 2 ,C W, 11a 9-lu -x It F)u J,F C) e, . . . . . . . . . . . . . _C -C. - ? - . t c i` 11 LAI wu', , : , ; -, . . _ ? _ I . , C_/o 1? Fr am, OA.AINAMEDFND INVEST AMOW R'O o 11! ?? I O':':'O?, 0 W"Uc, (3 -m- ir 11 )"j,lel 0 0 Oi 0 0 El liil?? ALO.O PEDESTRIAJN/PED CYCLISTAI'll USIND. 0 1 RZ(!lION TO DIRECTIM PEDESTRIAMN/PEDALcyC, TCLOrHINCIC01.0n: 0 W- 0 ATKA U I Of no. DWA IV E N r rl DA- p u , 0 sIDNks 0 r+ OINOISTRAIGHT.EAD 3 0 DUSK 0 2 0 e-2 El TV?O WAI 3 0 sw-4 OUT. ITTRET [1 3 0 0 2 0 OVETITAXING AND PASSINO 3 C-] &NOW -1 a ON 4 oa 0 DARK 5TWtT .. 0 3 0 AK.11 0 0 ' 020. RIGHT WFIN OWVI Oct & Oot. LG"130rl 0 vs..4 RED 60 K, 11 4 0 INMACH?f 0 o'm 0 0 ILOOP/AAMP, 0 mowo LIFT TURN gtmcl Ts 0 FLAs? AmftEA ALLEY otKA 0 5 0 m"Na u TURN 0 a FIT snNAL 0 0 rNO AV- AIM., 0 a 0 uowm 0- 0 O-FcE.IFLAWAIN 7 0 0 0 ? 0 STOMM FDA TRAFFIC mylwA, A is meSMT .: - T y 'ro t _Es,t. qr {'•.IE? t?v -,. a O` STATE OF WASHINGTON PAGE ' POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY No. PIXIC[comnA,wrNUMBER PRIVATE WAY couffrr NO. clnNO. pHWq , LIT RD. I / ZLI y?/ qR. luu i.lB i u IN . f UZsE R oo pJ couNrv pupa p T?r? L..tSa, l 6ZZ' ?i0 P 3 pN QF pIN CITY OR TOWN NAMf6NO.Of Sipffi OR WGHWAY ROUEE OR SE I¢µ -: fWus ?3 $1W of ON .2. S/U .3 GOlrfO ?. INIF¢SfC11NG 11H 1111iOq ROAD NON INtER$fRION ,5 pRETq E - 25 ?1 Mllf -T BFRVEEN Y[A??Ak/@Ei6V DSCtif ?F??, /fZ? "FS .A DI IANCE6DI 11 N MR fp .C¢OSS SIRfEf 9NEApf51MILf Si ,? MlFS N 5 F W ACCIDENT RAMP p1A Miq O iFET Of C/Y LM Q MILEAGE ICY ' °COOE hl CIXlISpNINVIXVN FR IYIRO ?rv i ROnO Oq Ki[ ENCS - In ?q iy, ++ tDTAI NO. NO.KIIfD??N0.IN1URE0? ?SpIILWF It V INi[ cm CPOSSSREFi Po.IU V'A. W H o•V(HICf[5 PROFERTYDAMAGEONLY ? pIESUItFD v[ C wrlgRl¢rH ??' J (J , - ? OBxCt SiglKRllf/VAE Of OBEFCI SIRIKR AND OWNER'S NNAE = I fSi.pANAGF SpfCW [AGING IeF 9 f UNIT N0.2 'UNIT NO. 1 Dl Q VEHICLE PEDESTRIAN PEDALCYCLIST - ¢E - h ,? 3 DRIVE 'S NNAE: WI FIRST IV Q Q ?. _ .e? MDj 0 ERSNAMF. IASi I MIDDLE S ?"' STREET ADO4ES3 [) r?C ? I A - - - ` IPfEI ApDRf55 ?I 7 1 S r- 4% P 0: °^ IT StAif -m. p.ONE NO. D IIY iqt IP p IF ' - Y7 R f4's UCtNSf NJ? ?, SiAtE E% T R 'r15 IRTI i LI NSE NO. All % pA DAY BRM°3 p OCCUPATION {IIMNAM1. P1pNE No. ETEs IGHI IEIGNt E OCCUPATION TRIM NAME a PHONE No. EYES I IGMI i IGHi ,,, .,?' Si YDE 14w 2' of R p CHECK(( ? YFHIgEA AN U+,pt IYEFa ANOrWR. Q.CHECK (?) fppM 1 LI• CODES ?H' 7 a [ ! EASAN WPIOYfFO[ANOiHE¢A a' u sn W` / s uK11ox erK 1c. . CODES ?+ 9 a, vEHlel [ i:in W` 5 fxa N p 'S",°Ni01'e yn •. 2 Kos NAT R? IN RI b rv 4- a s FM..p ?Mw%Nl QM1 01, T'- Q Cf KIN F °M ?AMW q?ut° ? 6.R. ?? ?1:°? 1-TAR M MA EIODOGI- .) ELIDARTNOVAI rSITlE 1304 -CONV.1 KY R 1 V.J MOgl10AR NOVA) - Kxl '.t .? G 7 Ov061F A ?F .? (-/o? E m E '• .I ¢ NI N SIAIf IRAII[R RAZENO. -IE H VEH.I°IXOR AL 4L4 Wq VEHICLE IpfMIfKA1WN N0. C VFN EIDFNIII I c, L N N A •S'9 ? x '4 6 REGISIFRfDO-IR: WI iIRSi MIDIXf %:ONF NO. E SRG OOWNFq Wi IIR51 MIDgf r O ADDgtssaowN[R S C L_ J .OV,313 w wNR i r Y 5. 1#11; d-T i;•- NAM( IIATITRIMCI INSU4AHC(CO. Oq AGFNt E {A-F4 { I[ R St x. --, ••lo.yr,t Sn.rrf ?r•'7"ca..NSK?.•iv?, '.? _r R • pi qR a 'p'w.rM CHARGE CHpRGF INUf°°iCrlOrlu iM1AGl0 ARFA ..'.31 , !, - S E51 pAMAG/ ? OrW[Dw:e ft01 A.Al [SI.D [ , -- ?'I •50 ?AWAY ?RlMwNlD ?AWAY !1. F', r 1' A. f Ur ?,P.. •j[3'.( U ?10-D r: f Ici'arioM°° ?i a DIAGRAM OF ON: AWAY B 1u NDC ip NO4TH DESCRI f 1 le 'I ( •I 3M IYN[CCSSAR I.-- I e PTIONOFCOLLISION (USF SUppIEMLNiAISMEI IN[C[SSARY) .? f ic3 wfe?,r_.N_eT?- t . /. I . I I , GJE1-... D._. f pCFi/-£BY_. ?Oy. Cop4ACl r.. - r --?--' c J l? .? ?Cn t S'[ A%4N rF l G P' a r I t* 1 ?1 -ell vF (j2 C[(Jt. ?Cn ?MaNG _ r, 1 , I •-I I z - TI F f IT NAME,ADDRE5581NJURIESOFPERSONSINVOLVED + OCCUPANTS /WITNESSES lose Svnlrufnu Swn CODES 1 - (A 3 4 5 6 - Iro ADq IIONU NAAV 51 3t% •?? ,? Nye. ?CS4it AG( IAIVS NH tY ( Rl3IR (1l[i [r: I' _. /!. / nfrw o w. ITCle as}' 47Jd'_ [ 2 / l ( 'y 1 Y; ADDfIa Z7 a fp I Ipp+ / n-.'r?1MAlY r/HOt (.•G . r eY AMe. ?'rl`IKI pWH'r CTS ?{LRIx.hl . r q y yy ) NAIUf - ''Aw f 1 -y u. -1. } HAMe Morro rfwp N °'N Y. AMe. prD,RIQMIT. p HDr n Q 1 • r ? f. eh I Va ?) F c .OOIf37 ..-. NAAIf["?a ... Qrcolpxl ?D:n. Ot7S Qn'HI. S1?'! flvllllGAlfw:prKlltEpWl fAN[ fAOgq AG[HCy ._.. eY? FF KIDS AICND fQK1 ARf VTD DAllCFa1 llgl AIp.OyIDRr 'AR I NM,p ! X D ND 2r 19 L Uo T g rt .{( IT)TR 1 ,?? En t L i, , ? ? `i " ? '?Cyv1,- g3?T`??i ? i II • 1 t ,,+ro?, ? 4 :4. ,C} ti N? r i I ?17 .P, ? c - F? R wyn M. 1 3,', '. v DATEOFCOLUSIGN DAYOFCOLV4ION ,_.iIME OF COLLISION :• NFS rri0 I N D pPI F :. + fir' COUNfY NO. , CITY NO. g ? /.' C/ t A ? nMlFe AM O i S? PM ?? f / C ?'? a - GJUNFY GTY , TOWN " fgn:DE MILES OEl CIIY.TOWN O l ADM {LS PREFIX n a Llcooa LECTION w 3 aFF ?.er ITirus ,r• i (o DF'?Mrl???aseN MW 3 -cow= ?S DH GVE NAME OF STREET. -A.0.RNICIIWAY .. I IE I I..C RN. .1.: STREET . 1I ,,. R f . PREFIX EO MILEPOST rt'CUxWiueD 8 .. A ? r ? {J(?T \/fr t c•l ?i •F.T /y Ci? ??? NONNTERS E0CTNDNLOCA NCFCOW410N , I I }? / ,Y R"MP DIAGRAM DATA 1 - ? ' pF.TWEEN L.O L/k/ ?O/V?j/U ?'^v ,tl/ 4TREET ANp IT /L4-I?ISLU I © © ? ' ? On '..ZI^o^CilOrSl+WrrG IH S 1° + ? ° P n,- ( pI F ? ) C rr /CIO fEFi UEl UE! Df ••Ff . L M M /•' f y WFf'1-0 )s f f ^ (/,f o L: INTER INTER. CL3. aEitN ErC60?/ L ?fEiuna O /D % +nuOU,LD ? 11-1 E E -NC ucrTxE QO ElIIWnIFI ? TI ? 4PEO CODEUSE g,TIPDLEDWFDI oYE KLE _ vNM:IE PEDESln,N WN<XKU:a)N (]111( Ci1JECT STRUCK roof f!IFXUFCrSrPUG%1 OWNEROFOEUECT5NAMEAN1ADD1E43 I LOCAR ON 0 ° G IN FIOM N WAY ..?. _ OntnA n D T ?Ec FEET [00! S .? • • - IF Ma+E RI.W CTYVEPSlA3T NAME ...... FWSTNAME . . .. MIOIX.E 1NOYw9 -A- E. weVEfl4LA3TfUME.. ,. .. iW3T NAME... MIOpIE C STflEET ADDRESS ::- R0VT ENO ANDSO N USON Da .. .,. . . X Q N.- N wEaE STREET AD DRESS :::... ROUTE NO,AND DOX NO. .. ... ,... "• 'x AIND RfO UEFA EIN .. -.. STATE '....:... ZIP CODE. waVFJISOCCUPATgN. c T awYS2rr? W1,404y?68 ?Q 'j2eC/ OIUaFw AEPoM ION CITY SATE DP CVOE RNERSOCCUrAT DN fN1NER3 EN4E NUMBER, ,.- STATE SEX M` DATEOFDRM AGE. ' OflNFASUCFNSENUMBER '. STATE SEX CATEOFBIRM, FEE ?d-.foul- Y C 1. v 4A k y i7 66 6 7 M F MD D,Y YtW VEHKLEYR. MAXEICIIEV.AOIX'El MODEL(NOVA-0ARD BODY SrvLElT wil sT - VEHICLE YR. MAKE(GIEV. OpDGEI MOOEI(NOVMDART) BODY STYLE IT OR .1 194o jY SuN 2/0 V LICENSEPUTENO. STATE TRAILER PULE NO. STATE Fs7.rgs Z UCENSEPLATENO. STATE TRAILER PLATE NO. STATE -11CLE IDENTIFICATION NO. (IDWMODELSANEWERI OODMETER(MIEAGEI VEMICLEIpENtIFlCAT10N NO.. (1988 MODEL96 NEWER( DOMETER IM%EAGEI lo- a 3 077 IIEGSTERE00NTrER (LASTFWS MOOLE NAME(' Goa3r DRIVERSLKENSENO • _ flEGISTEREDOWNEA (LASTFIRSTMIOOLENAMEI DRIVERS LICENSE NO. -wawm' OW EflSAD E99 • _ , STREET,CRYAN09tATE) DATEOFDINTH OMERSAODRE9S (S RE ET, CRY ANDSTATE OATEOF&fl H R7 OwsYSt ?f/.f/ W DAY YEM1 a ES P.?W.Ty9?0?F VEHICLE DAMAGED nMAr foeosr PARTSOF VEHICLE DAMAGED erluAROeoSr _ BAf'T LA7V1?- ltNCie,¢ (?RQ(PAA.. _-... S ...v _ ..:. O.PgnrrNtte - -" a W"S THERE AITraMOE%LEU"aLm wsunwCE .y/ LIABILITY INSURANCE INFORMATION•VEHICLE NO, 1- YOUR COVERAGE INEFFECTFORTHOACCMNTON CM 9 YES ? NO I Fill F ' NAME .Yf AOpRES30F UA&UTY WSURANCEPOVCY HOED Efl... ,. ... NAMEOFVA&VTY WSURANCECOMPANY % Hwt ADDVf59 DIV. :.... 9LArt - ..• Zo `>s .. _.. Rc? kuy if. F - , :?4 NMJE AND AODRE990FUABef1 WSURANCEAGENT. .u, • On. W E o?. I OA&OTYPOLICYNUMDER f IST WJIMY ; :.., AGE TNDINJU .. . 3 ,.t (NSESFPM PEPOmFq. IQ_ AM gn^LIKNA.FJI ? NAMEw'f AI/A- _.__ -^•__ b? TOM NAME r? ... AGE ADDRE,sD ?7 -3 -/3.?/6Y_ ,e FUMs_. -rfvc? _ M % MORE59 __ - SEX y r e, FA =- A •wi? _ [IO.er:P000ram 0 N k t • 1 ° rlorl DVAa><r-- ®© =T1`-` --- ?.?.?.'. S1AtUa90F ED MARK FIRST GNE THAT APPLIES BTATU90F WIUR=T1`-` MARKFTRSTONETNATAPPLIES •,TVr WVEH4LE MS^BVrO NOlrriou,DUM 0DMVEB WVENMCIE ON.pDA tK1 POSVBIE . LJ xoR WILFD ISFvT.n[I IuWOT p w+°•NPUnr 0AastP N]F F * R KILLE O p D IsRVERiI N I.MigA ID! auniw,? BE] r ,W ?.,. .:. ,. qNf -.•I Fitl p pttDESrnw W ? 5? 8? /?n ,CI SHOWNORTII OV ARROW PI CIRCLE 1 DESCPIpE BELOW VMATHAPPETMEO.IREFEfl TO VEHKlE90V NUMBER( ." IP YXGw '"MAN" (.11 f/, T C M R zr ni47c .vr . . ' .? 1. ,o"RD A fu- sare rw1pl.?Fors \ i -- '- -- --- --?- -- fa' weu :rear r??, WIPPa,r N.rfF? ar ®\ ? --.oF_F_ .of'2oa?J?'1 -- Dr•faJ ( n daw S S ?eIAV9. , P NN?Prar.Drl Wr.TIE,ND'Agw ,Q c?Ro ?e b.ven._. T[.{.M Cor?? D?rD:DND.P,.wf•YM•,IDW .. ?-. . v -•? ?•- InrnarDa _w.r To.'?S rt P-. E A el 1 ?f -- - -- ------- --- VEHICLESPOSITIONS BEFORE COLLISION N°NO„ lD nerl^tM.w vFHKft .PMIaf wvEarl GAra D Br - P vCr1Kl! H r19?. E W ON SFRTET OR NXW W156 AY NAME ON NO DNRCIIDN Ifrc Lr P eD vtlKeR OCC p ?'+M. ? K y 1?r m AI ? W ? ?O ? ? ? ? ? ? ? rout( ? ZION ! "fir 1 j .r. ? ? ? ? ? ? ? ? ? ? MKIM ,,pb? L , I r4. vlww vA ti"7 } IY+? rYUM f'"""`P ? ? ? ? AOMIO cAF aa0 Tau DIRECTION TO FDIRECTION 1 1? jj I'TOC`+IILAI •VAD M:JNG 1?DIXW4K T?WMKWAY J?SI_mrv .?CfYVWYa 6?cUi+auiuwyA •',j' y ?I .t .• WWA0 SUNFACa NFAiI1f1M Y N rI WI lK1ICW01IOVa tRAiKCO (POI a0 0IIEn ICr11cK VIF1 TYPE OFROAD FYfJER_"ICLE ACT1wIS ', ,y .? 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SPIIIAGE -'? 1- un"I s Cg0$SSEll " X-RD q C!E V[NICIfS IMFN• CLS E Oq Rpbq'ICAD OR REIDI E PROEERTYDAA,A.EONL1 -gFS?IIfO VFMiCIf 5 .IyP ODIfCi SIgUC%INANE Oi ORJf ? ? { ?... Ct STRUCK AND OWNER'S NAMF)t/0210?? 1 *??,' FSI.DANgOE SPECIAL CODING TAE a a s p4rv[R SNAKE. UNIT NO.1 S ', + [ IASr IRS UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDAICYCLIST S l _ DRIVER'S NAM[: IASI STREET ADDRESS C./ S Y? ? (S '1 !: 4 I Y I / TJ, "TEE, ADpNESS l CI(vr \ SIAIf 1Z PCODE r' I -1 I` lGr.-f?iE:'il..\ LI,G•'- \/??E/? PHONING. ,l RD IIY IAIE NP 0 P NN I ? DR VEX SI CFNSFN 'S )( ?? (] 1/ •? Slgtf [? R H ( IV R LICENSE NO. ?' /. )l -/ -f I ?r1 I _ IAIE EX DALE Of BI41N (. OCCUPAIpry R. V R Pam NAME n PHOnf No. Na cnr I<ICnr E occuPgnoN "'O 1 ° i ra. EYES iIRM NAME 6 PHONE NO. 9 '? ? IBC-' /J? x R Erfs w[ICnr IflcNl CHECK VFHICiF1EANEMltiori[pPAiiorH[Ru P! NODES?* n - < i ,nR ? CHECK (?) VEH aE AS AN FMPIOVFEa ANOII?Fanl s In<T V, a ;NO„i°nNc.cV - CODES 1. 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NO.KIIIED??NO.INJURED? ?EPILLAGIE ? $RUN %•RD N FR , RpOA:l OR RfFER[NCE ]] yv T'r+i •I OF VEHIclES ? PROFERNOAMAGEONEY FIRF ds? IME Cls CROSSSik[ET04RO OBIECTS,RUC%(NMSEOFOBIEC}STRUCKANDO-1E $ AME) ? RESULIEO ? fHll?tEj "I"DVtDIH ?? . . .?- rl '? fS DMAAGE BDFCW (-0DING USE " UNIT 10. 1 j DRW[R'S NAMF: USi VNIiN0.2 FIR ?VEHICLE, - si ? PEDESTRIAN ? PEDALCYCLIS7 aA Ee kI ER's NAME: FA9 S RfEIAD f55 2 IT YE]ADORE55 Al -' . . ,T.. ZiPCODE pp?? PC' 1 Y ZIFCODE PHONE NO D „„LL++ rvfRS UCFN NO. S}A F f% ( rv ll NS NO. Ge ' ?' fVN+"?r M; IHYR. All ?DAI rBIR'YR. ? ?y A c "' OCCUPA,ION FIRM NAME 6DHONE NO B? V I D '' } 2 FTES Wf GHl HE-GHi E CUDA ION ilgM NMAE E FHONE NO. .+?J EYFS IGHT IEIGNI CHECK (F? IVFHCIEASAN fMRVITFFOFANOEHER. R ?CHECK (? .•& T v CODES S* 9 a Hsl. VFH ¢f ARAN FmftOYEFOF ANpInf¢ E !.?+. ,2 IfiJlaR i .ssr xsn "' ? 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CODE MILEAGE ISa Ei G COIIISON N`,0-.: FRAY: mI151N D H UN ONIY INJURED- DSPIIIAGF IunokClH - IOIM NOES C N C Imo. 1;:p ROKRIYVA E I Lf l "R S 1 D P CIIN B R EI R 'OA REffRE NCE MA IS U 0555rREETORROAD ,J Tl - . D RESULTED [ OBJFCT SIP IKK N E ' ?7 'L. Y-YV I AM Of OBJtCTSIRUCKANDOWNER S NAMEI fSI.DMSAGE SHCIAL CODING TAE "`" 5 UNIT NO. I D4lvlR' NAME: EASE IR MIl UNIT N0.2 ' Q HICLE Q PEDESTRIAN Q PEDALCYCLIST VE -- " ^--- Q ?E ko O N RNER NMAU Usr ?Tj?E ' TII31 / L //Airl ?? s? !N SIPtf1 A0DRF L IR[Et PAORE55 1 SEAS D Lea / , ' ' ZIPCOOE PHONFNO. I pgnERSUCiNSL ° L?'? x'4'3 ZY3 -Z9oo STATE f% R Ity?7 SIAtf IP p HON ?, cai S ....0 4//f 9'pj6P Jgs' r Z C S' 2 r A B H mp?.l D. 1 I V I IICEN ENO. f G?A f% M pAIE OIRI A I Al DYR.. / I. 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ORAGENNT r: MACt AREA " R 0 N I. n P _L awa w°,N cH ou AREA CHARGE 1 5 t5f. pA-IN ! -1-1 Y ADORE ,G ; s O IOWEDeY,TOWED AWAY AY Y B DIA R I MNA IDCAlf N091H DESCRIPTION OF E rA Row COLLISION 4 OF COLLISION: IUSE SUPPIEMFNIAA SMFt111 NECESSARY) p ... ... N[ SSARYI e ? .. ._ ._... ._.. .. ... er. ._. ( W C J I_HrcLIF N 2 hlAf... .]?"l.t Ni .?f ... L iyrT /N rO N . ^ , / . ?1 l A PA10 At/Av& 1_0 D!./...../10 ,?._.. NAME ,ADDRESS8INJURIESOFPERSONSI NVOLVED +CODES 1 - 2 3 4 5 6 N OCCUPANTS /WITNESSES =Mi.`N:if?sA AMI: 11i ux- Ac[ rAios ';,°I" s'Ar -IN, ll- ' R[sIR. encl ; ur. A awns HO NAruaE Or R rw eY DAM E. QTR' . ONx' ?C :A{, n o A w.us NAlu4t or .. R N Ep EROMDe. DicoItAI DAD' Dui Qn:.n. No A ?lp( DNESI NMJ01 D,I BV. ?AMe r_j-A' «.H. [Ar r <ONI. D ti,T' D A rIV r41A .+G W CIB'S TY a NE NE BADGE GN K,INCr wr0 ur aK msr lcao Tau ARRIVED pgna wro.l Amovtoer Dqn X , ;` 'F r°Q@y ?' 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OTNFR ISPLbIYI DM1R AOlF • Q•iREET LM1Hf3 C) 1 ?ILAlH04 AMBER [LOOP/RAMP) ? E ?ALLEY ? • ? MAXINOU•TURN 1C L • • ? ! ? smwl F ? OTL. ED • ? MIIEWAL TWO Y aC 1 - t? : I eAOY/AY CM UI ?}? AGWAY 6VN E i ( , ? e ? OFFICER FLA04 AN ? 6iOrrEO FOR YM/FTC I r 4? M , 1ry 1 ^ J N K *O l Y ?Y nJ n a ?NH c' . WIM. Y 1?._ f r T I I "l , , 1 (' I a L K . i3 Q. < 1 fi I r A , G r v -? f ?9L? K D: e +4a: ?' ? ^ ? LLINeDVIN ? sLOVnND ? • l ti l ? I C) DfBVEWAY 7 ? Btprr[n Ai & I Yu Ik / - ? 1 t ^'qu } J 11 b?°? , ? mo, t?'!0`r x,r.4t Adh??r.;?`4 V {y`•5?:; 7r• y ' ? aw?.. - : l I1 r l la ., ? I,ILUIVIA ? J) * 4d0TOR VEHICLE COLLISION REPORT _ NO, Ch SIGN IwE Oi,CRUagN JY? GAr l `Y? +ux lMox ?uEa w¢n n? fw 9A1 Pn : '` ?M.I I' COUNTYNO/ LITYNO. ? Wn ?OgaiPERf:00E C C' ?x pE p 9.fOV•'x LNG. p A I.` 4p" G6?/o « 10,t Ea apwpa?o,f lVu.t?cL ON fle"'A i'wuOGE. ,.? •' EHS¢rnwvnrH SrgEErrnnDAD ,ER ( wl% x 4"' Y r°ti.? . '1 sEC > sInEET . Or /?-.• Y ,ry; m ' '. ©© •ETwEEN "•+i 7 ?' OE? Atn I ?UV_et c2`.Ya`oC?i°. 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D u 9 :eT T_ -1-9 r; Ps i,LT??t by, F. VEHICLE Yfl. MMEICNEV. OOOOEI DEL (NOVA DM BODY STYLE (]DR) VEHICLE YR ,MAKE (GREY: DODO 1: MO LlN VAAM ). BODY STYL (]Dfl).. •^ T a ?C UcltclancF?? uLplkrldJL u$ 19cq Cl?ev INaIiI?L? Ll?r t , '. \ LICENSE PLgA,TE NO. ... S?TAyTE, TRNLERPLATENO. y W C?. ?_". -? ? I V STATE TFwLEA PLATE NO R•' \Hh??c? Wt1 ' VEHICLE ICENTIFICATON NO. ?':.:.. : VEHICLE IDENTIFICATION REGISTEAEDIONN<EE I'LAST•FIRS-1 LE,N?AMEI. II ONV_E_S LICENSENO. NEOISTEflE(DLOWNEgI FIR?STT••MIDDLEN O1P?1VEg5 (U?L?EN5.E N0. L• t" ¢h 1 L ?(,\JIC.? 42, 'zTI ,'\I li lr_SI?I kY?:'d. D, V .N ?,:Vlllt r••L?l.?lf ?U ?7 f`I? r 9 Ps T ?.y`L OWNR'S ApDflES9 ISiflEET, CITY AN08TATEI PATE OF &gTlt OWNEfl'B ADDRE69 .1 REET Gtt MD, AT _ A OF& TH,.. ??. >V- I .qty . 13L'•_L ?%r-f-T?\aL-sQ?le?u..?i. ? s'r .fin / 112 ?rT ?i?l?' ?cr-t- \u ?n,L? (s/r.?i8?6 L? r? I r_ 7n, $?' - E ' PMTS OP VEHICLE DAMAG?-f 1 ;. .. '..:.. }SwuGUkRIr?YTk?i. .PMTS OF VEXICLED AGED ....? .`.- ... ... 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NAmtfADDRtssaINwRANCIco.p+ACFNI f a A T / R I N N ^ .tt } t AREA R - Dw:o;p f70 CHAg GE V 4Y elIHIT ; '. ' « y, 5 '. 9,DP . s esl avAACf OfOROY K?/ f p wARCE ? AWAY ?REMAINEO • DRIVEN AWAY ?RfMAIN[D AOWfD T . IwcnoNU fSI DAMAGE I gAMAGS ARU SLOP A S ?y + M' L DIAGRAM OF COLLISION e C] OWED AWAY er: u MNU IND CAI[ f IO ?OrIGii ? NU91H e sH nuNECfss Rrl- er AR9ow D,E/SCRIPTION OF COLLI?SI?O)?N?: lusf SDPPIEMZN,AI SNFIl'I Nfu55ARr) O 4 Rp,,E,6 r¢/' r. ?• F. Q ,l?/',•dE'/' +vd4 ? _ . - d >s E ?E e?E ?[ NAME, ADDRESS 8 INJURIES OF PERS ONSINVOLVED + • ' OCCUPANTS/WITNESSES IvseswneM[wnlseen CODES, 1 - 2 3 4 5 6 . ' l • Ido PLptIOHAI NAM / dd .. UG A/J S O E 51 YALU Np? jps•' S HNH II MI R _. . ES1v, ufa . ' w<Y Ir . h P 1 ?L ? AD e133 rr rBrvA' .? J , [4/' f• dV Yr'S it! ???? , . HAmo a IM9Y A Me. ?FRI E O HIII . Opx. ?i C!{,v X + ? % ND SSdsgs- NAIUR - "' PNOVID 19 • j . pSp s """`;,Do?.vs ECd?a.dn Fss 0M N Y ?AMe. 0 Pp.KI ?CH. Nix ?ipilY •w ?S/77 ? rt p o ar ? " ?Pr; i ? 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NO. lD- NO.IN111RFD ` ? SPItUGF ? If 9U wNRel9rX 1C11 I C Irv S R f 4FCAD Oq RErf qt OSS SLgfFr Cq ROAD ] - CfVEXIGLS ?'PAOPERiY CAMaGE ONLY ?FIIRSULTE VF 9 OLl SrRUCKINAMLO OBIfCr SIRLKK IND NfR'S NIJAf7 f1 DAMAGE QD 4 L MC-- INGUSi 5 a -?urT ti . UNIT NO. U UNITNO.2 ? VEHICLE '? PEDESTRIAN -'o PEDALCYCLIST 21 DRIVER'S NAME: wl 11- -ml /a U.V T It -5 'q I RIVER SNM1E: U5t I{-?j3T? 2, J SIPfFIA 9231 - i ORE55 '?•?? G Y IIP COOf PHONE NO. D AlE II DE N , W 51 404.? ZWMA R ORrv R' L CF O. SLATE A ?HYe. I o V• I ...... NO. MAIL Sil I i .L OCCUPAIXXI 11 NAMELRION EYES GNI PEIGMT E. CUPAIION r IRM EL PHONE NO. EYES IGXi IGXi ., ,2 C C35 lsNy toS B 0 a R C] CHI (?) vLN RE A-UA I mfa AN ? CHECK(,,) VEHICLE AN YFE Of APtNE4µ rq?. CODES ? D a 5 E 6 ^s'.,D A °?y? cIWN tY iii rqN nKrN CODES ?* D a L °' S w * .? wE3 INAIU 3 v; .DM MRAA E ? W" ? c8k.. ? =.V., ? r N Kra:or D ? M. ? u ° ? sk.. ? w.a ? V-T r yEX.rua MAKE IIRODGE{HEll ILLOARLNOVAJ, SLYLFIIDR. V.1 L V.1 IDM •NDVAI H _ ; L E ae SIAIE UR MIFN E I'I VEH. IX09 STATE . F•lT A A (roGTO ClY1L335 WA I C n 3 VFHKtE IplMIIICARION NO. C Lt.L3?r1?3i t2jc?iyl3?.31 /? i L VfNI l 10 N I l l II I -I I I ' PtGISRRLDOVMl9: NSi i195 MIDDLE PMONF NO. O WNL9: USI FIRST - MIOOI N ;;: ] 2 ADDRtS50fOwNF9 ` N WNfR (1 /' 3 r,t? Se u?vn NAM1LA009133d Irv5URANCLtO. CR AGtNI R I(ARCCCGRFCLFI • ]] pAMIGLO A9u CHARGE gIMAGtO KU e '' E Ot E31. DAMAGt WAY E] RlMMNlD • ? AWAY ?REoAmwo lS .DAMAGE t I •lOr • rbionor. S?p T/9L oi,v2an. IGKTI Aw -. OrovrtD Ar er: S IL INI. INOC NonH DIAGRAM OF COIIISION lu M _ r9Lru NE rl? , O I DESCRIPTION OF COLLISION (USl3wRlM1NIA, 3NLFil/N[G[sSAaq ` L ' ? L U d 4 L• /? OR__ 4 1_tlL!:_ G F._Z l E7 _3 0i9 .0^_,?- ' I I I 1._!... ?I ORrCmt .:. .. d/QIJL'7C_. s?_._ r-clJ.tC±JGGyf T/jKOU?aV __ . .. I .... ,. -------------- ._. _. ....... _.. .__. AME, ADDRE ESS 8 INJURIES OF PERSONS INVOLVED * CODES I - Z 3 4 5 6 OCCUPANTS/ WITNESSES (1w. 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Y.; h «cwr.Ef T rn r C 1 c? -?ro.., / 'Jew a • en rx?2 ?. j? r+ T .`x. ?.? L N : NON INTERSECTIDNAOCA-NO .?h tYMEP DATN BETWEEN WREETAN. STREET •"???. . ? unE0.eNO0E I ®© 0//'IGG?Iy n"?bcuEtvosron[n[hiur+ar?.w? yy ENON ROl NlFr@Cr EiMMM <R cE wa a StPf4oRiDL<r,2 EEf, ylfE R[ rEEr ELCTO„ ©® / •f 1 $•i -l. ?wnse U , ? E eE O 1 5? .' Xiedp.;''Q6TAVi $vErw:u: vfruCLL (]vE„cLEeCV0.E ?or„ERIwnrO EC„wvuLV[o oF E„uEOMECT (]vE„CLE rnAN SPED WDE G2 [s -'-as nKLE.rFDEarN <DLDSD w„ - _t?_. ?vF .„ Ono„ ?nrr ?*AF:;,,..e =.,:r .r: 27. a. .,,?.. IrI.AIE DRrtcTrtn0.1c0.1. I;:.'y->z OWNEROFOBJECTSNAMEANOAWRES9 L«AT owecrSTR? W f0A0 aN -:- ?N WAY '''u W OBEGf FEET EDDE a ry nE DRIVERStAST HAME :...'......-....•w.i.. FRSTNAME ':.... rrt-.-::.MIDDLE- EwvOE o ORWERSIASrNM+E ..FRSTHAME "•..,.•.. ...?_MIDDLE-_, WER STHEETADDREES rvu STREET ROUfENO.ANOBOM kO a ADO [ /CAK G/- /CL[ • ED f OX ? // _ R.- A CITY C_ 'y?SfAT :u+2fWAYb3:CEL2Y CODE.' OPNFEiSOCCIWATKNi,. , ARAif CITY;YA;'?}.:v..-.' «e"STATE ,^-n,:a...,;?_p;r,ZIP WOE. Or4VEfi9000WA110N?r .`.n c f T t f: PErORrFdw u ! ?G CA2 C 376 p ?(} ?0At & CRWER LCENSE r.f•:ii '.aYAliti':BTATE-. .SE%:. Iry OATEOF&RTH:i S'. AOE .? DRNERSU SENOMBER -.•., . STATE. S .:,.,MTF?OP0IR - ?AQE: p L • EC - J,S3 &19 N j " ^Fk F Mo EW vEHaLE YR-. MA0.EICNEY.•000OO?F MOOEEYOVAOARTAIy :BOOYSTYLE120RIU ,;y VE""LL i tAAME1CHEV,0000EL.:.. AEOOELINOVWOMT/•:::: S001r SE1'LEI20RI.er.S. 77 e- L2VCC /t,ai?eJbae? 70 Ckev /91a?i6u LICENSE PLAtE W.u IiY.STATE:tF+y` 7TRFILER46AiE!!Or'I ..:y:.'A'..5(ATE ,.r. ,. • .?LICEW.SEMTENa.'.: :'"n•.,STAT&;:ri ..11WEAPUTENO.•?;: -:1i TATFl_1 1 fEF 3 Gva-; Cme 893 WA vEHK1ERlENTRCAT10NHO:Dp yi;I:.if?Yee M00E1.4i NEM'FNL.IIe;.' OOOMEr611MILFwGE) VENICIENERTIFICAigNNOI;;,':?,d liBe9 M006.4e NEWERIi:.:.: FA:IM¦,EAO G 3oaY G 38)93[9 REOUS,'FFW OVAVER rS .:RA6[A6M1ME6EI[ 0 r1: - dNEASLICEN5EN0....? •:.:. RED6IEREOOYYREIM[F>RJS?iYtlFMOREnA_._ MEY'yW.M<t ..u[tWP/9CUC6)EE n /er err 17 .. A- L-?T-t7S 7 OWNEg9. fwiE}r}];y,-.?•t.:, ?y O?TEOFOIRTH,?;- OYINER4AOppE$g .?-rr•.J:uJSR1EEr.a[V /NOaTATEI :.r.,u. .. >?aTEOP.BWifl(;:[ E W EM anGr .? /?n ? W ,?r y /BOO PARTSOF VEHaLE MEW=?tiSF-- ''.Y4i'ti csE::: •U( /'' •-J•, 'EsrourEn War. ..: PMfSOFVENICLE0AMA0ED,U.3:w•r ..G_.?.4-.J. .-.....:+. ]LWS• t ro ' at W'e' nd Wi, r s fl Tro pe , LIABILITY INSURANCEINFORMATION•VEHICLE NO. 1- WAS THERE AUTOMOBILE UAdUTY N "I'l-CE WVERADEIN EFFECT FOR THIS ACODENT ON YOUR CAR ?YES NO NAME NEDADORESSOPLMBRJEYN9ILVKEt?IICYNOLDEA"!.ti!,L `4 :""'Orv n_..^a.L.^Mis r..t5;,v.. 1:..:1J.' F ArxRLaa STATE n rl'Nl°AEOFUAOrUTY WDURNICECOAPMIY.{?ti'.+dX.wviY3Lwl NAME ANOAOORESSOFLMeIRYEW9LIRMM,EAOFM --:... ....'-?:.d:..' _?tlrv..1N .t:vAEG'D Sit[:.'-..:aiix+n. Fti2s,M?:I:WBYlfYP000'[.MW?R.r...:[..`:f "r:»?lr':1JESi:it'i'1i'xi?'1( STINXRr ::' .; ,..GAL v,?+.....yrd ?,,.-tik; 1.rN•..1[. . _• ?" 5.:? :;`GE:- TID Wx1RY• NSE 'MIT fORr FORAOd GNK 9 6 NAME 1 NAM • E INAIR[D _ __ AOOREss ADDRESS p 1r _ -F1 Exri'r"IraF wlwNa M €- ,E r Awn rxrrn.A ®+ ...E r - e:.a«rom ®0 v0t . SiATUSOF NAKED ?..^ JiYALv - MAAI(feUg ONE THAT APPUEa,•w:,W? „?STAjOSOFWAKED -" ?,,,,r ry. u.:;MMIR MST ONETNATAPPLES?r",?, - (]OWV 1f NYENAlE DeuaaW w<il?elAlD ??devER WVEIYCIE, daABIWO NOxY ILUM P0548te?' ? IDLIFD IRI NwOa+ M1? r (]rA1A!„Ofn ?? ?? Q ABafxcER xILLED Y ISEVEAEI IMNde M1? .. CI E„K IE IN ? 5? R? 7?E Q- ER RTF.•IN ? 50 60 70 SIOWNORTH BYARROWNaRCLE \' wP`w«ra wmwn,ia:.w ':+i O " ' ?1 "y"MEO HwOw NIAwT PEf?RIR6FJIT0 _vQYC-L-E3?8Y IYJMEIO ,rI:.SAI\iE '''? 4W._-C.QJ` ¢fw? "it- ! ? < h do ? „ <:'D; MMN[q .c„ v[ncLx Arn Fbr. c "a ' w e h¢?. S6E D ro%e 4e e rnna D W.AA /i P ?L i r.d_{:L1ES'l Sp e; eL,? n .a[+ruWESruWOw. r[ -? 1? U?- amLno%r.onwAr no-?3-aF' BF1iC. /faaa //3 --? At T°wtsi /??/a1Ltl?a-Carte dtn?i Jf'0 "1 ?xi tea/ h ;d._rof_.Cva.k- 4ind?l.i2a?_anc?_Xna 5 ? n4L.-tJ_8f_G_ow'?-rl?i0? d? u c _ : / ? ? _ sWnron rr..w• . fall , VEHICLES POSITIONS BEFO RE COLLISION L wa? a w„cu Ye„cu YPArwLOw.a NVESTIGATEO BY VFIIK.IE N 8 E W dE STREET ORMDHWAIANAAE OR NO w E dA[crAW leB.lAr arwnrq r!e n0 uB.ur r"IM[o Ka W Wr.cu «eL.Yo v[a b ?i?r Ol ?ipc! I.dn ?,?.?.® ,.."r. 'j' rL4..•r "rl 4yo;ru R ' C ?r?. r?. i,?, ?ucx ?ar+sveen A; :Rr r ? O ? ? ? ? ? ? ? ? M.RFF ? ? ? raaEO .. .. ' *,.'•I -. . c n<evn :...' '? ::-.:Je1'?'-moM DIRECTION 7.-Td? HLDEStRANwU OSAa I O &Oevv . 2 ? W-AY ] ? SHOULDER A ? croti+wur S ? M'R?y i?r a OTHER q DSLR AO! Cxlt. dM1r WCAfNE ;i:';LaNTCCNdflOKa y iNAffICCOMROI::;;Mdl Wl_.'. -vln( L TVPEOFROAD •_ . '.., :.. VTKt[ 'K nAbN IYM.R/KNICIL ACTOFre .... v[rtl.- rCrrtC. Ali dluprMj 'A1 ...... 1 1 [Kyr 1 ?OAYLIfNf ? 1 ??;JrINLLS On No ?11 ? ONE WAY ? 1 ? OOM*TRAgMr AHEAD r [L;ltil Ir[•J??Y ] ? R... 200... ? 2 ? sfoP.q $0 2 MTWO WAY 2 ? OVERTANNOANOPAS.'4M ? 2 ? W[ r 2 [?;woWNa ] ? W30. ? ] ? YNLDSa ? ] ? RE E 9BLE ? ] ? MA Ya ROMT TURN ? 1 ?Yqw E?fW DMC3TPfET A ?La„fa ON ? A ?FLASHrvO KID ? E ? Ua, rr----11 TJ A ?MIxWOLfRT /URN O A ? cE F S ? ° pIC a ? L4Hf! OEp T ? a ? rLASHwD AuIIF.A IOOP/R ? ! ? ALLEY ? e ? MA%en LATLRN ? lJ a ? NCMY S I YT O 0. NC, 1 Ie r am ° ? a ?IR a0.1MLL 13 a ? ? uR T WAY- ? e ? aLOSwa . wEr.-owroR NOT xEN [, xfoW.vT prrwK DIYM[R P±:;x lOw Arcl oT „ Ep L a T?SPFGrY ? [ ?ORIC[R.MOMAV fa -63 ?:1 ?!TOPPED FOR TKAFFIC ? e ? OTHEIL 94C'" ? 1 ? UPARATfO - ? R ? p1 eioPPeo DxY?AL K ) •. '•. _ -. ?'a ?WAMB, •'". .': ?STOPPED N ROADWAY:'1 r a CICNTITrvJLa ? ] ? VNdVDFO ? ID ? MRC?MEP. .1 i til IEOC[Il aS . .. ,. ]C% AOC ? 11 ? ST RTD IV"^+igN Mina NO URI em (L ?u Ci ' c •j r}{ ? F t y ?? Y?tY? ?nE uE { pw. r f ? ?t 4 Y II<. ^f?3 yF E ??,. L ! 'fti ?E 0 I l „ rr i a ? 5 K A ?* ? fy ?DS k N 4 STATE OF WASHINGTON a 1?AGf POLICE TRAFFIC COLLISION REPORT ?y.TRAFFICWAY IaollucECOMnwIMNUMeFR PRIVATE WAY Srl UAI U?CIXII - N _ DA U .. - IiMF COUNTY COUNTY NO. OrvIW. 2 IDSE)WDNWRI u 3 2 SO m» mn. N K S F1-E(-50N ?lu4eu ?N ?E I?IN ttlr DV TOWN NMAE6N0 OF 519Ef10R MiGNwAY KI ttS Om ROVI pqv > 11RA1 + /G nv s ?s ?w ®oF I ON 'a .3 ?O?ZO lF. ?NIfR$F IM1Gr41lN. ST9efl OV ROAD NONlrv If45KilON Fi ?dR ?j? % FO. MITE ROSi tI G BfRVffN ,,.?JJ,, Fcy/ SiNFET R •?JJ ?? ;/ ..-- iSrwN ?I R ERi. .C405551RtE 4Nfw9F Mlr SI 51RfFi6 ? - _ 4E5 f M 5 F W '? MIIEAGET 4 R DI RAm MIn ?... iEFr N OF cja4ury IQ: L / CODE IXtISpNINVIXVED vfRltY. ?? fOIM NO NO. %LIED??Np INJV9fD? ? $PiLIAGE ? ?J1?wxeveolri " IMF/4- [{5D W0535TRlflOR ROM wD04 Rif qE ) - OFVENNlES f? pROPf41Y OAMwGEONIY ? Rf5F1JLT1. ?MI iTf Yy 5JECT5fRUCKINwMEOFO0 I5-KMIDOwNER5wMF1 f31 OMAAOEf SRKUI COOING USE -' ?, UNITNOLI UNITNO.2' VEHICLE IVERS NAm; IA01 N ? ?PEDESTRIAN- ? PEDALCYCLIST aR 9ff1A00REt5 51RFfiApORf ??G?? ??t L"?NC,?N - 4fl' SN S ZIRCOOE RNONENO D ?y SfAif L c ! ??rNt? f9J 35$ fRS UCENEE O. Sr rE ??? ?ow?. R I D Iv'RD? p 51n1 t% R ?- J _wnIIDN N9M NAMea RFnl4f NO. Erfsw eNl NFiGM E occuRnnoN ? '' ` ?Pl ? mo i ? ! ' - f19MNAMF6RNONfNO. EYES GNi ME GHI EP f R E ]CHECK (r7 ' WN A»ws AN FMa Yr aF ANOrNr?wL ? CHECK(,') ?DES?? n ( K i 5 r e,MO, CODES t ICIE AS AN fMRIpYFE OiwNOtHERAI ?_ JNFS ® D p K i+ "I O 5 u a s, D trv- l.EAR ? AmtDIANK[ ? uy [ ? t:N. ? KKK e ? -%p uY ieareom ? AVewNCe ? uy [ ??1? rtry . mAKf IDOOGe.CNfV) fL IDARI.NDVAI S!Y[E 1)D4GNV) N EAR ? CO%R4 ?y? l! ?i ?? V • 1 NEVI MpDEt IOARI vA) ? 1 .1 , R 7 L. ?t CiRF E a oor c F1RG?(Z OR F Sfnlf fR.UIfR FLLfE NO ST f H CIXO4 ll " r ?? F..• t.?R xz I q C ' [IDEMINCAIgNNp. v A L z r., 6 I ?, z ENittE DEM 1 t,S S !L9-G,` `110,ch ,R4tDOwNfR lAtt {1451 IpgE RNpNE NO Q 4f IS eFDOWNf4? lg5i N451 MiDIXE 'YN Nf CJ' :',r i? v» Fssorow"e0 ?Q?' S• W n 4 aF ?R.? $ n Efr E anorwfssalNwRwrfceep. GRAUNr P M..# ^I.l cERr"-- ?- y 15i. 0AMwOf ?R[M4NlD 0 !TO YN Ww [ST DAMAG f Y Tom. -AY Ar ?-FD l BY- DIAGRAM OF COUISION. 1 N INpCA eNO4rN ?nW 5 'r r' - sw[iu wC[53ARY1, _ R 4ZNY DESCRIPTION OF COtLI510N: IDSE SINNEMFMN SNeeru NFCES5MEr1 L 1/EH... k Z stFHS GEifSTBottA p__pA!__C 2 4E98_.._ PorNr of m `-E A- zn,»9cr i.. WNEN...VEH Z. _DACKED oar_.oF A_PRc?r.E_ '?^ ' ? DRtvE..__ UrN•...?_?..Losr_con?rRo(-._.oF F I I Uwe, -s I _.. n OCCUPANTS/ WITNESSES ?p""4;,?"'I^trD"rE,µ,"'' 1 I.. -_I ?..I 3: 1 4. 1_.5.. X Nk k4 X56. 4 { I X3 y. n T 'Upe `? _ .... ._......,,... --.?, _._._. rvLCfcDMpwNIN_SER -- PRIVATE WAY DAEOECOLL N COUNTY ?? (USF ]RODHWR; k,w i?/ rt cOUNlYNO. 5 son /G "'NO. ?i5-C; MVA ?`Gp- t rD LDWN ?N ?E ?IN NANE6NO.Of Sf4tEr Oq XIGXWAY IS A RWLEO SE 5 ?w ?.1 0 ON Dial '. o? e O.L?U INLf FSF NG rH aLREEi OR ROAD NONINTENSERION )yE.(""' EO MILE M" --') BfLWffN STREETI STREET tIr- 1 DSiAN 8UF I40MF RE .CROSSSLREf! N RNEAF.I.IIEIp ACCIDENT RAMP DAGP .,A DO, MILEAGE MRfS S f W CIDEN Q ODE COLLISION NVOLVfD VERILY, N . TOTAL NO. NO. KILUD?NO. NIURED?? ? SvIl1AGF ? 16RyEE wrleHpm CIS W? ?o?3OROA.CW [NCF OFVEHICLfS p4ppfRlYDAMAGE ONLY fl4f siQEN ? PESUtiED ? vFNIGIF D .// OB1FCi StRIKK(NAMF Of O01(RSTRUCK ANOOWNFR'S NAME) f5l. DPMAGE SpFCW CODING_ s ogrvER UNIT NO. 1 :-: - UNITNO.2 ? VEHIQE ? PEDESTRIAN ? pEDAL,_p r,T.. S NAMF: UC51 ? IIR ] MIOME ) 41 ON VfRSNAMF. W5I _f75f- . 4J5 SfRfEiwODFtSt 4 A I L I C C S 1 ?'hE S W 5lRFEl AODRE55 ?? I STATE pE -NE NO. S Enk? r,awze.1 gb?34e g5-t75H DRrvER'S UCEN N SL LF D R ' I STALE I C p I-NO• DAR yS?i A w?? F% M B 113r 1r sr I V Iv R' UCEN NO. A F % L BIR 3 MD D,. OCCUTAIIDN ITT M f6i4gNf NO. EYES GNT XE G.1 2 E? is $'f E R CUpAIW fI4M NAMF6 PHONE NO. ETFS WEIGHT HEIGH T , ? CHECK (.? vEWnfA AN- BY wAFM,oLNER IE' n Kr W „?rKR CODES D. 7 A y y ! 6 ;° O ? CHECK (? VEHICLE AS AN fM%OYFf OpwNOTWR."L CODES ? 7 a s. 5 lncrlDN y u rtw F ?K.?r q'? ` zi -11 1 N sF" 041,0 °? o AVauIANCE ?' ? ram. ? „ ? r?? M <L ;;' 1 vEH. YEAR MA F(DODGECXFVJ fLIDAgfrgvAl V'EI]OR.;pNV.) DsC/s h/M (frz? 'zE?R E ? M, „ r ? y ( FCNf 1 ° ? raaD. o ? K o,? MODfL (DART NOVA) KUE . V,) Cv ?. PIAf SLAM MfRMif NO. SIAFE H vEH. CROR L -11 NO . A Y1.-.DENI NCAigN NO. 3 N S EN V2 ;0 x :31 i VtNIC E Ufflr NCA I N I I I 7 7 RfGISR4FOOwNFR: I.KSI iIRS! MIDDI! PHONE NO. ?ino/se aas CXC SNP O P DOWNER: LASI, MIT MIDDLE D.. 0-1. W R r b'oL,t i f K Tewf•soA.cfl w- N E NER 'I]I 7 NAME a ADD,ess or afwRANRCO. GR AGENT u R m DAMAGE ARU ru e`noH.L cHARU DAMACfa AVu w s aAaef rD1 D s S y ,- 0. ?DRIVFN pRfM.VNFO tSr. DAMAG ETOI-- AWAY -E) roioTioH TOMD 1-7-C- // k7 La V. AW -1 r I O l1 O S DIAGRAM OF COLLISION:.I IL's N IND ^LRe rH DESCRIPTION_OFCOLLISION: ILnfswplrMefPrM Ie• SEPEfrn Nee[SSA rl A •.? .. .. .. ...... .. Vohiclo #1_was. Nort.hbound on Old Discovery Rd - .- _.Driver.stated. that an.unknown vehicle vas . _. - - travelling South on_O1d.Discovery,in _the middle of the road.and forced Vehicle_#l_off. _the road .-. .._ - -. .. ., and into the ditch travelling_Z34.feet and came i . - I to rest on its side on the East aide. of the..rd.. „ t7i .ove - _ NAME, ADDRESS BINJURIES OP I ? PERSONS INVOLVED a CODES I - 2 3 4 • V 5 6 OCCUPANTS/ WITNESSES ioR AD?DIUir ui'Aiuii S. Ac( Ieru '; ., R[sm FxR ,". ,D N, I n , ,. NAME Aa - NA]N NAnm a . - " H ANL. r ..._ o ... _. .._-- A tplss HMrvna .MOVED rPOM H DN ,} N r, ?AMe. ?Kw*L ??HI. NO Z IfR en ?AMe ?[ "' ?c"F.rnr ?iT ?n nro,lr - X N N X . ,GafK:EE s r..Mr ERB? ID NO Ni'ii.r /?°fflAl?s"D Loy/OfO ^re?? A.rROVrner D,rE Y?? p nil EA kN l I C E R, ???I A??I ?? `It ?i1 I4 ?iP•fiDA`.' ? I , 1 ?. p i I 4 1? ? I i 1 F Ir'. L Fr I 4c t' _ L V.: ti J,ff 1 ( ,rl - ' I t 1 L y ? i E . ? r' f V651R9 e r'' J 1 r . . f t y? 4 - _ a L !rt 1 711 T ' u POLICE TRAFFIC COL. )NREPORT I"J TRAFFICWAY WUCF IADIfNUMBER PRIVATE WAY Dal OI CUII f UYir . ll ?N CO 'L 1 A ; OSC• W u0X NH wlR hcf I ? •( USFJ DDNOVRI 6? J e r zc COVNrY NO. ,? CI1Y l10. pFHwA RBAN RUR F. ON OE pIN GIY00. TOWN N 6 NO. OFSf4lfrUR HGH'N` mats a pw pof P(}C r`?l.' ce: ON rZe' C r 'e ?' o N iCiCIS 65 ROUiE0931 Sk tl A?j ?oOG/O N(f45FC11rvG YAFIt!3r( ytf 104 WAD NON I......... .. PXEfI% f0. MIlE W3i 1 \ rn??l n ,_- \ ? BEIVIFENQIQ riC.. iW SIREE,d ? ?/.>: '[? •S,PEE, O IAN(F6D4 ?I ROM ifX F. C403331Pfft04 rvfARESfM If POST ACCIDENT h[3 0.00 ? ? R P DIAGgAM DATA . . - fJY C k ' •- ( N 3 E MILEAGE RFi ? DF ! . CODE - ?N ToINVIXVFO SEVf FI,Y: CIXU NO. KIIIfD?N0. NIURED? ?SPIUGE ?HIi LRWI tOtAI NO. RE stIX[N wxOCeorw F Cf VEHICLES ?J PWPFRtY DAMAGE ONLY IN l X R Of RE IN IN1EiL Cll CROSSSiRICET0?R0Ap / rD ? Ulr R fD ?VFH Y G _ p OB1CCtstRUCK(NAMF OF OBJECT STRUCK HJDO'NNERS NMIEI / Eat D.MpG1 ?-evLCe. aG..w) C., T rF_SGi? $ pn sPfCIAICODINOUSE - UNIT NO. 1 UNIT NO.2 0 VEHICLE p PEDESTRIAN p PEDALCYCLIST E Dal-s NNAf: NSi fIR31 MIDDLE G? 4NfR'S NAME: IASf {14 r si4efrwo4fss <Zo Pt?`rJCS' ) DY sI4EEr ADDXfss n j. I ? . G SIAt D ry? 21P000F PHONE NO. IOYT ow?? wo 9&3C° R r ' I v s1AtE LIPC E -. DRWFR'SUCFNS!!E SIAIE •G `1 (y ,./??.???Z-? ry El T 3 SFX At OD,BIXn ( Iv q' UCErv3F NO. D -Alf 3X DAtE 01R A I MD D . ?? 1 ` _ ? m 1? V L _ IXCUPA11pN 9M NAMFe PNONFNO. FYFS IGHi EfIGHI E OCCUPATION FIRM NUAE6 PHONE NO . E- EIGHT-3., 0 CHECK (,I yFHIA-<N rvii orFEOfAVOiwER.AI Al ? CHECK(,.) yflilflF ASAN FM'pvFFOF OMF v lsn 5 E ct oN a ,°r "'i-- CODE' ?t J n AN 4 ODE * r ? _ , -7 S J c,Aii 5 NECtrov 0 'sbry'Ory 'u` ! ' S 41? ,(l F ? A-A.N , N RI 'N y e ? 13 s:,E. ? H u ? rs 1. {AP VEH MAXE - f CHfV F AR1 wR (3 , B ,.N E ? (l p zaar. p „ o s, . ( . .) ll .N0VA) SrYlf li c f-' WMO E nY E M ??3G w Fl -- F H N l.N Vfn.CIX00. AC T VIHKIE IDFN,IIIG11pN NO. C I(°t z Qiy ?s7 REGr3rFPlpOWNf4: IASI IIRSI Dl L F E vEnl<Lf IUEN111I All NN I 3lE PHONE NO. 1 S' Yl1 C O 111FP DOwNtR: 1A3, /IPSi MICIX , Il Ap0•ISS Cf OWN ? W 14 N NEP A IJI E NAMft ADORfS3p M3U4ANCFCO OR AGOR AGwr A QP(5?(} ryt y' ANEW I( (1-(j ?? --?. ' R 1 DAMAGr IAN u '^ES iu°ncnD AD ,I iA • V iv.? ip? g.MAGE ARtA ° A C L c.... CHARGE ,l arew0wro F . ? 3 IOi-.TiF •? ES DMAGE O+r,Y N ? ?REMAINED ?owlo ?AWAYN ?Rj,ANNFO fSi.DAIAAGE I 110A o iaf o? S S (;1 EJ w.r e.: 1 'Cn ,owtD ? AWAY °r: S t l DIAGRAM OF COLLISION: Lu u IMNAI IwPCAte ND41H Ie sHftl FNeu33ARrl er.RROw DESCRIPTION OF COLLISION: IUSf SUPYIFAVN1Al sIxE,rt NEClssARr 1 ` (? .., E . I ' ve?, ? 1 1?1n`5 Fl?ncp?:? So????t EAlI=, h ? ?- •?. 1 ` QllY cVL CL.s? " D K 4 whC,(? Vel, i. 1ra "A m Cu r vC Qir=r ? 3 _. .. L r1 C.J? CHt3t. ArJ . QtA Y ?KG ?n . IYl t.r.d oxY . IA.F v_I? '\ ? r? 11 NO r •Gh? 0.vtd 7 ? ?? StCJ ?< f Cy Cr` w.,ul T?^t-e . NAME. ADDRESS & INJURIES OF PERSONS INVOLVED F CODES 1 - 2 J 4 5 6 OCCUPANTS/ WITNESSES ?? °.n?orixvr°fu nA',r n; srX Gr vA,u ""n R 1. In, NAMe: 04L IS I SCsYI I H,o t a S^ T 7 / n ' .DD.rts Z •rp•e ir1i? a+ O A Me ? Ka%., ? 'w . 0 0 1, ADrwra .,.E un tr mIr(,?ferD lgwl pAMB. ?."."p7(", . p 4, ? ;: w ADnlrns i FN R Hr or ;`ail: e:. K pAM° O "".I pl »nl p ? ffi»Y (] •• .IroolFCr. NAw E.AN. p,? x ""? ! ? °alKi? •""N0• °,":ur r 'D' tolvuann ?? xKS 7u ?y } ? D.1^'?ero.r Ar..(EVro er DAII C.:O 6 W'.T? t i• -f J:1 F... .RR_.._...... LSD;` c L 1 ,. ,1 • rs;, T? 4 • 'u 1 . r'. ., ?' ^:?n't`,r?<'Jk?iT!aF rte i? h? ,t I POLICE TRAFFIC COLL )NREPORT Q9TRAFFICWAY Tut, .ANINUmneR ? [] PRIVATE WAY COUNTY ND C'rYeb. i .All OI,CO4SON 0Y FCOL11- T n ,. 'w w, TIME (USf1 I coUNir ? u4eAN O t0 X 3 ? ??J?sG' URAL E QIN UIYOR?OWN N E6NOOFSTRfFIO4HbHWAY ON RCS ADM IEO45fR % RW & ?' FALES ?5 Ow OFM.Fs5 caRl?r ON Co, RD 3 63300 „ NI RSFCIINGV f Sr4EfT OR WAD NONINiERSFCTION PREfI% f MITE POSt eE1WfFN p STREET e STREET _?Y' ? I/ 11 ` p151nNtE%DI4L POM Rfrf4FNCE. CRO555tREEl OR Nfn4F5TlAHEPO MLLES N 5 E W ) / ACCIDENT MILEAGE RAMP DIAONAN WTw V FEET OF C', CODE WAD R ERENCF N I REf TS COLUSbNIrvVOlVEO: SEVERITY: NO %ILlED?1ZNO.INlURE0?1? ? SPLLIwGE I.J."'.uN .I It O rWILIED OFVEVEHIC O PWFERTrDAMAGE ONIV ? ? v NiC.F m l! wN4 Roma IN %Rp INTER ClS C D ROSSSIRFEIOR WAD S?'70 I •^ OBEFCI STRUCK INAMEOF OBEEGt STRUC%ANOOWN?R'S NAMFI f51.ONAAGE SHCULL CODING USE - y (t, V RA) 5 UNIT NO. I UNITNO.2 Q ' VEHIQE ? PEDESTRIAN ? PEDALCYCLI5T _ ?• S DRIVFNS NAMF: VLSI NR MIDDLE l2AEN J. , C5 VAIL o J'Ljl- S NPME: UCSI DRIVER R slRffrADD4lss 6 ? LIFE, ADDRESS h 51%.iE 21PCODE RHONE NO. U? D Y STglf IP E ?` DRrvt rS UCENSENO SIAIE St% Ftl RH v UC NSE NO. SATE ` D' RAYeIR r' u h/ n / ! %y O V ' ? OCCUPAIWrv RRM E6PIIOrvf O FY[S GHI HEIGHT E IXLUPAIION IRM NAMf6"'ONE NO EYES WlIGHI IEIGI ., R IIAT o R Q CHECK (.? VEH CiF AS.NIMVIOVEE OF AUOmfa.M ? CHECK (.Y} rFN at ASAN FMHOrFE OFANOTHE4?l R CODES ? * a < e "` 1 5 l 6 v •m oN NN CODES ? c" % s. S Fx 6 s"P.I „` sDm crorv rv ro roR ? uiu.fS NcN6- H W ;F w'." '°'" ? AmN%ANEI ? WE ? 1:8. ? K?t DI ;f o O AMNA.NCI RPom ? u8° 11 '86. 11 VR ; wU11 a.,. 4Dm VfH.YfM Rf IDODCt CHEV.) fLIDARt.NOVA) STYLE IRDR..CONVI R MnR ( .CHFV.1 MODEL IDMTNOVAI Y TI DR. VI D 7 FnRo !S o yM,p P,?A E '? V lK[NSf PIAI NO. StAIE iRAIIER HATE NO. Alf H fH.CIXOR Y N l A E' R / S wN I x J A,vs N 7 O C vtHl IE IDfNfIfl A N O VLHKI(IUFMIiKwIK1N NO. L RFGISRRtDOWNFR: USI flRSi MIDDY -NF NO. O t ISf 9tD WNfR: lASt IIRSt MIDRf SAME As ABTJvF_ W A DWNER DI I ADIIII I -11 N E T O ' U AN „ RACIN NANf LAD-SOr INSURANCFCO. R DAMAWDKtA iO iRw R IMMrDiN =AMAG? MEA C I w CHARGE CNARG! er,tt r R10P tS1.D ,RAE ' S Ay ?RlMNNID , IU?OItGM ISL. OAM.VGf ®.DRIVI ?RfMNNFD ?AW Io f /DD O ? :war°er GOR.b6£ ? ?W?er. 5 R 6 lu u n M N w INDICerwAIROWIFNORTH DE.%CRIPTIONOF COLLISION: IUSE SUrHEMfrvtusrN[r rlicESURYI ..._ .. ... _..._ . .._.__ DIA RAM FC_OLLIS_ION. .smear N[ClS5Mr1 _.. ..? ..W4S..M+.ESTIIb"NO . ._ ' APA. .tj,Ef r'gD,y Ntss GAA„IC/T" .IAFT'SR. _ . : _ swFaVA Tx ,l?ss_a aos.TN d?r_ - ,E , w o,+Ta. P,4 E G?OAYZJ, A-r-,_s i.O4' • _A No AJeNER I J 73d;uG NASTia? Pwj.,-fb. IIack--orN.To THJz...I . - _ , _..., .._ xoST C-01N'PA0J-..ANb, . i " ,. ¢o, RA . ;.. ?. v rli ?AES7 ODu?G Ae-120S$ T/J.c OHCbA+IIE, D.C w,EN Z3RG405 AMD QVJj?nY _Poe j3AN1( a~.4%NicIJ .pCI', .. .. i VeJ4 M"eO vP oivTo iTS S%,I NAME, ADDRESS B INJURIES OF PERSONS INVOLVED r CODES 1 - 2 J A 5 6 CE000PANTS/WITNESSES iw:D1DD,H,IfoM.fl:ir?RASMm eii SEx .Gi AT '" RISrR. INK Mifiv NAME. O r ' AxRnY A rIIEd N IwFPev. QAme.?c Q"" .Q.. Q wl I 110, M ! AfI?R , .. NAItyR d .. RMOVIDIROM Y, Q AMe Q Q"I',=,l. Q Nr Q iirltr O NAMI- N _ nmrd Attt•1%s IriAA+s ?.FN er QAMR QL` !':'Qio"„If ? Qx' QnANt, DAII PIVISTK.At K,frI.K1,SIFAMI54AN, eAUGip MAµY w.ry KIOISRATCNID W.KI A,RIV10 ID FID ? D,f F l x? 7 2?3 7 v ( 3 DAlld%WRI J_! G ` AI,wWIDRV c . l RA E vt Iles ? f T ft p wRR11f ` V ?' V1.. _ I t - '6O "'rJ !Fi h .S; - if nl'?n'1 M'SW dW""' IMf}A y..t L . + 4, LV1A?j 1 '>, L ?tF? ? 1 ` 1 t } G I E t} . .r i y + ( ' r t ' 1 ( IL I 5 I' f_ w? E e ) y lih J M1 Nlaf, d. r h r? .f{ F T ?4 ? sue, k RW / t l ? s l r; MOTOR VEHICLE COLltS10NAED6RT NO. MTE OFC041510N '. MO o,r v[,w _11001. iu 111 „ ^. HME OF CO MIN I n FH .Ea AM COUNTY Np? GTY NO. / ?bn AH y ztl w MILES Y,T"WN ADMGLYr IN FBI /[WOarnEtTCOD[ Z?O S SECTION c w © T, ?` G (p ^ GIVE"AMEOFSi i,fl0 ORHIOHWAY ?D WTERSECTWOWIIII:STREET "10AD. 7 PREFI% EO MILEPOST -U.03?I:tG`? INIEflaECiIONLOCATIONO OLLI;AON N .N Hl TWEEN STREETAND STREET MMP DAGRMI MTA ' ©© H.NO.?CnOSVNr'iEO MAHC.' nOfr?tiF". LAN- EHDPopcE. INTEN %RD INCH NTER CLS no E OR RE[EEiKt?GbiI S N ©® O ' N p ? Y ?? Y ''ll ??.?3 ?' I -' wvIXV[O V[w[LEv EncL[ ?VEr DicrCLE ?OrnE-1x11110 % Sw ( ?J ?wHICLCOwl. ?VE"UT I uN 1.L%. 10-11 7 SFEOCOBEUSE i O ? LES t oVR OwN g,?rIID OBJECTSTRUCIL PrMYE CIMECTar-11 OWNER OFOELECTSNAME AND ADDRESS LOCAI - INROAO _ ION A WAY ?© 110 oilEPUiO?blKi FEET 2 S - " - • • - - UNVERSWTNAME....:_,..._:. .FIRSTNMIE. ..._. '. MIOBLE F MORE 1.. TWOCAHS YrtRE V • • . DRIVERS LAST NAIAE FIRST NAME M1DOlE c' • ?.• ?(_ 6 ' N II OIwo COLUSONDn ?• 1Ort x .. EET AOORESS ., gOU1E NO.ANOBOA NO.. . MO tMAH 1AO 'TREE ADBRE59 ROIRENO.ANOdO%NO . I ?? 159 - FLI ED E + X 3 GIY ,...STATE ZIPCODE G(WERSOCCUPATION CD, H ; a CITY,., STATE 1.1-E . , ORNERSOCCUPATION K3 rl? nEPDn W g33 WA GIIVERSUCENSE NUMeEq _ OLL-RA -LP - L515 _9K3 SiA1E SEX 6 OTEOFB'RTH AGE a3 r DRIVERSLICENSENUMBER SITE SE% F DATE OF BIRTH. A, I 'T. AGE VEHICLE-- ICHEV.-0ODGE) MODELINOVA-0AR1) BODY 9TYLE12 DRR VENICLEYR. MAILE(CHEV:DODGE) MOOEL(NOVA-DART) dODr STYLE(2DR.) T' 1 I I c G ? CNZJ A KIT old f LICENSEPLATENO. 11 STATE TILULI PLATENO. STATE UCENSEPL"A?TE NO. 7z0 STATE TRNLERPLATENO. VqA STATE fvEMICLE IF ATI6NWQ I IDESMODELS•NEWERI ODOMETER(MILEAGE) Y VEHICLEIBENTIFlCATIONNO. (ION MODELS& NEWER) DOMETER. IMILEAGEI QJ ,?????( LU////((oo?/ '7' 63 / I HCGI EREOOWNER, ..::.(LAST'FWST?MODLENAME),_ .. ,, ., DRIVER UCENSENO nEGSTE REDOWNER ILAST FIRST-MIDOLE NAME) -. ORIVERBUCENSENO., ._;. . RSADDR TRE T I'AN AT ! ' E59 .:. .:. ....... IS NNE ,CR DST U E E) ,,. 1 ATEOFWjTH MO OAr vfAH OWNERSADDRESS. (STREET.CITYANDSTATE) DATEOFORM IEA- Ir'ARTSOF VEHICLEDAMAGEO ,.:. ". ', ionMnh vC?r•c 4fIMA DG]af I PARiSOF VEHICLE BAMAOEO -REP vLnICI6 /,r S ] ,,, AU INSURANCEINFORMATION•VEHICLE NO. 1- WAS COVERAGE THERE N E TOMOBILE FOR TH15 LIABILITY INSURANCE FFECT C RYES ACCIDENT ON YOUR CAR WYES ?NO .MME AND ADDRESS OF UAd .INSU EM LI?YHOLOFA ,., NAMEOFUABILITYWSURANCECOMPANY f ? MIr IJA ,, = -TE P s? le I ?elve??c? AME ANO SSOF UAEYU INSIIMAN EAGENT Gtv rE Y" U BLITY POLICY NUMBER •- Ue. .. Q ISTNJURY // ??11. NAME YV/J--/? .. ADDRE..9 AGE SE% t tK _u I. ]NOINJURY . 5EP NAME ?.I ADDRESS / qOE SE)f M .. ._? M F F..MwoloNn°"uocro-• ®I• W" ? STATUSOFINIUREO 0- IN VEH •.. MARK FIMST ..o0A0uxD ONE THAT APPLIE nONrd„mrHrq S ro5L-+E STATUSOFIMURED pn INVEH !E 0 MARX FIRST LG,nLwO ONE THAT APPLIE NW OUAOLNO S ? ntE r . ?P wtn NJLI A ` IyyEP[I u M Pr? ulLi l-. Cl SfE [ LLED I-FEI uugin TIE COU? OF IC 1 QPf aI.AW ?u nME.br ? 6 ? ?? e T-n ? . 11.V ? ? 5 ?, 6 O ) S,IOWNORTHWARROWINCRCLE rOICAW,U Wr I. I 111E .111c" \ O w CIX SCE DN O • HIT DESCRIBE BELOWYMATHAPPENED:(REFER TO VENCLES BY NUMBEII) ' L, N LJ ?/ WL?? - M[CTCw OFRMwLOr AWgw AY ./?/?.,1!%% ? 4 . « VEHICLES POSITIONS BEFORE COLLISION AC--1 YfrACU I«cIt .ra .? VNEsn"'T"'DY VE X cG q VlIIICLE N S E W GV SIRfET -I[GHWAY NAME OR NO ? "? IwAAA ? ? 1:1 pIM-I ? 1i El ? I[Oau l+ [o Pn.CTXw [a " - Llwa w Iuuln v U' D ??einp °ouG[ IdNgOy' ?« '' ? Oyu-!1 o°tiahK[ ;;IM aN ?? ?!J Sr4-11 ? 13 ? ? ALONG < ?ovua mom DIRECTION To DIRECTION 1n.11[sI_WASu`N0 t?MDEWALX 20 WALXWAY J? sHolUt ER •?C?ru?nAx b0 T_ "-. [$A S?OTHCn ROAD SUnFACE IO.Atx Or41 W I•CLI I w I -A,.[. GrIX,- ! C' I ICE LqN TCOYGIIOHS ? Wvt XTHi IRAFFx:c-ot. IT-1-1 Y > ? II I ? CONAL] TYFf.OF IoAB HCIf IT- IX,L yp Np [ OH MOIIII ? I ? "1, WAY DFINERNF-LEACTIONS [ X;.4p ONE On LOnEr rCL W [ ?I11 ? DOW STRAIGHT AHEAD ?/•1 WIr ? f ?-1 J?Il4MMO P?OAWH ? J ?RIOP 6r0H t TVrO WAY `ABLE ? ? J ?OVCn1AXINt1 ANDPASDINo J ? SNOYAHO J ? IXIGX ? J C3 IIELDSION J ? ION) ? J C) MAXINORIGHT TURN ? J ? wow • ? rm [ tV.Ii 51011El ? • [3 FI AM-REn c] [ ? WHrK.H&VCE ? [ ? MAXINEI Ik FI TURN ? • ? IC[ • ? ON*H r' J y DAMX f.TnFFT FI ? r ? ? ] ? rlA..w AMNfN ? S ? ALLLlY/RAMP) ? 5 ? MAXMO II TURN ? S ?lr4CI%? NG r) I w i W ? I C ] • ? ? • ?mfAd'AL IVq WAI ? A ? ? 0 ? tA0YAN0 IIYA'-0N rO-NO,"I.N. GANGER [LrrDWVw(IA.-rtrrlNA rrtr OR kEi L f 1, ?7PECIiY ? F ?...... FI AG-11 I'IT IIMN lMN] ? [ ? OIoFPkUFOII TRAFFIC ? A ? DIHFn, f!•lCIFY ? I ? fZPMAtEO "SAL ? a ? OI STOF ON -_ _ M ?1 • rro lR rr?C [I r A? mnDko ? J ? I%'mFO D ? BroPPEOw raAmYAr ? ? 10 ? ?n.ii (w'i4rE a L l ?QYe Y i `a POLICE TRAFFIC COLLISION REPORT J!IVRAFNCWAY FoLlcfcOMFTAIN,NUMISER i [:] PRIVATE WAY DA F QD N Mo 'n+ rv? 1^101 LI O ... _ wr >c 1 t' T'N ur 10 f IMF 2 (ustlj•ZNOu?RI i COUnrv OY? ? wu-NO. CITY NO. / /E.I/ ?IMWA URGAM fAL N ?N ?E ? N _{CIrv'?OR•]StOWN E6 O.O STNff,IIOR HIGHWAY Iwlf1 &5 ?W E90f (•1 IWEJhSQ QN ? • •(? ECI CtS AEA,_ - OR,S/ /S ?? ?7St% 5t I INI{9SECFI ynlH: SlRftrOR eOAO rgNINLER5FC110N D*•I??fn.( /? P 1 ?? 5 eefilX f0. MIIf FOSi /? ? 1 BfiwE! 7 •s1RFfi 6 Ce I Z'•? \ FEt p''AN 1 RFof .CROSSSIRFf 9NE MIIE .,,Is 5 E W ACCIOENr MILEAGE DuGYAM DATA { FEET O Z 1 GI ' COOS COtUSX)N WVIXVtO: StVER 1YI NO. KIIUD?NO..IN1URfD_ ? SFIIUGE ? T R i01AL N0 HJ,µipnpm IN IMF CLS gffl RROAD lYOS551RFfl OR ROAD FO - ? . dVfHIClES g'RfpGfRIYDA AGEOMY ? g11SFI1T., ? FHI LL ?y ?/D ry _!! 09JtCI5TROCS(NI EOFODJECTStR KNDOWNEWSW I ESI 13- S S-e& S DU OOQ-UE& ' I : 'UNIT NO.1 De E SH UNITN0.2-" • ?VEHICE ? PEDESTRIAN ? PEDALCYCLIST L s. n AM: lASr 11 sr T I C N , L AA R 0.W rn Ntc?ri IR DxrvER s NAME IASr 5 srRffrADOeF Mc- AI /v J rRttr AL»eEss ?' ? fY -IE ZIRCOpE rlgNtNO. D I StAlf N F: l. R MfR5l1<[n N SAI op H . F IV N NO. At X 19N MD. N. w fl kG o7 Z i I 2 OCNRNXXY E6 RgHf NO. pEYES IGHr MIGHT 1eYeTT4 1A/?t{? Drire)n B I[b ?Ur E R 111TI FIRMNMAF6-I NO. fY[S' IWfr IEIGHI ? CHECK (? vfH CIE ASiN Uwvr ANO r ? CHECK(t+) I VFN CIE ASAN fMROY f dAND tD CODES 10- ? 3 3 t b s1MO.nr.`rvrfL' S5 JKr F,R CODES P. + 3 aw I irinr S M c9ceoN 0 sot n IN I ?? S DrgM SIJrE CY. ? AAwAAHCI ? U ? 86, ='n " ? ?uNY ° ?'µ N t ? G ? *4 ? v°I ? riAHY V V[JI. YEAR KE IDDDGf{HfV.) -73 M IpARr.NWA) 5rYU 1, DR. v.l vcty 2 V E .1 imcull- I. .Y l raOv b ?. L t PL.S SIAI AIItR Mif NO. Vv A H H. OIOe VfNKIf IIXMHI KkJ NO. 3i )C 5 177 I 1 i 1 vtH CIEIDENNI N N! i I I I I "` RFGISRRtDOVmFR: LASt IISSI Ippl! 7" c t Et D 1r G rNONF NO. 's 37, 0 I wNER. LASt NR11 MI F ?I l o AC09lSS CV OwNE4 / 7 L ?t' N OCT. 0' wNR - ti w E NAMe aAOOetssd mw eeo. wAG r e INS. C R r TIFARFCSTA °rMAC•°JweA p AeuA DrvrC?4 CHAIG! •? CNARG• 3 •DVw. ° ? ' 51 E •Rro. _ _ f Es?DAMAee ARnIN -uN{D DwIWN RIMAINlD esl.° t OTI:FI U C] la i0W[O ? A AY ? tU:GIT:w ' ? OW 9 s va I L ? - J G AWAr.Y. s wA 2 le DIAGRAMOf COLLISION I N ItoMAIF NORrH DESCRIPTIONOFCOLLISION MIC-ITAV 1usEEElrrrMas 11 -- ' ?r(ae :., Loot o?efr?-- ._ t _YCl?e1J- ? ? I • ` ? T , /mar _ l _ ccw) f E4YLll.eD' .! vA..._ ? Y•LL.i{f `_TTat_. ^+I ? I .....-.:. yj.., .. _prler. Sev+•Y.-. cjYavel is 0e... I i NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED i CODES 1 Z 4 S 6 OCCUPANTS /WITNESSES lily r oilrlEOw.JAMI E?iA'MMi ii 1.1111 AD! ur N`x" H•; w w rc. sn. uEEi ° n N w. C•?N \ •cc oss cd _ . O /OS6 wn }1S ' ' ! •? . .. 9 [.k F` . NAluff o7 AM .. ? M, ? •,N.. O ? MNo , 4vE NH p - ... .. NAIOFd R? uK - M . AAU. ?? 0 :?F?«.n. A o?• ?? nrr,ArwodFlElrf w.wf+•N• fApG,d AG.•Kr KF DISIATC no XE A9FVfD DATid e1M}f1 AVr•ONDRr DATE •`?i vo..aaF-,,., r _t';i;nt?.., ...??},. r. a 'durl ~',., 7sT,r? rJL1A-- fS 'ufSAa ii ryFt ? ? " _ • .. . ' r d6 iry?] : .? r a ?.? '/ '?L"!?.•` POLICE TRAFFIC COLLISION REPORT ev TRAFFICWA'/ roucE eaMwuNrNUMee4 PRIVATE WAY ? UAl fC va k . uME C (VSE aqW NW RI moo WNfY se QR S o n CouHrv NO. I/ Grv inwA ?ua „f! ?N ?F GfYd10WN NAMfaNO.OESIafEfOa MGNWAY MRES s ?w }' D.0 s. ON ?P„[ v i GS M Rp1rl OR 1 Ej - 'G9360 SE INIERYC(H0= f?M. Slatfr,/O?R gOAO NON,H FRSKTION SQL V eErwEEN Sinfta SiRffr Pfffil% ! MI,IPGar ?) /?/) (/ 77 `? 3 b-isT 6 t ,GIOSSSrgEEr q NfwgfS(MIIEY •SSr ACCIDENT R RAMR D M A / . MgfS • S C Jim a iEEr d V ^ MILEAGE CODE _• *'r "Y CMD-.INVOLV( .. ER,IY. l rOt•I NO. W.. IWO?NO.INIURED ?sRIIUGE ?NIT. RUN ® ,wopO,R I O NfL4 (15 E OR O4 NCf Glpy SraDT O4 ROAD .: >7 _ d VENICIES ? rROARrv OAM•GEOHtY ? R'FwlnO ? V HfCIF ? Q ` .5• iT. ZO' - p / OafECr Sr4UCKINAMEdOe1KT51mK%ANOOWNfAS NAME) fSf DAMAGE S ? SR[CMfGMING ? - i•Hi..sn?vCr''w rr"?;yrx.Ff ?v? ,..,g5r? ' :•: ??.... UNITNO-L ' UNIT NO.2.-'. ? VEHICLE - ? PEDESTRIAN ? PEDALCYCUST an 1,9 DgNEIr NAME. fns C M, .. D rvE IAsr r-WIME ti n s a [ SIne000 l n f t o 3 `` lye LQH EKMrE NO. GrY ll 5 A ZIRC OE t?mrCT 7GWn5PiE? WS"Q51 D R rA f t?mtft, ?wr1 A. N;.Q / - NfR' [HU A % A N I , tH ND. A a+q N e87 wIF AFl lD i.3r /3 NenQ n%I h ;G ' q OCGJr•rgra NqM N4AEa RgNlnq tYf3 r Kn:NT E' <UPAf10N {IRM NAME 8 RHONE NO. EYES IGrI( KKM ryry tJ r .? CHECK(,) AH or•HOmea. CODES ? * 3 n 11 ia"" O 3 r%crRrr 6 ,MO, • D ? ?CHECK (,I) vtNKi AsAH fAwontd ANOrKa CODES ? * D n • ,: "" / 5 f%clroN x e ' 'n ' n ? ,riluR%s , ANN M D,=P- ? ? u ? 86. ? ? r H ?:sMDN Ar.•M.G 11 u ? 6. ? wRK? ? r.1"A JIM ? D KN. YEAR M•%t IDDDEIf-02r.1 G rn C DIDAgr.HOVA) srvlEl Da. .1 !le ie o1.c E . E .1 MODfII AI v,l r ?? cony of Q l2 r z s j9"` -/ s vN. sur rqufeR nwre NO. sur! H _ f A M , Ueuc FEf cLD is. 02? 01 Nor e p '3 v[NRal,DEHnrldrpH Nq Iw log 19! iS!fh t'3i? 81 L cff, ul N S ?!o tl 'n?oil;B?Y?31 I I I I 'I •3 RECnrtmoovgHlR: fASr rmsr MIppEE• 5/lr?e s a6o?e RHONE w. W wNfR: fASr ilRSr MI E/se Tod 3 sx ADlmssdow++eR N r E ?wY 0/ Ce rJ9/ •lneaAlwnssanvswAru m. OR•GfNr R /m•sf Ah / ?L• 3 G s DAM•G! MfA ? - ?µ CNAgG! rv' MA4GE ? ? ] a ?'u ' e i0r ? OAM•G( Cal A?fAmAV ? afAWNlD .. ? AWMH rp fSr.O O%01T0? i01Y0Y 3 U . CV auwwro f r O =L?Au S lev.EO roweD •w ? DIAGRAM OFCOLUSION SKItu NEG3S5arl-i' e r DESCRIPTION OF COLLISION (UStSW 1-MIAL LfI/II HIGSLVYI w4. Sf rF. ly c a _ tc -% e-- I I I - 77 , NAME, ADDRESS & INJURIES OF PERSONS INVOLVED • CODES I - 2 3 4 5 6 OCCUPANTS /WITNESSES IuvswlsEMeHr.ESN is •oalpNU H.EM ru esl ._-. ..__-._ six Ace uru .;;_j r -. n I __.. sn fuer ,N.; N AME . __.. _.._- __. ... ..... .__.._ _.. _..... 1- _.. r ' ° A n<nss N A r and •M er• e ci1 f ? "" q ?6 . ,".Nv N • AMT. t%Mfss _. _ ?f•r?nd ... __._ - I F- v Mo QED r.ow . ?AMe ?Wf ?.nn. ? .MrJ ? n ?v N AMr 1-7 ?AMr : v ? :? (ra EcErs,A.Mea4•Nr. X R e•DGE O4 n w ?O fuMCr F eS O aE. f r. xtonRA(cwD 2mmc1 ra%a Aenv, :lao 3 D D•nd nro4r G?/ y?8 .nrovaonr DAn 1 k n I. ? ff f, r ? t. l 2 E ?'x < k rt v Rp?y FR,LI a ? ti? SIM InO max„ F .N I N I f? I f j ova;' i I Y E i I I I ,a 41 ?.•?Y•; a E .i . F ,. d) 4 ?a o > ? pro o q C% r? a H? a ?°oo I,I c y r . ;idit Ea x.x _ _ ? n °+ ? .• J; ` I9TATE OF'?NAliVG I UN AG ?oF( ; J IY?uc??••?••- • •:,I ? z ' ? T UNIFORM POLICE TRAFFIC COLLISION REPORT POLICE COMPU NTN UMBER - ( ' •. C, '" _ . r0 T vOFCOWSION 0 „M ; Y Yfl. OAYOFCUWS T SUN I MCN 3 IVES D WEDJ ION RIUN S FRI B SAf T.ME IUS 3:CO HOUPI } COUNTY NO' / CITY NO. FryWA ?URBAN w'jak ??JJ?I?V 4 E '?f, COUNTY ?STATEflOUTE ® COUNTY ROAD 3O ?CITY STREET Z Q DMCLS. PREFIX UTE OR STREET CODE URAL .aECT1ON b 'I? e SQL ?OTHERISPECIFYI ,VWj Z `o O Y I?N?,,/A CITY ON TOWN / MILES[] ® ® ? ?,N.T /:Jati//f C' W U I.EF1X EO. MILEPOS//T--yy v. iC r hM.P E? , I CA NAME 3 NO, OF STREET OR. N INTERSECTING WITH: STREETOV ROAD LL RAMP DIAGRAM OA. - I T ON Q tr'? I. . 'IR rI?' I Q r N NIXJINiERSECTION BG'TVEEN STREETANO / ! / OT S/1 6-d TREET ACCIDENT MCODEE WTER• NO ClS FI CR05NGTFEE 95IREETOH RO pOR REF. E 'ly, tl N S . / OISiAnCEO MILES CTION FRSOM REFERENCE ORCRO44STREET. Q8'41'.. N SPEC..... H OUSE F ET N h F-S - + ?VEHICIE•VEHIC[E ?VEHICLE-SICYCLE 00THERRNRITEI COLLISION INVOLVED: ?HDBRUN SEVERITY NO. KILLED y y >3 ? x `P, T ?VEHICEOSECT ?VEHICLE-RRTRAW ?????? I I OF VEHICE9 ?yEHILLE PEDESTRIAN ?NON CDWSION M T ?STOEN VENICE ) NO.IWUREO ? W' ."rod •tI f ?. V ` ' A2APDOUS A ERIAL -ra. QWECTSTRUCKINAAIEOF OELIECTSiRUCKANDOWNERSNAMEI LOCATIONO FD&IECTSigUCK ?PROPEgTY DAMAGEONLY EST DAMAGE { ar .. _ . 1 . j. ?ROAOWAY FEET ? ? ? ? RO,EDGE S DRIVERS NAME-LAST FWST _ MIDDLE DRIVER '3 NAMEUSt FIRS T MIDDLE III-GUST ON PEDESTRIAN CHECY.I .... X D S Il D R E'ADORESS R STREET ADDRESS ?G, s% r w •. E ITY STATE' •.. ZIPCOOE. I PHONENO. E CITY ??. -. STATE' -LPCODE PHONE! R , C d'am' 3.3 •7Y/ R N DRIVERS LICENSE NO. 9TATE SEX DATED &RTry N DRIVERS UCENSE NO. STATE SEX DATE OF BIRTH p, 7 [ 1 MO. OAO YR, p MO. DAY Y'i O 42 /1-11 DRNff75000UP?TION FIRM N AME PHDNENO. 2 DRIVERS OCCUPATION FIRMNAME P NE! v /V H VEH. COIA R UO FLATS NO. STATE iRNLER PIATE N0. STATE : VER COLOR - LIC. PLATE NO. STATE TRAILER PLATE NO. ' STATE Y ..RT s? I / o! ice ?iJ R I I - ' : p VEHICLE FILAR N NUM6ER .. .,... _.. ., ODOMETER :.. .. '. .. C VEHICLE IDENTIFK:AR. N NUMBER .. ... ODOMETEfl,.I. - w R =' E OD aL4G a e I • 5.Aw ,d REGISTERED OWNER-LAST .:... .FWST :.. .:. ... - . MIDDLE REGISTERED OWNER-LAS .., FWST . : MNDUE .. , r ,-, ?& r a. s p. ih YG YS/'o-.fd? O ' ' D ESS OF OWNER - ... . :, _ ADDRESS OF OWNER ) J rs 2 _ AM AND ADDRESS OF WSIRUNCECQ CR AOE ._..., •, _...,-._.. NAME AN DAODRESSOFINSURA :CECO. ORAGF /?T G I I . -;. CITADONIq. ENFORCEMENT CHARGE , _. ,... -- - Cl ADON.-. e, , ACTON r NAME, ADDRESS & INJURIES OF PERSONS INVOLVED 00DE9 - 3 ' A 4 C NAME: O ADDRESS: U P NATUREOF INJURIES: REMOVEDFROM SCENERY' A NAME: N T AOORESS; S iwUmE4 SEErvE gOFROM HI NAME: T ADDRESS. N "AlUlll RI FROM SCENE By 5 NAME' S AC'JRES4. Sr IN :.I Sf.Fr.?RV'. -- I n ?• C' C 11J Sf AIUD : VEO 4fP AN BICYCLIST I3I SEA TPQ K 4 MtgN 3 T.OTHEfl POSITION IJI IWURY CLASS p.OEAD A? SCENE D. pEADONARRIIIL O NION DI$ BUNG IEMOENTI IWURY O ! D E 'Or'-- B YRTNE59 S S (BUS MOTORCYCLE) B. POSITION UNKNOWN A. DIEDINHOSFITAL T. POS: INJURY NOTIl;STALLED TNOT EJECTED 3 NOTIl, USE S. TOTALLY EJECTED J.USEO G PARRALLYEJECTED. A. UNKNOWN A UNKNOWN IF S SEAT BELT FIULURE EJECTED _ IORL '? J .trl(tAT'l?a'F.1 1a?4'7 Y..Y^?+„ T``'ai q.'?, s M { r r !1 r0. t I 4J L. 7 J r14 i `-r W77 17 It'. IrV ., fpr t" ! n-I 7 1. t,1i U t 1 t! '?rd?'¦E¦Jx? J'.1 p', wt cl ? 1 SF J,}'i' VhP , ? ` b? , ?? .! T IJ 1 L I5r ,FI rT J Iy Ii u r I , , V ?T t e ? + x ^ ? u'z T ?? d F Y { IIYJ IHUt; IIVIV$: i6RAWANROWISl CIS )WPRIII PALMECTICN OF FORCE Q -r'e' r : DAMAGED VEHICLE NO.1 IUSF. TMIS SPACE FOR S(`-TCNNG DAMAGE TO rRMlEPS.MOTIX3CYCU:S,ETC1 DAMAGED VEHICLE NO .2 x . s ,a.Nxa .. ? ? qml M re - 13. TrunM -.r----I'? Ia.TVYt"' . _ . re.Urcra/tlrt•Vlr x a omm ? ? ,e. uAS.cn•w. EEVEPITYO OAYAGE VEIeCIE NO.1 BEVEPoTY OF OAMAGE:IOTMEq VE SEVEPoTYO DAMAGE: VENMAErv0:2 I QSCTOWLO AGE aid DMMA.V,DAMAGE"' IQdaABLY:p DAMAGE' a0OT0TNEq M.V,DAMAGE 1QOISABUN o-D E aQOTMEfl M.V.OMIAGE 2 FU FUNCTONAL OPMAOE { NO NO DAMAGE 2 FUNCiIpuI DAMAGE NO DAMAGE 2 FUNCTIONAL pAMAGE ? NO DAMAGE TOWEDBYr• r EST. pAMAGE /. T OWED BY EST. DAMAGE TOWEDBY EBT.OAMAGE TO T IAORAAIOFCD,_ . oN , Fad G' PI ?• ,? ?. ! ?7-;- 1 j : DRAW ARROW SHOWING • : i NORTHINCIACLE a r w1w.rFANnEa ?% I n wrprFno.owAY. 4? I I . I 'I j I I I i ? i I i ! 1 v?i' `? '' - I 1-O M' -r ' Rcog Roan I i- ... L. I I. I r • I7 01 i I I I :o crwo?° car°-`navs a : _ _ taa ?A,oaAe.E-OF >?a?E•.naFFneerr...oP iravruNaArIMPAar _ : I' I I I • '^?- , . N ( ? I 1 I i•- r ? r I? I r I I I I-?T C? AbAr,<s 1- I , 1 /JJ I j I h'/T 1. I ---?-?- i I f f I /:' F I I I I i DESCRIPTION OF`."'o1 ' COLIJ Im u T 1 NCHCATEWHA ?TON DIAGRAM, E.G.ORNER OCI WLITY EDUCE V 5 R ,P io ? o O l W F , . a xl..,-'.:% : LS 1R E I R EOESTPoAII TM1 COIORCCNGTPI I CilON 0ligEPAW O K ETC. 0 ,/???It??d_?`/ Gdo?SJ1v?'•- o??a';:+ar?,A,.:?L'.•r..dZdn_c! i?rr•?d dnc.?r?%r • iGd1J__JO _i% C _/'JJ?!L+ =G//C?•Ai r/.C??? .r.?/s?°i o>I' T?1?o,rr±±?? ??'rd •- / d ? ' ' ' ? ' - 6? . ?%?_? tG dS' c•T _vl l. ¢/L?_i_ d 1 ___?la /rPO%GPC!? oi?cd •o?n o` d ? Cl1cl?%!'??_KG.'?r? AJ?E ?%r1? Ti(? ?y N .r.r..y,,,ASe'. PD D ' .xse .Np,pF lANE9 ...`S EE0.4 V N P VEH. NEADEO M LPOSI CttA NO WCREASWG OECAEA91N6 ONSTPEETORNgNWAY NAMEOfl NO. IN ONEDEiECDON TEa rE 'LEGALLY_ WASVEN PARrLED 'OCCUPIED - / W . -.,,, _ ?..c C / /' .. Y r ` • S NO YES El- YO 1 _ E-7a c _- , n ? n t PE0. L11 1 x ?Y L a Cw r O• cpiNFn rOa fEi PED/BICVCUaf WA9 USIN 1 - - ? p - 1t r ' •?wtDLP (? rrvux 1 1 ?°E r[O fit `.-: ,AOADSUWO CE ?y;,W T118i .;;•:; AMC ,-,,,•, ?CONTRmu TINGCIRCUMSTAN GnanD CESi ti: 4} / aPNTn ` n t-? .u_ .. ' n ?! ?a. 4! .. _L.-? ?„_IA?.aEw..Lt+e•tca- 1 NO?? F? nv h . rnFq . ??? u? aroFnW!M.?,? mwart LJ L?.7{ :f?=1 f °iAev u zCl x:r z n...a ??x Cj u?.aa.swe?n: - ?I, (-l corm ,- _ ua is?v nr ._ . .. _ . Qo? gMOn O a4- - rJ °b»° n A? . ?oQ F-TO - , El ` • rm_? ?_ e iJ P -- o°vEC meNO Eauv. ° c r n ,?e! J OrNtR?_?- a OMFA aPl ' _ e ! fO?C°YM1VIr.P/W I _ ' ? ST°4v°rR°.:-_ _ _I /,1 r,J / / ?I1KLS f? Ja????Cf _ ?e? 9.bM•O _ - . t , 01 l ( f '?inn ^ t J I .l Prs uC eTM L1v? mruL 13r'EGYI '?a?; wYaunal ... 1?1>(Z rOR Tw. L_i LJ . TFwnc ..: LIOHTCONDITIONS rc•rtee D y,TAAFRG CDMIBOL,. 0lff AU?AE1._TYPE OF ROADi x TYP ale on AD _ ZVMEHICLECONDtTIONL'. °`E li 7+uSOSAIETY;*-„"r ,(,y; vtNrxs °rrEnAT s°N.i' a ervaaN N0. = oEr ee rcN a a•n . ND = TI-El QM . 1 °Arua"r ?_J x'? c10 I_I m0^AwFn ?' = n pA N- ' l _ "t LEA. - 4,L_. ?_ D( n ? MND 110N. Ln frJ Iaa.wul. . . jlx? ,J ? ` ,rooaaawErr , =G '. ? ?dO pT r,, (?1=,,,?q ?}? ?J I T 1?•I N12'r - 1•,d- ?; ,,- d 5uf ?L 1„a .AO„•0 •- -.. ' LJ w°?`.•rac'?ir? W,,,L AEU L? * l et J ni1..`iwe I-7 a? rureo a a•w'LR CHEM.TEST a.; -• enuae' r? ruG ? A 4ieo owl r I iEaraNYN orRm raveDlm• > J .- - _ L 11? I O1? pyp,p __-_' ? NO CaFFCra n r-? TFarntwNO .,? n: O1Nln1aM'Or'rl i-y? I Npr:uFElO 'rl; e ? cvRa a•-, uMYnOa ? ° ?1?N:+Ay?,OIK?I![CrIYI w{? % % TEST RESULTS E. - " m+rraorrcma..AMeaeA•w ? LC , i s.meNO. s o.a aA•.wm Mw•ca i° i'n b?v0 7S o = ^E M ° _ ; ?;?rLa r e / 117 '71 w ew ,o rcA a X1 ND ur.ra?R lOer.actr. ar R roar ArwoYTOSr wn Ao< "J § Y? X ,t - -» t%1PUCAfE COPY:IOCM.IAW ENFORCEMENT AGENCY'S COPY-.iRiPt1CATE COPY:INVESiIOAtOR'SCOPY -' rMry 'ir? ?I s F ?Y Y d ? a "w F t. q t ?. /1 r MT ? ."?"s ° a"e. ;??E' _- -.? ^-" ?"?v " " 't ' m : .. ,r.... - G _ • ' _ •- _ - . - - - 4 •a, .-> .r:?:: `•, ...._ ;M`,,a? 2L =s `: •u n . ' yA A ???? , . POUCE GOMP ,. r - UNIFORM POLICE TRAFFIC COLLISION REPORT LArNi NUMBER _ ?: , rt ^ . p , PAT A • E OF COLU90N M qY fL? DAY OF COLLISION SUN MDN IDES WEO IINN FRI. SAr TIME IUSE 3+[O FOUR) y COUNTY 110. / [R'I FIO. FryW UFBAN . ' URAL j T COUN ff ?STATE ROUTE T?CWN ROAD ?CR'/STREET O PDMCLS. - vREfl% HW/IE OR STREET CCAE SEGPON F ?OTHER(SPECIFY) N CS C/8C0 L N 5 E W ?IN CITYOH 1.WN PREFI% E0. MILE ?? ir. J , • C MILES [:1 JD_ El ? ?OF LL O.U q ; A NAM A NO.OFSTFEETOFHGHWAY INTEflSECTING YIITH $TREETCR POgD LL RAMP DIgGNAM OATA ` - A ` • O NW INTERSECTION AC CIDENT IITEI "NON Vt %RD CLS iERZCnNO STREET R NOAD OR REF EF N BETWEEN ID STREETANO MtEAGE . ENCEC OSSSTOR OpD ~F' }, : DISTANCE ANUDIRFCRONFAOM RFFEAENCEOR CFOSSSTAEEi 1T ? COO. O , ?MILES N 5 E W ?• ?1- ] nvr.?pE1n5 SPECIAL CODIrvG USE ?fE. b •MC [.FEET ? OF 'L . .1 <??.!i/.1'l-., C.• i..., COLL ISION INVOLVED: ? VEHICLE-VEHICLE ? VEHICLE-BICYCLE- '?C'?ERIWRI TEI ?IIITS fiUN •EVERITY Ty ?' f y, ?VEMICLE09JECt ?VEHICLE-RRTHAIN TOTAL ?STOLENVEHICLE NO. KILLED C Z ?4{{R E9 ? VEWCLE PEDESTRIAN ©NONCOLLISION ?--RDOUS MATERIAL NO. INJURED PROPERTY OHMAGE ONLY S.- q , v OBJECT STRUCK (NAME OF 014E0T STRUCK AND OWNERS NAME) LOCATIONOFOBJECTSTRUCK EST.OAMAGE , LT? t M ?ROAD'WAY 5 F W FEET ? ? ? ? >]. EDGE 5 ORVEIII NAME LAST FIRST. IAIDD:E o CR'/ERSNAMCLASTFIRSTMIDDLE II I.CYCLSTOA%-llIIANCHECK) i?:out?_, era k`?' o i __.. .i r A ..iRE,ET ADOflE53 ?7 R STREE( _"ESS '!EY , •4 1 V Z V Q E Cott f STATE ZIP CODE PHONE- E ICRY STATE ZIPCODE PHONE NO. x 1. ?Oc N' 0. DRYERS LICENSE NO I I J ?- STATE ' SE% \ t DATE OF p RTM MO. DAY A N CRIVENS UCENSE IIO. O STATE SE% pgTE of BIRTH MO - t?"qr \ i,,6 I i i i EI . . DAY R. A 1 DRIVERS OCCUAATIDN FNM NAMC ?PHOrvE NO p i-ERSO CCUFATIOrv FIHMNAME N NE M1O ,.k ! CODES >10) C' A55 `I SEATBEL / ISI EJECTION CODES > ?], IN TAI S - . z F LA55 _ C SEAT BELT I ) EJECTION AU EOF yy X i '.{ uTE9 g SCE A yN K[ " 1 FR A NE BY: MAKEI ECHEV.) TO MOSEL OARTNOVAI I STYLEIZ R.-CON`/.) IFAOM SCONE / -EAR BY'. MA%E(DODGE-CHEV ) TO MODE rf 7 C'tv - T /2, H1 S c . LIDM iAOVAI STYLE I20R CONVJ v Z .: V E VEH. COLOR UC. PLATE NO. STATE TRAILER PLATE NO. STATE E /.- TOR UC. PLATE NO. STATE TRA:L.EH PUTE NO. STATE be.)>, t , L.72"i Wa r C VC-HICLE IDENAFICATION NUMBER pOMETLH O I Y EHK:LE IOENiIFIC.1 N NUMBER ODOMETER yt ` ' t REGISTERED OWNEfl-LABT FWST MIDDLE REGETERED OWNER-LgST FIRST MIDDLE 0 0 ADDRE59 OF OLVNER . ADDRESS OF OWNER 'IY.?. 2 A NAMEANDADOHE55OFwSUHANCECO.ORAGENT A 1-11 AND ADDRESS OF IVSURINCE CO. OH AGENT IV co CMAH E GITATIONW H R , ENfpRCEI,, A C GE - CNO. ITAI n Icno I NAME, ADDRESS & INJURIES OF PERSONS INVOLVED C00E' z A s N T ADDRESS' S lIATUIrt. F VJUIUE9 .A]FH M S f / c V:?. To W NAME: T ' """'S N ! . lul t. 1 I ]FFOM e4' E •.: 3. se To S NAVE' S 1CDIIF.SS E i D' 10 N o? ?.V' IgsL nEU I m u1cN , 111 E. I En } ur ( Ti - i \ O ' C D f 5 I r ? 0 ERC J. I VO S ? Y l U Fo D I[D ] AEi E n Witt SS _ 6 ] S PO,.'tU?LOlr:I.pV F! I I. . ) POS. F •J?f?+ O S GFA I 'V LL EJECTED A t DEL FA I E FJEC rED L Tr I r S a G I r? 35 '? )I .>J JLLS'?i''L'?+?%IY ?' : is Iw p, 1n?JS4" iH ?I 'tb? _ ! R, ?M1 r fin, fl'. LW? ` ?" VEHICLE DAMAGE 1. IN EACH BOX GIRCUI THE NUMBER OF EACH DAMAGED AREA. . LS t1w. (} 2. INSTRUCTIONS: SHADE AR EA OF SEVEREST IMPACT. 3 DRAW ARROW(S) TO SHOW PRINCIPAL DIRECTION OF FORCE. I O - D ° DAMAGED VEHICLE NO.1 (USE THISSFACE FOR SKETCHING DAMAGE rO TRAILERS, MOTORCYCLES, ETC.) DAMAGED VEHICLE NO. 2 12. HOW G Ib l ? , a /?? p.`?-,//'?i_`9Tf-"-`lam,-_?.? 14 NOOI PL-_ ,. (r, r'.5 r1 EwR IS. Trunk ?I NN, .. l(j I. 111 .. IIEUI Trunk ((L " 1 p ' I \(L" DS I1N1-l U ! 18 UnJac r C . _ [ • 1T.Orsttuml 'E ? ?? .Um1acxruOR >.a HMR C3.TYOFUAMAGE:VEHICLENO.1 I QSABLE A S QOTHERM.V.DAMAGE []DIISAB_MAGE:IOTHER VEEYO I LINYIDAMAGE DQOiMERMV DAMAGE SEVER TYOF-AMA:VeHM;LEND.2 1? DISABUNO DAMAGE 3QOIHERM V. DAMAGE ONAL D MA 2 F'UNCIIONAL DAMAGE NO DAMAGE 4 nFUNC 2 FUNC,IONALOAMAGE 4 NO DAMAGE 2 FUNCTIONALDAMAGE 4 NODAMAGE TOWFO.BY ?•-{GlC ?Sr.?i?\ T?.v'" EST. DAMAGE TOWED BY ..DAMAGE TOWEOBY EST. DAMAGE TO SZ'OC',i? ?' TO 5 TO 5 DIAGRAM OF COLLISION 1 :DAAW SHOWING "v°.K,°'LLES aRpwr. FEAiuREy ro RDDwAY M.T5. n:l N 'C RTH;N I - r-- ??-T - 7 NORTH IN CIRCLED ( i EKa ICEPArcn.coN°rwmaN AREAS Erci >.LOCATEPRpuAEUEP°wrOF I I I r l II I ( I_.? . _. r T ,... _' _171 - MPACr > EHONNE?p 0N Ey C R :. .. R - T. 3 EHOwrr YEnK:IEOM' 1 I IANPAR uoA:-mrEncoi'"9i,IOilFORf _L I DESCRIPTION OF DQLLI$)QN' (INDICATE WHAT PROBABLY HAPPENED BEFORE, DURING AND AFTERTHE CRASH, INCLUGEINFORMATION NOTON DIAGRAM, E.O. DRIVER DISABILITY, REDUCED VISBIUTY, PEDESTRIAN CLOTHING COLOR,CONSTRUCTION OR REPAIR WORK ETC) • PO ITIO NB NO. OF L"ES SP EE0 5 VE IFPAR D VEM. HEADED No MILE POST DIR. WCREA4N0 OECflEA51N6 ONSTREETORHIGMWAYNAME OR NO. INONEDIRECTTON !Oy re SAFE LEGALLY PAR KEO YYASVEH O CCUPIEO , - C ? ? ?( ( /! n YES N O YES NO RED, '-__ ?? - if OR ?? stPrE oR nK;nw WECOBx[RTO C EW alEiow.l PEDrBICYCIEST WAS USII: G: EwAM( IwAtKw.Y I yryWLpER • c65 y<lmSwALK AKKE °I. OESCLLE fro E- >I O ;: MER ROAD SURFACE; >;}„WEATHER CONTRIBU TING CIRCUMSTANCES, -r !':. ,.;:.::wMwYEnKyE ACnons _., ICHZCK CnD or,W w > f.•.CK ONE, (C d°YE No HECK ONE CA MUEI oRNER NO .:: N0 IE Ipq MOPE] E L cars xrAHE. mr ?cEnc Doo _ oeRC.r mr 1 11 4Cpo¢E O r 1 ?OSe°LY j ypOyR? ANO PAS NG }. WET -' r1Of FnCEOF ( ° - E CE PP LJ ASL 5 Ll NO Nm1 L. • TATED .. _ P O fa - - I F__ l-.1 L..j LOCA- - -? -TURN CE l __ E .. 1 ,. pAF .. D. rIgPER 0D EFE" C E EQUIPl i? 5 U TUroypr 11 ! ...._- O HEAI3PECVYI - _ .... -_.... OtnER 5>ECPYI i °I°n°rIC'E R......_ P GO CH ,.t.. O .T._ '- _.___. ( 1 IM ER I .. I > i y[I I,-I NAL NONEAOLAiKMm r_ IJ ! ? PEFti FOR UGHTCONDITIONS ICxECR ONfI , TRAFFIC CONTROL rAO vfnK%E yfn?Y,,. TYPEOFROAD: M ICH CK E RMDRF VEHICLE CONDITION VENICE[ -—ONE OR SOBRIETY:.. L O t - ?°y°TPOEP ( I1 EMx4J I r ] I NO ° uME CEFECn cLmwsurfm LEN E I.E. I N j M. ,. eroN D' j?w Aw ;? T•I l TY .AY I iw m ; L VE Li" MFG J oANN wflfl > Srn r - 13 r! a LR[ ... L J ' O 9 T L NO wM10 _. __ L C?1LP ] SAMEOi P091m P f CV. - "° BE. Na LvH? I Wr ILAwE f ) , _ lOOPRAMr _. R OEeAN Wni9 . .: -CONPErv 5 - II L ^_I MF116 N6IFNTFArrO ?1T ' iMFFlCI l D.Rx,y -Ty .... iMnE"R"O : __ _.. Y ? ALLEY . r '. OAESVOprH LD -KtM, ._. -? I Ls EA- .__. ...? Y CAR[s T UdrY . __•. °._ ... SON4 Two iyn wfY ..-, L.A N ° __. OPESPUACNFEO I -, R&DNH Dxrvld CHEM.TES7 NO > I--T -.] I J NO 6T°AnCKL1LXY. 5 '! - !LAOU.An ONE( SOP 7- I 1 (' 1F51 O'.En . OM[RISPlU rvI -.. ,. > DMDIO F[Cry IA RlNSFD rtfii err urc .i> 7 7 `,o r v+u?n [y 9' TEST RESULT5 2 nY.tfnOArrvp O!!C[K SHAME IrwK 1 - AN-I lUA:E.wu'24 ?lK:f fR E [LOW ? O ^` wMMOA1M0r AYN y MMf AAVrt 1 WOES M?? MIxCV i O nF X .- t p f !ELpi? APPIY>rEOYV pArtl DUPLICATE CWIY. LOCAL U W ENFORCEMENT AGENCY'S COPY-TRIPLICATE COPY:OIVESRpATCR3 COPY ?-Fi MOTOR VEHICLE COLLISION REPORT NO. r? V D/IA]E OC CgLyyUJJYON h O D IA AY OF COL U11 `., TIMEOi COLLISION AM u V,[] COUNTY CITY NO. ?APA A Tr -! /' Y" CN X ^ O PM ,, ? Pu COIMTY CITY, TOWN ,I MILES Y. TOWN ACCCDENr LJ J4? e \ p"? o L r? ww rA;, ©oF O b W n C h AOM CLS PREFU 4nOy,EOR3r SECTION /V/ l//O R 1 " 'A 1' fAVENAMEOfSIRE ,1R1O?OflHIGHW? WT ERECTING WITH STREET OR 11 ? 1 rREFI% EO - MILEPOST S A p .t ne n N Z ?. ATI NON INTERECTIONIOCATgN Or COLIIaIOfr-' ` 11 y K A ' RAMP DI GNAM DATA k , ?•.. BETWEEN C_ A O \ 111 ..EET AND STREET PAAKDAD CROSSwc.u LEPo]TDNiDErv, rrrvc LArvpuwx Fn RRDDE. * R NON CEO L • EFT?rtfi?RO, R Ncr ©® KN' Fff, R CI o INTE ? C . y }F. 1/// F lE. COl LlSOrvwWtvfO fn ct( ?vER 0DI.ERIww,El [70 AL"o wELf-0wlC, ?v[n¢lF iA I f ( SPEC C E C - E -LE e[ofS,ruAn JnW ?n ,} , irY,r - OBJECTSTRUCK Irvu,[Or DB,FC!],AIICKI OWNER OFONECTS NAME AND ADDRESS LR.. IN R Y P ?'+' - P - E 'Y iUAE An D?oJ C, - a FEET Dcf w • ORIV SLAST NAME FIRST NAME MIDDLE W ORVERSLAST NAME FIRST NAME MIDDLE r Ar•' . 1'nr?E-=-p •r ?o,r' ??.bs DU M?Drv DA • ' ' N ? STREET AOIXiE55 ROUTE NO.MDBO%NO. 3 l 3 V ?X ApRE Tnw ,vq e--EW[ ruWE USE STREET ADDRESS ROUTE NO.AND BO%N0. ',. CITY STATE _ 21P CODE DRIVERS OCCUPATION. owSGN CITY, STATE - „- _2PCODE DRIVERSOCCWATION !I• r• „ , L7„ °t. ? . _ C ? E psl li BI L ? T I UR u 1 , V - NSE VE S LCICENSE. NUMBER /1 f? STATE SE% TQ Q WN ? r P) DATE OF WRTN AGE I,.q DAY ^? ? SE NUMBER rMVERSUCN AT E uES TH AID vWRYEw Ao g a ^ VEHICLE R. M A?KE{CN EV.?OODGEI. MODEL INOVA-DART) . BODY STYLE 12 DR.) VEHICLEYR. MAKE ICHEV:OODGEI MODELINOVA-DART) .- BODYSTYLEI2DR.I ' (o ? e V, a„ GLr S k or? Y ..: ?jtt• - LICENSEPLATENO. STATE THNLER PLATE NO. STATE .? ??55 W h UCENGEPV.TENO. STATE .TRAILER PLATENO. STATE .,J _ VEHKLEIDEN-ICATIONNO IISE(IMOELSENEWERI ODOM EtERIMILEAGE) VEHICLE IDENTIFICATION NO. IIBSBMOELSANEWERI DOMETCA IAIILEAGE S USD PEGISTEREDOWNER ItASi FIRST MIDDLE NAME) DRIVERSUCENEENO. REGISTEREOOWNER MAST FIRST MIDDLE NAME) DRIVERSLICENSENO. P j _ J ? OWNERSAOOHESS ISTREET, CITY ANDSTATE) DATEOFBIRTH Ad DAY rfAR OWNERSADDRESS [STREET, CITY AND STATE) DATEOFWRTH A%) DAY rEw ? G? t{ R . ,-..( 4 PMT FVEHICLED AGED f„MEDCDa, `?' .... s,DsLAIR VFHr?LF? PMTSOfVEHICLEDAMAGEO ,.: ES,VAMEDCO]r - .: - sTDIEPNAYE„cLE f' LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- COVERAGE INE FECT FOR THIS ACCT ENT ON YOUR CM ? YES ? NO (l ?NAME ANDAODRESSOF UAWUTYINSURMCE UCYY HOL NAME OF UABILITY INSURANCE COMPANY dAr VE 7 f0.f? , N: NAME MO Of UAW INSU MCE AGENT U BIMYPOUCYR ER P W 1 o LG xxJq TTV" IST INJMY / AGE 2ND INJURY: V RE 11. AGE I ,D,AL NAME NAME l.? Y - I I14MI 5 d?._--451 3 - I`.r ? • I.N?-'-f. G L!.a.M_- SE% DURESS E AI-1 All -- -- ----'- a ©? r Q U E © E3 n I rv „nSTAYUSOFN MMKf NST O PP UR E T AT J I N H A ED UE STATUS OF INJURED MARK FIRST ONE THAT APPLIES ? psAeLN Urv n¢Aw PNlur f D D n N6 DRNER i [I AKw nAnlK%o •'Ve-^+nif vEnKLE n 1 KILLED IN VENKLE I wu W fEDa •fllj uc[ MwDAI I I ca HuR ?PASDf rvcER KILLED v ' ' ° N A ? D POF,CI Urr,Nirc ? S o °rw s o,.D e,NAN ?, +_?.:..,E N pu,Irzn AS-r-„I ? 50 - G? 7?. r. + SNOW NORTH BY AFROW IN CIRCLE Ll wpCMf fn,nSrwd-DM1 YDNADD„rFURfDfAA YA.,wDw MDwfA fKn,T,<L[ M.D NrON ?? ?' i DESCRIBE BELOW WHAT HAFPENEM[REFER TO VFHCUES BY NUMBER) JC 4 0. - !A7-GS?_?Lte-t+n $- :_.: _ 0.n. o ._rr n __ I !t t-o__-=J h_I%- ,, DwfD,Mrvl„K.wL.YMwDW O ? -EID I=- i - -- -------------- --------- I , I 1 ;yy 4 VEHICLES POSITIONS BEFORE COLLISION NO LI? nlv[araaLD Br 1 R UD Al- vf„ULE OCCI, ?':iltt KlrKtf N S [ W GiII[ET ORIaGNWAV IIAMC 011 HD [,I(w A r6 ON ?D'igKr! ,;fill 4hM1+' 'd 1 O ? I,L.? ???? o a a o 0 0 ?Uro?DE° DIN ? ? ? ? ? ? ? ? ? Er naM DIRECTIONTO DIRECTION rN.Dt slwAN w.K LJ]MO 1?SrK'wMK ]?wMKWAY ]?SIOULMR .?""M"l- E?? a?OIMA AD,.Aww. t;l NOM aIAIIK[ MSAIHfR LIGNTOOIOIr10N5 ,HMlK CONIMI Ir,KCApMI Of ROAD -E e. Lr.I L wll I ' f pYVnraVr FNKL{ACrUNe K:Hfc%UH[mua„c• L - r I 1 / v„rCL1 E fA" I ? D ' 1 1 1 ? ] t• M AYwWJ 1 A? O ] (pIf0 aTRAI(RRMIA...... ?O-5 ?? VF A<J •I ?1DoY ' I P ] RMAm16 ] ? DAWN ? 2 ? SIN. s, AI 2 ? TWO WAY ? 2 ? OVERTAKINGANDPASS114 ? WET Wnl[ ] ' I L ] ? Ew No ] ? -5- ? ? ,,LO b N ] ? ROAD ? ] ? -ING FONT TURN `• • } Y J Y f i ] SNOW DARK SINCLI AU L W ? A ? MAKING LIFT TURN ? ? • ? FOD • ? 1-s ON ? f ? ILAS.Yq R[D ? [ ? I?t r', 1 I I ?r 1 n I ? o'NR COY) e ? L.11sol,[T ? ! ? fl%yJVq A4BfR ? e ? AILLVY ? 6 ? MAKING UTURN WAY ? A ? Ornfw ° ? ? e ?SPfCNY Is"I DARK AC, A n • ? ! 'L11 ) I .? j S 'I IIFN ? e ? BL01NIq E?9fN[[WRS ? A ? ML(W4. 13 e ?l I [ DR NOp st(K ?DMALR 'AN IANES I I F r ? r I wv I FKE IE LADMM I ? 0 I ? ? 1 ? VT lDfORTRMfq r [1 CI O CITY &T I ? E ? OI,•C A. Y•[CIFY ? 1 ? --to ? e ? OR 610H"D GNAL ? ] ?f%ND[D ? e ? BTEN'CD INOADWAY 11 -,RB IwI°,f[ X21 -^EIb.W-•'"Pi'°d?"[RN1".L ' ?L""> " U' .7%,,-7' ,: I ,?>.Ft'?SR1R .r M'°" „ ? - 777 N ,t ? r? n IF ??L c: 1 Jr I 1 ?r7 1, Ir yiI X11 ' L ? -t ilk{ ,t 'xf v. ' 71 ??. v nrt. A-s, a 0.0.16 1,WEACM EACH DAMAGED AREA N?oin y I• VEHICLE _ H AOEANFAMFAO FSEVERES SEVERERTIPRIPACT. 2.S iT. INSTRUCTIONS: : ;l UftAW nHHOWISITOSHOWPRINCIPALDIflECT10N OFFORCE. DAMAGED VEH)CLENO.1 (USEDIOSPACE FOR SKETCHING DAMAGE TO TRAILERS, MOTORCYCUES. ETC.) DAMAGED VEHICLE NO.2 IG. H,qJ ". Hiw° a roM In ?r lA. ibol I?? .liool f 1I AR IS. TUnM ? I-la III 1,I 1 I?? IS.T_k \\ ?_t,-?c??? T 18.UMwrrHps ?? Vl?? T p rx p'T n L r CT. UDiwlvn? ,T OverNm SEVEWtt UFDAMAG .VEHN:LE NO.1 1?DLSABUNODAMAGE GQOTHERM.V,DAMAGE 2 , FUNCTIONALDAMA E 4 NODAMAGE SEVERRYOFDAMAGE:IOTHERVEHICLE) I DDSABUNGDAMAGE 300THEq M.V,DAMAGE 2 FUNCTIONALOAMAGE 4 NODAMAGE SEVEPlttO pM1AGE: VEH CLE N0.2 - IQDMABUNOUAMAOE OQOTHEHMN.UAMAGE 2 FUNCRONAL DAMAGE 4 NODAMAGE . TOWEO.Y EbT.DAMAGE TOWEDBY EST.DAMAGE TOWEDBY EbT. UAMAGE TO $ TO a TO S DIAGRAM OFCOLLISION_ ce =--3 FEA1DACa U, - ' - }- ?- - - ? > ? L j DR -; AW AR NORT RO H I W N C SHOWING IRCLE .OW AW AY. anrflcMn I C - I I L I I-? I ? . L . ( ,- r ? Y tJ)O? fwv.caglgHT IMW?IOrN1WC,l0rl x a a - _ _ ? -j?"_ -- - ? ? f } _ - I{ ''? ??_I f- ? 1 '? 'T ? ? ?? -? ?•- 1 ? T nnaAaLercwr vD+cEevEanrRAROq OWFRPWIIKH A nwA r ? - L 1 -1 --1 . ? _ - - ??.{G? . p r -?.. _ - - I S T CT. AIm AFrEflcauAaaE hF ? f ?? . t _ _ -? __ - i DESCRIPTION OF x` LVAS? ffII -TEWNAT PROBAB LYHAPPENEDOEFOR EDURINCANDA FTE RTHECMBN.INCLUDEINFORMATIONNOTONDAGRMI.EMDRNER COLLISION,, ?. . OISABIUTY,REDUCEDWSI BIUfY, PEGESTAMNC LOTHINOCCLOR ,C_ NSTRUCTON ORREPAIFWCAKETC.) V" 41,c: a'n l Z ^ l, ?[ G __. a ?1 •T `(u S_S J?1 _ r c ? GYr C ?C K ns ?f Z c o_ c e?L_U, cL _17? ----W ...y its ^ _. ... . SIO VEH. HEADED MBEPCSTdR. ' INCR A . i' k. iJ..'• .,...:..^,..,...vw: ?:..du u. w?iu.wif••• rpl. WO NE DWECEE ON ?•n ON 9IREETOR HIGHWAY NAME OR NO. WASVEH PEED ?E LEDAILLY I F-KE PARKED OCCUPIED N0. .. • .,. E BMG DECREA.9WO 'nN Bn E? I-W ._ ... IJJ +I G I G 1? V .. (! ?, L I) I ? ? ? ? YES NO YES NO __o? c ' • ... 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Ea NE w+Nannar i ' TSM^ H R J a F Vial Nj:.: k ? 2 ?I.TfA a ?. A4.C eakLF# r Rqr?. FyP?Y'?ppL• STATE OF WASHINGTON FADE ,..-. -OF -Na ' ?• POLICE COMPWNT NUMBER ! +Lu.Y) UNIFORM POLICE TRAFFIC COLLISION REPORT "m D DATEOFCOLLISION DAYOFCOLUS ION TIME COUNTY NO. CITY NO. FHWA ?URBA. T M OAV YjJ11.. SUrv MGI IDES WEDX RNH FM IUSE?400"OURI ] 1 2 D 5 D? JJT I >. ?gUHAL E ZZ Z ON STREEiCODE ADMCLS. PREFIX ROU SECTION COUNTY ?9TATE ROUTE ,COUNTY ROAD ?CItt STREET O TE U??? v ?j • ?'?C' 1T OTHERTSPECIFY) ? TOWN N ? (O PREFIX EQ. MILEPOST ITYOR C o G O? O O GOF r T01-*ASe.+%v S/ O INTERSECTING WITH: SIPEEi OR ROAD MILES N E6 ).3 51 STREET OR HIGHWAY LL flAMP DIAGRAM DATA T ? I ?L i c ON ' V ` f? U. L T R ROAD OR REF ' V ACCIDENT . NTER NON X D IN RSECRNG STREE ERENCE CROSS STREETOR ROAD INTER CLS O NCNINTERSECR MILEAGE . '70 N iREEi ANO I?4 CA SRE ET BETWEEN CODE J SPECIALCODINO USE EF Du5-EOMDISSECTIINNFPSOM EEVRENCE OR CR09S 5?TflEET I uNIIAORS .• SL%tl FEET U Li El 0 OF L \`. l SVRN W . 71 MITA RUN A VEHICLE-VEHICLE ?VEHICLE-SICYCLE COLLISION INVOLVED: ? ECT ?VEHICLE-RR TRAIN ? OTHERTWEITEI ?STOLENVEHICLE NO.KIILED NO.IWUREO - OTAL NO ?VEHICUOW OF AIL NO, S L ?? ?VEMILLE PEDESTRIAN ?NORCOLLISION ? HAZAROOUSMATERIAL © PROPERTY DAMAGE ONLY DAMAGE EST - OWECT STRUCK [NAME OF OB.IECTSTRUCK ANDOWNERS NAMEI LOCATIONOF OBJECT STRUCK S E IN . F ?? 1 O ?ROAGWAY FEET ? ?? ? RD. EDGE S • MIDDLE FIRST DRIVER'S NAMEUST FIRST MIDDLE IIF S2vClISi OR PEDESTRIAN CHECXI ,.. lY I - _ -E ? - D DRIVERS ME IASi r{1A. P? I CV ; I I ??{ A SQ' D g? 1 . - . .. ? lam/ R STREET ADDRESS .. E h I STREET ADDRESS (.A• ZI L S y E r F . STATE ZIP CODE PHONE NO. E CRY STATE ZIP CODE PHONE R CRY 1. 2 (T A" R I TH F B " N Y N 1. DRIVERS LICENSE NO. STATE S" GATE OF gRtM N DRIVERS LICENSE W. STATE SE% Y D YR A MTOE O ?. 4 o UQ L1 PK4ob1T wl4 m Mpg. o La °' FIRM NAME P ENO. ?OCCUPAnON , FIRM NAr E DRIVE RS PHONE NO. Z OWNERS OCCUPATION ?`'J W I oFF`c ?G ?'1`? O'?1 rte Q ` 1 i ? : 1 r..Ra D c SS [Al SEAT BELT 51 E ECnON CODES 5101 a CODES > I]I MR ^I SEAT BELT 51 E ON V A NATURE OF NAtURE F IWUR E9 - WURIES V cQ. S, Q. TO -T FROM SCENE OY: ' __.. _._?.. ..,...... REMOVED FROM, FIVE BV: TO ••cw.... .... -.REV., MOOEIIDMTiJOVA) STYLE 1200.CONV.1 11M? .?,,,JJDry' *TdACTUR.tiL'A . K' - '• • ; v 7G TD• o CD.rCla'w. Slit-S- v E vEH. R UC. PLATE NO. STATE TRAILER PLATE NO. STATE E VEH.COLOR UC. PLATE N0. STATE iMLLER PLATE NO. STATE I kdi6vr Lilt, " (?` V M: I N M:ARON NUMD ,. ETER ° VEHN;LE IDENIIFICAi N DOOMS L TL 37,-36 13 VI %l k-yw1 E E MIODIE REGISTERED OWNER- FIRST .. ,...MIDDLE REgSTERED WNER- T FIRST N N 0. ADORE WNER LU C'Y- G1 ` [ C j O• ADDfiEOS OF OWNER .. ... NAM ANGACDRESS F RAN ECO.OR ENT NIMEANDADDRESSOFINSIIRANCEGQ Ofl ADENT.. •.i:....,. {emco - rftf(?e N E NO. CHARGE , .. CITAT NO. ENFORCEMEM •. .... '.. Lf'Iv;1 ACTION .• CODES 1 - 2 ] S NAME. ADDRESS & INJURIES OF PERSONS INVOLVED SEX ADE STATUS "p" w"sL EJECT, C ADDRESS- REM VEO FROM TO U "TAL EAF SCFHF RV. A NAME'. N T ADDRE'w4 S LM EO R TO AUIIE SCENERY. v / W MURIFS ? IIAUE' I AOdrfSS T N UP C' I SCENE RV TO E NAME T T T 3 S ADDRESS 9• Tf T,7, .tl_ __ rc[Nr nY TO ^I SLAT DGLt 1'+I I:JGCIION G h' L, ° IH1 ]P L.LFR ITT NR ^N ^ D 'O :.I S?HICa I J IlN1 UIV GL^SS _ 1.bWIlIT1Y SgDAIILINOIN IURV TT{'1 \ EWDATDCCNE AIaOXI TRLIND J I s I J.-)??? 1' OT.0'11`01 Y;YCLEI .,AD Nio5Ri^^L 7., SSIUIEWJU,IY R?9!?? OLD 10 L- 1 I. NOT [D ]. A IIU,ZOTRIIIUSE USE w' MN SNF^I UELT FAILURE 1. NOtEJECTED .TOlALLY EJ[CiCO 2 +. UNKNOWN IF EOTLD EJECTED ,1 Tr.Fa4l G`? I IT Y#,i ` m ^ - 'r'?Yi^11rR',,= •I'fl A 4 ?sPr ,R STATE OF WASHINGTON _- IcMLU Ec.. ?r MOTOR ,EHICLE COLLISION REPORT NO. DATE D co, us n DAY F t I I L ML o l w L I .I M COUNTY no c rr NG. .n `r n.-..; c T _ : ?? -.- ' MILES. TOWN_ ? .CS PREFIX A [ T w r oN ?x: ENAME OF,_7.. E_ T, .OA H HWAYO .... ANT R.E .IT BEET OR .w, ,. - pil% EO - .. MILEP [?x?T?FO .t f o C-Ln.s l„A c !/cnY /AYT?R, p NO N INTERSECTION LOCATION OP C MP DIAGRAM DATA BETWEEN ?y? TREET AND ow ?o -/ ? ?" L'y r i":ra[xoar on rn[nrli.Ino LArvo»Ax» T'". PAID..[. ra . xrw ox a R RD IN o - N I', OO r lp G O Y' I rax.aeNOx.? en Oi L - O HT. CL.. + xaxa sr,a-c,T axa / ll coaLlsro»r»v°[vco "- [x:cl[va»ICLC YfMICI['blcY[lc rn[n IwnU[1 U o °rxL n°. D Y[»K[[.Prt.[[r Y[nI[L[.TAA,» )'L <i ? - SPEC. CODE USE . . [»raa. . _ _. _ Y[nra[_x[Pa.TxL» x°x.[nl?r°,Px O x,..xJx ? OBJECT STN K Ixx», or. ol?acr ar I - .. OWNER OF OBJECT5 NAME AND ADDH 'S LOC . . ATION El FEE, n o ?A DRIVERS LASET FIRST, _ _ - DDLE a ?+rn? pHIRS LAST NAM FIflS A w a ME IDDLE TREET..OD.E -_:,ROUTENO.AD ISO. NO. ...:.;,.?n ! _,..; xcol STREET ADDRESS - - ;1:. ROUTEN :AND BOX.NO. "-- CI v-._ ,. :.v.c. TE Z CODE 1 -_.?. _ only ...000UPATION..; .. 1 CITY _ sT _, _S _;. IP CODE DRIVERS- PAT1DM_. ' .,DRIVERS E fiNUMBEp sTA E % OAT pTH AGE DRIVERS ICENSE NUMB R .,.:.- STATE SEX p EOF EINI AGES [ vn. M E •vo O EL I TI. B DY ME - 12on.1 I xlcu ? MAKE. IcnW ooc[I MOD L -( __ 1 OY STY E13?ort.1 ! TI! SE PLAT .-STAT?. Tqq E PLATE KO. [Z7 IS ?-7 -SiATE•; LICENSEP TEND. TATE_;; rT LEq?PLATF .'SA E'??y;y VEHICLC IDEN FICATIONINO „11938, xoocu.t•'n<w[,I OD OM ETERix:wc[ VEHICLE. IDENTIFICATION O'..; It9a ;e. n[w AI OO OMETEfl L[ACa TERED O ER luar - >\ oo,< ». pRIVE .., ... ...... NS LICENSE NO. •. REGISTERED OWNE. .-Y?fl .xloou ?.ORIV Rs;,L -f AT, CENSEf?..v L-? HERS ADD E/...f iii n[[T., cln 1 ., i _......._.'.u,-'.• DATE TH :.. ADORE - OWNER ...:?.??. U-- el,nulo -. .;J;.T:.e :D ATE OF BIRTH'i ? run PARTS OF VfiN LE pAMAGLO ...,T. n?wwvaxl0.[: I-?I'-. ? lam, ?h? -?V•?\ 1:. 1a, -. S ARTS OF- VEHICLE DAMAGED. ... S rt LIABILITY INSURANCE INFORMATION • VEHICLE NO. 1 - C.-RAGEIN EFFECTFOR T-ACCIOENTON YOURCAR ? YES NO' DAO 6._ N„AB1Y SURANC ICYH DER ..r .. ? ? -.NA E -LUBILITY) U Cp P ' xnui -.. .. r. nooxcss ......?.... .:....:'. ....,' '..? .. - .. ...: -...- _ ...., ....... .-. .-..vii SYa"-?o-V' NO ADDRESS OP LIAB rrr NSURANCE Q .T:-'.nk- ??:._ .... l.i, :._ :__'t..; ... ? , y:? _-:?.. ? TY POLICf.fl.... ,!L;,:i ?.Fi.L..+?'.;xw::.•wi.}f.:ao1l g.: :11R.:._ _ .rb._lw...•L. u.3..iu:L...J. S'.A..F., I..f-:_., J .. GEC '. 2ND INJUft ': 1 [ 1. I AGE} - '. . .:.:. NAME E ao . ODHF50 A EES o0 ° ^'O® TAT OF JU ED' : PI STO CTH T Si U9 OFINJU D MARK FRST ONE 111 TAPP IE APPLIES I yl o o»1 6NICL[ ?I KILLED rx I ' rvIL L c. a vl " ` r^ NO Is[v[nal Inlxa,l a.c r 7n ? 6 Q 6Q rr p17 ? H ? ? S? B? RT Y A R CLE •, O o .. DE GRIDE. BE W WHAT HA E i :.IR CIER j0 VEHICLE BY NUMDCRI (.O?Ll'_?19 no .vu v A„ow. 1[` `o VEHICLES POSITIONS BEF ORE COLLISION nr . ? •' INYESTIGATEO DY V . CLE H[AULR N S C ON SIR on 11IG»'WAT NAVE On 110. 'I nn tau , v cr nOa° In ? ? of ti V s 7? NO. OURI ? ? ? .. .... .. _ ? ? ? ? I ? n Inv [xN Ion ? D N o L ???? Ll ? 0 ? a ?a»[,1I a EpIA R N "??u? IALONO 'r'I 110 - . - 58IN0 IROM TO ".."..A. Y ! h0 1 . ?? ,w ("I ar [ I? : + ° A K --I I ..J.wl.x .. _, ei^ I 0 D ;JRI S NC lxCR )•' Ar r' - LIOIIT CONDITIONS I ? OAILIGH! T- Ic C TR L ICx ?? ?,'1I D).-ALS [ [ TYPQ Or ROAD Ua I I ONL +Y O VCR/ CHICLQ ACT -1 L111, I_I GOING GI.AIOHT AHEAD r1.UHY ) Ai I NO D F ) [-I DAWN [j (-I .,o,. SGN ? TWO WAY ? l n OVF.RTAKINO AND PA65ING (I l F? WET )? nNOWING ? f D Y15 U C[I LEI I ? III LO SIGN 1 1 IJ I? RLVff 9-C ? AD f C I 1 rI MARINO I116HT TURN + I SNOW JI ] f06 I (?" f (' ' LI' S I I I t ? r'_ L 4 ! I f1 I A L IND 11- I J (J V S NO j r I I S [] RAMnr P L. LI • ? " M AKINO 1.1'PT TURN A L ?? l- I.? v (C I Cl C7° L. ,1 O- c LT.1.H., AMD 11 t . {. I 1 C1 II Al 1 I .T (? []'r DNN r? 5 [] HANINO II•TUIIN l -LOWING ? A L t'rV I r-.I Dv rlr(N/I-LINAN I. 4AhY5 . I I T I -,1 f.TOPVIO FOR TRAI'I- l r. VI..,..:. ,..:. I:., .x..r.r.xx rr. II I nI (CrII I A II I -__ _-,_-__.•----- rr lr:'OnvrDA15ICNA1- II ( I - _.__?_._.._ _ ._ 1 I I L ) _. I r J A t I LO fO IN IIOADWAY nrn . 1...1 Iq i I 1 A. r I A .I ii 1 _. '?-a.7 '_._"'. •'. . _'-'•• - -. 'i ME F L ISIC— ? ,? ??'L Z ?•? .. GSM u ` T* 'r ??? tf /}? /`?> ?Y S 91? . [. f TE }py?,?L:.uTO}v ( ES IO GTY. W n n []I ... ?L.?/r'L'" •?,+YaSILrEN?l1SP.Ct?1[A $rL[{ N,WA -, ;I ITE SE T S7R EJ p i L .PRE L"- x.a gl w /? ?-vc ? iLILC CT-{^c?' fj'asr/':c.?-L?,.L`??..u:rC.? ' ? VDN INTER cTiD»LD?,T o E LLI..IDN xr F ]{ EO POST ?.l ,.cr MP [, U STAEET wN0 HEET - O E 5 , El ? B CTylTq '!y„I a. -,54?YM :OP..OUJECT9?NAME,AMP wOOgE S" J N FEET mr y V£q L4;TNAy4Fy 1RSS,.NAArE ,,,.r-. , _, MI LE R AS T AME_. ?F(RST NA E n 1 a /E11LV ,Y `••i ? K ?I?I II??/ S R /? !'?? j . . •? EET A 9 Y _ ?? vT?? ? S VG.awe nT ?H:-'?. tfTE... O.' pu 4 xl'i C }? 'Q.?f?HOt wn, rex 1CL"C.l?? S?r Y --' TT-..l.?y:y"k'WL1itilllfi. Z_P?G OOE pRIVE OCCUP!1T ,y?? 9TATE ?.,LP CO4E ,Qg1Y q+"iP000P?TjQry?, y ? /1 O ?1 4 •?^?C.3 L'?grL{? '"ORN WI'1 G??L'• / g + Y p E IIJGERg:NU? 1Ae:'. -SLTE NEl(., OATE r/•/r•F.t[ -? A Eg3_IG NSE NUM9ER ,. n $TA E SEJ( -pAT£'O?F,B Teri . .31 ` • ?7 a/ / 7 •J/! A C% V? - I 12 ? • O nlccc NAME " ]W y [I ylppE - INwrnMrTt 9C SME :'[] w.? • - =.La.__-._..-.. :u _ .. 7 _:,S.R. C'ncc ?,i_•c. n ?ooc4? "':.o.I.TI. eoo?..?,nlz'ow: . . LI<ENSEl{ T W I c/?' _ ry „RfiR?U1f?E.ryO,,, /.Aq'SZ \LT. 1.? IPJAI U- CrNSEJ?LA E_ D. •y : TATE 0 V 1 5 EH.N:y??N.j1PntisJ.SYQ9?laoq[Na>.rylE•vRn1, 000MPTEJRwica[ VEHICI:E I pENTIFICATION 2X/2X 295?.3/fY ,Py.? R EP18T -' , • _ I [ /cow .?f/Z? SY'? ? #g :4R54YlL'r {._t •w?pR1VERS'LIGENSGN yy ?- ?:,-? ?E4. _- AEp; M, 1_ LlTE_ .9_ 2+f9:..: TsJR. iwow[;e•!t[! • -•o8p/6nsd5!?Fry o Eye ; . " , /?1r -LI-l3 M p .x .ow,?Eps ?ooftr_aAzl . a.!Y iT.r t? .s[iI[I k, ,•.?... ?S A .TF9fa_ 5 ? ? P . . . :Cr'H $pFVENICLE OA ?' /I IoaR4.NR'Y/M [I1?6 !7F [A:?. --,. .• >. A'•C /eLQ C a/rTQi S O??^L.G?E1 /„' ??L ?""'+.' ?, 5 LIABILITYINSURA EINFORMMION-VEHICLE FI .Y- covERAGemuTPE `E THIS ACC DENTONT R YES CAR ? NO NMIp-µR u61c]rx N3uwAt{cCro1:1^+apL4ER, , r >u ?'?? . 5 '?".Y ? : ? •'"' j MEPFlf 91L ` 1 . , . . . ? r?? .? i KrIHuryR?NCE;'C p ? .PP,r ss.3 .a _r »7' . a ?•vE.?S Zr ??-????'?.. ? ? ? ran R - + w\ N ' ? , . n ;Y ]S •/yO@Y.::r pA'r. .. a .2 C: N UR -e.. wy.LRU.ui.:w,u] (ice AM[ x" ' '-? - • NA E 11 -.. Ao [ M F A -0 [ ® y[ ? I ° ?? WF.?1?rLSMAY?IpPCIE$D. - -Y"!'s-s .BJ,ATUrSOF INJU Q J, ''8' ' I(SIB?TONBnHAT1? u I., IN.ytwk;- T. ILL[D P??w r Iw roa.: RILL[ , n , w ? ? 1 1 rou... I ` ®? wri iuR r ?:u rHCMwwlrc.IN. ? 3? 8? r7?" ? `I u DrHEP avr. :ET• ? g? gQ 7? 9 H O w NORTH eY ARROW rN clgt l[. - ?p[EC?ep?:D4OW J? }} .. ?f.JYrui13?PJ.9S9?1 -?w 'A.A N?PP[,?O?pEF?E .RCTQ?.E.?l(ST+Sr?> I.?; ^al:f,?.?..'..',,,^„1? . H ?r2.?,•E[,y'_-_rc.L_ta•?.1]uC_?ca?.aci.?_ ,: p,?> ? a ? -? C?. Qom- C v?'+ ? ?? > ?f 5 h ?_ - w1'' j^ /. G_xf•3 _d.-/Y.c.?Y-<,.%_f?.....J-?.:ec?,-s..L:[? i -mac . y n rov-7# / cu, ?G._4acao?sG.3__?-? ••-- rk{F' . L.I _ _^?•?LL ''??ai•JiNPl GT/1i UGGL. ? ,( ?3. ? le'] ...,r, .. x,An ? I C :GGJ/?e?l..[j? ..Wf _>? I?CC:., (LC vtLr"' VEHICLES POSITIONS BEFORE COLLISION nP [9rlowr[o er v[ rL[ erA [n o r [er PR H a. n INV _ Yo IYO R?j •"' ?,'k^N". Sr T"`.y i t ,,,,?• ?/ ! r-??e p; ? r.r,aL ?=1 N [ ? I-YJ LJ ? O na.[ ?r.f r/ r'YYl L!1- ? .ti" ?.M .Ji. 0= r. y r? -??T n ?? ? lIy LL?/ ° ro opl'MAY Q N? I'LLaNO''4r+N. .t^:.....1 ) r r .I[{. A?"3? .?.°} 5 R0861NG.?r1 ?,L .?. IppM?'? vr - on.. LNOAAf411P_ T!!S??Ja. .rsL1ON,TCONOIrpN9.fc ,JJ1IrFFK QN]11aL oR[ PI OF ROAfI. 1L.i ...r ? {IN9_._F, S1 vr??h ( RgrfR.`$dIQFEomS , l: ' ^ ? c i.! oR IArPr[r ^[ 1 ° OA ILIONT ? II ?? ]9 G L ? II LN[ WA,rI O II .--?OINO 9TIAIaNT ANGD . Y rill ORT ]? RNNINP .0 DAWN El ] 1:1 ! D y 0 L 7 !1011 •? Y J TWO WA r ? ] ? 0V [RTARIN6 AND PAIOINO C, ? wTT ]? -WINn 1 0 0U-R ? ] ? YI[LO fIO NLV [RfIR [ N ? ] ? I ? ] F] •AANIN6 RIoNT TUR"• 6 r • El F q0 `^ ED 1? f ? 6NOW . I00 • ? E] DnH rf ON[[T LA-NINE I:,p El [ ? IN < ? H. .' I ? . NARINO L[IT TURN "•? Long gN.ngr[r n ? Ir[ _ i ]? iv[urvl ! ? ?.? ! ? rusNlNa AMnrR ?? ? 1 ? MARINO U•TURN ! ALLY El r? ? - •? NO r ! rT n ? f ? R [ rwo wAr. TR[IY LIOn r! R 61GNAL j LOwINa rr rwN 'T ° ? Mnt i1 t fnNF9'YR!A IPU.q.P 4ANO(q T ? S?[foY ?? T El o,, c[R/.LA..NAn - I n.mr e?.•.,.rr. r•r. I R[ ? STOPPED FOR TRAFFIC 0 , r q Ll U % < rl' -1 9 RAr[O ' ° ? STOPPV La NO L C' ? ? I? f ? -TOPPED IN NO DWAv,;;' 0 /'- r fc -? ] V O[D L.I (-? rARTIr101N r/I ??: ?? \ r? n In ? nr ' [ vl ?p " ^; TY e.:n nnn ice 1 ? Y t } I? t t K' r K + /rFr? • ?a L t' tx V S 4 i ._ G I 4?? i p Q of .'? tt(( IL{? X! F S"IpK ?y ,'Sry G ?rp ?f I ;. 1 Ir , r \ MOTOR VEHICLE COLLISION REPORT NO. .XTEOFCOLUSIGN DA A, I_ I YOFCOL Nfs NFD USION TIME OF COLUSION AM lx nWA Mwu,fs COUNTYNO. CITY NO ? nB F y • ? COUNTY 1111,10WN XXNT? FIT .?Q,'.Tr.s. 1?? V'?i?\? ipul I-E now F. MILES aO CIi Y. TOWN ©© OF AOM PREFIX I /ty HEFT !/,Ean SECTION I - W 1 dVE NAME OF bTREETtPOA00RHGMWA/V 0/iC!<. T!-Gn't7??•( LRAfo',/' "?( - WIERSECTWG WITH: sIREET OR MAD /?SL'/v'??' ?? ?'/?-? P. EO. MILEPOST n j ?i L l ''d-. eq: LUS N -INTERSECTION LOCATION OF BETWEEN STREET AND STREET RAMP •L 101111 AM DATA - )5p' IF .1 Q© xAAAOAOCPO55w0 uL[Ppsi On[iOEMiv nc 4xlKIInK P. BxIBGE I.ITASECTIW i[[r ©® O INTER ? NON CL6. • RFFn?IICfOLnOSS 54nFEroi Own n?OAB O ) t014 OwvGKO ? ?v[niLIE V1. KLE p?VEx CLEIVCVLLE QOIx[nl-LIE) / vEx ( ?• w ? ' ?K 1 " S MC E.,' o<v[xcLFS I. ?J L[ P[oESi n w ?NDx tauv orl ? xP A. o nK LI B ) OBJECT Si?UCK InAMEOE -SIMJCKI OWNER OF OBJECTS NAME AND ADDRESS _ LOCA LL ROA A-u 1+C? ,wh I LL ,\) O TION _ O r DWAY FEET onL .. _ • • DRIVERSLASTNAME FIRSTNA3[E MIDDLE IF NOn[ 1H5 TKO CAR e DRIVEflS LAST NAME FIRST NAME .. MOOL£ }i ?, .. 16- N "T[AJ h LDQ Tc k wEAE -E. w Tn s LxD aNOR V ?. STREET ADDRESS - ROUTE NO. AND!>0%NO. u0PE 11. IVA STREETADDRESS POUfE NO.AND M%NO. '± I A Y CITY - STATE ZJP CODE f %uVEflSOCCUPATION O CRY„ STATE ZIPCODE Of11VERSOLCUPATION LMIVERS LICENSE NUMBER SLATE SE% DATE OF BIRTH IAGE DRIVERS LICENSE NUMBER STAT OATEOFIT AGE . %J -Cot •-tA+L1 • fJ ; . F 1 v4 M • "A S? ?ll? M ., VENOLEYR. MAI(E ICMEV DOCGEI MOML(NOVADART7 I ?;, DOOV SIYLEIR DR.1 YR VEHICLE ME " T ± T STATE LICENSE PI ATE Iq! STATE TR LER PIAIE NO -71 -lp? 2-s W? . STAT LLJpsH NSE E PLATE NO... STAT TRNLER PLA P • IIBBBMODELSSNEWERI NTIFR:ATIONNO VE LLE IO DOMETERIMILEAGE) O I1ObB MOML56 NEWER) DOMETER IM LE GE VEHICLE IDENTIFICATIOIl NO ' NI . E 3?3? y?`B t#a y . REGSTERE00WNER (L -FWST'MI)DLENAME) DRIVERS LICENSENO. J1 Wffir,7J; Lc15 Cflf!+?N 1vn- ; .--IL-L1E>rYt REGISTEREDOWNER 11AST-FIRST MIDDLE NAME) DRIVERSUCENSEMD. OWNERS ADDRESS IS'REET.GTY AND STATE),. DATE OF dgTM OWNERS ADDRESS (STREET,CRV MID STALE) - I EOF BIRTH ' PM150F VEHICLE DAMAGED [STMAtEOCOSI PARTS OFVEHICLE DIMAOED ESNMAIE cost -y, ...? Ip nEPNR VEIxcIE\ ... IoicPMnv[N,:LE a?r?:?.. • .? c G WAS THERE AUTOMOBILE LIABILITY INSURANCE LIABILITY INSURANCE INFORM ATIONNEHIC LE NO.1• COVERAGE IN EFFECT FOR THIS ACCOENT ON YOUR CAR SfVES ?NO NAME. ,_MESSOFUA&UYV WRANCEMIJCYHOLOEA NAME OF LIA&UTY INSURANCE COMPANY. ,?5 i nI? CA2 Vfv 14ti\r,h\.Ff•rSJI. ?ZL C l;Lfd('.LL1\ sILuT n? 2? 0 2 N r j.'? f^ }l3 # ??? r. 1.1 &UIY WSUflwCEAGEATT OTV AMEwDAODRE N IAIE SP UABILITYPOUCYNUMBER .. .. .. f1l. ry,' x 7 W-. N1\ ?•:\\v r t_ c?;- ?L\ut\'.S:a\l 1STNJUR1 _ IDE LU . I ?NOIIIIURY; IusESEPAnAtE a[POAI iOn AOOrgxAt lxnAnESI AGE T?c?i i NAME ? ' "? ? IOtAt NAME - •. ?. DDRE. SE% p O ? ADDRESS M %F ? ? - _ _ .. o`" x _ . -__-._ nFloNx.A000,on+ EDE3 °N°.LHF 5 ? .. ' STATUSOFWJURED MAR.-S TORET-TAPPLIE Z STATUS OFINJUflED MARK FIRS T ONE THAT APPLIE S pwtA KHICLE 1 A llEO o15?AMMw SIKH FI HON dSAet M I MSYBYE II[ pD,inl•uCl EHICLE 0puvEn OP/SS[xGFR KILLED yip FI eLNO c u I Pm.'S,xLL IQ vu =7: O0 ? S? 60 oF 7QF I OKO ? 5? 6? c 70 .HOW NORTH BY ARROW IN CIRCLE DESCRIBE BELOW WHAT HAPPENED: (REFER TO VEHICLES BY NUMBER) L , O a,nNF 1R.. Mnrsn \ \, $OnI rI.6. , _fK[(cC.,, (C4.?G (G?:1 _ _.-!' cEG?GL'L j' CL. . _ & Y [ wMxFn F¢ w10v Bw[c,oKr: \ \ SIA<L . . IMI: ?'"•? -- ?J-?11L r' L _^"+ ? ` - . ,V • ' ?.. ..? .. .....__. V ?_r+ ._..? ? .._...-._ - I f ? ? ` ???1??-4'.St' - 6?l•_- 6t?c... t-L? A wA-'?/y,?' G %2f? ? t ? L / ? Y a ` ,, ? F" _--..- (,... ..M T :> C _L .7.,2 -Ct'• -..- v_- 1. - ---_.-----` F ? ._--'" s Zl ??A:r/ ?i.G.. LLC.,i•c;?-[i_?Y "LAl 41 l rY' ._ tom. _ ?.,u L?,?..1:?-• ! c>?c-c)- -?1i4 ??? -ld_rl...;: ? - - I _- ^ S VEHICLES POSITIONS BEFORE COLLISION VEHKLC M S F ON STREET OR MGHWAY NAME OR ND "AN .nK[o v,iLE OCN?O NVk TOAIED BY K Nd, nClpn p[5?SIAWO LlKS VFW IKS AO ?PA p. ?onpUC O E -,) b J,AAe ? ? ? ? M ( O ? ? O ? ? ? ?DnJL[ ?c M) A, HAI ? ? ? o ? ? ? ? ? ? p M.Ha / •? nnalKwA ? ? ? ? .oNG cKOSSNa FROM DIRECTION to DIRECTIO N . yG n c V Pf MSIN.w wwt U&NG Ipr•MwAIK 1?WALKWAY G? dWUIMR Ap [irx vwur 50 ,=.u+ 800TNER t , „Iy; a» Trr: I Y f`v ROAp TALE WEA1HER U TCO10RIONs 2V•[[MI yr AO[ E yT I ? DAYTfiHI IAU`lccO'NOL A:MC+PKI vlKll ? 1 ? 4GNNS TYPE OF ROAD K,G[ II',•[C •+DN[ pl 1 p[ME WAY p1WERIVEIIOLE AC1gN9 [KU KW[+ES.L to UY41 p GdNO SIRMOHI AHEAD J j I ? f{ y Y N • r 0 1 OOAv ] p AMANO J p DAI[N p 2 p STOP UGN p TWO'',AY p 0 ? OARTI.KWO AND PIASINO ? i ?w[I ] pYAYTA S pMSK IT ? 5 L"Dw p .t p -'r, -N ? D ? ROFD'IDLE I KC T R ? ] p MAKAIO R014T TURN • ?'M • ?DARi SON p [ O cir a ? OA ICNYI TI ? DARK Off[T 1-7 p S p ° EyY DAA+I O A.? 511[EEl lOHT9 II[l'OH fOP 9,f[WObANO[A O1Hf YQ RFD ? A ? FLASH ? 5 p fUtnNO AMM[R ? e ? M SIGNAL r 4AN ? ?.'.1."'. [ G p • p W ? e ? AlO [v/RAMP) NO WAY ? e ? IF,, TURN LANES ? • ? Ma+P Glffi TURN ? E p MAN NO U'URN ? IT ? .0WIN0 ? T ? SIOPP[ D FOR 7BArF10 u f f 1 1g ?4 1' C4 (y I 1 ,1F ?? pp tlr !l {f?E /??f•{?A •?i I?1 G• [ e "V ?i-/ ! LL ? ? e ?ONrtR u,fc- ? ?. 1 .. [MIMED a SIOPP[D AI fAGNM ? ?OR s10P90N { t / /. ?. Il r t' ; [ ! U I 5°w CL It C f`C f C (1.. J -?`?1°"°r+dl? .l.t. ` -S NO IIC ]?_ _?S .vw%:.. .. , a P ? MNMO . L,J D u [.Ymeo :?F R'M NFO D AY S I--I 10 p s'oF LrJ?,. i yt ??, LK •. .1, ?..` `I L `???LY ll jf?wl •?, '? ti ?,L > al ' 1iA 1 i (1 I A ? dig ,, a T 1* #F i ?tf MOTOR VEHICLE COLLISION REPORT NO. GATE OF COIUNCN DAY OF COWSION TIME OF COLLISION OaV vl? sun a.Orl 0 nvR F Sal Mwv,[S A4 H? : O 7 Pw COUNTYN0. CITYIq. ?? 6 •.,, PuEE ••{{?? HTY CITyyY.''T???OWN NSaf MILES OO G' IN TOWN f ° ro ADM C45 PREFI% AO/ 1E aR 61 A[[ltd% SE iION il cI i ?}?. , 1KCIl?4 f W ©© OF ? j I ? 3 // IAOWItn°1 LKVENAMEOFSTnEEi ROADORH GIIWAY NTH'-VIG WITH SIREEI OR ROM PREF11 EO , MILEPOST , -EU=- O e 74. ,S IC SPY S NONcINTERSECIIONLOCAigN OF COILISIpN 11-5Y E%+%E TA Lo - wa. tl L61 y(/??e [ TRAMP OIAGRAMDATA BEIWCE .f [ '?/ y L'+i EET AN6Lf?'O?QL(n ^' ?- ??" { T (r??ii p ea°D b"?.©?y' 'x RAA80aowosmq ulcfvosi oa w[nNivwc uxaawK. E NON %flp Nl[R XcRWI: Efl T CW. "'? a {j9UUCLf v[xCIF ?wH LE aCrtt (]OInfRIWa1f1 M'< ' ° Y [ SPEL. CODE USE „ELE or ver is lo L.-Jp E w ? rON Ca U. ?rcllrrRUN f 1 OBJECT STRUCK IXAME Or aUE Li 61RUCKl OWNER OF OBJECTSNAME MTD ADDRESS LOCAT IH ROAD ION O© O WAY [van OalFt FEET • r DRIYEASLAST NAME FIRST NAME MOOLE T»O D'WS a R ONVEflS UST NAME FI Si NAME MIDDLE _ .-O 7 s STR ADDRESS ROUTE NO.MOBO%N0. TWO STREET ApDRE55 ROUTE NO.AN000%NO. GTY -.E -Tl A , O STATE LP LOGE .? c,?L ? ?T il ORrvEPS OCCUPATION CITY TATE ZIPCODE GEIVERS000UPATION {{VVEE SR RSL ETL EA CJf./ STATE W OF FYRTH ND YEM AGE DRIV ERS GENSENOER STATE SE% M F MTEOFBIPTH DaY YEM AGE - zZ 3 / V In Y VEHICLE YR.. - MAKE ICHEV-DODGE) MODEL(NOWDMT) BODY STYLE 1113 VEHICLE YR, MAKEICHEV.DOFIGE) MOOELINOVADART) BOD151 YLEIS Dfl.J 77- o f?U?? P, U( ?? ?,?w LICENSE PLATE NO. STAT .. TRAILER PLATE NO.," STALE LICENSE TE NO. STATE I TRAILERPLATENO.., STATE lJln ? VEHICLE IDENTIFCATgN NO. I'.EBMODELSd NEWER) OOOMt1ER(MILEAOE) L VEHICLEgE 7TIFICA IO. (1968 MODELS[ NEWER) DOMETER (MILEAGE • / G- l/ C <' C, ) V RE EREDOWNER (LAST-FIRST-MIDDLE NAME) DRIVER UCENSENO. ? REGISTERE OYME J 1 iFIR5TM100LE NAME) ORIVER5LICENSENO. . rrti?e - ?r, OWNERS ADDR 53 ISTR ET,CITY MDSTATEJ, DATE OFBIRT. OIyt1ER5 ADORE. v (STREET.. 'Y AND.-El GATE OF BIRTH P •I 90F VEHICLE DAMAGED r luart0 ppniS OF VEHICLE DAMAGED t 5 G S'f. !' .?•• •.•[ `F sio lEawlOlcLE Sioxv vFH°DtiEL ' - _'., WAS THERE AU70MOMLE LIABILITY INSURANCE LIABILITY INSU ANCE INFORMATION-VEHICLE NO. I- GDVERAGEREFFECI FORTwSACCIDENTLNYOURCM ?YES ue-11- '? ?.' `+? NAME AND ADDRESS OF LIABILITY INSURANCE PoLICY ssHOLDER prv S-E [m NAME OF LIABILITY INSURANCE COMPANY J NAMEMDADDRESSOFLIABILITYNSURANCEAGENT [ -1 DfaiE Zn r ??? LIABILITY POLICY rvUMBEq ?- • h . :' .IST NJ[NY ME ZNDINJURY: IVSESCPaAMCPLPaI. ORADa1KK1414JUAV51 ^" '? -. . AGE " NAME - - WOTA( NAME - ADDRESS SE% DURESS SE? .O. Q Ff ED El nr? 1b. L_J w.ravtl El FBI S. STATUSOFNJUREO MMKfW51 ONETHAT APPLIES STATUSOFINJURED MMKFRST CNE THAT APPLIES T $ OORrv[R , VEHgLE wlw0 NOrl wnv asae[ma wuc ?f 'IE ?p Q roSMe[E P.•JU wa^ -5111F0 F1nRE1 Mwon Y INVEHIIXE _ _IvYI[-0 [ DYE M . f.. 1'oFCr u is It rq ` ? K - KPFI -' Icl ILt4D ,. i ? u1, N 1 ? _ 6? 7? .r rr.?•. ? 5? 6Q ' j?E SHOW NORTH BY ARROWIN CIRCLE; 1:. \ p DE SCRIOE BELOW WHAT HAPPENED: (REFER TO VEHICL ES BY NUMBER) i ?( C mxufw,w aKnau ,? lA wHa1nNY'lxcD Y ?-- 'Two, °" n•aHW.Y 4:,? DR \^ ?\I i `. [? _ l?_. s,LA.?ccc.c ?w?J r?JtL n (rMwK M.V•WA \ 4•L. ?.rLi '. .?rccaL? ?c?_f ?7 I wHttf AND A ?? IT fD, arDa.wl.. 2 • _/J ?i RI Y y?" L•1G f ^ • * _ ..... ...I ?? - ? ?"lO;r'lC ?Ql ti/yg?l+?ts.? LlvL.r?{?yc1lR./'W. E.'O?•E.'Cr??----- i ?? /i ? ? /1:t Ct J %l O'"L!•`z,j.. ?. f. ('LI'Yc••6'C. / ?C • Y I WYAA•. I - -- -_?-._''-?" S ?Cyi.?'c2L?. ..ffa.tf. L[t; '.f_r?e ?^J GO ?' i-..': 1 arl4.r[w .,.wf. ,," i ' _!X `?.2.C .C.c!-*-t.?,-:-C.. C(?_..5,.•C+.'Le?C.. C!tt.C{. VEHICLES POSITIONS BEFORE COLLISION RD lwcw vIJ,Ml AA„D Ws INVESTGAIEDDY nlr 31axa40 I(D S?V?Aa[D R ? KrIICIE N 3 ON dl STRIP OR IFIGHWIY vlxG,rOCC O? NAMC O N .VR!/rp // aKFtllOx r D,pa1RMf 0 nIR PpK:( IvUR ? ? YJ ? S.f.(?CV A: L?G .1A A 1 r? ? ? ? ?r0ou(f 32 Rrmetl {I? Ti ^ No Krnul ? ? ? I I ? ? ? ? ? ? ?AHIRrr NDraaMK ? ? ? ? Al ONO I. T°Alase•ra---- - -----.- .rnou DIRECTION- TO DIRECTION ,' IH OI aIRWIWU USND ---I?3M WALK T?yµ ly-Al 3?9g;LOEn ?E:wxv,uA aQ ?Ip;wy°II eQOTHER ..; ?. .. rµA' fq.0 S1111r ACE WCA1HCn LIGniCLNdNOrv3 Trill eq CONtnOI R.ae+eAN1 TYPEOFROAD dvVEfl/V[HICLE ACtgN3 4R R+f C,Mf r.xC wxCLI KLxInI,WI v iII[II I<nr[vMfOR,(IWI p . Hxcu F , ??>R.u, I,(]'oan%wr ?? r `MQ sg4ua ?1 , ?. w.r ?r I ? DOINfI3lnNpnrAnEAp ^: ? ),. ? s r 'i ' ©4 Y D ? RN•rMaK o'? D.- Q T ? 51Op qN G t Qiwo WAY Q t ? OY1mAKNG AND rA551NO ? ? ? z ?WIIT ]QsO ) fD Q 3 QvrkD LcN ? ] Q nA'NPLE ? ] Q •1KINGF,C"T TURN ?3 QaNpW 'on DMEK SI nI Lr e [? '?LnHID ON Q • ?n.rxMD nrD ? • Qlooo a:"MOE ? + Qu.KNDUR TURN I,. Q QYOrDryCrKR ' QO' CI I a QE WnaO f(f ? ( ? It.YreA AMR(R ? e 0111f Y Q 3 Q UAKMOUIURNYf ` ?eLJ VV M1?GiRIkI,M 13 0 a ?IW w(14.L 13 e QlliT VAIN ? a ?N.OWNO {' T IL .r r Kov TOR wTS[[p.G O.4G(r-i •p ,?.. •h and f(-°ic?Y Q r QarK(n rLA:.u.N Lw[a Q r []5lornkoroR rn.rrlc ,^a. rf;J:4" e Oinf 11 !flGry S.0,1 AIy cNAt iif;:; A Q ? ?-QuPM.rm ? a Qr. C F 1 ?%ua4?imh%A s r. VEHICLE DAMAGE I:INF CHSOK.CWCIETHENUMBSROFEAWOAMAGEDAREA AMP r - t!.°y„ INSTRUCTIONS: aDIUNMHOW(S)rOb WPRNCIPALLWECTIONOFFORCE. DAMAGED VEHICLE NO. 1 IUSETHISSPAGE FOR SKETCHING DAMAGE TO TRAILERS, MOTORCYCLES, ETC.) DAMAGED VEHICLENO.2 1 13.H 4. Ibol f IS HDDU r I /? Nbx_> t? Vf}r???,1` LJ. 1 I4. Rao1 l? 15. TIUnM ! 15 TIUnN Ia ? 16. U,xlwcenbcs ? ? --1 UrMwcanVya IH ? J . 1 T. alHMK - .. la f u -e ? 1>.am„n. SEVERITY OF DAMAO :VENICLENO.1 1 HUNG DAMAGE 3QOTHER4.V.DAMAGE ] FUN TIONALOAMAGE 4 NODAMAGE 3EVEPoTY OFDAMAGE: (OTHER 1QDISASUNG pAMAGE 3QOIHERM.V.OAMAGE 'L FUNCTIONALOAMAGE 4 NODAMAOE SEVERITY OF DAMAGE: VENIClE N0.2 1QDISABUN6 DAMAOE 3] THER M.N. OHMAGE 2 FUNCTIONAL DAMAGE 4 NO DAMAGE TOWEDGY EST,O-uE ^ Vv TOVIEpBY EST. DAMAGE E31,OAMAGE T OWED BY TO StL?~ TO = T O -. a DIAGRAM OF COLLISION t 0' ~I }I ( - ? 4 '- r T-? '- f- I'-- DRAW --i' N RRO ORRTH I W N C SHOWIN6 IRCLE IYIADWY F ruMi! F _ , I I .. _ __ I „ MivATMCaWtKU?cFpil I I / _ - - F r A BLecONTp ] W I D B ' • - - _ _ _ I ? C ?i? ? I T M? ED MK C I l! a I a C ,, W_ '06tANlAT.=% asHOwvROee°WMnEON 1N--L : H - ' - - I I An?o ?1COLLL?9bL°?OR ^??y"7n? ? i ? I 1 _ 1 - H ? I 1 . S} 4X I i. li I r '?UE$CR?PTION O,F.?!W+?!!:`S? COLLISION jj??„-c;,. is yw pNDICATE WHAT PR03AM OISA&UiY,REWCEO V131 Y HAPPENED BEFOREDUfMNO Af1DA Btt1TY, PEDESMIMCWMINGCOLOR FTER THECf1A5H,INCWOEINFORMATIONNOTON pAGRNA,EG.OfM/Eq CC? S3MUCno.ORREIAIRWoRK ETC.) ?• ? 53 t? 3 t -? S i . t,.??, ? v? o- ? ar> > ?,-(o_?' o ,, - --??`-" } .? ? -'- - :s7 zII (NE-t__5_ h -f1.i-o -?-? S 1c 7y 1_S_- v.??57 Zc jr . 1. N. .. E LLI. wyT-" J NO.OFLAHES S EEDS VEH IF PARK .EVEN. HEADED MIIE PO ros' B.Fe LEGALLY WASVEN. T.D ONSTREETOq HgMWAYNAMEOR NO. WONEDIREOTION DS NO. _ . YICREASIHG OECI?AS°Ki •' -? PARMI) El PIED N E W -{ ` - ?? s -- ? z , IL IJ 3 \ . )- YES NO YES NO --- _ _ ? aoc n __.__ - -. n 1?; PED. L_? ? 1.-J IN. calnvn °D rosv [noN- _- µ o 0 a> Rcow.l IFD/OICYCLLSTWA9 USW F ? O: II__.IFiDewALK ° nwA '[7-.AD wFA vwAU ?n? °n ? N?.Ler Ri Eut ....--- ROAD.SURFACE,, IMlM ONG ,?.IWEITHER;yw IDNEDK OMJ .CONTRIBU Ic »+E TING CIRCUMSTANCES IKCx ??OR AKAEI .. ,y ,,,;,,?,;,; {?1 yTi.c ' ` L CS 4 1: r , Jmi.eorwenpocLIIAC•rlnt+<N,=r. HKae MOReDI°E O01NO 1 _ l J_ w± !?w,eeFr r 1 H O. It _ _ L-! " LC° b= D I No ] !o LcL?FLr '-1 ?' ! •r:+ I No > R J_>L 1 _.anAROEOwAAr ! ? w"oNrr,KAO 1 r DID: mM`Ay o ^ l ? -1 ' I 1 wR _ a K,w.wO _ _ '-' _ I?1 OEMWSwExCeOF _ _ ? - !`I= - - ART_ .`__ 1 + (? e ? T-1 - MCI' FAIK" 0. -_rI ' OD ?.-.. l Fa`[ AT .. 1 0 1?'1 I? ?VP?POVfR L_F'CT'E[Wn. l LS - . U.lu?Om ?°[? _0 __. 10: M ( _ ? -7 - 4°L.1. vrrtD ?wr?w J , ? _ __ r - ? _?..: ? . ?°o.. °°w?"° hY I! T!D DDNKr! IC I Al?AA ?° a° n ;D,DA . LIGHTCONDITION3 IcNKK ONq ATRAFM?CCNTAOL';:, M vtnnl[ Sh ti ,TYPEOF.ROAO:. ND ] KV.I<x ON]OA IrpR :,VEHICLE CONDITION t. F % ! O l l ' C u ? i• ' srprFioer lA.M? ? Oq lron NON / 1 C] 1 L] [ I U Ll , /)) f w!r ?IrL? w+ V I vzo x oK M Dr.r? a f -1 cONtnwr[DI l l J +K IilxP w e or I ?-7?f>-t L1 I I °` m j?? ° l_1 ?AVN f IIOo iwFIC L.Wwe 1 w al r ?? 1 . C. 4 °fwD`ls Y 1t1o iTMt°APP&11ON L -I ?° _ . L C J C I T _I J C ] w"a: _ - f p'` ___. _L?i AmNE ---- N - Clr>C:J ;lK IW LM1A ,Der. [ I ?...1 a?d.eDR, -- Dr t%INa+Nxwa ( to lucxNo i) C1 ! J aal° ?..'°L I Ywu 1 ? r I tR`w.°w+rt ?! { rce M; uNCO « CHEM. TEST - 4•-'• 1 r r -l? l.._; ?? (l L Tlar eAT ameP INNeFn r 1-. ] 0nt t lit ? %AD ( ? ] AM lt! f ? 1- rrlr NR V:{D t . ? otNeNnnc+vi.. 1cccl _ _q?cqI?`n ?. /. i nM.q V1--LaNnu s1-\V?`-{1??.> ?? I j prAmMO _. _ V' I`? 'T ,r.cZ JII D^t" 1 ? . ,?onunro?nvl .. ..ro,u _ l)t?Ctl ?! ?L1 J'wa ,x % TEST RESOLT9 n*1L??LI aedD' .?._ 2 row i;;'ovnL ._._ K'07 a '? X, -n3-jam-' .?. I?t1 ? mnirc -' a rz I i . r man= 7 S A. R ?Y'??'Y ?TG?O?YCA?S ISI?V? I VIYPAGEyOF •O. ?`• ^ POLICE COM-NUMBER ... .- ? ,1. •9 .!AI!• UNIFORM POLICE TRAFFIC COLLISION REPORT a= ' Iq F[1 D DAi OFCOLLIDION DAYOFCOWBK)N TIME COUNTY NO. CITY HO. FHV ` .J S)?3° j (1? ?V ??11. T SV I MUV 7 HIES 5 WED " IxUN 5 FRI a SAT IU?4 NI J ? RURAL - f I N V Z AOMCLS. PREFIX ROUTE OR STREET CODE SECTION OUNTY ?STATE ROUTE COUNTY ROAD ?CITY STREET O ??' -???? ?OTMEfl ISPECIFYI y ? G39? ? ? ?r ??., S'a L B E W ? CIIY OR TOWN W PREFIX ED. MILEPOST' N f (? E, 0.3/ kd"4tk ??,',/ C MILES L-I L'-f ,OF?CT?EET ?HI MWAY /03% INTEPSECTINO WRH: STREET OR ROAD LL RAMP DIAGRAM DATAT t T ON , (. , 3?sr NONINTE ACCIDENT INTER NON %RD NTERSECTIND STR E OR ROAD OR REF- yySTp (A ?jJ>T /o=>! ' O CTION INi CLS. ERENCECROSS STREETORROAD IliiaaXXYY 4 Q MILEAGE / N t N BETWEEN •--?I'L"`? " TEL I Il?? BTREET AND /STREET CODE DI91ANCE,WDORECTI0NFROMREFERENCEORCROSSS1RE BPECIALCOOwO USE T ET, .. ?MILES N 9 W -r ,/? 0 '? c 4w FEET OF TRD'lt?I'LL? Iyl? L it "3'A kt COLLISIONINrVOEL?VED: ? VERCLEWEHICIE ?VEHICLEBICYCLE ?OTHER(WRITE) ?HRARUN NO KILLED VEWTY ? . TOTAL NO. I? ?VEHICLE-OBIECT ? VEHICLE RR TRAIN ?STOLEN VEHICLE NO.INJURED OF HN;LE9 ?VEHICLE PEDESTRIAN ?NO-OLLIVON ?HAIARDOUSMATERIAL ?PROPE-DAMAGEONLY VE 1 OBJECTSTRUCKINAMEOF OBJECT S'T'RUCK NJOOWN-/SSVNA?M??EI ?LEOCATION OFOBJECT SCRNCKS E W ESi. DAMAGE L i • ._1J0? V?kY?OWY CWNLEC. Id ROADWAY FEET???? NO EOOE S 51'R''G d T, of ? - yR 1*c DRIVERS NAME-LAST "FIRST ,. _ .MIDDLE DflIVER'S NAME-IAST FIP9T MIDDLE IIF BICYCUST.OR PEDEGTWAN CHECKIU. ..r.. -. .. 5 E D } D ?SC?nt? L°AKL Tl?,o } R B TAODR R STREET AGGRESS ! is E CITY STATE. LP CODE PHONE NO. RE DTY STATE. ZIP CODE PHONE NO. R k IAD?txK WA 98a3`i 7S2_1/g D N DRIVERS LICENSE NO.. STATE SE% DATE OF I.T. BN DRIVERS LICENSE No. I STATE SEX GATE OF BIRTH L 1 Q• `I -7 DAY YR. Q• MO. DAY YR IV DRIVERS OCCUPATION FIRM NAME PHONE NO. Z ORNERS OCCUPATION FIflM NAME ; P _ EN df y? CODES > ul CA59 IeL 9`E 1AT BELT /? ISI EJECTION CODES ISI cuLISfls IoI SEAT BELT ISI ELECTION ATUNEOF "R , xt. .al ttAIURIES F C_ri zqA VOVL JO t?4,V'? f"l S! IWURIES rl R. 1 ,L AC\ TO REMOVED 1-l" ED?N FROM SCENE BV: TO V N BV: IjAiq' VERYEAR, MANE IOODOE?CHEV.I MOOELIO RT.NOVAL STYLEI]OR.CC-I VEH.YEAR MAKEIOODFECHEV.L MODELIDAflT•NOVA) STYLEIS OR CONV.I , v !,eel k P-t c. loocc. ' ? STATE UC. PLATE NO. TRAILER PLATE NO. STATE E VEH.COLOR W. PLATE NO. STATE _ TRAILER PLATE NO. STATE ?_, T' -. u •• ix E YEN. co- " 6gtg 'Rua (iFl "' ' Q v H 10 NOFCATVJN NUMBER ': '. .. OD METER -: :,. C VEHICLE IDENTIFICAII NNUMB ».:,; .,... DOOM T R._;;'ri ,,,;•?• x L E q`t1Do 30210 L E - REGISTERED WNER-LAST FIRST .. .. MIDDLE RIIWTENED WHER-LAST .FIRST _ :. MIDDLE " N O $M vc-L ?flvo? IN ... . . .. ... . 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I IlC.. ,k I Iw J L?y I I I l f ?? ??? I +, % E? , yy Y : . Ilk R i ? I t TM _ :2VSNYR*d7 ?*A1M1'A``KI ? -DAT¢OFOLUSgN 0 p '? °? ? 79 rw /l 1YOF WLv N JSION :. TIME OF LOLLISIOp Ff AM ??:bU ?Q urF PM COIWf\ - f 4 U v?.??.?•. ,.A...,' ®aU nACE COUNTY CITY, tOWN FroulSOE '... ,'... .... CITY.TOWN ..'.: "E" ADMCLS PHEFCt WrL D1 Cw• SECTION GUEni i.1jr F--JE'C' /J - /}OLoc?l! "o°CW:'NEI ©0 OF NO r0•D ON dVENAMEOF STREET, ROADOR HIGHWAY : NITERSECTINOWITH:5TREETORROAD - pgEFl% EO.-,,, LEPOSi ; ?, pr GS DR R S'7 ) tYa z . z ) ! O D? ?it L NONINTERSECTION..DCATIONOF COLUSON fiAMP Syxw dl:riRAA1 DATA NLY` Y/? 1 i i yYYh 'vr x BETWEEN STREET AND STREET J IJ ab ?MtFfOSIOn'ioEHi 'VIE. ?L M•w . a.D P c 'NO %iiD WTER WTENR Ctg E Ef WM•° aE afnCLDOrDa aTRL[rONirO•o Er ©® °./fi-1 A v L S P .- 8 8.3' r/t,? 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S 1,,_ :' `y ? ! ? 1 ?y? ?UNdV10ED ? to C) TP31 OFICOFNON .NMI S9 AMl ^ >Y 4:: V AOdIt!l. ?,A• LA... a.t 'L GC1 ?yy-_ iF K% .4 MCyj ? IT ? PARKED POSITION T? R ?y I I t rr11'?t" T' )? -?• f ?-:. r??` ! r.- . ,.P ?{•,.•? `?,"1[(' ??:a? a 11 -i f I4:'h I? I ? III, - ?G ? , Vill APaA ' c s ?.>/+.u, ? Fl'='?/ r "`Aw Ln /? © of t 3. ?, 6`3 ?F5C7 ON ENAME OFS7AEET,IgADORNq WAY .-,... - .2 WTEPSECTWO WITM. 57PEET OR f10A0 PPERX EO M EPOST? ? - - j O 20 • VOV INTEflSFCiION LOCAL ON OF COLLISION c. ?f ??? ? +? ? ? MMP . .. dAORAM OATA rETWEEN ?7.L?ItiY I+r)-•- STREET (J AND ?F'. •?C.p-[I-G IPE ? H l YR,.- I]© NAAnOAP<IwSxuq«u {rppsrOn nFNflPV rq LA«WANn Ea. MEME NON %PO a(UEC ruq Sra(!l Oa aOA " Ix[GIwN © ® r INTER . INTER CLS 0 U1069xra[[r. _ ° 0 19 63 300 ' r<< ocs I ? )Hw oYEaICLENLE EN'tc D EO t Ov r a ? 40H ?9rNERI-IN ( rl,,., sP coDE usE i' . . ?_.., ??nu=n In.xEar OalECisIAYCI OWNER OFORJECTSNAMEANDAGOHESS. INOOAT WNY DD IOalA" Oalf. w EC FEET E C INVEn5LASTNAME RHSi NAME A.gnE iH(N MIDDLE ?` µ DRIVERS LAST IIAME. [ FIRSTNAME MIDDLE D Atsfi! jii BEET ADDRESS ROUTE ND. ANDDO%NO.. MOa! SIRE ApDP E59 .OUT. W0_ /?{.?• E3?07 } ? ?7U? YNIUEDU E ! gO%NO., " ACA x STATE LP CODE DRIP 5 UPAT*N u CR ERS LICENSENUMBER .v STATE SEX DATED IBM AGE Mo vEAR -/ 7T t -7n S' ' pWVER9lICENS ENUMBER. /]. STATE % DATE FDIRTH AGE ?•'I / M r Ar rENI !FINS-EM-Llass Ni I /EIIICLEY/R, MANE (GIEV DOOGEI MOOELINOVA OM17 SOOY5TYLE12DR.) VEHICLE YR.. MA%?(CMEV.•D000EJ. MO LINOVA DARTJ- DO OY StttE (2 DRJ ' • L C r ? d G?h .yY 3 t -Z.7CCt ?1L I ENSE PLATENO. STATE y' - iRMLEHPLATE NO. STATE . - LICENSE FIATENO. . ISTATE. TR_MRPUTENO. STATE ' IE E OT ?, 'VEHICLE IDENTIFICATION N / 2 O. 0988 MODELS&NEWER) ODOMETERIMIIEAOEI CL VEHICLEIDENRFlCATIONNO. R9Bd MODELSB NEWERI. f pOMETER (MILEAGE) /JalIV9G: ; . - PSioao REGISTEREDOWNER ILAST•FIRST-MNMLE NAMEI _.; OPIVERgl1CENSENO A REGISTEREOOWNER- ' ILAS -FIR -MIDGLENNAEJ r pRlvERs ucENSE YA.. /? V OMEHSADDRE5 J_ +' E e •HA7 -??' S-lj - N N S_ M" S'12G „'.1 .BEET, i7,AONpSTfTE1 IppATEOF&RT F, CT•'• `?% u, OWNEfi SAOO R E S 9 ISiHEET ,C ANDSTATEJ DATEOFBIRTN ......._.? ...._ J V 3 L1 / , r T, , / T-?T./. `luT.. L( Gl?//I/t1I I ..... ... -. .... I5 TOIEP yp LIABILrrYINSURANC€IINFORMATION-VEHICLE NO. T- WAS E COVERM vAM E ANDADOgES I OF-UTY WSURANCE POLICY HOLDER :. p? t <t ?.G = 7K,- 3,9 N?AM-1?E1A,,N ADpgE55OF/UARIUTY WSURANCE AGENT arr 'l=LL/!(fC ,Kt t?J ^ -?.4 ?tiC-l!/ l IG IIST WJURY -,.' .. G NAME ADRESS u -- u.. re.IU/ I RCLE U -El SHDW NORTH OYARgOW 4V G r--PMGa~, o IM f E 9 OF ' PN[C oA mVAwNa! AA"wlROwiOV' :• o UTOMOB CAME EFFECT FOR THIS H15 ACCIDENT DY YOUR CAR ? YES ? NO NAME OF UABIUTY INSURNICE COMPANY 'TAIE ? ?`.? ? i? o?•+..ca G? u.,:r%? --? G?eY ... r. `.. UAO UTYPOIAY NUMBER ? 2NOIWUAY 1 E E..AaAR Pp( fOa ADailOV Es)..` ,• . 'AGI NAME G ?? `_ ADDRESS - 1 - ? ® ® N- ^- S TANS OFINJUAEO MS H C M TRSTETHATAppIIES . W i695; A ° I IE IIOIr aA(0 NN P"1NO R1E ° No ... R norTP°AMnerc ?D En uAlrr. ? 5Q g 7Q DESCPIBEBELOW WMATHAPPENEO:IREFFA TOVEHICLES[W NUMBEA):;., . F? l d „a 4 4 s 1 6U -? ;€ MA[[IOHIApINV.Y . ?_; U 'VEHICLESPOSITIONS DEFORE COLLISION 'rNICID YA aP LANLa vElc[e v[.H LIONIr dIANOrq llOALLr :Il +P.n+esws INVest%LAIED DY PARn[0 v[n [pCC P - Panl N 5 C W ON 5111EET OA IYG(WAY NAME On NO. OM[CIIO,I ? ? ? d [d n' L IlO xrA1[ InEn AO M ? A ?IaIC[ j w -0. c II IOrL{AI ? ? 13 ? (,a .Nl?p-tt J rL0-+'-[•?... o ? o ? ? o V ILxK crx N ? ? ? ? Kaa e ' DIRECTION . . c assND 0 SIDEWALN ]?WALNWAY ]QSHOULDER I SINIfAGE wEAN(EN LgHTCOHdTION3 A?<I, „;wAln FROM DIRECTION To s?c.oaw`.°, dQonrtn ' .•.r S. M.^ IAAFFI000NTADL IC,KC%ON[I e Y TYPEOFROAD dAVEn/VEHICLE ACIAMS . wr.IY I 'i 1 ?v4%H(1 EM - I O '• I l« u I M ! I ? El SIfNKS vH.eR H[e- Q ND]ONC WAY UII1 SN'. vlwela a«leAOaeoruonu v,0 ] QI 1 Q GONOSTAAION -? I QON, 1 + )?"' ] Q IIAryAA ] Q DAWN C) 2 C) STOP sww Q 2 Q TWO WAY TAHFAO Q 2 Q OYTRTAXING AND PASSING .. .. -L JQYAW ]QSNOIMIA ]QMASH ' ? ] QwFLO SIGI ®J 0 1mr SIDLE nom) 1E[I D MANWO RIOIR MAN !M -' R,1 , (QK.1 (QIW .Q? YIo ONE` AN 01 '` ? ! QfLAfA 03Af0 . ? WTfMn1'AIIOE ?IlOOrrnAOPI A ? MANWO If/T TURN , . r ??``--Y1 OI Er I d f ? til[ l IY H( n / 1 D A.nrAl 11 d?I`.:Pl CU YI - L-11%?r150ff C] d ?1lARYYWO AMDER ? S QALICY Q 5 QMANWO UTURH ` _ . AA, -? A Q 4iH1 EYf'OLICNTS ?l A!A]N full IAI N lI1A pAN+iLR ? d ? NI SK 4 ? D ? TWO WAMAN Y, 1E?/I 1L W A ®SlM?NO .•..ARO,vn tnla Kr%Y.x [rC, 1 ?U`EC I""Y 1 ? Of IKEA. iLAOMAN 0 LNICS ? ] QSIOPPLD fOn I r/ry1 LtiJ S I-I O JNGFY ? 1 ? S[PARAIEO TRAFFIC Q a Q ORRID? SIGNAL Pd lei ? ". ....__. -._.__. ? 2 QdwpEO ? 0 ? STOPPED MROADWAY 1111.1OnNAVF l OPf 9, F?/AI Iq l A!/IC ? v N0l .. ? 2 UNI%vIDED SF% AOl. ? STAR L R ST TNQ ? ? 10 ? P- rICLAN 11 DTAAT MIRE. OM I . 1 1?1t?. I y1 ?7 1 O 5 " TION ? I] ? MfNGAIp1ENTEnNo . I . , ,?.•??v i L ...? - /•>'-mil fiai `io'. ,S . S' rn.nrol ?I T: Pcmw ? p wWO ?`? W+IdA WAY 1 ???,?,, 91 +, ? d+' ?t (?pEyg?epgr 1 ? ?? n v]I f _??p, '. I }?? 1 ?H, 1{ nr?Jlp????." ' rt3N#? ':? •?? I?.'id4 ,"°'!l"? i' iil.('? a?y? ? ?1r???? r 1.1/? ?'" ?? 1A 1 ?I ifs, I - '-, I A -P ?y hT( f rt "F i.L M C ? y, FFY .? I fw 4 ; '_. VII VEHICLE DAMAGE IN LACIF tlO"111CLL THL NUMUL It OF EAC1i UAMAGED Ali EA._- AMBLE f? SItADE AREA OF SEVEREST IMPACT C?'• I] • - . _ • ]. INSTRUCTIONS: S. DRAW ARROWISI TO SNOW PRINCIPAL DIRECTION OF FORCE, DAMAGED VEHICLE NO. 1 RISE THIS SPACE FOR S-LANG DAMAGE TO TRAILERS. MOIORLYCLESETC.I DAMAGED VEHI CLE NO. 2' in u,^ ON SF VERITY OF DAM 6E- VfHICLE Nt/. I DISABLING DAMAGE ] ? OTNERMV D GE 1 O SEVEN OF DAMAGE IOTHERVEHICLEI I ?ITYD D NGDAMA.E ] ?Ni v AMAGE VEHIClET104 )i%, %'. ,.•• LIFIG Q u„ DAMAGE ; O OTNEfl MV.OMAGE ? GL + ? NO DAMAGE. CTIOx UN DAI ] ? F CT AMAGE CT I > o MADE ? DAMAGE I OA EST M Al TOwEO BY E TOWED BY .-SAMAGE }OWE. BYJ [3T. DAMAGE ] . TO TO TO 5' - DIAGRAM OF COLLISION 1 I I I DRAW ARROW SHOWING .• i 1 I NORTH IN CIRCLE -} -,-' -- I'- H C i 1 I ? O U., CE-IT1111 M.- I I a ?? _ ?. I z - r~ M, r T a - l a - LLIM 'DESCRIPTION OF NDICATEWHAT PROBABLY HAPPENED BEFORE DORINGAIDAFTERSNECRASH.INCLUDE INFORMATION NOT Ox DIAGRAM, E.G,DRly ?'--COLLISION, m5ABILIT . DUC SIBILITY.PEDESTRIAx CLOTVtNGCOy R?JONSTRUCTIOIIF.R?REPAl41OZ!, ETC.I 1 ti, f. I I ?_ lT 1 POSITIO F . HEADED N BEFORE COLLISION MILE PO I ON TREET 09 E HIGHWAY NAME OR NO. ? "' ONQE?P 1.1, 11 1 iTEe D sa+!x• ,VE C ; P IFeH D OCCI I .0. S LL E W<PEArvG .ECREASING _ - . .. I _ _ •' f,? I • ? Q C (-? ' ' ;? j _ r - --'?,_a 1 • MPn E S -ND Y' ; YES -ND ? ??-_I I ,. . ?S..l.C.^i? L 7 CI , . 1 ,\: S J I , L? - ( - r.D. O'RO55 NC_.. w ww+ if/=LBCH?`y?kJ[Tp W.I ALONG -. ' ix( I - E R PEO/O CYCLISTww HG. ( t-, ]n ]( L 1 EvCL TED .OTHER ITE l cnosswnLK siwiE IstouLDER EI: l K.AY SIDEWALK ROAD SUflFACE .: ICNFCK ONEI WE A KHE -1 fl I I ...... CONTRIBU C TI H[ CK ONGCINEftCUMSTA_NCES OP MORN _ DRIVER ` :'1?' DR, - P IEtl}M iD ry ??Z C"Ic L L 1, 1 DR N E 1 %EZ N a o 1 7 SOFA ONT AHEAD L f\ IrI OILY I Y E CLEAR. CLOUDY s?YEflCnSL r rv Ni LUENCE OF ?l L'??J'LCOH?L G }„eJ}LI tOO_S64tL4= ?-11,'!-]1 OFFWAR 1?'SF?1=1Eix_jIGG_ d_:.? rµVOP?WG -II7'LL. G ? r-i 1"7 T 1-I nI ] Ll A= NG OE FN CE OF DRUGS ?9? Ov ENTER 1. ASPAR O LE ENTL1 1 I I> IGHIT TURN l._I NOW I i f I SNOw NG ?? fKCf ED G TATED 1-11 FA w GTO I. ls?l IMI"IIERIA"KING .. LJ `1 L?CAIION_ ? I-J LEFTTURN ^ _ s - _? • OG E EY EAS EO C r?I I 1 0 ?LU O f 1'-LSn i R T ?N- GP J' iEt ) KING ' E, MA ry I N a„" R ? ( I?SL1. ?S `( TH_ J ? S? GG 4 F- 0 - IF LOw NG S OTHER ISFLCIlYI ER IMEC.F VI IGrr 1 IM OPER , DISREGAROSIOP NIMGNAL S rl.Bl-l OTHER ISPECFYI I PP 1 11 xO VIOLATION OPPCUiOP 0T? TpwiFIC L TONTCONDITIONS 6HFCR ON[I ftAFFIC CONTRO i rvO.I VlNICLE F CE 7ypE OFROAD O>ICHECK ONE OPNDRE 7 VEHICLE CONDIjTIQON. _VEN CLE gr?iASt 0 ] : SODRIETT._ xE 'ICNECKONFI •' IND STROPPEDArSIGNAL ??-.IJBL(-,I 0 S IGN ilrl SIGNALS I 1 ONE WAY- ' 01 . ?B:-J ISi00.ADWAYN 1 I 0 4Wi Ixl 1 S a x ? ?. I_ ' BIIAKLS- ) NO wtl CITY DI`1 iMfiiC LANE r ?I I 1 LO S ?J _ IIOAf 1 lICTIVE .. 11E. LIGHTS SD ABIMPALITY ]?_.N.LR C. ST ARTING FROM I.-+ ?.1-IDPOSITION . ...__... ]L DU : . FLASN CO. NG. LOCI PGC .ICJ ? l ?]r.I.RE GN 9. .. I\I UMIL-tlR ETY _.-- I7? TRAFFICI If NTEPIN6 G? . _ . aDAATLGN ELT I 5? 7 F. II NG 1 A tl R I LE []5ir Lf ;?j I F OH 5. OOIH 1 0 0 MNG H D ? I . Lf16J BACKING . S (`I o -lT CET L..I G /0 F ... .IBf i S GNAL .. .. LEFT LS .LWi10iH L,ixt I J_I L _ IoEi CHEM. TEST _ i f-1.. L LJ K-HO B liRECTLG TS - -P-1 FLAG MAN o 1 S INII I '? i F- 1LST0 _ Y ISPIC ':. HY1 ' IO ] r NO DEFECTS 1 J i I ilsY tiu5[D' T' . 11]THN IY[C 1 I - _ ] ux. IDIO '?.NHHIVFC FVi `_TEST f1ESULTS.( _ 2 ( `-• , Hvtsr10A1 ING 011ICLR1 NAMf AHANK OAUGI NO• LI[E DI HEM nAYi' -S POLICE AN IIyM V lFNFTIC FLOW NO, Hns - ' X _ INVESTIGATING OM ICTII's NAMf AHANK D.[NO. A OINCY NIi On URLEPET. ATE OF nVOPI RROVIOOY oArE F DUPLICATE COPY: LOCAL LAW ENrOIICCAI[N7 AC.FNCY'SCOPY-TRIPLICATE COPV INVESTIGAIONTS COPY J 1 .11 ?yR T"y^i'Ai' ?7qU¢ geNR-?'r E1?T' 1 I''i? 1 1 yL 7 !'? ?.1 k'L"T•.. - r > .'W,P?R. J'.., . . JL"x ???t,'I 'ti. IX 1 I DATE OF COLLJ&ON DAY OF COLLISION TIME COUNTY NO, CITY NO - F , Y R. T SuN l Npi } HIS ] WE A IIIUI S III 'AT 5 M RI s . / ) HWA 6 URBAN . .•. : COLA TY ?SIATE POLITE J?]CWNTY ROAD ?CITY S1nEEi ?OIHERISPECIFYI O ORAL -. ADMCL9 PREFI% CODE S CTION p N .._._ B E W ?I W HC % EO E O O ILES ? ? ? A NAME dNOOF STPEET INTEECTINGWITH:STFEETORROAD O DAMp1AGRAM p-- ---- ATA O NpN INTEflSE0TI0H, ACCDENT NTEfl NON I % RD INTERSECT,, G MFIEE OR ROAD ORREF. '• N BETWEEN ?O_Rh*I.. ?.YFCi ANDCa_.i21? 1_T _ M EAGE CODE E LS C ERCNCE LROSSSTREEi OR ROAD qs Q... gSTANCE?M01 PS CTI NN FflSOMEEF FENCE Ofl CRO5551REET. I- El. SPECA COOING USE E ' LL VV 1' y? ? • ? fEET ? OF CI'?. .F J _ _ _ - ?VEHICLEBICYCIE COLLISIONINVOLVED: • ?VEHCLE-VEHIC4 ?OIHERIWflITFI Ni6HUN y ? SEVERRY ? •P ?? ?"+T'' ? k4 1 , TOTALNO. IRVEHICLE-OBJECT ? VEHICLE RR TRAIN _ _ '?STOLENVEMICLE NO. KILLED 1 NO INJURE ' ' .P A' C F I S O ? OF VEHICLE VEHICLE PEDESTRIAN ?NOCOLISION NAME Of OBJECT STRUCK AND OWNERS NAME OB I STR H ? HAZARDOUS MATERIAL D ?PAOPEFTTYDAMAGEONLY ? C.. IEC UC I ) LOCANONOFODIECt STflUCR",' _. ....., •. ...:.. EST,OMIAGE ^ 1 J I N S E W ?nOADWq flo FEET ? ? ? ? R x ? ' - IV HS NAME-LAST - -. ; FIRST - MIDDLE . - - pgIVE.. ' . AME LAST f10.5T M ODLE'-NF BKYC 51 OR . EDGE PEDESTWAN L CCIt1C]; _R R Y • _ E ORE ET qpD E55 ? V S 0 RX E R _ - ST?LTE ... v 21P PHONE NO CITY CODE ? . - STATE CRY ZIP CODE . PNONE NO. W . . q ? N O• g?WE/CPS C/E/N?/EE "b55_ I SE% DATE OF BIRTM Y . N O. DRIVERS LICENSE NO. STATE SE%. PATE OF BIRTH M0. JAY QV V I • D • p1irvERS OCCUPATION MM NAME. PHON NO. 2 DRIVERS OCCUPATION FIRMNAME -. „ y - PH NENO + I y. ? CODES > I31 uu •I SCAT BELT__ I'vl FJECTION __ CODES >113, 'CLASS la' SEATSELT 151 EJ CTI ?• . a RES F ` - A ADM _ 1tUiE6 ?_ OV-- _._ E y , _ r E O --'' P MSME VEH. YEAR B MA IDOpGE CMEV. TO MODEL (DART NOVA) F 1= TYLE I2 DRCONV,I O SCENE EN YEAq BY MANEIpODGECHEV.I TO MODEL IDAgiNpVgl STYLE I}DRCONVJ v_ 6 ' n E VEH COLOR . s11 IFUVEI P LATE NO. STATE E VEH COLOR UC. PLATE NO. STATE ITATI PLATE NO SIATE H, h . L C nl V E TFICATIDN NUMBER 4 D ?;. --._- ODOMETER :. C vEHICLE.IDENIIFIC ATI N NUMBER OWMETE q - , - E ^ ??// /? I? PrYT I P D 7 x176 E a F ' REGISTERED OWNER-LAST . FIRST . .... MIDDLE REGISTERED DINNER-LAST, FIRST MIDDL !•} _ A p ' h - E ., 7C'IR ?' • : O. rm A ; 7 ) ADDRESS OF OWNE. .. .:...... _: '. . , ; ...... _..? C ADDRESS OF OWNER ... I ..... . .: . , t. II 1? 2 . . NAME ANDADDRESS OF INSURANCE CO. OR AGENT ?_., ... !.. - NAM EANDADDRESSOFINSURANCECO ORAGENT '• • ? ? • p 4' _ C C ITAIN)N NU. ENF ORCEME NT CHAnGE .. :. -.: ,-... '...: CITATION O.... I ACTION • ADDRESS & INJURIES OF PERSO?JS INVOLVED .• NAME CODES •' } ] A e ¢ '. , .. .. SE% AGE', STATUS EJECT 1 Y L. NAME: ; I ' C ADDRESS- 1 t I 4' A U NwuURC OF REMOVLp inOM p A' I R¢9 'Cl., pv TO NAME: _i 1 T- ADDRESS.. • S NJU W S OV?OFNOM 4 ' CF TO W '. NAIVE ADDRESS: T NA U _ M7S?OVtp FnoM - N URIES - SCENE DY TOE. E NAME lax 1 - S ApDRE55 ( {.L? `1? F J y v S SCENERYThSAf? TO I ISIAIUl, 111111AI POSIION IJHNJURIcL NIELAIDELT [1,111ICT" ] NOT R PCD SIII?AN .} p? 0A1 SCC NC o os AHL 1% IN NOT U`J: LCO IOIA'Em CICp O' tI DCADONA E ! 11N[85 RI 4 0 MCryCLEI INCDWIIOAL I POS`JlllC Jun . U NOVrt! u HE. ? NfUAIDUNM1OWN SPTAIL S U-NOW[TINANaWN""CllD r` rc... +R • i .1 ? `Nf1 ? I . l l 1 , epr 4 VEHICLE DAMAGE INSTRUCTIONS: 1. IN EACH BO%,C ROLE TIIE NUMBER OF EAC HDAMAGEDAREA, ]. SHADE AR EA OF SEVEREST IMPACT. DRAW qq{IOWISI TO BHOW PHI NCIPAL OI RECTION OF FORCE. EKAMPLE - I aC - O? - DAMAGED VEHICLE N O. i I., TN S S_ V sK[TCr. N, DAMAGE TD TRw LE{IS,MOTONCYCLf S,[TC.1 DAM AGED VEHICLE N O.2 I E> Nnow If ? G , O. Hooa Toor `Y "9'!!. • t' t6 Tr? M' - (1) [ I run. 11 L - rw ^ } E?1VA1EfRITY OF DAMAGE VEH CLE NO 1 AMAGE LING DAMAGE ] ? 11" El ".V RY AMAGE', (OTHER VE CLE( LING DAMAGE ] ? DTIFR M V O MA 1E OR O " sEVFRITY AGE' vENICLf NO ] • ? O MADE ] ? O E DAMAGE x O ;.:t+, Y L] FUN ] TIOr1AC'OaMI3GE- . N 0 DA C E G A ISN ] ? i .AGE ?? DAMAGE CT NO u Acf . ? O GE' CT o ` i TOWFDBY .2 E, S T. DaMti` M i T OAMA E TOW ED BY 3 TOWED tlY r /Y Y. F ST?. OyA[{-MAGE ? ' FA? }fa *y` G F Y W O ? / r F• An . , %G/ Q F TG DIAGRAM OF COLLISION . 1 ! DRAW ARROW SHOWING I I 1 I I _I I_I? -r-- -I I - j NORTH IN CIRCLE LL '?T ? _I_ I I ? 1 f 1 V;. . ? I E 1 ?_ 74 j_ z s 7 1 -4- ? 1 ? .A.LEPDN I - I I _ I I 175; I ? ?kk ??a a _ CIS 11 2 i i- . _ I f I 1 _ J a IM.A esia°:H::ilvri:tiG`n AND.Fi[HKDLLr3DN 11 I 1 I _?' _? _ 1-j -t- ! -- _- _ f ?4 ^'.. DESCRIPTION OF I I 1 I I I I C I I I I? l HNOCATF NAT PROBABLY PPENED BEFORE. DURING AND AFTER TIE CIASN INCLUDE INFORMATION NOT ON DIAGRAM, E.G. DR.BEfl 1 s? yCOLLISION •"v ,Y. _ ?\ DISABILITY.FIEDUCEDVISBLTY.PEDESTRAN LOTTING COLOn, CONSTPVCT ON ORREPAIR WORK, ETC( l _ IS I}• i TN „ r,• C/E_.__ ?G Ltl t,_?J. - S ?C•?P I$nl ?UP \._ ?JCC /'?Sr/ f?f]? I .Yf e,-( " T uK?_,_w_c?/? s.917 h9, - ?c? ntCLF i_ a1- l¢'s / / f ' C' ? I C , I?P P h_ M G 0? f1 T?G J IJ ?? ?'U ,[ - a,d, ?tina. ` -L? _' ____ V _O ?h L/ ?[ , .? , '--' POSITIONBEFORE COLLISION - -- -- - - -- NO L-l SIEE VEHICLE ED AS EH. nF OR H G -AY NAME OR NO - - IN O E IRFEIIIIN s LEGALLY ? E HEADED STREET BRLEll ON 'R Af ? OCCUPIED INCREA SING 0 EASING NO, EGN J PARKED j j ? 3 E`.w 1 O ?1 J ? Rw ' `• L / _ -' D C i _,10 J ?, CJ ISO. L Cam'- C - r nn • 0_ co falDf _ -CROSSING -.: OBICYCL S NG } 1? IKFD E Sr1DES GNATED T 1 . s10uLDE IC"OSSwALK yI .ICRO L L"_I 0 E I 10 f' ,E Fy - ROAD SURFACE•` Ec M r . . WEA?aNR.. 1 .. - ,_ CONTRIB ? ER C .. t` 1 TINGDGI R UMSTANCES O ORE(_ H\ OR VEN C ''tt `VER T • L r NE ' N Or1 [ -1 orPh OINa CJ G I NO F} I II .FY I / ^'^"?CLOUD _1Q:.4?VEBCASL NO.] -- E CE OF I '__I1,LG0110 NO } 7 L L.I O Y I Os D ROEO wI P GNT EA E'? I? LLl=LOa. wsS- AFn 6 4 ' 1 ]r WET I RAINING ] I} OE INF f CE OF _000G5_ F-I y E TEn E APPARENTLY U E n K NO C? NIGHT T RM . I r t 1711SNOW !- II_. Jn f C ING STATED . EtD LIMIT 3 BI t Lc TO I? 'SIG ... I?IIS? O "RKIrvG ' I J _LOGALON_ • ? 1Fy-? 4 Nc ? \ L RN { I_ CE • 1 OG _ ?W_v A?SL RO [AS Ir LI?•__I ? I, 4, 1'Bn DtE Ft G I. 31 K HO . S: { ?' n F y:^, __? =--- _ I y TG orf E NT I 31 OA.4_ ? I ITT ,l'_ ..._ .(CIF SLOWING .._ 1- .r7r tN _. ? GT...... CIi vI IG CONDITIONS ISIEtIf YI OTHER TRAFFIC CONTROL r?yI, l PASS NO E, I - TYPE OF ROAD v E . i...?]I _ 1 S EG 0 O VEHICLE CONDITION r? H0 OLnTION I SOBRIETY " 'lI STOPPED FOR CJ]C? TRAFFIC i ry ' TA I CTIC. ONE( O} L CLE tNO } IC NECK ONE OR MORE VEHICLE ., 5 ' i i : . ,. _ VEHICLE ICIECK ONE( 1 F orisvlo Tacxa ° TOPSG .,w . c Ats , J w"r 7 {h fCol RI. l ?°`,-noAOwwiN. ... m ^ ? DA w O r- - j2__j G ;. ? - T[ BRAKES '? utlD ABI l1TY -MPNIItO_ I?_ C *sTARTN CTRAFFIC LAN[ . ,\ ] DA f U SIBLE ] L.+_lJ - . I OT MP?IBY I ',?II? PANKCD OSITION S \ r? ] .DU.I I R G [.r..flEO _ . . (?J 1f I FRCTANOf CJ LJ..LOOrM r I - OEFfCTW[ ?:... .n G _ i3 ??_,] ?NK30RIETr ,MERGIN (ENTER ING .Ct q • ,?? I1 Oan 3 LIOHTSP U i I MBn16 _r y. 1.. l[ 1 ?AJ 0 SMOOIiL l 1 ` BftN nRIHKNO ?' `?? BACKING_ \ k o"nK_STREET I Ip-kOrs_ I-ly I nR L- s c AL ?y. l Two war-LEFT s 14 f ?y?-' IIr I[D L.. ....I mr vEn CHEM. TEST I NO. } f--1 r1 .' ' _..- I y'V D•n o -S1R[EI IGITS //l1 M ° _?_ . ll TfsTC vfN OTHER cr I' I II 7 t IEr1 - .. ... NOOEFELTS - ._. .-_-..-_. 1 I I TEST REFUSED • .I I ? r 11 OlI•fR [YECN VI OiF r G•I ° ynr.rri0 C R C • L 'Li WIOFp - O RI[I.ufCI{rl % 76 TEST RESULTS 2 .ry r Sflr ING 3 N I Ml• PINK R 1NO. 1 LICE O YA-ED FIR IC[AH 1IV t0 B Ct I V[D G tOw 1N,Fp!ICD [ 1 ?:R INVf tT GaIrNG O11 f / ) K[RSN•u[ARAN< 1 INO G[rr[v O H Ii ON ?F, a0 D131.A DfT i[Oi IIf PORT IRS M0 I s 0 M Nr0 [D tlv nOAIS T 1 ? { r • pyiilCAi[CgPY LOCAL haw fNFgNCEMENT AGENCY SCOPY ?TRIPLICATE•COPY?INV E STIfi iGril COPY `Y S Ills f I..? ? ?? 1 3' 1 I ? 1 ? Y,S I? HYJ ti :? '. R ? y n N. ,r I 1 ? t ?X.B? " ° { "?r.... . ' ?? - R" 'r"+?.'' .., ?, '` ` f ? ?°I •??,t't ? ?>< Faar?" ,n. ?`', ?t?v ?. ? ??r'r v ?"P.°!?? :°??'' " .a I' 1 T a t"? ` ? I j e3 T• .r d, r - - LT r" ?• l 3{ A IUI WA?1 d1•NU ?UN PACE 'bh...._ ?6:?ba' T.)$i41'i I?O. 6.'2'JI .'./.:_. V•1 OF ' ,• UNIFORM POLICE TRAFFIC COLLISION REPORT PoucE coM wNTNULIDER .. p d d < .. DAY OF COLLISION 'M1 hh MO DATF OF OACy SqTIME COUNTY NO CITY NO. Y . YR• T SUN ( MpN 2 IU(E 0 WFO A IRUx S Fql G SAi IBSE Yd00 XOURj } J EI URBAN M COUNTY. ?STATE OUTE COUNTY ROAD ?CITYSTNEET Q AOMCLS. PBEFI%%/ POLITE Ofl STREET CODE •CTION f __ .. kIV OTHERISPECIFYI W ???O M, yyy5 L N S E W ?IN Ir-I, OIiv OR TOW MILES ? ? ? ? OF , N" ) Q PREFIX EO MILS _ A' •Ix C -, i-{! I YN Q-C-L(. _.__.A{? .. (L ' AM A NO OF STREET OF HgHWAY.- NTEPSECTING WITH STRE T ' 0' T z dst O,N : E OP flDAO- LL O RAMP DAGRAM .-.. DATA t ., 1 d,(''° ,%E•^( ' Y -, I 0 NON RE T TR : T Y.WV '•:• , ACCIDENT ME G NON %RD AS NTERSECNNO SAFET Oq ROAD OR REF ERENCEO 5$TgEEi0i1 0A - f (+ :? BETWEEN STREET AND WSTANCEANDWRECCIONFROMREFEREHC R E _STREET CODE y Q p - ` /O 0 . - COLL ?Q OSSSTREE ', M LEG S E W Ip # FEET ? ?? OF_ ' !_k - ISION INVOLVED. VE CLEVEH CLE ~ VER VEHICLE BICYCLE XS .... ? SPECIALCOO NG USE 1 .. ??. __ O TOTAL NO VEHICLE.OWECT VEHICLE RR TRAIN I ' l OFVEHICLES . • __ ? T L N 5 O E VEHCLE - O LLEO • f ' L-- (--d , ?VEHICLE-PEDESTRIAN ? - - NCV?OOILISION ?HA2AR DOUSMATERIAL - .. c.-. ?. NO . IW URED II PROFFRTV n.u.ncrvJrv I 71 N'--- _ _......,r• ......... v rvnc unV CI . -" LOCATION OFOWECT STRUCK .. - M EST.OAMAG ' '••: .. ... _•. DRIVERS NAME-LAST FIPSL .M D __.. N S E w L AY FEET ROADW ? ? ? I ? ? R I DLE OR-I N AM E LAST FIRST MIDDLE' L P DESOMAN CHECKIU R b Iq - D I 1 , . • / I j-L SIREETAODRESS •. R I J' ? F X? ST R EET DD E55 _ - ; ; ?(? I .V F ? R ... TIP_COOE ._ _. PHONE NO. E CRY . ; . ! STAT - R ... - ... E ' TIP " , CODE PHONE NO d' -N _ LICE 5 NO.. :,_ .... STATE SE%• DATE OF BRTH N. A RIVERS LIC E N E 0.. _ ' ST • 3Z? yG? o • w - - - E WA. M MO DAY yR S , O . . ? • -O ; AT.{E (? SEX G C ATE OF BIflTM YR MO OpAY . j I DRNER9 OCCUPATION . FIRM NAME :. ._ _ . .. ... 1 -T PHO ENO. .'•j - J OPrvERS OCCUPATI N. l J PMNAME ? , fir ? y P EN S ? ry . . . , t ? _ TI CODES IJI L VSS? IAN SEAT REIT_Z_ 151 fjECT10N CODES > 3 L _ NATUR 1 1 LASS- AI SEAT DELT_ MI EJECTION U rISS E. _.E. 6CE INJU DES F ? - F , LP NE VEH.YEAP RY' •.- TO MAKEI -HEY.) MODELIDMTNOVAI STYlE 130R.GONVJ gaOM ED SCENE VEH.yEART BV TO ?4 t'1Yd MAKEI CHEVJ MOD V E ?eV /?Y<•aY. /? ?A?AC /Y V , ?8 E [DAM-NOVA):'. STYLE120R .? N/•r I? .S • "` V H. COLOR 1;, LIC PuTE NO,. STATE TPNLER PLATE NO. STATE 75JZ E 4i Z VEN.COLOR.. Lq. PLATE NO. STATE.... TRAILER PLA NO. TE z 14 `STATE.«_,.... `E°' ' C V N tlJENiIfgATO 4 w/ . (tea, .a L N NUMBED ,? DOMETER - :e.•• C VEHICLE IDEMIfICAII N NUMBER .. •. '..a ODOMET Q { ER . sJi _ tF fi „ ? n v . ..t - j REGSTEPED OWNER-LUST :_.,. ,,, FIRST ;. MIDDLE . •' E, - 'f ? / Z i flEG15 ERE OWNER-L o - 1 - TRST R i.?_... gptE _ \ ' ADDRESS OF OWNER o . OF_OWNER-.. ?:. _. 11L1 AN ADDRESS OF SUNANCE CA ¢ ENT • 2 N GSA 5 /eQr AME A I . NO ADDRESS Of NSURANCE CO. OR AGENT. ??:_. E ?• •. .:x ..,..:.?_. :. L:..: ...r -. ..... ..-. CITATIONNO. .. ,.. : :'.... ., .. •`I t r.:. : •-'., -: •.. CITATI ENFORCEMENT ...... .. - . . ACTION V7:. I NAME, ADDRESS ffi INJURIES OF PERSONS INVOLVED CODES 2 4 5 L, NAME'. ?:"? E, 1 SE% AGEi STATUS N Ku P EJECT. T A, c U AODPEGS nx 3 i<_ Jm c -3?!vo 6 y p - A , NAIUR // t PIONFs - L.V q(J (?EJ R[MUVEUIgOM ,Y -? SCLNF RV TO , NAME'. MESS w 1 T II ?4J C_! ^ S ?L ?.X P 2 3 R E K I S IE MOVEV— E IJU scFNE n - N w TQ AMe T A DDRESS E WUUIIES ScE EDTIIDM II 70, AMT . II A DDRESS 1 " 5. Wl1 uINl1 D C F - ' . 5 II IGlAlU3 PA 21 )[Ai POSI1gN S FH nv IJIINIURV Ctw55 TO NISEATDELT d L u C " : roD - S Nq EP Y.E ,y pCOC P4rtt151? OIHCP T I o1HERPOSRgN "loWUIiY i] Ot OOH wiIWAL I 1EJECIKIN a .-LING INJUiir 1 NOIINST LIED 1 NOT CJkCTCD If10FNTj?NJR i usibN 1E j noni L iv'wic - 0 ATN[5$ ^- 1 IRIIS MOIORCYCIEI a ? L PD41TK1N UNKNpWT1 1. DIED IN HOSPITAL Y lA i i[D 1. POSSIIUE INJURY %. UNKNOWN N dUKIIOWNIF -•---" 6 ?- 1 j - .. •_...--• 5[AT IIfLilAKURE - TJECTLO• .. L tile. ud. T• ?):N. p? ,'!w 1 a ,.i1t? ?? 77 rv 7T7 77,77 r R i I I ;'i G, x f •E E d ?, INSTRUCTIONS; o ALAI-IS to wPRNCCTLORecIONOFfDRCE ,+, -- _ - -I?si;-Ll to 's.iTININC DAM MDiu«cY EH - DAMAGED VEHICLE NO 1 acE TO TRA itn, CL[5. [tc.l DAMAGED VEHICLE N E O 2 ? n H wf?a ?1._ ? ? . A ' .! ?j •i r•Iu, SEVtRITY Of DAMAGE VEHICLE NO, ITV OF DAIAAGE. IO [LEI E PITY OF DAMAGE VEHICLE NO - '• Y ^ O osA LINC DAMACF, ] ? I.E. oM.v. DAMAGE ,E ORD SAeLINC OaMaeeTN DE?DT RM.v acE , ?DISA LNC UAMACf ] OOTHER rA.v DAMAGE F sue' r ) ? uN norvAL DAMACf . ? N cE ] O FUN DAMAGE . ? NO DaMAC ] ?FU A ? N o DAMAGE" , YC L'-JAI- Y- r.1 EST DAMAGE T Til. DAMAGE TOWFCT ESi. DAMAGE OWED DY D 9Y /., -/ iIL.JNSYnd rr' J"? ' S Ni TO ' M.OIAGflAM OF COLLISION I ;DRAW ARROW SHOWING 4 i -1? --? NORTH IN CIRCLE ; AIwA«.s _ _ NmU,Lnm. cD«m s , o D,,a ; r/T 1 - -- --- - E DESCRIPTION OF IcATE e Y RE,oURmc AND IIIE N, NcwDE IrvfD NOT ON cR c:D IvER COLLISION Ds:e ur .HEDUC[DrII FOfsTRMNUOTH NGCO consT RUCTIONOR RCPARw.. .ETCI• 3 f _ _l.J!-1 .1=. l C..?r-1? ?i rt't..]_li 55 C>`'-tom :..?hc,h lir l.:4-c n `J?., r-, F 1. `•r? n r' ::s L` 1 E. _ L _ aI ,.A. a' `- - a ROSITION BEFORE COLLISION --- - ' NO 0' 1ANES DIE- REAl 'A MC.. HEADED ING ON 5 EEi OR HIGHwav rv4M[ DR Ho o s,. KED Y wa ErD7 MILE IN .. E .-..'..N AL [uvT"D -?f _._ rL L r i J - L; A. - L _J lu A - dY} A IFO " I JI -- DHDISHSINNN - [.c " G _ Gn f PED+elcrnm WAS USING l51DFwAL ] ,=. `-noiswnii ` M _ln - N 1, p w - _?sHOULOER CROSSWALK . I EROUTE iIER " ROADSURFACE:_ WEATHER- ....;.:._: CONTRIBOTINGCIRCUarA FIANCES' - ?rRI ioe"E?.°LE t- HFCK OnEI I-- ONFI D Iv O E LfAn. , N H r1N r-' _I I ` ?_,NaEl U" R cE of DRIOE? I r Dw Nc or' EG RDEy' -;(' [ t?-L oTR",TA T wHEAD a EN ?.P LEA ''?'11_AON lcohol ^ 0 CENTER A c AE Ly no vASS ri] wEl__ ING ^!°I S CF Or ' 1of I _4. Ef T I IN ?: ? An fu-7 c NT :]-`SNOW SOWING I I]IJ. [[`U IIM!i ED D?'. L O r__ DFR PANKING : I NG ..-l r D G F E n f 0 R, G - 7GG t s ED V 9 ._Df 5c . [oU j. U u11f' OTH[N -C-1 - 5' R IS EC ivl G9.1 J Slew NG I a55AGR ] °GIAGNAt ` i E O S ONr QTD TRAPPED FOR 7 C LIGHT?NDITIONS CA 1.1'1,%C ONTRO I .T ?P oOF ROAD VEHICLE CONDITION SOBRIETY... q STED i IGrvAt - MHFCKUNCI IC L, ,N6 ?E K FOR MOREI ] E H ? O OP 5[C[ON[I L_le1GN A N 65?t 1 I (i r c S ( I r oc LFCIS?`9'` ? Sogow°A Ir" ' 1 ` o. c I 1 r . _ - - nD ARI R WA. G IN 7 TART .. - N . _. •t.NAA 45 _ _IhSPA^ l \ - - ,IN NE I ^ ] O A -,T Aw NLAOLG. ?.I IMPq Rfp___ ?? RTING FIROM M _ ,11 _ • s I yr- u` NOT ] r 1 ANC[ -D oos ........ rc I_--. rIRD SOenR it - f- ?'? MERC FNICI ILNTbUNO b '' ern I i L?]?1 , A . PlD L.. f 1 H L •^ ' `-OAR iET .. ?... I" l k. '1 Af C r •' .. NEAR G r _NK.m ??eJ INC1 f 4i. ^i r. s "" ss oN Is s G lsl N 015 SMOOIt. n CHEM TEST j 1 t 1 lrcl FO S D IfsF IT L? .. r{ A l o -T a F- - T j , .. _I 1 J oTHFe IVFCIrr1 1'I e 'Ell -FII 11-1 WON,$ LAGU f' ) - . DtO I .0DEFEL'TE Ill-EII-D 1 ,/ E N- A N- 5 ?' MI O /Y ^ T, [ r - utcl q6 TEST RESULTS Z e ! G 1 11 P GING CE A. l« V[O ^N« ANCI C L r1? ,((? rf r. ]P 7 -7 1 7 r 1 ll. R._ P o t r .f ?.lb I _ ) 1 U t _ D. MIN' `. II P; 1 L. _'- AO { 4 nYi s, i cu IcE s n.S N°n,nov 'o Nr o T LLL + I DS]NIe UN.OR 10111 A LF.OPY' SlND1O GID TAi[PAlf10L-DYMPIq•VIASNINTO11 RBEM/.t 11 t` 144 w -+ DUPLICaI[COPT ^LOCAL LAwfNf URC'FASi NI ACCNCS SCOPV TRIPI CgTCtCOPY ri . INVCST GAlOR5C01V r ?1/AL: f.4 ?` A ' I .. .-.?_ - :• ' .-.-' .. .. -, • :" • ^... '1 .: :.. . rf. AAA4lL:YMt'iYvtiltY,T! Y,MiSA.f a• ., Ttiwrta?.tMf^i1TVTU: IIYn- ? - - 1 ] ?'i { e 4 ! ?? YI } L [y, 5 f ? ? - I r 3'pyl ,I . I lf:.? L: 1 - • '...f.,i I /r 1 I . I; ?r 1 ° I ( ?dn ? , u a vac '?'*` .-,r „M..?i$k(". ?, .: ..yy?....:....°•. :::-?ra._.:.e__s: u:?ytir§k_Y.zrrm+iL m, ?, ? S"E OF WASHINGTON PAGL r Of Na TAI C ILL COMFU IUM1fUEN , -..:??. UNIFORM POLICE TRAFFIC COLLISION REPORT - .I - ---- -- D /L DATE OFCOLLI1tON U vq A Y_R M? ? DAV Of COLLISION 1ME 1 SJN 1 MLw ? G WEO A 1xUx S FPI G SRI ILA. EP W 11"I C OUIiiY NO / CITY NO Fn WA ?]UflBAN 6 - gURAL COUNTYr? ? ' ? ?STATE ROUTE IAICOUNTY ROAD ?CIiv STREEt O DM CLS. PREFIX POUIE OR bTRFET CODE 6 SECTION J rr .Selu 'l ?Ol.ERISPECIFY, CITY OR TOWN B) P RElM ED J3 MILE F-I 1MfC ((N I {?/k ()L - C 0 ' N \ y??•J .. O .Aa, •. •^ ,. iAXk C II? ? .. - _? ? ? Id DF--`9 E1 .___._-._-._.. MILEb U AV?. C EA OOf STREET OR HIGHWAY INTERSECTINGWITH BlFEETORROAD LL R AMP DIAGRAM DATA } T ON CIS ° I NTERS L I NTER N01 NflO INIERSECTINGSTREEIOR ROAD OR REF. NO . E rt, /I n? < / CU ? A'CIOENi E ERENCE LRObb STREET OR ROhU N TA D. BETWEEN- / E TANCE!I)DRECTIO FROM REFERENCEORCROSSSTFEET DIS S S nV PECIAL CppING USE 1 /E /? < ?/ {{ IOVUQFEET4 ? E W O( `? cle k I?.. C?IY I .. t CLE BICYCLE I FIE) i6RUN SEVEflI}r COLLISIONINVOLVEO ?vEHICLE VEHICLE ? VEN ? OTHER ?NI _ :0 KILLED " J. 1 " VENICLE-OBIECT ? VENICLE-RR TRAIN ___ __,--_-_-, ?S10LErv VEHICLE /, OINJURED TOTAL NO (? l -• Y OF VEHN;LE4 L_/J ? VEHICLE-PEDESTRIAN ?NONCIXLIS ON ED HAZARDOUS MATERIAL PROPERTY DAMAGE ONL E OBJECT STRUCK (NAME OF OBJECT SIDUCIC AND OWNERS NAME) jy L )OCATIONOF O?BJ?ECT"""KS = ^ ( I ? Trd fk ?v°1 r1? Joyakti Fa•fGL•/I ?ROAD\YAY/J FEET??L'Y? RD EDG DRIVERS NAME-LAST FIRST. .. (AIOOLE .. .. .. 11WERSNAME LAST FIRM Af10DLE xi.BICVCLISI OR PL . RIAN CNELKI [) _,,,. +,f Ri ". R F D ?,?1 F?LI Lo2f?i! D R •... ? • • R I STRE i•pR ESS 0 l STREET ADDRESS. E R CIT / STATE _. ZIP CDOE PHONE NO. E R CRY STATE ,. ZIP CODE f'HONE NO. L?O? `7l 3---6 'N DRIVERS LICENSE NO STATE SE% DATE OF BIRTH N DRIVERS UCENSE N0. STATE SEX DATE OF BIRTH t`' Y[y? O• r ? 1 MO Y YR. L1i `,JL O- MO BAY YR. " ? "I ONE NO. DR• RS /C<(P-N FWM NAME %L.1tc fir/ G?dEZI(c?f^ ee5,(cr '2 DRIVERS OCCUPATION III NAME ..,. - PM NE l.. N I :. CODES > IOI;IA NI SEAT BELT_?.- SI EJECRON CODES IJI ClA_ __ S- JAI SEAT BELT ISI EJECTION--- . INA,IUR ESOF ULJZ CF J•4A. (?"Y:IGE INJURIES F - FR SCENE pY. TO ou 9LENE By TO Y MA EI ECHEV.1 C' MODDLI AgTNOVAI STYLE ItD ?CONV.I ? VEH YEAR MAKE IDODGECNEV.I MODEL IDARLNOVAI STYLE 120R.{ONV.1 . v; ? ! T?LL J 2 / V E VEH. ? U=.. P??E M1 STATE TRAILER PLATE IN STATE E TH.-OR LTC. PLATE NO STATE TRAILER PLATE NO, STATE ie ' H ? 3 ??? - s' (` VEHI LE IDENTIFICATION NUMBER .". .. ... . ODOMETER.... _,. C VEHICLE IDENTIFICATION NUMBER L" E L E -LAST ,.:.. FIRST MIDDLE [R REGISTERED OW N REGISTERED OWNER - LAST. FIRST O ? d , ? N ADURE54 OF OWNER. _ . ...... - ADDRESS Oi OWNER. - - ? 2 ? 1 NAMEANDADDREBSOFINSURANcLDO.ORAGEN G? id ? NAME AND ADDRESS OF INSURANCE CO ORAOENT :..• .. ... ? P?'v1, • 15?NTG A ?WA L r , r u (L, - - - C CHARGE 11A 1 ND CNFURCEMENI CHARGE .. _ ,.. . .... - ' UAVONIO - 1 ACtION , ADDRESS & INJURIES OF PERSONS INVOLVED NAME copes _ Z H s , SEX AGE ST ATLAS - EJECT. D' _ NAME. lU -Ion '" " G 4 I / Y // v v" C ? _ .L-? V IJ AcoRE54. SI (k?'??• - L LL-_ -Ar HEMO F M V P VkD ILD IUPE W scFNI BY INJURIES T O A NAME N T ADpRE54 __ N iU DF G r? S I S FN -. fS TO „ W NAME I T N Hy INJURIES scENF FY To . I T ? S NAME. h ADMEIS E S' FMY 'PGM I'MJRIk1 NF DY T -. O f f1 y ! V IfISi AIVS IZIIE AI PO•vITIOFJ J NJURrc" JI4EAT FELT ISIIJkc110N C 3 PI." T.I. nl5t ll T ?? O Z DEADAICIIIC O p ( 6 HON OSABLINGRY Y NOT IINN USE LCD ] 1COJlALLYLJECiCO 'JCCTCF I P ` I J D E ' O nk 6 WiN(SS 9wT[, 5 ' S 004R0 U? OI(DIN HOSPIIAL IN , (1 011 pLC AI Y S SEAT pCLI (MLURC A kJCCtEON ?? J S Ir ? ` r T p `; J } ?( {:F fLt 1 L J ir y1 '? Y?i ? 1-.. . rv•'f 1 ? a "L?iym ..?]..1 '.?. 7 . '"?, I ` t? M "R )'miSl E ? 'Eyyg?yt _ fNfA1 J ' '? ?. n F Fyr?v??' 1 t F 2y,? MOTOR VEHICLE COLLISION REPORT OAIE OO7FCOLU90N DAY OF COLUSON TIME OF COULSON AM COUNTY GTY1IO .Y?' tF,J </'i is PN COUNTY CITY.IOWN IX MLLES O Y. TOWN AD PREFIX FEET LION D e{evie a l f 3ai??.kE INK -HE GVE NAME OF SIREEi, ROAD ORHIGNWAY?", NTEfl""'WITH. STREET Ofl ROAD , PREFIX EO, MILEPOST / ?sL' ' to-c Grav •) (a 2 EDP S?C e Rcl NON NtERSECTKkILOCATION Of COW510 RAMP OIAGflAM DATA . d1 ,w BETWEEN STREET ANO STREET .:. t C, FfFT ©® SlalE, nifww a, Nu4A ? N c?1,? ?^wa'a S?n I Son ®©tEV M A—. C'ROSy?4n[aOS, OR KKN,+v Nat.v+o4 u. eR E. 1NTEP ? OILS M . ?Y Ta1 xvuL,a ? ? ?VE 4 ?. SPEC DE E `TE htcle- t us9? ?? DF r°ES s i?a° 1. EIE A.N ??"A? ?. L, I RR f OBJECT STRUCK aMFCi STR Iy OWNER OF OBJECTS NAME AND ADDRESS LOCATION N U •' IN ROAD tDAMCWAY ?® EPAN EkP3 , .. FEET [ n t F E IF .0FE I.. t•V,? -,=,d DRIVERS LAST NAME ffIRSTNNAE MJDGF c?3 w VEPSLASTNAME FWSTNAME MIDDE aafNUSbv DN a+ STREETADDRESS . ROUTE NO.ANDBO%NO. STREETADORESS ROUTENO.AOBO%NO. . FO 0 2c? GTY STATE ZIP CODE DRIVER5000UPATION GTY STATE 21 CODE DR RS OCCUPATION } mF "5 A 3? `? NcYd ia,, ida `tk3 ??' .le D X '? AE-TF DRJVERSUCENSENUMSER STATE SE% GAT OF &RTH AGE ORJVERSLICENSE NUMBER STATE SE% DATE OF BIRTH AGE 1 F-7i - 7 46 4 t1' 4, aAY M F MY 1E AR VENCLEYR. MAKEICHEV:DODGEI, MODEL INOVAOART) BODYSTYLEN2GL1 VEHICLE YR. MA%E ICNEV. DODGEI MODELIHOVA-DART) Ill DYSTYLEI]OR.I ,Try 7,3 Gr>C Jr,\•],<„u 2 ??• LICENSE PLATE HO. STALE TRAILER PUATE NO. STATE LICENSE PLATE NO. STATE TRAJLER PLATE NO. STATE OMETER IMREAGE B gl' _'{) V[HIOLE IDENTIFICATION NO. I1B6B MOOELSA NEWEFS ODOMETER(MILEAGE) VEHICLE IDENTIFICATION NO. IIBOBMODELSSNEWERI 5k lei I? t??'!/ J 0.000 REGISTEREOOWNEfl ILASTFIRSTMIODLE NAME) DFBVERSUCENSE NO. REGISTEREDOWNER IWTFIRSTMIODIE NAME) DNVEflS LICENSE NO. OWNERS ADDPE55 ISTREET.0ITY MID STATE) GATE OF &RTHM OWNERS ADDRESS ISTflEET,CRY MJDSTATE) DATE OF BIRTH 44 PMISOF VENICa O/JAAGEO 4n,EO PARTS OF KnICLE DAMAGED .. ?PIX •? f1 6• Sys s os,W ' WAS THERE AUTOMOBLE UABILITY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- COVERAGE NEFFECT FOR THIS ACCIDENT ON YOUR CAR YES ?NO NAMEINDADGIESSOFU UTYNSURANCEWLIOYHOLOEN NAME OF UABIUTY INSURANCE COMPANY .. r1 XWF53 `?1 O A P.UA?? Y Y sTM 3YM?r5 'Y', ?'YL. _`- NAME IND ADdTE550F l1ABIUTY WSURNJCE AGEM,. aIY s,AE 2p UABIUTY POUCY NUMBER G l., le, ?av cwr.Sr. Wa E I 7Q 7,1 SL 6/ y ISTNJLRfY - AGE 2NDINJURY: IVSts[PAAATEAEPCNIfDAA IGN.,NMArE I AGE NAME ;E. NAME -___... . .y ',. DURESS X ADDRESS ? . T ''. ' , -'..'':_ I..A.NMEN e.AwclDA• ? I N.4E°"s E..Mw1uN ea?"axraT+ ©© °N°.c4t°AS STATUSOFNJUREO MATI-ST ONE THAT APPUES STATUSOFIITJURED MARK FAST ONE THAT APPLIES y r'. 5¢"- ?MMR wKHCIE a.=. NDN o-?)MAaa roivALF 0- NVEHCLE aneLNa -Al"I 1-11 ?2SI -e ?r w IBLLFO yv4A[I PA+.a4 cD" 4PL ?PA NILLED I vtA ?uwoiy PaE aa41 oFP ? , Ha FI LN - p°,t-°` ? 5? 6c] 7? A Tr.IN D 50 60 ?ac,cl. SHOWNORT B APPOW WCIRCIE \ DESCRIDEDELOWWHATWPENED.IREFF,RTOI£HICLESBYNUMBERI u ,.Mt, aA r.DN.•?Y N.41;??, 91, ABtB3 a14aMaw \ K).INoz.A_.a.-_}f ?7. ' ol'F???".? Kl.YA[Flaw Qt o •k w. _ C Y.3 b'.2-1_._..?33? -- . -=D .. L I V { --- - - ------- / m; t ib VEHICLES POSITIONS BEFORE COLLISION aLNI, vH.cu Wnatf +..AaD wu INV[siIOATED BY Nart RuL. MANIA.n MAUI. ru.ua vtHCU xar[D KHCtL N 9 E W ON ST REETMI,OHWAY NAME OR NO _ NO AO M ?iiiHOl 0za, !. INAAN ??w??dadtoaK (lea 1 AN D D O? O O DD 1 fob w, ?. ArvtAI ? D ? ? D ? ? o D D ? R .F EX, 'j HE.- '" ? D D Di-VG FROM DIRECTION 10C] DIRECTION J 1 :I 1? i {KMSIHAH WAS lI3Pf0 10 YOEWAM )?VIK%WAY ]DfM 11 1?=M, wN 3?CM+,waA sDTHER y ? H ,J HOAD StPFACE W ATH[R UNiCONOTION3 iTWFC COMROL ICHfcE VKI TYPE OF ROAD IXBV[R/VENCLE ACTIONS - ? IF Intl ] ICHICA aN[[N MYEI ?,?`Al ."+ K 1-SNE. 41M pN•t1 ? M[ IHF %f-N;I No \{ , ' K'"•? 1? UM•C?I? 1 D DA,INHT D 1 D• AS D 1 O MC WAY Q I 1 D COW STRAIGHT AHEAD J. D 1 U DR, ) [_J G-A ] D L\wH D 2 ? STOP YOAf ] ? 1- WAY ? 1 ? OKRTA%INO AND PASEA4 j ? 1 ? T ) p1 &No.NO ] DUSR ] fEv YON ] ? REVERSIBLE ? ) ? -110 -fT TURN - R?I P.y 141 C) ? Y ' ? ROAD y ? ] Al-Y, L 0,. f OIGIHS CN [T ? • D FUYIPA fI[D D t DNTl HOn [r[ D A D MAK NO LEFT TURN I rI ?{ r ? A ? ICE s f'1011KR 3 O °IIAHi s o:rET ? s [j fLASHIG A40ER D L ? MILE ARAUpI D S D 4AKNft UITURN ) 1 ? , D St4GRY 0 OTHER L ? I. [NIOIAMS D s D F+I YGNA ? s ? JEW/ W- D IT D hOWINO ?Yt' R[ASON FOR NOT SETfAO DMAfR DT KR I pfKlN fl AO4AH LANE$ 7UNN ''?f y I T?vKGn ? ? ? 1 ? STOPPED FOR TRAFFIC i I! }? 5 KM+O "^t« P,IA.[T[Y., IICI s ? O L D EITHER 111C.11 I D LIPARAIED D L D slomO AT IXGNAL D OR slop NON f 1 21?f • , • . ? 1 ? N'Ro O B p STOPPED W Ro AOWAY I 7 '• J 1 qin C LI n11N0w { I t 7 `rq B (7T (? ] n1 E OrD ? R Dn rcl eA 1 r [n AFCF. _ _. 1- l fl fl c ?..I I SAY. y;S'•9 c+"n - '?,'?"°LA 4,,4 _ 77 ? J por. YI ' TPA • ,._ ac_ MOTOR VEHICLE COLLISION REPORT OATEOF COLLISION OAY OF Col.-N ,r0 TIME OF COLU510fJ N0. COUNTYN / ciTyNo ' I y w W ? N `r 5M a 7a Vrkb PM [ I /V/? ? M1 t {, r /` PuCF COU TY CITY TOWN • u+h E . ryro'SMOi[ MLES O© CITY.TOWN w low OF DM 5 PflEFI% }}'' ba[fl COOL SECTION ' ' F _ 1 oc anp p ovE NAME OF STREET. RO DORHGHWAY INTERSECTING WRrI. STH ?Ei OR ROM -C-RED PREFIX EO /q' / C/ C :Jx+• v Fi IN"IT NON-SECTION LOCA ON FCOLUSIO O P - RAMP DAORAM DATA ' I BETWEEN STREET AND .P'CI fF' STREET , F - xtA:?? (I }f? 'Pr a"aaOAOCrgssHC.u LEPOSI Oa Okur FrWG Lwd,wa Ea.BwInF O INTER IC C K?FA O ES1NEFi ar - ' qA.uu p ? fEEI ©® D LS E bAp 0 Xb q y`_ ?pA?^. • ?4i? oOQ kAIL ?oF vpvEO ?V[ KLErvKIE ?vf KrCLE ?OrrvEA lwwrEl ?I ? ' rv •C[EB / ?vfxK[E v w E b n ?v[••KLEObIEC1 IAAW SPE I?L --E 4 n -?? 4 ?v[HK,E PFMSiPow 13 raHGd[HSroN ?Hlww OBJECT STRUCK I +uE Or oLECTSIPUtq 1/ OWNER OF OWECTS NAME ANO ADDRESS IN LO CAT ION O © a i A EOCOSi ILECT ORFPAno S' FEET EDGE - P ' •' ORR,ENs_1_E IF CAI _ FWST NAME. MIDRE pq yEgS x A • • 8 . A LAST NAZI _ E E _. w [ d,11 5 ° / F- If ..... FIRSTNAME : _ MIDDLE j n L'2 CO[US oa STREET ADORE55 . b - .. .., ROUTE NO.AND BOX NO. uoaf iHw STREET ADDRESS vA F -S ROUTE NO AND BOX NO { ,•' v ?. ) Nw.. GTV .. STA E CIT A Y SIAIE ,... ZIP Co. -aiWERSOCCUPATION , .1 I ce. 55 C I ? ? ? E STATE &RTH ORI ICfiH6 N[REfb/ J- DRIVERS IJCENSE NUMBER l CJ iCL O FU r . SE% A T E .. STATE 5E% DATE OF BIRTH AGE % .. [ ? v[.w u F +a DAr A ?G.. [?u•( VEI(CLE YR. MAREICHEV-DOOGEI MODELINOVA DART) BODYSTYLEIPDH.I VEHICLEVR. MAXEICHEV; 6 8 DODGEI MODELINO-DART) .:.. BODVSTYLE(-j _ Y 1 q? EW Y , LICENSEPUTENO. STATE TRAILER PLATE NO. STATE LICENSEPLATENO. STATE TRNLERPLATENO. - STATE ' N n. btir t - VEHICLE IDENTIfICATgNNO. V INTSMODELSb NEWERI OW.ETEIIIMaEI RE0151EREDOVMER _ (UST-FWST MIDDLE NAME) ORIVERSLICENSEI m;re NA ___ ? Ion ?: .. ?G - . 1 naP S l _ LIABILITY INSURANCE INFORMATION-VEHICLE NO. i AMEWID ADpgESS OF LIABILITYINSURANCE PODGY H U.Eq NAMEANO-ESSOFUABIUlYR1SUFIANCEMENT.. qlv NAME ?IwNEI VCHICLE I I IM V[ LI I Nov d5,0[ ?P,bS( •(P KILLED NNOyI? a`r•ria*nu+i°.ro [rIE nA O \ -?wKA1? w?f- , RID VEHICLES POSITIONS BEFORECOLUSION •/ 0 1MAOED DRTHISACGOENTONVOURCAq LJ YES MNO Si,fE TIP NAMEOFUAEILRYINSURANCECOMPANY ME TIP UABIUTYPOUCYNUMDER r• STATUS OFINJUREO MARK FIRST CrE THATAPPLIES ?O'" IN VEHICLE o Hd, 06APLF+6 PDSYq[L ?n,su KIlLEO uw uN ?P[ofs wur ND ? 5Q[1 Earl II 7Oo,rc1 a OESCRISE9ELOWS ATHAPPENED:IREFERTOVEHICLESnYNUMBEnI t IwE '' C ? c Lu,lb •KL[ VIHK,f Lpl?, r v[nICL[ dMCI I..D uK'L. P,rIaD+,o Y r•KLE ?:,tlra ?r°a"[ICi y i N a E w ON STREET OR r•a[w.r HAVE OR ND r.D.A ? ? ?? o o ? ? o ? ?GP?Ff ?oslabrl t , j ?o?f23Maa ?AOSaND FROM DIRECTION To ,DIRECTION not DtlY,NWASUSnn IQISIIXwuX :?w.fXwArIC DQ ymuLO(n A?«.I• s??N•A.LD eQom[R Ie`? I RDAD SURFAOE N[AIHER IGH CaraiION9 iPAFr CONTROL Kr4c+dFI 1YP1'OF HOM DHIVEnrVUfKLE AC11dA J lYA' '1 pnY C+FnKI vrr?Ktf ( WMCLI 41?liiwfi[ 1L •+CL[ K?IC+OafMUOAIT }} "oVl KU i ? 4v o?Itlh?o ?t? ( Q DAr L10NT ? t UGN4s r ' QI 1 Q CAE WAr (R t ? GOI O SfnMG(I Al1EAD , ry 1 )Uf Jx`-?i ' ? [ ?r nn r Q R,,,«w r ? oAwN ? r Q stor vcH L? t.-? •,X;. I-? I? ) ? Iw0 WAr Q ) rn OVERTAKING AHD PASSnID I © lia ]? NYOwrr•0 1 OPUS. ? D Q -( o NON nr :l."KE W L E A I ? ? ] r MC NIGHT TURN l 4 5.ow o- V"'Ll n O ? ? MA ti n" A` r. r.3 3 Q ?r0f4 ? '?L ( (lYnlbN ? QFL,•,n UWo ? . ??p,i(PCrr,NG ? . ?MAXINOIEfi TURN 0. 0 cc I A— l ti"tl l W inANPIE ? S r'1 MAXMGU TURN II? m? 'I`" I r O1HLn lJ ti ?5 I rr ? S ? h Y C[FY S ? mil' ciYl " ? DWAR. K NOrI T Q S ? I[ASH YO .ullfn ? S o' f e?blPl[1lK1HiS ? e ?M-I. ? e ?flKY C] e Q t I Hf.1.04 fON ND(5(l MO D4rD[n &ow1NO ;r f ? w+? - M1i I s Ar,.Nd Y.o. nb.. Xnl Ilcl r ?.oi?i[ir ? r ? arKLn rLACNAH LANis 13 1 QSId`P[D FOR TRAFFIC -- FOB E FQolrrrn'rrcl(r [] I Qur nMm"-- Q E `j??sio(°vwoHU c rJ 4;? ,i YI l l 1 J fOrPfDM HOFDwAY i ? y.. ..- __.. _ Y ._ .• " •...1 f ] ?Ir4 L ? 0 ] Q D?NO f0 S rT f R O'N, ? "?? 5 ? I T ] Il?! A 1: 1E? ? ? ?^ ?7 H (] to to E II y y ?? iJ?/^ ? r : ',T?`ti?T!a: „'n?: ? „?4??j4rYr J J -l ,r?t,.?.' .I . ?,,Ad - r ... ,• Itie'??i;f *.?, ? J ? ',i r i I ,1iL p1 I IT, ( ti ^i,n ,?m'?'h%D+fa 3:w:rYS :?.• 4 Tx _ _:;.'.,a:...?_=ate ai@S ;xls?"r?'hV'-.-' ?_.., % e°°d. t VEHICLE DAMAGE 111EACHDO%,C.CLE THENUMBER OFEACHOAMAGEOAREA +EAAMP I INSTRUCTIONS: 2,SHApE AflEAOFGEVEREGTIMPACT. IK"' ' 1A to "?^ D.OMW gRgOW19,TOSHpW PRINCIPAL pRECRON OF FORCE. DAMAGED VEHICLE N0.1 (USE TRIG SPACEFOfl SNETCHINOOAMAGETO TfWLER9 OTORCVCIES,ETC.) ©/ e OSP DAMAGED VEHICLE NO.2 IO IbDU /v - 1e.RD31 I [??4-e-. /'?OtL ?J ??.: 1S. HpeE ° !tWlt ' t] 13 °'w tS. Tllnk IjpNr t t IO.P-1 j'?YO?A If tl TD ! ° p l IO. UIM1nc+IIWs 'D le.irunk 11.Ovarlwn .. t? 1 tt I ) 18. UldercelPps _ G ?•'?? GEVENIY OF DAMAGE: YEXICIE NO.1 S V RRYOFDAMAGE:IOTHERVEHICLE) SEVERITYOFDAMAGE:YEXICLENO.2 1T OVpivn 1I?DIGANINGDAMApE []OTHERM.V. DAMAGE I SABUNGDAMAGE D? OTHER-DAMAGE I LJ=ABLINODAMAGE SQOTHERM.V.0AMA0E I£, 2 FUNCTIONAL DAMApE < NO DMAAGE 2 FUNCTIONAL DAMAGE A NODMAGE 2 FUNCTIONAL-AGE 4 NOOAMAOE eIN TOOWEpBY Nn ().+/?(? EST.OMIAGE TOOWEDBY N2]J f:. SES??AOGE TOWEDBY EST,DAMACE °•" DIAGRAM OF COLLISION r TD 'P' 'f' I. cFnn .._ __ _ n: --7-i---- i I I I 1 ?•-? DRAW ARROW SHOWING ' RvE°rMC° ids ]wWr.IEAnRE9 I I ?? I r' yr/ ?r.._i °'. _I- J_ r.__f:_ I ?'I--I NORTHIN CIRCLE g r 1`r:w.dc daN Al d e' f ?wPe.? aaePOwroNOF ` 1 I ?'i +. `"(. I I I(-- + f M e = =fir f t + -J- T 1- - L - _ DESCRIPTION OF 1I11NDICATE WHAT PROBABLY HAPPENED -BEFORE, DURING ANDORCAFTERONSOTXECRASH, COLLISION VIGIBILRY,PEpES W FOR RK ETGMATNXI NOTION DUOiW.1 _ 'iry...,. , dSABIUtY, REWCED N) IK TR1AN CL , E.G. DRNER On+INOCOL CTON IOgNCLUDREPAIR WOE p V.e?N A_-?moo / "Y'^q5 sa nA = +"? ?7! L?_r-?_/SAV? vAS. AeeOMPnivY???G- ??' - ? --/i=C H_?Sl3•wi?•o '.. v,?.N1 .?.:: b..e5 .i T l:.c'N._ / / ?_x a7 E?r12 STn Rrr_t?_ e x FLT?3?!! fl,13 wQ «2 ?cl. J 1?Q. 5n, TRl7J c Gialn p N? iG!!G'0.53-S_an??-??R N /eF Y M y??+Tiyc G2 -?stt?AtC?-_T%Fr" was }3?ati.N .J N. ?' n- p 10 DL ISIOP VEH? HEMS MILE POST pP SON STREET Ofl NgHWAYNAME OR NO?µ "?` •L" ,eINONEDOFIANES WECT" ,y am X P D NO. WCREA DECREASING .. SAFe LEOAlLY WAG VEM. ii ,N r PARNEO OCCUPIED 'S.C-:?,4 '? - 2__• I?-? ?(`T (L? 1 _n n _ - _ - YES NO YES NO -: - PED. :IJI if AIDrp M.` ET On _1 - q I fE. Ma ..I ,. ?.L, I PED,BICYDUGT WA9 USN0. IneIORRY.tn r °nwWlnlq •nerosswMx °I _ 1 na vD ?npjHeq , ' •, , tl 'g ROADSURFACEti .T._,WE:ATHER CONTHIBUTIND CIRCUMSTANCES,°;,,,,,,;,,?;.?„, Iloure ]. ,:arweuw.cLEAIaoNf .•.:., I .+ 10afCN Ona Itn C oqa OIYrlA ..' . .. rc wI _ OH! OR MORFI 4?j t rNp f W°CLL 1p?Ly ;? '. Y ? 7, ?? T qry] °1N'Ej poKnf ` eNrtA y 5, }?v,' IGI?Y(?.OdA••OR YDnLIR Y P X LlI do r. <[M nnu '1 oFXC[d M (-? Tv-4al-f? IL.J Iry?? Mw _vl°EnwnUDC[d !l'_.4d-. 1_ L?1 = w --•.si_EL\ IWOPA3vra Y.: - I lfn iC R.1n'/0 C! I? app--- (-?I,? WROINrFR-_ Y ?3? ROIn11M (- L.,-? 1. Iy .tR 1 , eXDEr '? SIgWNO . C1 DCEIw1g3TAlED TD ((--II I ? 1-j_ KY- 100 ?I W F EO AS D? nWVEN ff-?L ( GPFMtI11D ? ?. ` A, (n.__. n !(?..?! _ _ Q ? nm -_-_- I„d'°4„? DFTFCrnre Faun. genq ?, ? omen°vicm {?111LTCWa- r J lJ. torEr.Li"eµ__ 1...-ltl?.J__ n°ioouan ?i? AdhYY. L I ?. J aD ep.roµrd ?K r°aD'vialATlar?i T mowEDran 1 yy ' LIGHTCONDITIONS '„TB?FRC CODI?wcu;,TYPEOFROAD VEHICLECONDITION SOBRIETYx?y ?fi1 e?D AaDNLA? e , F ^ ' X rcalc. oAe1 U U °0M"L°_ ?L(?' ?1 ae w or.e at AaaFI Kw i ?wne oL°r"F°rar°n ' rsrxlf'?' IuIECE o, I-I LJ ' +.,? ] r i p ,'], J 1''-E-blltDl ? M a ?? DOE] -j r ' fi?• '.' ] J °Daa I iA I eior'rMO n. t..J. Lao:D"µ°F. ___ n L ?. coca e - LJ°t_7 HwnDTeonn -..-__ ??u? IEIEMBHrelwNa 7?? J wRSOa I I ?..._.... -_ ? ? onaiooM I AI X.nww:a..n 1e? 11AptNp 1 1 ` d e IuRlO I.mn CHEM. TEST (, ed r ° ' aBa.N. f; j rv,«uAee LT! _ _ w i..-J .?._ ...__ f?. ... nlveerrl •+ F :c ,' .I . +, o". ---------- V[Ci3 ?/ V a0 I/ pK OMeA1fE01Yl • 'i 1. ° IDHda ACOningO f' .'I dtllpU _! /SD?'Y iFerKNeeO Ircrlow 'i TlI a1 r•.Igta.rcod rY II ? % % TEST RESULTS 2 ///9 /`I?o ° DFDt M /" . N { ' L 7 "cr wtdwer.IUt mconr e?, AIYwo..TDfr lun DAre J + °r X lit rl:< c?!-r^r?.=,; :? ?',] '?' G S G °F?7.I j / ! 1•? ,? ? af% ?N 0 OATEOFCOLUSION DAY OF COLLISION TIME C OUNTY 110. CITYNO. FH" A r2f0 , t SUN I N0.v IUiS S YlE A 1HLIi S R G SAl I/3?3n% OURI J /- I / tt1 / Y K FIX fl O E OH RF CODE RRURAL SECTION COUNTY ?STATEROUTE ®COUNTY ROAD ?CITY STREET O A DMCL3. PRE ? j ? .ET SZ CXJ ?!'II'1=f??$ C•N ?OTHEH I$PEDIFY) CITY UH TOWN N P I REFIX EO n..- 71 AILE VOSt L ?IN / N S E W W . ?D C _ '?. NILES ? ? ?-a ?OF P-ktL .C. C_^ - LL O.bG NAMP,d NO.OF SLHEETOR HIGHWAY INTERSECTINGWITH:SfREETOHROAD O R AMP DIAGRAM DATA A 7 / (i?f.r. Y.fJ• N-FITERSLURUN ACCIDENT IN IEfl NON X•HO I INTER CLS. E NTEHCSECTINOS ORHOAD OR REF. RENE CROSS STFIFE TREETOR ROAD N ?j N STREETD IC..S<. CZ)ry?L'I` STREET AN OETWEEN ?1CJ?.JC_ LEA MDODEE X 94'/50 % FE Oy9TANCE.W DDIRECTON FROM HERENCEORCRO353TREET ' HEi?s S VECIALCODINp USE ]MILES N S E W ?? ' OF jy LG ??/\ NI< F ' FEET [:10 F-1 ®VEHICLENEHICLE ?VEHICLE•DICYCLE ?OTHERIVIRITEI ?HIT6 RUN SEVE.1 .I 0 COLLISION INVOLVED: ? VEIIICLECOJECT ?VEHICLE-RRTRAIN ?STOLEN VEMICIE W . NO.INJURED TOTALNO. OFVEHICLES D ? VEMCLE-PEDESTRUN ?NON COLLISION ?HAZARDOUSMATERIAL ?PROPERTYDAMAGEONLY OWECTSTRUCKINAMEOFOWECTSTRLICKANDOWNERSNAMEI LOCATION Oi OBIECI'STRNCKS E VY EST. DAMAGE ?FOADWAV FEET ? ? ? ? RD EDOE 5 DRIVERS NAMELAST FIRST MIBOLE DRIVER'S NAME IAST FIRST MIDDLE Ilf rNLICU>i ON VEDt SiINAY CIIELKI. . D A C}i fi1c^ ' G-A) 1. R P<7?25rDN C /A,6R.L.ES' L,SS-f4-,_ R STREET ADDRESS ' STHEEL ADDRESS V E CNY STATE ZIP COOS PHONE N0. E GTY STATE ZIP CODE PHONE NO. R R Al N WVERS UCENSE NO. STATE SEX GATE OF BIRTH N DRIVERS UCENSE NO. STATE SE% OATE OF BIRTH O a RS-c?b_?; 5 3 N ?Jw F MO. DAY YR. O, c -v' ' -?619?J: L'N MO. DAY VR. ?l 3 DRNEflS OCCUPATION FIRM NAME PHONE ND. Z m uF DRIVERsSOCCUPATIO- N FIRMNANE PHONE wiFc' vNr< CODES > In DwLAUUgg IaI S[AT BELT I'I EJECTION CODES ? IJI CaSS ? I•H SEAT BELT 15/ EJECTION NATURE OF /G C?GL A"Z d5r14 N.E3 (' N Ug1E5 F A AA ONJ V EMOve. C V TO C NE BY REVED FROM WERE BYT TO S : MYEAH MA%EICCOGEC.EV.) MOOELIDARTIOVA) STYLEIZDrLCONYI VEH. YEAR MAKEIDODGE-CHEV.I MODEL( DART•NOVA) STVUEIS DRCONV.) V 79 /iaiya4 Ncpm'L C%C ,6 v ) Ari H -- -t'c1-6 E VEIL L W. PLATE fX). STATE TRAILER PLATE NO. STATE H VEH. COLOR .C. PLATE NO. STATE TRAILER PLATE NO. STATE H i Ei1s? c•67C'o w?? I I bk 13i_? ac i37 L.: IJ c VFINCLE N) Nil ICATI DI HUMBER 0 METER C VEHICLE IDENtIFICATION NUMBER ODOMETER L E P 0I ?, I J ?? L> L *2 E F'C; f O? 1 REGSTERED OWNER-US fIHST MIDDLE HEWSTENED OWNER-LA,. FIRST MIDDLE 0 SAM A°_ ,CS pLJd i'.C 0. <ONN.t '. ?ISs^'•4 f?? , ADDRESS OF WNER ADDRESS OF OWNER z n ?nt,o /6E NA1v.aC1: TAM ANDA ESS WSLIRAN EC ADEN NAME ANO ADORESSOF MSURANCE CO. OR AGENT C E CITAII NNO. ENFORCEMENT C-FUE _ G A I N NO. J?LTN ACTION NIJI)/L & INJURIES OF PERSONS INVOLVED CODES _ 2 NAME, ADDRESS SE% AGE STATUS ? EJEC7. c NAME' C ADDRESS-'. ------------ U P - NATURE d' NEA'OVEOFHOM VWAfS SCENE Rr TO A NAME N T ADDRESS $ --LJTOF Al NINKIHiF.A Al',F -FIT IA TO HI NAME ' ADON[SS _ - -"- -- _ - - N s111FY?III I, To T:. E AAir -? .?------'----- FI DDNFS: _ ._..- ..r-- e S. ?rlra- --- -_.._------ --- ? i? TO l 11 1 l : f l I O • p N A . I . L Yi R . .. AIIV, nro !il .. 1.:? : fOTAlLYCFJ? IfN r N ?' \? I U D li `C r N N !ID rl N16t• I Oi 11UMLlfD 11 AUO V IIVOF rl r J l•.1 A? IMt f LCK. F OL C r M f f p L . P l II A O I - 1- ) 1-11 Ulf O L t PTSSr Lf 1Y I l 'A• TA!/ GNNI '.Lj I NNN?YnVh"f? 1 T-. 3.:CT':'TI A 1: 1?L? ?l' ? yp? B,WeL a eA ? , ?t 4 p - 1 ! SLATE OF WASHINGTON - MOTOR VEHICLE COLLISION REPORT - NO { ?'? PAT NTIT.: ?>. Y.O N lwTl F OyL15 .L AM G ?? 5 PM ?. ES iiQ? -CjY PTO N ?ti '] ?/ ;. ! ?? t; V FO' _TIT1iEDF STfEI?T4R _D-,NIGH AY-.ry-1.. _,?I T 6CTING N.. 5 R E 30A O . _ /J ECTIO{I LO?.CAT OF ION pF ?,L?IjSI(OyN /-? •.... _J O ?eA C/?I.T?/?/ - TRE/ J YJ STREET .5 ET wN0 "-' OU '?'r CITt .; ^?l: ION PREf 3300 , % EO \ MILEPOST O? .. GRAM O MP A aT .0 ??77 xrew? ° _ L^1D"!'n iNTOER I CLS, nerrx.x i - eT O ` O ,ox,x ? .n vex eLa x F? v.x cL. orwcn Iww,re ? EP....... USE rs° a,n • IrF-{7y'°? x Q / ` x r nuw ?.. J .. JECT: $TRUCXiµ?.•yf yL °raLTl]3aV91bI¢iVYCyrL:.T~OWNeR„OP%DBJCCTS NAMC,ANO'ADDq _ LOCATION ?? '. R AT:. FEET .a [DIVERS D IVRS LA5 N ME II ? 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EAS.A ES$.' ^a ?y(FT`II[([f urx_-"n?n]:?.,{L. '.: ATE P.BBt M J .. NER.S'AG ES -." TJT;? a -tieL wrE:orB q;fr P y RTS GLEIpAyApBp •, ' w . : ? ?r,? ,yyyy?L g.-.-?, To PORLS,OP.VEMIGLE: e. ?,,,a - / / aafMnavnlrviO.C, 4AAIAGED.-? w u„-•"-.,??-y,:_:c_c..N ... s i g S.?areew r.n : LIABILITY INSURANCE INFORMATION • VEHICLE NO. 1 - COVERAGE IN EFFECT FOR-EA.c DENT ON YOUR CAR YES ? NO E NO wDD R y 1 " 'FIApltw-ITYS_UFANCE. PoLICL L :. ,n Nom, ?k. F,? r *` 4 ?,A,W ... N E OF LIABILITY INSURANC 'CO e = ra EA ADD JGl L1}Y'INSURA C; 5`>e.9e T-^ •. . . Cy y? Q/?.A. a?'?I.?(,/j•??- f WB .T'(t LC7 N BERSdY1,C;.t ' I ? ? ? ^"SYw..iR?Au?'LY'?i)+Idll'??A?6Z,eG GE' 2NDIW UqY h? •n ,?,?" .. ... nitro .u. ITOiui,rl L ' pVd -? w+V, A E ? ? _ OO x STATUS IW R[Dw+i. 'y?ww%flK PIRSTO ETNA PGIE ,•w .rc,, L ATUS OPI JUR£ - 1n 11 e. ° a K FIR I kr.--0 N,VCNIGLfi x^ 71 (? STrO NEITHAr APef. ??,• ? -- NILLEO [] N N,GL{ KILLED Isrv.nel x 6 I F , l Isave, l T L J - - ? { L .. ll e -j C.I C CLE I\ I I D RISE. [ W WHAT N e COF RE.fCR',..?OyLNICLCSB OMB{ 1 a _. J YC 1 14- -1 0V-X_1NAT [ ;..a „oww - -- - o. C? ?f1,41 s A . r Ui? O cJc?. L? ei VEHICLE V051TIONS UEFORE COLLISION cAO p L Y I, G r ecr oR • AMC Oq NO, • 0 E-1 0 -L 11, El 0 ED T M f O O O A L 4N0 " ' , O ]?? G a. A ; I ' I LDF9TR1A•• NG 11 _l a' . " )[? I? NOADSURI, CC {•WtA1 [ '. LNINT CONOIfIU t[ T cG J _ L: _I ....... p T• [O ODD I. xrT Da VIR)V[Lf CL I{ AIG CO CSy f, 41^ 1_?wAVIT.Nr ?II f] YIG ALB ?? L ON[. WAY •t ?'In1C 001110 STRAIf.NAHCAO DN G) ?_ DAWN rJ) 11- -. 1 '!x [ fW0 WAI n )OVF.P TA VINO AND PA SA IN A D w T f! 1 Sr OW,NG 1)R ]"D ?J ] ?IrLD SIGH I A iJ J DR11- ] O MA,TNG RIONT TURN f'1 ' ('7 I Tn NN HD, l J 1 rj 00 GR T r, r L 5 R r-'1 r-1 [R CNAHn,, !-I A 0 -FIND LEFT . ( L._I D L J LI I .r, I 1 TERN 1 E L _ - r _ I c i l : reR U 1J1 ] [-1 I. [ [D tT L' --- U. TUaN [ .Or [_7 A [ J AL [ ? ?[ ; iU AN LJ A c] SLDWIYD NOTSrrlNOD NGra ] ? 'eL .. ' [ 1 r I/F .MAN AH[S f-l r'1 . •.. .,, T sropneD 10R TRAFFIC . • •. ••, ?'• ,.: r A [.? p '-7 '7 111 lJ rprpcD TBDNAL.,, s AnD STOPP[D IN -DWA y O [^I n D V D [? o ? -T f ."alVR4Y'Y'!'RIf9gIA];APA.'!". •9"V1(S•dNRNrRTmP1M,'.•.dM'Nropnf».x. Aemnrm.,Anw.: .l..w.:.w..«....-...":._ ..-_.t:"_-?_ _.n rRl ISTARTI OIN t t f u S"r T "rV 3 VEHlC LE DAMAGE INSTRUCTIONS: DASIAGEOVEHICLENO t-' I.U EACMREA, OF THE NUMBER OF EACH p>1.nOEOAREA. a.HAOE AREA OF yEVERESTI.MAACT. D.DRAW Agr10WISl TO SHOW PHINCIPAL DIHECRON OF FOflCE. - U - - EXNnPIE O " / - r _ r I SE RUS SPACEFOHSXETCgwGD M I ] . Ip.[bo0 e ADE ro rnA ERy,MOioflcrcLes.E cT - DAMACED VEHICLE NO. 2. . 11 Y.. +1 1 E T- U(le E IB OnUmcmlWe 141. Ro01 .... (v ? I Il.Ovanum S V gfYOFpAMAGE. VEHICLE NO1 "? nM emuD+ La ?^•?, 1]Ov SEVERITY OF DAMAGE. (OTMER VEHICLE) S EVERITY OF-..; t?OISABUNGDAMAGE 0?OTHERM.V. DAMAGE 1? OISABUNGDAMAGE VEHICLE N0.2 FUNCTIONALOAMAGE A 2 NOOAMAGE 2 FUNCTIONAL 00.\IAGE G OTHER M.V. DAMAGE 1 ?DfiAbUNG ppMAGE ?OTMERMV. ONAAOE ? 4 WED BY TO / / ??"h ?,)?/, EST. DAMAGE TOV/EDBY NODAMAGE 2 FUNCTIONAL DAMAGE 4 NO DAMAGE EyI DIMAGE TO ' 7 `,` . TOWEDSY C,f ('1_S J EST.pAMAGE h iJlliL ?E.?l ,fc TO U S TO (," $ - Hx? , r OIAGAAM OF COLLISION 1 DfNRiY ? ' r ]i •'], .rr 7_`Yi' I _ r i I I L, 'DRAW AHROW SHOWING NORTHINCIRCLE I I . . ? 1OCAiE Nro. OC a.eLEXpNEOi HK ECT'PoSInOng FT. -.2" I I -1 r r _ r _ f .3 1 ? • OR.. PXDDARLfYEHIKLEDq a mN X I _ 1 I I I i I T ( f (f 7 ARaEE DHE A? EAKDDOON I i r [_!_ r 1. r f IT- r Lfj I- - -1 '-- t y OESCAIPTION OF _ COLLISIO N BEF RE, MIA' ATE INSPENE OURINGANDAFTERTM SH WNEpATUC PROEO BABVIBIBItIT/,LY HAP PED CRA CONGTgUCR04 INCLUDE 0qgEPA NF N ORMATIcrON NpTON OLIGgAM, E.O.ORIVER IV, gESRttANOLOrHINOCOCOq,wnar r? ` ". ??1 I r h A° ?fJG"-c Vr_ .. ... POSIT] e VEH. HEADED MILE PI NO. WCflrEA;SING z 1 'r1l'A PED. st , - T. ONSTREETORHIGNWAYNAMEORNJO. VIES PED/.ICYCLmrwASUS ROADSUAFACE DIO iYpEwAUt WEATHER ' .. 1 sHWIDfn C I_, ! "aassw F 1° --TO_ ICHEON OnD - X , " _ rcHfcK OVM " - ONTAIDUTINOCIRCUMSTANC Sri ' ^-'^?? IbIFCN .1 OR.-o r ? ?K °AF ! f_? aqY `/ Y 1-rl RCLWOr ovErcASr r N°j J NcDXa. - ?[?? I? t_i T Loa Vt [ NO.', } XCIE "V s°XUGHrNIfAO ?sl - ? o v EV? aj J r S i 1-;-- E [•, ONHIM _."._ n ? ? O?RU HCE°f ?- r " EVE Fq__. - L l J µ ° - J r ? °soX?° LJ 0 ED r?f ... IV' r-" MD AYr rW 1 -I _ P'CrrvE _ YNM ?. u o fR(SFEO?Yi orHEXlsvfulYf . _... /Y .- 11 w q . I- F L•-L _ -.-.__- ?ejJ aLOw.a U GNT CONDITIONS TAAFAC O A - ' r- %=A uT? a oEOX . C NTflOL ICHECA ON4 vfHKLE .... ? vzHKLe. TYPEOFROAD NO f ICHECK - DquA29) I VEHICLE CO ONDITION. VEHrC1E C A '' ? SOBRIETY " ." ..• C LOHK ? n9 ±' o Wart I dKW1a _._ ... .. "? l STOP CNE WAY y _-... ._._ Iy l r I NO I DgE tt-cl9 rCpl DI r Wf) I O LI ` I_,, row°°FwA°r"[ u ] D wH ... - l xow `I ._. RIV 7 rJ oEi rtYE e, _. - ' , X W P ? I -ACC- 71O ...- 1 Wa% I eAW I -".. 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" ? ? . . : ?.>..?,i'u4?'?k'?i . t ,? a_ ,?P`ti .pyhat'?"` ?E s. .:.-;..? ?4 • ci . % !'ry,,s o H I G %ar vv tlJ] jII'd kA E %_1 14 PACE ILF I ?sL •+ UNFORM POLICE TRAFFIC COLLISION REPORT POLCE C-LA.-MVEH I D A GATE OFCCLLISION MO pAY YR UAY OF COLLSON SUN I - '.YID iHUP FRI MSN SAl IU`' TIME 0 IO IRI 7 i COUNT'(NO CITY NO. FH'NA i . i D E S J E J . ? ? (? T J / ?UFBAN r R HA t+ .sq. _. t COUNTY ?BipiE ROUTE INCOUNTY ROAD ?CITY STREET Z O AUM CLS PREFIX , U L ROU TE OR STREET CODE ECTION P 7 J ?OTHERISPECIFYI T++ N '? ( DO . ro ? C EYE] ?I /CITY OR TOWN SAilES ? ? ® OF \ I I?L1 LOG W LL Pf1EFl% EO. !AILE POST ^ ,T ? ? T.? C K T _.I I O NAME AND. FSiI Ei OR HIGHWAY ' INIEflSECi1NG KITH: SiflEETCfl R0A0 O RAMP pIAGNAM r? ? ATA T ON OR ' • N A++ J ?., f O N ....INTERSECTION 1 ?J BETWEEN ` L+ STREET AND ll?\y~\ /+ • TREET ACCIUENT MILEAGE CODE INTER INOK XRSD STREET OR ROAD OR REF. _aENCECROSS T L DISTPNCE AN'u NRECRON FROM REFERENCE OR CH 5TRE' O/5 ?5 IAILES N S E W ''7 I 6 ^? ? SPECI LCO LNG UBE / ? ? ( FEET ? OF • l_ l ?'? ?qE VEHICLEVEHICLE VEHICLEBICYCLE COLLISION INVOLVED: ? ? OTHERIVIRITEI HIT dRl1Y ? BEVLHITY KILLED NO TOTALNO. ?i uVEHICLE OWECT ? VEHICLE RH TRA•N C. VEHICLES ? VEHICLE PEDESTRIAN ?NONCOLUS:ON ? ?STOLENVEMICLE HAZARDOUS MATERIAL . NO.IfUUREO PHOPEgiY DAMAGE ONLY OBJECT BTRUCKINAME OF OBJECT STRUCK AND OWNERS NAMEI LOCATION OF OBJECT STRUCK EST. D:JMAGE ?ROADYIAY fEEi ? ? ? fl0 ECGE ". D DRIVERS NAMEIABT FIflST MIDDLE 5 i`K 1J ORNEflS NAME tABt FIR,,^.i MIDDLE IIF 6C1 CLST °H PcD ^''?.l•I GHE"0 CKI L„ .. R ' 1 ?1 e?l L D 1 K Lf IP ; R STREET A00HE RR ', ? S - 1"", o-r-- 7w 5 R V STRE ODRES ?,!{ I R-C70 E R CITY STATE ZIP ODF ENO. atl,I`v An-am ?3z5ON RE CITY STATE LP CODE PHONE NO. (?/kA? t?C? t< cutl ?Q ?e , N o. OflWERS U EHSE NO (? g ( STATE v? SEX t DATE OF B'RTH Il °+ G Z N 0. . . ORIVEflS LICENSE NO. L ^ g P' STATE 1 44 GATE OF DIRTH LAO. DAY YR . ?E T < ti Z? I? T T U I OR{VC(15000UP AT IO N FIRM NAME PHONENO. Z R OCCUPA TIO FIRM NAME DRIVE N N . p , ? ? tTI??U { ? C ? ,, l? ?Ll1i L ODDE$ > I]I Cau IAJ BEATBEIT 7 ISI ELECTION CODES > IDJ cipss JAI BEAT BELT IBI EJECTION 4r .. F NATURE' INJURIES R - MOVED NATUNEO 11 .^? INLURIES N - REMOVED ^ _ .= v M"i'l-ENE VEH. YEAR ' j EIV. MA EIOODGECFIEV.1 EDC(c: TO MODEhIOARi NOVAi i=-r- STYLE (3OP.-I A? . v FROM SCENE fl v€ YEAR I 72 Y: AKP IOOOGECNEV.1 M 8 TO MUOELfOARi NOVP) STY EIZ OR.CONVJ ." i E " VE OLOTT yea. LIC. TE NO. ?lA?i a STATE -? TRAILER PLATE NO. STATE E VEH COLOR G?? I : LIC. PLATE 10. @n2-r 006 STATE -w TRAILER PLATE NO. STATE ?E.' v e VEHICLE 11-1FICATION NUMBER LLt(IL+ 66 f83 6µ RECA91ERE0 OWNER-UST FIRST ODOMETER ?I?'?'Or MIDDL C E VEHICLE IDENi FICATnION N?UM1BER A--Ab?(1. I? a?3 LA OOOMETM . 5?IG? pp S .. N E ? ' N REGISTERED OWNER- T FIRST MIDDLE 1 0. arcl6 C 0' k ADDRESS OP OWNER ADDRESS OF OWNER 2 NAMEAND AODR`?('''O°f INSURANCE COLOR AO EN DORESSOFINSURANCECO.ORAGENT a P '1'ft?luLE?S- ?7 ' CHARGE C ITAIIONNO. ENFORCEM ACTION ENT CHARGE OTATIONN . NAME ADDRESS & INJURIES OF PERSONS INVOLVED cones _ s e , SE% AGE STATUS N T EJECT. ABC M' U REo NAIUHE OF REMO EDFROM IHIURIEB. I GLFIlE DY. T O ` A NAME. ^ k i y N T ADDRESS $ NA iURE AIOVEO ROM WUR!ESf f.CFrIE OY' T O W NAME' 1 ADDRESS N _ uHESJ- - IA C. t PIER SCFN? M1Y T O j - I S AE _._ J . ' "' - I S DOM1ErSS AQ,X °_ ?T I? ! lr ? $ .wl !M1 I 1 S .rL.I `0'TILN J CA TO I! F TOELT 1] I E.ItC110R Y ' O C ".11 SIE AE C I C •! ... 7 t LE C I- IE 'E n N D( fl pi ?.G ] 1011 t '?'ED j iOTAILYE FCTEO v I D . ] o I IINE B I I { A 5 ] ? (1 0 Iryl J E DU I " D.I lJ.P JAL I?ou c E I ?? I 1 V ( 111 NAURr I PO.i.:luLEl•..UrLV ] us -D ,} U, E X t ARIIALLY CJECIEU E ? H F L <. {J 4 L`'.. ' . E .• .._ . L B I NN.VN c. E'. FAIURE 1 EAt .IEC D Y II i, mq7 2 R3 T! I45 L111 r1 r it I 11 T ' c s 4 5 x.? R 1 J!]?.. STATE OF5 WASHINLiTSPI FP?J MOTOR VEHICLE COLLISION REPORT NO c - € " - " DATE OF COLLISION..... DA M DAr wN N YO C O N Noue TIME OF COLLISION_ pM R Ex 1 G nu CgUN? p_N i Oa°°"n d( F ? ??r ri nT ? r ey CA NTY. - CITY, TOWN u u? uw ! E E MILES ?N :CITY, TOWN ? ' AOMCLS PflEfXy E+0? 91RLEi%pf 9EC I l.:io C?r?P?/$GL1 ?CL ?4u\ '°"' •!& Q OF ?CJ,' f ' INTERSECTING WITH; STREET OR ROAD Ew GIVE NAME OF STREET, ROAD OR HIGG.W?AY xTD SE_A/ a Ilcf. 0.S'-LV? S JL, PREFI%• EO ?? t11LEPDST??nJIYd .,?- "IYMi?"sV.:.?.'?f?:S>. ' ? ?,i; I S 1 IArt NON INTERSECTION-LOCATION OF CO :7 n ll4 a RAM?P1?.:WL?.y, DIAGRAM, DATA p"?{ 6'-^ 11 Y!rI = ? 5 i L BETWEEN STREET ANDGtiQ C SJ: `1;,,`I STREET AND yx(.1ti•:..-yK[ A'.°. w J"? , r no 055 EEROSi ox loervT Er {?'.•-.•I.??-' }' f1'! wo•o cA - rvc ux0u•R". Ex nRw xo Q + J t . NON -X RD HT 61PFETORap?pgA INTEI.I-TE yG.,LSS,.: lyEREsy/gEET?R, " D ra L / x ` x l(RS[GTroF? ' E Ei OJ OF m EvEO aE rvvo E O ? LU.. . ... w S PE 0 P. T' IW. .n E ..L ? nxc EauECT i E6 ??vExcM HDMIw ? aoE ? Iwx o n / 2'1`J'Y`} '3„F7=Y' ' NAME AND ADDRESS-; LOCA ' Ix•uE Or oaJ LRUCN). .:.-? _ ..:.. OWNER OF OBJECTS OBJECT STRUCK : : TION;_ ?N Lqj D ') Fsl T 4 'y *1 - . ?x '.. . . .. ....,. L IN RO WAY,. j AFPW aRGL. FEET S W ' ' 2 "e DRIVERS UST NAME .:. -.. FIRST NAME.'.; . __....,.. MIDDLE rnoG•RS DRIVERS FIRST NAMCi.C:t.z.!.._.- f MIDDLE S c ?\ f ee ' E NV-E0 "IZO?DR TWO C- DCL?l S EET ADDRES q0U E NO A OX NO '•' - ! ? yl"? NO.,AND BOX ND STREEE ADDRESS . _ -_.....' ROUTE ? SWERE . NO B TR ,_,,:,?„ ,?,,;;- S J, ? ev t- ,tq? ' U 7C. I b _ w e } N CITY_ . ". STATE....,.-.o".-::. ZIP.CODE DRIVERS OCCUPATION' COLLISION RT -M w 2IP CODE- CITY71?ia,..,...:§_•;, STA?E F ? .DRIVERS.000UPATION,w T( , ``' C \ E ?T ?\ w ?y TE. Ei154CENSEN B DRI MIX. .. uDA BIflT` AGE DRIVERS EN ENUMBER„?• . ,,. „MO7E.351R N. T.. _hOE: :, F „ ? i r u EA7-L Gi ti 83 8 Ya / 0 EE 3 i w VEHICLE YFL MAKE (GREY: DOOGq MODEL INOVA-DART) BODY STYLE (2 00.) ' VEHICLEYR. I MANE (GREY: DOOGEI MODEL (NOYAAA g T)r .:BODY, STYLE.(2.D0.: , 1 7 FoeD I 1 AfQLAGY Q . NSR•sTEJ1p '.. STATE. TMILERPUTENO iT ET is G .' .. STATE_. LIC NSE PLATE NO- '., 1 l LER PLATE NO.:?;SG„STATE'?>.-:,::. 1 - -. J . ? ??? . - R\ ICO— S NEWEF4,... VEHICLE IDENTIFICATION ODOMETER IMILEAGFJ VEHICLE IOENTIFICATIO IL NO,_ 11960 MODELS I NEWS) _ OCOMETEq I-eAGO _ R 00 7 F b/ 7 REGISTERED OWNER (LASTFIRST-MIDOLE NAME) _DRIVERS LICENSE NO _- REGIST ERED OWNER.. (LAST:£IRST;MI DLE NAM DRIVERS LICENSE IVO, V;yy STCN` ls%n TF_ Y- I-?t sr- cv- Ijc iD - V11ccL. rv?M OWNERS ADDR ... '. .,. (STREET,CRY AND ST B RTE :. .. OAT 0>? ATq .-. : OWNERS ADDRESS,.,;: .(STREET, GTY ANO STATE ) E DAT OF B - ,;- Y ?. S ll e _C. LY1S4 l C 5 5 Y11cVv ? i c -I\ .Mdl , r rE D Aa P SOF VENICLEO MAG ''' •••» -i0 REFAR VEHICLE, 1.G,.... ? FLL IKP> PAITTS OF VEHICLE 0AMA0ED.1,.,..,.,,,_,.;;,»,ur.•.v..G-:::;_.S:J io AT (+ EPAEKVEDE' r ' X rJ.aauu?- J WAS THERE A A VEHICLE NO 1 - N UTOMOBILE LIABILITY INSURANCE T FoR THIS F C CAR YES F1 i Y G: VER GE w EF EC A CIDENT oN YOUR - - NO LIABILITY INSURANCE INFORMATIO LIASILITY INSURANCE POLICY HOLDER ......' NAME OF_LIABIMiY INSURANCE COMpAIIY:;.. .: u•*A,: NAME AND ADDRESS OF ? '. , Gp, TcYE?101 T I577tTE F???s /lJ+ruµc ? To I ?. - N E AND A00 SS OF LIABIUTY.tNSURANCE AGENT .., LIABILITY PoLICY NUMBER 04 ? 6 Fod `J ' ' e ' n? .?a v nom ? S i , 7 EW 3 65 u. 1ST INJURY AGE. 2ND INJURY.'-._..~,.:...r...,._,5..+u...E.w:. ?.::-... k."...c,-?.. :AGE,, NAME TOTAL ,. INJURED B E% NAME ADDRESS S E Y e F ' Sd ( AODRESB .T Oy a ? {{ ?? r ' %yC, µI I t T Fy >? XI . . E STATUS OF INS' _?ORIVER IN VENIOLE ooCloxS ` .: ;. MARK FIRST ONE THAT APPLIES ?. •.:.- ?,?i?q NDxIryIa•eE Puss KILLED ywoq P EVE [ 11 A STATUS OF UREO., ?DIVER INVEMICLE ENGER PA56 ? ...I yw,I ,? 5.' MAgK QFST ONE. TpyT APPLIES - Gurir "o"iN KILLED hl yroq NO F Cou I vERF „yp IS^'ml 5q "; d ,I .. ?PPEA55[HGFR N0_ ?DEBIRIAN ? ? r?Ix lTCI ?PLDESTRIAN NO__ O ETC. • ' S L5 , . ,t.y.d OTHER tt PITFIM1 ? 50 6? 7 ?01 NFR WRIT FIN El 5? ? 7? 6 4 T SHOW NORTH BY ARROW IN CIRCLE INgG.1F ONt S DIAO WHAT I O \ ?.'Y OCSORIBE BELOW WHAT NAPPENEO: (REFER TO VEHICL . ES DY.NIIMBEM LA. 1}1 HEr ?+ 1 E. ??,?J '+ ? " ';r w•rD.... w•. ? 1 '?a _ , VENICAE H E-OE-7 NO "nQIRB 210 J K11HEIp ? ND[aTFYl1 ......? ? ? ON STREET OR HIGHWAY NAME OR NO. r7a TR o 11a o IS oEy ?n+ 1?-1,ieoi?j ulct ap.'rq of FROM .. DIRECTION_ To DIRECTION, ` - .naf ROAD CMJWAM'•., W'LATHIM LIGHT COTIDREOYI TIAPFFC CONTPOL p•Cn. ONo .IYPE OF ROAD DRIVENVEHIUE.A4TRIRB?; .KAT•dRJ hx1G1 Ip ?! YIM.LE IOI•AIO IDA NDA4 4Nf . vINl41 ?wIxK,EET IA 1 R01 E MMUE,. O I xO E 1 I, RO FL / Clwni a 1 ? DAYLIGHT ? 1 ? SIGNALS ? 1 ? ONF WAY ? 1 GOING STRAGHT AHEAD , ?1 M 7 ? MINIIIO 2 ?] DAWN ? 7 ? STOP SIGN El ?jWp WAY [:1 2 ? OVEREAKWO AND PASSING j ,1 4 f SNOWING 7 OUSK 1:1 I El YKLD UaN L;JS E] REVERSIBLE ? [3 MAKING NOFT TURN I ?. DI ? WET 1 ? IJ J 8 ? SlpW A ? !00 • ? EIGR Tb TON ET ? • ? FLASHING RED ? • ? I IFRCINAW E ? MARINO LEFT TURN El .?I 1 J • ? S OTHER S C] DARKsTq%T ? S E] FLASHING AMBER E] 5 C] ALLEY ? ? S ? MARINO UIIMIN 7 S ? SPECIIY B ? 61REE1 LIGHTS C) S ? RR SIGNAL ? E ? "LTURN ? B ? SLf NN0 REASON FOR NOT SEEING DANGER 7 ? OTHER ? 1 ? OFFICEFVFLAGMAN UNIX E] 7 ? STOMYD FOR TRAFFIC ..%CUAID WM0?I, 1-11I.CT-S ETCI SPECIFY B STONED AT SIGNAL ? S [:1 OTHER. BPf 01FY El / El SEPARATED ? ? OR tTU1"M C] 7 ? DIVIDED E] S ? STOPPED W ROADWAY "I FSTARTING W 9 ??E?NO Tn^E4 ?r r 110 VI0T0 1 J 10 1 ' iR Ert'IARF r,"ES°°?gdme3"p l ?G'n ''??'a???)T"t' r' 1?UI'4?T flCAWA?SA?RdMN7RT4!':. R?OBIMRP?DpyR] I Y a Ail ? 4. r?rrr ? .,6....._ ]. DRAW ARROWIS)TOSHOW PRINCIPAL DIRECTION OrFORCE. O/ F INSTRUCTIONS: , DAMAGED VEHICLE NO. I RISE T«IS SPACE FOHSKEICHING OAMacE TO TnAItERS MOioncrttfs. ETCI DAMAGED VEHICLE NO. 2 ?E ., Rool R51 - It IS ? l. IG D x ? . o..x,x • . t aP L . !f EL1 DTY OrL DAMAGE`' VEHCLEN la E F MAGI' IUTNE.-IEI S'8..TY OI DAMAGE: VEHCLENDV •T A Pjy IISABING DAMAGE ] ? OTHEnM D GE IO 05 BLNGOAAIAGE ) ? ERM.V.D GE 1 O O'AMAGE ISO DAMAGE' A ? FurvcTlaxAL DAMAGE _ . M < Af Da4wcE ? cE ? x M c ) (:1 Fuxcl oxaL DAMAGE aoA ? o A.AGS. ' ]' E TOWED BY. "?- _ OAIUnGE LOwEO BY ". .. F DAMAGE EsT. DAMwcE iOWC by '.: .. _(.? '. T° IS SO TO f TP. t I fJ: ?' DIAGRAM OF COLLISION I ? OW SHOWING; FT?? 7,,,,1G PAWq H NU IN CIRCLE 'T ? A „ . Tx - ?- •, cT°J( eu Nr«Ia1 DR 1? I I I ,? _ I ? ? ? _.1._ II r? ? E•I 1: -1?_?f?l.z-+~___'I E - - -7 - c I P[ntn.,N.MNSevoR[ ,ND AnIN CD.[SOH - ,- ? ? ? ' Ls .y __ _. .._L T 17. -'. L'RIPTION OF. LLI$IQN = uNO UlE wral PNObabtr l=APp E uu A TnE CnnsN ELUDE IN[DRMaI ToN EG. R _ N .E c o A Ery?ISISItrty YE NCLOiH MGC Ei?eoxslRUCTIOJ ?i ? ??-?thri/. -:.yw 1 ^Y !^ .-- ?- =vt 1 ?? ,-`? !,?f'K- -J-? ?--. JJ ?'? • ?;i ? ? t_..L:r'!11 4? .z x ?'- -?'-w- C? ?S_lL?}•}-1 ----?P ]. ,: .-L`?? ?: 7?c??'t LL >a-?•d`: ?2 ? ?- 3 ' t _ . _ . , ..- . '7 ` _1 . I`Y' .. Ti-_\- ?. -:V: ??3? V1YT?Y1 S..i ?-'1 ?-.J:. -:-.-. ,?__ a 'J "'•.-.^.l -: `. -.._ 'w , y • -' x .. , .. \ SPEED' 11"I'Ll 11 -- POSITION BEFORE COLLISION ux[s FARMED . IN NE O N Lr[ rvO LEGALLY DCNPEEO E?"NfnoFO MILE POSTDR oNST R G W4 ME On Ix O O PARKED -.. .. - INCRFA.SInG OECREwS NG NO, 1? - - ! -' ' M .`-, , ,. I;? .. T "`' 1, --( L . ??? In -_>? - . L r' J • . - s rn&? `r . r- . T ?? y4-_'? t 1ff'? . W I F G AT O L f 1 cROiw? 51 IrY L v;-' - _ O 5 UTE . I? IS C CLIST H° -- ANCES-- ROAD SURFACE „WEATHER.. CQNTAIBUTIC lro YLtIt E S-' I f nE anionU :''i Yq. t y K I <NECIYONEI- 1 NEC ITRIIR L K ONEI L, [- a rr[ 4 O .1 NA...T AHEA- IS G ;. IS" OEj IxO ] , FO [OWI G [ 1l D EPA •F'? ?- LU CEO 1 f SP ' •' ? d G N ISID 1 . _ F E ?, uMO 31 ?J1 1 oar LF Rouov A 0 ? 2CL4 t ]P LGRtl i -?E I\ Y F M1LHEAGASR _ v u o f ? (7 ER LIN ,.7 rT s AAIRNTI >? 1I u ,>- F ) rt ?. .?._.?? OfI GS f °F 1 I ?? T M° HN .TO I 1 1 EFCEED GS ED . E ANKINC AKI ` x VY. A . . GIGN 1 { NS - I ) 3 A, N - D c EA f L L _ °C oIn Y 4 C - E-c f i ?. SI-J _Y ?'.t'"' I "T T 1 . 7 S. I G I D < 51 ? -- - - ^"? ;PEtIFn o IEna i6-n FDR OiXfl1 I\ 1.1 1 1 . u ° R ? y , . 4 ,) ASIN I> ! f VENCLE N 1 I ] ?I [?NP IENO ' 1 F ?Uf _ O - . Y ? t . OI t 1 [ 1 N. WAY LF ?D D sc n AT :' I I .GAL IG L ,]1?. ?? 4 ]t?_ _ -,.J}E AECS` ^_ .. A1Pd RFD \ ? aCLAE 1 L ? r 'i- c E y 1 A ILIT9 o E O ) WN `) S G ?II ) D G i5_, NOT "TA KT MPA IIED._-- ON t 1.._'Ef LASHIxf I Ix NBD S°blNf ir" II); G IENTENING ] fK -1 L-.tGO IA4?C?... .. ....,'' IT Li°IiT6. IRA FI<I, E0 I , ' I I - - {-' KING SI_ ! DARN-STREET FLAGNIN 1 A 111. TINFS wOnN xA°N°TDRINKING— 1 I SIGHTS ON f EII.. __ I __.- L? I. OI 5 OGT BEEN L. 1 , Two l[IT nr E ° CHEM _l'.? TEST S - tIGR150 f .f I S 4 L IEN IN EIT rl r 1 r. r? I „ A, 1. CFR r[ E E - DARK I I' ^ STRIC LC Tc L! c ILA ) O OED o n Is '. I TF r s[D F ) S _ . • ? ? , .. ' N tir,I _ ..1 ... ° . " _ 4. .._ InmK T F Isr 1wj S\A `/] I' LNDIIRR p TEST RESULTS YSNGAI NG UII IClR3 NAUl?«AHK Nv UGf NO LICA LISPAY OIIGI wnNIV[p ANC[ NCILUW. e VLID MPEDFD Ann r IS D ) GG .. ?? 5 «Nf ?? DAl 4tN rllOll l51.A DIl [O ORS . JAN' 14vT5T14 /IrCIN D O ?l L?,1 ' .?E / u "RE1 N X ???. 7 ?7? ???! }?L ?r / ??' ? . , 1 f DISTRIRU TIOH: GRIGINAL CEXV'. SEND IO WASHINGTON STATE PATROL-- OLYMPIA, WASHINGTON9115CH '? . ( DCALLAWENIOIICEMENTAGENCV'SCDPV-TRPLICATECOPY'. INV[STIGATOR'SCOPY AN?Tr DUP LICATECOI'Y' I . I I I ?P?YI•r ? ? i ? ty I ??ylq y{?L h "bf?l l't '1 H oo!!. a . ? PPpp '?',dilJg?svv7NNPIA??1yy4Rff/+?,,ltt tt ??W?.?,,. ??i4 KY ?I! },y'? ii fy1AC .,'l'1-'??I m. !:'A.r, ?,?''-K ::?7'. c?' I " ;•fi' ; 'R';'. '??°' 4 L?j { wrv ''I ?1 ??A'?. ???,r n 1 I? fi`d J ?r 7 I tE ., P 7! I it SF j WC ? U `A 46 V '' 7 { A I f 1fY ,hl UN AAGE OF ' ??• UNIFORM POLICE TRAFFIC COLLISION REPORT '.' I'O11COMPWNi MdEfl.. _. r J ti n 6 1 V> OY UlEN3Yt h?40 . f ? DATEOFP..ON DAYOFCOLLISION WE S :NUN fR TIME US CO a fMWAI ` A . S S p HI j L 0 i18µ t4 LOUNTY _ Q ?STATE ROUtE COUNTY ROAD ?CITYSIREET ?OTHERISPECIfYI_ .. o W DMLLS PREFIX ROUTE REET COOS ?l, _ 23 TqH TR'J` 5 E W CITYORTOWN 1 .. w MILES-: ?? ? '?OF Atl.Ca_c,?L Ci/A. AME NO.OFSiREFi,ORInGHWAY.,-? INTERSECT NG WITH; STREET OR ROAD V J ; REF RAMP EO., V 11 pI GRAM D T ro O ?T , A A- P.i I . f1QNIN1ER5EG ." 9 7 j A l p DE /', TWEEN STREE ?(L/71 /C LJ JO AND?j? __ TREET ACC BENT MLEAG. COME lER HON QS F ERENCECTI O SR EETO ROAD Ofl REF. .? 71'T 11LF " TTJ._ DISTANCE ANO OWEGi FROMREFERENCE OR LRO555 PEE. ?MILES 5 E W /? J ISU ?"ET ¦ ¦ F ? . 5 EC C O SE TG O VEHICLE VEHICLE " . . al WRITE) A- T SEVERITY Itf" ^ 1 VEHICLE BICYCLE OTHERI NIT IT RUN I COLLISION INVOLVED: ? ? ` _ TOTAL NO ® ?YFWL F-.EST- ?,oIvm s,0 IN _ -_NO XLLLED OF VEHICLES NO. INJURED ?HAZAROOUSMATERfAL ?SIOLENVEHICLE 60ECT.SiflUCN(NM1EOf OBIELiSTRUCX ANDOWNERSNAME) 1';,:• ':.?;,,, L, ROPERTYMAGF ONLY :,; ,: ,,, _ LOCgT!ON OF OBIECTSTRN CNS E?µ :,.. ",,;°ES_PMAGE...:.f E] IN ? El D ROADWAY FEET R EDGE S ? ? f DPNERSN EiAST .. F n: v ORIVER5N E7-F i1Fi5T MDOLE?IF;bK CU$lOfl„EDESIiMI Ci E" 13 .. .: r _ //S 77 A1 '31REET DIXLE 3 - D R 7Do - ?1 ? . ? ,,,, A _ _... - _ I SIRIEi A D ECS •?,,, ,• _ , - T % E q Y S•uS._::? ,..SIAT y. . Z CODE.:. 36(NO. 4S R pTy_l .: ,.:...,_StATE : :a... 21P CODE ": PHON NO, P/a 111h .`S ?, IE R X DRNEPS LICENSE NO Si E SCX ;AiOE OA P Y VERS CE SE O STATE u/A SE%'. DATE OF BIRTH.ii._ ?? M OS i 7 YTO y R l ORNERS OCCUPATION FWM NAME/ r_........y- . ... .. I / ` :... r iO ENO. - z Z _ DRIVERS OCCUPATI .... e R MNAME. _„ .P NEN .:. T S u r. p I._ 61' CODES_.> IDI CUSS_? MI SEAT BELT NAi RE OF ' ISI EJECTION .. l i CODES.> 101 IMIAR IAI Cl SS SEAT BELT_ 151 _L EJECt10N U !f IRON SCENE BY TO VE H EAR MANEIDODDELHEV,I_ ODELIDARTNO N . OVEp FROM SCENE BY TO STYLE I2 DR CONVI . VEH. YEAR MAREEHIODGEC HEEV 1.. MODELI AflT NOVAI STYlE12 DR CONY) •,;T sa kW V ' - V_ _ VEN C OR _,_ LIC PlA !.0 '- STATE_ -.:...,. fP PLATE .NO::. ST E ,. •; _E VEH.CDIDR-„h_... IIG PLATE NQ_- STATE ,h TNAILER PLAT E.NOI STATE,.,:c--.. 33P V' . Wily l t ?i I K?m? /r5l VE lE IDENI X:AIANI BFfi_,_.. W D M IEIL (?' ' . E NAE IDENTffIC 1 N NUMDEA.:?.•_ - _ OOOMETER31,11'G2.C I ?/ ?F ?/ Yf ?F -? y P7/iC?F/ ?IJ ?7??sCJ REGISTEPED OYCIER I.LST {_' FIRST 'k _ E 1 DOIE.- flEGLSTEflEO YER'- 130. ': FWST ".w ?S..:J\MIUOIJ=:r >EJ' f 4 ADDRESS OF OWNEfl . ' :.: ?,. f. r. .:. .:'_ _ e. AODR WNE .d._ v..a.li.? .. 1 .te:°.._:+._•> i:. I ?YNf3 ?1'3 .. F § :" AM A ADDRE 0 IF - E SUfl LE CO OP GENT :: N E p ppRE550 5 RANCE CO. OR GENT _.... '; - , ? , _r-rtG? ?t /A/s ?o rr?a 5J O IL ?- CHAR GE ,.n .. ., ? _ _ CIT LION NO ?ENFONLENEN CHAROE _ _..I. C AVON NO.. ?. 1 : ! .: F . i - T F:T2T- Y11 71]IFI Yf i 70 ii CODER NAME ADDRESS& INJURIES OF PERSONS INVOLVE 2 D ? SE% AGE: STAT415 LA rcT EJECT.I nn y NAA?Q? iv pLs . r ? T91 ?? NATURE S /?vt / .C?r?f_61?L1?'_l/L?L 1d./J!rth.P'J YATURC O M /? ? ?' •3 '" •2 ?' ?, a 5 d I, 50(NEH FNOM TO VANE f ?N Q. C C U P N ` -N•T U .;JURIES - '?..5..' NAME. .. s AIXfgEST. .. _. E .: S• N.N IN _ryCe_ I Ir151AlUS ITISl AI POLIICFI C 0 ) rASFNn[R RC 1L LnAN Ol im .. r' j T GTW lr s. { E C e PoY' IUMOV0O FNOM E f• ACf Nf OV _ TO : 5R NE nY TO M ,. I IPW rCLA55 11 SL 1RELT ISIEJLC•T,ON -- 1 OI UURY 50441 NG Nrt1RY D/ 1STALICp .IOTEJECTED_ 1 I DI 0A1 SCE E O O U """"0 ] O 11 IUSE SDCAp ONANRNAL IfV pL J NTHN URY 000 ' ] J IOIOI ALLYALLYEJECEJTED CC ? I DILD IIWS L ? PO SRl J RYI U TOWN V - - f r UNX FOWNIF d SS(Af RCLIP INHC .. LJ[CTED f, r A P sRA '; r y 717 t n6 =! VEHICLE DAMAGE AcH aox.c CLt T11LNUMGCR OF EACII DA. M GE D ,EA INSTRUCTIONS. ? SNAOE AREA OF SE CREST IMPACT. 37 DRAW ARROWISI TO SHOW PRINCIPAL DIRECTION OF FORCE. .TrPCE _?L-y-- I Q? ?laF 'y?•M'y _.*FFR t; 16 -A DAMAGED VEHICLE N O i H ID^.E iH ssPACe fDR SKETCH Nc DaMAC[TG TpAllEgS. MOTOACICLES, ElC.I w DAMAGED VEHICLE NO. 2 •- 1 1? , ddqq Pw ?I .... , I r DyA E IS. III- I - O1 ' Vt FD M G VEHICLE NO. I ? 0 L AGE ]? OT E MADE SEVE r LD AMA C IETHERV EIII CLEI 1 0 MAGE SF qITV OF NAM E. F ENO] I ' u ? DS I L O LE ] O M V O ] f NC ZONAL DAMAGE , ? L ;; ; ; T D- aMnGE , ? NO OA E O LE ] ? OHA 4M WEO DY'a S ;RICK BHQS? 5 ALE TOWEDeY.. - 3T OAMA,f _ .. ... io FORT 106R15}HiD TTAL 5 a To Y - DIAGRAM OF COLLISION - -- I '?, t I. T r , I `? f 1 f IDRAW AflNOW SNOWING I fl " - t' NORTH IN CIRCLE 'a D A -_ - i I g A m r ? .. n / _ I a DESCRIPTION OF COLLISION ,_" I c w f DURINGAND FTCR THE CRASH. INCLUDE INFORMATION NOT ONDIAGRAM. G. DRIVE. msa[ LITY, REDUCED V SIGLIT Di IM-1. CLOTHIN UL q. CONSrRUCTIprv OR RfPAIq Tnl ;: ---- =W=T- NAS--TRAMI11G EAST OI?_ HILLEB _ROAD AT A HIGH RATS OF SPFED HIS 2RUCK LEFT Tab ROAD whmE .IIIDICATED. AND_ TP.amm 114. FEET_ON. THF. SHOU DEB OF TRE ROAD HIS TR CU K THEM . _ _ _.CMSSED_OVM _THE"HIGHWAY _L?VIiG..SKID_HARRS-63 FE ;)?O" e-STRUCK A TREE STUHPR-ROLLED OVER --. THREE.-TI!!aS - ._ -TRAVELING 48 .MT,_ HIT, AND KNOCKED _DOWN A COMITY ^CURVE E SIGNE AND. C1U?E t. _.TB?-STOP_ON..ZTS_ibP_IN-TFL?-MIDDLS_OF THE_P,OAD a4?• ?,._ D POSITIO [LADED N BEFORE COLLISION MILE Vas E. ING D cHEISIFIG ET Oq HIG AY NAM G Eoq G E HDK E[ - a ED ECIIIIED 2, ( - II?_ ' I •-- ? N O YES ES NO T j = -MrH_ u. lam' J . ED I S USING E BICVCL ST O G : ] -CIgiOSSING _ Kw { {S1 0U ID ER AI CA OS L.fn EO' l F1 f I C uif ' "" . ROAD SURFACE -MC ONEI WEATHER HECK ON[I - CONTRIBUTING CIRCUMSTANCES . , .? IC HECK ONE DR MOREI - . i, :. D o q Lg Ci D 5?;,,1 t [ I Z. r l ER ] Y r \/???? ! R LTI',11 P51 0] - ED ? I O EG F] ? X /'l 6 `D .ING FS' ? T T A. F? ] -1. t ? _ ` ] mnc N, _PLCO1fOL . J .GI.0.SE4 _ ] of Lufn F ErviER I,i G-4TLY f- APPAREN LET, _ . ] RD FAM IrvG IN n , RICHT TURN snow ] J ] i o c FLOI ?J]IJ.s EE -LIM ATED SA F f lyl c %L 1 t„ s?. orf lrAn[ ? 1 JAeJ ieFil?uR .. -? <E OG ". _ v 1 K .. E t DE[D [A i ` E I GrI O C . vE [OU q 4' LPN 0 i OT.I. - < D N NT 5I _ OTHER E • ° - MPRO R L u s O` It D CATION OPPEDFDR S IG?fCpN-OITIONS TRAFFIC. CONTROL f E TYPE OF ROAD VEHICLE CON-DI TION y: SOBRIETY- Ir CK OnfI .0CLE + D. CIIt CK ONE On EI ; LJ T FF C ( f STOPPE AL D AT SIGN ?B I J ? .... ?Cgg pr, Q(F F Cl[ IC [< O 1 1 NE Y. L.. I STOP G DR ? - 0 J??/ OAV ] 1 W. ], 1.. CHVE :? D • L X -? N L5 r T^ 0 G I ?__ -.i .l . IM, IN G Non aN ',ri,.TY RED - `.._. W-.-.... _ .... .]....... 5GV ]: J. DS.. f,. _.... Ht ADt GH11 ._ - - LANE -? A `IN o '-_ I-- PnK DPf1.IT ON ] DVS ,ASH G I E C nr+0f 0 ( DAR FIET -' MF •-, NL LIGHTS Sr, S .. E IILHIi ON A FEN : MERGING NG BALKING '+ ; .,-" -.- -_ .. ON SMPOTH ?_, EIN.PINK rvG CHEM. TEST ° I+ i [l a n "N"' IT cHi3O. F.-. L-... 5 NAt. 1.115 - _. H.N - --- ?1 .s - -? j. t a .C -• - - HCCI N ' DAR NO ' S.......D } TI1T-1. `Y ° ...ET...... I CM ... 1 OTHER SvECFVI LAE N NOOE(ECIS TESL REFUSED T' . Si N[SULTS - _.__.._ i ? 2 ' Invl s 0 rv. E ND •u u rOllrl AH vl D ? LA'r,t[ [ AM :u£`1 -'?'1- a-Lt ncY ?aIS LD All X A C L 1 M x. •pmv o I u lE -1P_.L.IC._AI[ .. COPYLOCAL _..... ,.__-:Ir,i 61Itl :•"rvY nF.i r ,f.v,,".,,,- v,-a,.1-1 I,,. 1-111111, IUN UII'vDa I , fri LAl '5 COPY-111.101A 11 COPY INVIST IGA IOR'SOOPV , r .? t-Yjf. _Mei s I F xxtt„,? c?i63 n , .. e yH .Tw"' la{7 Y r '', rV ? y " a ?'rl f I ?? ? + Tdt'iH "h _-'A9?'f'?"T"61°'r's4',od!' '"??" '?.m, ." ^se7-;^p?Y.eanr^^-Imfe;-,?p!?EFF. 1'7(? ) ` ?IMIA PATE OF COLLIS ON. '" :.' DAY OFCOLtLSION TIME COUNTY NO .-- 4 CITYN51 iHWA. M0, OAY Yfl 8 SUN MON lUlS, WFO iNUll i{ll SAT IUSE ]K00 MOVPI t T J . E B B zozD Y DURBAN Ru rf•. CWNtt : ?STAIE POUTE .' ?COVNTY ROAD OGIY STREET >- O IS PR1% gO111E0 RST EET ADML CO Z 5 T phi ?1 ?OTHERISPECIFYI - y -. 3p t F L _ -GT ORIOWN :.. ?'N ? S E W.. " O IN F1(, F t M EO ILE POST. '} { MILES 0 ? ? ® F C :NAME tNO O<ST.PEETO Y IWERSECTINGWITN STNEETORROAD.: LL T RAMP ) G GR MD TA ?t ' T:I - --?- OIV m? ?z IlJI ILA ?c: D o _r? " D. y NpryINtERSEO7gP{F. J+Z ACCIDENT E GE NIEP N RD TENSECTIND BtREEI OR AD OP QS CRENCEC/gp5 REE/[Oif TiOAO N BETWEEN__? --?- --MME -- STREET CODE ' 'EO Z (p.OO 1 `^.. DLSTANGE ANDGPECTION FPOM1I REFER NGEORCROSSSTR ,'.:. S • l S D SEC AL COOW U SE : - ): J '+n. -IT( ?Gy MILES FEET y } . 01ENICLEWEHCLE ~-?VEHICLE`L CU- E]OTHE IWRITEI ^ ?HITI RUN?? sEYERItt 1 NO BLED" r=. N COLLISION INVOLVED: VEH CL _ O .Q EOBJECT ?VENIL IE RP T{WNJI;?S._, _.+'?SYOLEN VEH CIE NO INJU TOTAL EU, t? OFVEHICLES CO VEHICLE-PEOEMRAN . ?NQ1l COLLISION i•' ?. AEARCOUSAITERAL PPOPEFl DAMAOEONLV y :?':.J? ESl„DAMAGE ? D Qty IERS NAME? ?W. \ "; LOCATION OF OBIECT STRUCKS C± TP : OBJECI 31: KINAMFill: KECT { (Iri. y ; E + ` Y tI i DN1 Y 'tizc Zv / , \ 1 D2OA0IVAY5 FEET:O 910 RD E- S 4. n ` FRST-?, -+-_MIpDLE-:_"--- UP VERS NAME LAST FIflST IODIE'. U_BICTCtISI Ofl .. NCI EGKICI ,..31: 'J - DRNEPS NAME-USi _, D - ....' 1 T F lST l GAIKCi '?Z RICri.13D tST 3i . g Si R STREET ADDRESS "-i'-"?'^ .? R NEET ApORE05 : - . Ply CTTiL3`S4 ' lai.'.-ISTATE$ S ::....ZIP.COOEN:...... PNpNENO.. A _, GTY CODE,Le-F`.IPHONENO, 1'F ?h'- ,:...t-'6;68 ""° 35?z:': ? .: r. '. i' ?.`•.?' a ? ,ats•n ni" fi _t . S . a R. le- . N OPoYE0.5 LICENSE ., rte.,,, aL1?u.+ a STATE.,. SE% : GATE OF BIRTH ?,.a:. N DRNERS UFENSE NO.. ?r 'STATE SEX DATE OF BWM ... D Y O.i .. O DAY MO a:A h '; ;1L5 H 12 15 ) T pFUVERS OCCUPATION: FUiMNAME DRWERS OCCUPTION. FRMNME.L ,. i? •.: P Ery0, CODES _! 1]I ?uDgy !AI SEAT BELT_ 51 E ECTIONi __? CODES 131 C1?55-- IJ' SEAT SEIT___ I51 EJECTION ' NATURE Oi . riD' SftTEfPr.S - ES ' F> LIRE OF - .., .. ....: -, ' . INJURI . i h}tbl;L ['Cu TO tiJl.:{ Gr'• E BY SCE RgMDVEO i .-F -1 TO ' . FR N VEN.1'EAR . MAKEIDODGE'C EVJ MODELIDART-NOVA) ST LEI20RCCNVI.1 _ VEN, YEAR KEIDODGECNEVI MODEL IDARiNQVAI STYIEIZORCONVJSN_u; , QS E VEN OR L1G. PIE 1.0 STATE TRAILER -TE NO. STATE H VE COLOR . TIC. PLATE O STATE TRA ER PUTE O STATE A C AJ .':.. '.. VENIGE WENi-TN)N NUMBEA ODOMETER C E ICLE DEN FICATION NUMaR .. ODO EIEN ? - '., REGRTERED. WNEfl+51Abi ,._..'f?. i.?... FIRST::-. r -4-- MDDLE EGISIERED OVINER -LAST FIRST O O - ADDRESS OF OWNER AOOPESS Oi.OLVNER,' 4ME ANDApORESS OF WSURANCE CO OR AGENT.. ,. ... . - NMAE PIIDAOOflESS OF INSURANCE CO. OR GENT. .?... 1._. I 1 I L CwWOE n.._a.t... ..... . , C ITIOrv NG ENiORCCMCryT, CH RGE_ ' le TAT' "Ill, .. ACTION. n:, ._.__ .?. NS INVOLVED S p ]- I O IN NAME ADDRESS & JURIES OF PER sE% AGE STATUS EJECi.; , m 3 6 C ? . . V p' .. .f J.? NAlI1RE OF„ NIMUVED FNOM - MIURIED serr,eBY 'io .Tij'F. GT^FF•R%:I. .. A..: NAME ^ ' T YT Y - 1''5_ .'% AUMFBS " T[+l _- . S ? ? Ta To I Yl •. NAME I.: ADORtss :. N NA U/i gLTF .? h 1 [ B -- -_ __ TO :. E - NAM[ " ?il E Sr • 'ivv-CL7__.-- '•.- c. ..-_ _ FFM6 "L FRGM ,,_.., P,iURt'S .: C. "• i..' - - Cf r,i NY IIISIAIVS ITT+EAl W51%]N JIr•lU1Y t- L ?1 t I O r J?Il?C4 1 )LI () D CI OS1 N ] DONA •C I[ f 1 1 TD I.„_ I.1.1-RFLT O T lCD `UC F IOIIV - ISI EJECTION ` O I i{LI fD I ]O T, N lL 1101 CIf0 'nzy y } S O I C. l R DCUP, H( L > PC i?lf :.u . j A t I r j ? S ? PIAIO 1 F 'l OPIIt ''• IIG:V.•?IOW` ' _ t., . B1,US HtE,e? .EW SICA, 111 I IE l- IACT)D ..4 I Al I 4 1 ? - T ti r 17Th = .1 1. { I I I L 1 » L IN L+ f F' EA ` [ ' Sti? a v? ? ? ? 4?. J.n:=. a• ma1 ciJ MOTOR VEHICLE COLLISION REPORT DAZE OF COLUYON DAYOFCOLUSCN NO. TIME OF COLUSION AM MO OAr ;AN N[5 wEO 1" UN r s n 0 wlut[s PM • COUNTING CITY NO. µ R COUNTY CITY, TOWN - 50f MILES N Co CITY. TOWN vE - r_-O 11 © DF OW r_ zl ADM CLS SECfgII PPEFI% II tll srNFflGOOE 622gp GIVE NAMEOF SiflEET,ROADOPNIGWAY I T-CTWG WITH. STR ET Oq ROAD PREFI% E O MILEPOST NONINTERSECTLOC OFC ISION EETLVEEN a - PE T AND . STREET RAMP OAGRAM DATA '.. '?. C ROI NBEC IF . wo J NIE J N Nc ? A u lFlgsr50RE w "r ,N MK. °OE C? . ? Q IN ER RO RON E CL Ca?5? AO OPp. TE f f i R © a r e rs? E E T Z / .YCL I? ?vE wCIE ?vf CLE ?OI"FRlwatEl bPECC EL6E 1 NO c 0-- IIIAN OF V ?I I? EMCLES v "I 'IN OBJECT STRUCK IN,Mf oFOaIFC, S,RVC10 OWNEROFCBIECT5NAMEANDA00NESS LOCAT . ION ®© OF. ? [ I ROAD Ty q - WAY O eI Cr t O FEET r MORE t [ DRIVEPSLAST NAME. FIRST NAME MIDDLE I fn Oro?iv Wil gSLASi NAME FWSTNAME -. . -- MIDDL `` e L)-P-- L Q W L ?. ca. vo'. oN STR EIADDRESS ROUTE NO.ANDBOXNO. 2 2 w0 NuREJ VSE, STEIEETAODRE53 ROUTE N0. AN0 N0. \\ CITY ... SFATE - L P DE OR VERS OCCUPATION CO sERAR,t[ CITY STATE ZI CODE R P ??J J?? gq -A , l G 70 (] nEroa IONS P -. ATION E S000U ... DRIVEP4 L%:ENSE NUMBER TATS E% DATE OF BIRTH AGE - •(] - _ ?- - emu- E rq n,r IAA x DRVERSUCENSENUMBER \ STATE 5E% DATE OF [uRM AGE u s W a,r rcAn VEHKLE YR. MAKEICHEV OOOGEI MO OELINOVp 0ART' ROOYSTYLEII DR.I VEIIILLE YR. MAKE(CMEV DOpGE) LiNOVA DART),,. BODY STYLE 12 IXi.I T ^ ^ ( n I LKENSEPLATENO. 5 ATE TRAILERPIATENO.. STATE UCENSEPLATE NO. STATE TREJLERPLATENO.-. STATE VEHICLE IDENTIFI-*N NO._ 1196BMODEIIINEWERI OOOMEI EFT IMILEAGEI VEHICLE IDENTIFICAT7NO. , 11968 MODELS 6 NEWFji1 DOMETER IMILEAGEI REGISTEREDOMNER ILAST-FIRST-MIDDLENAMEI OR.ERSUCENSENO. a c 1. Lewl'6 Aeo,Y. < - F--TL- 8 REGISTERED OVV LAST-FIRST-MIDDLE NAME) OPIVER$ l1CENSENG, ? 0WNER5 ADDRESS (STREET. CITY AND STATE) DATE OF BIRTH OWNERSAA (STREET CTTYMDSTATEI DAT 5t. Ri O I °5 ?Ce , E\IgTF? MD . o i 1MTSOFVEHICLEDAMAGED (+OCC KK -o f I p f' E'er(-4 • YN PMTSOFVEHK:LE DAMAGED RTOfUFI ...... SiO rta WAS THCRE AUTOMOBILE LIABIUTY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ?NO NAMQ -;D`SOOR Ln U[y?FUq; CE I(j1 0EfIE 'u ANEOFUllUTYINSURMCECOl-Y IJ Iv {.l'?/JA ?l r - ?Drt lows. c+v 83?b ?iomeY s' ;??. sgFconsur[i^ NAME MOADWESSOF UABIUIY INSV CE AGENT CRY IE To UABUTYPOUCYNUMGER _• S ; { t?J a ( `1g3G8 ISTPYJIIRY NAME AGE - INDINJURY: IVSF 0-TEREFOR OA r u ESI NAME . AGE . ADDRESS " I.HRI. -A - - - --- -- SEX pp E55 -- _. -_ _- SEX M F o ? . . 4„.r o.A L1aA, EB M,MTaRS . 10-1 - -- - - ---- u „bNer. laR, N.MERS _ --STATLSOF-ED O CnNf RVENICLE NILlEO MARK FIRST Oe ICI SfVFRO ONE THAT APPLIE IO.s•Ba MaORrI S RosvnFE IIOf W Fi STATUSOFINJURED p N VEHICLE KILLED MARK FIRST o-sAOINO ISLVNFFFI ONE TNAT APPUE w.O?e.IK ' ONO H ' S PosyalE E[OMR Ov[ o,,.. wRrL.N ? e? B? w OI 7o N O O o F ? 5? Z 101 1o SNOWROAYH BY MROWINLRCLE RKE r \ O ' DESCRIBE BELOW WHAT HMPENED(REFER TO VEHICLES BYNUMBER) x Luc s . Nuulti. wes+-o>\_ G_R,_.€{' 9g _ \ ? I (A!I.zh I _3umPeb ors tJ.? roe. IM,AKNAe,cHH"aE.NJYKAr OREDI%RaErA.U.IB.ARRaw '? i y je_d--'f'o_Y.YYLS h'rCR1111_-(3?---Yr?. -Z6w_-c -1 ---? '? QQ .- ? ? rS,RLEIORI.,"w - 1 L I t'_ 0.1Ar)__ w±z 1 ? ?? - ? ??.-V_? o? f ? O 1T T VEHICLES POSITIONS BEFO RE COLLISION .6-6, HW1 vTncu 110.111 I-Orq YF"cu Kr.AKm wAS IwESTGATED BY VCHICLL N ON SiT1EEi pi AME HKW WAY N ONNO A 1 I ltONlr r,RKEO rE5 WIRCIE IKCVtJ K6 iiinG OPgIC( TAO RPRN ? 66' fEf? Q l`-' ? ? ? ? ? ? ? W [II ?E K ?O of IR D ? ? O ? O ? D ? ? IKI .N E 1SIENNEF AYUnKMN ? D D ? ALEKq c oa..D FROM DIRECTION 10 DIRECTION PCO(BTpAN wAE 1f5W0 1?YOEWN.K I?WALKWAY J?S .. HOULOER A?60 Cro.AiwuK 8?OTHER ROAD SUR/ACE c.ORI IW WEATHER LIGNICMDITIONS TRAl FICCONTNOL K-cKMEI IY'PEOFROAD p1IVERMII%AE ACTONS W- MD I AG I DU_ 1 ? GCE KaViR 1 ? CAYUGNI AD, MI ? 1 ? SgNALB ",- OI?CMOANE ?I 1 ?IONE WAY VIHtIE H:IfW ON<OIAKKAiI & I ? GOIMO BIRAIOHT MEAD 8 1 ? ONr ) ? RMIMD L ? DAWN ? Z ? sTOP RON JA I ? TWO WAY ? E ? OVERTAKING AND PASSING ? L D W" ? ] ? YAW 3 ? YAWING 3 ? DUSK CT ? I ? YIELD SRN YBLE ? ] ? LOAD ? ] ? MAKING RIGHT TURN ? E ? f00 A ? L- CN ? A ? FIAS,N(1 RFD ? E D Wi MHUAE VRAUPI W ? K D MAKING LEFT TURN OTRFR icARHisarET 5?II-CNY) ° ? ? 5 ?FLAYIRG AMBER D 6 0 LEy [3 6 ?NIAKINO U TURN U 5 0 SPFCIY 1 q DARK NO 8 8 RR Yf K ? ? ? e ? TER R[A.SpN FOR NOI 6[[ 0 . C?? ++ S HRIT NRB WDAMMR .OEGl I Kr211C1 F ?O ? I ? OIFC[RIfLAGMM TURN ( LMC9 ? 8 D SLGVANO ? 1 [3:1 81OV10FORTRAFFC ?? F ?? /Efv (r( ?(,(,?•n ?: (^ I?EK? ?n AI )??a ntuf j - • ? 6 ? 01n[P DRECKY .. . ? 1 ?mPMAI[O ? 7 ?DINOCO ? 8 ? O's IMCCA, sam? ? Y ?Ei01T[D [I ROADWAY U L O -_ -- - .... . .. ... Ila • (l Nfl TRAFFIC L1' lJ C7 ] ? m.to lI'4 ? ID ?iRNi!C N[ ?! .,?M l ?! ?.f., .;'"'„C ?r?{,?,,? . :? .::i?E"t? ... •_, 1 RT Ti (ROM 4c . ,. ,L. ?,r'sul'?i 'i?]'c'?,u .. DATE OF COLLISION eDAY O CO uO U 51 N TIME OF COLLISION nu ¢,r nO nu fs u ?OUNTY 1>; J C11 o D i? AM .S . r r• PM '. //'/O 4i / COUNTY LITY. TOWN w ' , MILES 1??? 1 CITY, TOWN L'J ? Oa ADMCLB. PnEFI% / I r Lr coof y i SEC 1P ?c; f)S?A •/<,7TI•ns<•,,: W ra s®oP yn?7rt.n'crl? Z DW coZ GIVE NAME OF STREET, ROAD OR HIGHWAY DOR INTERSECTING WITH. STREET OR ROAD PREFIX EO 111 E l N ON INTEPSECTIONLOCATION OF COL ION RANP STAG RAM OATH--':.- BETWEEN STREET AND GTREET - A,NO1 ?N ?E pop IE,RE555NrvGNUECEIoSisORE OEw1 ?v rrviGiirvouixµuubf RR • O DGL IN ER NON TNT R %?RD CL 5 1 TF "I C' CO FEET J P31 OF ?: i' ?•C<"Y ISL. 2•t. r'•Yl-O T , GpII NON INVOtvEO(??-? Qvt Qvt ° f SPEC CODE USE _ ¢ d i f U Q:::K: u a.a ..col"e; Q,,,a.a i - OBJECT STRUCK INAUE.1 OR,f<r slxucal OWNER OF OBJECTS NAME AND ADDRESS A TI _' •'_ . Ou DF,_ Lc IN O WAY FEET LE W E., $ Ca DRIVERS LAST NAME FIA ST NAME MIDDLE IF -N1 N 1- ."1 1 DRIVERS LA57 NAME E FIRST NAME MIDDLE 13 / Lic4 I STREET ADDR ROUTE NO. AND BOX NO. OaET-AN TWO 'ENJ PERS STREET ADDRESS - ROUTE NO. AND BOX NO. fo uun 159 A CITY .- ,. -... STATE ZIP CODE /(CRT T ' ' L ' 1Lh DRIV RS OCCUPA ION c . Tc- .1 UNION E..TfGR CITY.. ,- . ... .. - .STATE.. ZIP LADE, :....,- DRIVERS GO UP I AT ON E [L n:Sc // 0 9S i 7 l* - DRIVERS LICENSE NUM. ER... -: STATE SEX PATE OF BIRTH AGE DRIVERS LICENSE NUMBER- : ".,. .: STATE G .,DATE OF BIgTN.i AGE' 9ya rLZ !r 9 z' T)4 it r[AA VEHICLE YR. MANE (CHEV: DODGE) MODEL (NOVA-DART) BODY STYLE R DR.) VEHICLE YR. MAKE (CHEV: DODGE) MODEL (NOVA-DART).. .BODY STYLE (2 DR) /573 «/) SiJ/c/3iLL-' l-LTAq g,& Lf UY Soon LICENSE PLATE NO. GTAT TRAILER PLATE NO.. STATE LICENSE PLATE NO . STATE. TflAILER PLATE N0,',; .. STATE ;. AL /Y'f LL// , VEHICLE IDENTIFICATION NO.;_., (1869 MODELS It NEWER( DOOM ETER MILEAGE) VEHICLE IDENTIFICATION NO.. (185. MODELS 8 NEWEW .,;. ODOMETER (MILEAGE) 3LG9h/3/113z,-/n/ zcyryo REGISTERED OWNER : (LASTFIRST•MIDOLE NAME) DRI RS LICENSE NO. REGISTERED OWNER (LAST-FIRST-MIDDLE NAME)., ,. DRIVERS LICENSE NO- /ifne,14 , L /r n "t L 996 rLI L OWNERS ADDRESS '. (STREET, CITY AND STATE(.: DAT OF BIRTH OWNERS ADDRESS. (STREET, CITY AND STATE) OAT OF B RTM 410CfY,7 ?,oA (de ri O.iT7Z+¢o."Si i? 1G' IIA rf,N 7 22- CY ue paY vFAP LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1• NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER f 111F 11D IFIF DD Lrt'A'c•L ,PT3, /FAIL/Cc-/>' ia5 veM ,NRESS DF LIABILITY INSURANCE AGENT 1ST INJURY NAME - )r ADDRESS ?I cl[r ST?iF- - ` - NAME O?F LIABILITY INSURANCE CO) L Tl It'/l.St'A 1>. [L't), 4Pe? L/F,.S. Otr ¢T'll NP LIAB/-IU,TY.POLICY,NUMBER _ /.>Z 8.36 L/3 AGE - > 2ND INJURY: TOTAL NAME REO _ _ IE% A.. FEES STATUS OFI R _ )HARK FIRBT ONE THAT APPLIES STATUS OF IN UR D MARK FIRST Q DRIVER 'N VEHICLE pl - NO -1 Q DFI ER IN VEHICLE 'S,RNN N? Is ?uiioN, r NILLED SNiupr NILLED QPASSE GER Q PASSENGER a IF AN D wuNF UG I QOTNE`iR-TENN. ? 50 LOEE HRV^F El . TI IN 550E b.?v Or?. .O( SHOW NORTH BY ARROW IN CIRCLE j DESCRIBE BELOW WHAT HAPPENED: (REFER TO 1 INI ON rwspG I /'?/r'Cl x Dccc. /7 WHAT .1 1.1 t e?i L7 n _..--- ]_2.'1.61! 1 ccc I RL7?':a?_fL5 ???L r_Jt[ I-L !n tL}?»< ------------- 'EB 5 ) yr??y fib- ?) JLve•" uP N 60 ES BY, NUMBER)0[TC f 1d _r E%C L= t s y VEHICI ES POSITIONS BEFORE COLLISION »I a y ' :IUIVESnGATED DY w VEHICLE E ON Si Nl E7 OR nIGwIVAY LANE OR rE5 0 ES NO I-., -- I1-N ? L" cl v1 ? ? ? 1" 1 ?. Ow III aft) n . El ? El [] _ f +[t+ESt nIAw ,G FROM DIRECTION TO? DIRECTION CrIp..4:?i'nio{7ft-4 T f1011INAN WAS U!INO ? (1W,Ia ) L ..[ ll??.. ,Ia s uwu.a.l t OTHER !, ll t.I ROAD SURFACE iMER EIGHT CONDITIONS iR IF f CC'. OL I rFr 01 0 D OR VCRVEHICLE ACTIONS _ ,tnlf., [AU u0af ?i X L'I 51"41 clfe a u I 'CInO) R»IC• ONl ON N. I :;:y.[NI I?'1 F r?J .e 1 n DAYlIGr1T 0 t i •iG 6 I,,1"1 (] DNE WAY uD l I n GOING STRAIGHT AHFAO 1 ?I t 1 ll) '`,y ?a Ittf:J 1 (1(1l ORY 7 1.1 RAti NG 7 (? ? DEWN L, j I q SICP G GN ry, 7 r'i7 1PO1. WAY I, 2 ?? OVf.RTAN1110 A110 Pp S51N6 f y Y - J J 1_3 , I J 'VET S 1 "CrG 4 I.?.]1 IMISK ?. 1 j T, vILLO SIGN I.? 5 A11i51LE i? 7 0 NANNIG FIGHT TURN 5I I]7 ?, SHOW Do E V(" h?v E i 7 1 i rCH IANOE 1 I,J 101ar[t4OHLT k ? E ?fLASH IIG AID L-?t rJ 1] . MAKING LEFT TURN U C[ S I 1 O fP 5I, 0 PASINf ET r( I100P-nAMPI ? ??T R1 +154 ` "T { C iY) UARK, NOIf 1l? 5 I? IIASrI NG ANUIR r•, 5 ?1 ALLCY iF]'1 S LJ MAKING UTURN y ?'1Sr'1?}1 5 't Ol ER 1F ( i.7 I J 5 ISV . I' I 7 SIII[Fi IIaNI4 l.? d i-1 ORSGN,L Ll IT i_J TMO WARN (F E I? SLOWING f ?S?.f. {y?• f 1 l IGYOtIC0p+.'. 11,11 JI'141+LGIiY I?Of11CTRl1A6NAH CI'AA ,IC _ O ST ROlfaPPLE) An F114 T DIGITAL IG SIGNALIY J p I. 4 , 1 yU. f Ff a { .. 1 1 ? Ot IA YfNY 1 J I,] N l L 1 l . 1` 11 n F] 1 I O A 5 , rer mia uF { r LNrr ?t y I I U .AYe. .ll . t. 11,1 ::tt 1 I L ?i zr 1 Jf I/L: Y :d J1 Al 5 -.5 11 AI?p { J f' / r f Iwly r' VENICLEDAMAGE - ' - 1• A + RA AREAOFSEVERESTIMPACT t INSTRUCTIONS: I CRAW - ARROWIS,705HCW P(OICWAICWF.C^.'3.•1 OFFORCE ®? i DAMAGED VEHICLENO. 1 (USE. SPACE FME I`C r.CGM,AOETO TRA4EB3, MOTCRCICI.ES. ETC) DAMAGED VEHICLE NO.2 I HPOa + Nool 13. Hao° I•.iboi R IS TIUn4 ?? X . Q CC nn 13 ?? 15.rM4 ? 0. I+dWWmp .An Icr?hFJ•}l? - I0. u?eworrd°. v Izo n v. w„ n.ow.°.° SEVERT'OF DAMAOE: VEHK:UE NO.t SEVERITYOFDAMAGE:IOIHERVEHKU:) SEVEPoTY OF DAMAGE: VEMIp?E N0.2 - IQGI3ABUN60AMM1E- 3QOTHEfl M.V.DAAMGE IQgSABlY10 DAMAGE 3QOMER M.V. DMIAZIS 1QDiSABLING 0AMA0E 3 Q OTHER M.V. DAMAGE 2 FUNCRONAL DAMAGE 4 NODMIAGE 2 NNCTION I-AOE . NOD-AGE 2 FUN IO I NA CT .OMIAGE 4 NOGM.IAGE TOWED BY t{x..IG L? SaN ??S EST.DAMAGE TOWEDBYTOWEDBY _ ESf.OAUAGE ro' N 1. li t,??ISs.w•9 ±I, Lt7J, s TO s -_ DIAGRAYIOECOLLISIONgs x'f."_' I I i ! I ! ; :I. !' '??rJi Tr - I•i-CR AW AR RO W SHOWING, I.IxNr ruTUA• o"e??Me _ I I I I i I ?? 11 T? !! I I I 1 1 I I I NORT HIN CIRCLE D?AaAD.r f ,I i ; t I I I I ? r O is I I i I I ! I I I .• 7r l . x?xA?vnoe.,e•ePawra - ! I ? I I 1 I I eND EFeoesTm N a ? I TI I I I I I { K walKweArwP PRae•BlE OR Ke e I . _ _,? ,. I f ! { (_l= I / ?=j' T •._.. I ti °,D,D? °r'° AN? - I I ?_ ? i j' I I L _ 1 ! ! ! I 11 i I I I I I I! DESCRIPTION OF' qt ,.?.CDWSION•r?;,.,..f, j ?;5 QNDICATE WHAT DIBA&UTY,flEOU PROBASLY NAPPENEDBEFOfIE WRING ANDAFIERTH CEDV44BllTY,PEDESIAIANCIATNINOCOLOR,COn,4i E CAA3H,IN000.EINFOR"TION RUCT10NORNEPNRWORK.ETC WiONDMO .E.G.DRIVER .I > 1.? L WAS- i (-1 uu , v,G1 tv J2 - • - G!?Qc.J?l?-t ?v>, ???? - 1? c ?.-- ? 4.+n. .S?JS/zu4:0. IO- ?. V1 -IT'i 4w;? f I O S(I N U C V ?1 : _ Jr1-n CJ •. {1-? t- 'a:. VEX. HEADED' 0 - -MILE POSTOm. - - WCREASm DECRE N ...:.v_.:?w.u ON STREET OR HIGHWAY NAME OR NO `?'W NO OF -ES WO EOIRECTICN a SPE w ED 9 s•ce VEH IE LEGALLY PM KED IFPI D WASVE1 OCCUPIED . N N S E W ASI G _ E _ _ '?" ? ? I c K• cl V O _YEB ND YES - PED. ? ? ? 4bp °A 0?4y1p OA M . a]W,fA COwElOvR w.I m PED/&CYCUSTWASUSVq r?so[w,•u x : rl j wwcw. a^ l Ja?°una -?a-iws 1 ?--7c- °1?-1 I RgRe „ROAdSURFACE;/j IaKCR [M ':S :nWEATNEICB'u KHEGa OIp . _:TOf{.TR.I8U _ Ka n _. _... T1N0 GGRCUMSjANCESS t:CK rw 0/1 MDeF) o m ?` „?, ,f S t?M ? ? + ???? vrtw•ea¢encx??GVA.c?ec,?K.rs:_ • ? .: tl1 Nuq ? w . ? , x _ m . x • ? r.a.+ .rrFF ?1 ? QI iAGHfN:f C] 'L] e fir- ,..YIB+«n Y a, ..: ?. O,aQ WUN ?,Q...,IG x wer : ? n:w.Xa ? _? on•0xf°•wulo,«n ?e? IA°'?"e c?rtxR ??I"1 An?rtv . = ? ?a? pd:rrulW 1:1.1 ? aXO+ a ? x•o,+o ? a?. eA®°wOU,rt "rtn ?x? rmN?loro .: ,eGL la- °° rJ' ' ?'?-aFrnlie•I __ _? ? ?fCT2 [qY. ?e? LLNIN e ?`+e• aL a ? ?M?e ? yj y0°'?OOlpl,f n .... Ir ?• ?0? BLDMYO ` OIHRIIYN1Ir, OIHf Ie Yj ?° ? o mn O E"-L,I-1 MO°KVIOflIIArI0?i1 ? ) LLJJ ' ? ,? LIGfTCONDITION3 IDMiK axq ?T1fAR?C01f1A0C'.: M x veHfAe. :e-ienY".G'iYPE DF,R0110G - 2 Kawal awe--0 •VQI ICLECONDITiONg carte pM w - `? ?i SOBR IETY; w»cia ?e? ? -.AT . ... ... I - m rt ?] a l? wl.w, ?x? 11,0- WAY F:-El -- ? , Na.x .CDXrwlurt0l ?,? I , NGx I? w..wa ? ?,? N ?lo? ncrw°r NO w _. , a - , r _. Lx wrlwwlm _. . . ?II?.r°riwlmOimnw a ? oueK ;_ ?? . C j ?'4 _ ? .? ?? _.::. Q, _ r"l s 4..1 ?af I' mmewerr S ? ?,x? Iraw?wlaro?o I _.F w io"'"En l?J ? ( '? :},J ""rT au^° ( -? LJe? A`?!- ? al,'?a..mm nuMOOmwwo ... I? ' ? ?n? cacao .? '., .. a ? ua?" nr° ? e? +'a`IN. ?'? rliW?iAw.a? ?e ? aiowXO I ra CHEM. TEST ? ?. _ mun? s I r rn,.w?iui ?I n evw renwd oTl w,r+e on t ? ? O °"O1 ?a ? °n'°'° ? ? ra «rN.•re (? rl narl,eruxo ?? b Iv I i ?I "6iwnlse<:w r u •j? cMOal?iroic '( !/?'`,? I"?^°O .1.. 1?' ?.~'?I DrI<'Aleiec.n % % TEaT REwlis 2- ; ?A 1 anD.,vpn.,nwsw. e•w. ?. I ?. ?'? n' ?1 i 7 L_ v1 ` w 7 Kuc oe.. wKxe w..vxD 11 ??2'f W I j a'°° 0?/ 2 a x.oo -n Amve + _ x. wiYao ro -? ? Kyrwa°rrc}I,a?+w•wMK? V ? "t 7 7' r?? ?.,1' a.myHO X17 Jc?c? wrwpn ff 7,. -rlln w°r ?, z? 77 .r,rwa°nr -n J a+nie?iecavr: ioc?iuweiaaPCeerHi:Gi?Ner"s ca"vr`=iliwueAiE COVV. wv"esnaTOrr"s coPr t U k lo. 6 e PSfdI e } P ? X ?I . ?[I A UATSCFCOWSION DAY DFC.Lu_N PME COUNTY O. CRYNO. FHWA F+ T E MO. OAY R. ' zJ WEO TNUP FPI SAi >!Urv 2 I J A 5 B IVS ]/IOO HOURI 1?:? } J .r ?UREAN CjKRAL COUNTY ?STA ROU - COUNTY ROAD ?CDYETREET Q ADMCLS. PREFIX ROUTEORSTREETCOOE. SE ION .P Fi-f So AJ ?OTHERISPECIFYI N 2zZS CITY Ofl T O IWN ?IN N W P REFIX EO. MRE PCST ?1 ,. , J ?1 OF ? I E ? ? ? 1 O /1LJ C MILES . • l V W . LL . NAMEANO.OFSTNEET HIGHWAY INIEflSECPN6 WITH: STREETOR ROAD LL R AMP DIAGRAM DATA T ON C 2ff Iib 1 NONINTERBECTIO N ' ACCIDENT I NT R N XRD NTERSECTI-SOfl Ap OR REF. N ( ?] BETWEEN C. S (??- VQ) STREETAND {ELI 0 STREET NILEADE CODE I TF CLS EPENCE CROBS STREETOR POAD 6 OIST,INCE AND OWECPON FPOM REFERENCEORCROSS STREET LP,a S PECIALC OIND USE []FEET N S E W OF C 23 ?^ - COWSIONINVOLVEO: ?VEHICIE-VEHICLE []VEHXTLE-BMYCLE ?OTHFAIWRITEI ?HIT&RUN NO. MLLE. VER)IY []VEHICLECBJECT []VEHICLE-RRTRAIN ?STOLENVE.CLE TOTALNO NO.INJUREO . OFVEHICLES ? VENCLE.PEDESTRM jg]NONCOWSION ?HAZARDOUSMATERIAL FRI. TYDAMAGEONLY OWtCT UCNINAMEOFGWkCTSRUG(I D0 ERBNAMEI ., tACAPON OF GFUECTSTRUCN ESt.OPMAGE. []ROADWAY FEET ? ? ? ? R.. EDGE 5 DRIVERS NAM -LAST RRBT MIDDLE ORNEFTSNAME-LASTFIRSTMIOOLE IIF Bd;YCLIST OR PEOESTRVN CHECp .•.._ .-.. D LK?K E UCE MF, E Dw°j\j D R R V ?t3 6?K 1'43 4 STREET ADDRESS .: _ .. ... ':. _ , . E ... STATE ..:-CODE ,::-PNONENO. CPY ,. E . 1W CODEPHCNENO. CfTY ',::. ... ...,STATE,. : A . TownSEn?l &A 98M8 365--,3187 R . N DRNER 9 L1CENSE N0. - , S T ATE SE% D A TE O &RTH N -- O -W3 UCENSE NO.. ETAiE, ,SE% DATE OF &RTH - O. ' 1 l , _1] D 50 Lc-V 15 ' ? ) w? M /p / t / t 1] L D• MO. DAY YK DRIVERS OCCUPATON.. FWM NAME.. :. -........-.. ;,.,.PHONE NO. 2 OPWERS OCCUPATION FIRMNAME, .,:. ....,. :'-.?.. CODES > IJI IA) SEAT BELT I51 EJECTTg1 CODES > IJI C?URV (11 SEAT BELT SI E ECPON AWREOF WUgIE9 TUR f IWURIES FgOM SC NE.Y' O FROM 9CEN BV: TO VEH.YEAq: MANEIDO D GESHEV.1 MODEL fIOVN 9TYLEIZDRCONVi ,' VEH. YEAR MAM:(DODGECMEV.1 MOOELIDATIT-NOVAI. STYLE I2DR-CONY.), .., V 661 ? t( :I h7, V E EH. COLOri;;?, DG PLATE n0., STA T)WLFA R/TE NQ. STATE r VEH COLOR '.. -PLATE NO BTATE TTWIER FLATE NO, STATE , i J3 w - 16t 7 9 (?` Nu_ VEH b FICAiION NUMBEIE .:.:.r: .- .n.. .:, .._: ETFA.:.: :. -. L 9t/ 3t3 89( 4 49 9 e o 1ovSr1 J , _ REOI NED.OWNEfl-1ASf - ..._+•.•.. FIRST.: -:...i ?- :... ?:.' :..,.MWOLE. REGISTERED OWNER-lA5 MIOIXE;. o. e ?E 11 f'2+4+11C 1 / N o. ADORE59 OF EA ..:.. . •-. .. ADDRESS OF OWNER .. ,:vwil s ctd P. o, q/,3 Z NAME ANO ADp1E55 FWSURANGF MH1T_..,.,,,,. NMIE ANOAOORESSOFIWRURMICE CO. OH AGENT cHARa ..:Jn ......... ..?. ATX]FINQ ..._.. .:......: ......:.... .. ..,...... ENFORCEMENT. ACTION .. . , -. MAROE ,.. .,-??_.:_:. _,. ADDRESS & INJURIES OF PERSONS INVOLVED NAME DwES ' - 2 , SIX AGE STATUS N EJECT. `. NAME: C ADDRESS: U V NATURE OF R MO EDfROM Pt111RIES: SCENE DV: TO A NAME: N T ADDRESS: S L T VEDF IwUUiES: SCENE RY: TO r L YY"i' . ?N i S-?Y It ' ? is x ? J k A, II #L. W NAME: T ADDRESS: N N1IRIES' SCENE fl?'. R TO S NAME S ADDRESS-. E 5' lu"un ScrNERY TO II)STAWJ L2)SFAtPQ51TVN IDI IHA1RYClA39 1RI SEAT OEIT 1lI FJECT)ON `. 2PSSENGER I. NOIWURV SOISABLIN6IWURY I. NOTINSTALI ED NOTEIECTEO O PEDESTRIAN DCYCUST " y 1 Z OTNF.R POSrtlp1 2. DF.AD AT SCENE A J DEAD Olt ARRIV L e. nDllws"BUND IENDENTIIWURY 2.NOTIN USE J. USED 2. TOTALLY EJECTED J PATIN LLVEJECTED D S OMlR 6 WRNESS A J IBU9 MOtORCYCLEI POlITIONUNXNOIVN S A_DIFD IN HDSPIAL T. POSSIELE IWURV .UNKNOWN l SEAT FELT FAIWRE A UNXNaNNIF EJECTED E , . TI L SET C -<L wE ? !hC I . I I ly?x. I '4 I I I -2w q INSTRUCTIONS:v S. oRAw RnnoWS, ro SNOW AL DIRECTION OF FORCE. 1 USE THIS avncE f ON SKETCHING DAMAGE TU TRAILERS. MOTOICVCLES. ET1.1 DAMAGED VE H ICLE N U.. LE N0 .r ki DAMAGED VEHIC 1 r . H! H .. noo. F ' •I T I r _ r wn I Is rt,,,,,A IS. U I B O I) ' ^pX 'S . SEVERRVOF DAMAGE: VEHICLE NO. 1 SEVERITY OF DAMAGE. IOTNFR VEHHCLEI E R DAMAGE VEHICLE NO.J I ? DISABLING DAMAGE ] (3 OTHER M. V. DAMAGE I O OISABL xG OPMAGE : OTHER M.VE AMAGE 11 ?'u LIHIS DAMAGE ! El OTHERMN. DAMAGE o ? NO DAMAGE 4 1L I . ] ? FUNCTIONAL OPMAGE ONO DAMAGE ] O FUNCTIONAL MAG 1- DAMAGE EST.OAMAGE TDwEO BY R ..... MAGE T : DBY - 1 O OWED Y ` R., { % TO { O - T 1 - To I ---E1 I t' DRAW ARROW SHOWING .DIAGRAM OF COLLISION NORTH IN CIRCLE 1. ..INN r'' 1 pw -'k _ { ST. C DlT,DN f 1 I S' -Y,A,LH.- i TAT I + - i-] ?- K J R,D,..[HL.F..LDL -si All-F-ceLLFD, •I -"I I -; -f7 DESCRIPTION OF uxo,CATF wHATPROBABfr HApPENEOe[faNE OUPINGAxO AFTER THE CRn$H.INCLUOE INFORMATION rvOTONOIAGRAMIEG.OR1VEq - mSnenI"FEDUCfD VS EU CITY. PEDESTRArv CLOTHING COtaR [ONSTRUCTON Dq RBPA RwaRK ETC., e;. COLLISION ----------- -------- - I LA POSITION DEFOR E COLLISION 0 E iR'tcnaN . v[EO FAgKEO occJVElu MILE P HEADED ONS RFET OR HIGHWAVN FOR NO. _ ST CUT ^ CREASING O CPE43 NG W E ?.j Ir NO YES NO ?Ir?t? ? Mp. E- A o xc_ - cc°nR"oMS nKE If-''I1 R? FEB. AA 5 I- B O J [ _ ' F I< O o I J f `Jo N I IOFOlSwALK 'JI IN L PUNAI o SI f C [ N IIST WAS U IBCV Pf ROADSURFACE. WEATHER - - - CONTRIBUTING CIRCUMSTANCES .?L I iL- EAC O ONE R ICRECK ONEI ICI ECK EI ICH11K 0 EI r ?f D 'FIVE" H : GO G O O] H A RIVE FZ S ,, D O) -1 NO gJ,) o He. r,r FI-1 CLEAP n o I-I UNDER INFLUENCE ?I u c '12 LyOYERCASL ! _AEGAtlOL F .L! D 4C9 F6.?- _ PASSING AMD Dnv A A a _ - LUENCE OF {? 1 AIN NG ?)?DRINF ( O CE.". IJ .[-EEPNL? RIGHT TURN 1 J I WET ] RUGS - [APIFNG. ..1 J G t _ _ ?? ECDIx ATED LG40 ..PER S EF L. 1 D 1 SO LJ- .I 40G.. 19N_ L...+ EfTTLPN a`? SxOYI ! Ow G - F J: 7 ^ 1 3!1fC YECO 1A5 r? r) U PE ?! rI?EE C vFEOUI-? ? OG I UR C H" C l y' •f T 6 .-R L? SLOWING . ??n ? 1? D D CLE T R -Alp . - 1,9?- J I I r G; _ y TflO C GR OTHEPIY[Civl OTNER ISI I r iSl-, ,ASS rl FJ D HIGARD ISG S w ??IBu 00 fOLA Of I r ,F I HTCONDITIONS RAFFICCONTRO N f TYPE OF ROAD VEHICLE C.N..TION_ SOBRIETY OR SGNAL STOP N ICLE ENO ]f ICHE NEIr ICNILK ONFI I NO.> VEI [Lf 1 NO-] ICNfCK OxE OR MOPE V ? ? ' NO j? l {}II{01 FD I NO DWAY 1 -GfFECT F ? LTY ' r 10 i .! . 1v.O WA Tn C ANE I] _ 1 J UA Aflt LOT ?J ) G n?.? BR AKES D -- ? ;. • - - STARTING FROM 0 ILITV !-, f' [ E l] OL IE FECi ,OLG 13 _ APCO..- _ PARKEDpO{TION I 1 I]? I DAWN ? ? D{HB L . SGH ._. -: • I -- . _ --- ? 1 N ( '? (? ? r_? UNK.-. fTY TRAffIC11ENTtgIN6 A I FL I INIERCHA NG I-J[Ct.. _ .?? .. PEM LIGHTS L a av , L nm._. LOOpRAM[ HAD NOr f I LSwO 1 I?IB? BACKING ?- - _ N DRINKING 1 D 6TP[fT ?S( S ?6 .. A I _ DII i. DOIH BEE _ AM[R . ALLEY -' - O CII M TEST iC LIGHTS" ' . I.- MI-ID . r tf j {D F SP[C FVI LB ° 0 ! 1}} 1 ' ? I - . ERI _j.. I. o6N?51Gp _ L_- - IK ONE V U ? 1 , O [MAN °'? ogtnucNrs ! M _ 1 o ?- f _ N TEST RF Iyi •?.. NO D EFECTS ?r-' NO t h % TEST RESULTS 2 L AYH I _ . - < , ] 6NOHWOfo KO m+ ., AOC[ GGk HO OLHCI DIS1A t fOLlcf Ann,vtp L{ ODII L[IHSNA L{RA.K IIIV[ R[OEO JOB ] R )FOG N41 - ! ATI 6 C[RS NAM[ANANK, AD11 NO AGENCY IONO SI.A OI T. ATLO DIIT M1ROVfDFV NROAII II M ' , NVISTHGAIING O ! .......n w,cMINDTnN STATI "TnOL-OLYMPIA. W AS,IINGTON ORS01 DUPLICATE COPY: I.MAELAW ENf OIIL FM[NT aGLrvUT S?Mr,-,N,rl,?n,c..vim .. .?........... ?..-..... I WE OF COLLISION DAY OF COLLISION TIME COUNTYNO. Cry O . YR M0. /DAY . T GUN 1 MDi 1 U.S ] WEU A 1NUN S FHI D SAT )USE 1XW HOAR) 7. /& 1HWA ' UHUAN '? . I 2 Z COUNTY ?STATEflOUiE HLOUNTV ROAD ?CITYSTNEEi J :.. . RAL ADM'CLS. PREFIX POUTEORSTREET CODE E LT.N - /y?tY>IIYt J Ii,'1t ? OTHER ISPECIFY)' rn •,.. .. :, _ L`© _ . N 5 E W ? IN CITT OR TOWN W . REF) EO LE POST . D ,/ MILES -____ ? O _O YC r {Eq V ':..'. , ,,-.. ,., •: A NAM E a NO, OF STREET OR WA " W ECi NG WIT STREET OR ROAD LL DIP OAT .- .T... w1 ON _, :. ,.. Ng11NTER5 ECT10N; ER U RR II L? ACCIDENT TT NON AND ".`EE SECRNp STREET OR PO NO OR REF. F CLS ENLE CR TP 1 N -EEN ?.CGKG?YTS_?Tl.EETANO SQ GrOr_ t_?K fJ.STHEEi MCODEE S ? EE? POO 1 C/O (? OLRIANCE AND DIRECTION FROM HEFEREHCEORCHOSSSTREET n : ?MILES N S E W a sW - - Sf•EC IN6 USE - ff?? // Ll[ ' O ® ??m? 7 FEEi OF.DCrJ ET?G .T ._J.1 - COLLISION INVOLVED; ? VEHICLE-VEHICLE ?VEHICLE BICYCLE ?OTHERIWRITEI ?HITe RUN , SEVERITY NO. NILLCO © VEHICLEABIECT ? VEHICLE-RR TRAIN ?STOLENYENICLE M ? A NO.,RU.ED OFVE ES ? VEHICLE PEDESTRIAN E)NONCOLLISION ? HAZARDOUS MATERIAL PROPERTY DAMAGE ONLY OBJECT STPULNINAME OF OBJECT STRUCK ANDOWNEPSNAME) LOCATION OF OBJECT STRUCK^ -. - EST. DAMAGE - ?NDOE DRIVERS NAME.IABT .- - R.ADWAI FEET --..FURSi-'-.-MIDDLE-- DRIVERS N?AMEIASTFRST MIDDLE O6O? l 1 AN CHECK) D .p... - ... . 'G R STREET ADDRESS- _ . :: .R STREET ADDRESS ars E CITY E .. .. STATECODE PHNE NO. R CITY STATE ODEPHONE NO o L)o, c7`2 z? O N DRIVERS LICENSE NOwSTALE SE % N DRNEflG LICENSE N0STgiE SE% TE OF BIiH .. O 1 Z I . . IT O. . OAY YR. DRIVERS OCCUPATIOME 2 ORIVERSOCCUPAIION ONE. IN HY u CODES > 1]ISEAT BELT L') FJECTION DES CODES >1.31 L A _ _ .. CL SS GEAT BELT_?. _ IGI EJECTION___? NATUPE Of 2 - I LMOVE - INJURIES - - FRMSCENE BY: TO RaOM VED SCENE BY VEH. YEAR MAKE) H VJ MODEL (DAR-OVA) STYLE 120R CONV.I Hy ER MAKEITIODDE-CHEV.). O MODELIDA NpVA).. STYLE IZ OR.CONV) v C. . VEH. COLOR LO .-PLATE NO. STATE.. TRAILER PLATE NO. STATE H VEH. COLOR_ LTC. PLATE NO. STAT TRAILERPLATE.NO... STATE : I '' 6 r WA • • ._._.. C VEH) LE OENNFICATION NUMB fl.:. ,,....'. .. ?... ODOMETER C VEH%:LE.IOENNFXTAIION.NUMpER Op0 ETEA -- ?t 10 3 P E . , HEGISIEPED OWNER UST, .,_ MIDDLE REGISTE ED OWNER-..LAST.' FIRST - MIDDLE IN 0. a S a / ?. N O ; ,, .. ADDRESS Of OWNER .. _... ADDRESS OF OWNER ' /?07 'DM .. AME ANO ADDRESS OF INSURANC... &"'A-- AME ANDADDflE55 FWSURANCE GO. OR AGENT _.... „- ,- CHARGE: C ITATION HO " " ENFORCEMENT CNARG •• _,.. :. -'- '- - CITAl10N N .. •. ACTION .. - NAME, ADDRESS $ INJURIES OF PERSONS INVOLVED CODES _ sC% AGE STATUS EJECT.' C NAME: C Am.Ess: N X oV OFH R p jumEs t OM NUR ES fM T A I N NAME' O T ADDRESS S NA U FS IM VEDiROM ' r SCCNE pY TO C T ADDRESS: N I NJURIER' Ar. EDFI OM RCCNEUY T E NAME O S ACE. - E ' NA ; '- rtra?J[ti rri&T - I S Met Alus 111 SLAr PO.LIMJN IJOHKINYC NF br. Ro ` ; PASS[NOLR . ry01 iRLL4 I.IJO NNRr )D[ADAI SCENC LAOAHfl 6 HISAULINGINJURY a ON USARLINO 'I IIURY TASLR D[lT 1l011NSTALlCO ?NO1111 USE URCU U)E`CT- ).NOT [Jf.CIC D IM r fJCCTCO D (MIS NOIg YLt CI T . DEDN N0511TAL IT NJIIRV UNKNOWN 1Al LY CJICTCD U OWNII -S ON UNKNOWN BLffPCll fAll UI1E [J[CItD . , W.` v "ry ?' x HGxfv?n ,K r si$ 19? v ) 5 4 H a 5r,;. dA -fit >!3•? "?"•" a, 1 ..tiff, Idr V t N If sL ,1' I S l i liU 1 -T r? l? > y t'( l ; it ` nL :h r) , MOTOR VEHICLE COLLISION REPORT NO. GATE OFCOLIJSION DAY OF COLUSICN TIMEOF COW=N WED 1 HO^ -TES AY W /l S fY • COUNTY NO CITY NO. ?,J°Y^naAn vlA COUNTY n CITY,TOWT1 ??(( Fdn58E MILES GTY. TOWN DAc-RE a F? -( ,. ?=E DA'U iaw?lul' > F o ' IUt ryl?Fl r - AOM PPEfY /°R?O°E 6ECTgN W^O,IC °X GVE NAMEOF STR T.roA00R WAY iERFECTWOMITH;fiTflEET OR FORD -mad ca PREFI% EO -MILEPOST- - . occ°wDAER F -c nlic ', D t ,. ?F.^. .fr .r / . ?? NON WTERMCT LCCATKINOfC ISBN ? I 1 F ?? -? s? I ; d f ` I -P GAGRAM DATA - BETWEEN ?? ? .e .Le. STREET AND (Z - Y% 14 STREET r N N E epWC ,50 P,INOb CfA094 0ulfPOSr ORD Nr rrwn IAlWNn M t? b NON X C [ES f °P O O ' E , s RSFC,Kx ® « `k iZE'?A•L (: L ruT 'J Ugss ? t f C /µ C r R nx P WTEfl lO Z o a o .,. c°u+sonrvvaLV[° r ? ?VE, [ ?BTN[1MITEI ? SPEC OD USE A „xK° s S L 1 1?7'NnCIFOa,EC ?vfwtLF.inuN _I_J ?v[nKLE-PENSrwN ?Nd,co[usgN ?nrt-nuN . -. -. OBJECT STHUCN WAM[DEDaIEClb,RUCA, OWNEROFOBJECTSNAMEANDADDREW ILfl?OAT a? -. WAY TOPEPAriO[cI FEET ddf DRIVERS LASiNMIE •FIRSTNAME MIDGE -cA^5 DRIVERS LAST NAME • FIRST-E MIDDLE 49& WSgx(x STREETADDRESS ... -„Np.AND BO%NO. . 1. TWO STREET ADDRESS ROUTE NO AND BO% N I .y.?L .. . . '" 7 ' L/. I,uMIE DUSEw CRY STATE -„-.: ..,. LPfADE. GONERS OCCUPATION ANML CI C CE-ATE -,., _ E RY STAT . ZIP CODE MIVERSOCCUPAigN .. or '' lowm. ?. i$31•?5 PaRTfExM .. DRIVERS LICENSE NUMBER-..:., .,.'. STATE SE% OATEOFWRTH. AGE, O R,VEISLICENSENUMBEfl ' TE S DATE F BIR - L Z- T-LS P ?C_L ln)a. M i° 5? :Z . . STA E% O TH AOE M r p Al arEN VEHICLEYR. MAKEIGIEV:DODGEI MODELINOVADART) BODYSfYLE13Gi1 V EHICLEYR MAKEICNE BCCEEI' MOOELINCI-T). BODY STYLEIZDR.I FuPJ p ?k-t LICENSEPUTE NO. STATE TRAILER PLATE NO. S iE LICENSE PLATE NO STAT TRNLF P ;?S _e,_ c lJasGl. . E A UTE NO. STATE VEHICLE IDENTIFICATION NO. 09SEMODELSeNEWERI ODOMEfERIMLEADE) EG VEHICLE IDENTIFICATION NO. I,DSTMODELSANEWERI DOMETER IMBEAGE i Rays 77? REdSTER FDOVMEA (LAST FIIISi MIDOIE NAM E) GiIVERSLICENGE NO. REGISTEREDOMER (LAS-IRST-MIDGE NAME) DHNER!IUCENSENO. f H f. ? - 1 --L ?t•-R 3 OWNERS ADOP SS ISTPEET.CRY MOSTATE) -E.-FT. F_ BWAERSADDRESS ST r l r /p 7 I REEf, CRY AND STATE) DATE OF BIRTH p PMTBOF VE-1°C pwAOEp • iorE^?vEOSwcLE P_,So,vE.c_EDFMAGEo ... io°oin i $ S vEHrc E LIABILITY INSURANCE INFORMATION-VEHICLE NO., - W COvE.AGEIN EFFECT A3 THERE AUTO-oBLE THISACCioENT ON YOLHicM YES ? NO NAME MDADpREESOFUAdl1TYNGUMNCE roL1CY HOLDER.; ,. NNAEOFUA&LRYWSURANCECOMFANl -. _ ?/M._ AmnE (' • . ? mf_)t T S O frP I ? ? [ F?Lt NANEMD A R ESSOf UA&UTYNSURANCEAGENT IAGUTYPOLI DDD YNUMBER / C TT II -- • Si IST NJWY I ), AGE )NDINJURY [P WAAVF51 uur[n[roaEravAmrirox,t AGE MAE N ,Or _ ? ? '?} u NAME ..___.. - xAIREO _ .-??L•IC•I f` _ S4 ?? ADDRESS I IL SE% ADDRESS }- 3 nun 3 ?z} B _ 1 p sE% MNa n,uAYf NTBr «AANa1?t?IE._.??Jlcd _ J? It?.(;•?'S_ _O-? --..----_.. O ? _. _?__.__ Mrv Frl n.,aNarAdKrDA °^a ®D 6fATUS OF NWIIED n,ME MARX FIRST ONE THAT APP 1 LI S I 1Q°„rv[n NV[HICLE O? xa ,Kn dMiu^Kt ,Nyy E STATU90FIWURED MMNRRST ONE TMAi APPLIES rvG Pµ 110 KILLED YNPI IL•li•MI rrvJw O?P W VEHICLE autlwa 1=1 ? 1 MILLED da N1F1 n IM^ARCRR11 u Il0 [*t r 11 rcN xN 7 I 5Q 6? l ?RDE CI ?[,?':'+'n llr, (. nI ? A'r,:lf ? ? S? 8? 7?` SHOW NpRiH Dr MROW WCIRGIE , xDG,?ta MNb t O ',\ DESCRIBE BELCWWHAT HAPPENED :(REFER TO VEHICLES BY NUMBER) - Ltz l k? D I VEHICLES POSITIONS BEFOR E COLLISION wl,rvle unr YMp q rPAA.LD wu WASigATED 8Y W M STREET OA HIGHWAY NAME OR NO ,Ata aNlr M VENCUM D AID ? ? ? Ta ?{ , n ° ? ? ? ? r? sJ l . ? LJ ? ? ? ?- nwsTx,N ? ? ? ? KOMO Pf"w R,M WASUsWG 1 ? w"w"K ) ? Wk ^WAY ] ? rI FROM DIRECTION TO DIRECTION KNnDCR A ? c wxr a ? ??ayr?l°^ a OTHER roADSIrBURrIrKL Kf1 C WEAIKR 1b11 CONGfIOHS 1nArfIC CONIPOL Krrt^b,[I rlrtlf VK Of MAD NRE x Cr K I DibVER/VENICLE ACTIONS v[rACIe C N,A ,1 ?`I ?LNY QIN 0y??, ?DFN DHT M, MS ? , ?yDNAIS "!; I D p ,1 RS ? , ?ONE WAV KM. ^6NMfOA31 ? , ?M STAA T..FAD ? r ? WET I ? nArNO 3 ? DAWN ? Z ? SLOP WN ]g r .MTY00 WAY ? I ? OYERIAKINO AND PADsINO ? ] Gf OW ] ?sNOwuKS D ? TASK DARR IMCT ? a ? 14LD SIGN D ? ? IRMA!I°L[ ROAD ? a ? MANWO FIGHT TURN ? A ICE ? S A C] I-T ON ? A C] ! AsHNO RED ? A ?R? "" ? A ? MAKwO LEFT TURN 14 D". DTKR s WCrYI FT e?LrG," ORF ? IT ?llAymq AMB[N ? 6 ?ALLEY (j e ?MAKWD UTURN ? e ? srr CVY ° ? e ai f L ? e [] FR sMY ? IT t RE ASON PDn roTSEEN D DANOLR i INns [ lu C) L Wik. ? e ? ROVJIND K.K,w°wvM wl,vt ,Ar.N l,t, I ?OTTHER ? r ? OIIICIR •IIADM,N IANFs ? T ? svd ro ron TRAFFIC ? e ?OTHER M•ECrrY ? II ? STORPff)f li GONAL ? U ? Y ? sION'EDINDOADWAY v.sR?rt-r?-n 9tNreMxxaxNlcwww •• -- rF ? F-u•IdNMO P E] ,n C) S1.1 ARE ••InI Y?' Irr y? I? "? Yl 1 B ?! < •i 'F 5 ?; t{rt ] I E-+ F VL-Ii1l:LLIJAfJIALit ] SHADErAREAOFSCVEPf°T•IMPACTUrLALrrune.inULUnHI.n. ?'•'••? rI;. -..?,.? INSTRUCTIONS: DRAW ARROWISI TO SHOW PH INC IPAL DIRE CTI ON OF FORCE. ; r C L E N DAMAGED V E HII 0 . I FUSE lH SSPACE r4A SKETCH NO DANAIH To TlA LENS, NOtoACYCLL5, LTC,; DAMAGED VEHICLE NO 2 ? ? - , ' I.Vx, A j /? ` ? i - I ,a T ]. U •,IxIR . mz_ I I S. U. Or •'un F HITYOF DAMAGE: VEHICLE NO.I I 11 A A AMACE SEVERITY OF DAMAGE: IOTHERVEIIICLEI DAMAGE g o Ong 4n r= CT N 5C iITY OF DAMAGE: VEHICLLNO.]p DAMAGE xon A L L DAM GE E NO DAM ] ? FUNCr ON ACf ] ix GE UN 10 .E. O No Al FUF CTION DAMA wcE GE O No TOWEDBY E5T.OAUAGE loWEG5Y ST. DANA - TOWED BY E5t. DAMA TO 1 TO 1 ' f - DIAGRAM OF COLLISION - - -... ., .. .. 4.. L L._ DR NORTH CIRCLE I. IDENnr. .D,D.,r Aapwr.r „DaLf . .. .- . . . -_.. iiolsinE,NS Du[c,i OniOrr aegpwwv Tawrrrc cex,aOLS 1 I I . ? I ... :. T_.... 1 I, i r - v- - ' - _ urvusu,in LMr.coNDrr Dns HKE P„DI KDrM,aNT,roN LeLw,E.aDI.FLL.4w,Dr I - r I , _; .. ? I I ? qc, ] HrDwYE«aE..FDE3,ar.N,Fa D.,LLT.DF,IDxF,T IxrwL, l _..: f• - r- ' I DESCRIPTION OF 11 DICATEWHATPRODABLYHAPPENEOBEFORECUHI-ANOAFTERTHECRASH,INCLUOE INFORMATION NOT ON DIAGRAM, E.G.PRIVEA _ COLLISION DISABILITY. REDUCED VISUILITY.PEDESTRMN CLOTHING COLOR, CONSTRUCTIONORHEPAIA WORK, ET C.1 . - • I I I•' h r1. t. r I POSITION HEADED EN BEFOR COLLISION R. MILE POSST O ONSTREETORFU HWAYNAMEOANO. orvf owAnT I50 [c ' ED S VEHICLE L G LL 1F PA KE WASV . M p, 1 N 1, s q INCREASING C LASING A ? O D ? _ lr _ I - -- o YES F PH - U - PED L ?? J L G_ w . _-__ -- Oa0551 - -w- P'•I xn -To PEOIBCVCLISTIN-SING ] 'I SIDEWALK I^ S- r E IS RKEO:BnpF51GHATED ]( I oT MARK ?OVLDER A C CROSSwA lK l IBCYCLE ROUTE 11 A 1 .IALKWAY SH OTHER ROADSUflFACE ON" ICH ..WEATHER CHECK ONEI .. CON T RIBU TI?G MI OCUMSE gNCES E uEAC P OIV HTNI F 7E gllv[A FR O ] VF O ] ] DE II??1 STRAIGHT AHEAD I NO ] : (l Ir-1-a? n CLEwP L P OVER CALT . 1. '7 fR INFLU O ALCOHOL- 17 1 OLLOwIN4 CFCLOSEL I ?]n G GEO W G_ AAN• 0, 11 AN. PA551nNG - wfT ] ING C)? DR 4 FLU- O _ Bj LINE E AREITLI I S 14 -].F =No TURN _ 'N_ t_. DA,NG I''•53 1111E GSTATED _ T To J -.._ _ I ISI. J EA PARKING _ _ OC ON. - J MA L-_' iTu RN Af. ¢E oa EDNO RC ?- 4? [SPEED 5 0 aP[w O'ElATING 1 1fr EC IVE EOUIP_ - L HG I' J URN J°r . . _ G A O F L s -. , D CQ4 IO _ 71'__' owroa _1.. OTHfH ISPECIF VI OTHER ISP IFVI . _ r U p . FC - 0 FN lSPEC YI OP ED fOP ? ? °LPw55 NG ISIGN FF NP VIOLAT0 'TPAfiIC LIG -TCONDITIONS CK ONfl RAFFICCONTRO INO.2 VEHICLE VF" TYPE OF ROAD 10'] CHECK ONE PA MORE VEHICLE CONDITION, VEHICLE ?Iy?[[?II??€€II??pp E??C? i ? ] SOBRIETY EHCLE ICnECKONEI x0 I STOaPED AT SIGNAL I_°LJ pA SHIP SIGN. SIGNAL6 !J N ---' ? BUTf.I IT GON FR I ] Y []°?1 ntO-- OAOWAY O PLIGHT ?J ? . . L-_ 1] 1_-51GN .. _ _ -...._ -_ _ I] TWOWA• +- r 'II C11VE ' I A ?I4 J w11I7C LANE L TiIA `LANE ... _ .-._.. .. ?.. PAWN 71 . . SrGN - - POAO Lf. -- ?t AI,C IGNS THO ??... -, O AL ^1 ? FJII' -+ PANKfD 10-0. ., . ' I-' ]_ WSK 1 14 RED r I l"l wNG[ S""' I'.._ LOOPHAMF _ ?Il i OFr FCT VE ..1E LGHTS ]' ? H D500R FTY I...- -. NK.. -.r .?._ .._ ?I] TRAIT CI IENTLHINO .... LG CIA I- FFT^ t s I I F U9[H O LL" ? L_ .- 1" S TN ... 4JK.. J.. 01 . A- Rf[ Un K1xG . ? B I.. I1 6L. _I ?CKIH6 --, f F,.- s RE CLANK G 90 FT R ° IGNA _ B PLw T l NES - ? ' - n a.Owrc` x vln CHEM. TEST -? F IF OMK-N :... ] 1 F OLP I'M f CHHIN - - NEI ft w11D• .. ] UHHOE. . ND DEFECTS T TEST GIVEN '. f _ .. TEST NFFUSLD I OTH IN ISP[C IFVt , • Olxi -Girl unDWIDfD 'M TEST RESULTS 2 -: NvE3irGAl I NG.11 itE 11 NAME AIIANK Nvl31rGATIN44rrIGln 3nwM1 FI„NK tKl NO UDI NO LIC[Ur5 LI nn1vETF RIiVf A HIS A41NCY Hnri U13, ALIT 111TI ,il P011t, M[O[UILOW DCE RAOp i LIN Pn0 [rD3BY HI11 DwIE DIIPLICATL COPY. LOCAL LAw-NFOPL[MFN1 nG[NCY'S LDVY-TINVLICAT[COPV. INVESTIGAtUl1'S f.ORY 4 ' DATE OF COLL SON - DFYOFCOLUS - - ION iME l -_ CITr HO COUNTY NO '-A NBAN 7R E E O` OA?Y '?qy. MQ _JL--V-/ b _ SUN MOM IUfS R'ED IIIUN Fnl IUSE 2<OU ,OU^RI i 1 2 ] ? u.SP IZGO CIO". L ?? T YZ ? / DM LIS. PR[fl% OUT CR SiREEi CODE p nu C. SECION T _ NTY U NTY R []STATE nOUIE LOUTV ROAD []CITY SLnEE LU ?L 7,50 L 6 - ?OTHERISPELFYI H n _? Pi[fl% . MILE LOST EO ]} CITY-.- L DIN , / Q• 93 se? c? 1 T P N '? - . ICJ. ..._ LL o.?r. J [ . aY ICI El ?F .._ D 1 MILES C• E E NO.OF STREET Ofl HIGHWAY INTERSECTING WITH SLPEEIORROAO LL RAMP DIAGRAM DATA [ xS.T U pqk ?:4 G T 0N _ %RD NlERSECtING STREET O RO OAD OR REF q . INTER NO ACCIDENT CE ROSS STREET OR ROAD M1/Lp?IyR I NpN WTEflSE CLS EREN 'MILE GE 00? D / / riTG VC{1i??LL ?Cl1 yA/i??E((?lEEET ANFL.YY?a-.VtCYtLC REET CODE LY ` Z N BETWEEN GJ j; HuNI%I[INS SPECIAL COOING USE SIHEET BETWEEN EANp DIRECIIOrv FPOMRE RET?CTI O 5S Nt9'I ?,Y' / 5 T?IMIU y D ? G ( E 2 / it . y.. c I ??? OF G'11T G ECL FEET ® SEVERITY ? T []OTHEnIWRRE) ?HIib RUN NO. KILLED []VLHICLENEHICIE ?VCMICLE-DICYCLE COLLI STOLEN VEHICLE SIONINVOLVED: ? NO.INJUREO VEHICLE-FR TRAIN LU ,. _ []VEHICLE-OEUECT []PROPERTY DAMAGE ONLY IOT NO - } OFVEHICLES []VEHICLE-PEDESTRIAN 13NON COLLISION []HAZARDOUS MATERIAL ET-3 X OBJECT STRUCK (NAME OF OGIECT STRUCK AND OWNERS NAME) LOCATIOI OFOGIECT STRUCK ESI DAMAGE ^ E . . ..0r ? ROARWAY FEET ? ? ? ? ND EDGE 5 MIDDLE DNIVER5NAM-II FIRST MIDDLE If UIC C S10H YL RLSTNIAN CHECKILJ URIV RS NAME LAST FIRST p n/? D C I AIN ?' S Rvx MI D R R STREET ADURE55 '. I STREET ADDRESS - K , !' ? O ?• ? V oy E GTV STATE 21P CODE PHONE NO ?? i . 5 ? PHONE NO R IATE ZIP C0 I S E R C . IC7 SEX DATTE OF 6 1ATH L ; 1 N ORI LICENSE NOM STATE SEX DATE OF BRTN N DRIVERS LICENSE NO. STAiF YR I Ell DAY I M+JLM6(?yL) W,+ M p ZY YR O. D c-C Y - NAME HONE NO Z DRIVERS OCCUPATION FRM NAME NEN pRNE-s' CCUPATION FIPM ?y c S fr wuflr CODES > IJI cinss--- -IPI SEATBELT . _._ I51 EJECTION COD S ?! IDI CLASS -- IPI SEATBELT. EJECT ---- X NATURE OF NATURE OF I-R ES T } i3 wURIES RCMOVED fROM SCENE flY TO MOVED TO FR SCENEBY? VEH EMI MAK?OOGE?('EV.1 MODEL (DART NOVA) . STYLEI2OR-CONV.1 VEH YEAR MAKE ID0DGE-CMEV.1 MODEL IDARTNOVAI STYLE I2ORCONV.1 ! d c '2 ' \N ? . i O E . VEH. am UC. PLATE NO- STATE TRAILER PLATE NO. STATE - E VEH C0.0R UC. PLATE NO. ATE 1RAILER PUTE NO STATE ue 1 H 66`7 w i ODOMETER B y! C VEHICLE IDENTIFICATI N NUMBER ODOMETER C VEHICLE DENTIFICAiI N NUMUER ':. L a 30p a?w167 7 L j E E MIDDLE REGISTERED OWNER-LAST FIRST MpDLF FIRST ST -L A N REGISTERED O W E1 YI f 1 / ? ' :I, ? 1 ( N. -+`T-/ l}/??'•'__?_ _I-? O. ADDRESS OF OWNER O 1 E T 1 1 '. AGGRESS o y n 1 . s YkL\ S ?A z GENT T N NAMEAND ADORESSOFINSU WICECO.OR AGEN ANEANU AODRESSOrINSURANCECO -A LITAtIONN GIATION O. CHARGE CHM 'E ENFONCCNENT fI - t ?oL;I?,Y? -rD ?s? o?? I ISz ACTION LODES , _ 2 wl S NAME, ADDRESS & INJURIES OF PERSONS INVOLVED sEX AGE sTArus EJECT . L, NAME: P C U ADDRESS: (ILCCN OLD rIiOM NAIIIYE OF REV Dr TO l L I; P { F A N NAME. xE _ •'r T DIXES5' --- -- NEMOV[D FROM To ":A S !± S ? IR,E ? SCENC PY ? I _. 1 T D?nOM TO NA URI S??---- --- SC N E n MR 5 E S _- NAME f S S AOORESS ?CWb'vF1i7R25/a- , LNF Rr ro ECT ON ' I ISIAT POSITION o. lu 55 ISLAI IIFII ISIEJ JIIN U 1151AIUS [LEO 2101A LYCE [CTED i O ?i1 IORr OL STAT 4i ? nS J I C [ ' T I US II N UN 5^ HGF.R jpCO 2 CENE ^? 1 I NIfJFOTEO PEDt51HIAN _ i o?US MOTOnt L EI U O1 R?DSPINA i t'OS19L INJURY P UNKNOmI P UNKIIOW FAILURE urerzo IA . D E 5 ° .,Nf s SEAT uur L. ° FOVNaIUIKHOWN , ) I(? ? ??'.?u,f?? r 1. IbT rm?l 1;-(IRE+F@A?iJd. L'4: lif.'.!F 5_ t," 1 i [ + k 1 i 7^. c PI x i•, ,.<`('7?,{{U"n: ?'!'" ,?.?A, ,e.?dl i NrSNA ?1 4 L ,? J ?J 4 ! I `? ?T y E1'?Ew'F 1 1 !dN' Y Y t' IF d^{ . ?'.INSTRUCTIONS 2.7HApEAPEADF7EVEAEBT A?AC .t` I f r? I •t 1OMWARROWSIiOSMWP INCIPAL DIPErmnN DF FpgCE ... J.,? (. ' .. DAMAGED VEHICLE NO.1 (DAE rHIS EPACEFOP SreicNlNa DAMAGE TD TgMLER9, MOrpfICYCLES.ETca DAMACEDVEHICLE Nq.2 r , $$ t7.ikw ?, , gY ? nFt-'??1=:J{-?((??S? 6 IE. b la 1b 1 ?•A 9'9. IV I`? `iNP 16.T T- runk' (? b I floo@ I Mk 1 'Ix r ,B.VN.rwvV. C f^`^ IA T AR: IT.Overturn `?--L/ i IB UMweemy„I _ &EVENItt UFDAMAGVEN '1q.1 YEVENTYCFO.IMAOE.IOTHFq VEN1ClE1 SEVEFE OF DAMAGE.'I ENiCLE N02 e IT Orwluln .M 2O NBUNGOHMAGGE 300TNERM.V.OAMAGE IQDSASIJq DAMAGE 700 MERM.V.DAMAGE I? ISASUNGDAMAGE g NCTICNALDAMAGE 2 i NCgpNAL DAMAGE OTHER .V. 700THEqM.V.DAM?OE 110NALOAMAGE 6 400MIAGE 2 i NO DAMAGE rA ,p,V? qlt TOWED DY EBT.DAMAGE TOwEDSY _ ESi.DWAAGE NOD-F TOWED 3Y d ER.OPMAGE TD S NOW, TO TO DIAGRAM OF¢OLLISION w. E aSD?`?+` r •'I s• ' I I ( I'?IYI ICI }I. I It I r f Y DRAW ARROW SHOWING vl«cb iES NORTH IN CIRCLE - ,? ?qn? ? ,, OFF ?? ?a.awA, E, ? ? i I I i' ? i I ?,• I I I I uw°sll wrcoP ennno,a `" I I' I. l i 1 1 1 1 I I i O ?& s ETA; «? P , - -r r? - I r ;-r t F x oMrT apes EPaNIGF L a N,D ;P? PEDF?,?P I I I i l i l I v l i, i-J' , (' I i ?. 4«PPD?MP.e. .. I -?6v, l ?t=Y?'?-4Tr. I I- Iq I .'.DESCRIPTION OF•-; IINDe:ATEWHATPROBASLYNAPPENED BEFORE, OUINO flAHDAF'IERTHECR,INLUJDEINFQRMADON NOTON ?MGgAME ,QORIVER Q, I COLLISION ?K 1 DISH&UTY,gEWCED VISIBRIIV, PEDE3M-000THINGCOLORCONST?UCA7H110N Oq gEPAIq WORKEfW - ' fya t 4__J'}^ ?L Te.)S= I4Au:Vi y?E Ct?oC -3br LULL r t I SZ r.. tr_1C Z. Ih?jD( 2,?r,Li c.J?? mGac O It$Y? ?t ,r? tL -'!?. h I -1\;Z c n- c __?T n t r ?.K ` - 7--- c'? f1 Y 1= a: ? ' x.,..?` I -n,.:.i-C ?? a -S c ? I„ : ??--;?"r-S _-i?ccT2?SS, s 4_ ?? ?,_?' ? r? ?;a. TER I'I IArve?`?COPY: LOCAL U W ENFORCEMENT ?GEnCY'J COPY-TRiPt1CATE COPY; INVFSTIOATOq S COPY „ 1 ? r 1 ? '/ t ' f 1 Y L1 1 Y ? SSyw ( d r I?Yy'.ggryrylqr?a" Y ? { 1 ; q?q r%'F"'T. , ?{!(Yia.w?8''}^!Pr f'1.???I! t 4V 71 D7Ja t L I 11 I A ? { ? 1 I 1 I t i`i ,? tb l T tl ,. 91. ? - { f 4L k"v" 1 J" J / 11 „q a¢ ? --y 4'o E (+T 4 ?W 1 JET ILJILIJIL.; . -.- . V EH. HEADED MILE PO 'D??'w?'?^` `i.'i^-i+i"tt - 'aprC'v?pj?,'?"tyj ON STIIEETOq N ND.OF UNE9 SPEED? VEH LE I PAfl OECRE ND . WCNEA9uq ECgEASMq NKaMVAY AME OHNO _ WONE DUiECDON .obien s.iE p EO O ? ? EU ?R -_?_ 9Jx2(?tY? st?L _ . ? ? C UP i ? C YES NO YES "'NO PFD. ? ? L-I _- liana - p, S,nrM Oq NaHwAr. --uPH-- P COPPEn I ? OOE r, ROAD SURFACE„Y IcNECe oxD -,wE4TNER.,• IONEee oNU °'? . . - ---- CONTRUN1 IC _.-_.••••"••,, M,>, TiN0 gRCUMSTANCES?3 NE p.E Oq uagEl w- , eu¢PaulE I Io ".,wjur?„ly,,.? : L+T. 7A. S:YSL-awYFnrveleG 8 ... rl0. ?/ ("- -- ?A.ORI f?? - , e +61 - .- N OPrrYn ..._.? I? W?,aa./WPC[M u0. O l _.J_--Atr;0 OWVFA NO ? n-lt° iD,9E?r f`-I .lwllq .J..t}., .:.A ?_? oSZeV M't M6 YD.C ?MC? DgMaNTA„FAO ?r? OtFIrtAMIrq '. ?2 •- ?xn WET _I_.l al_.I 'aww x_? .1 a? a.DWw ? ? ? x ? ?a?aEmusrAlEn WwOENIEP ro ?P? --- : '6? i °A"wf0 ? ?Ntl1p ? 42 .? 4 ? I00 - ?eC ,KM _ L MpppyED ?'Z llw LJ x ?E? ?AO1NEEgN° ?•.? Irsr iupl uulpi ' ?b Y o 01UIIbPEGSrT .' L OI1,FA1 [fiYl ? n ro?rOa+quw OA,q? „ sio. _ .I-"I,;. _. L1 T '. , `•m+ ?;? aawwa LIGHT CONDRiOMS IcNECe oND :.iAAFFK CDMIiDt:; NaE w, TyCEOFFIOAD ICHEe DPe oq Mnel ?1e? mo0°AFOm° ';VENIC CONDITION v«ae?' C "K ? ID a-WMV ___ J '-SOEIAIETY[ gl^y;?r. , ?M y Nw `rx? ? e ? o °` ? ? ?' oNe wA I .o ne x xcor.rPmulrq w C ie • lu. x P sro. mN aw® ii-M ?xQ Iwo . bErEeme ?r t-, " ? ? > (:-..7! D wN _ ?. fi ^n° ..! =5 _ _.. a ' -._ ? ? r? _ x NuouoNn_ _ ? A ? ?- - x w o."°a'Nnm --j (oG'1 .Amnw ra wIe . R, ''I v°N a_l. l -.. 1. 4 ! ? ?. r --- .- e? "'+a^ NunE - - LCT/luw -,? ?? ? r-•? bErs me ? ? 1 MAga Nr! ? ?' Umt?H? _.. = "?0 N0 r P Awcm w iDN I -llx? roµ?IpHTpyp ' • °_? ucari Iln - ?e? sew - r'1 (-'?Wuart-- ? wEU?tN '?e?=Ed?"cluen 1? I? ea r.4 o w,•.,b ..... I ? x CHEM. TEST B eACwo .. ?I ? -., I . ?- . lIIAMRDI LLD I TexrOMN ... . - - O I YED M rO3e16PECn'j L e? O,Hr __ ^ ?I? OvaEO_ .-- ?1 ? wOE/Etla '. r r T[a1MNSE0 f :7 'a.? ?ti el oDNlia a e:Elrs ru..eL `q?y?Ta?L,,? I I? __.°?..J Lvnwa?o [ aAp' NO. or -.: ,w.A •."T'C.y °jDm % % TEST RESULTS Al wc0 rOlce Arv.veO In,KE 2 Y4°VI ?.. µ lY.. , 1 '. ?`L {,!-?•'I F wn ..`C ?? o.n ? ( vl I'{ ?? S?Z 7'Nn b ? 2L'? ? °? Aw'no^r euD :.ab ?r '-' amApvooF•uA?Nwe.A.Ne x J/ I,o T- C ur.run °? xT. areor n{???? As rwvEOer I N DATe I . i b ? F yy k 1 ti J F ? r ? I D DATE OF COLLISION DAY OF COLLISION TIME C UUNrYNO/ / CITY NO. / FHnA AT I.10_ OPY T SUN 1 MUA 2 ?Jr • O'NED A TMUH S FRI B SAf IIJ) UR) ?J? (,/ L'RAl E COUNTY ?STATE ROUTE IPICOUNTY ROAD ?CITY STREET O ^ LS. PREFlA ROUTE OR STREET CUOE ScOTION ?OTHERISPECIFY) N G l Q -? L O ryNT B E W ?IN CT'Ofl TOWN / MILES Lpl ??? OF T- V L O W III vt W V P REFI% E0. M ILEPOST 0104 C OR HIGHWA1 INTERSECTINGWITH: STREET ORROAO F STAEE f NAME NO. O LL R AMP DIAGRAM DATA T , / c ? ? {??+ nEclC4ztf-/ Yt 14?. O ON INIEPSECTION . ? •? • ACCIDENT MLEAGE NIER INN No %RD TERSECTINGSTTic ORROADORREF. °-E'OR POAO CIS. EPENCE ?iIO N ? n _? /^/ / BETWEEN I` 3TREt•hl!® -.? ST EET CODE ' / W _ ^ DISTANCE AND DIRECTION FROM flEFEREN EO CROSSSTPEE VrvcHETHS S PECIAL COOING USE ?FEETS ? 5 E W OF ?LvFeavT t`co?. VEHICLE-VEHICLE ? VEHICLE-B-CYCLE ?OTHERIWRITEI ?HIT ARUN COLUSIONINV ED: SEVERITY NO. KILLED I TOTAL NO VEHICLE?OBJECT (]VEHICLE-PRTRAIN ?STOLENVEHICLE NO.ItLURED ' OFVEHICIES ?yEHICLEPEOESTRIPN ?NONCOLLLSION ?HALIROOUSMATERIAL PROPERTY DAMAGE ONLY ODJECTSTRUCKINAMEOF OS:ECT STRUCN AND DOWNERS NAME) EST.OMIAGE 'I' LOCATION OF OBJECT " , S E W ?20-AY FEET El C1 ? ? RD. EDGE $ FIRST MIDDLE DRIVERS NI.E.-T DRIVER'S NAME IAST FIRST MIDDLE IIF BK:YCUSi ORPEOESIRIPNCHECKI .. D r? L? V ?SOI.r? PA ?cy' A D LAzz ,o&) MFl? 4°n L R I . TADORESS STREE f ) v STREET ADOHE55 Q 2 g? 83? E N STATE ZIP CODE PHONE NO. E CITYAl. _ .IF CODE PHONE W. R R ?J IILCE:f?? LJA 9937 N DINERS IJCENSE NO. ATE , GT SE% DATE OF &RTH N DRIVERS LICENSE NO. ST AT E SE% OaTE OF BU TH O. \ I '' W ?O. rD?AY YR. G I, Q. / Y ' t W I-[ I'-? 1 YR. ?--z ?--z c- DNNERSCCCUPATION FIRMNAIAE PHONENO. 2 DRIVERS OCCUPATION FIRMNAME PHONE. CODES >1(3) ODUU MI SEATBELT I51 E,ECMN CODES J IJI CU55 1+I SEAT PELT ISI EJECTION N u""' F NIURIES INJURIES „ M V MSC ENE BY: Tp cE WE ROMSCNERV: TO VEH. YEAR MAKEIDOOGEL ..) A100ELIDARTNOVA1 STYLE1200.LONV.) VEH. YEAR MAKEIDOOCE,CHEV.1 MODEL( OARTNOVA) SlYLE12DR-CONVi v 71 Volvo ZD? v C?a P? CP E VEH. GOL LIG PLATE NO.. STATE TflAILEA PUTS M. SKATE - E VEH COLOR 110. PLATE Tq.-' STATE I- PLATE NO. STATE H ILK ... Q?(? (?$3 L.3 A H C? 2 nt - YAG 179 WA C . VEHICLE IOENt1FK:ATWN NUMBER . ...... ... _...:..... OOOMEIEA.... ..?,?,,._. C VEHICLE IDEMIFICATI NUMB fl .... ;,... ODOMETER L E L E REGISTER DEDDOWNER-LAST - FUiST - :. MIDDLE -LAS , .FIRST, -„ ... MIDOIE D OWNER PEGISTERRE O , O E A ? . AGD OF OWNER .. ....:.'.. •..--. . -.: .•.;: ADOPESS OF . ' 2 NAME AND ADDRESSOR 41St! CQ CRACENT NAMEIWOADORESS OFINSURATICECO.ORAGENT ,., l Cat I?LG Sr-L ?A , \bLJ-tS !1 ,c y? Tot-t -Sckakd Se v;rt - rAe,y CHARGE - C UAIgNNO. ... ENFORCEMENT CNARG ,. GTATION ,. - 1 ,f? q 1 . N RIES OF PERSONS INVOLVED J coDES _ ; ' D NAME, ADDRESS & IN U ' S E % AG E 9TATU9 w w ELECT. C . NAME' C %? L ? 1 / C C AppRE53: F REMOVEDFROM iwUR ES: SCENE 9v: TO A IMME: N T S NATURE IN?U14 90F SCMUVgD,FP M TO W NAME: T ADpRE5s- N V D UUw4S SCCNT BV: TO NAME' S ADORE. SI INN1i.S SCCNf Pr' TO 1'I STATUS I INJl1nY C455 III SEAT GF.LT EJtCiION ISI CTtO O 1PEDi5TPW1R B,CYCU5, A L S t TOTHER-INOII DfA1DAf 5CEAE DEADONARR AL F31 ENI(S, U'SERIMrRY IFMOIT11NJURR 2T iI1115 0 IUSD CE,EGTEO 3. J D PARTIALLY EJECTED D E d wITNE?Y BUS MOTOnCCLET S D B POSIIIONUNKND- DIED-ot,PITAL i. PoSSIB'EINIURY UNKNOWN S SEAT BELT FN LURE A. UNKNOWN IF GECTEp Y f ? ? rI b /R°R AA T, 1 r ViN ? Y Am F p?+a < b5 44 81 T 'rd i 7 SEIn _r t N `Y I I 1? 1?" nt alt ! ,+?, 1 4'rFYt y;`"+'•s a7t''v+:p 4,e' »,i?? „?6' .?1. fi'' s ' L+'1 I t ? J. dr ? I 0 ?. tll ... ? r f7J??- J Ir ? iI 1 VEHICLE DAMAGE weacgav+c N e c°r^ Eo ) sF+ace AREA cf sF Res c ' - ?rcNn Fly (! _ . INSTRUCTIONS I.-w ARROV, 15 roS O R IC i H C IU 0 f L ., . /-p OAMAG, ED Vc-HICLE N O. 1 D_MA GED VEHICLE N0 .2 IT O"rY SCVFNITY OF pAA+nDE: vEH?CLE xO.I +IfV??iSaDLIVG DAUnGE ] ? oINIHU AA+AGE I l_I FUrIfr IO?:AL OquAGE J ? NO DaxtaLE ITV OF DAIIAI:E, 1-11 '. E, CIFr IF OH-A-ING OArAAGE AAIAGE I ?J fuNCTiONa?. O='.I:,tii a ??U IAGE al SEt'F-::v CF DASI=DE V-N [_E NO.) 1 [, C?SA='i'.G D..4ADE ] ? OTNFR AI V. DauAGE )-I.'•:<'?ONgI ^a'.r.CE i CI N AGE TOWEOOY / E5 ONEO BY f Si. DA4.:GE ESt. OwMwGE S %7 ,I II TO C G OIACHAN] OF COLLISION OF ?cnA+ANDWr rF.JUAES DRAW ARflOrv SHOWING t NORTH IN CIRCLE L C, •-.. C,H` 'i%o: o Ne ?s // r A%ly If<SG 4L /?L f C .F ADaow.r c aEDxTNDLS Du.xPS k,aLTLN. EDxD,1,x3 ,? . r Y J i u 7. n O J. ' ,_ ._ . 4 7 L.,cLE, rlOlsrw. ow r.csrT axs AT lvrwtt aee..lle vENKU Ox ?G .A, ? ? s+RUx.wlxs elrwF A.O.rTEx cou vex. ._ ' . M.cJSa _ ? ??• 'ham!-r_? • _. DESCRIPTION OF uNOICATE FVNAT PROBADLV HAPPFnko BEFORE, AFT rHE CnASH.INCwcE iNRCNVAncN NOr ON Drwcgnnr E.D. DRWFw COLLISION . OugSRITY, REDUCE NILITV,PEOESTRIAN C,QTIINC C OfoR. GONSTRU<TION CR RE aiR waRK,ETCI p ? ' 7Jf?=?f POSITIO NEAOkO N BEFORE COLLISION NILE roS w - Si EET pJ NIGHw AY FDR NO. ON AYN orvE pRECnDN .cs+ LEGgiLV As vEMU I REASING OE EASING EO ED FE rCOIBICYCLISiJVA3U51NG. d . re ' - Sr0lWALK ) INALKWAI 11 1 -A. 1, SHDULOEN a ED S NUARKF. 6 OED CROSS{YALR CNOSSWALK T TO CSY'CLE P iE E Rt7A?SUyFACE ICHECK O WE[cI ONE CONTRIBU - Ic TING CIRC?ALH"f ANCES On r[. ONE Hnlnrc criiws oTH+O.]VErvKLELE DH?lR] ? U ?/ EAR CLOU ER O) U 0 I UI -EOF L . 09 vEN 0. I ?I YG OI I Ow - . O1 DFD? V GO No ? Cr /I GNT AN w ' JL 1. O r, .El /} 60VERCAST 2 AIMING _ A CONOL? UHOFR INf LUfNCE Ai _ RUGS O C I OSELr f rRCf LATIN 1] SKN SIG- IA NPANFNIIV ASL"F FNG AND .K.Na BIDNT TU N ] SNOW •. ICE SNOwIHG ] .. rOG x FFn OIN TSiwIEO ] E ,.. .. SPE N X4 ?FfOwt AS. I AVt II'W iAIt HJ41 D n 54rIAl I0 IS L?PB-nPAHAING: IEEA-N - L6 UIFECI IrIE E.." - Iv - '... KING A ' ?LFii TURN 5... O . IURN S CI IN ISPFCIFYI C O,HFR IYlCIFYI 1, S To YI N L F IuPNGPIN II O G 1 ?] L USII S AL y 11 >INFI ICPlCrf Yl hO VrOLnIIUN 6. SLOWING 77J ?Oh TONIlO T TRAFFIC 1 flT"cON01TIONS CK [ nNFI flAFF10 CONTRO I ND } -SlNICLF SILNAlS I L IND. NI]F ICTYPE Oifl)AD N. ON NONE HFCY , ONE "y VEHICLE CONDITION vlrUGlE O[ ND.) ?july Ali. SOBRIETY InreeK ONEI. NH,f Imo) SI rFDAT%IGNAL :8 ON STOP SIDN p TOPNfOIH• 1: ?. 1 DAYLIGHT ] - STTY 61LH ,Y] Tvq WAY /nT 1 Ct[iGnv! NAakt IINO AILIIY '_BID ROwDHAY . STAN 10 i1HGICIN f AH N Arf DAWN - 7 DUSK ]' YIELD 14N ... .._ S BIASHrNC r ) NA. EL! N.A. .. - INTINCNANL! ] pl fC"Y' Hr wII LIL ITS, ] OFFFCTIVf X? rv ACTurn AN LriYrALllfO . ] HBOSOBNIETY I A gTINa rNOU - rA .T... ND. 'ufHGING IEXT[NIN6 ) DARC-STRlET LIDHrf ON BE D -... f ILA-No AMF[N ,. LCW RAMP ..! .S _., i ALLEY , . . . IIf AR LIDNTS ,InFS LWYIN - A .. .. ..W UINU,r, UV<. uwD NOT ..e EkFN iININI HG I .. TIArfltl ... - IS : HACKING "'- DwK ! f IIDwA T s O F_ ! - T C PR SIGNAL .• C' lwO WAY-IFF I TUM44He5 +.,ISrv. ,,,xlu 3 o, rltr: urnvErl CHEM. TEST 1 NO ) --- ' J/OAw[ NO n SrKEer uawn • O c[N Dryown XE" ?,.l7iL 1• rPw K. V ?S ,. /'?;C!/'L?-.F vE Li ` f f .US "D 141v F" ,IST NEFUffD i .- R ISPFC IFY I OINIH ISPICIr YI f CO,?jIIp?K ) UHOWIOFU OrnIH1.PL01 TEST RESULTS 7 NVIkl10/A?FnIHG Orr ILTnSNwukENAryA 7l?!-/ l/I17f Zt7M r// tlAOGf HO. C LIL[pvA1eINU : ?: / vro IC?I•AFrrl?veU .JL UCE r CIIOw roLf./i ?? wHi AN.- lHA NEDLp 5 ?'?7 CT?_oA O[/?,?N'3 Os? /E •4-.?. N!. w41 vCY _ ?/J` ` III y UYT SUr I. ]wll Ur llfr0 ? :?M/i Uf0 ' :. C?IwI I WPL,CA fE L'ONY LOCAL IAWENf OIICf rAlNl,Sf.ENCY'S CONY-TIIIPt If.A IF. [DNY. INVFSTIGAIOq'S CONY P i f r - 1 p r IS I, r 1 ? .I. 1 I ? E .„ a. giw{$7 I+ / ? f f b 4:?'Trp'"" f/ I j ? 4 R 1; ` r b L I n ? { 4r 1 I. 31 31 A - ;D aTE,??F COY LISION ? vU' L ION - Sa roGpO lus ]a ME NI j py ?? I FY HO L T S f A ? E COUNTY ROAD ? CITY STREET ? 3 ATE ROUTE SdA? ECIFYI C ' Q W PRtFIX /E O /f OE R CJ OF!/ O L n OTH EH ISP T?M1 E C. IT OR I... IN ? D N "' %!O. M { I EPOSi ' O . .J ?1 ? ? ? ? - r O C C J IILES p M - i I H:STRFETOR NOw iNTHPSFCTI LL Rw A T ON AA N: ? o srRRDA IN R in R O 1 off UVrER3ECT1oH ,q??_ N ?'t , NO R ? ? ? ? E ER C"°33STREEr ORROA N BETWEEN T AN I ECIAL COD USE ' E OR R0333TREET // OI3TwnCEA? OIPECTJOH FROM NEFEREI ??, o Cl-E1 ? ? ? W D F T VEHICLE-VEHICLE ?VEHICLE--ICYCLE IWF.TEl ? T UN 1 PITY _n0 K E° N INVOLVED: S ? COLLI IO _ //CC-? ?+TOLEN yE"ICLE O. I"JUPEO VEHICLE-OBJECT ?VEHICLE-PR TRAIN - i-I TOTAL NO . / ? Of VEHICLESW ?yEHICLE-PEOE3TPIAn ?NON-COLLISION E] HASAADOUS MATERIAL ?J PROPERTY DAMAGE OILY AL STRUCK INANE OF OBECT STRUCK AND OWNERS NAME) LOCATIOHOF OOJECTSTRUCK N s E W EST, DAMAGE. A? ? GG of IN ?ROADW? J FEET ?? P°. EDGE OR.--N.M.-LAST FIRST NICOLE ' DRIYENSNAME LASt EJRiT MIODCE IFOICVCCUTONPEUiSIRIANCHECKIO..:::_. D ?k p SrtCk? E. R R. y STwf ET OgE33. r 3 ?IASTt1J4S 1 v ........... 15 21PC0 E OnENO. Y TE E ... ZIICOOE HE HO CITY ,,. STATE , E R ,.. CIT IT ?Pzse7ub -LJA Ci n6? R N IVE ENO. ?EaR 61 STwiE A. I PIE 9EX TF OOf? IRiN °?D..zt 1; N 0 ORIVEPS LICENSE NO. Ta SEX ATE .1 Ay AY . gIVE?ISaCCUFATIOH FIPM ENO. E - S , • tl V u?vsf?D 5 2 yEp SOCCUFATION ° I„ONE NO. FI It E - T . r Fr lal SEAT BELT IseJECnop - CODES CLASS - 4. CODES Imc?s"sY w Ear BELT LIRE OF neoie- pIE1 RAll"l 11 ' ENOVEO M H "Y. -CHEVI H. YEAR MAKEl00°Gf i ODEL APT-NOVA .-LE ] w.-C ON V.I .OCEHE lY fM SE AR E1D°° -C1yq _ vEH. YE U TO MOOEIIDwR i-NOVA STYLE I3 °P._COHy.I :V T Gr• .? v E L. PLATE HO. T.T. SPAILERILATENO. TATK.- E EH. COLOR ATE NO. TATS TPAIIE"ILA TE NO. STATE H. 1 5 Lu H C L VEHICLE I,OLNTIFICA -W X 3 L 13560 / ODOMEtER _ X'" e c I . yNeE vEHICLE IDEI ICATIO OOONETfR E l OWMEP-W^T .. REOISTE ... _.. E MlpOlf FIRST pEG13TERfGGW -LAST . D. DRESS Of OW .. • D ORESSO OW"E" . a ' ? ? Z An<!<O.OR rLGe NT q NAME AN°AOORE33/0^/?1f INSU °wOORE54 OFINSURANCE CO. OR.-T . CH DE CIJT?ATION N0. T O ???? ENFORCEMENT ACTION CHANGE CITATION HO. CD GE3 Nf?M D IES OF PERSONS INVOLVED 9f% AOE STATUS T (JECT. ? Dne3s (?i o D rpaM I/E MY L14 t=61 eE LL TO C P A T S vFD/ROM w. Auf? •- T N Ne of 'fi3 E S S S' L 1 1IIBTATUS IsEwf /OSltlp" C '. /w31ENOtR t. PTICYLIIfTN T 5 T D a. orHLR a WJTN/SS a a e. E . t ?a= f rte" ? Ft' O} F s q IE NOEAf CELT IlaflgEl=CTION L. NOSH ........... P TIH3TALLEO OT OIFCTFD -OIfAeLINO .1. HOT USE .T^TALLY [JECtED IL VIDl NTI INJU qY . US [NrIWN NNIUWNYpJfi LTLD ). /OSflht(INNn? ?, SEAT ULLT FAILURE CJFLRO ?I. i-' f IN EACH RCIE THE NUMBER OF EACH DIMAGED APEA VEHICLEDAMAGE PIE „ 2. SHAIDE AREA O VERW IMPACT. INSTRUCTIONS: 3.DRAW AflROW(S)T OWIBITOSHOW PRINCIPALpRECDON Of FORCE. Q?,t 10 DAMAGED VEHICLE NO.t (uSETHISSPAOEFOR SKETCHING DAMAGE TOTRAfERS, MOTC-CILES, ETC.) DAMAGED VEHICLE NO.2 E 13.H000 r 4 1 wmac. Nn 1 T. o..reum Q. B-ERItYOFDAMAGE:VEHIClEN0.1 In CISABUMi DAMAGE 3QOTHEflM.V.OAMADE 2 FUNCTIONAL DAMAGE t NODWAGE BEVERITYOFDAMAGE: (OTHER VEHICLEI SEVERITY OFpIMAGE: VEFfCLE N0.2 1QOISABUNG DAMAGE 3Q01HERM.V,DAMAGE iQDI3ABUNG DAMAGE 3 Q OTHER M.V. DAMAGE 2 FUNCTIONALDAMAGE NODAMAGE 2 FUNCTONAL DAMAGE 4 NODAUAOE_ TOWEDDY E1T,IAMAGE TOWEDBV EST;DAMAGE EST.DAMAGE TOWEDBY ' To To (DIAGRAM OF COLLISION F;v.Ppwr.efarvPeB ( { j ' -• ?+.,? I IT;L' • I. 1 I t IDRAW ARROW SHOWING _-'???-?-I { NORTH IN CIACLE ._ -.--tc'? 'C,S?i«WPO.a«,Y KEwS. E:CI MOrPa9°,m?iGrbn _ 1 I ?I •,ao`- I I I '! r- '?r _ T . ! O :I T-. r-,._ , Mf.1CI.rPOBAtlEENKNTB CBEC f a5N0iBHATIIlRADTO.P PDxNON3 IMn, I I ??ss?• Ji. 1--i? 1 1! , r I LL r r _ - I i ,T I I DESCRIPTION OF (INDICATE WHATPROBABLY HAPPENED BEFORE WRING AND AFTER THE CRASH, INCLUDEINFORMATIGN NOTCNDMGRAM DRIVER EG .. COLLISION , . DISABILITY,REDUCEDV BRrv EDESTRIANCWMIN000WR.CONSTRUCTION ORREPAIRWONf.ETC.I - / : ,1 T /t t'/ t? F 4 lu _.r, r Irv rG,__ Z- sr ! v cP0 IBEFOREC _ NO. HF.AOED MILE DR - IN T1°•FS- `•?WiCit4v_.._,.11D!r;'s,r."-?y?r,i',? ON 9TREETOR HM)MWAY NAME OR W. NO.DF LANES IN ONE DIRECTION S R_E p9. lEAN1 Y PARKED WA?SVEM Uq? CREASING ING DE DECREASYIO NO. E r. _ E S NO Y YES No 2 E, ---- n - - - I f PED. ; ? ? C DND_ PpsWq sTnEErp -Al ^___T,o NRn[Nf n p IGL 1 T PEDI&CYCIYSTWASUSW G: SpEw,G[ _ xI.. JWANW,Y °L7- 'Mwsiw,Ix 'F7c- 1 BKryit?E rzPWIE_ Tf I_ & nl '•.1. ,Y.?._`JA ...... :,ROADSURFACF,4 EDt -11 sWEATHER'- . ICHECK O?q CONTRIBU K . TING CIRCUMSTANCES_ Mf. - MORD .. ?} 'a,?„??-=•z r + - u ? i,.-Dfnw,pfaencl?l?aa wn f LfCLf r?M f Orv+Fl1 Dmh'R . D OfavEA y ql , 0aq 1 ? . 1(,X_W?;° DC P«B A? - - .- C .1 xp . t^• M'E T ? RAnwO - _ ___ ?O?-` Wr f« T ___ r-le? -iiDRf P ?-2__ ___ _ _?_ "-a- .___-ltd ? U _ 1 _E 3 ? _RZrT1pN ? L! ?I E.n a? swWNR Ja?=_D^R3rA»? m i0 f''? ? '1 L?"L; IMncA°"p°EnwP r,An.a p .•L,J?. :. ioi»?r („'. 1 O 1 ,UrN ( «rfC,Nf C«lIP B 4NM1 -- ----- .onen,vecsn Dmtnivirni e_? Er'I ?r „r and e!? r°.DrHEWR noC" " ?,? r«E LIGHTCONDITIONS K°fCA Cwfl JRAFRC CONTROL' MCII 'Yqc r;.TYFE OF ROAD- CNECK ONl OA Mp I. f ,VEHICLE CONDITION, 4LH:LL' KfECK ONE OP wi`SODRIETY .';c!;, ?::•: E n;I! ?n?:-Dn e°ron°'aKH '?. - a [`_ ? ,wNRS I I I ? «. W,V 1 NO 1. MOM «rFC,a •CONrnrrttq V ICM[CK pr1q 1 IeO. ! _ nrdP[O N ?°?,,.PO,PWAY .• -? w -_? ° r? E r? n ° rt - .. _ a OM« n[O r 1 WG W E OMOM3 xnpsaN°m ( ? DNK. - _ ?12{? MILT I[NT[RM MMl On [T ., rV.w.p 7 Alfi ? 4 T pI E? 1 r--{ OIFH WUrMM----_. ?10? BACRNO 'i .. w ' [r "" ? ° ^ W T TUrrtp j I woven CHEM.TEST ._::.. .. - ?« N cv.a : mm iu.ei e ul ro»v pia KN, ,.,?v?ww.-.. .I s[ rc acKas ?'-f -`, '" i rEBrmsN gil m MEC?PK r f -?>DMCw i ;? ro ustcn I? rarneruEeB I "'T S •d . EST RESULTS % .1-T 2' •• Aa-u KnT,.,yM ? , woof rq xC(utr rpxE,ISwrO +M?IUON« K:IEDw -`- f.? l ? J [+e ruA r.nr acET ( ert«r_ fT,fBln rz I ?A F?.n x ]?Y Y$1 4 Mil M i •f C' ,A3? s? z t I?I t x1. TT' ?;. pUPUCAIECG`Y. LOCAL TAW EN.CRCf MEHl AOENGY'SCG'Y-TRiVIICAiE COPY ?I.YVEBTiWIOq"J°CCPY ? i A `' I F {fr a I T t, , ? ? ? A r fy ,1 I '' 4 ?2 I r ?Y ( I -. ( IL I IT I L ?0: 1 i y • 'r/..uJ" A- - 1' ?, . i . IF"+v i ...'. ?- ~+?? ( Ll I? . k t %Mu STATE OF WASHINGTON -E OF No. WSP.159 REVS/l6) ? POLICE COMPLAINTNU.,N UNIFORM POLICE TRAFFIC COLLISION REPORT L D A DATE OF COLLISION M UAV Y DAY OF COLLISIOfI TUN] IRON 1-C 1- -R SAi I 2 ] A 5 tl (USE TIME 2ADONOLJRI } J COUNTY No. CITY NO. FHWA URBAN .'. E COUNtl ?STATEROUTE ®COUNtt ROAD ?CITYSTREET 2 O AUM EL3. /J PREFI% ROUTE ON STREE CODE URAL 5 CTIO / ii YS? ?OTHEn ISFECIFYI I 06 j 1 L - N5 E W IN CITY ON to- ? W PREFI% EC. , MILE pOSf - S Syr • C ( J1 ?^ AtILES 1.7 ? ? Id OF ?J n I LL O c U ? ?4? ? ?yJ ]I . , p? AME J]NO.OFSTREET On HIGHWAY INTEnSECTING WITH: STREETOR ROAD LL R DIAGRAM DATA 5 J T jI - I Q f.ONlNicflSEC - ACCIDENT MILEAGE I ON/ W[I/T?\R %RD CU. 'ERSEcTIN I STREET OR ROAD OR REF EFENCE ROSSSTR?E ETORROAD S1" ' 4 N BETVIEEN STREE-13 ,STREET CODE / T S Q / G Q !E J- 'Lt°` , ' '•+ CSTMiCEANOOIRECTIgN FROM nEFEREICEORCROSSSTRE N 9 E W ?MILES ?4 ( 1 ? ?FfnS SPEC. AL0001 NGUSE = -•' ? , Tiyy II )))))) ??AA ?^7 ?/? n ;2C0 FEET Kl? ? ? OF?L'C/ ?'J ESL f /G /J TT 1C / 35i .. ,.. K i ((S+? COL VEHICLE VEHICLE VEHICLE BICYCLE USIOY INVOLVED: ? ? ?OTHERIWRR EI NIT 6RUN ? SE-8ITY } ?^"?+• f AL•O ? VEHICLE. OBJECT ? VEHICLE-RR TRAIN /R?CLLS VEHICLE PEDESTRIAN - NON :COLLISION ? - HAZARDpUSIAATERIAL ? ?STOLEN VEHICLE NO.WLLED NO.INJURED PROPERTY OAMAOEONLY ? 5 V OBJECT STRUCK NNAME OF OBJECT STRUCK AND OWNERS NAME) LOCATION OF OBJECT STRNLK EST. DAMAGE + fr A ?HOADWAY S E W FEET ? ? ? ? H k DD DRNEH NAME-UST FIRST MIDDLE P ' D.EGOE 3 DRNEF'S NAMEUST FIRST,MIOOIE IIF SICTCLISt OR PEOESIPIAN CHECKI T 1 ' _ -5 A k R ? I STREET AGGRESS 1 ST ET ADDRESS 4 A w ?A ? V 1 4 (J /? E GT STATE ZIP CODE PNONE NO_ E R R ? N CHI'/EAS LICENSE fi0. . SL1tE SE E OF D;T TH O . , N?857 23 / NI O OAY YR ro ?y 4y Q- [RIVERS OCCUPATION FIRM NAME pHONENO. 2 . v L u v E EM. CALOq: VG PLATE NO STATE _ TRAILER PLATE NO. STATE - E VEH. CO CPLATE C TI NRUMSEfl VEHICLE .. E //: M/3 S 7C l E ` ?x . l N . REGISTER D OWNER-b1•Ji• AM00R FKST An.noe? _. y1e7 N REGISTERED OWNER-UST e ?l,<A>z o. '..-., ?. t AODRE,% OF OWNER .:. -. ...• .. ADDRESS OF OWNER .. L - 0/ 0 Osycrrt_ b JP A S oa 2 -11- RANLE COLOR A ENT , NAME ANDADORESSOF INSURANI CNAHOE. CrtAigNNO.- ENFORCEMENT CHA OE _ ACT ON NAME, ADDRESS & INJURIES OF PERSONS INVOLVED 3 X P LWURIEB'. I SCENE BY A NAVE N T ADM F. S3: 5 AtuRCO INJUNRIES' EM V DFn M SCFNERY' N/ I RAME: T ( ADDRESS' N ue +x.uNlea R?- nc[Ne n Dr 5 uE ` E i .?; aFf LY T.;:M1^FbCSUR' en ,L ON .IJ+?u cu T y J ff51NPUN F ` 1 1 J n in A 5 G BLM1 O "..Y I c ] \ 1 ?` I 1 F p A ICI A U F00 RN L ? R tl NJURY V Q I I $ 0 F C I / / IS ?- 5 2 IJ. J OfU]ICYCLEI O T , IN nO`+NtAL O I ]PO,nJBLE IN:URV E 73 Y . J=/ 11 K OWN O I MO. DAY YR A nE NON NO. , 1L 01 SEATSELT IS) EJECTION - T d,?gi ELI T-NOVA1 SttLE120fiCONV.1.?%u.;, `„5F'? STATE TRIILER PLATE NO STATE - ODOMETEA r:..Ca ). OR AGENT 7-7 CITARONNo. ? 1 2 S A T STATUS EJE TJ 110f NDTALLED NOTEJECTED 2 'OtNUSE 2 TO 1ALLV EJECTED 3 USED J PARTIALLY EJECTED A.U' +O4VII A.UYKNOWNIF 3 ,sEA; BELT FA.LUNF. EJF.CIEO _ L ?7 fI `.?? (?hS?Ir?W` '`n ce'I.. t',.. I S:r,:?r r+?+iT(•,.'•j ++`,."y'"` '??.+ul"MLL* T..??i„ i ,.,??, , .?? 'I y!7^? J? rte,F Y t '4 ` ?`I zJ xl?`ti A M L? l , 4 I J} } -M_ ..;?_;tiaLf'?F'?f. .Y?'???CLC...?"tF{'I"flri?`?Yi'R?'i t .m •, ,, y .P e i a I'Ixx" } SHADE NRI EA OF SEVEREST IMPACT. INSTRUCTIONS. ] DRAW ARROWI5I TO SHOW PRINCIPAL DIRECTION OF FORCE of DAMAGED VEHICLE NO.1 ETHls srwcE Gx sKETCVmc oAMacC r9 TnA LERS,MOtovCYCLES.ETC.I DAMAGED VEHICLE NO. 2• 1 . 's T ? • Raa. 15 T,..k r 9•r?••,, -_ I., U-11.11 ll?' > ' I. " ' p O.nmm w S Y EH C ' - !' q skvEnRT OF DAMAGE VEHICLE ND. I L Fn rY DF OAMwGE. IoTHEn E cLH DF owMACE v x ??,,55 ry I DISABLING OwMAG [}?? v DAMAGE 1 O ° MAGF ] OO E MALE ) lE ?nGI IF„SABCTI IN4 DAMw0E ' ] ? P MADE o FUNCTIONAL DAMAGE A LJ F Oi .- x a FUNCTIONAL DAMAGE : a NO DAMAGE oo ? To DAMAGEcft. DAMAGE T 1 WEDB L( SEST DAMAGE TOWEDB ESi. DAMAGE TOwEO BY f TSG? x 1 !' - { 3 TO - - DIAGRAM OFCOLLISION ,.-- _?. _? .- 1-:'I 1,•,'_ ce NO DRAW ARROW SHOWING NyRTH IN CIRCLE , 7 y 7 -7-T7471. A ON ;/ .REAS. ErcI - _ -1 -1-1 PORT OF ? I I- I ., ]. .1-01l1 , T- t NIDWFND,..LrvF. LDA J c _. ?+ COI. sIN .. , I-••-?- ? fit?-y.-r. ?I 1 I ??- `?' r IDLS,A,,.ATxL DwL _ 1 - - A,o,,,FA O DESCRIPTION OF Dsq CATEWnAT CE D PROxABLTNAPPENEDBEFOnE.ouNNCA?I..AFTE°rnECRASn.INCLUOE D w_LRaM. SO R ..COLLISION r •- CONSTRUCTION ETO.I -.? . -'L r r POSITION BEFORE COLLISION TION PEE O$ E, KEO _ ] IN ONE DIREC IF ON STREET OR H Gnwwv NAVE OR Ho. ND of L XEGAi PAFI ir WAIVE y xEADEO F OCCUPIED ND INCREASING MILE PO CREASING RKED ' I MPII ?. 1'„t PED l 9NG_ cc_DSSINC _ • L A, ?? ?.c rnor ,TO... FD w.I E IBIC n As USING ID ], IsnoulDER • ,cnasswALK yL E B t c c ° IWALKWAY E ROAD SUoN ACE WE ?THR CONTRIBUTING CIRCUMSTANCES'. L I'll xveN?eL E G °S,F C EI n KOE ONEDR OREI/, y ,?1 'a! OFN E IVE HE NO. RIVER 50 G l O RAHT AHEAD Y'.. CLEAR, CLOUDY - I E LUENCE OF I-I I - Ow G _ 1 { DISREGARDED WARN. ?Ir V xo 0 AA KING v _.___ tY 60VLNC ST -_. LGQk0 C 41 r?? '1 ve r x T } I NINC I-' x UNDER IN' LUENCE OF r1 R CE ARENTLY MAK N SSING CPU 3 .}-. e. d? .V'.a •] SNOW ] WING -,PEED -: D -1 -1 L MIL. [° 1 G O f? G_OPARK NG-- I KINVRN U'Rra,? s L9 T ON LEFT T "'N rEl 7 0 S ?E F AT' C NE EQUIP. )S MAKING U UP. y l U Or R ._1 D R S O1HE ?ISVI<Uri OTHER ISPF 1 OCF 16 D O LICtIl ] J - a SLOW N° G i} GN S G ° 6r I °O V OLA" 1 _ PC ST LIGHC CONDITIONS RAFFICCONTRD c F TYPE OF ROoD. VEMICLESCONDI TION SOBRIETY I J I-'l onp A SIGNAL FK ONFI 0}vENI E D C.ISC KONE R- RE yDI CLE RC nl ICFCK pNEI SIGN P Q J L SIG S AY I NO. S ? ?{TiFti°it?Dl I Np ] J I NA 11 ONE STD EDI ?. ROADWAY ?yyYF _ D LIGMI - 6 •.}+ _ - DEPFGTWE - BPw L NGIN.. "?9' : ..._ ...- Y D DnA is -.1 q REO TY _ wF CLANE DAWN ] ] Rs?xL < Ix Lnv -I TA TI c nDM .". SIL O IL i5 r A 1 E°___ I ,JI P KFO POSITION ~ FL G -.. E CH ANG[ E EC F .__:_ I HCD ,. __... ..,. 100.PAMP -„? .. HEAR LIGHTS '] U 0 f r I I ERG NG IENTERINO I i .... _ __.._... _ - . J A D STR1 Er y. FLAiFn„G S TIT FFICI ., s ?. LIGHTS ON ALLEY , I-SWORN N . A.- O,14X NG -.S BACKING R _ F I D -S,REET .__-.. -WAY .__ IDN, ,NU , rio?i EICHEM, TEST • e .. L c s orr. B "" ^ uRN u.?E °" ° I flLET l G ° I K?Cf _. G VE n Iw[aiYl y IF LA If OF } 11111D NOGEFELTS 'IS' .11-13 0 "C" rI .._ 1 ., l1 ?/S ?' ] vlUm '? % % TEST nESULTS 2 31 G OF Cl 'S MAnGL NO u Cf IC U IIVEU AMB IANCf ? i?IAF'F CILOW 'Cl °Anr ARRIVED •D„ E?ED fr Y w 1 Sur 3FA [ NO lc - a1[ OfrNfPONrIsl PIN.VIO BT RUATt M 11 I ? L ?N'I DISTRIPUTION OnIGINALCC Y SEND TO WASHINGTON 57 AT E. PATROL-OLYMPIA. WASHINGTON 911504 - - tf WPLICATECOPY: LOCAL LAW ENF ORCEMCNT AOf NCY'SCOPY-TPIPI. ICATE COPY. INVE SrIGATOR'S COPY E f?! k I4 ? I . r V i1 !rI? u; T - A 1 r/IIr f ? ?' L Pa 16i 1 Ptr 7 I I I _,;t p I ,- a r14 ',,,d? L { d" ' STATE OF WASMNG` ON PAGE° OF D POLICE COMPLAINT HUMBER '? - UNIFORM POLICE TRAFFIC COLLISION REPORT _ DATE OF COLLISION DAY OF COLLISION TIME COUNIYNO. J CITY ND s %,,? AY 7R T Surv 1 Mp Z f ] wED IPUP 5 iRl 8 SAl IU$w? ON QF ABAN L J !. } COU ?STATE ROUTE COUNTY ROAD ?Cliv Si FEET O / RAL (t ?/. . FIGURE ORSTREET CODE GTON I.7 n v ?fZFFte?.-. ?OTHERISPECIFYI y ?. V Z 0 ]- N 5 E W ?IN _ CITY OR TOWN L Fall. EO. MILE POST ?? l q }}???? ??.v fYSJI 11 ?r ( 5 }'j'1 °"hwi 0 MILES ? ? ? E A 'J A E NO.SiPEETORBGN-- WAY ,.... UlTERSECTING WRH: STREET ORROAD LL RAMP pIAGRAMDATA _ . $ 0 _ TON N' BETWEEN C...- 40 _ STREET AND - __ REET CODE OMCLR PREf1% NON WTEESk .-• ".' t? DENT TEH % D -HSLC i EE.TU HG DO EF. ?Y ACC ti r O MILEAGE T CLS EI CHO:S STHEEiU 0AD 'F 1 1?Z 530 DI$1/A/ lg'l OIEPSCTIi}O1gN FRSOM EEFEPENCE OR CROSS STREET 5 5 EC 4L CDC l ke M /1i EET fO ? ? W OF nuv V I 9- ?VEHIC"'EHICLE ?VEHILLE BICYCLE ?OTHEHIVIPITEI C3 HIT'Ru 5EVEB., e .. COLLISION INVOLVED. S _ TOTAL NO. KILLED ?VEHICLE OEIECT ?VE BCLE RR TRAIN _ ?STOLEN VEHICLE _NO INJURED OF VHICLES L'EHICIEPEDESTPIAN NONLOLLI50N AZAROOUSM TCRIAL ? ? A PROPERTY DAMAGE ONLY -OBlECT STRUCK (NAME OF OEIECT STRUCK AND OWNERS NAME^` _ '._,•? _.r_ .. LOCATION OF OBJECT STRUCK EST DAMAGE..:, , T ? ROADWAY FEET ? ? ? ? RD EDGE S xi DFINE 5 NAMELA.ST FIRST _ _ _ ?., MIDDLE „ ORNEP'S NRMEIAST FIRST MIDDLE IIF, SICYCLISI.OR PEDESIP AN LHECKIQ G.:-I?Zt? v C'-I- Su R STREET AOD? ? K - :: .>. R F I I ;._... .;-.. -:. STREET PPRE55'.:•.. .. ':_:.: •. ,-... a v / 2 3 25TH S(. v. E. CITY ..STATE :. ZIP CODE PHONE NO. 'R .CODE:;.,.,s,.. PHONE NO. R ??, Towosc ,mil vA. 98368 'iii-L ryl i y ! N DRNERS LICENSE uNO.. STATE SEA OA E O OpYTIt N DRIVERS LICENSE NO. STATE SEX DATE OF DIRT 0. 5 e..5VZDIA GL1A F 19Zy YZ 0. MO. DAY YR W, I DRIVERS OCCUPATIONUS WM;-a" EATRELi_ AMES - TIONPNONE NO. Z CDRIVERS OCCU ODES > JiI ON., FlRM NAMEAI SEAT BELT? CODES > ID1 CL= I51 EEC ci>ss _ !51 rn EJEC11pN ?KR INJURIES F o-lc- NIURIES F '?r FROM SCENE BY TO 1FMOVED OM SCENF RV TO ' VEH. YEAR AKE OGE?CHEVJ. ELtDARTNOVAI STYLE I2 RCONV.1 VEH YEAH. MAKEROUGECHEII MOOELIOMTrNOVA1 STTLEIZDRCONVJ--..? a F f v 7 S CFA ?Ap sfc,, v. '"Axr E VCH Ce UC. PLATE NO.. STATE TRAILER PLATE NO. STATE H VEH. COLOR.. tlC. PUTE NO... STATE'. TRAILER PLATE NO.. STATE-.:., t K" H G??•1c SUSI£Q vA .. ...: _,...... ODOMETEH . " (?' VEHICLE KIENRFICATYDN NUMEER.. C VEHICLE IDENIIFICATION.NUMITER..:..:. ...;. ODOMETER E:, 5'oJ 5e5.4 ` REGISTERED OWNER-LAST .-; ,. FIRST., MIDDLE :.E. REGISTERED OWNER -LAST. - FATST .,:..,. MIDDLE a. N :?S j 6?A1?'r ?Oti., JET TW-AE55 OF OWNER _ 12-3 2- r" PT / ow.,isc--4 N O 2 NAME NIO ADDRESS OF INSURANCE CO OR AGENT. ... ... :. ENLORC""VT CHARGE -. CITATION TY ART ACTION SONS INVOLVED copes ? 5' C I PASSENGER III NOINJURY 5 DIRAUUHGIHJURY NOT INSTALLED I NOTEEcTED21 O S N, Z6S AN ] A I`OSITM]IUHr.NOwt, U J DEA RCYCLISI li 1 A001 ?I FINAL I S INON OCSTRNJUnY I ] URCDI USE 1 .2 TOITITILALLYEJCCIED D lGIN[R RUS NOidICYLLCI GE A I. TYISSIM INJURY AUNKNOWN AUHKIlOWHIi E, 5 SEAT OELT FAILURE EJECTED - NAME, ADDRESS & INJURIES OI C 'MME -- C ADDRESS U NATURE OF p. -A.. A NAME N __--_- T ADDRESS 5 .fs? N NAME ADDRESS _ _-•-- N NATUBJE OF s S NAME S -BESS E NA9i II ----- S' s PISIATUS IZISt At PGSHION ? T I.. (La .F3?_`iL1^Yn+,¢'F-?.?`?'? ?ilte fY'F$1??uCF?4 d 'C - « , _. .s r r E RA REAOF ] EVEREST GT. INSTRUCTIONS: E SHOW SHOW PR PRIINCNC AWW AR . D DR ] ROWI5I TO O IPAL DIRECTION OF FORCE, t DAMAGED VEH C EN O. T lusE ,H 5sxpcE cow sKtlcHlrvc OpMACE TD TRAILER., .oiORCrCLFS, Erc.l DAMAGED VEHICLE NO. 2 r",, p ? r " ? v I. „ ao f 'A1, i tr.Y -n l6. IG sP V'A I SEVERITY DF DAMAGE Vf NICLE N01 IOr? SEVERITY Or DAMAGE, IO FVEHICLE) SEVFIRTY OF DAMAGE VEHICLE NOS] 1OpISAGLING A.A. E ] ff IITHER MV. DAMAGE t ?DIS-NG DAMAGE p07,11, M.V DpMnGE ppDSAGLING DAMAGE I pO,HIN MV. DAMAGE . DAMAGE ) FuNCr10rvAL DAMAGE N : ? ND a ? FD , ? N ) ? F MADE N 1AL DA CiI CT pMAGE d ` S AlA MAG[S TOwF[IBYd/? MACE r0 OBY ....... ST.DAMAGE OWEOBY wE { "FE . f y.G,•. TO TO cc i S _ DIAGRAM OF COLLISION HNN -All xD.w Ls ° I I DRAW ARROW SHOWING 4- I y 1/HfCI i NORTH IN CIRCLE ` *` • Fe A ,,°?;:SKDN°dD "r YC,. r I HEI -C. _A, F Da,elvD . r 2. 1 _ __ 1 D.ELKr.D,H,DNS,r I ? ? 1 J .fneMR,A-Arise DnL" .nDArrEACDLUSD I r' I I f?/Scell Gd n L' '.DESCRIPTION OF' COLLISION u mCATI'HAT PRORAGLY.-INEO E DURING 0 E T E CRASH, INCLUDI INFORMATION NOT ON DI AGRAM. E.G. DRIVER FOR E. DISA ewTY, R EDUCE D VIS El LITY, PE DES AN CLOTH NG LGfl, CONSTRUCTION ON REPAIR WORK, ETC. I "?' ' _.l?e?,ra!_s-y?:`/_ 6l/d.s..- sov>Ji-_. o/1 _. T?.? _ ,l?i`s. c.,o?N??_.?odcd? ?'a"2 lyorr f-f T?? d '';. - __ - _ ET -- 1 1? % d - ± Itl ?• POSITION BEFORE C011I1ION INCREASING rv STREET an VEHICLE vEH. HEADER MILrIGHwAYNAME R O O PfRHKED AS V EEO NO. F SNG NO O< IN S E f o NO . y ? IF FEE I q M . H-- _ OnGSi G DRICYC ST US c,SIDEWALK 1 ( I OTH ER O IWA ] ISH Al -C3 ' "I --. 1 - 2i - -Al. ;CROSSIALK C- ^ 4 al ++ flO t?cURFACE WEAT ER CON TRIIIUTIC aCIRC MSTA.CES - i E 11 NE K ..5' DRIVER y, E] IXI E,.G ING o,I N I . LL?? STRAIGHT AHEAD 11'N: , LI ORY _ 1 Ik 44Vf CI u) AL INCE 1 I) p Ow IN I ?) f EO WARN,1 `] OVERTAKING Or"i0L AL FP D _ PASSING - N ER r -- l? WET- ] rI RAINING ( - I .? DRUGS E C O 1 7-- 7 CE A APPARENTLY r1 } FG _ EP I ) i _ ` R .HE GH TURN ? owH n r E 5 U AR SNOW _ -? -G 5 , k kOl. I 'D l I KING MAKING I OC ? _ AT10 FT TURN ti I, ICE FOG } EKCEEDING RE I r G [E I pKNiG __. ___.- ?._.I SI I I i I o NOT GRANT 11- l n " L r LOWING ) os CO L4 OlN-FR ISKlOIiY1 - O,II[R ISP(C' 1 I _--`Y _ OSN DITO THEn ON FYI f 16? ASSINGR - 'I) SG Ai !OP `EC iON IS' L No VIOJ T NDITI •,R?.' ONS TRAFFIC LONTRO TE OFROAD VEHICLE CONOI TION SOBRIETY FIR ! S,OPPEDATSGNAL ?H 1 (CK ONEI ) t CLf O]E ICII YPECKONE OR NDNEI • L ? 5,pL?p I. J f-- VEHICLE I.Fb OR STOP SIGN ONE 'fM1"AbiP CLE ICHEC NEI WAY S 1 I r 1 ] M1 tCCUI NO .. J I S PPF V ROAD ` y, WAY U tG , i) SGM X) TWO I C C q• t 115 ii GIN -L G C NOT RtO REO rl ! NFD 6LARE ] D .... ] i..t N O f. .. ) RTON STATINO I ECTIVI S _. 1 .? W ANG1 S I R A0. G I I OOPR P 1] SORN ET "f HINT-N. FEAR kCt TS I ' K DA ilC1 NFFT ALLEN I"I 111- -__ 1 LG SON A E I.? KI I IS p J G CK 6 U ( ff OINN S'GG S .S? W _ O - O I TEST CMEM r 6 DNOf] ) I I x I E CEIR .-N P F N I T " O ? I an- _ I IS ECI YI SI f ,_ f G tN y GMTS OFF 'GNAN ER ] t OvIOID P\ NO OEf TFST Rf-ED )' s TS [ ( S' Sr br vl '.5 ? I?I UNDIWOFD O N R -1IRY Ni TEST IIESULTS Z nvI111UA IN..11. e,I` 1 ? S rvp.t AnpnK VAN IHVIfI'cAbNG U, 1 .IAnANA N A _ D U NA 0ueemsPAmmD DVID ANCF LOW •V a M NA,f3 /853,,; 9? ?•° ;- :oD IIS AGtNC, ' S, UnU A U uE NlPUn, Uv[D RY UA l ./ ... DISTR DUTION ORI DUPL I[AIE Croy I_ -wPY' S . . END TO WASHINGTON S1ATF . .. PATROL _DLYMPIA WASNINf.ION DGSM _ Y. .. " ?? 1SrN ? 3, 13'? < Y;C vA:; '.Ali •• - - '•'!I'^° .r•SY • "dFiRN12KISWN+NWN1 M+x 4sF§N I 1. 2 r I ?'I 7 1 I E?? N 7 S - ? ? 1 rl 7Z 7'. ?, 11 iy 1 . T<?{ Y ? I t K k ? !- _f r rr F ? : ? t 1 ' I I r-V e DATEOFCOLLISION L Y YR DAY OF COLLISION TIME SUN MD IULS WED IxUN FHI SAT IV E "OQ N 1 2 J A 5 pUPI P- COUNTY NO CITY NO. ?? ? r FHWA R CWNTY O 6 Sr Q STATEROUTE LO '-I l(/ AUMCLS 'PR , BAN I M U UP. U TY ROAD []CITYGIREET Cj? ° EFIX ROUTE OR STREET CODE J LTION ,' to iry?I Y9 []OTHERISPEC"' ILL v^? ? I- O LJ N S E I[]IqIN CCITYORTOWN Ip W PgEFI% E0. MIL ??j C /MILES ? L T eg:OF_ GT GO.??/J.S E11 ^ U ,. ' A NAME 6NO.0 SIR TOR HIGHWAY INTERSECTING WITH: STREET OR ROAD F O L ia;41 RAMP DIAGRAM DATA , ` YV T NON WTERSECTINN ° N F /f a.'e °L. G e n6 G /ef ? s ACC DENT MtEAOE NTEq X CLS IMERSECTING STREET OR ROAD OR REF ERENC Et ROS6 STREETORflOAO, ? Jr BETWEE / _-_. ST REET AND _.._ ' JL -STREET ?iANCE pCS CT ON FP OAE ?EFERENCEOR C g O656 IIET CODE S PECIAL L / - . Y.l ZZ d. . a ft "fix S ? J / / , Ncri[1H5 . O IhO USC D OFEET OFR(•?./ JL ljd 0.G SS/__ s . CO LLISION INVOLVED: []VEHICLEVEHICIE ? VENICLEBICYCLE ? OTHERIWRITEI []HIi6RUN SEVERITY hI R TOT AL HO CL T. []VEHICLE RR TRAIN _NO. KILLED - + []STOLENVEHICLE / NO INJUR OF VEHIClFS []VEHICLE PEDESTRIAN []NON COLLISION [] _ . ED HAZARDOUS MATERIAL ? PROPERTY DAMAGE ONLY OBJECT STRUCK (NAME OF OBJECT STRUOK AND OWNERS NAMEI _ LOCATION OF OBIECTSTRUCK ' EST•DAMAGE .. . ... .N * OF []ROADWAY F ? El ? ? DPMERS NAMELAST. ?fIPSi , MIDDLE .:.. EET RD EDGE S DRIVERS NAME LAST FIRST MIDDLE I IF BK C SI OR PfR IRIAN CHECKIO D R ?d ,? D STREET AOIXiESS .. . R STREET ADDRESS V Y?''? e l"/ E I dY r7` y SLATE .... .. LP LODE PHONE NO, E CRY.. •... .. ., .. . ., ESTATE - _IIP E ,. PHONE NO. N a T /aYd Nnd ? n 983 8 38.5` // 83 . „ O• DRIVERS LICENSE NO. J . _. STA/TE- SEX GATE OF BRTH ?? MO DAY N - DRIVERS LICENSE NO STATE SEX. ? DATE OF OIRTH I ... ! 76 LI/.17 _ jj S- .S .D O. M0. OAY YR. DRVERS OCCUPATION FIRM NAME .. PHONE NO. 2 DRIVERSOCLUPATION FIRM NAME N '"0" OdSP ? , . + /L CODES >1131 CV55-. - IKI SEAT BELT ISI EJECTION _ NATO EOf l' A CODES > IJI CL/ui55 AI SEAT BELT I51 EJECTION I'Y• q ? INJURIES /?`'O' ?' /?,0 TUBE OF NJURIES •' FR NE 6CE VE N Y EM BY TO r i f SF'n? gMOVEO rfr PAlet;?' OM SCENE BY TO . ?f / MAKE(DOGGE LHEV.I MODELIOARTN VAI STYLE12 Dq. CONV.I VEH. YEAR . MAKEIDODGE-CHEV.I MODEL (DART NOVAI STYLEI2DR.CONVJ V CD/ - /LY-IY y . E VEH. R •. LTC. PLATE NO. STATE .. TRALER PLATE NO. STATE E VEH COLOR UC. PLATE NO.. STATE. T"LER PLATE NO. STATE `C a9v H O VEM lE I NIIFICATI N MJMBER .. ' ODOMETER ... O VEHICLE.IOENIIFICATI N NUMBER ,._..... e w -. ODOMETER .;, E S y3 97G /?/ Goo - 6G<9 E. ? . REGISTERED OWNER-LAST, FIRST ... MIDDLE i .., REGISTERED OWNER-LAST : FIRST. .. MDDIE N o. /n N ° . _ a. -E- OF OWNER • ADDRESS OF OWNER. 2 2 NAMEANDAD ESSOFWSURANCEC ORAGENT .. ?. NAMEANDADDRESSOFINSURANCECO OR AGENT , . .. 1 LIAR , . LITATIONNO :. . ENFO RCE ME NI CHARGE ._. CITATI N /F On/C± A CTION - NAME, ADDRESS & INJURIES OF PERSONS INVO LVED CODES s E% AGE STATUS H EJECT. C NAME: C ADORESs' J u URE OF R - - A I'? P E " IIOM 0,1 ED UR IE9 VY ,NBY C 5 TO f H ' NAME: 4"k •h T S ADOPf49: wi Y? ' ua, FM DF OM SCENt'IIY T O W NAME ADDRESS. N A VED NOM SCENE RV T O .J E S AME S A E N lxwtss ?? S• x iAJ S SCENE Dr TO I Ne"H- IJI SEAT POSIIX}E J IWAJNYCLASS I JSIAT BELT H HEJECNON C O jKMiTWW 1 OIN.NRY S DISAOLI•q NNRY 2 DEAD AT SCENE a NON DISARLING X NOT WSTALLED 2 N0I 1, NOT EJECTED D eCVCL41 m;yc ! - 6 ; / Z OTHERPOSRION VQ M U T NNNYOWN ) I S DEADONARRNAL FVIOEINJ INJURY A DED IN NOS%iAL I.PpS`WBLE WJUPY ? IN USE 3U SED UNKNOWN 2 T07ALLYEJECTED J PARTIALLY EJECTED A UNNNOWNIi E e . JT WE I L S SEAT DELI FAILURE EJECTED IJ _.. - •f, { L ?'A { 1 1 t II 116 Ake ` k t Jf ?I.?'1E?7YAt'Jnh _ - I 32SN ,''NLY ?, °f ?;'_ ?'d{IA ?I7A !r•Y?- 1 r.r, .y SrTr WJy,ka r . ZT ? ?I F U KKe cu a ? ;.1 4+,^ I f n 1? r 1 1 DAMAGED VEHICLE NO.1 IUSE TXIS SPACE fOfl SREECWNt3 DAMAGE TO TR.UIERS,ApiORCYCIES, ETC.1 ?? la x la I?a,l DAMAGED VEHICLE N0.2 R q . O O H 1 1 O a E I I I 4'. ° t n R o a l T u h _ . 13.UtgNUnlea. ". - In'aRMh =21 - u ?? n a r `\ . IT.awr. n rr:x o. SEVERITY OFDAM OE VEI}IClEN0.1 BEVERITYOFpAMAGE:IOTXF.q VENIDLEI SEVERrtY Of DAMAGE; VEXICtE NO. ]. ' 11.0- 10DISABUNOOH AGE 30 OTNEAMV.OAMAGE " IQDIBA-W-MAGE DQOTNERM.V. pAUAKiE 1QOISABU NOO AMAGE TX FUNCTIONAL O DQOEfl M 2 .VAAGE l NOOAMAGE V DAMAGE ' . . 2 FUNCTONAL DAMAGE 4 NODAMApE - 2 FUNCTONAL DAMAGE a NOOAMAGE TOWEGBY Bill°S Cara a EBT.OAMAGE TO, BY EST.OAMAGE' TOWEUB E TO Residence Si.OAMAGE a 4C0. TO a ?p1AAAM gFCOU.jSIONc,,,l w"r•q°r^ "° ku^^IEi a? a TO DRAW ARROWSNOWING 1 x - • ecCFHiswuasrxo.uwA t y.Y uw lwrew camlaa I.we."q¢rcwrarwcna I .- I I I I NORTH IN CIRCLE I ? I i I I .. I I? i I ! ??? - I I I I I I i 2M A?XbeAr.EEDMM asWrNVRxAe, PEAesrw,w cq -• De1EDTPD9,I«..ATUtFVC} m I I i! I ?? t l l l l I I I r1.1. r I I? I. '? k f I I I I II-"' I l i- j I I i I i I I I I C I I I I I I I I I I I I I ? I I I I I I I i ,OESC;RlPTION"UF +n 'COLLISION t'?^' _ yh.. I I l I I I I I I I I .IINq-TE WXATPRDBABLV HAPPENED BEFORE WInNG ANO AFTER TXECRABN.INCWDE INFORMATION NOT.ON DIAORNA,FA O,WER d9A&UTY. gEWCEO VISIBIIIiY,PEOEBTRU,N CtATMYIOCOLOR,COXBIAUCi1pN OR REPAW WOgK ETC.I Driver informed this JO that he had just passed E vehicle d?i approxirately 40 to 49 mp$ and when he- , ed back into his lane of traffic he started fish-- nn dui-0-the C o y con-, on the road my aad lost con ro oP-thG ve - cle. ?Dhen ?iten?-?nE0 tTia a a?T _ t?K3? d=?e vehiclo to 1 0 its side causing moderate damage-to the vehycYe. ?'ai'x'irhdR VEN YEAOED ... ._. -MILE POSE p EV?F•Z..Y.'NL_ilsnjGdCie?S.+tz] " - ND.OF UNFS SPEE09 V lE^IF M . R. ONSTREST piXgMYAYNAMEORNO. r WONEOAEC110N sAFe LGALLV WAB X VE . PA UPI ED j? 3Q NtED OCC , 50 .... - .. 1 ~ !r luX . YE9 NO YES NO -. PEG. -,L 11 1 Cxu ] xa srpkEr RXaiwr M cDixeRi CcDW,EPoVIEi wl _. ?o I ^ ' PED/BN;YCUSTWASUBNtI:. l_J a¢EwuA >axD II?? y ?MAmm xl-'W a 191,DiaDFB °I =L-:2•.-T'".'l_°._. ICUaoTS' .L Incvcle 1°° t10AOACEr ' .THf3?'irb ," _ ro um 3zx6A;sch5asdCONTRicNi1G CiNCU ANCESF ynr ?sucsomxq..oy.,'. ? ?NTRx- eA?e DmD ?..I ?s ?_?E,•' .DPe ? mr t L7 xv •.eiw°°u°r r' ? Mwv'.u a'a°r ?r Y -j3 sa01x.o.rmo- DO, ?a?. _agow' a? aNDAws [Do ?a? ? arAT[0 _ ?°?.. AyoM"°X.`lo I-;5.? M?NnP?mrMxi.q.- _• •????; ?L ..z - _?• ' ? c° . ? roo - -- `I. ?Rns ?lo P.^o°m oPFnlv.o ? ? wwm r 1° EcmEmuv. - a a ,..: .e _.... oneRlrocrAFYI oTXeRla9eorq UGHT CONORI U .... _ alum !. _TO.a n°s "rn. 1_. v°NOwNr r?. _..... __ ?°? -anw.to• -i n ?Ix? m rrP? »D?OADN°m ?.? K°„a! p?$ RAff7C, F^euoW ._ aw. f?wrse ?„ly . m O£ROAD' a VEHICLE. NDITION; SOBRIETYI +' ? ' anol+co ATdnPi = a? Ic?tu o.aa reel vet,gc x?o°W"e oR F :... 4,. ?n? I poN°t Tp aDN 1q. x . °' l `'e° x?? ow al Wxtg UTml ?.? ?iO ?mxrz?"`x ?1?=?rz ?ia? irw Iwle xDa , _ .an - ? aa _ rror wars Ix ?It a ?: ntol . . ?'? ? • iwN ? f ?a? ?ur in ?Pmr 4.1 ?.!a_?,..7.=_= . "w,cooewrr u, T•M1vflMOq lDDelOq , ° ? orr° ?°? iexAL . ?°? Tuww"we"a°f ?°? '°osewwuclux qrn Na ECHEM. TEST ? ? . 0 r ^JO""" "-7 A?? nej 1rnmcN olXale.enrYl -?- ? L.J ? _ ' ' o e _ LJx? °?°? ? ? Xo oertrn r; n rznAeNato t '. ?} a r'?' -. ?j 1 w, a Y prrl ??-y.?? x?Tn.nc '.'.' r? ea 'ow "p?enullartv+l % ???? Iw..oe° t S taaaXeewaxAw•ww .' . % TEST RESULTS eAOCaw PdC ouPA - _. .. Deputy M.C. Gebhart Xaace Axwveo we. 6 YDx 1Y24T 7 211 4 x m 2120 x.m "N"om°p (D 0 x `./ Z7 wrR ? y r" gt Y?O .oeV, so v3. c*.s "M40h .rrgoeeoer _ I X rz I +t mlmw. rW I WPUCATE COPY:IOCAEUWENF'pRCEMENi AOEHCYSC?Y-iRroUC?T[COPY INVESTO TOR'SCOPY ? a ? q 5 S < 5 : r 'fir + I a ` rY l r? hy " ;I ? 'V7LK - 7P1 ? ?N 4 .'r ,S r I ;a 1, ST?1?t7F N SF a iN -' : to 1 A lINC y PAL. DF Na. ' - UNIFORM POLICE TRAFFIC COLLISION REPORT POUCE COMPLAWTNUMSER-_. : O DATE LF COLLISION n11 24 UAY YR. DAV OF COLLISION T SUN 1 MDn 2 RES D WEOA 5 FPo E 9A! THE 125i2OO 400HOUR1 Z COUNTY NO. / CRY NO. /w YYX/// FNWA ?URdAN pAL ?? ,.i N. CCUNTY ?STATE ROUTE LO'COUNTY ROAD OUTE ?CRY STREET O AOM?CLS FREFM ROUTEORSTREET CODE EL'ibN T r Jefferson ?OTHER FY) W y yy?? IN DITY ORT-OWN • ? PREFIX E O. MILEPOS( ? C 4 MILES ? ? ? OF Port Townsend, -Wn. LL S. - b A NNE&NO.OFS EETO/MNiHWAY WTE?LSEC DYN1.: A .TREEroRROAD O RAMP OMGiL1MD ATA T ON c.R. 38 ,F O ON NTERSECIION ACC DENT I S NFER 5P . XRD CL4 NTERSECTING STREEI OR GR fcF. EpENC LRO&S BTREETORROAO ?$, n ,a Jdy IR ? A S N BERVEEN STREET AND DISTANCE WODIRECTION FROM RE R STREET CODE 1 Z z ? p ry 4T • t tt . F E ENCEORCflo.STR ?MILES N S E W AnlEnq H PECIAl000WOU5E ' y; i. 1 .? ?FEET ? OF R. 20 -1 r-1 :.. 4W ?- 1 A T v VEHICLE-VEHICLE VEHICLE-BICYCLE COLLISION INVOLVED: ? ? FftEI HIT&RUN ?OTHERIw ? SEVERITY NILLEU NO i :L NO ?VEHN:LE-0BJECT ?VEHICLE-RRTRAIN TOTAL S ?STOLENVEHICLE . No.I WUflED ' VEHICLE ? VENICIE-PEDESTRIAN (OnONCOLLLS10N ?HA DOUSMATERIAL _ PROPERTY DAMAGE ONLY T y } ? OSIECTSTRUCKINAME OFOSIECT STflUCN AND OWNE0.4 NAME) ... LOCATION OFOBJECi STRUCK EST.pAMAGE . : . - ?A } ' I' ' . . . ?' AY FEET ? ? ? ? RD EDGE 5 - • DPNERS NAMEH.ASi „ .. FIRST MIDDLE DRNER'S NAMEiAST - FIR97 MIDDLE IIF dN;YCUST OR PEDESTRIAN CHECKI .... _.._: - 2 D R ROGER, Corey A, p . R ,tFa Y ... } AOOpE55.:„.... .: .:. _. •, _ .. STREET ADDRESS ... - ,.. P • V Route 1 Box 901 V A ft STATE 21P CODE,;, PHONE NO. Port Townsend, Wn. 98368 385-2800 R 0"' STATE ., _. LP COOEY PHONE No. - rAC; S • N ORNEp9 831039 STATE Ax SEX N DATE OF BINTH 7 09 5 N °' ORNER9 LJCENSE NO. _ : - STATE 9EX DATE OG BIRTH -' MD. DAY Yi I •y DRIVERS OCCUPATION FWM-E PHONENO. 2 DRNERS OCCUPATION FIRMNAME.. ... : !? 3 T UnemP1oYed ? 1 :L 1 3, 1 CODES > IDI LI as HI SEATBELT 151 ElECI10N 'CODES >113i ?uq y IQ GEAT BELT 151 EIECTNJN $ WUP ? Stated NOII E TORE IN t I I S Q JURIES REMOVED ? 5 y Y• ?T M9CENE FRO -YEAR BY: MAKEICODGECHEV.1 TO uODEL10ART-FOVAI IYLEI2 WLCONVI SCENE FRO. VEH. YEAR AKEIDODOECHEV.I_ ODELIDART-NOVA) STYlE12 DRCONV.I _• k. V 1 65 Ch V _ S y , . E H 9 VEN. COLOR eTr PLATE NO. .. MATE TRNLER P Van LATE W. STATE .. < - : HF. VEIL COLOR - LO. PLATE NO STATE TRAILER PLATE NQ SLATE --. . I 4lhi lu T61116 Wn ] V a ?e C e VEH ID IRCAl1 N NUMOER. _:.., ..'.. : «..: r.. ... .. C. VEHICLE IDEMBTCATI N wMBE .:.:... _;:_..... ...:_ DOOM R ?i:...•. .YS - ? G1255P133355 63479 E ` W b^' . REGISTERED FIRST ,:.-:..._. __...: •...--. ., MIDDLE . ., REGISTERED oY,.R-LAST ? N 0 ROGERS, Phil N - , . ..: t ADDRESS OF OWNER_ ?_ .. -:- -- .77777777=1 T O ` ADOpESS OF OWNEfl ., 1708 Landis Port o•nsend Wn 2 q Y NAME ANDADONE89 E16URANCEC0.WAOEM '. :. EHK NAME AND AOORE590F WSURANCECO. OR AGENT - .'. u ?, yy Y ' • CNApOE .. ._.., ...:. ... ......: .. .:.. .. WAAS.NO. ENF ORCEME NT CHARGE :_.. .. .:.:: _. .. ,.., .. _ ATI ' . .. J None ACTION „ .. , 'S NAME, ADDRESS & INJURIES OF PERSONS INVOLVED _. -.. cooCs 9E% AOE STATUS _ F' .... . .... D ..... .«_ a ELECT-: KE. .• .. C ADONEss: U P. NATUREOF REMO EDFROM WJUPIES' SCENE BY'. TO A NAME: N T f ADORESs NAT , M V D M VERIFIES' CF.N TO W NAME, T ADDRESS, - -- N IWRATUwcar UAI 75.1.6. 310 TO E NAME S N ACO ESB: SI I1 I1 iNJIJR' S .CENFRY• To 11151ATU5 I215E Ar iN) vRON I]pWURYc- p I5I EJECTgN C 2 P E. A'sFIG N01 DRY S. OISABUIO INJURY I.NOIINSTALLED NOT EJECTED U P 1 SOYLVSf E T 7 OTHER POSRNNI 1 2. DEADATWENE 1 ANON DISAEUNG 2.NOTRIUSE 2. TOTALLYEJECTED D AvAME59 & ! . ] D 1BUSMOIORCYCLEI ]DEAD ON ARRIVAL % OED IN HOSPITAL IENOENI RUURY i. PQ551RLE INUURY S. USED A.UNKe101VN O. PARRALLYEJECTEO .UNKNOWN IF E _ EPOLTKNI UNKNOWN S.SEATBELT FMLURE EJECrED m I ?I' ? n li ? 4 _ ""}}1 yy YF` A ? ;. -.. .,........ _,? •._-...._ e, ..`J'i.. .:3fYYr P'?$:.:C`? ?-....u? ? ?ru ., .> r ' u ` Fn•.fl?/ •. Y S./ MOTOR VEH VEHICLE COLLISION REPORT D A1OF COLU SION DAY OFCOLU9ON TIME OF COWSION ..+.ussuvnvi uru i , rin xy"?'uii ur?..4 ? NO. x fL, KEW T ' 3 ? -Aq MAM jY l1 PM mC/CITY, TOWN wE MILE •O CITY TOWN cr,? YE •'?i I()L.., .., IIY' 1 r Tt .Y..1 ,NN i L Moll- an GNAME OF SIREET flOA00RH 8sm COUNTY CITY NO. ?yE"q•MI ADNC' PREFq -11-f,nEOCODL TION o /?° J I Y T ?q , ; INTERSECTING WITH. STREET 11 10- AccIXNr CJ/aC0[?r::: : ?`Ea' G 1.?- NONINTEPSECigN L00 igNOF OW]ION "NE". EO MILEPOSTt ..Js /_I _ /- /' r -P gAORAMWTA 1 / / / / BE?? i I•-'. 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VEHICLE Tfl MAKEICNEV; DODGEI. MODELINOVADMT7 BODY SIY}EI2 rn.I VEMgIE YR. MAKEICHEV: DODGEI MO4ELINOVA-DART) ?BOOY STYLE(E Dn.) \ LICE SEPALENO. STATE NLEq PATE NO STATE LICENSE PATE Np. STATE AµEq PATENO. BTAE Z J VEHICLE IDEMIfK:ATgNfq 11908 MODELSSNEWERI ODOMETERIMLEAGE) VEHICLE IOENTIFlCATpNNO. I188B MODEL56 NEWE DOMETER ' -- E y? OWNEflS AD RESS ISTREEi, CITY AND STATE) 1 ' _ PMTS OF IEHICIE AMADED Y ?_ LIABILITY INSURANCE INFORMATION-VEHICL NO. 1- NAME AND ADERMOF UAWUTY INSURANCE POSY HOLDER E G E7 NAM ANDADDRE55 OFUAWLITYINSURANCE AGENT Ry u'.•i 3[' Y ST JURY NAME -- J f '- J" SfATU50FfMMiED 111115TONETHATAPPL •p ?? ?tAAVEP INVEHgLE fASA•.A.O D4AgM ?LLED I IsEY""'"Enil I NoeH"'•D Yn RaseJ OoFDESui J 6 ?' D IFWflTH OWNERSADDREW vEt PMTS OF VENgLE DAM/ 5 THERE AUTOMOBILE LIABILITY VERAGE IN EFFECT FOR THSACCIDEN IT- 2ND INJURY: 0TH NAME n IN VENgLE RANANO ro[R KILLED 16•MEKREI NO. ? 50 BILITY / -P?OUCY NUMBER O -(- 747 - 1.5 OFBflTH ?1 { y 'TED is '"'N ? : ? Jr ? 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Z ..r Yt 7 xpr rx ..r d^EE /Y/ n•L COUNTY CITY, TOWN MILES Ja CiY, i01YN ADMLLS PflEF1A A.UTF,OnSTREET CO ESECTION T? fr tl !5 w L ©DF{?Lzr u?suN GIVENAME OF STREET, ROAD OR HIGHWAY INTERSECTINGWITH STREETORROAO PREFIX EO MILEPOST f r, NON INTERSECTION-LOCATION OF COLLISION ' RAMP DIAGRAM DATA B'N, •K" eFT.:EEN - STREET AND STREET N E s• Ir v tr •. .;:rnt e. ..r. ER C 50/s Nn iinrar px Vii, r i 1Y OF ?ZI V`iL ogT?ss n.v•??<su1'?t ?_ A? I_<.._ HQ qi;(d<<???aiD nw IIEC, CODE USE ?- rJa OEJtE11CT TIUCK x•wlpl pa.lci STnucKl o OWNER Of OBJECTS NAME AND :.DRESS LOCATION ` ' h CSST LSD IN ROADWAY 15 ?E p "I FcvT W DRIVERS LAST NAME FIRST NAME MIDDLE DRIVERS LAST NAME FIRST NAME MIDDLE . z `tpVEZ I _ ALL GTREETADDRESS ROUTE NO. AND BOX NO.""'•` STREET ADDRESS AOUTENO.ANDBO%NO. k; 3 vAZ4-3 f CITY _ STATE 21P CODE 'DRIVERS OCCUPATION CITY STATE 21P CODE ORIV ERS OCCUPATION DRIVERS LICENSE NUMBER STATE SE% DATE OF BIRyT?H AGE D81VEII LICENSE NUMBER STATE SEX DATE OFBIIJTH AGE DAY YEA) J IV'h-7G'+`R-A 4'. t'il`l ?) Zz --- MAKE He :m MODEL novapnnr BODYSTYLE IIDA. EHICLEVA. MAKE c.rly. DO.e 1MODEL VOVAO•Hi L10BODY STYLE Ron. 7 1 OMC T PE SL--,4,, , )'a' -Taw-t-? LICENSE PLATE NO. STATE TRAILERPLATENO. STATE LICENSE PLATE NO. STATE TRAILERPLATENO. GTATE As -ik?Z N L VEHICLE IDENTIFICATION NO. rwe.0.111. 11Nen1 o00METER LIACI VEHICLE IDENTIFICATION NO. "AAA-<1.111111"i ODOMETER rwrlE,aD V Z S ?i 3 r6 0(X? SGa x? I?j REGISTERED OWNER •rr.rl sr wr.OU n,NI DRIVERS LICENSE NO. REGISTEREOOVANER I..r........E x,wl DRIVERS IICEN5E N0.. mJlYEIZ ee- nALLsE i MA Yi_-ER-A431lMIV 'IF OVINERG AODR;'E')SG ,{ ISTREET,CITY ANO STATEI J DATE OF BIRTH OWVERSADORESS ISTREET,CITYAND5TATEI PATE OF BIRTN ?1. L7 Elk L4-.z '. &. r / YEAR MO YEAR IART 1' PARTG Of VEHICLE DAMAGEDr oie V Lr,AVENrts LGFr 5l(?C ?G Une ` - LIABIUY INSURANCE INFORMATION- VEHICLE N0.1- WOA-VERAGE iET REIN AUEFFECT FOR FOfl IS THIS ACC IIDENTNSURANCE C ON YOUR CAA L-JrcS ? NO NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER ?- NAME OF LIABILITY INSURANCE COMPANY - ' E ADDRESS TY? TAT' ZIP c,::' MAYEll- - Zox ? ?cei laL SE& l• S3 = si?F7E fifc'hf `.?$ NAME ANp ADDRESS OF LIABILITY INSURANCE AGENT CITY STATE 21P LIABILITY POLICY NUMBER `?TL 13ZIC10 S ?lcLDE245 Icw 6llA3 - lt1Z -¢Y?-fk03 -$Y y"7Y _ IST,INJURY AGE ZND INJURY: USESEPARATE REPORT FOR ADDITIONAL- ESI ? AGE Awf Tl- :.E A ' OD 153 SEX -40 DD 155 I r•r w.•w• .. 0.17 I.. vwwD •v SfATUSOFINJUREO 1 - MARK FIRSTONETHATAPPLIES " STATUS OF INJURED r ur r MARK FIRST ONETHAT A LIES r H _ IH VQMICL! INpV ENILLE r _.dLc?. - Sry KILLED of'n w G nrvvo ? ; wr Cwr1ruu •. li? 1wr, Nu'wanr r• 1}rO?J%7 r' N i •ru KILLED r er r ,nr k 1 Ira nt ??^ $?.+ ? S ? ? T 0 rc. r a ? 50 6 ? T O c.I (?i L SHOW NORTH BY ARROW IN CIRCLE DESCRIBE, BELOW WHAT HAPPENED: IRiFER TO VEHICLES BY NUMBER) „ •" \\? D1241;II'JG.:f0.uh't,il5 F'DT,7 1owNSEN0 ft?AaA4t/J!/ W <> w 4na'? A . G8-I)uP o,- N/ca?tAl?,Pei3Piri? T?? _ r o ; .f q qn,. n.wl^DOnn `?\ \? _ SNac?QgcG_, ttT-/KY_..t/EF,'000C .- J?VE_Gi? I' M, ?vQ f••-• ? ? :..rinllran ?'?.q.. T/fE CJYii.?Y2EN h?UrVS-__3uLY7E>I/<Y--O!!l ,. I ?o +VOtD !tlrriNGs CHIc/j - pW4-e ?taFllfG_ ?_- --_ .._._-.__,r--• -_ - -- zs Mr'N b.:E TO FA'65[?- -fNOtt•+... fr!CHl4Ll f? : - ?L. i s?T t niTi? lt5c,1,? slDclvAt'S uPC!N-- ) r ry ... S r!. /??tLr A/!D i-Y?/'%.J/ L7E.'r Cif]A/ Ii /1l4c !J/?CC'M//V/^ CUPS JEJ? - f1? i L3?tN?, 1 C, 4e? rL/P5 ' g GPI i5 %S s/cJ_ /4Ni Sc1L$ /UF6f=T, -ll?it5?. i A6'L5 re- G?N.fe7_ evr G**b4: .Seac -,144 Cdi._ r J VEHICLES POSITIONS BEFORE COLLISION •] `' ' NvFSne.reD FY 1°4 v!"¢Le ADSD wi :.. :?,"«iw.D ?:. t ?>c jF ON STREET OR HIGHWAY NAME OR NO. ? ?9 `` IYOVRI Ll' ? O O ?sr OyEy-? F/rT I J a?1 : G '. rr? ? ? N,r IJ""'••Rw,T- IJ 4s p DT.tar ? ? ? ? ? L ? ? :IA-...... MvirAaV4AR /FI 1 p!f. PEDESTRIAN ? ? ? ? ALONG CROSSING FROM TO }B I 1 / x 11 PFDISTRIAN WAS USING 1 ? I,r1n•1. I ? n••. n•. ] n 1-.I. r. ??if ni.. C03 Cna;s+.1.: B ? {'0' 1 TI vc' ROAD SUR FACE WEA)THSSfR LIGHT CONDITIONS TRAP F'CCONTROL .1 ATYPvvc F OF ROAD pRIV[RrVENICLE ACTIONS y k ', T t `- .' °-,'Ai. ' ?3: (:guy" 1 ? DAYLIGHT .. r ..4: ,x .I. d rcmcn.wEww.n I t f t ? RAINING ] /DAWN ? I "?SIGNALS ? 14?ONE WAY V © t,?OOIN63TRAIGHT A11EA0 a 1 f?. ?Dxr J 1, 1 4 u II IR 4 --• (3 ? J ?STOPGGN ?TWO WAY ? ] ?OVERTAKINO AND PASSING .VI ?I T ] SYOW NG ] DUSK REV CRSIBLE 0 M1v GT IFCr ? S ?vIE LO sic r, ? S ?ADAD ? ] ?MAKINORIOHT TU A RN ?JI J S+.Ow < ? FOG ? LICH)S ON ? l ? ? A ?1LOOPIR -NGE ? A [3 DAN S TNFfT IIA..N NG-Er MAKING LEFT TURN L A I 1 ! t F _ ICF S ?t'?S ?.r S ((?LIGHiSOPF y S ?iLA31ING .sVBER [D S ?ALLEY ? S ?MAKINOU•TURN A 'J SOt nEFT?GHTS 6 ' r- ? RR SIGNAL B 1 ? ?Lr'1'rOT 1-1 l,YEl ? e ?ELOWINp i ?,? r ?' S?I? ?' h t C'OYfO -Ot Sl. NG.. ;LAGER T?vrr rr L"')?OFFICEA'F:AG.,V ?1?STOPPEDFORTFIAFFIC •i ?I -~I .n ? Q ?a'.I??i?, 1 SEPAHA7[0 STOPPE D ATSIONAL F a 1 II, ?B?OH STOP SIGN, i t 'tf ?1 ?1 1 C] f ?DIVIOEp ? 0 ? STOPPED IN ROADWAY ) 1 1! Xr '? ''?NIiAAf ITC COYT OL T 4YOIV OCO ?'E OnSTARTING IN I I L` 4'' _, 7. i •, h 1 rl. ti 11 t? 'Y,I t! f 4? . ' r tlF ,ud r, HR 99 AIM 'r: I E? IF?? dp yfi s a ''•'ydv. ' I ?L- .,,L VT1 A.5111r S ,rl? LI" \L .J MOTOR VEHICLE COLLISION REPORT NO. DATE OF COLLISION .[AH I ?YJV(?OA 7 91 Y O CO II TIME OF HOL?LI SION L SI NNN11I''•.'' COUNTY /NP. CITY NO.. n _ COUNTY CITY, TOWN °: ?5 ?lstru?¢IZa=.os.r1 " r MILES I]r? CITY, TOWN 3 ]fw7 of o? a AOM,CLS PREFIX [o •1xEE1- X0/2 O 15 SEGIi INTERSECTING WITH: STREET OR ROAD GIVE NAME OF STREET, ROAD OR HIGHWAY " PREFIX EO "ILL-5T ION ECTIONLOCATION C LL OIAGRAM DATA RAMP L NON I NTERS . BETWEEN STREET AND STREET - i IN Nn°n'c'E4xt>x iic?wfL[xrro>l ax ctrvt f. .c L..ou:u ?E ? NON XRD a Lf C <FO.s sl TER TE OI S / II-II (? O A r,lx>FCNON. BQ(2rEErlLJ IOF L . IN El OD uBE ( SPEC I T V0 . :. : ?ellx ,1,,.r xu" Of rFw?CtE5 ? . . OBJECT STRUCK xED ob- brxuCn OWNER OF OBJECTS NAME AND ADDRESS Lo OA -t TIWAY S ER4AObFEC1 x F E $ FEET S W - v? qS ?F?L, ?- 6t1i:?ay?st:B.YS:S?.. FIRST NAME MIDDLE ' DRIVERS LAST NAME FIRST NAME MIDDLE DRIVERS LAST NAME S x 'TREET ADORE ROUTE NO. AND BOY. O. o v a STREET ADDRESS ROUTE NO. AND BO%NO. 1'3,5c ? xE CITY STATE ZIP CODE ORIVERS OCCUPATION CITY STATE ZIP CODE DRIVERS OCCUPATION + C txoxr fox H DRIV EflS IICEt+SE NUMBER ST AT E SE% DATE OF GIFT H AGE DRIVERS LICENSE NUMBER STATE S f DATE OF BIRTH AGE d_•G - ?- wN .,° 9?+E.x ?3 H u D.. YE.x VEHICLE YR. MA E ICHEV: DODGE= MODEL (NOV, T) BODY Si LE 12 Dfl.) VEHICLE YR. MAKE LCHEV: DODGE) MODEL (NOVA-DARn BODY STYLE (2 DR) LICENSE PLATE NO. STATE TRAILER PLATE NO. STATE LICENSE PLATE NO. STATE TRAILER PLATE N0. STATE O VEHICLE IDENTIFICATION NO, 11LS MODELS 8 NEWER) aOOME1ER IMILEAGEr VEHICLE IDENTIFICATION NO. 119:5 MODELS 6 NEYlER) ODOM ETER INIEEAGD F? 5' C{J rid'?'oZG ?1. y ? T-i IRST rn ODLE NAME) DRIVERS LICENSE NO. REGISTERED C:+NEH il< S I DlE NAIAE) DRIVERS LICENSE NO. REGISTERED OWNER (LAET-FIPST IA / f OWNERS ADDRESS 1ST BEET, CITY AND STATE) DAT OF BIRTH OWNERS ADDRESS .(STREET, CITY AND STATE) DAT OF R RTH PART-so F VEHICLE DAMAGED E ?,.?C? r?• ?vAEU rE??it $?ipu.tEO o51L PARTS OF VEHICLE DAMAGED E P41x vlnc • AS THERE AUTOMOBILE LIABILITY INSURANCE YES ? NO LIABILITY INSURANCE INFORMATION-VEHICLE NO. I. COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR NAME AND ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAME OF. LIABILITY INSURANCE COMPANY n4u( s0a"k5b C1+ 5141E Z1R E NT AGENT cTl tl.,E zi" LIABILITY POLICY NUMGER NAME AND ADDRESS OF V:BILITT INSURANCE E AG N ST NJURY AGE 2ND INJURY: GE AME NAME of ,(/G.v e - _._ _ _ . .... "U "'O s s), DORESS AE% DDRESS 'w- m F M _. ..-.. L f Q 0 ks _ E A 7 FOIST ONE T -T PPL ES ti 1 S OF f UREO_ 110K FIRST ONE THAT APPLIES STATUS OF I?SQ 1? v[ L CL[ KILLED L•'?'" "" F3 1111ING rN VEH CLL KILlEO 1 a I•,EV A, max, ND SfiC GER t,a' °; E 1 7? O D, ? 5 60 6? n ":, p;:w l,•: ? 5? DESCRIBE BELOW WHAT HAPPENED'. (REFER TO VEHICLES BY NUMBER) SHOW NORTH BY ARROW IN CIRCLE OC E 0 ' S l GR4M i In_ O \ a V.?Y? d Fo p ?? ' in I- IT I z \t II,If 7511.,. i l i il_i'fY L. CN .Sr Cnt URY .. Y ac _, .L E,o x 11l I 1 l IIJ l ] (]N E J? ,... z,l, L ?, I _ ,, I I l 1 i.1 (7 _ l ] l_J I J 17 ° (7171 1(1 ' . _ . '?(11 URICT1ON TO OIRFf flON_ .• -,11 f f Y ..IE Amc a , r, 1 .f 1 1 I 1 .•. , .. ! .I a T , ,:? T :.„ 5 I I AY r l I i i +T CAD 17 ., n , ? I? .rFl i I I "'t I I?? ) i I J 2 ?. ] 0 f T D ll.U E .". NO ( ii I _ / i p 1: I I J I.1 AA Gli .?r11141LN AI 11 I'T l.': 11 1( K I I I) ,r:'l 11) I A . Ti :r 111 (i ',;i1 I I I 1 .,•., o 1111 i;i if i ] 1 I i RIL(T TWIN I, I i 11 11, I I Ir,'.I :. ,.,rl 1 1 5 1 1 AIIIY .A tG 1 1 5 I.l U, u,N T 11 ,, 11+1 l '.Y Y) I l 'i4 ,,1, I I A I] r l•, I 1 1 A 1 1 1 i7u?„ 17 6 f 1 ID;,MD +.'IJl /I i n.nY (i z I IIJIr ..:'.'t l M1 I] = L.I UI/DI 'll nut FIG I .liD 11 A I I i 11 )Airy ;NAL • r, I I Y I I I .,,f 111 I _ IJrI)' ,D I1?I'I NN,AR:AY I I ? i rl ?•- -Un Vtn1L:Lh GOLLUON REPORT`' NO -?I pArE OFCOLLISON DAY OF COW''" TIME OFCO LISION f ? / 1 / ! C ( xb, d rnUx SAr n01f wurF9 AM [ Lr . COUNTY O. CIfY O _ - 1 ? © P . rlAtgp " ' COUNTY" CiYTO N' •. Ns'E MILES 0® 1 'CITY. TOWN - .• dD E X. TEFFERsDh! ?'` F. s7 0 c"L ©© DF eb O v"1.5E D - ApM CL9 PREFIX rk Og3iR[ET CDUE S 3 ?o/Z 1-0Gm _ GIVENAMEOFSTREET, ROADORHIGH AY ,.5 WTERSECTW6 WITH: STREET OR ROAD ,.. PREFI% EO LEPOSi NUNINI ERIECT /gN LOC1ATIEO-N OAF GyO?LUS(IO7N, 1. H 014A5P GOLF eCLI/VfT ?f [S C1 / 1 1 -?? ? RAMP . DIAGRAM DATA .T? [, I 1 I'U C OErWE[N 1 `/ 1 STREE*lWo. STREET iET • [1LL?? Sr10 tanb cESrwlmsECrmc srrlEEi rl oN Nece n'1 • L:_Y© n3vwc MurrosrdUDrx HAY xA aE n SE pM„ ?u ' K QD St R DI W c ?® GF cHL y CtiASC c-??1= r g ET ? INTER IE EP ED _ r ? KLE lowr aluFCiE ?v[?K:lr rri4w E ?EF?EfCLC - DEP Y oivF? <ES Quo I SPED OOE E ... . _ prA%.causav ?HTHmI [ 06JECT SIRUCK IN•ME C1 7. /ECTSIRUCKI t? DWNFROFOBIECTSNAMEMDADDRESS Dr= cR h1EDi vr?1 SI Z 4 ?? LOCAT IN ROAD ION WAY FEET P DAEV p?FCT ET EDD?E -l In•N DRIVERS UST NAME IF FlgSi NAME MIDDLE rYYD curs DRIVERS LAST NA '- ME HFn w wtvFo •- P IflST NAME MIDDLE F r T [ l 1?l>?'?FA \S J •??L.VI /? f-T . causroN OR STREET ADDAE59 ROUTE NO. MDBONNO. Enlu. TVq 6 TREETADDHES9 S FIE „3 WAJFfR Sr, I--- ROUTE NO. ANp BO%NO. CITY ATE : ZIP CODE DgIVEflSOCCUPAfION c[ MAT[ CITY PC r TL,'NSIEND WA 1-1uusewIFe PEPOLIT?D?RM STATE LPCODE ORIVERT CCCUPATION DRWERS LCENSEHUMBEN, STATE M SEX pATE.FEIRTH AGE M.ERSUCENSENUMBER STATE SE% OATEOF&RM AGE. N-on l as..K?ssD IN ` µ f - 3 ?2 3 yy F Ab D, M Y YEAR YETI CLE YR, MANE ICNEVCODDEI MODELINOVA-0AflTI FODY STYLE(Z ON' VEHICLEYR.. MANE (CNEV: OOOGE) MODEL INOVAOMi) BODYSTYLE(]Ofl.).: 7 L1NC,-CCNTL A1I+RK37 CAjZrlp-T1 - LICENSEPLATENO. STATE ;.-,_ TflMLEHPLATE NO: STATE LICEHSEPLATE NO., ur-1= S'6 VVA - STATE.. TRMLENPLATENO- ,..STATE :., VEHICLEIDENTIFICATIOHNO,;,,.!;?F[BSB MOOELg6NEWERI;_;- ODOMETER(MILEAGEI VEHN:LEIOENTIFICATN)NNO. 11938 MODE448NEWFR) OOMETER (M4EAGE) PEG11T EDOWHEfl (IASTMST?MDOLENAMEI',:• ; DRIVEH.UCENSEN 1. .. REGISTEREDOWNER,,..ILASTFIFIsr-%E NAME), '.. pRIVERS LICENSE NO',-. -rN rviAs Gtl Q A M A'1 -1 1 -6H., * M73M OWNERSAODRE ,.:.,. -„-..., ISTHEET, CITY ANDSTATEI. • DATEOF&RM OWNER SADDHESS ,., ;• 1131 WATER Sr or- ,,w(i. IF. ,; ISrPEET,CrtY MDSTATE),..; MTEOF BIflM; dY Y , o PMTS OF VENICLEOAMAGEO r[DrASi TS OFV EAR ISi NJW NAME ,..... ,,.. ToMI NAME . E .. ADpPE55 .. AA [ EN S? Q F ADDRESS M % FF 13 bNn+Di oocron+ ®? F TArU90P WJU ED A W VENICIE • •., plLEO MMKFWST CNE THATAPPLIES oGAamn xdv pS•IxM [ py "A"T' OFINJURED MMNFlRST ONE THAT APPLIES :. W VEHICLE np[ ? oSY E " . ? ra•x 1• vC My anI I I O rvCFA NILL[D 16EY[I,FI Erc NO YI A p,.':. 1. IL.N ? •50 60 7O nm ? I p iTC j SHOIYNOnTH DY ARROW W CIRCLE 5? 80 rr." . TO Pi Rpxp -_? ... u:rn rICLE90v NUMOEAI . , . - --UFu-ICi_F 'rf.>L?Ur r l7rir? 4A VEHICLES POSITIONS BEFORE COLLISION xDmo fxL3 e YCWCIE ML •xnb Ifnu Y?•u,in V[ix?ir actr[o VL' I N S [ W pI STREET MISGHWAY NAME OFI NO IN STMATEDDY NCINn G vf5 xo ?p• p[ Ql4hitf o ?? o o [?YSrQ ? a o ? ?-1 ?1o ;4t; ' ? ? ? El ? ? ?Srt wY a yy w o r 11 ? ? ? ALONG cnursNO mom DIRECTION to DIRECTION Y 'x MD15-1 WAS1151 +ED IQSIDLWNK ]?WALIVIAY D?TAOULDTR A?[?,Tiwux s?f?nfsrvYN A Y +, J IO4DSlwrACE WLATIUR CONi1N)L LnWFnJVEHN:LE ACTNIN9 ?O1HEn 1.,i N:.IC, uNI LGHTC-.1- TRAf FIC K+'FCNn.h tVPE CF nOAp " .[1Kn ? Yv.cu +KLI Iwi llnrMlf VdKlt } 'TSrTTT [ M I ] IUACK b,1fR AF)n11 © •Hr K.u 1 CAYLNirl/ 01 I ? --S 1 Q MII WAY ?t OOIIN19111MOIIT 1 1 011 ?LNY ] IW[N[L ] 04WN Y A ?] 1?Nfr [] ? ? ] Q:i OP;;.GN ? m &I ] 13 TWO WAY. Q 1 Z Q OVrTNAKNOANDI /.LEAD -SIN0 m 1- ) QYgN1EA) ] Q WSA ? J Q YIELD rXN ? ? ? 3 ? EVrr nlE 3 MAMNDIIIGHT MnfI '? y$ ? 3 ?, E ?r00 1 QOMIi? F/ ? 1 IIAS•1WO nf0 E Itr11C A1N1f A? f; 1 ? N QICY Or HR DARN 9lf fCf ? ? ?1?[Aln, r?ALll, ? A ? MA"HTLT.FT TURN if{4 I.? /? DIr.IR 3?4CIFYl e?l.H'Sol, ? ! ?rLAEN NG -HER Q 6 QALIT.Y ) Q S QMAKWDUIURN rt E l_I s ? 511C1rY A ? 0NIECf 1N:.11S ? A 0 lUl SKNY ? E ? IrW l AY4 't?;'I ^A.'SOn fGn Wl4rNODU1DFR ? ? 3 ? BLOWING Y }?• l vrn.l •y?F dsr.•C rt hVlKr ]?:JrI1U1Y T (j Ww(FF'f,AGMW IA!!i`i f 1 ' 1 I T? )? A- 1 JrMAlfn ? I ? Sr Oil-ED TOR TRAFFIC 13R0,P CLO SG' T I LL? ? A 0OTHF"U'rc,FY ? 0r ? D ?DIOI'rPD?I' NAT, ws ON" ,Z• } Y SC C)Ah[PIC r- •S;C C?12 ........ ? ] ?o.0.D ? R ? n o n INROADw4Y /= npK C ? ?/ Q E Q rn frlo Q 3 Q u avm o ? In ? in4iiiF•? NF {{'.'nr. " PIMP " 5 4 hhI L 1 ; n I £ T? ?T ^3 :Lert'd.. L Rr. ?t EP DL?GItr R F?INDLC S oEnKgW v EN CLE DPMAOED TDsnAE Y X U $ w_-? fY INSURANCE INFORMATION-VEHICLE NO 1- WAS THERE AU OMOULE UAeILFrr WSURMCE ?y-?( COVERAGE IN EFFECT FOR TH19 ACCIDENT Opl YOUR CAR ly YES ?NO IAppq'SS OF UMUTY INSURANCE FOUCY HOLDER : p _ _NAMEOFUASIUTY INSURMCECOMPANY LW AM h1. L,MAS' U rETF r lolon D rA I S'AFECO I Fu A&UttWSUIWICEAGENT - qt _ [w... LIAR UTY77POLOTfl - , 1 ?P s SMM4 NUR AGENCY ?r,iT-wNSENP, WA q9,?,6 I CP 1NUMBEbAlO .. ,. .?.--.. '.:.: .. .. .. :_ ..::... SCE AG ]NDINJURY: IUSE9 EAFPWTFORADgrgNUmANkEL ? ? ,,..-.,.,??, ?......, .. -' ,+ s? § Y TORVEHIC V M O LE COLLISION REPORT NO DATE OF COLLISION .::. DAY OF CO LLISION ...TIME OF COLLISION COUNTY NI , CITY NO COUNT'. - , ?.C Y OR T WN MILES Oa CITY, TOWN / AOMLLS PREFIX x Ox si REET CO / 'ECTION -)? / , OF f YI / ? V O ?Q GIVE NAME OF STREET. gOA00R Hl NNAY-.._.. ..INTERSECTING WITH: STREET OR Ap -. PREFI% EO MILEPOST C 7 O? NON INTERSECTION- CAT( N DF COLLI' ON NETWEEN STREET Al. STREET RAMP DIAGRAM DATA c [x nx W.[. [.o [ ui .° to t E ' xry [ Es x{ c E 1^?\\ w? ? ?/ / L/ n ? S •?V OF ? /1 j C O S W aR NTER CLS [ r .. ? I x / 'D Dvrx; x[x wx .E. SP--d-0- . Y[xL [. IxEP a.N .: .Tx°N °N JECT STRUCK OWNER OF OBJECTS NAME ANO ADDRESS COCA IN ROA 75 -g 7 '0 ° 1 N O n DWAY i I.ux WrucT .. 7 FTnnx FF ° I IVERS(ASTNAME,FIRSTNAME.. '/MIODLE:,• DRIVERSLASTNAME FIRST NAME MIDDLE ADDRESS EEIAO.RESS ROUTENO DBO%NO Y STATE --•-_:.,,;_..+,,. ZIP C00' ORIVERSOCCUPATION Rn`^•rr r CITY STATE. ZIP CODE ..._, ,. .. -............ DRIVERS OCCUPATION_ - 4 4 nrnax . SL CENSENUMBEF ,:_:, STATE EX ., DATEOF.IPTR AGE DRIVERS LICENSE NUMBER STATE SEX DATE OF BIRTH AGE M1t0 AY YEAR O VEHICLE YR. MAKE. Kw v.GOaN. MOOEI IxOVUOUrH BODYSTYLE u00.1. -KLEYA. MAKE cx[v-° - MODEL INOV-1 OODY STYLE. 0x.1 LICENSEPLATEN4 •;;STATE.TRAILER PLATE Hai . ."STATE,:,,- n LICENSEPLATENO. STATE TRAILEFIPLATE N4 STATE, ;;? VEHICLE IOEIrtIFICATIDN NO. ?:j!51E Ewex cU I 0001ETE TI. VEHICLE IDENTIFICATION NO. v°°[u AN r ppOM FaI+uAFEr Sf REGISTER EDOWNEA., IA+xrtu0? : r pglV SLIGENSE NQ ,: gEGISTERED OWNER ;. xn ;Ott y_ , DRrv ERSL CENSE H4 :ii OWNER ADORE ??• SIRlE CT NO STATD -i._v;_I.. . DATE OF DIRT " w OWNERS ADDRESS, ?P„•-,:.M FET, CITY OSTATFI-•; -.., ?. DATE OF BIRTH, - . __. _. . y? y S S 3A6 b Np A EAR PARTSOFVEH1CLE pwuAGEO-..-: ;;;;v,'lu i.lsu.na.. ,..:w.'ti..'loiilMi: n°v r°?rKLF, • Q lL_ FARTSOFVEHICLE,OAMAGED I,.-v; :,., ,,. .....,. a_ ••_+:•.? r0 wTiciF LIABILITY INSURANCE INFORMATION VEHICLE NO WAS THERE AUTO ORILE LIABILITY INSURANCE ?• ? NO COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR' YES N,ME AND AODAE53 OG LIA9ILJTY INSWANCE FOLICY HOLDER ";tt ...:wL«L..w+ STATE ..ZiP f NAME OF LIABILITY INSURANCE COMIANY 11 xE55 CITY .??"•?- .._ .. •'A;: AMEANDAD ESS Of IABIL TY INSURANCE AGENT LJ__. .? STATF 'ZIP- LIABILITY POLICY BER a 5`YAAC?1 P 0 (3c L Ion Q45? ( cA,,v;, ., NT 1ST INJURY".?".:, '.? ??. .. A: .. _• '..:v ?- ..-:-mss .a AGE ,]NOINA1flY (USE ATE REFdIHON?L INA1 !SI AGE- .. ... .._ .. ,. _ .._. _ ..x.l.<.ux ._ AME 1011, 1 _ a00RE33 --- 'SEX' DRESS SEX" F M F A?lq .., STATUSOF INJURED ?w I N VINICLa KILLED MARK FIRST ? [1NE THAT-M. roN v [ I STATUSOF INJURED Q IN VEHICLE MARK FIRST ONE THAT AMLIES U c xa N '; I )J ., eI H- -1 D ? 0evln 50 i?ro 6?nl .r 1 °7?r? 1 N r S a 6 KIL?LED ievr?e. Fu rvox ?u c ?oe. SHOW NORTH BY ARROW IN CIRCLE ro F S \ aPr< °. rP.xr, F..Px? DEYRIDE BELOW WHAT HAPPENED:: (REFER TO VEHICLES BY NUMSERI ??j:- - - - _ . -d3el1J 1 VE A N LES POSITIONS BEFORE COLLISION flncAT# Nv 0 al L :w< vl 0 w L[ [ VE"ICl xla0`0 ONETREET OR IIIGHWAYNAMEOR NO . °'IC"?° ?v10 ?i: ?iu a ? ? ? x IYOUNI ??? ?ioucr ?r'0 i""rE " NI IOT11111 n ? n o ? ? ? ? v- PEOl SYRIAN .?? ?? ALONG.. . CRO FROM . . T--? WING TO ,1..%.; PEOESTr"AN WASUVNG 1...- Z ?x.. ? 6 ? E rx,.. r.;n ROAD SURFACC W! T 1IGNIf•1N0ITION1 t11 CO" 11101 a•rvx I11E.1-13 ONV fRIVEHICLE ACitOHa Ix, I I efIA YL G4T r IF(?011Y )?-AININD I?DAWN ? I ?lIT.IIAIS xwr. ? ?xJx,QONE WAYxv wr ? GG1lGSTRAIGHTANFAD 1 TA rr, ? Y ? STOP 1.rN t J l [] TWOWAY E] Z ?OVFRTAKING AND PASSING + ? Wf T 0 ? SN WI ? NU S U DUSK J r DAH1 SlliffT U 0 ?vITl051CN ? U ? ?(nSIBLC E] 0 ?MAKIND FIGHT T . l F URN _f :1 ? SNIIN A 'i . JDG A ? LI TE tlY IT A f II V ? A ?IIASrHNG 1110 ? A ?IL E ? ?LIAXI)IG LEFT TURN ?FIRAMPI l_1 A ? ICE ] ?"IG v'r ] ( J CT , l1(:III1 OFF ? ??TIA:rI1 r, ? ? L T I?arl.l+r !r) IA IV N AMIICR ALLfY ? 5 ?MA%INRUTURN f ll 5i i„ f.HTS ;? ?1 (SIC VAL `? A ?I[?I fVnV IA4r.S ? A ?SLOWING f ) tlT SF Ar t V I r`" • , : `FI G O IL_? r _,;v t-1 (-)J Fill rl:f La(: ?.InN __ _ - L? )?ST0PPPDF0RtAAFPIC I At SIGNAL "?•_'--•-.-. - L? C?.rl ,?. ?.J I USFPAII•SIfD ? B ?OR DTO 310 L? J ?UIY CID ? V ? STOPPED IN ROADWAY 7 f ? ) ? > ? ?.t Tyr?. tr 111. (-? n..n. n nRTAR N. ?qp 7.RRA1 I _ J+nYp7le? pY T"`- 'Y° ffi eR .!?. J r 1•l Vl (r 17AN -77,77777'w SGLIlLTJ (, "4l - R m r b *` t:4S R 'Y' wSL,? N ? Yn. I? 'T , Y? X7 t t - n" C' - ilk t ? 1 f'. 1 r url LISION REPORT DAY OF 1111510H TIMEOFCOLU ON sux wx ALD n r ., xwq rES vM 'OWN [ou UOgE MIL E4NrO©.l / CITV.10WN.•1??1 ?- Vw r ( i[[uulu' I R OF DL DGC/I/SO'? )ADORHGHWAY INTERSECTING WITH' STREET OR ROAD 2 n _ NO. COUNTY NO CITY NO ?A°`... - 1/ 0xux., AD. C. PREFI% RW(F Gns,ALF, CODE m0`CH ?/ O PRLfI% EO MILEPOST RAMp q GflAM DATA STNEET AND fPA ?O?APOb NON %RDF RE FDf O ff NTew00 AO CLR. PA%POADONSVxG M R ro.x, it NO wrDA•AAA ! (NOR IT -- CIE 0.7 ?O, M(f? 5P[q COCE _ v S,P 0 -I1 ?nOWHER OF ORJECTS NAME AND ADDRESS I LCICAATDIworA+Y ?'RE€T ?N PDGE (O . ( cis pRNER4 L0.tiTN E f. FIR ryryryAAµS l/?f MMf?EE j MIDIXE DUE ;'fYF111,R,ST NAME 1/yL w0 710 ' •- \ -E -3 PND 00%NO ' L ` G b . ROUTE NO. 1 ` •1 •( STREET ADDRESS NOUTE .ANDDO%N0. E1PAN rv.O PEZ• 5 - A u PfO,Y STATE ZI?CODE DRIVERS OCCUPATgN S ZIPCODE ORIYERSOCCUP RON CRY ... .-. ._. 5' re STATE SEx 851E OF gRTH AGE. o f wY Y A STATE SE% DATE OF?IflTN AGE DRIYERSUCENSE NUMDER U?t D v m y ?n DOOYSTYLE120R.) . P J X M- VEHICLE YR. MAME ICNEV 00WE1, MODEL(W-OA ]OEL(NOVA DART) EVOOYSTYLE120FL1 6 o STATE TRNLEfl PLATENO.. STATE NO . TRNLER PLATE NO. STATE UCENSEPLATE ? ! ^? 1 SMODELSANEWERI OOOMETERIMILEE-EI VEHICLE IDENTIFICATION NO. 1958 MODEL56 NEWER(.. DOMETEfl (MILEAGE OD v IJGENSE NO . DRI ERS LKENSE NO. PEGISTEREDOVMEP NUSTFIRST-MIDDLE NAME( DRIVERS AEI E N / ( { , r ,I ?j yG' JC«••' DATE OF gRTHM ET,CITY AND STATE) .. DATE OF gRTN OWNEPS ADDRESS ISTNEET, CITY ANDSTPTE) r i uRDV <E PMTSOF VENICIE DAMAGED ,. :. :.. S I-T ' ?.... iOKPwwVE10.E E URANCE C3 YES ? NO A WA R THIS HIS ACCID ACC1.E E-E R EFFECT FFECT FOR NT HCLE NO. 1• COVEPAGE dI YOUR NAMEOFUA&LRYINSURANCECOMPANY,.._.. .-- CErt CE /POl1CHOL DEfl // S, / •?(l rr»?r6' A1?? IC IVI ?1 ?1'NY I u DEN u e ur Pouc CE AGEIrt s ,f I . 5 Q / /L o/' • Q? 1 ?m AGE f51 ... uu( 2NDIINJURY; AGE lu .. NAME ___?---.-- SE% ADDRESS D - -_ M F 0 0 - . ® ® n MARK FIRST ONE THAT APPLES SOFINJURED T !r• STA U MARKFRST ONE THAT APPLES a.PLyI xONbsAP Pp55PP 0P^ RvEHICLE KILLED SEVUEPEC ?A•uimOx !°O Fi D D I :D IxNPY w Dorf I QO NO 7Ol:cT 0 EPMASU xc ? 50 8? TD c r 6c] 5? i pE RISE DE}? AT HAPPENED (REFER TO YE IC SCq NU RI C S _ Q S .LiJ (GS 5z0 Olt, •f-Y A? \` . ?4111 --112y . _ .? _a n.N Q r b t??eo?v?d T G?r ro a ?l tP l J ' l \ ? _ '? G ., .P.rD wAS wv(snaATED DY euL ` e s IRE COLLISION Iw`o?r?5 xmrc c:u ??. v1HYCm OCar(D ?i:•na ?:o, Fs HO 0 C3 CIT Y W 51 REEr OR HIGHWAY NAME OR NO DAf C C3 ? ? ? ? El ? ?p RECTION TO DIRECT(( rROM 0 °R 5 aiv.D .n.f I ? ypEWALN 2 ? W N.NwAY ] ? SHOULDER A ? crnsswAlK 5 ? nn 1 u 0 ? DINER FROAD p(IN (R/VEHICLE ACIM)NS TYPE ? 2x(CA WI br uDl LIOHTCONCItIONS IflAiiIC COMFKK rCxlCK brU fx ` x E I 1 ? DNE WAY ? 1 ? WING STRNOHT ANCAD ? JCNALS ? t 1 [3 DAYLIOHf ?r /r? OY(RTAKINDANOPASSING - L- TWO WAY U. (t 2?DAWN ? 2 ?STOP SIGN - ? IT TURN R[LI SIOtf ] M-0 RID DUSK C] ] ? YIF,D sr.. ? ] ? ROAD( ? ? b ] RN F? A tJ IGHT ET [D K ?f1 A.111". RED C:) . ?I(ILRCPANO[ ? A ?M AMP( ? 5 ? MAKING U TURN S ON ( Y 5 ? Dgr?i50fi[t ? p ? FIADrnHG AuOER C3 6 C3 ALLEY ? p [3 fAOW1N0 Y I ? 5 ? LLIT IUPH p N[El lrbH'S ? p ? RR MGNAL LANES FOR TRAFFIC MPE D ? 1 ? STO i Ar SIGNA 1 ?OJ'(GiT ? T ? OiFrGLR. ?.. ? 13 R STDSId PEDMf N I p • - I'" ,(nANAIED . O ? p ? D ON- "I'" ?yr/?{- ? ? ( ?GwOED ? 0 ? SIO(PEDMROAOWAY St(.- NO IN IrMrC r7? ?U'IWIOfO ? 10 ?,RN NClA1NE p f-T NO 1 J f(Ir(H ... _... .._ - (1n11•IG Fn-'ru R A M m ly i %lk ) x Y NSA t. N ,.m a 6 z W w ?Yw 613 ?a r N ?? = 1 IT t A 1 ]5 $ ? f]efy 1, 1. L I I Ai oC 5 I NOL 5 1 77 ? L X LISIONi1ME OF,< LLIS p ?12 40 ? C Tr KO s / LS4uNP"wu ?S7Y..T n. waw... JEFFERSON Port Townse + - - sy?? y_..aS.. TT,_•,ow Cl o..Port Townsend wOM• neF o Fr,cn e J L5 ^lor0 ZO E •orov 'GIyE.[MM[OPST,PE,RMAOOR NIaNW ,,?-; ,.::1-TRASECtInG;,wlTtl_STREETi OR NOAny, .., PfleFIK eo wlErosr ' ? C R 8 i"7 Z S i (J D RUN IN teas nowL.ocwnoN aF ICOL -oN BETWEEN \ STREET AND STREET MP 11111A" DATA ww500 ML ?...w [w...lw.. w.Laro[. ww I.rw,,.,,wA ....,. [,. •w,n.[. OO c.r<<. N?R aN IpTE .? ,w[n., .:00 o/o{,n ? M was IwPl ral * vw® -" SaEC. CODE USE n o. vawl<L[s [trot oww swK ' \ OBJECT 6TR .. y, auacT„ I:.Yn4'...I:ei_.iOW"eR'OI„OBJERS;NA»E AND AD E55?eiv -..IN.. _._._.___ .' am x.. AOWAYI :...: MN own w,oe ? FEET b S - . w? ^.? • • o ..• : • . . ;. ?:? O ERS-tAii.[A1NBti=?;?u.-A:....:. P.IgST:. NAME?ii:nw.wtJ.L..- IOOLE w a w ORI RS LASTN ? AME-?..,w?.?,:; f,IP T. NA»E ?:??ns?.,yy?w.?MlpOl?- ?r MASTERS JEFFERY ALLAN l.low ow .w.w,wo A ??w' - ,.3+[avu']" T.!«e"_ ' Eou[a? BTflE AD ?? OUTENO-;ANODO :1C? 16th & Sheridan oL.la?ow LF O OFCUPATIOMS Gy?W BjATE???yjylu ili:DP„000E _ AI GCGUP_ATpIq? 4 P.% Port Townsend WA 8368 COOK •..'.OprV[wSyyLj?QeSC?1{]MO -. 6TA -F_ 5[X NO C O BI TNT - - R YBRSLIKNSe bU "-+--i STAT[ S - p rRTZ, MAsTETA428C6 WA x 2 26 8 1 vw ? -:.lOrny_ppwv ;Mmn_:.I,row...,,Yl .Snlr t . ;:. . V{wKt[ wRG :..1 1 , _. ?rl.%..o;,r sTn?lc?s?.M.L 1966 PONTIAC GTO 2 DR. LKENSfLA_?Np * TE TRAII[lL,ILATE ;v i?`SjATP',?? 1.; LK[MSfi,? - G. 4. ,.. TR L81L PU E? TATCy:.? G'K q3 VE"ICl¢?[NT}RI?, AJIpNp•",4Rpe9_rolasu;,J., titysn OOOMET[M {: YENIG.LtIpENTIF,IGTI n X119 A._roosu_.., w1000MCTEMKrams 92 /7 24 2 I-5 16 1. Ono REa18T_[wi4O•YFNCJ[?-ls!s?E ._ZP!.o?LS' ... _JnS? ^.iy..?WE UCC-. G,[JO-1??_ ?•yLREO13TCACp _NER?I si,ursl ?OArvE '. LICF014C.,,[IQ'^• SAME AS ABOVE OWN[gs_(?oow[ss_E?-..?+nF?+li!.:. t.'v: .. _.^"?Tl?`rr3 i ?.pATC ...:: :__.._ . __. .5`+'Z_a:v"-vSSi1.) .. '_n?± F7_...:.5!a::?+.s? OF PAR'TSiPY'_oo1KtIF] ORpisli'+w*5. ..,?L'N?.`..ELGvu'rfivw4u:" ie ii.?iiVCOi: Figs: ALL OF RIGHT SIDE 5400 00 PM AF_YPIKLGAAMAa[O`...•yw.i?.Aw`.:. -.^ . y: g? .n LIABILITY INSURANCE INFORMATION-VEHICLE NO.I - COVERAGEIN EFFECT FOR MBSwCCIDENT ONYOURCAR ? YES ® NO n w.w..,....woE,,,,ecurrntlwzuogRA[.e[P]eTral?[mc• n.,F '"Film tiElwa?rtvr?.^.wRANCCCarP?.NZ' I . _`!8244!!4oLfs??7P)S!!.FlI.IT£.Wm!rt,.NCE.,c[Fri::YwS'.rl:sm.•3iM1:x»?:C.:4'.ii::, _. *.•x'a,+::I:i e;2.>•.. .,.?e ?.rY..o up. w.. ] OsID6Y •k'.GiY1Ai4h`iy ?8. p11VUR? ,A Yr1 NAME .L j . N-E O IX - _ - DO E55 w ;5a" _ V M __---- CIO ' •;,,• T 7 NYWKLE DLU[sa'4. 1?.'y RlL rlwsr o»ejHAj'wP?L es.g K. KILLED l w I srAru u EO CLR ?V.»MRFIR;Y ONttH TAVKILS" 6?y LEO 1 [ o F o S[Oa IeK^wl o?O.T ? w . i5 El 7 Oc.1 16Q r LL..II El NORTH BY ARROW I" CIRCLE '\ I •.rp. a D 8D6 OW WNAT NA [M[ :?R C TOVEHKLETy,YT.NUM[?•. IJ^+h ... wu»o, rc,sa. w,N wo Iw \ \ wloww. ® nnrsr ow o, .. U5 HiGU-- ?kl u1A5 -fR??l1?LlNG - ••' 1 U ONJ O,R 3$ 1 I, a o .w.•.w .. Aw,ew \ , 1 W?i2VGD - - TO ANS C f ..,. ww., T, _ N1 CQ Ee- -C4?ti1TEl2INC? .Z?t?. V?. ?ttZ I S ON _ T? ? . SOFT -stfDULri"?tR O? Ttt?- r __. k0 R'll k? --------- -------- I VEHICLES POSITIONS BEFORE COLLISION v[Bna•reD Br eLE X10. RTIT OR 10 , El No o No..;-. Geo. ?:auu 0®?? _,,^i ??8.. Ar NA»r tvalw . , ? Y C,,. . ? ?.?'. ? uca ?KO I,•oao.noK .:. . . PEOE?rw wln ? ?? ? Low ,,. ' . c°w a '.:y. .. : ro J ,+ ' .r.. wis13 - ? , ?' 1 c nCa[RTRIA UBINa?. ]?n n w ,orw... ..rw.. f"l Al J?• ?Llc e?o wow. n., l-1 .=%'. PO Dwlw/A4Fj 'a.!TMER..[. ., uc»r cpnano e. rR rrK CONT ROI •mwaas o.Nr rrrco wo O ORNRRIV[NKIL ACTION ?,"- ••a.?•, Lr ] [ ] 1 ' yr Tw r. ow I ¢wrcK ow. oillroerT I ' a • -1 IT I ? SIGNALS • I IJ DAYLIGHT ? ? ONC WAY 1;f 1 ? GOING STRA1G1IT AH[AD 1 as ] r c? ra ? ?s? [• r r ,V ? ? OPY I R.N.N. 3 ? DAWN ? 3 ?_1STOP SIGN tY ? TWO Fug T E] OVERTAKING AND PASSING RS RL[ rl ] ?? LV[T ] SNOwMO ] ? BUSK ?7 ] IJ YIELD 1-N u ] ? kOAD ] C] MA-IN6 RIGHT T.R. L? T c1 [hOW . L? f00 A Cl D T T N CT ? . ? FLwSHINa RED ? . ? ILO OPCIRA»PC ? A ? MAKING LE IT TURN n O 'rr 0 . ? FLASHING AIR- ? 5 ? , ALLEY ? A ? ICE ]? JvIC ,FI 5 ? 5 ? MAKING U•TURM N N ? ] ?Ji rCI n W RR s1aN•L Ej . ? -0 inn. ? A E] -WIN. ?r rr on.] El R ? ?T ?? I f r I.J O CrR/ LAa MAN L-1. R,A-IOR -F--- GANG- T U ?PfCI1Y C I-1 T ? STOPPIO FOR TRAFFIC ?J _ In•r. •rn• ••ow rrH•,•[+.n+• rrc I U O I , C Y A r?I 6EPARAIC. STRD..ZONAL ' - El IT 11 STOPPED IN •AOWA? O G (( ) nE. .._ 1 ] r? UNO VI r ? P I D D CONrnnl. - 1 l--1 P•nKID MJ111T1aN r a, f4 x +? 1 3: t r? ?, ? r cY ai x 1 n? 1 f ?a 4 ^T I 1 V L?` z?ve T?tN Ki... ?ya.• k71' R ` j B ?•n ' Y 3 s wr? t ' ? py i r3 , Pk I l ?A }Yf ???4?r'?2 T IY{? I , r. WS°`I•I I=l. 1 ` c'. t r: a JrGF All • ... 9TOR iR " ,. '?.V iSi'. ?,... Y -. •,. may" •:_._.. >' MO VEHICLE COLLISION REPORT _utYL'YLi-r........_._.du s :una+? NO. 0 TEOFCOWSION DA a E l- YOFCOLU [O In NCH i EOFCOWSION VR ra OW ulES AN COUNTY I ? C-NO. ?wsw ^ FnE '/ ?Zl 2 .? J PM / /? yf? ?'ruNK R COUNTY GTY.TOWN «CwvNTE -JC ;'IyL{1 SOF M roW LES O© (? 1 Ci .?..:'nTOWN T ©© OF P.1l i.'F-( ADMLlS PREFIX /W EOBS1n?Ejfl C00. vE-O/G O SECTION ? CAVENAMEOFSTREEI,ROADOn HIGHWAY AD ? 1ERSECTPiGWTTH.STREETORROM PREFIX EO MILEPOST W HI U NONINTERSECTION LOCATONOF OWSIO BETWEEN STREET ANO STREET RAMP DAGRAMOATA , rWI 5N onE RY KA. vFAUWVBFR BHDO[. At © •n Cigswq MUFVO vi I T- 1G??FEET a® DF R?. pl,,,,L r arm ti, INTER ?;. NON %-RO IN7 GS iF0.5EGWOS,REfl ORIIOAO OR' ?E HE[OCRWeaTAEET aR ROAD' o FGUSAYN INVgVEO ?vl-cse vENOEE OWHKLEIK-E 00THER WRTLI NO. ? L SPEC. CODE USE «v n S 1?= Otu51Or1 ?n,.RUV 0VFHK'E vEMSlww '[?ROrI C OBJECT STRUCK IH,MC OK OBIEGS,R«N OWN EROFOBIECTSNAMEANDAODHESS LOCA IN ROA TION N © wE PI ' M, -T DWAY FEET DNIVERSIASTNAME [FIRST HAME MIDDLE K I ,OtvEO CRIVERSLASTNAME E FAST NAME MIDDLE L-r. ( 15, T : V J -- DR __ STREETADDRESS ROUTENO.ANCBO%NO. uli- - STREET ADDRESS ROUTENO.AN050%NO. H ?, Z2 3 HI_W N„,RED InE A CITY STATE LP CODE IOtihAVw J? tAq3(nx OnIVEpsocCUPATION FS$6,IIJ COw510NE -T CNAI CITY - STATE EIPCODE, DRIVERSOCCUPATION ORIVERSL ENSE NUMBER STATE S" ?F Rt- L v5v7 P+1 VJa X DATEOFBIRTN to y" sD AGE B DRIVENSUCENSENUMCER STATE W. -GATE OF BIRTH p A YEM AGE VEHICLEYR. MAIUEICHEV:DOWEI MODELINOVAGMT). DODYSTYLEamw VEHICLEYR. MAKEICHEV:DODGE) MODELINOVADAITI ,. BODYSTYLEI2DR.) 1.+L FDrll ?b r6l?tn ?D?? LK:ENSEPLATENO. STATE iR--PLATENO . STATE LICENSE PLATE NO. STATE THAILERPLATENO. STATE LtIrP.1-)y W(ti - - VEHK:LEIGENTIFICATIONNO. 011"COELSd NEWER( ODOMETER(MILEA0E1 VEHICLEICENTIFICATIONNO. 111"LIOOELSe NEWER) DOMETER (MILEAGE) REGISTEREDOYINER (LAST-FIRST-PADRIVERSLICENSENO. REGISTEREDOWNER ILAST-FAST-DOLENAME) DRIVERS LICENSE NO. Plr-51- C6--y5l1all OWNEHEAUDRE59 ISiREET,C YANDSTATE) 11111111T. OWNE.ADMESS ISTREET.CRY AND STATE( OATEOF aRTH / w PMTSOF VEHC AGEO ri T PMTS OFVEHICLE DAMAGED av io ,A, u r I 'FI f 1 WAS THERE AUTOMONLE UMIUTY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- COVERAGE W EFFECT FOR THIS ACCIDENT ON YOUR CAR Y,y YES ?NO NAME MD ADDRESS Ov LIABILITY WSURANCEPOLK:Y HOLDER NAME OF LUEJUTY INSURANCE COMPANY ?s E h.-ltt,.-. ?nE'. ?L't'?i tines Z2?a n,'l IP11?kSGo.-1 U1k WESSOFUADUTYWSURANCEAGENT Cnr STATE UMIUTYIGWYNUMBEI NNAEA D A ; , -1 \AS,f C+Ir ,lo U(t?v'e >1 1ST INJURY NAME AGE K 2ND INJURY: IusESFVARME PFPOa, FOR --E. NMAE AGE ADDR ESS SE), F ADDRESS SE,, M 13 © w all- ? e®?DDc KA 5TATUSOF WJUIREO ?pwER INVEIIGLE Qr,S.i LED MAAK FAST OW ENO I]F VFR[I ONE THAT APPLI E/JN WAwM NNOrri1 ES rosYR+E 1 DO OP U 1C STATUSOFINJURED 0__ VENK;LE ?vAssENtFR e KILLED MMKFAS 09,UA&?vq IYVtR EI T ONE THAT APPLIE ON.DISAplep N IrO?I S PoSVrurlE [COu ""T °D ?nDESrn.w ND O ? 5? e? f E 1 TD ?rtuslNM n ? 50 B? 7(3 SHOW NORTH BY ARPOW NGRCLE 1A DESMAE BELOW"IT HMPENED: IREFER TO LENICLES BYNUMDERI A,[w ri.s M1,OaM, ?\ "PCNn.1 NM.LNLD I ER.ee,NeoJnNrHM,RU.[er[ ?" \ .awcY%Iadtc[M.N..I..DIN [';.r:l^ K????"["?? j5/ ... _. ?, ?,. ?-.`_-'-- .,?a.c?P? ._L.?t?'a ?`l'.?A?L-_vJ'u•Sll__?--- -- 1J 1t ? F i ?. VEHICLES POSITIONS BE FO VEHICLE N 5 E W RE COLLISION ON STREET OR HwOHWAY NAME OR NO Mow SANE[ oNt OA[C1ON K1 [01[ r EI,? r1LnE D.ur r.R, 1 rr.R.[DWU ED r.c1[«Dren Ye HO WvSSiIGAr[o Br j."0. 1 No, ? ? ? Q 0 ? ? ? At MI raa[nw ? 13 ? 11 ALD„G cAmR.ID FROM DIRECTION To ..DIRECTION PLDte1TNAN wU UeHp 10 SIDEWKK 2?WKKWAl ]? GHousI t?.so-..,. 5?OTHER u. ROAD SNRFALL KWC.-I WEATHER U(stfICONDT10N0 TRAFTcCOM110t KMC.Ortl VInCU TYPE 01, ROAD NrACIt KnIL.OIt a1NERYVCHICLEACTIOND vEIGI KItD.ONt ORMONI s YE A.Y I b 1 1 10{ -?? ?F?.1 1 {.^.l DAYLIGHT I ? 1 Q 90NM.5 NO 1 2 No, MROrr[I ? 1 QCNE WAY NO I W I Gq 1 ? ODNO STRAIGHT MEAD ? 1 ?CRY 1 Q wNEKI 2 ? DAWN Q 2 ? brOPSrGN ry W 2 ? TWO WAY ? 1 ? OVERTAKING AND PASSING ? 2 ? w" ] ? w No WNO ] Q mu o ] Q YIELD SIGN ? ] ? NOAO Y' EILE ? ] ? MAKNO RIGHT TURN ?]?BNOW A?F00 A?CUAKISONET ? [ ?FLASHsNG RED ? A QNTFFECHANGE ? A ? MAKING LEFT TURN ? t ?ct DRI[R F owl- ? Is"(CMY) pAIIK"TRf CT e ? L[YRe 0F1 ? e ? /lM1[n1G ANGER nAMPI ALLEY' ? IT ? KLE -10 U'TURN ? 5 ? 0a ? lJ eF1 CVY 0 ? 5 l0tURs M11 ? e ? RR eIG11A1 ? IT ? L[n WORN ? E ? SIOWNq R[A10N TOR HOi e([NO DAIFOER K?%UFGMAW M1RA[OIrn11,t r l C Ot [R /?fr(GrY ? / ? plctll.FLAGUM LANE5 ? 1 ? STOWED FOR TRAFFIC 1 , nat \Si fy SCG [h YVn rY :] ? E ?ornu.:rtclrr ? 1 ?SEPMAT[D SIOPPCOAT SONAL ? E ?OR 570r&O, u- . _ ? E Q?I rr ? ] ?aWDIED Q ] ?uy DmSro ? IT ? SIOWEDINROAOWAY ? ID ?°i ui cN6 Nr. - - ? - --r- ? i n • 1 , )M .,S u? r sr ? , y 5 pL,a 0 uE J MOTOR VEHICLE COLLISION REPORT NO:- OAIEOFCOWSM DAY 5 WLUSM TIMEOFCOLUSOS AM W ? D q s LN ,rOr, n,E Al ,... W Yt x -S COUNTY GTYNO. ?s 1 1 1 1, y • ,y 1 PM ?) -`, A A •u 7( COUNTY CII ,TOWN rDU15nE MLE$ O© CITY,IOWN ' 01 ^ ' AgACL$PflEFI% [DRb1AfEl000E SECTION ( ?:7YcrtN.ir o ,c?E `/Z ©® OCw Qr .,I ?WwF41 OF g C•gsE•od . / ??20 3 1 YENA , cI ?d GIVENAME OF STfIEE/T,fR?OI A00R HIGHWAY / {NTERSECTNG WITH: STREET OR ROAD . 0 PflEFI% EO MILEPOST c 'ke _ ON.LO . . OOLUSON NONWTMSECTTI RAMP DIAGRAM MTA / BETWEEN ) rl STREETANO ?/J I } f/ STREET ' IF NO, ©© sl R E rn E Fri R. grupL /G ? 7 o,DCnOSSxa.u l[eoai onlo[xi W,w A NON %RD LI w DainEErox IUAn DR © ® / n E0.5EC,xW ` ` fFET l J•1 LT Y.) INTER iE CLS. ? E O AEFEnE CMSSarnEElOxroAD /E ~ CALUaO YTD ?YE ?K EE -E ?-Rww,Fl / orALxo ?HKHKEEOIU c1 ? Mel orvEHKlc ? ?vExKEE eEDESrn Ax ? - lalusroN pwr 61 SPE C.L D IlSE , -. OBJECT 9TgUCK INA4f VOalECra I C OWNER OFOBIECTS NAME AND ADDRESS -AT IN E" 11E;_ ?® A" T /• /. IN RO AD WAY FEET EPUn EC DRIVERSLARFU/LAE [FIFISTNAME .,B.E M =C X_ DRIVERS LAST NAME • FIRST NAME MIDme tl t7OL . p e •es L- owrHb W " STREET ADDRESS ROUTE NO. ANO BO%NO. flu w C e 3 l3 L? r f I AE Ix iN - °Raao [NE A STREETAEIMESS ROUTENO.ANDBO%NO. GTY STATE LP OODE pNVERSOCCUPATION baP Ap CITY STATE ZIPCODE -ERSOCCUPATION n t 7 d l ?a rF aR ow scJ? c U UHIVER5 LICENSE NUMBER STATE SE% DATEOFSRTH AGE ONVERSUCENSENUMBEFI STATE SEX DATE OF8IRTH AGE p j/ T MD YEAR I VE"ILE;R. MAKEICNEV.DODGEI MODELINpVpDART). BOGY STYLE12 Dn.1. VEHICLE YR. MAKE (CNEV.•DOOGEI MODELITKIVwOART) BOGY STYlE 12 DR.) I 7e De LICENSE PLATE NO STATE TRAILERPLATENO. STATE, LICENSEFLATENO STATE TRAILERPLATENO. STATE I Nh? 7 CE %)) 5 . VEHIOLEIDENTIFIOATION NO. IIDBBMOOELSa NEWER( OOOMETERIMILEAGE) VEHICLEIOENTIFICATKINIEO. l'o"MODELS&NEWER) DDMETER (MILEAGE L .9,. n „2..ZG63If 7 4,1 REGISTEREDOWNER (LAST.FIRST-DDLE NAME). DRNERSUCENSEW. REGLSTEREDOWNER -FIRST MIDpIE NAME( DRIVERSUCENSENO. /t1o It ? a / OWNENSAD ESS ISTREET.CRY ANC 'ATE, DATE OF SflTH OWNERS ADDRESS (STREET,CT'ANDSTATE) GATE OF&RTH 3 Bcr, t. ll•? i" SEW PART50FVEHKLEDAMI EO 79 Ir k " Y A M " t [• PARTS OF VEHICLE OAMAGEp KPAR VNnC 'S _ .• ?? P ? r c-C. !io To LG 9 M ? •N EFFECT hh _ LIABILITY INSURANCEINFORMATION•VEHICLE NO. T- W coVEFIAS VERAC[ THERE N EFFEa &LE FOR LITHIS ACCIDENT ADILTV NANavCY YOUR CAR ?YES ?NO NAME AYDADpHE550FLlABIIIT•F NSURIHCE iVIJCYNOLDEq "AMC OF UABIUfV INSORMIOE COMPANY a""Y NAMEANDADDRE550FUASUfYNSURANCEAGENi rArE p UA.LJTYPOUC'NU..En 'J• 'S cE'DJ 4 ISTNJURY _ Y AGE 2-INJURY: IVSEa[ew,rE A[NnrrDR AtgTK%wt NnlSEal AGE 1 NAME NAME -ED d" - ? tMtxr Dr elAA,[s ?Sw STATUS 0F NIUIED® 1 MARK FIRST ME THAT APPUEB D STATUS OFIWURED ®© MARK FIRST ONE THAT APPLIES ? ? NVEHICLE oe O AON O,s,AVrt .i•WF ? IN VENKLE DSABLIIO Ox -A.- encv u IOLlFO f uun q r ? r,Otµ YKxl NwDF1 r Orin I ? KILLED IEINVENEI ? 150 80 I'OiQ[ICN MeulmwON to Gw ?" •Pon,:1,r ,., ?e D a, w",r, ND ? 50 x e? 7OEre f, r S0-11THBYARROWNGRCLE `\ r r1 DESCRIBE BELOW WHAT HAPPENED: IREFEn TO MEFICLES BY NUMBER) NOU?[OI? MAFAw O ATI'll { > w"""iMM?E1C TMs[ 4? arrow ` ` L,atLI d IDYMKK,w _ I II kti VEHICLES POSITIONS BEFORE COLLISION ND Dr11NU Kwct[ K,«clT rP-D"A N 87GATED BY L - VEHICL[ K „If OCCV[p M [ ?. F _ N ! [ W M STREET OR HIGHWAY NAME On NO yycr? UDUIY a,ANnq u?; re. ! ?I,r'M 0=1 , Y 1 AID ? ??® ? ? ? ?o ? ? ? [ ?-111 In 11 ? ? 113 ? ? ? ? ? ? ?aMwrl ' ? ? ? ? 0.["O uoaw,D rnoM DIRECTION TO DIRECTION I ) L ?f I'[pElTHW wAS US,rEO 1 k xV? ? NMWMK 2 WALnwAY D [ W '/ e ? ? SHOULDER 1 ? m w". ! O ro Y I I Pr`' wp 6lMIACE WEATHER WNTCMGTiGO TRNIK:DDNTROL KsaLK p`r[I TYPE OF ROAD O`IIEItlVER M - EDCie ACrpN! ! OTHER A PJ YKl1[K MI KKAI K,rt[ ?ICe UII KHCU KMCK OxI dILWII r E p u? 0 r W I rK: r rp> WAIT ND IJ ` 1 r y OII Q p1Y I ? rn ? 1 ? DAYIrOHT ? I ? EIDFAL! ? 1 ? ONE WAY 1 ? GONG Iin..IT AHEAD rI „ l,h 4 l1 L ?IIANND )?DAWN ? T ?l,oFSON ® 2 ?TWO WAY ? 2 ? OYEnTAKINO AND PAS ? SNO tYy" ?r s k??: Y 'Ie 2 ?w ] ?FODYANO D ? DUSK ? ) ? YI[lO GrGIE ? O ? P?EV.nSKKE ? J ? MAKWO nqM TURN ? l ?' ,?? r S ? ! ? LW 1 ? 10E1 1 ? LIIGGNI a1 ET ED 1 C) lU- NG RED NTFnCHANDE Z :. 0. ?KE DIr1[R DAR-1R[[i ? 1 ?ROOPIRA4e) ? 1 ? MAKNO LEFT TURN 1 t Y.\ ' DTII[n ! ? ISP[OM1I ! f?f?1I lgNll 011 ? ! ? FLA.,WO A40 (A ? ! ? ADO' ? ! ? MAKNOUTURN JAY r??' A'r Il ? ! ? lKCW ! MD "MI' "IOLgHI! ? ! ? M -AL ? S ? = ILE' wTURN ., ? S ? YOWINO N W?? T ??' „FI IIE Ar /M NOT M[M pAJq[n ? IPRG ? F ? 0IFIC(R•IIAp4AN al F OirIERIY lAN(! ? / ? SIOM'LD FOR TRNIK f- KwILUKO WKw [MrAKraw, (ICI ? ! l?O1HEK. tJ`E GIY ? I ? EEPMAIEO ? ! C] OSTOED AT n&TW SON 3 ifD` _ ? 10 ?l Mf AGIN ' 1 I i •tr`? r Z T r.. ?I ___._ ..-_ _?_ ?-?_lJ f.Wile?.- O ) ?pM1V LJ I_J (3 WAY .. ):,, T'-•9"q?l""::...,I'"?_. 77,77,77, 7L T -7 'TI?M,t Tf, a 'rl. " 1111 ST Cr;, I r 1 ! +?bT' r & . r ?bt,E"a H ?. an 7 i VEHICLE DAMAGE I. INEACH BOX, CIRCLETHENUMBER OFEACH DAMAGED AREA E%AMPLE I INSTRUCTIONS: ]. SHAOEAREA DFSEVEREST IMPgCT ]. DRAWARROWISI TOSHOW PRINCIPAL DIRECTION OF FORCE -n Q1e DAMAGED VEHICLE N O.I .-TNISev4CE FOR SKETCHING DAMAGE TO TRAILERS, DOCCLES, ETC.' DAM AGEDVEHICLE N0 .2 1 ? - 7 ?( 1- ?? ? ( 7 ? ? ? ? I .. Hoed Teoi• - ? ? ?? ?? r _S.IE.e ? ? J ?, V ? J iB T D. a.N ? n ? ' rNGi• l 1 s run4 e. uro...r ]. a.IUrn? SEVEAITYDFDAMAGE VEHICLENOI I [] 0 54BLING DAAIAGE ] OTHER MY. DAMAGE SEVERITY OF DAMAGE: OTHERVEH CLEI 1 D SABLING OA-B I?-+1 OTHER M V OaxaGE SEVEPITYOF DAMAGE. vEN CLENO:]• -..' }n{ OISAIL NG CAMaGE OTNEP M V.OaMwGE ] Q FUNCTIONAL DAMAGE a N MACE ] lJ FUNCTIONAL DAr. G [ L?1 NO 4MaG ! T'[? FUN [ LI NOOAMAGE CTI TOWED BY FST.OAMAGE iONEO BY Si. E DAMAGE ll AMAGE I TOWED BY TO TO S ' TO DIAGRAM OF COLLISION -DRAW ARROW SHOWING NORTH IN CIRCLE .rI RDFDwA ow u u _ „?? ? - - Yfn cus FmuTA ANS .•. e.rznsaN OFF AG[Dwa rearFKCONTHDU ree. D omG I 7 _ ,.. -7 ...: 1..? .. . O _._ ... _ . < n Ns ONUSmv niri sici°tl _ - ?- - snpwven ae rmesTR.N OA' s ? - _. - - _,, - ? oumr.os ncns Ar IMFA<i - '-' - __._ ! L . F Fvo+rrzpcoumDN. _ .. __ .. -. _ ` ? DESCRIPTION OF. I INOICATE WHAT PROBABLY HAPPENED BEFORE. DURING AND AFTER T-ECFASILINCIUDFr IN FORMA T ION NOT ON DIAGRAM. E.C.DRIVER _ COLLISION - ,DISABILITY.PfOU<EO.VISIBiLITV,PEDESTRIAN CLOTHING COLOR. CONSTRUCTION OR PEPAIA WORK. ETC.) - - ?- L.. - - - -- . POSITION VEH. HEADED BEFORE COLLISION 'ILE DIR. - '- - - ON STREET OR HIGHWAY NAME OR NO. x .aP LANES INONE DIAECTION SPE ED S V ICLE LEGALLY Ii PAR ENO I OC C E. NO. S E w INCREASING D.I. .Al.NG PARKED `j U. I L1 I.: _ 1 t-r rl ,--. - YES NO ES O - FED I I.. _ PlDII CYCLIST WAS USING LONG...___ I SIDEWALK __. - CRO33 G _ '- - ]. ED Sf R WALKWAY SHDUl.- CROSSWALK CROSSW N GahleR pldl. eWI _ I .jggA TO KEC 3: OfSG ATEO > ALK ' ICYCLE ROUTE 'OTHER ROAD SURFACE ICNECK ONEI WEATHER ID-KONEI CONTRIBU IC TING CIRCUMSTANCES HECKONEORMOREI -? _ - ongenvVEHIc ACYioNS ?,.., T.aoCE ). O.]vInICLI <?nl -_ DRIVER NO ] DFIVlR b ] DRIVER NO ] 1 RI ER - I NIL ] H `-? DING O1 • TRF IOHT AHEAD 1 . v. /i OPV _._ 1I JCIIA CLOUDY 1OVEACASi. _ . I UNDER INFLUENCE OF L_ ALCOHOL. . ' FOLLOW NG ] 99LLOSE4 _ =^- DISREGARGiO WARN- L 1••1-I??-EIIT 1G vAU1Na AND - W!T ] 1 _R._...R 0 _.- I ] UNDER IN LUE CE Oi .-?_L OF." .-_. ,._ . -" ° b FR CE ER '..1.? _L. e. -? PENTLY AIIIK SLEEP_??? rrj]? RIGHT - BIGHT TURN SHOW ,]H SHDWIM6 ], ?_'_]?' FXCFEDIN63t TED YEEDLIMIT_ J B j ;4IL GTO GNAL - -• I-ROPERPARKRIG III GC TI I I J •+ CL -_.._ 1 OG _ ? _ I E CCFD NG F ... $ . ? 0vE D U N . A -._L GN_ -' E "T IV C IT F!DULL OF ECT - LERTURN I MAKING U-TURN B ° ' . .. '--'1 , DO OTG T OVEH'ILI . - I DS EG GHS :LlTQ-O _ _ 1 ``\\ r ^? I?? SLOWING ?'.I J _. _..._._. OTHER IBPECIr VI .. __. _ _. v OTHER RIICIFVI y_??,-_ IMPp OPFR °- P _-....'. L DISREGARD STOP -'] lIGNISIGNAL _ _ _ .T ' OTHER -C.", NO -'° VIOl4i1pN _ I TP!.I{IC FOR LI CONDITIONS ICHEC KOFII RAFFICCONTRO O v' NICtE TYPE OF ROAD ICH D'3 ECKOHlORMOR! VEHICLE CONDDITION I SOBRIETY I AT SIGNAL FOTFOS M ?I°? ST T IN . 2 VEHICLE ?mom VI NO. ]E i9s I OR S ION O SIGNALS 1 ONL wAY ?_: ASTOP- 1 O 0I]AYN 1•-? D LIGHT . _. ...__...... .. ST4 i ._.i. .{i] i(` WAr TWO ?. _...._ ........... . DEFECTIVE ++.-BRAKE; H.O ABILITY :-.. uFA1RED??.. _ rib STARTING IH _ I-.I •-? TRAFFIC LANE _ ] DAWN ] rlfl0 .31f.Y F - ]' R[VERSIBIE ROAD.. ..... ] OF ECT E -'-.. .... _.. HEAD LIGHTS T, HIOABILITV -..i..HOT IVPAIREO_..._ STARTNO FROM - I••111-• PARKIDPOSITION 1 DUEK A,....• FL45HING REO NTEKCHANa! .. ' F DAMP OO pE1[CTIV[ REAR LIGHTS ] HBO SOIA ETY . , . UN2... ?11]I T MlPGING IlNTFfl IN6 TRAFPICI - a OARK-..E[T _.. LIGHTf ON 'S - ILA! HIND AM./R _._ ._.. ! - ALLEY [ TIRES WORN OR SMOOTH r HAp IIOT ?•??'-. .E E N..INKIAKI • --' ? ' 16 BACKING L__I .. _. DARK-sI.... RK Two WAY-LErr HI LR G CHEM. TES ? ! 46NTf OIF I _., fCNAI ° P.v LANp s On . ] t .... DAA A - N O ° FCIpI L OF EE A I ' R!"GIVER OTH IR IfIE GIYI 1 lIGR Tf 3lP! l ADMAN S UinfR T DIVIDED _ NO DEFECTS .. tlfl A[FUSID , OTRIp ISPICIF YI p ?I• I ` ?]. ? ulmrr !DEG OTHER IsFECIY r TEST RESULTS 2 NvE3lIGArING OFF 11.4N4MI .ILa NA - - ' W.e NO Ol?It OSra•Cnep ..?Cf AHHA'fD AMBV ?:•rC FLOW nIVlD IFl OID Ne0 A ...... r,A! I ? XI ,YV ESrr4a NNG 7r ?ICIR CAAMIARaYK G.f N. L._ ,r Cn .,I LOh T. a?E']F I frONr IUVID Rr DALE `r ?I 1 w..`..,...p.. .sNlgl ".' EI11p ,v;;?• R PA. '''.V.r? d'!1049?' I 7-A `'7b.LW 11 Y+'1 H)rc ' 2 u? ?C z W b P- ' r L? t t ? f (-DA DATE OFCWLISgN •r4 DAYOFCOILI.ION SU -' TWE COUNTY No NO. FNWA i E i ) N ILLS D WED A IIAF S FRB SA * 2 IjSL2 ':?I 0 PBµ ORAL WrviY ROAD ?Cn S- --T O aDM{LS PRE RSTREETCODE SE RON l Q E CIil OR 10WN PREFI% E O. C MILES ? E/ s = T INTERSECTING WITH STREETORROAD LL RAMP MGG .ATA ON Ro ° NON INTERSECTION C CENT G SIPEE RROAD ORREF. 1. !(?? BETWEErv NacN L??GfPEETANp MCCDEE SSSTgEETO'OAO LESI I EW llGG.. J O ! S10NINVOLVEO: ' HICLE VEHICLE ?VEHICLE BICYCLE ?O--IWFItE1 ?HIT&RUN SE'%ERILY COL NO KILLED • TOTALNO VEHICLE OELECT ? VEHICLE RR TRAIN ?STOLEN VEHICLE p"""EO O .; OF VEHICLES ? VEHICLE PEDESTRIAN ?NON COLLISION ?---.0U5 MATEPIAL PROPERTY OS.nIAOE ONLY OBJECT STRUCK INMAE OF OBJECT STRUCK ANOOWNERS NAMEI LOCATION OF OBJECT STRUCK EST. DAMAGE S OF ?F?iDWA FEET ? ? ? ? T RD EDGE S ORIYERSNMIE LAST. FIRST MIDDLE DPI•JER'S NAME LAST FIPSi MIDDIP IIF BICYCUSI OR PEDE 5111"CHECKILI ' R L 1 D L K Cif A N ° EM p n CIS hE? F ' STREET ADDRESS R STREET ADOnE55 ' b a - C3c 6s ST?a2 r- c3a? 33 ?.. NE CRY STATE ZIP CODE PHONE No. E CRY STATE ZIP CODE PHONE NO. -3 cf,-a v i LONE w&? -7k-,S A aft= 13 c?AD •73x y-3,91 N DRIVERS UCENSE NO STATE 5E% DATE OF Blgin N NO. StAiE SEX G -- ATE OF BWTH r• °' 1?I ?m ??c:, C= bi °' S'-? 1 Li ?i ? 13 b DRIVERS OCCUPATION FIRM NAME ONE... 2 CR• RS WCUPATION FIRMN 1 P ?S-µlacv+? • vOCruT A ? I..? - 161{ (+kV--Z S?- 1- al C°OE$ 7 I7' C 55 - "' SEATSELT EJECTION ,. CODES >; I, DI pUSS __ M' SEAT BELT.. ISr EJ'CTION ... _ _ NATUREOF a INJURIES c S , LIRE ••:,UR ES i ROM CE NE BY' TO FaOtOASCEN E B• O VEH.YEAfl MAKEIDOpGE{HEV.1 M(IDELIDARiNOVaI SttLE I2-iT {ONV.1 •.EH. YEA R A 1 KEIDODOE{NEV.1 . L ., MOOELIDAR $TY -COI v E 7`•F ??GC z?cty p l v v _7 G r rit SGx V, VEn. R LIC. TATS tA. SiaiE (RAILER PUTE NO. I STALE E M vEN COLOR UC. PUTE NO. STATE TRAILER PLATE NO. STATE ??+•? L CC l C35s ] w&J C VEH LE (DEN IFICARON NUMBER ODOMETER C VEHICLE IDENnFgail II NUMBER .. ., ODOMETER .... E W1 c?t33SQg99)a D e -ti ??q a I REGISTERED OWNEq-UST FIRST ',. MIDDLE REGISTERED O):rvER-UST . FWST . AUDI : O BZ- OF 'A C.V'? N O _ , I *'1 &t>r<.VYr SClx-L * Y9 ADOR AS OF OWNER • AOpRE55 OF DVINER S(? v' 1? 2 c Q ;L1 - G i Acvw ? NAMEANOADDRESSOF wWHANCECO.ORAGENi AME AND ADDRESSOF 1511ANCE CO.ORAGENT L O SAF?c? HM CITAtNtI NO p 1 ?? ENFORCEA'EIIT ACTION CHAHOE h?""' 1 ?•?? G A NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES y ° s $E% AGE STATUS W A EJECT. `. N AME C A DDRESS F W F P P ROM UU 5CE0 DL ES TO A N AME: N T A S DIDESS uRE F .. T ' uRiE9 SC-,?FT9• R TO NI N AME T A DDRESS N WURIEA sum.-°>C _ To E N S AME _ S & DORESS E N Sr N Aluht „ UaifM1 gF:,'s•S^•"iST I t o C ] .. . E +'. tt L ir•:; ._.. . u,a:. R n0 Ap • N • "III AI OFl1 ?NI EJtCn:i ' • ' O 1 PE fE •a' D t _' I \ : ` JU I 5 OS ,i .JURV yva O NON 9 I •E NOtI WNSIALLEO I NOiUSE ^ NO F.E rED TOT: .•EJCCICO D '. K. . S DiHEq ' vn:nt :'.> S 7 ) (HER RDSINON ?.•J 0 ?/ o ) OE A A C•. I IENDE'.• LURY %D?EDF:HCyF •a, )P055'E.C'.IU11Y ] USED ] UNKNO').'1 & s .. PAa•i_.• EJECTED U•..•.::. •.•P E &p , `,01% I sEAt BELTFAILORE EJEC =: Burt .. '.i M rte, 7 s1 4 YR M i r { rAS v ? • ?• al 7 G 1 y ? l } r ? ' IEE AWLA c rJ_ ' r STATE OF WASHINGTON d10TOR VDHIG D COLLISIODI REPORT NO F C LS Jr,Y K All 7.7 CITY TOWN--- TION -? E E O,F. T 'ET. ROAD OR HIGH W,AV . InTERiECTIN4 11 1": .•TREET OR HOnU O ) LEP yT ' , -{,,? RON 1. 1. ET <'r1oNC ??NOF DLL., oN J/' f 1A •iAY ?_L? IceT?. AT "AIL.1- (sl L-1=7?£tL yJt; I CL z La ,,,,, - r .»?.x° 44 I.TA, N.. 11 ILL ` LIIATIII OD ECT BTq Inn WNE O E n E OAO E 5 'ICI N 777/'77d/ 1 rnrc/ ac?fiLtf/ ???' ICJ non T R ' fir ? 1L?a`J3 l D VERBI.A T 1 we . :: HST HAVE MIDDLE VERS AST NAM. E FIRST E ' - MIDDLE . , ,. „ . X r fr 3' / ' ?{s A: T HO E O AND BOX I'D r i 7_Q, STREET ADDRESS ROUTE N O ROX N ; ? / S//1/Jr[i/1 r7/ _ .°n[r ?lr cj •r? 1/ ,rl N '..:..y STA E ..Z .... DRI ERS OCCUPATION j / . }A lee.t{t/?I Lr?.r? s?lr C D?".f?? CITY: STATE ,- C DE RvFN4,CI000I• N /'fir iu C,r/D /ie(yT?,/[i vERS IC SE UM E 4TA EX 00.T TN AGE DHIVF.R., C N E UM R .,: STATE SIX OF OIRTN DATE AGE -,n_ E ^1• _ DEL nr1 O OY ETYLE IZPA I e»icl¢ Ill. K_ cn eucal MCOEIL? ,BTTLEI>t ENSE PL Ear ii ST E';? TRMLER PLATE. NO, _ STATE .:. LICEN4E PLATE NO. STATE.. RAILER PLAT O. ". STATE." 'HICLE, IOENTIFICAYION.N _;11968:» La R KPwan1 ODOMETERI V L- VEHICLE IDENTIFICATION NO. 11908 none., P HTw OGOM"TE -c-411 RE TEREO O NER O IV S LICENSE NO ua nr°PLa HA ' I REGI TE E N I -r _ , . S ER usr.rrncf.K PRL¢ n,Kal - DR ERS-LICENSE rr; S O I : D E OF jNT._j caJ//?lyl>r 1 L z pVYNIlFIl ADDRESS I n .: O TE F T '. I' I A Afl VENC E A E -. :. ¢ /L Ill/? S [PARTS VEHICLE E .....- ..-. ,I - s ST ERE OB LEL U LIABILITY INSURANCE INFORMATION VEHICLE NO I COVERAGE EFFECT FOR < rD+ro D CAR YES ? NO - MO 55 a 0 I HA O YHO OE ". N CF LIABILIT 1 HANG AIT,: tDw\hli r yAeA? /ni61! /ti r u r?.? .:+r`!t r?Eri? rt • ?/fir' F ??' 511 x??775'??//-/I/?"/?`: E,,. D, D RESS OF LIRBI ITY .RAND ENT. 77 4 . - - - .. --- - --- SEX.. D ..[X ..'.. rl B T U50 INJU EO- 1 F 1ICLE 7 ID .. 771 11['" MARK FIR4T ONE THATAPPLIES a xun n „nU nc ?? G ?N cry[ r LLD {ulx,° I,rv[n[1 '61 l- - LI STATUS F I EO CHICLE 1111 IT . ?. I K,,. L.D MA'PIRST All a[v[nr¢I ? 5 -o+THYA1P1 u^ In' rl I IES , 1 T c.IT G 0 T W I C {ICLE •? 1 I ., E F- UELOW WHAT H PPENED: IR- T EHIC : R N MDE{I .[[non A,nL m .» ow I , ? I ? ^ _ I ~ D nt-• '1 - NC f?'?T? f G''nJ / /? ._.._ ? ----_- • L r _ . r /ov / __. O 17Z. 4, ?1 r__J ?IrTfCtT' >l ' I . ? .. %%/t:l/: Seer/J` 5 n i --l--- 4 --- -------- _- VEHICLES POSITIONS C EFORE COLLISION V LLf 'AUCP W OU elm i I OII rll R7AY NAME OH NO _RNi f-J D O (tom c z ``g ' --- -NVC4TIanicD R ' n°. m ur„x • •:' a? w,uu • ? ONOCK l I ( fil' CJ ?J,•» Cl' . f? rnuran°A.. ? L U I ] f ? P4 r!t ? - - ?`-- _ L l N rq ALONG 'n 1?1 f.] 17 Ll 040IND _ r:Drn, HG II I• Jf..l? 'L.l '_ AI 11 ^tlr DCl° G1 , n?nil q%ACC` A,R i?.rIi CON[?ItlOnS _-CfrrYTw?L I 1 Icv onv-ilP uO?U R vFR%[CHICLEA Oi I•,I J! :NA1. ,. .1 (IAYUON! f I I • > GV ,,;. ( I. I f 1 NE L:] II LI DO NG LTr IDl T AHEAD _ D-FITAKINO AND PAIL-iG { ff? J V\f' W Af _.1 GNOWING f f _f UIIr.K I...? , 1. ) D - .`R .-I t j 11 t1' I_-I ,T f., MAKIND NI.NT 11{RN !+I '• f_1 T. NI'1W Af•.] r0'i a f-I T'rr,?•rl Gi,ii:,? f..l A ! I ILAr.rIIN^ . N,.D (.I • L_I 11 PI,I'CIIA Ue? f .I " f_I n1 AKI NU LCFT r111{N f . I:l I<r ,f7 q1 1,r ra „•1r' C. i • i) Hlr [ ' IT 7 : -N N f l • f l (a f A 1.L LIA1.IN1 11.TNIIN ' J I •• .I .. A. C I ° f:.l 1"] ° f_] AInWNIr: T ;r, iI ' 1 I r1I f a K C1"1 f_l ^ „ 1'l. .h u, r".r^.rv0 !> <, 1 t..1 I:..ry ! 1' 1 1 tr1Ir10/rl A6NM1 lAN[I ° C] / F J .I pl'I.111 !"OR THAFrIC IDNAI __ ' I' i7Y ( i n f I ; . .Ar f:I G f l L I R E ,l :TOHI•ID N ROANWAY CI I1n r a '%r 4Ss't 7t •!r s "" ,: t . .. ,:" .. t ice' F .•. ?f t. I lr, 1 ??II f r ate' . JI• i?l >I L 1 ?.. ?( { E4 E c e u? a? - d Y ?I TT ..SY j0 ?• ES T TO .. _ -, f. Ff .P ?? ,? (C i t ?_ DM-CLL PNfiil# c #na[ SECTION Lx?12ae ? _ ? no.. w ,,,,-„ O E,Nw Off. TNFPT P _ ii ,NIGN A Jl .- ,,._ NTER?ECTING- N-STREET P.F.A. ,. PNEFI% EO -E- .- f ? ? NLrrity " n Nre N wTlo p L GN RS ;' RAMP DIAGRAM DATA +? 11?? // DETWFEN ClAC1? CO U 1-i 41•.C, 1O- STREET AND ?L[, SrREETJ , I-1 x, [[? T [ ' S/; { M.I IJ? ~"" x, »ix», cra oa» • u»ux?xnu cx axloc[. A .R LV R CLS r[»anccoca ? C l L70 _ rs - ? u c.v r o vo - ' •» N rw<w Iwv„FI / ?^ v o [ SPEC. CO E USE O JEC'r, TH -yy'S,yJ•MNCaf?oal TRUCnL;?. ,,..? OWNER Di OBJECTS, NwME.'ANOA D EL ,NLO IN RO -W-H f,? oY., [sT f ADWAY LLJJ aofu 'I n FEET ? Twee.», . , . . DRIVERS TNAMS51$5'"v,.A:..ii:I)R T..N ..,,., .,:,MID LE,,, '.: ;. waxy xvoLwc OPIVERS LAST NA -,FIRST, NAME ':..?. PD E. ?:. Ixr»F .. .ax,._. aLU[,ox ew 'T ANrwo P4 1 r R.Q f? n n{ w»[w.x[ ra E ' STREET 433Jr.T. ^.` •.•. i,:,ffOUTS:N 0.0 HDBO% funao ua[, STRFETJAOOq FSS - - UTE NO. AND BOIL 0. '. ?. o o ioy xa aw o?K Rd ,, CI ...:::Ti[b»o„.•yaw3TAZ -ZIP GOD[ O IVERS,000U ATIOH.? CIT ?? .a_?n....•u „3 TEx.-.- .,,..,,. PCODE DRIVERS. O< V.ATIOrli 4nA k<Nc-1 ?c:^ ar iho tt • v rfiC A .. Are.,oc elR FBRTN .wcE - a7 i -8 i3 [ R - - _ -p AtaT 1?17? 19 R,ece MwxA ) .TR: ,?v OraV_go?wl »eWre[werr BODY STYLA:1 '1 KNr<L[vn: M NE4 Poaa[I M EL '1 pvro,wir. BOGY TYL[•.12s _w., a C h60 TEN ATLNO. ST_AT_63_o-j: yTR.Ut[? [NO?.??ST-_.+.?,k:: LIC_EN_S_E PLAjE,N - _,?- ATC: ? T ILLR I, E. Oy T?_T_2E?',Ej. -C1.0 VEHKCfpD[MTi1ChT10N'.i}O?'?09,pA?,rw[SfSppOw"r DOOM[} #e[ ... - ,._ y[jIKLE•OENT,IF,IG T n N6,i•?tl BbB Data wawiwl ODOM, EAfrrru#ac _ _. . 9§0 1 J '.. 1 ..? STIX[D'OWH[q-_ 4.A T2 T#?•- -'lq[Ijy yyORWCRS LICSN[L •-a-??: [GI-.TCREO OWNER.A.LA+n[II.i: el??aw[/?4DRrvEASFYENSI,.N t OVINEA,S}rOOR16T._.`. •- Ir?t.4mTe TN _ - Ri o Axe 'd PARTSOE.VL)LG[LLD)IW16m*- ?».ID'tiauuTiC,l-'tiFL..;ir_ ax PMTS„OI:-VEHICL[:OAMAG[Py^j; •ww;:y-?,>. r':ct:JM;,;y.'?,y „„c.? a+ .n NK[ K < b-wL rfe 5 d ` 5 LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1 - cove AOOEIN EFFECT FDR TNISACCIDERTONYOUMCAR YES ? NO _ AH[ApORCI[-w?T:JfR1,IN301[MCEKYIKLtOL? 7ffRC n',3),T y wJ 6flva.4.ih.1SkME.O?',LU[ILIT UI[YPANCE,C?M•P_AN15'%: i.' »[ aa A C_(.J'c SaTcr (?TCVr- /or%rau ? ? li 9d?6C/?L¢51fa cciF.? ri7 Co, AMLAND,)i.: J9R.AlC?M1lSY.P.1?IfW[N?4G(M]St??-D ..) _^y ,itDS.M• ?.)"IY:•Y LIAR LI YOLICY )f9EA t d St>: 1 i % 7 ' ? ? 7 ? /Jc P t Y ai . n I?T l Cdv Sz TTCe C.cyn 9J7OY 1O7 7r0 .SaoaY ?? ,y f? ?q??? +.. WY ST NJ Yds'X'. -6J)1+'(NU]L??V ? r.C)"S.w':?•.? M? 1N NJU Ytr 1 W ? AOC? tai x, ES SIX D E 3 M F ?4TU3OI.fUUR[Ov+)!!`•15^?[{[RK[1R54,ONCIHAT AP [ S?1_11,1111 J [ "_I.: d.MAgK dIgSTGNETNATAMLIC$;?y%?+y" 1 N.V[N(GLC KILLED wlxfu[ro N CLC KILLED a [ uni 1[rva,<I 1»Ixo,I,» ff'y? n0 l? rt, » » ._-__. O 1[avcnal I»»onl ? 6? 6? x7O[.c ? 9? 6? 7E] LJ OMTN IfY ARMOwIN CIRCLE 1. T wwrfar.TfstMwr[rSn. ..... r[?? N?+maa O` [aLLIHa».[.,., w,,.Ixa I» I 1 I O RIRL-[ OW VM H P[N[D Iq[ CR?TOV M L[ ?BY?U [ID?1 ' -. •?.. -.... Car. '?,2 We S._ driul'nc? dowc? ?whb? -- Ro?a__t? 1 »...<w a.[.r v,„[La .»a .xaN ? wr, ?? - y r,?a . cnLlL?n t_L>p ? . ?e,'>-, ?' b ' ?? ?? [,w..TaA» »w.. ?. __rp n--Car e • h ._?...Po.3?-Ca.r"?o 1_ I ' o,, hhmA t. my -ri?h? _P?rcrit._ ena? QU?h.Wt:?1'h . Tih ?..?-tFT_-reer .F?-aaber_ s ' - ?t ? t I // f Cc?c- a __ h ar, .? tLA.rr? ...1•c?• ..cLtSF?. L r h l` ' l y a,xax . O_.. r 31 ?nct . (fie .. co11i[1?t1 ?. h{ Car 1..l??rLC?i ..0 c>fld _in thE] __- s= V F. )IICLLS POSITIONS BEF ORE COLLISION »;: r [ Inv[STICAT[O DY IcLC nc D o 1 , IYOU o E ,o w rI F o o. « I 0 [j El X P A fTA A_Q0D? A VM TNI P [U /wG[ LONB i Lq . -S OSSINO.. IAOM. TO -C.w An Ln .ate -? r, .. 4 , wfr r 1 r 1 1 I.J L] ONY )' II AIINO ? NT C<1,IOT, N 1 1110'"r ) DAWN N K TROL. IO•a<a. o-U r' ] lJ7[ Ll .NALa LJ L, bTOP LIGN T CO OAO , D /V[hICL[ CT OIIf. "[ ,{)"f? ' c ] 1 v I ] Ic»r<, a+Tow wunil I j ry wAY i t-] 1? 'o". STPAIONT AHEAD ! TWO \VAY ) ? OVERTAXING AND PARSING '(I l wlT Jn aNOWInO NOW cl_l i0G l 3 • , n DIINN Aiq[ET 0. El ilELn LICH 1 l.] T LJ ?OVi OR SIRI.[ 0 ] r? MAKING IIIONT TURN v L_ '- . CJ L?U? ? U YLASIIING NED nl[RC HA E] El A [] I " ? MANINO LLR Tl1RN IL OOP. RAVPnOF I ? 0 < Ll L ? ILPf CIiv1 / " L 1 f ati Er rl C? f4 rIING A-.'. [_][.,l ALLEY C-1 S r? MAwINO .-I... i.l a c "l r *i rrs ? rl n IUN.L l,] ?iin wunn Cl" ? aI.-N. VONIM Nq [[LINO OwM6[q. T l.] iY 1 ) / f.irl /f I.A4 MAN ??.] ( LAhIS L? T ?, AT11-111 IDR TRAIIIC -.- aiOPPf0 AT f10MA r l a1 PARATfD Cl w ? L OR STD. SIGN r I J ? 0 L (? J 11101-D IN ROADWAY' /7 OYIROLIIf. 1 UND V{OfD ? ' IO? TPAYIIC LAN[ 1) - 1 ? l_J I I ? ,TART O ON PAR Eo roA noN 1 Y ar? ? ' ;d Yam L . Yp a R t r - IrVJI -.-CF; Ar.-CF: 3. DRAW ARROWISI TO SHOW F;RINCIYAL DIRECTION Of FORCE. 1 •- DAMAGED VEHICLE NO, 1 IusE TN iYgcE FUN SKETCHING DAMAGE TD TPAILEH3, MOrOntYCLES,Eic.I DAMAGED VEHICLE X0.2 r U ?y I]. r O'ItlHS nool Ia. T,r,Ae fun 1 0 17. CHIA DAMAGEVEHICLE NO.I SEVERRY OF DAAIAGE OTHEAVEHICLEI EVLRITYOIDAMAGE. OISAbLING AMAGE ] ITRMV DAMAGE ] I OFUN MAGSABL ING pAUAGFE ? ? ; OOTNER MV.AMAI ff-AeLING DAMAGE ] C? OTHER M.V DAMAGE A Fux ERM,V, ' CT CT NO FS EDby • \ T. DAMA E TOWED BY ESiCpAMAGE - TOWED BY '• EST. DAMAGE T_ TO IF 0 f D S T ..DIAGRAM OF COLLISION V. r IB.XL AMOr`Y'`LAIURea._ ORA ARAON NORTH IN CIRCLEING i _AY IF " cpxTRDts jT C- _ - _? '1 1-. ?[ _.? I J T I LL_ I_L r ? O RY TrDN IOrNTD A T -_. I-1I1- 7 V i ?F - R 17 T -- - I : _ ' -.,6-TS " _.. -f ---?'Y- }J 4-?1-? .uT gr.eilii eiFene u.srDn. 1 ... F i 1 _f L ! DESCRIPTION OF COLLISION [INDICATE WHAT OB L F E BEFO E DURING AND AFTER HE 5 INCLUDE INFORMATION NOT ON DIAGRAM ,EG, DRIVER DISABILITY, REDUCED VISIBILITY. PEDESTRIAN CLOTHING COLOR, CONSTRUCTION OR REPAIR WORE, CTCI _?. - - ' -_ .Yl_L t." Fl.. :/? C fG-T t<? _G/ LAG ,•5 ? 7/_.?r. e GJSL "'/? . ? - ?.IL7.-.f S4. !l r' / ??[ )f['f ( i 77Y /.Z 22 IJ4:TSC _%.[Y!!= A. .?S r -?. ti? C?_ ?J__Y?[c1.:? _rr."`y'_ v' J i ; ,r?? i' r C f 6') - - -yi c A, ! mil! .'?/ ? ( / . •! T L -C , T- -` OSITIO HEADlD BEFORE COLLISION M F _ - o OF urres SP EED S . IcLIS FP HKEp O DPOSTECREDRASING Af LIN INCRE ON fTAEETOn HGHWgYNAMEOP NO IN ONEDRECTION p[GAKLY IIED A Sv OCCUPIED a IF L CAL1^ S .1 i_1 Li `L I? 1 LO G SI CRO LIST WAS USIN G. SOEWAL 1 LKWAY I3HOULDE M NK_ Iwn K D G r 1 HADSLI FACE C FCK ONEI DRIVE R WEATHER CHECK DNEI I CONT.- IC OSS IINCCIRCUMSTANCES -ONEORMORE1 WL P C C RDUTF. 0 E K R _,. pRV "E eLE c NO] r: Yf AD ] •?]?? DRY r' C E A CLOUD ?.A.OVEACA1T. DRIVER Y O t ?, UNDER ENC O . ._ALCOHOL oNOE] 1 I FOLLOWING 0 L 'FIVE" i r D S G OEO W n ?II [_, O G j]? G"K AHEAD O A RUHAU4G _. - _. ] DRDGS. ENCEOF -- . 4010 EL=- E fP B E _. 1 EEF LY J O A9SING ]I I l J !NOW l I ?S QY NG ? ? EXCEED G L1.?_Y LI T T? GT 1 9 1 S G - v I \ ? KING NIGHT TURN nA J . I.ll•,.1 ICE '- ^ _i !FOG IA:.. F CEfEO GREAT 3 i YEFD - _ I I'D IMPROPER -LOCATION - ar OF RATING 1 D E l f tEFTTURN NG KI ?a? 161 I OTHER IYEC iYI 6 -r OTHER ISPfCiIYI D 1. HT . O G NTP ?. iOV C E. - I li DISREGARD .?._.,,,L STO 6GO LIGn -_-L? OUII E C E U _ UT PN UEL7 fLOWINO IUMU r ASS NGR P I] SfNFi AHD iTO GNAL OE SEC YI Ian NO OLATIDY _ 7-? OR C I]I i NOITIONS ICHfCR ONEI RAFFICCONTRO IxU.I VEHICLE YENO LE TYPE OF ROAD IND.]' IC NECK ONE OR MORE VEHICLE CONDITION ff x f?C a R E SOBRIETY CN C --. RAFFC ONIGNAL ON TO S • -- 3G L3 ?- ONF Al W f C O. t I??i?4W.r{EDI E K ONEI fHICIL I D.] S P I STOPPEDI N .y? I }? An _!L2_;, o• GN".. ?] \ Two INAY I. _ I .I 6ff ECT VF' ISH 1I HLD AeRIrV 7' j .RO OWAY -I O t ]I D WN .. 11 YIELD ?.. _f IN.. _ . ] I PF E b [ ROAD .- AK93 _ ] „f.FCrIVF l ? 'AIANLD 1 Hen AB 1 A XA TPANT NE I RTINOr110M II I ? ?T 1 W]K EST OAA9- I LAb IINC RID.. 'EAST O r INTf PCHANM° I .. L OOP DAMP _. I ,. 1ADLIGHTS_ I]" "F"CTV[ I .,-REAR LIGHTS r NO1 . REO_?_ I NBO SOBRIETY I _ L_ F?A KED 1.11-hp If 11-] Mk ACING 1EVIIHIN4 LJ rRAFFICI I. 1. 0N - "um E A LE - - - I E N U .!_ ON 5 DOTN HAONOT a[EN." xK NG I-l j b 7 E?CNING o K srR[[r IF LGHOOrr ° n ?, '. SIGNAL 1 Iwo ° T ANf2 T '; ALD ° o I CHEM. TEST NO.J , I- j ° 31X!!1 LIG Tf fFICtRU -.__F GAGMAN f[ AHAIC?r- ..I i'I TESfGV[N - IYLC IFYI TI I OTHER IYICIFYI ° D " 71 DIVIDED -" NOOIFFCTS I I• I ITEST REIUS[D- - I I ILO I nGO rN NAr ` ° "A` IPf to AI ]'; ?• rVID[D O roLICf c 1wlN IY[C?FYI y. TEST RESULTS 2 - . .. I L . 1-11 ILOW I. . ]loo Li AHNrvtu Ao0 n 'AN" ? iwr ,t IoeCI o INt•ISTIG 1 OrF IC[RlN NA EAUG H N S Ir f MI '-• X - A lx V.11 OH 1. 1 AI r IUIIr NOYfU J 1 I I?°A° J I t Y ?• r?? A f .. ..4UFLICATF COPY. LOCAL LAW ENFOICEMENIAGENCY'S COPY-iRIILICATE COIV"INVFSTIGATOR?S'COPY E ? 1 A I FIY m -R ?sq?p?ar 4 L ( L} ; ? - t'c''^.,K "S.I W? ?", =•ry•, r:,'.-. Imo, 'IYQ1""FVr,K?'{'w.' "°71" I .' 4?•. .?• 1 41`I i. 1 ? 1 vI •l I / III - - - F -oX lei ?? D DATE OF COLLISION DAY OF COLLISION LIME COUNTY NO. / CITY NO. FNWP SY''T°' P I, aa " MO DAY YR. D pDfll T I MDY 2 TUIS D WEDA U5 S FRI B SAi -E T J /?J- URBAN RA j I 0 OR STREET CODE S PP F H UiF _ O L SECTION J.¢p? X`. N COUN (Y ? f ( ?STATE ROUTE ?l IL ICOIlN1Y ROAD ?CITV STREET T_ Q LU ADM CL IX • E O O / O I ? E• - Y xa!? ?OTIIERISPECffYI CITY On TOWN W YPEFI% LO MILE PORT f ,fi T 2^r ?n L f'/} N 3 E 1?1IN ?-A 1 MILES ? ? UV OF__.PT- _. __Y-vVN. ?L??__. .. _. .. ROAD LL NA" DIAGRAM D • D O ATA t .,. C t E NO OF STREET OR NIGHWAY INTERSECTING WIIII. STREET OR M O T ON C, NON INIEFiSECT10N ACC D T LATER NON % RD EREtERSECIING STREET OR ROAD OH REF. •'T EET OR POAO ClSN Cf 0 NT 55 ' //II--?? /?1/-?• ?11G i ? . MILEA E /, '•?- A , N ' REST BETWEEN.. STHEETWD _._?-{?." ` CODE ts A DING US E Mx w SP L O C E. D DIRECTION FROM PEfEE-CEORCF-STREET DISTANLEAN „ r _ 1?C > ?T 4 `? lJ S ? ? ? C N •'2? Al OF . FEET VEHICLE BICYCLE OTHERIWH17EI HIT a PUN SEVERITY Y HICLE-VFHICLE ? ? ? ,.. NO NnLEO N INVOLVED r '?Y I Ip. n COLLISIO : M Y[HICLE OBJECT ?VCHICLERRTflAIN ?STOLEN VEHICLE NO NJUREO ( TOTAL NO ? ?PROPERTY°AMAGE ONLY LLISION ?HAZARDOUS MATERIAL N N C ?{' S _ ____ - O O I -J ? VEHICLE PEDESTRIAN ? OFVEHILIFS DAMAGE CT STRUCK E31 F BJ A;? f . O E OBJECTSTRUCK( NAME OF OBJECT STRUCK WDOWNEfls NAME) LOCAi10NO 5 E W ? VL{I@lLlOCCi lL OA i/ll C? 3/ r- ?+ _ ?POADWAY FEET ? ? ? ? HD. EDGE 3 VFyy? 't I DRIVERS NAME-1 FIRST MIDDLE ORNERS NAME USI FIRST MIDDLE IIF BIC Ul l OR PEDESTRIAN CHECKIU t4uS E O r WO ?LA , - - = Otil 11RAF.Li(jA) A R D CL,uF=7nSS d , R GT HEET J? ESS STREET A7 Z3 i?r? ?K IgSz T?2 ?aX 3 r . v . i TY SLATE LP CODE PHONE NO. E CITY STATE ZIP LODE PHONE NO. CI R R T• ?191C7 ES CCJFt. 467_i' . - N DRIVERS UCENEE HO. STALE 4.y IRTH N DRIVERS LICENSE NO. STATE SE% DATE OF BRTH L°1 o. 0 6z V-7, uA. Wt it -A iR o. y'Gd 19 $ ?cI/! V , . DHM? R^SOCCUPATION FIRM NAME PHONE NO. '1 °RIVERSOCLUPATIg, FIRM NAME PHONE... tTl?U? uAeL- CLS• GO'VT•• UL•?' l?A:jV??- _ D CODES >IJI LLA55 '.7.I%I SEAT OELT_, _ISI EJECTION. IHIURV .? NATURE OF NJUR ES F 1 O«. NWj.L?C • FN h ? UR ES NE FROM SCE VEH YEAR Y - TO (DODGE CHEV.I MODELIDARTNOVAI STYLE I2 DR.ZONV.1 M RE Ov[ D FROMSLENE VEH YEM I Yp M EIDODGE CH V.1 O OD LI Ri NOVA( STYLEI2DR-Y.I M • SI' V _ v `? 3 t{EK. V(=-CA Gr-z,)ti v Cr1n u f - E F COLOR LTC. PLATE NO. STATE TRAILER PUTE NO. STATE H YEN, LTC, PUTS NO. SLATE TRAILER PLATE NO.. STATE , C E VEHCLE IOENIIFK:J.IION HUMBER 6 5 - ODOME TER 8i 133 C E VEHICLE IDENi1FICAlIUN NUM P 100 ? CG 15n a A ODOMETEfl 9?6?6 t M E 7 331 I V -7 ST F RST MIDDLE REGISTERED ? ON?N/fE•+R•-LAG1 FIRST •??n ?`? MIDDLE I REGISTERED OWNER-U ADDRESS OF OWNER ADDRESS OF OWNER S2tiLE z N OR AG . `' NWE WDADDRESS OF INSURWGE CO.OR AGENT • lCE CO NAME NlD ApORESSOF INSUR ?' ?J /'?•C?6EZc:S T C -G C S ( ? .tiO.VF • [..o. ? MG . . CHARGE C ITATION NO - ENFORCEMENT CHARGE .. CII ATI NN . ! I T ACTION INJURIES OF PERSONS INVOLVED NAME, ADDRESS & CODES sE% AG E STATUS " 2 ] 1 S EJECT. . C AL KCi. A?? ? NAME: - 1_ M-X _C _ [ 1 ? L . ??.-- ss T'?5 [?_G_v?..J?C A l o tl D AE OVLDf1iOM ?URC Of SLf HE Ov TO f, INJUFnF3 NWE . N $ ADMESS HC MO CD FIIO FNF IfY 2AI a M Sf TO l . o W NAME ? ' , ?• T ADDRESS ?VF?fll M TO NA ,l.. r ? S N Wf0 Sf.F NF fIV Y •i f E NAME ? r er' s . 1, 11 6*ic6srr6r?-- ri nCS HF Nv TO ` p '? S INS(%IUS 121 SLAT POYT pN N.I., CUSS TAI B[AI BEII fl kJk CIK1N 'llI NO NJURV S DSAHUNO INJURY NOI MSTALL[p NOT EJECTED F : C 2 PA35[NOER li USE 210TALLy CJCCi[D NC PFOrSNiTW 2DEADATSCF EID RY 3 USED USCD DPAl1TIALLY 4CCIED I O I HI)IN. ; IC VIDEN111HJU BICYCIlST 3 2 I.OIHCH POSIl10N ]DEADOHAIINVAL IEVI NIi HOSPIfAL TrOSYOLC IHJUHY % E EJ[CIEO S SCA1BELTFAILURT 6 B Ail'OY1C IU'.o.1 .DIED H TiN Ew 6 T C 5 •J 77 A ?? "!'•m*n? VEHICLE DAMAGE I. IN EACH BOxCIRCLE 'HE NUMBER OF EACH DAMAGED AREA. EXAMPLE - INSTRUCTIONS: 2SHADE AREA OF SEVEREST IMPACT. a k. ' S. pRgW gRROW151 TO SHOW PgINCIPAL DIRECTION OF FORCE. O/ ] r "_ k ` I DAMAGED VEHICLE NO. 1. ufE THISSPACE FON SK[TCH NG DAMACE ip rnA LFns,MOronCrcLFS. FTOI .?c1r ', DAMAGED VEHICLE N0.2 P 1 I I Twl ] ' 1. ' k { L" ?' ",.1,'° 1 •.: , i ?r• UM.rwr : I V•' ?? - E 1' '`.?• 1 T. O..NUrn'•p 1 A P PRITY Or pAMAGE VENICaENO.f \ 1 SEVEn Tr OF OaMgGE: IOTNFR VEN CLEI Tv0[OAMgGE VEN LE'N0.]•+ - {..? .I ?• ] L, SABLINC DAMA qGE` ] O OTHER M .V. f O DISABLING D FU AGE ] n V IEO D ]ABL NG paMAGE OTNER M V.OAMAGE FUNCTIONAL c , A ? No DAMnc > El FuncnaxALA.- MacE . ? pT Np DNEAMMACEpAMAGE- TOWED BY ]'p slincT onwL DAMAGE MACE 'n?'.. }( ?. (?I ?, `}...r AGE TOW ED BY F ' Si DAIAOE TO WED AY ?l ° _ SL pAMgGE ] 7TO h-''1 Tr r, c •/ > ODC ' TO 4 z To r i DIAGRAM OF COLLISION ''- I ?- i?_ I 1 - L ,I _:.i jl_? ___ _ 1 I L; +' I r }. DRAW ARROW SHOWING EL, ,??? •.?; f I?iJ????,1 f i I ? I ? NORTH IN CIRCLE L yI I i \ c I. I 1 If ' i:v;E I I -i. 11 ill I/I - ?.2.;° ']. LN-VI-LE. P[ -1111, DNf T W,3 a ]NDNFBB...LEY AFB , I ?, 11 TI 1 1 1 t-? _ 1 r S .?"?' ? z R? A 2r .E°tE,.Ea"toL'L", • N DESCRIPTION OF II-LATE WNwr PRO MJ, r ?COLLISION, DISABILITY. gfpucE BRlrvifD R NccorHNN NO ?? "E °L ElNfonMnon ,°r ON GRAM, .c bglvEq A C.L EOrSTq T O FPAl1 ;OR K.nfTC.I - I I _ . -,.- '.:-RO$ ITION BEFORE COLLISION F NAOFp MILE POST DI o IS...YNAM 'r IJ. ° E° I[P nK ',¢/?P2+J ° SING D,C.EAI.N. IN srneer ?'`I' oN Efno cq EsVEN° s [ neA - I3 ° [I Y I vA OCCUPIED MP [fj E7 0 c R -I-aiSi WAS USING ROAD SURFACE -WEATHER CONTRIDUTFNG CIRC 1 UMSTqN CES ° E. C C EI ECKO EI MFII {.- LEp,L qpt. N0 E l \ .?It \ C {' 1't C p 2vrl°C?]! °YT on[7 ,?.1 I NO ?. Y O., > D Iv A RY ° ] U F INFLUENCE TOLIOWIN I? °t 1 Tq G?'_ANE D: ((--?T ?I ?r GAS ?!?AR _L•J.-_9.L14F51?_- ]u W' cif WET ] I I RA- AININ° rn?]n DAVGS INFLUENCE OF n r? ?1E CENTER n1aI?1 pp E ADP BIG YIR ]I .t ?sNOwINC ? c ° sTAr[p L LTD: _. 7 R LN. EED 1, M? ] •L?IS? R nP q Np_ `.J ° M`A Sa 1Ap _, . I IDG - CfEpING RFAS tr'-I1 _ LEFT TURN { t 6? I ?B 1LNYf[O_--]4 OPF I?BI J °. C EVE I 6 .IIURVTF o Ir O `EANT qqY r O [cA 11 EOU [ OTRFR ISPEGDVI -p-F IivEC I Gd• .-F.,ONF ORM ?frJ °.GA. I lI ?? 5 ?:LO ND r '] L I'BE-1 EO A1Cf 1 ?]? 5 `F L H CONDITIONS RAFF IC CONTRO FH C F TYPE OF ROOD. TnD Fc FO FO cnfcA ONH o ] NICLE y No ] qE VEHICLE C A ONDITION - r' . SOBRIETY •E•.L.y:;:. I-'l ? STOPPED AT SIGNAL [NOCLE I4 xVA7O 1 1NO.i In IEC fl t-_ls f - I F- ! M I ? ONF WAY VIN > OR STEPSI N STEP— I^. TF1917i f'? LIGNI 1? 6Td >I? TWO WAr ..•rl .-C -L V ROfOWA HBDAIRLRY- O 21 I . DAWN t YIELD '{- I]I1' II[v[q SIBI[--' tll C] PAWL Ir I10? T Af FIC LANE n I L+ ]IGN__-L?y?f TI°AO. '?lv? DEf CTIV i5 I OT MBRI F ? AOKENG TO..INH6 ' ?(I . DUf r[wfHING AI? INrtNCNANG D fTn[CT .. Gr.'Ep LpOPHAMf:-. ?? LAII GTS-.1 y .? rI51 I L G r I6 1 AlLfr N TRArFlCI i , 11GNTS WE..? _AM En Lr.?' ? ? - + '1 W S !lT 1 7 -1-:, ---I. 01..5Mpo[e .. vl ornK NG ? e? J1'`/.. I [ t_-`.LID FG r_ `B 1. 61G AL 1 ° l 'r?u°Wi eKD w.,ti _° I pr'.M Np. ] CHEM. TEST f y/ lu pAAK-no s a:.['FEET LIORTS 1 *1 rAC AN ICfAll A k +, f I R.. TN r 1. L: - J TEST u[n ouE FTI R M 71 I __.-__._. ] I D D HO pEf ELTS • 1 11n114sm '1 ;3 r• JJ 1 ? I I LI 4. .. 1 i cm Iv IU[0 "E"'? % TCSTRESULTS -I i ( NvesneA nne pn ¢uss NAME •NaNA" D ATCI ° Y eAnruvrD ti.°: f iIA ". I E• "ANA Eno An E 41 Dn A cc r -D - ]ABO I - N+fD nmirv[u u 7 L i I venw+rlrre 0"leLNS NAM[ J°0 n.UGI NO +GIN<v UNIT 9R0 El.L UATE II.-... f 3 +? pv[u ur lusTE M 1 .il 1 I pISTR ICATE IRUT CIONg OOIGINAICVY. SFNEI TO WASHINGTON STATE I lff L-OLYMPIA,WASIIINGTON ORBM I .k ?-..1 4t.,. ?W H' 'I '1 I I._ ,- ,. DUPLY' IOr:AL lAW CNf OOCI MLNT AGT.NCY'S CDPY-T„IPLICATE COPY; ,NV ESTIfiATOR'^u COPY I f* r I4r _. _._ .._ ...... ......_- _ ._. _.__.-._-_....._. - N^H rig J 1 f ,L ,! C C ft 41 rC,. t ?, r I 1- ,rrl 1Ir ., , H SLi' Q t r IR f;C.'?1 JI 'L 'F ry t4 ?•,? }5 • 8} 1 \ I I y¦ ?i?"f ??'7 ` ..i ? s '""..._LL: -, i nV??..P t?}pp- 1T' I . 1. n EP?+K ? +?, ?p }. J? T ? S i I ,? 1 + )4 ,..'-.,','&,.?:^,? ??:.'•'tt'1?a,??@' .`]s111'C??RF? }I:v 11 1T a '..: 7.• !i?_ RR?FinT/ - y? 1? ?,. CSirs 1 f 1 ; r ,wR?wr,..E. ??W+ I 1 !!! T. ay „N 4 `uE ? i f B 6 Y ? YV NN RA ! kF i i A P ? v F 1 ? t r ?;., yam; ? y S A 1 S DATE OFDCOLLISION Al Yfl W . T I M E SUN YDR S FRI SAT CULT NO.- CITv - LWNT , e ? p pa?R1 ] i 3 ??YEr IU/A G ' V l I J -J / ..? _ JCIURBAN - / - r - Y ?STATE ROUTE I?CWNTY ROAD ?CITYSTREET Q .. RUP AL ADM ClS. pREfl PA iE Oq STPEET CODE b TNJN ?Oi ERISPECIFYI -4- L' '.N b E W IN CITY OR TOWN E ? - W F I% EO LE POST L S 1 ?. ? OFowJ?ss.1 ... . - NOOFSTPEETORMGHWAY Q LL ,- O 4 A r O O i.:--nJ _INTEPSELtINO wItH b1PEEi OR POAO L j, Q RAMP WAGPAM DATA ;. 1 NONINfERS •. Y ,.s OT"• N - - BETW ACL DENT MLE GE ER W %IIB INTERS Ci GSTRE TOR OR flEf- ; I LLS ERENCE q0 RE ApY.T . -. EEN _ STPEEI AND r 'FEET DISTANCE AND DIRECTION FROM REFERENCE OR CNOSS STflEE CODE -. SPEC . 1 W ' ES IO FEET OF !C.L._lV+iiJ!v?-* _ 5 EH C DIND USE f.. - A Y.v?'?? :t I' (r.. ! CO LLISION INVOLVED:- ?VEHICLE-VEHICLE- ? VEHICLE BICYCLE ? THEFT-TEI ?? - DHIT 11UN SEVEFIT', TO TALNO VEHICLEOBJECT E] VEIICLERR TRAIN I?? ?STOLENVEICLE OF VEHICLES VEHICLE-PEDESTRIAN ?NON COLLISION ? NO. NJUIIED -AFIMUSMATERAL y y` ?PROP ERTYD AG L Y OBJECT XINAMEOF OBJELTSTflUCX ANOOWNERb NAME). .?' _:. fN '.: '-' " -LOCATION OF OSIECTSTRUCX fl ? + , , STD E... T ?- DWVEgSN EIAST -.-cWST'.--".. .'-MIDDLE-_ -- ? ROADWAY FEET ? ? FD EDGE b pgNEq'S NAME IA SiF !RST .IOpIE?I!FBH 'YCUSI Oq CnE , . . , _. S .-..21P CUOE:: PHONE NO. V E N OFNERS l1OENSE NO ....:..:. ... :. . bTATE:_ .SEX D ATEOf qtM._:'. N DRNEflb LCENSE NO.: ?; .., .'?-.. ,. .STATE fiE% OF TH s , ' MO DAY ?VR- ?_ DgNERS OCCUPATIpI iNM NAME _...,... ?., .... _: .... PHONE NO. •j' ORNERS IY'CUPATION .:. IIHMNAME :. __. - ,,.-...•„v _P EN IEI CODES > 1]I'WA°sRb? "! SEAT BEL. EJECRON_ CODES > IJI'" °RY S 'A' REOF ' iWUNES ? - " CLA55 BEAT BELT 131 ElECTAJN ATUFE F p F S C,_, JURIES 1 ; A CENE VEH YEM.; BY' JYI U MAXEIDODCECNEV.1..• M TO ELIOARTNOVN .-1 bTYL E I]OR.{DNVJ_, .._ RE MVEO SCENE VEN.YEAR BV MANEIDODGE-CI EVJ ' ... * 3a TO ? i'& MOOEL D T U ,. , „ Ag I .NOVAI ,. STYLE I2ORCONVJ,;,._^,J E . yFM.CW .,UOPLATE NO..•ST.?TE :.. iRNLER PLATENO.: ST TE .... . E vEM.COLOP..,..,-IIC.PUTEINO.:?, MATE .n. TflNIEq PLATENO:: STAT I .+^ ? (,+ VEH lE NTIf ATION NUMBER. - .y pOMETEfl 73,58 (,+ L VE ICLE U)ENTIF CAII:NUlU B R. DO Eieya2LJSY]BC w... E? O ! 9 E STEREO OWNE - i .,...: FW$T, U1DLE ; .I . REGSTEflED OWNER- T .1 - FIflbT_ ..,;_ I ce.w+'.A._.l- M DIXC. 5 ,F f' H ? ` - I ss of ER .. AC?y?p/?? ?? .. Jv f- -_. : vl ODRESS OF OWNERa„.. .vox.?r:.n ,•?-• ., ? ? _ : ? NMI?E)MyID?AD/yOR.E?590FINS RIHCE CO PAGEM ...v .. •I,Je ,, CJN ? A._. ANO ODgESS OF.PISUR LE LO..M GFM L.? r«p•,?, " CRATIONNO. ENFO 'A RC[ EN CTION i .. NAME E i•u I ?; : _ r ADDR RESS & INJURIES OF PERSONSI NVO .: vt : coD[s ] 0 T ri ids 1 LVED ' •r••i ^, ,+, „:• -.•' -, , I ,:-? SEX AGE' STATUS 4 AOORE59' - _ f P IFLU ES REMOVED FROM SCEN ..N . NAME: E DY TO T AODILESS UNEES OfROM FN vE SC . W N AME' E , _ t TO M1 . :. ( t A T oDRESS . 1 +, f * ri "N N P E., uURIFS M vtofn M / SCTNT RY TO • - L ' I IS N AM'. o 1 S A S DDRESe WI .. .. P 1 YfS 131 1113 1]IbLAI POSITrcw J Rd TRY 1 IJ INJUR 'ro ClSP? C ] Y CLASS I ) TAI AT BELT ITIEJECT" I f N Q - OLYC- 1 - ' NO N-' 3 DY:AA 0 NJUR rf ]OCAOAI SCtNC AHplDS NO - NOT W31ALLEO ,NOlINU3 .NOTEJECTED , D 3 DIHF 3 M?,',.• 1 E ! 6 7 t• l - 1 ORN: fI COSH ON . Df ADOHMR AL aVOEHN NJURY. BITS MOiORCYGCi OrcOW NOSPITAL T.'PS WCNJUR e PO vrgN UNXNOwN \ E 3 USto ' UNXNOYIf ! ]TOTALLYEJECTED ] PAnTIALLYLIECTED AUNIIOWN IF J J , 35EAt PELT faLURC EJECTED , Ia 7 4 t +, I ,??' I I IRt 15 77. Ili T(? A Lfi ""'eT *T.•c'nM.x 7f } df r J ry?? `"'•`S'^ G µ,. ,.?g.'. ,..I. IM•' 3 {•?.I ,? ,v?ib'? 1 it 6 I A ,- 1L Ik + 1 r?roY{.L I )). F^ a , N: _AJ a ?A :?,s x . rte. MOTOR VEHICLE COLLISION REPORT NO, DATE OF COLLISION OAY OF COLLISION TIME OF COLLISION tuff w[a IxVP IPI [ NO R , NINES ? AM A CO UI{TYJIO. / / CITY NO. U Z A U ' PM .SGI-r .?'?- /cI ( ? . IC c. COUNTY CITY. TOWN °° MILES ?N ? CITY, TOWN AD?LS wtFl o° cTl 119 ^ GIVE NAME OF STREET, ROAD OR HIGHWAY INTELISECTING WITH: STREET'OR ROAD PREFIX EO MILEPOST 12 1'- NON OF COLLISION BETWEEN STREET AND STREET RAMP DIAGRAM DATA ` ?lIfl a saasa::raa.^ella.a;,a:^a,.,rva,ouxaMxAAN .... ..laaa. ` vw J ...,. [F ra i ? ©OF ? C0,7 PV 7i- v[Nlcu.vnwrcL[ ,xaw rwwR[I / ,a,AL now rxva`v[o ??c 9ro[atwr.x ......,ui.L[ 0 1J xO SPEC. O E USE I:;: OWNER OF OBJECTS NAME AND ADDRESS LOCATION G ?E OBJECT STRUCK Fa¢J[CT STRUCK) e IN ROADWAY o [[' FAIR uu[ P[ uli7 ?? n i S DRIVERS LAST NAME. FIRST NAME. MIDDLE. r ° DRIVERS LAST NAME FIRSTNAME MIDDLE EET ADDRESS ROUTE NO. ANO BO%NO. T S R " " w STREET ADDRESS ROUTE NO. AND BOX NO.,. J y[ / ^ ? ` CITY %TE .ZIP CODE Rrvc Ano CITY _ STATE ... ZIP CODE uv[RS «CUwwTlon /cW E? -L TE SEX DATE OF BIRTH AGE ER• S T A __ N B ORI VEp S LIC DRIVERS LICENSE NUMBER STATE SEX DATE OF BIRTH AGE -J / J ? ` ` , C(J ?J? XSOV J ??IYA yv/X, H F M p ?Q M F .. I w v cnl<L[ vR. MAKE ICf16v,•ODDO[) MODEL INavw-owwil BODY STYLE I2 ORJ rcLC YR MAKE --* oooau MODEL'. (NOVA-DART) BODY STYLE 12 DR-' vcN ATE NO. ?. „STATE TRAILER PLATE NO.: STATE LICENSE PL . STATE TRAILER PLATE,NO. STATE LICENSEPLATENO. .. ... / .=f / ZlrI 1 VEHICLE IDENTIFICATION NO.. 1 Iaa[ MODELS [ H[W[RI COM[TCprw.uail VEHICLE.IDENTIFICATION - N0.119FC MODELS ancweu OOM[T8111M+LUa[I / - ,yam CLZo 703 ICENfiE NO. REGISTERlOOWNER._`IWI JI [MwMU .:,DRIVERS L ERS.LICENSENO?_. REGiSTEREDOWNER:., ILAt_ T-a?loocc- M¢I, :. Pony J ?G? / v ?? YSa4 OWNERSA O E55,.;,aye.-STRFET..GT:YAMO STATES°yp?, ?:DAiE OF B1iCTM )STREET-.,QTY AND; STATE OWNHRBAODRE55 +y,..y - N.x? OAD OTrBIR.TH PARTS FVEHICLE OAfTAGH01wr. Law.. _!;l{a;[.:.,4 nocaaT. a ," Ta[ IA r[weL[; pARTSOF VBHICLE.DAMAGBD •"'- `j ::(5: :.._:.,ir.. ..A[[a WaT ?.. T¢RnAlRv[KIGt .• ` . " ~ . % I? . . Iy 5 1 IF ICE 1I `E ? ?5 E LIABILITY INSURANCE IN FORMATION-VEHICLE NO.1-CWJAGRE€NV EFPECTIFONjT.NIL5l ACCIIDEIiTAON YOUR CAR ?YES?N0 NAME AND AOORF_SSOP:LSABILITTINSURANCE. POLICf,NOLOER c?:.:?. :s<HAMEOF LMBILITY,INSURANCH.COMPANYy '; ' . 21P NAME AODq ES CITY A, STATE ? Nl i r? NAMEANOADDRESS"OP ;LIABILSTYINSURANC6 AGlNi CITY STATE. ,;,• LP'; 'LIABILITY POLICYNUMOER ';r,.;: "+rr,r"'r•; /e Taw ?sLFi/O cvN q,934_X 211 37r8 ss" oa 1ST INJURY ::, _ ,I .I:?r. .... ... ..... .. ... AGE. 2NO INJURY )USE SEPARATE REPORT FOR ADDITIONAL INJURIES). AGE NAME TOTAL NAME . S SE% S / r^+v ADDRESS -, M ADDRE M .alu.[.xO ... 0 O .. :.......... ?.. ? [RMI or r "ra+r or rx,u.r H . oo<,O,t ... .. c,a.a .rO ?xx LJ , ? Q", Y1 • •, I x IN1UtID '. STATUS OI A n FIRST ONE THAT AIFLI lS .. STATUS OF INIUElD AURK FIRST ONE THAT AIK RS ... ? ° a[, IN VRNIQ.! ILLE D ++[ 0xa • IN n °+,a. Ivru. ? .r + xn.a r?rv. I,o,l rof")f?nl[ ,xitiC CO IT ?°+I IN VlNI[LE a+ xal. O ?ILLEE o, Muir rt ?vMU In uAi[ I. • Ino) F r?l}I[ [. r<On1)icxT rloF I ? x No Halu,la O Q S B ? , ' °17. °NnL, N° .. ? S ? 6 ? 7 ? O ? SHOW NORTH BY ARROW IN CIRCLE DESCRIBE, BELOW, WHAT'HAPPENEOI (REFER TO VEHICLES BY NUMBER) 7 IA/v p66,P ri`rA f[/c c X it Al I ITT. 1.10 o. oo?fl°x r»wu..M.riy°o^ C,/?oIf,EO /fnM?/7//¢-iG`L?/K f/?c^?? ° :fi Of (//iN/GL? h/d, / FC2t /.?? //. AC. Y u1 A.a S.Dw 01 i.; IL o.ITT'.. .RDR. GOLL/J/Oi?. /?oTiY O,sG4 w6f ?`-7,4OPu? ,T1I[1OR11GHWA1 o/v Co [ir /i Y 1?AE•tr?w"ar /ni?ca.Yr j -,1 ir¢J VEHICLES POSITIONS BEFORE COLLISION HEADED ON STREET OR HIGHWAY NAME OR NO oL[[[ n x I v IFcl. ARxao w,[ ' t o<CUFr[o ' [, I .N S65TI0ATED BY ? .^ ? FoL . ?q VEHICLE rOIVOUA1 ao a a I CTIDN D / O ,O Q ? ? io r p ,y?w° rwvgnool j1OTNERI ? ? ? ? ? ? ^ 1 at TO IEOCSTRIAN ? ? ? ? ALONG GA06SIN0 FROM PEDESTRIAN WAS USING 1 2 ? w . G ? ax0 . S ^^?? L OTnf--^ ROAD SURFACE WEATHER LIO[ITCONOIYIONS TRAFFIC CONTROL U CNGritr TYPE OF ROAD COAIVCR/VEHICLE ACTIONS MORII [ va Nl lIT ¢R[Cx axa OR C O WxrLL[ v(NICL[ r< w ? p? vl CIt ONO 1 L [{°:^ 1 ? OAILIG HT a ? 1 ?°SIG NALS ? 1 C] ONE WAY tr (• 1 N? GOING STRAIGHT AHEAD 't^a tI I ? OHV 2 ?RAIN G 2 ? DAWN ,f-,< ? ] ? SiOP SIGN JZ t ? TWO WAY ? 2 ? OVERTAKING AND PASSING ? 2 ? WEI 5 ?SNOWING G ? DUSK ? 5 ? YIELD SIGN ? 5 ? PEVc A, LE ? S ? MAKING RIGHT TURN EET O K SiA ? D ? SNOW I A ?OOTo A ? OGH, S I' C3 A C] Fl A5NIN0 -0 ? A ?:t wr..A.°• C] A E3 -.NO LOFT TURN F C3 5 E] MAKING U-TURN ?? A G ICE 15 ? SPC CIFY ? LIGHTS OFF ? 5 ? FLASHING AMHEA ? 5 ? ALLEY ?S C::.i ..' Ap"i" ?A?RIISGNAL ?6 E) r,,.ra•Nfa ?A?SLOWIIIG •, IC ; +O' '[T n6 o; r.4I.N ) C3 SPftllY T C3 OFFICER/ rLAOMAN C3 T ? STOPPED FOR TRAFFIC ' • //? C3 E ? OPEC FY SEPARATED ? A ? a. aawAL OA a,ora J?2 OOV OfD ?D?STOPP[D IN ROADWAY ° 1 f Y I`1,I1 1 ': f xxr? t• t E 1•I TE?I.1 J t 1 ;d`? 6 N raak +x a x' d _', .11 , ,""tI,ra,. -, Al_- _'_-'A L 1,14 _ _ .Idirfb?Sw,. .'- ._-&,4s?,_ s-- Z-Ak. --- MOTOR VEHICLE COLLISION REPORT NO. D DATE OF COLLISION Mo ,. v `` I AY Of o I L 5 ON TIME OF COLD SION , a ~ r COUNTY CITY NO. ' ' ,. // ,r -? /%?3?- +?/ }1 ? ??sM l_L•l. u-?s T • ?. T 0 X COU TY CITY, TOWN orE_'.1,TE FFL ASIA: ?'/?CrL[[S:A/l I ?l^o a r MILE5 IN E CITY OWN [N OF ?r 7/I !'iT?C,- /? ADM CLS PREFI% -R .:,[ 1[O - Cr„irCN GIVE NArAE OF STREET, ROAD OR HIGHWAY I ETFSECTING WITH STREET OR ROAD PREFI% EO MILEPOST r ,., /r NON INTERSECT10N•LOCATION OF COLLIS ON / RAMP DIAGRAM DATA . I BETWEEN `r.....- STREET AND STREET uii[rtiivsurx+fntririi?w r?ous[NU tR. uRU+GE. T (_J ?E p,uuo•DCx4?slu4 rive i•ucV•un vN Ea % 4+rxE[1 x-oV '. NON6RO ?ttr0 . L-,1 Rstclo r OF INTER I T I.S. ? G sou vvoD r' --'I V` v[ ?m ,x n.rN: I ; Gt ° ? + SPEC. CODE USE • v[ c •ts p x[ fro C.. > _ OBJECT STRUCK IuaM[ or axr[CI LTAUCU OWNER OF OBJECTS NAME AND ADDRESS LOCA R (? ? TION l"N LJ [ LxaM orarE w IN O WAY FEET S V/ A o $ q? ^?9 w E DRIVERS UST NAME FIRST NAME MIDDLE [P DRIVERS EAST NAME FIRST uJ ME MIDDLE /it- ,T6s6: PC T/ Al: STREET ADDRESS ROUTE NO. AND BOX NO. I+'o wEU[ TTREET ADDRESS ROUTE NO. AND BO% NO. [? E CITY STATE 21P CODE OFIVERS OCCUPATION c4:us oN CITY STATE.. 21P CODE PPIV EHS OCCUPATION ' c • rc.• ?5/ . %s'3 ff oust 4,, '_ txox TroA DRIVERS LICENSE NUMBER STATE SE% DATE OF BIRTH AGE DRIVERS LICENSE NUMBER STATE S DATE OF BIRTH AGE r- =_ P S n .Hsu M x z yR 3G R E• VEHICLE YR. MODEL (NOVA-DART) *DODGE)' BODY STYLE (2 DR.) VEHICLE VR. MANE ICHEV:DODGE) MODEL (NOVA DART) BODY STYLE 12 OR.) -73 I Y/?A_ PV_tct WA-6 ell LICENSE PV•TE NO. STATE TRAILER PLATE NO. r STATE LICENSE PLATE NO. STATE TRAILER PLATE N0. STATE T 5 s'7 y VEHICLE IDENTIFICATION NO. I— MODELS 6 NEWER) GDOMETER (MILEAGEr VEHICLE IDENTIFICATION NO. (1958 MODELS 8 NEWER) ODOMETER IMNEAGEI 35- s 7 'rte rs_r,- 7T 7/6: V REGISTERED OWNER (LASYF RST-M DDLE NAME) DRIVERS LICENSE NO. REGISTERED OWNER (LAST-FIRST MIDDLE NAME) DRIVERS LICENSE NO. J.yf/rJ'r SR F,r/i_r OYINERS ADD 11IFEE1, CITY AND STATE) SS DAT OF BIRTH OWNERS ADDRESS (STREET, CITY AND STATE) DAT OF B RTH RE ; 3 23?w i _ / aY'acA'7 :C/1 2 ? PARTS OF VEHICLE DAMAGED oFv[?e [ nio PARTS OF VEHICLE DAMAGED - e • R v[ne $o 'WAS THERE AUTOMOBILE LIABILITY INSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1• COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES -? NO NAME AND AODRE54i OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPANY ?cl3 L=PT A. N/-'/%A-`SP ?7'[i /?cJ/3'1 NAME AND ADDRESS OF LIABILITY INSURANCE AGENT c+*T sT,IE vu UABILITY POLICY !UMBER _ cd-n'%? I' i?Jn /o£ T .z;;? c ?!ar e« 1.3 -c2 2 l ISTINJURY AC a . 2ND INJURY: ?`., ar • • [+.,LUr rc -u•+++.up ES AGE N ME 101aL NAME ADDRESS SEX ADDRESS SEX M F G L ..._ _. L ___ ... I / I Es . . x. E r L n. -? ST AT .$ OF !V?F? M PK FIRST ONE THAT PP ES I t STATUS OF I J ED MARK FIRST ONE THAT APPLIED rs n4 o E4 v0 V Fj E IN Vc HIC E J ER I N IEHrCLE LI ivrlUn •+yi4H i?M ?R R J KILLED vp P 5'E OL KILLED .:EV uL E G! _ t °Ur7 E b NO Or? E [ 111___0 ??..JJ LD 6 s? 6? ? ?5? O ^ O I]. . SHOW NORTH BY ARROW IN CIRCLE DESCRIBE BELOW WHAT HAPPENED: (REFER TO VEHICLES BY NUMBER) INO Ca1E0 D GP N.9 _.-LgrL:.f?._.. ... _,S 1'_ .. __ __...._...__ _....- __. .. _. .. _._._.._ V //1f 1.1 :F151 IJ :J1 GI E CQ(l I"N +: n -L.tIO i[O 9Y o 5 0 [M1 ,0[ou LJG Itt 'lE S E v C S 1 ir 1 rG NO .1 N I C ? CI [? o I ] n r? R' I ]c7[ ]I ]I ____ ].J I:] . I l _L1. _11_0 . Fat .:__ I ,.' rN [ .1 I_..I I.1 I..J .a •? •'° .; .,, FHOLI DIRECTION TO DIRECTION ?jj _ ..... ....... ' `^. i I i Lr-+•IL. I,Gr.S I,,;rY CL :'YF Or p D,1 VL 1?L HI;;I.E ACIICN t ` I 'f 1' 111] '..nE I I 11-IL AY I1?] 1 [ J f:0',1 . i fAp J ! . a A- I 1 [ ] [ I•,1, : 1 11 :;N 17 + I ] I• 1 } I ] T .Er AY I ] 2 [ ] p t I A I !,-m _ l 121 .]I••IT ,[ 1. ,.,:; ,1 11 % I ] ., ] , .'I [ J J Ll nip ' ` I a ? I J „A• GRGH, ( ( JJI...J G•'FJ'Y 1[,11.3 FI 1 OMLT I ] F I ] I.'.Aa NO L 11 r t Ullf! [ I , I I if ,D I ] ( ] I 1 lt . .. 11 i .. r A.11T 1 rCE v1...1 OIII'Y 1A 1. 1I ] DA Ii OIiT I ] S I 1 'r .r. Ar'JLII I ] S [? ] 5 [, 1,'Ar.Ir:R UIIIIIN , 41 LEY [ ! ,. . , 1 I1SI]LN M1I1tlYI.IOIf.Ili3 I] I1 I_]M1I])1.11[116nr1 a:'1 ;'I:l. Ir'IN !I J '. ,?fY I J I I 1 fl'Ir f,V aN IAf11S f'1 ! 1..1 I JJ :IUP• 10 YOII EIIAt /IC ., • • +' r I- ] E I. ] .. _.... I .1 I J !'1GI.01 O AT RI[, 1lAL ' - .. •I I'?+('IIY I ? I I , . • •:. • ] `.I I"_TfR ? ,i ' t Ol+t [:N . , ' 1 1 1 J I I I"111 11 D 1 1 GlrJ 1'IDIIl N; AGIYAY .t. rr! ,. Ir. 1 11 1 I ? E?vY ? y .?«': T? t a'.-: r,L7'• , ,.. 7' , r! _ ?Yr 1' r+'v S ,.+'r {tixFl?f 1. 7t . C4kC w r 'ItI IT 1:: - NyA" 0 Mr l MOTOR VEHICLE COLLISION REPORT - NO. pw as <a4 SION - o c° uz t •• oun I CITY "I AV zE ON 0 ooa PREFIX ION 1 n+. ,,,.,,,.GKarJ._•sNISgE eET„RawooR_rywe.wwX -;,IN>;cns c wnH r_gET.. N e.D,-. PREFIx Eo MILEPOar /, 'Ai O OF C9El SIGN N1111 C TI ON• RAMP DIAGRAM DATA - / -( tl O N /f' /5 / /'fL ??Il STREET ANO C ' ?L' /% ? < CC'/ - Y ? w uxioL P? P i OQE nili a cw x NCi [e [,r. n i.e uw/rcjpv.=•wx:. [a N%%er', l r,`!,' rd.t': o9a wr':r'YO/%9F Su.?,r9 l ER ? q GLS. n r " =r" ?7 mow w ::?ZZ[O[O d- n IwwN[I -Ya' L(r/ y/y cr - u w -`•PEC. O USf v asrw L n ?; LOG ADDRL „o '.. -.' in .,: y;y Y' 'OWN[R?OR;GBJECTS NA E. Np CT:?T!S4!G -:;:" © o ? , . . ... , . R '- ' [AIR. WAY; " r., fl"!; J?/ca?h<?77c i0 / 7/ 1- ,)47 /'rNl s w ? a ? ? YER3.f.?5?'NM1Q<,??'y..l.?jlg3.'[:N .:,,,_:.,. ?y_.•..35 MIOOLEf' a xF RST.; DRIVERS LAST NAME.:; _ NAM--, i/ i ? 7" T f Fr• T L F? 5 rwY . w[w[ 1TRE .`_•. ?? ?`R. -YL... ., .wNO SOX',MO. • :ANO.eD+G,y° ST-REET.A DRESS/?„n.... . ,. I i?1 ? Fn i31/ ?± .Pwrlaw w[ -,' yF "+A•,. ;AGE NIV, :R000pATIO"_ CITY ST TE -"' , , -L.T7P CODE ORN[RS:000U4ATI0!C: B!T^-;3' STvS EY 40ATE RTIV' yfG-g: o - 0 ,ER34CENSE NUMBER ,?y?y+ STATL 'SEJ[ - +O TE'Oa^BIRTN; ,?G?.a - r. ?•iJ?rl'.A, :77 y eM.?!xI =c, r[? 3Fi t,:. 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OflVfASCESE NUMBER STATE SEX MTEOF &RTN- GE' CN-1ZJ SD L J1 K War -IF 3 ," a 7L : . A ° VEHICLE YR: MAKEId1ESr.-0ODOO ?. MOOELINOVMDAR0- SOOYSME17dLY .. V ENIQEYR. MANEICHEV.-0000EI.... MDDELINGVA-0ARR DODITSTYLE17DR.I 1Q7/ DdDcr POLAFZA 2-0k. LICENSEPUTENO:? iee:SLATE_.,.? .: TRNLERPUTEND.: ..-. STATE.;w;• .. .-MLFTLY-iXATEN0.-:. :._,: SLATE.:..:. ::TflAXEFi PLATENO. .:.. :.;.SLATE ' : .. :. . . ., ` YFNIGEIOEtITV1CATgNNd.::.Vw.: /19aBMOOEL46 NEWERI .. ,.. OOOMETEPIMXEAOE) : VEMILTEXIFlTTIFiCAIgNNO..?...:.11DBB MOOEI9[NEWEAL ?.w. IMAFAGE //Cpf Y ?Q " , NEOISTEREDOWNER.a..._6:L4T?FAST;RII?OIEtwA4:..:.:.._i_.ORWEASUCENSENO_-_...... PEGWTEPEDOWNER .-... MST-FpiSi#IgOtENM1E) -.-?-:'. .` IXCVFASUCFNBENd.'?..:.. C-14glSV, DONALD L NN RisD ?q]a . OWN .... ,wtsrr+EET,. -_duYOSr?Tq DAREorewrN .:: - =:IS' :. T OYnvERSAD0RF58 .,....,. ,-,.ISrPEErorrAwsrwtEl,:Y..: P „,DATEweY1TN ?, 76.13 YG - u 5 i e 8 w "AN DAY nlwrsorvEFaEOAMPDEO•v.c ....:> .::,_;. _. ".: „?(. 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'1 54 .A+r T'l i S s .'. $ M. ? 4 'J POLICE TRAFFIC COLLISION REPORT LEI TRAFFICWAV IGDCFCOMPIAININUMBER PRIVATE WAY DArf OI COIII N ,D Y LIME COUNTY ,.R ] yrl(? I 1 " .1 IUSE ],DD HOURI i1 i b loa JFBF'F£?PSov? COUNtV NO. CITY NO. I WA 45 Wwµ C Oq HI ? N ? E ?'" f{ss 1 0 t0 N NAnMF NO. O/F,SiRFETGH(]WAY .F.a FS S ?W ? ? xs FCi CL5 ROUJIF' fS RE $E TI N ? / ON AIN I C.Z'tsr KC? INIFRSECIING 1NiH 51REET OR NONINIEgSfRION ? ""? ]] GIGOGR /'.rO// /? , PR X. EO If POST - BEIWFFN SIFUT 6 STREET D15IANC11ORkcr {ROHR IN '6 9 Qr 1` . ` SS SiPffTOR NFMFSIMIIf 51 ACCIDENT MlES N 5 W MILEAGE 0{ lo/ " D RAMP DIAGRMKDAIA .' -". LGIW I N NVOIV[D fVf g11 1 N? n IOIAl NO OKILEDy-NO.INIURFDQ ?SP-w ?H runbe{plrv M7111 X RD N qS CIN STREORROAOOR REFERENCE INi[ CLS CAOSSSiR[fIOR ROAD RB R? IXVEN ClFS © ?paOpERIY -GE ONLY f VOLFN ?RIFSUIrED ?VFHICIE CBIfCi StP XINNAEOf OB1ECt STgUCK AND OWNER'S NAM,) EST. DAMAGE 5KCIAL CODING USE - N? .- f I UNIT NO. 1 fR 'S N OME: IASt iIRST IDDI UNITN0. Y ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST DRWEN'SNNAf: NSI NIS 3 24 q 9 y ? Q 1'/On Sal Q13IP ANc7 W,-, F A/ 7-r4NT -ts, _ l? vgefl ADDafss 0 /off AVF inl - , gfss ?- T. I So 7,50 SiAIE ZIP LOGE PNONE NO ??'A?KF W q81/ tt. -s ,? D R , S1AIE N fN NO. > aYeGS WA 9833 3 7-ssdb I? D wuIUCFN. NO SIAIf EX A FbgN I IVF'UCENSf NO AtF f P)oAA r?F B 1(a 0 wA f?l D o i pa i v . WESTET x' 5.80 wa % IE Of BIREH F o i pr IrR I 6 OCCUPATION tCA IRMNAME{1-NENO. ?o/A1C? EYES 13 ' HEIGHT , k& E R OCCUPATION FIRM NAMf{pHONENO. ?K FIoN P,?ser? EYES WFIGHT NE 1 I 53S i 0CHECK (?) I EHCIfASnNMROV[EOFANOIHERM ?CHECKL?) [HCIIASANGPOrffolArorH[RAL CODES P* 3 1 4 s S r 14 6 :3rD u CODES ?+ s 4 it S rI 6 Mp ra{O { ; ro y1; p ? MNIANRr ? u fIDODGE?CHfV 1. W eKl ? s.,r9 ? MO DELID IR ANI?NOVAI STYLE DR CONY) V nip,eO'31 ° MN nL{ ? .K{ o bNr. ? P Y a AT13 ",u_ VIN u{Hf nrg K ( E HfV NODFI f O A A DI '77 e HC?/ s?)g. Lf- E H ) •N V ) I V) I TAIE wr1 IXOR R VEH CL GISrtR[DOWTI[N Wl {I ST MIDOIF P O L EHICLE DENIF N 'r?Iy? 9fG k ? stt/J /?7Af'71N N NF NO. 7S`)-9Y&? O W I PED OWNF4 U151 fIRSI MID lE H N NO. D WEST"F,Rv C7i?un/ SS6 J IJ^ K ADDNk35(I{OwN[q U AAR4 1?,, IJ 17 ?? 9 ? rllC N / A [ s OWNER , , D n nMil E Snm£' As Ada VIE MAN[{AD09F55IXINSURANCE CO. OR AGFNi .4in't_ Ffl? - T ACC1Mq DfFlN H4.lIJfR R U AN AMEX, ,JAI 51k, SNs - ABF.koe',V,J ' DAMAGED Aau as.N,Hp ' o ? pAD U I N _4 3 lsl.'DANAGt LIIARGE FAWN[D WeY ? /D CIIARGI • ?ORIVEN NI»5''Cl lorpi.u I51.fD[AMAGE D MAACt ARu Iraf TTO y p . lovAloeY: Av r ?R(AWN[D ? Tow[oar Aw 9r f I?00 __ IceoriuM '? DIAGRAM OF COLLISION: III I u NAl IN IC?YVOwi" I fN[a SSARYE SPQR gp I I i i N t ^ DESCRIPTION OF COLLISION: Illsf SUPPLEMINTAL SH[17 FNECESSARY) l Vlwio'44 I.?- tZ45 MAKING PT.._'(TVRN poet s'iPPtD OFF /AKE P61ML, mil) cow-DNIT MD.- 5 r \ veilicct vEUlcr?, I L+/ASs7 Ruc60N "D OUT Sibe R- ? N EF C c - . , . W11 VkNiC4E WNIJ.E T/21/11JC /AVOID B£IUI?. •- ?nL.3 ; ? IMpnvr ? _ NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED T CODES 1 Z J 4 5 16 OCCUPANTS/ WITNESSES I??bo"orlni rm+Anu ii s[x AGt arid' "Ir ',( A'i y(sla. 'IECT N ANiptA0.;AVTnriJlnSoN E In 7511-11LASID. 4 I 1 13 0-1 1-1 n A a Pns 17 E A. IL M _171G-114) WA, r I luu or .wl A. AM{ ? FRIAI ?' E ? DIY D(v133 .. u91 Of "' v ..V ylD lv IwKr ?{ ?L. ?"nm..?UY ?ie r .. .o ' L A m.rY3 ,vl GAl pI L IEAr {ADGEW AGINC "rA1wJs°f D%{r OAM{ °RXXl 1?CEinIR O U?' ?11- ^1 I I ? C ?.I K. ??I?IATCrgD P(X?(I?CJVID DAl10F {IgRI APP90V10{Y DALE X w'- Ion lV? (( %? 6- • y, ??LW r 11e. F" Xf' 7?? ",w, ti -.i '. it -? dl L . A f I tryY + {? fEl I { Y Ill l ? ? I ?y 1f4 1 V , y r '1 4 .i., I II III POP, - A apNt'. "yI ...-PRIVATE WAY ll aF .. DATE N - P'A TIME COUNTY .. CZ)UNIY A C19 ?3 !&!Z fRH I 1 E.I -M I . 11m, IV SE 21WHOURI NO. CITY NO. fHWA 23 UN ®E QIN ? Ct OR tOWN FBNO.OFSIREEl OR HIGHWAY CLS A ROU ON SIR 17CURAl` n aNt ,._Q? 25.L VIFS ®S C] W OF f.C,, ?H C ' - '+r' INrfRSECr NC wIrH. srREEr RoA ON Opp'=4 .pCpZQ- NONINtfR5EC10N PREiI% f MITE FORT -, "? ?. . n: J BFMJEEN DIS IANC- SIRES! 6 SiRfEi /Z-O'S? 6pIREICVjLU FROMRfS E ,C`YOSSSTREEIOR NfARESIMILE-T In ,` [ bb?? fsy j Z ACCIDENT RAMD OIA RAM MTA- NT, 1" IZ.S fEEi Of 5 p I? I MILEAGE _ 'ts Y COLlI510NINVOLVEO: ERIlYr ?? ACODE y ) TWI/ NO. NO. KEUQ?-NO. INJURED ?SpRICE I ?HIie RUN Nv 1N %RD NIER CIN EllI O R EV.U C9 HFIEREIKE _I ?;? {?' k CF VHICLES O ®PROPERTY DAMAGE ONLY FIRF SfOIfN W RID 1 IN,i? 'CIS Ci055y1 FfiOR RC/.D I 6 ly I E L" OBJECT STRUCK (NAME .10BJECI SIRUCX ANOOWNFR'S NNAEI ?RSUIrFD ?VFHtCLE R , --AGE SPECW CODING USE -- 1{ Y -y', 5 ., fk `5 'TJ?M UNIT NO. I ,_ z;, s DRrvER's NAmE: Lur UNIT N0.2 ?VEHICLE I Hcsr mmDIE DarvER?sNAME wsr ? PEDESTRIAN ,? ? pEDALCYCLIST? _" CE-I A I.1Cc fl '.,??9"? yTRtfI ADDRf51 m??A LD MI ( REEL ApORE55 `? y„/ ? ? IGrbB N. Fe ?, N^ i"/ Z CIlY StAlf ZIPCODE PHONE NO. D IIY L' ATE N N . L _ DAN- IICENSFNO. 50 35Z-?2 R j SIAIF EX B R N I A Iv D N No. mD I IMY IYP ,? ATE X HOAIf BI2 H f 'R Y DAY IR C A1JCM 15Q c E.L1 F LID Im5 129 T? p OCCDPAiIOV IIRM NAMF6PHONE NO. EYFS GHl HfIGH1 E OCCUPAl10N fIRM NM,E 6 P1gNf NO. EYFS IGHI HEIGMi 25 Q CHECK (r7 fHlftE AS AN fM%OY[F OFANOMFRµ I R ? CHECK(/) Y Y CODES ?* 7 n"s? V( A 5 5 E yb onKrC .L wv VFHClFwS ANWROY'EEOFANOll" GY ,sw CODES , ' H D 4 iv 5 EA- b yam,, Z NJURR, AJ b INJURIES - VFMYFAP Dm MA I(DODGE.CHEVO ro6cE ?/fQjpARbIfNOVAO VSlYIf 2D R..CONV.) ?ygRVD IQ AmpuHCE?U ?CSIPr[v ?y? Qlj?y ',?F AN ICE 10 I f FV.1 MODEL IDAR816. ) Y CO ( DR $'? l5 PL_Y AurinlT 40e E Y r I UCEN PNt N SLATE FRAILER RATE NO. SIAIE I'I VEH.CQJE ?0 R EN AI .1 AaA) J II -IA - - vEHlafIOENDHUnoNNO. C 2v L VEX CIE IDfNIIfI H Nf , F `• IC'SfRIZ17iit,;9lIl71'I-I-I- I a5 •f?+j ^ REGISRRED.-UU WT FIRST MIDDLE PHONENO. O SIEREDOWNFR. I IASi I 1 fIR1 I I MII OEE I I W. I C 1=- IAJaL -? _ Is ApORfssaowNER W A D - N RE wNFR ?IOWID REMAINED 0AWRrvAYEN fSr. DAMAGE [ flop IOWIO [MAIN[D _ ..... y loeorto: DIAGRAMOF COLLISION: IUA a MEN Al El -BY $ [t I[C A ... S? R IN C RoNOVFRTH DESCRIPTIONOF COLLISION: lus[suPREM(TMS EEI FNEC- Y) ESSARYI. a Y;K - 1 LAPP, I wAS ca5'rESOL.LJ?e oa 111Hc uPPen _ y [?OreT mp 1'{d-?P_L1. WHW Z? - AROJE. or.r'.. 'L'H? /JoeTN .S'TRFGd,,46r A 'TCw ._.S'TL[ M>p..-_ >p v NAME, ADDRESS S INJURIES OF PERSONS INVOLVED r CODES 1 OCCUPANTS/ WITNESSES IusESUPPLEmrFJTAtswu - 2 3 4 5' 6 I TOP ADDIiIOHAI NAM l SEEK AGE fATU5 1 wn" MIAI wi' "" '-" "• yl[V nA.Me. yam` tl?At-TC2 (L Ly P[slR. [l[Er ., I, i E W"35'2-- 5q,z g M T Appel St L MPIA JA HAIV9 01 - I r NAM[. 1N- ?-a. Q'r$1 [ u-,,-. Opp'' ;la,.o. X TV kiw?O STATE OF WASHINGTON Mf pi/ PISVIXfV.IWI i• ` POLICE TRAFFIC COLLISION REPORT No. 2 XTRAFFICWAY PO ICE COMPUINI NI mBER . o or Gllr `2 ? PRIVATE WAY - / r j,+-.?luu.iw Iwn I.1 yl. IusEiHOUaI COUNTY COUNrr NO. CITY NO inwA ,• I P. 'i{ D .?.... •? ?VRBAN L / Avus s ?N ?e cjIN GTYORTOWN NAM aNO.Of SIRFET04 GHWAY C{CIS? ?'' ?. RN 8 AOUKOR pw ®oi (' ON INTF4YCTINGWIIH Er OR ROAD NON INifR5ECr10N PR[il%. E MITE POST II v Aj f BfTVEfN STREET I F STREET n IXSIANCE R FRE .CROSSSIREEI OR NfARES MITE M1l[S iaDM s F W ACCIDENT RAMP D GRAMMTA '1 iEEI pi A) C T MILEAGE - • /' OEU-N N IXVFD: ERIIY? CODE •i; N / T VEHIGfOIµ NO. NO. RIIIFD??Np, INJURED ? SPIIIAGE TaRUN SSIREEr OR W p RD iN 4 OR fQfERENCE 3 Oa s ® ? PROKIINDAMAoe ONLY F E $TO rvpn '" INTER CUS CAOS ROM OBxCT SIRUCgINAMfOF OB1ECt STRUCK ANDOWNf4'S NAMEI ?RFSUFKp ?VFNICIE EST.D L SKCELL CODING H $ UNIT NO 1 S Rwt UNITN•O. 2 ? VEHICLE ,. e} o RTYNTI E; uv ? PEDESTRIAN ? PEDALCYCLIST t ?n l I a. IREfr ADOaf53 sd ~ C / .E Ayl ` L .. Y VT ?k -A T ?? //S Q ?/ aEtIMOREss . ^ IY STAtE 211[0 PHO ENO. D 1 ?'?' SIA E / l R 3X a fRS ll N STATE A B N I V NSEN n AUI SDI BIRTH U- 5' .. B OCCUPAI10i! IIgMN= NE NO [YES GHI HS.- E' PATION E? a i-NAMf S PHONE No FYfs WEIGHT HEIGHT ? CNECK(i7 VFHQl ASAN aVr of ANOrHEq: /.J 0o R p,E'({ECK W) Y _ NODES?t o a i FHCiE ASA FMKOYEf OEANO1NFR 'PQ+' V O /J evu 5 F yyo CODE ? S+ Gn Aj Juc FPS nY rsn nclroN .y°Y A I S fxaaN 6 yNlrv ruE ' p IN, ruq OE000CE.CHEV.I? ' 10 Ac- 0 n1.NOVAI WsYA E N °' ? WA Nc ? W ? cS.a. ? vi nz; ? Vx.v. _ F 1 1 MEV) NODEl 1pARi-i VA1 Yl R. - R Iz lIG PIAI SIAr ,?IRMEERMTE NO. $rgtE I'? VH. RO??AAE5 /,3??'V" '?•}. QLI..w. - I VEHIGtIDfMIiIGiION(XO., r• CVfH CI RE ? ???0 ?? N? ??• 10 "A L eEG131FRf00WN IAST 11451 MDDIE. PHONE NO. O SrfRE00wNER: UISt iIRS, MIDIXf N NO. Y q? I?z MDRFSS DNt.Eq • yl'' +S,?PP: r. N owrveR ^' NAMEaAOpRtssa wweANCf ca tNi E V? .J El 4,475 (,' R a e D.AASA jE Axu 6 r h YSI • Ia?r' ((??,;;, i % cHAxu ??? .rar owc:o..".cl °' gAMAGto ARU 1Y' 4(MNNED cHAacE r1NNA. a r 4,. g ,YW X' I .. 3 151 DgMAGf ^R VEN OiH i 3 '..' I OR WAY i •' Lttf??'' - •--• ? ? DRIVEN ?gNFO [51 0 • w! 3 rOr 1 $ ?wAVDSy. TOWED AWAY f peon r ?+ r, ? " ?• V: FCOLLISION• A AY er: 3 X 'G 'ty '' I 3 u NoI d"°grH DESCRIPTION OF COLLISION: lust sulPl[MtNrµ 3HEFr Ir NECF55AgY) 1 1 -., uiIP NeEaawr e A Rqv { 3 4 DIAGRAM O... . s ., Nl .... AA- N, / -19RaKeNO 4W4 A414 x N ., +? Tv l? de'H J°e % s p N t I CAE /r / SpAAl ' 0 H L /N?c. l A) OC-kAy I x " I CRAB *`2...STRUCN e4r-)R(.Wd 0'r _T?i9/Gfl' wk/ch cvA5 sria ?AJ r '° /.SNP Nc= Lr?T , • Au Ile v X) v '? 1a Nw' O/1N ONCNUPE, A ANTOS??W SESES NOF PRS NS UOIG"'NV A3OLVED ?s"' /O? +nx Ae ODES i r 1 rus',iH u2;.. .(wi ae>ru. ci ;6..° L ?1 C 4'ss NAr PeE Or T er ?AMa. ?31° I ? 3srs,:. 3 gMUVIDiq ?AM.. ? O rO?SF?w1!. H ?nw ''? IL ,;il Ib, ADOYIfs1 , GAT of x? 1 /YacuAk !?9c/L? NANRE Or tsl a Cl N NN E sY ?AMB ?i" ? -?J ? 4ADG O. AuNC. ' ?' J 4 I? r rh H P r Nv .1f?("fI _'??, L ?j C i i {1i {4 4• flvr 7 T t3.dY'k )., ,, o- I 'aA+, IH^"fi E 1 j A tq 1 'd I, 1 4 : rs 2 r S +?:, y 1y? ® " ( IYU. TRAFFICWAY POLICE TRAFFIC COLLISION REPORT poucECOAT-TNLWBER J E] PRIVATE WAY - - x'l LU L OL CNEI I BAY EI. i r rlA1f COUNrc 185E RRWHOUR) COUN(YNO CffY ACT 1 rHWa ?URBAN ' osroc -AAS so 7:) BRA ?N ?E ?IN CIIYOq TOWN NAME b NO.OISIREET OR WGHW Y CUS AWE SER"'ODGE 17, SfC" Af5 ?W ?CT C )MA J ON cd aIN st J >7AJ U aR INIfR5fG1 NG 1MTH: SiRFEI OR W NON INTEgSEC110F1 /n? BFNhEN C +S STREET L F 6 I STREET pNEfl% f0. MItEP051 ? -e ?S DISTANCE OtL 11 N I'll R i[ .CROSrSSiRFE1 OR NEARES-1.1 05 MILES N FEET OF ACCIDENT MILEAGE CODE RAMP OIAGgAM DATA -.: COLLISIONINVOLVED: -IRIIYI TOTAL NO. NO.ULUD_NO.INJURED- ?WILUGE ? UN wrvpR[pM I -al "IN I N if} CLS. N EI ROAD OR RfNCE CROSSSTRCEIOR ROP D BD LIVEHIClIl 0 ® PROPERIYDAMAGE ONLY ? pESULiFD VE LE , / • C V 7O ' 9 OBJECT STRUCK INPME OF OBJECT STRUCK ANDOWNER'S NAMEI Si.OANAGE 5FECULCODNGME Pa Pxcc^ NO fib cE a1,Oao UNIT No.1'. - 'UNIT NO.2 ?VEHICLE ?PEDESTRIAN ?PEDALCYCLIST x' DRIVtR'S INVAt: IASr FIRST MIDDLE a t OFF PA-PP) C DRIVER'S NAME: IA51 TIN ?( 51Rtf I ADDRESS I o ??' oxo Tzaq TREfi ADDRESS ' /? CNY STATE LIPCODE PNONENO. D CITY N SIgTE C sTu^ o L N X186!/ /rv/ c R D IR'5 LICENSE NAA. %/it F p I STAIF 1-111 IN D j •I .. ii I v IV ll NENO. STAN X OAIE BIRTH Ir9. pY ctS 5 C..J wx ?( /? I '6i 8 OCCUTATION FIRM NAMEb PHONE NO. EYES WEIGHT HE GHT I E OCc"PADOIH F IRM NMIEB PHONE NO. EYES IGHTHEIGHr . .?.. l.aRiGCfR "+ B ,ta 66AisYS p ? A / 6 r la R . ? CHECK(,') VfHIOF AS AN EMROY( OF ANOMER? L] CHECK (Y` I YEHInEASAN EAViorfEdArvrF°FIi'G IR r CODES 1. H' 9' d i 5 U.- b SN CODES 1. * D a d iv 5 to d sA .ii svM D N Ten°cr[u n ` IriEENIE' G a U 41,R PDw ? - KL ? m- . ? " Q °LI. ? MfM „ ? n" ? n6 ? ? u ,K MODEL IOARI?IgVAI "'EE DR. CONV.) VEH. EAR 1 NDOf11-1,N VA) ( o U Cn 7' E n ll SIAtF TRAILER RATE SiAIF R -D UC lE A N i IN A G L C V S wK VEHICLE IIXNIIFI-1- V NI I EY N SO N4 IC:6!al !0 6i 17i i t L I i i i 1 1 1 1 1 1 1 PiGis-5-67 Nfi itR51 MIDIXL PHONE NO . O R ISILRFD WNER: -I FIRST MIDE N W IS ADDYt55pOwNIR 9. S ?s'RA E ADDRESS Ol' -HE. NNAUADW1. OF INSORANCT CO. d AGENT R 1-1 A ACIPRIS$ OF INSURANCE 7 WTON DAMAUJ MU o w cNi [ "gy -11 H , DA-' TAREA CHARGE OiHiipwl i Iq p LOA ISL DVAGf " B1OP t D G . > ?RfMNNfD p AWAY " . AMA t I ?^RIN ?atMNNID tS WAY 10 ?OiION s10oo OVADBYi AWAY ?iWAVeY: S A q u DIAGRAM OF COLLISION: I u H NdlH sfutt EYNECE'a.".. INmEr A9ure ROw DESCRIPTION OF COLLISION: lu5e suppunst"ru sHEnRN[CESSARY) ppiVFR 1-0 441.o To wATcI 21/K ROAD.. . :. .. ... ._; .' wHU.l. ayJrE^o '7L 6c% TN?_To.. i OPi?l1g wIEiy-)°.L. in heM 6oT RP F ea ¢n?+ /P . . 7HE'.@.r2.4 Erfj. AHo 0aNTR4L- AN0 aRa/rd ef)c q a. .Lana olrgrER ! ' . I NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES 1 - Z J 4 5 6 OCCUPANTS WITNESSES Ea imnlEwiu r?+I °MHE ii sex AGE urus fl ":' atsrR. Exa :r N,AN. H O AnoRlss ATUlf Of I N-11 Y ? AM e. ? Y".tI L ?.RU. P ? pS ? C3:,>r R ID TROIA H%Xt ?? A ?P9 13 V?i?Y. l.*N. T L d1Ah1p9 AGIN"Y Arr +J u. N aY . i3 71 i STATE OF WASHINGTON FACE OF N0 C 2 T . RAFFI WAY POLICE TRAFFIC COL-ION REPORT rolrc. .PWNFNUM1IB[4 f PRIVATE WAY ?11 a DAZE OfCIXII N 2 JA 9Z AY ... wx /pl w A IME U;F MNOOURI ' 3 cOUN1Y lbw^! GITR.J? COIINIY NO. i?' CItT NO. {NWA ?UROAN uau IjLIN ?[ ? N C1 OR TOWN N F6NO.Of SIREfIOR HIGHWAY FNLES ?s ?W MOF C 1)'TE ON C ? /9 -w ADM I gWIF O....... & 9->sii?d q?? l VON 1 INTERSECTING WTIN: 5l RfCi /FORD NONINTERSECIIONCC i NTE{I% EQ. MREFO51 ` •` ' STREET1 F-C N.I EEIWFF DISI 6 I .CROSS SiRffTO R N FM fSt M IIE ACCIDENT RAMP DIAGRNM WIA Y 'L ?.? , 1' \'7? „ ,, `` F(fiS N 5 P CODE [ w OF Lg5co 0, MILEA E ?G?J IU/ CIXIISgNINVIXVFD: ERIITI ?3 lOIAI NO. O. KIllFO NO, I.NIIJRID ? SPIIIAGE ?MIIE RVN HvHpnpiH IN'. %.RD IMER Cl5 ROAD09 R[iERFNCf 'CT'NG 51 OTOES R R ...... REfi O R ROAD 15 OFV[HICIfS ?PRO.11TINMAGEONLY ?RESUTIED ?VENiCINF , ( 91150 OB![CI SrRUCK INNMf OF OBJFC1 SrRUCK ANOOWNER'S NAME) EST_ -AGE P? $ SHCW CODING TAE UNIT NO.1 UNIT NO.2 ? VEHICLE; ? PEDESTRIAN - 0 PEDALCYCLIST R' 9 DRrvfR3tKME: WI NR- DR-SNAME: USt FIRST T j L 173 1-7Z _ 1-169- ol_ L,45•AAJ Cf. S1RFft ADORE j 3, / 9 a G9 ,Lx? s r. / ki YS--A 4 I STATE TIP CODE RNONF NO. D CITY STATE E FNON IP A Dalvf°su?eNxt GENE A'slAlf U74 I H R 072 OWNS?'N tI L A /? "D ?o? ?? I Vf SU fNSF NO SiNF f% D'IEIXBIRI Vv PoE? 1?SG574CM ?U74 F 02-i - 11. OCCUPATION FIRM NNAEd PHONE NO. 5 wl E OCCUPATION fIRMNMIE ONENO. . EYES ?tt V• /'i ? /V R ? ?/7i/?u /ZO?6? rwA ? CHECK (17 'vf tf AS AN 1AIRRYEE OR ANOTHER :AI ? CHECK(. FHCTFASANFMFIOYEf Of ANOIwc CODES ? t 7 A; 5 Dw w e ,"'O, 'pt:.. CODES ?* a 14 s 'ACTION Z NI ITS 17;F DM ? -I ue F ? s:,Iq ? Ka ? rug x yoF DM W.s.AFF El MCI ? MITI. ? =KM ? 11- 1".Y1AR MAKE IDDDGE{HFV.1 ElIDM1.NOVA) SITIF lROR.CONV.I /967 - ? H. R I H V.1 NODEIIDARI.NOYAI 1 .I AP Ar, iR DX O?? as N N N SIAIF IRAITEaµM11EN0. 1f IL VH. I 1 N VlLUC oG /o wA. ' C y E, c m asd . W f rcIfIDEM ICAIIONNO. -'; 64,141 1!H'2! S .' L vEHI fIDEM 2 W 8 7 iZ,61N;5;61V!31 191 1 1 S RfG15RPE00wnlR: UISr FIRST MIDDLE %qNf NO -MC L EL E L E• 0 W f URID WNFR. IS, {IR51 MIDOIE H N AAl I Pbko TM C fe R. 12 ADDatssaovmu N AMVWa _ wnl- SI I LCENE E (30)C Yg m ?,?r?WFVt:EAID LtJ.Q. NAWISADDRIUaINwa IC. -ACT , I IE R RR I Awce ARU o- ' ° pHUIN gYYA[ K!A AG ? CMARti. R EST. MG! -IN RFMNNIED C3 WAY C3 ' IO iOYIOM cNAac ] 91VIN ESt,FDIAMAUf EIDF ?^ S • ?9IMNN[D ' . 10 iiE ' 50 ? f roY?iDeY 5 GAP -50 - AY AI. w W Ay F 10 i Or p IT Y FTY, R K ?WF S F c ° E IL+D CnrE NDaDI I IAAAM lIS1ON Of C Ol AI Y DESCRIPTION OF COLLISION: (InE SU°nEMINrAISwEIIr N[CESSAaYI ? A 4 I : .e o vEK "IF I gAdMk)& &LT of MUA? ORV. ! }D STM TED to NO 18 • VEH BD "E ' - A R C2- . N a mi ?N? 1 1 - T: n 8 F'f Mi I C 5 KJG r-ACt -I ' ?1uaL Pwr g No. ??J 'TIE sof B?, C f?NE, oeltLTVG _ NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED i CODES 1 - 2 3 4 S 6 OCCUPANTS/WITNESSES (1`4-l""r,,;4H UK AGE LAT. wn YA, "ST. eltn AWE 1-1 085. C ? ,mrre 12 - Ip O REA16Ei PT. T&IN51JD, WA A 1 " '°°10'FIEAC CG.T' .IM BY •AMe ? en°F ? ? f ? U. ? V " ? , ADDRISf NAr d R MOVIDIROM ? ? n .» ? c0 1 ?G A Ople1 ffVVle?? ryAlella !!?? fwV ? EJ AMe. ?YA ?CDTI ?Nh ?n VV e? uy wFrEe eADGIa AeINCY D cwD {?I ID DAn or n.wl ROYEDeryY?qI? De IF 1 e. a ? s!r 9 Q I F . r d Ld , ?.raxc :rw ,.::,.'Y.M•nu, d. ,;e'?Ci'm,.1E:u5?T. s`J?'Y?"''n's??§a,.. - .'' :: H i t OF VVH5?IIIVis70iW PAUL i O. No w..,ll A y. ?y1 J '.??lsYW3as 9 f ?+ U POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY POLICE CO.-HTNUMDER PRIVATE WAY ' ..PATE E Olll _ ... IIMF COVN}Y MO ^n I j. SUx IMOn ^T n. iw .f ly ?HI. IUSF ]eDONOUR) / COUN}YNO, Ctr}q f13WA.: / -,.__ Z'3 I '7A 7'?r l l ` ?r • .-4717 G • ^ µ /Y ' L[?9J VUyMI ? CItY OR tOw N ?f ? o IN NMIE6NO.OiSIgFFT OR WGHWAY t ICT US OVlf O U SIREt SfC30N . o Cl AVUS?s ?w fop ON j ? J INILRSEUING N1t ft OR ROAD -H PREi% EO MIE POST ? J - BEtWfFN SIRFET 6 SIRfEi . V y 1 , 0151 CE DIR R qfN .C405551REEt R NEARES}Mll 5 ACCIDENT 1 s F w RAMP OIA RAM WA 1 {[FI OP ?.`i Q! MILEAGE CODE COlUTOTAL VIXVEO: O.KIL1Y; V'ESIN„ OIAI NO. O. KIIIEO_NO.INJURED? ?SPIIUGE UN RUNOe101 ? I X. N t,l? RLftOR RJaD 04 LE RD ,nCE IMF C15 CROU51Rf Ft0ROAD .? ' - 9 WVEHICLES ? PROPERIYGAMAGEONIF ?FIRE iFO F E OBJfCIStRUCKINN FOf OBJFC SIRUCKANDOWNFR'S NAAEI ESI DAMAGE SR /Q ¢ S'L' 11-F ? $ UNIT NO, I DRIVf 's NAME: LAS IS UNIT NO.2 ? VEHICLE' . ? PEDESTRIAN ? PEOALCYCLIST l s R ? RIVER 'NAME: LAST I DNE 2 stRLN DDgEss 2779 Cra /' IRLEIADDREss 5}AE ZIP CODE PHONE NO. D Y -E IF P ae I o 3 2 ' R NE -+ DRIVERY UUNSENO. SIAIf EX B IN I IV UEN fNO AI So 9XG r S D.Y Ye. . E X ATE OF BIRTH MD.' N: D 2 OCCUPATION {IRA N,VAE IPHONf NO. EYfS IGHI HEIGHT . E CUMTJON IIRM NAMEAPHONENO EYES WEIGHT HEIGIE} A dn7 a p- R ? CHECK (i7 y1N C1E-AN- 'Yff AP AN.I.M l L' CHECK (r7 VfH [lGSAN iMPIOVFfWANO}NE AL v CODES ?+ s sY , i He s u1owH a ?,1 'C6 CODES ? + 7 n"iii a isieMwl 5 Inc1 a 'MO - /n 2 Nlya 3 ,, H ; M I t °? ' ? M N MI ? W yr ? V&P. ? „YAIr ? rg VFH F R a °ie ? ? usKE ? Et:n ? E ? r xKU e .Y A MKK((pppG[?CNEV.) El10MI.NOVA1 51Y1E1201L.-VI I H R 1 E{Hf1) MOOfl IDM1?N A) R row l e;2 r? ? E ?e U [ CY U ENS PU F 5}AIf IItq RAtf NO. 1E H VEH.CWOR .1- ILAE ._ VEHItt[IIXMfIGtION NO. C L VFMICtE IOfNiI A O G I t l I21 Bilj2i 'f3 !B I I i l l l l l I I I I I I SD R[WSRRt00VMfR: lA5} 1145! MEOIXf PHONE NO. O IS D WNER. - lASt FIRS} MIDIXF N I ADD.t55p OWNIR W N NER E NAM[AA000f Sa{wsuRAj Co. d.wwt - u K?!. of S6a' R 32 DAM ARU ' - CNAaW ITAAAGE MEA CHARGE o? ^' , ?']] -• e 1S1. f RIV(yl GAMAG ? D ?O Aw EIOP I! ?? ?RLMAINID ?A4N[N ?REMNNED, f51,D9f _ _ • WAY I lO OM 5 EO TY Ie DIAGRAM OF 00.1510N: w D NAS NDIGAU NORTH DESCRIPTION OF COLLISION; (WISUPPUMENTASM[IRNEC[ssARr -_ . ... SHEEtV NEUSSARYI.- I !YA Ow _, .. 1 I I 1 p /. I,`+/! -/E'..? ?) - ? A Q? Of 'vbrl? r Cl? ?T .S U G! F I?rJ I •.• _ ) r i GD 2 X " 6 dl a G " X.facl-e' sus pro//td rJ?,LO-t ?;5 Lsf? 7 ._ 1 , NAME, ADDRESS 8 NJURIES OF PERSONS INVOLVED * CODES I - 2 J 4 5 6 6 _ OCCUPANTS /WITNESSES IUSI SUrAfWN1AlSM IN AOdiIONA NAM1 ? 51 ._ .._._ 5!X AGE IALU .INHN .s,:? ? ..__. .._._ 1 l If StR [JIR H AW _•.. .._._. _, .... T_ -7 - , y ?e,a n] NAIUR OI IN w weY ?AM e. ?' ? "" . QCi„ ?iu6s. A .... ... _ .... .... -. ... .- ?. .r A .... ... DDRIlf W ... ._-_......_ NA! R N IDIR ?AMR, ?rpK1?W rl ?NX' ?Ii0 1 ,NLA O AD ........... ... MAhA?W ...... . .. ... DRISf .. ,A e ? AMS. ? I ? ? ?Iw ? 1 r M Nvl1q 1WGW KI thAM(E eADGfd NHNC DIS RILMD IVIO 0 IIW MIWI NO ROND DA" ? I D .. 1Tk'iv,,,, F' ti, IF ' f , . to ! 4 .1 d.,l 15., EA C : v>r'4_ ,L^, " w?ipn u,..k,<,? i t /" L ?'? t .rT T ? ! M, 1 r y?pr. ?N1 A I 4 ? Ys 's I' r i rr` I ?t r 1 1 r - ?,?{ + E -j1 ' 1 a r I '! I t f 1 %WWAn VY{ I r 1? Ii7? ' `'r '7 tif. 4El " V [ a;. ? t ,Y ? r _'d E f a ``,, }Idl IVU. u .. +P)LICE TRAFFIC COLLISION RE TRAFFICW I' „ tea. PORT tJ AY MICECOARAwrNUM5ER . ? PRIVATE WAY r ? At orcoli sl ° T Do 'o nME COUNrf courvrr NO. alr NO. '- I l 051 ?Z I xj % N ' .a y A , µ Ifs ? , k G o 7 SEF,c- E?°so,,.J /G? I N DE DIN C.-RI.-I. . ? NMAFBNO.OFStRFf10R GNWAY f ICIS A 1 ? - GT 1?`URA I. D'' f? _ q Ifs J?js ?w of ( FFr•w%1 c u ON C'd 2 D . r? RUU2FOk SERff SECEION %3 ?S /' ' INI[45tC11NG WIIIISIRFFI OR aU NON NfER5fC11ON C EI yLE ?OiF/f?? PRffl% EO. MllE % 1151PNCteORI 110 tlfIWfEN -?, SYRff1? R " 1NO ' ? J R F P05f 1y-? '_ -7 VV Dr y f-: '. L:I + M /lam CNOSS 1IN[f10R NEAR MI I POr mIES N Es S?F E ACCIOENI RAMP DIa RAM LMIA !$ y N F f " iVtl [J OP /64/ MILEAGE COINS ONINVOL Ell SE 41Y: CODE OIAI NO NO NIIIED NO IN2URfG ? SPIIIAGE ? HI xI^ N %- D IN EP [ 11N S REEL OR g t R] _ dF VNI CIfS PROIYRfYpMSAGf ONLY yy y Iun°nDln IFx C15 CNOSS R ? R SU ? MC1 AD OOR RFEEREN SN (,OR kOAU l NED V[ 1 ? ? IY[, OD,ECtSIRUCNINAmf Oi OUEECISIRUCKYWDOWNENSNAMf1 11I.-AGE SPECIAL CODING ibE .:;,q 6 a ?Ci? 5 - - EI UNITNO.1 UNIT NO. 7 Dxrvfes NAME: IASf NNsr IDDLE ? VEHICLE ? PEDESTRIAN PEDALCYCLIST m DRrvws NA E ? Rx Q ?.4 '#; m : ws NRS Aar .? T L s Rf[t •: AODRfss slxfFf gpDNE53 3 ?r A? ?, A 1/ c- .aN? ?' x t cIIY S1AIf 21P CODE D ? ,b ??? PNON[NO. IIY SIAEE Iv R s INNN O N Lc.- ?. s83r.? 0 7 q 6- 5'/a R _.- Dx 0 f NEN . P T Ft - r;`. Ir I IIC NSE NO. v OCCUP N AtE DIio0y09fYx D A ON NPM NAME 6 PNONf NO FTES WFG Iff1G II E OCCUPgrION S?(f iL iRM NAMF6 PIgNf NO. M 9r T Sc ? G2-c-r (ct6 v? FYfS WE GHr M1EIGi b?v V R R []CHECK(?) v- lASANtmROVFFOFPr oENFaAL ?CHECK (?) FHIlNAE CO ? 'aL ° r9DN AN CMROrf[nF DES? s n A•D .c.r? CODES A .F 9 c a s°. [ • gfFOlr [e S N n I Clo 2 p .. b. -Im ' l II . ll ICE ? ?AxNaMKt ?CPa Cf ? vEN rfae? MO(pOODEICNEV?W El?j DAk11NOVA VSI F O P [0'mR ?v?n io'NSr ie ? J rI I ) ONV.I YFAR ? VE ( JG .CNEV 1 NODfI IDAR Y f T I NOVq) LDDR. V.) fO'^ _ [ ? ) / / L E v" JD I C n IIX OR ]0 . . T• . 1RAn IICEN5tPU1fN s1AtF f90.PlE NO. sAIE I"I VN9.CIXOR I // " ? % t tD .? ,II ..• - 7 ,/ 7 O L,,_ w G O O L vfN CN IO a " t- 'rE? % V ENNf GAIL' N IGISI?D G, LAST E xee I I I I I I I 51 , µj - srfufD wNEU Iasi a51 O N m DLE N No. ADD9FSS CPOWRRfu WAD owNfR Z ,9:AL w N AMU AnD9usa NsuRANa co a+ E +v( h . gcfrF' IN u N a _ firr cSCJ C, Ilp.. QwI?c FEE R m ? e1MwINED ,°,wnvN efmMNm Esi DnMncE `?s - .? ip:urt Oi,- = f JOEL ry AWWIN - nWAY° ? ? ?D..-.11 ?. >c tEi ? $ ?IDa __ DIAORMIOF COLLISION I AIL NGNr" DESCRIPTION OF COLLISION: I°Sf SUPPI(MlNIN SIR[I e 4YI II bT A JS [II Er,[C[15A APROW if NrcfssARrl -xt P Ess C-,1 RyL(M Peo O N r o /''tJ frL9 ''? .• . 4 /?1 (^ h v r'- U G-/-l-?C L ?- NAME, ADDRESS 8 INJURIES 4 OF PERSONS CK INVOLVED + CODES 1 2 9 A 5 6 ? - H.""'° CUPANTS /WITNESSES IrC. S " "!A NAM ArD 1 E rAM[si - s1A I ?cf AIIIS ... .... _ MI2T A X R*f' 4' N.Ttz ? TL "? l1 ry' tf?k ? ? P.. 1 s - ? WM L r ???? 1 T I- R a i' ?, kt^ ^'IJ V ? A ? VA? E ? 1 HI ?I YR"'41.,. t r ?1 r y III;, fiE :R' Bea '. w POLICE TRAFFIC COLLISION REPORT e j TRAFFICWAY POIICf COMP[AINT NUMBER !) [D PRIVATE WAY RI 1 OAIf Oi,COII MO =rva . 9AY Y COt IME Wx f NI. wax 1uH w is (USE 7r RI COUNTY ' • COVNTYNO. // GIY NO. iH,YA ?UPBAN . ' - . - ' XJ? CC qAl .7 ?IN CITY OR TOWN N/WE6NO.pSIRfF10R HIGHWAY MISS ?N S ??WF , Oi A ON ` FCfGS 5 ROUlFONStRfE O AC. 5 93itso SCCIION JJ NTIRS(CTINGwr"71RUTORROAO NONINIERSCTION - PREFIA EO. MITE POST •7 BF fN / ? ?? STREET 6 ? '% 'JJ/SIRFfi ?" - ` 11 DISTAN CE BDIP ZION{PO RUfR[ f. CROSS STREET OR NEAREST M11 PO MIIfS N 5 E W ACCIDENT MILEAGE RAMP DIAGRAM MIA [ti O1 •'.Rn %.: CODE RJ COLUSIONINWlVEO: FVFRITY: NO.INIURFO_L 0 SPIIt IAGE ? IT RUN ONIIIFD O T T ruxOV[DNx I N -D INiFR Cl5 C CIIN SIRETORROADOR REFERENCE ROSSSfgfF10 R ROAD ? AL N . O Cf VEHICI[5 ? PROPERTY DAMAGE ONLY ? RIFSULIED ? VI r OBJECT STRUCK (NAME Of OBJECT SIRUCK AND OWNER'S NAME) III, DAMAGE SPECIAL CODING TAE CC/ b UNIT NO. 1 UNIT NO. 2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 2 4 3 DNWfR'S NA/Af: VSI -.(iR51 MIDDIt RvFR SNPME. U51 I.F11 MI ORE REVADDRf55 STREET ADDRESS • /4 GIY?J 3TAIE EIPCODf PHONENO. D .11 SIAIE IP Df PHONEN T. 4vfR5lICENSfN STATE E% BIR 11 r •r., I V Iv l1 NSF NO. STATE EA OAIFOf BIRTH D Y. AY B OCNPAIION, IPM NMI[6PHONENO.. EYES WEIGHT MEIGHr E OCCUPAl10N i 1gM NPMF6 PHONE NO. ETES WEIGHr NfIGNI •'-?' .1 J • R 11 CHECK(/) ' NFH CLF AS AN MFTOYNFE Of ANOTHER Al ? CHECK(/( 1411'CLF AS AN BMHO"rfE Or ANOIIiFan L rRtDl 7 _ V IXJ CODES ?N Jl M'x yr sv CODES 10, J n R s, 5 N e "5'A° n v ! / J..,/ l, / U.R5 IJI:'/ "° N ° ? a `l o ? c N 11 a. RGm ,1 Ir oI ? Aw5 f a ? ".1k, ? c 1: . ?; :». c? °? 'Eic Yl A4 KE (DDDGf CNF1.) ?J MODEL IDARI.NDVAI STYI D CON I'J ' N. YEAR ( E. NEV.) MODEL (DARI.NOVAI T l DR: v.) ID,? /. .r N, i'vNr / • '> :., n E 10 _ X P ql rAIE AllF RAtf NO. SIAIE H VEN,<IXOR l A NO. Ar L V[NICIfIp NII ZION NO i 7fH1 LEIDENTI I 1 N .? RFGISR4EOOWN[4: LAST fIRSI MIDDI[ P,ONF NO. , O O FGI Jf R[U OWNtR: lAST 11951 MIDDLE 1H-INC. ADDRES5 NEN 21 D' AD 4n5p OWNIR N ET AME SADDRESS 5UXAN000I pE AGE T rvr ' R IN U AN N . SR . DAMAL) AREA 1• ,__ iiiitlgrDiN CNARU , c ?., R CHARGE rwcnlorOiu ?MIAGCO [A ?J P 0110 f lSf, DANAGI, •, FRWAY ? ?R(MN,JID _AIN ? Y 0 REMNNlD fS1.IDMUG{ I?5 - ^ A AY u U AI INDIUlE ND4IN DIAGRAM OF COLLISION: SNL[i IT NtCt35ARY) BY AP OW DESCRIP110N OF COLLISION: (LA[wPHEMENiA SHEET IF NECESSARY) -5 10 , -7 4 • tR_ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED - CODES 1 - 2 3 4 5 6 OCCUPANTS / WITNESSES sfx Act AT „" R[SIR. E11C1 ; ;" • • A y .?,• .? , _ nluf bi • P TNl nr ?AM B ?'c31"t ?'" . ?YH+ ?C11'NtP ANT ; O AD[w155 A N tuR p vlEITHW ?AMB. ?PYOINI ?NII l ?ns ?1r,D W AAH O ) AIUPIt1 ?UIR1A? ?IlAldep 'N up M IM OY• ?AMB. ?c?:' ?jPD " +av f1 wEPq tYIK:R 11wNARANA BAp AKV D p?x'ly' K(DIS.AIGMD NIJCl A11LV10 DAIIp RIPORI D f / •' P ? ?' ti ? ,T ,r s,N ( 4w as 1,1?t ?,Elry,.wr dJ - - Ilk: E..u{L ??t 4? ,.a xtI . 71 }1TMTM 4M '?I L•S IIEEG 5 it • • 5 r xcr u 5?1'H7'r OF WA5F111?1G701V No. POLICE TRAFFIC COLLISION REPORT JZ?TRAFFICWAY $ 5 F', PCLICf COMRLAINfNUMOER ` DAIEOO ausl rv 0 Ej PRIVATE WAY U AEI n it IUSE T EIME RI1 COUNTY COUNIYNO. CItYNO. T" L '? • ry u 41 IRO HOU/ /??} ?'''j FHWA uRE- C / ?N ?F ?IN ?C Y NIOWN N [6N0. Of STREEt RHIGHWAY iCI CLS 11 RW ON SrRFf V OREU RAL eii .+ p 4 MIlf3 ?5 ?W ?0?• Y' / ??ON .?{ p SFCIION {1 INIER CI NG VnIH, SERFfT OR ROpp IN /?/ `? %'AYYSO r ,y NINifR5EC1 / PI.[FI% EO. MIIf POST -TEN 6 STREET 0I5IANCf6DR ION {ROM RFFFR NC. OSSSER rvfA SIM IE VOSI SfR111 /v L'YJ ifEt ACCIDENT RAMR DIAGRAM Ogiq it eu qB_ {` ?' tOL 5 Of y 6 tl ION IN OLVFD: fVERI1Y: TOTAL NO. NO. KI(IfD_,.2_NO, INJUREO ? a OP VfNICIFS , ? PROPERTY DAMAGE ONLY ? M+OOWNER'S-I) N ? o UNITNO.I 5 DRIVtR'S IAME; USr Y ' SIRfE AODVFST ? x. - ? i ` S All zIRCO R D ' RIVER UCtNSE NO. El, If. m S G C I R I a uIaI_ I O IDOOGE CHEV.O 4 MODIL(DART-A) V51TLE IT ICENS PLATEN STATE -?L iRAI(E9 Rg1E ryO.J rl0 NO ? w5-r 43r MDOLE IwNI ?_?=AJ.LJ 5 ) P(M Nf0 1.2 AWAY U r ?HII6 RUN rVNOR(DIn H ? V(NN FC'I£ FSt.ON.+AGE SRFCwI CO S UNIT NO.2 ? WHILE RNFR'3 NPMf: USE pZ? %%S7 SIR( R ? su I IL-11 NG 1 V C E E OCC RAEIgN r 11 MNAME, ? CHECK (? RvtNIaFA CODES ? + D C, si Uv EDS, HNRD ? I- YFAR f nEV. .? E 17 H vtn. COL.R C 0' ' 7c F fnltIT TIENn A F ryNN O Rf EIFNED NER N W -S?c 5 N R WNEN E R CHARGE BRIvEN TOwto AY C WAY BY' IPTION OF COLLISION: (WE Sum IL:k-)^ ihF 1 u;.; 17</ , 1 REMAINED I fSE.DAxAGE IIf LR- I/`?i JAJI ?J?4r??F LfUl'..? -1F-7F2-F3-F,-7--,7--, 1l1 P ;LP No?UR M ?? 1 " rWISlWATW OYFC HAW EfAHK `` • ./? M 1 v BOE AGENCY i7 0 ELL IC[OLSAMCMD IOLKJ ARRINO I IqT ?AMB ?c:KI?F,;TF?Qa' ?lii?tr p'"? I.'A?1'4 DAZE OF RIFpOr ANaorlDRr DATE 'fi ?' 5 ! • ? •,J-?;.?.;? . t " y,? ` { y I. ?F`7 '0[ ?, ar+1E ` 4? ,( 1 '. I J r M i }N 4" ? ? {'} • ` ? QW Il1i .IE , i{ Lf? I1r? i .T p ? xv l??v ii? s s ?"S `? ! ? CM1E 4 ' ? J ? / ?iu?? M? ?E l 1 ;,' p ? . } 1 .: C v . I A % r' I 1 f t ? Y L _ I? T t 1{ f 1 ?? ? % 'w l y tI ? Ir: •I?^co I 1 yyII r' J (3C4 '., f !l LL I ?. ?4 I f ? l lF AA I . r r t` .. L f} {r I ¢T? i Wc? W,,ra } S ?:, d ?bAfl N r :'may" , "?^. kk t ? f._ r ??uG I 4 T,+ T 4 A t k { . T 1 y ?t ELI ? s f 1 9 ( kt?? I? I I w, ri YH POLICE TRAFFIC COLLISION REPORT Ip(IKArrlcwAr fol,cf comruwr NU«eER / EIPRIVATE WAY IXI N O 5 A V N Ilmf C 11% u.) OUNTY COVNIV NO. GEY ND. IHWA N ?f o',, NAMfanEErORMK,HWAY ON - ® O SF . ON ?`N , ' mN% EO. .. i ZI C S14EEr6 SnffT N, .11.N E E[ET I (I- ACCIDENT MILEAGE CODE INYIXVfD: ? ELAGf oeton IN pIpSSStiQL[Ce 4C1W P wCl[5 m ? 05Uln G3 1fCT Sn11CKNiDOW R'SN ) 2 - -- UNITN . 1 NITNO. ? VEHICLE ? PEDESTRIAN . ? PEDALCYCLIST Z? 3 DRNE NAME: IAST IR MRNS0LO J aZ ST-TACOR 2 L s 1A Y1 Pry EIRCOa rHO"e NO D RIFT RE55 I r ." R . S uz 9 382 !$3- 74 R 04WfR'S UCEN LIM 1. IERl2 SrA % & H l>J LA OD' e,r i Y4. ( V I NO. A D,r'In. \_. rATK%R I4N NAWtarNOaeNO_ 3b.T oea -lGl(o tns IGH r Htlefli 'E wArroN rw ea rE1DNe ra. fns IeHr HeKAR 2 wnT_ D R CHECK(.) -Al A rt K ? N MEO I A D mw ? CHECK (? sAN Awo [ wN0 qy? , i ' "j, S e%erKn 0 - CODES 0- a,sa / - CODES ? + I 7 a y'- D z MAMe3 ? A«.AAHn ? H YtAY Au410DDGeSNEV ) m" ? M6. ? 4 ? ra HIDART.NOVAI Srv ltD I t," ? " LJW JD 126 ? .Y E 01%ArKl) I A \ nw2 ? Mmr. " . . . 2-Dp. E m S u ru s RA Ue avert NO. H vw. a STAR BC NGR- O C VFM,Ot IDeMIrlui,oN NO. C v H I NI _ ??"!7i IL!C!4' ,$ ? I . I I I! I I( ? - efW3RMOOWNI4! EAST Ne3T MIDDIt /WN[NO. O , R: IASf rIRST t - E n ADOefssd oWNt4 N WNW r Z E NAN[\ADwnadlNSURA ee eo. M-NI R " NU 4e,K.iD ?"N CHARM L M rw• MfA• r lG?OTTO? \ IST. DASUD! S ?-AY ?RIMWNID wwi °er? ? ? ?AR ?\[AWN(D iv en ? E _ \T - Eoiono { DIAGRAM OFCOLUSION: I ! ?e NOnrH sf4fEUNmSNirti. fe'? Rove ? DESCRIPTION OF COLLISION: (BSESVntNfrtlAl SHEfiD N[ussMrl _ -?? ?- Ie -- ?ThL? iT.PQ? ??_... l?T? ® j ??` L I t _ -1 - r/EH? ?__ FAzGEO_7z?_NEboTxgr_E_A Cuet.E_._slvo_/fkAjo _.?r?E b&s,Nr JsaE_oF .7?v6_/FbaawaY_? - _flneuGr; R_..JREb.,_IJ?,D.- ; r I 1 1 L_ _ :.?. IPOGGED _oNrv.._ Tf/E._OR=vERS.__LS.cOE:, _ ? I I I L<' ? >? I _? -_ 14 NAME, ADDRESS 8INJURIES OF PERSONS INVOLVED ! + CODES 1 - 2 J S 6 OCCUPANTS/ WITNESSES ,w SeurDl^r'q"[NA"'l wsw ii w . D iAr "" '-' fern. eE[er :?+•R N ANr GE Rz/frpuw^kZ ?. S- S/3y . A _._.. _--- ... - DD\ft{ NAr[N r. t e-- AN 0 \. 14" ? Hnl ?.m rus M AN b A .. ..., ..-.._,_._._._-.._.. .._... _.-__.._.__... _.__._ .-._ ?Mw ?Am\. ?u"" • ? 7 ?71 A tID•I{5 MAn?3 fM\r ?M4 ?Ui f ? MN ?N?i ?w, w X pn .lr,Of c t Mw[ •A f,DU AaMCY K:[DnrA! 14 la v+D o•ndnro4T ArrroKO\r wn oso.? p.5/z I Sm 4S )•OD H4{ lDE r'.v ? ? -, ,Riht 1; r:,. s W 41 J 'Jr'i' I a? t Yet go I?aa 1ni, STATE OF WASHINGTON IPpAGIE / GF / ` POLICE TRAFFIC COLLISION REPORT 1q1 TRAFF)CWAY DAIf OF .111 N CCAII I N TIME COVry IY _ D fux u ui ?l 03 82 NIII CIURI n UNB H4 e7 ?r-ceto/y /G -? r -C 7 AN s I _ ? 1 , UN QE WIN GIYORIOWN q NAMf0N0 «SIR %l . tEION NGHWAY FCI ClS p I R -EIRE EIC StCHO O MILES QS QW QOf /Q N y c-F ON 0- 4 /8 NIE R CI UmG WIN, s1xEEI Oa ROAD NoN INTERUCnoN R PRfi OfTWF[N l,D /• Ix EIREfI A L - 519fE1 DIIIANcf B DIREC ION MRI FERENCE CROSS STREET OR NEARESTMI'1 POST l5 R f EO. MILEPOST i / .N_.S' E ACCIDENT RM1P DIAGRAM fNrA H?00 nn - MILEAGE OP I- - 0 '924,4 COIIISIONIN-VED. SEVERITY: r CODE IO,A'NO. NO. %IItFD?NO.INIuRED? QsPllflAGf, QSHIl4 RUN :unpatpl ?RD N SEC11N IRfEI OR ROADORWESENCL VuI13 N" IN INIER CLS CRcss-EE «VEHICLES DI L? ROA } D PpOMg1YDAMAGE ONLY 'IRE SOIEN OB1FCr51RUC%INAMEOIOBItGI ST RUCK ANDOWNK'S NAME) QRUlrFO ?VEHICIf (p,3?(•3Q 9 EST DAMAGE SPfCW CODING USf 5 4rvlgs NAME: asl UNIT NO.I UNIT NO.2 QVEHICLE DESTRIAN Q PE ? PEDALCYClIST FUI51 MI DLe DarvER's NA a ME: usr u l ?IAGe C L / n r NG . srREEIADDgtss d444 c z R 2 aOX?? Nv Sr sTNElTAODRFSS Aif CODE PHONE NO D IIY STATE IPCODE PHONENO, c,c? uk gdl36P 7f, 6 R OR-RI I CENSENO ,5 M yAG SIAIF E% p. B NiH I IV N' t FNSENO. MD I AIf E% D IE Of RI. K R 96 62 0 q IXCUPAr10N R F6NgNFNO WA M (" Z V zo R MD. Z _.C/lld/E . eE,Y.?S? GHT KIGHT E OCCUPATION {IRM NAMFB PHONE NO. d• G• /µ,r.,R A? 2 rUS R EYES WEG1 HE- 1 Q CHECK (,,I CODES to Y I A OR _ nrvrM°vtovlE«Arvomr4: L Q CHECK (:4) I V-11 EAS AN FmnoY o A3 EE«Ar - N D / 5 t e;; CODES 4 is 5 ex 1 5 n z li y° F -u- 3 p 1 If w . ?M ? ? S 0 '? ?o• W Q N QA« ..IU p u rE Q M-1 Q".;,s. M IDOOGF Cnrv. ? ES:nR E nR r` r NOVA) s?nc UDg .coH?l n ? 1' 1 HEV.) MODElID-NOVA) Yl( V.) ID (y Pti E n J I aou lNxNU N . IIAIE TRAIIFRPAIENO. SIAIE H Vtn. C030R U N l ? 1CE ?? y I N Al nK'f F Iarvnecarl«t No C 3 1 3 6 8 o q K q o 6 g 6 2 L YtH LEIDfNIIFI AI NN RICISIl4[DOWrvtq: Ut51 N a, 951 MIDDLE PHONE NO ISIt4f0UWrvFN: O 1A51 fIN51 MIODIf H NfN ?. '? I ADDgtlS«OWNEP ` , ' W NFN R. 29' _>34 0, r [GNLA ??) ; E A AMIAADDPI5«INSURAN,CO -NI 11 H FAA-7-,ec Q. nwA - o R N,uA OMAAG[D ARG ?iuh?G ' I 'v.CI10 u CHA4G( CHARGE '/?/ry (,? 3 151 rD-AGt ?P,VN 000 C ' N:I.?I.N.- i"IADAREA q] N , ] ? 1 S R[MAINID ••? ?D WAY LJ.W.NID L YYYY,IIf .-?L???JJJ??JJ v(, AWAY Y: IS - IJ OWED AWAY AWAY Br : DIAGRAM OF COLLISION u t P ISr,DAN,SGt E T1. I ) DeonDN 3 : l S M r u INDIUIf HoRln le sruanr.CESwr) BYAR9ow 4 DESCRIPTION OF COLLISION: IUSESwnnxNU3sHEmFNICISSAPn 9? JE Fa, car: -t-471 r/o r.Y Bo...o qA 0 _ _ ?A p ?2F ?c.ts Sr oY_ / .e ,, Tr ,CQ de ca- o / D, ' _ - - GDr..E r? /fwcE C'y 'j"o .B4N/C Or ??_ - _ - Sore Sr'i" rflr• LDO E NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES I OCCUPANTS/WITNESSES I36t 3«nFANNDN SIq? - 2 9 4 5 6 on ADpllowu4AMfs sa Aa ums '" , Rtsl4. Ntcr " AMr "o D ADCP1 ss n,qt « N ;? a 1 ?AV.. Qlq?xl ?"r r C) -,;y 0 11 r A w SS NAIUPI « q - 4MO ?fQ[xxKl ORAN, C) p r n 41W rA.vf SIA:AIr.[: n,vxr-.... •....... _.__.. ni NP%S _ ...? L1 AM0 FBI ru41 nrrlY l"1 NOr S n gg???lL f: ,??p'0Y:'C• ? ff ? ( ;? R ?. I T it ??b 1 ? q° r 7 ? t R yy N 1') (i \?I r ti 1 ry yp U r, ' II t 42t.. ' f ? Jr . 1 S l ti Y! 1.', I J Y ' y f E ? p /r ? ,1 r V 3 ? 3' AE r a , ? ,' { r h vi 1.?! fie, No. POLICECOMHAININUMBER COUNTY NO. CIrY NO. T won . ??11. D Iry A ? . r`???? t 5 "A TIE yr VVASHINGTON I ?r PAGE D ., vu?' aN a OF W iYY POLICE TRAFFIC COLLISION REPORT OTRAF - `J No. ? DAI[OiCIXN51 N FICWAY ""CFCOMPIAININUMSER ? rYFI w LY 4K. ? y 'i? a +W o.r rv -, E PRIVATE WAY p m lU ?,I rlMf ylx ua / IuSE ]MpHOUq) couNrr cm-NO. CIIYNO • ' _ ?'r . 9 ?N ?f `? C OR O 1 " ? I? f-'I"i` 1? ?[^IJ ?(V ?D J V ?UR9,W ? AMFe NO. OFStRfEIOR rRGN / E S 1' ,?, p.? ? VIay FC[ OO QN / Cl5 k RO IE 0451REE C ILIRt,RAI NIER)ECI NG wI I FfI RA 1 \ A? SfCt Ory NONIN I•?I' ?' 11 1' .i Y: ,. IERSFCIION i 1 I '.• " PRff1X E } ' DI rANCfeulat i I eEIWFEN MIlE PDS SPPFEI6 .^?`? /) MIF FR(N RfiE .CR OSSSrgEF10R ,?7 " Y W I NEA4tSPMIIE POST SlgFfi ??,[?? FF r ACCIDE Fx ', ? '1. -0 NT RAMP F DIAGRAM WA CO 1150 VIXVfD. V MILEAGE TOTAL O N _•? ,f . -- . [D o Km IIFD NO INJURED CF f C (5 ?? ? PA AGE ? oOpN" ® PROPFRIYDMI GE ONLY ? 4 3 ®NI 6 N %.qp 1 R fCIIN fFl ROAD OR REFERENCE ?? O [Cr5 UCKINaM[ Otl 5 INiFR v Cl5 CRO 5U ;'.p I) ' ' ...\ ? ? _ f Il[p ? SSSIRfEiOR RDAD Cr51RUC DOWNfR'SNgMF) . 141 ll ' 4 1 I ` I ' y? ? mo 1 1 .. FSI DAMAGE SPECIAL CODING USf H7 ? ' ' ''' .. p'{" UNIT NO I .•r r s I(?•-.. : p [ sNA y - ,.1 P _ T Mf Nasl UNITNO. p ?sVr EHICLE ? PEDESTRIAN J m DlF DA vER's NgME. ? PEDALCYCIIti L- ? ?? t? __ aY _ : Rs r nrapuRtss } ,}..\( - I? JAI ! . I t - {{ E• '+I r ADDRESS CITY } _- tREfi ., f .rl i'T ' S E I COIX 1 t I- i %! PNO F O. D IY •' SIAIf --s c no ', _ R mcop PeonEN I - ?' 6 !? C ? . SIA f [ 1., }?.\ N L I } O ?I I RVfR'S UCFNSE NO. e ru. S Vq .; ?. 'R[ A '. KK I,,, CCU ION fI b Fla M AMF 6PHONF NO. V7 V '' EY ATE SF atFOOFB RIi b -.-; t ? (` 111..7 I ES wf G HE GHr E OCCDPAtIGN FRM NAMFe PHONE 1, ' ¢ ? NO ? CHECK (,I ^I=j I r ?. I j R VFHC . EYES WFIGHI FEIGHr .' 1 1 ? FASANI OYFFOF AN-- CODES ? + al ? CHECK (?) ) • crro.F a I vfH CiE AS aN GMIiorE c m m ' m r ?'; , FdAN )^ N rHFR H N" CODES p+ n" O R s+ " K55 ' I g i ?' '" ? ? ' iriM 4 5 Ut ON waver -IZ) Cr cU I VEH.YFa40» ? Axx-a ? rolKe ? ?b'vrER v 1e 1 v MA R _ ?'' H ?r . r i KE (DODGE.CH[Vl MOOfIIDARr.NOyga w51Tlf IRDR?CONV.) itT?ev ?awfVEA„ [ 10 v^? vH ? ? ?~ e°"?0 ' aR I fV 1 H, MODFl1ORi NOVA) ? M ? a llf ]fICIN. ,.i 1(, F! ff i.? E ? StAIE ' V) ? BYO ( R ? ? ?-• ? Idd ' , AtfR ftar 14 ENO. StAtE -\ - T- ,1" H VfH COLOR l v5Ft 7 _ ? .. yy,,__,. ,aFI,v 'b'Sri`a+? f' ?? VF dR :: R1 VF C f IX l C O NO, U -, l l4 `I C 1 . rO Ve ry ; 'Yi a?Y ????77 I vfn CtllptNrflCAII NN afersrzefoowN[R t ?c_f : _ N45t MODtf (- \ `'I?) I aDDR(SSgO !4 ` PHONFNO. -, R ISIf P[DOWN[R: lASt -_ O FIR11 MIDDIF ?? I .. A DR WNFR N NO. t '. N • L I. ', NAMEe DD ISS Or INSUPANC • IF•11 `' II':••'t - )' [ CO. Cw AGINI E - .. I . i ',. R U AN RoAMACi ARu 32 cHA - y 1 ?.?1 u 1 q - ' ) ROB ) E1r, pAwAGt D E ` I CNARGI eWCtIGw EAMAG[ l ?9tMANfO \, ARIA A ' I '?i _ I 'p);AF 'j A ] r"u D» O' E" LL U ^RIVEN 09EMNNED [S?DAMAOI eIOP )' DIAGRAM OF COLLISION '' 1 , l.ll !v, ^owlD waY _ -" lu, v w l?ni E f .c y ar BYE t Deo , l IN e?iAU NOa1H I sEnfr FNecesiAxrl A ROw DESCR PTION OF COLLISION :. I I UPPIEMENIaI SHE[I IF ICt55,\RYI Y n t " C / I ( ` - • _ -~ 1 II r. 1( L , 17.11 ^?. I T 0 La -? I . , : r I I "I. ,..r,IJI ll [ ) , .. . NAME, ADDRESS 8 INJURIES OF PERSONS INVOLV I 1 l'I 1 CUP L 7 ' AN ED •I ' r, x[ IUf E TS/WITNESSES I SWgl fNVy )HI[I 'CODES ' OR I F AJR%noryµ NAwESI ? ? 4 5 6 5[X J N `n) Ace IAIUS ?,?'" „)',' J E1514 fRR » rr }' f, NAIUR 0, AMtt? NAIURId YI Av. ?AMe ?['11K'?rRU.F?N•i ?i'A4i,y K Y RM Ip IROM ?• L1 /74`)y'' Z, ?f 7 Axn w r ?AMe ??:K'?r.l.n. ?Ci,1 ?ii:.v 'p 't t, T hv'' :. \ ,NVt1iL 110 ONKt11 MWe ? Ju,fyGF _ ? ,4 ?..r I ?? >?? s X )C.,rL w ay,FT? 1 gADDeea +uNCF 1 e ? e ? ? oFn. ?:17 µfr k 1 5. r?4µY 1+0 KI AICMD FG\KI AIR ND D Ilp (PORT ArogpylDeY S i' .? 1 t? ?c+,` ( ? ? I IT A 1 hCv ) Y ".l.l x_ 4 Y - r DAIf N ? r )I r ' ?, y y L IIPI 739rv.W,r -. ? i r I-0 tt 1 ! t I '. faro V y I .t ?? I'F J n t ? p ? I' ?a? 1.R?EJ y f 4 t -?T? r J y 1 ? ?' ? I ,< rlI a - ??,T, E T. P ? r Ow Y`S 101 TU[S f° M MUIESV • , "I I I,. n. N ? M I?FI ILK JQA? EG Y g t Dfl 1I.M." UN 2R ? ? CI! YG?01'/T. ` 8 C' M 3 05 ?W DOF A NTLH3ECTI1G1IT1 IAET 111. NINTEnI Ci10 41 "'TA_T I', A IT I N E - ee I AT O4 ABC, FloEri[B p T Ile, _ FCi OX T P L Ywry [OLIIS ON IHV OLV 0 ?? l HA)AROOUfMATIUl S)EI1 Tn AX-I1B iOIAL N ' ? O. Ofvw CLl3 n V[S 8 O 6OT N I 'LTIO 'I' -112AL ? Eu A TPAL S OBECTSTRUCK I 1 a' -. .. ?TA OWNEfl OF OBJECTS NAME ANO AOORESSr apfrMXOu 1- UN 77 N DRIVER'S LAST NgNE- »._.... -,..", ;•,SIflSTNAME-.-,t.,:; .:. _...._..:. MIDDLE.. 'o",' GR,Vin,4AGT NAM No. AD 6iREETAO fl OUT No•ANO RD%NO.. Rt B aX 343 P.Or BaYc ?FGx CITY, ...... ..,,. _..,:STATE ..•..•;,,,v_ Ip fApE. OflIVEfl'SOCCVPATION - ElDgr fOq CITY-.: _..... _...u: Y" WA• E OgIVRfl'S LICEN$F NO - .,,,__ STATE .?E%,. -,; GATE OF OIgiH _, .AGE, Ofl IYEP'S LICErySEN VEHICLEY8. ,MAKEICHEV.DODGEI. ..MODEL(NOVA-0AflTI... ., 600Y STY LE O GSA_.. VEHICLE.YR...MM E It 'D GO [ 7(v UfiTS ?/ L-lozA/t, NS _ ._.,,STATE _.. ;,:TRMLEfl PLATE NO._ STATE. .. .. LIL NS lAT AI LAI PS r?s z WA VEIIICLE IDENTIFICATION NO. _.._:,.,,.-,-..w.?.?v_.?•.a... ?•,?,. ................ fl FGISTEflED OWNEq IUST.FIflSTMIpDLE NANEI';:.: -„ ORIVER$ LICEN5E.N0 .:. :._. SCHLADET9K, Rog Sc 6W EIT R€GISTEREp OWNEq ILASTfIRST?ODI.k NAM , OVJNEfl'S pODflES6?-, ,,- Tfl ET.CITYANOSTA EI _ ,. DATE OF BIflTH ;.. Pro D,[ a 8a C ' 3 6WNEW5AODRE55..:,_:,:;._i , . ? I PAfli50F.VEMICLE DAMAOEO ; -, - wr _ ? ? it ,, $.AIgN Qa PgflT60F .NICE OPMAGEI LIABILITY INSURANCE INFORMATION-VEHICLE NO T• WASTHERE aUTOMot LELI,81111INIURANl COVERAGE IN EfFECT FOfl iHISACCIDENT ON YOUFCAF YES 0 NO NAME AND ADDRESS OF.LIABILITY INSURAryCE POLICYH LOEfl , ,. .. CITY n E.wDADOR ssG IABI IT IN Anc AGE 7/1i.{?O/1/F W? ,aEiATE ' P, L 1ST INJURY: _. .. __-, __„ • ,. ..- NAME AGE )NO INJVRY: ry TO - TAL FLIURED NAME ADDRESS NATURE ANO M F A...ISE sEK- E%TENTOFINNRIES CIO ? pF M F EKNATUE TENTOF NJURIES OIO NMRIES WIRE ' ? ® ? F%AMINATIONBY DOCTOR) DOCETOR S OINNfllES REOVIDOCTRfOR) DOCTO",I E%AMINAT ON OY A 6TAtUSOF IN REO ® E A M RK FIRST ONE THAT APPLIES ?% STATVSOf INIUREO .... MAgK FIRST DNETHAT APPLIES : - ?On DW,IL MOrN p5 q N VEM CLE ? Oq v[n INHgvB x xu pv'nG [ rv[P IN VEHICLE. ?r.SxNG[q O KIILFD IXO NOx BIVe H[VEgU IM NBRI prAESfxclq on [ ? KILLED 1!v[gll un nrlBl r " , "?" A N i X.r, l ' ' ?,[DIltq.x -- eFIAI, BI ' ?I. rI •.mnn. I. ? 5? 60 7Q MOTORCYCLE SAFETY: QHELMETUSED QHELMETHOTUSED M OWNOgIHB PRO INCIRCLE MOTORCYCLESAFETY; HELMETUSED ? ?NELMET NOT VSED y a B?„B aB? O ?? .DESCRIBE BfLOWWMAT HAJ'rEHFO:IgEfER TO VENICLESBYNUMBERI f?itoic? ulEsr_m.?l c?is??•e?y?c%?y_?i?,s` ?Op_..QO? ya+?1'//_Cac?J i4iYtct FQoM ' B,I4rrBN s[ °? ?? I r / (??? ? [__NrBXwA. _ - 1-ASfuRES_Q7V_ ?/m ? -.COLT L?N. -??El_/ =?J ?V.•L?? , ? T Q e J -- - d • _ 6; 0-f! X p VEHICLES POSITIONS BEF VfH ICII ORE COLLISION a.Lw[ NMI Xroa1 LIO LLr Ir• B NO YI ML 1 L n I..? X, «N B INYE)nDAIEpeY N f 1 yN??[ q0 IrgIA[ ? ? . ?. E]I ON ITR[[ T/O RR?fHIIGG'H/"c-NAME OR NO. 1.4/acr_cs ........ IF ' N 1 00 . ?.:. .C]N .., rI1 N?JO L ? LO( ?? O ? L ? • y? ?R ?iA?nOL ?IONCI X, ? 10iY 54 " ' Ot.t•I 13 0 0 El . .. . , . CE T .. ? ? ? ? ? ? ?Wlglll NanMw 000(3 ALONG O epsslHG : FROM To FI y r„J.'.,I• PEDESTRIAN/PED AL CYCLIST WAS USING: 1 ? Ir n..L• [ Q ....... 1 0 M• w [ ? 1DY ) ? n=ul 1 ? C: Br I Q Q!; " ° ;i ° n .0 AI KI CYCLIST CLO W'IATHIR THING COLOR: 1 Q B• I 0 •rwr I ? m l L[ . ? [ R 0 I -AT I i a ? N.I.N.144i.'CIe: r"qul . •0W 0 ? v.c LI 4Un1 CONDITION 1 QO,YLIGXI ,RAIIK aI anOUw . U wr•xo _g of FOR. rrrK[I KuAi l.. OA 1 [ L , [ Kmd MI Oq MOell ? I "? 1 DGRY E; Iw-i Py'k:8' ) ? RAINING 1?DAW1 ) Q OMIK ?I ?fIGNALf ) I'OF11UN M I 0 1 ?oHE WAY MO> XO 1 ? GOING ITRAIGHT AHEAD t ?) ? WIT 1?WOR1N0 K ITRIIT 1?G C Q1 ?YI[LOf10N ) ?K{VIM ILI ) ? OVIRIAKINOANDFASSINO ?) ?1HOW 1 [3 L. . DRKIoN ) ? ROAD ? ) ? MAKING RIGHT TURN ? 1 ?ICI . 00 GINIR I ?LIGHT{OFF ? R ? 1 ?/LAP-Q RID ? " ? ILOO,/.AlIOj ? ? 1 MAKING WT TURN ?1?Y/C IY 1?IVICIIYI 7J ?R)? R NO IONit TAIA L DT ?1 ?ILAWrHG Wtln C) / DAA [ L LL YY . 0 1 ? MAKINGUTUIN NIA 10V1CIY ?4 ?A {GN ? L yy 01 ? rV U N FM i 44 S t A L? O DWAY fUAFK1 'Yr[ ? 1 Q DII CI Il GMAN p t AAA f 0 1 0D L Ar Q 1 Q/LOWNG 0 1 ? ITWIDFOII TAAIFIC , T ? . s HII?TIYW L ?T ..«r tuA'"+4 ,.""'?Ei 211r ? r' 4 - I T D q"=6 w&{ 3. g ?'. `K2V 1 1 v ua ?; a .'d t?IXi •?Iy7 a :Y i ?F?'Xy?951??;j"?qF4RY:H1 I t / f rr Ir; v.'i T? .A .? ? ?, ? .?x.r-.ie ?!r YVHJY-IYYVIEvY'C1YV .E;L l ? .I • - POLICE TRAFFIC COLLISION REPORT JR TRAFFICWAY POUCE COM-NT NUMBER . PRIVATE WAY !' AT i E LLJ COUNiY no. CITY NO IUpOUR) ?VyW.T1 j_ Wx? Ox. IuU. wle.f II?.Iyt TIME /n ANTES ?5 ?W ?I 'O TOWN feN .Oi SIREEI NIGH WAY i Cl1 a m RW E r 5E URA- L x Y MI[ SECT NG WI N. SINEflO OYV `? 42 -ld ! I » AD NINI R ECNO PREFIK EQ. 6 3 I,:. BETWEEN SIRFFi. STREET JI ?'?^'? ff 1 wuayl F, / DISTANCE 60 RF I FRO RfiFNfIJ?F. CR0555TPffT OR NFARf51 MllE^ } T/? Mu S 5 F W ACCIDENT ILEAGE R.u«P D • ?R r• FEET OF K ?I I? MILEAGE A ) a i ? COI11510 vIXVEO ERIN lOIAI NO. NO. FRI. INIURFD? ? 31IItAGf HE UN WNDPtBIHf L CACSS SIRE O RO.+Dp ROMO lEREI+Ct CITY fHIClfS OPERTY DAMAGEONtV FIRE SIIXEN /? '1l 'F 31 1 OBJECTSTpUCKINAMf OF OBJFC STRUCK DOWNER'S NAME ?RFSUIiFD VEHICIF .. 1r. c.?-,a_, G - ? 1 FSi DAMAGE SPECIAL COOIN E UNITNO. 1 UNITNO.2 - ? VEHICLE - '? PEDESTRIANS ?.PEDALCYCLIST<. aR ,? DRIVER'S NANF: T fl t F RIVE 'SNM1E: Ur /? IX StRLETAD04E55 M? ?? - ?' /) : 5 gEEt ADDRESS ? ? _ A _ y I _ O1 iAlf zip CODE PHONENO. D ItY STATE - Ip p N R Rv IICEN5E N0 STATE fX DA -qo FBIR50 " I IV LICENSE NO. ' EX DA E B RiM ,gsoa? MD NY ?Y• 1_ CCCUPATION N.M -I.- NE N EYES GHl HEIGHT E OCCUPATION f BM NAME 6 PHONE NO pP R Efts Ma cNT ?ICNT ? .-(? ? CHECK (?) I A 7? vfHOf AS •WEH"'[F°AriovFfof ANOrHF ?CHECK (?) ENClE.SAN VANOYE[OFAN NI4A P71. . CODES ? G a i°s4 + °s:inM"" S E, crw e s D CODES ?+ G n"v + °s:i,°(M'"t s fu H y 4 01 m°C cno / " F 7F .DM? AMEM KI FJ'?Yr4D« -BILL AN<I C) u6" ? E8rrl4 ? G9?2? C] ? 4t" ? b'RS ? .. U ? AN V[ YEA4 f100 fCHEV) MODE(DART3NOVAI SIYIE 4Dq.C0 . Y O 1 HYfAR ( HEV.1 MOD(L (DARtNOVA) ) ,I a lJ ;per E I OR UCf=S PlA1EN S A? RAILER MiE NO S1AlE H H .C OR 1O SIAT ' I A 717- yw!?? C f .1 1 1341, V[NICIE O[NNFICAI ON NO. L VEHICLE OFNIlG l _ N y 1 r i l!]; I I I I I I I I I i l l l l l l l l I '?„: F=. /VG? RtGISt ?PIDO?,?, U,?3t fIRSt MIDOIf PIpNf NO. 0 q IERfD WNERI tA51 FIRST MIDOIf N EA, 'I y? I,v. ? ?? ADORlss DFDF OVRN W A NER B I 'A?5 .':?`, N W ?? NAME nAOOR(SSa NSURA cE CO. oR ACFNI E' wy ??' '.'L? `? ,? t[55'7,FiR5f11FA7tFL8"A!'xGFf+T-'- ?"' ?, M II _?II) F_Eror_?5 i_. CHARGE AWAY. R? ' AWAY ? AwAYD ° er__ H( fill luSsAJIn Bvna NGDw" DESCRIPTION OF COlt 51C ?jVCm ..< b?un OAS.( I 1102 TES I ACT tAIUS INN. UCCUPANTS/WITNESSES vA«E. S k HAMr ° u+l ey ? A.M. ? ?HN . ??IY ?"3LfF h H•r 4 a . _'- q w AM H Iw1 Im x'ovlo„r4 AMn .• owa, . a ?. ' f } !I eM 11xiA1R.p gFKlIf IJAW. V EAN. ei J4LEAl A,AAxs .DKIDISI.LCRE, TIM eY ?AMB ?i 'I ??bit• ?(i. ?m! Iv K AA uAlEa gllOrr Arr40VE0 er oA '. «W '.. t ?'bS I 1 1 I t r li ? ?x +?. 71L'l.??L 5 Ti f: t , ti '..} '.Y n {,. I""" _'I.,f.IIU wA'?hI+?NT.RIr N •?_ .+rt ? J j N f 1 .(161 rS ,; ? 1 1? pp,'jt° I r !. Jr R 6 P 'M r 9'' I L 1?0.F.Y'Y ` Tt_ T y,'± r, a? ??!s POLICE TRAFFIC COLLISION REPORT PR PoUCFCOMPLAMINUMBfR PRIVACWAY VATE WAY - G' 01C LISI?0'. 1 DAr Of 1) - Al IIE1 _ tIME ?30lINtY3 COflN5Y N0. CI1Y N0. iMWA --lur (USE TWO HOUR) „? MD .. YR I I5 X I 5 ;?, 1 14, oURBAN DRNS ?N ?E ?IN CiY OR TOWN NAM-N0. fsIREEIOR HIGHWAY FU Cn A M I g0U1E OX Si FE SFCI 4 ? mFLES s ?w ? of l • ON ?? IL ^' INIfR3FCr NG Vn N. 3yi,RE1EiE1 110 NON NIfRSEU ON ,•REfI% EO MILE Po37 4 : ?t•n •' --EEN EERIE, a EIREE, ° OIS1ANf BOR MI MRE R ,Cq Ss STPffI RNEMEStM11E ACCIDENT RAMP. DIAGRNA MIA FEET TS 3 NE Kpn;` I MILEAGE - IE A " OF CODE CIXL, q INVOIV[D: ERITY: TT' %? IN R DOR it NU 101. NO EEO KILLED?N0.IN1URF0? ?SPILL.Gt H 6 N ,ur"FiOptCiHS 141 IMER Cl5 CROSSSTREEIOR ROAD Cf V[H ClfS ? PROPERTYDAMAGE ONLY I / }' ? 4FSULIFD V ICI, ?' Y OBI[ CI STRUCK IN.w,E OF 101[Ci Y. ANOOWNfR'S NAME) E3T DAMAGE SPECW COOING TAE \ OLCOp y . UNIT NO.1 UNIT NO.2 ?.VEHICLE ?PEDESTRIAN ?PEDALCYCLIST -4 s LK-K'S NAME: r NRSI MIXA '. DR,VEgs-E: LAST FIR MIDDLE 2t1?L1/??15 STc-c?wC! stR E ADDxE STREIT A e ?rl E? ?ZZ 2 UIY STATE ZIPCOIX PHONE NO. D ,7Y STAN IP D 7E10: L LN LM N tic, fq -LLlA. 'Ei 'o a?,• 'ER's OCENSEN Sf SEAT SW DATE BR YR rF#,4 B 3?i Z4 i'i fJ C to ;Z° I D,r Y D N N. xD I D Y OCCUPATION lIRM NAmEe PHONE NO. EYES WEIGHT MIGHT E' "C"A"C" FIRM NAME B 1-110, EYES WEGNI MIGNT ^ z LI $.lY. 2t).4j .V=6L, k /3 C R 1 'VEHICLE Al AN FMPiOYFE OF ANOIHFV •E ? (?J ? CHECK (?) CH vEH CLE ASAN UM orE ERAL ? CODES ?+ D a 5 [ e ;° CODES ?ECK * D n" a A5 [x a sM°A I'}> E 2 n. x MNr w ,„ .<= R .,,r ^, crbN rvk,cu s AMNAA,W[ ? u cL ? ?biac ? ?AY,pS "DI ..", rfoFRDM ? --m-NLO IIU ? R[i 6. ? 1.1-1 ? i'3,5.. !!?? VFH. rFAR MAKE (DODGE CH[VI MGO[l1DAR1NDVA) s1YlE IT DR CONV.1. N YfAR f 1 MODEL IOMINOVA) Y IT R• V.) E D C U-S(PlA 'N s1AEE RAVER-11 NO STATE H VEH C STATE LRA- " U , R7 NU. STATE J BL N n°? TA ! VFHICL[IDf IFICA1gN N0. -^ CI VF , LE OEN f 12'9'Gr'9:B'2 3 1-73:"1,31 L ! I I I ! ! ^m i REGISRREDOWNIR: .IASi FIRST -E PHONE NO. O HD `^ WNfR: LIST IIRSf M,DIXE NE NO. .? ^ .mil" ZE: t , . J Ap0gf550F OWNIR N' 1 N NFq rvA,WfsADweessa INSURANCECO. ORAGINT R A TGE", LET AREA T. w•ciq u CH N NGE CKiIOrDi.u IANZ %?. f t 1'OAIAAGt AY ? PEMNNID CHARGE ? AW"E" ORE-ID tSI IOAMA F , I IOF _ ' ' { ISE?pyEFAW Y 7'.. r+ U AWAY Y) AY DIAGRAM OF COIIISION: DBY? IOWtO 11 HE ' SMLIY ? . .':. $ ? s !-b'CAE1 O'lR-H DESCRIPTION 16 A lu ?dC Q.L_G`?L•/? suvvLALwm, NFCESSAgrE'J1CJ.Y`•??Z Je .47TV0 n ,v Cam- ov' aC.GT GJ/- Y! ?'Z ?iL1CLJ A /U.P .?Or¢ /? -? - --- -24 GL fP.C?(1. ? 9 9 a , q NAME, ADDRESS 8INJURIES OF PERSONS INVOLVED + IUSE . " sLrneME nu THE" CODES 1 - Z 3 4 5 6 OCCUPANTS/WITNESSES rw Amrta"u NAMES, SIX AGE 11 ' AT 1'"„"" -D•'.. REVD, uEa ' L. Nu+l?r?/?/?CFt/ ;y; li?c?7S/d r'EO `? ? E 2 S Ip ( MI%vES3 . y,?- ??.c-r: /7 ..:?/ riuuR or ? . (K'<' u?BY Ame. Oi.21 5 ?,^' t ?"" ?{13N5r ,L? ? d •': >u ' /fc? 1?"?T' L. 7Y,'?' G[/?A°C' NO .--. JS1 2 yEp _r ADw1f3 J i5, ? 1 c .']. r I olod,c l NA a - O?`p -... R MOVED Fx p AMe. ? Fw L ?,Rlinf ? nX ? u° W t - 11 ? ,E, .Owns ? L-. /JL7?ry"SC_?f/E7DT.. wAI?'I?°F rw er ?AAU. ?c;? 1?'c'°' GS?I"[DiHV « @? 1 ? ?E',' 'T. AM51 r 1 Av eADr AGEHCY pwn KI DISIAt[MD POL GATTO nnfEgr ABry p R 1,: ':; ' tf ) 1 1 s I E .. , c=F r I ?Y , wr d Si U?. . SIM S AYIE OF WASHIiVCy-rnt v i lLE tq? AGE OI I1 No ? /, 1V? POLICE TRAFFI 4TRAFFICWAY . C COLLISION REPORT POLICECOMPLANINUMDER PRIVATE WAY G fU{ uIS N aus N courvlr R O rN q" IYD ,rIR IxYN, 1.1 ,4A1 X _P RD (USE ] I couNT q f/ - cnr NO, L ?u Rw p - ?/sG ? ( Al SR[fIOk HIGNWwY ?N ?E ?IN CrY ORIOWN NAME. N. iCt Cl3 DM I% ROUlf 045INFFI CO SICIGN / Mlfs ?s ?W gG nsr/,E6 ON / / ;: INIEX CNNGWITH:SIXEEIORROAD NON INIERSf T- BETWEEN STREET 6 / D stRFEt PRENX f0. MILE FOSi I? / S 41SIwNC[50 YF?lON iN Rfi fNCf C405311RFEIOR NEARESIMIIE ACCIDENr a S F RAMP DIAGRAMMtA Q /? MILEAGE n Et Q ? OF CODE COIIIl ONrNVIXV[0: EVf91Y. IOTA NO. NO. KILLED?NO.INJURED? ?sA IIAGE ? ILSILUN rurv" I" m Rp IN CING IR-R.AD0k REPERENCE INTER is CROSssuctl RR OAD O N ]] CE"N'c',[S PNORg1YO-AGE ONLY ? LES NFU ? VfHCIF ? ./ I j-. / 11IEC151RUCX INNAFOi ODI[CI SIRUCIAN-14111's 1) Est DAMAGE SECAICODINGUSF $ UNIT NO. 1 x rvex s NAME: s F-T U NITNO.4 ? VEHICLE [3 PEDESTRIAN [I PEDALCVCLIST - ]+ l DklvfRs NAmf: usr II T MIDDLE uxfss CITY SiAIF , D SlRfft ADORfll 31P CODE PHONFNO. -c?J' ^/ 9?yD 9735 R IIY SIAIE IP ODE PNONE NO. .-. OxrvfN'1lICFNSF NO. SIAIE E% I BIRTN I DIV X'1UCENSF NO S1AlE SE 0 DA °,r ?.R V . X IA1EOFBIgIH MD DAY rN e CCCUPAiION NRM NAMf6PHONFNO. EYES WEIGHT HOMI E R OCCUPATION FIRM NPMEB PHONE NO. EYES WEIONf MILHi '? " Y ? CHECK (.? IfI aFASnr'I?unROrFioFwHOlNec'A COD S N ? (?) CHECK CIF AI AN FMPIOVe[OF ANOTiRfRAL ? _ e L? 5 F a «orox. r a CODES P t J n" a is 5 u 6 M° , I n 5 ? A-- ? I?YEAN MCI ? 1181n. ? ?r;Kfs ? r°' euuV< ;???ol ? A« F ? In"' ? 11. El C,r;2 t ? r.N11 . IDODGF{HEV.) MOOfIIDPRIWVA1 STYLE I]DR CON V.1 N. r... MM ( f NEV.1 MODFI IDARNNGVAI Yl 13Dq:C v.l Y _ 10 Z OR IICLNS[RAiErv Y . l IAIE H E ~3B ? 19 RATE NO. SI ? AIE I VEH.CIX R N l N. I L A V[NI?fIDfNNNCAN ON NO 4[ r C . L VEHICLE I1E1IIfIG1I NN S(J 9 REG111EREOOWNER : IAlI {Ig51 MIDDY PHONE NO. O RE ISIENLD WN[N: lgsi fIR51 MIDDLE Nf NO. lyl G AGDxessa ow..lR W N A OWNR Ohl E AM[6ADDRE55UINSURANC[CO. ORAGINT Zi'IN;^U 'tCFp?TA ^ ONAwEO M[A " ,r ' N • A S ?AMa ARU CHARGE / CHARGE RvrlNc r] o"Nn+"rcFi Ll?'t i^? nnuR e'i"'ivovcl ISL. pAMAG[ 'RIVEN - " 91 , 101 pri ? WwY ?9[MAINfO ?AWAYN ?REMAIN[D EST.-- ' t? oev ol C` ^]i ' s r J ?'tD AOwtD l Ar Br. J do N. / ? war erS 1777777 _ DIAGRAM OF COILI ION: I„ wpncM NAI INDrcAIE rvo... DE5CRIPTION OF COLLISION; I- SUkrl[mfNiAL SN[[ru N[cESSwgr) _ deil,ale / /.d<r s Soa/r 6 J ! n P / % > C i , u. / n/ I] Site/Ce'C-A?? ?l?l.• /1'C'ol !J/ Cf?l/3A? /% C: ll - -' -' '? _ - ? - ?e'///G/B ? //Pn%` G?f• /'7i ?= u/rJ T ,f A c%r. / e- "? G' .J/1/G d Orr? CJ !cl 9% rs ?J? ! / / r / r O i - ..Z'r. rfr, ii:9d?%r /i.r.+G/f' %n ?a/i fJ' Ln?X?= v . /oG/CI ulfE?e/? Tdi?es/ire Iv ./ ?elySW NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED " CODES 1 - Z 3 4 5 6 OCCUPANTS/WITNESSES IFDO bD?t10NAlT RAA ,ML 4I11 SEX AGE rA1V' ''i o" pX' 1 1 11 r YE SIR EJECT ;6 d T Fyn //? / X S /f i1o. / 27 1 1-3 w MYrl\ Y)!')C- NATUYIOF XINLMY" ?AM y ?M ? "I e ?Ci ?CYN I M I, Nuwta LG rkcvA ?AMe. ?racl?"o ?^;T ?r:° ?ryly? DDRIIl v"NRMS°` rEa BY" ?AMe. ? ILL ?[g; ?f:ii ? iO1rly , IIGaIV rOpFKtR1EMW SPAHX YApGE tN AGINCr vwld {?/!?F5 [LlDyL1D Itp giroRf AI.YOVIO! DAII n - ? - ' X y Q 1) t '.M T. x M1? 1 ? i 1 t Z f n- 1 I , ' 1) u, t ? 1. ? dl?I y.x 4 I,Yl J IPl Y7 f t - ?L I? ? I ? ? P y , A t? 7 t ?Y ?. y : t e?.m 1 t N 41 x a v a .v oalm [P, 0 0 or o g.?m 1 1 ? ' ? ,? , }?>t ?Yf r0 f ?'i'rnr Ott l 1 . r ! ti x kl ?-Sk ? [ ? ? 1 ? i d ??? ! mf '( I n1 ? ???hSl ? I 1 )Ikf fl wSK ? n? 5 n ? t" ?, j h?. c.-i F f 1'av , •.R ?,;? 1 ? F 7 t ?. ??,?, x .r ?' ,' f7?xoc r'..' ?6 ?._?' Jr E A ??t , F 4 ? T ?! 7 ? E? ? s kY.s SU>? x x ' .3: . J AL POLICE TRAFFIC COLLVN REPORT 'f TRAFFICWAY ppllcf uNt HUMBER PRIVATE WAY xl f CthI SK]N, .i?D. o.r'cU AY O O W rxl w F, .I TWl C ID E].ODHOURJ OUNTY 1y; COUNfY.W ) CHY NO. . HWA 0 HMI wN SIP-Et OR HIGHWAY T ?N ?E OIN GI YORTO H ?IrAVlfs s OW ?,0F(f, n I ?OA ON FCT CLS ADI a5 I ROUT!OR54E SE LION IN ENSECHNG To: REETOR ROAD vONINIf4kC110N FIx EO. mqf POST e1 \. - BE1WffN SIREETI SHIIET ' w l0 1 Dlsu"cfAD ;ON N41FHN .C4UUSiRffl Oq NfARESiM f S L lf5 N 5 F W G IZ: iFEi OF ? AJ x,4 41 ACCIDENT MILEAGE CODE p x DAGRAMDATA <OIt15K)N INVIXVED. kVf41fY: '? ? N t6 RUN ? SPILLAGE NO K LLED NO INJURED (OTAlNO vutt4"' X?ND ME IR 45 ft RE I q gN[PEPfNCF CNCiS31RFEt R p^p ^ - - . Df VEHCLES PROPERLY DAMAGEON'LY ?'.MH 1ED ?Vf?itt ? ? ! ¢/S'O ? . OBRmTRLICXINAME OE OBJ 51RUCK MDOWNER'S wwFl fs1. DAMAGE SPECMI CODING USE - UNITNO. 1 UNITNO. 2. ? VEHICLE 0 PEDESTRIAN O PEDALCYCLIST ]A Dgn(JF•?'s Nw^e: IASr 1 mlDGL( ORIVENSNWAE N51 IN I'LkT- -' \ tC it 6? 3t4Ff1ADpREU AZ 14I r 13u 33 17 TaEFI ADDRESS UIY S1AIf ZIPCOOf PrgNENO D Illy SIAIE ZIP OD -ULA,. 5'.4.3a S b¢ ` R , Ex LICENYN sx•t S yd743 SiAIE wn kX M OA "° j'e l" c I V IV-ICENSE NO. SIAIE fX DAif Of BIN1H B occlIPA1NJN NM NAMF^PEN)NE NO. fYkS IGHT EEIGNI E OCCUPATION FIRM NAMEA PHONE NO. EYES WEIW111EIGHt ?CHECK (.l) veHCiF AS AN FMnovEEA AVLiTHE ?A ?CHECK(?) VfH<If ASAN FMPLVOVFFOG ANO,HFiAL ? I CODES ? * D c- A y "" / S e Kw / 6 ; p CODES ? G 'c K ° 5 Ex 6 su Jx' /f UVi,IfS AVI w :f H. ? ." ? : ! ' ? .BAE 10 O "_ m . 'e?; ° O .m-L O M" O Eb:D O n " VlH. YEAR -1(DOpGE{rEV.) ,.KAELIDART?NOVA) S1YlE 1]U4 CGNYI H YFA4 -11LOO5 fv.) MODfI EDARi.NGVAJ Y E] N. ) 0!', z E ]7- A1LI-Hl NO A ? .nHIaFIpeN11FKArK,N NO. 3%18 y ZO ? vfH:GGDENHH All NN I I RIGI......OWNS ?? NR31 MIOOI? PrgNf NO.4 A O 4E I IFNEDOWNER: LAST FI451 Mi°ME I NO. AD G, OwNE4 Y 6. S/ N A RE -IT T)1 'F L.t I C47 n S+r w: R E NAMFgADO4e5salNSUNANeE CO. DRAG.. R e A111111 OF Iluu AN ]] ]n^I.LAGI AifA ` "DT"..:,br, eHANCE nAMAG[ IKlA ] ; ] eHARee o"" R:o"G 1 » .10. loeurTO a Est. DAMAGE AW ? IAr ?0EMA1NID 1 ' 5 .x ,.D ?PRIVFN ?geMAINFp esr D,uw;e o°.T•.,-7s I AWAY 14? J ? t3OL u •_ ?Sl ,°?r+'Y°nr: ?it ?ekS.D GJ ? ?wA?Y°nY: $ . DIAGRAMOFCGILISIDN: ID u NAl IwI CAIE NO4m lusf suP PI eMENrnI SHffru NED[55.wrJ DESCRIPTIO.N OF COELISION: _ r iC K k;?2 _ _ . . . . . Driver„was notpaying attention left theroa overcorrected for skid and went into he-roit . chch.._ on the east side of county road 1112 4_ „ NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED ICODES 1 - 2 3 4 5 6 OCCUPANTS/ WITNESSES jq;,pp"'",pryµuNYr q}? S!A AG[ IATUt ";?" N p i$1q EIIO N AME.. _ 4., Sw 164 a At _ pp y CJ M ? S / I A ppgNf ,mE '';n'eJ. OAMA O.ml O",'. H.OF„'A' ?M I L?lllq.+t t^?,%I Mb? 162 z / A INYISf A k 0 v R?r In IICW QANb. ??: G O;'-'. O M' I ? 1i' RD ; NO ?AAH` X bVNtgAIYai VIKF.ShwN ^EANK AADGW A,;INCY Y FqI /glp'yA1C1xD ??V P pAiI OF RIKJgT NPPOVEDnY Arl ?,.? n .n 33'.YY [[ I.A }j? a ? r ? d J 1 , ?1t3J I i ' F aC ' 1bF fTi 'M1Hrl :.A§ C E yb tl? I r tom,'. I ? S M ?? I r PIS ?: ? 1t R Y ?'13??J POLICE TRAFFIC COL NREPORT ILRJIHAHF11. Ar Pales nAwrNUMefR ?I 7 PRIVATE WAY 3 --t-6111 DAY 01 CO AuoS w E ZEOO r,ME IUS NOURI counir COVNI?? Orr NO. 1 >t? iHwu URBAN O ? n ? _ V-p !O J 2 ®N J. ON CITY 09IOWN A'Af6NO Of SiRFEi OR NGNWAY N ICI OS A C ROUT OY Sr l 5 IION Y(' ? •D ??/ -"o,, ?w 0 jAm oG ON . ? NIERSECiSNG NNN: S14tt104 ROAD NONIN1f45EC110N / PREFIX EO. MIlE P031`? ? = BETWEEN STREET 6 C L IRFEI DISTANCE p IXMP Rfif NC .CVO531rvfE1 OR NEANE51M lE Sl ? " M u N 5 E W ACCIDENT MILEAGE DIAGRAM MfA w All ' !7 iEFt Of C CODE CIXIIi ONINVpVTO SEVEROY, SP LIAGE H118RUN NO.INJUR(D I ? LJ KIIIFD NO wNOelom N N fER XRD CIS WIE 51 OR ROAp 4RUtRENCE UOSSSn Ffi0 9 ROAD IZS - . TOTAL NO dVEHICLES PROKRNDAMAGEOHLr ?9ESUlTED ?VfaCIE ? / r / 9 MIMI STRUCK INANE OF Oe1ECI STRUCK AND OWNER'S NAME) ESTDAMAGE 5PFCIALCODIN-It Y a R !• - asr G S `' • UNIT NO 1 UNIT NO.2 L ] VEHICLE O PEDESTRIAN 0 PEDALCYCLIST ?' om 9 # 5 DRWIV-TZZ;E: M, iIRSf E -1 IASI NR C-,o,. L b en"ow 7 _ SINEFTADDRE55 , 1 So lcg-A 51RtETA 7 A 7 -91 F2 STALE ZIP CODE ONE NO. D I SIAIE ZI C E P 1 okl GWNSE 9R54? 184--93 R - -ER 'S UCENSENO. Co-U--TD' fG3L1 SIAM f% D B H W M Op p.YRSC6 I V R LONSENO. STATE SF% M dB,RI Mp i pY i _ U?PAIKJN C `c ?q HRMNAMESPHONENO. EYES M:IGHIHEIGHI E OCCUPAION IDIM NAME HONE NO. EYES IGNIHEIGHT '-" 2 p / L SNOlF MAIV RN 10 R - 0 CHECK( Nn Ps aN MrtorF o A?orHER? vE ? CHECK( nEASA NovEE a AN - vEH - J CODES J? + 13 a . " s°nn "r 5 utcr off a s":en 'ca CODES b ' a oii E i+ir ?" a wm°c'c Dp n N D"w:.!Rp ? MNAAN f ? °A6 ' ? C96. 6EJ : " ? a T EPf; ? AN NE< ? D ?yKf "86. O K 2D O i ° p. _ MAKE IDGDGF{HfV.I " M EIIDARrNOVAI SI-IRDR: CONY I -E 1 HEV.j r YEAR MO ll I?NDVAI 1 R .) rR0•. 7 7 ? U D E I 5 ? Cf ? . SIAIE AI1 RauER RArENO S H W-1.-OR u u n . AI ? D -2 I p $ vEHKI[IDEMIfICAtldl NO. ` VFnICIf DENT iIUII N I 17S17!/'6!5; !NI i l l l 1 1 1 IStEVfODWNtR: US HR51 M,DIX R[GISRRfDOWNER RSt MIDIXf PHONl NO SI I : U , . V O S M c Aflmc I,t_ I - - PppNISSd OWNE9 N A R NE9 51 - ? 2 ? t E _ QI?4TN , V . HAMI.AODEE55OPIN3URANCf CO.1AGf R ,nU . p ]] j c"L..Ip ? gAMAaeD a ?'? k ; - _ ,VHCripnAl CN od CNPR p I?vc O?ORO?E" tSi. DAINAG[ W^Y ?RIMAINED ?AWI V ORTMNNED tSI. DAASMiE 10 ?0l1OM S or4L 21 i,w:v er: 1 /v wai en S _ DIAGRAM OFC VISION Dc oEq IN DESCRIPTION OF COLLISION ItISt 5u KEME -SHEET fNECESSARY) '_ _ Wf1a NtU55MY1 Mf T. _ I ZVER D S E.V V ? O R S E tCURVf i 1T E R H E E A o D -A M fi V C 1 G I F I• 'I - _ F.. ..I .G R. _, _. OOGJ !v oL G T LoST. P T _ E ? E ..T D _ . ? ._ T .?/L ? 9 ,. I tljg Y- CIA,— SrRU r? T!/&v RacGEa OVER AMD fL f1 CcwER E E ; y ._ .. _ ._ - .? _ __ L! ID ! .. ; :_ vcN 54NIE..m ,PEST .oN e o/ LERS -- s - r I - __ ___ P F .? ClNY C XMA?cT fGL? -.I EEi. I° NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED f CODES 1 - Z 3 4 5 6 "rye ' - OCCUPANTS /WITNESSES IUSE sLwHerAemu sa FOR ADdIWNAL NAMI n SI - -- - 51% AG, IAIL M INf C- - - - fRQ ; P ?. NAME: ?Q r • AOpaliS 4: SCAM eY. AM e. O t? 1 O nl • O ?M. ? {ruNM I A - A N f ........ _..._.... ..._ ... .. ....... ... --.. _.. µns q. NO NAllNfd-.. .Al,. ?AMn. pHAKIOnI isP O 7, C]I:p N r • _ ? ? ? A DDKns NANVFd -... . NlLFR rs O KI wN. wier" OAMe ?u. ?rom. OG; ?:° I + ' X JDD.IaG f f eA tiE OR .Dr Gi {r N•nI K/D,WA(Gap 20?? IO?YMl AYR.?V10 O ? ` DAlld Rl pql APRO EDeY DAZE L. DO Rt R °Y. ?F ;Y x' ry STATE OF WAIINGTON AOE / WS ISOIRN,L9P) N a POLICE TRAFFIC COLLISION REPORT (ETRAFFICWAY Ij o 9/?/a o7 -.carARNNiNUMbFq 7 •a cool oN E) PRIVATE WAY r w. _ .ry J, .. •, P IIMf couNrv Iw , (USF 2•atigU9 w+ E5. wiR Y COUNrv NO. arv . ) Q OL Q X t Cn vo J ?Fr-c25c .J QFURBwN /G ?N taE Qw ?urvogrowN wtar - r4f - cnwnr l AA N S ? W 3OF O GR ? ? - os geurF 3 . -- ? 4; wr 9sfeil wlrNsr9feroq RO•D NoN wrtgsfenON logo J ? y y ,?,`• 5 5 CE6 R BFiW[[N Sr9E06 MNf f -UT SSSI9fE . ((,? rititry,Q u CeEY) S E W fSfM4 MRES N ACCIDENTIAORAM [A /'s? HfT Or MILEAGE -._ -_a, qE. ,r„{r -s p- CIXUSKNRINVIXVB} f rv! CODE -.? -. R ?py.-?' NO.4RIED D N E NO lOiAI NO IN1u4 D? ? ? Mh IGwI V N . 1 •• ' ?? . [D . F Ni _%J(R SRIIUG! N R iNS OF VlNK[ES I90rfgrv0AMA0F ONEr ? p S[I[[RP OLII? ? NiClf R I qy CgO1SBIgHIOOpMp O° If cw ? ` ? OBriCi5r4uCK( •MF OF OBJECr Siq«RAND OWNfgS NAM[) 9 [sr. D.vAAee -r S? srcewcooR4DUSt a /?! . F } .' :. .•...--•:'-,: UNITN0.1 £ IASr VEHIQE. s DRN[IY NN•E. - ? ? FEDFSTRIAM.I Q PEDALCYCUST as N F`•"" ' "'r< AM: -RJ JAJ 1 Ll!-} - srREernoo9E ? _ •oDREss [AST I --! - - - "?- ` Ca t s r C7- z CICEko 2L to fIaCO E- i R Eq1 uCtNiE S A, 1 / 2353 s L M Iz?rz ilz v -? «curnr RM NAmE aFNONE NO. Ens IDNr NEicFlr E z RcTd BLul55 5`g R Q CHECK (i7 vfN AFA A ANOrwe uE I I ueA FIRM NAME t 4FgNE N0. lYES CHECK IONr D IG11 ?. iA. 't " NODES?+ nA"'"• / • T in s uernoN / e wi°n°C = - CODES ?+17 vfgitt[ + w win - A von 2 Z ?9 os p C N•. _ - -- 3 . r? =NM- ? m! •N« K ? ? slg4 ? ?..N ? ?i ? Y?,.? Q --o ? I- . Q oil. o ? ? u .. ' I VfN. YEAR lIOOOGE{NfV.I Ell AR NWA) SrvIE (ROR. ONV.I 10 - 7 n ?" K ( tV.l MODfl10AA Al /i0+. v iMPEfL1Al, A{ bfe E _ z 1 ??? SrAi RLUIl9 gArl NO VAi FI vEK CIXOR R(FR7 ?? ? Z73 L ? _ __ p r NCit 10tH IIGrgN NO. C VENT IDtNEII ' ?. ? - I 13 M ?-l 115 8:Q;5i L REC SR/RTFDOWN 9: IASt I f195r DOLE I i I I I I I _d^, 41, As DRI `((- RgNI NO. O R OWNtR: U5l IRS •? 1 1- T: I' Aoo4ess ev ovmee W }E L N • OWNERS E NAmet AO°etSSnlNwgANU eo. E?Aeenr ?I o Lotil l Z F?F"jAj M ?U R n x F ? i iUian a Est. SOD ? WAr 4LM/,INt6' ? D9MN efAwNfo [s.D •rar s !?'4Vi n r ."rJn AY ' } E.. DIAGRAM OF COLL1510 AFB •E ?rIUG9/I?BV, AW ? S ioeortor rryl _, aJ 2 n )-IenvfeaswW? Br Aglow DESCRIPTION OF COll1510N_Ifn/wvMf rA<Sleet rNEassar) I I I I I j 6 ??-' pt,. ua cR 1Fcr? R?u?i2?Ro f-f Wu _so f5_o+J UPPER f?•?i.E2 L?yF,lj s , v i I i - I I ? -- - RIJeR gI.ACY.6A 04T_?N D ?'?).'"Jy?TC's IS' yt , - _'1-- I i - ,?_I -? f jQ N oFF __RIGHr _SNOU146f'v-1!!Tp ON ' S I ? I IaI- ?' 1? tW r r I PERSON '4 la NAME, ADDRESS & INJURIES OF S INVOLVED + -•- u f °t' OCCUPANTS /WITNESSES a.nlMtaa swfr CODES_ 1 2 3 3 6? ,' { ,, h Nwr AOprK)N•l - - -- 3H R1 E .M._ - NIfMIIS i 8 ?.?? s?B3! •Me NNCRf i;0"T ON""N uc'r?"'. ,,?? {?r,.l t -° .[ V "a, n lASCAJ .CA ?l a .?? .r-. I ? Am! `S ( N•rura ?? RMOV)or9cM DAMS. . ? 1- nr,a E .RF NDr n/v c . ? ?x i4.N,, x r-V . ?AMB Q?w?c!? ..? O?wv - '} ,,; X a. 506Argq urrcrn NAw .• s•PUw •uNC INAn,ES°r---- • C?r ??N? ,. ! N. wrOr ._ ID?Y•tOeo RKKI .. "0 DArf- , ArAWloB W DArI . -r A) Ill.- 11 ?? M,a 1 nay t ' sl& ? . 4 2?EIF. -. <.M CV SM MxES .•Q© ••...•.: •,:.,r;?CITY. TOWN a,.»•. 1 AOA.cI • - ??9 nf?ti G/y??. SECTyxkl: oc ?1CTrFGVIVi QUl J ?T ©© OF v5 /!?'?/ ' '1VT. r ,.. GVE NAMEOF pEETJ10A0 HNLIWAY ,. - ,;; WTERSELtW0 W1TM: STREET OR ROAD _ PREFIX EO - E G IIONINfERSECTIONLOCA1gN OF CO SIGN ? RAMP.^I p ) F1ETwEEN STREET ANO S1pEET 1.-' I1y/Ep ICTEyJ• =4 CnO`ISSwONM IEVOSr OngEiaiKllw.rn u1Mly)jF(p.•nipCE. MHI2S Fv rvGlwpL) __p NON %RD INTER INTEfl LS. G cE Oa E ©® or Z roreei Resort TOLUArDS mues Cmek< ro O - m IED ENKIE Y-L ?VEw[ E ?0I.ERIwnIN sON M SPEC CODE USE ? rvFHC ES ? t..__1 ?vFHKIFYFOfsrnAN ?4G. Ca saN ?Hllnurv '.- .""-^ ! 1 tt: DWECTSTRUCK INA4E pDW1FCI4r4UCKl •„ OWNER OFOB[I?ECTSNAMEANO AESS?!'? LOCAT I f-?,/ T Yom E Ec iJ e fE So X nr/Ve a7ex, N OAO ION A WAY, FEET ?© foce R CO T' ORIVETISLASTNAME MIDDLE C11eRalx Lt rd '% rd 11 -B Fit- tv4 CNIS I wonED DRIVERS UST NAME FIRST NAME MIDDLE^ - F -6- S9/2,uel STREET ADDRESS .. .. ROUTE NO.ANp BOX NO. MDRENIAN IVq STREET ADDRESS ROUTENO.AN000%NO. ISo ?u 11CO,I 'Rae =Fg.-+ e `wnnto ScA o _ftSt , O .T3 CITY .. STATE. ;. ;:•-...,. ZWCODE_ DIVVERSOCCUPATION sErMATE CITY STATE . ': ZIF=DE _ DR UPATiON : ( ? Y4vn Y,TO CO 9S8ZS (?' NYKse1Du' E-1 F N _ ,.. Jlacal4_ WA S3S?s -E .. .. . DHIVERSLICENSE NUMBEfl ,. 4J 5 Y80 STATE SEX. CA r TEOf[4RTH DA i4 3 RGE ?6 DPoVERSUCENSE HUMBER FL-n&-6-s- 3s7, ST?YiE X `WASE r DATEOFBIRM. AGE .o VEN.LEYp. MAKEICHEV. DOOOEI: MOOELINOVA-0ART) - BODYSTYLEMDR.) VEHICLEYTE MAKEICHEV.4OEGE) MODELINOVA0AR0.: 801YSTYLEIIDR,I ^ . 4`•4 TJYo A Ce41cV1. 2 U2 -4( VoLC3A.OLA,o CINmeA)G ,c. 2 b2 LICENSEPUTENO. STATE":..:. .: TRAAERPLATE NO.,, ,,;..STATE 1s5148 A WCENSEPLATENO. _ STATE..... _ TRAIL ER PLATEND. :STATE ?. ROM 6 W IA VEHICLEWENTIFICATIONNO. .. 11968MOOELS6 NEWERI. ODOMETER IMILEADEI VEHICLE xIENTIROATI0NN0.. -.: 11V6BMOOELS6NEWER) '.(MxEAGE 2H Z1S 3S Z 1-+36 2- REDSFHEOCINER LA9Tf1RSt MIDOI.E NAMEI -,, .. ,'. DRIVERS LICENSE NO REGISTEREDOVINER (LASi FIRST-DOLENAME),:_ DRNER911C ^NO. ,. C4.ere.x Qu ?trrd t kd'v ?ecr I'l W4 OV EIES A[I? 4 LSTRUTCITYANDSTATE) !Se 3 ?a E Rve Y ?i9c7o 6A - DATEOFORTH t - ? OWNERSADURESS .: I1,1_ PTREET,GT2Y?ANOSTATE) „• ,,,, -s/ore /t d. 0,,.I,?1GAi, V JA DATECFIRTM b D r rEAn ..iFD E6 SnMAifowsl rMiSOF VFHK3,F t•-: w vfR?E SrnEP R ro - P'L r . 'fS PARTSOFVEHICLEDAMAGED .. :`. io Ri.GwDV (',tE. 2?+. u^lOl°r nQer -•G t?f s rooo WAS THERE AUTOMOBILE UABIUTY WSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- COVERAGE IN EFFECT FORTHISACLDENT CN YOUR CIR YES ?NO NNEEANOAODRESSOFU UTYWSUR EPOMYHOLDER ?..- NAMEOFUA&UTYNSURMICECOMPANY :. ^. „ ..,_ ..':.:. GI f (PLC-la.r ?' rr??nElSo 1fp S9u't E: C.R 95815 J¢//S7 7? NwFANDADp1E590F WBXTTY W.rA1pANCE AGENT ... Glv ATE.:: b. UAp"I III NUMBER ,,... .: Ss I •f}er tom o,tT..l SY; FnAnc.s,- CA fl// 2-:7 134 66 Z 541 cb W NAAIE JUn ADOnE59 rN°NAAU s ..._ AGE SE% ?M 6 wAm`A [D ® 2ND INJURY: -, 'NSF -M,I.- FOR-FgrvAIA',KA4LM NAME ADDRESS o NAKU ___ ADE F OBEx_n x ® G'ooctom E'4N " ®© ' =?"' Y SIATUSOF 4,/UREp ?pwen VIVEHICLE OR•6E NUq '•uf_.., WILED M-IRST AN•p p° IXKRIt ONET-AF% NW14.&M INwOM ES ^ STANSOF4EJUREp ?ORVEn WVENICLE OrASSENOfn ? KILLED MARKFIRST ?fNaLM ILEHn(1 ONETHAT AFF- NONDY• M IM"?NOr, IF E. 1 Cn t C Iw 6E3N ?,T n.rn WRr1E N ? 5? 60 I Ol rAw llC 70 ? HRn wnl rE.?N ? 50 e? I 70 SlOVVNORTHBVFRROWWG CLE wc.e e4G16nAM.. O \ L lvice e1e•A? cli ! YG,nro51?:." ?. I?,H ? ,???, r.or:E.Y A.ME a \ ,-DESC.I BELOWW,IATHAPPENEO?(REEFMTOWNICLE3 BYwm8E11 WH'GA_CQ'Tr yal,rvly-_•CF'._^_l_9!_'4EiCS._e/'eeK,_? l?e_h•clc'??! of a r?x_r _ ?( Pr d?ecd et? 2S_f+? SD!7PN Cru `• fp d? ? ?JTN o,nlrr '! 'auC ( w /'05 f ' wnrKoEV? ""F MWOr°i°W ? 9 _ _S . ..-. _ . ?PP I l l ? 5 -.? Q.- A?E?Dar.D?wAr IwFX ETA?s?_ve ,.? ec_ 7? ,_y.._ r wvrs_f.NSS_w??._3?r'?1_enT._ihe_4?r?e ----' _ -•-- -14Ne_cv.,,_4, _ -_--"----' "CYOIN6 We3+ b ?.,s ?J- i ? vf- !aq V rLK?EdIr _2r5_f{GNt._bun,pNr__SZructSy?{,?_- -- Cam] CQ?L? ?? lG Ctr.L../w?, lea.- --• - So.A+I,Sl.cre ? i? _a1PAccECle?-?-------------------- ? 1M.IDAHG.M.. / I d Wi43 r'IREK6o At %N Y}rTe ?J - W'{2J OiAld? VEHICLES POSITIONS BEFOR E COLLISION No pIAM• Y NCE L Vc- ...ffVM INVESTIGATED BY KIIICIE N S [ W W 6TIILET On HIGHWAY NAME ON No G/"iICfKH r •11xnrA fE .. r rARIEO UNMI n• vEHtt[iC•D AG. ?i:Arn"(X ?S_ IN"Cl "' MAn 1 ? ? (? Sou j? SkO2c QokD O?.)E ? ? ? ? ? ? 1 ?;"aYICE ?•q:rw°N. oN4? ? ? ? s d L. s,E O?JF ? ? n ? ? ? 0..." ? ? ? ? uDrO . c° ri_ , Foots DIRECION TD DIRECTION INDESIH4AN \VAM1 lr6rN0 '•? I?SIDE- I?WMKW.AY DO E liom-i •0= 6? C 6 OilRfl ROAUSIAIrACE WEATHER IIGHTCCnN1ION3 twmcoNtROL ICNECKOMI TYPEOIIAAD ?.KTr wr rn"ele. NHKIe aDNE rY 1 1 ??? u 1 ?DAVLXNr O 1 O E1H(VIAL9 O` H 0 ONE W? 1 ?r t ?pIY t O HNN4r(1 2 0 DA" 0 2 0 61oP TA(HI 2 0 T14V WAY 0 2 0 WLT '0 EJrOWINn J 0 WSK 0 0 0 11IDSIOH 0 2 0 RC? rmc pIM•ER/VEMK.}E ACiK]Nl vrHCU n:HEC4 aNE LYA MGfI .. I??p GGNG STRAGinT MEAD 0 2 1fy ownTAXNG AND PAS5M ? ? D 4AKN0 RIGHT TURN ? l 0 f".1. DAR', 3tn1'(T LK.Ht00N ? • ? FIA,n rq 11kO ? • ? NIERC r? • ? IUVO E ? ? E ? MAKI DLEFT TURN T? I H KC ! ?? 41H1 ginHEi ? 6 OrI A•.II NO AMIIIR ? 6 OAIEEV s {-I L) 9 n 50%T1, Orr " ? 0 0 6 OMAKING U TUNN I T F ?., (yc Yr_I!'rv?YGMY g 6 ?TIAn_ TM WAY K M) ? 6 0RR ,WIN. ? 6 0l 1rEFfflK'V1t6 ET It 6 06LOWIND f r4-o. rFJT'.rEMTOANDEN . q r0Y ? r 00r11C1TfLLGMAN L ay0aw.nr l.c.n r 0 / ?6TomoroNTOAF/IC / re ) uCl A ?ON.En.U•EGrY C) 0 1 0!{PMAIFp LIrVLAIU 1 C rHgp " VQr NaF ? 6 ?0.5T,IW9NIONAL / ? E' y ee /, ` LNI'Y y ? 2 ? pNDEO H?GCAQ • VLT„G?( ?+ , 1 Q 4Q Q 3 "•LI 2 w fi I STOMMINROADWAY 0 D ? ?'2 l 10 ` . NO 1 K; DL.1 y3 UNDIV OED I. M r MRNO ? IO ? STTnIFFICLANE .. arw AOprE3, ? 11 ? P1111` I'OFRO"N /1 / S ? TA ... N1fR 1K1 L. f7 cT+2 ? Rltt '- Y M1 A fibr „1 ( ?F {Ln r qy AC eEY 17v^ A >?i L P r F 4 r {i lY?i ? .. qn 1 3 G •tl. a , vk TF fl 1? y trio a {.?, - T s ? a a A. ? a` r J r.. ?} 2+ r { I +t ) I k L'. II Y{.?? i r1r .T Irx?,'JI. 77 /1.I~ 1 rv•I I 3.f l b'04 9j r ,rM TOFVVEHICLE COLLISION AEPORT'' MtEOFCOW90N,C': [M MYOFCOLIia0r1EN a•I IIF: '.vT.EOF COQ ON M-AM - COURYN/O//?' ?ITYNO .,. NES wF0 m PM . 1'!«'ci'S?j :pfAllk'?/.1 ?`iC,iW Rf1''?y [.IV`yC ruE ,u, L[g, IN Yis.aywraUTY.iONN.vr-IM•.. rprtSAx MKEGaw (??'E ...«:.G`EY.TOYM:(AJCwv n`:l-0. Aj..h: ADM PTIE ROUTE mm'-' ECTgN ?Lv90F ?Ih Ca Nl1 C.. LcYCS` f nonOW 'u V. OVENAMEOi STPEET.ROAD ORMIGIIWAY,f,'Yty`.`:i.^..:ir':i NTERSECTNO WITM.'9TREEi OII ROADY.r'rk-. h;i P - •n EO S NONINTEFMCTION-AIgNOFCOW I.' (NMP" T EEMEEN - STREETANOx ---.. .. pDyE RTwVE? Y NKPSECrNOSIPEETO 1 PP• I Mi, ON E©Eqq /Rnwo.uLE ?EPO9 rrnD ou.x.. °DE wT'Eg-•NOK1Fx ;.;+'s?g*?E?u 4?ISFCrnH. Ec.i. ©EO Or U l? WLLF MC ` VI'C .fl l?J. ? '?'. .- , cDFF SronwwlvtD J5 LE tt ?v < ? - (/ r SPECCOC€LOEY Y <KD VE.c Es ?' t_4-..? ? 'E rn.n ?rwn E ? nTFNx / ?-•a"J -5 I .a a 0097 IF OWECTSTRUCR ..:: ......'.. I..+•LOmrtRSrnucRE..„... J... .....'.:OVMEADFOBIECTSNAMEIJIOADOREa9 N 110ADWAY AOAO O Fv OAKCr . ... FEET EDOC. Ir AKAE TNN. • • .: 1GRIYFRBLABTHAME »x4c4 FU3 NAME ,..« w,. YaMOD E wOCR9 DPo ERSI.ASTNAME . . . FNSr-C AtlOEIE':_ :' wERW ?vOLVFD h?°0.;:.::1' ? C>-? Wei.. (?DEION? Ga..cu ?:??.L_?cd ?c?. SFREETADORE59. ,,}} .::'^.:ik (POLITE Iq. ANOEOXN03 9TREET(nA]OORE53 :. ROUTENO. Oa0%NO.y '. G .7 ? ' rNC 1?\: JA yl , ;? 'NDCaADRSnfE -I cll. r- CIATY ..:. STATE'.JXa :,LP000EL CPoVEA4000UPAigN ....s.'.. U GEY L .;:.., aiATE. .,ZW CUOE:: OFFNEIt9000UPATgN:: wQ aW 9vlh iG:L ???ie .d Lv R. GLVFP9LICExlENVMeFM1is k:,;2A2CF55r STALE. 9E%. -\WTEOR&RTM^i 'AGE: ?' DRNENsuceNlE 9iATE SEIG. 6YTE OP SIR7H,:. ;AOEr (_-DCl-U6 -4!4Zfd Lti4 b ^r i Z2 CR -se - Ql a3rZD urn y P Ab Dr rEM 70 C1EYR+: MA,[N?EIG11EVr000GE1: MODELINAO?VA0ARr1:,.: EODTSTYLEI2OR2%ir:: VEHICIEYR'. MAXEICHEY.-0jODDEIA?. MOCDEI(gVA0ART)3 EODYSTYI.EI2011'•i+- , 2i, vEHI ULG1=r ..7 Ff .a. 3C 1 l YO'nllGL LG I l4NEj, 4C. LgENSEPUTENOa' ..:1.".STATE?ERf# 3,ilIMFAiLATgTpi?.i' ::+:L?STATfl:.;J'? ,,;UCENSEPIATENO. . :, -.. ,S1ATC:??: _nTME,ER PLATE NO. yy .y,l: STATEiuii!'. ffn w l? kF I s''A t?A rE111CLEgENtIFICATIOHMFi:ETP.iC',:L'.E1.VSB.MOOEt81HEWER/•Y. OOOMElEHIMNEAOE) .? "? YEHICLEIDEMIWOATIONHO_:aY?.E,DSB.ERpHB?•NEWFATy?:?. CR?_. ??l .o 7,Z. `?°?; i•FPiSY,'MgDIGNAMF] =• ;DfNF1FaUGEN6BRD„W:,,pK. PEGSTEHEOOW.EN.,;;riiW4T:F??ENA!AEryy+.+• ^^(+?ORrv `uETgtiL. Sc:w.z Tss ribov OwNEIISAO0RE64,r,IL:{?y yYlL'E(gEJ!E?Ti?!ATEkMl.CY.in4'.Gi .:A,wTEOCaIRRF:: ovIRERSADONE53.',:':a:i:u::?ISrPEEr,CTE'(ANDSrAiE]. <j ,p:,:I,;y*. :;;LMMTE wB61'f: . - b IF- PMrSORVEE.c?oAM?'.;.3+ti0M'?LITIFSIi?'n`,..3i3..+.rv5r-v G EDms •t PMBOPVEHCEEDAMA6F81Kt : .r!r l.. .?:N' x'itEG= ?''? (lo " C nd s r { E T ?-Y?YES WAS THERE AUTOMOBILE UABIfTY INSURANCE yyA ?NO LIABILITYINSURANCEINFO RMATION•VEHICLE NOI COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR UABIIRYNSUR/JM,ECOIAPAMI: M-.?: «.i.tifnl. NANEAHDAOOREMWOFLVCLIIYNS TRANCE FC"DY HOLDER.::A"Li 1 NAME OF rWAE .ADDRESS !E 2F ?7+ SwYwe a cbn o?:? ?uNd E ist{ a tce NAME AMOApOHESDOEIIAIWiY tl6UPAHCEAGFNT: t?r.ij 4.v,.c :•',,::.: Or.`....;E` u... T.Ai!...... '.:::.. ;:: WOIUTY. .NUMBER .::_,, .. SEi ly5-o ? .,?.} ...rod '1 AGE 2NDIIUUPY J'., ,' NEEBEPAMTfiPEPM iMADORXY. n4wwE31, •_..v iir;S ' AOEy; IST NAAFE h •TOIAL': NAME AOORF93 _-_ ,'.sExE': .•?r' ADDRESS __-- t Ir".rD:wAwFS -- -- 4 9 roi:Nwlts _-- ?_t1 DDwAA axO xt a C? ADR ® E rEMw Amcroxr ...E STATti, USOF WWNED •m{r : AEAiiKFNSTONETIWTAPPL M i-,L .+a. i'. .SrATUSCFN.lAtEO ::....Jr;r :..: Fir qTM 7 ly irY tlFVEI•CEE owAerur.a ?WVK WVEHICLE- rED [E N Iw.ao IaA.NErei QPASSE WLLED ASERNDVExiI IDpy pI ?n mArr FBLLED FsEvER pntxD'«arrE.,H O 5Q B? 7[:] ?OTxER wRrtE.w' ? s? BE] 70 STOW NORTH qr M1gW N CIRCLrTE[[ :v:t4w:'RYF!!_??TNAPPETIII?Ei1RTOVEIOCLE89Y-MIDFJi,,.5'l? ,ti .2 xIA.ANI a I.v Fla N.Dw _L`!i$lr ?.F 'L?0.?.__?Q??n1r?.(G? tZ-1- 4c451.]lG _? D? vFQ?- NeIM=N_ - ?4Y'k%_-CQ.OLQ?`+L63Y?V?4?t vse.__-?+•ps.Y.-b] Ll?,b..._-c.F,.r_vcc ?.r_ditJ 1 - i?"m?"11! ' E CltF_c saw d-41'DJ?= . :? ??]L: J_ DELI ?_; a at+?Y\ C.ALtY.-E ?r.?ET[Si?4. VEIiICLESPOSITIONSBEFORECOLLISION w veNCU ve.cu tl ST10ATEO BY oni a rer.xNw u .ur .AEe il.eu«evD Qii:al ?°o"I'fei VEHCIE . e E W ON STREET OII NgHWAY NAME OR NO 6MCTAW M Kn Aq t5 W Ran ? O ??? So .`t1n' "SIAie re iQ' .`+ :lf ..Qd f"4>r ?.O •`',l? : ? '° Oz 70, 0'S O%`OCE ?oAn 'a °". •4 :1 0 9 ? •i ...?L.. SY. L1 .!a f\d_ ? ? ? ? ? ? J$J- v. A ?.? ? ? AttAU ;r `;;1 :;:•.E,A?,;D ;,,1 ,. a'TIgMi;'.DIRECTION,'{iTo E'.DIRECTIM IFDES}NWFW..U 10 DE- - 20 WKMYAY4 a?ENOULOER AOc E? e'.IOMS?wEADFX e?OTHER Iq OSF:NIKS ..;. M(ATNEA,!?I. UGHTCCNGTIDNe R; CONTROL:q K!ficRO!G. TYPE OF ROAD. '•u iJ DIIrr[R/Y[1KlC ACTgN!„(?y,{ `,j.:: yp v[KU c=M! VHrtp2 IF K c dt.-I n•FCn MI rQ2 NOI N0E Ip1 • 'I 1 ® l.. I ®pArlGNi ? 1 ? YDNYS ? 1 ? ONE WAY Ly I ® GOING ETt INR NFEAO D9 n2plr 2 0 RWA-KI z Q DASH Q 20 SToF_ 21 2® TWO WAY Q 2 Q OVERTAX Nq PASSINO r?1 M?rI N LvCI 2 IC -t D ?rwOYANO D Q DBAR ? - ? WELD SET. ? D Q bPylll! O 2 Q M.NDRoaHmmm ? A ? SSW • ? f00 A ? 0E? ""E"t Q A ? tLAVNq RED ? E Q NTfK-ANCE ? • Q YAlfIq LEFT TURN e1PFR STT. UGHTT! ? ? ! Q m4smNO AMBER Q S Q ALLEV O e Q MAXNGU•TURV ? • Oct S ONES ! ? OAFK LICHISOIA ? e Q ELOYoNa , ? S ? wc- ? I1[Gm a ?OM NO E ? m MEY AL ? E ? ?TTU WAY. KAR0.1011Igr S[LNO DAIgf11.:.Qlii?. r O$tlGrv ? ! ? OIIIfl RIMDMMI 1:1 r ? STOPPED FOR TRAFF q 90NAL ..,v'FnD..rw L,rA.clpw E+El V•? ? e ?OTHER. SPECIFY Q.i.?=ATED. ? a ? STOPPED D AT IDN G I I TLc? C CT C` L2 O 2 loft O E Q STOPPED IN PDAOWAY ' T FK D Ey UNGNDED ?0 -1 to 10 1 PAIFgp ANT. -? •-•nr..:e -.... _ _ 4.. .... nT.Q°w.V>-. 4wAMb DMAehuMddYirlJ?MfTIlOMi4AAMY!REartw^.?I c>c Y Y 5 " , - N L ? s S pF spa; D r R, rr k? t m LiSAE -. 1 ,.0.GLY9utii' P OLICE TRAFFIC COLLI 1, )N REPORT ?I TRAFFICWAY 4pD? E? ,INI NUMBER El PRIVATE WAY palE Oicaus Ar N 1 Sf Rx00 HOUR) ly , 4 w. r9 "4 MF munrr NO. CIIYNO. iHWA X? 2 O O ?p ' EMSU H ' VYRAN lo C1*2-1 4M / cIlYdrow N ? ?E ? N AME INO OF SrPlE(O WGNWAY k CIS I ROVI OR SEC / .q5. -80 s 0w OFD` /p hr ON o zr/t Ao, Irl1[RkCI VniN. 5f9fEIO4 Wap NpN INitRSfCiI N O .-J? /SD / J ??II BEIW[EN ?/[ O? SlRffi b ? SIR[fT 4vfil% FO. Mlll40S} ?/?.? ?'V JJ ?} / 015*ANCf 6pI fCl I .CROSS SrRfEfO4 NEARFSIM IF Si ACCIDENT ES 5 [ w , 9AMR DIAG RAM !A n / MCOAG E i rlE .c Or R -.5--ID: kvER rv1 ,,yy Tom NO rw %ILtFO??NO.INJV9F0? ?-LA.' 0A NISRDN Iy pjonri a"CUS PRORERtYOAMAGl ONLY ?FRE RESULTED ?V[I?Cf R? N INtf CIx.50 OIOB55lRElTOR IIOAD TER! OBJECT S1RUCR(NAMf OF d.fCl5i4V[K ANDOWNFR'S NNAE) IST.OAMAGE SKCWCApRw USE -'- S UNIT NO.1 UNITNO.2 L 09NE4 rlR t J VEHICLE ?PEOESTRIAN ?PEDALCYQIST xa MID E ? A.1' i9/7E ? b i pNVF9' NAM Sr l - - sr4ki REE ADd 2 ox 8? f urv srwt nR COOt R wrvE w. D I r Ar R NfR'SIAM E% 1 N ( IVR' LI NO. At A l ?5?? M ..J MO I 4A. YI. V r IYR- i w OC<URANON AMf b RKINf NO. EYES GHI IEwNi B I E -Al- R119M NAM! { iNOrvf NO. EYE, f3 ': Q 2 R Minr IlK,ID ? CHECK( %sa%sMi Yr NorNEO4 r vEN1a CODES * F A ' ' ' ? CHECK (? vN eASwN wxorEE ANOINER. 9 9 9 ?yy 10- 3 o:u 3 r KI w I 1 z s.sD 6 "s a°N ° K' ? cu CODES ? * 3 n:u A mNNNI 3 IACroN 6 swn r 7 7 7 ; j 2 IN u4I[' w °°• I UP ?AMNAANCI :: ?,8'R4 ? n Aa ? 4G Ow NcE ? rPocl - ? K?Inle ? K ? Ivwsr a r FN YN9 AM%?f IIwOGE CN[V.1 Fl ID,.--YA) S1YU IRDR C V 1 A9 / / . IX E Sr EE H -YEAR v.l MmEt (DARr.NOVAI 1 A A LRAllFR 0.ALEN SrAiE c-P38S W? ? vfN IXOR LC' ? VENI EIDfNiiICA1wNW vFNCIEONI I N 5 4 A087AZ9298o 4tG5RRlD OWN" LA51 Si Mlppl! RHONE N0 L ? I iIIIiI ISf D 1 -bAN MM4t55 OF O N - O W LSI r195t 9a N. A 9 Z ?+ 2 82GA QU°1C?Iu E A Nt9 NAM[a ApD91-0'. RA co. DR-1 )AMADE AREA D ' R OR =z? IY n r "'S"a°;R,'f cNARU aly? ? a?AON"a gAMAGe?ARrw p A A o a R lSi pMEAD t ? AW.M\V ? 4 MNfO ? AW Y ?4WAINfD t51. MAAG! I IOr R AO O'i S OiOI t ^ t f (/ 10.E DBY ? tOWSO I 17 P2 DIAGRAMOFCOLLISI N u N p AIE rwR1N DESCRIPTIONOFCOllI510N lull suRNMfNfK SlIfErIWCESyA9 { gRpw » R n[l1Ir N[CESIAR E e I _. .. _ _.__ All ' Ir I ? /'V ?4%d . •....?IrFT _?D:" 4 r.?_v+17f)k!l .., I NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ? CODES 1 - 2 3 4 S 6 OCCUPANTS/ WITNESSES Euk slrnweNru v rd ApgigNAl NAM AM nl I51 - LEM AG! IAiIJy vAr_ 'Ny?N -wr la ,.-,--,, Mlcr Rf 5t9 IXCf A r n N I t Y AM e. 0 cAR- ? wrll. ?Dx ?IUrNE1 A .. rw. A004153 AMI NATIIRfd. RMWEOIYOM?AM{. o,-" wl R?w Or:; p q f AOdI\S .. NA RId 1 ?rGK1 ?Cl?E QpT. E_In INN Rf In ?AMe Nu ' Am. ?rvI51K DrIK1RSrNM/ARAN aALGEd AGINCY ;I DM1rAICMO 101K1 AE41 5 OAtld 111dt AMROVID EY DAII p x O rw ??- !7 (c s G 5.1lslm ?4.'S>'N+S -?^ I 1 {Pa ?,IJ $ 9• t, rn {+ d C tl > ? ' y! u A .?._."r.17"A. ?'- ?;?ir '{th.'hY$ Tir ..? y.w.v.?."- ._. S ? '1?5'utlu li'17e?F?i,?a?.t? rYrl'n.'av?^ - •.. iW....r _.Ye; ? ?.:aLYG?rY.;?r? ? W3.1591REV. I"ml STATE OF WASHINGTON POLICE TRAFFIC COLLISION REPORT DE i DE I TRAFfICWAY ® No. IvllcECOmnurvrNlvIxv '•° 2 x i . ? PRIVATE WAY AI u `O. o+r , A x.No- ;N .. -ym ?a.i nm 1? •aoNOURI courr ?-• muNrc NO. / ur 4'"?.'??r +'?,: f? Nw u?µ. _ ?N F ? CIIY ONOWN N faNO.O EROR NKNWAY nWotv8 i •3MXt3 s ? CS RWr N 4 Wrf4 nO WIr.Y.3rNfROR RO NON INRR3FRI000OOO??????,,,, II fM'f!N 1?3t+fR1 !!-Q 0- ?/t?Ylee? RlNX 7-F ,/q ?(p ?•7' '-° 1 n R cRD$$$r+f NfARE3 I //c0 //?? D11.3 o MNF3 5 t w IZ E.:..? {!er or ACCIDENT MILEAGE I L R/'MP •. D,f - w E ` ,.... r" ' CIX11510NINVVEVlD: ND.INIURED ?3VIlIAOE NO KIII[D nNl UN I!? ? I WrIWIR'iNf IINRR' X fnossarauTa4ROAD ROAD "fft°f L - ? O. TML I,VL TIRE pVtNICIti ? n RgOKR1YDAMAOE ONLY ? n IXfN f / - OalfCl3i+aa NAMf O{Oa,ECrsinKK ANDOWNER'3 NAMfl hJ / Far. DAWAOE S SRKINCODNROIat,-". r7t1'Y;6', _ wT ° ,:.:..__: _. _;UNETNO:.T._ ...-.:•.. ,. -.'.:'.• ' :- UNIT NO. 2.- ? VEHICLE. . 0PEDESSRLW 0PEDAUYCUSr; Z r.°I A - s o nErs IA31 MOT- E-cbpun.-F -A1ub ? f6 , }n ICJ nR ADORtti L ?y' ?: Z• arr? rAIE zi.?o vNONEra DR A-, 31A DNN YSU fN• 3iAr I lZ? 5 11a N V ,.. a?raN „RM NAMeaE,aNENO frES Iwr r E t7t PATE v u No. A w Mo r tN I w I VRAl1pN IRM NNAt ll '11-1 : " L ? CHECK (.e) IvtN AN rt aAlmiolwa. ? CHECK(. vt 1 I0WI-ANO1NlR. ODES ? 1 e:1° A X i S! a Mornxr CODES 7 a sn.?•"' s ucrw a a+wrr rcu r w C 14 ws 0 0 c'96' 30 7Z. 0 10-' M6. 0 'I I 31Ylt INDR"COrv) r R AgOEI IDMIwOVAI Y V NJDOE{.rtV IR "L -? vfN. YFAR I.l LIDARr-MVA ° 1 720 3 E X „ IDI V .??• t [ R1A 3rA1?? 1NA11(R 0.A1t NO. 31A1 i VEN.<IX R TJ. ^,1 VtNKlt lpeM6KAfKN NO. - C vfNIC IDENII. i 2 11 DI t01 I L I i l l l .I I I! I f RI 0`7 nGl3nn0DVwfR: {, tr {IRSr DnEf R.x]Nf NO. I Rf wNfa: IASI NRSt MI NO. - ?c Ali Dke A ut? B. w ? ADq?'fpphNtR (?? fl§ - 2 f'Og IS3 rT• ?f'3Ctt,A7.SE7V? E'' , 1 b - NAMesAOO+esspww+ANa eo.pAee t R s ..t g•, A • pCMAG? ARfA Ra..IM ? 4 MNt • .w ?? CNMGe T•_ - CNARGf OI"1 .e. ?i - 3 RfAWNEO 9fMAlwO 1 " f ' O?OTtO..? ? AW,V ? ?AW Y ? f .D•t IOIDTr E I AA.RAM rIw CDar. OF COLLISION: fu M INOKAIe la+rN DESCRIPTIONOF COLLISION: lose surrl[MeNru sNFnn NepssNlrl l; ,? ,JJ I• _1 __._._.er ARROw -.... _ _ t l11G?T"iOAT$sve ' ? A ?y y v ,6aucd.. (.etv? ?.r??r.?-fSirr?-airy loss= ? ? , _. ??•---i-t? f _?1_ '.-i-?-- - [.etv c P"-STJf°G1GD.C"?•?T=?+IIEeGLt1/QT. ?. ?'?4?.P T L ' , 61 ?- '? ...- NAME, ADDRESS 8INJURIES OF PERSONS I too su E f usw OCCUPANTS/WITNESSES laAwrKN l u e NVOLVED R sl *CODES - - u Aoe 1 ui 2 ?Ntl» V:r 3 S 6 N, - Nrc•': nsn, t!1 . i ?, 7y d ` !.' +nD+ea _- - N•ru• of AMa ?M, ? 1 0 If PEI= - -. Z/ •rlntlv",(JE---- y L-1 7 1 .MwlDI nAMS. ?'r;"lO"" 'N"a'. ? v ` r E u i?' ? ? , .. AIA Jr r?o}}fl??•• NIA,R? , '?•^ ? IN111r. ? N•,- ? • ?Kf rw ' wv. n n MR ~" :gJ? ' ¢??Jf.'F ?° "•""II? T ` - ( - N 1 ro•r•,r. p.Kl•y 1 •Arv ?.I X 7UA r+C zv Kt D1y/ ,r[wD 4`l? lOl AO o•n nRWr D io Mn ?0'2? l? (? !! I ?Ep!r f I o ,4 4m. I. LLf l f ? p Sb POLICE TRAFFIC COLLISION REPORT US TNAFFICWAY ppIICF COMPIAMlNUMBfR C] PRIVATE WAY DMEO,CIXI N Aq S YD 'C R,A »R Ill:AY AIR, "X DME (USE afoo HOURI OZ o COUNTY .? ?rFr?lI,? COu-No. All "'N. fHNA URBAN RAE ' f 0N 0E [3IN CItYOR rOwN NAMFBNO.OiSIPfETOR n,GNWwY / ' N.l ClS AM 5 YE RWfORSR 9?i6Q' SFCI ZMlfS his pw of el-Ir-WCclm ON C. ae, /? • as IN>ERSECTING Wi1n. STRffr OR ROAD NONENI[RSFCiION BFM'FfN STREET 6 S(vtFi PvUI% EO. MllE P031 ??Q.f?- / 6 OISIANC 60: A lE5 i SRf E .< O5 SfRtEt UR NEAREST MRE P031 w or h rr-/sccrjr-, G.2•/ Y /0J ACCIDENT MCODEE RAMP DIAGRNA DArq CIXIISIONINVOIV[O• SEVfR,tY: R tOtM NO NQ MLIFD?NO.INIURED-L- ?SP l1aGE 40 oxRl11 x.RO INrfR Cl5 IN SRFf 9ROAD ORN R( CROSSSiPEft g R O OvAD ''17 6VEH CEPS 0 PROPERIr DAMAGE 1 ? iR[S?ITI. ! ' " ? ( / / ? ?7? _ 9 OBIKT$TREKKINSMEOi MiI 5TRUKI DOWNER'SN EE ST. OOMAGE SECIAI CODINGVE 5 UNIT NO. 1 UNITNO.2 0 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 24 5 D---NONE: I/SI fIRSr 5 mAd sIX DRrvER3 NAME: IASr "`?'k131- ARM! ] ° $TRlfiADDREiS 1 `I Al• ?10 m -V D.- 2 T ?? Nf NO. D r STATE PC E Alt'4 42- ./ /.[l>! } JO 3>3- y a) R DRNlRSUCtNSEN 0-S7•AM-S4/20 & stal oA fX TRH D'oz (. v ---N.- AIE DA BIRTH ? OCCUAwllpf FIRM NArAEE VIgNf NO. EYES iGHt HEIGHT E OCCUPATION FIRM NMEf6 PHONE NO. EYES IGHI HlIGMi :, 'At / l7 S =CG R ? CHECK(. yfHlc fasnNlMgorf Ar?omlRAE ?CHECK (,,) 'EyfH OF ASAN-OYEFOFANOTHfRM r CODES ?H' 3 nA33 .sn / 3 f Kr oN / e'E'„°E1O,.'cY CODES ? 3 5 ex<IwH a sM°.n•cle - n ? INl E, s N ? A»Ha N11 C] s: n, ? Kls ?ra o 0 MIX ? a:Rv o w ? n. r Y Po M V TLM MAKE IDODGF.CHfV.) ? fl10AR1•rgVA) STY EIa DR..COVV.) X FAR .) N9DEl1 Mt A) M 1 -(I.R., IX'' rp 13 (,R C,rr? v M / E I W V OR Ct YIA STATE RNEER-A IE N01 SIRE H. A VEMC OR l A W[Jr ?2?-ZS6l \ 1 WfS ^V C ar ICIF IOFMH CAigN NO. EHKIf IDENIiICAU rvl V "3 G S ?'S4 P 7 Z 791w'?' L I I 1 1 I I .....r( "4'0`CR: EASE NRSI M,DIXE 3L IJ SAN/EC S PHONt NO. O t ISR t0 WNER: LA51 iIP51 MI 1 Iz ADORlssa -owrv1. eR 544,/9 N A awNfR 3 / / TA CK ? /1') / /cca W[S E NAN[E ADanualNSURUKecD. oe AG(Nr No n! ? R u I ax DX&lD%lA IjAMACIP AAFA %N . GE D A/ /y M W^v ? WR(MMN(D DRIV[H ? -VE ?1-NID I jplf0? ° f S"0 D^ ? ios^ DeY ? IUe f DIAGRAMOFCOUISION 1 N I-C-NO»r . DESCRIPTION OF COLLISION (EESF SImnfine lu sw[rlr NfassARYt s .1 .... .I .:..?. ... VCHic I-e NOI.._I- .bWA.S _ /+lp,(Y//__Qi A..NO... f•i?NO/•/ ".... ? v ! ? ' Odes Scc..._.CcnlrP.l..L?NE _CAr/SEiA??_ .?'C'.NECLL .L.L '..: .,_. Nd /To .Sf/CAL?E _rO .AUDIO... A_. GO (1150__. ? BNT- QNNNAN (f /N T-a O/YC"' . NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 3 4 5 6 OCCUPANTS WITNESSES in:ro?`II[n?[f."Err?[uu i su AGf uws 'U. ;' : nsiE. rna 81 AMI A DNISS NAIpR d Br, ?AM B. ?m 1 ? "' . ?YBT otal.,. AMf w %' R DlNls1 NAIURIp ' • MT- 13AM4 0CT." ?"•' M. ? 7 0". rl o W rN 4 f 1 A Df`Rltt 1[A1110? p [3 ISAKI o 1 Br. R ? 1 ? ll [37 /?sIASAtWG01•SIR 3IMM{{.AIIK X /? N?yA??I I BAUGIW '•NU I? WINCr ? 3,.1,I GSV KIDISPAICHIU otzl mHRS MEKt A.IINU oz7L sRaD lns OAT{p Xgl(R/r A.rRONDBY ?O lI'/i DAZE w? • k , [A Y I 1. ?A HIA (l? 1g + Sr+ I?v, I I s r r _IF?t r( d 1 r s t?NM ? i r - E t F.TU 7 i. r ? al 1 I I _ _ 1 ? + :,Z,'A3E2 &rc. '•rO"?ue?m?E.Y?`u?r A`i.'? Y'p?fA ?Y3.G9?.v,,.._.. :sh 1l'.?5..,..?-. __. ?ili,:" `dViV51,NZ-ca "?:......?...15x' ?_' ,.;?a; 'y -? --- oFFICIALUSEO LY ) .Iltl - T 1 . *4 r TT 'J r MOTOR VEHICLE COLLISION REPORT •+-f". OAlE OFCOLILVON DA MO , SIn1 Y Q E Y Of CALU s wE0 R SON twEOF fAWSIOH - urE° UA t " COUHTYNO CITY NO 1'r -t / ' L .2 ?•I PM : 30 ` ??O ' ?1 HTY CT,TOVM.- O U WnE E G DYr M E -. Gtt, TOWN M I LES ?N © . DM{LU.; PREFIX sm auE Enc .,ECrION (r `? (/ -IIPr"if r.S C f.1 C h E •. T An r pw ^ ? /? ` L Q OF C[? EM", vi nl ?? 4 K ./!J•"?lf?/!/1_.. AC OH GIVENNAEOFSTPEET. ROADOR HIGHWAY M AcD`%wr ODU") • ?'eHc /g rf.?uNP[P - VITERSECTWOVATN?BiREET OR ROAD PREFI% EO REPOST ?'!?}? Dl y.; NON INTERSECTION LOCATION OFCOLLIY N flA , dADflAM DATA r"IL - _ BETWEEN J•. STREETAND STREET t vor ©© nAiiI. 'wTSSww xiliros FErNNK.wIw?,YN ?nuNe[p nwCGE. +rtnSFC ©® Mfr T d?Ac.••?£Nl aw on+; o?Gc?.l.'? Iccq? /,'S O INTER 1E CLS fd FIA[E[ I]VfN cYCI `Borw[Alwwr4 00 CduSKW wYa ?vErICIE V OvFHKI uN •.'? r LNO O Y[.PCI ?v :? E OW SPEC GORE USE _ ) -. .rr T.-- - -.. FNKI[5 ? ( ?PEOES r D ?, h ,E MAN O InN SNn ?NI A1,N ?? ' a C _ .,. ODIECTSTRUCK INAUE CF OMFCrsITNKKI OWNEROPOBIECTSNAMEANDAOORE58 - LOCAT INROAD ION WAY o4 FEET O u caR.-, r - p11NER5LAST NAME _,. •FlRSTNMIE MIDDLE s WE Y.- ORIVERSLASTNAME [ FWSTNAME mlom SIREETADDRESS ROUTENO.ANDECI IIDAE INAN lwo STREEr ADDRESS ROUTENO.ANDSO%NO. }'o C;cx 35? I'II.-B-.1 -A ruWEO A .:. CITY. SLATE ,.?. LPCODE. duVERSOCCUPATN)N SdAnATE U°Ox CITY,...... -STATE ?.. ZIPC(IDE W1111S000UPATR)N? _'.. hi rn??cru fn 'IL 4. c g1 _5. L wockt? 'M:1/ nEfOR dM .m.s I)CFNSE HUMBER ': - "+ STATE SE% 13 ?J • tJD Y3 .J 39D2 E * - 11 DATE OF&flTM- _> 17 d'J AGE ;3z : ORWERSmENSENUMBER STATE SE% F TEOF&RM R. DAY AGE VEHICLEYR. MANEICHEY.DODOEL MOpELItg1VA-0ELRT).'. DODY r' r- - ) VEHMAE YR. MANE ICHEv.-wDGE) MODEL(NOVADARTJ . BOOYSTYLE12DR.). ,.: 7 S c-8 - F•150 qepc LICENSE PLATENO. STATE . TRAILERP ATE-, I STATE CQ td"7 3z mash, LICENSE PLATENO. STATE '. TRAJLERPLATENO. _STATE W ETERIMILEAGE) vEHND.EIDENnFM:AigNNO. ,.., (IBBBMCUELSANEWER) VEHN:LE IDENTIRCATgNNO. OBBBMODELSANEWERI OOMETERt-EAGEI ; .5"1' (11 ?p A- 9Y a7of;gb f NE.StERE00WNFA IIASTFWS-E-EI DRIVERSUCENSENO. REGISTEREDOWNER IUSi FIriST M00LE NAME)..-., ,DWVERS LN:ENSENO.... R u la c? SF R{:Y Sc RN z r4 y7 Ss.3YD'7 OSVNERSADDRE ?' IS TREET,CRYANOSTATE),. "-" DATEDF&RTH . OWNEHSADORESS : - ISTREET,CITY.ANDSTATE)... 1D` N DATE o f'c scx 35 i Ca n'UH 9SS3? etirR,A Ad wr TEAR _3 1 7 . MD v[ 7;;S VEHCfLCDAAAAGED, - S Fr'n • E-A, l? ... .. ._.. ... /S J,/9 FsnM -ISO' VEHICLE DAMAGED ocpnT r?REP nvErxCtE: .... IS WASTIIERE AUTOMOBILEUABILIrY INSURANCE ?VES ?NO LIABILITY INSURANCEINFORMATION•VEHICLE NO.1 (AVER AGE W EFFECT FOR THIS ACCIDENT CH YOUR CAR '' NAMEOF UA&LItt WSURANCE COMPANY ,:.-.'.? ...,... _,: N ME IRO ADORESSOFLUIVUTY WSUPAN CE PoLICY HOLDER ....: - .• EP nTwrE . E T 17 no Lrc 312 or H', rYA '!M` E 3:3a i - c E/Aj 00L, NAME ANDADCRESSOPlIA1rilTYWSURANCE AO NT ", -.,. _. alY ,...... srAl[, ,_, ? xo UnBIUTY T'OUCY NUMBER ?...,: '. C o 'f - J J S r L" 5 ZU .S G 2 d Q T ' E it o c N la U C: I ?u E IsTWJURY• _ '-?:/ .' NAME .1cCCy AGE ITIAAL 2NDIWUflY:. IuSESEPMMEn11CNlrURADdlIOIMLINA%MS ;..'.. NAME ---'-'--------- . . -. AGE. ' . " r ?l 4T ADDRESS ?)C (\ll l.?._ !?.?_._r`?St L i M% ?C ADDRESS. ..._._ _.._ . _ , MK}C , . IA l N101FIJrAUA9 U IS t AL - ".I -. \..IL _ ___... 1 1 Ons _. __?_._??_? 0_IJ hs l 1 T ? N,NV FA STMUSOFVAAWED -B ONy{R WVEHCIF. ?nASCANCFK .-,. PILED MARRFWST q:MnIAIC ISFHAn CNETHATAPPLIE HON dSAN Nw[iM S F?M1.J . STArIISOF IKIURED QOPoVFH IN VEHICLE ?PAS,ANDLn N%LED M..... W - S IsEVEAH ONE THAT APPLI ACwAMAA- IMwOP1 ES P0.5wE' VE t QPECF°rMNr NO 0:; 1,.=:,.-rEI„ O s? s8 Or 7,611, ORdnlMAN NO I ? 5E] s? OrPEW ETCI E] 70 SHOW NORIHDY AnROW WGRCLE \ ' . OESCR BE BELOW WHAT HAPPENEO:tREfER tO VEHICLES BY NUMB[TD'? 1 _ r rruc[Fr,[ Mf Cn INA! r H CpN°pl [rt.?wAnIA! fw \ -Al °NwPr- AC rt _. .. .. r : 2 dMCA N _. 2 +' _ O! v . Y I VEHICLES POSITIONS BEFO VE X r RE COLLISION oN Starr glwNWAr HAMF on la pulClfWC 1[°ul+n `wo».D `naD rRU Y: 1 .o.c?i«cl:?io WvearlDArco nv ?o:ina ?n?i i H A N s [ 11 b I.drt ? © Cl ? . ou /t'c•?? /s / ITn ? ? ? ? (q ? Ln ? 8 c ?COK[ ?UYH„ATI. _ ? ? ? ? ? ? O ? I ? ? eAnl Rrr p ? p ? AIo CC AOawn n10M DIRECTION To DIRECTION "."s1RANWASIITAAIK) I?-W- 20WMMWAY ]0 :IIOU10[TI A?A?A [] OTHER ROAC` W"CE KNAE, UMI ,A 1 I W[AtHFR 1 N D ArrM LI[IH[Ca10IRCVS 1 p DAYIf Ir -F iccO tlloL K.1c-o Ktl ?1 1 ? :XVIMA r,KOFROAD W?,E MC ?I I1f0 d( WAY dwnLVk-tEACTt0N3 ILUECF ONC d1 MC1rtI 1 ?Wnq Bn".T MrtAO ? I porlY 2 ?AW T 0DAW p p sp w. J Ly i eTWCI WAY ? 2 ? mr.PTAKINOANDPAG"" ? 2 ? WfT D ?GAIAAM) Z ? DUSK ? D ? W1,Dul, ? D ? I%A0 www^ ? O ? MAKVIn RIGHT NIIN ? J ?:NOW A ?r00 A ? lnNfD IONFI ? A ? IlA'A•Wr1 iIm ? 1 ? WII rIC1l Mrnf P ? A ? MAKAIO LOFT 1UnN ? A L9 cr A on II ?ISPfGIYI -K 51111 e! °?L-3 'IF ? A ?IIA!..,-AMAIN I fDOP/RAV C] S pAll II ? A ?MAKPIOII•iIWN nl •[N ? A ? AA'fifY A N [IAMK NO ? C (3 R S,- ? A ? TWn WAY. IFT ? A [] 140W1AN1 NLR L F srO1M`EDfOR TRAN: C] n pore "FC111 5 ANfO?NO(srRVA DARN CR srn(ET I.-I's L / ? Of`11LCiRfY ? / C) OIIK;rR iIARMAN ANfs ? ? qi ?M lift 141111 I ' If `1 T4L k, p 1 ?'JPMAIFU ? A ?TNO OnOfTAL ?S11? ? 2 ?dNMOwpp? - ? 0 ? °T01TED4W PoADWAY 1 ,'?'tTR' Il lyixp °: r'?i 11[A •mrv^ ???I'?jl :., I,.1A Y ?'L, ?I1r? f11+?? .',= MMIIIyY JI ??' WL•I•A INfV. 1.0 0, '' - STATE OF WASHINGTON nL DI No. :?? ,,o?rrss P Ar ti n v:?•' POLICE TRAFFIC COLLISION REPORT tal TRArNcwnY ,a„LE COmP1nININwnlmx '-'- ?' k ?' °i " > - - un rcc ,uv HU l Da+uE COIF or+ nmE PRIVATE WAY couNlr tturvrrnxT arr NO r Y '? r [ (?? a% Sb 1 4f N: f.I L R, rt: AI C CIIYOH IOw NVOE ?IN IVSI /'!rl r10UR1 g7nn N !r .. r. ? •AfSNU Of 51I Ox 11GIIWnY II. Cr GS Um 4 A 5 vUU1FOYSlkkEICUL[ ['J L MAN < 6' IM: R` Y , L C / ps , w-,?Dr Cc]AJ/s.Nr ON Co.[A,TI '??/S' ; •=r.".• f ?G? - _ IlFSrCnrlG W IH;tR [I Oy AV NON NI[RSlCIIUN wEIN C??Nh'e fM 6N+FFI e Ce,4-,?e /^ swNN: r UIV InNC t I gNNU! N ' RRffl% [U. MIIf HJSt . • 'i' y .2z ] - , -"I .• ,A 1 1 r / . A1 A E vENCf CFCl55;iXfN UV rv!n.E5lm tt ROSI !lr l? eES 5 [ tIol c?A I' /' [_lrtn O D9 C7 O oldA?m4C ACCIDENT MREAGE CODE rnv CRAM Mtn ?.. O . , LUl11atNl1 DIVID [v[Y:fY: 7Utl R Ur1 IOIAI NO. OKII[D_NO. IN/URED- ?SP IMAGE ?1rq ruNlhlRiN IN IN N %-RO N1fR CIS NI-l M1',51XIEl OX kll%'.•ui Xt.tkENCE CR0;551REETOR- ] ' a A': ( ? O`vDUClls Ix pRORFRtYONAALf QNIY ?IIIIF IFITI. ?V[aCtF? % ? ' + j UN1ICr 51RUCKINAIAF Of OiUrCI STR?U+CK NIV OwN[R SNNAEI 'IT"' SM[W COOING USf 2 • ?'nq? ; UNIT NO. I U+.v [N'SNNAt' 1/31 MI Otf UNIT NO.2 UXIVfN'S NAME: ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST U54 rlx5f ?? t ]q k:?u L, • R ' ?+' C•IPi?T?.il JrFF?-?E S - a k ' * s.+f. I,WUXt51 r, ox z ?c SrXEfI AVUXE'3 ,5 ? - y ?, t srn1F ZIPCODf PHONE NO D 1111 SrAif 111O M wNtN Pr - Er-. - 41 ?.'rcWfJS?n/rt?, LJ CC. yy J'6ry BS-06b I? R L2 ? L VINStCtNXNO Sinl[ IIAII UTIN I -1-UCENSt NO. IA1F S% n if Cr UIXIN r a r t 11ON. 110 fYF v u.rr E OCCUPAIIUN EFM NAME r. 1-1-f NO. Er15 vrt 14H r210E11 T, ? -J CHECK (?, p . r 1+oIHEn:AI 't ? CHECK (?) of ns nN nviriNg of 4oN=Tl EUAI vtlHi v. [?. l CUT} n 9 c / 5 r crw 6 ?: j1 CODES ? 1-3 ssr q i+aiiM"' S rrt wN 6 ?n-.c•c.E - Cr ]] n ,Z. iN ? U,r; t f [ .. ? .,, .N.1 ? ? .,Il,x ? ^ ^!t ,.... ? nYN :,.r ? rou° ? rs rt. ? 2!, C `•S A VtN AN A•AFf IEriIUGf CHfV.I wWEI IUARNNOVAI Slr.f IRUX t?:'+v.) f M -3,MIEV.) MOMllO RUNOVAI 7 , [G E S J r ?03GG7 AM uAT C I CUIUN F l !. SA 1-1111 AIENU. '? IF `r L -' /rr, •' . t CA -1- p ""OFN AION v n C I n SD + •'] ' l wusexmow 1. lnsr ""' wolf '•1rol+f NO kle Srtvroo NzN: lul evsr mI rllf vHONtrvo. - - o.rsPSr?dre.? Gl S. Frou? 7:5-.3 ` o 1v4;S ?CIrOViNI¢ y ` W OwNt4 A"' OF ._0,150X 22SFY,OGYrr]P (.f/LL %.PS07 MkOnVORI55pINSaRANCf CO OXAGENI E x : U+ eaNCl Nn N . f!/o Tie R -» II ' l • CNA 1. CNARGF nsA?l HlHCnOHN DAinwr n A¢u ]1 .t -' ORO4 r S !51 UAAN4t O ? A DFDANNF' WAV / /1 ? ?REANINIV AWAY L5I VAMA4f ' 1'V°olt i S/ A OV ,. •-0 '? AWAYoy HIY< f/?KAO f ? WRpOr: t ? 111-.. ??/.•?J? ~ y DIAGRAM OF COI LI . SION: '. At wn cn rto¢rr I s e r AIII. S 2L1 NfC1S5A 1 DESCR IPTI ON OF COLLISION: IUSF SUpntmfrrtu5 tLr M r NFC[ssARrl ]s . Y?. .?.- E? , E - Q . - ?.. • ?.'• _ J( ??'?EC./8%(/QS/I'Q?Q/f.vy Snu-Y'fi 0'V . LTO[L<+le?/'urrz? _ ! / ' :? ' I ,u r/' `\14 J uNL•(A. •- ,^y .:K . h •--•k ]: X-''R C Y 4 CL'r I3 QN (N 23 7C.S?TAYf' TJ t QSS. RN C!/iN?.. l fc/O d,ihE- (1( e R! A s' b . ?,? - , ? ? - .. . e ' yo- . .ry 'I-o Fis?T?laL I. hQ. l e-{- o.? UPlr.c% Sf?r?i Z]E - 1 _ / ?? Q[Cr.l rJo, L[ To MO.'e Id'fv Fir LrE,? LoS>L! eo ?frw/ Vo./Ec.?-spteV Are -d ? ? • ? ? ... i•N C/<- ?i nt.vl /.??LTD/'?Ie P o%.4? f'd kCLrS I S/CIdA/ N f/ (LhcY roll- QIfP/?f(N't1/N? . J ,/ Df,1 Wke. /Cf lL,{'?.¢av 7?ir+'- Ho!/<Pso.ct . , ti s r ' L- NAME, ADDRESS ES OF PERSONS I OCCUPANTS WITNESSES ;"sL SUrnlmfmu srv NVOLVED u r CODES I s r - Z " " ' " A 5 m ° N } r oR AndDIwu NANI SI IK Act u us n r: w r:i w R rncl y' I Kwru F]o c 7? ci fl ! f /l? YYS- ry '1r. a [J Am u n e L7 .T" D Kf1 " ( ?"' 1 ? t }, ( N,- } T - ,,,.< f ( ? ! AMt f- ___L N . rn r ?, . n , R Sa fZ" 1 { f '' I} Y A ,?1' 1 'u A r N:XI55 q NAIU¢I Or R. IMOVIOIYUN K N ? ANe. ? r. ? n . ? M-1. ? ir _ er :11 M ( .7 . \ t ?, - Lr t i ? h,. { u?, l_ wt _ atDr ^u' NA , - K ti • 7 ` '( V'".. +` , NHt. rt.xr K;At .,Gplcu/s,7..wr1ANF eN¢a DN M-c r.r?G S N1 ou:w1 ¢,IKeosvuerau ]MO HVt l lA rulKUVV VTU Ob)r1v5 ?-, rj DAlavlvlrr (/ , - cj MN. nvrvtmoer ?ax ?.°t,u wlt '? r - { n 11 ?tA+?M*'3A.,i A 1M'-' nG'I+,t+tit' wv+:i.u11 T Y 1 N it I tip l Ik I l ahv Ir R T'u 17 l . I Ii = Irg? ?' r u ? `?, ?? ms's I ,r J r rf ? I I I 1yk !}< ? t ? ? 'fir I I rAr'a ?? -'? i 1 L J `I t? ll t .l 1 I. 04 M ? f',i f ?I }E114'E d 1?. J uq z@ ?? f. s a ,r e'=5...??96.....?.. b ' y sd ?wYS:2'r idY- i rg F? t FTr ?yP .hk vin m 4 CC11 ? '? t kr - '. I COIWTIt .w..e...:'GTY.TOWN .n?!: ?DPSOF McLES:n E."CRY-TOWN r N © - p 'C ?- ApACW... f [ ...FID? . xir R? w AA ©GI VAR Q .sr NEE .FW .lTi . jS- Ar _DIV EOF STREET,POAGORHOHWAY- _ EASECTWD VATH:9iflEEr 0R 110A0 .CM PREfI% EU .? MIFPpgT p/ ?.' . ?: .? y NON NlEN}ECTIONLOCAi10NOFC UEION ?f ? 5 ? 5l dt ff tWEEN ? StPEET ANO $ tREi [ MMP? ?L' DUORNA pATA? ?? -v .A? aFS'.aiR'?S''•?!?`C.-'°"'s?s?; {.•T'F,?.j; a E ;r rrOr ©© xES ?ob Esrrxl.xsFCrw°iraEEt xrww[r x°uSe WUe CapSVKLN IErosIdrPEilr FruglAHOK.WK. t r NON %?ID' tt?enq arae NDEn NlE0. WTEPr1 fDCrKYq PDFps. x fElrSFa gv: FEEL ©® OE , ;DUwN«v ?O r??virncEFOwFCr tED E ?amExlwwr[I Uf, '?(AyG? ? o°vFiKE ' I Es E 7 SPECCQDEUSE ]y,jA.. ? F„MNS {f f' ' .I. .. I_? .. ?vDrCtf PEDEar ? c°wspH ? WrR« .. OPJEOTSiflUCK INAMf OFO[RaT rErlN:4 - . pWNER(W BJ w aK?K ia. '^ %i7T' Yvnb Es: - +<t• n3 , . CG, . 0 Er-7EANDAE IN ROAD WAY...?FEET ?© 00[ i0 niiraileiECI • • DRIVERSt TNMEE FIRST NAME NOODLE IF -E AN lwpD WERE 081YER5 TNAME . • FINST NAME MN]{%E. ? ? r VF° w Ma .. c i; cow Dx STREET AGGRESS flOUIENO.ANOBONNO. . rEDRE tNAV Two SIAEETADD9ES9 ?/ Ae ;4 usF. E1O NO. AHOBO%NO. CITY .,.... .. LPCOOE ORVERSOCCUPATNON .. _ cOWSDH CITY. - ST TE L DE DRWERSOCCUPATION r E rF girvEPSLCENS BE ...-., F STATE 5E% :. ATEOF BWTN. AGE r. . DRIVERSIECENSE NUMBER y AY YEFR i STATE SE% DAiE OP GNITH ADE M F EN OAY ? l??? 1 vENCLE YR. MANE ICHEV.N]O-1 MOOEL(NOVAQARR. ffOOY SrYIEDDRI VEWLEYR MANEICHEV:DO MODEL "ARTI. -STYLE110R.1-.. A4 u . L MPLATEND.. .;. STALE :: .. TflNLERYLATE NQ: STATE I MISISEPLATEND. STATE -III TEND.. STATE.:;-? v HCLE IOENTUTCAtNlNNO. ..119 MOOEW SNEWERI '., OOOMETEA IMAEApEI WHCLEIGENTIR NO. :' LOSES MODEl98NEWEfR - OOMETER I L o1z ??? Z ?'oG?a R6Gr5lEPEDONNFA ..,' IUIST FMSTMWOLE MAMq:.,. ORNEPSIECFNSENO. - bus REGISTEREDOYME ILAST-FN 1ST MODE NAME? OMERSSADONNES4 DATEOFEMRN: ... Y YF.w 40 ? OWNFAS FEW ISTPEET.CETY_OsT.,o DATEOF 1H^. w av w . ` / .-J iCJ /I 'T I / (jJ LI!' l PARTSOG VEMM:IEGAMAG(D. n EO rE. C I T s ioaev YFragE Ile? P TSOFVEHICLEDAMAGED .... .. .... ... gioiv.Rw°v °ara. LIABILITY INSURANCE INFORMATION-VEHICLE .1 WAS THERE AUTOMOBILE UABUTY BESDPANCE COVERAGEW EFFECTFOR TH 9ACLIOENi ON YOUPCM ?ES ?NO NAMEAYDADORESSOALLARIUTY wSVRANCEPOIECY IEOLGEA':.:;. .. _. ryNE.F UABILTrV•WyUgµT{COANANY SP i !7' NAME AYDADDEESSOR WBAEIY VEgLVTANCE AGENT :.. . .;. .... ,.. crtr . ;.... .:?..: F ]P .. W&Uttf'OUCY BEFE :..:. 1 7` kA O~ IS'WJURY .. 5...,..._ ...... ' 'AGE. LEDYULNFY:.... lusESlvwMr[aeFORIfOaFmrMIxFLWRNEFe1 ,.... .. _.... .-' . '..'.v ... ,.,. .. ........ .. ..... ... .. ... w.. _.'.:. .: ?. .AGE. NAME TOTM. NA AM .. .?._____ __.__..__?__ •EAIr MO . ?_ ADDRESS - SE AGGRESS . O_ L1y F O___ ___ P JI !® L J rADOC Om . AuxMN)N°YA rOm ©© DOC ST iUS OFPUWED .. MARK EIR}T ONF.TMATNTU g - SrAMSOF WJ UNED' MIAKFRV*O TIIATAPA,,I ? WVEHCLE D r IWa%la 'b'E'DdAq ?[WNEx INVEHICIE IDpO pYdp 'pyyyp• ? OF- ? IDlLEO ISEVEMI IPKIdI F I ?E KILLED IsEVEaq IEmOp .p o bc µ ?P 70 «eitl ?-.......n l4rf-lx ? $? B? . QJnrFq wxrtbN ? S? B? 710 SHOWNORTHGYAHAOWWCIRCLE \ I Be. IKE gY ATHIPPVN ..IREFERTOWKt Es HUNBE _ ldiMa r ' v r \F\I 4 -Fi^?rraMEn[ wu ]°M S-IT e I =A -1 cr _? ? Q,? l6 +J^iOEE?YyLL_'Li TDO i ?A. /_ V ??y y VEHICLESPOSITIONSOEFORECOLLISION Enw IANEa vt?arm vlKa[a MM a wvEgTgerED BY VEEEICLE dE laaM aWO MDALIYPMFlO YIEFaIl ODCIPFO N 9 - C LY LYE SIRfCf OP EEGHWAY NNIE Ofl tq. IK+ECINri S [] AO DF.A? q, ?OpmlrC[ pA E1 ? ?n R . ?Mp ? ? ? ?. ? ? ?°ra DIT 41p.E6M1 lpy K'. ? ? ? ? ? ? D ? ? ? ?..- nuA?12a3 ? ? ? ? IMGND c•ose.a - FROM I? DIRECTION To DIRECTION USFEO PCOLSIRAY WAS 10 SOEWALN ]?WALKWAY O?SEIOULOEN E?cmvwMN 6L.;J -1 i01 a OTHER AOADsWFACE _-LA IIGEEICOVDf10N9 TPAffC CONIHOL Kx[<K daE ryPE OF POAD ORIVERYVENCLL ACTNYES A?r<.EMr v x[ , I? KwCM ?E?I. RAOy rr.lE KrNDAdFd WMI vI• rr 1 __ _ ?i 1 ?'pAYL ANT C] 1 l ? yCJIKS ?' 1 ? DEE WAY Nlr 1 D GOING STRA ] 6 IGHT NEIAO r ? DIY ] ? R4E A / - VEN Wq ] ? D D ] C] STOP Soo, a ] ? TWC WAY ? ] D OVERTANWO ANa Pti131N0 0, ?"' O DDEoA a ? DUSN ? 7 ? IIELDsON ? O r] Am SOLE ? S D MANYlD PN1HT TURN ? l ?SEEOW A Et F ?ro0 A ? Mrl9f)H ? N ? FlA "IORFD ? N 0 WTERDIANDF L! N ? MAI(PED LEFT NRH ? E ? ICL MPE TWO— 6 ? DTn(N 6 ? LnX"S OIF T ? } ? fLAYwN1 AMBER ? 6 ? ALLEY ? 6 ? MAKPEG u."N ? 6 ??'f CrY• I:V'k CiFVI --o TWOWAY- P(A_!OHIF)NMfV(•+]DMKiFR ° ?SIAEEI lK r3 ? IT ? DMYEAL ? 6 ?LFrt 10. ? e ?SLON'rN0 rcl.rra n.?. narEKraY.a FrCr r ?DPotl.f L'pfy ? ! ?o"KERrRAGMME LINES ? I ? STGFPCO FOR TRAFFIC -- ? e ? OMEN. :YIbFY ? 1 ? m.AJ AI[0 ? e ? 0 fDMT? AL pq ?E _ ] ? DNO'D ? It ? 3To"o W ROADWAY , C] W rn IFc J ?UNDYNIfo ? ED IT ? C N I.AfFI A E IYNNPSY •r.M! .. ,rpDRE11 . •... ,•.: i,:, »!Y.. .:..r.Ir.A at., !CAM 11 grAREW FROM . sncF, 17 D MEAKWFI EIITEA•EO ..,. I Q SC1A ';: [ a r `E ...E ',i ± t f i k I??x 1 . FNtFEf '. 1 ... ?I 5, ?nC 's ul S ?.? M1tUTOR VEHICLErCOLLISION REPORT PTO, OAIF.OFCT3LLNCN D O , ^ AYOFCOL /y.\} LIYOII FIMLOFCOLU510N AM JI?IL?y1I.?C wxrrr[.•1 vI}j'?{?.pm I D I COUapp ^Ult, U (L TY City, N • CUl'N r 1az , Weis ? ? > 1 Dll,IGA?l •p IAILFS 1,, O j tC?1 .,OWN ! 91 ? L ? PON , CL.. . PIIEF LC I4N IN ICH SEL f I NGVnNI" GNENAM HrIIOHwgY 111ILOFOA EOG.'.TRE Er. 1 10.UU `?''•`,?"2'll'F'D C [1 Yh?C..Li•'?1 41c?_I+C.i PDEFIX EO MILEVOS! •,j?''E'^J.??.. - - ^ ZION"IF II1Fr I ION ION LO 0-N HPMP pIAGNAM IIAtq „ yL ) StD[ET Pr14Ety lQll7Q,f! WEE 6I.1w,"1 10L I t EEl L FI »L;rr to© y y ?j ester ?}a???.et7o lli7 l??rl,, u,w i' ?lll ® / ZION XND NfEH INlEi CL5 © "1 ?I...,? x,. F1 . It ,. lr '?qty ? r sP c.cope Lab - re .? _? .6;I`_rcn rlL O f???Ir, ?tyEDftirf!UCN'n (F?NwFCa L a 1 01 NFII fOIUF.CiD rIPME PNUADOHESS IN R1 ADNA, LN OL ur LAM - ?hii+ 'SamraTkM? AK+rrc.?lur?- 1._ e)r;L::15?r:43.117t:.6.w1a ??f U11IVFl15 LM1SL NAME FIRST IIAME MIDDLE DRIVERfi LASTNAME FINST NAME r7 MIDDLE > cvL e CeLLJ llen ?Cr 1 StULEt AUURESG HUUlE NO A OW%n0 SIREEIAODRESS ROUfENO ANDb0%N0 . . . . hala fox ?. A L1fY V ATE - ZIP CODE UHIVEHSOCCUPAf1ON CITY STATE. bFC(JDF MIIVERSOCCUPATION D C/ 5176 UCL? - --h- M I.ENSENl4FF:R STATE SE X DAIE FIT 'TIT AGE GRVERSLICENSENUMD5fI STATE 5E% DATEDFpI AGE f N.CLEYN MAKEICHEV.WUGEI ODEL(NOVAUAHO ROUYGf VL[13 pN.1 r•u-.rev vFN:ucV.f»MF1. MODFLINOVA-DANl1 1 1ODYSTYLEI:ORI' THAILEHPLATENO llr-EN;.E PIA,E NO StAt SrAlE LICENSE PLATE tNJ. SLATE IHAILEHPLAiE.NO. STATE I i:?'rJ ,H 3 ,rs ?, .r•:LF.IUENNFICATIONNO (ISSSMOOEI.SANEWERI ?0 O4pMETEfi UAILFAOE) iq 000 yEHICLE IDENTIFICATl0fl N0. (ID»D FAUDELSB IIEYIERI - OOMETER II R:{,R ERED OWNER DASTFIRST MIDDLE NAME) DRIVE SrLICENSE NO.. 1 /Z.1'i?,.Q,/i 1117, 1/G•7K.??G ?(r ?l?(I?1 HEGISTEREDOWNER LAS TFIRST V, 'DOLE NAME). DNIVERSLICENSENO. 4,'.'',V1IS AODH 5S (^ifl !,CITY AND SLATE) UAfF OFUfIfH OI4NER5 AOOfiF.S4 IDIHEET. CITY AND STATE) HATE OFD RTH ?c ;lcene,". 5E,)%, I.Z• b• L 0 r , I VEIICLEDAMAGEII PAHTSOFVEHICIE DAMAE;ED i Ihf'FU E?••C1 E" -5 p LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- CAVenrAF WE FrELi FOnnnsgeelDFNr al rouR CAn ?YES ?NO ' NAME: AVDADGIES(S?O,FLIAb1U,V LYSUN.wCE FOUCYHOLOFfI, NAMEOFLIADILRYINSLIIIANCECOMPANY ... J=+,?w;h R•A "'n_? ILti L a3i 7i1?1'?A C?•nllc_Izne WQ•pt•L!y63"M t' ?( -A ihe,i4 SISr o UM ER H 'ArI AVDADONESS OF LIAWL II WSUMNCE ALE T I dtr rP UADILIIYPOLICY.NJ N I G Y e,1(oy I, C+r CU O t 1 Wo. O a+?,? IJ ?U3 V[?h SLAG-CA I 1ST W.IIRY y [ AC(E) y NAME IN 1•1.,/l\ICCJ .. _ .. fJ,V r ' 2ND ? 4HV It 1» Inx,I IN AGE Z, SEX ? A.MIESS P 1 .z TI T i.I L,1V•? ?"'"? 5 % . A SS J ... 1J0}C ? . LNIHIU xeLfic?r.,?.;ftFD?(AL.YIP6L, 1?aev%ec,c? ...Ks(r?i r ,I " , Gha„Putly, ?L't• 98326 ..>i.f ? / ' " ` w; l« TfArr p E7 "9r I t: ' --? f i1 TO., O E I YAM,N,i 7r . MAHKFIASIONE THAT APPLIES F IRE MAHKFL IST ONE TIIAI APPLIES tATU50F PUUREO •[dq W YFN4;lF pn 1'iui rD IMr Itnuvr ?? WLLED lave»rl INJI STATU50 O ? rc IN V[ILCLE x,An 1lxe N? I. 0 L KILLED I•a'.vLrul 1 1 N iej` ?)i O O _ Ir E OIVNONTN.1A11IOW CRCLE Df.CRME BELOW WHAT HAFPENED. IREFFR TO VF.NICLE50Y NVMRFRI O I 1 n 1 dR is ? ' •rl a, r•ar»... NAwS ai ` nCI'?OLYCI(L`?..CY1-ipv, il•(iO..l?vveA51 nj 5 pgcj L\."KT ptW I D a4 tt 7, y?'lvla, [J1LlL.uc(,(e, ?}?,• Ji({11iJ -Ff H151'1 l b 11. tN:3 OA ??"?",ADrrr K,lMID,rnYN 1\ I rzvl' +;var wus-?rY,az?tit??l.baw?,-»a5-3alnph R bbl. > D»:?IXr,N.»,:»L» w.,D. I OLa JL?IY1ptl1 Fto1n RT,S'rdzoE..?er3lode.Pd'3cH dttutl+ S,rILIDHrealq ._..?? ?.F._ ? , i SAtCJJcJ io..`BLk)1pu{ )VA ,74 d cA lLQ -170. n4'10,te SinacV, GUul A(P(w. iV1.. oe:(-k, 5?rY?iYl:l me 4r-PC ???bo4?id S:cle of ruiEE w11ed?? ,4''eEx K 1x1„K oYl r-Ll __, _ . , . _. . ryDh?. lo;i ::i6,e Df Of W', txr.,„c'i by me L'ti,ck off, YDga,?n,1 r ' c ' ' ec?h,;.?C?sse.rc>?crstde.?i Tny scih`. u, t ? : 1 i _ f+Lw4? oh (;D0e4µ f10TG :{YO'•l5 h f lNf `, x L?dl'. SCYU?L C,Aa c 9 "? yaw {o0r r7 JtwnK,CCybxlol,yec Jo?h;tl^ IF © C?•,ta(?cJMiwii?tSL,-,q-SAM>sIILY°Z;,GeAw, We n,DveFlcv ' I f k 6 '? W 4 I I i "_ r II I r.r. I • I { . i C GACI Jj?eCt fa• rij(CE.C.j C I?iF.G -s 0.v- U ? VE-HICLESPOSIIIONS OEFORE COLLISION YEIIX:I! N 5 0.1 51111171 OII IC 1-1 NAME OF NO k 60 Nl W?. o CE.t FP. Nj? 'A'Nri?"' `'D'?`F nrvr5negrep ur uR•ur mA•nan v D Pu w,.v P tID .rnCP'N D,I Nu. Y'.. %:f. Ap ? i i.r ? rr I ??0 ? 0 ? ? ? n_ ?_ 0_n' •++'•tl• ? ? ? ? uGra u DIRECTION TD DIRECTION a•.p rtw >? rln, vMUl WASU•a»o 1?!+1HWNN o?w - 1 vlouu'LN e[J_' ?•-_St.J R _ ODII•R _ IE}N nIA('4 YA AN.111 i%ill' IfVIIrb15 1NAI Irf.Cnr11•r0L 1rr./< it r I O lAD IN IIlyl ll'C F G )t NI .'rrl ,? J::NAI •. I ? ?, L I ? DAYI V.a II ?1 1 ?rl? ml ? ?3C WAY I ? 1 I'OIM.. Tr C li A fAD - 0LSIr >?IrAl I?NNNI ? 0f;,"r .. GN 1 Oallt Nn A•.n1 ASr:Hn 3 ( rno WAr Il . f ? ? > fI ] ': rpV.MA } ? f%)Sq ? ., ? p1IT '.;:N T fJ '1 [.J ;V)`;1;14x41 t"I p [l I,AKWR RIOHf rWrN ?} Ja1W AIIL?VAA11Kr A?[(b'IK1T?n- . ?IIA.`.riNGIH.N t? , ?r.,ll r,;l,: lF ?. A ?,- I,, LI t II,11N IIUf 1 ? E ?CI' r Otur it Dori ` ? ?J II 1. , 1 L-l ? 1 r4rr Y tC t? S ? Ab\K NU II-01 IIII `) G CJ l [7 ± ? L, ?J IT ? :A -------- T 1 t 1 e'rrtM1 ? A ? ` 1 xCl to N [J rLD,4IrR ' U Ay`+. ',!alt [f frM CAlKP rr NN•1R '1 .'...... n.l., .+n l.. ....t •. n,lr.r t..?•,Ir'rr t_J ' [lUII If. IT II ?AAN A4 -?? / /?1 •:fOlr•INIUH ill,! f'1C ii :TTI?I? f "'.'Vk- ?c .-.. ?,tA?do ?;•srnn ??Urn, ..- ° ??I.n?t,'. ? ? ip,- jkrt: F T I?R y r ?? r.: POLICE TRAFFIC COLLISION REPORT JTJ TRAFFICWAY wucE COMRwIErNU«xv 1 - 0 PRIVATE WAY 2,1 t ?N QNMAfSN0.015fREfIOR MOHWAY qW! 5 gs ON J SfR[F -R 1 N9 IDENT MILAGE CDE DIAO4AM ff I NOKIIIfD-NO.INJUREOyj,`` ?S41l1AOE ?Hie 4UN r Oe ._ _... UNITNO. l.• :. :. :....: .. .... .. UNITNO: 2, :." O VEHICLE . : O PEDESTRIAN:., -'O PEDALCYCLIST'.: x' a p4rvlK NAME: w51 I . D4NE9 N IASr I - ? _ SIVEEt ADDVl55 , SI A , yJr?! e a D r? ? D n , / O ?? ?? !?- Ty Swit Z19 CODE E`NQ?p r u'//L/ .Q R IA V f/ J -Av fff111 wrvfRSUCEN SA 'I _e • S- S/- - MD R,Y v e XC AION AMf S9fgNE1 a?>P lYES aEfr E URAilgv iIRM NAME6 RFKKfl NO. EYES CM, HEIGM 2 t•r 3 ' ?s` R o9 O CHECK 01) v[H F i 'r [ ANOrHeR. ? CHECK(.) ' vfHKOFASAN ottE A R CODES ? * 7 n + is 5 In 6's"O °„°? ` I CODES ? 3 o,.Mss'r + Tin: ` S EACr4.E' 6 aNin r ' ?x iw?ES M S NA' `.! cd'• ST JGS ;f;°;r- WA a O VtH YW MAat DODOFC>tF/ MIT 0 8941. O ?»a! O I4[D. DAAt E A StY f t DR V 34' ° NA E O W-11 ? Vim. ? H K? 0:3IA. . .) I . U : .1 I ) I • ( •1 (DART- AI 1E V l1 AIE r4AIlE4 Ml NO. SMI H Vf . I r f7 • C » CEIIDewrIGKIKN9 NO . H I I 32.51 6; S I I m L ? . ' 7-3 REGSRRf00v fR: VSI NOT MIDIXE / RHONE NO. O l4: 1A I WI 5 fIR3i MIpIXE t N1f . v /• 5 ?? Ili G AoonssaowrEfR N E owNE -?C 991 E NAMee AD 1. awsueArEC'e co, GRAUNr ' s9? a DAAVEW ARfA nMeWD ??? gAA1AGl5 Axa . °N y.«croNN cHARU CHA9p O • .1O' eio ' fai. ?U H ?R[AWwD ?AW ?RfMAINip fit' MIO?OI,OY IOiOTOie Sd• 1 ? 77 r lovnoer• ' A.[/ Mf AWAVeY: a ((/ f DIAGRAMOF COLLISION I N INaun wa.H DESCRIPFION OF COLUSIDN: (lRl slvn[MfxrN Swnvwm5ARY1. . __ _ ?. sHlu woe Y)_., eV _ --- G ' ?''? iv;o'5 r a.? .r . _ LEI I- w. __,_:j _I9i? Ts?/f ±?a?$_C?ro ?'d o7'7`_?/tL._ °f?? etpo, tr . a?vp/ Sul T Ti? c IFfY- SrP • . f _. _ ?a _ " ° • e __. ' _ /J7 .//rC GG [°/ ?/%r ? S//'/ill ? --r eeo .orlfc%rit+ /1`y1Es?2 ? .6dcn'sL.G?EradS dn o? T!K ?dtT ' S?? o?- >Jir //ri i{rd . - _ _. - - ' .C v tf Fi' r NAME, ADDRESS 8 INJURIES OF PE SONS I NVOLVED ' CODES 1 - 2 3 4 S 6 ? OCCUPANTS /WITNESSES is ADn"r'K3?EfA"ir?+AM""! si xx z G I. ?" V'r He! , -•VF' RIM 1X M'rr If AMr?J GG-- • /T1.CGs•a.? - + Donna f3 /,r F er f ®AM e OK1r O N m OWN ,. C3•N,R » "- ' .. .-- A ro.nti( n. '/ / N ' ArEn a .?R R ID r.oM AMe. Oo-.'O"I",k,. OA'» OM1:.rK w r I• AMI trT f. C°d/7 r+o U r .. ,.. A , :n•na ) o' L !/f.?.5.. efweY AMe Oa.'O""m:n. Qx- O?:u A - • «.rfroAl«oo»rfra N.w a.. K ..^rH. .uN?C.? a. I?syy/ywo pylgO ?eD DatE Or MIlEpr a oer /?wYn ,r x . /7 ' rl •'6'iE? "? ?/ • /7n j, •GTOEOa HRS .T; vj E7?• [1E(? . II Y;S N E A S Yt,? j P,yLY1 I ?y ; e ' P,rv ?IIS ViC,,..,....r .«,. «..6•tJ.'S .ih. rL IN Y{ ? Y ' .... . . . _ ? WSP•159IIIEV. SIFEI STATE OF WASHINGTON PAGE OF No ? I '?E\ % . POLIGC COM1IPLAINi NUMOEH ' ' f : Yom' UNIFORM POLICE TRAFFIC COLLISION REPORT i f *, ? • a ,,. . t { k D DATECFCOLUSION DAYOFCOLLISION IIIAE C UUNTY NU. CITY NO FHY/A (7 i MO I pAY / YN 1 /r _ 1 SUN 1 Myl 2 INIS D WED INUN 5 FW SA1 IU'F3.t0 NOUR) A e L I 7. . / f ?j URHAN E CWNTY E ?SIATEROUTE COUNTY ROAD ?CItYSTREET Z Q A P GACLS. PREFIX ROUlE0R51REE1000E QRURAL SECTION ^.14•?-;h:? OTHER (SPECIFY) N 3i3o O F{h} ? CITY OR TOWN C?/ LMILES lLJ ? El ? OF P REFI% E C MILEPOST C . NAM B N F STREET I LL T GNWAY E O.O ON C INTERSECIINGWITH. STREET OR ROAD ° RA MP DIAGRAMDAIA 1 O NDN WTERSELTION ' IN, ACCIOENi R Nor INT , .DO TNT RSf.Ciltq SIREE OH pOAD OR pEF N. /> \ 1 BETWEEN `[)[, / `::'. STREF3 ANO m ,,% j. ?? STREET _ MILEAGE CODE E ? R CLS ERENCE CHO55 TPEETORPOAD ?6 DIST O S 0p1RECD FPOM EFE EN EOfl CRi TET y ' N 5 E V/ / A4 S SP Wont Nl ECIALCOOING USE F y C (L,JFEET OF .y L. , -?- COLLISION INVOLVED: ® VEHICLE-VEHICLE ?VEHICLE-DICYCLE ?OTHERIWPREI ?"IIt B RUN SEVEPHY NO HALED 'TOTALNO. r ?VEHICLE-0GIECT ? VEHICLE RR TRAIN ?StOLENVEHICLE OF-CUES NO.IWURED ? VEHICLE PEDESTRIAN ?NONCOLLISION ? HAZARDOUS MATERAL - PROPERTYDAMAGEONLY OOJECT SIRUCKINgME Of OOJECTSTRUCK ANOOWNEH9NAME1 LOCATION OF ODJECi STRNCHS_..E ' ?ROADWAY FEET ? ? ? ? PO.EDGE S DRIVERS NAMEAAST FIRST - MIDDLE DRIVERSNAME•LAST FIHSiMIOME 1" BK:1CL151 DRPEDEETHIAN CHECKILI D R V?Z9 D N 5 c•-r-X I' <- 1 on ?, Li , I STREET ADD RE .. ... STREEt AODRES E CRYSTATE ZIP CODE PHONF. NO. c?L//L Q?it?c^ vL/I. (l?77-• ti/ f E R CITY STATE ZIP CODE PHONE NO. C?GlICCJL-/_?E-. LG1A ? `?'7? N 0 I DWVERS ReN% NO: STATE SEX DATE OF DIHIH MO DAV YR N DRIVERS UCEN5E NO. STATE 5E% OAIE OF BIRTH . / /-) Gt- r r i ?S is • O• r 72. iV z e, / , 1 7 A D L <,qY YR, pRN OCCUPATION FIRM NAME PHONEII 2 DRIVEfiS CUPAfION FIHMNAME P NENO CODES >'JI LAC?55 ..-/ r VI SEATBELT .. _...I.1 EJECTION... i_- 1 CODES > Jr •JURY CLASS r+I 7 5 .._ - ._._ EEAT DELT_... ?. I 1 EJECTION ._... ., - ) NATUREOF IIUURIES L ??Jl7 AL.. ?' - INIIAIUII JU ES F j 1 7 •F FROM -HERY "R V -YEAR MAKEI CHEV.1 r MODELID/??""i NOVAt STYLEL2DN.CONV.1 ffJ?/GU. v VEN /YEAR ! •r> AIAKy IDOOGECHEV.1 r crf b M?q°?LIDAHTNOVAI STYLE 12ORK:O.VVI Frl?Cc/r_l VA E " VEH UG PLATE NO. - A?' iA LAc7. STATE ?? tL TRAILER PLATE NO. STATE E . VEN COLOR 42?). UC. PLATE NO. kva( STATE ? • TRAILER PLATE NO. ?. STATE D E VEH LE I pEHTI ICATION NUMBER 3 KJ?)L /y 7V 0001ETEH 3 Q C L VENICIE IDENTIFICATION NUMpIH ... E 1l Tfq- ! !{-? ODOMETER .. l?Z-zq N REGIST RED OWNER `LAST FIRS j, -. MIDDLE O• REGISTERED OWtIER?_LTAS; MIDDLE. . A ESS OF OWNER _ A pORE55 OF OWNER N AHDAGORESS - ANC C .OIi ENi N AMEANDADORESSOFINSURANCECO. ORAGENI Nf I?/. b. k. CHAP E/??/ y/?. ?d of GC•'G ?i/itr.? CI Ani ENFORCCIAENi //. 5?l1 io ACTION •1 Hla 6E CI A 1 N NAME ADDRESS & INJURIES OF PERSONS INVOLVED CODES - 2 , SE X AGE STATUS ?' EJECT, C RAMS: - em C ? 1 C 1./ U ??1 ADDRess I ry I 71!(1 ' c ' F .. v .. r I. Moved ITOM FJc u Nf RY to : A N 'GEI A ADDEUM $ L IO W I 5 N V"W NFIVFIIY1sT '1. 1 0 5 N AMf S A M F..S5 I Sr N I.Fil I'll V C 1 O 1 Rlill9lII•ILA? A RCYCLISI r1r SI Al PD 1. ? V1%y 2 i ? 11 ` I UCIAi+ 11 1 IN, ,pOAD)CIN ACIi eL I -R1 1- II I1WrilN t'IN U^iY 51 AI INLI I;?oiu0l? O fJI Cigv A YfJOICTDo , o "`L D = SDYHIR .1Ht" e D- l j RU'J OIFAI(:YCLI:1 S1O: r I '? V DM1DWH05 ITIAI 1 P09:JuPIJ r, UNKNOI'Y'1 U- N-1111 ' r E •.l l •, gNtI JH).V l 1A URI D . M t 411 a XAS':? ?i R. r ,wF}1 ? f ? 7II7 CI A O ?* ' T1 " Y . a eoi tltl VEHICLE DAMAGE NEACHDO% CIHCLETHENUM ' tl INSTRUCTIQNg. , RL ROFEACIIOAMAGEDAfIEA. 2, SHADE AREA OFSEVEREST IMPACT EXAMPLE i AMAGED VEHICLE NO.1 . DRAW AHRO.ISI TO SHOW PRINCIPAL DIRECTION OF FORCE. IDSF i1115 P _ Iii - a` • • ? - S'? 5 gff FOH SKCiCHIN4 Dg51AGE TO TRAllFRS,MOTOIICVCLfS, CTC.1 . CEO V EHICLE N0.2 ' ? r p' ((( ??? L ? a mw?y?e - bry ? .y 1 1?V ? ! 4 19 ?4 IoM 1 { r? ? y t JC?'u ?p P ¢„ ?• 'C3L9 ?? . STATE OF WASHINGTON of - POLICE TRAFFIC COLLISION REPORT WTRAFFICV/AY mua uugrrA Nl NUVbt4 --- - PRIVATE WAY 4 If CUf'.a' : - UAr U1 CCnI30N 1l/t --?_ Ill$E)+ OVRI 2 IZ ? ,. xl•r N?=,i 4a• ! O ?'S ('V t=."?\ ?'`-LnJ a Y L r '3 "c....... O. Cllvrr? - ?U U .1 r ( N _ - 13 Ct . Y L ?rv U?R -,'/.^N 1 1. ,, ?U•alv([rFIO411 t..rV/hv ?+ rT n CC--r? !IJ/F Y` LF f Ih t!3 rA3 ?W ?nf; Tl1C/> C9 V C ICI CI. n,C. NUVf c Sf .I U' A :: , . j . i T... N t.[C :N 1r .;IRffI O?HOA ONIYIf`?NS}}[CflOrv /??]?J -A l,+ /?? l~ rtClWffh•_? ?'??C' Trim a? „I?•?w?'G l?.$1 r? U ( Tn4 R FU// Eh)3! .n% ? ? e - ?, - { NE [ C.. CX033a1u[H 1'Ull m,tt N 3 f W { .a U 'u X V nn4 UAin M1 p (? MILE E ![. K? CJ n ? Of lIJ E3n7 LC? 71.1 CODE E CO E l/4y' f NO kIFD_NO.INlU4FD ?SOkLA('t ? II64UN Krnr rnt.? -AI rv0 N t 1'rIRR Cl5 CNUSSSIRftiOw RUPll; kOAU Ua SFrkaENCf N rrt Cr V:,NClf3 I? ?fRUK4,YUNAAGE ONIY ?11'E - ?VlO1ICtf ?' 0911[1 S,r(KKINNAECT rRUCs DO'NN[R'a rJFM1I!! [SI.pNN.(:f /?J."•'Y' 34ECIa1CODINOVIf 3 _ UNIT NO.1 UNIVf4'i 11 N+.k: l^11 rIG ( /AI?Utf UNIT NIT N0.7 ? VEHICLE ? PEDESTRIAPI ? F'CI:ALCYCLIST r :t I -- -' ' al RfEl n' :'wka3 ? l N U11 1431 MI p ?E^ ,? , ; {?oE3 l33 ? D 31NFfi nDDNE53 •-? ' ? Y slnlE cope or.E ro. K)ACIA4 -u?A. 4kR3? 653-Z3? fr1 fu'S U:fI:::`,u 3fnif Ea nlEU bi U, X I enr snlt nveuot 1(m -I, A F YO IZ ZS V , AIIC[NX Nu. alAlf t Dnl.?yaiwt`I4 _ Z.. OCCU4AlCV! Ilald rlANE 84NONE Y.O. - cuts Wf10N 00- r tL{!1 t 1Y1 ! J-?I E R OCCUNAUON II4/A-Ea 11-ENO. LY[S wflOnl 141N1r -?• CHECY, , Atrg vn3 p+IVIN ? (.11 r.•c:Ir rn•crnnr(Ai.-f4i.Eien' lAt ?CHECK(. nn'r :•1f V[rnl , 1,1 11 ` CODES I> i" a c w w A 1 1 CODES 9 'k 9 n its N Z 5?r- q --? s: e 4 iNl r4 t5 G VIM. YfnoX x E'?'?99°°G? ??)1 .vupf(Ipnw:IJOVnI 1 CO.,V{ V vI. tn4N< n%t4 (D(U.:rCirEVI »fl luANrrw.'nl "^,il)puIVI '^ 5 N.c . , 411A EG s n uuI Alf - H C vNECOIOa 7,- n Nuw.i All I al '? I[t[IIX In6A1H)N NU. -- F` 1 o K P, C 5 4? 8 ? ` L uKIE IUE rv111ICn PUNK -- Yl ::?o NL013114 DOI?Il4. IA31 114n51 MIDUF E 110. PI- O w [fi1liX+uUVI,NfN. EAlr IIR31 MlpDlt •1 OIlt1: ?? I•? L%? AGDUfa3p .Vhi4 l6tI?O SeAZts 11? cam' 02?r. --- N E _•? AYN-.,,. Cw (1h114 C N +uEanpu4eas .. w.N•kcn xA 1Nr - R N .5 Tts-iu ZE CO CAA p L faM14?uo RtA T'-- ? 'c a l od 3 ' •?• rM+wm , 1'l p4NlN ?4lmurnp ur.umm?ck u r: LJ ^•?^Y oeono s2 1 - - z RRn<?5 $ l '?Su- e e IMfN nI I ??, • D l DIAGRAM OF COLUSION. I S.RIP+ION OF COLLISION: Ilnr3u4rurnEN swt lrrncl3s+XY rlp lC13U4v1 U I?/UNIT 1 Y ttete Or +f3ccc.:A cam '- •'• Kb. Lat;r ,C --,,?. ?NTIeDC.. ON ltt$?5u•. 3-t-1? C"LAGT o? 10 SE C+K A ' ?' ?c-fi l a r -- 7n ITH T roP f u 9 =- NAME, ADDRESS E INJURIES OF PERSONS I • NVOLVED + CODES I Z 3 A 5 6 N lull uu raMlAll.r OCCUPANTS WITNESSES I-a4%hoN r nw 1 Ll su A. - 4 n14. Incr l +. IVNxrx „x,. n 0^ r ?•OC+•%IwSrµ?y? ?. C.R A ff C%r(I U.:`Alt.rl lI it-II U'.rIK !Vlp9Y Ir.,,E ?? ( f F 1 •_k )Y ??' t ? mm a Wt"'? Y? I eW ll Ej r h T? n ` ' ?? II:: ( r?T4 I l l d F1 1': 1 ; y y-?, +l .tI R . W,1 I ' "s '••••t?ryy . "..i ...,w,Pr y ;F$p .q a ° rA n a ? 1 r , 9.L*Ulr' { ) A I II_ rT?:; .. .. -u? .2!•' ff.'3?;fiidJ73 _,._.. R•.+3': `tS?+S'?: ..emu! 1.-d'L,:_?.,.?-_,.s:daXtir?7 ?. -P i'- I) ? R l setl.§c'r ' 3 , ? W31•I.5'I E4EV.1001 t'• STATE OF WASHINGTON Gt I pl ? No ?; z R ? . e?' POLICE TRAFFIC COLLISION REPORT u,f TRnFFlewnv rooacD%•YlA rlr rluMtlfx _ P M PRIVATE WAY DAIt UPCIXtIir:N DAYUl CUl11 UN ' ! " 5 N e 2 Ly n` c..V xrr ucr luu nln Iwel. r. s•r l IVS[Nf I UR IO ,Ij? I Cf- COU Y CODUfTNO ,?Er(` ' Y"F?? - ?U CIYNO ENWA Dua (1aDNAl - l _ 9` --- oR pwN ! I/f ?r ? Nl,f Oi 31RFF104NGrINnY ICIIIS Z7 mI:ES I•p s! 00", ? o TbGU,C7? ?-N N N LP G lQJ " _ AV•n 43 P,tf Olt .UI? - . ' pY .l• r $ x MII 5 C ; -11 04 WAD " D tr % o U, ••^ oE,WfErIN ?KC?r 1( [O^ rA , 'USt '? "?R - f f ''? c '? blsiA EnD ? y rEl p, [[I ?, prn NOM xtktxehe! CNOw31x[t, - 14 MILEAGE J i^ Q yl- '•'Y ,• .. ,r rrfl ?n ? n Of C'W 6?// (. I?1J ?.> - CODE CIXVSgN v S A N pVFO. E Vf41Y ,piAl N0 © NO. KItI[D?-NO INIURED O p l'E1xC1E3 ?PROMRiYnM1MAGFONIy ? N ? 3 I Gf ? 1 rUrroN?iv F lIXF ? a ?S rl R N r, %'41 R R 51 rN fC 31ifE UX W.?O4 VeflNlN? INfFx 4pAU C11 CO353 EO d 'V olu:ctslxuCKINaNEOf OB!!CI S,RUCY fNUOwNERs NanE) VE uum clF ? J.i?;'J ' ?? r? Esc Dan ,GE SVFCIA1CODNp11 ;r• S r / > UNIT NO.1 uRlvf4's NNnE: NRSI ?' UNITNO.2 mt A+ DXrVIX'SNNAf ? VEHICLE ?PEDESTRIAN [T I'EUALCYCLIST ? T t? ? ^ S,NFft ADURl53 . U.t IIXSr /AIUUIf g ( r 9T Poa (mss 114ft1 AUUXt33 - '.5, z CI1Y S,Atf EIVCOU! NAII-4es -cud gF?R37 rvlx311ClN5t r:U ONt NO. D IIY E153 Z33 ,AIE -C 1-1 NO. . SIAlL St% /UD v? - UAIE Of UI4,V I ! v43l CENSt NU. iz zs b'o V 1N Stn,f DA EOf tlIYln ^ ,' Z OCCUTAIION {IRM NM1MF6VrpNF NU. 1 90 - (Y{3 WFIpNi IQIGNi E OCCUPA,ION 140 59 R • 11R. NNAf6NNJNE NO. FYt3 WEIGNI IRIG R`Ei ! q ? CHECK( vnlni nrinrir aN'vN cpMxfx;+nk F+O1 fFCAifnvomfR. ODES ?• ' ?CHECK (,) vt fvl N.rteAS a'r+DMMOnfof nrlolii[x'N . . 4..' ^J 2 • N n s 2 5 F >!1 orrAM?,H,. , .1 GODfS T 11 6 m lF l'OS p? ACCIUENI IV .YAM W,A ? S rN t,,, '? n, 1-u?.u l E -. : Rf Er . Cl%O4 lSt VIAE tnf RAIIERRA,[NO. 3 VAIE Ii YEN.c«pN N A N> un I )KA, - BD?? 10 ok? -. l x HAlkrv InE lKIE IDFNIIfICnirou r;. i '?3 o ' K _' q. q '8 2 NfGr11[4 UOWNlR. U151 ?I IOU [ Vl NICIEIDf NIINCAUUNN D I O?c?cr VIIONF Np. (US?fUOWNEx. 1A3, N4S1 , MIDDY ti YIIUN f1?[ ?, AUDN{•.3OFOMlI W A t Sp0'xr:fR m l(01LO seQzCS:K, L?..Cd,MC, AA- N ? - BY f A5t+4as ac S2`JCOY'I{?4 IWIY D !Nun •=??? O n°rn`rn nr. t? Awnr DIAGRAM OF COILISION E> we [A1! UE RIPTIONOFCOLLISION: Ilnr survlfvtrE,Al srn[,rNfef3snxrf `?1 .7 ..) 3 Rf1 1N Cl35ARY) n Av/OW' A? Y?-flet.e•lL-t-1.)o??r+f3sacfup tY•5G t?18 CuRYc `tv C?Fr Ego accUt- ".• to :?;r Q_bx rRoL ofu Lus I -"D cuyr 4 a..7rCoc.-: Go'" BV-P- - ?(?6LCL?LI? WP`OA SIQF' ? 1 ' STAaCQK r c?z wITq `Mpg ?-cc 1 1?K at'1ro W14QM_ NAME, ADDRESS R INJURIES OF PERSONS INVOLVED 7' CODES 1 - 2 ?, 4 5 6 OCCUPANTS/ WITNESSES _ :°•t,J1'"'"'?':"P.3.'"" _ r 7. ... X IM1Vn L Aun ( AK„ , l 1 I t? F f ?r v! '11 I^ >, 4t yfr t• 11•'i I. „Itt ,??•.~?? ?lTl:-.". .,,,,.,.,•T ,1 Ij? ?,,,%?,? ,.nlni°f-. ,?""?i .{.,. i ' F'? ?? ...,. f POLICE TRAFFIC COLLISION REPORT .1?' TRAFFICWAY wllctcDMNAw1NUMRfR PRIVATE WAY D' OAIF OfCUNS N eb DAY 1 r!I 4r. > N 1R;5 • ID ?E LAME C 'POSE Rxo NOON) WNEY -r? 6 Sn J COUNfYNO, /!o CNT NO. FNWA ?URURAN C CITYORTOWN NAME A NO OF STREET OR HIGHWAY QN []( QIN ?2,2 ARlE5 g5 QW OF Imlcu?]I ON G• R)• IS' I -c. IAG 5 RWrf O43r f C SRC ION ] I IERSfCHNG YYIIN: SI EFIQR WAp ITFRSEC110NN IREFI% EO. MIIF FOSr _ , / RS /. /l A nE1WFtN?1?l V I STREET d jDIy p0/% STREET Gi?a7 ?' •' II. i / b UISIANCF6 IRE t ,CROSSSiNEEf OR NEAREST MILE NOSE ACCIDENE E ll, SSE w AMP R DIAGRAM DATA OF D / EIL J• fi CUOSIONINVIXVM: STRIFITY: 'l NR6RUN OTAE NO. NO. NIUFp-NO.INNREp? ? SFIIIAGf ??_,? wMNOnom iN N .RD IMFR Cl5 R SRf 4 AOORRVERENCE CROSSSIREfTORROAD ]] OF VFHICI[S to ®FROFfaiYDAMAGFE Y ? 4[S ELT, ?YEN:- / CIBd[ S1: CK[NAMEOF GSEECI SE RUCK ANDOWNER'S NAME) EST.DAAV[GE P ; S--C*"-" S US P IF- rr S Ut4 K '. UNITNO. 1 UNITNO. Y ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST s xrvtxs rvAMD Vsr n4sE MI Dlt --SNAMC: LAST Nx LAD 7H c ILLIfJ 2 SrR{EI AD04E C-c ?? G 5 RfET ADDRESS UIY SA EIPCODf FHONF NO. D rtY STATE F tHO. cease $37N ?'5 397/ R R SD<lNSfN SigE K1JU 58 PJ EA f F If I Z R 55 I v OCENERNO. STATE SIX DAN-ERRIN .. D . D, 1 RE OCCOPAIIGN FRM Fl [ND. EYES IGHI HEIGHT E OCCUNAIION FIRM NAMEd-NE NO. FYFS IGN1141G!IT ' z vA ESS IIrnB£x o xe gtll F R ? CHECK( 'vH tEA ANVAITOYFFAFANOi+FRA[ ? CHECK(,/) I. ,RA-OW-,=1YFFGFANOn.1- CODES ? N D n e eenw. a 5".On°TY°"" s E CODES 0- 7 ,"'O•N ' * K'"T d 4S 5 FFECRIN a '" R] 2 iris S S 2C f F DN $1 .-AANII ? ? cS,IER -KI K ? 6 ? AwId,NEE ? WE ? 'W"- ? %.'u ? F °I,v. VEFE-/AR MAKE IDDOGfSNfV.) ? 11Og41-NDVA) STYIf I]DR-COrvv.l .YEAR I E.CNFV.), Mq%110ARIrvOVA) ,vu (2 .I r RDM r ID p{co b E - ]e H UN U Y CtWfN{ 1i RAHT. HAIE NO. SIAIC iH ' vfn.CIXOR !N A qll q AE ED H53 57 ; WR I V[H1CI-NNNCAT-1A. L. v IUf IT NUFI All j ' a IASI &U FIRSI MIDIXE a[G151[RtDOWNf4AA RS ?C PHONE NO. O W poia 1; Nf 151fxlU WWR: lNl NRSt MIDUf '. I] 'Z ADD4lSS OFOWNtR N ALRDkjSSOFOWNNt 3]I E rvAMtaADO4ESSV mwRArvee eo. ORAGENI dNE A67FSS FTu7nN?Ct•3." ' ]] t AREA aS,AwD4 w cHA4GE CHARGE _ gAMACf AREA S OIIO? tsr u ACE W ? 4wX. nnMNNro ?ARWRrv ?aeMMNFO WAY lsr.owwei I nD r0110 S ?r IOWED AAY nW IOWtD ? gwgr er: S e DIAGRAM OF COLLIS N T ur u s"CATF NOR,N [ .... %N rl n vROW _ _ ?. DESCRIPTION OF COLLISION: (DS, SONFIEMINTAI SHEET D NEcl-Y ._ )_.... vl 6 s 5 RoiE60IAJG i 6ouan a Ai Ca ' n Ds /? _ " . RE)• I rJF C COLA ?ht -0 . $• s.o L,n•v a Cy?c x f4 rr OF l ylr f^'r .. A ?1+r. RJ For... GO TAP erc.tc_ s7w4l(a)6_. ? ?R NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES I - Z 9 4 5' 6 OCCUPANTS/WITNESSES ?a AN1°pD,^,toM,E,u NsA19 Tii $n ACHE rAlus ", ?" ° R rslx. taa AME MIN A -1s, Ngm4rd AciNr nF C) Al . QML"' ? i° . ?Hx AFHA K, q r. A DOafss rui+4 a ?AMe ?i: ? Q My ? NI Rr. 'n. N ?? A {Kfa1AK nATURI Or Nq,4nE QA,IA. Q^"•'Q{D.N.?"r ?,•? NH x rrr+.":p{CIS wAW b[ AKS1/?w S''dovar?r eADU O4 ?? AGIKr ? c.r•c• E Enr gKFU5FM04D ]ND,.RS IK.YII ARR ND[LATEp RER?RI T..)I,RS Iva79C AnronOnr our - ?rokt R qi ••W Y-rt .I:. ro d. _ .u•cz I ) 1 sti t' ;r r 2 POLICE TRAFFIC COLLISION REPORT LN TRAFFICWAY LIX¢E CannAlNrNUMN4 0 PRIVATE WAY al oAE .yaLU N Ar I N - 11MF couNrv ?S eaQ W. r5 ur IUSf 1RW NOUR) S couNlrno. urv w. rHwA ?WeAN ! 1 O ? ouson ? o R E IN U1Y 04101VN NAME d NO.O 5TKET OR MIGHWAr 0 ? , rCl US RCUI iS 5 Ow ?DF • e ON 1e 8 INfERSfCr MST-1-RDA0 rypry NlfgSFClI .? 9E3%sa a P??? o? •Nr? r?_ efrtvFlN SigfFr 6 T .RErI% f MIVE WSi y. t 3, c1. 1 pIStANCf614 qE Rt .CROSSSIRFI RNfARfS MII ACCIDE IDENT Mr4F3 N 5 [ W RMN D OAtA MILEAGE rEEr OF CODE - - CDLlI510NINVIXVFD• f41rTr IOTAI NO. NO.KIalED_NO.IN1.FtED? ? SgIItAGE ?H «gUtl wN4w0 O vFHINO O'Ro-,D-t my ? FIIE D ?V?I M.E. ICLS CRO5511R[ETOR,OAO. OR C::1... 9 Oe1Kr5IgUCR INAMfOF CBI[CT 514UCK ANOOWNFR'S NAME) [SI.OAMAGf SRCBaI CODINGt6f ?- s K 1' ; Z f,F X , - f ... - :- UNITNO:1 '.,. -. UNITNQ 2. ORNFR'S NAMf Lt ?VEHICLE.: ?PEDESTRIAN ;O PEDALCYGLIST : . a' : NN fIR a s K d /? .e ?? ORrvfq'S NAMF. IASt FAImE E Stgttl ADORE (3ofC X30 -l3 5 flADDRESf ??--??? ? UI tt ZIR CODE ONF NO. D I StATF c cone 3,, 9@3? 6 65-35? R DRNEICS UCtNSEH Ss? R?zSl. ?N t° SAr fK w/? M BI H A, ter 'I'ti I v I U NO. Aa i D,. f... , a CM:CUP - Rw NAMF 6rWNFNO. EYES GHr IEIGHI E OCCURArION RM-1. fYIONF NO Fl EYFS IG r 2 r2 IBS G n R . H IGHr 1.C. ,? ' Q CHECK (.? vfM, I As Ax lorF aANOrHE4. ? CHECK(. v1HlaeASANlmnrirE aANOrNEa Z u S u OqH y Y cu CODES ?* ] aii % °s.sn rzr . t N CODES ? ] nAa % i inwwr S ucrroH A y .D r r Iw ODlos oE? Cbet e o a I ? p K r ? R f N ... 6K ? M" ? K:K O r..1 4aw or.o.. ? ,m.%AND p rya [] dirt. ?w ?iiMSr . 0 V[H.YhfAR %f 100DGL'C/qfV.) S 4 " FEIEDMr.NOVAI SIYLF Ia OR. CONV.1 S /h? FF R H I v.> Llwn ) . .) aoM r < o QQ L [ . E R? l RA SIAI IRAIElRMrE NO. SIAIF H VEH. Oq ?[f A pea Sl!- HV W VfNKI[IDFNIDN;AINNaNQ i VfNICIE IDfN Ifl N CB;7!S o;?Si/'7 x.1'(0, ! 1 1 1 1 1 RfGI5lEgtp OVM[R; L5T flRS! MIDIX[ gIM)NF NO. O I D -R; Nit NRSr MIppE W N NAM1aA- [ O E 14 ANco. w R J CHARGE 10 ?REmAINEO AwArer: lo- ? AwArD S GRAM OF COLLISION D ,iwn DNLttviarl_ I s tRO °tN DESCRIPTION OF COltIS10N:_EUSeswnEmEN1AF SMe[rlr raeeswrl l Z ®?• DRIVER:-STATED FRONT END_CAME LOOSE_ON_H/C-?. LF?T FMY FOR_APPROX.lyl FEMCAME-TO_REST-ON - . 4 i - -1 !71 FT - "HE WEST SIDE-OF C.R.18o 1 1 R NAMI, AIIIIRISS 8 INJURIES OF PERSONS INVOLVED CODES 1 - Z 3 4 5 0 Iu515anrMFNIER SMfII / OCCUPAN WITNESSES -" . r.m« HAr --° - laADpibNAlNAmlSI SEX AG[ IAIU wll MST.. l1fC1 mrc? AMI- H . . A ,lu N%Iwfa a Ame o F "" • ?R^" IYI4J O ' • A _. - pM!af . _ a rio HAruna N r a-.__. .mown N .. nAMe. OraFl?M?. R ? x««' ?n.H ?.D 4+ ati wf NGA: r GOl. .' wr ur er OwmE ? u"OE"r:n. cI aw . oCr S NAw E4a H. x , eApG10. D Iq AGHCr Sr E L.1 es m KEpa.ArCMro zm?;o IIXK1 ALWw0 Y? 4 pAIla Mlar AMOVED 1r DA, ! ? , ED I 4• i , i s ? f fr? f eEi. r f . F ?h I '? POLICE TRAFFIC CCk ONREPORT LJ TRAFFICWAY pOllfEZdMplA1Nl NERM.f4 I ®PRIVATE WAY RI , UA,EOF<IXl rv q O QH 10 CODNIY HOUR E V I l COUNTYNO CIIYNO. i 1 230 Xl Ef". I,1 I Ol 1• - 85 • "" "H qEn Jefferson 1 230 Il URWE /li . ????? > ? !7 uggl + (]IN CITY ON TOWN 7T."O. ?Gi 31RFFGl OR NIOHWAY ON 0, _.Es,nS 0.0 ol ON lCI ClS 40UtEOX TREE SF 11 N ] D INIfREFC1ING ISIREEIO4 ROAp nONIN1IRSEC110N Bf,WFFN SiREft a SiRFff y pREH% E0. mIlE PO3i / 1-{ \:: p I DISlANCEeOU Rfh[q Mf. CROSS3tNEFt ON NfARf3fMXf POS MXf3 N 3 f W gCClpEryt N p D NAM -IA / FEEr Oh MILEAGE CODE C-SpNI14-IO. SfVfe1IY" iOfAt NO. 1'101( lE0?N0. INx1RF0? ?SpIL LgGE ?HIle XUN HarvDapiHS SD INtFR? Ca 1 Sf R RO.OO4 N[ Rf NCE RNROAp CROSSSRE[ rO °d pERrYPM OfVfH"ClES /? RO EONtY ? `Ih' .U. ?1E1 CIN Y•/ / - J Z7GG Oe1ECiSIRIICx (NAME OF 091tR3fRUCR ANDOVMER'SNNAfI FSr. DAMAGE Sp[CMLCOMNG I.E _ S 3 UNIT NO. 1 ' UNIT NO.2 ? VEHICLE 0 PEDESTRIAN 0 PEDALCYCLIST ONIVFR S NAMf: Ul5! X431 MID l p41VfR'SNwf: USf ?.$r? M" l /. : PIERSONo kenneth Ivan _ fgEEi apO4 ss 31 ]L* blk go. Ironda2o/POB 574 S1Rffl ADDRESS '? UIY $fNYE EIpcom ONE NO. Chimacum Wn. pH D R "fY SiAE IPCOD N !1 I D Su frv SIAtF SEN e1 IH I IV UCFNSf NO. IAtE X REN PIERSK13870C WnR H' 3 A 03 162 V Aq W ! IY' e OCNVA1pN FIRM NwfxpHpNt NO. ETES IGHt HFIGNi _ E OCCUpgNON FIRM NAME a PHONE NO. FTES hFIGNi IGHI Student Bl 15 5„Rl R ? CHECK (.? viHK ? riffs ANOrHFR:M A 0 CHECK(?J qN fMfYOVEF OF •hg1HFR? [^ CODES ?* a n X j s CODES ? * D u:v % n 5 [xc. a sO , [> T uNts I P1,41V °a.. 0 A".AANDE 0 D W'" ? i'b`RL. ? K Ktt ? ?. 3. KY, 9 ? AN A.«:E ? '" ? rb:.i? n ? C8 p " VFH. YEAR fIDDDGF{NEV.) V.1 MDDE IIDAq,-NwAI STYLE IRDX:C A ( HEV.1 MUDEIIDgRI. Al .) rH _ ° 1976 Ford Custom fourdoor E t H OR Y V fNSF N M1 SIA,f tRMtER RArt NO SRAfE H vtH, sox N q Green IKN 004 Wn. I RR VEHICLE IDfNf1F"CArgN NO. 6 J1 5 3 B' 1 0 1-7 2 i of HIUFIDFN "H I N ..! I I I - NtG151[REOOVMtP. Wi IIgSf MIDDLE PIER.SCNe Robsrt/Rena pHONt NO. 0 W f I ffN p NwfR: USt FI431 MIOIXf Il ADptt53p ONYFt9 Nf4 UI ? 1 lSS Blk So. Irondale/00B 574 Chimacum Wn. N 4 AMeaADORessalNSUeANef eo. w Yosemite Insu Ind AGwr iana ' I R FT-- DAAMGF A4U f , CNARGt CHARGE gAMAU IARlAf 'Z" OR MAG D h f 3 DWAr ?REMAINfD elOp __ 3 ?ARMN ?RfM.UNFD tS 'D p G iono WAY (( ?? y,'?? ?nn f/.LVnn 10'W?OeV. Aw N I ?tOVrtD AWAY er: S DIAGRAM OF COLLISION t M !F1du1[NO4nl _... _ Row 3 RU U Neu3sARr1 e DESCRIPTIONOF COllIS10N Lust sLlmeMf rAL Sf4e11Frau3swrl R ? . , I _.. _. _..._ .Driver_ of . Vehiole 7?1, informed this A/Q that he _. j ;.. _ - , was entering_into_the-pared area where the garbage. dumpeters- are. set and a veho atruek ' . - _ him on.the_right front, and left the scene a. This R/O.went back to the_scene of the hit.. but was .unable.to_..find _,any debrie 1n the area m _ --- where the hit-run occured(debria. should.hawe.._._. been crams and plastid from the.t urn signals)-..- !1 This R/0 feels that there was no hit-rap 1. , NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED i CODES 1 - 2 9 4 5 6 OCCUPANTS WITNESSES Ira inNO"RUpi:ir?+.iN Si stx Aei uru '" „u,A' "'[ Rrvo. ever Aw: rss .. u4ror ......... r AM e OW, O "." 06 ?V.W- N "' .. j ?. A DDpss Nn. 0 F1.c10»1,1. 0.MEX ?n:,"A .o .. we rq ? A DDRESS _ .. NA1Ur1D• "Nx.N3 __... r r er ?.we ?ui" ?l m"'nR OH ?o ND yx3• ahcl J•wwfuN. so-?A?Tw A.AMr ! ' KI DIH4CH10 IYxa w.mo D•na4rroR! Axiovoer D•rt X ~ ' •Sr u ' ` f / /%3 f?^ t3 t. JCSO 1 SQ.3 lt 6 01 180 d° , ? w ?Aa !'?.:? ?. .. ?, tr,i'r' ..•' ?!r't'^1'ri.?r.?'?? .. r. . :,. ?•I:r!+w?.?;_?.:,+ ? .vt..?? .?..? ?4? : '."!FC { awmx ? r= , ?E'1(1LL6 . Z ;2kLtrUl_OUx ' - - -- no a I', T - ...KA w y,....... INST - r motE I IN ;ACH BO CIRCLE THE UMOR .f EACH DAMAGED AREAAREA. r T aI>;!1 yEST ? VEHICLE DAMAGE ] 51 ACAR AREA OF SHP t; 1P' ttUCTIONS: 3 GRAVV A51 TO SHOW PRINCNCIPAL pRECrION OF FORCE 'O• I, ` I. c w DAMAGED VEHICLE NO. 1 (USE T- SPACE FOR SKETCHING DAMAGE LIC W DAMAGED VEHICLE NO. 2 ^n` F TO TRAILERS, MOTORCYCLES, ETCI EEVERITY OF DAMAGE: SEVERITY OF DAMAGE .fwM Y `l e i QpSABLING DAMAGE I ,I- pAABLINO DAMAGE T IL VII 2CIFUNCT10-DAMAGE Rw111 . ZQ FUNCTIONAL DAMAGE c 12 ?o-e 1 SC?IOTHER MV DAMAGE 1\`lI-' ??/sL! T GQ OTHER M!/.DAMAGE 1G` 16 UNOEPCARHIAGE 4ONODAMAGE 16 UNDERCARRIAGE <Q NO DAMAGE 11 OVERTURN 1I. OVERTURN iV YT:D BY `( t (y ESi. DAMAGE TOWE00r EST DA ACE TO ED BY?\. EST DAMAGE TO ., DIAGRAM OF COLLISION DRAW ARROW SHOWING Y.RINw surunes ^? ? NORTH IN CIRCLE v"°E his .farsrK ANS I I i I I _' _ i OnlECraoN Orr ROAaw+r .. - MrKCw,RRs i S"u7"P.L"iluP eaNnrlas 1 I AREAS I- v ' _o fvROOAaEEVRNTOF I v 5 --II-IF My+A"c°" . sHOwvPDOMae.c[c 1 ` I I li.h I L i T-{I 14nESrnuNPAM9RfORFR+ ANU AriEPCRUSKW ?[. I ! AI•,PrCol? U,ei/ 1 I I I -I ?r l-? C I -I i DESCRIPTION OF IINDICATE WHAT PROBABLY HAPPENED 1011. DURING AND APTER THE CRASH. INCLUDE INFORMATION NOT ON DIAGRAM, EG. DRIVER G COLLISION DISABILITY, REDUCED VISIBRJTY. CONSTRUCTION OR REPAIR WORK ETCI A 41 ?( taffy' . S 7,t It 1.6 Lc it z- t` z t(./lS-;Z.I42if 1"-<?J??-c-?-?GG?(.r,UE -- I.OTO 08 CAS Fl- ??t? . F G- LL(Zi J w q, POSITION BEFORE COLLISION NO. OF LANES POSTED VEHICLE VEHICLE IF PARKED _ VIER HEADED MILEPOSTDR ON STREET OR HIGHWAY NAME OR NO. WONE DIRECTION SPEEDS LEGALLY LEGALLY WASVER r _ NO INCREASING DECREASING STAN.NO• ''P?ARKErD rOC'CUPIED ... X`. ..-t- .-- I/A YES NO YES ('N'O ( VEERS NO D l I f7 MPH 1 3 s! avert •'?..' PED IlI- 11? 1!`- NA K v [ rOw ??wuAA a K'w+ - '-1 ' 1T PEDpCYCLISi WAS USING I?•-.? lwAUt T?;? LxwAV ;-iewdl[aFR ";-? OSSw+u SLJ CPoSSwx[DuK CIUCYCDESIERWrf LJ OTHER } _ lMwlr sl '+++EO . j nEiERfCMf Om[R 111CF-AR., PED BICYCLIST COLOR OF CLOTHING yb ROAD SURFACE WEATHER CONTRIBUTING CIRCUMSTANCES es PORVLA.WE.cLaAOrroKe. Icw x xOYN WCK ONO f AEI U HO } of KK;LIbl! 1' A ' WNEw Ravi E j I? r ''77 DRr R -_ DERr (Or R p ?L. Cj II-I AREA o <r».Ln 0-0 vr.RER- E _ f _ - _ axi Brow n;Srowo +-- L r Sn aw EO l K ?1 oc:w"rARNNO LI•LJ urrR+aiwl A 1-T. .._... ; __ _ _ _... _ 1 _.. .. _ _._..._.._ I cE I rw 1- F °" nMIVR"N°°En wr.o !._i5 uAR.o L, n F ; RYL : r.? M? r x o s[,NI,w .[Tl _ -- __ WKD OwwISAe Riri - - N _ L.' rr ?sC 40 %^ OrwRI..+•e rn ,ter" a Ai[TSrAla4lw nr .o vn[MKW ?_ ?i r u R, orrn __ rc LIGHT CONDITIONS TRAFFIC CONTROL TYPE OF ROAD ROAD SURFACE TYPE VEHICLE CONDITION SOBRIETY 1 eO 1 E r-? coil re° o: A fwAL 'c e cr.LCK Ow. r?ro > v[r,KKf ? <K Ra M cu KHfeAOHH eexonrrn IafeK D". vcHKLe POwH uoAe wrrera v[KCL? -e,-i eravrtON o 1 O.rLlwr a Ov [ .r I coN< E E iJ E - r i r em:iic wiE IKA AT v,ro rnea IINTlPNO ° r ' uuA+ _. Rtw? X 5 at MOC I _ _ ` 5. (5 '.. _ .r Y 1 EKif:1 C . pw+x YM OOrw 1 vA) I. Vyyq Y MIT, e ,I r. ilAlai°rArn ° w r .. E.N fn Iy orcT .J e., Marc O!e? rCHE M.TEST ln_; awwlM+ern f t r?' 1 f e Onxw > RwRO I\,/` uvr[ X. Xl -- ,:. arwwrv,crµ` E '[< _^c AY ?uw0 .u rr../ oR w.w enl<aor55 % w? % ?wEB 2 1 II r'-n7 Is Q^ ? uf?(/O.'?«l//t f(,7'- /? UJS wd"r ?ER? ?E? o / •:1 r 1i 1. /'I' r JL rhu t k f ? 77,77 1 , $Y? 4 'N7 4 s;,, p?n ?'? k x STATE OF WASHINGTON PAGE I OF >'?YV ` _ •. UNIFORM POLICE TRAFFIC COLLISION REPORT f? i PJo. ? P 'r D UNTY YNO. 1' MI C? [; s MGN ES YqG mUU rw sA• IUSe i /.o ol ` f ((1•Wq L'_,`? w5/ ?HBAN N E J Gam// [I RURAL N S C LV IN I1 CITY ON TOYIN C1 MILES ? ? ? ? O -EET LO L NAME 6 NO OF STREET STREET OII ROAG LL MILE tPREFI.L. MICE OE RAM OAT. CODE 1 DETWFEN G';K, j???•?!.? ?.(STREET AND STREET I 0 d5 ANCE AND DIHECTpN FROM REFERENCE OR CIIOSS STREET-NEAREST ML `POST [ GRLGn6 INTER NON XflD Tel1,E NO R E OR OAI? OH SES M. // 11 HL66H IN_T CLS RkFERENCFC{N?}?SjSfgEEET gIt10AD N FEET ? ? 3 ? OF dl/ _?G7O COLLI IONINVOLVEO: SEVERITY HITA RUN SPEGN OdnO USE TOTAL NO. II''''?? NO. LLED NO INJURED ? ? HAZARDOUS MATERIAL I OF VEHICLES ? PROPERTY CAMAGE ONLY .. .. ? VEIOIIC E SPECIFY: ODIECT STRUCK (NAME OF OBJECT STRUCK ANU 01•AER'S NAME[ LOCATION OF OBJECT STRUCK EST. DAMAGE N S E • ?%AVWAV FEET 1 ' W G RG Is DgIVER S NAME LAST h FlNST MIDDLE DRIVER'S NAME: LAST FIRST MIDDLE IIF OICYCLIST OR PEOESI{IIAN CMECNI ? z ` i?rvf?n k, t n ? ? ?C( c; Cel'cA_K;A r _. STREET ADpF1E55 . STREET ADOgESS D O r ?.] I D L l l4 2ti IO'T,a 1 CRY STATE ZPCODE PHONENO R CITY -ATE ZIP t? //?? CODE PHONE NO. C°??tlV:/iL<.C:.! CU?i.?L 4?`_: l32,.C •'i I T. ?I >CcEZ(.=a fit'/?' ??i? . - E ORIVERSLpENSENO. STATE SEX MoOAIEO -1. E DRNER'3 LICENSE NO. SLAT R 6, ;14 ? _ G BHT. ;-, t7-T; - H DWVER SOCCUFAT N HRM NAME 1 PHONE O. DRIVER'S OCCUPATION N FlPMNAME o. SrLFI i k tr- b n 0 1 k 1Zc• PHONE NO. u .. . . _h 4 ( L F wL 1 ? CHECK (?1 v[?CLtNAR?Nr uGgLrwWRAwuyeuc ni 2 ? CHECKS?I vEH?ici EoM[inlwN N G GrHEP µ 0T KM ELA MS CODES )'131 p / ) sis 151 aN l61 IJF - CODES 0.(3) '-AE" 11I iv'sii ' 161 so E r?_ 161 uLnroN ( R VEH. YEAR MAKE14OD GE CHEV.1 IAOOEL IOARTNOVAI SIYLES,O CONV.1 VEII.YEAPGYMPKE IOODGECHEV.1 MODEL IONITNOVAI / 10 ? I ?7 SIYLEI2 URCONV7 `` ,' , t.J nl-?• / na. VEH. pLU?R? LICEt15E ILA, TE NO SLATE iRNLEN PLA TE NO. STATE VEIL COLOR LK:EN[ PLATE NO. SIAIE 1=111 . STATE ?U/t Nor h 1 : 3 " 1 1 ( _? e Yt Plf. (t .1f 1) f'`,? Gl_If? E H Vk11 CLE l0ENi6 CATgNNUMSEN H VE CLL IDENTIFICATION NUMBER ) CAI TcJ1.? REGISTERED OWNER LA T 7 L . S F r3T .-EPNONE NO. L E REG STG{IEOOWNER'. LAST FINSL UOLE FHONE NO, r _ SEi'Yl•i( ' . S OF OVmER N AU OWNER dikSS OF? N 0. 0. NAMEANDA 530FINSURANCE CO OR AGENT NAME-0 ADDRESS' OFIN7111) ORAGENt • 2 r ' L .F. I i 2 ! GIANGE CITATION NO ] ENFOR AC CEMENT TION GIARGE CITATION NO NAME, ADDRESS & INJURIES OF PERSONS INVOLVED cones - 2 3 A b a GE AGE sr u2 N? °1 s "i i i veer tr _.1JOF•.?ts c '£ c r w ..n r6 . M e v - C TIIYIrb ?SN. rc-"``} ... ... .. _ I C ` •7 -.. .. A.,1wH Or PU :.,., FO c rE(7,f: ,L, TD A N.Mr IPrrovr T AraNv TO W .. ... [ y N E 16cun nv E TO S A.w no,e E A[oKN ... nlrrre TO III SIgIU3 121 bLAf fOfA1XIN 131 WJUnf CIASb TAI HESIRNNTS.STFMS I 151[AOIO ICYCLE54F 2 nA•.•f NCFR / OIHlR I.MVNUN I `Oncsf-Ntb UGCO I NONACTNATfDAIn UAO ONOT GTAiID C 3nO[ATrV.W 10•TON ]. I%MAT fK:CNF 2I.UFLTUOCD NORELTSUSED .1rELMEIu" L II 0 InK,YCDi 5 ] MI!?iON JULAGUN-NAL I OUI.dRD[LTUIED bAUInAOACTNATF S OIH(rl O ' n EIY (G) LJLCTKIII 1. NO/EJf.CiCO 2. TOIALLYCJECTED . ]HI LMITNat IGE D UNXrpWN Ad[ONIp:YITAI A- L f'QlOLn DI.I T U[.EO OFLIbW LOE 3GYC F{IOIfCIION D a rM1NF.ib 3 3 PAn71AILY FJECIED V Lp1G1 ' d3Ad Irp WJURY S GIKD IIFSTRAINIILALD It A•RnAGAC1NATLD 1r USED E CYCIL aON dSAMM O NON ACT Y., L NR M AUVXNOVM IF EJ[CTED O . l NOir11SUSI.D RE, AMTNRSIUIIB I-59.(FL Y I U3 to ORLSI. -11 I,SILAIG UNKNOWN N i'+ A ? w• 1e•(, !, ?.-.. !{'"T':Y... 7-r?:? . t - yl'"?.. L7F; .n t -? ? a ?a ? r J'1 it f I J r r ?1 1 yf: ' ? lr{ s . POLICE TRAFFIC COLLISION REPORT LJ TRAFFICWAY roLlcE CaMn.NNrntRAeu - PRIVATE WAY - Wrz Fcau +•? 05 R` •4 Ar w'1Na' n I fusE 1= O roua) wunrr x N NI r FF cse?J • ' wunrr w. /? urr X•o. fi ; , _ rnww RAN ?u _ YI., .. C1M CIIY ON TOWN NANf 3NO.OhSlNfffOR ?N ?f ? IRI NKNWAY -IS 5 ?W ?Oh ON GU. F?• `? 011, S O A NWrE95 t - '/ ???0? f • INtfNSFCDNO t I4flt04 NOAD npflnrt4 5 f RIDN pNEiIA FO. ] / ' E 1 /` ^ BlRVfEN LA, ?, IZ STRFETE`O- ,,eo• 51RFET '??•??? ?C . ' F ? ..'^'. IS AN SDI ROSS SINE 04 NtA4f5f Mllfb MtE5 15 F ?W ACCIDENT RAMP Y. . O W1A : f 1 Ft fft OR C• A C•+ I MILEAGE CODE . A COL SgNINVIXVEO. VFN rv. -IL lOfAINC. IED?NO.INN4ED? ?SPIEIA('if 41M CfVEnLIES wnfwepm ,N INI[4 xAD AD DR fTOSSSFREE[OR1x)M ?- n r - ?pRORRrvDAAf,4EONLV ?GESULTFD ?vEw€u g3Qp S A? Ax• in OBxCISIRDCxINAMf Or OR,xCTSfWC[ANOOwNEk5 N4AE1 [Sr.OAMADf SPfCLLLCOgNGLLEE M1 ?, 3 5 UNIT NO. 1 UNITNQ 2 '- D41vW 3NAME: y5r IgSr VEHICLE ? PEDESTRON .' ? PEDA cLIST`.. IA5n -' ?t M M1 A D Af A. ?9 9 -7 -c 31A1 R I ? I. Np, A x TAT. dSI? 4 CuaAllOfl NR M NA/AE BpM r l . ,D 2 P oOUC¢ . NI NO. ErES EGNI rEIONT , E NPAI fIRm NNAEa YNONE NO. Ett5 IOnr fEIGIEI ' A (,0 . R "< 3 ? CHECK (f? As:N a riEA AHOm a'u 'ttN A c CODES + p CHECK ? (f? ' nKIf AS,Ef rYAnott! rnEa A Ebf°'" -'k %1 u ? D V u , y Z 3 ulcr aN avi n r DES COP+ 3n,ssY x snip: 3 exenw e s.wn r - D t. p t ? C eT 5xE 1 I .. NEIxIES iFl+` p'• ? AMNnwNCf ? u S0 ? ?S . ? viwKlF r •?El ::`.na. 5 NO•.e`?or.a•. ? „A,r,R,.,,Q ?uwc ? ? N ?F1°A:.Y E N p vYfAR 7 DooeetNtV. ) oOLC fs DAR . I AI SrvlE 1]097 -7) V E v YEAR I MOD fv.l fLIDART. VAI P - '1 SL _ 4 ` lKt LLG.vGL SlAlf tauLE40.A1EN0. STATE I'J N ?/. . 75 VEX.CIX A ! ri r - aB p nt' ? P J o VfnKl[IDENTIFKATgN NO r Z? ' i s A RR 4 i . H vEnl IDENTII Q tW5RaE00WNr4: IA51 FIRST MIDDLE 3-1 z I I 6 " ; " I] J ADDn pONnt4 PnOM NO. 'Z tl tt O V,/ 1 0WN q RsT I N Li - t wWea,DDnuarwwR we[w rx Aer r E A WNf4 P 7 rrntac K , . n R A n ` ,?..?a ! o•Mpu IRA • hu,flw N A Dly.pwA cN.RC[ cnARU ILL "w1°crtp"?.E gr'"A`'E 'ER`t A + FF r'?'i• y Tw s 10 ?OlTGiI [sr, oARSAee ? -° %AYN ?Ri-.D TOWFD S ? AW ' Dgrvtn ?RNWN[D p110VrtD AY p NRRp fs . «c. _,f raP 1O BORD? I J ? I ? ..... I AO CAIE DI RAM OFCOLLISI N 1 N M I DESCRIPTI S ay/ N AY Bra u Agns. ON OFCIXUSION IL/sE SLx?nEM[ rAL SN[[1 rFxussARr L F `r` r .l_.. .~.-r .I... _r V6N:p$ fsyr _.TkE U+l!oy TAU 09Atfp?c tcr_./vE.?oraa 'w 4 ._.. _. I . ._I ? 8' 4 e K? uXl, G Rvaa.,Splrwru6. 1/i5_T/KEr..?....TI?AVKL,f{L,._. . a. Acga= CC ? O y E u ? __ - ? C? . ? ?•` .,_ ? ? ? ?•? ? OR ubc ._L UEH A'Z G? _.wSYa"l?. 71 ° 1f Nr/ A +.,rhr4- 7-As E r . . , .. _... _. - pLOE:AL', ./f/ lG ./g?Rf2/A,zi 4mIY is IC/ti3G ' XZ ?' NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES unf svneARr TAL 51 OCCUPANTS /WITNESSES ro4 ADwlpNU NAM ru ISI ... .. six Ace uru5 '""" "'•? ";p' nan, exa :, NAMt - L:: I ? r ' ' C1? •OD41u'? C. !J -V A . NfWp NArw or ' rf0 ?. AMR, ? FI on"! cl STiw rA , ' q? ', A AfKl 1145 ._...... ._... . NAtURf Or w RMOVID w-0-8 ?IEOwI?rw raS. ?M4D 1 p ,ro.rEt N,Txa x»I?5 sfr .. ?AMB ?n:: I ? •ro 5n. = 1 ? =1,. k avls +XC Kr s fRRAnR I X - ,. i s s A i5 uffer t. p1 -[DnrArer4o rax] D ovrr T DpL D lea nw4T A rovfow DAR t r I " it n ...r ti . 7 1 n I T' I I Y ? I . 1 ? Ap ?. R .. Z 1`w . ?" r I ? tt1 ?{ 11 .1f fdi Yj., lE i''1 + I y 1; L E4' r f?, A41RH ]tlD 1 p ! : rka' .l3':M { ?1 r r rr ' v _ I y STATE OF WA, ,AINGTON PAGE 1 GE No • TO Z S 3.(4fV.h ro) l ' ?, . POLICE TRAFFICCOL )NREPORi LRJ 1RnFFicwgY ,?, CE INr ND MBER '• } n P PRIVATE WAY DA;EOfcas :oN D o oN JI t 11 ?'1 - s v r n NI EI E nM 113E J ?H ?R) - `` rv o I COUN1-? C EHww N NO. (', ? ? ? p URBA 3 N ''. YR 1 ,'V?:. + I 4 .tY9FY R ' pN pE p N CITY OR lOWnI NNAF6NO.OF 5141ETOR HIONWAY ECT US 1? MIES ps W ?oE`f w4 ON ( JP e-L 1 f <t NG WI S1PEEt09 ROAD AOM US VG NWIECYStaf' SFCVRAL ro ? I T .•'$ NONIN......IION PREFIX / E ` r r!? BFMtFN SfREE1 EO. MRFPOST /p /? ' ^W' 6 sr-t pSIANCE6p Kil E'IQAGY[ PNC .ORO55SlxfFt RNEARFSIM IE YOSf t•%U /?F Z .?o _ ARES N 3 E ACCIDENT Y NP 9l j UTAG4AM DATA k. s W 1 dTs x 3 , rL ?5 1 s B F MI LEA GE / d FEET OF C R / / COI ... .1 VOLVEO: Evf 9lt : / CODE TOTAL ND. M NO. XILLED_NO. INJURED- pi;ALLAGE ?HIrP Itvr EVHO.INN INTFV ??a0 ?e..:..R'...?TRIT O440AD 09W [NCE A 101')3 Fo c f IICFN 1 E K f OfNNNCwIgN NO. l'b Ya'I UNIT NO.1 - i ISSI UE / MIpDIE / J Tff ?VqE! Ld pRWf 3 4fE El- "PCODf PHONE NO, D pry W M -' R WArE SE% ?v f A Of Rr. Y %(c 2? I Iv V HON[NO. EYES IN, HFIN, E « DF !!/ lY TE AI R g i "'6 s NH;IION / e sN,° p Co., R ? u " p bP?. Z „ ? u-EL(D-1-A N o' E J SIYIE LE D4 CONV.) F/ In O zqJ Y KYYE E STAY T4AIIf4 RAZE NO. STATE H VEH. CL 4/V I i vFHICIt :5 E FIRST MIDDLE PHONENO, R ISLE 0 1-4 A N AGtnr E. R I vs??o ?E "s+*w a "?? r "'a Ia. .••,•• _ E:HARG[ - EurOroN ) __.E .__. J?'? /i\/ 0? ISt DAMwG[ ? ! RIM.UMfD N ESr OAMAGt 110E • X ? 11-NI D AWAYORM ? fO ?ORTOM S ,Ag ''I. JnJ SJ?QDO. IONfOPY. I 11 L ?AWEAY k?+°tI DIAGRAM OF C N: t' , ON: iweNi nic[ssnur) 1 eK TaROwR' E$CRIPTIONOFCOLLISIO [uses PnfineNrµs Eel INKnsA4Y) -' O Drivers. dog jumped in h r. lap. causing her_to loss control of the vehicle, and_striking the Puget power highline pole. n 5P I ,.roe 4 .__. 1 • NAME, ADDRESS & INJURIES OF PERSONS INVOLVED 'CODES I X1 OCCUPANTS./ WITNESSES lus[ swnlMr ru sran _ Z 3 4 S b }'? a f 0 rOY Mp1?U1 NAMIs i , L NAW, I SIX wGf rAlUS ul SIR. IJ[CI ''' r ??J.?' r?.µ;?;a - • YD,[ HY.. p AMP p ?. ' p ? r;L,. 'tee , 1 1 iEf>' n J ?K I,. J r T ''I u LB' ;1 A T Npwu run or Wul•ID rvlrw pAMP ??';AI ?rX':n. p Mr ? ;°.;,o - t Y ' 147 rl wlrwat .. NO un of 1 ?` i e«1sJX;AIY.Ga1KIRSI.A«a PRNA Apxw A;RNC REC x i?:Y ?wASP per:°p?„P, ?:+. ?"..;,•. / IvA CD?JSC:$O 'PE '?DnP?c aD /J? N3E?o.&p A`^p'rper own #? 2iI Y. 'Pm y?y X P [X...ff/ J r } ti:, t '- 1aA i , k"?+?'?I??-w•,9?IIAlypo•t -? ul 71?I .rll 1 'L I R '?? ?'5?.?' ,3i Y` , J,e ? tEkM1. ? r,??1 :r I ? r- 1 I ? t ? t 1 Z.CC 1 r - a F ? ti7 r, r E, I 1 14 1Y 1 'I 1 111 l ?rR Y , ?, 1 5 rEq E 145 I yy?? T'f U E It 6' Ts ?lf Y * E i { Ir„ S DES y.. ,, STATE OF WASHINGTON PADE I Df I No. POLICETRAFFIC COLLISION REPORT TRAFFICWAY POl¢E CamIwNrNUmnER PRIVATE WAY QJ . I N IF OYC t uq n,. .. .., F (USE R HOU9( !l .l, COU-N(IT- l F? COUNIYNO. /? CItY NO .%, rte; 1t HWA ? RIAn _I O V V ._. .? N NSIRFEiOR NIGnWAY Itr CIS , RW FOR RA( ION QN E EI?D AID??N. ?l2mRE5 5 pW ?O 1 I 1 8 y 9?/J o' Y1 INIRSECTI -SIREETOR WAD NON INIERSECIION _ C. BE WfEN /Z STREET A ?777/41`-Tll,r PafFl% EO MREPOSt. - f 1 DDS ANCF 019 I 1 iF .CWSSST9fETOR NFAPESIM ACCIDENT MILEAGE E R AM DA • MRES N 5 E W E Z F[EI Of L COl-ED: lallYl - L USgN NO RRL20?N0. UU-D- ? SPIIU1Gf ? SI UN IOIAI NO TOTAL eJ a FIRE H on N I ER 7 U WSSMFioe WAO OR 9s?? •_ pv . PWPE c ? RI,.-AGEONIT ? IrED OF .,. .? fR'S N+Mf) OaRCt519UCR(NAMld OyKT TRUCK DOWN lST. DAMPGE -UU CCR%NGUSE ' . T..'S•-J ... I T • ' ' 'I. UNIFNCt: ":- '••:"' ' UNIT N0. 2. 2 ? VEHICLE ? PEDESTRIAN .. ? I'MALCYCLIST ' n9 2- Fs 'SNAmE: IAS RNIR Rs NAME: N51 1 srREEr- aEET AO REss ° / I / -IN ? O STATE 11PDDDf PHONF NO. rr D I SiAI 11P ?? GvA . 3B'15 !R D9rvf SU 0 egg o? t SIAI f% u F nti Pz !q"s I v Iv n ATE Ar mD, i D P ION FrES rIRM NAMl SferONE NO. GNIHE- E CUPA FIRM-11 PHONE NO. ErIS IW1r EEIGNI OCCU - B I ` R .. p CHK vENa As:N onEOf.NOrHEa ?CHECK(6 vEH CIF ASAN MSavr No A 8 . °?r "" "°" CODES a s % i "" S e a i, :in v IuroN n S u 6 s""O,N -S1. 1 a n A i 11 Z. E i ai w NjUll(l v1 I l ls F °R:Y °" ? m. AA ae p u Dy ro O Yo R, ? K e 8 ;$ v. E n ..DM p AMw N S'N. ? G " 2N ? V om I vEHXfM FE(-ECHE¢) 1. ?-IyI?DA?Rr AI S".(2 EI ONV1 ?J?/ f U ZA? E HT E o IDARr VAI .I ae ? ?I{A1 ./1 END. X STAtF 19AIlFR RAIF NO. WA -_ SLAY H vEH.< OR E u Ar - vFHKIfIIfIGI 3C?S23!? CI lit i lo: 6roiZ: i N vFH fIDENII I Ar ? MIDOIE RFGISrERfDOWNfR (AS FIRST -L PHOnf NO. / S O I Rf00 LAST (last Z r LL l W . Is Z ADD%ssd R 5 S N _ A O AN I _ AuNI ? >z - R DOaessdlnsuRAnrueo. N fa COL'oN t'q L N 61LA, PEE AGE ARlA '?? . ' gAMAGIS ARlw ON+R "" -p ?M CHARD! CNA9Gf Or 9eiowu STOP ' ?AWAT ?RIMNNFD ISI. DfM f I 10.OIIO? s _ 5 lSf. DMUG!' DRNEN 11 ?REAWN(D - Io DI• S Towm F ? TD'S 101 AWAY", DIAGRAMOF COLLISION iwEtuneefssARrl.._ I ov E4=TH DESCRIPTIONOFCOLUSION IusesdREmwru NNFI fflEeessARrl _ ? I-- ,---i - _ _7 oFf ?... St{a?( o? cuy??E 0 774Tru?-/?--G?uvc uP ?A ? ? F " ? ? ?- .._ . _. cocci--ol/r?-orha- •____ ---- ? i ? : _` .1_ :_._r_? F r..._..,. .... --C?oCD :¢@CviD?,-vi-?-zr??FSnG'/t7?O,iJ -- _ _ :A 7 ADDRESS 8 INJURIESOF PERSONS NAME INVOLVED f CODES 1 - 2 a 4 5 6 , OCCUPANTS/ WITNESSES lia ildlal ru+.°.w' ?ii u% Art ATus I cesiR. I'm ", ADG1. •• ••• ,.., NAII-RI IM AT. A R. pu ' ? . ?n iA21NY Aml ND p yIMO ^D,wO+r?AMR ? ? ? ? 5=17 '.A N-I 1 ....... .._ .. ...._..... .... .., .. .._ .. .Drano wTUREd .. ... Res R ?. ?AM pb,%I?, I.?.^. ? • ~ r ? ?._ Iro/•IIQ..od % s'NUArE•.N. •ACaaR 7 ..?._.__._......_,... --.?.,..?..... +cf.A:r e.w........a•R.I..,...••I.. SE DISP+IarD 1.0Hx ...,...,<.rl..•r,I.?I,.,. ?/?? D o 1 s .IwelwlPwnRSn +pre vEWpr w.-... - on D+n ? '::,etw msmf••. v L t4' ti py W • ,_. i '. ......pxt,.LE a ?F,s 1# .„?..-,4?_. A ,Ka+.a'd . ..?i(` ,Gya•a E. ?'; 6 ? ' ' ' °L"+ C: *r x r? i STATE OF WASHINGTON PAGE °F W5-(REV. .BD) No. ? ^ • ; U.,. "Jill 1 ! ?n %, POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAV FacfcoMPUmtNIJMafR PRIVATE WAY rf f all DAY O ]I • / lN IIMF COUNIr HpOV. /VSF ]bOR) C 6 X" r ry1°O vv X ryes A.D rq.ES rn ,,, °J,J / S J^F sT?$ bN O o COUN(YNO Orv NO. IHWA // (? ?/ /(O `13`.7 t, 0 ?U - 1 R / ?N ?1 ?IN CITY OR TOWN F 1?EEIO4H:GHWAY / MrLEK'?S ?'M ?OFfQ+0MnQ4 57dRIr ON co Rn 'a'! 111. 1 -1 ? I RWpF?O4?5 Ell /Y/DU SF U N 5 ,N 951CNN1(G WtIH }14111 OR WAD egN:NtFRSfCHON / ; -. ' / EFI EO Milf W51 ?°' ?j? ? J \ SENJEEN Ga Rp /. S1RfET { CO nO SIREtt DSIANCf{ I4 -114f F CRO SSf4fk RNEARESIME- -A j VAG4Am t L 6 , pg ACCIDENT A M lFS 5 f W MILEAGE 3 O D FfET §0 OF rh Q / CODE ' ': KIL'Y:D F w4DVt4r" N .XD IN ' 1 SR? OR AO09 M ENCF O""'TOIALrON IN'N -KILL[ NO. INJU4FD/ ? SPIIIAGE ?Tf1E RSLl/ Wr,sN N IHIf . NO Cl1 CRCRSSIRFfT WAD Q / 5 0 - ? . CF V(H CLES © nRWMRTYDMAAGECM/LY ? `-IND nVINi<lE " ,v ? 091KlStRVCKINMEE0i Otl1ECI5i?UCx ANDOWNfR'1 NgMEl EST. DAMAGE SPFGIK CODING TAE 4 UNIT NO. 1 UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST NvE4'SNAWE: USr N- MIDOLI D41Vf4'SNAMf: UST FIX '?i,Ip - 7 ' - u V -/N 4Q $7 ?YGLY rA A 0 k r- 4?1!NL.Z,n nJ /f C SiRFE1ADD4E55 SICEIIADORE55 A GIY SIA f -co. PHONE NO. D Cr1Y STAtf ZrP P-* r'1 PYAnlbf:)q 'wN fR'SUCENSENO Sfnl Af I R I 11>n X. c•' '4-N ' / S . M,-NE RS-T 6HKQ " % I 0 tl 4 NYV 8 '?.Y D41 FN 1 fN5E N0. C-4! : r,- c.'1n 3 1!q E u/r fK °A Ot XIH ';: , V q OCCURAIION IIRMNA II-NENO. EYES IGHI HEIGHT E OC<UVg11Orv FIRM NAM F. PHONE NO. (Yfs WErGHT MEIGHt ) / x 600044 s.4rc.' wq b]v /6o G' R I3r. 64 ? CHECK (.? yr flf as Arv EMnorNff DEAN rHteAl n CHECK IV) W F [H CIE AS AN fXROYfE OF ANOtNERu W N CODES?t ° a av[Awr Ne s 1-1- a :°xrfOrct % s oMN cr u COD S A 7 na ' j 5 E% N p "'O n ? ss ?- IMU4 FS 'b?o,rJiN H4NU GXa14aq 6aNf C E q ,, SA/ kwvlorroM D KF ? TS:°R ? R 2 t ? ,? N 4 ? AW s." F ? u9E' ? brriv ? v wKie ro N NA H YFw9 MAIL IDODCfCHfV.I EE IDA I ?NOVAI YE $IYIf I]DN CONV I H.Y AR MAR 1 ?CHtv.l A-L(DA41440VAI Y (] R 1 ' 10' 70 7/uMPH nfoToR cycl E To' ?T O!? ? m y N OY UCk FN STwi I4MIER MIE NO. SIAIE H VFH.CIXOR L I D L f- k)= 71, c- v C L7RANG r /< .^?G /[ n V VFH CIE IDEMn 'ONNO 7! oRP 0'3':k 3 / O L E vFH <tEIM KA , E'; / ?I r /? RfG SRRtDJWNfR IAST I195T MrDOLt SAME AS A orC RHON1 NO. O W Xt 51E4ED UWNf 4, LA51 451 M:DDEF C-'/AT [ ]x AD09FSSa ovmw N A 9 oWNE4 L?I ? NW e a ADDRESS a INw4ANU co. w AGENT R 4Ti5 Li I'FSuTAFZC'6Zi;c TFIf sT ?'?:? I-AQ 3] oA=" JCIA ' NG r ', • E 'w inG rEM .1 ? s CNARC! nNL _ CNANGE 1 n / CJ. aw o'Miv gAMAC(D/Jf1A. ? ' 1 OTl0ii M lS1 04LMMNf) AWAVN A4NW WAY C3--D ESI.DA f v c:o iSC f5 0wv°er C v ? 1OWf0°n AWAI s 7C1 (S DIAGRAM OF COLLISION: 111Sutt MNAL INEAUn-111 -2 SMI II M<ISSA AR YOW P 1. ILnf su9n[MLNUI SHElTIF WCfsverl DESCRIP1ION OF COLLISION: s . Q'i,, r sA .t NO I.. w,0 . w-J?S7 ACE.v/? GN-.-CCr., u ? --" ?!0 /FNRJuJ '' T'n L(?? WfI :N , Co :? . . L .., V-4-H) /vo r5, role FD ! c_ o F4 hF ""-' Ano P1AD• _!L Lk'!-T TjrN /(jc-/Zr7 . r !'N F- L.-], >TCJ it t,ND J.AN.C . 7.O FlYT ?rZ ... Sq s ?. ? NJ's AR w•. N4}n PREw17J: ^=7 pa,JV? NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED F CODES 1 - 2 9 n S 6 OCCUPANTS/ WITNESSES jpX1?g11pu qunr1 51 J NK AGL A' ?y?" ;, 4ES?R. LgC? ti. a.ap04+t4 GJnr-per+o w . M4r, ar , . , r0J? r- N A,V4f01 5CIr4? D . M?AFf q ??+^' n ";, . oa nr::L:. WI C N A-Of `IMiO ,IRON 0.- ?rdxl nSriRE QN? n1?' AO WI p N . mol 'N wrvISfGAlnppr[I{SNAw{{AN[ RAIXUOV N:fNCr gICI D?SnAIL.IQp H.AKI AV VrND OA,Id NIVYI APPnOWDRr DAtI d ?r f'.1 ?J 1 X Cf / 1?? A In. i ?a J ? 0 ? O G••7 H + L n . a .111 FIN: I m " JE f4Nu? r ? ?0t, t1 - [ Si' d3' 7 ;{' iFf' ?S?YyIIk+pNt" ry?,y4, ""' ?CCI' ° 1) vI m L }? ° ? v"I) I `tyklIX: I L R i IW 10 \ aA. I J[ t Y , ' ) ?A R 4) -4 L ?'1 1 xn Y 1 1?4Y -R1 ? I 11 ?L??f I J ?u 9?? Y ? r c ; j IY A ? ? 'I r ?? L E L m ? r c ?3 ' r • a L,TRAFFICWAY POLICF.TRAFFIC COLLISION REPORT -C(COMRAIN-VIBRII PRIVATE WAY DAIEOFC lS DAY Cato, N rv.fE COUNIY N rR.I .10 Mvs m TIT Ia$E ]ROD llDU91 I f. ra x u x ? R tOUrvn NO. Orr NO Ou?µ /? ` ?? ?? URAI F r e 12. 7 AME6N0 Of 5T9[EIORn Gnwnv R 045 D N RW1E KT CIl A 1 [] N CITY OR TOWN N QF ? ??0 ill n AT'. Clti? ON C, 1 f PRFfI% MIll POSt . EO Cf1 ON NONINIGlI OR INifR:FC1ING PAIN. SIRF RCAO J . r / ?, I ?• ?•, ?? /, ^,,^,xYL!.P++ /? pfM'FfN 1'M(R..II?i?I' SLREFf 6 tiQ CiCN STRtfi ?` ' - ' x pSmal DRI M,f-,VC,C9T-EjFtfI.R NEARIVIVIIIPOSI M FS I TV J ? r[Er OR ) ACCIDENT MILEAGE CODE M Usw R P DIAGRAM WIA %RD S E 09 ROAD R FRINGE N p COIUSKIN INVOSVfO ERUY. 11 IuxRR[RN NO RlllfD?NO. INJURE. ? SPILLAGE ? H UN i S INIER? CYS CROSSSrN(ETO??? / D (f+ Cf VFNErrICl?ES ? P,?OPERIETAVAGFLNRkY ? gfSUITEO F (ST.DAMAGF ' ,' SPKIFL CODING IISE _ _ S NAMFI EECi STRIICR NAMFOh Op1FRpIRUCK PNOOWNEp 4Y? +l-, lN4?c to go- S 0 UNIT NO. 1. UNIT N0.2 .n:UMf Dv v(R SNWAf: ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST MI n usr NR uRlnlr r vsr nRSr 3Q +? A - IJect1-t? -- - . . WRESS > RFft ADDRESS siRE P CODE PHONE NO CITY STATE CI _ -? SLAY LI 3 ' Li I R fl W Y1, I f SIAiE' % E E R R H I I R' IKfNSE NO. IV AIE sE)f 91R AsD y ? RwG'S )IICENSEN A MI5 ON ZO6EA wR M io 2y S ? p N OCCUVwiION fIRM NNAf 6PNON(NO?Is S? AIS IWrll O? M e z L? R OCCUVAIION FIRM NAME6 PHONE NO. EYES IGHI IEIGHT , . e 2 ' CHECK () ANOTHER N I O CHECK (? VFNKi A ANOrHER A A O FF ? F AEAN xIC e a Y A Nr ' 5 n 5 e fcrwx a "s',r°?N? iin4w CODES t 3 A 3 eec x pl n % i irir . CODES 0- 'R 3 R.,; ? Cs<. WAru IN 0MVdv, rOm ? AYF? ? ? C". i. ? vi v ? rvia . w01 AubAwxC! ? M?Cf ? C5'rrtA ? K,YiK1( 0 nA. - M mOOfl IDNI. FAR M MN I NV.) VAI r '0M VEN.YG4 MA[f lqCnFV) M/?Df110A9T.NWAI S(YIE I;Op'CONS'.1 L14: P'U ( r E IO Q i NSf PU EIA IR/RlF4 RAif NO. SIAtE H atrr? fn.caoR ? 04 ?ft lPs?sb1 ?? p i, c v nclt ll%NI (NaE DENrNUnoN L(o I C11yy651 yz,l;o RgNE NO I MIOIXL SRRDWI9: 31 fIRSr RED, . tR, fASr rIRST MIDOI! RIGISRRIDOM O 1 W N - 13 ADDRfssavm+fR N ry v R IN A, n Li ADDHssaINwRANCF CD. OR AGfNI ATa LAr,d 6elloe ihsa l? I i' l MG - I DAMAGIO ARG _ fI"x0 CHARGE ON,x Ow.1 ) CHAPG! •10 S R m rO?N"P? MN DRIVEN ?R[Mm NFO =S • U!O 0? S •TOP lWAAG( - 1 ? - l S f5 ? A If . _??._.?. AWAY D•DnD. / mD ? wiY ? r 1 ? pr. III E QrA Nu INDC re NO DESCRIPTION OF COLLISION: IDS --- --------- lob DIAGRAM QF,£LLISION: _ iWiru NfCFSNRrI pY AR '- wAS TRAueI _CRt9 WAS _. f?,. 168 Owe . Sy f1, 1_ . ?1( loT5k :. S dEI Fb4ReS1 r V?Ll,lelf ...IFT.- 9QAA L T=L. Jf,n?t. ,..1•f T1.4.E Iuso- sraEtx i _ -- "5_ O.V /08'. i .$T2?ce. a Ct.Pol£ ?4n??--•. E I / x ll f14OJ!Ov CO " Q l1 T 5T?4rK>:• U4/.FLf_. uA../4 f 9 r C2 y l? T 4 .jdwrlt Rf?uE (a? 276....[o A t , /gr o NAME,ADORE5581NJURIESOFPERSONS ' INVOLVEp +C ODES """ maY OCCUPANTS/WITNESSES ID?R wa 'Kx?i"u rMaw e+i s(% AGE urus Al Rl SfR. EAR l ( •,•°L Ir1C1 ra l.Arlf/Li' LJA 1 1i0nIR of QcLNd L NA ?R pr Amp ?RW' ' ?" . ?D 7 i' N,. N Aranx 'M? Hrf. ACISO'.) 1461 - OR TA S.h:u' f A maveDnaM 0A,,,- pralcr ?wl.OvTY ?v " NAVI M NAIw fN INf pv QAmp ? ??C' ? E"'p,nv ? NX ? nawv wpn?s oat An Rfs ?rKJ.Arv,G ?Ur /Jxyr(GNI ?.rM KI DISV.iCWO ILA Kt ArrrNO DAzlt+v •1 1 AIMOVIOEY •px? N, NC. 9MI ?LSC) (XDSEA /{T?ya X U4'M A11rSN i1iE ,?? ],uDNn_..- ]Kn Wy 0 t y ? rf f l f F ? &f R 4011" F? I ? I F Z f F ? H I T I t L »n a/ 'gip T1R.S K{ T + j7 P 1 i ' ?..ix v : RAI I A 4,µ aM j. x } 4 k ??F L.. a yy?' ?L POLICE TRAFFIC COLLISION REPORT NJ TRAFFICWAY P _,cfcoMRAINTNUMIHR 2 E:] PRIVATE WAY ;;Z " : n D°r fsI I NO"" NO HWA /C `CG I 2 QNF Q N i1 CIV ON tOwN N f6N0 Or51RFt10R HIGH WAY fv ANas Qs w Qor NAD? ON ?-/ A C C 5 PREF ROUtE 0451 F n[CIION :.3 -?•'%u CJ m INIf45lCIINE OR RO°D NON INIfRYCN/O?Np-,{?jF? Bf1WF[N t:.^• STRFEi6?? StRFFI PRtN% f0. MIIf POST ??7 6 DDIgNCF DI N I WMRfiE.F m .CRO SBr9ff104 NEAREST F ACCIDENT 8 IES N S f MILEAGE R p pIgG9UA MIA E e E i Op / CODE COIUSNNfINVIXVED SFVfRIrv: IOIU NO. m INO KILLED NO INJUPFD? ?SPIIIAGE ? A4U CFVEHICIIS v %Rp ING StRFt ON 09 RFpf NCf IMfR ca C4p55sIRf//fl09JROAp J 9 RpRRirDNRAGFONLY ? p[SIIIIFD ?vf OBJEC 1514UCKINAY+?q OBJECTStRUCK AN NfR'S NAMF) fSi.DM1AGf X63 s -s .Z l (Y33G?O SPfCUI COOING USE 5 UNIT NO.1 UNIT NO,2 DkIVfR'S E ?VEHICLE ?PEDESTRIAN QPEDALCYCLIST - •?' 24 : IASf IRSt MIq% JAO T RWER'SNAME: -1 fIN$i mlDmE 1 SfRff I AWRES ? ,.IRff I ADp9E55 > Z of36Sf Urv SIAfE ODF pNONENO. CK, :51 3 s- D CA D4N[RS D Y SIAIE I C p ? U[[NSF s SAIF f% w f IREN v? 16 25 v Iv N' IICENSENO. SIAIF SF% DAiF Or BIRCH DAY 1. g Z CUPAi1CN FIRM E6 %N)Nf NO FvFS 1-1 HEIGHT ( b E R OCCUPATION FIRM NAME B pHON[N.. IYfS KEIGHl HlH.. V T _. (IJU- (c I?r ?U ' ? CHECK (17 vFH ntAS °rv rMrio F °.ifitNE4^L MWI CODES ? a ° iD 5 uF<IRJH e y° ? CHECK (N? EAICFtj A Ea N;TE; OFANO HER^L CODES , 9 cI 5 u B N rno Y m Z loi i N O w H. YFYAR MA E °A {HEV ) ? m,H ? "I t D M I I iNpV l WSIYlf I1 DR CONV 1 DR ? l ? <CnIl ? b:HK ? =!i ? PN H YEAR K E •FV - - - Y . to Z O/`? : . . ? y I, J /y,/q.V S . E ( .) NODl MiINOVq) Y F 7ik Zirrv ! ae .?/U lltt IE SIAIE RAHIR RAZENU. SIAIE H vFH.CIXON N A A N AI C VtNKIE ID[MIi1UNON NO. ZD 3 z ?- 0 35 E VfnIREIpfNEi I ?" IR RfGISR4Iy'?+QWQT+f.?pL Si FI451 IDDI! 7NO. R415DRFDOW ER. 1851 NRSt MIDOEE NNO. I? ADORfSSOf OWNt4 L N JNf WHIR =1 L ? _-NAMEa.KJ>D9essa wwRAIOECO. ORAGfNT X R N A I uI AN `FTC' yARfA f? r.6 ' A E' pi " "?E N CHA CHA9GF nes NG RN[nONN JAMF4E,DMG . . v 1 r Cii s IS1 ?OAMAG ' " ? R vfN F/MIUNFD ? O ON V[N ? AWAY ?4[MUNfD ..SSE t5E-DAMAGE i sTOF IUI S _` // ) T rOMDn 1711 -)M? ? AWAY BY, s O RAMOF COLLISION I 1 Y a EH B I s EnurxcesuR) B W ? DESCRIPTION OF COLLISION: lust supnEMtFJrM SHEEPDNtcessA4r) 7JEErd/CFGCj'!'??'7.v?7FL?JLU.EJ,d GK1[je+?/??!/ v7? Z`e- ar C dI?E 5 cry A dcv o c ED o t/e ?.uE . ?R TJ EST il?iLaYSr 4 /777 ?R ADDRESS 8 INJURIES OF PERSONS INVOLVED R CODES 1 _ 9 4 5 'c _ OCCUPANTS/WITNESSES ,w inplgNU F"'FAi%e rii sEK Acr rgim p "",,M," w ' otsu. ena Y ^ N°ur ! ADMISS wMl rURr fH , IM er QAMn. ?11' ?n't.mE ?N ? :ZwJ o , NA ADEHFSS AVI NAruee a. MwlOr QAMn. ? %' ??",;, . ? ^ ?"D: tin A 111 KrW,Y - ?- nl :% "' ; ?;i;riv SIRSAIUg pf ' " p IseAr 4 nAD K:1NCY N:ID SPAEC"rD bl Kf A Z tp p.lf'O R? M hf ; ? ?? Y 1 ---- - ?O 5 o N A 1 F 1 F" t v -. ?? ? 'i?U? tT:,.; t.'it?? -, '? ?1N1 _'.?ls '•c st? P.?r. ,:x•svv ?W +.:rrll?ta.T.;?gD=,wr? ?. MOTOR VEHICLE COLLISION REPORT '?h.!.. NO 4 FE u>A3 _ .. °AFEORCOLLLSIOII .. < OAY OFCOLlA90N ..-n.l TIMEOF COll1510N - AM '? COUIT CIC/NO 'Y P wY? 7 MO AP Sd ryK .? / '^>7jt ? yP? ' ' O 7 PM S''T' FTi 'J Q6Un,., 5y?E -? a ..•... COWTY GTY, TOWN ._ rd`Irwr MILES ... O.-....•?.:. _GTY.TO- - SEGTgI ApMtl3. PREFUL ?•? RWTecRSr FT 2?J"J . ' KfbEW ( t-t rowiiq V ' AOd .. GNE NAMl OFSIPElT,FM)AOOAHpNWAY ," ;:'..:_.WTERSEGTNO WITH: STREET OR NOAD ., PREFIX.;, EO MK POST. Y mcw. - NON'IINNTERBEGTTI-LOCATK)N FC LLICION / PAY -')' GuORAM ??? fir' Z ?? - BETWEEN STREETAND STAEET w?- Y.? ; arZ!s.: ArNOr ©© nitROb CigSNwgE.u EWSi OUloENrivuq UngtiilKVYXtn.bwUGf NON %, - A'I' EcrKW- ©E® - WrER NTE CL8 . 0 T n0 t •. oou savwv«vtD .Ov llYer'e1F ? XeruF ?D ER.IA-1 - EC eooEUSE .Sd6 n wvir«c°lts ? ?? I ?V[tu-YTIX M,N ?w%r «ILYMw ? Nw i 1 + IEx'" f -- .. 'A , C I E I OBIECT STRyCK --' ?• IRAM ORIECi/SItB?UL I OWNEROF OBJECTS NAME ANO ADDRESS -ARCH IF]?T© qp Aw Oa:ELT '.,fit 7 G V 014: INROAD AY ^ I T 11© DOf r ; '' FMOn Av F :. -a DPWEAS IAST NAME FIRST NAME . .. .. MIGOLC- rvgcurs DAIVERSUST NAME IEFE FIRST NAME AGOOLE ' 1 WvoLVfD J D _ 3 SYnEET ApOHE99, O. PAUTENO.A? %NO. MOAE T.. STREETAOONESS fiOUTENO.ANOBO%NO... -. _? PERSONS W- k,+i?r.Pk T CITY STATE LPC" OPoVEP9000URATgN «usgY CRY STATE Lv CUOE DRIVERSOCCUPATION FPT 1 A GRNEPS LICENSE NUMBER : :.;,, ::_,: STATE SE% D?TEOF &RTH AOE ORNERSUCENSE NUMBER - STATE SEX DATEOF BIRTH', AGE w M F XAY Y`f?Aal ,. .. F Mo wY rEMI 3 VENK7-E YR. MAKEIGIEV.-0OGOEI .; MOOELINOVA-0ARR JEoOr STYLEI2b°R)., VEHICLEYR. MXKEICHEV-DODGEI MOOELINOVAOARTI BODYSTYLEI20R) { -Q 941h 1#/J/, kip L ENBEPLwTEMO. STATE - TRMLERENATE NO. STATE LI°ENSEPLATENO. STATE TITNLER PLATE NO. ;:.STATE., P v 2q „? VEHICLE WfHiIFICATpNNO. SIp60MOpELSe NEWERI - OOOMEYERI-ADEI VEHICLEIDENTIFICATIONNO. (1958 MOOELSM1NEWER) GOMETER,IM%EAGE? ??.. "• , REGISTEREDOWNEA :. IIASTFWST.MI°OIE NAM pANEPS IK:ENSE NO..4 ?t""r., E) PEGLSiEPE00WNER_, (LAST FRLITM11111 .-E) DRIVEP9 LICENSE NO., q?', OVmE AOdI SS , (STREET.CItY ANp STATE) - GATE pF 0' H J OWNERS-E% ISiflEEi,CETYpfI°STATE) . DATE OF BIRTH ` •w Et TIMMOFVEHICLEOJIMAGED O.rv TEAM - ..,. Esnu,rfocwr PARTSOF VEHICLEDPAIAGED ... .. Si nAiavE?NCCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- WASTHEnEAUTOMOBILEUapuainNSURAI,CE COVERAGE W EFFECT FOR THIS ACCIDENT CN YOUR CM AYES ?NO -m:e yj NAME AND AppRESSOF LLr&UTY WSIIMHCEFOLICY1gLOER .., .. NMIEOFUANILITYINSURAACECOMPANY 'a) - ? ? Hwf AoOntSt . ... . a d2T R •• I •: NAME AND ADLIRESS OF LIAB%1TY NBURANCE MENi. _ O STAIF IP UABIUTYPTTI-1- I P , ,a NAMEJUIIY •. .).:• /.. ::':?.'? -•.,E 2ND INJUAY• ME IusES PAWIl RtrNlnrrd,Gargxu.xu Y ?1 -. :. WeES1 TOTAL NAME ADDRESS SE% ADDRESS _-•_-.-- y F L If T. ... p SE% thol"" 1tI STATU90i PIJWiEO MAPKF WST ON THAT AI'PL E9 STATUSOFINJURED MARK FIRSr CNE THAT AP ES ff0rw NVEHICLE ?E NVEMICLE D Os,XLWO NdMNan1 IBUq F 'Y v:r} „[( StAOf %1LLE0 I.fr t?'Lil(1 NNOrVO 1 ! COtrurl ?v nnf KILLE 1'+WtVFnEI 7 ?? y OINK ? ? '? D?Ofrc ?Pf« NO I IQr eie '.wa.ol 5 6 ? ,I•L. uE. tt ? 50 6D 70 Tr K)W NORrH BYARNOW NGRCLE 1 2 -ATfd \ I .'.,.DESCRIBE BELOW WNATHAPPENED?(PEFER TO VEHICLES BY NUMBERI -, wMO a M I ? I. In.ce r»E cTa dnnf r Tour Laltlaw on ??.r? DnrrorwM ,MMMff;°a 0 _pro-?'-'?=--RrRC..!_zE-__SHl?2PNFSS__` r + AMMMAlACKwH«f.AD,HDtI _..oF-cv..tu_E..._ftuO--Rt+u.._ UPE_--r')4.r•_..-_ '? .DMC.wIGrlwrlL•. M.ow d'., t -+? Qz ?'- aINtYDRr< !>utcN_--._541/>._.I21F .__._/PTO 1 I A:j I I .4a. a EM,i ?' / I [ 1[awlr erANUMJ UOUIr PamIO vrrK O r a INVESTIGATF-n BY h ' 7 • r.. ton f VEHICLES POSIT IONS BEFORE COLLISION uoa nn r f',E^ '?: VLtuGlr N S r w ON STRfEr Of11AGHWAr NAME OfINU U'LLCIKKr I! M M ?IiinQ 011-1m,", Py r,, y r1 M Dt1W ? ? ? ?? ? ? ? ? ? ? yC fMNIr ?OinO !r {..A I ! ;I t 1 nnaarwWAr y " 1 `•A 1 ^uld''. dA ?? u"IDM.K, IM FROM DIRECTION ? ? Q ? AL. ro DIRECTION 1 ;. 4 y1>) 1•rpf51RAV WAA IJ^.Yq IQYDI WNM ?WAL%WAY N /Q?k,ww. a?Iryl; w4% eQnilf t 2 JQt1l01ADT r1 i I 1 } PpAp SLWIAC! WFATHFR LIONtCWn11ONA iNArfIC CONTigL KMIr dH TYPFOFIoAt) OPNFn,Vr,,R,tIAcNGNs ^ I , y, ? 3' r ?I?Y.aAAt • YW v ti vlHCrlM> opt'aArr rrK'clr In'rcldrrnvwN ? E ? ? 1 1 5 IA4T AJI'. Ku 1 Q DAY, al 1 [I fA 'L1 al I ? WE WAY EcrE 2 Cl I ) Oh ? - rO r1 QDRr Pr t t ?1 E Q f101NC1 arMM11r AHEAD W f _,r L 2 Q n.V- 2 Q °AWY Q 7 Q SIOV S%W fR 2 Q TWO WAY ? 2 Q OVFnTAKINEE ANDPASAIW R t I I la r ? 2 0 -ft J Q NHoAAM J Q r%ttiK Q J Q -,o sI 1N ? J Q IqW LRLF ? J Q MAKING ngllr TURN - r ?" ((1 w1 03 ? Rr10w 1 QlOC 1 ? lC?rT 3°rttr, ? 1 [] II-IKKIRFO Q 1 Q Rr1fYKRAMIF 1 MANWO LCIi TURN ! •'Y 1 t 4 L :?• S_r 1 ;h 1 I ?, 0tor, R 6? 1NCxYI 1 0 0%v1i5 Ulfr ? 6 Qr-SHNO AMIIFR C-1 y ?Al LCIP?'/nAMRI C) 6 [:1 MIXING ITYUAN '}I IS fir L.?3YfGHY A??-,,>TDAN%M a RR N(WAI A v r Y ] %InIET IIG 13 ? ? ? ? N I WTNA1N Y• IT C] SL OWAn Ar A.90YTCA rqI 61l NO DANGfR lt ? 711 AI vCw h1MKttw• I rGl 2 -]%I 51'(EG/Y ? Y Q Cf FICin,rl Ar.MAN 1 µ iR , .1` Yr' xovn. ? I Q A OlFn AT BOHM FIC p°' I f} ?,? ¦.1// ? e Q OiN/Yl. 'R[Cr/Y Q 1 Q :r PAItATEP ? e ? 011pjfllnnON?N? •-1? ? 2 Qnwnrn Q D Q DTDM•ED IN fgADWAY Y1• '"E,?,?r,?,' L? -I W P ?Gm pax,` ? 3 QuNarv urn ? ID ? ?• inAFFC-l 1 „ilif'1 ?iG;ttj,I -M,77777, 7-7`7, Y'y r???w n rt Y^r^r.': sr"j ? n •,nn v ,qrM ` ^ a ' .t?rl...• j u ??L7J POLICE TRAFFIC COLLISION REPORT LXTRAFFICWAY PoICFCOMRwM1NUMYFR 2 [j PRIVATE WAY ] Dq o¢ au r Z oar au oN ? t (USE ] IIOU 3 courvrr munrrrvo. cm NO. IHww OUR AN 2 C11YOV10 N NM Ea N0 Of 5T4tE1ORNGNWAT gH..pE KIN AU[E"OSNOW ?Gr ON C / MEN A EOk SIRE O ° l/ O SCTION ] ] INItYSfCfING Yr11N: 5r%[ETO4 vOM NpN INIFRSfCUON /.' BETWEEN STRIET a -Ifl -U, !°. MITE POSt??i?j/ / /, DISIAN ES 4K IpR RE NE .CROSSSINffI 4NI.....MIU ROS MILES 5 f W r[ET OE N/JO W14 / ACCIDENT MILEAGE CODE v .11 RAMMIA MU-INVIXVED: 'N15 To`A31E0, n NO.FtIED_NON.lURED_ OSRIIIAGE OHRCRUN CE VENOUS -R]YDAMAGEON[Y O -EUn[p O V[aEN AYSf31N wNDn4,N -1. 1 N IN1E RD q Cl5 (ERSfC ING TREE OR A00R REIEREnCf CROSS5T4jEIO41gAD /]D 9 OBJ[CI ]TRUCK III ME OFC IC St4UC%ANp OWrvfRS NAMf7 ESI.OgMAGE S Cw COOING WE $ UNIT NO. I - : ... UNITNO.2 p VEHICLE p PEDESTRIAN p PEDALCYCUST ?q ?y DNIVE45NAME. 051 AS M D9NEN'SNANE: U I ??INTI?T? l F AIV ALL A Gt joo/v 1 c e SIRfEIAODRf ??..e W? 2a -- 'S Si NfETq PRESS 7,5-7 O L OI IAM ZIRCOOE MONF NO. D CIrY SIAM ZW ENO. / 23 4 R LoG C!/ 39 37.2362 09NlR'S CfnSN F 3 STATE 9 f% MD" /S4%/ I V RWfR'S IICENSf NO. Iglf X DAiE G L L GdA M 0(0;o r j:q 1 CURAt10N IIRMN E.-NENO. EYES GNI wIGNI E OCCURAII(xv IIRMNAMfARHONEN FYFS IGN wIGHi 2 ?ecb / R e pCHECK (? vFHI<1Egs nn rMl%ov EaA.iomrc OCHECK(r) WHIiF AS AN OgaorEEagwarHECAt ??MM [[?DD CODES ?* 7 0 x y S CODES ?* 7 u a is S Ex 6 3"pur r ] 2 NJURRS J O , , { p "4 p T;m p VI K1i 019IV ?WY .Kl ? u6" O CS.NR 0 MIVI 0VON. v T wN.YEAR MAI MNfV•1 ASOADAR1 rvovAl 51Y1f 1]OR CONV) ? E vAl r { v.l MAX( r V.1 EAODEl1DAR R 5]n ? v UCEN i NO. SrAif IRNUq RgrF NO 5 I'I v[HOIOR w . A Nl 1 N Al 4- C,00 7 C C e o56 WA tval VENICI[IIXM41CArgN NO. i2'' SJ' 1-,3,9 v ! RIGISR9(OOWNl4: lASI 1901 MIDDY -NE NO L I-it 1DEN 111CATIQ1 F./.0' ,;K-M ,717.90i I i ! ! Rf ISRREOOWn -1 IIRir MIDIXf >o I . O W 3 ! z3a • I,l_ E/G`J•• wDDRtSSR OWNtq N E A 9f OwNtR ,/ / ? l? ?OGK W?x" ?I Ngs3e aADOxeSS V INSURANaeo. o4ACfnr 1 BI LeS 6--111J14 ham ' R -/?/ L /- Y 72 /LCS?h1V 7e/ ]wMwf ] ,vtu ° WFSgNU CHARD! ' ?AAIAGE M!A CHARGE Sw[r'KSMGrIU E R f l5 ? OAMAGt i(/ -Ay 0 RfAWNFO Idiono: IILJJT1 S,4'00 iw1- 00 A- Y RUAAINFD t51.TDNAAGf 1101 (? ri5;i f AWAY nv: /G?0)l/•s S?SOO INDKAIt NO4rH DIAGRAM OF COLLISION SwnR wCL53ARY) n A - DESCRIPTION OF COLLISION! (W$ WMfNTAtswetl N[Ct55ARY) ]s Ia -. I kNd R _ S7?o? : sf >° - T i r fleN• /.. F4//` M T ....Fo//ow. CCC CdL? r ?o ;e d ??t # s „ I u I ? { o , ,?.! I /s'oata/ 6Ylatf'?a6c __lugs _Gvc T >a " oc N. s __ NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED + CODES I - 2 3 4 3 6 OCCUPANTS/WITNESSES (USE" WNTAEfr4 IOR ApIXIp1LAl NAME Er 51 - - - S{% AGE 'AT U H, w,„N RU •, .Ir y - 4!510. tllCl M N grE'/ocIPAJ G'i E? /Ill1.t? "? `?"? ?/? A opfm iu4 lr ° u " I`"FI`Ioa,?,v 111 CL /C V,•/ . . 7.53 ylSG . A . DGRIU N 9 AME NAIURror RMpvID rY pAMn. p'iO1KE p'E'r?.n Ci2' O".° ?r '0 Su / l t/ Nj !V r?/o vA// p a Z 9 -r . vunt 1 c "irw ?s° I ulrrer pAMn pp?'Ew ,. p ;3 f G Ilgp KI fNAMta1A ? %AD:.1 U4 AGINCY v:«I K OS.ATCNID KJIKI AY ND p w F/ OAIIpY{041 AMRO„DnY DAIt hC 71T_' ,L?l S.,r n4 S;N - .. _ dl._ IF "Ir"mm WSW- r» "M I Y EF ?el C k?f q 4 m a 9 . ?rU V I I rr ? . gyq` i. 1 r. I36 y t C -r AEA AY ?.wcuNaKA mnuMNEq - 1 I -PRIVATE W l0 KJ CIX R 1 ! 43 N C TIME COUNrv COUNrv NO CrvNO. _ FHWµ IU$E aa00HOV91 /? ^ ;? U ? 1'L 12 'O ry >E X 5:r ?,s J 4i-t?cFFa?N J ?? ? I 4A ?Yt CIIYO410WN ?f NAMf 6rq OFS!?[LlO4 HIGHWAY fCi CE3 I% RW IEORS REE 3EC1 hVl[5 ?3 ?W - iqc. ON (°218 ?3 ?`f?CsD INiER3En NG i 1NEH. S 4ftr Oe AD NpNINIERYCTION P4ENK EO. MIlEP05r BE-N SIREn f 3 OI OEANCF{DI9 I ?k .CRU55-EE RNEAESrMREPO rREff , ACCIDENT P UTAGgAM pArq MIlf3 5 O fEEr W pF 4 MILEAGE CODE Cau3lDNlrrvavtD• {{ TOrAI W. K'LIED_ NO, INLURf01 ?YIEIAGF ?1 E?U,N w HDI" n INIEq %'D E I--- E gN?Ap OR 4lNC ICIE / QS CApaSSLRFfSO9 ROAD OF V[NIClf3 © ? PROPFgIY DAMAGEONIY Ita ( V ? HSULtfD ? f ? 27p .C1Y1%1CS(NAMf OF OeI(R 51-AND OWNERS NAME) F To "" Si,DAMAGF SPFCULL CAGING USE si _j UNIT NO. I UNIrNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIS'. ,.. RVlYS f.WF• FAST rlgai MIUDI GR , ? VE95nAME' US Flta? MIUIh 9-111 J -1 ? ? L OLI1rQ "" 3r4EElA 9ES3 3fREn ADDRESS O SrAEf Liffiff ONE NO D ItY SIAIE ZIP N !A i I 1 f1't:,d A ti't? 3isrSSt6 R taK"vtK'S UC[n5f n0. LfFV+It ,]}.. Stgr N I D I V Enlf NO IR l, . 31AFL 6L1 V qD. R E 3Z 7 9. q OCCWAiION {I4M NAM1{PRpNE NO. FYf YFG 1NfIGlEr E CUPwrION FIRM-E. PNONF EA, EY1:5 Ifall HGNi R ' ? CHECK (,? Iv[N Ci A w MNOYfL OFANOrwfq? A ? CMECK (/) I O O pL veN f AS AN FMgOVFF PAN rraf4 CODES ? o u' x n S t .Da. 1 a i °m`tY CODES t D a % sy ncl Zi 'sn+"r 5 tx N y °1r •cu nr ? a f .. a) INniOI" TOEIAC p -• q' R?° tY °x ? AN9 ? u ? pS rta K,' ? 9°? ? AM, Ntr ? uV ? 8L,16, ?N t11 ? wn VEN YtA4 E F E e " ? S . v IOODGE;FFV.) FlIDA4iEgvA) SIYIf IaDR tGNV.J v ° 2xD2 E Y7a ?oec/Y, /a-s?LC?AI ?a2 . J Sh _ ?? _ . PU N. 31ALF RA ItR IAIINO. StAif II EN OR A I N . .? I %RN zIS N N.7 1 G.1?F YAN3DS uG! vkNlnLIOENDFEUnoN NO. ? vLHICLE IO N I I A I n I..Z I I I? i I I ? i j ' I I I I j . ? f i R(GSg4fDOWNF9: LASr {IgSr MIDDLE PHONE NO. rr N D w ER: lASI NRSr MIOq aD O ?FJ'T Eev hgle,I?S- E ?F}2Trr1 Pr?'i 3. $R 6 ._ N 3 a ADOgeuagoA++ER ^ ? nownER 1 L.! fLs ?, rvT?E fX E P0. &x Sti7g ?ocE? L714 ?I NAAEeaAOOgessnlNwx.wcE COpo4AUNr , F} I l'1$ ' R as UZ.E? 7 _ cco) 'Ue ? 5?•-s??.. DAAVLGE A91A OatAr?Np I V _ HwrngRh tN CNA9G[ raVr?i ,t ]AMF4FIA4FA' TO' Sf t ,OAAE A G 1. K ? Z 3 ??. ! AWAY ?LMAINEO 09IVlN DAAVW! DA 3 ,E ' 10 il 0IrOM .c?W ^ ? AWAY°{r: ( Ics •a' , E'IE AWmy WAY ?REED IS1. ? IOOOrIO+i er DIAGRAM OF COLLISION I INDKA tNO9r M DESCRIPTION OF COLLISION: ILfseswneAEwru sNefr r ftluAgr e ?- I- .. SunII NIC[S1AgY1 ? evA ROW' J E11.....L AT + OA, C NL G ii E - C E S L. ,.f 5qL t 'L L.f?.L1C- // j ? ` . i..,.. . _ . F .... ?•Cri VIR la 2 `F 1 C . - ? ...i r ,i 3 .F Cf -: f T6 . ii+. J ? }L1 "C4CL f ; i i .S7KUf.e•L tN.;S 014 .JK j, 4,. (`J ... 1L%. oK. 7/s•'E_ ?'L1 SFd c c eUt/fT .._. 'w I. -j uc.( Le sk Jchlo A I ?u Z . i .P i x o PP w-.. . ?I o y : N L1 ti f l ? - 'b LZ 2 + 3 C.ITr-E. U-'TCcc p'iK) " 36 1lQl I • NAME, ADDRESS 81NJURIES OF PERSONS I ' NVOLVED • CODES 1 2 J 4 5 6 OCCUPANTS/ WITNESSES ,n,3,pu o,?r(pfN1„Ilr?i,3w,E°Ei rEAML i $uLLay°r t i b 37- we Ac[ reru. N '" -R"' T K3r9. (HR ? I N ' 2JY6 Ar e !? O 1 Aowlss O r.)f 2$( C! HfMN 4 u orr?0a1 Y AM e ?$s' ? ?; ?M., ?r .o r %i ADpp St H U p9f d > MUV10 rYOM N r. ?AMe ? rPCI ?N? 11 rnr ? ui , „ 4v w D' AOfYEU INh XS GAI pEKIf3 NAA4{SANK eADtxW AF•IM:? N r ,w1K YO,1Ilr' ?AMe. ?A ['?rrmmm•?? NM y ? X K ? ID13rwrCIMD r ? M1?T f fr1 J ?? r 13p rRKf AR9IND OAIlM 9t t / i St ? ALE91M0{r DAII .. R3 ? s /L r ;? ?y? S d k??T v 3K7 tS ? ?SY# .. - 5 .. Ma"a ?.ry 2 Y .37 .?i r: y: - N!? 1 ..?......?..................... F ......._..... PRIVATE WAV follcfcoMfwNrNUwu9 _._ .. .... )1 " DAZE UV,CGU DM Olo ivn COUNn PA v 1 "I9 f IUSE )vroHOYRI CWNn NO. On NO. /NWA /? ?UgW RA " 1 ?N ?F 0IN CIfYOR rOWN NAMEe NO OF SIREf1O9 --Y N(l9SFCIIN0 WI1H: SigEEl09 ROAD NONINIFRSfCtION KI- A 71 Q 1 gOUlf 04 3 5[ i n BfIWEFN SIRFF! [ SnEfr pgC11A FO. MIIf POSt J ' '' /4.J' ?? .CW 3531RfEf Oq NGRES MllE p051 ISI.wCEe W4 MIIFS/ NRE59fM1 AC RwMp DIwG9wM A 1 {F[i Of MILEAGE om COOS ' - COEISKIN INVgVFD SfVE41fY. MAISN K 01N1119f0? ?SP,IUFGE ?HIr6 9UN WHPRO,N IO NO ND. ? , %.4D 9 01 E INIf9 l1 CROSSSIRt OR ROAD ]) -? ' Cf VfH CIf1 ? PROpERN0 RtYDAMAOEONIY ? RSUlnO ? VFOlf 091fct5fgUCRINANFOF 091Kf519UCk AND OWNEq'S NAME) tSt.DAMAGf SRCIK CAONVOIe! ' UNIiNO UNITNO.4 ? VEHIC.LE ? PEDESTRIAN ? PEDALCYC115T rv sluRME: Nm FIRS MIDDLE D4WER'S NAME: 31 , E. - W.Itt AOD9f55 vf-iDpRE55 - Y SIAM )Ip CODE PHONt NO. D ., Y Slwlf V p R mNEq'SUCEN SlwiF f A H Mo. PA: I r9 ? i I V Iv R' U [NSENO. rAi % pw nro I w 1. ? Y I. eLl. R OCCUpw110N MM1NAEeRgNf NO. EYES IWI HFIONI E UpwtION /IgMNAMle PHONE NO. r 1(IGHt '_I;: R 7 . CHECK (7 rfNl i W fmpMr wuo]NfRµ A A 0 CHECK(,') VFHI If AS AN MR OYFfO µ , CODES ? a n A i 5 ! d ;,° w rHER 13 N _ CODES ? * s olcroN d sAn n IN "Ys a?:;..DH ? wMNAAN ? ?,[! o ram. ? n <,: ? ra; N ?Y7;, DM n-- ? m ? M6. ? o r.16 Ku N Wl YIA4 MAAf IDODGE{HfV.) f1IDM1-NOVAI SIYIE I)DR: CONV.I EV.1 lADDEIIDMA) fADu to E 7Z `.? LVU P J ]B OR KfNf PAT N SiAffG,IE9 KAtf NO. S1Alf H IH COI Ar I u 1 3ly; A GNbBSo (, A ,.? VCHKI[DtMIAKA110N NO, I l 1 i vWlGll IDFN1F A i t Pf[wSnRfOOWNf9? I, Si HRSI MlDplf MOVE NO l l l l l! I IS RDO N W Ii : IASf fI43t MI . O w OpF ???J yyy ??.,, ??' ? E fu A 7al-Y O AW4l350/OWNfq N E `` ?/ ?_ ? AlAdloc-k &A NAME(AOORess of lNw9A/Ke eo. aR AO/Nl 14 R pAFSS I?•? [i T}'EUhGI/44J Ssrr/? '• " DAMA.OfDMFA NS NO , A AwC NN gAMAO! MG CHARD! 1M , MAR,! M A _3J - IT FU?OROii S fS1 wJAAGf ?.%AY ?I-NI. f ! i)O AWAY ?9fAWNFD lS .D 'Y S [- AWAY BY S [?° Ioionali rONZO , ? AWAY eY: f DIAGRAM OF COUISION; lu u mN ei^oe IH DESCRIPTION OFCOLLISION: (use upn[Me"rwtsHefrRNERSMRr) _ i . Ip - _. SH[ll4 NKLSSMYI ...._._ _.. ; I l I i NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES I - Z 3 4 3 6 OCCUPANTS /WITNESSES ?Oqi anlafinN.' A i?EAwl esi ?uz Aci urlr ";"" -° _ - ; _" '"'"" ,EKr' wi. j AMl w wlnNi, f..eY. ?Am f. ?m I ? "" . ?= ?ra:,o >D xnss NAmf W , NAruf a NmOV Dr.om ?wme. ?,uKl ?Hn . ? as ? "n°O. 'D No Alcr.. wnw riO1 uE.Aer?Ame ?'r`.".,a ??!'r'+r. ?:i; ?'IL°.w v . .. . X nN4AIVgOIlKIP1NAMI(GNa eADGI Ow AgNCY v[aI KI DISAA1CHtD IIXKf MRINO OA1EOf 4fW1 AnpvrDer wn ID ND _? )A•i9NM )gOHH a :e ?b ° T r`'t" 9 1 J ?, n ?pp?yy :E:., Wi W •F . i /` ?- ALY' E' A $• ? g M ? u "'r, " agEi 1 ? ti , E . ` _ POLICE TRAFFIC COLLISION REPORT IXI TRAFFICWAY EDUCfcomnnwlNlLMIkR PRIVATE WAY '?11 DA fO. COIp ON A EC IU ON COUNTY COVryiY NO. CIrv NO. 1V Yv yr VGr lute A r+? IH IUSE ]+00 HOURI {ER A R X 20^ ?6P?ECZ:1Jt-l /o p°u MEfS QS ?1V ?01 O LADS ON C-P, 10 It4kCilr(G WISH. S14fftOR ROM1'J N INiFRSfCI ON PREFIX ,L NO f0. ME POSt {° [] In- VREEi a Sr Hl ?• 15 ]' OSIANCf eI%Yt/CAI EON 9OM csuE Er,tW SSSrRFFl09 NfA4E5r/A lF P061 / ACCIDENT P DA UTAG9AM TA MILEAGE R 1*11 CIXL SN)N INVIXVFD: O%RLlFO?NO.IN]UREO? ?SP RAGE ?Nre RUNT ,UNDMe1H INtFR CL5 CROSSSrRtFROR ROAD4 09 WF4ENCE ?]] ? OB;FCI SfRUC%INAME OE OB]ECr SrRUCK ANDOWNER'S NArnFI ESr.OAMAGE SPFOAICOD,NG TAE 2 fbs^5 pn;Sl P c? rraRftL.l ? o?T s UNIT NO. I UNIT N0.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCUSTaR 9-. 314lfi n0DRtS5 SfREEi ADD9E55 .L SIAIE Z,P000E O "NO. D CIY IAIE f r. t?OK N O(o _6 67 R EP-E LICENSE SIAIE % 0 I w R'S IICENSf NO. iAIE % A AIE DI IH ? 6') vEHnfns•N frAAOr EOiANOIHEVInI ?CHEC (?) AE rp•. K VEH1ClEA5AN V0`fM rHEp. ! ° sor DM AM, RE ? Wc, ? c".- ? cii ? iY° ;4r ? A NEI ? MY ?j c"S:R4 ? w ? la :,•A. VFH. rf.W AN%F IDOpEif CHEVI MODFIIDAYI RgvAI SIAIE IRDR ?CONVI Y. IEAGPo4 1-11-1-114 ODELID 7) p, vH.Cp04 UFNSIPUIN YtG15RRlDOWNF9: I0.5r IIRSI MIODEL PHONE NO. vfGl IERt00'wNE9: r fIR5f M,DIX Y ,.-- W \ ?•F (..Y P Y aE FtGFF A n O ..I i •DD4f550F OWNER 0 5 01vN E ON ?f ?1ry Ctv OR TOW N 100 51fi09HGHWAY iCr<l3 A 5 RW IE0 4 SI E C ION p • // ,?.DO Fffr OFEN UGE SO CODE OIAL NO Ci VEH ClFS ? PpOMRir DAMAGEONIY . ? $. ? RFSIFOIL- ? V aCiE 5 4VlPSNNAE: USI HRSr M,pIXE Y1vE43NAMf: IASI I p °y - N ? NDOL Z s?oY- H U' - - - 44w WR M 12 ?o ' to R Y LYE R O_CUPADON r A. -WeVEL iJG opeM EYES W F,G Hi Mf,GHr E IXCUPgr,ON 119M NPME 1gNE N0. EYFS wFlWll HFIGH I 2 1 P. NO Ck! o. P.Z /8 Z 1 5- R CHECK ?RP-.RD CODES ?+ D % i S tclRN 6 ° ? t;?; cR CODES 11 , ' 1 2 , r i INrvR e5 , 1 D a A 0 15 encN,N 6 ss sn,. ! r Z8 cIEL• P ??E - E ' J S rR•rzF9RAtE NO. S tAIF H vfH.COEOR LICENSEPIATIEN A q ZLVE? 620 WR I C I Y 1° .-I I.-I-AVON NO. e EHCIE ID[NI,I, A N N r ?Q 6 Ct 8S 64 1 N AMf anpp9eu ar lN;u ceeD. a+AGlNr R w p t? NKr .ti R DuAAGI A4lA o: +`??E cHAp? c?EACCf Nw'"`croH.l O ? AMAG ? IW G g m F OlrO? 5 lo, l3i DAMAG AWAY ?RFMNNfD ?091vlN ?RE-NED AWAY DAM ESI •rRP 10 ?OTfCw A, •y " 5 O? RDVnoeY• TCWS1,] AWAY ? r°"/EOeY: AwAr s , '. ^ "+y1 ,e DIAGRAM OFCOLU SION' 1u uP MEN AI ; ev?IwROr'O°1vm DESCR IPTI ON OF COLLISION: EUSE5UPPLLMEMAISHEEr 1 E[fS4Rr) :6nitT2quoE°L.'TOAa•Rl?il.'r`( .® _._ \/E.L{, -?-? --luRS ioy.'TiIBOwA+O.orv G2b'?o ,: I '. - L. --- AND.. LOST 6Drr]TROL or+ PE CJARYE• SLT-0 R ? ?, : I, : rC.,_. ?. ? PO S, .. Q pR,RasS 1115 NaRt1{AOLANO._1J?NE... STR'2KSNSG.,._. D4 '"w . -----, 'Two -C`O T?vSCg ANO A. RPILW, O?LE01R0 .. e ?T Aa Ne To Res ; . vEH. M- l L R r P[TSPRa% _ u e _ r " ott . , 200 'FT OF• SPEED SVms UP TIC 'ni•E _PowtiX.. e ,. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED F CODES 1 - Z J 4 5 6 ` OCCUPANTS/ WITNESSES ??wprltororie"ir?+lw ?ii .1 AGI rAI IN VEH L n sn. Ina ; ?: . Rtu NAAI OP. ewer. ?AMe. ?EXSRI ?.tl.?s^r ?it`l,l. ?.t!F Grp ?A;l v?. i r 1 m N .. a Y4r s A 1 N°.mp{a . R MovrDERw ?AMe. ?cr ?.., , O Q O W.N. Ni er . b s ?? :'t,rf?`;µ?7 t* ,>?t )1? YY?,IF I F] .R ' 1 r ? ?h . D•,u 1 snouneu <l...NwEa+ a eA o. r EA¢v w111ol IN w t Dy etan ' la er ? e S HE ?mm1 . ?G: Or:°.Nw v1vl i 1 ., ? ??? I'i w 1`(rl J I "? X ; LI q , as :nE 2 O ? m 1 2q J E n D•na nioRr AE+AOVlo er an , f: Ak ? :?? y wE. .C. O _ 5 1 19s DRUO I. OS- _ - - ? { ",rNrr:?, 1? i•1 yI ? ? dSI??E w1??1'x`.,E ?t Yx: „I,y? .aalA?h" 1R ? i'3 )? ?"?` ??{? 1 L r i ? ? / ! 1 + t , } F? ry y L BVY ?'. wrr f'1C1t??? ?Y X ? II f i } y I • . ' ?. i $ I , k ? ?iwj ' r t . f 1 .,R ) .? L t ' 4 i , i ; 1'c t { f R?•F f !1 ?/ si( J ) '0 "" ? ..s.9cA 'E•'iA" ? 5', ' ..'X":C+f7." ?w've'.d?W.n u."r' -. im??? ? A ._It.. trB?x n _.. NVIt a g? i 9 E •° I^A •3 101, K?' h Ik 1• ))) } ? h? ? 'Z? l a 1.- r 11 :k `.? .•., \ l?i.? •!'"L'^`w"•7'74 ',. ), fT.1 ? ?. Iy N ...? i ti,_ ry'naa'1t IR?It }? 1 .Ill E ?r'H 7 n i? Ii ''' ( , . 1• ' MOTOR VEHICLE COLLISION REPORT NO. , xE _ DA .OATEOPCOLLIYON.: ..... ,ION OF CO. Y xE Es' .... TIMEOFCOLLISION ,. AM _AHES nuN r ..Dy COWITY NO Glr NO i ?? ':: rwl ? l ?` ` . ??il u L I•uCE COUNTY CITY. TOWN PED S" ?r•'. ._ Gi'?L '? WiSOE ,o°?I,Nr MILE9 O® CI-TYY. TOWN ?©OFICI •?'/ •: ,?.,...I ADMC.L(S PPEFIX ?r nnu W xFETGOGE ?? C?rl? SECTION WVENAMEOFST8EET.gOA008H11YVA1 WTEnSECTWO mIH: STPEET OR il0A0 PREfI% EO IMLEPOST. - A 0 il"i C NONINTEnSECTON LOCATIO OF COLLISION MMP DIAGRAM DATA l HETWEEN C STNEETANG Y' dI c- 1 ! STPEET • T ' ?® r rql ? PA?vO, CnSICd'A+G.MAEP09r On __AR. N ONR0 w CIO SIRfE10RI%HAnW OOtI.ER-rE. ? SPEC.000E l19E TSs r ? i_?.._; pvErrc.e PEOeorm.x OYNn+n causwl 00HNIMN EC OBJECT STRUCK IR,ME OF01MKi5rPUCAI OWNED OFDBJECTSNAME ANO A00RE59 IumAAJ TT WAY PO,D tOati.q I I FEET 5 AiIRSTNAME MIDDLE DWVEfls LAST NAME ` ..t -1 wvMVFG E . MIDDLE .. ORIVERSLASTNAME C FIRSTNAME .67 GOT= a. GIPEEr A00PE53. -, .. ,. .... ROUTENO.ANODOXNO. wnE THAN- STREET ADDRESS ROVTe NO.ANOBO%NO. !] vEPSw]wE Ix A . 11P000E. CRY St TE.,- DRI VERSOCCUPATK)N eIX CITY, STATE ZIPCUDE ORNEPSOCCUPARON , { ?:f;i ?CLL1?G'\•?' ?/? ?O J' C nEPwrion IlI1NEnSLCENSE NUMBER .. S TATE BE DATEOFBIRTH AGE DRIVERSIK:ENSE NUMBER STATE SE% DATEOF dRM AOE DAY VEHICLE YR. MAxE ICHEV: DOGGE,.. MODELINOVADAHT) BODYSTYLEIIGR.1 VEHMAE YR. MANEIOHEV: DODGE) M OOELIMVMDARn BODY STYLE (1011.):. /g;]p ?Nz"V C-2? Phu, E TPMLEfl PLATE NO. STATE PLATE NO. S SE LICE N LICENSE PLATE NO. STATE TRaLERPLATENO. STATE ? ? I VLHICLE IDENIIFlCAiION NO. (1988 MODEW^ANEWEfII OOOMEf. 0AUA,GEI VEHICLENENTIFICATK)NNO. (I9RBMOGELS.NEWER) OOMETER IM%EAGE) r.&a z/-- ?z l2y z NEGISTEREDOYMER ILASTFBL4TNn)OLE NAME) OPIVER NSENO. gEGISTEPE00WNEP IIASTFIPSTMIDDIENAMEI ONVENS LICENSE NO. ,.. u: Al 1 ] l3 _VWRV - .SL; 5 ET, CITY AND9TATn OWNERSADDRESS .(STPE OATEOFEWTH OWNERSADDRE59 (STREET,CITY ANDSTATE) . MTEOFBViTH p ''i / 1?iC:K ?3U -l:_; i?T u? PARTS OF VEHICLE DAMAGED _.. , .,. . ioTffnwwvEixCLE 5 PARTS OF VEHICLE DAMAOEO '. io Ews. v WCIt $ LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- WAS THEEIAU COVERA E aiinugcal ?YES ?NO TOMOF OBTMSAY INSUR FFECT C 1 ?fjt?E•SNAMEOFUABIUTYINSURANCECOMPANY ..... NAME ANDADGRESSOF UA&LITY INSURANCE PoUCY HOLDER nn wwF Sr rE iY A 7 NAME.WDACDREWOFUABIUTY945URANCEAGENT .: On STAtE xm UABIl1TYP000Y NUMBER rx / 6n ear i?r GwN'For7 W 79 /eSt5L3 77 67 ISTNJ1AiY ?/ IIAME ? AGE TDr. 1NDINJURY: NESS RATEREWNr FDN I.- L .... NIME . AGE ?y DO E.S 'IAIVll A- ... .. w.R SE% M -- ADDRESS SE% M p r m E s ,w":."ilAR nv AODCTI I'•' I ,.,.x,roxm,nncroR, ®© R RR 6TATUSOFINJLIHE MMKfWST CNE THAT AFPLIE 9 STATUSOFHAIURED MARK FIRST ONETHAT APPLIE S - ' ?. •, (]wnER WVE ICLE trt?AwRwr wlYas,Iwxa v?AiE DuI IN VEHICLE 05u%wD I RDrI?ALAID PDSSIIRF E)P/d5Inr1R WLLED sEWRfI 1 IrirvOnl C04PUC'! IInE PASSE NO. RNU KILLED ISEH nFI IMIxOfi IIF <[wPiNxt oFPArIE,n ?nlusrmAn ? 500 600 700 DIYDTS I 00.'.,.,1.1x-,,r..... D 500 600 700 '• SrIOW NORTIIDY /JINOWWCIACLE DESCRIBE DELOVI WHAT HAP ENM(REFER TO VEHICLES BY NUMBER( . WDD. ,a wKO O \ I TRACE na wnwe,x.r RFn?ns.. A,NtE, nR DR Y?CO11W0MCm."r upr?a w I T _ _ D 11 o oq _o L .d__0, i L:?l _I r> u1,,, ?_- f? Lt NL7. _?G/LAk./. /7.t L: `- fic,>, L'E?Y1- \ ? I R' _ /\[?i•?G S uf-x-?E; I: U'L-/? i5J /,/? Ti? / i'// ? ]rVI E"cxw•cLEAxDVww R .n IYIIKraNV m.vTLe.,Rlaw 9r,HIE?oN,.Gn,Y,Y r.._. . . _ . .. ... . _ ._ ? -- [ ` Is - G VEHICLES POSITIONS BEFO VnHK LC RECOLLISION dE STf Ei OI1 FPHWAY NAME OIM ?Gwa•+ES rLrKw v .c'.r 1r04LV SI,?PxD Yn ca lltl4lvv a PAR,fn.,AS ?CII OE.CUr•10 `H INVER1GAfEtl OY D1?19d; ?rcnK [ : M S E W LAN ? ? ? ® rs ? ? IS ? D S NO ? ? L ?° `N. ?9GKF ? ? ? ? AoIM ulw..n FlIOM DIRECTION To DIRECTION f STSrPoARV WASU4•XL 1•t DT .0T-.:WALK )?WALKWAY ]? SHOULDF.N A?Cmt!rv•IA S?f1I??':wKK n?OTHEn ,IOAts ylrrli ACL K• C•(Y.rr WEATHER IIEJHt CfYEdtION] IRAS IICCON,ROL --- Yutill TYPEOFPOAD G Klr I m IHY"'WHK:LEACTIONS -- IEMnA_,O _R,, It ., I -_ 1 ? uur l•Cii' , ? DAYLIGHT i L 1 n tNMAl9 -01 ] ? ?rrI t ? ONE WAY ? I-, ULII E 1 00.1. STnAGHI AHEAD ? I ? IMY ] ? RIIrKM1 ] D DAWN ? ] ? SIN'"GN EC ?ti ] ? IW'O WAY ? 1 D OvInTAKIN0 Ar1U 1•ASSINR ? ] ? WDT UNOmMI ] ? ] ? OUSx ? ] ? " LosYA ? ] ? Ru ERvoir ? ] ? MAKWO fIg11T TURN ? ] 00 IND. , ../ A 1? 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ND{ ,?, oN C, ?? • 11"5 DM 1 PRE". p0U1f0451 fE 3 9Stisa N " O INTE9atCONG PAIN: S1NE509'9o- NONIN1f91ECi ON / 1, BfM1VffN SiRFE16 511PUT PRfNX EO. MIU:POST 6 ' OISIANCFADIgf`ttfS??RF E.CW 515tPFf10R NEARESIM if {OS 3I IS L 4r., OF ppfrq UG , f Q fFfi Y STCILF ACCIDENI MILEAGE CODE R P OIAGIEw MIA SEVE CIXN5KIN NVmvfo 9IY: ? SPIIUGF ? 99UN NO wM nolH IN .40 INIFP CLS IN SERI SI OR ROAOOR 9FI.f2 CRO35 SIREfTORROAD 1?J TOtM NO OE VENKlFS ® PROPERTY-9 ONIV 11 NE15m.D ? ILSIEN El 9 OBRC StRUCXINM EO{OB1 RSIRUCS ANDOWNER'SN MFI fSiDwAGF S SP CD4 COO NGUSF UNIT NO. 1. UNITNO.2 1$VEHICLE ?PEDESTRIAN ? PEDALCYCLIST G S 9 DNIVER'SNwl: IAST 145i c - ? DPIVER'SNwf: IASf I eoT 7-0.s M - $iRFfiADWESS 0 46f U IREFI Ap0uE11 D• O 4/5-3 UIY FIP COOS PHONFNO. -ll P. L >ow gP36s N3? 2833' D R IIY AIE IPC D ND. NAOtfrcrc W 48_I 7 ifs 5383 P/ER'S NCEN NO. F 807 tP 51AIE wA k A ie N m ob w°;4 I Iv NSE NO. os IAEE LIP M DAIf 1 IN An. I o ,z s7 r OCCUPAION NRMNAM-_NE NO. fNS IGHINfIGNT E OCCUPATION {IqM NMM1. PHONE NO. lYES IGNt IRK.NI ?, QEri.rao Gl•'f 2!o d cl R b/A+emPt. 27a 603 ? CHECK(?) MFHInfA iN rM ovFfaAMOrNER ? CHECK CILASANEM LEE OPANO-Rµ CODES?* s a A i ' 1 S a i°rfOr Y S CODES J? O a 4 s, 5 lx a s?.rt n n f c, c, !-CS uoxs ?t S S PM'14Dlw... ? AMNAY.NDI ? W, ? 1, > ?'=- :<rmm- ?.MR,A.fKF ? u8°- ? ? H KD 14 ID H. vfA9 MARt IDODGfX:HEV.I 68' -oR0 MODFl IDA9tNDVA) 51YIE (q ORCON" AN. E YH.Y 1 ER.) IIDARiNOVA) Y 6 1-o,2n P?1f p t?_ vfH Caa Pu. sw ARER MIFNO. 51AIf H .ca u l nr S I W4797 ICIf IOEMI{ Ur10rq NO Fz5-YR0-4:z;glL/ 3 L f C f OEN AN F1.CIYRfIl Si7,3iz; f S 9EGISRRfDOVrJIfR. VSt {I91r MIDMf PHONf NO. S mF w Sf1PID fR: DSr {IRV MIDDY 13A E A/ceorr R. C 3dr-s38?. IJ ADDRDt$OP OVrNf4 A R OWNE9 .ITT {?. .2 N E SA/rJF I? NAMESADDRESSOINSURANCECO. CRAGENI 1 L S .4 N c p- R I/? ( Ho/NGa J/ilA cJNSr=NO - IN H• wM DARIA ' t CHA4GL CHARGE of ,b.t 1 A"'C? P I}. AREA A S ?OiTO? DAMAG! i31. ? WEAN ?PFMMN(D TJI 091vFN ?9[MAINFO AWAV WI fS1.0ANAOf RrDP IG ?CIYOu 1161 s ODo rOMED AWAY"' ICLo LOS 10Wt0 ?AWAYer: 37.fO =LISION: I u MENU INDIMIE NO9rN DIAGRAMOF. YARROW . sHEfr NFCESSARri DESCRIPTION OF COLLISION: ILaesw9urneERru swn NECE55Mr1 IA . _ . I .. . 6N/ctd _. / ..WAS 6o/Nt Sn2F1?NY ANago. _- . ! . JeHEU¢ a 2. STJ9.[f"CA Do Onrr_.O?e.oec .J ...Cj ?'?.. -....,..:_. ..?__._. N5 xIG?.?Lp. NJT MA/!O. /Yl...STEi064 .L/IN7lY. & 5 J - • . - - .. -. - . E. ON 2418, 9,14/, 7b....N/S 14, 5 FJC 0".r OEI ON ?bH /CLCf k _. .... IR &°K 444 7.0ar CAFgSt/ai USNICL2 ? . 1'd 60 O..r OF C0A1Y-"4L 'M *r +F, d6p7 _ _: wHRYea /Y H/T TH¢ 0/TCH q,v0 ?lor.6cD, Io NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED H CODES I - 2 3 1 S 6 OCCUPANTS /WITNESSES Il?o+ba, ONM ryAGl 3? R. AG[ VJUS .,?" T : RIsm rAo -.4 "°' Keulr/ D. Watto/u6Q "D: 437-292L M , .NSSSO] /d 1LV 47NA of A- /.wOLJw. /?A . ugra v I, ,?Ar ? AMe. ?WI ?^ R ?°7- 0111E• MI p/1N/6t Q. CATONf r + 8Y2 -82/4 ^ ?D91s5 +lll.ll /7NA 0[. /S/51NG4fD6• NA Lill RIA lDr40M?AMS ?c"" Ell:RA O.^++ 0-1 J0 wE fiti A Dn+lu NArwra ?All- ?l:11c)cgNIR?N" ?N '" A,vtSIKiA1wG Wr21P'. IMMI SRAhS X eADG1 OR AGENCY KIDDPAICNfD I D Pa , ? 13 Ta1v ?? ?s.En IXKI ARViNU IS.a ?s ONICR RIIMT AnREMOSY Mil /•0/-YO ?r -? f ? n w?em? L, T .CA g " ,.htl uI f.,. ?t 'N•1?4y ti? ? {?£ ?gq ?ly. `?Y„t S. $ 1 ", NYB" , lift A*!N`' 'NI \J POLICE TRAFFIC COLLISION REPORT qSI TRAFFICWAY Pouct coMPUwrr+lRAeEa 2 PRIVATE WAY Eofcaus •• r ca n wIPur tlMf IUSF 4) courlrr [ J counrY NO Grr NO. rNwA ?Uegw RA Z ?N ?E ?I LIYO4 )OWN -7r" >.[JS6.u Its ?w ?" /07--r" - N a.NfidSNOO StaEFIMGNWAY - N ?-h•# L2. ICEC13 7 FpIIfO43i L% 9A?5o ] S INItRSECiING :51AtFIOF 40A0 NON BEIWEfN IfV..W.N ?•f?jl9Efr( ...... . I DISIAL NleDI9 RENC .<R0555t9f OR NEa9f5r MRE PO ...5 Ml N S E W OF Vtp LL ACCIDENT MILEAGE CODE RiUAP DIAG9AMDAtA COLLISR]NINVOLVED: --Ty; UGE TOTAL NO. NO KII[D-A'O INN9ED? ?SPII ? 89ff.+•' CFVMIClES ?PROPERIY DAAUGE ONLY ?p'FSUl1rO ?vaClE rUVRSeP?N IN 11 1 %?ND INtfR CLS 5 f NWAD OA R[FEgt I'll CRO5551R R09POIA?p 1R] OdhCl STRUCK INAMFOFOtlIfCi SIeUCS ANDOWNF45 NAMFI FSt DAMAGE a T c I 5-e- SMCW CODUgG lSiE - UNIT NO.1 UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PENOCUST 8 grvERS NAME: WI {IR MI pl S? D9WER NAME: IA51 fIN I t SAXTo,u, C Lorgp (1. e Sr9fEt AD09FS5 ?A ??72 SGCI /.ev/ ./? IREr ADOPf55 23? LaQ?4.J Sr ^L OIY StAEE EIPCODE PNONF NO. D R Y IfY SEAT IC Pr. -T6-C.0 .V S.EIt-7p ZEIA? S '? p9rvf4' UCENSE NU. SAiF ?lo2?T au/?_ % 1 0 N % ;2 I , IV q' UCFNSE NO. g?OKlo pA tl M' 'i 111 l dz OCCUPAIIIXJ Q!r!? EdPNONf NO. ENS CAIt HF GNI RM?- B /?G5 E R A"— a NR. Ed 1-1 NO. ENS GNt 71/Li? ©f BU NEIGNr ? CHECK (.j VENICHASAN 1112 AN r ? CHECK(!) fNICIE AS AN fMAOYlEO ANOi"fvM rp r A No _, S CODES 0.+ ] d CODES ?'' 9 n 5 F% a "upt _ R ?i ' 2 IN-Ts P N N C S M1111 +' ? AM.AA"c! ? IT ? [! ina ? llal- „w e?r.p ? AM. ? E1y . ? MI+,,. ? .KU ' VEN. YEAR KE(-{NEV ?67oyo 2y° ac(ev SfYIF IROR.LONV.) E ( 1 I(DARr- 4?'1q CMNA? MODF201 rIH _ l I V W SlAIE 4 fR MTF NO. SIAIf I H VFn.CIXON A U N rE -wA LO I,- V[NICIFIDENtIiIUEWNNO. FN CIf DENrIUp NN. E3 r ('-79 r ss L cm s32: ° elGISNRf YINtR: LAST NRSt MCME PHONf NO. 1 o2r? (_e (Al4A A. 0 I I[4k wNfRLSr iIPSr MlpplE N NO. SA-Mt;r ? Il? A.-O-0. N E VOWNt9 - 41 y NAMfa.3 Reu arlNw.ANn eo aR RlI LERS - 0 ?N b? R N u n A FFT t tS7ATt=- CVc??TT- 41 ;lAMAG! ARN °rf ? ^_ ?. ?? DAMAE G .!A V DI A F.c ?4grlr 3 noN.l CNAFG! CHAR m.uovpr r • Or . D RNIN pA.AAGe Aw'?r Epppr tt--?I -> 0 RlAWNlD aU AWAY CJ R[MNN[D tI. DAMAG! I4 a0lTO? 5 S? W ramoeY. ? rowtoer A DIAGRAM OF COLLISION IN DESCRIPTION OF COLLISION: ILnf SL1PAlE f IAL SN[Fr rFxcESSA rI "._ . IIYA- NEE IIN Y) VE?//QGEnfYc S'6 0 A , 04$m s ..._ . - . "A Vt if IQCE -.SB C'Of2 PA55 /.Vli-..EI67f?GTCE- . ? ... :. r ..?_~....V:G .. tel. GU!{EM 41!2!5. Ni?CeAYJ?EAC ff/IQiP.e .EEIT.Gy ' - - - ?P6 / D f O f (? F ar - ?.! F??? - F ?C ea .2N? 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AGINCr D7l,GlS ?!Y cQ Kr DIS.AICrNp ?lu,'NY- ? aJKE?Axurs^ A5TS?5 oA?rE O/ywroRr W •:Q Fp r ` DAN v # r f ??LL r r' , i yX 'S! r L( } L ^? f .i.iN mayy, ik I Elr ?D K: 1 N,^ 0'. 7? 3 Y ?T ? x i POLICE TRAFFIC COLLISION REPORT Ly TRAFFICwnY POIICECOMNAMtNUTABER E] PRIVATE WAY UatFU plI NN COUNfY f z- x .DD 11 . Mr (USE , +. BI u 111, D COUNtt ND, / CITY NO. -A DURB ? f ? ow Y ?) /- - OYJ EO µ / N O Oi STPFEIOR MGHWAY D F DN DIN CIY EDWN —" k1 US tl ROUIEORStgFE CEI w W ES Os Oi ON IH fR` I GM„ 9s?/.so xx 3 SI9 gOAp NON NffRStC,ION BEIW[FN U srRFEr 6 STREET UISTa. CEe D9 ,CR0535t9Ef OR NFa4f5f Ml MR Htfil% RA P f0. MRE NSf -/ (J ?•() - /•J? G• I CJ J I MnfS CS` F w ACCIDENT MIEEAGE M DIAGRAM DATA I FEE, OF /? CODE COIUSIONINVIXV[D: SEVE9 TY: . NO. KgIFD?NO.INA1RfD? ?SaIIIAGf /D?f?Q?LUN wMr,DgDiH OTidNO S!rR D IN NGROADO4 REr R[FFCE IN IMER CLA CAmsS,R[_ Fp•D 3 P I CIVENIU[S DPROGf4tt DNAAG[ONIY ?FESE1- DVMCIE ?^ ?`>Z OBEECI SIgUCK(NAMEOF OBEFCI SLRUCK AND OWNfR3 NAMfl ESL DAMAGE ICW CODING USE 3 UNIT NO. 1. UNIT NO.2 ' pRWE4'3 NAME D VEHICLE DPEDESTRIAN DPEDAUCYCLIST. x. : US, ?? IR ?? RNFR'SNAME: U3T 11 I ELAp0RF55 gFEI gE53 SLATE xIPCODE PHQVE NO. D R 9Y SIAtE V f , CDE UR'v -S C SE u [N N StAt/f? % BI n YO ( V MFR' t NSE NO. LAZE Sf% OA, BIRin MD. MV ?n q OCCUPA,ION 1I4M NAMEARgNE NO. FYfS GHI wIGn1 E occuPArwN FIRM Ee PHONE NO. EYES IGNI wIGH1 ' R D C CK(,I yFM.E AS ANfMPtOYE OF •NOrwttµ IA IT -N D CHECK(,,) RFA NFMMOr[Ep ANOrwR. qya.. y / 1 NODES ? 7 n A i 5 N 6 H au 1C i0N nN ass rpN ry TOE CODES ?* p u • s+zrlM 5 eAe ° [y, ro n ? RTES R Fes DM AMMAA O u D MB . D ; ? u,s. °H^or N D W owl ? 7S" ? ? SC KIT ry y YtAR H MAKf (DODGE{nfV ( EI IDART.NDYAI SIYIf Ix D0.-CONY 1 Y FA % I ,) MODEL I A) E •1 °pr'' ° y W /OOU E . 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NO. iOIAI CRVE"IClfs ®PRORR,V DAfMOf ONLY QVIESUIIID ?SMIIClf q OB[EC151RlKKINAMFOF OBIECI SIPUCK AND OYMFR'S NAYEI f51. DAMAGE SPECI.4 CODING IGE S UNITNO-1 UNITNO.2 Q VEHICLE Q PEDESTRIAN Q PEDALCYCLIST .LaA DRrvE4.5 NAME: UlSt FIRST MIDUEE DR I-14AME: LAS, H H l - L "qfzp IT, A ?{ St4fF1ADO4E x4l go T LA ! S,RFF,ADDRE55 O 'o• x z S 5 IF IRCODf JIG NO. D ' N E CAD 7oc ? op ?722,1 I- G R Hsvt_o?.x WA. C19339 • 2 ORrv[ SLICENSE NO. SIAIE SE% DA E ., M wr l H i 1 I N' LICENSE NO. a A,E FBIa1N % D 1 f DY IYR 8 O o l o`'{! -o -L ¢- U5R M o2 OCCUPATION fIRMNAMf6PHONE NO EYES IGH, I61GH, E OCCUPATIO N FIRM NPMF6 PHONE NO. EYES VIFIG"t NEIGNt ,,, F I l90 0 R , YZ O /60 _ 0 Q CHECK(,') yt"I iE ws:N FMPiorFEawuD,nfaA1 Q CHECK (? yFHICIE ASAN fMROY[E OFwNO,HERIM IC CODES ?'? 7 n A i S u 0 A]'.° CODES .+ D a Air S D 0 wI 2l 2 NJLNXS E aMe@FNw Q AMwNANCr ? u? ?S;rt. ? H a ? Mv:.. +?o Nr xM D.F Q A --D, ? PDDf E ? ,SoXN ? ?, . 41.. VE". YEAR MME(DODG?-CHfV.I ELIDMi•NOVAI s1YlE1RDa.CONV.) R ( CNEV.1 -11DA4t""OVA) l y C I 7 DOGE E 8 CH P-4 p q 'B i' IICf"YPlwi " S,w,E IRUIER MtF IVO. S1A,f H vEn.CIXOR . LSFS' I Ilt A NO. GSA z?Z Lk oo w p WNKIEIDENIIFKAIIONNO. VEHICLE L S12121&j?! lIt1-7 1012: I I I elGISReFODWNl4: LAS, FIRST MIpDR IHO"E NO. O R GI t IID WINfR: EAS, {IRS- MIDDLE N t 0 V W jq mr, AS O/ JI I.J- 2 ADD4FSSOF OVAIfR N ..,E E I AN N HAMf aADp4tu0F INweANCF CO.dACtNr ZnJ R /v DJ acm A,MAw MFA A . f?MtA CHARGE CHARD! TOI , ] ' A 5 D ap OY DAMAOf Ip ] IS1.pwAGt AWAY ?RfMANi4 ®AWAY ?RFMNNED Est. iOWlp I-D f W AWAY BY: ? AWAY - MI/ SION (IS11-1 E IAL S"FFru NECI- 1 I RAM OF COLLISION DIAG s:Xn r"eeE5wr1 i eu RBI DESCRIPTIONOFCOLL - 5 . I L _ 1__i T L t p...___.V?H ..---? ?AND__ 2 WER 84] N NoR7H=. L O CR 2 2 w VEtf S lN , ON- r. N.. 1 1_.4 I?O __. A ccfjt;r? AD, / F37i zNG H. I' 1 .ANA vca , I . ?IAQE R _ J, LEFT._TURN_ INTO VEH #_2. - - b ...E ....., (L--' I - ..- _...-.. ....-._ - ., _. _._ 1e NAME, ADDRESS& INJURIES OF PERSONS I NVOLVED +CODES 1 - 2 1 3 4 5 6 OCCUPANTS /WITNESSES iov im?rlLmmtA?i rMiww ii xK ew rAlus In _ sra tna : i°i: N- " NY AM B. Q31`I INI? Q ??? QiL4]. N SMt' A A .-. _.. ._--. .. ...... .. ... _... - .... -.,... CORI1] _..- .. _.. NAllXld R MONDIF N NY ?AMa. ?MXL ?M' • ? N op X) N AM NO A ppMtf NEUYIS 41FX NV. ?Mla. ??'At ?CMNE ?a?rY ?n ,~ r 1K,A1. , Kle at,H, BApGI dF AGEFX:Y[' KI QISR , ND FIXK AR VID DAlla%roRi AMq!{p DV DAiI E :..ALS, ., : • !'..:1. POLICE TRAFFIC COLLISION REPORT Le?TRAFFICWAY Wucf wmgn,N'NUmnf4 PRIVATE WAY DAZE FCIXUy N v ?v IAlll CIX'41 N fur ... ks wl0 lkl!) IN YI OMf IUSE-HOURI COUNir COUNtYNO. //_ CI'YNO. in WA ?UR4At ' OEY OR IOwN ?N ?E ?IN IN.E ®S ? W ®O' 70- A: V C ,14 MnfeNO.Of SIREfr04 H,yHWAY N ?fuJ Ai 0 g CI C45 R 1 U, RgFIF0951Rf T O - 99/.5"0 5t ION INIEi5EC11NG w1fN: S14fEi O4 W/ADS NONDIIER3f<tION / I DE1WfEN Q SIREEI a CP STRIll PREFI% E. MITE POST (// ~ ? 0, IANCf e01a MIlFS N RESR E ,C4wOSS5TPfEI RNfA9E31 M,lk roS t/ f[Ei O[ Cuw ,-,L RD. ' O ACCIDENT "CODE LIAGE RAMR DIAG9AMDAIA CIXlISgNINVIXVEO: vE9NV: SvIIUGE ? RUN fD ? NO.INNRED K,II NO NDgDIR NIFR W CLS i RSFCfING3 ffi WAD099[Ef FKE UOS55 ORIEOAD /TS . _ rOtnl NO. 1VEHICLES ? PWFERTr DAMAG[ ONLY ? pE5UL1FD VF . D, iT1!//i'A 091ECI SIRUCKINAME OFOSJfRSrRUCK ANDOwNERS NAMfI ESr.DAMAGf SRECW COOING US f ' UNIT NO. 1 UN IT N0.2 ? VEHICLE ? PEDESTRIAN O PEDALCYCUST J. S DRIVERS OWE. -1 11R II E DR, FRSNAME: 'ASt NR ? j< A (' troy c;N c coT7 _ sraFElnoD9Ess sr9E Fr Aoo4ESs • OX ? ? / 70 2 crr 1 z,P CODE RrlavF NO. D • c P O,u/,-_ 1 2 . /07 R aIVE4'S UCFNSFNO. SIAIE Sk% -G.T- MU ltJ OD" D•+, rrrr, ? I v O W 4' UCENSf NO. C_O - J-S /V S AIF IQ DAIF DA.e1 I •. 0q:e17 M D / FII ?? CKOS MNAHf ePnONF NOJYD7r Sj 5 E ES IGNt [IGHL E OCCUPAI'ON RM NAMf e P qNf NO. E ES GNr EIGNI 2 TO or C ,7k, t- J R $ ? CHECK (4 'yFH,RfAS W,N (MRV'rEFOPANOMER"k ? CMECK (,j) 'vfH,CIEASAN lM_", OFANOMEOAI r CODES y D Q 3y s 5 r a CODES 11- + D aii+ a i="1 5 U,_ a ew A a Z ;uV4,ES ^p k PI uu, P P ®AMNAAH<E ? MAKE IOODGf{nEV I ? m- ? ? iu fI IA.A) SIYLf (IDR .DONV ) r,w V 1 EV °4° ? ES.n ? It, ? '" MOMI D 1 NOV . P . . E . •C. - I A) 9 C IONNOr-'6?2,4 !'3.'7 )k"771 E I A.41 /! t 4FG,STI.DOWNtR: USr FIRST M,DDIE K' r L' m ggN[NO. W a Ow"tR: IASI 11951 IDIXf C 1 Y r- ^ L ?- IT AOD OFOW , `? NAmEe --HS. eANCt U. DRAGIN, I R I RZST S 72/1 DAMAGlD ARIA puicn0"?r,N C«ARCR - - • . _ gAMAG[?t MlA CNARG[ ri •ro -? S !Sl ,DAMAGE ?^W?V Rf MN I ED ?OifO? D rT0• ^41VfN I3? W Y 9lAWNEO I ?G i rt 3 IDweo `,• .f ® Aw er: f IA ' : tH.IN DIAGRAM COLLISION: srreru NEa3sA DESCRIPTIONOFCOLLISION. (U5E5lAgr t TALSHHTIFNECESSARYI . ... ®_. squrHOoWUD ?/E ! ./._ u)A5 N o+A GR#12 I . _ _. Ppossco '/}'P£ CF.NT'IERC.7[/vE A-.._" i -AND 57RUWC V Ek . 7Z? cuHUN WAS Nc rNBou!?a OEV CR al2 _ . . .... SAVLD wcrVfz)_Srnrco..NE tarofctccw - ,2 - . . LnTb VEH• z . AND._ 08ufJ2VED VEN. ! ,< ?? CAvs, -e C6+vtER L r AjC , - - l T1fE PASSEN$•4R5 zN VEN• SrATEd rNEY ( amr ac 771OU61(r 7Nk dRZ(14R OF VEN, ; / U/HS..ACA/acv Jy TNP94r By TH•E LtdyrS of- O,VCOAfnvb TRAFF". NAME, ADDRESS & INJURIES OF PERSONS INVOLVED +CODES 1 - Z J 4 5 6 4 CC.CUPANTS / WITNESSES IUSf SIOglAYNIAI yN 104 ADw'law NAme El1 s' seK AGE rA'us w« 4Ar '" . Ena N A AM' OcP ggERT?/ ? ? ?TZ-E Arl L i oonss /, l Iq f PHONE F ru' ?Am n ?T1'?"' 7 " ?Q" ' ? ? e Nlr r . P H ? I MO 0 ? ?• A OONSS R . Vl r9Wk ?AMe ?A"KL ?N'Mly WHw ? t 'FXie ?E Frxs iON; uN-=nr ?AMe ?i ?o_?•OQH ?n'?l• ffi IO X 4 V p [ ? ? , 2 C.J CC I DO Ia> -<7 Gf C *Y? 5 M t? 1 r r ? °i ?n- ?W RwIll p 5 F' ? J. s\+ ;. POLICE TRAFFIC COLLISION REPORT Id IRAEFICwar WIICFCOMRMNINUMSF4 - PRIVATE WAY c1x1 rr DAIf O! LYUS DAY, <WH ON IwU HI IIMf . (USE Z410HOUR1 COUNTY CDUNEYNO. UIY NO. nWA QV4BAN 4 QN QF QI Cr OR TOWN NAW[s nO.Of sl9Ffr O4 HGHWAY p m,IES t ?W DE •.? H ION iC1 Cls A ROUTE OY SI U N IVrfxSICHNG WITH. siREki eOAD NON INIfRSlCDOH §Ervv[fN I STREET C I-EI P9EN% f0. mIIE POSt /Z 3 G x sANC 6U9f I N CROSS 5IR[EI JR NEAUESr mII GO ACCIDENI ° e R D,AGRAm DAtA . mlFS F EL•??s W /.QQ r[tr OE CF.Iq MILEAGE CODE COLLISION IYVOIV- VEINY: NO.INlU9FD? ? EPIl1AGE ? ,I U NO KLLfD whDRf4r„ n D IMFR Cl5 INt I 9f ORRWDO4 RE RtHCE CROSS SEREtr O4ROM - - ? iOIAt NO. OPVENICIEs 0 P90PFRrYOAMMfON[Y ?FESfi1UfO VE ¢O•y _ OBRCi SIRUCK(NAMEOPOBJECr STRUCK ANDOwIUEPS NAMFI ESi.DAMAGF ,- SPfcIAICODINGUSE UNIT NO. I UNITNO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ' DR Ve9snAME: r ?D? EIHSr .3- x'3ta5 CP41*G VAN Ti ffi,- FRSNAMr usr PIx - SrPFfi DUVES$ R+ ?5? UIY SIAIE ZIP CODE PHONE NO D SIR[Fr ADDRESS OtY srAtE ZIPC F PHON N I . C C?+Ettif3c?t-c 1...`,A g8S2 5- -02yo R rv(R'S I,CWSE NO. I ?44zaac SIAIf I III COA 1 ?i '3A: ( ,V LIEN NO. AIE If. DPr IIIRIH ?D D.r IYI ' OCCUPAIION fIeMN E6 PHONE NO. ???_t(i., ?? lol s GHI HIGnI 7 ' E R «cwnnoN MNM1f6 PHONE NO. Etts MGHI IlIGHi oZ ocrtc 4 rusE co Slli ? CHECK(,') IfvE,`, ci As:N o oPAfM.orHEE%l Q CHECK(,') WttF AS AN FMPtOVEE OF ANO_- r CODES I' 3 ssY a i+in 3 ueo DN L e e"N° n INIIA f i " CODES 1- * 3 Z,,' 1 4 is nM ' 5 fAC-_ a n V zf +pJ- '14Dao, a Q w A E u°1"` ? S,4R ? 'M ? C°G LLB eRr Dm Q MaMAN E Q PuDytf ? mr1n. ? 2 ? , ° v. GR Muf (DODG<dHfV.l Z ??-oed 7 EL (DA9nNDVA1 SIYIE (ZOR.CONV.I C Nro E H.Y[AR [ ( •f HEV.1 MUOFl1VARiNOVA1 V.J m uE uu srAlf r 4ulFUrurE NO. sIAIE H vtH.caDR A A A a FFSFTC4TFF(5.- Ysllo a I IZ 23 i w? VIHIUC pN IfIU1gNIA L VfHIUf UENIIE A N '4 - g 2! .S I 1 I I aE?AN Nri..SS 1 w°I?'lam ?ODIt L-, r` 1 ` PIgMNrOYyO VV!!?i O R ISrR VOwNF4. UtSr fIRSI MIODIF NE NO. SI I,? 'C M04f or ovn+eR ss }Z F :L E. 1, f M?lc u W N A OWNER - IR AVIf ADDRESSd MSURANCt CO. O9 AGENT x R IN U fZST?FEFFI ? ? 7 _=D - •"? ,,W CNAaGf ... . CNARGF EwciroN.O.N ' gAM ARG sinA S UI. PAMAGf ??WAVN 0aEAWMD ?AWAV ?°EMAINID [SI, DAMME I IOIOfIOM - f OCb`T° O IoArer: I I IOw, Aw ? iwwfAry f ° IE ;u emNA INDKAI[H091n DAGRAMOFCOLLISION: - .. N(U.-DISSAoyi... DV ARROW (USE SUPftfMf rA SEkerlf NeeESSARrI DESCRIPTION OF COLLISION: ._ S I :y ct, , c tc?..t? 5 Arzo, 1J E v?ti Slru IB Il I A Q I n?o Lc EL ?fo? 15a O_-t0 -fie. Sf NAME, ADDRESS & INJURIESOF PERSONS I NVOLVED E CODES 1 - 2 J 4 5 6 OCCUPANTS/WITNESSES ('.uw ii SFx AGf IAlu MH msi4, IRCr r ?• N AMI. n? Lrn1ffn ltJl M 7_3 .Z A Y fwans J??t 13 J..J• TS/A.. J /lnn°ix r ip A-1 wF eg.sL EJ• aSc • TER riY AM 4 Q?YL^' ? '" . U.72 ?X::o • ND N A MMSt NAILf p . AWfU 1VlYA ?AMA r.,,cl ? `I ? 1•n q 4 A I DNrsv U e d 491 ?AMx ?C+ ?Cn •?N ?ii S<INI II'r 1 " X rL,fr, 1 C1' W .,?, AU JcSo ? "fi CIDOPAICrxn ot?e;;d 9,vfD 3r „s DArI 41yC4r AIPPOI'fOIY DArI dEL., ?.. Y?. ? • ff 5 ? I1 h ^?Ay .k ..Yd ? t ,{7?,N, ? ,s t i ?T t t' f 5 v ? r a ^,t i i ri aw j it 5 •uo i to u Ln ' ri.tm ; . i T, 4D 00 o oo mo. "I a, I mm , " ?, tt i A f9m, .?', ` ?4 X71 4 k , - - .. fi >a?T get xt STAVE OF WAIINGTON AGF OF ' 'Va- Oulz h e 1 M "g yW( POLICE TRAFFIC COLLISION REPORT ® " ' G' TRAFFICWAY pOUCE COMRNNINUMBfR `./ C] PRIVATE WAY ; ? DAT fC u IF IIMf COUNTY 07 ?tl'6 RBR ? ir...;;.? ?IASELR?Ou3l ,7??'Ff?lzson fAUN1YN0. /? CITYNO. Q`u RAN QF QIN 111-1-N NMIFBNO.OF 51RFEtOR HIGHWAY a -a-ft- - w iCr ClS ROUIf OR TRFI SIR E CD N of ILc0- O G ON Cen/er 4</ INI[RSFCTINGWIT 3 /sO H:STREfi NON INTERSECTION DE, i PR fIX F0. mRF P051 w /.} 0fM•fEN STgfFI 8 $IR[fT OSIANCFb DIRE iION{ MRFifgf CRO$TSIPFEI OR NFARF51MIlf PO5 1 ? \ ACCIDENT FEET T t 5 ?tV OF DAM9 MILEAGE AS O RAMP DI AGRAM DATA I?,+i CODE COII SIGN NVOLVFD. ERITYI 11 TO(AI NO NO RIIIED??NO.INJURfD1 ? SPIIUGE NN 1.1,.N OF N 11 1 X D 51 E OR ROAp OR PfifRENCf CROSS 5IR[ETO R ROAp VF CUS APRON-DAMAGEONFY ?FESFI}ED $1 OBJEC15T4UCR (NAME OF OBIFCI STRUCK ANDOWNER'S NAME Y e ? D Os?? .3 J.?+ V Ye 1 A ? l? .QA y Ur7D f51 ?^ ^E 5 G 5E ??PU UNITNO. I F R UNISNp,E2 QSVEHICLE ? PEDESTRIAN Q PEDALCYCLIST 24 } S DRIVER'S f. IAST E DRIVER EA M fl i ,_ STREFI'A}D'OgE55 ? - ' r? 1 - I X ?O gfEtA Ogf55 '?[ xt. J"?v£kfILE •1=? ? 2 - WY f L.IIT SIATI T. ZataASe AD Lj . ' SIPCODE PHONE NO. D I}y 8368 R ?IAIE IRC • ?) DRWER SUCEN? NO. STATE % E FBIRIH I IV R' IICFNSF NO . ATE DAII E% Pu> ST WA 22 ? I MD. ; l - B OCNPAl10N {IR.N NM1fbPHONf NO. E ION} 141('.HI E CUPAT ON FIRM NAME b PHONE NO DISABL6p BL 2 5- R . WI EYES ? CHECK( lu nl ASw p3MPl . Eu NorHfR Q CHECK (,,) I ` CODES ?+ 3 r (o + sriv o MW 1 5 1 la aN a CODES ? + a VENCl1ASANM1Pl0Y1EOFANOT.- a Ass 4 iviriv.N1 5 111- 6 w f aNJ DR o, < l r D 7, "° MA® M X p uy" 0 81D. Q K:K6 Q V v ev.'.oM VFN EAR M I DODGE I p MR N I Q ?6"' p b`FHR ? CE C VD 9 . { I fV)ulD MODfLI 78 I4ARI?Y DN1.NOVA1 SiYIF It oDR {ON .)PPM E .v G{ 1 f NfV.) NODFl (0-N-) T >? 2 Y R IN FPEAI SIAIf H IRA IfR RAZE NO WAVE M H OEOR R'? I-K 06 ?1 (0 8 G1A I l N . ar r VINICIf ILfFITIFIGDON NO , DD 2: 2;1 H; R[GISRR{DOWNER: IA i i VENI IF IDEN A 11 i t i l i l ' , " T FIRM I TAKE of ? MIDIXf PNONf NO. 0 ISR WNER: ' LASt fIRSr MI IX N N IS AODRl330•OAN{R 2 to NAME E ADDa{u a INSURANtt co oR AGENI W WNER on?nu ?. ssg2a E R AGIDARIA : 6.7.0. 0 P PI r I}p1 IX CH N ( CHARGE o"yc 3 ISI DAAUGf DA III IYiO(TO? I DAD ?TO'MD s ?RIMVNID ? ??te? AWAYN ?RlMAINED ESt. DAMAGE I 1 0 ,.:{.? I. '. 'Sf - IY -Al ........... ?. ??. V lKI ?AWWIDBY f 0 4 _ D11lAN1aHE1 DiRIIR, pA?I??AY tS u2j2EEL n" 112 D{?G D Fl Tf09 SIGfJS W62G...._ tt''-9 l r ; IR NAME, ADDRESS 81NJURIE3 OF PERSONS INVOLVED + T OCCUPANTS/WITNESSES ';o; bDn}gHA1NA W51 SCODA01 IA1- -" {12r WI R4 S MKv I? 'A ' ''1" J POLICE TRAFFIC COLLI REPORT IECJ TRAFFICWAY ro11CEC m„u- [D PRIVATE WAY _ I1 wr (c 11 N 777M 61 i COUNTY : COuN1YNO. OIY NO. fHWA (? p N, w jU5 3 L S 'I o ?NARAN /lo (t}(4u 1 J ON C]E OIN CIfY OR TOWN NMIESNO. Of5fREMORHIGHWAY ?MRtS Ea5 ?. IE Gta e•dn +?. ON FCI CIS .. ROUif ORSIR J 9¢x.•5"0. SECTION - INII4SfclING Yn1M: SIKH 0 NONINtEg5fC11A0N / RE1WfE /? STREET 6 '/>1?? StAEEI PREFI% EO. MEPOS} !?/f? // •fA+V UIS'A", ADIR p 0 REffREN ,CR05551RfE OR NfME Mill PO ACCIDENT I R GM-GAIA 6 M LES N f .W MILEAGE 0 C] 2L DO «Er of !? Ave co DE `.:.-.. - COUISIONINVOLVEO: E E411YI RUN ToTAINO. NO.KIIIED?NO.INiUREO GE rOH S o-1- Q IuNO DIH - ,N VV.3 116 all NIA 1 NG fE OR . NCE (Zi09 gOAD CAOSSSrN 20 . _ [[ CY V[HIClFS pRORA1YDAMAGf ONLY ? RSUIIFD ? VENCI"F ^ / /` / Fp / ? %y Otl1ECi 5IRUC%INAME Of OBJECT 5IRUCN AND C-11CS-1) fSt.OMAAGE SPECW000 o- y '•?' 'UNIT NO. I UNITNO. T :'. O VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 2l NAM: MOW d Ip.ONEN. D STA E 9 99 SIAIE D IE f01RIH v nE IICENSENO. SAtE fA DA B TN MO 11 E 5ECUPA71ON PHONE NO NEIGH} ft - ?a• - - cif A - uAP -l ofA - Hm O CHECK (? vfM CIE ASArv fMMOVffoiArvorHI. CODES 0. o e A 3 ul<1 off J a "' ° r n Aua . u CODES ? 7 n ii "r n s , s i ua Hn A i 5 lucrnN p s, . :vfM Tin v- L Ie l ?u wl oryD v ri cu a »tr. ? yell ? "&, ? o v ~ O or M o f o y gull (03 816 o KAKI, C3 u _ VFH YEAR MA%E IDODOE. w.) fLIOARt.FgVA) SME12DR.C V.) yv" I 11 MODEIIDM-NAI Y ( DC VI r^Y P d, „' O H ? ?,,s ?• R NSf PLA1EN0. I ? STATE 14MIER IFNO. STAR I VlNCOLOR L 1 N A b, 2 s L ,. y? 4- vEHKU 1DfMIHGfION NO. L vFHICll1D N'If L'. I 3 G ?I I Nl 1g,0101 121 131 l • I I I 1 1 1 1 1 1 1 1 1 I I .AjM _ 1 R(GOrf R[D OWNlR. IA51 1145E MIDDY PHONE NO: ? D r.ED OWNfA: lN1 - i1R51 .1-1 FI'N N 12„ A4 L AuoRlSSaowNE N A wNt4 I z E NAMFSAD i- . INSURANCECO. GR AGENT N-1. A.-IS OF N AGENT A i N rI I R 32 r b R DAMwlO MIA a OM FO B oYel Ha DA='",, CNM I 3 R DxIrOVG . G! cHA4GI Oir"itip.Gi rfpp RrvIN' EST. DAMAGE RiOp A _ YH C] RIMAINED ?RfAWNED 1010n0? I ? AWAY 0 \O IO? 5 ? ? ) . S 1 T WWiLVD3V: • S t ? AW?VRY: S IAGRAM OF COLLISION: 11u u MN ND G« o4tH DESCRIPTION OF COLLISION IuSlsurf,eMWru s„etTIF NECISSARrI v I = r) F_ RY A4A" _ .__ 0? 1??'!;c/d ?}y 1r 6's sJ?^sr I i? 1 ? ? ? I I C '%P % ?% .. _ _ -- --, , ar - - - -: •- ?5 ?Gra 19. 7._ ? L_ 1 ._ Ga??r'rr/ii2B tuvrYnff.?d.Satt//.._Siadb vr?_ f ? '2 ;. r,? a 1 I I I ? .._ a..rvddeddy,.-fluor' a...(d.,,X, _Tlpi S/nI•G!'f " .__ ) ? r.. _... t .. _.. .... _. r ? 1 I 1R .. .. .. ___....._. .? , . v PPS N E, ADDRESS 8 INJURIES OF PERSONS I NVOLVED + CODES 1 - Z 8 4 g 6 OCCUPANTS/ WITNESSES ioa ecD"IEOMri:iru+A3.ui ii st% Act lens u , 4 r lsu. ulci s. , 1• 1 AVL n v f N 9 Nf er N0 11. 111 • C1 ?1u 1 IS ? 1. -..__.. r ? A r ODM,t " AllI9 OP y WJE ^lD IPQM ?IM3 , ?<r- Ae • ? vl N ...._ _ ...__ .. H I A11n1 W' A R. O fMn,1 Ap Q EI Y SRI 0 41.1 :o 1 l ?rtU rpOOri,Clrl Awr % bW0 _NCY O , cwn D Nd IIOR "A' tD DAN I a ' I 1 5 ? !f ?1 i??T NN 1 TF?t ? r M YI+'kn. < F1A l-FIY U ? is L _.Ii (4 , f.t. ?r ?dl;i^{I ? ndf. ?t'? ' ?? .. 4hy '(} ,? unifafY.w + 3; w ,9 9(A b S5 i An t?` h ?v( l? 1 •I ?t 'j? ? 4 P I L I -4 t r 1?6 I f? .I ril.: I, ) r r Tlrl i 1 1 ~ l? [. } l '.?I 4 " T ijt? v 4 ? ;1t r Ak. NJ r ?- 1 .? , x s f[ r '\•?Q1°'i./ POLICE TRAFFIC COON REPORT ICI TRAFFICWAY Pa,c nnwrnuMnt4 2 E] PRIVATE WAY 29 D,rz rac w qN A u uu.L N. pmt coo"Tr IDSE]Y1DN0URl ° coo"rv NO. cnrfa. I 11 8 I o80-Z .Je.F-FcRSo.J / OU9RA %l0 uRAI ON 251 ?IN Orv OR IOwN " ?AME6. O,,E S11rafff UN N:GNWAY //. moles ME ?w BIG, a2KS ON V PPc2NO t?oN i , 1ERHVIIN G W1tN: 514EF10:f:QD NONINIFgSfCiNJN IN tCf CIs POUlf OY E 2O- 3 R CION dEll1 MRE WS ] 1 BETWEEN - STREET A SiRffr p 5fANff 1 N A4f I Mllf bUIRE 'L RFEENN [, CROSS STRFf 4E ACCIDENT 4 DIAGRAM MIA W ES ES N 5 f W ILEAGE fF[ S e D Of . CODE F• COL.- NINyaVED: YvfRHY: .RD 1 45f ? Sr tEl O4 ROADOgK 4ENCE H NO 9l1[D? NO..N)URE.? SPIIUGF ? 69 lOIAI NO. E.:NOxpiN N INTER CLS CROSSSRfftORROAD fI OFVEHmES E f I]] 5 ®•PPOPfgrYO,MAGE ONLY ? I1fD ? Ea Ql[ /Q? ORRcrwl IcK N,Mf O/CBH SiRLKK ANDOWNER'SNA" TDNAAGE S-IALCODING- alaEaR. 7-7"A,1.AI•A Pub : SDO°° - . UNITNO. i UNITNO.T ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST ONNEYS NAME. AST {IRS IDIX pR VERSNAMf? USr -3+ IRS F- I f RaCc2 A A 9 LA J. STREET AOD4F STR[Er ADpRfSS '-' U PPEe RD --P 6. Bolt I Z1 `4 Z Cl1Y STATE -CODE PHONE NO. D Y STATE fI O i N , FoeKS L c)p 483 I - R D N1"KENSENO . . SN1:E DA TN ( -I I.-SE STATE DAI OF01R" '}83C?R wa F Il of isy v R OCCUPAINYE iIRMNAME bPWNE ND. EYES AE-HEIGNI E OCCUPATION iIR NMAE6 PHONE NO. EYES wlIGNT Hggi Z - BWL) 125 50 R' CHECK y ? (.7 yf-la ns+N EMn v nr?or"Eaµ CO S ' "' ° ? CHECK yfN ClEASPN FMNOYfF Of NO Ml DE ? D a s < e ss Rcr a. mr _ :in.: A Z CODES 0- D a I is 5 In 6 u nM41 cTroN ,Kn .ce EE NI i E N ED Ff Rr.ro ?AM„ owl ?o". ?n..,E ?v vEN YEAR IM " Rf1DODGE-EV, -EIID-I.INOVAI STYLE IRDl-O-V _ F ?AM Hu? .° ?2N:R'?".I ?10N .FAR 9 .1 ? - CNE? Ptl 2D2 E 1 EVi MODEL (DART OVA, YI I °a1 ?-,8 Z YEH. OR <W -1 NO. STATE -'Ll-An No. STnrf H --oR N A Al 1 - WFa•T TAJ &-3 g4 ui - - I C VENglf 10[NTNUtpN NO. VE CF UfNll[ ,rI 3? CC e:2 4 2F;3"7.77 0 _, REUSRPtDOWNfR: l Vt L I! I I . 11451 MIDIXE PHpNf NO. (2AY FtZ E u 6- AJF- - I Aupaessaow.NR O W ......... UWNfR tA51 iIRS, MIpOE - N - Z STAR TT I ?, la B ?o2K ll., N E A DR Nf4 ?I NAM-DDRESSOFINWRANCf co, as AGfnr - K MDUASTAIA) ?GRA[J Er-E R A AN N DAMAGED M[A E u O : • u''' " ° " AMACeDIAau• g fro. - S -I rmN.R.w EST. DcAMA,A_Ca - e"ARU o e ?nwly ?4[AWNID = cHn9ee • ??wl,r ?9FMAINED rro . i ,c o",.DNC? fsIlOAM,Gf -'TO• o? f ,?? fZ ? rowtoer ?r Er.i ,. owsD s rr R DIAGRAM OF COLLISION ' lu PmNAI INWUrf NO4m _SNNr NfC[SLUVI er Rpw G ? E ?' DESCRIPTION OF COLLISION: Iln[ sugnE lNf4 sw[Tlr (C[ r) E o r' ] R Gf. .. 1.. _.: .f'WE - Q NICL. V _ I -I FI Lc PPc2 NOH. QD c - 7 p AJr&)?La E a '-?? iy - I. . 5NOLAL.pd2 OF Ao'AC104y, [-N j TriAJ&-_POWae_ y PDT , UPPER ND.I RD - NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ' CODES I - 2 3 4 5 6 OCCUPANTS/ WITNESSES 'u'l-fK1NA- ,Mf S1 s'. AG[ UIV? ??° i 9t SIR. EIIR y w ,IK»n5 N,rogf a Nt"a ? AM R ? "N :o uo ' nVnw A 1 Pf or 11.1 •oA,vln f.ov ?,Me ?Ef?,AI ?a . ? n ? 111;,. 1 ? ?? .r Awrs. !.HSrq+INplY141E3MME RR,NR '- r5a ..??,;Y, w?nnR ^ ?(s"I ?`1i ?m ?;: y4• RAq ION X r?. ! n, .n X-I L ? 8S? :,. :• KIDIS.ATCNfU Il%KI ,N>IVfD D TOE PIIh Ac"'n' ,I +Pf,n]ovfsr D+IE LsP g1 r v, F IozC?S I s 8F 9 ? -.!'. ?/ j !y ks RT+Mg ? ? h rY r.:. , i, E 11 n r. T? J ': 2 "AST 'fC'I 4RAf 9 f]M1MA. .la,l aq,-cv '. ,? S I T Pw:?: paai ? ?, . ? ? ;r r 1, a r;, EII" .? ; l ? 1 I I Y 1 ['?L J• [ . ? T I % I 7 F ?- J r ?£ R N Eli - ? I IR P 'fi'r ' SrJgi'E OF WAS GTQN PAG[ GF , No No e .I / POLICE TRAFFIC COLLISION REPORT . ?TRAFFICWAY poucfcoMFwnrnuaeER .y.,TMjtx7 l if 0f PRIVATE WAY O ? ? d4 •. ? -._. -l'. • "yl N_ IMI. S 1391 a ? RR.iiw:? Iw 11'e . IUSFTep3 HOUR) COUNTY COUNtt/ vll0 ? iHWA ?uRIIA H 'Q >! ? E '' Ms. , F yk 1 r CIST OR TOW ?N ?E N N S NAMf F{ /?e / LO ?.E r ?7 , qg ? ' 'T^ 'G i { . O 6NO.Of SIPFEIOR WGNWAY Cff - J AVCfs., s' ?w of % a4FA ON a? / I fRSFCfING WITH: SIRE R AD NON INRFRSECIION 3 ROU[ S '.. "Y - tla"... ?.J R PPEFI% BETWEEN T BLSO SiPFEt{ CID SIRFEr DI IAN 6DRf ' Nf CROSS SiPfEi OR NfA4ESr MICE POST VI It ' f I G rn LLPOSi MFS 3 f V I L FEET OE GD RD /? _O g(j C) C VISION NVIXVFD VfRI[Y ILEA E ??yy??.. . .yFy VV : I TOTAL No NO, KILEED?_NO INIUREO0 C3 SPIIIAGE ? FJU?N Ci VEHICLES ?J pROpER[Y DAMAGE ONLY ? RESULrFD (F R M f I ? INTER <I X SRC: RRGAOUX ISlERENCE CPpS-,S i1110R ROnD j /7 ZJ ./ 7 . ,f?YyF - d OBJECT SIRIKKLNAMf Of OBJFCISIRLKR _-E. 'S NAME) , ,• f , ? " 0 _ a ? 3i.DPMAGE SPECIAICOD NO tr;E f E s - _ `(t'? ° '. '.. '...,. I UNITNO I ' '' gNFR' NAME: CAST UNI7 N0.2.,?VEHICLE ? PEDESTRIAN ?PEDALCYCUST E A .._ f ? C Fl t/ S w/ r c ft RWER' NANf: USL I I 6 ST N E' L ` ' - .?- N slRfel,RppRE . . N STREET ADD RESS '?? °? 3 0: ??TsC lE T P - ,, Y SIAIE ZIp CODE PHONE NO D III - SIAI p /C . : iS F,?'7'Ow File YvK 3 68 D w R o w NN " 9SS? S N 2:9 // . . f rvf s uc[n N . s Ar x DRY H MD? I ... I IV R' ll FNSE NO. Al t ' n `, p OCNIAIION II4M NMI[[pHONENO. JJ EYES WEIGHT MEIGNl E c 6/ wf/ CUPAi F 1 1 [ . . 'Tvn N AD. 7a Pa ?lSfxD . R 10N "'T. NAM E6 -E NO. EYES GNI HE GMI &? ?/. P K•, a 9 ? CHECK (? yFHKIEA •:" FMnoN[a ANOtHEa °CYu CODES1 +1 a ni iY ` 3° ° ? CHECK (.? VEH OF ASRN FNAtOYFF OFANOIHFN. R, ,? pp q f. R Y sn IC 5 1 c1w 6 vi , u R yi MNr t iorvsrue CODES ? + ? c;is"'6 x s°: s eR N No b w p C vCDreCaw 3F w er. ? AY ..' ? ' KI ? c"5m" ? vi?cu ? t'fi°A?v sE e e Li Awwuna ? "fpwDE ? wk l ? i? 2 ? f44? ? 1 Vt .YEAR AMR[(DODG[{HEV.1 ELIDNI•NDVA) SITtE .C (2. - v 1 u v. H V 1 IXIIDM VA M N _ - . N Ta pa O ll lA FN /'fv ??eJ+[? a Q E . I DZ baosE ? C ?R ? ' t , ?e'S? ?° Q1 3 SIAIE iRAIfR RATE NO. SIAtf I"I I FH R . C I N o j y arm -_ ?# fHK1[ IXMiGI GMV / Wn NO. W C .. r Y6? S3 w?/ " - , 61 lo!yIP!?lolglgi i? I I 1 1 11GISR 4 L v H Lf D N I 9 1--' ITT 131/.1 I I I I ?? ° . Y K?g - ?L fI L FDOWNt4: {ASl IIRSi MIpDCf PHONE NO. ? L AID, ADDRE33pLONNFR 0 IS D WNF4: IASI f1451 MIDDL e 'Jfl b O '. ? ? N A WNER DI ' A e n ,y S7 P NAM[°AppR[SS C!INSURANC[CO. OA AGFNI - E S/6 V 57Rc'c?T ?]Y, '• ., IK R A 32 I !pm :',? DAMRGFD.VU N3R4nD rn .. . J... ? .. - n °rlVgl ^ ?. ^`•1 tr 4 - ; ? r _ a Ear. wvMGl ? Awnr ? pr 4[MNN[D ° nA'eD ._ - o?w?roxcr pYDI ?N ? [3 .DAMAGE I ___._ RGANN[D D4IVlWA " f7 yl. S `t i 10 eOT10R A ^ a ?$ IB DIAGRAM OF COLLISION: INp c.v NORTH _ __ r ,_.. sN[[Au NtC[ssARYI ... er RRROw DESCRIPTIO OF COLLISION fus[SUppuMEMU3HFn IF Ntc[ssARrl 3 .. . J'sF .. .. J.._..wq5-__SAO.wh?.6.-__/.i..pf(,E'JAFL;. hl Ei. i tFl'T ?Rx . ots J81 1 c '9 I I I I J- S O - w rf4T4ME NO No , .f ; r N . .`. I FO Pa sSiJVm ,. ? J e + 1 .,, yp ;;. ? l . Ip NAME, ADDRESS 8 INJURIES OF PERSONS I03f slvnEAVNIU sav OCCUP INVOLVED er + CO DES 1 - 2 3 4 6 ANTS / WITNESSES tp4 ADprtIONU A _ _ S" ?(? rar I w' u t _ [sli. utc[ Alcr:' .' 6s. ..._ ,.. HAruqa ... _ e r Owl C ]" ulpe - p ryp enI' A N ... ... DDnu NO. NAr pF .-. .. .__ p.IR ?AM4. ?aKl ?MU.e?Nl ? r tiANV 'D .. , " _ lnlr ' STAYlt OF VVAS NGYON M N 'J POLICE TRAFFIC COLLISION REPORT L'].TRAFFICWAY PoLICE COMRNNI NUMBER PRIVATE WAY µxl .OAT! FC U N ... AY ll I,. DAY CDUNIY r rv (-2-IHOUR YAUNTY NO. CI(YfA.. N- - ? ) / // pN QE E]N CI O 1 N NMAf6 NO. OF STREET ORHIGH WAY Cl5 R EOREH. SFcI N -IS s ow of m c ON C IMFRSFCIING WI H: STREETOR ROAp NONINtFRSFCZION .? •?-Lj?j?? n BE-1- STREET 6 C / Z. STREET PREf I% EO. MILE-11 '^? ?J f?J J''I 2'7 DISIAN 6pIR 11 ROMR f CROSS SIREf10R NFARESr MIIfPo 1 ACCIDENT Mll[5 N f W RAMP DU RARADAIA 11 . ?, MCODE EAGE iFFT ...OF COLA TON IN'IIXVfD: NO. NOSEVERI.KIED NO.IN IFO N II}RUN HMwDI N ? ? SPRUGE ITHE. RD REEIORRDADOk REFERENC! INiF [45 ?OSSSNEETORROAD x ' a R vlH E, R S 5TT aF V[HlClfs pppPERry DAMAGE ONEY ? RFSUIRD 4FNIClF 9siT ? COJECI StRUC%INNAf Oi OIJFR SIRUC%ANOOWNER'S NNAE) EST-DAMAGE SKCIAE COOING USf UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN Q PEDALCYCLIST x% S DRWtR'S NNAF: EAST t . DRIVf9' NAME: USI 777 L L - J Al EA/A 519fADf Lr S XQRf IS-,4 RfFI ARESS CITY SrArE ZIP CODE PRONE NO. w t: fJ - D R Ily STATE ZIPOOOE PH DRIVER-SUCENSENO. STATE x 3 t.j- t-A .r! R LZDAI D.. .. I V q' EI tN ND. AIE pA FCIf BIRTH R. I q IXCUPAIION NRM NAME 6PMONF NO. EYES IGHr HEIGHT E CUPAr10N FIRM NAMf6 PHONE NO. EYES IGMI 1f:IGM z ti ' R ? CHECK (4 I VF ZEE_. I_OyfFO ANOIRIR? r ? CHECK (? EwnE asWASDRIVI""o=005$- I e SEE. 1 S., CODE S NI S 5 a 6 ,:n ? c CODES b- D E 6"510 55r ^° ? t IAN .dDNP[rDY sxi Z ? IN?I; Ios C.w Y tin ,r .T. A RI , FINT RO -ANC ? ? [DF4. ? C,«21€ ? I'P ER V[X YUR MME DOWE< E D apx w p "--o C] u l[I S:R ? ? o° cu . R V.) I E41DAR(.NOVAf STYlE 1]D V.) F? 1 N V.1 MOpEIIDAFEI. VA) l V.) _ 7 =J Cgi57 E qx0 41Cl NSt P4A N S1AIf AIItR RAiErq. SIAIE H V R. R N A IRAIIT. -1E, + W A 1 a9 VFHICIf IDtNNFKATION NO. L VERICI IDENTI I iE C? )a 8'l, 7LiS9 ;9!S"o 8 Rl l G15RR[DOVMER: IASI IIRSi .'.IT 'Honk NO. AJ ciSiD L O W IE D WNtR: 1. T1 FIRST FH.E N u z AD4wessaoANee 7 c F 6J? 837 N E ADDRESS OF wNtR xl 3 NAMecADORIssa INSU9ANa co. AGLNr R m M10 iw `UMN I w iWn gMAAG( AJIU ?IDI w . F CNARG[ -.G' C ° 4 P I Rew >7 Ivdiy ?+M• G E ESS fE4A/ O?A RFMNNID ?AWAY ?9LN.UN[D L .D E STpp .. WAr w ED ar: iorrDR e ? DRDSYKArt NORTH DIAGRAM OF COLLISION: . " . ARgow _. rann N[ussARr) DESCRIPTION OF COLLISION: I- SUPRZAYNTAI SHEET IF NECESSARY _. ) D Vol Vl.NicE.c Yo.u-y-.6o. .0"o N1 r.. OF Wir r2{ or Llood, A'V.0- A'i Lorf^ ('puYaoC lv& So-Aw, 6E,f.N/ s, - - - - ILA-as 0,re.I A .Fa-CF, Arlo A TICQt., I IR W4TCSt Q 10-it 4,vo CA IC /UFrr 4 oor Do•Jv NAME, ADDRESS R INJURIES OF PERSONS I NVOLVED ' CODES 1 - Z 3 4 5 6 OCCUPANTS/ WITNESSES io9 ia?D"LOF,A"iF?iAeu sfi v% A( uws '"„„" Ru "II RtSi1. IJfCI Mi°ir N ARY. F ,O A H MWIi -1 4eP10F uMeY AM 0 5. 1]c'ARI 1 11 PA.. I]Nv ?IIwtiLL :O A . DEUISS AMI- W NAlu.la 9 .15m6_11;4 . QY6. ?-.. F 5^5 m I:° w A I w IRVYS r4lp ?AAS! 0,-." Dio:nF or ? n 1- . r IS A A MipI . . K SFAMF{fAN4 IApGtO AGFKT K1D51[IICND K%KI RRI D 11G RIRW I AH ,OIY DAI! P y (7 - "-t11 ' 4-iwn Al _ v ?k 01 r _ r ? 3• A 1 ' e E? a{ 3ffk..^..S 9E YNJ K: 8i ?'?r? ?3 l W: g• k r., v. r 9 t- f? ?9 a ? I C toicau r, ul al N r ME c USE}IDpfNI ouN^ r AUNn NO CrY NO. «wA ' ' Q y. A •7 ,[ W" uov NN wtp wN If S.r URI I 710 D _ _ l ?,1-?-•E? `r,?T,Y^ / I(O . •? OUR AN 4AL QN QE QIN CIIYOR ,OWN feN51RE?OR EXGHWAY 3,3M1F5 OW MQf O CI, N IN IfNSfC1ING Wlin: 319Eft OR ROAD NONINIERSEC I- iCIC15 3 R FOUy j?? Y TTFL???< 'T (- REIWEEN Q a 1 SIREEr b C P-ATREE1 EREfI% ED. MItFPpSf "'?' "• .? ? D STAN 60 RE t mgfi f. CROSSStNkEt OR rvFA4F51 IF POS ACCIpENE lE3 i N \i •.-W ! R P DAG4AM DA,A .. ` .. • MILEAGE EE! OF C O. CODE COltI50NINVIXVFO SfVE911Y. NO X4U(D_NO. INJURED_ Q WIAGE Q HI TO- NO Iur+oXlom N %FO 1 gSSl I SIRE RROAD R R Of N R INFER Cl5 INIRMRfEEOR POM O V[MCLFS P4 11, DAMAGEONEY Q'IRE ?VFO1CI, RTID OBIfC13fRUC%INAMFOFOBIFCT SrgUCK A D O ' y S?IpO N WNER S NAME) ESL. DAMAGE ?e c2- DSc' t o Ner S G/ 11 s d SRCIAI CODING USF _ UNIT NO. I U4 ' UNIT NO.2 ? VEHICLE ? PEDESTRIAN O PEDALCYCLIST rvfR S NAME: 1.151 RS vt N pFO?Q a DLL URwfRSNAMf: USI fl9 U 1V N ?L 319EftAWXf SlRffr ADURE55 .( Iv SIAtf EIPCODE RIONf NO D v StAIf rPC Of R N NF4'S UI NSEN S AH SFX DA B In ?0 :O.S S,S' V D iv U [NSE NO. tAlf DA E IgIH Mp. wY1 in. OCCUPAIION IRM NMAIAPHON NO EYES Vlf Gfll «EIGHI E R OCCUPn,ION FIRM NNAE6 RHONE NO. EYES ICMr IEIGnt Q CHECK (.I I vfnrcif ASAw.rR`wlmPlarFEa ANOrHfR. t Q CHECK W) ' °N aE AS AN EmxorFEOEAN ?iaAf 2 CODES ?* G p •, s f T. 'R'•°„1ON Or CODES 1. * a s a i. s u E° .IwIEs T a of o M Q M. KF ? `l [I ES.rI, ? "al O ; YEA r ? 0- NKE p PD HI c, O B6R, O H ? y 8 ?EE r Y19DR;aW.7 r/r71 MA fFD?Y.1 MODELIDARhNO nl S 1 f f Uq MAK l Ev.r NDaIIDARI.NOVA1 ) (. t ` V u SEP ` ` U N sEAtF 11 E. _ W? nllE9 R=rf ry i ST iR ` T [1;- \\ i VEHCIXOR N l 11^11 1 l NO A N ? _` ••? f E 5 l ` =HICiEIg IuraNNO F :0GL:P S- S 2 vE«ICIk IDFN1EUI N I gtG32(Rf?UOW/f/f?f E4A IXSt ?/L ? i1/9/Si'?' ?`EPHONE NO, E?0(1 f• a u E r 1ERFDOwNf9, fNr r fIRSr MIDDY 1 I V Elr>r , 7 / AoDREUCC OwNeR W .OAS. S I Al 3 N E A M ov wwtaApoRessnlNwq co. DRAG,., IN u ANCECO. ACtr.l--- k. R _ wMAGIDAaIA NNt oN? -- .'. "as.N no gNWAC? AAfA 1 ro. 'w:o. i CHARGE - cnARGE or.S o? ° , . vD _ I0 ?Ol10 tar. L351AAGf ??WNAY ?R,MAINtD D9NFN tSr. DAMAGE I 1rpP ?AWAY ?4[MNNfD tUii 3 UYO I , S oO iOWYUnY' ?AWvDEY: $ DIAGRAM OFCOLLISION: lu uv INpv A'Y4ovtn DESCRIPTION OF COLLISION: Lust SU REMENrA[sneeNf NEet55ARr) Hftl fNfCtS3ANY) -. _ .._... Va. / w i __NOr?flibeunel_.cn._.CD-?ec?e,? 3t3 ? I I ?,;/? s aE?S or- clt;?,A?L.cnr. r ?- e?? _,. yell. */ ' ?• (2ar ? ? I yV Okt iD .. Y. kr_ Stiauld C.c EA.p?OII.KE11t ...0 VCY'CE:S t•/•[• lc2Aavin ' C J I ? COIL Elw r . o . LcFrs;,Ie oN_E 1 .. Ve( _ sT5 111- ..4. Ft cc..A/e. adt ti7 -cer.m. - , .. ff^icer wrriver.7 6roTAer OF-- -vek, dw Fyi d r) 6 /u•os•st _+ Fr;oAb s'kl0s '27 P cis e1 P. (DC II'.E 2 Ck b ' qq T. LaLn do c3• '/-S7 t.A•¢1t IL IAIAII E,R.rS ..j'E.. Ikr . NAME, ADDRESS 81NJURIES OF PEk.[ONS INVOLVED * CODES 1 2 9 , 4 5 6 c OCCUPANTS /WITNESSES ?°DUq i3,pupIR1,ID'"ENA"frNru.,' .AME' eii srK Are .urus '"„"" D r.. r • S .. - R[SiR. IE[Cr MrE.. 3 .r rr . •DEw15 Pr%Xr NAtUViq , I.l!iY 0- Qi t Q 'R' • ?Nw Q{ EUily Np .Iwfla •wFa , IMOYIUI QAME OF: ^IOo.f 0:7 ??° "No •oDft S N •nof NN15 ul ?AMn Q.°.'"10."°".v. O 11. er arY O :° A vI31N .. NOpIKIfShVN Ef•NK r X Jill DR J A?A?O F\wi pE K?Ir'l:AiCr4p I? if>Y All E'J14 /?1 RLG IJS D Z/W AF1ROyrDnY S . n • t DAII asp .;.: OAfEOFfALLL4Wl.'-r -..: W YOG COL LI90N..., _, ,. iIMEOC COLLISION .. UNlY NO. GTY HO. . ??? 1-1- . AM ,? E n r . ; /l : 15 1,81 1 11 :45 r+nx. PM p er t uCe CoLrITY CITY. TOWN MILES Rj CITY.rOWN - -= PREFIX EElt00e- wblR SECTKXv a uS"E Ja.E'fr:raon nter qW ? CM of ;Ern 1'r t `7 nOAD CW GVENAMEOFSTREEGI1,AOOfl HIGHWAY DIfERSECTWG"III; S(PEE OR NOAD PRE E O MILEPOST C Ri° Count c' d :'!T NON INTERSECTKIN LOCATIONOF OWSION •.. PAMP GAORAM DArA r • iPtYf• P MTWEEN The 1?1 F.-.•iliJt 9f':': azTpEEf", a ?1' i r - i HFft lr rrWS r•n.pmp6[. ©© wNEA Ns le i O n: o NON XPO ON E w ET? n uErrr µv°.uurx nn cn a W s ..:Wa INTER INi CLS E AG brP[ E % !?0 "er) R:•r, r i-I' n [ n ' iTt t "'fE E nE r 0 G?7 5 °r L °ry (? 7 ?vt"rLE a°rttE ?°rrvENlwkrEl - 0 Y ? DPEC.000E USE L 4 2I 0 s ? (- vF C,Nce?rm..r p h°N w.-. Owr rnrx . GWECTSTRUCK IwWE OIOeJECTTeUC•1 .• . OWNEROFOBJECTS NAME ANOADORES9 LOCAT ' I O ION -• ?N © °e jOPE /n tr DWAY - " A N R _p FEET © i0ct. S • • DhIVERStA3l NAME FNSTNAME. :. .':;,•- WGDLE M F MONf NAN rwO CAP4 • • ORIVERSLlSI NAME - FIRST NAME ... .. .... .. ..MID0.E ;•.. . :Zoabach2 Vernon Pranklin causwDA Srbauer Janice Marie STREETADORESS .'.,:. .. .: :,.: A r10UT.W.AND90XN0.. AroAE mAN ISO STREETADOPESS P. 0 ox 64 Dnhnh v "^E0 " P. 0. Box 2 4 •. . CRY ...:. STATE _...r, ,:_„.. ....DVCWE, VERSOCCUPAUON..... EPNUrE COtusON CITY. _ .: STATE .. LP CODE DRIVERS OCCUPATgN. Eiadlock {';7,q r a tr Chimacum i•/A 8 2 Hswi DRIVE-ICENSENUMBFF-„-.: :...:..•. STATE S X 1 DATEOFBIRTH -AGE DRIVERSUCENSENUMSER ,?. TATE S SE% GATEOF SRTN AGE )O.5-F ' ef'JL , W x 06 °•8 YE6 ?4 SC-HA-UJ-M-61084 1 1 'dA j M' 12 04 1Y 34 VENCLE YR. MA0EICHEV:000GET. MOCEL(NO-ART).. 101STYLEI20R.) VEHICLE.YR. MAKEgHEV. DODGE) MODELINO-ART) • SOUYSTYLE1.GF.) 1996 Pontiac Sunbird Ha ^h., .19 3 cord (;r.Torino 2 dr. LICENI-(ENO. STATE. tflAILERPUtE NO. STATE LICENSEMTENO. STATE TRNLERPLATENO. STATE J r.LT o4 E. d N 44 -CLEIDE.NTIMATIONNO. IIOSBMODELSe NEWER) OOOMFTER(MILEAGE) VEHICLEIDENtIFICATONNO. 0 MODELSe NEWER) T?+ IMILF.AGE) nob available viable RE STEAEOOWNER. ._.(LJLSFIRST-MO0.E NAME( _ CRNE IJCENSENO. REGISTEREOOVMEA _I{ASTfII{4^TAnOCIENAMEI - DRNERSLJCENSENO ROdBACH Vi NION H. C - V-F 01 SCHAUE2 JAE. S or.J i '•' OWNERSAOORESS ,,.(STREET,GTYANOSTATEI OAT1501-TN. OWNERSADORESS,.-.-:. 'STaEET,CRYA.STATE) OATEOF BIRTN P. 0. BOX 648 E-EADLOCK WA 06 8 rE6 P. 0. Iny ;)oLL M E d g u; E< k S y T :l 17 • i f m'Q? I ?i. t6. L L 1 rED FW9et? DMA .. ? t PARrSCFVEHCLEDAMAOEO -- 'IGHFYFRONT QUARTER PANLL & BUri. a a RG•RLAR PANEL BEHIND DOOR WAS THERE AUTOMOBILE UASIUTY NSURANCE r??('" E _ 1 LIABILITYINSIIRANCEINFORMATION-VEHICLENO.1- COVERAGE N EFFECT FOR MIS ACCIDENT ON YOUR CAR r9-IES ?NO F NAM E ANO ADDFESSOF LMSIMTY INSURANCE POU YMILDER NAMEOFUASCTYNSURANCECOMPANY ._: :. " .M •'::: -IE R08BACH VERWON & SHLR IIi O DO X + a "A NAME aNDAOIXiE590FWBUIYNSURANCEAGE T - Orr E- E SN, CK VA 98339 P:'WQ INSURANCE Co. it UABIUTYPOUCYNUMBER - { LL" "S $ F T '? - f - E, .. .. N "T "'A m' -1.1,! a QJq1 ()a 14 - ''•' Y"? In< 1gT NJWY E 2ND WJUflY: IU.- rERFFOiItrORAI%IrIMU•uDIAE51 ., _ • . .. _.^:. ,-. ...'...: - ? AGE e n - ,... NMAE TOIAIL NAME y, no in?urie. WNRED no injuzizs ? AOOPE„S SE% - ACOr1E55 SE% . .. r p E E AMKS ?_LI f E _ _ O E. I Do01DR ®E E h ME` D E - e, MXWt, oDra ©f NWE°" .. 5 _. .,- ... sTAYUSO rf•ccn -.- uAw%cwsr ONE iHAt APPr ra¢ vATrt¢ncwnrRCn uAnKnnar nuc nur APa rc¢ _. .. -.,. .-n ., °.4 .. '?'',^"',:^: U NS.SrNAN ..._. .J .. ............. OPE f9 .._ - ... r..,..,r e t ?:'F -3 ?, wH:J«-,•r ..•?.. 5? 8?___. .-_?? O r-,.'m'L ? 5? -_'SO 7? t SdOWNORfHOYANROWWCWCLE `\ DEBCNIBE BELOW WNAi/WPENEO.IaEFEHT04EHgLE9 BY NUfIgEP),? ' _XXx?EI__ VLHICLI #1 WTW NTx2uI1G To r"?"`W"`.^"' AtIp CAME; UP01V BLACK ICE ON THE --ROADWAY B GAN FISH TAILING AND TRIED CDIAf ° 4ND'tGRLINDLDFtlIlEE..CAR SLLD ARUVzh cle 7-1 slid on the black ice and slid off T ' -_tiie._roadway to the ditchCar 1/ _r_emained on the road.,, Thevehicle(s)- -,speed at all tunes was agRrox.__30--to-. _I . i les- For- Hour• IG g m 'I rood 0 -tl e , citcxire?1u ErrLwa orx'Y P/ 1 u brr,Al ,K , .. _ VEHICLES POSITIONS BEFORE COLLISION aLANO YI^' Y .cu Axabw STgATE0 GY ;f + , ""wwf nNl. ai.M.Rt V. Pu occ? P [s rWVEf VN"(CIE N 9 E W ON STREE10R 1•GIIWAY NAME Ofl Iq n[ ION ES ITSI`•NA 111 I.-CI OMIK[ R &] O O O Count a d'1?_ ° ? ??o wArI 9 ? O ? Cnunty road 12 .inr? e0' cfflr O : O SJb«N.Fy+ ? ? ? ? -- cnaew FRO" DIRECTIO TO DIRECTION, {IJ r ?? , Y If [H STTKAN AS IrS`NG 1 ? JM.WN.K 2 ? WALKWAY D ? S,4OL R • ? C O%Iw4rr a ? cM'hw4K a DTNER ( ,. ?, l.•c^i? ill',t ',A. 1 KNSUN ?K! wtAl.f. L-TCON.I.ONS TRAfIICCCNIROL ILre-, TYPEWAOAD KNECE61E ? KVE E? 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En.uwWE. .xIEH=rLro FEET Aw WiA , IME ?Hn» rr,EAAMNHA9 MArl ,19BEw0 rP.waF«ITED: .:«usUxwfOLVEn ? 01,1x0 MA&ElNIUO Eax05vES wlwHF Q O,HER S "T w? K«xsD wNA Rw09rAF wro,Ow roAO AEFEnFNCFDCA0IYSIAEErw NII 4 ?AED ?wa a?o A AND LI EM w NANH? BwMDM, aro?pE ? ? ?,??.7 OIMcCl3TRUCN IxwEOFCWFCrsiRrN:NI 'NNER FO LEUECT3 NAME AND ADDRESS F^ir0 Jc??^ $7t 5 fnES 1C_cODE WE ?. DRIVEH'S LAST NAME FIR TNAME Ec 6?e?c ??lurc? MIDDLE M sW IEREIN-L ` - r DRNER'S LAST NAME +FWST NAME MIDDLE ose3ae"?l STREET ADDRESS 11111:51;17 LT/ %Njl. 7 pP•yxSwE»E STREETAODRESS •aF flOU1nN AND ?BOX NO. X CItY STATE ?l LP COOS . '. ???/i?.K';!//1/ L'??7• ??j'2J OPo 'SOCCUTA " DH.Y ? c0.uswx NEPaprF CITY STATE' -/ ZIP/CODE DPIVEq'S OCCUPAT Lu.?F UWVFF9l1CENSE NO. S A 5 x GATE OF KITH AO% DRIVEfl-?? 3E oG 9`?E SE% OA(E v 11111" " 1E VEHICLEYN MANE IGNEV: OODOEI MODEL(NOVM-1) DODY SttlE 12 Wi.1 VEHICLE YR. fAANEICH :CODO EI MODEL (NOVA- DY YL 120gI 'E/N3yE PUT?E!(!?/? l1STA<TEj?. TRAILER FNATENO. STATE _ L SE PLATENO. SPATE TRAILERR- NO. Jold/ Si TE VEH ? IDElyRF1C? ?/ I / / ? .. .. VENEIDEf1i1FlCATq rNNO. I F/ ?/11J .? .. . g E 7? EI `!7'7/ 6/VQ REGUTEREOGERILAST""F-RSUCFNSENO. S .G11? , • ;5 :?d ??i/ Dy,,SgqENS ADORE59 Tf1EET, CITY AND 3TATE1 DATE OFkYRM HERS DRESS ISTREET.CItt ANDS AT 1 A OF 1 PARTS OF VEHN:IE OAMAO ? ? ,? Eli . ? /r?r- ? ??'•A+?? S ? ; ,? PARTS OF VEHICLE DAMAGED i ? ? ?r??? - ??,? Av 1 LIABILRYINSURANCE INFORMATION•VEHICLE NO. I- GO-ACERIE FECCT FORiN4SA000E TON YOUR CAR Jg,YES ? NO NAME AND ADDRESS OF UTY WSURANCE POUCY HOLDER >, i. ?,? ADw • .. :.... -.NAME OF UASr TY INSURANCE?yDMPA,aL -'..,. _... , ?ArE ?i ?ls- n ;? < cr 7 Gd/G'1!/>/GAL ' A ' : NAMEAND AOIXAESSOFUA&Ott WSURAHCE AGENT. ? •- : . E, LIABIUTYPDLICYNUMSER .. _.. :... ,. CT-. , . I AGE 2NDMURY: IUSE3ERApAN EPOA, FOX ACprpxuuuugEA AOE' ISTWJURV: : 'NNAE . ? . 0 NAME .. .. SEx E ADDRESS MEF ADDRESS M F NATURE AND E%TENTOFITURIE3 NATURE AND ?? 1 I EXTENT OF INJURIES ?? 80. DID NJURIES E%AM'.VAT YnDYARDOOTOM DOOTEOfl:4 IS RUUPIES IL?JI E% SO INjUPjtS AM NATIONRDVDAIOOCTORf ® NOAME RS T AT USOFVUURED S ?CFWw WVEHICLE Q PASSFM.EA KILLED MARNFIRS rsriAiuuvO SEVEAEI TUIETHATAPP Nw NSwavwb MarORI LIES F«S4ILE PE COMgAw, STATUSOFINJUREO QONVFR IN VEHICLE QRAaaENCfA .._ KILLED MAriN FIRST DsARtwp Iu AEI ON THAT APPLI fWF?sluq IMPNMI ES .., 59NIE PW n^?MT NpF Q EEOESiNw O Q. --T- ? 6? 60 OFP6-1 7 QMOfSrrvw NO C1 50 6? P FTCI 7? MOTORCYCLE SAFETY: ? HEILIET USED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED C] HELMET NOT USED SHOWf:oRTH OY ARROW ORCLC DESCRIBESELOWWHATHAPPENED,IREFERTOVEHMAESDY NUMRERI ^°'LWh;lOix,P.LxE t N.. N1 EUI- ' ran c«lwo. Nc we - i Q5 1 __ 16UUDEp h a (:,or:vr?E Ilb'_. r, ^ P0 -- / SNfEr w wn w xM,EFrW ) ? .v ct nEL - -t.`I..c . _ roa.L3. . way / c,? ,?? ?? arxEE,onLDxLY,. hh?- -V.72rL1..__..1 r1EAo ..._ _C _. s i t dL'?.. 'trLc N?. I...C,cL•r . to . ?k h 6 } ICE 5 ?th - n ? 4? I , a.E c/v?:,S .Lntca In¢ CIAL ,. On -bIla....... kv.40 . A O ..ICU,-, . ` dAc6L On [2171,{ 51?_G 1 nbca W ? \ 1 ? fVcQ7h' t; _ _ _ _ . _ .. VEHICLES POSITIONS BEFO Vr.HK;LC N Y E W RE COLLISION W Si11EE1 Wl HN3NWAY IIAME ON NO «L.xI wDxr s ?mLC,rM D.° cIL IvxvMrorw Llvtf HO YLwLM ITONta PMruo ,n.mw,D v LL UCCI,rND WvemaArmDY ,-,,.!•a ?nmre L7 `Ipq, r?dICE po P- o ? ? ? fil! r/, p / ? ? ? ?' ? ?' ? •cv'rvi.1. ?n°Iw?sN a000 / ? ? ? cx ? a ? anlHr, 1M9^ ? ? ? ? uc.ID FROM DIRECTION TO DIRECTION - PEDESTRIAN /PFMCYCLLSrWA.4 USING'' 10- a?- A a?rHax« nt?crro4 •?un +?-N r?I.w K?ro PCDESTRAN/PEDAL CYCU.ST CLOTHING COLOR. F?L ? aLNn A?v ?NtiAD nNLf CrM. F?y r?iUii?i?rwt AOAOSUNFACE :F,(r .t L.f CP var WF.IK. IAirt1 co-rCN9 1 ?fUYI KiHT vN.E :RAFFC CONTROL rr'L rLr.v CN Cr•rl TYPEOFHOAPrC.twl v .• P. Lr U .T 11 <H V•b•YI a r D'IVFR/YEHCLEACTION3 K ILHICN wFw WtAFI vN .L[ A (??/? ' EH I . 2 ?DA DAWN .3 so-'r IS I ? (INF--WAY ? 6 1 El COIfIn SInNNIr AHEAD C] 1 ? plir ""u ..r w: 2 C] n.uNVG D ? w3N ? 2 ? STDP r+r,N (a 2 e•IYNa wav C] 2 (y'ovLnrANPIa AND PASSING r1 A ?WLI 2 f"1 SArtT.AVND ?E JJ A ?LX111f30Nfr ? 3 ? rl[IDIAGN Fq A:r"`RE ? ? 3 0 0 0 MANIIIO RKHI TURN ?O C1 vFOw ? Or. a ? 5 C3 n-ARK T 1oriET S HVVn NFD ? E ? FIA ( ] El + IJ 11001EIIA pl r_1 A ? -N. I FKT WIN (?-a L-l + [I.' IC[ ! ? oAYCNYI . n ? SIIN'E PAYS C] 5 C] f1A---It. ? 5 E] AIICV [ J S ? MANINO U.TURN ? S ?1- y E 0?lOr f F Ll of •-'T1 A WI EX.N AL I C] L A IWO Av U ? l1IT I A N µI /? ATWn 0 (l tJ In NIADWAYC Af fR IIOAp AY: FAL.f t [-? ) [1 I L- ['l I [ IK Y 0 T [] r( ftt l'11 Inam t" J I ? x E'kT' R POLICE TRAFFIC COLLISION REPORT L"! TRAFFICWAY POLICE COMPIAINI NUMBER ( u?10 "•' •.. J" E] PRIVATE WAY couNTr courvrr NO. 1 0-0. L - DAro[cou N x R oar COLLISION IT., 11 ?'e (USf RIW HOURI Rx MN ?E ?IN CIT p`uveul 1 P Y &TVP1' NE ?Y •v rust wl T?Y OR IOWNOaIe ?C NOSIRRFff`HIGNWAY FCf CIS A ROUIf 0451PEEi Df SfC10Nl .,IS ?s ?W SCOT ON CR.-1 fi<i??0 9 /SV ?i ".? INIfRS[CIINO FYI H: SiREf10 HO NON NIFSEC110N ?? PREFIX E MISF PoSI (?!J? ?" BfTVEEN S.N. NfEr6 DIS ? eL1+.J• i ANCE 6DIR! I Rfif N SS STREET RNfARE rMllf SI A[[ DEGNE •.: MA i ' T rR y ? •-., f' IDENi NAM? DIAGRAM OAIA ho r9 ' 4 P MIL15 S E • W OF MILEAGE RFb?a RD CODE LCJr COLIISK]NNVOIV[D. lRIIYI l IN XRD N IN FF RROAOOR RFFfRENCE ?? 5'r" lOtAl NO NO KREEO NO.INJURED ?SPIIIAGE ?Hr6 RUN EONRRtDI. INIE4 Cl5 CROSS T. ETC. ROAD 94?""? ski R r ` K J OI VFN Cl[S © ®'PROPFRTY DAMAGEONIY ?RESUUfo ?-ICLE Muses / S/f>00 T, y (yfA ? A/". ODJECT STRUCK IN- OF 08ACt 51RUCKµD OWNER '5 NMAF) ESi DAMAGE SPEOM fy C0?0/iNG USE -E4 S`! NG / UNIT NO. I UNITNO.4 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 24 • Y. S RIVER '5 NAME: -1 iIRS, MI Dl DNVERSNAME. IS, PIN MI t _ A P19 b PLOP-A %•"'SI SIREfiAD0Rf55 SIRIEI ADDRESS ` ` .*.. (rRANZQUj9tQ)C- ' 4 (r CITY SIAIE EIRco E PNONf NO. D IY SIAIE EIP DE PHONE NO ` . C IIILC JJCc WA4 $3 R 12 yfR D ER'5 UCENSE NO. SIAIE IRIH I NIV .R LICENSE NO. SIATf 5[X 0 IE OiB RfN tAokEMF* 6-13C3 WAr. 5fX IA7- 2-5 G v tl OCCUPATION URMHAmj6pf19Nf(p.OO LiJ?Y ?p Q7 A1 wIliHI E OCCUPATION PIRM NAMEd PHONE NO. EYES WEIGHT HFIGNr 15 ` ? CHECK(.,) EH?JnLLESSA??s:N{{EM?Eaovn oEA.MiorHla Al`l ? R ? CHECK(,') ` ?Ix f As AN FMPIOVEE of ANOIHSRA1 CODES ?? ] ?; A s 5 Incna. 6'S',°,:,°r"Y CODES ] ci < "s: 5 u 0 y1 uvrts 'IiSr aES lol yoEPDM p AM R ? YS.yI ? ? " p AM E O u ? pS.R ? C] ^qI Vt N. Y[A MM R EIDODGE.CHEV.1 ILIDARI,NOVAI SIAIE II DR. CONV.I UN ° icE t9 Form 5C M? I ?'??EY.) A"DDEEIDARI.NpVA, D u' Q 2-D ' E x R tl fN5 PU N SIAIf RMltR 0.AIf NO. SIAIf li VfH.COI R F? AI f IIAL VFHICI[ID[NIIFICAIION NO. C of HlCIf IDFN IN I N R[GISRRfDOWNF4: Wt IIP51 IDDIf PNONF NO. O R ISIf4fDOWN[R: LAST FIRST MIOME H ENO. ?? M6 . ? E-4 .? •t ID DRE35 OF-1. ALALLRESS OF OWNER A F•?r Y?Y „h."m Z !LCi W N I ^ ? NAME SADDRf53 OF INSURANCE CO ORAGENT E AC-L IN U AN A • e. `[ R DR %--l 5E IN EoAw(ct Jwu Iwcia? wUEL., AMACfouleA ; M CHARGE CHARGE ti xiR pMDI DS 1 =1DPD •5 I51 'DAMAGC ?^WAy ?R(MNNIED e?AWAYN ?4(MANEO IST rDAMAGF r. I?.----e S o` i°wnvD A ?. ? A-1 f oeonoR ?:•,. DIAGRAM Of COLLISION' Tu N w u1I NORTH DESCRIPTION OF COLLISION: IUSESUPIL-ENTAISHILEIUNECfssARYI swsfcesun? er ARROw ?. ?' ms's) o-? Eu No. BD crz t 8 WT 6Lack.rcFE AM SMIRTED F/Esh'TA!!?/) G- C: SGs D 6a. 3D ^ t ;; ?_ AAAA5- OAvzb OPr MKOU4. AND 0 - ?Cc 'X > 'Mat Y.-D LbWIJ A 6 ISM& AJT, J4.0 JOEGN 3AAJAXD E2 MR S 101* ,,BCUr ?u 16 Qj 04"55'D .-- ••_,. .? ?' M; - 5PDA T 1'PX 30 MPH >u?50 ? N G ?tl I r ?5 -", '+ :'- - - R cR )a NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ? CODES I - Z 7 4 J OCCUPANTS /WITNESSES J. AIR ia+u.-IT SEX AGE . uw5 4lSTR, [J[Cr 4 ;°i, , ` '( N.AV rc ' i AIKI.ISS r .nI4E OF p AMe 0 M-11 0 "' . O Cs ? ":. 71 N Y 1 "NH 5 NAME. : pWilx 0 ?wt ISS N IU4 W MMlD ROM QAMG 13IgKT ?C'rn4 ?NN ?EtiS. RU M [ I 1,+-i0.yi Fx r ! r +??? N NO .. R v + .` + '.IN t c _r J y ` A-M IrtiAiu.?sO1 EN SY ?-8 ?IA. 10 16 oqx ? i ?, w ay wu?E UAN 4AOre O4 AefNCr uwl E RP 1 wr rau weeSm oMEanron APPROWD4r o TI vr Fr , ?.?y7-r T' y?E'f?l L Y' I I I{^?f f I T I S r r I 11 ??? E I E l {?irh ??'? f ,'I F I " t' x i - N ?g?NTpyis?, ?_ 4"ia xr, ZI. M ?n s- 1 jtg' f 5'ligd :rte ?:. A ,. n REPORT MTRAFFICWAY POLICE TRAFFIC COLLI Inuctc Nr N,1MWR ' PRIVATE WAY E I pelf o Cal y w,,°nr "e Lolly, pnl. a ImF eounrr o,. ID$f a+DD MUg ImE m + I counn M. rr M: NwA f • mo I 8 Y YS trAa`,tlo?/ ? ? ? u4ew N _ LIN OE ?rN c+rroq iov,N AME6EIOp Siyfff04 NIGNWAY rcrccs I Rou [oqs pry / ANES 5 (]W ?Of C INTERSfCfINp Vn IN: SrgfFrOR N F ?N C•.2. lp O MN NIEySFCTIOE+ l? %lJ?jo R YREfIK EO. MIU!fO51 .-IN -Alt .C'O'!O ,?.m-' ,2- JD(/ w., l-fr ?C1 ul IAN(f DIe ' f rq CROSS StREft`y NFpxfSrM (f 5 ACCIDENT R P OIAG4AM U/A $ A14F5 N t,,.•.w MILEAGE aH. _ ffr of - t.-En -17' ODE COIIISgNINVCKVFD SFVFR n, 'N E CLS l"ISECT, RROAD4WM 4 lRFEr(r (.A TOfAINO M.KIllEO??•NO. N+UafO_ ?SR IIAOE Ntd Rll'I WNDgRnI Eli - A > OFVFNIClES IROH4Ir DAmAGf ONIY ?p[ElIFO ?VO1c. JiO¢Q ? _"Cr5MI4KINANE b CG-5TRUCKANDOWrlf45NAMF1 -DAMAGE SIFCUI COOING -"- - S zco?-- 5 UNIT NO. 1 UNITNO.2 0 VEHICLE ? PEDESTRIAN 0 PEDAICYCl15T 24 WWtR'S NAM!' W /145r M,DIXE o4:VE4'S NAME UST k -- l ° ITCIaErT ? SI PN LAIY9 1 -- 514ff wDOgf ?? ^z ? Q3Z I of SAIf ST-• Y D SfREFT g00RE55 , I ZIRCODE RNONE M. ?• .a - wA 4x368 YNg6 R I -TI C I 4W kS UC n STATE A m I V U ENSE ElO Alf SEX OAI a 1r x 38s KA wr+ m oir O1 L v I I OCCUTArlD1Y IIRM NMIE6MYJAF Np. EYES .v T 1 1 E _ -IION 1IRM-1 RHOM M. FYFS NEIGNi NF G i z - CHEC - - .Z 1 W o D R N (] K(. vEN,Ci 1AA=.Ml bwnb N 4A1 O CHECK (.? (jZ wSpN /MNOYff pf vfN EgI r j y CODES ?* 3 5 Iucl 6 yA1O„en rcu S 5 A NF CODES ?+ ] a.vr A i sn1 :Nr 5 wclK>N 6 in rcu R z wlv?` I;AO KN nr 67 N6un awr F G ? pw ?" n ? w n8%. K ; 5 t ?R ; s,D. ?m o N Mf 0 8; ?n or.?? Lt V[N. YfAA fI000Gf {EV E1(D-1WAJ fY1 5 E I104.CONV1 .Y fAAK ( EVI MODELIDARr VAI Y ( R: .1 .Dm '0 3 00U GE '- p y, E -- Ra 1 N O C[NY VU u e+r SIAIE wLFR-TI NO. SIA/f H vfN. C.- AI Af f F.L Y•3 ?'f L.•1 1 C Rq w ,CLF IDfM,rIUTgNEAJ. 5;2212 8 Z Z 4lGISD4EDO L VfN CLf DENI,NUI NN WNFT IASr FIRST MIDIXf PNpNf NO. 11 Is FDCQ Most /N w 3sr• os ei W 4 51 FfDOWNE4 UST IIRSi mIDIX u ADO4essbovw4 Z •0. Q?x 3 Y It oe L? 9 S?.}9 N E A OWNER - NAmedAOOeessbww4A.+cfeo. arAUNr m u R as AOEDARM i••, AMAOf ARM °. M ?" cNARa a.R«• ow:'?9 4 ' .,A .TD. ur. DAAn.AU °vw ognfN EsI. DAMAGe +U?OIfOii a ? ?REMNNfO ?AWAY'--'-QRfMNNFD _ ._ i iono ' N ID f ? oWTDnY ? TovrtD Ar n S DIAGRAM OF COLLISION, lu o,cA NwN DESCRIPTION OF COLLISION (WESU RlMfNTAISwlr IF NlCtS5ARY) Ie -...- - . ?T+Lra .. ---------- l Qe7 . ? . _._; I I I _. _ I I la NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES I - 2 4 5 6 OCCUPANTS/WITNESSES 10' urnemeausw R»w NAMl er sI - . __ sFR Ace _._ MTLr. ' „;,'" wi 4esr4. enet AmE:Oqu/JYNa D. G4L?4fj4y o - z Ar4nrx (, y E u4f b V . Iw eP 0 Am e. ? M L ? ," ? rsI5. A NO AExw/ss - An»EOr _. RlAVSVIDrypm QAMe (]?^p'?-' Rnvir ni° aD N'T.u .?DRESASA N Oq, D, saN„nr' 0-s n :"F n^MN. oc;? ? ,NJU4r5 I puvFp b/KHl1.AMle N e.DCR r? N;rACr .I1N Iuun.AlcwD Eix,cE A44IYeo n.nbaroel 11E4ovr011 DArf H) M X rcSO ?yrs lio cG ac k+ ""'A•n?` s,l? F " l m fi .Y ? ? J .w k5, tI _ .r rl I .? // STATE OF Wq NGTON I 1 ?i AGE Oi IE "* 1 a POLICE TRAFFIC COLLISION REPORT ® No. ,r?h+ TRAFFICWAy PDUC. comnAwl NUMBER .Al o DILL _ _. TIME PRIVATE WAY Rrt++;;,, 1 urn ?tyN_ i„y 41 (USE [GUNrY {Ln •, I,? I?, IR x F'. xtlD HOUR( COVNIY NO. CITYNO, I.w /q N'i. lv C 1 Oil ?? ?f []IN Wc4'5 n il UR. ?RBµ - C-) ME6N0.0 SIRFFi OR HGHWAY CIS URAI gulfs ?S DoF u I Can QItJ ?iQ "? 1 (! FOU,F ORSIFfF /? GN'' INPRR?SERIINIG WSIN. fFIO WAD NpN IN]FRSFCIION U ???`? ]] F'?AP•JO Q,? PREFI% f0. MIIE POST q J DI1µ[f 6DR A BOWIEN NFAR SMEEIA Sigfft \1`lJ ?I•"1 ( a ?? MEN S E •CW SSSINfF10R f51 MIlEP SI ?-'7'CO q? ACCIDENT F[Ei F ?O E-? T RAMP DI qAM COLLISION IrvVIXV[D. ERIIr; OF ScS ^Y, MILEAGE Wig CODE r I .? To., N's NO.KIIIED??Np INJURED?? ?--1E ? ® pgppf T6 N I+,NRMDIH RD N d VFMIOfS giT DAMAGEONIY ? pE3U 5@fETOR tiED VF Iflif]? REE R OR Rf{EREFKE OBJECT SIRIKKINAMEOF OBJER SIRUCKµp"AGESIJ.AASF) iIX V/ CIS CRO55ROAD 9 -yar?o p r fSI pAMAGE SptCUE COD NG IJSE .L $ M T II y,, s oalve4•s NNAE. IASr UNIT NO, 1 tY ? VEHICLE t = ??' rF FIR 1 RrvFR? NNAME? lASl CI PEDESTRIAN ? PEDAUCYCLI5T a aw z sREir. .... 4 /:vx-j-/ R ?v2 ? T t g,5y< UIY •.F .., F.. E.-CL D. 1 7 1v SrAtE , IIPCODE PHONE NO D IN 2 (C IY ' ' ` , 1 !, AE •n E zi- nL ?J ORrvER'S UC S/1(u 7GS341z R ENSEN / P j u A ?r? CIA Ek F B rH I IV R' U(FNSf NO. ?S? t l?• 1`/P{: ,A S K 1I I J M % l M / ? Ey V B OCCUPA}ION i 4M k ?D If I "YBIR p aP NAME 6 PHONf NO, I !L OU I S l ,] EYES GHI WGHI E CUPAIION ' RMNAME6 f PHONE NO ' I 4p YA ? CHECK (?) VE W l [JU l/ R N . FYFS WEIG"1 WGN I , F H CIE AS FM EE-f Ot ANOrFIER. E CODES O n Y ? CHECK (?) ^ii e El rvuRES s e a/ pDNIDxrat CODES? Da INHCE ASAN FMaorEEOfkrvdNE. ?' 4 is l i N ^' IF+ 5 u 0 [ N ?DKrcY _ sF?e'?rv°J er. a R f 0 NH.YFAR IM? r olPoM i r ? ?6ci V ? 1? o a IDOOG Hf{ FV.) ?„MSU.WCI ? El LDARI1NOVA? t4 .[ia", I S1YlE1tp O? ? (?ilI. G 4 yuN _ / N T A4 NEV D n ? C°y ? ' . R vK° ? 1 - 2 V "' R Q Fl Sr / l CtC ! fN U N SIAIf .) NODFlIOA4r. K E oAI 7 ? 'i o I4AIl[R RAfF NO. SIAIf H L D : , ]B ? pVA 3 60 wA I NH loR N A b S ; +ISY,p VFHICIF IDEMIf GI I IOH NO u ?, _ $ f?l?\IQ I?Ii1 ? ? 1?,.?I,?I C)! i L VEH CIE IOENI fI IN1 'V" RfGISRRE00WN[R. ?• LAST fIR31 I I .I• - ?. • MIDDLE t' Il i111 • zac ' 1 Apoafss of oWNee F 1Fy I , plgNf NO. IR D WNER: IASI O EIRSI MI DIE I N N ? F _' . 2 r w A OWN R 4 N /-YE'NrO N E ? ? . AME 1 S ApDR{,SSdIN3UFµ 0004 AGfNI 7 nu c 1;m T // R A ter -----_ EoAMACE ARU tic A l Jx b i I ,I rRM CHARGE H 1 .._ S ESip AMAG CHARGE NNC D AR I N Y Y? f Z 1 ? g ? O ^R V N EA fr O N WAY ?9[MNNFD " ? [ A N YI r. DRIV[N ? /(I tFC NAAGf rOWED ! = !' ?AWD AWAY ?R[AUINED f5I.0 AWAY BY. ?JYxn (? ., ' I Mp DIAGRA FCOIIISION lu iorio:i e ? I V\ 4 : Iv qr: S IPv1 1 I .. SNEEI4NfCftSAgy) IN py ?ilpOpµ l" DESCRIPTIONOFCOLUSION: IUS[SIIPPIfMEN,N SNEEr Ir NECE53ARr) Ir A ? •' ? .._.. C bF /2n?D ? _/ Cj• _-•n? E?'JtlIb 6?KF, A_y /I 1? ? ° ?? .. f• ' a n r? ? L r s L AK ?-' ? s ,° ? ?S• 'IC? u h'U IIN I . Q ?I rL C " e?1 ? a 17 K ( NA ME, ADDRESS 8 INJURIES OF PERSONS INVOLVED .. OCCUP ONO 1 k. ANTS /WITNESSES IUSl s-R M Ei CODES I - NAME ?( , J IQ• ADOIrgNAI NAMfSI - __ 2 3 :- /\ul, 11 stK AGE ur 1 s'yn" M .. 4 S 6 ' .._ ({ - - r'c' . ,y IV r u ADp11$ / 110 a N,AU: ., IeRd N /rl z / / ff?? k ... n HY'c h B r ? s Ier Est bE .r . qpq R ?f J ri `? F l t.? a ?rlnrd n .E ,.suit v YO, rgoM?? ?? t?"'o~I ONE./??D ?v w ..•S'`M ? s ... / .r,. ,i}t R r? - Y r F '? .rvulaAr.,OdreuswusuN. _ E 1r. w . _ ADGEa ,alKr ?AMq. ?wK ?[an. ®:t, ?I:°.;,s1 ? 10 NO IMl KIOISIAICWp 1q K)AIPMp pAlldfllOlr AnFONDgY DAit ?>y Yt '>I? ? r/?NE' , ??N m f? Y E. ; ? ' rS v I ? N cY 'S. 1 ? n 1 I l,?r•.y,z POLICE TRAFFIC COLLISION REPORT O TRAFFICWAY I' I Ivy. Nk PRIVATE WAY .DAZE CO I N > t CO- fUH,H(-BfR 3 /, /('aJ 5j• i Wx X 1 .IH AI ??a,00 NOUg) COVNIY COUNTY NO. - CIIYNO, iHWA ?URBAN _ QN QE E3N CITYOR TOWN N-IR NO OFSTREETOR HGHWAY [CIC[5 ROUIF ON SIRfEr O SfCII N J // R. ?S ?W' ' o ON ?/?0 INifNS[CI NG INIH SINEfT : D NONI IFRSFCIO .r H pgfflK fO. MILE POST A ? BFIWfIN ,/? ,./ SIPFET6 SiRfEr DSIAN f6DT(TCTI {R CR SS T I W REE S UG fARf5l Mll Si ACCIDENT RAMP DIA RMSOATA . MILES N 5 E , //. I F[fi Of/•? i'--,•„C X ;/.? MILEAGE CODE COLL S O I I N INVIXVFD: ........ IN K- D N LF RROADOR R[ifRENCE IDEAL NO. NO. NIII[D? NOINJURFD- ?SPILllRGE 6RUN •'AllD1H INTER CLS UGUSLRFEIOR gOAp oi-RCLES © O pgOpEgTYDANAGFONLY ? pF5U - r 1 LIE. Cl, v 27.5 0 '?/ OBIfCi SiNUCK INNAE Of-11 STRUCK AND OW-S NAME) fSI.-AGE SpECUI CODING USE J_. $ ' UNIT NO.I UNIT NO.Y VEHICLE PEDESTRIAN PEDALCYCLIST 3 DRIVER' HMME: USE IR LE RIVER' NAME: I M51 I T m aq . ,.'7z ? ? , - Ili' SIRtE ADDRESS ... I RFEI ADpRE55 Iv TE 21P CODEPHONE NO D IIY . SEAIF I PI N R N . ST E - J AT K BRN R I LICENSE NO. All fA DAiEOfB RIH V A•O i oAr rv. q- IXCU/PA)ON?R iRM NNAF 6PNONf NO EYES WFIGNT HEIGHT E IXCUPATION fIgM 1NAE1 P HONE NO. 1.5 IG., HEIGHT ? CHECK(,l) _ORAS:NEMHOYEEa A.Mi01HE4'R O (?) E4Al CHECK ",c`HAS AN EMPLOYEEOFANOT I" N CODES Y? ] n 4: f A ri i 5 1 cl ox 6 ",'„° ` CODES ? * ] u?u . ir;'v..iN1 5 Ne DH a "s° O°`r ss 'f rfn °U 9 1 P IU 1fp, W DM o N N l ? ?n o 8,H. o YA I' MAKE CHEV) .NOYAI VFH YUR IDODGf F 1 . SIY R HE o -NO o ?a°l o zsxR. ? :K? ? aL *'6. ?? 1 V) AgDEl1 A _ / / ! /, / 28 f? N FPUIE SUf i lER 0.AlE NO. 5 E /r, H VN IXON ' ' " ? , MK EIIXNT {ICAI IXJ NO. VF FDfNI I I r I )i i 1 ! I GISRRLDOWNER. I IAti {145! Mlpplf PIgNf NO. L iL 7? yy1 I/ I( ? ?..O I I4 Cf I R [O UWNfR: tAll {IRSi MI DDLE "Ho // ? .,I, ,? fir "'_ .//..ic' o',?. .? NAx[aADDO. eun INwRANaeo ORAGE. OR AG[Nr N E NfN 's'?'//,• .,,/.'i Sid /?i,/:..•.,:![/c/" ?:•r /?I q . EDNA,!'I AN. iwKlgv4 , lap OI4RIwcE CH oGE CHARGE ilia[w - ??J N i I ]] - -- - av .r IOlOIIOii 3 t3T. y DAMAGf 0 AWAY O REMAINED ARIV[N [)I(-N(D ??,Irp /A,cj, 1 W Y 0 ORpOM ° D - A_ =.. .. f eY: f IoM. MY I ? AW O e,, /` - serf. c DIAGRAM OF COLLISION lr NO RIH N _ Y) . a y? S F, ?NLO r? DESCRIPTIONOFCOILISION ILISE SUPE INIALS LEI If NfC[55A4YI is e7 "r NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I Z J 4 OCCUPANTS WITNESSES 104-E- L HU Uq - _ x A S 6 A _ NNAI 777-7--777-7 SIX AGE uw 5 . TA r CwE l Mlcr. N[Siq. IXO 1. I rr / ?Y A eUw'0.I pO^x ? E J ' ?• AppPi Sl/ i?! / . ?i ,.• /.. HAIUR NAM •• ''I•../ rxr NAYNIDI dA ?AMe. ?ruKl "; LHi? ?n.«y p C p h - AlrcwI .: •.;' ,, /','7 ,: 1J. r'. ; wlwfD1 VMSIK]Alsgp KIa3 HAW a[ YNY ?- ?WE?c- Vl O? v "i,41. N eADGl o1 ,GIK Aulw I[(D AICHu. pp . 'r0. .-.4dA:'Y ...?•.. ._. Y e .a Fw.- N'n..+. ,.1 .:: Y,.,e.. ., _ 'i: N'.. lp a IN0 OAllgnrwl /pLV4[p r oA1 ..f.E r:.,: :' r».,L ?.. m ., t ??, w ?i ? k ?n? ? ?k 4? j::( yr Ad i ' ? ' F , -' ? ? t ?? %??` wy ?E t„ ri A ?rTP n t? {rfi. } ?: ?.,, ?, r i ? ,C` r•, $F ., x "L z •h l1 1??1? A i Rw l pn ?y a .y '?Y1 POLICE TRAFFIC COLLTSAON REPORT LN TRAFFICWAV PoucfcomPwrlr NUmeFR ?,. PRIVATE WAY : ??el / _DA a EGDL N 'I ND I R µ1I N _ tIME C u lUSF 1% HOURI ; ; aRR OUNTY COUNtt NO. /? ) jL- / ENWA ?URpAN - v , ' OC Ifi , 1 ?? /? Jr r? r.?, . ?G Z EtN ?E ?IN CIIYOR TOWN AE6 NO Of 5IRfFlOR HIGHWAY ' mxfs ?5 ?W ?DF C ON Fc! IS ,_ I E04 SlgFF Roul? ?, b RR INIEF NG VATH: SIREFTOR - 'pi NON INSERSECtION eE1WEEN WREFi 3TR t PRffl% EO MLE GOSt /? A T ?/ f 1 1 / { EE DI f DR TI i EIFREN ,CROSS 3iRFE OR NEMFSi MILL POST ACCIDENT MI E GE 3 N W RAMP : DIAGRAM- L A • MEi OF BODE COLL SpNINVOEVFO:- ERUYI AAte?,? L U N IOTAL NO. ND. FILLED INJUREDy? ?SPILIAGF ?H 4 ,u" I ?./ p0 L ME R DLS 5 FI RROnD gREfERENa CAOSSSiRFEi P ROM O 'S (E? J O VFMIClE3 PROPERIYDAMAGf ONLY ? pESULiFO ? fON[ICIP' " I / ? ? OeIEa STRUCx INAMEOFOBIECr5iR1ICKANDOWNER'SNAMEI ESt, DPMAGE 7 ; fr SPECIAL COD NGIAE UNITNO.I .UNITNO,2 ?VEHICLE ::';? PEDESTRIAN.?0 PEDALCYCLIST 3 RIVlR' NM1f: usT RIV R'S NAME: IABI I mmou - SEREEIADDRE53 SiRE11 ADORE. - Y BTAIf EIPCODE PHONENO. D Dr Sur IP D N[ NO. RIVER SIICtNSE NO. ra y 37 SiAIE E LaH RIH nod DAY B I, v IV R' LICENSE NO. BATE EX - DAEE BIRT I i p .. OCCUPATION fINM NMAE{PNONFNO. FYEB WEIGX T HEIGHT E. UPAEION FIRM NAM E{ PHONE ND. EYES IGN l IGNt E R ? CHECK ( EH AI. AN ov E A ANOmfRAI ? CHECK RADR-DRIVI T" S AN EMF rEf f Ra N LEA A ° 1 CODES ?+ 3 uii' n "I 5 uE r e "A°,j°r 10° { EY n,.Wt CODES 01 + 3 n"i: 5 enclwn a L. ' Nn a //Y :Nllw f l itt? '7 :fy i ? NP,MANDL ? MIT ? 1r" KN ? IwuY P A m v- ? ANRM ? -0 ? alp., ? G I ? v NN VEH YEAR -1 IDOIE-1, cL^ MIX FI (DMI. W I St LL R-CONV.) L{ ( E R E HfV I , MOD I IDARI NOVAI R- Se r DR uaNssnn N . SIAIE SI A E H 11* COLOR N !RT 4TN A r Al E? • aA; C V[HICIE-'N-KKN NO, VEHICLE IDFNtIfI A f FI/ 10+ 1-y ;x 1/ 19121613 1 1 1. 1 I J a I I I i l I I I I I REGISRR[DOWNER: IABI 11111 MIDDY PFFONE NO. Sgn.f a QS cR kjpy J_ O W R ISRRfDOWNER: L St FIRS( MIDDY 111 N . IB ADDRESS O.OWNFR AD.Fs. OF OWNER N ' E F NAMf{ADOR[53pINSURANa CO. oR AGENT F.SS?i b: LPiFCF T- u R SE WM?[ K[A WnCtq,°iM I {iDP • mwflMer CHMG! Di3AR1NHµ gAMI:GF MEA% CNA1G[ mNIPDMeI F Ex ISf. DAMAGE ?^WAY ?R[AWNto. ' 1 p ? ?AWAN ?1fhLUNED fST.DMUGE I 100 Oii 3 S/. IoW [rDeY. Ila Tmo ? AWAY pY: $ { DIAGRAM 01 COLLISION s EEru I-INT ev'? o T DESCRIPTION OF COLLISION (WE SUPPLFMENiu SHEET If NECE35ARY) F i I I r ,._.r I f .._.,-. . I V< IL. N?..fu," r-L I, K N+, d__r filr ?l,7fyL't-.t <E^.GI.n . , ...?N t 4-1-i - 1.. l , yas.. Y ` Lyy f r?T or z . ?f1 a fe . _, ' . n --... F? i f I 1 1 - - 1._ ., r Nonr r N( "p CQ /fi ... 7.L/d• ,?. 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Q? sfcr. ?' • ' S; yL` w ? wr[REE?w ON pM . „i ] ?? Pflf Ep cu ARIrHDBL ?,L I °I .,.y Arm g,?fY w ]r Er ® bc(nasswroM vo°sr]o FpaErirlw°r"?b"YiA"NUWMEE?rxuMe Kn RAMV pApnAM p.rA nr? ro ER]EC Oo TEEr pf LaCgp Fr / ?/ CYQ CZ /,B/V dr -x wsNe wYU ) - q.zAx 7 nA OFVEngLE9 i ? RAC ? pWU9 M.lEwAL9SEPq 1gwSMAtEp ?f apt FLMIMA&EUOJp `] FAM09vE9 ?GILORwE ?OTHEII wrEfl w?FA Cu REfEP0?CE0Cng5ysLRFEI dI xpNl RE ? wOtf BcaRro]NE MMEwAL ?AMMOnI. Apo ACTNEM [RMLS pr, OBJECT31RUCK INMEOFDEM` TRUOq Wry ROF BIE TSNME MOADDRESS ? 3300 ."` ?$rdllPr??r EPEC caoE usE v ?U oG?H/9!/ { { 0 E T.- ,t OflIVER'9 LAST NAME MCOU, wq AP { ... I TNAM wWXVEO DMVERSLASTNAME._.. ,FWST NAM MIDDLE _,; •- C ro HIS _ k1F D?C '. OR n` t S ET ADpR .- E .: ROUTE NO. Mp BOX NO. E t SJ l cum ?l dX (y q.+ RsWS wfPE RE S(flEET ADpRE$9 . ... .. ?5 b J NO. MO BOX NO. t?11 y"' ? s tiL? O o k .'? .. F `-,E GTY BTAT$ LP COME. DRIV?$9000UPATKIN.: OuugNA CITY _'lea ?4 61 i,E'>.? [,?•f !.Y •J REPonrfgw .:..STATE .:. LPCODE ORIYEfl'8000UPA N.. Y VI D fl:9 LgEN N . •?'? ?STd//fsT? /P'D CCN Lri 339' i;. ) p A :.uD iE,F &flTH ME ONVEfl'9 UCENSENO. .:. STATE SEX ,. pA o.v RvR AOE k EP 7 M MO. ' VEHICLE Yfl. ,MARE CHEV. DODOEI MODEL (NOVA-DMTI _. BODY STYLE 12 p(LI .. ??? 3 n ? ? NIC Yfl ..MMEICHEV •DODOEI OFLI VA•pF . BOGY STYL 12 DR1.. I :_ 4 /` LICENSE PLATE NO. STAT ....TMIL PLATE NO. :. STATE.' d Lq PLAT ... .:...STATE...:. T(WLEii PLATENO >.STATE... -,,, f VEHICLE IOENTIfICAPON NO.. ., ,. ' .A :..:. :...: •- VEHICLE IDENTIFlCATgN. I RE TEREDO Eq ILA9T IflST#xOpLENMEI :- DipVEfl SIICENSE NO. ... RElp9TERED OWNEq ILASTFIfl3T-MIDpLENME( :: ^ bQ h/7j?7• 7 y, pV DRIVER•s LICENSE NO.._. ) - O '9 ADDH .. 19TREET.O MDSTATEI DATE OF BIRTH ... OYMMSADIII-- 'yy ata , N?' AY H?j 0AMA0ED3THEET. GTY MD A MN DA YR 7 : ,- PMT OF VEHICLE D AM ED Mi30FVEHICLE TO ?' So.oo s LIABILITY INSURANCEINFORMATION•VEHICLE NO.1• WAS THERE UTOm0aLE uea1UTY WSURMCE COVERAGEW EFFECTFOR THIS ACCIDENT ON YOUR CM YES ? NO F NAME MD ADDRESSOF.UA9ILR'f WSUflANCE POLICY NOLOEA :, ' -- LSL??? 'VAE. ? l^/V ' / ApoxEU ?• qry .. E _. ,.....INAMEOF UA&UTY INSUfLWCE COMPMY Sao c77/EL • A 3 qB NAME MO MpRE9S OF UAOIUTY INSURANCE ADEN T/SEEL I}lY ...Ne Sc LL...? SIUABIUTYP000OO d S3oa o_.. ? ....., _ ?f n ME 2NDINUURY: I.'Y9 ARA!EREPgRFON,NGi(yt URESI.'.:? NAME VVH"' vupuNEp NAME ADDRESS 'Falk, Y NATURE `M AND M F AppRE53 SEX N FJ(fEM OFINIUWE3 F` ?? NATURE MO M F Y y DIDIWURIESREOUIRE ? NEXTENT CF IWURIES ?? y?( EXAMWATION BY M TOR, 0 ?q ?µpjE RS - NATURE ES PEOUIgE ED EXAMR'9 3(1)ME n SfATUSOF WJWIWATroN BV ApOCTpgi ©? OOMCEO I ?' MMK FIRST ONE THATAP ES ?oM WVEHICLE OF-RED ip 0 GS DUNO M IIW- Puce 3 - IT M?E H ? NCFR .EV[n ONWRATU U FIRST ONTHAT MPUE ?rt ND gmEp p MwORI OEfE?w ?P fOR WVEH CLE DL EO ? O .A --Y ? µ.: 1 rt NO ISEVL'INFI N IMwOaI IlpEfrA p t .. .,....n g? BQ El 7QwEm ? A„I L ? 50 60 7 rcl MOTORCYCLE ? HEIMET USED ? HELMETNOTLGED MOTORCYCLE SAFETY: ? HELMET USED ? HELMETNOTUSED I. SHOW NORTH BYYAanOw MROW Wa RCLE llfl:wOEATE ON pRSdAGAM © . ___ DESCRIBE BELOW WHAT NMPENED:IREFER TO VEHICLES BY NUMBER) rl YnMN1AIWIN(p \ \ I 1RM:(TMf OMRwlrHAT wYI[Cr] '' _-_- lvo , .• rdw CgIISOR M:TNE wRNKiGwI ,\ 1 .... .. ..___ . __ _.. __ _.._ '• ]NUioiR9? rREwwAr NAM[! p ? , 4IwKP (ACH Vfr,CE[ AHO SnOW J pw[Er??g..N Of??lx.Wln. MwOw ',' .. .. j,I I I nwnon ln,Iw ? ._..._ VEHICLES POSITIONS BEFORE COLLISION t aLWrt nwc lH IF FAII.eD wA] y WHICtE N S E W OII STREET O INVESTIGATED [ WON! l vn OLY (O VtI O OCO D O f ? _ i - 55 II raDNWAY 4Mf OR NO. NO {P M IYOVq ? ?TT.? .S GR(ETlfri 0 i ? ? glwN ? CI Q / J / ? ?RAIgN M, A I yy6 pQ KDAO ( A ? ? tr? ? ? ! A rtMalw4t 1 x i f ;. 'A'd I cADw,D . DIRECTION PEDE9TNIMAPEDAL CYCLIST WAR USING IQ mom DIRECTION TO D aq[w.LA r?wrFwA. ]Q[IpLAp[n rsµK ? D ? IID] ? p !n ? AEUri ( rom(wAr 1 ( L PEOE9TRIMAPEDAL CYCLIST CLOTHING COLOR: IQpInA 1 noe "E 1 +f?J t,yH noM SUR/ACE MEATNa( ] ? Eli a ? wlO w4[ ? NYMIVn ENE ]r, ?INe wMn. . I1•n ° •z f ?w?y? `., KKalul LwR (:oNamNa TPAfiX: COhIPOI nne L.l ROAD •eic Ay. ` y -?a 1 J L i v1.KU I Y nr ! DRIVER/VLNICLL ACTIONS ?DAVLGHT cIKO,OH11 I ?C?w w l?? IGi ll ( I ?CWOYM 7 QDA(Wt AO I! }MO( 401 OA IUWIIL Mvlt01 KIwCAwE OAMpwI' 7 p t N ? I ?ORY ONKier ? I ? blf?t43 ?1 1 ? ptE WAY %3 1 ? 0040 nNIOHT MEAD P{ '? ! D l??.n 4'?il n? ? 7 ?Mti O r ?O SK.STR[L7 ? 2 ? S70P 81611 2 ? TWO WAY ? 2 Q OVERTAKINOMDPASBHVo 2 P&8L! j al.I 2 SNOW ?LXIMSON ? 2 ?YIELD SK?1 ?.:? I ? ? I A7L /pp DARK STREET ? ? REVfEVE ? 2 ? MAKINO PONT TURN - I f L ?tl f A ?K[ F? ! ?110HTS OFf 1?? [ ? fLAYWtO RED ? A WfFRCHAIN 1 r j AOAO OTHER •ECWI 8 ? Q Rf[ LgH10 LJ ? LA31aN0 AmOER ? ? ILOOP/RAMP) ? A ? MAKINO LIFT TURN I Y ,")y i 1 1 ':A Y , 6TH(R { ? n RI: El ! ? {P(LYV ! / ? { ? KLlY ? 8 ? W .No U-TURN, w ( v hT y. I, I, E I. I (?Rn FY ? { QMBgNK ? ! ? fWV WAY. ?.) I tli t ?. Yh t CHMACT n ADWAY BUN ( ? 1 Q OI11CfR ILACJ(M LEFT fIN ? 0 ? BLOYKA ; J - 51 5 f19A r HF ? T Q {TOPPED FOR TRAFFIC ? dVYEWAY 1 a .+ e ? L;;. xnaa Dn l e nM +! fA{4I °N A ' 1 I V 7'L a I Nr.: I ty ,1 ,t I}, _? la,' X11 S,f t A ????; 41 r? t? rn. 1 CC ?. ?3cq %L r d P YEW. ? .." 1. ? t. _ I = _•,; POLICE TRAFFIC LOLL NREPORT TRAFFICWAY --- pJt¢E INrewnbER ? PRIVATE WAY DAif Oi,C u N llNf COUNTY p u IVn I NI (USF]bOigUR COU NTY NO. CItY NO. FNWA ' pp CJ y S / n I / ?' 3 S? / csr, ,N r •o ?URBAN (o _ l s.; IIgAI / ?N ?f ?IN CI OR TOWN NNgE. Aq OISrAffIOR HGNWAY AMM 2 5 ?W ?O a ' n ON ICl- 161 O ROIIfEON3 C CI- 3 '?•if%SO s) IN f95fC11NG WITH: STgEFt 0 NON IN)EgSfCTION _ BfIWfE ? STREET f. '/li ?? 5)RffT Mfil% f0. MIlE POST / / •Ef,? (?y ?? / JV? DSIIWCF. NMIUS N glFfgfNCE,CWO55 Slkff OR Nfgqf MIlE,O ACCIDENT GO [[Ei OF MILEAGE R P .,AGRAMMfA COIUSION NVOlVFO ERIIY: NO. INlU REO-L ? WZAGf • ?1Tn RUN 1-0- MH5'" OTAL NO.K LL[D?NO. 1-0- Gi VEHIG[5 © [ N NIFR CCS CROS. SIR v ORROADq CW Rl1[ NC[ _. %y ?pRORR1YDAMAG[ONIY ?M4 i)ItED ?VfaCL OBxCI51gUCKfNANFOf OBJECT S)gUC%ANpOWNfAS NAMEI f5iDM1AGF ???? SpFCULCODING U$F - _' S - UNIT NO.I UNITNO.2 .. glvER'S NAME ? VEHICLE ? PEDESTRIAN ? PEOALCYCLIST q' : WI HIRST IOIXE - DRIVER'5NAME: Lw$1 15 V •L 2 S.lEI ADDxf -El..I- Stgl(ZIp -c o,,- D ?. --.cfrvSE NO. k% DA f f r H of DY I Iv U IN NO. Mf E pA bIRIX OCCWAIIW NAMf.PK)Nf I.O EYES IGMIi.mr E R OCc..,.- FIRM NAME. PHONE NO. EYES WEIGHT HEIGHT ? CHECK I") `="C A Ar ov fAOE ANOINERµ ? CHECK(, a I I .f ILL ° µ FFFccc E??. :o. CODES?'H J o i 5 1x<1- / 6 " llcH li ,R.W' FASAN Un I F f-W FR COD i "' _ } 2 y N . ES ? nr.Fp 7 ngiti ? is 5 N[uaN 6 ,;w gplo; R AIM ;. ?.MN%wN 1 W, ? a:RR ? K K,I ? MNV O ?°al°? ?NyNw M1 ? ALE' ?zs;x. 0.- ? . 11" 0 VUI YEAR MA%f 1DODGfCXEV.) A•.ODfI IDAkrNOVA( UYLE()ON-C V.1 . 9 1 cNEV.I 'l I rIDVAI Y l oN l d E b OR LI NSF pIw IE s1Alf RAIlC4 TE NO. STAY H Wn. Cp N rv. 11 ql lw N A -• VFNrOEI.M IIGtION NO. ! 3i 'IV' R[GISIFREDOVMFR i A i VfnlGlf lDfrvXFIC'II H 1 1 I i l N l l _ : NS t NRS l XK)NE NO. O IS R!D WNER: t/St FIRST MID. I ^ L gpDRfssaowNl4 N w NfR -? ?I E HAM1RADD 1-1-RY1.C[CO. OR we N! u N R D) r- WM/GIDARG rcnwN I 'a- gNgAGEOAAG Mp, CHARG! CHARGE V INiKl"itn0 u ) OI xt n"w aJ D ,? ! ISf. ?...^Y ? RfMIUNID DRIVEN ?gf lS 10 ?OYIOii AWAY MNNfD 0 ?OT 0M 3 , 1 1"D ? IOWEp _ .Y: AY BY S IAGR OF COLLISION: 31 AL Ipm Al 0R1N DESCRIPTION OF M1.15ION IUSt Slime INTAI SHE[tlf N[<fS5ARY1 ° - - -? Eti INIC[-) .1'A c/ I ,r / a_ air Cat'/. ? /es6ro?%a9 ,_ ..i • t _ : _.+. '_. Gey»^ci'/iiie .sUvv - nf/ To&. lbddtt/dy,.-DOOM' _ '" i° NAME, ADDRESS $ INJURIES OF PERSONS I NVOLVED + CODES 1 - 2 4 5 6 OCCUPANTS/ WITNESSES iusefLnnfMrnwsw OR ADOItgNN NAAE [r 31 sf% AGE rAnn N '; "" m : N //JJ AW yO Lr ' L , r I E Rl51R. Ixa ; , it / C. _ A N DDrylf N?IUR1p AM IM., ?AM. ?E '41' ?m'^'. 11 .ii ??:?•, ?. A N poR111 - . -. HAINI OI AV1 NO RID iROM ?AMn ?i.YK1 ? nI I ? n ? rio N! v • )wv A DORILY .. NAfN101 %IR IS H r - kliR ?'Y ? R ?]'O' rRI y ?n I " yfg ryONYKIR Af f AUAM1. RAN% ADUW AGf NCY r- SE by I?/ NJ H[Y.?) DA110[RI,OR{ EG ID D ? ?yyAry?? 1 Y t I / ? ti - u _ _ I 2$,_.;-(.1??.',??,,,.' Yrip„G: PS 5 PAf STATE OF WASHINGTON to x f 1 DE 1 %? '!-v •• POLICE TRAFFIC COLL NREPORT L?IRAFFICWAY E'oI?CFC INrNUMBe9 6 ?qs'"'` ~~ o? UAIE O{CIXII N UAT C US ON I: PRIVATE WAY ? " MF COU3-N.TY O RA• r9 Wr wax Tun w ,1 Ie Nr (Sf }KOIgU91 ?\? IR ? ?-'G COUNTY{q OfY M. _ L? {''?• Q; {X 4a ?UPo ?I V ~ s ? ? gu,,, .'i i ,I n ?F?v '' ;4 3I g ( CIlYOR TOWN JAL ?N ?F ?IN Oq iuGHWAY 1. RS 3 ROUTE S I oZ REFS ?3 ?W 574F ON N ' , ?? 1{,_ 'E . .i'!?•I INrERSfC NS. µi IX•SIRfEI O/Rp? D NpNINIF45fC11pN w PRfEI% f mItE POSt 'TT ' ,%"pF f 1 ? BETWEEN r + ' n SlRfft A OISIANCF auu M LCAOSSSIPfE OR N.AR 5 m l 5 I F /! ?I$(FI .CL ?i . - ( Ais N ?. I lFEI O{ CIXL S e4mVw ACCIDENT RAM pIAG9AM DATA MILEAGE CODE ' qN INVOtvfD. f 9 iT1 IOIAlNO. NO. AIIIFD?NO.INJU9fD? ?.SPIIIAGt OFVFH ClE3 ® ®PROPEAfY OAMAOFONIY ? pjt ? N6(/%It1• IUrvowo'Iw IN. 'RD fl RROAp 9GfP9NGE IMER f:L3 CAp155flFETOV ROAp =( ?ST EN I UliED OBJKlS(RUC%INAMf O{OSIECT iNU[%µp0'IMEAS NAAIEI (5! DAMAGE SPEC COP - ?i s yLL ING s - ' pT ? p9vEgs NAME: NsI UNITNO.I MI ? • M` ? I UNITN0.2 ?PEDESTRIAN PED EaR`/EHK1F DRI E93 Si ? ALIXvalsr j MNAM NR ^• v3 .T '? I Q ' Fl SIRFf1App9t d 's - ?Qh I "' R LeU' - / Ud I ?*. s Pi !3 I EEIAD09E Z61 W 9 ,• _ Slgif -c- PIgNf NO p T N g 'ne;, rc.. DYNffiS UC NEE SIA f D D UY SIA(E R 1 ' W ?' ?3 ?? _ _ 1 ' A BR H I D N fXSE NO. SiA1E % B9 ?CDpPAIO?` Sat Ps WA % io` I YR v MZCL ,s Z ITL315LB W M o6 A E E ' • I ^ irons WEIGHT Ik GH tk ?J OS EV F tV? 1-' T E OC UPAIION IIRM NANf B 1-1 NO, - fY[5 WE GH N E p F r rL ? R , I , E g N n w I 11' ' Ir • Al ?1?1? CHECK (nRW D 1 L D o?1 :n NODESyr c- veXn A?AN rtXNr Ao El. n` 1 { 5 el[cr,D-, 6 suE?n `?? s. . l I ? CHECK (n fVEIRCIf AS AN EMPIOVFF OP nNOiNFR.I CODES ? 7 ?sAU slca,Hr 5 ul <? r I A X:l :E' c oN y rvH. N L :r ? AVBMANC! ? - f ? pb,_ ? H;K. 4ry. of t Y AWRf 4HEV.1 (OAST-NOVAI SIVIF 1309.C V.) RID MNA %I y YBr O {HIV.)? Tf EI? NOVA ?vl ?TO- MO 1 cu i 1 FREDLI r . l I l ^{ E / `.J,/ /-/ Y ?i' .§,? SIAI. flAlIEq HALE NO. F SIAT W. w_ rr 95 9S7 T - l.n I q n H VFX CIXOR l I /-I 6G?1/? W 14 ,1 tyv- yy ftSS - VFHICSf IpfN11RCAiON ND ' !_. - G r 6 y l 'z/ _ G GRTFRfDOVMEA: ! 1-T MIDDIE HO i VfHICFE IDFNDi G1 ? E 10 , 1 rv - '" ?.`? t.' ? f NE NO. Fp All, I?Arowss a o W NER ? t ISIERED O / ,/ IASI E RSr - MIOUIE N 3 ? WA f !/i?R.-5 ?'LOVE•+y$ L, ? ': - [ -' ` ?_ ry ???,s /? EE TI ONNf rv FYI E 6 ve N MfaADDRessa wwgANa eD. O9 AGENr r e IEG 66 / S EAGEn,r `t Sri i? M ' _I GI M -f: R p N ?' _ on _ _ DAAGE SEA Wt- V? ern y ? .,. IS ' rnrRPw,Ki CHAULE ? 0a tiDVf 3 l5I DYAAC ?VH ?9tAWNEO S I tA/1 r? mW`o _ CHA9GE - IONw3 [fin (F DT'?AG[0 G ? -[l D91VEN l0E 1a AWAY ?9FM4NE0 ESI.DAMnGf I 5 '-SV? .( ,,'` K • -' DIAGRAM OF COlL1510 AWAY N: (v MNU INUCA11 NO9m DESCRIPTION OF COLLISION: (UESUPPIemFNrAl slletln NeExssARr AIt l B Roy .._ _ - A POINT 6F MI°gCT en1 NE[esuf 1 _ t wks__WcaTVoHrI?._.oI 1tS_'tviT1_ - l is IeFr 61 ink O - a.llei 2?d 300 _ cr A. rlve ._._ _ l a k ' o _ _ _ h'•. ?- _ A• C? NO PIv NGi r i h t ....wt-c._..rta- WDrK/A j stid..._br!ive? ls_ . i 1' L•oK f3?-f3_c -T6n..m4dt. aP?r._I;'1c` _? 3•ifj1A? V,/f? ..o5n, Vel, _?.. p.Nll? ow 10 r F I P Eruct.. F6o? F I `3 . . Pr?ss.? -r as yek,?/ wA?s i-v<rn't„ .IeFT wb PACK;w( 107. Va1.a0?, str?c!< .7h ?IeFT..... i d F 'r '?/ H? ' ' e o . vc. 3' 1T E Is o E:cL.?rr•e? 6 - - NAME, ADDRESS 81NJURIESOF PERSONS INVOLVED _ + CODES 1 - I I r I ' - I (lY.f sufnrMlNlu sHeel OCCUPANTS/ WITNESSES IOU ADMI4 , - 2 3 4 5 6 uVl N4 NAMffI PIVNt Sf% AGE SrAlU3 4,m RISiR. lilt! j urv AlgVlff Np NAll 9f OI "'- I ? IN Eclf%er' ?AMe. ?McI ?I." ?? ?iW4:y W33 II19l 01 R MOVfD IUOM ?AMB ??"I ?Im Apf RfR w331KAI fb ,iLRE 01 INN4{? wOO,IIC11'SINMIa RANR aAUU U1 ,R ?,RiRF,Kf SCINIITV ?ANB ?wC ,? ?Fwv ?;nl WJ(E%v 1 )CI?tnACIMO I% lU AU9INU-t-ii-I ATVftWIDBI UAII S?rl?i I J-7_ - n_v I Vn VtH1ULt COLLISION REPOR DATE OF COLLIS p- . ION YEAn OAYO SIGN _ TIME OF COLLISION n IOx NFS w D (nun FN AM DEC 12 Mr ltwurfs PM • OUNTYNO. / / C0 CITY NO. if1AµL • ? / f COUNTY CITY, TOWN b[x OuTµnF MILES OO CITY, TOWN AOML PREFIX L 1 PWIE 0115 P ETCOOE SECTION 4 .nf 'Kf E Dccfwx ? © OF B GIVE NAMEOF SIRE .ROKOfl MIGMWAY?w WfERSECTING WITX: SigEET OR ROAD ? 1 I .?. ?'.' C' \ ' - "DCD?iOO?EB CO RD PREFI% EO MILEP08T °" NON INlERS[CTIONLOCAIION OF COWSION MMP DIAGRAM DATA BETWEEN STREET .0 STREET ' ?4 ©® nAaAO,n<n095wOnu tFPO IOFfOfHilFy rlG L,nq,AR+. ER.OniDDE INTER NON %RO INTER CLS E xFiEP11cEOGg599TREf ioxx„w . r rtft uF -® ? TV 7'i??? • v0 F VEH°LEY-11 ?VI-LEBCYCLE x UYFNCFE rn ?Di ERIwAtU --CBEUSE -El-IS 2. .. ?vEruCLE PfDE$In,N ?rCn{OU SqN ?xFnux • OOJECTST(UCK I-E is CWECT 61xuCKI OWNER OF OB JECTS NAME AN D ADDRESS LOCATION N INROAOWAT ?© N °TOxEPAR OwFG! n ° ?? WH r P f EELP E Ix,x ED e FEET 3 f - DRIVERSLASTNAME FIRSTNAME MIDDLE ns PEcA1VED DAIVERSLASTNAME FWSi NAME MIDDLE MAYER DAVID LAROY w•l RIAECTADORESS ROUTENO AND00% w"T'll WHEELER GEORGE A . NO. NUWES DET INDIAN ISLAND CI(Y STAT nE lnAn iwO s° l WERE 1 STREET ADDRESS ROUTE NO. AND BO%NO: BOX 483 E ZIP CODE DRIVERS OCCUPATION CO WS%W CITY STATE ZIPCUDE DRIVERSOCCUPATION HADLOCK WA 98339 ORIVERSUCENEENUMBER y US'NAVY flE°O ,,- HADLOCK WA 98339 SECURITY HUFF E7ATE SE% t F DATEOPWATH AGE DRIVERS UCENSE NUMBER STATE SEl( DATE OF BIATX AGE MAYERDL394MH WA ° oly 7 8 61 20 •' VEHICLE YR M WHEEL617847DU WA N P 3D 16 16 65 - . ANEICHEV: DODGE( MODEL (NOVADAR71 7 DODY 9TYlE 12 DR.I VEHICLE YR. MAKEICH[V: DODGE) MODEL INOVA•DARTI BOGY SiYLE(]DRJ. ;? 3 DATSUN 610 4 DOOR LICCNSEPLATENO. STATE TRAILER PLATE NO S ATE 74 DATSUN 710 STWGN F ? 1 e? OREGON . T UCENSEFLATENO. STATE TIUVLER PLATE ND. STATE V 69 WA ,. ( I VEIL CLE IDENTIFK.ATgN NO D08MODELSANEWERI ODOMETEfl(MILEAGEI VEHILLEIDENTIFICATIONNO. 11008 MODELS& NEWERI DOMETER(MILEAGE) F. v [ REGISTERED OWNER (LAST FIRST MIDDLE NAME) 1 ONVERSUC NSE NO. REGISTE REDOWHEA ILAST-FIRST?MIDDLENAME) DRIVEgSLICENSENO. - 1 !- ' • OWNEfl ADDRESS (STREET CI YANG STATE( WH EELER GEORGE A WHEEL 617 847 DU , . DATEOF BIRTH OWNERS ADDRESS (STREET, CITY AND STATE). DATEOFBIRTH ] I c PMTS OF VEHI R FM BOX 483 HADLOCK WA :r CLE -AGED Sio rE"r"uF VUUCLE PARTS OF VEHICLE DAMAGED FENDE ioPEV.ruNVExCLE LFT FENDER&LR pJ , , LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- WAS THERE AUTOMOBILE .-LITYINSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ONYOORCAR ?YES ?NO NMAEEANO KORESS OF LIABILITY W SURANLE POLICY 0.. u NAME OF LIABILITY INSURANCE COMPANY DAVID L STAIE MAYER NUWES DET INDIAN IS, HADLOCK WA 98339 i VIKING NMIEAN,DADDRESSOFUABIUTYWSURANCE KENT G11 ST,TE 50ABILITY POLICY NUMBER 97 STIZIF NQRDAHL P-0- BOX-24a 221 w- IN SU 3 MEDFORD OR &B%SD 1. ' .•x ISM WJURY NAME KE ]NOINJURY: Iu5E5EPAAMEnEPgIIFOn App IKw,L wJUniE51 AOE I ADDRESS1 AAO 1 `i1 H1 DlrvMULtl 6E%F ? ? NJUxtD r , NAME ADDRESS ... .. r E9 .. SEXC L. s F ?' 4 ri rl"i?lOrv xr,tutlOnr ® 1. "OOC'g15 STATUS OF1NJlN1ED MARKFRET CHETHATAPPLI I 'l t`V•/,[•[' wO w E DOC nr ®O -"A' -. .... M N-1 ? UUU n •1' ?pwln Du,1Nw IN VE11glE ? NGln KILLED I 13 EYf?f ES rAW DS,nt Pncvute STATUS OFINJLIRED MARK FIRST ONE TMATAPPLIE9 ?DRVEn IN VEHICLE Dm- xWrp_. PMUnIE wJ u .=. KILLED 1v[?e1 '? IO wr'rvpt vF Crv rJ O Kµ ? ? 6rOW rgRN18v ARrYJ W w Lw 8 NO I l l T I ? 7? ?mfnnun ? 5? B? ?aEC _.. CLE r 11MCe Dx axl.wnw,r xtnlaf O DESCRIBE BELOW WHAT HAPPENED (REFER TO VEHICLES BY NUMBER) Lq7 'D A(`t I ,. aAt cti5r cr'rw:: n",t`.`ra°D« l _... -. Trr'1 '(( Zt d Cwt .- a t <l,p lE .AD srgW t,x LCD- rcL..J.92?" 124 c ?S t z.?' ??i<: ?. T (' f SRAtrDx1G w % 5I eec jA ff, t,?/?•- (n?r.l. 6-4 -f Xr t E ir . d c 44,-e r _u4«- Z LLrr? [A hrcL c I S. f-['f` ?!= 1. l' C I / I .-?. L^'\?? cr 'I'??•E[j?(GGv-•i ?In(.C [ ?{AC'.? /]E?•li(F ? f- - $G • )Q e 4- c- \ fJh45 re Il t ' ? 1 . _c 7 L_I.1I 4-. . Cs2 CA "4 R ljh I ? C .: ?L?1-tr,_ M•/ . J''•'1•. II- Il •- LI. .. Ll _ ?'?. AJhn ^Z Ff '.J 1 ? e11KEIpr+Un„ ?Gnl "O bt. Jf? 07 ?rihC c / t P' ?r VEHICLES POSITIONS BEFORE CO I P -rT - LL SION Vt'gLE' JGA1rD BY Du U lc r•C u tr eN MDr•D My . ED Yr --= f00 / ^' N 5 C OH STREET OII Ir(,w `S , IaOIIWAY NAME OR NO CI%n O ? t el rOL?Drnlx rAn•r01Kf a n s I?, rr g1x,w ? ? 13 ? ? ? ? ? ? ? ?A°uCE ?D".°M.Imt°1 ' ... y^ wM51+w ? ? ? ? AyD G 1.11 ? ? ? ? Q ? ." y? -? R{5,j 1 { T 1 L I PtDCSuILIA WAS"No 1 ? SIC-,WALK CAOSWD FROM DIRECTION To DIRECTION ] ? WALKWAY J ? A•IOULDEA E ? I- 5i+ i ? n[ E '(?[LL.. VJf '?(( ? ?? VY4 L "4-?4 t+ S + A ? OTHER F ? Iq AD S{AIIKC M[A-1R Lgr(1O04pilUN3 TR.VFICCOMIgL -:A6.f1 IPE OF no- MVERAVEHICLEAC_A' Sr <, OrK1 l . ? ' I A ' C11,A ?M vlrNll MICIONt VFr,Ct[ vIrKA[ KNACK W[0r1 MJnll On,KIA[r 1 , }("n r t 1 -:, JR{yy Or1 D" 1 Uovire?i? 1 [[??(( lJ DAVLYJIT d1Y ? 1 ? SIGNALS ? 1 C] ONE W M?1 1 ? GOINO STRMGHT AHEAD p{ 4 \',? ,-I :,. F 1 • , ] ?ILBwWG ] ? DAWN ? ] ? WfT E) ] C] STOP SqN ® E C] Two WAY ? 7 C] OVLA/ANING AND PASSING ; BP C ? '/ 1 0 ?S AMVIq J ? DUSK J ? SNOW ? AA,I E ? •1 ? Y,[,a MoN ? J ? KIIABOLE ?K ? J ? MAKWOIIgr1i 1URN T _• I pp --EE SON f ? . A ? o I ? KC [I FlA5XIq 11LU w 1 f RG1 P ? E ? MAKING L[FT TURN t ? C) 1 ? r P !4 1 1 } T CJ R DARK 9tn([ 5 C] I 011Y.cc.VI 3 ? Lq.I OFF ? 5 ? O I O i ? 3 ? rlAYtxrO AMOfR ? 0 ? ALLEY C] 0 ? MANWO VTUAN 11 ? , r 42?+y 5 SP[CYY 4 ? SIR CE?gN REASON I'OA Aqi S([wO D4AfA TWO WAY. i3 ? C ? RA s,a NAI ? E [3 LEFT TURN ? E ? SLOIWNO I Y ( Krt<WOKI[H pfrKKrKY,f (ICI r?OTHER SPEC" ? E ? OFr1CEA11VIG.AN LANES ? E ? STOPPED FOR TAAIFIC L TN }l.y to h 9} Y ? ! ? Own, wic" ? 1 ? SEPARATED ? S ? OTeTOP ORAL FAP cr a a a Ir??l? T ? ] ? DIVIDED ? E ? STOPPED W IgKWAY .r"r7w?•y1'yT?°,^-" \' 7?r` '°?"1PJ5'i. 'T"'M?r-?.M+?mml ,, T yxF-, L tl I [` i ?t ?? kti,l 4w X.„ L I ) S , IA ' U. H I 1? ?? ?' : DATE OF COWSION .DAY OF ON „ TIME OF COLLISION, AM ";° o.?M sw' s w n Fw s.r -. r•n _Mwur[s J PM - COU NTY CITY TO MIL[ • UN TYNO. CITY NO. ?Uwwvl // ?•'•, ? IV [.M 7 w? C/1 ?11VNAL , . ? / ti F .... AuI B..OO .. CITY. TOWN M M %r? ' xI J I AGM-CLSS PREFIX NWT F Mm R - SECTION FEZ CVPN EO . h , /L / C7/G ILC' ©© OF GY J ?W OF ? ? ? ? ? ? ? --T"?.? /?. } ? GI VENNMEOFSTREET,ROADORHIONVVAY . WTE WITH: STREET Oq ROAD - nSEC . W C PREFIX Ep MILEPOST . 1 2 O 0 C wneD C. tN f9 1:CIr"J NON INTERSECTION LOCATION OF COW610N WIMP DIAGRAM DATA R BETWEEN ` - + _ _R "?b _ rr ?-1 STREETAND STREET `q1 ®© R?AInOAO n F WSE eNUOEn pw.1 rw0 CESiwssirTin "L¢vOSi Onlo[iiivwA NON %.PO no4n ox wO UNIXeMK 'S _ INTEfl INTER CL9 FRE t ROW rERg[ciXw. ??: FEET © ov ,? ?(rALI:7i [ _ 1 J ' . r c r ? ? Y• + ? n C WSwn wVhVFO ?VE CIE VEIUCLE ?-LEMYCLE ?0 TEl j/-?/I/?<%r ,.?Y//../< SPED CODE USE 1ALnO ? HH<lE-0DIFCi ?vENFIETRAw OrvEIPCLES ?• ?? LF PFI , i } %srwM ?wNCOwswn ?-FUR OI[iECT STRUCK I EOF OIMECi 61RL<M OWNER OF OWECTS NAME ANDADORESS ILocATDI. O A. FEET EGaE O MO?weci -.'R• , F "ORE III. . '. DRIVERS L;A57 NAME ,,, ,,. FIRSTNAME :-MIDDLE'. TWO CMS ORIVEfl3LAST NAME ..,. ,. •..FWST NAME MIDDLE ...., _... ......_ .... WEIIE A-0 _ P4 . C/GCr'`L_ /1 eUp/r'L'G[?/: sirg?DR co w STREET ADpgE6S 4 H ROUTE TIO.ANp BO%N0. rvro STREET MDRE AKIP FiNW RBO%NO. '?' P[RSOxs .. WERE i Nw REDrvEA ' w ?`L• / t. -L5 ' ? /.i n CITY .. STATE 21PCO SEPMArE DE DflIVERSOCCUPATION ' CITY Cp . : STATE ZIP000E ORIVER i Wgw I , .. / .. . - . _ 9000UPATION _ '' i/?/6JLC! ur le.i.i' ?r-<•- 6EY,%1v>. RFFwRTFOrwH Z4l?cm e •L/ 5. D VERS LICENSE N M 4 . I U BER ,. STATE SEX DATE OF &flTH AGE DRIVEg3/JgEy6 STATE. EX. DATE OF B(HTH AGE 'I [L r/ '? -G? 8°7'70 cL?l " F 3 G Vic; LS / /J-r b4?3 IVY Yun I VEH ICLE Yfl. MANEICHEV OODGEI '? • ' : GG "lOELING-CART) BODYSTYLEUDR.) VEHICLE YR. MANEICHEV.•OpDGEI MOOEL(NNOVMDMTI B0DYSTYLE12Dq.) d. //7? pL1iSNd' cl T/U s` c );, A y . l?afS:.x K-/J ;^[ LICENSEF LATENO. STATE TRMLEgPUTE NO. STATE Y/1 iy/ 76 ? W ^ UCENSEPUTENO. STATE TflV LEfl PUTENO. STATE ^ VEHICLE IDENTIFICATION NO O . 1196BMODELS B NEWERI. ODOMETER(MILEAGE) VEHICLE'DENTIFICATIONNO. (BSS MODELSEWER) OOMETER (MILEAGE( T- REGISTEREDOWNEq IUSTFWSiM NAME) pRIVERSUC[NSE NO. REGISTEREOOWNER (IASTFIPST i• Y.l /C'•L C ?I'? MOOLENMAE) - DRIVERSUCENSENO. CZ.it1.4</L-:-,tt?•N Grc.'Jf N. GLr• -cG T OWNERSAOOflESS ?? ?•i7 O I7/ / a e Y" 4439" (STREET,CITYMOSTATF) DATEOFBIRTH OWNEgSADORE STRFET [ . •-. CITYMDSTATEI MTE OF WRTN /•?L> " /?) Ll t C' C[17 3 / 1 /L 1 I 7/i q83 L, r G<irt, ? / , - `u? .• d I L PMTSOF VEnFLE OAMAGDO ?LV1e ?` `Z .r - a vuHK PMTSOF VEHICLE=AMAGED i -/'c.o - F? K'C-N r_ i0FLP LE D r . eoa s i owLEUnBlurr wsuRMCE LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- AS THERE AUroa COVERAGEIN EFFECT FOR THIS ACCIDENT ON YOURCM YES ? NO rvAMEArvOA?OgESSOF UMPUTV WSU EPOLICY HOLDER T NAME OFUABIUTY INSUNMCE COMPANY [ GL?G l.'Gr? .44 •.""[,`[-'C?q?+ /'<Y t3''A </??rr //</</L' ; [' ? [LI r . . , gi.tE a. e' -' 4 ?. •H NAME AND ADDRESSOF UAdUTY WSURMCE MENT On sIATE [ - P UA&UTYPpLICY U.S.. H g 1 /:r•...<r_c- G FL+.//_.L'ri .zH?A r7 ?.3 r2/^r /'cI:•,,.i 7 ? i/? yy' `!vC•s ISTWJURY AGE 2 ?i: 4... NDINJURY: IYSESEPAgAIE RFPOgr iOR1[CIrE%HUIHMwES1 AGE NAME r0 AL NAME ' I AODIIE39 SEX ADDRESS EX}r. IUixAN[4 EXTEIOF-CS ip -. ... - ? of ` u,wLiq ov ?oOCrOM 6TATUSOF Xl1UR[D MARK FAST ONE TH T"E A AT TAFFLE9 ST ATU90F INJURED MMKRRST ONE THAT APPUE9 ?IXR MfA VENwLE r, "nL[ ?gvylP NVEMN:LE IXS"NwO nDNrnsu%wa p,>E ? = WLLEO ElHnf1 III ?IRn'Awi ?PASSE R NILLED ? IN - u On ST.." UNM . v NO I ?MDEgrwM PD F ? FF<? 1D 5 ? ? ? 8 .. ., 7o 7? ? ? ep 5? S O .. ? H WN-TH BY MROWW CIRCLE DESCRIDE BELOWWHAT HMPENEO:(REFER TO VEHICLES BY NUMBER) WPCATl OV nrg PAGILW wwINAFVLAaD O F G'/JC' 1 G 7_: C L•v J T !+N ?:' I rnACUrvE w DUnwlrwrnnmu a. /a C acFM ?uiw e rsr wNwAY OR [ TVJ ?i < ,? F f J T'G G OC n wN ' :7c..:.?rc ,?cc< F/•r'cn / ?MCC ItliMb?NVA'wi • 2WTF // /--.1 Yn[L C r//L-.L p •^.' .. .._ T ? _ On ?'yy?? -iLJ ?t- ? ?Yy'rinaioRlwrv h.n LJ NG• <. CAUL r<'ro .'i'..clF.u, _ f?I, /[;•p.I rAe+.?.... d ?" VEHICLESPOSITIONSBEFORECOLLISION IoXTOrLan v[n<u FLCU r. eDw.a u[vESraATEbBr" ' VEHICL[ a ltpMl.ITwOwp N l 7 r*I L/O LY rAwEO vLMCL acUr<O ?iAn ?Ipf?L%e N a e w aNeTREET O•R NgNWAr rwa NAME OR NO yH Ia ea ra Is no ea Iw unw ®? ? ? I'JA,'IC'?°A /?? O,'F U."LL/I ® ? ? ? 0"", ?WE" 3. Dawn mr,Hw ? ? ? [Dt1/J C.••. /]c•. ?? ? ? ? ? ? ?..." ,ty A wusin ? ? ? ? .aor<I T .' L cnolu+a ITIOM DIRECTION To DIRECTION PTp(BTftl.W W W ULw6 1 ? S[MwAL% 2 ? WK%W AY ] ? SHOULDER . ? 60 n wuA 0 OTHER { O4TNA? • ?? I qAD UAIACE MAT W.R UGIHrCONOIT-5 TIWFICCCNTROI. cn 6HI TYPE OF ROAD IXIMRJVENICLE ACtgN9 OMI v <'Lf A.rv1 v K [ I Y rvK11 ?? I' 'I L S ?-$5!} 2 I Iw2 r(w DAYLIGHT ? H ?DK 4AL9 D 1 I t 1 l I HL WAY Df1v ? ? ® 4 ? GOING STRAIGHT MEAD 1 ? C] 7 ? RMFANO 2 ? DAVM ? 2 ? STOP S ) . IGN 2 ? TWO W" ? 2 ? OVCnTAIUNO MBrXIDwO ? 2 ?-T ] _„? l,? . 1 ) 1 ^"? V ^RJJ??•A,))I i 11 I'n ? i T1 1 i rY 1 ?yy - I?A?'? j? It TM]Y ,.v K 'Y'????` 1 T,E?L, 1 ?SHOVAAIG ] ? GU]N ? 2 ? YIELD mOII REV[RSIIKE ? ] ? SHOW 11,11PCIT ? ] ? ROAD ? ] ? MANWO RIGHT TURN ? A ©ICI 1 ? OMR [ ? OMK eTaetr ? E C] ILASHrq A[0 ? E ? IAFEAC IAAM'O ? < ? MAKING LEFT TURN E C] a ? E C) PUSHING ALI / THE (CNr IY[I}Ir) ?wFq IF C] ? ALl1Y ? 0 ? MANWO U-TURN ? E ? {r REASd11011 NOi a[EPq OMrtEII / ? STREET LIGHTS ? 1 C:) M ypNAL ? a ? LEFT WAY- 0 a ? ILDYAIIG 4 1 k T-??IFtk n%I.•<,noVCd P1M.CnO,L Erct T?yEan ? T ?OFrICERJnADMM LANE' ? 2 ?eroFafDFOn TRAFFIC ? a ? OTHCR S ECIIr ? 1 ? Z7. TEO ? a ? on TBp opp A6 HIDNAL 3 1 rRSnx.I? errs H ? 2 ?ONDfD ? o ?' STTO PP E DINROADWAY ? PE p ?r. FIR {{?rew, ?1re??. •J 1 I .A loll Fj i '- -,SYY'W!RNl' M 1 L 7''VFJ tl' 1 ' tills ar :lL i f A rrt? T 5. 9 ? c X11 [ ? 1 ply t t T4P id J ? S I ? 6?^, I I s?tlr 11; I {ia4? I? 1,•,?LI "x rp F? 4 h• d' $ E A m' .. t:r t o ?a ?, ,R,?; rEE ? 1 w Ipe } T i,• POLICE TRAFFIC COLL NREPORT TRAFFICWAY + WUCF Nr NUASntR ?? PRIVATE WAY D+rt u! l N ? , .? mu15. IN -ul >uR'Ra, 1?; .,R nME IUSFT WRI / 30 couNrv 2 raLA?DO? coumrv NO. /G urY NO. ? '>`, 'c':,7 rNMA ?U AN oaAl t ?„ o[ w',, CI,Yd 10WN N E6fq.0 S,RE rO4 rhL»WAY lE5 ?3 ?W oor.1l?fJIJDAl.S VIA, ON KT CIS 1 RWrt 0R5, E -3 O Sf pN iNl[RSfCrING tEr OR a0A0 fR5ER1.0fN PPt 1% EO. MiU POSr y STREEr 6 BfTVEEN t Epp ONE rAR E NCf. CROSS SIRFf xf5lM if PO DStAN AwL» s E W 1 A ACCIDENr MILEAGE R DuWAM LA. QE o Of 4 E° -f.. EA D CODE CIX[SpNINWIVfD: SfvtR U IO,AL NO. NO TLLI NO INIURED 1 ?;AL'1Gf ? OfVFNICILS © ? PROPERIYDAMAGf ONLY ?pjSVIrFD ?VF »?`fciEN .uNDNDm FFy Y %'RD CU SM R dRUERENCF CROSSSIRFFIOR ROAp OV ]] - - ?... ??.)f 1 ODA[ISraIY,tNAMf Of OBIE?CyT, SIR/UfC%AND OVYNFkS NAMEI lSr. pAMAGf 'Ll G 5 I .? ._ SPECIX CDpN6Ih[ .. UNIT NO.I UNITNO.Y QEHICLE ''?PEDESTRIAN ?PEOALCYCLIST 1T. q fr NMZS? f: lASr 15 MI ` P_IA• DRIVEkS NAME .,..{ fl t l ?29h25t' l Y?EIML?S 111 __ y J F ? sraurAOOR KT- RtErwoR ss f ?$ ? 1 733 : su[ TlPCOOE PNO"f NO. 7S gcy , D R rAle N -c- (6Gk F ?J C+ rvfkSUt[NSf SIAIE x A 9 N A R I uc NsfrW. ` rn x iE el N 73 Z85WG381 riLi_ WAS M a7? t ?8? ?. Q.n?cuEb 1 li;li ,: M 6!2 ?t j °2 OCCUPA110N NAME6»rONFNO. FYES GNr )[qNi sra t_ 13? S E R PAIION FIRM NAM"-1 NO. Uu?ntP. EYES WEIGNr )41GNr 1GC 6 c ? CHECK(/) vFNICIfA i [?ANOr»[ufd ?CHECK....SAN fMROYfdANO1NfN i?M CODES?+ J n x i 5 1 wN f b'S".° CODES D p 4 i+in "r 5 ucrw» 6 [. ]) I.M. UML SS DIGET hw3:..DN o -A- o M" ? E96. o K9 o ;R. n an. f f°? ? ?1" ? ESm. ? 1L ? rD 5•FH. YfAY eIDODGe.ofFV.) (DARo-EgvAl $rY[E p...ca%VI l MODEI [DAR. Y N ( [ .1 4p ' " D '7B iEano?! ANP?92D 3-D2 ) E CooS.4j 7/ _72)VO 5 W SIATf N RRAIf NO. S N C _ ,r 1 N. z xz? w? t2 y,4d 8io it A w»IttEloernrtlcArxx+NO. L Y r » "Z X15!3' I 'E i 1 1 1 I I I I Rfclsrtaeoovmea: l.sr ,rlasr MiDple mroNe rx). ?i4 -S / Y G• 3/ °, rlcsr IDgL N srt EoowwR: l.sr a/5 - rD 2 ADOREVaoANu n - 7 RUL08 wa 39 E M. a . M Loon a1NwRANCf dACENr R u N MA - iLT .] DUM AREA I-= I%W 4 9 ; Z t;AMADL; AnEA • A .•. a?? .,: p ? : 3 f reP ?A'WAY ?aVANNEO LS,.DNAM' 1 SiDP S LSf. DAMAGE RJl WAY ?R[AWNED OI O?OlrCii • $ / IOWID . pf IOWFO EY: _ AY er: lL ? '(!? In . DIAGRAM OF COLUSION lu I v 11-1. OESCRI IONOe OLLISION: IIaf SUMlA4N,Al WDrrfeussARrl Slit iIFNtCESSARYI.- f l r f _T ' .? _ l 1 I ? Bo "t?S 60 80U.VJ--?2?u6?? ?-? rQ ._ I. t I. _ i I -•-- r +`Y ?.. _ wA.6-D Rt7gkr AND 7RG0 C&VNI'?ti¢".t6..14..-... U?'?uranl . ?gjLlr_4o. yJr r._ w?.>c_?*_r_--??--•-- , y ._ . a lI . 7; NAME, ADDRESS BINJURIES OF PERSONS I NVOLVED +CODES 1 - Z 3 S b OCCUPANTS/ WITNESSES Id Apq<fxYIAl NAM 81 SI% AOf AIDS yM' °?Y , ..M" lest Den NAME ptbm 8 M• R&ST No ,uoA? tuck W0.. 8' ._l%vbpj t1s L ND " ADprU I. -fd ? A•OYW ?AMe. ?'. ?•t•?. ?•h••.l• ?n: p N 1 0 AMfRISf - ?U. IHMfa fnf er ?AML ?fi ?.6.?_X Onr,M x In N+Mf L.+N. e AOUd .cENCr av :'r /? ??cNr IF,? D D2 _?) AnROVEOer wIL r fi A"fu ,t F. L I 1 Eh J f L - 1 ' POLICE TRAFFIC Co, 'ION REPORT 4RAFFICVJAV POIICI NI NUMBER PRIVATE WAY ?? A lE OE I)3 DAY _ FINE COUNrv COUNlY rm IIUO ID$f}N}NOURI i8 ? ° NI / I IXI I Ov/S 3s FR7.cRSonr AN 1""1 1 RU RAL' . ?N (HE ?IN CITY OR TOWN NAMfeNO.OFSTRffTOR HIGHWAY Cl 2 v0U1EOR3 _? SF I ? / S - P^ , MILES ? ? ?Oi J ON SEG ON C O /d '•. U% IN [45ECTINO WI,H: 3 OR ROAD ry0ry INTER S E RION }} }/ PRfil%. f n iIf ro3i ??y? ( ? / A y" p1REEr p C ld;?DA n ITNIEl DISIANCF601 TI E MP C40553iNfffEN I-TIC (] , R NE MIl B E W ACCIDEN! VAMP Dv.GauA I MREs ?o O FEE OF V RG MILEAGE CODE COLLISIONIN VfD : EYI It Siff RROAp 4R(ffRFNCE T- NO. NO..FIL KIllEO?NO.INIUREO? ? SPIIAGF HJL?RUN Iu DiN I: IM[a/' CLS COS 5 [ROR ROAD OF VEHICLES ? PROPERTY DAMAGE ONLY IN FIRE , S }} IT C3 ? ?.' ..?42?0 OBJECT 3TRUCR 1-11E 011ACTSIRUCK AND OWNER'S NM1E1 far, DAMAGE SPECW CODING Wf ' -- 'I UNIT NO. I D4WERswmE: LASr FIRM MIODIE UNIT N0.4 ? VEHIQE - ? PEDESTRIAN ? PEDALCYCLIST ORIVER'SNAME IASi - }' .aoo,r -TA naES Ti o?w S,REETADD . IDDLE :z J2T ?. o 2/ o fi ADDRESS r IY ,A,, }IP CODE PHONE NO. D I y STATE CHi AO -IV VIM .S--o/6o DRrvfR'S UCENSENO. STME R . IP O Nf /•?, BIRIM MD I IV R' IICENSENO. IAE DATE BIRTH I c/D o?T392TA Mra h} iAj / v MD. I DAl IYI. d p OCCUTAIION fIRMNAME6 PNONFNO. EYES ME-1 MCI- E OCCUPATION FIRM NAME R PHON . AedUF?°E? AD/?igD REsT, RT d / R E NO. EYES IGHI HEIGH , '. ? CHECK (13 VENKYf AS wN FA+ROYEf OFANOMFPµ CHECK (,? AL - IVE i R + d CODES?3n Au .Ln uN:tlaN ,try of 5 D 'S'A° CODES ?+ S a ANFMP IFAS OYFEOFANOiwf . ii in d i+ N' r cu . ` }R I u N, 1. A S u b LA M <roN Pen V r a.O nM ? SANK ? 1 ? ta„ R ? rATI ? a? [H YOUR - RODG RII OM HE of ? M e Nil ? Mc, ?;R ? h ? ;? . KI[ RY ? 1 . 1 E-EV I ft(DARINOM) WILE(}OR.-CONV.I 6 8 I . .Y R EV. MOwlIOARi VA) _ FoAD M.vs7A.-GG 3,,o E x STAR MERMTENO, -IE H N.caOR r l D K 6RC Aiv6ll3 wN I N . A V EHICEEIDENTUICAIgNNO. C VEHICIf IDfNIII I N R[ 7IA;Oi/•f,9: sl/!s?3 ?l l GISR4f00WN[R: IASi FIRST MIDDLE PNONE NO L I l l s 1 1 1 i l l s 1 1 RI f0 R I4 A . S .OFF 0-1RAS II oV'D: 38S-o i(o w WNF ; LAST HRST MIDDILN ? N A WNFR ]I N AME a A TwESS O DIwRAPIU co. oRAwNi E R }} DAMAGE AREA -VI O NC CHARGE uINN ?AMAGI ARtA CHARD[ ± F IDP ISI OMUGE f .3} R . LOP ApVAV ,ll ?OllOU 3 ? ?4IMMNFD ?^RI ?REMAINED ILI. DAMAGE I ,AY 3 loiono:i s f?7$vp ??w,v°er: ?R/C/CSON 13 Qa, ?AWAY 3r: OLLISION: lu u INDIUYANegRpM NO4tH D ESCR I PTION OF COLLISION EuSt SI1PNEMSMAL 3N[f, If NEC[SSA4Y) 9Epr; Nfa3uRr e ' F.AN'WDU 1 .:- ..EASLQo?nro oer ? ___. i. C.O? ?QO . ?. / Q /M... J RbNOFLl!_ •.._.Y A?'/?/. ?e \ ?NTdRAN6._A Tu.4N. To THE A .,F- Ca ?, •vyg .I HPSTC?OVNO .G 4K._. WAS_./N NO_I__PL AfLJr, '„_ Dytiv4R ,/yo1 ..1.-'f-,rp TW.fi Rm 4d. 7.0 _..__. AVtip.r0_.fic`AD al f- SD Da1w6 So H H?T A Po w?R 1'oxa= , , __ _ . - N CAvv, v(f../?` 7D. •ps°F'63J:T ' i 1 .. __ _ ??k'S. 'AN•o_ R N of TKO'" . I Io y R6 A. . col a n7Tn C. o viv A? _._ #S / NAME, ADDRESS 8 INJURIES Oi PERSON INVOLVED -CODES 1 2 AA I - 9 d , D OCCUPANTS/WITNESSES MEiwswu -- --- - -- M1cr Oi r?AwgNuN AVEN 1tR AG! rA1US yN Y I- I OISie. IFfCI u Y: No .. ' _ .. 1- Iss N I AIUR DP , y ? AM R. ? C%KI ? I. '"' . C) C.' ? P8.4KE. - - . _ ADD e133 NATURrOf . ._ R AKJVEA II ?AMe. ?Upl[I OIrI ,•? ph. ?2 dD w0 . .. . ,aDE X . . N Ess ... pplsOr . .. ,r en ?AMe. ?-KI??DK,.?t7x ?n1J3r wt 4 IF G0 KE 1-111 sou OR M1NC K CNIO q KID SP r KS RRIYIO fAllp llPORi N IeOND - O er N AII D D M a I r I 1 t s A R4 l 11?? ?1 6 , l ! ?Il S 1. ' (} ( py, ••I.+I Urt VLrIrOAV`yOOLUL yr V. .? FCALUVCN f, r Y! 6uV MOM luE9 wEp rHUn f `xOUl1 ill DES N ? pOUxiY 1' UN TYNO CITY NO. ? pu µ PLACE r X 5 l dV iW ?? /? Cie R b U. DEAx W txO.OF STPEEI OR WOnwAY fm.DLOLY. PPEM q VIE REGrCOOE '.R. ocsE? METE ? s ?w ? ONpM NAME RE a noM 4 MaIWTMISfmMn o wt p.nm sr pLTwEEN '?+-a. ,9 TO ?yprFyV•?"E © / N lE UiePO°o STREET NEHiTwatwo.A Mlux.pruoaE, BAN, o11 fax--A ?drY 0 FE ©® o T q.wwo EMESrI) Ianwv«vm - ''YT . u wrER ALS 1, EWCLES r YJ(„jT SLIDE Q -11 a fis EOO cnLalwE Q ?OrMEABLE STflUCK A. n I? w. -t FITUNCLOC x0A58rR Er AO V x • w,?; ?ne"sM.repF ?vEW ? INEIATER- A AMrDAmrvEMAiERALG ?. ?•Z%<.' :.: OBJECT ?NAME OF OBI O Pucnl. WNEfl OF OBI CTS NAME AND AOORE55 VSgE6:f„p?€51 sPEO.coce l,sE , .• 1 $ .. iAY'ty? E ( ri MORE in.w } •, { ORIVEfl'9LMTNAME PI TNAM MIDDLE Ero WEVeO ORwER'SLASiNAME. WZ3, NAM .MIDDLE R .--' +•' RN Tn3 1 G OR • J STR DDflE55 MO l @ [k]'qJ y flOUTElN?O?ANO BOX NO. E EiHuwx3AxrwO i -E RETADGiE59.. flOUTE NO. ANOIiOX r~ Gg v? e .?K MME A 106 $Q F 4T' r CJtt - STATE LP GOOF. DRIYER-SOCCUPARON cOwSpN CITY STATE LP CODE OflIVEfl'9000UPA N REPORT FORM GATE OF Y? h ` k • pAVy, BE IT 3 o W A 6?} OWVER'SUCEHSE NO. .. ._,-r. , STATE SEX WT M M F & AGE. R p J VEHICLE YR. %9 MAKE(CHEV.•DOGGE) -ML(NOVAMOMT), „BODYSttLE I. OR,I VEHICLE Y2 .MANE( HEY: DCOGEI W,9 MOEL(NOVA•O T). 0 Y 6Tri 12021 o?D #/V -5E 76 nn.' F 6' . PI.ATEE NO. STATE TRAILER PLATE NO. STATE Y/] m 790 ?? TE I n TFWLERPLATENO STATE VEHICLE IDENTIFICATION NO. L F 7! K .. .. , / VEHICLE IDENTIFICATION ._ REGISTERED VMER,I IflSTMICOLENAME) DRIVER'S LICENSE NO. .., N REGST-ED OWNS ILASTFIfl5T M100LE NAME) / OWVES UCENSE NO. WN 'SA 0 59 ISTflEET, CITY AND STATE) .. OAT F&qTM WN .. t aox 4 Lu Mp. pAY YR E29 ADDRESS (SIflEET,GTY AND A AID BI TN av PARTSGF VEHICLEO ADEO ?? v, ryr, y? a ?H?? c?gE io ANTS OF VEHICLE OAMA ED r . l Cab aadgp?bxf $ S S/ S 5 LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1• WASTHEE AUTOMOBLE UMILJrv INSU MCE r Y--- i CpVEflAGEIN EFFECT FOR TM19 ACCIDENT ON YOUR CAR JR?YES ? NO NAME MO ADDRESS OF UMILRY INSURANCE PO EHOIDEq .. _ .. AME OF UA&IJTY INSUgANCE COMPANY .:. 7 82 s ?rLu S,AT a3s ' /n ecs ?3us. Ca 64, Usau %i'F AIAE MDAppq E550FUMILRYINSURANCE ApENT , STAE -UlY UCYNUMBER R ed es s . CbLu,-wb r d 0l? 17ao) LQ32a0Qo39t3a, • 1ST WJURY: ?J AGE 2ND INJURY : 1 SESEPNU EPE TOR Marlyn WIMUEOI ADE. y NAME uuuNf NAME ... ._ + ADDRESS Q r S .( ?',b 6'_ X NATURE ANO rYMPIEO F? _ NNTORRE MD s? S rT1?r L ? ! EXTENT OFINJURIES' /• (f(p / ILLYY U EXTENT OFINJURIE9 ?D I' DID INJURIES REOVIRE ??YYF OTOR9 , 6 ? E%AMWATION BY ADOC D J NAME a01NJUR ES REOVIRE . TOM fiN STATUS OF WJURED EAAMWATION © DOCTOR :VF 1 NAME MARK FVIST ONE THAT MPLIES qy, VER SIATUSOFIRV ANJUREDDOCTORi KFIHST ONE TNA7 APPLIES. q,,?W V[NICLE pr3AnlWO AbMasp wq K'?'^R KILLED rOSURtE ?ayVEn IN VEHICLE WARtWO nWa5A0uv0 Y LJ 1EOE]rNAM NO ISEVCnEI Mw0111 E COMVUWi ? 53[ KILLED " OI PAn E.1 OpFOEEiR An NO. ISEVFPEI IMwOPI pC Ci o ? sD 5D 7GW/ Of AWE 1 / ,•,EIx D 5D sD . MOTORCYCLE SAFETY: D HELMET USED D HELMET NOT USED MOTORCYCLE SAFETY: D HELMET USED D HELMET NOT USED a I. SHOW NORTH BY MROWIN CIRCLE • WOOIi[rnlW3avnAM - -- ____ Ufl?_ A #PENED?(REFERT VEHICLES BY NUMBER) F. ' w wIN R, lp ?i,cTe { - - RMfraRLWErn.TgE,EEpr, STo?c lJe I 6.3 I oad..tE? O U/ SlgfE onwAe ICES DR YW,p SEEM: ,p,„DW L? ?erse 11"'D. b ck.. iuro L.a?za. n Mp[R] ] wuWR [MN V[WCL[ Ar,p Yqw o/} M r K?n1 GAT - C? c! n w OwECrAP.a mAYYLav wpw ? p -?? ??- ?s,aE Knw,Y I (11i OYL, ?i.ci AJ07_. P2VrL4e_ COU'LiN oFid 4 ,? - roceErl .T o C3i ck ?P _ c .? _ ?cSClLtP??'_.z'/V f}CCrCI e?T mt VEHICLESPOSITIONS BEFORE COLLISION . nE] _ M oALLV ?lu,a,p LEO; r E O v[rn IE OCCUP[0 INVEDTNIATEO BY {I E Re VCHCLE N 5 E W ON STREET OA IxOMWAY IIAME OR NO f! nW ,"L `Ens rrwYA .E w e w DP:i? D- ', ` e:, - w "a'N ? D ? fWp ? .IQ ? D., ? D. DCrW4 xu,OrKw = I . r No D D O bd A ? ? ? ? IOUtf M„ ?Hj t rta.rMw DD D D N.Ow ? ? -F Y I f 1 I crnApaf.w FROM DIRECTION TO DIRECTION r°^jr PEDESTRIANYPEOALCVCUST WAS USPFO' rDMaw..A EDww.KA DEnoLAnA tDw,ww.E. (D? ?.°. AD mran I ? e4 iqV I% fD low*, y + PEOESTRUW/PEDALCYCLISTCLOITBNOCOLOR: .DoAA ?uOnT ,DwIEO Dpnwwn,cYNE D r [L HOAO SUgPAC( Y.E ATFLR LONE G]NdiK]N9 IP...FfIC CONTROL E??N f. C d4. rM..On11 IYPR OF ROAp DIWCR/VEIIICLE ACTIONS :-, { v[KLt I IAYLbIT Vln4L( Kx{CA rnEI No 1LrKyI I IOCRn1 KM1 VlrMll ICHEC%rnf p140H(? ( 4 L 'I,.; ?? f .gyp{ 1 I I ar I nY_Y I l7 ?naK•u ] D DAWN D I D YNIAL9 D I D diE WAY Or No GOING STRAIGHT AHEAD 1 l L , 7 D RAINING ] D GuU D] D STOP S DN ]] Ltrwo WAY 11 1 9 t M ? ] DWCi ] ygw,q OMK6TPEE1 `? I-7' ? a ? OVERTAKING AND PASSING 1 { Jfl 11 \r t' D ] D SAID. D t D Lgnt60N ? ] D YIELD SON C] ] D ROAD REVERSIBLE D ] D MAKING RgNT TURN I f r °? 5p9 E D FOG ° ? IgHIS OPr(T D l D ILASN RED ? t D NTECNA(gQ S I00P. RANPI C] ? A 1 4.,?i rr .P D r .0 A MAKING LEFT TURN DARK t T??FY i qryN5 D, S DISPLGIYI ° OernEKEri°gnTa C] S D/LASHING AMBER u F h, ; 1 ,Iv'ry D ° D OISPEN(R GFY ( pTprEq ? ? D ° D MAKING V•iURN 4 TWO FT TVAY- S f , 'Y ? M GFY D S D RR MONAL D ° ? `LE URN D S D BL YANG '? t 1?E 4 1 { r. ( l.. ?4 ADWIT CHANAGrLR E?AOLADWAY SWYAGE IYY! D I DOF/IC(RiFLN]MAN ET?? yp I. 14 r t IN FS??L L1F '1. 74?R. D ( D MIVEWAr D T LY'•'OPPED FOR mAFFIC r • 1 ) r +\ Oa'Opf S Ll LJ N D ! D OT ER w CIFY -Z -nm BTOPPro Ai JDNAL I i N ?I, 1 it .? .G M d;l ,., 1 ,r r?., a. J?';FI ??1 ? ?'s"•?`.?I ".,? ,{.' U4,.i -?'? i ? ??' ?. - J I ?11I ? r G J I 71 >A ?""'°i-n'?7•-+?,mmavo• ?v?._?au.' Y?.. -..._ __.... _ t?_... «.,,6 :Ztr.•:w-. ?..i??°7??'-'Pi iL -_'?,z .. Z''.'ri3?:llvu.??.m___ -.t87N9.)pfz7r.'G " 1 1 UH VtI IIL;Lt I:U LLiSIU1J I1tYU1{ ', 9^vC`I[vOn 6MV .- NE9 WEB MUR FN. pOH ? WA = rr; ?. COUNTY NO CITY ND. ? > ?,I E ?N ?E ?W OWN AMEND ATPEETW WGNwAY FCT.CL ACM.CL•. M6TREp [XNIE 9ECT. ?. nio MILf9 ?: ?w ?pE DTY ?IDC-r' ON n wL- N PPEFlA ?>Lx7Q0 I '9 tA.Pau?F EnsEpr+oWTNSrPEET rnIUMD wrEAM:cr 5 ° BEW EN 6n A P 6TREF [ 6 PE W /-io ?, D 1 FEE nFrHD"YEiNDO1rA6,Ew{.MeEPO,)upaF.? PAWP Aw.Awr „Ia "stun`IOiH aan (OIL © oP Lr-[- E "" r[ }A', pu ENN6 BEVp mwsroarED {r;t:. 5 n' ?? anww[vE I r ? ?waE ? "Puna, .12_f Ar n/[' f EET AooP ate"' tY ° ° Z f fLE LNIIID p ES ?CnLD9WE ?OTHEP R i C[H.S°.- PE U099I C --as ? ?nivArED ?liwaE BWNrIDSYEMAlFNA1 ?^MM ?PADN)ACTrvE MArENPAS ? 'G?e 9775) •! .+ v ODIECTSTRUCN INPME OF OBIECTIWCIR WNEfl IIE T NAMEANDADDRE99. ?$rR? p w r,r. SPEC.000E U3E ,?A'"r • .. IFMDPE,nAN r AXJ 1 DRIVER'S LAST NAME IT NO .. .. MIDDLE -. v[o DRIVER'S LAST NAME. W TNAM... ....MIDDLE -.? a '1-?Y?C?LLI C C°wE,oN'°P S.G t STIEET ADOR S ROUTE NO. MID BOX NO. rPOPE inµ rv.O • ' .flOUTENO.MIDBO%NO. I ER60NS WIPE ETORE .:. f SrflE AD / I 5L'S I' SUrRE[ureA [[Y, V C Y STATE DP CODE OWVER'9C000UPAPON. .. CowfipN C STATE -LP COOE.. DRYER'S OCCUPA N _ L wA. p? PEPpiTl- .'t _ Lrl 1LU QUA ? •3 ?61SlA.V'D. '+-LU-EQ ?zL UU0. ??3?•S 'hx t ...... NSE NO. A SEX DATEOF ORtq. AOE DRVER'SuCENSENO. STATE. SE; DAT & AOE .I a alp _ czlD M . ?D. 2Y. F MD °^Y YR 1' VEM LE YR. EN:H?,LpOppEl MEL INOVAOAflTI.. DYS LE l2 DR.1' VEHICLE Yft. MANE E el OD IDHEV.-0ODOEI -.MO LINOVAD TI : BOGY 6TYL IZDR.I. 'P (? ?[Bt rr? r -OV ?` OrC? V6 Aa -:?' t?j uCENSE PLATE NO. STAT TflAILEflP TE NO. STATE , PLATE BfATE., - 7FWLEA PLATE NO ., STATE :.. I._ 712 L / ?'I 7D ?U? VEHICLE IDENTIFICININ NO. V MIGUIpFN IFlCATN)N NO. ..-:..:_ IU?57? AlS:72 .?•? At REOSTEfl2 OVMER ILART•F N9TMIDDIE NAME) DRYERS LICENSE NO PE019TEflE0 ONNEn (it LA9TII•FICST-M.-IDDDLE NAME) DRIVER'SLICENSENO. y r &1 4, l 'T _ , ON'NEq'S ADDRE (STREET, CItt MDSTATEI.: DATE F&flTH' OWN ADOR1'E'ST9InI`,&,('I?`S'T'REET.CITY AND 1... .._./. A F& M 31 -r LX JA PARTSOF E VE?CIT, DAM ED. . x nl??T. iD PAAT FVEH CIE O/zMIAFD ??. ??..\\.. ....3(D 0^ A.'. 'Lc )ll ` i?-•?c4' , U.'LA1G lGi.L,:.? • $ ru " LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1• - WAS THERE AUTOMOBILE LIABILITY INSURANCE M-C COVERAGE W EFFECT FOR THIS ACCIDENT ON YOUR CAR RYES ? NO ' z NAME AHD ApDflE53OF UAOLIlY WSURANCE POLICY NOIDER ??1 y..?! ,NMAEOFUASulYw5URANCECOMPANY ... . [LAU.C ..,L,.` ?AODRE59 S[AiE .-, _.... b ??C c,n N NAME AND ApORESSOF ApILITY INSURANCEAOENT .; pTY ' k mATt .'.•-uTY POUC IUMBER:_._.:.. f- L ? L? I I r,p, LC 1c `' .7',l. 2 n 1ST NJURV. AGE 2NDINIURY, 1 E rEFE10RTrOP pNALIWUNE41 AGE ` ...:..... ... M - NAME C YUUPfO NAME ADDRESS SEX ADDRESS F NATURE AND M F ? ? NATURE AND Y ` ODINJUHIEs REOUIPE pOCTOR? M © ,DOCTOR'S N)NBYA A p © b r _J ?STOIUSOFErMURE EE NAME psA•uN)?TONETMA ??E1IAMINAN E0MINATFON B 6YY A DOCTOR? OR'S TAPPULB - STATUSOFINIUREO KFIRSTONETHAT APPLIES. . ., •Y.rv•••?N IN VEHICLE HDN°DASUNO P°6peLL NW.MSUnO D AD r E , r pPA I-. ? KILLED IW?pFI IM?ORI I CCM uHr ?PASY6ENOFA IN VENN: KILLED p-?rD DIWUR E9 REQUIRE ? WCE L'1 O[S TCI NO. IGEVEPFI IMM xOPI IOFPUNf CIT •1 L ?iI i ?Pf µ NO OFPAW 1 O '.r„-I. ? 5? 6? T O?xDESr- _ u.?Y• r:..... El 5? e? 7? j! MOTORCYCLE SAFETY: ? HELMETUSED ? HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMETNOTUSED ', ` ' : SHOW NOPTNBY ARROW IN CIRCLE DESCRIBE BELOW WHAT HAPPENEDREFER TO VENICLESDYNUMBERI d r '• [ w,uTnAPnIO O ?tA. JF (.._!l+rtC'-,(!!y)?•fl ?. f?,"? -1 GL-f??L a J c rtouRr+[mAr rcn[cr9 Cr .YS'//? .'? "`'A'ri?^•? Y 1 Y wWAe EACH 11-1 .np sNOw ! I s [e o NGn Ar uZI'J. r. Y"`?? _D ? yT? ,-0 ? 1 YE , S. '- awFC arnAVe[e. Pmow ' ...... ...?('G...4:• 4 ' l.L'/'?y/?•?' y?.. _..W ?? ' 41 a N iLl..._G' 'CU.I, LLS•1 PL._r r?:L,L.(_L?. ?L.?ti !'! ..FDA IY: .. ? i Tl,.? ? ? ?-G-f•L. Yr Z 4?LLf..Y `. /Q..Q•,t_al-_?Y?•C.- .LL'Zty ro _ -- I ?I GL-L. ._LD__?,ntrlc:_w?CG--Ad'f-Du ?t?i`??• A ?-t j i $ rl 'E ' 1 x - } i ? G -G?1.-?L.cL?r._.../?-i u...o._ZOvCJcc . t nwnon l.pY«Ar I f.U-i.?i.1Gl..Lly?,. LlJfr [•2. vL??t,(.-4+.?..._C•.-? WA• INVE STIOATEO BY VEHICLES POSITIONS BEFORE COLLISION No ware Ee Y LL I-. ARAeo C--Al B E W MON WAY NAMC OR N W O Np :1 ? C--Al ?Vow ? Q Q •t1 El 1 ?.??°mE '?. 10/i. . IOr.. a o ? ® ? a ? ? ? ?INIAr.a lOCSrw ? ? ? ? ALaa owa Wn FROM DIRECTION ro DIRECTION I 1 ?y?? ? xP PEDESTRIAN/PEDAL CYCLIST WAS USIND. .0-.A. :?...... 2?pauu• .? °W", a?iM,„.00N_ r?uvl?I;I, E?ROww,Y PEDESTRIAN KDALCYCUSTCLOTHWU.COLOR. r?P.n. I?IA•w 9?un[o ?nnPOlvnecrlK {? °wSDiiiuu.?9:.;p'""` ?' ?t c 00108 1F a WEATHER UKW CONOTC[9 TRAFFIC CONTROL TYPEWROAD - -ER/VEHN:LB ACTIONS T E A' K?ICA b,° 1 ® DAYLNYIT vlryAl KnfcF ON{I v{HGI -cA Wl v[wCLL ICnICNONIG-I., f # rc II GIM 'A 1 "° I AN1 1 b i O•upA<I NO I M I # ?I 1 0OrtKUr t (3 DAWN [D 1 ? soN.LL9 ? 1 Q ONE WAY ? 1 ? DOING STRAIGHT AHEAD _ 1fT ?rl W ?11 d°RY i ?PAUMW J ? WSM C3 2 ? 9TOPYON -T E) TWO WAY C] 2 ? OVEnTAKIN°AND PASSIN° U?SAtI?I"11 { # { ? 2 ?N£T ..1 ?OIOWINO [ ICI DARK90N Et ? 3 ?YIELD Sol ? J ?ROIDJBLE ? J ? MANWO RION7 TURN (.''I , Fi 111 .IYZ+ ). ?prrl(" t,• ? J ?W f ?f00 ?w10ARR.9TRf of ? • ? FLASHER RED . WTfnCHY10! ? • MAKING LEFT (URN (LOOP/AAMPI ,t If '? 1'?' NjI II ? • ?Ce I OTHER Lgnreorf ? ? ? WWII yl 4r yA r t r ;v OTHER ? IO•[OFYI e ? eMETT Lolls ? e ? rUMIWO AMBER ? e ? Auer ? e C3 MAKING u•TUnN tt ??7$$N?? MO WAY• Y, ! 7D (?? 1L1 I4'f>'1 1 ? ? SPECVY 1 ? y: GrY ? e ? M %GN. Q e Q WHES?N ? S ? SLOWING ,YI•L I I rl { I t 'h, 1 I 1 t ADWA Cr ARACtEN rgAOWAY SUIT( YIC ?y ( 1!`I$ aQf•,iI [ I f ? T ?pI(KLRAiIAGMAN ? T ??,?LYAY T ?S T 01'PED FORTRMfC uj„ 'Yv AT dONAL 9999kj11 _ S10PPEG flWa t1 J '" R9?. p7 + i. i s Iv ' l',I.t IWy A l t {S "1? I ` ,, 4 I ?7 ?I iFEi, ? ® ? ? of 17 hK SY (-IS ISR)N NVOIV[0 ERIEYI 10TANN NO KILLED-NO. INJURED ? OF VE CLf IFS_ a ? PROKFITYDAMAGEONLY m S N I, I I??;?: vE UST NRST MIDDY PHONE NO. 'N p.. HL?,hDt.F: oTT rdoC.,r. RFMNNED ?" i^I 90W R NAME, ADDRESS 8 INJuRIPS nP RDocn NE cone x o IN R [ ST ,urvUttoi,I INIEP l5 CR05S5 MMMMMM IF FW.DNAAGE 5PfC1ALCODINGUSE 5 UNIT NO. 2 ? VEHICLE ? R' PEDEE s NAME. s[ -'?NR5T a ?LAJClf,1, ?irfJtF.a -IF-DD gf55 D 42-r E.IE R I n aa fnsE no. [ V -)Tt Ci. F_ OI_ U) E OCCUPATION FIRM NAMf 6 PHONE NO. R AS.tpP.i' ?Q.E_f• Fu.PI[WF ? CHECK ([? I vENIgFAS AN CODES ? + G wl,un a i:iM Orf A INJ R ?yARpM y?}- Mf`V.E? n.EL,?aV E u -,g V.Lvo 1 n -5L i vsN,"0" 1 RFLP.G tlrS-/I lIka =j %7J V <??o i(-?LN1'LI?JiI-11`Jll_I l I?'OI?u171J1? O F ISRRED^ [q; IAST???I?\,[IR5[ IDDIF w w 'F r.5 Hfio,/E N NER E R kfiRYFoRp LEVY, I.ARrn1'n?gV ?r.. c .r? y ¢I F? , . (OWED EJ AWAY URFMMN[D I. VAM E , S Q w r ar r+• _ ."'„? Nr s)b'??. Id e'airuu MCRIPTION OF COLLISION. Ilnf sLJPPLeA1lNtµ SNF[T Ii N[cESSwr, Ca ?E1 1?s1=/ RI.KEn ?? .P.6um) oN.-at? T{v'UC+? Al raI <F I?t. it ??uxy VE4, 3 ulaa..Pr,?t { n '? I n- { V?11• I , F?'t ?Cl?I'"L1JC ya ?^?E VF,? •tE I r TTIjRT. Ve-N• U- Z, rfpr? 'N r. +1r -JJ? /IC'.EY? (Z,Tr. `IIJTO 11 Ii1 .Sf F GEIiR, ,„ Uf ? 4? _{,IJG tU .. ?D6. i f cP E 1 (LLTTE.LL Jr, tx,mr, M-'llE.1{• 41?1, Ar 11iF rrrf iF- -rirn7NEKFTPr- F or- ?? VOLVED +CODES I Z 3 4 S 6 13 Sfx AGluws v „ - el3TR. (ACT ¢K: r. W .f I O I -) I -_ I- I I I- I - I- - 1-lY ? I ? I - 1 tra ,r++. `? Jt rRa t I k ? P t ? yy i q •n ; ? ? l - ? T l .. ? d ? ?• 1• ? _ ?SM 3-{[. °d? welu _. _ .1Fnf. C4_ ?,A:NL?' ? ? .V> -Ll?' y, `F?^ y " ,,?, - .. i AYE OF WASF VGTON RAGE h OF , v i No. i ?. POLICE TRAFFIC COLLISION REPORT ? iRAFFICWAV IOUCECOMI4AININUM3Eq • y ?P PRIVATE WAY .' . Ri ?f' .. CAI F.DC ll N -, LIME COUNTY rR Wxl w lvl. (USFRbO HOUR) KIR T COUNTYNO. CITY NO.. .. p111Ne/ER A0 , M y ' I I FY F ? ' { CIYORIOWN N"Ee NO.OF31REITOR NO WAY UN pE OIN Cl3 IA ROUT, 0431 tf SCII N puffs ?s pw OOF ON 3' ?fyD?/O "3 Ef., INiMEC11NGW11N SIREEIORROAD ON INTERSECTION PRFfI EO zz SlRffi MR W ACCIDENT DuG / : EiOF E COL iEt1$ION NVOtVEDluEc fDEAL NO KRIfD _NO.INIURED_ SPItUGE gUN NO, DAD OR IMFy ClS CROSS S1RFEiORROAD R ff REgENCE 1 . I j CF V[HICIls p PROPERTY DAMAGE ONIr ? pFSUtiED ? OD fCi v[HICLE ? yqg„5'o 21 my R `I) J STRUCK}NAWFOf 00JEC13iRUCK AND OWNER'S FlPMFI fST.OAWAGE 3PECIAI CODING U3f il}? $ ss3 , " , s - UNIT NO. Dglv[RS NAM: tA31 NR UNIT NO,, 2 p VEHICLE ?PEDESTRIAN- - p PEDALCYCLIST 3' ori ? N/ ._ MI t I STREET ADORFS3 DR VER• F. s l! , WIND, ID[NIILL ION NO. RFGI S TF g f D O W N! R: IA 3f L // I? ADpRl35 C(ONNfR NAME { ADDRESS OF INSURANCE) /44.5 R 311 v GHI HEIGHT E CUPATION fIgM NAME6 ?9 / Y R p CHECK (?) IFOM AIEO vEH CODES III + 3 u is I `6 p AANCE CONY.) r AR ,v E n SIAIE I'I vEn. OR I L v nI t[ MEN1. T A N I, O I U WNER: tASf N OWNER R N fh??kWh ? . . ED I. e5 - 11Or •,,...,,..., C.IARGf OiMie ovil S .? IC?OTOii S [31. DAgNG( ®AWAY pREMAIN[D ?DRrvEN pR[AUINFD fS1. DAMAGF 1 eIDF A AWAY .._..... 3 I-.. IDeonDN d ?? ? AA eYr .. ? ?w?ver: $ RAM OF COIIISION: ID IND?aie NDRIN DESCRIPTION OF COLLISION: IVSESUPNEMfNIALSNFEFF NEClssA.') IS SHE[) II NlCESS,u YI.- B . YARROW .. _ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED I'F CODES_ I - 4 4 S 6' ?J f •- OCCUPANTS WITNESSES (ate^;aM,I,"W'Ng3,??ii six AIDE TATj I,w," efsi fxcr :' F -r -11 NAME.. f I I rr WISS NAIUR OF- ... R ID FROM MC Y ?AMe. m D -y, 7 r... ?.,? • Y JI ^i , iJ L l ? k T ?' r s?rrF Y I??V``?.[??FFJ•' '? 'rpl?'GI { I } L } L i f (, rp ' t ( a'r?a ?r?PA6?B I Y ? ti`' ry E +v4 ? I. ,T Yvi A 7 r VV; , '' m . ,f - STATE OF WAS 9GTON P E Of No j, ?? TR F " ' . I Z A FICWAY , ?• POLICE TRAFFIC COLLISION REPORT I?y PRIVATE WAY gAICE COMPLAINT NUMDER . 0 1 OE '-N Y Of ?OLLISIO .... LIME COUNTY 'IN MD. i nr 01 fux I.. ' 14 I... (-Pm. . No LOSE-IOURI r...Ir I O. ` -LIN J? CItY NO. /? i«WA ?URRAI (V;KN OE CIYOR TOWN EKNO Oi SIRfEIOR WGHWAY O IN N CLS RWtf OR IR N I N AVLES S Q W ON Y '& 11 INIFNNGTING W11H: SiNff10?gE0Ap FFN RSfC11ON STREET A STREET ?ffl% E Mllf POST ?. S\? D ANCE DIR ION R MRf R .GROSSSIRffI RNFAREN MILE MlES N S,•+F W • iEFi Of C ACCIDENT MCODf E LEA AGRAM WiA - - COIl13ION NVOLVED. VfR IY? SPIIIwGE 1?lUN KILLED NO.INIURFD1 ? -2. ® mIISIH WNDRFDIX AIIER D I NI/Eq, CLS iR R RR[E R NCE CIIOSSSiRFETOR R D' ST , CF VEHI ? PROPFRTYDAMAGEONLY ? PFSUItfD ? vUNGIf ? V v? O ..1 OBIECTSIRLICKINMSE Of Oe1FCI STRUCK ANDOWNER'S NAME) ESi DAMAGE SPELL DNGVSE - S UNIT NO. I UNIT NO.2 ? VEHICLE . ? PEDESTRIAN ? PEDALCYCLIST Rx W NAM : I I Iv N e: LASr '!x'ii i•F' STREET wD Rf3S BX 3 i e ?'4 ntt 'cal ums.?v IbN 3 RfFT ADDRESS - STATE EIPCODE PHOrvE NO. D IY AI I N coDE -.Yl........ -STATE % I I V ' LICENSE 11, AIE X DATE BI IH 0167058 AK M 469 41 V b ? wY ?Y, R OCCUPAr10N EIRM NAMFLP«ONE NO. EYES IGHiiEIGN1 E OCCUPATION FIRM E. PipNE NO. EYES WEIGHT 14IGHI z 1 " ? R ?CHECK(?) IvE«ttEA iN fMaovfEOf AIMio1HER ?CHECK(V) A worOA . . ?"nfA L v DES ?+ Dq %i [ 5 e "3',° CO e , ' A CODES ?+ D 51-1 a n Z WRS a b IAIUREOF l syf.GM X- col Ua I C] CsnE. C] _;; ? x- ? AMNAANCI ? -I'D' ? CLA,. ? .zE ? r.°- 5 -YEAR EIDODGELHEV.) 7 MQQV- MODtIIDARI NOVAI SIYIEIRDR,1-11 MARQ 2-DR E 1'i 1 R ( E HfV.) MODEI(DARI-NOVA) Y j R: V.) ?• Slt- N U 'l I 1 `f IAll A 1R 11-1' NO. S1At! C H. IX R RAITFI A / VEHICLEIGr(IIIICATIDN NO z:G 61S 5 ' I . V M L I N A i i i i i i RfG13RRt0OWN[R: LAST 11RSt MIDDLE P«ONf NO. m o W 111111111DOWN11: -1 fIRSI MIDIXt N I] 2 AR 0I OWN(R Si4ma N E ADDRESS CY - R NAME A AD DR- a INSURANCECO. pl AOENI -AGINI MM DR DAM.ee ARU ' _ sARmDN UAMAG(D ARIA• 1D ciiow Y E ' 1 I% i u CHAPfA ni r CHARGE S l I .s E U > E ne ? AWAY ?REMVNED ?AW Y ?R(AWN[D lSI. DAMAGt I ICAO OM3 1 IU?OITOU IOWSAV 0. ? t AWAY er. w E ?? NEE SWIaEMENru 5.1111 Ntas3A.Y) DIAGRAM OF COLLISION I (T. Aa _ InosYA/E{EV m DEESCC/RItPTION OrF?COLLISION: SWN ASSRYI O w r A s JJ WL D,A7 YC?I E. W FAIL C-D Th IJEGOnIA'['E A *144RP "5" TCMN ., .. Ua5PED OFFON *WOULDER AWD.Dowili • . I&M A 'DIMW M-406UA(S A ' D;5T'nAJ 5..QF ?-? 219 .A)JD $77WI IG'A 60 F'E2, T26G . " 77 d W AT' 122E BASF- . U194- ) 5F4GI1121 AG t [ Td QEST FAdIv%G IzAsr. DRWEfZ WAS eA1W j 'JUSr lu(bcutz in A . 3 GA/e Aur6 RuN - owl) 07AX ?cxs i4drS, iL?T!/e?/OR F NAME, ADDRESS 8INJURIES OF PERSONS INVOLVED 'CODES 1 - Z J 4 5 6 OCCUPANTS/ WITNESSES ESSES IuusDrnEMtmu3« Ip ADWTgNAI NMV _ In .SI N% AG f IAIIY. IH LEA1 "v « m E - Mmr 1E. (HCi RtS •??I/? HAMI' I J 11.4 y?E iq 7J.V ? uwEns X' C-aA QT' L.LI rwE a ?? w a x, ? AM e ? f".h ' ? '"' . ? ^1 ? C3:, A Aw NO. AIMMIS 1a101 .... 4 VOVID ivOM ?AMe. ? MAI ?11c e ? I•Sii ? 11I.D b NO • - A OWIS NA?p , ?AME ?:°"E??MH1.? ? vxtl'S,AVN e1ANK EADfxlp AWNCr 1 A1C«lD A iH0 Dul01.EfO.r ARnOVID 1? DAZE x"4y ? y, II r XITd s S 4 1 ?s fi u L Cr'' t• a' l ^': s ,III4(((???rIIII' ' Y I 1' Y PI 11,1 ' M. ?A Poona g rt ? ( hi i 1?' - ?Vt ?1 4 T ? u?tty f?.?a .1 f4 ', + 3 k SUPPLEMENTARY REPORT . G'Jb LC..e Stan /s,_---T NO. ? ?. yR Clafnlimnon . - , N: , . ?,,^r ma of C-plai-nl - Add- Phone No, l Y t?J. ? r? ? F JI,P r _ ;i ''r ly I: R dy 1. il[ h I y t A?'a? i =? I 7 ?tp 91 J17- 11 ? 4 , A 1+?F4?i N t , A y?, 16" 3?N5???1°TN4'P6.....?. _ . STATE OF WA C ._ - " l f SHIN TOiV r AGE _ No ' POLICE TRAFFIC COLMPN REPORT ® TRAFFICWAY . paice Amr NUMNR ? I PRIVATE WAY' ry _ N ^• wn fV CJr Rp ',IS 10 1— vl IUSE }.BB NOU41 I S COUNrY 7?t ""u ODUNIY NO. ?lo UIY NO. iNWA ?u4 I - .,., ?N ?E ?IN OIYOR TOWN NAMEaN00 Sr?Ef10R WGNWAY I MEES 3 ?w ?Di r. ?Zw2us?wA ON Z INtERSECIINGV4rN: SAEf 9W iR apM RWIF O4 [ 3 9yriso 4nl y -' _ j NONINIfRS[RION Dcl1 [r # 2 p?SIAN ape ?. ( p[rWEEN ? IoL SAE[r O SSIREE R aefSr MilE N PNII% }} MR[PDSr k ({ 1 I MESS N VI I EE T ' 0- ACCIDENT MILEAGE RAMP 4AMMIA I? p'+v ' E. . OE , ISU CODE F - I NINVOI V fD v"ILE; : NO llfD??Np OlAl NO. NIU4FD? ?SP ILAGE ?N RUN rNNpvspm A D' INTER C S IN S E RROAD 4 W @ I . pF aYt.r 6VFWOf3 PFCFE4tY0AMAGE ONIY ?REEUInp ?VFH I I ll . .. OEOSSSA[EIO4 Rpap L?S•C?SO 1/i ' q OBACISAUCa1NM1Ed Opt[ IPUC%ANOOWNFR'S NAME) fSt.pAMnGE 5R{iAE ' COp?NO IM -- w?Kl ?e?. e ' -'Er NAME: UNITNO.I UNITNO.T s lASr NR M'_ p4 fe' NAME: ?VEHICLE ?PEDESTRIAN ?. ? PEDALCYCLIST - - Sr -?T ?? : ?yr,r a -• EIREEr - _ ? ? _ °Z X29/ G/44' ,C!/sAE ?T D• pEff ADD4f5y ? - ??w,?'.? , ?4 SIA}F ZIPCO ENO. D DR r SIAIF IP ` ?^ ? - NEr 5 A 5 % 1 I NSE i ,//E-,vDe-2?3 g'3.ve suA- :"t /?j 62 V Q ATE IRI MD i D, "I '_. ' k3 PC R __cupnrirl i14:.1 NAMEd PI%9 NO. Ctt3 AE: ? E? - .' ' 4 ^ ? CHECK( WR As AN vrf apAnotNEn'AE ? CHECK (.4 A ? CODESy? ] t;:y % ?I°N vENKU Nrnwonf oiANOrnia. l rsn 5 urenoN ° v rvv<•p? CODES P. 3 n v r r N G %MNS Z 5 eA<E DN y y roxre E .?jj a 4 'vilr nir • gq 1 ? ? MvuuM1 ? WE ? 9894'. IAA °g ? w r eorwN ? vl vF` f 9 MNIf IDppU{NEV ) [l ANI Li ? m ? Wrrt. ? vrw[?E ?rur,3r }p . -NpVA) 5trIEIED CONV.I l 73 1 ' , j v cN v.E AwoEI IDAa +avAl .1 . ti r w ^ I e 0) S LJ E V Z' ?Q L ( p ? - Ji 2 v N /??? "??E'?,! vE ? ' U f lA N SIAfE IMIIER RArf Eq SlalF 1'1 N.CIXw 7Z Zu?_ C l }p }E-F(?' 1 u ??» , P NKlf ICfPrll % ,SrgN NO. L ven oENN l RfG5tt4E00WNFR ( `Ct -- : Uy EIRSt MiDpIE PHONE NO. SIE OYM -Ct?/.u Bu/s. Ltl ,'? 3/GD W / IASI iIRSt MiDDI - U a ApD4f55 f Z /D? / N • NfR OV /1/llfid yE }I : E NAME aApD4Easa Nw4ANUw. waeeNl . ?RFRT-- ,.._ - R . PGr ANA o-wwa il.bPU + A,.c4DN.l cNAR?d ° 1fr cwt tt 1 D CHA4Gt Nm.'"°.[+?o".°N gAM.GEp A%u W .°ww • y ?REMAINEp - °4 t ?Mn ( iW Vp •}OP ?^RrvfN Esr ?REM4N[D WAY" 'MD f0?0lIG? 5 er, DIAGRAMC)FCO_UISION: NAl INOK'AIENO N f 1- `(-i !_?#/i ? i t-I-p+- I s ? W BY: 1 E DESCRIPTIONOF COLLISION: Ilue suPPl[MENIAL SNEEru N((315Mr 'rxH/O[?S?,BsavOctvl1.2?7ti, 1 ._? _ /PFfb.er?J[y-..?rvr?CoBSe;+evc?A Ao4 . -?Ros,Iw ir _- . __ovra.-cro-Hiw.oy_/.L?.orrt?har_?a - _ - ,E --- 1 - A ° -- ? > ._.__? . -' STOP _ . ZvEV? ovc? dRaK Gyro "y/?APuO/Za[LGp ._.. R NAME, ADDRESS8INJURIESOFPERSONSI NVOLVED OD 2 3 4 OCCUPANTS /WITNESSES IinrlwN%u?wva MI: si x ?w rei R.I' _.5.. 6r NSA EEfC1 u n /!/OAiB P ARD rAMr• rvrpn AM S. ?['41 ? '+?" ?H;NRq mnu F IATw d. -. .._. ?1 01 ?AMa. ?.a%r ?wN? , O ? ? ?.', o ApMN lSrp;wrwgplKErS NAW a4AY. aApLrW Au HAWIK? .. KINpr. ?AM0. ??.'.<I ?,rrt• ?N ??tiv NC X .r? D rq? KIDISPAIMp / O RS NO MII to nro ?/ 12 P, eY DATE /1 W 1 +, w a ?rr`.yr ?yf;? Sy; kr? 1 ~ E 4 r ] as ?u I ?14 1 EV. .%'JR?a, ttli t by ? t 1 ' 7 2V? ? ? I I 1 1 4 . M^ 2c. ,?1; ?p?b?l nl7f?`jy?? ?I?n 4 7 M% I g .I I f t t - 1 1 . F5n1 ERY' 1 .1 r. T ? I . `' ? I t I .,{ ??.. ,..?..,.. ..-. __..__. INEC?pINr NUq - r) mil' _ __•__..-... .... .. .IL PRIVAT_E WAY @a9f y d DAIf X us N coG rr NO nrv Itlwn Dl- vb COUrvty r •• tur-Y4r lan l I t wI USF]bO HOVR t Z _ ) y I? ^r(? Fie /G ?I,4RA R Al / N CItr OR 10WN .ANf6N0 N SIRf 0 p ? F ? . V ? ?I M 9 wGHW i ClS I RWI/E}O?S/IR?+?f SE MlES'?T Qw gp! r %Yf O 3 l [% r TR INI[X RING ?iV51p[4r O4W NON INfERSECIION RREiI% EO. MIU:POSf - ?/ BiTYEFN a ( I FE! SrREV L J-? ?1• / / OSIA NCf . EfR .CROSSSIRFf aNFAXFSIMIIfW ACCIpENf RNrx OIA 4AM OAIA A'AES... f W / MILEAGE Z f[Er _ y W ?c n CODE COWSpNINVQVFD: fRItY: 101A11R0. 1+0. %IEIED???NO.INlU4ED? ?SRIItAG AtEIf 6RUN rurvpto IMER CL5 CROSSSN[RO4 WAp O? ENCt _ _ OIVFHICIES m s.jRORR1YDAMAGFONIr ? PE r t - t 1' rv E ??/7Q } S l1lR0 4 V CI OBKC}SOIVC R INAME O[OeIFRSIRUCK ANDOWNfR'S NAMEI ESI,DAMAGE SRCIAE COOUVG - S - UNITNO. 1 UNITNO.T ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 24 > SNM.f: NSt IX51 DRIVER'S NPMf: IASI II ,f - SIRE RAODRESS 2 B o? / - , tr IAIE ZIY CO p? A V ND. 3z `/I3Z R sucf . s nI eI IN Iv l NO. On IRIH S^ 1 z6 ;Y 1 Arf Y V ND. I R r Ir4 a R AIgN - I NNAF6RMJNF NO. [YFS IGHt HFIWr! EOCCUYn11pR FIRM NAME6 RHONf NO. EYES ICNI HfIGHi ". "{ C A? 11I R ? CHECK (o IvfH i :N tMYir'r oFANOrHteAt ?CMECK(•') 'A RA±Ai fMYI IrEf oY ANOrH[R. j(a??+•• CODES A' J A s "' ° ° 'er 5 utcr:w a 1 , ,F r, ?.. CODES 1.- * J a nmlFS 3 uoIDN a "'° JAR ?+•wo rR.foM p Ar.tx.w 'g,c'ry t ? 18A. ? ve?eii ? i3?v ^'0.x:4'°0"" ? M.e.ANR ? go ? RE ? r< ? roY;It. vfN A . . YF MA%F IDDDGfiNfV,) NIOARI.NOVA) SIYIf (]Dart 1 k.) MWfl1DMI.NOVn)( .) 1•pn . O4 t SIA-IEE .RA?Z IRA ER RAIL NO. SLAY H vfH.CIX04 I YIA N S-E k/ I ll"?„ A VFHICffI MUKAlgN N0. C I NUFI 4EGSRIRO 1/a NRSI DIXEYHpN f NO. O W I OWNER: IASI II45I MI I] ApORfSSp PAr•E4 A Ht SI COS A[?r?irnS B/ N ad , s E N?pjA AOOafsstx wwRANaco. a4 AOeNl If9? /1?S PILL a AtStn E 1 R DAInA01 RATA wRAA I loti MA Axa gA Gt :Y . D? R a aA4u cnARGe n %y` 5 A O 0 • f IO?OIROM R f51, ?AWAV ?R[NNNfD ' ?nWAtRN ?RtMNNEO ESf.DAMAGI I OtOx ' w JTI 52000 TON'EOer: G ?lovrtD diorio Awnr er: $ I 74V C A DIAGRAM OF COLLISION! , ?sn le -.. .. .._ _---*-- e uN[uiwF t. /s.'- .or{ R?... f -? y f 1, 1 v _T_ r# ( 1 _ i pffgvrR C d 4. ?o /?N n. v?__kasfr. _ oZ t . PD1G 1 I ,.! 1 ._ vn _ Fa r _ _. v ec?., _ oos r or??t ?-af _ . ,. NAME, ADDRESS & INJURIES OF PERSONS I NVOLVED CODES 1 - Z 3 4 6 OCCUPANTS/ WITNESSES is io?DIR1ItoMNtiirMiAi:i ii ...uIt Aiii in- u.r` Nf- ; - Rfs. 11 :IRr` N,P f ._ .... - RDDRRSS NAMe tUR10/ .. r. AM e ? cAll ? wEI • ? N; ML. . No a? ADOMi1 AMf N NAIVR/OI _. _.. _. - ..-. R MWIDI ?AMe. ?•rO • r •Nv "-"-"- ADM- SlpAISGY CI4S AN1 fRAN NO T N Mta .. _ .... t lir. ?AMe ?ti"t Mn• OH ?nhV [ N OOGt OR GNCr X Dw ;f1 KIDMAICMD A4•IND DARO•Rl ar AR•ROMDfr DAR ? h ig" y { J s?l+ t ? x as i ip' I t ?;' N? i ? I r t rat l'f , Y u c) Mp °*, ( O? O i flff I I t f V t ti p I Turn r I?e3? ?y ?? { r n t? ? r.. t`, , I r f r I ' ? r i, ? r1 , +? ,? r 'i ? r r , ? r6 f ??k RI ? ? ,f ..YC, >: ? t h €'¢e !?`?ev M ??Tr ? ? 1 I' _ a(SJJI ? ! )1. u POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY Rol c[comnwlrvrNUmatY `. ?% ¢' ' PRIVATE WAY 4 R_J oAFf orcouls rv oar usoN caurvrv coumrNO aTr NO ._ 2 ,? ?? ro 7yC.wlfs . ?u lut .s U t.l IUSE ZR00 NOURI } ?3 wY I Tw E I(roR TowN / n ;s.> ti '? A ?F;, / c pN pf p,N AMfd NO Of ffEOR M'GNWAY IRCtS ROUI(OYSFYFE COOF s pw ?or ?A,I k k;,q, UN 6>11k irvwA U p NRA" $7- SECTION Z j h o K V E f IBFw„(EN SERFFF MilfS I OM P[TS x Nf ' CROSSSEREE(04 rvfARFSF Mllt POS i[Ff -p p Of V E, oz tz A' s u O S0 1ItUr; UVFD? YAO.I p SRR NI ClFS I p --Y -AGE ONLY IY n W .. ,, I STAR zlRcom RNoNENo. D 63 & 5 41•3 R vATf AEOEeI EN I n V 9 ').3 F S v? ,S' V m NUnf6RNONE NO. k" frES W41GN(iEIGNF E N Iaa ?'z R /97s 1moh JAt y IC[N5E FEN SFAFf Allfv RAFf rvO. ? e?Fn r 35' W x NcAFION NO. A P, S" ? K 2 G x 8 fWSRR[OOWrvfR: UISi Ne5` `i 1, MIUpIF RNOi °%a .w a rt .5 c( Y[fn.SINfO 'w. - -.... - i Q - - - - - f 7'a /.tn?o t NAME, ADDRESS 8 INJURIES OF PERSC ;v?ESµTUw"' OCCUPANTS /WITNESSES '\ n3.4-K - 1-4" , --8ELt Un Ar" 'J"-"" )ESCRIPTION OF COLLISION: lust s wnEEUNiAI sErtn Ii massARr) l/ty, / was 3 u{!) 13dN,J oil OH,K/ (jn KR( /e Nr y!` l i f'f TIC ?E l anc( c T ? ;.' Ro??e•in.6v.L w l,a'F ? ?•c t., S/P lwirEA< Nal.f,..lr?E(. Vo.l,, ?nf,.? ?o L414? on YAe c,ies? Ji a'.. 41.. OHA ony n A. ao..1 lTm?i.Tn L'•lb•B3 +y?nN ! +t+ Q01 ?[ 1 Y h t + I+MwltAr'.}z+t^N!ffli4t"R1.N'f.^. F.CrSI YI'Yi ?' Z W»'?` f? ?, 'f T r/jFES:>d 1 ??V AICIf ?. "A ;.b , I. i J 1 1 I ?1 ?4 7 yJ r 7 1 i _ ( Y E? l a r 1 ¢r7 '? I ? 1l xs T?1: AI?E? d' , c l DA COU T I PRIVATE WAY ?.+x.,...wnlnuwneq -- N Y M n fl jl qax hilt wID I. (USf ]qO NOUgf w(/? rR Wx I O 0? CgMyNp, CITY -A /? ?URIMI ON °F IN CITYORT- - / • • -ESN-Al Y / MMES S °w ?Of ON IN,FRSFC,MG NSTH: ST fqR ROAD INITI-- ? ?/ 3 q?J o?/o I DIS,wN<f I qEi . CROSS Si RtflEgt NEARfSTMIE STRIE,4 PRTSi lpfflM f nE rosT //'' p 7, ?0 MllFS ( O '1, w OE /F/? ACCIDENT MILEAGE RA.M DAw 1-1-NINVIX1ED fR TOTAL NO. NO. RIII[D-NO INJURfD? ?SPIIUGf 0 H1 6 RUN VOg HS rUO? ? IXV[HlClfs PROPfRTYDAMAGE ONLY °'ES lTEO °VIPIN IM[R CIS gCKSSIRRTOR WM C, SIRIK[INNA[gOSIfCi 14UCR PNDO q'S NM1f1 B `G6?`? `/ a /Y/ 2 a Y DM1AGE s 00 p SPECLLL CODING USE DgneR's.uxe: usi UNIT NO. I R ; I x J UNIT NO. Y -IF-WE ?sVEHICLE ? PEDESTRIAN ? PEDALCYCLIST l 2 SittE, ADDRI 6 7/D A? A RQ .. Rt ADDRESS SI ,F cox PHONINO. ? f? ?3?0 U D Y wTE P N N. NCW - s c?ss s,wTl E R x ( I N FNtt rvo. (/? v 09 3 CA /$A 03 oxr '„rP _ V OCCWAT 5 AIF F BIR r4. ION M Ea PHONE NO. Fns IGH, NE- E CUPAIION FIRM E6-I NO. Ens R IGH, NDCHi °CHECK('') vEHaEAS:NrMaov"ia.NxHlvlwl CODES?" D o A i s f e;p ?CHECK (f? ."'.vwl CODES 0 J n . e IXAS'J Ti p w a s. . AOO ". O [ CN ° c " ;oEw r 5 f MA D I eV., ;`NOVA ;:U 1]D° ONV ? D Y Aq : HV ° v?w[u ° ,° - I Y D ° ?`NOV n ? /C ? , O DfI R A , I Y 1 R. A E N N<t N LD SiAI[ AIf[4 MA,f N0 H W, xOR A I , C H ' A t n )Y 1 A UI ? Si. J fAy? STATE OF WASHINGTON PAGE I °' IND POLICE TRAFFIC COLLISION REPORT '?RAFFICWAY Folrcf cOMPIAIN, NUMB[x ° PRIVATE WAY D.n o[cau •ar IvD xI S IV$[)A00 HpURl C OUNTY couNTY NO. NO. an P u4: ?DeeAL 4Al ?N ?f ?RN c" OR 'OWN NAMf Brv0015FF,OgNGNw.r FCT C15 gWIl OA SIRF 5[ 1 IN r r • c o Jf-°rR[°R °.` TN Jl N Nt[45[C,r `3 9yDyo / a I , BlM•FfN I4[FIe SrPFFt FP. (O. MRF Po3I ?j ?/p /• % / I µ 1A4 a CI aDIXF ,r F t. <v°15314FE1 N iMllf ACCIDENT MLLIS R Sq! F P DIA RAM DArA 04 , C MILEAGE Y? ?, CODE 11 fD CIXU'.. gNNVIXV O[IIFD? NO NlU4FD uI nw>I?,•• O W IEl gD IN D RFF,OR gOAD OR gfF[RNCf ' 1 ' ? I a a [N es © 4rv DAMAC[orvsr 1'\"°•?.??rl?t?N OBIFCI SiPUCRINAMf Of GBJFCr SIPUCe gNOOWNED SNAMF, FSt.DAMAGf INiF9 CLS CROSSSiRfFi OR ROAD V ?•y?D SRC AICODING USf Iz _ S UNIT NO. 1 DRIVIP'SNMA[' Iw51 St Mr UNITNO.2 EHICLE ? PEDESTRIAN ? PEDALCYCLI$T z' [ IDIX S,R R 53 ?; 66 c Po F; / rR ft AUDNESS 17c -2 n rU - C"PS zrP Coa PfIOrv1 NO ?1{g ??? ) 22)' ER'S RCENSf NO. Alf FA Af D R I IIATI /r/I ?x i? ??j)PjoDE P$ ?12 - \ 41 N 6 S3i( ?vA D 12 " PG 41 V S IICENSE rvO. r t<v C H U ? -T l' SIA OAtFp BIRIN 2- zy IGN ( It R vfNCl. 1f 6 g ZZ; AN ROV(FOF t ;: .,o °R? W ? , ? AMSW.N . ? ' ?? 0 c".1 ? : IDAX1. Al E q 1] ?' P S r??EI? H I >o Fl- Vf.,IGIyypMIFGn NO ^ Cr1A. •3sF?S"'j1ti3E y3 L fn OtlDf CAI ONN 3?1z?1 r)`sC7 tlz 4tG15Re[DOVmER. 1A11 31 MIDDtt PNONF NO 0 RIG SttgFDOwNFq ASt f 51 IDaE N NI NO W '• q 2 ADDRES--l. N -.1- NI. / E (a.oD4us IrvsugnLCt c° ao AGlNT A N A AVIN r r R • ' S DAMAGED APlA ` S A w3 a µ . CMA4Ge - CNAPGf - MSAp r°iG oiw ie Dai I.-I IN DAM -II-A ' tor _R 3 ,o.ortoM lS, DAMAG! $ C. : IvtyN i?s:w ?etMAeaD ? °,.t°e. ?nw.'N ?em.weu ? IOrw(Der i. l lst DArnAC( $ rG f - , oi,s DIAGRAM OF COLLISION. in1i11iritlusv,4r'I IP a++u4oW" " DE SC RIFT ION OF COLLISION; IuSt SUPPIL-TAl3NIINI 1ICI55A4r 1 ?s 1 I . s c P..• c? ? ?A'!, \ r.lr•1 ? 1 ? G. r Y. 1 1? n J° v t.7 F .4 , NAM ADDRESS 8 INJURIES OF PERSONS INVOLVED I 'CODES - x 3 6 5 6 - OCCUPANTS/ WITNESSES ADOIrONAI N.NISr Ste AGf IAl R11, FACI N 111 7171 A _ s 6, . n, ?AM e ?-A"I? ;". P ?? ? 7. . A DpRI SS ,Al Valp • y q`NAOV1o FgOM ?AMe ? : ' ?'I"r . ? ti ? : AD do A -11 ",°?e°ri°' SSI 1 u.Ie.' ?AMe ?:::' ???;:R. ?;C:: ? :':L.. y. .,G a,1(11.3/.,fAM aXAv / y nA(KA O. AG1 lc, , ftr OJ I?I?C?.10 RA [. ?Iy\RVIVID UAII CR PIR1gl APPROV10 er DAtI 7 1' I R. I. I TV -7 1 y?7 _ wREYL STATE OF WASHINGTON RACE D ' np) ¢ ? o. POLICE TRAFFIC COLLISION REPORT N I?'TRAFFICWAY - . pq cNNtNInsxR 2 j E) PRIVATE WAY 1 cau fll y? `.p 1 ,. _ R• USF]HOUR) COUN}Y r• [Rx •M ru61r[R rwn. FAUd}Y NO. CIIY- . FIVWA rP? yr ( '{1 ? '1 . O ° U AN ? ? 0N pt ?Rt CrYOR}GWN NAMf6N0 O(SreFfr Oe wGNWAY CEn Q 9IXIIf OP RURA AulES ?s P ?' ONCO Rn) 1 L% wrtax I ' '.? 1 ` oyRwc WSEN RE o9 ROAp rau wrtaxcrioN wEFIa nF PDSr 87 7 ?? nfIWFFN Sri Di Cltq I MM1fS fElR .CROS55FR O9 NFA.... PO N ACCIDENT R pl 3 [ h I+? f W DATA 1 _ rEFi MILEAGE OR ? ? C« CIDE t-l'L IISgN NVp[vFD MOOE xVFR1IY. Mn r0}M NO ND.RII[D??rp N1URf0? IM[P 0. CROSSsi4Efl OR ROAD ROAp NCE CFV[R.i PROxarrpunAGEONIr ?utr[p b[ wNwRr. OBlfclSiv«RIN•ME OR OBJfG}SFRUCR ANOOVMF4'3 NAMf 3 y ! ?? : ? ?° l FSr. pAMAGf SP WCOWNG IbE S UNIT NO. 1 fv ? ?ad i{- ' S J ,',. s Doly sN•Mf. usr iR r UNI L S NAMe? ° VEHICLE p PEDESTRIAN p PED, CYCLIST FIR r ta s e u ' D i ? A ta Y C "-~ _ j vN, srREf} ApDRfss C?rFA? rftfrnWRF55 ? 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O RF Nt NO. n R,' sY?,'.q ? u Apoafss«oWNtR W Z SS-OU e owN[4 J?. 1. t? 11o I I N Ri Z F {r , D NAMe n ADDnss a IrvwRANCe co. 04 AGE E . v f .r• OV?? R p AN oAMAClD Apu 'r da< Rav k rc' -*w Iei[ctcwa 4LaC?MbouN.1 a,. oYFKB!?JY ,lol 7"T 7 ' ? dviw.? ww ' MdrrL.a/0j slTiRi.L? g., AEn'b„•...T;c ?'ho.ruwE:xtiaE, «n? E.fl' ''h IFti? i' • ?'?? e.L/e 6 vL„?7?5, y, i1A? j'Ye.?.,r wkc.? c%M a iii tkl. ?t?y*C(? SlC'o?dctl n, z ? ?'llfi I ?1dl'ff/?+ 0.L?e? ??•?? 't.a.? i i+unE(y?! _ NAME, ADDRESS B INJURIES OF PERSON51NVOlVED 'CODES I OCCUPANTS /WITNESSES I., suvnfMFrvw srner - 2 3 4 5 6 1Ff, pYl['_ -' N•M! oe •ppnioryu N•Mfsl sr. •cr r•rus """ u N-I [ ? G ?? RISrR I1rC} R , su+ L<' Y w' RIerO^ =•• A N R. p •Mn p EYlcl ° .. u ;;z 0;,4,- L No I i i +DO•rss NAIU4I Or ^ . Movru r4oM ^ '?? Y p•Mn p.l p o'.R. p C p ::1, 'p .+ NA ll11 N v yg[ ' ! I r •DDRI3R NIUEIRI ROf lil }u?cM.w a.cl4sNA+•F SR•Nr nww o9 .GE NCY scan nr pAMn pc".- pio°lI. p:+: ?".:w.. qb y?? p NO ]KEDisP•rC D n K}•RRRD p 1 I Opr uroORDnr p•0 if rr to ":/?=r?E' .2.OZ GZiO U%a'b'3 - i I - a A ?q , Elm R f?$rt i l wry,; ttG r:, d?"i Sid sgm P ?I 1 u 1 Oi I 3+ i C s f4 ? '•• _:? P)LICE TRAFFIC COLLISION REPORT RTRAFFICWAY pIXIC[COMNNM NUNBfa NN PRIVATE WAY raw' 2? DAIF O{ IXl , . N Av ( OuNIY /ry? COUNrv NO. CITY NO. R //1 ?1r Is ?'"V IUSE ]bpnOURI ?Ilu?/1/? 1 / lnWw _ ? . U l.'(J CIC.SON ?LO ?UR µ iTE , /(t/ A ?N ?E«o N iCHV --N LL?, No o sraEf?roa wcnwwr rcr cl5 RouRON SrR f r } Mll(s s ?w Gro{ DL.oC ON ?'a ` O D !J sf u r<•:fD. •'?; T,'. NI[45FClING WIIH SI ! ROAO NONINRRSfCiION ? ' yC?' ?' R _ RHfI% E MRE PoSI ]] •?r`rilo , DISIµCf6UR r nfrW[EN I"'I(n 1(.. l,l psi W IF IF l?liY'1-(; I?I,_J SIREFI 7yD 'Y??`' MIlF3 •CNO55 SIRFFt OR NEARES]M lF 51 fEFI S VFRItY: f ACCIDENT RAMP uGRAM DATA Oi MILEAGE 6 CIXIISN)N NVIXVEO vcODE ° ra}5 rOrAI NO. NOKLLfD_NOINJURFD I ?Sa E(AGE ?'IF d RUN wxanRlN N rt ( aVfH ClfS ?pPoRRIYDAMAOF DNIY x.RD fR KIN Sr4Ef1 RSUAppq niF4fNCt ]) ' /'N_ VV; On1ECI5rRUCK INAMFOi fCI STRUCK µDOWNf43 NAMfl ? NSF rFD INIF Cl5 CROSS Sr4fF ?ROApn Ikp.,t1# L UI ? -IN f SpECULL COgNG ItiE \J! Y?L'/(F. ' S ,??$$AAi?7 c u R Y? UNIT NO. I S ? ]„aw.,31 (.f . s Dglvt4swvnf Insl ilR l UNIT N0.2 ? VEHICLE 's' 41r.. ON Ivfa sNiv.E, usr ? PEDESTRIAN ? PEDAICYCLIIT ), -'B SlRfftADDq[.55 • ?°" ? SNfEI ADDRESS fry,. t 7u f1 nv .»./cc_ [ F_), "'F 1^ nY " kz.C? rKY II coo[ RnoNt NO D SfAIE 11R- .. ` 'RSUCEN5F?0?? ? L.JN. Srwrf zlr R RMON NO. I .L..• . ` ?/ I _ ?I G ? ,D DI n'R I I l ENSE Np, IAIf Sf% DAtfw nIRI.R + ? L. a accuvwrKw IRM NwMEepwNErw. Erts W'f CHI 1<ICnr E OCCUPATION z •3.' Z RM NNAF6 pNONf NO 5 NTIGNT CIGHr I Rx. L . ? ? CHECK (.? vin cit AS AH rMxor Eoi wloTNER: l $r CODES' a aA ;» 5 e emu ? CHECK (,I ENc., SAN=01FEO{ AN14Fawl 2 I M r iv HcI n rn[ CODES OFD w.uN. ? 1Lq E5 MN N Ass iiir%iN' t: N Io.erOe v . is 5 ix n DH r vEH YURDM MA0E000C(cHly 0 cl (l?io..Rbr wYw? Nsme uoo Lx1vY Y a ? ••rN%••,a ? `%ycI ? -11I D? ?„K° ? ? :vy ro l Y' _ 'rl]ca br41_? G ND.S VL?L 1 EYeR + tcHtY.s Aoo[IPART FIOYw) NI]o.. Y.r •«• AN d R SrwiF e I -?,'. ? ° p"L rRgEERRNE NO? I`S ATE H N '+ ? vfH.caoR u l m ]n ? '? _ U?(?T J°J L LcJ A? I A R A f No. E [[14 D VFHKIEIIXNNNUIgN NO. C vfn UflIXNlli wll NN ? s L RfGRRnDOWNE4 7 fIR3r '? ?:R' __\ ,/ MIDIXF pHON[NO. Rt ISR DOwNfR: lAtf iIR31 MIDIX( p 19-. AODRf55 CtOWN[R qfW"'?. N " ovmeR -.s? NAME RAD0Rf550 1N5URANCl co aq wGlNl E OAMAGID M[A A4[A y. He CN D? • M(AGED R +,f ] ie0rD r10ii' S ISI 'Dy, G[ ? ^vry ? RIMMNlD CHARGf r Ru'UiNr?naAiOH L J? ID AOWtDeY ??p ?AWAY ?RIAWNID tSl 1IL?.I?ri-o ' DIAGRAM OF COLLISION: AW 1 u r eKAU NOnH BY. f I?KO_?s sNLIIR WQSGRrI Row DESCRIPTIONOFCOLLISION: (us[swn[mlNru swlrR Mas5A4r1 a r 4 rNo.BAE?y?.0,,7 co.Ka?io 2ov.valuq COLL6 A _ I Gp ?? 1 `Y 'DJk7l0 D06'r0 coAti A?SnbvJ'T ,C oSbt3? RD + d SAD v,? 15i7?p w INK W, t? F!'A P ) N? L? NAME, ADDRESS $ INJURIES OF PERSONS INVOLVED * CODES I OCCUPANTS /WITNESSES '?,',IXw^ITN,u;?s? - 2 < 5 6 F Nww: f-I 11_:D G. L_L 1 i? s(K Ace IAI H'" msn Iner a. _ Alxa[ss ?ugra/JC45/A'I. ? ") h/ ,1„„ C', I? - n Hw.u NE eY AMR ?ICS ? . ?..:. O .`:I.s. Y . {L7y u NARwtar .MorrolRpM ?AMn ?;aN.l ?»? ;? I I.? lna I r 1 p L An.eu {io Y . I:,I. ? N. ?;,.,.'.A. HATW OI ? ?A r;S E ? ?., y wVE51K.AtN6pi[IeSNAW IRAht eADGr OR AGEHCV wI?S IN llr ?AMn 1 c{ /? iL• ^ D rDS.AIO?D Iart,RRnD DATof n.al.r.I ?r_T:,I. ?N„ ?„„u i' ??? ?„<? t i t J {?.?? r r ( n. -T :ri ? l?• ? ? ]m as ? ']Lm i:vi' I r? ( ? •? A.woVfoer DAR ? ? ? I I ? ? 6y ? yyy u, I k+ F r K ''?b 71 ?? luS Il "? iY? 4 N KGkil ' f?.Cr .L M14'o??.,.i ?(L L 1 i-? ?,. t B ?r 4?'? ?+ 2 6ri u ? ? x ,I t??rr?F,? r ? r ? ?. Y ?N ! r?.rlegy a1xt..? v ?r IfL4 I? ; L 't l .?>a? w 1 ?- f ? E ti s u? iN 1 YM G 1 ????. +: + ? F 77 r t s s .sfl fr .n r r ? 14 Y1??P ?? ,', v I , f n I I '? S r 1 ?s m rt r i* r I Gr ,"? li;' t l ? 1??r fir... ? ,^..? .x... r... ... e '? «- , M5 ?A MOLE` R STATE WASHINGTON ? OF ? W e'wlwEr O POLICE TRAFFIC CO, IONREPORT L_{.IRAFFICWgy ?O' G•?+ 1 POSH: sIAINr NUw&RY.. A. TE WAY :?? DAI oFCat N DAY u'u ? PRIVA •' w" " lusf]''?,DURI cou"rr foulrrw. ° Aa ms ul ul Orr NO. b 3 ' • / pN pE pN GIIYOR TOWN F6N0 DESrRfEtOR MLHWgr /? prUWµ F16 LV Uggl e "y. rt4uul cEYnDf?ss°O? gcr 'I°`dV "' 7 .OP1 wlrrF O4 r F sfc faF '" _ wNwrFRSFCroN ?? yHG?fO +? F ' E'?C"' RRtNR f vast -3] S fK ?`,}?, ]? DS ANf OR MN BErWf[N SIR[[lA SrN(rl MHF p _ ? r? annn»i8 RFS w E CROSSSIRFEr OR Nta4E3r MilF WSr p?('jy FEET W ACCIDENT eAafP D 4AM MfA e ' Of MILEAGE a } COIL SN)N NVOW[O' f. IOtAI NO O v[HeInIfEY D . CODE -- ENO ( i INJURED CFVEH CIfS ? ?.RROPfR1YDAMAGf ONLY ?N 'Nxgwul" 1N IMF CIS DRD35$rw^^•,r.OR ROADOIf wif4tNCE >] x•n . (? OBEFCr3rRUCK INnmf Of O[IRCr sigUCH gNDOWNFR3 NAMFI ?J"?6)/?? p f T ' / fs100.NAGF SptCyy coONOIEE kr / -, S s vERSNAMf UNIT NO.I sr `.J UNIT NO.2 0 VEHICLE /' L( I S 1,q /\ I?N raE .s NE.Mf, 1 ? PEDESTRIAN p PEDAICYCLIST;:L srwm? f ?I ' V I ?' DR F D t . • • O . Siwfl A[gw5s ? .E - cHr ' l0 f ] co? RHO?E NO. D Y •, y?3 •- R VAR ]vcoDE HoNENo gl ` - T1 • ,,.ES UCENS(NO? srAlF Ex Eu H :4 G a CI r R S I\S 4,,o0RL LA,A I n SUC NxNO xr. Atro uwl E 6 G V AI[ Mo - . 1 .: a OCCUPAIMXf f 6 HNON[ NO. /z IR3 4 "All IIRAIN R' s Z ?1_ _ 4?7?2t2z s mNl cHl E occuvANON AMta RHDNE NO '§ '3 'E ,vt ?..f spFl No 'b A R m N Erts wfw"r He ern ?• _ A" i p CHECK (.? v[H n[AS aH EMRiorFfaAN Y br` CODES?D pCHECK (?) vFHofgsaN (M%ON OraNOrHW'At r,.r RwH' NcI EA, A.a?w.c.ry? CODES 9 r ' ?•' 3, ?s ,°i ? q N . f p u rI ?p ra M o „ ?RR :;^ , r. 3 I L .;; .. , S, k T AuA mooa.cHEV 1 d ?MODN foARrNOVq le uU coNV., ? "" Ncl p u <r p ?„ c p ' :1a?Et < s? 1i SIY ZCi f E r„. YlaR 1 ?nfV) f+9UEF 1DARr,ruovAl pi,.WVy LD, 1 lKF Y f SIA1F qI vll l]Ue , k' E4 ngtE NO H veH.eao4 ;?•` a dd~eIDE°,rc.;,bfEF SS7 lnr'f? - - I A L AFN 7 C AIF 4 i 3 ` V fIf D ,r "`A flH L v '2 • etersrtefoowNFR. usr Rsr ? A NN ? i mIML air ,E C' RNONE NO = •?E: G?'r%? w>, 6 O csrtm wNI4: Lsr n4sr M,DrAE rvl NO. '{(?" r ADD4f53 (R OWTEIR W F _ N a n s avmte y eagooelssorwwawcf eo,typ?yr E ??s W Y rt ?..E.f fv?, 'I• DAinACE ARU y 3 13r. DAMAG[ CHARGE 'In 100 --aw U WAY 0 RtMA NEfD O / ?AW^Y eM?in,."?cNr - A Fom L1 t311DMUGt /' Jn •lU f ? r ?' .? ?JJJJJJ f wWMDV Y I • E ?. • lT• ? R WNI. 1 DIA AM OF COILIS ON: lu w l m ,.,D ygp[I" HY S 'eo ^?' . c ?{f ' ?i• l.?E/' sHttru NECessnerl ' oW DESCRIPTION OF COLLISION: (USESU1-NIAIVHFrr NIC[ssnwrl ???-???? rs µ? y V V Q 36 q "0 (he vehic? .:a f Sf3 i?Nborr_R.! c n opi K r/il : q 1 C` R•?C MS wA j{? ?' sK:. V'e? fro S f,.Krw-d e.,7(o I r ? rfl ? ??• _ r _ __? ti3rlR. DF 8fdd •., sT, 'tha i?•Ly(135? /zy , (ap3,.a c r 11a. , ?_ ?I'he_s.. Y?TEANyN,,; ..jy Tr•? M1 •?? 18ov 2-y ?1•14tL1(_ WI N of "Jl? c., d R e,r ci r ?_ te.. ?? 1rw(.: rtr_ Tly_ ? ^ k ?y ldu'k' ? 'As \rIt' .M "(k,A• o?ihA•. -1TNa. b', ki H b c:T •E. \ , nEeA.FC Ar.r....._ ..... _ _ h E: s`b?.: _. , ... ?lr.? CJ Y, LNti.? Sl'u•'!c ? - ? _ sIx I Ace ?SUluslm I._!-_L-:•. Iw 4. I I.I ?."6 x x4r ,? TnHye- ?,?1 ,','gW ?f ?"p I s 1 At "r? Wnau"I"1k"" `*+r+ru"°hKRwAlfr•vMt374@f "C -.Y.v'P tiL?S? l??ll ',TrF,??.wi al f 'ny.'(µ .l? ?C _, rl 3 y y 1 IV .a r ?v a . 1 '1FO s'.r '_ r _t f , ? I ?t ( } fi ? r 1 y t 11 ,1 i 7 L ? 1 r 5 . Z l Jk f - ? • ? I? yy h E i 1 h ?? ru. 'I '•., ,,_:' POLICE TRAFFIC COLLISION REPORT ?iRAF 11 AY POICECOMPLAINTNUMBER A 7 PRIVATE WAV _DAIE OE COLD x-.N.I_a (L IMF COUNTY wurvt"6 cnrvo { P I2y 1o i:Iw,D.I,I?is?i?. i I '?:?: tyslai. s) - Oua II I b E.FFEeSW ^J ?N ?E ?IN I.OAYEORIOWN /1 nFe NO.•O?$IRFEIOR HIGHWAY CES F'p S'EI ffCilON A41fy 5 ?W cOF ??E1• \a[, um Y/j .. INI SERING WITH. SIRE CI AD NONINIERSECIION ? r E ilfroSl 1 ^?1 11 ?r n RRffl% BFTNffN OQEST I}`,11 STREET a C(ZI STREET - 0 0 DISIANCEx DPFCION OMP L N .CROSSSIREEIOR NEARESIMLEPOSI q[[IpENF RM1P OIAGRPM D^TA MTE5 S E 1 MILEAGE _ if 101 OF CIRY I-tAcyI CODE COIL SON NV01V E E S D 0: EVER IYI %PO N!k rv IOa e:]pp OV R[i[vfNCE '4S ID}AI NO. NO.KLLED_ NO. INIURED- ?SPIUGE ? 1 RU WwONUin INI CLS CRCrS SINlf r4 .VEHICLES ? PROPERTYDAMAGE ONLY ? NINE ED SE R HICIf O01[CISIRUCK (NAME Of OBEFCi STRUCK ANOOWNfR'S NnMFI -1 ESI.DAMAGf SPECUI CODING USE 1 S 3 DRIVER UNITNO.1 UNITN1 .2 CFVEHICLE ? PEDESTRIAN - ? PEDALCYCLIST' ' NAME: VSI IR ' r ? DaIVfR NAME: LIaUCY \lA2l SO??1 K1c1iA I?wTRn?II S U A L, 3iPFE1 AOOPE55 IRfFI ADD If 5 plll 61 123 5.?, POX66Z 1-G?3ao CRI2 sure p RIP- ONE NO. D Try 31AIF DE D? Il cs? c.[.Wr1 9FCC& 6YZ) 6 sY R ?-j ( dl R % , L, DRNER ' s U CE N cw W R 983bS tiaNS Y N0 . ? / E I ' ' ` C'f? yf,? / l [?,? LF1Y?k?I Y?523 N? E/?JN ! 1 osllSY I/rR. v 0687 (I E % DAtE2p{B 1 E OCCUPAI dR {IRMNAN I ? - B. Ee PNONENO. EYES WEI i IGHT E CUPAIION II4M NAMEe PHONE NO. EYES G N 2 - - 5*0 5bl' ISO R - - 6e 14 68 • r ' ? CHECKI v{HCLFASANfMaaYEEOf AN-1iAl ? CHECK (? MASE + FH CLf AS a AN FMPtOYEEOF ANOFMRµ CODES?+ 0 n i a i s I a?w s°(°rr iF? "' n " A1° Y ? CODES ? G n A °siii: sex N ( e N oreRCrcl?. ^ss "' a ,Martz STRTEDoNg O ?z D 1=1 'IF NWOR oN ? M'w'A"`E ?Ct ? SIR Vf H YFA4roM ?E lpppGf CHEVa u MO ? v[nK ? v - x ? C ' a W ? , ) ^ v DFt lt ARI NOVA cjO SIYIf I]TD?R CpONV.) F L , V 8 1 I Nfv.l AwIXL[DARI.NO//V?3A( L I R - I'. 1 S CCl/11 be E E ??? ?? ?? .W . LICENSEPLATEN STAY rRaltR MtE NO. SIAIE H VLN. OIOR '? •6eoj Nubs Wn A Np. - KttP36s wN, a?u f 1 - VEHICLE IIXNtVIUFION NO. C L VEHIC a[GISR LE ID Nilfl All H!Z!91jI I r FIR Sf N O!31 IIODLE I I I I I I 1 1 1 1 1 1 RtDOwNfR; v3f {IRIE PIgNE NO RF N Q . Q I RR D WN[?? 1 IIRSt MIDIXE Np, ? SAt?ti? S f ] ADDRISS.OWN(R W A OWN[ Z N , pl [JI NAME { ADDRESS.INSURANCf CO. aR AGINf E FaePtees D4LbGIAS52TT, k?f llEUU l U R &-lANA Tn&Ntj 1 ?L?wO11lLCE0ZQy?(P AI /Pi " A DNAAGIO ARIA G wC a 1 , , i^, .1 D. CHARGE IrviI3F!C,ING jAMAGfD AREAA TD1 y IS L M O D N Gt -VIN ' '? g REMAINED PN[N ESt Ff.??/w DAMAGf , - J ?C 1? ?Rf OP Q AWAY IcD O O MAINO fG..V.IJ LJ 'D 3 OY AWAY LJ AWAY BY $Z DIAGRAM OF ON: IU uP N !.D-11 NORIH OCO le. I ,art[In NERSfA4rI. YARROW DESCRIPTION OF COLLISION: IUSESUPPLAUNt LSWEIFNECESSARr) w 1 I I I ..I. ?_I 1 I I uti??I LUGS F2r1 tl n yJ?g Cpl W?w U _ ' I 4T, LEont, ? ??kvL?i v?p C?Mt ' --- ,t f S;rtu?k I UC?1A , I . C77 i f ! _ TT 1 , ?_ 1 I Z I _ Ce 6x- (k P b _ u?lCd rv DoT OzMt b,< teit, i enl L lq?irr ?L , P .--- . he, ova -Mir V?xion yr Low r?lnSl iII u{ NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED CODES 1 - 2 9 4 _ OCCUPANTS/WITNESSES lust SIMMfMINIAI I. TOR N-,ONA1 NAMI AMf. " " 1I P, ..STK AGI ufU3 ' ry -NAL_ o n .^, 5 6 RES[R. [1[R M"r .n r A«f N mR a Ax. .1 AM n ?(ql`L ? "'Ih . ?My 011.7w ? T ADpRISS - NAIURI OI ... Aw. No .e R MpvI01RO« IT. ?Nn'mF ? ? Im r ?AMe. ? a A.wllf NA Uq OF .. _ I IGAI CMIKIIINAMIItANK I R?S X •1wlX pa NN 'IGFNC p,An Y4?/QI ICWD P¢ tW IY. ?AMe ? IOIKL ?CO'i,tt ? Va. ? V:l IP MO 0 II.-1 I All Day DATE rIAF??ppy? . %,E1'... V 71•.i? ,+ta5?rnlt?J'?- k '.fA OF s ?r n? l N u [I k 4 AN:r Et ? r Ik I fT` ? H y ? R 4 ? 1 v. q tF?' I 1 POLICE TRAFFIC COLLISION REPORT ?TRAFFICWAY roLlclcoMwANr NIRAAfR -/ PRIVATE WAY DAIl olcbu N A l oN nmE cour+rv muNrr NO arv NO InwA t$ ? ID$f ]RDINOURI lz $} M" '? IRN "IR'"'' o? 3 S Fi=c , or? . pUROAN ?? DRAT NyDR1Dw AA pN pE [3 IN NI ANO S1RIEI OR WGnwOV mllfs s ow of p,Ai iv(gc _? ON C o n) 'may CLS RWif O41fE Sf '3 l/,5r/Sp a MIfRSfCI NG Wtin SIRfFIOR W • ffpfE NItRS[CI ON AlrwEtN<"o. ?{ . / slwn A G t / RD s14IEI UISIAN<f6D VE LI fNG[. CROSS SIREEI (APF I 1 R [ O Iwll% R- N'— D G / M_ w S f P S N OF ACCIDENT MILEAGE COA IA RAM A y CbIISKlN NVOLV[O IOfAL NO NO Rlly -NO iNlURfp ? SR ILALt ?n"' nMOwol" O `E N ' 7 Rp I 514 1 R0.0MOR 0fERENCE IMfR ?l5 010555@EFIOR 110Ap - a0 •? bVIN C1E5 PROP[Riv DAMAGf ONty ?] vFSULIip ?vF iI N lI<1 SIRUC%INAMfbOBI[CI SIVUC%ANp OWNER5NAA1tl FSI.DNAAGE \?.6 CO SHCVI CODING l6E / ; </?cc + Se(, vAioNr f 3n• -° UNIT NO.I ' UNIT NO.2 0VEHICLE p PEDESTRIAN p PEDALCYCLIST 5 DRIVER S NAME: -1 IRI MI D-R'SNAME -1 14 t /z o N e? 31REEIAp-E CITY1._3/ 4 DD SIAIE ZIPCOIX PNO D IRFfrALI_,A Nf NO. RoRi 7b-".SxvD MN, ( $5 6i5J R Itr "A" IP PIgNE prvlTS UCENSfN 3 SIAIE wN / % M A N ? CAI 5 .5 I v vR lCtNSf ND. I "1 SIAtE 5! % . .. A f OC<UPAIION MN F6 PfIONf NO frYS NR IIfIGnI E "'PA"' FIRM E. 1-1 NO. I x ?Z1- tr 6i"r R p CHECK( Nc A AwGiNfv" D ' p CHECK(,,) -ATOR W" Mw11- A-I.EU v CODES ? t D " ' / 5 e ',"'" • CODES ? + a ," 5 I 7., up4rts N? /VC AP ? ? vN 13 "N" 0 DRR µ Y? X vFA4 Vrn MA%[IDOW[IV.l 76 Af'D/E -LIDARINOVAI s 10'D )DRCONVI E r1AR mA,I NEV1 v IDAVI NOVnr -1 rLC IROR.. v.l ? v oR n ucFNSt PIA EN AINR EXAII NO E H vIN 1111 N L A ME I AIE uII NO. /Ro w C W N C w f.? VINICLE IIX NNlICSAIKM, NO ? J / Q 61 / 4 / L v NICIf IIXN1IIICAII N Q s iv PtG15NRIDOWN[R NSI 11851 MI-I Z74/cJ; ?'a 14,v NE O O W u IIEVDOWlf R. A1 IIR51 MIDE Nt NO. a App Ressb R A I-M 3 /.3 / E '?a TaA'N tN.p E NAMl IADpwS5bIN5UR c0. O4AWNI ws A i R .- I IN U AN --[Rl? ' V J1 DAMJGIDAREA •. S d r.?Arli'M Urw.nwA 151. DAMAW CN oIX Ipl I^YN PfMNN(D w YSI IOWID <NARLI ?PfMNNfD 1D ?w?r w wva?N1, w`?n?n I51'UA\+ACI DAMAG ?D ARlA IoP oeono? ' L O N DIAGRAM OF COLLISION: yrurlnn N[CISSAY1I AN N N Ar W1 DESCRIPTION OF COLLISION: IUSISpn1.WNrA1 swNNnlclssARrl e Q NC/-,1A N0! W4` NORTH &0-0 ON Co RDILiZ ? .onq 4T AA`?vk 60 'IP4. Ht' 04 ?T ".c' tnST ' Co/+Y'Ra< AND 7Ne vENA HINT ov411Z TNF v &AN/E ANrl P-024S.0 / NT6 THE 13ARn ynftp 47' THc we/t?nrER ^c?k/v?rT? HoRSJC RcdCEJ. „ NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED CODES I _ a OCCUPANTS/ WITNESSES w.uNUpm N..w \I u% •L! 'A J ." , w s W r N AM! - A lxws\ 11RIp R v MMU, ,M pAMe ?,". ' n' .-D C, n AMI f 10 A pMIS\ AISN IM bV 0AM pr• ' pry • nvis ?Wi W MNSIgAIMfipIKlR Sr.AA,l l11Nl x C 0• AlH p No MlNir sI II+I <r"D O? la%KI ARwHp ? DAIIp wKMt APVw]vI O AV DAII ?! C.SO o/?n bm ws Y? + C ? 'iY `'a rn YPy ? _ 's 7 + ?r lE, YN ? T, k 4? ??Y p V lCWAY POLICE TRAFFIC COLLISION REPORT 14 TR PIXICECdARAINt NONNR V PRIVATE WAY / 1 Dnf i cau AY l I N 1mF cou«rv wlmrr NO. nrv NO. FHWA ^ / / ? (OSf >tlOHOUJ ,R..DI 1DD «IR xDN „ I SSl? _ Uu RAANl / []N (:]E ? N CIIYORIOWN EC NO. q stFull ONHGHWAY /-'Mllfs .®5 ?W ?OF (/ ,?-></ ON -- -1 LE 19-1 ROUrf WI Sr 11 Al INi[RSFRING WIIH?SIRtNO NON INIFRYCTION Z. SIREEI 6 51REf1 PRf)IX f MllE P051 ?? I DRIMICF DI I ER .CPOSSSIREEIOR NFARFSI MII[GOSr mnf F w FEi a ACCIOENr MILEAGE CODE RA.w DAtA CIX1510NINVOIVu, fRHV: //???? l IOtM[90 NOFIIA (_.) NCIANIU-_G_ ?SP IIAGF ?NII. RUN wx9NOr" I .RD MfR CI5 IN CfING 519lEt OR ROM 09 REfFRfnKE Cg0655iRtji O gpppp >] 6 VFHCIfs © ?PR ERIYDMIAGFONLY ?p?SUIIfD ?-lN p iN9/?C!/JJ 9 5eaC151RIxa(N.MtoPO.c-RUCA ANDOWNER'SNAME) fs1.DAMAGE ? ?• SPECIAL COOWGIAE ti 5 UNIT NO.1 UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST >' s DRNfXS NAME: Nf1 NR r MI ORIVfR's NAME LAST I lE 11- n rrm?? SiPEf,,1 (A(DDRESS nn IRtf 1 AODRf55 VAlf ZIPCOOF PHONf NO. D IY SVAIF IP .9t . 1' %CPc., £Y9?I. V?l`i '/KJL?X YJ'D (5 R g11VFNS U<FN \0i vrr,k 2k(? SIAIF cLam/ F= H Ma">w r. I 1 UCFNSE NO. IAIE HX DAIf OFuRIH ND DA. .. e 2 OCCWAi1I`W RMNNnEf PEIONE yD EYES WE GNt I[GNI lomiKoLC «eiy,?lo ?nti- In':Lrti l X IECJ Qi E R GCCUPAIION iNM NAME6PipNf NO. ETFS VIFIGMr HIGHI ? CHECK (.? " AHFm-1_.IAPmio1H[v_ I ? CHECK(. VFHICIf AS AN [MROVff d ANOrHFRA` T 5 l / 5 CO DES ? * 7 =S1 A W CODES ? + D c. A ° 51x a M K1o,.D p w,.« l ? W ? $nl. ? M V ? ? M111 ? C ? ? :.„ oNI w I fAN IDGDGE.CHfv.l tI IDARr.rgvwl StYIf IROR-CONV.I E Y 4 I HV.1 rnoallDARr VAI Y IZD9? v.l L N PU SIAI! RMtFR RAtf NO. SIAIf H vFH.CIX R l1 iSFPCATF Il A NO. lei, ; 1 f)9(. P23'F [.lll-1 HNKI[IOfMxIGrgNNO i vtHKlf IXN li v[WSR.IDOWNlR: UUtT I.- MIDDIF _`? - ) Z / `A b _NENO ^g - O ISR f w«f R: 1A51 IIRSI Au.., NO. z-i7il 77 , 1,2 . W ' AfnwssaovmeR JiT ?Ea>.^? .I JY. E ADDRE- FR NAME aADUrcsso wsuNANeee ORAUNi E .,I_ti b O L?r? _ w4w /Y' .3 'off G11:A S`41i.? V if R I u A sR p.WlfilD KEA ?nO+Diu HN 51 gAMAG[D Z. 1 E L ISl lC•o?- CHIY? n ? IWIN D YRfMAINID O CHANGE IOWIO ?AWn?" ?REMNNID t I. DAMAGI -- IU ?f?rl? I W w"? c,Ate IH DIAGRAMOFCOll1510N: f oOw e S.N lu K 51ARr DESCRIPTION OF COLLISION: IUSf$UtR[MtNIAISwHF.CIl A9Y1 ? . E 4 ) G • -? `/ %51 oe/'12t? RjAS J041 isv". J L'/,'rr?S - I _ /l _ ,, Fx- v-,- B+= '5> OF I? NAME, ADDRESS B INJURIES OF PERSONS I NVOLVED + CODES 1 - Z 3 4 5 a OCCUPANTS /WITNESSES ,a: wRixx?i"a NNwe"i ii sre AGF IArus ? [' nsle. fntr i ;". « AME ?,nrC'tii i;f;; r; J ?s•- ;???:.?.' "° - - r l , . ? Dlwss 1 .. ?,9.1•r '7Cn, ;,.+:+...E:.1 INR? y', " r, e. " a ?"T" ? % ?iL:.?„ H eD I cy ilda MDVIDrREW.?^v ?" "0'" . ?» ?o` ° i s u xrrss N AiIUR?I?sa FM n.. ? AMe ? ?: " ? i"I;. I. ? h: ? u: r .`AtStgAlulO-11. SAME a.AN. a.FYAM .D w .GF.KI vw, IwHAtneD QLmt.f:, AnIM p an OF N-1, AMROVID er DAO &."a a k T 'S . x -__ •••' 1411 " vn[ _....__.- 'o'-COAINNNTNww DA IXu PRIVATE WAY ",+•vTI Mf R. ID$f RRm HDURI <OUNIY OOl1NTY NO. GIY NO. _ ' NWA R ,wN R j ? L fc3 vIL "' (o 0 0 7C?YSoY1 ?? 0. ueu ON OE OIN CIIYON TOWN E.NO.OFSTRLETOR WGNWAY Cl5 s W ROUtF OR ? ARLIS $ &OF pN INiERSECiING W11N:STRF RROAp NON INIFR S EC iIO N , ,' pgN% F MRE p05T ? ' ? ? N BfiWFEN WLY iS T? yN'E[i 6 S-Gh%C.- ?if(?t ? DISIANCE.OR Mif ? E ,<ROS55TREF NEAREST MIIf PoS I N W ACCIDENT RAMP MIA, - - - .. MILEAGE S- EFT OF £6G i I ?04J CODE COlll'gNINVIXVFD. v[RITY. rA lESn D GI SREETORROADORREEf PRG NO RIII[D_?NO. INJURED / N wNDNpIN IMFR Cl5 SIR[FTOR ROM OTAI NO, CROSS EY VENICE, F I S,IXEH 0peppIRTY DAMAGE GNIY LT? OBl[CT StRIE<RIN YAI OF CIBIFCI STR ' . IKR MID OWNER S NAME) EST. DAMAGE SRCNL l6f TtLG ? I O ? c .R_ ?t 13o y .. - I a UNIT NO.1 UNIT NO.4 ?VEHICLE ?PEDESTRIAN PEDALCYCLIST S OR -5 IF ;, UST mFIR I ORrvfR'SNNAE? NSt R _ ALGN Gc7. 1 en;x s AmRE TNlt ADORFss w 2p Y [NO D I STATE hp Cm PEgNf STAtE "pc" o?T Tb 9k3 6g- zv,o R NER'SIICENY CAR R N I lI STAIE DAtF? .IRirv GD?i?6cF \SN? i=% ozAa sz v NEND OCCLgMKIN NRM NAME. NrONE NO. EYES mGnT NET GNI E OCCUPAt ON MNAMF. P-1 NO '••. . EYES Wt Gnt IRIGN I ? CHECK (.? VF.IC AS AN MANOVEI a AEo,NFe A` ? CHECK(,) I A A a O H M '"" A F AN t Ee D c CODES?* 7 5 L 6 A'O "CO1? CODES 11 n s l% a p'''°A In ° F. I DM T S wJ:; p A-- ? H YEAR MARE 1CN MI P ' ? tb.,I. ? ?. ° ? ? J4::±' ? A 11 O u R 0 M.'. ? M RV?-11 , FV.I 1- -? LOARt ) sTYIFl]DR ONV.I a H. YEA Ana L1 1 YIR .1 l ` r , j E >a I CENEtPU $IAII 1-111AIINO. PAT H Nn.<IX R IIAILI 1 EN F763 1 ATE NNKl[IpLMIfKATION NO. i vWICIE IDFNTIII I a z Fr4 9 RE s RepoWYaR: IAST Nasr IDIXE `- • 1 L .l)-.. ADORfbSpoWTKR PgNE ea. 3Y ' z v 10 O R RE OYMFR: IAST FIRST mIDIXE W ENO. 6rl ?' is368 A N[R N E L)I NAMI.ADDRFSS---. "` a Nr I. OR O' LLC er R ?E OAMMUDARU • _ ° - ?' D DNAAGFp ARU ' ./ Ibiorio: 11 [wAAGI a _ CN,vW M ?iww wr INTO OURD[ ??WAH ?RFmAINIU ;: IsI. DAAnwI:! I ` b _ : TOWSANYDeY • O;,°,Y^fo r er: S D?'?Y DIA R/1M OF COLLISION: SIRF1iu N IIC ?TQRNORTn 11 KGSSARYI OW DESCRIPTION OF COLLISION: loss sllpN[mENUI SNE[In TaussARrl • S IL- q Yb 'a0 _ v ?-Y\ . I W'C, ?OUI Ew ONn j AYeY V L?G ( ` -? - I r ? ? ? - b „ Rr- -- - ? ^.._?' _? .?. .-?..? - _r _ s. _ ___ .._.: - aE T6?W Slru er lv. oc1C ?'4\, I ?y? IlY?C I•NL lu r. K*lAY M0.3 •Tr' ' ? Y G.IrI SR -YE O.Iw L ro1St1 1 .?., Y1ct?1?IC llM+J IFYu olA _<? - " l:r -?\... •Tr • l F/fYfX YrE a(tY Ylr? 1 ? P " </?¢?C Ih E k. lu q? Y. VeA'l:l'I G C I ?b ' ' 4?r . ?1 _Rrssw? t•cST G< C C7v Y.+\1C Cw. 1".. ?' ' NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED CODES I - 2 9 4 5 6 OCCUPANTS/WITNESSES i-bo",'O'"`N:'.?IA°A?F A i? SIR Act IAIU • ?,;;„ ,H. [? s R A FSTR (K[i N AV: S7N? G>!r[NHa?S t"a a` s Y %O r z 1 FU v . "A gar.A r nr ? e ..I Q rr.I . 0.7 ?i43{,+. u E1_Sp vA L KGT rt lye O' i qy- Z•(7D l s +u+lu S 'nom u? N DeE OF R MoYID EROM 0,? ?.+I O ?' . O My ?': 'D NAw ?LYR; TcA- /' ?• •: ?:4? w S S S •2't !O s , ... r SpGAlwGprKIR. HA`I"°J °' , ar..- 1 Ysr. ? ? O Hx ? 7211- MAAV.FANE eAnu CM AGINCr X vMILV KID SYAICERD Id Kl AI91ND DAIIP Rippt ApIVOyIU.Y pAll M1sl E NI 'A ?d s y?' ?ri ? LL j 4 ?C I POLICE TRAFFIC COLLISION REPORT p<TRAFFICWAY OKECOMRAINiN HeFR PRIVATE WAY ?I ' Mrf Df qlI I??3 + lI I I Yx YD YIRr n lrr m ,Imf C (DST RFW Nouxl 0 S' OtINtY S F r o COIMry M. GItYND. fNWA ?D?RM ?^ ?N Qf ?IN GIIVDRIDWN NAMEINO.Of T.-ORNGHWAY ?. s rWUS Q& ?W Ede{ G - Yv. ON :G ? ROUIf ON 51 ?R INt[RSECfING W11H: e1R[FI OR NONINtfRSECtION i PR[II% MIlF PD51 ??? '- BETWEEN t ?. s Er :./ s(a[u. DIBIANCF eDIRtC11 { iFRE f . @DSBSrRfFIgFN tMllf WB ACCIDENT MIIfS ?• `? MILEAGE ? 3 fffl DF C CODE D MIA CIX1I510N INVOIV[D: SEVM IY 1 UN NO. Ylllff NO.INIURED??0-- lO1Al NO wusrv rYAUOw°rH I I RD ME CLS IN BIREEIOR ROADOR R[ifRfHCf CROBe51RFF10R ROA D . Di VfHCIFS ?-K- DAMAGE DNtY [jF - / ?lOQv - OBACi e1RUCR INAMF Of OBEFCI SIRUCR ANUOWN[RS NAME) EBr. DAMwGF SRCW COpNGIAf UNIT NO.I UNITNO.R ?VEHIaE ?PEDESTRIAN ?PEDALCYCUST 3 ORNFR'S NAME wI {IR 1 MI DRIV[RS NAMf: wl it I l aYKIn- 'zwAi - srnFT Z7/p is .c _S s RFFr wDRFSs D -? ?i1uIF <IRCOa ,ND3C s+` +T 1 tiL c??5a ?/ `I?36Q »DNF D R r r sulE -c- 7,- NlR's UC[NSE NftKPtipZ36;o{' s1A[E W{t N? BIRTH A °(°,r 64 I V. FNSF ND. UC IAIF F OwIF OF tlIRIH Dr Y. occwAllDYF NRm NAMEaRHONf YIO. Irts IcHrM r E OCCUPATION mNUAFe RHQVF ND. Fns If IC"r h !h li A1? 011 !f7 ?r R CHECK (4 sa W.HOrFEA ANrH[RIA' O A ? CHECK(?) -Cu AS AN D-1(t DI ANm 1, EcA` CODES R n A `s s r C"°•' a • rin rH CODES W ] 5 I n +siO " Ass sranm N ue ? C SRR I UEI[ I r ? °..i'e1O .Dm p AM.,I,N<I ? ?5' ? ?dHIY ? ? . ISr "I I ? AMYA.MI ? m° ? Ylt.lY ? ? , / MA fI CH[V.I _HID,vr.egvA) 'IRDR,-CONV.I rA I .-.) MODEL (DAxr.NDVA) rul DR. v.l ' NC[N RlA srAtF xARI-All- I'I vtH CCYOR AR A I Arf ?/v. ( Ff?E zrt r1 - 1 V[NKIF IDEMRKANON NO. ` VFNICIE IDFNUfI 11 S'.+ E-12Ttf 3 266 a3 RFGIBRKD OWMR. Wl NRTI MIDMf ??`G? rv?ar 4? L r PqM NO. O [ ISIExID wN[N: wl iIN51 MIDDY Mw - (i._ ADDwssaoW.YeR PO/3 //7- a. -' 4 it N w o«NER 41 NAw1ADMfsso nwRANCECO. AGFNI IIAT Q I u AN 2bZll ,TCFIT-' s> MMree Mu Y RE-iod6w > rlw,c?iorDiN [S ?rfMeoAGI H.w? L ? A NIN `OxFM IN HARGE ??Wy1N ?R[mA,_,. AY I- ytliowr [:I DAMAGE DANA FD ixu ion S $ 30o 1 4 11 4 1 L D A-1 eY !lIJJJJJJ e , A'l r DIAGRAM OF COLLISION: I . , -2 -1 5 - NIN SMtrRMassARrl H DESCRIPTION OF COLLISION: Il4F elARI[ME `s f I 41/s' - -- .V /R+T 1. Dl. `'FY.( W ?j?afiC. ,•<.t. ;?T+ }C=-hF[4 " -° -s ty..ck 1 '11?.. dic?.Y a.A.i S?+uI.. :<. ryMAA.r? / v ` Y.? ? 0 evJ Cp "r TV 4 ,%Y<' .YC: N.YZC 1? - - -> - ? S'Y?uc( ?ll? D?< c?Yw I,/.i:f. c:?fahJ w..k?<, . r~ cJ?4e1? i'A.ll of c c-4.. JU, L ttc IA.43 k.v..rr..cJ b p•`+'S?"t vrYOID.%.1•? 7 IY NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 3 4 5 6 OCCUPANTS WITNESSES Ia <s,1°?HrA"l'uNw feii x% Ace rAlu• '° R es. [n0 N MV A DD.eu wnlY or v ? Am IM eV e ? F.1" ? . ? C. ?.".H f JO umf NO A gVEe1 TINT DI HMOYIUIYOM? ? ?"'s ?r ?ri° b H MV F A [AH11 NAilM150{ tM Ar ?AMe ?xrcI ?[nHY ?5" ? Ii + 11G.YIYYO (YRKII5 iNW 11Arra x eID<,I pa b M NANCF wI cSu JVYar KI DISMICr4D 7SDO?ls CI ?RYIN / l 6E1oDins U AIIh YIHJYI ??': /}• AYroGY(DBY "I DAII I -crrv- ` ` - .?? h +.hs lv v 7 ? l + . . D$ 4 7 f? "GC' ?P y???Fdn? 1.2 May I ' J POLICE TRAFFIC COLLISION REPORT LZsL-r'LVYM' P«¢ECOMPUINI NUmpFR ?/ PRIVATE WAY DAIEOECau N v DA urs aN lu+ wlD Ivln I. s•I tiR . umf lust x•m H- courvrr murvn NO. / cnv NO. HwA ?ua ? .?? s ova s 'j'4fFK.zse G URAI ? N ?E ? N CIYOR-N E6N0.0 SIRfEf09 HGHwnr -W M ROUIf ON SIRE SFCtI t? 11 a mJlf3 ?3 W ?Of E VN f 4CLLC ON co p 1RSfCiINGVA1N: 51 ROAp NO Ni 3FCIION 1 PREII% f0, MIlEPO3t G•ZG REMRENI, os- 4 StR[[16 -4 R 51REE1 S 1 SNOM RIN.' I.. CROSSSSRlt109 rvFARFSSM IF 35 DISSANCI-Pt ACCIDEN E I DIAGFAMMrA / [3 [ w 1 r[E DP J'? VCs STS E MILEAG CODE C ISgNInvIXVFO 3fVER 1Y: (1 0 ? SpILUGF r1Il6 RUN INJU9FD .H NO NLIfD?NO wNSIN wNOwo,. n %RD IMfR Cl5 N CSIM1' S19LEIOR ROAD OR IMSf9fNCf CR=51Rff EOIRIIOAp 111 23 _ . rOi OPA CI[3 0 PgOR9Ey DAMAGE ONIY ? p[ vFaCIF L ?J ?JrO •C '[) OBACrsivUC%INAMF 04OBI[Ci s1vUCK ANDOWNtPSNAM[I fSi DAMAGE SRCIAI CODINGIbE 7 Ra a SNoE.?tiD'C s O ' 'UNIT NO.i UNITNO.Y ?VEHICLE ?PEDESTRIAN 0PEDALCYCLIST S IVER'1 NPMF: UTI IRSr MIDMF RIVERSNAME. U51 HR MI IXf ' 1) q- C J & C, b1 r.t A SIREEEADD 51 SiNfFi ADDVf55 e2' 7 GZJ!??4AM Avw PHONE rvO C E D PHONE NO. IIr SIAM llv< . OD UIY SiAiF ZIP pE lS Ld•N `f !w R % D9rvfR'S UCEN5tN0. S1AI1 A OIEURI. I W u tN5F n0. IAIF E o•r r. .D a NN 6D Do Z V . M4 OCCUPnII Mrv E. HE NO, EYf1 .1-1 E(IGM S E OCCUPnIIOrv MNPMF6 PHOVF NO. 1111 vnIGHI MIGNi 5 ' Z. US N. R /HD -D7 Nqv R . HECK (? <iF AS:IRiMPioy[ aAPmorHlelµ H E ? CHECK (?) FHl(iE AS AN -111 a ArmIr'ER. I E CODES' 5 -1- a Mip1OKr clro CODES ?' ] ais i:sn:ro 5 In v e iA;iD?'c' yy .t IN wrt AIUR1 .1 om L M;;;Dm o D.H<I a <' o zsrN. ? t rs'H - • NA r o M? '191. ? ? [1 ^Y 11 1-- II -YEAR FIGCHEV1 MODU IDARIHWAI lYlf lx04 CONV.1 5 M1I1AR1OAI MA% 1 .C Hfv .l fnR N Y IxO 7 Paoli t/ V4 r'( VAN E OR ICE EN SEAIf IvAILERHAIf NO. f H I vFH. R All AE A Ill" -11 NO, 1 -11 8c"`` Ps s "ti c VEHKIE Iq NIIfIGIpN NO. ` N+ . rfHl<IEIIXrvIII M DIXf rv rv0 OwrvtR: VS! NR31 MIDDY NtG15RV[p PIgM NO. O I 1 R -ER. lASI SIR51 R . DI V MAo- W A -1 31 i'` AuoRFUa ow++ER N 1? 1 7? GLE NoN Avc E ORAGENI D•AN. S NAMf.ADORl53OPIIRURANC1CO. PIK)N R D NIASSItl IAG 3 wci•ovu CHARGL ti' CIIARGf ol.,•Nw.r lAMAG( A?fA y r 5 E Id:'aEi:? 1.>IMpMNGI ASIAN ?1lAwMD ? ?? -A, ?RI-11) 1510AmAGf .uri: - f 60p i?Der, ? ?oW.D nn f INIXCAIIEgRIN DIAGRAMOPCOLUSION: 1 RNOw sH![IR MQSSAir{ er A DESCRIPTION OF COLLISION: lus[slmnEMENEAS SHenRMnssARrl CoIR? V-cHl NR/ - SDETND.?ND Or,' I+ /1 b--c,OFv To P4SS A 4 Mtwl'. vi H•. H4-/c-Ay 7N1R,vag7AV . va A R4PPEOi,;r APIZagWr . .. VZ.04i . TNr V'EH1(-1,) w4S .D4LvxFe ,. O FIV THt' 2oq.? Te A vO/A A (Z,.L.%S?aN Al- b ' n ADDRESS & INJURIES OF PER NS I NAME NVOLVED CODES 1 - 2 D < S 6 , OCCUPANTS/WITNESSES iol:r[IwueA%SE? ii sl. AGE Ur : NSIE. In0 :;°i. .uwu ?iuRla 1 e., ?AMe ?2:f" O" .057 ?L"". N•ml ? JD •rowu NAllN101 ACNIU SROM ? AMR OF, c ISM • O Si' ? I:° 4 0 •DM155 NAr?fsa ? I:° ?AMe ?,O1R' Qr=H. ?".H e . r p•n .EaaiD ? X ..vf nAI..GU.l lctrsNAw s..N. NO .cFraY +,.n. 07 J<? p7?/3 6rt ? + ?_?.5,- 2 c s n x.D5 H.3 s.n l,.s T??K I ?q;. ar '9 :; v n:..:.1 ..a?i 7rk:s3'•'?Pt?iNY%V+?' ± ) .? 1 ,an<di'? U? &S?q ?K? i?3F 6Rf17 "?.LNTi?;!3t . PAu? 4 .u If n : # V ^ ? L°n° 7 f ,?? hl( T?ykYy'?ZI '? y '41 5 I E ? ? . ? I ? l ? ? ?1 h I Y _ ? { t r ` ,' it I S 1 1 All s r 7r t?Y 1f > ! N - ?V4?5 Ir.'j t r. Xfi {', 3 ,y Mf ?t :: AW.- _ S L _ - A _..._ a$. ?U auNA v31H ?a, TATE Ur vvASHING'ION -- _ L E(n.rce?sr.. 1 t - dJ - MOTOR VEHICLE COLLISION REPORT NO ? x L I'" COUNTY NO. CITY NO. FDO?L3o +DD?a °rN IF"oew ?, i? ?::? N ?i '? A{ R t&" . . LU6k 'u,? r r_.? ?,. i Pxl 1 J li ?A?y R ry k -T^f l .i A??'GT¢?'?fF c I 11 1,r ?` 7Di1`.?.a, 1 I ?N ?L ?N ., H "„1lwy ° D 111-5 11UTC B ?w gDF cLC m ON oy 1 3 ?</f5`O' 9 FPS[c x nD Y\A? n E_ rvI s[[NDx IT. , rC`1 l N Ocx Upfniiv r•.G • "' 1 r 4A.w DATw 1 ?. ms o ?ED E 4 "oss FE D ° a:LD°oD"n o=E eo ow e CT4 C[F v[ o :? OBJE 5TRUCK ,LKKI OWN E.OFOBJECTSNAME AN. ADORESR rAlnDw i [ c[uDF VSl - 1 r1 K $ gffm { •. DRIVERSLASTNAME.. ". FIRST NAME..;. ?..'MIOOLE FMO,CTNAN TwOCAns W"U R" DRIVEfl5 L0.5T NAME .,. E M ttl • FIRGT NAME.': .,' MIDDLE.,, v re Bc-e-erk-n 0 V'N n) . .. .. .i -... .. ETRE T....E - ,. . ROUTE NO. AND BO%NO." Oxs wER STRE TAODRL G ... .. ,a. ,.?.. ROUTENO.ANDBox NO. a C.PLY R.Tl AATF LL HOx CITY.:..... ITATB ZIPCODE A 8 ORIVER'SOCCUPATO FDnTfDB CItY?w .. STA TE ZIPCODE DRIVER'SOCLUFATION ON.- LICENSE NO., STAT E SE' DA OF BIRTH AGE r - DRIVER'S LICENSE NO. .,,.,,, STATE I' l ?- .DATEOF -ITl 9iAG /? C 2 WA 71 I l , J. A VEH M E CN -0(I EI MODEL INUVA-0 R I Q R D.J VEHICLE YR, MAKE ILIIEV 0004 1 :..MODEL NOVAUARTI BOD L 0 .Fi 99 ` M STATE TR fR PLATE ND. - LA,? N BT?4 LICENEE YLATE ND. ST iE .? J. TRAILERPLATE NO ..3:?SF TE al W iy VEHICLE IOENTIF CAi10N NO. PI yEHICLE IDENTIFICAT ONNO. •- ., ..,.w -... .Y REGISTERED OWN LASTFIRSTMIDOLE NAMEI DRIVER'S LICENEE NO. REGISTEREDOWNERILAST-FIRSTMIDD LENAMEI DPIVER'S LICENSE NO. Qi Ow ERS A00RESS TREET,CITV AND STATEI GATE OF 0IRTN OWNER'Sa00RE55 ISTflFET,CITY ANO STATEI .DAi OF BIRTH ARTSOF VEHICLE DAMAGED n ?nvP[giF FD (ARTS OF VEHICLE DAMAGED .. r. YHIu ! LIABILITY INSURANCE INFORMATION-VEHICLE NO.I WASTHERE AUTDMOBILELIASILTYINSUTRANCE COVERAGE IN EFFECT FOR THIS ACCDENT ONYOUICAR DYES ?NO A .EANO ADUHESSOF LIABILITY INSURANCE POLICYHOLDER 4TY sT,tl Jr NAME OF LIABILITY INSURANCE COMPANY... ., AM AN. AOORESSO LIABILITY INSURANCE AGENT CIT. SLATE Nr LIA"IL11111LICYNIM111 ISi IUD- AGE INDINJURY. NEE MIARATE 1INIFT FOR AODTICIAL IMAIAIED AGE' O `ss N VLNICLE KILLED oierME ?,I NIx?x4ni •q' •rp LE ?r, KILLED 1-11Y ofe - ' H7IHG rvIul OM rCO?i " D D[:; ? ? ?NO[srgl,rv NO, , or ? I , ., El 50 ? ? 50 60 7 O MOTORCYCLE SAFETY: ?HFLMCTUSED ?HELMET NOT USED MOTORCYCLESAFETY: ?HELMET$JSED ?HELMET NOT USED SHOW NOIITH OV ARROW IN CIRCLE DESCRIBE BELOW WHAT HAPPENEO: (REF B TO VEHICLES BY NUMBER) '? •: Ix FDN AM K14Xto ;:,;` M F.F + N ? Wro ????;?, Sa•+-kL?_oYV4rr'ier_ t?cl .T} wu.o c?Prk.ar?l9 catY?tq l?cLrd,_ wcLSLuL? n - ND . wDM.I. E.K" YF.a[ ,"D 13e.lwoeL- y5-5t> PH S r oL=? Gled e? SrrcLL1 F -p? beec MAFIT D, +Kxw.. - •-- _ 1, _ - 't'L.,f.,!N. ct.vN61-.'Mn2C<_\UfJ.•S'--0.CY 1 1• h L ?,. ~ a.he,..L _ L.LcY.ed.:?t eel_-sha.rply_-1o..-..._ •e.._w _ _o _? 4e ?•9tik t p.?t on. kLe4orrlceS,.y.cavne._ ' _ __-? hLL-L•?. L r',Ar> w. 1c lle OL•YL cl.,. IC) 2 ...co.!1+rc y c_c.E.r, ? co c• -5.1-ari-ed b - k d E 4 ' - h 1 ' - f at O-v% A: Ner,n e e_6 OC Or t . G i.e., Z t.,; i i k e d I t6h r w4E,a . 4 h. C l " I - ? rcw o? ac.rc - cLv d i -A-e ;&Ls ll l 1 d? -x ' l e [„L?v, ?ec (. FW - •,2 ccLr 6.f •e.V loa.nlc... t IHICLES POSITIONS OEFORE COLLISION' - - K t N fff l DN 1r.e(ro. a -CORING. ITOIIM'.. ? La ? ? C? M,+LI ? 6 ? ? M 3b. n, . fND, 1(BIT•`JIW.YI {A(-?3',I ? PEDESTRIANIPED AL CYCLIST WAS USING: I ? --'. I D ..L.... I ? -,... . L] ? ,ai.°.[, (? i; ? ?. .0 ...... r D i:i a"o?ii (? "D•I PEDESTRIAN/PE D AL CYCLIST CLO THING COLOR: ? D. I? "[" I ? "? .0 ...........r. (?Y?"ot%:tittttii " ROAD W.IACI r "91THIR IONIC ONOtlIONS iRU r6 CONTROL 1111.LOAD DRIV( [MICLIACTIONS u " K,1 • Owsl 1 ? -LIGHT + 1 K'+I[.4NII I NI+K KI I H I OiuD.II I Kxl<.OxT O. x " M I?I??YBD2Q. 1 ?OAwN • ?SGN.LI ? C) 1 ?1 ;?[W.v 1 p GOING ITRAIGHT AHEAD ? 1 ? 0.r 1Ix..,.,AD `/II S ?pn, ? E ? TV 'CH ? Z ? TWO wAY ? Z ? OVf.tAKINO AND PASSING 1 ? .ET 1 ? {NOWINO ' ? ?IGII"T10Nf It ? 1 ?'It,. ON ? I ? .O;O.fIII[ D s C) MAKING RIGHT TURN ? ] ? INOw ' ? roD El li;M1 O1I 1 1 ? s ? ILAv.I NO Rm Nr[RCHANaI C) ' ? i .AMn OO ? f [3 MAKING LET T TURN ? . ? IC/ (? fI[Clih 11 ?ft?Ilfl10N1{ ? 1 ? FL.ENING AMII. q L ? { ? ALLEY ? 1 ? MAKINGUVURN OrN(R ? { ? V(c", ? .,H'. 1 ? 1 C) RR1 GM.I 1TWsyDp ? ( ? L?j7NN ? 1 ? {LOWINO .pAD,r.s'CHA. i Y't i Ill- CiiCI .O.DWAY wR%IAAC?[I?'ll I ? r ?O-CE.FLAGMAN ? t ?DRNIWAY ? 1, ? 61ORMICIOR TPAI/IC • l 2 `?"I L b O I Q[M.[AETr LJ 'LP'•" X6 ? ? ?D ? 1 ?DTH[,VICMY ROADH1A.AlION ? 1 ? aV Dl0 SYCHN DA'SIGNAL [3 (' C] 01$TVIRON ? { ? IT I V hffi' ,I E. 1 } I ,?,Ti. l e5<77 ((''?? E F l ?? oI [D IN RO O .A r 7 f yltq! i C'6 ?r 0.o'SD.4k [(f (aEID ?u on D{o 10 ? TAR T Na IN L (: J?•5? I K ? T " D>rI " 1' ?? ,.r _ - F .f yu?t 1 wle a ;tY1`??Fi r nl : r {p? 1 - IT ? *S X _ b 11 1 S ? 1 1 l iFl r+j? I k h i d y - 3i gR Nu 'S ? . Y 5 E ? W w " ? t ?r p 4 ?I TRAFFICWAY I Ivu. LJ POLICE TRAFFIC COLLISION REPORT ' _.? • PRIVATE WAY ULME COmrSAIMNUMBER OAIf Of<IXV5 AY -ILN RRH IuI f Ir1 f ? w vie f • TIML IVSF^ ?O I• COUNTY ?/ a [OVNTY NO. /? CI I, ?UROA URAE r'lN ?E ?IN 2 MILES ?5 ?W ?pf IfrOR (OWn NAEa NO.OE STR[[(OR HIGHWAY oN N 'a [Gl CLS NWtEONS(M 3 93/So xCt B NI.-ING VAIH:-Ill I eOAD ERSECIIOn / BFIW([N 5TRIll CI(J STNEEI PREFIX f IlE PO51 M ?/• 93 , DI TAnCE aO NEMII RfifRfnF .CROSSxRFF10R NUet MIIf v051 n[S S FF[I Of ` CIDE MILEAGE "CODE"' R DIAGRM A COIIISK)N NVIXVID xVfeDY. ? PIIAGF H NO NO RM1l[D_. NIUR[0 ? IOTAI NO rn llsN •,Dn DIH XIIER _ .RD NI[P CIS ER CII TREfI NROAp04 NffRFrNCF ROSSSIRfFTORROAp RB . n CR VEHICLES W RR0R(RIYDAMAGf0NEY ? jE ? EH1 /Q 9 ORl[CI TRU XINw fMOB ISIRUCXMOOwrvfRS DAMAGE I " SRCA CODING bE S UNITNO. 1 ' UNIT NO. Y ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 3'• ., RMS rvAMF: LAST FIRST MI DIE D ? L E ER'SNAME UST NR MI IXf sTRFfI oDR // 1?1 Ss/f Gyi?/ D mffl Defss oI ST zmcoTA ENO .__ 3 N o R -1 -11 nR COpf ENo NERS UC Nx NO. SIAIE fX D If rB n ^J ,5 A I V evFe' lCfrvx nO. IATF X 1ATEOfBRpI 9 OC UrAINDN NArvENp. EYIS N4 GHI If IGNT E VHONF NO. EYES WF GHi 1<IGHI IXCURAI ON MI z do R N ?CHECK(0 1N rL(a ANOTHER ?CHECK(r1) 1N(HICIEA tMaovttoFANOTHEe?I N 5 t CODES 1. 3 ,s 5u A'S"„° ' z VV IN RI _ 'FK ? ?u ?n'; 1 ?; M ?^ l ? k ?M11II ? ? V NH rGR MAIf (DODGE CHEV.1 LID?T.rvovA) 5TYlf 1109. CONV 1 YEAR MAX 1 nfv.l MODFI RiLX)vAl H l 1I R. ' E m 6 aoe uaNxrv surf An(e M1A ENO surf H veH eaoN 1 , A No. AT 1 L H r M NNKIE IOEM ICAIgN Np. 1SA: 110 62.7, 6.5 0259, 1/ 5 L vE ICIE NI I i R[GISRRfDDVmER: 951 IIRSI Mlppl[ -NE ND. O R I IfREOOWNfe: LAST -E, MIDOIf W li _ wpORLSS CS OANtR N Owrv[4 A ' N•Mea ppnESSa mxnANCfc AuNr R ti N n5"IIS"Zftb" AL4-'Eff+T- Jz DAMAGED NfA 1A OMAAGtDMEA E __ CHARD CHARGE ? .y a Es wMnee nINN 0IE-.NO ?,°•wE"`,r" ?R(MAINED Es DA •Ge 1 f Z ihAioeY WAY ? lOVAO f H nro<ATe NORTH DIAGRAM Of COLLISION: E sI<Enr NEassAVn er•veow DESCRIPTION OF COLLISION: IU513WMEMSNIAI Sr<EIn-XIEAI11 ' u O-? _ T,sic G/riYitcF Gr,--r Tyc /?09dyi4 - ea T.s/e rP. wr .(loaf .• /T 7-yEx! ? m 4 - - Cm?? ori ?Z/c i9a,sd RatsUa w F r G ^^ j 1 - - - F Tyc , er oi,a O T < iGc L a ! fo?n? 7 ?PatTT Dor.?+L? a- C+ • " Ala ?S' Tv? ,(30ntC? Iv NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES 1 - 2 3 4 S 6 OCCUPANTS /WITNESSES ;p,I; w"TIEONeirH(Iwi ii xX AGE um xI"' twn ASV • t<wu NArlnl Dr • (.,Fer. 0- ? ,0"o ""'r ?^r: CJl'Mr . .•A•r r:o N ro • (MLltt NATURIp fR :L1fiv IroM?•W ?ri<'?'[•rinr?+ ?r".DT p rq • Dnn: I".,ele`".?°r I er ?AMe ?1`::'?'L"D:e. ??I: ? • <? Wpf<IeS r,MV 1• ? euw(d AWHCr KI DIxAT<N ro Q sronn rIXILI ARRIND zm H.s p•II OI NKMI •rre0510eY ' DAII 1?p b ` N cl D.? yy qt.c POLICE TRAFFIC COLLISIONREPORf Q?TRAFFICWAY CoMnuNrN 0 PRIVATE WAY -: -: . ....DATE .. I .. r 4 ._. IM[ Wx xo, InR MNF I IUSE tA10NWgl o COUNrv TE FF o pp q ?N ?E ?IN CITYOIF IOWN NAMEt NO.OF SINtfTOR MGHWAY 4pli 1 AMLS S OW UOF A ON c. 9,3zro INRPSECTING WIT.: SigFfT RO NONINRRSFCTMJN eFM'EEN SiR[R t SfltFl , P°tip1 AVR106T/ot? E .CROSSSIRff NfA F iMl AN M0.[5 fET IX ACCIDENT MILEAGE CODE A IDANA' a CIXlISgNINVIXVfD: RlllfO?NO.IN1U4lD_ ? SPIIIAGt ? HI-. TOIAI Fq. R I ES PRORgrv OAMAGFONIY ? HSIILi[D ?vFHICLE wNDgOm I Lla IIIECTIN0 CROSa51 r- RYD fsa I? , ST2 C,B1lCT SiYVCRFNAMfWOBIK151RUCx M100WNER'S NAME) 51.DAMAGE srtclAltnD I- - UNIT NO. I - DR ER'S NAME: -1 I t UNITNO. Y ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST DR VfR SNAME: N51 ml-E TA O y SrR[EI ADpRE , FFEl ADD4F55 e2 C '' . , ' ITY SIAIE ZIP CODE PHd+f NO R r I 5 AtE Iv E 'Y WA. wA? 0 gp3i? j%aS-e9 R NER'S U<FN O. SIAfF (., L7dDFG'SRi,i NO. AIE 1. p 1 E A F 4 i8 rx OCCUPgIIDN MNAM[6PHON[NO, FYfS IGN HE GM E -AIION FIRM 1-11 PHONE ND. EYES IGIEI HEHSFR R. CHECKS VEHKIF, AN Nam[q. A ? CHECK(.) 'vFH C1f -Al AN--'V. FF CAMNIA, CODES 7 a 5 uN 6 s"0.rt -? CODES b- D n w sr 5 u a sM.° m .? I Rs INAj.Il I 0,47"', p WA4MAHl1 ? u [ ? b n. ? P5, i ? --A- ud`E ? bm[ ? " KU ED VEN.TEAR MAAF IDODG[2HfV.l ILIDARI.NOVA) Si LL I2O4 C .) Y R ( H V.) MODF11DMr. R A) ?B TowSw O? E m f H. v EICE si [ lR MIF NO. lAif H vEH.CIX04 t LTE9iq NO, qI WK QL OI L.1A ,I . rE gElafnnlwgN ND. L veHlcu lDfN11[IUI S S CE U (6 k' C 236 2 d o REGISRR(DONNf4: IA51 FI4SI MIDIXf PIIOM NO. O IS KD WNF4: -1 FIR51 MIDME f u - ADD4fssaowNE4 N x NFq ,?? Y O N T N 'N NAMea,DD4essalNw4ArxE CO on ACerrt R• ?- !:. . ?A E Z "T -D I1A A IOrGi. A4 C ! HA- & REA U & ? ? AWE ti AWWSY ?RfAWN[D TA. STIM4. I-D M AWAY BY - ,tot ? TOWED AWAY eY: S N DIAGRAMOFCOLLISION: ID NDIC?Ip NO41H sHFIIUNeuss,Rn ' e Row DESCRIPTION OF COLLISION: (1E131MREMENIAl5Mfl1[NECESSARY) b R' 1 EiP ms &AroN &d- N• $otiAtT iAJN C-N THe C POl lJ6A STEED -Ji A//k• 0- T4V LAJE.vT &,r ' 4'+ TEU?t O SN4 LOST 60,V AOL! Chit /A/t rE?t 1 (E,R/.IrVl4 LIrK ONet dcFOef GXOfS /A?6 S gwFn +O 44.g 4.4.v µ/r rH[ T"Ft a IR G. ?E IQ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED *CODES 1 _ 2 9 4 5 d M N OCCUPANTS /WITNESSES AtfalwHAl NA.w 1=- 4l1 sl 51. AGE AlD W, N '" I. nsn Fna NAM[ 0.0'j le a, oaror+ ND ¢3- as t i m 2 I . ronss AT Aluo R IM e. 0- -0 ' ? " • ? FD " N (^PS'A'I AN Y/ouT No )!S'OS Ly I I Aoona t- or N RMOVEDIxoM 0 Aw,e 0IGIKI ? n' NAMI NO 1 . pn4ns NATwRioT E ?AMe 011 1 ?:` ~ HfI,GAb,G (vfKIH eApq 04 AGINCr oKIas lF4lI0.D IC X "n . A .,LPL,". DNO _ ,leta DAn tIoco 10A l llllPO41 -IlDVED.1 _ -- ?a itL r Y ?xra: Ck??? °i ? k ?2: ?, m r ' yA P I Y t ,?0.Ny I TI. .4'6 L f? F ? l Ir , EA T I? ??&P`,? 1 ? t E ?:w N?a? tvr,?.?? ? ?° ` '. ? I". , L...? _-J[41n.11 .3 - '15,..... .?e___`__ Y?._::a...c:?.,•..E,,..r. -?w.A.?P::???1r'krS '- ? alnFC ur nwa ? . . qpy .E?Ir ,` nFnm un ,...ter,," .. MOTOR VEHICLE COLLISION REPORT DATED YfAIUSgN DAY OF ODLUSTGI TIME OFCO NO. +. ` pL -, _ rFM +T iuES wfD iNUR [N 5 PM AM U`S 0 COMAY NO. CRYNO ? , . S, COUNTY CITY.TOMILE9 D . TOMPI ac Z Z o" ;p _. EECTgN e© TERSEREET OR RO 1 cy• /• MREPOST NTERSECr IO MATIONOFCOLLISION DETWEEN STREET AND 9 el L•` GTREEi N ?'? N E IVxNR+DCroN,wD Mx[rosH n[Nr,PrrK;LUlouur K INTER CS E x E ck umj9 ro FFIA','N _- - 1.111.11-R ©® r[ a.E EDw[crE QJ ?.N.L.,W-E, D wEfl T Eia ? E G?iC?ZO SPEOCODELSE R AD 'FI? .... I 1„ H,t,Eb P ?vT r•DESIn An ?_c ?Rr.Sn OBJECT STR ' ' I IA;N I x+uE ,Y I%KCiaiWIDM1I OWNER OFOBIECTS NAME ANO ADOgE59 LOCAT IN flOAD gN Q© OMN ronfPSa WAY per IYEVpA -. `: r.. A DRNERSIASi NME _ _ 1 • I= l AMT. E FNSTNAME MgpLE w o ORIVEns; LAST NAM . FnBf NAME MODIE c M ? T f ?LZL Ca ' Sgn ? Si REET AppiE RW EIRO.M lb%NO STRESTADDREBS F4WENO.ANOBO%RD. ° wM ?. ?r ~o wE RI a A _ Gp CIIY STATE ZIP CODE DFRVERSOCCUPATRDN _ A F / I / L ,pn CITY STATE ZIPCOM DWVERSOCCUPAT`CW v / POAripw & J 1 It C` r IXHIVERS LCENSE NUMBER • y STATE SE% DATE OF BIRTH E ` _ piWEflS LICENSE NUMDEq BTATE SE% MTE AD( I I r D" D.1 . Q ` • rfM l Wrl X VENKLE tti. MANE ICNEV. DDDGEI MODEL (NOVA-0MO BODYSTYLEI2IXt.l VEHICLE YR. MAKEICHEV: DODGEI MODEL( VA-0ARII BODY STYlE1Z DRI s r LKENSEPUTENO. STATE TRAILER PLATE NO. STATE ? -CENSE PIATENO. 9TATE TRMLEq PLATENp. STATE L?79. ?. ,:, • vEH CLE _ CATION N) Fl 55623 >! 'l? =? ? _ i - . gEG......0WNEfl DA.4i MST MIDOLENMIE) DRNERSLKENSE NO. FREGISTERED ONNER (LAST FIRSTMODLENAMEI OR IVERSIICENSENO. r ? ? ". a5 tt OWWERSADp11ESS STREET,CRYANDSTATEt DATE OF &qM OWNEflS ADDESSBTREET, CTY ANOSTATEI OATEOFBIRTN p;4y, t ?T, PMTSOF VEN LE DAMAGED PMTSOFVEHKLE DAMAGED TOrco.'fn° ` ` OS fO C°" i ? - Ir Y E r S .lE fAR F•[iJV ?wh' Yf ,.c LE I- WAS THERE AUTOMO&LEUMIUTYINSURANCE LIABILITY INSURANCE INFORMATION-VEHICLE NO l p . COVERAGE IN EFFECT TOR THIS ACCIDENT ON YOURCM ? YES [I NO ' NAMEANDADIXE55OFL,A&uIY WSUWOE KKY LDE ' '' RA I "I NMIE OFUAGUTY MSUflMCCE COMPMY 2'l -'141 •r, a / , ? 1 _ w ua O) NAN[A4p ADDRESS OF" ABWIY -Cl AGENT air 5T < iP UAG/IiY POLICY NUMBER A M „ A 1 ?3N a Isf WJW Y , i IDE A IMWJIM'/; IUSf SEP ERE Gi-RONAEKUUW[b, ADE / NAE /s a TDIAL W YY N[P ,rte C04 ?T Q Y'• NNAE y ny (,L l? /? in rJ CA / maar 1!' st /T?d %Q PIk• ADDRESS ? ( T ".°;Sr aMR N ?°C dcrDA! 'La / N Lacy o E 1°1'-RN I wNSrAfUSOF INJURED U' MST ON U f D ®? 1 f P ? • W VENKLE M1Rl[D g6,yVwO u pSIE N m 9 BTATB40F NUUREO MARK FIRST ONE THAT MPIIEB rosNw ?dOHR WVEHKLE I 1 ?liw siwAn ND r vinl r r A , r ?P+ N? KILLED A r I ° ' _. ., O ? 5? e0 71-1 prYOesI.R ur ? 5? e? 7 SHOWND Ti Br AR-I.RCL<E -- A,IACA a rr n s O GESCRIBC BELOW WHA7 WlPPFNEO. IREFERTOWNIOLESBYRUMBER) ' Drlwxq dovly f-oacl hi'( S/icGc t Nrr Icrb?I rI rM• ? sy0YUanicl spa W 6 CA Ill-114s (E?u Nt? 1` g 1r I V IWR? ?{yj NE 1CLES POSITIONS BEFORE COLLISION jt'15 RNK rrM ?m .r•.n-1o +s INYESTIGAILD OY ;• ry1 ?I rr..cle i><cLreD „E,.r T?qq G ! w CWBrMIT DnrAGrw.LrNAMEGHNO .cl "Or""Q alWC?O ? ? ?.:irRR,. ?P°a'a'llc7sN }t" ,u?"jl J 000 ? ? ? ? AIdA ? ? ? ? ? ? ? r. rW 1 ' 1 ' cAOSEw FROM DIRECTION to rDIRECTION LrL I h'.?.. YIN.tIMANW hUYNf I?51[ICW4M1 l?*t Al J?SND M" 1?i ?D 50 [M• u1n A?OTIER Z. .??f1J L +Y NDAD SM IKC MCAIWEA WNRTCONDIgNS RAIIK CONIRO Kwcr Mr nPE DaVpR/VEHK PAOTgW ? YI''?'',? i 3 r in Lrar r NCII r-."7 orWw.if v[HCl[ K:r,LawErnuar,fl ?• t AL`W^,,t'f /l, FF.. ? i ? 'NAIS ON[ DA, ,a GOING STRAIGHT AHEAD T ?.y I'I M t ?r±••?+[AIr )0PAAKw 7?On- UAWN- x ?rl ?W1 :)I yrT ?v 1 A 1 SIDP LrGrH ; 7 {JY ? ? W T ? TWO WAY ? Z ? OYEnt-JOANDPASSWO T ?r Y 1 AFS ? J ?rMlD pfJl *0 i T 1 3 J , JJIMrA] ] ? w u D ? NE.. IIAE ? ] ? -ING RIGHT TURN } W ? ? ?WYEr NOW ? T PMK S1,LL11 A ? r ? A ? ? R [3 MAKING lCff TURIN I IJf '?' lv f IF ( I ? . ?rff '0 OW CJrr r ?DSIII[[I ? lASwrG RID HW Nr?AN(iE 1 1 !{};? ? ] ? ol.. S I?? FMK Mn f ? S ? r'IASrVp AUII(11 ? S C] ALLEY ? 6 ? MAXNDU IUIIN Pf ASON-NOT1M/IA MMiR A?/SrR([r 1-19 ? W ?rN •WLW4 ? A ?L[Wf01111LN E) A ?y[TW M I1 b vA•` ?' 1 4 rf A t', •rn rv.N lnrw.f r. Nrr cr [ ? •OA•(CY%Y ? A ? ORRICIP fI. M.MAN _11 ? f ? STO,l'fD,cRITRMFrq -I) I t iSrT.. C 4 d r, ?. ? A ? GI1N N, Y'1 c" s?vnuDA ? 1 ? &TRARATEO ? A [] OR 61 At µ f iil 1 'I Y? H f k Ili ( ? 7 ?ONf.YD ? V? IIgMDINMADWAY • I S f I 'L J 11 1 0 (m1R„, K ? 1 ? LH(1N?f]1{ RLR' o O IN ? I..(..I ANNHf y,,,„ ?DE-• ? I ?I 1 ?? ?r I l ? d"?'iEi'^^xy> ?v '°???:'. ?' ? v P ? A"` ": VAtII•,.?`? s •q4 ?' ? "xj? 1 1k t ? 1 I'.. I'J'Y' V,rS. T ??ta t T r5dw?, I ? r ( AID"? ? rt y N n v1nYC vlf vVJ'LJh"YYY V`vi'Y VY? T4c'? - '; ^ / °?` POLICE TRAFFIC COLLISION REPORT QTRAFFICWAY ' IOVCf COMPIAINi NUMUfN w -y; I ? .rMl Dgff Oi O(11 N Y ? PRIVATE WAY a I , > / ?,0 Y IO? Y 1. N..I llMf COUNTYI?-a-?M ,mil / COUN TYINp CITY NO loan l(vI ? j • 41. IDSSOIL, L uWA 1f I -Y - C r/?l?w-FiVN ON Qf IN /LIIYOR TO NaMt6 OOESINLNUNHGMWgY CI ClS a A M,llS QS ?W QOF / ?/ • ? µ FOULf ON SINE D CNON i6YYiR' ? P Ldr ? IXIfR5fC11NG NRIH-51 ROAD /C ? QN 3 _ ?f0 . I NON NIfRS[CI ON f PvEr% E } D ' MNf POSt DEIW[EN STREET 6 O,SIgNCE6 N M LS F90M9 f N E, CROSS SIX[f10 NEa sL?' / OI f 5 Xt - ,} r, D f V S FEE A L ACCIDENT RAMP DIAGRAMDATA ' ". DF r COUaION NVOLVED StVER I MILEAGE COD . r. TOTAL NO ® NO RItfD??NO INIURED ._ CE VNI ClfS PR IIIYDAMAGEONLY C M T E ',LAD, ?Ht6 V ff E ?DRInIHS ?pE5 ?VFC Nlf RO v CIS SCTIN STR f'OR ROgp OR RIffRINCE CROs-REITONROA?1 yr 7, I SINUC%INNAE OF ORI[CT SiRUC%AND OWNERS NPMF) llrfU C EST DAMAGE S afro ' ` ' ' .d) - i UNIT NO I PECIAL COONG USE $ il,, 1 I 7R _+ 5 . ? ORNE • AME: Un51 1 SI MIO IE D9 V RUNIT E ? VEHICLE ? PEDESTRIAN ? PEDAICYCLIST 1 ' ? • !?'?r ?,? Y SINfETaDDRf35 ? TCp l1U S NAM ??,'/ ?? ?"/i `?YJ NS _ /LFC ?? ? / ?., ?? ,? SruFET ADURFE ss ? _ r ' t / SIALF ZIP ODf O Pd`' PHONENO D l G /0 0 51ArE ;` T pI - ,,,,,,..,,....,,$$ `b" ' i .3 2 CENS[NO. sl IF r S tx -7- - .2 U9 R O.?/ IP NE NO. nr FD LH ? b HS- `1,r?s I uN tv 5lff S - d 'd , ? „,Q? sssZ3 A R OC<U INI IRM M tNO. aTAIF E% DAIF UFD NtH y 2.3 yS F , P C IF / J I +'P^ afi L ?? NAME6NEONC NO. L A/N ? . A a 61?t WA F Gt?ol%3 EYES WE GIII 14 GMr E DCC ON MNAMEB '? v / /r/ AL/?LZ J ` ? C CK (? Hci ^E vt s H iov a PHONE NO. ? UO R Ens wElcnr Ic cNE aISC'LU,`/ I `g?: a Y 1 ? r a EMP Er FArl_'R CODES ?.? ?, ^-1MHI C1 S NI.I is Y2 YNI ulf • .? V ?CHECK 7 (?) nlar ASary FMnorFFDPANOmr9"t a .oe I CODES d * ?.ss v a is . wl , ai s u d i 4 . 3 ' l ,t , s n EHEE p a I?naRRDM a ? ?oKER ? ? " 3 W ? w •D YN IDO Ew MA CH[VI MOWill L(DART NpVAI ?^I'?IrtANq ?Ex,4CI ?18.RR ? ?1?Lv S1YlEIROR CONV) H II vtAN R _ 10 R 1 LHfVI 7" MODE (DART-NOVA ti E 1 ` IC IICFrvSE PIA STALE INM f 4 e aD Nv ?/y/ J . ' I A MI G'ZCvW ?4 96 Ct/y E NO. SiAiF H /-'r H «DR N I (. I , A N AlE ' fH,CE[IDFNi NCAIgN NO. I io0!-s ?o;iIix13 _? O f tHG11 LIEN ?ry 6 w / T d 1 ,? REGIS,E.D OWNER. RST UlE c, yJ / U ry q Y -I C 3 I /T / I / ?SI / ?? I O IPHONE NO, [ IIPtU OwNr U I I I I 'T - ?Ir r ? ? DORr55p GWNER 11951 MIDDY O W n.? ? Lr 4 I N NO. !? _ l . 1 I A 5 U N wNtR y pRr } I M(AA0p9t5ApINSUVANCFCO, GN AGtNI E 2 DA 'h GQtde(sif R [ - DAMAGIlO.wlw H? . w., CNANf.F 'Jk 7/-2 3xp f/ T? X_._ Lat a lVq/ I NECESSARY) .1foW vC JI.RIV I JUN OF COLLISION; I- sUPPIEMINN, SHE... NICESSARY) A/1R?E,y %r?JFF/G ?Lt/9/TiN< /y14?(/ M ' A LEFT 'Tlr•C.v. Tc• I R /-??T'oyn Ac4?i/ntryE y? a ? S. l l..Jz.HI2, l 3.1 I S F6 Lj A., X 5 ?..MA, 1 t ., .NR.?9E%R?.,:.. ..?19Y,'e.wR;.r.ihw Y}IF ' :;Y }n..sw?wwt[lo,?YRE:la L5,R,y?` •R'; I S '1 Lj« I ti y, J ?t ^ I l e r l l? f N <. ? ar ?.I ,1 1 J i ,1 i 4 .C4 5' C I ) N; U .1 1 ?9A 1r R d r - l .( } z j t . f L 4 r 1 + F " DBE L .tea. ?J g na J "lot fi1Tm'.H+rK14 :.. 7 C,_ .y+i• d.. ?iirX"'?i@:i&Lo.. ..ua "~ z x ' r-?r" Zo It Or WASkillVCvVuj,? No ???'• P t „ `, kl S OLICE TRAFFIC COLLISION REPORT TRAFFICWAY IGIICE COMPUINT NWAB[R , PRIVATE WAY . p . " OF Y 2 ~ I (» . D ' L ?. A FOFC HI rv T. Ol TIM( COUn IY 1 ' IDr. I (USE ].00 HOVRI i rR IIu¢I IMI COUNTY NO. Cfrv NO '-A ? ? OURE- CN ,.UE CIN M CIIY OR TOWN NMAEfl rv0.0 SIRFf104 HIGH WAY i TCI? II2 5 ( URN( ROEr. oR 51:: t .. CE S 0 ®Oi Hadlock ONCR 4 INI[RS[CIING IMIH EfTO AO ' ON INtfRSECIION PNEFIN ED. MITE WSi BEEN FFi 6 DfS1AN EflURf (NOM R[fERF CROSS SIREEIOR NtARfSf MI[FPOSI EB W fEl ACC DENT RAMP, DIAGRAM O?"? DArA ( FF .,Lower hadlock rd MILEAGE CUHISfON NVOIV[D• EVEN fYI CODE tOIAI NO. NI, KILLED-NO. INJURED_l_ 0SPILGE CY V[FIIOES I mHS N N OLS I IRUF! ruugeRlH INIE R CROSSSiq(Ft ORNN'JAU UOR RUfzE ]] 0 PWPfRIYDAMAGEOMY 0 pFSUIIFD Fd IF _? S OBR<t STRUCK INAMf (OBJECT STRUCK AND OWNER'S-1) fSL O . D _ Person Ronda C i . N AGE SPECIAL CODING USE _ ra $ s ".: UNIT NO. I . DWwsr+AMf. IASI IR MI l UNIT NO.2 VEHICLE a D4WFN'SNAMF: NA PEDESTRIAN ]+ ?PEDALCYCLIST ' I _ _ SIkLFI pDDNF S f 1-f??'"?a L, - CIIY STAY ZIPCODE PHONE NO. O ' P4 Townsend Wa 85-4807 R P / P NTH" 12 DNf F SNCFNSf NO SIAtk fK A FB ( o HI CK ER K866 C A a M 2 I 1 ?14 IVtR s<fNSE NO. V K e ¢tl h° FY 1b ocmPAl oN H RR f 6 PHONE NO. FYfS WF 11 GHI NF GF t E CUPAI DN FIRM NAME 6 PHONE ? g EYES WEIGNi H G 0 CHECK(, 1 [H Cir AS AN MRO fF OrAN pf ' - Am " v? i OrHfR CODES?? 7w <e S l e iro J RS .ss .M[m rzcl DN ox.ct (] CHECK (V) ASA-P, r CODE C ii S ?* ] a gs:'llli«r Ef oFANmHrap[ S N A° 7 V (rn rin rc I ?AmquANee Rvprz iLt wa: ° aKE ? v C t ? HYfA9 -MAKE (DODGE CHEV. fa pgt'NOVpO S1Yl[1]OR CONVI yF Ef ?M's N[I GvK[ I Y AR CYSmv Hrc ?Ii v v! AI[ D ID - 78 Ford P/U I HfV I AbD[ E Y V I r m ( R. L LDpq TNOVA) y R IICEN PU (N StAlf t4AIlfRRA1FN0. SIAtf H VtiF COIR ]R 1O?Z Red / Wh PS 8163 Wa i " AE 9 vnunElarvnicuroN NO. C nYB V "...w^.v - - N C]R(MAINED ISt"OAM.KGf -Y' 'In t0 ED i I.M S A*A . BY. AWAY s UYOTlOu I AM OF COLLISION I M IND CAll NO4IH DESCRIPr O 10 i 5 (EIIF NfCE55A 1 S R NOFCO(LISION: (USESUPPIEMEMAI1H1-1 ECESSARY) , q C o°W ed wa.s walkiocq West on CR 4-with.2.wi.tnesses._aft k ark. fhe vehT 1e was, also west.bound_and came-pa -he victim and struck victim in left arm with.sid r i lirror. Victim was walking on the wrong side.of"-t ' nknown where vehicle was at time of incident. -.- urther details in police report.83-0246 attached I LL.....1< 'A nt ?Cal9,_-- .. I '::;:?85-6322 Lp I I I I Sara J, Craig AMB ? s r ?:>ao?Eaa??. USA 1 0 L u1 1= ? V I a ?o U 11 O O r H L 11 ?l t iJ N y i 1 S y... O IBS 0 0- m r V ? C y i ,a u ? off' v?` S 4,f v\ 1 L C /? a ot, Imp M r? ? ? r W ?c 1T'V W? yf tati ? ? 't ?, 1 l 1. >{ ,?y 1 J ? ? fl ? '?'r? s STATE OF WASHINGTON 'AGE I aI. POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY \U. PRIVATE WAY PCICECOMPAENTNwaeER R DA EOE Ou A TM[ COUNTY / /? Yx upr NI3 wIR Ixuvs rP Yr IUSF RRDDHOU91 °S c TxrfE2s° i CWNTO. DING. CI-AN ?O CITIORTDWN / CN ?f ?N f6N00l SJ9Ff109 HIGHWgr URAL l5 RWI naffs Os ?W CoiN ,hoc ON c c D rvtERLC1rNG VAIN. S1RfET0990•D IEPSECIION " [3 f-?/Oy0 t] I BM'fEN C ? 51R[FI DS ANCt DI FMTI ,- FeErvCI P0551refFTOa NtOf MIEpOST 5 ^C? F.D. F RE P051 Q-Z.5'" ti q•J / N Rf5 ACCIDENT IFFY 5 E W / MILEAGE R-P RAMEA- CODE COII SON NVIXV[D EvFa tv //rrte? qq TOTAL NO. NO YIIFDy?NO NIUP[D_y? Y I I ?Hi69UN wrMUOno'i" pYFH ClES ® pRORRTr DAMAGE ONIr ?-H ? ?VT E. IN IMfW CIS ISOSfSR/Rl OR 11E . °11.11 NCf V _ ] 9 TID - aenclsrRKKNAmE0FDencrsrRUC.rw°DWN- NnM[I - DU.IACl (p ZZ.s Q sP Cwco«NC aE / S s_ UNIT NO. { DR Vfa sNanr IAST flpsl UNITN0. 2 C VEHICLE ?7DESTRIAN CffDA LCYCLIST z 9 DR 1 s w e X01-04 SIREIIADDRE55 N 010 JN RoJV co/? F1L / IeEETnODP(SS ^? d G Rc 4v Coo- RO "* r sort £ / D1DGR V ONF r zncoce p"oNE NO St QUJ 5'8?$ >~? D sl eervsfN p R r' I sATf PC JAJD-A//?SfpJVp ss-N96S ? NN /? p 1-G c z LAAry GCCUPnrtON F9M NAMF6MONf NO 5 nl FR H I v cENSE rvo. E DA E ereTH 2 Cl• Cl? . FlES WT GHI fR GHI /NO/AN /,SG qN,p ?D t.SB bO E R oeeup,oN M rv 4MF 6 PHONE NO. F S GHT GN W i/^.F i C CHECK (.? vlHnr•snrv uAViortra ANOTHl9 Al QPJ 130 3'°J. CCNECK(") nl R CODES?' D?"°' / s [ A ,wrox•n' , ucT Z ttf AS•N DnviovlEOF ANOTHE9 s RR CODES 11- 0 ' J H At, ,°,M"' rclH * 5 u 6 ` p ?n Iw. NONE :e 0 ' N ? s, IN .1 v °I? E C EY R o cCMIR IN "?,:« ° taTP ? MN .NrI C - r C s:Rp C O ? 7 `i F R A 16 v A IR T b Rcu?p Jjf] ` E W E.cN V 1 MOD l IDA9l gVAI A-1, ! v UI ]f 9 r St RATENO $TATI 11AItfRRATEIO All I'1 v . ?•` eN e«oR ? JJCtI•isr iEa'?7C H CIE DINTFICATONrvO I C . p R A No. Af Wy r7c POB l.?.5 N .l zv 3 Ham/ S63 I afmsrtRloowNw. as MIDDU ".Nl NO E FH «[ DErvT lKATI rv Isr DO 3 SO - A?' A3DV. O WN1c L-I TES MID., ENO. r3 + $O D., D no09ESSaoW*1t9 C Dh>N AAV<p V- So4.bR6r Z N N A oWN,R ] " 1a ADDRESS«INSU-11 CO OR ACwr E S'q Myr AS l3oVc re"I C. ° DAMAGID ARIA R USA A U AN 0 OR AGE 71 AGE S ?1 or..AD.DY cHARa .; QAMAGtr IAREA CNAPGF Dw 151 ryDAMAGf rj ] F ' N y G 1 IC WI T AY ?RI MAINID AW ?5 YY C C]9EMMNID 1ST D A= -? so0o O:° ;.° " ° E VY , . a. ;.< Gn Gr f coS 44 DIAGRAM OF COLLISION: iruiE[rn Nicfis%o:I IN IC.I. NO°v°1ry DESCRIPTION OF COLLISION: IUSESUPFE fMENTnISNrn Il NECISSARII ?" VEtJ. n?O. / Arun 2 wERrt "? WEST 1 ? Ij OWN /J PN Cf+ Ro y y 1° Na./ ))/{.gHV4 FcQ A SOVJRLJc _ CQ"=//vpTNG. RDAJ). No J, fAitED To z od33Rvc -r", Str 'JJrg vfHJCG? AND -°-"- R i T >e ?,- O x AN a TNF R?q/? e,ar No. 1 NAME, ADDRESS & INJURIES OP P%RSONS INVOLVED ' U OCCUPANTS/WITNESSES O11- TI CODES 1 - 7 J 4 5 6 f +D e:M ADDRI SS NO v. N SfA AGE TUS i°' R ESIa 111[1 S N I Arwess ' NJ , Rl -11 pr ° CAM. 0 A 9 ?iU AVI a 10 rYDM . C N ? U-8 0- 0 AG 4•r. • N IY5r w15AA N° n uw U. r nr ?AMG KHr . C,1.1•? A .? n F YO R , Cy fPJnIf HIG IG X 'J • ? f1 r..((• ND DA", PI7 ro OVrner DAR 1NY?_ Iz J7.OY L. { W N. Ilk I A s.V I t d r? • k 2 PRIVATE WAY z DAif Of COl 15 N,. _ COIFS _ IIMF COUNTY 1 re P$f ] D ? COUNTY- CITY NO. I HWA R yex wIR.Ixu I ILr. I D NO?I ..-? / ? / F 1 , R (? RAL 2 ?N RE ? N C OR TOWN NPMf6NO.Of StXEf10R HIGHWAY N FCI ClS DM 5 RWI_E ON I0.FEI CODE StC- lO . -EA Cgs ? OF GOOK ON C ??O y 3 INtLR C1INGMIH:STREET R I ..NIN... ZION PR[fl% EO. MITE POSt / ? BF-E /K 0 IREET A C SIREET p151ANC[601NfcIIl- REffRIN I:. CR05551RIll"NFARE51111P051 ACCIDENT ,??]?. ft ' ,M ? RAMP DIAGRAM MIA (/Q_ TIES Q lEEI N 5 ? E W OF MILEAGE CODE COLL15ION INVOLVED: RIIYI ' f11I60.UN lOIAINO. NO, XALED??NO. INJURED HUGE ? Iu4oviD?H INIIR I" %.RD INN CIING STREET OR ROADORREFERINCE IN1ER Ct5 CROSSSiRFf TOR ROAp p -? pV[NICtFS PROPERTY DAMAGE ONLY FIRE nED ?VfOMiflE RESU // ODI '151gUCK INAMF Of U51RUC%ANDO- NAME) ESt.OAMpGE SPfCIM LADING IGE 7 W Gr/2 Is UNITNO. 1 NIVEN'S NnMF: 10.51 NR51 MlpplE UNITNO. 2 ' ? VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 2 DNNER S NAME: Is, FIR MIDDLE p'?J SINEtIADDNt55 SIREfJ ADPRf55 . ^) SI UIY AIE ZIPCODE PHONENO. D -y s-1 21P DE NE NO. P I R OR V[RSIICENSE NO. SIATE EX A B IN M I RIVER 5 LCENSE NO. SIAtE Sf% OAIEp BRIH D i R,r i n. V Mo RAr ?rR. R OCCUPATION FIRM NAME A PHONE NO. EYES WF GHI -HT E OCCUPATIONM NM5F6 PHONE NO. EYES Vrt GHt HEIGHT 2 R ? CHECK (1) 1y&,-_- PS-,N FMriov"FE OF ANOINER.AI ? CHECK(/) yFN Clf wSAN FMROYFFO iltify AL E i COD S I* 9? a i 5 1 0 CODES ? e 15 N D i° 22 " M D P ? MNA. 1 ? u "' ? ?8_ ? H:iK V ? R ? MP LA„ 1 ? u " ? ESri1, ? ? ° 111 L' A" VLN YtAR IM%f EDpDGf{HFV) MODfII ARLNOVA) SiYlE (2PR. C-) "AR I E{H V.1 m IDARLNpVAI Y (ZDR V.) 2 ? e ? E B VH.C O UUNSfY fN . SIAIE IRMtERRAIf NO. SIA H VEH. IXOq N L qI NO. A1E ?f `S? ''LL I V[HIC'EIOfN CAiIp, ?iP'..z131L1?1?1?lzlZlsly!yl i E VFHICIf IDINNfIMII N Ni I RtG15fI PtD OWN-R; LAST IIRST MIDDLE PHONE NO. R ISItR[D OWN-N: X51 NO MIDDtf P N NO /J / SQ?J / -La O W . Ap14155p OWNlR A . N[G ll //? 'f Lu ?eIL 1? nJ N NAMe aAD04usp NsuRANCE CO. wAGfNi R INSURANCE N - SR ? " I wMw?ppnu [ .w4. u s c " to "" iwc ? "v I I;pnIAClD:au II y Oi°nP4 s- . D>H?o r Fst. DAMACE CHARGE ? WyN ?R[MAIN[0 A omRaE N ? DRIVE ?gFMMN[D D N FSI1'DeMAGF Elar " 5 f 300 IOwiO \ A AWAY t-I IOW[D BY IJ S 14!0714x a a E le u DIAGRAM OF COlL1510N -'a-) o4ln - -.Sr4E. B p 1 DESCRIPTION OF COLLISION: IUst 5UPPUIVENIM 51111111 NEO-ARY Ts V sad .v,Tr,:,y a ?w :P ,? 1. DD NAME, ADDRESS & INJURIES OF PERSONS INVOLVED F CODES I - Z 9 4 5 6 IIAE SU.n-MUnAll OCCUPANTS /WITNESSES vm roR ADDnroful rN..w» u% AGt IAI US ° RE SIR, Ria u t r utu4-p •¢nn er ppiA e. ? ? '" t ?Q!Y?tV'A';. F A DDUSS r M1 ulwta N tDINOtA ?M1e ?.cu,c1 ?cH, : ? ? .1 w -- r ro w p .. .' .Y NO .. .. .,. .;....m ..n... .... :..+.... WSPI W,REV: LBO,.. C? U..}' STATE OF WASHINGTON PAGE '%.!F7f7a POLICETRAFFIC COLLISION REPORT ®TRAFFICWAY Po cE COmvurninlunofR evP "' K at ET,I , _. Pleb. P9- 1 1+ r? 1 POLICE TRAFFIC COLLISION REPORT TRAFFICWAY I+OIICE CGMnA NINIIMB[v PRIVATE WAY n FHwA L - IEOF a DAY Oll ON IIMF couN lusn.DDHOURI ?. E 1 Y A c3 n N p AN uau gWIE OX SIPEE C kCIION prv pF pON s pW ?O1? n)AK s W 9HOH0 1F 4051 / y/ E-EFN sT.111 ACCIDENT 055 A SAGE ILEAGE ITS OF ".CODE gkC1IN SIX[EI OR ROAUO4 eF4tRE CF pp Eeo p HI 5 RUN ?ua COIF SON NVIXVFD: NO NIURFD TOIM NO ,NO OIIED? N sUI O VFNIOES [2PoRRTV pAMAGf ONLY SSSfvE,sZ 747 DE.CI sl... IN- UNIT N0.1 p VEHICLE ? PEDESTRIAN ? PEDALCYCLIST -SI U51 I [ R'S NNMf R DRNte'SNNAf' v.51 F MI Dlf : DNwt P?(I ? Y ?i I` l1(-( (• ? /? I" L. ~ SIRFFI aDDUfSs ? SIPFLI ADDRESS F E) R G I N F, HD ENO. StAlf 2 vCOIX D v SIAif -c- -ENO !1 • Olv R sulF % -SICENk NO. 1AIE su DAtf o4a Xm ^^' ta'suuNk NO. J? FI A7 (1 `L' pl IL NG 1 E5 -GI [YE5 wRI IT rvO E occNIANON FIRI-E& PHONE NO. EYES WfIGH11EIGHl ° . OCCUVAION mNAMFe PHONF TN ?9S s,! R 3. I w N N o pCHECK(? Al [HrciFAS:Nrm4or"FFOANOIHE xO "" F-I E2 QCHECK(?) HIaEASANU Y11O 6 0 CODES ? ` 7 ri • `s 5 I'M 5 O • 5 F cN / e ; .mY nM CODES P. 7 a 1 Y t 5 , Np ? .. 'I- p .5 C c V iN s 9 a x ..n m ? v o:nx p p p c O N11 H Ku D , ? n FF,H M IN f1 °" D p A"AA .1 ? L rcl p cn- p [ rc ,4 RI.NO Al moo l cnfv. 1 MAK 1 I AN v I la MODfl 1-1 NOVA1 StY[E 1]D4..CONV,1 fv.l mAK IDDDGE'CH YfAe VF". A p y I S • r E w v F 1 \ ETAIf I'1 N lA T A ,l 1 COIOR l A vfn ' II(CE,N?k 4lA 1E?N 15 G Z IIFX SIAIf nAT(NO C . zEf N T/t 1 -II-NO L NN vfnlLlf lO Nin ICAII 2 '•.+ . -11EIDEN1II F. \ S..p ^ d FR NO ISIENtD WNEV VSI FIRST MID.E ENO. v . R(GRR4IDOwrvfR: IASI nRk MIOIXF PHO O A4 W A Owrvt4 u. ? ADDNISSaF OmNle E1 I L N '- • E IN U AN F'AZFR'r'- n NAmI a ADDRIss a INwR•NCe <o. a AGENT R Aleu e I D.vAACID Aau ? " ISA.SSAO[ ARU . IN cnARU owc ro°?G T oir"Ci?pO"++GI I: fSI.DAm [ ° F X ?.EMAINtp , f S 1 . F IvtN 1 __ .. r vIMAINID T 'D ? ?WA 5 ° TOTN'- :w: ° r k AA i' or i p T ? A— er: S O DIAGRAM OF COLLISION: 1 u4n IrrorcAlf NONDF DESCRIPTION OF COLLISION: Ilse suPne4uN1u s1<FtNN[ctSSARr1 -eunencfSwrlT 4,&- IIF(-1F Y(1 WAS d Et 7 N _Snc(N'?' 1.? G•4K MR . C1(S RRE TTE :.. ... p'aK 13aY DL( C3A 1' R.'(, iEJAS !IG HT2 /.l 4 1 [EFT THF_ re of. AAIP sT-AclCj< A TnEE • t] 'L ... l? , 1 EF I1 ADDRESS & INJURIES OF PERSONS NAME INVOLVED 'CODES 1 - Z 4 5 6 . MK 0 , IUSI SUTAEAYNi•l sti OCCUPANTS/WITNESSES rw ADaIK]NU NAw ll a k, Acf ullr '""'" ; ns1e. (ACT n N•w . N ° cF wer. ?Ame 0 i`1' ?"' 0".,* MOW ? 6n.[ss HAA•F. •M1M a3 IAfWIGF O DIXOM pAMe p.o,Kl prp . oha ?i'. l? IC N , 1 " f OF . ?Ame ?1O:"I pn;:II. 077 ?I:°'Nv e • MF« N ti. ,1 n4.1cH1 P Y u1w a KT A.nvID DellalXlo.T AF.Rwloer DAT! T.sFK:•I.FOOFIK:IeslwAV aR•NK ?( aAE>?a AGINCr X1111.1 :j C y Vi n.L ii ^ ?xm ai ^'r H JnK r o o ] n L 140 1 ;' N 1? - W ?, T l Y 1 WI i 9F 1 M? raFVn ,,x T II 1, 'QS t, h a tl ,d [?? -. 'h `?} 4.'. •?s LPo11 14E I??I' • y 1 D'Y 4f Mi t 7 ' r r / I +1 v J p 5 ,, J J ( 446 1. ?. , 1 r 3? v ? tLl ? l 4 ,IGI?kX ? x ' Y 1= Lr? ?a ? ? fr S I f C 1 #'Y I 1 1 t• ( - q ? r? 'i r C 11 I i L ? Y? f tii: 4 h ! +I F I 4 4 gum= lx , ?_ '` ¦+ .' :1, ., a?JiSiL..YS •-.-"'?*-W 'id,.., ?" 'sdem-:.emv?` ra.{o6Gi. k ^ '" :. '(. '' F. e -E=.^.??s?-..- _.aeeir wv I r I"EV..m1 STATE OF WASHINGTON RAGE GE No ° 4 v.l } r T P d It I° IT ? Th ?f E x POLICE TRAFFIC COLLISION REPORT QTRAFFICWAY IgICfODeWNM NUTANA E) PRIVATE WAY EEIWA I N DAF ,C l D rR A AY l N sa w. RDR mp .rR tw 1 ,413E N Y E fr6, /G Clrv ? RDRAE b \ p S,REEIOR NGNWAY FEND RIM RGNEEMI DN 5. ° N CIYOIEIOWN N . 'y ? Y3 9?'°s'O 3I .a MILES Ds ?w of jS E.e Ck f0 ONO k MY P, ?23IY Mee P03 IN,tR3fCTINC WI,X 09A --,ACTION Bf,WIFN .11 Sla[fl6 tR[E1 7 f I _ ANCf p f .CR0333E9FE1 Rn[ARF31 MIlFPo MM1f3 S E W OI ACCIDENT MILEAGE DI eNA MIT. IIG tf FEET or -sc S CODE OR Cf COITISbNINVIXVFD'. vFe1, L IAGy []' IN RED n wNDRD,• INTER C43 O1CYd 511f[ETORRMO JU I. NOMIIIDRTYDAM f OIALNO lJ pE51111 DvFNIC[ QV[NIGI[3 g.¢RDRR,YanAGfoNLY Oe11e,3,-(NAMf Of OellCi IT.- ANDOWNER'S NAMEI f3,.DM3AGf SnCw CODING TAE IF . % $ - UNIT NO. 1 UNITNO.2 oRWEas-1 D VEHICLE D PEDESTRIAN ? PEDALCYCLIST usl 19 E elvfe's NAME: LAS, IRSI Ilrr \c I S1REEIADDRES3 3 nf, ADD9f55 - ' 1 O`f S /I /•, Gf IC •? IT \ 3,AIE IIR CODE PnONE NO. D _ NfN IY -7 1 N ? R CK..J oA,E BIRTH ATE A gENIR'341CENSEN FlotcoA3ss7Rt `M m E Ar N is ZI 62 v a lcENSF NO. I w wY •. fXCWMION M F6PNONf NO. EYE+ GNI rEIGN, E EXCUPA,ION MNAMEE -NE NO. EYES I-T.1-1 WE.( /YS 5'lO R 0 CHECK(.) NC4EAS/W.N(MROrFEOFAN0T- w ?CHECK(?1 VENCEEASANE 1-110FAN01N1aM DRCY CODES ?' 7 a:ss . ,: n:N' S Inc, N e ynN c ` 7R CODES (09 * a ssr t ' w os u; ? t „a, w ? A„RM.NEr ? rs.,IP D H:K,t + s< °" N ` °? l ° ?D . ? K e,r ? r: N Po V Y p MM (IXIOGf MFV.1 [Ae ?o f?rnc R.cONV .I 3irlf D El IoME.-Al II -?? E EAR N ( I LAIINI N S1A,f ,R [R RA,F NO A, 3 H 'I v[N C-R $FTAI NO c v ? 3O -• 1b C ` VEN Ctf DEN1 F A I N IE IDE t i CA N vENI 7 z J' ? MIDpE NO. FIn, I nG1 RfDO 1 PNONE NO_ O Rf 3RVt0 vmEa'. -1 FIRST G ne ac W I 3 A DRESS ar OwNlR LM 36S , ' R N E A -ER - + L4? Z D FsszrN$rs? xcFR,- I NAMfEADpn330FINSUaANCFCp ADEN, R = pA4A MEA t • nw<oi.. 131,•DN.UGI I ? 91VEN I [D ' CNARG[ ?R[MAIN[D • nwt ?owi f31!DAMA •t 0 IIMAGf?1MG 1??3 n _ y 'J IOeOnO ?MA N A AWAY ` D $ $ ?) Y_ iw vD Y BY ? AWA Is V DtAGI M1 OF yiun lr NiCtSSMeYI f1°'IAEpM,N A ® DESCRIPTION OF COLLISION: ,us[3u.P,PEE.E?N?tn1/t^A sNEfln NtclssARr1 6 kG? Q ?'E ? t C I ?? ` ^ ` ' G p l (?. E$ ?tq n ? ` a ? OA-k t A y t+• AY / E/e..r..l R VC ?' [?ic?-EL k'4- se t ?` E 1 .._.__? l , ? . . F. sw.y . , e?., ORK ADDRESS 8 INJURIES OF PERSONS NAME INVOLVED 'CODES 1 - Z 9 4 5 6 , OCCUPANTS /WITNESSES ,AR Aa un ", „ nvR ula NAMt - D - (lrU+t uaelu w H Al'_'O F wiY ? AMe Q N0 D . 0M.' O N AME WIT ? ADO.ns Alu9t of R MoaoFROM ° DR:"' ?",' . O D ? :° AMe. M.I Fp N _• FIAT- Alxnss ,n,s " ? una:r ?AMe :"' O'E"r.R. °:+? ? ?"' vn1M;A1«Gat 3MVE aEAN. e.uraa AcINC+ Icf o:}.A¢.RD F? .l' E4R. - ID FO _ 1?FUI [11/? 3Kf D D•np nroRl PP OV1oer D•n V?IS FA.N_Y zx? arr' ' ?? 1 f NAM P` •? i Al•' 5' ( 0s J AT vi POLICE TRAFFIC COLLISION REPORT IZQ TRAFFICWAV rout! comnnim NwneEa PRIVATE WAY pAIE OFCgIS?Ory DA 7 V COlll limf Ir o (US[R.DDFIOVR( a i F > ,RK RD, rR0 ya rw., Nr ,.I / 7 4 o c F' F F e r 9 ?l COUNTY Eq. Cl TY NO. Zl A OWN S 0R-11WAY pry ?f ,ry o[YOa TOWN N Eg o o s III TTR 11WAY ECICI ICICIS ADM s RWIf Oa sINEErc DE k Mlts s ? rNA•D[oc K W ON L3p I T 1111"I"THO9 Fz It z" OST ACCIDENT R P DIGRMIA MILEAE FFOF AI 'r Y [ CODE 1 TOIAI NpLLED_ryp ryJUeED?S PIIIAGE ?4 ry SEC1ry $IRFf10R ROA°OR C405SSTREETOR.. OILY ? Uis l1F ?sa ci .11C1SIRUCK INAAE OF OBJECT STRUCK AND OWNf R5 -1 UNIT NO.I UNT O VEHICLE ? PEDESTRIAN ? PEDALCYCLIST N f' w51 RSI ; pR S NAMf 5T N4 T K C::? K war E 51 RfF1 AD55 ~ 9 to i D o TA CK c.N n c 5wlf ,P PNONF NO T ,-.E SCL: 4•A ?1i•r ...TRSUcwNO51AIf R c P OD[ P-1 O Pe IR 4F/)ow t_A 961-° X3o•S• IF ' / . 3 6,,3 r? wa N ENSE ryO , L• e. /LA +i r ' GNT NIG NI y OCCUaAIPMF6PNONfryO Z 2 E•7 R ?CHECK (?) ?CHECK(" FE vE nF ov ° CODES ? * S CODES ® 5 RR w N /•. ? 0 0 s. DO o A vevlAACI ? ? c"8; ? w rt -AA.•KI N 1 13 C"816. N Vte -. E hl fL(DARINOYA) ll DI-LONV.I 096, 1' 3aIc. tLt Cf E Yl_ - 1 IZ-.1 .LI-- Al "U , 9"IN7' 1TZL 1 YQ S1AIEN R AIE 1-1 v?cC,ol A3 UU 1 vtnrcltaNTlrlurloN NO G t O 4 MIDI[ A7""- ErC t W IB U wryF )9)24 0 RAI D S'. G E A wNt ino: .-tg AODRFSSOF INSURco R A " ., ) 4 r1 'A clo N N o ® AWAr FMAIN ILI ? AWAY A WAY .1 DIAGRAM OF ttION: S I 9xx n DESCRIPTION OF COLLISION: (USE SURKI - 5"[1111 MCt55ARr1 i3AZV:, .9 V6N, a. i?.(`f p 7ni F VAN, / Pn :e Q Q / OAK Pay no. NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES I - ? I-$TPFIEmlNl. - OCCUPANTS/WITNESSErn AOwlloNa NAAV 11 S) - Apt Iros '""" A J • p NL IT T _%s F SS L l AII'RFa ?AMe ?""' ? 2 NAFn ra u ,I?: ?A x «.tvKE De•AlcaD IKA EAU FIl'OF. w 5? 27`Pi l 1 ?? l JY M .ef?rryadca• N L - A 3'Z * t r, +a 1 r 4w, J I 7r 11, T tltJ+ r 1T f("1 4`1 a 7. 4 "rt ryaC'' T, .. '?'e ? G d# t'b`n' } R]FV P d TG _ _., STATE OF A y 6i.r rUALLm FAV lMr Lr- -.: .+7r ? MOTOR VEHICLE HICLE COLLISION REPORT caluslc? o Y usDN ar?wrursal mr "UH wE N. SIT. HDUITME Dr E ®,F, 9 P I. Y 3 6 U J ' OUNTY NO ITY NO ? ti7 I r'•r .}- . . p1 r? + F/3 /2 S J ,Y • /Gi ? LJ'"M n W" ?" ?I" DAUP iOwr: nD OP 9TPEF1 ON rrilw,Y M EDTWG F5 ?6 ?W PvaT }, ahGw oN 0141d . 1? r2,no fl ATf.e AUM ?DI6 RFRK EEW 31nFEi CCUE sec ?9y ,yv t. A: ` nWWTEWE4rp" r'I-1.?/)u/..,S.EEy?. (31jS7-?U.C-Z Ll-ca?F'F11? . n4?? w "MnEn ` ` " ' w " 01 " ?M ED wLEPoSi i.G1?ETCT F?y _ ?'I'; ?,` .u F. <r no s•+ .ic nE csr?xAE.ii._r .a . urJ:n N , ?rlna cl wn/r] . ,L r [MIN P. PoQT i.u•p 13 L P ol, Dxw wrA _.-. o , r _ rr S T /r_ c,.'r / rI ? :4 ° _"? ? ` ° MwoIA MArN•.LSxWU ?A,NSaIrEO v ? T ? ? ° E F 8E ?D vEM 8 MDn, Ba? . TN M AT DIECT BTRIK:K IrMME OF061FLT AIMUC4 WN i NAME MID ADDRESO rf?T11?i8t ' DRIVERSLASTNAE - • " IF -1 N MIDDLE DWVEfl'6 WT J ; P .. _., STREET ADDRESS ROUTE / H I 421. W ), A /Y!_ NO. AND BOA NO. w. STREET ADDRESS x9w I,At005E A arY STATE ,., LP COOS aYVERS OCCIXMTON tp?sgN c" . -s, .. ?u i27 }wOL. uw ....:9 ri F3L. EF ' rTlc: :.- L"r-r2 FPMrrar rYOR nacueo yon HO lJC l EPLATE NO. 1 STATE TTWLER PUTE NO. BI /? i)•F )?E W 1? - VEHICLEIDEIITIFICATIONNO. !c a / F REGISTERED OMUI ILNTT?FWTST? NAYEI atlVEq'9 LICENSE I- uy rTorr LUJAarnm ?nwrr2 uL. r' Om-.ADDRESS ISTRFET•CIA ANp BTATEI O?1= w hhAYrB E? RYAvoO - (A /) PMTS OF VENOLE DMIAOEp 42/11, /On Ohio& T ; Y3/ras Rn a,n ra r7 $ LIABILITY INSURANCE INFORMATION-VEHICLE NO. 11 ? ? '•v ; v;-Z- WAS THERE AUiOMOOtLE UMTUTY INSURANCE COVERAGE N EFFECT FOR THIS ACCIDENT ON YOUR CM r/ rY/- O iri,AO w' u: M,E MIDDLE Is YES ? NO NAME AND AODIiE590F UASO1fY1ly1RANGE AOENr pry gr E LP UAONTV POLICY NUMtlEq /YU rra ISi NJURY NAME AGE NMRE ALU ]HDINJUflY' IUSESFPNM,E RFVUnirMAUprgNµ nlUnnS NAME AGE AOURESti NACU MD III ENT OF INJURIES SE% ADDRESS M F r l ? ? 1 1 EITENT OF NJURIES 6EK M F ? ? aEKMINATION IT A&TON'I ®® go So'. IL?JI DDVIIURIESHEOUIRE © E f1 Ep E N:: E -" S TAiIIBOF NIUR -- - ATg DY A %ITDR, iN6f THAT APPYlEB %AMNSTATUSOF INU D M4iKFHST ONE THAT ? m ? IN VEHICLE Ib KILLED E t µAi "'s•"11N I'mo'" [j M N VEHICLE Iy pi ur4iOnr criuttA ?nA NILLEO yµ?? w VrM? r S N I c n . ? ui ?nUl..Nrr,n ? ? E I t N NO I R D7 OErc nPIU UAr. i B? 5? 5 ? : ',. 1,a •I III, ? 6? 7 MUIUHUYULt JAFETY: U HELMETUSEO U HELMET NOT USED MOTORCYCLE SAFETY: ? HELMET USED ? HELMET NOT USED SIIO W NORTH Ur MIKI W INCIIMIE DESCRIBE BELOW WHAT IMPPENED (REFER IO VEHICLES OY NUMBEIII ?rw..n.MS O 0. Omit h+-- reran L] T ?. r/rGNwn TPuT o(vmy lit:/):C;?] n'0 FiVO,0,=3 TNT=rYT fiui ll, ..rJ -?µ`?R ?N ?-- ..I.Ilrnr,rK.n,. (Y(j T n up:Q HI-, Tr/v. 1) -r,.l ./ /3l- r=l? TI-I rI T hr=//Aai .) [rr / Q aogo ?l Rl2aTL? I/V r/7 UEYY Ur n)J:. t; VEHICLES POSITIONS BEFORE COLLISION VLHICI[ S E W ONSIREEI OA fwON -H WAY NAME OR ND ur I u rUN c 4l. sr O ' ?r:. r t1'I: r T? ? Hp•Ir lC1 ? ? ? / Ic ? ? ? ? ? „ :nrrA n: C) ? ? ? ? ? ? ? ? ? ? .•n,r ? ? ? ? Md0 c"tnw n FROM TO -_- PEDESTRIMPEOALCYCLLSTWASUSWO r?NC[N. J?w.. . J?S.Kw •?[wa ,05 •?uI r?;:. .r, r-- A n KDESTRUN,PEDAL CYCLIST CLOTH14COLOR r?P.n r?Ir ApEOlUIF rdE A4TMl1 UOrIT CONa EONS TRAFFICCONMOI 1?u .(?r"rl.Unnrcml .?'?',.? - nr -" ? , ^- A I ?p•'LIGHT .r "r raxF. r.ur rl r r APE OFAp Wrrl rcn w DIVVER VLH:CIl AC1iON vI ter". r:..: ..rrr rU. I I ] O WY I _"O'NK ''? I? UAWN ? , n? 5.W45 +:l ?r I r? ONE WAYr r Q I •? rJ,IM.I:1.lAIrd11 µH.,U 1 ? RAFMA ] DUSK ? T ?" D T I-1 ! 1 ? LJ ? P LJ nvuH Alr .an ANUIAV,,.wr ] ?M,D,M,i0 , ?L [ tl ON E [? ] ? SNFTW ? ] ? r"109UN n YULE ] C] ? NO. ? I [ J MAnuH'.IIILnI IUIO. • ? TOO 6 ? bIiYA f[T ? ? • ? FLASrWO RIU • MftnCHANfi nAMry _ A MAA V1f.1111 Illlrlf:j l O, 5 ?I.wc FYI " ?611Vf rr.T.Y ? 5 ?.11 .' ? 5 ?IIAY"MI AMIII IT ? 5 DN J 5 ? M -'i rl ll lUlr c r ?DIHE . ? N ? I"1-m ? " ?uNO uN ? r. r] .IOwml 4MAYQHA rIr' M((A?aa •MN r RpyMr•r ACr IrP1 }I, pLr 7L',7Lr U?LI?a?.IE UIMM ? r ?ot'CF" ,-m . /' -fS ? E U a"VEwAY ? ?'rHN,IHI(N1111µ 111 r, F I r A,".Titili' ' . _ qw„ E M.T. FY,Atlr gm I LI LI ?E??ACnM ?I °A' ?J?r" c.?n p...?r. ? ?DIr4R VrG/. rr?'" nAq IUMrIC MAD st.?, ? r ?DVtKD •I(H I•In AI M(JrAI ? " ? pIISRV.'.({N [J n []ArDrrrnNUD•nwAY r. -. , .I µHx a. F air r, AY' .I 917 , f N.ff 77 r?Sa Yes.,.r r d 1d` ?,k J????r4q } kzr I!Mr rrT ? ,t1` 1 1;. IL?`fc ? r-' IJ? i L' ? 1 ' 1y,14? T 1 i fa 21 1 :m•.lo UO LI) f0 I CO O 01 O 1f. I(: 4t.} t? ?!"? 'M Y t,?i? t Paz a ?. " } All _.._ a .. _...,..... ?.. ? ? .. .., r'. _.... _.-._ r ... _._ _.i???? ._.n .. .. ¢ tC r. POLICE TRAFFIC COLLISION REPORT) TRAFFICWAY Eou<E COM INrNUMaz4 PRIVATE WAY ATF OF COOS rv „No-, ?nl o u o ?.. R lustiwt"ouer -?/?" S6 muNrv NO. ?lo arrr,o. rNwA ?uv Ru I r low ?F ? N OOESTR 4NGIIWAY Mlts CIS OW of kT4C`G ON in ClS RWTFON I4 .3 9?/x?;J Sf<I T I RSFCT NC. vn TN SI4E[rOe ROD N CIION M1VTFN SIRf[I x STREET I.N. IT O. MllE 1057 ?/? / DISIaNCF 6DRtMT ONleO Ft![ .CN05551RlfTOR NlaxtST MxfIpST ACCIDENT E MILEAGE DIAGRAM DATw CODE A??5 C Il15gN NVIXVfO StvENlltpy`NO rNNRED?[? 0WIAGI O."'IT.N S .. CIVDr CIfS a ? rNN wp?. x' Cl3 1-71 CTI STREET OR ROADOR REfF4fNCE CFOSSSTREETORRVAD - 1 /]S T []RRpRRIV DAMAGE ONIY ? v tSUl Tfn O OBfFCT ST4UC[IrvAVf Of ODI[CI ST.— ANp OWNf v'S -I) fS ?? ?V D Y t IT- 111-CODMGl6E $ UNIT NO. I UNIT NO,1 OVEHICLE [3 PEDESTRIAN OPEDALCYCLIST Rx ox vev's NAMT I I 451 ,vFR SN AMf IAST IR MI Ff pZ SIRIE ADU.11 _O ?t ?- c r - /?'E'? IL ??IJc?. ALP. V'• D FFT N1 ORfSS i ilRmpt// p 3 p 4 R c . sulT fN vC Df RN _ v s l cFrvse NO oIe R 0A / n? ,, '? V rv llcfN No ATI [x DaT[oiS RTN pa. r. UC<UaatION N E6RNONi NO [v[S wf ?GNI .RrGNT ??uJIJ e?? N / ?o E9 E R occuvNroN MNAMf6 -ND. FYFS wEIGNT ttIGHt CHfCK (.? vfNClr AS:NrMVPIOr [o[a"ul"[val UAI OCHECK(?I NrMViov"fF Oi ANOT" AS Ry r CODES' ] 5 1 n • rw I ass < t, "I rr i?UVtrt t CODES ? t ] ?? 5 [n e i ,tT Rrt; R 18.111." O .MRwa l ? F ? ; ? aR f IgOGf c.- a Vr r urrv MDDtI 0 nor O p - r1 1 I ? vv O I awl E 1 1 " v 1 MUIXI -R(.No I} v I 1 = z N[ IoNSF ;l.T r,o M1/I AIFRA NE No ;&0 H CI IXDR vF A A E No rA f FT vfrpaf wNTrcaTrON NO :T F T 5-3 O_fe C E 5_0 Fj Al 2 L ! raFIDFNTNU N N v vlDSnvtpowrvm v wool[ -NI NO O Nt xmowNly uu NRST MIDpf " t ? V 'Z .-R, U a -1. ' N .-RISS IX wrvt4 51 ? J NAMI aapovfSSa INS 1.1 CO cR AyLN1^hQn-,? / R --RI 11 u -1 C.OR-INT sT EwMw?DAV ON __ - t IM u A. tn c"Axu C I?xrvnr I-, IOWTD olAecr ? nr,ar ORI.AwrD IS' u mace a4IA on??, ; 14C f / ?TOWfD DIAGRAM OF COUISION: i:ueT liNtasr`I ev:vvowT C?R?IPTION OF COLLISION: Ilnt suRVLLwNTAS SN[1[t Ir MCEUaerl "Dl.?c l"L'.C1TF' ^- ? Q ?P/vcPi,CAST L:glJTQOG elf NAME, ADDRESS 81NR RIES OF PERSONS INVOLVED 'CODES 1 - 2 9 4 5 6 OCCUPANTS/WITNESSES II?:n°Dn?o.f.Ai a:Ml ' i? sr . AGE TATU ' R ISV nmr :. N NSS[ a IMR N lrRl Oi YIMRr ? AM A Q ri'?''1 ? ?n • ? w 0 N' N A luMnf wl R raRrvtu rvcw 0 AMS pr. 'O;", r 0» ?ii '0 a aV Rlff ... I?rRI? E +(/????) Nwpl(.Mi., OAMR w7^''?1 O:? llI.Ovi"r Oir•:r ?<NE I X " y ?v(, R.IjrMA (M W . ?ID DnT, ^E RERn WVl?? DATt. " 13Aµ O ' / ". 1 T ui?aza x ?.y c . ?, fi E M .C Ki ql 4 f Hi 1 ? G v, L (f 4 ?' \,rryr(ry ?A? l? j ? SI' I f L dY `w r r I? ,. ly ? j 1 61 R, 'l? x T54'+e v POLICE TRAFFIC COLLISION REPORT QSf TRAFFICWAY PoucECOmH.vNTNIxmER E PRIVATE WAY Dalf Oi COlfs µ8 :tS By Or C41l IM[ x1..DR `111 0.2 GUVNIY f FFC-San) CDUHry NO T? CITYNb. fMaWA uNU t N ? pt :],N LTY 00 SIPtFt OR MGHWAV 3 DA: ?w Q4DICNl/124CG ON ?C?JTe7e ?/ -a Cls gOUIE ON SI E. ODE SfCfl If R51ElINC TMNI G[FI NWaU NON INIFRS[?C[IIO ElwFtrO[p /ORICe450AJslE4cl, , r blRfEl PRfll%. E ? M%EFOST ?,.3d D51-111 bVU N CE SIRtEIOR NEARFSIM Ir P051 CVOSS m«S R Oh ACCIDENT MCO E DE vAMY -,A DIKRAM ONISION NVIXVfO NV(u11v C -A. NO pxINID?NO. NEURED Q `y IIAG! ?nl%YUN s .a PROHGIY DAMAGE ONLY p c? sIQFN ? vNE1Clf wwr.owulw IN11 I %RO MfN CLS 11 E iIP si t 04 OR gfrfR[NCf CgOS551RfFl OR YO.AD !/? DO V OtlIECI>I4UCx lNAM[Oi OblfLI R A N aNDOWNfRSNAmfI / ESr DAMAGE SPECGLL Cg011(G lbf UNIT NO. I UNIT NO.2 ? VEHICLE-':" ? PEDESTRIAN '- ? PEDALCYCLIST > RIV(N'S NAME IASI NNSI .1-1 DRIVER SNUnf: USI FIRE, ml..E O?E,C'xJ G r1.PCL-?5 Lc_77o srvNlADUxus /.2? si ?` OS slgFFl ADDRESS {? Clir slwlt 31Y CODE NF rvO. D IIY SAIf ZIY Y E ' 4, JA C = P/'Lf? R UNw-1UNSFNO Kr PC L L? /}I'AI,f s[x [NAM b41H bA / yo I V Vt a [NS[NO. TAif DATE Or GRIN HD D,Y .. IXCu-1- IRMNAMI NENO. fY[s N Ir[1GNr E ."A".. NRm NAME 61-1 NO, EYES WEIGHTHE- O R ?CHECK(.7 1iI AI AN 1. 4' AND V 1. , ?CHECK (/( FNaE wswN NANOTIER 1 CODES?" D? S CODES?* Da r's' s lA ew " n uvlls y J wJa:1., ? ° ?78PRx ? CC"?"I Q *M1.1111 U? p N Q A6l1 Qtonlx ?; [Ii Q.°La Y M? vIN %(DODGE Cntvl y82GNcV MODllIOARTNOVw1 s1Yll l3DR.cpn.1 C.w E FAN rygpEl(DAx1.NOVA( .) H ( V.I x11 l IA Nf? H IXGx w,. N V l A AIE ?C G,r KSU3bS _ WA - I nNKU wm 1unoN ND G Ably ?6C7 '7-1 SY v[n ttt l0wnn<AI NN GwISNYEnowNlx lASI nxv mIDOIE C <kv c a ;4 A_ v1a[.nio 3z s33 J O W Isnxm wrvw. EASt _ rlga mloaE No 2 DDxlssa owNlR N A wNtR Am1aADONISSa INwRwrxrtco wwuNl T T? Fi rm R I INU f NT 71 DnMAZAD iA six rvu .I IATI • gSwxiNC NAAGID AaN (' ( ix xuPw.1 CnA D CNANGt r rx°YAVx ? ? "?? u S RR Isl. Gl " RIVE ?Av ?PIMwINID ^YIVfN 71RIMNNID WAY ISI"OAMAGI ' '7 15 { Wf O IOWID A w. er I -r10-DBV $ INDIUn NOx N DIAGRAM OF COLLISION lu s?lll NlcE?Yl nr AVWW 4O ' DESCRIPTION OF COLLISION: I-SUPPI-NIAL-111INICE-RYI OiPiuc? S'TArcO Ty?9> ?l ,F'Jc2 ?2 ,PAN OuT Iv F,paur OF Nit ' CoAe. 727,e v e-* T /W, cS i T , <as T ?cn ?.e'U L ? (s ?.••? ?o //G•? TNT „ -_./ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES I - Z 9 4 5 6 OCCUPANTS/ WITNESSES A., w 1Mx A Y ISIR. IRCI ' OCltJ/NS ? p SvTT "q".?Y-?•?"10 / s. NAluxla ?, Am eY B. ?"Sx' Q : . Or N Oi m W, ?o" _ u rxN SS n tw101 movlDlwN p,l,,, p": ' pwr . Q p..o ro W1 T :;r"Hti' srui e. Qw.Ne QE". 'Q.". .OQ ?".° H X ?A Io .<iw .?;? am• IRD aAa?sf -+ILI AYVIh Mks U DAlEa nlwl APYwmoeY _.?xS-y DAN ?.. sR 6 nA aTd -? R ?! 4`s r'f Z 3W , *`1 o+ r t. I ?y T 'A?'... . ._ . . ._..?.x ..LrkDS ,. . - W.?n 1 \ _ JIAf t U1* WAbHINUTOM P^Gt 1 °f 1 No ?TRAfFICWAY POLICE TRAFFIC COLLISI . 1 ON REPORT PRI`lATE WAY fWK[COmpAINI NUMBER RI _Dglf of cn DqY Cr ccunl rv um[ coDrvn 2 ' Iusf R.w HGDRI w ?. wunrr r.o. orr NO. /? rnwA ?D,bAN °PLL 1 Ov IOW„ „AM ' 13. all ?,N fdNOO SivFIIOx NIGHWAr CT C[3 % NWt[04 IRE SE tI 23 MMES k3c ?W of Forks ONUpper Hoh Rain INI[xucllNC Vnm: slRln oR Norvwnxs[clwn 3 9/yzd rFEF,x Eo. MRE rosr Wf(rvPfIr g $IREtI ?? 7? ' DIS aNClaDwfCD .GV033lrRFFI OQ NtA4F51MRF rO31 I ACCIDENT RAMP N,RAM Mip _ 1 11 . ([IS N 3 ® W Oi State gout.,, im CODE E ;roNINVIXVfO v'RITr tAN ? %.Rp JINIII CIIN45tREfrOR I.bMOR Rf{fRfNCf CdN 10 INJURED- ? If O ? SG UED OIAI NO. lg U ,uNONUr" 1 TER tt1 CROSSSTNE(TOIT ROAD ds VfH G F1 Sr I N ! 1R. I l ® PROHRIV pAMAOE ONIV ?ttS IIED ? . 'F OB,ICI SIRCC%INAMFq OBIICI SIPUCR /WDOWN[v'SNAMFI t .-- -1- CODWO USE is " UNIT NO. I UNIT NO.2 ? VEHICLE ? PEDESTRIAN ? PEDALCYCUST S .,-S NAME. Wi IIVSr MIDgf vlvt R'l Nqm(: N31 I' MI I Fraker Franklin A -II I ADDRE Slx - [f l ApDxF11 1220-15 Deer Park Road 2 n srpn glrcoa OE NO D r sMIF urcoDE rorvE No _ R - rvIN'l LCEN NO. - IAIt I rV v3ua. NU A I 1 . SIAIr _ f . DAtf of nlRw V Mr .. g -p-ON f MN.tNI.-Nf IVO. Frf WEIGni fE 1 E (KCUPAIION MNAM[a IHON[rv0. Y wflGNI IEIGN s t - 2 Q CHECK IV) fAs wN rMYiorrfaAYMiorMVA( ?CHECK IV) N Rat I HOV O H G r OT NOt fN C F ASAN FM Fr r g I R CODES? - x ausr 1 1 5 1 cDO1 e's^,° - CODES ?' s? r ^': S I 2 n , 2 uT3 'None 6 Q < ? 180 ? g X Y,r? 7 :IIR Q C:KI1 ? ' HN AN LIDODGf CHIVI C 72 Chev ,AOpfllpAVt?rAVAI PU Sirlf l7 DV <pfvl 2DR E vfAx I f nEV.I /eODfIIDARI NOVgI Y(IIDx.. v.I J J H pl r lA NU AIF AAtRRA1t rvU AIE H vlH 7 01 N l A All IHAII NO III an/Wht GJ3069 WA - - I V[NKl(I(xNtpKptKn NO C . G C E 2111 2 F L v[M<l[IDENIIN AI NN RIGrltf 4F DOVEI,[N USI IIR31 MIDDLE PrgNINO RGr51[PtDOwN[P. LAyI {1431 mIDq[ PHONE NO Frak O . _ D ADpv[ssa wrNfR N A Nlssa UwMR rl 2 ? I .D.-OFINwRANCE COCRAJ R ND AN N v D.MACfo.wu ' I or,..Mr:r ouva u " - - ro 10"o 1 , ,-I Ell. p AAGI C,., ?W??N ?N(MAIMU AINto F 1 mvngc ,I(? L, ?'_??. ?, ?^W??N ?NlM ! ? I - ? ? $ IpeD,ID \ s 3 00 ? 1OWf0 r West End Motor 1O'"ID _ 01 GRAMCFFCOU IISIOrrN: ir°rE[11iNiuuiarl ' a+ pow'" DESCRIPTION OF COLLISION: I-SUPPIFAIN1ALSM11NNf C.-..1 Y Vehicle N1 was southwest bound on the - lIp" Upper Hoh Rain Forest Road when it hit a - stump just off the east road edge. This ' -! y caused the vehicle to loose control - ! and drive off the east shoulder into the- b . ... e - 1 - brush. - 1e NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 3 4 5 6 OCCUPANTS / WITNESSES ':w^'aia'l IN, NAMI II si. ecr um s "„`,(" w ITT s1R ina Prx;,Nt pNelMV'I\t rIYl U1 v Ir" QAMb Q<A ' ??' .?YI ?ri' xt .? ..__... - A I lS IUUI OT YlNlvr IMOM ? AMB ? ",.tI Q" . Q i ? g4;Yl tt vv(ll ul OpI R NAi;ifOl 1 u1rX Dr ?A 0, %.-Qhw rv ?u IN VI eRArr. Ki X I[w RA D MIrKr r GII D.vAr<MD qK1 AYRIVlD DAIIp YI VVI Pr r All J. W. Martin Troo a 80 WSP 8 1818 81 ? 1 ty -5- 1 - ._ N "» w1"irn Y .w? 1-t pfc F.var-2?)h.r uc ._?7Ay Jr ,'p y -.ply 444I1161 1 1 1 I E ?L{fl Q w y'I tC, J f J .???l1 L 1 4 V ? r,E?[(?Y I s? t ir??{y( • ?1 1 . I L I!;N!. 1 I C TL i .T;. 99 ? r ` ? 1. - M1 ea : £P STATE OF WASHINGTON AG( WWIw14tV I W, L jji?ffff Df '-!P•,` POLICE TRAFFIC COLLISION REPORT 1"T.iRAFFICWAY - `` ?O, ? IOUCf COMHwwIrvuMBFR .. + a H O PRIVATE WAY Datof -IS N sl c W % Rn 1?(?f .lu Iwn n ul N.1191 V O cDUNrr - . /??? K. ' ZYA jd'( COUN1Yrq. cl NO. w.q oRDgN - 4y y f 11 CIY04 T0'IN F6 O.OF 514!!1 OR NGNWAY '- Avlfs jgs pw pof Chlhnl4Gu ON AMh4-- 2D INIt9YCtING VAN: STREET ON ROAp kI CAS RW If O451Ntk O Q 110N -3 9.3?so _ NON NTf9t ION S TA Ta PPEfI% F }] Mllf ?], /f ,f a% N , a k °xk ,1 DpInNCF6D R' R!<NENC[. CROSS SI9kE1RfSI t I4FfiM YI Ir/aY4A+5?NfF1 7'tpxY Py ?N l utS??'K 5n? ?l cMF T ACCIDENT 9MNP DIAGII wEA M,IS IN E T ? M' f[k/ ? Of • , I, I? K.E Af?? f MILEAGE CODE C.USroNINVIXV[D? SE Vt RITr TOIµ NO ? O+IItD-NO IN lU4ED_ 0 SPll1AGf 0"Ie4UN INTER ND INIFR]lCI NG ]INtf1 0Sl.frv ruNRU[R1n Cl5 OIOSSSTRf[t O9 ppg CP VFNIUfS P9UI4RTY DAMAGFONIY ?FFRE 04 NOAp OR TftRENCE p LUTI OB1FC1 ]I4UCK INgWE OF 09)EC! SI9UC%AND OWNIR 5 NaMEI .E c3SS70 EST DAMAGE SPFC . W CODING USE S ' UNIT NO.I Dlfm9s a lwsr FIRST u 1 1`1 1 fy - O EHICtE O PEDESTRIAN M ' DRVtR .. f19 ? PEDAECYCUST MID. li2. M STI/f A DRE ? SlRfti gDD9F55 I T Rl ?? sIAIF [IP-DT TTY STATE PC DE N E STAN .)rv?R'S IICf??? Oq O Big N V IvtR' UCENSF NO. STAIf t e F 4° r P OCt O RIRIY4 Mo R?r U ATIW NRMNAMFAPIgNF NO. FvfS WFIGNI NEK: E OCCUPATION FIRM NAMF6PNONf NO . /•1`J FYFS WflcNl f[IGIN ? CHECK (,1) 11 A, A. rVIIFF AfA10- AI O CHECK (PIT lgl i F AS AN FMPIOVFf or nflol?ia CODESP" 3 n 5 f EN t CODES ? T ?, % it 5 11 13 o " y Mo n O `"• 0 CI .' `I O n. f p ? O ? r ` 5r1 „ " " ` I cNfv,r MGOf g9 io SI- t- one., rEa9 9T.N .rv P (oa 1 ?.1 MooF1ovg 1 Y O "? Lro tIF aD l E T h E / / "?C?'N 1 9. or+v.l oR All N surf slATE H P " " 19AIflR Wolf Nn vtN.c. i] l - ] A all AI fo f NO. All r5'If --A1-Y NO C MI 10- _ ? s cF?j?S1.Dw rrr0?1ti?('7Rtw? R.pf a jS'rv ,fP4) Ea? i sid.c !c F Iva S K irk hm q?C] KS 'F+ I 7 Y ' E? a Yar 'iT`° 1/dv r '"'' 2? IVO 3 TRAFFICWAY POLICE TRAFFIC COL. ONREPORT PRIVATE WAY P ICEC..M4IAINTH-FR S. p1' ^? 09 /a «lsoN Wn won NI) .lo Iw.f r HI TIME IUSF ]4W rvou4 7 couNty _ grUsa.'l co.NTY NO. // ( cllrra. EHwA ?U 4URAl IWN ?f ?'N it OR 10wN NAME oOr Sl Ft o4HGrvWAr 6 M+Efs ? 5 ?w of v. IGSi.no ON Cs Ev?Tf,C F UUF 4z 51 tt C 1.A.3 0 5fC11 1 N IN (RS[CI,NG w11H: 514{Yl OxlpAp NO 1t[45FCtION i °[ wfFN I Rcbon Val ,I4 A ?b Rc?. SINN 1 ' RREEI% F MI1F 4051 /O.D3 J p,S1ANCF ao NlMI IXN! NC .CP055514FII O4 NFANfSTMNPOSI IFS I (? .q F[Fi s E w OE (L6" L., L<I PI.A ACCIDENT MILEAGE COOF 4 pIAGR-UAIA CIXNS ONINVOIV[D 5[v[Rrir- TOIAI NO 10 nllfD_NO.NJURED 1 ?S4rIlAGf ?FITARU pvtM Clf3 ® C] 4ROMRIY DAMAGE ONLY ? FIRE ?_'cll ,n,rvl ur ,r„ Nif% l/ %R Cl5 NI XSfCI NG SINfEIOR ROAD O9 R[iF4feKF <ROS531R7O ] I] ODRCTSTR«KINA EOFDDJ[CTSTR«[MIDOWN[4'SNAMFI 151-.1 S SP[CIAI U-NO USf UNIT NO. I UNITNO 7 VEHICLE ? PEDESTRIAN ? PEDALCYCLIST 3 U51 1,01 I-DIE Oxv[?? u I I O. v .51 NR1 MI It NAM, / EcL A2 ( Scoff -11 M Nl N. A 9837'6 D R 51ATE E 18376 7 9 MN-1 a 4IwN1 NOc 1 E R «cu L M NRHONE NO Crv 1 T 0CHECK(.1) lAS nN [Mnovtf OF ANOllfl A' ? CHECK(,') Iy.I AI AS AN UR CODES ?' ] r) 1 5 I d .: 1 R, CODES ? ' 13 i?:s? A ,,",:;xM •• / a - N ] Nmm?s .ST,p9Ti.? F(.JEJy,E / ?.orW ww P ? Pc1°' "' ? rs.1. ? .,,Z; ? 4`111 AN „ rvE C] Sri' M4 , ? ? u;... ? ra.. w nw M r 4U 4 ' l vFrv YEAR IDODGE.cr,EV1 74 Cll?u MODFl IpA41 NOVA1 51vIE I]U4. ONVI Luv ?'/u E nv MAN I rvf vl w -7A1 foadE u. ONVI x ?z T P 1 ' fw 9 ,Z v 1 PIA F N R? I?EPSI?io SIAIt A pR NAT NO AIF WA H vFN C«Ox I 62? LL .. A WA I RA F NO ATF J 9 [HKIFIIXHIRKwIN)N NO CRu1 9Bz85967 L V1.1111 . DlN1 rKA11 FzSYI_fKg27Z/6 fG,SRPIDOWNER. IASt FIRST MI-I R SAKE Nl NO 5°N DOWN 1 F,R51 M,pDlf 0141K, 42 ONE NO. ' 5 Z AppeTUa DwN1rt N E 1.S I4 ?13 337 G?i v?lcc Fey CJA' rl 7E N 1a ADDRfssa N-ANCFCO CAF ACENT SA?'F c o S s u ?.eru & WE- DIMAG?O NHA ?wncN'wN•D•u CHA DGI deonD.r Rn c1 ? Aw:r ?R1MA,NU' lmoer UQ.RA1 S IcFJi R AN N I?IOh E IN „ lD? E AC,FDAFIA OIARGF ru•?i :iriAi ?nwA 41MeDan r n?'4D^,.? E{?E??,L/E r ?i,wnv°nr r f5`? ?J 'e`?o a"on s V /J ?] DIAGRAM OF COLLISION: s.OinlDNtciSSnarl N " CIO 4.AtCc. lidow DESCRIPTION OF COLLISION: INS, su4PI1M1N1Al srxil,r rncrss.url oLL IIIII Q16 cs-Tv-?W r` t ? ?o ? - T U ?Q (,u,EQ aosscd ? } oLn h+.Aj ?LU Grp ? C S Z? wl-out w ps S?YS, _, NAME, ADDRESS B INJURIESOF PERSONS I OCCUPANTS/ WITNESSES 'v"eASE?w"?n;.'?+:w NVOLVED i 'CODES I a. AGT a - 2 J ,., 4 < 5 6 IVR. Fna Sw. NAw ?xn . Ixvlss NAm4I or O A e ? fC" ? ;", . ? H ? i`2Lv N ww ? • A I%M5e NA1p410r R,Aw„fprRDM oA„A ?? ' n^ . ? a:r ?;: AMI H A IMWSS I?IOI , vl ?AM ?,".'?;", .?H ?n I Orr,cle Sr X aM(A OP D rA ? . r%D D °] ° DAlI Ql 41 rt>rl 1127-84 A DAII // 2S ? r c? f k Y6n 7` TY Ta a ' ?? u ,I ?b? y 2c1 r; J Y 1 POLICE TRAFFIC COLLISION REPORT LVJ TRAFFICWAY EC]IICE COMRINNI N-LOT 1 Y ? PRNATE WAY v paIE OFCIXII U4 IC01USrUN Im[ COUNty COUNTY NO. CIrv NO. FN WA 1 5 D?, !x_ i I fun Aux AI. ,. ,r ,. '_I NOU.I T? 2?T? /G QU R . 8 IG• QT Q rv CITY 01 TOWN /?-[ONO. IIORNGIrWAr ION C?uT?.R ` NGfS to°' ? ° v S ' rCT U3 RON9 OR at9ffFC sd ON ON SICII t ? INllR]ECl REF WA Np I y 51IWIEN C - Et xAEFI% E Ilf WaT M /3,G G - ? AnCl I9[ I EROm xNfx[rvCl CxU:S Ef104 N[a9ta1MIN WSf O OL? N 3 1F[ a ] o I ACCIDENT MILEAGE CODE AMR IIAI-111A [OUTS ONINVpVw ]I V! Iv NU n4NlD NO. NIUNED_ ? SR IInGF Nt'a.RVFf "INNO 'nDNUllI I f 90 Cla 5lCt rvG -R- OAD OR RFFEA[NCE C ROSS 51REf10R ROM RT . NRF STIXIN vFN clfs RxON41r pAMAGF DnIV Q ?T apl L?3 G/Q Ob RCI atRUC"INAMf of O"1lCt SIxUC. NID OwNFR'S NPMF) FSI.DAMAGk CK 73Q2R F3USUES - Uh.1TY s SM<VLL CODING Ihf UNIT NO. 1 UNITNO.2 Q VEHICLE Q PEDESTRIAN Q PEDALCYCLIST T' a _ DRIVIRS NnmE: IASt n9sr Mlppll STU.m P L 5 1 E= ANNA v14 sNNMF: wv II4s mI I - Stx FInDDR SS 1?1!ELJA RD. IFI app4FS5 l suN Rl -1 orv NO LdA, G?(ll 37 RN 5-?fll D R , swtf fncopl RNONEN . 5 S DCINSEN E" F^ nN o V -NOIll-" - AIION a E N4M NAMFA NO WtIGNI Nf IGNt R .. rvrt A CHECK (?) GF rna o L_ Q CHECK Ill) ?1 n 4L L f L e ;; CODES 10* 13 CODES 1. - 3 5 a v " 1 IT ""d".:'°°m Q .,.4,N?° ffi .L'° Q i'n.N. ? C. iK'i ? " ?.. "`?n7°•° Q N.,, NlI Q Q FL.. Q "....2.. Q it.N' rF. IDO Uf,r Olv) 7? C W.?U• El(DA4tNOVA) sl rN I- C-) I?'A"BLL z-DR E 1v DRV I W ;M- -EI -E IRV I [=I l11nsERlnllN wIF AIf4 NAN NO STAIF R S H . l lA! vIN CC"OM . FSF}TT •- 1 KU Q556 - - Wq I >o -NCIEIDENIFKAfMX1 NO i vEN Cf[IDFNIIfIUII NN S ID37V6D520758 - 9tclsnnpowNle wsl 11w Ml-1 SALME AS 7J _Iutz _NI NO. SAM O W RIGISNxw-Nl4: ws, Imsl MID. N NI.., - A' D z. wo4lu Fr omRR EL •L LL ;7 ` 5 N a l ]aGww4 N IN AILFCb??ZEaT - `i - AO O .Nw9ANClco -NI R U 1. R)( 9 MR. Pr f.u. WMAS L @ - DNnaelpA9tA ;' - ' ,:, ° o A?IDiaeA - E lal. pNMGI cNA4- ? AWili E] R1av.IN1U ? ?AWAYE YfMNNfD I l TUAMa l f K ? S s LOCO°-° QQ .-Y dY NVARf2A s GArv c,5 I n "W"'IIY o? ?yucrll IF erc. ol?N, l" DIAGRAMOFCOILISION: y,"Er li m DESCRIPTION OF COLLISION: Ill 11111111N, 111 1 - S FwALPour 0/ O-* UEH Q 50, ZD•6E-I Ce-115P R1). LoUe1 FfZC „ ,r l;' 1 t?hA'` L rae?ow RIGuT Z.RG IBL-6W BLLT CAUSIQ UCH. 'CU 5LO62UE OUE2 007-0 S _0UL.Cf 140' f, } A PD 'DOLO#.1 AN fZr' GA&3W fA T-IT OF APN -----------9°yv F !5'ANUC&,)T7ILJLLt)QGALOtJGPOIZAWM - - ' -' - -' `- ?` 6001 C0vv%( JG Tb (ZEST' UP-RLGwT' F;Acm/ G v ` . t I W I SO. IQ A LAPGE PATCH OF PSL 1BERRIeS, ' ? C ,`JI` J 3 N Iv NAME, ADDRESS & INJURIES OF PERSONS INVOLVED + CODES 1 - Z 3 4 1 6 'T°'•i swA•ntMlrau sr. OCCUPANTS/ WITNESSES on,EwauFAMF u a u " AG E .IA Tm -` R utR ulcl ° " urti LLAt1FLL'SOtJ Z- 3B5•Cu287 - - - - •rss V R.J 5T, -r EJA. kn 41368 NAINRIOF •_ yNAlly am n BNy, HN: I ETP4"•',rs. ??cc= cL ??a? 4w 765.3733 - - - - - a - m.tn F3 7 -UICCC'CA: WA• 3 (?_ rvlol RlmGVIUI-B,," r a atu?n o' " N Qam Q" OM " 0T Y Y ro•IR. I4 s'.wl• „ A.lw G?tLecLNt+SGT A'°"` L r,lvt U-C o w. S 13 uIuRE, I Iu FI A mo Ie 7 RW IarS Dora aloRl OS 1744 vDVrD er Dail a x i a ON- ..3 7 :., vv?lrfu , ? j - PY 9 'rul4F Rg , ? . .All Orc«r 1mE courvrr counrr NO, cnrNO. PHWA R p r„4,s IN lust ?wDrwuRl 0DR.- 'Y ? ? ? . ??5 rJ W P^t I < I u Of OIN Y OR 10wn 1-1 NO. 01 31R[EI OR I-R-Al FCr CL3 ROUrf 045 ?. lES ?3 pW ppl UILCFJJE ONCE/vTEi p, 3/(Sd IN fv C G 3 f O4 FpAD rqN NIEN3FC10N R 1 TM` ?/ PRf11% f0. MIlf PO3E L/ - - - BETWEEN M'???EiIL?Ii1RfE18N1?U E??3rRk1 /_/' 71 0111 A C UNI (O/ P mF[rf pFNCF CRO333rvfFt OV Nf^xE31M IF YOJI _ GRAM IA DIA -,A '' 3 N E Y[ ` pp MILEA E I r,? r F L7 Of M ..1.NNES T? IJr CODE ? S tolls ON mv«ND wvlY -RD j'NtfR CII IR RROADOR ERENCE NO lN0 A LED_NO. INJURED? ?1P LIAGF ?N18NU wviaogpix INIE4 0. CNp133ary of"ROAD CP VFINCIII PFOMRI DAmAGEO V 1 N 1: Y NI ?iy uE'. ? [wCl[ IO?IJ OBDCI114uCFINNAE OE Op1[Cl srxUf%^ND OwNER'3 NAMFI i t1f 0NAAGF RCIAI CODING TAE 7 s 3 UNIT NO.I UNIT N O.2 E VEHICLE ?PEDESTRIAN ?PEDALCYCLIST D-IR'SNAmt. v.1 1 fIR31 mippFF O. 1 ?s ' ! Sr ?Il rll )o(,>JIJ `. A? IRfa ADDRESS - sIR[EI ADDpas atr sun n4coa onF NU D 31A11 .1c R NE ININRSUCI-NO 31AIE 1f% Aft 11 Rnr Y I V IVER UCFNSENO IAIE DAZE Or BIR H D Y ra m0 R OCCUPAIION ,,NAME E-ONE NO. El. ATI MIGHI GN E R OCCUPATION MNAm E E PEIONF NO. EYES WEIGHT ,SIGN } Q CHECK IV) No m AL m as Eo A CODE ' A [I CHECK (?) «'AYiorl°fa'AE vFHInEA AN I4 S y S . e,:.r. `r CODES ? 1 D ?:ss' 5 f% ,, a ukrn Ya, IN, ? ; .v w ° pWG[C Iv o . ' °O NpNA° "s„ RD4°oN , . RD ?w N .Ntt o aYE ? ra.D o K(f ? ;°? v H I / 1 D? '9 L? VOLVO 1427 ?v E N I <HEr.E mGDEI IDARI.N AI Yl E V I °p^r' ? pF w CFN ulNO sun AILERaAIINO 31II H vfn.G«OR N A IACY1- EsC 2/7 LuA C N A ?NI<ar, ?N L EH<LE aNIDIpA 1 N ? 0 S In 3 pIGISRRID OWNIR IAlI IIVSI MIDDLE PHO v GKEB/v ?O?/El) ' NI NO utiK O W I Rtp OVmER: 1A11 NR31 MIDaF N NO. AD DRI53Of OWN(R //8U /O/ S= PL. tiE. k/kkLq v N E A OWN[p 711 NAMIEAppR1130, INIURANCECO --NT IN u AN A N U /L I ;/ R DAMAGIDAREA in nxM G DEJAADtD AAFA pA t l A J CHARGE - CHAVGF wClior iN r , ' M GE i ? ? D AY ?y yy? xrtD ' AWAYN ?p[MAINfD f3o 0 ANAL! 1 s ETIF>L 11 ( ` A-1 fl? lJ OIOWED s • rtDM ?.y-_? DIAGRAM OF COLLISION: Ni<ME' ^n N a: oHR DESCRIPTION OF COLLISION: ID:E SImn[MtNlAl srrttl lF NECt35ARr1 - Q I VE111CL,'E -P. VC). O V CtNT?q- PD, (ZOuwpN c C6 - ---? oeV6 To L6 t-Lo2 caSRpL_ WE-V-, I?rro $CQFlDSID bAGO/u? ACCEtpl/ /?O.?br LJ?LJL- 9x Qv -4• o v Eft r. A, hn A, ECwE:v"t' i,;to leu sN`r -TWKINCG-LEL. UUKNOLOU ?J VG-Q, ?TG"?bLLIto 70 7$6 C EAJV Lp M a NAME, ADDRESS 8INJURIES OF PERSONS INVOLVED E CODES I - 2 4 5 6 OCCUPANTS /WITNESSES su Act urus ", , R I319 Irtn r lu A( %ulil Aml pf 0, NR O AM f o'' r ? 'x r ? rNi ? iu 1 rq WI« ui M^v r4lIM OAME 0%.A'?w , ONS ?- O A • a?f153 np?0' VN?nY LAMA Owxx., O crw11P?Nx ?NiH rr M p"''? 1,t, frJ4 Lei Afvlvjy yD?Ar ??°'1 AN90NDEY ?/ DAII IRA N X UJ ^.? Ck`.ur?6C? "5 u3w, 1 f 6- ! /b 8 ?'?la. i-f? cat I r - +.?.:T,I'a3S?''P??3fE47t)l':1 .-a,. ? ' s ,scE1?:t,aist _ , ' rx•.a. ? S I Yu 1 L- ?? 9 J ? Lad L L i' ? IgU(.[?E ?u4(?)tAn N,d! ' F?f '.`???1d}g w{"fMR'tAi ?zry }, 4. rF?FWr, III''Y 1 I ?nI1 3" ?dl i 11 -? J r t?a? t I f. i I S - o l i a f L+nre .TAI ?E L ? F- L I I 1 4 Y ^l I; f 1 F. I 1 L rt' . r LL P r r t .l r ' ?'4 1. ) ..:J 4 1\ S l?u r 1 _ - ' CIA F?L - . f.t 1 5??''t ?t54 .. t iT }??19 ?Y , I 'I ? ? n - ,SLY • I WSP IN(REY, IB01 STATE OF WASHINGTON E'[[A?GE 1 DE No 'O POLICE TRAFFIC COLLISION REPORT TRAFFICWAY L? PRIVATE POIICECOMMINTNIpARea }S" >,r "?:1 WAY 1 w 1 'r r .. STATE OF WASHINGTON w3RI r(REV. O PGf OI N -) `3 , ? ?? o. POLICE TRAFFIC COLLISION REPORT ? TRAFFICWAY ' RJIK[CO '°• I z?u[u m _ • ur < MPUINl NUM4Ea ® PRIVATE WAY "E y,-.t x„MV c%I sroY Mn ,.,r Da, r ws ,,,, n ,. I m! Ius[aifn NUU41 ,w "I <OUNrr COUNrr Np. c?tY ND. iNwA Z tk, ?. Jl "y ! 83 U Sd p pN pr ?" clrux loWN N arHO dsmrn OVncllwgr [clcts Ruegl R r, vw(f5 ps pw p01 ? aOUTF OR wlt4sscuNCrArH VaNIOx ROAD I-Jr?aoiuvc oN ON ?3Z. S?b _I? "' .? ? C P4[iI% E MIIf POSt DSIANCt6 U•t ? faOM ?Ik x0 514WfIFN Sla([I n / 5f4lFI OI/2 O4 Nln4t5Tm IFPO r ) ? 4 F' AApp " 1 d MM1(S ACCIDENT PNAP OIAGRgM DgtA 1 ;R'p" n' t E I(E (], 0[ ? MIIFAGE •A +yy„ __ 1lTE I Cd[SONINVOIVI •' "CODE OIDVIN NO ® NO RP tfD_rp. N ? SGnlgGl J?NIB RUN HEEHEKf NEER— CEFS p POn4T AGf ID pl f srdEN ,.,HDV,I„•, IMF CU CROS551RIEft04 ROApR xISUIND ? E.?3 - '•,? k ' v! (y RCt 514UCr.INMAt OI OR-, Sr4uCV N,DOWNf43 NAMlI 7 ESI DPMgGF ?. ? "r SefCl.4 fgDiNG IA[ $ .) ?? N 'lu4 3 nfR's rMma r UNIT NO.INasl m UfaISNAM2 VEHICLE , E v ! ws ? PEDESTRIAN p PEpgLCYCLIST D4 FIR Yt' • ' slwtl AUD4 l ) . tss _ sr4tfr ADU4fss S "? '? - 7 dlr I s Arf I PCOIX NONf NO. 7/ wASN..r4PCN S'(I D sigrf J S F- Z . .:.:p „ . ? •) OR- sucfNU NU IAN r P R N. r?..A La.aO P n 4Rl uAr I asudNUNO Ixl F i?. _„ . m o . .x of y ' L EXCUPADON MNUnIn4HONENO v s wEIGHrnwrn E o<uvAna` S ?mNUA? F 6 PrgNf NO wA *7 ? E FYES IGHt IEIGHI ? CHECK (?) mm R UR ?^. Orrw. ??....o A. / S'dI o A AN 1" `t""' E i9 °:r °= J? S 0 CHECK o I?) A[ COUES?' Uw a „n fwcif ASAN[MnavnaA. n ie °aA 'i?.' 5 ? . A . CODES p. ' z Sr Awf a ° ° M ° 4 n 1 yq, ,. rlgv [aG »!r, ?mfA.fll ° p•;HI ? .I. ?K„ pn Ar rA; IlI4Da°` "; 4` D A4 1 Nv.l M91%t IDARI--) Z H - b rI '+z Q. c.? 4 1 [ ;"'"rtry n51 n N<r q11 .,T oloa /O 0 '4 nl4nAllru) qn H4 KO .L a ... 55 % q WA I AR A 3C N . A . - -- r EK HIt 1IXN111CANON.- C • L p '/ cvA resat tNIICAI NN s - bxE4 ? A A Q Q ! 4 S E atG15R4 DOwNrR Asr R"Ev C° S° S r 2 Q T 3 6 f 0 8 0 0 Z 3 2 6 PHONF NO 4 + OYT _ r Ai'G i- SC a ADDntsSUOwNt4 `r sliv[D ! 1451 Mi D E 0 W A q me a ?' .. i owwx S N LE.S V O ' 31 ) / ' + 3/ NAMf agooRlssa mweANCr cD d[ACrnl E R .N u AN N .. .. ... ? urc. MO. DaonoR 5 10 DIAGRAM OF coif ISION IU srRi , . -' ?IAOa..a.c µwA< keL r`.A~r CD 1 rvA t, ADDRESS 8 INJURI OCCUPANTS / WITNESSES TgEnN a L! C Ga....r.. a. X f o?w lV'""""i A rl INrev:uuow lrv uAWAY BY ?p DESCRIPTION OF COLLISION: 103[sUPnlA4NIAI5Wfla raeessARrl G E/tr",c r M / 6.urErtve rN/ GfQ,i,,?/,r,! LO/. r17' n 4 „I -9 Ur N/CarF A L NNVC/clA C /I'F; /M?.G:•fagfs+/ YNtr wrr.v/sr 6or aa/AS EJ,yN/-oL / t"' IS, 01-e rc. PAA:.r jglHrv rC? ?1N/CLO Z rt//S .trio Q%D /VOJ' SACS' TIYV e,oge, ?tK U3 , o-"c ut // f eLY '? L wrF S /..r t /q!! /!<',grvrD6. ES OFUPERSONS INVOLVED 'CODES I Z q nlmflnu 5 R? I S 6 GI J WSIR IACI nn Ur.PAlou, 1<AKf Axa ivr9._ /.PYf ?,Y lr ,dl?c57tTiiTL°t .y ? \ -AT.1 ,_,N, , AT/'F?Ya11? Af4'?e; M, - j, r i l I !r 1 v T r ,? [ {{ r4 rl I 1 r ,h C