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Home My WebLink AboutReel_0024B~~, ,~ ,_~~~ .'fir` TT _. • R ~.. ~. ~~ I ~`i7~ POLICE TRAFFIC COLLISION REPORT ICI•TRAFFICWAY PoIICfCOMNAMINUMBIR I ~ PRIVATE WAY 18' OZ o• G $y ,,. x~x, Deb . olw., ly w Iu,I .; o~louR c 7C ~S ou"rv 5 N couNl~~ rr NO. NIA ^ b RA, - t ^N ^f. ^ N <n. ov rowN ormvtnoR ngnwA. MMES ~5 ^w 6d I ~-\ a c• oN NAM INIFV%CUrvG VnNI Slxttt UX ROA n~O I I I Err ns Rou~tt¢ vRft ~ %i3~,5~ n N N NI[R%C IC N «ftwttN ,IRtft a StxfN SIANCf grvIROM VN[ NC[CR u aD ' PItEH% f0. MIIfRMt 4. 68 . •~~o OSSSIPtFlO N Rf SIM If E OSI ACCIDENT MIfS r' MIfEAGF EtFr ^ w Or ZN~ CODE R DIAGRAM DATA COll15gNINVGVFO: kvt4ltr IOIAINO NO fIIRlD~NO INIURfD~ ^SVRIAGf ^nlla xUN ~ .•rvnNDl~i I .RU NITER/ Cl] INTER%CIING StRFflOV ROnp(Nl HFfvfNG CROSSSIRfftOR ROAp 1n CEVN«ClfS ~•PROMRIYDAMAGf ONIY ^at SUlttO ^VfIXIC f / Vt~7lc~Q OBf[Ct SIRUCxINMA[ C«IIG SIRUCx PND OwNFR'S NNAFI [51. DAMAGk s Cow wwEtz >avK, SRCw CODING Ibf _ UNIT NO. 1 UNITNO.2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST Ivtv'S NAME U.St NR51 MIDUIt F45NAMf. IA51 I4 MI E`~ 2"~ J y SIGta ADDRt51 'vF_R " }IRE AUDRf51 z f orr rlR COa xn D Nt NO D slAlf zlxc t C. ! f-, .i V~ ~S _ , ^ G-4i5 R rvt4'SUCINYrvD StAI! fv DAIf CN bIRIM I Ivfu SUCtrvk Cp SIAIE k% DAEE~BIRIMv OCCUVAIIOrv MrvAMl6NgN NU HIGIr E UCCUVAIIDN NAME6RrgNf NO. [Yf5 vxflGNt IRIGNt '~ 'L FTZ R \ / ^ CHECK (/) AS ~N CV. No A N ^ CHECK (~) A A ^ y ~ M CODES-E 7, s a "" w a CODES- I ~," s r e u ' 1 ~ `] 2 ~ ^ . NR, ^ m Ir ^ a(.IR ^ ~ ^ ~ . xr '" w ^ A.RM.NII ^ (allx ^ ~ ^ ::~,. ` i" J , cnev. fA4 ~ F MDDn IDARI NovAl s I .u Ifn ~ E r n vfAR f.fntv.l aIIDARt HOVAI E> . c v.l '(\' ~ G04 t " nk Rl AuRI,An NO u H vncaox N IA fA't MI aA N Arf L VfNICItIarvIlNUtgN NO. CZ.N ~ Z 2 E fn CN. qNI IIUIION N x ~~ 9(GSNRtDOwrvt R. IASt I4S1 MIUat ~ OV vnOrvf rq O W 4 StxfUDWrv[R I IIRSI f MI FNO. - DRtssGO rR 1„4 A uR ~-.-.~-.~-- f , OWNFR 11t1 N E !-I taAD ANa co oRAGNI ~•Jo N ~ R IN a AN R ~- ]] - OAi,AGIDAR(A rIA r ~^ ~/~~.~.~ R •. DAMAGID~KfA psANIND ]l <nA G 1 -"~.rlo~s ut~WNAG ^ iomo []xf M.~mn oaorr nnv41 ~^w~r ^41MU"m ut ~DIAMACt oeun~ ~_~_~~~ ~ S •'- lovno S ""lll DIAGRAM O E COlU510N~ s~iltn r.[~[ssi~ur'I ^II ^ "„' R<,w DESCRIPTION OF C041SION: IUSI SURnIA%En.u srfrln Ntc[ssA4rl m ~ VE.tI d ~ WFO ,cjOU.YNQ DUL.TD Owl M ~~ RD. WNE.u ST uT12tAC.K F1 COW T fapPROK. _ "tNE AN~~'.~••• wA.] PtPPrzOlC, 1-1-6 Mo. HL l:i! ~ ( ~ERE~-oRO L ~-}F~(rE,R. Z MqD~ ]« RD~ JEV$FifAL_ Cf`la~'q<rTu wZTFt 1~,~.STOC.K pWU- '{ZS 'S1J 't\~E gREFt T ~-Y WLW lA4)gQI.E. 'CO P. C, Z', l.ocoT~r6 `Cw.E. o.uw»R r I ` NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES 1 - Z 3 4 S 6 OCCUPANTS/WITNESSES rvk su4nrMnaM ,r« MpIIONAI NAMI u ,I ka A41 EAIU ~ gSIR. NICE N AMI iq . , DDxr„ D I « x„R «. ^ AM « ^ ~n t ^ ~ . ^ a ^ ~:tl,. N rq URId 4 MD,.tDER~.oAM ^~:R1oM..^~ ^: I ~ A I~ « X .. .._. ~.IOcrllc lu//c[7L)~~IVR O DAtf arnnwr wROVID«r D«n ~~«E -,~~ i T x, Q ~R ,~ ~1 Q f ~. F ,~R a, r ~ fi. ~. r r~. 3 ~~ 9 n~ ~ ~ ., ,F~ '~~~~ POLICE TRAFFIC COLLI~i~N REPORT L~TRAFFICWAY NxKfC MNUMG[P 2 ~ PRIVATE WAY ~~~ AN Or COID ION r IrON rME YDx rm. »m rw lusE Nrow W„ 3 5.1 I COUNTY ~r'r-~izsov COUNTY NO. IMNO, / / !/ nWA ^fUR URAI r ^N ^f ^IN C YOe TOWN O 5r FFOR NGNwnv miffs ^5 ^w ^Df ON /N~ f r45 NWI[OR SrPf 9,x,350 ~ n rNIFRSEC-r~NL-G W11n 5~r ful-N~v p / „ frl ~~~ NpN NrfP5FC110N DEIWFFN 51PEFr FvFFIF F MIlElO3r O•~7 t NC vDN YtIFNFNCf. CP0555ruttr Oa NlAel5l m,f eOS1 mn[5 M 5 .'F ff(r [] [] [~ Of ACCIDENT MILEAGE CODE AM DATA COU SqN NVavip Vvfvl• »-r5 rAPN u 01al NO vUfuyLNO rNI.JVfD~ ^; I (]$ m,15u nmownm 1 I -0 MEj. CIS 5 EIO4NOAD0111lFFRfNCF Ot0555 r1 ~43 1 ~ vfn ClfS ~ ^ vv0ryviv UAMAO[Only ^ v ^ Vfa C1[ ~/ ~`7D V 9 OD,rCr 5lvUCV INANE Or OD![CI SrPtKY ANDOwN[P SNAmfI FSr DhMAOf S SMCW CAOVKi U3F UNIT NO I UNIT NO. 2 ^ VEHICLE, [] PEDESTRIAN ^ PEDALCYCLIST ~' 3 NF USt f1R MIU 1 ~ ~ evfPSNAmf. U51 r r F Z c _ tfrADDRF33 , rAle zlYCOa NF D er s1A1t twCODE NE NO. T L g~ 3 R DxN R~s ucfNSf Na s1Arz k fA DA of el rn .I, p.. .. I ~ I u NsE NO. rnrE sEe DArfofelarn mD N.r .. z cuvALLUO--N~~ ~!c A oru rlo rfs vn cnf r<,cn1 ~ ~~. ~4rZt£ f~ (00 O E R occuvnrloN MNAWfAYraNE NO. fns wfwnr nflcnl CHECK (.~ of cif ASnNFmAOr fOFANOD,FaAI ^CHECK (/) orfFOf AlgmrRA1 m ~ CODES - ' a ~ (.. ( 5 ». ~ a :"' CODES - ~ 7 ~ 5 1 A '3^O ' ~' ' Ku "~ of IDOUGe Cufv, n renx~ MA ~~ OOfI IDARI NOVA1 srrlf v ONV.I ~~~ E TFAR I E- n V.1 vn MODEL IOARr NOVAI l a. V.I r x YIAI sr.rz xA Ua nArt ,t H vfn eaoa ,I FH3FTixT n AE ~z ~ fnlaFruNffcArrDN ND F ~~S L vfN CU DfNr rI Ar NN Rtusn Nfu vme usf sr MlDar SA 8 ana+E NO O alasrtxfoow.Yea lAS1 nxsr MlDaf Nf la_ z ADDnssa Dw+uR N R fR X31 -- ' AMIaADDYfsiv riisuvANa co wACtNr R u A, . BRED n »LtD NItA ~ ~~1AR(t Dv ~3'~•: y~'~m fJ AV Ar YfAwNlu O .. DAMAG!)D ~fA <1MR(J UAWAY ^NLM,mNID 151 rUAMAGI ~.~o~s 1C S°rr Om J I D wfD"v t 4I I ~ I f .~ J AV. s OWT ^ ~ rArtwwl DIAGRAM OFCOlLI510N: sr[Er El Neeisv,Pr i "~o 1 DESCRIPTION OF COLLISION: lus[swgrmfNrAl sNffru NCfssAPVI ~~~~ o~ vsh, lvr-~s pTr~~~F.{~//YYJJQQ„may ~ b ' r r ~ 7 %~' ~ ~ GNQ~ /~ L/~c ~ G ~h~ G~ GUh$fv / ~~oc s hE tom = 1~h ~ ` ~ - , , ,eo . o ~ /G a5 E tJk E~ d J ~' ~- , , i o• ~. tro ~ c ~8~ C~ ~ ~! r a b~ ,~~, ~,. , . < ou ,T ,~ 5R +P~c:eMSS' jp,`~ ~ed-.en~ ~ Soafl,. L.oYE.~ ~ 1 NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED F CODES I Z J a 5 6 _ OCCUPANTS /WITNESSES ;u~,f swnfrnaA, 5w Ar,Oma.A, NAMr u Sr sIN Acr um N fvR Nrcr , w A [TYltt umxr a ^AM ! ^utifl O rr. r ^~i ^ (rw1 w1 fq+N Rw153 NAIUY1 Of 1YGM ^AMN nn•+r ^H Y O„ []ui A D(w1t5 ,wl Of ~AmM1 ~~~:. r L]i' v ^:i ^ii ~.Ir~"r I r15NUArM.Y» ~v •rw • X AGfA 1w "D a rte, /I DrSrA r RN nrt ~Yy~ rrf `^!r~ ~rM ( DAlf lx vlnwf lv1DI1F / y DArI r»; rt~1 6~ ~ ~Y ~ f J -ia " JyA,"ir ' f . ~~xf- ~ 1 tM' . mu T ' t 7 . w . . ~~ , + r. ~ 1 ^u,2 9 ~., F J ~zs 4 l A x ~, r t~l yF~~, I ~~ 9 I ~ .~ 1 ;~ ~(' 7 ~ , ~ ~ ;'~ ~I ~1 ~ ~ ! I F ~II k~ils ` >fy,H ~~ ~ `~ 1 , I 1 F ~ 5 s ~~ !I , ..~~~~~~44 UY~~ J p _ Y ~ 9 Lie r f 1 I I I~ ~ ~ {~ N J~ t ";~ ~~ 1 1 ~e~ ~ j ~, ' ~~ ~~~ ~ ~~~ s ~ r 1 l ~ s a ~' t', 3 ~~2Ck 1 4k yA,+- +++ +s ... s I + r v f ~ . i ~_ ' I~, ~:~ )r rxr - FYI ~ r .rx ~i ~~.~ t 3 R ~TI Ss". *~ y~T ~~~ ~ ~'~ ~ S r ~~ - 19 yv . k~ ~ x J U ` . * P'~3R.: y~~f~ POLICE TRAFFIC COLLb10N REPORT ~TRAFFICIYAY Paxx uM Ntvteur PRIVATE WAY ~ ~~ _ ~: ~ I DAIF Or OlN •a IRD .I P IusFa~m NOURI coumr NtMFiY W. a - yy1WA ~N QE CIfYIXF fOWN f6NO.OfyfR4'fOR MONWAY WU L INrtvsFCI1NG REFt OR WAD NONINFFRYCTION H rfeflx ~ Met 1 ~.y BfM'tfN ]iRF[i t /// yrRFfl / !'t~0 UI]rANCEt OIP MNfIFRF .CWS]yrvEEIOR NfAVf5l Mllf ]i ACCIpENi MIA ~~- m%fy s t LOO RFr W OF MILEAGE CODE CIXII]gNINVOIV[D, vlR rv: iORMM NO xIIRD~~NO. INIURFDQ ^]PnIAGF ^Hi6RUN R f IX N wxoafDlH I ~ D M[R N , (ypy55ry[/E1O/Rq/OA/D ~' --- y QVtIRCIFe ~ ~ PWfERIY OAMAGEONIY ^ pE ulrFD ^ VI Ct F W ~ ~ Z~ OB1FC1 srRUCx INAMFWOBIfR SIRUCx ANOOWNFRS MANE) fer.OM1AGE SrfCVICODING tb[ 9 : y UNIT NO. 1 UNITN0.7 ^ VEHICLE' ~ " O PE TRIAN:,.=^~PEDAICYCL:T:-~ ~ R' 3 gErvFR'S NrME: D31 IR]r IDf%f Rt? E LJ/ LL A rv[R ]NAME. Uel TITiST I 2 sixlFi ADORES] SIAIF ZIPCODE PHONF NO. NY D ]IREFt AmRfss UY SAr `` I~aOwcrc f.t/q 9sT33 3+'~= /~/ R ORMR']NCEN]F NO. ~ = FJ7 v sfAlf % M B H e. / / o 4 I V I fN NO. AfE OAR BIRr MO. I wr 1 y I OCCWArION RMNANftRION{NO. frfy GHI rEH:NI E OCCUrAFION FIRM NNAF6 ggNE NO. EYES N:HI HEMrIi 2 -Mv 1 ~ti /bo -/ R ~ GHECK (.G vtH Cif ASwN Uwivr o "N r ^ CNECK (,7 fH Of AS•N FMgarff oP ArarHiR~ e a',^,° ` i~ • °.m.".N cl~o-, IDRC.cI CODES-* ~~ S Au viv:.wr rxR+ xDRCruR CODES-~ Dn %: sIA Dy 1 ~ 2 NfwRS IN a 7 ~5°:o..Dr p A„HAA~Rf ^ uyrt O ib:In ^ „„K i O Iw~v ;*I» ^ "" t O u6° O c"Am. ^ „ ^".° v ~ %u H vfH. rtAR w.u[IDODOE.cHfv.l tIDARi NOVAI srvu1ZDR.cONV1 .I tlO.wi NOVAI r I l ~ l _ 67 ro,CO M A~ ~ E 'B r W r r lKf IF ttR q•IE NO iAIF It y I"I vt IXO H I A A ow -tAw wA I VEHKIF IpENHr1GrIOrR NO. i VtMI f10[NIIPI I '~ 7 F T ~:9 s PtOI]RR[DOMNFR: Uyt fIRSt MIDDII ggNf NO. O I]IIRIDOWNER: f/31 fIR]r MIDIXE Is z •Davssv o«NtR N E vnlR 'D' NMSetAOOassalNSURUxi eo. oaACENr R II n oAM.sGto AAtA '" S y DAmAeePMU ~ ~: wa CNMW „r OAOA rD CIIARCt °11x ~ ier • y t51. DAANO! ®AD~MY ^RfAWNID yior t r _.~ y ~ ^AWAY ^R(M.NN[D lsr.O I4 ~OITaR s7bral roMSO `"'"r er ~rovrtoeV. f I sluQNOxm DIAGRAM Of COLLISION: i - yH11uHCt55ARY1 ROM DESCRIPTION OF COIUSION: Ita[slfgtmENrAl srenlP Ntc[ss•Rrl _ le m4, J<te,~t„A,erz CrAR ..w<vs _o6tvt•Aun 6_,i . AN W r r NFaJS TD N /r T we ATAK 4oK.¢S I AN4 AN aF4 T6t?Avpvlr.../c tr .b JJ><O. _T¢_..__.. MARY A DF~//dLs/A/ An0_ TNaNrOCLWr~T..._ . _ _ rii6 At~Ar u1eTN LA.lcreY tgr7 Ar .T~f_F _ . SCL'rVC Ago THd LIGFwsft° OF TNd CrOr~ - ~ As ~FAfomr`rcr• ! Gor~rAareo ~ Krterrar[ptri. U p ~ ., wtro Alo.~err?O 7v 6vi~+f TNO O.R/«!fKc e NAME, ADDRESS 8 INJURIES OF PERSONS INV04VED * CODES 1 - Z 9 < 5 6 CKCUPANTS/WITNESSES ,n :E''~ulgrE"QwNr~AH iii slx AD[ wu "' x vR. eftn ° Amt: ~ . ro.tss ueea p i un e p 1' O "' . [ JM ^lu H AMt s D n ttwfu l•rwt ar movlor ~~ ~.nxl ~Rl, . ONx ^u; a N AW ru •D nns w"~"u:~iy uu~e. OAme Oi.".`f OI„r,:~I. OCi: On ~,v wMy]I.,AIrw aRxles wte•NR x e•trr oe Low Aptrx:. u.ul xlDnrAlcr.D y ZD Z ra lU •RnYS $O VO O Mna nWel ArreoRTOer Mn ~ eS? ~ RNH RROB]~t 7A . ,t f~~ ,ts'Ixdld , ~. ~ t ~ i~ ns~f ~~ti:` - - ~NFrlrs'v',rqu5 ~ r r G. y' 8 Y / ~ . . . d ~ l ~ i t.. t ~] ~~ I jay t fJ a - ;1 ~ '~ 11 } ,i ~', 1 '1 i - , ~'I ~ t: ~. _ _ _ I L 'I II'il J.r ~ ~ ~ ~1~ E . t ~ ` ~ I ~ ~ , \I J ~/-: '1 1 ;~ n~~; h E, C'. ,. ~T~ , twvrsviRfv I.ml - O ST/~TE OF W/1SHINGTON RnG[ GE No. ~' .~rp ' it~erxa~a ;`, k ~j x~ a ~~~ ., ~;~ ' StYt!A`a 3 Y r~ .w 1. ..., b .. ~~ POLICE TRAFFIC COLLISION REPORT I~ITRAFFICWAV pGtICE COMtwNt NUM&Y 2 _ ~ PRIVATE WAY 3]t wn3 °~;3"' D.v Gr cou ,. Y. ,r:.rY rrN lua u5f NrO nOURI X20 DN~F F F: OL., couNrr NO. /Co nir NO. ENwA ~URRW R,u '1 L. I~fl ^I ~IIN IYUx 10wN ~r NMAI eNO Of SIPIf[OR wGNwAY fCI CLS M RWIf OYSr /yG/o • ~ MuES p9: ^•, OsGr r n:..oc,rc ON ~2 3 ~, INNUSt[rNG'MNr Slufrr GU Vt InU NUN rNIFNi[CNUN 1WFfN SlxFtr 8 rREFr pRtfr% EO. MIIf IKISr ~~< _ IN - h ,I NC.r tv0;;5lut[I Ox NI nxf 5l mllt lrrs A nl rnrtf5 Iv gut n ACCIDENT MILEAGE R Ou RAM MIA 7 NEr n 1KJ n ~~ C p• F eo CODE ]] rvt. rv N C01 IsroNrNVUVID Iaxu ^ n t ^N rn rr1 rr , r D rr . U s IN A x Y O INrx tI sREtloxAwoox xutxENCf ~ l AGt rUfA, NO ENO. NIUYID~. uvN4u[s Q pxcvnxnonMnc[arty ^uriuum ^svi`iini r rN r IN[E CRO]SSrRFFOR~~ `/O 4 ONrtCt SlurvxlNaA[Or IXUtGr SruuCn uu00wNF4SNAMl{ tir OMAAG[ SRCIN COOING IbF ,~ uNll N0 I UNIT NO Z ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST 1' " . I usl r x,r ~ rt ~~ D4wtx's NMA[. usr EIx r a I t r nouuus t nuou[ss sun [mcoot _ 4 ruN vnrt srz 1 uv[usrc Est NO sArt stz DArfamNlN E txcuvAr4lN n I%NN]Nt NO trfs wtwrvr talcNr "" z, cuxAr n! mNAMInNroNr NO mt GN cr r.; n1E 130 «-0 R N M ... ^CMFCK (/) vi nN rio ,•oiirfunr ^f ^CHECK (/I sn NAVlovieaAram A v NODFS-' ] "°' ,"N' 5 •r .. •. A "" . . 4 n Y i 5 e'A° " CODES -' 3 ]] 2 ' r T'(1 AD' LA.. •I M r ^ •Mrv r. r r ^ "Ar" ^ a,aN. ^ ^ t:~r„ v„pl~r ^ ,,,, rYH <, YS:rrx ^ GC~67 ^ i 4L,. c( x~ r~v[A4 MA.I Galrwt Cntv'. MODNIOnur NOVA .tf 1]uv CUNV.I MA41 FCn[v.l YtnN 4 fOOSrIOnNr.NOVAI r ( OY. v.l '~ r rRf u.~.~r> E \ .. t . wr Nv n x nnrt no nrt H v n. caox n. FiSF}RT u A t N Atf rruDON NO L vtN <n utNl trur NN t snxroowNtx r t www NO O W Nw snR[DOwNtx NNSr mID No. ]I ] 2 nooxtsswGVmtx N A ut aowN[x ~ IeAODxi SS fY IM Pu](I CU Ui AGf Nt R n IN ULAN [ A N G'-'t. N' nti-~t~L.rn A«1raD Axu -- M S.Nwc ~ AnsACfD u A NtwA.or Ia " n / ~ O uux ts~rorAm•a _[O.. N ~ s ^ xtm.~mu ~ w.r • no _ }SCW ~ iowtD L:: : Y r ^NtIaAImD ^ gww ~ oaorrD+ owlo f nlm rrM N u DIAGRAMOF COlLI510N~ IuSIr Ir N[(1SSA4rr r,D nN [,w a DESCRIP110N OF COLLISION, IuSt SUVxlfmtNIM 5lYfrn NtassY.xvl ~~ _ ~ (- EnrfriilA,c•,~ rn !TONER ( 'f : VEFI. ~'1 Wqa Jou-rk80L%NIJ ON G/iKBRY _ gl7y n i.G} r /! Rh J ~6}.L (.ED TO NEL;.OTLATE R l:;.tRVE. ~ D WENT' :LNYO 7}i E. ~D.CT'~.H /jND RO[:.E,L) OLL`!2 ~ ] ~" $~1V F tcr.~x.n,G• ro (ZEST UPR.LG-HT• CaK 7 ~ - ~ >e r / ~ ~~ £~ [' \ ;* IY NAME, ADDRES581NJURIES OF PER sONS INVOLVED 'CODES I - Z 3 4 5 6 s OCCUPANTS/WITNESSES su a.ns " s nsrR u[n A.,t r YtG[ yMUYIDrxDM ^AMa a : r ^,•; . o a ^ : ~^ n " rr rvlr nv X .r.,,r ....r.~ ~r .Ar.t?~.~:,~~ `~7 ~~5 ~ ts;„a r rl~r~, D DAN I%vucwl rwrom Dnn ~~~~~ , ' t Cd s '1 n~ f~i, .. - ~ '`f ' i+ h I 1'txintSiMY Y~ wr.V r~. Sf~m ~ rzT']G~,P~SCI nlg ~+ I` r L,fY t R.rI ~ s i r~. .1', )171 1.' 'L ~U 1 q !{i ~(• T ~ f% / ~ v ~ ' }jj~ y b I~ L 1.~Jrr' t l I ' J I t'; ~ S{ yr ry ~l ~ 7 yF ~K ~ _ ~ ~ ! s ` 9y I I , f t:r ' r i g ; ' ~ J i } M1I ~~I l ~~t IfI I }v tf } I' I 7 } t t ~lt t ~~ ~, ~ I M I f t , ,i ~ ~ a ~ ~ ~ Y I~ ; • iF-~[ F ' ~ ~ t 4 1`,: ~~.. ~~. I r ~ I _._ ~~~ ~' 1, ~ ~r ft{. _ ' ~~ '~..~ .~ :~x .. ~~,, a i r ` ~ ...aan ~ n.:?, ^ , .t6 :~.~u~i'~ryl~~---+:: ~'i+~~f q~,~ g rye,,, ~ . ,i ",'f~'N.d": R -~._i?~"'.o.~u.~~L'S'i._,_,~*/ril7 ...~.i`. Sf'\Y6K`t`. -, ~.:. - ~' STATE OF WASHINGTON w~'I'°'q`"'~°' `,4_ c~ G w x I(~ °` No. t ,t~ 'O POLICE TRAFFIC COLLISION REPORT LY IRAFFICWAY rolKfcoMfwNf Nlwsefx 1O uv ~ml w n ~. ul umf ^ PRIVATE WAY RI v Dglf oF^caus of caa~ o <ouN v colx+n NO. arv NO. ~' ' r / ~O IlouRl ~~ / iNNA cwoq lowN Ru J- Yf, ~, !~! ~,~ ^ f ^N NgMF6N0 MeiRFfTOR NiGnwav {n C15 q k095i ~~'!~ fE~ ^~ ^w fd°F.~GHIE\nHcunn ON C~~F 1 ~ ~~'/SO. ~9 ~?. - ~ INffpseel NC f sluff gwai NoN NrtRSfel oN Prrcra fo. MnE rosl /`JF pp i UiSIaN[f 6U xf ~1 Orv IFOm RNfxf -f CR /SIR [EIN SIRFti g SfxFFi Z T ` 0 '~dwn .. Ifs N S If '~W 5 4NFAMESf If RU51 ~. ACCIDENT P OIAGggM MIA (y(@y~ p ~~ ~'"~ FIFI ^ ^ ^ OF CI\I(f11 MILEAGE pf.~ '~.Pf~„~•{ 1 CODE LLC'M'MM~~/... ` CCNN'ION NVCHV[U u116 Nlfx CI NOS gfEtOR PJID p(p{FEpENtE ~~:~, oTAf NO. p~{\ o:Riiili~NO.INTUgfD ^s4ugcE ^Nln puN ~.,NOxrol~a .,,.. :f."O ~.. _ P ~,,F or vfwaes L'7 p 'L" .~~:. _ ~y~•- oxn^slqua lNAMf or oD~; ....f " - ~~~~P 7 r~ UNIT NO.I ' 4rvfR's NAM ~`~~ E. IA51 riRil MiDpF ~lh ~i:•-.. SIRIFIaDO4f5S R~9~ - ~ Cllr 51 If /v~~~T1C2~ ~~• I V I ` R7~f 7~4 Danl ' f v o larf ~ . NES 'R~ ca l ~~ ~'Pq. W~ $DA ° x ~: «CDPArvDN fpPNONEND 4 F R .'. ~ ^ CHECK (~ vrn of w awN o CODES-" ]I" nN51i s *`° i °s. nl I i~ t ,l N ~ ~' a vl wl I N I~ )sT\s ]s vT I[ ^ [~ ~ 6 ~ ~I2a~C., ,it I]nR^coNv s n. Q~ l Cf Nit Plgff NO Siart RMIFR garf NO qlE Va~V 1' ry -~ ~ 1 v~ - ~' vfNKIt IDFNlIfI F x a oa c aa~-~ @, mcl~rtRf°owNE sf sf Mm f r14 (~ I \ x'10 ~T1-Cs1 ~~, \ PLANE No 1 I ,r r f for .-..... I IU iariO~ S t51 DAMAGI I-~ ~wg1r,N ^ I~AININ _... ._ _ .- f U fOWN f~_~I~~ ~J(~~. DIAGRAM OF COIIISION: lu ul n-~T I~m~Cglfl sweT lr NfefsgRrl er q4R~ ~ O ~ 9 a co qp I~ NAME, ADDRESS 8 INJURIES Of PERSO OCCUPANTS/WITNESSES ;°°;;,p'"N,!o,,,;' NFtFPf S1 .AMf - luw ss PS IsIA. Te e•a:f cw Ac D cllr salt rlPCO E PrroNEN . R ~vE4 ucfrvsE NO sulE sfx qfE OF 61pIN ~ x .b° pA. r4 E occuPglloN MNgmES PHONE NO. ErES IcNT I<m R E R CngRUi • ^AWAYN ^R[MMN10 Fel. `UYAMgDI plD~ ^ ew~r°nr E f TION OF COLLISION: MfSUPn[MINIAI SwrIIr NIoCI55q I 1 F. F_ @DOh~ I~f ~.~~aFR ~~ bll~i to h Gwssg~ -~ a~`t~. ~0 1-E n~.C Iv~.EA, /:L3 *`e,-l,~ 5'i'R~t-K-~e~v.aN ED l CODES I - ~ 3 4 5 6 su IAGr LDI< .._ _._. d..e .... Mlcr ~°~' I t V ~ }1 i\ v l ~F : -roro w +~'r w parfr-.r~wM+¢SC + P .1 - il ~i-i r y, ~y,n y lE.,m v;,l,l _ d~.~+ ,r' ~r '+~, t ~ s T v V r^ I i aS~l K~ ~ ~~" ~` ~ 1 ~ ~ 'n ,yea a} f F eNx., ~ 1 ~~ I I YW~101~~Ir~')) } 1~ v ; .y~ r J n ~ I ~ f ( Y h ~ I it 14 ~' _ ~ 1 }+1 SI t T-~1 I f !~I .~ I 4 r I ~} 11 J~,lt f']F}1 1 E i '~ 1 E l~ _ r; it 4 7 IF~iF I 3 II ~ ` ` l j ! 1 E f , , 1 '~ 1 c l,,y 'IMS. Y i 0tf~ TI Pt ~~ ~.~ 'WSJ IJ 4. I C W ) 'J 7 Y 11 ~ 1.. Y t V; I ~ y~ ^ ` l ' V 1, 1 II`~ M { i Yrn _.. ~ ~ ~ $ .. ' ~ - . _ r'd ~ C ~A - WW,~} ' a'~~ - . -. , < -. > .. - . .. ..~ I @@ E'C._ • - ~'~ ;{a'yr~aks er'u"'"~ 'S' ' l' ~ ~N ' 4 ~ ~ ~ ~ ` ~ ~ AV P ih L{. fhE~ ..t .le ar_ -.,. " ' Ve.r i ry tn+A"^"" .iuu v~ ! >v lxlV 1.rxfl { ~' ST{~SE OF W/~S ~GTON 'Y•n ~ ~r 7 ~ ~' `'/ POLICE TRAFFIC COLLISION REPORT C;?TRAFFICWAY You<tm mNUmmx Y• PRIVATE WAY ^ oe-o3-n-o161 I~ ~ rwn ul.[nuswr. 21' 811 07 Aru '• • , r"" ~• R" , 2''IjiL~"o., cvNU Jefferson courarw ~~ rr NU fIMwA p xeA` 1 r aA 1 . ~ ~'~~.' pf ^1N C1r. Lxl:[wn rvAM[11nU U(SrxILIUVn LnwwY prl 11.1 M1fs CSs ^Yr BJof Chirracuen pJslDeavar Va]1ey Rd. tl Cl1 x vOUIlOx SINLl CUUL ~ 9//50 SICI JN r ~. "~.. 1tx]ICUNG wain -JnU ]~ ~ u, / rCNiN.000/N ~ E'GG rw[frv N>s~. swfn.a R~ srcft+- 111x tU. wnf YD]f y 00 - ~ .D, D~]IAlxlf .IxtNCf. CYU~:5lveil Ux Ntwvf], mi11 YUSI ' s w gC~10Eryr MV UiAUVUn DnIA 'J 4 G . rue ^ p ^ ~ t -} or Count road mile ost It M IEAGE coDE R ~~ ~]~~1ALf ^nrlAxr,N ~~~ Ytt o'•",~1~i ND ,N,r,x~ `°'t; ; .~"rJ1td;, I N xD rHif cu r,l.]I~IrNL]IxlfloxrNwox.[rtxlkt ccasvxtff ov voAD I~ - ' _ r [ avfn¢us © ^Yxo+fxlY D..Aruf oNn ^!i viAOi °•:D,rtD ^ Co. Rd. S/Goo 1 9 p~ ' ovxclvurf r.nMnxnen,;1 uawrmowNfxsNAmfl fs,.DnmACf srtclAtmD~NCUSf went into ditch s Y ~' ] UNIT NO 1 UNI1 N0.2 p V ICLE PEDESTRIAN p PEUALCYCLIST wiv li,., m.DUlf wtx ]rvunl NSr N4~I MiJ tF ] v' f ' . Shierh, Richard L. ~~.i :S ~~~ slxfll wuxl]. slvter ADUxf . 80 Dickey St. D j* S _ ! ]IAIF 31. CUtt Yr.UNf NO Y PY. ~. T,ITdI oy~ 'In 3 br -2 1G R ctrl , ] If iYCUD[ 1 of NO. 4 -- { 1v ]l•CINA hU ]Inr! Dx lx 780J9 Yln. [ 1.1. DwIIU pj~ 2q x1n~ V I vWtx', DC rvU. r D / InIE Stx DAIfWBixin .,o i D .x ~ e a~ea Allw. n.NAmLf vnLNf NO ns vn Lnl r.flen, E occwnnoN mNAme noNf Nn tns ,nuenr .L;~enr '- ~ 2 ..etined }31u 17 GO R WX.~dY ^ Ck,.CK 1~1 > <', f w p CNCCK I/) f.~~nwE xs wN WY1v0 0 ..~~++.A. ,f ~F • ~. Y CUULS -' 7 ~ C a "' 1 5 e - CODES D ' ~ r s a :;; ': r1:""`° T , ~~ 2 ]"sore n ~ hoult'era D.Id .ills. ~ ''L ~{ . ~Y VY 1 ^ ^w'" ~alr ^i8:n. ^°„ :1 ^".:',:. + ` rnx 1wwf.cnlvl 1 xll 1.N:v I DN n ] V t lrtrx ° "v"` t vl woonlDnxl rgvAl rtf l3 Dx. vl om :. D 72 Ylylnout;h Gold liustcr 2 llr. E -,~ (T ucv luNV VUr n„ s,Art wmxYlmr :, aAle Y H vfn unox N w N A nn Alt NO. nl ~. J OnT/Yrl } •J.JOh9 l•Jn. ------ 1 to c t N, r uua: NO ~ vu ~ttuoua nw NN G 113 i L12;9!C'2 B 5 :0~7 312!8 I E l i l l l l l l l l l l l l l l - xmnnvwowNlx wl nusr M~DD1[ Scone as dri:•er n.wNf NO O W xtasrtv ownfv. lAS, r1xs1 miDlAf noNt NO. r 1a2 • AuDCIS]Lr owNty N AD xf> owNty 1~ E Avf aADDx1 ]c[Y NwvA•.,ICU OVwclnl R N AA.. iN,uvnN L IA. r. none a fwY';1 w~. w ~. ITnna '-"` .... . y x3lCZri'. `o:.:: ; w li - - I ,~~~5 11... V a 10'`0. :^n+ a ;y C•1.1~ FU c n.` lJ i `Y ^v~•~ 0) ,~~!u rickson TolainC rncur,^ ^AWA[Y ^xEMAiN[D L~;,°„1D , rwc1 DNN f]11DAMwL( s DAn ;fD afA • • ] _ f n DIA(rRAM Uk CAll151UN: _swil uvi.iu is:cvl_ sn:v;irilri l _ _ I ~~..~ ' DkSCRIP110NOF COtU510N: usts uutNrAl b1[U1r Nea]sAVrl South on Ucavor Valley road, Sailed-'to"Titigotin£o ~~ j ~ ~ ~ a curvy ao the rrs[;ht Ylen1; off the road ncross r- _ ' -~-~'- C '°~ ' roadway rollinC onto its right lido in the d~.tch ` i e ` ;; H• j . riv r appeared to tTe uighly intoxicato~3,ut tha I _ s ono i __ ..._ . _.._ .._.._ .. .. ._.....,__ l.C't .~-1- ' fL'eFch•k~- vlrl _ .. ... _. ......._ ...__...... .... .. .- _ _ - NAME AD06f ;&RJ1UkiC5 Of ifR50N I C)CCUi.\NiJ WIINFSSfS ".". . •h•rtha i 1 I i _ NVOWED CODES I - Z J n 5 6 1 l.'Y fa" v1 s ~--~•~-~1i . I it; .I'- _ fl 1 .,:une •h ivl.r 1 T , r I~I• ('I: r '~. --- --~ _ 1 i~ .___ 1111„,.. CJAS.1 LIE~.~ hJ" -T-U~ t~_ O _ • .r, ~L~-I---J-_.l_L~ X T»• K.1 IhLlan ~3t1+~WJI 11/j ~2l:il. '1!i9.1 '/-Y^2-911 i},~a.~~ID; E',`-+ I r, r r..`: ~ . , . ., ... a~~, i I~ >HE; _ ,.. ---._.®,..,...,,.,«,.,...a....~_ ,.. z - >....v~ arrw'~,~• n*~rra' ~rearrsr ~` g :;.. ~>~ ^rt~ :'hsin~J.(!°'.. ,~ ' ~„ " I`' qA;` i STATE OF WASHINGTON P' SUPPLEMEARY POLICE TRAFFIC COLLI N REPORT PACE Z oFZ IDENTIFICATION OF COLLISION `~> ~ SEVERITY OF COLLISION ~ FA1AlI1V ~ INJURY ~ PROPERTY DAMAGE ONLY CA)E NO. ~ ~ Od0340161 i .., ... _... .... ..._. _. ..... ' MO. DAY YR. ...CITY .._.. _...___....._ ._.. _. .. DALE OF COUIIIY ~ STREET, ROAD NUMBER OR NAME ---- 1 coulsroN 07 /21/ 8410`^1'oN Jefferson Beaver Valle Road .. ... --- _.. ... Y ....NAME ..._..__..-..N~._..._..____-.._._........_..._.,_... .... .. DRIVERS NAME...-'.__._ _._.-.- Richard L. Shierk Vs vs , DESCRIPTION OF COLLISION `~ IUSE fOR ADpIIIONAI IN(OYMAIION WH[N SPACE IS NOf AD(UUAI[ ON ORIGINAL RLPORI ON AS A SUPVIEMLNIARY IN(ORMAIION SHEET 10 CORRECT DRIVER'S NAME, OCCUPANT IOCAIION OR ANY DATA NOI KNOWN AI 711E TIME THE ORIGINAI REPORT WAS COMPIEIED.) ~ ~~m ''+ Result Df B/A test subrtu.tted to 47ashiaT~ton State Toxicolod Lab .17 $ -. T ,• is e ' - -- . , ~ :SF -- ----- ---- -------- - --- - ------- ''a DRIVER/PEDESTRIAN WAME ENFORCEMENT ACTION SOBRIETY • HAD BEEN PRINKING (CNECh CHARGE CITATION NO. "•nnr x or uooD wuwv ._ _.. wruuo AICOHOE NOT wPAIBI Richard L. Shicrk ~ SX~[ ~ .17 % 1..--~--°r------~.._ O . _ __ __ ..._... _:' 'Yo i ._._...._.. _... __ -- O bGW OUGYAM DI [(YIIL[Y. YI/ w ~EaaEn arr 61JLL1.11G7T'1 ..:..: :ir~:::::.'.u~.. d,.,;. sa._~_....<......~_'._. __- __ . _ ,...I - - ....__ - I __ - -- ~- _ ~-- I •-- _.... _. ..-, ~~ _ _ - - - - - -- - - ~ ~.. , w ~ - - t - - - - _- - ~ ~- ~ O _ . .. _- 1 ... r - ~~- ~ .. , - -- -• - - - - ... _ '.. I NVI )IA'MI I I I -- ~-- I -'. . ~ . ~ ~ NM:(M I. 1•')IIAMI A I -- TI YA ... ...I _ . N• I i ~ I K ..- AA I I'rI ~ GT .; .. . IIN - ._... IIIDI)1 .. . NI _ . - _ _ AIT - -- _. YUVI -- _ _ U HY - -• ._. - --- _ .. -•- _ -~- _. oI I .._ - __ o72dd4 '~~~h'eSenfA~..j ~~ ~ . , ~ P ~f,s vfr` _. - - ' I y . ~. 5V ~~E i ` ~'~ - ~ xy > _ .--_. _... ~"~' u~~ FY`-~~+6Yi~l+?1* Hi li..~` R6 4~.. i ~hif°- S~ 4 ~ ~ '°1d _ I ~ ~ W K ~ p"' STATE OF iNASHINGTON AUF ' 1 W~"'°'"'~°' '" ~ n ~ +kki sJ , ,ae} Of POLICE TRAFFIC COLLISION REPORT I~TRAFFICWAY No. IOIIC ~,W , ~i . ,,;A ~,a, , " J ^ PRIVATE WAV E COMPWNI NONBER Y~ ' .~ f ~~~ DM cau roN : ~ viu s w1R 1wn ~.1 ' W " "' IDSf ]I1Mf~uRl COUNTY S COUNTY NO. GIYfq. f M,A . ~~ D 1 ~. CIEYOR TOW ^ N ~ ~Rsa~ ~ / U ~ N U l ~ .K+'x} i N E6NO.Of SIRfftnR wO!%6/ S u • Ct O ~ Cl5 RWIf OXSR ~ y Y '{ O W AVlfS D ^ 1-t'1~9CV ON ~i ~3 9~'iesa INIfRSFCl NG N11N, SE [[I UR ROAD NON INtFRYC10N ]] ~ • ~^ A a! ~~ ~ flWEfN SIRF[I d PRfiUt E •.Mlf P051 ~~ ~ // _ ~~r Sfeffl USIANCf6 N~ ON EffNENCf. CNOS551PFE lON N F ARES)MRf E T ,u' ~~ ~ II ~~ // yy .~ M Ei 1 fFEI E • 2 RAMP RAM DAfA :'. . 1. ~'. COpF OF WV O 1 COII SMNJ IN $fVLRIIY. ~ _I ~. G '. ~'. 1O1µ NO. NO R1tlfD~NO NIUPED ^SpIIIAOE ^ 116 RUN 1uH1RnD~n Of V[H1CIf3 DppppfRIYDAMAGf CINIY iRE SIOIFN ` ^MSUIIfO ^VEH1Cl[ OBIECISIRUCf.IN A NFOf ECI S I R I EC F ONDOWNfR'S µ1W[L l I ~RO I IN~If/q~ CES Y N E45FCIINO SiRf[IOR NOAp DR REitRfNCE CROSSS]P[Ei UR ROM L~IL OD rnC.'t~ a3y y~ i,.,v: ' I %~ _ y , f51 DANAGf . E ~ J ~ ~ ~ 1 `. ~ •1 ' !'Q. h T(F\I FF~~ {•_ SRCW COpNO 16f + 1 ~i ~ r E UNIiNO I 1 ~ ~ ~ ; tt ; '. ~~ . E UNISN~O.E7 Dnlvfrs NAME usr iIRiE O ^sVEHICIE ^ PEDESTRIAN ^ PEDALCYCLIST xA u -~~ - - : ~ ~ ~ ttt ~ SI ^AOOR~ ~~~ ~ ~ ~ fRfEl ADDRESS ~TV f xe~ SIAIF iOE HONE NO. D DY ~' A~ fSp~ Q ' ~ ~ ^ ~ W' P SIAIE ,PC D p F ~ f.~~bi~i 'I ` T ' l DYNFRS U< lJ W R ' ~, 'm~ DR4~' L3'r.. R 1u1 UA ~ ~;IRI V I sll NsEND. ~vc~p, 1µE ~. OAIEw blRire F f: p Dccw~noN AssfdHgryE NO. s ONI fElcflr E acuPAnDN R~ fI RRJJ ' ~ ~ i RM NAMf6PNONE NO. FYfS V•S UHI I(IONt '. .Y R ^ CHECK (/J avff of ANOlnlrr.M ^ (~) , ep HECK fHlal ASAN fmnor"ff of ANOlfs~fewl CODES-* ~ ~ . tis •`I v NT 7 h~ y ~ 5 E <1 CODES - * ~ n„M D i`1i. 1N1" s E U"' r w1 U A e: 51A N e sw'O.,iicrcU ~, ,~,,,,,;,d ~Y b~` ro.W iI1M`sif ArNluNCt KE : nvA1t o1 R ^ U ^ c u WRr ^ u ^ P ~ w ~ ~'., W y, k 1 VW. YE CNFV MAAF IDOOGF. .) [ IOAPI VA) SffEE 1> P.CPwI N,YfAR ^ /• ~ /1° 1 3 'h wV E D ~) ~ cE ^ cnvna ^ vi ^ P MDDEIIDANI.NOVAI .~"I] -~i~ ~M~ 511 ' .~ V V Tu: ~ Yf31..v l1G(NSfNAfN 1,x.0. ~~ I~(331~ z44-~ I ~ 3!X ~ ~ Uffi. ~ ~ ,~Y, dX REGSIFCPIOpNN[N; U5f ~NLR~51n ~ .e Ki ~Ay1 ~: P~R'f ff~E '. '- 'MX 5, d. _ J Ta'Y'EY~R, ~.S rI ESC) V'• 1 H vEH cEAON ~ ~: i VfH <IElIXN1111UN11 of All A ~~ co~~E~ 'I' l .Ea- W .C- G ~ ,a., .~ • it ~w• gauF;~ oh Cq#AY , titian 'P1 s'C'Rwia?ccl. (3~: An T r!n ~S~ YN~ ~61UA,o,, ww*Tpi?.r:~ ovcF. c.+~h"C,~•rn.o~ oV~t~- CoRRac'1'.ul. i1-Ru~IL.,~m 13FlhK ti'1'1 • arc c>r~rtrt ~1R^ t,L-ru~ qj, o I l~ rA I~ fi mr~j i n~ i R ~. o r*o r,h ;n 5 o Ra.o'f o h l_ f 1 - ~ 9 4 5 6 I ~~YV'~~~:~': w5p rsv le[v I BD, STATE OF WASHINGTON =-'>~ I ~-' I INn ' ''~~J POLICE TRAFFIC COLLISION REPORT Llx TRAPPICwnr vOUCECOMRAiNtNUMBFN ~ PRIVATE WAV - ~' ~ I• •,a ~.s '1 sF 1a,n Np c r` o. ~aNN clrvw. fNwA t I,, 4 .. x• " l. J!' ,7e-I=r=E[~.s~•„ ~~ ° uBeAN Al r roc,oxN c 1~ nl ° IeNO USIVffIOVNCNWA• S nw 'Y1 cN, ~[ ~~c '. t ON ca ~~. # /~ iCtClS • ROU[E0951v1EG -3 yy/so CNON ~~ ' .xi. I .R, a- rvrf frv,(fN .L.E='! 1 r~..«D+n Cc+ tiD. /~ [EIM EU m,lF VO51 ~~~ i r~l•~r;,Rl,M xuwlr,a c - ~rar,ce a rl 5 R., s Ice Nl ax r Mail Eos~ •~ rc rl n n ~~~-i>ES t,- ~- /~ AlaDENt MIIEAGE CODE MR DIA R,vnwu TV ual0 r~ ~[ [I"IM1e , a .'~n w D INifv CIS Nr e5fC1N SiRE[tOe rqM Oq vIIER[nCF CROSSSTR[EI OR VOAD _ Q na ol~r ^ n ^vll'~~ l D ~S-,GOO _ < D r + r~n r ( v rum xN ' SRF ; r=LL ~ ~vlxsN,vnl wsl Ne. Mi I _ A e ~ ,. ~ Dw~Dxa. - L vn ~ r~Rrr~ol ,(xxl NO ~~~ D e„ - vmf r~xeoDl ntero - ~ , xti/,IJM flivl , . ~ ~ n•, .: r u e tinD r L~ >r ^/H~x,J.' V I E iSlxt NCINSi NO x S,AII r Ualf Or tllerN Rn. •x ~- .. . ,, . , xl.o.., w ..u ,. ~. na `rc..~ i'•: -~ n~,~ c , ,[S kYY TC-[ iE •7c ~r•"[ R r ur nuoN M Naw a RraDl Na .fs wNCw .E~ent p CHECK h~l v~ ~[ .N r nr,~ I. ^ CHECK trl arir~r .r,,, v / ~ . ( - CODES - • y ; A + „ COUES - T ' e S '< .,. r,lx„ 1cr~ivi < r. I r A, iy~'uac/Xy . r.ONV, v/`,.I`r E r+lau fIDUWI CNfv, 1MlIDANI rYJVAI IF IVDY v, r we _) r, , r ox ~ , r,o Tc sl nAr , _ n ~- F'I I v N aAUe N. a al A., x nA f N0 a [ - ~r/ ~ /`i75 4 w rl<Al,~,rb ~ eNE,IDfNIr~AI~.,N Se r~esr ~ ~ rnn NO xlasnxfoowNle usl nasl M~DDU Ne Nu n v.. W., x N A Dxns a owr,ex y lsr.~ u ,r, [„ AmN, :.tic[.: ,y' ni.'ICr/' .. ..., ~ ~ % R A .N D AN ~zrT- " ~ Bi - •IAd.~ii ,n ,~ ~ ~~ :1 . , t w ur ' Axw -- ~^w^: ^eIMA~mD cuA.,,l. ~ ^:wnr ^umawr ]flA:n yri DuAAO D~AM[:crD A.vu1 ~~ .D'-°.~ s E.SCa. ~ n :rxfo ^ lowm S _ < nrcnl! DIAGRAM OF COll1510N ulsw~nl MlN n' N roil t:r Nl AV r IS' Ir, ;1~ DESCRIPTION OF COllI510N' lust sw'vumlNtnt swltir MrfYnu+, ~) -' , } + L• ' t:.. Grd <k •.r c: nR. ' ~ j; /hGrf GV~t H c nC ~ff ... r= /:..~ v i=//:~.:....1 ~e EL ' ~ iii: r ~ c~... / [. •z--.z: s~ c Se. F . . --. NAME, ADDRE5181NJURIES OF PERS NSINVOLVED 'CODES 1 - Z J 4 5 6 OCCUPANTS/WITNESSES ",',two^I",,;'.'; ~;""~' Acn xra In^ ,,. r.Y l[a ,.+A D<M A °" ' n ^J.. ^1~ ^ILn Y y'I^," W []AMB °n 10" U': ^~: '° ,r / I Imo/ .~ ~•/• ~~A~~tl n n•.,,.,. ra,: ° ~:,. DAn r _~ ~ .,t~~ ~/ ~ / f C _ ' ~ ~ I ' ~ f ~ • <r _ .( l' ~ _K~ _ LJ_L .% ~-L ~ f ! 1lt.l--<_ h..__T__ ~ .lz` b[ ~~~. YLI• .. "I 4 g:F ~.Tka n ..~.M1~~~~,y w<.to-it,.. '~r',n • e~~" ~ w.A a tr^ a . N ~ ri v ~ yea ~ ~e . ~„ , ~I ~` 1 wc' + z ~ ~ `~ ~ ~ "} tt r ' r _ ~ 5 ,~ -~~ ,Ir ,~, a d ,~~~~A T, LU r 1 ~ ~~Ypyl z - T 1 ' I ~ I 1 "' ~ ~ r ~ 1 1 ~ ~ I ~ ~ ~~ ~~~~~ y a ~ ', l I r t D 31 tl l~) ,{ t TE R4 I , . f s ti t > { ~4 i ~' 1' , L~ S .. , '4 '; 1 ;, - ~t + ~ ~~~ ~~~~ POIICE TRAFFIC COLLISION REPORT LxRAFFICWAY iglgE COMPWNI NENIBEN PRIVATE WAY UAIl OJ COIOBgN ~. DwY fl Orv xN, rvls ~,w., If. ,. NK IMf oE~~rD"' COUy1Y J~~i~ ~oP\ COUNTY NO. /G CIIYNO. f1JWA ^D AN I .y CIV OR fOwN AMEn NO.dst It ON NGNWAY ^N f ^ N 7 MrlES ^s ^w ^qE ~~Jll sl fiTti.U\I ON G ' ~ J+ fCEGis RWIF ON 3 /l'f/iLSL~ ION Sf NE 1[u5EC11NG VRin. SiN(EIOU PoAD NON INIfRSFCEION 1 BFM1V[FNL ^/~aSL ~L' ~K S~jgGN-fd SINFd PRfiIX FO. MRF POSt "~'~~ INfC110N iNOM DINtNJ..CPOSS SiREFJOx NEwkESi MllF ro51 1[5 b~! 2 w ~ r[El [~ Or u., pi' '^ S G ACCIDENT MCODE f P GRAM M1w D CIXUSgN NVIXVED SEVFRIIY~ f IOIwI NO y}~ OKILFD_NO. NJUR ^SpfL E ^~'IX NN ED wnowDln I ~D MFR CIS INifk CI J/G 5IRFFIOR ROADOR NEEfRENCF Q10555TREF E O R f10Ap 1aB .,. f dvfnfl(5 W ^PNORNIYDAMwGEONEY ^RB ^V[n[IF / J ~/Z~OO IBikuCK INUAE Of OBI[CI STRUCK AN OWN[R'B w.MFJ ~I ~ ~AG[ D~~YDLshYYl~.ls.til. /~i' s3+~ SRCW CODWGlJSE UNIT NO. I UNIT N0.2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST ~' 5 AM UKBt ~` NNBt MIUDIF Ivfk'SNAMf: IABt it I IX ,, 'fr '~cr'I ~ S' t ~~76~1Z two dt ` 1 f PnONF NO D 1JN![I wDDUE55 Y Siwif IPC ENO ~ , ~A ~~ ~~ . { \--`4 R . ~! ' I C[NV I+ O • ~~ ~ p ~ r o V SIAIE Owif OfO N n ~N v DR V! a Erv5E N0. AIf DA1fw BIRIN Mo Y. O l F SI E i ~ ut3 ~n b OCCUPATION f6RR]Nf NO E alfJo rti. JIP R~~i"ou.£ C~ rn FYFS wflGnt of lG 1 ~1- ICU ~~ E R OCCUPANON FIRM NAMF6 PHONE NO. EYES WFIGNI HEIGHT ~ CHECK (~) vfNKif AS nN U°APioYJf cAif wrvornfa~ ^ CHECK(/J v[NlclEwS wN fMPiorfEawr olHfaw` CODES - t 3 n 5 I e ; ;; ;"'p1 CODES -' ~ a:u ~ iin::nl 5 IAgwN e u ' fmlEs ;rii~i e:INO.x 5 Y K` 0 f MAK[IDOWf Cnfv.l lg73 P 1-~ ~ODtI~[ywui 1 Ix DR CCYNV 1 L?I.ro la fi st`f- ~ E Y .YEAH MM 1 CNVI MODEL IDAR1 rgvA1 E ID R.~ V.J IdNVPAe xf,($Lv ~:GJCbyt AnNRnn.nl AJf 1.~~ H NneagN w l A I JufNO. AE vlfnCIE ICEN1Il ICAIION NO 3~~ 1.4C2 of ~. 5~•3-3~ i V nICtE IDFNNNGII NN cE~~JI~jf O ,.}- Igtl I 1 IDIXF PIgNf NO O NEOISIFREDOwNfR I,C51 fIRSf MIDOIF NE NO. ssa dMNIR N A Nf Owrv[N AMfXADORISSO wsuRANee eo a+AGENJ v w R IN u AN rv ~ .NGID AVIA w I~a E51 „~w~nwi E CHANGE ^UKW~Y ^REAUINFD O , CNANL'f ^wWAY ^P[MNNlO fsl'DFAMAGE DAMAG[D ~[A ~f ~"_ ~ s3~ I WID Y Q3 5 awlnG AYe ^ tDNVID s . MJN AI Nq'1cJr1'NnY'JJ DIAGRAM OF COIIISION: lu sfeftli Nias•,ARYI (~P'i[~jP'• DESCRIPTION OF COll151 N: IUSf swREmwlAl sH[t if NEdssARYI ~4 u,• ~auti$ ,p C,P t>;- I;~, L,~.t R wawa 'I}.w1V•a4.lt fJ,sdl' "J~rO r>n5 E c (~V ~~ JS w ~~ ~ _ CO'4~1~ _ - . ~ o.\b E 1#'S•~ 1~ C,LA RV-t'(bO.V.~TG~a fr, ~~1Y't' ~h`~'' ~ " ~ ' > - r ~ ,~~ . o>L C, tug tom..,. I •. a 6L ., a r,, C G k , R ~a '3 ~ - I fl 70 6 'yam s 'FJQu' ~ t ttr-~ whav~ R ~., fi stti d.,.. {po c~ ~ v,'ta ~(i~ IGa v1i4,, o I o Po ~' T' ~is`~ 1h tom, ~ ~ h ~ •E ry6 ~ ~ ~i4.aS~ b.~ ~Y;~3 ~YAhK NAME, ADDRE5581NJU TES OF PRRSONS~ NVOLVED 'CODES I - 2 3 4 5 6 I OCCUPANTS /WITNESSES quR Aoou~ofi~i NA,w ii sEX Aw .ul R tslR. u¢t AMI R MI w NI 01 A•ervID IYUM ^AMe ^n. KI ^rilr r ^ N ^ii I A Jj froror MY u NI ^AMn ^"."'^;Rn.,. ^~e' ^:° n x IXlRfNAMI •RUU ,n Ap `J NI "D ~c eANI %~b1~.!'RD ,}~~, ~RR~ o Id nPOPI ArrooWDnY oAll $ 4'f%'k'ENf i .. -i .......„ ~:: ~8f~z S # ~~wxt3 'd .8 .~ ~'~. 4. a. I; ''~z y ~ ' '5A~.iJPli 1 ~~ ' : @ ~, ~ ~~ j S ..mow. -W. P r ~~J POLICE TRAFFIC COLLISION REPORT LC11KArNCwAY Roucf coMw,uNr NUmnfx ~ PRIVATE WAY C ai orcours .. O DA x •Ux mf •1u 1ww u n Y w ImE ID$E auU npu41 BOO caunrr ~ ~FF R O muHtr NO. /G cnr NO. InwA oDR6 / N ONHGHWAY OIS II N 111YOx IOwN QI ~ ~N r/ mEES @s ^w [for // iYJ ON 6 (fall ECl ClS OUIEgf StP[FI '-3 R9~1/Sd SE 10N /z: IENSfCIrNG VnIH SEPFFt DN NOAU NOn1N1tNSfCt ON /~ RftwEtN/1tRSOa GK SINENa ortT ~ SIREEI vwHx E Mxk PO51 G.s3 I USrANCE Dul Nlf CNOSSSINEFION NFARESIM if v051 (~/7 tf5 E IS I ~ O of G RU ft ACCIpENt MILEAGE CODE DIAGRAM MIA COU1SgN nvIXV 'AVtu AOf NO. NIUNED_ HII NO r1«D ryryWtftxNM 1N % D INlfj~ Cl5 NitNSECt NO SIN[tIOx ROAp OR RtiFRfNCE CROSS SINf[I OR IK)AD ~D ^VfNC[ ~ IOIAI NO pvFH CIFS © RNOITRIY OAMAGFONIV I] ~SU D/ ~~0.~00 tll(Ct SIRUCx INPMf Of OtlxCt SrNUCR ANOOWMWS NAME) fst.DAMAGE SwCw CODINOIEF UNITNO. I UNITN0.4 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCVCLIST /a' > y owWxs nAMr ust NNV mlUlxt Ro 0 ~T C AME. wv NN,t I E '" / LE _ FF S StRi[t ADURf55 ga/ tou/s L- G~u~r Dv[55 =RHzD z 20 r6 ~ .2 nlr Ar zlRCOOf , NE NO. ,y S CUG s/ f9Bd0 D R c1rv zrvcaof RHONfn L72CeC, s(./ S~~ S~SSy3 // L• DNtNSIICFNY N ~ 77 SIAtf tx O FOf BIFIH NM M /l A %o S-? I ~ E rvE 'SUC[NSf NO. S /k S 8/ CJ N no aREgnfro «c rArf Gi/A SFx oAIFOi 819tH NI oz % r 62 rYES wF1cHtHFlcrn ~ 2 NONtNO EYES WElcnrwgw HRmN1v..t «curAnoN YH/uYL~s S Cep ~r/m a{Ekx Co. R u A N n7tl . MnAME l56 ~CMECK I/) ian ro o u IH An OCHECK I/) EvEHC n N t n tr ~ S 11N, ~ e "'°ro H ODES - ~ D a~ A s i n / a N~n>x.c1F / CODN S ®i D ~:ii a 2 N o 1 V~ 1 YC1 ' 1xxANCV „n vt~e~ nsnx H Y DAw~NOVnI rf11EaoR .c AVI D[s M j flDOOCf cnEV1 g~/ Qt.I~S IDAUR NOVA1 s rlt EapN CONV.I GtG7 2d~ E .1 E S~ GU// . 1 o S ~ J ~ r moR t fnst vlArE NO stmt NAntRHaE NO sutE H W caoN N u At Attr I 1 AtE ~ ~ ~~ P~ O WA - - ~ DoN 1 A~3S6 LJ,R ____ - SA vFHKU1DFNnnunon NO ~3~,e y ~,~~~~vyo~oy F IE OENtiuN y`s~ F"A~y~srsz ~ utO151FREDOWNFR.//~1 IA51 MlDplt U~5 /Ce.v7- -Ca•~ iu~ NHpNf NO W . Ru1DOwNER. 51 fl m1004 NSArrJr< ~N,tJ~ HONf NO. ~J ADURI33pOWNlR n DUNf55pOVmFN NAMI aADORtas fY lnwRANCE CO ax ACEnt R IN u AN 1A N ~a Z L'S F R K u CNS AIU /,CZS DAinrcED Axu o 1'~".'.' "'"19`~f cnAxu s EsD1iD.wx;i ~i nwwr ^NEMMNw ' a • . ~ ', ~ 90 ` ry. ~ ,",~'" Y DAMACE,D'."nfn n,nRar W o~~INUw, ^qw"'r ^vfMMniD ur, nAMACt ,~°~.._.. tl u ~~ RO. ,wiD wrD f pp s O ~A Ar r ~ G C T R v Minor rm~Mn tH D DIAGRAM OF COLLISION' lu swttlr NtCISSnR 1 Ow DESCRIPiIONOF COlL1510N: IfnE WwrMENIAt Srattxrx[rsSAxYI EO PtEr• dkN~T.l+y Ve'iY• ~'"/ L~/AS ATTErrI~Ti/f1~ ~ ,sou P Foe 7'.~-Fi~sc ~.l~rr~v lJB Vii' ~_ ~ s Tstctcr~ / T F.<'o m •r?e7,~irorJ as S] ~ ~ ~]~"'~~ /-FJ~7YfJG Ar/ /N To YilcT /~z8/L~'!~d!/ raE~~i ,d IN 3 C7 QdAJfiYL (!6 Y 3 •Irt k' ADDRESS 8 INJURIES OF PERSONS NAME INVOLVED 'CODES I - 2 a a 5 6 , OCCUPANTS /WITNESSES lust sanEM°nu sra GN AcD1rKxNAi NAME n SI su AGE anus '", ', . N atty ufcr ;" AmE c/s~ %~ O/~IlGS -/y.f,Y~s ;~ ' d S-o97 3 - - - / s~ IIR ~ .rL ~r ow.U d r1~REDr .f/o•~v vrrA~Y ^AMD a ,'1 o,m . a~x ^I. 1 ,p N +111 lAluufp IufYA ^AMa ^F' EO:!1- r~N ^:u O AM1 .f~r.I, iuwRi or ,n,DRR, , ,rr,.~r ^AMa ^r:°1o,~;:11.oa: ^r r µ u1R:A1 -a1cl.,....=Ea•yE, n.o i~ A:n1r.. >~~cNA1rwD E ~K~O v~P DAna wwn uwwrvEDer DAn ~" F, ~ w M r q ~ .. w ~ ~ .• ~ ~~ ~ ~ p ~ K ~^ p ~rc ~'~~ SIllIP, :•'A .t S..:~A~F'M11 ~' tlA 1 .~d'~! A mxy,rv lbW n•y.11"'~ RITI 1 r 1 +kq 1M `~,~ ~ ~:~', ~. it s /'y ~1 }~ ;F*v~: rr 1 ~' IT ~rt.[ F A ~ ~- s ,.ion ._ ~ ~_.. ~ a^ p & h °~ 1,'. . MSifS....~.. .>q.-: ps~ ~ iq /'TI r ~y7Ml+'~i~ ~ f f it p~~~~~4 ,a I l l ~ ~ f - . ,' ~ I _ I ' J I ~Iy~ Ni 11 ~ r ~ ~ ~i . L 4 q''~ .I ~ ` ~ Iti ~4,~. 4i M t ~ ~ ~, 7 Ir A ~~F"L e~ f; ik. - - ~~~ F i^ t ,~, {y 9 '' >9f~ :+a~..~~ ~S.m it ~'~ ~.- l ~ T ~ it ~, , M _ ~~ & ~ ~ _w a`~~ v, k ~ -., __ crab' ~ .; ~1. -_..,hs" ..,.s_~ua,.„.,. _sGr~.ia,~3~+.`~ssee~yE c~, e*>'°~., ~S9aFi~:~IRia _ _, y ~., `°'1` '"° WSR 159tRN, I.wI X ~'A. STATE OF WASHINGTON A f Dr ~t~ ;' ~~y~ '~ POLICE TRAFFIC COLLISION REPORT ~TRAFFICWAY N~' r~ fOIICF COeW AINI N WABfR n A ~'., ~ PRIVAFE WAY ~ d pAfea eou sloN oa oN .'(~~/ L eouNrr ND. enr NO, rmvA V{~..lw . .~w Ian ,ro gun I. ,.I uql C V YL l`R C\ ~CP ^weAN `~, _p 'f ~Ru~'" p clrox rowN RaI ~i 64FE&'.~ O N fyf ^N NO fIORNGNWAY CIS ROUif peS O (~. 3 is'o ~ . 1 wltRUCnnc »Iln^sIRD~groA~pol C NlEqucnoN ~ ON ~ fD. muE post ."S r. i eflwaN NK laG6 .. DIS`txftBUxICDtC511tOMgIrEREN ECR0551tfr0R N[auf SlefEle SINIIr 1~ lPlP11 t ACCIDENT p puGRaAt wIA p .i C Nfl ^ ^ ^ ~. I.~T MCDDEE ~~~. cal to a N IXv D eR n /}~ ~a INO NO [f1[p ~ NO. N1uPFDy ^ `Ull GE ^N164UN ruNRwDi~l IN M~RD Nif CIN f OR ROAp OR HHRfNCf ' INIf CIS CRDS.SSIR[ OR ROaD -,ry OE V(N CI[S ® ^pPopfRlY DamAGf ONLY ^RFSUIIFD ^SIOIE! IS ~ ~l Y ~Wf(I51q«xINANf Or OBiFC15reUCx oNpOwNfR'SlwnFl UNAnGf1 SvECLLL CODINGIEF / ~ ~f*'y'y ~ k~q. ~TJ w s Uh1~ . ~+ Y»; ~,ht } {;, Uxrv wsl UNIT NO. I UNITN0.7 ^sVEHICIE ^ PEDESTRIAN ^ PEDALCYCLIST T' ~ } ~i~ Nu51 mIUMF rvRSNMnf `~' 4~ UDffe~~fsl Slim appxf5s ~' CI Y Slarf Ip OIX D I S1AIE flp I DyRy~~ y E iss 3r~a R E ~ t~,._ ~~ ~ y~~"~ps' ~( )(~~~ ~ I D vex IeENU NO srAlE ux p DAIEOOrD Rr1P ` '~ ~ ,' l I T 1'`m'f"1' o n m R ~ x V x «eupnnoN NAmEapNONe NO. I s wfwNl e E «ewarloN _ vfaNf No. r n rr~ R m NAmE a fns wflcNr Nf cnr T" ^ CHECK (/) I m ~~ 1 ~5 O ~ i ~~ - CODES o ^CHECK (/) rNnf ASANEmnovEEOr ~' "J" `»~ ~ -r ~ N atw.i. fanNS IN A; c~ CODFS~ r 3r a5r A'^~ I » "':~ 4"ES 5 ~ \G\ "M ~ ;'i~' . ;S aelmN .ri~n .e I ^ ..Y,.a.. ^ ~ ~moDE~ Aw~~HDra,^ N„I p wNa.Ngl O u ^ <6.Rx O ~ ~ ^ ~ ;;.,. (~ ~° , ,p : x. ,N~^'`~~~~ Slrll C NY[ArRro 1 CN[VI mOp[I IDUtr NOVAI Kiil vI ~ ~ ~ cfADe ~ \!1 V~/ DR E v T '11c-E~~~~~N4 ~ At4R RRIF NO SrAIF I'I vFN CIXOe N A 7 l a NO, A f ~~. ~~~` ~~ nn ~oernn ulon NO S ~ vu, of DENT f cau ~NN y; T} ~ nelvremopx+Rte: ~uv rl u _ bolt NIONr NO O efelvtvfuowNEx IASI ngsi MIOIXf fNO. ~ ,<d ~~ ~ . ) xy.' ID Aooefssn o`wf.le ~p~C~IQ~ m ~ ~ Q ~ N ADO E DwNER it Y•ft-~ VR~ YC~UV'~ E I NAmfaAOOetssa mwRarxn co ca ACf 1,7a ~Ii. R -- IN u AN. A r » Y ' ! nn-r A v ESS 8 INJURII /WITNESSES ~~~~aR ~S~da ~ ~~pau(jh C~9s(~hL (3-9hK-n'~2h'C) ~S KlUCK OI~.u.1~c~ Nv 5'i; i[.~ m`i ~R1Gb f I V OLVCb ~D ~ CODES I - 2 J 4 5 ~~7~~-,~a-/~ uq Act warm '" Rt uR. fxf o O`u"7-[~O iyl+%_ii r _ scfN e.. uae ^u'1" p" ^ oADruNxf-f is vfmwto rRO,s ^ame p"„'I Or"o'.'.. .'~~ ~~ uxia xfn4nY ^Amn ^... O~D'!n, O~x C ~~ ~ofu~Aloro ~~Cna~viD ~ IE~» Erk+~ arrRrnauer Dal '~." ~'R`I~ '. ~ Yw ~ MOTOR VEHICLE COLLISION REPORT NO.... . DATE OFCOLU90N DAY OFCOWSION TIME OF COLUSKN COVNIN ND, prylq. MMM~~E111 ~~ -N ~ s , 1984' xun rw 5•r ouR . MnulES AM ::I~ pGTOBE'R 2 PM EE COWTY CITY, TOWN nE MILE? Q© CITY TOWN ADMd9 PREFDt XOUrE bRSlRUrbo^E SECTION c ~ TEFFEa,SoIJ1411mpWM ID. ®p of CufMSwM Cj" IrP/.SO ~~ ~'- GIVE NAME FSTREEi.fiOAD Ofl H10HWAY~ WtERSECTW6 WiTN. 9TREET Ofl ROAp PRERY' EO -, L14.EPoBI ~J.I a BCAdE ~ VA LLE "/ RO .., 7 a ' NON INtEPSECTIOH~LOCA CO ISiUN > RAAAP) •., ~ GAORAM DATA BETWEEN OAK Of~~r M1V STREET AND B~1-c^r'vC. w. ET n~..~. ®© N. ouc~svrric^ iws it MDIA u~.I'~• xBxiOD[. - IeDN +1O rt CrW NPEETEARDAUM E(IQR; ,Y ~rICEDCN0Be0 MRDq..: one ZOOEFEr ©® of OAK RO .r"IUF.NOFFM ONion iH;~a~ Lww'A`•1k KO .f]~ BLS, ~~~~a 9Z'.G$ I, w O^~YrE cuaLn%LE p~E {golxEN,wwrF V~111u-E -- OED , + ^ -o + ^xrn~.FPE~sRMn ^xwco.psnn`E ^xrn~n y:,;- 1 OBJECT STRUCK - INAME60BIfCTSrRUCq OWNEfl OFOBIECTS NAMEANOADpRESS INfWAOWY ^N © lb ~LDbnifcr FEE! FDe°% S 9~ ~ N~1, X~,~ DPoVERSLJ 9T NAME eFNST NAME MIDDLE Iwb t•NS YVi! • e 9 +ro~~_-~ i wEnE wvIXV D IX^~RS UST NAME FIRST NAME MDDLE ~~`~~ ~ POR7tIt KeNaEt •SolErrF,iL DOL~r>~DR STREET ADDRESS flOVfE NO. AJIDBONNO. MOPE rnAV rvro STREET ADORE59 ROUTE NO.ANO80%NO. ~I^~ ~ ~. ~ Osq QUIUGH 57 . PEnSOxs~K^ .. UIY SLATE LP CODE VERSOCCUPATION CITY STATE 21P CUOE DNIVEriSOCCUPATpN s^ paa7 TowNSEND WA 9$36$ ~fA`f" ErORrrOR `~ ` ' MAeIAGErI . ' •F IXUVERSLKFNSE NUMBER STATE 9E% DATE OF BIRTH AGE M ppNERS UGFNSE NUMBER 9TATE SE% DATE OFBIRTN AOE ~+ ~' PcR7EKs467~-6 WA M r of u 30 rf•^ i ~.a ~ - VENKLE YR. MAKE ICHEV: DDOGEI MODELINOVA~DARTI BODY STYLE 13081 vEHKLE YR. MAKE ICHEV.-ODOGEI MOOELINOVA~DART) ~ BODY STYLE I%M.) ~° ~ .~ 19.7$ ?OyOTq CE: LIGA 2 ~R•ACk „~ ~ ~ ~ +~~ LKENSE PLATE NO. STATE TRAILERPUTE HO. ` 9TATE LKENSEPUTE NO. STATE TRAILER PLATE NO STATE „ ` ~ 14T720 WA VENKLE IOENTIFICATKNIJO. IINIBMODELBA NEWER( OODMETEfl IMILEADEI VEMKLE IOENTIFICATKINNO. IIBBB MOOELSA NEWEflI DOMETER IMEEAOE REOIBTEREOOYrNER IIABT~FELRT~MIDDLE NAME) DPo'JEfl3 LKENSE NO. PEOISTEflE00WNER ILAST~FIflSYMIDDLE NAME( pRIVERS UGFNSE NO. PaaYE0. KENaE~Ib $PEf+~+1• PbR1Ers467Gb a ~ OwHERS ADORE99 ISTREET,CT'ANO STATE) OATEOF BIRTH OWNERS ADDRESS ISTPEET.CITY AND STATE) DATE OFBWTN _ (OiF1 EMCf( Si Pu0.'tTuwWSfNO WA a2 u • PMIBOFVEHICLEDMIAOED PAflts OF VENKLE DAMAGED w rcvAnvDec NDOG,alua Nab uG11TSI[aDAC4DELa.,&JfApIfIL16p~TCL9 s'3T4Fi~~"E ]io"M - LIABILITY INSURANCE INFORMATION•VEMICLE NO. 1~ DoVERAGEINEFGFECTFORrHls noc~DCHrpi vouncAR ^YES ^NO NAMU MID ADORE590F LUBILITY WSIIRANCE POUCY HOLDEN NAME OF UARIUTY INSURANCE COMPMIY 1xlc ' . wKErJ rETM S, (wR7E/L /oSY A/I^KY IOG,LY iGNNYI+DS ,irwA $jEP RrBucflAPLO~3,N,17MAL /N1, CD, NAME MJD ADDRESS Of UABIUTY WSUR.wCE AGENT brT siAIE tP UABIUtY POUCY NUMBER 9 cA ~ 4 '~'~ ~ Pt MC;GA 3:-$ EA57 LAIC( A/f. ~. 3EATi/{ I+xAA ._ lOasEDLxA-wl.w.u,~i Z2$o •.:..~.N.....aAK..r.LM~...9~...,,,'.-- c~ arww%,I+Y ADE \~ r.~,yy NAME E ~. D~~~° AODflE53 SE% ADDRESS ~% I~ LA 'u.lox0a•nDOCran ® I ^ ~ U U wuooM,irw lnacrdP ®0 i~~ ^ ~ + -..v. $I` 1 M nSTATU3OF NJlNED ~rOn MMNFNSi MEiHAi APPLIES • - SIATUSOF NJUREO •Mr MARK RRBi ONE THAI MPLlE9 , OO ~^ NVEHKLF D~ND Mn n~IN wr,~xl ~q WVEHICLE ~swun aluDal~N Pw~il rA- KILLED NNLED pONwa~An ~ ^ 'Sail BOIL Io~oMaA I ~p NP o mwAn ~ Isr.lnr MnDnI EroDM FaErc"I O M K ^ 5^ 6^ lo7Oiuc SrgW NDRIM nY AAROW NCUKLE f OESCR OE BELOW VIIIAT HAPPENED (REFERTO VENKLES OY NUMBER) i d~oiAOrxMI ~:~ ~ Imo, t .T wzs drivingq horxLe, r} 5:3~ Po+ olf\, T ! iy r.r+w,.. x , D"N O ,•i, 71K~,, Io~zS/i4 / i~ vew~.l~, nc. 1 at SC MPI'l , ~ Ja~l^ ANY tL^ ~ Thy v~s:b'lit~ wt3 go0d,4hc rozdwa.~ Slr T --r b~•W~r- °rf:~ '.a s~rl~ «:`' T-.~- d~eef~)~ur-ped FroEV, Trv-S rand brvrh~ •r on. iML~, r;E h naed s~f~. of ire. ro7.d abod4 ~ ~N oeK 12x241 xhletd in m~~yy 1dP•e.. I StEVCk {w. ¢ ~ ^ ^I', ~~~ ? ~ y, GAY R/, _dtaf br:Eoft 1 COW b/2k•t, Or $wCrdGl i.nd ~`. .hi{. i{ 4r;1M, 'Me, r~flhl Efar,~ GIri1VJ' OC dCkiC.Ii l , . , •I-brzw..l to a Slop , The. d•.ar w is knoekaA t y' ~ _ac__E~U oEE -to {,.,t IcE{-h•wA S;dt of •~^e. rorl• a lfo_v1~^El dahicltS v+~!'G i+swldC.l. T celled 911. i{ , II ~ , ~ a.,,;loczl E cnn l lord w t;1C~1 For •}S.c G 2,AAA. W t( la I {ira;~ de Pdl<1ned Cm,e did no{ snolFrup 6e~Orc. derk L - ; VEHICLES POSITIONS BEFORE COLLISION I Le - PM rKC".•iR NVESTKATED BY ~~ ~ _ 1 V[fNCtE ON ]rPEET G1 EgNWAY NAME OR NO Ici n.,, •KPF Ina PAn. K;U ^ sl n ^~OIKF T ' ,1 - r«wr ^ ^ ^ ^ II^I. s`I^. I^L. OD xE~^I ^ ^IV;i cF ®D".°rbN^rl• 7 _~~r` . I ~~~ uawN,K x~ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^s.nwr O• ~ a ^ ^ ^ ^ µG'u aoaIIND 11gM DIRECTION io DIRECTION 1 ~t 4 PE Df SIPoMI WILL lISWO I^4O(WN% 1^WMKWAY D^SrWULDER A^[wniwHn 5^cmt5~.vi~. A O1MER ~`'~ I ,,~.1 i n'!~ IK)AD GIRIAC[ M(AIHCR IfONTCCNGtION] IRNfKCONr11pl cwcx axrl IVPE OF ROAD p%v[R/VEHKLEACfKN9 0-._~1 ~i 1 Y' rKrf. Ml ~q v 'c v K I w[C~IX OrI[ v r~CU ~ICx wE bIMMKI ~ 1~. r .II, '' li O'r~MO OILY I Id on l:iil I ~OArIKPIt ^1 I Iw^ SKY145 ^t llO WC WAY I ®I r ^ OINN(19rRMNII AHEAD ~41~- ~ y ~!(T~{'' ~ J ^ TLYMq t ^ DAWN ^ ) ^ 9IOP SKN ® ] ^ iWFJ 4yAY ^ J ^ OVERTA IHG AHD PA.9MNO ~` l ~ t ~~. "•+f~ ~ 1~' ^~I s ^v.owMa s ^ asK ^ B ^ neLD:mN ^ J ^ inbn:ABLF ^ ^ ~ ~ nr ; ' ^ ] ^SNOW DARK SIRE Fr J fI•--1I MAKWO nKrIT TMnN t ! I . ;1 S.{ ~i+Il ^^^K^ !^U0d ,^OARK]Rfir ^ • ^TLAYIwG nFD ^ A ^ItIO0P:M41 ^ A L•J MAKIHGIFfr TURN T ~' `~p ~ OIMR ^ISPfCKYI 5 ^LKEIisOIr ^ 5 ^IIAYnM6AMn[R ^ 5 ^AtIEY ^ ] ^MAKWnU1URN ~ Itrr I I L ~W''~dlr J ire { I t } -" ^ s ^ wc•• ^ ^ e°I•"n%fi°KNrs ^ ^ ^ m SKWAL ^ ^ ^ ii ° iLi~r~ ^ A ^ sowlNn 1 1 + ~ ~~ ~ 11E~ lpEMOi'J[fMODAAgf11 I DINER lµF9 4 r l ' ~' _ DvAKx pMAACrYPA rlcl ^.,p,Gry ^ I ^MFKIR~fLAnMAN ^ r ^fiIIXY~EOFOR iRATiK 4 I ~ '; } DliA CFA/ep FMM ^ e ^ onrtR r[clr. ^ I ^ .v.rfnArcD ^ n ^ fltrXrrD AI e%wa ~11'I ~I 'p/1 ~I dAUtN AtMU4 MAOWA 114E NAO D on BIG'MaN I ,` ., f ~ CIM~E,t iE4 ~ rKS NUrrlf, ^ i ^MnDED ^ ^sf ONYnINfgAOWAY } T ~ 1 ~i r 1 N/OO~N I7, ~ D ^ r ^ T ^uNtrvrrrD ^ n ^ " ~~-~ ~t r ~ n4~• },. i n;T ;''YY ~ `~:k°147i^" :....`q I~ir ..~mp..'fID1+X m%Lt fyTIE i,, ~. ' i ~ ~,. q! ~~ fyR'K` -, t r I' ~ ~l - ~ r _ - .~"~A, t'~~ V ~ ~ -, ,'~ rl ~, ~~c -~ ~ ~gM~ . ~ _~ ~ Di f~ l ~uxVa 4 d ~~ ~ • ~ ~, t~ L ~~ ro Il t i .. i~ .~ ., 4~ r I t • u ~~°' ~, i~FAF9Ya .:i4':f41„ r~Tl`;hMl:." " .- ~. ,A.~ ~xx'':. ~ STATE OF WASk" 'JGTON r•Gf Gr ~: ~ • R-'~ tak, ~A° s §4K _.. a," w~ .`.@ 1{ ~~ t ~ h }y~ N , P ~~ ~y ~ f~: YI r. k ~ x~ E r. r ~" T d I ~r~l ...:' ,:. ~~' vT~; el~~ '~ (~ F f ~Y i;l.. __ ... .N:M, 1%fk'it7/iil~a"_.u ';I~a6•r.-1 WSalw latV I.ml ~' . No. ~~. ' ; ., - POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAV ralu comn,uNr NSwyx ^ ~ PRIVATE WAV fl}x DA orc s nMF c ouNrr COUNtt NO. cm NO. f11Wq lusF x.DO HOURI pN pf ®.N cn+oa iowN gMFaNO.asrRfFioR HlcHwgr N Mlus ^ s ^w ^ or ON GC1JT /"$-L7 INifRSFCIiNG VgiH: SrRE[I D AS INrfRSF<rION BFTNELN SrRFFi 6 SiRFFx rgEf°t 4105} ~~ f~B OIS r^NCF6D9 Mrl[5 1 t C90555rRFFi RNfPgtSfMYY03}}~, ~~E CS~t,sl..c.'F_faL ACCIDEN} MILEAGE Miq , M1O IEfi Of VE Z~ E CODE COlI SqN NVIXVtD vEq rr. rOi•t NO NO RFFfD_NO INIUR[D~ ^SILAG[ ^H 6 M1fsH wxgvtDl~ %~D IMFq. CLS / OR HIE4N(2 Ot035 Oq gOAp ~ a vfHan Q ^vaoxgrrD^MgcroNl+ pRfi ur ^st~`ni V G~U t_ -' ORhtI SrRUCSINaAF Or OBIFCI SrRUC[gND OwN[RS NAMFI eSi.DaMgGf f SRCULL COdNG LEE _ UNIT NO. I UNIT N0.7 p VEHICLE p PEDESTRIAN ^ PEDALCVCl157 3 DRrv[R NgMF. Wr IIRSr MI A 1vf45 NgMt IASi fl .7i~i =l - N>J aRFFi^DDRess 3'{024 Hw o~ s z ratfi fu 3 Arf ZIr CODf rHONF NO l~C.rJ.51~ WP. I D R i r Srgrf I eR NS[NO Rt St^rf Ex ~ HrtO I v rv UCEN NO. qrf Sfx AF B • n. e r RM F OCCUrgiION 6rIgNF NO. [+ES WF1GHi wwHi E IXCUrArION ngMN 6RHCWF NO. Ett5 IGN}IEIGHf ~ Tt.S1aC> R ^ CHECK I~ •N rMnovf "of gwor"[ ^ ^ CHECK(/) rwttfA q GfANOs CODES - * D ~, a ^ M O 5 f e i;~r°n°c' ss n --~ CODES - * 5 ~ • °1, 5 e i ° ' ~ r uurts T x 'M° :p11QA' p q.,4,1•«<r ^ ~S rIAR IDOU+FCHEV.I ~ u ^ ~Snl. ~ : ^ 4'.3. lllDggi NOVAI rtF Ix D4 ~CONV.I e: ^ qr. Hrf ^ u 8mr ^ ~ p . ~Mr ua tq iRU 1 ~HEV 2 1 gRr~NOVgI X111 V ) ~^ -ICO OP. E . . _ xe ~ rufN f. eN sulF ReR nut NO. qrF H vfH Caoq s s W.+<<. e- 13 I C ~ VINICIF DFNiIfH:grgN NG !il R2 28q ~ Vt ClF DtNi II q I N l '30 ReersrtafoowNfa: sgsr sr MIDDU rNONf NO. O R I RD wNeR: uur rmsr MIDIX No -- a q°anuof owNrR 4$358 N ^ w"eR ~ 3x1 f-1.3 qMf agoDRfua wwRU¢f co. oR ACwr No E R G " AG< MlA ' ' • s Awa D cHARCt aAac ; f u = t uiMD.M^er ^ ^w~.r" ^veAwwD ^r°,wnv ^RUwNto tsaouMqu arD. f ifDw[o r A w~Dar f 10 D GR OF COLLISI (~~~ lu eFSUavtl ~f s.~ ru ~ ~1., " DESCRIPTION OF COLLISION; fast SUrneruNru Swfi rNECfssARrl ~fEFI ¢ A ~- ( S NO B Rzv c,¢ BP. ~co I • dA WA TH 30 ON CBNrLR ~ ~ ~ ~ p FgZ[~tD 7P /flE('OTLgTE. A Rt6HT GGRI,E,~ N D \ ~ ~y !~ _ ~ WPJ-ST o~ OL.x '1'b1E. C.EFT c$zD(e OF TH6 /CF`M'+'A T ~_ 7j~E VEH• SE.tID r$Za6WAk5 FOR HPAROOf• 175/ QFq, ~~ O[LED oV~R, ~ RND GUEA,T RPPROI(, 30 MORE, „ F ,F ~~., ~ BEF~O,Rr~E. C.oMSNCr/ 'To Rk„T oN STS ,(~/HEF.I.S . 'k liF VE.R OF V~H. 'I (STATED JHE COULD iPF.c.AC.~ AIUVTNrJUG' ABOUT 7NE_ AGCSDF~vT. a~ u csiTE fa NAME, ADDRESS 8 INJURIES OF PERSONS f'sf surmwNiu s INVOLVED wu ' CODS I _ 4 ~ 4 3 6 OCCUPANTS /WITNESSES ~ oo uwnloNU NAM fsI su et uru y '" Hn n ne. exn N qw ~ . Dfvru 1°Or rwar ^M e pFYf'O " . p+ ^1:7'N,r 1D 1 p ,~ • Drwu N rua}a R ManD raoM pAMe. ^ ;*"' p^' , p „^ p ;° No • Dnfu NArw~w (war ^AMa ^:'"'p'q"ornr O:;H ^~ r rcrat N•wr3 •N a^ncf oa •cfNCr Sf Dnr•r wD ra X .., ~ ~ 2'4 ~- _ A2/S"T 0 Kx vfD Dena nrogf ar D•n 2217 .:~.'.. r5 a e. ~~ rte, r Y± x' t t a ~A P• ;1} ~ ~ Y .,; ~ ~T S e R~ ~j _ ;~ L • rr,~~ 4e ~ i? ~ '~ ,ry ~~„ t{ .,,,>r '~r~~~ . . ~9 ~~ - ~rh ~ v ' ~ J~i^.'"' -s+^. ,,.w•vp R ~,..~,p~..nr~ .. ., r., ~ p„„... , > •m, :W,~ 7 !~ ~ ~ + , i r ~ ~ ~ ~~ r t a ,. Ya ' Y l 1 s1.~~ ~ I ryq I I 1 ~" 1 ~ .. .. ~ I I 1'' y ~ f s rlA i ~ ) AI ~ Y} / 1 ~~ I ~ 1 ~ ~ ; . MM 1 .) ... ~' ~,. ,, ~~ ~~" 'I ~~ \+'f~ MOTOR VEHICLE COLLISION R EPORT NO. 'ch SW ESU Oa„ ups L~ ` sNN k p Wont cIX; Nrv CAS couxtr Q,M pLl 7E> ~~ V= ~ : P COUNTY NO CITYNO. I"I µ /lo ~~TV~W pH pF p1N GINDI,IDwN rvN.E,NnDF~,REL,LX~~ N nr L L6 ORSIPEE,WOE e<pT pus p pw p of pN . 2 yw .J ~f/~D LRAD,HawItN„ DR,o. _ Irvn- HERx ,63 ,r,r, ~~ In• rr u+Rrnnn N u . r P RAM DnrA " I I u .~. °~I~ -I ~ "` 1 O "sr~En ~KMCi i~<awM Y n. H:MM n`~oK~NLNMER„s° F O l R,AD ,SiQOaREET OBIECI STRUCN IxNAL Or Oe,LCT..TRUCAI OWNER OF EJECTS NAME ANO ADORE89 Ft~'n[aiiw ~~tl ~c000E UBE ' • ORNERSLAST NAME I 1 MIDDLE vliwD DRIVER'S LAST NAME-~ I MIDDLE L __ _Jul~- LYNI~I I ' SiflEET ADDRESS flDVTE NO. MOBO%NO. ! STREET fDOflESS ROUlE NO. AND BOX NO. piY STATE L CODE OWNERS OCCUPATION CITY STATE ZIP CODE DflIVER'S OCCUPAP N n,/I II SIICENSE NO iAi E% GATE OF RTN AGE DRIVER'S LICENSE NO STATE SEX OATEO BIR H AGE , J u VEHICLE YR. MA%E ICHEV.DODGEI MODEL INOVA'OMTI BODY b~1 rLE l2 flR.j VEHICLE VR. MAMF ICHEV.-0OpGEI MOpELjNUVA~UAHTI BODY STYLE (3 DR.f .0-1- - L' V - ' 71 LICENSE PLAtE NO STATE TRNLFA PLATE rb STATE LX: N EPLATE NO STATE TRAILER RATE NO. STATE (~~ t ~- t•cIL VEHICLE IDENTIFICATION NO. VEHICLE IDENTIFICATON NO U 1 riEOS1FAE00wNER ILPST~FInST MIDDLEN E DPoVERSLICENSE NO REGISTERED ONNER IIAST~FIRSiMIDOLE HAMEI DRIVER'S LICENSE NO. '•v L Z12~_L•. .~_ OWNERS ADDRESS ISTREET, OTY MOSTAI I UAIE OF nRTH OWNER'S AppRESS ISiflEEt,CITY AND SrATEJ DATE OF BIRTH CARTS OF VEHICLE DAMAGED ~~ li (L` n (L,AnC •_ ~ r v- Ir/i'wu v!n€iEt ,o PMTS OF VEHICLE DAMPGEp r Cr NAV-I LIABILITY INSURANCE INFORMATION~VERICLE NO 1~ vrA+rHEHE ^u FDMOwLE Uaeluir lNSUnANCE covERAGE .N E FECt FOH THIS ACCIDENT ON YOUR CAIi ©YES p NO AME MO ADOPE53 OF UA&UTV W SURANCE POLn~IY HOLDER NAME OF VABIUTV INSURANCE GOAIPANY M,E I , s,.TE wP _ q5 i~r: _y1 c GI MC ANU PDWIESS OF LIABIl1IY INSURAr:Gl: AGENT Grv SMI[ AP LIABILITY r'OIICV NUMwN :5!= LL1C_E_~1... ~ ~7 try rL, _ _jT~ ~ E t. 1. -7 I+r WJLMr AGE tNpINJURY' ~rI.I.IInHnN Ia Y'I, Ar Alx., u,Nai i.,wul ., AOE n ~ p NAME POMICSR SE% AOpRESS SE% ___ M F _. ___ _...___._ EXAMWAIgN bYAUtn:IUHr LJ I~1 u N u I N u ~'..) i M ST 1 SOF 4MURE0 MMAFIRSr ONE TH LS SL TUSOf NJURE M HHFIR tONET F P LES I f RCIE '^ i, N L lC I . n , --- t i) Sc i ~L1 , ] Br~ ~p _ L _ _ _ _ ttUf O(rCl'CLE SAFETY. [~ Mlr wAn ~,) rn, I .. ;I, MJI ORCYCLE SAF[TY ~:) 14I MIl,r.l 11 1:1 Iu LMEr NDT USED M r;rn nl m 1 Dw wuA I I AI•PErrt D nrtn n to w nXX l I. ur rawnvnl ~0 ~ " ,... . ~.r N&• ~ .,. C CiAI,/~C: 1. F2;.,2 Sc'2VIC .,, -~_L ' ~°J~- .... ~ZrC Laz~• ,= 7~..a\: T" Ci>_i~ w -4y'C~ Pu LLt~~ CJ~12 IEJ"I C C.71•t GG1-l V6HICLES POSITIONS BEFORE COLLISION . e, nWesr rrU -' ~ M M, " GN tin I op r.mr;vA. , ra ^ :~ ^ .. r.'1 cl ^ ^ ^ ^ ^ ^ ^ r_~ n..,xra, .. ,ri.., u ^ ^ ^ 4DNXl viva FrWM f0 I-1 PI.Df SIRIU.. PFDALCYCULT LVAS USING ~^vM _^r~ r^.. •^ilr '•^s. ~^~> ~^jy A^rA)Apwnr N •' i'lnE:5T1DAN T'EGAL CVCl151 CLO WING COLOR ~Lju _ Nl r,., -[)r. IpM Ipw •CJ ~ °` - x A _ c+ nuAl ' ACC w.N i+n.~ a ~NnroNS nir c -T rrre or no•n p E I ENX,L[ ~arlDNs ~ ,.... ..... aI o..,l &1 LM, I .. • .,..YxHn,Mn4r ., ., Mx., • .. , Li ; • Ll II•A L 1 i l 'K (;1 ' CI 14jI wA• D~ I (-1 xX•,n.allAf4a ANUn (A ' UTA" ^ "'^', , Ll ~•• C) Ia ~ ,"N 6d : U t+ ^ : (') r I IA NG Nn PASSwn f::"l: (')AI' C lPA4;,•,.,;' f) O. ..,. C1 ' ^ 7 ~• ( ,II Cl I:J M ,11X4NiNIIN ~ i . . I ,A / C; l:Jl.w,w I , ~ ~; ~,'' El r) I A.r.A,InD [~ ^ «~ ;v' ' ^ C7 MAA NGIIrT Twbl , „A„ I:) `) {) '~ OAwr (] s ^ MAA mr,u runty ' .,,,r, ,~, a t~ W. L] L ,; 1: r _ o H HLA r n ' o Lr .,LL 1 LJ r' L) 11µr IIXIN p l (1 A OMM - - uADwu cHL L t HDAD E fJ Oor r A,.MA.I ' I~' r IM~rln ron nurF~c ( ~ JGNAI. .. L J .l [~ L.I. • ~ I i I.1 "~ WOAD Sf IrMATXY. ^ b ^ C ~ l M 1 wGr I . f W r, ' CI ' I ) C1 t NIAU (~) ', (~) If In rI1M f WAY ~ ~ dq ~~ I ~ i~~~rt .1 ' ,~ Trdtr~~ ° i "~' I s I ~•: r~~ ~1'h f ' L +' „ +'~a _... P ' fi ~ f ~ hr ~ - ?f ' t w. 'i ~ d`at?y tA~e+k 'riS;` x ~°i~ ~' ~ O1i 9wSF ~ 3"tP'~~s ~i r,,~ i a -.. j :., ~ .+~ i f xk~ ''M~ ~_d: .. i3.AF%h~ r-""ikq;SE .~ i:a~~.. *.~ t;`.-i I~ .; _...N `.,~ H ~ ~ a ~ 1 a; 7. i ~ v o ~n m .~ o ''-~ U o o'U ~ '~'~ ~ o':~.- I ' 1:NO m o rno~ H ~ ~~, ~~. , 3 3~S :: ~ ~J '.y~~:., t p~ 4 ~u4Gliid4t/i{~yi2`Cnix ~ r ; i °Y ~ ~ r ~^. i",~ F 47 t'<Y1r{~^' n~F~."rilt~• h~ d"R9T v ~ ~_ ~ r ~ i ~. ~ 4';' r wti ~`ra i~h ~ i ~ ~ ~ t r 4 p ! ~~ ~7(~ Ir lj~ ~X ~h ~~AC ;~P~~~~~ 1 ~ i; i 4, t aM I r4'.= 1 ~ ti h I ~ i { r '. ' r 1 y [~ ~ n^~~ ' ~ ,~; )dam: ;~ I t 1 11 ~~ { •~i ] ~I: w'k'~ L ~ '~ ~ ' : ~ ~ ; I ~ ; .+ l - ,I It ~~' ., ~I +:; _ (~E ~ ~ „~ r ... r....... .. ... E .... gyp{ POLICE TRAFFIC COLA ON REPORT {ty TRAFFIC'~4v (,'-- u' N0. KECaY yniNy Nlyy 3 ~ PRIVATE WA ~ „ ~ ~ I EO. cay~. e ..~I~ N V_y o _ u, p,y. - w I, ut , rmf IU]F] OOI cour+rv ~ p~ppNN w. 1 + ntt Nn rrrvrw ^UIIe.W u / CpY04 TOWN NAm[6N0 Of Sietft Oe HIGHWAY L~f ^ .Z rul[s O s Ow O L ON CES aOUtE t 9,3/SO , TON ] iNIf95fCpN0 wun: Sr4fFi 04 ROAD NON~NYER][CiiO BFTVFfN 5 /1(?3 PaEfpt 1 ~ MYE POS] ~~• ~~ ~ perPNCF6Div r feOM RE[ERFNC .CPOSSSrRFFr R F fS Milf POyt MlFS 5 E w ACCIDENT MIL GE~ pIAG4AM DAEA RAMa REi pY JO 3 COII ]KIN NvOlVFO: 5[vE9 rv. D ~ DO nifnrlCt ~ ~' ] iOiPlrq NO. RILfp~NO.INIURFp ^SPiIUGF ^HiA aUN OP V[H Cl[s ~~ Q PIIOP[R]V pAMPGf ONIY ^ HSUltFO ^vE~'ClE owvi INIEN C]S Cp~5514[a[i OR~D ~ /Q OB iSI4UC41NAME 1[Ct ]leuGa PNOOWNLR' E) [ei.DM1AGF GG tdYL ~~ a ;/700 CUt COGNGIAf _ ' UNIT NO.1 ~ UN O ^ VEHICLE ^ PEDESTRIAN ^ PEDALCVCl15T [a'e NAME VSi ri451 i pl vF4'3 NANf: Uer iR I y u/ /~ ~ R ~5/ AJ rnftA afSS Oyu ]t ZIP CODf PnONF nlO. cX ~ ~ce~v6 376 0~6 D R i Y SAE LIP F ~ Dvrvf4']DCtN][NO. pS.IA,IF / 5!~ WA M %OA o ~ 3, I ~ 1 V FNSF NO. PrF DAif Or Biarn Ar e IXCUVAriON NAF6PHONF NO [Yf] VrflGni HiOnl E CUPArION M Ff PHONE NO. FY[e iGHI IEiOHt KFTaKOL ft ~ 4Ll40T D R ^ CHECK I~ 'v[HrcIFA : rMPir'rFEa ANOrHIO.~ ~ CHECK(/) ¢IFAS FMROrn OPANOrHF4 ''°'~' CODES - * ° ~ . ; ' / 5 [ a ;,;',rRC.°~ CODES - * 7 ~ x y, 5 ucnoH e y"'OA IAife ~p :g[rD„ p A...DI.M[ O ~e l O Vim. ^ u~]. r u~yo[Pp" p A„em.„a, ^ u°e' O ~bm. ^ rE~Kn ^ ~~,. V[n Y[Ae MAef [DGDOf~GnfV.) i Fl10AaYNOVA) 51r1f 14°A~ ONV.I u E n. YFA l n .1 NODEI Aei NOVAI r 1 ~ ~I ~ {p v UCFN StAr nilEa PUrf NO iArt H n l P N C :3 vtHiCIt IC[NrxIUiKM1 NO. ~L(~R 37 17y9 L vtHiClf i0 N i i I RtasnC°t"^vmu IA t n4v wpofE vnoNf NO. O ~s t o wNFa: usr rms MiDae J G~ It W '- ~( PDDnssn ormef N E - .wFf ADwESSaiNw4ANCtco on ACwr ~ RiLCt!3L~L[FT R DAmWf APIA ' ' AMAGtD A4U C PAUGt 6rrn0AM,AGt ^ O4 Atf REMUNiD • ^,RwEN ~REAWNlD lel p wxr i : s~~o raweoeV ,~ /~ _ ~ iowfo Awwr le DIAGRAM Of COILISION~ lu MN NOKP pe~rH DESCRIPTION OF COLLISION: Iuet surP]EMENiu sHefrn NfassARr y r ~ iu[.EC}ssyr e _ _ r. - _ ~-- - -- cMk., - -~_ . Uc~ _ 1-~F J~a4. -r~Gir[_rfjE_ tufT_ 5/~ - • C .. _ t/pcc~,o q -~,ror.. /_s_' Fr--- - F--~-I-«- ~ ~ - I ~ _~ i I r 2 acG~ L~/~CLKG~ : Co~fJ~i~vun0 On/ _ . . _ -. _ -r -+-.~ rT . V ~ 4f` I ~ 1 _ i~_ 4F .., .vclr I l ~ a.--e .. 7"/j!E --- -r f i- i , I ~- cENr_o~ 4NE --9-Ee110 qF~_./J CUiK~- ~ ;,.,_ I _.'_.. _ . ,, C 0 .. _ ~ ~ d~ely L2-~e~ v 4iv tloiEotp ~ ~ ~ ~- _ . _- _.... --. -- -- ( i l I E NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES I - Z 9 ~ S 6 OCCUPANTS/ WITNESSES ',a ,o ^I,p°,t,~~.iAS,,'i i su Aci~ -i:r'u~ "" "E;- ~;'- nsn ~in6i ;:'S: ~. 1 [x] A°oE ras xrer •p e ^1'Y° O .. " e 0^ ^i4s. t iD°. PoDRr]] P y} pANf ^~.K'p« ,p; Oy, wl .. -. ..- r.o y w, [. - - I ....y f Im er "".O•w Q.. Cl.~.o ON. ^ ., > ulo..-Nn..N• • ~ w~oE X r.r.:• S O C S y , .Z c nr `"o p,:,J . c~ LrLp °,d.E.LL DuE C. 4lron .?~0%95 o•n A /2 02 !, "' RF ~a e, EL -% d r s h~ 4A~G7 .r ~ ~~I gE a l ~~ , ~ irS'.f:sY S~~ t~~1 ~ v ~, .~ ~a r k"y` t ~~ ~~ F F ~ ~; ~` I ~ ~ " ~ ,, I ' ~~ ~ 21 . /~ Y ~ ~;; J~ y' '~~~~ POLICE TRAFFIC COLLISION REPORT Ibl TRAff]CW/a~ PRIVAVTE V/AY~ R%K2 COMPINNT ~- f ~ '-, !~ E DP iC I N L3 85 C RD .ID .~,; "r MF 'i~E,'~°D DRI <OUNIY ~Ef FE.250~I E~f+D ~lQ CITY NO. iHVlA pN RAl ~ !~ /,. pN pE p CITY OerO~vN O.Or SrRFFTO4 HIGnwAY CD rulfs~s pw poi ~ IDW N ~KDIJDALL R'D• ~ ROUrE 9u~3S0' I n NIFeSECr NG WEH 5r4fF1 OR ROM NON NIERSECfION /~ C q DfIWEFN {~ AVE SIREfr6 ~ AV STREET ReFHX E MM1f IOST ~ D•z~ DI;I~CE rON RFrfRf .CROSSSfREfr OR NfARESr MIEF PoSI LL mIES N 5 E W rEET of RWOD DQ~V£ ACCIDENT MILEAGE coDE RAMP DNG4NA MTA .. ] COIUSgNINVOIVED vfRITY: LOIN NO NO Kllf0~N0 NIURf ~ ^SRI~F ^HT6RU OV[N CIES © p RROrtRrY DAmAGF ONIr ^ rRF1UEnD p VFa<IFN I .RD IMER CIS C ~ CfI TRfETO4 ROA0OR REFERENCE ROSSSIefF`fOR> ROAD SGOD 9 OBIECI STRUCK INaAEDf IECI STRUCK NJD OwNFR'S NPMEI ESE ~~ ~~ SRKWCODINGIN _. UNITNO. I UNIT N0.1 p VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST R' S DRIVER'S NAME: wt 1 mI Dtf E R~ suAr~DN ~.. vFR'S NAME: USA IR I STREEt ADDe SS St4ffr PDDRE55 I~ l arw srArf zlRCO« RHONE ND. ~Ari--oc!{. WA 9$338 8S-~L~ 0 R nwrE IR N N !2 rvF4S UCINSEN Alt sL.3 Sr"n ~ A tl H Ml'oz'6~ I ~ I R D FNSE NO. Ar DAIF rB RiH mD i RA ;r. - e OCCURAIION NNAff RgnE NO. FYfS GHr IEIONr E OCCURPrIpr FIRM NAMfa RNONE NO. FYFS IGHT HfIGNi z ~ ~ +~eW~~ R W p CHECK I~ ~KIfA AN U"RiYr f" wNOrNEe"s ^ CHECK (/) vFwaE ASAN MnRIOVFF OrANOrHfR~ v CODES ~ " ] ~: a ° s'n 5 I IwN a "s'.° ~ CODES , ~ ] a.u " 'slrin:Irv 5 IX N e s.°rtn r n ~ Niu e S e N u ~Ew '° ^ .mmK..KI ^ ~Kf ^ ~S:D. p .a ,.°. Rt NO SrvU ]De CONV D M9o..Dm p MI Na p Y I N 1 ul° ^ ~SGe. ^ IIDART.NOVAI K«2D ^ «°A:.,. I . . I A VAI MAKE IDODGE.CHfV.I FI I :1 VFH.YNR GORON ~~ o 0 9-QR E H . . 7gfF AR R0 "~ TAN SRP 213 srAl tRAlll9rtAlE NO ArF WA - ~ n. a KlF1IXN}{CArIW NO. e RE•v~ 3 07 1:`}1~3lc~---- --- L I D I I. Y ~ ~ ~ I I~ i I f Rlasnef°owNU. wT rmsr mlDDll vfIONE NO nesT mI f I f wNFR~ wT ~ .DOwu a owN Ill 3Kc NAO,AC,K WA• E E4 _ AMEa ADDVfua wwauxE CO ce AUNr -JoN~ j R I~~~- pNAPGf .RU No ' " eNC ~ ~ gAMAOEE ARU" ~'~ y,K'R°,",cNr cnARwa p nuRU a •f°r I A _ , onb: ' di i~rn t ~ E ^ WA1 Nl0 A pAW~N pRFMAINID Y (Sr M _' t IC:UTTC4 I ~ x7-E ~+ w': oer. low]D ^ Awer er f I• DIAGRAM Of COllI510N: I KAtl EA n dI ruNfus5N+1 eY.RerfyR1 l~l/~" DESCRIPTION OF COI ISION: lafSaREALLMAI SHrnu MCESSARYI dEbIICLEA ~ J li]AS £E1~BOUNp oN • , ~ SI..LD oN BMX" RpaAl.~ RoAD• ~11C1.~~ oN RlsilL• w t / " .g s of of vE 1iaLWE.•^xl.~ ar,'sc.41N~ ~ . \` / Y ~': _ lr ~ ~ NAME, ADDRESS R INJURIES OF PERSONS OCCUPANTS/WITNESSES I SISIR'M1IMFNINSN io wDlrbN.E NAw INVOLVED ` It (/ ~ sI i CODES I "~ •(:! !AN - _7 ' n° _ 3 ~ 5 6 Ste. [RO Niri .ml ib ~ .mFS~~/ S ~Y W A• ti- /1r O/P4WA NA1 aRl p r q 3 2T fN r AM6 ©GhKI p ~'n i p IT~Htr '~ ~ .ronu . 4 / S ~ N Ara a /VOA ' rROM U,we. (~-..".K' pc" . p Hx 'D .q ' . f ~°;°' ^AMe ^KH~41 pin.. par o~:I,. t . J X >. ,, ~, ,,//~~/y'j~fyj`'~~`~J ~,./ SA'-'N~F!LLY=fNC!V'~~ ~qy a/Y.K' "(w••c• d ~•.I ~.•- /:YY"` aoC' `r}9~)Ryc..D S~>.RYu SSs ~ly y ~o D / 7774m•~ws Area nrlo. 1 ~T _ LDAre __ ~ l7 8 __- 'iar~'; / 1 ~"`" ~ ~ TE~ ~~ ~ ' ~ t ~; r k ~ rk ~i R S ; Y; 7J . I ~° .K.~' 4 N~ r . ~,' S' y ].. 1` ,n~ ,} :! U~•~~ I '~ i B 8 4A ~ L I~ ~~ E ~}~ 2.. t :: I I I J r-"~ 1 4 1 •f 1 ~a~ I `~ J v~f~' _ I 'r' f ~ ~ - ~ ~'~ ~F ~ . , + e . .+a 4'~^f ~ :vBrrs} ..a_ - _ Lb .+sY. ~."a '!!i;~, 5~- MOTOR VEHICLErCOLLI510N REPORT ~ e°o°rar ~l0 Nor p.RGn,L ",rF O. c«LSOn R,r or mu smN rNE US mu;"N unrv Yn r,., ~'~ 9"n Nr,n rl,F} F rn"A rnl 9,T ~ .,?Nr ,H ^~ F/-'C S'a ly No. ` ~ fj. ~(~, ,2.I,E9 °" °^: °^'or 1'T 7ow,vs~ r~nF.r~"r91PF ,«".W,. oY"9 F .n"wlrn9rRLLr"RA"," nIN[„"' P 'v,o,(r~v „F Nr~FF, F, PFrI. Ero9%U pn"r 9+."wnF.RFLrInrEP,F~r+nR9,aEOr~;°.~~..bnsFn"~.Fnon,P~F Loo R.NP rl,~nAN",JA .o ~F9 i o~ oaf eg er ~" w '~ ` `E~%o or~LLrDa~~A o ;M e.: I , r V ~ BTflUCX In,HE "r "9+FCr lrsuc%I OWNER OBJECT OF OBJECTS NAME AND ApORESS {gia[PWNa tci Ec ccoE USA DflIVEF'S (AST NAME FIflST NAME MIDDLE ED DRIVER'S LAST NAME .FIRST NAME MIDDLE 7Tr71S'oN FRRNk ~ GTREET ADDRESS ROUTE NO. AND BOx NO, ///~ esr-CRAnS' E STREET ADDRESS ROUTE NO. AND BO% NO CITY STATE ZIP CODE ((i JL: /V D ~ ~ DRIVER9000UP/AiION EC/~ , n CITY STATE ZIP CODE DRIVERS OCCUPATION flIVER'S LICENSE NO. 'TATE SE% / ~AaT7-c FN} 792 1~i1- DATE OF plfliH AGE 2 % G D RIVER'S LICENSE NO. STATE SE% DATE OF BIRTH AGE ' U VEHICLE Yfl. MANE ICHEV. DODGE( MODEL INO A-PART) BOGY STYLE It Dfl.l V EHILLE YR, MANE ILHEV.DODGEI MODEL INOVA~pART) BODY STYLE 130fl.1 y~S- C~hf ~ Et C'a~nn LICENSE PLATE NO. ,,ST/ATEa TRAILER PLATE NO. STATE LICENSE PLATE NO. $TATE TRAILER PLATE NO. STATE VEHICLE IDENTIFILATION NO w Y .~-. s E V EHICLE IDENTIFICATION NO. REGIS RED OWNER IUSi-FIRST~MIDOLE NAME) DRIVER'S LILENRE NO. REGISTEflEO OWNER ILp9T-FIRST-MIDDLE NAME) DRIVER'S LICENSE NO. uv -.t.~ K kl .~ 3 WNER 5 ADDRESS (STREET, CITY AND STATE) i ?~Sr-'c 9lVS T b' GATE OF BIRTH OWNER'S ADORERS ISTflEET. CITY AND STATE( GATE OF BIRTH " PARTS OF VEHICLE DAMAGED kiv~wv[€"~I r" pART50F VEHILLE DAMAGED :4'v+"n'vso~~E. rc LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- was THERE purorAOBLEUpBUrv wcunANCe ^yE5 ^NO COVERAGE IN EFFECT FOP iH 5 ACCIDENT ON YOUR CAN NAME AND ADDRESS OF LIABILITY IN9UflANGE POL CY NOLDER NAME Of LIABILITY INSURANCE COMPANY MED. ~a'rry I~RRJC',S.n~RF9. /i7~:cr'friu ~'f~PMsrv, l~J,L rrP'1¢'~ S%A?5 /'ARrvi NAME AND ADDRESS Of LIABILITY INSURANCE AGENT I Y 91piE SIP LIADILITY POLICY NUMBER " / v ~~ i.n P,pNS 7J7Y S~ hl~ N ~T~N/tS rh'D y7 ~-7 ~G b- ~./c~ -~ (~ y INJURY AaE tND INJURY lusE SFPAAiiF P Iir~~ AGE AMF rJUNEU NAME SEt " SEX ADDRESS ADDRESS NATURE ANO M F fff--- ---111 NATURE AND ^^ EXTENT OF INJURIES ^ ^ 1 1 CNTFNT OF NJURIFS E%AMINAIION BYOA IOOCTOfl+ ~ ~ NAME n5 u E%~MINAiION BYOA (DOCTOR. ~ ~ N~ME RS STATUS Of INJURED ~(]0 NN MI L ^ «, O NILL[D MARK FIflST is nNn ~nx.p 19T.L LI ONE THAT APP "s•lu .H un.f ,~+nR, lIE9 roNUS cuulK r STATUS OF INJURED p" I HI L ^ P NILLEO MARX FIRST O +s n.in siri~lc NE THAT APPL o s,s. in unr IES "sius m uxY ' . oLLO~:~:; .^•,.,~ ^ 6^ 6^ w7 ^~I NO ^P~o~;~::~ 0...,.. ~ ^ s ^ s ^ a Por7 ~nr MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED _~ ____. MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED SHOW NOflTII BY ARflOW IN LIRCIE DERCRIBE BELOW WHAT HAPPENED'. REFEfl TO VEHICIER BY NUMBER) S - VEHICLES POSITIONS ©E FORE COLLISION -- INVEBnaATEO pv vLJRa[ E w off }rn[cr on mm~wpr rrAML On NO ~ r, .~n 1R ' O .LQ "LT " ^~~ ^~, I.",A,I jA ^ ^ ^ yr!~a Y,r ~ O O C ^ ^SW M ^~;~~~Nrl. nn R r"• ^ ^ ^ ^ ALOHO (ROM TO Pf,DE9TRIAN.'PEDAL CYCLIST YYA9 U91NG. ,^n+ ^~ ,^^, ,^•„ ,^ `~ ,^,`.~' .^nr I^n` .^I„~ - M PEDESTRIAN+P(DAL CVCl19T CLOTHING COLOR L]~ .,,, J^~- ,^ ••" h„ -~^n~ ~^ N nl I•.~ol~~f.Inl yin Nn+NH,rnr uv.u + .n.. r•r L,n. Ilc ROAD SUniACE WLAf HLN MppLG~ryI~I,i CONDITIONS • , a•wl+ r~ ;:,r o ~ }wNN».r ^'' ^`TWY ) ^NA~N~rM1~ ) ^ W9A IRA/FIC UGHIROL OH~c. `^ sR:Hp },•onl~ ^ J ^ 910P bIGH TYPE OF ROAD pRIV[IYVEILICLE AC110N5 ,c•0 oHT. wpY ~i'~nN Nrr ,IaL^J nown RNUlma`urcADw n`I ) ^ 1WOwAY ^ J ^ DVCNTA%INU ANU rAR91NB ^ J ~]w[1 } 9NWr+h~t NRLT ^ • ^ll IY UN ^ } ^b"~ 1' ) YRLD 6n.rJ ^ ^ ~s VfRRilllf ^ } ^ T U ^ ) ^ MANINO RIUIIT IIJIIN • ^IUU } ^ Ut.H1Y 011 ~L ^rCL DI,RR nAR%rNJ ^ • ^ 11!:HiNU n1U INI[NCHANUI ^ • ^ II UOP HAMI.1 ^ • ^ MA%INU Lf iT IIINN nrr•lp } ^ 9n(f.Nrl 1 ^ ANNA LK~N1} ^ ! ^ ^ f ^ rIASN Nn AMUIR I A ^ } ^ A EY ^ } ^ Y %INf1 U~fURN }rtl'Jir r ^ YPIC Ir ^ 1 ^ n115K.H,L ^ 1 ^ ~NL 6lRIN ^ F ^ I.I nWINn R A Y RA DWA C Ln NOADWAY URIA ~IIP b GC L ^ 1 ^ O 1 ft s Af.Y1r' l i (IIOPPCp fOR 1RAIIIC ^ r ^ ONwf WAr ^ ^ ° ° ° '~ n ii - ^ 1 ^ fJl [ 9 CGllr ~ f -~ ROAp SEPARAT ON ^ I {J 10 P[0 IRUNAL UI 9. DnR ON " ~",''~'1 f`} ~: `s!F1- ° n r]~: ~':~ Ep 9 ^ W (I'~ _ .. 44!'. ^ ) ^ nvmrn I ^ ^ ror Ln Nrn•nwAr n O,wDID ~Il-~.~F~I ~%~' IF ,. .. -JAI ~.~ SP:I: N Qew ~. Y 1: ~~~ ~ ', :., ~. t I I I ~C': 7" 3 1 ,' ~ ~~~ ' t ~ .~ir~ 5p 1 ~A J + ~1~ n ~.T r- A "4'0' h r.j 4'" ~"~~ti, ~. ~. ~-~~d~-~IT . .- T~ I tJV ~T,, .b'v. t'. ~`~s^ ~ ti - ,~+ ,t ~''ti I r ,,' f ,r.I,K r ~ JA .u+ .. -:~ ~ ; ~'`~' J ~ ~,t ~ ~ ~ , 1~ -~~' ~! - N ~~~~~~~ J' . e~4i ~ arty :k~ t ~ ._ . ~~1. 4 U~_ !J.R f a ~ r~gy - ~ ~ ~AIeV r IAi ~r ~ 1 4 ' ~ nrr ~ - dkYl' ~.}}ruir 'Ya/ . .(k 4 4 ' :i7 l R 1• Y 8 ~° Y 4pc '1 ; ; ~ STATi E OF WAS INGTON Y Dt DE t;~:: 1 .~ -, No. ~o.~-S-no.~ Y ~ n `- t ¢J , ~~`'~Y ., h~ }~nttm, t .t ~ ~.I weWMb.• +A' ~ y k ~~ ..; ' " a ~~. Tam POLICETRAFFIC LOLL REPORT ILITRAFFICWAY Ivuclc u11 NUMpIY ]I ~ a7 ~ PRIVATE WAY ~ nll ~rcul N un ~ I Isar ,, ,, ' Wr{ ,.,. ~Yr .,w ruf nn wr IMI copNlr IUTF ].fAr,n11R1 ' coup lr clr NO NnvA ~UAN i i ' I ~I I . " r.. C)/Ni ~~ ~_ Eef~~'Al N DN ^I DN <IV 0410wN AMl6N0 WSIN fIUR HIGHWAY ilds M 11 S YWIt O451NllICOd O ~ ~: >tCION Mrln s D oE CI m e ONCE).,, v • • ]] N~ NI{YSIe]N4 waIH SluI U NlluSIRI ON vRlr% FO. Millv0l] / r 70 - _ pp UEIWrlN •U~~V CY2 V TIRIEI 6 - - ~ 4 SIR[EI ' a51M.C1 UYI~IpY eUY NCf C Slut{I UU NIAU(SIM It vU51 [T S f n^ rlll Or jj ~s,C12 VflE-L ~ /~A~ ACCIDENT MILEAGE CODE My puUUAM MIA COl15~ONINVdvID N'1 ~--fill 16 RU FnG[ IOInI NU O%Ilf ~_NO INIURIO-~ OSid[NN ~ rarNUU/Dr,. N Yf NIE C11] IN:IUACI NL TrvIlIUR ROAOOR RIefNINC[ <YOSSSIR//IyyOR POnD ~/'O ]5 l ~ D nPt RNDItM.cloNn cr varcus ^YRD v __ 7 _ . GT FTI. DAMAOt Ob11CI51uuC%INnMt Ul OBR<I TIRUC%ANU OWNtR'S NAMtI / SIYC~AI CODING the " -" UNIE NO.1 "' ~ UNIT N0.2 DVEHICLE ^PEDESIRIAN ^PEDALCYCLIST ' s RnIYSNYMr. wl NYV Mlpal ; ` uR Vlas NAMD Insl Hus M~pae _ L. UVRt55 SIY{5^ ' a al. ~ sole :wcoa Hara NU. v ; D SlYlfl nUU41S v dlr sw IRC HdNt NO r O / R IZ Slnil Wlvl IICtNy N N ~ ~ V79~PL A StA F 0A f010, n to R..Y;~ ~ IvfR SpCU NO. - 1 tAl[ Stz DnItU BIRIN YD ~ R.. Ir. - ~. DCCNANON N1 tb ONt NO ~ lr{5 wlWHl KOHL E OCCUVAIION RM NAMI FnO. lr[5 WTIC:HI NC OHI r ^ CHECK(/) v". A tl or.°rM,ori,re Al I s wN Mkor ' ^ CHECK(/) vrNlcll AS AN [Mnontwnrmi~iRMt i sii°vc•u{ 'f % 5 Icrw.. a s°{; CODES ®* 7~ :~ ~ - I CODE$ ~ 7 <i:ii is 5 N N 6 l 2 n s•,a~ i r W ^ <;>;i ^ ^ ^ a.. V xr ; ^ AvN% Nll ^ sal D ss.,l. ^ ~, ^ :~',,,. ~ I ' ANY(1 uGf Mf tAY W [ 11 Uv 1 IvIt I]DR W I]DR V.1 1 D(:t H[V.I AvJUtI IDnNI NOVA) •l v(AN Ul ~~ I9 I cL,ac E ~. UR l INSt vIAIIN SIAI{ lP 0.All NU. An SIAI! H I II.eUOq N. t A Il .A Nd AIf T3 n 2 5. •/~ - - c 0 VINKII la NIiIKAIKYV NO. V IHi lE U{N II A NN . 5 X615; '~ 10!~ IS i t I I I ` I I I I I I I I vIGilltRfUOWN{R WI i~R11 MIUaI vNONt NO. O YEOi511Y0 wN(N: lA.l rIRS] MiDa N ~ n O ~' W II 1I~ ADDYIS N A ul WNIY L .33 MOGC.= T OC. E NAMlYM0Y1SSO iNSURANCI(O DY n41Nl R I ~~C~ » 1J w _ " I ""' NO awwlDi+l ':; `::, oAM:DID AREA% .'... :' i ,, o ~ 8w"I Y ~`(~ AUI ^ ~ n^iN ^RtMAINtD T~ s o !. ^~wwN ^RfmuNm ul pAmnct In uno:r '- .11~ 00 ~ ; wlD r ,Li I_ . C I d S.'RN w.. n - ^ ]ovnD s YI DIAGRAM Of COllIS10N' iiu~l YirHIIMINM Wscnll NO N ESSA YI .- - DESCRIPTION OF COIIISION: IlnlswntrnEN]AI SIgUn MCISSARrI - 7 le O+'_ ~ I I f. f a i~-, ~ - T~ Rl•'nY~D 9~! _n!G_4'U~?~2 v~1n~ l t~ wns ~•can, I _ _ , ~ ff { ~~w»~ ~ ~ ~ I ~ ~r~t.cc~ nvFm, vc:~„~Lf t I w~.ru_?t..n~c~ ' ' - _ ~I._ _ I :"'~~~ 1 _ _ ~1ERO/YU'~q-C.11~•D_Si?21EtIC-_ ..nr RIG.t)r S,OC ovi2J J~%t_ ~~M E: 3~rK I~IL•" t3+TII/Y-umO~T ._ ~.._'.. . (_J ;_ : ,_ I..,.~;~':;.<Ir7.l.. _- _ . . , .Rcwwnx,. c~~iNC,._aNrz~.zTS_z'r°...__._. _ „ _- L_ 't:EkrL•h :vAL.LCY Rcui-n, ~ - i__,...( 11 _I 11 I l i l~ i I' 4 II _ ._-.__.-._.~__- _'---_! _~. _ __ - NMr1L ADORf S5 R RJIURICS Of PRY ONS I NVOLVED ' CODCS 1 - 1 J 4 5 6 OCCUPANTS/WITNESSES { ) r% eu ,lop; ~;;" ;,'; (, {ISIR I_iel $;c;. ~a rss ur a s~„'~f . , v n n D....I [ ~';;.I fl,... ^it M .r ~ - ~ ~~L AI I fY /`~ DL ... ' ' r.a, I, •. r; ~' o.MA r I rr 7:r, ^,:., . .,rl,',.,,......r..,:.~-~-~-'-~ x ~'iL? IL~_R~1,3LZ~ ~~f~~ ~ _Sfn r,.. ~u sf'-- ~ ~=•~- __ p`.?.3iT ~--- ~J l I~~~ _. ~.~ 1~,,.h, a9pP, r II 1 I.-./._~`l _rl../~.~ pl, „ ~t K L ~ d ~~. rk . Y ~ r ~,K , , d~ i15 _ Ea r f ~. ~.~ ~ ~E"~' ~ ;', ,' G P~'y4k I C. .~ `I ~: ~~ ~~ 2 H . ~~ _ ~~'~'~ R ~~ POLICE TRAFFIC COLLISION REPORT I~ TKgFFIC~IAY ~~~~ 3 ~ PRIVATE W Y ,R Y _ DAr Or {jxl .. 4. ^L. __ o I r 15TH r. F ~ ~ IM Nmt (USE T9DR NOUVI COUI+rr iy~q / Clrv N6 QFHWA IIREAN - I 2 I 13/ so,v IY/~ 1~ la ^F ^ N Ct OP TOWN NNnf6NO.OE SrRFFL09 NrGNWAr ~ 1 qW Dq O • / Mllfs ^y ^W Rlo! Q c ON c ~v 9,3/S Nt[RSFCNNG yNIH: SiREEt O990AD NON INif9yFCrlON rWEFN SrvfEr 6 ytRFFi v9tf1% MIlE FO51. /~ ~~ ' OrSrgNCE6D VFMD rROM RErfREN ,C90ys5rRFfi09 NµRF5tM if ROSr , 3 Ef5 EI 5 F W r[FI DF ( O ~ ACCtDENi MILEAGE R DIAGRAM pAtA .., ._ cou swN Nvavm. ERirv. t OrgI NO. ~ NO R llfD~NO. NlU9[D~ ^ SR IIAGF ^ N R9UN . D ~ RwD atEra q~55J y[Fl33 ROAD _~ R GVEN ClES ^ RROMRLY DAMAGE ONLY ^ RFSUlrEO ^VFIXCEF [ /~F+'~~ ~ OvFECr srRUCR INanF Oi OBIfCl yt9UCx ANDOWNFV5NM1fl FSr. DAMAGE SRCLLL COdIRG IW S - UNIT NO. i UNIT NO, T ^ VEHICLE ^ PEDESTRIAN ^ PEDAICYCl15T RrvfR'SNAME: µ5i N95r / mr DlF ~1 Al J E/ RrvER'SNAmf: u5i N9 ~{L "' A SivfFr ADD9F55 p p OS£ /l ~V ~Y O SIttFi AD09F5y 2 utr srArE zrvcon oNE NO. D r s At[ IRC N It - .P.~Nart/ w/4. 98.3ao 79G-/f~`/~ R /z rv[R'S UC[NSEN DRPS o3 yrgiF oa. x F Br N m7~os~& ( ~ Iv UCEN NO. tAtF RIR N A' OCCURANON irvM NAME6REgNF NO. 79G~./~Sj/ FvFS IGNr E[K,Nr "l E OCCURgrION FIVM NMIE6 RIgNE NO, fK5 NEIGNi HFIGNt 2 iSI~ N•nl "rze/tD/N Co, Bz~l /oS •02 R •-' ^ CHECK (~ Asw aorf aANDrNFenl u ^ CHECK (/) FN ttF AS qN UFRiorEE aANOtNFRAI ( CODES -+ ~ n 6 w . 5 l 6 uN1O~ ' ..55 F CODES ~ ~ 7 ~ S e, A s° z> Z C J- . arts o ON >f ~ S m ; ;oEa ^.MN..NLE ^ ~etE ^ zs.R. ~ ti:K; ^ :~~5. M7:'ro ^M,NA.NEE ^ ~;.<E ^ ~srrt. ^ ~t~K„ ^;.;.,. vEN rµ9 MACE IOODGPCNEV.I $S a 0770 El10AeNNOVAI SirlE 1409 CONV.I PIcK'u.P E . l f NEVI MODFI (OA9i NOVAI Y 9 1 .1 °O"' I ie Z v N. oR uceN G srue HER rtArE NO. sruE H vw.caoR N l . R7:R4fFl -~ . ,gluE Lu 626 wA I C ' Y[NrCIt ID(NNNCAtgN NO. S ~I 610 9 So6 8 6 ffl$ ~ V NKIf rDEN19r A I NN I I ' R[OrSr[MOOWNfv µ5i rrvyt MIDDLE ATSON TOSLP ~ vNONF NO. 732-~oSS W r5F VMG: 1A51 rl9sf MIDDLE f ..y ~~ t T; ADDReuGro WV P,0 A3 37/ g LocK w N A WNER - NAme.ADDRfssalNwvANCe CD oRA LNr ~E~rra R7- R FE6FFS IN RN4 AuS Cv o W/LL/S 4vTofFGt1~ az DAMAGI APLA _ ' ' ', gAMAGED ARG CNMGL CNARGE ' t O AMAff 5 i5t DAMAGE ^ ~v Ntv ^vIMNNID ~ ^AWAYN ^RLMAIN[U E51 s oo rED QED /L[ s Gq /~ G ^ toweD s Rr AWAr Sr , DIAGRAM OF COll1510N: s~yo a N f pc Ato ~r DESCRIPTION OF COll1510N IuseswnfMENrAI SNLetu Neceswrl ._...._ ~ ~ VtJf/cGt ?'} L r~.~s foaTlt I ( ~ ~ 'a! /p 2R! '~ 1 . . -. - _ .. .. v t.r _._.. -1- - c £NTLrC_LeP ?T. /N_i,<cX• ~fS.+lif} OR L~LG~_ . _ .. ~ I I 1 ~0$J' ~ CON j'Ko< Tiril v£fILEL~ OF ~[~!PWFL .J__I r~ ~-; _` _ .~ _j__1__ _ _ , ___ .. _. __ OF rtit Corr!/R~rFtl~vw !rs~o icE.~~%_77t~_.._ .i ~ . i.- 1._ _' i __ .._ _ _ -II ' - RoA~WirY-,.. /rh`/cLE_. SL/v .oFF rM~.Fv!!-D.~_.. - i ~ 1 f . ~' TccRNSNG avrct or~!Tc /rc TOP ' I I i ~ _ ._ l._1_ _ _:.. . __ ._ _ °--------~ _. ~ NAME, ADDRESS B INJURIES OF PERSONS I NVOLVE ^~ " 1 ' CODES - 2 3 4 5 6 OCCUPANTS/WITNESSES i°oa :,oDU~o.:n"i H:ui ~.~,J i~ _ _ eix ~:ct i.ius "i°rn v.r- -~Nr- ~iri ~inci :R; we r7 ., R . w n. ., n ..,v w NAME _ .. ... _.. _ ._.. ... ...... ..,.. Na ... AD(Vllf NAtUeI OE YMWID rROM ANR ~ni'SE wI, nir. ^ ^ ^ n • ^ N ^IiD .p AMI .. E 51 '•[I OE .. 15 SCIr,l jlr 5+5F ^• l]i. '' ^r~ • C:i ^Ii '0.( ti• µ,F.f ~ O.r [ kkKi• vID DA TOE RIroer Aex • DArt yl~!~M t4i. _~ ~i/ F . "'~~~ `G:i y. >sk ~~' ,; l ' F' ~1 a of 03 ~ .. J ~ E ~~ %rz ~ ?; ~E ~ ~ <: ~ ~~ : ~.o- I"` . 7" >rt~~fi ~~. - P ~T' , I E~,frs~i ~~ v M ~ ;.. ~v _ wT ''„„ 3 ~ r '' v+ . ~ ~ d s ~i~ . v'q. t fifi y99 •' ~~LLwwFF 'k.~ ` ~"s. ~ ~' . , A ~ ~~ >• ~ r~ ~„ ~~,~~ ` POLICE TRAFFIC COLLIN REPORT Q.Q TRAFFICWAY PIXKF COm. ~~NINUM&R ' ~ PRIVATE WAY Da{F OfCO{e N a rCg15 N CODNIV { 1 r yr won rv,v wl. "u s ,r t.• „~uvl IU51 ].DD COUNEr nX] / IY NO. i"WP ~Ve N ~ O ~ / U4al ~N Q( ~ N C,rr O410wN 6N0 Or SI IIIOV N,G«War N iCl ClS . eOUiF ON SIN StCndv MIES ®5 oW AGE oN IteSFtl NG WAIN SIR[tI OV ROAD NUN NIe95ECIiON N 3 9.~/so !8' o[1WEfN /n/ ~, sI41Ei 6 SI4eFE PNeEIA !O ilE P051 O ~O. O ~ - D51•NCE 6D41M{ON EPOM4f.eRINC[. CROSS SI41e1 OR NF•e,SIM le W51 S N S ACCIDENt P D,AGegM WIA Or n O ', O E ~ MIIEAGC D CO.I N NVO{ VfO ~vlN tr I, wO n I,FD Ie F1 ..r"R°,RI., NO NlU4rD~ ^SO{{•G[ ^" EOia NO " N a~RO eNStC ,NGSRF OR RDAOO4 ReiER(NCE N I lf ~ ~ t OV[N dFS Q, ~PROREeIr DAMAGF ONIV SIdeN ^oE ^ u cl N q. CIS CPOSSSt4[fl~~n~ Y/ .C A V .~ OBLIGE 514uCNIN EOE ONI[CI SIRUfv NfOgwN[e'S NaMFr [St ONnnG[ S ` li SPtCW COO NG USt ~. s / RLgND UNIT NOI UNI1N0.7 ^VEHICLE PEDESTRIAN ^PEDAICVCLIST lu DR Ve4 sN•Me u5I rvv mm { D4 vteS Namr. wv ws i l LAR _ 2 SIe[FE DDVt55 320 5 R[fi AODRess I ,DA o 55 '~ an valE z =cone v"o"e No D en n4eo PNON 1 . De vlRS=NLSF ~~ 9Sa7G - NRI • R , 7 ~- O iv Cfe( - Z C , O. Y6 ~ eR II NO Z ~ SEAfI f •Ie OE Ni RIN wD Da. r. ~ OCCUPAi ON NamF N Pr,ON[ NO erf5 w[ G«I nF,Gr,E 4M E OC<UVaNON M NAME 6 PrgNE NO FYES WF GNI Nf IGN 2 "' ~ R . i I6o ^CHECK I~ Molonr"ov <rMizi**nFa°' ^CHECK(/) rvlNdae asnNEMP ov or m~ a{ ~ t+ CODES -' ~ ~ 5 r e "°;`; °'' ~ ' '' .N l zz EN CODE$ ~ ' 3 i~:i`s a ,. 5 E. e i ' <t~ 5 ~ •, "'z 2 e5 ~° a t D ~o.wP~,.,<I ^ ; ~ vlN tae w PE IDODGI-c"evr :~<' ^~~°,I , o ,. mODEIIDavI N va, s nt IZDN coNV l .ro, oM.,N,.«<, o ~m,<t ^~oa1P ® ~tAe o ww v + I DGE c n ..f ;e'"s. ~ o ig ' SZ E . "tvl wDEllDa4r NOVAI ~ ~ r {x R. el r A { N n"se Plan ND. uan N•nR n.n NO vaE H vNC 4 l al AI NO. AEE C3L A 38 W c y vewat IDENI,E ur No. N (oS.DO loS 3G1.01 0 0'Y !o Rle snetDOwNE4~ vsI Nesr M~DDIt v«oNE NO ~ v NI E eaI oN "(3~ FD M l DS Sa 2 Nm sn4eoowNER M S O yV usl n4v Mmine rwrve ME. v V aooRess or owNE4 Re SDr owNe4 " N E NaMENADDVessd ~NSUV•NCE CO GeN ' j~J ThbRS'EN GENE R a m u AN e AM FSNrvE~.' AGEJ.IC~{ ] M _ DAMweD•ela N -- L K RJl1i.IM ,S'8-9953 ' t ~v owi CNAPGE ~ C. aeGl ~~ nEU A4E •= - o~ S LSE. DAMAGE ~ li/I AW,1,,N ~0[MNr•[D C~ IO 1 fD MA ~AW~v ®RF IN[D IOwID ~~ { L s ^ W ev ~ r Nv DIAGRAM OF COll1510N: SNlttu NlUSSier{I ND~: sc Rp,y l" ' N DESCRIPTION OF COLLISION: IDSE SUnvllmf"r•I SMEENN[CISSAerI ® ~/EH. ~ / UA9S NORT7yBC%zNG OtiR CEti+TbR RD. RAlD S7rec.C.k R STEER WH=c=H wR5 S7i/vDZ/~Yr,ZN TFIE A.CIR77yACGNTj LRNE.• 771 =MPRGT THREi.J THE PC•.T-. S7E.E2 zn~T'D THE c$O Ur/dao/n.'D LRNE . b~N. q'2 CJRS cSOUTFIBOUNLj ON GENTE 2 RO RNa R N F~ ® 1 . A OVER. '(•i~lE STEEP/ WHSGH CAUSED THE VEH. 7b '71 _ (j0 OUT Of CONTROL / CSL):D.YNG RRo;eND RNA .~~j -..ajC~ CFNlEl2 GCVJJG OVER R BRNk ON TNE. SOG?F~QCGND ~f ~~ F THE z@7FiA DOtN~ A ?700E( RE E Rp; Iv / . r ..t./ ~ 'b S NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED 'CODES I - 2 J 4 5 6 OCCUPANTS/WITNESSES iustsuPntMtm.{s• a •DDn~o""NAMI uI S~ Sl. •GE EAIVS v{« u ~" n ,n 4E SIR NICt w,c. , N AMI Ti /f L~R ~N ' . xw5s '° xlwer DAMN ^~:1' O"k...7S"= O . N ~HN BO V837G (pS- R38 O NA o A nan r EUR n ri. INUM Q•MN ~«.tr ^~ . O ~ O :°' ~ . •N,. b " ETTY D. 8080 s7G ~ 765~38Q0 H° `~ rc:. w r ~°~5°' SE,re: DAMN ^~:alow.Loa ^~~ •, " •" s vy SNAwE v N• N•W c>w d HD Pd+1 NP Dan (H Nlrttel DatE x 4 it mryyrK/~ 1 ///J ~ DYI _. r /~VP~ /LS~~ ~.~'y _ t . ~ r,,. r + ki ?R ~~ . ,~ a~ ~' ~ ~f _ t ~ ~ ~~ a F .. j ., f (~ ~;1 ~~ .• ~~~ ~ ~ '; 6. ~tq ~. ~ {~~°~w..ur} .`SrSV. Ol.. ~ ..: ' SUPPLEMEl14RY POLICE TRAFFIC COLLI519 REPORT PAGE 'Z of Z IDENTIFICATION OF C ION CASE rJ0 SEVERITY OF COLLISION ~ FATALITY ~NJURY lY DATE OF MO DAY YR COUNTY CITY SIFT E1. RUAU NUMtlfR OR fJAME coulsloN ~~ /~3 ~95 IOCAIION x~EPF~EFZSON ~CA.•~ / NAMF NAMi ~v G~ NAMF DRIVERS R D. ON ~rl~ E r• c R v5 Y C ND DESCRIPTION OF COLLISION USI EOH ADDIIIONAt INFORMATION WHEN $RACF IS NOi ADFOUAiE ON ORIGINAI R[ROPI OH AS A $URRIIMINIARY INEORMAIION SHEET 10 CORRECT DRIV[R'S NAME, OCCIIRANI IOCAIION pR ANY DATA NOi KNOWN Ai iH[ TIME THE ORIGINAI REIbRi WAS COMVIFI[U I IQOTH ToNN v~ 8E-Ty Q~BO WERE RT THE SCENE OP THE gc:czDENT RNO Z. D. r &n 7r/E ER Jq.S BEt:ON(,I._AJ~ '~ 7FIE~.=/~' NE-: CrtISOR, RAY A'1 D'FARL9ND, JOHN {~J80 HL^O ~pTE~D NE HRS GHASED THE S,gM6 v"TEE2 BF~t:ic OFF THE. RORD~ YQNp HqS /1.tlY,i.ti.~E.,F) IG~fRR~Al~D ABOU1" ZT BEZNC; GuY; ON PREVSOUS OCCgS,;SONS. ON I~-14-£iSA S MK~GE rcRsONAf... COP.7'i'14CT WtTI~ IPHt' C, MEFRP.caNO RT/,(ts 74~ssObNCE, S/CJ 7~)Zo/u [AniE, tyl;[r~.GENE L{jq. 9876, f~/. ~ 7tJiS-3413 . MR. iU cFRR~AND RCICNOWJ:..Ep~~ HE 4uHS TNE. pLUNEIe of 7NE JTf•~R . NE ZIF:.D /~E HE HR,D REc;OLE.RE.,D THE uTEER. A/mob cS%RUCHT?:.RJE.D ,LT, RND SHOWED ME 7NE_ CARCASS ~ l.~HSrH WaS l-IHNCrtNCy FROM !~ ~'R~ ou-r7or~ Has RES~.DrcNC~, blR. !a~•FFA1«.AND RDUS;r_p HE NAn N~ LLVE.;TOGlC ZNSURgNcIE. DRIVER/PEDESTRIAN NAME ENFORCEMENT ACTION SOlRIETY • HAD lFEN DRINIfING (CHFCN) CHARGE CITATION NO. ewi~~iiY x~ r uooo Amrtr 10 ICONOI NOT R•VAIFFO DIAGRAM OF COLLISION DRAW pIAGRAM OF COtU510N SCENE IrJ RCASONABIf PRO{'ORIION$ VRORFREY IDl N71EY VEHICL[S ANp HIGHWAYS. SHOW $NID MARaS AND O7HFR MEASUREMENTS. wilO~i~ I I MVI SII I P 5 Ml w O RAN flADW rJO AG(NCY .UNIlYp15i D(1 A ~DAII q R[IVHI ,:: ~'`f ~T I ~ - ~ a I a~. ' may, ~ Wsa iSG,viv , n01 4^I ~~~ TATE OF VN INGTON L l °' ®fTRAFFICWAY ~~ y N y POIICE TRAFFIC COLLISION REPORT ~ PRIVATE WAY wOCE COmquNf NUmOfa D<,1 OrCO,D1 r Ds. _ ;,,,: : • • rmf :C:.!+ CWNTY ND fY ND. frvrw 12 8a .., , ... .. ~S E.p e~t' /6 Da,u I . .e ~,; CJE ~~„ o,. oe!o e•, •o /-!. m~us ®s ^w ~^' ~T ON r 'E A rp cu aoufE sf x n 3 K 1 3/SO , . Eastcl NC mf„ vaIH Da RO<~ , .~. rettl. , t mnE eosf ~:, ' I D,•.I,NCf n., aiu o5, om eoEaENU : Hn or ..e<~,:•v,, .cs' S S f ~ ~J['~) I \ l' ~' •euotNl MILEAGf CODE ma ,•eanm wfn ],US~p,I'.rulvlD . NO uiD_•n ~•wwD3_ ~J'P~ ^„~.,, r ' ...",- v.n ~ cis SFCfINGS RttI OV VOM Oe gfftRtNCE caosssma*oRrom 'v6 ' i„yam m o°. p cRnttc.. c<.•<cr u::+ Oui ^viw" SG3Gd ~ 06405mUw IN•mr O'OBRUSiR/r <hro Ol+tt°.•.<Nf vDa••ef E saEp•f <oD~NC me - EE 5 UNIT NO. I UNIT NO. 1 ^ VEHICLE ^ PEDESTRIAN [] PEDALCVCl15T r fv'SNw.f tnSt 5 m~DD,E 4~~v1 Nur.l Unt ,~v1 m D.i 5rvifr •DDaf 51 ~ ,f <D YE55 a ~ <O RcODf V D ..n , _,<,f nRC NE NO ! . ~~Ees UCiN4 NO .r<iE I nC'6.,„ I ~. es:I.INSI NV ,.r•n D•,f ;N 6~. I„ . Da +„ON m N•mE n P„,,Nr No , ! ' • E c cu°•,~ov m Nw•f a r„oNt No En; wT,c,n „t~cNf - 2 y EP ~ I:G -0 R _ ~ CHtCN I/`. cif •s au E.°<ttnni °ciui<:i„tin, ^ CHECK I/) f "' •riot~i~~ S v CODES -' 3 c :, • `. .:" 5 a ," • CODES - ' 7~ 5 , " „ -]] ;~ :x: 0.E F•c N~.v' Y v< , •R +,^ Cot CMiv 'D•vl NOr<. ,•r; s.,f ~ mV V rlnoeD r vf`C„fv e, o» • ~ C]IaE~i 4tT~ `~ ~ E . NOV. u¢,~• , >D Wv . -x A oo f wsEru s,•rE ,fa a•rt NO H v„caw N f nEN • - T~ O'~i.L Z !-LSO 1 tJN~ ~ >r '~ v[~KEl ,DENT r,C•f,ON,+O a D s 1JJ ~ O 3 I ` t„CU DtNnli • i N ~ '- eroonamowNfv uv nvs m~DDU J Ed AS Pnr•VF_ a„rna me O w ° Dan RED wNIR f•v r,e, mmofE NI N ' J 2 •DDet53p bw+,ly N ~ owwR al ~ wmu •oDYExp~NSUa•NCf co n•a Nr ~~]... ~ (~`, • R •TfGETSLCS°Su6,IFL(>a"ESBZ ] '.r W. q _ - w f>..eet, r m, • f ... on o.~ Es! Uur E ~+I ~: ~, •w ^rlm<..,m [~~°1~~N (~Rem•NfD < n r..ef n, i s r ~ -"--' ~ '1 :°w::De. iA6:~Y' ~,l) :w:f.D e. w 5 o \~_~~~ v •.e~® DIAGRAM OfCOIIISION ID "'+I'•^ •'f -`°" DESCRIP{ION OF COLl1510N~ ~vx wrR,lmEN]•, 5„rf r~, Nr:ESS•v.: / % c~ - ~ Ei{, lcJH~ /Y.ta2TrfBC„rhN> C/J IbNT~£F. ' ~ / ~ ' /~. , Lc~.:- C:Or~: r~t+~. cn, ~]~9~:< S-I.E C'rrv ~ ' V r : ic./..._. --" ~:, •-, A CAF; :;;.SRI/E,, RNO cTJtrv- C,iEiL AnJ , _ ~~ -~, Elyl;ArvicMEn,~ Rnn SrieucK A ,~"4i°EE.. L'. - , NAME. ADDRESS 81NJURIE$ OF PERSONS INVOLVED 'CODES 1 - Z J 4 5 6 OCCUPANTS' WITNESSES ,`: i~'i~,{":!+.' ::. , sn .a .,• Y, •, ~I ' .'AEF~T G VS1~~iLt °VTp ~~ .•,7 _ J~~~l~ Ft'' ~ , ~~ [( - ~ , ~sz r ~?;'i~Ys ~.. ~~._ , , ,: ~'.'° bl, ' lsf 3 ~v., ~~ ~ ` ~(;, ~ y ~ ~~ ~. ~ K ~ ,.~ ~~ w,N,w 4t4.4E, ~ • STATE OF WA' NGTON =« I G' ~ ~ ' ~ + No TRAF ICW9V ON REPORT ® ~ POLICE TRAFFIC COLLI POtIC[CO nMNi NUmBIR, / '} ~. PRNATE WAY I~ • 1 SF > • ~ Our... ~ COV rN0 Clv rvO. OF,rvIn UNBnN o ~ ~ OG: r ^J ~ x r Sr4ft 9URnl x roN ~ ~ - >. { { srv!{ narv "':,gl• ^^ .~ .. ON B 1tC 0 ls +DM , ou toN 94/5~G v :4 !., r. •,.. ,vfl ~. .. - ~•i0•. wtt•,.,llF~.r~E: ~-.•0 L. ~ •MII NRlHx f0 I 031 6, 99 .. r.ct ~ - • rlr G~ ~,.< .. sr r S r Accro[Nr CooE v.N Down«w:+ . 1, ~•orn. NC"~n ,~; ~•,I--•'c~....•°fc2 r7 s.',:.-., ^^~•+°..{N mr•,ces JD N~•NN- ••o>v<JfaN.• ~- ^ ~ ^'J~ r ,o r. .. wrfR 4u , cu c NrtNSFC ING. m[I OR 4pn0OV tt{iNf NCt vosssmm oR ROao 03'Y'G ~0 9 >•oennevs•..•nl nrnnw<er noa•f sum,o..rvto.<.e:a•uv~e. S snout eoD,NC, f UNIT NO. 1 UNIT NO. 2 ^ VEHICLE ^ PEDESTRIAN ^ PEDAICYCLIST - -~' .+ , wsl r~NS <., ,e ..IBC Cx N f{ I ,~ Mint m4sN.v,.t. u.. --- _ SlNlfl nt'Tv.53 St4n, nD04l55 " ~~ ~L oZd ~ ~y~ - Z ; . s,. r>con N N D .~ .cct Nl NO c s^„ ^ v Iv SU(ln3-N0 Mc Li k n1 /t 21 /N S ' F [ Wf}- -F o{7< /O N' I ~ ~vIV SUCtrvSFN? D Srar( F n,tG'Bi4, Y, - -.roN r..v.N,F~rvew N.~ trts wf ~c.•r .rtwrvr • 14 E «cu4nr~Drv MNAe,nN„nu •.:• tits +rtw~r w~crv, ~ ~ '- SRN! 5a6 Rz /R £0 R '•] CHECK I{"-~-6 p,ft ur <v~~w <N N Ir- ^ CHECK (/I O p„ ' 4 ~rv s ~ e -' `OD 5-' '' ,v CODES- 5 ~~ a ~- "' r Z ,rv s u.+ oN .CC Tl£R - Sc Ti~w 5 r e " 'o ., f ooDUt <vn /%7S CtfL!/ wwn a>4 r MOd/L s nD crvv 3 E nnv w 4 rote ro>4. NG4+ 4ov. Nv, , " _~e rn • ,aNSt .,wnN s ! +,tNn<rt NO ,t H ..c~ov N I< N, < .!! <n.o nn wf ~ Al 32 w/4' ~ ~° vlNC,E,MNr{C+rr NNO L vNClf iD[N,{Cn NN G ~ ~ 2 ~ _. wr D4sr N~ t N.,oNr Ne DD! vec o GnrfRtoowntN Insl rv,r N at Nt No t f'Y/< 2.l T' n SS-S~ G"i CR /iL' 4/ D W n D OwNtu < Z +DDRI eSp ONNIV lp7.33 /-~Y ZU >~ /OWni S f iUG N E /'( svt a "DD4tS5O irvOUa<NC! c0 W nGt Nr N R ,N. V +N < N )} .--. C!/J t/~J wn/ •' N ~ " ~ ~ ~ ~/ D.«<m D.vf. ~s '~~ 4~~.°~~:.. t>r'Dwv.cl .i r. c,wcul rr • - w~iN NLU<~mo ~ ^ .. cR<RCf ^°fv+~N,D ^: t r u.•. sc oav .cfo Rtn > .7s ~ o S /SUp iowiD L J Cn i ny . wa. O rowfD v By 5 .~n - , u N"' G4,~ DIAGRAM Of COLLISION' lu wfrn NirissnNr, ~~ o~y DESCRIPTION Of COlL1510N. lust SURV,f vi Nrµ S~Ifin Nl Cliv'n4. A ~QLV w C E"'l"l•~ ~ C VEH/cLl ~ / S~.rTNBGUn/v ov Bf.rrvE~C -' ~ L/ALG£y if'D , LOSS CoNTiCGL 6N ~ R CvIPv[, ~, ~ ~ ~0 Q£c.5'•a3L of Sa CIO lC£ aN T//'!. ,C'Gyp wyy ~~/~ 4y V£y/CLE C<(VSSEJ Tif£ RG/t0 /1NO D~PJ ~G 1 ~ ~L. uP eNTa ~ dy,/K ow T//L £.3ST S/O~ ,,((~~ ~Q~~ ' '' of Bfia-u£,P v~tGGy Z~, N£.TT ~ ~ ~ P ice/ . J~,F R IVE w/ry~ R(u/HS I p e NAME, ADDRESS S INJURIES OF PERSONS INVOLVED 'CODES 1 - Z 3 4 5 6 ~St SvVhl v!':r4 Srv OCCUPANTS: WITNESSES .;D•o..,rv,•. ll r r sf. +GI ,.."; ns•v tn<• , .PtW gzcs(s~i(on °' Oir Q~lf~ me l / •Iy3s ~'• ~ . y rt Z7,2 7K~£,JTfvee~~/,Fa,{0. /N/e~E tl.{ L .". g(_:•e ^'. _ ^~: <, > ' 4ia ^;. '~: ' ~ ~ ~ ;. .......r -r-T- fps ?: , ;:~-_ ~~ T;~", q~ ~ ~~ g~ ' ~~' ~ . q ~ ;r; 5 ' ~' _ - ~ _. - by .,: 1, .r '...'. "' -~' ~ ' as"- +psHF-'. Cat is ;.yyprr~~~... - .k .. ~~ ~~Y - x. ~'~ POLICE TRAFFIC COLLISION REPORT ~ iRAFfIFWI~Y PoOCE COMRArNrNLLmBEe I ~ vRIVA1E WAY ~ ! '~ orcausor. I .. p. I ,~ ~~ r ,I].Mf u«ouR. 'o~ couar. 3~~FF~ N couwn NO / crr NO rr.ws Q~oe,,. RAI '~ I uN Qf Q '•GN'O/.'. _ 5 fflUp»Dww,. 2 ~ m fl - ^w ~ Ct5 ROU FDe SrMf SCI : y , , ~ nn~,cu oN .~ r ,.wr pt rCR °Cnr_ e.Gr, ,•r ' ~ RRfriz ~, am.; f II WSr .2 _ 9rtwlfrr ,:plrt ,. ~ w ..pflr a. ~~ I nu 1 ,o-r, cpals~Nlr GN ra.a; v,r ros AcaDENr MIIF AGf R oucRAmwu ~ ~ L 1, . CODF . rµ OFD ~ .;,e(D~ ^'F It ACI Q»'Ap w '•°•lo-'•" ` ~~ N z90 r.rfN L N Nffl0R 40AU 04 ef!leFNtt wrtp rts caosssra¢*oR ROAD ~~:~ N^ `•'f n r ae. ~ g 9RDnpr.DAm,cr v..• ^uiiun QCiac" - ON,It:r lrpNC.,NAmt Of CS,[:1519~(. aN!:O,:r:Ip S•Jret f;r Gnv<Gf $ 5 U SHCV.I CODING OSf 3 UNIT NO. i IS I 1A51 .IpS• mUDD UN17 NO. 1 NA• UR vf°• Q VEHICLE Q PEDESTRIAN Q PEDALCYCL15T ~ - ~1 l . .l ulr rip>I , II IpFFt ADDNt1'. flr N(-i5 2 13 8 ~ ~~ Nth D ~, r ... r ~ IRLG~! D N/ vw l Cnr5l NC °9 su« I fO ~e rw A I weN S. uNx N,, , •rl su ~e NO. rt LEE_~E' C-r- 1 J r O^ O v ° p OCCORADON v, pwoN vo nes wi c«, »( c»• fn~~~ ~JB J- O? ~ Nm m .J E occw,ooN vl A prroNl No ~ f MIG«I HIG»I s 2 ~J F4W. T "~ Rf S R QI CHECK (/) O~fF~, Q CHECK (/1 - •w r R NODES-' ]r S ~ ' w , CODES-' ]<' I... -S r E ~ ^ » reap :DOCwf ewp A mGR. De + sere :op ow i~ u•p r .,c, c fv I pe v. . K .po ° f VHE_~ r, cacw !N .S' ~.% sr•If H E r u I \ o w I T 44-173 ,w a. ,rn,o sun u s. 1 ~ of«caep N ,• N An A ~ f Nf, Aq \ „ »KUrxNrulurK*. NO 7 P^4bX ~-- L 1w¢II IofNn I A I NN r ~ srf RlDOwNee wv npv m~DDU nNI NO ~ Isrtpm wNfR t•S IIRSr mro F F / Nf No N V~ BAt~Gt~R W I] •ppNl SStl OwNfv N A rOwNep ~I E Amf aADDRIISa INSw•vclcG oe ACf Nr IN a •. v L FS R % Am:.e~D Aee• -_ .. '. - I" .1 R• r ~~rr: c~ruu .~~ c»•RGF [r]~ I» ~~..i:ovr i ~•MACff e[A ~ _ rn AoJ + rr . m ~:w;." ^pl ..nm ~~' ^:w.. ^plrn.Lao . u~D,wAC! arnr•~5 ~rr ~ $~ ~ :w:f'e ~ R1aG-fc • ,, L'1 .w::Der E v V_ ~ ~~ e DIAGRA Of COtl1510N vl .- ,Im •, IV .rlr » i»flru nusrRr ~iiwl ,nr DESCRIP110N Of COLLISION :vsl su°Rlf mfNlAl s»fflrr wcf ss•prI GANEw ~ RG.` OW s~f:T.v~R ~ VENT K/ WPS /,IC,n_TNr'jC..lf.JO GN o"Ela VER ~LL E`; _ ~ , IQi. GUHN- tNTP i N~ D2r~H A~••uJ ~CC~ C• ~ I, LC2y` ~ . O'/E(`. ( LfJC. 70 / 0/-1 ST 'E N 77~E ~IiZ E { . aL- Q ~ , i ~ + V . . C . 3 Js4F_. -- - - .~ L~~°LVER. fT~r6D NE. H9D MG;/E~f 7'D 7'NE_ - v'NT C~E~.HGSE. OG /a!V C/JC.OrwFLIJ(y SEM Z' „ ,~ L, c rcfa . 772iJC.K, An.t~ THE JOFT D~ J}1nuL L C k - ~ ,r pu .. . .L? .. f~zM .LVro THE dsrL;H . HE yL:so ~;zTr°-.D TFf~ E/.,s - ;~ucac NEL r~r c:.ccti;sE~ rHE -n E NAME, ADDRESS 8 INJURIES Of PERSONSMNVOWED 'CODES I - 7 3 4 5 6 CKCUPANTS~WITNESSES ;ml, s(e N llr __ ~ _ .~ ~ "~ ~+ Fa ~ ~ e~,. . !~""'. ~ . ,,, .F ' - _ I ~ h ~~ _ ... P . k . .~ ~ -' ~u ._: Yt s 'f ~t'~r• li~, •a.. .li, £~ - 1 `~~ hG' ~ SM1iCt~ iy. .aY,xK. ! M S ~ ~~~ '~" STATE OF WA INGTON ICI / No ~ w'°"""`°'"" ~ '~ l - . POLICE TRAFFIC COLLISION REPORT ~ raq'FFIC~IAV Faict<omnai~ N icy ~ - ~ f u a R PRIVATE WAY ~i Ra for . ' i;• to tisoN t o .. X ~p ~, s, I ~co~~i~.: w. v.. ~a~: ~ ' mf Cu'r ivtgr nue ~Nlr COUNIr NO. CI rv ~ ~ rv NO. 7:~ fNW~ ^~ _ •: ~ ~ 9 (]N K ~ 9 ~ I]f ~ N Ov. r, ~eNU w FfrORHGHwar K1 C15 a M ROU1tp451Rt u oa t ~ ~ ~ ' • Mnfs ~ pw ~y".ui r .. ..,.. .~ nnL . / R ;a~'zV „ sf cu N '+1 1~~. ;di _~. ' ~~~a r ,a ". r ~rR~fr-FLA $ ~,uz~2_ QD•s,Rlfr ~I u c ' t YI-~wM it s via ncaoLN~ ~ n j E G 1 ~ ~ ~ °u' ~,"~ s~R,cr~ G .f S RG..a pr -- ~ . < aMaGl f i=,: .,; ~ N~ s .,, ,. Rs Nant u.t UNI7 NO.I v v.Pnit UN?N~7~~ r: i.' % i aupRl ss Kr aonvl ss v.•f ~° c ~ oNf No D r ~i R sai! t n. I p vfRSi cfNSt No e u ~a ~ at ar ~. n nom NO ~'-f_ I~~ ~ ~ V ~ iJ .n nn ~, r E uccwaooN r)aer ~ ip . _..r. .ter. .: rP .., ,F R ~R' ~ctNU V 4 t< hl- ~' TJ '~i ~.. .iii i,a... .. D7 rta~ ,. - U .»NF.' (J RIM,~Nro i rRAM OF COLLISION. ~I ~~ yla: inn~can 3~Ift.•~NlCISSaRr, Rr ... ~ ,J ~. :'~... r.r _. OCCUPANTS r , a,c. f X ~ ~ +~ ra RRpap OR RtrtR[NC! ~~ I> J , yy ~ o -..t '! 4 7 R•aNf Nn ++, /J ~ art ore tuts w :~~,r r~cm NtiGr~t s w . ~r v cpvv ,:u ~ alt No ,. U:wa: ^RLMa~NfR is Gt m. ^ ewno 5 r RaM. R~ ~' DESCRIP710N OF COLlI510N lust su°ntvlr.ral s~ur,r Ntct.savri 1( C f. 1. . i /. ~' a //: , r.. r ~i • J . r ~ • r r ,~l~a .. .,f' r.~fl. .. J, a.•n .,.w rf c~:runnn cast, °°~ho onla Rl w.~l .ry~~ c JIS~fU` Lilj>~~i ~t r I 4 I( i ~d ~ ~a ~ ~'~'~'~sH4 ~ ~~ T ~~ H1k 1:~~' ~' ,~ a~L ~ ti ~ , ~ I r.r„ r ~ ti 4 i° r~ ft r I t ~ t I ~~~ F ~A W7 ~0 1 f~ 1 ~ ~ ~ I :~".' '~ Yi ~ L t - :~', a ,~~~I j lA ~~~~ ,~.~~~~;~~ 4;,t1 { ~F ~tlf fti .{{~0.1LI 1~ '~ `t : ~ ~' h ~ t L .~ ~ I ^ t ~ ~ i I l'~''ktlF " ; ~. r' t r I '- r~ 1~ ~ ~I ~~ v ,1 ~ tr~ l I 6 '~ ~pq'; f 1 t S l L, L 1 +° P I ~ I /~ '~ Y~~ ~~ I tiS 1;.~ I r I+ t t ~ ~11 t 7 ., I ~'t } L ;.Ri ~ a ~ - ~ ~ is I d SY~, ~~~ +~ r ~: ~. dpJ ~ _ P ~., _ i ' - . X , ,f id}TW ~~v ~ R ~~ .4~ '-4 $ -`"+.~~~."Z,zs~Te~,ztm ~x"4'.E.~ae~",4'x, ~ ,. ~ r 'is~ ,. ^ _ .~ e, ... ~ _ i. ,~ x ~ w54,pR Rfv •,U m ~ `I '~ STATE OF !N INGTON ~p°nGIl ~ D, t N ~O ~~ POLICE TRAFFIC COLLISION REPORT ~y TRAfFICWAV Iw¢e cumn•mr HUMFER v,#` iln 'T~l x.~ U ~ PRIVATE WAY 1, ~. Dn,f D, U ; Ov 'rnl + [UVNrr lq/ C,irrq NWA rj y , - .'4. ^ Y.° r ^ ~f ,t .• :: r.n,aC /W QfURBAN ~ V ,~ L l v 1 U4 C U4N ~ .. F ~~ ^N QE ^, cr+w ron.. nao as E ,.. cas . vourto4sra o s t' `~, ~' M;tp ~~ ^W ~~ o U ' n~ W3 94iso ;1u41; r...nr stuF Ov + ,n f^ tf. !O Mltf 4051 /~ ~'~ '1~'y' ~ . euwet, '` . 1¢•pvur .~[- ~ 4.1 RDsrvar D. D 9 T ~, ,nra:lYDVf<^O.. fvl,vv f !.C S.aFr OV .uESrM;I+~ CCIDFNr M4 DwGVAM WEA ,~~ D+ r ;ES 5 j~ MICAGI ~ t +x ltr C1 ~or C,<I. l~"b, CODE r+ (DIIIS~Dnn rA> a4D I v CirK. prKFr AD UR HrtHFNCf .olu,.c ° tD ND n,w ^. rPrtD Os'~:n ^,.~,•. INrt4 cls c4nsss*~yg 4ge9 2 ` ~ t o vra r,ls tD ©g 4°onvrv D.M-Gt rn... eD 76/S ~/ ~ e~ ~ .rzrs;vucv.NSV.ro oe.m srvuu u+coro.EV Sr,AMn vuwMAU s4tcwt coD~f+c ust _ ' ~~ s c"' 6 r UNIT NO. 7 UNITNO. Z Q VEHICLE [] PEDESTRIAN ^ PEDALCVCLIST /T pv vtv Sr+AMI wsr +~° t DvivtRSNAVr wsr ri s M Ixf ~ F' f. pQ c,u ..DD;T I~.,r-stJ ~ c ~-s - ~~,. s;4w ADDataT slvto ADDUtss ~~ ~ • Z Cl T`~` swrt n.<oDr .f NO D ~J ~ ~"' 6AOFiF_ <o No ~ h~.p,.~'~ - uv vrvsnumv aD ,,.; E I .a4 stuns NC °An t Ar po+e vn, - .. F ~fuini~y r~~4.Fz.Nn .ES Wt ea, at ea, E «cuvA, oN M Nu+t a 4aor+t r+o Erts wt ar ae car 7 ~~ ^CHECK (/7 4[rp Aprw+o'°` ^CHECK I/) n(AS aNiMnon 4 "~ '/ ^~' +~~ ° CODFS-' ~ ~ s e,"^ CODES-' ~; I{fps ,F p ~ `d ~~ + ~' ~i"'R °s "' Q • Q i` ^ Eli.,, ^ ^ ~ i'/:' ^ ^ eQ i ^ Eb... ^ ~ ^ is v!a'IAV MAat DODGt Catv., t'DAVtndvAl rrtt lvDR-COr++ v .,DO VFCnFV t; Ca4r uJVA. ,r Wvl v S5 ~'.~.~,~ 'MC.,tPi~l .,s E '„.t.i M~.L~aL<" ~D `- 1`-f L'i' I„ _ I v. a trct4sr4wreN v.n 4;tRnAn NO 4n Has eaov A ~ ; . N. Au a LP 739 lJJ ~ ' rN 50 ~ W ~ ~a NaCt1,D[nl r,CAr,ON NU aiClt sf., '! GCEC 4 1 F1 ~ 1~`7 ~ L I G4AN ~ 52~t~22 ~2 ~ '~r ~:~ T atG Sn4tooWNty wv +~es M~DDU onT NO O 4.sty r+w wsr .RS: M~Dat 4oNE No J NI ~ 2 N ^.: li DDVI55tl Un++ly W t ~~i 'C wuADwuso NSw•anc nwnn E .. r+. .. ~ SN ,7,; ~ ~' AMwtD:at. dc~~:lTti. '"'"' Dun.cED.aw _ s ~ •.o~s ev D e .EVtN -- ca.vet -- r wiin°"roi •rm~ m f• IR :W.. ^atM. r+ID ~:w:+' ^vmArrtD s~DAM.ct ,d:'onDJ~s ~, DIAGRAM OF COLDSION' ;u .M'.+. NDC'~/„ovm DESCRIPTIONOf COLLISION uv su4vttwnru salrt rNlc[ss•a+. ~: } ~} 10 Sattrll Nl:l SSA4r, ! ®OW r b .; VsI> ~ l Wns SC:-~Tf'GCUNr cnr ~F.4V4.R , t ~/fTL~L~+ ~. r.~~EH.; ND VE ii ~~ Gt,]NS...E. » L ~Gsrl./~~ LDFIVER i>CC.EY ~ ~J~ /vC~ 1/Er~. ~i, I/Eli ° l Cr_•~r i.Grv'h0~ ksk~~ ~1~# ON "~:i1~K .ZE~E~ S~2uc.~ ;~6 d~T F~/v'r „ ;~ W. ® ~,. C+OI~/VEJQ p7C l/6 r/• Tr2~ C9JSt/vC.s• BCTN f/EN~ -~ ~:' ~k ~ '~~• TG SPLAU qaT GF C:Csti/~~i,.. ~ STRLKriU~r ~ Q~^,~~ ~ -i ~. f? UZRT ~EMBI~/Vi~htElvT Fi_C~1J(w+'-~ETNE.. SI ..,,, ` /SON, G. . ` p { .~ N ~ . NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I - ~ 3 a 5 6 -: (~ - OCCUPANTS! WITN s"°°'1P1'' '~ ~ It t.• vl iv t r.~ " 1 7 1 '-. [ ' -7 w -. ' `"if,t'', 'Y' ;.~ ~. Y;.! `;l-i' _-r''. , _ ~; ~~ r.9..~i i^ ::~~ ~.5 1., "~ ~,. ~'+ ~ u~. .,w' FBI ~. r sf~1 ~. a1 }rill i ua>~ __ hdti ~ [yD[^ y q '~' ,cv rfl'] '„W.'T 41x-j~i!„_„ ~T--E'_~" .Y.._~~~~%u'";.++rt. s. .... ~~A'~~y~vitssv'a~il4 fm _ _dsi.. ~4°1't.~~~ °~-+"~...--~ ,I ~ J~ ~' .. ~1 WxISa IRfV. I.B01 /e STATE ®F WASO°IINGT®N RAGE ~ D[ / ~, "' ~. No K . N REPORT ®iR">7jFICt{g Y.' COLL . Rala N N tit I ~'y . • POLICE TRAFFIC / s~ ~' ^ PRIVATE W `~ .. '~ .' y~ 'C,: S - DA f Of C 1 i1ME USF ZNDD HOV41 COUNIr TY G ~ iHWA p 15 nD lwH H ~ I .y. . ~Ir4''s" ~ ~ ` ;,~~ pf ^lN arvo9 sow V `NI'N,~` sr~`O ' ^N Lu ' ~ :• ` ~ ~ 9/~/Z~ t` ` ~ ~ :~ ' t ` lfs s pw of ON s PRfi% .. : AUIE L ~a , ~• ~ ~ NEFRSECNNG WIEH: SiRf[109 ROAp Np~ iNi[exCIN)N BEIWFEN SIRfF16 xRfEt . ,~~~ , ~~ ~i U B ,~ 0[SIANCf tD [MI RE[Rf .CROSS SIREFt OR NFP9fSIMiIFROT lE5 5 F N ~ ACCIDENT MILEAGE C DE 00 ~ OAIA _.. ~ '._ .. ~ ~ f ru, '.. i1: ~ T .+4; a rtEi taus NvavEn~. ~R rr. ~NO IIED~NO. INNRED 1 ^SRIIAG[ pHi6RUN y1 //~ .yyy [11D1 ~~~155555yyyyy WN INtt CIS 11Cf QOSSSiN[fl OR ROM ° s /~1 VV )~~.~ tT.^„c~l~ ` OtAI NO. Or V[N U[5 f J pRRGRERiY DAMAGE ONIV .,~• ^pj SUITED pVE~i<lf lS ~~/ ~ ~ x, i. p OBht[SiRUC[INAM OBI[CI x9UCK/JVDOWNFRS NAME) f51.DAMAGE SPfCW OOGNG W[ ..- ~ i -'UNIT NO.1 UNIT N0.2 ^VEHICLE ^ PEDESTRIAN ^ PEOALCYCLIST ~~- ~R' v~ ~ ~,. N9 r DlewfR' NAM[: vs[ MiDa ri Ees NAMe wx v , -C.! ~~' ~ IRfFi ADDR655 ~F ~ xy~e "Hi f•,1, x FADDRF ~ y ~ Y.C ~ D ~, ~~ SlAlf ZIV COLS E i D41vfR5 UCENx NO. Q[ L B IH I n ~ ? 8~.~' 8 D D.. .. V R ~~ ea RHONL NO. [r[s IeHr HE CHr E r avMG Qi~s~-Y C R Z SIAIF R ~ w' `P [ I Sinff xN vE451 FNSF NO. O OnrF CNB RZH Dnr VyryJ..R NNAf 6 RMDNE NO frFS vhlGHf fE ~A".a'~y 7n~e+ 1qq3 X15 l `B ~., ' p CHECK I~ ev EMw`Ir A ° orHfn AL ~ DRC.nI H K ^ C E C f/) fns NfNA °r .eu 'al : n AS e%cv ~ CODES - ~ ] aiifvE ~ ° r ~: CODES - ~ G au t s .sn s 5 r . D . < s ~ i r~ P ~ 2 Hiw F' wol ~ w: '° ^ .,~[~,~.NEI ^ u F ^ ibme ^ ~~2^ .,,. 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NKH ,Alu AD I AJ I `D r I ©DA VIGnf ~ ^ off w.iil I , ,A%ul p ^r I wt^ Sr4VNS ^r I pl r I ^ OO'1a.• SInAgMT AMEAO ^ fME WAY I l~r, ~ . ^ ' rJ 4 .' II q ~~ { '. c L s ~}~~~CC ~ 1 ^ ' ^ G1Y ] ^ RIVInQ T ^ DAwll ^ T ^wEt ] snowvrD ] OUSA ~lqq ^ • ^ T^~W ET ^ T ^ STOP SrGN ~ J ^ TWO WAY ^ T ^ OVERTAXNDAND PABUPIO ] [LD Sr/I ] 11EVERSXA[ ^ ] ^ MAXM NOIIT fU1W ^ ^ " ^ ^ roAD 1 1 { ~ 1~~ ~11rT, . ` y A KY A ^ f00 I^IY~fB~ ^a ^ A ^IUTrNO RID ^ • ^INT~I~ ^ • ^MNtY10l[lTIW1N ~ 4 'Y 'F' ~ ~ll f // `, ~ ~ r ~ ^OINIR FMM ~~GhI a^~~IIS O/iT ^ a ^ lF4CIT Y. ~" A p I ^ ! ^ftAS.rq AMDFR ^ A ^AILEY r^~ ! ^MA%NOU~iU11N NWq ^ a ^ fYl y ( 1:,Iry~,+ l ff vv lMJ ~ ' E ^ 6 rnf T i9Ht! l' KASON RMIgTY'fND DAMYR s^OH [R ^ E ^ M YGN4 llflN WI ! ^ fl ll ^ ! ^DFIICIP/\MMAH lMliS ^ I ^810PPEDf011 TRAffq r l t~1y1V. r ` T ' ~ A1R:,MOw4tr MrA•Elar., IlCr fPFOfY SIOM[DAI BgNAI ^ [ ^ OIHEP r1NCIfY ^ I ^ SfPMAI(O ^ [ ^ IT t~C yy ~l ~.' I ~ OR STOP OIEYI r Vi' ' .' " '' L I ^ T ^ dwOTO ^ B ^ 81OIroED w (gAOWAY i / I I t f r ! i yql. ^ B ^ NO ;I Dff, ^ ] ^ UNONEXO ^ 'D ^ IRN fICDIANE J ~, y ~ , ~ ~ Nb/Mw EDM[S1 KX ARE II 9/NITNO TIgM ^ ^ p MaE01r04fgN ~ ~~~. 1 I f ~ ~~~ Y y ! ~n`""""~~'"h""yT'!` ,«cm ' ~. ~ Fr~l,~ B7~S ~IT~ r'.nl- r I ry ! A y,~t T . I I ~ lam.' I ! I - ' ~_ ,- t ! n` _ J It _ ~ yy FS 4 v6 ~•, ~~{ u •' A - y~ (' 77!~tilA~}: ! w 1 ' , h ~: ~1. 1 '/:'!`R STATE OF WA IVGT®iV PME / DF E No. POIICETRAFFICCOLLI510NREPORT ~TRAE'"'"' .AINfN a, ~ PRIVATE W Y ~ -. ~•',c-,. /. .. A EC l~ ru -;,/~~ I A TIME I.. ull '. n'~ I..V IuSf ]bO NOURI i a S COUNT. Y- t%14REIY ... .. fMN ^URO "I CI OR TOWN NMIE6NO.p51 EIOR MGNWAY ~ ~N QF ~IN ~ IpE ~ ~/ ~ AulES s ^w of ON aJ / INIF RING WITH STREET OR ROM SERION DAESm[i ETD LTAR(y~o f.lf. Rp. Bf1WfEN SFREEi 6 SFPEEi PRffl% ! MSi 'r~._: . ' d: X' - / 0151ANCF6DIRf PEFEPF f. CROS551Rff10R NfAPF IMIlf PO MRfs 5 E W ACCIDENT MILEAGE DAA ' - OF [fl f DC- ~ r' GR II J^j flip INVOIVfD: fq RlllfD~~NO.IN1URf ^SP IIAGF ^HII6 RUN ~i/1'~~ IOIAL ND o 33 D CIS I I (iO3S51RFROR WM ~ / / 1 'y . Oi VFMCIES ~ PRpf4P1Y OHMAGE ONLY `/ ^ FRERSElINEO ^ V NiCINF . ' ~ BD~._ __ , Oe1ECi5iRUCK IfE 1fR STRUCK ANOOWNFR'S NMSFI ESI.D E SPECIAL 0001NO VE _ ~ ~ ~ ~` k~- ' UNITNO.1 UNITN0.2 ^ PEDALCYCUST. ^ VEHICLE ^PEDE57RIAN 1~ ~~, DRrvfR'S NAME: 0151 IIRSI I .. RWER'S NAME: UISi FI I ~• ._.... 5 R MDR C ~ D / ~_~ ~ ~I; REEL ADDRESS . ,, v l + NE NG. 5 lPCO ~ Ilr SlwlE IP DE NEN f , ~~ #' = srA 6 s 1~ Dxr ~ o N No. AIE elRi " '/ /~ S /Y ~ MD I/ '~ V ~r ~ r R. ~~ 7 a M OC CfV ENO. GHi MN:Hi E CUPAIKKI RM NM1f6PHONE NO. EYFS GHT MIGHT '+ i 6 R - ^ CHECK(.') v(HKIF AS~NEMROVF of I AN ^ CHECK (.~ IHIttf ASAN IMPIOrEfp A ~ .''+.ss in ncl ox.r E 6 HO, S CODES - * D n / x s ' / ur i~ HI w„ ~, CODES - * 9 u a ° 5 rx 6 s~„N P 4~` ` w E NR s „ i ~ x ;FIM.. '°'" ^ •••^I^""° ^ u6° O iBM. „HKI~ ^ I:°„I. ^ ^" ""° ~ ue 1 ~ E'S'in O H ^ I4 Rli y"~. vTH. rFM RE IDDDG[.cnfv.l OT1 D MODel1DMI.NOVA) StYV:It DR CprvI ECna dL' e 1 V.I MODFl1DM1. VAI l ,~ r' '° ~~,. y ```lam UCt fN~ SlAlt fPAIlE4MlE NO. SIAIf ~~ H vFH< OR .O k Lk NHKIf IDIMI1IU1gN N0. i, vFHI IF IDENIIfI I N I I ~ `~r_T 'AR ^'~if REGESRRED OM+IR: IA51 FIRST MI f O I RR D :fR: WI IIRSi MIDgE ~ R'~ 1,'1, ' Y4Y ~~ 1 MOR[SSp OAN[R N E vMfR _ . Z .~,.:, I NAMe aAOOnupINwRANR CO. wAGENT ~ ~ /S,S R. z ,F ,. "jtwt7~ NN ~~ ~ 1 a, ~~ A DRAVCf MU o~tAwdu u N gAMME, ARUE ! N I cHARU .,D. 0 •D O~•S lsf 1DNAAGI WAN ~R[MMNID OAW:r ~RIMAINID lSi AMAE 1 10%ari0w - OaOrt AWAr er' AWAY aY~ s A;. '~ t ~} .w. 'i5% ,. foKAl NORin DIAGRAM OF COLLISION: sIUETRNERSSARrI - erAaROw DESCRIPTION OF COLLISION: lusesvneMeNru SM[fRM4ssARr) ~s ~ C' °F f ~ j o ~'~ Tb 7.d€ ouvd / b, dgx ~ ;''~~.~ ~ /l~.~liT ~jIrIP~C ~~A~PPN2R G ~ I t. ~ _ t.~ ~ NAME, ADDRESS 8 INJURIES OF PERSONS I ~ s NVOLVED * CODES 1 - Z 9 4 5 6 ti.~ ' fi, ¢ OCCUPANTS/WITNESSES is s,Dl~D,^Ifa "i E w ai si x>t mE ul ':' RESn. fXR M T HRMf. ~ _f~ ADONis NAiIN d Rr ! r551c1 ^ rvll~. F ~Mri. p1i2:.,. ]0 .. AroREU IW p ~ ManD Nx ^ ~ ~Y T~ ~ " A" No ~ ttwu wA~°~01 uFM er~ ^AMe ^'I°ifA' ^'RD:~i. ^CI'S O n :ly 1 1 ~ RRrISIRiAIfM pIYI OAOC d MI-'' / ~MD ~~~~D R M / WIIpflIWI Mit ~ , ~ ~~ ~ l ~ 1G ~~ ~ T r `: ra ° ` ' ' 1 ~ ~ a " l 4 : , + ~- ,. .. I' .. ~ q>$r~l. ..1~J. l .av ., .. _ ..... W e:;~ ~f A:- . N,,~, . 4' T ~ li (4, J + RI ^ /."' l~t ~~ i C ~. ~~ ~~ . d t Ylm E4r E.. I +h° 1 ~ ~I <;a+ I ~~I I~~F uy[ ~~ r~ _ AE4Ye t A .~1t~y!~ P.xt $ "t ~ 4. ~~ Yt~+ xuyNe Q" ~ ~ ~- ! I , ~'~r., 7' 7J:~ L4 ~ 2 a4 ~~ ~ ~ '~ Y q ~ 1 V PYr ~~ ~.)~ d ~~~~~ - ' ~~ POIICE TRAFFIC COIL~ii~ON REPORT ®Td~PPIE.yAV~~ ra a 2 PRIVATE WAY u [:omrw iNWA R ~. y_utor [I ra ...• ~~ t-'~ra -'t~ Iu5E t~00 MOUP~ COUrvir w ~ Oir pEWA I OG+2S ~£Fo ~ x ~ ent D9 rowN pN pf pN ev s e~ro enw•r y men 3 pw ore ,~,, -aa< oN eE/v ,~ o rN[F45fCr NG Wtrn. Sae[t[O4 M rqN N[[e5t<f ON pauft a 93iso 3 BFfwF[H OO ~ v. fad o FOsatn DS[•NCt6Dpl f CpW SS SI Vf F[O { [t 5 (S PRtflx mgt rOSi JOTS ~~ -- S I 0~ Ffl pt ~/~ ~ CCIDENi MILEAGE C DE •m DA[A ~ COIIIS~ONINV01 [D k vfr ~% O xl[D~NO t0 ^S4 [t•GF ^n[avUN wnoNpi ~~ r IM[q C[S [p06SSIpQi ON ROM ~ ~a v(n C[FS O 0409Fp[r DAMAG[ ~ ^ uF5ur510 ^v[~'Cif J 091[CI319uCxIMVAL OBItC[S[pU<x wD 9 ~ V .f/~/~Q 9 OwNF SNaMFI lSi OPMaOE SpKIA(CODING lht a 6 s UNITNO.1 UNITNO.4 u. nos NaM[: un[ rr9s[ m~DDtt D9~n4sNam(. [ ]VEHIQE~~_ ^ PEDESTRIAN p PEDALCVCl15T U C' /' s, ~IX 2 SlvtFr a°p4(53 ~INc / / ~I,~ r r~ o ' ~?3 SIPEII •DDpf 53 Uar 5 f I~9COD[ E U D Sla v as[«stNo'~LN rv C r.~ 1 D9 0 79G 1/ aC R t le o f [qNt ~ t ~i`R/~i~/YIZ?M !'i? xeu9•NON [ a 4noNe No. G//~ i+9 n iOsc ~'a~E- rv(s e I ~ E .v uctNSe NO. "' t ~DAtfwa9[. I _ 2 na K DNi ~Lr[C r$ ti IS NPiirF. DEi+T, tiF FSHfK. A2 (S.S $ilff R eu9anoN m N a e[wrvf No. p`m't trf3 WFIONa HGnI - ` ^ CHECK (/) c f •s a o o w io °~ N !M t r[[ •r ln[e CODES-' D ~ N. ,.p 5 [ e'"O U4'in p CHECK (/) [n n[as •N eMnor[f or•NOr~te'"' CODES-' ~~ x„ 5[x ~ 5 t+~o ° S: n ~~.~; ro p ..•w.ntr pro [. ^ FSh[• ^ ~ '; 4 .4 w porp°+. T ~ IDOIx;r enev moon loa9r NOVAI ant a D9 coN p 4M ^ Ev ~ ^ Ebar. p ~ ^ ~ °' ~<v /97 7 /~u G 09 ~u t•n SV, l v ~ E a9 f n l moayoa9[ Novi „~ lao9. .I - su[t p•tf9 RaR NO t iv'f£// L 7z2 Wit H ;I nn coop r` ~ ' _ nMat D[NUnu[xxx NO. C ~ I'I 1181E I! S I /I`il I I I 4FG 3RPlD OVmt4 L.51 ip5f a vtnlnerlxNan I NI I ~o MrDgf Safrht /-y-S (~~~ 4rgN[NO Q i5 D VMt9: IASr p Elli MI t R __ ~ •0041350r OV,NtP W 2 N fp ~tl N•mfa•oop[ua~NSwaNffeeo Qa AeeNr U ' ~ E T Sft/ft J rC L~+9000 / ' R N u N 32S T v£ S7-' DAmMi •9u s: '°'"°;" cn•pa ~ a ~ p c~•4cf g•mM[olAxtA s _ ` :uirb~ s esr wM•D[ t~ :w:~ ^ etmuNiD [e ^ D. °we." RtM•wm to rDAm cf o ^ ~ S SJO :°er A ^ om° o la ~ DIAGRAM OF COLLISION. N•t ND C•[[NOp[n - I I__ to Nfe[ssAprl.. }y ~er p~99ow f DESCRIPTION OF COLLISION: lus tWntm[N1m sMU Neens•p f --- _. - I ---vtti/_eF .1__wr)s ,voe'rH~l ~.f or' - ` ... I I i [ f , I . I j __ -- ~1Ni~`.C-_A'.G~._W.ClfLIN GfQ/,1G SL'!£O 1/wiCT -._ 1 ~. _ ~- ff,¢ ._ f...l . _ I I I ' _ _~ s<ekrt~p!t~__t~N_A~.Downic;,c.'9v£_._. -- ~ _ Y -~u/17Pf.O_ Fn at2..TX£ DITCH O~V ZN f ~fS $T .T/Q L - _ _ _ _ _ ._ f. 1. ~ ~ ~ I ~ _.._ ~ - . {- - t . , _ _o~ SE.J_tttC RP ~flf'~E'oX _(S~FT i,v_F_T9NT oF__--- SNL vt~t%iccC ' , . ~ r I t t I t I I tt . ..P~s~rsC cf TIlE._<.FGA~.srrrn ._I_..._' I ~. _. I I I f_..~!r~!/F'H/C4r~_~1lJO THE 0_lsT.ArvCG/T/IG.._...-- VfH/ SIL 2kcr ST pl~ e L ' • I I ~ I DDRES SOF NAME, A, ONS I PERS I _ -. ~ .. , . , /4HZi<t% F.. A...__.- [^ ~ NVOLVED * CODES 1 OCCUPA NTS WITNESSES 'iox9~s[DwD~+ari:im .wi ` 1 _.. _. - 7 8 4 5 6 N . . !pMf^F0/1ICf3T .H1i3 uC7 r / Q ~ [ ' •, :~' utsu tnci :;c ! ~~~-1'~O SS, UU ( q [ N Wont N r K ~r w ~ o +rut ~ '~ • ."i'. v ro .. --_ -.. ._. t Drat `N o ato! a __ ... _._. , ~ µnDr9om p•mp ^"'p^„ ^: b ac M[l5 N ~ aTUt 01 ~-- ~' _ ,cnrr[•3~.wu9. N, Do fc• of V 4 - •o r ~~ r "`~ t . .... QKl DS4. ~CML Kx xai"n. ^xmt ^"„" p ,. p p~ p i° Kt .9p-.T. Dxq On[ro95 V ,:~ ( o Pt,~: ~ - f ; S yz y. ,,may'. _~ ~ _, ~~' Yt ~ ~ J ~" .~ x~ -,. ~' c T I: S~ - d d ~e ~. ~iriilt~~ ;rA7T*I ti ,~. smmt F67 , emtr, v ~uE, h I7N. r s r { l 1 ~ PdM1w41, .. .,.,T..,- r •......'mmRPRPi~?^jF,: irGF~STa~o3!~rat+~`' C„GT4Iryg(4 ry~}.,.yti '~( 'T ~ ~' ~ 'l° ~4.1 1' ~T °`~' u~ ~ r<j7 ,,yj Er~ ~ s ", • l 7 '' '1 a t t P~ t fy ,,rr ~ ~~ t ,5 q„yt,,,7p~. ~ 11 yy~~ Qpprry~ _ r 1 I y 1~ 17 1 .. t':4 ~, .~Z ~ 1 ~tr~~`.:_ n }' I ~y '. w. ~~" r .. ` ~ ~ ~ ~.. , `' ~~~ ~ ~ p~Mr`~ Y ~f ~~ 3T w - N<Fk, f _ ~as (f+ '~ . ~ WYISq IRFV. 1.801 £ i ~~s O STATE OF WA NGTON Of ~ ppD~r ~ No. ~ ~~ w f n ~~s ~`~ q POLICETRAFFIC COLA I N REPORT I~ TRAFFI4y~AY fJrN f ~ PRIVATE W ~ - - ~ - t r -P1 ft -CML N ImE [OUNrY ~/~f ~ ~~ ~'~ ~ ~~I f.2r D ~~ ~ + tl lfr. ,yr IUS[R,OOHOUg1 A ,,.. I ~ ~ ~ .. ^URpNE - ' ~N ^F ^IN CI[YOR TOWN 6NO.OfsrNFE[04 NOHWAY A'~ 7 e N0.M of mnfs []s ^w oP ON 9~/~O INrfeS[CNINO MtIH. SIRffr Oe ROAp NON INEFRSfC110N RRfUI ~~MY2 q it BfIW[fN SINFEI 6 S[PFfr ~ ~LJn,~O ~^"~ r DISrnNCE ION , rROMei N CPOSS R[FION Nf RfSr Mll S pC D,ENT R I A S ~ I fr Z rff lS 5 [ W [ .. A, ,L. N OF ~ fD{ll$gNINVDIVq v[e rY N rOIAI NO NO NUFD~~NO,IryJU4F0 ^SP tIAOf ^HU6RUN IMF4 Cl3 QpsSMETCIB ROM ,: ~~ 1NY") ^ PgP[grY OAMAOE ONLY f srIXFN ~~ O V[rv Cl[S ^RSUIIED ^vFN E '~ ~j.Q ~~/0 !A/ J O8J[Cr5I4uC41NAMFOF CBJECI SIPUCN,NDOWNF4SNUnEI Cl ESr OMnAO[ SPKWC~DING - ... ~ y~' 7 $ R UNIT NO.I' UNITNO.4 ^ VEHICLE ' s Dgwf4s NAME: IA51 N sr MI ^ PEDESTRUVJ ^ PEDALCYCLISL. ~~ DeW(R SNNAf: V151 I I - P s ._ `~ SIPfFl Ap04f SrRfIr ADORf55 l ~ J CJIY SIAM IN CODE PHONf NO, p Ir SrAIF I,, f ~' ~ I [ f' GJ,q ry c R N _ - DII F SuCENSE Srnl[ H ll fNSE NO. AR OAR OFB R[H , ~' R acDUrArH)N i14M NAARIPegNf NO mD j D,r ~~ v FIRM NAMEa PHONE NO. FYfS WFIOHI I G 1 ' } :10 FYES EIOHr KOM E OCCUPArgN ' V-r ~ PT~ - ^ HECK (dJ VEH pf A .N D.no No SO R ^ CHECK (.~ k .. 1. k _ CODES ~' P~ A OF ASAN fMPIOVFf OrArgrrifNA' ~{ ~!. . "'J~.;w, NE Ds. •n A+r~ I . ii..."'r~f[ A Sr EE c~~ . N r a ~o~r •al CODES ®~ ]cirri V H ~ invM~' S IA roH a suin .cu ]t URIRS ~,NC I C V ;F M ~ ~" ^ w,Er ^ zb., ^ w ' ^ ~ ^ "~ f ^ ~ I ^ s~a:NN ^ ~°~^,l ^ uL,. Vfrv YF MAN IDDOOf-CHFVI IttWEIIOARr NOVAI StYIf IRDR CONVI urwe01°OM I HEV.I ngo[f ID r.NOVnI cl fvl ~'^ `+ ,.:~ vN7 Ae IICENSf YU fN s E H.Y _~ ~' ~. rv,. a vntf AneenArf NO raf H nH.caoe ~. z ~u D ~_ . I n ~ T. Ss i ~' a -,T vEHlclf o[NnncnrroN NO. ~ s C vfH ff IaN r cn I NN n 59 it "J.S I ~ IZ i I I~ I c18''. ~ ~ I L I I I ~ ~ I I I ~ ~ ~ ~ ~ ~ T,^^ m~ ~.Er RfGSRIRDONN[R~ IASr qSl Mlpgf NgN[rq, O SIFRf WNE IA.SI IIRSi MIDgf '~ s~,.E " N woxfssos R W fR N N ~ £ ,.. r"' NAMfanoomssal wRANC[co ogAwNr E ~ . ,"'{ ~ }' R I DA. OAMnO~D Mfw St d ~~ '0' Isr w cHAn~vrN o.Agc[ ow`o."D~"r gAMAUOAREA y ~ ~~`,. 1k. ~ w5` ~~~( ~ ~~, I DIIA fAM OF COllI 510N In cr _yyyr4aNiya vll NI'~K:vl:a rH DESCRPTIO^NrOF *LI510^N DW Ilne slrrt^eAUNru sH[[r _frxa55ARrlr D r q, *~., { ~F•; • r~~•, I I ' _~'.- lLE.rYi~'iC___L. [uns_..S/d-a~~.C~E~.!it2_ s ~, k . :, ~ tl. JE .__ . .. d.al__B19f~By.Q Y ' z ~ , ~ .. ;~ I . ~ F,/raufilfeld -. iSY~'Rsr/rsATP~SY / ~2_s~Y3 _JP~_ 1 ~. I_ I I r -. _.- ~.. , ~, 1 ,. ~...I ..._.. .. .. A .,,~• I I _.. ._.._.. .._~ , r I ...... _..... ... _. .._ .. I ".- i I _ .. ... ........._. .. 1 ..T. r. ,.. ...,.I 1 I I .... _. .._.. NAME, ADDRESS 8 INJURIES OF PERSONS INVOWEO P ' ? OCCUPANTS/WITNESSES '~nsl;~^'o"+,,;i a,°w"'i! ~ CODES I - Z 4 5 6 I -~' NAmf sir Acr r.rus'„~" ° Rea Dmr " vwln C.YiI/r'W.E i (~li[t/A.n N• ° ~qr a 31-YV S '/ ~ 6 'q e .w' S, r t 1x~ qa °vL'ii..°rqw.^Ama ^ppAl^~ .^M^Y ^: Vsk + .~ ».Ynl~,.l A,c crrrl..+...lf..,,, x.E O. .rw Nf. ~~ t.rlA`e. UAMe ^.,.I ^:,;: I. ^I~„M '. 1~~ ~ ' ~~ ~~ G.tJO fI~A %~ 3e'<rvf[ //y~gfo o.~A..n~r A,'Y'er - " Io.n ik., ''. ~, "fig' ~ R4 j ~ d 1 f ~ ~ ~ '>Ea ~~ ~ 1 ~~, ~ 7 ~: "Yk. t ~ ~ 5e4 I icr" ~d . - -. .rs'=:+~5.,.,___..v3, _.. +n-L._. _..._~li_~..-.:...n ,5: ve.~:_''~...:, _ p~~ce:r%, _ _ (~ _,1 r ) JEMEC yr vvaLJrII1VCsIVN ~ Gf 2 art _ Q L .... _.. 0 % ~/ , ~ \ POLICE TRAFFIC COL N REPORT ®TRAFFICWAV No. E d1 q,cE A,NrNUV,efrE ~ pAll oral s. rv r N IX nmf PRIVATE WAY ^ 1 o N 1~ +{l, w, Na .r ~., I.E `' bJ lus[~.ao NOUR, courvr. camrr no. arr MVA ' ~ ' ~ f. do ~Fer~sev /~ o~ . ~1 ~N ~F ~ CNY 0910WN 6 OOr Si FFIOR NONWAY O ~ ' ®.~ OW ~~ Cll m.c ONC iM(v5[CIrvGEVnrNerP[EIOR Woo ~1~ ~D ~ Rafr ~ - ~ ~. ~ ` NON NIEVSfCr ON ' r~ 7 VAE QFF1 Cam renlx [ /~J.c_J mul PoST n pp IFl -:.f .. . ~_ BlfW[[N ~'._' SrRtft 6 f~/~b SrRf[r D sJAN(f e p R!(r ON IROm RFfERl NCE CROSS SIRI[I OA ~ ~y ~~ I NFAREer M tf x05 j/ie ffr5 s f w ACCIDENT RAM DIA NApAfA Or L~ q MILEAGE SW INVOI u E Vf xlir ~ CODF y jt' ~, LS a fn [I!5 ~ QvppxEPEV pAmAGF DNIr [D~ O q(IIAGf ^Nr6 RV .uN w IMFO Cl3 CROee e1R[ OR~ROApR ~~ ?{,I s E rfe vA CNt N[ronr E cuv,noN i~PM NAMEe xNONE NO ~yi~«y < I(-O R fns wElcNr r<wnr - r ~,C ^MO (:0 CODES®C*lylc fn ur ASnNfMRirnff ar w Lg~~ f f W~~~~. A it AS N G ~ ,-/}) R,Nnne IRpR~.co.rv 1 r O,v rv I O ux" ^ ~b7e. c0 k ^ C.;.s. 'ash +~ `f ~1N1 e. 1 ~nfV.l A+Opft lOARt.epvAl Yl rl v.l °av ,t~ i,: ,.r[Fa srArE H vfn caoR i - -~ b I A C venleEE rtxNnNU~ n lDf - yi . ~ ~. L'"I iow[o UR[MMNfO t v Br - TALL CI ~ ~ ° rN ~R wEU s o SAC[ a}pT ti ^ OW[D ~ WA - -• o ow I DIAGRAM OF_COIIISION Ie j I I us ~ j"~ ~' ~ Nwuff NOeEn eY S er,vROw DESCRIPTION OF COLLISION Luse suxnfMfNru sNEn rrxetssARrl e I ' > ~ : f ~ 'j' ~- -1-i r - ~ CAN nr~.G E?2t]C V9 E.LEY~ -._~N,~.LUST CUN7)CL'L ON /~CHR t~; ;y~4 rjlcnl' - ~~'~-1 ~ r E~7i. vr~f y r ( ` I ~ ~~ i ~ ~ I "r , E}Irc FEr _ u~~ I V.lE?r.Gf~}-!}/f RI4HI SiOC. Af..PL ..... K(JR ~ , _~ . ...~. ~ . DWryY n...fl. iu f.LC~ Ortti 27r TZY~.. "' _ ~ n , ~ \I I ~... ~ I I L. t .. ... _ . , ..__ ._. ~ ~. ~.. ` I 1 E i• \ i _ ... NAME,ADDRE5581NJURIES u RSONSINVOIVED 'CODES 1 - 000UPANiS/WITNESSES'rw:o "!~„~E^;?~~~ - ~ 3 4 5 6 o ,Dfwrss NO~f_E+ hUY jbS•Y/d3 L.1 A_E uro:'_ °i - RtsrR i,ra «E<r 'cR I r p n,Ml (~'11~lL:Yt ~IIILIn ..DD.E,r 7iE.c c5v ... _ ~.. ~.. _ mRE x. ^AMe Q^5"f ~'" •~N iE.i~.~ ;,'°.,... 73E1'b/53 - -_ - - _ _ _ X l-l7•BS r i 1;1(1 ~~ ~ I 4; ~~ ~~u fi~ ~ t>~~~;, i1'c~ r ; ~ I ~T 4~ ~i x a ~ ~ , ~~ t ~ [ ~ 1: ~ `` - f '-11 t ° Y 1 r, EI , I s°~~ ~ r 1 1; .z 1 1 r. ' i 1 ~ r r [,c~ 1 ~' v ,} ..r~ ''. ~ . ~ I s X~' ~ , ,~ p i$ d [ tr , q f ~, r ~,~~ r , ' f! l ' t S, Y' I'; ~ ~i 1 ~ . F w - x, , I A fl t V .Y n ry - , - I~ 7 t l I ~{ e -1E~Y~i x.11; 1~~, _ ~^` ~ n~ I~ 1 t r ~~ ~~ D ~ ^' a y fI f , a f I ~yy fi~ ~sm ~.- u "vr .p, . ~~~+ ~ ~' r ~ J 1 J ~~,'~~ ~~ ~ ~~ { ~ I , _ ~ ~, 'r ~ ~~ l~ ~~'" y 1` 9 f/ 1. L". ~~f~ POLICE TRAFFIC COLLIS"i$N REPORT ~ iRAFFfCW KEC NiN BER . I PRIVATE WAY DAIS OIC«lls N ~. !. a N ON fun N ru I.u.1 ,p NI Om[ C (USE ]Aro N~DIURI ~ ~ OVrv1Y ~ a COIRfI'/ /ry/p~f v CIIYIq. IIIWA ^ UR{MN RURAI ~N ^F ^IN CIY0410WN f6rvO.OPSIREFIOR HIGHWAY pOUfFOA M,lfs ^s ^W u; ~ct/ryG ON ~~v OI 93/.3'0 IN [psfCNNG Va1H. slRFFi oe NOAD NON INIERSECIION ElWftrv sIRFFI A ,~ slRffl 4RFIIZ MuF POST 7 ,/ ' I ~'°F p J/~ Nu N< NO s DSIa CI eUVECII n ( vEEI OR NFAefslm LLerJSI ACCIUENI .'1 If1 MILEAGE RAMP D RAM MIA • L ffEl n ^ n OP a oDE ~. COIIISIOn INVOIV[0 ,~Vr4t U~NO.INIURED !_- ^S4 Gl ^HIl Nr OIAt rvO RU rv nt' ~~~~ I ~RD N1E Cls IN R{EI RPowDOR RfiFRFNCF CR06551PFfIOR DOAp JJ T aaH afs _ ca«vurv DAMaa Drvn f~NF ^vwcE ll ~~' ..34ga0 Utll[CI SINV'a 1NAM(OI OnuCI SINUC. N+OOwNFR5 rvnMfl fsI.OAMAGF L Y PN S SPFCW CODING ISf UNIT NO. I UNI ~ EHICIE ^ PEDESTRIAN ^ PEDALCYCLIST ~ DNWIVSNAM[. wI NNSI DR z S NAme y Jw s vIfl ADpeEiS !'o G C S~ IRFfI ADDRfss ' UIY If IIPGOOF IroNE NO 4 D Y SAF IP E ~f.pJJZr f r ~ 7G R DRNIRSUCFNSf rvO. $IAIf ~ ~~s ~ Pa Fz ~ i0 H o ozR .p 1 ~ R' UCEN NO. IAIF Sfz OAtFw BIRIH MD Y Y,. p CK VPwl Off rvwmf a4HONF NO Fs WL GNI IEIGHt E OCCVPAII«e RM NM1f 6PPgrvE NO EYES wflGHl IfIGNI 2 ~ -9ck so R ^ CHECK (/) rlaANOnneAl ^ CHECK(/) fws AN UaHDrff«A.mmieAl W~a p CODES -' J w 5 I a ~; ,ICI •" , CODES -' ~ ~, A° 5« a vMO. 1 p f JI 2 a v ~ ~~ ^ ^ ~. ^ r~:R. ^ a. .«, ^ ~ olr ^ zsPD. ^ ~ ^ ~::~,. II ~ MAV IDD.x:I Ully' Y R c :`Gv MODE IUwNI Wval t Orvvl P ~' '~ E .YEAR 1 HFV.1 MODEL IDARINOVAI H Y I1 '~ c w P I ucf AIFNHAIIND sulF sAIF H N I A Il nncaoR wI No. l N,'I S ff~~ ~" C Jv VfHKII IDfN1111CAIlW NO S O L KIf IDFNI fIUII rv V eGISRnD 4 sl Si mrppl! 4HOrvf NO ~ r To c= N O N{ IsnREDOwNFR: lASI rIRSi MIDOIF NO. IJ AD FSS (z R H, N A WNfp l• 'I .r AwnflAOORFssor msuvANa CO DR AOeNI /.. pNAAG10 ARU ~'i ry i ~ R R5~1FSpAlFCCCB'8>i7CINT-'.. DAMAOeD wu N .r x iMU UMpuwwV ~ IOn~s l ,I~VUAwVI ^ ^PIMNNID / . C.IARGf ow ~ _ IR ~---0. ^AWA`Y ^RIAWNID ESI.O ~f ~OpOITO~• 1 ~ 1 1 OWED s wY BY ^IOWtDeY f ` _: 1 - DIAGRAM OF COUISI iiufln NUfsuRYl ae`r :'avow lH DESCRIPTION OF COLl1510N: INSe slwnFmlNrnl sHfn lr rttC[sSARYI Ie I "Q a~ ,Q~/(/C~° .COST ~U7/~iE' ' IN ~OCrSL' G~UC'L cNiJ r r 04r.~ f~tfi/l~CYL 0 Q~ ~0.VG: J r C ~ " I , /I 1 1 e Nr 3 RGVJk~IS/ G ~- .f'.T c~Y92 or ~ _ -- t ~~ lea, v~ _ d T /' NAME,A DRESS8INJURIE$OF PNR SON S gNVOLVED 'CODES I - 3 4 5 6 I a ~ OCCUPANTS/WITNESSES ' ADOw<.~rvA'M Ji~ u. Arr PuD a vR Nln . w iRwu f or iN aM n .'1" ^ "' . ^w ^i2„u H f0 N AMR ; A a mws+ 'R101 r y. I; °'" ^ame ^F. ' ^ o . O M~' ^ ~ N. re f `~~01 of Rr ^aMR ^F."' ^" . ^W ^ ~ I ~, wvlawl al '.IV SIq'evAN. e~DCEw ra r,c. s• olsruc.IfD ~oio nAKFAwr f.opDH.J y owna nlwl - s a Dan 4 f;`;, 111~TTTF `' ~~ 3 v~~n:/.r~y~Y k r` 1 ~ u k 3` Ry ~ , ~~~ POLICE TRAFFIC COLLISYtTN REPORT j2fJ iR~EFlCyAV _ aalu coM~ rN R -- PRIVATE WA/ /~. DArF Of COIII N rMF USE ],00 HOUa; !'~ 8S" W" "R". ~Nl .la.(NI .,';~ 0~3n COUNT, _. ~FFF£f.'s.+/l/ 1 fC CIrv HO {NWA ~ aAl ~N ^f ~'iN CH, 09 rOwN •A,f6N0 O. SiN(t109 HiGHw•V Mus ^3 ^w ^of ~/'wn.D++Lt ON~Rert.,/] £ Ra 9,33/`^D ~NItRSf CrNG VnrH 3r NiEt 0R 90AD NON iMfv``3!<I~ON BfrwklNC ~/ T tRF[t ( ~ $IRftt Yvf t Milt IO31 ~' ~D 3~•NCt 9D~RF~f `ON{ M [ Nt.CeOSS SrNEF(OV NlAR Sr unFRO3. p'3 ae t 3 D ACIDENI DU,G9AM M]A IIO r[[r Q Or r FI Gf r ~ MCODEE eoua~oNlNVOlven:_ f9iF. i01A1 NO NO N,IfD_NO INIUa[D~~ ^SOVtAGt ^HUAaV N ."•.~uD hn , l p IMF/9 Cl3 Rene CCC6351R R ROAD fR O ..A] • V vfrnClF31~% ~v90nR1YpAM•Gt ONLY ^p[SNIFD ^vE~iCIF yN ' (/ ~A / / (pYZIiD I ~ OBnCr 319UCrINAMt Or 00}FCr SrvUCa MIp OWNtR3 wUntl i[31 AMADF~., ~•~+- ~t.t 4- L.~ avrtcts ~Fi[COi vw r ,jvo SRKMI COgNG l6t UNIT NO. 1 UNIT ^ VEHiC1E ^ PEDESTRIAN ^ PEDALCYQIST .~ 3 DeN(v3 NAMf: NS] riR3r Mi E wfe'SrvAMt' N3r NR ~'(~~ _ I L. LL ,ti SlvtttA DRF51 119tft ADDNt35 .~L S1ArF }IVCOp vHONlNO Ir, D v StAI[ Zee OF NO u w ~ , ~c 6"5-3af , R ~ L~ DNNres ucfNSf NO v / L srArt N-tfr to M 3 0 7 2 I V Nt ucwst NO sl•rt RiNIH •• ~ •, 0 Of.CUNAIIpa CNASF/L nNnf6MONF NO FrF3 Mt H~GHi ROJ/i/c'ti" ,Le .ti/ru! t31G ~/(0'~. E R OCCUN4UON MNAM[6 vHpt9f NO. Erf3 v]e1GNl fE1GH} ^ CHECK(/) wN r ~ CHECK(/) vrH~at AS:N eMaiovtf 00 ANOtHwMI a CODES -' 7 ~ t w I as",° 3 CODES - ~ 1 ~ 3 o e y.° ' - ]} ~ 1 Wit3 Nl iN1U~~ .n v N1 ~ D V KU VFH r(AV MArF IDDDGf.CHFV.I i9ff0 CrF.°C ft IDARt.NOVAI tF 1]D9.C V o~ C/Sa //e._uo E rt•9 a I DGt.<HF V.I MODtl 10ARr NOVAI I ~ V.1 '-x N N9A It .itf90.An NO 31•tt H vtH CaoR l ~, , VFH CIf IpfN}IBICAIION NO. vFHI<lf lDfNtIH w IN iC;zl! I/4'SSz 117'9131 ! i I I I I I I i l' I I afeanatpowrxa lnsr IRSr M~DaI eHONt NO O tan to w+nR. Wl nasi MIDae f u AppRes3aowNfe N A wNTr fv - l Z 1 E •, 1, f•Appatssn~HwaANee eo oN ACfM Nc,r,'z R I "~ D•MAeto•ae• ~ /'JCNa`. ./ ~ ~ AMACfD ARu ' .Nt,3 cH•act ~ p .r cH•RCt ~ ` g r .fl a ^,°(NAi°~" ^al . s Is D o rD. w.~AC~ D ^,°fw•r ^amAINtD es~ S.~;CS ®lowl 3r ~ 1 G L ^ rowfp f • r 10 - DIAG11~'A OF COIIyISION t D IND Un oo _. t~~ I.. -.I ~d Nf4,a.o 10, N O SCRIPTION OF CO N lust suR 1 lsHtn Wass DE LUSIO n[ 1 _ _ .. _.... ._ __~______~ _ . A WL ! 1 ~ f£ i T~/ _ . _. ... .. "_ ~_.. / 1 '1° f -- I ~I _ ~ £HIf 1 .__( ~ .W~~ i}r l)a]Nl//~__.~~/ .. __,_ • I ,_ I ~~ ~ ~ I _Ro~'4'•ixc..~~na:0./CEVC~ ffe[ ~f~~EEi~OR~'v_c_ , y.. .' ! -' ~~t ',..... . ~==• SF.F T/]'E_!4org0 STS(/{(TN4. ~ ?Rtr ._f+il?tf T1ff_._._. ~~. { ~ \. I . ' t 1 J S3t/optR S/Di of._Y~N/C(L~GtU7/VS1NSt_ 4fF_._ . .l ` _ r _./I I_} ' ~~yy,,tr opt I ~ .t p ~ T/K2 AA/lI. ~R lu..fJG:.F/r~+c oh' /role ~OLVER _._ part Guy wi/('r~., _ _. .. ._ _ ~" - _ I ' ~~ NAME, ADDRES58 INJURIES OF PERSONS INVOLVED l ~ * CODES I - ~ 3 4 5 6 OCCUPANTS/WITNESSES ioc won~otiu r~i•w i~ C: su :ci u3 _ '".,~„" °,•' ;' ,FVa ~Fnd :;~;~ t .~ N rntx ruNta a t+e. C•+ 'e D~`Lt'O '" . O~ iCd'N, •wr q 10 •Or1115 !~a p ~ µv1U r,DM ^• oxa' ^ c . ^ r ^i' ~ "'r wl rx; ~. •re.n+ H9fo lb u n ,a~.i°nr ^ •Me ^ N u ~.H~ n N., ~ ~.:", r v - .. a,., „wt un,^,. _.'_ _ .;: ,:.• In 4yi t.. .. -/i c. ~`f''i~. ~ ro 1~ ,( tin( w..+ IY /i n71 l \ _ ~, . ~ ~ I 71lFaT'~p~A41••rYG'9Yfa5pRji! tn. J,x,V~gR Y{al` E >r ''~~ ~" UU'~L~~ ~~ ~ ~ l ' ~ a,1.-E°n ~ + ~. axrrw+.n,..,_ .•..,,r»+ +Rn~e Y •'^x y'~~ r :: ~ ~~ ~ ~ I ~ ~ ; 7 1 : I$"fYA loU l S mJ Ncr x 0~ t; 1 Super INTly 4 J t 7 1 J ~' ,l' V L '~;'. . 1 i., I , ~ r r t r i f i r •1 tit f .I -.~ ~. ,l 4 L ~ ~ ( I ~ ",1. ~ ~., :1 ~ ~ `{ _ t II I l { 4+ ~ ~ 'Yq ~ , . •1~ " lt'., _' ~ ,' ~q,.. tr ~A ~~ POLICE TRAFFIC COLLISION REPORT ls! TR'QFOCW<' Kac Nr I ~ PRIVATE W V ~ :I ' D•.f 9icau 0'3 P18 , ~5 _ __ iRl; }~ ..',u.' uME Eusf R.DDHOURI 2334 cou"rY Jefferson mle1rcEa. nttfa. s eu- pN pE ~IN OIYOR TOWN NAME aNO Of slRffrOV HIGHWAY EMlfs ps pw ^of Hadlock ON lrondale Rd. eW %3..ZS-O INIERYC, NG VAIH~SrP[[r OR 40A0 NON INrfR1FCNON euwffN 4th st srRm a Market st, sraffl aafflM MRE POil ~'g'!~ ANCEaDCEM iv0.M REifvN f.<ROSSSIREE RN[ARESrMII[a01 OI lfl 5 100 lair E w of Market st ACCIOENI MILEAGE ~~ E 6G'~ppE ~~ RAMV D MA COll1'KRV NVOIVEO SO +RUiO ~ ^SO IiAG[ ^HIaRU NO. NNRIO N f ~ ja ~ \\ •aTalyrtywE,, IMfR 1:13 WOSSSfRIfTORaan ~ RS '~_ _ , a viwfc+IGES ' 2 aROafarr DAMAGEONIr ® ^ aisulrzD ^vi°Hlcif `~~-// to SG60 R~ ORRCI SIRIK[INAM[Oi OBELCI SrPOCA AND OWN{R'S NAMfI f51.DAMAGF Fence & Tree PNWB TX Box Scru 5 SAFCW UNIT NO.1 UNIT NO.Y VEHICLE ~•'•"^PEDESTQWN : :QP/~AtCYC46T;% 3 ". RnER'1 NAME: 1/Sl NR51 MI Dlk Compton, Ricky Dean RW[R'1 NAMf: 11 I i66i None parked in private driveway _ n2 SrRFEI ADDVFll 735 Blaine st Rlfr ADDRfSs on sun zlaeooe oNE NO Port Townsend, Wa 98368 none D R r srAlE Lae a fNO. 1 ~^~ i NFR'1OCENSf 0154941586378518 llArf MO A M A N MD a 08 !07r !63 ( V Y ll ENSF NO. A ~ A E ~OrF~ aRl :, ', ~7 OCCWA,ION MNAMEeaigNF NO FvES IGHI HFIGHI E occua,,noN fIRM NMIE PHONE NO. EYES NFK:Hi {EIGHT Y+". Z Dair Valle View Farms r 13 R p CHECK I/) YEHICii AS nN rMViorif OE ANOmfeM ^ CHECK(/) fASAN fMHOV[f of ANOmfRA` v CODES -~ ] ~ t i 5 1 a ^[',° _ CODES - t 7 n 5 u d y n ~ w li1lES ~ Dlarsgf.o p ..NA.N°f p P6H1. ^ "'»K~t ^ "~1.1. M ~ ;: e ^ AMeMANRi p R ~ ugEl ^ EbmR ^ h~211 ^ i.9~ WH VtAR MA[f IOODGf CH[V.1 MOOIIIDARINOVAI SEVI[IRO CONV.I H.r R I f{H V.) A•OfNIIDAR NOVAI I ~ aOM 64 Chev P U E 76 Dodge Van 06000 m v H. OCf vlwrf SrArf iRMIiR YIAIE NO. siAlf I'I of H.COIOR ILFnSFiRTEI~ ~$tti[- fl ~ ~ Whi Hlue LP74 4 W I' tan XA 9082 Wa veHKlela"nrlurwN nK1. ~ vfH CU OfNnr1 I l+ - I~ I I I I I I I I I i I B11! 6K(Jl 60~ ~ ReasnafoowPEe wr iasr MIDaI vHONE NO. Compton, Loujuan ~ IaER o wNfR: lsr rlRSr MIDaE BROWN, Douglas T. 385-0545 ~_ ~' 1 - ADORESSb OWNER same as driver N E i WNFR 821 Irondale Rd Hadlock, Wa ' -~~ %': NAMfaaolwnsa mwaANCE CO. wAGfNr none ~ .,. R I, + unknown at this time n ISUAACIOARU 1 N M cN• DWI F N i e d eNARGe °wciRaw MR~ IiAMAGeo Aau , 1 l1r OvAAG[ vl r010f10~ ^ ~ Ar ® REMAINf O f erOa RIVIN ISI O pAWAY QRfAWNED IU~UIIOii 1 s total °N':° .wA er~ ~ rosaD f300. Aw.r er. DIAGRAM FCOllIS10N~ _ IM fu "1 -'~ - ~!_.. )~ rl _ I iv.luR"o°Mw l" DESCRIPTION OF COIUSION: _IInE SUrn[MZMrAl swnrtieaslulr) ~ eh~ le ill was s on the irondala rd and failed ' ~ , I to nGgioate the curve leaviti~the~b lane _ _ ~ _' '( ;.. °~ ~ _ ap ro x 120 and st ck a fe c th hi l t .. E QO~ 1 ! ~ I _ _ ~ - _ ru n e, e ve c e co d t ~ . _ ,.. _ _ _ __ . _ F __ _ _ __ _ _on_an s ruck, a telgPhogB_b41S1. 7Ctfl_an3 monde ' ! _ uP .bY hit:tin4..~2~tehiole_which_was_FarkeEa a R, rr,~ . . _ .: {~•~. e . 1 ... _ ~I owners .driveway. The._vehicle_.than.6acked_up leau ~ _ __ I I , in9-.12 .of__tire_track~.from_the_N2 vahiclo._Dxiv r I _. ,. ' ,.1/ I ~--. - __ claims.ha_did..nDL.atrik~.&2_vehicle/r/o_notad- - t i.. ~ 1 _ _.~ / I i I f .i ~ ~ ~ tracks..lad.tn. the..tiras_on.t cle,- ---~~• -- la NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ~ COD ES 1 - 2 3 •1 6 OCCUPANTS /WITNESSES ;" s"aEMIwM>H OR ADO~r R>NAL NAMl En 11 _ _ -'- - -" 5!M AGI If „ Rr~H - - R ~w "" FSIR - " 1lCi Milk µz Douglas T. Brown E'.o 385-0545 - M 39~ 6 A DfA'1» 821 Iro d ~Rla I„1 ARA er e ps5" ^ '+' • ^ :: N Lou Juan Compton .lone ' 2 1 3 ' 1 1 • 1 U J NrY11DwoM p.Me pC:" ^"I p;.° p N AME r;o Ar„er o, Scl.. e. •Me ^r" ' ^io.n. ^:i: p :° -- «~,~c.l •~.c~1aLr•,.w ........__ I`H1' ~yC"~A R. M. fin nos Da ut A ~ • "ro •n 7, wlu. 5 A In,.r.¢~rc 3,~,(~Tr •uEKE .R.~HD 2rT~~~r uula Rlloaf 5/9/85 DAn 5'i t c~'3 t .~ , - . r l ~! pr. 3 s ~{ r$ f '~ ~ 3 I+`. ~ ~~ z' -t4 u.. ., ~~'~ ~ ~~' a ' w ~ .~ ~ p x t '"; Y. ~ y, ~ A ~ ~~~aN . g «• +' ray: STATE OF WAS iNGTON ' o Gt ~ L ' No ~ f-- '' f ( ~ • POLICE TRAFFIC COLLNREPORT ®,1RAfF~CWg7.i'~s . ~ Ra¢fc. ,Nt~r .w.ef ~, PRIVATE WA1~ r `}~ ~ oAn ar au MD o SS V Aro wx va Iu f .`. ~. t.~ rms Q I /~rV <ouNrv CF o C cou /rrvo. 4? crrr NO. rmvA vAl ' r5r¢[tr OVHG«Wn+ Cr.OV rOWN N Q E ^ NhNE y~ LS S RWrf 0R 51 ~ ~~ IOMIf1 ^~ ^w 2FPr l1~ ON CG D .~' }} N rfRSen NC VnrHsr¢uf oR RO.o .~~ ASONti NAE- C - [2.p RfN% Mnffos} ' p 1 \\ S}vFEt e[iw[f / /~iG p~iJS1A~N~.ESBDI¢f~ fIgM RErfRENCf C¢OSSSIRFFr 09 NfpR[SIM It v05 ~7lJLJ i(fi5 N e F W^ O. ~ CCIDENL ~EAG€ RNAY IAG¢AM [M}A COIL SIONINVIXVfD vfv tr !1 r6RV rOtAI NO. NO.IIfD~NO INIU¢[0~_ ^ YIIAGf ^" r N ~ ~~ IR?{DNR n~Ap IMfly GLS O / v O¢RE1EH IOSSerHEIORIpw In OIfN .Rpgety DanAGf ONir y UVFMnIES . ^ e[SVIrrU ^ [ ClF V D rX '~ [Cr SIR AM[Of GBIfCr Sr¢Uj{uFp Owrvfvl 11 (.. ~_r~ .~ Si.ONAaR(I sPECUE CODING U6E ~ l3 s . ~. UNIT NO. 1 U ~ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST -~' ! wfv5 HRSt MiDUIF CKK F¢'S N4MC IASI fIR ITnT-~ _ a srvffi ADO¢f55 ~ e14Efr D¢ESS ~ 7. arr surf zlRCOpE ."oM NO D slArf zIR R '~ o¢IVf¢sueeNSE NO w~ ~1T sun E. o Horn IH t"o 30 95 I ~ v ~ ueENSf ea. sun un e¢rH ~ ~. .• '- - z R ION NEN IrFS Wt GHr MK:Hr ` e s6 FE s~ E R occwArloN {I¢ F6 PIpNE NO. FvFS wEIGHr .E GHr ~ - v ^ CHECK (/) vF«cif AS iN F,M.IOrFF nE ArmiorM~AI 5 f ( a VO ODES -' ~ ~ ^ CHECK(/) vfH AS.N Em.iovEE OEA ~ CODES - * G ~ R ;; 5 fn a M° ~ ,}} H s , , ~ -- „ ' F 3 : ~w, .D. ^.mN><."tI ^ ~.[I ^ ~~.II. ^ ~~ ^ ..'Nrv u,~'~o..DM ^,mN,I..~r ^ za:R¢ ^ ~;KI~ o :~~:. ~ Ip fWUGE wfvl ~R'4i8 ~no~oTA oou DnRt Nova Nv 3/~Toa E " .w I f. «fv.l auon¢r.NOVa r I vl ""' ~ D ' ~uNSERwEN Tew~te HArENG sun w<. - aE - H N ,A 1I veH CaoR of ~ - fy~ '~ v[HCIF IpFM iKAr CwW EiN Z 8 t 3 S S 1. Z. L vfHKIf IpEN11rICAl -{Q ¢ECSnRE° w usr mmolf o«DNE NO O I nRfo wrfR: usr EIRSr ENO. 1 ~ ApD¢[SSOr QYR~E¢ Zo ~ZY ~A e F I. AMf aAOD¢f sn mwvANefeo.wAeeNr R IN AN 1 D/vAAGfD MEA ' _ I OMUG MEA • r1 ~~ ^ OR VtrN vfmmMU ~ ^ ~WmArI ^RIMAIN[D 10'MD E5r p .wAGE Iy/[~~1L1p• D oi1D~ ' _' ^ i~D Ar ^ f ~ ' DIAGRAM OF COllI510N: u f. E u n~°.u'ow°I" SH![i N1C153~¢rl : DESCRIPTION Of COLLISION; lust wROl[MfEluf sHEer lr Nee[ssARrl \ O ~ VEkl.~l "TKAJElawi6 o~N A sc~ R~A1 ~ LEFC FCAD °N AFT SIAE , . ~ _ 1 e.~o ti~~ oci F3c~AK~. MARti , ''~ E, ADDRESS 8 INJURIES Oi PgRB ONS~ PJVOLVED ~~ + CODES 1 - Z 3 4 5 6 r } OCCUPANTS /WITNESSES 'rro AD¢D,i;oNaa':m tsi J u. .cf um ~ „ r nuR ufn ° H,m, so`~N S. M~oJ~w.s ".'D 3gs-23oq S l wD.eu ZO sN N.rw a ---~~ xlNrer ^ AM e ^ fYsK' ^^" . O H'J ^ :44,. NAMI .o ..~ ADDwss NatD¢Ea ¢ fia fo,rRUM ~4Ae ~Iwcy^ro . ~ •• 0 :° ° .MI No +ooen Dvza xlNi er ^AMe ~<. •.~«II~ .ON ,-Q :° ~ .~ a .,c cvr Kl.s M e.ocfw .c}x. ~SKE pys2rc«ID r 'X t. . '1 iC' Tr.... .. ~ (11V(7 q Jay yno p.na w%4r .Rypv~. onn (1141 -~ ~~X/J .. .. .,. ~~ ~~:~~. 6 ,{~ ,~ r tfr NE_ 4 ~~ ~~ v ~ ~ .. ~. RG E 1 ~n ~ T,S {5 ..ti Lfi >~ -7 mil ~~ -~ ~t T ~~ t t {9 % ~ I ¢~ ' . ~. ~f. r ~~ , 3 R ~ ~. ~ ~ l~l °7 F b le`/ ~^ ~ } ~1 ggapryy CA'fR. ;a ~! ~>~~ "7 ~ y ~~ ~< ~ ~ u'~. ;. . -. ~ k + S vv ~yn .~ ~ •~ b •~ iiC _a.' /• POLICE TRAFFIC COLL~N REPORT ~ TRAFTICWAY - ~ RE iNINUy,eER PRIVATE WAY L ~ DAR rCOll vJrv = DAV r tl w. a4r N1f r 1 IiMf IDSl 1N0 Hit ,UV1 COUNt=~ ~ CWNlr ttl~~N /~ CNY NO. 11tS A ~UR AN Ru ~ ~ ~ / ~N ^ N 1 / C 001 t En O4 NGN.YAV ^s ^w/O GEC'yV/ 4towN oN NAM R M,u PCi CIS Cr. ~1 vWRO45fvE ODE ~~.~~'C SE i ~ RvSFCI NG t 54tH O4 ROAD NON rv1f45fCDON/ ~7~ ~ uQ N tGf,4 w iwf Pnr1x [O. Mll POST ~~ ~ 7 ] t Ds1ANCf SD Rrc r 4frtRfNCf Ross f t n MitfS N S w ^, I n~~ O l:fl l~• S~ R ncuoENE MILEAGE CODE yy P DACawM wrA ~ R CI s EFI094DADOa ISiERfNCE 1N ` ' ]] FD COIUS ON vOIV fvFR11v ^Sp ltAGt A9V NO RIII[D~ O 1 [D,~,~ ^N11 N IOIM NO ` ~~~~~~ .UraRf11fM51 N E C D le CROSSS R$).R~~ G/ ~ ~ . <If Or VFN CIFS ©r ^ ROMRir DAM Gf ONIV ^ of 5U11[D ~vF~ .9 ]SivUC91 [Or OB1FCt51 CR OwNF 'S ~ i ~ I~lon~ [St DAMAGE 5 ~~ SnCNICOD NG USf UNIT NO. I O. Z ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST 3 nav D¢rvta'S NMAE U5l D f lwv 1ws M~ ~ j/ 519FF1 ADDRESS / / ~ PNONf NO D FFt ADDPf55 SiY StAif tIV CODf PNONtN cn~ t if zw coa R URrvfa ICFNSlN S1At{ N t OiB 1 D q I v[a t FNSF NO s IAIf 5t. ~DAIt Of BRINv N/./~-// . `~J 5 OCCUPAt oN 1! GNI rE5 Nt1GN r E occwAt oN M NAME 6 vnONF N0. EvFS NR GN1 1E GH1 / R ~ CH CK (/( rf or. omfe ` ^ CHECK (/) vfN of As AN fenaorEf o ANOtNI9A` 1 " yqj / n CODES -' ~ t 5 e ;" CODES - ' ~ ~ S • a ; ,~ ~~ p .MR,~.Nn ^ ~ K1 ^ rs,11R ^ ~ ."., Ia~>o Y 1 ^ ,Y ,.,E1 p fC ;;,t1 ^ 7`D'P4P o n ~; ^ ~~"~ 1 1F 1404 NOVA P9I Yf MA.f IDODG[CNtv1 wN aj~/ / MOpfI ICAn.NOVA1 5]r!I) C vl f/ ~j ~ E Ntv.l rfnv . . DFl ID 1 '~ I «~ CINSE PIA tNO AIfe RA1f N0 SIAM StAt E'I NCgC4 N lA N 1 AIf NO. Alf ~ l ~ c vFNiClf 1DfM 1 U]qN NO L Y ER fHNirGAD NN ~J M1pgF RtG SRR Owl. v: ri051 ~Rw.~ PNONE NO O W SitRf OwNFR. tA51 NvSi MiDIXf R fNO. 1,y ADDnua on++f9 N OwNf9 " Mfa ADORt a NsuRANUCO wACENi R "u4~,£fZS35z'LFFf-- I A / _ D,.nvee R+EA ' . ~ '.• g wfo fA yu'Y° cNA9~ cNP9cf o`;i:o:i1 ~a 1~_o :vN $taIM.~NfD - ^ :wAr ^Rtm.lNfn fsi DAMAGt tnD.: '~' • ] ' ^ Aw te:aaa~ 5 O ^ :w:.Der ^ wwDev 5 • ] DIAGRAMOF COLLISION: u urIMN uR NORt, D~EE155CCC)RIPf'IO\N TO~FCOL11510N:1~//}y~us swauMfNt.l sNRiDNfnuA9+'1? iNff Vr Nf` [ 1 er ARROw N~~V ~ ~ r Y W ! ~ VGL~~ ~ ] jL 'y~y7'~~( O~ FlG7.S~C..N ~~~~~a~i`i LI~ ~! / ~ - ~ c ~ ~ / 77 Cu~S ~~C~ ~ 'I ~ ~ .I /~~_~~iCdi ~ • ' T~ /~ ADD E55 8 INJURIES OF PERSONS NAME INVOLVED • CODES I - 2 9 4 5 6 , OCCUPANTS/ WITNESSES '~~~Dn~:i ~iASei f ii -1 sr. Acf t . n ~ t, Rfsw N[Gi ~. AMI ~A , 1 •nwtu Dna ^.Me ^"S"' ^ . ^"A Apt ~,~ >o ADLwIiS lief d , t MG4fD1aGM^AM, a~;41o" .oa b ,w N I •DORESS I6RI G1 ns s nx nr ^AMe ^ : "' ^;"i;.1r ^'.'~T ^ n ~„P Dul - 4.rurc.e.w~ 4I ~ eaA~<w rt NCr c.KiDn4urMD n .. ~, ~, _ .PEOCJT ~ ACf AR4~yo DAna nro9t ~~ .-. _. ,n n .~ sA r'.,• x ~{ ~~ P~. X'N~ p '~ ., - "e ,.. ~~ ~~ ~~~ ; ~ Ir~4 i . y .k ~~, t ~ ,1 H l ~ t - ~~ 4, ~` :;~ ~ ~ Y3 .t . ) r~ ... r '!ly+ ~ i~ . B~1Y ~'~Y~E~~. ~..,~f~J~~ `•° ~ YU "YaL J~'~N ~` d "r8 ;t~ i~ u~i~ "~ rBE'"°Ir ~'x~ `.' `'~ ~~t .. i .,. . - ~ .. _ ~..a. .....r . U ctWw.a:v . ... ~ WSP ISR PE I BD N ~ t~, ~ '~~~ ~' ` O STATE ®F WAS 6VGTOFV POLICE TRAFFIC COLLI51 NREPORT AGt ( GrCC~ No. ICEC ~ MN BEN . I V. I ` ~~ ~ PRIVATE W S'.I ~,~ Gm J N 6 .] 1 y]", ~ ~ AIE OECOII OAr r •v Wx rxH n14 rw4 Nr t.r rn• >( 1r IMI IUSf )RDDNOU41 1010 COUNiv ..1 F a CW rv CIrv NO. iNWA ~UNBAN RAl ~ ' ~ ;/ +I "1 r u '. ere (FS "~ ' t IY OR TOWN MnEB N AvEES OS aW OGE H+~dLCC~I~ ONC 1' O.Of 514 FIO4 HIGHWAY ~ IS 40U1 1 9f32S0 y n~ ' t~I..ett'~ TMTMpp?(({~1 ) N1E4sfcl NC Yn1H sREEl ox nono lr R[EIUENCE.CRO5 E4 Dr51AN<I aO Rt m NoN rvIERSfc11oN 1 Bf1WFFN (19 Si4EE1 eOId I Y IxFEI 55ER1t109 NfA4E51m lF Nf1 ACCIDENI Pang RMV E rlu rose p./8 OI AM MiA /$ ~~~ & : ~. .,~ '1535 ' A Ef5 s iF[1 [] ^ ^ Or IIE1n ~ I MILEAGE Sw 1 ~•O~gfEHNUF ,. /]) I , ' ~• I CIXI NVOEVID OSp1llAGF ^H18RUN RuIU_ E 1 ~ ^VtNE [ HS :nro vr11"s OI•- Mf CLS Py I/ f:ROS55111E[IONROM ~GD Z ~ ( ~ , IX VDrC FS PxGH41YDAMAGE ONIY ~ ^ UEIFD t .1 3 ~ ~ 9 OBACI5IRUCR INAN UBI[CI SIRUCR ANDOWN[RSNAMEI ESf.O E s $PfCIAR CApNG l6E (d'~ UNIi NO. I F O UNITNO.4 DR Vf45NAmf: VEHICLE ^ PEDESTRIAN r14 IA51 ^ PEDALCVCLIST I ~ ' '. ~ _ 9 DI O4IVExSNAmf: 10.51 r451 I /~ j ~ r~ t1 ADDRESS 5 s]REFt ADDRESS ' ° ~; R 183 [.otscw ]a~E~ P.o. ,1Ad) ~0. 17 O CFJM17~ /1d &~ I ~ .f ~ } •~ Z SIA)F ZrP CODE NO _ PI I IOW S WA `~83F$ 765-3319 D R I ~ BAIE C N/H/iG.u1M CJA 98325 P . i ~ i "~ ~ ~ ~ 1CEN5E B91 Z K3 SIAIE c.aA F FA DA ,nD 1 i 0.a HrR I ~ U fNSf NO. ~ ? o /"Z f Lc19 M DAif Of BIN1N !l %9 5!Z ~ Y' i• ' ~`';~ ~ H„ '.~' ~ ' ~~ ~ 2 R OCCUPATION MNAMFe PHONE Hp [ ES IGNi NGH1 eILJ 13S db E R OCCUPAl10N R NAMFe PHONE NO 5flF EYES GHI ~ z : ~ ' I^' CMECK u ' CHECK (.~ Ar~oNnR v]HC vtE Of ^ (~) HICIf AS AN fmAOVffOrAE pliYe k Y V CODES -~ ~ c S5 5 N«rw e'"°',°«• J alo" CODES ®~ D ci A Rs+ H10 SEA 55 " ~n .01 e ~ ~ / )> y~. - Z - RfFvsE.o T,ew(n r DES t.t. e1. N, , ~ ~ ": . "~ n ~ .,." . I ^ ~ ar~E CONY l O 18.11 O ~ "~" AP a 5 Pa o.n° u ~ ~B: O AA,,,,1nrKE Oro' ^ c ^ O ~m K~K~ O ~ %~>o ~"' ~ ~ ` $, 1D FAR mA[f IOODOE C_IIEV I Sxeeu X79 MODfII AR1 v I )Dx ~CGNV I AS col 1~lDr E ML ID,w1~NOVAI I V I M Fo.~d ,L"/So 79 1) R 1 P v S~ ~ 1 00 , 1KSNx PrAn NO sole IRM1[x RAiF NO. 10.1E H vfH.eaoR I EN . A w / 662 A I ~ /uE ff 7755 `/ G.b9 A F~ R nKlt DFNIIHCAI ON NO 6 6 2 7 L __ V[HKIE DfMiG T ~~ •:~ ~ ''C4 ~ ~~ RECrsrt4EOOW+xfR IA51 rrxsl mloou ~ PHONt NO. O W WNE4 ml IASI rlRSr DOTE 4 ~E E ~ I .. a, ( ~ ) ADlwfsswoYn+IR A t4 (~J r r . a ' ~ ~ Z N ,~ ! m , t - + ~ ~ ~ a DDRtssa lNw4ANa co ox AGEHI ,M / inn R AN a 1~,9 D ~ r.oA1-~e~ ~) ~ t R;,:%. ' , T . wACio ANEA a , [ / aMVreeowREw .~ I. . ,,,I . T .. ~ 1ti ~, ~ ~/ g rIS L '_~s I u n4u._ r1xEmA.nw A4ct nD... n,~A,AND N IDAm.ui 1~~5 ~ 1 ', J I Ut1.'~ 2 LJRaS µA.1 +~ P-aq,~4 i-ur.., L:.,~ '~_ ~ IA;.WiI.Jn t'11d f'lou r Ado {~6wcS; utl. ~l fO~.So N~~ 5 i12 f -5 QSBATt~, 1] 1~u.;w'~ I ScHrc~o ~Rd E.+a: sE Tu.w DPI . ' ~ IB ~~~ QDS No CK4! GE~4Jr- o,-. +~ 2 .4J/ Ctp~r' 4dasE "' c ~ MJM1iE4j6 ~e PA -~ I NAME, ADDRESS 8 INJURI C]CCUPANTS /WITNESSES .,i'.~ NAArE,ESS~ .SCOTT' 0...r ~IPI M 1~{. 3 W., r __......__....._.~_......~_ .. t CI Sfa 3 4 5 6 I ,5 PE S19. Ill /1~3 ^ a rs„ ~r ~ N ^ If0 I / 1 fOR ^: Ale 4 Z 15 N i'k~`:9"t~ Y ~,vw, irk` LM` ry tT -.:'l°'P" 1 "r n" r,~ A ~ i~ t, ~; In~~, ~ i~AdT i t r~Ft~ ~'f i~ 3~L,nn""t 19Y~~L~,~'A~~iS i3T ~~ 4d9re F r s~~~~..171~H 1 .1• ~ ~ Yet ~ I ~ ]x i ~ N'~'~ ~ . it ;I ~ _ I t ~y~ t:~r r:r r $ u~'~^r r' u, ~ 'I ". ,~ t ~~f ~L , ~ ~5 ~.~}r ~~ L H ,.ys( :n~~ )' ~ r + I. 1 , ! y1RAri N. 1 1 i "i( 1 .~ Z ~+Y I~ ~ LI Z ~ L ~ ~`~ 3 n" ~ ~ 1 '~.~~1 ~ ` W1 + ., 4 E ~ 1 ~~~~ ,,,; r ~s°. EN L .gip ,ti( ~.~ STATE QIF WAS INGTON, ~R~~f ~. ~eE 'j JJo. •_. ,...,.,, ~ s POLICE TRAFFIC COLLI F NREPORT ®,TRATflCWAY MNUMNA - ' ~ PRIVATE WAY ~ 1 . 9Ar( fCgEI IMf ~ <ouNEY ( ` .'~' I o. I ^; ~ -I. A t il~tf•~ fu5 D9ttlDHOURI .,Y / ~ II ~.. ~. DENONI .y ~ 1. Z. rIU7 ~I ~~rX lxto lwa i ~ {f7s ~L~7~ft~ie$N9 /~. .: { p pf ~ CIfY OR iOwrt NAMfeNO.OESIRffi OR MGN Y f Mlfs ps pw ^ar AD G' ON ~ r~3.351 ~~~:!4 - IMtRSenlNC srREFr DR RO.D EEDN IMteucnorE C7ti ~ ~ ~ ~.c awElx M9f •a ~UC. 9EIwF[N 519EEF 6 s 9fE1 I ' 4 } 'E I DISMN f alMt E MRfEE ,CROSS SiRFEEOR NfARfSEMIIf 5 lO ~~, D i lF5 5 E ACCIDENF ' EEEr N w MILEAGE ' Oi COIIRNJN INVgVFD FR rY I Off ~-~ ~ 1~ 1~ I }~~ O~AI Eq rq ellED~~Np N,l1gfD1 ^5911UGF ^NII{PUN µ IIN fFOG55TRlfQYPMG I`I - Q< F C ES ~ p pppngiY DAMAGE ONLY ^ gSUIrcD ^ viaciE ° J~rx2 7 Q F 08 C 5 TU~C1 1 f d OB [C 5 RlK O F 'S fl F5r D AG( yEf~(, ~E 4A .1.' ~ ~ -~- - t ~.., I ~E}NTN GGL 1 S?jCJrJ ~ F ^rW„~'I11 u .. . f CV~ .r n'~~E. 1ir 1 ~~~: •L~~. v~~DR nri..f;,tt I.sr'u~~~:~'UNRN 1'~RS:~~'vh'•"rb. s ~* f,+N.fir:F yM. r.-NCFN07v'..p,YEI{ 3' LON,%,p-E17AlCYLUST.,•' 9E _7d /~ y RmR' NAME. IASj T - 3~~~srRFtrADDRF IGN 9'CON)~LL~~~ rte' I '_ -. ~ -. fr •DDRfss L n 3 AEF CODf RHONF NO. D. I Y S A I 1 IZf ' N )~l ItwNy~un v.J gS73~ R ~ E D.ra ~ e OCCUTArgN RM NAMEIRIONf NO. FrES ONr H[IGHi F CUVAiION FIRM NAMff PrKINf NO. ETfS r IGHt tENiM r{La ;32 i~ LAt3.R B / ,; . ~ CODES ~*K I'7 vFHKIEAw ANOrMV'M 3~ ^CHECK (~) ctEwsANrE~AE~ED~gA ~''" (, ® ~ n . ^ s NI<nw a w '. CODES - * 3 u u ~ { ° s FA a +S~DIDRC.aI Lei Z wA,RU~ •~L6Xi rs. - vN ~r .<F ~ H in:E inN .NN H M ~~ .D~ p AM9IAANEI ^ E°,1 ^ ~b.n. ~ <ii ^ I4wE r.9`]:' p wr NR ^ E%6° ^ iSI IoooGE.cHfv.l F mARi.rgvAE srrR 13 DR.CONV1 r .oM F HY.. MDMIIDARt mwl p K K'~I ^ 04 ~.1 RDM r 9G;'7 C.I}yZ s ,~., ~} DS2 E I ~ r. oR a EN 1' sort RA eq RArE NO. srAlE H vtH. loR a FFST7C;T u VFHKYE 0[Nrn ICAIR>N M. C CtF ID Nl fl A I nt N~ - I _ Si /~J' ~I ~ 'L. Y I kibl I i iM1F:,-, I REWSRRDOrmtR. IASr fIRSF MIDq[ 9wmrq O, Isrc RED WNf4~ 1. {r f1951 MIDIXf Gym Ij. f 1 CIN ~ U4J.V i IC' ;E r ArRweuor CAM.YR W ,_. ~ P rrrT ,~. ~ ~,~ w ~, ~ ~ NFa 4~1 NAMFfADDR[s3!1!INSt~gANCECU ORAGM Fps. ~Z~ *f h ' FEA.MA jl AREA r Nc ~j OG -:. ,,..rIONM cNAece ,.~ RS 4AMAG~DAVU :~ alt Idiuno~AS esr DAMAGE, ^r°,wmr ^REMA,NED c Ru ^^amN ^euwNfD fs~ •rD. ~' !j~" ~ N L~u:J` iowmar "i LLr i GN pw `~ ^~wmr°er. wAV f oMCI Ibiorib+ 6 - ,~ t~ OIAORAM Of C04151ON: _ fwA . AiFOWrN DESCRIPTION OF COLLISION: Il15eSVnfWMAl sttEeru NettsSAerl j. '' x E y+~ ~ ~ _ }1 ~~N-- t_ii .~f.t..F"G_.y._T'__C'1ssG, Z'l2__ [i'as p_~ f2'C-=_ ~ , Y s ~ ~i ` ~~I - . r.~..~ ..f _ ~~cLL~D-_owAT(~~ay.Y,4~A, .1.G,fL~. ~ ~ I ' Lr+I~3'.~D~E&Si~ TJ r + ~Gx,~r3S~+~haa -~ _ _- _ - - _ L~'1/~S._~~ ~1~./~) sP~~sr ~__ r. '"' t F {~ ~' ~ v J a •. d... _ ... __ _. ~ ENT +5'.i]'1.CNL SLl~SrJ_-~-~V ~ ~ ,~ J, ty ~r ~ ~ .. ~" W _ 5~;~ F _ ~ ""<~ ~ ~~ `.. ~~' ~i +(~d 4~`S t'^ ~f ;;~ NAME ADDRESS 8 INJURIES OF PERSONS INVOLVED '' CODES 1 - ~ 3 4 ~ S 6 ~ "~~ - ~' ', +'" CKCIJPANTS/WITNESSES ~uv swntwM,u sHFa ._-_ -....._nrssN -mr "w 9rvc~ ~Ertci Rrer I~{~ !: ~~ a ADdnDNU NAMFM u. iGi rAr N~i~ ~.~ ~ i I .` A ~ x - ...... . _.. _.. _.___... . Noilalnf __..~__.._... R MwtonoM pAMe ^I(^~",<t Q~tl . p°: p :4Lv ~>t~~ Jr~~ 0 - ' 111 a .aaF+.nl. o- HAaA°r °r - _. .... u mer pAMe prS I pF'~:n. O p".°.NV ~ ~ 9 ` X vFr N.AV eeAN. e• ~ AGFNFr KID V.EC wD RM FARRIVfD DAN a.rfoar Anaortoe D t ~TiJS " I '~ ~ 1.11 ! 17mEHo 17 2t1 .Z-17•~ F r DEDD ws ~~r `E~" I ~~' 1 r~~f ~ hl I I ,~~ E r` "~:H_'. r ,J '"4~ _3~'~~,. r. 9'. Y"_ '~ .~5} 1 "E bplati ~~"~yl.,.~}~~'°o[:Nn1'~5,,~, fRl: 191 ~~~ - .. ,. L~ y=~ F s ~ ' ~ ~ i '. I _'b . ~~r Y~ ~ . ~ :ii t ~1 i tf'~~•,trl 7 ~. Ilt~ef ~'~' . t , ~ Yr Ins I;; 1 Y+, 9h1 31~ ~~ T. `~ k'2~ ib '1 + ) 1 l ~y I ~ur. [.. VU ~ ' ~~lN' I y N f.. E. -• r ~7~ POLICE TRAFFIC COLLISISN REPORT I)~J TRAFFICWAY pllc{ r>fysa~sp 1 l ~ PRIVATE WAV '. ~' /.1 D 1 SOIII oal YG~! g A l i p.j~~~.i { I., i + IIMf 'ZZ'~'~RI COVN)Y cTEF1~c,R~oFJ (Ul1Nrv A10 /lc iNWA ° f,9A( ! f CITY OR rOWN N E6NO.OE SIPfEIOR MOHWAr + /lz MRn ~3 aw oo, Naacloclt oN' 0+4K 8a 2A. ~'_ 9h'~O INIFPXCIINO KPIN. Sivffr Oe ROAD Np91N1EP3FCIION II..~~~~y(p ~vEVC BfIWffN LoIAER M'~^y^d1AIRFi C!A A~ /1SLA/~a •DK IPFFD( PO~~ Q •~ I • DISI~yf 60+ ON 19QN FS ! CvOSSO` F 31 i t PO ~. • W ACCIDENT MILEAGE rw V / ~ 1 ~I ` [[[ CGff ca(ISwN Nvlxv.o. v(ert IOrnI NO ORIIlD NO IN 9[p?. ^SVIUGE ^Ni89UN W iprN +~ IM I N. _ p~3 }) I P VlNICI[3 ~ ~ RPORRIY DnMAGE ONLY '. ^ RHIltl0 ^ VfIX[N NKIE ~ ~'~ /P7~.~J~ _~ A 9 OBhCr3 UC INAMf OE OB1ECi z19U< DO E9'3 FI .. FSi.DAMAGE - SPfCW CCAN6 UJ.. 1 f'~ .. r~ , . _ E a ''-+ ,'.UNIT NOI::.,.-. r. .?'.Y +i':4fb ~ ~ ++UNITNO4 :; °VENICLE .,'`O PEDESTRIAN~.l°PEDALCYCLRT .. 3 V(93 NAME. IASI 3 I 5Fr/ ~, 6RAac~. S , D9wf9'S HANF. Uzl I l ~--- ez SIR[Fr ADDPESS oHKBa RD P(o) 8ox 73Z rtFl AD09f5$ nr. sutf :~PCOa )•IA1~l.pCAY W q Q$ 33q SSS-3 /! 9' D R I ^r sun I UfN ~ NS vs pE.ND F,~ SA WA M I l I o 5 I62. ~ ~ ~ A Af R • ' :• e Z OCCUAAIICN MNAMF6RNONf NO. frlS IcNr MIONr uNK f3L too 6D/ E R occwnnoN NRM NAMEd PHONE NO. EYFS I(vlI M:IGNI ~ CHECK (/I AN M.PIOr[ anAM,orMeA1 ° CHECK (.~ l AN wpilirnaA rNF9 A CODES" 7 ~ "' / 5 I y ywlo«.euO CODES ~ * ] n A `s 5 exaaN a >,. ~) ~ ~ aI.DN ANNAAN(I p c°°A%(` ^ EB.D. ^ .'i~Kii ^ IMH,A I eu ^ AY. mK(^ L'A6K' ^ Eb:~ ^ w ^ C4Nf. ~' e VLH Y[Ae LI ~CNfV.I Cog TO ~ MOD[lIDA9r nOVAI '+iYLL I}DR ~C vl CgRRoCA~ ~-D!~ E V.1 MODfI IDMI Al 1 ~ VI °~ r za stAtF rRNIFR PULL NO. SIAI f " PI, VfH. - .. uM9 6y wN• "- - $l.U Ir + KL[OFNIIiICA1gNN0 C VENICIFI N O 112 RIT15~211 5511 71-I----I-'_, ~~ I I - rtcunrtD Owrnr ust Pmzr Aupa[. vrIDNl NO. Nuu77NGFo2D S'{JAWr.~ ~ I lASr,, eRSr mloaf p - ~' ADD9fuaovmf9 " I ' : P[of Rox a.~3 bIADt.oCl~ Wn1( ~, .;. NAm[aADOP alNSwANa co. o9 ACwl uN~ R 3AR n IIIw.AGI ARU D ~ AMAUDAPu y 1v~cV. olwte MAU iN CN DIX g p' CNA9Gf r(N •DNu "'~ P 1 ~~ ~ ' ! y PSI. CAMAO! ~ Aw~V -~3.-~ S I~fQL IDwID AwAr r ~rtMNN[ , ) ~E~. D .. ^~wMY ^R[AWNID f3 now Tow ^IDWfD eY f - DIAGRAM OF C q OLLISION ' I L. ~~ _ ~ No9rH DESCRIPTION OF COIISION• Ilal survf(m[Nru seen rPhc SSA9rl ~su«P~Iaags~L~Ho~KD_cN~K~Y RD P? R--- L _ l4At£~oF ~~ ~£N!C!1. LosT cn~Ce u~s[+1 - ,.. ~,.~ ~ ~' ~ - ._ ~ _ _. ~o~1'[q}1 DRLVE.K N~!D ANA ~ l~EAa Qv£ '2~ t _ 1 _ _ _ . .. ~I a~ _ __ _ _ ~$_ , \~ _ _ , f ~l _ ~ ~ _ _~ ..._ _ ( _ _ _~ _ ... _ . _ v NAME, ADDRESS 8 INJURIES OF PERS ONS I NVOLVED 'CODE S I - Z ~ ~ 5 6 :.. -.'' OCCUPANTS/WI NESSES Iuus rn m vnlw otrlon NlAasw A[ NAAN u SI _.. _. u. Ac .. _.. l retos ' vn ~,~" rt r:' .. va ..._. ml(A. rxa won~rP.L~ $Q}b4q FALRBAAI~S 'AL . NAr~9ruSP AMe °1'11 ° "„ . OC+ ~ 11.x+ N Aml No r A ..._.. _......... (Ip(SS NAtWl01 .., ... ~ MvID IP °AMd ~AaFI ^N~e ~ N ^ IUD x) n MAI ND A .. _.._.._._.,._ DDei33 NArrrrqq(w._ .... F(lUYR3 NAAI nu XIM Or ^AMd ^..r ^rn+tA ^`i: ^Ii~tiV ft• . eAp01 ( AGINCr n.p KI D~SPAr~MD P0. KI;~p D DAIId RIWet er DAtI ~~ . W .`F y^.~xi~ ~ `~M1 la . i Z~ , 51 • ~~ '•~.~;., s r 4 :!I ~r ai vi § ~~ ti ,+il ~~ ti -A D '~ ~p ~~ (~ d ~"" •' ~^ jc~P k ": ;.~j ~; fi, .v ~ n > S s.. T '" w ~' l' ff E ~y, ~ d . 1 N 1 wlyF q ,~ ~ ~ ~ r r r~ 1 P r ' ~' PA ~ j . I ~ ~. ~ ~ ~ ~~ ' ~' v ) _. ~.. +~A I~ ~u. POLICE TRAFFIC COLLI F REPORT ®TRAFF~WA~ rol2E - ~ PRIVATE WAV ., ~ Wx x,Ix ~..,e ,.9., IF. F.. ID3[RgDO~U ---_ ", J~ YND. J~rt7e o~~ pN ~E ^ N Tr OR TOWN N OOFSiuEFi DU wGHWAV iL ROUIE OR3tR[ Df gPIEµ p s ^ W pol 1, ~ N O C O N OAK ~Y (Z ~ ~f NG t 3u[ R O tRSF<NON fPI% ~''tO '~~ LlYW E3. FO MIlFP031 n[TwffN µ1f„ 3f K E~i7319[Ft . G!d• i F-N ~ S¢- L MI[S ~~N ~~•+. ~~•i•Maaalxell Ox NFgREStM IF POSE /IIU ' ACCIDENT P M E DIAG9AM O.tq E[Fi [] ^ 1~ I~ °f L.Gwr )e Hsr~~cc ~c. C« 510 N « c~ % CODE V VFD Eut l I NO D%lIk0~N0 NIU D ^SP llgGf En Clf3 ~ F~ ^nT89UN wrvD~vD~xi N % NE9kCIN 31REEIOR ROAp O9 REPENfNCE INTF9 CES CR0533iPFETORROgO ~ ~PROMRIV OAMaGFONIY ^pF511 %H, UBRCI SIUU[a if qMf OF O¢1FCt 5tRUC%N+D OWNf R'S rNMfI `~' ^SEO1ClF H -~- FS ~~`SD I I/ ~. / I<Mh/~T I OANAGF SPEC q s -~J- I COD NG USf UNI1N0. 1 DuIV 'S NgME. 0131 mIDDIE FI 31 UNIT N0.7 p VEHICLE Q PEDESTRIAN Q PEDALCYCLIST DR f 1 IVf93NaM[: USt NRS HI DlF I D L. 3tREFS~sU _ 3i9fo q°DUfss P I°N . , D eI r I - 3 9 Nflr' DcENSf o C \Yv 9 F F% iB n q R R I IvfP' uCENY NO I' algte ilPCO E PHONE NO. - L A L~+~ :~ IG kiq M .D l 1,'~ R ~ Srgif Sf% pql oq BlRtrv "'° B OCCUPATION f6PrgNF NO EYf3 WFIGNt H10Ht E occu9gNON NA M MFB PNON(NO ~ I~L~R~ (IR+~ ) 7H .S' '1 R . EvE3 WFIGHt WEIGH! ~- E p CHECK (..) rH IOE as.N FinaionroP.NOrHFaal pCHECK (/) P al ~x n O O r NODES -'• ];i A :s~ NE s`:s 5 cl~on p'^o~o _ 'IM K, I v[w CODES -* ] i ;;s F gsaN OnvwrfE rgN t fR x s x.N S r n mo~D.c.cu n I IIC „NS `~ r >M ~ ~ ~ c s 1rsnM , I vEgR Ivq®IDOOGF.<rM1V O WFO au IfINOVq~ x O M UM Q~ ~v ,CI ~ ~fl[ Q ~OrIIe ^ v ^IUiia 'E 3i Ylf ItD UNV 1 Y °i3 C-N3fP~gIFND ~1~ RFRPIAI °R f No siai~E tAR %E I «,F C E FH N lq H vEH c«ou nivl NOO[l IDA9I.NDVaI N IP u va -Re A Il q E No GI Jr ~ L ......,.,,..,.,.,.,,,.,.,... DDIE pHONl N( j O R 131FVfD OwNF4 E/ N - E R INDA cH.ca M~Ir ~ r-~ nxw =~-~' SgjCGW' //,_~ mwlD r. i`+~r`,-aJ~N U wn:DDY, ._, mow... l - I I ~.1~ DIAGRAM OFCOLIISION: I H DESCRIPTION OF COLLISION: IUSE SUPPI[mrNEAl3wHlr MCfssg9rl maEt lr Ne<fssavrl I evO o~l ~,//GCE'sf,2 1 S (~ i I S~OUti~ ON 7}lE y R~ I RIVE SAID SIC A(L`ll icK cN /L /t-}ll/L.E. \/f~'I(~(C t,d l~ <i1'G ~!E IGyT SIDE O~ illE Q(JA~ fbl, O~~R ~ f)Ni~ :~~21iGK /~.V E7`'1 IL/t7 ICI[ .e f~i, > Rva~ _~ /l i, ME J~AC I< Cl../7'(,J ~rT- Y ~ lE KOl~lui9Y .~.~ I~'OLLey~ OvE12. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I - Z 3 a /~ y~O/CICUPANTS/WITNESSES ~~f s1`D"Dn~oNal:i.3rn~lsl 3f% Acr uro3 '",,,H," v S/i~l~J`'~IA I~LF,'.~GZ I\. R[FTR. E. i±D M 7 4 I 3 ,Rrss 3Leo CL CVrl sf•.n .., _unnln... ,..,. NauRr_or„,_. - - -- - - - Y ,... ,~. , A R S , = . ii ~~ E - c. ., '4 '~~ '. h .t'.).+ 9 }IP cer '^ uM GI ~ .+ 1/,Bn I~~~; i .;h i r 'yrr~ dri ~ ~ n ' _ F 1 1 t'.~,~ 1 t ~ i P k I+ , ~(p~ 1 n4 ., r f I 1 F. a ~ 1 I, t (~ I ' 1 1 R p LL r t i '' 3~ ~~? t~'' . R 1 1 i al I't~y" j i',~ 1 1 }' t ~ E I al i f ~ tl '9~ i~ yy 1ti~4. fl 1 I 1 , *f~ )f ~ I 1' r l' ' {~ Ia~ I~- ~7J POLICE TRAFFIC COLLI~N REPORT ~'""cr119^T Polwlc mNLLMSER 3 ~ PRIVATE WAY ' p IF OfC l { , -u. ~ w I Erg/ u 'Var rl .. ./-~ r IIMf IUSF ].09 NOVRI O S COUNIr ~L-VT."j"JCSDN COUNIYtID. r // !Q A ^ ^f ^ lIrYD910wN f6N0.0 SrRFFEOR wONWwr 7' f1 ~,5 ^W E c ,lit oTV EAI,E vnttc G ' . 3 ~•~i,SD „ rNr[R Crl VAIN: SIREN OR N•p NON INIFV5fC1rON {~ BFNVEEN SiRf[1 t 519E[I .Rftl% -y ~/ . f, :/~ " y + DISIANC aDrR RO1M Rtf t CROSS StRFfI RNEAVES(Mllf MrlES 1 F {ffi W Of CIXI ;N)N INVOtvfO: vERNr Ol•l N0 NO RIII[O~NO, INEURfD ^SPRIAOf ^Nt6 RUN 3 ACCIDENT MILEAGE CODE WfA r 1. ~ D ~.1 C96t55'rRRTO41gID ~~ S - OrvfNCl[S ~ ^PIIO4ERIYDAMAOf ONLY ^y(SUl1FD ^VfHiflE : °.h r.a 4 -- a~. ESf.p•MK+f ODatCl5lRUCeIN•MIOr OBIFCr S1RUCl ANOOWNER'S n•EAEI - ;.-ty N ~(`~.. t t ~rj ;~ :y '4 1, s ;µ^Af r4v 1 ' E .,.. .:~:,; .'.~UNITNO.f~ :l':., ., ,.t;E k':RI'"" a ,:5:...•,++r F ~ 17 -.{!. NO R'fi':dS ~ O: ICtE.. ]~. IAN'.,W ^.:ffDAtCYCl15T z• x, `~:: DRWf4 SHAME: Uvsl f LEw ~ S ~ Rs s ~ MQ r ~ ORIVtR's NAME. .. U111 ~ I l ---- - slReeuoo9fss y:J a pR s a 8~ L~ C S'~ El'o.v ~ y oN SATE zlPCOtt Era r ' r I ~ . Jr.L~D' 7}.vR L1.S Swan '-fb - Y5-~r 35 1 DO R. - v: . 2S-Sa-B rl,~ 3 ,;. 4 •1 .. DAtf~ B RI I NPM NNAEtNgN[rA.`c~_. '. t EYES 1 IOHr 1fIGN1 I :; CUPAIrON {rNM N/JAf IPHONF NO. EYty NSIWI EEG a ~I WJ4 t~ ' o~ D W EATuwa A-v c).va~ ? .. t44 O ~ ^GHECK (.~ vfNCH,Sww rMnonEawrROmER ^CHECK (~ ltfwsANEMViorFEOEAegiwfvwl _ ~ CODES - T ] o',`iR . siv "^ S l e i,° '"t M y ( CODES ~ ~ 7 ~ a ° 5 t.clroN a y'x0. n Z 6Ru .N w,A SE tf °`2.~ PDM ^ AMN.ANlE O 3:"l ^ ~S~r. ®~ K9 ^ M.)or4pM ^ .MRw.Na ^ ~!r ^ Eb.Ra ^ rt~£N ^ :.Lso ' V[N rU9 f IDODO[.CHEVf llDw9l NOVA) S1rU I]DR~C of ~ Y ( N V) MGpfl IDAR ~ AI I ~ 1 ~ Sv Par 3 cAe~~E~C ~E ] M lCN PUr SiwiF RMNRRAtf NO. SrMf H r ~ A vfN. CCA +xTE- N w+'~e ~i rti~~ 4zzs- rtiaC VtNKIf IDEMrrrCwlKktrq i, . w E r VE I NI 1 3 s o I ~ I I ,,,, 410411R[DOWEYR: IASI rIRSi MIDDLE PNDEE NO r R WNtR. USi ilRSl MIDDY OYf..' LEw) S -~~ssl~ a ADDRt550rONMt R Le ~ ~ --' IN SRRT AMfawoo4fuor lNwRAEKECO.wACENr ~. ya 4ANAOED MEA _ U x M f~NAAO[D IAUy ~ 1 CNMOf .~ Zhu .CU..1~ CHARGE ` oru PD, ~ -'•, _ y t1 DAMAGt ^iwM~ ^4[M,UNfO ^~Wwr '^RfMNN[D Ee rowm ~ r a eY, a ~ _~ S QL].b ror oer. 'cX u wwr AWA. e DIAGRAM_OF COll151 N: I N E .e4ow i" DESCRIPTION OF COLLISION: IlA[SUPrtEMI lu srEei rNfassAR 1 _ n -- - 7 t1 J9il~ ~ -'/SL/f ~ /11 ~ ~ tt t ~ ~ k yr ~ _ _ p c~ . . ._ ... - .J L _. . / ff ~ -~- .fios~~C~ ..q_ c~s.v.~ iu_TJi~~.~..~~ . .~ ~- --- ~ F ~ .. .r. . !!!11 . -- _. I ¢ - ~ow••~ G,J~9_4F V!~li~ c4~_ SGr.~.. r. ,~'; _ ~ _ _ "" B~ T uu ~ l i _ o yK~_ .~S_!_t ~fi _~1L jC. 't- T _ -~~~^ s)e~ .~Cta E-:..k T= /~ SrcA .y .. 1 r . . _. _ - . . - - _--- - ' ~. r_ _ ~ ._.- -----. _. _ ..~ ~ I._- . . I1;IIr,II ~F. NAME. ADDRESS8INJURIES OF PE RSONSI NVOWED rCODES 1 "~" '- "~ ' - Z 3 4 5 6 - OCCUPANTS /WITNESSES ,n S.nD^ ro "i wwi ii ul "w" u.r Mrcr N.Mt ~}QIC S I>'A-uS~:ozGS~ 'NO Z • "" ~~~~ ~ •MVEM Y -..N N•rU4l J cAc• Y,uv er e N vE . ^th ^ w'n • rwiw ^ ^i1:w _.._._. D •mNx 9 ~ NAiwror a _N ~.. ~ w.r ..D. Dr AMe ^~.At ^"r'r;.r. ^rE ^., r. I ~ N.. ao N •w ~ . ER»ES r NAruEra NxwNt tNE nr ^•Ma ^• `•~`~ ^<an. H~ ^ r,N.P INAw ER•N. X ' I EwDGfw ~ J .czNC. 1,t7 „r. R B-f•, Oj~SBwc S.IONa1 NaI~A.tR~ o z.DO NIIS p•Ila4l nlrr ,3 .rr9ovlpa p•n 1 _' w :~~ ~, + r~ ! n ~~ ~r `~ e ~~ '`:~. 's1 ~ o ~li ' . r~ 51 ij , F n~ ~~ ~ 1 yt,,~p~ "" r n C: ,~ ~~ ' ~~ q v~v'~. . ~ /. ' k ~ y I , 1 ~'. ' F j~pFy P +M . J I r '.!J 1 'ti,li ~ 3•~ s ~~ u ~~.~ ~ ~ ~ . , ~ .;, . ,, ~^ ~ .~JW S '~ tA~ a. ~R V.. u ,-,kr ~~+" ~ e1 a ~ ~ L I ~.. , ~ ~ T z Y~ ~ ,f~T ~ idT~ $ '`IA f. ,~tltl J 6~1 ,. . t ~I ~ 1 ~ f i 1 T ~ 2., ) ii ( Y 1}, ,,~ 4 I t'V'~II {); ~p i y 'r1 v (i M ~. ~.,: STATE OF WASHINGTON MOTOfl VEHICLE COLLISION REPO O . u (./~~ ~~ ~ uux: c,°rv~°'~ISHnx aM ~o~ Ifs"o y"~I». ~ ~ 1 E ~ '7YN TY ^ 'nAN .~f' / eu Tf/-J-L S~%V _.`. ~ ^•~ ^[ ^» /J/Pg~:'~c:rc aF"n»~~, ~[ ,I,w . - F °xA,x[ETY,PE » [o I[[~JIJ x. x,[x,wl°x (^.l'IAc%17'`N'I~~ NA F ~9 L w orr [,w[E ~~ 8. o ^ .»° °~~„ILxM°~;~;s ;F,~~~~~.»°..NOw.x, Nln„ .[ " y, Q O LJ' /c,`~xo o'w.4F MILE .[[ [[. °PAN°.[. [rIMMFNWPTRAI.,P°R[ ^ so [ ^ ~ [ ., /'} »°n Eo~[b~E~TaE ,°6H~aA su11° [ 'v ts[xucM OWNER OF OBJECTS NAME AND ADDflE55 {g'Aernx°Ye Fc ce°e uu OBJECT STRULK E01O' i?nL%QY c 7' lr/L T~~iYCS'S 8 T Ta/ -T~ /CC/' /S.vo, /I Urr 1~ - ~ ~ (~ Tq g[R4 OflIVEfl5LASTNAME FIRST NAME '.f~ CnC~r iO DflIVER'e LAST NAME •FIRBT NAME .. MIDDLE T[.An STREET ADDRESS POLITE NO. AND BO%NO. RE PEas STREET ADDRESS ' flOUTE N0. AND BO%NO. L ,T I ~T 'U /E i HU CITY STATE 21P CODE ORIVEP9000UPATION N CITY STATE ~ ZIPCAOC DflIVEPS OCCUPATIO T!1 -t///r S'~3uo/a- vRi ~E.~ c c ws+ DRIVER'S LICENSE N0. STATE SEX GATE OF BIPTM AGE OR VER'S LICENSE NO. STATE SE% DATE OF BIRTH AGf, VEHICLE Yfl. MAKE ICHEV, 000 ~I MOO~(s1VAC`n) DY Y 2 .1 ii r''v / VEHICLE YR. MANE ICHEV. DODOEI M D L (N VA-OAR 1 BODY STYLE 12 DR.) ~~o ., c [> _ 3- O oRD TPiAC7c~ Fv,~ v -oR LICENSE PLATFJNO. 9TATE TflaILEfl PLA ENO. ~ - 6TATE LICENSE PLATE NO. STATE TRAILEA PLATE NO. 6TATE_.. ._- ~ 9%` ~/'t wA J•v/oZd77 wA yAN ~,5~' wA ~-•_-- VEnICLE IOENTIFICANON rv0. ) ' Yo G 4J/r'7 ' VEHICLE IOENTIfICAT1ON NO, ' PEOISTERED OWNEfl ILAST-FIR5I-MIDDLE NAME) DRIVER'S LICENS N ~ ~ ' REGISTEPED OWNER(LAST-FIRST•MIDDLE NAME[' DRIVER'S LICENSE NO. l ~ ~°• i c.rr TiPAINS~ OWNERS AOORE63 I6TREET, CITY pND 6TATEI DATE OF BIRTH OWNER'6 ADDPES6 ISTREET, CITY AND 9TATE).. DATE OF BIRTH ° D.. rR /S .v~G/w/~J- c'~ /vv~ Y1.2o °° nAr rn PART50F VEHICLE DAMAGED AFT FRcNT hiiµ:'[".~01° PARTS OF VEHIFC/LE OA ~~ANG H~VL/GHT !! Mf h4.d~4R€.€'[° ,cEFT FNEL Ti1N/f Ac 1416 Hy S O v =~~~ FRa^'T S LIABILITY INSURANCE INFORMATION•VEHICLE NO. 1• WAS THERE AuTOeeofiaE Luo L TY INSUflarvcE F3f YES ^ NO COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CM NAME AND ADDPE650F LIABILITY INSURANCE POLICY HOLDER cnr ~ sTAIF TAP NAME OF LIABILITY INSUflANCE COMPANY NAME AND ADOflE650F LIADILITY INSURANCE AGENT ~,'; GIY „ ..~ ~ BiafE 2IP LIABILITY P04CY NUMBFA ,,. , _ I6T INJURY :~.J AOE 2ND INJURY lusF SE iE P[POPT fO iIORAL UMmlE6) AGE ._... ..... .. . ,. ..: MIUP LO NAME /' NAME I 9E% ADDRESS •- ._ M F ADDRESS ~ F NATURE ANO ^ ^ %TENT OF INJURIES ^ ^ E%TENT OF INJURIES p O INIUR ES REQUIRE DOOTORS D O JUR ES REQUIRE DOMTORS E M r TION OY A DOCTOR '^s O NAME ENAM NATION DY A DOCTOR ~ ^ N E BTAtUS OF INJURED MARK FIRbT ONl TNAT.APV LIES ~ bTATU30F INJURED MARN FIflST OHE THAT APVLIE S ^ NVEHI LE ^ NILLEO vr.N%~~ .v[v[r[ un~ °x ^ I V HI L ^ NO NILLED irv"unr° s[r[nN vux01 u»an °N U~nv c^uPin »[ ° NO ~"m[~.. ^ 5^ 6^ °Tn^c oI[o~FI..» ^ 6^ 6^ fT O[: MOTORCYCLE SAFETY: ^ HEL MF.i uSEO ^ HELMET NOT USED MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMEi NOT USED I ::»OW N0nNl0Y ARNOw NCIRCI. 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ON FavF V4uE RD INlfq)fCi NG SNIH. ){BEET Oa FOAD NONINi[RSlCIKJN ~ ~~/SO ] S R /a t nEJwEfN / e sEaEEi . QA sIREEt J PttfIK [ MlLL ppa• 9.08 ~ / DISIANC[nD RI ON MR nRFNCE. 0001)SIRFFEOR NFAPES{M IE POST ACCT^ENi Mn[S f ) E c RAMP DI PAM DATA MILEAGE 00 IFFI (] ~ Of I D M p ~ .GODF - ' COIIISgNINVIXV[D. NVENDY' ~-Mn15 iOfAI NO. ONLLED~~rIO.INJUa[D„Qr ^SP iUGE ^Hib RUN IN IInM) Of VEN CIE) ©~ ~PR0f4R1YDAMAGF ONLY ^p SU , I RD RSf INGS PFf10RNM004 REEERFNCE f~ IRifR C45 CRO55)]REFTORROAD ] ] E IIF ^VfaRF ' Sf OBJFC{)rRUCKINAMf Of OBJECT STRUCK NUD OWN[k')NM1E) Fs1.DN,IAGE .S.Q /O¢- )RCLLL CODING Ib[ ~ S UNIT NO. I UNITNO.4 DRwfRSNNAf IAS{ HR)1 ~ VEHICLE ^ PEDESTRIAN Q PEDALCVCLIST ~ ~~ MID f DR VfR'S NAME 9 51 ~~~ ME YHeMfS.ifY RKcH.cRO Pc ERScJV w.tJ.v S'>•1 ~ s1aEE]ADOREss raEES ADDRfss ~ f/73J RnSc wank IPCOa PIwNE NO Zb 3 j ~,E. JSI~ D EPCDDE PrlorRe PEDeT 7'o~•nst w4 9836$ SS-'~.T$'1, R f~aTt.oNa o ' R -136 76/-657 1 DxvERSEaNSENO uJSrE E 1 , A fa H I n sucENVNO E AIE UAifpOFO RIrN u OCC DON RM NAMEAPIroNE NO FE) E ~/ aRK I GNt IE GHI OCCUPAEION fRM NM1E6 HONE NO, EYES GNI HIGH L•G ~nenT c'i.cvtRPK TA c. J %i R 7oEcrG, s I3uE.$ MoR J+ ic'l Et ~ ;J ~S •~ i ~ ~ . ^ CHECK (.~ ~ Ea A NO{HFa a ^ CHECK (/) sax fMnovff aAr~ vrH cu A i ~ia A' K i . NODES ®• ] ~ 5 <' D 5„r° CODES - ~ ~ r"wii HE .A s in:"r 1 5 E .,1 y „O~ «• I IN '^ ~ tiu n "c~ ^ ±JLK' ^~b.ll. ^'.i ^:°v Yf~ YAR mA~l°ooGE.<Hfv~~"moDD~iDAUrrxrvA~`I.ul]D~oNVI nMru~a Nw ~A« ) K a E v { A . E ~ 1 n[v.l KKJMEIDON-NOVAI E]Da vl DAB 3i H «Da ,~~ PIADND sMlf `tRP I C yr~• 2 ° IEi ~IX p. Jn R~ tD 693 I ERRAD HIO , YEH q 'W.{, I F C TP Z 7 5 RAZE NO. Aif O Rr' » , nHKIfluNIrKAIKxR NO ~ vwlaE DENtI{uDE.N ~ 2/12,356 LHt 3/07/+107 RfG11RafDOWNFR: 0111 SI MIDDFE p p ' IN)NFNO. ISRREDOWmIq: USf {IRS DDIF NO. DDREssaovm~ey O~~ _ S ~~7g,. 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DAMA E ~Aw ^REMAINED 1 d ° ' nr~ Aww° f oo -.- :w:v ~ nr. f ~ D DIAGRAM OF CCCO 1510 lu N CAn Nogin \~\ ~ Er fEUCEysnR er ARROw DESCRIPTION OF COLLISION: EusE SUpn[M[NEU SNreiDNECfssARrl n ~~~ ~ ~ ~' /y ` ~" WiE'/~ / Ne ~ wq9 PA 2J~r~ O N v ~p ~ TH ~r KY !3 avND SNof/J.U<'l? o f '7~y ]c ~3I a.,,q«.~y RD /3.°AVER vgtJ..~y )4aADTCHrFC..KJiyc A M4 P, ~7 ---- ~'LN! !ra l T/RNcm aNTO 13 V, RD _- _~ ~- v n ~ L F,RO~ SR A l0y ) CRc:~rD rTNt Pa Sr- ~ ~ L~nK6' Awa ,r.TRvK'/S NO a / T -- ~ ~~ ~ E1=7` RFr~Q w ]Tl~ }1 i S R J G 4 Dly CI ` NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED I ODES I 2 a 5 6 OCCUPANTS /WITNESSES ~~:Dauai:ElrMiA"wii ~ A"E f"~ /ri[S aN pF gn]gl~{{ D 'o" 1 ~ M 17• 3 /~ ' H • u. Am ur t~ ~- y= r " ' n nsEN. Eno EDR OVINE), O I'•/Jf LN .RT l,sO LOI+A Nfr,v r' AMI ' ~ ' ' pA Me ~FtK"~{ " pN ~ , T n ~ _A I _ AwJ.EU rE AMI uap °r N MnvfD{NOM QAMe ^ ;" ~ n ^ :u r . r ~. .Nv .D ,,.. ~ 1: u+ - nvl>IK.AINrG(AEKIK )rµ1V )RANK nADOE EH AGFr,Cr ~.NORNORiiY xrNf w. ^AMn ^" :'OM;:u. ^ :;X ^.:'.w y `. V JO eeo KI OISrA1CM0 ~ /~]SIlNS pEA KI AgvIND 7 /~JmHis Wllp 11l<JRI 3-~9•StS A nr DATE s ''+e•1 { t ~'my, i ~N ~ ''V4+e+ l ~~~~ ~ T+Fd ~ x ~~ 41 ~id3. t - N ~i~,. ` _ ~ ~~d t ~ ~, n 1 S ~ y - .Y..... ~, ,; { S i_I~, e v '. ~ I .% N L O C f 0 ~~.i ~ ~ ~ I C ' . o ~. ~ ~.C7 .~ O U o O U u1 a~ 2 ~ ,~6. ~ o 6;~ o ; s~y m o ~ ~ %C~F~-' rff- o, ~1 _ , '1 I •.~ `` ~ . ~ A. ,y { ~~ ^ -T~ ~ ~ ~~ '.~ {, j 1 i t3 J axe , ~:~•. ~ i '~ N F Y~ T ~.. f ~ ~,~1 ".S 1 i ~ (, ~' ~ `I' i I~r ~ •~ - u„aE ,h • G~x. k. ~~ r ' ~,» ~t 1 ~_ 4 ~~ 'POLICE TRAFFIC COION REPORT ~QTRAFFICWAY I NNMNUNa[R ~ PRIVATE WAY gl DA,E Or, .Olll ra Ar IIMF COUNtr vlx~Iuar rRD. IUS ]4W HOU41 ~ I a.I :.6 I I ~;»u..f"-r,.,. ~o o eFF COUN]Y Gtt NO. pnWA ^ ~`°u L fa ^N ^f ^IN [IfY ON rOWN SivlF10R HIGHWAY S Iw pWiF O R INlFS 5 ^W ~Op ON ` // • 3fC]ING Vnin: 3rRt[r OR ROAD NONINrfRSFCrION B[rW1EN SiRfffa RIO SrRt[i pot MIlF PO51 7S~ I b DISIAN<(6DI4FMI `(.W iROMRf f C4°'.SSr4fFIO4 Nt.KxFSlmllt 5 PCCIDENI I[5 5 N[f MILEAGE H[r Op COIX RAM ARIM DAiA COll13roN rlvdVlO- of vl,r. NNNNNN 11JJ N al 101M NO OKIIfO~Np.IN]UR[D1 ^Sn IIAGf ^Mi6RU + ~ IMFa Cl3 Cp06M151REE109RF1~O ROADO4 qif Nd - _I ]D . P vlHlCl[5 ^pPORfR YDANAGf ONLY ^~ sIdFN tUli[D ^ f <lF •..:,. !~>j~... ~uJ »>. ~ OB![Cr STRUCK IIIAMf Of OBJFCr SrRUCK ANDOWNlR'S NAMF ) =AG[ ` 3pfCVa CODING U3t - : UNIT NO.I UNIT NO.Y ^VEHICLE ^7EDESTRIAN ^PEDALCYCIIST I]' s Rnfx-s NAMt. IASi Ix I mID D 4Nf4'sNAmf: usr (, N D _ .--, OSSOM, YA~CP uA T ADDRt53 3raEFr ADDRESS O 31Art aIRGODE pnONf NO lir D f1 rArt~ 9 E Ii I ~ ~ZA93 ~ R - 8 _.. Z D4Mf4sl efNx NO iE E I IvR a Nst NO. Ale DArt a14H - o "C}1 L343D mD ~ RA. Ilo~ V SS 'csl a 2 , •r I r. 1 OC<UVArION [6 [YES GNi p[GHi ND E OCCUpAIION {IRM NAMF6 PrgNF NO. FYF3 WFIGHi pEIGM ~ +- ~ 2 R -~ N2I ~ r ^CHECK I~ IHd[AS KW.Nwavr NornfaAl A ^CHECK I~ vlHdf ASANdaorlfwANOr»reAl 5 l a ""° rc•ry• CODES' ~ c ~ ^„" crwH i,° °K"L'L CODES -' I a . i+ 5 u rDN a :ss '"O inw < «: ~] a w I Nrts 1 s A ~ v OFC. rE ~~RO .D,,. ^'c°.1c' ^~S:nR ^v^iw~: ^i4°Atrv v[n YtA4 IMKI DGDGE <HfV MoDl UA4 u~.~ormm ^,mful.»u ^'K.°sc' ^~S:nR ^i..'»v ll ~ ,) 1~NOVA) SiYlf l]D4 ~Cwxv,l I LI C aDR E n. rtA I nEV.) MOpI I Ri~NOVAI l l] R. v.l 9 ~ ~ , ~~" _ ~• r"va O4 H N3tplAE 3M 4AI,t4AA,t rArt H Wn R I, M1 W •____ I C Lvu: Q J ~~ nH¢lflaNrnlwK]N NO I I IR I I IZ I I 11315 L vfnlClFlwNr A ILL I INNI I I (0 81 I atelsrtREDOwNIR lASr nau Iodt l-} 1 ~1Je1 SgMn K. rIK)Nf No. ,°N 1 I rtR D wneR tASr rlasr MIDDLE e 0550 (~IPti1 '~' a eSSw OWNIR A~ Y3 N E Nfa SRhtJ AS iJRIVCn n]I J- a uADDRfun wwRANCem o4AUM '~AT a ' N R ] wM.u Aau D3A~~c ""olur a lur.cro»+I CHUGt r,3 <HARGt nrgripri AMAf>E~AAU rU~Ort 3 l31 DAMAGI ~ •W~~ ~RMAIMD ~^vI^(N ~alMAIN[D [51. DAM oR W O rOWrtDIr AIEA rOVRD I s N,y IO ~O,IOii 3 Aw.r Awar en ' wU DIAGRAM OF COLUSI lu N vl eu oa~IH DESCRIPTION OF COLLISION: 1 [swauwMAL SIrn rN[ 133.vRrl ~ l SW ]u lc __ .___ - ~ ~ ~~-- - SZA UCHR1 516---~aL._V~1b . RO_1Ti'N_i~~6 g6~._ I ~~_ ~ Ic ~ ~ - - y R9 .-DR~V6t _VeH I 4oses_Co hx.._vF ' ~ s N t Clt o * 1 1 . °, s 3. ossc ~t _{ }}~ _ _ p,t )e In b_ T~._.N 6 -l~.px_oS Qe~1r~ - Ufil4 RO T1k VeNll.le SQ,+iJ 18o # ~~-I ~- ! ~>" I ° '~.r( . . __._ _ __ . SCf`R)f V¢r~w 2 Y N 'h1t N x 16 oF BtM±V l ~ ~ I ` i 1 ~ ~~ I _ + . _ _I J_, ~ . - _ Af _ ; i- -- . - ~- ~ s a va14 R~ I j L ~ ! . , __ _ Ay -4..L >, - ; - ~ I t -- ~ _ I ---- ..-1 ~ ~ ~ .1_I L 1_ : ~ _~__ 1 f ~ ._ _ _ ___ ~ i ~ - ~ I, __ . ~ ; f.- -~I. ___ _ . . _..._. ; t ~ ; _ ... IIII NAME, ADDRESS S INJURIES OF PERSONS INVOLVED 'CODES I - Z 3 a S 6 OCCUPANTS /WITNESSES ~pp S DR ON~NASMI S\ SIK AGI Yu ,,, aura ulcr »AMI L R sou eL o by~l I- _ .r ND 385 O) /Q - me EY1K' ^.r. I ~ >o `"' S h uKs, RD ce - ~ ' ~ - .43fs~ ~ 2 ~--. . ~ D°nsf rl lwlr ~ ~vwsDrpw .Me ^rH]~K,^ n . ^» ^".° .D uTCN.31~ M I l.u e I k No 3Y - ~-~ L H+135 ^ ~ ':~„`.rs° uQ~~}~/~7 fiNls. '^' .m1 ^":,I^p~:H.^;; ^".DI rho C+rKly\wvlfvAr.r I ' T A ti C• ~ + »~ OI 1 •w KI .vuIr10 D.IldvlrO.r vvvpvlDlY D!AIr9I ~b p A7 X Wes? , b ~-~ 21ip2p'45 12do•YL. ~Ab d ~s ~~• ~~ POLICE TRAFFIC Q. ION REPORT ®TRAFFICWAV ~~~ J ~ f ~ q'%I ~ PRIVATE WAV IM N4NBfR . I f f0- a I A W1 Ol4 IIMf COUniY IZ!~ ~yJy~uo lruN ~we. Iw~l IUSFN00 HOU41 / JX~ ~D` 61I SCr'r~ensc.FJ COUNIYNO. CIrY NO. f~A p °'° crtr oa rowN 1 pN pF pIN AMt6NO 0i ttl OR tuGHWAr N iCf 1 RWSE 3 S Mla 3 pW pD{ c~a, ON vtr RO IN Irv3fCi,NG NtrH. SrvfEr OR WAD NON NtIR F il N S C O 9~~so'' /^ ' f ~^, .cr~ I' 1- ' N B[IWfrN Ufy l~.a I/(}I!O aFtr6 ~ Sia[Fi O~SIA ' RatIIA 4f qy1 /' M Di ~p7 - NCt 6D RF~ RON RNEVFN t CROSSSfaFNOR NEAefSr Mll[v0 ACCIDENT lf3 5 E W v v DIAGRAM DASH I([I O{ IIVI~LV.t'S MCODEE CONK ON NVOIVFD NFV[eU V. M is rOfM NO O •ILlEO NO MJUR[D ^ Sv ttAGF ^ H t6 RUN wr,ow°iw IN tEl RgOAp OR Rf{fafNCt IMFR Cl3 CAOSSSre[fi OR aOAp 1 xx dVM<lE3 OaORE vOnrnAG[ONIY ^p['stUlrfD ^Si~'Cf ~~ OBRC131RUCR INAMf Of OBJFCr SreVCR AVDOWNF43 NAM[ Ir o2O -L I tai DAMAGE ~.e. ~•~^ L 0 le s I - SR[CW CODING USf '_ UNIT NO. I UNIT N0.4 Ina's NAME. uui yr D MI IXf DNVr93N p VEHICLE p PEDESTRIAN p PEDAICVCUST ~'ul a F~I.tMO L ANf: N31 Iv ` - ° vRtf t ADORrss BeA~N 0~ vaeer AoDRtss OI• (~, SIAM 21RCOa fNO. `~~ ~~ ~+ 3b ~ 7- 3/ ORrv[R'3 NCtNSE NO. S,AIE f D R I• SIAIt 1 I RRy 31<E ' o ~ n ~ -,~ MD i D.' RI7a ~ ,v - uaN No. An DArE e MD D.. °r.. _ a _ A { OCCU=. F MOM NO FvtS wt GN1 H GHr S~ ~0 s t • E R OCCUrA1,ON NRM NAMf 6 RHONt NO. [rt3 t,GHi H GH1 _ Q CHECK (~~R4TIEA A vrr~AGr o,T,ie l CODE ' ' " ' ~ p CHECK (.~ 'vFHraF ASAN fMnovF[a .rorHfeAl 'ply.' a S f ~ . s s 5 t a s"'.°.~ °c~ ~ ~;~ ntr w u r bN o~ .Rt CODES ~ ~ ] c A iv 5 Fn a yam, • -Lxr ,r, ~ INJ ^ .,.eD,.„cl ^ of ' O ~bHl ^ C n~.~Aa M MA.f IDOOCr.aEV.I r IOAVI NovAl srvlr x DR .coNV ^ w. r ^ u O ~$.~r ^ n ^ i~ s. ~ ~ ~ ' ~ '~ ° M . .r I I~11 q ~~ ~ ~ r t .l f wARt. I A. Ix . ., .DM r N . siArf nfR rtAr NO srAtt H N aoa a - vtH10[D[NNf GALLON NO. I ff" I I WI III I I I atusnaroo C L VtH CIf,aN{ I I I I I I I wNEa tws easy MIDDLE rHOM NO. ~ ~ ~ J~ ~MG O veam wNee: r rmv MIDaF t _ lip Aooatss eR VU A xI ~C SA ~5 ORIVOL N E NAMyTADwr~tysa mswANCr co. aR ACtNr IIJJ''1h~ii art" L..~..I 0 R I A xx D.SMAG,D MIA p ""' ' I M I AMAGf 1 Aa{A ~ aura ~o Aaa w~a O.N ~ ; R . s C~OirO~ 3 is DAMAGt f ^AW~~ ^etMMNID D ~ OAWAY ^vIMAINfO ° t3~DAMAGt ' ro iw ` a ^:w~r ev f . - DIAGRAM Of_CO11 i__ .__ 1510 ~ lu I N A ND CUr NOn s vlt er Aaaow DESCR IPTI ON OF COLLISION: IUSI SUVrItMtN1A1 sHEn n MeessARr , y ~~ ~ . ~ ~~~~~ ~ ~ _ Se _ _ -_ __-_ H^ I SE ON $eeva Vnll JSn T /aCL ._ - .. .-. c ..,paLVC~ ~le!'A 4 0 $ ~ ~~C i j 1 i_~ ~-~-f.- y ~ 1_f 1-f. I~ L ~ r ' - eukty_o.~. .man L°'T_. Co,~Tr_gL.~F L~F,'S Veul..~e 7 I-k.~N.~ON7U D Y'-}~ t i ~ -r { } { ! y .,. ' ~' S^T _.SE -SHDVIDe2___.2Wr3_CRo55SD_SIJC..~E.~._ ~ -I-~ t t i-~- -1{-- { ~ ~J. ._ ~ ~ ~ ~ N.W^_LgNTCa __~!D5/0~. TiJe._VeN,~_ST.r_of.k. ' N I,,T j I -+- 1 ~ - I/ } - -~ -_ . . . A__FeNxa... oa__ (LI: _NW__S.F}a~ IDen... Tik. VCKtr.t<__. 7NI R F/ I . L .._ t L. I_ . .L..~ l . _ i . ~ . xn olleP..._I Z Tthas Co~f~dt._ ~ _..RIr~T. qJ_ ,13- --STS w ._w PAST3trc,, . . -----~-- I , PA~~n,. ~- . ~ ~ I ~_ 1 _ __ __. _ _.__ .. __ - -- __- _---- -- NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ~ CODES 1 4 3 ~ S 6 OCCUPANTS/WITNESSES ~a::~^;o",',a~.'M" A Ftii _. ..... .... ""si.~ AGl 'GIVS .u nH ^uel_ ., _wr.. . _._ ._. Mrer HSIa l,ICr N ~ ~f MI /A S L2 a .. ,. N Mt , .~ nner pAM e pR~:t-0 "' . ON pC3wv >a _._ __. _ .... _.....- ~ i.: A N w.rss AMr rmF D, . ManD,ROM Nrer pAMe p'°'."' O",'.N. O ~. ^ :aA. ~ _ o ' _~ . DDans ~G ~y u•.cl.sN.wau.,• u . Arl.rt. 'o°,fsc ~ N stNi er " "'p.Me ^ ""°'p aN. ^+: ^: N X 11~ 2 p ' ..~ °$' a~nms..ICHro 612 xAet.auno °x«~iK+ DAnpalroRt -7.8 Ar.onoe. z I Z DAn n r ~,W b [.' , `i~ Y~Y ~, , a ' ` ~,T :~ , 4 , »~ ~ q '4!AL~'.. ~ kC ~ ~ ~ f :' ~~ p ' q W ^ ~ • F } 1 J.'. u ,~. ~ ~ ~ ~ ~~~~ GP1,.a., a .. .. .s... l -. ~ • ~ } 1 I' 1 I ~ y ,~ ~`~~~r~ 9 4 t I T }~ru t i ti '` ~ l i ~ Ss ' ~ ~ I l 4 u f ~i ~ -. ~ I J ,1 ~ ~• r , + ~.t ~ qg c c ~,I ~ M J 1. ' tnf ~n i~~~ ~m ;~ ... -;, i ~~ ~~ ~ ~ . {~j e~ '~`Ud( 1~e'~^••mau~e++r+flxr-(~._~JtSiLL"L M~_~.. v~ ~+ ',~i ,~ rn 2! ~i k 4. ~ ~ 1'~ ~rmq~ W,j ~, ra ,°~ , ~ ,d:ta: ;~ gyn. L n~ i5 ~ ~ ~~. ~, ~ 1 /~ t:.7F ~ x L1 47 ,v ~ ~ ~ a ~, ~ 1 '~16 ~ + ~ f~~ x~ ~t ._~ 1 ~ ,ti ~ ~ '!G' ~~ } }~. ~ d. ~7 ~( ~~ ~~~ ., "T ) ~ ~wn'i'.~fe~ ., t I ~ ''~~ ~~ ~ ~ . ~ 3 , } _ y', I ~~r ,,1 ~, t _ r I ~~ .., J' ~ ~ 1 ~ . I ' I 1p N ~g~ 4 ~: c r+~,r 1 ~ I • . xb ~ y G `~iF.i~~' fi+~ 2 a s F }~ _. gar I ~ µ` S ~ . 5 ~L ~f Ya6tgl . . 11 ~, ' '. ~~ ~' " ' - nr~y ~ ~, Y~ ~ ' ,~.r ~ ~~ ~, Y ' t",h I '~W..~~ POLICE TRAFFIC COION REPORT ~TRAfFICWAY rotlC ~SRWNINUM ' PRIVATE WAY - f a1 DA FprCOV __ _,C N UMf COUNrr rIy 11~ ~ IUSf ]'nOMOURI 2 IZp ~6 °" j~ ~ {,~. OIY ~. tHWA ^UR ~ ; , i 1 O 3o Tc -o,,l DR„{ ^N ~f ^1N C T0410WN E6N0. d5rR[Fr 09 raGHW.nY CAS Rpfif rants ~s ^w ~d (,~ ON ...~.9OQ~. ~ NIf RSECNNG Y% S~RFFi OR VO,D NON NIt91[C110N L ~,., ~nf~ t ' 1% t Maf Krii p BtM'ffN C SIRFEr6 nIR[Ft 'N [t p, ~¢ DSrANCEaDRfr ROMR rfatN fCROSSSIRfftOY l,aF5r M1 5 Ml[5 5 F W ACCIpENi MIEAGE p AGRAN D,IA «tr Oi ~ CODF COll15gN NVOSV[0. StvFR rv: iOr%t NO O.tIED NO. N1URfD~_ ^SGLLIAGE ^ N1 y Ui~N 6 RUN wNDwD1. IN MFR C15 WOn55TREF10R DOAD. O¢R(flNffCE l D dV[H C![S ^paORRr 0%MAG[ONIT ^pfSl lr[D ^ OBRCISrRUCR INNAF OE OBI[Cr StaUCx.WDOWNFR SNU.VI V[~ 'CIf tsr. D%Mwf 7'Q rt SRCW COpNG USf Q { 4= s UNIT NO. 1 oR Vfas NAMn Dnsr UNIT NO. 2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCl15T ~' . m1 Mf oa vfas NwMf: .. n fvZ stptereoovfss 1 srnrf zlpcou D srum %DORtss •- ~ pNDNf NO. $33g 3a5• R ur rAlt i DRrv[Rn UCFNSf NO. St,tf fx IH a I n t fNSf NO. •nrf D l d BR W IMA l rr y0 I D,r M Io V i o irf «eup,nrlaN xMtarNONt Np. fes eHt ragHl E «ap%t DN mNAmfaprroNe NO fns wfg t r<g '__ R . H Nr ^ CHECK (/) vfH n[%s,u D.,pionf or,NOlHec f y,1 ~N ,rf CODES - ~ J ~ 5 e e's;°rin` ~ ,:: ^ CHECK(/( yFN CIf AS%N fMNOVfFd% .u• ,:~°DN H~f.f CODES ~ ~ ~ ~ . is 6 i' " a ~ o a p ns ~ ~~ mr.N ~nr, nN r~ Poy c1r ^ i .;v MASt IDODGl CNEV.1 M ID%Rt.fgVA) Slrtf ltDR CONV ) HR . ^ ^y r ^ 'u°. "ce:,r. ^ H ^ :° v r Kii v~n~vG~ Sf . '~v` rf `v g'r o ~ [ E l vl ( Nvl tf[D,Rr NOV%1~ ~ se UCFH ArfN l nr.`t iRUItR RAIFn Sl.rf I~ v[N CgOR TRSFTAFR _ w 0~tt Sb3 .^ _ Wf~ ~ nN ne DfNrnle%iqN NO. I ei 11 l a IPIA 181 I t !4 RGSrFR(OOwwIR: V 5r ` fH ne lnNr 1 ~ r I I I I 1 1 1 I I I 4 r1R11 MiWt[ ngNf NO. It`Y. 1 p ~ O O W SrlRt wNfR~ riRSt MgDIE tl ,pDR(SSd OWr+(4 % t 11 ~ ns pi N I AM(a%DDnessd iNS UVUxt<o oR %G[Nr Q u N xL[FT"'- wMwt %xeA ' a ryr.C~WMU <NMGf n' CNAR gNAaGfD ARN C S iSl 1 MM.G~ ^ OW C ~ R[MMNID AM•nGf • s ~.DnWAYN ^RFMA'NFO l5t O oL uio: ` l f r W T r 1 rOWfD LLS 'Ab w.nr er: t a DIAG AM OrrIf_COlLI510N I fu a I I ~.._R, I ~ ~.-~-fwy xf._NS1r td N pESCRIPTION Of COLLISION• If5t supn[MfrflAl SrK[tu Nfc[ss.RTl a - Ye~~~~.. g18. .F~(Z~L _~D ~-rJr . _.QIbNC_OII~O 6t~~.~_ _ C'~ . I I --1-~~- ~E~- {---1 p ~ "F 1---"'1 0.D..__~(11V[A __1-OYS (~ANteeL_0_~iS ~(QN-{'. $1LOt,5_ ' . I T I , ~ , ,_~.. _ .! 1 . _~--}- - L + -~ _ f BrunlYSla~_._Actraet (3o'TN_cil~pLe_Stt.~,LV__Snl-c~.~F ~~j ~ ._ Oi11L {4jr .aDr Tf1f,__VCH %f(!fY11 A ~LfsJ oa . ~ _ 1 1 1 I-III. ( w ~ I l . . . _- r'.~uy 'ilk, Sw .SFbulOti nfF1. ~aAr l;y r1ti,_ UtHfUe. 1ilMlcl.s_ ~ Sf 1 } 4 ---.-~- I- ~ V+ _..DfiCN ~ .Qv11S 0 .1~5-~_WNVL_,~[-- - t. I I ~~ I ~ f11 ~ I l..;Y _' - .. -1 -- _ ._i ~ __ __ ~-- ~___ ~~ Co Mai ib T • I ` E, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 Z 3 ~ 5 6 OCCUPANTS/WITNESSES iDOa :nDOwi:i rwr,v'i i '~uv' e¢t~ fnus '"„~• -~•~. .. _. . wi. n _-._._. slR tn<t si{c;,. N M.f 2-#11M1 MIl.1LAa D _ .p ~ i +o""" a , u R ~-~ _. _ ' . Dara H p l ^%M n E41 ^ ^..,. ^ias. M - . _ _.. _.-___...- -.. r x a __. - , Wnn N%tueEd R tD 1ROm ^~rr ^ ~' . 0 C ^ :° °f Nl er ^%mn ° rw _.- , r•r.rew•1nca1<IR • roM VYRSDr unnnr ^xyn ^ ~ "^itrlp ^Nr ^:° :y X l fto,• . nwct o. iD rA AcuKr U•.., ~o" cno µ1l/ ' ' woo no DAn DlnroR1 . aovm Dr D,n ~~ ~' a, Y I I ` " ~u~~ ~"~". ti~114t "~7~~; '~' fElklr` -1 ~e l ~r•~"~ ~-", '~ rc~fya'~m^r %~: RS~e ,~,~~,1(y~tj~,.i ~'•( mYy 1 ~{r t ~' 4' H 'j'IP~ h~~&~ T 'R l ,. " J I ~~ J p 4 7 ~ r,~ ~y lW~^ ~' ~S~l 111~gr ~p 114~r ,[ _ f l ^ i u s I 1 .~ l ~ ~ ' ~~i~ i E' tis t. c[ ~ a f~ - ' ~ t F _ 4 ZP '~ , A h!T ~L;. n f},~~~ .1 ; 1 - ~ ,. ~ k l I rl :r~ I ~~~ POLICE TRAFFIC COLLhEJN REPORT ~TRAFFICWAY foFlcfcamnA / ~ PRIVATE WAY DAr OF COIII Ar0 rlmf COUNEY CO f rF. wr. u ou t ~FI 4 IUSF t•W nOU91 U .I yNp, f ~ a© ; e~~ T.sc-f-.. N OOr sIPFFr 09 nIGNWAY ~N Qf QIN Orv OR rOwN Fl6~N fls ~ MIIfS 5 QW Of yfA 0.C ON CLNELY' INIF95fcr O lY IN SWrn. SEV[Er OR ROAD HINIFV5ECIION BFRVEFNE H-i rd SrR[fr 6 a_'( S~hN 5 9 Er pgfflA f DISTANCE 6plvEM iON ROMVif9fNCf. CROSS 519FF 09 Nf vF rMIlF p05 Ifs 5 F W ~ L I A if[! Or E ACCIDENT MILEAGE CODE P coulsan rovavm: sfvFRUr: rOIAF NO NO. KnI[D_~NO.INIURFO~ ^SVIItAGF ^NIr6RUN wrvanom INf[ h v[nIClFS a ppppf9rY DAMAGE ONLY ^ e[f ^Sl~i~l[ OBJECT SrRUCKINAMfWOB1FCr srRVCK ANpOWNER'5NAMfl Fsr. DAMAGE FeL,c * sTs-AAGF,,.I_B(-~J,I a ,., a.5o ~'' SROIAI CODING s UNIT NO.I Rlvws NAmf+ uKSr iIR mmOFf UNIT N0.7 pvveR~sNUAE ^VEHICLE r cc t/LL Q.. L J U 54 : us ez SrRFftA v s ` ~ ~ srREFi AO09F55 sun coa pEaNE NO. D r I Ae 1lS Ll~ Q~ 3 -r R NF9'S U<FNSf 1.3S,r.Ty24~d1 SEAEF F 9 ~ 2A6 ~ ( ~ Iv U N OCCUpAtICN mNNAffpn pNF NO. [rF5 IGnr leant N E occup,.noN {IRM NAME6 pN0 Z / e C..t ~, i :< 120 SzDI R ^ CHECK (,~ ,rtn sf.s:N w.a' Ho A r ^CHECK (~ Fnlnf •s AN fMpioruaANOrnfaA •°( ° CODES Pn 7~ ~ .y^ l K.. ~ e"s',° 3 55 CODES ~' 7n A's+ 3fA<rroN aiD -n ~ UvIES d N ;~~v;~r.p ~^ • F a ~ vfn. R eIDOOOf.cnfv l ,EF ^ ~s:,t. ^ ;a~,. ulpARr.pavA 'u I. D9.conv ^ ,. f ^ usrl ^ ~s:~ o K ^ :s~ " cu r y . cc••~~ ~ Nc~ N .l ~ Z ~ r I vq . l .I I nv.l AapEEO r I N pu sun ne9nwn NO s H snn I o. D ~(~/ I C vfnlaelaNrlnutaN NO. /!2~ ! 211 .F! IG ~{l01~1312 ?I I L fn aelDFN N INN I I I I I I I I I s ~ Rfcrsn9EOOwrx9: u~sr rlRSr MIroEE ngNE NO. 4 5 O W Is wNF IASt iI sr Mloa I~ .C .oo9 ssaaM.E9 1 l ~d 5~~~`L =cv/~9$3Z~ e wNf9 sl NAMfeADORISSO INSUVANCE<o oR ACwr fj cY ~J~Q ~LI f v CQ L~ ~~ 5 IJ ~ ,vr' R I u A. 'ERT~- l9 DAMAGE ARE. O O 1 Z m0 w AM 4 . c Cn•vOf 'AV Cn•vG[ AGf MtwK T Id:"ono s f5. DAmAee ^ :ww ^ sMANED ~ ~ ^ iwnvN ^9EM,vNeo faE ~p.mnE:e t °ra. s dion: SfS'FticJ towmer. ~~~,~ ~ ^rovrto er: S t . ~ DIAGRAMOf CUIIISION ire tuNysSMI I i:o~ln ..... DESCRIRTIONOFCOll1510N~ lus[5upplfm[NtAl sEeetRNeeesv9rl s E 1 i I 1.. I- ' \vl l xl~`.e.i-Vf.Lle. ~ 1-I--I I ~ _ _ _ _ ~ L_ __,,_~ r - `V.~•E'S 1 C_ ~.-.Jr-~ V\._ CQi.J!1_i C r ~/wC.~4/__r-li- rKVV o Aee Y5 h gref ~F -. ~~ r ---. f ... I I , -- -- ~CL~ rct . ~.+ Tv a 4 , +- T b r o . r I , ; : T_ .. ",y . _ . .. -- (-$+-~ c 2 e Ile !- ec+ h; e 8 1"4 S _ ..f _ ~ ~~( . . - . .... -1,t_ : r_c l~-- • ~ ~ ~ 1 f. ,.. -> F f _ t-v . ...~ 9.1.._..F_o.cr,,,p.. soE-'^'~I-l _.___.._ y I• ! ~ I ~ tib o I - .. _.. _.. . __- .. _ ..~.. ~, _1. I_ .. FT f I. f ~ u NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I - Z 3 4 5 6 OCCUPANTS/WITNESSES Iusl sufnfmFnw sEe ra ACatanu N,.w n a .. __ _- ~'ii. ,AU urus u.FR u.r- ' -mr s R __.......__. wcv rsn Ueer N E _ _. .- - -_ F io ' ... _ _...._.. . DfLrsS NArILRe or .N rRVer Am e ^E41" ^ ^" . ^H7 QYB~.v » .. .. __ ._ _...-..__. ~ wml ner of ~' Re.rovfo rROM Ea }~~ ~ p r ~. j ( // o <fnn. ruu wtcE p ytD Dul o. Rf ruRr ~ rovfper DAn .,, r - ~ , f J 'T' ~ '~Y h lClwr•~. • 1:1~ ;~ ` ._ I'T'r~ STYS;'n'£:/ T^r '~~ I r' j~t '.i ° ~4.4~.~~ ~ V r ;APIA ~ ~ ' a a~ I , r , ~ ~ ! ~' ~ . , r t L; - ;i .,s~: I vfi s ,•., i "'7"~d~~ °s~ ~~l I IS •t t .y } '1) k 1 ~,~ ~I t i 1.-~ ~ ,. - ~ - I I ~*I~' ~.i~ 1. - I ~ ... ; ~ ,,,~ ~~r ce I ~ 4 ,._,l ~J'y'i a~ (i r ~.:.:.~_~m:..~ . x: ,. Al1vn vtnIOLE WLLI$ION REPORT ougrr clTr uc~~•x Nox ^;,° ~ o ~ Se ~~~ ~ i ^N ^E ^rx c,.oP,Rw,. NwE.«oDl¢,a[[+DarxaxNAr r~r.us AN1u, axMM %D~+fDA¢,x[D¢DP{ ,[~, EA:Laxo/a[[roa®o^w ®clx xr[x:[clrox ON "~ Gf O~ eaaf~ ~/ ~.u~ ewFE TLEQRrI[r eF. ^" ~ A,xLa rAO:: rra M Ea u cnu1 O. % o,TDarPE TA T .r »DLWPrMw 0 a ro..[o ^¢~ ^ r NAUPOOUw+wwr¢wD ~ al _.. fox c" ~'~ " ° "i e" nn" ` f i ° ° ° INNa u 8 ~ n F ^ PExLED A c s s s r niir an [ r .[~.,Ea.L ..[a D2yd OBJECT STRUCK IR 0 I,PUCy ` :OWNER OF ~0. F,C,(iST~M6 /y/O ADgI~E$S ~~~Q s~,;.., cnc cmLUSL __ - $ _._~_ - IF NOaE rnAN ~ -B,ryIVEB~B 4aBLMAME +wD C.ws ... .. '.:..,.._„'.F1144LMAkE. ..: ~:.,; Y : MJRE4E N ~ ~ ' ' ' .. .. . _... n _. wEPE Uwavm :~ .. 4llf d • ElliQT.LdNE......_.._,'r...::,;.„.:.:.kIR.PLfF...~-.,. N1N¢ 'rz LDLM¢DNDP tau sE NDP[rHANTwo l7oN A ~ STREET ADORESS . t g4TE NO. ANP.09_%-NB:,. vEPSOrvs wEAE §j[IEPr[/,>!7p{~gy,,. ~~ ROUTEN AND BQA NQ P ~. '. . .... . _ . .. . ~ IN¢EPAPATE A )~ t OITV ~ ~ : $ TATS COgE. DRIVERS OOGUPATI4N „ COU S'ION CITY' ~... ,;'- - ,v. ,l _....v6TEV.§.. ~ IF CODE ORIVERB OGOUPAT!ON . . . fl L p OSS ~ CF•Ern~ D IVER'6LICENSENO. STATE S DATE OfBIRT~~AOE gIYERSUCENSE,NO,t;s•..V,,.r, ;.: STATE SEK DATE OF BIRTN. AGE Bi+z 6 9P M r ND oA. .P ~~ M F M D. oAr rR VEHICLEYR. MAKE ICHEV. DODOS) NOOEL IN ~A•DAR 1. ..pp4Y, ~ R$1 v...,-., MrS~1G[tEYa r ODEL ~DYA~4A 7 0A6 El M . _ .. .. ,gg4Y STYLE IZ pRI EN ~ LIlIICI SE PLATE NO. 'ST'ATE. 'TRAILER PLATE.NCIr...: ....$TATE,,,-, `, .LIGFdiEE?LATENQ'.. ~..,;~,SIA(E ,.:..: TgAILEfl PLATE NO, Y/IN S'LI tJA. STATE ~~ ... VEHICLE IDENtIFICATION NO. .. ..... ..... 'i.._ .r '` YE!JIGLEIDENTIElDAT10N~NO.: ..:~...... .. REOISTEREO OWNEP (LAST-FIRSi•MIgOLE {iAMEI. DRIVEP'S LICENSENO.,,;;,,-J...,_flfQl$TRR.fi4,G.¢Ytt€Fl.It!!aI.EI!!S,T_~A+J4RkE NAMfI OA1VF1{'(,NGfrIVSE ryq. , ., .. L isE y ' .OWNER S ADDRESS (STREET, CITY ANq STATE( ..-...... _.;.... .OAT o f,BIRq N..,O1NE~8'HAOGRFS,S,,_:.-1@TAEEI.0IIYANggTATF1 ;. O I 7 OF ' -- __ ,B RTM A o r rP PARTS OF VEHICLE DAMAGED .; . . r •-_ , .; , ,, , ~ ~ PARTS OF VE ICLE DAMAGED ........ _ .._ .......~..-w...~r.~...-._ •. u.a rfo oYr re I IdRll ITV (NCI nc r.rc ..:...... .. ~. _ -._ ...._ _.. E RAGE IN EffECT FOR THIS ACCIDENT ON YOUP CAP ^ VE$ IA NO NAME ANDAODRE950F LIABILITY INSURANCE POLICY NOLOFR--.,, ". ylp.¢,y;. '~ ~ ',p:ai4NAMb; FAIAEIUTY.INSURANCE COMPANY-,....,. NAME AODRE¢¢ Cir E._ ¢Ai ~~~" NAME ANq(IDDRE55 OF,LIApIIITY INSyRANCE.AGENT .1:.:...~...... ~STS;,Y;y.,A.j ',':.aiFiE~~:~.... I~r.dlJ~k.E~IY.f,AUf~'j{UVf14EN NAME - L. ' N1JDi!PEO -__.-._-. d NAME C/ ' _.. _-.. ..ter . ..... ......... t .... V,..• r.~c ADDRESS •' NATURE AND ..SELL M F ADDRESS , SE%' E%TENT OF NJURIES • ^ E%T F " OIO INJUNIES REQUIRE DOCTOR'S E%AMINATION DY A OOLTOR+ ®^ E ~ ENT O NJURIES DIO NJURIES REQUIRE EXAM O a NOMEOR'S ^ ^ ,STATUS OF INJURED '•~~ MMK IPBT E NA APP LIEE NATION OY A DOCTOR »a INV I R ~ a o Po .+Lr $,OEJ NJUgEO' y;'-: xMMK-F1RST. DNE THAT APPLI ES ~'^ N~ ^ KILLE D ev[at w uxr rv ux~ o w ic"+ ~ KILLED ~qx4 i i n - , ', O , r ., .... ^ 5 ^ 6 ~ a7 O O orr~ _ sLV a a Mxo ^ caxa ~ 6 6 T^ MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOi USED MOTORCYCLE SAF ^ ETY: HELMET USEp ^ HELMET NOT USED SNO NOPI PRO NL C E M4tw oaao¢w; . wlwrNwlMRO. O r` i ' ....r. ~ WpE /E~NY W/N . I!I~/EMEP.-(~ JER r, q -yEHIDLEB B~HUu DEA~~ '.y [ ~bxw x xax» ' I S f l ~ ~ o. r.A..[¢ [.~, .L»K.[ .rra Pbr. ~., ., .dW_ ac6et i -- -- --- - _..------._. ._._~-_---------.....-..... ~w . I - - -... -- I - I / I ~----------------- -.. . _ l , .,. _. ,_ f ------ -- '----------' ,. Q --. .- I. i '---._..__~~.- .._. ' e ._ _. _.. _ .:____r.-1 ~ _ _ _ I .,..II.. ~ ~ I __._ _ _ _ _ __._ _ _ .. ~.,.... I ~ ... ..._ __ __..._ _... VEHICLES POSITIONS BEFORE COLLISION INVfaTIDATEO ar VEl11ClE N 5 [ W ON STREET OA nIOHWAY NAME ON NO. w 1°a,~ "N1i'A o`u uI.[o Dui o[cOCinEo olwxr Q'^ ^ ^ ^ ^ ^ ^ ^ ^ ~Nr,All I[wllrxur ^ ^ ^ ^ ALONp uouun iROM TO PEOESTRIAWPEDAL CYCLIST WAS USING: r^Ha Nx I^wA +^~„~ ~^PD~D. I^u [^Pr r^IP~ [^w PEOESTRIAN~PEDAL CYCLIST CLOTHING COLOR' w ^ ~.. ~.`..,kTaa ~r ~? a~ ~ f' 5: J Ww ti . ~ rA y 8. j C` n.~ h J f _ ~I I A ~ yy " EgM pgfik' ~ r . ^.. , ^,,, , ^ [ ^ ilriii r.ii~iiiii M[. n.r } ,- , 1 ,P01.0 MAgfACE W TITER LIONT CANgT10N8 a• TRAFf10 OONpROL ,-, Io TYPfr,G/flQAP.. - DIIIYER/VEHIGLE ACTIONS.. j.1; A 1 T 1 ~+ r{rWWtx owr I'"' ~~x~1+ I ~OAYl10NT r[rxG1 w owl [ nxKa[ Sf e r ~~ IM I ^ )"'c o' a orrf on mw ~ f r ~1 LLTD'Ir T ~] PMNrIrD / ^ DMaA ^ ^ f1o1AMON ^,/ ¢[~ op[ wAr [v ^ . ^ Go ND araA a rt umep ~~ 7 t I S : i S ^ F ^ »a ^ ^ L7 T LL~77./rwo wer ^ T ^ OVfP+AKINO ANO PA¢BINO ~ ' ~'a ,^~ $1 h14 i T sNaw Nn DARK ¢+PEer J L ~k Try 3S y .. ^ r ICI taw, ^ 1 ^ MGw1f ON ^ ^ vIFIO ¢ION ^ { ^ POND ¢lµ¢ ^ J ^ MANINO RIONI TUPN IV f + 2 ril lJ 1 ^/UG ¢ ^~IOnI¢O Ifl ^ • ^ ILASIrINO PfO 1[NCNAIH}[ 1 'I ~ ~ R ( J, ~. .j.~ ^ • ^ Kf ONrIN OAA%w0 ^ 1 ^ IIOOP,PAMPI ^ 1 ^ 4AK 110 L[lT TUPN { I 1 ^ ItHtllrl 1 ^ ¢IPf{t IIPH+1 ^ t ^ ILASIUNO WB{P ^ ¢ ^ ALl{Y ^ 1 ^ MAKING U TpgN ~ l 2} r} { "M1 11 ~~t ~r ~ ^ t ^1°a+i~uY ao H{n Iwo wAr. ~ ,.~! Vl T t yP1 `t l ~ {. ., 1~ i ^ {Cllr ^ 1 ^ AR 1gNK ^ I ^LIIT TVPN ^ / ^ 6lOWINO L~, 1. 5 S r ~$., ^ ^ I ^ OAIV{WAY ( K { J ` I I ~~ AY TEII ~~ AN aW11ALE TYII / ^ OI NC{RIIAOMAr1 ~[¢ ^ r ^ 9TOPP[06N POADWAV I~ ` N4'yy4 I I f , r w r , 1..n C7 nr} 1 ^ ^ OI i ¢WLIY O'ROO VAMR%}.... ~ 1 ^ Bi R}NO IN90 L ~ !l~ r ., ~'~tl. { `~ IJ A,,~} 1 i _ ~ r a d.'~ - L:,.-. N.~.rt ?e"" ~`Cy l .. , . I ~ ~ ~ ~., r ~1 1~~ 1 ' r ~~ 1 ~ r t ~ _ - ~~"h '~,, ~, } r r 1ru hA,l j 1 ,~4y { ~ ,~ ,1 ; ` u~'" ~. I ht~{r{r~r .F t r~r r ~ H~yH~~~~~1 ~+ ~y~ r( 1 I '~'~ h+ r r! yr'' ,~~ ' S 1'' ELISION REPORT ~ nounrr crtr ND r' ^ b ^ w ^ N.PT- 'lGFL~/SGU/~ ON 0.0,E NN °Q.Qf'' N ,2L~ ~j A~ [ l °"ilj0/ 11J / II R R°.L ,.~R11RIl°1KR. 'M / p J ~ 4 / ll / .O . b, , ~Y w.IR~P°F. ~ nNRA , / ~:; •, wa ° .o t:R a uRAY °.. w ° ,,~ J ~ ~ T r~% Ix1ERSEtiI )F1 • -+ °R 75 . B a YrC ;p' ~JJ'- S.a~ln ~ °°^as,;:~o ° ~~ .°o;=R 8:~;~:;:° Bwro°o~1 9~~~ =°E~~~. s,~ nEiFPFN~ o ;~ <l .~'~3b°a~~o, . . °FPI~% ^ ~rF :~IEhT~Tnt1GK,_`.':: n4r,,..;,PYKIWO1J1eiF1NJMgl,~A '"'OwINER..Qi'OWCQ1-6N+WC:AN„DM~D/I~AS:: I~~rILPSW~~f~ ~ veaco°eusa • R - R .. `.~. FlgaT u• - - ~'U!"^^' R - 11 L S n N°NF mAN E NvO Vfn 6tLl~216 • • .. a~E~eirc'.~st+ ' ~~swi. ~ A T NA E._ _JYEBS D/XO DCN/N wFA L ED.,"9~~n° /;F_rr~ T~=J~JPr ' ~?'a~_r , EEI AO E58 ~ 4~ '`~ , p. ..:.:.tip .Jwe pox.el~Y RSq+9 W fAL [ NJUNEO U9EA s[Penere ~Beer.~RFSSY ~ .,,~YY~,M.,;atw.Tetts .eu%.a+A. w CITY . ..., 9TATE, ZIP,G9pE» E?YJnEN4Cf+44?1T19Jb_. // °OFL~SON ~..W....::~4'a.I...~I/JIfr.;.k`.w. +.. ...:.~P.000F~. OHIYFiR. S. V.GQV?AIION.,:: ~~; `vim" ~ i - ~YX. ~ .E. Q~i~ i rnRY /!A ~ / ORIYER'S LICEN6E NO, SATE E% GATE Of BIRTn , A -XOy/U- ~ ~ I pflIYER'B 41CENSE Np ~,. '. ST T SE% , DATE p Dlfl H... AGE T? l ~ H%l e'rJ,CI " i M ~ 'S .yEHICLE YR. MAKE (GNEV. DODGE) MOD L OVA- AN O . GT , 7_ ~ ENICL Yfl. M~ GF1E1( Op _ EI 'MOD (~ O B (/ ~C Ofl~) .LIGEN$E PLATE NO. 6TATE TRAILER PLATE NO,- STATE _. :~ SE PLATE NO„ ~~ATR.': :;TRAILER PLATE NO. ~BTOjE..:. n ~~ V IpLEJ N IRC TI N ~'~EGP~GE GAd ~ '.~; .VFl.1104E (DENT fIGATIOIi MO.,.'-:i',ti:.. .-:. .,J.yt .;ryy .'...:.. - HEOISTEREDOWNEBTNIS.L'fJI~T.~MIppIF'!A`"'C1-;,~ I H{'jEN6E N0 ,;-;~ f]Efjlaj(~IEO OWjIEM1ILAS,TfiANS,{;MI$D-6E NAMEI,~.u:.. DBLNFRILFILE.NSE yO „, ,/ -~ ,~" G plyNER ADORES,.- ..ISTflEET, CITY p ATEI _ ..:. °. pF T n ~ ~ pWN~i'¢~SA,. :1BSi1LB•~~+~'~b~°I' -~ '.~ .DATE OF, PIBTH. U Sg rro " PA OF YEHI~,DAMAOED V `. f _„--`_, S 2(S __ CIAEIILITY INSURANCE INFORMATION-VEHICLE NO. t- WAS THERE Aurobo6RE unealTr INSURANCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ^ NO .i::; ~OELMBILIU'.INSUMNCE [gMP.NfY. ' NAME AND ADORES60F LIA6ILITY INSURANCE POLICY NOLDEA..~:~.. ,. ~.:,.;,.,. aru4::~:~,..n..-: ~. _. p NF NAME AND DRE650 (ABILITY W6U AaFILL... .:.-:'.:... ~ 4]]:._.Jr;,[J~.JI%llNf ri .. yz _., r...a. .. ..POLICY M9EN., ~_^..." _~. Fcrr/r~•r~.f.Y C'o -Ls~f!~ so27 P/kF 37' sESarl~6u~o ~i - • AGE r N FREroR ADWi KA ~S ' 1ST INJURY _ .. .. 'ice. .......__ _: NAM AOE ~... IINAI`T[O . 1 F Z DIWUflY_ .~......._ ~ ~ .. NAME ,,(( "j ADORE96~ M. $EF. ~•~ ADORES ~ / $~ M F NATURE AND E%TENi OF INJURIES ~+ ~ CCC~~T E%TENT OF INJURIE RE DOLTO ~ DID INJURIES REQUIRE CTORS OID INJURIE$ REQUI E%AMINATION BY A DOCTORT ~ NAME !^ ~ E%AMINATION BY A OOCTOR'Y Is FY~~-. ET ,NMKFIRSTp THAT AP EB..,,,;i3~1r0.. .'e.-i..SIAT{bS DF.JYJURED,:., '~ yj[MSf~SI.ON $,,,•.' STATUS Of INJURED r:: : .. ., .. I LE -~ry~ ~ ~ ~n ~eAtt[ N~ KIIIED Is v[x[I ~'~ oxi w4 /LJ ~ ND.. KILLED x[ iu r~onl rA o. R ~' 7 7 wN~,fll, ^ s^ s^ ^D 'OOH ,,,..,,.,,. ^ B^ s^ MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED "u SNOW NORTH BY ARnOW IN CHICLE ~ ~ ~^ DC6CRIBE UELOW WHAT~IW+RFI!ED; 11!EFCR]gYfNIWLf9 L•Y MB6R •. ~ ~... .. i _ T KMrD.°"R•I' ( O ,~ !~ .. ~ GK:iG./oLY~_e<!f ~"tr ~. /•.r ~ .R , I ~1~zL--v ^~~ fir' ~-v`-~ ~.~ ~ ,,,~~r~-- DR , R,A• T I III'"=-' z ~iJ~~tn .C r Ord (~i1~e <r/~~~ ~ c ~~ ~uA.Y.~a~ G-~ r ?~ I~ Y - _. :.. ,. ,~. 6~1 _.. _. .__ .... I --- _ _. - _ _ .... oY++ ^ ^ ^ ~ .. L n ^ ^ ^ ROM TO nr ^ ^ ^ • r141%;Nw ^ ^ ^ ^ ALONO Olouwn ,•w• l 1 ^Ir~ ^°w iiFU FD~wX•~ ) A1 SINO: ^ ^~•+•w•• ^"dAOM, W i+ A N , + wwNA ) PEDESTRIAN/PEDAL CYCLIST WAS U i°Kliiic • ~r: I^un ^Y. .^xY1RO~ lcN. I +^I• +I '° "l+• ` ^ COLOR . : I n.R. PEDESTRIAWPEDAL CYCLIST CLOTHING -- _ TYPE p[.000' pRIY[IWEHIp4C AGTI0N8.. ~. ROAD SUII/ACC WFATN[q _,FIONI.GQNDITION9.,. TRA[f IGSON~OI,:,.~....... O'""' ...Wxuf luw oNl OA UOMI ^ I 1MGNf 1 ~Y iufil 1 I°wCA ORI r01 t 14aC.w J a W1• Q1 ~pQ SIONKL4 ~' p^I 1 O ONC WAYS ^ 1 ^ DOING BTRAIOIIi ANfAD i 1 ERTAKINO AND PA6hINp l L 1 1RpaY ^nA ) ETON bON ~) ^ TWO WAY ^ J ~OV • ~~-'+~~ ) N~ ) ~3R ^ ) ^ i D LION ^ ) ^ ROAp llOlf ^ ) ^ YAXINO RIGNi TURN ) ^9Nf1wINp . ^~IGNTb ON[T ^ ^ Yll YANINO LFiT fURN E f ^ 1 ^ Nl l~p~' ~ f ^ ! ^ uc~r orm ^ ' ^ nAS.RnG n[D NOW OS TURN O U N ^ • OtO[R D)R%~NO 0 AFIWO AYU[A ^ 1 ^ IwO WAY ^ ! ^ YAKIN ^ % ^N;[ ^ ^ fl ILDWIND [ ^ uRIY'RV1 1 ^ bIP[Yl LIO.,1! TLKIN ~ [ ^ ~~ ^ 11 . LL~, ( ( ^ 9 ^):(CN• 1 ^ WYI L;:Y LI { ^ N:1 ININAL ^ [ ^ ^ ^ 1 ^pawlWAY ^ I ^ S10PPfp fCR INAINC J OIIICLWIlAOUAN IAG[TYfC .. AT T ROADWAY WI 1 810'P!D T60 Al ~~ ~. ~•n•.r. ^ 1 ^ OINlN.9KLIFY ,~ {[{E[ARSTIpN .h. ^ ^ 011 STOP 61011 N ~x~J 1^ ] ^ pIVlO[D ^ 1 ^ BTON'[O IN PDADWAv ` v ^~ n ^rQ ur y~~/{((' yR~ llAN11NO IN JJJ ~ . __ ~ LLL ;~ ^•O•I,•• OIIIAl11L ^ IU I 1 J ) ^ UNpWp[D ^ ^ IMrrlc LAN! ~ y~ " ~m~• I Fmi eu. N•ir ^I^ E LONINQ 9TARTINO FROM I ( •,•n~m. {{{JJJ ~• ON YLB ^11 ^P R ' ~ H1~~ T J •+ I ~ M1 N ~ F~~TLf I Dip COlL1910N OCCUR INACANSTNUC NO DANOfR IID LI - ~ - "' ONIOAD 4AINII NANC[ ANCA1 ^ NO ^ I) ^ 1 fIK:I ..._ -- Yn i 8C% AOL {f~~L~lb N~AC ~ R t.J.wi.{e.~AM1EFenRRrMrnYRem,4~-r IM~Y:•.•JrrJ.t+)••r•~•.~~rV+S~/;ELtt!A6If'MMl•C"'?k~'.'C.I~l49LY'~" ~~.^'"-"~ ~r.. 'R'!~'..~gNA})+Mn T}~'1:'t 1 ~'i .'1 Hr" ry ~ J a . ~ ..~ r n ?55 eMMMloll... P M~ ~ E` ;. 1! , ~ ~ ~~~ ~ ~'tta, rtyl~' 4rA,ri{ro sF, "~t+^-,rls r.;./ I a _ n<.=~.:~ ~ vu~.$Li it ~4r'r.'T,< d ~+ .. ~ }~ ~ STATE OF WA INGTON "'~°1RfV1e01 ~ ~` '` cr _ 9•Gf Of iJ T~ POLICE TRAFFIC COLLISION REPORT ~iRAIFICWAY' ~O~ ~ ~ ,' ^ ', I ~ •'~ ~~q L. WIKE CO/,.:W NI NUMBER PRIVATE WAY -gy 1~} ~~ ~~ - 4 ~i{ 0•rf fCOt4 N. .oo N Sl counrv ~ } ~~ rf ' m. 'ryc G ^N f ~ Iusf 2 OU91 couNrv arv NO. EfwA ^UURNF ~ a ` !'."~k • ^ p N r.` 7 MIES s w f nN O{S fEIO GryWnv f Ej•. RWiE OR E p gl o D. ~Ni(asECt NG Ve E eFF109 vOAO NON NrfaeECi ON pN ~ 94/so P9fN% SERFfie DSr•NCE6DV f L . Miff POST A ~ y ~ MlFS fRpN 9FVEaENC .CROSS5r9fki G9 NFAV SrMIIEPOSr ACCIDE 1 9AMP f w DIA qAM DA2A ~~ Cf ~ MILEAGE CODE C0 ~ .~. 450NINVIXVFO Sf vf9 rr E r64U fOEAI NO NO [llfD~NO.NU9F0_.. IU ^SVIUGF ^ry N ,rt Nr, ~ uovi0t - 6VFn C [S -T IM[ CIS I tAOSSSiRfFT0490 ~f~f i - - ~. l P90PFRt DAMAGE ONLY ^9ESUlrFD ^SldflF e~ OelfC1519UCE1NAMf Oi DBI Crs RUCK •NDOWNf95 NAMFI Esr DAMAGE SPKI•E C ODNBi _ ,V) M Q f _ UNIT NO, I UNIT O. Z s Dvvfe's e~ IASr flan MIDDLE Da ^ YEHICIE ^ PEDESTRIAN ^ PEDALCYCl15T }1 r 'SNNnf: WSt ' ~ f I l ~ iJ N sreEFi nODeEne I M ~ - ~ p ~y ~ n' jG~ ~ ~j PAL.FhrJL. 02 Crv a sle[fI ADDafSn "' _ P Epr, ~ ~. :. SrAFF 21P CODE ONE D v Srnr 2iY ~Q 34J O?1 ~ Ztl St fAM A1 R f ~ P { ~ yy k' R DeNFe~su< n ~~ p~s ~J si ~ , Ir a ° ~ I N No. IO I °~"r ~"r. v ~ nr -~ on fanlRtN ru. w r.. .~'~ a - ik. ,Erx, accuP•uaN 6 PfpNF NO. EYES GNr {(IGNi E CUVnrION ~ M N•Mf 6 PMONf NO. l ~ R [rE5 WR GNt K GNt - , ^ CHECK (.~ vEN nFA : rrE OfAHEnNEeAk ^ CHECK(/) nk ' ~f lAx ' ~ %! ( ry CODES-' D ~ y f e ^'O VfnKiF ASAN [MROrEf CkA rryea ~ mE u ua ~ ': in ncrwN CODES ~ ~ 7 ~ ur - . i:ssnwwi 5 E% N 6 awry rcu ~ 22 r <rro a °5 1 ~ N r ` ( . ~~. ~'• ~._ ~, ,~~X}s;, ~~yy}}.. r ~ y+ .k D{.~~ ~. ^ .Mew.M vvraA{a O ,w Vf ^ sUOLcE VFn vG9 ^ ~o ^ ve MA.E IDOOGf.CNFV O ~ E El^jDMr.NOVeO 3 LLI]D4 C~4V 1 m~ ^ n~r `D ' f p 4 , l kl AE 141 rouD (h a E, N r~ I ! nAFR 0.nrE NO. SiAlf I"I VF I { ~ ^ p ;~ ~r ~ ;r°' I ~~J ]r e.. Vf KF10fMfCAtgN1E0 C EnICtf DFN ~ W I ~ ~ 55, ~ 'V~ v A N , ' ~~~~ _ I L .'s:~ ~~ S 1 Y M vfGISRY[DOWNE9: WI fIP51 MIDDI[ vNONF EfO O I WN 'E9: fIR=r MID ^' ,~41 .P ~I.7 ~ 5 } J' nDDekSS CS OwNf9 V ~•6 W ,% ;~ 1 f " ° (f 4 ~ wN}e N S (3 ~E ~ ~ %; AMr s•Dafssor nw9Af,csco o9 ACfrar E I et` { ~ ~ ~ ~ ~ ' T' DAMAGI Mk• YY,rq ~ n n9GE ~ o+".ai c ]DDAM•Gt E cNn9G Ds; `~ DAMACfD •RU " . & ,#x ` y 'f4 I I p E . f ~REMMNID yy ~vl~Y f W t~~D ;~wiN ~ rOWfD ~ Ar ^efMgNfD esr.DM1n e I _ roiu ioii ~ ! , , '~ w " DIAGRAM OF COllIf10N~ IU• er-. Np can -°1 la -7- iai ` + _j:` el n9 ~ ~. } { ~ i ~~ -~- ) t e ~ f N DESCRIPTI OF COLLISION: Iusf su9PUmf Hss lflAf .Nf: ESS1R R -V~1i"i:_s1B_3eAUrn Valliy- RQ .V~ ~ Orf. I7Rvlte~.. Roapw oato O rr S r. ~~` t' - ~- I r ._ ~ ~.. - --f--' r + -~- . _. - f ~ - ~' _ E w _ . ~~ - V I vs'P Cb rt ~ f ^ _~ •;. . . ~ , ~ ~ r I ; r ~_ 11N ! ~ ; ~ - ~ ~ .. t ~~_ . .. n FU __VeMf;.4 eo2H..2Je._, w<~.~.~ . ~ ~ j 6 ° a - 1~ ~ V ~~ ~ k. ~ I _J.. ~ ~ I I 1 t ni C. Cress a . 4n,~c.. ~: 4 t m e.. w-Qv T , ~ ~ ~,n, , ,. i _. _ _ I `% r '~ I l _ _ .._. _ _ F ~ r ~ I I - t- It - ) I I i I I ~ F ~ ~ ~ _ . _ _ .... - -_. .. ._..._ -_. - , ` • ~. -~ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES 1 - NAVE OCCUPANTS/ WITNESSES 'iai:oo~ov:Err~+.ME ur Ky u - ci 7eius 'N„f" ~2;" 6 ,: v T F ' MnYle~ ,cans ~ ^ Elcr ; ;r rq ~ 022y D ~ ~ ' ~ ~ S ~'d ~ ~ t ~ r N.r o9r _ { _ r e. •Me ^:1 ^ .^.. i3v„ NO -. s I d'7P y; s~l0~l'~V~rtl~it '~`ki`~ ~l I~, .v91~fi"• P~~~~ E ±.us __- • { r wf OE °,}rw ~fD{9rw ^•Me p~ E^27~'.n. ^C~~ ^: No ~ '0 ., ~~.,NV9 . _ k ^ a d n~L>~,~a~Sn ~~~~~~,' " X L ,~ POLICE TRAFFIC COLLISION REPORT LtJ TRAFFICWAV / PRIVATE WAV yplKECpMPWMNIIMDFR ': ,. ~ ' .. ~MDg roC N v IUSE ttlp NOVaI COUMr .. `>•~- W U::7~m" F~. l 5~ O GGUNiY NO.. nn w. - ~ f I 2 0 cnvoR rowN g N e / ~ '"" °qy ~ ^ ^,N in[a ND.asrR[fioR nlcnwAV 3 MtE3 ^5 ^W Or R ON N ~ ~ } HC}NG wtrN S}RF[r 04 e0AD NON~Nil45FG}ION N ^s RCNIIf OR 5[C ~/~lO //~~ ~ t ,, •• II pS}ANCI B[MFfN Is.J IJ` [F}6 oa (,~f} Oa[ ON raOM a[r(efN IREEI% [ MRE POST //,~ /J . ~C.'!7~ 6 ,CROSS S,ef[r 09 ,~tARf 51 IEyp n MIFS N 5 E VOA MV SSE ~.~ ACCIDENT iSO r[f} W pr MILEAGE ODE RNN DIA pAie COt US DN NVOIV[D fvf 9,rv. N rOrgl NO ~ NO RIIfD~N01N1UR[p~ SPIIAGF ^n,i6 RUN weRerp~w Dr VlN CI[3 ,N}[4 ~ND CAOS rR[[r OR aOAD apgDOR RFRf SS Ii] ! 9 PROrtaiv DAMAG[ONLV ^N[SVIrfD ^Srdt:lf OEJftrSIRIKeINAMFOrOreIFCiSIaU<xANDOWN[RSNgM[I FSr.DIMAO[ y ~ \%~Cp~~ bPfCLLLCODINGIISf CG f DRWfRS NANf, usr UNIT NO.1 ~ EIRSr Ip ,[ UNIiN0.2 ^VEMICLE ^PEDESTRIAN ~ ~DALCYCl15T L ~ L N[R SNAMf usi ~D--~ ' 3}vfFl gppRl55 ~ /ErcJ 5 P[[r pRfSy 2 C,ir srA}[ D zlP COU vnoNfw DRMRSD1uKcr Po~l3 So SIAif R , r"rf IR G~INKA z c~ WA r 2109 ISP OCCUR pr 6Prx)N[NO ~[ y Iv 1. fN ND w}f q}f RD R.r ':. 2 FYFS On} qn} ~7J G 3 E R CUPgrION NRM F6 PNONF NO. FYFS IGNi f[Gn i ^ CHECK (.~ v[n clf A a u+RV r[[ • ANOr,[R:•l ^ CHECK (/) ,Al i v CODES-* ] n ~ ~ . nc„w a c! e l ey",° v[n c [ [MRDV[[oPA o. N, CODES-~ s~ arch i ~ 2 lw,os Vfn YFApM Mq[ M°N•Cnfv.l fIIDARr.NpvA( nUIR pvV.~ v s •s srx eu rmn w [U , AR °~ Yr ^ MO V " n OS yp E . l DFI q( I ll 5}wif IFR RA_=F NO. SigiF ~~ ,a , H yf V[n CIE D[M IIC r,W W C L of nlCl ,pENI, A ~ / 7/ 9 RFG fRafDOVMla N31 ,4Sr Mlp i ' pl[ ~ ~~Q P,gNE NO. 7 /~Q Q vas fDOWNfR lgsr rlRSl MIDgE E l OR[sSp DWN[R W . Ownfe S _ N r f a ADDafssor INSDRANCf co a Acw} E N ~- ST E aryl iRKLsY.vt~ DAMAaowvu o-s•N NC R ' ,v~.CroNN CRg4~ wC wW gAMAGfD qR[A CMARa _ ~G ~OirOii S f3~ O pP Av ^%Mx1NlD ' ARryIN [SO10gMA f I eP ' IOl ^ W,qY ^efMMN[D ' s p s onB~ OV :~r er, ^:wi ~er: S roi a DIAGRAM OF COll1510N I zu r Nec^P4~rn DESCRIPTIONOF COLLISION IUSl SUPRIMINiAl sfefi rMasuR( l I 17. 777 p~~{{~7 o ~- 1 fNAD S (7 / ~ i y .._ -r .. _ E/ --f• 1GG6=QN _ _ U~T i ~ ~ ' 1 j _ ~ xf7r/{ -KSc f oR~ ~._.Lould sf'_Ta~ ..__..~ a ~ - ~t ~ -~ -r _ -~^-~~ -~ ~- _ _ ~ _ «__s.H~._1y~,v ~,~ ~~~ -_CtJ /cH_ ~/_/AS_ G~uS 5 %N6c f/a~ T . _ _ ___ _ _ ~ - _ I ~- -- 1 ~ ~' j I - __ __ __ _. _ ~_~ ~. I NAME. ADDRESS 8 INJURIES OF PER ONS INVOLVED 'CODES 1 2 3 4 f OCCUPANTS /WITNESSES lets nfMrwNtsvH rOR ADD~rgNAl I NAMr //UG~AN AR rl 51 7 r , ... SI+ AGI -,- rA . 1N41w ' ° M,' 5 6 "' .fir.- f,[fr ; n u R .l nx ^ eM e ^ RU° ^ ' . ^ H o :~ r,• NAwar,a -. ~m~vlD,ROM ^ • -~ ~.., ^ . O N ^ :` ee mm ,. ° -~ - ~ N: . ~ . n1-.,, ro , ~ ~ „ r ~ ~ e ' js:fG tq - r,OR ^f jRlwl ~ ~.G D A ~' Dq„ / ~ } ~ y~ /~ ~O ( , (/ . ~ C ~ lhvh~Y 1 ~' Ft [ l~ 4~ 4~~, f( r 'T Y¢~ . Qy.. } /A ~ ;1 t 'F Ix, .~ Y'~~~~ X+'?; ;~ ' ' r' . ~ ~~. J M:B;? ME 4, =.m bECr ~ ~ ,5 _ E ~7y' ~~: 'H,kk ~~ F' ' ~ ~I ~ Kt I ~~ ~ a~ ly' !v '~~ ti pp,, .u e^9 ~ ,nw ,~'~~I.C f a f I ~' . dal ~' ~~ t Me r A ' ~ ,» -. ~ ~~~~ 13"T ~~ a .,x 'r ~ ~ [ t p-' y r~~ l R 1 .TL y 1~-(` t 5 ~~ r ,, j I . _.,. 4q( I ~k~ ~ l ) ~ ~ r I ~ i - 5 t ;3 r~ I I ~Ifu i ~.1. Y: F ^Ni ~-~ ~ erM1~e „ ~ ~. C r.~ a. ~.;J '~Z ~~~ POLICE TRAFFIC COLIIa`S~NREPORT l3TRAFFICWAY ~_ ~.~ ~ PoIKfCW..WNi NUM Fv - ~L ~ PRIVATE WAY RI -DAtFtOi COlli , N . --~_ J, _G yEI ION-_ ,.__ IMf COUNty ~.. ~nr ~ r,. Evu. mp, '. uH. ~15•r IUSf Z•oO HOVRI .I° I.P.I. ~ -' COUNTyyy CITY NO. XWA /~ ^EURBAN ~j 3 I l I X 9 0 0 o7 EFF~'t S v„/ / ueu I ^N ^f ^IN CIrv OR rOwN f6N00 SJPEfi OR NIGH WAY fCr 4jj ~ ROUEf O4 r E{ MRrs s ^w or c ON E'n/T Irrtf vSEC11NG mtrH: SJPFFt 0440AD rANIN1ER5FCIION (l ~ ~-~/SO ». p eE1WF[N ~ SrvEEi 6 C O Y L !~ SrRFEt GIS pN<F DI4l i OM 4ErtaFN E CPOSSSiPfFrOV NfA4ferM FP051 PRtiIM MllE P05r /J % DQ I ~ . R ACCIOENi rev nti 5 F W (/ r(rr ^ Or h~ /- µCODEE RM1P puGaAM DATA CO{lI'IONINVOIVID- NQ ~vll(D~NO. INIUR(D ^ SvIIIAGE ^ H~ GrAINO r64U wvpmpl+ q V[HIClFS ~ N I %~RD E v rI erafEl O4 AOAD04 R[FfafNCf IMF Cli CROSf 51a[`EIO4 aOM aJ ^PROPfatYOAMAGf ONLY ^RSUIr[D ^V(a[lf OBJ[CiSJeUCK IHAMEOr OBJFCr eraUCK ANDOWN[e'e NAMFI _._ [Br,DAMAGE S ~,J S~Y/ eP(CW CODING UGf / UNIT NO. 1 UNIT N0.2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCVCLIST ~' s D4Nta's NUA[: IASE rlas, mIDDEE DRrvtR'sN•Me wsr Nv I t - 1 .c~ YV ~~i~~ .E} C-- Ic $ - S,4([rADD4F55 W E., /'~d r4Etr gpp4[ei Grr ~ SIAIf ZIP COD[ PHONE NO Qu/ C~~ w 9g D R • StAEF I Nf ~ r v FR'S LICENSE NO. H-r~t~L !~i r~ 4 ~ 1J t SIAIF w +t% 1= ~ i S hS~ I ~ I 'SE LNSFNO. rArt SF% D IF CM BIRH "~ ~ °•. r4 B 2 OC<UVxiION NAE6PHON[N -~ (Y[5 IGHr HfIGHI E~ i~Er SS E R OCCUPAtIDN iIRM NAMFL PHON[NO. EYfi WFIGNI EEIGHr - ^CHFCK I/) E~KiE ASnNfM>invEf ivAUOiHfvAl ^CHECK (~) NEMPiovFFOrwNO,H[aA` CODES Y~ ~ i I 5 1 IcJA.,/ e , x . " ° ' ° C9DE5 ~* 2 ~ ronN N' " iO :ii ' ° ~~' , , .vI n ' S N 6 s N u i:snu i .. ~ ^ v c C ~ w10, S m ~f~:. R° ,meDl.„cE p ~~DI ^ E5m. ^ N.~~~t ^ ;Svs. rom ~°' ^ AmeRl.NCI ^ E3L~KE ^ <S:R ^ n ^ ..:,:. ~ P ~I '• I v[AR tIDOpGDCH[V.1 FI IDARr.NOVAI S1YIf Ia DR.~GONV ~ 'W'1 r. ~ 1 E n [AV 1 E.eHev.l mopfEEDAat. A1 n f Da. Nv,l ' g. Y~~^/ /frX68G9 sr~~ R[4PIA,[ND e,Art H 4 « a A IE A A ' VFHKE[ID(MIrKAIION NO. N!~i6 ~ a b I PIGISRREDOWNt9 U%Sr rlPii MIDDI[ I I PHON[R10 L, vFHKEl IDtNDNCA I r I I I I I i ISr[af0 WN[a FL a/m ~ nJ ~... J' m Es O W lASr rI4i1 MIDgF fN . DDalSS Of A OWNE4 ~w E AM[aAOp4tss or wsu.ANCeeo. oRA [Nr R IN D ° ""' aAeu,{ ~ y tovolY. cHpeu gAMACtDAatA , ~• I P y ~~ ^ _ S IS~ty MMpGI ^REAWN[D • ~ ~pWptN ^atMAINLD E51'U Y ' r R O ~u fex f ~D S f" ^ pW I T lOW[D WA v Y er f ,~ ~ . w I E DIAGRAMOF COLLISION ND ~Ato DESCRIPTIONOF COLLISION• IUSISWRtM(NEAISH[Lri ee[ss RYI P _ _ __~- _ - cl I YO EN-I C r ~ A-7'. ~ tr l7 [~7 5-7" ~" 1~ I -f ~ .~ ~- _, R3 t --I - - _, 1 I ~ ' _ - _ I _~.. _ S M . N IP 0 u ~J J_(r c,,~ V r To ' I _ I -+ .L E - r --f. _.._ F<,.__fi E}I r_G C P' Sfj'i OlJ-r..0 0 ~~ , t , _ 1 + L}... } r- t _JEd/-1-0_wR`J _G-D,J G. ~~/r9_ ~/.T_CJ~- I ~. 1~- 7 ;- f--- '_~__i' I_ _¢^/ E.'/9-csJ S!Oo- O /~ ~ioR~J!,1/S c ~ ~ I .. _. ~ ~ l L ~ 1 ~a ~i J l a F~~T ; J I ~ r ~-~ p~c~ ~ ~ti „ _, . - -- .. _ _._ I • I f L I ~ ~r EZ J d 1 ~ ' ° /t d` ~ ~ 17 d L f ~ . _.. _..._ -. __. EV.___ .+ f _! _. _ . O.r~_ . . __ _. Q_W1 -1- - /rT. _._.. _.; ). !.__j.. i__L. ~... - --.'__'_ __ _r.~..- -- -...}_. _GO!~ Timmy r'O_._.~ N D_TH_e'YP_ 23...../CT le I ,..~ ,J 4 d e-JT W AB'2'LS NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 - 2 3 A 5 6 ~ OCCUPANTS /WITNESSES IEUSE su wm 4nrmteut sw pnlorul NAMe n sI __ _ . sTK AbT ~iwius IMHH _ (r .,, ° _ "'J M .. _ _-._ u,cr ESH u¢r s I ,. N .mE EHri~ C. L~'E r',D 2 / S' N A J . _ __.._.. _______... . _. _..___ . __._ .. ~ . . «w. PRD _._ ... __.. _. A awESS M itprtoela ~ mourn room rn eY ^•me ^•4'."' ^F'M~. ^ HT' ^ ::s, 'D ~ - .. .... No .... , n:wKK v~lE°' EM lr ^•me ^w hO^<Mrl• ^vi ~ ^". n ~ •. ,+ ~.{ra • 5 ml s +.. e•Dw . .GINC. '~~~ 22c~1c 11 ~ c~l q~ nD U3.{d/ p•,~~/4 7 pP.4ov[pe. Den I '~ ~i? _ - -'T"~~3 +r M ~ , ~ ~. e s: r Y}~ ~~, off. _ Aw ~ ~ ~ e ~zu~/I ~"~ _ ,. .~ ti , ,d,; y~ M n x ~ w t n v ., >w. 'f l ~f d 11 r_ J ~, ~Q k,~ . a, skt~u~, Its k.° ~~L w,~' ,I.,+F ~^ '~M° a.( w ~ c,E~ - ilr E R ~ ~, L z }'~ 1 t 5 lE r L~ I , ~ 1 Ott I .~,~~. I ~ i + S i ~~1s t ~dw dNnG - , ~. 1/ 1 +F/1 L _ I L 1 Ala! 1'S 4' ! I r c Ciy 4~~~t__~~~,,,r)~ I ~+ r 1 y_ t ~~~~I 1 +pri / I _: ~ , I.1 ~' !/ ~' - -~ 1 d, ~ ,•N "` 'l '; 1 ~~. ~~ - ~ ' - ~~t ~i ~,'a~ s q Y4 4~n~. T ~; 1. S ~L F L S YI X ~~ t zapJ.~ . .4 R ~~ .E~ r y f $ ~ y ~~ r y . ~ ~. ~ ~ ~' ~ +L y: ~ ~ ~ ~ i'~inE 1'if ~f' 4 : ~%: :~ 4~ ~. ~' 7 .i ~'_..~ .y' t N 3~ yy 7e3 T ~Y ~ , `~=" '1 `.i. ~i ~ , ~~4 ~ ~~ .~A ~ 1 -S1 ~ ~ / ~ ~ .~ w.!~N ~.TT~..mm~ ~~ ti lyre Y~ l u,~ ~ ~~ ~dd ~ ~ ~ 1¢ T a l ~ ~ yF1 ~ P~ { ~~ y 1 ` ~ _ f ~ ' C ii. ~ i~ ~ ~ t , ~ ~ ~ ~, y}~ 14._.^ .. .. , . .., _ ~I i{ (~ ~, rx ~ .,I.~I , ' ~~! ,,,.. POLICE TRAFFIC COL N REPORT TaAErl~wnr f ~u. I PRIVATE WAY A' 4ESOiir. " nmF co ucF ,~R _ - ~ ] ~v~ uNrr •. w n ~., ur lus~ ~ual ~ muNrrw clrrro.. r ~ l ~ `~~ O S p uae r ~,rrPPEpwN ^N ^[ ^ NAf6NO. OI SiPEF1 GXWAY a„4AE. RW, MIES ^ AGu ON L ,N F45fCr NGW N' S1RtE '9r/,SO . i04 ROAD NDN,Nrf Sf ~~ ©^'/ f..~7~ -^ DfiWf[N EIt~{J SIR[Fr 6 '/!` Slaf[r D iANGF 604t , IRON 4F,FRFNfF CROSS SERFfr 0 PREf miLE PpS, _ E - ~ ~~ ~ O - ~~ ' I , 4 [ RFSr MXf PoSi ACCIDENT IlF3 5 E /S ~. ~ ~ MCOE~E cou saN Nvavm~ FR rr~ RAM. AH MIA - IOInI NO NO xal[D~~NO, N1URfD~ ^SP,IUG[ ^H164UN OVFNiCU3 qJ 4tN -0D IOR V,,h', nNU. Nrw ~ QS CIfD55511f[FTO4 YOID ]] ROPERiY DAMAGE ONIY ^ Rt SUIn ^SrIXFN ~'~ o5ncrsr4ucx vFX nF INAMf OE OBI[Cr S= RUt:S AND OwNF4'S NAME) [SI.OANAGE ',~.f.J7~u GU SRCW <(H~~rvc US! _ _ f ~~ 'i 3 UNIT NO. I gwtR'3 NAM[: I0.5r N45r MiDOIf U NITN0.2 . 'SNAME ^ VEHICEE ^ PEDESTRIAN ^ PEDAICYCIIST' ~- .~ ]' ~ S : lE SiREII ADDat53 O C11 S1A 4ft1 ADDRESS lf ZiXCOC[ w ~ ~ ONt NO. 39S D R , y SEA ,P ~ ` ,r DRN[R'S IiCENSEN ~ Ckf Lob SIAIF W M "° ~ B1 N^ ~ i lKFNSf Af D FMBRI„ ND .I ~~°~] E P,WNE NO Ens IcXr ,F~cXI E E occuPAUON MN4AEavXONE NO Ens / L ~~ 19o C R Gff EEICN I ^ CHECK (/( vtX nE As:N FMVIOVFF a ANE'irXEa A` ODES®~ c """ , ' S l x cr E», '"O ^ CHECK (,~ FAS AN fMPIOnf bAVpi„tanl ° }~ r 2 C y „ A ~ w x.cu CODES -* D a x `sr 5 In y s :i s 'iv:, N rtD ' ] i ,FS o E o,.o« ~n. ° D ~ q ' - rU ND ~ s Z ^ A.xn.NCr ^ u6u. ^v~:,'c u R m+u EDDDC[.cXEV f ^ c bmw ~ w ^ c"b'm ^ W„K,[ ^ :°NV ~.~REn ^,sN ° ^ ~ r u .E l j D, i4 vA t EDR.c p / ~ 1 I/ B~~ E X . E MO oe y EDAR. vAE r I v., E ]° '~ Nx Rur RR ~~ s ~ MIf No. self H rE rte N ~ _ v(f,ICL ArgN ND. C vEX,4f iDlNi ly l a F 1 6 RfGR1F4fDOWN[R Usr II4S1 '` . MipM[ a1pNE=.. O f , nRFD wNtR, t/Sr fIR51 MiDp ,t'` ~ ~„ ADDau vow«FR W , ,C f F4 N ] AM EADO4euamwRx„a ca. oR AGENI E M s. M y a DAMAGt MlA O,v ] ^S t~ov - u DX ~~ CMMG! EpinMtiwwa 4AMAGEp AREA Dr„ 131 rpAMAG[ r 7 ~ ~ ITOP IC~OPO~ > ~ W1Y ~a[MAIN[D ^AW~Ar ^RfAWN[D l3 ^ r Rr: f 1O DIAGRAM OE COLEISION lu ND SSA a~NO4m DESCRIPTIONOF COLLISION; IVSf surnEMENrAI SXEn II NeassA4rE 5 ~ ~DL/171J?O(n/5~ N v fl _ ~ F712EOF _ I I ~ .E_G• rv NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 OCCUPANTS /WITNESSES '~~; bD cau Nu:i ii ? ~_ 4 3 6 -- ~s l N,mf UIOFK ,C_ _ _ , xMw - -~ ~ ~-- 1 D f "' '--'--- y six Au urus '„ ,., ,„ nsre. Nra ~;;~ ~ ~ 133 N,MI RGI~ J ._~_.__ ~ - - - N O ~ O ~ " Irx nT AMe ^cT1"' ^"~. ^~„ ._.. DW S•. H ~,y N.IrGtlf pl O-- ~ o ~ R m4VlD lapin ",,, .m5 ^ INr xr y.I ^ qXI 0 , N Nw f .~. _ _.__ NA f01 __-..~ B r,yf St::AtryGpEKIISiMmIIIx„. A 4 ES G INt ~r (.v1^AVS ^[i ~'^~(wnI Hw rxrnr D I 0 IN:r ~y 'j ~.~'[y%~~~j~ID X 11$x- ~.,, w,sP ~'J IXS~r,b~" ~ ND OAIip RIPO41 MROVID RY D I ~`~` E ~ / ~3.ID/_ ~~~ r~ y ~ . F i '~ ~~ ~ L ~ ~~ µ ri G A ~ HY` ~^ 'yi3.w 33 ~'"ri n x , ~? <4 ~ ~, = r ~ ~ ~ In { r. ,: ~ ; ',tt > ~~ ~ •, . Id+ ~~~ @ ~ ~ ~ 4 d, h s 4 ,d Y' :~ ASi~ ' rr ~ 15 ~~ ; ~~, _ . 'u _ t{~'. x .~ ~P I ~~ ~ P, ~k .n~~~l Ai N V r.ri 1, .,. ~..~A- t Y~~ r- ' ~^ .'~ 4ys ~s l+ ~~'y=~' :~,~' fi, ~~1~ d~' ~~ ~..:_ sin,, # ='_ ~~ : ~~r~~,~- F c'" ,y a . ~~,~.: ~~ 5 a , M ~~~ ~ pmt r 9 {~ ~ u ~ h`Y. yqpp n ~, ' 9 ~«~ _ Y ~r ~~ ;~ ~~~ ~E`~~ Y ~ :l r.F~C~i W .fa: 'r, 7~c ¢u r ~~ ~' E ~~ ~ R 1aq~gC£~.e . i ~ ~,r~+~~ B~ ~;r ;.~~~~~i ~ ate.,- ~ E~' ~~~ :! . 'ID'S v~ "'I" ~,as ~ ~ , .t~ s- ~, . ~ #Y hN , •~ • ~. .:'yam Z~IK.S'.L. ,~ lI ~ ~ ~~, ` .. .~^ .Mg ~ o ..ff~ r ~3A'a e ~e~~ • ,~ '~ I ~~J POLICE TRAFFIC COLLISION REPORT ~ iR~FIC~AY WIICECOMPVJ rv I ~ PRIVATE WAY A /]' O FU C ll'S~~ COUNrY 1 wf.~NP Il O_. ~ IU E NM/ ~ EF E a~ t CHYO TOWN F6N00 51 [E109 HIGH N I F N MMA C~ ~ CI(Y eK1. QFORDAN ((( URAL r ~ Q WAY Q N S M«s p]s pw or ,~ E E ON .~°/' N1t95ECr NG VnrH RF vROAD v E l5 ! ROUE Ip ION ~ . NON f ~]<r1//0fIN s// BfIWF[N (f/T D~ SIRFfi 6 ~ H CJ $tptfr ppfrlX [ MRl POST ~~. ~~ DISIANCE6DV[~r`ONEROMVDFVENff CROS]SIRFE RNfAefSr MIIE POSr fs N s F w ACCIDENT RAIN DIA RAM OBfA /'O r[Fi Or G /f/./Cs d MILEAGE CppE COll15bN NVOlVfO: NFVt9~rY +Y r6RUN N rOfnl NO Ovll[O~NO. NIUR[Ot ^SP IIAOF ^N wrvvwoe° N A3~ ~pD Irv FR I F OR ROAU OR RDERENCE M( q CIS CROSSS(pF[IO4 pOM ]~ I ~~ OPVFHClfS ~ QpPOaRrYDN.tAOf ONLY ^vF UIrFD ^SF«Clf OB,fCr SrRUCXINAMt Of OB]fCl siRUCV NPOOWNF95 NPMEI ]r.DAWAOF E / /E y -°~p ~C~ ]PFCIAI CODING 16f ... , ~ .~. S ! UNIT NO.1 UNIT NO. Z ORIVtR'$rvaWE r ^ VEHICLE ~ Q PEDESTRIAN Q PEDAECYCIIST y _ : NS - iIRSr Q ~lE vFp'SNNAf: IASi PI I l Srvf[I OOef55 ` ~ r ~ RfE DO4f55 CITY } IIPCO« PfbNEtA Y ~/~ ~~2 ~ ~~ DRrvEkSDC rv0 D R I]Y 5 AIF IPC F ~ . Fs 0DA BI ( Iv IKEN n ] Atf DAEE«01ptH R CU AtION M f6vHONE NO. f 5 OHIH Hf r E OCCUVAIION N NNAE6 PHONE NO. EYES NS GHE PE GHr ~ O S R ^ CHECK (~ FH of AS:N rMPir f aAP~,«HFV.AI Q CHECK (P~ „f IE AS AN UnaorE(w ANOrH e°1 7 CODES -' 7 ~ °111° 5 I a s",° i,f X ]r~wH~ ,ICI aH F~rv .cu F CODES -* 7 c . s: s IX .if nwH' r N y ~~ K.cil . =• n W E; C v DI R~ D„o .D. .,.N,,.,a ^ ;y<I O ESm. ^ ~~.K° ^ v' ~I4t p AY HcI °a, cI O i Sin ^ .r ^ C° ~ ~ lI H V[H v TIDO,Dn`GE.CHEV.I MODtIIDARt NOVAI Srvlf~l]0 ~COrvv.l l ~ ~~ ~ / O ' S H H vUR HFV ] MC«110ARi. VA] v I l v l '" ~ 2 H IKfNSf Plw N 5]Arf ' IER aArI NO IAIt VFH.C«DR H ~ A No. A _ G 7 ~ C [HICIEIMrv rKAIION NO. F~ 2: ~I it 1 ~i q ~l I I I I L v[HKEF Utn A I rv I I I l l I I I I I I ere srtRfoowrvfR~ lASr NRSr MIDOU PHONE rvo. ~ O W sn D wNER: lASt rlpsr «e ID AUDRE55 CP A WN R I N ~ Nx Ip.DDRlssav.wRANaco. GR ACwr R INUAN _ OAMNa ARU c ' ' " - HN cHA D« - ... °°U~~'"~N g.^`ACe I u. cHARCf ' _ I]t. DANAG ~^.N ~p[MNNtO ~ ^AWAYN ^RFMNNfO FSi DAMAf.F in ] O ] j f I WtD ^ rOwfO AY BY: AV BY~ t r DIAGRAM OF COLLISION iHyt Nice N Y] a IN C L11310 Ilne SUVPUMW]N SHfetu WC[UAVYI ] ~I ,~.,pp~~ DESCRIPTION OF O N .i , , , ;.I ~ ,_,_{ ~ ~-~_~ .~.~_~ - -pia. %._ ~~o'rp-~vu~~o ~r/~ f? yy T/ C P~' AF~y P~M Y - ~&~,rc~ ~d ~ .rain, _ i I tt I- tc~~~''fi~gg~ , i ~~ .. . r _ ~ilc.''CV. C? yT .O // /t T'~//f/~/N _ , ... . _ OT d F S~ G~~~(~ 922"S 1 _ ~ _ i i -- - NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES i Z ~ 4 5 6 _ OCCUPANTS /WITNESSES ;a; a^„fGM,f,,;f NArfl31 -uA "_ .. .. __. Ace ~NRfH v ~~ "' -,NE --~'- --- «Il+ RfvR Nmt , . X! ,wr ~6Y ~ ~,( ~ /n~dEZP < u~I R(• I 'A. A U crnss f~ R .M e O t21' O N P Q H ^ ~g A ~ A pOP' 0] N°r~P p RIMOr~O IROM QAMB Q°p<I ^ n' ° ^ n ^ r:° Y C NO ~ 0D _ ?'BOr Y.l l0Y ''° QAMB ^< cl Qroi•I• ^ i::n4° ~ OR Mr U 10/~4]°~ KX~[f pArl Or Ri roROVID! ~ D~A/II~!~~ lf:RZ;' .;~ G+- '~•a '4.:r~... 1 t I(~~'F,n¢ ~G _1~~5 w~iS,.i.~u"~'~~~`~ni'~ .. ~.; ' W § ~'nrS ~ ` „a s y~: ':~ ~ ! ~~ 7 '~ ~ ,~ ;- 7 ti ~: EYy~] ..~ ~~ '~ ~- nx' I. ~;. f ~] ~S , ,~ `~,~+`5.:. ~~ , J t ~ < emu" ~'"/,~ d ~`~ ~ "'yqj.~' r. i r ~ ~:. ~ a n. {'• v~ 2n ,. ~~n< ND. -~~' - ( ~I ! +I r~ SD ~~'r IUSE ]•00 HOURI C~DU(Nry FC nc t` GOUryrv c $ l ^ CIfYNp, / z s t~ Id I I l ~ I I ~Z 2~ V~I ~JO IV ~CP ^D9BAN 4 ^N ^f ^ry CE O OWN E6N0 Of5fR[EIOR nGnWwy DES R'u ROUTE MES~(s ^ iglofCl~llMAI+,LJM ONF3EJ~VfR VAL. 1ZDa ,~ NrFRSFCi NG WtrN~SteFfr04 ROAD 9¢/S~ tJQry~NQ p$E$1~~ON VIAA r C ^ ~ T nO, pgEF1X [ alb •1 1` A1 S I J mLLEfOST !iR(Ei r MITE VOSr SiRFfi { ,lCE60RFMEI N 90M Rfr[efN F. CROSS Si~iOR N f^RF S lf5 N 5 F W ACCIDENE VAMP DI F[Fi ~ ^ Op Ntl bE, PoST CODFE ~./ RAM MSA ~ COLLISKN NVIXVFD. [9 rv; URfO tOrwl NO ~ OKVIfD~~NO NI ^ SP IIAGf ^NIr69UN ,NNOxD~w IN ' OVFNK ES ^ pROpERfY DAMAGE ONEY SfIXfN INrEV C ^tt ^ ^ RD r fl R90w0OR E'FpFRE ]0 ~ UIO SS SrRfFT OR pOAD _ __ t ~ ` A YFn CIF V~Y ~~ OBIfCi5i9UCKINAMf Of OB1fC1 SrRUCX,NDOWNFRSNAMfI O ESr D•MACf SpfCW CODING USE l I $ ~' '•.. ' .UNIT NO. 1 UNITN0.2 ^VEHICIE ! Ogrv[R'S NAMf: UESr Eq r ml DlF ~ ~^PEpE$TRIAN ^ PEDAtCYCU57 ]• DR VFR s NarnF SE S><~NESS RANDALL S Sr9f Er ADDVE o 1 ,J ~~03 ~^A6IAM ~B {, ryf~, BRfFi ADDRESS ! E~ CIiY !Arf ~~ n1 PIA WAF 9e~5~oD~ a IY ygiESo p 'p ` , oZ DRNfR'S UCFNSFN SAif FX DA B 91n I V lKENSf NO. £t..NERS 3X3 inv WA Ir1 0731 ~LR v Arf X DAI 0 vin "'° I °^• Ya B OCCUpw11pN EIRm NAME 6prgNE NO. EYfS IGnr NEIGni E OCCUpANON - ~~ ! 1 • NN CNA4Dl: • CNAVGE y rNiw°^iCnor°iN gAMAG[ IARfA . u. ~NDwW p,W~~N ^RfMANED • ESQ. UAMAGI •rD• 9 W~ ^~wiv ^veMAIN[D ruiorio~•a _ f ~w voe 1 OIJ O\/.l ^ ~wswr°er~ = I DIAGRAM_Oi COLLISION: fu y~ NDKArt NOVrn la '- - r' xu ry t er wvRGW DESCRIPTION OF COLLISION: IUSE SUrntMENrAE Snfern NFCl53w9r1 _ _ N i VtN_lC1.f.. WA~SOU'TFTBOUI~'D n~[jF„j~V_~('-_., I ~ ~~~~I`/A~,"7 I I I~ 'I 1~1-VAt.~-E.~/ RA_ Sus~_Sou1N oC .~leF4• ~-~E~~~.L_'--' I.EF.. RnAD wAy ON ~,ast SIDE,_p C•(c,><{_., ^ -1-- ~ DR\VLR WAS ~3.t~,TE.A FRPL1 VE.11lCLC_ -~I -~~~~ ' - i I I vhori 3NEED .-_.~_.__. I. i- _.~._. ~,-r~I~t t_i_r._~.f_i_~_t _ _. .._.._ ------------'---------~. I _. ._ _. -rl Ere. 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F,~.F~,~,rm.N.v.,~.,-.....~_---- r.y 1 + R• X*[. tAyY'K'iF~""JlDwnnEe,x~•+Y0"'-+v4^,4 ~.-; k°"S`•A` ~~ -- - N'' c.RNNa.• ,F« , r _ r - I r _ -, antN T. rp~, . ~kr Y r 5 ~, { ~w~m+ 5 ';k .4's: ~~w; 1, ~ W~, N : ~" Fit ~ 1~ '. ,E~r I i •E 11 tlrS ,~` + ~~ I„ S +~~ +4 ~~ ,~ !' ~ I t ~~ '~~fs 61i~ ~ c s s ~ ~'Ne'~ 1 ~ I 1 1S I ~ 3 r - 4. ~'~.r "• STATE OF WAINGTON =AGf ~ G, ~ ®TRA `A' No r~~~ a ?~ - POLICE TRAFFIC COLLISION REPORT RDffcECaA4wrvr of ~~ PRIVATE W 4~,t Q EQ CPfI~. rf i ~ i / I 9fL wn w l~ s ~ ' ~' nmE IuSE ]nOD HOURI O courvn ~FFEr N Nn NO. clfrna lErmw ^V AN RAE ,' ^N ^f ^IN LiY OR IOwN OOf slvEEIOR MGHWAY i,SOMnfs s ^w DoE D c ON O !C'f CfS 9W 1E 0451 9~0¢O rtR3fCl rvG wItH: S(RFEl09 ROAp NON INtERSfCEIOrv N 0[M/EFN SlvFfi 6 S1RFft EREFI% E MIFE PO51 O-h'S~ ~~ OSIANCf 6D RfMt M9fifefrv .09035 slREEIOR NFA4ESlM lF VO3t EFS f4 5 E ACCIDENT GE RAMR A.Sr WIA FEET O!~ ~~ ~ CO COEl SKIN rNVOIVfU: FvF9 tY ) NO KIIIEp_NO INIURED ^SPIIAGF ^Hl69UN IA t r %~Rp INFER IN R 1 'i 440A-O9 RFfE9[NCE CR055314 Ffl OR ROAD ~3 I K O Cl VEHClES ^vRORERir pAMAGf ONIr ^GESULIFO ^vFaCLE ` Sz.SO OBIFCISiRUCKIrvAM O.OB1FCi STRUCK ANOOWNE4'S rvNAF) ESi.DAMAGf S SRCW CODI USL ~ __ _ UNI7 NO. 1 " UNIT NO. Z ~ ^ VEHIQE. 'Q PEDESTRIAN ^ PEDAICYCUST ... 3 [e'S NNAF: wl fIR3t F NPME. NSi I ml LL TE /L _ _ lv[fIAWRF55 5 iRfft Ap f55 SO G S R . E °ItYrnAR SY/LLESrAr~ 91Rf:2 O ~~'G2 R rr rAIE I E . DRIVER'S EKENSEN OLDS T~`536PT SIAIE 4/.~ f% D e1 N "~,~' I v Iv uCENSf NO. Alf ^ OCCUVAtrON vM NAMF6vrK)NF NO. FYFS cHt fflGHt ! E «<GRANGN NRM NAMF6 ENO. EYES IGHI HEtGHI ' FpfMA9N i'ERE F. Dx lG S R ^ CHECK (.~ EAS nN Unar [Ea ANOtHE4Af ^ CHECK (~ EH of ASAN rm rrff aANOIHEVAL ~ p M CODES - ~ ] u A i ."'iZ... 5 t e !^'.° CODES - ~ ] a Air '+ r4 a y: I _ -'r N,uclES E M ~tp ^ AMeI4ANCE ^ f°OA1 ' ^ r5„mR .rr ^ ~~>, ~`i4r ^.,. r ^ ~ u xr ^ c ^ ~~ ^ ~. ~,.. x R VFN. [A4 MAKE IDOOGf~CHfv,l /983 c Ev 110ARr rAVAI ~CONV.I S O St:~u, E .r R I Fv.l Agpfl IOA9I. I l .) r e0M ~aRo fIUNSf REAIF z5 SfArf IRwrl<R MIE NO. StAIF ti/,~ I'I I C vfH.CIXOR OGtTFFd' A ~' vFH CIEIIXNI lICAIION NO. i s Ti o o/ 7 9'~o L vEH CEf ID[Nir r A I S 1 R[c15rtv[OOVM[i Wt iWSi MrOpE[ ~ ~_ RNON[NO. O I !D wrv[R: wi I145f MIDI%f I Ar L ADDRESS P`ON'NE9 N A oM+E4 SA F E wm[a ADwusv mwvAN¢co o9AUm ~-L of E u cA!~ a c! R _ I f oAMACEO ACtA ' ^ ~ ~. uAAUOIA%ew R ~ cHAeee .-._. eHARee ' r g A ~ Ibi"orris + pwmAee Ese f2 fl ^w a ^ E° roMep LG ^ °wwr+ ^9EMUNEO A AY ^ rorrtD wn,AC[ t esr. D S Lro. s Ip eOltiii ._.. DIAG RA M OF COIII $ION: IV en Aru All N lvi.IRiOW irf er. DESCRIPTION Of COLEISION: lusf sfrPnt fNru sHenrtn4e[ss.39r) _ - ~OLI/114~ o/.v G r~.~TO ~~6~T L IC 5 -f O 2rC "7 ~O / 4 EF /~ r_ _ - _ , . _ . _E _ 0S„S/RL ~ t 7 T _G ~ I- - - E-LE~ ~G 221~ O I _ ~. ,~ . r1L/T_.L~!//~£~•uS ~ ~~ ~ ~. __._ _ _ _..._.-- -~~..__-- l _ . ~ _ - - - - - -- --------- ( NAME, ADDRE5581NJURIES OF PERSONS I NVOLVED rCODES I - Z 3 4 5 6 OCCUPANTS/WITNESSES fia :o omwi:it^+EA'A'i i~ ux Ace zeros '"°^E uar ~r Nl-n ilR Ana l;L: . . _.. .._..__ DOVESr ,'l, / +N ~ ~. !^ . ~~_ ___ NAriaor . `e Y. AM e ^~21' ^ " ^7 3~.v . .. . . _ n A L . ._ _.__.__ ._._.__ .__..____...._._._._._.___- 44 En l.Efd ~.... _.....-.-- !!~~((~~.. rt,'rn,lo rROM QAwe Q~%cr^ro . ^H ^:° s~ v 1 . rtifT No I. , ~. s R. _ . 'c i5° sfNfrn k ,,~' ° o ~ al~etESS.9Nr~ E ~. 4w~P ~•~ °..,~~'' ~;~ ^AMe ^ p.gOr-NpRy -z3 S~ `"<'^ 9Grep ~,~ ^~31s. iAr[ L,~,~~,~G 30 ~ "' a3 p F !~~ L 2 xa ~rr~ `~ ,lrTrj. ; ~~~~ N.; . 4 `` `I} ~V / "4 1 T' ` ~ ~ ~ ~t 1f ._ ,r L....... ~ih F a_~' _ - ~ ~ ~ { . `k ~ ` ' ~ ~ f. ti s x« a*L~a ak o ~d~rfa . ' e' , ~7k.- ~ mP3~SS:f~ . ~ . ~ _. 4w ~ ~ STATE OF WASilGTON POLICE TRAFFIC COLLISION REPORT O R.Gf , DF I ~7RAFFICWAV ws"'°'R` ~°' I No. ~ ~Y pEkRFCOMMiNINUMFfR ' , NJ~R ~A `~ ' D Eo coos ry <ouNrr - ~ PRIVATE WAV ~~ ~. rr R.r •• c 1 wE..A ,..' rvsF x.aowouRJ cauN~NO. / (O urr NO. ENwA URBAN ~- u ~ ~yyr ai I (]N (]f iN Crv O4 TOWN EBNO OESigff RNiGNWAY N~ CT 45 4URAl RWif OR RE C 1 { .. ~ MIEfm ^5 ^w ~°` pN INTERSECT NG r .SIR OR pCpO NON NEFpSECl ON pREN% 3 -1x3350 F MITE POSt .. - ` i BfxWF[N SrR[fra D~sl cf ao Rf oN fgoNn RfffvEN cgcs slRffroq ryfpRfsr.A EE posr STREET /J ~ J3 ~' ~ r MI IS 5 f w ACC GENT MILEAGE q p DAGRAM OAEA ~ p' iEET Op COIL STON NvOlvfD sF fq rr CODE TOTAlNO O%hIFD~~NO. NJURFD~ ^SV tipGf ^ OfVFIIClES © ~pvORR1Y DAMAGFONEY ^ 4FS TI T6RUN wvoworw N %'RD MfY Cfi SF Siqf OR ROAD OR R[i 4FNCf xx CROS55 FFi ORlppp y ~ ~- UtrfO ^ ORJ![r SrRIJC%INAVfO O FCI SERUC%AfID OWNf R'S NAMFI ~faClF V ~j3JSQjJ ' A 1~'fi FSr.DMnpOE SRfCNI CODING IAF .0 pNONF NO. D 38$?L4 R R , ~'L~03 ~".R ~ fs cNr NEicNE E ~l 5•ll IRlI R Y }hf ~"i 'Rm... ~: ' t { s .~ ~Y~~ ~n ~r>~~-- '~Ji O K'd.- ;,~ ~, 9 UTA4RAM OF COllI510N 5 SuvFlfivtH l ei'gf NORIN u - ~ I-. .i-_. _1 _I-awuu wuss.Jinr-.., Row ~~' f 1.-~... ~ i 'g ~ . C.~... ~ ' >~ ,, .. .. '- I r r 1 I I L E I I a-, , _ ~.._ ~ ~ ~FIO~fpAIS RDJ I , J .. .. NAME A I DDRE5581N ','1 ~; -' ~ ~ , OCCUPA JURIESOFPERSON51 NTS/WITNESSES ia::~,v~o~:i .rASw" . `~ ^.I .n.rTT MI I ~ ~ Axn 6~YttCU~p_1 _BESraG _CitAS~,o c3't_~q~RD.t~. U.1v(T ~.VGt\IC~6.~ l .W6ra't. tw,to_A K~WC__ "'C~RwL.IM1~tc.K Too. rt'gSC. AN4 -~55C CCN'\Pat_.. V E:FItcJ.6 n..l_ ~~..SC\A .\rfTa_.A-~OWEfL__. ~Cl-E, .. __._.. ._.. .... _... ._. ..... .._ 13\'nn~cE 4t~n,sE~ .+~._ -~ R 3(03' CODES_ kulNSl'". J^ I u~! I .3L. L:°. . 5. Md ~sef I Acf .: , ~n ms+,.a -~~ {'a':7 xLr...E S rJ 7 ;li ~ ~ T $t ( f~ °xp„ ~ ~^'i~`i~'~ ~ f~'4„l~lv+1' ~ r' S~21\R~xi4% !~~ E'ir I. 1! Y. YY t ~ 1 f. ; , ti A ~ l..~ ~yy~E' ~~ l { j / } L 4y~~ ~ ' 1 I ~~ ,~V r ~ ?~'~~ ~ I ~~ ~ ~ I "y ~I,}l ~. I t ~xK , ~ I ~ ~ I1 ~~y 1 ; I ~ ' a,. { r I ._ ~, ~~i ' r w , ~ Q ~ ~ 3 ~ 't , ~h ~ - 4 "s ~~ ~ ~ 1iiv-. g",~ ,s~E~ [~gg,,~ ~S ~ F.s~`+Tt yfS f. Tf~ ~x~ ~:~ ~,~~'~.~,s.'.:~kf PL ~E' ,1~.~:......_.,d.~C.t, ~.~~ °~3.*.s`s_ u~L.NR~~-.P~1~.q.:~a~. ~:~ li,~~.~ r r STATE OF WAS -~ GTON P•GE pr 1 No WSP ISV IREM. r.Epl O ' I POLICE TRAFFIC COLLISION REPORT ~ TRA. CWAY pplgFCOMPINNI MBf9 -- •--_L PRIVATE WAY acau n _ nr nmE counrr NH I - ~ ~ r IUSF 1. wOU41 S6 .,. t. ~ counrr NO. atr r+o. rHwq V9eu. . I ~ JEFFE~SO~/ ~ p RAI I pN pf pIN Cr OR rOwrv N f6N0 Oi5r4ffrO9w Gwwgr S US ROUrEOR St F / mlfs ps ~w or LOG/(' ON D GE d ~~~d IF SfCr~NG wrw: Sivffr0440AO NI f95F<rION BfIWFfN Si9[EI6 SE4[Ei Pvffl% ~ M0.E POSE Qr/O 6 O51+NCf6p vfMr~fS vEF5E9ENEf (ROSSSfvfFrOR N[ARfslMllf POS ACCIpENi 4qM D+tq I E M E % iFR Oi !~G CODE COll SgrviNVOIVID. Sf vfa rr; ~Rp CTI Fi R O4 Rfrf4[NCE NO [ llfD~~NO. NIURFD~ ^ So ILAGE ^ H IOtgI NO xvU rN4ogoi~ 'N IN19 Cl5 Cc06551vtROR ROAD OVEw CI[5 m E rv ' I RD P40PtRrv DAMPGFONIr ppE IrED pv[aCiF SZDO 1~ OBhCr SrNUCf INAMF Or Oe1ECl SrRUCI(M DOwNF4'S NgmF . I FSr. pgMAG SPFCWC DING USf r~ r Pot ~- o ~/c s 3a~ s NITNO. 1 UNIT NO.4 ^ VEHICLE ^ PEDESTRIAN ^ PEDAICYCLIST D4Nea~srvgmE: r~RV mm9lE azrvAmf u .~ - " . uv rw I IXF ' 0 E' c C 9/{ G o 2 SIaER ADDaQtss OU ~ aEfr ADDa 1 orY SrgrE ZIPCOM ONfNO D 9v Sqrf II f i RD Go ~~ ~ ~g 3 385' p4N[45u<ENSENO _ . SIAIF f% H ( Iv IICFN rq. rglf Sfx p rF Of eIREH OCCUVwiION MNAMf6MONE NO. GHI Ifgnr E OCCUPATION {IRM NAMl6P ENO. EYES WEIGHT rEIGHI pCHECK (r0 vEwaE+s:rvtMHOrtEa+.M,orwfaAl ^CHECK (~ NEw UE AS+n fMROV orANOrw RA` ' ° CODES - ~ 9 n 5 l e ;;~r ' E CODES - ~ ] ci x is 5 19 e i ' ~ Z ~ VRIES w.sDrrD p ...,xANCt ^ R H MA%E IOOCGf CHEV 1 6° ^ [g„,. ^ Yt "K,E TUGS. fllOAVi NgvA Stv E +b E4 p AM f ^ ~ pct p cbn ^ hu<N ^ ~i~~v . /6 G V 1 l I4 D9. COnv.) E Y YgR I w v l MOOfl IDA4r. 1 I _ -A q ~ MQ L!t' UCENS PNf Ct 3y S1Atf vA lf4 FEAEF ND SrArt I'I c of w.COL P A T~Tk~ Enp I vtH~ClfigNrrUrgN NO I~ I $IZI/ 31/ ~I~ I I I!! afcurt4epowNE wr rmsr mIDOIE PHONE nO E v IF OtNNIA HI I I I I Is t wnta 3 ~ F O W : lASi HRSi mma e ~^, AD osaownu N + wrvea 31 ~( A9M ~ afssa lNwa+NCe co wgptnr ~//d.ve R ~6FS;~iN u7~.FLfCSZ~LERT- _ n - DugACI Aau Ixt.~;o $ . s r,,..uoHH cw.ow t cwARGE ~ walo.°,.r 4AMAC~D'A9EA ~r ' A y fSr pgMAGE 91MNNtD AVI~YN t5f DAMAGF P ~ AWA rU~ n0~ ,/ ® IvtY ^ ^ ^vEM+iNtO i0lOIfOw 5 SS lpw{D O rOMRD Awgr er. +r er f ~ is ~~!sq~ OIAiRAM Of COLLI SION _/O~ ,~, s~~ li r+e~EE am ON OF COLl1510N lose SUrn[MENrgI SHERnruassgRrl - _ _,~ _ ~+' C'~/'V~' DESCRIPII r _. _ ..; I _l- _~ M _ .._ __ __ L J y~ / SD ~ l -~7 ~ ~ '" ~ __ , ~yr . _ 09_ . ti Ur f 1 !- ism ~ I~ t I /.~/EHT oNT_o ~Q/~'AT_ ._ ~ ' ~ ~ I 1 I 1 ~/{ G S lrOil~1 ~ EO / I . - _ ~- -: i I I ~ I {1 ~~ . _. . ~ / N i SS --- S ' /U >'"f ~ Q^ -~ vo ST c~ ,. ~ i _. .. ~ i # ~ I . . _ i /l~ .__. /~_ ~ ~lTL - 4 / /?,LE' ~ / I _ r ~ ' t r --r r- _. '! . . _ ___ ___ - ~ I I I ~ I i I 1 I ~ ` ~ I II - __ ___ NAME. ADDRE5581NJURIE$ OF PERSONS I NVOLVED CODES I - 2 J 4 5 6 "' IusESwnlMwui swn OCCUPANTS /WITNESSES roR Amn~orvu rv.w.e r sl -sfx Acr~ 6rui '"s'w a r- 'Im ~ ~v~ ~inci p1C' we _ i qu 4eeu ur'eY p.Me po'Rf ^" .p.^r A E nnar55 + t + u11 Or•~ a i?4ONr np iaoM p.m pi: N' ^ o' r p ti p i.T " NO N r s n n., r a5" .l s , pn 2e (IIp p ", . p ~~ ^ X 1 ~ 4 • ~t ,.C ~~ .. l/ ~ tDn / DgrE J Q~ 0~~ I ~ ~ f./ Y ~ y ~ 1 ,3~. iHl t 1 ~ ~ Y~ 1 b Y , .~~ -fi ~ .o1 Htt [ t"r rJyi} yy ,.~m, Al _ ii.,. A}Iw.. I1 1 ,. 4" ,i~. ~~~*.~Cy r ~EO ~~ - r~~: Cm t !kA I ~,0 ~'u / T ~. ;a - y~ L2" , i t( ~ y. E s[ f 'I '; ~N4~~14~~1 (~d ~I„ ~+y~'l~lfr~41 9 111 E T ~ I 1 ~ ~~ ~4`i hdA t I 1 r I t i l l i }}R{{ !}(( ~} N~ t U ~ ^ F+ JY 1 ~ ! RI ~ I1~~"~ ~ 1 ~ III ,~~"f 5~ ~~~. 'l, 1 J3++y~ 'yp f 5 ~~F'a~tTf I ~C i y1 ~ , I ~I I ~4~ ~ ~ E I v . { off f ,f ~[ I C ' _ ~ ~' y} ~ I ^ ~ ~, Y .. 11 ylr ~. ~ .. M1 J s ,~ rs ~~~~ ~~ POLICE TRAFFIC COLLISION REPORT LZJ TRAPF'JCWRp PoucfcamilAlNr eE I PRIVATE WAY ~ y. I AIf Gr COlll$ 3 / C c Imt 19 .in ~ rmE (USE ]a°p NOU41 O COUNtY ~FF6YR n! COUNryA'O. GEYMO. HWA ^D RAN - I ^ ^E ^I Crv09 fOwN 4NC.Oi SIPEEr OP nGnwgv iSUmllfs s ^w ~,Oi D G ON p iRClS _ 9WIEORa1PEE 9¢O ¢O NrFeSFC11NG wltn. SrefEr09 R0A0 NON INIERSECIION Si9FFr a SIPEEt RRtil% E MIIf POaT D~ DIa IANCf 6019E MfI N OM VFEFRFN F. CROSS SrPFfr O4 NEAPESr MILE ROSr nFS 5 E w q[CIDENi P DIAGRAM WIA / i[[r Of~ /.(J~ p' MILEAGE CODE COIUSION INVOIVED~ SEVf RUV: nIrA RUN rOtgl NO NO alll[D~NO. INlV9fD~ ^ SRILIAGE ^ wND°fDrw 'e0 IN9FR CIS R LNG 09 PF«RENCE CROSSSIRFf10R IpIA ri - OiVfnICtFS ~, ^p40RR1YDgMAGFONIY ^vESUlfFO ^vFaiCtF D 5z.5"' elFCr 5r9UCR INANE Oi OBIFCr Sr9U<R gNDOWNF9'S NAmfI fSi.OVVAAGE S SPFCUICODING USE UNIT NO. I UNITN0.2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST -~' 3 DRrv[R'S NNAF: i145r mlDOlf E95 NAma IASr f19 ml Dl LL TE /L -_ rREFr ADOeE 5 SO G /Z. REFt AD ESS CItY~AR S~/~LG SiArE_ / ~ZIR CODE O RnOi,LN07~~ [,.,6 ~ 2 /w ~ R Irr yrAiE LIRC D NFN ~- R'a uCENSf NO DROLL/ST~`536PT SigiF ~/.¢ A D "G?,~P'n° I v Iv e' LICENSE NO. iArF fFOi el9ln "'°~I°' ~'° ilR OCCVPgrION NAME 6RMNF NO. EVES vrtlGnl ftiGnr E CC<UVANON MNMAf6 NE NO. EYES WEIGNr HEIGnr fJlgfeM9./ v£RE Fi ~• /L S R ^ CHECK (i~ n A Aim,EiINEdAI q o ^ CHECK (/) sq N ~ INEPAI A q ~p+~ CODES-~ Dc ~Z s a;° +i CODES-~^ a~ sN ei° a~ -L p1 UOIFA ~~ ^ • ^ ~CE ^ Cbnr ^ ie IV° w ^ Av r ^ U5C1 ^ < ^ v ^ ,v Kof ° •v w NN MAaE 100DGF.Cnfv.1 983 c E v MODEL IDgei.rgvql SkvlEl ~<ONV.I S- O ~Gc, E E EAP M.vc I .Cn v.l MODfI IDAer.N f OR. m l °D'^ N ~~¢o uunsfvu EN z5 sure vgllER nqn NO. surf ~/-4- H C v N. aoP l No. >o vFnlCl[ICEN11NCgrpN NO ici i Ti /i (3ioi4D 1 ~7 95~~0 ` v[nlCIf IDENIIN I i ~ ~ N ~ ~ ~ ~ vlWSRRIDOVr»!v Wr II95r MIDDI[ /YJ E~ RigN[NO O W IS PFD wNlP: lAef NRSI MIDDLE F IDZ AODe[SS p OwNfR , EP SA ~ e lawDORISS Oi INSUegNCI CO o9 gcwr of E urlGl~-G.~ u c! PAMAGE AREA EI ~ ~' n N R IN DAiAACfD A9FA ~' 4 µ CngRGE ...-.. ~•l CNARGE ~crlo.iif --'.•~'•'. '-'- S l51'WM GF ORI^!rN ^eEMgINEO ~ ^AWAYN ^R[MUN[D FaDDAMAGf I f ia f2 D `~J WEOer LG ^ wY :r°er. f wAY . . •'" OLLISION Iw ~ IN SC f ~In DESCRIPTION OF COlLI510N~ IDSF SImnE [ r Isw[r i « tssA rf DIA AMO ~ I~ } 1 ..i ~ r r I. ~ ~ J.-I ~. PT.1~+~ _.~Q~ _. ~7/O _1 .$OGfl~{~~k'vp ~_GoS~'~- i l l I I GOLI%/:t'OL Go/.v G .o.o2O .R /~~~_ _ _r 1._ ~ r I ` ~ G _ S,S<j~CCLQER. CROSS/N_G_~_T DEFT' oG~2 O v~.~= BfJN~ ~ (~RD- gAS"/o~ i5? R'yl I .~_. . ._ . ~ ~~ ~-t I r I ~ ~ JsB LoR - I .- T'LG/~N/~t/G Got/~C.t~.Cz_~'o_ RES. ._. _ 1 I_I __ ~+~ r~ ~ i s __ _ i ~ ~ -~ ~--. . ... _.. ..._..._ ._ t_I o 1 ) r i ~ I i f i I _ _. ___ __._ _ .. ____ _ ~I I I ` t NAME, ADDRE5581NJURIESOF PERSONS I I NVOLVED CODES 1 - 2 9 < 5 6 OCCUPANTS/WITNESSES 10sE SwnEMfNfgl SNl Ed ADDrNp.•1 N•MF ll 1• Sla AOE lAlUS rv RESIR NfCr t•iCT~ ~P~i ^ //~ CS G ~ ~ ©!~ K!N ~ NO .. ~ z ^ e<lx s 2 "° ~ NO. IIRf n gN~ : ^ AM iA r e O E21" ^ " ^ i ...E per nn.rss ,:eE Of ~ .~voY D,ROM ^AMe ^"i"" ^m' . ^ ~ ^ :: o NE r.o D- r'R'1sc aNirv ^.Me ^ ^ ^ :`:'Nr. a o° Prnm DArE 4 ,. ~ fi _ Cp,p. ..l .. .bu L4yf ,M ,~ / ~. 1 l' ~ 1'Y l'li1 4 ~11 y l 1 ,y r 44. I ~ ~ ' ~~~~ A l QQ M ` ~~ A` j ((E41 I '~ - }ll I 1 ~ 4 1 .y ~ tAI", E ... ~~. ~ ~~ti c xg £~ ~ ~~ . l 9 , 1~ `' 2 ~ i . ~ a , iX arryn ' Dx, s d ~ 4 F ".~..`° STATE OF WAS GTON P<GE ~ GE 1 No. .. , _, ~~ _ .~ z '` POLICE TRAFFIC COLLISION REPORT ®iRAFFI`q~vAY~ 0.AKECOm0..uNtN ER i .~ ( ~ PRIVATE WAY al r '`3E28 lgq iu,F 0 S. '. f.l IVSE I.DDHOVVI COVNr. CWy1Y M. CIrY NO. ^fUpA V ` LN rRSd~EI /(/0 9Al ~16 ~ r ~N ~[ ~IN Giv O910WN NAMf6N0 Oi SieEE,09nGEfWAY CLS P 9WiE 095 E C m 'pc • S MlE~OS ^W poE ON e ~ 9~fD//D n iF ~r,NG r SlafEi 09 POAD fgNIN[t9sEC1ION fH% f mIm PDSr N BFrWtEN C.PCG.FIC .QDL Sr9Efr 6 't ./ SiREEr ~.~Q •~ 7~ O~S,ANCE 6DV 1 i90m 9FEFXFN .CP053519Efr09 NfAafSr MlIf POS ACCIOENi P DuOPAM OAtA MlfS S E MILEAGE /1`I'J n"" f[Fr ~] Of - .2 d, CODE ~ ~ A ~~ COtltS pN NVIXVEO. N Sfv[9 ir. M,fsN W ~ I <rl 5r9 F10990AD0R afif9ENCE a3 S.xA~ IOrPINO O[IIFD_NO. NJURED~ ^SV LLAGE ^n1e vUN n,xovfD.~ NfSR" [{y Cgp555r9[ETOR ROAD - E, y Ci Vfn ClFS Q BPROP[Rrr oAMAC[oNlr ^eFSUfrED ^vi~~ L/ 96/Z 70 -~., ~)7 °~ 09JE<ISfRUCa INAMf Of OBJfCr SrvU<a PNDOWNf95NAMf1 fSf UN.SAOFS SPECUSI CODINGIAF ' $ '. ~ UNITNO.I UNIT N0.2 ~ VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST aR ~ ; '~E ,rte ;~ s- Dalvees NAmf: us, N9si mIDDIE D9 vE9sN,w.f. usl [a mID E _ - - AR/c U9Ffr AOD9E55 SrR[lr ADOVt55 Giv ZIP GOOF ONE NO D SiAIE lIPC E Nf YJ3 3~S5-d//• R 1Z i V 9 '~Y 09N RS LICENSE N0. SIPrE E% DOA 01 N I Iv ll fN NO. PtE [ DAif OfBarn 4YZ.?:'_ r.csc." - 4i.e ' ..E.. /Z ~ /9 GG V MD. i DA. CuPArn%V MNAME6PfgNFNO. fvES WEIGM1 NfIOnr E GCCUVAIION {IRM NAME6 PNONF NO. ETFS WEgnt rflGMr ~ CHECK(/) fN ttE PS nN rma"r"Ea ANOrntQ Al D ^ CHECK (/) v[n aE PS AN [mPiov[tdar osH[aAl pia ~~ ~, ~ CODES - ~ 7 nii M 5 F 6 s,°,~ r u-' CODES -' 7 ~, 5 e e s; //! A /i;,rvW.~• ~ -. N 41!35 O/r/ < °:inM tlci .iv a ii nu"' %cr N rtrv rcV ~ f ~. ;.J ~_ k. ~,°;. ° ^ .Me,A.x:f o ,wif ^ ~s:~, ~~K[~ ^ ;a~,. o,M xG ^ «s" ^ Waif, ^ ~~ ^ :.~:, n YfAVDM SFIOOOOECnfV.1 flIDA9NNOVAI VSivIf IRDR 20NV1 •A9 1 lnFVl DFl IDA9i,NGVA1 Cte10R. v.l ~~~~ . yw, ~C'~N FcJ ,IDU~ ?~ E v ~ y E sum A9E90.ArE NO. S1Alf H vEncaoa 4 n. R f of~c s~ c N A Il A `~ vinglFlDENrNGigN NO. vtn CIF DFNr AI JO ~~: 1,~ /t I 71~-t171~.1/ 1710 1 31 3 5 I L +' I NN I I 11 ! I I I I I Rtelsnxo osvNtR- tASr n9sr Woolf PnoNE NO O R v[9eooMNE9 u5r n9sr mlDDlt 'N No. / fG !S k .. I IS PDDRtssav+m[e N A Nta ~ L v NAMf3i ADDausv r.weANC[co o9 ACtNi E Ir u u i~~ ~`. E- R ~'.' O An i5-r /N N.~ff~~kk~~ DAm.c[ Pa[A Rs:n, NC f/4392 ~. "oS.. NC ~AmACto Aeu Y•'°" - or'A`: o9°.:u cnA OCE cnnacF o'~;ii oD°w, '~ NNN f l3i DAmAGf ^ AW DIY ~a[M1UINtD ^AWAYN ~9[MMN[D !Sr OAMAGF f~3 "eft "" f ~~ ~ fOWEO s . ^ rOV/[0 s ^~~' DIA_GRAMOF CtO:LISION S,R aENEr{Sya s v;'J;o°,v;rn DESCRIPTION OF COLUSION~ Irrs[Sw [MFNrAI,SM[ r tc[s 9r1 5 Ro ~~ _~. i I 1 1...~ ~ ~. i.a ~ ~ ~_. I i 1W/};/ _ vfNie cE ~/ _ 4i/d _x~cc<rc a.~.-a C9h.__....... g i~~ ~ _' 1 I L..! ~ F I. :. i I (. .( ;_,L I_ C3AY AT ///CN...SG'!(O..__[JN(./ NE_. Ca37-..... _ I .1 4 1 - I.. !, ~.-.I. !'O./J'iCO G_ _~v7 ifi.+./Tlif/L_.77 IPcJQ.iO_ /T ... .s 7• '.~ r '._'- . I i ;_ j .j.. 1. Ufy/CC F_r?ucCli"JC_._.. o.~ia. Tirc...Ra 4 G.!5'AY-.- a ' . L-I,. S~/NNitiG' _ ~y~foAr3/O.. Co/.dG oA~. THE........._ ~e f _' r~-~.. .. w°'-_ /(iC.{iN saJE Nf-. Ti/F. itO.vD. ifocu.re C./ro... -~+' '. I ~ I G.oe ..... 5/FFd . SS.c C3 _m/N. i.J . 44. to...rf.. ._ ._ ....._.., a ,I 1 I '~I I i I I 1 j ~ 1 _ _.... • IR NAME, ADDRESS 8 INJURIES OF PnRSONS INVOLVED _' CODES I - 2 3 4 5 e - +! OCCUPANTS/WITNESSES 'ia :oo NOV+iiav~i' ie: ce iArui '"„' aim btn $;°;, 1 aa! .w Tna.-E ~Sa-3 ~ E7~[N./ S, i+o" 73 7 •YYS/ ~++ /~ z /" ~ / '- .1~,~ 1 f .Dr;anS i ar or i o: e. ~ AMe ^ "1G ~ "".~ . ^ ":3'xs. ,~, k M .M, ND 1 ~ ; '~} r .:E NI%uns ,:Re rn u~vforROm [].Me ^RxG Or' .Of ^~: '° i rw ~;~ ~121r ..1 ~ ~ ~' .rwss f:o',~ar c, s u.°e. "''O.Me QI: 'OMa•1. Oa ~" 1 ,, ? wl NAra ! v.r/. N :af5 !Vke P(%<I nV rlC DA Ib Vl war n OvtDe ^ DAif ° '++ .r, E '~ ~fy, a n~,~ d• t l fn {~~ s SMT ul a ux,C'2 ^ n. IE ~S~ts _':. ~~. ~1 , ~~~dE ~ ~ ~~~ ' yloN ~. ,,~, - .. I ~1 h, N~ 1 til ^ ~ ' ,~fr ~+~~~~~, f y 1 ~ I: r c~ r. 7~~ ,r J S t tl i ~~i P F r 1 {. C ~[.4 ~r 11 Cr ~~ ' 4 S. I.f~1 ~ ~ ~ ,1. . i:• i r:- ' r Fri , ~ ~ vw y ~ .. ~~J POLICE TRAFFIC COLLISION REPORT ~ TRAFPItWA~r Eouc<capnu4R RfR 1 PRIVATE WAY ~~ UAiI OipCy9OryryIU[(J7P' IV CJI/ DAV C USON Svr ~ 10 ,. s.; -.~. rlMf IU$f ]"DD Npuq COUNiv COUNTY NO CITY NO iHWA Al n ^N ~F ~ Clr O O FEND Or 31gE«O4NGNWAY / Mllfs'gLs ^w ~oF ~ ,TOW/SEND ON~~OIJD~LE 12`x. N r[45FCTING VAIN SI4E[I O4 ROAD NON iNReSFCrpN l5 gWif 011 sI4ff Cil ~d1 ~ ~' 9.3350 T~ I . --" rvifeNRl-oD D2. srRf«a CAVE. SrRfFr Di5 1n N<F SDigE rOrv fROm NFFF FN f CROSS SiRF 104 AR 5l M f 4 gR[[1x F MILEFV51 O.O I I M . il F Nf F 05 ACCIDENT ( ~ 1,/CJ fFFiS s F w Of 'Tl, \/E. MCODEE - RAMq DI RAM MTA COll15pNINVOFVID SO "4illlD~NO INIUN[D _ ^s01IlAGF ^NitSV mills~v IOIPI NO sIXfNN rNNgnDr. ® I IN x-RD IN r SefF RRCAD 041¢iEKNCF IM[q []S CROSSSM«O 4 ROAD IS ^/~ IX v[NICI[5 ~RgORFRiY DAMAGFONIY ^ g FSUIr[D ^vfNiCt[ ~- OeifCr 5f41y<INAmf Of 091lci 5rR Cx ANDOwNFRS NAMfI lsr DAMAGF / lOlm3~0 SRCDLLCOOING IEf ~/ = . E $ I UNIT NO.1 UNITNO.R VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST , 3 DNrv14.5 Amt. UxSr iq r miDOFE E U5i FI4 MI 4 f ~ ~ ~ ~ /~L, Vy ~/1~~~/ W o /'I I SreFFI ADp 55 vf f l ADORE55 i - ~ - V F~2 V /~IJA Clrv 1Arf IIR COIX N ONF NO G ~/./ °I0 CIS- t D R 0r SrAif I4 CODF FgNf NO. ~; LU I•V - ~'j '" . ya, I D4 Wt 'SUCENSf NO. ~IEX:C..fY7 0 S1Ai[ Fx ~c/ M B rN ID!d~4~0 ( ~ 1e'S IK[NSF NU wS vv rf 4v~ sfx M DnrzaplerNN ~ I D.~,L Z occ iorv 4mN avNOrve rvo. f s W[cFlr wcNR SIL(D ~ fC P'lALGM 1- L4 I S E R MNAMf pgNO fns V~v 4./ Cur~NG I1 )ST Lu ~ mcNi pNr 190 -/V l ^ CHECK(/) y "f[aAr~oi~f4x . . ®CHECK I/) 1vfN Ovff of ANOri°fgxl CODES -' ] NNe. p I p~',° "" CODES ~' 7 ": "' S In 2 A~q"fs NON - p s a NE ~~ ao1.D„ ^ .,.x41AN« ^ ~ 1, ^ ~b.n. ^ ~ 2,! ra~5. nN !Aq DODOf CNFV NMO S ; :~`"Iq,.DM ^ ANR,„.N<1 ^ ~M ^ zs~n ^ ~ K! ~ v ~L Y i oa .I pFl1DPe1 rvpVAl Ylf II Dq <ONV I I ~~8 U,IJ ld iCOuP A E FA4 qi I~15Q GILuNfY, M GyooA Y~ s ~ ` ~ oe N o. N siAif nfq 4lAR NO self H n A l~ IF A rvo. e ~ LL+E F I - - ~ w o ..S''I wA - - - IY v[N CIf 1D[Ni EI<wrprv.q !u II 0! IS~(U1 ! ! ! I 1 L vfNrClf DF Ui ! 19571 I ! r RFGisR4[p OWN[R IA51 NRSi MiDDIf FgN[NO. S W /f'is1f4FD wrvf R. Wi NRSi •t~ MIDIX[ l.. LL/ ~1f1 Lt `O/ [NO. ly., G ADDgessa owNfq owNf4 I I E>2 ~2 E 1 I OX Z C/Iir~Acur~ 9$ ' aADD4«Sn~NwgANa co oq ACeNr Yn/J G R . 11 S/h D - Ly' - LUM/A W.AF Y D Acfo AR[A ' " S.E S3S P 1 ,w d.orDiN CNARG[ () GL/J_ CHARGE wCGMU DAMAG[D AxFA N •~. 1G~ fIOY 5 Sr U.vA O( ql .9r^YN ^4[MAIN(D ~ ~~WAV ^4[MAINtD f5 OAMAGI /~^~~xEf IOl w stor f .D ° iomD p ° O a ^ xCLi'• ^ i vwxv >~D 00 ~ ,~ 1 >_ O DIAGRAM I su iY ~~ f D< onln DESCRIPTION OPC 1L1510N: IlnES neMlNius « N[c[ss 1 ... -, 5 T _ 0 %~ V E?l. a f~ WAS _.W E~~x '~-/-1urn D GYM J~2. a.~tLay~- ' ~ I I I .. 5 1 ~' 1 ~ ~ I ~. TT J~A9 JLSJ {'!/LL.C1~? G~J ~]~ _ . 5 ~ ~ 1 ~ '° j q ~ i , i ' OHS)LvH'Y FRvc`! ~ .SGIIUUL 131.5 57vP „ 4 Z I I ~ _ _.. _: I ~ I . A^'2~ wA5 ~EVf-r~G_ fJT ~.5_Lyv lurJt Ur - _. . ! 1- ~ -I I --i I -t ~ _S?~L~L"F~. V ~.~2 ~C//15__ WE57~14•~~ ~N ~ ~_ Sp ,N ~ ~ ~ T I I I I r~~E . ..~ n~ C.AMC AYlliv^~ sJ_iuQl,~~_. I E : I . ( ~ CJ:F~Sl~Cr~ Th J3L.s yE9rrr~r~JV_ II ~ H ' ' . uwcvq~ SLrD_2YT!!_7~>_ I ~.2~.7172Ui=_.. ~ ~ I _ i£ r,3Cs. _ _ _ _ _ _ I NAME, ADDRE558 IESOF PERSONS I NVOLVED 'CODES 1 - Z ~ a S 6 OCCUPANTS/WITNESSES If°a SADO'i~ov:~~1`:v~ s sf. Ai:( r • ~ ~~„ _ ^rr' - 4.rc+ VE5~4 N[<~ •M' HRISA1hJ5E?/~ m~~•E tb" pJJ C I - - - - . :D [lY'n5 I I ti I - tot N~3!-E, ,SJ h~fW~E Nv D4f Gi ~ Nb" ~ ONC' ^AMS ^~`1 p," . ^~ °_°• - - - - - - Y r w ~r~t.., 57'- u9'i7wuc k u01Or -.- _ . N uYN X101 f,M Ox„ pw,~1 ^ ~~ . ^" a •p ..7 ~ J7a5pJ./ I,Jro S_~ru3 . I - - - - - - . ,,. w,+. H r~41sc• ^.o„u ^ sif r'y'n"e "' 4uv ~xMe W ::A. i. "rir~1 " X .nr,;^'.1 ' /Myam /~ / ~EC.~~ I ' jN ~! iDa 7 ~1 Vim. P .. c.,,'~h~~1c ~ y,ri~nD D.Raq /~i 1 ~~I~/~~ ~r ~~/s u ~ / 1, p~ IA1xA~ rte If -.~,xT'CTj1~"^"riuiQ{ r~r' ~ i SG!_s/.lY .... - S_ r. .x ... ... ~4... iw~lF r.~.~,t ~~yy 9 acv, ;7 I „~ ~. .. .. .. F - wx~ `, ~~ ~ly ~ ~ .,. twin _ .~1, _ ~ ~. ~" 4 r ~~ ,~ _ ~ 4 s ... e~^ n N 5rc,~ ,._ ~n ~, - y _-.~ .,~ hy~~, ~y W iN'` ttiT.Fanwnavr ~.•TdC~.ava"a~~ `~ 'Raa Yd'v~n l . ~~Y 1 `9 ~II+TAw1 ~ / I ~L ..~ ® °° ~ ' STATE OF WASHINGTON '~ 5} SUPPLEMENTARY POLICE TRAFfIC~COLLISION R€P~RTy ~G~~ oF ~ ~ 1 ' . IDENTIFICATION OF COLLISION -; , _ CASE NO . rcRITY OF COlll$ION ~ FATALITY ~ INJURY ' ~ PROPERTY DAMAGE ONLY ~ u ~• ~ f I '~( ' ~i ~ L MO. pAY YR. COUNTY - ~ CJTY DATE OF STRCfi. ROAD NUMBFR OR NAME COLLISION ,.~ //(~ /Tf'/ LOCATION ,( ^~ ~,(e%~~n. '7~~ oa~7'7iu/uc~/~oL -~v~(e'f// ( ~~ . DRIVERS / "~~. A „+~"', _ (USE FOR ADDITIONAL INFORMATION DESCRIPTION OF COLLISION " ' WHEN SPACE IS NOi H GEOUATE ON ORIGINAL REPORT OR AS A SUPPLEMENTARY INfORMAiION SHEET i0 CORRECT DRIVER'S rvaME, C{CU PgNI N OR ANY DATA NOT KNOWN Ai THE TIME THE ORIGINAL REPORT WAS COMPLEtED.) ~ Ja [~~L ' 1 7 - f ~ N _.~/CL 1S>Jxe%1._O; )... 1 .~7 ~x/1m~_.I~LF}.--C l~.!~-rt.~~~,./ :_ S ~IC'E 0.S i ~ ~7on.._..~_[.- °~%) _.__.___.... . ..lick Jo%rt~~, G~F~~/~ea. /~.r//er _ ,/~y~ ~ ti l/ ~LYS/7GEA i'GLUCa ~s ~ / 12 G~) __.. __ _-- f E~-lico% Fu~~in - -- -~Sccu ~JinJ~ _.. __ _ _ _._ __._. C ~tU ~r~F nJ _.....- [/ ~i J fri CPC. _._.._ .-- -'-'-- ~[. ISf2UJ r _.....__ ._---- -- ----- vl._ l~a~~ma rt ..._ .. _ ._....._---- - v ~7~ ~ l ~ frill I ~ ^I~C ~ hIW.'M'n ~q+~~I'~` SI (` ~ +~ ~ f~11*~W (i 1 ~ ~ AQ f! ~Y ~~2 ~~A~ 4 1,,L 1 ^S R ~ I It n. , i ~ 1 L; T I iE .1 Tr ' ~ 1 ~p y ^I e n~~ I 5d ~ fl ~ ~ ~ . f S TliNa~ ir ,w, ~_ - ~ Ek ~ I I ~ k P ti . I IT rfoi I I~ li. , ~~ . ti I E Y 1 I I ; T ~~ ~~ !1 tI L 1 ~I ( ~ I ,~ , l - l .-t iti l _,, ~ 1 t t t~l ~R ~ I II' l I { L 5 _~S 1 I ~I X51` ~ , I t Y' ~ ~ ~~~r~r E r t f 1 ` y r . Il ~ ~ I ~ r I t` I { 1 ~y u l i ~. I ~I ' ~ ~~i L ~ 1' ~ dh G3 9 4 ~~;4' t .7 ;it+ ~~~ ~~ n E ~• ~ ,p d < Mr , v I - ~~ >~ _ . a ~1 ~ 'P ~ f ~ }sr ~. ~ ~"' _ , ~ '~ ~ a~ ~ POLICE TRAFFIC C fPORT I~ iRAEFlcwnv ~, JMBFR L PRIVATE WAY I `2 OP f OI COIU N •i r ECOII N wr rcu. rAUR. .. f.l nM( C IVSF ].OD HOU91 Ol1Nlr COUNTY NO. CItY BU. fHWA ` ~ V ~£FFL.eso~/ /(0 pURDAN 9u pry pf ~N CEr Oe IOWN t6N0 OI SiR[[r 09 HGHWAr Itl C15 ROUrf OR Si fC / mus ps pw ^oE /f/}OGCC/.( ON ONO.}LL ROf rEV5tCl vD wtlH. SteEFr 09 WAP NON Ntfv5EC110N 3 93350 R ,.2.) /~ BFfWFFN Gf<xt T'f SS Brv[tr 6 /rte ~ LEO y SIRFFr v9fvlx f0. Mllf Pp$i `/ / ~`~ _ L i / D rAnCl6D'v! O E90N 9EEVfnC CROSS SivFR O4 ryEA9tSIM Sf v05r ACCIDENT Ml[5 5 F W RAAw DI 9AM DATA L MILEAGE O rRi Or SS SO'/LELr ODE M COEE SNIN NvUEVlD fvfe Er: 9 ~_ p SvnlAGf ^ H l[D~NO NIU tD I69U ....rvoel°iu tOiAt ryO ~ O rt CR tN S ry IN k~RD CEI R EI R OR YFEF9ENCt M tp Cl5 CIIOSSSI R ER O R ROAD R V Clf p 09f 91Y DAmAGF ONIV ^ pt SVlrtP pvl~'C~F OBIFCr Srv N m C + ~ / / ~ ~ u~ - Y (pJ /LjQ 1 A U f O .I OBI[Cr SteUCx aVDOWNF95 NAmf1 tSr DaAAG! FF.vcE J-TR,E£ L SASSEQ, s oa0 SRCNf CODING Ebf ^ s elvt9's Nast. wsi UNIT NO. 1 I R I U i NO. Z ° MIPPtF D4 of 9'S NAMC ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST UL -2' SN£FG 5 r£ ~Ln/ a H , l StearAD swEfr APDefss 0 ~ T NG~I D A 2 tlEr SIAIE II9 COCE HONf n0 r D CUV SrAtt 219C f ~ H~tD/-acr( w /isff, 9 fr23 8S-3osr P9nf9s R ryf NO. ~ t .-- uuNSery S E FL S S~/SS/( siArf Vt/A .Ex M DA ~% / ' Nr6 I ~ Iv 9 uanst NO. ~ I i A t Sfx OAtE eIRIN "° I °Ar j "• a ON E 9m NAMf 6 vNONf NO FVFS wF GNr MHiNr u /tsGK E occu9AtloN IIRM NPM[ 6 9NONf NO. fns Icnr .<ICNr ~' /Sry~ CO+-//hw+/ S LL LIL DSO SD R ^ p CHECK (n As my vA9lovtr'w AHOi:r9 Al p CHECK I/) MEN nt AS AN EMRIOrR aArm Al + """ CODES S' 3 ~ i < ) s r <r 6 i,° s , E G 1HE9 CODES - ^ D n l Stn D sD 22 uerts C C oN l C ~ e so+r g~^AM,vLNfE p vytl ^ zaal9 ^ ~ p .v IrfAR'M xf IDOWECN[V.1 tlIDA91~NOVAI xlF 2 U9 CONVy M ^ ^^^ l ^ S°F° ^ ibdn ^ ri ^ .: • r v ~11 l ~9fld GN£E/ $E2QvlC£ cKE,cP v n. CIXOa IIC! Sf vEAfF n S1AlE r A lf9 RAtf NO StAtf E H NrfA9 "1 Hv,l mooRmA9r.ryovAl I2DR ,l vtN CIXOV - ~ ~ 11 ,,L/~ ,V R . ~~~7~~ ~~ I ~ lA A Il A AE -+ ~ l3 Clf Ipfryr f CArIOry NO. G K z 3~Ai~' I I1d:31af 717; D RrolsrtvE - C L vtH Clf IDFNi I CAt N N i l i I' I I I. I I l i l DOwNf9 19u IDDIe waNf NO P~ K ~ ~R L 2~0/~ O W Sec srt9toowNER ,EAST Elan MlDaf tNO. -- tz APDxssaownw 712 ff JSf6z7 !~°'f}vL S S Gt W N E . 09 r owryt9 ~ ~I taeoo+fssa lNSUeANa co. o9 ACENr ,ry N 6 ~ R _ DR .--. 2avAACIO A.RU ~"~ ! 7 ° " r.. - .ci cHARCE :o, W " aw ~1~ 5 ESr. pMSAD[ ^ AW;~N ^ IM,N[0 M ' o~:o~r DAmACfD AREw c A9ct DPWfN !St ONAALf ^9fMAINFD ^ AW ~ ' ~ . f~00 ~ RLtc•L~ Er. EAOWXv°er. LLSl. AY Io iDRDM ^ ~wir°ar: S '•~ e DIAGRAM Of COILISION~ IVS u l Al INP Un NDRIN . -...aNfnuNfgssAa au9eow ... DESCRIPTION Of COLLISION: Iu5f5w f E 1At SHtfilENfc[SSA9YI ° D ~ r ... . I I .. .. _.__._._.._.._._...__ _. __. _.._. _____.. _. .__. _. _. ___ n -, .. ~, ~ . . . 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I r 5. ° r a ~ ~. .~ '~ u.'. t 1 ~5~~ POLICE TRAFFIC COLLISION REPORT LCJ IRAFFICYVAY FgSgE COMRUINTNUMBfR ~5 ~ PRIVATE WAY ~ 1 DA1EOKOUI O 1~ ~~ Av u N Wx Y.9x Ims ~ ~w+t EE 3. r umE IVBF RxD0 HOUR) O 5 OU couerr ~i/Fr ERSo~1 couNn NO. Flo on NO. iesvn GUR u9u ! '~N GE QIN CtYOR TOWN f6N0 Oi5iq[E5095xGHWAY 3 MILE, QS ^W AGE cNlmac.~m ON j Ro>JDAJ,£. Rte- IRCIS 4W1EO451RfE ,~ /~~sa Y I „ Nrf4YGl NG NtrH.CrR[fl Oq 90A0 'O~n 4V~ rqN NIfRYC10N BfrWEFN ~~ s19Ffi6 SSRFEI RREiI% FO. MIIE ROSi O.OG ~• 0 iN+CE 6D YF r NFROiM Rfrf4fN<f. C9055514FEt OR NEA4EStM IE V05r MRfs 5 F W 25o if Et of j{FIOD •D2\V £. ACCIDENr MILEAGE coDE RAMP A RAM MIA COII$ON NVOIVfD: EvFR rY- r6RUN 10EAl NO. OKIIFD O NO. NIUREDO ^SD IIAGF ^H rn UtN H;NDVt0m5 IN .q0 IMER Cl5 FRY 11 IRFE R40AD04 RFEfRfNCF CROSSSrRfET09 ROM ~] tl VEHICLES ~ G R40RER1Y DAMAGE ONEY ^ eESUlrfp ^vFa<lf 96zoo I 9 OtlIE 151YVCK INAMfg{CO1ECl SiRUC% OWNF95 NAM) Fst DAMAGE ~owt2 Yo LC QvGE~T ~owE2 s7.DOO+ BRtCIN COOING IAf I UNIT NO. I UNIT NO. Z ^ VEH ICEE ^ PEDESTRIAN ^ PEDALCVCl15T ~ 3 - DRIVERS NPME: OSL NRSi ~iER ~cN ca~Z~ MIo. SNMAF. NSr fIR MI l srYFElwo°vfss ~,o,BoX 8G3 1RfEr DDgfss UIY SIAIf ZIRCODf RH ENO k-IA~l-ccK WA• 98339 q5-S241 D R IY SrAIE IRC E RHONE 12 DRNEk SIICFNY NO. 1'~1~,r~co~ol m~. SrniF wA E% m BRIX o7Ao°~} !~o I ~ NFR IICENY NO. AIE Y% MtE 0 "' 0 IXCURw110N NAME 64rgNENO. FYFS WFIGNr GNr i E OCCURAIION NRM E6 RIgNE NO. ETES IGHi HFIGNi _ 2 /voNG uN EMPL BRr1 170 Sl0 R G CHECK (~ vENIClF AS nN MnaYVtE aE ANOrHreAl ^ CHECK (~ FNaM AN rmaovfi OE AnomElenE CODES-' ] ~ R "5 s l a. 1 e t"',° :;n - CODES ~~ 7 ~~ . l s u e v :ss N Hn .crt 3n '2• IN elES N o N E 7 m ~kY° ^ • G ui'cl ^ 2S:r5 ^ ~ G A« E G U ^ E ^ ~ ^ ~ ° ° N ~~ So vFH. vfAR MAKE IOODGf~CNEV.I Y98 CNE.V mA0F11Dwgi,NOVA1 IF IROR. CONVI P.U t Si~-DR. E R vFAq 1 NV.1 MOD IDAAr NOVAI 19 .1 _ Fe ..• v N FN elArf Al[R aAiE S1Aff H vFH.CIX09 u.TFSE[G l N w •g~K Nu 3441 wa - - I ' vFH CSF IDErrtrtIMElON VO. CE 1482131og,3----- i vFHICEE IDtNNi A NN 3 '- 4Eelsrt9eoormER: SASr ilRSr mlppE Sa ME RHONE NO. O u I SE4EDO5vneR. wsr il4sr mlDaf N - c•• ADD4ESSar ovmw q YYI rC N A o rowNER Z" NAMFewODYt550i INSU9AKKEC0. C4 wGENi NoN~ ' x R P+ I+IU N ZS I~R ]Z DnMACfo Aau 5 ' '^`°"•` fS ~DAMAGt I OD cNAacu q y eN UL I~(N ^ nW, ~PEMAINFD .. ~. cHARGF Rlv(N ^AW r ^RfMnINED o~':o..v;•`r f5i ~°AMAGf DAMACEO ARu I~5 '-''~ S ~IOO ^ tOWFO "v v ^ION100Y. s u R mN yE NOYIH D AM 111510N: lu SNf[I Ii NtC[SSARVI N ~NSRJ'ROw DESCRIPTION OF COlL510N: IUSF SURafmfNrwt srxErRNtttssAevl 5 ^I e lo-rN Q VLHIGL.E. ~'I wAS wE.$7' 3o VNa oN ,Z2oNDA[•Q, A ~ 1ZOA D D !•~.fT ROAD WA'/ C]N NORTH SNOVADL/l PDwBR AND S"T2.VClC POWE..R Pof_E• il n PDE_[, ~ D2LVER WAS CilVf.N SO~lfF~1/ fl E! D .. • f4.5•(5• NAD PSEEN DItINKIaG ~ 13vT WAS _ _ _ •- _ ,_ _ _ _ _ So/iE2 Q.NOVGN To PASS TFS-/'s. ~RLVE2 Torte /ham N~ N/LD L3EEN /N AN R rNA7 A1oQN~NG• Acc! D4J~T EN2LlE I!(ONDA(•.L (1D. . --°~ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED • CODES 1 - 2 ~ a 5 6 OCCUPANTS /WITNESSES ,w ioo~;oHii u•'Iw ii se% nee arus '","" " . RnrR uta :.c. iq " .DOYESe wEOi 9 uwr°nY ^ AM e ^ EYSt' G "d . O °+ ^ ":2«5. AMI ~ ~ Aoonss u4ra r y,MgvrDrYOr.. GAMe G~D,~t Gw .GC. GI: i0 .. AMI ~ a .,..r,• y l,Gi W ~, r..,. r ~ r,.., n ~'h•Y ~ ~rr~. ~~~' x • yrl .~ . 4r.F~h •J ~- }, a ,;. ,. ~1~~~ 4. '~•- 5 Y't,5....~: a .E k. s ~ } ~ 1° 1~, d E ~r e. ~~' ~ % •~ ~ a~ ~ f ~Ylh f4 :•R' r.rry ~ .fit ^'IIi~~i ^~& i.' 1 tk - F,y7y' '•55~Y ' '~~5~y 1 ~ Iz a !>r ~ ~ 1 ~ YVdt~ ,a 5 kp'. " T ~ I ~ r I ~ iar,. n Y ~ ~ ~ } 4 a ~ 1 1 ~ i '•~ .v III ~ rl { 5 E ~ . ~ ~. '. ~. 1 J: T i ~ I ~y~{ Q E ~~ ~ ) 1 lY - ~ If (1 ~ Y~ ~~ ~ ~ 1 1 , ! ' ( 5 1 ti ~ ! 1 ~ j f h5:' ` 1 I ' ~ ) 5 I % , 1 ' e~ - , r ~q' il f~A. . s~ ~ ;, ~A ~_ rt;a :; ~~~~,~ ~~ I .!rP s I ~. ilaraRm. '!H ~J MOTOR VEHICLE COLLISION REPO R T ,A L Is Y NOy"~. ~, V.. ~h'. ~}` /U ?O ~' o ~~ ~ ~ n UE, Nr.I 4 ~ ~ r .~, Nn» ;4a ~(oQVr L , CONY FW. .ITY~ 6 u H w~": N.NL Pw °~ . ~ arR r R a»., ~ ~rL1..L, a~~~EP ^, ^w ^~. - .. ON ,~ P,~.J rRLII.4P r . ~, ~NrL4s[cNI»ow r»sr»a1 o.I"c.o r .. »1w (.' ..J 9i ~ S D ? ~ ~~ ' Y!i ^ ^ nA Lria.pclo ~ v w ex UCE a. " =o~°o~~ ;. r~ L ~~ ~«= / J y ? ' tLt%N I { `S{R'A+~.d N NLL.o.r ,N L X~.1an r. 0 0 0. .4. ~..4P.r. P^ r, } ,, 11 yf."~1N,s~lo ~ ^.`, ^Nr. .nowewn4,.Le ouNa no,~~r„ u1 n1.n OBJECTISTflUCK • ~r ` ~EiinseerwesrnEESrTOicr on°a „^ Cl .' ~ ". r IN Maul OWNER OF OBJECTS NAME AND ADDRESS I~rn[ Ar[o ru.r ~~ FwxOw[cr srtc caw u:L a Y~ ', _ _- - - ~ , DRIVEfl'S LAST NAME FIRST NAME T MIDDLE y; EO OflIVE/t6 LA6T NAME 1 -' " FIflST NAME M D _ - y \ ~T ~jC 11 IL.'I L I~r~I~~F lr (1 ~11 1 I I THEET AU q 56 Y`~'~1 Jlr I 1 ~ 1 I DLE _ I~ p J~RO TE NO. AN BO%NO. _ ~ L STREET ADO 6 ROUTE NO. AND BO%NO. fY S ~ RJ:ODE.. AgIV/NS OGCUPAirON,• H i/I li / , / 1` 4 I I CITY. . , ,„ ,, ~ Y,~ f ,6TATE ^21P 000E OflIVEg6000UPATION ` ~ ~ 1 1 Ill.-' VE ENSE NO. j}... _ StA E LSEA OF TN GE pRIVER'6 LICENSE NO. ~I~1 ~ ~~ l l I _ `,i 4 fr ~ ~ ~ `'•'i ~jL~ I 6 ATE 6€% PATE OF GIRTH AGE r N U ~.. I k HICLE Yfl MAN IGM V, DODOEI MODEL NOVA 1 ARTI B 5 L 12 Dfl.) VEHICL n.Y yI1 ~ ' E Yfl, MAKE ICHEV. DODGEI MODEL INOVa~OAq TI BOGY S1YLE ) OR.1 ICENSE PLATE NO. STATE TRAILER PLATE NO. D r ~ .1F ~~~~ EAR. -l~-L_L.tis~r.~--~L~C:~[Yll r I-c~n~~ ----fig ~ IABILITV INSURANCE INFORMATION-VEHICLE NO. 1- was rHERE Auio4D6HE uaoartr INSUflagcE AME AfJQ ADORE65 OF/`1AB LITV INSURANCE POLICY MOLDER COVERAGE IN EFFECT FOR TH S ACCIDENT ON YOUR CAR NA4L I/_ I! V ~~ II!~T.1'~ir.... J 'L s. 1 1~ .. _ _ Sr Cirr I 1 n ~1 / ...... .. ., NAM~OF L A 4' bEVV~ R ~Enlfo~r ro - s -._. DES ^ NO DAIPANY ' ~F 1ES1 , (• /.AGE ~ daF '~ Lret~@1 ~~ 'S/ STATU6 OF INJURED EXAM NATION BY ~ OOCTOflI L"! L! NAMEUH S 'sir MARK FIRST ONE THAT APPLIES STATUS OF INJURED ., R4 IN V HICLE MAgN FIRST ONE TNai APPLIE9 - ^r..strrt.I" NO NILIED U» nos.u rx uhr 0 IN ,HI L ns. ^rL R NI Irr+u1v- x. ~r - 1 o BL:,",.». ^ 5 e p ~~°" o L~;rl~::-- IVIL`=F`4' "c ".~.~m~'»;'" ~ , ^ s ^ 7 ~`m I I MOTORCYCLE ^^uAFETYt-Q-77E(Mmmr~QLl._nlLMEi'NOi USED MOTORCYCLE SAFETY: -a-NCw ~ 1 r . SHOW NOR}N OYARROW IN LIRGIE __~~__'''I~`''//II``''--'' _~-_ ~~~/'I -~'~MET NOT UGCD ' .. 'wKAwlulrWrSNSO ~, _..._ ,__~ DE6Cq BE BELOW WHAT MPPFNED (REFER t0 VEHICLFB BY NUMBFJI)~ .i "A[f 1M Wrlw< ln.l nir^ii 1S O .,. •• .. ....... .. o1A:F°o1;"~ 1~,::L ~:~.~µ ~t iC~l, ~ mil' ~U6~ ~QU f ~S~I~'y aL ~i / wpAS CL~IL ..S'fe~? ~ ~ :: J ; .~ 11 k! ~Y T~ ~3. S ....._ _ Iii ~~, i-'S ~ „ ~ Ts a xt 'i': ~• " r~~.rW S .... ., .,.. _ ~: { r'~ VEHICLES POSITIONS BEFORE COLLISION ~ '~1 ~ t VlrRLlf N 5 [ W ON BTRCEt OR HIL' " rw.l LI n1c .lBwna INVES 'IOATED UY }y L Y, NPUI ^ ^ ^ 1wAY NAMI OR NO. I r H .4P OHIr .x.LP »r,»PC]rC}U~H~LO l I'FS~~$,Ylt ~ ^ w 1I! ~~ wnl on r ~r H ^M r :~~' vlr~t/ L-L ~ ~G ^ YOl ie y I ! S~q~~h/1"" . q{~~Y ~ 1. u; 101.,., ^ ^ Y ,/ rTeY 1 [~-- ^ IRQ" ^ ^ ^ ~,.,1EF ~';~I"r.".. ~wAJ~FF~{{~y~eu$`{rli~'lCryPy ,A~1, nwarNA4 ^ ^ ^ ^ ALONG "R 11, 4V+'~A~~ ~ 'k v 1. ~AP PEOESTRIAN~PEDAL CYCLIS W S I ~ nw ~tl"0 FROM TO" PEDESTRIAWPEOAL CYCLIST TI r^w.,.w.. ^L»P4, w. .^i:oie:4. .^~«miw:,°. A^o114A ,^:" 4,~~~~,It ~ ~ ' '.?Ir ~ I I'. tom ^r. ,^1 ~^",;,'r`P :^m.L4.. rY I ROAD SURfACf - """ r^u..rn ~C { t/ '~ n.r..J t wLATHlR' I LIGHT ONDITION6 r CCONTROL '^nr rl,U.Nlrrewl r^ e~nin r~ir.hevii[ ~ I~ f -} I F .. ~2 r~ r n.L1 IMFFI TYPE Oi HOA ~ r ~~ / IJ ~1UHI cKC trw MIVERNEIIICLE ACTtONO 1 ~' A + 1 g`"~ t?Tr .,~ ,! / ) ^UawN ^~.K."^ SONALS DNF war 4a1L1 fi~r" rt»rc. a.L Onw L I 9n ~~``aqi a~A ~` {l ^w ) ^4A Nti< J ^DU54 ~ O STOP SqN I IJ11[H~OINO S111A OHT AIrFAb " ~. i ~T ~. AI, ~} ^ ) fI ^ ) ^ tWO WAY tl s{IPp{4TA ri j4 T 1' ll 4 ~ ' ^ J ^SM)w S ^~~,~ " ^ O ISONCI ^ Y ^ •f10 S19N J FV[RJ RtC ^ ) ^ OV[RTA%INO ANp PASB NO ~f~71{V ~ + { JJffr l'1 -.~~LL~ "^r~ S ^t ISOIICI ^ ^ ^IUAO /^//^MAXIIIOq G11I TURN ,I h: ~MMMM''''~~Tr ~ 'T ' i r r ~~ I' t~ ~~ ^ X ^ qL ^ r:r'Y.ItI / " ^ ILASrUNO N[U ^ " ^ NOOPLn~u IF lLJ ^ MEKI lY~ J A ^~tllnlll0lgrrl3 ^ J ^ flurrW0 a4BLK S AlllY ND ILfl IURN YP ~ y 1 ~. ~ ^ J ^SPFC~Y CL I I_1 f~ILrfY ^ a ^ AA 6rUNAl ^ ^ ^ S ^ MA%1NG U.lu11N JVVN ~lA ~ ~hl 'db~. ~ ~IyA'N~ ~ Iw0 WAY. p p1 IT S ~( I ,, R AOwAY UUUCIlII NOAOwAr SUNIAC[IYYE ^ ~j ^ tl ^ TAN(}unN W ~~ '{' P t ~1~ (((~~~f ^ D.NCIN.IL Afl4Mr ^ 0 ^ LIOW HD yJ ( J t ' ~ r~^J,F} (~. ~ ~• w ~ !~ ~~, ~, ^ ^ OIY VY wAY ^ I ^ SIUPPLU IOII IIIAIIIf. I f L ~ 1(, A T,1 ^ •'^OrnLn .Pf Lllr .: 1' ~~.r ~I ~y ~OAD BFpAICAFION ^ S ^'rOPPCD Ar LIf.NAL J 1 j I-I1[~~c - l`V-J~/pYIOFO k OP bIGH ~, T n(~~~ IJ F-~ 1J F^r ONBI _ 4 ~~~ ~~' ! ~~""-~. - 1 1 ~ 1 V• IJ a r~010 O ^ SIAfPi1 Nr1111F0ADWAY J~ *~ `~ 1 ~. ~~ ~~ ~ c ~ Yr"` rl,. , "C71T r F I ':{'~ti L G-. s tl r v Y ~ i~~?;m. ~ ;.. , ~I~ qr ,'%Ipl~'g vr~CP~ _ ..,t ~~~ ~y~,6 d 1{~ ~ I ,t I, r r ( ra,~,l9 A+ ~'1 'M 9' - + ryy '- ~+) I ~'~t S~Y`R+~l. ~i,^ ^I; ~ y ~F~ .7r I _ ~~`' tihal x 11 .~ ~ I.: A:.. ~r C~i~/,'A ,f I f'' k IY. L;r I EN I r ':'rii' I 5 1}T ~..I TIJ I 'i al Y ~~` 1~~ u I, ~ I _ Y s i ~ 4T i ipL~~~ dAvn ~t ]t:' t I 7 ~~-4Wr \. . .. r .. ... ....... _ A. ,.. ., . s.A n.. -.. _. ........ rnulwlnFE ' i~:. . '~a~ POLICE TRAFFIC COLLISION REPORT V-Y'"A~~11°"L~" volKFCaMrul uMeE ~• ~ PRIVATE WAV ~ ~I l D fOEOC~IXU (~N ~ V C'~ DAV, 4 ~~Ix I i. txi 1mF ~f'90°»O`41 ! CBUE1[L~/[' /•F /!'/-E i~ ~)/l~ CWNf/v/Np~. ~•l'.' CITY NO, inWA ^Vg9rY 1 F NAMF6N0 OE 519tF109 nIG»WAV ^rv 1~f ^IN CIiv OR iOwN gOUfE045 E ` 5[ M9fs ~s pw 8'nP 1 A ON {! (.~~ ~'Ni~~ „ rF95E<tING',NrNE1REE1 ov Rp•p NpN INIF4I5~FC1IO~N 11 BETNFFN[%~EIE nR~(_ -T~Er6 E"L•1 L~J~ RSr9EFi PN[il% f0. MIEE POST n D'OC~ 2 D151aNCF eOIRE I i 9FN f. C4053 Br9FEt OP NFaRESr Mllf 8051 MIlfS E R S F (app iFEr w oi(-FZf:E uE.K +~r7 ACCIDENT MILEAGE cooE RAMP DIA qAM DATA COluSKNINVOtvfO. SFVERIir, vOtal NO OgllttD_NO.INIV9F0_ ^BPIl1AGE (]nlt6 RUN ~NOw4tw S I D jR' M CIS IN I rgFf 4ROap Oq REif4ENCE CROSSSIP [109 ROM E ~~ CPVfNICIfS © ~.PRpttRivDamaGEONIY ^u'ESUIrED ^v[~iClf V / - loSZSO f •~ OBlEC151RUCR INAMF OE OBIFCt 51vUCR MDOwrvf R'B NAMEI [51. DaMaGf S SPECW CO DING USt UNIT NO.I UNIT NO.Z ^VEHICIE ^PEDESTRIAN ^PEDALCVCl15T ~' 3 D9rvER0 NNAF: UBl iIRSr mlpgF Lo co. ~ G DRIVER'S NAMF: U51 Iv I l "' 2 sr4ffl.DORESS {/.[~ / II /1 ~f~/ N 7 Cfo ;U,G /T /Y//Y ~ O w ' D EE •DDRESs S C E LIP C D nn Nf NO lir 51atE IP( I NEN cx.Y_L cJ W /.l 9 7G 79~'fSY'f R 09NfR0 UCffISf NO. Lorv1/~ssc z~sc, afaiE WA E z I Ri;R~".. I ~ N R uCFNSC NO. IAtf f% MD°i"°.BR~1.R ^ OCCUPa1lON MNAMJj,`NO NO 77y IOU EYES vKIGN1 NEIGNI .F~FR OgG4 ~ E OCCUP•1ION iRM NMAE6 PHONf NO. EYFB WEIGN1 IfIGNi ' .G <L~RYs ocJf; .u ESQ ~u R . CHECK (/) ' VEN <iE as aN EMnor of •NO1n[4.l ^ CHECK(/) EN of ASAN Dnaor[[a aNOr»FVAI 9g~ym,~ R CODES-~ 7~ .s` 5 T a["x° sR CODES-+ ~~ <s at a'sr° " dT' Z I pelts G AJ F sf ~;gERDM p .R,UIx»[t ^ uo ` ^ 2b.gR fB ~~ "~17 ^ aw,. O NrN.„NTf ^ E: « ^ 2S.1E. ^ ~i:KiE ^ ".°~,. N vEA9 MA9f IpODGECntV.l 9c9 c~•~EU / ~ n[ElpaRr.NOVaI StrIE Iq DR.COrvV.I J" V / E vFA4 1 nfV.l DFE IOAR1~NOVA1 1 ~ V.1 ;qe z n var[ 1RallER n•1E NO srA1E H rE»caoR I N. W N ~ Tr_- { c:. 12Z L-~-'ID • I ~P KNKIf IOfMINCAigN NO. i vFnl<IE IDfN11N f N N !G GI I L Ifclf{ Ialtio I 411 tz 313 I I I I I I I I I I I I vlGISRRtDOVM[R NSI fIV51 MIDDY PIgN[NO _{c ~ o ' ~lACicraio ••r-•• ~-vc, C) W RlulSr{RfD OWNER: 1A31 NRSt MIDDLE N u Z ~ l ; "° .ZCir1Y~ N a wNFR 1 O C ~ uE E N eaaowtssa mw+•N eo o4 ACM IN u N R FEA~'F~RD ccf bs,v ~ oAmweD wu Nc~rv.E .. '. gAmMfo A4EAx o'm~rp "° N AR • s s , ° ~ c»A4ee , ... oMCt c» ~~~_~o~. ~ f estt~wM•Ge I,fM ~ °ewnr ts1. D•Mac Ik_ru• ^Aw ^RtMUVfo ^ ^gtMalNFo I~s y.4E- s t' 1ov[Oer. (jE C.Lf \rJ I..J..~ ^ wwEO er. s •war r u DIAGRAM OF COIUSI N. 5~9[ttu MC} N ` IND,C•rt NONN DESCRIPTION OF COLLISION. IuseiWNt N1•l snttrn N[eessA4rl - .. 1.. _.... . , 1 I I l_ . I .,. _~ vc,+l ~ L./~_ ,E/9,yJ__CJ ~ onx__rAy ,~a . R~a>~. I '_ r ~-}--_ ~. ~ I -' vc r+y .i_cy , ~_._~a-I vc~ a~~,~l..rnen.---.. ~ 1 1 ! ._.._ I I I ~~I. ~ ~U ... S.I.G...u __-t~O.W N W H.f l_f._90, N ,. i~ J I f- D ; U..r/H11-L... E NIC..IC~._.Sar}~.-_. .V._. CS , ; i cE L,EfT f7 i 1 Tv 1:NF -Y `F ~ ~ I I. ~ _~ ' L L•C T~ I __ . . . .I__ ... . I _. _ . } '- I I I GJL~{~'_.kM(~A1V//fA,fiv~"'..o N?G.... !?-. ~.L _... m i I I l ' I (' I ( i ii~~ _ _ _.. _.. ' I , I I , ( I •I I It NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES I - 2 8 a 5 6 OCCUPANTS/WITNESSES 1Oa :mnfoa:i ~~uxFi i` ~se: W[ A1U5 u.r ": rix .'NI "_'~ 41514 11lCt r1a •.Mt ~ NO ? 1 X •vt ,q ADDREfs . J~vf,en R movsDr.oM ^•ve Q,^*sr ^ o' . ^ .f ^ ": '0 ..w „o .. .~,., LJ M nu M~x n,` . ,. „~ !- I n -,.. ..~. r .. . ~. ..-..... I tf .... ... f, 4 .,E~ . .,.... ~ . ,... E..aw. L i E f ~~,~ I' ~[ . y~iSV~dw..: f E ti 15 7 r e`t~ ~ 7' r, ~ , `` " ~ ~ e [ ± l~ ~I r~ ~~~ I s 1 a l y alr - - t ~ -i: ~ 1• cl - I! l ,~ ~a , '~ . r ~ ` M ~' ~ > >_ ~~ ~::- - err.:=_ra "^" s ^,re - ; ` ' ~~ " , .. . - ?~m, .. ._- aii'R.. .:..A...3cat P` r~~. , a _J~ .,~' ~ ~~ STATE OF WAS TON WSRL:91R~, ~ RAGE ( GE Z N ' ,fD- n, "` a ~ o. POLICE TRAFFIC COLLIaION REPORT ®TRAPHCWAY ~ ~ ~ ~~ ~Ql~ (~' ( POUCEt.wARIAINl NUMO[R PRIVATE WAY E • l-'^~~x' ys pp '~f r / ^ Oa F Of COtll DZ OG ~~ A O N Wx wox ruf , wio v u>S ,r +• x rlMf ID$f]MR HO RI 1ZI ~ COUNiY C C c~ ,~I cpUNrv NO. f~LFFL~. I OI" /~ CIrv Np, RNW ^URG a ~' AN . a !~ 'y;;; ~4 C J f ` . ((~~ , 1 A y~Oy~ N F6N0.0 SfafFr 09HGHWAr Kr 45 T 3/ qV([5 ~5 ~W ^'N {"f ~ TJ R ON C 1 ROEIIf OR iR SECr ~ t ~ ~ ~,y'~" >~~ D • /~ INIfRSE<r~NG wt H SrRIEEOR NOAD NON SECION 1~1! 93zsa r ~ ~ C1-~ NADLOC.K (ZD RREHR fo. mREEOSr BFiWfFN SrR[Er A R NOD DR; S OIS ~ , ~yy r ~ yy[f rREE! R _S' O~Rf 'ONi MNf FRFN .CRp555IREE109 NFaRfsIM~lF i05 S 5 F W N Q~ O~ w~Q V ' EfFr ^ ILA y ~~ CO °P N ,DLCC,1,. Ctl Er DAGRAM DAtq cf~ S~ tY E *S . F : ~ N DE llS NvO VED SFVFR rr. /~S N~Eiu IN rOral NO OI(IllfD_y`NO NIURFDY ^SR IIaGF ^Hr6RUN uoxur ru x t CF VF/ICIFS ~ ~ PROMREY pgMAGE ONLY ~ of SrOIFN ~~ ~vF C OB INTER Cl5 CNOSS SiR[kTORRE~EI~ORROgp OR RfffREN4 ' If] x: • ~ lF 1FCr SIRUCRINNAEOf OB1fCr SiRUCR ANDOWNfR SN\MIEI Esr paNaGE SRfCFLL CODING VSf .S Z ~/~ Z J ~~~ ~ V4 r Y '4 UNIT NO.I \ UNIT N0.2 VEHICLE pR fQxs NAME wsr sr Dif ^ PEDESTRIAN ~ PEDAICYCLIST I V 1 l~ 8~~.-•~T ~A° oR xFRS NAMF~ sr I'1 L3a-NSRlD6E ffr Ig If• 2 a Y ,!1 npoaE33 ~ . Q,Of 6o~t 5iF2 1 1AD . o R~2T G. Er gppRFSS S 2 . WC~(, IZD• ~ POE 6oK 303 ~~. ~~ a . r SrgrE ZIRCODE CIrv HADt-OGI~ WA• 88325 732-'i143 R L-IAD 6dC 2 DanERSUCENfENO Y. WA Q`61N~ f 9 R ~ , .; BILL~BA3L ENE ogre A EN , x D , A ~ ~ D8o5 ~~ ~S 3 3 ' f 3 E= g$-Sa DarFOReRrH l2 : : m OCCURAOON Nm E6RHONFNO atul RG368PP EYES wFIGHI HE GHr E OC wa m to i7 L~ ~ ~ ~ CVRgr Ory aME 6 RHONE NO. ~ STuDf.>r7C ESLILMf FItL•IJ Sc.l'IooL l 51 R VNK Mn :(~ EYES WF GHr EfIGHi L t' a~ vY-.+ ~ ~ CHECK (.~ vEH 4F,s nN EMn o<ANOrHER. E $ CODES ^ CHEC« (~) ~` ~ ~ia5:' 1 ~ ~ TEFL s r EH4EASgN rmxEirEEa,NOri.FR"` apN e;nO CoDE5 v v ~ ,. -^~`" 2 .N, aos ONE- a: sf, ei° -1J erO ` , N RR M :;„ r~ 0NL e~j romp ~,.,x~wu[F Qe°d ee ~~5~irta V[N R[P4Pom ^IDOWE CNfv )^~Ct ^gRi,rAVA0 MStvIF ZDR CW 0 e~c f " " x ~'R R ~ ~ ; ~ fv., v 1 ~' I FcHEVI MopEllpAarNOVgI 6~] ~CNT. FIRE gLRD 2-DYZ E N (9 '1 CNf.V CAM ( Oa LCEN fN sr,rf ,4RRArf NO ra H U ~ v r IR ~I 2-D a S„ i ~ s°,v2-F ~~pp d ~de ~ r,~, . s1 . rq v 4pR n A I to ~} .~ rE ~ 4V ~. I P'1 E C RE~ IUCXZS~a l,.lA vEH<e ~ ~ ~- ~ ~ ; _''3~. '~ _ ' ~ pfrRegrwN.ro. ' Fz t G 2 F S 8 7 S 7 F L~ 2 4 9 ,~ ~ L vfH 4E of ~ ~~ fGSrf R p ~ i; /+ 3N7 9 -~ r 9 5 l q I ~ ~~~, ~. 5 fi * ' R :a w. Fx. ~ °~kn x4ai+~'". '~ f GWNER~ ~Sr Iasr MlDplf ~P.V E N O LD 1 NG CoR P, If ,ppRESS OF pwnER L Z1.n EJ ne QnD f.s.., n i-r.f e _ _. ~ D . RHpNf NO aEG~Srf RFDOwNfR. Atr v rJ K O IRSr ipplE yy SL~ mi:.. ,. _ _ _ _ ~ aowNeR ~ ~ NE NO. ~ ~~-SZ~ S ~ v Ni' x~ ';v{"~ ~... ~, 'A , X'^.u"~,Vpp ~~'ldH tl '7~ i ?. ;~C~!.". • - ! E . ... rEfr Op ~ ~ ~ MCO r y~~ E 1 DE COUIS~ON NVgvFD NfvERlrv rOIAI NO © O.R II[D~~NO.INIURFD~ ^SVIIAOF ^nre9 ~"srv " ~RD IR Cil tR RROADOq AVERFNCE UN w«9"f9r" INrf Cls CRO55SRIEr OR Rpgp Or VEHICLES pROp[REY DArAAGE ONLY f Srg ' 1J r M EN OBIFCi SIRUC[INAME Op OBI[CtTrR{K<ANDOwNFRSNAMF, ^RFSUliFO ^VFnftF 5~~~.0 FSr.04MAG[ SpfCU1CODING Ibt _ z :~5~ l, l~' S . '~ ' • UNIT NO. I UNIT N0.7 s 0 DRNERs NA/AF: usr rlRSr a VEHICLE ^PEDES7RIAN ^pEDALCYCl15T F M y L @~ l ~ ~ 5 /I ~ DR ERs F J'/I Y a CO JAJLIr_.5 ~ L L ~ r I ~ , 1 : sWfFrAW9FSS i - i C. NJL6 ~ e 4 '. ~ 9 i FFr ADORfss °/_ ~It/ ~! I N. .V' ~ `^•' k' ~ 5315 ~x~, ,a ~ f? f ~_ non, ~_s srArE tIpGDDf p D W~ ~', .,c w i rte ,' «DNFNO ,rAF NAa OAY, Y~R wA 27~ /~7y-1327 R ^ ((r~Jlpc C• L FR'SICFNY NO L Lu~,LJ,..E,w 903~ ~ ~~]( . $rArE fx A B « q JJ a •z zZ I v l<f"sf NO. ArE DAr ogeRn A ~ L I z ~ ~ '~ sf ~ . t "'° IY9 J i 132 w >4 /Ll % 2 s V xn q Aw u!/, W F ° OccupAr oN eplwNf NO. F fs ~vxlc«r rRC«r E occw,r DN I ~ S ~ 1 S r ~•;,,'„ ,} ~ w K,°r~ f 6 pNO~ NO ~ ,u EYES WEIG ' N r r - «, Ff « cc-~.,,f, - /vA' I314 IyS" S'u R ~ r,G /10 .ER ^ CHECK(/) JQ"~ ZliS of«cf, : v a AI .:~. s NUAa v ANOt«ER Q CHECK I/) CODES-~ ] a y°s•r , R 5 t 6_vq E«CIf ASAN [MgOYFf Or,NOtnE4Al ,ICrD« oK.<N cones - * ~ ~I ",' M .:, ;:"' I s RZ ; ~ x, '.,y' . S f.=x ~ " N « ! n ;; N A Fs ~ b ~~.,D ro,. ~ ,,, ev ~ bba O ~i.ai I"9°~v ~ a' .D„ op Avfv, a ~ .u <t O v D " ~ :, ,~ a~^~ ' 4 ,, ~. Ve « R o ^ ~ E c fv. ^ ~opn. FI jDn y ~ r+ovA O ~ ~c~3 .~DG~b , slrlf noa.co"v, R ~/' .nfv., Awofl Rt NOVA, r°fI DR Avl E ~~ ~ ~ µ L ~~~ ~ i t_ f ~ ~ ~' {17 J'oP ~1 .c ICENSE pIA EN F9 Mrf NO surl R Z- I"I - ~ ~~ ' -: b SEAM v CqO .R•cJ• WR3Gs`L t-~l A ~ f_3f_K GT '" l Ar A wnF uNnncsrKSN NO C ~lc~ ~+ V•' /~- '° . L v['Clf DfNi{ A IIFIT'/3Q11 o R of>lul/jl I~ 4Iq! I I-.IIO,4Nw1,11'G14;~;7191 V I I I 9FG15 IOOVM[R L A S! 95i Oa[ ~~ ~ / ~ p«ONE NO O RfG 5x9F00wNF9. // 5r 51 IOaF n ENO. q ADOel53d ~~R IE 1A W S'N )a F'/'!. YL ~CJ•(J C S I ,',. k E '~ A 2 N owNER ' ' l~rJ~ , ~~ -lA1Lcc~1,.,u.gsf~~3 NAxfroonnsa lNwR9Na co oR ACINr '-" E N A ' ' ~ ~ ~~' ~', ~ , Z 1- 1CJfiL <'Q s ~i N S R ~ ~ I ~x y awACl Iwu o / ~ % fo `i CN oCt gAMAG(,D KfA N A • CnARG( R f • V ' n. ° y f lsl 0 O~ii ~Ui~ ' IG~ Ow I [~ ~^ ay6 ^w~VD ^RfMA [D ICy AWAYN ^R[AtAIN10 FSr DAMA E 1 fi0r`o, 5 ~ 4 ^ IOWIO Y s Q 0 ii .CSf~,vs R DIAGRA r Y A .t r . ~ i M OF COILISI N~ lu to I I r~ .r_ tr °I" DESCRIPTION Of COtIISON IOSf SUppIFM[NfAI SnE[tlr NlCtSSA9Yl AYPow ~j - •°- ~,, 1- ~.. _ .._ __ . _. _---- --. ~._ ~ -r ~-1"\VrA ~ "YII-I. e f-M.i f 'Q~ _. u 1 ~, JWRtIt u L3EA - - f `.) ' l l 1 n n jL -- -. o. U~1t .VJJttFy RD I , i I I ~ . w a n re t- A~ ._ ~ . NA E.. t ~ + .I , 6 . ... I I i_i /nnn'_GfFr~"` • A L( 1Jfh r E, , v ° ' F • -- i r rc L' / N RT!/ 8//JJ/r(• 1/ / i . •-9~ f- i ~-. ...-.1. i ~ i I , •-. AE. L L. /l.b. I} E f Fu/p S I'i MJ7~f R / [ { . .G fi -.., -,, I I I , I R - `R N z r~ ~~, I H ~ C-AI~N w i T GFY T FRv ~ I x r 1 ° _ ... - i/6 I j I ~ Z L KIVEIC...VAL1C, _ ~. ~_«_ • I. ._fJi..c.v '1• Si~r_LCK l Rrf ~ -~'- - -~' - ~ C /s ,e - . ._.. .. ~ I I ~ I ~ ..W.f_TH_.l A~ lynl. L i~ r r t . _: _ L. , r . I. I I I f i NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I f T OCCUPANTS/WITNESSES ~~,s,OD^o;"„",IAS„"is! 2 ~ 4 5 0 v N ,HF •NN~rA ~+ sfv Au r.rus " °fsn lxa "'c' .~..LorCY,if_<. °n ~i.5•Gr~~• ..1 ~" .~,. ,• tr-- 7...•-r m91ss O {•if * Il r1Aw U}E1 prf isJrJ rJI x A.a nx w. ^ e ^ .7ar ~7LI. ^:i O :'A.v ° p , , 1 sr r f.. , I .moos ~ fl c. ~+IOVlD r9oMG O"'pti, ^ R I a y KxM . 1 , -. ~ .__ ~ , NU '' ^ 1 I } ~ ~ , ~ _.. . .'n ''] M ~ t 1 Rl~ ~I I .. ,. ...,f. .... .. ~+r .: fP5 .2J d r ~ f Y +~ .:~ 1 ~ d - '1T ~ _ µ Y ;~ ~ i7p 1 a s.. .h? o F x ~ t'S~ ~` i M a' ~~ f 1 _ ~~J POLICE TRAFFIC COLLISION REPORT JAI TRAEr~cwa~- POUCfcoMPUINI BE9 1 ~ PRIVATE WAY l OA1E0 X51 N ' r ~ 0 CO Ory_ y~ 5 fD P. f.r tlmE IVSf l900 HOVal COVNrv COON ~ CITY NO. iHWA QU9pAN J I ~ URAI I C OR rOwN NO r5laffIOR INGHwgv ~N ~E ~IN ~ No gW1E OA M,IfS 5 ^w Dr c~ /m/acl~, oN; v[ ~ 3 Viso INIf45ECr NG VBiN 11PEE1Oe ROAD NON INIE9sfPCC~~i.IAAON BE1wfENlnEC. fl7 L S1R[EI f St4fFT • PRffl% ED. MRFItlST ~ D.SJ 4~SEANLC~EeDef(Mt'ON rROEM 9tiF9E E. CP055514EEE09 NEA9FSt MllF 8051 •S J l[Et5 5 E w Or L T). ACCIDENT MCODE E RAM DNWRAM Wiq <OEl11 UN NVIXVFD FvER rv~ R rOfAL NO NO !UfD~NO NIU4[D~ ^SPIIIPGE ^"r6 UN uHS~N .iN4ND~x IN %AD INff ttS IN SECI 9f OR ROAD OR REFERENCE CROSSSMfTON ROAD ]l . Or vFH ClFS ~ ~ PROPFPIV pAMAGf ONLY ^ p('SUItFD ^ vfaCiF S030G ~ OBIFCI SERUCR NPME Or OpI[C15i9UCR YfDOWNIR SNAmfI EST~AGE SPFCUl0001NG USf Lo ,vK,n - f s UNIT NO. ] UNIT N0.2 ^ VEHICLE ^ PEDESTRIAN ^ PEOALCYCIIST _ p9NfRs NAME uur nav MI a ~~ G 4vF9 sNAME: us1 NR ml l - - lvfff App E55 y~ 5 / ./~~ REf1 aDD9f55 CHr 51wiE TIP COpf ` ONE NO. LOt'i ~ ~ ~ R 1 v StAif LIPC HONE 1(r O4 VfR SLILfNY srAEF ~ f~ F% VO I e.r i H I V 0 v ICEN ENO. $Arf DAE FB W. I DAY 'aI1Y9 M OCCUPA110N AME APHONf O. FvES wE GH1 HIGHE E OCCUPAUON M NNAE 6 PHONE NO. EYES wfIGN1 IE GHr ^ 2 RE7~P2ED Y 1 R _ ~ CHECK (.~ vPHttf sAN EMPEO Mo AN 1 ^CHECK (/) EHttE ASAN EMnorff aANOIHfaAF !~ 5 CODES ~. * ] ~ » f e 59 .- St~ L E c' CODES ~• ~ ] n . i 5 u E, :' ' > ^' ` I aES - LL 4Ftn,.o,.p. p AME,%..LE ^ u R ^ F8m. ^ .< <9 ^ :~:,,. ^.m.ma~f p .~y~f ^ ~5'.rt. ^ ~:KIE ^ :°~5. RD ~ H YfAR fIpODG[CH[V.I 0 FD R MODflIDY1~NOVA1 51Ylf Il D9.~GONV1 1'1'Jia T c o E fA4 A 1 .CNEV.E MODFE IDARt~NOVAI V 1 DR.~ V.1 r P~ r- ~° OR CFNSF PIAE "LUE 05R.5'Jy 5141F AI l4 RA1EN0 - SEA1F H HCIXU9 A All AI vEwttE aNr r egrwff NO. ~ vfH ele DENr H ~ NN I ` I I i l 10 I I~l! I I i I I I I ~ I ~ ~ ~ ~ ~ I _ RfGlsrteEOOwNfa ust sr MDpEE Halve NO. O W 9fe sn4 o w fR l sr rl sr MlDwf N N Ili J ADORt55 Di OWNl9 N A • wNF4 ~ ]I 4 L AMEa ADDeE55a INSURANeem Ge AGEN1 - i '7-/ J C .,/~~~ R RSS'La IN u ^ pl DAM YEA ~ A I N ~ AMAGED YEA 'm ~OYN p, CHARGE CHARGE aµ p, ~f D ~ OgMAGI lfi Ae,Vl~v ~RIMAINID ~ ~afMAINiO ~WAVN E51. DAMAGE i ~OOp00 1oweD L C ~ / . ^rovrtD f D RAM OF COLLI SION: AwA er "ro'y " DESCR lu lu i i ~ r IPT nr ION OF COIIISION; lust suveuMfNlu SHfn n NEC[ssARrl _ ~- _T ~ N c ss R l ~ w~~ -I .. ~ N _ .. VE1~ ~ 1__WAS_~DulliBou;~r,"-_%}~ ' ~ ~ ~e t `Y 2 at 'r '~ ' ° ~( ~R ^ -~ f - L., i E .' ~„ ~ ,,, L.1._~_.i.. r o? 7. NeR SG.tt~2vm_J~Mh3_._ - I "D ~ DOG..~rvD W.E~+rOr F ~/E IRIC~vTS/0E-.. I I I + I I y, ~. c~F 71is Ro~nw~y ~ oFt ~~'t7na9tiwNc? r - - T I _? ,.. I VEl-1. n / C!)/''TC_?Z!_RE3'T.C~ 2TS SIDE I ~ f- , I _ ~ } I t I - ..Tn I 1 ... ~ ~ ,..~ ._. ~ L_.. _.. - - -- ~ - 1 ~~ BOG aW.~t~2> Eft/wcc~ u.c~~. _ Ii' - ~7.' LNDLOW 1. ~ . L. ~ _. _ I I r _ _ _ _._.. _.._.. ~ I I I ~ I NAME, ADDRES581N1URIE5 RSONSINVOLVED "CODES I - T 3 4 S 6 ~ r~ OCCUDANTS /WITNESSES rou w.nIMEN1a swn W MD~tiONM NAWS~ .. _ S[% AGf EAEUS ~'Nlfx Ytt- -1Rf` _ .... K51a f1ECE MrLY .MI ... iq . CRISS ~9<Or . . r. wr p.v p ^~.l".f O ^ . O~ p Al AME ra .poRO: i.Rf :,. r ~y+~aDrRCw [JAme ^."."Ors .O~ ~: N Avr q _ , r•..r.. I.ror ~, '.: ~.M r.m, n ^~ <~ I'1^•.. r'•;; r'1 ", ., ~..~.T' P... C : E.f...-,cr t~f.:Y:~., . r, ...:' 7 7 E~~: t'L.1 ri~%Z'. it ~.-~.~i /. '..~° TEN ~ ~, rc t ~Tds GI: ~kT _. r Ve ••nV I1~V1vIV qGf / Oil '\ Y-. :. vC° _ POLICE TRAFFIC t _ N REPORT ®iRAFFICVJAV ~' ~Ta , x, .C INI NUMBER 1~ ~ Npr Ivn wID lwxf Iv 1x1 IUSf 4b0 HOl ~~~D ^N ^E ^IN CIIY OR TOWN t : 14FF1 OR ROgD NON NIE45FC110N BFTnEN d'F'A <' lll0 EfEetN E (; ~05351Rttt 09 NfaRE5l MIlf 31 MI [S R M 3 E ffFi ^ ^ ~ Of MaPAe ~7 .V[D. ~ NE Vf RNY: Q O xIIIFD ~~NO NlU4fD-~ ^ RROR4rY DAmgG[ONIY ^ NPMF OI OB1FC1 si4U<x AND 01vNFR 5 NAME 1 PRIVATE WAY ~, I counlr fnulNrr rfo. crtv NO. RHWA 2~ o faNO. Or SretEt O4nGHWgv RCl ClS URAI ~'.EE~~ '~"' 4 F ON 3tR SfGI ~ 17` N O J `t a. 9~Q y + FREfIF EOM Ml1E 8031 /J {~{~ "-~, ~.,.~~I S1RFF1 6/•'I c~N)'A r:.,2 F ~ SfRfFt ~ 93 ~j~l. ~" A CIDENi RAMR DA 4AM Wta ~ ~ '~~~' ~'q, MILEAGE CODE yRAE f~, ~UgGf ^HiB PUN H,NOworw H MF Cl3 OFOSt3tRffTOR ROpp !00 0~/~ I~ ~~~i, r 4F ^vf~iflF O fS1.OMAAGF SfFCW COD NG USE ' Nc< w 95'5`1 52• 5 UCENSF NO. Ex I /.~ 31S .N t. w4 M 7 q/ 1tION FIRM aM[6RrN)NF NO Ens vA CHECK (~ «ci[.sax fMAOV"[[of •aMiol«fPal s <•r:<~ a c.a. I a,MRI.NtI ^ ro , ^ rq.ll. ^ H ,R xE IDODGf Gntvl m DELI a NWgI 3rY,E IRDR uuNU RUrEN sr neeplAn NO. •. Y~ XX u SS/ u4 314ftr gpORFS3 y -~~ ,, y ~~ ,~ . , (13 n O u ' I Iv S UCf NSE NO v . tAtE Sfn Da1FDw BI4 ,. 1n Y. ' E cuvanoN R m NaMf a vIroNE No. Ens WilGnt I EICHI v i. ^ CHECK(/) v[«Inf as aN fMnfir[fw•NOr n gl ~ '" " y i' CODES - * ~ «f . ~ u, < s°:ssnv. 5 en v <rD 6 'E:°H1O `~Rr ._ . 1? C tf ~ ^ ^ ,M ,n.N<I ^ ~ ^ zo.rt. I ~ ^ r. cti • Ir v Y AR 1 CnEV.) MODEI IDARr~NOVgI Y fR R.~ V 1 °W' I / ~ v «. caoR N Re I R a A E ~,_ v(n CtE DFNNf Cgll N „~` 5 „ '~ DDRESSw ONTIER - W • N D ~'~ AMf tapD4fSSP INSURgNCf CO DR gG[Nl E ~+'~' -f-- IV/l(EING /NS ^73A/2(},c,RA Sc.E,TI F.'T. R ~ a nam:weoinu D ~ R wclpx iu CHY.pGf OI/C lSi DAMAGE <nARO[ DAMAG[D SAfA y '1 ~ ^w^rN ^RFMAINfO I IU ionC~ S ~c,~ iw v0 D'tNwGF t ~RtMAIN[D ~ ^AwnrN i3r r D I~S D _ I/Sl ev: J.1. (~.1 ^ aw r ev: f M DIAGRAM Of COll1510N: IU l NOVtn DESCRIPTION OF COLLISION: RISE SUVRIfM[N1AlSM[i lrNttE55ARVl 3«[[I If N[USSARYI I A~ROW , V t /I/ A!w D /i f V~: r' C s' [ ,• r'r, ! F'c E'/'+.:. /1 ~i F. jfYa ., r!' ~_/<'~/-~ i.<rI' Tp-Il r0</) /J F.'Dgl,~.f',G~ I Nf,~ //,% I. f'•.', L f. J"Y'/f' W r%f! ~T fl: It N7- J"tli Oar ~• -'' ~~ /~e'3'f.,3a.i ~~~ ~ _ ~ -~ ~~ Y ~ ~`/~ Y,.i I: ~'r 'n Cr.J Cff TII t' /'r:.tr ~lY CJ rl•'' / l'r< i11i!%= Ci Nf.+ f ANIL~ ~Y' ~l';.r' l!( - , ~ y ~~\1 ~J'-~ - ~ - 7%-!/ iNG/C~~l'!f• jlr. ;•~T/i~Ji Nt, //tT,. f,/ He IC Na•M-N !,R /hAa.~ 7•r, f~E l.a: ~. . \ ~ .. >x~r 0 NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I CKCUPANTS/WITNESSES li~m ~u " ~ e w s Z J 4 5 6 t l w r s i uv qcf urns '",,,W," E[StR N[R M NO ADOe1S3 NAIURl OI IrAOV AM B ^ ~[I ^ 'R'I. a ^ Hw ^ i`L'4,a » ND •mafu NAIw[w v~movlDl4oM ^,upe ^ED,NI ^+lom.^.; ^~° b No ADO4rtN .f3NG•1,.,GalrlvaNwE aeA. ~.•iwHS°E Y ^.Me. ^ ~aKl ^wom. ^:i'S ^ "n`:: . ,Y sAOGE Oe AGI NC. , aKlDn!1LC«ID .u}Kf vo~vtD D•nwvtlwl • DAIf _., ~? - ~~ - ~~, fi rv¢~ r~ ~ ~ 4 ~~ ~~ •' STATE OF WAS GTON vAGf / Dv "°'~" "I ~. ~ No [t O ~TRAFFICWAY Rol ctcoM NuMetR R 7: `~ POLICE TRAFFIC COEU510 REPORT f[{, ~ p a~ Ncv.~~~PRIVATE WAY ' P^• .µ~r DAtf Or Ort n r uV DA Utl It ",. 5. IVSF }v0pw Uvl CO 1+ COUNIY NO. CIiY NO. ^U µ Al ~ r __`_ /Cri /~ uaAt rp / m~ ONwa r^IN C OR tOWN /NAMf6NO.Of SIF NiGNW Cla r~ ~ f 3 9~iso >z I. ~:}Pf5 - MlfS 5 ^w O° o PPtI% rtf v0al ; - 4 ti ~~ Ntf°slaNGSMNStvtltoR NDN fSl/'~ .R~ M yB0 i R,~ .fn 4f7 t, r r Et .V •. f ~v b DsicnCF 6D V1~f N MRf FVfN CRO55a AvfStM .`1 ACC DENT RAMV Ui aAN 05tA FE[t W Of ftr OV nt if COOS pD I 5[ I vfEt0R a0AD0R R[F(RlNCt /]] ~ ~~:J wc%~~~ .~~ ~" ;~ ~ LFS S f v N Mvw oOF N ~. c u o vrnvfD N No.:°ueo~_NOrNroRlo~ ^soli.ee ^ntnRUN m°'r~• N INrz cls eRCa°s~jy0~ (_ totAl NO sdlN '.~ r avfN ttts vaonmr DAMACt oNlr ^ aliu ^vfNC ! >m st DAMACf srtuu coo NC USt >< ~ oanct stRUC.INAW! roB cr sr°uc.. AnoowNta sNAMl1 l! 5 ~ UNI7N0.Y ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST ]' y~~ ~= ~# ,~~~.+ ~ UNIT NO.1 a DR~v NAME. ~ east MmD, DanfR~s NAMr. st Wt ! w Id F ~ ~ C? /-• rafts ADOatss ~ .~¢ I ~, a tl A RI55 '^~ ~, ~~ ~ D srAtt :~ cot f - +~ ~~ OIX vNONE ;yt R v a UClNaf NO. AIE Sfn v DA FOf B9rn ~pp<rv !x A R N 5 Y DR Vtv aI CINY NO SAtf ~ w ° .xs ~ X 0.. . ~~ "f r mD V 4 `' Y 'S ~~"~ ~/ ~ G fvfs t E occwntroN MNAS+taRNONl NO fns wficnf r~ICN] .~S « u AnoN NAMt a RNON! No R +.e ~ ~ ~'~ CHECK Is7 w ~ Mo ^CHECK (/) vlNn[ASAN UnvsovlfpAUOrNC°An .iitv`c`at Sa ~~ facie A•AN IMRm:! AN nl ,~r n stn o e i y x r yy~~ :3.~~ CODES -' ~ n: .vl I 5 ~ . D•. a s"•,°,i CODES -' ~ c .ss < s. w"r t 'h 7 ! KT N9 Sf. [I uv f5 vvAtt ~ Amxn.xrl ~ to ^ iiivtty ^ vix[ I ^ tenvv aw 4 - ~ ~rnrwD ~.5memnn[I A5~~C1 ^(~%11 rtc^vl.crt ^tuwv rtAa MODFIIDARt NOVAI VIII vl '~ la MOD nOVAI stvlf l]DV <CNVI uweorro FI f. NV_I Al ' nN rfAa Dm DG~fv 1 ~~ ~~~ E v .. ~ SI l!R a H veN eaoa l T No. w t " ~ ~ ' ~; oy l unsf rln a sort An No sot! I -~•i~Y/,/rf./1 C vtN e e a ~~ A vfN al Dfw ncAt .a ~ N i I I ~ ~ I I tl I ~ N I lAat M DDl[ I NO. ~ tGrattaf0 w tv NRSt ~ ~~ A' Yf ] ', 6.., afG.SRatD WNfR' Wt Naat MiODI[ ~vrgNF NO O ]I e '~a~; W A wNtR ~ IAA-..,~ ,..g N ,__- ~~ $ u ADDRtssa OwNlR E A iN u AN A, n one anoovfssv rrsup•rxe eo ov ACtw R .TI ~;~~ ' r r s.a nc DArnwlo ARfA~ N krc r'' 71•: c.5:::0 ±~oe .: DunwiD nRf: r,,,,cta..r eNAD a aAaef ! D Aced t ~ a F - m.,. n.Ke ~Rww ^RtmA NI- at !at pArnAGt uvftr RFMNNlD ^ WAV S .. eY v ^ AWAY y x ~ !..r ~ I toem ^ iw:v°ev - v If ~ ~ n .. .°°~I t S ^AwAi BV- ..,••~w.. nre~e Dirnunefnll SlON. Ithl SUVVIt MfMAl a~lttf Ff55A°VI t' -. Y ~sr~ f J ~ z a a s e NAME,ADDR[5581NJU IESOPfPERs50Ns INVOWED 'sCOD.a utos'".,~" .. ,5 RfvR oat OCCUPANTS/WITNESSES uo5tl.somD"~oN:iN.Mii~ r fGYY'T9~ .v. .rRRn• X u ~ ufvl"e: /~cl .w ~I v i_i.vn ^. ata.l roRr ^ ~ . U ::: U ~.:.... I O c hH - , t ° C ~i pp ~~ ~ $l r !! "'~' nl ~" ,t}'TiR-,'~ ~ .;. ~ ~ .~' ~~~ ~ +~'~ ~ ;(~`~ 5S'~M'`. ~ h I s d~ ,t.~iS,~,f".'rd,t ,u~"'r"~v' ' ~ ~ ,r ~ ul `. ~ ~ ~ _ ~I,. ~F ' w ~lar~Za4 Ux ' , ~ t ,~"ry I ;;,! ` ,~1 4ii ~`., ° I 5 !r l I ', J I r+ 1 ~ ~ - ~ ( ~ STATE OF WA IPIGTOTI I•GE t OE I 11. ' POLICE TRAFFIC COLLISION REPORT ~ TRAEFICWAV N~' ro:LCECOM WNI NUMN%. ~~y~ IY ~ PRIVATE WAV ~I ._D•tE D_.C. E N., 0 O N rlMf CDDNIY OJUJ]Y f40. OIYNO.. iHWA i;~g~bl.~ ' .I . r R~3a~l .i 2 0o J'>:FFFiPSon~ /(o ^'"°"" ~~C' ' // ~ry QE ~ N GEYOR tOwN NN.tE6NO. 04 EI4fEf04 nIGNWAY f IIOU 1 2.IOMlfS ®s ^w poi 1 cu ONC£ RDi 3 9.3/Sd N]F45ICt NG Nafn: 5lefEt ON ROAD HOrv lrvif95f<tION IRFfI% E roS} ur-,;' +EtwEEN Ru fL 3a~rw~ £4 G. -l~ ~' sREA /. y0 ~- t\~ / OIStANCF6014fiCAtIION iROMRi3 ENf .CROSF SfREFIOR NfA4F51MIlf VO[ ACCIOENi R AGRAAI{Nt,- 1/Y_ ~ ~ i[ft W Or ILS POS% ~Z MCODEE YY§~y {{,, COIUS ON NVOIV[D: vfR tv 0 I O OR Id/EgE +-=] 4"~ IV- IOtAlNO O•tlFO~NO.INIURFD I ~YIfUGF ~SIIXENN ruN0ne0tH IN1E) Cl3 CA!))~iB/E[fORJW1Ap ,._ _ pVE~ICLES ~ ~ IROR+tY DAMAGEONFY ~ pE ^vfH Clf Mit3 rv ~ E/ ~ IO OV I ~ ,^ 001fCt SSRUC%LNAME Oi OB%C]St4UCe gNOOwrvFR'S NAMLI ESt.OAMAGF SRCUl COO WO -~~ ~~ j7/ l'cH s ".'~i7 } ~N Vfl UNIT NO.1 UNIT N0.4 ^VEHICIE ^~PEDESTRIAN ^PEDALCYCUST ,.2N ~~ - DervtR's NA«E: ust TERR~~eE ' 4we4sNAME IASr R I - -~~~~G n Stefft AODRFSS D tRfEt ADDRESS ~ngB,f. {~ Utv ~~ ~ ~ NE tIP COOP IHOrvf NO. D I V StAIE --- E '`~~ 732-~kf 85 R ~ ! ~~~ rv[ ' CENSE rvO. I I U EN NO, qt DAtF~ B R 3H ]~~ ~ Sn! RM N a B WA MD ~ ~. ~3 ~ 4 M N RD OCCUTAt pv AMf6M0 fN0. FYFS GHL HGn[ E ADUN MIfIIEgNf NO. EYfS IGHt NfIGi ~'" ~w]¢PtT t.c N £rs7Plo O Bit N /!/ 5•c}1 R ~x+Pt ^CHECK I~ MEwOEq. ANOmfa'G Oa ^'CMECK I~. 1 CODES VFH CIF /.e AN WROYFFORANOSIrtPAE - ~ ] ~ 5 t e ;:t,. CODES ~ * ~ ~ .a i:inM"' S E% a 's; I n ' R' Ara%s LO iYint SLae EO R G tulP ~ j ?244„ Sti° .MNAAi%i ^ ut° ^ ~88R. ^ „~2,E ^ Cw„,. s°fENOHr O A,° E ^ :S° ^ S.R. ^ H ^ ...,3•. _ k vfn. YFAAroM MARf IDDDGf.CHFVI AgOfIIDARI~NOVq) .stuff l]DR. CONV.1 .Y I ~ M V.1 MODFI IDMI rvOVAI K`il D V.1 I°17~ AaJRI A J(S6SoAE M~< E' H x ff~ ~¢"~ DA UCEN StAI! t41F4 RglE NO. SiAiF HI vEN ~ 1 A I,.. BLUC a63713 wfF I. . t '° [HICI[ICf rvDEIGtgN NO. C vfn Clf DENT I ' '~tA ~' ~' 21 FL OI 0 '0 8'I ~ ~ ~ ~ ~~ - ^ vfG15 fDOWNtN. UASt H45t MiDOtE RgNE ND. 0 4f IS Rf0 wrvFN: ,tASt NRSt MIDpIE .~.. fAGKSdn/ !°~} fciC A N ~~ W ~~ r ADD4essar OW!][R rrf+ ~. ~ K ~ Z P,o, BuX (o ?7 fi?DLo[K w 9ff339 E 3]I AMe agoDRlssalNSUeANCE CO wmwr I DAMAGL A.u A' a AMAGEO~•RU4 "', A..1 ~ wR:° enA OGe w 4 V/YV CeAnef ~. ~ .._ ~.. .nwi.o~ g :+.. Y jy„ ~ Esc pAMAG! ~ AW]"EiYN ®4lMNN[D ~ ^ eWAy ^+fMNNfD Fsr DqM~ ~ iM. `R ` s S 00 p torA[DeY '~ ^ wvrto s ~„ 1 } ~!y ~ DIAGRAM OE COLLISION ' ]u w~ ev:tl NO°" DESCRIPTION OF COLLISION: IVSLSW%lMENtAI SHen lr NeeessA4r1 l -. 1 ~_ r_ ~_~-~1_ N '/tNlG[L *'Ltsz~.T~teoaru2_2~! ~£ntZ~&_ ~~ Fc , ~ ~ + . I.~ ~~~~ ! i ~.--~ ~"~^~ fy%L°n~_!~+~SLOa..Ja1s_2c1WN~.~ll1<<L i ' " ~~.; I !~ 1~{e RDA ' c,¢csic0 c£.r!!~ iCtN~,t]v2.%tl~'LK~I?irbiy :. ;~' I ._,_ Ed! 4~ f..tsT_s/iQ_oE_krYtP_._URt!!ti+C__WR.~dYTccy;rG_ _ ~ ' T~ r.~. ~ -~:~ ~ ~ ,c, 1 ~ 1 ~ . '',,~ ~..I ~ I ~ _ FRa~.Vfn~4cf _8l D/f~1~~9NO~ro~~!N~ o T'cN a F I I 1.~ fitge]_ teems?T/OAt)_.!LNKnIawN_e_~R~/t'.t._~ fS_ N Z'_. ;..: . I _ ;, ' _. ,fcu p t(ivao w!YA?__~usla. TNL_EosJ of c.~..7,~dC . ,~ _~. X03 [e I !l~.~pD K~ 3 ~aNG_ v!?oit,__or'.if]CtoIML ~ alucp..BE_..Sm }~ .. NAME, ADDRESS B INJURIES OF PERSONS~NVOWED _' CODES I - Z J 4 5 6 ## ' OCCUPANT$/WI7NE55E5 lio: uon or::iiu'uLi iix ~ACi- rAw N6f" ° -~N;-nin ino :1°i I Ef~` 1 •ME ~ N r Y ,.DN' a wL o. _.. n%e. ^ AMe O ih<I awl • O »y ^ :24sI ~ .xnss ~~4t n. ....._ ~A~oYtD rNOM ^AMe ~ro,Kf O", QHT ^: n /( ~ i N ~. n. • m'v ,~ ! .., 4 { qvl • ' CT_LLZ " fl CENili N 4130E .. 5 INIVB• ^ I n r~ v ^ n • ~ w" ^ ~ I ~ r R Nv~; - .•VIl44r,• .•Y.L IIR ia,i D SIG v1D OAIIp RiroEl v DA31 • T Y ~~ ti •X ~i, /0~ ~D i i Sc50 N~ oy~rt oNox ~ _ta-8G ~ ~ a r~''s -J 1 .~.y t _ 1 t [C /~•f NT~14 r i , w '' ~ 1VA. .I , r 3 'S ayuy c,a ~ :bfbl 11 r na T '~ 1 NknY ~ 8 S f~, ~ ~z - ~ l , j' ''rr 6~ I .. :! lA , ~rll~ r`.:_• ~.s 5 a' ':~ '. ~rE ~ Y ~ ~ ~`Rv S ~ ,<< ;~. ~t~*~ X ~:~ f,~ ~-_ t ~; ~I s ~ ~a'~ , . °~ i ,'~?, ! <~~., ~~fr~~; ~'r n 5._y, ~~ 'ny,' '~ ~~~ M~~F ~5~~~~~ ~j(~-~,+ ~,~a~' ~~s ~~'`' ~, ~~;. ~ ~,~~~~;, 4~3 i ~~, ~,°~,.~ ,a-~~,; f; ~ ~ cam' I v~ ~ i ,' ¢ , 0 '~ ;v N ~o vo Y ~ H O~ ~ o o °o i. a rn O ~ 7 M O f J r ' '~ ~. '~ .N F ~Ji~ Y~- ~ :. ~~ a~. ~' ~:I "5. `~ STAB E car w'RL,~rvc~ i c~rv GE ~ DE 1 (' . No ® . f .y . TRAFfICWAY POLICE TRAFFIC COLLISION REPORT DS1 .. RoucE COM9wN, NUman PRIVATE WAY I 5 N ~'A.. D ll5 ,~ 9 ,:, NME wsE,7,+DD .9j COVN,Y C' .s"0~9 COVNfv ~~ CtiY NO. nWA DR aAN RU9Al ^N TRH ^IN CIV ORiOW t6NO OE SIR[L109 nGNWAY /Q MllS ^5 ^ DR o ' o N .y1i r- I ~ iCEC15 6 ROUIEOR IRf[ /1 D StC 1pN 5[CIING VnI :SiR[[i OR ROAD ngHINIE95[CiION ~ ' RRFEI% f Mttf W51 ~~ / Y'~/ / Rl BtM'F[ ~ /o Siv[O / DtS,ANCl60w MIGN R M9f NREN f. CR0555t9EFi OR NI•Rl51 MRfR 51 ACCIDENT RAMS DIACRAm win ~ K ~ ~ rt[5 5 F rtn DE Q MILEAGE CODF I] COII~SIONINVOIVID' Sivl ,Y. V ^SVIllAOf ^n1t6v NO INIURFD ORltl[D N IMFR I <LS C MF IRffi OR WADOR RiIRFN~ RD5551RfflO9 ROAD _ ~ lOIAt NO Or VfnKlfS m RP09FREY DaM•Gf ONLY ^ gltSUl,[D ^v[~Cil 5 OBIECI SIRUCR INAMl090B,[C1519UC9 •ND OwN[9'S NAMfI ESi.DN%AG[ E SRECIAIC DING IAf UNIT NO.1 UNIT N0.2 ^VENICLE DPEDESTRIAN ^PEDALCYCLIST j DRNIR'SNAME tAS, FIRS, MI ll rvIR'SNAMF. IASi N MI DIf ,vlft ADD9t55 IRt F, ADDRESS 5^ L It9 CODf ONF NO. ( • Sln,t D CI,Y SlA! IRCODf NfN n / G R NEV SUClNK NO SiAI[ F% A Wf4 uCEN NO +A! F DA9F Or BIRin o i i IvFS IGni H GNi «CUVANON MNAM[6RnOt+t NO t E Gni GHI «cuRA,loN MN/VAf6RNON[NO. FVES / 2 // ~ R ! o EEa.tMiD,nEa At D CHECK (.~ EN <iE• ^ CHECK I~ fAS AN rMnorn or n"o,~EeAI t ~ 9(q CODES -' 3 ~ 5 t e i; ' CODES - r 9 c, . is 5 t% a s`~O. ' ~ "'' ~ „I ° ° - D .. ^ ~ ;f F 'LI ^ zs:,l ^ ~ ^ ; , S D ~» i D ~a r ^ ze:N. D ;, ^ : tuli v CNEV.I. vINY MA4ICOW l ODfIIDARLNOVAI S~nf ppR.<Onv p V.) Matt ECnfv.) MOIXLIDAR4NOVAl iAR rn I ILL .~~ ~ r / E " '° S .LL ~~ vn O R li<i NSl9EA IN ~ ~ilfv RAl[NO ! Sinll I~ vfN OIOR N l Il A NO. A ~l/ ' ~ -^ `_ C 13 tDlr,111tCANON efn.~ I iw,GL~J' 0617 G I I,~ ` vinl[ll tDlNllEl A a i l ,t I N I i l l I V I I I IFN uIGt5llvIDOW1/M1R'l 51 tlRS, MiDOI! 9nON1 NO O d Q 33~~ O W M . Rt t511 D WNIV. lASE IIR51 DDIt I] ADORlssa ow++~ wNtR ~/ 3 ~ ' /G/r w N E NAMta•Dafssa lNSURAN<e co oR ACtNi F• I u AN p G •GI MLA ' R , ~. DAMAGED APtA RDAM 1 +" V ( ARW 1 L,t a CNA9GE wf ow.i 1 p AGI ^pY(v ECXRIMAINID 1 I1t ° i ~ DAMAGI _ DRIVIN ^RLNNN[D lS, ^ AWAv / V ICiOl 4 Ar ISION: 5 " I io DIAGRAM OF LOLL ywll N14SSM I a • R ,. DESCRIPTIO OfC ELISION tln[s[w t [ Al srR9 fcESS 1 I I ' r~~..s~ ~ s ~, ~, ~ ~, ~ ' s - I : T~~ ~ G%f ~ ~6~ ~~~ ,~y m_ ,~~ ; .. _ r ~ Yr /e/" ADDRESS 8 INJURIES OF PERSONS NAME INVOLVED 'CODES I - 2 3 S 6 , CKCUPANTS /WITNESSES ;"` sw"' 1"'%' 14 a •conlw,a N. tui n, st% Aa •im '" Rnii inn " M' io ' •DanS DSt o, AMp ^F`1Y01 ^'" . ^:i ^.: ~MI r ru .Dan, Q,v9ta RMnvlo r9DM wi ^.Mp D : R' ^ ~ D ~ ^;: .ran, t (~. • + ' ' uRrcr N < r.~ r.i I D Sctvt°p: M D.Mp D : ~(t r1G tAN G.E WVI :" Di% . D~ ^ .vOVlDer. ~' DAN •• , .r .•.a:l~.~.,1. N•1'.t•: A s vl N(r ~ E ~S FA», r K: cf ,~+. - ~ - :, 'i'~• ~" N~,.ti~iRnr I. ~ ,1. .. I ..7 .: s -. tfrr.~~;n u us. tA - YTi >~ ,„;~^ ~ .0~ , + $~ . ~... ~ tt~q~( . ~~v :kv( [~ ' ~ . ~ ,~n `~u ~ i ~' ~a"7a4' r f~ ..~ A ~' POLICE TRAFFIC CO; ON REPORT ~TRAPFItwAY Nt I PRIVATE WAY _ .' j ~ ' _D•lor N -IwR 1. whi.. , s.r l W' ~ ~~ ~ rMl IDS!)rm NOUaI ca rr ~ tt No /yo _ NwA.. [3Y~ •..~ , '. ~~ ~ I g~ ~~ Q ~ 1 a~ ^N ^f pm cnr owN Ati, { oors~xµtoR NlcNVfsr ~ / / _ . / ~ / eot, ou ~J Mnas s Qw or O(~ C ` ~ !` ~P fJ '~` ~ rNIfaSECIrNG N. SIRfF104 .D NONrN1lR5fCirO//~ ,y L {[IVREN /`~{/ 519!!1{ `'~ ~ l{ wt140"it ~. D~ •NCI{ ~ r .CROSS SIaIF NfARlS MRI Mn[i 5 f w ,~. D I rln or ACCIDENE MCODE E RAM ~ ~ ' COIDSK1v rNVOIVFD ! tv~ 10iM N0 NO [rllfD~NO. MIURlD~ ^ SRiIL.G[ ^Hf{9UN wvanDi~ ~ p. r ullf OLS. [ N f R(t Rat , ROSS Siaf[l09 M Rl dV[NICI[5 90RRiY DwVwGF ONLY ^HSUIIlD ^V[~'CLF AA /y OBhCt SraUCR INNAf rp Ct i9UCR U+DOwrvl9'S NMNEI tSf. D/.MAG[ SRCrAI CODING t6E UNIT NO. 1 UNITNO.4 ^ VEHIQE [] PEDESTRIAN ^ PEDALCYCLIST ~' N51 51 M ! ~ s~ ~ ~ 9nla'SNNAF. IASf r I slRl,ftr OD9155 2 ' 2 ~' IO MDRF55 y'/. E~ ` t b i.:- air `~-I ` r CD II.CODE .NONI M. (o . A-L O Y 27 D r v { E i ~t f54CtN'1N >O1o212~-~loS- - Swl /YIN ~ I 12~r ~% ~ DIN [N At aD 19.r'I.. Z, aw w l{9NONe NO ens GNt raaNt Sl,2i[.I~dLAn/6 ~/ S E R u9.t oN ram NrM.e{rNONl NO. ens IGNt riK:Nl ^ CHECK (r7 No • rN ^ CHECK (.~ vFN Ot AS AN IMnovRaANOtNFa ~/y CODES -~ 7 ~ S E ~"O '• rsn .rti CODES p* ~ ~ .~ 5 l e y .U rsnw N R "~ ue f5 l ° Q ~~rm ^ N«NV ^rinwsr N VIN M+R D~O~DG~[~y~ lv,l C ffL`(/ IDMt.NW.I Strll D C vl ~~W Nbl~/}- E Y N vl MoolllD vA, I 1 r~ S - t ~ q rR sut .w nMf NO v.e H N v p~L ```~" C vl«rnl NnncMRxl NO v r l r N I r r, r vital R[DOwrv[R.. IASI N95t MIDDII aNON(NO [f ~ vM WI NRSI t , wDDa SS p OwN19 AIL ~X-~-s1~~ N E . q .D ssnrNwuNCf co aR AGINr R u WMnGiD NIA cNA.a ~w ' w aA9el g•M.ee .eu, c :o ..u s ut ~ wwrN ~~~y-I 9tMM.nD iov o 9EAwNlo O Aw~r O towto Es ' s n er. W •w ~ e. .w.r S N ~ 'N . I - , 1, °~ ~ DE RIPTIONOF COll1510N~ usfsvn{w uslan lr Neelswvl ~` i ~z+~ 6~.1 ~~~°~~r~, =Na ~.1 Igo ~,~';~, r { - ~ _ ,U w~Pc-rZ ~ ~ .. _ , ' 1 ; . ~ ~ 2ArJ DF~:_.{~,1GI.1T ~i-Jv .:OJGILCo _ !. I I I _!~ 1 ' . ; (... j _~ I\_ 1.. i i.. 1-- ~ I , ja (.1SIC! _ _A-I~I,D _:jJ /l~f~ R.l ~{N ErD__- 1V ~I~.- ._ ... _. ~ ~~~ ~ _ ~ 1 .. I..r I I_.I .._ ,_ ` i:_ 1 I I I I I _._.. _ .. _.... ...-- - _.. NAME, ADDRESS d INJURIES OF PERSONS INVOLVED ~ CODES 1 Z 3 ~1 S b lull su.nlwNtu sN OCCUPANTS/WITNESSES rn.DDn oNU NAw rn sr slR .u .+u~ ° - nv~ ta~ ;; N.w ~ • _ ~ . ~ DD.US ~ a,~. or .Ne R1" O ^ . N O~ ^iL.;v N 00 .M - ~ ._._ - ~ a oD9fa Natwla 9.wmr9 ^ ANe p rD,KI D" ^ r O :° v m .afr 4 wf . DaR15 N NY9~ Or N v N l ^ M9 Q rPKI^M r Dww QrNi°. If r~NG ON(! ;yµya .. M. ~ / J ^~ X ~~( ~ O. {. .GIM1Cr r0 ~y ~plftSltC.fO .951 1 d !/ J ^D~ rl~`j U/~%~ ~ /zL+iD Gpy~U//}yjo,,~~r ' O . ' D L ( {' - -~- 217 . N S.m RS 3 1rmN.s ./ L/ / _ ~~~ ~~ ~~ _ b F ~~ 'Fj ~ l ,.. ~, ~ t. ~~1 4` M 9 ~+¢+ lffi1,~ ~ ~~~ I fi .~ ~ a t. °,~ x G, ~ ~ 'R W , ~~~ ~ ~ tl. , rl !Y~ MI ~ r. S uti~ TM ~~ ~I ~ 2 yy f 1 a d.~ ~~ ~ i r' r . ; r , r , 4 Ia r'- ~i' Y- ,. ~ . ~~ .. x y~ J 'yn- R P R+q ., ~ r~ ~ V Ix ~y 1 !. ~ ~ ~, / ~~ POLICE TRAFFIC COLLISION REPORT yy iRAFFICWAV - ~~ EIXKECOM4WNt NUMBER PRIVATE WAV A f E9f O _.O . FIQ COLT _ _ x,v0. !1 L ~_-.. NME COUNTY s` ~ i R.; I;ID f,.•I ~ IR, ~,.I .~y ~a I - "° z ODUNrv CIn NO. E '~ ^ e~E l / I . . EFF- KLSU qu4,u ^N ^f ®IN CIrYORtOwN OOSr4EN04nGNWAY MlE3 ^5 ^w ^Dfc oN ~ IMFRSfCr NG SMIn. SI4ff1094pAp NON MF45FCtION CIS pOUtf O43R 'I 4asoo 5f 5R, .Q/) BErW[fN {ili~rf K K~ 4 ~^~~~~^Y~E/~' q 4Rff1K f MILE WSt. >7 AJ j UIS ANCF 6D P[M t[Sf MRFSRfN[f. CROSSSrRffr O4 NEA4FSrMlIF PoS [CIDENT RAM A RAM OASA iffr Ol QS 3 MCODE f COlU30NINWlvFD. NFVfR IY. vtfSlN O.K IIED_~NO. IN]URfO~ ^S4RIAGf ^nrA RUN wr+DttOrw CF VFn CIFS © 4Po4fRYY0PMAGf ONIY RE ~ IN a.p FR t 40AppgfOlfRENCE IMF Cl3 CROSSSiBF ]] _ ^ S LtFO ^v[aCl[ OeltGr St9UCK INAMFOf OBtECr STRUCK URDOWNfRSNAMEI fSf DAMAGE ~/~D S4ECLLL COOING IAf '~- . UNIT NO. I ~ UNIT N0.2 ORIVI4'3 NAMf~ UY3t last IODIE 4vFR SNAME ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST t L LG ~^J ~4~WAR~ qp / t L CU%/ v - 3r4[f!AOD4F53 SrRFfI ADDRESS C D LAGUNA a~ T ~ GIfY GGDf 4»oNfNG6,~. D SA~ I 4 i /AJ ~7~/ y Z-/34S R SS^f78 6 ~ ~ D4rv[RSUCENSfN StAtE x In I R~ uu"SE NO. • F % D $~/ 2 7 7 TX M .t ~ ~o ~3 % `/ C m WA . /r1 AIf ,~ D•YeIR16S i q N OCCU4At ON. f F6NANE NO. FYl3 Vh Gnr t4K:nr O T Gmrz, u0 i It~W db E R OCCU4AIION fI4M NMA 64rgNF NO. EYES W4IGHE EfK:nr (aM+vTCUx ~ r~2 PA1 6~ 6 0 '' ^ CHECK (.~ Eos ANOfNte Al , ^'CHECK (/I. W E•SAN 4iO O •t CODES-~ ]~ 5 t b •ss 1 yN nctioN RI ° ° 1O°c' ~- FM VFf fANOtnfR rc CODES-~ Nr ~ 2 v` l . n U l~^ ~tt .u ~ snM • is 5 N 6 y Icr N ren ]r x M F3 R,M ~ K p .MN,IA~ct p b ~ ." Vkn. YtAR mAK[IDODGF <nFVI I ^ <Sm. ^ ~...~I p vL,. •MCD[110PRf NOVw $IY rRDM p •M MI p royKf ^ c"o4m ^ n ~ ^ :.' S. CU I ' / 9 8 (a ""////''ff L I 1f 1]DR.CONV.I ~rzA R 1 nfvl MpIkIIDPRr NOVAI O T] vl y ~ /~ .u,.OS lClr+ tF SIAr lfR RATE NO. S~if I"I n.Cq~. Il NO [nI IE ID[Ntnur Kw ~ C . AE ~ o ~ 6 ~~ '3 NO. iPl 16 i3 biA IGIc~-z15 4fG13R4E00WNfR LASt 451 MIOME /'~ 7a~° L t l I RiN ~ s o 8~yi~ g / ~ I R - - ~aR 6fgN[Np [) yV t ISRRfDOwrafq: UCfI lIR3t MIDDY N NO. 6 d[= ~ p I B ~ ADD4tu of owNU N D c owNt4 . ' ~// /.fV~/ S Sc`7977YE E i I~ N•M[a•Dwfua msueANCe co. oq AC[Nr " R FSSRWSuPA~ETa'iAl'ZA EFT-- .~ Arz .~o r 2 lcxrAttEavd ]1 j DAM.ct a a vsa [ -• wcrcNU cn•gcE cnA4c[ laD", dp„„°" ~ Ac[D ARU gto • N or.r.o.~ce D•MACe ts] _ j Y s . Aw~v oK I lQ:p ~~ 4FAWNtO ~ ~SRVI~~ aq(MAINfD tat. DAMAGE ow[D ^ I loi'firrn~ s sR~00 ^ i w•r Y ' er; S ^:°Y":° /000 ~ i I u DIAGRAM Of CO LISION: I M u IN OC•lo~tn DESCRIPLION OF COLLISION: IUSf 5U441[M[NSAI SNterlf Ntcfsu4rs f..._ ~ _-_.. __~ Z i$~- ~ I f-. •"O'~_ " f/B°l/. J /Y.JO (~Ci~TP'V/OM u~l!/~.~___ _ ~ I ~_ ~ r t_ _ /EN, ~'/ ScNTN.Cfouvd oy ~ ~ GQ~iOA ~R (C /1 I ~ _. . _ __ - r I ._ C K3G.r~~._ i r f Z ._pU<LE~O__.G4L__OF .(JIP/f/6 Lr/A~~~LPer/_rt1G _ .. I I .. t - -- ,, ~ e~T r I(.J OA.Jb - - -- -~ . ~ ._ t /e~a Aye ~ I _ y__ . _ .----- - I II Ve ~ ~ ~ ~r ( j r : y f/ E~~ ? __ _ . - _ _ t , ' iT__.__T_Ac!~ ./_ .- irNT Sine _a~.. -,--It~f r- r-- r rt-r -r t-r-'r- i E-~ r I . UcN. _'d~/ __.. ---- --- ------- D ' - . _ ._~ . ... _ _ -r .r r f" L..~.._ .. .P~vex_ of vcrr ^~ 2.,_srA»__TR.9Z i j 1 ~ i ~ I j ~ I I i i Ne Cmucb n/oT S~~ PReCe]zf 9 _~./4~drl-.~Rfric I . ._~ ' .. .._ . __ ur ~... H 13usH .14~/Nn in/ T f/ G/ ~ _ _~-- -_~ ~_ _I__.I _- f I ... c_ .¢~i __ ____ ._. r NAME. A DORE55 8 INJURIES OF PERSONS INVOLVED 'CODES 1 2 J 4 S 6 N OCCUPANTS/WITNESSES '~«wa o.[.°u wMi .Mt ii ax ~~:ce TATIis '" •.~ Kr INI ~ x t~I. --" -"'° st4 [nci 'a¢Y ,.If.. . ____.__ --.... ..__..._. ..... ... _. _._ _. _._._._.. _--_____.. N M _ _...- • N ID _ DDn3s wt . .___..-.. ...._.._._.. .. __. -. _._ ...__~. N•r~4 cl ~ .. .. _. __ _. n~f a+ ^•Me ^RS61 ^~~~.^Q;; ^CiY,o . N DO4ff5 AMI N•ru4l or R , ..R w]Vto woM •Me i.":' s N ^ ^ ^~~ . ^ c ^; reY .n I. .,,. • DN41 NrYlSEG•l. <vr<la t•.Awl f• c4 e• w Auer. Uf i3 N KIrM!• M^AM! ^T n tr ^rn,~rl. ^vi: ^~i~ilyy X D o ID wl f • cMD n]l p c A 0 ~~ ~ ]mn4s n43 ] m %387 1. }'l' ~. 4"r! t.. 3', ~' ~'~/~ ~+ E I ~Af~~~. ~'~Ay~ ~ ~ ~q id { 11' I1 - ~ ~ ~~` rv r ~~, b _ ~ ' ~ ( ;~4_, z f',~I ,i: ~ I E . I, - I ~ (i L~I ~~ POLICE TRAFFIC CO ION REPORT ~TRAFFICWAY ~ E wilt nAiNr NUm tw PRIVATE WAY i 3 DA EO{COtu YOC r E ~ COUNIY ox IUSE t•AI~jO~URI p ' I R .NI Iwn.~.ut .Y7 ~\ S~ I COUNY OrY NO. prywq ^U / •~ ^I CIYYOR TOWN ^ ^F E6N0 «SiR[fr OR NiGHWAY URAI 45 m pOUlEOR t CnON mlES 5 °W ~« oN NiteSECrrvG WnH srR I V A ~~ 93/So . EF O w O ON M[PSFCpII B[IW[tNSR SiREH6 SiPEEf PP[pDt Mllf p05t /.~~ 6 pStANCf 6pR rUN {pOm R[ RtN<E CROSS 5IR[fr OV Ul ARFSimI p t ACCT NL M lf1 5 t P Du RAm MiA MILEAGE ptEr ^ Of CODE <OLlSrorvlrvv«V[O. NO .vlltp NO. iN1UV[p ^YIIAG[ ^Ni6 PUN MniN IOtwI NO wNC°_IDtwf i CLING RECTOR ROM OR H{«EMI IMfR ClS CIIOSSSiR[[r OR wAp {V ] Of VtH CIFS pe0 tYDPM•G[ONIY ^R[SVIr[D ^V!~`Cl[ 1/O ~)-/V~ 091[4}IRUCV trv,W [ { Cry C ~ . _ . U a ANDOWIV[95 W.M[t ISED AG[ 'L\ Sc3~ C 3 SRCW COOING USE UNIT NO. 1 UN NO. Z ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST s vrvlR~s rvAMC r npv miDaE W DelvteSNAME. wv Np ~ w l ~Ar~~ P •l . _ Stpfft AD RESS 3o I °IT" $Y' SrREfr ADDRESS ^ OYY ;Vn\ Siwrt ~~ ~~M~S/~ fIV CCO'DE, ~/ ONF NO. L/vP'T IO ~cO ~~ DR CUY SrgiF I E DR V[e'SUCErvSE NO. ~WI~M SS SiwrE F iH Mod oil-] I ~ vt' LCErvS[NO. SAF OwtEp«BIRivR ~ ~ a mrv OCCUPwiION AMt 6 MONf No. EYES GHt H GNr E OCCUpAIIOrv M NAME a pHONf NO. EYES VA GHI HiGNI 2 ____. e a~ ~ 5 ' R ^CHECK I~ fwsAwNiMpiovrrrn AHOrH{ewl ^CHECKIp~ 'vtH14twsANrmvio E«ANmH{liw` CODES - ~ 7 ~ s r e r^',° CODES - * s ~ 5 NI 6 "s'° ` '~ n 2 uPRS nI~ ro mnCllOOW!<nEV °p`,.,DpE°nR~:Ii ~~OV "3~.,l °WV; Y ov~zi ^~~~v °~: »° `igO ° N' ° . ~~~~~ ~~ l wv:y o . AI I] c~ Jo ~ E , C I v w, fl p D ' ~ S v H. aoR u4N vwn wl Rnnn rvo H nN <aoR l n e ~ S ( 6 V.~ ~ I C x nHlcu l«M NUrIOrv NO. ~ weal ~aI ~ it i ~ , 91G15 P[p OWYrEp ` v EN~auaNDn AI N S i, Irv. i i i i i i i i i I U51 IrC51 . DaE PHON[NO ~^ . ~ r'~ W O R v I rlvtpOwNEV: A51 fi Sr MiDa[ N Is wppvESS Or owYRER owNE ~ SRH~. ~1 <R N E Amrp•oopESS Or INwpANtt co op ACErvt irv u AN - SM, Pvm- , R DunAC DwRr '"' puAncEO~ACtw awit;"~.~ cH• Gr cHAe "p s..~Nc D p ts~ pun. ~ ~vEN ~aEMNNED ^~w^v ^RtmuNED Es~~DI.VnwcE •rDp io o f w:l , {~ rovnpaY: S ~ o DIAGRAM OF COfLLISION s ND CA ORIH pESCRIP ION OF CO LISION: McSWn[mEMUSH[Et PMeessnprl l~ ~ ~ F I ~ 1435Ap 1 . _ SYifO^' L~ t a ~ + ~ , y ~ I I I X°) ~ " ~AI~ ~ / S~d Ro A=9~ . ~ 7 ` _ _ y ~, n y _ _ ., ~ ^ ^ ~ ~ ~ ~ ~ I (.1/h¢_ 1J~.1*1 1~oA (n11b_PA7N AF ~O 1- , ~: ~: Efi ~ ~ . ~VC ~' ~ ~ ~- ~ A I Vek - . . . . . ,f ..+ . . . .._ _ ,:_ (~OC.R.(y _J.Y_'~~.t.S y _- ~ _ - {- 1 ~ ~:.r~ TDacO Achss _KDnC~q r u'.l;o ~ -J~3~ ~ , .. _. _ ~ _ I _r1 ~. i~. U~f~c,. R~~i~o o~xa._ smTx,.k. ,-- ~9~^ _ ;- 4 ~ ~ f I 1 '~ ; { ~ I ~ I f I ~:. _I I I_ I __ - ; ~ _ ,~ , ; I . ~ -- -- - ---- . t- - 1_I--r .._. NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ~ CODES t - Z 3 4 5 6 OCCUPANTS /WITNESSES ~uov : A oo uniu :i.ev s~ -ii. ~ e6i iRiui '~,~" u^, - . ;r pole otci °;°;, N MI . _ '- I~ N N,p1 N _ _ _.. N~ _ t pCa1SS ~nt4pr« pmovlDnoM N,~u wlu. 1~INrpY ^•Ma ^Y. ^[n . ^RNi ^ri U I;p w nal++ _. ali`J°1n°r -.-. ur".n ev ""^•ae ^^" IOT6. ^". » ~ I ~ ~ X vrs~ . •wc D.ICn vrerum• roR .cl..c. /1~ cy y,p~stcwn ~b~tiD Deno Iwr rpeovm D•tl ~ eD ~Q /SI U1 c~oJ I.._ h L ~ R.DOHn >«.o HRS T/ E1 4 _'~ ?~ W C ~.'~ . YY~~, 31 ~ , M . k % ~ ~~ ~' ^ ~p 1 - ~ It •x, .r~.t Yi A-`'.'i ~~Jn 1 a r~~ ~~Ni. e ~~ ~J 1 7 ~1~~}DS. ~ ,J.{yyy ~FN~~'~ I ~' ~!~ ~'~ F .~ *''^~i ( pV'iNTnw~i~ 1 qry:~ M. -~R If nj r _^' J, ~.Y+x1~'~^E'+ 'S t '~ ~IIfNY"~ { ~ I Il} ~ { A ~ V ~ ~~ 7 1 I ~ 1 2 O~ { ` Vi I'CI'.. 'E .~~ - f 1 E { J is F ~ l t7~ } :~t } , ' ~ U . _; :r ' 4 r-, T / I ~ ~ , r I ~~; ~ r9 tY 'u, 1 V ~ I r ~ ,t r 1 v t r r~ ~ ~ ~ l T l r ~,~ r{g 4`i F '7 }- L ` _ Y f , ;i rr u ,J ~,, I o, T• - _ ~` .~ I . If~, . ;rr, tin y ~ :. ~! C ' ~ ~. rJ ~Y y ,~+~ E[ i v~ . f xaRC ~ .~ a~ 3~ ~" ~,~ r °-: ~ ~~ ~~ '~ ~~. ~ 1~ ~ x ~ ,. ', t ~N ~ ,~ ar ~~` ~ I .. ~ >4 . ~ ~ POLICE TRAFFICCOON REPORT '~TRAFFICWAY roll AINt NUMBFe .~. ~ PRIVATE WAY O IXV IM COUNrv r! ~~ '. ~ . ...,.I vn . ~ I I~.TH~. IR hw S. N (USt] OURI 06 /- ` .~i,C L~~~._.~ll~ COVNIY NO G Cllr rM). M1VA °RUggF ^N ~f ^IN O OR TOWN AMta NO Or Sigtfi Oe NIGXWr INnqua NG w, N-sretfroR ro•D r ~~ ON fC}Cls RIXItE 0431 t k ~3 1] Norv wrequo etrvrttN fS1.o,IG sgerr E A/3G~rrgezr vgenx E Mntrosr ~ ~ "' ( - J DiSI•NCf I RF tR rvCt. CROSS SIRf( NF•RfkMllF ACCIDENT gtMnes 5 t W DIA 4AM DAlq /~23/ 7 MCODE E r[Er Or .. ~ , COIL SKIN INVIXVfD lvf RlrY NO .nIeD-~ND.INIUq[D~ ^YIIAG[ ^N+ 1Digl NO INUq rUwldinTw R I W IMFe Cl5 CgO3S5iptti Oq pp~SpR ROAp Gq MteRFNCF. ~ Or vtNCns ReOttRirpgM•G[ONIV ^Y[fuOtD wi°cit OB][Cr SrRUCx N m(Of 3/T/' ~ g I SrRrUC. •ND OWNtR3 I FSI OAM•GF SMCUI CODING IISf _ S UNIT NO. I UNIT NO. Z DeIVtR'S N vAf 51 ^ VEHICLE ~ PEDESTRIAN ^ PEDALCYCEIST . Ng51 MI if //JJ IA pgrvfR SNMIt USI I I swFf' ss t~.°/2 G ~D moo/ ~' ~ ~ uefn •DDRess ' eIIY f zlr eoa rrlorve NO T G~D~G~ .~/~ / ~.3oS ~ D R r An ?, E SIIDFNk NO 5•II lAw~~i~w S312i wA rrl i~ ~' N ' V I p fN ND wt Mp i p,r", I CR _ OCCL/~ ON + 9M N•MF a MONf NO. ~STjyj¢ fir: ttt5 GNI GNI E OCCUMtIOV qM NgxF a RNDNt N0. EYfS GNi lElGrli ~ ^ CHECK (/} NnrA • w.nvr Ar~o+Nte A` ^ CHECK(/( veN CIF AS AN rMnoret orA 1NFC l CODES-" S~ SI °;;° .snm nclgy. ,l„ ua CODES-* D~ •i Su °y ,is in»"' rwN uoD.c.c ~] Nfyw s > rro R l . ^ . . ;Il,l.; I ^ ~ I o zb' F ^ ~ K,; +uMr vlN rlAq M•t p , ~y~r N o w r o ~3C1 ^ gem. ^ ~ ^ :a+ Ku •D ~ y C I OK+t~ty 1, ulD•q+. ql strlF ROe.c 1 / C/3.-oA~ 9 l 1 Nv.) pIIpARr. vAI '•°"` lam e D~~~ aG ?J. E yqn IRA Ugnue NO suF H nN. oq - ~ -'7 g off/ r o L•%Q '~~' ~ I ~ ~ v(N!Cll IDFMeICAIgNlq 6 GC ~ 02 ~ ,~•^ J !. S'/n ,2 O L vtN Clt IDtrvr I A I I I I I I I 1 1 1 O etc~snRtoowrvn IASi ngsr IDMI hgNf NO q I nqm vn+w. rlRU ml a ~-' Apoeess n ovmlR OL ~~~ woo . N E mgtq a NAMeaAO tss or~Nk RUgce eo oR.GwI S .91 ail wES R I u , wmwFD.su rs•: al -- ~ gslACt Mu .w,lr cNAeu .~ CNAR ~ no 4 • IO~~noii a ISr~DAMq(j3_ ^ ^W~i ^elMmveD ^~q AY ^gfMwlN[D lSi D•M~ TOii 3 G~O w ' 1 I ^''Dar rowto f 000 ° qw •r er f ' rNIMFN KAIt~~iN DIAGRAM OFCOUISION WG NEC[SyFY) ° ESCRIPTI OF COlUSION: lose slpvuruNrAf yen rNeauARrl D ON ~/ _ ~ ~~~~ r ~~ , .: 4 To r//E. _ .rri _-+- _ F.E~ Z bray]. ,~ .. _. _. _ _._ _.. ...__.._ _._._.-... .___ ._ __..._. _..~._._ _. -- y C ~ . I ~ ... C .. _ T ~ ~ G of Icr. ~cJ- I _._ ._. .. _..-_ ___ _. .--_ _____-_ c.~, ~; r ~ X91 is,~ -_ _- ___- --__ _.-- ---- NAME, ADDRESS S INJURIES OF PERSONS I NVOLVED ~ CODES I - Z 3 ~I S 6 OCCUPANTS/WITNESSES ,w:oo otiN:i N.AV ii ~u. eee~ I.mi '"„'^" ° ";' n sr. ~rcr ;'c;, N •w . ; .o_.. . ~tss NAru.a pAM e pYl+p •l;,. pa; O;lR;sr A NO • ppRt15 AillRad RMO'IDreOM ^AMa ~raKl^'° ~. .^a, o: p . FMRrM1 r rul I+ c ar R wril~i °+ IMi. ^•Ma O p: l ^io:Nr O:;'x ^ :°:t. ,.MU . .N. atn X T~17 ~ Jri' a•xl o. ~~' •GtN<• we o. ' a r .3 o•~R.r< tD ~~ q. K1 •umo ' putyynro I G •nrovm °. out .. GJSi s ,~ „~ „ //i 9 ~/ ® ~ ~~ ty a '- 0: .~y~ ~ ;'s 4ww ~: 1 x '~ 3r ~sb W, t ~~; h~~. ~~ ti ~; ~. ,"Src~', ~ u ~ }'. . ~ ~ ~ Tj~ ~~ ~~ ~ "~. ~ ° ~I , ~.s~ ~~ ~5` .. .. :] ¢+. ~ ~~`" i~ ~J~1( h,.,' I lr ~ ~'.=. , l ~~,' + ?y~ ~`J ~"~ e . v, 5 a. !° ~ ~~ `~ _ r. - ~?4[ ~' ~°j f ' ~ 4.. ~ I - - I ~~~~ ')~ Y ~, ~.." .. .:-'.Y `.'?~' ~«!'~ '.ts.~ +.r~.y ..t ~-'^'".'reT. _. w.s°'~` ---~SICSQi~E'~'^~v~-° nc I~. Y . s ~... _m. ,€~. I STATE OF W HIIVGTON r•Gt i Gr - ;~ F~ ~ N ;3 9 ~ 3 ', ~~it ~ ~' i`"~~"J T...r~.14 I Sr 5viviV.r.eO, rJA~ ° n1 3 ~ ..:~.' ~. POLICE TRAFFICt ION REPORT L~TRAFFICWAY ~ rpl nAINENU,v,ety / II J-I PRIVATE wAY ~~ .o•,w. a I N r ~ Loh uMi IuStxwD NOUVI coumr couNrr NO orr NO. , ~ rNwn URBAN UYA4 C Ov rOWN NO p3ivffiOVWGNWAY E ^N ^I ° N 5 ~ Rgxr[OV Rf C nis s^ OE tit u ON C e l/R 93150 MIFVSlCrING Vn N. Srvf[i OR •D NON NItvSfjCJi((ON ''\\ MM// ` e[rwtfN ~%G Ly/Y SrvFEr [ W/y` Srvtt E F MlF xur ~ . ~D O j 'F/ DI •N(f I M lity .CeO555rvftr Uv[51 I E '\ v rii15 c 5 f W dr ~ l /J//l/ gCCIDENx MILEAGE CODE DIAGVAm OAEA '. ~ COll SqN NVOIVtD tvt9 r• Nr6 vUN ^ SIOIAGF ^ NO [ IIFD NO NIUOFD wrvlDwoi. IN I M! C15 INrv II HEr vR0•p OV HrFVtNCf C90355a rxl ~ _ . IOf•t NO pviroats rvonvrr DAMACt p+lr ^aiiu ^vi°~ai '- 5a 6 D OBIIC1SIVUCVINAMI O{Oel[Cr SrvUC[ANDOWNFVSNANt1 ESr.DUA•GF ~-- f ~~ SrtCWI [OD NG USf UNI7 NO. 1 UNIT N0.7 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST x 5 Dvlvws N•M[ usr ml /C~obb~ i G Dvnevs Nwnn usi ~ I - vveo•ooviss ~ / ven AOOVUs uiE [ncoa oNt NO D r ArE I Dvlvi.sucENSiN~ ~O , s zQih s sr•rz uiA . /~ I N ~ ^zs: y I ~ I u iNU Art DA el N r i r. I OCCUrwrION v tt MONt NO. FvES IGNr NFK:Ni N E OCCUrArION MNAMiEr1gNF NO. [KS IGNI i[IGM 2 L ~" !b7 -Pl"•7wvn Bl/i ao S 2,C - R ^CHECK (.~ nvlraA ANOrNre~ ^CMECK Irk viNCU•s•NrmriorrfpANO ~'' r CODES -' D ~ 5 i e ; ~iO,."'~- CODES -' D c • ° e ;° xx Z INluolis ,a Mn;I.D,. ^ AM.D,•N(l ^ ~(i ^ ~a:;r. ^ w~. ~ M'ao,.~. ^.mNl,•,Ki ^ .qd zs.~. ^ M:K,r ^ :.~. r vin r[AV ta>oGt~CNtv.l n ` ~,~ 7 lID•er. AF s~nt lx OV~ vl ~O~ E N r , v.l mD ID vwl . 1 v. / ru sr•u Alfen•rf NO n H vIN a o•cv m A Gvf~ --- - I VtNICItIaNrIIKAIION NO. 3(0'29'F'(o'/~i/iii I / 3 i vwUl I I AI N I I I I I I! I l i l l I [ vEGlsnveoowwv lwsr rust mlDae ngNt NO S E E>7JC ADDVtssp owNte O HE Is A+. •. s•si Nvsr MI A i N NAMISADwsssp lNwuNCI CO ro•ciNr ~~~~ R IF.57P,S / x AM MI ~' 4"""G' MIA aAea CNAV [ 131pD•m•GI IviN -7 I tar. D•MAGr trot Do E EAUIN[D ^•,M~t" ^.tAWN[D - •- > rdiorrb. y - s ~Der~ CrPICCSAr[/ /~~ ovno er_ = •w r . DIAGRAM Of COUI510N ~ s~ ec iiro° DFSCRIPTION OF COLLISION lose svn[w r•l sN[nnreassA+rl I I _. _. .. -... _- . .^ r tus I ,..eEif~/~2 ,{~AUEY; .~ _ i .. _1~i4•// ~ _ _C~2o.~cec/ o ~e r. / ec~.~ /ne _ ._a~ ~b fie _ . y~~s> ~~~ • • °f ~ / h O b.9 c ? . v~ , % ;- ; ~ S »~ aP`.- i., dry - v~i- -.C., r - - - - I 7 -- -- • --~. ~ ~ r I i 'i< i it I r~ NAME, ADDRESS B INJURIESOF PERSONS I NVOLVED +CODES I - Z 3 ~ 5 6 OCCUPANTS/WITNESSES ~pls,D~D^r,IG"A..,i'.~iASw~ ii ~u. ACi urus '",'"' ° nsn ~ecr ••N w s oo•rs3 1O' er •M e ^('S'1"'^ " . ^.Ni ^~3'+v Awi ~ F / . DMIft rW p r • MOVID rrpM ^ANe ^1p1KI ^ n r ^ M ^ lio AMI ~ . DMISf i ~1UI wlu'.~Or ~ IM lr ^•Me ^~"I ^fonlr^H ^irD • 1 ~ ~Nv NvESI~G•ItiGprKl[f MViE..Nr X /!J e.OGi G. •W N(r 1p rq < l~6~ u~~ 01 d3 S II G dK D~Sr G D 0171 M x.Dn~rs rU 0.3~SIN x.oD N.5 D D.rip.rrWr -/3• •n rID. D•ri .Jr ~` .? q ~"s.~+ls.~ .•~~ t r ~' (~._ ~1 i M~%~ 'II lx ' ' A. ~,H; ,,, .~ 1 ~ ~ ~ l~ ~ -. C7 I ,_i •• N .mM~. .. 9j '' 1 r ~ ~ty~ L ~ ;~ ~dHrJ~~9 + a~ r l lr ~I ~ ~ r l ~ s • vv r.. ~ ~ i I ~ n~ i 1 I u til 1 /;ly I ( l ~ ~ !~ ~Ir I 1 1 j I ~ ~ I~~ ~ ( 5 f L - I I - !, - . ?~ W ~ t ~~ I~ ~{Y ~~ k 2 a . rs, , ., ~' ~ ~fr~ + ~~ ' ~., ~ ~ ' ' ~ ~ l w~v ~ ~ ~ ~ b I ~~ " '..rn`°• rra k L .ti'~ '`~4~ ._>Dn..: a'~ 4~{.. z ~~t.i vx7aTa.a'..5x~~+5.'` fei~~a'ifnlc7..._.ssr,s' ucu L _ ~x STATE OF W~'-IINGTON 9•Dl r DI ( _ _- --.•.,_ '~ ~5~', ~ 1~:Y "" v v ~ ~' ~' r s. L ~, f ( rl , ~~ tl+ X9 r v°.f~ a ~~ ..~ / ~~ ~ ~ ""~" , ~~ T, '~ ~"c ~~ f ~y i ~ r ~~ • :4 ~E ~~ l , 'O " I POLICE TRAFFIC COiON REPORT L.JlI TRAFFICWAY I l-j pIX,cf ~.,,nMNSHIyaBfy / L ! PRIVATE WAY (~ DAIl O1CIXI13 I D. D v a ~ w nls I i r.~. i .r ImF IVSf ]•DJ HDUeI COVNIY ~~4~~ ~ l%)IlN1Y NO. CItY NO. iHwn ^WBAH Ru / ^ ^F ^IN CIYO IOwrv AmFBNO.dSIPlf10R roNW r IC Cl5 RWif OR ainf ~ SfCll roles s ^w o ( ON Y 3 S ~ n NIleSFCrING N SrRtfl099D D NON INrt95tfllOrv BFM'FEN SIR[fi { aIRF[I RPtN% f0. MISF ROaI /~-.,) ~ ./~ 6 nNtf{041 I`Orv IROMRFIt NlC al4tfl09 NµRF51M44031 MI t5 5 E t~ Dal Ills O "V l T ACCIDENT MILEAGE CODE 9 OIAO4nM Win //~~ COIL ;pNI vdV[0 SEO ShIlD„a,j_ OINIURfO~Q, ^541Ln0f ^Hr6 RUN OIAI NO dvtHlClla iPonR1Y DnMAGE DNIr Srd[N L{J ^ ^ MSUIi[D ^vEH CIE WISH H.IHDnD.x rv 'RD IMF Cl5 W CLING 9f e9JnD OR FfnRf Oaa519ffi09 AD ' ]] .I-~ _ . •~ OBI[Cr r9~01 OBItC1519Ut%M1DOWrvfR'S N•MEI fSr DAMnc[ y. anew COdNG Ibt UNITNO. 1 UNITNO.2 ^ VFHIQE ^ PEDESTRIAN ^ PEDALCYCl15T z% S DRI [9'a rvnMt: µtr NR MIDDIt S sl .l.£57Fs.~ D9neR'S NANF: µ5I fI9 I srR¢I noD4ua G nu noovtss s re zmmd vHONE NO I D er Inn Iv DE n ~a ~~ R D4ne9's uuNSe NO. slnre o ~.. 4j"~ I v I sl ervseN. ne a on E~axlN mo. . rR aeuvnna+ IRmrv lavHONE s eHl .front E ocavnnorv Mrv.MI{vwNt HO. ens WEIGHT H[ICHr z an ~,L - s,)e7 a R ^CHECK (.~ vEH~eAS:NtMftornanr;orNE9 ^CHECK I~ veHnEns nrv lMnorEfdnrvorNt9nl o+c.cU ' + u ~ e CODES - ~ 7 n: • °.in 5 E a. / e "'O,°K' 1 s ' ,~ CODES -' 7 c"I+ii . i:inr~.Hl 5 In H y z 2, w Uvrta L m iF w dDI.D p .HiDl.xll ^ pf ' ^ ES~I. r;~K~~ ^ iu~sv I ^ •^^ I ^ ~1° ^ ~bm ^ ~ ^ I.°HV 'I r VeH V[ne tIDODGF CH[v.l MODeI IDARI NOVnI SIrIF IR DR~ ONV.I ~ ~ E N.Y ( NFV.1 m.OdlIDn91. vnl L I ~ ~1 _ I ze v rlAll rv II enu Sµ l 9un9 ftMF N s H vEN. dog I rv . ~~ C ~ vEHICIEIdrvnnurwN HO. I I I P121/ I 11 L y fNlneldNrnl I N . I I I eFG4nRlDONNIe µt1 IIRSr mlpq[ RHONt NO. O E I 9l WN19: 1A51 flRal MIDDI[ W ~~ N Det55d OWNER N A wrvd nDDRlSS mw9nrvee netr+t_. ~ ~~ B In R I u o ls..~NC gmm~ee~s A9u '. D•M ID AREA CHA9GI• IlncrIDHN '"'~nWr CNAe ~ r D e r D. uen s u~wmnee w.. ^RlmAlmD ~ ^nw~r ^REM,uMD es~o Idiorio+ s i'oiio~ ~ lowed ^iowtDDr S r A i fy _ l r~E e.:~ooowlN ESCRIPTION OF GOIIISION; Iu5t aU9n[MINIAI aMIfi II HeCElu9r1 DIAGRAM OF COllIS10N; ILL T:1_.TT~ ? _ _pDR, Yy;:3 IG~..: C'bT~~si:1i~ ~b-~,u- rC,R~-rt+ o~ ~ r~l G ~~ _ _ h ~~_.Lt7f~S I I I I~ ~_1_ ~_!- i ~ ' _U,U/~l~r.~_.T o~_L~lX~er~i-ar~=~i1TJe.~- -r-•-j-7 I -I -r- -~~ -tt-~-I-- -~ - _ . _ .p~cr~.. --- _cJSC,...gs cE1 _.. ~rtiTa~__- - _ r - i ~~~ ' i _ID 1 I 1 I _ _... -'- ~--'---._..........__._~-_.^.. • _ _ ~ /. ~'' I _I I - -` -- --- ------------------- ` i~ ~ I I I I I i i NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED * CODES 1 - Z 3 4 5 6 OCCUPANTS/WITNESSES wsuvntmENra sHt Iof ADauoNM ww n s~ -' '- --- su Aa dus _ 'N,N," -RU- -'~- -- ns R nla elc+ Cj }~Cj N.ml w ~ _ _. _. _._ N%nard__ ~ .. MDViD IRUM w.,a xll~ yl -- ,~ .r9<rtt _ HAl~ld a".'„r. ^•y ^F.°^ii,l.^:iX ^:' x T50/ '~.~~1 u O,~c~ i~o7~ /l Y ~7 ~^ R ~ ~ ~ Cw r'V ~ A ~ G~ ~ i ` L, ~ v ~ ~1 • 'k Ii I~fi l ~ a . ' m. ', r , - ,r~..~ }~~! ~.~ r' " P ~9 a9 . '' ~+'+ >z ~ u ~,' 5 ' e ~,. ~.. E .S. .w4f~ D4 '. ...~.... ~ . .ry u• p ''~ 0 Mt~ Y ~+i "~~ :. ~t' r:5.1 I - - - -~-~ rvUtt <OMRMNr NUMDFR / \J 1 ~J p ~ PRIVATE WAV ~ o y t orc d rMt <DpNrY / 1~ ~1 p ~ yy ~~ couNrY arr w. HWA w.I IVS[]tW HOV41 p~~ 1 /~~O IV' T i0 / '.I •'n.• I I I ~JC ~V l-``~S~UN W ^rU NI URAI ~E ~ N <rY OR rOwN O.Or Rr4ttr O4 wOHWAY Kr~ M gWtF OR IHf SFCr MtF ~Dr 05 oW -i C V / '~ ~ , ~ P oN tK n Ilo J 3 Nrl RS[Cr rvO 1 s14tFr OR 40Ap NON ~rvrlRStCHOrv FR {O M E 40 R 5r srRFtra Q pe{ sr4ar ~/t q Disr.rv<t ap Rt r~G.r-M >; ~e~o C ~ Rtn4sNd c4oss R t•R sr M,lev s t 5 y f ACCIDENT v DuO4AM dvrA W Or M MILEAGE rFFr ~ COni'iON iNVOIV tvt Rir ~ ///~~5 ~y CODN S iN OIN NO tOm NO niIIFD~NO.iN1U4[D lU ^SVRIAG[ ^HIr64UN p~" R ~ CIN REF RROM O4 RIrtR[NCE d VfHKI[5 w iMF4 Cl5 C4CISSSiRF[i O4 ROM dFrv NoR RvOR4 YDAM.GF (IN Y t !+S _I G I ^.Rj S irfD ^ vt opA r Ix.IN.Mt or panel srR;x. rvmowuers N 11 u+t dt 1 ` nn E esr.DanM t snelu eosuNO USe E ~ !2 IOTA. TCx~.1C I ~C70 ~` __ s DRWtRS wnMt~ r UNIT NO.INRSt Mio it UNI N0.4 ^VENICLE PEDESTRIAN ^ ^ PEDALCYCl15T ~ L DRrvtR srvwY.t: usr I _ SrRtfr AppRt -1 a a c"Y C! ~~ ~ O S 4rtr MORf55 r F RC t SI uer ltna q s rroNfNO D _ R N sort ii c f ' Y N R p4Nto-s ueerv><N ~ - sort en Linq fM pi n I MD ~"L~I ~(03 ~ rvF u w No. An DArt pi4m Mp D.Y Y. p peeuRArioN AMt[4HONt NO Mrv I I . ems em nroNr E 'F54 ~KI 1~(r ~I~ R M oc<pv.norv rvAmfa RrwNt NO. tns wTiDHr raieH r ^CHECK(/( vtrodtAS iN U.nv ANOiHrcAt ^CHECK (~ 1°` CODES-' ] ~ Yrl S ' e's',° OC Hide wsAN rMOiovtFd ANOrHre CODES - * ] ~ .t is s rA ' 6 ~ °uet~D n~'.~:A MA°I~~p~.<~tY ° c~~:,~ ° ~~~': ~ :~ o~~za ^ra~ °~ ~ ~ °`" ' , ~,, F~p4.< p, + ,{{ YuR t H°r fl°4 R ~ D°,r ;l u NSeRU eN sun 4A4l4 RArl NO. SrA rt H wr edo4 - . ~~ ~~ In N U~.f"1 At vtH¢u iarvmrcArrort NO. C veHi niotnrni rv I~I I I I $F I I I -r-----=-~--- E RwnRRm ovnrt4~ usr n4sr I I I I I i I I I I I MiDpu wgrvf ra ~ Y1~ ~ Q i] I ~- t is t tR: lnsr rmsr MAD e MDRSssa oWNtR W wNe4 N !kS I~ E Nunt p ADORtss a irvwvArxF co w AgNr 1\7f. R DAMAGto Apo " p ~ ]z u. ``o . r. cNA4d _ '" •' rirmAOtD AVtA pp cHAVCt a °.N ~ia ^ w~:v ^nMUrvm ^Dw4~wN ^ ts~p.vn..ce iB A at nor m f S:uno: s o rw v f i eY ^ ewir er DIAGRAM OF COLLISION I 'p '~ i -~-~-~~ 7 ~ 41LtA tll- eK we tiW'H D SCRIPTION OFCOL IS-IONj~, sML~esU4ReM[ r tSHt[rn NedssA4Yl I- -' I Y t ~ -~ _1/E?ii A.I /~~ `v'A+I~ /13xe ~b._-DR'v_t/i--S}~tsD____. : 1 I ,'~-~"~- ~ y - ~ - ~`~ I + A _.UeNl.k_ _sle Ca.~k.__VeICRO_l~ ~u?r . ,-1 S~B_ I ~ i"' I 1 ~ Ca~krLlA,e _L.lZtucn . ~ t 0. I~ Sw KD _ MISS ING ~ ~ USH ~f EI v~ = " D _ _ . UL~ r r _. ._. (ci.J l i7 ..._ ~ ? ~~ . .,lgo-CD ~ _j_ I ~ I~.. ~~-gyp d ~Fw sA~ o m ~sn ~It ` ~ 4 I ~ .. ~ ~ I ' - I I ~ L. ~ ~ _ I,~Llwn (ou1Du..T__C~plJiroL (JCNmc•• l~us}L_1MNf:GL ' I ~ ~1 TP.11~4) Cnos/,c0__olta 7b S16 TNo~ tW ! s I . .. ___ .: __ ,. j ! _ !-,-;- - --i... I __T-~den_SIrE,~K_'~__ Pnl..~,._Pote ___,.-_ ~ ! ~~ _ . r -~ I ~ • ..._. ~.... _. 4b1 _ ._- --. _-~ ^ ta~TrnotR N Q S7~ NAME ADD • , RESS 8 INJ UR OF PERSONS INVOLVED CODES I - 2 3 4 5 6 OCCUPANTS/WITNES ... - ---.. _._.. SES in:oa !o ;ar:+iiii -- . sr, ua ar ur Aci iwi '"„~" NtMt tiJjyo , t~. RtvR utcr :~~. AJCISr+.J ~`12•.5YS8 MDnx .:+ _ .. uRl ND (k bt M dal n S vC. rrn ~Y ^ AMe ^ (:1" ^ ^';, . ^ Nom' .aims . ra ~ Nu _ Nuura ns urrn e.•' ^.pp r C.C/r[I• Itr.rvr pW[,.r~iR -Ir.<r 4KI D~:rA~CrAD RA KI /..RIND p VRIWOt irp~y~p p; ~ p.O t ~ tr. V z W SP aooe aais S`I rY,~, T, ~' .~,Y i y~ ~...- p ~~~ '+Al (ifHYr ~ 4 ~pl!L9 Y - 9'N+T'W ~iM1"fdA J ~i mnlF w+t4`f /(PA'.Yr fi+ .h °arv .„~,~~ j2, ~- 1 ~ ?t+'^ 4 •'•. 'FM N .'i I~.. fjitw. 'F„ y~ 'b _ ~ .. ~W }' \ ~'N I I ~~~~T~S f~; ~ ~y ~° ~k- {~ r ,M~"' a 1 ~ 1~ .fr+t'z~?a;'~L~ya~ 7 I,y \ ra .re i'{ Y i tip l ~F Y - l ~1 ' .. l 1 f l 1. I I . i i~ l t \ 1lh f r r ' ~ 44 1 ` ' ~l~I~f I' 1 ~[ t I ~~ CqC tf! I ~ , I I r 1 '. ~y ~ - i~ ~I Y f t~ t~ I~ ~r37 .. '}y~~ y~ ~ 3 ~ ~ ~ I f ~ Nrrae 9 ~( ~~ >3 R , ~. k. is ~p ~u POLICE TRAFFIC COLLI?RIPJ REPORT LJ TRAFFICWAV "L ~ PRIVATE WAV D F Ot CIXIi runt w.l',.f Y~ ( 5t ]bB »GVn .: W. R COU»tr A , I a83o / l~ - ~ 1 te TE/I C/~W'N Z ~» ~t CIIY Oa TOWN NO.Or SlatFt OR NiGNWAY Mats Os ^w por Q/%7/y!/f000 NB+<.'?t/e2(/~L, .F//0 ~»ney{Ct/»JG Vin IAN slR~ftt/O~V g0o.0LL »pNINItaYCtiON C.-CiY/C C /CQi/ B[iW[!N ^- StvlFt { Slaf 1 D~51•NCf 6Def u a0~ e[HVFN t C+OSSSIatFt »[AR[siM It 5 M ltS s t rtn w Or ACCIOE MItEAC CODE COlU50»»v«vtD Fv{v rr »O, iNIV+[D~ ^Yal•G[ ^NtI VUN tool No »o . um_ Grva nn ® r+onmrDAM•ctoNlr O`+'iiuum ^vi«~it _ OB1[CI SIP«[ I»MAt O! OBRCS Sr+UCV •ND OWNl+S wvnfl Ist DAMAG UNIT NO. I UNI7N 0.7 5~ DR»tv'1 N•M[ lASr St Mi DIF c-~.,~,s~- ,pc~,ulJ D. ~ D+i tv'S t C Z statn•DDR'ssr DC~ J~~ o-, 0l ~c l l nt ADDeess ~~ Citr S~IA~IIf E r C IX O»t »O LllDLdl~ Y•l//t ~ rN ~ D R r NE D+»tas uctNx» st•tt . ~'•..uSrpD523~if dU? -tij A N?' 8+ ' S~ v i st Ni KO q' Z «cw~no» tar«o»t ra. tns icNt Hro«, .dfidEC r~.eC~iS1~l.SPJ~EJ 2 / E «cua.n°p~ /S~TJ. CHECK (/) vt«c~[ASnN •N ^CHECK (y CODES -' 7 ~ S t B i° ~'~~, CODES ~ Z tWnS 6 n « A MA.e IDOOCf ewv.l rt ~ Moon ID~I INOVn'l s u'lm/a ewv l ~~ r ~ rt ' N « uee» sut nAtt »n ,An H vt« cocoa KIt 10(Nt uCAtpN rap s'~J /~ ~iassr i vNKIl ipuDri ~ 1h ete~srt+toovmte cwt nRSt M~DOIe E rNO»s NO O W a ~ nat owrua: -~a'~E Is Z AoD+essa ovme+ N E A w»la 'z »AMta•DDesss ormw+•»c[co Qa ACt»t ~.VO.vc R , fZ3Q4,ZL[RT N~ !l.UDFiZ'tfl.C/TE.t^S o•Mwto Alu C c«•+w ~ ~ D gAMAG( AvG c«•mt c ~ DAM•u :w~': ^eerwNtD ~bi'orio+ 5 u~ AMAa t ~ ~:wq: nrwNto t ~o TR - f ~ 00 tosaosr. A ^ :w:v er f 1~0~ ~' NU wrNt.. «.l « DIAGRAMO L1151QN: SR[t,u Nt<uSMh s+~OWI DESCRIPTION OF COLLISION: fuseBwnlwl»*AI SNe[in MCtiSAa I ?/E/trPcE-+~/-NOrC-Y,y CfyG/ P,~~ orr,~t,~/! Y S'~rF ,drus r ONFY.fc.J . , ..__ /~G'.r*D <r~ .CNG,a~yj ,CL£/YE), F 7/Fl/(C+CEiPF-Z- Sfrfi~~o I?'T~SJ'O/~'5 ~4.EJ /~NOLL Q " , {~y~ ~E~l7L`.C' I~iPLCez .fD 6~ ~h~d~ .DiP/!~E (. . c /U ~ I ' ~ !1/='/uea° ~ Z ,~,ccn ys o.~r~x/rE/~~/ ~.sarr ' _ - ~ -e'~j~ _ . DF+~/ o~~i~.acc2c~ n/i~'i//.vn~cJ'r-one ~ ~ `> _ NAME, ADDRESS 81NJURIESOF PERSONS I NVOLVED 'CODES I - Z 9 ~ 5 6 OCCUPANTS /WITNESSES ;mot swnw.wty sNt a ADD~uoN•l N.M n OI u. •a Atns ' v nsu Exa '"' GI/¢~ SSyeO ~ z 1 • DD+tBB ar 2 u+ °r e twv r •e e ^ RI" ~ ••~ . ~ w ^ .°. 50 •w ~ .DD.t55 GrtDr ° ~ µviDi.DM ^.M+ or;e, o ~~ . a ~ o :: b t ~ • BwuS va:~5°r m N lNrev O•w ~'1 °'u Oror . m O~ ^ ~ w.oNC.~+.earKtn ».», n.a• X ..T. L. ,Uf, - sDi/4 l•DCt o• r~ .etec. ~'y9, .rl , aKtDar.¢.IC D>9C7 .aa ..auto ~~ ~~ e.n o~nro+t 5~~~ Arnovm err 9 D•n ~ '~ ~ { J T ~.°, 'i r as ~~y ~ 1 ILL, ~' I FIB ($7 I . t 7{{ ~ ~ ( I ~~ .. 2U+ ~VV ii rJ. 1l ~ j I I - I v , t': ! z - } v s 1 ~- f 1 r + i -. y F ~.I I I t7. 1 f ~ J~1 ~~. I , ' / ! ~'i I Z~ .~.. - WSI13019N.I.e01 ~' ;.. ~ STATE OF WA GTON AA~t / Dr i Nu ~ ~ n _f ~ ~ fiz ?r f ~~ ;~ ~ , ~p~F JR ` ~,.. ~'J' ~, ~~ P, ~.. ~fi~ pp yy55 r~~F E_; ~ K>~ iJ~ ~il [ e ~ .a . J 1. a~~, ~ .:;~ ( 5 ' " A as ~e ~ ~ ' ~ R~ t ~ ~ ~ V al r ~ ~ ~ < POLICE TRAFFIC COLLISION REPORT LZcJ TRAFFICWAV IICtCOMq,yNrNUMe! PRIVATE WAY ~`*S '~' ~~ r boo e~ r I~+N~J Ime eouNrr : J I /110/ I.Ox.l un. .Iw l~'~.i .r lu %~J ~ cou rr,,,, eln.l„o l/G'J_ ... ~u A U+AI !~ , ~N ~ ~I Clrv 09 tOWN NAMFf NO Oi3r9ffIO9 HIGHWAY .8 M1t3 ^w ~'a c%/.~.e~ oN TI~.Z ~ INIfASEClINOWVr»SipflrOp pOAD NON INrfR3tC[N]N ppV ~ ~'~ ~3l56 eerwte li-i-.L Srt[fr f oe,/GV $'~ttr Pvt/I%, MllE ro3t MI1t3 S f'C905S SipEE ANtA 3 Mll ~~jj • rtn W or miLG l~osi oC ACCIOFNi MCODEE IA 9AM DArA COII SIONINVOIV[D: fvf91ly: OEAI NO ~I N09111lO~NO.INJUptD ^YIllAO! ^Ntl`9UN dvtM Cll3 I~ ~vro9f9rY DAMAGLONLV ^vIISUITED ^vFafl[ „ " "I~~r N IM! CV CvOSSSrAtfr09 roADf~ 9 ~5 OeJ 9UCRINAMl Of OBJICr rvUC%AND OWNteSN.J+s~ [Si.DAMAG! SRCIAI COD NO Ih s ' ~ UNIT NO. I pNf9' NAnf Wt UNIT N0.2 . ^ VEHICLE ^ PEDESTRIAN ^ PEDALCVCLIST' --z,% . ' 1 Iv NAm usr I , ~- -- 5(/7 Sr9~fJft A009f `i L/T ~ ~ ~,r `/ D'~ f f zlpwof r aMNC. D V A I /LCF~,SE ~ 9 X ~5` R Nt9'S Ut[N N c o 90 ~ ~ N 17 7G ( ~ I lI N "° I D.. I l r` + «e~ RmN ea N[NO. r s w»r .e"r E uAl rI9M NAmef 9NONe NO ens W21e r Jeer Jr~i/~iA/ li ~.9G.ay /~S. _ . » - ^ CHECK (.~ vrN A N ' A r A ^ CHECK (.~ cannon » p ' A ' CODES - 2 aui S f 0 s",° K'cJ4 % i : '. CODES - * D !~ s In<noN e u ''i ~ I vales ~Y ~ ; ;~.;;,.D ..N,n„ ^ ~s~rt o zs:;l. o ar~,~ ^ v~>, VtN r<wv fID DO F O t V l IDMI.tgvA Srr f 09 C C rM su,y~TS'p r ^ ~pf ^ ~sM. ^ ~ o rg~„ Kn ~ ~7 f / , J l . ONV.I le ~~( ,. / ~, ~_~ 1 %/'C..!/' NO ~/~' r~~/~ E l N .I flow vAl l rqm „ / v Brae tpnnfRlure NO. srA H v I vlNltl[ MMIi CAi ON NO. I >JI LI I/s's~G, L I I I ANTI TIN I I I 1 1 X 1 1 ~ 1 1 1 1 1 RlGISIE9f0OWNt+ Wr flp3r 7DIXl MONI NO. iS/~~ "".Dfl.~+/~L/. U ~.~i W WN Wt Sr I ~JG~ `~~or.JC~fL .oo9e5s d oW*Je+ 97 S' >~ ~ 1xi e . NAMl uooteyp w+.fJCe eo o9A ~ DAmACt MtA ."., -~ t N<Ipiu CNA+d ~~ CNA+O/ rlryCnOwa gAMAO! MfA A I o > tst. DAM s ^ Awev" ^ tAwem t aro~ r I a ro ~ t A !D eM ~ rovno o tD d e ~ / ~ S ^ r Ere 7 - ~ DIAGRAM OF COLLISION lye r ~~eiiurl ~c ~rgtNO+r» pESCRIPTI NOF OILISION Iu3[5 rueuNrAl srelrr eCISSMrt 1 I I ~ __ __ r I . ~ f f f ~ ~ _ I_ { r ~ ~G' Ai._ -s~13 _ o-~? cc~~~2=2r5 - _ { - I ~ ~ I I I I I ~ I ) L %~ . _ _(__I. ._ -~. .. _I_..I. .r _I-Q. AG/!i sl~_ a,J.E~1.__/_oGB ~1_~fi~'~.J J __ I I_r_I '. ~. ~_.r_ I I. r-I ~- ~~ .. , I I , I I - I I I 13 LLY~LI .. .. --- -- I I I I I I~ I I I I~ I L L 1 =- NAME, ADDRESS 81NJURIESOF PERSONS I NVOLVED ~ CODES 1 - Z J ~ S 6 OCCUPANTS/WITNESSES tiw wD"'q.'J:ir~+uv fi it%~ Aos rarv Y, I" _uA,_ _, ;' nv~ utcr uc~r A fJ0911f Q ._ I(CCrL'S "" ' NAr + ~ SY5 L~' M E CYIq Q om" . Q.TX ILAwv n . . Zv9.J F~cr .Z- ~ /~_.. . ' w S-73G a ~. - " ! µne ,$ . NAr 9 ~~~~ or+m a ~.olcl~"N .OCt7 ^ ~°. 9 c ._. _ _.._ ._ N la1~30 ~- D91K 51N V1r ^ Mf ^~ lOtOnr ar ^li~ . 1 4 '.r G+r{11 1 IDGJ ACINC• x No D I c 5 ~f-m ra o ny ~~ ~~ a.9 o Ea nron A+rrovto a./ o.n o~~" ~/v I ! r lf~ n,:;u< ! " :;'f78il~f; - .., .., ii ~ti ~: aw~ wr7 ~ti. - R ~'- ~~ ~, 1111' ,n did 4jh. ~"~~ : pt% & : , ~~ ~~ ~ ~ + ~~ .. .. - PRIVATE WAV ' " ~ ~' . `'. IUSE ].DONO R) COUNTY CWN NO rcfl0 fNWA , ~E~` a~ ~,~eD.I DIY «Ia ~w.l fly TL lZ~/5y ~EFFEPSCN I( ^ B!W I I ~ p IrOI DF DIN C I TOWN [6 QOESivElIOP iGNWAY ICI ClS f0R 14F RUPM -Fl Mllf: DE ^w DE V,a/ q t IC~~,e ore C'emc ~ N r 9315 Nl[ SfC11NG Vn1 Siattl OV gOAD NO if vS~EJC O / S~ I\,~ rPIEIR < ~. MIfPWI - 0[M'fEN O//IS,~) // fafEi{ (~/ Q Sl Efi I~-I,I~ D STANCE DRt IONf OfM frt4 N f C4055514fF tAefSf Mil[ S ACCIOENi P DuGRAM MIA MI [S B f W ~~ // pp~~~ MILEAGE - ~/ ]]]]]] + 4 nn Df ruS~l J QTY- ~C`.-col>E" P COIIISgNiNVGV[O Lvlvilr. I PYCII S141f1 RROM p4 Rlft4l t a<V[NiCl3 ~ NO [IIUD~NO. INLURlO 2 DSr llACf DNI16 aDN Mild" I" IM[R Bl5 L.a03$SrvffiGRROAp D PPORV1Y pAMAGE ALLY ^ Pi5 I D VE~if [ ]]~~] n1_ q ~. l [D l 3~ OBhC1 S1eUC41NAM[OE OBIECi 519UCV AND OWNIV'S NAM{I fS1,0NAAGF SafCIM CODING USE /7 7 EE2 ;-- UNIT NO. I DvNlo•S NNAf' u51 1 i df n4s UNIT NO. Z ^ VEHICLE ^ PEDESTRIAN D PEDALCYCLIfT OPNW"B NANf: 01 1) l r-9~ y7 (J ~f CJfn , // sZ s1Pffl AODRfss 6 EQU9ivn P7: ,e p m w an slAlf 1RtfIADDxss -( ~ ~ zirmof noNt No. DRNl3re~e ~ w4 ~ z - Est' slA e D nr Alt R r ~ . e. N m Gg I o J l 517 I ~ u<wu No. V I •• / «cw.noN NAME { M10Nf B ens ieNi lueNl E «eurANON MNAMfa rrroNe NO Z Nt_'nocv B/U23 // . R fxs iedI IEIGN i DCHECK(~ ,cIEAS.vr Riv~r orANOlNt ~ DCHECK . c R~ CODES-* f ~ 5 r Ia.. / eMO~°IC'cn/ N n n S I/) CODES vEfoar AS AN MaionEa ANOi AI w ~rvxrcu f-'" J its . i. Ac rox B ;. ]] w uelol S - QUn9 ] WO fH D l N IOI RDtro enRpM .M.,,.A I D b Rf IDODGf.CNF V,1 ga ^ ib'm• ^ ~~K~P ^ ~~,. fl IDA41.NOVA1 Sr Y E ]D C ;„ra°' D ,... Nd D rd ~bm. ^ x ^ :°'N:. ~ ~!; I i9Po /~2/ l _ ONV.I 1 ~~ v MAA 1 NFV.1 IDAR1.NOVA1 1 ~ ") E Y _ U fN SBAIF vAOfPRAIF ND. S1AR H xN.caaR l KNKII IDLMIEKAf iON NO. C vtNKIf IDFND iU I G ~C. ~ I ~1 7 ~ 17~J ~Q afGISRP[DOWNEa IATI 51 MD0.f MANE NO S1 I- ADOatss ar ~~nEC ~ O~~ '377'° i F [D f0: tKl IiRSI MI E W L ~~~~LC A N owwfP A«I. AODRLUOINSURANCI CO o+ACENI E /T~O/l/E DAWAGtD ARtA "~' n R nd CNA4GE CNAPG wtii06N gAA1/LtOMG I ' • 10 iOTi0~ ! lS1. DAMAGE O Doi^: RlMNNfD DRMN 15p1DnMA0! { ^ AWAY ^PfIMINfO r Iw' ° f f DO v a IV I •u ew~'r°ev: S I ~T ~ Y"-- DIAGRAM OF COLLISION: surd.,. cAn ESCRIPTION OF COlLI510N: (lnlswneAYNUISN[ti lE NfassARrl e ~ mu cEISSNAM erA row " ~~I ~ -~ -~ ~~ =v_EN ~C~~~ty~J=T~ ~ ~ ~/ q z ~ ~ ~ . _ y ,_! {- __ -{-f-- { - -~ ~0 Speed ~ , ~ r I.- _ .?~pp 1 -f o~.k~t _ eE!C __OG~r - ~-{- --'-r- fi- _C1ewrL__-eeajP~ ,ne a Il/Qz-1~ - 'T~-~ - - Q ~ ' ' ' ~ o , _ T , -~ -~ _a ~ ~.P~ ~~,,sS o J . h - . D` _ _ _ . ~ -er i ~_. _~ - - . Z3 ?...~ ~~ ~ t - o E~l ~-~a~ ~ e~~• I i ~F_ Vh _. rr S7_StGl ~ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED + _ COD 2 3 1 l OCCUPANTS/ WITNESSES .o: ao^!I OwNa:~,~,'~ NAMe N NOp~ ~ ii r s 5 6 A`f rA NVf •vAf ~ -N!' -'. --- M a• lus ~ r ,. s n n tact --- --- /! ~ No 37 NAIU{I OI ""' ""' ~!/E5.7 '° __ /J ` -- . _ r ~~- ' " ' v ND ' ZY 7233 IM~r AMe DE`h"' D'8.,. D.". ^ .::4s. a, - - -~ - '- - m n> f H AMI N NAry Ia l/iv = >IA~ID rroM D DrdAl D., AMe . O h D :° r u. 4D.n .', . b ADC+ns _ - _. --.._. .__..-.-....-. NAilwra-. -. _--- Ie.I,..G DIIeI I Ml.f. eAwl o. ,~ ,K, "'°I~ N llw r s C i DAMe D~ ;rvl D~wP. DD: D" . : , X Tiw . L. , 6 ~ ~ ~/~ dfIa DII - y, IZ? ~CMD >.DI".: Y S { y~ ~1 ~S IYD >.m NR: D~~I ~ . v10 Ol i1 vV B /J ]~~ ~ Z ~~ r ` Pt~'"WE:I~ L ~„ +uJ ~ :9 `' ~ )M e; I, ~; .~~~~ .~ '~ a E ~° STATE OF WA fdGTOP! ~jG(f ~ Di / w'°"°'""'°°' POLICE TRAFFIC COLLISION REPORT ~J iRAFFICWgY N~' ~~ ~ ~ O ~' ~ 2 ' EOIKE CO MINI NUMBFR PRIVATE WAY - ~Rr Y f~Odp~j 1.~ ' '94`/ $/ i~ ". IUSf ]bO NOUgI CGUN(r CWNir CIEY ND ~ - J ENwA / I ~ of o -.~EFfK~2so~ ~p ^~RgAN ~" ^e pw errogrow" oovgfnoq Hle4w,5r as l E _ 4OUrF 4 !qE( Ip~ - Mlf3 ^3 ^w ODE .<< _ E oN cc,, _ z C/:/_ 3 S IrvrFeSECr NGwI1HSrgfFr Oq ROAD NO NIF93~EC/iI/ON ~'] pq(Nx f0 MY E051 ...3R D m BfRVtfv///C//,i~(~S SfgffiE /t//~/~LGLUL.~~Er /a~q _ ~~~qE .CROSS SrgtFr R ( 6 p q 5q F W ~hB~Po d ACCIDENr D GRAM Wt .~'.Op fEErS N Op MIIfAGE COlU310 NVavfO O CODE ~l OIAI NO OKgIIED~~NO.iNNRFD ~ ^31lUDf ^Hid RUN ~urvglDtl RO IN Sf EF'Oq ROAOOR F[rfeFKE '~ f O<VFH CI[3 rD ^ egORpiY 04MAGF ONIr E SraFN m Mfg ClS CmO558ogF[EOp gpAp` R f, f~ O r3rRVCKINAMF Of OBIfCt SrRUCK AND Owrv(q sNAMf p MSUlrFO ^vfH Cl( F•A qp0 ~3 I I fSr. pAMAGE SMCUI CODING USE ~ CG ~, .j UNIT NU.I UNIiN01 *]y oglveRS rvAME: u3r I ^VENICLE ^PFDESTRIAN ,^A Iqsr ^ PEDALCYCIIST k ~ OgwFR SNAMf: IASf r ~ '„~ ~_ ~ ~ SrgEf OOq[53 ~ -/ /A~ ~ d / RffI AOpRE35 cale2 rJ r (!AT ~o L6 _ ~~~ ~ ~~~ ,. kRE~ ~ fJDLOG~C.. sArf Frreooe oNe NO. D r sA i ~ N N . ~ :;K~~ S~; ~M .~ ulvfvsucEN rv G/A 9 rAr~ H ~ R Iv l En - !~ -' Are x DAr //.~c~ b376 L Z t(r/~ ~~ $r G3 v pAr°' I .. M 5 I ~ e OCCUTAr Crv EImONErA EYfS Onr r E CUTAFION iqM NAMfe IHONF VO _~ 6r q fv[3 WFIONr HfIOHi ~ '.~ GcY~crS.e rim ~ ~~ R _ ~"..~. ~"_ ^ CHECK (~ veNtt A .~ ~ i .: avr A AriorN,c ~ ^ CHECK f/) vEN CiE AS AN rMnorfe a..+iorrvEaA ~ "A . 5 CODES-* D~; s ( °yD~Dx.... CODES' D~:°•• •u~p•, ~o.c.cu ,5; N,°o es ..a.. TS/o.J~S ° s•5RM ~ r ~,,,,, ~ ~ ~F ~!: °°° p ^ ro ^ i5'm. KS ^ v~3. Su'~y°' ^ M, H l Rp F.1c' ^ i6'N( Dp H ^ ~ :~3. ' . H Gq IMKf IDOCG(CH(V.E (yDAgr.NwAl V6rrl(IE Oq dONVI N w • I qv.l MOpEI IOAq ER /980 aT ,f!/cAl .~taiZ E H vAf KuE [~aY.' ~ ~ u EN E rArf fq=An NO sur` H v(H. acR u:ERFRTFia-' I N . -m -~- H ', ~ u~u ~c.uoNrro.~ (i0 SGJ~ C ~ ~. v(n of aNr I r~s~ -.fir ~ ~,,. °' H ,3 7 S/; L N Rf04rFgfDOWNfq' U3i q5r I I ~' r d i mloou IHOM NO snR vmeq~ Wi . a ~ ~ - ~J!o/1FJe( ~~i 77~y w ~ r~g3i MI _ a ADDns3a owiREq / JG'GT~ ~~ f;. ;,ra NAmiA.A~r..G.~'''4'C1J•'O c2.~ -r~i2lvc: F ' _~ R.~ "~~~~"' :~ ~ qEa ~. h~ ~{ ~~~I 4Sid! r~' ~' ~ iris /~o/tT rz„E,~s R •w` ow° en. oe( v.iN oAMAeeDAxu aA(cE r~ ~' ibi'ann~ a es oAm ^,'v:N pgemurvm ^~wii ^gemuNm es~o~w MGE ESm1 r = ' ~ 3 iwv° A ° f ° Lb0 ~ui ori5 °r..S/J.JC~ • 5 ^ ~ w :r er: f DIAGR OF COLLISI N: I E ne.. H . ro~exn NogEn E «rE+~e ~ gROw DESCRIPTION OF COLLISION: IvsESwnemENiu sHttin Neeeswr /f/aL / ~ J~' /p/ - / ~ ~..~/3,lA.+~..+G•pT" !iG/ /. //.lS. . ~/[3. _Cu+.lTr/L.. Rb y- ~~p0 ~ ~ :7- -' ~ i Q ~~iJG2.._ e'_osi: Co„~Ti7Lr ~ >/~C ~ .. ' ~ I /oJ/. real. Gc~% _~/lG _ jl~,~„~ _- ... ~ . U L --___.. -- T. /Tj ~a LE I I. 1 I I I ~ - .. _._. ...__._ __.__._- __._._____.. __. V ., _. .. , _,. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ~ CODES 1 OCCUPANTS/WITNESSES lo: ;co°r oEtu NA,:}i 6 - 7 ~ ., S ~~ NAmE ~` ^ ~J - ... No a~S-JJ1' y • N r SeK ACf ~ i , ~ i MSre fNCr DOen3 / a - AME ~! ..~ N e E er Ame OF4f r pw. ^7360 - •~(Se wfu. a ......_ . mw Drgom pAMe p.°,KE pw. . p „ O.: Y •.r3~.,-warKE.3N.~rfE.nc uou o. wfNC. ~..E!_.. a<I OnlAroac pa ~ ^~Me~p~u pion ^:° c( u.~,.~ „ ~. __ ..~. 1J p id7 ~ F~ 1 ~y h I~. - .. ; ;, - „ ~~ _ } .8.vk ~w~ . k' AEgTR.4„ .y,l ' 9i $ ~P~ 2'~~:RW~e_.°y4,.,,.:9 .,:5:.1. lk".\eM1M"',-"" :•%5 +"p, ~ ~~3p ; STATE ®F WA INGTON ~ f s O W~"'°'""'°°' p~1 .S ' k .rn,~ u '~. „-•^ POLICE TRAFFIC COLLIS ON REPORT ~J TRAFFICWAY tp ~ ICE COMIfMNr rv LLMBFa i r 1111 ~ PRIVATE WAY pAf E Olli H -- ~ I ~~ 187 I'"'°~s.~M....aD..:.~ I I I ms x.mwaual 0135 couNrY couNrr c SE~kSa J mrwx. _ ENWA • ti' c E f , / ^N ^f ^IN h-, 04 TOWN 6N0 0 SrvFFr OV NGNWwY ECf CI lI, , ^W GE ~~ C.~17~~~~ ON rvC°~l~~,PD ^uVeawN Al ROUtEpt 1 pN i iNIF95fCr rvG VntN: Sf¢EEr094pwD NON MERSECriO 3 5 ~,// ~_ ~ / ,~. ~ ~ . BE1WE[N E-iCT RfEt 6 (,J//~`(~N[//~, DisuNCF 60 RE r '~•ffI ON MiIF vOSt q 12 _~ ~~ ,S (b~ < ` RN9 CROSS Sr¢fE OR rvfAVE51 E ~ w/OD M [5 5 f ~~ /~ ACCIDENT R oAGR W T rffr pE CK MILEAGE AM WrA L Pp I NS}~L ~, {^i ~~ I~~~ R ~ CODE <OIUSiONINVOtVFO' fv(R rv. IOrwINO NO LLlF0~~N0. NlURFOy ^SVttUGE ^Nr69UN wrvOnRIM " CF VFN ClfS m ^ RORRIY OAMwGE ONLY ^9ESUlrfO ^SIIXfrv `~ .~ ODRCr St9uC91NAMEOf OB1ICr rQUCt.WOOWMRSNamfl I NREV '9D Cl5 r riNGSREE 09 ROAp OR V[iFRfNCf CROS$$rv FE09 aOwD L F V SL M ESr pIMAOE SMCNI COp NG USE -- - ~~ ~ ~ s ~ 9 ~c~~ ` ~ ~~ UNITNO. I UNITN0.2 ^ VEHICLE Dv - rvERS NwMf: Nsr Iiv MiD DR ERS NAME sr ^ PEDESTRIAN ^ PEDALCVCUST N¢ ~ ~In ~.. I~ ~,. E EZD.eI,Ola~ /}i7ii0,eErr/G~. , '' , , sr¢EErAD9¢fss 9ffr ADDRess _ 1'~q,, . ~F I E , , ~ orr surf u9coDE r ONE rvO. D I S AIE ¢ ~" ~ ~ ~' - ORNF¢SI C Frv Y N O . d UC[N NO. ~ ~ [ / ~ Lf.r C~ _"~~1~/ ~SSI 2U~ .~/ ~ I ~r ~ V Atf OE (1RMR ~ ~ aE ~ ,~+d E' J a dE f 6 Rfprvf EYES iGNI fEiONr E OCCURAtiON fi9M NMAf a aNONE NO. I z /~OL!@E' ¢ ~/TGj OJ~f 1. 7DGV.l.2~' ~ R Ins cNr fa GNf I ~~' . I ~ ~ ~' F r. ~ ~~ . ^ CHECK (.~ vM if wsiN urRV r CHECK CODES-* D ~ "' ^"5rf a+olD.c.n_ ^ ('~ eN of ,s AN EM ~ `:in: ~ F.c~r aN .nN CODFS - * 1 n+iirv . z , v a Nor"ERwI °p+~ , ~:. N °"~ ° Ixi 5 fx " E s H~rKYCN K .~, ~ ~ ~'' ~lI '~~ ~ b" ^ .NeM ^ ism. ^ K.KR ^ ;.°~,. ;: ^ M.n„A f ^ zsNrR ^ °°.a,I ^ :~~. ' MA9E1 C" I MOOfIIDUfr.NOVAI SrvlE 9 CONV.I V wMfA'p I • n 78 " G ~ M CYyl~n -~ ~ L( E OOEllOw9 nOVAf I Yf ~ r ~ ~~ • ~ ~ . ~ v " l' M surf ¢w xa ~ ~ ~ ~ '~ IER MIF NO. SrwtE H nN.caoR ~ ' ~ ~`: INKIE IDEMiNGiKRR Np. i vlNKlf~gNr ~ Ai rfN 3T"Kfei ~i8~sz,o~Bl~r,ol I I I ~ A~,~,,~ r ~~ :~~~ ~.' - RlGISrF9ID OWNER: Sr ~ - , . _ ' ~LQ2/DIES iQr/D2e T~• ~.- Ix wppnss aroWaeR ! ~, Nwme a.po9e~o~f /~NwRAweeo ca ACENr - e~ R' - D.MAUOwa 4 cNARu L ~C• 'r AGe Rl,.n s lS ro ~ S~ ioWwfD ar .u. DI AGRAM F COL O LIS IO N Iivuiv rvfU / ' L e , • ~ I I i ~ - VCCUHANTS /WITNESSES ~. N.Me ,U/E~ .. i~~_ ~ -~ _ AooRns (Tl T ~. ~-Q/x !9~/~ N,ME -r--- AOEVESS 7 G'..7 II-Isla ~ G ~ ~ . ~ ri?~.~f ..~ ~ t ~.,C i R~ ,~a ~ 4~~, 't~ 9R,,D[~~~pll ' .: - .-_ fM. _ ISt _.. ... .. .. .... ........_ ,_. -.._.... . NAry fOf . _-.. ... ___.~__. / 'oKr ^, ~ . ~~~~}}SS.yy,yy V ~ 'BV'fll ~ µgp} ~ ~~~~~~111111SSSSSSFFFFFF t'. X Wv1lrp,r.NOp.KI. SN,wfa.,N. aADGEW ~/y C/ KA.Kr YU,~ r IXOI -'(MG rfc/J a 1 OI~~D Ma ^ O.rl/p/E~~~q//p ~ , ~'"'YYY~T~~ ^t0 rn :Iw ^r~i~iv, ~ ...ROvfD D,r( ',~ 'V+ .. ~ i x.oo x.rp / ~/ 3 ~ ~4. h I o xl ,,gip , ~~ U ~ 1 A pibli~ J^v1Y .~ ~ r k~~r' `~" ., . ~.~ ,,,~, ' ' 4".. '~~ BR'S ~ G' U v J I (jl 14, ,`~r s 'rat '~ a ,,, `si ' ' ~~" ~ L l ' ' y1 fly,. w 7, ,~ 'i Av;. (_ .•~,.'~~ v 5 by f T ~ L ~ ~~': ,~ ~>„ 2 n ~ss f~ P t 1, -,_ ~~ ~ FI Y ~ ~ .n. M1 .~~ :~ 4 1 ~ ~v.' ~ ~ ~~ ( ~~ n urs K T k ~,r ~ . '11Mr,s ~-0'~ t r, F •~ 6~`A- W y~~': EY{~`r I , _ .. J 3 ~~ 9~A ~ 1` F~ ''~ .4 ~JM t Ir,.. ~~ .r` '~ 1 ~ ': x ~1 ~ i i~ I~~ ~ ~ P - {i r ~, r 1 ~ ~ ~ 'L. r ~. f~ ~~ _ x I ( - ~ _ _ n, 13 i Ir Ir, _. ~. ~ .. .;*, ~ _ ~'~,I ~t ~ ~ I ..i ~«,aa ..._..... I ~ PRIVATE WAV iol cf cD.MnA mwuMew •- ~- _ ~ I D,IF iG ll N IMF ~ i. ~( ~ fur. • ; ~.: . ur Ip3[].p0'.] I I COUNrv ~~j+[~ ~ ~\ ~rY."~-r~~l.C'N <WNlY NO CItY NO. /G w A ^ HRa.f eu E QQ ~E ~N CNY09 rOwN F6 N005r9fft09 ~OHw,v •C„7 M«s Os ^'" ^oi ON NAM rR CIS I gWtl O451Rff ~ `~~/.S~O ` Nf95ECtINO wIrH SreEfrOVgp,D NONINI[v3ECtION ~ '~1 •- NY~4u«1~A- SrRFF]{"L~~Yy~R EH% E. MLLf PO31 1~;i9 6 DSIANCE 60 MN NrPOM VE[FVf f.C9µ 5'v3r9ffr09 NFARfS1M lFW ACCIDEN( ,ij lFS N 3 [ / T rfft Of L,~'1']'LE u~LQI,~JE~, MILEAGE D My p1AO9AM MIA COLIISpN NVIXVED FVfR rr- Fq vll[D_NO. NIURIO~ ^SV ILAOF ^HIt6 vUN rOIAI NO Cq VEH Cl45 Q F Sta ui i,~ wN9wet. N % IMfR U r9 t r9ffr 9e0AD0R RifRFHCE C903331REFi OV eOAp ^eIID Egrv OAMAGfOMV ^g3ulrED ^ CIE v/L OBIfCf 3lvUC[INAMF OE OBI[Cr 319UCIt,N00WN[9'S NwFI FSf -' .~ %GF SPECUI COO NG Ibf UNITNO. I DR V[RSrvAM[ , St UNIT N0.7 VEHICLE ^ PEDESTRIAN ^ PEDALCVCLIST ~' : IA Hear MIODI q vii ~ }-HtiV Tc~h~tJ.U~=. 'vvt . D91v[v'S N.wf: St ~~~L$iT• (.~~2 LC -- IvffIA009f53 3 t9fft ADDRESS G~ 1375' CE~vrFx-~'n, zz3 i33 ~--:r~,u~l CI r S]wlE lIRCOCf ONE NO. D I Y 3rw1f ~/1'~ Z ORrvfe3 ucfNSf NO ~ ,Q p 3 2 ~-7! ~,•~ ~u~"' • '`/uR I-}~!-NSX/1 SZL Sr,IE k~ f 1 I~ I ~•r ~ "g I V A; IKFN NO. f Sf% DA OrB 9EN GeOS3/d ~tr~A- ~ 2z1 1.• ! occy!ArIaN rlRry~yf {E `R ,DN~NO. I frcs ur i. cH] G ~[l/'rJ0 L/C• _ A r M A E R occuR,EnoN /~~ rgNf NO. FYFS w4 cHr rcM' ,~L~ rlgEa'.~L.41 7~ ~ CHECK (.~ v[c"EAS:NDffrt v .. ior ` CODES -' ~ ~ ^"" ( u is S l , w a f' ° ^ « ,Ir ~CMECK (/) vFHCi[AS.NrMnovEEaE.NOrHfq~ .cu COD * ^ ' ° ~~ Z f , vs ~M 4c'ds ~ u H~ ~ ES - 7 ~ 5 NlrnpN a , , "' , " ~n ro .N ro rn vus e o, , ~flm e. RO .Ml9n. l ^ uKI ^i~inR ^ vwKe ^ "u:.v • w'"O„e7prw,. ~u,m.Nn ~ e.°.'u ^ e"SrnR ^u.~.v Ct I I MA fI CHFVI MOpflI0A9l nOVAI Stvlf l]Oe~CONV I H 1.3 ~ U~ Via E l ,] HrF 1 IOAgt.NOVAI ~r lQ,s~i% c?~v ° '~L" / z . H . AIE t<En3E nwiF vAlll9 nArf NO StArf Sr FI vF 09 , 1 ;~ . I ~ I l A ~ G ' C ~~~~ "~ L(/ VtHKIf IOFM NU]ION NO. VU I .B 31 I l1310~6~38i I I I RFOISRgfD Ow+vf9 y5i x1951 MlpOll npN[ND ` vFHKfEI rli Al i Imo" I i 5"; I I I rtRE ONNf9 I Ls O : lA)i Ngst MIDp Z DDeessa ow+EeR W A fq E I E AMfF.DD9fss or INSURANCE co. aR ACENr D,MAOE MIA ' ' ' CH,IC1 <HARGf _ C HOED ARG fo i3r. Gw,G1 OY p :ov~t p gIMUNID. owlD ~ ^ wW ^q[M,IMD iv E [S°C iM,GI ~ ~ _ • 3 beorrofr f 0 eY. iw~rper • „~ f e Id q DI GR OF COL4510N~ yle lu Hec S.uil - er:ovpw rH DES C R IP TI NOF COLLISION: Ilne neMENrAI SEgnn MClsugrl °~"~ r QG!/LO -d r ,P ~ A ~ ~ ~ (/ ~b`CQ. L 6 ~`(- ~.O.~Tff.~rLG~O ~ ~/L(/CC~d..~ . rr rifi F p~~_, r~x ~ aa ~p D ~~-~~ ~"'c.+: ~~j~ A R h~ ~ C , , ,, - , ~. /r[~ ~ ~ ._. ~~ -,r ~T ~'' ` ~ U~~nt~~2 = e 6s~~~9c~zer/ [.~'a~/;~s - - ' z _ y ~ ~ ~._ ~'A- ~ ~' ~ , .. . i~L//~j ~fIL C~s!! / e~ ~ ~ i ~,_ : r r- . - / .r T ~ dtj ~l. -Q!llLIEZ _ z 1 ' ~~34,rPiJD.~ifer~7D,JlPI/. _ ._ _ , ( ~ 1 .. ~ r ._ . . ,r rot! L~.CitCS~A~.4e/K .U:C~eet.HO ~:uE II r NAME, ADDRESS 8 INJURIES OF PERSONS IN L OCCUPANTS/WITNESSES liE~,SID~D^~o.ti:iH,we ' ilr su ~ilc~ ieius t '"~" °? ;'- nsn ~ei cr r :6 OG E. _ .. N: .o ,n, N. rl~Rf or .. ~ i e. M e ^ES1' O "' .O~ ^ :. NI. .. _. •~q13, „ r . .._ - N,tt~Rl Or Y • tiMV^O r.OM I]AMe ~MKf ~ ~I • 0 w ^lii • ~n + NV .0 K] DMI,' ' • NAU~RI SOr ' IM 1r ^,a.cr ^id~v ^ ^AMI .i ^ r~0 .N,. r I+.O OI,~I+)NAMI, R,Nr „DOE O. ,OEl,fr ~ • OE D 3 CHD PplCi ,vR VID D,rl r [1 ,r.,OV10 er moo', .T[E ~~~~ ID NG~ ~u ~;,~~~ q7.~- !,~5~ i ~ ff ~ i DArI z E fE1fl*~:~. ~ '.t:!tc ' t,[ ~E.:t t c ,}r x~::• ~~~ ~ k„ I - y U N ' ; I~ E I I w6 A lye. ~ I g fl { ~d . , T!'" ;fit ...... ~~ ~ ~~ 7 . -•~ ~~{+ F~ _ - - Y. ~1 .~^YS~.~ xr ~ ~ ~ , ~ ~ STATE OF WAcHINGTON ~ ~ W " ""'~°°' • nt]hL~ POLICEiRAFFICCO ON REPORT E_;JiRAEFICWgv O ~ ~ I ' M L L 6 [I 3 ~~ -~ ~ PRIVATE WAV "E.3 ' " r - , • - r IMe ., , ~ 1' I a:l I u7~w.s.,. w. (US[tWeNOURI I eou t ~/~~~~.',.. ~,,5 N~sLCn.~(i~ .}.r ~ r '"`" ~ ^r ' erroR FOwN ^ ^e ~' N•mEa NO.O S ttl Oa MGNWAY ROU1E W Z ~ 7yau ^ s w o Zl(•fJCP ON -~iPA,/JAQq~E . I I4stcr NC SmiN: sra loR 4o•D NDN INr[aucl o Rt!•N ~ . .~~ rx N ~` ~ ~ J/5~~ RR[ if PoSl II1 s AN f a etrvrtw zra[Fr a M6RFF +''~.. J 'C9 OSSSI4F NFA4ESrM1 A C M{(51 m 5 N ~_ ~ , - 3 IY - F CCIDENT 0 AN 1 l l ~.tiEl NFl O( MILEAGE COU SgNINVOIVtD f fRrY ~ CODE :~ -' '~~ ~' ~~ ~ '?~t>7 "C ' rOiAl NO O R tt[O~~Np. INIURtD~ ^ Sr IIAG[ ^ N 16 RUN rN D Cr VFN CIti ~ RPo ~ INKR Cn '~- F CRO555' 40Ap gtrF rR(t t pp `Si A . KRIYOAMAGF ONLY ^RStUII[D ^vtaClE OeltCl l,aU[a1NINt Cr OBlt rSraUC[µDOWNFRS NAm ~•- - ^ tI H~~ F5, 04nAG[ SKCW DING ySF ~/ s - _~ ~ alvi4'S N.w,t UNIT NO. I U NIT NO, Z wr 's NM•s. ^ VEHICLE ^ PEDESTRIAN NSr ^ PEDALCYCl15T a. - ~` ~.• ~ ^ ~ D~ S1aFFI ADDaf1 ~ J / t1 r # , ,c~. - ~ D ADDafu °Z Y `Y" ~~ a il. oa .NON No ~ -1~~° I i /y A1F -7 r• jf _. J3~ 1 Nt.~~ . ~ ,, / .232~~1j ~/~ i ll FN /h %~ "dd~ ~ A ~ A D. Y _ P R oc y~~ naM NAm`} ~t~ ns cNr .elcNr E cur..loN J Q /J /S U~._ m NµE a rNONE NO A rTE~TMVI ~~ R L I I ens IeNr salerlr ~ ^ CHECK (.~ nN V : ~ r ti t (A CODES-~ ]~,."s'S' N ^CMECK (/J vfNltt(ASAN 5 a i in 1 cr I _ A s t D ~ D~o.cc CODES - * ] ~ 5 ,Nri v ~ f A " r ~ A S tltcrroN a 5.yn ' n - a, ~~. w ^ •m,~,.Nn ^ ~~« rl R mASt .GNIV.I °~e^WV, vr5x[ T ^ia°.VS ~ r•Rrpv ^AVNn. ( 7 ~ ~m " ' Y ,~< ~b`mr ^W:KU ^i°.~ ~ ' 4 - I ~ E AA ~~~ ~ 5 "N' 1 ~,. q IDA vAI N I "°" ~ S,Art ry-11R K,rF NG Sr.{ H YtN ~7 /E ~ lam,'/~'E" ~ ..>~ k ~ • , nNrs arnn¢A1roN NO C Y ,...t. ~J 5 IaN M A I N D.C~ ~ ,~ ~/ ~ NI ~ ~ ~ g~a p~ /' .h t~LTe .~ t~~i~" h t ~ { se Rt SK4100WN W 3 Mi t ~Q'' J, ~ I I I ~ ~ I I rNON[NO p usr I rwsl I ~ r.N .,r<d~ ~ ''«4nsr ~ sf flM a Aawess a o•mfR If .V, ~ ~ RI :l~fAU <rl ~a .~k.v.. , . ~. `~!'L'/K~ N o Awe.yQwfs}aINSUUNCFCO aAGINI E ;. .~ ~Ir K. R r?~ wM.ct u ~ :~R ~~ ~~ Dl~..w. CNAaW ._, ^PUAINC N....r~ .... 'Pf~>~~ - ..~ s 1O„Der. RAMO COLLISION: N r cA NOa1N ~, ,s ~ _. a,utr HicuwYt_ ', ~rAIRGw, DESCR `-^-----~_ ~ t~ I I I`~~ _ ~~ ;1 ~ - .~ __. •4fn?.y ~ ~`~ ~/?n(~IY/rl'S Tv E~ ~ ~ w•r e ~ = f N COlLI510N: lust 5wruruNru sNter r weeuARYI • F "` ". rY..r•IO,..watwaeew~URIE50FPERSONSINVOLVED +C 1. NON ~ CICCUPANTS/WITNESSES ial:oo,roM,llNr sNt(Si _~ODEc _ ~ ~ ~ ..s- E ~ -`~ ~ rF r _~ '~' ( w, s,Y~.o ~ zs32 .cans N•1 or t } rI ~`r~. ~' ' 'e a , J _ 1 r A ,Mt ~4' / N ~ 7.(/ e. .MR ~ ^~ K: K44~ n• Aµ 115 •ryr M ......_. .. ~.. ~ v ' 4 .~ N , Y ivOVID 1• ^1MS ^,u Kl ^~v~r. f ^ Y~w ^rio~ No p b 1 ~ F {lF M . ry{ NESS ~ 'Y _ ~~R( A~'w5•tSILA~+NG p,fK1F5NAM1a1AN, 1•DGIa AGI•%. N•NISOr PCI „r(MO INtlr ^•Ma ^9KI ^eaD i~: ^iiwv D. DNO p • ~ ~~~ ,~'`~ . / qa IWr •r.rovsOS , 3 6/¢ ~0 l D.u ( y 1 I 1 '. .' u +-vts r i N' ~ ~~r ~li ...':'LYS.-' ~~'r ,~+ `rn „n 'SD ~N I ,, 1r ~ , U 1 1,' f ~ ~ ~ rxt(pl R rit t } 1S ~-, ,~~ 1.'.,~ I lie : i ~ ,', v 1 ~i , i `~ , :~ ~~ ~ . I T.ld ( - '.~ f- ~~ ,,. - ~~ '. G~ „ q ~' ) ~~ k _ Y" L~ ~~ ' ~~I ~ ~. >~ P ~~~ ~;~: . ~77 SK% Ft ~ ~~~r~Pa n POLICE TRAFFIC COINREPORT L(J TRAFFlCwgv ,~ R , PRIVATE WAV ~ _ ~ -(~tj ~ -06 P~ t r oiu Fu o - - y~. ~, I,I4 ~ we IOtg01bUR1 l eouHrr 1~~ GI ND ;_ MVA D 1 Tt V ~I ~~ S J,V , . ^N ^t ~iN Orr Oq 10WN NAMF INO.pSrgfti ORNGNWA M,lt3 ^e ^W ^GI ~ oN Tyr ~L s ~ 93~Sd ,vIf45FC1iNG W1rH 11Rf[IOR gOAO NONiNrIRSECnON --- .~y1 .,y/ a[rwe[N ' p SIY([f a ~ ` •, SfYFE il[I~Si Oi1µCt ,Rf I CROSiily[ N[AgfSrMilf 1 Mn[s m i t W ACCIDENT MIP ~ ,'. J. /.TN Sf / OQ nn p MCODE E ' ~ eouisGN nvpvtD' vev -r: lOrM NO NO R¢llD~Iq.INJUR[0~ ^YRIAG! ^Nra FUN wN'wioi" s D IMta Cli r q ,Vplq~gf~ pOSSSR[ ORpM vJ pveNKUS 0 ®IRp4gn DAMACf oNlr ^ wiulnD ^vi°cif 72 .~ ~ y.~ oencrsrvuca lNwufpoorzcr srvucc AND OwNfvs NAmfl lr~{ -- lsr.DAmACf sn<us coonJD llif :. .. . f r PG.a.v QcLt: {l.•[. T 0.+-t'R l.wc7l~Jt:, ~P E 1SCl~ ~ . UNIT NO.1 UNIT NO.t ^VEHICLE ^PEDESTRIAN ^PEDALCVCIIiT ~' DvrvtRS NAMt. Lli, i9 t Mi t gvEgSNAME. IASr i i D GL I} S1Rtt1 ADDg I// lRtfr ADDgf 15 +n :n<oa .rroNe no r D • t r Z_ ~~ ~ R j rvf es ucwsfN G t.tC R 1~1 (r3S-2 l.-T surf a ~ ~ 30 1 S' V ~ u n Ae R ei H l I oeeu.Anon eangne NO. ens eNr HfgHr E occwArion mNAmta vrgNt NO. ens IeM KHrt - Z V,tJI''MP o 4 IS3' ADD R . ^ CHECK (/) 'v[N af. Anor"fv l ' ^ CHECK (.~ vl MCIF AS AN iMMOVf[pA rM0 ~p. T ..1 CODEE -' 7 c . ~ ,r< °.in s l 1w, ~ e ,M°, - CODES - * D ~ ss' a ssnM"' s uc N e ,mO, °'° ° p ~ Z , ~ ~~LFo ~ ~ ~.Dr, ~ I: wN o ~ L ^ ~bal M r~ My;,.D.. ^.. r ^ ~ ~°' ^ t"b" r. a „ ^ :'eM. [U se 1DODGt.CHev.1 ~ ~ (o T'7 ntDARt-rgvA) st [1]DR I C-LFL a J 2. E r • 1 vl Maofl lD AI t 6 sun nAnu nAle NO sun H nn slL-J GSCr zg l.r~ - - I MCII IDtMINCArgNEq. rti ~ 2'tf a3'S ~'Z i i ~ i vtN nlDfvr I i I I I . 1 i I I' I I RlGlsn R[D DWM1 l/St NRir MipOl[ hgMtJO UR~vt,=s Pa.~~ ~ "' O wNfq~. Wr I151 ~ ADDRtis p CWmlq Ise-i'7 -7q''"s~ Arc +-~A,vr ~l tr•.u lam e tq ~ . - AMfaADwfssa wwRANCt co ov ACwr N~ R i >z DAMAGt MfA o o ~C ~ AWAWDMu " 1 "v pWA4 CNARGt G 7~D AMY DNARGf 0 roNN g ISr G1 ^ W':Y ^RtmAIMD ^,DSW."tSY ^REM4N[D l31' AM~f ITD. 1Eiortn: f ~Z5" rovrtoen. ti<11.(_- G ~ ^ rovrtD Aw •r ev, f { DIAGRAM OF COILIEION ~+ usiAil I ~eAr~~rN I DESCRIPTION OF COIIISION lust surntASeMAI SNt[ruMpssAtrl .. . ....._ . _ - . _. _ _ _ _:. _ ~ I 1 '. ~ .i ~ ~ :_ ~. ~ ~ I . 4 ~u I ~ I - V(Lt{L[.L({ w~SS~S+-wD _GJ. ~2orJ0AY(f_S.D H ~, _ - nD~sEr i I ' 6 ; La .~20,+~ rtif3N~f2_ y -4A+ 1 E - - ' _ ~. -~7- ~ _ _ ~ ~ ; l~' E r~ ~ R"~c.K CJ _ ~ _. A ~ 5 _-Qll LJ•N-'r fi;al-e ,~ PuJ~.~:0. ~L.~ $ .5~~rlpa _ K~ ----- ~f -... _ I-.1' i - .._._ _. _. _.. __~- _- _____. 4„VI rt~ ' _- r i -DSIw R L-ltF'.. s t~LSalr. Al.+a c-Nl-c.ct7 f41: >F~ C~ Sl_I }.NP :__. ~ .~._~ . R Mot N,w -- ~ --- ~---. _. ^_ R , NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED ' CODES 1 - Z J ~ S 6 OCCUPANTS /WITNESSES llp:no~rtJ~ltu r~lAiN ii _ u. Act uru ' vr. u.1 "., ' W nsn ten :'°;. N•w .. .. .. . r •Datss ~ °^O' , AMe ^RIN' ^ ~ M' . Ns. ^Ci ^lu .ml w' •DDRUS rut p ~ . . mo ~rD r.om ua .ocl rn H ,mt r , q . DDass , .~~tis°f ~ ut"t S. ^.ma p ~„lal ^iD:Ht ^~7 ^I:O1NS. wrlftp.~NGplKIq IANA•11 q•,.• I A. u saya I Ali' •DG O. Jt~b ADI~K• w5~' l„1"~~' OKI O~Sr•ICMD °; ~ IQKI •IIiND °~O2 OArIp nRWr 8•csfiT Dar A~F~I} DAII c~ y . . > ., .D tc. Q ~~, '~ ~ ~l s C ` y ~ ~~ .M1 . ~~. ~~ i ,E ' 0. ` ~ ~ c, I ' ., szd~ ' , ;~ ~4' [ ',J ,. J + ~'~~~ I', 1 ~. r~~ a ~~N ;S I Tny. r. ~.~ POIICETRAFFICCOEU'SIONREPORT L~'TS[APfICWAr '°'~`"~- -- __.. 1 ~ A[IVATE WAV (~ _~ ~ ~,1~ r li ~ COVN Y 21+ 87 ~ Ira Xl.' - - -. 'ui' (Nk].DOrgyq ~D ~~~ ~ X0250 Jefferson . pN pl DIN cr.oa wN Nw»ea NO arsmn N Ar W •95 wles DS W Ocor Ha~lock~ ON Irondale Road iN FakCilND 3v~lw: Sra O lOwO NDN iMIIk°rKN DIrW,lN Montgomery Sr,llr, Fitchburg sranr ' ' wN ' ~~~ 6 ~ .Ca 5 a ACCIDENT 375 ~~° N 3 [ W a Mont omerY McoD~EE aA~ ,.~~;_~. ~: *, - '~ ~~-' N ~ v ° . •. ' caucKNINVDSnD faM: r°iµ r10 r10 Rllll ND.INIUa[D~ DY'lL3G! ONRaee1UN NMOi'Dn, tey~ Or vFNlfl[S ® p r ~ ]] _, AD[OMV ^ hsulRD ^VI[II • ~. Oa1lCr SrauC[ INAM! Or Dall°r SraUC[ H1D Ovmfa'3 Nun[I ::g [Sr. DwMA4f Power Guy Pole/Puget Power ~ s 900.00 '" .~,~ ""~y~ '. • ' UNIT NO I~ ~ :.; ~'•t . ~ T I AN. i N~ s. `_ ALLEN Curtis Eu ene . sneerwlron .; { - _. a 5a0 Irondale Road . ~ I-" 2 !»C Dt ngrlF rb Y . Hadlock, WA 98339 - _ N DN. ~ ALLENCE3980T WA M 03 ' 30 61 ~ • oe<urw°p. r.a»NA»lar"oN[rlo. ens Ie»r KpNr E NarnN a I~r K~ ~ 2 Cook uilcene Lo ers Land BR 17 601 +?~ ^ CMECK (r( w •N ~ ~r N r ~ w ^ CHE r[~ nf w CODES - • 7 ~ •,•• . ^l~ '"' B S e "'O 3 rto CODES - 7 n a i 0 s.w ~ ~) ' 2 .N, .IS Head a Inte p,.o I w` » rns <~ 7 O ..,A,,.ul ^ t w !wa K wN lIDDDD<~Cnv.l ~ O iSm ®^'..rt O :.,,, 10 wl 3r3l ItD ~ Dv l ;~7:' O,» .,[, p •q' ^ ~m ^ r „ ^ 1986 Honda . CMC MC E N v.l ll AI spw ;. 5 N s. wpr] Rwn N0 S w H N txlf - B1ue 440302 WA I ~ V[NKll ip[NT[KwrKNrq J H 2 M C 1 3 0 6 G K 1 0 8 0 1 1 ncnrtn°ovmla wr Nak MiDDtf N ~ v f "~ ~ NCI Same .orrt ND O ~ wN wr rlnr I ADDae33 ar ovmea W 2 " N E 1 Nw»[awo°amomwawrKe e° wwelNr _ " O.w.AD Nlw n•.~.D ' R ` ,`ryie„W CNUW CNwaD[ ~ uCFr . a 1°r 3 .C~OnOii 1 l3r MM.DI ^wD~~viN ^,IAWMD IIHN a[MA'N[D ^ AWw ^ [% ~ _ { 20G0. '°Y"°,Y Bi 11 S Towi n Y i°"'!°,r: i _ DIAGRAM OF COll1510N: ~~[rY N1C11~ N~cwr ~r" DESCRIVTION OF COlLI510N: lus[SVnlrNM.4 Ylnn MQSLUrI N35 awaiting blood test. - ~ reo.l[>,.ct ran Vehicle N1 westbound at high rate of speed ' A , exited roadway to the left striking a power support pole. ~ _ NAME, ADDRESS 6 INJURIES Of PERSONS INVOLVED 'COD 3 1 - p ~ S d - N OCCUPANTS/WITNESSES iuk sur^°"lNr.3 sr as .DpuoNU Nww .w alr s~ fi u. ee uru D'; nua un "c' .. w . DD.ns rua a A M N wa131 rya fY • pA»a p.acl p,»... ^ h« [] n~:r .° fir. ' ' . Don ..vw uwca 3 ! •N. [ o• wcl•.v ..wk !3° r wr • O.»s p-_1,Kr O '.. O H. 0.::~,. X ~ .¢-lo rq DSiaDa Kl D~s mover P. Suo AnG WSP B/3 0318„ Kl ua ND ownornroa •. ! D 0405 , „ „ ~7~29 ~" :~ Y r M ~ ti 1 ,.~ I^a ~~ ~~ n a ~ Ar~~ ~. "S J w ~~ ~' , k ~r ~~ R 8~j,'; . ~ ~` _ ~ F ~r ..,. SiA~tvrwJaShINGTON ~ ~ 4 PACE a r~ 7 No ~ ~ ®TRAFFICWAY F POLICE TRAFFIC COLLI " . IY r" ~ REPORT • • PRIVATE WAY POIICEC NUMB@ •,•, ~ D•fOi <Olll N A ~• • w.. I Ir 0., Ll tlMt Ill;[~.DD NOU91 rL CW _ ~~V~'~ vcTTJJCC//~~ < NfY CttNO. iMWA pU9BAN RAI ~N pF pIN ~~ C"IIYORtOWN fAN0059Rt[t Oa NONw•v •.SMUS ps ^w or C/7T••OCpO~ ON ~o//OAL~'~. Cl5 x Wit OR SI StCI ( ~'f'33SU NI195EL5 NO PAIN Sf9ftl Oa NONlN1ER5tLj~N: Rv ~E B!M'ElN •N~/ Siat[I l ~N,r~~~f9(tt [IIX [O. MIIf POSE I ~2 1 .J/ ' 6 DISIxN/CtaD9 l ROHR [R055519[[1 [[tAR/I~St Mlttp ~~ AC<IDENI 16 [t13 N 5R "t w W !/?hK .G~J~SJ _l! MILEAGE ODE MP DN RXm WtA a ~c COMISgN NVOIVED Ev[a ir~ NO ntIt0~N0 NIU9ED~ YRIAOF ^Nlt6RUN Ot•l N0 m wNDnD++s IN a K RtFi a9DADOR aEEFRFNCf 1M10 Cl3 CRO553IP t R AO RI tivtNlCllS .l--I p •vOPFRfv DAMAOF DNIY ^ HSUIrlD ^ vlpClf `~ 8 OBIT![H151RUC[INNnt OiOBI[Cf slsl9U~Ct [~NVD/QJ~Nt9SNAM[I /~ //"~ /t,,' ~5 Fsl O•MAO[ SPECIAL CODING USf 5 UNIT NO. I D9nW5 NAml DD f UNI1N0. ~ ^ VEHICLE ^ PEDESTRIAN p PEDALCYClIST ~S I DR VtRSN•M<. Ms( 5i4tt1 ADD9lss ~ ~ ~/~ to ADDatSS r ~t f f~AAl1-l~0~ ~/~, ~~39 38~-~7 R StA t I wta5l C[NSF N SfAI[ t,ll T/ A I N /Z /2 I ll Nsf NO. At •f 6 N • ;~ oeeurA9 oN • PNoNe No. s GNI t(X;N9 ~!/%fT.f' N ~~f7/!'J/'Q-llL1/17 - (QQ 5"~ E R oceuR•f oN m NAmI a PNONt No. ms wT wl tclcnf L °Z ^ CHECK (.~ nNltt A iN u•n° •volntR'Al CODES -N ~ ~. s l e's",° p CHECK (~ i•sAN DmP N CODES P N 7 u AS lX p s"'O• ° N wts P r ~ 9 ~ TD,ro„ p ..,.,„.«<1 pro, . ^ pknlr w~KB ..;5. iI nN Vtw mnxl CN M t , O M Mx ~~~'•O p ~ •" ~81a• p °.,° ^ C.9L,. 11 r ~ ~ ooftlDA9t.NOVX1 l ty l Slrl[IR ONV I B ~ ~ n t '1 1 vwl Y 1 v t 'r°•^ ~ J v P eN 9 ~~ ssAln t9Allf9 NMENO ssAle ~~, -- H ~ nn a l l . HNICII IDtNIi LXNON NO. ABfl~I63o•fN IQg I27 Rtcrsn9foowNfo- usl ` if MNtIN .I vt a loon rNONt NO ~~4-L~IfI.C1~S O W 9t rssf lD vmta, lASI n9st mloaf u2 ADD9tssa owxlR . 5 o NER Off. ~ / / ~ . 7drau - r "f NAmt uD us a INSURANCt co 09 Acl I I + u • i N s9 OwA•OID MIA aS.M~ND 15' b~.:o~:; <N,Rw g•MX«S <~XOGt• owl op u _ [ l19 OAMAOI ~ Awlwv alMUNlD ~~ IOMD RS.~~ t ,o I~AWw9V pREMAINtD 131. DAmAOf t fOwtO IC ~OViOii S ^ •r en. S R DIAGRAM Of CO ON: Nsl surnt.t"~ NDIC ~S D91N snenaNtetss n ow t DESCRIPTION OF COLLISION: IuseswrumtNUlss[nl. Neeess+ar 1 - i2zss~,voaCe-- 7/~-rl/04El+~L /- zu~~ur0 ov.zPou.~t~._' ~Qt. ~/ ~"yiLE2~ 7v it'L~for~.~r~.Lr~r-lkaur ~~~jj~~ d'O Sl/.~CYC-~J YYl/I,CeI'~SC' ~oAl77yl(/.!! ^/~ s '^LJ~ ~I ~ eCE~.C/~¢119i91iF~rl/pC E1~CiC'~ ' / D ~ ~5 ~. '"' ~.. ~ ~i~~~~/.e 5-a ~- A6.~ /.v 7r/~x G~rr~J~S+'•f~~ ~fre%C .(~1vlJk:/.!/G-~}'A/~L.U/ r ~ ~~ ~CCc-~. ~ 3S'nlaH-~c~rl ~.rrii/4' NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES I - 2 3 ~ S 6 " OCCUPANTS/WITNESSES is i~D no•+r:iNEsM~i ~mf ii ux •m utus '4Y1" °• ;l nsl+ fxr<t ;;D; Qi LG E .00 H ND L. 3 ~J •3.38 . » DD.t53 S' ~ CJlIy 'CldOC/~N ~D.tDE w R ~/E A • Datss ~O 1!.' ,D Ll • a . MosDnom p•ME p'[O1't p^ . O » ^ :° b No . DPas+ -ntsl."•'nJ<XI{I.5rgM11 ••Nr . ' ' .w js°' " s rNt e+ p•M. ^~. °1u pilwn. p ::'ns. " X 7zs; J.l.-16.F«^s~ii , G C QT IM,, ~~-Gf' "pl.~='' IX41DH•RML 9.Df.•S rP¢ ° a~oi p.N p9 qn 6/ / ...POVIDE, D.It I :4'g R .~ o ~ p a~ hi T .~ a> +~" •~ ', y~ • ~S~~j u a', S w a r ~ • ~il~:, ~ L ~~M ~-; , .. ;. s i r. ~ k ~. ~ ~~~~ '. ,r ,~ 4.i fd E t~ . .'~ ~ v ,} STATE OF WA5ii GTON AGl l of l ® No. ;? ~? ?_ S 9 ~ TRAFFlCWAV POLICE TRAFFIC COLLIS EPORT 4oueeeom uMxa , I ~y ~ PRIVATE WRY '~ ~ - ~ ~_. D•n c u s N N rwn . r. i. r>•i~ r v ' '4. aD I IiMf 1~t]WO NO URI COUN ~~~ i±n -~ /~JIV Q ~NIY NO. / / ~ CIrY NO ,. ~ HwA U BAN ^ ~ d.M'', ~ ~ ^ N II y " 7 ll V . l ~/~ U4At I fir; ~ N f ^ I~ rv O4 iOwN N0013r4ff104 HIGH WAY • SMlts ^ s ^ ^Or ftf1,O LodeF: ON -7~'O/JDALF~D. Cl5 ~ 4Wrf 04 t [ -~ ~~ xCN ~ ' iNrfexCrlNG VnrH: SflFa Oa ROAD NON Mrt4xCr1 N Yt /~'~ SfrWflN 4v 5rR[[i{ ~~!" ~Siaf[I P iDt' t Miff WSi ~1 ~ ~S AN f i ON aff N E.CROSS SIVfFI Nl•afSr Milt 5 Mxts 5 E ~/~ .6 rf[t Dr D,fK,~aQ /`~~• ACCIDENT MILEAGE CODE RAM 4AM DATA '~+: coun~oN NVavfD slvtR rr. HnAeuN rOr•l NO OalltD~NO. NlU4ED~ ^SVLLIAG[ ^ Muses IN I Mt0 l5 C Nr ax rl al aROAOOa ¢ffefNCe ROS55fl[frOaapAp {RS ~tiS dvfH~C1f5 m ^ 440H:Rir OAMAG[ONIY ^ v[SUIr[D ^bt°ElF ~ O ~ ~~' 8 OBIICr Sr4UC41NMAf Oi OBI[Cr SraUCR AN00 NfRSN/U.FI [Sr DAM•O[ ~e~ - Ga .C~uool~.s/ : -s- SRCW COD NG VSf ' UNIT NO. 1 UNIT N0.2 ^ VEHICLE ^ PEDESTRIAN ^ PEOAECVCl13T a• s l' D4 vw's.umn sr n v ~1 1 i7 /J?L!/~/D.SOiI~ /J~il/I~G~YI- D. vlas NAMr u.x N ~ a r / xaw ADOeess fIrADD4F53 ~ D / _ / D~ (1 ~,~ ~ Y(t Z r sr•n :..co oNl NO D v IP r•n Do f~RJ/~ CMlrvxlN /E ~7~~f ~J ~J,~ 's~rA,rnl H I v I~ INx NO. Af EOf 9iaiH C Z OCCU4•r10N H4M Fl4HONS N0. Fr(s GHl Hf iGHr G~L~'K n'1.55f`.C /J- oGS ~ E R OCCURAr ON MNAMF t RHONF NO. a f'If5 IGNr SfiGHr C ^ CMECK (/I ul •s •N tMn r o f AN ^ CNECK I/) vfH n[AS AN ~ 'u ^ ~~ p ""oio.cr< CODES ~' ] "' r .S .in:.x~vK S i « 5 lecvoN D 's'.° CODES ! ~ D n•ssr Z. - ~ IN ueit5 o~ i ,( ~ ~~no,.DN •w~,.Ml ^ ~~' ^ ~srl. ^ „^C ^ ;a;5. H[ ^ •~~ F ^ :1 ^ w ^. s;5. ea 4 ~x v[H TSAR !/P°°~1~<HSV.I l06 l`S.FD fIIDARr.NOVAI Srrn 1}DR CONV l YhclS>r z'7" E rlA I ~ 1 . Q vA) IDA 1 V r l v.) •~ ''° S v uaNx uA t N Anfe naf No xA l H v oe s ~ N. A I V[H~CII IDSMiriCAnON NO i SH CS iDSNr Ai ~ I '~ arart4foowr.e4 Hax moose .HONE NO ~E ADDalss ar oA«n O W a isn4eoow>+w. sAV NRSr MiDaf • NER ' ~ N ~' - NuneaAOOelssa ~~u~ee <o ov AClNr R ~T 57 15E . pAMAGED MIA Oi p nt ' ~ N ~ wcq D 4MMOEDMG 0 0` . ! r . l w i 0. CHAt CA ,(/~ CHARGE , i ~ ~ • S 41D• ' f o S ,4~CriG~ E 4[ 13 D i^.N fD ^ ^4[MNN WvIN ^~R'Ar ^REMMNFp DAM I lS r rU~Onuii S ~, ~ f n rOVrtD4Y, L I ^ AW~V lr f DIAGRAM Of COIUSION, uHeciiunj Ne:A vo°w91M DESCRIPTION OF COLLISION: IUS[slNRLLMSNrASSwnnNlcfssARrl --• , _ ' r/- tff E"K/- ZIJF~b~L/i/D Q~J-t.,~'O//,C~rCE- E'U 6 l ~ C ~ ~ E . l c~ 7a N~~fOr/ r T . ~• A I ~ ~ wE ~ / ` /J/d~6'E 4/'~ Grlf,C//EJAr%~ /"f/`JD Uyc"1i6~[!J~ ~~~ f ~ / -~_ ~ ,r.,Qo~ C.~ LrfD. ~' 3S-N"ri'f/ ~e ro .~N~_, /y'o .SKitLS EYi ~ %x „~ 1e NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES I - Z 3 ~ S 6 OCCUPANTS/WITNESSES ;a :`D'Dn~o.f.:ii~`uAi si ~u. •cl ~uus '".,`"," ° nv4 Era :10,. .M! 'a .oDelss u4 a e r er ^ AM e ^R11 ^ "'~ . ^~i . ^ ::,,, f N oo4lss ~ rsba or . Moaor4oM ^•Me ^.acl ^ u:n. ^ +': ^ :°.',.. •D #I w ~ n oars . ~~oY°~i r ) D s l.n s. ^•Me ^'l°iU ^co. ^ „ ~~ i ".rul.ca".cy.arn a.vl n.a• a xH O. X 7~2L.' ~T..:LAfY~'...SCJfi/ ~ .w•a. .,.o a ,. •• a~n onn¢.ln 07 ~~ luevlD O~C / Dulaa ~~~ .. vtD D•n ~ ~ ,~ ~' '~ ~y ~{~ Ji ~ ~ ~ ~~~ ~~ 5 ~ ~ ~ ~ I ' ~ ~ Rx% . } i l ~ ~ :IkG ~.a.., f - • r L l • 1' 5 "71 ~~ A S~~ ~if~ 1~a~ ,~" f ~>x ssr 'a bra S '1 q~ ~y E`5 ~.5 °~Tr g4. ~# ~', { ~ lr ~ N ~ v 2Y f _ ~ u , ~ M ~1~1 ` ~ " ~r ' - ~ ~ ~ .P ~ wryy ,r . a ~L' ~~FPAyt~'tH5' _ ... POLICE TRAFFIC C N REPORT ~ TRAFFlCWAY r atuc _, ~ PRIVATE WAY t .'~ f :~ ~., ~I,: . /~i ~~ Wvi IL'wID. ~~ Yr 1113E ]y1DNOW1 C WNIr ~ ~ O A U 06 0 e ~E' S0 n ,,,;[ b QN ~f ~]N C1IrdIOWN fa Np dSln[tlO4tvGNWAY ' O M1[S Os ^W Hof fiCR~CtDtx ON OAK B9 iNr[vXCI NG wiIN Srvttl OV gOAD NON INIfvS[CI ON Q ~cYO, ~ nvEfly e[rWE[N (~~ / Srv[EI { F/LI~P~L~e SrNEE ~ t- r A O 1. (J i ~N~t{Di F v t .CVO5351v(fi NEAVE51 MnE ACCIDENS v 5 N 5 f w / I d A t/ MILEAGE _ /K/ ftF) CODE -. ~ ' COtIRiONINVIXVtD ~KlIID~NO. INIOOFD OSMIIAOt ^tt116vUN D i~+ 11 vE vPowPe cal(mr4 OlN NO wrMi'piviN ~" 1Nrte Cot CvOSSSIe[RdvOAD dV[NiCI[5 ~ ' ~] ~vvOVtviY DAMAG[ONty ^plull[D ^VtniC1E dl[CI SrvUCKINIJAF Ofd1[Cr SIVUC[ANDOWNf v'SNAMEI fSr. DAMAGE SvFCW COpNO USE / f _ UNIT NO.1 UNITN0.7 ^VEHICIE ^PEDESTRIAN PEDALCYCLIST ovWtvs NAME Iwsr .v MI DvNEV~s NArAE- ust ~ L o ~ ' APa b ~ -T e~/ 2 IvitrAD0vE5 5 y3 s „J ~s sT sr v ~ t r D IRFIr ADOVt55 :i cou NoNe NO. / ,PT ~Grunk'rt! GdiE1 cjF3~ •~S- ]/D/ R i r ArE arvly 5 UCENY N LAPo* R},t~1/~/C~/ { Lv/7 m Z IZy~s v I 1 tNSE A f j D,Y'I:. e Z Dc~uPA1PN t{vtwNe NO. ens cNr IDNI yp OSI/L' 7!c/] S . /I/AJ~ !fir S / E cuvANON fIVMNAMEa vttorA No EYti ICMI NlIDM ~ CHECK (.~ WN atA ~ er ANOlNte~ CODES -' ~ ~ A11~ G "' s I e ~ '<'L- x<r ^ ~~ , ".:nw % C' (] CHECK (.~ VEN of ws AN MSnoneawN CODES -' 7 ~ A ° p Y,t ~ i~w"' A b., o~.c.cu 3n o ~ t~ an M9P,N,N IF ' ° p .+.NA.N<1 I VtN vEAV MA f IDODOE CNly 1 W O ~b:N. ^ K ^ " 11DAVr.rgvA1 SrrU ]DV CON p MA 1 ^ ~ 1 u .x Ebm ^ w ^ IiD Ku ~ 9tyU 70Y07A . N.) E '- Pw E N I V.1 VAI l _ Z l U SIAIt AilFV ftArt NO rArf H KN.C { t FAltQ7Ei~" ~ N BLvt um ss8 w,~a - - I t nwauoemn¢A1ON C v1N CU IuN I A RNti G 175Z8 ; ~ C I l i l i V I I I ~ 5 ~ nusrtao owNEV sr MIDDLE SylT~E .9s .9bo,, AD moty ND SiI.>7c ° I Ea, wr Nvsr MI aESSar owma N A I NA.MEa ADausa lNweANCE CO dAGINI E vn,F/ own R aMAGED MIA • a"i.w c '' S05G8 O IY.Dr.D"N AMAU Axu / 1 e:%~ f !'D cNA.u t31 WMAOE ~ Aw f ~// to Aw .oc/• ~v ^ IAwMD e ~EOer /3 ~'S ~ awcE ,,; g 1 ~ eMN ~ '~ •for •> AWAY ~ eLMNNEU 15 0iD~Mc I .._... toaorto. ~ w~v . DIAGRAMO FCOII ISION, . i ~~~ IN ~c 1~r I I ~ A er~ f DESCRIPTION OF COLLISION ItaE S1m]Ma Yartn NEassAVrl ~_ •l g •_ _ I YP/'~/GI 'L _ Q 7L' O J - ~ ._.l .~ 1 . t. I I _ I~/Ory( _ ~II'~/I(/_ _. LU57 _ _.. !G/f .71'O.I ___ _ _ \_ 11 _ 7 i I f I~ fL/jy'! /J~ IoSS _, GH CUM I!!! _ I~1I _ _ _ _~u//!c'/S'yJO, [fiJ-J!t"._... ...7~_.Iels?` ! _ .. _ _: 1. _ ~. _ __ .. _ ~7 .I7. S _ .._ 7Q~ _._ _. _.___ . - ~ _.... I i '.- I 1.. ~~.. -. _ .. . _ _. __ _ .. _..__ _ ._ _ _ .. -- . ... ._. '- 1 4 I I wry -~ _;_ --- _ ..._ --- _ __. __ . __ - __ -- NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 - 7 3 ~ S 6 OCCUPANTS/WITNESSES NsESlrntwmAESlx I d ADDIIIONAI NAM1 u 31 SII AOE rAlUS ' w v . t n . Sle lXCI I'' ci . .. NO . Dart ua a . oDI1N - AN No NATIA a -- . e N Morlon []AMe ^tocl ~'"' 1 O.N. ^ :° O ~ A DO•ISS SI4.I w:. ala.swMrauN, e.ow o• KA x. """~a ~ ° INI S+ ^•Me O ~"O~o:n10 ~: ^i3'NY ~( ~•~~ !m / o No !/Gc' { Dn ItSP ?'-G uclDnnr «,D °,.°DD Est!' KAKI Ue ND ~„r./ wnan.o.r 8-/S~~ oaoer +~jO own / $ '~~ POLICE TRAFFIC COLLISION REPORT ¢QrenFFlcwnY ~ ~ -""~ ~~ pOEKf COMEUINt UMBF PRIVATE WAV .O+It 00.9111 ,._ OarQ_ O ll IOrv (Y CDU I I ( l =` AY> w uex.l eulf.l.lo rnr).I rFi, t.l I SE)bO HOUR ~ I O3O ~SO,KJ 0'HN a I YO9 COUNt NO. ClrY eq, iHWA ~UR µ U4.u ~ am~oF 51RtEE Oq nIG«wAY 9` ) K5 M1LE5 QS ^ J ^1N / / N p FR 5 RWIEOR i ~ SFCEKTV O ~ i 1NEFRSfCi1NG'Min:SiRFfrORRO•D r/NOY.NGIN~IFRSfCGr1C x ~/ 94a~o ` ~, x ~~! 1~,~' Gv./ 2 BFI'Nf[N ~ Srgffi ~/7~~ YG ppfFl% Ed MIlFP051 O, e3.,~ •"~ , Y , / O15raNCF DiREMrI FRON 9fFEREN f. CRO555rRtEt OR NfA9E5r MRE 5 ACCIDENT ll[5 5 F p DIAG4AM MEA MILEAGE RFI OE ~~~j~ J CODE COlUS10N 1NVOlVED. NO. tRiIIEO~rvO.1NJURFD ^SpIELAGF ^nI tOlal NO N wMloilO~R RE %~vp fN rl rgtF gRDaOOR REEfRFFKE IN IMF CLS CAOSSSrRffTORROPD 3x OVEnIClfS pRORFgrYDaMAGE ONLY ~ ^ eF lrFO QS[a[~E OBJECT KINMnEOp OBJ Ci SrRUC%rwDO'NNE4'S NaM.F FSr DAMAGE / ~ `~~~ SPECIM CODING l6f taJ ~- . UNIT NO. I UNIT N0.2 D4Wws f: usi l Q VEHICLE ^ PEDESTRIAN ^ PEDAICYGl15T -x. ~ s mmmE DgrvfR~s NAmf: usr 5r4Ffr aDORt55 33 oDE ~.2 su npco k D lgffi ADDRESS o v«oNf NO. •~~~ 3 G &s~ycs R nrr surf Elp E / •~ 9rv~R DlICEN5E rv0. SrAlf DpA I IV UCENSE NO. SIAIF t% DATE Of BI4rN ~ OCCUPATION MN•mE6pnONk rJO. wfl i 1Gnr E OCCUp+r10N MNaMf6plgNE NO. EYES WE1GHi IfIGnr "' G .,..~ ~: o 'sD R ^ GHECK (.~ EnKik as:rv FJ°eviv'YEFa+FmJEiln[el~' v ^ CHECK(/) En1ttEASaN io ~"` s l a .s,D raE„~ CODFS-* a ~ ` EMp rFE Opa CODES -~ S a % i+ s TT, "i ° n alES /S a VEt~.EARpy ^.mel%•r~ ^ UyTT Q.S. ^ .~"2.6 13~tR t yoveorv0 ^.,.. «a O u ^ ~B:~T. ^ ~ ^ro°~,. lnF ~ 1 Mw%f IDODGF~C V.l mJn~c~tt~~((nn<< NpJW0v SivIF Ix ORJ~CONV.I K/ `F.SNe.Y~ C~/`a ` J E l °R. v.l Y AR I nfv.l llD%R .NOVAI - 7 . u la s Y ~ all raTf F4 TUrf NO F H v En.<aoR ll A - ~ ~ ~ .~, ~ I VEHKI[IIXNr1NCa ON IJ'1 ~2 i ci ~ S o! a i oi -l-r-;- 9FGRRREDOWNE4~ I,+Sr ngsr DDIf prIONE N i vF«KlE 1DtNrlEr 1 i N i i I i REGISRR O. n..LScJ /~ .S.y.Pr ° W ED wN q. 1 E1RSr MI Dlf _ Ili //~ ADDRESS CF pwN[4 N n EDWNFR . ', ~ S~~G NaMf a•DOR[ssalNwRanee co oR • E ... eENr IISua~TFi!3-pfzCFFT o.JG R _ DAMAee Nr[A ' ' to p - v is wc~ow DunAC[o iRU s~TD. oK:e.:ci cn•gcT Ff/ C a.4 l ^ I Fsi D•m DwneFe rdi"oTiB~ s Mf7 ^ J°lww ^ %[mNNtD ^ ~w Ev ^RfM•1Nm est .~ S. ' Ioib ~ •w~v°e /(L~j O ~ iowTo wA er nD. - la ` DIAGRAM OF COLLISION: ~ SMFlE NEUSSAa II ev~t4"oO°v r" D RIPTION OFC VISION: lus[supplemeNru SM[Nf NEees5ARr1 - - r T r r ~ -~- E r ~ ~ ,`, ~{- _r_ vjr~~/J-~~'-was _ ~/.a-~/~%3-¢~ / ~'v l L ~-~ ~L4 Cl~/~ ~.. Lf J~O ~ .> / JG /¢ G' Z ~_ J _ ~ _ \ . _. . . ._ _j _ KJt /E%_...~ ~ r I I ~ // s -I. r i a.__' I I l I_ t f T/~u~.. F•~6~T- `p 2/ C~.fi./ - r ~ . OQ ,;,~ 1 .-1 ~__K/Gifr sG_a o_J___iC~_.._~r~ _. L_-sT . ~~~ t I 1 ~ - - - . _.. _.._ ..r _; ~ _L © A.,~_.1 '- .' f...' _ __~.. _. /~-^!i~_ L//r1S ..S%.._ ~6G.~CBs _`et- C~ls?G /~ I L I 1 Z •-i- rJ6 ~ NAME, ADDRE5581N1URIE5 OF PERSONS I NVOLVED "CODES I 2 ~ 4 5 6 N OCCUPANTS /WITNESSES lion :oo^niP::i i~:w .yE ii " -iiv :ci iims 'ur« v.E- -nu' ~ T - - rcsu utcr uR+ ~/JD .54JoCb_ .. .. ' ~ 73R-~/8tJ . ~ cDNTSS 7 .Y _. r~ ~o, _ ~ ,~r ruNE OF S5=/G 83 ~ ;~o ,.%eY. ^ ame ^ 11""' ^'"' K O n; ~34t. / ~ t s tG+ R MgvIDrNGM Q Q..~•I ^ ~ . ^ •ye + DORrss. nn dR t°F . _. yuv Q.me ^ i. ~u ^ om ~~ Q v. - n KIP 1ruyT l r • y F aNr %.DGI OR .;1•.Cr .~... •• Sr•ttpp PUIKE• ~/J ,D •q ©L71,/7 O, y~jo D+n Gr IIOR Rovk°e °uk X _~ ~L1..GL W !~ 8_.~ E33.aTT.RS x7aonR(srJ ~ +,r„ ~~ ^A.NA. '~'e• J s~.^1. x.15 L. ).r. ,J ,.. S,.vQ~ _.! n v .. .. i... .~.1.~. .i. ~.... ,r. , J. ..~. .. ..:v..~).i •UI L ll'h•. nl ~ 4 '.f .55 D . ~ '1i ~,, ~ L~ ~aU ~+ - s ; u a. a, ~I ~R _ 1 ~r ,u~[A~ Lt - '~I µg . AAA ~ x 'F 1 >, ~~ £' ~9 ,. . ,s,, ,~,^ ~~riiri t. ON dE U/rLLE Nr[v°tCrrNO wUN. °re(frpv qp NON NrlRSFCigN [N% ~ ~ 'LIIJD-- _..N t ~ f ~ pls gN<fapeE °frwefN dAK QR j~ srefera G///1:esf1L sreffr faD Vf[4 vFpO]r y N ~. /D N CROSS °rvEFfOR N[gvf5r%Ilr[pOS [[3 5 [ • Z p[ll AC~IOENr v p MILEAG plgcegM pgrq - Or // ~/./ L.~ICE /~ CO[I SIONrNVpv[D SEV[RRr~ E CODE V. - ' IOrµ NO NO %ll[D NO NIUREp~ ^ onlg0[ ra RU ^N O Vtn CII° m ^RROHRrvpgMAOf ONIr Srp[ N , w wN~p= N S %R INI[R Cl° wIRSF i SrR[fr v qp OR RfFRlNC Ce055°rR[(TOR ROgp ~ J 1 . ~'i N O°1fCr°rRUC(INANE Or OB![Cr SrvUC%M'DOVVNfv3NgMfl ^ H ^vfN C[f [ f°r.OAMAOF SM<NL COOrNG USE 300 }~ ~ (~ f;,~ 0 ~~ f ~ ~ ' s oenfR's Nqw(. u5r UNIT NO.IrRSr UNI7N0.~ ^VEHICIE sr ^ PEDESTRIAN ^ PEDALCYCLIST f Rrv[RS NqM[: ~,q ~~ ~'^ ~"~ .L ~~, '~' u frR[frgpORES/S ~ RETT L f1R _ ; ~~ ,~ rR[Er DDRESS ~ .~ L ST,gT y ~., Jrr srgr n.copf NONE NO. D r srgrf / 1 r0 E L5 Z 7 X76-~/3 R v rvtR Er CENY NO. ~ SrgrE E% I v ~ [ W " rAq DA RrRN F ` U H O/ M ~d ZlPIZ 4 upgr a« E Nt~ YYl u Z ~ %% ~ 6l «D I Rq. .. F fanpNE NO. fns cNr f(ICnr E <u.gnaN N,r~ //t ~ / / ~' p p~~ 1 ' qMF a vlgNf NO ff-~ iC/ Y t~ r-8 Jw a ~~// L I [tt5 rGNt HR:nr CMEC (~ f% 'N '" o ttn q _ _ [ rnfe gf i ^CHECK (~) Eq nsn•Nrr ODESS' ~ aii' 5 e qy°~ n:.o_ CODES %,.. vEn %s qN rrnp[orfe or gEJOr • w E tNr ~ ~ 7 cuss in.N A r °(' n °~ '. . U S fq N d yn [ k° ULE O ' <[ ' ~~ ~ u r ~ ~ r•o ~ ~ _ ]J s 1' ~' ~q« ..<fl ~_J .E[ooxfc rv. wopa io. i • ~ arq, ir.u lxo a.lvi >Q ~y [^R wVq Ott ^:4`Ny 0 NNJAL S. COO lflr7S ~/f,CSSl1+FiA0ER ~ LG ._. _. r /~___PivT/...a~ ___ p //.rtmnrKi ?o Fr..~_ z"CE, ~cST _CJawrf?aL_ r7i2cYlE. Aa?cYS_ ~'E ° ~ ~ CE.vIF.-.[_L/.JE. Nn>v ti GN.v ...... L.. _..: ~ I I ~ I (/P_N tt/_ /d .. 6..OF_.._7?PEi4p~_,_ I I ._ ~ /YBIQ- A.ZVtIE ._ 7o Er cw _~irvtci~oE.2 JJ!E.rI.. ,Y7iZcy/E__/~r_fT, /nJ ._~?RT .G!N/fiYN~C a.r ~ _ I t~ i ~?J ~,. +_ Sif. l-0 iic/i . /:EFtt2E d6.Y_rt/ --- .. ~ G/i/~iiE// O!ylo II 1. 1 j f r _ i ~..i__f _f ~ rr~_ /ueyt77. ar~..~-_a~ ns~ - - -_ DRESS B INJURIES OF PERSONS INVOLVED 'CODES I _ VTS/WITNESSES ~a:oa"uoE;."rf~i.Miii '~ - ~-- -- ~ ~ 6 ._ sp qcf~ u' nvR rticr 4.cr No Rrm XI 1. ~ asv 1~'n % ,~?I; Il'T{'a*, M~.rt w• ... waw.{,t~ lg .ro .,,. ~f{~L R , ~ ( - (t. a ` }W[s:R:l ~ 71 ~w,t~ w -~ ~ _. [p~ hl•i~'~ ' fl,.~ An .1 1 J ~ ~ U{tl Y'', t k !~ ~P ~ r r u §T 1 f r r ~ T ~ ,,~~ b ~ ' ' 7 ~ : Ir I 1r. i r 1 ,, 1 . N[~ 'YS El ` j t l r ~ t I - ! r [ - l ' ~ f p Ll ~~ I ,I it t I 1 'n n ~' 1 1. ~ .. ; ~ ; ~;#A ..I.~: ~~' POLICE TRAFFIC COLLISION REPORT I8.1 TRAFFICWAY - P' 4 ~ PRIVATE WAY ~ f ~ y ' _ • T- swe eouNrv ,,tO4i e ~ - «D i5il E7 I .i X~,rR.~rwnirN. ,.r, IOSe4nR»OU41 e+, r.-y+.r ?~ tir: ' ~ 0820 J¢ uaon -w~, ~+"~~ <e ~; "' ~ ~ -a; ON Oe OIN arro4 rowN N eaNO. orsuu, oR r«e«w•r ~` ~`a,~=° " 1 Iwlt35X+ w 6Y6r ChiDxceum ON Seave2 Va,Efe Rd. °' '{, `-s . iN t4StCrrND VAI»: t O4 ro•D NON iNnRStCigN rOFT t ~y lrb ~.~.x' atrwteN C¢nfph V ra E 8 I sttetr r ~~ s's?`'L -~r(7E~ . {r ~ 1 ~ /v. t MRU N 3 [ CROSS Sint Nt•4f Mil ACCIDENT 3y~+, 1 ,ter Cetttert Va.2f¢ Road MCDDEE ~~~ ~t.A. ~~.~~ - ~" causroN wvavEO wm w ,~ roes NO No .rue ,NN4eD ~ ^vnlwe ^»naRUN w;Rtrsra"« ~ w s~ aOsRO 5 I ss b ~, 2`r,, ~',.. ove»reses © O rro .ec a.nr O iivnreo O ve~ine - '~ r. ~.9 .~`r~P: ~. yam` 5y, _ - ~. . ~~~ •-..,8 oanasttue4l N•Nea oenersnsxR•NOOwNe4iNwtl 131 D4A•OL snsw ~ W; f ~~f.. y;E„ ~ .. , UNIT NO.I - . UNIT N0.1.fJ~1 VEHIQEt~ '. ~ PFDESTRWJ O PEDAICVCDST :, 1 °~ vu swwE. usr'. 3~'.,.~ ~. " ~•. 8 Gibbon, Heruy W. BISHOP, Tert2i LE nn ~ ~~`' I~3"' W sttur•oo4e ,,~ ,•DDnu , + ~ 71 QuitLart.Cf Loap Road x2691 E 8 I Ra 2 i r • e :~.eoa rrwNtNO D ~ i •' k ~~,~; Portt Townhend, WA 98368 385-3682 R Chirna WA 983 5 732-4113 2 rvws ueeN N s• I ~ r..r '" GISSOHW822NP WA M 08, 17 18 V. SISHO 336 F ~ 1 •20r 67 ,• w»s Kw»s E cur• roN t ~ ~ = ~ ~~ 9.. .: - . ~: a aeur•uoN eR•s N•NU r»oNt NO ens nR•s t t ie»r ,RwNr _~: ~ - 2 Re1ia¢d N/A HA2 172 511 R ¢¢¢ #'o i P#. T tul Lea RN 100 -2 _ '` O CHECK (/J r CODES - * D "^'•• «7 • • ".~G"" 4 s s 1 e ~; - ~ CODE s ' won a • 1 n 2 IN, ho3 nat'1~ S#¢/utum "~ H¢aH ' `"" ' .D.. a .".;~ ' " i ` , ;t w.. ro- o ~+ ^ ~ ^ gym. „rt;I ^ ; ~. w Y.~;,.a. .«ra ^ ~L" zam o ~ K; ^ ;:..,. .: „~ n»YGR M•tIDODG[~C»IVl IIID•Ri.rgv1 •StrIt NOR. Mv.l «. • 1 1 R•1 «rl - " 1983 Chevao4efi SubEErtban 40R E 1986 N( aan u.Laa/e 2DR A ae '", ~'' 1 ». N u sun m•ru. n•re No sr. H «. ~" ~. Gx EUD250 WA - ~~ - ~ R¢dl r r 1628EV WA "~ n»¢u roeNrnK•rKRV ra. - "~~ r'" ~~; 3 1 6 8 6 C 2 6 W 9 0 F 1 0 5 2 0 9 L rJ N Nl M' N 2 4' 5 5' 6 M 0-2 5 9 3 1 ~ :y RwunuD Ow.wR sASr n4sr ,•~Dat rwNe NO i w++t4: uur nRSr ~ ~r. 3 Sam¢ a.e Abov¢ O Mr ~, ! •oonssa owNU $a7D¢ W 8ibh0 s N,. .•.4 _~ ~~ .. 7 A . 4 2 N 2691E b I Road, Chimacum, WA 98325 4 ~ ;t NA°ea•oasssa mw••NCteo o••eeN, E u ~~~'. , ~~ ~ fir. 'q USAA -San Antonio. T¢xab R APXb#at¢ o, 4 3 "t' own.cio r+l+ w - t+~~ ! u ~'' _ ..D. rr..c:°...." c«,u~ - c«..a• r°~w~~~ ~w 4"".aoruu ~ +'F~ •~~. ¢ , s •> t>, a.« t ^ rviN ^nw.rNto -^.wir" ^RU.wNto `> t ~ 1 ~ ~' ,6i'ori6V 's~~~~;ry^; ~^ s2, 000 1O,y';°,r En.ichson'b ®:°,':'.°.,, Enich.eon'b sTo#a.C ~~,;`~•' ~~ ~ ~`'~,'~~snr~,~ DIAGRAM Of COLLISION: L°rin i"r.ecisi.Rn i:il.o~w'" DEXRIPTION OF COLLISION Iusl3u.ruwNru sretnr reusu4rl _ r 1 + !~' V¢hicf¢ ai boufihbound on 8¢averc Va,PR¢y Road. m ~ ~ ~ y '' 1 ••~ VehicYe a2 nonth6ound on 8eavert Va,Cfey Road. ' ,` I, T ~vt ~.... - r > ~i <z.. b{~~ T no6~#h¢~bou~h6~nd e4nn¢.on #h¢Dalae#h¢ ~~ ~~. Va , -1,. ' ", -"' - ~ ,~j/VEQ !/A//Ey.Ed.rof r ~ a22 wlob# cantnoP.o6 v¢hEef¢ . n R+ 7 ~ R NAME. ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES 1 - Z 3 ~ S 6 ~ ' ' er -i OCCUPANTS/WITNESSES IuusvnwtN+asNn EFL '` , ra •Dauowu «.wn w Act t•ru '«"' °' ", nna tea ;{`~ L l . ,~ ~ ,tacT Tblop w 732-4I I3 _ ~ -~ I~y ~ ~,,,g W 691 E ~ 8 1 1'h irrctCUm WA 98325 roaa t¢~L ~•ua O'tY1° .0~: ^ 4Ls, 4 `x,11 + '"' I 3'yA .oaks iwta ..•rn'oNOV O.w Owr<r p., ,O~ O:° '~'',' Issr .~. u,~c.r..c a,<u s«.naR.N. Nnr`LR~sa tNti. ^•.vF O~w~cl Oi'". 0;;. ^:° •X " uou o• •GI•<. ?<rD HU<»1D .3.. <t •u no outanrw, . wn ~ - ' ~~ L. AI. 2¢6~otJ ro4f~2 WSP 8%bRtr 08.m2•f Ogo21n 12-IS-8 /Z /7 « Yu~. ' ~L I~~ r ilkc n,'A ~ v~.~4~.41~ ~ ~ ' 1 ~Rn~.r vA' I T ~ r - I f rat ~ .':7, 4 - +' .. ~+ ~ 1 /r~ ~1 1 ~ +~. 1 ~~. r f ~'. 1 ~' .~ ~ + ' J ~~aj/ POUCE TRAFFlC COLLISION REPORT ~JRAFFICWAY 1 NICE COMq.UNf NUMBEq p / ~ ~ PRIVATE WAY ' - 9A:' DA O M. w - -v ~ I ~... I...t. ~ {' llMt Illft fRDDNOURI COUNtY ~ CWNfY NO CItr NO. - / ~ tNWA ^ BAN 'E!~ ~ ~ N GIIYOR IOw QN F n E nAm 6n0 Of SIREFt09 NIOHWAY Ct r RURAI ~ Q . Q M l[S ~'S QW 01 ON P1v V ~ E} ~RS l pW '/ ~ "'I/ 5D . CEION 19, ~'~~' Ir~, ~~ ~Ntl RS[CUNG VnrN. 1rptEr Op ROAD NON ~nr[gSICi ON SEIW!!N SrgtFt { SrpFR RvtN% f0 Mllf roSr ~ ~~ _ - " J/V_ O~SIANCt6 D4F RIR[ .CROSSSIREE RNURllr Mn[5 5 [ mllEro ACCIOFNT MILEAGE Am DArA D R - ' ~' t^ Y.y~ Y ~~ K ~ rRr O/ COtUSgN NVCIVfD FvtRirY 101A1 NO OEIIlO NO INIURIO ^SPIIUOF ^Nt6 pUN v.i~~ R tr W N • D iMR l5 i yE 4roAppq R(rfRENC! CRO55 SrgtROp roAp ~~ E CEVlN~Cltf ~ QEroRRt OAMAOtONIY ^gSUli10 ^vtaClF OB[lCr5lpUCp NAMEOf Oe ECI Srg ANDOwNfR'3 NA C F ~~ ~ QO '~ -' ~w ~ ( h ~ t 1 U q M I tSiD E - n e ~ SRfCNI CODING USE t ( UNIT NO. 1 OprvR~snAmf usi mlD R t UNI N0.7 ORNlR'S NAMF: VEHICLE PEDESTRIAN ^SI ^ ^ PEDALCYGUST N srpttr ADOpE ~ I R R+ - G t Aoovtss u Y RAr zvwu None no. D r s A I I - DR ' r r NtR S UCENSfn Id SrAI ~ {l'~ A X .D ~2~ I~, ( ~ w 1 [N n0. At B N RD ~ DAY I Y. ~jyft' ~ { OCCUVAriON pMN Ff. RNONF NO. r fvFS GNr KONr E CUV.r~ON MNAMF{vNpnt NO. tYtS IGNi KIONI ,~ I Q CHECK (.O U5 vrN a A A A A.~tirN vAl R ^ GHECK (.O N~ttE AS AN rmRioYE n r A '~' • CODES-* l ~ . ^ 5 t a ~D pp.=y "'" s'°p rN~w ,~r°, ,.1E .,~„ CODES - t ] a:u . °inMN S r n ron 6 wtn • u , E!' ^ e{ 'n r o f D9 R5 ; . .p M s. " `°5 . ~ ~, ,I ; I. ~,,.D,A»<t ^ ~ t ^ ism. ^ .~:ta ^ 41. DV aor Q AR Npt a ~<r ^ zam ^ ~ h~ztt ^ ~:~. . ..try. ,,4! ~~ vtN YFAR MA•tIfAOGt<NtV.I I tDARFNOVq frvlfpORC t ~ ao~ E YA t NV.t w004IDAp VAt I ., •OM •,tL+yi, .;~~- I N l u U~ EN NAr p sw AnfR AAreno. su ~ I H vfN. R l A A - vfNiCll iOtNi1lKAllO rE NO. ~ vtN CIF DtN A N ~ ~; N(~ND W 2~i RtolsnpmovmfR Wi npsr Dou rNONe NO L I~ I I I I I I I I I i R Eq: vst fiRSr m e N wopptfSp OMNR M ymtp ~ NA E ., Me{ADD•fsso ~NwgANCt CO aACwr R i u A sq f ~``~~ p ~. ' pAMAGID AIEA oi 1 0.w N •• Ynn A ' t .<r M rwN1' CN CNAEGf A/GtE MG g • ~. J~es-;. tia y..~ 4 1 'y .-I ~ ~ Sf DAMAOt e <~' Du ~!•n ^ OglMNNtD ro. D ~ ^.DEWVittn ^gUUiNfO Y (SODwM eiDR > ~o:or:oi: g RE ~ : ,Y °•, ^:ovno = u w ' v~ ~ i ` ~ DIAGRAM OfC sN r v! OL11510N:. I itiGEiwq a ^aROwRN OESCRI S I Bur~Mlrv',El sNlt1u UcE 1 ~iIiNOFR2,Vllf~E' IVIC..Kr l(]J„vWJ','_ ~ t q ~ " '` ^ -C Jr ~~ ~ (,O .. ncvF .. ~ 01 ~- + ~ _, m , . . o ta~PAVL SPEo~a~. $C~eKtalr -(E.Snb. U°4~;L b ' 1 r ~ L Chi '6 , .. ~ _ . , . unb t aw5 W1kn.0~14e~ . ({eyTi4N Ccalkre0 ~ cry ro a 'yrt~ X"i;' _ _ I - -- - - _ __ .__. i p , { `' `I ~' - ` ~. NAME ADDRESS 8 INJURIES OF PERSONS wsESlnntMlNUISN O INVOLVED fR ~ COOES `. I - Z J 1 S 6 - - ~ '`~ ' ?~'t ~ CCUPANTS/WITNESSES rp ADON ONµ nAml fl fla AGI IAru N N f, •If e 1 !Ci P ' E .,tt I e al FN~CT K°tx.x. + - n . ~ ~"moo x'0 I ~ wig ~ 9, ~~ T I 1 DD~nf U 1 1, ~' .M° ' ^"' . ^H ,8w Q ~ t • DD•I13 Uv10• e1MOVID fRpm QAm{ Q.a KI Qw • ^ N ^ riD t~5(~ ~ A ~~ V at i. N Non ~ ~ .C { ? ° ~ ~r ~: x +. scu.,~cf cl•Swww . ~ ~~ e•xF C. wlNC• ~ J~_ os o-tc rot~," do o.n Dr •non roan o.n a~~ OIL 12 ~ [,Sp ~ q ^G ~ ! I E s 1.t1q 5 • /G~' ~ f ~. t ~ i ~, 1 k,~.. r, ~"'~'TIJ "~'Mj ~'' t Iv,~ t,r~'t ~n~ b`~~ g ~I ~ V ~ t jr I F ~ ~{ .I. - - tl'. i ' ~~ k ~~~ 1 v,. , ~ ~ ~ _ '1 r ,~~~~Id tl ~- T r . i I r : ~ !, , t 'A (., :r v. ~~.~ ~ Ali ~ S ~ :fit T h ~ I. I t 1 1 ~~.. ~e "^ V ~~ i .igyy a , r ~ al _'.. r tN~ ~ ~{ 1 ~ rEf f"' RIR:a~ T ~iRAFFICWAV • EVIKECOMRA N1NUMBfR ' POLICE TRAFPIC COLLISION REPOR ~ z ~ PRIVATE WAY couNrrw ctr w. PNwA / t cau r o riMf couNrr : ~ ~ IDSEI.DDNDDRI ~cucµ / ~I; r S~FF /y S' • ~ O IvFFt OV NiONw•r r (~J f/ v f04 Br%t C CIIPN tR CIS A Z N QIN Cir OR tOwN 6N00 ~f ' 6 3 9H~sa JC Mlfz Igs ^w w ON E UF_ Y EvsFCr NG VnrN. Srv[Ft OV • NONI rFRS[CDO[, y,uE ~O PRt[IX FO MiIF POSY 1 Y BfM't[N //n'D Ssrv[tr a $A1A,J3onl StR[Ei , WIA RAM D SAN f6DVF ONE My EfvF CvOSSSrvEErOR MAVfzrM If POST ° ACCIpENT M IEAGE vMP D G ~e s f w G o s 1 = ~ 0 0[ 2S E[ ^SP tUG[ ^Nt69V CDIIBgN NVIXV[D. ~LL N ~ wM~w~M N N X D IMFR le N x0f<IING Sr%EI Oe nJAD OR niFRFNCk CROBe SR[E[OR ROAD p ` IED~rq. NIVVFD r NO. E ^vlaC vFH oO - I 1lrF0 OfVtNr~S ~J RORRty DAMAGE ONIY ^ r AGE O BnCrAI COOING VSf 9 . =- OBItC130tvUCXIN•MF OFCB,(Ct srRUCe ANDOWN(RS NAMFI FS t UNIT NO. Z ^ VENICLE (] PEDESTRIAN ^ PEDALCYCLIST _ UNIT NO. I M St iv r0 f ' D%vfR'S ,wM . USt (1 ' E ~~ S fwwa. IA NtR 1 v l DDVLS %El ADO%SS 3i lE A /y35 L G > / oZ v Arr . SrArf 1iP CODE PEgNF NO. D rP N ~ r surf N Olr ~ 98368 E J i R ~( t7 jp/,,NS paZ a t X N s A ~ . f FNS(NG ArF D F . n oA. re r. MD .~. DRNFRStC[NU ssy i zsi " roR m y ~ i ' ds ~ ys EYtS ONI NDGNT tangnt NO ' E CuvA[iON MNAMEf fNO. tYE3 IGNI HGRr P _ . OCCUVAIKN - ~/ R Z C-~ 5C=o2E% pCHECKI/1 [NittEASAN 'pr[[aArorwe•t ~~" CHECK /) v[NKIF •s AN Dwn r OP ANa S NI e w ' i • n n N CODES P ~ ] ~ . ° s F e „° ,K CODES P 7 c Z r v: , o ~ ~ o r o ~;,<t ~m ^ ~:K,F ^ ;°',~ "" o M„^ uw ,u ~ .a , ...r,Ef ^ c' 9 " o ,. « ~ ^ ~~„ ~ ( .CDNV, it DMr. •MODR „ MODtt EDAR VAI 1 ) V .uR = ' / n ~ MAtF 1000Gf.GN(v.' N~ vFA z~ ~ I E , se ' 8 '7 1 W / a fNSt PIA SrAtt ERRA NO. f H vfn. 09 l Fr7~Fl '~- A , ~~ r ~~ -- d ~ O vtN IerExN I. A NN ~,~ IN <lF rOFNt tKArgN Pp. IIFIDI .Et ~'/IF16i I I 131 i t F PNOw rq O L I I I I I I I I MI I I I I v0 wN[R:, WI IiRSr i0 E v _ MrD I %GiSrt•tDOVmIP IASr NvOt O Sr9/yJE A5 D,rz/vE• w A ,„„R IZ fssa oANFR A N S~~~+ E .N u A A n N•Mta ADD•[ssa rNwR•NCecD c•AGENt R N~ r7. ~~ ... _ gAMACeDARU s..~NG wMACt uu µ` oA".it ~ 1 ~ -F D cNA[u cNARU 0MMAGf v.NicNi ~ ~ ~ lMM [D lst '~: ° t w V r oPtMNNtD 1, Aw o,xx .;; ~..n wn rNecevAR 1 ' DESCRIPTIONO COLL _ ___ __ DIAGRAM OF COUISION a vP' NOK Nwm f ISION., IustsWneMe uts ^R°., [ 5 I I -, >„t(tR tt ,[~G~vEPe Y.gc~.~J~ E3 oni s -vEN ~/ G~qs _ - , l - , _. . I i.. ! f y~ i- i I (~l I R~. v~i~ ~ i __ bzo~E-_o~F l2dJ~otf,,~y-- I ' ~ ' _ I .. I. Nfi SB I '_(_ drOTo __SNCtc~OER•- _-. P,2/J[~.2_ Tu/CA/EEo. I I I I ? ~ Y ' ~ f , ...__ _ ZLZ9D WR o~ __TJ/E . / f3~cx ~ i I a ~ . , _ . .... ;_ a I , AG/r.J E !E CEn/~ E,2 i t { ~ r~ ds5 \ ~. ~ _ .. Pa- ~~~1 ~ _. , ---... C 2 E _ SLDE JT5 tArJOE'O O'+1 . I * 1 i _ ~ , I_ . ~ ~ ___ --_ _-- /JlvO ort! E Z~ O - T I I I I . 1. I I f_. ' I 1 ! ~ C,~.9 ._ , _ - _--- FF. J y/E .. /Z .~ oF ~~ t:~r~<c a vim - 1 ~ ( ~ ; ~ I_%_ r . _I:_'. I ~_ ._. ,/ -- ---- ' ---- I F uER As1 ~ I L..._l_~. ~ .. _ t .J _I_.. U i f _.__ __ -.. - --- _ _ " -- I I NAME,ADDRESS 81N1URIE5 OF PERSONS 1st suEn[Mwuu INVOLVED 'CODES 1 2 J ~ 5 6 Ntlt .'iu ice r.rDi '~ %+u inn °;ci r. v~ OCCUPANTS/WITNESSES iw.Dmr oN•(NAM ' FS _ Klc ~ l D'AG'051iNQ / Z Z l ~ 3Bs- zsi6 __ - O°i AMe O~'O" E V 000/7n! .Lr ~ . u~Rw d ner ^ . D.rx SA2f7 ~ [ /'a ST/'E/O - ZS/ ~:rla ads 6.. .n%Df.w• ~.Me ^': ' O ° . O^t .r a wF rA •r .n o.~ro scimi. ^.Mf pti, `IOm:R. N. ^ip1,w N D. aru~ `s~; pm nn ~~3 ~D D tro RE ro.r r..ovtor D•n ~d, [Aaq• .GENT.. "`fir' 1 7 S L-S- / mo o ZZI ll5 ~J3 1•D ~n ].DO wS X ~ ~EJ!(•_~(1. y L S ~ l , ^~ .: ~ ~rl~ 1 ' : _.• 'v r ~4 a ~~1~1 '"11 _ . , + Jti t I t'T I E i , i ~r ~ ( - - t n+.WIDRGtl>i~IF191R1ORPlm! . ~ l .tlZ P~S ' tv ~~~ ex. ~ , ~ to ~ . ~ a.. . x ~~ l + ~ ' -~i 7 Fr ~ P • t ,~Gj r~ ~,h;~ ~ ~~ I~ ~, _ 'y 1 pE .' µ 1~ w ~ ~ q ' ~ y .~ ~'~ C . : ~- C a~~: ~ ; ~ ?r t ~ ~ .~. r ~~ti ~. s I s~D .. _." pvn ,. - _ d ~~~ ~ ~ - ~ ~, ;, _. ~ S~IrATE OF WASHINGT ~ ` ON R. Z Z -"` ~ w,9.+9.,,R '~ b DE POUGE N 1 ,. TRAFFICC ION REPORT '~iRAFFICWAY 3 i) ~ 7 o+ or,co rs v _. PRIVATE WAY F RAiNt NVA19Ee -~ iw~ ~-, IN, MEN, ~T. ~j Cirr ' / ON ^E ~'=~F'~O~ FOVNtrN0 <,trND r ~,A p eAN , p O4 tOWN asmfe oarwNwer (o N s N cls mul lfs p w for ~GqM ON J IN (RS(CONG VnrM Si4fEr OR 40x0 nON Nt[ey~l ON M 40Utf ON SIRf t t ~j "-' fo4 onlcBttiRn ~lEVOSr n 4 mst+NCFSDNf rloN %ef F4 effwFE smFfr 9 M MFS 5 E.C9055514f[t09 N[AefSrMNf St }refEl w r 9 ~~~~' «Fr Of `,04 MIIEAGE COll pviNVCkVFD vf9Dr ~ OA09AM D+tA - nl , : ~j CODE OrAI NO ® n RIPofR_~Fq.NNefDy~ ^ 5991AOF ^Nir E9VN ,,,yyo„y bvFN CI[5 ~. x'9D iN 9 C0 S m............_.. _- ~~. 1 rt o x.r/ .~$ ~ 1CO1 S5 .--- pRiS `_ ~ N.rf A -- ~' /.~ T ~~ +004115 -._.._ .... __..._. 1 9 +r.r ~~a 1'JJ~ ' - i~ 1 6111 ~'~~ ~ `I l '~ 1 .,ln~es", I,,~ ,.~.... .L. ', • L ~•+~- ~ TRA no .~ l5 n •~ 3 4 ' ~ FFICWAY POLICE TRAFFIC C ION REPORT PRIVATE WAY hAINI NUMBEe 4Art OE CIXl15 N Ar .. •a re I .~. Hr w ' 15f NMF uel COUNir V ~!'"~i,R.X•~ COVNty ~ OiY NO. NWµ QiUUVAE 4 Crv Oe rOwN AME NO dSlef[t0 NONWY QN QE Q 6 mlfs ^5 ®W 61 o1Pc+21- ON iCT CIS/ Y/ eOUif ON toff Ao ~ESO' 5t 1~ N F4YCtiNG w11N. 5re[Fi Oe cOAO NON1Ntfe5ECIKeI BtM1VEENS~ 1~ 5r4f[t iP[tt % FEI EO M1lF POST ,1 T1 Osl•NCt 60eEM aF l9t vO555ieFEiOY NFAVFStMlE V05 lfs fe s F - 0 1Fti OP ~ ' Q ~" ACCIOErvf MILEAGE CODE MP 41AGaAM Q+fA COlIISpN NVOlvFO~ SEVf4nv. /~ iae rOi•l NO NO SII[OyNO.iNNe[4~ ^YiIIAC,I ^" UN dvFNClfs ® ^PeOReiY OAMAGE dIIY ^HStilln0 ^v[a<if wu-r,4n4~. N e 1M! Cl5 N Sf 11NG r4EFr04 WAp OR e[it4tNCE C4pss5rvEEr O4 e0Ap 0 ~ 9 OBlFCI UC[INAMF Oi~O01fCt 51eUC[NiDOWNEes N4Nft ESi 4AMAGE SM<iAI CO[IiNG IEf _ / ~~E f UNIT NO. i UNIT N0.2 VEHICLE Q PEDESTRIAN Q PEDALCYCLIST 9 Oewt•S NAMB w1 11451 M10IXF P-MSAI/ .'f'bHN F L vEe'S NAME: U51 1 l ~ t/RMAN REGO2Y Ci- siveel Aooetu 548 N-E 55 etU Aooefss Po. ox 1373 _ u•n D ~ s1 m P 5~a'LTrt~ WPB 9 ~1 os 527-43 R r~1oN~ T~ve.s o AE. r ees ueeNStN su Q~nn5A~6~oo~ WA ,nil ~ j ( V ~ ra. F~RngA~~C, 4o5urt WA n+1 e~em ~I f '~ ~ Z occur•noN AMta PNONtNO 1c«1 N[1cN SAEt~ WN M PRoD. RY 6 E R cuPArioN NAEa PEgNE NO ns icNiK LABok (~¢~/~ Z97•Z3 ~ _ •" Q CHECK (.~ e•s AN FMx`r o •N i ^ ^ CHECK (.~ ENmEAS AN rMViorttd ANOmw l p~ CODES -' l ~ 1 a ~'.°,°c'~ S • ".;'a .ci '. N R~ .rrt~ in". CODES I- ~ c o • w 5 u 6~ I ~r Q "ua n C ~ 5 ~;„.; ,N,M ^ .rAA..K1 ^ •w<F ^ ~~ ^ ~;~a 4;,, : w~;;1b. ,,,EwAN1, o ~ 1 ^ ism. a w~z~ ^ :~;,. ' ~8lo M rrsu. ~El,4Ael rNV^E~ Str~F'-tJ E M E '7~} GH ~%I NOVA I-F o~.t ' WNT UL•3459 Nlle Mtf NO. Slwl! siAWA ~ - - H 1 C c s A 13~v. ~5Z-A WA --" vENKI! IXNnNCNKIN NO A~7iFPZ14:v~3,6~P,o4igb9'7 L VEN CIf OFNin~ A i NN IIXiII ILA ~31g1q~618~ ~ I I rtelsrtemovmte wr s1 M14at rwNE NO fSAIME AcS D~I~l~2,' -' O e nn a wrvee: wi ni Ps F ~S DQ~dE2 -- ~y~ G A udowwe W N A E e4 „~.. LL" T E 'Z oeFSShcNSwuxFCO oe A Gar~prr q OENr N ~ -boo E R 1 i VN-CNOhIN ~ o.MACEO A4u •' ~:N ~ ' cN•eu ~ gAM•et '•xew cNA.u L ~"~a"`N ~diono+ s m rMMAU ~ :w.r ^ 4eewNeo oervfn ~4EMNNt4 ts~o•M~ • DIAGRAM OF COll1510 i r ~ f SNN tV ~tAln ~ An Ir~ IPgetn DE RIPTION Of COLLISION: fuse SUrrtEMU+tN SE~ttn Ned5.u4r1 N aJER ~ V R ' r ~ 6 ' " - B - 0 .. _.S I J&2 ..SIG ~k~~~/C°, . (SE 5~ _ ~ ~ ~ _; .~ _ _ ~ ~ _~ __ Q.D. lKes__VFFL'aZ WH lGf{ _ ,. -, - ! -r - }- - - -~ i l Ig-BEN PJ5F~E0_ lN~o_ /Ea!'~'~3.. - , , Y ~ ~- NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED OCCUPANTS /WITNESSES ~q:m^~aw rNiASiA~iii _~ CODES I sTw Ace i.rus - Z 4Y1H °a;' J -s- ~ 5 6 uisii ~uen M~cw• ~. N.MF ~ r _.._.. E .___. _. . w ... . •oo415r O/ N•tu4Ed E e i er •M e ^RI" ^ "' Nv . Q.'l. ^ :: N.M1 u0 .,. ...... p .. .......__.___..._ .__ _ •4MI51 -._-__'- NNU4 d-_..._ . _.____ . f ~101eVM Q AMa Q KvK1 Q o' E ^ H ^ r~i • rr1 NM b AMI _ • oo.nr NN.~s t ^•MB ^:':'Oio:~ w: ^i:~sr ,,.~.y X ., ~ ~.~~F /I[ B~o~NOO+ r.E tC w'~ /'Gr~~"/p,~+'~ !'J15 "4i/EC ~.Ooo T4 O'~~ro.r ArP~ /O I•n ~.. 1 d E, 4~ ~v F f ' . ,i ~,y .~ • J~ '~~ „ / 4, ~` ~ ~~"tt i ° ~~ x Fi ~ r ' ,: ,~ ~~ f r+y ~ > , ~.~,. ~~ ~;~» E ~ ~~ i ''~ A A ~i k ~• . ~E~ 1~ . I ;~ ~~ 1 '.1 r f ~ I .9 ~ ~ `{I£ y, ~ ~ -¢ t ~ ~kc48 i" S s_..._.>`L-~...._~,..: .,.d:~.._._. ~,u;;ranxu3iQ:P~Ti * ~ ,~ ._,v3_+_~,.__d:~ ,1iN..__~._40- °f' ~ ~ ~ ~ ~" _ . ~ t .. ~ cou rv arv u "~ ~ r f ~ w MOTOR VEHICLE COLLISION REPO T ND ND 44x :_ ,M wx^AM MoN u<: o xRA r ~ ~~, D ~ 2 9 7 ~ ~ f,.f ~~ ~""' . e x N .NO.o o cu. rx[Fa Roui[Ox EMEE coos ei aeeT. ; ^~ ~ e ^x ^e ^W ON ^ ^ ~ ~ { S '~ '~ ~1 w .os Enaeerwo 5 a or Nxrexa[e, ox ~EET RR E Eo roar T 1 / .~ ? _ T V ®^ c"~ra~DMLEPMaTDxIDExr.YxDIANOMARa ER a"" RA D.` ' AT s ~ ~• r IADR,I,D.iA .r _ C , E<o ' x,eR P .~ ,E[T ^O O D w t na M '' - l ~ p IN xD i~xaPDw~eP ~DLDa,DNIxrDLYeD erEa TOTAL NO 6wuAD[ OIwxD 9 ^ ^ Os vFN LLE R y a ~ / ^PESULifP ^VfM CfE ^CLM vvE [NAL ^ AEa ^ ^ xrex ^ rxioEq <is xr¢xseel xD eiREEr Dn no.LD Ox P[FERExC OCWa9 aixEET OA ROAD 3 ~{{ pf - PT ~ ~ ~ _ ~~. ) Y - ~ ~ a - OBJECT SLRUCK„ ,/ (NAME OF OOAECT Biqucn~i-oOWNE1~Of OBJECLS NAME AND ApDFE3S, .~ ~ ~~yiiq°~~[~ s y _ ar c one ufe IJ . ~ ~ , I ~ ~ a tl Pry K~ a 'f ~ ~ A 0 ~ ~~ ORI ER'S LA9T NAME FIRS NAM MIDDLE Y__. ._._... .._ ,.`._.__:_..._a. .T_•.€ .....~.. . TWO WERE NVOLVED P91YFAa?.MY4TS1!1ME_. .... ~ ..:_~:..:._: FIP9T NAME~._.:. ._MIP-I,E t1J + ~~~ ... eta Q 4 eOMla ox ax O E rxA iW0 Meu,Le , ~'" I A ~: ~~ 9 REET_AOPRE$$ ., ,_,_ „_ _. _, TEN ND BO%N.Qa- ~ E aONS E E STFEET ADDRESS ~ _ _„R,04IE N0 ANP BO%NO, y Y f Y ~ ~~ r n.', Ei/ ~ ~ / J CI ~A -, STATE ,._... ZIP COOE. TYO _.___/ ~ ..,..- /rl ~PJ 7A .ORIVER90 C ALON. /) ~ ErARATE Co Lao roar CITT'__,_.__ .,_..._~. STATE..__,___..ZIP CODE .~. .PRIYERS OC44PAT.IQM.:. ~~' ~ ~ ~-, .. T ~~ f .~YS ~ PR17gSLIC'NSE[ry00:_.___. _%~, ,.M~SrYE xS~ ~T p2ROI AGE IV __ I ENSE yO ,..,, ~ ,_~.~, 9TATE fiEX GATE OFB HTH.. _A(iE, R _, __ .. Inn F L v ~ MO R _ I 1 L VEHICLE YP. M KE fCHEY~O, ffG€j MODEL j[10V .OMiT) DODY 9TY~E (T OR.) ~'i ~ ~ ~ + ICLE YR. MAKE ICHEV. DODGE) (NOVMpART BODY STYLE 3. R -~ _~ _~ p ~ A M UCEN9E PLATE NO,. _,., 6TATE,... ....TMILEfl PLATE NO ......fiTATE _.__ LICENSE PLATE NO._ 6TATE„_.. ,,. TRAILER.PLATE NO, STATE.,;,.,, k ~RcF u// / ~`• • ~ ~~ VEHIPLE IDENTIFICATION NO ,... __...._ ENICLE IOENTIFICATION_NO ,_,._,_ f l070 44 1 2 02Sr-/ 1 RE019TEREP OIV' N,(VST-/)?9T:MIpDLE.NAME),,,_, OflIVER9yCEN9EJi0_~_,_,__,CEO)3TERE00)Y([ER,ILA$T•FIR$LMIA04E NAME). ... DRIVER'SlICEy$E NO,_,__,:._ s ': a~ ~' d eve ' r ~ OW E SADDRESS, __.,,($TREET CITYANP STATE) .., DATE OFBIRTH_ OWNER9ADP1[ESS „(STREET CITYANP STATE) OATEOFBIRTN_ R ~_ PARTS FVEHICLE OAMAG O ,__ _ _,,, .. ,,. P,,I,I V[xXM., PART OF VEHICLE DAMAGED - run ' ~ LIABILITY INSURANCE INFORMATION-VEHICLE NO. T- WAD THERE AuroLIOBILE uefialrv w9uRANGE ~yES ^ NO a r K : COVERAGE IN EFFECT FOR THIS ACCIDE"NLpT ON YOUR CAR C ~ ~ ~ „. NAMEANDAOORE950F LIABILITY IN$URANCEAGENT HOLDER _.. CITY ._...._.. . 6T E_: ~. ..__._ .... v.... LIABILOY POLICY.NUMBER NCECOMPANY ____, ~~ ~•.. , .Y IN,GRY .DF ,ND IM,HRY „,ar ~ ar.n ~ ~r~RY.rnx,T,x. z . ,R,.R, .GE -•' , "y •.•:: OoNYEn N VEHICLE uMUV,o w.uMe,wc E ... - ~ P+~uw,rR IN VEHICLE ~' Oru KILLED MwNI Mu.oN Or~AVU NO KILLED IeEVTneI IANaII riuxlt Or[uElMelx r ^NOEai~NAN CFLw, 0~,.,,.. N.,n ,,, ^ 5^ 6^ ap7 ^cli ^on,ER xN:re. ,x ^ 5^ 6^ aw7^ y:. MOTORCYCLE SAFETY: ^HELMET VSED ^HELMET NOT USED MOTORCYCLE SAFETY: ^HELMET USED ^HELMET NOT USED 'A ~ 5 j- SNO AORt tlY AxIIOW IN C,RLE OE9CR DE OELOWWM HANENED. (REFER TO VEHIflE9 pY NUMOERI ' ~ letwlwa PU4MY .... _.. ~....-. .... _... _.... ® II -d~.~lre..__Ga.r-~a_ ~ '-3~asY1 ~I~ -.eel~nfv~.- ~~ sNULt ox waxW.r _-s.a. Q-!K_ Lc(!:L _Gi~ . - i : ~ - ' ' ~ ; a r - ,I,11rDR ~.., j IEHI LE POSITIONS BEF ORE COLLISION IHICL[ N $ C W ON 9TREET OR HIGHWAY NAME OR NO ° IraMa ^ ^ ^ ^ ~ RI[r,[N ^ ^ ^ ^ _ LDEfIRwI ^ ^ ^ ^ ALONG L ~ 0 o.L RxoRw m.L n.e fwL uNEO ^CSOROL ^r°foL"',ci ^ ^ ^ ^ ^ ^ n~..... )I '., Pc ucaln,nrvrclrnL L,.v,L,al was Ma,nLR ~LJ UI.u. rLJ w.u. aVbxwfdx .L_I Cnouwuv ILJCRURawuR •LJOI,KR rUnu RUUH ILJ w.ONAr y' r PEDE$TRIANVPEOAL CYCLIST CLOTHING COLOR ,^,,,,,, .^,Y..r .^~., .^..I.n. .^: vi::i~wliiii u,H T.f'. f ROAp SURFACE WEATHER LIOnT CANOITIONS TMFFIC CONTROL R TYPE OF ROAD r I OIIIVER[VENICLE ACTIONS ~~ n ,. /R Y[.+ELw[ I cian.w I ^pArupH[ arvdO[ loN C. oxo Ox,cLQ[ w1lwAilxa ~vn,KL~^[ IcI,EaA ON[ox MOnn ~•~ ~~~,` y Kxru oxn ...rppl~~TT, J ~,~I ! ~ ,AI •~LOVTAtal1 [ ^DAWN I SIGNAL] 1I~~I ONE WAI ~1 601H06TRAIDHT ANFAO Ii,~ ~ ~ 1 ^ dW E ^ RAINIMO ) ^ DU9n ^ ] ^ 6IOP LION ~[ I J TWO WAY 1 ^ OVFRTAMIHD ANO PA991N0 A ~ 4 131 l S WYL .~~TT- 3 ^ WET 3 ^ SIpWRp 1 ^ ~O~IIS ON[/r ^ 3 ^ rl[LD 610N YY^--++ 1 ^ POND MOLE ^ 1 ^ MAKING RIONT TURN ~ y t 11~ 1 I {~~ t~~t'~" ^ ] ^ ~W 1 ^ r~ [ ^ DGHi90(IET IIAM.INO PFD Ni[nLNAHOE ^ 1 ^ MAKIHD LEPT TURN 5 I ~ V!4rt•, ii ~ t1ir~I ~Y/ I' ^ 1 ^ ^ 1 ^ Il00WPAMPI _ t ~ 1111~r[1a r, W ^ a ^ KL [ ^SPtG IY 1~IPI[t lGnt3 ^ 3 ^ ILA9HW0 A40[R ^ 1 ^ AIIEY ^ 9 ^ MAKING U•TURN I" } ~' f ^ ^ Srl Cli• [ f AN 61GNAl / Tl I }URN [r~~r E BLOWING +I ; I{A'n~ f~~(i~ / ^ SrtC iY ^ ^ ^ ^ lAN[S L.I ^ I ~N~~, V~ n ~~• )~. [ ', OwOWAY CHU1ACi[R ROADWAr ]UN[AGL fYPL ^ [ ^ OFaIC[n~ILAGYAN ^ [ ^ DRIYtWAY ^ i ^ 9rOPP[D [Ofl rRAIF10 ~'~~ryY~1j!~' 4 '''555AAA 1 ~~a f1 1 1 rf lA' ~^ 1 ~"j'rrl n" co-r.NR Yr ` au,,,, ^ / OINIR. 6Pl CIFY RO 6EPAMT 1 910PPLD AT SIGNAL e t{~ )h"""'I'~Y44' J A ^ Iw:'Y" I L~T) N* R.Z . ~L..1L ^ E ^ ^ r.l •. a'" ^ ] ^ D V OLO ^ 1 ^ 9TOPPCD IN ROAD AY ~~~ ~'~ ,~~` JS F`}~~ 'a'w ^' ~ ~ ^.. c"cwTnDL, ,. ^ ^ ^ gAeraulHE I '~ F 'r~ l~ 1 '~ ~ r..r ^ ^ ~+ IyL•tT O1 IC l DVO[D 19 6TAn11N0 N N :`I I Vf kiln ~~r 1~ s ~ I S ~. ?gg?ryry1 {fig ''~~), NI~`~' ~I ~ i' r ,~ «~~ ..,~a.. .~I{}dl'Mh j3 i R' s J tTf'~ 1 '1 ~'~pp r T t I ~ }y ~. .. ~ _ ~ T ~ ; '' ~w ~ ~ k.~ ,~ A,t `.y]nl §i Jd . .~ 1 vI ~~` ~~tt 1$ ~ ] .,: ~ ~~~ .. ~ . ~" ~• ~~~ ,u~~ "~ s~' ` $ . IY' t[ K9 I I I_- I- ~l -I I- i~_ ~"R+ .-'•- ~. ••, .. 1'i ^ <.. __IVN.-~INLK]__9~ ~ K.LDS.!.J~._ .. I I A 01 ^+ P r1-._ pnu, a.J SNcwID+q -~ 1 .. - _.,_ 1 ~ - - _._ . ---- _ ES OF PERSONSINVOIVED g 'CODES 1 .w' MM ~ IUSI SW%f wlNt.l ]Mlt OCCUPAN $ WI TNESSES rO..DpitgN.l N.wlfl i4A M T '""" _. _ . _ N~ - - Z 3 4 5 6 SI, .GI t.tu1 iv~t+ L.~ - ._._. _-.-.. wt[v ,., , ~:, n(Sin 1,11 ,..... r 1 w. n . _ n N. ~., a Qa 1ut(~]~. w' 1 p xr.a w. p.we pK1" p:::,,. w wrwlp ..o ' /lit . .. _. oruow ••°1"N`iri. ^.Mn pN-,.p pro w .Nw .. la 'X'», ,,..~1„,N,.,..wl....,. . wrN<. ~~r, 2 .`uv ~ ° 1 w„. p.w. p~ :' o w, p ::~,. c/~~"F o °o~f,Kj..?HO o.n ..out oaon. ~ o.n l ~ 1 L ~ _ u~,~v2 i 5 Fr X° e 9 ,39 67 ~ ~ i 1, ~9 W ~` i ~.,~ "' ?`' n ~ ~" ~~ c j ttr 'r` yh I; ~r~l . ~a ~` I "~h'1 5 ~: ~~ ~r ~~t3 ' ` ~ . ~ F ~/ I~r 3 ' I i ~ 1 :N A IArF r .. - 'ou+..i ~~ ~1 ~ •rf 1 -' i 1 t .ynx POLICE TRAFFIC CO *~`~N REPORT [~TRAFFICWAV - N ~ PRIVATE WAY _ I - pop uy I I ~ rwr - ". ~ I ~ n:l.i .' 121 low couNrr J~ muN,r NO O rrn~ ~. n r o R rowN AMtaNO wsrRt r wcNwAr []N ~t ^IN c s ~ ou oR ~ / ~~ , IV Mµts s ^w {tu5.lt„ C•N £ Ll.. I - - ~ D n INI{vSFCiINGSMNSrv{FtOR gpAD NONINttRS[CtgN B[rWtlrv S ~\O `( Srvt[ra ~ Slvl[i Ivttl% MILf qSi OI • { I CRO553rv{( NtARf3r Mllt R ACCIDENT AMMA 6 "^~ MB[S 5 t L IEII w OI ~^,O MILEAGE CODE COlNSKiN IrvVIXV10 vtvrrv: OlAl rvO NO [ll[D~NO.INNRtD~ ^Y11•G! ^Nra 4UN M v wNYtpr" IN - ~ D IMly Cl5 I ING 1 vROADO4 nitvFNCf C4~SStvE[r OR POAD w VINrClfS ~ IpRViY DAMAGE ONIY ^pSUtrID ^vlaClf OBlICr Srv AMEw OBI! rSrvGCa ANDOWNteS NAMtI [Sr0 Gt S SMCMI CODING IRt UNIT NO. I UNIT O. Z ^ VEHICLE ~ PEDESTRIAN ^ PEDAICYCLIST 3t DvNiv { IASr I ~R~1 t,I e A -J D v(R'S NAML. VSSr r I _ ~ Srv[It ADDRESS l s~ ~~ e - ~ T • v tt pRt53 t , .NDNtNG ~GO</ 7p p ~~ `~ ~'~~l D R I. A t I 1 rvse r+ 9 sr.n/~ ~ J CO 20 V r I N Ae A MD i w _ u.AtloN MrvAMt a.rroNe NO. vts cNr r<rcRr ~Y.yl'L~b 2 E R occwA lON N%MIa.rvONt NO ens Iwr NtwNr - ~ CHECK (rrJ vtNC • i Rrr N ` A ^ CHECK (t~ .SAN DMnor ' A r~' s t fi e; °,~o'c•c'i CODES - D ~ •; CODES -` 7 n s u e v x' Z Nnolfs 7 ~:;rN, ^.MN,,.NLI ^ ~ NN tA1 M ,<I o ~m ^ ax~a f. M w»~y~l o A. I ^ M rt I ^ ~m o ~ ^ :° VKU NoN r MAat IDODGE.CNtv.l Q ~~-(~ v.l l ID r AI Srvll}~ Y. l~ . E 1 v l Ctl ID vAl I ~ w• N sut nuts nut NO vA H vtN f ~ ~ vtNrtl DI rNCAi ON NO. ,~ 'B R A I I~i ~g l, 8 q' ,6 E v N l r rv I r I l I I ~ , ~ I I ~~ ~ ~ IEGISRRLDOWNt9 IIRfi II%S Mlp(%I MONf NO O r WN lnfl EIISI I Aowlu w owrvtl N _ E - N•Mea woDRtssw m5uurxl Coco wACwr LS t,rR ~C R _ AGl MlA ~' Y AItA I .R ~ d ., DrvA.G crvuw a g '~ tdionoy I Im. oAwGe wl^r ^IIMUNto i ^ IInN ^nMMNEO Aw%r t ~ Ire I ISioirS s ~ oY~Dlr ^TOw+c ar_ AwA S I ou ISION INevsiu0 ~NOC'r~o~tN . }"'®'~" 1 ..f _.I_ ~ DEXRPTIONOFC LUSION: IuslslrruMlNrusr/EtrNtgyAarl .I CLE WA'3--- ~ ~HL V - n _ ~ . } I ~ ~ I1 ++ J . ~.l I ~ _ I I i g ,_ - { ` _ . - hP2oAcl~inlG se.-.1o4_ wN~ErJ ~- - V ~, RD :. I T ~ S ~ I .. .: r I I _... SCi _ .LJ§.fE. -._. _. __ _._ I I I I 1 1 1~- ~ f ~ ~~ ...._. _.. - - - --- -- , I I i ~ I y. - I i i 11 r I 1~ ~ T Ors' ; ~ ~ ~}~~n p . ry. ~ - '/P'~~~~~`.~Q~-~_q~1 _~fJ _ LCT3 _.. Y`~~ ~¢~y - s ' ~ h' Nt Y ., f I . . wD - ~ _' -I , ~ . r ~ I I f •11.U i KLS -- a 3 ~EJc -- -T--- I I F i-~-t _~ -i- i -- -- - - - _ _..___ ----_._-__-_... ~ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOWED ' CODES 1 - Z J ~ 5 6 OCCUPANTS/WITNESS S iu:no~~a:a luRw"i ii _ ~u% Ad urus , ';,"" ° r '; nsn dcr :.°i. NAMt ~.T ~ ~ ~2 - _ _ No Sgn.E M ~ - # •Dtl.tff G I w E •M K a RI' ^ ^ R2;v ~ AMI N : ' •ooatff . i rO1 a " a vID II ^•Ma ~racl ~"I . ^H Q"n° '0 w ~ lff • w~~l{II Ot 1 IM!• ^•MI ^ rP CI ^vw . ^w ^;.° " ~ +rrtfrG•r.NGwr{Ir SN•r111~~ I.DGI OI .GI'Kr ryr ~yr jl~J;f"'~D vv~~o Z'I SyL ~'41N)Ar AEr101D1• •rl ' ~~ 1 ~'l ~ .,l ~{ I.1 { .. ~"~ :., _. "~ ~ ~ ;~ . ,~ „~ .; STATE OF 1IVA INGTON G[ ! DS ! ~ ~ " ~ ~ ~ I I iVu, POLICE TRAFFIC CO T NREPORT ®TRAFFICWAV NlreuR ~ ~ 6 T - . ~ PRIVATE WAY f r I A :~ OURI COVNir }y0 C Np f O~j ll_•.~ pi IY.I 9. IUS[]~pwDU 1 i° ' - -3, `f1M'A RI 'S ~ i ~ .~ I b S ~ . o L.00 ,. ~F~..R.~N /`//-l c~ ~ euT . . /q pN pf pIN CiY Oe IOWN Lf Npd519[[l09 GNWAY YVS pp ~~ allt p4 Avlfs ^s W DoE '~ N{ ONDIEA1~ ( V/W ~µ Ci ,Ey INnvsFCN St9{{I peipAp NONIME431RWN ~ (~ ~ d` ~~~ mfNx~ rosr M11 pp~~ 1r Y, ~y ~ DI A R[MT[N V Si4i { N k 1 ! ff CR053519fl1 AR[5 E f N SMtfl q. -~ w(~, e MNES 5 f 6 EEIi W pr S f ~ COU13roN rova m plAz__ ACCIDENT IA MILEAGE ODE ~ ~ `~ ,A~~ /~ v SOfµ NO NO NwillfD NO.INlU9FDyL ^YIIIAGF ^NII{4UN dVEN ClF3 repg4iv pAMAG[ON[r SrdIN p RSUl1tD ^vFNI[lF OBRCS SteUCN INAMfd OBI[CS StR ' B I~ oiw ~ w~w~ V 4 ~d5 OR ~eeNd ~ dIOZ55r9[[}O44JAp » __ UCN AND OWNER S NAM[I H1~I S1~ [SiONAAOf SHCW DINGIyf w DvN[9s NAMe UNIT NO.1 UNITNO.4 ^VEHICLE yE p PEDESTRIAN n9st I Dvv[9~sNAMt: u ^ PEDALCYCLIST .j' the , ~~ ~ r, 519{(1 ApOYFU Iqo~ FEpE2A 9[{i ADDel55 _ - _ ~ II. ~ i y1 5 ASE COCt NO D v oMuAJ ~-4950Q rlb Af IG I 'S IC[NSf N ~ " - SSAIt D 316p$5o6 /N1 M N I ll I (~2'6~ ~ ~ Np ~{ A ...N I oN. , acurAi oN vNON[[.~ z ~R1Nrc UIS.Nt. ~' 6~ ~S ^3 'urs Ni ER occuf..noN {I9M NAMEA rHON[NO. [rt51 IGNi E[N:Mi p CHECK (.~ viwde NS iN M AvdN{e A' ^ CHECK (~ l NODES-' 7 a 5 [ A „p ~ vfN <IE ASAN DMr[on[dA u~ ~ n3n A ncS a CODES -~ R n .. 3 r te ` - 7 n Nss • s. nM N wl{ D y I .< NN ] ~] ~ i ~f~:4 ro ^ „,.D,,.x[ p 3s° ^ ~8n1. ' <ii iul M ~I ., .,. pAV I p~~Cl ~~ p N ~ I SU .FAe Nt I00pG(CNEV.I IDARS NOVAO 61rLL 1]DR CONV w rt ^rio~ K11 _ 5 N . I v.l ID vAl I. o R ~seoQ~''•~ Z D~ H 1 1 _ 6 yg~ I N SSAtF I9Mlf q RA,f NO vF " o5A WA ( w ,~ ~~ ~ NwC1EIpM bCAfroN NO C [ 3[,aNll A. N F'A P.P :2 1 9 N W 6"7.2 9, ` ~ ~ ~~ I ~ ~ efms rt4 [ DO ]' ~ P~y`~ 51~~ ~~~ wwRr IINSi nesr MIDd{ ` ~ L SAICf~LB ApD f55dOWNE9 EVE ~ rNON~NO. O I ,NI'lf R. lA5 N45i ' I ~ . NAMe N ADD4us a wwAANC{ eo a Ace R '+ ~~ ,.~ ~ - ~ I . u C7L'~M ~ I = '" ,x ~° ~ ~ ]OAMAG fD MI ~ [x t 131~tpAMAG1 CN DeINN _ CNAR _ __. _. 7 )MIA p~N,N~~ ~ ,{ ~ ~. Ni x.f t ".~~ r I ~'r. d~~ ~:, _ "fai N..' G~`n, A..~,y MOTOR VEHICLE COLLISION AEPOA uN = J~^^ LN^ Y N ~ , UNI Nan .E:wo`i,` ~~~F" ~s ' ~ ~,~ ~ 'EffEµ3c IJ 0 ~fPN o t 7 ~ ~ 3 1 ®n ^E ^„ TYaxlew w+M[IrMaeAIxLLTaxwa,w,.Y ° w ° x[LY°°° [ N ` •l. + • S I~" I • cAnA4 S s ^~ ^w ®or IKDD BRIDLt ON QEAV M1 vn wsecnwow ms,nL[r Rx w,wl[AS[eeXW E LLEH HILHwnN om' ~~ ~/~~'-I A ~ >y`~. ~ w ' ~ EF Lwa, [ • O ` LL,1f ®^E M sx Uc[. ii oE rx°ux°wulX r w •[ P cxAY oArA +1~.~ ~' ` --y'.' ~~ . L~ non ec, ar I00 . ^9 ^w INT[ASECTIC.-I LN/ N ILHL~P + • nlx olveP I--1 ^`nEi.cs nrs wrLwu wxD rnuuFONH° ,. - l~~ ° B rLx T1 91 a ~~EO A °E;aRR [ 3=~ ~ r A ~ ' ° B ,,.LF 8 ^ L• ^xr,e„[e ^ E x..L a ~e YE OB O FE E , ND - / (/~I Pp 4 , 4 U r JECT-S~TgUCN INque el Ow XI - OWNER OF OBJECTS NAME AND ADOflESS I7j MPAlx°w[ci L" c°°[ us .. i ~' .~.'i ~. ' .....-... .. _..__.. _. . . 1 .~, ';.~ ~ ~ • • rr MOn[InAN DHfVEg5 LA9T NAME. .. _,. FIRST NAME„ MIQQ E Oc+N9 D V 9 • • _ __.. y -. 1 nvoLVSO ..BI_€P I.~LJIM:!E._..._..._..FIPSLAAME_,...___.~..~~+JP4F€.r.:. . -_ J~~. ~, ~ rIIM1TEII ICENN ETy BfLf LiNAM ,JOHNN9 2o$j SPf N[E IA--~ MDne ~.~iwo rat ' ' '~' Y y ' $iP.EE~.%P,DRESB .,,,, _- ROUTE NO AND BOX ND._, P[gsens w[AE STREET ADDRESS gOUTE, NO~AND BO%NO 1136 ~ " -_~- E - A , M1Y LoGP in yz7~ LJ p4.Ept.+.rf siv, sr. ~~ u y CITY. ,',.:.rOwMS[yln STATE 21P COQ€ ORIVERS.000UPATION. cxOFLls CITY.. STATE IIP CODE DRIVERS OCCUPATION` ~ LT e P T. -1 . " "' I+ W~sEEtmp WA Ifs6$ AETn:y M.NNAG'f- P4K0' W:L:L+/rftfJ vvA 4Y3CC FoxM ' ~' OflIVER $LICENSE NO. STATE ,$EA DgTE DF BIflTH•,. AGE. DRIVEfl'$LICEH$E NO_. STATE .SEK. _OAi oQF-pINTp{,_ qOF,,: ~'t/ 33 .._._......._ PLA.7EKSK6•lc6 Wn ~" ~~ gA~ F Mo. ~ [ P -' , H+A ~ yEMICLE.Yp, MANE ICHEV.,0006EI MODEL (NOVA-DART) BOGY STYLE_(] Ofl.), VEHICLE.Yfl: MANE (CIIFV, UODOEI .MODEL INOVA-DART) BODY STYLE (2 Dfl.) 1 ' S ~~ 9 I VO L VD 24 $ STPT+r/ w+'6cU iY7 Z DcOCb C-GL.T Z-O[A lt. LICENSpPLATE NO. STATE TflAILEfl PLATE NO STA ' . TE,_,_.. LICENSE PLATE NO. STATE. . TRAILER PLATE NO. STATE $IS ANN jq//4 ~ - f '; VEH14%LE.IOENTIFICATION NO. _ ........._. _... VEnIGLE IOENTIFICATIQN NQ.. _ -...,._ , Yc'2-`tSt581035930 07101 _... ... ...-:.__.. __ -.i ', ~„ ~ ~' 5 x "T NE015TERED OWNER (LAST-Flfl$i-MIDDLE NAME)_ ,,. OTIIVER'S, LICENSE NO_ gEQISTFgEQ OWNER (Lq$T-FIRST IIIIODLE_NAMEI __---, pNIVEflS LICENSE -..__.... _. NO. , ' ~ - ~' ' " " - ,, , PQATEI:, (CENNEFN •TPENCC/j, P4n-ff tL ' SM67C 6 -~ ' ~ ~ OWNER'$.ADOflES$ ~_ (6TREET, GITY AND STATEJ....._ .- GATE OF BIRTH _ OWNER'S ADDRESS -(STREET QITY ANRSTATEI GATE Of Blq H _- , - ,~Y l ,; ' p . - A r I13G 4oG N Pa R-i TDL.+~7 G,-o L.+o 4836 'Ji 2i .. .~/ ' S 7 - ' ry C a ,PARTS OF VEH CLE DAMAGED „. _ _.,. _ .. AIiiCX EnIW ° PMTS Of VEHICLE DAMgOED a I~L~,. ~~ [° rre (~~ ..... .. _._ ... .. ~--... -. vEn -,._ rWH[ LEfT [41r_H[A_~dvHPµ IT°AN CIGHAL SL+7(-gcHQP $ 7U~ CANT RlcwYj-RtAFL C6ANE/L, BULKLINL I Fi-Ffsn RfA $ ~ ~ LIABILITY INSURANCE INFORMATION-VEHICLE NO 1 WAS THERE AUTOMOBILE LIABILITY IN9UR NCE GqI COVERAGE IN EFFECT FOR TH $ ACCIDENT ^ •~ - 911r }' -", ON YOUR Cgfl A71 YES NO NAMEµpADOflESSOF.LIABILITY INSURANCE POLICY HOLDER _.NAMEOP LIABILITY-INSURANCE COMPANY ;,,~ _ A •, .. IcE NHM $ U/'i[+L 36 ULAr+ GnT TO MS O ~ PEMCU ~ '_ NAME gNQ.PQQflE$$ QF LIAp CITY INSURANCE AGENT 4 N ...,...,:.i.. 5 .. E p LIABILITY POLICY NUMBER ... _' - .. PE+wcG lNSVYLANLF ~ ..~ 32 A O 3 -i ~ fn3 L KE AvE F. J(ATTLf wA ~81DEi OA y!'12g sr INJ ~ ~ JRr ...........,._._,_,_ __-_.._,...... _. -_ AGE }ND NJURY ... .-.-_.~~~.-,~-~„-,-, _-„~- 1 POei lOn p A[ WugIESI AGE ' -. - . a ~ n 4~ . . , _,_,... -. NAM TOTU NNREO N ME ~~ _ ' Pi ) ADDRESS $~' gODflESS BEA_. NATURE ANO M F '7 E%TENT OF INJUR ES ^ ^ ~(7 E TENT OF NJUR ES M ~. ~ nie ~ ^ - ^ L I OID JURIE9 REOGIRE ~aDOCTORS 1~ IDIDINJURIES flEOUIRE ^ E%AM NATION BY A DOCTOR. NAME ~ ^ DOCTOq'S E%AM NAT ON DV A OOCTOflT { ' N E $TgiU$OPINJURED - MARI(_flR$T ONE THAT APPLIES. ....... 5 ATU T SQF INJUREp MARK fIRST ONE THAi APPLIE9 ' ': ~ . ^ M.V ICE a. we ,~°s.a. ^ L_VEnI.L .. 0 NO KILLED Islr[w[ ,u wOn, "• ^ NO KILLED If[r[n[ wu w°ux ul"~"A ar~,o~,l ^DN„x "..I I,. ^ 5 ^I B ^ °`~'o` o ^ 0 pE :'JB~'NHi,:E2...,T3f3N . 5 6 ^ ,y'-~•L - a•I Vna.r L.Le JNYCIT: V rIELMEt USED LJ HELMET NOT USED MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED , r . ___ SNOW NONTN OY ARROW IN CIRCLE DESGilOE DELOW WHAT HAPPENED: (REFER TO VEHICLES DY NDMBER) ... ,~ a aLt';"`;.9, AH.e~I, © \ \ vc+lI 1:LE r-A~o z an+..nPO -ivN!64. RT (IMT4. /C,x vCAVAFLf"i '_ o„aw •a1w1. wxnNaa~ ~ NGL(w aD cu NGn~-y !o - nbww,. w..IS LWa'+[B IKNCL[y- ELfN -GAM1S HAD .TP_S7D/ SuPG N4Y ~~ ] waYnA eACw rlwX,g1 ..° sw°w aXLC,XWaex.rn •. wxwxw Ir2 f•ASt'Jf4ttYD~ TO A -. MN-(rf,~p l..ThvcF 7'NPr_A+L•LtU....S/Onf P!L!1._FALM_ .. ~ --~ Q~. i TD AvIn •Ix[Llaxwa,«.. P+'ARtA-IOC,.r!LT N71L_Tn[fM1.[AHE_ANO vNrL_µ,cni PAtLatuG_- ' 7rt°cc~, t QfiU ti_--. STRIP. YEHIfLfJI AND_2 ThEc! REP 44:J..En•A TEP ._70. __. L. ~-L7~ K H ~ ~~ il+ P Si ntE TF/C{. ,_.k3 VEN.ILMk I.Y .MGVCO..MN![!p-._ ' y _7Nt 7P.uLL4_ vtmgL.f_ Z STPPC(R._.avnper+l-Y _An4.. _. ... ~. - _- - L--=--J ~ ! ..CvrtP46f~+..y...C AawT_!.S_~zQ fa~~L._F/nsi~.P•ACr _f~npr[p. ' I o~ PArtk A+O ;~ ~': -JrJf...PFdi._+nE 7F/SIL._.BY.TN@_.rr!.TeAnCN..rr...TnE.E'Wn:(~_f~_ ACL LET -~ -!s .RI/76_G.4i,_Tnfy0.F/pL.oF._~CN_(L4(I d.+wNY. pFO.NOr..SCk...A._._. -~~ „~ f16.NAL.fM1YM.. VtA1L[C.7r+-CWLp. H.Y.T..RtA CT_IH. TIME-.T6~pv0/0 i li 2 [OLL(JII A!.. N.. hID 4f/i. /(4MI-.!/~AL P+Ah •E yrAlCll Z CTAUCK. .~~,,.,.,, ~ `~!" }YAfVtPi[O. GAGi(h.tvY4vE)LQ[in utn!c4Ef wcFLC ORIWCfE.AFiNI... , . L . x ,..D... ........~ ..... .._ .._ ..... -. _ _ .._ , YEHICLC 10 navel H 5 F W ON STREET 0R NIOIIWAY NAPE OR NO atc IpN ° ~ ^ ^ ^ V F IY Ir N° er~iL p r ° e re1MY An•e v[. .eL oeeVn+O ^ 1t re ~ ^^ KKI[enL .I A LL. H NIL y.LA c~~. c ^ ® ^.. ^ ^ ^ ^cr«ice ~"y°,nwisN. °I^Y I r A 1~l ^ ^ ^ CAUYti PA l.4Ed N(LN WA LT ® ^ ^ ^ ^ ^ ^N, xu ' LwuMN, ^ ^ ^ ^ ALOl1a iROM TO PEOESTRIAWPEDAL CYCllST WAS USIND: ,^MP • IwN nw rr I^WL ^u.a ,^u .^u a^oI r^~! I^ra a~:w n "w• " VEDESTRIAWVEDAL CYCLIST CLOTHING COLOR: ^ eu I^Lrnr [^ .^•e i~irclo 1."".wu v~. e^°IMIi Pe" ROAD BUgfAC4 c'OM• WLAIHEP LIGHT CANORIONS 1RAfFIC COHTnOL TYPE Oi NOAO ORIVERNEHICLE ACTIONS , nr.u~ I ~DAYMDnT r^'~ I KMU ONN , ~ ^XAe IaMC• rL ~A dX r.xc[ I[nl LA awe OA U°x[ l ~II ®I~r L[--~~ I gl wlv+•~' ] ^DA WYI ^ I ^616NAL4 ^ l ^ ONE WAY ^I l ^IGOINO BINAIOHT MIEAO ! ^PAN,NO ) ^py9X ` ! ^ 9iOV S,GM ^- ® } ~ IWO WAV ^ ] ^ OVENfAXIHO ANp PA9EIN0 a; O;~ } ^SNMNNO + ^~IGnIS bN [ I f 1 ~ ,L ! ^YOIO SIGN ) ^NOV~91NLE ^ ^ ! ^ YAXINO RIGHT TURN 1 ^ ^ICE 1 ^ 10G ] ^ L Itln16 UlI[I 1 ^ + ^ ILASn,N4 NLD ~ 1 " ' ^ ~LOOP~IIAMVI ^ 1 ^ MAX,vO ltii TARN CCC ,yM1 ^ 1 ^OIIIN ,4 W I 1 ^~iw 1~YN + ^SiNie l°w.HS O R ^ 9 ^ILASn,M6 AMOLN ^ 6 ^AIIEY ^ / ^ YAXINO U~TURN ~^ . Y IG 1 ^ VpI G, ,r ^ 1 ^ NA 6,GNAL ^ L[ f TWN E ^ ^ / ^ BIOWINO AY pNMCIW MU UWAY MIR+ADk iTPt kI AI 'I ^ ~ ^r ~ W', rt "~ ~• Q ~ ^ ^ ^ / ^ Yrl,Ctn IIAGYAN ^ 1 ^ OInLP M'tL fY Yf5 ^ 1 ^ DN, [WAI ROAp S[PARATION - ^ 1 ^ 910PPlD fGn If1Al IIC ^ 1 ^ 9IDPYFO TOONAL ON BIDP SIGN , T „ (((~~~~~~iii (`T (-] [~' l •„^•r, I^::!',n ~~ "` ~~( , I !.fi~LfeN4'~ ..•Yn.. u PiFD^L _ ~4L. . ~l ~,,1 J 1 f f(MItNOI~ ...n-aaelvrnnmmx.~erne~vw......,•.. Y1 ] pDIW0f0 ^ 1 ^NNOWIOTU -~..-__ _ ^ 1 ~ ETOPP[D NIIOADWAY 0 _ ~ I IrJ In~iII IG lI%Ne. 7H/(~ ~"¢ }a• ~@.IL.. t g ~' s s -. MTei+i~d'4EfA51'frii7 kK ~ a~~ ~ ~ nm+'~ .:fix ~: T'na~r} ~ , ~~ I~!'~"tx '~: C rya ~ *~ ~ .r.: W fs .~ .5.. ~~ .wT --P•~ I D, for a ^PRIVATE WAV coum. ~ o . N ~ •_"~,Wn m '^~~R~/aO7O O .jai L: 1.• n. .u Iw ,. s.. lus[] OOe00R1 b +.. »,,. 4 o m '.,w ` ~ arvw. ^ R rowN ^N ®, ^N c NuAf6N0 Oi5fvftr ORNiGNWwv fLIW ~ U°'(] swn s 4 Mlts ®s pr, ®or Ch ao ON ~NnvOfCr nOVnrN SiR evOAD NOn rlR}fC110 ~'V/JO ~ N IttNK F M POSE ]] 0[rNRFN IS SrR[[r 6 ]f9[El DISIANC[ D.R MI t tRfN E. CROS]sfe 1 !tl 9Nt, MIIt RD r a ' ACCIDENT •ZO If[r0 5 [ W OI ~• MnEADE RAM MIA cou voN nvavtD Ntvfmn CpOE rOrAl NO O.RI! iv0 NNRED~ ^ SY HALE ^NIV6eON M rf N wNOnRI. ~ N IMF C RRMDOR HiERtNCf IS CROBSSfl t I]] d v[n ClfS ^ pR0 ,MAG[ONIV ^ e{SULrFD ^vfQrN t[f OR ROAD 9 OBJtCr SfRD(,INAMf 0100]FCr SrvOC[aNDOwNIRSNAMfI [sr DAM GF SftCWCDDIN0 t6 / [ Trees Jefferson Qount 6100.00 s UNITNO.1 UNITN0.7 ' ^VEHI ^ PEDESTRIAN ^ PEpALCVCl15T -.2 ~ 's NAM[: sr '- aer Wa a R, sfleu,ooefss °~ YEtr ADDVfSS 2 Susanna Ct ~~ CI • Sr,ff lIV CODt vnONE NO ~ Ir Lan le _- 8260 R O Wa ' ' I _ _. sf DR fRSlluNSeN O R n t I .v f]u N , O .. V KINS&WA68 Ha. H O D 2 we~R~ A,f"• _ ° C4=pQK MNAMf °RnoNf NO f s wE CN].<cnr E «curAl N tl 1 T - B U 2 6 E 4 R D. t.t5 MILNr f(ILNr CHECK (.7 MM v e.Mho~fr ~ o CM K r AN 4 (.1 CODES ~* ~ ~ S f a i CODE iwn N r • . S ~ ~ oRS , s n n i D Iv~i p a ...,„.,Ff ^ ~,Kf ^ ~a.,f. ^ „xa ^ 4~,. fw ~~.~ ,p ^ r ^ (r AR MA • IDDDLt <nfvl M«ft lDAVr NOVAI ]rv4le De CONVI « w N V I n V 1 . Es:n ^ .. ^ °sv,. MODF DARr A `I .Ow ' l Ford E . V I I ° V.1 ^ C oR uctnsf el. N sfArt .neR aAre NO rArf H rR f vfn caoR , A N A ]° ro Na. -- ~ C ..........^...... _ NlcwaNr nc.noN NO _ P Y F 3 8 6 4 486 S. Vleta Rd -" ~J s CST Vehicle 1~1 southbound on the Beaver Valley Rd, ~~iunrr 'The driver failed to ae6otiate a left oorner Sa ~~8 the roadxay, Tha vehlcla traveled down n steep , -~ ombankment. The vehiole struck several treoa -~ ~ 1 '1a.fN C.rx while travelin; down the embankment, 'Phe ~' N~8 sues nw.. >a iw "T vohiole rolled at the bottom of the ombanloment n1e7~ VAII<~ ko C\` 4 and onme to reel on the left Bide of the `~ r vehicle reatin6 a6alnet a tree stump, ~ ,t~ .u, i,f~~y Wi /WITNESSES e uR.O. Lenz Troo et W9P 8 =11 ~ 4•IC .< 35 a . ta.Iron • oaDR. D. }~QT ` r r i .t ~ ~ ~ 1 8 d I b $~ `y ssl'* ~ ~t~ 4 ~ ~e ? 6u~ ~ ,r ,, ~ , f - - r c ` ~ ( }d r ~~ '~ ~ i, I ~ ~i yy + ~ n~r4.~:~k' tit yI' fAd U r ,. ~ r I : ; r ~ ,~ ~' a ~ ~ , . ,' ;4 1;_ , ~ 1 ,~ 1 ..... _ . . ~... ~ dh~a' ~ i. Y~ I~ _ . '~ ~~ i't w. ~.... "4°:"-`F •- ~ ., ,.~ "V lMNY6''~,~ ~ •_ YfESec~.v.~.c.:..-~__iE~i`ita3Es..f ~_.,~ ~t r~ r^ WNISP (4N I e01 _ i 5~ ~ STATE OF WASHINGTON DE ~ DE 1 I ~' K •~~ ~T-~~{{ ~ POLICE TRAFFION REPORT LL] TRAFFICWAV ' ~ ~~ ~, l nA UMBF ~- ~ PRIVATE WAV ~2.1 G!.. OSU n __ Ar E riME COUNTY COUN ~~ -~ ...: ~' ~ k I I~ ~ ~i I wv I.D.. Ipt 6 ~f,~ IUet R.OD HOU41 I C I ~ I Ozoo EF eSaN• ~ CITY NO, A ~;~; ; roy q p~ ^ ^r ^" .._C PRJf~'"tpw AM aNO.asrRtEro4 nwnwAr ~ is ~s w ,~ or F~/~++ioc'vbrc O N N fH/E2 ~/R 1~ rcr ss A 4ourE O4srwt ~ ~ ~ 9'y ~ ~ - D"- .~,, a r 9oK - J I i~y ~r• ,~~ ~1 ' b ' ri Vii. ~~ ~y ?~,r t i . ~~ ~ _ f ~ ~ ' 1~~. ~ q ~I ~ 4 ~ . (. C t !, ~ ~ / ( E t. ~ a E'. ~, A/ INIEVNC l N4 verH. SiRFtr O4 vOA0 NON IN1tvNCiION Rvt1 t • ~ 1 % M4tf051 ~~Te ~~ elrwFFN ~~ 514[[1 a Si4![l 1, DI +N<F tO VE nCttlE M4[ vl CvO555rvfFt OV NFwgfSt Mil[ Mp Miw , ACCIOENI 4 D G (J1 M FS N e f W ~/ O N[i _ a /T/ D . MCOLR E Coll lOfAlNO V[D NO SVIIED~~Eq.IN1V4[D~ ^SVItAOf ^Hra4UN vD IN 5[11 4fEr0v O44tEERFNCF ww'oRDiw IN IMf4 Cl5 CROSSSR[[t04 vOAD O VFn LIES S O ^ vRO0E4rY DAMAG[ONIY ^pE3 ICED ^ l 1<I! SG9 D C"IICr StRUC%INAMf OE OBI[CI SI4UCR A U ~ NDOWNF45NAME1 - [Si OAMADE SnC AI CODING USt f ^~ UNITNO. 1 UNITNO. ~ ^ VEHICLE ^ PEDESTRIAN ^ PEDAICYCIIST Ovw1R'S NAMf: USr N M~DD,E • - n~ rE4 aNAME u,r EI Ch~~.vooeF G.gey SE4[[1 ADDelSS I4FF1 ADORt55 3 /~1/v/7E~ ST nr s t a4coot rnoNt NO. D r srwre ,4c 7own•5~ !v/q 3-63 R oRne4ss~ E NUN ' L S7~ ~~ a Mo i cp. I b I 4 l ENNNO. ME ~D+ttw e.4 H V ~ CKCUVAi ON t64Egrv[NO EYES WI E[iGM E occu4Al oN INM NAMFa RHONE NO. Ftt5 IGHI IIO ~ M ~ /So F/U R Z ^CHECK (.~ vEwflEAS:N ttrr A.MiorHEV'+1 ^CHECK (~) E • i tH~c Al A l s A' cvv or E inr4 CODES -' J i:" ' / 5 uecl ~ e y; CODES ~ + J ~I Z IN ~ss s N1cr DN a y"O ' ~'".~ H,M ..,a„.NEI ^ ~°s 1 ^ EaN.. o ~;2L ^ °~,;,. ;;t ^ NY ^ ~.~. ^ ~~za ^°'H,. RI IDODDL~CnfV.) MODll1DA41 NOVA) SirlE >D4 CONV ,Y ~ x D _ . .) n l G4 1 IDARi. vAl 1 ~ ~1 9 8 ~!~ U579/7 Z~OIe• E (/ Eo nAn NO. tArE H vtnc c[R VB/Uc L Sol euiR -- '- I NnICIt IDFMiIiCwigN NO. C vEH C F 1 > DFND I 7 ~ZI ~ ~ Q. IL I ~ ~ E I ~ I n NN I ~ ~ I %GI / SRVtDOWNt4 EASr N451 MiDgf ngN[NO i5 D wN[v: 1.51 nRN MIDIX[ .9Q ti 2 ~!/~e ~ ADD4lSSO CM'NEV ~ W A 4 Po aox /yv3 i'r• ~ry~~ E N.vneawoxtuvww4ANCe co oe AOew ~ __ D ~vcurr/ R ACED AREA pS.y NG O ED..CIwHN cHA4~ /vi aA4DE w`w,`,'., 4AMAOEpARtA w 1wwc :v DI"4DM;1 I I s t ^ Av:.." ^ 4fM,utnD a°v C ~01fOii ^ ~afMNNlD ISr.D+MAOE ~ Y 'DaonDN f .~J :ww°eY .S 7k/• ^:wnr°er: f DIAGRAM OF COLLISI N^ .LNitEi usiurl I e:A aeo"O~ DESCRIPTION OF COll1510N IusfSwneM[NrAI SHNDNtassAerl f l . afG I -- - 1ft11 _ -{(''-~7}- ~" ' /Er/ /C l E !! !F~crS`s aiv `0.9K_6!9Y _ _l.._.~ ( g l _.~ ~-I ( S7oP ~ j/!iC ~~' ' ~ ~ gip / _ I.'7 S/GN Cos~G on_tecY I Q ~ I - _._ III I ~ - I 11 1 -y!Ii0 l/~c'~.r o/E.P_E.!~6?JYK.rJ_E!a7 ow ~ i`1~1-T ~- --~---~--f -f_~ _~ _r*~ES7 sioE of-.J3Fi~vc•~-v_/vc~N1_.P/ _ _ 1 -_ _ _---- - _ i I ' I ISYWS - I T 1 ~~-~ ~. ~~~ ~ I I ~ I ~ __ __... _ .___ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ~ CODES T Z 3 d 5 6 yr OCCUPANTS /WITNESSES Ip ~NON4 N+AYSI N% AGI GEUS ' yNJ '1v - -M' „SIT lllCi 4I<Y' N A41 ^ ( M I• _ A/i 6~v__ aTut_ ~ s - m zc z 7 3 g7 pl _ ~ N+w4 a _ .nopns 27 -- N+ ~ m ~ ~ Ns. . .._ .. _ .. .. ..._ _. ~ NO vDb4ns N+IU4 a -. __.__.- 4 MovlD row. _ __.- _.. __.___. e vi .M.ns .,Yiua.l%YC (vEK14 sN.w a.. aAD . l~ ra N rNr e. ^•w ^Y ';nE ^i"o:,1. ^ "~ ^ ',~ ~ X G ~ aiiinn ~ 02o~MD I.DH., vzS3D i.oDH.s D,na4lEpr 5'-2s8-i .oYt er w I % z l ,~~ ~ ~ E / Q 1, a'FJ jj +~iA:ul la ~" ~u /U Fl F n ~ f ~~" I. ~' II ~ ~(i ~ ~ N' ~htsu. A.. ' ~ ~ ~ ,a :1l ,aULI? ~ {. z ti ~" s. e.W e~ ~_•u'"•n"'~",~'Sfl., - 'tea s~: '••%~.^rv^'~ ~.^+aw . R4, x..~,..~ ] ~ ~ ~...r ti'~•~ t3aIW"t XV9~4a ~"~ I ~ .~ ;', , y~i l I 'd r ~ I ~: II E ~ ~ 1 i ~~ ~ r'I'.. ~rM ~ ~ 1 l.:r ~1 1 ~ .! ky ~ I f a: . ' ' f ~ F ~ d ~ h f ~ ~J I +~ ~I! ~ l n~ r ',t M ~, R 1 1 1 7 ~ 6 ei `t'' 11 r g f ~ 1 S ' 1 ~~, 1' .?Y T' ~, 5~` ' ff~ i ~' {'~ F ~~'~~~. , [ ~ , / n,; ~~ 1' i~ ~L ~~~~ , ~" ^~~ 4, s I 19R 5 P ~ M~1~ P. a >~, Y J, d ~[ JJ ??~yy$f ~T1yy~~ 1 A~'1.1pNi1 y~ I ` POLICE TRAFFIC CO REPORT Ijsl TRAFFICY/AT DER _ ' / ~ PRIVATE WAY - / ( , At iMf fU5[]KDDNOURf counrr co N rNC c My Q v '~ - ~Ru ~,/ ^N Qf ^IH crr o°rowN ~~E,,a NO../a Sr~R/{~[II OR HIGnWh /.S_M U5 ^w aC irlAG/.rf ON 1~7[~ 1~ iTu Cl cls ~ 4 // ~ R ~'T ~JrlJ ~C ,,,z IN,FRSEC NG Wrn. Sr4Flf OR 4pAD NONINiCtRSfCrNSN Dt,wEiSr'G~~r~,affra Jur.4.USo,,,,1 RtH% f FNS ~~ ~'(,~ -J OS •NCf ~ 1 N CROSS SIRE[ IARf51 ~l 5[7o M%ES H R 5 w lal of EGG r gyp. ACCIDFNi MILEAGE CGDE , D G DAIh . ", .,~ F f ' COIUSgNINVgVFD ER rr. ~ ^SPillACf ^Ntl4UN NO IN[V4fD KI L[D wrvlDilDr" N %4D N IM[R IS C ERfNC rF ffrOR RO OR 405331R[f104 pOAD . `. , ~ . E IOIAI NO NO aVFn CI[S ~RPOrt4ty D•MAGt ONLY ^IR(SUIRD ^VtaClf -~ ~S~~oD ~' , M AG[ D A OalFC13rRUCK INAMf O[CBI[Cr Sr4UCK AND OWNt43 NAMFI ESi SDEGAI CODING IbE - ~_ ~ // .~ ~ UNIT NO.I UNIT NO.Y~ ^VEHICLE': Q PEDESTRIAN .^PEDAICVCIIST• ~' - DR V(45Nwf vsl1 NR C) {i•1-SON l t s~ OR VFR NAM[. N5r I ~ _ r e~ 514tEr ADDRESS l ~~f RFI MDRESS f -- lhr :scow oNf NO r~ ti D r Arf I . r r o ~ _., G SK .3E.i538~ 2 1 lR'S DCFNSEH 3rArf f% n I i lK N N A t K t A ~1 TO~/J.S/u-/[ ~~ D II S!~ i I ~ ~ AMf a RIgN[ [ E GEFI iG t tYFS OCCURA ipN HRM NAMf { °MNE NO . 9 CHECK (/) ~v[n¢fA: Divv AHOrn OCMECK (~ wnaE•sA ~o IaAHO,HFV J~j~_ CODES-' 7 ~ ' L s i e ~° CODES -' G ~ . s moon a is , `' °L _ wes si;~yo, ^ :,M ^ A,Kr ^ zs~l ^ :. w pn O•" wn~~;r „ o .M ~R ^ ~sN, o vE o r.~5. KD ~ UY O MA.f goocETcn Vin rl! fVl 1 [ q MODIIIDARr~NOV I 5rrll 11D9 ~CONV.) S (O $(LrJ E .r ( 1 A°. vAI I = x N u A sl.rF A,lfR n.IF NO s,` H Fn [RER5~,1 ~23 ~' titl.4• - I C ~ 0 InKlf DIM HCAigN NO vfn,Cl DN 1 • C~NL~A f of I~o3 y'~ z ~~ i ` I ~ ~ ~ i ~ l ~ ~ i i i i RIGi5114iDOwNiR IwSr 6451 MiDOtI RHOM NO S/~~rE- /~.,'G O W WN R: L 41 NvSr ~ e 2 •DDnssaow«f4 N , 4z,. , ri 4~'~ a•clNr AMU ADDRU xn.NCi cD R 1V ' -. u . ~ 4[A u ~ ~' p4hAG MG - R wD DAMAGI M. "^CiO"'~ CNMCt .~~ Cn•1Gi ] 4TDI IG~OT10iiAa 1St.pwAGl D~^N ^41M•iHlp ^A°~r ^4[MYH10 ip'~ • M I W ' 10 ORO -b ,/ rOWID4 awA1[•~/C~~ .. ^ lOwtD f •r erg - _ _ I AG AM OF COIU ION: NITS '.in No c•1 NoRln DESCRIPTION Of COLLISION: Ilne suRneMaMU SMnn Ntau•4rl DI ,_ _ ., ,_ ecEts•Ell J sr.d4ow ~ ~x~ I ~ _~ I _-o°- _ _~« . ~ _ s~ ~uro a~Y?c~ .Q,frJ-oU~t'- QC/,P6/rtJG. Yo-~Gdr Ada I.v e ~~ i ' ~ ~ ' ; I ! ~'D _ " _ ~ , - . . _ _ . _ .; , . I ,_ , . , _I~4ua .Qo~cNl _aUe~.2s!car,~Uiv,Cm~.--~m77~eii~:/.rJG_rriaOc~ ,_ I ~ , ,. __ _ ~ ~ I-; I 1 _ ' ~ I ~_ I . _. - _ _ _ _ 1-- .~.. I 1-~ I I I~~T-- --- I f , ~ __ -- ------------ ------ ------._-- I I I i ~ NAME, ADDRESS NJURIES OF PERSONS INVOLVED ~ CO DES 1 - Z - 3 ~ 5 6 _ OCCUPANTS/WITNESSES nl won~a:a ww" ii _ ~ii4 •ci .ros '„'"" nsn irci "~[~ EnoRiS ° ..i vCC/.S. .K..S er w 4 ^eY5"l ^'"~ ~IL4:,v wl Gi '-O l) ~!J e1 ma N7 ~ ND A ~ y . .Dwla i~ ,.. ~ lw L Ewa al ~" ~ ;° • S.OV101 OY 5. .D _ wi D~ ~"vi~ .%S.S o.J Sig ~. G°• No ~ ~~VR IIS1 .s,'~.,.. 0 NlUR ~1 E Oi.1~_ S IM ~. ^:M4 ^la Ki ^ do : ^~.~.,. D M D•n «.ul •~+.car2u sN•MUUa a•uD4 wINC• "ol qq • o•na nroOn •rnovl X [ %' .o NO ` J J ail i on ~T.~~ ~ i~ G A//"~3'V _. ., yidhylwrnR,xO,y~K. .. , ;~ ~..,~ ~. YA T EFeV~Til ' ~ Nrv M. ' '2 l ~¢~ ~ 43 ~1 ..~ .~l(9 ~ y ~ 1 ~ ~.~ ~r ~l C- ~ 1 ~ 4 ~ ~ ^~ ~~~ x~.:~ ,. Mtn'' , '~ t~ dd 4 ~ -y. x.4 I >t< ~~ L • { 7 tl ~ ,~1 '~.~., ~f ~ :. , ~ a! ~~ ~~ ~~.,4 '' ~~ tn~'t`~ v r-~- ~" ~,'F' ,n 1 ~` •„~ ,. h :: .~ ,.fit ~ ~: vhn ~ ~' .., l~tq ~ w: ~>f F d~~ E ' ~ ~} ~au` 4'''. Y 'Y. r. t '4 I~ 3 ~ s ~~~ ~~ P ~. ~.. - ~~: ~f r- vr H{3•tf" 9 ~' ~ PRIVATE WAY AEE OE COLE •"•~ ' ~ ~ .. ~ ~. . v .; -I.a ,rurl ,w ,-r::-,l l.~. IDS/iY Y'J co~CTj4~.L0~ cGUNrY ~~ Crtrw. .:... Q`uo" . CIY09 rOwN feN0. 015tPEfrOR iGNWAV ~ S Q rR ClS uPAI r PW L OR SrR r ~ (_JS QW ~~~~r1~~// I( OE NrERSFCr NG wrN~SIRFr09 ROAp rgNrNtAf9ff~ ~ ON L CriON / ~ TQ~..SO n • pSrANLF eO Rf R RFiPNC CR OSS ~// /~E Pf~ r~' (( BERVfEN D/ { E- dr4Err{ ~'!`~10 7ytR[Et SraffIOR NEn4f5r If POSr PYff% f Miff POSt ~ 6/ V 1SD Ml[5 N 5 F ACCIDENT 6 EVEr O! MILEAGE RnMV OnORNn OArw COIIBON EO SvfR rv. CODE rOtAI NO 1~.'!~.~ NO RllE0~N0. N1LPfp~ ^SR IIAGfR ^Nrr69UN wrvrRrNw ~ bV[N <lE5 ^PR w %R N P ri Sr OR 50Ap OR RfiERNCf Mf CIS CROSS SnlF10RR0A0 1» L pRRrY OAMnGF ONLY W ^oisultfD ^SE~'c"u. O/~~f~Cr~Sr~RU{C~K IN ~(,\OE~O.B1F~Ct1StRU RNER OwN[q SNAMEI [SI04nAG[ ^ F{ A la O SRC AI CODING IAf - _. f '• /_~11-._ ~•l•l N•A 1`_t I lit F A/'D•E~ UNITNO. I UNITN0.2 ^SVEMICLE ^ PEDESTRIAN ^ PEDALCYCLIST S Ov vfR SNNnf~ NSr ErRSt Mi OR VER'S NAMf: t ~• P I SrefEI AOORFSS lRffrAWRE55 rJr. ~ ois ~~rv~r~. Yr~CC .Pa Srnrf D tiP COIX PNpN NO ~, i 5 nrf T CLI.¢L6s~T/ -Ld/ - ~ R ' _ ~-• DRNER 3 UCENSEN ~e~r~ ie 3610 F S A f ~t ~o~~'~• ~ rV l ENSfNG ~' ~ I.E OA FOf BrR N occuPArroN E 6 RgNE NO Ens s cNr 1<c1 t F occDPnr oN AMf s R Q1ge~j~ Ens wNr r<roNr Z DAL r/! r~ ,~ 6 R M N ^ CMECK (.~ vEN Cif AS AN rMrtovEE OE nNOrNF ^ CHECK (~( AE CODES -' % ~ r vfN Cl[ F.n%OYFFOE •NOMFR n p.r Z 5 1 ° sa1D.c. ~ CODES ~ ~ J ci 4rF5 5 1% y y ° p1w '• ]i n~.uR M ^IAMBUI. cnfv ^'c " °•LMWEQ c6r. ^ vi ' Q.or~ rii:uE~~v~ N~u .oM r ^ <roL<' .'^ cSm. w I Mv) MODfI IDARr NOYn Ku r '°D"` 7 7 /`fl~,0 'b I E ~ f ~X E Y CK LK I~ X6.3 5 nrf R fR RAIf NO. Srnrf H vFN CIXON •t~~ -- I ve K: oeNrnrc~aN NO. C Y A L FN Clf r N '3 ~~ p! d1013!0~ I ~ ~ ~ ~ s ~ ~ i ~ o ~ l ; I RG rFR Ow N[ R 1 A5 r TT ~~ 51 MrpDl[ RgNE Np O P rt D wi,ER. t N st MrDIXf f~~~~~~I f l~~~vE~~~ T t~C~ ~ . rD AooeessvowN W N GwNER Z to ~! D ~c~}-vEl2 ~ ~ Tr p , A L i AMia AOOREUarmwe.NCECO oB ACENt E ND,t~~ R oAMAC D eA R ~ SR _ L N CN Gu CNAPGf r NnCrp° g•MAOED MG IS~OnwAGE r ll ... LnYM/ t r S DAMnGf p. ^AW~v ^RIMArNED ^nWAYN ^ FSI owm RfMAmEp 5 "~ unbii s v ^ iwir°er: S re DIAGRAM OFC-QLl y: ~u~E nEMFN w~unrEwm DESCRIPTION OF COIUSION: usf suoR[wNrAl sNen ENecESSARv !N~-r 1f Newsuq Row }}~~ ~ ~~ ~i a~~~ Vil-e.~ex, ~A. ~ OAK t,L~s->~arra~? ., W - ~- r Va~• ,ks to R ~r- dc[R•~ ttc~L) A,~+.~r - 5 ~ f L.bss- Qe,LJT~oL av-~eai ,: U ~ ~ . ____. \ _ _.. ~.. _ I ~ r ~ : •'~.~ Aa~~ Ger S Sc-A a U~ ,pcc~c-~.t.~JG. _ ! ~LIr.U-- _ ~ E ~ , I v ~U~-E~_ w•.GT /A1lr-_Y'O es7~- p~t~.L(~E~c'c.+..~t.,. I iR . I ~ I i i ; ..... - ..._...__ ___ .. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED C0DE5 I - Z 3 ~ 5 6 OCCUPANTS/WITNESSES ~~~^rt wl"i NAnu ,.,,,E si . 3 _ Ace uru 'N v.r- - " R Y nsre ena :c N r .~ ~, .Y ':,,. AD0e155 NAEW • ... ... -~.- 0 '~ R MWID iROM ^nMl ^lar%r Qr+wne ^vi: ^ri~w5r ... NOf .. . __. •°01145 N v55ro.r„p-,•r.ct 5 e c<a a .. N w MV~ ev uE ^•Me ^e ~%E ^'t"o.nE ^ w; ^ ~ :;v X ~,J. L ~i.S~cr&~SUiIG' °di rNC. 6U.S~ . r ciDS •rc rc ~ 3 K rOIKE Ruao ~.~ oul~ w r r P AP..DVfoe. o n >a I Ai.E, s~ ,_r..... _ ~~ , . .~_ „ ~ e ., _ _ z :~•. r~ $ thy. ~,~' y eS + ~? ,~,Y; ~~ ,. f tr a ~~ ~ I _ n? N'E+' ;° ~{ n l ~, ~: ~ B °~ f - ~• 1 ~. (~ ;:~ ~'z x. ~' ."~. tfi.~~~ >P.2T e° ~ ~:' r "~ a "~ ~ .~~~, f 4 t ~ F '~ ~ ~ n ti ~'. ~~ ~ ~~ ? .,;~ ~ L ~~~ ir~ 4 ~: C a S ..t a,__: a ~ .. ~ j~ F'" f j7 1 ~ 9•ry ~y ~~ ~. l'. ~ ~,_ ~ ,47e L I~ . T 4 ?. ~- ' ~ ~ . 4~-.1( ~. ~ ;r.. [ YA t s } 1 l er~ w• ~ i ,:~ ~ . ~ ~' ~, ;5~ F ~r~ . i ~~ A~ * 'r' ~ k { ~~ 4 , j _ - ,~« 1 L . r ~.. ~' 3 I j 1 i ~.... i r, 1 ~~ d i_; ;~ ~ .. r~.w ~I" ti:0 o° ~ ~ Y i o ' W . , i ~ ~ O ' { O ~~ ~ ~0 Y9 ~~~ V ~ I: ;, G =c ,~ ~ U . y t QQ K °~!~iv jr~~~(~~fIS 5~1)y~~.'rt: it ~I',.~ ~ ~~. I i } I i~ y 7~. J ~ ~ 3'?N ~I~ W'~'' ~~~ ,- ,,~, .; L - - -.o--- `-- iy ~~ ~ STATE OF WAINCsTON vcr / Dr / W59de119 ' 3 No.1 I 12 77 fi {i,~ / ~'+O POLICE TRAFFIC COL. ON REPORT ~TRAFFICWAV PoIKe cOMquNr NUMpte t. ~-ry ~"'~ ~ PRIVATE WAV ,kr~ _D.EI rc«rs.-.N I lus Mrp co c CIrrNO qvA ~45L.f I ~, ~ li. ~ ~ r./~~ SEFFEJeSOw ~ p`wn•N rr Oe rOwN a eN {5 O Or IN f o st ovw r cu D.N I M cdJnovsrvcF c r v "'•~.. n mACVVn ON ~` t E - of 05f ^w ^O NoN lNreesect oN ~hOCD ~C iJ ~ /.~.~Q` € f•~"~ INrlevcl NC VnrN tvgr ov eo•D fn06=PSOsi x _ '9 Mer ros, J, ~ y ~ ~ p ' D~suwaap r 1rt9nEN EQ/E/ vema pCG` near Y• T I Mx'f a erf el r CIOSSStelrr N[• SI MiI[v0 ACCIDENT a 9AM p•rA ~~,~..,, rEI w Or ~~/ / i..7. / MILEAGE I e call~sloNwvanD vH, vRelrr f~L//Ty cow Ax vD IN I srq[I OV OOw ov mgoENCI 4 4 {~'^.~~a IOfN NO Il[D~NO INJwlD~ ^SeRI.OF ^NIr64UN wvogor" IN I fe CIS C405531Pf[tOV WAO ~ ' bV(N G[f ~ veOglly DAMAGE DwIY 1rdrN ~~ O ~ `?~ '~ osncr v+ucxlNAMea Dena sducv ANDOV.mle s.uMn OwsulrtD ^vlN fl[ ;. Est DAM.wES sgcM COwNC USe S "'~ UNit NO. 1 UNI7 NO. Z VEHICLE Q PEDESTRIAN ~ PEDAICVCLIST wivlvSNNnf MIDwr Co vre SNAMI: Ufr - ~, - `~} n ~/.Q7/SS rtes ~~y/'/~ ~ /J _/ a 9 Sre,IIADDef15 teE1,ADDerSf ~diy -~/~ J~ ~ Zz / ~,e ~' otF u on/ ~ Q6 ~ ~I ••"~ fur xlvcod vrwNrNO D I / It. OP_ ~kuq r 4~A 6 .~/ R /.S6o Gcv~ ClF3X 2 / s~' ,~ Demes uceNV" sun x N I ~ I Nv NO Are . DA eleN ` DccDeAtGDN~T//JJAMI 1NO /fi Ir'/ 7 ~ Z7t04 V ~fTt/~ /~O~// ff /~,y9 ~ "° I °"r {~ / ~f MN `~~ cNl rawNr E oc<D •rloN eagl/oNe NO. s iGNi raK,N i.q .Z _' ,~ C-7/P-F/.~ ~ s R Eat' r (0 .~7./ 'T/J `/~ / w ~ CHECK (/( vrN Cie •s:N M vlrnn•NOrNSe •I ^ CHECK (,~ CODES -' ] ~ . y I A,,,p{I~, 5 DAgogra ANOrNre I {~' CODES ®' ] ~ ••Ai°, s rx A +~ •E n IR Oi „ ON n.,n nb °.:~ :",' fn»"' noN IoprCr n "ice ~~+~.,I,..c~ly,°"`'`I ,°,~`"S"nov.l „itvn l]DO ONV, vMOD`n,.o.. ^.vv..NCt pTgc, ^'c5"~I. onRl.~. ro ,rY X73 N Y. MDdI ID NovA,/ ; ", , '' [-17rv IPO ulreA•rENO SrMr H „N Pv S /.nT -OL /~iC,/LrK,fa~ ~ ir~i9 ~_ C ~ 7 f ~ _ 9~ 1 v IN Cll Id Nrl I 0 L v ct ~zl~1i s ~ ti t~~ /,~ zl t a i I. N ~t ~6~ t t/ t erasnnwovmre uur riesr INOM UO ~ nel vmre. Asr I nesr M~roff = J: N Apper SlP OVMII S~~/I/E W I S~E ~ ~~ `f.'M 2. S-•~F~C E f1 S'~r7C Ayb- I AMS UDwISSb INw1•NCe co ov ACrm .~___-_ ' ~ ~1~ /f/o,T~E R ran - S6~t7~Lf" I a . 'i ~ D•A./Ll AeIA ~ / 7 D ~ I ~ ~ " ry[iON•l CNN K CN•IG `- w~cr ~A iMM,GIDMG ~ F4 ` ~ '~ ~ oY f if pAM DI I,r ^eeMUN[D D9~H ^y1MMNfD IS IDAMAG{ I ! 4 .~ 3 DMTD ~ ti ~ DIAGRAM Of COLLISION O a a.q,. N wc•n ^ p':r ar. f~~i~D ~ F ~ ~ } f. r ~ '. I 1 - - ~ n NI u 1 • •vlow DESCRIPTION Of COLLISION Luse sunruM, wLlH a5wn ID }, : y'+ ,~L~~ f ~ ~--~ #-~_ ~ ~ ~fE 1 ~O _~!E.S~iL~~ d - _~,es~i~/ny ;Sow-Ti-- ~,;,~~h ' ~' ' ~ ' { -Vthrc%._ _7/~P/~.7~i /T/ara•~r~ x,'k: . - __. _. N , .. _,.. wrr ~ +~~--~- ~_{ i..: , ~ ±-~ --~ t - .. ~- I Vrhlclc .~ d1.. 7v~/7.~, .~f~G~O"~-i' r 4. '~ ,, ,.. _ _ ~~dy 4{ Jn jtI i WITNESSES - I 4 1 J I~ , ' j ~~ ru+n ~5 _`~~~.-c _.- v`_ i_ .... - 'r°rwroY ~ 7S~S7" Fr - _ _ p.. I ~~ ~ +` ~~ Cu ( ~ n r .. p AMe o ill" O "..N '~' 1:UdFyS bD11 s5 7 ... /1 .$HrYJt T x •rwra ~ - ~y .,. I,: ^. AMr.. /CC _ k'e iS No /J/OXG MasrDreDM Z•Me aCA ` { pFp"~"' ... ~ ~~ ,,. Dn.f+.rnrK..l..o~ _1•! ..... N wta ~''S`0./+/ f .7 ^.ME ^"":' Oro:~l. 1 ( X eAwr .u.K. ~ cID S..ICwD IQ[I •v1 .+D DMrp nro.r • viD N" o^ ~:v NO ~ ~Drl ,, „ ~ ;l r i ;-~;_ .. ~. ~i ~ ~w ~ r , }: I, ~~~± ~ ' 'K..~~''~~ _ _ c , n;~r *3~` irei ~ . r ~. - [Si~ ~ ~ ¢k 4 ~~ a -. ., ~~ Vim; - n .: v .. ! ~ 6 - -- - - - _..._.._.. ~ ., s... .. ." ;~., . . O STATE OF W IMGTON '~ .r ~o `~~' ~~~ p O ( / Or/ WSp..R.ISD `~ ~ ~ /~ ~ pl ' POLICE TRAFFIC C ~~' , ~ ' OLLISION REPORT ~y TRAFFICWAy tE I ~ rouc(coMnw ' , - Nunsefe o+rE Orcaus ~ VRIVAtE WAY "r , ~' l ~~ w cou"r. f , 1 , fD, ,.lr „nr. rO IUS[]r0p "OUaI <OVNIY <IrY NO. ' !o ay -~G~~FL~/Z5'o..) Up d_+_ Y.~ >{ WN µ MI[s ^s w' or /~/~G / E . a0u(E i c x ~` ON E' F - f •~ iNre pxn NC wnN xneroa RO+o ob NoN mnaxcr o" ~O F , f j' J7f ~ re. ~ ~ MRF LOS of MR[v ~~ A/ G r l0 S e `~ L j ' ' ~~° 11r ° ~' ~ ~ 4 .w ( (NRt EQVI p~, !vt[rt l~A s A[(I L +w [5 H v(59f fF Cv015 efv[fl NE+RE r~ w A R 1~ ~ CC CENT p f11wGa+.wP+iw rffr Or MILEAGE CO(US ONI Nvav[o R'~ ,,,,EE.. , . r ~'u.~~n i a Cow v[R ror,s(Ea No . [iic '~• No INluaeo~_ ^ sp [i+cE ^ N r a Ruf ,v,;q,r , " .RO .N Or of"nfs ^pROpeRrvo+M+cf oN(Y ^rR ~ "^[ as ca P 9OipaR mrewNCE assrc oet oe U " 1 !' ~"' * ' y~ I a ffr ~ gwn S Erto ^ve°fli (cr/sraua EN+,«(/oJpoaecr srvUCR +woowNER Sra..Wfl ~' /MULE / ~// FSI. O+.M sRC4N 000~NG (bf I G F~ r'~; ¢~ °' ° E~~v ~ UNIT NO.1 EG s oarvtvsN - ~~ '..y'~n 5 ~~ ' ~~" 11 w.Wf~ vsr qer M UNgI7N0. Z ^ VEHICLE ^ PEDESTRIAN J EG ~ sNwwf B1 ^ PEDAECYCIIEi s f ' COL/ Cit. 'r~A i i ~ ~ 1 : 9 ., srpe(r+rroRess ~~ S _ / O. 3 afr.ruogfss _ ~ s/ 1 ~('. r. ' s+rf npcoof Y A J~C w - ter" rxE easucwsE 33 9 ~ a ~ ~,~ I sr V E eNx r+o. • e el n CoLL j DSSo3L /~ p / c LsJ G•J'T H'/ CO (~6 S + G ro i w t apNONf NO. r :' ~~ s ~ ~ R c~..rA~ ~ /!. ~ J E cup+naN ss EEn+Ee 1 naNe No fns IL i - R ~ '~ sa i ~ NI IcEEr ^ CHECK (/( U rclf+s ri s +N CM ~Y CODES ~ ~ ]r" ~ v ^ CHECK (.~ I vEVKI(+ IN ! wN~ e w rc.<s~ CODES - ~ or+NOrfee ' rrn N ivtts + [ { ~ y~I~ .. 7 ry ,~1 ~~ ' ~ ~ ] a .u i:in+°" 5 (a ioN 6 vw'ncr< q w G nN M~ .fus[IEVOGf.C"[vO ~ M:: I a N e . y M9E Io EE I]o ONVI y ^ ' ^[~' ^ ~~ J/O ~E (~ /A .i // s~. ~ ^rE ^r:°NS. ~ ~1 NrcoE(ro+R "tv ' y ~ . +I l I "v" ~/2 E I xn+ sr+r ~ ~ " ~Fi l wneaa+r[w I'J el+f I'I nN COI - b A " r~rlGl NO. ~ , I ~ 4 ~ ., '~ ~ v( ,~, y viG,Sr[afUOw+RR E,LLr ~ I ,. ~~ _ D I qSf OOEf npr{rp R IS E wNER: EASE I I ( I I ( ~ I / nnr M, nnoaeuor ow+fla ~9E ~L" W /~,tl~//-.G iJa.27Nt~ESl T,jrrGG r;~ a R~. a ~ S.s~~ +..Ef.oovesso~NSw+ 'DtE DiL 3" NCECO c++c[Nr E /~o/z ~ a , oNM+clo+RU S3 b~J/ sa ~ ~ r ~ ~ E Prr~7~. ~ s.D. of owa° [N oo ~ -^ "o s ~ e': s [v o+v.~ ^ . ';:" cN+ICf g.w,fcEp',51 vl NIO DCr ' w a r: • c ,~ ~+~ ' r d ~ t '~ r w[ol p f .~O ~i(E +o ~ oR~nN yI-7+ l Neo Iss on•+ E eY DIAGRAM OF COLLISION c+e7" ^!w vsr. i.%~/Y RM+ Y 1 ! ~ i I I I I 5N~1 I «fsiun • Row r" DESCEIPi pN OE (pf11510N Iuu swnewNr ` '~ . ~' b~ f .u sE.EEn Eepss+uYl h% .dam . //~ ~ ^~~ f ~ ,. Y ~ s .S ,/rr~ c,.J fl~ t ~/~l~ I I ' tv P. ., ,. ~ P 6+T T.v G.r.~Cl ! I~G~Y ~ ~O6 - C'9 f 6/~s/6'!~ _ G . / ~. ~/ w a ' ' ~ ,_ ~ I~ • ~ •r ' • . E _ Tis~B '~ L~~ ` i ! ' - v.~,s/ T/I~ JT~ . ,l I ~ • ~ 5]r . 1 A..ittac i ( f-r I :~/".-a ~ ~ D6 .._ .rS I 1 ( ~ ii - _'- ...f~ LOT r ..; ®I ~~ j~cCE ~iyz9 __ _ _ . _ __ ~ ~ - Yt ~I %r+ , ~ '~^~ +,A;.. `~? '. ~; ~ ~ ! . ~ Rev/s' 1. 'E+ "~ r ~ ~ ~ rAwacC ~ I..1. o/.f/a2 . °~3. 10.3 ~ S S, f ~.._.. ~ _- -. .__ _ ... _~ '~ NAME, ADDRESS 81NJURIES OF PERSON ~ ~~7`a ~~T r ~ + 7 S INVOLVED _ _ OCCUPANTS/WITNESSES Ivsewne+vNrusEaerCODES 1 rw+opu M y ~.~ ~' 5 r y f . 1 t N M oNU NUAEN, va f p CA S : ici ii, NSTM. v at. a, S 6 rcv ~Mx~ll a ,. n fit"' No - G ~ / § ~ ~ j l ; +~~v a ~n + / i r _~ . i ' ' 3 uy •f v J .aWlorloM ! a ~ ~ ~! . " ^.. ru .... ~ ^+M. ~R.E __ Nit yi0f .. wall ++tiOpr ~~ •Cf ~ +fiN. .. y 5A ~ ~ <I E 1 rla+NV ^ ,T ~77/. .~ / ~~. 14 !O +GINCr aw~rW Oslogl+<Me rpr+. .`..,..~.MI ^EURr ^c~ainv.~w. ^:°..... 'i ' ,.. (. ...v POLICE TRAFFIC COLLISION REPORT L25 TRAFFICWAY IaKrcoMrwNtNWAUR ~" - '~ ~~~ PRIVATE WAY I ~, ~ ,, D+[f 0[CWI~ COIL IiMf COUNT, COUN[YNO. CIrv NO. iNWA ~~; y ~4. • Wr uWp YI NOf~ /OI -y~~ pURBN1 t: 'W / x Oe IOW M1F ~f...~)QT] RAl ~i' k'+':P [ pN p nNO o ft[oe Nic«wwr ra as eou[f ~t 3~ I uNC. s[Rt NONm sfcNDN --// K Retrix a Mu[ros ~~aY~y, µ~_ -.te,' atrv+ewLOWL~K !v`s~R[f[n L /ieC ~JO/Js[e[tT D.N T '~ / Dvw coRfa oN raoMeut fNC cROSSS[RazoR NUefvM meosi R it ~ [S 5 ! W ACC DENT n DUORAM O+IA ~~F 11 ~ D~/~ MILEAGE F 3 riF[ Or ~Ltl L~ /,OL /l KJ CDDf ~.,R• musovwvavtD vtvtR~,. "«sN w x. m cD Rtfr RROw00R artnNU R~ w roof NO No n4[D_NO. WURtD_ ^ eO ll+Gf ^ N 16 RU rovoam. iNRR 01055 s1R[[loe ROAp -/ W vtN C1[s Q eeoRfv[rD+m+etowY ^e[SUl[[D ^vtO1~i[N yst .~~' OBIlC, 51vuC51NMntW OW[CI5[eUC. •NDOwrvfRSNAMFI t51 OAMwt SPfCW COD1N0lae jr~'`[~~ UNITNO.I UNITN0.2 ^VEHICIE pPEDESTRIAN ^PEDALCYCLIST ~' .G /~" W[esNUwa NS[ ri i IX ~' ~'~ E s ~Ye,C/ / ~0 Usr ro ~ ~f --- ~ Y 51v[FlwppRS51 IRt[l DRf55 v SZ f~rY nSA)6- ~ DNf ND Y .R f / su,f nr coa D suzf oR 35 R ~~• pRN[R'S 4C[NSf NO 5[ [f fx rB~R[N I ~v 's DCtNY wif Dw1fWBi RI« ~f 4y n oe<uRAnoN MNwMfae«oNt NO. tres ~eN[ rage«r E ocewAnoN •z"[n RNON[NO. [ns wf1G«f inieNz Z rJ~T nR g y R kr,` '' ^ CHECK(/) s:Nw.nortawi,olNfewl ^CHECK I/1 ~~i lvtw +swN fmaortto[wN""'"ofNtewl ~" ~ t ~..>Li .~ CODES-' ] nis w/,tA~ n s loc. o, ~ e ^'°ro°`.n'_ CODEf - * ] n.u s Nl wN a ;; o„ .1« n ~;; ,. ,~ R~' ^ +MN,I.NTI p rol '" p 2bN1. ^ aNSO p A„NA.„fr p L2:,rR ^ H.al p :4„,. ~ MwRf IDODOf.CNtv.l DID rNOVwI •¢RDe toNV, nw I .CN V.( •DtllD.w[ vA1 I vl v< twR DIP IN7D 5Y .2 ~2 E « l .l w ~:. N a ua ,w,[ 1fRnwrf NO vw,f H vt«<WOR m 'fib; c. acu /a7QAC 5Wh - ' ~. V[NiCIf iIXNlirKwEgN NO. i vlNiClf D[N11NCn1 ~ .'~,~, R[eiSRRF00 [R Wt rlesf OIXr' RNONf NO O R ~S RSD wN[9. 1A51 ri SR M1 ~ ,~e ~ o~ ADDRfaWO.w/tp~ W + - `.: . ,I ~ ~ ~ .4 N+M[a.DwuK//JiiJL~co a.clNr OIti~C/47f~~ E wNfR GNU ] M Ili. d r ~~ R ~ .. fuMwf .xrw DuAAee ~ u S yl - ~ Dw0.ow CNwRW CNwRDt Vow corDiN ]] ~~ n+ 4 ,~. 1a !S[ pwMwOf wwvll`,N ktMWNtD ~ AWAY lSR ,DwMwf V f OOO ^ erV O. // ^ ^etMNNFD [owsswi~D ~C.S b ^:wvrenr f 1 ~ _. f DIAGRAM OF COUISION~ 1u • c gNOR[N DESCRIPTION OF COLLISION Ilxi[sun[M1M sNtn MCFS I • r ' r .; n T .., _i Inez .Anyssxa., a ow .,__ __. .-, a -. _... ' ~ I :.. I f. I , , 1 -i', # i r-I ~ R. _.,!>~P/ddx tr/.95. i9rYc:sr>idG_._T ---- ~ .'~ • ,}, ~' `rn .: .~; ~,~ _ , ' ~ :. ,~ ~ Nor ~QTAc.Dac~LarT~ C ThoL~_.~ ~., 9` .' a s t' ~ ... .. '+I 1f NAME. ADDRESS 81NJURIES OF PERSONS INVOLVED wx sR+n[Mfmwl swl, 'CODES 1 - 2 3 4 5 6 OCCUPANTS/WITNESSES .~" ~•~ ",<• ``e Ip +DD'ONwI N+Mr3 SI• A01 [D5 «. n1510 IllCl • ~ r~x ,, .r Vnr v. wr or INf e. +Me p :h11 p~" . p~ p :Y4. ~ :uYdB"O"p.Mn p••ti1p< .^C p~::,.. ~~' r~ l~ ~~ ~~ ' ~~ :A ~~~ ~ ,.~ R+~G1OR T r t .~f` X -~~'~,v~~'rsZ,~r T fcSU 2 ~ogi~'«wo~~.70~a~•P~ <Di9fRf~ ~ '~,'~,~~ ,. ~c ylvl ' ti ~ 'r•e~.,:: '~ t '.:'.. I_ , ~ - j f4'•4'~ EI Y 7 [ ~ , .~ p u~ ~ I Tt r 1 1 - ~ b iP~ ".I~ DO" A V~[Nd5 _ 5 [' ~~ff ~~ .!~ II YA is{{ 1 v ~, l 1 ~. _ - r ~i -.q 1 c J tr I~ S •cl 1 . r z 7 - 1 ~ 4, t ~[11 ~~ ~ r'pl ^eya a ' ' tii ~ .' 11t l ~, ~1~1 t ~ r ~I Y • .'. i I..l~i ' :~ 1 ~.. ;5. r ~t xy v~ ._ ~~~ )F N.~n U[ '• w~ Sr ` ' "'~ , r' L~~~ .x v~l .... ... ~M' 7 ~~~ POLICE TRAFFIC COLLISION REPORT ~TRAFFICWAV IOIICF COMISNNfNUM&4 PRIVATE WAV DArI Or COIU / 4~r ~~j jfj3 1,M[ yi ~f]'UO~OU91 % COUNiv E FE OOUNfV NO. CIIY NO, iMVA ~U4BAN 4q, ~' ~N ~' CIIY OR fOwN nN0 Of 5iPFf10R»IG»WAV E ~ MNS or ~.Al9iACaC~ OND~K f~ C15 it Cat y C ,t rING wIi» fr4t1104 wp NON INrFeHC1ION '/ p4ff1% f MllE qli /' / ~~ " BIiWi[f~(J'E KAOE4f1 SiP[fln LCCNOS. 1-Op fjtv[fl ~E ©•~ / / psl Clnpa reON Ptrta[N<t CROSSSIaItr OR Nlwatsl Mll vO yt 3 s F w ACCIDENT v a DIwG4Ml p.iq ^~ r OI /~C ^~ 6~ NF1 MCODEf COII;ON NVIXVfp NO SeII[D~rvO N)UV[D_ ^Se IIAGF ^»rneU O,wI NO N wNpn4l. IMF4 Cl5 0106551F504 BOwp vWDOI1 F[H4[HR .I]D OV(»Cl[S I40R4fv DAMwG[ONIr ^efS liFD ~S~OIlN U Cl( ~l O• _ p % OBIi(tjJYvuC[IrvwMtd FC, SIeUCr..W00W swvntl FSI.DAMac[ ~ SefCLLL CODING VS! ^ ( / f ~ UNITNO. 1 UNIT N0.2 ~ VEHICLE ~ PEDESTRIAN ^ PEDALCYCLIST ~' s p4nl s AMt. usr flan MlDplt nasNw•ne us* e I t S Z slate, gopafss A'7o Fl_AGLc-'~2 /~Q etli paws vwff :Iacou .»oNf NO r D r t II sut Iec O d C.,9nJ Ctl 83.5$ SOys7 R p wta Sl CtrvSlrv T D Siw1[ [. F O » N7w / a70 ( ~ IICENSf NU wlt DwlEpOr BIaI» ~ ; '.e «cueADON rv fse»oNt NO f s wflc», »t c»i E «cuewrloN ugesvrwHt NO frfs wOCN. nc»t 2 Tu B ~ o R 0 CHECK(/) nrw nN a. v•f[awr~rn»te wt W ^ CMECK (/) Ngaorre w gNO,»'faA1 Ewa A v CODES -' D ~ . IMr I • assn 5 B ;"•°,i°n •`4"' ^ S Ia B i.Dlox•cu CODES ~ ~ p ~ •v N urn }, 2 NlvFl R j ;f~ o .M.a,.»[I ^ ~tI ^ Ea~ ^ rai ;:' ^ q. i ' + p U lr l. ASA eIDDDGf afv l t IDARi rvOVwf cu la Da <ol+vl o ^ ~s~l ^ w ^ :; s. v fwe ne ~ I R a o. . CD~ ~~ ~ E I I alLpwar. vql n I v.l ~ » w lI l rv srw,f wleanwrzw H » IXoe Il N wf t l ~ NP .9 -' - c V[H CIt ID(M DAIION rvO L vF»CIf ID[NI IwI NN '~ IC!31/I / 617.915/i~l I I I i t I I I I I i I I aw srtelpow,.te lwsf rlRSr Mloat rrgHf NO '~ 8.S -S O yy a Isrealp wrvte lwsi rmsf MID tHO. wpoausa owNte 7GF7C7 GGcn2 N E A le B tawpc4essa mw4ANCf <o wAaNi x R u wN r » D•ASAOt A%tw 1 .w°o".°.N ~ I a ~ NO w° ANAL[ G i c»wvq A c ce w w ' u IC ~O.10~ 5 [11 pwMAGI ^ DaI^sN ~ IAS.NHID i t LJ AWAYH I]4fAWNtD l51 D4Mw ! f QQQ ft weD i CIS Av er r ^1O~0ev. wwwr f DIAGRAM Of COLLISION I 14 SfAA 1 et Mt» ,_ , .; { ~ ~ ~-:I_. OTC }~ DESCRIPTION OF COLLISION IUStS nfANNiAI S»fti rNtC555Ae I :.~.v<x w/~s _ ~rrr~?:~~F _` _~_.. T ---- ,p ~ /, ~ I ~ ® ) , EGoT/ATG __A , lQacFiNd!%/.__ CV~rva- __. . _ b p Q _~ . l 1 ~ E=.SJ~awn~rrxeY~ _/c~ ..ovA_/os.> ... --~ .. ' 1 I7 ll _ ~ ~ ... ! .; -i I ~ -- C TIfOL. _UGriY/C G....C/YOSSL° _ THe^_ ~ _-- ~ ~7 .. .~ ~ ~ - / -._ ~f .. .._.. ...... .... NAME. ADDRE5581NJURIES OswER 50N51 NVOlVED 'CODES 1 - 2 3 4 5 6 s OCCUPANTS/WITNESSES',o; ,,po,uom.iNAlMi i~ su Act •ros '"„" nm ukf MI :,o • c VnB. NaI CI o r ^ •M B O a"' ^ .^ . _ O:f O :?~N ~ .q Yr ~ J7'°IUraoM ~wve p ;.KI EMI . ^ ~ ^ :` ~ S. . µ f J • cso •.2 !•..+'1 E«ID».5 o//i-6 01 1Q 8' y o ,Fx ~ ~-~ NA r t ~-. ~ I ~ ~ ~ ~ '.L. !. „ ~ ' i ~ r s _ ~ `~ 5L . +>&"r~,q v c H ~~d'4B wl _ f.:.•, .+na~Rg veI wz ^ l ~ r,*; ~ J ~ ~Si~,S~ ~ ( ~ ,~ I - ~n.s(k, ,M r, rv.•' ~~ ~ I~, ~~ y 4;t YF ~ Est'. 4g, I , .4` T~& ~~0 ._ ~~ POLICE TRAFFICCOIR~IONREPORT ~TRAFFICWAV ,. NrNUmxR,.. ,..1 ~ PRIVATE WAV , ' ' ' Art ptl nDfl ~- IUSf ]•oDCOU41 • uN.. n Tyr COON /~. CrVrq. ^iwWA '' ` ~^`_~ IV'J ~ ~ UW I ^N ~,F ^IN < rpl rOWN AmEa NO.psnffr 09 wOHWAY +mES ^ 5 CJW 6d°' ON « C Q /CIS Lo 4WttO• t ~IS'2.70 5 IwF4vu NC Vnrn re ov voAO r.p. art4sfera« DFM'f!N Sr4[fr a eA Si4FFt sxru maE rosr IYJ- D,Sr+NCl aDV I OIrO .C40555t•FEr «IAVfsr , mnFi 5 E un a (~ ACCIDENT MILEAGE coos AN DArA CONISgN NVIXVkO vE4 rOr.I NO NO [1110 NO INIU4l0~ ^YAIAGF ^N,r6 •V« mU1 N rmNMO,. ~ D IMF4 Cl5 W F 44p+p OR Hf(MNCk G065 i1f AD ^ pVlNKI[5 QJ ^YPOn4 DAmAGF pAY ^vt SfUlrFO ^vf~'CI! ~~ O Y ~~ OBIICr Sr•UC[INAM[p Rcr sr4UCa uV00NT1Ee'S NAM[I lsr DANAG[ 'ePScJ C 3 Oc~~- SKGIAI COgN41Ef UNITNO. 1 UNITNO.Y ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST ~' s Dvrvees NaAf wsr , I F Le ~D Cf4Sn15T Nei MPr vnfc sNAme. ws I I a r•If r ApD•IS of ~ A P rnn ADO4ES5 sure eoa o«e No -~ Wr1 f;33 ~-~-SCI D R s of rveAS UaNU NO S ~ srwn Ft M D 2Z I V I I N «o Are el n D.. r. _ occur+noN m AmEangNI NO ens wNr .ewer E accu.+rloN mNAmfavEpNf NO fns IeNr E4K:nr " oZ lJ(r BIEx 210 ~ I R ^CfEECK (.~ veNKie AS:N ANOINIem ^CHECK (/) vfn,Clf AS A«fWnoref A 'c A» CODES `' ] ~ + ° 3 r E, iO •c'L m CODES ~ ' ] n + ° S u e y, ro cZ «,ucvs a I.b ~~ ;.n, ..m,,.»<r O 'v m °AI"' ^ Ebm. ^ ~.K" ^ CB~,• My~,. ~ m. I p , ~<r ^ E8m ^ N ^ C. m ~'r rFAV mw.f IDODGeCn1 V.1 ~ 18 l IDArtr NDVAI Srvt~ a °NV I 1n11p\ E 1 n V I NODEI IDIu ~ v+l l V.I r'OM' a u E rui n,mlf4 nwrt«o sr•rF S H n « Fk' _ 1 ~ w - ' vfw uarrtlnw w. 4D 3 z 4 a S S ~ awauam , A I ~' emnnvmovmFV ussr rwsr IDDIF n.DwE NO ~~ A~ ueQ 34~~.~1 ° v rsrtv vmn umr rl4sr' m, e ~3, .°Dttss or ovmty W N + 2 d SecrT~ AS Welt E Ame a+Dafssp ww4ANCe eo aAU«r STR1c R I =' DAm•DIO MIA wwoc ' S « Nu gANK,ED MGf F CNN ~r UI Q p C A4DE ,C ,o~ f ISr ymA°t ^A'KV ^4[mu«lD 1 ~ ^~W~V ^4[MYNfO 151 W GRAM OF COll1510N: Ery~eesi Ain A~ ow, r•, DESC RIPTI ON OF COLLISION: IusFSVnEm1NrAFSKn4NeefssA4rl a ~ V a ¢ TurAxp I Q,=r orJto l SIB oPlr & I ~\8 . , ~ AC E~6 7LIUe/l +~i D2oE,< o Jb IeR RD ( _ O u\B R ~ ~ , , . `~ 611 [YN~OJIdP1 LoS+,~L- CwTn.t_ c~- p{~IU<, C~aSSep (~i't71 -II~~ y`„IK I e 1 h , . . ,5 of T~AVF I Q S`~K The w ~ 6 g 'Q ~ 1 D2 ve DAwa DIieH Rollep rt~hF, ~ V~Lr 1'w ~ ~ I ( '. eT cNJ I ~5 l.,~Uarr.IS n7' ^ n_ ~ ' ~ ~ ~5 ~ * '~ t~we-1 NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED 'CODES I - Z 3 ~ S 6 OCCUPANTS/WITNESSES ~y~^F~:~r~EEsN~k i ua Aw w nsn ucr :;°; +ml 'No .Dana ' °' a. Am e ^ iR" ^ "" . ^ ~'r ^ u A ~ AoanS ra p . movfD nom ^Ama ~NACr ~ c ~ ^ ~ Qn° Aml «o ' ~, N r ~ •MM ~~ ,~y c+,•NCO•rKl•sNAmEUwr X K~~ I n._~ T2t2 DG O• l.~iC .I,.c, ~JS(~ ~/,I '~r nD .••cnD d0~0 ra~a.mrro D 002'x. I n/p}ron Y7/k'9~ rrrogDar / 3~ ~i DAn i i/.I"A ':ri ~~ G ~, 1 ~; ~ ra t~ '~ • , a ~;' {. ~. . ~, r' ~ r~S~a1' :~ ~~•»V S4' ~~ t ~ a F; , 'g ~ _ / E t , d ~i .. s .. .. . «U , . .,,~. ,. ~ 7 y ;; ~~ 1!i k ~ ^' 't , ., bnd Y ~~"~ v ~y _~~. _ T lF E7 yi. nth l ~ _ _ ~1 '~p T l ._ - 3 iNt JkR Y:- _. ._. i. _:~... 1'.. J~_.yc,av:- ~tK~:. L ?z.Uk "`p„` 5 ^. ^w ~D G •N c^ yLJN AiR~POkTCut'-c7~T ~ CC ~lJ`/%Y~ rn 6ixfE1 OP NBAU x ni[xs[C10n % Lw - " a ~D51 xa IN,EaRI,oP PaNNx„Na LAxPPAP% w PP,P~t. o o 2aorFt ^B iR1~04ZT R a NP PxN. PAr. A ,~ ~ ^n~~1 ^ w1w ..._... 1°°O ^FV~$ma '~ ~~ i ,~~,.5 - ~ ^~~,n.rFP ^..~~E a~~x~o,R~E~,Nk eANND~A ex.ooa. -~ «o n. Fnc%D Wass eTH Wo ~~~~ EL{ I per°ox°xaA ~~ ~~ F . •; JBJECT STRUCK WpuaO ttSrque%1 OWNEfl OF ODJECTS NAMEAND ADDRESS F`LP'U OU[tt eooa use `FALL[-CN Fl~DER TfSr-C f_.'SEPFt~co Cov I'C~ a _ _ _ _ •~ "~-_ 1 • • IF MDPE 1NAn • - TwO LUIS O IV ,ORIVERSfcA37 NAME-, .',~-- FIRST NAME..., - MIq,OLE- ... ...,. .. ___:,_.. _,,., wEPE NvOLVED fl .€H.§N!$T NAME FI(ls7 NAME... _.. _ MIDDLE - • N,ELTl NCs MICl+6LLC INTW! llrou c<tLSaNOR NORF THAN LwO ' STPE:ETAVORE$S_ .;, ,,__-ROUTENQ;ANQ}10X ryQ., PEnsoNSwFRF STT!EEj-f[If)RESS- ROUTE NO. AND,BO%NO. -.. .. _.~' nr ',. . II,, 11 NJUPFO USER Z~ fa/ ~ /}F/G~ y/¢// r q, SFPAPATE -: OF~~ CITY,:_ _.-__.:,_:..~._.STA)f,-. ,,,_ ---ZIR CODE DRIVERS OCCUPATION._ < ON CITY STATE _~~,. 21P CODC DRIVEflS OCCUPATION. g P - F<RM • ?s • - DRIVER'S LICENSE N0._.. .. _. STATE SE% DATE OF BIRTH AGE ORIYEP'S LICENSE NO..., - ...__.,. STATE SE% DATE OF BIPTH AGE 4A :, r D vx ': Y9° ~ YEHTCLE.YR• MAKE.ECMEV, pOOGEI M DEL (NOVMDPPTI G q,T rYLE,l2 P.P~'.. YENIQLEa'R: iA!IER.IGHEv_IQRD,ggI...MRREkIN ~A•P.nffi1. _BRRY.SLYEE.I'F.PRd. ~,r~ ~ Lob TO OTA CORONA t~DaP TWA 74Y LIC~E!NSE PLATENpO,-.~.-_STAATE ,. ,. TRAILEfl PLATE NO, _. __-,_STATE_.._.. O•,C IS/ ~~ ` V .EIgE!{SE PLATE.NR,, ___STATE,..,, .TRAILER PLATE NO STATE ,._. pl' . ' I g E ID IFI YE AT N ' ; r r M . ~ C ENT IO ND,_ .... ~.. _ _.. .:__ YE71C4R IPEN7IFISAT10NN0,..... ...:.«_......,.._..-.. ~.. . 1 ` ' ~ . REGISTERED OWNEfl_(LAST-FIRST•MIDDLE.NAME) AN DRIVER'S LICENSE h0.,,,-.___~ flE~ISTER[D_QL,NEIi (LASj_FIRST~MI00}E NAME)_-,,.~__ ORIYEP:S LICENSE NO. ' OWryER$ADDRESS......,_.49TPEET.~CITY.AND S7A(T~E)~. DATE OF BIRTH.. 7AM ACUM M r , 3 Z-T 7 Y Be_ /} I/6Y I/ = L~cJ r U OWNEfl'SADDflE$$_.-„_ISTflEET..GIILAND.STATEI .. _...--,. ..,. DATEOFBIRTN,- A J .; i• - pART90F.VEHICLE DAMApED ~kv~a Y51RG~r r° 5!~ PARTS OF VEHICLE DAMAGED ~ .. .. ... _. X4'Nfl V~. GIL,..~... -~~ h E 5 g ~~ ~ LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1• WAS THERE AUTaMOBUE UpeaITY INSURANCE COVERAGE IN EFFECT FOR TH 5 ACCIDENT ON YOUR CAP ^ YES ~Q NO , NAME ANR.ADARESS.DF 4IABRRY INSURANCE F~DLZQY.NQLDER_w,__„_c ,_ _-_„ __ __ _ ,_, NAME_RF.LM$1SIIY INSURANCE.GgMPrNY..._ ... _ _ _ AMB AD Es rtr srwrE a,P ~1 ~ ', y ~- "' ~ NA(.1EAND AODRF~S$-OF LIA$IEjLY_LN$IJRANQEfGEt•_L`-~,,,,,;~,,;~:,{~iiY-~Yy__-~y~.bL*E~,.,.-,:;J-~~-,LP_„~.~41A~IL1TY POLICYNUMBEf1._._.._....~...._._. ....._:... __ _____._ __ _ T _ 1ST INJURY AGE ~ I 1NOINJURY Iu5E 5EPMATE RFPOq OR NA gIE51 AGE ............. ......._...._:...~.. ..___... .. ...__ .. NPM p NAME .... ....,... ADDRESS 'bE%. SE% E ADDRESS M F NATURE AND rrl~~~ NATURE AND E%TENT OF INJURIES ^ ^ ~ E%TENT OF INJURIES ^ ^ -'_ D D INJURIES REQUIRE ^^,11 DOCTOR'S DIO NJURIEB REOUIR[ Q ^ DOCTOR'! E AMINATION GY A OOCTORP ~ lJ NAME E%AM NATION BY A DOCTORi 1 r" NAME , ~ ,-$TAIV$Rf INJURED ,-_-._ _--MARK fIR$T ONE.TNAT. APPLIE$_. :,,,, STATU$RFIN UPEO MPRK FIRST ONE THAT APYLIE9- ° axl IN VEMI LE . x vnL ° DP vw IN tll Lk ^PAss ~ NILLED P.b P xo ma Pr ^vAasFNGa NILLED I ND 0. T_A ___ D .,^ NwRHt B, ~~ I ^ S ^ s ^ Pr7 acl °° 01 Ili NrtF O, ^ S ^ S ^ of ~:x^EiCI tOD MOTORCYCLE SAFETY ^ ^ xi : HELMET USED HELMET NOT USED MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED ~ : ) - SHOW NORT B P O C PL E r\ i DESCRIBE BELOW WHAT HAPPENED. (gEFEfl TO VENILLES BY NUMBEPI _ -y-~-----A~~-.~....-_.._.__ _~.--_.._._ - M ~ -, pf wW,r~ »ANa. O ~ I --~_W.ES d3.LV~N.g_.!~coNG wiTN_l't}.t °n" ,n •. ~ FLoµJ_o~TgLi, FfC. DorNG--FI(~au~ N•FP aA<N %F,~ut __Y_s_'~8~ ~r+ (~1*CN B '?'Rcc L-t« - ,, Y yxaL~P..FQ:.._ ~ /' ~~,.. ~~ROSS ~rfE ryfe-HwLty ~N FP.o(v:T-4F. ~ I ' a( Dkt~? „- M_c. S._~.MM6'AifLtE4y._'A1?P6It D__./i't.Y . . r s --gAAKaS._7.tS-L1LO6A__ftCiou:T ~ .© ' zo'fr ~ r kND ;; ~ te __.. _ _ SLhLY%fT.E~._~NT9~'YtE TRe:~E P(!SdtNr.___ ,» R'PREE .~"1--. A ftov.~-- ?-o X10 F~-c'T, I GJQ F!lt7Na 6 . :' I i : c A-M 5 R~NS!LN Cr V.P._ ~ GG !N (i /l!E' -T[~1E_ ~I , 4 ' % I 1 s~4W T1+E?REE ~.f~.~, CA.N4T Nr_R._cA!3... ' a ~.rtoi_N.. _T.st6.---°-P.'DS'I:LE WA y RtSo Lf[~J'T . . ._ i' ~ I 1 ------------ --._. _.._.___ _._.__ Mw VEHICLES POSITIONS ©EFORE COLLISION FR w.! INVESTIDATED BY [oU o[P ~„ ^~ o xtcrwN L ur •T NuNB L[oAUI•Mx[O vfn:t% VEIIICLE N 5 E W ON 9TPEET OR HIGHWAY NAME OR N0. I ru No res No vt• ina ~[[ ((~~11 ~Ipp Nl lrgwl ...... ..^ U lp.^ ~ - .../... .. ^. ilN~frP ^ ^ ^ ^ ^ ^n%~Ca ^N _. .. _.. _. .... . I M ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^N:FP,rF Rl rLSt{tx An ^ ^ ^ ^ ALONG FROM TO ~ '-` PEDESTRIAN/PEDAL CYCLIST WAS USING: r^uw r^N.L ]^R"au A 1^ul t^G •^oN r^n: •^xo • ~ R ~:;y ' PEDESTRIAN/PEDAL CYCLIST CLOTMIN6 COLOR' , ^PAA ]^.,`,,, ]^N„ ,^•ar r xoAlNacrNt Nrn xrrucnrt N•PAx I^ ow u u P r CC~I..[ V .,:,j_ A uas, He _.. ROAD $UIIFACE _ YVUTHER LIGHT CONOITION9 TRAP fIC CONTROL TYPE OF ROAD DPIVER!VEHICLE ACTION3 C•Ow{r r"•<a IL"NC•oNal {~ [. Vrut{ O G u tt "r A UBNa IGrt[:A Ox[ VLr•p{ n.rpa[~ a ptD~io, I ^DAYLIGnI i~~AA T 1 Fat IK.s~ ] ^ DAWN ^ I ^ SIGNALS ^ I l ^a ONE WAV W r 1 L ^ 6DIND SIRAIOIIT AHEAD I V 1 I ^ DI11 rr~ ] ^ I0 p ININp ] ^ DUSK ^ J ^ ITOP SIGN ~ ] ^ TWOWAY ^ ] ^ OVFRTAKINO AND PAlIINO ~J T~1 •~• ~ ^) ^WET I ^SNOWIN6 1 ^ ll1WIS ON ET ^ ] ^ YIEIO SIGN ^ ] ^ RO 5101E ^ ] ^ MA%ING RIGHT rUflN 0 ^ ] ^6AbW 1 ^{00 6 ^ I~GnT%O IET ^ 1 ^ INSWING REO ^ 1 ^ 1 K NG l[R IDNN E ^ ^ YA I LOOP gAA1P y ... I , l ~A ^ 1 ^ ICE ! ^ ~~GFYI { itil D11R[[l Olgnt! ^ f ^ ilA51PN0 AMB[q ^ 5 ^ AIIEY ^ ! ^ MA%INO U~IURN ~~•~ ,. ^ f ^fYICIRFY T OtNIR { RN BIGNK { TWOWAY- URN ^ { ^ SLOWING ^ SPI f.UY ^ ^ ^ ^ F' LANFl '. RWADWAY CyEA wNOAOWAT SUNFACE ITYE ^ T ^OFNC[NrILADMAH ^ T ^OPIVkWAY ^ T ^ STOPPED iOR TRAFFIC y L y, I ' 1 , ~ 4Y O a l .-1 L- J u"•r• ^ E •^ OInER. SPECIFY ROAD 6EPAMTION. ,.. ^ { ^ oR 9i0P 616N10NAl , I , • """ '"` ^ ^u„•, ^ 1 ^DIVIO[O ^ { ^SIDPPED IN ROADWAY Y~r ~ ... .. ~ I t , ^'^~y ! NOI IFIC u~l s lTARrIN6N ww LLLLJJJJ ++ ~ ^ CONTNOI ^ ] ^ UNDIVIDFD ^ r0 ^ INAf f C LANE ' Cr ? NEJLlONF RIFOi bELING OAhGIN hO COLLISION OCCI,R INA CON&1f1UC710N ^ yE$ ^ 11 ^ 9TARIIN0 fR04 PARKED POSHION ~ FM 5 ~ 1~ OR ROA04A NI[NANC[AREA) I[NIl111NG ^ NO ^ I] ^ n i O T t ^ IS I N1 C ' 4' WITN[lS NAMB AODIIE[S ~_, j q, ~ •... .,• .. ... .~. fiL[_ „AGE. ^ If ^ RACIIINO , r~, .~~ r,~~' yy~~3ry My hYi{-j ~{ ~~ 1 1:[3)45 ~~~.'4 -!" - .~1 POLICETRAFFICCOIq~;;NREPORT QyTRAENCwAr I KE NINUV&4~ - PRIVATE WAV - ~~ • A E D Ar IME ` i - .o. twl l«lo. wniIN ~w~. Iuse v.oD NOUeI couNSr /~ ~ L~-lCc7l~~ E alrr.o ~? - ~ ~ ,. N ~~ NuL' ~N G i~ pq~ ^N ^ Q IN O/' ~r [Xa 01Y~{ OiJ~~ /G~ Ar _ / N /T~/ ~ / CIS OV~q ~ E O ~ N G J m Es s ^w or { ~ ~ f INtfeSlClING N. StefFl Oe AD NON IMfeStCigN Sl4ttt{T/I ~/ /Lr//f .~.f/~j &Mt[N V~IIi~G. SI4F[t ~i1% / ~t D. O/ / 01 ANf Dle .C405551•tft N[••StMRf Q f[l5 N s f w Or /f G ACCIDENL MILEAGE CODE AM wG., 4 - " ' , ~I ~~ COIl5K1N INVC[V[D f41r: IOt•tW p~I NO [illtD~W INJV•tD~ ^ YIIIAGf ^N~It OVN w DYD~. O IMf[ CLS N I gOAD04 4FNCE. C•03551eF O ~:J d VtNCI[S ~j ~r•OgnYpAMAG[ONIr ^pSULIfD QvlaClf 7 - I / OBJIC15I4UC[INAMtd OBIfCI St4UC[NiDOWNt4'S NM.fI fSI=AMAG[ SRCNI DING Ibf ~ { + S UNIT NO. 1 UNITNO. Z VEHICLE ~ PEDESTRIAN ~ PEDALCYCLIST ~' NAN[ IASt 451 •IV[e'S t NSt ~" r _ wtss CCC ~ 3 S/ ~ ` //d/ •fft ADwtss ~ f~J J 2 / C ~/ r A ~ AtE :I.C INGNf NO D I ~ l I C ~ , „ , ~ ~: 'S UCENSf NO. SG f I U A F "'- 1 { 2 occu noN ~eArrwNeW ns :cNl 1 S% - ~.'~'lL4 ~~~ i3` ~ E R curAlloN ~ IcNI GNI tsvWNe NOJ r% i1~/.5~ fiws~ o ;v %~{ - ^ CMFCK (r7 Vf NKN• ~ RV'r CODES - ~ 7 ~ . ° 'NSt 1 D s"'r° °'i'1 N~ U ^ CHECK (~) veN ttf ASAN fMNOrff dA tNFa I CODES ~ ~ 7 n . ' S u p v q M ~/_ '~ ~5 '7 Wes - /~ < / ;E,Mn:,.D. o •,,.•.Nlf ^ ~ ' o ~N.. o ~;z,; uw ~ 7;,.D„ ^ Y,,.w.N[l ^ ~,~t o zs:D, o ,; <,t i N:~ "N VtAe MA[tl ~CNfV.I f11DAat NOVAI stvtt l] [. " t v.l MODft (OA vAl 1 61oc + rlA f N ~ StAtt teAttf•R•tf W ~~ -- S1A E - H ~ 6i l/i'! - v!Nr LAST Hnt I r> - •DD•ess a owrJO °~ G ST ~ / tvti r2 E • S" . G NAMte•DD•ISSp~NSWNG <O L«•GNI T - cax-.~ R -~ a/L v -~..i.56~ OAM•G1 MIA ' ~ t.YwcN CNMGf (r •tDr ~ ~ gAMAGEDMG M••W HY w+i• o"~tl • - S ISi'orio~ IEI ~ ^ wMV ~•1•WNt0 i ~ AWAV ^KIAWNtD lowtD ~ C S IG ~OITOii f aw+D _ Q {r - S y0'V DI GRAM OF COOLLISION: •hiu .I^ilr•t'oNOtiJt" 1- . ~ ~ 11 I ~ - ~ ~ - ~ DESCRIPTION OFC ELISION: IUSI SUrrLLAVMAL SrKelDneassA.rl __ dG/>' ~.2 . -G~/fS - .5~..r _y~iiZi~c/li _ _c'~T ~~ta ....~ EEIN ~ I ~--~.-.~.. - !/G/~ '~/ LrrAS ~iF/i.J4 .57b/~_.13rPtZ_ •~ t _; ~ Q ~ ,~'~c S r.>N Tv ~Tf..Q._Lf~2 .Tr7..-~ 7?~ - -E/d .Sit S{c, - _/~.~G4.~a ._o~T.r..i_~.E~ . _ ~ - _. _. I r I ~ ©I . _., , 5 ._-a' f_ I._i_.. ,! .T~ STi4.G~G ...l~G/r/ ~/ . -U'~-/dG/['_ -c3% - ~ ~ o G I i I ~ . ... r NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 - Z 3 ~ S 6 OCCUPANTS/WITNESSES iuHSVnfwwMSr{ pADD~1iONAl NAW n 51 ~ 31[ •GI tAIU ~ ~ Y~c~ HSt• EJEDI N.Mt S .?..~ CG. Ti9.-.~ ~ 3?fi S'ys •r ,sz •DO•HS ~. .Li t • nor o A Me Oi41' O"" . O.~i t3Ls. .«f ~ A •Dwul - N•tl~na non ~•ME ~.a.l~~~ .OB ^~° b ~ wl W •CD•t 41 Y~V~EIOr f INe Q•NI ^~'~QC~N :~'.' ^ti°. r Nv X nvtfl .•~+.G ptKt•f N•«11 ~ ~ ... Ge O• IOW WINCr w V pVYi[ Df t ' %C10>r•~C~10 ^ S ...OV ]NC ••f rgiCl ••1•nD 'S 3 ~T~.S D•t1p 11 ~ (~~ G~ •rr•OVID[ / DA11 0 E ' f ~~ f "~ F ,~> Jam, ~ P .. ~;, .~ ~.• _ a _. `~ s~f, ~ y. `fie 1,~ ~ +ti Y~"~ I ~ 'rw . 6.~er J 1.. a .R.... awes 1 \~,~, POLICE TRAFFIC CC~lON REPORT ~i-TRArNCwgv ~ / ,.D„ ,,,N,NIM~.fa ^ PRIVATE WAY 3' •rldcaris D r ca a cwNEr ~~ ~ n' lust ]em ouvr a, ruin I " ;.~ 5~0 JC~iGC/~O~J I ~ muerr cnr NC]. {~`'~ pu •N I < ro4lowN wcNw•r O ~ ~~ ao{ /~ N ~~lO ~ ~ u 4u {n s l u vounoR SlnE xc roN M ~~1~ 1 ua N w Vnl ,vl ~y~ N eo Muf ros ~ A ~ ellvrtlN 6e ,.'77 sear a Q9.~ ~A+ smin .-. Dsl•Nn eDVI noN {voM VUlet e. cvossslvttloR {x•Rtx Mnt pos AeCIOENI M E! ! { p Duee•M au ~J ~ MILEAGE I[E1 M J!'J/Ll /'O~$/ CODE - <OlIlO1MN0 Vt0 NO RrIIlD~NO rNIUV[D ^Yill•O[ ^Mn64UN u rM.'D:r4i iM[v ~ Lax ,iND llv[f10R RO•DOp 4lrf4FNCl rN CIS C40S55ntt[IOV 4p•D '~ dvlNKrls pROef aIY D•M•GIONIr ^ asmnD ^vi°pN /n ~ ,__ oencr s,e«eIN•Ml or ae Cl slv«•M]DOWNl4'!N•Mf es, D•M•et seECw <oorND asf `- UNIT NO. 1 L~N IT NO. Z O VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST 1a ! Dv v1R! 1' Irvx DIXt V r 'l NANf: __T~_ - `~ ,-$~Go? ,~irLc~ ~ii~ _ xv~ooatss r/~ ~-- C I elC/ ~ ~ N slxn AOOxss - C x.n I C/7 ~ R nr alt we l /~ ~~ DVrvly llr[tNY O. llwl( Bi I rvt rKlNx NO. •I[ D• «eup•,KN •.seep~w..ew {ns reNr r.aHl 2 ~ S E «ew.nw ri4M N•Mla.wwNO. Ens reN, nlenr .4TG O //GrCE~S~iG R - ~CMECKI~ MK~r wsiN rMgorllaANamtR CODES ~' ~ ~ S r p swv'.°'c'E+l- ^CHECK (.~ veNa{AS•N ErnonEd• CODES - + 7 u ~ i 5 ee C v ~ ro T , / ^ •,MW.Mr o ~; Kr o ~a:R. o ~:za rs~,, •• e "wrw o -~ ~Ke a u ^ ~:rr. ^ ~ ^ r. ~ ~u '/ •I IDOOO[c lvl MOOtr ID•vr NOV•I srtn l] v.cwvl Bd .l~ SG NCO ~~/Z E .rue I w.l yD•el. ., .I _ ~A 'D [/ N eNU sr•rt ! H E vtNC _ J ~T GSG37v ^ ,Lr - I c A NrrKrl r'p MnUKMgI N~np. I~ Y, ~OV ~ ~ C/ I I 1 r ' r L vlnr4trpENUr rN S ~ ~' ~ ~ ~ ~ ~ I y Q N vlGtSn RIV OwMV NM1E {re MrDDU gCgNE NO ~~ J /'!•7~i •DDatssd OwNle O W nvt0 v, {p51 MrppLL a N ~~/~,L E Imo{ NAMI a•DDeEssd ww4•{Ke CO ae •Dwl R rNU /~ lif'~3~ /-'Svl~i>7i/G6 •DI Ml• I S ~ ~ ~ __ Aw•Gl0 •RG ER•.d F -.esr cN•e 4 w• .~ ww.• ^ DvrnH ^ nM•r{4o ^ Aw•r ^KUwNID ts~o•Mwl owi ~ D ~/ 0.+~ rowm s - •w•r er re DIAGRAM OE COIIISITN: y~il~H Wn np~1N DESCRIPTIONa COlLI510N: 114E Slwl[MewM S{.Dnreass•4rl I sr ~r- '~`_ ";~ NDK rE:/ ~i ups-~r~r ~ ~=~~~~~-- - .-. __- ~~ __irt?_T2i 4.!6/1 Gol2~{ti 6~ F~/ Y _ _ f I 1 I /7 _ ~. NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED 'CODES I 2 J ~ 5 6 OCCUPANTS /WITNESSES j0'~p bD~1'ONN NUN SI vz •ra ui wsnr ~RO-- r _wl_ n r. ao un M, r r. N •MI _,- ......_._..__... ..____.__..____..__.T .._.. _._..__._. . N orals! . Mp N , s<lra Rr ^•Me ^fY1Rr ~",;,. 0~; ^r::,Y >u - --__ .. .. _ - ._ .....-- -____..~..__ w • awss - ---- N•iL+I M" - a Movrn r4oM ~•Me ~~c"K' ~":;,n. [I H ^ ;° ~. .._... .. _.__. ___ -- ' "' r N rUIM N rwn lElr,.r o• o~ Rror~r.oa. o': ., X .. .,D .,.,.r...N. ~~, 7~ G 1 t ~ l.ocl c]a ~ rl N:. pir 4 Dll Drs.MO+o v%i~ m~u• o ~.~~ D•nd ro.r ~ e. wn ror / T i ~~ 8.g iz_ o ~~ 1, YT b,l' ~ ~~~ ~ ~ .r~ ~' Y~ ~ .... ~n rst T ~ ~ d ~i ~ ;. IF ~~ wv, r~d u } ' PG ~ W HT ` a. `' ~. _ ~;~ ~ ~ ' J Y~r ~d, t r 2 POLICE TRAFFIC COLLISION REPORT (~TRAFFICWAY RxICE COMRA rrt Nlunefe ~ PRIVATE WAY ~ ~ ~ p• f0! I ~ vo •r 1. r., ulf x .'ur ~ fUS~ .y0 p`RI <fJ2'/I` COUNfY ~~~~ VT COUnfT NO E.n/J CIfY nO. '. iMWA ^ RIAN 4URAl ' // N ^f ^I CI 09 rOWrv ElNO OisiPEFfO4NONWv ~[iLMRS ~s ^w or~ IYI ON C iR ROUIEORSIRfC rI 9„$"ZCD mlE UCrINO W+rN. svEfrov AD NoNlrvrwslcnoN -- EEIW ~ - tt U fEr RRERx f MILE rosr ~34 t 3 0~5//•N f D I 9fn .CROSS SIRfl10R NEARESr MIIf 5 MIl[S R 5 [ W ACCIpENE MILEAGE R WIA rEff a! S LDD CODE ~~ COIISgN NVOIVFD vlR rv- IOIAI NO O[IIFO_W. NIVR[D~ ^ Nll•OF ^Nr6eU Or vlN Clfs ~ ^ RroRREY pAM•GE ONLY ^ cESUIrFD ^ vFdClFrv rUNOworw -~ I p M[ Cl5 N14 eEF ro•DOR REfERfrlf CROSSSrefjEpfL4Q"gO /G ~~~fG' ]5 OBxR SrRUC41rvNAEOr OBiECr sIRIIC[N/~D»OwNt95NMNF1 ESI.pu.n0[ ' / n~ 1- ' '~ -_ SRC AI COD NG IAE UNIT NO. I OvnlR'S rvN.Sf: Sr IIRSr MI ~ N U I i N O 4 VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST pen[R'Srv AE N :~ I I f ~ ~ ~ / ~ ~ ~ ^ ~ W^ CJ/r' SlRIfrADpRF33 Rf1 ADDRESS b ~ `s ~ - /03/ ~ ~S ~. 3 •rf EIRCO.-.k .NOrvE Z77~j' ~ D R „ Sr•rf G ~ USA, .~, ~ 6 pvnfR cen ~~~~/ ~ surf • N ~ ~~ 3 I~ ( , I u m No. ~~~ f 6D.~/aeI r ~ ~ I L Z OCCUV" ( r mIO,U~. Nf~ , G'.4uro 22 6- E CUR nON AMf f RHprvf NO. EY[5 ONI ~r , /lam d ~ ^ CHECK (.~ vfN ae •s:N rMRV~r dArMiorNfvl l ^ CHECK (~) AN rMRio.Ee ! a•l CODES -' ~ "' S l e ,^',° ~. r rcr ~ E °.in ncr orv •NOme CODES ~' s ~; 3 l4 e u . i:sn«"r <r rv Kn rcu Z ~ Irviw ees Y ~;~~a, a„ ^..N,A I ^ ~ ,EE ^ ~sn. ^ :°;• u:>. n ~ ;i.R o.N l o ~,RE ^ ~s.~. ^ ~ ~ ~ ~ N ^ :; K ~ veN rf~Z M•vel Ec'fvf ul^.vl.wv.l sr AeD~ v.l / // E ~ x f v.l mopEtlp•R NovAI N 7 N ~~ r he vN. a 3oo~ 31A1[ •RIR RArf NO. SIAIE ..- H ~ rl~ l ~ u~ /Gd zv p Kll ~Df rvDNC•IIOrv NO. ~LJ`"2 Z233°~ L v[N l 3A 01017+878, I i I 1 vlasnvfoownu- ^~^ nv~ r ~^ MIDwe /7 G9 /7u ~" R OOd 2 O W I R~~~~~2j ~~uG ~. I - IS Z •DDRFSSd OWNIR 36sa .~°,El~ ,Q~ f~DGp~4~ 9833q e n ~ I rvAMlf •DU sE~ a~!rwe•NCe <°_o,R A=eNr /7 ~v ~ R ~~' E ~~ro";N ~ " ' "~ f uAAU Aeu I cNARU s c~A.eE w irn o n j f _ -~ 5 ei"orio~ r l1r pAM•41 ~~ ~RWIV,M e1MUNfD ^ AW^lN ^ r ~fMAINfp •r er: IS DAMAO f~ r fdiori5:i s IR DIAGRAM OF COLl1510N~~~~~EfS~'i 1C15~ v~ieaW IN f DESCRIPT ION OF COLLISION: fUSISWRlM4NlAl Lxlrn NECESS•R I ~~ t~IQ~E~/^ n ... __ E !/~ r ~ ~ . _ ~= _- x/J 7i t / if///~7L~ /UE - if~r~l~i7•vG Yri )2G~J /.~l.Bm1GV,D orJ_~. ee~r,=r need uvm- /- I : ~ 1 e~ -- // oe~~z- S'sr<Tt,~.-~yd~y~cec~o~X._ Lr ' I .i -;- ,.. I . v~ L~ =`~ j j Sr.. f/~CE ~ ,!J/t-/U D .G - _.._.__. `` I ~O _... _ _. 1 i ~ ~ - ~ _ __ .... _ _ .. .. ._.-__-- _- __ NAME, ADDRESS B INJURIES OF PERSONS I NVOLVED 'CODES t _ y ~ 1 S 6 OCCUPANTS/WITNESSES ;a;~R,'°°,',•"f'„j,,~ ;; ~if. .a tiros '., ' _ -~ - - ~?;, nw -fxa ...f . in - ... _ .awls, .; ref a •Me ^ RI"' ^" . ^ ~, i3:f. A ... .Wnfl u11 ~ N•1 R q E MOVID ieOM ^A4f ~ ra Kr OMi f ^ M ^ rip b .. NO r .Daft, "t,uti7,°' ^.ME ~ ~;,EI o~D~I. a. ^,:°,,,. r. ,oal~c1f,wwff. n. ' E X wr~a• ~ // p ,Q •c~~r~ upy",n ofr ~,y~~=yj MD /`71~.1f5 •IIZ~( "r•ro,~Er D•n ~~ L ~r.Fi d ~~llAA LL 7 Y E : ~„ ~`' t~ R~ '~ 1 .~'~~~"'(. v1 rT~.~ mf.i3J~$rr'.~." 4 7W1. ~.~ .I • `.4~ l~ ms JFtt ~ ~ ~A {. .a~ ~~I. ~~Y '/J L. ~~ POLICE TRAFFIC CO ON REPORT ~I TRAFFICWAV ~ PRIVATE WAV [o[ic rvt NUMBfa T'T ' DMF Orcaus rv _ courvrr .. , . _, . [N~f9~gOHGDRI fT I ~ courvrr 4rv NO. ?= rNWA ~ ° U pIIYOR TOWN N f6NO.p3iR[ftOV NIONwgr M F3 05 ~W I URA[ M rC145 I RW[F OR tRF kC l ~,O NfvSICtING W'ItN. SrR[[t OV PoAD NON INr[ v5[ C r~O N ON ) '' ~~ -~ ] ~ .~ .~ ~~ ~D~ -, BFM'FFN~lf7•.1L 4NK S(v[n 6 l3Yls siRFFt ~ p31gNCtf p4f vpM 4N[4FN .C40335tvFEt04 Ntg4E5tM IE V05f ACCIDENT M l[3 N 3 [ C MCODFE vn w Or PR{rx f MNF KMI v P plA RAM W[A COU ;Nn NVOIVID Ntvf4ur. OrAI NO m OxU[D NO INNV[p ^SPIt IAGf ^NN6RUN r.ni plv3knt" OvFN CI[5 PRO YpgM.G(ONIY S 4 IN ~RD I <IIN SR[r0440AD04 RLrFR[NCL IM( C43 CROSSSrR[FIOV RD 1]] -1 N(~ - ^p(SUInO ^ f f[E RU [ OBJ[CiT51 [NJAMF Or i[<r 51RVCa.wD OVM[v'S NnMfI [Sr.p0.MgGF 1 SPf<W COPING WL -- 1 / ~ _ 1 r QJ. 5 (AL ! UNITNO. I UNIT N 0.2 D4NlRS rv MtF: IA51 Nv I ° VEHICLE ° PEDESTRIAN ° PEDAICYCLIST MI DN A IS R ~ D [R'sN f: I ~~7~1, J f -- smw ADDRFSs 2 0 3 c tr surf n4coa oNf No. D Orr srgn . c S (e 'Xo$" S DNNFRS FNk rvO lg $ R F A 1 ,i^l V S'~ ~ B t R l I ) v 4v[R' IICFrvk NO. Arf fk DAtFDOIB RrY „O I ~ R B OCCUVArIOrv MNM[6PNON[ O frES w[IG"t H[IGNt E OCCUPAi1W MNNAFIPfN)NE NO 2 py ,~ ~ ~~~ Bloc 1 ~ l R . [nv w[GM fE GHt ~'w~A da- o.zo MtL CHECK I~ 'n Fg3AN[MNOn[ol ArvomfRA[ N []CHECK I/) i AI ' "" CODES -' J cM. ":s ! e "O "~ • v[NC [wsANFMNanl ,NOtMR CODES ~ * ~ c 5 l e " 'O 9 n [cns A~ ~; rro• s „~: ^ .,.R4,.Y[I ^ ro nN ! " R rD' . " ° "" ~ ~' ° ° zs:tt ^ . ~ p ro ;:KID ^ :s~3. ^DODG[.CNlvl °~~~ ~~ M [)UAR(NOVgI S rlF l]D CONV ~ F R 1 VAI [ 4 vl _ ~ ~ n _ ! oR uT! fPU eN s E H '° 3 un AufR NArt NO Af~ (/ I nN CaoR A l q rv Af RN i U r ©.. " vINK[na.n DCArarv -----. I 1 1 .vl V I I I .w sn4epowrvfe. n4v M~Daf motif rvo ~ vm¢u lawl I A -- I I I { I I I I I I I I I I ItF4eD 4 I v ~a-C e1 n ~ O W FR t rlRV MI ae ADDRlSSp DWN[9 S ' ~I L~ ~+" J~C/~ N A N[4 NAMI aApp4[ss arww4grvee CO wgewt N 01.E R N u N [Ri' J] DAMAC[o AA o I N v gAMACfD.wu ""' c" o~ cNgMCf wn"~w±N p m . > ut DAMA~ °~ano ^RIMA mp towiD ^^viiv ^RfMAlrvlo fu pAwcl ID RpnDN s ^ Awgr nr: f DIAGRAM Oi COLLISION I BPt t Nlnc t aN DESCRIPTION OF COLLISION: IN3lsw [MLNiu SN[[r Ic[33ARrl - _ P L4l rYl4 itAR 1 - e _ I ! L _a I I I J ~ I ~ _ I I _-UetF R_I _s1B -Fln~len RO- DkllJOi Stntco~I.,enV. eI~ I ~ ~ ~ O - ~ ~ -~ t I _ ~ I/ ~J . _SoMflBnx._oa-F F)ocvY<~ Wlky.- . 1-i _ I.!. ~~ { --j--f ~ ._•i5~jg _FUV.ttA RDA-__AZ)uq_SThkO_E~,4T SA+'!T1eD_ ~ _ _ ~ .S~12 SYeweO 'fa . R6kt-_T~, OJer ~ I L_ ~ I ( ' C { _ ~ { .. I _ ~ -.I ~ I-' ~. I j_I_ ~ - I ~+wteO_.TO te~._ Q CMskd_e?!s_ la4x --~-- ST/~f-K .DINT._ t~t7Ba)kdwT' ~ IJeN,c Cc4Ttu1,e0 VP I _I .. I .;.. I _ ,-._ 4 .1 I ~ __.. __. p .] p (~e~µlyf`;~ f`OI~,.~lr QJ)t! Gi C}S S _ ~ l ' - ! - . I _ _ _... _I!! T_. SQC_Y _ T?.mz ~N i ~K A G P I . ~_ _.~._ . j ~ ,o ~ _ -,. a _..._ e -1T._ M±._._h_i ecT---- NAM ADDRE 8 NJURIES OF PERS ONS I NVOLVED 'CODES I 7 3 1 5 6 N OCCUPANTS/WITNESSES lion ino~i~oi AVI itn w ii -.u~.. Acs i.rui '~N„" M"„_ ..wr r t ~• -.-MUr 1318 NtCt { ., tr P _ _ _. _. __. .ON wt P . ...._... g lAVls3 Y --- a N[B. pAM O °~nNl ^ " . °~ °CawM .... . _ .. ~a _. .._... . N Dntn w : Atg4ta }rA A, SID row °qvn °~a<f °co':n. ° r: ^ :::.:. ~ No • NA~p 7Or . .._ .. _. ~: a rn 5 OC, r. ~ Aa4Mr.[IV 5ruYlffAN. !,(,4f O4 .LfN:. qKI U~S.AI(.Np rg3KlNfoorNO D.I°tpA 5 , •Y a . (~~; ~• I ~ ~X~ I.fJS /~,>~~,s ~~«aS,s, 11/YJd'7 o.ey ~. Q ~~~. f J1 I: L ¢ 4 ~! ~r: ~ ~ Y~' ` / r ~py...4 Li. 9 Jn ' f t Si zp ~ ~ , ] Y ~~~ ~ ° a ~~ '' .I ~- ): :~ i7 Y i ~~ ru ~ ,t*tiw»~ ^~tm _,.~yo,~, o .rr~ au..,:n au.v_a,r, r ~~;:. ~.`r ~m ~ `'~ t ~ " °i yA' ,Iti~ e' ~ STATE OF WA HINGTON q•Dt ,':'i .l ,V ,~ z _ r f ...o ' ,.T., [) n i{ 5.~ 101 ~` 4'. N0. ~ l~ ... Ij 7 0 'a, POIICE TRAFFIC CO ION REPORT Ipl TRAFFICWAY ~ 4p1, M,NI NV.N9f4 ' ~ PRIVATE WAY o•If al ,~.~ 8~ ~' .,~ ~ a Iy~tylnpNDD41 eouNt ~-~C~xsc~J eouNtr NO l~ nn NO. ~ ENwA °9~9M ' ^w a rogrowN N ~taN~~t~ 0 •r ^ ^E 3 M4[S 3 ^W Of la s, 6 ~ 4wtforsst4e~ L1 se wn4uenee xa smtoo9 qo•D NoNlmf4uawN ""~ etswttN trt a a v9na ro. Mlle vosr 2 /I 2J r3 AH l p, M t tH .C90335ig11 NFA9t31 , 5D Mnt31 S f rm Ot x~T ACCIDFNI MILEAGE CODE My pIAG4Ax p•iA COlD51oNl vIX tvf 9rlr NR69UN ^vli•et O *oul NO Y II~~ ND xufD_NO Nsueto N .. .qD unt ns iNifvS( tlNC Ott 490•p O9 RIN9ft1Ct c9ou smfno eo ~1~ .7 _ ovw tits 16J vgoRmvo•M•c[oHlr ^uiiuum ^vi°[it -~ ~ Danes smuex lH•Me pF Oe etsmucx.wpowNt9~s NAxll to pAMwt f svtcw eoDiNC lae UNIT NO. I UNIT N0.1 VEHICLE ^ CEDESTRIAN ^ DEDALCVCLIST ' Mwl9's H.~ NL~ ~~/~~ M. rt p9~n9sC~~~n~~! k ~l ~}}lQ~t-~ e~- E' ~~ swtel ADp9tss 118 D,4K Q-r. to s "~~~z i • ~~~ ~~u. Z + vte ,veool oM HO ~J ~- p D R r Il Ct}-iritr7~ii~a -y~4 • E~r2 s' 73z-4~z9 I z eSliCtHSIH SSAIt F[ me2jEti Q~523/ESA ~r//+- y>' • l° °j'~ I ~ li fNU HO S~~-~S7zS~A -tuiQ, rit '~!~ Te28 ~ a oecu.AnoH _ f a vrwNf No. (ins /eHt ,eHt lIF.1AAn"-'~1. V Jam' ~ IX /tl S"I E e'..I,oH f ~ Axe a vwNt No /tns IeNt I</,eNr I W CI ~ (7 CHECK I/1 vtN nt •s:N u+viY •HOSNte•l ^ CHECK 1:) FMNOV![ OF •NOINFR•I C DES-~ ]~ s l e; ~'°,K' CODES-* 7~, su es"•°n L. s' s wrzs ~ if w:orro« ^ •wu<ANO ^ F21K` ^ EbHI. ^ ~ MN , ^,ww,.,cl ^ XHI er °" I° i:l'c' ^ iSm. ^ Yl~cli • VSN r<Ae M•xt IDODCt~<NfY.I 7B u7 I MODtIIOUti NOV•1 SnI5ItO -t1~*ro,E. LDS 80cb 1 NV.I N?g '17%~to Abell Ywl ~ru 1 1 oa~ H {E ~tq f l N~J~3 vre •ltv n•rt ra ~fJA- I _~ H I vl a ~• q A ZfJA~• YI KLI~+ 1Nrtl1lp(vI01C.tIpHNO ~ UI p/p/ 5533 L vlNClliDEHIV 2~.3 o,E 6 998. I efG SR9lDOw+n4 IA5(1t 1,95! MlDplt HqM NO IS 90 !4: !r~{~aNt~~"-"_ r451 Mr s Aoowssa ovml9 rev N E H•Mea AD tssa,NSln•NC9 <o aACtNS (Z, R S''f1~Ttr a~ •'Td4•/NSEX~,D oAMACt utA ' H qs.N NC ^ 1 rwnoNH cNUw p1N•o ~ u gAMAUDARu aA9ct rnM °~ 4 °• a Dw^tH ~nMUMC roi"ono 5 p o nD• ~ ,°Swnr a9tMAN[p f o Idiurio~ 5 ~ ~~ to,~: er ~sovnoeY f DIAGRAM iCOll1510N: aNVtn i+riieessun NDi:~:osMY'" r DE/S,C~R.I-sGT~IOgN ~OF COlLI5110N:~~gIlnE3wn[MiNt~u~sMtt,r NeasYwrl -VcrF ES:.i ~ (~ W~~~fiW~ `~"-/ tl/~f'Y/~ _. ~ ~ ~ D ` ; . /tJi/J .~.7Z5!~j. dGhD .rJifG ... I ~ 2D( Ul 7? tI fT ON C J U . 7~.t. x ~ ~ i . T . ~ /. ~ ~ -- ~ ; f i~"!!1/r7~/~~, (/Q~z'uuFi'ra7C1f~C.~/SE ' ~Z ~ U ' ' --- .~ ~ - E7}1 [.lE C{/.C~ Oi7.f1'6GU Q 7D ~ m Pi ~o a ~ ~ , yd ss tq ~ v~ r O ua ~ , NAME, ADDRESS 8 INJURIES OF PERSONS I NV LVE + CODES 1 Z ~ S 6 OCCUPANTS/ ITNESSES lia •pDn~oNAl NlwN ril u9 Ace rnus '"vh v nv4 un N•w ~ •DD4tss ~ 7 u9 a ' • r My wl ~ L ADMITS tWld • vOnv'Dm ^AMO ^naKl ^~'m1 ^ N+ ^,i~IHSr b •xl NO • .Dahl wvISrLAI HG MrK11YN•r111•Hl a•DGI 91 ,D Np WINCr Ni ~ts°1 N VH~Ia DII GKI D~3.•rIwID s lM w. 14vID O•w ^'t OArI r11 t l . ~: .:,u °.'u^ om ^".° A4glOVlDa D•II X .~~ v;i ~~ 3 p A3Ga ~1 ~ it z~~i'7 ~ _, - ~ . 0 ~a4 ,. t am 'i 7 ` +~,x C[~ ~ .. __ g~ ~ ~5 s xq. r... .vsi ~ . , vw~,`,' '' S I t+y ' ~a~~ ~ _. R.A~ W ~k I. Ay ~ ~ 'f r. F G n. l " F iC#.^~ ~~ 1 ~+ g7 yr _ 'u 1 ~ ' ~ i~ ~ - ~. ~'~ ~...... ... f. ... a~ ~.~~ ' t t. ~. - ~~ " ~ CT ATG ~AG \~i f;,::~~ ~~~~~._r'~''c"~,'.....~~ ~d ... ~4t '~'~5 ~ K ri~~r~:~v°'4'ek~rPx.~ t ~'-~ ~ c ' < ~ ~. ~~',' 'rf ' - n~ L ~+.. n ~::' 'r {~ ~k p . XS i-.p n~ A7 ~ ^~~ a^~ ~, ~ , ~, a~.~ - ~~ ~,.s»vSwa ' ~ z ~m~`^~~' ~'J POLICE TRAFFIC COIGN REPORT ®TRAFFICWAY ~ I PRIVATE WAY ft~l f rt eRwEn NUmetR '-~ ~.' I _ wfr I Iu3F ]bONOURI COUrvir Wx. u Iws nlD. ] ~ _ CouNrY NO. CITY NO. ~ 8 IS •l. 0125 SEff~(5ont ^LRIBAN []N ~f ~IN CIIr09 rOwN FEND OISER1fFOR 1N GH W AV C4f I gOUi f pq t ~ / /1 ( ~ ~ mllf5 ~,S ~W ~Of PDr Iot..DnSESn~ ON ~ r CVT~I'F Q~ INrt9ucr NC wrrH: searD99o•D NoN Nr{ R U aION ry YCf O 151 TZJ . = . . .I /` (~~ ~.I~ /~~ 6[tW[[N I nfA~y~ fgcF N6rRFFf a 1 R~~~ PO S S+REfr r D R9[NY fo. m9e vosr 52 [ IS u4C[6DRF ONE 19[ kCRO5531RF[r RNtA9t5 F903 ACCIDENT ~~ m [S 5 MILEAGE far or '~ NorrL. Ef3Y! wGE . RAMI DIA aAM DAIA ' COfl,SpN,NVOfV[D'. SfvlR tv IOr•t NO O[4lfD~Np NlURFO r ^SR IIAGF ^Hr69UN ,Vmr,'pgD~„ b ~ ~9D CI Sr 9R0•p p4 R{ff4ENQ ' INR9 OIS N0655RFF10R ROM ]) J 9 VfwGl[S ~PROKRIV DAMAGFONFr ^vt SUlrEO ov(«(jf OBlfcr SrRU[Y INAmf OE OBRC1519UC[MDOWN{R SNAM[I fSr pANME ~r~so SRECw CODING LEE _ - f :_ UNIT NO. I DervfRiN OF~ µ31 q3r MIDDIt UNIT N0.2 - 09WEe'S NAMF' I ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST ASt 1~ _ sw{^MDRfss ~' £R ~` BAN t D r 220 CondoN (_-Ang ret{r MDgfss S+Arf ZI9 COtt RHONf NO. FE~Ri 1.5+cllou W A 9 36S c{3~- D R r SFAtf IRC [ 1 ~ DRNf SIIClNVN Nl~.nec~535~3 SIArF LJA FY mDi D•.'~"r9 ( V r U N NO. Atf DA fq BIR1H mo °A rR aeu9wnd. m N•m{ anwNf No. ens IeHr HfIGNr E ocew•noN m NAmf a 9HOnt No ~G -" BIU 1l5 5932 R . fns IcHr Hflc" r ~ CHECK (.~ ' nH ca •s:N [mnora A Ar~orH[91i4 ^ CHECK (.~ •t vfHa i a , x.c l CODES-* 7 n.A'"is~ A iin«N a+wH +D + I S t a s',°N+. ...- 2 [AS AN rmR orrf ANOrH[e : °s' inM"I cr N CODES - t 7 n . iv a u a ,;"° qen •cN ~ IN,wlts L c~Ad.--~ To E+o„ + r TFI° ^ .mfm.ME ^ 91 ^ Ebm. ~, ~ .. ^ ~ vfH re•e m 1DODGt.e"ev.l moDLL1DARr NDVA1 rrtf l]DR..cONV 5 F ;„7:' p Aw O ~ ^ ~: K+I r R ~ ^ D + O . 7$ RtSu,n 2802 2D! ' E I nFVf I mODft1 RI NOVAI yf _ ~ ;, ' ~ H_ U SrAIE aR 0.AlF NO. AIE N H vtH <R 9 GRw Cnz ~~~ WA I H . A KIe IDfNnr urq]N NO. ~ vIH t[aNrulul o GN ~ 3 I I 3 Ym6 PlGISIFe[DOWN{R µ3r PS r f eNOfE NO ' ~ ISR f0 '- lJr~ht L JOn ] •DDR1550f ~ ~~ O W VmfR: µ3l {IR31 MrDpll f 2 g"G ]A S ~Di d.I NAm{aADDq[uaf mwRANCe eo o9 AC{Nr E D WNfq .__. fJOn36 R ~~ 7 I,;..aoHN cHAec{ c~AOra w Bw~N gAmAG{DI..PfA ~ • .~- - S or wmAC{ ~Aw:r" ~efmmwlD ~ ^iwAiN fst.oq~ roR ^Rfm•INm I Ibion:: fI:CA°-° ~o ~f c:'o:ro+ I "t D ~D f W r er. (]~ er a DIAGRAM OF COLLISION: luau f f ND,cAn~m DESCRIPTION OE COLLISION; IUSf 51A0.lmfNlAI SH[fr IE NECFSSARrI ~ _ - ~s% y-f~_1-~.ls_~p~ VE63:c16 CloS56d { f -- ` Y~~_1n~6--$ SL-a.Ador 8 _t..~s. -c :-.:lo 'p,Y~J... ~,o I Slaa ~' ~ -- _ _ _ -- slc.d~__~ .,-J, Drf~.~r pr~sssv~r~ t.E~ sfs...a ~ _ L _ ._ . . ;9w 1,rS__A~e15_T=tk'd 'ls~.~r w ti si.a~eo_ - I _, _ +4ar sl ~t^s Y1 EEJl A 7 wq s I~ i __ , .~ ~ , . . 6 v v ~ .. ~- __I I - ---- ~z sic ~ -.1_~__.I. !_ I_.. I : - 1 __ P. _..-.__-________ .. _ _._. ._ ____.-.__._~._ ~ _~.- .. ... .__ _. .. _._.~_. ,_L R _. _. . . . _.__ .. . _.__._ -_.___ __. __.__. ___._._.__. _.... NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES i u OCCUPANTS/WITNESSES io: ioD~lofi:iN NIISI ~ "' 2 AI 4. V _ ~ V' 3 ' Wi 4 5 6 N•VI NIFne~4r, Sofa 887 . GD ' 437-2 Aaa.ns 2 _ .._.. _ .. __. ___.- ... Nn 4r ai SIY AGI N rAlUS 7. n y + E,.f f 41514 F>tGl ., +, m L T t... UA N• f u , q , , N er pAm e Oct" O ~ " " . ,. .:,f. ^.^I O :- ]B _... .._ - .. _._ _..... ..___ _. ra .rw.a3 t NaufE Or __.. -~ ° 9 µ~wf4om 3~ ^•me Oc""cl ~~ ^w ^~. .D _. No .I3, q.TOf 1G1 _ ~~.ff o-I, ~.. ~ .D •x "' 1'T `'~;. f.3,..v11.,,, s nn e. ^• a ', . , \ uucl oa wn,,:. ,..•~r, Iwsou<~{c nncl •:uaD D.rl DAr{ •,• DrA s N` Ao r ` . 1 J :~9 oI Scso N 1 ]RZ55 e~sa ~ s~~,~ 3 ~`" .: :N ~ `S~ " ^ p' T6 ~ ,a ~~ ~ ~ ~ ~~. G ~ ~ 1 y ~'. ~i - ~ ~ - ~~ era: ~ - _ _ ~~ lc ' - n4 . p s 1 y ~~~ ~~1 IY° ~ 43;L`~ 3 xi .~iAikP !~GkRi+R9,yXa' I~,~' P'NO~+¢¢~.~_~"~~. r n f , +~ 7 C t°. rl I ;y ~ ~'~ ~ ~ ~ { r ~A +I T~ S ' 1 4 I H T J ~ ~!~ L F j i ~}~+~ ~ H ^ U 1111 f_ ~ ~~ `~',, r~Ai ~ ~ c. ,' 1 1 ~ yy 11 ll ~ gI.1'I' alb `r ._.. ~n~ yam. 1 ~ r ~,. ~~E:,: w5. ~ R" b ~ STATE OF WAS~NGTON vAee < or < ~ "9 ' ~` No• POLICE TRAFFIC COLLISION REPORT ~JTRAFFICWAy "~ ~ " V ~ ~ 1 KS CO.Mq,uNI NIYANV ~ ~ ~~ DAf r u N IMt PRIVATE WAY ' ~ ,, ~ ~ v I 10$t ].DD NO u- I ~ i.I:Ts:7 <y~°I f I COUNrv \ ]Y .-~ / d.~J ~ • Citt NO. °ENwA .S! Y rc jj ~l p.pa6y~F}~p ~ ROV E04 4UeAl MI ° °t ° ~T~/fIQ.</ H 'J S I .t: ~ ~N C.a oG ~~r',y ~1 ~r+'`cx criNO V n ~ssR roR AD NON NrfRSfCii O N ~ f .,, di (( Jf /•, W[UI MIf NSr •~ etNA[ AT. OC ~ Sla[Fr ~~v~P s [El ~~O N OR AN t f ~( N ~ J ~ CRO555rR[ fA SIMI wll5 N 5 E W ~ I ACCIDENT Du RAM rA «[r OI Q MILEAGE ',' ~, CODE ,;,~. Dal151oN vav[D fv[Rn /~ rornl NO No ufD.__NO. iN,uetD N 3S°SV IlA4F ^NrER OVFN^FS w wrDrN I K D rNlta cls Rft, RRp.ppR RfrlRFNCt •„'( cvaas ] F Sffr DRR~ , IRORR]Y DAMA4[ONIY ° ~[ °v1aRf N ,,.. Oe,lCr SraIKRINNAf 01 CI Sra`1Ca ANDOwrvfRSNAM(I t51 p„AAGE SI[CUICOD~NG IAE p~' ~\^/\ P , s •~ 6 r{ DRnER's f~ UNI7 NO.1 UNIT N0.1 wr nasr I It RrvfR'sN u VEHICLE ^ PEDESTRIAN ~ PEDALCYCl15T -23 5 ~ ~% ~ ~ - 5 ErwDDRl55 ~6 Y ~~ _ Fs~iQJS/0..~ n~ a rADORfss /~ ~ 4 ~ ~ ~ i c . ~ srerz ]neon vaoNe rro. D GJ rvfP' NCfT~E ~ / S W7 R r,fl ,~ ~ p 4 `5 !~ ' O\ s'"r 93 L` rla. fEMONfNO I l No. ~ S-~ " n o s.>~,5- E At At - D.r r i- ~s Nr ~oN nRM NAME a vNONe No r C U 3 R R ,y~, rrrr `s ^ CHECK (.~ vEN «A i ° CHECK (r~ ~/ ~ r nN. eA AN CODES-~ vfN a[AS AN U. c r l '. ~ '~ S r <~~ n ~ K,c1 ] ~ . nov«aANOrN[ S~ r. , n^ CODES -' D c~:a R ':snw" 5 u b ~ rnL /]] f KW ~~ ~~ , MDI n ":E:R~ °IDOD~<<:fY,° ~`~ fo ~.n. ° ;;. ::~,. My~,N,. ^ MM,kI ° zs~ o „:z., o, ,D NDVA) S~v l,] .CONY, ° ~~ '~ ~ ~M ;, ; I ~~, G r N l 1, G ~~Z E .,J S ~s~ SIAIt r. ~ _ ~ 7 ~ ~~' '' . - Lz~ w~ MlfR0.Arf N0 SrArf H vtN - - I _. _ ~ Z ~ ~ . , vfNKl[~pMilKArpNM ~ vIN~ It D N i ~ i f . ~. A i.~ •^r~ L af44Re1DOW?HR C O NaSr ~ Mipplf INO ~ It ~~~ ti/ O ° 4j. ~ bs NF NO i WN R. 1, r T T~~I~ n ADDRf55d OWNIa ~0 ~ /~fG N t0 T(J ~ ~ ~ NAVt.ADO.fssa ~NSURANa co nACar ~ ~', ~ (~ ~ I ~ ~~ n~? ' ~ Y ~, . `~ _`- ~ R rD4w01 M~ I ~ ~~Q~S'I/ ` CY~-til ~~~^l • ~ ~ y~ ~7 r 1' s ` ~ 1 u CNM ~~ L 2 CNMOI 4"""~ MG Dr~ ~ ,: ~, 9 II.. U'4 ~' ~ / ibionb? nAwNm ^RrveN WAY ^RI.MAINtD D iC]MD ~ S ~ "- l5r r Y. '.~ (, ' _ ~ ^iONtDav r6iorib~ RAM Of COll15lON rsu Ni swl r10 • NoRrN DFSCRIPi ON pf COllISION: 1Wt surnewNrM Sraer rxa5~ ! ~ ' N 1 a./ -~7XlrNt~[ T.rl+etE/L V off. . s ~/~ ~ A _!~~ ,1975 . °iz~} ~~, ((~ S xt NAw ~Eit __.... .. .~...,~ iw ubi~o+~Ai NAM fi.J oGA is~ ~ u. Aw _ ° w. u. w, ~ ~ •Kr nsu txu ., ,r ) K Ik ~ : ~ I t ~ r~. a r ~ ~ e, E A /~' ~ / W ~~ ~ ~ e: ~ AMe °11ar° w .OC. ~34~ ~ ~ ~~~ 1~ . 1 ~ .DDM N.Mf r`6a •J ~. s.'ROM °AMe °r~ar °~ . ° ~ b i!• "„ ,3. M s' ' aP ~'" .DDaI»5 f i .r,uarKras N.Mfe.r yoJ. `~ li . _ ^.Me °~au ^~o ::~ " ~ .r ~ r n A' A ~ X e.D41 o. NO .u •.c. N o. ~ b" . Dr ? SrA•C"ID d K 1p a[rOar rn . apvfDer ^ ::;.. DAtI ~ N ~ ~ . ~ 3` ,.~ R R ,' ,. w ~. •vl Ml k F - ,i ~ R~ ~V'` ~ „~ l ~11. v ' H ~~ 1, r r ,~~ i...' „ .. , ~~l~ .-'~l1 .. ~ 'i ~1. 4 ~` ~.. c " ,~ 1 u 4 ~ y Fi ~" ~.5. ro ~~ i .. r. r M 't~~. ~ ,~ ~ '~` , . ~, w.< 5 #+~'m v ~.- , 1 .6~ra, ~ts% POUCE TRAFFIC C ION REPORT /Ly TRAFFICWAV - .~ ~ •J '~~ 7 I PRIVATE WAV D. for CpUNtY f LI Nr NUMGF? •. ,.... ~ /B ~ ~f.Y Wv.:mu N ;w(y r .. ~,.j wln ~. r ~ fgUS/1~NC Uei rr Np. arv NO. rsrw.s Q AN / (-]N QE ON ^ r%~in~ ~ NAMttNO psrPFF109 wpnW.Y /K~/ mil[3 IQyw1 ^W pl /p!-'J ~ oN ~c ~~~ Cut off Nrte%CriNG lMrn ereFFl Da cp•D NON NIt9% r C ON Cle - eW k09 9S/'~D ~ // MILL YOSr EE' ~ efrwftN fZCC1i EC7 sour a C/JSrvtn f I._. ~/,~~3 y . ms •NCt ovf I cvouuvft NE•efSl mD rr ACCIDENT •MC Du clan MrA 5 a Nf W IIEAGE [b N J ef[r pr E • ~ coDE coursaN Nvavro vee rr : ,. us N rpIAl NO I1J7 HO ell[D~NO INIUPED~ ^s•IItAGF ^Nlr a((9UN .uNONOm IN% LDS C40SeeiGt DO Cp•pc •OA004 FMN<f C•vtw C%s L`-{ ~pc0•[erv p•MAGf pNLr ^HSDIttO Ovf°iCLf '~~ OBI[Cr ereOCK NWnf r TI J I O OBltCl sr•UCe AND OwNt95NAMF1 1e10AM•Gf S^CIAI COOiNpIAF ~- rte. / ~ f .. UNIT NO.I UNIT NO.Y ^ VEHICEE ^ PEDESTRIAN Dunces NAMt ^ PEDALCVCUST uLSr Dvnfvs NAV.e. sr 'fiEi1'- /~9~ yiu r 'J• z h.~ ~Fli~/c' f!IUSSoN //// uvauoovf /CL~ V/ ~, / 7Q ~.9~z "ter-~~~F ftr NDelSe 43 ~i 2 A D 0 Z ,~J :vcoa vnoNt NO (/" ~• 7G.c~~t'/,rI /ti~ ~~Q ,UO~VE n 5 Cf %N SrArf R •rt ~J /GwgS~f GU/~ 9.G368 385- 6 / ~//-/~Fi~ ~~qz~r~- ~~R x 2 "sig s ( v n l N N ,v civf- x Af - rn ~ 2il ~q / ac m N e s rwpNt NO fns wr .a,onr Ne E acuvr oN r qM N•MF a •IgNF NO ~~ F~>.. !_ //_S'~ ~?E37 5P. o/ <r f/S S-6 R ens ipNr N[icNr Gi'(~G':/fi •(i (aS' / O CHECK (/) vfw cLt• w N N rwfe CODES -' ~ ~ R ^' A s e w .oy, ^CHECK (,~ t•s ANtMnp.[fa• rwtuL CODES ~ ~ ] ~ " a . 5 u e s• .c.c` 5,c vas M ua D» +M~ID000tc~fvp rv o•~o t0 ~b~wv ^sni O CuVS' ""yo,• m ^v'•^^ EY1" ^'8:,r. ^ vL K^ O :.N,. 1963 r-or .O t7DV if/lGOwv 2-OQ' E =~` ", ' 7~7 o!.'rJ" v /U/onslct7 Z - Oe. _ ~m w/h• I N 953- .u ~ J er•r m•nu n•rt NO er•r -- "-- ~A H I vtw ~/ /7 F~1.1TF~ / a:'~~/iG - - ~ kA S A nwKUiuNUrc•rroN NO 3~ ~ qV f 2 SSOM efp~e^e[D OWNIe Wr riRer IW [ C ~ v D«.. / "' ~ ~ '~~ / / ~ 5 v I, .. G l •wONI NO /t//J~/~CE~V/S f~l/p ~-- •DDVtSSa.owvu W i t ( IAer 11151 USSON C/~P/ ~ 1/UO.•e p ~GY ~~iof-`t:CY"aCt !~• /C~:•s-:P,rE Z~ S 1d S E Z . . Z7?- Es7/l/ •MU •Dwtssa WwuNCf co o1 •aw -----_ ml pAm•GLD N(• ~ Of VC ' S-~L-) ! 1 • ,'c C w iw ~i~~•OtD NU CNNW 1 • . ~ / /1. _ r 1rD .. 5 l51 f p•M•pl Wei r. E'~ yIMMNID D~IVIVIN ~eVA.iN[D t ~ ~A ' .TD. $ Q/A/ r~Da /L/~ C :w:roer 1 ^S fT~/ reionow DIAGRAM OF COIII$ION: Maur u'rlecuw:l iv "oaW r" DESCRIPTION OF COIII$ION: tatsurnemaNM SntnDNCfss•1rl ~M VEf//CC F ~ / /Lbr /ii an ~!71/rvo``f - 1 CU7 nff %//~cF~„ti 7Ak~ /•~ -°A \ / r ~ 1~ 4U / ~ . m~ 2 ~ ~ l/Ei/iPc F ~' 7 7i~Fi/r~/ sw~19. -- DE-k"iI -> ~-- DTkh Lv~/ ~c ~,/io/ a-c',/~ /mFi f/1e E./IS"r T ,r~/7G // ov~C cq,PfE[7E'~ ~ »~E/k,FpS.S. 1/rh. r /r a / Ale , . _... NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 - Z 3 ~ 5 6 OCCUPANTS/WITNESSES ,a ;,pDn!a;;i i~uv i~ u1 •pt ums '"„^" % "',' n su tna a°7 //r< ~ til~ G'/ tl: ~ ti ° • . uD.ns - . t . rL~• a _ .m 1 EYI' cL 0 ••, . 0.7: OC u` N o . Dens N M.1 uLa a , MDVID 1 O•Me O'°"' ^"" . O N ^.:: Np -.. vo.l.NC l N lri,v O•w Ou" cane O' ~ ^ :9NS• a clnN.ms n.Nr X C .~;_c'o~'~ic," s•DCI O. ./;' Ncr . o-~`e$P A/S~' a".- a~a Da••;c"ID zzaw ,.~,.e w.cL N•,vlo ~3U ,mw., D•na n•wr .[ • ~ i D. ~ ~~~ POLICE TRAFFIC COLLISION REPORT ILy 1RAFFICWAY POIgECOMRAMINUM9E4 f RRIVATE WAY ' EOi CGIIr I N ~ $~ O'er A IU rON tlmE C ro L4P Wr Vgv~rurY r., v,. IUSFIbOwOURI OUNIV JEFt~rSON COVNtYNO. /~ CIrYNO. ' fHWA ^ ulA 4Al N CItvOR fOWU []N Q( ~rN (MOO S/4(804 NgNWAV Mufs ^s w Hof ~,E)ck ON ~ INrEV3ECriuG N+(w: 5lvfff 4 R 0 0AD upN lNtEg5FC110N OS ? gGU1E ORS L! 9500 Sftlr . . G J J. Y]. ~ BE1WFfN Srgffr f srREEr 0'e PAnCE ADi4ECAir `ONP PE9EU f. C405S5r9fft04 NfA9E5r MIlE POS ACCIOENi rfs vE3 E fEEr W Of MILEAGE COIN 4vEfl% f0. mIIF PoSt 3. ~'9 4 A 40.N MIA ?, COEUigNINVOIVED. NO KhIfD~NO.tNlU9Fp~ ^SPIIEAGf ^wIrARU m'esix OIAE NO N wuowot"f © IN D r CrI FE OR40A0O4 MiF4ENCE IMFR OS fAO3331NEEi0v gOAD !11 Cf VFwICI[S IgORgtYDAMPGE ONLY ^gfSUIrFD ^VFaCIF OOJtCt SrquC41NAME OP OBIECI SIVUCA ANpOWNFOSNAME) f3r.pAMAGf ~ G33o0 SPECI.4 COPING USE UNIT NO.1 UNITN0.2 D9r4f43NAm. f' Ultt f1951 MIDD E VEHICLE ^PEOESTRIAN QPEDALCYCLIST 1A L 04IVE95NAmE: w3i I EE - s~.aie Shlef~.~ SIREfr ADOP Crrv 1 0 SrArf ZIP CO ~ IM~ UM D 5 Rffr AOO4F55 ~~. Ufe..~7?lt~r Gar, s~ PO- ~ ~ ~/~ ~1 ~ ~ DE 4H fN0 1L IIIAQ(L\J A c1833 732--912.6 ' R I~~l~r( ~~Arf 9833`? 3g S'-y/3/ / /-r 09wFq S DCENYN f F% I w ( I ~ CENSE NO IE , - Sf So C~,St,3~ of WA M D9 ~2t ~69 ~ ~~CS259yCy WA % rF OF BI9rw F Dz~zv w/ J OCCUVwtION 5116/EW+T CHECK / NAf 6PHONE NO. EYES IGHr HFIGwr N 5 732.4126 GKLI 1 b~ ' AE E R acuPArloy FIgM NAME%fHONf NO. EYf3 wErw4r ffrGHr /-/'[.r.~~ {~ / Sd7 ^ ( ) vEwl EE SS AN fMROVFFpANOrwE4 CODES ®* ~ '" . s i "' y s E o" J e mo .nom ~: %<r~ ,'°." : ~ ^'CHECK (/) 'vEHICiE ASAN EMViovEE Of AHOrwE4'AI CODES ~ ~ p .N tea. i is%n: '"r s u w ~ ,Lr~ x~ry .I_ s t ' ?n Z" riE%~Rlos SY n+on e . 57,A-'fin (vo,~6 ~ QY°`1. v0 ~O.MM„A«<E ^ uyLt , ..14 K;6 .°,~:, VFw. G9 M f100DGE CnfV.l EEOj DARtfNOVAO VSrYIE II OV^{ONV 1 mD°, Ewr erq'0 E4, .. p.m4A.„(t O E.. ^ EBdR ^ ~~~KS ^ ~ .~,. V ~ ' ~ . ~! turd MI, s ~ z~r CEN3E PfAtE NO surf Y E H 1 HfV.I MODFt 10 NOVAI 8 ~ F •^ol Pfv ,~ioo Y,, L3lK . o~R 777 RAIf NO. Serf wA , C cao9 /~.~" A 1 A Af f..ADA~ TP7QJ79 L./f} r3 V[wgl[10[NrrPICAigNNO. I IFI 15 H 1 4 212. SI I I I 4fGISR4FDOWNf9: IA3r flg3t MrOIXt PwONF NO L alaErannPlup JIFITID F / y 81 'S PIA p5 216 71 I 9E0 wNf 9' So c.E.. ~ lLas- 73z-ylz6 W . i fIP31 mlppEE SEe4~.~ ENO. ' u~ 2 A AopRESS owNeA N ~ Sew ~S ~Y''l! , I r F. N~hUrsd lNyygANCee wAGey IA I.YIQ ~ E IN ~ / ~ /~ SH~ ~j°~ ~7A]/l5~tf` R f7~Ont5Y .Sh.`(-~i ~i7AL1S~i(..1~ 1 ~ 1 DAmAGeo.wfA $ ~" CwAgG( LO 1 D CHA4G[ AMAGFO ARG E r rOi01r ) t31 p AMAGf ~ ~vlVl~v RlMNN[O ^AWAYN ^4[MMNtO ISf DAMAGE rowed o o i'oro l 1 ~ vrto ;L~,n ,T~ E4 Sla . ^ Aw.r FY Y 3~~ t r~ - DIAGRAM OF COLLISION i~a[E Uw4suq E npgArt NO.rn DESCRIPTION OF COIUSION IVS[s [ E rAE SweEr c[ssAR I H ..- er.9ROw I _.. -i- f ~ r l._~.- Ftg~.t~-j: , 4D vEada wns ti 6 P.F«4j a~ `-:w1` -- vsL.~ts Ir-- ~ - ; ~ ! ; - ~S ca~._(:~ _cEae•Ks a.,ae- --} ~ ASR : Vin/ ~ s,-rE,~ z a~ ~~:~~ I I t r i l l .. AclEitseK! uo L.IhS y~-bEaF,y~.1• e.Aio u~seSC~-.~• - :. ~ -1- -i -I _ f ' ~ ~ I .-'I~d t sTAVrsn ve~.r z --lad E, l - ~ l ~ . ~ ^ i ( E i °ew''et 1 ~.._ r ~ ~ .- I ' ' I Z t.nac 4°.'~ ~D I fKTs ~J!l1~ Il .SSA y'I:s ~ S1 J l ~« ,. E ~. .. , ... I I ~.._ t I _ t nEs l l •t E T. G + - +~ I "~, I I 'Ck~crf r ~ t ~ I _ 4- - . . ... g s ~L.O.S.wa D ~6~h:.vio- S' ~R.d tccv~L ~ -. - i4L., Ohss 1 LE.FY ~ Atlm( Arr~vw(. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I Z - 9 4 5 6 ~ OCCUPANTS/WITNESSES liouaioarprfuiua"e ~1t~ I'~M~E r t si i N Acl Aros 'NYt, M.r "iu - ~ '~ ~ N s - r~ i ~""- ~ Rena [na Ma. E 1 c. f '?d k q U~ ~.eD t l . ~,e33 c c E LJa ~~ ~~°' un e. o~lr ^-' . ^a ^ss~,. m . M16~ STtLLG . o l s i i°Aruo aeS ~ 6/54 / o n A,r 2, r .d~ 0 f : }w.wtD,4oM O.v p~; a O.~ . O C ^ :° a rid • ~t,•,~ ^ r s ^Ias f uer:r nY "" O.Me ^ ". ' O n . ^ H: ^ : ' ~~ . D ~ ~+ r~r,0 tn,q 4 IIIUt vA0<a 0a ALIrK• ~:.,... lG,:rArCr.IL hh'CI A4viNL PArl ~U, 411 Z 1 -Z D DY~ 2n5., 3~y/8] 3~~ ~Q 8 ~~e _!1 - ; _! t l 2 E b ~1TIC1 .fr n q ~ yq „ t '.T r rA: „I~ t r ~f4Su - 1: "~4 tl« . AY - 1 7A~ITr#w,riF4`A'~M~~ ", `` 1'Q,. I E i ~ 4~ryr~ t I ,-4 r.;,, ~:. l ~' . t ~~~ ~ E 'r,' c , 4; '7 ' , ~ r, r } r. y s !` I i~;'E _; , -1. , ~ ` l f r .. ~~~~" ~'{r ~~ +.. d' ~..~~. F WASHI ON GE ~ DP / No. ,EI 4 '.- O STATE O ~TRAFFICWAY PoucfccMn^INtN y ~ ~'~~t~p•~~. 's ~ POLICE TRAFFIC COLLISION REPORT ^ PRIVATE WAY Pnwe , r"& <ouNr No on NO. Du '~• ., qa y~ couNtY ~ Y ~ uciloN ~:~ N IU51~~HDI SCF _ ~ gWiE 0a 51vt 14~u DAIf Of COEEI rv ,v 5. ~ . ~S.I C_r 0.5 ~SI~D a ~ a ~) r' 0.NE6NO.OP SrYE~IGNW F r ~~ ~ ~ $ '. T ~ a.O H .I ~5"0~0~+~~ ~~Cd/ G'i~ ae x ... mat POSt - .. ~4 P . '"r' ~ 3f .s M E ~ o /~ o . o/ J P NoNmlFVSfciloN ~smFEt OIM+aAM wtA ~~ '~ gy~t N SfGi rvG MrN. S OP PO p Sra(N L T J ¢D I BFtwFfN~7.~ ~ ACCIOENL a~P J ` 't MILEAGE CI IaLEtOa POADd vEEEPEEKC I'D r ~ / I nPFSr M if v05 CODN Ef' P ~ SSSigfEl OV N~EJ M11S N _ ~' DSrtNGE yDIaFf~l OS ivON PNEPFNE F.CPO DP 2 O wrvD.EDI•s INffa CIS CAOSSSrgffiOP POM /,~! -63 ~. rr , S PFfi SvE tr. W ^SP IIAGL nlt6aU SSIQ«D ~ DIVFD NO NIUgfDSL P4E ~VMC EN DING USE ~ i ) COLD `pN rvv m NO YPPLED~ UItFO FSi.DNMAGE SlhCUIC OiN NO OPfatY DPM GFONEY ~ R y ~r ~ avfwclfs sNPMfI l S ~' PEDALCYCII$T _ r",` ~(y, ~ OIIRGr StPUCFINAMf Of OBIECr SivUCa ANDOwNFP VEHICLE ^PEDESTRIAN ~ - ~}~ , ~'aa s. 1 I ~/.a?i ~~i/C M Derv a1T N0.4 ^sr iP '6 UNIT NO.I E s NOmt ~5. _ Insr Nasi N . 2ye~ {~'~.- ! DIVIP'SrvNY.F: 1 ~(~jJ~i Slgffi~DOVF55 ~~" ~ ~a t, ,~• PCLL~i' d~ N CPC ~ q, s ~ .t Y A~ surf T ~ ~..^^ StPlftwDDVE55 ~TG/~ / D D rf Blan U h~~ Pn0 ENO. Y PIE ,p I o~v Irt gC e/lE ~~ St f 2z1P C2ODE ~ 0~ SS ,, ~ ~ rv ' ~~,f~~ '~ , ~ /` ~ 981'' PUI I IGEN NG. M '/'~ 5 ~+1~C/ f ~l {~ ~, frfs wElcNt lalcnr 31 rvEa arvsE NO. ' t~i~/ ~/v N.ME E vEroNf No. .i ~~ ~ ~. v 1 DPSp ~ ~'O $ ^I /g ~rEwnt E oc<uP r a+ a/qn Er{~ N e UypiION rvnMF6 PnONE NO. E))~~ ~ R A i '^Z/ v occ 4l ~~ ~ CHECK I/) r fns nN EMxavFFaA rnEPP1 a vD 's ~~:: ,~ s'~ ~ ~ /1J OiJ~ ~ O.J P. - .ii ~., s iec oN .N1O~ rcE ~. v 'E~ CODES - ~ ~ a ° , CHECK (/) i«GiE ns Y.N FMNOnFOP DNS n`a bs: ^iv°.'.s. M ~y ~ r 1 CODES P t Iii • s.sN+ ^ c$:n. ^ P.~r a q v 1 - N[>• . 9 . , 0..1G ns~.P NI IIC l nlu.nv r QweM [vl^4 IIDAat.NOVnI l w~ ys 1t .$ ~ "9.i X nNtt ~ ~eE ~ ~bnl. ^ v K~ q.CONV 1 . t~e N `~ 9 ~ ~,q¢ Sea+ ~ Puwl MODEL ~J~.NOV~I ~YIf I] E Ol a ^ ~ ]`7? f N EIDODGECHFV.I O,C/~~ S (~ T~+St~ ]9 I UCEN v Si~IE _=rF NO, I v I ~~ i vEnrclf loENtlP Utl NN I I I I I I ~ I ~ ~ ,- '~ ]~E `~ I ~ ~ ~ { 1 Ngsi ~ M~Dae r ra. l,y y_~, *+t ~~ vfnKIE DENEIE CADON NQ,~I.Lt~ S/I 'MISI~{ { I SrtPEDOWNfP.. '> / O'~ „U ~,: n ,L ; ~'/( ,DD,E PEgNE NO. Q P ~I A y~nY, , .ry /G Iasi ~c ~ l 1 T '~ vfG~SRPFDOWNFV USrC W N "~ ,D voovessaow«w /~~fG E IN u ~n , + - M{ ~~ P Pr 1~ sDPN+Gf~/a"'~ R ~ ol:~ o ~ gAMACfDMEA/ ~ t. $(A( ~' ~ NNAEa.ODaESSd IN ~ I~S ~v 'F Gn•a ~ Est iD.Mnee ~ _ ~. 83/ 4 _.... CnMGF "'p. _ ^1W.SY ~PUANNFD .... ...~ nl:v~, DaMaGlO M[~ f S DIAGRAM Vrt.V I .{--~~'~' 114 s ~J ~,-, ~~ ,~ I i. I ,~/~J ~ I. II I _ t. AWAY 9 S[SU E NINS EE a+^~.. _.__ cA~ovtn DESCRIPTION OF COIII$ION.__._s~ O~ . -~iTti1'r ,~ . ~ ~ ~ ,. S~Xwz ~. ~:~. ~1+'~41 ~ I Y I f i t '~ S ' s '':ii ~'>~ x' yd , M ~' ~ ~~ ~~ j Dail Ui COl45 D~~~ wx i DMF •i. Iv5E tb0H0/V CO~Nrv '/ /~ CO/l/ryt//Y,Npn ~~ CIrv NO, 11lwA J ~7 (7 ^N 19(f ^ / x YOa~ftllJ /` N Mn O UI~4wGNWAY f RWIF 45i 4A[ ~ dG rh+us s ^ D N SfCt NOm H~59ffi09 •p l ON NON NtfPSf[t ON - ~ / ~ ~`,~/'O EEI% f BftW[[N 52 ~"'S o SfRfft B T~cI~TG 4r1RfEt pe Di CF6ORE iC9Rf OM RfI'ffN .CROSSSiRffl 9 MI FpO }R '" f pOSO 3d - •~ FS 5 F W I~ pFEi ~ /f /~~ Op /L V ACCIDENT RAMI 9ApA D•1A MILEAGE CODE <IXI SgN~NVIXVFD NFVF rv rof•l N0 0.9llFD~ NO. NIU9l0~ ^ SPIWOF ^Nid RUN rvND9iDix INfE tt5 ' M RED ~{~~ ~{ 9 bVfN~CI[5 Q pvOfERFY DAM•GI ONLY f~ f OBItCt~R~NNAE Op OBJ Ct 519UC9 W+DOwNERS NAMES ^RESU StdFN If[D ^vEN CiF % v UOSSSt4E{10 RO ~- SR a~ `~ :t "~ [S1. DAMAG{ ip{cw Crw~Nr: ~rt9 _,__ 4u _ 9~I ~~ I Y r jV. r, ~, fr ~ h'f ~b~il. ~ ~ C ~ .~- 4 ~ D~,~gx ~° a, ` . ~k FBI ._ 1 .~:~ ~,,. C~ASUUKCJJ611VJUKIt NU iw.tiH~srOu SHNVOLVED CKCUPANTS/WITNESSES f 'CO[)ES I -... .. _ 2 9 4 S 6 «waibr,a NAM N ,Mr . .__ - .- .. . fsi r ~ ND sE4 .•ce i.iui uK4 sEU- ' ND .. cB1 -_ -- M¢r n5n f,af .~ N . . ._ ... .. _ nFwns .Mf a N.mR a .. .. __.__. ~.9 rte. ^ •Me ^ Y" ^"d . ^~^n: C3wv GNAW Sf C9IM .... _ NO a .. ~vO ~DrRCw^•N ^x'yxl^ n . ^ti ^riD rv 9nDRE9B .. ... " WG.YfKlr S•MMI E9•N. DOE UR •UIIK• N•f fE Or-....... -.. _____' Iti~FS - ^• ^~<i^wiiD. SY ^Mw ^iD ~ X w au Dn22aoto ~ ~ D Fa rroR) mer D /~ e~~w _ ~ 'r ot. ,. ~ ~ d ~ 4 _~ i n a ~ „ F~ MI ~ ~ ~~ ~ , ~ , ~ a2 _ ~' 11 arF ~.~; • ~~ j a i FA "_~e ~ i ~ ~ ~ ~ ~. ~~ ,, ' ~, ~~ " ~ ~ ~ 71 i' ~ .:;.1 ' I ~ ~~J POLICE TRAFFICCION REPORT ~.TRAFFICWAY ~% °IX1 r N i tl V ~ ~- ~ PRIVATE WAY ~ ~ .' • ' //~~jf ' r9f1'5 4. IMF COUNfY ~ 4xOIN .ID.I'V, I /L~ /7I Q~ t~~ ~~ ~fFEP_Saly 7 CGUNIY CrvNO .nWA pU4aM / / OIr OA IOWN N tom 40U f0El ~ `ts ps pw of f) COG ON r~/96CE.2 2!J NRg3[CING VnInSrREF10R 90A0 NON NIlRSFCNON ~. 'i' 9,,3"o2TO ~ ~_ e[tWEFN C 6Ay srRftra O[p ~C/h~ rgftr [ t IIF.OSi ... ~Qy- ' DiSrANCI D~RI I 1. C4055514lFi OR NtARFSr MILE ACCIDENT NI[5 5 f N W 4AM OIAG4AM D.IA ZCXJ f(tr pt O KQ• MCODEE COUISroNINVIXV[D vtR f.: NiIf~N .[UlO~NO NIU4tD-_ ^S4gl.O[ pNtd RUN wNDRRf. 10TH NO N}O IN .RD [1 gOAppl Rlit4E I CIS CgO5s5R 10 PoAD. .. ]5 I ,~ aVEH ClF3 LJ Id PRORR1v DAMAGE ONLY ^RSVIIID pv[~'CIf ~ ~~~~'¢~' OBl[CI SrRUC[INNAf Of DBIECi Sr4UC[ANDOWNtRSNM1t1 [SI OMAAGF S.FCIAI CODING WF S UNIT NO. 1 UNITN0.1 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCL15T ~ % DRNtR'3 NAME: y.51 I Sr MI D~eSON /Yl/~BLE _/~ ~nE DgN[R'SNAMt: IA51 fl I - Z SIRHI ADDgt55 z'y8o G: ~Jf1e,~l.f~s~on>E e~ Rff I ADO4t55 srAR zl.coa rnONf No. Y D I s A t t 02.UC.ANtl GdYa- 988 -y4s-i R / / NtR'S UC[NSE ' SIAIE n A ( w l FNX NO At[ DA '~• :• /ULLF2/h1 73cL w F %3 ~%B 6 ~ ~ ° Z OCCU.Al10N [a.nON[NO. Ftt5 IGNi of lGnr //~R - E R CURAiIW MNAM[a.nONf NO. ftts iGni .EIGHT p CHECK(/( 'vtnat.s:N M.iYr A ANOrnto ^ CHECK(. vfntttASANrMaoreta.NO, 1°~ cu CODES - * 7 n i° ~ + ° n:W s IrKro. a ,"'°,,;,°.°c' s •l .crcu CODES - * c n + i e u s^M a .Yn. Ro fOA Z ,w o6 U7 p 0 BLKSOO Y /YOS N ,. M ;flM" '°'" ....D,. ^ 9 ^ Ebm. O ~ Kit p I4L,. VFN YtM IDODG[CntV.l MODFl1DAg1.rRYYA1 S1rLLI}DR ONV 1 u,M"i9' ^ A«N,I..RI ^ ~e° ~.q. ^ „ ^ i 9„,. wCU n . . 9 O flaa/oa Acca2u 3-~~ E I , nV.1 ID AI v f eNSf.lAt suR fq RArE NO. srAR H vfne s I3eN /rNPS~/7 l~//~- -- - ~ VENKIF InCA1roN NO. smiE Z v s 8 9 0 £31 I nG13RRfDOWMfR Vlfr NRSI MIDgF hgN[NO 1 Yfnl llIIXN I I N I I I wNtR' - . IAfI I145r ADDRF15p OVVNIR N q ~E II E NAMtawooR[ss ar lNSwANCt co aACwr S.sm Pa . G/J/vr~ R l u ,•R'Cp-L~'Q[gf-- ~' MMAGID MIA ~ NNCnW MAAf DMfA N DnA,U fn.. ~R~`.N 4 / , , tvawrnAU Af WAS ^nMUNED ^onvtN ^°usAwtn u.oAn~ACe pro. 10%DliOii AWAY ' Oii S O ~G1 : I f f~~ ICMRD V HI ~ TOLV ~ WWfD /'l' eY: a Nu DIAGRAM OF COLLISION: ~iiir°Nl 1 ~cl,.r~laF°~fn DESCRIPTION OF COEL1510N: Ns[swI[Mtr+lu sKn RNtuswYl __._ . . ~- T _' ~} ~EH/C/~-f_~~ veils SO_v).!L o~li G9~c B!W~ !_ 7~y.Ciivp ~~ 1- -- /l°r9° $~7 .t.v a91a - ~e - _ _ _ _. - i i i r _7 I oRe aay _5'0 .mi~r_'_ ~_r~ir/ R/v tcsz~~~e_ ' I ~ 1 ' ' _ -~ ~ ~ -{-~--~ ( . J_ S3!i, E~.r~._~~e_~//otfii B.nrt ~i-P~ ~ -{- '_ ~"_ T--~ - ~.44727~N6-/OJO 7/~_.,V/TCf/. I 1 _T' ~° / ~ _ _ />~.~ ~_ ~~~ -- ~ E wAS ~AvC>! or> >~ lO.rn3R.ry ~ ' / ~ ~^ I? f. ~ I I _. ~._ _rl/v/~ _/.!//fjJl(yy_!( L//Y5 Lf.K~- - - ~.. _. / NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES 1 - Z 3 ~ 5 6 ~ R i OCCUPANTS /WITNESSES iG .: w Uwu N:'wii v~ Am uw "f°r 'r -r Hsu Eeci ~u;m AMt .. _. " __.._ _... __. ._~. .. r _....__ "u Mt . rona ._.. .,_. _._--- -___ .. or ss t , No N.rwta > _- ' .nvto noA. p n:wv F a. p.Me p a.[l p"d... p Ci: .... .. _ _.. _.._ ~~p fW _. ..._._. ro. »s INAAHS nq er p.,.e p ~Nl pro... p:d ^ n ~l. r. rvl r w. a .c a.Kl. sNAw a.. N. ~o Act r.. pi"~r, on / o"t ~zc.ED ~t .~D o.na newt A YTD ar D.n ] X 6 ~~' ~ ?~t~ L %~ w gO . ~ yoz sP fl- , .3 , 3 z-/yam s E e r ~~' ,~ I~ T II ~ ..i ,adVlr~ !'. 1 , ' S( fi ~ ¢..({r ~ ~; v t .^ ~ x ~rl~ M ~ ~1 ij 't ~ .'alfi p I h.r .~, ~ .h `~ ~"' ~ '.o-k ~ '$ ~ ~~ ~ L~ ~~ `~~ ~ ~ n t ` l ~ ~ ~y, T34~"", P1i ~ I s c.~ ii 1 i ~ ! 1 1 E _ '. ~ .l ` ", 1 ~ tT •tl ~ I of ~ ~.ii _ ~ ~7 t ,,:yy& 1 _ I YN!'~Y ~ - I P - I ' h J r ~ 1 11 +. , , J 1 .~ ; i I , ~ p ry , r I ~R , XE) ~ ' ~ - ~ I - - ~~ 1 ~ Y 4~ I • •. ( ~ ~ .~ ~ . ~. .~ f r. {d ~ ~ ~ 6: ~' ~y p~~yV' E 3 t~: o:~d45Q ~ ,c,~v u r ~~ ~ ~ ~ y F ,~ ~ 3' s ~ ~ ~& ~S. ~3 r': vim,, t & s ~3 .~ ~ # .w ~' y _ q"! uti1~• ~?Y 1: t ~ - %~4 ~ ~~ ~. '~1~ k .rs ~ y.~ _...,...--.3~__~4~ ~, _ __wn~ _-" ~~ to- x, rt ~'. ~.. ". x ~..,i h; $ Ti t. ~ ~ 6. - ~^t ~l ,x T1 ., ? / vA. .~ 'N~ Y ~~_NE &~' ~ ~.• i*1 j ~S fu ~ ...~~ 'h ,~~ ~~ Vii.; '~~ ,~i a t y } ~: fl F' S 5i n~~ +,tl ~~ ~ ~- ~ .. a~ilC.~i\ C.TeT~ ~'1C uiwcu.~...~..... --ter- -- - - ... rvluN~SiMiNr MrABF4M /: ' .. -. PRIVATE WAY rrt ..Dn.f~QS91 N __ q 10~r5.~ ,iMf LY COUNTY CIIYNO. ~ e IUSE ]EOONOUeI COU^\ rNWA ~ '. ~.+~ L ' rli ~ v,. ~,ws bq I D ~e1~Y-ev`~vN ~p ^V eAN i p pE pIN O,r Oe TOWN N4AF6 NO.Or Ste[f10R G A iCT Ou,F 09 f u `~ miffs s pw for C}T i ON :,' +,.,Fm' y NrEVSECNNG Vn,n. Ste[ft 00 gpAD NON IN1Ee5tCt ON /' „' ~' 9~i~ @ ~y[ .Z~ • gRLIIX [ Mllf W5, A':. 10! . ~ r"4~~~' B[M'EEN ft. ~ Sr4E[! d cen rer F `Swff, ~ ~Q ~~ Vp~ I ~ OSRANCf6Dq i`pa ON gEJFeFNCE. C401SSivl[tOR NER iM[E POS ACCIDENT R DUG AM W,A / Fs S f r[Ft Or GGiwT~F Y` ~"(' .~ GJM ilKa CE.f MILEAGE _ r, b COlI SpNINVOIV[p. vE4Ur: W CODE , lOIAI NO NO all[D_NO. INJU4fp~ ^54 LlAGf pN164UN mlSIN N KiO CII q eapAD pf afrfftNCE ~ ~pJ - - OVlNIClES ~ ~egOK91YDAMAG[ONEr r E slOl[N NirraNar~ IMf ~-Cg065SIRf pe apAp - '. _. OBnC13reVC[INAML Or OBJECt SteVC9 ANp OWNF95 NAmf p of SUn[D ^vEN CIE ~.~ ~'~ E? -~ ~4 I [St DAMAGI SRECNI CODING USf l{^v. ~'r"T~ ~+ - Din RS NAME: UNIT NO. I Rst miDDU rvfwS N~O.f4 p VEHIQE ^ PEOEETRIAN p PEDAICYCLIST i `~ _ fry„ . S'i~* s,4fN op4ESS rvus,µ N LCY Y`Y ~~ t-OU.~t/2 C{~mrL S - 4#~~~ t tefet AOOglss ~~ ~~ ~i W ~~ Z c \ G r ,E xiacoof vnoneNO D itr O 1 ee U'~ / u''t(Ra yC~ t i 1 I CkU NSegrt [. ~ DgIV '3 iCENSt NO. ' ~O J L'I S` R CF'S UCEN °4. '~'~ ~3L - 73z- ~R~n , ~ I . ~' O~ L ,u t.~JeL 8DA?4 3e ~ OwY<' C 7~ „~ AE'a.r ~ ~ :, «euaAna+ A.nLeenoNENO, /Vl ens IGN,NICnL E « rNmNeMEaarJON[NO evES wNrNienr ~• d , '~ Z N ~ .u L CPC/ R .(f~~{ ~ _ ^ CMECK (/( r r ` C- L \ V'~ ` r &1 (a r ~. IvEAN SMr~ pCMECK (~ EASANEM4lorEEa 'l^ CODES' 3~ .'C".sn AStf A'sMO I uwo,nFVA1 • ~r ^ I ~Di IµrUN 1<Nw «IMr[n uv VFN srsnwWl [r N ^r rtn - Y N CODES ~~ 9 c AS Lrt 6 s. r ExJ ~ L n~YLA pm m ~IOOOCf.CNFV p ul~r Ep nb'T ^ vi."CIe ^ IuLf. ~Ip' ~w.~~R~~l~~~ ~~1~I ^ TB.Re Dp N~ cr1 ^ i.°{+s. ro d .4 _ e nV ~ / " ~~ NOVAE StalF leO .`ONV., S~E73 F~1ry-UFVJ r+0a1peer NOVAE 1 v.f t ,.. ~,' aruE SN srAtE r IE4 aA,EEw. D~ H /E Cao ACr7 OOei ~~ ~ ,0. yka~y r,~ "Y;yl nl~. nnKIF IDEM CAigN NO ~ C E CU iDf",E A ~J3~ w ~` 'y~ A.t Y Z 4 1 ~'-LI ~ vE4~SR4FD0 lAS, rie5l 'MiDOI[ ~ pNONF NO. L Rf niSLf q[ ~ Ee r IASr ~IeSr ~ SIpE 'p. ~rivev .~Y`~v 1r • ~ ; - D Apoe[ssar ow.Jea W A e NAmEaADORlssowsu4ANn cy wACEN, 'E ~ • • b ~ :,I ~, ~'~,.... ~ ~ S I Of T ~ Ff:+ v ~/Ln R AC.L D.g?G 7-Q. 1 ti~S (,~ ~'. DAM.oED Aau' r"s .~ "au q. ~ F. cn DE;E S cnAaGE pAMACID.uu per' ~ E •.o ~rt~5 e5r~wmnel °'N w' .rD Y I Edion ^ wnr" ^ eImAINLD pa ^r ^arMUNto Est p p~E E 5 ~ J y s ~owwEO 1 YS..Jef~ev~ `.' ^iw:r°er: ~ S. luion r,arfYp s1A DIAGRAM OF COLLISION: ID Ar Nprc.~r NOgtN pESCRIPTION OF COLLISION. EfJSLSwneMLNEJU SN[Nr NLYSSARrI °f~ E ,' I er aow `J - eY11 cl-iP_`wc ___5.v_ ? N°er ~ + '~ ~' A', I 2 ~•'C'f- T~'.e_ri~_->~y D ~r_! v~.v~¢~_V_ l t,c - E__ ~~! ~P.._~9e~_~t~-8.3~iv~r._S1_ttt_Y-y L , la ,: .. '', fA -~ I T k~ ~ r' - ~ -l-^~ P_>^~.fs..e.ss.~.._. -u-ss.r._cv_y- -l's'-0-- y 1~ °'s ' ~ ~ ~ I I - -~ ~- - - - -=~ _J True . ~r., T.1¢V_ ~_~ .v_-~4X ~ _ ' ,~~ ~~ ~ ---- I I - Y~ev.r_ ""'7~,~,GyyivS~C( lSMOtK y c V __ !' ~ WG__ ( NTO J ydti y ~ .__1_~ ____ __ _ - -' ______ ,~ l~. ~ NAME, ADDRE5581NJURIES OF PF.RSONSINVOLVED apt t IUS[SUaRIMEN,y 1NIt .___._ _ ~ S b ' ~~ ~ I OCCUPANTS /WITNESSES 'CODES I _ 3 q I pp ~ rE.m IOV ADD iiONAI NAMESI slF AGE tA,U3 RJVEN ry9a- -la}- ._.•_. ~. YRV"' I v?L I. s Hite lvECl I ~~ ~ AEJOaI[a ..._ _..._.___.._.. At bald • ~ ~ ~ w NAmE f -- NO ~ y t • r ~~~ it ~ .pcaa.ul a - ua.Nr .__e ...E Oa...:.n. "Drw ~° [EC SR., __~~"•rR"~"O.me ^`.`r p'De.r pD:rDp,1 ~Y p t, ~Kf 't `y ,. r I .,pyry ~ x rp ~ c•lo Ho p•n or Rlrort "N , Y KKfr,Wi' , Q~:~. '~~i~i ~z-II-,~C " 2 3 ~Ip a~ ~ A1~y .4 {' ~ .l ~' ^~ :.~ >WO NIS J„ ~wC~ U~IJI h r 'li) ~? ° J r ~ ~ w. I r;,cl-'t•N :~:'~' 4.... ~,. - wlsw ~x+;zr r - ~ 'a L S. fry 4 •~ ~ ~~ "~~ y ~~ k . } r 1 iV ~,. ~ ~ ~~ ~ ' r ` I 1i1:..__ . , .. _ .._ _ , , _ ... .: , . ,. ,.. ._ ... _ ,... ~~ar~ 1;~~ _. ~, ?~ ~I ~ , ~ ~ . ` . ~ > ;. ,~,`~; ~ 7 a f ~ ~~~' ,~~} ~ a yl r WSV ISR IRfV. I.BpI GF pr } ~ 5' ~ ~ STATE OF WASHINGTON I ~ ~ No. f i ~~ "~' ,y~( ~S ~ I POLICE TRAFFIC CO NREPORT ~TRAFFICWAY ~ rop ~wr]r ~lrN~ ~ ~ ~ . 5 A p/!rF OrfOtU 1~. .. i ~ (;. W ~ ° «IR~.RRtr{ ~~ runt IUSE ]ROp NOURI 0 3 ~ PRIVATE WAY COUNTY elzSurJ CpllNrr r~p, /(/r)- afYNO. FHWA QUR xl !~(~'' _ ~~ r i~ ~ c ~~ 49U ~~~,.~. C I^ d C C I QN Qf ^IN GtYOrR tOWN ANF 6N0 Of SlRtft OVNGnWwT ICl 5 pOUrf CA it F URAI 3 RRlts OS W or - N " ~ w,,K¢w ON I lI CfJC ~i37>O ~ IN fRStCI NG Wrin: SrRFft O440AD NONIMfPSlCt O N R FfI% MRf 8051 1 R r BfM'F[N yQ s1R(Fr 6 ~ Stv[fl C.'. O~ 4 DiSIANCl60Rf HINT MRfilvtN t. CROS55tRft10R NtAVtSrm If ROS A[[IUENI P MIA DI Ml[5 5 E w MIIFAGE «Ft N Or ~D~ C lUSR)N NVIXVFD. NF VtRNr' IN D I IRfft RhVD OV R]fvfNCE lOIAI NO O.[tl[D NO INBURFO ^SP IIAGF ^N16 RUN uv°nDr„ IMt C15 Cpg55iR[[I O A ROOD / J b V(n Cl[5 ~ RRORRt DAMAGE ONLY ^fSUltfO ^v[~'ClE ~~ Six OHIO ' OBIttr S1RUCR(NANF OI OBI[C15rvUC5 wNDOWN[RS NMIFI fSr.OwMAGt SRCULL COOING USE <rre s UNIT NO. 1 UNIT 0.4 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST erv{v'S NAMt: N5r 5r DRrvfR'SN t AW( U5r .R L f MMK 'R 5rvil w pvt5.5 SrRt(l gpp f S v S ~ wAfn{.T '- L ~ ¢i cnr sur( 000t vno NtNO. D n. srwrt 1~E_T 4D B DRrvIR~~Sf rv0. Srwlt ~ E% pn ~ R ' n n ivtR S li EN NO, rArf F rf BiR n l CUVwI AMtBRWN[NO. (rF5 iGNr HWnr E OCCURwiION {igMNM1F6 RNONf NO. [vf5 iGnl Nf lGni r 2 l len US AU µZ ^ R ^ CHECK (/) vtN Cif ws:N tmRVr wHOrNrR AI ^ CMECK (.~ fAS wN MROrf[a ANOr CODES ~' 7 ~ S l a 1^',° .-, CODES ~* ~ ~, S x 5 y aes ;~~ y;r.D ^.,m,A,NCt •~" ^~S~r. ^ ~ ^ aL ^.:. Nft D'q;p ~3itr. ^n ^ :° vfn ruR N mwfe lDOW[wev.l IDAAI NOVAI nelxoR CONV ~ r AR °A i~t 51 v . I nfv.l ,DAxr NOVwI r l ~C!!10 ~Qftn) a~02 E n CM OCFNS(RIwrEN H . e Ml(P RArt NO. 5rwt( vfnt Ov it 5A N e Slu - - I cu iotNrinutlw NO. C vtN ulaf]nrl I ISII LI I-1 81 L I I I I I I I I RtcnnvmowrxR u(sl Rsr Dolt ~lA'4_ ~ 11Ci1 RgNf NO~ O tm eve vmfR. N sr MiDa( ADORtss a oW*rtR W ~F1Ae-. 1115 ~Q111CR- N E tR Amf f wooRtss a inwRANCr co aR AC(Nr N u A FLRT--- Nou~ DAMKED ARIA p5.y h~ ~ R vNlro«N CNM4 cH ° _A ° gAMACtDAxu e lfraDwmwG[ s 4= Q AWriwY ~RIM,ONID ibMD ^,°SWWRr ~RIMMNtD lOW[D tS~M wM~l r •1°. IU ~CliO~ 5 BY I Ar er S DI GRAM OF O1L 151 O aK[] f°U Nus _tipcMr~m DESCR IPTI ON OF COUISION: IustswnfmlNtu swn i{M[f54ARr1 _ I \\ ~- ~_~•f ...h. _~ i ~ ~ r KI _..~ ~ T LI ~ I ~ 1KH "_.I_YJ dI S22o ~"~cu ua au~__.3 a.~a~. GxT_orr RQ,_VCN~I 7AICaT_LtFC'-LoMG~_[1~T OAIe 1W1 JP H spP.v NwL ~1 C ~ ~ D - . c = 1 - Tr,. - 1 D - _ . _ _ ~r 4vB,._ o I{f_ ?1~ ' 1 I ~ ]TcK'. f. or*_lo . ~I8 SFkuTOrn f11w 1Ken.>_JkRo;s__T1~, ;- "~ I r-~~ I ' I -I ~ .N4 ..,I { 1 _~. . !_ + f ~ 1 ~ - 5~6._q ..M IB., IMKS VF Af(tperlT' C.tt_(j0 dvn DS/Oc _~k.. Vettt~l. ~T`f re s__7uc NIB D,T<~ RRII~ t SyMBs IG ~ t , .I I I t ~ i ~., j ~ j1 ~.j~ ~~ _ ~ _ _ .. _ ResT vv rte,...Wlkal+ +F! _.T]!c___(3,3_._Q•P~Ir'Ci.-- ~ ~ ' _ , -I-.t ' - 4'~ ~Ij- --+ +-~-'sli - QAr.,kf.N. -l'°T'--- --~''eN__AAtrsrrY ~fW._.lo_M.4, , ~ .., ; _~..I . L_i I-1. '. j_i N_or i+»osn,tfaT_ _. __....__....._ _. ' NAME, ADDRE5581NJURIES OF PERSONS INVOLVED 'CODES 1 Z 3 4 5 6 OCCUPANTS/ WITNESSES ,n iooulomliai;:u'i AMr ii ' -sr.- -:cT idui ";; "' -~ ~~'"' Rs ~-- -- cr wsn rxa ° -... .. .. iq _ NAruv Or w/ _.. .. ._..._.. ADM151 1 NAtuRfa .~~v~°{voM ^Ame ^ ^ H: ^ ^:° ~. S.rNr er ^AMe ^°:"^7r:nR^~: ^". , ^ »,carct. S,..mt u.N. eACCa o• .:na• %t Dn.Aluyc vcR,a .••wlD onfa RroRl A aaoer oAr X t F~ ,o NO 1.5.)S e'.,~ 02Y0 °,~4e 12.2D~91v p] 1 -']J ..~ ~ , < ~ ~ -- ' ~~ ~ ~; ~y 3rD ` ( ~ ~> S ' .~ m x ~~ 8 1 ~• (~.~. r~ ~ ~-. A~.y~ ~ ; A ~I I R .. _. ar ~;~. ~"^ ~' ~.~~` _ -~. r ..~ ~ -; ~' ~` ,; '~ _ _ :1 ~ O STATE OF WIlNGTON No w3°"°'°`".'.°°' f 5 j Gf / Of / ~,$~ • 4 { f•3 ' POLICE TRAFFIC COLLISION REPORT J~7 TRAFFICWAY rou<fcom4fuNiN3uA fR ~' / ~ RRIVATE WAY ~-~' c1~°' 'yF~~^' pnn ofcouls o N couNrr 'Z ruse RDMto eounrr NO. e1rv NO. ftfWA pN pfRYp orro4 row faNOOSrsftroR Nlc fR63 "3 ~ - . ~/A If3 s ^w G ~/u~J ~A~7 ON 1.~61~ ~r ~ ,~27D 3{~~ rt SICr NG rnIN: Srelfr OVV Ap NpN lNrfe C10N PRtNI FO. 1uRf POSt ...1R N BF1WfFN SrRlfr I E ~f~f3 / / ~~ ~ ' / 0316 v< N vUm RFf et NCt. <40333rvFEr Ox Nf AVFSrm if 403r ACCIDENT e.•M pIA 4AA3 DwtA 9~C 0 NS 3 f /J rffr p Of ~C MCODE E ~ ~ f . "''• musaN Nmtvm N fvt4 rr GA /~E~ ~RD C fft xROI.-OR gitRlN<E .j Dy C', rOIAI NO ~ NO 411[D~NO.iNIUR[D~ ^s41tlAGF ^Nr69UN ^'133» IN INSFR 013 CR03331R[F ;~Y . ,~ ~ ~ Ovtw C3t3 4ROSTRtr DAMAGE ON3Y ^ RFSUIrlD ^vFaCll wNRNDI. ~~~~~ - ,'. .~.' ~ OBhCr sr4U<,IN,Mf OS OBIFCr 3reuCe ANp OWN[R'3NAM[I F310MAAGF3 s4E<W CODING Ifif ~ ~ ~ $ ,. ~~ .'4>" _C UNIT NO.I UNIT NO.Y ^VEDESTRIAN aT'.' s oxrvws NUnt. rx ^VEHICLE ~'tj + j° ' rAlopft D [xs NAME: usr p PEDALCYCUST 3 ~ ` ~,~ _ / ~ a I' sret[r Anpvfsss G T++ ~ ~~ 31R[fiA~ tss '~ ~~- ~. ~ ~ ~a~ .~ w s a IrY z 3rArF 114 CODE 7 ? O4rvfR 3 1 CINSI NO ( f o "~ °SS~~[.9L f fs f o is cNr 1GNr E + ~ i ~ p CHECK (/I rtaf AS•N SA,nortf otAworwte ' PjY~ CODES- ar 5 ~ es",° {t alts r<. rf e . Au oooef c ~ ine , k. i . nfv.l I Aar vAl s O 2 / ~ I F 43 tN 3N r~~~p~ NO4 oNV.I '< /2 E b F ~ ~ - : " , F r „ . IF4RA3F G s~ ~~ - N0 31Rit i '- c .~ »fNatf pfN,NpAraN ~ ~ x~"'`s ~. IjGjJJ//YY~D OwNl4 Wr R3r DOII ~'9/~ 1M1 4NONE NO ~3 v a Appvfs3a ovn+f4 /.3:75 02 `~ 5 / SC W ~ N J rZiJ r ~ ~ r ~ E N ta•~s~INSU4•NCfco eRAC - vc/ / E ~~ ~ .SGT/J~~G R .i .%t'.r'~S '~ ~ I pAWACfp•Ru ~~ o..Aee»r, cNAecfN ,~. ,. /Vc~, EE - - ; -'D f J ~ ' ' 1/ A t. _ f _ a ~ _f f_ _i; T- ~~ E~_~ r !~y Lc 4 "115, O ~ ~~R~X /SOT f. .J.. ( .Sr. tfJ\ o oo.o NAME, ADDRESS 8 INJURIES OF PERSONS INVOL~ OCCUPANTS /WITNESSES '~ sf sw41s»fmu>~tu n •DO~uoNa N•»n1 1 w 3 l iq N uvl OS x vt 4wf or w No ° ~~ ~~ .. ~ ' - ....:w. N•~lfirti r I ~, ~~_ ~t 41 !a.}' ~ ...., .a%/PS S/.c3..cJ~~I.vGC~G ,•.~.i Ada/C~l~ilE~~~T T/~T J ;[ a~ 'ti k~ ~~ ~ ~°` .. .~-'-' - -- _.J <i Ti~E J GN .lld/r/ ._ CODES 1 - Z 3 4 S 6 e TZ _. L ~~ '' 5 $: _ STATE OF WASHI - TON R~AGyE i GR i No. - ~ ~ POLICE TRAFFIC COLLISION REPORT ..... . Ip TRAFFICWAV RgKECQMRUI xa ' ~Rf . ~ ~ Y PRIVATE WAY COUNY afYNO. IHWA J DAIf OICIXU Av 01 11Mf COUNT fur 4Rr. lugs. wo.'Ixu.°N, f.. IUSF] NOURI ` ///~['~ ~ ^IJR uau 3 6 O ~ , .,CLJCJ ~ ^J 5 ROUff _ AMf6N0.IXSiRfFf OR nlc«W v ^" ^ t ^ N C~nyOxx~/)t~GWN ~) ~ /J UOK~a L.4.NnJ - otJ " !~!G/L s ^w GR 3 f 3 ` ~ 9/ z 7!/ ..27 {T4-~ ~ Mlfs . 1 s 1~NC W,In slRnJ OV eoAO No ~sfa oN \ /- /N7J'/~I/ ~5(//w1~IRff16 ~{/~JJ ` ~J~~ ~~~~ /~J f MILE R03i ~,17 ' ~j5' 051•NCf eDUl MI CIN IeC1M UFlEUIN<F. Ce05551vEF10G NFAVfsi MIIF ROSI w t5 5 E ACCIOFNi MILEAGE P R DIA RAM DATA $~ ~' Fn GR ~ ~ C 15 " RF tORRWUOR RIiE9FNCE D /RS lo FvfR Ir- ( U15~0 NvIXV10 NO u U[D~-NO NJU9FD~ ^ SV l1.GF ^ "rl E RUN $1IX CeI . „, 4 " INff Cl5 CRC6551R[ET~ .N^ ~ , `/ l01<„NO ^ e[ of lFO a f cus m ReORfRiv DAM•ewNfr CIF ~ V GB1fC1 SIVlKRINANF OI OBJtft SIeUC. ANDOwNfe'S NNAII FSf.DUA•G[ SRFCW CODING Ibf 5 ~ UNIT NO. 1 UNIT N0.2 O VEH ICIE ^ PEDESTRIAN ^ PEOAICYCLIST I I ' ~' F N 119Sf p9 vIVSNMA~ 51 MI If ~ ~s ~~~ ~ S NAME. U51 OR Vfu ~" "" 5,9FFl ADDRI55 SfeffF ADD9F55 I1 ~. / / / IIi<ODF RNONF NO CITY N p ~` O~ D R Y SIAM IeC E"O ~n P yl ool IRnua"vN ucINSF NO. IYF Ale DAIF ORe eI« , .. MD i R u OCCURAl1Cw fIRHONI NO 5 f E OCCUVAIION MNAM[6 vrgNf NO. EYES wflGHf If1GNf M ^ CHECK 117 f«I<I(a5 •v IMRt ANOI«FOAt ^ CHECK(/) 1.5 AN FMeIOVIf OI OInFV inK~c F " vJ , 'xi CODES -' 7 ~ M" 5 I 6 4O a'~1 - l s CODES ~'~ 7 ~ • is 5 Inc N e ro N OM V OONV O viv 1 [ 1 ~ ^ O ~ ^w Nn^u ^~S:II. ^~ O:°v rAR 1 FM nEV.I ,DFLIDARI.NOVA1 C1if .1 r« .04 ~'. . AOVA l MODFt j DA91 I IDODOF.C«FV.I Y AR M Vt F7b r1lC ~EE~ 5Ca-.S E -. G v Nse RUI vTf Au1R IaAn NO t H of«eaoR AI I n A ._ r /T ~- ~ . N _ I~ VIHKLL1DtNln KANON NO ) ~ ~ Is IOu 71~L, Nl i N I L YF«IEff ID N r I I I ~il'A ~ I I Is fvFD w la. N 5f MI IXE v(GISK9[OOwNty 51 3f MrDpIF ro ENO. s ~ ~ W T s ~ ~ N[ 131 ~ ~, . 2 AD09tS3dOWN19 A " r~1G E • ~ ~ ~ NAMF a•DORtssn 1NSUaAfxf co ao •uNf ~~ ~O rl W R " "" sR ~ r DAMACI rat• " D + gAMACfo AREA J« f `+ N cnAaD N v e c Rcf 1M.DMr.1 E 0 AGl S "r ~/ la RV(N 5 151 DAM ~ ~ ~a[MAHfD lO aOno~ QU foWiO r cG c/T DIAGRAM OF COLLISION. 1 MNM u~ f" SH41 N(G55•aYl Br •RVpW ~ `~ _ ^AWAV" ^R[MA N[D I ~ tOWFD f oy Y aY A< ~) DESCRIPTIO OF COlt1510N: IuslswRl[ t 1 s«e[Ir [<eSSARrI ~~/~ 5~i: w2s ~0~~,;4 T/ !1r 1 ~ ~ o- C~i2 ~ To . T/ E /-i G(// d~ ~ + ^' / .~L!o11~~ o.~TO T ..~ of ' ~ o ~ o ,~ f _ _ _. ~ 1 c _. NAME. ADDRESS 8 INJURIES OF P RSONS OCCUPANTS/WITNESSES i(`~iRl imaif»r~i:+1J.5M4 INVOLVED ii~ 'CODES 1 u. Acs mus - 2 ':^„" 3 S n RfsIR 5 Ella 6 41 ~" I MI .((.155 Rla C.1:.1~. „M ~.Ma ^ ^ ... ^S ^ :2r. + («IL CI ND GAf1 ~. Il'O Jvlo lly r D.11 0 3 Q ~ ( U ~ ~ ~ .4 ( ~, 3 % 0 a .: ;: `~~~1 °. ~' ~ ~i e { U ! 1arv V~' - ~ 5' . pppR~;~~~~ V k ~ ~ `r ~" ,. ~'~ t t. :~~':a~ ~T.' E ... ~ ~'~ P~,~. ws.e ~ ' ~rff~ POLICE TRAFFIC CO~' ION REPORT ~TRAFFICWAY {~~ nuNi NlJMefa ~ PRIVATE WAY ,zl pAif Of COlI N DAV ll N tlMf COUNIr (VSF pEOp HOURI D, rP R H Jms .IR Iws fr . fl)UNIY NO. CIRYNO. fMWA ~~ 2. s, 's 3 EF IJ / UR ~CO ~ ucu ^N ^E ^IN CIfv OR TOWN NAMF6N00 iR[[10P «IGHWAY {tl ClS RWif OA SIRIf N]N hVlfS ®5 ^W ®Dr n oN aT 3 9si~o „ rNIFRSEGi NG wti«. SiREFi OR ROAD NON INiFRSfCEION BFiWF[ ~ PFF16 Qjp~LT51RFFt PMIIA f MIlf PO51 <~~~ ~• G D$IAN(,E 6D NFCI { MRfif4fEKF.CRO5551Rffi0R NEARESEM LE POSE ' EES 5 E W ACCIpENE MILEAGE R P pIAGRAM GAZA • ~ ~ FFi DE ZL~ S CODE COIUSN)N NVOIVfD StvFNnr: NO R IIFD ^ SP IIAGF ^ H t 6 RUrv NO INJURED iOiAI NO 'UNRn~H " A.RD IMfv C CII S14EEr RROAUOR NfffRFNCf fS 1 DS ~ - . OrvFH CI[S m ®pRpP(RtY DAMAGE ONEY ^~4UliED ^VFMCI[ l5 O5551//REEIOR ROA/p CO BO~~ _ ~' OBJECT SIPUCa INAME Of OeIFCi SERUCK M'D OWNERSNAMFI EST. DAMAGE S SPfCW CODING IAF UNITNO.1 DRrvER'S NMAE t UNITNO.4 ^ VEHICLE ^ PEDESTRIAN ^ PEDAICYGLIST y : VS rr __ NR 1 DDIF C Z ~1 I.NU.RENG • N FR'S NAME: NSt ER _ $tREfI ADDRESS RPEFI ORf55 ST', ~ Il.) ST ~ZR 2 c If zrPCOa P«oNFNO. D I r SEAif IPCODt 1 T Q1..t ~F. 483 S R ~ DRrvlRSIICENSF NU. Gk2N E I CN Stwtf W DAEf B H ~ D,. ' ~ I V rvR' IKFNHN SEAEE A DAIEOfe Rrn DAr ,r. - ! Z CUPAtION N Ee MON{NO. FrFS rG«t IIfIG SR PE R M S~L_F E R OCCUPAtrON NPMF6 PHONE NO. EYfs wE1GHi IEIGM -- ^ CHECK(. 'vEH Cif AS nN FMnovfF O{AHMiorH{a'AI ^ CHECK (r~ EH< ASAN fASaorffaANOr ` CODE$-* J n:s's~ ~ 5 E <r oN 6 iw~D M { •- wE CODES `* G ci.ss s'v 5 A N A ~" Rr`~'cu n ,) zJ I ~I^~ ^ AMAR„NCl ^ u °` ^ ~s.NR ^ ~. a.. ^ r~~,M W«. YEAR tIDODGe.e«[VI RJAODfII i.NOVAI s1YEF IrpR. CONVI ^ ,M N<r ^ zsm. ^ n ^ ~ .~ SN rtARD AvA I [A n[vr DARI NOVA rU ~- vD^'' ((,, E N E . 1 l v.) I m r ~~ N % CENSt EN ` SIAIf RMIfR MtE NO. SIAIf H I vF«.CIXOR l Il A N A f ~ ~ C VEHICLE IDfMr{ICAIRBN NO. vE«CIf IDFNi Ree srtafpowNfe: lASf nRS MIDDLE S 60V PROM NO ~ W R E srtaeD OwNFR. lwsi {IRSt Mrp ND. u pDRlssa ow+JER AD f owN1R 51 N I E NAMEaJSDwfssa lNwRANCf co. paR ACwt OC•ONiq F•F;t~+N : ' R A - AMAGI KEA Q ~ gAM.scfD u r c«AVCE Z c«~ocF r A I IO e0ii0~ 151 DAMAG~ RfJAUMD ^ AW'~Y ^ ^w^~ ^ ^R[MNN[D fs~ DiEmncf E>OOTnu ! l DIAGRAM OF COLLISION. lu MEN AE IND CAr{NOREH Swfi llMQSSMYI er ARROW DESCRIPTION OF COLLISION: lusfswn[A~ENiu sMHRMa55ARrl e ® _.. ..... __. VEN• ~' 1 WAS SCS~ATk{ BO,.s wJD ON THE AZRpoRT , . T[YFF RO WHEN THEO IDR nVER ~YU y DD6uC ZRFU,C'T 70FF ~ . . . . E.q MrA Eta GN T'HE BRAkE S; CAUStJ~i> THE VEH. I .~ ~. . .CiE.-LnG ouT OF' CA N'TRn(~ T ANO X70 aFF '(f~16 ~ Ie m . . PSGHr of THE RoAOwA`{ RNA Rcsl10/bR oNi-o ZTS To P , SaR=.vER S'rATEO HL WFS ARGuLNb WctN HLS RA E.~.CNGrER RND WANSTEO Tn PJL.E, o/ER ANSD STOP GN THE s~C:Al.ocR. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES 1 - 2 3 4 5 6 CKCUPANTS/WITNESSES ~o~R,lpompiuiiA:A" iii su Act ums ',M" " , R fsIR. fnn ir N AMr Z=N ~R(TO I' NriEt.q " ~ o /{3i- ~y2.°. r . Dells 0 JuL R T ~EefJESS.AE~ J10. 94? AtuoFa ~ rover AM e 6p p~' ^ " . „ ^~ ^ C34o '0 /~ wE DEP:IT'Y /TeN s~AkERT ~ 3R5~ B31 3 A DDRfa r (U ruR of w R movlD rNGM ^AMe ^`''K1 ^ o' . ^ NS ^.".° r " AMf OFF MR2rSN ra sas-as~~ . tr.fe, S ~ ~ , J'Jo ~° u~ r ^AMe ^ :HI ^~ °:B. ^a~ ^ ~.~„ c GarKi .. 1!R eADw oR X R D ND ~[~ AeENC. ~ aKrosuaap ~~ E/JD HV3 O2~ss+p Btlp«RS DAnasnrGRl A DArt (/f .OED "~ ' a ` K .,~ 'I~~ f 533, :'.4 uc M.4 i ~: J~.. R I= ` ~ - ~• ~~ ~~. R~ ~!_.: f ., 6 nr -JFx~ .. R.ar '. f { ! t7~h A v kFtri~{'+y^l~l W 'bl' 'S7LY ?4 J I~ ~ r ryy f.. _ "'•T .:YilAi ~....,. "s %1js ~. •~~."r,,Yil Zid°T •.t~$I I~ ~T.:~ ' ,F { 1 ' 1 v~~~~ Y 1 hV ~ 1 !-I~ ~ JI ! ~ I 5 S.~ ' a'.~' . t I 1 , ~ h r '~ , jl r ~ ~~, 5 I. aw4S ~ '. s k - - _ ri I~~ Jl " I: ~ ~, > ~~ ~r n ~~ ~- ~ .. ~a s ~ y - ~ .. ~~ :t'Xe~~'xa~A.'~4~~Y,C'.,,e>~ ~+ v.G~utca.._ ~ ~ a~S~au .r :~ ~[ ~t Xn 9 _ _~~. ., ', '' y e - w~ ;? 3" ~ryt ~a ''„ x .~ ~ ~ ~~ r~ ~~. ~, ~ zrcv ~ . ~~ h i kq s~~ ~ a _~ ~ %e ~~f. tl ~' -~ J~~ t 1 '~~~~ POLICE TRAFFIC COLLISION REPORT IXI TRAFFICWAV R%ICfcoMpwINEN azRF PRIVATE WAV palE fCOIII pN OE41 N LIME COUNTY ~ ,. CO `RI o~ N°. ,. , , IVSF 3(00 NOU91 3 EF N UNEY ND. / to CITY NG. HWq ^Uq aAt ~• ^N ^F ^IN CIIYOR tOWN NANf 6ND.Oi SIPfEt OR HIGHWAY Clg pOU/f OR Stv SCI N Mllfs ®s ^W ®4r ~ ON aT (~ 3 9S/7D IERSECTING IMEN: 519FFt OR Wap NONINlERS[CiION PRfflx O. MItE p05l ~ eEAM2f REEL E QiPE,GTsraFEr 2.30 ~' p15LrWCFeDIRF I MgfrF9f .CROSSSiRfEt04 NfaRfStmllE poll ACCIDENT MRfS i S f W DIAGRAM Wtq G •~ MILEAGE RR Or `(C„ S 6 CODE COIERO ^`NVOCKVID: NO. [RiIIED ^SPIIwGF ^illtb RUN ru"gnRIH NO. INIVAED INIfR 'RD IN ERSLCt1 Rfft RROADO4 RifRNtE CIS CROSSStgf 1 4n _ ~ CL VfNIClES ~ ®p4ppEg1Y DAMAGE OrvIV ^cfSUliFp ^vE~iCIF Oelfti St9UCK (NAME Or OBIF<i S19UCK AND OWNER'S NaMEI FSt DAMaGE RORROAD l0 8D~lJ SRCIat COPING USE '~ . S _ UNIT NO. 1 eIVFR'S NNAE: w5i Nov MIUDI UNITNO. Z E9S NA E ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST ~ s ~uRENC L.I M : w5I iIR .- 2 S(vfft AODPf55 ~0 W sz- F=a ST, LvfEtq ORf55 - wAF LIP CODf PHONE NO. Q1.~ l',~q . 483 5 D R P IE SIAtf I p 1 4 - DRIVERS U<tNSE NO, stAAE E ewtH 1 ~ t Iv ucENSE latE x DArfaelem e CUPaiION N E6NgNE NO. lYf1 IGHi HfIGNE ~ 4 4M E CUPAEION NAMF6PMNF NO. EYES IGHt HFIGH L Z PE.Ei .i LS~.C.F~ R ^ CHECK (.~ KiE asaN piorFEOra ofHia "E O CHECK (/) vEHlu a onE Of argt CODES - t a n x i S e 6 i.°.er ` ~. CODES -~ O q 5 u y~ I '~ n u es M ~f8n : '°° p .mNAAN<E ^ :6<' ^ ~bnl. O ~ ^ I&~>, ^ aMna..Kl ^ ~ " ^ °°~K ^ ;.G>,, CO V H. YEAR MA9F IDODGL.CHEV.1 MOpFl lpa4i~nOVA1 YIE IRDR..CONV. s I N .YEAR 1 nEV.I Y DE ID.utt. VAI I ~ •1 _ r E. U E :e r ~~ 9 UCENSEPWtf qtf eallf9 MtE N0. StAiF s H NN. C(%OR A ,~ ~ t.Ca 7 l R ~ >o NwaLIDEfnlnwRx(w. ~ ~ ~~ ~ S vLHKlfI NII INN ~ ~ ~ I 4E41s EDOWNf4: w5t iI45f MIp PNONF NO. O of ISR4LD WIRER: IASi {I45i MID •~ S V yV 1 ADD4EUaowNEe " l Z'S,vNEy• v ~ N ' E NAMeaappRlualNSUeANCE CG OR aer"r O l.O e..sZA ~NN R AN A ~ sv AAVtEDaau I I cHaeu Z ' aaxcE• gAMAUp u ' C DNAAGL~, ^ ANAY" ^RLAUINlD niG(14~ t11. p aMAG( _ ^ AWAYN ^A(M.UN[D E51 S - ®tov~ DeY wEp s DIAGRAM OF COLLISION: u Ne tN al Nw,e,AOF NORTH SHRYII N[C[SSA9Y) I Pow e DESCRIPTIONOFCOLLISION: lus[suvllLMwru sH[[ilP Nee[s5ARr1 n ® LIEN. ~' l WAS SaATk480l.t wED ON THE AS.RPO AT .. TeFF ROI WNEt.J THE7~ IDRLVE2 ~YG,DDEu(_y r LR/-bRT G.ETVFF . ~MMEA ON T'NE BRAkES, CAUSLNC+ TFIE L1EN~ . ~ - - .--. ~. JE$DE OuT OF CA N'SfZOC. J ANp.. GO OFF TfIE m .. PLGNT of THE RoApwA`{ Aluo, Et~DL1.WbR oM' o . ... ZrS AP ~, P ~RZVER STATED NE WAS AR~=,NCr WITH HZS .... R+sSEnfG¢.R. ANA WgNTE.o Tb. Put.t.. WER AhtD In ..... $TOp olv THE .~iou~.oER. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ~ CODES I - Z J 4 S 6 'USISWNMINIAL S OCCUPANTS/WITNESSES oq AplnnoN.I NA.w MFt sl S(x Aa um '""" '• ~ ~;; Rsrv. ufcE :10Y N aMt ZLN gA1'r0 ' NGE~q ' ,~/ ti3~- 9L1?2 " ° . a+gru O nLL R ¢ CYOLG.AR r L wEO "tq ~. lrRer~ AMe. 54 FYti°^"' .^C. ^i. A DsPL(r ~ ~ E T 3A~ - 3831 ~ a tu4ro Dpvlif Sc: cO .~IR A4 V~(UR 9 o n RM~vID r4um ~AMe ^1OiK1~n, . ~,^" ^I:° er '0 N ,M, ;3"E~F MARTyL.1 Hq 38.;-:3831 C " . ( ncwns ! un - "di° Ep Ki nv un"eY. ^AMe ^c^ .".`.F O~o:n.^ ~~ ^C.°'N•. aDG10v aGFFAC ~ X rd ~ Kf DISIa C p P0 a ~., 1 Ml q4e ND R ~3 RRx1 N.5 p tp vlipq/ - er Dqn Sb l ~ ,i E ^+ I I ~ ~' - }E I " 1 `. I 4a W aA~ at P ~q7 f ,i '` ~Y ~~J,I r 1 1 ti;,: ,~ t ,+s ,il I a' Y ' y d r - } '~ E n ; 1 } ..'- ~ ~' 1 1.1 i (:+I I Y J f - l ) I ! •. ~ , 1 { ~ I.- i - 1 i'FR. a 1 I' "~.9q ., ,. , w, ~ iti~ '' n -'-Mq. D ~~ I ,, N t ~ l:.t ~ ~$ I ~' -wN' s~py,+ `T~~h' - R y+J ~~ ~grva ,~ ~'' ~' d'' S ~ ~ ~, - ~ ~ ~ r ~~ IWL~ ~~:~N. ;q°~F,: oLL«~ ~woN^°' J~e iG-r_°/PSG 9 ^w ^~ oN" ~b 9Nw~~ wxmwD »rrN9 Nno.9 .wllNUnxaxy N~ 2 O v~J ~ ~ . MJ AJS27DL O ~ " y ° a pi,t Eo L c2 sG ~^~ P ~gAN9AT. ~ os~ a: T N ~~ ^ a G / ETDEE,sa~o ~~~ L ~„,„ LN niiE ° w N - ~ B ° ~~~ o V ,VEN ^ ^ B B pA 6 'OpJE q PUCK _.~d. ~, .. -rLLl- -_L _.... ~'nl- ,OWNER OF PRJECTS NAwE AID Ap0g~3 E~~ :3[~ ~. ~9 .~_IYF.IL'A.lM~Id!^_4!€:. ~,r. aR,TNAN€ _.._.. ,.-,..-:.:,:.....MWPS€-. ww a D - . N Tms "''' ""L' ~'w vd G G°h aR w ~DLL9rDNDN , o q o U DRE IRAN two Pn uI E_ ~ / STREET ApDRESS ~ - ~ :NPNTE NO. ANp BOA NO EnsU puseNA 'g-T-PEET,fIpONFv$y ,J _ '~,. gOUTE NO AN4 0%fJ01 G asa PL c ~ "'°RF o i('eE,~ i(' o av - - " A P CITY LS ;IPCODF pflIVERS OCCUPATION ON CLTY ~J:: ~ -, ~ STATE ,~~,~. L STAY ZIP COD DRIVERS pCCU~ATION _ ~ N 0 N k ,P ~ c/ / ~n 9~(0~ ~ ~'y'i/r'r .. DRIVEfl5 LICENSE O N . 9TATE SEX pATE OF BIRTH AGE pRl II S. LICENSENP ~ -~~ STATE SEX OAT OOF DIRTH .AGE.. w ~ ` .~' ~ ~Lrie// ~ f'83aK le 7 . i i V I L TR. MAN IL EY.D PGEJ MOOEL,IN.OVA-DAfli) pO~Y Ei~~ DR.) VEHICLE YN~ MARE {yHEy, ppO F,J ,.t,IOpEL IN VA•OAPi) pOPY,STYLE 120RJ ~ FoYP N 7 `I Fo ~ Cu !~'~ ,P .~ LICENSE P T A ~ ~A~R/, n `~ ~~TATE LICENSE PLATE MO~ .STATE TgAILER PLATE N0. .STATE 73 3 ~jv /D ( VENIC N 9 V < H / W LE I DE TrIFICATION NO, ~N ~j / y EL!ICLE~DFvN TIF) PATIpN FjO . REOIST flED OWNER ILAST- IRST-MIDDLE NAME) DRIVER'S LICEN ENO ~' ti .-, gEPIST~F0 PIYNER ILAST•fq]{TMIOp4 .AME pgIVER'S ENSE NO ~ thin a ~ / ~ OWNER6 ApDRESS...... STREET. CITY ANO STATE) pATE OF gIRT~ ER'S ADDRESS -;;;(ySTREEL GITY AND STATE) DATE OF aIRTN ~o ~-~ ,y L v o SA L A ~ e ,:~ i°~' MD YR PARTS O-F ~VEHICLE pAMAGED 1 N Nu. N L C LI S ~ r~ ' RT9 OF VEHICLE DAMAGED _ __ s ~~ LIABILITY INSURANCE INFORMATI N-VEHICLE NO. 1- WAS THERE AUTOMOBILE LUDILITY INEURANCE / COVERAGE IN EFFECT FOR TNIS ACC DENT ON YOUR CAR YES ^ NO NAME AND ADDRESS OF IApILITY INEURANCE POLICY NOLUEfl g ;, NA1Agy~OP}IARILITY INSU(S~gNCE COMPANY S r ~sw{~+ G L/Lr-l- pb~(GMl-LLL/J~~ /JZGSLI KJYI ~ ~j'(~KrL/1 %O ~j'Q !/~/7'1l~'C d"' ~`S;W Yy~? G. NAME AND RESSOf LIABILITY INSUgM{C,E A(aENT_A~/ ~~U, SI .,~ -Y,>: ,-,,,~ >IP.; LIApILITY POLI„~,NUMDEN / Iv ~Ir i w' ~-~Y~ '. z' Val ~ x ` x ~-~~Lx /~_>~ E_..uz ~iu~~ti~'.>I G8So2 5-~/ >fs IST INJUflYY, -,-- .~ _ ,-~` , , y , //~_ . , ..- M GE >ND INJURY / ~G ~ ~$M ' VVV ..~, i sE EnEPOgi ApprflORq. wuN1[sl AGE SAY ~- AM ED NAME ApDRESS ~~. IN AODRE95 -5E%. ~- .fl a TORE AND R NATURE AND M F _ E%TENT OF INJURIES ^ ^ E%TENi Of INJURIES ~~ ODINJURIE9 REQUIRE t pOCTORS ~ ODINJURIES REQUIRE • ~tlrJ E%AMINAT1011 DY A DOCTORT D ^ NAME DOCTOR'S ^ ^ '$ ' I " ~~ ;. 9TATU3 Of INJUflEp MAgN FIRST ONE THAT APL E%AMINATION pY A DOCTOflI ^ ^ NAME ,Y I" O .w 111vE111 PIES TATUY DF NJURED _ . _- ' q ~osRnu NpRET ONE Try TAPPL E9 .l y.wurw Nus... O ItlY .... .. I i I ~D ND NIL^LED ruytxl uxuw vA ~ NO KILLED Is[v[nt on 5 0 6 ^ "~ o" o yIr,IN,rI„L I. ^ 5'^ N9NB ^ or~ro~l ~~ '~ I MOTORCYCLE SAFETY: ^ NELMET DEED ^ HELMET NOT USED ay MOTORCYCLE SAFETY: ^ HELMET USED ^ NELMET NOT UG[D 6,7 ;I;.1 r ', ~~ ~ ~ ~ l= DLE -' 11.1id ~ Olds , - _.,_..rrCNSINf VCHICLE N 5 C W M; ROVNI ^ ^ ^ ON 6TIIE[1 ORr N9 M„rNr n ^ ^ ^ ~ PLRA,AN ^ ^ ^ ^ upgD PEDESTRIANPE DAL CYCLIST WA S USING' I ^srol PEDESTRIAN, PEDAL CYCLIST CLOTHING COLOR ROAD BURfACE `^'"°N'r ~.v-l~ "' 1 ~ONY ~ ^ i ^ w[I ^ J ^ eNDW ^ I ^IC[ ^ L ^ NnER [CIIT W[AiIL[R ~)phtSvN 66'' y w > ^ AMN NU ) ^ sNOw~ND L ^ 10(1 nmlN E ^ SNICrIN LIOn GONDI IIOI I c DAYLIw,T J ^ OAwN > ^ DU9A L ^ ~Kn~in DM l l s ^ °c"ii oriu " ~ ^ •lhlli~lGn19 I ^ SYLD'~Y I~~IIl~~~''J71I AY C>L r ~u. r AJU01 W NOApWAT SUflFAGC lYR ~u r ~n~' yr r~-~r~u.. r.V ^yL~^~ 1 ^r^Irl _.. "'~.`~, f 8 iiiur~ O ~rl n -1~ __ 1 INVE9TIDATEO pY oN lul u9~M dLL ruxl rrxG C~PriG ^iiiliiw ^i0irii __ iHOM 70 nnrrla,_uun LNroN _„ rrrN n rlrrur u4Y, F~Of ROAD r rcr l V[r -DRIVL(1/Y~ILICLE ACTIONS r CnYC~4Nl A ll ^ u^ 91GN46 I ~rl ^r l ^ ONE WAY w I o ~ ^I DOIN091RAIGIIT AnCAO ^ > ^ 910Y 61GM ^ > ~WO WAY .r~~- ^ pVLR1ANIND ANO PAP9rN0 ^ l ^ YIILp SrpN ^ > ^ RU~S.W[ I ^ ~11 MANIIIO fl1G1111UNN J ^ I ^ ILA:iNrNO NED ^ x ^ Il00Pri1AN~ IF ~^'" ~ "rrU L[ET TUIIN ^ I ^ Il4ArNN0 ANNLII ^ ! ^ ALLEY ^ ~ ^ MANINU U~TURN ^ E ^ IIN 5r4NAL ^ % ^ IANI'6~N ^ 6 ~6LOWIND ^ 1 ^OIIILlI1~IlAL'MAN ^ ) ^ pI1rV[WAY ^ 1 ^ 6IOPPLD POR IRAIIIC ^ E ^ ONrl N. 91'I:CR• • fIOAD B./.YAIFTIION ,w ~ ^ E GTOVP[O A1910NAL ^ ,~ ,_, „n y,,,r,,, ^ f ^ prWOlD OR SIUP BIRN ^ + ^ 9row~ro w noepwer xE i. ,':l. 11 ~' ~ # ~' 1 n I {?h" ~ 'r A, ~)E,~~~ ~ r.l f 'F~d~r 1 .d`:'°r "~„"~""`:) ~r'"= ~ . 4' {wl 1'!.a ^.. a ~ ~ ~ n ~.; r ~ r .v 1 F I 1~.I r .-~ I I r I l I .. . ~ J ~~r ,, 1~ ,~ _ I ' '" " ~ dv~'. ,_.-LOYIINLX~VY1 ... Y~: ~. .w _.. - --,• .__.. u.__ ---.~1M1Y..w,t_l ~ .. ~~~Y~ '~ - EHICLE COLLISION REPOPT cools ox conxa ~ ouNTr 1%rr Qny'^ ~ ~~~ ~( NO ~; ~,, K ON~OcoO M" s ^.,. _ Noq ~ ~ E 4f ~ 4 - m - "~ ° ^ s ON o / o''j ARII.> ~ I« R ~.J 2E7IJL ~r,X., - ~' L sEC, no nsInEETOA o n nT ` MM rosy u~ p ^ , ~ Y, r, RAE. . ~,AMtl,TA °.EAiL~HOn / n bro [.x w "~ Lu, a .:- `,; y; vo.vEn nA+NOOI.IM6.. I^ ~ nji - Cz ^ ; o ~ a - e a e` o EAE~~EOUIO=sESTAFE,~~R A sx t~ Y ODJECT STRUCK W A " _ .._ w "6~ •;. - .... ....,.. .. k-.~. •v. OWNER Of.OBJECT9 NA~IE+Al~O~ADDflE^~^ ~~~:!-~~~ ~...: sx catt usL 'Z•. r y¢ ~DRIVEff L9,~RT NAMEy, ;.flfl$ J '~ ~~' F'e~C - ~ TNAME _....:::: .`..,.,,:MRASE' olvco $RtyENSLA,ST NAwE .:._ "-, ..:aEIRSLNAME ..._,:•.J_+..:..MIPP.I€......_ ~' ors. oR .. ~„ En COLL sI ' uonE inAN Tw _ . ~-~ R ET AOOflE59 •''. POUTBN .AN ~Olf Nq. E ST ET ~~~ ~ Lr2~ .~ •?~~''r -n, ~_ ~~ -- ~~- -. r[xsons wUl NE M.. ES ~:.....t .. go!~TE LID; ND O NO,, mluaro usEA 9 ••E ~ a~ ~-z.~ >sz ., 6EPA"ATE D Lao YI J ' I L j ~ CITY ' ..._ STATE $IP gDDE, DgIVEH6000UP)STIOh; `RfrOR~" CITY _: rr9yAT€vu.,..4.,:,ZIP DOPE O_f11YENS OCCUeATION ... 'rf • .t,,",. ^~A X A ORIYEflS LICENSE NO.. STATE DATE OF BIgTH_.., A PRIVEgS LICENSE NO ,,, Y ~ `~ ~ ~, .~R F Onr Irn / ~ - • ~ ::, :STATE SE% DATE OF BIgTH. AOE ~~ "' MD LZ ~'i N.D W F M tlAY YN ' f VENICLE.Yq. M =E ICH v. OOD I MDDEL (NOVA; An BODY ST _(1 Uq.l MI LE Yq, MAKE LCHEV. DODGE) MQDEL INOVA~DANTIO gOgY STYLE 12 qRJ ~ yIN m.l LICENSE PLATE NO: STATE TRA LEO PLATE NO. ~ STATE.,. ~ ~ ~ $rl~k.l !If ,13: ~ ~. ~ LICENSE PLATE NOr_ STATE....:. . TRAILEfl PLATE NO. '. STATE `~~ `; _aa,mF vEHICL IDENTIFICATION Nq. _ . ~ - ~ ..:.:.~. vFt1uJLEADFrJTIfIGAT1oN_NO,.. '._.:...~ ~ vE,. t '~~ , '. GI9 ERED OWN 1 T•FIRST~MIDDLE NAME) ONNER'S LICENSE NO. ' ~ ~ ~ L L AL •. gEGISTEPED O EP.(LAgTT,[IggT-MIDDLE NAME) DRIVER'S LICENSE NO H w in , '~ A OWNEN5 ADDRESS 'ISTgEET, CITY AND STATE .,T " ~' a - 1 DATE OF B flTN:. OWNEfl'4 AODRE$g_-....I$TREET. CITY AND 6T.ATE1... GATE OF $IliTH ~fc r O ,~ vw [-G SD WA N 2 PAflT90F VEHICLE DAMAGED ~~ ~I '4 r ~' ' ,. ,, '.+ ~ lrA nvenlel ,,, P~A?S OF VEHICLE DAMAGED r.t R .~ tiD - /+ s $ 500 __..._ kvANY1H,e,t~:'° "~* ~~ . S O 00 +. LIABILITY INSURANCE INFORMATION-VEHICLE NO.1 WAS TNERE AUTOS OBELELABILITY INSUggNCE AV YES ^NO ~~ ~ ~~~ COVERAGE IN EFfECT FORT S ACCIDENT ON YOUR CAn - +^''" ± X ~. NAME ANO ADDRESS OF LIABILITY INSURANCE POLICY NOLDER '1 - ~~ ^"~' ,NAME OFL BL YIN ~ .- Ael~' P ? NE AoOAESI ~r - r _ :.. ~ IA gURA ., .... y / ECOMPANY e #4~ ,~ j}j NAME DAOD S LIABILITY INSURANCE AG NT '. G CTY w. ~„ _„AiF ~~~/ _ - ', r ,~_. IV ..: ,, LIABILITY POLICY WMBER NC ... m N` ' L ~,JI' Y YQLJC.Y.'. "A.S 1ST INJURY _. _~r-~~v ~ ~~ O LI I ~. ~ ,. -.-.-.. _. ... yti.. AGE 2NDINJURY V TL RE 0 OP TIUN ~. INJUx E51 AGE ..... .. .. ....__ ....-_. _.._ ..~........... ... ,. ._ .x. NAM VYiEO NAME ..... ,.. ~ ~. ADDRESS _gEK ADDRESS ..SEX ~ ~~~q - NATURE ANO M F NATURE ANp M F ,~. ~l EXTENT OF INJUR ES ^ ^ E%TENT OF INJUR ES {k 1 UID NJURIES REOU RE ~-1 DOCTORS DID INJURIES REQUIRE ^^ j, ~f 'y~Y EXAMINATION DY A DOCTOgr fJ 'O NAME ~ EX MINATION BY A DOCTOR ^ 'O^ N~MEOR S +>}^ STATUS OF INJURED ,. ~ • MARK FIRST ONE TNAT APPLIES N D sigros op ',: NARU ~F'IflST ONE„ ~ ~.GQ}~, ,wY„ ^ rP"Aluncln IN V HICL o Tun r.c "Yn-„ uplr I H.Y H '- HAT APPLIES - n " ~$ J ^npilnun NO KILLED itun'x[ wrvon r.uK ^ NO.. I NILLFJ) IS[vinY uhcw Y fl 1 ?": un n ..n IA II. ,' iYY ... `y ~ MOTORCYCLE SAFETY: ^ IIELMET DEED ^ HELMET NOT USED MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT US[D '-_.J~~ '.. it . ~ { ~ ~ A i 6H0 NORT BY OW O CLE .OESMIIBL UELOW WHAT IMPPENED: 1`EFFR TO VEM ClE3 DY NUNBERI 4,L TE, :.....: NN+ INnfJ•LO ~~ ~ 4 ~, 1 ' V { n![T aA N ~ n.rM R. N,A~. ___ __~ I - .- _ _ _ .... ._. _ _ - ~~ _ ..-. .. _ ~I. ~. ._ _ r . I - _ ~- ~~ 1 i I ... ~' ~ -- .__ ~oL .. a~ ,- .. __ D _.__ X~ ~ ` VE CCES POSITIONS BEFORE COLLI 'ION INV[snaafD Br Iti k~~ sl . o.ANls LE _ ' ~ VEIIICIE OH STR[Ei OR HIGHWAY NAME ON NO II•^'P' tort Cc S b Pwll ^ ^ ^ ^ IW„ 11 no NR ,YP ~a1R ^.;c.a ^:aN« ~,I ~J, } " ,~nAa 'Fil ^ ^ ^ .:_^ ^ ^roLS[I ^a,~rlAll u! Yafi nE01PNMI ^ ^ ^ ^ o 'GH6L&R /pp ~ ^ ^ ^ ^ ^ ^ f ~ ~'T_I 1 n ^ ^ ^ ^ Atol "M;,L4ntl FnoM TOxn PEDESTRIAWPEDAL CYCLIST WAS USING' J^"A ^l„I ,^~ ,^uo 1^cT ^„ 1^xR ~~ ~d I e.o.A.,. .,.. ~~ n n r ARnX. n PEDESTRIAWPEDAL CYCLIST CLOTHIHO COLOR J ' I^T.,. J^Iw .^ ~ rt0.' . N o r....XxH y 1 1 ~y { ~r, WOAD SUfllACE, WEATIICN LI(i11T OOND1110N4 ^ '^ s• Irc v fY .J _ L Iwc. oNN TMl/IC CONTROL . ,TYPE OY jiOAD DPIVENVEH •,1 W YllUnl ICLE AC (IONS a - v nYAE I ~ w`i".'N>, cwc. oxN ..c l ~K E" rwl on ~IOAn ! T I lli ' I{E1 1 LJ i~~~U~,'• I ^ MwN ^ I ^ SIONAIS 1 111 , p 1 ^ OI1T I ^ I ^I OHE W ^ 1 l ^E UOINO STPAIOII! All[AD qj -~ J ~ '_r 1 ~ ~~ jA 7~ v! J ! ^ R•IhINU 1 ^ W SX ^ } ^ STOP S UN I~I i ^ i O W Y ^ T ^ OYfPTAKINq AND PAtlCINa ) ~ ~~~ I•J." I' ""-' ^6ET i^SNOwNfi 1 ^D'RK'91NLlT .^l J ^YILIO SIGN S LYI0.SIL4[ I ~ ' ,` r~ %~ LJnI{UN LJ ~~.,`t ~f~U~• ^ ^ ~W 1^100 S ^l4rlIS U/1T 5 hO R[D ^ 1 ^ NIfNCnANn4 ^ ] ^ MAI(INDR MIT TURN 'i ~~ R K ~(I~ W ^ 1 ^ ICL DTMI D•NK~ND ^ 1 ^ It• w ^ ^ IIOOPiNAMYI ~ 1 ^ MAXIND l[Il TURN i 1 T f ^ISHC~IYI { ^{IR[[i UMITS ^ { ^ ILASNMO AYP(N ^ S ^ IWOY ^ S ^ MAXINnU TURN / ~.'~ IY ~1 1 ~1J ~a,~i3~~rch~1 ^ ' ^ sO1d'c`;Y 1 ^ >'«~'Y ^ { ^ RR sIDN.L ^ { ^ un WunrJ ^ { ^ sLDwINn ~ ~ /*? I I 1~ k ! 1 ,I• AY CN IIOApYAY BUR•.$$I~~ACL IYYE-_ ^ 1 ^ OIHCINI I•GU•N LAN[S IIw"' I^ ^ ~u .IN L,JI~'. ^ ! ^ DW LW AY ^ I ^ tl1UYYL0lOP IPAIFIC 1 `~ ~~~ ~' I~:y L ~ ~I •'I• ^ { ^ OTnf R, SHLIIY ROAD O{PNIATIgM„ L_, ^ ^ 1 p}r t ,O ^•O°'• { oe 7rov¢ai'ahu ~~ ~ ~~ ~ I ~,~ (b0 a9'LsF7<-G ^ 1 (2~a DeD ~ ! t~T~~ 'ry~q 1'~7~g ,~(~ ~ ^ v ^ RTOrYTD Nno•Dw ~' J I~"~""T .4 ~,~~' '.' v~•,.'r `Q + i'ITt•nP'"DyY, 1 RI Nn r Y J $>0' fi rl I, ~ ~~1~t~.uu' z ~.- ~,,,:.J~. ?.~ {~^rIA' dL r-T 1 ~; ~ ~ 1 4, 1 , 1 ~?~ T y~~~,yyyy.'`7 S ~xri} ~ ~'„ ~%~ ,X J- .~-~r6'~'_''1 A ~~'ff"~ny~~~~~~Fr 41 'Y )~ ~' JT I. ~ irr~X IJflFSt.,Illl~IS 11,1 I3v1. ~ ,a `Iu ~„'^'p~ T ~y 1 " fil '">"~[I > i t ~ 1 r 1 q ~~ Y - 1 ~Il 1 ~ ~ttvrti 5~.1,~ t ~ N r~ 1 , { '~~- IT 1 ~ it ~.~ 1,I - ~ I ~ETTNd7 ' - . ' W eP7 - r ~ .. ~~ ~` ~ ,f 'fiD - ~ .+~..._Lt' _... °~....+5.~~2-_. eiq,rA _~:, .~ [ww;i Y,; 4e~s+~~r.~ ~, ~':"c t3'n', -~' +~ MOTOR VEHICLE COLLISION REPORT - 5F ~' ~"gw xnxr°"~:.o°`~~ Eq `~A~~`,~i:°N~y Do Y rvsl$-.~ ^ < ~U uqu ~~ ~ I 3 ^~5„ aW ^^ h ~ rpxrpw h.xE. .4,q1 Tp1,,, nn,Y rpTa] E qn,~ ©~ "~~~ Sd ~ga~ °.x°wraa.xLErpq O^ ..,.,xx+n~p,. LPp3rpxPl -ra rqn,. E. .,r-`r-~ ~ ~~f ~~, ,~,. Sd. ~' rEL p p ,° x. ",r,.x°L+n°M,x. a °q,Mn+.+ ~~ {~ , ,;,! r nr ~Lwsax~-Ln ~^w [ ^~~ A,r~q,EP q,MP ~ ~ ~t~ ~°°°~°E ~. ^6~ ^~! ~~a"~"`w:°Igl..1o<B o~,:° B [ x~ ~ ~+ E_/ LrpEE~dA~oA .~, 1~, "`~'~z OBJECT STRUCK L or uoaE raHWCXI ' OWNEq OF OBJECTS NAME AND DORESSr v FEH' r? r -.. ITS' npru~Gi .... .coos my . __ ..._ 5 __ __ F voxE nAx ~ P ~ 5J3„~. ,. MIDDLE - y~ "~. ~ ~ ,~ ORIyENS LAST NAME FIgSTNAME„-, wEgE HVp vFp PNIVERS LAST NAME'.„__, ~ ~ ~1 [ AU T-T \ t J O 111 I N rq ......ffH9T.NAME .. .. '.. RIDDLE:.,. ~.V _ ,~ n MLpLD,lpNpq _ STflEET ADDRESS ROUTE NO. AND BO%NO. ~ r O / qE STREET gpDgESS nOUTE NO. AND BO%NO, r I - STATE ZIP CODrE pRIVEg50 CUPATION A CITY ELF t4(d'` '1 ~ ~ S~I ^%y^~ _~.,. STATE ZIp CODE OgIVEgS OCLUPgTION `WSJ' ~. ~, _ ORIV q 6 LIOEN NO STATE OS IF% -D`ACT•E 0/F, BIgTH., AOE ~R i gN„"j';v.lAwR- ~`. .' C~- ~ ? '11y1. M v +r rqI DRIVER'S LICENSE,NO.. _ >i° 4 FF J WET STATE SE% DATE OF BIgTH AGE t f _ . ~ VEHICLE YR, C E (CNEV. DODDEI MODEL INOVA-OARTI ° DORY STYLE.12 .) M F M p+v vn ~A¢ !/ c~r1 q~,~ /~ ~ ~ W VEHICLE_Yq. MAKE.ICHEV. DODGE) MODEL (NOVA-OAgT) BOGY StYLE I] OR.)T"" ] O LJ lT r ~, ~ , LICENSE PLATE NO. STATF TRAILER PLATE NO.. STATE _, - , L~Q ~'70 1 „~ LICENSEPLATE NO. STATE TRAILER PLATE NO. STATE W 1 VENICLE IDENTIFICATION N0. 3 39 ,v VEHICLE IDENTIFICATION NO. ~~ t _'L, ,pyy ~' REGIS EREOOWNEF ILAST~FIRGT•MIOD ENAME) LD-'nWER'S LICENSE NO. flEG15TEfl EDOWNEq ILAST-FIRST-MIDDLE NAME) ORWEIi'S LICENSE NO: o- _ - 'k: ~H ~ CIk~UA7~ 313s' _. '~~ E I OWNER'S ADDRESS (STREET. CITY AN STATEI. GATE OF BIflTH OWNEq'S ADDRESS ISTPE£T. CITY AND STATE) a r F~ ~ ~ p. v ra f OpATE OF 61RiH M Dv •ktC PARTS OF VEHIC DAMAGE r r (~ L i S. i .. sr u,rrp CO ~, ~ C ~ - I.ev+,xvwuFr ro PAflTS OF VEHICLE DAMAGED r,v+rL°r r ro LIABILITY INSURANCE INFORMATION-VEHICLE NO. t- was TNERE AurornoquE LIABILITY wsuRANCE $ NAME AND AODflEbS OF LIABILITY INSURANCE POLICY nOLOEq COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR •y YES ^ NQ ' I ` ~' v;' n,vE 0 I Aowl r r W~h$ O NAME OFJJ~IADILITY INSURANC'EE~COMPANY .~'~* NAME AND ADDRES OF (ABILITY INSUgANCEA T U N£ 4r i < L'31 r yj. h '.}• L~cLT ` C, IY .: . ElArE. '' ,[..O~Ii ~~ }(~~ n • I I ~ r ~1~ ~ ~ ~ ~' O LIAR LITY POLICY NUM Eq .~1.____. ~ V !G`L A ~aln ~ I[-(.f7RE <. , v ... .. _ -:t _ IST INJURY ~~ ~ 79 / s~/ ~(~ / cY 'U ~ AGE (O O c 1 ~ ~ 4NO INJURY I f9EPANA NEPoPT FOq AppiTlpN+, q '. NAM 1-~t .1. M ~11.~~n TL~ .. IE31 AOE ADDRESS ~ ~ { ~ S Ik /A r(Tr .~E% iN f`p NAME - ~ TURE AND OV ,"L M rAF~( AODgESS .. 5~ EXTENT OF INJURIES ^ lC NgTDRE AND M F " AY I ~ E%AiiNAi ON nYDA IDpCTORT IIm LJ 11Y 1 l I E%TENT OF INJlIn1E5 ^ ^ y DOCTOR 5 1`iJl STATUS OF INJURED NAME IL ~ E.S DID INJURI B RDypq Oa ~ ^ DOCTORS `. t I ' NA E - MARK FIRST ONE THAT APPLIES F%STATUS Oi CTOR'+ ~ -~' ' ~ IN V HICLE n s.o. w r.ox o ~ NJU I qED MARK RRST ONE THAT APPLIES ~4 T .~ NO. ~ KILIED ~[v[x[ 'M Cp -^.n .. IN VEHI ..•_. xN S'° Pp snL - ^ , I r Or NO KILLED ~; ,^ nn[A », I,.,. 5 ^ 6 ~ 7 ~ ^ °' , .,pug u ^ b•~1 H° s'^°x° 'ur ~°"Oc ~ ~'~ MOTORCYCLE SAFETY: ^ MELMLT USED ^ HELMET NOT USED •] ' MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED '¢.-~, SrrOW NOnfN BY AgROW WCIRCIE .y1- '~ aAVUrI ON rwl n+uur ', ` __ DEECNIDE BE~~HAT~PPENEO (REfEq TO VEHICLES nY NUMDERI ' I ..;'a~'`~ ~ °p'K""~w.~°o° ~ '~ j ~~~ _ ~.E3u1ng crH.'~laflltc Park. Abou-~1-~ ~~ Y , hpxWY r.~, YInKLI .xn U~fR ~ ~A- i >L LL2H •. (JLA Al°raxprr LLY..,,» °~ , a ~.IxLlrnx„ Au>cl. Q~"rriurl~L~~1-cA ~.rx 5rx~ ~ aJ;' '--L~ U~- i~ ~-----_p.AY. p;.Sl-Y2~hf-_. GrgR(~~f.._.;whe~i r7-.(J~.~ ~..._ ~~ .. ~ eR9rm~a} ~u`~ ., d._ rql# o ~-. ~~ ~'~~°~ n' r7-+'._ _.. # '' ~ti~ agE,, `% ___ __ I ,_-------. -~-UV~4n'.r~- V?'_1Avl._C YI?E. _ c~, i-~~ _~a~ _.-- .. .. I CIS. (ASK. i~~ .W~2.oKgi/, ~ _. ~ ~1 ~ r 1~bt~.. r~ld.._. t ~~.~~ YY12 K~.PL _ ~~M? 1-lukL -~-- ~~EV Y L~ 1 D gNNk_, _ - ~-}-~ Fo/ :adz-1 ~ . ~ ' I, ~ . °I.uCS~. qq,, s '~ rEr v !d i~ 9 'Hues{d . ;on'cLL ~ yfiQ ~~rL-e: ~F I ~', r 1 VEHICLES POSITIONS BEFORE COLLISION rt_ ?~ 1 I I YENICL°. H ~TSy E W ON SIRLCT OII IIIGrrWAY NAME On NO « "p L1xxq °'ll +A+L n<L cwh INVEST'OATEO DY • ) .4 I, l L °p Yr I pE In .A« °url ^ W ^ ^ t~tl` ~ P~c°in„ .IL vp .l h rl1 ~° ^~: ^iaKL };~ 4 ~ a. .,'~ ~ HWlrrw ^ ^ ^ ^ NONO nx ^ ^ ^ ^ ^ ^ ^Nxxpr ~~, L~ v av ~ P[DESTRIAN'PEDAiCyCLIgT WAS USING' , ^,y ~^nw FROM TO NPE f ;~. '' .AU. .n+. ~~ ^x+nrr:w. .^uisiu• PEDESTRIAN•PEOAL CYCLIST CLOTHING COLOR. ^"iOi^I rx `OOrwx I ' .I t NDgO ll1111ACE wGMER l10rli CONDITIONS ^lunr r^ur r~xrrYnxNrrcrnX ~^ar,annrHtcrvr+rP++ L ~ ~ ~wc. a+L, TNAIFIC COYCROAL[ TYPE OP hOAO 'xxA.rMnnl rrr. `L 4 n ! r ~~( r ^UArufihT -~--- ,n „r Y ~~ rL~ORIV[R/YENICLC ACTIONS 1 r,iiV ICTI ^EWY [Nrxv+L~ ) ^R4wN ^ I ^ SgNK3 rllA Oh[WAV E+M x01 I[w C%4A[pn uoxll L, Iy t I ^ ] ^ w[I ] U AAPphn ] f ^ I ^ SfOY SIGN ^ ] ^ Tw0 WAY ! ~ r ^ OOINO bIRAION} MI[AD ~! ,` _~ ly y~ rJ ] ^SMnsV r,p ~{~-,~yL~U^~+~~NK4rgllr 4 ^ ^ ] ^ OV[NTAX NO ANO PAYEIND ~,.. ` r L1 LrGnl4 nh ^ ] ^ Y~[1n 3,6h - Ju.} ^ ] ^fA4W ^ ] ^ROV~RSIBL[ rF~'~1 ] ^ uAK NO HIGH! 1URN 1i~ ~. ' 'G" I „ ~ } r ^ [ ^ ICE [ ^ O~ln a ^ DMwihO ill ^ L ^ ILA5nrh0 A[n ^ ! ^ (LOOP p~YPIC LLJ-! + ^ uAlr ND ICFT TURN J'F 1 r ~~ Y --X ~~ ~F ~` ^ 1 UAWCr/Y SPICIHI ) ^SII[jYIIGrIr4 ^ < ^ IUSnINO AYpIM 1 AlL[Y ^ L ^ MA%NGU TURN -;~. • ^ ^ qN AK.N4 ^ ^ rwo WAY t •4 AT 4MNCfEN RDADWAY WN/ACC TYPE (~ I ^ ^ [ ^ l[~E iIAIN ^ 1 ^ SLOwINR t*dT I' { r y~ OIIKfRTLAGMAN fE 15 {III -~ ••+wn ' wn~ ^^ H (-J.~`u..s. ^ 1 ^Oln[R. EPIC IY ^ ` ^~IVIWAY ^ ] ^ ctorr[nron Tnurle I ! ~h17 I I' ':~ (~{~ ,,, ^ ^ .P A YAM I - ^ 1 [] BrpnrlpArmcNAL d ~~ 1~1 11, F 1 F r ~~ ,~ - Cl ^ •a. ^ r ^DIWDlO oR ~to~EON 1 1 ~ Ix •t, li f ' t ~ ,~~ ^ CI ~ ^ ~r x (~ ] ^ ^ ero Pm N nDADw r 1'h i, I ~ 1 1 ( 1?~` ti 1 r }" ,t C 1(J ^UNO D[n l''~ 4r rrvnN !': t ty , ~pE ^° 1 1 IR 11 L I NE S d ~ Y,l J r , •tii- Y, I r.., t ~~~~,--" Ia~~T"'~~'~~'. ^C^..~m ..f' F" r ^1'7L ~ E.fr~ 1 - + d h ~' T I ", v~ T} t Ib.~I! - I T d~-, ,/b I I 1~ ~~ ! 4~ 4 ~ 1 }UST 1 471 ~ ''~' ~ ~T ~ . ~ ~r{~ k; P ,r, ~~ ~, ITA~ .,. ~~ ~ °~ ' Yl yJ $ r ~iii~~~~~(((YY2 ~'~~,n< ~~t ~ ~ ~ '--_~ '"& ti d v" ~,N NAr°IwMr! ~,n rv,, Nuxu • N I`•~ ^ ^[ ^ ~ °" A l N °r.~-°N Ar cT. aS Ir Ln coPE ~ l o 1 wIr,TAELI°A~ ^w ^ .fi ER ON ~ .CIS/~!J T If C 1 [L, e O l7 . ~ ir.• ~lil 0 0 ° J I ^ fu 7 ~x L - ~ IY, TAI/ -~ , ~ I ~, .~ I ANl, '~ ,~~~w ;f2~ T'~ r(n )~, . '-, w ~ GE EA rrnit°6A <~5 HEfE nn» ^ NEy(TEO CgO&56TPEEt OHpO.[ ¢pi % ' • u° xmu L§W~~~ uLs C _ + - F ~~. ` .C~IECT.$TRUCK,; ~,., -,.I..„¢ M 1 ~ OWNEq OF OBJECTS NAME ANO`ADpgESS .[KnTe%NGA+°S.~- ^ ''nCJ -~~ I[ wEC. rox[usr ! ._1M '. ~~ '.. >6 ~.. I rY [4fllYf{!'~L?13?:NAM.St.•_..-, .~...::».w..:.f195T.T A Tn.N ".~~'~~ .~` N!+E:., .._. MIP °rlvavco BIKE^e .Sm. T• WER ~-~pF' :. 'LIS.'N-~,...m:...v-.F1N£.HAN€.:., ..y...u._kIP4i44.~.,;•:: L' D t)~.Ll-. ~ F ~' ~l LnElslo~Y, G (7 /J ~, 6TREEj APDRES9 ,: ~ 1 ~: ROUTE NO AN _ , J~ u°nE THAN Iwo ~ D ~ II I+ D (/ 1\ I~ E PEnS ENS E ~i~ ~~ r S2P.PES9... ~° C~I~ -~-~nC ~ r ~_ !~ ~ n4 uTEno.A._.eo%yD ~NSEPAA !E ', _ ~ CITs : :..... _. STATE '21P CODE pR1VER$000UPATION rouslONA CITY - ~/ _ E RU `'" ' •- - - RTPOni ._ D .yam§JrZTE, ~ ZIP COD/E ORIVERf OCC/UPATION ~~ ~, f ~. ~~ I L~ .3.3~~ P s5 O/ ° ~ -`iv` "Es3D 2Q~,.d ` I S~~A~ '. ~ ORIVEfl'S L,CENSE NO.` / ry' ~ STATE ~S IEX EDOT pOF U'gTN AGE ORIVEgS LICENSE NO.-. ..... STATE SEX ,PATE Of DIgTH .AGE ~,~ ~{ ' r `; ~ r L I ~ I 1- r a ~ a l~ I,. I . r~'r ~r t ,.,;.,,` /~ •. -l~• -~•~••.. r. r-....~ _~:-...~r~ ; rnwlLtn PLATE NO. ,'..;STATE VEHICLE IDENTIFICATION NO. .., IJI Ur ' - l i `.,- ,... . ~. _.-. yEHICLEADf?JTITICATION.NO. ..._...., .-., .. - REGISTEREOOWNERILAST•FIRST-MIDDLE NAME) Ofl,IVER'S LIClN$E JJO -•~,-;, REOIST€PEOQY(NEf11~j;NRB[MfOPLE j~IAMEI.; DRIVER S, LICENSE NO. , .. OWNE11'S ApORE55 '. I6TgEET. CITY AND STATFj ~, ,, ,,,, ,, ,,, ;,uJTE OF,BIRTH..DWNER'S.AODBESS,~_,,,-L$jgEE,T.CITY.AND.$TATE) ,, ,DATE Of BIgTM DAY rR ~~~ ' u0. nxv vn 7RTS OF yENICLE DAMAGE ~~ ~ $ „~~[~I ° ART$ OF VEHICLE pgMAGED _. C/ LIABILITY INSURANCE INFORMATION-VEHICLE NO. I- was nlEREAUromotluE USOIUrr lNSUgaNCE COVERAGE IN EFFECT FOR THIS ACCIDENT ON YOUR CAR YES ^ NO NAME ANO ADDRESS OF Lk1BILITY IN$UgAN.OEOPOLICY HOLDER . N'w ' Y - '-a..v JiAME OF LIABILITY INSURANCE COMPANY F I ~~ b E ____, -- /~-- ..... NAM6 ANDAODRESS OF ABllliy lNSU CE AGENT •r ~ '~- - J~ ~ ~ L-G - ... "".'-'+L'L ::.~::1 C-.. _..:.: ;:_ -..~:_{,-;; U!WILIT .,POLICY NUMBER ~ .......-.. f ST IN.u IRY •.-r.••• •.• .r..rur.cu _ .MARK FIRST ONE THAT APPLIEg, ^ xux os.lx n° ~~ ..-_$TATUS„Pf INJURED RI! :vlA INV I xrMwnrrr. -" - ':.MA FIRST OryE THAT APPLIES, '^ AMlrq[A NO _ KILLED n.urw ^ox v[n Ois[x[n° x°N ~ ""' ^ Mr[n[ unwr sA ^vA! NO _. KILLED ,siv[M[ unwr ^° .. ^ s ^ s ^ a7,Of1 °^ ~ 1NLxl ^ 5 ^ s ^ °`~ Q°I MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT UGED SNOW HOgiH nY ARROW IN LIRCIE -, rrrolcAll LNrw PU.nnw- i '~ ~ OES IBE BELOW W~M i1MPD~Eq TO VENICLFA tlY NUMOEgI _ .rw14o MYNMIR •- pp~~ rf'{,Qx(!~nL w[E In[ Nwr ru .r © - - - I.. -. ~I afG. ... --G/ ~ n L G•. ~~ rE~w - r µ. ~- of yc' i a a.ru. Nu.__[~I' . ,t _, - __. - __ . ~ WL U-Q--. J Y/LL.t~ - VEHICLES POSITIONS BEFORE COLLISION +°~w~wrA.~ ~•„,LICC2 uY1 ' r +;~' ° _ ' I .<' VMIICLE INVESTIO TED OY E~ ON STRCFT ON HIGHWAY NAME OR HO °L Lwlr [L E r.u an ^L^'^~ ^~IR HMI U ^ ^ ^ rvcrrnl n[[ unMl rtw NI~ Ir^a °ct O.[ rgoM TD PEDE5TRIAHrPEGAL CYCLIST WA$ USING' , ^[,,, ~ ^wN ! ^~, .uA! ~ ^ U l ^r~.lw ! ^°1 r ^ n . ^x° PEDESTRIANiPf.DAI CYCI IST CLOTHING LOLOR , (1,.•.. . f•1. _ f7 n -•- _ ................. ' ; i. wr I ~ I ~DAYIrGnI "r K[ .., rA`1 ••...rv VUl4 11 rEr ~DNV ) ^OAWN Al xnlr ^ ^ fgNAl6 Ly ^ , ^ wn , ^ HAMrN<. o ^ DusA ^ , ^ voP LIGN ^ ~ ^ar.ow , ^sNOWrNG . (] °;".~sor.`u ^ , ^ YLIamGN ^ { ^1La ulna ru I ^ oEn ! ^n~ ^ 1 ^ rIAMI ND RIn •I ^L ^alTCr~Y l a^IVtfgr !^Ol fNrlNlNr3 ^I ^IIAMINO AMPIn r ^l.ICN• ^ ! ^ nfl MONK AY ~yNOADWAY LUNIACC 1yPL ., 1CIUI. ~[ (~~ n n ^ I ^OII'rLINIIAGUAN ^ ! ^ nI1[n lPLEllr ,, J ~ ` n n ~~ r ~~^ ~N~, ~n y L +zr ~` AvM'~' ~ '7~rA FA f ..± J ... .. <P ~~' ~6~°a''SRi~IY T, ?`1 v .~A ry` ~:1 Y I-.. .. v '. ~.f 1p5 :#pQr'. $bw ;KTirL" ' ,.. . ,.••w.w.rl+^ -..ravel t r nq[ U i I ~ ' 1 ' r^/1 1 ^' ONE W Y urxrll WO A I ~ ^ ' ^ Oxe 011 •I AI LAD d 1 I + , y` . J N W Y UG ^ , ^ naetiu tl1 F n ! DY[RIA%1N6 ANO PASLINO ^ UAK N01011 N Y} ~ 1 ^ ` ^ ~I rOONNAMPIE ^ A Ll/ 4AK1HO lLl1 IURN Y '- L } I ^,1. t ~~ LJ ! ^ I ^ ! ^ uAA NO U•tuPN L71 •~ i T vA w.v~ ^ a ^ LANES~N ^ 6 ^ EIOWINO 4 Il ^ i ^ tINIYLWAY ^ I ^ 510PPLD 1011 tnAr IIC I I 1 ~'`•; IIOAD $Ef-/JEAIIDN .... ^ ! ^~rnrrEn AT nIf.NK ~ I'p ^ , ^Dnm[n ^ 1 ^ nslnr MGN stonWD MROAOWAY t I+~, ~r~wOIVIDIt ° 5TAn11N ~~ ~ I IF e ', ~. .. , I r °t r tV', ~kz, r~ ~I ` ~ -~ ~ ~ ,,; , I~ t~ ~~ ,,~~~ ,. - _ 4, ~ ~ ~ rA,.,,~ >~, ~< ;-'.3"~r_ -,-,. f~~ _.,..__.~ - .~:, ' s - ,~.~ E~ .~ ~_- u... __ . ~. _ v.._, _ +trx..::........:: max.-._- ~ '~'~ i{ a ~ /~ EHICLE COLLISION REPO couNTr NDTy uUlr~ ~ _ s. iii ~?1SY '~; '•• •rt Puso ,s NO 6 s r "..,~ k R ..a Yan Er °a ~nln :` ~3~" °~-P"Y" T erro»' N0. ~'. ~ ^n ^E ^In nraNiaw„ n E N ,NEriaaa ~~ ~. .,~~ r ,~~' k aiw~awllN.INlEian®a ^w ^t`µ„EN°~lan ON tCl1 /'ns. ~SEJ JO, Y! 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ORIVEq'8 LICENSE NO. - - ~ ~ - - 9TATE SE% --PATE-OeBI TM ~ AGE IVEflB L CENBE r • E;j '~ "~°l, ;J 1~ ~'~ ~ M r rnn ~~~ >.~'^-~ ~ SATE SE%. . GATE OF BIfliH .AGE IJ R. Js ~ssl- TL ~ W G RAr r ~; ,~ ~^ , VEHICLE Vfl. MANE ICHEV. OODGEI MODEL INOVA•DMiI BOGY STYLE,L20N.1,. HICLE ~ ~ ~.- ~,-"~ f r~ e A / T(4 MA E EY PQ40_EI :MODEL INOVA-DA TI ROPY S YLE (2 OR 1 ' 1 J vY a/rA' / 71-F ~'~' 1(lV' '~ vs LICENSE PLATE NO. 9TATE MILEq PLATE NO. STATE ~ ^~' y w ./ / ~I ~ .. LICENSE PLATEN --,,STATE „_., TRAILEn PLATE NO.. STATE' ' ) ~ ... T - ENICLE IDENTIFICATION NO. ~~ ~ /~ 9 - ~ e .._ VENICLE IOfNTIFICATION HD.. - - - Y ~: ~' REOISTEREOOWNEIj ILAST•PINST- E) OgIVERS LICENSE NO ,_ REPIST EO OW_NEq AST- fl5- W % !. - _-... -. _ ,Fig _(S- .((_-j Mf00t.E N4AJE), DRIVEri'S LICENSE NO_ _ N /3i e~ / ~ :,'~' ` ~ ~• ,, OW I-.. ISTgEET, CITY.ANU STATEI DATE OF 01 . '- ~S ORES 9 ~~ -_ ..... . .:..- Mo. oAr flp H. 4WNER:&foD9E5F.,-.,.:»(47AEET»DlT.Y_ANP S7AIE7.,._- ... oATE OF OIgiN Aire Rs ba -~ r IN ~ PARTS OF VEH CLE DAMAGED vE I~ r0 PAATE OFVEI CLE O MAGED ~ ,. ... ,. ~~lP~ ..... ._ _ ._.. ~~ AyFn~~r re ~~ apex sJdee~r ~dr<~d~ $ ~ ~7' ,o e7~ eZ ri % a ,. % ~~r~. ~- LIABILITYINSURANCEINFORMATION-VEHICLE NO.1 W STNERG AUTOM PILE LIA CITY INSUflA E ~ N-y ~~ yy~~ '~ COVERAGE IN EFFECT FOR TIIIS ACCIDENT ON YOUR CAR 16 YE$ ^ NO ~ - ', ~r NAM[-ANDAPORESS OE IvIAB1UIY INSVflANCkp OLIOY,N,OLDER_-_ -~_ +• - _- (NAME OF.LIAry!L!IY wsuflANCE COLIP,AyY _ y ~ ~. NAME AND A00 ESSO LABILITY IN URANCE AQENT. F.T .:_~: ~ ,M~. ,C _ S ~y- -' "...:.-__E. ,.'.:.,.;~ .,.u,IFIABILI Y-P ICY MBER .'~, s ~~ .i7.~` AO~are ~.•l~ Fp .~ ) J / ry.~ / Ly ( , I !~ ' 1ST INJUflY l // /Y- /~> ^' 9d 3(efQ ~ XSte_~ `~~~~/// - -. - ' -- ~~-- - - ~-. ._-. _._., .AGE 2ND INJURY ENE 0 ON AO0ri0 n, nIUN ES/ AGE t ~ ~g -:-. :. r.-- NAME - _..... .--__._-.._.~ .._-...... - k. 'Y. ~S En NAME LLss~~ tt' ADDRESS .,SEA, n ,,:t'l "~` .~ NATUgEA O M F ADDRESS SE%- .:- E%TENTO NJURIES N LURE ANO M F %' - OIO INJUfl1E4 REOU flE ^ ^ E TENT OF INJURIES DOCTOR 5 F%AM NAi O RY A DOCTOfiI ~ ~ NAME ~.~J D O INJURIES REQUIRE DOLTOn S ~ ~, ' ::.STATl15OFIWUREO E%MINATION BY AOOCTORI~^D N M." AME ~[~~ - ~~ ^ IH.YCNICLE '-MARI(FJ,gST ONE iMA]APPLIES .STIfIM90J'IWURED ,w_v_. :1 ~' I aw' uarra r,an ars.w - MARIK. PIPST ONE THAT APPLIES ^ ^ x ~ ~ ' '' ..° AuENCE, ~ MLLED Gswnr, 'n.unr .. O rA I U J I '.. ° N NO ^ rx non N ^ rA 10.. ..--. NILLFO rs[wnr lu~nal rn -;poi uSw Il .. 5^ 6^ w7^tN Oo Sin wnnEN ^ 6^ 6^Na °T"^L'a ) R- . p r,, MOTORCYCLE SAFETY: ^ NELMET USED ^ HELMET NOi USED MOTORCYCLE SAFETY: ^ HELMET USED ^ NELMET NOT UC[D F J !. ' '~ SNOW HOATNO In0 C C E ' ,. 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Y _r r nr,n s ~s v c,la qs. . _ . _ i ^ IT1AD. _ MIY[NVENICLE ACTIONS ~ l ~ yV iplt` f ~ r q~ IIICYII rllvtt I xN rnfA~ ICNEC, M[aA Wn11 Y )' r I ,' J• r'YI0111 I °-. - r~ i ^ d'wN ^ r ^ sgNAltl ^ I ^ ONL WA/ W ^I 1 ^IGO Nn STIII IOIIi AN[AD l 1-'kl ` . 11^OO) ^ W[i t ^N rNM 1 ^ WSA ^ [ ^ SrOP LrGN 2 ETyy,.~,WO WAY 1~ ip) ,rµ~S I I ~ )^tlµM .~ OAIr, SNIIIT ~ u ^ f ~OVfnIAAINO ANDPASSIND 1 I } I~{^ ^~I yI ~1~ ^) ^ONnN l ^IrGN)tl GN ^ ) ^rllU SIGN ^ ) ^NO~41BL[ rl ^ YAII Nn lllnrli TURN 1 il', ~~~ '% i ~. t 1 ^ IOG 1 ^ ~ nAirls OirL' ^ I ^ rIASN Nn NlD ^ A ^ ri IrnCNANO[ LQJ~), Ir '{.~ rti. +• A ~~{!. ^ L ^I.L 1 ^OY[(:"rl ° ^91N1l1 ~IGni4 s srr NO AYBEN [ IOOPrMAYrI U ^ YAN NQ lLrT 111RN ~ , ^ ^ rL• I } ! 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'.'~~ 11 ~T^,.' 1 F I 1FT YV{Ca, 1 L i N/ ~ ». ~ ) h. , „~, ~ ~ ° LIdIJ~ tl / IP qP r 1 ~~91t ~ stir X ~~ _ - ~ l~~ ~ 4 ,t ~Tf rr Tv•y 1 v ~ 111 ~{ ~ ^1~) x~' rw , c. ?¢ ~ BI' hh R 'u~~~. ~t ],Q I ~.~'. `~~ ~ ,~ ~' ~` ;~ x~, , n ~C. , ~, a T 4 ~~ i h ~3} i~ t ~ t '/~~q~ ~ { Y'' '~ • f' ~ , _ f L ~ 1 "~' , . ~~'. ea , I ~~J POLICE TRAFFIC COIN REPORT ~ tRAFKRWAV ~ ~ 7 1 Pof a INr BfR ~ PRIVA T E WA Y , _ eOUNrv f.~ ~ IUSF]WO HOVR [ --~Ys~r f%IUNtt NO CIIYNO x. EwrO t. ~ w o ryn / ~~~'yy~~W~~A~~ ON Q e0~ ,, Ve,it ~ QN CIIV OR TOWN L6N0.0{SiR[[IOR AY MIltS o5 ^W~r{ oNF RO ~ Tuff ~15~a~o C NitR5tC11NG NSIH. SiRt[10e POAp NON N1fR5FCil~O]N B[M'FFN~p Jl~,$ SiRFEI yi/`xt/~~r5 v 1 PRI F Mlt i/~ rd5i / / _ 0 CFBDR MRf [R NCf CROS551RtF~pR AESIM IF ~A~~ ACC DENT ~/ [fi5 R 5 F W O{ ~ IAN .++.~/~ MILEAGE CODE RAMP Am (v.iA .- ~ -. COIL SqN NvgV[O. fvER iv. iOIAI NO IlIfD~NO INIUR[D~ ^SPIItAGk ^nt6 RUN m ~y_^r..x /"/, I n D NRP CIS e Rv.V W NE ufNCE ~ SS Et OV OS ~ eP ~i OVfHCI[S pRORRtY OAMAGf ONIr ^kF5UlR0 ^VFn<lE tY - J S~ OB!lCISivUCRINNAFO{OB1 Cr SIRUC[MiDOWNEP'S IYMf) FS p Gt , SPFCIAt CCDNG WE; UNITNO. 1 v v UNITNO Z Q VEHICLE Q PEDESTRIAN - ^ PEDALCYCEIST -' ]~ n[ D SNAMf. VSSi iR51 MIDIXf U i L w~ DvrvFR'S NAME USt fl I IXf S1R[D ADIxrf55 P LT ~~tE o IRfft ADDRESS stArf :IPCDOE pHGNENO _ I Y Atf .. tm P2Au 92~6v o-s R J rv[e'S IICFNSENO. SiAtf ~ M BI H .1 ~ I ~ W UC[NSF NO. SATE DAiF O{B A ~2 _ OC<UPAIION F6PnONf NO. FYtS S,Y2tACT1 NI~DF~! ~ IGni HfgHV 711 ..b E R C<CUVAIIW {IPM NMIE6 PHONBNO. FYFS WFIG i HfG t _ QCHECK I~ v[H,n[ASiN U.nr r[FO{AHOmiu'"l ^CHECK (/) vfHlaF ASANEMpiov"ffaAfmmfRA[ CODES ~ ~ 3 n,u 5 [ 6 i,° S x CODES ~ ~ ] c, A iv 5 [x e y ° ^b snM IDN •NN st 2 wrt i ;~;„ ;o aM ^.ReDI.»<[ ^ ~ w[ ^ zsm. ^ :;.aa ONV~ ' ^ ArBR.HIX o ~ [ ^ ism. o Rf:a~ ^ .s„,.. MARE IDODCE6n[Y.I S D MODftfDARI.NOVAI SrYLL IRD .C Q9 ~ ~ E v 4 , H R V.1 MODFI IDARL VA) Y 1 D .) H ~''^ x N vn rRA Efx nAl su H mH. a . K C. ° ~ HIC MIf ICAigN ND 9' I L rtngN g N l l A RfG15RRf0OMNIP: 1/31 N431 Mlppl[ RgN[NO. O W I PtD WNFR: fASt IIVSt MIDfx 'U-:', I ADDRES50{Owr,tR N A NFR ]~ NMfAAD0RLB50/INSURANCE CO. OR AGtNI AGED API M1 SAR ND - ARm R. , , WL ]] ooHN cHARU aAaee ow "a,°,r 4"A'A~PAxtA eta] ~°' ' IOeOrt e I I O AWAY ^RIMNNfD ~ ~AW~ ~RFMNNID l51 DMUGI , s ~~-eO ~,q11'.° ior~Der ~i ~ ~h~ ~~ Y dew: v S 16io rx::. DIAG RA M O E COLL ISIO N Y e~.eeNDRm DESCR IPTI er ON OE COLl1510N: (DSesvPlfMtNrAl SH[eN rwasSARrI " V Or/ AiyfFJ _ - _6~zue~ S_e~~~_~~~Iss.- I o'- - - - - - -- - ... NAME, A DD RE SS 8 INJURI ES OF PERSONS f w ' ` s INVOLVED * CODES 1 - 2 9 4 5 6 OCCUPANTS/WITNESSES ~W; ~^ g Ny N A. A iii sF. Aw utus TMOfiT ~';- '?; wslR tncr ': t;: N . wf _ .~_._~---_._ nESS _ -~_'_~_ n e,o __ TuB ..._. rNrer AM e OEY1"' O ^':.. ^CI , ^C.Lt. N Al A N ~ ...__._._ a ss ,M ~, ~__ NA147rTbt -'-' R 1M pD reuM Q.Me v Q~AI v ~"m. o a ^ ~..D ____.__.___ . A ,,',A.A',o s w. DM QAMe ^ rH".^[I ^iwtt. ^r. x X .lvoALrc Ercln.aru FAr,. ,ADU OR AGEx~ I nrt~~~ Iqy,} _~ D D.naRlroa PP orlDn D•n S ~'~`+~° l ~ ,~ I ~~? 1§f QE k j ~ ES ~ F ~ ' ~ a i ' ,; t~t t J ~ .~~E ~ ~. ~ fK R 1 I) (VA , ~; l 4 .. ~ ~~ r ~ ~.. { R , S . I I fr~ 9µ ~ i' t~ s , 1 ~~dkr . i ty .,. ~ti . . Bar, fry" ,r ~~ ~ ~ r~, , { ~~,,gg~~11B.ytp^ h k y .; t r I rr~ ~ '' ~ I ~ l ya ra 5~ M .74A J~. I{~ Sf~~.G?Ly _'. ~~;. f~ ~~ , ~. l ~ a .: , I ~'tl ,~`~ Y °`~' . . I ~Kts . ~ . ~ ' ; Y f X K~ ~ yV "DRRAD'W'~M~". '~~~~ POLICE TRAFFICCOON REPORT ,~TRAFFICWAY Roll NTNUmefR ' PRIVATE WAY ' ' _DAIEOE 0141. a"~~ 911'1 '~ L _ AY, TIME axla0x tv6 n'N Ju, IUSE]eDDHOURI i l i i i l b l COUNTY -E. .\ FJff fb2S0 N COUNTY NO. // [c CIiT NO iHWA ~U RDRAI clrra+TOww ~pAmfeNO. asTRlfroR wcnwar MRles ~s pw En°?ORT TOtJ N AND I~ V rcTas Roulf ORSREf 3. 9SZOD '. sfci ~ INRRSFCUNG M1iw S1REF10R ROAD NDN INRRSfC110N ON BFtVI[[N ~~' STRFFT 6 StRfFT pafflK FO MRE PO~5J1 OC / vaC _ f1 ryl Dl~.syCf6 I iEXG .CROSSS1RfEt OR NFARfSTMllf P01 ~ mRFS 5 E W fffi Of ACCIDENT MILEAGE CODE RM1P DIAGRAM MtA - ~ ' CIXUSM]N INVOLVED SEVER tT: //~~ tOTAt NO. NO KIIND~NO.INIUREDy~ ^SRIIViG[ ^ntd RUN ve sIN IuN Rm 1 IMF D CIS I RSf SiXfF10R ROADOR Rft[RfNCE CROSSSTR fiOR ROAD ' Tl f STO[N CF V[H Cl[S I~ PRORFRtt DM1AGF ONIV ^ PIFSUIT[0 ^vE O OekCI StRUCKINANEOf OBJECT SIRUCKANDONNFR'S NAmFI fSt DAAAGF TEC.6P/JoNE. TvNG 10 /J 8GX a 1000 SRECIAI CODING USf ' UNIT NO.1 UNITNO.Y ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST ]' 3 Dvl ER'S NAME: 1/St I 1 Dlf W I~soiJ '(Zo~2T (Y) VEX SNamf: IASt fl I Dl - - _ ~ staff ADwffss 2.37 'z ~lA57'//JGS AV ~. D staeN DoREss SIAIf TIV CODE RFgIRf NO o2TTot>,AS~2D WA • 483G5.~ -35o R Y IR It SLA]F nON 1 - DRrvERSUCENY NO. BvsP~DE..~ (qtf WA m In ~los~g I ~ R R FNSf 5 AiE K O E R n I I - 9 z OCCUVATION nRMNAMEIPIpNf NO. EYfS WI HF GNI RObFER owA QuS• N So E R OCCURAIION fl NAME6 RHONE NO. EYES IGHI IGM - ^CHECK (,~ VFwttE ASAV rMRionfaanotHfa'Kl ^CHECK (/) IvEn fASaN fMnfinFORANOtNEeAI ,Xa, R CODES - * J a:i"~ A iin 5 t c]wx 6 "]',° - m CODES ~ ~ D a:u . i.snv. 5 ucrroN y unar .DE Nl I ]I ~ Elvrts ONE. w:s„D„ o ANSDIA.~ ^ ~ I ^ ~x:RX ^ ~~K~ u;~,~oI.DN o AaaA.Na °°s=t ^ ~;R. ^ K~a~ ^ :,~.. Vfn.Y[AR DODGE{NFV.1 IIDARI.RgvA) SrYIE I]DR {DNVI 7q ~ot~ 111vST. ~-ro/Z E n .Y 1 HV.1 IIDARI.NOVA) f V.) °~'^ ',.~ SIME TNULLR RAif NO. SIME H C VEn IXOX A N A ICl[IIXMfIOSTIpE~ 7 D;3! rf l l01~71 III-;-I-.-;-I L aNtf 1 t rEn IE I LIE I I I I i I i l l I R[GISRRFDOVrtRR. 1/3i n45T MIDIXF RNONf ND. w«son- Ro>3r, -'-'1 s-aso2 O W IS FD OWNER. Ultl RIRSi ENO, ADORessaowTREa N NER SAME, AS A6DV~, E NAMFd ADDRessalnwRAN¢eo. AGENt R n No ~ - DNAAGfDM[A usAa xO ~ wua N6 ,D..c.D.IN cHUr~ W cnARU o",'x'i.~+r4 gAM DARU mNKnw., , m _ OY R fSt.DMUGE AW/~iY LJ~ E9 ^Dw~ V ^RfMAIN[D fSt DANAGI -- .. 5 OeDTI ~a ^ownDeY. i.I. GI ^AwwAreY f - e - _I DIAGRAM OF COllIS10N: I ;NDC le NORm DESCRIPTION Of COlLIS10N (us[swHEMEHTU SM[T NeassARr) _, . 1 M sfB~u r~.~~i) e. AReow ,. ~_~~eE]x i .. -,~'f .S.WAS Fou.olallJG ~SuspE.c~r' J£Ji/CLE ~_.Sou1N ]5 i BouN a~ aRfb2T eufD~ .~ AT_ mllE/.ns r.. a.-- I ! AT ~I5 /T' ,c 'L _ ._,_ ~__ 1 ~. _ 1.(aH. VENIr tI._RouN - I E•F7-NA/aD CURUE1 oB5£ VF~I i2~F E.~' I ICL D ~ ,, '- - _ _ - - , lpp 'D l Vc I Y . _ . . .. . . ._. _ __ PASS oru~e. vFNICtE.s_..{INd l.oSE. eoy.TlCot,e_. , I ,,~.~I~ AFT Ro~D~A s ~~vvS ANa _ ' R I I V 0 s y _.. sTKuCK A E1 E ~ d N B ~ ~ sf~N sw i 1 1 t ~~ICE UNGTI T - .P oNG N I C~(...__... _ _ _...-. _ -- . . /. : i a R I , STA ~ _ _ .. _ . _...... NAME, ADDRESS 81NJURIES OF PERSONS I a NVOLVED 'CODES 1 - 2 3 4 5 6 OCCUPANTS /WITNESSES j115t;, p^~N fu,ASA,ME f o ii - sn AGe lwr - ' o TI "' x s~R urc] mR. ~~• NAMEIbNA~b C Rlsrl~as _ ~ b S-ISSS _... 'x I - Aenlss ~toU7r PT. NArw p 5 o f nY AM e. ^ u'tK' ^ ""~.. ^ Ra' ^ C3NSE p nAml ... _. ~ ApOR151 NA1W d v v MOVID 1vOM ^ AMB. ^ u RE ^ oI , ^ rNi ^ iK~ p hMl - ~ A nwfss IHi'EiXa[a xu eY ^AMe ^'K "':' ^Ctinu ^RX ^n. nr , X ~GAt IX p ~ V.T-[ SCr50 Osl~ ICI DISRAICMG ]n0av2 ~Eo 11YED DAl`//_~~ ].DO WS FF//DD_ AMVpyfDeV I DAL[ }r} .~ P ~ ~ iT { I ~~i ~.~ FC ~~. f f ~"~ . ~ ~' : t ~4 3~ # '1 ~~yy C ~ 1 1 ~~ T~. A p p r il z„ ~ ~' ~ i [ a r `~ `.t a, ' ~~I R ~~ 1 M l 1~ w] ~ ] } a~I tTR ~ . , ~~?~~' ~ i~ !~, 1 ~~ n 4 _ ~; J ~. ~~ f {,. ~~ ~ ~ E L~ 3 r f \ ~ r `. I cir `~ "~ , ~r ~ ~,R~;~ ..~ f~.4fwa v `I i G ; PRIVATE WAY ~ . , ~(O n nmf counrr ~~ ~Ir CIIY NO. i I=.~~! vlx w Nis wlp gut I. r (US[a.W NOU9 ` ~ . . . 4 1 HW _ ^f ~IN C1v Oe IOWN gMf6N0.0 SIR(LIORr GNWAr 5 RAl' RWif OR REf /~ 1 iNitR, <1MGfvnIH^55Rfft^OV ROAD i `~T~\q ~N ` L C Q`~ja00 NON iNNRSF[iIO N PP il% O MRf POST 4 OiS1ANC 6D4F i RiFRF .CR055519[fIN NfA4[Sr Mlff 5`^~~ S 5 FEt ~ ~~„~' l ' MlES 5 f W ACCIOENI R IA .ALA MiA p(,'E «[i OP ~ \ MILEAGE owSroN wvdvm~ uwt4nr: CODE C ~ ~ /' tO1M NO NO.R EIfp~NO. INIURfD~ ^SnlllgGf ^NIi6RD wNU Drw / INfER " f¢uu ,~- FN 11 N 3 M / l5 OIOSSSIRFfTOR eCAD P VFHIClfS O ROt4RIY DAMAGE ONLY ^ p[5 ^ V[dC 1aa ~//O t1ED L Q OB iSiRUCRfHAMFOf OBIfC1 StRUCR NRp OW SNAMFI f51 DnMfj.GF_ S«CSSI COdNG USE f~ L/ ` :.~ i`Q - ~l.t J f~iC ~~ UNITNO.I DvvE4snAMf IASf UNIT NO.4 ^VEHICIE ^PEDESTRIAN ..^ PEDALCYCLIST 1 a p ' ' ~ RR unER s nAMf. vem Apo4fss iREE1 gDORf55 ~ 00 re 51' ir sraf xIP COOL P oNf w D r . srA E ~a Lc,CK W 4E33 73~ eoL3 R `"D DR BR'S LICENSE NO. A A ~ , ~ .IAI)/1O G- G~ 35riLt u M M 2 I 4 5 UCINSf NO. w i 4 Is Alf DAtF Oi BIRH wo ~ r4 ~ xt B CUPAiroN f 6 PHOnf N M 7 ~ i. ~' FYFS GHt iflGHl E d:CUPAI de I~d MNAMf l PHONf NO. FYFS IGHt Efro '~. ~Y C .~ BM 17D Go R 4 ... „ . HECK (.~ vfH of ASANAiMPi r oPANOrNEeu ^CHECK (,r) CODES~H 7 n iN of ASAN fMVlior«aANdHfanl lee wr E~ 5 ' A s"O CODES ~ * a f , '~' o 9 xis 5 1x y s I rro z . r • a> ~~yo,.DM ^ ^ C ~ R.II ^ MHR..%E ^ ~,y ~ ^ r"b'mP °,;.,. p Aw.,l el ^..° vEH. F ^ iSHf4 AR EIpOpGF CNfv :K ; ~ ` MP X l . r . U .v. l fIIDgR1.fAVA) 51rlE It D4..Cdrv1 ( ! A,~EI ~{ ~' ~ r R E ( t VAl -crc\ L'vl i o 2~2 E IR R /Rpw CEN Srgif il[4 RAiE NO. StAff H VEH.CIX R TFi$Ff7~ ` o p nHie l fluNrinurgN NO ~ In ae DEHlu A u .° 09 I ~ ~ U 1 PFd5R4fD0 IASi {1451 IDMf PrgNf HO O E i iF«D OWi1fR: twit {1451 MiDgf f fIJ'C.Yi l ADpe[55O OWN[R W wNF9 `~z. E I N AME IADDR63p INS Non U4ANC[CO dIAQNi E '~TIiT-_~~~. R as D4x.Gf ARfA "f. we ~w w °.x',`a".°.., 4AMACrDARu Ci eww !~ eHARGE i ~lo M A 5 I IC~OTfO~ ~^v es g A mL ^ yI-~I RIAWN[D 4rDP N ^RIMMN[D ESt DAMUGE t _ ~ ^AW 8:,. ^ 1 f~ :wv°er. l"/~tJ tQ, ~'. ^ewTr°er. f DIAGRAM OF COLL ISION: lu ~ E eYAreR~1H DESCRIPTION OF COUISION: IV5[SNREMfNfAl sllfn lr NtasuRrf -Elstsi~0 ~ s~ ~^ ~~~'1P ax- Y3.yf ~GL ~~ ' yh_ ~_LtJ,S c~ `} r NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + OCCUPANTS/WITNESSES Il~ia ' m ` : A is COD^ _ ~ 9 4 S ¢ o A . d+M N Nqw S cf uws DtvtR' sir _9~ a v- RfsiR utct N N 5 A _.-_.-_..~__.~ App4lss .._--.-._---_-- iTU4 d' --_ N 1 ° c~ OvIO IRON . 'n YM+1er ^une pica%f ^co.f^N ^: . .p ~_ .. __.~.. _..._,.__._.___ ._.._ ~__ ~_~.__~ _._ ___ 1A NAVIl4. N. ° eApG1 oR wf u1N1er. ^.Me ^ ~^t' ^i'wlr. ^ H. ^". r x ~Ty vcC~ W /~l ~cwp ~83riO ((jj a4r~~ Am ovlD er Dqn " H TT77K7 U~ .. ,t ~: E[RE@~P'~ ~ .sRM++RwR C't1ls ~'~': u.~f A~lT; i~ fb. x ~ V1 ;. ~t: '~ 3~ ~~ . 28 y, ~. ~~ ~~ ,~," - +~~F ~ . ~. - d"' <. ,~~§a s EPORT IpI TRAFFI(:WAVO ~~~ POLICE TRAFFIC COLLISION WIICF COM%MNl N a I' ~ PRIVATE WAV ~ r wrfo eaus~ N o•r eoe4 N y wr ,e, sy lusf].wwo1.,41 T'~ couNfYrp. / Cn ^ wA fw o 2t oA/ J ..- L euqu ~ri ~F ~~N CIrvO O'wN 4mF8NO Of srRFEIOgwG v iR l3 M gOU1EOR 1 SE ON .~ mots Os ^w $i o. v ON ~ Ih FRSfCr rvG VnrwSRF O4 qp•D N }}ICr ON N ~.~ rf.. Sz7~ ..n ' // iwffN~ ~Lt...~SERFEre r•[f3 Peffl% f0. Ml1f 8033 /J 2.io 2 Oi3rANCE 60 uEMr ONE OM4FEF4tN , ES 5 F CYOSSSrREf304 NEneF31m tf 403r s I 3VFr N Of AC DENT M IEAGE oDE q R DIAG4AM p•rA c COEI`O lF0 OE E NO. NIU4F0~ ^SVIIAGF ^wr8 O3•l NO ~ •+.r.Dttpr" Cs \Ew <lf3 ~ ~ RgIr DPM•GF JNIY ^ p S~ ^vFa< %RD N CI Rkf3 RgOAp04 gFEF4fNCE IMF/q Cl3 CgO333TR FIOeeOAp ~ D ]D •/~ 7 F l3fD F OB1FCi srRUCUIN•mE Of 00 (C 5 UC AND OwN[R'3 N•MFI S3.DANAGE y SS~ 3PEC1•t COOING U3E 5 3 UNIT NO 1 UNIT N0.7 OR V[v~3 NAMf I•Sr ~ VEHICLE ^ PEDESTRIAN ^ PEOALCVGl15T ~' . RSr m.iODIE • q vt4 3 NAMES I IASr ilq I n~ SlRefl p0U4t53 ~~ F Fr ADO4f33 c' c oD F woNE NO D ~ r SIAfE I C Q ~J / Q 87YS R NE C~f(NSCNO 3r•IE ~~•V 4I\ O ~ `~~lV/I' 04f f Mo o•B !n ~ ~ V I v lCENSE NO. Arf E •lfw ORln Atl. L OCCURg310N AMf 64wpNE NO Fvfs WFIGwt [ LAEoA. G E R OC<Ugnf ON MN0.uF6 RrbNE NO. EYfS WE Gni rf Gnr CHECK(/) 3w Cie AS aN frD%aortf of nNOrwtq •t ^ CHECK I/) Ew ei[•s •N FMNOrfFM ANa l i v ODES- ^ ~ : "` s I ec a ; ,N„ w .: ;;° % ~~ + rw q CODES ' ` '° "' ~` ~ ~ 2 N , .. Or ~ c - D c si • is 5 u e l " ICr N r„" 7w > . IN,tuRES £+t. NS- R ~ ;t~:e • ~o .M„,.»<E ^ bt• ^.a.,l °K;; a r.. ,. vln reAR " .f D000e +ro, ^ w ~~I ^ ~v pov ~ u K' ^ zs.R. ^ c~ ^ ;.' KIF ~ , ~Cwfvl f~•Rf NOV%I .F~1304 ONV.I ~ YA J s E fnR w u I nFV.I MODEL IDA41 NOVw1 I vl °D^+ , ~ ri an u al~slRUrF s or H ~ ~p .ULN Z vtw e e,DeNrf u3oN O e' 3q•Rwn•rzNO su / Wie I C vFweaoR N l • Il .3 ~ ` N ~ L ew aelDFNrtu NN O 3' l I I I ~ I ~ ~ I ~ I , ~ 4f00Wr+EV IA r I143r mi001f EO / PNONf NO O p 4 . , , IFRF Ow E4. t FI sr NO q l M V I] AIW S30. O.wt• W . q O L N wN E ADEwusm •Nn co ~t • ~r. u N N Du••GF •ql• ~ u "^ rAMAeeD~Aqu erD.~ Cw•eG! Cn••GF r r ro o. .. ' ~~Ot ^;?v ~(N RF•u,N[D to o ~ Neo E ^~glAV O a FSr O •MAGf .. a. jwyN~ • ^:w:r ev f ~ 18 RIMN•I INDe•re NO•rn DIAGRAM OF COlUSION; 3uftu AGSS•AYI er ••vOW ` DESCRIPTION OF COll1510N Iuse,u4nFMf rESweer lr recess rl ~ ~ _. ... ... t'~/i~.s E'A1TBo+.N~D._!./.t~.w.uas,GoFWi,. Mif. . ~ROVt OFPt. R~cor S~Nwa.os4 4~ ~~+Ay__ _ ~ ... SrR..a.r, TRls ,Obo fS/u~, ,erar~,w. otir+o S~ > Q ___. .. \ _ _, _ . NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED 'CODES I 2 9 a 5 6 OCCUPANTSiWITNESSES '3°r':i~o^:o.`.:i~i:~ ml ii~ • sr% •GI r•rus '";'" vtsu ~~~ Ena " , • ~ ~ u :n" Vw.., ;•3 or glmorrD r4oM~ ^~: .'~<r •Me ~ r ^ : •° c+t13 '~ 3.~'' • n . ~ ' ' - ~-c~~ -rn...s~v~_~!rLisP O~3 ~'r~~sE~ - wy Y-S . _3q ~ ~r,!~ f. 'R 'C , 1~.: F ~ ~ r 'f~a~ 'f b..~ ,,'d ~~. ,~; "~' ~ ~ ~ C 1~ .~1 '4 : ; r ~~ . z .~ `'F 1 ~W ~~ a p l ~. ,r' ~i Vin? ", ~ ~ :; ~ I ~. ~ ~ ~ r~y. _ ~`' ~~ ~ ~ ~ ~ ,.- ~ u.~3 I' q °~ , ~ ~~~ POLICE TRAFFIC COLLISION REPORT ~TRAFf~CwA4 V paICF COM0..UNIN BFR - VRIVATE WA Y on o.caus N .oi< 1 umE couN _ ~ .e I ~IISc ; '. IUSf~fOON 1 g„R 1~c'~F~~SvN c°u rr /~ 4a c°r NO. [liwA ^UgW1 Rµ ~ry ~ ~N Ctv)OR tOywN f6N/0~0/} ff109 M~G~N~E~~~ 1 MIfS ~S ^w ~0E SCL C.O ON 1C-l CY~ ~h.\\~- iCl LL A~ I RWIf OA t-RtfEC C[ ~s./v I f9EFCt NGW iN. StRFft O4 ROAD NOrv rvN45ECi ON BF[WfEN ~~ iCTT..r 5t9fftA ~ StREEI 99tf1% f MIIF VOSt '/ ~~~'}A \ DiStANCF60 REM1 NEFOMR EFPEN F C9O$$SIRFFt 09 n(A9FSiM lF 905 ACCIDENT ~ DIAGRAM DATA R S 5 E w 0i ~ ~~^~ ~ MILEAGE •° I iFFt ODE v~••` M GGU SGN NVOIVfD SEVFR rr~ nigEfi RROAp04 H[E NCE total NO 04111F0~NO. NNR(p~ ^Sp llAGf ^ntq PUN wNOelorw N Nt[ CIS CROnSS ET 091lOID ~ ] b V[NKltS ~J ~ RORFRIVOMAAGE OrvIY ^ 9ES It ^Sf~iCIF 8d2O 00JECt S19uCA1NAMFOi ODJFCt 519lJCA,WDOwrN9'S NUAEI f5i 0NAAGE SRCW COO NG USE 3 UNIT NO. I UNIT N0.1 (] VEHICLE ^ VEDESTRIAN ^ REDALCYCLIST v[RSNAMF. USt EIPS[ I OEE 09tvEP'e NAME M ]' : USi N4 I OlE Fk~S 1LWr~E,I. I Z Ste[ ~P(~]f(55y ~ /~ Et U~~ ~. F_EC. E Clty SIAt I FEI AD09fe5 [l[lyy_ G cc ~~ yy ON[}J ~U•1 *E ~L~ ul~ IV.EAD R J D9 R v latf IIRC Df NF NO. 5 ~". rvEesucENSEry Hc6~,~Ct33'-IOCy. wA t M X18 ~° I ~ IV 951 Cfrv5E NO. UiE MDDIt`DA~RRI.. 9 OCCUVatION Fb MONF rvO, EvfS WFIGNt NE Gnt R E occlnaNGN FIRM NAME 69nONF NO. fvfl VIEIGHt NFIONt Z GOO . S 4?&: t~ '7 R . CHECK (.~ FNICI[as:ry rM F[oi a.~orN[e"1 K.R l CODES -* ~~ °1 S E <I ~., e i °ir. r ~. ' {'° o ^CHECK (/) MM [NKlE a3 AN fMRLOVF[Oi ANOiwF9Al CODES - t a ~:iy E S°: 5 u e~ 1 N H~ .9 l ~~ Z ry D o, a~Z.o ~ ~t~ ° a..DM o ..w1.N[E ^ VFN rfA4 AN FIDODGF.CNEV 1 ~ ^ zs.4. m FIIDARt.MJVAI c i o ~Dr lvlf ,9~NF ^ A. 1 0 ~« ^ ~seR. ^ tt ^ r ~~ K" ' . ~ FCc -~Z l]09.~COrvV.1 `,T E Y vFA4 1 NEV.1 N.OOEl10AP}.NOVAI 1 .~ V.1 e0v. x 7 C. v CIXO9 y9Utf F90.AtF Np. StAIF 51 [ H vtn.C OR ln.E t A I 6~ IBC.. C[ VJ1~t I l q ~ '3 v[NKIf IpEN1IlIUlION NO. iGl ~o F'I 1 IC-~i5 ~ IA3! 1 1 I i 1 1 1 R C ~ fNICIf IDEN[IfI A ~~ I a I f I [GISReFOOwrvtq~ USi Si MDDIE 9NOrv[NO. HRP.S ~~ O R I N9Fp wryfq. IASt 1I Si MI aE Pn F .D ADD9f5; [9 W A s o«NER- I ~ Yhi - I!~ GC ~ N . . aM(aAOD9es m;u9•..Kf co oR AGEryr a E I u j ~ gDAM.GEO A9EA ~ ry ~6 '. o,Er,<rp~u CwARGE ItAMAG[D MEA ~ CNA9Gf I I .'nC f f511DAMAGI ~ D9I ~{N gIMAIN[D ~ ~awAYN ^R(MUNID tSarDAMAGf E \ s ° ° O] , , L °a°r,° . s W nr F. ~ O:°vJ:`r°er s A I e DIAGRAM OF N_ DCANN DESCRIRTION OF COLLISION: 1[bf 5U9 e F ISNf[I I[Ntt[55A9r1 r ~- tvr[usiJ~ 1 erA-~ . _- _ ~ . _ ~~ ~TV -t -~ a ~- i ~t t 1 - ~ ~s ~ I ~ _ i - -- T V ~cl.~- _.; --- £~A1 S~~cM _ 1~tLP~xCr ~. I ItniN"k ~. j.. I ~ ~ 41LDfLt ~~i .-~Lll1~.YL ~"'f'r1Z0 'tY1~__. I. I . r i j . b , ~ .. 1- .. ~ ~ I I 1 i ~i2-ccrt~' 'rxcci~z=ci i I I I `~O- --- ---__ ~ _ - ----.__._ _.___. I L_,_., I ~. _t_ I-i i I ~ ~ ____ -- - - __.. _..__ -- --- I I! I I I I I I ... _ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED "CODES I 2 9 4 5 6 ~ OCCUPANTS /WITNESSES '[[ia :pan(i ~:i.~+(AU AMI ii~ , si+ eci urn; *,;,1° .A°"~ ~ ~- xsn -Hari :;e; ~ . _... Dn.nS AMI u9roi f oan. ^ AM n O<"t1' [] "' . O:. ^ ]D Np ~. DOtl[ 9 or uE EAwnD[.aA ~..Me ~sKl^m . ~h ~": a ~ i ' (14 cf A>t'K. E NA I 9f OF Nn.91s ' unn e. E"M ^•Mn '• V ^ ~e 11 ^[w . ~ ~i ^ ~i ~ ;o~~ .y [%aoEEao•r Eac D DuIeERIroO ov[Dn .9 I~ r DAN J ips u' L \`~~I Co n D X ~~~~k~`1 ~ • 4 r _ - • ,.« , 4 .t• m ,~ - ~ ~ :~: n bY&Td~ ,_. ..~. 8., sl'9T wS ~w ~ ~~ ~m-~~ ...._ I__.. ar • x~ ~ ~.~ . i ~.~ ~~ • 7 l~ t a ~ s T _ 1 ~ I ~PI[r1WlM1'Uk'tfib'7P M1~•,M ~ '~.~(. Yti ~~ ,~[i ~,; s ~ I • I 'A ~.1 )1.lu '+r ( ~' 1 ' ~ YJ 1 T~ 4. ~ , N 1 ~~ 1 '. . . v ~ ~ T 5 I 4 P z _ - .~'i . ~ _ ~l a , 1~ 14 -9 [ I. l t.E ., }. ! y 1 ~V. ~~4 !i., I ~ F ~~Yr s • ~~ ~ vp 2 '1 `~ \ro~~ POLICE TRAFFIC COLLISION REPORT L~9 TRAF'/.`•WaQ roLlcECOMn,vNr eEF DMEOpcau N p. rmE couNr ' - PRIVATE WAV v - ' ( SF~I.OD HOUg1 couNn NO arr NO. ^PUPoAN Y/ O ` AMF 6NO.OP SIgfFi 09 nrGnWAY I ^N ^f ^ C~O•R~ 3 3 Cl5 9W EE OR 51 r ~ ' MlES ® ^ ~O ~ L ,V.A1 oN Nf95fCi NG N+rn. $IPEfr UR 90A0 NI F45EC1 ONr ~~- 9Cs-~7Q 4 C BFRYEfN P fG SrgFFr t DrS fA N Cf U4E r N 40m vFFFeF .CROSS Sr4fF109 NFARfSrm LE V05r `± 1 ~Y NGVy 1 Stv[Ei PRfiI% MILE POit ~ / F,p r •~ ~ 1 W MlFS 5 f (~ ^_ ~ p(Er Op `_ `~~ ACCIOENI MILEAGE CODE DIMgAM MfA COILSON NvOlVfO. SEVER rV fOrrU NO n OKDFD_~NO NIU4E0 ± ^YLiAGF f ^n wNOx9iw N S ND I F9EE rlNG SiREE OR DO N[NRErf(F IN INr~ BLS CR0155 R[F TOR RO M R O Vfn CLFS W ^p40PEgtY DAMAGE ONIY ^9ES~LifD 00JfCr 0r9KKINAME OP OBJFCr 1r9UCK Ylp OWNER'S NAMEI ^SEaCNF ESi. DAMAGE / n / (/ C96 ~L0~. SPfCUI CODING ISE I- UNIT NO. I 3 RIVER'S NAMf~ USr N4Sr mrDOl! UNITN0.7 p9rvfR'S NAME: ^ VEHICLE ^ PEDESTRIAN ^ pEDALCYCl15T USr rv MI IXE ~~ SrRfft M041 "Z GrY S 41P000f vnONE Np. r9Ni ADOgF55 D Irr SIAIE I `( OgrvFRSt CENSFN R IP COOF lgrvf NO. ,igrE E M Of0 n 4 I rvER t FNSf NO AtE SE% DAIF ofB Rr ~ I I 4 Y4 e OCCUPAr10Pf MN MONf NO. EVES wFIGMr EtIGNI E OCCUVgrrON iIRM NAME 6 PfgNE NO i I R . EYES IGHi IGM r ^ CHECK(/) vfn CEE SS nN a aL pio O ~o CH PM vfF p Ar rnE CODES-* ~ a 5 e e s,°,~n°K' ^ ECK(/) n[AS AN DAnorFEaafomEwAL CODES - * ] a,is~ VE 5 'D + a~ ; Exclro e is %!~ o .DM ^ .,.N,u.,Ke ^ A~KE ^ E5pn9 ^ ~~,~~~ ^ u vfn YU9 KE (DOOGf~MFV.I mOOFl IDa4r NOVAI $IYN 409 CONV ^ Aq E ^ K'4' K. ^ ~d':rE ^ H ^ "; ~,. C1f ~~ . 1 I O t~A ~ `SW E ruR K r y. R,1 I nV.l mOIXl10ARi.NOVg1 l D p vDM ~ , aoq DcE sf PEA E N 4AI F9 NAIE NO. SIAM ( H vFN.C OR A m B LE1J 3~ W Pc ( II vfnlClF DfNi IIUIpN NJ. FI X115,11-1 1 1 IZI.71. l 5 5 ~ ~ I I 4EGISN4FDOWNER USi N95r MrDIXf »qNF Np i vfn OE MNrP ~ 9GISNRfDOWNFR N ~ ~ I I ~ ~ Oll'CS K`t11 L L Cf : lASr {IgSr m10IXE N ~ . . D A W q n~ ~ (T^ Z. ~~ ~0 1~'PI~G~JC_1L- ~ ' ~'~~.l.1f~} K E WNFR .Zn NAMU ADDgessarEfwRANee <o waaNr NON ~ DAMAGED NflA p ~~•~ R IN D "" V .r " CnA GE ~~ wG u~ CnARG[ w<awv gAMAGID ~U O ES~ A ~ rrEN ^ ^ Em.uwD s iEiw o ^ ~wwN ^gEMAwm Iwr.Dw.P Es~DAmacf ~ S e er Z~C_ " ^ row[D s 10 eortD~ le DIAGRAM OF C041510N: lu [ INp CAN~ 'T't'1 -I-I ~r~,r ('EC.{ss+nY + e NOgfn pESCRIPTI .. ON OF COLLISION: _. _~ lu5[suprNMe LSRN _... NECFSSAgYI e `J ~ I -1-~ ~..I I ~. -- ~--_ -~ ~ ^ _ t • . I , . r I S , .` ~ ... .i t c aCC1.~E-~ _ L~ ,ST ~ f~"-- alb b1__ ~ Q ,---- -3~ cL Sl t ~ L i_ .._G . . --. . ~fs45~Q.~. ~.ll„_ _ ___ ._. 19 ._ _ _._ _._ __. _ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED `CODES 1 - 2 3 4 OCCUPANTS /WITNESSES a san[mEN+u s4 fOl App~NOrUI NAM ' Lrt E51 SEK AGI~ AfUS i "~.%p1R 'U.1' ' "rlf~' S 6 RISie [J(CI 4rf• S cwt y4uol.x~ Opl{ rY1 - - ;~ L 9 .._- fN - " - _ ~ e ~KAC-~ U r. ~ SCENI:Y ~^•M 9 ^CII~IE ^ ~n , ^^ ^: b .. ,DD S ~ p Ar 4 'Y S ~J N 101 OR ~AwvID NOM ^Am ^rK,KI ^'o • ^ .i ^ ri Y Q , Ke E N ~R ` r _ f X y L.GU~:n..,vl4,... :rau4 " '°; N ' f : fNf"ev ^Me ^n„t'^7,;:.1 ^::'~.•.. ~ 2 ~ N ` • If. t{ rID I W vE ravl v10er DArI $ Z~ ~~S' S u \U ;0. G2 W` ,~ .~ 3•'Lb 54 3~ ~~ ~ L r, r•l -.A ,1Y1° Sh4" "YN{~, .Jx+'K4+R .. ~~II~ .'f iJ,r.4n~ - f" Jrp!i //MLV) Jqk' v~h - .., k~ ~~yyEE '.NV~ ~5 Cam' r e~' vi .. - . ,.,.._i 1 +' ~ 3' ~ ;"r ;; ~at V "~" ~ ,' ~ ' L 1 'r~ ~~y~aQ~{r_ ' •,+ ak. w C.. <~~ 7 ~~ 4. e C p ... -~~ [~~ - ~ L , ~ v. xi q ~ : y f !} .eti F ':~ "3: I ~N~Q { d .YL . ~~ - 4 . ~i] ~ r A~ r "",~ Yfa+ - f 9 a PE IE ~ !1 q ^^i/ti r Fit `t' ~~1 ~r ~ I' ~ 4,~ *w L t ('ti ~ j F ~ i 4 I f K_' z I~ ,+ I ~ ;~ r ~~ ~ L , ~~ ~1~l~ F r't f T i'~ i~ ~ F r 5 ,rS2'~jn .ql' r "~ I + lu"`~~°S! k~ . J rl~` ~ ~ r~~t~~, ~ '~-:L. N, ~ F M, . ' ..___. _....__ __--_..-- __-_. _. _-_ _..__- _~ __._ ._f.~.-_~ ~ ~__._ lii ~.. ~~` . I ^~" CrION IRON Rfif4fNfC40555,NFF, OR NfARFSiMIf P M f5 s f W. Oi M, Pf ~ 30o iffy COIUSION NvIXVFD. Sfvf 411Y. N ]OIAI NO. ~ O4llfD ~ NO INJU4Fp~ a VFH<IFS ~RROi44rv0AMAGf ONIY (". OBIFCr Sr4UC41NAME Oi OBJlC, SIRUC4 qNp OWNERS NAMfl `, D S4llAOf ^gfSUlrfD ~~~~~~ ACCIDENT RAMP MIIEAGF 4CODN ^HU64UN tpl. IN °„Hp4 s ^SfgFN ,I vfH CIF 7 FSr DAMAG[ S4fC AI RA f MMIA INIf4 %u CROSSSI4(f104Rf~F~N OQ RNff[N(Y yD COO NG USF ,~~ ~ %•Yf. 14 ~+w}RFE L .~ r ~ . ~ "g~g b! --: UNIT NO.I E lu ~..~.. ., ... .. z _._ -_______. _. ~ ~ ~ .. LR • ~ ~• ( i~i ' . { J '. .~c. ~~9 7 E'k 5 P ~ . ~ "a- „. ~1 ~~ i .sue ° ~~~ ApD4fs A S f, a ' yy~_... ~D A~ C~ i " ! Y o RA IN IE.(L N, °z srefn ADD ss '~-D BEAVER VALL.E, RD' serf zIR<ou r oNf NO D oRT LvDLCI~J WA• 98atos 37-2~7[~ a CN(MACUm WA. D 732 z I4slclNSf NO. p H I ~ S]A,F fX A r N £,w~LP[.,~(y,f.s4-z NE. w A 4 pce u 4Ar oN ~ HONE NO. '~rr cfrJSf NO. A t DAZE F oe os 3l'o ~ No ~J f. FX os !"I '' . FYFS E ~ `, °gS >•1' . e..r F- 2 Gx-N 1 WoSPETAL CHECK «r eH, occu=ANON M 6 RHONE NO. EYES WEIGHr IfiD ~ l3 Sc7 R !JS W F AMf ~ I ~ (.~ f«af AS aN fmnor FOf AN.i,«ie Al CHECK (~) CODEE-* ~ ~M°' iH Cif ASAN VAxonf aAN r ~ I.ss ~ "' '~ 5 , oN ( e y D~o°c.c ' CODES - * "' ° RM ,~~~ ' ~ N cfs NON E ] - 3 ~ d ~. ~ S N ~ 6 s"`p ~:Ys ,~» ,eD« _ ~"°~opN _^.Y4e,AHfl ^u6" ^~b:~,4 IIDOCGf~f«F V I MWFI DAe, NO ON 1 N I4 ; ^~.~~~ ~v:e c; °,~9 ^,.4D f0<g fl ppbl„ ^.;~KIE >. `~ ° ° p _ . I VAI SrYIFI]De CONVI f ,.I e4.i.R vAl 4!0~ ' 81 'mDc~, ARI~.S ° i~ 2-DR E logR cuEYf ~ NS[ f o =r A f4RArf NO S,A,f F'I v CIXOR wa -_ I l I N . ItiRP K.E. 1l~S c g~~ c.,hla ~,s~ wA. _. of«CflpfN,HC AIGNNO 18 3 S ~( ~fl$58c 4fesn4fpowNfe: us, 14sr Mlp YEH Dwr i 5 t4o395~13(c3NggK3982~g- plf HpNf NO O R I D NfR. fa las e ~ rrN NEWf,ca_ e,oR4S5-PATS L{87-28']x} w vDD A1, CE. M 3a-+~y1}08 D DD4fssa oW*,la SAML " s f4 SClY1~ aew4usa INSURANCE co w"clNr 'Z KE.M PE.rt 1 NS . E _ a NoN £, N W° s I E I'fpt~ wy ~~ <•{7 YG//ICLE.P4t Was NoRTNBDUUp pN RWAy DR\VE, ANA WAS PASSING V~FIte,LG ~ oN LE.~', ~HIU-E ~D, nv1Ae. A EE,FT-61gND 7U~W ,- INTD agao Rtaopy DRavE,. VEfJIt:tE'0~ ~. ~ - - - - IJtT a'vEUU~. ~~ Lu ~.Ef'T REA2 fENDE.Q. d X ~#N j R r.. Y ~J~ ~'. ~ <p . 4Y' p ~a `~ CODES I - Z ~ 4 S 6 SNt AG! S,A,US_` n 413]4. flh ~. EM prv~~AM! Q [SKI ~ H , Q H ^ itiiiv ~. VOVIDIRON^~p ~rpAl ^«I~ 4OH ^rii p Ira.'. MnAMR n;r:f'n:!,:..nr.r n~,~._ _. I, L ~` A D kV ~i~f - N 33 L '~ f ~'ftl AIJ in ~ ~ ~~~fdKt•'h. ~: f _ 1 "~ l~ ~ ~yp~'. 1 ~ ]4~ ~ J,~tt[ ~ I 1Y .• r , ~{ ryN d>~ z$4~EDi(ns` r 1 ~ "~i ~ 1~4., :~'. I 1 ~ 1, ~J t ` ` 1 7 "N t ~ ~' ~ Y Y J'l + 3 l1 ~' I ` ' } s i .r -; ' - - - ' ~ 1a j Lr 1z ~ r: t 4 Y1 ~ f 1 t ~~ - I ~'~ "' ' _ ~ ~'r Y .. -, ~ ~- ~ .. - % ^ ~ " ...E~~ t E ~ro `L~ '. 5~ Y R ~i', ~ f~9W ~ 'S4ya'~§ ~ }M.a+~';Jfif~f ~R ~h_~ ~ ~t4n'TR~ Di'S9't2.n1~i.,,,~~~s'M4 ~'' .:-u~tExv - ~~ _ , ~. STATE OF WA TON 'qGE , Dr L O WSVISR19fV 1.901 N POLICE TRAFFIC COLLISION REPORT ®TRAFFICWAY o. rtxlcf coMRFNNS E ' '~.. _~'~ I ~ PRIVATE WAY AFf p{CO14 COI IME COUNEV .. ro w'r u. ~ ,y yl ( IUSE,F00 HOUel x Se.. ~..T~ ~M F ,•• ~+ NU ne[R 8 COUNTY NO. CIlY rvO. ' FMWA ~ _ " ~ L7 ..RRgq h ~ ~/ GN ~F G ~ CvOR rO'nN tLOOr SreEEl09 NIGNWAY %,It~GS ^W ~~ or:F~q ~ ^uaenN ~ t~~ I% REiUIFOR feEF RAl I G -~ G ~~,s 3 ~ ~ I T y ~~ rFRSECI NG srREt a RpgD ON tRSF< O ~ N t T.1NDL ~I~SOSt ~ 7 r~i_ CC OSI%NCF OeEMI ON EepMa EE4FNCF. <aOSSSEefEl O4 NF44 SfRFFt~I- I9EFt 9sz ~a RRffI% f Mrtf RpSf u /S.~ ~' y~ I k , ,~ ' ~ r ~l: I ~~ ~ t5 5 F W .~- Et Fr OE ~ <OIUS ON NVOlvtO N SfvER Er~ rOfgl NO OxIEFD~~NO. NIURFD I GSV IIgGE ACCIpENi NAMR MCODE E ^^re9 N wuMrlcvi0~^ N e DuG9AM OAIA %4D Irv EI ST4t RgOAp Cq RUf4ENC 3 y Y% o ~ ~i ` E~. ' ~~'' v~~/. aV[wC1[5 I~ G090vf9EV DAMAGE ONIV OehCI SrRVCxINAMf OF OeIFCr SIeUCx ANpOWNtR'S NAMfI GiES~lEEO qQ SEIXEN ^vFN CIE FSr DAMAOF S F INfFIy CI.S CtED555flFFTOR PoAO // S~~J ~Q _ I : Y„ ' I ~ ~' ~Ed~,. UNITNO.I RCp4 COOING USf UNIT NO 4 _- . •a ; ~ +I r vla sN+MF. usI E RS Oplf . ^VEHI ' CLE []PEDESTRIAN [I PEDALCYCLIST I S ~ Y I ER S rvAMf: 5f t _ - 5 tFt A0paE55 ]~ T.~. SrRfF O0Rf55 ` ~ ~ d ' _.~iay~. O v SfAIE (Ia COO[ RNONf NO D Irr ~'• . w~ D4vt45UCtN rv0. SATE l% OB4N R I Iv CE IAtf tIRC R NO IZ .,''yy t ~~~ ^~.lRi MOI o+ I ra l HSFI V AIE PATE OE B19IN ,wl' I 0 I r4 ryJt S~ ° ' ~ B OCCURAI CR! AMF 6vN ENO. trfi GNr rE GNr E CCCURANpJ S N NAMF I ' _ 6 vNONf NO Fv[s wEIGHI r41GNi ~ j~ ~ A; r ~I ~ ^ CHECK (~ vFN nE ARSnrv FM o O ` R "` ~~ n EFaAN ^CHECK (/) CODES-~ ] ~ I rNEEC~ vEN I 4 ,~. . ,;, .,. s r C sDrox.cyL~ CODES -* ~ 4iN°. E AS AN EMnovFF OE DrN AE p ~ rcu . p S E T i s ~ ~ IN LO FS M , v ~ A s n % {C lI 0 t aD t „ '3 T71 V[N rFA9 MA f IDODOF CNEV 1 MGOEI Ip+91 E+DVA) ilrlf 1 <ONV sN Q ~ ~ I ^ Cbrir. Q M Y ii ^ ri~r sr l M:. n4y,. ~ .I - S v N oe v FNx RUIN IAEG L` P w 9A l[4 RArf NO. srgtF I S FA9 F N E H vtN.CaoR IiZFF5T7lZT fv .l Dfl IDA9E NOVAI IRD ~ E 5A '~~ '?„ y ~, ': -'~- tvA O'Rv 8 ~~~ I l A AI , ~,,~ NrrIGAE 'F z aaT C INN vtN CIF DtNIIN L ~° ~ : S~3tSIX,D.EISio13:g.4;I I I i RlcyrtefoowNfR uI NRSr uDOle vwNE NO O R sr vfoaw.IeR. ~ ! I 1 I ~ ! I o , ADORessaowrvw W ~ L,. 2 ~ R N • ~I ` `. u r ~ .~ ~ a - ..wE%.D°rrssalNSUe%NCtco ofNl _- ~ E ~ R I D ~T l f~. ~; T ~ ` ~v~ % u ~~ DAMA4lD+R{+ ~~ N ~ ~ ,Y I {{~~ u~k ~nsCYE~ ~~ '~ I~p'e'~I'~S f51f IDwMg4~ CrvMU Crv Of ~oe~vru .~ ..._ ~~ ..emu ~1Jc~ lF .. - NFU I J -~ QI• Ow "•~~^ Ur {. SUN IUS Flf {NIµ SN[[E fNfC[SSA9YI - . e ; - L r r } - ~ r V EHlC4E_'~ L__~PL$T~OWa4 OeJ. ~LA6CJaFt Rp ~__ _ { ~ ' ~ - ' ~ ~ =.i, ~ I ~ RAN APF . ~A^Dww~ ON _ LL-F.t'._$\4E O_F_gt, ... ~ -niAVE~p.A\tCtt E ~iAN1cFOR_.1S9.L. .._.__ v Y '' . ~ ~•< ~ ~ j. DR~~EtI. STnTEO~liAT.SKE. WVOIOE~ A DEER ~, I ~~J. RON4wPq~ . ._ _._ F'LIuGLCR.RD.-' _. _. _ 18i I .... , _.., ... _. I, ~ - NAME, ADDRESS B INJURIES OF PERSONS INVOLVED '' CODES I ~ 3 4 5 6 '" OCCUPANTS/WITNESSES'sES°'Rlur.r°AIS^nr _ - I % rw+oD lo.uvl+Mes ~ ao- u ~~ N w u% +w wvs "„ ,,, Resu NEn te'e' °F.o ~ '~ }I:. ~: r.r. er or , r. 1 .4,~~.,: ARE SS ;.rh p.~e p,".1°'D~R .~ti ^"dLv n, 'DE.E~ cRr> RLrvo,l r.oM O+ (JF -' O ~ . O : ^ : Fp ,. ~.. a ....` s. . .. _ e~ ~_ - ,... I I r r:.A: c.. r....r :.:.sxs I ..F2 ~ r~T.~GS:a;kr'L.C1Jt- ~~ I _ . ~- - ~fc , -. ~ .., t r mEriS y~CCN~j ~ 7T ' _i t jjy~~ - V~ A ~ F ._ ~ R ~ ~ ~ . ~ ~ 1~ ~ _. 4y1~ A - ~ l ~ MOTOR~VEHICLE COLLISION'. - ;OUi cuuNTr ~ cltr Nu ..i ND °. ° ~ ` '~7~)-rU,3 ~ S • ~ ~I .os °N , ~ : s~` L co.ux.° an r No E, w °;~ wA~anl,° .~ asn o~ Te-~e,~sd,ti. "d3 ?_ 9 6 3 2 ~ ~ V I. T .~ .. .m o ^ , ^ L ^ ,n al,. an la.,n ~P A na a xrnLLT aA n Fn SNN, ~s ^.^a.~,,.i--r~.,,"~NA~N ae,. ~+n..~ ,~~„ '`LL a~ [ a~rL aA AIntLT aaa N~~.~~` _ O./S .L 0 o LNxn,aaL °r an...aAIA Nn°, a~o,=rL^M°Elr~=1°a~EOE~,.:~~.~,oe.a:°^ N. PI. N.A.. ~ItATFa,an o~ ILt, o °. _ ~ ' ,s;.,x,a°n,n.a~t° ~ o;o t o N;;,,,aanB 41NNL. 8~. ~° t E.~~~;-~~~EL;c~~a : ~:, ..° . ,.,I.a~a r,ax~tx naN t°c s OBJECT STRUCK n~,u aPl N OWNER OF OBJECTS NAME AND Ap0RE531 v~~IliAVNN °w • Ocaoc u>c 'a • • - I NUr1 rnAn a • • ...... ar: A ORIVEP'S LAST NAME IrvO CAnx FIRST NAME Y 410pLE wtnE LD DRIVER'S LAST NAME FIRST NAME MIDDLE .1 ~ o .~- k A , 6TREET.nODPE39 ~~ ROUTE NO. AND BO%ND. N'` ~I` ~ //I, ~'A' .!J'-'~ ' ° STREET ADDR~ETSS ROUTE NO. ANO BO%NO. . 30'7 - a S~ ~ E 7o r 5 I, PrL ~~ ~ V--, P,J 'T++95 ~i. 55 M C ESL } -.. - "4~ LL7l'L ! '.ATE LL G "~%Y_. .1 %_-7L,1y,- D L DF a qTN At Aat I O TY STATE ZIP CODE. ~17a..:'__.W/1.' S,ls agWEN~ LI NsE DE ND DRIVERS OCCUPATION cc~,r;~i- _ ' ~ :!IS S !ten 3G VEHICLE YR, MANE ICHEV DODGEI MODEL NOVA aAI E ,:`. E of plHl Aal NplrrTe Ow~S[{D w~ ~ s 2a .~ ~ ' ~ ~. •; . I ~ AgTI BOGY SIYL (P OR.1 l $o ea VEHICLE Yfl MANE ICNEV. OODGEI MODEL (NOVA pAgfl BODY STYLE I?DR. 1 q ' ht l 6 ~-~ ~$ ll Pr,lf, ~I~ SLI,,b ,-~! 2 nT.-,- ~ LICENSE PLATE NO. STATE ?RAILER PLATE AID. 6TAlf,_r,•_. uJ , _ LICENSE PLATENO.. STATE TRAILER PLATE NO. STATE d VEHICLE IDENTIFICATION NO. DSNpSS Ore cn '.~,; VEHICLE IDENTIFICATION NO. REOISTEREO OWNER (LAST-FIRST-MIDDLE NAMEI DRIVER'S LICENSE NO. ~ouz k Y11 ~ pEGISTEREOOWNER ILAST-FIRST-MIDDLE NAMEI pRIVEq'S LICENSE NO. <T ~v '~ ~~ . e aw. 6tcs OWNER ~ ~, /~( SL,-~ L t ,` S ADDRESS ISTREET. CITY AND STATF) DATE OF BIRTH Q A Y 3t7'! - a-S~I-2.. 5~ ~F- ~ OWNER'S ADDRESS (STREET, CITY AND STATEI DATE OF pIgiH ~G Ma oA N ~ r . f` . L.L PARTS OF VEMICLE DAMAGED ~~~ _.{~_ L ~` SfP•Min~v~M,CigFT '/~ p - ~/~ 1/ . Y ~~ n PAgT3 OF VEMICLE OAMAOED ~ .. ..CO.q~}~f9 ~T{~i1 ~rLai, ci~F1 Y .T . / LIABILITY INSURANCE INFORMATION-V EHICL'E NO. 1- AS THERE AUTOMOBILE LIABILITY INSURAN~ £ COVERAGE IN EFfECi FOR iNIS ACCIDENT ON YOUR CAR NA/MWE~ AND1 ADDRESS Of~LI/A~BILITY INSURANCE POLICY HOLDER NAME OF L Ilf l'tP L?en: P i1rV OIL I'11./•Y•"1 ~7~-LI. G.L. Lf11-rte - >I^rV1 .1_ `...I_.. I 'PEUCSTIIIAWPED AL CYCLIST WA$USIN6 ,^va + ~ L^~r L^N+%n • PEDESTRIAWPEDA L CYCLIST CIOT/IINO COLOR , ^ nu [^.,;, flri"p BIN1/ACL W[AtFI{' LWIIT CONDITIOrvS iRAFF10 LDNTRpL •cAl I ~UAIMGnI ,frltn anN r r.~ ' ~' ~ ' AF-i ~.°~°~"" : ^ IMwh ^ Mah.La Q I oN. ' { ^ N ~n~hc J ^ IwsA [] > ^ aror Blrh ~ 1 ~w[I s^shDA~ho . ^ninhAaoH[I ^ a ^.,LLO61eh ^ 1 ^sww min . ^roa s ^ uc.aio ^ ' ^ ILASrohr, elo ^ . ^IOL or ,LN ^ s ^ i B ^oNaq s ^ D.NN ho ,Ix cr¢nrl sIA[IT IN:. ^ s ^ rumnhc AUULN sr oFr r ^ iviiv. ^ A ^ AN MahA4 POAgYAY ((r I-1 y """~~~CIER N: ApWAY WRIALt[ TYPI ~T I ^~^ ^~`7 may. ^rn ^ I ^ Ov IICLILILAauAN ° . [~ alrrER. ar[LOr VEHICLES POSITIONS BE FORE COLLISION ° I W ~ z oni INVESrIaATED nv VDNLLE H 1: W OH SiRCCt ON INGNWAY NAME Oq NO w•lcrgn I L rrMwdno . [ Un.Nrrw o° • rt, ~c c D iMa nrn ^~~ ^nn T ~~(( naAl ^ JAI ^ ^ ~ ~ ~~ pI (I Ja ^ ^ ^ ^ ^ ^iiuiC[ ^~A°ii °:; ,,,.,. ^ ~ ^ ^ - i ^ ^ ^ ^ ^ ^ ~'x,.I,,.,, „`~^ ^ ^ ~ ^ ALONa FnON TO I~,~, rrn~c:L Le 1 YV-O ~fkT/ecE.O I ~ .L.°^'~Nn.°r::`w~L~°.~. Ve.lu~.l~±~a~,` ~t:sera../eh~c.(e-~++.~C y ~s~x ~;Q ~ ~ \ >I.,,l an,,,w~„r ~~ ~LV~-t 1. ~ F- usQS ~ ~ I _ _ .. _- .. -_ ~._ _ _ ~ • __ _ _ . -- _._ _ - ~ I ~ i I ~ --- -__._...~..._.~~__.~ , -...- ._.... ~~~ YES ^ NO }~, .. .. ANY ter.., w.Y. w° LM ~..,..: ,k(w 'P IN JJII ' KILLED ~-NM6.FU1S7 na OTIE.T/NT wow Rx.u. ha Mvox 7i.?L:~"~ iTATMi GE'YAN/PED=-i.:, ~ w'rw: . ~ KFINBT.o ps.uNnc 1 NF n°u1MxLC.P,PMEa _ ~; .I an NO I O ^ xW[na 5 ^ 6 ~.. r. ", O°i ~ NO 1~ ~ [°... KILLED ^ s[v[n~ ^I 5 ~ ,u xon 8J^I °17 Dal '~ r MOTORCYCLE SAFETY: ^ rIELMET USED ^ MELMEi NOT USED MOTORCYCLE SAFETY: ^ HELM ET USED ^ HELMET NOT US[D Y z 1'.~~~ ~ f •~. LNOW NORtn pv ARHOW IN CIRCLE . NOliiL ON r,u WdLAN ~rN.,N„~ [ar. ~ ~ OL[WIIE BELO WN 1 lML0. __ .__ C.~i L Ve.J,: e~e:.^K-l ~~ )REFER TO VEHICLES DY NUMBER) ,') .. u~ beh,`~%icQ ci- I,,; ~ :. ^ I ^LOhe wsr ~`II ~I~~ polha arRMmn Anuo°Dm Y TWO WAr ^ ) ^ OVGn IANINO AHD PAYBINa ^ 1 ^ Pp~U SHILL ^ 1 ^ NANIIIO NIOIIi TUIIN ^ [ ^i~am n~u"ijL ^ ' ^ NANINU LLn mnN ~ ^ s ^ I ^ s ^ MANwG wTUnH ,,j ',~ wo WAr. ^ a ^ llAirll Ullr a ^ ^ LLOWVrO ,I ^ I ^DAIVIWAr Ar l~ {'YI I ^ BIOI'I'LpIOR InArfIC pp^q [EP!!MTIVN. ^ L ^ OrOPrfD AT OIONAL _~' I On B10 610N ^ { ^ pIVID[D ^ B ^ BtOPP[O N POADWAY t {~~i(h6~~~T~,~? '~x~4M"~r ,Yk~''~~fitVjl LY1k T 1 ~ tl R II h , ~ ' ~ ^ .- nn-_1..t,r1 [ALUN IOn 1q1 btL ANULII C Aly Tr I+c.. +h .l~: ' r o f ;~" ~yy Ll.~~hO nllC ,^ ^1M01 _ S. Ifs 1pp~~ he1,U11 t 5'Sy ~ ~ ~ ~I~~ a'^n11NR N ^ ^ ~~ I• J,L M J ~' L`~ 1 iA1 ~ I~1~i~ ~•I rr 'L x Ir ' ~c ~' ~' 1A.' ~„'X ~p, ~ ~ ~ ` A r~! d v. y 5 .: -,:, »`I I . , ;, ;, q , IiYO ~, },= ~4 ~ , Tj `R L `~'~ r~ 1~ r z; c a I ~, a~~~F ~ ~ ~~~ ~ ~ 1 I ~ ~ ~ ~ I C d~l~ I r L~ ,. ~ ~„ ~ .. ,,L I ; ~. . ..,, .. .._ .. _- .. .... N 1 1 ..~L .. _,,. _ '.. F - l ~ I ~ _,. ;L ~i ~ Yea- sCWYf + a~ ". y ` J ~ r ~ ~ I ,~ ..._. ,__ ~ ..... w,o,.._,.. ,.,", I~ ..~.~. ..IVaAr_ v.~.e __ _ _ pe o.c MOTOR VEHICLE COLLISION p RT ... v,+7u2`sa.+.L3"SI.' .nd~ NauNrr ~~!},..UIW'w3.~o .._..~ WP$:.....z"' Narr (~ ~ ', ~ ' n r F NH rnl i- 17 ,N NOH ~i, . o`,~ E+. ~ I I o,~r«" o:w p ?' ~ av "°3 2 9 b 3 2 ~~` ~ ~ ,< 2 S ^" ^F ^.n <, <HIRw n p r AnF ,ErN < n Ar f p L E Y E H <pp ~ :- ~ ~ ' . 1 ~, ~W ®pr f I ~`^~~wnsen~ON oYt LN,F<IH<WIrH,rH LF~o yS~yD ~'I ~~~ < nxN A n N~,AEFxn,L<rI0 p ~ VrM FPoAD./5~ ~ ~t ~:°~, nwL~ r LHNnp<F OO ..,, ~o~M:+ ~-- X10 DeSCOV ~« "nM~ti N R nAN<.rA T .. ' ~_~ OrBJECTC6TRULK ~ ^ AN ^ B co uvN J // a~I 1 OF ee[ o ~E~~J O~~RIJIVEgg LAST NAME A FIRST NAME ilk ,.,~ ,.'as rlO~mr~ .~iCIC W-~~r i i( ~~e ~I STREET ADDRESS s( r ~ ~Otr ROUTE NO. AND ~A ... ° ' ~.„ ; ._ r - „ ` l/. Rol. CITY., STATE. 21P COOE_ DRIVERS Tr~ ~' ;. S, n~ yHr /'rant Bnd ~ 96_~I~-c' LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1- NAME ANO ADDRESS OF LIABILITY INSURANCE POLICY HOLDEq „ B:~w~;:FF e~.LpxnLl rNopnyn of L ~E~D~~j:~~E,DRR ~r~ A Y DDJ i AryryMEAND ADDRESS V}~r"EY Fo co < {~ _ r- 70 ~ ZS.tAC3Y ~ S Mn ,7 cr - ~ .. rMpxF mAn -- ..._. , ~~' iw0 cAx5 ' ' MIDDLE p DRIVERS TNAME ' }AS .FIRST NAME. MIDDLE «LLIfi<nnq x ; Oz c ~ rrpNL NIAn rW R . NFRSONS w[xE STREET ApORE55 ROUTE NO. AND BO%NO. w , InlpnEpn,EA1307 as'~s~-• ]FNAHArF r TION, ,, cOLLSON CITY Jh Afapni n.. -, ~ _.. _ ..,, 6TATE _„ ; ZIP CODE DRIVERS OCCUPATION ~l 40 ~pRlp hti(lST ~'.~-. 3 LICENSE PLATE NO. STATE TRAILER PLATE NO. gTATE K ,~v r was n VEHICLE IDENTIFICATION NO. ~A,. REGISTERED OWNER ILAST~FIRST~MIDDLE NAME) DRIVERS LICENSE NO, •~~ ~./} Z G4JQ 1 fl- flnTH OWNER'g ADDRESS (STREET, CITY ANO STATEI GATE OF BIRTH t3o 0.S''~'~ DP iDLals~.li, :~ Ito PAR(T~S OF VEHICLE DAMAGED ~'~r srivIF<rE`Fl ,p ~ r ~EGL K']L ° d__j4'._~ ~-.511 $cv"~7~- ...~ RE AUTOMODILE LIABILgTV INSURANCE 00 (~FFr' , iE IN EFFECT FOP TH S CCIOENT ON YOUR Cqq u 'E$ ~ ND NAME Of LIApILITY INSURANCE COMPANY (-/"'rYi ()Y (r/~x ~.~I~ P ICY NUMBER , i $ r .,, d ~l7 voro260 ' 3N0 INJURY IUS ENFPUH rOx,, --.._........__~. _~, un CSl AGE „tl~ O DID NJUR [] REOU NE ^ UOLTOR ] L-I L.I 1I I ~1 I E~TENi OF NJURIES ~ `~ A ~ lO if' L E%AMINATION tlY A DOCTOR} NAME " ' STAT ` J U D NJUN ES REOU RE OR S M E% AM NATION by A DOCTONr ~O NnM U9 OF INJURED YAgK fIRS i ONE TNAT APP LIES 9 T TUS OF INJURED C Cti a E T' ^ oN IN VENT LE "~rv uni Itl MARK FIRST ONE THAT APPLIES suwu ^>+ KILLE ^rLOeslnux NO D si EMi ~ u ~ ulicwl IN. IHI LE y ~ NO <", . . KILLED s uun x.o •,ul xc voss NL H< I"~v[~~ " Hunt N ^ ^ 5 ^ 6 ^ . p O u , " 7 0 ^ ~ I~ ~u0 cn 5 ^ f i MOTORCYCLE SAFETY: ^ HELMET USED ^ NELMET NOT UBED MOTORCYCLE SAFETY: ^ NELMET UBE ^ SNOW NORTH by ARROW IN CIRCLE D NELMET NOT US[D WoN'.,r[Gr irAr oupAAY Wr.A1 rMFFFNap '~ IN.n rnL w.Lxr rH.r AMLf<r:' OCStfl OE BELOW WHAT HAPPENED: IflEfER iO VEHICLLB OY NUMBEgI - ,_....,. .. ...... Cqr Z L"!it ~ .... !7` 'f/ .::. roM<plL,]<NL<LNL Wnrx<x " .w.. wuLF o .A . 0 ~u,• A yJ pPu ~~ y / I q ~ i ~ ir .!7 Ta ri ryfr _ rn / . }Ii •tli ~rl./) CaML Gt rO HH~ '~'/TC, cpy.,Ter H~A.. IHfLr <ANdAr ~"o .JG7~' G, cjli.n Pf o>< Ccf/ yL 1 ~~ LC»~.FF 2 ft~C7~or•e at B'rach' ~ Tjrrw ,f/u1~I - vny/L1 L/,ndrhr:ltd uncl ; ~ ~ '' © y© ..TNTL af~C/ = QO/ Inr Lt~'nd~/IGiJ/sl L~iN ~ r -Z SaW CrL/ 'L o[J' Z i9 G~CKd SJIb r: ,...._,_ i I~ They w-raLCt~._._~'a C/6st . 8 .and t~cn ~ F;r)~Jt.. fRywy ThawI'' ••~, ...... G JIICCn~ / %HC rFTe o~r aYn t VEHICLES POSI710NS BEFORE COLLISION ~---h6Y~A~P~~CprYy',Lu_ rA1S~ )/ ~7L~yyo ,Y~ fi YrA(,• VErIICIC PN gT1iCCT OfI HIGHWAY NAMC OfI NO. cArx/.w~ 114A.~rE.xw „hll,~r.2 vwICCIN~jrt (.Si,0A7~GY ~ ,. ^ ~ O O MHj ^.. ^ t ^~ .anl O bS ^ ^ ^ ^ ^ ^ ^ ^ ^Ea;rp ^ ~ i ^ ^ O ^ .LONG I' 'I~~'IT~~ iRDM TO"r - E W. Ih PED[STRIAN'PEOAL CYCLISC WAS USIIIG ~ ^yN ~~M"< J ~ u j 1.1 ` PCOCSTRIAN~PEDAL CYCLIST CLOTHING COLOR .NUI.~t r^. .... ^e..lv,w .^__~~ r^~'°`iwu. r^or„NI r^eni:niiii .^W I ~(L ~f~r r } -T1 ilOAD 6UR/ACC WIA1HLfl ~`_J `~• `^....n r^xlrxn.ll..alnl '"r""NII<r 1~ / .t ow UOgI fAN01110NS vlRAifIC CONTROLn I^v e^ ~.. r. i,rc.r LV%Irl ` 1 +A vrrr,F re ~ IALAA MYLIGNi v r.c,L cwc. c+.r, KY' E Oi IIOAD ~pI11VEIVVFl1 CLE ACTIONg t l YI: ~~. I `~ r LOI / r r ~ L G~l<A Ox1u TI `~ } ). 1~ AY T- ~ ) U WN I ^ 61GNALfi I ,~f~ ^I II `DAY F `" fir. / ^ A ^, ^'II ,^ q•IL WA >w III ^f OOIHO SinAIUIII AIITAR ~ 14 { i'~I~ ~I}1~~}1 ~ G ^ NMrNH^ s ^ UUM ^ 7 ^ SIDP SIGN ~/r l~ ~ I lq ~ / ICI WLT / ~P N ..~ f ^ O.N.I Sr"L[r ^ T !pl l ~ 1W0 WAY ^ J ^ OVCRLAK rrG ANb PASSING ~ yIJ L~J~ {{~' L ~ 1t... :~ ^ 1 ^5~ G.. /~1 +IN ]pN ^ rIILU SIGN ^ 1 ^ NOY~SUrE ^ ] ^ MAMNn NOIrI TVNN ~~ I/: !>J r. ~ t' .^I00 ~1 ~T~r]rNflr ..~.'. ^ a. ^ ~ ^ nA,.rmGIND ^ ' ^ }}'GEOID ri:u~°t ' ` ,. I t ^ L O,~iHfN ' ^ ~'i cNn, ^ Y°iiri°IC.rn ^ L ^ n+vonD AMneR ^ L ^ Aufr A. rm rr unn I~yI ~/{~ ~~ T1~ fC I~YI 1-~.~ ' L'yl^DWAY r , CI^R ` flOAp a1'SURFAC, rrlC ^ I ^ OI IICln 11l AGMAH ^ I ^ PN VE W11 rN ^ I ^ St011 (Np,lO lni Af 11C ~I ~'^J ~'(I ~ I „I R y ~t ~-.. OO Orp..r. ^ L ^DINLn wfcNY - 1 ji~J`~~ ~' - w prON. ROAD fiCftJ1AT.IQN. ^ . ^ mprPLnusmgq '! ~ !~ / 1, ~ ~+~ p ~A'r oR BTDP 610N "5S ^ 1 ^nv ro ^ a ^ TD mNnn Ar t u ~ ' .:'_ C] f 1 I] ~.. . CI f) LyV' Dw Im rl D Arrvr ~ ~ ;>, A _ (?d ~ Ilvrrt ^ ^ Ii IIL NI I #t i'"i y ~ rC1 ~I r r ; -Jtv~ 3' t~ :~S 1 a. I,1~, ry'M t T,"'.1~""~7r .._I.S., ~ I ~„ ?; L ~Y, ~ Y t tl.'T~ _ -,y,» pp~ .!/.6 rl r)r /4r ~;r1f ,S r '~• TY .~ ! I I ~ MrAI j' d+ 1 1 i'' 1A . ~ (I ~ .r ( ~ w,H i ~ ~~ ~ ~~~ r r. IMM i, ~ Y ~ r ~+ 1 ~ ,'. ? `' \y~~ POLICE TRAFFOION REPORT ILU reaFFlcwnv '(~}~a.,,P1,~INrNUmefR -. " PRIVATE WAY DArtot cfnss N Z $L ~ISN?~~r`" ~• ~•, rMt IU)f'benOURI /-Z..r. couNrv couNrr NO. cm NO. w.wA. / / 5'LfF Sort) (O ~alcB uuAAt OWN f6NO D. )r9t(r 09 nGNWAr Cr Ct) f 7, 3 ° t "" M,f) ^) ^ Df ~7°'ED oN u I etiTO~Fle,7 ~' 9s~>o ,EaS[CriNG Vern SlRFt109 gpAD NON iNif91FC1rON 19(ilx } efRVtt co~,vtts QDa9«r, os ~ .4-I/ 2.35' D~)rANCt 609t NiROM 9f.tefN C90)))r9ffrOa NEAR{)rM tF ACCIOENi RAMP DIA 9 } ~' h . JM M A a I eRr) ) t w /~ ~. MCODE E • COI )NJN NvOIV[D SEVEaIrr nit89UN ~9D 9 OR INt9fMCf NO NIURED ^Sn IIAG( ^ wN^he~. IN IMf9 Ol) CROSSSI NO.IIFD R RN p i ~ _ ~ AD rOIAI NO ff O // O vtn Cl[) ~ R90rtRrv0AMAGFONIr ^vFSUtrtp ^v!~`Cl[ COO~ZO l os 1 9 ' ncrsr9uc.lNUnfaoDUCr sr9uc9 ANDOwNf9s NwMtl fsr DAMnct srt<w coDiNC lSf 9L r• rhr.r~~ ~c.c g 5 - s D9rv[as NAMt. wsr UNIT NO. I r~asr MiD L Da~vEalsNanf? ~S EtiICIE ^ PEDESTRIAN ^ PEO ~CFYCLtST A'KI LE Bs ~~ e vvar.DD9tss 9tfr ADO9tss ~~ £ !] % Orr SIA1F IiR OOOE RnONf NO D I • ) Arf I N urLc N S 76 7 -3 /3 R #: Darvta'St CENY NO r! '~ L 3 P AiE O rn I v 1 fN NO. .D a. .~ ~ A DR OiB Rrn MD , DA. ' 1.. _ ) «CURAr DN MN E)MONf NO (v{s wi enr [P Cnr E «cuPArloN MNAm{a RfgNf NO. tres wflenr .< C00 K C pL~£/IS / o R ^ CMECK (.~ vrn nt AS AN M (taAHOrn[e ~` ^'CHECK (/) to ctr as AN VnRloretaANOrnraAS CODES' ~~ 5 e z ~ CODES -* T ~ s r y ;b i ,iss . :~M"' NtC, ON D,Dxrcr ~'Sf A f: n.Nr xtr N .ri e9rc.r 2 IN Uerf) ~~'.E~ PoM a .MNa.nlf ^ b,ll ^ ea.,l. ^ ~ :~,o ::~,. n ..9 ^ w I ^ ~: r ^ zam ^ .r ^ :.~. DA9r NOVA 511 ]Oa t DGOGf CN MOOEL E CONV " C :'r n . FV.I I 1 I I 1 I - 1 v.l NODf1IDARI~ AI l ri 98'5 ~ ~owr^AC ~t cP Z F _ 1 n tHI CIN ylAr( R ILFR RAtt NO SrAtf H vtn L ry A G /UV y77 W I vw¢t(IwNrrf ur,oN NO ~ vtnn t , iNn N A . . ~: tz~PiEl 7 :yl ;plzl6; -,ter I ! .' I i I I I i I I I 9(GiSr(9tDOWNty 411 N9)r MIDDII argNt NO (1 9 r wN .tA)1 119)1 ~ H S.s-irJ I vt.e H, Do9tss a owNt9 ~ N 1 NAMIaADD9{ssa E ww9.Na co aAeeNr AfE /rrS ENS ~ /VNry/oo1J R DAM.eto,ueA '~' A r.r.R en.9ee c~•xet g MAC .wu D W • ,G~OttOw > t)t AGI OW^r ^91MAiNtO ~ ^AWA+N ^9lM/JNID i tS ~A IC~OIIOii 1 ~ . ~~ _ ~~ ov~ oPr ^ rowtD Aw AWA+RV. . = F DIAGRAM Oi COll1510N yfLLL}uNf4StAa 1 ec o pOW°.m OESCRIP710N OF COLlI510N. IVS[$WPIf INr1l )nttr tct)SAIrI r .. - , .:. i t_I I _I . ~ . _ " ' LE I I B~ D t ~ G ~ ~ pt G 36o NLO Ra s/ O~4L y . f O L _ ' O F IQ~/?D /1{''1'te S7~/K/ir/4 TEL %H NG A..c _ - ERI°CC( T CttT-DP Y NAME. ADDRESS 8 INJURIES OF PERSONS INVOLVED CODES I - 1 J _ ~ S 6 ti w i asvrnwtmA s.or OCCUPANTS /WITNESSES rao ADDrnaNU ro.Mts~ s1R Aa r.rus '" wvo Nfc} w 9 ~ A N ~ ..., 9a Yr ,unu ~ ~wovrD.9oM ^.MS ^~. `r^~ .^.~, ^;: a ,rev ' ac ~~ ~ X ..v....r,_„L.C~...,. tl ~cSu 123G ~ N:. ,r ... dD l2lfp :..a .;. a.;u F6 our ^ ? 2~~ 1 .i_(9- ; 0 , Nei" ~~,' K ly ; x° 7~y1Ft- ii _" ~ 1 ei . ~, P i ~ ~; ~~ . Y ~~ ns ku ',s~ ~~ ~~! ` . .. .~N w.wy{} { r'~? ", n~~y` ',~ISi~ +tiw~ l3~ii}r~~ ,d.m '1. tinz.ro axu.r x.'o Z nuwp,~ -u.r .z"FlR+W t.yh.,.t<"~3PIr1 C~6b.tAr iNYG`'t.. ^t ' ~b~ Y~I~° d'dw{~,1~ ~y M1,~~~,~~ +~ r 4i ~ rr.R t ~ n .1V~vE ~'M~E ~ ~ c t , ~~ q~}~ k t ~~*[ 1 ,1 t 1 ~~~3~Py~ A ~ '-1 JF1 ~~1 T9' ~141~~,r~$I~c ~ e ~ r _ t Fir~Y~Y ~~~ ~~'~ I k.' t. ~~ vW' `. ~ ~ . a• ~ ~ ~ h ";~. '~ l 1 ~~ 1 4 ~' £ ~~, ~( ' ,:~. ., ~~~ _ 1 ~~~. { n i. s t ;te ~ ~ir~~~ -> _ ~ ~ '. g~ ~ ~~:.n ~1 i 1 S W {lR},~,~ p a n Y~~ li" J a ° ! -, ~f X . ; i ~ : ~'~d~ ~ wx ~~ r, .. ~. ~i~F 4 ~ Pi i ti ^t ~! ;"~ I i ~.,; ~ ` z rtf~- at ~aWt ~ ~ 'fie ~ y ~ ~ ~ '~ ~~ r h ~ ~u ~ ~': ~ A ~~ :'l..'{ a i ' ~ "' ~ ~ ~ .', 1 Y.:.~'u _ _ _ .rLy r 7 _ '' kx._ ~pw~ fµ 1 al~ ~~~ ' aN,. ~ ` # ~ >rl r {: ~I F1 ,~ I ` ~ ;y ( 1~3~. ~~ ~ qq DC ~::~Yi SSA u~rSer.i~`i.R ~. ~7 POLICE TRAFFIC COLLISION REPORT v.3TRAFFICV/AY IOIICE CGMPIAIMNW y 1ef1f PRIVATE WAY ~? rcau apIIN__ nME couNir coE%ErvNO. cm NO. fHwA .'.w.~N nr ur (USE Igpp HOUPI /~ ^ REIN '~'zo SS o - ~< 3 o Fr~~seN RURAE ~E ^IN pITY aA IOWN AME6 NO. UFSiREEI OR JaGNWAY ftt C15 gOUt ^ OR , . f Es ^s ^w of tnG ON F.<-hCL~ ~. fC',$"270- .. iFRx(:rING w11H: SEPfEEOq ROAD NON INi[RxttION PRffl% EO. M%EPp51 N j ~ D !, sTRFEi 6 I+A V f i2Yt,FsroffT V• 8J2 /~ Os LANCE 6D,q tl fgOMV ifvF .CROSSSroffr Oa NfARFSr MIIf s ACCIDENT RAMa DI PAM MtA nES s F W ' ~) MILEAGE on FEi of /~ oDE ~ COLISpN NVIXVEO~ xrf RlrY1 A ~RD , s Rff Oq ADO4 WfRENCE IOiALNp NO KIIED_Q~NO. NIURFDyy~ ^SPIUGF ^Hr69UN wrvpvtpm IMF CIS OEOSSSro ElOR ROAD © n /.. P VfH CIFS ^ PpOpfRrv DAMAGE ONLY ^ pESUltFO ^vEMClf ~jss!{.Q OE ~ . IEtt SERUCKINMAFOF OBIECTSrgUCK ANDOWNfR'S NAMfI fsI DAMAGE SnCW COOING Ux N ~ t"c S n 3_ UNITNO. I UN ITN0.2 ^ VEHIQE ^ PEDESTRIAN ^ PEDALC'YCLIST RlvfRe NAME: UyE NRSI 7TK Y a , M, Ol 's NAME: sl f A/ /C N/s/ 1 tax6 E GSa AN N rNFfI ADOgFSS i rofEt AODgf55 °~ -Z - C45S 73.EHrNp P,4 NOPrp /..OND SfAEF IIPCODE PHONE NO. D Ir siAiF ZIP f oR~ TD•.rN5c N0 wN 9fs'36g -may/ R XDQO aN I.v 9$ $ / Eks DCENSF x•iF % 0 H I N ~ xra. S -D7 7~ vA ~ // ~ %Ar X63 v S53TL rF wA F DALE OfB N MD '%3 i ~~~ OCCUPAINDN RM NNAFeRgNE NO. FYFS IGHt EE GHt E occuP•noN / s fIRM NAME6 PHONE NO. EYES IGH IGN} ) / s5 c/-s q~; s.. ) o R )«c Nano RC $ ?b ^CHE+K (~ ~N YffaANOn Fe. ^CHECK (~ . VENCIE ASAN (MNOYFE OFANOE uI CODES - E n."'i'sr S l E ; °k„ ' • nin:Nr Ilcr OV D HFq CODES - ~ s n.u D . is nMwl 5 ExcrpN E Jwla6 No N/- ~~°„ .DM [l .IE s• NO//C " ° YI ^ AY.MANDF ^ ~ ^ zs.D. ^ „Y ~;s;,P U MD E ^,.NKAMI o u: l ^ ism o N P K K vFN.YFM MAKf EDDDGF{nfV,) MDDEIIDARr.NOVAI srYI F IIDR.c v) , n~ Y 1 Ln 1 MODF DA r N N I 73 • Q RNNOVAI II 1 R. .1 ~, ~; noon-~ 2~a1 ~ oR, E 76 Pi~E a n NCf PIAF Aq stAl[ ER MEF NO. $iArf H VEfI.Gq , ` A I?f /,'.i/.~ / 8~ `-A I E~y l; -,QN 1CJSZ N8 V[nICIE OEMIfKA1gNNO, G .r-,!Z G;S'!Gi/ 0'71/ off! vFG SnafD OWNER: UESI NRSI MipDl[ PNONF NO i V nClFlpfNl I N ~ . 6 ~S' /; /'Y 2' 5'6'7.1.1 I i ~ f ~ Sa J .E SAME AS A o~ E ADORfssa oWNEa . O W isR D WNFR: IASr NRSI M,DIXF tNO. SAMU 'S Adcl/u: N N E OWNER ~I NA«FaADDaess or lNwau+ee eo. aR ACwI A ~yE~-- ~, VNK R VNTC• ~ i IMIUDARU __ RnASnwN Cn DGF ONC UAMAGEDMG L VoUrMicrwMC a +•cE CHARG[ NON SS - f ~j e ts. DVAAGt WAVY ^REAWNED DOI AW^YN ^RfMAINED ls1. DAMAGE I~ f TO ^ ~~vDEY% ^ Aw:rc er~ S on 11: DIAGRAM OF COLLISION: 1 N e Derr DESCRIP710N OF COLLISION: IlnE SUPN[Mw1AI Sw[TIf NECESSARY . 31[[TII MCISSARY) PODW 1 e% ~- vxN. No / woS APaeAeH/NG• ~ '_.. _ I . -- .. -~; -"~. ~_ Trt.e . .. . iNOr4N IS~Eno ORioC:~= VNO.: /+, v/: /~!. - . _. "-' - '-""' -- /cy Gor/O!~'l o1YS ANTE:/~ ARalviN p. 4'PnN ' -r! Or t " r ~ ' -.. ' T. 21D: vr, TN~ DRE /j /.vST Go1y f(~yl. - '~ 1>3 ( 1D6C_. _ __ _ r; ~r+55 dD TNC UAYCE. nIH/NG /.AN~'I STRue/~ e _ 7Nc ru4RORgE,E• 13o,/NCep oFF ANO ~ 1 4r//..~E_`iN~,. To i2 tST /N /-/fg ! ANE= O/= TRAVt:A ~ NAME, ADDRE5581NJURIES OF PERSONS I NVOLVED ''CODES I Z 3 4 CICCUPANTS/WITNESSES ~a;~a o~f ° Pi u ~ ii '"'"" 5 6 l +A e r AMN x% AeE rAlus r•; „( xsro. uftt ,".;°: • i ooRFU N o AluaEa N AM e per t ^ wl,.. ^^ES p :4„v A N d - A DDnss N Aruaf a a MorID 1ROM ~ AMe. ~ •«%I ^rol . O N O r': fio ' A awsH "+~n i°hsO1 ueMer~ ^AMS Oe3"O~oln. O:i~ ^,:°~v ~ VISIG•iMO pIKUIfMW IUN [ eA0GF 0a IGOVCr DIi At MD Pp Ly10 DenaaDYni AfsapVED er DArE o fp n X :Av 5.~,.-, -.s-.. 5 ~ o ~= ~ i.D~.s~ o ~ % y 11-Zo •~, 1 r ' '~~ ~~ n ~~'{(~~ y~ $!K :'7 y ~Af '~ _ b }•I I ~ fr'iM ~' ~ l ~i 1 ~ E ~i L > _ 5 ~yTI~~ {Ir P 1: ~ ~ I •GF~J } yry r ~ ' , ~ ~ y ~ IP ~ ~ 1 F ~ y ~~~ ',f~ ~ ` I 1 ' 1 ~ 1r ~f '` 1; ` ~'~ ~~~„4 ~ I @ t L I ~ ~~I ,+ , Q ~; ~ ~, I ''., is ~~~ POLICE TRAFFIC COLLISION REPORT ©7RAFFExW - I, KFCOMFtAINT e[q ` PRIVATE W~tY I ." ~ DarF f / 3 f l COUNIY ryNO. Ch w. I:~ { "~~t'iI' ~"' lusE].aDHOURI 1 ~ A 1 / 11 12 85 XI I 20q•O Jefferson 5O ~°q $]N QE ~ N C1IY Oq ]OWN E6N00 SiglFt OR HIGHWAY ya ''l N 1 MlES ps ^w Zlyof Chimacum ON Rhody Dr 9~lZoo t SECT NG wt1N. SFR(fT Oq RpgO NON INIfPSECiION PgEf% f ~ MRE P[6T ON igOM gFiFRFN BflwEf{1Lndereen Lk STREFte Neaaes Cornev yZG OISIANCF 6DIR Mt CROSS StREF1 O9 NFagf51 MIIEP ! I ES N ! f ACCIDENT gAAV I 4AM MIA 6 'Eft. w of And on Lake Rd M~oACE <OFl g I~ 1 NO • ill[D~~NO.INJURF 1 ^SV IIaGE ^Ht6RUN .u e " %'4D O4 R[fEq NC[ tOIal NO I'n'k' Cli (p~SlTIfITOR gDAD Cf VlH ClES~ © ] / I]PgOttR]v DAMAGE ONLY F StIXFN \` q OBIFCt StRUCRI F OelECt 5lgUCa aN00wNER5NgMfl I]'NSUIrFD ^v[H CIF I/ ~j'.a0 -_ 9 Est OAMAGf SPECYLL COOING t6F - $ ' UNIT NO. 1 ! De"EP'S NAME: NSE fIRSt MI Mf UN IT NO. Z ^ VEHKLE ^ PEDESTRIAN . 0 PEDALCVQIST ' atkins Lois C R s NAME: E smEft AOgatss ° 2 tY 2 6 Be ve V lle Rd StgtF D _ I Etr aDDRess TIP CODE PHONE NO. R I Y SAIF IP _ wENFR's ucwsf"o. 8325 732451 t F I D v UCENSE NO. wiE OA WATKILC715NA WA F S ~1 '29 V "'OI° OCCUPgiION MNAMF6 PHONEtW. tvES GHt HFWHI E CUPAEION fIgM NAMEa PHONE NO ' 2 LU 20 5 R . EYES IGHi FfIGH t ~ ^ CHE *K (.~ H cll+s AN FMrtv rFf A .NOrH q'v ^ CHECK (~ gl CODES- D ~ % ~ tK, ON s l c Moloa.<N !t F 2 " w M~ N VfH CI[ASAN EMPIOYFf OfA tHfa CODES -' 7 u .~ s le a ;a ~„ n . rcs n acial Abrasions ~ µWDI,o„ ®.MgR,.„gf v.Il a' ~w F ^ EYI ^ ~bLR. ^ ~ ^ ~'Rt. KH vfAq MAa[IDOOGF <HEV.1 MODFlIDA91.NOVA1 Sivl(1304. ONV uY°`i:' ^ NP Ncl ^ ~ v ~fl ^ ib.R ^ ri ^ :9• q I 1978 PONT GRA 2 DR E Htv.l 1 llDatt. vAl Y l - . ~ ], v puNSe PU N . surf mAnlq watt NO. rF H vEH <a,J 'D YAM556 WA - I l KH CIE OENDfICAt gN NO. C vFHICIt IOtNt P "~ 3 U 3; TI Y !8 'A 111 8! 11 218 !6 HGISRalDOWMER I. 51 flRSt MIDIXF I I L PHONE NO I I I I I I I I I IS f , " Same As Above O wNtR: lA! fIPST MIDOIE IN / E! aDDPF55pOVMla W f. 2 N A wN 1 ]1 AMEEAOpgessawsuRAHeECO wAGlNt E .. _ NONE R DaMApI AReA o- I ,] ' :°wYaAOa rive n er n • cHAC ~,, ;, gAMACIp'AgIA es~owst G , , I 9B ~' Idiono": ! e ~ aw::" ^aEMAINID ~~RIVEN glMNNtD es~oAMAC lto. ' ' ° " " D WAY ~ Iu: ori6B + 3 1 W A Y eY Erickson Tow '„p,°,, s ° _D AGRAM OF COLLISION: I iMUT~ MN Yil NDe eo~tH pE$CRIPTION OF COLII$ION: (lAesWn[MENtu sHl[rrMC[sslgY) ~ TT T-~ {.Ey ------------ V hi l ~ ' ~ - ~ -~' 1 _ . e c f r ~ I , e number on_e was south5ound 1- ; t-r- f-- - - I ~.__. ' ' - on Rhody_Dt_-cXOSSed__the roadway to the 1 ' I ~ ' I I I (' 1 left and came to rest in the dit _"- h c , __._. --- I ~ 1 - . ._, - I I'Ti --- _ _ -__. .... - ~ I ~.i. ~-t _ ,..- t r-- r-, I I _ _. _.__ __--- - _.- .___-_ ..__ .__.. _. ,IDpYI I I I ~ I ~ ~- - -_ _.__-._---... . ..._..... NAME, ADDRESS 8 INIURIESOF PERSONS INVOLVED ~ C l OCCUPANTS/WITNESSES ;o;'. O^a„:~r~ 'i ' s~ O~A ~. . 3 4 5 6 D JU . ~ N ,_ S u rp a Ne DoP a I R o• Y t N v p. v Me pc".1'n O "' . O^ O :4tA, .MRl S! . E 'A arc. i)EwvED.gwA ewe ^.". ' ^m . ~ n ^ o I ; ...ur,;.L.,c.ON;IRSiaw A.Ab. e.D.a C.q .fu c. ~•n ~::~L. 'ONx O ~~I ^ , X D , . • w.aDSr.rc~EC KxKF.aq~ND D.nagFro O vloe D ! R. YouRg_ ~ma~mvaesene~...,,,,.~....,.,.... 6 4 WSP 8 3 dw. _- ~.g~0 ----. 2 16 I~..n ]12_85 v~ l~Lg~'- _.. 4A+ Il~~,.I - ytl ~ ~~~~ u ' ten ~ J stwa'. }~.".. ~~ U ~ t r L L~' , P:+ ~~ .~ '~ ?a c ~_ ~ ._:lTd ~ '1 :~ T6 ., `... '~ r I .. ~~ • tt ..,...ss...L"1~i ^....,- i ( I~ f POLICE TRAFFIC COLLISION REPORT ~TRAEEICwnv WAY Iru. IppCf COMAA Nt NUMBfx ~ ~ PRIVAIE • NwA couNrr NO. rv No p c cars r, r, D.U COr s•~a r .. .~ ^r. rv< rusr+.o,nD~R cowr , ~~ uxeAN xu /rolp ~ V I O 5`c£~E2SE?~1 R CR rrGRx.. 1 CLS RW,F OVS l CI ' 1`'` a. 1 ~x : p5 ^W ~Dr ON B Mrrt f POSI ie, iv;f CiraG mrrr Srvll'GR ROnC rrDN attvll.r!G'/ (^~ ~~/ B WFEN ~IQ f rvtlt 6lllV~h Srcitl xxFir% Or~~ A "f U~1rnaCt kUVlvnt tfSUtN<f CN ritr OV r;l.xt1'v'.tc r . rv I ^ + ACC Uf 1 MILEAGE v DAGRAM MI 1 Gc Eflr R r CODE v.'., ~ %xD GStxtfl Ox RDADOx xIfFRENCF R xOM N /S CDrt10N NV v SEE • v- N~ II rlAGt ^n.rweU IL r0. rFD~~ .,, .URIDy p S° lh" llp ~r rc IMf Cl1 CROSSSEx (i O ~ ~S3L . iDiM r,O ^ c[ r:rC p vfniCllS ~ pivOMPi. DAMAGE O]•.r .. DrtCl]rxuCS lNwICr OBIlCr StcU:c urUJwn(x SaAMI ISi OAMAGI 5 SxfCiAt COUING rAF ~ UNIT NO. 1 - UNIT NO. Z rvfxs +AMt p VEHICLE ^ PEDESTRIAN ^ PEDALCYGlIST us: rix M at AMB r,x~ ~ ~ ~1 A SIDtlI AUDxl1. pp 1 Qf25 •D ~.rtc~, S~ ~ D Si Ritr ADGUFII r~•cool NtNO. t. ~ ~ r uA+E nr a n c . s // ,' / / ~ R W l% crn~x n e'~. RSVUr,u ao vAn s DAt R ~rl sDUast ND vnn I ore~xrn uR 1. ~DAnx.. I D M413"Z-`1 ~r ~ M O vAtGNr nfiGnt ~ t trFS nErGn, pCCDRA,iIX+ MnAMt lcnOal NJ E U"CUVntiON MNAMf 6vnOrvr r:v trt5 9 2 ~,,~ 135 SE~j R p CHECK I/1 n~<rtas:r+tn•">o."Ee°a <v'u~`ia P1 ~ ~ < 5 '-~ e;:~ ' ~: []CHECK I/) cif .SAH EVriorfto. sN"~rrrtdA1 , CODES-.. T :'.;; :: s ra; -,' e::.,"...r ~, CODES 1 : 7 ,Z ~ Acrwl,o.. ~ ~ ~ ~ .F° .»B~r. p ~ w ^ Fb.rr. ^ ;, ^ :a.. , ~t f ^~° ~~ 'e`r I <ntv c ~+ ^~8:, ^ r~ wosr loAm NovAr r11zD~ ra.~ r ro v iLNJWI <.tv. ~~ O C~af auR-oar . u tnn s ZD2. 1`(s.-At E L.x r ~. ~~ I ruau Rr.uN ! .nfRµ. slArt rt NO H r. r.aox tNo A An A t ul.~ K ~ ~ ` ~ VlniCrl iq NlxrCA,rON NO L Nn rlnirrt~D,r,tni<., t nnxfoowNtx uv rrRSr m~Dat tra x xlasnveoowmR ws, nxu MrDOrt moat NO O _ W .. RaauwmR u2 wDR Ua oMmlx N AN t r N n _ MLEmDxtafv ~Nwxura co roACtN• l r6au-~e,~-, r ~~- R . A iau .W M W t .i A..ra .. •.• iwC~o ~. IA jNA/Lf D ID.RIA DM1 1 ~ . •,a emu. Cn.vfA 111 O'xi^!a vtMA:afp Cn.vGF w ~^x ~irr ~RiMAiNlD , ~.rrnwn ISt UAMAGf n~7 r~D ~1 X1 _/~ ~ ~~~DBV ^ AwnEp er E ~/ x ' N• Q DIAGRAM OI COElI510N 1';~Li,iNiusll+i r`r ow rn DESCRIPTION OF COlU510N~ ~c"+t luvvreMta!ar s.(t, ~f NteIlSARri vcL,~l u~0 FlaTta, iT<!_ ucL LaS~ ce....C..L o..i ~ ~~ .~~ ;P~"_ ~1~.J ~ v vF ~~f/ ~ $I~fLi tcE Rdr LTr4- ~1dw~ ~ /LlIJ, v .l ~ , ADDRE5581NJURIE50F PER50N5 NAhh E 1NVOLVED 'CODES 1 - 4 3 +E 5 6 _ , OCCUPANTS/WITNESSES fI ~ rl In ra.r s rDx .'m t nr,a a.v ~u' u r .. u. AGI .., r. ~ ^ orvlx Inn . .I i ~~ " ? . :. yek.L ~ rth~ cE, C ",I~, ,. .~:,,. p, r ~.~, .rr p•: vli. ~yy( AC~pi.lts6:___ rn ,~ - rJ^, ^•~~ tl '' F T'k 8t x ~'•RSm. :' d ` v~ tp ~ 1[ 4 4^V°.~'~.e~i. }} lid ~~ '; t gE; ' F ry Sf, ~ ~ ~ a r I f ~ ~~y f Y ~ i J W "Y 'I~ E ~~, 'i ~ en f . & 'ih ~a ~ ~ [fy, F W a ~'yi~T ,~~~ N ~ 17 J~° .I~ ~'~ I~ ~~ y Ea~ 9' °~., ~ ~, ,~~~, ulS ~..~ _- ~~ Y~~ '~~~~ POLICE TRAFFIC COLLISISN REPORT IE~.I TRAFFIC`AD1Y ~ ICf COM%NNTNUM PRIVATE WAY - , DAtf Of AOflS N IXlN DMf COUNIy u I e1 lei s IUSE)WDHOUpI LOU tY NO. CITY NO. NWA []N Qf []IN CRY OR tOWN gMFa NO. p3)R[F[OR HIGnwAY O E OF N CES Q pWlEdf TRfi Sf KKf NIFRSFCRNG SMt SIRff1 OR ROAD NO~SEC110N ON ) ~ ~/~ D ~ - (j7h6R0. No. sIRRf1EE4TRC RD S6. SIREFi D SI AN 60 EMt FROM Rfi NCE CROSSSIRFFIOR N[ARfSiM if PoSI PRfPF E / MBF WSr ~Qi.J~ RAMP ' ACCIDENT ' w _ GE ~.! TFFTS F W GP . THE RD. o D AJ.i [NIA N ~ ~ CIXIISgNINVOIVtD fR IY OVEH CLOFS ~ \ OKIIFD~,LNO N1URF ^SP IIAG[ ^H18 RU s ~ J ~ PRORRIY DAMAGE ONLY ^ pES ^ VFaCI IN tR5ECf1 SREf10R ROAD CM REFERENCE ~N INIE Cl3 QEOSSSTNf OR ROAD .K)) Or. UIiE f OBEFCI STRUCK INMAE OF OBE[CI STRUCK ANDOWNFRSNAMfI FSI DAMAGE ys~ SPFCNI CODINGIF•E S UNIT NO. I UNIT N0.2 DR VERSNAME USt NRSI ^ VEHICLE ~ PEDESTRIAN ^ PEDALCVCLIST . MIDDIE ~ DRrvfR'a NAME: USL FIR I.DIt - slv[FIADDRfss stRE[r ADDRtss • ^~ SIAIF ZIYCODf ~ PnONf~~~~ gfrvfR'S IIC[NSF NO D R CRY StAIE Iv f PHONf / . AIF m 01 N °!~ Ar ! ~ I ~ IKENSE NO. Alf DAIS r ~ OCLUPARON MNAME6 PnONF NO. EYES IGnI HEIGHT " RETL E R OCCUPATION IIRM NAMF6 PHONE NO. EYES WEIGH( IfIGni 10 ~ CHECK (~ vEn ciF AS aN UnaovFFA ANOTHER °` ^ CHECK(/) " I ° " rox.K CODES -~ c . ,: ° vFn a[AS AN FmPIOr EF OE ANUtHFRa ~ " ' $ „ pa~Dn c 5 I a y ss CODES - slp aAiD 3 a i : . ~:i~M"' °r N ,ter .9R Emloi ~ K µ;.:.DM p AM,N.,KI ^ ue° ^ ~s.a. ^ ~..r[ N°r YfAR MAKE (DODGE Cn[v.l 111 A l~rgvAl SIYIE [)DR ~CONVI ^ .MNA N~f o •Poa ^ ~smR ^ ~ ^ r~~ T Ku v ~~ ~-- ~.~p/~~, ' ~~ ~ E . EAR I F MEVI AV)[ItI IDMr NOVA( l y.) ~ oR ~ u lwtENp. ~ O~ nAnfp nAlFw srAn r''AIE11 sKJ~ H I vFncaoR l ~. A V[nlClf lDfMIfIGIgN NO. TE 1S/ ~ 5 RlG SRVtp OWN[R. USE Sf Mlppl[ PROM i VEnICIf IDEND I I ~ ~ ~ ; , i I I f I I I I AppRE55p GWNtp NO. O W FD WNER. USl rIR51 MIDDIE N F WNFR JI E NAtKEa ADDRISSOINwpArEeeef'~ Acetyl I u A DAMAeeDApu ~ ~ i0" ' '"` i N m CHARGE CHARGE _ D).VAAG[D AAGA ~ _ s esl wMAeE ~ DRIVe ~ Q REMNwD iow ^ ~wAr ^RtmuNFD [s>. DAnNC[ I f tDBr. ~ AWAY ~ toWVArtoer. A 3 maonaKr ~ I DIAGR OF COIIISION: I U MNAI IrolY ~lptp~tn F~ sn[[11F NECISSApr1 DESCRIPTION OF COLlI510N; IInFSwaFMFNIAI SnFFiR NECESSARY( s ` ' Q ~~ ~~,( -~~y~~~~ ~~}y~~. ,~f ~ ,A~t E '~`i.eJ •~"'r ~1U~ ~~ ~(.1IVTf-. F/V .i~ItiG t~ l t~ s .... E QE' ~ . F F iw~. ! ~ G ~ ~Il Fb:!¢a.yOW Yt•+-~ ~ ! h:' [~~ ` J) _. - f~ f ._ 1EF V~i1~j` ~ ~ fYliG C~t ~E+~^~ >a IR~2~ ~1.lrUFF / LI T ~ ~iiU~ TO R NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - 2 ~ 4 S 6 N OCCUPANTS/WITNESSES io~R aDnfaui Fri. ve Aw [ii ux AcE um "„"" u^ ;i wstR Exct ;'c• iv - N ~rss IIRta I ^AM FNI R pK21' ^ "' . ^W i titl,N ~ A [nFss tlwea R MOVm rROM~~ ~K.[.KI O"[;..1 Ra O:° '0 A ..o ' PmstK.A[ ANK New is°f NM er ^AMR Q'aKr ~"rl'o:n. ^~; ^i;H[. JJJ X 8 ~W .41NCY KI DIt~PAICMD PQIC13AKNND DAllp%qRl A OAR o ~~MYS ~!w,3rF _ d2_Lg a,- a~ r , ~~~~~ ~:. ' , E ~~ ~~C~4i ~ I ~ ~~ ..:~ ~~Z ;iS ~. _. , sri "a ~ ~~ _. , b X ' ~t ~~ ~.. k .. r ,_~.j. _ _. tf ~ .Y Ye ''f '~ ~'_ °. ~"E~ams 'fix ~'s~ v.~'ra g. ~u..~~~_,PSv~ac'•~i'.cr~~;r.Y~L i~ eta.: ~a1t ,R ,~ •, wsP rsa ran I wl O STATE OF WAS NGTON axDE ( Dr ~ ~ No. POLICE TRAFFIC COLLIN NREPORT ®TRAfFjCW.~ E POU<EC maz I ~ PRIVATE WAY • mn n.cuu cN c rMF ' FJrpD...,R <ouNr+ COU IY NO. , lYrq. EMV. au ^.: ^ +N Siv [r ORNDNw .,ES Os D O~' Ch,r'E ,~ ON ~I~Lp~! D DlC S (':. r ROUIf Oe IRtF ~~, 9SaOlJ Clr ' .n 5[at„DP a,<, +~ra C~-lirMAe~• ~ 5~ `K„~,Rtt[ s, Patrrx f0 MitF POSE S. 09 I JNrRJ„art ;G, 5~^xeur .ds = untxar3'M,t RO: .N n ' W tir ~ L, D tt cr R„D! ACCiDErvI M IEAGE COOF a DuOanmwln r,vO,vlO ~ R J, r rO~H NO ;`O: IFD~vD enatD_ C Se NGf ^"~ Pjp~. m N X.eD M[ RS , to ND SIRt 1 RaOMOR a[fEefrvC[ ~ Ca0355WR10 ~) nrvEN~rI~ © PeDNar+DnM,OtDN., ^L', ,•tD ^5{~€ asD 3loa.J 9 nns•v,x.,rv.Mr or ce,Fn .rout. xr+DOwNERSNnmt, vDxM.et srte es eoo NC USe t 4 5 UNIT NO.I UNITN0.7 VEHICLE ^PEDESTRIAN ^PEDALCYCIIST D ivfRSNNxt wsr ria r YiDDtt DRV qM f Cf' ~ I Mr qF ~UQ.I ~.~... srattrnw~2 rAP•l S Ee,I.A4..~._. sraar _ s I ~£/~ e U551gIAbRF,a SSBN 73I 6oid FBo nooues II ~^, I l10 C~IH~L,vM ,W z or. n=coq o•:E NU 5^' D c srur Pco orv D !T Z EA#-l~E R 9~7f9-ZIf1`y 376-6DY Dune SUCINN NO sr4r1 Gat r R I t C~,tf-1gGcIH t.,~A 3ZS 732-yrz3 D FeS ~.o6o8g5z PA. M iz z4e ba ~ , CEN>f rv0 Srnrt 3;ll~-RM8g1 LC. wq tx F DarF Orn eEN a6 i3 ii ( a Cx:ruawixW t 6vnON[rr0 l.ES wf Onl M Dnr a E OCCUanriON M NNnt a anONf Nr, [YES n , z NAuy VS, US NAu BIvc170 70" R W[ D ) NNON1 --- - Blv ISS'3D7 ^ CHECK(/) [„c„as :v tNPfor"EE Or.EmorNrc°1 v ^ CHECK (~) ' ^ v' Nrfp. vrN E. .NUn OrE P1 i ~ v CODES-' .f n~~ a / a n./ e~:i°" N ~ ~ n v ss' Dr. .FN CODES-' ~ ~ - , sr, ( eti _ ~c: ~~ v :~ n r Do ES hxorLE . : ^ STM'Ln ,iz~..F 3 o ~gro , .. ^..,. ,,.,cr C~.° CFf,':rf. ^:9.C~ ^o„,. IDOOCt wn Utat E n ~~ ~~~~ n ~yo so,.D ^, yr ^. ' ^~b.rr. v.: ^~~ c.r ^u:' e ~ I l F I NpvSr s e nD eovv., ~~ ~~ ~p ~/ / U/ h1O/l.elf~ SOU ~ c ZD E V v taa ~ Mn^I n[v roxer rvovnr I)Da. O 1' Vol Lgre ~I Are 3~ Y~ P, xrtN rg2c E86 s rEe a.rt NO sr+rt PA H ~ vEN coos IAL~ YAN `ISZ w N E lu1R ~ >9 '~ EgNrrK.IxIN NO 3 N H A 8 5 2 2 9 E C o 0 9 0 l y ~sn mowNte uv N Fc E vfn Ctf gNrf C.N asr miDgt PNOVt NO SRne w a csneSDOwNfa wsr nesr miDq[ NEN 59~~ 3 r7~ L. nooausao+mEa N . Fss Ea 4)r Ea.DOetssa ~Nwa.NCrco oa+eFNr N R u nN N 'Z IJAr4to,w:de- Ngrr~sbvey, PA /•!u•IE,aCaf fytvrHG/gL,~- 57LOldA9u<r,5E9J=t,~a y' D.mwtD rau ° ^ "" ~ ~"~ °o a .c O . ~T , E r!r L_'.'~, ~ I 1 D ` < . • tsf~n ...c r cnaoera rq .wA~ ^eFM..~.,tD ° + cweeE Da~AYN ~utm•n,to ~s. , . Es[rruw, cE Dun,ncE wte r 5 E ~1_ _Gl f~D~- Iw+R~D L~ 1 g n+ p:°1:°nY "W :N~ ~ -. re PrMNxr wD~c oars DIAGRAM OF COIIISION~ lu sw E~NEgssur.r n•" ~'_ ~ DESCRIPTION OF COLLISION: 103[SOPPtfMlrvl,xt swer,r Nrass•err U4.ti ~1 wAS, p.LP„L1 p„-, o.,.tc QJ,, .r~L D2 s/8. ~ ) ~ I ~ ~ Z l..s A'f IJ,L..i~ Ly.~ („p4 S-`SRI ~~ E.!/4'T .- Q ti J sR.Y ~-l 17a..+,t. x.-,60 l:5 uLio,n UhG q~~n..e~ g., ~ C~K. ~tltd ! PoIE o~: Ne -- ~ - 7r . p . . >t STK.w~4 ~'-Z 6p1~ uTS IES ka / P .. . . . ..~. rGo ve0 To A+u.:+nd. ~ )0 Y fdc ~~ r • _ y T `K NAME, ADDRESS 81N1URIE Oi PERSONSI NVOIVED 'CODES 1 - Z 3 4 5 6 OCCUPANTS/WITNESSES icwt aanr.;.',:i N:MU MI w .m .na 'v, wsu Er¢) ~'c' + DDarss "to' a ^ aM n ^.`: ' ^ ^, . ^ n ^ Ydl, n ~ . nD;n•. .,at n ' a D u: P E . mar s•. t c u .,M ^.M ^'~' ^;t . C:. ^ ~lr er +r Y u,:~/~~-I~,I.:r... NnM,.r1 f, .. -. .. ..r~.irx,.:,,r•. N v f~..- rrU D.,17nr,r,~-11 ~ D.11 t~f0 ~w p a"tn n 's1 .aU ~ . s! `~ ~ f ~' . „, Na j ~f"~f r ~ $ t S ,'~ r~ 5 ~ ' ~~~ L ~ ?t ~~~' ~ ,~ .. : _ ~` ' I d~yro, - F r~~srp a f w~p,,,.P i .te J'"P• :+Y,a` ~F' s tl r i I'~ y, y "`^~, ~ rol,er"A, y6 ~"?~T, y"3 E ^r., 5 .._ .~ ,~ 1 x I j rli{ i ' t ` s a I ~ i, ' Jw 1 a I. Y :un-u £ R, w , ~ s 17 rr~~ 4 Rx ~ ~. '. ~ 1~ ` l , Y ~i ~y~' ~ i 14+I n 7~ l ,T~qt' ` i ' i ~, §l i l F 1 1 I , t ~ ~ '~ v +~ L ~, X r k~ ,d'~~i y 1 r r I I t ~F k 1 J ' ~ _ n ~ fe~ ~ 1 + Nr ~ T ` t~ i 'r F ~ J ~ n i ~ b `` 1 r4 lF I ,. ~ t f 5 ' ry~4~ 5 ~ N,„Yt ~, 11 y ~;; r ~ .n, ~ ,; ~hY~ '~ Y k {i 14 ` `.' _. Y ". 15 P ~ ,. ~ • , ,, , mvl•. cn L:LC WLUSIUN AEPOAT lll p p n 1 NO. os sVx wax ~ues o~ ww r~wv ,P , (~~.` S(~ Q`O Sx~w c x,r~TCAI LJ OYL Ty O / ~. CITY ND. f1 A T'lpnp (:J 1 7 7 / ^N ^L ^ R H Px xln . m•LGnawIx,IPIGpR®p ^w ^ ,I„NIIPIEGpn CU1+p oN pr u~w.c ~ q., PEn cpoa ^W`).5%70 O ^ Llw " H 't ' .R41, Lp NLL.p]T /.voar~z.viv-ar O D I.P pcl P.IPC,cµp^Inc N lPp d ~E l ~, x N.I.wDI•xpN,R. NP pP•N • .3 ~" L "e J n l s we ysp ^Mnua, Bcp nwupw ne n^~oe "....~.....8 ~_____ «-.^al[H" ~-~' ^ l PfiEPENCEp OP0999TREET Op AO ~. :.~6 ry` • ~~~ Y OBJECTT6TRUC% M SlECt ~~~ T} 4 '~ q '. V ~ YaTI$n t~ ~~ .:TJS+ ..'..W a~u~° V 5 .- DRIVER'S LAST NAME FIRST NAME - , , MIDDLE w0 cARSN D P AIV S LABT I ' EN NAME //f ~ - - wERE INrocv[a ffRST NAME .MIDDLE --~ &TREE ADDq , S t j -- /1-•J Jr oN OW --~`-"-LARIO-UTE NO. AND BO%NO. wtPE STREET AODgE55 - ROUTE NO A A ~/ F ~ . ND BO%NO. CITY STATE PATE LIP COD D IVER60GLUPATION CITY STATE I . 21P CODE DRIVERS OCCUPATION D ERS LI ,ENSE NO LE SE ATE OF BIRTH qGt y O ' ; . ~ ORIVER 6 LICENSE NO. STATE SE% DATE OF BIRTH AGE VE ICLE P M I OOOOEI MODEL INO -DART - L ( R. VEHICLE YN MAKE ICHEV DODGE MO ~` . , ) C V ; 2 r DEL (NOVA-DART) BODY STYLE 12 DqJ LICENSE PLATE NO. STATE , TRAILER PLATE NO.,_ ,,,, STATE LICEN6E PLATE NO ~, . STATE TRAILER PLATE NO. STATE VEHICLE IDENTIFICATION NO.. ^ • VEHICLE IDENTIFICATION NO. ) Q REGI tERE00 NER (LAST-IRST-MIDDLE NAMEI DRIVERSLICENSE NO. REGI6YERE0 OWNER (LAST-FIRST-MIDDLE NAME) DRIV ERS LICENSE NO. ff~~~~~ S~ a ~4°~i' •` LIAEi1LITY INSURANCE IN FORMATION-VEHICLE NO. 1• was THERE ADroHIO6R.E L Aaluir NSURANCE COVERAGE IN EFFECT FOR iMl6 ACCIDENT ON YOUR CAR ®YES ^ NO NAME AN AD RESS OF LIABILITY IN6UPANCE POLICY HOLDER N"`"L q "O~xIVS ~ LHr ~ ~~5~q NAME F L BILITY INlSURANCE COMPANY C i't ~ ~^ YI/3 T UALti.QTF K' 'd : i•[ ' LfTA'()L NAM:AND ADDRE56 F LIABILI Y IN6 RAN E AGENT -- ~. , -G ,, ... .. TIP, LIABILITY POLICY NUMBER ' - •~• STATUS Of INJURED .MARK FIRST ONE THAT APPLIES ^ o I V NI L rv nl Nr x o i,n ~ I HI ^- ^ P NO xILLED x ~ xr x uxr ).~ NO. xILLED s p, N N I .,I I Pp V In o Lpl„x.•x ^ sY^ s^ n N ~ ^cx o ^ pSO~ I, s,^ n p Y N^~x MOTORCYCLE SAFETY: ^ HCIMEi USED ^ NELMET NOT USED MOTOACVCLE SAFETY: ^ NELMET USED ^ __ _ HELMET NOT USCD SNOW NORTH DY ARROW IN CIRCIL OESGIIpE BELOW WHAT HAPPENED: IP(FEA i0 VEHICLES pY NUMB[A) wrist R4YLJIlp .. .. .. .. .HP,».. «.^l. p /~r.w, n a~ N O/1 /Ieur/' 1//~~ry y.l~t~P:.•r~:--. •IxtHpPx,~,x, ,D~cr ,TKArf'r~/ f'~~.•r ~) c!'/e L vP Yaa/ fij~? is Qe~i Y'n der •~ruyE V•tC Cur » ! ~/u /' Lff!ucJ+- ~- ~ -- Gy !'f-u~! of cur an/ ~Y rs lam' ~ /"ah ~ o'er ~r C'C~f^ Y~~~h~i L1BV3 ~:a ry~d{~ IC -Y I ~~, -}I t t .. _..... ) e (' (; ~ d ~~ VEHICLES POSITIONS BEFORE COLLISION 1 INVESTIUATED pY 11• 1W ~~ V[NIfyE, N 9 L W ON ETRCEI OR HIGHWAY NANE OR HD bl wu' blL N,~(p IN; t^OU NOp L~1 x .,~ f.: - `%rw/M^f ^ ^ ^ ^ ^ al~^M l;O• n IJii ^iplc% ^p p' Ida ppII . ~~ Nr ^ ^ ^ ^ .,. ~. . ^ .. ^ ^ ^pPp K[ W MUpi ell' I ~ I PEDESTRIAWPEDALCYCL15iWASUSINO. ,^LRxAN. I^wN.w. ^ a ,^uiq`„°.N, I^c„~"w'pLiwu, ,^pI~NP I^„",y,~ FO~,•p„", r ,, ' PEDESTRIAWPEDAL CYCLIST CLOTRINO COLOR ,^p,,,, ^ ]^rr~r ^ tIM. I^ YNgAnllcln.Pr,M. t+ 1~;'r POAD WR~ACL WGNIlR LIGHT CONOHIONS TYPE DP ROADAu ~ ( aY. y TRAFFIC CONTROL Ip DRIV[IWENICLEIACTIONS •T ~ /, J yµ , ^ D,tuGr,i I. ,wr, Ix •I nxlt v rr I 1 f? ~ t ~ ~ ` ^JDrI. I a ^n•wN ^ Ir ^ arr.N•La JDNI w•r~YU amc^Im pq upAU I ` L ~~ ) ~f~. ^ ] ^wLI ] ~ Nn ] ^nla, ^ J ^ aroP amN ^ I ^ Iwo w•r I ~~ I I^ aoING IrnA Grt AnuD ~ - 4 1 11 I ~,.~ ^ ^ ] ^ OvIp TA%INO AHD PAEE NO I TI Y ~ ~ i ^ ] SNOW ] ^MnM.1Jfi ^ ^LSIGnIS UN T ^ ] ^ •tIDLGN ] ^POiD aIDI[ ^ ] ^ 4ARINgR OHI TUNH ~~ I L ( i ~ 'l 1 +f~~ ~ ^ 1 ^rCf • ^ N~ p 1 ^ ~iGnIY OI IIT ^ 1 ^ II •anMD PLD WTIPf.HANO[ ~ , rJ ^ l ^ILOOP NAYPI ^ " ^ uA%INp I[II fuRH V{ r~ ~L",~~j•• - ^ ^SPN,pY '^~ CSI r, a ^111n11i~gN16 ^ I ^"4•Mr NO W91R ^ f ^AIILY ^ 1 4AM NOU•TIJPN ! Z~ I ~~ y.'~ nl~ L ~. S 1 OIICI I ^ ~PI (Eli• ^ ^ AP TWO wAr '1k` I• R AGWAY AA•LCTC ROADW AI WRlAC[ IYry 1 llfiNAl ^ 1 ^ l/!I IUgN ^ / ^ BlOWIHO ~I i 4 k~~~~~>~~ ~2+ )V L ~ t 1) j~ , ~ I] I ^ OIIICIII lI•G4•N l•HtS y 1! ;! I { I } r7 ~ ^ 1 ^ OI IA M1 tart IIOAD BEP TUITION 1 SIOI•I•Ip AI SIONAI - ~ ~I T~u S t }~~'~ # I ( ~•_ '' (y(y~,~~))1 .., ~"u._.... L7 ^'.. ^ J ^avwmAr ^ 1 ^ OR SITOP MOq IHAIIIC 4) .'rf ~ {f~~~` PIS a h L a r IjY I CJ fl ~ Na l Q ^ ^ ^ LTOP [D N RU ow Y ~ ~ jyh/~~F'F' ~ l Ct ,f ~ 1A:fi 1 I,~)* Y ~.. n al 1 Jn IN '') ~p~r7 L Ir~ I ~ }jt."Ik t. a.r r :.! ti ~ ~ A n ~ ~xil~i '•!hi'~~ i"+'^TS hn-,~ ^Lt~~' A(, ~ t ~i ~~N~ ~ l ~ La R 7, dl~r .LI' ~. ~`-F_ 1 ,all~"'+v~~'"" k, i1E , ( - '~ a I 1. T ~ U, _ ~ ~ 1 '~"f~~ POLICE TRAFFIC GOLLNREPORT yy TRAIFICY~/fY ~~ 1 ~ I<f C NUM ~ PRIVATE WAY ArE OS CaI Ar II oN nME couNrv ~' I w ~. IR .w . lusf x.oD «oual R~ ~' X * E ^ N couNir NO. an NO. flrwA GF ^uRaw URAI ~- C IY Ow TOWN L DN DE D N oasrREno9».c«wAr ns wun oe r wlES®s D'" ®or pON .r (Ti r~ 9.~.;znn INtER3ECi NG YAf«SRfEt OV ROwp NON MEVSfCr ON f MILE PO31 0[iWtFN L4f[1 a NN reFFl DI LAN D ~ ~ 7 ieOMV iF9 NCE. C90s33rvfEr04 NEAV{SrMlF PO31 A[[IDENr M4f3 3 E MILEAGE w Or CODE DIA 4uA pAt, C9lusION NVOLV[0 Stvf virY: IOZAI NO rq Klt[D~NO. Nx 9f0~ ^ SPIUGf ^Nr6 RUN »+MOgSD~»5 W %-0p I Sf 3 f O4 WAp Oq RLR4ENCE IMFR U5 CROSSSrPFfr04 ROAD 7) % OVLNIClF3 ~ D vgOPtarY OAMAGF ON Y ^ pESUIrFD ^ vFaCIF ~ OBHCr 3i4UC[LNM1F 0 lBIFC13r9 C • ~•~/ ©(p0 ~ ~ U K N.DOWNF4 . NAMFI [Sr DWA.GF SrfCIN CODING U3E s ' UNIT NO.1 UNIT N0.7 p4lvtas N.v%f. uKSr rwst DVEHICLE PEDESTRIAN D PEDALIXYCLIST D - ,~. MI DlE ~u_ vEel NAV.f. wsr Na ~- ^ si4lfr Ap09fss SERtlr DRE53 ~•(P ~ ~ 2 CITY 31I.IF ZIVCOIX Nf NO D it SrAIE ZIPC DE ~ 3 R-S R NO - E UCLNSE ND srAlE sE% I V ~ R ucwsE sArE fk DArE DAY YR E 2 OCCUPAtIpv E6r«OM NO Frt3 WFIG»! MIG»i CS1iFA CARL. UTJ50NS E R OCCUPA«ON AMF 6 P»ONE NO FY[3 WtIGHI EfIG»r D CHECK (/) rL[AS aN UAPioY far,fM,orwERAS ^ CHECK (~ t» [ A wA A A M..I ~;oK CODES-' ~ ~ 3 I e i. b rn D +n ~ CODES -' ~ <i % ;; LIW« R.~ I °°1 ~n Z. ~ ~ C, ~ ~us45 F" , w,. ~D A.M9,A»< ~ M° V[« YFAe 4IDODGE Cn[vl MODEL IDAVi NOVA, ~v~l1)OR <ONVE` v r « Y v f ~n V [ y ~ ~u~ ~ I E ta K L , Ipn9i NDV,I l Ixp9.. , IP :e l ENZt NO. WNT ~ s An u4 nAre NO Arf H Y » caoR AN N u N All AI No Mq ~ . ~ VFNKIF IpFN1NGrgH NO. 2 3q( (0 7~ C L VE»CIt iDFNir CArl NN - ucurtRED Owrrca~ I4sr MIDWE CN rEaNE NO ~ sn pow,+Le~ us rl9si plt NE No la Z ,DDxuaow+9tR W N a IowNE9 xl s ~ E NuAea ADD4euo wsuRAN¢co o4,ctNr N ~ r u AN R ~x LsrusAUO%RLA ~ ,' ' ~_ «•' c«,a ct cNAe~ vM i Acs' u r o ~; - ~ i s I s ~ E ,GI ~ ,Wiv ~ R{MYNfD ^ ~w,vN ^4lMUN[D L r pAM,G! n~ s roiSrio~ ovrtD r o I~ = owrosr S ®' e J ,r V IF D DIAGRAM OF COLLISION: Al Nnl~~~p NOer» DESCRI ION OF COLLISION: lus[suPPUMENru SM[tu wcsuA9rl SMtI If NlC[SS,PYL ROW xs ~' VEH• WAS SOU'T'H ~JOVNO ON R,y00y UQ. . _ ~/~QY UQ•_ _ - _ Q FIND VEERE,p Tb TNE. DEFY AGR0.Sy~ _7HE L~r n ( 9N F U /~~- -' lU ~ F, q/Vp RN Y LE T ~ T ~.,wQ a,2T//g^UNO c..gNE ~E ~ f s, -`~`~ ` g..-- Q~ _ ~ _ -THEN ~RAVEC.E.D INO FT~ gCROSS R FzEc.n ~ qN0 772UGiC A 772EE, ~ 7NERE ' RE LUO cSk~ca F.+gRkS; ANO T!`IE -- ~ D,QZVER ES7'g7'IEd HE F~E L_C. AJGEfc P IR ~ . . NgME, ADDRESS 8 INJURIES OF PERSONS INVOLVED "CODES I - Z J 4 S 6 N OCCUPANTS/WITNESSES .n:oD Oaiiiii.+u Aw i~ st% Aa urus '"„'" ° M R um tna ~. iKi " , N DD.fv ,MI uRl or R D,M e DF11"' D m . DC, ^ :46s. A NO ~, DDRI33 URI O• . IM ^I~IRDM n,NO D:. rl Dfn .D: ^;: A ~D rn R r , ~ ns r.G K N, ~ iy xua nr D,MS ^?. ° Dio:.N O~ ^ :` " . X ~ ) /~ BD~UR AGL rrCr rl vtl~ AKt DtrAr(MD ISA Kl~R=1ND DAlIq RI NDer AMV~r~ U,rl sid C d ~ Ay A ~ ~ ?m. L V~ ~ ~. F •~T11t F~ ` Cv~ ~ ~~'. '~3 S •~" "" "- . _ t, i _ a5 } r, ~~ 6A Y . , ~ ~;~~r _ Y k Y ~.~ .A I ~~ I ~_. ~~' huF f, ;_ ~1 PO CE TRA FIC COLLI:.u!9N REPORT .C11 1~4FF~S+AY I\V. ,•~ 'f POIICEC . NIN NR /U . N F ~ PRIVATE W ~n~ DArf iCIXli N D i N ulf COUNrY .. w.. COVNrY flO CITY NO + r i .r IUS[]gO MOUR _ I rNWA ~ _ ZJ ^N ^[ ^iN <NYO fOwN NA[6N0. Of Sretfl OR NiGNwaY N f 9pUrf of ~ I hVlfS 5 ^W p N Nr 45fCNNG n 5r4FFi 09 AD N1Nr[PSFCDON ~S~IO . p9[N>< f MI[f pOS lFtWf[N r SrRF[t 6 ~O STR[fi (/. ~'I~ DiSrANC[6D4 i i ~ gOM V[iE9FNCf CROSS Sf9[[i 09 NFAVfSrM rE pOSr ACCIOENI RAMP D D•rA MntS 5 ( w MILEAGE rF(, Oi CO E D COllSgN vOlv[D fP11Y ~RD iOrgl NO NO k[I[D,.,~_NO INlU4[D~y ^SV l1AGt ^ Hr Irv I IMER Cle C905551REfiOR eOM4 Do R[rE O VlN CIf1~ © ~'^pgppfgrY pgMAGF ONLY ~~ \ SIX[ .V OR'rvs ^ ^ RS ~ !9] q U,IED C '~ S~ aO OBIFCr eIRUCK IN IfCI S1RUCk AND OWN[45rNM I~ ~ ~,~ -_FiIS qGF SRCL4 CODMG Ibf S s UNIT NO.I DmvFRSf t UNIT NO.~ ^VEHICLE ^PEDESTRIAN ~• : ucsf E iws Mi If Dgnfu's NaMF sr ^PEDALCYCLIST s ~ [ SrR[fiq `55 •V 9 SrArf r4Ffl gpD4f55 ZiR CUOF pNONt NO. D Y srAff I1pC NF ! R { PF9,lp[N N ~ ~ ~ OCCUVwr10N ONL NO ~ q rn f~1~+7/~ rv~ ~ W yUCEN5E N0 q[ FK Du oa e, IN ~ Yv _ EYfS Wf1GN, NF GNr ~~.'~~ Jll p, !~ ,^{ L71 IXJ E R OttUVpIiON MSFd pHONf Np, A5N Frts wflcNr Ia,cN r ^ CNECK (,~ vFN ar AS:N fMN:ovff or •.M,orNl9'gl ' ~ ^ CMECK (/( egl vFN n FgsAN fM a or q CODES ] n ro x+[ +i s N1Kr oN a i° nartF ANO,NF CODES - * G ., ss ~ .cYCn ~ inn:Nr N s IR n so rO n N iNE lmlts 9 ^ ,r NN A9 tlDDaf <nfv. (I^jDAgI NOVA^H ~I[ RDO ~ SY ^^'^ MI ^•UD6cl ^~orNV ^ %H~BA EM M `t ^1e~iav v" ~~ ~~ I^ ONV (Y ~'I E q I t V., MGDFI IDARI NOVAI ,] .I °e^' l ~ !.. l.9 \ I [NG Ale4 NArf NO S surf H vfN.ca l m 1W ' ~- B 4S .r~1 (.A/ 1 • NG. A f IX K 1CIF1 C•r 10N NO. C vfN CIf IDFNDNU , N .~ 7 9fG11R4IDOVm[R UlSr I L . I4sr MiDIXf vNOM NO. O i IFR OWNFN: lAer N95r MIDpt Il •DDR[53OrOWN19 W '~~~~~ N NFR A Ny[j a•D ,NSUeANa co D4 ACwr E l ~~ u N --- E4.3C. R ~ •.. m_ awACto ~1 v po, r ~". w v cNA4~ ~ cNARCE 1waroNO,., gun•cro Axu 1 5 - S ISr pAMAGF ^ A w!N 9tMMHfp orwr9gw,e N ^R[MNN[D f5r, 0AMAGt ^ ~ , ~~ AWAY E Ide"onn f w`i,:D r 1L~.i ^:wiD M U p er DIAGR~Of COll1510N: su N N cgrt ~4lN ESCRIPiION OF COLLISION: IUSf suepurnt A15Mfr NttF5tA9rl M[hl Nl411•PYI ~ ev.R ow p Au~~oa>_T- c .T ~ pE ~ ~~, W WnP,y 1+.r bk~s --a l,~ Y6h , ~ , ~ . E, I ~ Ip 02~c~.T~ J Q1J O -1b l:-!jRpo}2.T C.rtTo~F 72d G ~. 1'YC~ 19~ E.OSI~q CoAJ~V-o l_ D'C= - -_~ :-_- YBh ' } f , .. f r ~(~d£l, ljQ.13~PA~rtrlt~ _ =~,-.,,~ lT~E+u(--~z~~r ~ IoRnltoS ~sssd. ~ F' Lk~ h o%~'~ ~ -Jf e nis ---- ~ lo«lu~~~ ?h I. ~ 1 c.rd NAME, ADDRESS 81NJURIES OF PERSONS INVOLVE OCCUPANTS/WITNESSES ,['u s[AnfwmAl sN o9 AODifIONAI N•Ml fn sl ~ DES 1 - '" Z 3 A 5 6 N AME ivna -TAYYI ss 1 0 ~ (N+AO[ q ~? 3.Z u. Act r•ru n uR Exa , ~ ~~`~" O4W.SOrvr ~ 034 3 s • N DDefss 1V X Iw + Ho 9~Nrcrvror9frn ^wMe Y KI ^<o I ^ N ^i9i • DD9154 N•rUR10r tNU{is ill J MrISrK:•IM- 9,[XA 09 ,CA N<Y X ~y _ ~IDS••1CMD fU fCIM AY ^•M9 ^~+' 19^N+ ^1i, K(~a4 vJ_(y D•llgvl Ki9^1 r 1 ._ I r fF.-.[..L 1r)/iIh I/)•. Mr-I'!//~ I Id rn 0.1 r;~y~ ~ I ~ ,\ ,t 1 ~ F ~ y f ~. ,~l A ,~ ~.., ,. :Yr- ~ ' i~ : ;; ~, f STATE OF WASHINGTON AGf i o, t No. POLICE TRAFFIC COLLIJ REPORT ~ TRAFFICWAV o Nt1wxR ' 3 PRIVATE WAY ~ ~ Il.f .. -- P -E9 cpf, N l 1 I nmf cou«rr oDCw~~ In ^ T '- ~w I `•. I ~.)S uu.'x T - fPr lusf 9gDHOUa1 I f1M'A ". , ,. I- ~rJ - ~ 0 7l _ SEfFt5e..5~+Na _3 ` pN pE pIN CIrYOe IOWN feNO Oi StR[f10R OHWAY ?J ~~Mnes gs pw poi oR ~" ,~ .cR ON iR Rl"G.,RTuFG ..JF ,' - - ~.J-/7'Q n INIf95fCt NG VniH: Slvffl OR ROAD NON NifgySF.C.11pN n /1 {ylv Vyfp~ ~•'°h-' B[IW[[N I IJ LIC ~SIR[fil /'IRrvRT ~DSIRFFI ;' O.B~ ,~ I~~E W . mN J s ~ jY ~ e 4 r~i? ~~ ' ~ t Irv . ~~ R ~ ~ ;~ ~ . c n S~ ~ J p; ~ ~ n ~ 1/~. ~ ~ }Al~I ~ k?erl ` ~1° ~ _, r {:+ r ~~ ~i 17]gpE :'I f54 f s ~ 7 IJ fe _ VP~ (~ ~~iFi^: G~ ~ F~ A Nid ~ fE3eL ~. . ;'. ~ ~ ~I~~~i;~ DR ANCFeD t f EFe NC CROSS SIREf OR NFAVF51 Mll Its N s F w ACCIDENT E M r f ;, • o O fftl Df d CODE CIXU'IONINYOIVID. vF41Y OfAI NO. NO Rlu[p~NO. NJURlD~ ^ YILUGE ^Ni64uN .wM Ih'R CLS CROSSSTTRi OR ROM tl VFH CIfS ~ pPppngrT DNAAG[ONIY ^YfSftllt[O ^vM Clf '- .S.R ZO OB1fCi SIgUCR INAMf Of OBIfCi SigUCR ANDOWNEq'S NAMFI FSI.OAMAG[ ~ ~:_ F.':. _ UNIT NO_I -. ~::VNRNO'7 ..,^ VEHKLE. :i: p PEDESTRIAN.1:. PEDµCYCUST Wrvt NAME. IASI ilRS Dv VEq' NAMf USi I I ~- i2\ W ~~ SletEi AppRl Y D nfr ADOn55 urf nrcoof RHONE NO I sAf suc .. .,.. K.. ..:.. DA eRrH ~ C ~ R.~w Sii 't ~ 8 42 CUPAIIW fIRM NAMfe PMINF NO E MD i aY I. . [tt5 GNi wIGHI ~; ~~Tafu w~r_~a>< coysra~f.tloN ~ /F, ~ Sri URA ION FIRM NANFe RHONf NO. Ett5 IGHi NEIGNi p CHECK( YfHnfA • AHOrHfe `'~ ^ CHECK(/I VFM CIf AS AN LM%OY F Of AwIrHEe CODES ~' ] ~ n ~ ~ s r e y"1O,H ` r. :1'~« m CODES - * ] ~ . i 5 u e y,M° " s~: ~. ~ry .cu . IN Inlfs I ~ d- L -ar wL.. .,..5' ~` N I ~f"~7: '°'" f ^ ~1 ' ^ Fd:~. ^ H~K.: [7 r.AH:, .r ;< wYi.°°'°°"" p M,q,„Awf ^ :1' ^ i2rn. p h~K~ [J :gym. VFH YtA9 MMfIOOWf~CHtv.l ID , AI tYV:fRDq..CONV.1 : ~ HV.1 AgpfIIDARi~ H AI Y 1 v.l f47 Doe ;fER RA~ ~ ICEN tf SiAif RA FfR MIErq. SiA Sl i VEH. A .~ PR H•aS4 ' ~1Ns;; W A Y,HR:feIaN,R¢A,Rx+NO. T ~'` vfH IDFND r I .. Diz ~- s o z 3 Z I I gFUSRgfOON?Rq IASI fled MIDDIF hgNf NO. R ~' S 3L-RR g I R: 1A51 IIRSI IDDIF ADDgessa owwR N 18 ~ A1T i .~ .nn 5:~u.6L~A E-E aAGFNr ~~ NAMe eAOwfssa mwaANCe co AT•}"iLCCd'apf7R RRf-- . , O.tJ~ 'f-: q, AOf AeIA ' d ' gANAGfDARfA .u»'roN.°.M CHAq a r no.w Z1 cnARCf Cr,.. rt .. s far, DAASA~ ~ oo ~ N ~ nMMNfD ^ iw^v Fy to ~R[MMNFD "`"°' I•~~ ' f~cloo °W'.°. E. L.GrT' Tow A Y 'O:°R:9.Y. s LL .. pRrlpRrH DES DIAGRAM OF.~ION: RIPTION OF COLLISION: fuse surnefxNiu SSenrt wossAer) C ' 1 .___-~5.:6~ .f _,eC~/~t C.fIO ~tIGRTM n AJ ~ iRAORT' f ...~ LA aT' Go~~D'.Sr ~ N _.3NOw 4- Z` CaG .' . .. .. _ ... -- _ -- _ L-fi>~._L-EEY G.~2.fs~~Bvaa, wAV ~_~ -- - - .. ~._ _ -_.------ I ._.. ~.------- .j .J I ~ _.. _. ._ . - _~~ ~ ~ f K _ --- _____._ ___~_ _____ ._.- _. _. _..__ NAME, ADDRE5581NJURIES OF PE RS ONSI NVOLVED CODES 1 - Z J 4 5 6 OCCUPANTS/WITNESSES I p ~~ fq~rf k rA'iAW A SIR AGI tA1U5 1H Nw v.~ ~w~ wsrq uici ;;D;, NA.w v A/!a~( Gf~..f_i'!> S . ~~/ « a42 ,3tUS' : 1 .onrn5 9' ti ~ e .R.1 f• lfWCrClar f C S rDR Rcls+Rkp .A e+ AM e ^ FYI' ^ ^" ^ „^: ^ T,°ln, .-.. NAMI _. _.. ~ .._.. A~ 115 Wa ord A~ DrvoM pAMn p~Af pi"orH. p r; ^ ::'N.. 1 N fl ,.::.I fRwtx ". ;,D~°~s°R .Ewe. ^•Mn pr^"•'p'ro:.n ^~.:~.>. ~: .~avoewH.. r. nNAw eeAN. X n qoR 1 Acfa:. oa:~IVI w SP ucl 7ms'nrc,RD °rr0 05~ fa¢Xt ARVmE~D 4.16°wN Dufa n.ar .Z'9't°S' ArRROaoe ~ f, > own C ~ ~1 ~ ya ~' .~ tr ;- . 4n ~ J ~rr; ~ ~' ~ ]I .~ fJ t}~ ~ ~T ~~' ~ f~~~~ a s 3~4 , M . A !d ~ a y,_ ~I ~' V iN pp '_ ~~I~ (~ D ~ f s'. ' ~~ ~ " ~ ~ ' + 0 4~ .4 W tY K5Y'J~{I'`£ ' 1 I ~ ~" A.~ ,,gg gw{t's} M1r+51 ^I~A~Y~1 _ k ~7 .?yr `~*°t: F! R ~~ i! ~ - ~r ~ 5 s . 'fk .a ~~ 444111555~~~ r~• ~~~ a ~ ~~ ~ , r + ~~ , 1-, fE. ~, ~~ II µmY,~A xl ~~ ~ ` F ,~ ~r, ( JE. ~ 5?l . ~ IEnn J I ~I X~~ a~ ~t~ ~ ~ 'S~ ? 1 ~ ~i v RINf~~ ~ fUA ' " ; a2 , r.' ,' ~~ TRAfFICWAY POLICE TRAFFIC COLLIS REPORT roIKT;S[]M Mxl1Ma[R 3 PRIVATE WAY 0+!(o GP. I I3. ~ ; 1 ' .. IUSF ]pO NOURI COUNTY COIMIV pf1H\NE 3 ~ pN pf pIN CrYOR TOWN . [6N0 Or5rRffrOR ERLNWAY MIf~(~5 pW gJ Lr PoRT '(o WNcND ON YIt RFbR7 CJJT(oFf. R -3 /70 INnauct Nc r swRTOR ROAD rpN NRRUCnoN ~ Rplf < r . p~ (] ~~~ \fiW[fN~~TEJC IN50 SIRFET6 5'\~.Q SrR[ft (~3J D ' UPS A 6 I ErwFTF ;vOSS StREf OR Nu fal Mll[ ACCIDENT DI MM1ES r 3 f W1A . Z MS P 2. MCODE E rffT Of ~f ~•ll r' - - ~ ~ ~ ~ ~ causpxwvavfo. v[RI IOTM NO NO.tIID~-NO. NIURFD ~+ ^SPIIIAGE ^NR 6RUN CrvfnCl[5 ® pRRO^EirY DAMAGE ONIY ^rR[SUSrFD ^VaCIE N, 'pno Z' ~ ' MI/ Ct3 I),I fRO5551VCRTORRWO - - ' ~V~'T C ]D 1 / WhCI SIaUCR(NN.1F Of OBI[CI StRUCa IND OWNERS NNAFI FSt DAMAGE .. . SRCULLCDDVaO J ~1 5 ~- -~ ~ UNIT NO.1 I c ~ '~~ ~.UNITNO: S;: [-., VEHICLE '_ ~~p PEDESTRUW ^ PEDAIGYCl15T ]' i DRIV[R'SNNAE vl3 i145r NE:WEI 1, (`~ {,tSS G ' RrvFR'S NAME: ~ Sr ~i. 16G~ O~S~oRAI '~ A -~"" DDaess Sr~4 NS RA! nitE,(Z -' ' ' =. [ AoDRfss - l ! z~ T L.£R ST n r surf Rn zlRCOOE oNE NO. ~ D ~y A ~ oRT I.U w~J Wfl 4q,3/~S tF37 287 R WA 483{4 AJou~ YORT 7wN5WD I~ - rv R. [ , ..... NEwELGG~ia LN A : Wq .- n1 ci8 ~8 3~{ :: ~ " ...: oR,sBoSA 3~50(,J wA x earn /`/1 oR Pb ~6 .+~ \ 2 OCCUYAIICRR RM NANfIRx)N[Np FYfS IGnI w10 i 4(Lo~ scaLfucarrs><kV• @R~ Z Sto CC MI R CURAt ON NRM NNAEB RrgNF NO. FYEqq GHI H:IGHI ~aR.P. Nv3TPar,~ ConkS7• CTW t Got 1~ ^ CHECK (~ V,NKUA • ANOrnEO~ ~8 ^ CHECK (~) ~ VFNKIF AS AN xMIOV(E NOrwN l A °""` , CODES~~ 7 ~ S e roN („ 63",°wn Y • , S ry " t A ~ x.cu~ CODES ~ ~ 7 ~ ~ n NI l ~ . n p 2, N, . ucus ONL - ~RA7 ol.i ~ pOSyE N R J D W:;I.DM p...MA.»<I p ~ « p ~b, .N...1 s. ° V ' ' x ~:Br .RN.T KI ° M,. p Cbi~a ^ nN 1 ' ° ~D KN rEAR \Op'al6n[V 1 Ay ~.J S~Y~E (] .I R fl I , . .( ~ ~' RED Kt_E.IGz STAI IWIER RwI[NO. 51 [ w,~ -- - H. r~•` ~~ Vfn. G2nl I A W ~,o Wq - - „ V[wClf ID[MIrICA1gN NO. 331019 fl¢1Rl~kis' 311 7 -i-- . L: VFNI ID Nil I It O O 227$ q r -"-~ ~i~ ~- RfcRnmoowrxR~. usl nasr Mronf St-11•D&LER RpNE NO ~ I o vmf lul ~, f OR rl ...,St 5BoK ll ~ nbN~ „ 5 . o 1 ADDtt33d OWNIR ~ 5119 Tt~1s-r~SE P,-Al M, III TyLEK S7. NAMe l ADDRESS or INwRANCf cD. a wwr E ~ ' ~ ER 1N5. - BFavgQ-GoTJ ORS ~' ~ots& ]] DAMAC[D wu NaN 5 . r,ici.o_u cN ~ \TOR 1 CNACr DRIMAG[OMGa I,D ow:o"r"w I 5 13T DAMAGI ^ AW~i ^REMANID _ _~ {~.> 10v,TU 1 A sr Q,R,IGSO ToW ~ U ^ AM r rOWTD RIV yN RfMNNFO ES M l 10\ortOii 5 ^ Y GAf1 L~ r-' DIAGRAM OF COlE1510N: ~-~+~~5 r \r ~R "DESCRIPTI -T~Tr-~~F I I I- f~-'--- uW4V5~L ON OF COll1510N IusfSwruM[ ru sncfix rxassARrl R2 ~r+ws foTitsi@tiv-LD or1~ACIZFliR%V_G~7p-of~_ ~ - c. _ -.,.. __... _ T ~ G "- r> . _ snb'u5. ~!z cRo~t~ a~E tcNF?o4 4N 9 ~ ' G~+J'P~ _ ~tLNf 9n1.D S'TTZvGK~I~'~I SWF„~,V~ 1~I'VO 1 r _ .~ ~ . . ~. __ __ _ ' ~))51oA .NtADINC WRGJ $QyAtp, "D1RrN ~ a ~D ~ ~} _ _ oN AlR S ti P : ~ L1j.L'~P _ J .._.( _. ,. _.._ . \ C.. _ I . NAME, ADDRESS B INJURIES OF PERSO NS I NVOLVED [CODES I - Z 3 4 5 6 .. OCCUPANTS/WITNESSES E T DSES OR A ISnEAU Dpigx4 musw NAMl> n I _. S[. ALI IArIb NNN L rNf pSIR IACI 3, ~ir AM, N . .. _ __.._ _ _ _ _ . L ua ~-za ~ 1 I :, D A @ N . D[rESS e ArIIREax~IY N [ RY AMe . f21' p "" . ~~ O' I t,' N+R p AMf ... . . _. _ ~ l . . .... N onlss Aru\ d . ., or. pAM. pEn11 ^~;.. p H ^ :`. '° n . Aw w . .. .. _ ......., .. . . ti R mnss ,AIwG. Ita . X ~ \4XA 0I ~ . NAruft]r_ .NM s AGNCY ' ... K tCMD . \r. NO p• \ p'""' . p DAII 1 ~ H; p" DArI , . scso h7~2 °5 ~.,~N~ ~~ oZ .a ,~ ~ t~, ~3 w. 4 ~t ,p ~, Y~. ~.. 8.... ~, r~~ w a ® IYU. TRAEFICWAV _ POLICE TRAFFIC COLLISION REPORT ' ~ r IgICf cOMR/uNtNw10[R 1 ~ PRIVATE WAV DArf of ausgN mn n .. oar ur ww Nt n wut Nl~ a nmf IV${].OD NOU RI couNrr couNrr NO // arr NO. vuwn. []URA 2 ~ O - (f / ~ ~N p[ pIN CItY ORIOWN 6N0.patvfft GR II GNWAy ps pW GI C' N u ON NAMF U ~ m,If EC'1 [13 RWrf OR 51 ~ y5/>O , ~ ttRUCr N tN. sifltfroR AD v 1 ' oN NrtRSF noN RFtM'F[N . rRFEi 6 ~ CvC (/pRiff vaNx fo. mluvmf ~/ 1 • / J ]I CrIONIW FvINCt CROSSSIRf[ NtARFSfM IE s sIANCt 60 s F '~nn '.11 tfr W OF Y~ V ACCIDENT MILEAGE CODE v DIAGRAM Min a COIUSgN v viD StvIRNY pav llAGF pNr6 RUN NO r allFO_NO. NNREO_ O ~~Mr.nwui~~ IN INIFV 'RO CIS R CI SRf RROA00R REEfRf CRr653BIjEi~~ )1 IX VFNI CllS ~ ~RROMRIYDAMAGf ONtr ^ItfSUlrtD tl O G 9 OB,[Cl arv«xINAME CR OBIFCr arR«vaNDOWNtRSNAMFI fSi DMnAG[ SE[CW COOING USE / g UNIT NO. 1 UNITNO. Z ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST ] fR'S NAME: Usr FIRST ml Mf aNAME. USr I I l ss s ~ /~ /S srRtet DRfss f arv surf nv DDE r"oNf NO. D I r srAtt f,vcwf r,E NO. r R NFR's UCR,sF NO ~ -_ .7 r/ C tArt fx ~A F O'Z ~ ~ I E Iv NCFN NO v fAt[ x ArEWBIRrN "'°° °Ar Y. FEIGNI G B~ G GNr F.IC «rURAIION MNANf 6RgNF ~ O d R «cu AnoN M F 6 RFgNE NO. FYES I Ni ^ CHECK (.~ AuolNrw ^ CHECK (/) ~ NoIwliAl w N GFw CODES- r ] a 5 I a "O,p4C" x CODES - ~ ] ~i S t 0 v » Z S D Ni O .wM...«I ^ F. ^ «.,I. ^ w:M ~ ^ ~~~so ^ rwt oc ^ Aw Nrl ^ ~, ^ 7S.rt. p H ^ ::~,. D ~RU t MA.F IDUWECHFV 7 FOB ~ W~~ MODtl1DARYnOVAI srrlt f]UR coNV.f ~~//^1~ ~ E . 1 NN_1 M01%l ARFNOVnr .YEAR I DR 1 ~ v O iIA l< [ N X AIItRR Arf NO SfArF srAtf 1Y I'E c l v OR l A l Np. Alf ~ ] ~ / S ~V , / I K /. /.l ~- ~- V`~~ I ]V . V ~ I r Q ~3 NNKIf IDENr,FIUtgN NO 7 L v ICIE IIXNIINCA INN PlGlar WNIR: USI I,RSr MIDDLE RgNf FN, O PE 'ISr! IU DWNt Y; lASr NRSt MlppE fNO. R NlR- 0 O W n s FOwNIR Ayl ADD E55 W N // NAmESA lass wsuvurttc uv AGlNr rCU - P - t (Yt1E1Sc]W '~ I I R INUA ~ V D.MAGEDARFA .1L+Q°'.. a f flo:ori~ t.I o ,w, ul~~Dwi.MAGI cNARGr ^ :w it ^RIMNNIU ,~ . . cluvcr ~ ^ ~R'~y' ^RFMAINm W c ,:nr t r. uAMACt ,D~ I f~aAACfD.nu ~B~s st ~ fov. vDer~ A ^~w:r°Br f Vr l KAll NOfrR DIAGRAM Oi LOLl151 ifuafrn NiclssARVI I er oW DESCRIPTION OF COLLISION: Lust auvYlfMiMAI SWNUNFCfS5ARr1 ~1 ~I1O "~ - Ll4/r/r~e LosT Co»T~foG OF (/G-yf~cC~r' „ 1' A' mo~~J /cE, Uc71. GG/7T /QUU~lctJ~9fi ~~ ~ /'~~a/rT 04'v//:fy ri+•+To ~rJ' TU~9 ], >e Aiaffaxr cuta~v Rc~ /I~ ~ ~1 7 1' t° S Oµ S I NAME, ADDRESS & INJURIES OPwgR NVOLVED r CODES I - 2 J 4 5 6 r t I OCCUPANTS/ WITNESSES roRADwuoF,uNAmt y u. Au uma '" s wuR Ntn "',.r :u I Att+na wEa ~ tnR er p AM B p FS^' O ^~ , p N p Cit:,>. NAmI ~ u nr nss NAru.Fa ~ ~ImrfRr IRGM p~ p.": I p". p Hx p :` o Aml ~ .rR»nc H"ruf5O1 IN pAMe ^r:"pS". •pN ^~i u X ,,,rfs~~L~=l••~r_ _'. nAnu .r,N,c. ~. ~funvnrcl«D Iu151 ,ytn DAtt ar Rf rfwt Dnn "' WRrv: ~ : t ,~ f ~1 n ~. , V ~G Ir. ~. ir~fT3A.3 , ~d' .~'N ~~ we ` t~: ~• ~ h1 '6 ~, , t. ,~ - I l>< v'y ..:~+:d wSP I50Iq[V. ... ~; } l ~~ ~. r_ ~.' 2`. A ' 1 / '/ ~~~ POLICE TRAFFIC COLl15~4REPORT QSI TRAFFTSWAb ~ ~~ rollefe aN eeq ~_ ~ PRIVATE WAY ~ I UAIf UI Olt]ON A. llSUN r COUNIy sf awoilouRr `-=~ os 1i 65 q,. ,,., rr,n .rq rw. . ,.. 19 o s T~.F~~So/J rY NO. CIry NO, inwA ^ugeAN gAI r ^N ^f rtYN CrYOR IOWrv f6N005[RffrU4nGnWAV Mrl[5 ^5 ^w ^Of GNtMaCV GN R~JO'D ' 995 RWIEORS[ { D Crr 9.3-zoo rNrfNStCiwc vnln SlRtt10R WAp NUNINrtRS[CIION p euwFfN CNI Acv slRnr a 41E UATlr IS~RiFr PRI{IX F MRF PO51 ~f'~ 0 N[f Ap v(MI ON iRUm vtif ufN I. CROS51rRFFI OR NIARFSrM IfP 5r ,. - i 1 IES ] E ACCIDENT ..MILEAGE P DIAGRAM WIA ~~ ( / ~ .XJ ff[r Df CODE Olll]roNrNVIXViO fvty lr: l r0[AtNO NO .AIfU ~ NO NIURt~~~ ^ SpllPGf ^ 1 R ~ M v ~NVpviDrvS N A.qO IMFR Cl5 IN Ctl rRFFfORRWOOA RFiERFNKE WOSe]rgF[r Oq gOAD ' ?~ ' «vtnrus ~ PROngn DAmnc[oNlr ,,,,, ^LF ^5O1 ~, 9.~7/`~7~ ; (} N/ Otl:ICiSfROCA INAPtO[GJNCI ]rRU<A AND OwNtR']NAMf) FSr.0N.1AGf f -- SnCIAI CODING USf UNITNO.I UNITNO.4 VEHICLE ^PEDESTRIAN ^PEDAECYGEIST aA f 9 DgNlRS rvAMf ul5r NRSr EL Got oN MIS DRIVFR'SNAmf: r Nv ~i (~ NGL£,IX] / ,o . la.. .. SrRtFIADDV[S] oL m3~ v)t_ sP~3q ~ol&~c7 rnfr ADDVfSS Si Nq~T tti. Pa~670 ~ E rrv cow nonF NO A D slAf F P No P . IAA wq q$339 38S37y9 R ~/F1ToAi (/i4_ 9 s8Y 26-!!k~'; la a- tR'$UClNSFN ~[, ~'~~Gg~#gyf'A ]rAII wa Fa rvT I rn io^o•i 5~l ( ~ I lKfNSE NO 6L~F 9• ]rAIE 41A /'') o DR1912R ~ . OCCyPArION AMF6PnONFNO. [yl5 WEIGnrfilGNl E OCCUPATION MNAME6PIgNENO. Ftt5 WfIGHrIEIGnI I ~ Kt.P>; 3q(,-~.(~ o ~ 210 /<D3 R Ns. 2G-~27a / O ^CHECK (.~ la,[nlcl[ASnNC°vio+[rn[al~Dl«[eAl CODES-' J ii:s~ 5 , e ~^'.° ~- ^CHECK (/) Iv ' F CODES ~ * ~ ~ r, /'c FA,'AN Fmnor~ A~ iHFaAI G ~ - ~ _ 3aa IN NorJ~ ~ 7 v~~.~ W ar~ • sc . ~~i mA ^ I mA.f IDOpG[<nfvr oon lDARr. VAI s.~E Ia DR e Y Mu I F enev.r l1DARr.NOVAI ~ a v.r [~ or l ~~ '~U~ R ~~~• ~ ~ ~ '1 ` A l v IAIf NO ]IA RARtRRA1f NO 5rA1t H R I A NO Af wHr~{i !-1MX531~ wa ---- - ~ G/NT HN - -- I (nrClflD[NII[ICAIIOnNO 8 9 s t.~ ~Ig ~ ~,-1-;-:-I- nGr]ReFDOWNf e' NRSr MIDDI[ PrKINf NO L v CIf ID[Nrlfl I Bh >,2'R ~ K~~,S ~y ;y I IF VFDOwntR w]I r D 5 ~~ SAME W . l fIRS MI IXF SA/h`~- n NffA, ~ u ~ ADDRn]«OW*l[v 190 oL nl- o E R - ?T W N A , FR .~ r' p v r AGLE.n~ p, I l ~ A• e ~ Dvus«~NwRANCf co. oR ACFNr SAAD~ co - 6 ~A~ s- .as R A r ETNA I i~vs. ,laa '1 DAMAGlD AYfA ' ' /{J~ I Mmlcip.UiN CnARGt «:,r O ~AMAGfO ARfA [nAPW •: ~' V!r~~arv,N p`~ 's' N[p ~~ o.i ^ °1 .t{ 4._:,:_,,,J] - ^R[AiAwrD t01 • [ ~ f Aw.r ev ^ ravrto f ~~~ _~ ~lC'1= AwAr er '~ Ir AGRPM OF COLLISION: ili}turlt l EK "~'" I , . ~ DESCRIPTION OF COLLISION: lust 5urnlMFNUI Srgtrn NfcfssAgyr V~yv/~~ ~; .srAf wFSr,~~o a„ Aes~y rye/uf . .. R~N~y na, i~r a i wvw l~Hiwe ~'a n~ u!FSr Eo cti+/o _ T~.evc~ _ _. ~ I Q1 /N f.(tkUT. Of ~'/. - i ; ~ . Ir NAME, ADDRESS S INJURIES OF PERSONS INVOLVED ~^ ~/ / 'CODES 1 2/ 3 4 5 6 OCCUPANTS/WITNESSES io~.%oD~~a:iNA].n iir • -' su Acf ums '".;;" n w n[u uil. r rKV: • Dfsns ono. r s na w. ^AM e ,'ti"^ ^ . ^„^ ^7: MI ~ -.- x+l.a Drr« . Y ~rs.ovmfgom ^.M "^^ .^» ^: '0 AMI na A 'v was°` ~ ~..,: Iw c.Me ^ :." ^ ~':,I. ^ »~ ^ ::;.,. ,' tt~ X : a.,~~~~~.~ifc... I.VI UR ~7 INE. h v-cso .•C..fl `i~a.a f fl, f9.r~r pAN ,-. vIPUa :t/~S D.rf 3 ~ 'Tk~r I r c ~ 'PiA.VFrAr ~ & ..{rpFCHF.SI ~CS t 4 ~y I da ' ~` ~ f~} fR i t f d n . dr: F .: '~ f i ~f ~ ) 1 'i1 J 5 4 -~ _ 'M: 1 ~ y 1~ 1 - 3~~'~ 11~ yl _ R - ~J I 5 f 1~ 1 . .~Eh r ' 1~ . ~il :1 _I ~ . ~ • ,, r I .~ a ~ I I ~ ~ ~ l 1 _ 1 R~ .. ;)' v1. ~~ . ~~. - ~;rd L ~ _ ._ - :~. ' .~+~,~ ~~~ ,~ ' A_ ~y , STATE OF WASHINGTON RAGE I of z No. , ,,, • POLICE TRAFFIC COLLN REPORT ®TRAE~'zF71 totlcE NT , '~, ~F -- ~~~~~~ PRIVATE AY lal RA a x DAIEOicausaN oar cau IoN DME COVNEY CLUfIrr alrNO. HwA 3 "~ } Wr ux ID Ixuus E HI IUSF tEDOIlOU41 / QfURB _ ' .. M~ eta ' ~ a+ ERr-I 8S ~ Jcr ~ Z.3 SEfr£e5oru / ~ Ru .,, , ' ~N Q[ ~IN 1 Olv O410wN NO g1rR(f10RWGHWAY ECTCf3 RWIf f CI 'g~ MI,ES 01 ^w ^q I~eMRCU oNRb,gd ~DK. 9Aszoo ~, ..,,~.r. NlFRSECr NO VnIH. SIR[FI UR ROAO IqN NIER/IS[C``t OCN 11,,w' ,N, 11 u~' vRft1X f0. Mllf Po1T // BEM'eEN W£-J\ Vr~l 'MAltl 1D~ y tC„U IRFfI %il4D ~ 5~ f DSEANCf6DRE AIIONiROMxNENENCl CR05111RttrOR NEARESEMIIE 5r ACCIpENE RAM DIAGRAM MIA N Es N 5 p ~ MIIFAGE y (, - ,~ zOI~J f[FT [] ` ~ Of cJ.UA~i4 Eb ~ Y catsroNlNVavtD VvExHr' sREf oa RJADOR RfEfgENCE tfi,~'~ ~.,. ~ ~~~ VR No utND_ND. NEURfD I ^ vliACt ^srl ENUN X~ I 1" +. ^'k Lh ~OIM NO. ~~~ INIFR Cls CROSSSrRtETOR ROAD tr? ~ d vHl <Its Jn) pRRORRrrDAMACr oNlr Owl ^vt N v~-/¢/p 9~ I slRUCXINAMI Or w,RgSE. Du lus rMMrl ~_w esTDAMAet srceuE COarle taE _ Bt ' D£nE..65 ~~A IG T~R,tkl"w' ACA I ctISU~~ "t. S~_~_ UNIiN .I UNIT N0.2 '^VEHICIE ^PEDALCVCLIST Z' ~ '„~ ~ PEDESTRIAN ~h ~ uxvlxSNAMt a Exs Ml Dle OgnRSNAA+E us, EIR MI If r~ad~ I L)Qfl~k ET'~T 5~oc.k-Fort '_`. "'~ - srvEEEADORESS slRetr Anoutu - ~"" zlvcoDE ENO D AIE I E ~ ~'$~„ s Ef i'. 1o~JnS~ , WA X8368 1.~0~6 R T ~~~ ^ ORNfR 1l C[NSF NO. 51AIE EX n B n W ~ b . I vR l ENSf NO. 1tAtF DAZE OE BIRIn ~ v -_~ ~'~ V ~tl S7b56~ CA t-t I I A l4 b3 ~ DAr rX ~~ ~ e «cuxnr aN ER n~Ea~-vnoNE NO Ers cH, ftE Cnr E «<uxnrloN RRM NAMEX xnoNE NO. Ens WEIGHI EfICHT ~ -' I~-~ ~R ,. z U 4rL NW O~ ~,Id~n L3~J 149 .$70 R - - - v ~ CHECK (/( t ~` ~~~ A MRO:Ir or Ar`:olHra At ^ CHECK I~! arASAN rr~ARiovtf of ANOrnioAt t L CODESp * 3 wui, vtNn I..H 5 rncla a «o aK•cIL CODES ~ * D r a s, S eX D u ' ~R ~'~~ Z w RI~s LE2AilOn ~ 1E.( 4 E.~ROU vrH s{~M"' u N rin rct DI ' ~(.;IfAxDM MA~IDODCE,cHtrl MooE~nw~NrwvA~ s Euo^ ~ `° '";":'°° ^.MN,I..«I ^ ;V° p2b6nR ^,',."yK$ ^i„~ ° . ~ oHV~I TEAR 1 [ CHEV.I MODEL IDARI NOVwI IR . C 1 6 r5(~ Cb.4~ 2atL add E K Y H you INSE RAn N„ E AttR RAlf AIE H vt H.CIXOU l l RENO. Arf -' r 59y TKS C,A I t ~, x ' ~ vtH Ctt IXNINUrroN NO i vtH CIf IDENnE UII NN ~ - qEO Sr`EDOMNER lA 11951 MlpplE vnpNf NO. n R SR fD OWNtR~ tA51 rIRSt MIDDLE FNO. gnm ,~, t15a INwRANCt <o Ox AGtNI E 7IALi[ETC~E9!'$SLi' ^Su3 (L?,TI~I,'INI ~}- ~NI , g. SEff&tSerJ Cv. DEI HAe. Ca[.G" R I = ' -srrza~ cnngrr 5 ~EOwTO ~^wAr ^Rlruwm Ss uAMA D.-~( ON OF COLLISION: IUSe suvR[MtNTU wenlt N[etssARrl '~,.qt /WITNESSES ,~. a[ ,~ ~rs~ - 2` 3 5 6 ''~1r ~ n RE5 t1EC1 1 R.,rA {lEl H I U v DArI ~5 C~1~ ` 9 .v (; ~ -. y IIC~ , : , : , °...,I I ~~ ' / - STATE OF WASHINGTON ^K ', ~ ~ ~~^ SUPPLEME RY POLICE TRA I OLLISI P RT7 GE ~, of Z rY~ IDENTIFICATIO '~~" . ' ., 14.QF,,CQLLI5101'~L.u_... _. .., ~A~E :,.. .__ .......L~:: ' ~~ "~ O(LISION ~ FATALITY ~ INJURY ^ PROPERTY DAMAGE ONLY C'~~~5 MO UAV vR. COUNlY CIIV SIFEEi, ROAD NUMBER OR NAME ISION IOCAUON y/~/~r .~ `~FF'FiC.SG.tJ G.Ad ~2. AMF NAME L NAME - 4'; DRIVERS ~ V2/LEf2 ~2E/iT S, vs vs DESCRIPTION OF COLLISION - ~ '' v ~~ IUSF FOR ADDIIIONAI INFORI,InIION WF,[N.PACC IS NOI AD[UUAIf ON ORIGINAI RFFORI OR ASASUPMEMENIARY INFORMAl10N SilECt 10 CORRECT URIV(R'S NAME, OCCUPANT ~.} ~ ~ ~ IOCAfION OR ANY DA1A NUI KN(1NN AI iNF IIMF 111( ORIG,NAt RIIYIRI WAS COMPIEIeD.) , 4 Vehicle #1 was traveling N/B at a high rate of speed and failed to lt~~Y1i~~ ts; Regotiate curve. Vehicle crossed into S/B from fogline 157' then paralelled guardrail in a broadside manner for 273'. Vehicle then crossed both lanes a distance of 175' to the fof;line of the northbound side. Vehicle then corrected ~ broadside and went ~d,~ics(ttanc~ of 123' d ing that period it knocked down two sect ,l `# `~ ' r of fenceing and wen over two 8~10a apple trees, ~ ., ', _ .. ~~'~ ~,# ~ .. _. _ _ , 7 _. 1. ',.DRIVER/PEDESTRIAN NAME ENFORCEMENT ACTION soeaFEir•nwD EE[N DRINRINC (alECiF1l . ,:. .. CHARG~y l k4~.hdi.<I ..: ,:CIT,ATION,~O : r. NV'DAIKN ..'..xel[oliwi ~, Twi ~111R~D Turner, Brent S, DWI/ Neg, driving 6659 ~ .15y ^ L.'AN u. __1,.:r I.. ~n~.. Gfi~'~ i ^ y, ^ ^ ~ ^ DIAGRAM OF..COLLISION ,~.;:.: .~ <.::i¢~~,?u v, ~~.,...~v~ ..INL II, kIA:U(;ALtI I'RK,I't; RIIUNY. 1'RUI'ERIY IDINiI(Y VIIIICIIS ANU 111(:FIWAYS SIIUW SKIM MARKS AND OIIIFR MCASURFMENIS. 4 Polio.. T8K' i~r "'~~'~~21 -~ w„ ~ / LIE YfU _.~.I / ' ~ ..~ ` ~ ~ I . j ~ . Y I FLALf qtl ~ F~,QK.Q~ . , 0 I t-. 1 ~ 1 , _. i.. . I IeAasuDAUNU 0111CIR s Av AF.o R• K nA No Ara ,wuliDrsT. Del. A IDAT[ a R[ICWTl R, Haynes ~7 Patrol Dep. ~ S'L~SO ~ N_2 ~ , 4 10 8f IY a A gg x. uJY Y R~, yy ~ ikt~Y~ _.i ~ ' T' y ~~ ~ ~ ~ . ! BS ~; ~ .. , ~ . . ~ A^ ` t~ ~-;. a T w~ '" -s~ ~' 1 ~ E TRAFFIC COLN REPORT ®iRAFFICWAY • Ra¢f INi Nl1MeF4 , / POLIC ~ PRIVATE WAY •--~ EHNA ~ tlMt COUNtr pAtf OiCIXt N DA5 C I I N (US[4R00 HOU41 , ,H ,.I , .a ~ ..p , Cp1NEY NO. CIIYfq. ~ URBAN ~ ¢~1¢Al X u ss Sao ~Prcaso•r~ FaNO I Eft OV HGHwnr SfGEI IIYS ROUIF OR r / CIr pR IOWN N D" D f ^ " ~ q_JZOG . .aJ i /N ANI[5 ^S ^W ^0[ C/iJ ~.// ON HO NIEV5kC1 NO WIEN: stn[t OR ROAD NON NtFR5fC1 ON - 4nfl% f0. MRf aJSr /'/,¢ A/ OftwEEN IM. R sr4FEt a LJ sJA1C1• sret[t J AM MtA ' D ISIANCk aDRf M0E0 N ElR f CRO5551Rt[IOR N[A4(Si W51 _ w Et M . RAMV 1 RQ CODF M ,f[t I .¢D SF I f OR ROAp REiERFNCF / ~~ ~. M,It; N ~f ED~_NO IN1Un0 I D541llAGf ^Hra¢UN .. +Da RI. CpNSiONINVOtv[D. SrIXFN INfEy C15 fA0555tREfTOR'PO/, O L/ 9 .~ R ® tOIAI NO Or V[H CIEs 40nvrr DAMAGE DNIV ^pj SUIIED ^vEN,fIE Est. DAMAGE SRCW C[IdNG WE / C1 9 O01[Ci StRUC%INAMF Of OBIlC15i4Uf%ANDOWNF45 NAMFI S R. 1 ' UNITN0.7 O ' ^VEHICIE ~ ^PEDESTRIAN PEDALCf CL15T UNITN . i.¢5, M. ast ~° t p y B D4WfR. NAME. ~st ' i ~(J~i .o • nN.e L.O xo -1 f ,D /[ 1~.E1.1 F J IRF[i ADDRESS ~ Sinft ADgN ~ S:; a~Pr- c. R, S ~ • StA,f :RGGpf HDNfNO 4 D - /~9c cN/M•s,5P1~rn RQ END. 6 /~ . G,,, 7/-4175 9~3Eb w R o 73Z..y~ Crgrn'p /a~ ••~~. ~'A pArf oie nH q, a :• narJ-/p. ~n RWE SNGENSfN ,% D ¢ rv . A ( u ND tA,f Z 7n/A p R . / / ~ 5) V uv 7 5 ~(*t tEiGHr /y 9 NE NO Ens IcHt tR~cNt E Al M NAME a RHONE ND occ oN E4 E ~ . accw"noN vM NAmf avHO eRt7 •u / O 6-% ' ' ' R C .•.fFi...n ,R. DF aNcrJ. $?E.a+jitll' N t oR. Nn .v7 G ~ 'N N oi ANOtFHE4~ ^CHECK (/) Cu ASAN EMaovE v ~ ~ D CHECK (.~ KIi.S:N EMaorEEOi ANOmtv " ° ~H - b < is S me oN a 'y'ONloc•cy-__ ~ ~ is . ~~ CODES p ' ~ ~, "j° < ° inn 5 Nrcr a,. 6 v n :i 9 CODES - a w f1' IN wrcs ~I ~ was D .,,N%.Mt ^ ~,KF ^ ~a:eR ^ :, ^ :., MOpk IOARt NOVAI vU It D4.CONVY ..o, ^... ~.,,.I ^ ~a O 46.eo ^ ~~ ^ ~ .'N:e .. E ~ t ~fNxp ({NEVI pit IDARIN wAl ~Efl p r ~ 3 MA lIDC%GE CH[vl ~` J-rcpv ,' rDJ H7 E H caoR I . A it .ENO AE ~ W 7 / S1AIE AtE4aAIENO FN I tKFNS 4 t R I H. ]R WN•7'E )$ C2 u G vfH~aklwNtnicA i N VEHKtf IpEEe,f ICAtxJN iq. E 6 7 / 3 9 H 9 3 f RWNf NO ,5 kR D wN[4 USt N¢Sr MiDpf f NO. nG15rtv[DOwNE4. Ut51 NR51 MiWl O " 4 i 5 IIoyr w A G,,,,FR u ADDnss orowNEV N E ss:.rRSu~e[za-~~ee l rvAMe a AoDRfss a INw4ANCt eo. 04 AeENt R 1. o e A 1, 7'~'4'vl'_' T c l? .r. 1 < DAMACtDA¢u ~ W N' ;z DAMAGtD ARIA ds.• NG CHAOGF o o~l IU+KIaNN cHA4CA ~ARinN 151.DAMAGE a 15 ~04NAGt ~AW~~" ^¢fMNNEp ~ WAV ^RFMNN[D OeOtIO• i I~~a ' O , _ - Or 1 1GM0 ^Aw~ v Ics.;o. s n ^ AW . e. ~ DIAGRAM OF COLLISION: yHifrn Nic[ssARrll ~ e:ONOQ4w IH DESCRIPTION OF COLUSION~ Itn[SUVaEMwt"t SMfin Nfc[s5ARr1 ~~ No/ 'w A+ wJ:S)'1C3~~N VfH .~ x ~~~ ) C. N• ~, p c vll~ ~ PA9.S Jnf a Tpf 14~= e7 THa° aR~vc R wFn/T 7Sy' TVda y i3 ~" / C ' - ~ Tyf; LEgD cyC1~S'1' 7vRNC0 /NTo TNL ST REQ.=T1 JJ.IFRoJJT ©F /+Jc 1 /VO) T~RNfO Arles I34AhiO.TN/: hE STR~ck Nc / 1N TNC' Ri6HJ` D ~ ,oe. TNf Ao~ H Nc SFI{/e~ i/r7TTRY ~ .a. /.•d 5 6 NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED f CODES 1 - 2 3 4 OCCUPANTS/WITNESSES iil: wo~t~:i ~Aiuii sER "w 'Am " nstR ufa ' r """ CNC RJ SS Q/1-~- N t'm ~132.y~6~ AmR[oi a,y/T /O R'Eb llr DAMe ^FS:4"^••, .^~ ^~.°. Q , !u O. .DORESS ~ ~+ p AME tNi.tuna Mrmul4 ^•„Me Dr°'"t ^m~:nR ^ ~ ^wD R .x r . .H,. !/ 7 Amnss No „ t ~ ip, EM er ^AMe D.,,c ^"„ .^Hw ^I"..,,s. ui w r l t n•Rygyq+ DAIk Apc¢F 5N /,T{DUR. cHtp / }({ ~pRmD ^~trwn.^o,Rt .ntwAt4.catcu sNAREaa.N. e ~ nENCr 6/7~f~t d1 ~ ~6N/ d l7 9< X r.... . n ~ .. .. ,~ ..:, ~~ ~, t' •R~ r T• - '. _ 7 3 ' ~~ '=~'= ~.~:~n_ ..3...ilb _ 'u .~ ^ ~'i `'i 1".i` ~ -..~..... ... ~~i.~~5 ~R . knr ~x '~ STATE OF WAS NOTON '"'"""'°`"'°°' V.OE 1 art No. POLICE TRAFFIC COLLI N ®ieA1FlC Y' -' ''"' i REPORT r ~!, RRIVATE WAY .rFOr OIiS Ir ucEC w ewnpg •; - r1` F.- ••., ~~. off ~.. .usE °.w~c~u 40UrlI CW rY MO. CITY NO. ° " Uc l UR LL I I ~.. ~f t[,~ I- 1 M eS []5 Ow~. \ ` 1 Iar+O Cr 11RE~E04nGNW4, ~ . CGS M RWiE 0R5fl l$~ ~ 1 I ~ .may ,l m~E".I<Er~~„~I ,rRl.,~w - `.\'!.%LCr ~,~ _ ON .~ .E ~„ ( LE~C.~EYt ^C RP _ '~ 952>0 [ 1 "- ;a~~,acn•".;y FRE 1 E ~ MREWS, wEl~ nE)• E .Dsl~rE ° r:nE_ .,n ~IREI. v,•<aruov¢' On r°em REnvua c°m ~IVrro ~ esEM ~EVmI fj; /d IE M ', E OG ^ COIl~S~Ora iN°O~vE4 1f veRrr p r M t yl - _. ., n,• ~ AeemEal MI~~ E ° oieeRe.M Ewu _ s, tg >n ~~~~ n i ''Y v ~ ~.. ~' `4 +~: -^b: c (f' ~~ I, ~kr n a ' ~ 1~ A,~ 1~ i~; ~i~ v` ~ Rv' ~ iR r 1~1 ~`i~l ~iT~ ~ 1 "~~ ~ ~i f E I 1 i rS r. • y T ~ I~,N ~+.,~dti y fS~ ` ~'^"',`tl f,• I ~'!~ ~ J,lp.. r rl~a~1 .y c.~,' v - Y I ~~i + I , i1 ~ ' s ~L r ' '~~ ~ fir: ~ •I ~~r, ,. _ I r ~ a i ~a ~F ~ ~ ~ ~~ r ~ M` ~~ r r f 7+X l!}~ ~ - ~ ~ ~j-~~~°~ .. ,,; '~ ~ 0- 'i Y •~~ ~~ . ~1 i •.~; . - YJ v x: 5::~ .~ • y .+ I~ ~O ~ .•-kU z~ t 5' ~ ~l x r„., ~ ry ~ ' l ~ '' J t ~ F, , ~ l i Y , III h 1 . ' < rr I e ' a1.. I~ L°, i 1 ~k ~" ` '~ ~Ei ~kE ~ ~ n ? Ya~'' > > ~~ POLICE TRAFFIC COLLISy7N REPORT ~TRA~ICVY.4V;, y ~ s Ol><FL uv. _. ' ~ PRIVATE WIsY '~ Dn[41QiCOlI ON LIME COUNtr IUSf ].D)HOURI ' Qry ~ ~ , CIrY OR IOwN ~N ~w ~ N NPMF6NO.Of SiREFt OR WGHWAY r ~ 9.5270 MBEs s or ON vRErlx MREIOST INRRSfctING w+m. srRenoR RGnD NoN NrfRS[cr oN {~/$~ IQ6 BFiWFFNN •ISC•.^"~"EFt6 /f R[fi ~~4~-~~ DIS .Wff IDIxFCrI RfifPN f.CPO555IRtEt R EnafS Mllf 5 E N AC IDENT MILEAGE M S••:.- ' ~ ~ ~' -'• N 5 F MM1FS ,~ rnr W Dr P CODE ,. causgN NVavID ,.._. vtRrr' ~ ^vuncE ^HrIR ~NO fnlm_NO.NURID RiH on s INRR f14 gasssTUmoRRan >,; '.~~ ~Gy~~" tOGl NO av[wnes ~ ,~PROxmr Dmm~croNlr "'r ^ aismlEp ^v[naE OBRC RUCF INAMF 55r 5rRUCa PND NIR'S Nnmfl ~ ~[dUl L FSi. pPMAGf y -a --~ SPECIAICOOIYKr '. _ ~ ~ aP !e - UNITNO.1 UNITN0.2 ': .' RVfR'SNNAl Si+.• VEHICLE ~(]PEDESTRI4N •'::.0'PEDAE Nst ~-GII'l a Rrv!'SNwMf: r HRSt MIDpIE . Jr S1REf 5 K DDRF55 +~ C ~ LIP COp[ PHON[NO D r StniF 1 P S-oS9 R H I. 1 uCFNSf Arf DA fOf BIR H rv[R'S ILL NSEN L 5 ntE ~ F. rR M D I O r I V l S YES WEIGH1 Hf GHt OC<UPn110N f6 ONFNO E E IGHr 1EIGNt «cuPnnaN rl N••Mf 6PHONF NO. EYf3 r ' l Q , R ^ CHECK (/) oiHEa nH VEHKiE.s wN o ^ CHECK(/) vfH nE nsnN fMPiGY EFa AN'~n FRµ ` rc E "'O ' ° w7ji S f I w / e '~°„ "Y- CODES - ~ ] ~ + `:sn ~ ~ • s Bc tnnro n E i CODES - * 2 ~ n`s + is N 6 v 2 a Nn ius ~F M:. °°" .mN,,.NEt ^ ~ "v.0 0. ' ^ Eb.O. ^ ~,~K E O ~..NS. Ncr ^ w^ ~ a ES:;E. ^ DH ^'o Y' R VtH.YfAP cE IDODOELB[V.1 Flpnnl NOVn1 (IYIf I]DR.LUNV.1 HFVI Y I I ID•wI~NOVAI I SO ~ D~ E ~ ~. uuN ~~ NO Rnn[R nAr [ H nH c oR l 'l . ~ ~~ nHIanDENtpKnrroNm ~ veHiae DfNrru I ! I I I(pi~ 181 I I I I I I I I I I~ I ! I [ ~r REGISRP[DOwnFR' yst IRSr MDDIf PWNF NO R ! ~5 E fP: US rl St - w Y ' ~ R ER wpvessa ow.+[P N r R I.u l ' NAMeIADORESSaINwR Nn cD oRAUN onM.cED lau ~L J .1 ~ w"a.°w DM. .au+ "'"`'1-0""~ cH.RU CHAR p~w.Rwr l [u rvw.nct ~ RwtN ^l[MNNED ^,°.w~r ^REMNN[p [st. DAMw t t ldion s nwnr 1 gn u low<B f ' • IAGRAMOF COll1510N lu Nn c e~ RIPTION OF COLl1510N lusE SUPneru rµ scan rrxcfsw 1 1 _ _. ~~~- .; s~}to R DEX _. ~ I r r I I O . ur',v_E seF7_.. rs~c if `~~iuir. _,liv~_ I ~ 1 ~ I ~P~rzi~r~ Tiuv~un . A~P~raX . !Qa ~ ~ ~,, _ _ _ a~ • YiYC•--. 4CK...APPR~ Tj ~ F4 i°~7 Q _ is -- -- ~./4x_._/~,e~ __t ~ I ' t I /iJ~ ?~NC , - -~ ~ R~oJe~ 7! ~/ ~ o ~ ~ ; __ 1 . . f ,p ,NS 1... _, . ~ ~~~! %~ • C(NOZ/f ~ L[ -`~~~ _ . - _ _ Lt~_. .~ dlvA_CoxFTiN I -~-, t ; i ~ ~Pa ~' - - 1 z~i~t--_.a~.e - E?vo!N~.__~P_?.~, ~r~_, .. ' ~ ~" . r_n.e ~~ Gc=F_r _~S ? I ~ . ._ . _. ~ . ..._. .. I I , I I I __ ..__- . .. ._ I F r ___ _.._... I I _ i ttt '. N AME ADDRESS 81NJURIES OF PERSONS INVOLVED G/ t `CODES I , - " - 3 ~ i S i n 6 4¢r OCCUPANTS /WITNESSES rM ~M~!W+l Nnm is su nu uu ; r.. Rfs R f c OC O~ _-~ T uluura ^:fi ^"' . O^•:1 O :. ~ - ~s' RI.Lt1~t0 .De.ns ao t ,n wla ~~Ip IPEw Qu.l ~:. ' ^ ~.. ^ ~ O :' Hw[ ~t , ~ Inn +X Eri ,~~~.,• u,Gq a•+.• E~i~~/rc /SOD G [)aR Ear •PPROV[olr ~~ 1 IE40 HPS Is ~ O.~ I 1 'f w< ~F p ~ a~~ T , . z ~t £ ~^ p t•~~ , ~_r ~~~ ' ~ • ~ 1~ T+a~~ 4 ~~ `~~ I } ,. ~:: ~ , h r: ,~ ;_ E al ~ `~,. 1 - - Yl~ , y - # 1."_ / - ,!'~ ~,'`~.,.~_'R~ ~~:.°;:,"laar- ~;f~ ~ <.>.k*; T ~i„ ' .1 1 t ~' ~ ~< ' :'c 1 ''r l4~ai;~ 4 k ~•~ - _ a' I, , 1 1 l T.'~r I h , c T li {* N ~P ~"~-.~h- r 1 ~i ~~~"~~ ~ } + I F kr ~ ~~ _ ~ ~ ~ II ~ tl N" , . 9 ~~µ f -- ]]]i 77 fr.. ~~. .~ ~>~S~ ~ R , 'p~' " y ~ . u ~~ , ~~~~% POLICE TRAFFIC COLLISION REPORT P9 TRATji caMPwei PRIVATE W Y ... j OA ~/ l~~ rWn 1• - IMf C 1USFRtlONOUR) o OUNTY SJ:FFJ:Rsoly Grv - fnN ^~ QN QE QIN fS1Y0R TOWN NAMFafq.Of SrREfrOR WGHWAY M21fs 05 OW Oof ON 1ecAaGER o o - '93-Z7c~~ INIERSER NGWIIN SIR[fr~OER WAD NONINifR5EC110N /i.EE Y ({X i. S / • BETWEEN SrxfEl 8 SrR[Ei PRffl% F rmr i /• DIS ANCF ED R f RfiF f .CROSSSipfEr R NEMfSr Mll 5 ACCIpEN7 MttfS S F W D M of tF 9osT ~ ~ mu an pE . ~ CIXIISKHV NVOIV[D'. fPnY I6 RUN tOfAI NO. NO KIIfD~, ~NO.INIUR ^Sp1UGF ^H ~~J w~i"5 INRR QS ptOp511Rfl OpBW(1 ~~ Of VFHIC1f5 QpWRN1Y DMlAGE ONIT ^RfSUIrED ^VENICINE . ( ~/"v~'O ~~ OB%Cr SrRUCRIN OB2ER SiRUt•ANDOWNFR'S N•Mf) FsE DAMAGE SRCW CVgNG ~ ~ /~ f UNIT NO, 1 - - UNITNO. Z ^ VEHIQE Q PEDESTRIAN '" ^ PEDALCYCLIST ~ ]' 3~ WMR's NAME: I.VTr f1R51 I E ORrvFR'S NNAf: NSr I ~T. {~'~ C oL7bN r c%I~RD 1+ No 4p 7aHN ~•,. srnerADOrtf rRffr ADORSS "x ,elf 3 97~I !q, Sair .Lgk•r ddD D /9o Fc.osLC2 Rog1~ . SrAIE 21P CODE PNONF NO. ~oatT 1,uo<ol..• w•n, 2•yS7$' R Ir srAlF IP NORD~AlsCb wq 92~SS7 8$-yc 1 Z ORN R'S UCE SfN SrArf % I I 'S U nY NO. Aif N DAIEw BIRI M K ~ WA ~ ~ ~~ ` 6 O ~• ~ ' 1w_ ', B WAfIOEI fIRM NAMEERgNf NO. 1 RIG Ni E CUPAEION fIRM NAMEf PHONE NO. IfAll H[ EYES ~R .,.•~ ~- /+f~• qRO Nov N /7e •9 R. PJfc. ~' •i=rt Ce, RogD DEP N 6"~ ~. ^ CHECK (.•) vfHIRE AS:N D•ROTR Of Ar~orHfR: ^ CHECK (~ vfwaf AS AN rMROrrfaANOrI<c l CODES -* ~ e.s•~ 5 l 6 sw . CODES ~ * ] ni's r t ° 5 r% a s~'ue Z e Ntr Na NL~' ~"°7Br.DN p AM.~ANRI ^ u6 ' ^ ~SPR. ^ ~ K; s. Y[H YEAR AM[f ~ IF X791 ^ •M l O ~rl ^ Vim. ^ K ~„,. ~ ~ Ku . IWDGf{HfV.I IIDARr~NOVAI SIYIE I]DR~ VI S `i~q~ V STi NOA/j2~' 3 D E YFAR V.1 lIDM1~NOVAI ( l Cir•FV cs cA272Np ~ ~ p.U• ]B ' / H. oR U RA srME rwuR RArENO. SrArf H R vE u.FFSFP' N A 'IRA T(c'p Fr,E 9S3 +~ ~ Rc ~SII / 66' ~-'4 veHloe rawlflurloN NO. F/a aasoa~/ 6ii L Y fWCIf IDEN I I 1 lD y5p-71z ~, i~,~sl, I I R[GISRR(DOWMR: NSr {IRSr MlpgF C.E.41R1C rf~CN c~ S- RK1Nf Eq. O W I Wn[R: USr fIRSi MIDIXE S4Mc' AS q,BoVC . 38S~yty fi ADDnss or ws+ar wNfR - ]I ' N•MeaAroNssvlNSUNANCE CO. oR AGEnf ORF<roiif MvTugt. ' R ~PGa'iAl~ . 4RNyEC>'S oJ,~RJfN ~'] 2EUVGE A•fA -- • "'"°"" p cH.RCf gAMAGF Mfw • 'i"orio~ s wMAU es 0 r~ DR~~N RfMARUD ~ io u eHARee ~ ~ ~cfMUNfD esrIDAMA2>f I ~ •rDP ;s~ a:o s6ae Ae er ^roMtD f500 r l DIAGRAM OF COLLISION: ii•srRNEaswrl NeK•ro~rH DESCRIPTION OF COLLISION: (USf 54AR[MENrAI Sr[eru HC[f3•Rrl ~nar~,s O v~N/. Jvc / P ~' A PgPL:R iJV THz Rod y _~ Axo 1NTcN~2_~D To ~2o5S ISo~1'H A4Nit$ ~' p` . Ta THr ~cFj` oKTo E~AuAGL. S'T... _.. ~~_ NS F4Ia,Ep To Sk'i' Na•7, ._._ ._,_, ~ D~.F' Ta we'1` 13cAck1'oP. No ~ wQS „ I a vAY43~+~' To STa>fl. F,2gctE/l Fi t E"- ~4uRt r^ $T NAME, ADD E5581NJURIESOFPERSONS INVOLVED *CODES 1 Z ~ ~ 5 6 "' OCCUPANTS/WITNESSES ~n iDO~irriwu:atiw si v Acr utus "~" R sn. fAR :IB,: w • mnss nArlar2r A DY 'G"1Kl ~ W • Q lui,sr UC"x M N W •t n•ru Aru•ror N MDYEDR QMy QR.KI DWI •ORp O~° Ep h •Ml fa ~eir'a .%eY O•Me ^FAKI nW,,. • ^C.x Oi:;v •NYSrw +«: eYE%f•sNAwa••N. silo Aur.;. R:e Dn••rcf.D ra%E• NI D Dena Rro.r a DAn ~T ~ Aso /~~ /yes .z~~ 2q 85 ~1~ , 1~ 'fit 1 \:. r. .,sif 1~~,'t> N.i~ „f 4 '1vi 1 ~~ 4:~ ~ :::~~~ '.runs. ''~C`+YE~ rEWkMir..,;_mm., ... ~. ~. ,r ;a;fty ~~ 1 m~, ~W..~,u~, ~ t 7I I r I ~'y ~ }. ) °~ I . . r r d - vl' I ~ 1t ~ ~ ~.~ (+ s ~ ~ Pri • 7 ~ ~ ~ r L ~, ~ .i1N ~, ~ ; n ~: .. ,_ , . ~~ .. 7~ ~K ~ 6 ; n L ~ ~ ~ lY m~ 4 w~ r n ~ ~ U ~{ j_. A t _,~`., x `r _ ~ J 1~ { _ 1~'714M~f yY U ' ~ ~ 'i . d ~,. 1 ~ ' 41: ~(-M .L T ~, ~W !~ ~ X } 1 1L~ + ~~ Yn S~ } 'k' ~. ~~. Ir¢~ ~ L~ ~ 1.. '4 3 ~~ t ~ ~Ee ~ ~ '~ 1 f ~~~ ~ _. ~ C _ i 14 }~ f •~$ N} TT ~ ~ 5 ~ T j , ~ 1 a ~ r L 4' ~ k ~ Y 1ro* ~ ~ C ~ ~ ~ ~ r ~. I }t~,. ,r 1 1 lr ~ N 5 ~~. y t? J t } J R ter,? , ~ ~ , _, ~ ~. i ` r ~ f~ `4 t ~ j ~~ w 'Yl Y ~~~~ 3 ~. ^4~ s '`._~ ~ F •' i ~ ~ ~ _s, ~ ~ i,~ r t ~ n ~ ~., ~ y ..,,~4 a L~~ `~ a i ,~; m ~~ ' _ ~. . +' ~ ff o o ~ CL N ~ ,' x ~ o ,.' ~ 0 0 0 X M .r/ O . f O a _ y ~ ~~ ~~vo + roo ~ ~ rn f 'f ' i, ~~.', ~1 ~~ y ,, "~ ~ 1 ' ~ ~ ~' 7 lf~t 5 ~ ~ 3 ~ t~ . n ~ ~ ~ ~ ~ ~ C ' r ~ 9f~~ {'~t4 v <<'k~j~ ~r ~ " .. trF~r ' 1~ x i '~~~ ~ J ~~ ~i ~ i rw , y ~a.. ` ~ . .. .~a~~~ ~~ ~ ~,~.'~ ,,,; 3. .~ i.. ., Wr~.i . ,.. 4Y R ')a' r ~} r 3 Y r - ~ ~~~I{,~eJ , ~+ Y ~ ,M~U ~ • _ F yy l tL ..~ ~wfG~,• RVh:esimi_.~r~_~.~d.'~y Z`.;-~~L'.~_~U ~ a~l%..-' .-s, t+A.. u Y LL 'i ' <{ rtLl ~ `~ ;~ ~ ...13O STATE OF WASNGTOiV v"Gt / a/ wSR ISV No. , IRfV, I.nDI I ~° '~ '~ `~ ;' H. R ~Rarr T ~, n Y ~. :I ~~m, ~~ W y'~.. POLICE TRAFFIC GOLLI51 N REPORT .® tRAFFICwAY v4lct coM. NraumnG fo / PRIVATE WAY R' np foul srorv If o ' oproyc% soN IMt muNrr courvn NO. nrr w. r NSv ~ ~ ~` w. .,. wll ., 1 u .nc towN I sr,«,unnuRt 7C C, ~' ,ruaL s n~o~ ~r u~cNwav f / / (L rti 45 IF OR gO ^ u . ^N ^E ^rN ~ I Mlfs ^s ++ ^o{j'o,~l'To SJN1nm ON H.M1,S~/v ~ r• ,o VC. U 3 9~~.~a sT ~ 1FRStCr NG WINt SIRIFI vUAD / ( NON NiteSffr ON ulfwfnrL CO+J~ ~fY4.5lNfltx 1L~ Sfelit RR[{I% f0. MIE iO)t / /+ 7~ / C_ U )' qN MRFS -~1 tN'F. CNO))Sferlr OR NtpRt Sim It vp5l ap r ACCIDF.NI MILEAGE . DIAGRAM OaIa ~ C ift O ^ ^ { ~C J UJ'l .Q L•'c ^ CODE COlUSroNIN )fvfuirr: /%mU 'N NO.INIUGtOy ^)vM1laG! ^NII6PUN UigI NO VFO E ritN wrruwnrri IN I .R Nrf CLt t CROSSStgEf~O ~~ ~'~fERNCE 1RJ 1 © O ~ UeCItS vRUMR1YpM1nGf ONIY ir~f5111p ^Vtp<if /_o'+ CL q •S .L (~ 7 OB,f<r SIRUC%INAMf Of OBIf<r )kRUC%aJpOWNf R'S NpM[I / fS, paMAG[ ~ sn<W CODING IbF .: f UNIT NO. I UNIT NO. ] ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST ~' s~ pnvlRS rmMf wsr nvsl MmDlt oulnw; NwMr sf NR I l w NrL$iL.L C, cZ~ I' AL -L!T G~a[J1-d' MiCNAc~ D£Za/,/ 6 srvmt aooufss R[[I pooeess s ~ R?` 0 7~ 3 s ~~ RD CNY vrrONE NO cDpf yo/.~1 7b"~-/vS c~Y/ ~f3'~6 +3' XS-~7% D R t CI v stnlf [IRC R,gNf NO. yoRT JasVC-.clC':i wi,r Ps6 52-sYJj' ~2 R o Mtesuarvsfno. sum pp E R I Iv R u fNSt NO. surf Dnrf lnN 1/6~./i'1 rr,v T ? /~ 5' V 3 5 D ~' wN , 3 lg n UCCUVprION rIRMNAMf6 fgNF NO W'F GNf vEG 1 E IXCUYnrION {IRM NaMf6PNONE NO. EYES GNr 1E GNI ' ~ wi~r ~o /~o s's R DRsviQ c e ga[r Toro so ~Z /95 -$ ^ CHECK (~ vfNr° Mo qN CHECK (~) rtapNOmfe'u ' ;p.. CODEf - ' T ~' S f / e ; ° CODES - * ~ ~ 5 f 6 yn° " ~'r uurnxm ra e ^r ^e o: r u l ~ ^"~ ^~ ^~ ^~ en VH a r Kf N pe . vt7$ M4~el a'c. wr _ NlDq l r%lvnl s.i l]oR.cONV CE<ce4 GI' ~ 7`~ E r R Mn%I E. NEVI Ma%1 tpMr ti ovnr r7Y Fda2p V4N l ~ 1 TR~J e.IS '~" N cw Rt vral N n pnly npn rw Am H v c N. a I 4 W ~U: yA,r~,s~ ~ ~.IJ ~ R66 AVJ~ n"' N Vf nrlotNll{ItpraN NO ~_oQ9 / n L vUUCI IpFrvrINCArI F vao 26 ~:~' Rfusmnoavmfx ust nvsr Mloou SAM! A~ A fSA/~ nroNnro ,~ RGlvtetoormfu. ,ASt nest MIOaE ccpK,r Tldoon/aco~y .}. AN~ / S N ly .C pooRessnowuty N p _ p oxwe s E fo2.'J' Co /2 E' lS'7'~dRT ~6cX.E I* 1 puoela fr lrvwRANrl co nrlparvr fnK -~'i R I u x wMAGfo a v, ""' ' "''"'`":• cNARU o C o.onori s ISt OpMnGI wwwvN ~Rl M,IMp t~ , 1 ~ gM,ACfoARU cruRGr No Js• [^ ,wctlDN.l ~~~ ' An A[N ~R[MNNID tnr"DMMGt In W r Y a - - il/ O Cn ^ :w::pnr ~ rowtD ' f 3 o p DIAGRAM FCOLUS N: 'l "'"""" cAlr ~N' ilxn n NtussAR:l r ow n DESCRIP110N OF COLLISIONS IUSISWnfMlNlpt srrnnrxcrsnRrt /~ ~ V.Efr~/ Nn / N4 ~' d y'C RTA K~//J.6•.. A//,~ ~ ~ P4S_~N6 Jvp. ~ 'l"J~ J l+'0 9. ,^'gS.TvR~(/N~ /~c~ To /' !- N1' "` o, _._ _ --- ~~ L: ~ A .D R l V~ W A r ~- F o /~ A PPIJAN 1~cJ. I lrc ~ '~ .i x ~ ~~ N<SPrxgS qvc• T~RNtiN6 f~ NAME, ADDRE5581NJURIES OF PERSONS I NVOLVED r CODES 1 - Z 3 4 5 6 OCCUPANTS /WITNESSES ' " ;;"' sr. nu rlAru: " w su. Oru , A avn'. _. ^ AM n ^ ". ' O ^ . CID ^ N N .rt s uer a y~~ u. , m papa nfprrl AvvROVrpv wn .-- X 7 dYn ,,,~~yyypyyyyy~~~ggqI ~ s4 ~,4 v ) i ~ "~'awtY - "+PE' . 9gq)TRe ' '+ 'frXf'rR wli+~R' I 1 ~"~'' x t ~; t'. F N rt yt~ E•il r abfli+ '~ F o 2:r 4L . 7. c ~'r,. 1 $epry, ~ ~a .pA J f k x1 ( 7 ~~ 4L 1 r' ~~}. I'• : r. I w 41 v :; ~ :~ xr f, 1 ~. ~ T j I ~' ~ ~~~ ~ ~,Ir, ~ r, IIt " ` r ~s~ 1 ., ! N~ ~ I F 5 , pfy i {'r`L ~ Est. H, r { ) I I, I{ { I I t L ~!~/ J ri 1 } ~ . t ~+ ~~ S 1 ~ (.!1~r~.. 1~ 7 I i Y 115:14 ~{ , ~l 1 7~ Y yp ;d¢y 1 y . F t i j , J' Y l ~ (_~ .' J V ~:. iiJ... ___.. ~ ~~ - 1. .._ r. ~. . __ , +. .. ,.. t „ .._. ,..r ... .. ~: Lku~!. x:, ~~ Iti;-.' ' ' POLICE TRAFFIC COLLIS ON REPORT ^TRAPFICWAY PoIICE CO urvrNUmefR ~ ~ PRIVA7E WAY oaf I orcal N Mp Z8 $y Dwro • • 14...o rw.s ~. +' nnf lus i.ro nou4i l7Z7 couNr S t &cso.u murvrr NO. ~~p arr NO. r"w'" ^uReu ~f ^ N C vORt Sr Of tH O»nGrlwwr AVIf3 ^ 3 ^w Ja pl I-IAd low k o EI-! l~ ~' fCr Cl3 DM FO4 IPff I ~ W S27D RxcliNC~wpilN s, n r4ow1}tP .I N~ 3 ioN I ~NrT '^ RI~ I 9fIWFFN SrR((t 4Rfri. f MlF »D3r ~,/B ~z ~ Cl <I6DieIMI { [rfF fCRO>3314tHOR NEA4f31milf roil ACCIOCIJI R[3 (M 3 [ ~ MILEAGE w Or CODE P OiwGRAM WIA COUI'iON INVOIVfD OrRiI~FD~NO INIUeD Z CIS>illAGt ^rfiM1 OIAI NO. f RUN r.irn.rnirir ~ 'r SRU Ife3fCrIN SreFFIOR ROAOOR R[fERFNCE ~C iNlfe CIS CRp333rR[EIOR ROM SS ' pvfHiOf3 ~PppR(Rrv DaMAGf ONIr (]uf ZUIrID ^v[p(If On1fCi Sr4 C ' 'Fr • ~/~T JJto~l/EL(/L.(J/ 9 . U rIN Or OD1fCr SIRUCS ArvDOwNCR 3 NAMfl Mn AGI TR:C,~ ~S' ti s ticn(? sMCIAI CODING VSf 3 UNIT NO. t OR»/le'3 hrvnf U3r miDp l UNIT N0. 2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST ~'' l Aa -)okn j~, ivF4.NAMF w31 liRal MI DIf _ ~ sretft ADDRCSS ou Y~ ~~. Si, ff~,e~ ur. x"If li»coa » D EN MURE33 I noN No /phi Pd(,g,,J WA ~sf- Y963 DRIV f431KFNx rvO R slur! ~»com rvfNp. - J BARLoJR 6Z6GZ slwtF 4~R E MM1 O ~zwa~R38 ( v 4 v!4 nCFrvx NO sfAlf Sfa pwrf Or BlRln R.r r4 _ 2 f a vrwNf No fns w,ICNt r<ICnr ~q GL FT. C-lq~kt SYArG PAalt` NR 190 rp E R M NAME «cu»wr~oN e»wNf No frfs wficNt rKlalr CHECK (~ fASnr. Mn rAar wNOrN[e Al ~ c' ^ CHECK(/) y CODES- n ] ~ „ / :;n 5 I Mr / a "`~ u~7 r "w CODES - * ' `" - 2 s M ~ a n ' 51R a : + < " }' IN lwesPoAygs~o+r CS».4 r _ cL,ur NSO3 ~;„ ~^ AM,M.NrI p ~ "w4f IDOWf<nfv r 4 4 I ^ ~S:r14 ^ ~ '.. ^ : rMOpu Dn4t N w + v ^ M»N...~I ^ ; ~I rFa ^ 7"' ^ „ ^ ;.;, HOV ~" v I . p SvbARu $~ . l OV . fl>D». .l ~ ~fGN GI.IO E r » cNfvl Hipnxl wI I: .l _ ~ Nx nn f N s~~uck. NN3 753 ARIRr3Arfr slArt + srAlf wa --. - H I C vfN caoR rv l A it Atf "r` VfnKlf iO[NreK"LION NO f l y 4 3 d~ E 6 z l L 9 3 S L vlnKlf iDtNNNCAn NN r, 4rorsrtem owrne uvT r~RSr wopu KC AJ .llQ.l/42 "fw4faaowmR »noNf NO O W «c. n»muwrvr» Swsr n4st mmlxe n NE `.. L N s ruwmt4 ~oi E NuveM1MDetssfv wwewNCf co a4 wf:rNl Si~r~ r'~1 PTrcw/u>:..d, va R INU AN I N _" I OANAGfD MIA ~3 ~ rw YOVN urp pAMACf Cn"~~ w.r p fMAUap p ^ • CHARGE ^~R " ^PIMARJIp wAr ~o arnwl fshueMAc DMIAUE)D~f" (~ ~3 ' ,~ `~1R 00 s4°°°- ~w v° sr 8N11s CuRa+1 fi. :wwi.vD ^ Rr s rlotip: 1~:1_.~J - DIAGRAMOECOLIISION: iwU3ir riicisv4ri c al 4ny l" B DESCRIPTION OF COLLISION: IU+ISW»IfMINIAI sIINru NlcrssA4rl ,@ ~ NO6rIZ v£L.ul ula rl~yL,n 6.1 f;.L..,, D.f+' Iz,w oar Ia..F....r PS .Fl vc ~t,l ~ ~~~ I.....~ a <{ iq J C l l N - ~ ,+ , o. o .lru.. S 1'A.: k... j A. /:C ~1 » D6tt. / ~ i b ~ I~~ ..R •I~I _ Fia Dti~Yfnr4rr J- NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I - Z 9 4 5 6 6000PANTS /WITNESSES ' Acr awm s " '. „ , »r,14 n¢t 3 Mr IoM;~ ~ a~..lo~ I ~;• s x ~ _ A NVn3 la lw Stag On..~ I,:.r.(rt suref { r r.;. ^_ "M4 ^" ~ ^.' . ^~ ^tEt„. u 4w3s, A - rr; , .D OaM lyrfl SvMI °rA..r , ^ ~ I »IM r,, ° ;~. ' Y%I wnAM r -_ ~ c. '^.; .^ z ^r. li "V D:~r~ M .7 „ N, resD . nID ?~~ R t vtU 1~ ~i,., I I~jz~je~r pArl ~o so rsy ~ ,~ ~ $ ~ ~ 3 i q rl ~2 !3'+ r ,l .rJ ".nRU(far ll ~ ~ Y .. ~. » M .~ ~P n ~ r-,n,2'~ n, ltr r:r',1: 4 x1>t;:T'M I.~F1, x ar, r ,,,.~ gpW4Vrn ~6 .:rn AyNt':.:+7X'"'AtlRAAP.~Yf4~P''orW~.ll ry ~r C t.C'~.., r ~ ~I `~ 'GSA ~ " k t~ . q , ~~ ' ~ ~ . { ~ ~ ~d , 5 11 I J3' _ ~~ ' lµ I 3k >,'~ ~ I I P , f 1 f i _ _i ti rr~ I, e~ ~`. IS ~r ~ + `. 1 Y hSV `i ~~l !'~ I' L,I ~ y.~ r is .~ ,~ ~~..,; w:».SMI4fM.I BDI ,a „~ O STATE OF WA NGTON »AGf / on No ~ `' 9S. c ~ ;: ~~' .. ~~ ~~ ti . a ~~~ l ~5 ~ ~~~~ ~, ~~ POLICE TRAFFIC COLLIIREPORT '~FaAFfICwgY Wu<f co~~+rN umnfR PRIVATE WAY UAN Or U n;, N •AI ~ >, ~ ~ .. :°~,o ~N~S-e -?.rte COUNIY NO /G Cnr NO fnWA ^ +~ ~'/1 °N ° O el N~~ Ol,way ms f-1F_ S OS ^ ^ ~1~~~__6N ~ NrIVSFCr Nf 14[t~OR VOnO r fCi Cll ~ 4 • xOOlt Ox llxfl COUI ~.`r270 SICr ON ~l)~~~.. l~ ~ a ~ lNx FO. mlt Poll 7 J.,Z N +cfeDx Exam ~ ~~ m ~ ~ CC D[Nr Itff ^ ~ L ~TSptS~)~1~V mCIODEf COII K)N,NVOlvfO. U ``YY' ., x olacRAm DAu ' DoiAU,c, u ~ U I ^51 + .,.. ,,. Nllu cis IlusfCrN 51xl110440a}l OR xtNNIN~I cuo»vxlfrou vom oenrr.mu, mAm or omt<,I U...a. .,wrevsNaal _____ . I , , uaman ~ S svlaAl coo NC USI UNII r,0. I s DR,v ~ a uv nx UNIT NO 2 ^ VEHICLE ^ PEDEStRIAN ^ PEDAECYCLISi ~a~~ , uu,f vxulAO nx~ {-1'._.• vlusN.vm w.l N4s o;e b b~ ._-_ a auuxlss I aan r,ro-- -- D ~ -falf „Rrr~n ow N ~v+1 --~ . U R ~ NI SDCIrv•{NO I ~~~~~~~ 1 ` ^ VW Unll~nivin~ V uv(431i<Frvll rvO 11aN ' `•. 'Y vAl + mN Fa mm +' E «<uvar or m NNAI 5 inONf NO i ' ~7 F~L lr~ ~ N ; rf + R ^ CHECK (~ mm i. A V in Arv ^ CHECK (/( mm vfnc n` o~ s ' ~ CODES' ] ~ n5 N ., ,.. ..u CODES- r ~ ~~,. a 3 ~ x ' n, vf Jt,~? M ' ocf cnly, r. ... .u ,o a; , , aax N l uowlcnfv nxl o xI NOVn ^ .u uu4^c+ v 1~ ~~~ +~ anlx Hart na an H vl.cwoR N la N C A al ran na a,l ni y,IXr nNCwEKIN NO (1] ~ ,q~ ~ a9 a ~~- ,C;l IXNI1 CnI;UNN L ~I, I) •n4aownfR: calf ..R>f ~,o,r ,... rvo t- m2-- C.~ s . W ' ADORIll Of OVMfR >nxloowNlx Asl n4a o x` l m,DD,f ,l Nf N„ W rb ~~~ ~~ a Uulllu Uwrvlu ~' ~ E Aml aaooxlss NsuRArx co a > , w u aN „aLi H1---- R oAmwGID MtA -- ,w - -j' Dam I f„ Rr,~. » , DIAGRAM OF COLLISION. eu~,s,Wyi fls•.ra++~~~ "! ~ DESCRIPFIONOF COll1510N~ ,CIS VVUm s,lr, • ~1'~-`t~ I-DO ~ ~ - ~ }Ja sK do l ~ ~ a F34 t ~ o ~ v : -I - G a. 1YH( ' I .:a _-- ~- M V $xc.. ~.. l~ Cci GEC .h1'.~ ~ -p -Y J ~ -{^ A "~ `p3~\ µV.at ~ \1 ~~~h L\ V a yaQ/d~~ „ tx ._ J,., .. ~GICT'., 0 v ~~~ .. 7 -I u S I H a I . NAME, ADDRE5581NJURiES OF PERSONS RJVOLVED ' COCES t - 2 ] n 5 6 6000PANiS % WITNESSES "!' Au I,I,_I l - __ ~:~ CJ- ~.fl, f ..... __ _. _w ~;,.,, ~m E~.,.x ^~.. r.....:.., n :,: .. R+r, +... .,, .. .. ._ __ ~ ,: , A. ~~, v ~ ~ `J la . ~ ' _ .Ft ' .A ~ ~c I ~ i *. . I 7 ~ . ,~~ ~ '~ ,~, . .naD~,~~,E~~, a; ... .Y 'i. ~ r. 'G1 ~i,~ ~ , .'. ~i d ; Yi 1 a ~`. r ~` ~ ~ y .c, f ~. `~ ~. ~ . ~,~ .~ ~~; k n : ~ £. w ~ ~ >n ~•~ ~ 3~ ~.~• y ph~r'". 4r ~q ,.~ R..c Ask ~ ,. .. .. Dqn olcaus N DA rlu ioN ~ Ui couNrrlq alr NO ~ 3 ~; $'" R w" •~' INn r,I Iu51 ] E 10UR1 ibSo J.cFFcRSofr /6 . ~ fNww ueAN ^ I R ~ ,~rv Qe pN clroR lawN t aslRnrox NUllwar rn cES RIXIiE OR I N mR[5 ^5 ^w pDf Kris eDruvc/{ ON co Ro "~ / INI[RStCUN ,~ y,3-/7G G WIIN SlNflIOx NOAU NON INI[NSICUON RR({IX E MI[f ROSI J Ijcuc 5~' NI s[Rl[Il SININ ~"%G X[6DNf 1 ROM 91ffR[NC[CRUSSSIRFtION NFAkE51M [f ROSI ~ ACCIDENt NAh'-- DIAGRMtDAIA [ES N 5 MIIFAGE r[[r Y ^ Q OE CODE D REEfRENCt CgIIIOIAI NO vEO. Rl[ID O NO N]uNED~ ^SP llaGf ^N1169UN wr~unD~n N IN1E 'RD MIfN nI 514E RROA Cl5 ZAOSSSENfEI ] n RvFN CUS ^ ppq RIYO•mnG[ONIY ^p[R ^y! (/ Q~v ,~ OBXCI SIRUCX IHaA[Or C 54UCX NUD Owrv[RSNMLL{ ESI. UgMAGf SMCW CODRRi USE , $ UNIiNO. UNITN0.1 ^ VEHICLE ^ 7EDE$TRIAN ^ PEDALCVCLIST Damps NgMf: ~IASI IRSI ] mIDD[t vfwsNwME. uul Nx I SIR![t ADURt53 SIREFI ADDRESS Y Slwif ZIRCOIX RNONf NO. D y Blwlf IR T DRrvlR'S IICtNSE rvO. SIAI[ t pA O tlixlN Q RIVkR'S UCFNSE NO O D. •v . s1AlE DAZE Of BININ V D•Y rR CKCURgIpN MNAM[6RNONf NO EYES IGNI NEIL 1 E OCCURAUON RM NAME lR1X)N[NO. FYLS wFIONI HIGN I R ^ CHECK (~ rMnorrr of aE~o N~ raq" ^ CHECK (~) [NIa[wsgN eM ovl o O w n ~ °`R'' I n rr r gN l t . CODE$ - ] ~ S f 6 ;' CODE$ - ~ B ~ S [, 6 i ° ` ]] a O ~ a Q c~ ^"""""n ^P ' ^i!t,4lly ^°" ^I:.:,v ~ ~ ~` '~ A K;; ve nAp l DOOC<oav. moD[ ARr NOVq slnEl]DR.eoNV r R 1 MwX 1 .CN V 1 mOUt[ IDARI NovAl 1] 1 r "'D"` I ID 7 9 F ~,~ r- -~,so P ~ E ,~ vN acw uwsrvwl NO vqn agfNNart ND arf H vNCaoN Iq A ml FNO Af o aiy PS g'y5'o . w.r I C ~ VFN It IDfH11EKA]N]N NO L vfNICIE IDtN11EICAl NN II I`/ S l2DiE 7 0 RtasrzaeD rvER L61 rlRn ml ou waN[NO. O RwlsnpeD wrvfp lgsl npa mlDUE u ~ Dav t0 RA d DL ~'/ u ADDRlssa owNtp f orm[N A 02~~. C3e 739 pia«"NC` 983?(, N E NAMfawoopessa lNSURANee eo. op ACwl IN u qN R » ovnAao MEA on.: «~I 1~( •,•.• II I oN r cII Rrr• °„dp y gAASADfoI.wtA t ouNC IS ne L,rPMM A ~ wAN L .npwq ~lf~5 U ~5 fs RemMNEO ^,Divi~EN ^RtMXRNm EsI. DAMAGe lo wto f ~ ^ 5'O ~:° w' ° y ^ l c ur w . i nr A DIAGRAM OF COLLISION: s~ uvn MNA[ INDIUIe NDRIN OFSCRIPTION OF GOIII$ION: loaf suan[meNlM SNrUNwe[ssARr 4fIJ MO:SSANrI BY ARROW 1 r, Q VfJai A'o,3 PQRh~b Ano tiivpec~/>it~ Sc< P4c~ ! ' ~ 5cc PROgc ,. '° NAME, ADDRESS B INJURIES OF PERSONS INVOLVED 1 CODES I - Z 3 4 5 D OCCUPANTS/WITNESSES ,°f]R sn[„"i,o"~,,:Irmi,w,i NAM i; stX Act uro '"„ AI xslp ua ; r IX)„" uvWlx AMI NAn,RIw A pwMe ^~AX' ^"' N^r ^CL p •MAt]f IA vl d N MOV1U INpM pAMn ^ri"N1 ^NI • ^ ~h ^ h RD o •Nw ~s ~[or ul.per ^AMn ^r°X'^n»R. QH ^". w +A;[rlcfN Sl+w IN• ~ 5 N. nAwrw rwNCr lunvICnD Xf •NRmo D•It or altwl •R.wNiD Br own X c S 3p ESO "I.,., ~" ~°5 ~~f~r~w5 3'~~`/ ~ 3 of l4 5 ~ ~~ ,~ .~ ~: ~ 1 ~~ ~. ~ ~ ..:• t A _.,~3 s< ~``s`4 __ ~. `~. f( f 4 r~~~l r . + IUD ~~ F ~ ~ . ~ - . r ... ~,~~I i - m - Sd! x . _ ,----...:_ucrr+~.."_. ""--'. ~' _-~s"_ _ :!~ .11 ._,.~"~ F~;7,: 1Mg~r'N"m ~ ~I.~~' ; ar:}~.. .~.r. ,,„„r...,rl:- °~ - ` _ _ ' _ ~ eaas hann_ txr , W ~'••. • STATE OF WAS NGTON """"" RAGE ~ OE ,Z yam ~ : , '°°' No. P "~ ~ OLICE TRAFFIC COLLISI N REPORT ®TRAFFICWAY / POIiCf '~~ , C . NI NUMYEe p ~ PRIVATE WAY ARp aIS rv ~ F aI yl'.: _ 3 .~ S• one N w, .~. ~~ .u ~~o ~ w ~u;r JI.-ampo uul OO couNlr mumrrvo. C '.l'~ FFF:4.0 ry alp cln NO. EHw ~UR -~ ~ /~ ~~ { - ~' QJN ~ ~F ~ N C1v 0410W N NO.O OR HGHWAY ECi05 R ROUIF pf u ~•~ ~4 Iw(fS ^5 M =^ OW C O vNT D l \J ; uulFxSfCNNG'Arln SIMfEOa n y . ))I . tLG c S D NON NIFRSECIIOrv RREfi% F MITE ROST xElwfeN sluEfr ~ 3(T ,.r D " z - 1 ~'~ t ' / DSraNtff DxE I`ON CNOSS M Fs 5 E N 6 , , SINffI OR NFn4ESIMlE VOS SIN(fl ACCIDENT RAMa OAGRAM MIA +m~ ~ f 4t . rift MIEFAGE ~ CODE V ~ ~~ f ' - ~. ~,,' CONISgN NVgvfO~ SI iN Iv OVUfu~.NO Irv,uRfo~_ ^Sa liacE ^ura quN ~.,NIwIUI, avin ai5 ® aONNrr DamncE ONIr ^Rf~sullEp ^se01cIE mI,N IN • ' INTER cis cpaassiR Eroe aoavx ox EFEE NcE ~ ~ ~} /n ~, .M ~ S ~ OBIfCr SIgUCFINAMFOf CBxCl SI4UCq ANDOwNFq SrvAMfI FSr pAwaGf SRCILL CDOWGfAE DGo ~^ 'St I ~ { ~ ,} r ~. UNIT NO.I s~ DgrvfN~s NAME IASr Ervsr mlpw UNIT NO.~ ^VEHICLE ^ PEDESTRIAN ^ PEDAICYClIST ogrvrx sNAMf. ulsr 3'• ' c ~' s ~ SLfrapD4ESS t. E d L ~, 2q0 I ,. E,.I '. t § ,~ ~ Z rq ~, ' E ~ J sI4Rr ADDgfss Rd S H,E /d~N ~ Ja/ R ~ ziacopE ~ W/M RHONE NO. D ~ Rya' . $ '~ T` ~ ~a 2)• To wis- •c.crc7 `~?36~ Nonr R sort z,R f DglvfxsfcENxNO. F/o DC4 WN R8'S'-3~SZ0 6 IE Sf% pa J " i 0 373 F «CWANp, i t 0 IH I qV[ sl CENSf NO. wA,, F '° J 6 N6o v 93y3$ SATE t^' T ~DAr ~ • eINR ' s { ~ Y IRMNamEErwr,fNO of r~ES WE GHI HF GHr E «cu4Ar oN AMF6 RNONE NO. G HG M a N io a EYES G1I IRIGNI ~~ ~ ~4 /~ 5 , ~zvOLJC S BcfA /y ~p S'/ R 1~CT. - CH Q ~u ECK (.~ mAU n ~vrH ANS r, Q CHECK (/) / ~ .6 w vrrlnf as aN em CODES' o a ~ ` '' ~ ~ ,r,Y A~ 1 A{` ^ n rfr a aNOrH[q CODES ~ ' a rI 5 f % p ^'~ I N Os/yC MNI cIR», r~ryarof R N A y ~ jE ~) .~° ~~ ~ ^.~,.NI ~., ',.. .N.. "µW~„ N ~ I~• e. n ~ ,.. ~ r ~ r R poocl,rnvl mopC •+DVA~V n$ I ,..NA,,.I ~ N szIrDD4 co..vl .H rraq AI Hvl n~oEHf ~q~"novA ^ r M ' v'°r~KU ~::„,R r f I ~ r CN HEvc ~ epoN vRIARN ~ " D N 2 E G 7 ~ a -e~"`.,tx; 's _ S aIf 4R al • Alf fNO H yf ~arvN „ r f _ a ti N A l A F %J ; C 7~~~.-. Hlcs~pfNrlNCAIroN NOVO OQE ,al. BS' wN » ~s ~." I~ J G fHCIfDENIruIN Iaac~~Sa sO7296 `a~ C - 1 ",~ h!G i fGSRRIDOWN(q. U0r iI sr MlpplF ~y9.•2 $ O SINEOO - -'- yYE f ~. A~NssaowNpaT Cq cp~2 S WNf4 ig51 ASr mlDOff W SAMr -c'. A.C3aVc" J'~' 0 I~.. !. ,h~ ` ' - ~ ~~~" , owrvu s~/a.. f+~ccit c~Gc. ~737C N A ' s . ,~ I R A ~t NAME{AppRk55pIN5URANCf CO ORAGINt E I« R iN u aN A i a 'N Ss . pAMAGfo a 4. ~: Nn ' fsr ~n+Mr,ce ~ ~I^rrNNc.~ F. I` I ._~E DD e[mNNeo CC~~.1~ s ' 9u^/ c.I 4rI~•;a... ~-o ici.b v4 V o ~"p .w DAwACfp~wu n ~nww ^ .ro. gfMNNED E51 DAM ~f • s , ys ~, 'S A j O O •r ^ ~~~ s O Rorio~ ro ~ E { DIAGRAM OF COlt1510N~II Iw unl Naf IN w IH DESC sfRfl rrupsu•rI ucr A$ROw cAFE'?i( RIPTION Of COLLISION. IffifsflRRNMErvru. sHrrrn r%assnxrl ` J Ss I ~„ ~ ,~0~ 3 ~O vENJ No onc: W.~S So TH DO~NO ~ Q (iQAIAEl ~N ~2 oho. I1 wHc N IV o _ ~ T v~Nxrp ' G YHsk•o ~` cr1, clsvScfN~. No ' _ _ `- _ - - To s~-c ~tvf: R~ c.NT iN To TH cr' E;R4V~J. a> PARh)NPJ.oT o1; NANcy~ CAFE ' I p,. -.._~f~` ,_-mil vE ++i ~vo 1, wAS NoT STRuc~~ dip ~ ~-s~,o yyy r-tG~r IN r ~z 2 v '° t` ,, ~ r a . ANO }~tF f Ht'l {11T R~ f 3 , , -... A ~ B~rnPxlZ o f• 31J:NJ No f Vii. . I• WHFeia w4S PARKKD ANp fJN OCGI~~I]£,b " NAME, ADDRESS 6 INJURIES OF PERSONS INVOLVED E ~ ~. qr ~~ ~ ' .. ^:- R. OCCUPANTS/WITNESSES IUH Sp~HIMININ Sr•Ir scODES fcw afwnroNU Namfs f NAME I I,,,, - p ~ mn+ vM w, _" q g 6 ._ ..~.. ~ ,,. r ,Vj . ... ~ :. f~." . ars- rr f ~'1':. :~> h ~.v e i R„I., _!~ .. t ~ ma6.,. ~t ~~ gig . ~ rx~ S CTATC AC \A/ACIJIwI^T/1 w~ W SR 159 tRFV. I.ml _.__ _._ ~. .._ ...... ~ ... ~ ®TRAFFICWAY N~. POLICE TRAFFIC COLLISI NREPORT WIICfC :1AMINUMBER PRIVATE WAY ~~ outorcqu N onY cvq~1 N Nmt coumr ~, v, I. w lux r.weouv ~ O~~ ~ O S'O O V v couNrr NO. qrv NO. ftfwA pave /lo Ru ~ CIrYOR rOwN NAm[a NO OiSrNFfrORHIGNWAY ~N Q t fRCtS ROUIEOR SIRff Axlts s ^W G3Gi :,v/1 ON a R ~ 93 i7o „ IFRY<rING mIn51xtt1` xxUAD fl0 INrw N PRFN% E MItf POSt ' <.~ ~~ dom./ / _ UNIAN[t 60 x1[rI xE INUm xN WtNCt CROSS SrP[(tlE04 NtARf StM l~OSr ACCIDENT m t ~ f E M RAMR DIA AM DATA C J o n Of vt/ CODE CON SON NVgVtD. .tutu rv ~UVAt NU ~ OvNtD~NO. NIURtD ~ ^SROIAG[ ^NId RUN x rvN'Daiui" %~RD IMf CIS Cll SIRfF109 ON R[fFRENCf CRO55 dIR[iOR ROAD /v5 1 In ClF2 IfJ ~RNUHRrrDAMAG[ONIV I]vl utrfD ^vFgt ~0~.~~ oonelsrvtx:%mAMFOr nditcr slxua uxoowNlRS NAmtI E~ fsl. o•Atnef setelu eooae USE s UNIT NO. I RNfus N,w.E: uv IRx moo I UNITN0.2 O VEHICLE O ffDESTRIAN ^ PEDALCYCLIST rvfx sNAmE. usr "- rIR 1 of ~ - i /i' O// -.Vif/ raw aooxfss ~ /3 srxtD Aooxtss un avcoa D R D c . salt nR ax t ~ c ;=1 3' KS U`U R o,ll tN•A ' ~ . v.Ao dxs I D IvtR s uuNSf NO R wf xx oArfw slam r. GE l y R M / ~ «.cuRArIDN Ixm NINO N,vA %vtw Ins In mnr .% E occuruloN mNAMEdvrroNf NO. fRS wElcnt rEwNr EL~ u R 60 R CHECK (.7 sa Ea v ^' •N n ^ CHECK(/) mmt A q^ 'quv 7f e CODES-• ~~~. % ~..~ ":... " CODES-• ~<"ui 51 N ei:;~r~.cu s n m 'Y ' , O rl•v e c 7~ mA.~ Fv' AKxnIIDARr NOVA m lvnR-CONV.I ~u ~ E vFAR 1 n[vl MOgEIDARI NOVAI IF IR DR. V.I oox >a oR unNStrunN Brut AufR NAn lro surf H vncgoR n Nut NO. of C CI[IIXNrNI<AIION NO CAN/y38z L /7(,~ L rtN IOfIW NIINCAfI NN vtcs toowNly usr Rsr Mlogf RNONf NO O W xf nnxtuowNfR. EASt EIRSr mlowE No. woxtssvosvNlR A t U tv f U W O ~ / N E NAmf lAWVtSSq lNSUVA rco. oR ACt Nr ' / c?C.! R ss"Qi u AN t~TA -' DR oAMAC~o AREA I I u :~~wa of ~, - - "o,wN gAMAC~DUtu G o ' ~ o l ri`~' tsl. pAA1AGt ^ ty~y ^PIAWNED ' ~ AR f " `" wfN ~s ^AWAV ^RIAWN[D !51 DAMAGf ~DROTIOY I~ s OUP ~~ :°dr ~ SO// - ^.°...DRr s DIAGRAM OF COLl151 N~ lu u u,uNU Irwlrc•n Nt url dv (iW SI IIONEC ~ O DESCRIPTION OF COllI510N: Lust suRnfmfNlu sntEru MCfssAxrl ' ~~ t~ a+ Vim// Lcvr T.o'6 /1 aac/ o,tJ TNa' L~-r S.o%r ~;~L ~ ~fwv T%rs1 uecNY1 /JFfRKOX /.70 ~,. ~i ~' A DRrUesudsyi WeuT Gipbaicv~/p~ QCdouT 3S FT _ , . to NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED • CODES 1 Z 9 4 5 6 OCCUPANTS /WITNESSES 't a nla'o..ai`:w, iii sl. Act was "' N SIR ens ,M inx' ss srN~~. ^AM e OFSa O ^ . O.^t Oi1::. n ,»f uxlcx lulu uM O•Me ^ ; ' O" . ^ ~1 ^ :` b w M , A uewr`x srr"Nlri: 'M^%M E_7". 'O:" .0:+ O.: A X I.',..~: •. n,vt d~'.•/, ,'. ,~ T `r IR.. X1, `' x~t onruuxn rt%Kt •vvlvtD D.nu HruRl rrvovfDer A DAn •~~ r'iJ•l _r~ L~. L 2 ZS p -- r.N,..s o'/U88/ ~~~ ~,HSa a4 y 1a~ • '.~ 2 ' • N w_ ~~ ~ ,~. ;~.. ~' __ trove«ISgrv y., SN E o iu I,ME w" +r. ~~,o.r N t.l IusE iawnouRl couNrv counrv lr/ / drv NO. ^EmvA URBAN t5 ~ I s 6 t ;O~ URAE IIY OR IO Na`nf %rv0 ^N ^E ^IN $IRI{I ON ENC•HWAr CLS E, nV,tS s5 ^w GE p; . iowns4..~ oN c~~z IrvtlR gOUlE di E 3 ys-i~o YCi NG VnIH: S,Rn10N YpAD NOrv NIIRS[CNdI PRf/I% F M,EE PO51 rv ~2oa i~~ sIRFFra IaSz -.z S,NFtI /(o~/ pnuNU aprxr~i on EROm efnxENCE Cx F t DSSSINE ~ ov NIAPFSIM rosl AccIDEnE DIgcNAmwEA L Es `~ . itft ^ OI ~(I,pS C~ S MILEAGE w CODE COLL SgNINVdVFp. 5lvfN lr~ l mlSn n %qp rvFVSf<PNG SIRE OR OR REFERENCE tOIAI NO Np %41[D~_Ip NIUNfD~ ^SPHAGt ^ERte PU ruNVN,r rr INEEF ~Cls CROSSStRFEiOR N er vtH,dfs p ^ PRONREY pAMAGE GNEr ^ „sDI,ID ^~Id€, ~ O6o onFtct slRUC%INgME«onuct siquc%.wp owNFR~s NnmE l Fsl.DUnncf sncwcopmc usE S s usl UNITN RWE UNITNO.Y ~^VEHICIE ^PEDESTRIAN ^P,EDAICYCLIST ~ R ,RSr /~ ~tdR.LrI C 1-tVR~(LE • OR VFR'SNNAf'. IA5! ~EINSr~~j '- 51 tFt ApDeE55 P.l7. 1 ~ P.O.~l A~o~ (Zc, SlvFkI ADORE CN Jam.. _ [ lIVCOCE MOthNO. D IIY SigtE I,PC DF NO. pirvte's UCENS[NO. ~IDRI !~ B 1 Z K~ slgtF G,Iq ~.% ( 5 q FI'n,xto9 V RIVEN' IICFNk NO. SIAIE DAif D,r ... n OCCUPAFgN NRM rvAMF6NgNF Pq (Y[5 IIf IGHt E BIB 138 5'6'r R F,R UCCUPAI,ON MNPMf6N1grvE NO trf5 W[IGH11fIGN i ^ CHECK (r7 W D I vtH cIt qs Ar~E.ANOrEt of ArvorHEa AI AE ^ CHECK (~( EMNOr"FF OEA o " a ~' CODES' J a ~ 5 1 w( e y - n n E CODES -" ~ ~, 5 to e y 1R w ^ ^ ^ [rcn ^ <irrN. ^ yr ^ i v VEHI IrAV~ FIdMG(Crlvvl MODn IpARINWAI %IE DR ^ AmNnAM1 ^ ~+rcl n O AII Orw ^vF N U ,. dNV.I IR SU~J/~P U SIE.J E IKFN• v A N li A Y I v rAV I f~CH[v1 N90[l t ErovAI VI N°'" m y~ltow 662 D8 %E NAIE rvO Stnll wA I v IC«OU N , A q,l A E AiE c V[nKIF IXNEUICAIgN NO. E S~ 6LGZD8 Vf nlpf DFNt11 CAI NN . R RtGI51FPSD O'w~'N-F Nom. ')J`~-'~IASt 5, MIDd[ NgNFM O W RE«Slf xEO wrv[R 1A51 tIR51 M,Ddf Il ADDRISS CE ONNER N A v s WNEN 51 E N 7aAtweFSS«wwenrvu co wACtNt I u AN E IR R DR o.MACto Axu N"°"" - ' R -- ° e cHARd - ouea guu.~ED .xu N ~ s n.MACt °t ~ ~:wwv ^RtmAwm ^A ^RtMUnm ~ pwnv fsl ~DAmrwe RmP s ' - - S)$Qp ^:°wwgv°nr ^nwwnr f Ibi anD~ DIAGRAMOE CO/LISION: 1 E uPNf NAI IrIwUIe NGxtn 10 SHAD ttCESURYI nr DESCRIPTION OF COLLISION: IDSE SLVPIEMf Ntgl NflE lPrve[t55MY) O f SC L A .J p ~, ~ 1 U H NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I - 2 8 0 S 6 IUL SWNIMININ SH E OCCUPANTS /WITNESSES IcnAwnloNM NAw It a v% Acr utFa "'„ " nsiR Inn "„ AMNI SS uer« e IN nr~ AM n ^~::' ^ " . ^N ^itt„w A ' AtlWISf wl rq NAllvlp NMOVIDIYOM^~ ^ii<I^rN •^M ^ir O W AMYIl1 NAIrrN I(M YIFMnr ^AMn ^ N+HSI.:AINq NSNAM {RAN S ruul ^~'m1•^ii ^,~ • " I T AUE11 AGNKr rAx rl SPAIf.1%O GKI AIVINO 11 I arP PnW X ~ JAS o N -l r~S(~ l.~SE95 3 jg/$y AMgNDaY pAtl j~ q~. .,x •' r o- L H y.Agy'y ~A r ~r ~ ~rL ~ ~~~ W . ~' 0i1 ., r.~ A~ ~ T Ir'W12tar e, rk r I I. ~' .rr.. r. Ir M.rv M r ~dvl ~ nv~ '.a~67k ` r Y e k ' tifT S I f ~. F 'u 9 ~ ,_ ~ _ . . we .~ ti 3 YV ZV . . r -, ~ v k >'A'C ! ~ ..,ct.-.. ~. ~ w. ~ z 8 84 I ~, ~" "~;I,_•I~V~~ '•~ ,•' R« `HOUeI couNlY COU I S S ~p o „u NIYNO /~ errrND. ^ENWA ueaAN ^N ^1 ^rv r•OU IU N E O.OF SIeffiOpHGIwAr ( ' Rµ OS e0u1[ ~ MXIS ffi5 Ow JMD' Fi i ownse..,) ON Ce.l Z Wer Er IN EasfcDNC H ox roAD No rfasfcl DN ~S/7'1J ` vaUl IwfIN r(~OS EJx SlxfEre /'E I(L OQ{ SIXFFi US ANCt u X E MRF roSi / `/ f'G7~ I eUl lC aOM 4I/FUINCE CRUSlsralFrUe NEAxE51M lFVOSr A[~IDENI nw-N E w n 1 1 MILEAGE ~ DIAGRAM MIA - _ S. ffr ~ OE IWL E q IX D. Fenr JC 1' CODE Ca I , a r MD © NO vluD_~NO.INNeED~ ^SUx1AGl ^Hnexu ~urvuueplr~ SrgfN N i la[ C [' xpeEerr DAMAGE D Y IMfa Xl5 OtG555@ tOe eOM Oa REFfaEEKf N ~ ^ NI Onr(Cr siNUC"IN.wE O{OBrlCl slaufx ANn O'NNfRS NAME v'HC ~ OO~O O ~z ~~~ ~, BFI ~YzO,?vt~x i J ~~ Y "~ ~ ~ RR Cif'~ri'~: ~.~ (. 'I fSt. DAMAGE SafCNf COgNO Ibf UNIiNO.I lb 1r UNI7N0.7 VEHICLE ^ffDFSTRIAN ~~~~ ~ Daly NAME wsr Nesr mIDDIE DavfesNAME usr ^PEDALCYCl15T ATE ~ :,~, ~ 1I~-~ F `~'' S^ E~~fb Mali ~. :< ~ MARTI /1 I ~OMf\5 ~. t'~ ~ l o UPIAnd C. SIaFEr ADDRESS 13 I ~ZO 3fl Cad ~., .-l Z „Y 5 11`t0 c. QJ,Ic,vLl; N~dloe,k I E fIxGDOF aHDNEND D c,r SrArE le A I II ~ . ^''~ 2 DervfeSNrlNiEr, Wl4 18339% as- e,~6 R Q,,:lc,4.,.e wFl ~6,s 3s6 H I ,v unNU rvo. srnrE _DAr e a N ~ ~' IZv 3~(~ML 33oD 1..~~ F ~i' y,. ~~ ~ M,9ariTq S~sNN X I ~ ,~ ~~`" i - '~ «cuenr oN rgrvE NO c r E «cuannoN mNAME WA M ~ 15 45 _ ~~ I IrES VRgH K e aHON( NO EYES IGHI HIGHt Z STu,,s...- $l.] 14S 51T° R ^ CHECK 6') A HIS. 20o br11E +4>re y~`. CODES - ~ ] w w ~ n AHOIHre AI ^ CHECK (/) rNyA +u*~ k - Kdk v " vNIrA sn rr" 5 c~ 1 e;°,ii - CODEg ~ * ] r"ii vt,n A:N ExriovNaAS raven. M [rv r - ?t' ~` Z uurc5 ~Mrv .., Y I„ ~„r , M EAS :.w o . r L e sMiON "' ~ N ~I:^ ^ • ^ KI ^ s, II ^ : t. ^ : ,. ~~ ~ ^ .WNANXI ^ ~ ,rl ^ ea.xx pa „ DI `~ " MA f1D000 [ IDAUINOVA1 iLL IRU ~ UNV I rE e " aYl ^ri~HV +~ ifi~~ - H IA U n uftArf AIF MA8 1 HfVI MOIXIIDANI~NOVAI I ''SSaa I v17Y7rw fI-O~dN GRAI~AdA s ~I DR H v NSIXIp HA2dA A P U 1 ~ • .F Wl+~+g YAN (002. 5 WA I I No. A Er t 4 wrIGIIIDENrI gAEX1N N0. 5 ~ Liles HB`i'.]ss wa - R EwttFlaNrnlur N ~ r '~ , , T 7L~8 L171 zy$ L3r12VGZZI 3gOS0v,i9v y ep¢ -. ~' Iersnxfoowr.Fa: usl rlesr MIDDY vwNF NO a sr efoowNla. IASr Nesr MlDal No. p } "®% ~ I<' sE L [~RCfq 38s-13o1a ° ~yE'LC14.eSOnE Gln I,. J tY .i a ADOxISS OE fX W 17 7LS•3568 y ~ .~ ~ a,. Z PO Q 5 81 N ~J I~-llo~k lDA E t14o £. o„~t.C3A- R~ Q„°Ic,s,.~, y ~'~ ,P NAMEaAOOmss or lHweANUro wACINI IN u AN 4 qE° I~ ~-~oM4..2 .SM.'~~ ~ i.rs~ ti~ IoI.J nS 4.~ R 1'E. h1.G0 ~r "'"s wv(r' M~1 / •S' lira "DNnA"G~ C11, G9 vIN- ~NAxGE, ; u o~"E gAMILEp KfA ~ i4• ~ n ~. W- 'l rO~U~l~f UO ^AWAr ^ fMNN(p fN ^p[MNN[D FSI UMNGE Y ar-. ~I o.v;H' ~`»» `J S25(A- :,w:'.°e .~~5 GAR/d L' ^nonrner ~~wer S70o~ rdio.'rSEIE ,„ I DIAGRAM OF COLl1510N: iuy suE~vrE~~AI uN ~nl DESCRIVTIONOF COllI510N: IusESweIEMENru SrrcENrrxcESSAar1 I E C 12 P...nn, Dw~t 7 n; l\ Nn~ V4.1..t 16 y 3 WAS bToppw S.. Rd wti.i FW~4~~i.s; TawG~:c Y ~ - S/B 7o C\Kae SI+E ~'S I`o.,ld mare, Li. TVen ~wL - i ~4 f' `.: C----~ Pa ~wEL, '~d. +~ Z vc.L.. Slef.Ea~S d aL Ppc~E D~cc.,4l .1 1~ ys'Sr.d( C~_I Bcl.:..d H 3 Jtt,. ~ I Vtk. h\So N~6 5TRArcr,~ - :3, A; _ _ _ ~2• ~~ ~cnc C.Ax/5nN1 d L io Sl•a;.kt H3. '° --. I' ~ „~'[~ - - 'L z 3 T ._ - - wE~.a~sac aA~nnAr_l,c~ h6 obssa.,cd sal ih \,i1 ISe ;- 1°Q \ ¢ No-}4,.\ Sloe VAS nE'I' 4 ' Sloway s~ Ns Lo..r4,d h.;.f 2,avlkcx vpTo 'j n ° ' AJC ~ eoll'pdp:.t w' d 3. ~, ; o^ ~ Atl LL LS~ts•>t 5: n~.lC U)GCt aFY¢q;ivE n.~~zr~3 _ ' - NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I - 2 9 4 5 6 rr, OCCUPANTS /WITNESSES '~a s IMENrN sr+n ApMr pxAI NAMIi1 Sla AGI IAtU Ne w a181e. NICE ~ ~ ,,,~~ N.AV EbinbuE~ os E,~ „w; 437-2675 - I .Z y~. NXw155 321 IJ~.E.,vt Rd PC.Lxxdleu "a"" rNEnr ^AMe ^,,^4X' ^"" . ^~ ^i1. ~ ` ~ q ._ ~n+ Qd ld`p5.lten a- WA r.o oEa e..e xIMUVIDIPOM ^AMe ^;`I ~N''p^.'+ Or::v,. ~ rnT r rI S.cy',~.E ~ Y 'd ~ f,.~~ ~.; A[Kerx rLaA arrXlESw.w n~xAH. •.~••a I..4ra r'"!wf°i rN]onti ulNE nr ^nMn ^;"::'O<'o".n. ^GI'17v1 On:~,e ~ tr; ~' _ ~~rv 1~'. a ~~ ,o ~ ^`'"KV NI,••~~• ,,El N.IrD nX Xe Aan vrD nAll e1KKi Anwosro er DAZE 7 ~' lR ~ ';~. x ~ ~ ,emu ] SC SO /J-~~ I ;S~s ISS`1 ~ ;~~ ~yv,~r ffp~ .,~ {~.~ ;Y- REOU Nn5 3 8 8 Y d Y~~-~~~ I ff1..d ,17D}, Ild+XVt•'C~A W1ayt i 4 7 ~ r^" i r 1 ~ ~ al ~ ''t~a~ 4~ J. n r is 7 ' f -~rx ~~ a ?e ' ~ t r ' ~ ~i ~ t~ 11P ,t ' irk 1 ;I 6 t r ~~"4 1 rr 1 ~ +~ I ~ ~ y I ,~ ~ 1 ~ ' .gyp 1 1 rl ~ i I ' ~ r E( i t ~ I 1 ~ ~ - - ~ ~. ~ i< p l hE~ ~ d ~ ~ 4 ~. f ~ I ~ ` ~ Ir; 1 ~ryv, .. ,+ i }~' iM ~~~ I ,~ a a , "t L' ' ~ ~- ~: t ~uv;. ~~~~ ~ .; . ~ ~ ~ e~ .. FYJY9'1+ - .er,.esa -~ j§W,.~ :yR~.k .uy~ I ~ .~_ ~ .. ~ _. £, ~_ ~' In ~ ~ 33 ~.1 F STATE OF WA~NGTON WSVISV,N".I. PAGE i Df i No ~ ~ BD' a ~ I '~ , ,_ ~` POLICE TRAFFIC COLE.wi NREPORT ~TRAFFICWAY ra , lKl NINUNBEe PRIVATE WAY Dqrf OiCgll N A ~7 ~ N4 /~ ~ • Irf w01rue3. lu yl IIALL (USf }.pp NOURI !SJ O COUNrv OOIlN1Y N0. ~EF~ci~;c/v /~ CITY NO. IHNA pD . ~~ f pN 6 pE p N f.IfY OR TOW N .4 /~~~,~~s'~I'~°MPF ~ URAI OUIE qE 51REF1 ,{ pN L9yy f M+us ~s pw of f'of,'i To.-,vSciv~ O(~ RTi7o YIfRSFCI NG YAI SIR " ' N [EI OR ROAD NON NIf95FC110N RRffl% F MIlE POST ] ~ ] 3 } BEfWFEN //? 'Dh~ BIRf[I 6 A:4/-4 f'oxn7`sIREEt ~ /'9 aNfE ED RE IR(M1R[f R NCE CRO5551REf10 r~ ~ e ~ + . 4 N(gefSlM lE S ACCIDENT RAAV .. RAN MIq M IFB N `' W' i~.trOS~C'CT ~ q MILEAGE iffT Df 1ryr~T-~")'-'1i•D ~4vE COCK iSc. %l BN)N NVIXVFO: SEVER IY: ~OIaI NO OKILf~~~NO.INNR[D~ ^SPlUOF ^IIIIERUN luulRwpin INIf i0 I R NTER CII fliOR ROA004 HIfRFNfE }] ~'~ [NIClES p 990 DAMAGE ONLY ^ qRE 11 ^ V[aClf CIS CA0555/19[Ft OR ROAD ~ , 4 }fCtsIRUCKINAMFOF OBJEC1514UCK ANDOwNEkS NAMFI fSt OANAOf (O ~~~ SvECIN CODR101bE $ ~ vIRS NANf: Usl UNITNO. I fIR51 ml E UNITNO.4 ^ VEHICEE ^ PEDESTRIAN ^ PEpALCYCl15T l DRrvfR'SNAME: IaSI ~ ~ ~~-.~Y . fl tl '~H~/_~~'~ ST~vlty ..14A'1~~ StNlfi aDDRE53 ~ ' SaR / r + s SlarE tIV COUP vNONF NO. D fly SiniF ZiPC f E pM ~s- ~i 3 R ERS UCENSf a " /Y, ' f . sa¢ Sfx oq I wER u<fNSf NO. vgrz sfx DnlEq Dwm a.e D 1•, wN J ~ ~•J. 60 V w Dqr Y. - r 6 UPniION xM NAME EPNONf NO. [Yf5 WE ONI fEiGnl E OCCUVgDON fiNM NAN[6 P1gNf NO. EYES VIEIGNI IEIGIII y. ,(y.,a /~ R CHECK (.~ iE as AH lMgovfr of afM,DlNfa al vENC ^ CHECK(/) i ov a O i ~ I f , ,.. f as AN rMn ff gN lN R )ES-~ 3 a < Rs in:W IDRC . ENlc I 5 I <I~w / 6 :°ISY ~ I CODES - * D c Ais`rv °` s lx N B . sDlo.c.cu a K s. eMOn csw t r C 'S} : ~' s Arl.n aiEB~ iNO S f.4 LP CVT NRI t~ p. ~u ^~S.IR ^~"" ^Iw„ .IDI p.. l^ s< Y[Ae f r MY Y~ u~f ^iLn,. ^„„<< ^ ..: ¢ ~', }i IDODOE~CNfv.1 MODflI INOVAI $ITIE I}DN. ONV.I N fge n 1 ") - I ,sP MOOfI IDARI NOVnI Y 4 .~. 6 cHEv Gor{vr_Tf 2 oE~ E ) . V.) x T ~,~ oR q ucfNSf9u srAlf IeulfR Aare NO sl rE H vfNcgoR I ID ~ . " } ~• WJy AfNO. alf F I '~~ ~ ~~ F IOfM fKnl gN NO. i VFN2l[IDENUf q l N C]V t r P •5. 3 7 G 2/ 2 5 3 3~ E: D - ...eft `: ....:... _': ~-~ i. ~ ~ ~i 1 n° ~""0K1i/V UcNi i NaS NoRTHro~/V ~ I~.y~'"-- --1`--~ ` ~, ~ j_ 7'o GO AG.'a/Nl~ i.of•y~ ~ ENO STgRIEp i q S (~ l~jo VE iNG PU -.~._7Nc O~fvfS/~ CNgN6L:/~ HtS MiNp~ Rc%oR/ff D} _ _ _ To r/S o wi/ lq/IrF~ x TRy/nrc i'"o Avo/Jq a e~EA~{krvn ~ ~' . -____ _ cv~.K.~S~a~v v~Hi Nc i wd:NT ~F~ TN c" RoAO ~/~' A )N.q l ~. IJ o K A N p ]3 o t./v e1:4 tiYOc lS y„,~ Q,k OJJ7D Trlc ~ D AD S/~o vfOc 2 ~ I. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ~ CODES 1 - 2 J 4 5 6 ~' OCCUPANTS/WITNESSES ;W'u,`°ai~wlu~NAinis~ xx acE um '"„ N 91519 ill Cl ~ ~MON ot_~y n-E -0 Q/li' f ~ .:o yai''S•n:r2 0 ; .w+. ./ m9rq~~.. - -_._- M... ..;:1i YLIBY ^AM9 pw•AIO";:II.^~. ^:. ;', %Kl unrgaf9D nx Kf awE{nD DangNEfwl arvvonosv Y Dnn wtl ful S1 0 /S'3 7 %~/`~-8H 1rT~2.:~~ )wup NN1 X ~~~ E 1 a ~,~ : .~. ~I l.: :.:~~_.. ~~ . ~IY' ~U~''"_ ~'~' ~'. ~'i~ ~~7~ POLICE TRAFFIC COLLI~tC3N REPORT ~IKAfFII,WAr valet co" INrNUmOtR Y /.. ~ PRIVATE WAY rcaus H uNrr Onl ~~ wr v~,n oul+ AI4 wM ~N r.i 1115 I.~UfHM.RI CO /-'t>,y i'. n! /o o - t n t -a. b Si. I courvtr NO. crrr NO. ~ URBAN RAt N ~rv QF Irv <IIYUV rOwH Nav A OMSlNftlORfuGNwar fCl C15 22 EDx SINE 70 R Cf N 5 B ^w ^r)fJfl~f' l'G• NS': N/' ON%[, /(/=. :I' [/.•. :Ic• f ~~ d 7z IHII45fCrIHG waril 5r4 YOnO NDNtN11451C110N / N~r)x 9HwftN S ~ .~< ' T7 • ic. 51 tflx f0 mlff v05f D. Sd '~ psuN~expxl uaN rxo fxtrnexa;5vuttroR NtARtslm f rz51 / Tii- S f nee otNr MIIEAGF my euexAM DArn ~ f[Ef [] [] Uf Y / CODE C If 510N rvvavFp f4lr. rOINNO O[DtD~~ND NIURF6 r~ ^Si 1 [4N{ ...in.rl. IN A4p f/R CIS IN 5 ING SrRFFr OR ROM OR NiFRENCf CROSSSrRFF10R Wa0 / p VFN CIfS ~ ~ V40HRIY DamAGf ONLY ^ kF ^ Vf / 5 ~4 2 O ( ~ / S BhCr BIRUCtLrvAm[Or OBI[Cr Sr4UCx nND OwNFPSNnMtI Sr DAMAGr t SVEC AI COO rvG USt S UNIT NO. 1 UNIT N0.7 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST rz° ~ 6 OR VrRSNAMF wv Nov mlDmt pxwfvs Nwnr wv fIN., ml DIt - ccK: ,orfr GG.r/r~• Ifni ~.di C'. e vvro ADD4ess vRto MORtss Z nrr sort zvcow GNt NO D r srAlf zvcopf N N cu o t Vc/tt' . sic/ Y av % 11.E-. R p lv c `c l'!' J.. / 7Sa(.~ Nrs `y /~ '~ D4wEN5 NCEN5FN0 SIAIf . [ H Dar[OIB41 ~ I vv51 CFNSI NO SIAIF is DArf Of B4rN s :r,°~ ~ ~ w9 f 6? ~~ ~ b~ w /a it ~/ S B GCCDVPr10N MrvaM[6vHONF NO fvFS Wt GH GNI E occuvAl oN MNaME6VNONF NO v15 wR GNr Nflall /~ 2 sr.,~.,•,r Lf : /so ! ~) R W/. CSfr) / O ~ CHECK (/) v H s <N n of A omr4 nl r ar ^ CHECK (/I r x un w ac Mi.+ I v AN or w 0 r v CODES - ' T ;'"." / ° s ' e ;;~~ " 5 " e w ,. CODES - ' ~ ~'.`~" zz r Z. }ie r,t Y/D IIt. s ."w°~sw,,. ^.x,w,. ^: f' ^t<;a ^ : 0 : ' x 'Y ~ o ~' '~ °~ '~ ~' ~ ° °" , " NK vIAR a IOODGf CHty mCD[f IDANI NDVA Nv 'l , . EH a x H E I 1 DR )u<r x , vnl vl U t ~ ' ~/ (/ TS'nN l: f.[ ' E ~o /'~r/~1 ~ M /1 b• ~ 7~R~ / H 04 ~ AfN Are Arf AnfRgAr rrvo s H . N . vH aox A rxKafrv .If C iC el N t N 7~ r %~ v N ~ G /1LG~ Z3L``_ b-f - » rfn of oeNrHUUOrvNO L r fHlauptNr rlcanGNN 50 Rm srt4movmf4 wu rRSr mlD r Nr. NO to vtxeD wHfR. IMr nvsr tumult Nr rvo fio C,r4 A F!T ! J! t o-' ST .~ ~ O fr,/ G / r r ~' l- . ~~ i• / /. B' Il_ apDRfsgsaowHtR N DD t,cf oA rvtx /J 1~ NAmt aAOORfssar msu4ANCe eo aR ACENr R I u AN IA N u~~ V /» pNnAW MfA Clnis [in D ' ' ~ ~ lD AYfA -_.., , s w r i.l fSrU UAMAGt CHP4Ua v IC-~ l~ ~ R(MaiHfU CHARD[ y ®RlMA1N10 ~ ~ n lynx. I,r U.vnaG ^r I ,I `~f ne• ~ 9 IC~OnO f DO `v A ^ IOwrO E Awa --E lowrO Br f/ E r I uu r ~ DIAGRAM OF COLLISION: i~xU is iciissarl Art 1 DESCRIPTION OF COLLISION: unf suvn[mlNUl vrtrlnrRlnssnvrl ~ O ~ of /wGA./• I LNG Y., vet R•` rz.7"H ~CUNO %F1•G1 3Y O/J /'AFL q.J2/xil/</' G^/'OfI I~C T'1 T!'~"r~/'i c!'J IR .CLI Cam'`-------. r.,.~ /. ~.. ), s ._...~..~ A Iii / .r • :; r' SS•~ zi ir/ l K f'..1' ~ r s ~ r~ / .-_. ___ _ ..~- ~_ ~ J1/. //t;l 7;<•nh,a1 Gf •.f,:~ ro A~'irr~ TrI c: L. i` A. rrU of a e :1'h.~ , Imo, , tJ rl•la' Rrgn; Ty /Vn.~ )N e~ NAME, ADDRE5581NJURIESOFPERSONSI NVOLVED [CODES I - Z J ~ 5 6 ' - fmrNlM ux OCCUPANTS/WITNESSES „x :ol;,i,rN.., Namr fl S, sf. .a um5 '" w v4 rna 5 aMl , .nx N. . DDRISS R O' o •!rr A ~ A ^ i ' ^ .~ . LJ" ^ ~i:'rn [ f Q R MM55 4 d ..v:)vlp lxfxn ~A4 L~~•. ' Q'n • ^ r ~ii O F . Dtwns N rWIOr w,n "'" L7 AMx ! 1 ".:" [:1;".:,,r ^'I ^ ~.` uux n: ~ .r,+calrrx s....w u.l.. X E: s N ~~ n.aa.l. an.-. O'2;~~Rr, oz~R6rt o uulunN,n Ar •~j ° nen // G 8Q /1nAp .~P Sar z rvs /GS-7,%•b ~SJ ~1 ;n,~-e 1 <°f9~ ~v 4 ~ ~ ~ f ~. r ,' • ' ~i ~ F ~A~}vd ~" .~ `. 2 ~~ POLICE TRAFFIC COLLI~i SN REPORT ~iRAFFICWAY rVtKtC mr NUMBtc PRIVATE WAY ~ .7,N rC~Ir, J(- r " YUN yr r" 7n, ' GGUNIY NO. CIIYNO. iMVA Eu LJ Qe U~r.~ ~IIV O•tONN gnr0l WAY ha/Ga f'C r / ~=C /~ ~ f ClS I }gylf 09 t E C MNT ~ ^-~ cam .v :µ ore ~ `- ' ~ 9s~>a nu•t4eacN In vRnc.a.o NoN Mtau<r oN slutll n slvar t wenx w. M°E VOSi Qlsi t~ / p~s~ urrA. tv a4 .oss srcN, clrr• ~'rr.lnD,f MI.I~. y ACCIOENi T •~r MILEAGE S ~ n ~ 1 P DIA AM nAiA Q rl n ro . _C CGDE ;,.r :.u N.N.U. arL ~ ~' _NO N,UUtD~ L] r4GF ^ n N M'T" ~NnxDrw IMti Cl5 C903551Rt[l ON WAGE WAOQ 114 ~ p vlraC lT ~ ^ ORerv DAMnGE ONI. ~ -UtNP ^vl~ff )t(151°ty, rr Mn n.•ANDUNNf rtS r.AmF / [Tr DAMAC•f ( S/-i ZQ SRC AI CODING IEf V . $ VNIi NO. l ra UNIT NO. ~ vt s a ~ VEHICLE ^ PEDESTRIAN ^ PEDALCYCl15T -L/,l ~- 2 usr rIU r it °ISS / ~ [.-I+yC~ / %~ L~~ ur ADDUtss z~r coot arrN NC ?~r'-J;//FF ..~I~ E U3r ~,'/%ZS S D R c An nacoD Y Tr Nt ,,..~~^^~ uctN•.NO TrAI 4 I D vtu,ucwstNO sort t DArpwexrn U/~G,rE ~ 2/E'~i B /y7 1 ~0 3j ~ . aruvnr oN vM NA,nrnrnoNl NO .t: Moral 1 rn E CKCUVAIrUN MNAMtxvnoNt NO trts wtlGnr r~ICn r ~ LC x O R ^ CHECK (/I ~~ AI N .'nr ~'^ ^ CMfCK I/) ~ vrN n A A ~ n A ''""] CUDE50. 11~ ' S e : " ", ' t , N r s'i , , ,,,, K.cu CODES ~ v G . ,, , ,•, a `. ~ > MA .u ~ ~ i Vi t ° " < ^ ,. n O •r Vr r NOVAr sr y~ n E lxuu <oN ~daEt" rlE A.. / ~ r I w (° /'~,~' ~ .. 1 rr E H Mnv A. I t nnl I l oou wAU .avAr ri l D v) ~/~ ARNO vmt ~/~O L (LUE I C Mtn caou 1 A All AtNO AE IMNrnrCANON tit ~ L vtnlCrt rOt NIII ICAII NN 5 ;;PuE~tv9/ 6 ~S/ ~o~ oZ . "rouwNl./ //Ir~~sr sr MIOMr .nNt NO O ut IsltvrDOwNty IASr rlasr Mloat Ea L~ A .1 _ n o /. ~ 2 ` ~ N urs aowwu TI / yc.F,E . tJlr E DDV a <a .NSUUANn r o ov A<.ua M.,~/./.C//e.c.'. ~. R ' INDArr N EwMAGm AUU '"' / ""'"::• I i "° D , cnAUCa " r~~ E ,(~~!~~~ .r.~ G~ ^ ~w~vN U AMID wtD ~`- i_°_r ~T ~ ou 2M AMACtD atA cnACrr AGt a ^ AWAV ^YIMWNtD tSOU ` "" la:o~aw T : , s S , ,c'/:S~e . ~, 'iC s Av n IDwtD f .wAr D. • " uvvumrN A, o. ove DIAURA~I OT COLLISION SWIr II N[41TAUVr n (rN y N ~9 ~ r pE IP710N OE COll1510 IuslTw tnuNru vm Nr NlC SSAUrI `` ~/J~~F' C~(lc*"~3~"5_.r~~> iZ,ylJCt - ru/z Ei~ ~ ~ r ~ J 1 ~ Z CCJ .. , , ~, .o. , f~l ,,, i .sR /:- 7 o yJ S/ (~ cT C'n ' y ~~ ~ CA•e.: . a . ? y / ei:~ (f ~ ~i I S j i~L / /-" 1T ~ ~ e.~,~LN , l~ //r~r~Y ~ ~ / //l .S/u Fi-' eJ /'e 1-OC*.V 1"cf .T O,FS /'Z .< ~OC.~P~ \ L ~tll..? h I ~ ~ ~. z,r~ 7 ~ ~ , Y , I _ (~' C N ME. ADDRESS 8 INJURIES OF PERy ONS INVOLVED 'CODES I - Z ~ 4 5 6 D OCCUPANTS/WITNESSES ' wc.I;oN.,i~:w i, v. Aw aAlu s'" vtsrv uta "1°; ^ iti'I. .rr,. , ,~. , _. ,may' :. ,x ,<~.. .v w Dort n.ovr .E. rnln usn J1;a. .. Lam/ .._ ... _'.,_~J._ _. _-._.---- - - o.m,ws` ~ E r x rf - r ~y; ~^ A ~`~ as' • ^s ,~ I J -1 ~ A :'. 3`: ~~ •' ~"'~ ~ vf~~'. t~'J'., ~ ~T ~' '~ '' 'iFG"!:~. ~YI4ai3df4T i`'•`` '~1 , I ~'i, ;~~"'Se~ ~`~v~ 1 r ~I , y X177 I rl ~ r W. _~ l ~ f p 0~ t yy~ ti,i1 i r r F ~ ,f ~ 1 ~„ ra t Ml ~• ? ~ I I. ! r Ir ~.r 1s'• 7 a, ~~ u1~ rz F 1 J)I -F 1 ~~~rN ~ ~~ ° I C~~~ ~~y~yS~1~~ttNi tLIyUR ( f 1-i. T~l L 4 1 1 P ,gy x T( ~~ '1'n ~/ ~ - -. ~ I~ ~C~ Y `I~ 3 ~~z r } :! s '_h rl ~~ Is 1. - ~ I Y• . ~ _ ,.~ + ,, . ~. +~ >E ~ ~ri~ ~. ~ . ~~ _ _~ ~ ~ .___ . OFFICIALUSE ONLY r w.s. ~ ~, > - STATE OF WASHINGTON p, '~ _ MOTOR VEHICLE COLLISION REPOR LWTY CITY ND. ary` ,''"~" 1 , GATE OFfALUSgN DAY OF 50N N 1WEOF COLUSgN AM 1/p ^u~RXAN ,J y r Nar rw ~ ~ X+O vwats M I~ LT`""~ 'fi~~ N. '~ :'S i / rs. ~ ADM{LS Pf1EFIM MXTPEET .00! 9EC110N iEh" 7" COUNTY CITY, TOWN Surl I.~Orv C n[ MILES ^N Q x CITY. TOWN ~ N ir~~~® x Ay o JC /Ie. ut•\ _b WTERSECiwG VATH STREET OR ROM ~ PflEFl% EO MLLEP09i ~1 GIVE NNAE OF STPEEI.ROAD OR Mg11WAYrow ~/~/,r//1 'i r i Iz qtr- ),,.f CAIT4rJf' ` aan.~ ~~ ' • •# ~ alp RAMP DIAGRAM DATA ~ix .,. NON INIERSELTIONLCCAT n0 COLLISION y OETWEEN ~~' STNEET ANO v~r~~~ BiNwWIE NDN %~RG AEEGluq yIPFETOn BOAn aI 'v you ErosT OR Otwtrrvwl WTER WTE LLS. pEiFAENt[ofJlO4sSTnEltOI1110A0~ T^, _ © © noxoc ~ ~ ~ ..se lu ® DE USE l © O. LO SPE -x' ^vnuclE Un c~N ^UNrtnrwwl0~ ~' Y r.I r.x~r KK-P 1Z ~ r„clEOwt ,L Ovr~ rxuN ~I E ~ ~ 4 X~A OBJECT STRUCM avnAMEa aukcT SIA I ^ ONNER OFOBJECTS NAMEMDADDRESS IN flOMWAY Q© ~ TO RLPAiimEii nTV.. ~§'r _ ___._ FEET [oOE S X' w~ ~~;~~!1~~~.- _- MIOOLE wH DnIVERS LAST NAM® FwST NAME MID0.E ar DRIVERS LAST NAME M1StNK1E /• / ~~' MOnE r"An lwo STREETMOi1E55 q ROUTE NO•DANOBO%NO r ~ STREET DOfIE55 ROUTE NO. HOBO%NO ~ 9wEnE X ~! y.v{ S~- mvxA ~dA;rr Ylf Ar/i /.,. /'P /Ar~U L' lJ%TI P, ,°~} / ~'A" J /C~ 1IA E STATE ZIP LODE DRIVERSOLCUPATION y 'sl C1Y STATE ZIP LOGE MIVERSOCCUPAIION ruC0.L5UN CITY y A j;:/~r.v.Ic F%, 9Ycrrf J•fi;./'.Y'l` ELnRIfaIAI (I~IrA.Aa<Nrrl ~olill G/f <o.,•,.• »r•6.•Y f: ; ~" UHI EnS1.ILE5T AMSEP S j./~.Y STATE SE% DATE OG &RTMU ME pi VER5l1LENSE NUMBER STATE yE% WTEOF BIRTH ~ , lU~~° 'I !'/k M F 7' P•• ti.j 3G. C'I.r~fe TD 3y7 7_ lv;: M r oAr rEAR VEHKLE YR. MARE ILNEV.~ DGEI MODE,L ~(NOVA-DART) BODY STYLE120R1 VEHICLE Yfl. MAKEICHEV ~OODGEI MODEL INOVADMTI BOGY STYLEl2 DILL ;. "~ '/Gtr~U f~ /9'12 ~ f-c r.•( CrPrl T: rnC 2 d/ ,y ` ^~ :w /iY3 ~r7wo ~ ~ L~Cf.NSE PLATE NO STALE TPNLEn PLATE Iq STATE LICENSE PLATE NO. STATE iflNLEfl PLATENO. STATE ~' 6sc .ts3 lti~'1 ,~itat 312- oKGI/tA,.In vENICLEIDENTIFgATgN ND IIOBB MOOELSX NEWERI ODOMETER IMREAGEI VEMM:LE IDENIIFICAigN NO. IISBB MOOEISE NEWERI DOMETEfl IMaEAGEI '.''1 ~/ l q X EI7~ aD l ~3/ 783 /.~ vao .t~f kYlcwil flCGQISIEflE00WNE~R fIAS/T-f WST~MIDDLENKIEI OPIVERS LICENSE NO. PEGISTERED OYMER IWT~FIRSiM100LE NAME( DRIVERS LICENSE NO. M a « /"x/ /t ,tlr2 1. uc .. >dNI C. C(5 Aw !vt~ ~ n w TE OF BBiT [ ~. OWNE BAOORE55 ~ ~ IBTREET'~%MO~Si AEI DATE OF FARTN rw OWNEflB MDRE53 (STREET, CITY MDSTATEI v /Sll G. ~e Str f;f <I ND NDAr .E ~ rtPw° PMtSOF VEHICLE DAMMED / tn~~E PMiSOF VEHICL~E DAMMED vEInCIE h~~ /{ _ sror~LiO k' / YA'In f c.rc( s D i .~'~ /~_~/ /ec.: j•l. ycX. A../lxr ... YES ^NO W M (HERE AULOMONLE UAD CITY NSURANCE I ~L ~+1~ LIABILITY INSURANCEINFORMATON~VEHICLE NO.i~ LOVfnMEw EFFECrfon rlos MaDENr ON rOUflLM ~ OI NNAE Of LIABILITY INSURANCE COMPANY NNAE ANDAOONESS OF UABIMTY wSURMICE POLILVIIOLDER /~ Y /~ElU;.f An{ ~H:~crNd~ - rwAl rl h1 SCYVc° CO% ~l>rt lJ{" /iVt''• ..L•n ~ 2p LIABILITY POLICYNUMBEfl ;: .. ,. ';~~ _ NKIE/ I;N AUMESSOFUABIUTY wSURANLE MENT J71! IS ~~ arr / vi 5'~ S[/~ p3,j/ • , r " I ,, I'.16~A('v Sm lf~ r/ ~sE Z. Yr(e••fnr. f;pf(lP `fro LPaD fon AaAlgNU,NnwESI AGE I .__ Io5T 5EPAAAreR ~. _ ___._ ._.. _.. _~--1',(rrq...._ ME 2N NJUflY: I ~ '1 XJUnY I NAME 1 N E I wA[nEo „.. sEx ADgau sEZFF Ma+ESS MO F <<:IAAxIA O^ ~ n w ~wsw~oll«t ®~ a>craRS wul v::Mawrt rvr. © + u~a,r MwA fWSi ONE i1XA ,APPLIES ASIATUSOF WJUREO NNVE D~~%FIflST ONE T~AT~APPUES POSVnLE SI AIUBOf YUWIED a•Ax ws.+I vlX WVEHIfAE sNxw Naa ~Aq ND A ~ II I ~ 4t ~~r wVENgIE 'WA«''ar"in.E rA,r xNlw ^w ~ zaLED is Y I " 1 l O N.MIr~"` , t coNliANI ^PASVrran ' YYY .' ~ uL _ l ~ IDUfD awao or rMl ucl Ia E a C O wrAll ~ ^ "EDT 6 7^ p^WaslAUx ^ 6^ 6^ ~^ ~' Y ~ OESCR BE BLOW WNAi HAPPENED (REFER TO YEHM:LES OY NUMBER) i gT. ~ iol No )i ~ iJ+l o ~ c ciL / `~ ~ O ~.~P/I rL/v j S7D~/1e~1 7L~ mJ: ~e ~C{,/ ~'L•'1 r ' ~". .. N..z al .~~ [IV,.rrrrtJ~ flnrkA.ry /c~ 1 '~ ~~I~:;~i- Nw/ ly I,Illa,r«.,« ~/e/Im/+ ! rYD~j1A.( •fr /rh,c% i r 1 if 1~'.• M ~ I I~; I ~~ r ~-.~ l~) ~ ' ' z' My h~r:,lc/e .. e,nA!/A {r ;/ra •v ~'/r ~~f 1, f i.. rAT/I+ /<•f~ i•u, v f APANL/A, r { }. ~ '> i~f a { h ~ 1 17 il' F 1 ~ 'f'+~ 7 f rn M~!M5 v v IuI I LWA NVESigATED DY J VEh11CLES POSITIONS BEFORE COLLISION „',flx, `•N` ~~• ^~ '. ° ^,'.';;,a Dro•'a'c% ~t~, f~~y ':~1 anal N ,. l uN mla Er pllXGl.wAY NAME rnI NG II^~r:nl•an Yllr^"~ inf IXw 1aS r I ,.,x» Q9 ^ ^ ^ Calhf 1, ILA • r~-- / "O:"'D I, ^ DF~ ^n: MI ~:r x ^ ^ D fnoM DIRECTION ro DIRECTION ( ""~'~ F ,j~ »xr.,«xxI„ ~ D D ^ Kala r `"°""° .;;; ^ ;':",".°w:"" B DINEn r t~ ^MNA. 1( Y rNll Y11XAN WA'4 U'YA 1^NOX.WKX 2^WKxWAY l^ n.Cxu NI .^4Y i~Ax E ~,~.~ / 0. / fvPE Of HOM LI4VCRIVLNX;IE ACigNS'CrNCATJN[aI MDAfI 1 ' ~ RUMSIMf AGE NXANIIII lgNiCOlgtldl9 11WfgCON11101 vI +[ oli xll vw%f 4 TIM f t ~'lk \X r rr~ll•,Nr ICU 1 ~/ OAYIV JII ~IrfU,^ `ACNKS ^r 111^XLJIIk WAYS arT O' I~Ip GGllq SIRAIdII NIEAD rf.. f. OVLRI A%IIq ANO PAS&ND ER L #l r,~ ~ ~ '~~ ' I ~fYlr X ~ oNiru~ ) STOP SIGN p ] p•TNV WAY ^ 2 ^ ( ^ ~IA~ ~r )^nwrxrK J^DAWM ^ ^ _ IEVfRYOtE ^ > DMA%WOIIgNf TURN l~j~J }' ~ 1 S I; I wXl N.Dwx.r. ) DMSA ^ X ^ NI~ 11NgF. A MARINO ICFT fUNI i Y d t ~'~ ~, I- "~ Q > ^ sww ) ^ foc A ^ °rM.n%leaill D r ^ nT . XanlD ^ i DILOOP,w,MPI ^ ^ ~ ~ ~ ; a Q ~ DM SIINLI 5 (I AYIfi AMlll.ll ^ > ^AIICY ^ S DMA%WOUTURN r ~ E ~ rr, 1 >, fr {i}I, ^r ^ICl lDjyfCfvl y^IC IISOff ^ ^ ^X^lf flllRN ^A^SLOMNO Y 1 1` I yI U.. ~ ~ rS I.t IS D> ^SrtCVX A ^liW Lf IIC/rIS ^ X ^NI~ K .. IANL! ) ^ STUIX'1.0 TOn flUfiq ~ n1 A.L,N fOR Npt Sllw00ANGE11 T ^ •JN LN'Y ^ f ^ MfIONI fl M/AAN 1'{4~' l ( R101'PED Af !AOIIK -.6f ~~~ ~ F~ 'I~ ~I, }il 1 ~~'E{~ ••,"'nrc.r lnlw.E r.wv flc, ^ X ^ONN II •/'t Clfv D 1 ^TAPMAI[0 ^ S ^alnroP naf 1 {S J'; )` Y y~~ ^ 2 ^l%WBLO ^ X ^ BTOI4CDWIgMWAY ~ r' 1~1 d ,{{...~• I IL r ~rTtP~M1'u~ 1 ~ l1ilI1 TM: J ~ (VXID ^ 111 ^IRNf C11.Wtl~+ yr r, Y qy~k~~ ~k~rr t I ~~'- vim •?~ ~ ~ . ~I~~' R'~>~"~b`t~ '4~", ~r a' ~~ ~~ t , t ^~lt-- ~ , i4r• >Ar . '. R`~ d~"Tw:y ~ c. t ~rr~ypt k I J~~r L r.~ ~ L 1 , - < L,A I ~ ~ ~s r~ Jti :1 t,._', E ~~~ f ~i~ 1 It IL. c: Y~ 1,( („~u~t}~~ ~ ~ ~ ~' ~? L iJ t ., , . i ;! SIAIt Or• WASHINGTON ` OFFICML USt orvtr 11 - ~ f kdOTOR VEHICLE COLLISION REPORT p. y. _ ry OATEOFOq',DSigl p ~~ . (L .5`In wn ~ / AYOF uES wr JN TIMEOF COWSION AM Jll lrn I.~I nU r ununs I 1 NTYN/O C / IIrW aWVa u p '~ 4 . rL t l i ~C PM -1 ~ C/! ~rl~. s vW^mEM COLWTY -:.... CITY~~JOWN / ~~ r f~ fOV`sUE ° ^ ' M C S ®Q CIIY, TOWN • ADMtIS PHEfI% WrE O~ISNrLEII SEGiION x p~ ~, r rrsvn ~,ar/ -r «cw~D .o w r µ s ©© OF 3 ,s/ O r Q GIVE NAMEOF SiREEi. PD ORILIGfLWAY TERSELir OWJN SIREEi OR NOAD w. ~ f f/ 'e {~ d/ ~ «c ` PNEFIX E O MLEPOST D `rrv . .F if. .r : ,n/or1- .wo a ~ /~Oc ~f~.U~V(I.1f~ I NONINTERSECI ~ OCAIgNOF LLISION ~GJ`(-~~J1 // /J /'y/~I l ll. i, , A K (`Ls ~ C - ~ VAMP DIAGIIAM DATA . • y . a f ~ ..IYr lamo{ 3fRELTAli1l OEI WEEK /-'! I l .~ ru` I r•U.~aii~il~x ~r~rr ` "a ~ ti j1rv"r-n ~' n IFrWLCfgH' f ©® /rj/y~ INT^Ell NTLI CLS ~ s ll+a LlD.rww ~ ~ ' ^vE ^ M I f n...lC-GE C ~^Yf;K~p ^ O ' _ - ~ SPEC COUE U:.E J •rr ~ ~FYTrxGEE , x ,r ^YFnLLF , ^M,nL ,a.G;, ~, .. , J4 ~~ OBJECT STRUCK .' PrAVF IsNwc . a,IttrEH OFO WECI3 NAMt A11 0 ADDRESS Ln CAi 10 u OO .- -._ ... __. ., O AD ^ IN WA YCLI ~© 3 ~ • __ _ - • r : r pWVEA3LASTNWE ' a IRST NAME MD0.E r r ~s ~ 6 " OHIVtR3 LAST NAME FIR iNA MD ME OLE 5 ,~ l. re.:. r to mssF %~o. e C7 _ ~ Si11EtT E33... _ FIOVTE NO. AND M NO wu r~s ~n oA StnEEt ADDRESS NOU tE NO AND UO%NO CITY ~g.TA~T,E, ,J7 ZIP LODE •Irf4 OIS /,vA~GC .~I W/ ~ pfllVEl C~ ~~AI~ON ~! -~ ~ g Yr,nrrur M CIIY 3t%iE LrP CUB[ WxrVENS OCCUPAliON Y7 diIVE113LJC04E MUMBE/l,N;,, SLATE EE% DATEDh UNIH AGE UIYIVERSLILENSE NUMBER GTAIE OAIE OF NIIIH AGE VEH.ICpL~E~Y/ft MM~fJLICHEY.-000~0/EI MOpE~I/~F]/,,EDAgil BOU Fr: WII VEHICLE VR MA%E ICHEV ~OOOGEI MOUEL INOVA~UAIn, IIDDY 31YLt IZ DN) J T - n - ~~ TRAILERPATE NO ~~SF J:IAOTEIq. ; .; 9 /V / 9 l •`-/f . I 1E LICENSE PLATE NO. SFAIE NrNLC11 PLAlE NO SInIF VEHICLE iOEN TIFIC TION NO. 1190BMODELSSfICWERI : UIF rrCN IM IEAI.EI VEHICLE IDENIIFICAfION NO IIV4tl MDUGLSe NClYC111 DOMEII:N IMrLLADCI +~, ~'Yr REGISIEflE00WNER IIABT~fW$T~ E7~ !1 WI. '. CCNSF.NO /'~trfz •ATJ'IOV/ ~y~~..,rs=~oJ-Y74 REGrSitlrtDOWNCII (LAST FIRSI~MrDULE NAMI:I UIIIVEfISL CLNSL ILO. , w OWNEIISADQnE80.," "'S':,, IBTnEET.CIIV ANU 3TATE1 WNIN OWNER3ApO11ESS 13iNEEi CIfY ANUSfAI[I WLEOF WIiN ^~ . .: ~ w PAn 190FV ICL~E~ DLAMAOm I 51 Mn 'r PARiS OF VEHKLE DAMAGED '•I rlauW I.r rnAlru.Uu .. ~.wr>/ y~,rpq ~6d c+E lu~~urr.y - « rrtrxa vLrrka r. E w Altw ro f $ - _ __.-. ._-. wws7nLREAmomo ie uxu urv lNSUnnNCE -.__ ......... .. .. .. LIABILITY INSURANCEINFORMATION~VEMICLENO.L __ covwwf WEFFECi FOR rNSxcc ptNr GN rouncnR [Y]~YES ^NO EAND ADDFIF.SSOF L1ArEYaTY WSURANCE ,,nF~~T~~~~HOLDER /' p NMtEOF LIAUILITYIIISUNANCE COMI'ANV ~ a L.; r Y NAME ANO M011EB9Of WffIY NStIRAfICE AGENT arv ;:IAr N rr POUC ufe ~ ADt ZNU NJUNY. sU UTAIEr EPU GrxrnrwNx xwra. AGE s 4 Y a - NAME ~ f S IorAL , ,m°- y / o /„ L / NAAeE ruVnLU r/ _- y. DDNCSS Sf.X AUUIIESS SE% NAUE ~ LJ `^v ^M, - 9TATU8(pIN.tA[O :ps MMNFVISTONE t11AT AI•PDE3 51 USOF FO MMIt(HSI ONE INAf APPL E' wM1 ~:wc p ~R WvFI~ wufD 'H" ~~ "„~~) ^w~ NvE cft ra Nr ^r•A N E aC lr ~ ~ ^rlU O sue. D7O ~ ^ ^ s^ ~%^ ~nrrr. °a~ ..,,,, ., ^ sp EvgWNONirI UY AfUIOW WCWGL[ - ~ S I I ~~~' W:SCIIIUE BELOW Wf1AT WWPLNID NIlfC1110 V1 OLt.. I1Y NUAfilClll V~v'NA O In , 1 v A•i o /r !•. ~, , . ~ I % x EAC ~ ~ ~ ° H / ~ Qf~ •rr..,. ..,.A q /r c , ESrr !!~s!'r A, .'~ ~ ... ~-...( ~ ~ .-/,':mar rD.:~%1: /_G.. ' I 1 i I /J S.~J !I r ~ • yq~W r 4gvy l ~ } J ~ a . ., rnl raw r...nv. . ~ ~ t I I•- ,`k 1 ~ y ~ -_. VEHICLES POSITIONS BEFORE COLLISION ~ E IMAI I I rl rr% V[wClf N 8 f W CW SI14LT WI rwnr .AML ON NU 'n ^ ^r,~!~~ - r ErrA rr. M. rl. ~ r rn. ~ ~ ~; J,r.xr o ^ ^ ^ a o ^ ^ ^ ~ ~ t- F y ^ ^ rxr. r Msrww ^ O ^ ^ ,.. '" uaK ~x ""'"' ,..I rnuM DIRECTION to DIRECTION IYMS(RVN wA1 USVA 1^9nfw r:~n.. r.YA, E^vnl ll 1, ^":; '(h V r E~. w R ~ . , J tl ,,, O^ r. : = - tlC~D11 R:N RDAp W11A0 V N[AIHEA (%:rNCW IAf ONJ ~~ NAEIKCC/rNIOL iYYC Uf 110AD W E n.rx C. ar,Er I Ap .Ah ~~'~ i~ / ~ . I r VC11 VlHIt;It AC 11nM13 ~M C. WI n• r ®uw.~"c;.r I ~n.,L%o-ri ~ :.r^ .Aa. ~;r,.Il~~,r.rL .v.; ~~ [vJ 1 'Q Lnr.~r.~11.u.,. c.r.N r.raX,r 1 Lrn A,II AD ~rl ^mr l ~},~~~Y{ t ^.wwwa r ^aAm. (") ^,IC (] r ^ nw wxr ^ L LJ OmNUAf rNn um n%s•. Nr. ~l"~~ {f10 H~`1 1;;. ^ r ^wrT a ^sf.owrr.n a ^ Ix['x I O J ^ rN. ^ , ^ I~ivurvnu ^ , [] M .NI IuNN I IM Ar,rrrr. nx • ~ ~ ~~~t ~ ^ ~ ! ^ a ^araw . ~roD E ^ o,rris'iii:El A,,.,.a ^ ^n :wu ^ E ^ nuow.aA ^ % ^ A. ncufl lwlN M ' N , ~ Olrrrn nU~Sll,fft r/~Y , I W .IWPI lJ ^ A ^~ OiIMR f ^,SH CY rI f ^IpN13 Off LJ ^ rl ^ > ^ AL ^ , ^ MAnx. u lulnl 4 ~~' ~dl lal ~ ^ ^SflWIY 4^'iUT ~KAVp (.) n ^rVl. ^ p ^111 ~ rN ^ .. ^. RE Aldl IOn NOr 6f I w0 orwof n ' 1 . ~ ~ .. ~ { r ~ f Aw1wYYU4a l.,rxKrof ^Cr (^JfCIY (.~ , ^,I, 1 M4 ^ , L~'I' D/ IIIIAif%; ia - / i Y ~ ~, Y_-, ~~ A . ~_._.+( r .. . J~~ir ~ « ^L L , ^ I ^A,rM,.Nn l:] r ^cm"iL%`vL-.~.IAL r~ _ rtrf I Iwf ~/` IM~ ifPiY ^ ^ ^ I ~ , ~ r r%wlxv , [-) ~ ua•1•IDnf nn%nwxr ,i f // ~ /{ ~/ C / !y R _ ~~ L ~ e f ~, A ,'L 1 ~ 7 ~ `~. LA~+`1 ~I y AY rr ~' ~~ s a u ~ 4 ~ ~ `r F v ,'rS1:, rq f7~ ~:L l-0 _^ I_ (J (-) I' ull ti ~ rl d s t~ r'!~ ~ h ~I% L .=ln ~^ TiSkr'.¢r~L I.E~.' ,1 ~1~'"} '°nTi',;~.1 +~ "'~1'' ~ IS Iwr. y ~ „:: Jr r,~s A r 1, ~ ~ I I{ It JT e t~ an+~ n 4JVµ„~ ae , ~ L 11 *d.r ~ 1 ., v I ,~ T i ~~ r^s~,, .1l: , ~ ~ '{ , ',t ,ti ~ ~r _ I ~ zMtir{, ~~r, ~~ F~'x 5 .V .. ~~ aatr-:~€~ a _ ..~.'~i ~ ~ .-ice _~'~',rY.e~` - s~ t ~ '" ~ ~` ~ti, 1~ _ 1* °~ ~ STATE OF WA NGTON - WSF~%IRtV.LeO,~ of ' tO POLICE TRAFFIC COLLISION REPORT ®E I of q ^~O. 7 TRAFfICWAY q• I{~Y~ Nr NUMetR _ ;~ DArt I au ~ PRIVATE WAY A NMF CWNtY B' ' Q.Z ~6 Rlx ..pl IN, xrD rw.{~,I ur IUS[].cO rIOURI _ Nf1NiY N0. Cr1Y N0. pMWA ' N QE ~IN IrvOk10WN 2 I~ ^U9 NAE eNO.OFSrREEEOR {NGHWAY I US URAL rmffs s [~w or O(yyN5~7 ON QI ~ RourfogsrafE I INIERSECrrNG VnrNSrRF~OR WAU +NONINIfRSfCfION MIIf ROSi ~S/7O - ~U' .E ~(~ - R9fia f ] ] DISfAN[F6DIREMI { BFEW[(N IKVQ SIRfNe / 7z qE fgtNCF CROSS SIRFf10R NfARF51 MRE WSE ~~'S~ ACCIDENT RAMP DIAGRAM M]A ~ fEEr [] E W Or MILEAGE Y ", COIL SpN NVOIV(D' N SEV(u Ir ^CODN rD1Ar NO. NO KIIFD NO. NNR[D~ ^SpejAGf ^NN6RUN Iurv9w9rH 1f'RD N RCtING SrgEftOR OR RE{ERENCF n CF V[NICI[5 ® ~ RROrt rY OAMAGF ONLY ^ QESUIrID ^vFMCIF IMf C45 CROSSSfR/fFF09 ROgp ~1 ~ %! OB1FCr 5r9UCK(NAME Of OBJECT S{RUCK.NDOwNFRS NAME, 68Q~p ~J CI C•tE FSI.OANAGF SMCLLL CODING IbF 1 ` . l § ~ I -. I S 4. UNIT NO. I Du tq~s N.ME: u5r mlDa UNITNO.Y VEHICLE Q pEDfSTRIAN ^ pEDALCYCLIST ]~ I 11951 Dv vEq'S NANF' IA51 ~~ . ~ Srq~ E55 E KLICW.~2q D l FlNNR mr~ I ~, , I r rA009f55 ~.~ r'~'~;' ~ ~. °2 a1Y~~D~~ ~Mlt 3 3 R~,OD DR.fIpFDDE R„DNLEND o „5 7 8 W WY• LDy. I~J -1b37 R ~ I ^ ~l • SrAEf llaF Ut plpNEp~. r Z D9rVf45UCf NO. SIA{F R 0 n M-C~GN6 ct.rA. q. 3Z6 ~votJG- X ~~~ '~i."" °A ,, r~ 1.1ou~ F' dqA 151 47 ~ kU 6Drvl WA F DAff nRIH NAMf6pnONf NO ) ~' 1~ «` DN 09 oq 5 l~~ 'r ~ ~~ F 5 GN E Hr E OCCI f~A M NAMf 6 p{gNF NO. EY[5 FIGHr {4 GNr /C ° ~rt y ~ CHECK (.~ 'vfNC~m(u" c0. NA 1/8503 R ('~jpK-G u~~~. ~ l~ ~~ fir, ':1 NODES' ~ «K,n rMRioril ar A.miolnrR"u ^ CHECK (.~ ,,m,( _ vEN aF As aN rMworEl Df.NarirEa.Al "'"~ • Z N ueq IJOTJEEA 5 I °'~ - CODES - ~ ~ ci u A is 5 {R ° u I(]] ' ~Fr:7o;KD.. p...,,,E..«E ~ qcr ^ ~Sn1. p wr,lr Oc ~, N,~q 50R6 HK1+~lD. Hm MqU... p'r ~ riDn .c~_ ~J § ~~ R„(~Q EIDOOCE CH V.I moDF IDARt NOVAI sIK~E Nv xrw7o•`o„ pAwKl.....KE ~uR` '.r '.. ID n vD onv, ^ Eo ^H„N" ^~9;,,, tt 4 ~ MERCD M6N 2 D2 E ~jrt~ FOR.DY, MDDE1'IDA ~A, Y .I ~ V, . ~ ~ ~y OR a tN srA{E ~ E~/ ~. 'Z~ r i ~~tT, GR1J f}L233 ARtq„MEND SrAIF H w 3~ .l NAF '~ K:. WA. WNTjsta( 1-1U~52 S ., vrHKEF IDfmIr{urroN no. R C 1 WA• ~~ ICJ '7 r~ / , rtw~~/ 1 ~' L fHICEFIMNIN °~ q~~ ~~ ` Rf LR•DRE`Os ,'VV'J60.Ilc~:,'TT- QMIDaE R{~NEND ~ 2 5 C: rZ 5 ~1; 2 q I o 50 ~A E °I{ D tR~ U51 N Sr IDgf E p _ eBea a . 3&S•SG59 ~°, CA~.~.. WLu..~am Y4 p~oNC ,~~ '~~ EvvKJC. ST. ER ] ~ ,~ ~~ IZ' ~2Z5 fug~~/f~.yn~~ ~~ EeADDq,55GKIN5URANCEGDOgAGEM e A5788 NWY:109E QU{l..laA. Qg3'7~ 1 '`~'" 12 NOfJ~ R , , aA rvcN cHARU cNARGE iAin~D.wu l7 ,) i ~Q~TTYY . ea ~oAMAC~ D Awl.r" ^RfMUHm [1 DRIYIN r1........_ ... ,......., (XI :~ qY zs.±,9r~^qu.' -Ed~i ,. .,.ai ~~ Try, DIAGRA/M~,O 4 1 A I ` ~1 1 _ y~; MM'~ ,, ~r w "fif tx~ ~ uw•LU STp[.~p §N f?QQDWq ,~ ,a3 ,. ", .• """ w ~+tTC Y/ ~/ a yi OFF, IJEF{ ®CAINE CnJTO !t S W~UEt{d rb0 %(~, ~++. ~ f- ~tE ~~~0 zb /4(9U/D /1/ mNG /T-k3UT tRff 50 ~ST1u. Sz2ucelT OEU 7I/E CSF7 /692 APPZC. ' a t ~.f , ~ ~' ~F ~+ ~Z~72LR45NING LT DOUJN O/JZD 7RG --~'~t~ -' RG~D WAY WkEi~6 LT f.6Fr A• 4t GouGe W Tp6 (~A~ ~ ~. K ~ SuRF~CS' K~Wa ZTE6lS cSPUN fX20UA10 CA6t/AXrTD ~7' ~G.~ so. c.sautu~ p 3G' sCEL~ ARK AN.71lE u: p r y W w .rn~bog4 !N!-yRFi02'RRG, l-~-l®-dsurlytlAFT~a-61ErArusu,A~ •" ' CODE$ 1 SfA Au uru '",;; ~O1.76 2 2 C!!~. r. nr~ ^ AMe. [ aaT-o'oos m ~E , 7-5 ,Z I r' c ~~ ~~ ~ a ~, ~' ~'; .?~4' y`~ r~'", ,~,.~ i Yk '~ ~ ~ 1C` 11 j ~" ' { z 1 sr ,;~ ~~ ~ ~ o i~ -1 O ~~ ~ ~ ~ ); - _ ~ ~ ~ .~ a ~ - ,i.: ~ ,] G ' -~ vo i.ov o ~~ - ~,~ O Ii ~:. U. ,~ n '§ O I M O { 7 ~ ~ J J '- I _... ~ . ~ ~ ~~~ ?~ ~ ~ u~= .! y art ~. y ,I .I u . ~.. ~ai ~~fM1.i.~. { j { I- ,:. i ~y AY r ~ , vl tir ^ ~~~iY«V~rvr.. '.~ spb R.a ~" ~$ b .. 5ip-oe yr wASMitvGTVN I~AG,f ~ GF .'s POLICE TRAFFIC COLLISION REPORT L7 TRAFFCWAY No. PRIVATE WAY DA f f l N pMF C WNEY pIKfCQNRNNINLLNYq /al 10 ~~[ ~ (• ~ W \ NIS wrp iwRi n Lr O].Dp HODRI 3~ T v lJ (D(MEYNO /~ OIIY iHWA ^URgAN U4Al CIY OR rowN ^N ^F ^1 FI NO.Of SiRfFtp4 nGHwAV OS gOUiE ORS RFE q ARIES ^ taw Hof tom. [" oN - v' q - ~ s I FRSfCIING WIH: Pl[I NON rMEV5fC110N NSnls s . o f0 AD E '~ SR.• V nEMFfN SIREfi A SigEEI pr51A4Kf D I ENC .CROSSSIVFF RrvFARFSi MrIF ~vF . I R)51 Q' ~~ IO fFFiS N w OE Se'ZD y~+fv~w~-VwrEY ACCIpENT MCODEE I MIA Cpl {gNrNVOlVFO~ nl0 YglllfD_NO. rNJURfD~ ^ SPIIIAGf ^ H 16 PUN M„ N oiu NO. .wHDRRrH Q I 5 R Et R OR RffF4fNCF IEnyq cis aoss L~f T avfH nfs ^rRORfarr DAmACfoNlr ^afsIXifp ^vf°ai OB!lC15141 Cn NU f Of ~iZ ZO `CI 1 A I OB1FC151RUCK AND OWNEVSNAMFI ESI OMAAG[ SRCW CODING USE _ UNIT NO. 1 UNIT N0.4 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST 3s 3 DR VfvSNM M F : Lt51 rR51 Mr IX DR VEV'S NAME' USi I I f '- , \\ , 8 N SIRf[l ADDRf 7 s" ~ IREN AppRf55 iA ,E ZIRCODE RHDNF ND D II s AIf Y IR N ~T~ w _ 2 R DRNFR'S UCENSf StAIE 124rJ SOW q>r GuA Es Al r n I l A OS 56 I V W R' uCEN NO. SIAIF SFr DAiF "'° °" p '° ~ CICCUVAtgN !!.~ fKRgNE frFS W[IGHi rE GHI METi.E IYIA+J-931;2248 alu 135 5ro E R CUVA110N MNAME 6 PHONF NO. [Yf5 WfrGHI EEIGHi ^CHECK (.~ vfncrf ASANMPior[raANOtHF4 ^CHECK(/) vfHaf.sANrMROrffof ANOiHf4Al CODES-• c oAi• ~ nen.., 5 ,~[<,H~ l p Morox.cn_ CODES - ~ J n,u • i:snM"' S Nlcrb„ A ,•O'oK•al ~n 2 rN,w~fs ~ Fb~i64fl t R .5695 ' IN P •Nrv ~3- ° ^ A l ;f w a:. AR M VfH ^ fSm. ^ ~"Kr7 ^ wGw ;F. «„°, ^ Aw Nct ^ PoM ~ u6 ' ^ ~R.rl. ^ ~ ~ ^ ~ ° Y K.: . YE MA fIDODGf~CHEV.I NEB/ lIIDARI NOVAI SirIf IZD4 .1 VAS V/~N 4>C9 E n. YfAV I HEV.1 1 MODfI IDARI~NGVA ~ 1 °°w ._ A 1 N Cf N StAlf A lFR RAif NO tAtf t 1'1 veHC oR t l n RA No n p - ~^`, q ~~ ~! ~A ZT C . F - VEHKIf lIXM ICAIgrvrq c ~. ~7u~ s2az2 L C N v if pf Nl rvU I rv s' 4EGISrt4loowNFR usi Rgsi MIDDLE SAmE to,3 '~Rw RHOrve tvo O ~,~, r fD wNFR. lul rlRSi MIDpf H Nf rvo. la 2 ApORl53 O'pANl4 N A wNtR -" ~I Mt KE t,~gNElfi , QT I Eax• 105-G,'PT. LuoEnw, Wa. _ AMf a,nDlnlss Er rNwRANa CO wACfrvl N~ A}F R u N DAMACFD.AU e as.N~«D ,wcrbN., ' ' ° " AGf EA 't M cHARU c.uacl , ,, ,~,~°„ g ~ s t w °;A-7A~1'`ie 'u''~ sµ+~FS{.. ^:w~r" ®RlM.mtD ^Aw:v°er ^~wwN ^4EMAINm ^~°w~~er fsipun.a S t ~~s ° le DIAGRAM OF COIIISION~ lw Nu 1 Dry oRIH SHED U NEClSURY 1 DESCRIPTION OF COLl1510N: Iusr slanfMfNiu sHFn if NfcfssARrr ca-I ~' D Q I~ER DtAZI ~1lF~ 't-0 -.1EtoTIA'Ca/•CgRp~^J.t - . .. _ _ ~ ~ n ' M fE•A~•t SR•?A pJTO CQ-IZ•, u~~ QFJltD 6KOLtL. I ~IL C[f.DT CptitTTtOL„ WE ' D I R IDT lute A f3RQADSIDE ~. - . M,~IL for t K ~ ~~ t . JM1I~/H SKIDED ACl2O55 6UG+IJUAY 270' OIJSO A 6RAUE J3 ~ ; \ \ 1~1RIZII.YL 6~T 'TAI(IAY.s CXII F4 /MAILBOIIAND ST/u. GOING ' / y v ~ / ~d 7AD'SlCEf512tIX)F~AND7F1E.f~ L',$/o1R5TRd6GNTEA1FUCr ' OUTJMC.oMlti1G Ta A STbP AFT.E72.641'TT11,Y,> AFiR.7R>~ 6{F~1D'ON. n ~• NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I - Z 7 4 5 6 OCCUPANTS/WITNESSES Ilo::ou a:~rui: ni Awl i~ u. Acr ums ";;,{" ,°, „ 4fvR rnn wo A DOnns Dn or • ~ ~ A DCna uu4 a R Mov DIRDM ^Awn ^;; F' ^^, . ^ H ^ ; ° r+o A noasv NAU~i °r ux w. ^Awe ^ "A^, ^<n . ^ N ^ :' " , IRSNwf....., eA(R,I GR AGIAKr 11~ O, KF D1I-AICHFD fp .._ . P~ TiR cr. .. -- ~t st p pAII EY N.011 DAII nRDrIDgY 2tY7 l' .. l; _~' S tw~~~ '. ..:'. 1 r.ntrs? i~reevnE~'iu. k ke ','L ~~' , ~~E-~Ey~ 4 t ,t, 1 .~1~ 'L f I~ ~ I , 1 1 A qI ~',i' r . y ` ,e Rl~~tt 1, ~ . J 1 1 - ~ _. ~ S5 , a ~ t < ,171. S~ i 1 ~ 1 I - ~ ~ j. :' n I I - ''. , 4Y ~ ~, ~~e'' r gx17 ~ i ~~ - COU $roNINY ~' IOIAf Nt CF VfNICI ~) OBIECt SiRIICI unv S I fR'S NPMf )~ZQ MILEAGE •~ ~~~ CODE NO INIURFO_ ^SPfUGf ^MT6 RUN wrvOPiDM I ~r %'RD IN N IOR ROADOR RfiFRENCE PD NiFp CLS CROSS SiPFETyRRO p 4GEONlY ^pEiE ItF ^VFMCIF / ~~ z0 _ NFR'S NAMFI fSt DN.IAGF SP CIAL COD NG USE - E W~-I-L ~f°. ~iC.~~tiv lCA,~I •~~l~.G~ I~. - S``FfpIAC09f15 p ~r"~ ^ OlY SIAtf LP CODf ~ NE NO - (' 1. 1U4;)~$~"~ Wd\ ~~;;(,c, ~ ,~>S C7C DRIVFRSICENSF NO. SIAIE F% itl RIN ,-,~ '~~Ll~-, ~ ^ CHECI `~ ~ E v ~ COOEE-+ ~ ~ _ ~~' IN1uRRs ktr+nvlo .l a. Ro. . .~r. ~. ~ veN p 7 ``~ ut~ ~ ) ~1 use ~ ~ ~~ vENlc¢ urv°rl 3 D R I v E R L~~ 1'~~J E SiAIE rRARFR gAIE NO. SUIE h'I YEH. WA I I I ~ YfNlf IRSI ' MDDIfI 'PNON[NO. ~ Rf wA ,~~ E E 1,000 ~' I~ :°w°en ~aLf.CC <oN n°wnv° " nwn. ,~Sr~o R~ ^ nr, E ~~ Rpy ~ I k= M1~.' ~a xr~ ` `'•~°~~•_.~~I~ :_~. G~a.,L61 r.4 71~c~ L~.rr. ,~dw~~...,, ~=F'-,v,$ ,..~ v`f T fir:, ~G ~ STwct /3- ~i ~ ~ ~.~N, I~r-i~-L.... ,~ I I __. __ ~ S'G,G. s~ t~_.. To Ct' I I ~t2ti~~, o F~yof.d l~ .t4~ a C.Atiy..~.. 4h~~lti,a-L oossl [ a .a.c. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED OCCUPANTS/WITNESSES ~USISWhIMlN1A15168 +COD S 1 Z J 4 5 6 ~...,.. ......... ........ --- 1 ~-_. ....w e,. ...._ ~..~ .. _. .....~ A,Ae 1pp~ x,5.`!5 ~ l., . 4 ~. ,:. ~ _ ~ A Y~~:N" ." ~° ~ ~ ~;~I w ~' `~ ~~ ~ ~ ' ~ R,. a~ ~ .y 't c r °~&, ,r tw ~ ~ .YY~ '9Yia4L ..~.w~.Yr..,~..:au~.°.~ioau~aa~a:?.~ae, ,%-~»m ~' "Y"~ ~ ~ ~ ~:u¢~~ ° ~'"' :_ Ott - ~ryt) ,x f A WSPIw nfV. I.B01 y ~ : u~ - ~_ STATE OF WASHINGTON RAGE i Gr i ~ ,,~ U _WCasRit^H5L^2~4brj~4 ~ ' "~ lt~P~ N. ~ :~ , s ~i I~ No. y / ' POLICE TRAFFIC COlLI510N REPORT L7,TRAFFICWAY ~ PRIVATE WAY PaKfcomPwM NUmDu )~I AI oscau uMf ° s .IS twR N Iis~ % O RI l Z ^Y W ~ cou"n ~[-~ - C.l ft-Y S O~r~ muNnrJO. /6 cm ra. rHwA ^ uRe PM t' CIY OR TOWN NAMf6NO. OI StPEEIOR NGHWAY Q QIN p Qf ~ ,WITS a~ ^W raDE IDt~ ~tl,:w.rJ oNCO CJJ I •,Y Ta G5 RWIE ON SIRFF 3 y~iyo D Za INIFRSfGING WIiH: SIRfflof 40AD NONINiER-YICEION ' 1 1 BETWEEN fvfQy ~ ~ SIPfH•6 G.~G IW 51RfF1 YPEEIX E MM1F PO51 L_y~ ON 4 DRIANCf 6DIRE I MPEI[Rf ,CROSSSIPIEIOP NFANf51 MIIf I MItFS r W's f W 1 Ss.?L, OO [ET Or ) ^ L[J• er~ ACCIDENT MILEAGE CODE RAMP DI AAI ¢AtA J CIXIRR)NINVOIV[D: VERILY: IOIAI ND. NO. RIUF --~--NO.INJIIPED= B'SRItIAGE L~'~iRtJD Of VEHIClFS ~ IY ^ pESU~ ruNPHDn ~ %-Rp IMER C15 IN R CI tOR ROAD p1 FFffRENG CROSS SIRfE~ ~y~/~ (OJ T OBIfCI SIRIKKINAmE Of OBIfci SPRUCk ANDOWNEP'S NAME) fS1.DANAGf l./ y SRCN4CODING IRE ' UNIT NO. I UNIT NO.4 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCl15T 3 .. DRIVERS NAME: t fIR51 MIDDY ~ uf~~2 ~~VQN rY~ t DPIV[R'S NAME: USI rl I E srnfrADO•e $81 a Zz X11 /4v e S' v/• s REfr AJmRESs i GIY .~.. ~ SIAIE 8`io6 /63ND~T d R IY sIAIf IPrDDE HDNf ND. WrvFRS UC[NSF i L k G 3~ STALE RI H w~ rv; ~ A l yr ~ Z I V I IICFNY ND. IAIF ,~ aIf Dr. RIN o.,r .R OCCUPAiNJN rI MNAMf 6PHONE NO. Su EYES IGNr IfIGHI ' Sl~o csS: ~M t,~ S,b E R OCCUPaNON rWM NAME6 PHONE NO. nfs WEIGHT HFIGNI ~ CHECK (.~ wtH I ANOrHERIAI ^ CHECK I~) vEH CIE ASAN UnaorEEaANOrsiv'Al CODES -' 7 ~ 5 I e ",'„°;°„"r CODES - ~ s ~ ~ i; 5 sx e ~ " n lwRs ~w~; ^ AMRmA.KT ^ uL ' ^ ~S:II. C~"„„K;; ^ w~v ^ A. ^ ~ ^ ~~t•r O ~ ^ : v r~I ' VFH yJ,~ IDODGE.eHEV.I L 6 C ID.uN.NGVAI srrle la DR..ep+v.l L ~ ~G. cJ r - ' ~ E .rfAR 1 Hv.l MOUEIIDnPI NOVAI la v.l H 7t~ • NSE PtwiF `~+Zrv ~ti . SIAIE IRAIIIR pAIf NO. SIAM - I'I ~ VFN.<0:011 Il AIf A NO. (y~~ 3 NHKIFIIXMIi TION NO. v/ev~ ~v~z6 L [NI<If IIXNIIfI I N J J~• _ xcI WI I u ~ PHOM NO. W R IsrtRfoowNtR: I. sT rIRU MI°aE Nf NO. I pegs qg~++ A~ 8' l Y tRz Z rl'1 /r~'v~ S. (.c~ St~,1~ ~y r o G E NfN NAMt aAtXJRESS GwNwll oasn co. oR ACENr t ARIA C I w R I AN ~ DAMAGFU NEA mc T: ws . Ib:'ario:• T rI•rti0~ ul w.MAGE f~0E10 CNA•Gf ~ ^ AwJWiv RfM"HID TovrtD I'cLQc~ 1 WAY er GIARGf ^ ~w~r ^REMMNro ^lowtD onwN n uI, uAMACt f I Q~~jjrJJo'' ~eori~s !~ I sv ~~v NO•IH DIAGRAM OF COIUSION: I SHlfiII NEGSLVYI ,fr`ar~"~ o-I+etE ~3 __.__... Qt-~-•~-:------• .. t ~_. w r1J , ~ L DESCRIPTION OF COLLISION: IlRf su•n[mfNUl sH[IHMGSSARrI ~ u4r ~e~N, ~ ~ ww, s,wr b~ .~ ~~ ~~u H~, Z c, ot.Dl S I •'J a.. ~lo,L:~ Er c . ~ t; ,. Y~rJS' u I vK ~a f' c ~.L NAME, ADDRESS 8 INJURIES OF PERSONS OCCUPANTS/WITNESSES io~i swDl"iEio~rJAt N:Ma INVOLVED ii ~ CODES 1 u% Aa urs - Z '",,;;" 3 M 4 5 6 RtslR tact ~. NAw -n .E.. r .t c a r r• res'y "° A . ,q i And15S IDRt INS. AMD oar ^^. ^.: ~ Y 3 ~ ~ 4 W l s j ~ n il . LM NDVIDE .D HAw u%wu wlwwsO1 INt ar ^AMA ^"""' ~~ry . ^'w' ^ ~: . " . nuts InGarKt.{s ~NAw afA/NP~~ .~,I X u J~'VN:RN eDAr ~oP / Y Aur,c. wlu 3'cSa NN't ~D ~tfntn rwRN.S ra~c~.v~D ,.ml.s DAJE tX nro•I /z-Z7-3 Hwovt4e 3 D%n r ~r _. i ~ r ~, .~ r I iurr ~ Ill is ' T ~~ iA 4 I ,~'rl"~'h ~ ,T.~ 777 ~ , 1 I } ! I ) ~ I 3<~I - Y 1 t 4 t ~ 1~ t f r ~~ ~P 4 ~` ) . ~ t ~ I ~ ~ ~ rI ~ I ~~ '~ i Ir ?~ a * f - q I - ~ '1 t 11 ~. I , D ' , ~ ~ . t .,; ~~ J r M „ F ; -~U.I- )r(~ a I, is ~ , .. .... .. 4 r ~ v'.°.'°di~ ~~ r. ~ ~; [~~ ' >ml ~,~~~~ a, ~'~ (~t ~ ------ -- -------•- -- - - ~ lua. ' POLICE TRAFFIC COLLISION REPORT L^J TRAFFICWAY "~f' apucf coMrwlNr NU;ABfa _,. ' PRIVATE WAY ~~ D IFOfcgl I N P u umE courvrr Wx. "ox'1uR.l IxIH.lN ~I ( (Uif ZxDU NOURI 2r ' 3 ! I ! I R ~ Z S r•; ff~~/~s ~ /~ coufPrr NO. /G Grr ND. fnwA ~^/URBAN Iy.~pAf J ^N []E ^IN CIRY OR tOWN NAMF6NO.Oi STPEEr Op HIGHWAr 3. SMIEO ®B ^w ^D eri ~ ,-J. ON _ fC1 Cli M I aOUrf ON SIRFFIC SECTION .3 9xs-/7o - ' IN fRSfCT NG WrrN: it rD AD NONIfI1fRSFCI ON '/ Paffl%'~ EO. MILE POBr'. / BFiWEf~l (cVd SrRFFi 6 O~ SipfFr F 7 "~C/r / / ' 6 r CF6DRFMIII Nf MN iFgENE ,CROSS SraffrD NFAPE51 Mllf 1'051 D, ACCIDENT MILEAGE RAMR OIA pAM MiA ' /~ fFET Of •T ~ ' P . COLLIS ON NVOlVfO SFVFRIrrI Nt6RUN IOinI NO NO'KIIIED~NO.INIVRFD~ ^ sV IIAGE ^ ru oRfR1rv N ~0 INI Cls crlN spFfl RROAD Oa RffEPFNCE CROSBSrYF(i OR TB ~ OFVWICI[S m ^ RRORERiV DPMAGE ONLY ^ pFSUITFD ^VLnCtf g 3LO 6 /_ OBllCISIRUCKINPMf Of OB1FCi SrRUCKPNDOWNFR'S NAMFI Fir OPMAGF SRCW.CODING USE f ' UNIT NO. i UNIT N0.2 ^ VEHICLE ®PEDESTRIAN ^ PEDALCYCLIST aR 3' RrvfN'S NAME: /SI fIRiT ff DRIVER' NAME: NSr Tf l ~uT Ti`u ,E.Tesr~ .J -" s1RFfsnoovfss sr F A°DRfss 2 ~/ c~~~ ~ /t ~ GIY SIAM ZIRCODE RHONE NO. D TTY SIAM ZI U OF O. '~/rT' ~ J eLl d Lc~i9 9f.+ 3G h _ 'rS Zs'Y cf R ,T ' ;- ~ J :d ~ ~ 9 RS OS99 r Z -~ ONNfp'S UCENiF NO. STATE f % DA BIRTN I Iv p'S LICENSE NO, % A DA 1EOf BIprM ~ / ~ ~ I ~ .•I 77 n CGCURAlION f6RHONF NO. EYCB WEIGNr HfIGHI E OCCUPATION fIRMN f6RHONEN EYES WEl r HEIGHT -~ 2 : ~ A/ , .3f~S 25~/~ /J 0 S % R Td~/rrr ,i S rnd ^ CHECK I~ nR AS wN FmviovFF ORAHOrHfv nl ^ CHECK I/) N s ttavEfaANOrI'Ea°L 1FA CODES-^' 7 ~, 4 ~ nN"T3 5 I uaH e~O, * rvlr3 <, s Nlc ,. a yDID.R.cff CODES- 3~ ,rfrr ' ~, IN uane ~ c ; 1 ~;~R; wM ^ AM„%.„Ef ^ uaRf ^ ~snl. ^ ~,~~ ~ ^ wLu D °asl ®Aw A~ F o 'HV ~ oaaF ^ EeI,IR o ~~ o ;.~,R. R VEH YFA MAKE IDODGf~f.HfV) MODEL IDART~NDVAI STYIF IRDP ~CONV I fAR NEV 1 N9Df11DARr~NOVA1 Y IZ R~ .) RPV n.CIX R ICEN PUfEN S1Arf IRARfa MIE NO. STATE I'I VFNC A NO Alf '.u/ L J C ~ ~y y 7 v[HICIf IDEN11fIGElpr NO. ~'6' 'Iz I~ ~I I /i/ i J,'/ ~. L E vFHICIE IMNIIfI AI ~N ~ I I ~ ! ! ! ~ ~ ~ R(GISRP[OOWNfR: D•Sr RIR51 MIDDY RHON[NO. W Isl R OOWNfR: 1A31 flPil MIODIF , N 1]_ ADDRESS Of OWnIY A 4 OWNf4 ~I L N E - AMfanoovess oR lNSUp.wef eo. cR ACFNI T ....A~i1 e~::~ R uul --- Ds _ OAw4m MEn f " pf.MinD ruNCroH.f EN Dcf i6M s es~oArsAeE ^Aww ^a[MAINfD 6 i'o .. ,,. ~pinNINO DAMAG[0 MU cNAacf RIaR VN ~auwN[D FscDlAmneF I ^ew K DB 1 l f• Ot e.S ~ rowmeV. - ) wAr I A Ioeorinw ~ rover Br. f AwA f ..- le - DIAGRAM OF COll15lON: N u of IND Urf ~!PoRrH ,. - I SHlfrRh![ SSARYI Br ARYDW ab%rs s ; h/ , cr; rtir.tn '® DESCRIPTION OF COLLISION: Iusf suvn[Mfmu mffrfnECfss ae '' .. ../`' ~//T`R'/.'// /f'/r:i/F ff'/ /df+S fi/opdi:;y J7,~F u1i Ties s eds(i9 /,, /7+e am c,f ~f o/•.;/r•e' fd/%<~ ~ ITm~>v .. , ~ S<=/'/r. j/jo ) %r• /'~ N~N~ : /'/w'/I < /~O . ~ ~I L~~YY''~~~~ , i . < J _... _. t i{9 1 ,,!S / B ' ~I~ y K'' x/~~ /1 ..DD I _~ .. _ .. [. ir ~ Sfa eA //t / el: R . Rn> d/ _.. ~ I T /° rf dxv /fir /f°~AG/t d/r~/S //ROG<t' T/a .. '' o-s , .. ___ ~ Ca1e•J l/Y.~n'A i'~in N./r1 /'/Lc~<! I7~' G'//A'h : . . . ._. __.. la NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES I Z 3 4 5 6 ~~ 1 OCCUPANTS/WITNESSES i~iouniwuiiiASniii ~sf% ece urus „~" R'„ _ R[na. ufa :Ta;q f 'A"'C/vire'• N G/7-SXr ~o. 3FsS2 J/ .Dfwfu ~ •I r T /I C f/ > NuJRf or .rrvi r ^AM e. ^ut'cf ^ wl . ^~lY ^ ifPLsr T C%.; .1 cy /v,71..c-.~/V~v f' NU ' N U y .DMFRS NAM, R O( R rR O"I ^AMI. ^rU4f^N~ .^rtii ~. ^:: M In x.5 _ RIR 0/ IW ~f NIRY ^AMR. ^ [F ^~~11 ^Nh ^9~V yf .nES1~cuRrcafKfrs NAwsKAHa K.OC~ AcfNC "I r. D J{t~fD %.51~Y'D DAlf or fIURi nprnlD Ian -_ % R ,., .. ~ ... .. _ ~1 .. '~;. ,.i~I..I 4YCr tiM J !~ .. ~ . IYS~ 'f. +ta~ r: 4 49 ~F' ~; J e~4~ ,s..f`k'S N l1.. >. k` v. A lri ~ ~£ 1 A ' , D ~x 4, 3 ~ ~ r:~~ g9 1~ ~,: yFi, CRp. Y)Y ~}°t ~ , ~~ i51: c ~ ~~ a 7~wY. ~' wu+ ' r 1 ~ F.a~tL i ~r'~• ti~ .. '._~: i t ~~. ~~f~ POLICE TRAFFIC COLLISION REPORT ~ TRAPFlCwAV rollcE COM"µNrNUMazR PRIVATE WAY Duwrcau N oar Ec a o 2 rv uME couwrv .3 w, .W, IRIE ..R ,w., .e. .~ IusER.DDNDTNI V wuNrv NO, arr Ea. /lo 0`~4 ~N DRAT CrY«r0 N NvnE 6NO OE5reE[rON nONwwr QN ^E QN Cle RWIf ON 51R(f efCriON ~ µlf5 5 c-a~ orv F r9YCr NG W~In: rOR ROwO• NON,MFRS[Cr10N 3 9siTo 0 9, ~E BFIWFFN /CO 5ra[Ei d erR[Er RREN% l . MID:ROer I / / UiS1ANCf6aR N FiEREEKf. CR0555 rv[Er09 NFAxFSrM IEV ACCIOENr MIf 5 E W R P DIAGRAM Derw / 0 ~z ~ MILEAGE rE[t E CODE COLDSiONINVIXV[D -$[vfR rr, r NO. aaIFD~N0. N1DREp ^SV IIAGF ^Nr6vUN rOEAI NO. "'Nor" %~RD C EF RIgM«R[iERfNCE IMf CLS CROSeer af EtOR ROwp ~ IX V[n ClFS ~ pRORR1Y DAMwGf DNIY ^vESU ^v[~Cl[ «xCl eleUC%IN%MF Of «l[Cr SIRUCV NiD OwN[v'e Nano ESr DAMAGE / ~ (OOIZO sREClu wOiNG IbE . E s ' UNIT NO. 1 D rvexs NAMr UNITNO. Z' ^ VEHICLE ^ PEDESTRIAN ^ PEDAICYCLIST ~ . wv nRSr Mi xnfu'sNµnE usr M. a / (O r rGL sr uwpDRESS _ ~ a E Dress a OIY ~~ 5 wlf Iiv CO DE RnDNE NO D ~ 3SA Or / ~ E . ~ C R r SrwiF _ZI~ UE ~~ ,Il O / ]cJ DR rvfR SDC[NSE NO ~ C NF er f % ~ On OF6Rn ~ I xvEV' lCENSE NO. ~ Arf ~ 0%rF Die 4rn ~ wCURwpON N EI VnO NO, FrfS WE Gnr rfa E acuvAnor EivM NAME6vnpNF NO. ~5 w[IGn~~r R E ~ gW eY Q CHECK (,~) vEn,aEwsiN Erviontawwornfvw` CODES - ~ 7 ~. % ° 5 r error, 6 'y',O"1O°r u K /) vEn ttF as wN Eµatovff of •rmri`EV.°1 CODES - ~ 7 n":u~ irivM"r 5 r% rv y 'l"e°,i ~•cu <, ~'^ a tr wrvs R >f ~:. ^ • r ^ ~L ^ rs~r o ~ K1; ^ u~E. V[n. rFAR~ NA%I EDDDCe.enfv[ u DwRr wvw slr V M ;o,.D Q A~N%.NIE ^ nMr °~,<r ^ rs.IlR ^ ~ <D ^ ro »:. r . t .cONVt IE IE D f J FAR % I nfvt (/O ~ ,~ MVaI[DARI.NOVAI r 1 V.1 ~ ~""C~22 ? ~ ' rz y A /; n uaN "wrf . srwrf ew EF40.wrf Fq. r H vEN aou . s'wiC'- 'l wF / , ~~ -_ ~ ~77SL37 ~ n- YENKIE IDfNrRKw10N NO. ~2~3~GI ~ ;2 5160/. ~. ` /U,Klf rff rl2sRR~8;73;3~7:/; ~ RlGlSrtvfD fR: D%51 NRSr MiDaf vnorx NO. I W is v WNER; UESt 1 Mi E ~,vz / > ~ T ~ tt~ NO. __ ID •~, ADOft55 OWNER , 3 . w wN N E // ~ u~ JF C' ~I~/•~Q' NAMrawopvrss or iNSURwNCF CO. «wcENr w3 F '2 ~e ~ ~ wMwupuu ~.~" cNUU ~ ~ "w"aur°rW gMAAGf ARu cNAau e ut. raawee (~nvMwv ^ arMUN[D ~ ^ nw:r" ~aimuNm es~ owwuct _ f ~D ^ Awv°en ~ ^ iwiver: _ ~o R e „~ OILISION: l NAl INaewleN«rn srR[tu NEUSwrI er wRaow DESCRIPTION OF COLLISION: lusrsw"frnwtµ srR[trtrxcfsswarl .;• .. O ~ I/E//'"/. STARTr~ %O A1JS ll~iL~~2 PreveTr . Ue~/s ~.t Tvrvcm Cy Fr TNZ~ l1Eiv , drwt~ PM" ~ 5 ; f ~ tl rcne~ Esr~r~p T7KAr ~w~ f1i~ . , Love// fJe.Yrcc y4~ .ZO Tv/%4~i ,-[$ O,G 74.CN ixJDi~ATO~C3 , ,AFTH~2 TNE' „ ~ L~ CS -'1-- 9 .?GuU~NT ~ cNeGC'Q~ At/O Cu)e!/ NaT GGT TiYe' L~ Mf' To -« ` ` y ~! 70 e v N , . Gc ~ ~' ~ t NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES L - Z J ~ S 6 : 3: OCCUPANTS/WITNESSES lose surnfMiNru srR r«%DarKrvµ NwAV U fI sf% Aa ur ' n ,,,cr sn. fxe s N Aw. No. A DDaess ° a N r.x ev ^ AM S. Q u1 ' ^ " . ^ H ^ :t~s. A wWl Kr, ~ w DONlt N Al«IOr p IROM ^wMe. Q rdKr Qwd • Q w ^ ri0 b wMl M A avESS MUId 0,> I RIM Sr ^AMe Qr aer ~[o•na • Ir. ^M ^iE0 ' iw X R,rfEDD,rr~R e~ r,- ~ i~GSt~ •(,j~ KlpreRAE[ri ER,IN.e Ef.IKt MIr D OS ~~., DAllpngal ~y--P3 Arr.GVrper own .~ r4rsk ~ .Ik r; `:;~, E':x ~~f l C A •~ i ~ NF e } q ~ 1 '~.~~ ~w. ~~'r._~I~ "_~ S .. ;- ~ ~~f , _ 4Y , I ~ °~ ~'v ~ bx. snv { +~+ # ~~.~ '~ ~en"s.~~.a+ctauo2~.s.__.a..Y. ~'.,.>:~s°.m"°:'~* - ~ >n. '~;f ~• » '~j!%r` POLICE TRAFFIC COLLISION REPORT I~TRAFFICWAY WUCE COMRNNt NUMtlER 1+~J~ ~ ~ `: ~ur ~ ~ PRIVATE WAY I f Gf EOI _.I ); umE couNrv couNrr NO. atr NO. ~ - IL u.IWIO I t lust}.DD NOURI ~ s I ~"i l7 ' fsL 5 ~ I I '~I I t , 3n N~ F SGuV ~~ ^vGRN ~' T ~ ^N ^E CIYOR IOW f6N0. Of SlxfEIOR nIGNWAY C)CES ROU![OASiAf SfCt10N B ~t"^'~ ~`~`,. ~ f ~rIOC_;oLg4s-~ ON CK.1Z. .3 9,5"i>O ~i~ `~ k'T¢}~'. NI(~ 1 G[MIn SIkF~NOA NON NIfR5fC1 ON' % 2 Rgff % FO if YO51 ~ ~} {Y~ BffW[EN ~ ~ $1RLfi [ ~L.IV elgFFt '~ -' I 01 IµCEBp RED OM gFfERfNCF, CROSS SIRfEI OR NEAgf51M EPoSt ACCIpENY RAMP DAGR WIA 7~y 'E tF3 5 E .W.. - n ~g "iJ[E K.>,. ul~ iFEI Of Yr3 MCODE E • d 1)' COENSION f.VOIVFD~ N SfVFq IY, %.qp tIN gEft RIIpAp OR RFELFENCF } tOtAI NO. NO. NIIIfD~~NO.IN1URfD ~ ^ SPIEUGF H 64UN rung°~°"r" " /} ~~:; ~:~ 6V[H Cl[s 5~ INIFR Cl5 CROSSSIR/EEiOR ROAD' ~`•:.~ ~ ^RAOPfR1YDAMAGE ONLY ^RESIIIIFO ^NFF'Ff (oO/ZO ~,~ "~ % OtlllCISRUCNINAMf Of ObIECi SiRGGK µ00WNfR'S NAME) Fs10M1AGE SMG AI C00 NG USE E. s ~ ~ ~@" ~~ a ;L '{ UNITNO.1 UNITN0.2 ^VEHICLE QPEDESTRIAN PEDALCYCLIST =+ ~ 4Y ' y~. ' yY • _ Ou fq B [: t i t NW(q' NAM[' USi I ~^ t - .~1 .~~., r CF~~'lST~NSEN C~A~1~n~ -J, ~- _ ay[. v n~"~ E 9 f55 IRLEI ADDRESS ~ "" ~~"'6 • V £} 5 ~"~~i-p113 2vYT , ,„~ CRY / S1AlE CIY B1AtF ~ ", ~ ~%. /owRt-SfA,.c~ WI'+- 98~`~ 38sS17 R IR YH N ;~.,~ :r~ ~, Y ~ dR 'S tICFN5f N0. StAlf (N FB H I V U FN ENO. AF E% D tE0 :0 tY ~ ~ ~ '_ B OCCURAl10N IIkM NAMF6RHONf NO. EYFS VIEIGHt f[IGrlt E OCCUVAI Orv fINM NAMF6 RHONE NO. EYES I IGHi f IG 1 ,. ~ ~ I ~~ ~ ^ CHECK (,7 En [ [ AsAN !°AR'iovEE Of Arvor"rw.At ~ R ^ CHECK (~) ~ 4 ' I CODES ~ s OYFFb ANOfnEV Rt `~"'~. p ~'. °,-} r - ~ nA Y v7 + i 5 f y A•n YnL CODES - ~ ~ n A xA;!r 5 fx 6 s. }} N~i L ~ aES Yfid ;: {Cw"` xcian ,„°,'ro xf° :Y 9G"' aro" E f~ ~~ ;'1 ~, '"i'd; °° ^ Akak,Anct uV° ^ Fba1N ^ G~ YAk ^ ~ °LS. ~ Y~rt .°° ^ Aw",lAna ^ u ~ ^ EBRIf. ^ °N~% ^ r ' [Ak m MA%[IDOWE~C fV.) MOOf Hcu xfxa. I HfVI MOUFL IDAAI NOVAI vE YI (} Ay,l • .A E~~7 I tIDA41~NOVA) St(Ylf'(}OR CONV 1 n rlAR m pM A H 1o Y 1 ~ OG'.c] pd}.1v~ '1~ E ~-~ ~ ~:Ci• 1 V OR OC rvSf hA FN SIAIE IRMtFR RAtF NO. SIAIF H vt11.COlOR N I NO. AIE ~ y ~ 6r1~ C~. WA I VF CI[ IXNI NCAt ON NO. L VfH CEF IpENi it AIf NN +~ ~) ~~ 13 I I I i i l I t I I i I I I I I I~ i ~ 'DTI !-~ ~ N„ N[GISR fD OWNIR USt RSt MDOtf~ DrgNE NO. O klUS1ENF00WNfR~ [psi l145i MDDI H FNO. ~ ` "' C~Jels-I~EStrra ~o6ir~ (~J. 5-51~ ~' a ADdk' ao Eq ~~ W A F wNER ~' '"( 2 ~ ~ ~uu 2.~/~/ / N y ~ e ~' A 4 ,' /' / ~T Wri54[A~, WuA E ~ NAMFen004155 CI NSUVµC[CO. 04 AG[ 1 u AN ITALTR}~.~ ~~ IJOn~ R }> ul dM1AGEU AREA p ' 4 [nARU DAMAGED ARU t L _ _ L ^ ` s fsln~pAMA ,~_- D ~~ ^Dq ^fy1 YEMAINFO ``^"~_- S ~~ ^iw vp auxcf ~u+aronM • ((--•11 ^AWAEY! ^RfMAINEU ESI. UAMAGE ° IGSOriOUAS I ~}} < < ~ BY. AS DIAGRAMOF CO ISION lu wlmr IJ AWA ~BY. S J. ~ . S, e _, , Nu c.R NOkrH II SNIIf II NFCESSAeYI tl I I - YARtow ~ ~ DESCRIPTIONOF COLLISION. Iu5[sunR [M[Nru SH[eilf Nfr[ssAYr / 1 s . ~ '} I 6113 r 212 lY' IV I LF' 5 ~ ~ ~ 3s F ,.,, ~' I / A . ,.~ . c . t '. T r1 v18 CYLO< St.c{ N~6 N/ ~ ~J ~ ~ ~l a J } _ , ~ __.. , .~ .~-~- V~ a 1 H •/~ l < mac, S1A~£6" s~IF BIgG.k~.-1 ova PP-L~~,^lo Acci.. fN 4 ' C ~,. ' r ~ _ G.~,~u / I ' ~ ~1~~ ly•'~TII U~J°4~[r~ UCL. G.Lra~~y.. _L+rJS zUL~- _ AI.E,i1 <.~r h,'wl IJEJ,• SIOLA+J~ :D~~h _ ~ /~ ( /IFi O ~ , fiS ~ .. ~B ~ ' _-_, ~ ~ t IJV1+ '.. ~ ~ < ; ~ f vl.! ~Cr l - / . UfCvl (.4. -...._ {f~ f l1t L S ~ ~ "-L5 ~-1 , V( .___.. v GI I . . <L!- ,~ `IJV AJ +.. Kf VSh • .. _ _- [ NAME, ADDRESS 8 INJURIES OF PERSONS INVOWED F CODES I - Z 3 4 5 6 OCCUPANTS /WITNESSES IsvF:oo'~~iar'iul :~AiM'Rii sE% epe ,urus "„°,'," .u N[sl t Ecr MI<r s. ~: ~ t k ~l ~ I EBS 1 lcr_ ,w.~ wtY oc ;,1„x~Gr SCNr XY ^A M ^ B a~L~f ^ ~; . ^a ^ r. ivu ] / ' R' ' ;~ ~, ~ ~ l: 1]ff~ [~e t fit f I xl W r ~,° Yii)IVrii 1v M ^AMe ^c1O1Rf ^[!i • ^ n ^ ri° O r rn ii .r.tf p ~ '•~ ~' .~ ~~ "STN 1'." : "~Y• n 1 ~ I ~ A ~: tkwrss x ""N` iti~~la A .o n+'B r.`"' N. uds:Fa A4ENCr f~L~P1_,_ '~._ ~ ,~ E~Or. Ire~ryNl K DRRAIxrnD r[ , ~:z.. , scnu nr ^AMe ^rA~A"if ^'r"finfs^Hx ^i° A N:I ANN nD D%nu Efon ARReovED er DAIe ~.,, r __ _ . . ~rr R { 1 E a f ~'f Nl+" Tfl s ~i! a4 1 '~Il { y ~~'[ lin,'17P,N4' 'h~'N t G . 4 ~ ~ .~M1, w.rn1' y ~ ' e w Hl f c ~i '" IM ~ Y ~~,, 1 ~,P !F F~ ~ r 'E ~ ~41 if `, ~ 1 ' . t ~ ~ ~rti~,r, t w j ~ ~ ~ i f ~ ,` F ~ Y ' i [Ll c 4 I 1 ~ ~ tY !1 r ~' ~}X~ t' i tl a:r E 'I _ r y ~, I4c u ~~ ,1 t } L a : i tt ~7 'V ~. 1~xlY 1~ 9~ ~ ~~~ E S ~~ f Y l 7 ';II) ~ ~ - 1 ub` ~. h , I 1 {y ~i f Ih rF i. , 1 ' ^ . I L~r ~~'~ ~,~ ~ ~. r ,~ s }( a ~_ 1 (~„ . ~ ""`„~ F [[ C ~ ~ Ir , L • L ~1 r aA ~ (~At~ ~ ° P ~ .A1~~ +~ 5 L `~ a ~ f E .. / I.x °.:~ ::.,vR ,., '. L. ~.~t ` ~: f ,~ ~: ~ ~I T_ - ,,r•„3~.,~.,.,..;~w°., , jai : - ~ ~, _+ ~ I.n ..: ... ~. -. STATE OF WASHINGTON W°° """`"' "°' ~ - _ ~`• ~ ~ GE or i '~ ~~~ ~ ~ s_ Z POLICE TRAFFIC COLLISION REPORT ® iRAFFICWAY fOIKE COMRNNI N ,L1 `a oaf of au UMB[R ~ PRIVATE WAY ] I ° y` 1 ~ 3 ^N ~' RD, IW; .,q DNR ,.I DI ^~ ®N CIIY04 rOW lusf ].wiwuRl ~ N - couNlr muNrv NO. - gtzso,JW /G / F6N ffl0 G (YS c,TY NO. ^`~w AN t . ~' ~ ~,~~,; ~ ~ ~ ;u~r ROU,f 0431Y SF, NON AR/5 ^, ^ ^D, ~sDa4e oN NOD1i~DeuDr~~J u1 ~ 1 I {~ ~ ' , NIfeSFCrING VnrNfv IO4 ROAD NON NtfRSit110 Ce_ryff~~nn y`7 ~7c ]> / BfrYrt~i 2[IUOAL.E ~y S!q RRlil% MIIF WSI DISIANCrSDela r RWNE f.a°.,.. ...., ....._, lflsl-lOCJN,EW RArRffl 2-sB' 1 G la rvr f GGG ' a - ~2*"'~~.v~ ,n~ - . -'. .ISpNINVOIVFO: fRItY. Of NU - I~ ~t lOIAI NU. ND,gllfp~NO.IN1URf0~ ^SeRUGf ^NN6RUN Gf VFN [lF3 ~ egOKgrY DAMAGE ONIY F SOl[N Cr SrRUCq INAME Or OB/fC13]RUCR ANOOVYN[PS NAME) ^ NSUIlID ^ fN <l[ CODE IuM logo,H N ~RD ~Nt CIS rFR5lC1 NG Sleffi OR ROAD OR R[RREN<r ] 01053 SIREFl~OyR ROAp / a~7~ j~ I ] ~ ~ - ~ M ~ ~~ % ' ~';•) . UNI7 NO 1 ,/- FSI, DAMAGE 314CR4 L'OMNO VSE 1 S 13f1i r ~ Rs N,w,t: ~1 . agsr ~~ ~ f M UNITNO.~ ^ VEHICLE ^ PEDAL~t CLISi ] ^ PEDESTRIAN Dervfq'SNAMF. Sr fle A ' M I 1 R rADDel33 ~ G Y L [_ • iJA 5 TOE'SF_PG{ 14 ` ~` ~ rRFEl ADDRESS ~ SrArf liR<G D B 27 p ~` FAD R l wA. ~ q 8 ' , ~ `"° ~='93So R SrAIE <DDE I. a urx w 483 S 5.~ "°'2f` t z ~~- SD<lNSfN . 5] A rf fA N I~ m~~ z ~ t 11 IDN wA F~' NAMFtRgNE NO v 4 ob S~ _ -5~ !!,~ Co~+ ~ Alrii Rz4 ~ ~ e . c ' FY23 wEIGNr E <uRArioN AMf 6 NONf NO. !S Gni ,( IZ I ~ -' CHECK (. ~t_ ~ ~ S iov a O Aa z 105 4-ii R ~ w~R z mlr~ ass-l~ 16 Qua t s~i - V(NKU AS A R MU r AN wfe 5~• J CI L A 5 r °.in <rlw r'OT' ssr "u'°,r,° _ ^CHECK (/) [NKIf ASANf~OV[[Or AN~OIr~{e.A` ~ CODES - ~ J n.u ~ ~ ~; 5 r 1 `" I n cl F _ _~ _ v 6 _ n(I . n ' a1DODGr <N[v Q ~ ^ " a R 1 ^ D ^ AxeuArvO ^ ~kl ^ iiio ^ vi ~ ~ x ~~`. 3 MODFI jpARr NWA SI U[CK REAL YI 1]Oe <ONVI 2 DR E n° ""YEge r NfY, ~DDfI,DARINGVAI Y,tl]DR ,i°. ^Ctxuv ! ~,,, r F wilIR RAIF o 3(, ~ ._M NO. rAf H <O,Oq i~'•GV (,I '/.{r `~1,1 -~)` r•' AN ' z IRNIRKAI Jf~ Y~m 76 K I ! ND J wI~,--f~ KSF212 C~7A M~ ~ '[00Ymfq: N NO. 1/O Wfr ~ ~RS ~ ~ . i Yf NiafiolNlr<A / A X O 8 Z 4 ~ 2 5 / 6 Y , ~ , Ip~ Jpgf ; 7~~ l ~~~y~ l1l~irtl~ct ~C1R`! (p RpNf NO O Rf IS gtDpy/N ~' r I of N 85-4350 ~aoWmq . w SflnaE /45 D21UE1~ raY,:U A e[AwNlo ',~ E9' ~~.` ~ O-- UEHQ PAWtsD 0~ QoADoa.~ 5o.5c{ou~nER - ) ~~ ,l ~ ~ VEF+ :. Paooc-EbIa1G ~,. Bn. Dw2, FAtcE,o T° I~' Y. \ ~[~ ~,~,~I STAY or.1 R19ADWAY CiRgUEt~ PORTLON) l/EER>~ ~ Cl~~ ~ OFF STRI WA1G UEH.m OIJ C.C'.FT f26CR AND `Ln L"~,;„ ,~ `Or Y FT~NT F~I.7DE]2.5~(aUmDE2,. UEaI•{•@ STAR.I~D BOO , _~ 1~62E~ OFF BNTb S~WU.cD6R ISG FT P2toR Z-" F ~Y 4qN ~ ~~ _ _ _ I Tb STRtKtUG Ue1{• L "f116u5Lu9Ur f ~'Cca it - " d N6 LT 3O` Wto - cas s^ '[1L6 CiR1L5N Ar.1D COILIT oAJ AA.1~71/E+2 96' UEil. m ;~ '?r, ,~ I~ ~ pL WAS CCOmt6D oN ~ IMMEFD. DR(p.Q To dCCrDau7- ~ NAME, ADDRESS B INIURI S OF P RiSONS INVOLIV~EDH , `~8 E K YOICH U ~ (y OCCUPANTS/WITNFSSPC luu sufREMUnAISwer CODES I - p ~ 4 5 6 ~,esl4' N ~; L~ _ _~ ' ~ i ~') eery JX . •~ t f ~ p 9". v, w..,l'". '~ `~ ~a • . .w '~ ~~~ '; 6~p ro-aA. ' H ~,~r: ;, ~L4h •.Y~,1~k... r, '~~ POLICE TRAFFIC CO. .ION REPORT {i ITRAFFICWAY pIXlp ARIAINENIwefR PRIVATE WAY ,~ DAlrorcau TO 78 ~3 l ,Rx RR, Ili »IR ,wn ,~ >.I ~'~1~NDDRI couNrr Jefferson couNn NO. /~ aEr NO. ors p," ^N Of ~IN C1Y DR tOWN NNAFeNO. Di SIRFEIOgNGNWAY 5 AVIfS [Ze ^w gJot Port Townsen NCoRd 12 Rhod Dr RWIF IXIerRi Fl ~ 9.~~'~o Nf.IION J INIfYS[C1 NG VAIN. SIR[IOV RpwD NpNINIfR51CIgN &M'[F IR[[I l 51 1 RHII% ERDSI d ~, I DIe IANCf eD,4f v H CWSS efvfFi NlwRE55 MwF 1051 IEe 5 F fEE W Of ACCIDENT MILEAGE CODE A p.Nm MIA COIIISgN NVIXV[D' vfRllr. SOfwI NO. y~ KllfO~NO.INJURLD= ^3R4feGf~-.anu LR11N OVFHICIFS © L'IIWHRIY DAASwGf ONLY HSN ruNRnR,. I IN % p0 IF Cle EJ~~~ NI p S GslRff Oq ROAD OV IM1rFRtNCE CAOee SINF[I WAD _ OBJFCI51gUCK INAM[q Oe1FC1 StpUCR AND OWN[Re NAME) /; le1.DAMAG! / ePFt4LL CODING IAE -/ 5 l UNIT NO. 1 UNIT N0.2 VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST b" c1 1 DRnERS NAme uul N r ml f Sla le Nanc J DRNERSrvAMf IASr nR tumuli Golding, Lloyal David ~~ sfgeEEADDRE 6 0 Beave Valle Rd InEf AuoRfss 9929 Rio Vista Dr, "' S1AIf ZIICODE ENO. Port Ludlow WA 98365 32-4923 D R II elAlF 111 OD NO Sacramento, CA 95837 ~~-6932 L _ L ORNfR eI C[NSFN SLAGLNJ549BS SEAIF WA F v 8 H ~' i 0 4~ ~ I ' IKtNSE NO. H0295208 elnli CA e[% M ,F Or v„Y 5Dw16D 10 LaA OCCUVwNON NRM NAM[e BONE NO. Erie NSIGH1 Nf GNI Home er Bl 12 5' E ~ OCCUInSION NRM NAMF IIHOrvE NO. IYFe wFl rE GNI retired r 1 G 6 E 1 CHECK (/) InMS:NiMrlv'nfalANOrHra'v ^CHECK (/) f t of nswrv tmnovtiotA HiuAl v CODES-+ ]~ e°s' S r ny° °c'••' S ii i CODESP+ ~f1 a~ . SI T ~F:`1Y' O ~ O ~:i ' ^ pBAI ^ „ ¢] Iw e ^ ^~^ I O <"' ^ t' ^ ~ ~ g Hrewv Mw.e IDODGi c"fv.) EIDU+rNOVwI n lpDR.~eoNV.l E .r q I Hfv.) ~londa n¢willOAx1(NOVnI rulroR CGN , Civic Wagonr S >A - sure wnfe HA,E NO sulE q H vEN.caoq n AIi NO Au e wht VS 921 WA --- -- I brn 19ZMW CA ----=- _--- YIHKIf IpftKIRKwIgN w. IN 4 7 U C• 16 822 ~ vN, aelaNl rl n1 rv ~ W D B. 1 0 1 2 y0 ' RtGIS11RFDOVm[R' VESS llgel MIDIXF Thom son Violet Mae P,btIF NO. 2- 1 O yy e e11ef0 WNFq: lAeS flRet MIDDIt Same as above HONE NO 4~ I] Z wpogfssaaM+eR 6 1 Beaver Valle RD PT Ludlow WA N E A vrtIER ,I NAM[e ADDeleS Or INSURANCE CO. Oq AGINr ^ R AEI 1 V . 150 Van Neas Av JR DwmAGeDA%u Ni.N,.,r. ~... ~ ~ .:NR,~ I AM:r DwRrn cH ., cHAqu ~ r `s . lSrMpVMfA ~ RtMNNID .p ~ L~1°lwnvM ^R[MUNm ' is1 'D'AJnACE s 2000 ~wv°erNanc Sla le ^.°P:°er i ~ ~,~ = 100 q ~ DIAGRAM Of COUISION~ ilenuteassARV~I Ir elerAle~1H DESCRIPTION OF COLLISION: IuseswviEM[NIU~aEnNrcrssARn '~O Vehicle # 1 was No. bound on Rhody Dr.q Ve ,,, was parked on the shoulder of the rd. - ~~aoYA~c Vehicle # 2 pulled into traffic 3ust as ]1 Veh, # 1 was almost parellell to it. _- - _ - - - - _ _ _ Veh, # 1 ETwerved, but was unable to avodt „ being struck by veh.# 2. Veh.# 2 struck _ "' - - - - * the rgt rear of veh,#1 with his left Ern , .,r....,,.. fp. ~~ .a ~Iq NAME, ADDRESS 8 INJURIES OF P SONS I NVOLVED t CODES I - 2 7 4 5 6 OCCUPANTS /WITNESSES ;a svnIMENIfA sfg ADDnroNAI NAmI n SI x. A a .um: ., " H elq IAu " 'R"T,ouise E. oolding ~ 916-922-6932 - A DDIIS °r ------- er. O AM e ^ ^ ' ^ " 1 ~ ~ p{c ~ ' x A fKar15 uR1or r RMrniurROM OAMa ^" '~~, ^„ ^~;, uo A DD.ns " nn1~°f w scrNf e. OAMe []", ' ~;": . ~M ^ ~: ~ +n .. :~~~o wrtslcAl..Gnt%IVa NAw agANK X eA ~w 1 / AG1AK. v.lw wn N -i' ~,Iyrt A,cHiD Rtle HES i K~~vrD s /Ole~1 ~; ArwovrDn• DAII S"1s die , j p,. L,D, ~nN1,MlryD~'R "1'.tY , ~1L~R),~ [' f r ~ I ~ r .~ - r i {, I G, I t r P A hr ' ' z' ` ~ . IT) ~ ~~ 4 ~, li ~ 1 IT ~~ ~ ~ 1 '. ~ .' I ,q } E I ti J ' I . I • ; . r F , . ~~ I. .`~ . , ~,~ I (I 1 . Il irr~ "4$I 1 r 4Tr:._. i rY.`, _ 4' f ,s~ l . ~~~ F~. ~~ +~ ~ ~: ,r~ 1 ~.tYJ~ ~, ME ~xi ~s7~ - j b' .Y - rv / /' ~~~ POLICE TRAFFIC COLLISION REPORT ~TRAFfICWAY IOIICE COMpWEIr NUMBER 1 ~ PRIVATE WAY ""x 1 V ~i~~I J ~uM:I ~rlD.j`w.t~";-~~. USE ]~IDMO XDIIp, C DUN~F~ ~ CAUN~~ C IIYW ~ ^~F AM uRu I ^H ^E ~N CIIYOp TOWN NNAE6 NO.Of SiR[f10R1uGHWAY M[FS ^S ^W ^Of G ON iCI RS pOUIE ON SIF'(l9 SfCr ON 3 ~~~ .~. 9s~I7 ~, ~. . :,: INtfR5EC11NG WItH:1 [ p ROAD NON INiER5FC11/,ONry~ ({ y~ BF(WFEN M''EICS~WIGG S1PFft 6 R - SIYFFr pplil% EO MllE pO}1 +l {~ .~'.~ ~/U IE' 9N;f 9 DISTANCE BDIRE MNEf f. CROSSSIREEIOR NfARfSIMII! M N E ACCIDENT RAMPi DIAGRAM wrA /~ pLFt ^ Of C~ ~ MILEAGE CODE COIIIS ONINVQVfD: NO. KIIIED~NO.INlUREO~ ^SPILIAGE ^ f UN lOIAI NO. ~ IuNOttDlrv tH %~R IMFPy C11 D N S r SFpk R n°OU RE CROSS St4EE1 ~ a1 _ e ' OP VFH CEFS PpORREY DAMAGE ONLY ^ g5U11[0 VF fN/ ~ ?? ~ ~[N OQ , r' V OB1FCi SiRUC%,NAMFOf OB1fCi STRUCK ANDOWNFR'S NAMEI Est DAMAGE SRCMI COOING USE S UNITNO, 1 UNITNO.4 ^ VEHICLE ' , ' ^ PEDESTRIAN ~;. ^ PEDALCYCl15T.'~ ~' s DprvFRSNaME: usr I r I o NEp~s nwMU usr I I l 3'. B AFI~DDRE55 4 !5 R SIN~gpURF51 O~ ~ IfT StAlf ZIP CODE PHONE NO W14D1,0 9 33 - D R IIY IAIF 1 P E Cpl/n'la-CUrv~ 7~z `F34 " r 6 O R rv [ R ' S IIC [ NS NO . E SIAIF fX DA iORIH I RIV R'SUCENSf NO. SIAIE SEX IE Of BIRTH ~ ' , 1 ~ 1 ~ ' 1 I C ` 1 I [y1 lf~ WrLN/VZWJ /~+~ O I NT ~~ NxQ~ I`/~-'~ „ I l ~ ~ ~ ~ I / ~ Ve N i ~ c EYES IGMI E OC<UPANPV fIRM NIMf HONE NO. E HFIGNI 1 r c ^ CHECK (~ vFH nfa w o E aN 1 ^ CHECK (f7 w wN FM IOY[F Oi wNOiHFPµ VF nFn NPpp++.. I l Z CODES -+ 7 " % iv e 5 a+{ e',',°,e°I.°` c • I. CODES ~ + D RiAVY ~ s'vsv`r•. 5 e%n DN a if°~h r` n vs (;1 u SFR~I:gIRD ^ RNBM ^ u ^ Eb'.II ^ ~ ~.3 p M :fT~F ^ AY f p r~y pD EF ^ Ef,':a ^ K ^ :° f`~ • KH. YEAR MAKE IDOOGbCHfV.I Fl10AR1.NOVA) StYV IZDR.CONV) vM. YFAR MNC ( NEV.) M ODEIIDwRi~NOVA) I DR. VI Y ~~~ ID (a7 ~-,~ 73uG ?-D2 E CGU C 2-t~ ,o U FN IU N StAlf TRAILER RATE NO. StAtf I'I V[H.C 09 - N . E3G.Cl 54 W a , I C I,vN ~ wlGElaNtNUl oNflo. ~, ( 17i I ill ~ I I I ~ 1 I i I I L fHlaFlofnn I w I ! I I ~~~ ~ ~ ~ ~ ~ ~ ~ ~ LrQ RI~P~~~~1t S'C~PNAUrEf ~ PHONE NO. O R ISIENFDOWNfR: 1A11~~NR1 MIDDLE N S AoDRlsser ow,+lp N w wNlp I Z SAm~ E ~ NAMI l AOOYIS3 p INSUpANC(CO. M AGFNI O.U~ R I Cruru2 5' K~A,U~ ~~ DAfA.N;e ARU " ° ~ : R s wAa lu . oAV.DMCI tnARU 5 . ' CHARD( eIN~N 4AMACf1DARU .» lor f 10~0IiGU 1 111, DAMAGE . ^OPI^yN ® 9[MAIN[0 ~j.OPrvlN ~ ~Y AWAY ^RfMAINFO 1511DAM~f U I IG~OROu S~ AWAVDeY: ^ AWAYD OY: S f DIAGRAM OF COLl1510N 'D I ev ~uaow rH I ,.. I I- swRUruCE5l~vll ,<-O I .4. DESCRIPTION OF COLLISION; (lnF SUPRFM[fnAls [FIUNEC[SSwprl ` Uhf O TURNED I15tO TJ2r17EWb / OF WlZ7J - G2i f!~ _ . _ Ur~w"Cfarr.~r~ Pp2K UE~O w~5 ~~u I% _ ; I I ___ - = . _- IrK)G [2~ ~1rJD aID ISO i CXPECi ©ia..TU(2N r ~ - ` ( = ~ ^. , ~, r NTb TF16 DQ I U~-LUA`/, U~HI d roU.~?W f!JC-_ _ _ ~ T1x1 Cl-C)56, S~GI~ UE~I.~. R~1~D G1~ ASS - , ' DOOR, puSAUi/uG // /4i2P7uc,rO ANO C~9,VT" _._ ~ -ra<<-e! ~ p.U, ST2//~/NG A 'TREE TcS ~~ e0/19/.UG n~~a, uI ~W; ~ . ..._ r~~s r ,02/vE2 ~ wir Tr~~ s'r~E~e%~ 'j"(2AIl.ER PK, ' ~ ~ , .: I _ ,._. Ld~IEEL C.'G[~iUG /-lE.2 ,~lP QWEWA , . _ ....._..._..__._ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED + CODES I - Z J 4 5 6 OCCUPANTS /WITNESSES ,use sEnaeMmrM s% iW ADDIIKIN.V fIAMF n SI -- ' Sfx AGf rAlU1 -u.r' I:, nH ws - - "-- --'~" ' RESiR. lfltt Mlcr: r N NN: .. M , . DIwW •t oPE `=_ u1NK ^AM e p:ti'^ "'; . ^D ^C .°.;.,. ' H AMI ~ i ) _ AR ~-- A aX,fss AME mR Dr NIMOViU IRGM ^ ^.~AKI ^IKI ^ ~ ^ :° AMn '° .. ~ A N MAf1E Arlsfor sclNreY ^wMe. ^NXwI ^cwn.^ H N ^I:° }JCPSXY,ME IRANR 4AJGI OS AGIfKr KI DI TAI rn,P R%KF ARRIVED DM[p RINRI AIrR0V10lY DMf ' r, • i:F~ Y t .,~nc-r :w:=1.. ~ ., a=~ - .va-, ~ r-y.- 'r t~3uA tl t ~ I ~ L ~~ J htt b~r ~~ x ~r~1P ~ ~~ ~ .'I,. ~ I ,~~ S t l ti r ~ _ I I ~ 1 y1f ' L I I.' ~ ~~ '~ ., ,.I _' ~ .,'f _ ~ - ~~. 4~f `'' ?,~a1 ~ N ~~ "~` f'~1 8~n~ 4 - y}~ , ~"•• ~ ., ~Yw1" ~L. t ~ n'`~'~ * A ~ ', ~P°L ,e ~ ;,;;;. ~ ~' ~ y H~ c ter- vvHS~~w~C~•rol~~ I,~J~• P ti I OF I :9', ~!'r~ POLICE TRAFFIC COLLISION REPORT ~•TRAFFICWAY ~O• I IOUCf COMPUI Ni NUMB ~ y , '~~ ER ~ ~ PRIVATE WAY -• , , ~ •. NEGECaISI uH S IIMF [ ^'9 111'() 54~ ~'o~ I H. IyFi IVSf]OD NOVR) 7 S m~Rn. , 1XI ) I , ~ ~ I ~ OUNfY - WUNIY NO <rY NO. IHWA ~ = r r ~ ~ ~ {~ ~ ~ , - ~_ _ c'_~("SC`(~ '~l0 pDROAN c'-.r, {~/ ~N ~f ~IN GIrY OR TOWN NAME6N0. 01 BIRFFEORHGHWAY ICf CFS' M ~ URAI ROUIEOR SIRE OD SFCrION MIFES EJ ? ^W I~Of I~ I - R t~ , ~ !s t, - lT T .,:n R.r F ONCf: f.) r7 / - .~. 3 INI[RSFCr NG WITH. StREEFO 9Ari~o ~ a ~ ` NOFI NifRSFC10N y~ //I PREfI% f MIIF POSt L ~ ~ ~QE~~y "M: ~ ~ / BEFVlFfN C.A tl %/ SRRFFr g G~ I I,i.n $7'fY.Si~ pISIPNCf6D RfMtlO qOM RfTEN NC CROSSSIRIEIOR NE ~ , ~/ ~ '~j}./~,Q '3 F ~~ ,~ ~ ~ ~ l I~ • AREST MIEE b N 5 E W ACCIDENT RAMP ~ DIAGRAM WIA 4 ~ - .~~ n iEF ~ •• OF Cn ~ MILEAGE OD ~ - ~ ~ I . K ' ~ : N COFIISIONINVIXVFO: SEVER IY; ~ LO]AlNO NO KEI[D~~NO.INJUgfD ~ '~-SpIRAGf ~O'HIr6 RUN HuNOCt01H CP VFN CFfS ~ INTE 'RD R CLS CIIN St fi 0.ROAD OR RfiFRENCE -7]] CRGSggrR EiO 9 R ~ M ~" '~ - ;'t .Ai' . ~pgOPfRIY DAMAGE ONLY OB1FCi STRUCK INAMF Oi OBIFR STRUCK ANOOWNfq'S NAME) _O RESEUEIfO Ovi~ICIF ESI DAMAGE SPFCI/LL CODING USE f OgD .J-_. ? ~ ~Q ~3tJg7 ~ / b - ,y ; .: ''~l~ E -- n ' "UNITNO, 1 DR 's NAM UNIT NO.Z VEHICLE ~ , (] PEDAICYCUST• D(sr q ~ ~ ~ p E Q ^ PEDESTRIAN ~4 uR VfR SNA E ~ M . sr SIR~~,AI ss' ~ I- Fr<;..n 11 c~rAv~ I<~ ~ (~ t= 1_ ~i~ s tee! / Mil/evl - ~ ~- VI) /, ^ ~ w /i ,Fh ~ tp S IREEI ApORF55 ` 1~ AJ ~ ~ ~ 2 ~~ ,LL. _ FAIE ZIP CAG/E/ PNONf NO. D Ir Sr AI F P DE PN N f NO ( , I'fl ~- ' ~. I L v Ci ( C ` 1.1 , ~ ( ,-,F . • , , DRNFR SUCENSEN 2C S]Ai /'~ SEk ~ / I R ' , y/'~~ / ~ l~ FB IH r1 ~1 C4 I'~_Q,. vv" ~ ~~7 G,Y 7_~I~I ~ R E CFNSE NO F~ ~ '~ (: ~ r / ` ~ ~ ~ ~ ~ C/ ~ / l 1$J OCCUPATION FIRM NAME IDNONF NO ~ - Ir~ r() I r ~ I -z Rr V ~~ . ~ ~- C IE R R r 1. ~! I R S~ E% DALE OFBIRIH or z I° I ~ I~K ~y F ~.~' ~ Yf5 IGHI hEIGHi E CUPAI ON f RM NAME 6 PHONE N0 r Rt'F - Q ~ u I:L1' So9 R -' . FYFS - 6 •~ WEIGHT H GHi 21n 6 o' y ^CHECK (.~ vFNClfgs:N FMMOr(EOFANOrHERAF CHECK (P~ CODES -+ G n I a i '"' I YKH A,B r s e I vfH nE ASAN EMPFOrEEOFANOfi°Ea`u y rBRM qc 4~n a+ l B y _ CODES -+ G n g is S N B~ xrelF En ., :uY 9c"' EDr H „r ,Da p • ' S I / ` rD5 o~ ~;~ . Rte, ^ A,.YR,ANrE ^ ~ E ^ es.HR o ~ .. ^ ~,~,, x;~r~oIYDM o AANAANCF o •~S ^ ~a ~ MgK[fDppO F G H fY f fI IDMi Np o n,z~ ^>;L N p E r . - yAl SITIE I]OR .CONV) NR Mot ( {HFV.) AbOfI IDARI~NOVAI 7'l ~ ~ /r ~ ~ )~G~ ) ~ F ,A IY I] R.C V.) w U NSFPUIfN SIA RAEFRMIf NO SlAlf FI v[ G u r wN~ICVF II _~ r ^~/~i~~ VfNIC F ~Cx~)5i lrV~- -- - ~ g~k kN-~o`i~ ~v "A- rAf ~ rF ~ ~ I IOFNI LIGATION NO. vFN CFF IpDENIIi AI ~Z S~ .~ 11.1 j0 I p ~ o I :,~ L E I `/ I ~ I ~ I I L c.. ~\ ~ ~~ ~ t I.Y. ~I 7 I> I OS I I I Gil F,- C~ ~ ~ ~ ~~~ g; ! ~rrrnv._ ~ 4+,mum»7~. -EMan.4vw ~~i. f'-TS li L- ADDgns GF OWi.tFR Ctl 9yiG~r~l~~ 3~3 FSIU DAMAGE I 10lOTO~ f QDRIV[IN ~R[MAINED //~~ AWA S p CNAPGI ~ 'luvC'lionN ~}~' ~ ]l ~^PIVlN R[MNN[0 ESI.IpAAUGF I KIOp ., -....--- f W Y t_/ DIAGRAM OF COllI510N: O f~ NAE INBKAIlNaNH DESCRIP . ) I'' SO gC SSARYI . lOWfO ~ ^AWAY bY: ~^~.C f/~vv IOBORTOH _ TION OFCOLLI510N EUSf $WPEfM[ iM SHEET If NFC[SSAR) E E S ~ I ' ~i ~ + I Y,p~ V I, , I ~ ~ ~ .n_ .~ I r( _... _ E- ~.~ -- _:S A~rt ~ ` ; ` "` y ~ ~` ` L J-- , ~ ~ t ~~ r T C h E ., ~ . - ,l , , ~ r I:J ~' n~ - ~F ~ E l. I L 1 .1 .. I I T p l~l 1 ..lie g.'ln ." 1 F ~~.~ ~ r~ -,. _il~l I ~ , I ~ ( ~ i I I r Jac ~, ~, ri r.l !~r) rlE I ~F_r IlCs_i Et` rlu S/]wh r '~~ i V~1,.1 • _. ,~ 1~ _- 'a. 'sn~ ,r, D.. IY.E_ oi.r(c. of Vclf{r(. i c~_ F J EZ~_..~ I ~ l ..... I I _ _ __ NAME, ADDRESS 8 INJURI ES OF PERSONS INVOLVED + CODES I ^-• IUSE SUpfl1A4N1Al SrMI l OCCUPANTS /WITNESSES I(Y ADFNi -~ ~ 4 5 6 . KNfAt NAMIS M4 N , ....... .. .. ... Iq E R[S]R. EJECT ;rtr. r~ i ;ii .Nr w ISS NArUR OI - .. ~~w ~ AMB. (] ri~% NrtrY E OrR P ~nri ^lu ]ORifg N IUYFd r ....... .. .. . .. .. ._ .... .. M - AVOVID I4UM MFR BY ~AAN ~rtAKt ^Cn • ~Nx ^Ii0 AO A U.II .Nu ~~. r~ T ~ ~ , ~ . I a, ^~.` q~: -~~ LLL• WLLISIUIV IlL-111'U~~III IVU, ~ II{+{ }`" ~ IG ICJ/.I` ~I nl` Ilu[slw[oiii~uil txllsnil ,ou~wL 'M'uC i/""Q JI. J-~~/ CUUNIY NO. CITY NO. ^tiri, F p ,. ^ry ®€ ^N cI3Y Ox TOWN NA of sN1[ti / / Ff aVlF Ox alx Ei[00[ L ^'r[' [A Cl.l , ~J )i y ~I M ^S ^W ^OF L. QN I~1 ///'LJ..~/.1.) ~t n„'~-ryk7G~. id ' ~' ~+°d4 x.tCl,N~wll Ap x tx3LCi ..., FIK ~ ~" ~ O ^ m[[ /M Tc Rp / p .7",./ / r Gx.MDAT.P STZ / ~~ x~ N E ,1 Illuirir xr nc LnxuMnx%. P 9. h Ox/ [• ~ ~ tl` J x9.. / f'/n ix c ~C lnaECl i[FI { -vOwclts vOly ~ ^ ^ l A 0 Mn [x ni 0 wwOrln OU ~~_ xxOnO .e. ' + - - OUILCT STIIUCK I Li[ ctE OSIV[ L3 a OFO 1 ~ OWNER OF OBJECTS NAME AND ApOfl E55 I~xEPA xOUJ Ci ~ 00[ r, , I~ .: ~ UNIVFN'S LA57 NAME ,! { • ~ -. ~." ~ .. .... FIflSTNAME .. MIDDLE. If'OOxCixnx IVCfl SLASTNAME Ofl ' "" w FIgST NA E ~~', 9 ~, ~... ~` I, Ill.) ~ w[x[ xvpiv[p ",.. M .. MIDDLE ~R ~ L' f°NhL.C//V 1;UG[_/Va" xnonux ' Si I[F RFSS ~ [Utl3 - MONF TIIAV IMI ~„' I ROUTF NO. ANO BO%NO, rlxsuxaw[x[ TPEE AOOPE55 • v ~- I•.:. I ~~J - 'xs Pnxn -..... .. ..,.,. flOUTE NO, AN000%NO... R31 :. ~./ / t AG /Y ' ' „ '- CIl'Y -STATE... 2P000E pflIVER'S OLLUPATION x[aIx ISFOEN LITY .:,.STATE.... .. ZIPLOpE. DflIVEq'S OLCUPAtION.. ,~'I 4 '::/ / "-:/._.vt7!v,l FJ JG/ 5TU!`~~n// IVEflSLICENSENO. ...-...A GAF ~! DIIIVEI S L FNSE N0. STATE. 6F% DATE Of B qTH AGE Oq '^S~ '.. _ t',' .. .~ y P MD x_ ST TE SE% .GATE OF BIflTH.: _A E S ,_ - _ ; .- 3 s C: X a8 3'Y !.~ / % P F, MD. DnY YR. ' ~~ ' f EIICLEYi MAKE ICNEV OOOGEI. ..MODEL INOVA-0Aflil BOOYSTYLE IO Dfl.I yEMICLE Yfl.. .MAKE ICIIEV: DODGE, .MODEL INOVAOAgT BOOY.GTYLE 130P.1. L'+'1 ~-1 • ~ ~ ? LIC N kYLAiE NU. STATE ,TflAILEfl PLATE ND. STATE LICENSE PLAT NO..- BTATE •,;: , - I/,//J 1 , .... TflAILEfl PLATE NO: _:: ,;STATE..:.:.. ,r'- ~~. "~ + 7 rf/P, x ~ + ;', ~, E ICLE OENTIfICATION NO. v ~ 1 // ~ ` ~ /] •~ -r ~ ~C~ VENILLE IOFNTIFICATION NO.... .. . . .......... ..... 1 iJ ..[ .FMS.. [GISSE LOO EP BAST FIRSTMIOOLE NAME) OflIVEfl'S LICENSE ND gEGISTEflEp OWNEfl ILA$T~ 'MS 1,•, 1 t y FIflST1AlOpLE NAMEI .. DgIV Efl'S LICENSE NO al' ~~~~, L ,.~~~-/< ISIG///~I / /(/'/i~Jif ')X ~i/tom O f115 OU [SS ISTflEET,CITY NDST TEI.. DATE OOF BINTH OWNEP'SAOpgESS (FTPEET.CITY AND STATEI DOgTEO YBIfl yN !! / ^ Mo "• M o iT20 E CEO MAGf + D 6 x~i'[1 ~" PARTSOF VEHICLE DAMAGED /ro ~ I[, % " ~ - .. . '. .. . . ...:.. PU4R V x L - J'. :. iiGl:J/L/rT T':T •J S/. S' -: ~' LIAOI LITY INSURANCE INFORMATION-VEHICLE N0.1- W^s rHEREAmomopnE UgDIUrY INSUPANCf ,~ T ~'a -S COVERAGE IN EFFECT fOq TNISACCIOENiON YOUfl CAfl ']YES ^NO y,,; ~' .. L E` N OOflf550f LIAtl LITY INSUPANLE POL LY HOLOEfl ' ~ nw,. T' r I AOOxtss [ TIP N E FLI 9ILITY II flANCECOM ., , AM 0 A VSU PANY - 9 -~~ r7A. ~~y ( ./J;!/ it ~?!i cFlv.._aJ - ..~ ; ~Jx• ID EA pOn SSOF LIAR LILT INSURANCE GENT .. LAtlILITY POLICY NU BFR I .,_ l.x J , J: J- TP 7/"a9..~a L ~ _... i1F ~-~~ IsrvNJUxY. ~Ji nLOF j! .. I: ~.- 'Tit i/n . r>,9 U .~ (',. i ~e ! h i F AGE ~ ]NU IN1UflY: NSF SEPARwTF P[PpP c0 f Oxnllx AGE NAIAF TUTAL - +~~J ryC~, ~.'I. INJURED NAIAE ~• -' "xP'; t ESS SE% SEX ~ A tj .+ :,..A M F LESS >E[.~-~' ~i~.~l ADOI 5rK tov H M F ' ~ l AJn1Ee ~s^ E%iElll' OF Ix1Ufl ES ^ ^ E%AM HnIT UN UY ~IDOCiOR] ® O N MEOP s I~f 0 U Nnlq ES gEOU PE OCTOn'S ' ' STATUG Di INURED f%AIAINATIUN UYAOUCTOflI ~ O NAME 4 y MAgK FIRST ONE T1IAT APPLIES ^ STAlU50F INJUNEO I ^c In VE111CLL MAgK FINST OHE THAT APPLIED '•~ ^• KILlEO Ou tnFl xw xox ~uux ^ IN VEN CLE IHIiM VNIUeLx6 []P rn ° O NU. _ KILLED seV[xN IM xOn P iC IT A, ^ ~"„~,.. ^ 5^ 5^ o~7 p~" ^ [IS~xI.N ^ 5^Y 6^Y or7^ ~ MOTORCYCLE SAFETY: ^ i ~'~{ ^IIFLM[T USED IIE W[T NOT USCD MOTOFlCVCLE SAFETY: ^HFLMErusfD ^HELMET NOT UEF.O x ' OV IOHIII pY APfSOw NC RCIE ~- `~ i UCSCn BE Uf LO WIAl HA PENf01NEFEfl OVEM CLES BVN MBEA ~S ' Nc.A111W Iwn o • :' , wwai Hnrnx[0 nwu I .. .... .. _ __ ~ '4 ~ ~ I x,G,.wnY x.M[ O ~ ~ l / ' YL , c ... rcfrricc i ' AI ,x L `. ~. ' ~PN`AaP; yc[Lfn~ M1pn~,H~; ~ _ r : ^_ P J an ~ i'ir / c'/<'E;tJ~__. ,1 II +l _ / / l /~• /' q ,, Y c ----- r --- - __, ....,i ~ .._.__ __ ..._.________~-- " a ~ _•-- 1 I. I3 , ,. I :. - ;' ;, - ' --- I .. .I,IIIGx.M».. , ~ , __-._-___._.._.._ ! ' ~ I ' J --- --- ' t ~, Y VEIIICL ES POSITIONS OEFORE COLLISION -`---- I'S INVESl10A}ED pY ~ ti~ ~ ~~{ X L : t DN SiNttI OXn GHWAV HU.Il UN NO. " 3 ^;:~i41 ^ [ 4x~ iC. f / x ~ 4 J S " ^ ^ ^'^ Af r r ~, Yr t/ /'Jl __ u.~i .w ~'^ n.x^x xu uOL. r.x^.Ln ^ [^o ^ioLYCL ~ ~' I~-Ili A ` . ^" . ^ ^ a ^ ~~I/,i , IGr, I+ ~ ti~ ' P ^^^^ ~ _ __.._ x -I ." __ _ fnoM tOA L(.1~ l.. / :/I Ir ,jU~E~L IPOESI111\H-OEDAt. CYCLIST WAS USING I^u 3^. ^, ^°,---A^~~ .^o rf]~I,i:"wii L^ ~r ~ { t} ( rcnLSn_unra;;vroALCrcusTaarrllN000LmaO3wIQ~. ^ ~, p .pxllxpa~,lct%3 _ 3^g;g_~~,,;{~PNnxJI ,~f ~~.'I '~`~ Xff J, Ill ,t , nIACL w1 ATN(q llGxi CONOIl10N3 • 1 "L, IxI, DRIV (MNlII CLl AC110N5 nOwA J Y ~ jl ~J wl C[ v 'Vi[OT ROAD ~~TT 44 ,,AA3~ 1 ~ J' /i / AD~l'~M,. ' ~~' DAYIIGIII µ • ' cM •uxJl V" KHICx UNI Ux MCwI •: w 1 I ~u ~ ~~ y{~, ~N;YY°F' ~.{ I ~~'I,H. {Q p~'~;;~A ~ OOV„ a ~ a:~1I; 31 Cox 1,N 0.^ p.'LwA. [. Nxl OI'~ ~^S OV[RfAK11N0 AN0AMS'u N0 l' '` 1.`. ~'`' 1 rfA1, ~ pp R/~ ; ~~.. J VK ~ , {hS~1.b F{~~)^Mf )^WIM NG 1^IG;a STnlil ^ ^ r.J F IWOWAY ` 1 ~ lJ J ["S LH1N TS UN ^ J ^ NO~pI 3HILl ^ ] O MARIND PIGIIT IUPN '~ ] LJ ^ pIAN. fIN(La ~ ,1 ~, ~. ~Il L ~ r,, ~! ^' L IOG f ^ prSTS UIf ^ 1 ^I1A.11 NU NI11 ^ 1 ^ IITLPCNANGI 1 4AKnIG I[fT IDgN y I~1 ~~ :1 l_I 3 ona L nAeK no ALOGFJn AUrI L I ~s ~pp .~11~1l ) ] - 1 3 IfilC li ^ s ^ L1 I :~ 1 I 1•~ {, ^'l 1 ^ ICIFYI ^ ^ f ^ SN ' ^ F ^ MAKING U~iUPN ~' 1.,1 1 ~~ t tU,1"( '- Y '1 l I c c1L xo D^Ayw a FL ^ ^o SL[ I ^ ^ i H{I N ^ e ^ fLDxNn +11 ~ I,~1T ~ ~~~}' 7a~ ~ ~ t t ) ~I ~~I Y" 1 ~~L~.1,v~ ~ ^ ^ (] a ^~D+I I r ^ T ^ uD rn rpnrn Frc ~,j __ lIP t~ 3~5 ~.V A/ 1^~~h I~itil do I ' Z tl~~/11.. ,,4~. it 'n ,! .o +.+~LI °~~i~~y T~ L^ r.~ f~, .. ~i ~_ ~j,hY;iL r'd' .r S~ l ~ ~/ ~ ~.. t~`~ 1 A r Y r J~74; ,I,r PI I f, T ~ r ~ , ~ I ; r ~' tau. W t if / 11 "7~ H 1, _ ~~r l~~ Mx C~ {ice TRAFfICWAY POLICE TRAFFIC COLLISION IVU. / REPORT {glcf comRAiNf NUmBF4 PRIVATE WAV I ~ pA f OPCIXl13 N MO 84 iC0 ll ON xlx V ouH " IwR H t.r IUS[}lipU HOURI COUNTY T ° - o COUNTY NO. C /G IEYNO. {NWA ^UR DRAT 5 ^N ^F ^N CIEY0410WN F O.OFSiRtFt OV HIGHWAY .Z Huffs s ^w o{ {R CIS 90Utf 0451RFE ~ SfCii N mo O L ON iNl SFCI NG V%iH St r PoAp NON Nr[RSlCEION E 9SZ70 ptlp/ OfiW[f SiRFft 'l mss SiR(El P4Efi% f0. mRF PoSi ~.~/ / OiStANCE 601RE I {ROM PFi[xf CROSSSERFEIOR NfA SrM IF if[iS _ S O{ CA/RO W ACCIOFNi MREAOE CODE P DmGPAM DATA < Ell'gN NVOIVfD. SFVtellr. OIAI.NO. NO KIIIEp-_tq NEU4f0~ ^SV RAGE ^ RUN O VFEEKI[5 ~ V ITS" w"w14." N .RD NIA US NEFRSE ri SrRFft OR ROADOR F[EEREKL CROSSSIR[[TOe ROAp ^ pvOPEREY pAMAGF ONIY ^ pf uliFp vE pbJECI SIRUC%(NAME Of OBE(CI SteVCY ANp OWNER'S NAME / .58,80 ) 9 fsr pAmaG[ SIECW COD NG VSf UNIT NO. 1 DPIVf4'S NAME: µ5r U NIS N O, 7 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST } N4S MI IXE F Ur ! C rv f: IXF .e~ , E SiREFf ApU4t55 ~ .~ Y~7 ~oi 2 SrP[FI pRf53 ~ _ tArf COUP PHprvE NO. D SfAr[ iP CODE NF G-:W P to E R rv SI CENSE NO. IAtf f% nfpBRIH I Iv(R' IgENSE NO. SfAIE pA1E 0fB RIH 0 4 RM All EOhgNF NO fYCS WFI t KqH} E occuPANON M P1gNF NO. EYES WEgHt KgHt ,~ ect RT FLd B,2 CHE " R ^ CK (.~ vEHKh ns~N rmnoriE o{ANOrHEe A' ^ CHECK (~) Ia[A rMPiorFF OP ANOr ¢ E ' CODES - ~ 7 c,. °' ~ iinM I 5 l alroN a „° ,!~ Hf 'rv .nE CODES - + ~ ~ 5 t% E ' "D u" %5',~M"' erDN }' u . ,rT /Or r .en Z ' " ~ ., S '% ~ ~~ o,.D,. AN.~,."FE ^ ~s" ^ ~:;t, ^ W:K,. ^ uN,. H. YLA4 mn%f IpODGt CHEVI tl IDA4i~fgVAl Strtf lRp 4 ~CONV m ^ N.N, N[E ^ u f ^ ~s.rt. ^ K ^;s~ %U YF Y A H y .I ~5 ~ U~ 6/ U A~.t~ ~ , V E . E I} V.) R K I f Htv) MWLI E OVA) H /'~. NGEN w SIAtf Ee 0.Atf NO. x I'i NH. COIOR N A A f q A T S - r Gc/A ' „ NHICEF IDEK {GigN NO. G ~ o oa7 G~?;S i vFH UEIDFNiiN A I ~rvN ~ U R[GiShPEDOWK4: yy( NRSt MiDIXE I NylL90 /~ /l IHpK NO. ~ O W R I ER( WN[R: 1A51 NRSt MiDDIE l AppRE53OP OWN[4 A GWNf4 AMfsAOpefuaww4ANCfco. ae ACeNt VwL '- R i uAN A oAMACe AeEA Rn.,.w rVr.crgHU Oa ~ . . p nnCi AmAGEOwEw vow a CHA4G( CHARGE gr uAi 4 , 5 I:,Dr,Dm w [s ^Aw~'v ^rtmAlKO ~ ^nww ^etmAlNro Esc oAmACE t sfD. o io~ ' d s~Q~ ~:wvDer /~// C'i ~. ^:w',.°er~ f I r . DIAGRAM Of COLLISION: lu meN Al Aro NO4rH 10 514[t ll KassARYI r ROW ~ DESCRIPTION OF COLLISION: lusE SUPnEMLNUI SHE[rumc[un4rl u r Ts ~" F' ~~ `~ Ue{V 7"iCAOC•'G /if7G ~/OXTiV , Q ,1 Ta/~ ~ ~R1dA7c' I ~ tlxioc~ ~ S{(jN T/Kt9 GL F7 ~oa.(w.} ~ ~ ~. T.vFti S.rY,vDeyJ .G9if cif ,vTo 5, . /P9hf GliAla M GC FT TNc /{otr~ ~ Fcfpp:.E,c. /4pPRoT4 3 TiinG' ' „ - - - - C ~,/-y Zo Rc's ~ Off, Tiy~ our . FL-9Glc~G ,tc '~ ' NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES I - p a 4 5 6 (USE SVAI/NNEAES OCCUPANTS/WITNESSES {oR ArgltgPEU NAM NAw KO ,u ur AGE urus ""'" ° K i R tue. ~EEFCt ~;°;Y is AL%wu u1 Aruffa ^AM e.^F`riK'O " . ^Q A ugelu K}. Atuera u • S lmONp{ ^Ame ^'cK."%'^K~.n. ^H ^I:° f Ew ECiRS NAmE l4A OAKIp AGENCY F+o X IDi3PAECHID Pp4 AxNN0 p if pKEE0E1 AIPeONp 4v Wt( ° o7So }RD H.3 ~.~°~ -3 X 3 ~._~~ 1 b i 5` x ~~ ~ , ~ _ ~'~- `. r ~: "r~ ~~ '> pry„ R' S' ~ S ' ~ Z d"R 8~ ~5 I ~~ r w . ~j \,~;, POLICE TRAFFIC COLLISION REPORT Ily rRAENCwAY Palcf comelAlw NEUnazR PRIVATE WAY I~I pelf Ol. Ul5 N 05 ~ 83 OAr N ~" «D, 1411 N,I Irr uI IIMF EUSI a.DD nOUPI O COUNTY 3E. FE.t'So1J COUNTY NO. ~!v CITY NO. iNWA Dopa,A.i ' ^N ®f ^ N C(V ON TOWN NAME6NO.Oi STPFfr OR NGNWAV .wle~Ds OW for ON iGf ClS ROUEE 0451 fE t3 95Z'70 SfC110N NT[e5[CI NG I ~. sIR[fIOR 1 NONI.Vr[RSjCjQ Eu G,~e ~^~~y U'/'{iL V,N* RRfiK f0 MRf P05t O ~' ~" SrRFfr 6 Nl~ri SteFFr BFM'FFN `- •% 10 DSIANGf6p4fM {FRFN F.CROSSSteEEI OR NEAeESt MBE PO51 ~~ iE[fSl S F W.•O{ WQ~QR ACCIDENT MIIEADE CODE v DIAGRAM MIA COIIISgNINVOlVfO: SFVFRIIY~ NO xIllFO~NO.IN,U4[p~ ^SRIIIAG[ ^ tOTAI NO wNRR1BrB ~ INIF Cl5 INrf4 CTI SIRfEIOR ROADOR RUfRfNU CROSS StNEFi04 ROAD 'IF . GE VFHIClfS ^I ^ PeORR,Y DAMAGE ONIV ^ ttBUIrtD V[IY Q~ VJB7~~ Q I OB,(Cr StRUCK INAMf of OB,ECI BTVIKKrWDOWNFR'B NAMFI (.pAMAGF ~.E. 5 ES ~~ SPFCW CODING TAE UNIT NO. I UNIT N0.2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST WrvEe's NAME: Wsl NR MIDDIE ' !iA ~' R AN.~S perv[R'sNMAE: Usi {I4 Mr DI L SIR[fr App4f55 ~ ~" F su~ necou PIwNENO ar r D siRffT DRESS nr surf .PC E '~ I 11 , C~ IvoR•O LA Q 3r/' ONE R - D4rvfR's IICENSf NO. `h STAY Sfx D B191n 03A I V rv4 LICtNBE O. SlArf Sfx ATEpBRin °A" •• "' OCCUV+tION MNAMEe MONF NO IGnr HIGNr E E OCCUPATION {i NAE6 PIgNF NO. rE5 wFIGNT HIGNr •~" LU o OI NE.1.J. - R ^CHECK(/) VtNICif +saNEmoiorEEaANOmra~l ^CHECK (,~ ' v{w DAPiorrf aANOtNrRA '~ CODES -~ ~ ~ a w 5 r a ~,° ..~ CODES -' a ~; 5 r. A H ' ro N,IAIES s E L.ec. I ~~ aprwM ^ A«BU+NC1 ^ u: 1 ^ cbiiEK '~ N ^ w~v ^ AvRxAVC1 ^ u Kr ^ ' ^ i:Kii ^ i :ws, ~ ~ ' 1 VEn. YEAR ANKf IpODGF~CNF V.I Tk.RWTC. mtaDU lDAVt.NWwl Srrlf It D4 ~CONVI E n fA4 MAK 1 ~CnEV.I ll RT.NOVAI r "l la R, v.l _ . ~9' L v p4 UUNSf IUI n. SIAIf (4Mlf4 RATE M. Alf H n. IXO4 W N All Al Af BU.i. D1~- WR, I ~ '~ V[nICUi IDEMIfIGibNAp. Gl ~ 0 4 Z.i L vfnlClf IDFNTIN AI NN .~ - RECjSj''rt~~REDOwNfe: vsr rlRSr mlD•pl~E-• T'O Z V , RgNf NO. ~' O e Is E wNe4: Msr ilRSr mlpolf E .~ a u 2 ADDefua oW+xR Q83(o$ N A owNE4 /, I "T , RT. C lOZ ~- ti E AMEa ADEV+fua mweArxe CD o4 O M SM To R IN u AN r az DusAAfD ARU -- ..' onmACe' u Ed'"+I~ouW CHARGE CNAR or«iI o~ = a .rDA Id:uri:: s esr. DAmAGe ^ AwMr" ^ REAwrxD ^ ew'ev ^euAAwm Ise DAmAGE f ®roWAxper Al W Y rovrtDeY f RE cArt NOVrN DIAGRAM OF COLLISION: E . SWRD NEaiturl ~ er AReov DESCRIPTION OF COLLISION: IVSESVR[AVNTAI SNf[rn N[USSAerI ® ~f6k{. ~`~ ww5 SolrRli$Ol/JJO ol.a FLPfGL-~R ~• 7~f?o,I• . qN0 W6.EJr rs,YO 'SNE« b7LYC.1t ON TkkE. ~.EGT w "' ' ~, ,~, SS.DE. oG• ~lE: (2D• 1 'tRFlVEA.ED PEPPaoX, lS0 FT• „ ~ ->' i. , {J SN TNF. Q`C~GN , ~F14.1., CgME, OEtiT of ~Rt~ ' , _ '"' ~__ ~" 'V ~~ ou.< orr ConrtRot~ Rt~D W'EBS' AC'~'RnK•. PNOC116~.' y _ .~. ~ 5"b F~"•. (LHE RE ST STRUCK A TRE.E.~ WNyGH M ..~ ~y ~%' (~ THE UF,H• UR[I•a ARouuD AND GoM6 Po A SraP AP X, ~ R 30 rT• r86Ya.+a 771G 7RF~., ,pRZVER STY~EO N6 . NRD ~sT Go,vnFOl, cuHF~.A'TR.YtNb TO 91/ozD A NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ~ CODES 1 - Z 3 4 5 6 ~' OCCUPANTS/WITNESSES ~a:ro~'TEiawr~ ii sfK Aef ur etv4. rxa NAMr: !b wens NArlnr a r Am e ^ E41 ' ^ " . O N ^ "36,A wr`n +(xwss NArwt or a Martp r.oM ^AMe prR"" OPM • O w ^".° «E. ~ + Dpa>s Iurlxra " iu ev O+m p p"A' ^ o•p. O M ^"". N R Wvt BrpAl.,ppIS1411.VW evANK e~,NOa KAKr ~l~~rCMO AO/'/ p DArIp NrIWI wA•eOADIr pAl{ ~. I ~~ {~ ~~~ ' ~4 ~~. ' 1 _ 4~+ ;99 a '! t ~ ~ a 1 t . ~I[ ~ ' _ 1 1 [ t(V' .~ ~~ POLICE TRAFFIC COLLISION REPORT f~i'TRAFFICWAY wfKE COmnAim NUmete PRIVATE WAY D41f O4COll(5 _ ( pppyyy ll Imf Iu5f x.00 NOURI Nlv <DUNtY NO. CITY NO. fI1wA ^VVBAN '/ ^N ^! ^N CItvO WN Of Sl4tllOe NiGNwwv /V mnES 3 ^w ~p'oa T dpi n~ ON ' fn ClS RWIf SR 3 9sz ~o-. I -„ r ` rN1t45FCt NG VnlN. 1lRfft OR NON NI[45fCt ON BttWE[N ~~[[16 14[[1 4Rkfla E miff 4DSr ~ZO 6/ 051ANCfeDe[CArI ON IR nUtR[N lCeO5551RE[t R r rvta4E tm tF 405 5 t5 5 t ACCIDFNx M E R R DA Am W1A / . ~ 4ttt ~ Oi ~ • ~ [ODE EDII SgNINVRVlO Nv[R rr tOtwt NO Oenl NO NV4tD ~ ^SDI G[ ^ (j V vfN CIFS m ^ PRpn D GF ONty ^ p 5u1A1t0 Vt 1[fN nr Dr• N I K~4D MF4 Ct5 IEV N SIRLftOR ROAD OR NfifRE4KE CROSSSIR[FfGOR ROAD \T gIOO xD I {~ OBIECI SrRUCrINwME Of OIIfCt SIRUC N[v'S Nam[I 51 DUAAGf Sf V SnC1Al COD NG tAf ' UNITNO.I UNITN0.7 ^VEHICLE ^PEDESTRIAN ^PEDALCYCl15T x' S n e ust ,4s1 miDaE we4sNamf. usr Nos mi at _ . ~/i % SIR{ft ADpeFSS ~'~TJ '~ ~I~ ~ ~ StR[Ft AODRt55 2 OIY iF 4COIX 3 NtNO D r StAI[ [i4CODf Nf ~~ STti' J ' / < ~ - R /2 Rrvtv'SVCENStN 31a1[ t. wfUf B~RIn ( 4ivl R'3 UCFrv5[NO Slart DAff Of BiRln IX//~~I~ mN.w.t6Nquf e+QDf/`/ ~i ;, tuts MrUI E O<CVVwNON mNNn[dRNONf NO. v[5 wEi q ^CHECK (/) Nncit AS:NlmnontA w.M+oxNrcA` ^CHECK (,~ vlncif AS:N rmnontarANOr«fe' .y~5 CODES-' ~ ~, 5 t cr c« a ~;;;° CODES - * 3 ~:si i 5 to N e """~ "crc" -" 2 „ uR Es ;ff°,:" ^ .mNA.MI ^ ~ tt ^ ~5:,,. ^ .7«K,S ^ .:4.5. , ^ ,.,,A..KI ^ u ^ ~b:fl. ^ ~~ ^ :°.~v 11 NNVA Mw.unoocccNfvl mODFtlDwvt NOVw[ vr¢IxD4 convl +nA4 11 afvl DEUDMtNOVAI t f D. I Dv b N. IKLN RNit tw [R WAIF NO StAlt 5 H Nn.CIX04 N t it w N wf F ~ 2s/ /~n 3 NngIF IDtr4t 4KAt NO. I I I I 17i i i21/~I ~; i I ~ i, V KSl rxNllr CAl N NI i I N i I i i ! I I I! I 41cRrtRlOOwNIR'. Wt NR3t M,DDI[ nKrNt NO e O 4 flt4iD wnER. fASr RRSt MiDIXF f S ~2: ADwnssa oSN. N r wrvee /~" AveSADDRtfs a4lNwvANCteo o4 wefNt /,ire ' A R FS n+ u AN N • - OAMwLf MIA [ .wCnWU t>1MDM4Gt 'i!'~~ Cn OW iNN ~ AwA. ^.tmuNto towtD /i.Fr Ir ~ . CnAIG! D~^VN ^ A (]REmuNfo ^ towSD rwCipnrOiM tS1.10M+wGl f AGfO ~G R I-~-r•~o;; ' ~ D D - DIAGRAMOFCOlU510N I [mi I ov ~rN DESCRIPTION Of COLLISION IUSI SUR ImE ru 3N[tt f Ct35Aerl _ „-,. .~-.fi , , ,~•. ~ -1--~ } II ~ j/eilirl~ .~i s~+ds..~e~f.c.~ c~~~ il~~. -- ,}, r ~ ~ FF I-'j 't 'I ~~~ i ~ ~. I I ~ _ ' -' _. j .- J -.~,terr - _[_.._--~ li/If.°S/2°C ...d ~i// !r ~~i> _//~C v/FFl' Jdn~r , {' i I f- L.! ...E _ I _. .._ __._ _ I ~ __ ~ _., . I •__ f I _ ~ -a-ice ;•--- -~~ ..~_# t-~_ -f I I I i ~ f i 1 I I ... ... _.-... ...__ _.. . -- -. . _........... __ _ _ .__ ._ __ ... u t~ NAME,ADDRE5581NJURIES OF PERSON5I NVOLVED 'GOOFS L - 2 9 4 5 0 ' "i OCCUPANTS /WITNESSES rfaf fwntwNru sti tdADO,Igr+yNAMr rs fI ---~~ --- f!• _•.. AGI rAt •n N4 R.I . ,,,, n .NT•. • •_.-. ..... '.1C V' MftO IACI 5 u tr N AmI .np+ ~ • . arelf / svS .. N.tw! Am sr s ^,h-' ^ ", . ', ^.^. ^Y.2'•.I. n .ml . n a of , w+N . a , , r}.. ^Ams ^i:"^m I ^.~. ^'; ar .N .Nv ' ° ~ . ....__.. .. r _.__... _... .. .. a . . • r Darx ~ . ural .._. NAw/a AANt ..,, e. ^.me ^r.. ^cnn ^ ::nf. N. X Mf)r4.lr.0 pl (rR3Nw1{I.N. ~9~' I~bryC101 AG1NCr 7.3~ ~s/° .irr =31 ~CI~ICML x.oNRf ~`~~4,N xK»n.5 0 D.rt OlinXr ;~3-,Y3 wnROND I DAII ~ i ~ ~' _. _ ,. ~~~ ,. ~>I ~;ilr ~, '~; E , n:~ ms. ~ ~ T F .~ , w ~ ,r ~ : ~ w P ¢ ~ ~ ~ ~~~' = -~ ST E ~ rte. ~ .' ~_ ~ - w]915vIRFVIBPI ~ , ~ ~ ~ ~~ f ~,u.,a r I AT OF WASHIP~IGTOiV AG f or ' , ~ . ~/ ~ I POLICE TRAFFIC COLLISION REPORT uTRAfFICWAY KK¢f COM9WNInu mazR ~ ' '~ a fc l ~ PRIVATE WAV w r COVN Y + KVI {O ~ ~ 'f. " ~'D / _~ /Z ., / ~ vx Ea NlE wiP rrNF IUSE ].00 EMOU91 1U/~~ .\ COUNTY NO. CIE ~~~~-tC4~ /~ Y NO. IUNWA ^ t ~ ~~~ ' / ~N CIETO410wN ~ ~ N J ~ ~ f6N0 O ]i4Ff104 HGNWAY de RWfF O4 1 f 11 A dd J , k t~ . ,1 ~ ( aJ EEyy i µ 9~ I E~ ~LE'~i'JMl '~ hti.~ Sd. ~~jjI ~~.~v a ~~?.X, / f .,~` ~ ~; AVlfs ~] ^w.D Of IO[.T II)\t~L.I ~:C f..l'. ON [R ] FR N G NtIN ]IRE OP AD NONINtFPYRICN -~/ / ~/I1J (.1 '~ ~ 7LO I~lG f ~~.. dS , ~[ Ef (( 11, ~~`-'1 ~ / ~ ~ ~% BF1M'FEN SEREFI 6 ]i9 Nf 1X MNE IOSt ~'~~ -~ ' - WC .CWS]]I4lHOR NEARf]EM rP M4F] N IEE r FF} i RAM D _ ] F W If Et OE MILfAGF Mrw >~}F'{, - , I]XJN INVIXVFD: sFVF4IT. CODE it ,. R '~y '' tOEAt NO. n NO. KIIIED~NO.INIU4ED~ (YVlNCIf] Ej j RWPfpryD0.NAGE 0NlY ^fRIIAGF p ^NIE6 RUN ruNpgom ~RD INf[F Cl5 1 FR RI ]RfEEOR ROAD09 RFEfPFN 010$S]rPfR09POAD R RR 7 , erRUCK INAMf Of CO1fR ]TRUCK ANDONNEC]NAMfI ^ EwL1FO ^VEaCIF Si oAMwr.9 Nur.r ~rw..._r.. / r~L I~G/1 ~ 1G f~.'id~C'S ... ., '-'Y, I .'~f. E 4Fflwpp9f :?- ~, M c~uRnr- Alf 219 COOP 9Npr1{Np fR']UCEN]fN ]iAif ( wS 9 JP wn M ~ o,.' ~R ~ :uvwrKx+ NwMFKRaNF NO. ns IcNE fr~r E f R(e9.7r,J_ ZuDIPq~ '~;, . uAvN~.`t=ttii ~I~ !i(. S Iv R ^ CHECK (~ vewn w AN MNtiovFEw ANmNFe. l IDES' ~ n . ~ s l e;° i4iis ».r.FM, ~~ w.,]4uN.F ^ usK° Oro`. E. ^ N..r' ^ w x[wR IOORGELNEV.E PF IDA4LNOVAI ]IYlF IR09. CONVI i~r; ~L, nvSir~~.rLw ~P~ E ENS ]twrF wl RwiE NO. IwIE H l,uY~T `?'~ w~ 1 ~H ''='? /f~R: /~IAfi N9] rl 1 t ~~•~ ~:~ ~-4C~Za RAM OF COLLISION: ~ INDrCwre NORiN DESCRIPTION OF COLLISION: IES[su991[ASENru sNEHUIVeeESSARr .SNEEIU N[RS]ARVI Rr OW I d'-~~ 40G iR ~u\ /,EADIL.Y~ //n 4111 m F'fl, /. E<L IE; . . _.. _ _ SCE. ~..OV/f39 1.. fa ASE '~"I (i.V\Tli IPJfj L:IV:C"}rid ~ VCrI. n / L, I ;V - _ ~ci11~19 i w~lr. 50 51.. t/JA.'c[ N[ ~' 6.:.C f.i; ~•_ 1._... .... __.. ~. 1 - ~ ~ 4 5 6 •r~ l1U] rN 9ESIR f1fC1 (wMe ^Ph"' ^7 .O» O. IAMB ^f ~" O ~':w. 0.7;; ^ :.N~ '° X`~It_41--r'~~SC~oXJLO I•mS IV C~I~ I1.1 _MI I'~f ors.Alorol/4a:, Rls~eo ~Ay[pngr; A999oT1onY onn __.._ ~,~/ ~~ ~ } ~ ~ ~"" . .. ~~ f ~~ 8' 5 ~ r S ~. -. '+ . 4 „ ~ ~. ', ~ i ~~ , 3~ i ~ il: ,~ r ~ E r J ( ~~ ~ ~ ^~ ` ~ -~ . I - - ~ ~~~ 1~ ~ X~tl. ,~. ., { c I ~ ~~~ { , _1> .~. r. r• i '`' :~ , ., t . ,~ . ; ' r ~~~; ~ 4 f t ~ ~ ~ . h ~ . _~ e ~ de ~ s i r rJ ~ ~ ~ ? ~ i k yr i ~ _ '{' ~ I t i .a ~~ 1 ~ ~R~ i i z I - 5 f ' o r w 1 ~. N OK rY ~~,. _ i M W O I- O '. 1. ~ _ ~ :O ZO ~.. ~ _~ O ~ ~o _,F I x ,; ~ // i i I '~ ~. i 1 ~ r~~ P {d ~ ~ 7 i~ e i - „ ~ , i - L ~ t ~(~ ' ~'.i i (_. u. a i Y P Il ~,'; ~ J1,~1t~ r C,i. ~ m~~~ tp ti~ ~ ~~ ~y, , ~.. ~f. -~ ~~. i~ ~ , i STRTE OF WASNG70N PAGE I OF / NO. -~ ~ ' .," I POLICE TRAFFIC COLLISION REPORT L~7 TRAFPICVJAr - pOIICFCOMflAIN(NUMDFR;. , '. 4 :. _.DP. E E ~ PRIVATE WAY : '. .. ~ ~ :. . - R. umf counrr 2~ Z4 ~ / YI f N wID Il I i IUSE]ND NOUR) NIINtY//NO CITY NO. ~}~-/ FHWA ! ^N ^f QIN CNYOR iOWN /L GIU T,A: `l._r[,1D~ /CO J(p 1~1rD ^URSM! NAMf6N0.0 SieFf10R IDGHWAY {L1C RM ~~ ~ s / RO IE 951P S[ I N Avus s ^w of r UC Ir ON ~.2.°f"/~ Oa.y 3 9 . ~. O INIERSfR NG WIIH: SIRfEi 09 ON INIfgSfRION ~ ~r ' ~Ja pRLfU{ E MILEPCS /~] E^~/1 LE4= t ~Y/ eflWEfN SieFEr 6 ~ ~L~[~~~. - DI t Rf I MR F ,Cgpy3y RE NEMf5rM1(E SIRFFi 1J ' MYFS N. L/V~ ACCIDENT RAMP DI RAMGA 0 {[E} Op L I~ MILEAGE COLLISx)N INVpVfD: VERY'/~ V CODE ' t IOEAl NO. NO. KIUfD~Np.INLUgEDt ^SPIItAGE ^nl6 Runovl D 1 4EE RROAD OR fRE~ ] 3~ Cf V[NIClFS ~ ~pgpp(9tt f1M(AGEONIY f19E MNSD~S(~E9 Cl5 CROSSSIR(flORROAD ~ .r~ - A~ OBICC1 SiRUCR ENAME Oi OBJfRSrRUCR AND OWNER'S MANE) ^ RESUNfD ^ FH N .' /y~~rQ ESi DAMAGE SpECW COWNG USE OG~ __ ~ ' ~ N a ,Sivbo , ~`I~. Grve ~" UNITNO.I UNITN0.4. ~~~ ~ ~' ~ ~~ '~~x IMt ^VEHICLE ^PEDESTRIAN ^PEDALCYCLIST~. IaA ~~ ,~ ~ D Q I RvlR~s NAM[. uar I I - - NC19N /~ r3=tiT^ S~/IIV4dY •fC =/x/ StYfF1AD0Rf I ~OL L ~ ' ~• SIR Fi ADDRESS , q~ GIY iA F 21PCODF PnONE NO. D Cl S^ ~~ D' IIY iA f IP I '~ E>:ivro.J '2ZG 2H2o ;w ~ z rvfN'S ULFNSEN . ~ ~9~11'X R C .», u. GR~A Jy.32S" ,YS'' /O i t'. OL C D el I' U NSE NO. AlF FX DA Bgr.r `-~~ ~n s E f.(lA M o,>' ~L Ir ~2. ~ LLC CG 49r7 LAJA f MD I /Z ~ L q.. OCCUPATION iIRM NAME 6PNONE NO. EYES WFIGHr MEIGN} E CVpAIION FIRM NAME6PNONE NO. EYES WFIGHI NFIGHI ,. j~ ^ CHECK (~ =CL' /LL~% /Y I.C =N I'~ Z s^` - ~ ~' R ^ BdoS I~E+GL+.(( o of . vEHGf AN EMno~fE Of ANOrHfR. ^ CHECK "~ CODES-~ 7 aA A irsn 5 ! e sDlRwc ('~ fwGEASAN rMHOWEOPANOrHER.I ~"' . a~ I ncr ,m ~ CODES - + 7 aiir sreMNf uli°r °CY u f wr1DE 55 v Air 5 eA<rgN e s r~Y]i I ~R Tf.M.. '°'" ^ ANRA,NxE ^ ul l ^ EBmR ~~21 ^ C Nfp IN RI n r~ ."~~ VFH EAR MME ICODG({HEV.) EIfDMr.NwA srrll DR. ~fYS`7.°.'R°'A ^ AMIreAVU ^ ul ! ^ c"bERR ^ l'.i ^ C4'nsP 1 onv.l I v.l l IDMr.EMVAE ~x •,,yy {I '~ 09 IICENS N SrAIE iRAIIE f O. $IArE H ~~ /L (~ A , 1 N AI / g~~ .CN SS'7y/ G..I I vn.caoR 'AI [gR Tj~' KHIRFIDFMI{ICAIN)N NO. CVfH `IDEN Alyr}L 4f~ WlI ]° T[~,', ~' 3 GIciIR121S1917U Iy191G ILA ;81 f i ~ ~ Ir ISII>'ICIl11 'I 141 ?I~'I I I I I I ~ efGISRRLDOWNFR: LXSt {IRS! MIODIE PHONE NO. O R IS RFD NfR. yv5r SNMF n/~ fIRSi MIDDEF E yU I u. ADOeESS arOWNLR yy 17CC(_RAA ~ I' ~ .SZ3/U N A R OWNER ]I ,- ~L. NAMeaADDeessd msuYANCL CO. oRACfnr E SY¢Me ' R 41 ~ f ~~ .. ':z F i .rtl cA./ Srlrc. G~ S A - L/N 5/lh Go _ c P ]] DAMAGE MEA pEAyP,D /Pl /T/I GE+IJ~S L~N~ ' ~ o+ntlMi CHMGL ` ~ SAN ND gAMAGFpMEA ~ ,"S ~ ~ .:•~. E fDiDR A [ 151. DAMAGE ^RrvlPI CNMGf CIgW! 2 ~l ~.` I. 10~ R WAY ^9LMAIN[0 (a DRIV[N 9FMAIHFD I Ri01 , t ' x f/O UO EL j~Dgy. ^tow[D AWAY ^ est. DAM..[ 1 lueoricii ' ~~~ i ' 4'~ DIAGRAM Of COLLISION: 1u N WAY er: f'~U [~ +~,g~i Nmwl Ndin ~' ' _ ~ ,_ , 1, la - - SHL[iuN[cESSAer),. ; er Aeeow DESCRIPTION OF COlU510N_ IDSE SD pt[MfNf l5N!li If NFRSSAgY) 5M R f x.: ~. _,,. ~ ~ ,, __ _ rl ~ ~r~ , I , jQ ( } ~ ! I I. 46_ LLLUFC~r '~l___.SrA2rEzp _._~_ _ ._ '~ ~ ~ ~ l~o _ I i ~ _ ... l ...,'_~. I I .. 1 _. dlq .. Nut- _S r~ --L S~ /lo _..._ ~~ n ~.q _.. _., t.. /rl(.PAf Nd... CU NUKvl31/rE_LC -. ~. .Z MEIr/L. .. ~": /'~'. I .lp I4 >6 ~. Iti ~~ '- C/C ll1L.. I ._.. ~ f .r~,,,~ r \ .. .. .. _.. ~ _.- ._ - - id1 r1 ~ .°y' ' •.. I ~ ~...! ' ' P .r ;..; I i J - - ]e , _. .- _... Ai p p:_, ~,."?~ ~~ la r ~ ~NA~E,ADDRESSBINJURIESEOiwgRSON~INVOLVED ~ *CODES ( _ ~~~ _._.~_ _ __._,_ ;~E Y , 9 ~~~,! __ .. _. 4 ~ROCCUPA JTS /WITNESSES iaoAL»Ino~rEUeiN"'E . HAAN. 7 ux AGF alas n. _w~ _ _u _ n Mbr. ~; r ~i Rf519 I s:` r ~- ADOrEss ,a u-.. C I .. ... i,°ruR d 1•7:L 3 2 ~ L I [l .A ~' nAAy: P VJN2 RI Hrl N I' Y S ~ ~? h b .. ,~ AMe . NS ^I~IJLV. ~ .'IV,A~' ' r. ~p DWISf .. .... ~ Vr _....... ~ ''~~qR]F q ~.~' NIR NAM1 .. , ....e MRr 19 QAMe. Qra KIQ ,m/^YNi~ ^ ~ qp R~ Ep,I~ 1 Al l d +GM 501 ~ A Apprlff - ~ ,.. NAllp d r ~ ,. wv r~cAr++adfur[ry+vEL1E~NR '"o- ~fNf ![r r: QAMe. ^u »O o:n. ^U'S^^,".°.,1. ' a 4Ri s! ~•~147$.'~ LL,__ll.. Ei_~.// EID~L,ow AGINCr x:I DIs.Araxo EIXIS2 AREIND ou(durofE . .r,,,,~. ;n ~'f>.~~' , ,'~'~tk „t~, :A p~ ... Ga ~ ~., '~ .: .. ~.'r,: b~ a~?: * " Tx; ,~'r, /~ rP r.~ ~ " ~ ~ tic _;~~rq ~ ~, ,: a 3. ~ I H ~ ~ OIF VVJnL7tlIVGI OhJ D Gf / i / ~ ~~ ° No. ~°~ 1U POLICE TRAFFIC COLL15lDN REPORT ~ 7RAFFlLWAY ~~ ! PIXICF[OMPwNI NILMDER 3z.~ ^.~ oafF OEC u ~ PRIVATE WAY ~ lEe 1 ~' I IA! N. IO,~ u'w (usE'.gp~Uq) <OUNrv COUNTY NO. CIrvNO. _ iHWA •7 y~z y7 pE,. 6~1X ^N ~F ~IN CItYOR TOWN NMIE6NO.Oi 51Rff10q HIGH WAY CIS FON 1 f SFCII N ~1~ r ~' 'i'a~ i~ ,wIES O S ^w Od9i J ON j /~ (yyyyyy..., 1 RSFCIING WSIH SlRffr OR WAD NON iFR3 CIION ~T ~~ ~ Yy ~~~f~, ~ ~µ~~ t/0~~(/ CfJ 7N O/_ '~ • DR[fl% f0. MITE d ~ pISIANC 6p h r BE1W'EfN SIgFEf A ~ STREET Q.Q~ 4 ~~ ~ MIIf i N ytSR f .CRVJOSSSigEEr OR NEAgESt MILE GO f ~ q[[IOENT RAAV p1AGRAM pAIA .~ iEEI pi MILEAGE ~ { x5~~. COIIISgN NVC%VEO: ERIY: L wott0~n ,~.,,I_j^, ~ d~99~3 ,~~• i01µ NO ® NO RIIFp~~•Na. IN1URfD Q ^SDl RUN ~ %~RO IR I SIR FI RROAp Oq pEEEgfNCF ]S d{^C'g2'Y . p-~ 9 Cf VEHICLES Ik] DRODFRIY OAMAGE O.NSY fl E ~ SIIXFN ~ ,/ INIFR CIS CROSSSIRFETOR Rp•p V 9 OSIFti SrRUC%INN.1f Or OB1ECI STRUCK PNOOWNFR'S NAMfI ~RFSUlrFO ^VfHK(E Y ~'ffJ/JO6 f k~ i~ FSr pAMAGf SDECIµ COOING USF J"v r k' ~. y a ~ ~ .SOa.~o ~ rq ~~ ~ ~ s pR VER~s Dlµaf: usr UNITNO.I UNITN0.2 OVEHICLE. Le ^ PEDESTRIAN I] PEDALCYClIST RA i , MI SNAMf~ Sr ~~~ r~ SIRfE AppgF . 1... ~ il: kpj ~ ~ ~ NY SfAff ZIP [DGE PHONF NO. D ~,T Ej S ) f~ C R Y~ rAIE ~ IDC D N r,ys ~1 {H ~~, RNERSIi O. ~~ a7i.3 R C B . ~ ` _ YD ~ _ O /Er ~~ S~r f% OAf aB RI'rq V IvFN KENSf NO.I fAtf % ,b ~oaY3 RIH ~' ~tn ~ ~ ~ I w 9 OCCUDAr IXN IINM NAME6pIpNf NO. EYES WEIGHT Nf Gnr E IX tON 'i1RM NµtE6 PHONE NO. ~ d 2 ~ ~IGI FYES WEIGHT IEIGNI !2 YK:~ - ~ COODES-+K Din EAa^wr oiANSlr.Hew., A_ .oI R ~•~ECK (/1N ~EH CLEasaNEAw ~iANOrHEa: r"p"'p s~ ~:.R .~1~r t~.nrsh~E~ 2 N Na,o; - ~f9JN'°f:Y- ^.vi3pIANgE ^ E°OA6"L dt~ VEN YFAR~ MA fIWDGF CNfV) A e ` l kn PIA EN SIcA ~~~t~ ~, . ~... ~ N~.,~.,.r. VEHICI I e. -t1 0 ~~ ~~ .E~ ~{ f~ ~ , E R .__. a ..,. r ~.• w ~ 10 i0t10~ AWA~ READ a 1 1 f ~ iOWf /Y~ OC W[D ~ AWAY EOR[MµNFD tSr DAM~f f 0 ~ 010 O Ou ' DIAGRAM Of COLLISION w uY~ AE INOUn NORIn Ar en' >%O, I 1 ~ L~!~ I^ i ~~ ,.5n r yE ~ DESCRIP110N OFCOLLISION: Iusf suRRLEM[NiAL 3neftu NECESSARY! A J¢} n7uca ~s.~r ~rYk1 ~P y f/E%r• rJ~/ sr~a1 /lO~~~. on. SiivS/..ha cs~iv i!' I p G'EvST 6vvn ~ /~iby. /jol~ .ors /Jladn:wii ~ Ew_ A F F'h.. f wdS .9a/iCJ.id ay./+o!'.ScnS/iAd~'/_'A.. Y ''". Ei3 • /~/ dac /a;~d~a+d dTTc f~rj~Tijt9 Tn ~- Y '~ Cy Gv/h~'.ir' w s . , ./dd/1 ~C ih TC~/'S'NC•!'isEi{ d/1~/dam' S _ ... r ~8ddf .S7 dt.C iii i~G i'i,~irf' /!osi" ti~ / /irA/.~'s'C .. ,' K 7~eRYE! i°/i i~di~ fsc s~'i'd~X >ile ~iz,•.%~ a+rro/ deoE~-iir . : ql Pi v d ead di, TJaI ~'i.J/i i si bim . .1r.>79 ~ so 11 eY7 reF/ ~.. NAME, ADDRESS INJURIES OF PERSONS INVOLVED +CODES t OCCUPANTS/WITNESSES Ifu1l SUDgFA4Mµ SN[[I 2 8 4 5 a AMt d ADp1110Nµ NaMI51 Slq AG! 1 S NoIN . OIStO M E~ Y 1.9Ys "'~' FE r . ', :~ ~G ,~rV ; ~ ~. ,. w~ ~« ~h ~ rr .,._..~ ~ aX Je /G ~r B " K ^~ ' ^rv ^E ®w ry ~ ~ OF bi tlIN Y .~G99o ~N~ ~gy!'I. , sb ~ OCC NI VEe MIIE9 B ^w^OF QrT V nrERSECrNe wnN eraE AD Non wrEasec ~ ~ I O W ~ ~WO ,PD CL ON / / MSL % PWEEM ELTWBE B£Cr. - BEW,Et„ :~°r © BND aEEDr'r~s~EE BERew" ET Inwuci oisv"nrqu asEeno r i ml~ai •~~ fs 8:65:. I,, - ~~ ^ x: ©~ urosroa m Rw. i. x AaK DOwBI0NwY0LYE I e ~~ .i ~ ^ _NASAR ~~ 9g ~BYroEeRrEn ...; B ~ N~ _ ~ R ~ ~~ AC! ,~r~";o DDaaoewEMAiE~ D"ECT STRUCK ~VItN dOB/O Q "` F rtlb- °°DaDee "~EA ~j ,. ! .... _ OJE T„NAM ,AND AOOAES9 .. ~7Y'aEiAiPo612Wii.: ~ SaEO.e of InE ~ ~ ~ '. ~' ~ 5 `~y G~~ . ~ . . . ORIVEfl'S LAST NAME _.: IR NAM .. Oae LNIx .'. ,: •. - . ,MIDDLE.. tND tAP9 I . ' ~ kg *q{ ~fw`7 z, . ~ ORIVER B LAST NAME ~.: I- I wEaEwmLVEe ..... . ,. .u.FIA TNNA n r iM9 ..,._._. „-,MIDDLE ,.. _~: '~` tv-Y Y STREET ADD ESS WE s~~ rU .... ....flOUfE NO. ANO BO%(10 ~ ._ y -h ~ - ~ 9wEaE STREET ADDRESS ~. En u5E A ... . p ' ~~: .. .,. flOUTE NO, AND DD%NO.. , , .R` ;m, V * u . ' . . L T I 5 auurE ~ V ` W -t ZW CODE ORIVER ,STATE N :-. Dowglerv f '9000UPA LRY ~ ~~~ , r y ~ ..:.. .:, .. 1 p ATE . O DTI •9 EN ' ~ DE:_: OgNER'9 DCCUPA ~' IE '' LJ ~ l.`1 ... /~ ..:,• -. F. •~~W E .SIR M... ADE DRIVER'S NCENSE NO rL:.:l'... ,._,. `PL C I / a 8TA]E. SE%..pA R ~ ,,~ ' qa ~ ~ ~.~: VEHICLE YR:. „MAN '7 1 b NEV•DODGEI '.. !/E INO OAgTI.:. „[IpOY STYLE I3 DR .:. ::AGE.: Y ~~ %~ _ y'. 3 ~x n I ~ ~ ~ . I. VEFIICLE YR. MAI(E ICHEY:OODO 1 _ 1 ' °O :~ T ~ T} d LK:ENSE PLATE NO:. Y..,r_SfAT .•.:. .,:JRNLFAPLATENO.,•.: :..STAT I e - , . DY.B . 30R ~ ri ~ t t t , W VENICIE IDENrIFK:ATgN NO . ~ . LIC PLATENO .at': STATE - R2 1l E, 2 :,,,......,, wls.:::.: ,~ .,~, ~ Sa,~ #+ ~* ~ ~>A.. `~,: pp N~r. ' s ,,,gg {~~~4 ~~ I~ ,. -~In~1~F --..... , ~ ~.~ LIABILITY INSURANCE INFORMATION•VEHICLE NO. T- -e- ~ ......... _ .....-~. WAS THERE MITOMOSILE LIABILITY INSURANCE COVERAGE IN EFFECT FOR THIS ACCIOEM ON YOUq CM ..., ...._I.^~E. YES ^ NO 4~ I 1 ^ :. ~ / ~ ' , ~ R 4 ~t3 ~ { ySWR y /aU ~ >~ ~'y k~ ~ ~„ 4 . 4',t\~ I ~ I' , . ~, ~~' °i rR ~~ N ~ . r ~ ~^ h `~s ; ,~ ~~~ I I , 4 ~ 1 , ' Y}~ V~ . '~ -~1 ~ ail` ~ Z.~I , . Il i I b ~ ~ "~ i I 1 AK i " 1~; I L ky ~ J.. ~A'~ ...nl~a ~N NUUHEO __. __.,.. ,: w OOCTOq'9 _ ': MARKFjRST OHF THATAPPMES ~ E%AAIWATION SV ADOCTORt NAME -. OPABSfraER W VEHICLE ABUNO xy, ~AeLlrp ppgSiq -~iATUSOFINJUREO ,~ ~ ~. alggf ETHATMPIIE ^PtOETRAN ~ gILED IIMREI IMw~I ~PA96E a IN VEH GE ~ W xa.WBAB{Ix6 Wp651~E ^... Y:I,In. ^ 6^ B^ O~w^ECI QPEOE9 NO.__ KILLED .I,.:. 13EVEn0 IrNiwonl I. ^r la wartx ,.. ^ 5^ B^ o7Ql MOTORCYCLE SAFETY; ^NEIMET USED ^ HELML7 NOT USED MOTORCYCLE SAFETY; ^ HELMET USED SNOW NORTN DY ARROW WLIRCIE ^ HELMET NOT USED wpc~r ~tMATMiPM[K0 w \ i _ DESCRIDEOELOW WHAT HAPPENED IREFER TO YEHICLES'BY NUMEEID •_ i rRACe a carLw[ un ers ~ ~ ~ I i :, .T«A1~«~,~ wErK `` ~ i l~ee~e a / .r~us tray/e~ We x et 1 q ',,,;`A' "`r' °" ~jyt"f`~t3rf'LHe/%k1 D, s7~°7- ] Ww[A tACN LLNCL! BNBW /(~ \ ~~ ; / GQ'Lt/ 2s_ /L30_MPfj, BwECIICxprgxvtl BYAawOw 1 _ ~ ~./ ~~- ; ~ LYe%t/e noY,Z hit _._.-- _ _ 'r ~ ~ ;' I A/17L+ /~ /SIJ. tG l C!d.__s[vl _6!y P4-ay~LSI h /le r fie?''~r` ~S f ~v , ~ ._I. , w~, ~srar~>_ N ~ _e.~i,~/~ _ VEHICLES POSITIONS BEFORE COLLISION •~ ~ _ -----••-" V[MK%! N [ [ W bl STREET OR HKLIWAY NAME oq NO ^..,, xp NMN .. ^.^ ^~ ~ ~ d LANt[ NKLL % D wb WVESTgATEO BY dy0x~ UO['r[tANpy LLOAU•iuWt YewttI OCCIPA!0 ~ IOrNIp ttclSlRwN ~ ^ ^ ^ ^ ^ ALOrd '. ~ ^ ^ ^ ^ ^ ^ 6N[wII PEDESTRIAN/pEDAt CVCU9i wA3 USlq. ~ °"OOpip' " ~ ~~~' aCR1CM {.'DIgECTION ',Tm `-.DIRECTION I^r~WrN ]^wAIEwA. ]^y,ON~ PEDESTRIAN/PEDAL CYCUSTCLOTIIWO COLO E^dOYW4N I ~'0 I^ a ^ q, ^IW wBUI I^11DNW.1Y RDADLUafAC[ vl~trlER " i^ WED % a gAtn[CIM ^ - '~ •.. Ka,ICN OxtI- •. ,~. ..~.. .' L%INI CONaRWb [ TTIAFO . M ,, _•..:. A)1A COgiROI . EA.[i W,ru _, ~~AA ]Tq. 1 ~ DAYLIfiHT [NSLL Ip(Cn ONfI •. - Nr~cLiv[a PQAD. ;'I,DWVER/VtNK:,l ACigrll. > Mtip~[jt ~KK~] Cr4DROx[DII UDIYI•~• I IL"~JRY 1 ~ MAtNr ] ^D'°~ ^I 1 ^ BK~ AL9 ~ x01 {A Y ] ^ RAY-Itq ] ^ a:AR 1 ^ ^ ONE WAY ~ 1 ^ GOIA` I ^ ] ^ WfT .1 ^ SrtOMWO A WIK.STR[ET ^ ] A~1 S1M S+a" ~ ] ~ Tnb :: AY ^ 0 ^ SNOW ~ ^ /00 ^ DMM STp[[i ^ 0 ^ nEID S+GN ^ ] ^ ~ R'JOIE ^ . ^ ILL ° ^ LYrrnwF O I ^ Ful,r.a RED ~~ I ,11.1`'1 ^ ° OTNlR ° ^ °SMCVY) ! ^ 6~EE LIDNfe ^ ° ^ fusNnO AMDEa ^ ° ^ ROOP/RAUpE D sflafr ^ ^ AILFY ~Ar ~ADWAT T4 ] ^EP ffY ^ ° ^MSKWAL ^ ! ^LT RiVW ~" rrvnr ;~ ~AY WRI TYf ^ , ^OFTICLR/fLAOMAN LANf6 r t~16' ft7.7. ~;~ ~11~t ^ _I V ] cuM tgNtMt BAIN ^ t ^ ZITNf0. T[afy ] DVY°WT~ ] +'.Er".1itl~i "'2F1'° ~tl~aAC.rn ^s^Mr ROADUfNu rrh IN`v~~ a, i' ~[l-"' reS" 4 ^E[7aw ~~ r~2f ^ ] ^ aLnofD ~~ ~`~ y ~;" , bt, ~4' ~' - J y, ` -, r • `r~~Y •. Sri:, '"-ar"° '1~ ~~;:~ .. .1 '~' I~ .lTRAINR ANEAD ~ 47dkT]tY I ~ „AA(yy r ^ 3 ^ OITRTANPq AND PASSWO "I SM~IIF f. ~ ^ 0 ^ uAKPp RgHf TURN ~ i ^ ~ ^ MANNO LEFT 7Un11 h~ ~ ry -.1 lr I: ^ 6 ^ MANIRI U~NRN .. ^ a ^ xoYnno ; A I' . ~ 6 ^ f ~ S1OPP[D fOR iRAiF10 _ ^ t ^ !TOPPED Ai SIONAL on ETDP claN ^ S ^ Si01'PEOWROADWAV ~,~iM .,' .. , . r y ~11 'i MIYMr ~ y."'" ~i ~' ~, ~~ ~ ' ~ , ski `~ Y . ~,.I l ~. ~' ~~_ -'d,~ fa-. ~, r. ~.' ~ rd~A~i - ..,~.n,~m~e'~P- '°'PtaS»~... A ~. 0.~'~ ~ ~W .Y~...r7..~ ~~, ~a~~ ,.iii M • __------ u i. ~I __ i ~ V ' ~ '; O :~ U ~; v •. O ~ r't ~ p ((( Q O p~ ,~ H~ o ~ N O -~ ~ O~ 01 O E .-t v1 ' (( 1 _ ` ~`' gT a~ qTk ~~~~ 'j - ",!' ti . i F, i~~` i,~% ~~.. ~~ ~ , ., 6 M1~~ ~~u 1~ aji t ~~ r i L ~~ ( ~ , i~ £~ ~~ ' i 1 d: ~~ i , t f 1 .~f~+~~~[jr,~lalfPyvt''n,f~r~ i „4~i ' ¢ &k t' 1 t ' tix ~tt~kktri'# I' .YF'~,ntd~'~+'~3iVl~+yt'"~t(1i~1111 / 4 r ~ ttit ~. , , ;~ ~ , t i r} a w ~q~q ,~ C,~, r fi`~ ` ~ - ~ * ~ ~ ~' y~a .}~ , ' - ` ~ ' ~ ~~ jf/ I#~jY fL ~ ~ f ~i 'i 3taznl ~ ~ni i, ~' ',~,.- a rf~R-~ ~ ~ ~~ ~ ,~~' '~' ~ S.E q'. + ~ Y ~~ ,R a f ~. ~y bra ~,• 1 '~ ~~I_!,J POLICE TRAFFIC COLLISION REPORT ~AFFICWAV roucf coMVEA NreaMDEU At ,- PRIVATE WAY ~ 4 '" DAlroecau N nmE OAY co EER ~ ~ ~ ~ , 03 ~ ? .I,'Ik IRIS .I R v 'e,l . IUSf RA00 MOURI ®1 u ~e-r~ o ; , eourvrr NO /~ currvo. tnwA ^pReA R ~,Y x- ~.s,. ~ N W 1 ^N ^F ^IN ,,11CIYOR iOWN/- AMf6N0 Of~IRFEIO~.RwgGYiP~ I' J AVEtS ~ ^w F r'~ LU ' IL ON ~ P~ _f v Y I 5[CIIVG WITH 51R[FI OR p NONINEERSFCI ON 1 EGi ClS ROUtFOR SIRfE O ~ ~~U SECH H ~ , " C T BfIWffN SiPEEt 6 SIP[EL UISIANCF6pRf lON MRERENCa.CYpS SERFEIOq NEARE51 MllE ACCIDENT PRffl% F MILE POST RAMP DIAGgAM DATA ~ q F . Y 7 MlfS 5 F W MILEAGE fFFI ^ ^ OF OD ~ ~ N COll15gN NVOEVID SEVfR tY. IOIAI NO. OXllfO__NO INJURED~SPIILAGE l-~SilECIf~UN ryrvgNRln IXVFERCIFS ~ N X~RO 1 E TIN 1 RROAD R FRFNCf NtER Cl5 CROSSSiRFFEOR RDAD ' ~VJ '1 ' , ~ ~PR00.g1Y pPMAOE ONLY LJ pEyUll[O ~vORRE 9~0~ _ ~ { OU![C151RIICr.INNAEOf OBI(CI SIRUCX ANDOwNFgSNPTMEAI f~ ESt DAMAGE S, ~ 1Yl cl>~ 5 SPECIAL CODING USF ~699~ 1?l, 44 5 UNIT NO. 1 UNIT N0.2 DNIVIR' NNAF St ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST .~ :IE~ ` ~ : U Flk I DRIVER'S NAMf: IASf 11 +„ ~} '1'S ~ BtPEt1 ADDR[55 1 ~. Pad 3 .s- 5 Rftt AOpPF55 k GEV St Al f ZIPCODE ONE NO D IlY StaIE • A .p 1- ~ . t'l•I 1A~0-CUM+ 4NI V °18325 3'iS- I yLV R P I F Nf NO ~7V 1 `' ' L5, l ~ D N[R'S UCENSf NO. SIAIE Ek A F iH e ) IV R' U ENSE NO, qlE fX OAEE OEB RiH Y V ' S co 35361 INYJ N't Uz. ii !~ ~ MD ~ R,r rR _ 0 2 OCNPAIION F 8 PHONE NO FT 5 ~Ok (: ~ 1^1145 (3~E,5 WF GHt HF GHl l3s s; r E R CUPAIION {tRM NAMf 6 PHONf NO EYFS WFIOHi H G ~J Nf CHECK (.~ KHasaH rEEOFafEOrHFR'M ^' N' ^CHECK (/) AI vEH ttEa a rMPIOrF[oFANOtH R ~'r `~ q CODES- ~ ~ a ~ Q S t O i"° ,. ;R - a S CODES - * D », ;u °' s e, rv e sAN'°„ .clE , R' ~ 2 NJ vo ~ "`fi' ~ ;f; ; . "° ^ A,nwurva ^ u VENVaR M MA EIDODGF~CHFVI I ^ EB:;tR ~2~€ ^ "~ N:o • tLIDARi~EgvAl IStYIE IROR ~C O NV) wl ~rbq f ^ AM rvn ^ ~a <E ^ Eb~IP ^ ~9 Ku ^ C° Hsr XHY R , _ •sa 5r ~ l` ` ~ _ 1 HfV.l MOOEIIpMt NGVAI Ytf (] < V) , e rH EH E S(Alf iRNlER0.AtFNp SIAIE H VEM R I q N AE eI~aEJ pi+w143~`7 ln.f'y1- -~ " C '~ vtHlClf lDfNtIFICAtIOPJ NO K ~M12 ZD'3' ~ L EHI tF IDFNIIFI I H I I.17~ ~~` w I~ RW4RRtDOWNER: IAEt St MIDDIF S ER.r.Q PHONF NO. w ISifgfp OWN[R: lASt FIRST MIDDIF . Nf NO. ~ ./ ' D ADDRfssa ormEq N • owNE% ~~ NAMFaaooqus ar msugAHUCO. oR acENr R 5,~", ~„F '1 ~. ~ wM.eio ARfA ' .I~cl I " D.4ngeen Aqu CIEMGI y.E CHARGE o,"i ~orncE rn '~ - 1 r 1 ~' ~ } ~ ' ~~-73 lSt I ~o : 0ANAGE 9(OP pNAaG1 ^ wW ~[Y - ^Y[MNNfO ^ RIVfN ^REMAIN[D fS1 AWAY I000RaR P kM I.t , s 15~V idNfD ^~WAYDer. ~er ( S • a ~ ti IH pt ^loga tH DESCRIPTION OF COLLISION: Ilnf suvvuMfNULSwuo N[CessARYI DIAGRAM OF COLLISION: yru,IftsE?~r~[ussAgr r l /Ld /O' ~ Ve4.• n / l.AaS' /L1DlTl..(pIEP~ as.. PaYC.JL1e. C{'a../ ~I ~ - ~ ~ IJ [, ~g .~.~.. ttsYLcYlq. G,{- co,, P.ll '} 7+ YT•LwlecJ nD-'~aJ /I fu .cL'Li rL.~ T R P ~ ~ E., ,.. !o %1.,_ '1'lY,rc 1Tlc~ , 1 µl..(~ o F /( aU.usR'L~ 'l'D "-~ 1~ ~ Vt 1 ~ ' / ' ~' .u _ 3 ` r r /aci~ [cn E- O / GawE v' l . ~ ~ ~ t . ~ '" 7i"I ti,~`5 d :r A O- ~ S ; 9 h. Y} r-Ie.P- . It.l s r 5~ re..n- wkeclr Con't: n lA'41 _ ~ E kY~ ~ , a ^, ~' ' ~ ~ ~, -lam ~p,w L~.„tn/ ~ ~L.f3Ftil,,, L,qr.-YSaEG't- , E~ (~~ y o Fr. -n,'. s wE,s ev ~ DR"AL4fy1 s y ~ a),V'C- ~; 1 SE sFq .~rtJ ..f~= .,F (1~ b E...k. c/hE:.rJ. e ~ s ~ I ; I :,~ b . D; ~ / NAME,ADDRE5581NlURIESOFPERSONS INVOLVED *CODES 1 - Z 3 a 5 6 - - .E' N OCCUPANTS /WITNESSES ;~ sID"'p^EOEiu r~iAii AME c l ;i uX Au rAius '"„°I" " ; c ResER. fJfet ,"" # I ; I ; ~ ,r t: os.+ ~.~ w? T ' No 7 32 • y /P v rK ' p A C ar j +. ~tu I E. IoRea wHf nr ^AMe. ^c'21%' ^ °'~ R„ OtL"6sP ~ i IL .. ~ . ~ ~ ~ ~ 5 i 1 I l A DO.fss N iLN of to fRwA ^AMe. pro"ICf D"ft:,. O px ^ :°w., w ;. A K - -.. .J ~ rN -:;. . EX+Ris~ wAEi~gle F fE er ^AMe ^ c^;; E ^,HU E. ^ U'S ^ .::„v ISt9 VROpvGI sHAw aXAHR e,OGI Oq Il1NCr KIDS IC ID PDIICI AR9 ND D IIp Pt K111 I XF "~~ . ~ ISl ~ J` :~ M9pVIDaY DA I D w a DO l3 pn ,dt m ~,.. ~ d/R ~ ~ 1 ~ `y1T`` ~'1r±1 )~ ~`'w : A .~.'S~. ~kP. _ ,f. .dn~'l„ ~~a. ki.~~ .. r,. .. 7k. _....~ ~ ..am.._F .. A.1 / ~ F r ~~~~s ~ ' ~ ~4 7 r r ~_~~-qq' ~ ~i~ _.r ,.. ~.:-'P ~ y~E 2Y^`': . ~ ~~ a ~ ~ €' ~[ Ry~~y''~ F3>rr'Y `AY~~. ". ~ ~ FE yp 5,, A•YP~~rp.R ' • U'idiF-~V y E~'j ry4 s: • ~ ~`~' r ~ TRAFF / ICWAY POLICE TRAFFIC COLLISION REPORT FORCE COMpUINENUMefR PRIVATE WAY `~ OAIf OF COll15 N DAY LIME COUNLY COVNEY NO . CItY NO. iryy/p '(! Y fu u INS I. f.l. IUSE .OD NOI{ 1 `/'ll x W \ ^~~ F ~S ) / /EO ,^~/URBAN ~ xURAI ~ CII OR TOWN QN E ^IN EdN0 Oi5rPFF! N GHWA - \ ~ iR ClS ROUFF Ok 51 Rf F SFCII N Ml[5 ^5 W Oi ~ ~~ ON p / ~ ~ ~~~//Q 33 INI SfCI NG WI.N SFr ONR NINrfRSECt ON ~/J fj BFTVEFN StRFEi 6 SixfEi pRFFI% f0. MIIE POST S-BZ '/ D15rANCE6 RLI R F ROSSSikfErOR NfAPESiMIIf s / ACCIOENi Mht F ~ 5 f W if El Op MILEAGE D D RAMP DIA RAM DATA CouISIGN NVOIVfD. EVER tr. ~^~^..~~~~ m ES N NO NIII[D~E„~(-NO.INlUREO~ ^SPIIwGf I6 RUN IORAE NO. fuNOxlOm I %.RD IR CEINGS RFEi RROAD OR R[ffxfNCE IMFR Cl5 CR(MSSIRfFi OR ROAD' ~ /33 // CP VFIxCIfS ~ PROif RtY OpMAGF ONLY ^ RFS~FifO Vf if SJ L/O rQSO ' OB1fCI SIP [Of 1FCI3r UCK NRDOWNER'S NAMfI fSf.DM1AGF ~ SPfCIALCODING USF ' $ +l -. 1 UNIT NO. I UNITNO, 2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST 'S .RSNAMe IAtI NRSr mI v Cy ~ oR VfR SrvpME: wsr ex I stREUA1OOUfrss stRFEtpooRfss CIi SRAIE IIPCODE PNONE NO. D IIY srptE ~E PHONE ~ ~~ R ~SIICFNY NO SIAIE f% A ODRr IVER' LICENSE NO. SAiE E% D r A+e iM OCCUPAtI MNAMf PHONE NO. YFS IG SHEIGNI E acuppnoN (IYM.NPME6PHONF NO. EYFS WDGHt IkIGNi (~ ~~ R ^CHECK(/) IvfH<IE AS nN U°AViorffoi AHOrNFR~pF ^CHECK(/) if ASpN FMPIOVfFOF ANOrf'feAt v CODES -' ~ ~ k i s l 6 ;° ' s .sn ,Irv CODES -~ 3 c", a„ 5 u a i° ASS ` u A+[rv YC l r f /}+ IN URIFS iw ~ R o f~ ~~OVIprRDU ~ AueVtANEI Q a~Cl ~ i~ntR ^ iROArvv. W Ylwvaoffom ~ Wnd%ANCI ~ uRtF ^ CSvilo ^ viHKl[ ^ iv~iaY. H~AR MA%F fCp~. ~V.1 EL IDARf~ Al StYlE 130R ~ NV.) S i 1 (~ M -- .~~~ti E V N YfAR I HfV.) M9Dfl lDAR1~NOVp) Y (3 ~ V.1 IR 3B ro H. Q N ~~ ~ U FNS plA1fN ~ ~ / StAIE tRANfR 0.AlE NO. ~ srAl I'I I VEN. Q R N A ~ " of+ICl[I[%NrIiICAt10N Eq <; L vFHICIF IDENtINCAII NN . 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NN4FD ~ ^SPLLPGF ^Ni64UN '~"onole OIAI NO. I~7 IME4 CIS 0103.33RRi0a ROAD O4 f4tNCE 'I TB p VfN Clf3 I~'J ~ PPoH4tr DAMAGE ONLY ^ gSUIIFD ^ VfM,Cif ~~ Ohl[Ct3t4UCK INAMl Of OBRCi 3t4uCK AND OwNt45 NAMFI fat. DAmAG[ SPECIAL CODING IbE ~D yA J JL/ L..-~A $ UNIT NO. 1 UNIT NO. Y VEHICLE ^ PEDESTRIAN ^ PEDALCVCl15T I4% 9 S NAmF~ IASI NRSi F D4M4 ~o H nl M ~/ o~ gV[4'3NAMF U ~-L1' l a A Sl4ffl App4f53 INEEtA 4135 Az SS -~ tt o ZI PI ~ pir 1 31At[ 21PCO PHONF NO . 4a+30 pow (..) S R , s tW 1A`JA ~ 36 ~ ~ I DRNE45 uCtN3FN s1Aif % N mD t u eN3tno ,t zs A,E YN e a ~'1 WA M 0^r o S3 V S f.l Ohs ( CaJA ~ ^'~ DAr '' ' e OCCWAiION N f 6 PrbNf ND FYtS Gli Nf GNI E ~ OCCUPAt,CK9 M f 6 PNIXJf tA. EYES IGN, NN GM Z ~ .,a TI nl c b5 -I R r - a2 ^CHECK (,~ vtNat AS:N fW,A~r fof ANOlNfv^L ^CHECK I/) EASANrMnor a•NOtN c^` ~"~' r CODES ~* 3 ~ a w S t 6 i,° :ss rin ^c' yr •c I tf t CODES -' ~ ~ ~ ~; 5 u "/ e i° "' tc, yr rrn +v znv ''i Z, w w f i . 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DIAGRAM Of OL U mN•L Nolc•,op o4tN 11510N; Iu SMIII II NtLCi S5A4Y1 Ow a DESCRIPTION OF COll1510N: IVS[SUPPL[M[NlAl sfan vN[cfss.vrl ~ 0 CP,12 1 wns w¢sr Qovao oa gNdy I RNl`I tocltt (t,0 ~/¢A. ELo G.APL t wq1 N. ~ovAEtl y ON lfM3oN LTC. QO CA,t I Fa~f-,ta '` Q ~ `1~IL.0 ~ 4f+r of wA'! io Cd/C 2 U ~ w Qi ~~ ti NAME. ADDRESS 81NJURIES OF PERSONS I NVOLVED 'CODES 1 - 2 J 4 S 6 rvx sL»ntmwi•, sNt OCCUPANTS/WITNESSES for •DDmof+AL N.w tt sl sfK .er um '"„ s v esu utet ; TFWA+sPS Q~N/S rP4o" • DOVfss •tuvl a p AM e ^ ~5K' O " . Q ~ ^ ;° AVI • DOeeu w1p Mwtn loom ~•Me ^ ; I ~cw f ^ ~ ^ : 4D At ~.. A DD.t.S +.Y ea..GpfKly s.w%ea ~ s•DLf o4 ,ca.cr ,~ x>;~'1°' P r t.,;. ~^oAMe a.^'a«~n.a~: oa:v,. al ol; •¢MD lAK:f •vvlvru u•npvtrGV, APfrovtoe. D•n ~o .n , fL. CSr7 17~n ~ A T~~// X QI. 5J~ CG iJ`.41 ~~~~ ~ F w Ys ,. 1 v%~ ~ _ w...,. kll ~' z'~ ~: kart ~= Ir y J F " { .A,f 7^i¢ . +~ ~~ ~ y+: ~,.~ ~~ •~ Iµ ' ~t .~ r Y x. ~ _.., H, Y ~ ~~'A ~~. ~. ~ ~ ~Y+n . ~s ~ ~~ ' 1 ~ ; ~, a. t, . r.,, . 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POrsox[w[xe $TIIEET ADDHCSS :;, ,;,.__, -,,, ,,,,,,,,,, _-;I::Ap TE NO,AN070 NOS::, StA / CC . - n .' FV ...STATE "::...31P CODE. pglVEft'$OLCUPATION 6 ~ w$ A /4 e O X E _ .. '~ ~, 4 Ilcc,k VU `)FS?i°I ' i ... .... . ~ x[roxl raxM ~ ,1 T TE ,.,N ZIY CO O . DRI Ii' OCCUPATION ..~. otf lIS^f(lJt./ V 58365 ~ ONIVEII S L CEN5EN0• .:..: ....,, J.,. STATE $E% ~ '~ X F / 1 ' :.OATEOF tlIflTll .. _AGE, pHIVEfl'S LICENSENO - $TATE..SE%:. .4pATEhOFYfIq Yp.:. ,AOE,. 5 SY~k q .._,_ X " VE IICL[YR MAKEICHEY.DOOGEI MODELINOVAOANiI- ..-DOOYSNLE I30q. VEHICLE yq,MA%E ICMEY: OOOGE ', .:;MOpEL INOVAOAq BOD STYE 170fl. "" ~ •~ (+ l~rcc~ ic~cG~ YI P f a ' I Y [~cvPV ~ SEPI y~%r -'LAi NU.. ,STATE ,' LATE NO. ..::TRAILEq P ` :: STATE ~ ~ Ll9b 7Gl cu~- • ~ ~ . ... . LICENSE PLATE NO.. .::..STATE.. S.: ..~:TAAILEfl PUTE NO y. ~:_:.,,STATE , vEI ICLE ID(NnFlCnnoN NO. .. ..':, r I "~- ~.r ,ee. ~ a 93 --'~•`" " '~'~: - VENILLE IDENTIFICATION NO. ~._:::.,... ., .._._ ........ .. 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[^ ~^x ,^,rnuxouu rr [^;rg;; ;;;{~~~ ` AC( W(AertN t I LIDrN 40N1J1 (IONS InA 'CC?NI IOL TVY[OF NOAD OXIVf Nry CN CLE ACT ON9 11 LA -- 1 1 v ~ ~• I ^pArllGlil v[r I C•nr.. tMl vt I yN UOx[ n [ xr On uOn[I { Y =11 l ,~ rnr IOJ[Y [^b?.~i~F 7 ^DAWN ^ IVyu Srf.NAIS vO.l rxO IONF W,Y[A~ x0 r[I rtl~ A h {,~ t ^ 1 ^ ^ ^1 GOINO bTIr LIGHT Al1FA0 -t;t ( _ -~~ ip XAIn NG )^DUSK ~3 01Twucn Qom) t~'RVO wAY ^ ) ^ OV Eg1AK11J0 ANO PALSINp {~~) tll nti 1 ~1- 11 , r ~ D A SIA(( 3 ^ SNOW NO F ^ (IGNl3 UN 1 ~ { T ^ 3 ^ Y tlll1 GN 3 [VI XL hLi ^ ^I~ {~ ^ INOW -' 3- J ~L T i ~ E 5 J t ^ FOO 1 ^ ~ 1 ff G~ 3 UAU ] ^MA[ING gIG11FTVPN 1 ^ t ^ fLADNNq M[O rr~~''ll N IIICrrAN01 ^ I r 1 0 ,1 1 { ~ ^ t ^ L( O( IA ~ '~• J L^N`[Clf vl ~ ^S~11f(Y~I LJ ~ ^ IIOOrIMAMPI ^ t ^ MAKINO LIIT /URH ^ 3 ^ILAMNNG ANhIII 1T 41 CyypV i~ f + {-~ 1 ^ ~i~~iY DMI(P °"~ 5 I ! 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L/ Lc'. 7. r) - ~LYI= 1 •~- //i.~~Lrr.fC /!/A ~~~r5' l>[/ .S TLhr.`i'/ f5 CENSE 0 STATE SE DATE OFIIIPi11 AGE DII VEq'S LIGE Ste. ~ STATE SE%. .. GATE VOF8 Pi11 qGE II GLL YN. AKE ICHEV. DOOGEI M04kL INOVADAPII tl0U STYLE I]OIIJ yEHICLF YH. MAKE ICIIEV. pOpGEI MODEL (NOVA OAPT BOD STYLE IT OP.1 LAIk NU. STATt TPAILEq PLATE Np. STATE WCtI15E PLATE NU. STATE. tflA1LEq PLATE NO.. _ STATE.. vCI11LLC IOtIITIf ICAi1ON N0. n ~ VEHICLE IOENTIFILAtI0N N0. .. _. .':.:.,.'. .. ..: ...... gIGIStLIIL OOwNEq ILASTf IflSTMIDpLE NAMEI OPIVEP'S LICENSE NO. I IkGISTEHEO OWNED ILAST~FIPST MIDDLE NAMEI OflIVEfl'S LICENSE ND,,, . WNI n'S nDUlIESS ISTIIEE T, CITY AND STATEI DAtE DF UIHil1 UWNEP'S AOOPESS IS?FEET. CITY ANO STATEI .. .... OgTF OF BIgT11 y AHIR UF VUIICLE OAAIA4E0 +Il~c~l qiS OF VEHICLE DAMAGED LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1 - ~o~E Hpce IUE fDF[CiIf011 THIS ACCIDENT ONEYUVR CAP ^ YES ^ NO AU[IIILSSOr LIAUILITY HSUgANCk PULpoY =OLOEq NAME OF LIABILITYINSUPgNCECOMPANY ° c .'//!/Ir~~ rte!' , iL'.l C % 2.:•~ ! r. , r/[ ~:t: '..:1 /. _ ~w .l-I ,`>~.Y".~: r :.~'-~] CI- ~./'~ l %( /J UIiE55D'L ULIIY INSURANCE AGE i /1' ~` S LAUILITY POLICY NUMtlEP ' /, ;~ .!;.-~: __~/L•. . ,;~~-: -fir, , .: .-r-,. ~.L,, ~ .a ~J/ ~? 2 111U ~ AGE „I ~ {~ NJIIIAL TED ! TND INIUP Y: IuiL S[vaa+iE pE1o AvDHIVn - NAME AGE AOn NCSS Sf% M F ADOnfss SEx NnioNC AHn Lx FNr OF IN,LIINE^. ^^ EE[--• ~ 1 I uRL nfln I ExiENr of IN,uNES M F ^^ n [S IIEOUIIIE ~ O ppCT011'S k~tnMiI 4IIUN by AUOCIOn1 AMC lu DIfUu l nIE511E0UlllE OOCi0g5 E%nMrNATIDN IIYA UCCiORI © O NAME :IAIU Uf Ie1JU11ED APK FIHSr ONE iIIAi AI•PLIES []Ln NN V[IIICLf un xxrn aSi„ I~I+ r D KILLED D'~vlxU N'xinOxl °covP L~.I~„'„~;~I I STATUS OFF iNIUPEU (]vx JNDV IIIL'Lf ~f+ a, ~=;LE^ KILLED MggK FIPST IS[~~iIU ONE THAT APPLIE nMii Nb o~I S roSNb II~,~ oF;~, o ^ 5 o s hIOTORCYCLE SAFETY: ^IreLMEr us[n ^HELMEr xol usfD MOTORCYCLE SAFETY: ^HEIAIEr USED ^HELMET NOT USED ~:IIUIY IIr1H41 IIY ANnOW HI CIII[t E pCSCfIIPC U[LOW WHAT IIAPPENEO: IIICFEII TO V EIIICLES OY HUMUEPI ArnNPaxrV G I YNxLIE x~ND HrDw r r, r rrx r s irr+Yl. .xrlb,Y ._ r .._, x _.~/l_-_ .7.t //~f N.--- - ... ~ - ~ ~~_ I IvmnorrrrbN,+. '-)" _ ~.. ~., ~~ v.'.G'G ~~ir~/I ~ ;/-=T%/, r l. / _A_ I - __ .. - / / Fi 4 /CY~r ~''/ ~ ~ • ~^ / ~ - ;) Yt I ' I'i ,y _- _.._ .. _. - _......-_._____ ...___. 1 I .S ... ___ .._ .... _._._-___-_-___... , VEHICLES PO51T'IONS BEF Vl rl ritl N S l W OflE COLLISION Oh SLIIfIT011 HIGHWAY NAM[ON ND nrnrlL { HUN r. xo •ll AO 'rY1l~rNI INVE ncnr[DbY "~ ^i%Inol ^iU~lti ^ ^ Gl. ^ (i•'c'.s J__L_'':'i~~'~ ~ ^ ^ ^ ^ ^ ^ ^wiicf ` yiiiurilN _ ".--- --- RT • ^ LJ ^- ^ D ~• fRUM TO I's DLSTHIANiP[D! I-CYCLIST 14AS U5I N(i~^ s• +[) w. I ^ v. ~~-_ ~ rrA r I,+. ~ ^`~~ ^ ~~ ^ or r ^ ~E, t ^ no -+1- ` 111)1 TIii 1N.PC D -- AL CYCLIST CLOT - I [] r^u. ~ . . ^o. IIINC. COLOR r, L^°,~~ii ~~~W An+nN. Qxl lxunl - l w[AN•Ln `x•r ~P.~Lr11 LUNtIriIUNS ' ..~ r,+ 1 L.y DAYIIf.HI ' nI.A o nnwH j r {DDr ~' ( T ' I-~-- 'f _- ".rl Y~~•r...Nlr - w > III src;NAls 1T' IV'C Df HUAU o. I r-- For i~+.u.i ~"I I ^ I ^ orlf war nrIIVENNN CE ACTIDNS YI c~T ni rl IcxfcK O"I OxxanU «o I ^ I ~coulD SrRAIWrr Anuo . .:. .. , ~~MMNING )^DUSK 1 ~~SIW AryN ^ ^ IWOWAY 1 / 1.~, ~~ Wf1 r"1 DAPx [TR T , _, ~~ I ^ 1 ^DVFRiA%ING AHDRASSINO ) I{ y~IMG LJ' I ^llGni3UN i Y•,.N t J C i l Yr[1.4 EI:.'1 ^ ^ R VCIISrbLF (^ k ^HUAU ^ ) ^ MAKINO PIDNT IUNN I - ~- ACj rW i OIAlIK 51nlE1 1 1 ^L4rr13 Urf l r Lt to YlLrlV1 1^6IP(I~ITWIii 1 H t } tJ , f°S T IqY ~ ^ q ^IIA.r~N.. HIn ^i ^IlA6•I rr(. AMIII II ~ ^ ^ g I rliln(.IIANOf ^ ^ IIIAYIPANfI ^ 1 ^ALL[Y N ^ ^ i "LI q ^ a ^ MAxINO LIfT TUPN ^ 1 ^4AKIIlOU~IUHN p . ^ bLDWIND ' I U w wY CI l' L a 1. .i, iY ~ ~ 11 I~; i~u~~[ I•T,1,•e}•i n ,~ r r: ~ !~'t .~ ^ ^ I "1 n t;i~fr~[~~~.1~~~v~.,. - ^ r ^ 1 F Av 1 ,,.c, u1L.r1 r [] F Q nor [p Fml TnnfnC ,.~'i4'+Y1~~fr~, ,.~ n. ~~ 7 rl~ ) . ~r ~ C~ ;'ii y„, ~" ~ ~ ~ , v :~,,• Y ~•: '... txcy'.. T . ,; ~ 1 , , F ; ;~ 1~,[I e r ~:~4 I i-' ° Ir,~; IA t•, -I ;IIILIa ~urC°~'~': I,~~~~ I ,e t ~ 1 t~>i } - I t 1 I'~~~y~j~~ q ,p p Y .,, wx __.....L..~x I.,Spl.p[[.r„J - _ [ol a fq l S, r n~un : ^ I[ I ~ ~ ~ uu WW ^IN NwV b ~f-LJN ^E '~'J ei PY /~/ P `xN /~ ' , ~~ ~~l! % •~ ' S-IIY' OS ^W ^OF I /Od~e{/ ~ os~ r~ [ s J xuurF Ox[rx[ cap[ ~ S EN~~ . _ O N [r- Nr . ~- ` ° `~` L ~~~~o ~ ~S ~~ ~~~ fIK DY[F xSEr ,'~, p ~f~~ i[xGrw ^ ^ pass„~, <r [ a DF ~; ~ ~ .~ ~ MA;[N AL, s En ~ ~ `x F ~ F " wrFx~,. B..NMpx,LS ^xA p ^vi Bcp OO 'vE cr ^ [ FrF~ y'O x avfcrsrnu OWNEfl OF OBJECTS NAME ANO A [ir nRbo 6[ 0UBE55 PO1 _ _ % W ,Dom Trv T Yna./~[XI a fJUO • 1 .. OHIV Efl'S LAST NAME If MOxF rxAx -..:. ,.. .flfl57 NAME S S z Y. s G 1 ~ , .aE. N a.mwar r ~' ~ - -' - .. ._ _ :; MIDDLE rwa c,xs OflIVEfl'S LAST NAME AME ... ... _- ,J... ., - .. ~. E . .:..FIflSTN MIOpLE~ ~~ .. v sinfcrgopnfs-s-("~~ uaxE w.x Swo - ^ ~ e ~ --~•- :. ......:. _. flOUTE NO, ANO BO% Itnwna wEx[ STNEETAOOflE55 T ~~~ JS~A ~ .y ~ - ._, ... .. .. ...... ROUTE NO. ANO BOX NO,... M I - ^~ LII~ S A 21P CODE OgIVFfl'S OCCUPATION [xUxi ipn, CIFY ~yy 5 . TATE~ ~.. .. 21P CODE. DgIVEq'S OCCUPATION . OIIIVEp'S LICENSE NO. ~ ~d C ~//JY1 yl/ STATE 5E% DA}E Of BIflTlI AGE ~ . F L~ I N0. p,v vX Op VEH5L 5E N0. STAi ~E% _ - GATE OF BIgiH, , ,AGE Mp 1: L IS A ICIICV ~ . OGEI M OFLINOV ~OAfli, tlC10YSTYL 130H. l 9ha y ~ I'LNSE PLATE NU. ..STATE. TBAILEfl PLATE NO.. SIDE VEHICLE Yfl. MAKE ICHEV: [IOOGE) MDOEL INO AOgHTI B00 STYL 130q.5, /{ ' ~ ~~ ~~~ I VEIIICIE IOEN]IFICAilON NO. . - .LICENSE PLATE NU. STATE. ,TflAILEfl PLATE NO:... ,I. _:STATE . s ~ VEHICLE IOENi1FICATION NO. -- .. ., ...... 1 . ~.:.'... .. .. pLGISiEpEOOWNEq gAST'FI TASIOOLE NAMEI OgIVEfl'S LICENSE NO. flEGISTEflEp OWNEP ILAST~FIfl5TA1100LE NAMEI OflIVEfl'S LICENSE NO.. -,,,.;. ; 0 .AUUIIESS IST EE ,CITY gN05TATE1 ATE O BIgTH O ' .. o ; C/~.(I ^~y N o rx PA IrS OY E WNEq S ApOflE55 . ^D ISTHEET.LITY qNO STATEI ,:,_-. .. DATEOF BIgTN // /; N0. pAY Yx.~ V HICLE OnMAGEO ' "' nl{~~rnL&HFid rO PAHTS OF VEHICLE DAMAGED r : . : ~ . . .. .. . . :... xFP,Ix Y[HrcL r $ U~~ LIABI CITY INSURANCE INFORMATION-VEHICLE NO.1- covrxnce lx EFOF[CTIFOfl TIES ACLIpENTONCVO fl AMMArIp AOUHESSOf LIABILIY SUHANCEPO OOn SS LOEq a U CAfl YES ^ NO F -l/ISLSNISIA P ~Y \ ~ NAME FLIABILITY IN UgANCECOMPANY.. . . ' ~" ~ I ShS / - t ~ NAME ANU AUp '55 _.S=cA 0 LI LIIY NSUfl CE GENT F / ._-+" Tx~_/~ / V/~JH /~ ~ / LIApILITY POLICY NUMBEfl. IsnNJUgr: (-LeCIYbSLY ,E S{ n c c S' ~tfnsiA ]II ' / ..~ _ - .. AcE ]ND U+JpnY: n+sE SLIANArF xFPDxT fax ApmnaxALINA,AIFM AcE NnM[ IUTAL .. ..... .. NJUHEO IIAME npOAE55 SEX UNF ANU M F AOOHESS SE% %TfNTOF INJIJNIES ~ ~ ^^ AIUBE ANU ^^ IU IINUf51C5 gEDUIpE E%TENT OF INJURIES ~ EKAMINAIION BYADOLTON! ® ~ NnMEOfl S DID IIJJUI IES gFpVIflE OCTOfl'S SIATUSOF INJIJgfO MARK fIflSi UNE THAT PP ® ~ N EXAIAINAlION BYA pOCTOgi ME n IIFS ^ux IN VFHICLf p15,FL npii, lo}Srn ^v, ND KILLEp Is<v~nN ~wxMionl rxwn °"'" ^x[onr,I.n ` p1 fP~'r STATUS OF INJUNEO MARK FIpSr ONE TIIgT APPLIES ^pn I VEHICLE plili~n xpiL ro55rtl .1 xp Y INAJx ^IA ~ KILLEp F 1 ~o . I I 7O ^ ^ 5^ s^ s O 5 pl ,I[.LpWIL INi ^^x[~~s~n~N ^ ^ 6r~ O re, MOTORCYCLE SAFETV: ^HELMET USfD ^HELMET NOT USEU SHUW IIOgiIE BV AgpOW IN UNCLE ~ MOTORCYCLE SAFETY: HELMET USfD ^ ^NELMEi NOi USFO rxplc,lF UH rx SaAGnAU •. I ArrAi nMllxl0 I Sn.FESa., ~:L;~I~.•:,,,.~ol~ ~ ~ `, D~; ,,,~tlr Ir~.~FAY x,~ x,IMx[Nfp'I ~ \ I ESC pEBCLOW WHAT HAPPENED: INEFFq TO VEHICLES BY NULSBEflI ._._ _-.__. _ _.. _._.- _~_ ..~_ s f~,o 5 i~~{ y_-~r,~~~f --- --- - Sr~urC rAF'I~ lo~ NIhf7 rx,~.„;I~ ~ ~~ i ~, yJT~- _~cFV'd ~~ou/fv-o., ~~ _. _ . .-.. . _. ~_ _. _ ~l,vea~ yh _-- 7~~'~-- 5-1fi, o s~ni p7[ / ~ • / _ ,. l I I: . ~ _. St~ / ~ '1(sr1 4 SUm /w9 f/G.._._!!!O 4~d ~ n,urpx xrGrS;.. / ' i~ VEH L S T I _ ~ _. . _. ~ ~ ~ IC E POSI IONS DEFORE C(~kL .ISION vnunL s e DNS/[~~EIEr DH USDIrwnJr NnMf On ND. rS,NA, ~ ^ ^ o ~ (/U~ ~'~~ INVfsnagrfD tly 15 c,r°iv 5i°xm cn ;eao emu occru~r"IiD ~y~~N [.IS xp YIL YI} ^,.,.oL ^w,« -{ / f.Cy xJNrlxr O ^ ^ ^ [I Npw ^ ^ ^ _ ~ ^ ^ ^ ^ AIONG _--.- - II51 ^ ^ ^M _ _.. fADM f0 1'CDESTRIAWPEDAL CYCLIST WAS USING:I ---.-~ _I IN,:e:nle_- ^ uax,L, > ^ r.L...e 5 (] ar.x,l Lr ~. . ^ °e unxmp " 4:r: 1 ^ ° PEDESTpIANlPEOAL CVCLISTCLOTIIING COLOtI: I^p. i^uv r , rE .: K ^ mwx ^ u i5:: _ f ^ xD.ow+r ~ ~ [~ NSS AI>}UN ,KI w1ATHlK IIGIETCON01110 + ~ I^I 1^' ii~ISCfIA tYl fl ~aiiif`.i -- A 1Jp fI~CCUNIN I ~OAYLIGNr YIIA xr~r[. rE. x"['y' I x ~ UL 1 TYIF Of pOAp OIIIVLPNLIrICIC ALTION9 [w..i r ~ [ u c5 1 Ll Nl N j`J~, ~1+A ~+ 3 ^ UAwN I µ iji I l ] KNI L%pril Un NGN11 i~uo~ll f ] 5 ^ S ^ sILN.I. l ^"'~.fAl ~_~ I ~' Ur1Y ^ ^ 1 ^ ^ UN[ wAY ^ GOINO STq A1GNT ANEAO ArM~MG ] ^OEIS% ^ 3 f5 'N ~_~) ~~ WfT ] ]^Lg1W'1N0 1 ^lIGN1 /[i ^ ] YrELU}iLN ^ ] ^ iWp WAY ^ ] ^ OV [q TAKING ANO fASSIN0 [ F 5 ON lJ ^ 1 ^ $NfAY IJ 1 ^lit 1^fUG E ^~IG~iT5 OIi13 ^ + ^IlA3rrINU N SBI/ ~'yy V ^ ] ^ NOADS ~ ] ^ MAKIND NIGHT TMIIN I II ^ 1 ^ GE I C ~ ~M~ IIW J I S^ YICIFYI E ^iIKIITIIGIEIf ^ S ^TIAUrIrrG AUNT II 1 MAKING Lf fT fUNN ^ E ^ ALLlY ^ E ^fYl ll IY 1 ^LICEIIV ^ 1 ^NN Mfn Al ^ 1 MAKING U~TUHN S U W~YC CIIK 0 0 1 W f C/IYfI ^ I ^U/C !C r ^ E 0 IIUWIHG ALM 11 ^ ^ f 1 0 lWAY 1 Z r Ii1rSL ~ ~(~, ,vll I OS f SIICI/r ^ ^ ^ T SSOfIf0 !011 igAFfIC E~ 5y~xx~E~~. ,ry~Fq ~,sl[~~~p~ .'XJ^IK 1[IT {~,. r... ~.. ;I,J%ri""4'Y.~:~'C'~,, ..-. .- ~., ~. ,. aWIPoW.PMI^ ... fIDHfU AT SIGNAL ' xsG . , lqp , yNA]xwlae.ew..- ~~~ _ t ~Ir ~~~ A ~ U ' -~ c ~ p~.,`>ry~'.~ + ~ . - . ~. ,.y _-.IY~SPa~A.._ r.:rA' ....ia~ . ~ ..~;~ -._ ..n:,._. "•r` *~...sJ< _..,:;W.e,.~..: __.....~.L~,.......,,..: ,..(. ~.L..'''~fisFS~l~y.~_ ~ ,~ n k,~ IUIJ .:~... I:rr~ r ' ' " ~~. , ~ L + - t .IU fUll VL-hN(.LE COLLISION REPORT NO. L ~ S ~ UAiE OF COLLISION DAy OF COL LISION ry „~', - [xn ~ - ,vn vI (^~ r NES WED C' d/ TIME Oh COLLISIOfI a SAI ) IE9 AM JO I PM r COUNTY NO. C17Y NO. _ ~ ~ ~x ^ U ~. e'. q s t A ~ ~ xL COUNTY . CITY. 70NTF. ~ f J. n{, 4.~.LC IO(~ ~ovuL SpT rqW F~ MLES.OO.. .. CITY,iOWN I:I H'L LY© OF /~C- U-(-I~OiJ. ADM~CL9 ' PREFI% .. nOUrC pI ODE V CfJ ~~!/ ~ SECTION ,_ Y on IENAMEOFSi EET,flOMOq HIGHWAY.. a~~~"ED L r _ _r O~/.v~rs ,.. IN~qTERS)E~CTwOVATH: STREET 0II ROAD ,., .., T D7/fi- /f ~ ~`/ !~r(~. PPEFI% EO MILEPOST ':. ~ , ~ !/~ gq~p t'QM~V`~ "5 A' p~ - NONINTERSEC ON~LOCATION FCO LISION rA FIP 0 GRAM OAiA H Y T' OETWEEN StREET ANO STREET ERS Iw ~5 J EL G SIHEEI Ir EP. tlnIDOE O © nxM OAOCH064NC.P LEYOSTOn DGNr ivwD LAngnHir. Irsfcl Dn' FEtr n ® O INTER NO RO INFER CLS ' O ~~ %' ~. ~ roH E(n - ~~~; .wvOLVFO '~VErnCLE V EnKLE ^vFn CtENCVCLE ~OrnERIWR rE ~0 E o.~„ ~.F, . r~~o F E=,H o o.~ oHr Dn n E LOGE USE ~ 6 ~ O C[S IN ,CK ~ ~ ~. E OWFCi9 uC 1. ., n 9V/NER~i061ECTS ~µ Mlg ADORE^u5. ~ IN ROAD I// / 1- / ~E WAY "- 0© 0 fO r~[ r 1 ~ ~ ~ ~ , • ~r L ~f Ev G // FEET F ~ y ... . 1 s : / • • .. P MORE MPN f Lx i V ~, yy ' -~ ORIYLII, LAST NAME. .,..FlRST NAME .. : MIDDLE rWO C.ns wEnE NvofveD cowsKxl aH Oq VER5LA5i NAMf,. FIHSTN E . ~ MIpOLE .._ 1\~` ~ k L BLRL[T AOPRE55 _,.-,- _ -.. „„ROUTENO ANO BO%NO,. , r0/~Ly r{3 wnE nrAN rWD E r STREET DORESS _ ~ . I .ROUTE NO AND BOY. iL ~~ 1"#: " ~ n f A ~/•2 ~. ~T ; %' CTY STATE -, .;; , ,-; ZIP COOE_ DflIVER9000UPATION..; aL rv LItY rr ~ 7ATE ;,:. __21P,CODE, DRIVESS000UPATIpN; ~- SG~'t ~(!I>-t Lt/1a- ~5'S r/ Trlnc~oL/ nEPa,LFD~I ~ ,, ,~\~~~~, ~~ , 8. ~ %~ ', ~~ • E pRWERS LICENSE NUMBER _ STATE. SE% ppTE OF BIRTH AGE P rEAn ~'R ILC~F(J/~ KS~ INS S U OnIVEg9 LICENEE NUMBER f"," STATE, SEX. ,.MTE OF 815TH AOE ~ ~__.,. PD D.r rFAn ' IA F "' VEIUCLE r0. MAK//E/J~CyHq~EV: /DOOO-AL'/~1_ MOpEL n10VADMT)... BODY STYLEIa DR.I VENICIE Y[i. ICHEV, DO E MDOEL(NOVMpAfiil...:'-SOD STYLEIZ DR.I...:: ~ " " ' ~ ' ~ LICENffSEUP~LATEN STATIE~-,;..-. AILEq PLA7Ef O.. STATE . ~ O J ZS~ W F l .:.T .I ~ EP~ i . S .... .TRAILERPLATE NO - ... _, STATE...::',: T ~~. , ~ ,e V[ IY / 1 ' ~ ~ ~ ~ HIpLElOENTIFICATION NO. ,. ,.,,:, 11085 MOOELSdNEWERI.:,. ODOMETER IMILEAOEI P VE ICLEIOENTIFICATIONNO., , 11p80M00ELSbNEWEPI.-.. OOMETER IMILEAGEI ~ ` ,FS r ~ ~ ~~~ C y33 y. , ~ HEGISTEnEDOWNEn_,.. i~FIRST~MIDOLEN'~E1,-,, ,,._, DRIVEnSUCENSE NO. , R :< nEGIStE REDOWNER .MAST-FmST~MIDpLE NAMEI ,,,. _. ,~ ;,-..ORIVEgS LICENSE NO,;,'". _ ~ ~ ~ JCl-Y1lC% L Ih Cje.TQ 7S U () ~xjJ'~(~9. / G.V~J "'v .: . _, A ' - OwN(IIS ADOHESi ,ISTRE ,CItY ANO STATE .. DATE OF BiniH OWNEnS AODnESS STREET, CRY MOSTATEI ,._,,;: .., DATE OF GIRTH MD DA rE I ' ' _ ~ A rf OY jL 77 Y ' 1S Dr -:~yu ~~ ~"' rNITD OF VEH IE DAMAGED fsr PMEp FA,r rARTS OF VEHICLE DAMAGED ". ... ~ IOHPUHVF CiE S~"i ,./r Ei~ F /. L ErD res wvEn~crE ..... , 5 A E D I _ 'L .+;;~ ~ ` LIADILITY INSURANCEINFORMATION-VEHICLE NO. T• Co VENACe H EC~cT FOP THIS ACC~ENi ON YOUfl CAR (_g'SES ^NO ; ' :- ~ , NAME MiD ApOnEB50F UABIUTY INSURMC£FCLICY HOLDER.:. NA M E O F UABIUTY wSy~nMC EpCOMPM~ ', .. r`"'" 1 L.. ADDnEss ~ arv .. srAr r a , ~"- ' Q l , ~ nn . ~ n e ,LPe~ Ce., s7Y. CGUA~'i ~!~ 7 (C.rf AtP` ~U. GG ., .% ~$Z- ! (GV'~i/ /.u~r t72. ~Gfs_ ~li. • ~ , i~a NAMEM ADd1E550F WBIUTY WSURMCE AGENT Grv arnrE .. _ FP UABNTYPOUCVNUMBEq ~,_ti~, 3L.E-r~F., z GIs ~L~_ P~~Px i~~~ ,. {~~L n~;F~/ p ~ q - .. ~ •^~%r.GJ 0~ ~ C..I 2"Z~ /y ... 1 .. _: W 7 I>TeUUnY AGE. aH01NJURY: N,EffPAnALF nLPOnriM [51 ApE 1 nA(Vl.~~ rpIAL NPME .. * e l ADDI LC. _ ____ _ GE% AODIiCSB ME%F .. ___ _ . ..- .. Q ~ ~ D _.___.___-..- ^ ODC Oxs ' ME • lar ©©n MnH Ur A[nclarr ®^ H.ME is ~ r ~, Sr IU OF JURED - MMKFIRST ONE TIIAtLMPUES PoS fATU90F NJUIiCO MMK FlgSt dLE THAT APPL E9 O MVEHIDIE 3A(Ar0 Mln ps. sr ~ IN VEH CIE p,rLlw On D„AG POTS U NO KLLED IS(v[rnil M~xw xgri f~~ ~ n KILLED xJUxrD n M tio ,ErLnF p WO xix ' I I y `Y ~YN I r 1 PAwt r ur Qec °~ I ^ Ax "o I O ,~ :. ..: ^ 5^ 8^ ^ O ^ T Q 7 ^ ~ i YL .,.IOW NOHTN VY MIIOW wCIRCIE ' pESCnIBE BELO'N WHAT I APPENED 111E FER TO bEILICL E5 0Y NOMpE ' . ~t. . : ~ r '. ,./ ~ ` I ~ : RI uAA^A w E~ I uMCe NR r aem' ~ r ~ °1 \`S ,~~.1.. `/~ ......._ ~~~p~ ~~~ _ .GA.LDL son \~''~LOUJ~.). .V1~~J-CSL \vrc-r~[~tK..~ urnFl Gn .Pei°on Y ~ \' rmPnfny ._ _. ! ruMIKA ,K Or uu Dw~ `~ Dvn CIgN rAV[L "' :. . ,. R .~ ~ ~ ^ \ ~ ( ~ 7~1~r ~1,,\ J ~ --I_J ~2 f- ~~ I ~ernl. o rKnw„ ) ~..~ ~\/ ~ . r` - I ~ V (~ ~ ~ , ~ _ C . Ir_. ._ _. r ..... I y .. -. _. - .. r D~4 . , i b ~ ~y _ UrlD~1rJJJJT1t-o ~ ~ ~, ~Q~ Eti0 v _ - r..... r --- eIM,IDAI. ~ ~- ~. 3~. - ----~- } j-' ~~ - wu r~r I VEIIICLE£iPOSITIONS BEFORE COLLISION wvcm TED pr ' ~<le r[r ,rurDwO UDAµvP nPLO VErK[L OCCIPtD , I Onrlli \(HLIy N 9 E W ON SInCET On 14OHWAY IIAME OR NO. r.rK.n •A tS AO [, b ^PAfnpL ^L DL ^ ^ ^ ^ ^ ^ Nrf ^ F _ ~. ^ ^ ^ ^ uo"° '~ rnoM DIRECTION To M1 I DIRECTION I I I LEL w.su VHq r^blN:wu% a^wu%wAr )^w~.~uii IIL A^~ ,^'TA' n OtHEn rvr x ,~ A.,~ V r~ n v J I ~ `~ 1~ Y /( .uSA' 1 Ehl 1 _ v L.- Iw]A'YE~RACE v,(AinFR UONTCONgT10N8 fnArFC CdvtIIOL 1V I~t OI WOAD DII VFn/VEHtCIC ACTIONS 1. rr. 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Oj ~ i ' ~ N : ~.N ' n ~ n air o ~ ~ .u v ~ N M ~D ( ~ d 1 r ~mC ~ 01 Q ~ E,~~ ; ~ - 1 I V ~ - _ ` ~ b . y~~~~fi1,^-,~ n u ~r `'~ E '~ lh~~~ . ~ ; ~ a ~. ~ ~ ~ ~i~r~5 l , S ]V ~~4 ' a; JJ`~ F 1 ~ ,F { ~ i~ak y rv~ ~~ ~ r ~ ti r ? ` %%555~VVVVii R +~ mki~,~~Ci 9ti ,-, ~ '~ ~ r .. , .. , ~ "' s r , K a; ~~ ~/ k ~i~ / ~ia% ~ --~-- •••••• • •_ •••••••••••~• ~~• ••~~ _ _.. ropcE [aMAA MNUmpFR PRI VAiE WAY DAZ E Ofcau +~ ~ ' A N rmE wr •pr IA5 wlp twvef iv IVSF ]vro nOURI Y 7~ 80I couNrr OOVNIY NO. ~FFG1Q$ON / CIrY NO. IfrtVA ^uae ~N ~f ~N CIYOR TOWN OOf SrR[Ft OR nGNWAY CL] ROU +rRF I rEO D A4lf] ^] ~w QOf ..~.~ 3 ON ON ~ ~~ INrfR][CrING VAIN ]i4fflOg INIfR]fCr ON pRfflx EO. MRF PO]t ]] p BE1Wf(N rRffr .{ ]IP[EI ~~~~ J DISrwNCF6DRf MI RO REIERE f. ]]]IPFFIOR NEAVF]rmel RUSI ACCIOENr My plwGaAM ru,rA • 1 I if[r fl"l~l fl nr _ MILEAGE }~ • -0 ~~+ ~ ~ ~ ~ ~7 ~., Y. ~i& ` ~.'~., h i F i~rr~3k r .~p~ ~tXr. - ~~. ~ ~~ ~~ r1 . •~ ' J A !Y g ~ 4^' 4 ~r• fY~l ~w~i i 4 ~ . 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HvtxllY, wxRa RD IXFEtOR WADOR FSIlR(tKE as IorAlNO. o%uf0_rvo lwuRlD 1 Osnliwa ^NI .p IMFR as rA'ossstxfFroR WAn ° avlN nfs © ^PWIEVrrDAnvEGF OrvIr ^vFSUflfO Ovi°icilN mus ,-'`r 3 SQ3lo0 gYq Oe1FCI Sr4UC%INAMf OF WlFCI51RUCr AN00WNFR's iNMN fsI DNAAGf sPfcIN CODING Ibe ~`yYf~ f ~'n UNIT NO.1 UNITNO.4 VEHICLE ^PEDESTRIAN ^PEDALCYCL15T a" I} }~~~• pRN[R'e NAMf: IASt NR r MIDOEf DRWER eNAMf IASI I OlE •,~ '' ~_ V AfV I cA 02N I`'.RE~IHra.I N M SIR[fI ADDRESS IRffI ADORfSs • ~ ~ 1 Abc.~ P.O. ANMA .5~. n aAtf nvcooF vnoNf NO. D n srgrf zlPCODE ~S,y z~.- /ill ~' - v .1 ~ ~ t,a.~ 98376 65-334`! R ~ /o /+o l~9. 9v3e/ ORrvIRe DCENYN stAtf f IRIN I Iv LICENSE NO, tAlf ef% DAIf CEB REN ~m ~ '~ ~b93ED90 C`'A. 1- 1~ A i,r 6o V R 3 I I CA. M /O D„ iz j OCCWAIM>N MNAMFefAgrvF NO Frfs IGNt NEIGNI E OCCUPATION fIRMMNAFe PHONE NO fYFe vhlWlI HEIGNi pCHECK (/J MnorfFOF ANOmfaN ^CHECK L~) yfNCFf ASANfMROYFFOiAr~NNRIN wrA 7><Y"~ ~ o CODES -' 7." 5 I /~ e "'O,p°<' -- CODES ~' ° cliff 4 iii;,W' s IR n u I n i ~ Irv W ES /H IC.a WC:'~Jn(•' sR (~4.:l1C LI'I i.r. IN cI rv FIn rcII s"fI"'°ie".: '°"` ^ A~AA.At ^ u ' ^ cSvily ^ "~2~1"uiav sfiN°: _ ^ N"rDIAN<F ^ ur" ^ cS:Ir ^ li Kii 8•CRA'N,r ~ ~~'' V[N YLAR ANr[ IDGUGf.CN[v l ll1UAV1~NOVAI Sivlf Ia DR~CONV l H Y ( v l MDD[L IDA41 NOVAI YlE Ia DR v l °~' ~ B~ ~emal,l+ 4 Df E 7 Bu;c. k SK l,AF,.,k Z~r >a ~' Pl.rrf StArf NIte RAR NO SFAIF H caoR II A NO. Alf ~ BIuE Ea 667 oH. ~ t3/uE 52rHps (`A. ao VINM:IE IOEMRIGFK%r NO. L vENICIf ID[NI I~.AI ff ~sgAr I I ~ ~ MIDaE t . RFWSRR[OOWI4R~ wr IIReI Dq[ PIgNf NO O I I Il4ED [4. tKl iASt ENO. MI ~, D~l~ ~ c/; FF W A 5,4~& s al~z •{ a AUORISSOOWMIR N f F, 5Y I ` Id cSff•YE /~ ,G'f1'! E I .:~ rv.MffADwFSSaINwRArxE CO. oR AGENT ~~ . ~ JrTA ~ i-NKrf ~ iOE.;•95h•~A.:~, LEA`! R LIST T ~ " P Lo ~l~lpz ~, ~~~ a ... a~ y~L~{ DMAIGED ARIA _Ax,rw x,x DANAG[DANU ~ 'k'-' IFOI !] ~t•p"v'I CNA-D C'IA4Gf nhic~~xc. - ~ DAMAGE vI SIN RIMA NIO °WAY ^R[AUEN[U t]I OAMAG! Ididti5i:• ] ~ ^ AW ^ f~[Op~ IS e'Eiri~ ~z l f.~.G'..~' nwev°R. .~IS'7 E,:,~:]' ^,`.°w"~r°nr. ' '' DIAGRAM Of COLLISION: v~v N DESCRIPTION OF COLLISION: Lln[swn[MENru stRFl iMnssARrl I I 77 'I uRfFU "~[P° Itdn1C'7' Veh'f` 1 wAS NIE1~3 o/+r• F3R~ IcJ wl.~~`S Z..:L.. ' ~,E. 7%A ~+{.._-."," M E,[ ._..,.. ~l~cA~ G~~ OF .~~A+ SrL~ A'1 ~A2Ra~s<• t. 13•~~ A -SI~+iE%AAa P~ ~f ~. Je1.~~ I sp~,I_C. u G l.'~ '~c „ r, 1 f - ~ 70' Sesc Ltf=.,- 8.' ~ I t,a....l~ _ ~a !~ DoT r_-roy ~~_ I.><:~c.1 its°~.°1,4c\` ;I~, P.o.1 <;:r~•~,~) x n _ 7p~1..~_~ ~pV I~ r~')11:1-f ~4 Eel ~ V ~~'F+'1J l,, ..f L. ~, ~~~ b I l ' ~ z /oy\ c KQ.t~ dl l 1~C, Slrti4.o S(.c SA...) 'L C '_:F~~ 'k P tlo,s~ ~" ~ i ~ -~ 1 . T ..RnJ '~ 11 ~a~~t~~ A~(A,.y'L - b143.~•~AtI.rL 7-la'.., y.tll.t e..,`u't1, f r <\'_'`' 1 1'sv; 1.:4 - 'JL`E `L~L%k~ ~~i1,V., 1 J 11F.I Ulq (til~4fr I ;I ^I 1 L NAME, ADDRESS INJ RTES OF PERSONS INVOLVED 'CODES 1 - 2 7 4 5 6 OCCUPANTS /WITNESSES ~°u s`"nl AVrau slxn - c•ADDIIawNAANSI u% Act tAtu: "., RI StR Ina " nAMe ^C . pf .\R- •.vF H: T- ~ O ~, `." : " r..: / ~: Y454 L "~ Attwns 5.i ~ nT dC• .lure or E~.!C.E ~ IN r OAEAe O:w' O^.'»I.ON+ ~w,lA G91 t ~ ' f ~ "A"E l .tn Dt:f 'f ro"' L- a ~, r dIE' r y n ADD.ESSKF jyL ~/ luu or 4rnovlo r4oM • w •: N,M ,,, .. ol- OAMe ^"G'O"».,LO:I .8'lL.,. ' ~ { ~ I 1 Amrs NN~~a~A. OAMe O"."'O~,»,I_OH~ 0~~;.•, GF 4•,j, ~~ -~ ~ vlvf]IA..rIAA . (Ar Alr]NA`W\ •aANr e/U%AU A(ANCF ~,~ Ir„•AAICMO 1 NO DAI prl WVl NvrWID eY DAII I rr ~ { R X Nt FJ uY ~+ n ~ `O ~ ~~.~~u<rs am w] ~~'•-t'Sl ~ ~"•f• L .. l :1'.r ~'. (~-•~ r 1 i1F .3"r H i r q S io-... . .ti 'rl k6wlw+M+ry' ,j - .I 1; ,)~ I i l I _ rY f'ss q ~t n 1' ' h.. ~ Y`y'}~ ., a ~. b,?'~~L .e I Ir 1'1 1 '-~}~ I["~ 1L ~' t ~rt+~ ~ T } tf~~A a e ~ ~:z r 1 ~~L l `+ } I=~' Y [ ~ t 1 a _ ~ ~-" . - .. Y' ~~ ~ . A L ~y 3 PPP~~nn~~a ' ~;rt. ! 'j. ~. 1a ~,. ~ :~'° ~"~~. a• +vRE y. ~,~., / ~'~~yJ ~~ POLICE TRAFFIC COLLISION REPORT ~TRAFfICWAY falcz[onvtaNrrvuMefR I PRIVATE WAY P _.DMf fcou u^ .II .a lsorv su; ~q. lu, w,n I~utf 1., yl x HmF fDSf ].DO HOURI counrv wurvlr NO. // fI nlr NO. REroA QD auau QN QF QN CHYOR TOWN AMf BNO Of StxFFIORIRGHwwv Av fs ~s ^w ~of~ ON ,tQ Cla I ROUIFONSIR -3 SG1360 Cfl N S if SECIING WITH: SIR R NOrv INIERS[CIION L BEMF[N SfRf[I a SIRFFI NREfI% f MRF ROSI ~J ~. ~/Z / IANCFa I 11 EEREN CPOSS SIRfEIOR N[PRF5I MI:FIOSI MNFS 5 iF[I Q Of ACCIDENT MILEAGE CODE RAMP DIAGRNA MIA OglISM)N INVgV[0: Vfx lr IOIAt NO NO ROIFU~NO INIUNFO~ ^SPIWG[ ^H16XUN v.llsH ruvonDlH W IN A.Rp IfR CLa NfNSFCIN SRfF10R ROA00R IOFFR[NCS CRC655EY[FIOR NOM - Ea aR Vfn clfs Q RRORfRrr Damncf oNlr O aEiu ^viO1aE ~f7^i~~ OBJECT 514UC%ENAMf OF OBIFCT SINUCN ANDOwrvFRS Nano f51 OAMAGf SRfCINCOWNG USE ~Q7a~ i .~FF• / 8 O6 UNIT NO. 1 ~ UNIT N0.7 [] VEHICLE ^ PEDESTRIAN (] PEDALCYCLIST S HRI MIDDI DRNfR'$NAMfL U61 ~DUIS UNrv[v'SNNnf U131 43T~~{1MI hE~ SIR[FI AUURE O J~ - ~ 2 r sort nrcoof orvF NO D [FI ADDRESS I r sulE IRCOD F R / . 53/3 O ~~ R SUtff N p !5 D L O Sl A Af O D R z .o I ~ IV lCFNSFNO. SIAIE SEA DAifIXBIRIn R,x 0 OCCURAlION I` NRMI 6Rlgnf rv0 EYES wflGHI HIGnI E OCCURAIION MNN.IF6 RHONE NO. [tt5 wFIGHI MFIGH} o~e Lm. Bue! SG Gf .. GRA R R IY Q CHECK (f~ vEH Cif AS aN rMnor EOrANOIHfv'~ ^CHECK (~) sax FMgOVff O.ANO1nfNAl A CODES - ~: 7 a ..• ~ °s 5 I Ixw a r^',°„"„`~ " ~ u< CODES - ~ ~ ~ .si a i; 5 Ix ~. a i`ierK`cu ~ F> Z ° ^.^I"""~ ^ c ^ r~:il f~in° Q Q : ^ i . Q c ^ i .'rvv Q A•" Q c°' Q <" ~ ~ F~ ? MMfEDODGfdHIVI YFI19 7 G//t V tllDgx ENCNAI o vlF I1 DR. CONV.) 51 2 o R E H MM 1 n fAR HfV,I mOD[L IDAfII NOVAI NFI 0 v.l ]B G . Q f SF RIAI[ rv 2GID l57 SrAI( It x AI N WA -- SIAM •_ I v CIXOx N t fH ~ a~ a A ENO. Iwlf ~ V[MN;IF IDfMBKwIgN NO. s .N:4 y 13 i vfHltlf lDf rvlli I ISM1REOONMla: WI IIR51 MIDOII REN)NF ND. O xfGIS1ExFDOWNFR Nal IIRSI MIDgf NF NO. AODaE55 O`CIV~l4 N A (R NFR (SI I E NAMIaAODRIss OE InISURAIKf CO. OR AGf NI NO ,P C " R II V f A f MMAGf ARU ~ ' A 5' , ;. nuNH.f. DAMACID AREA I . Oii a O~Ol a~'u furt GIN/ nwa l51. 0/J.aAG[ CHARGE ~ N ((~ ORI IN ~RF NFD (HANC.f ^vlMNNIO ~ lurvtl HH N l I. UAMAGI Sn I n O~a ~ R f s ~i7 ~ iowlo AWAY ~ ID..aD : OR ll ' ~) B la DIAGRAM O _ F COLLISION: iwll~1lE wcESiurl f~"'v:lvROw IH B I_. R ~"" DESCRIPTION Of COLlI510N: IUSESw%fMININ SIRIIn Nlclsswxrl ~ B M •E , ~ ~~ d "Q yooY 04.v/~f0' on1 iD.P~b000/ ,~ .SN.tff /vOR7H. 'I d- G ~ ~ ~ c:Fr , OCf.GZGUNy o>v R ti~ 9h I) _.. a ® afitl Gr uNd pA7 CiGrtR~C~ ~Al~- GO r Ou 7 » ~. Loof`G'b w Gaye. rtiwd ?'/!~ ,Ji?ou~ UFO . Rnaaa Qn~ Rd b ~ -- i n NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED r CODES 1 - 2 9 4 S O • OCCUPANTS/WITNESSES ic"u,R Uio"r1,o .NIr~.Aea~ +ii slx Au um: '„Y;" " T N lslR Exa , .AMf,S-eat~~~ •~NOU1 SID'" 3 7 ~!6 9 65 A DDnu ~ SO ~ uw of ~ rNf ~.. ^ AM e O :5'It Q »•„. O.^I ^ " ~:1:,,. " HAoAr2 A'"' AA iN ~/ ri 37 oZ.~O~I /- , ~)J / :IWIDf '• RIMOVIUIRGM QAN ^~AI^~n . a+i;r ^: Y p ~p . nnlaa _. x,~~°' u~Hl~. n,ma n~ Ia ~ . ^~ ^ " H hvlal ..c lrfanf..,w -' Ana D" BID .a rA:r t. ~I A IDnRAIOxD 3G IuNIArvw1 .ZO/!/ D Mnp Wrwl AnRDVFDer D%n r~ ~"": ~' " ..~ ~. ~fi` & rl L ~~„ «r ,, 1 mwsb4ex„ W ~ ~~. ''.1G'iar~ _....r} a :~c ~ ...vs? ~~~" ad.~ < _ ~aax e~cseam ~ ;° .. ~ 4f~-r.^•eH'' '{'"~~~j~"~Y~H`~''~lliirs~~`~~~j~~'~yi~~la~t ' ti ar ~',-.r r 1~ ~ ':~~1~' F e.f ~+ 1 1 ~ , . ~,~' ~. i . ~ ,~ k, ~"~~. _ ,~_.' ,~ ~ .. ..~ a... , ... _ ~ ... , ~ 7f~_ ..... ~ _ ~ 1. ~ ~ ~J . 4 A ~ • ! {~~eefsfl ~ & • "d: ~•~yjj 1 rerxi - nw.>YL~~~ ~~,,IFa~ •~, i ~ $ ~ ~ I r I • !1„1S N '`. ~ a a ~ ; ~' l . rp: (' ; i} i w r~ ' ~ . z ~, ~~ F A~ ~ ~~ .a.. k'3u?WTMU ~f ~ r ',' ~~ -' 1 ~-' f ''4T. I ~ it 11 l..J ~~~I A. 41 1 Yl 11'yl l.. {}r';i~+ i rl~ r X'! f. .~.,..~.. r. I .,.~r- I .I -, 11036 IU~~ y~y~ I c i-4y, I~ I 7- VS ~ ./'7.1 I/ '7 O `~ d ~ tl I 'IN~•'1~.~Jy rq !{NL Y 11,sL tt It.. ~~'f lr inn "~r'<~1. ~:Y1 7., I I / ' ~' ' ', ~ F~ F=en, ,:a ~ ~: ~.. a t~4t 1;' .'.,, ~ ~ 1 ~ , ~~i ~~, ~- ~ ~ " ~;~ r , 1 t - + ; ~ ; I~. I1 ( r 7~S i ~ ( I y ' ~ r~, ;~ ~! ~ ~,I ~--_ _ .~ ., _ ..-. .--- r .r .. ,., - ~~~~ POLICE TRAFFIC COLLYS=ION REPORT ~TRAFFI[Wq~, roucf mawwr bfv 2 l I ~ PRIVATE WAY o•ta<o.[ 4+ couwr . cour+q NO cnr rw r 1B C ~ 1 xa ao NOUVI ""°I o-'I $s w.." .4.• " ~ i v 3 0 tSE;F FF,25 0 ~ . ^ nwµ //// u D 4t R e,GWN ~N f ~ r < O rylR[tIOR wGnw4v MnES Os ^w o' I-~ADt-L C, ON ~OC3RjIN5 ~• ETCI . f0Y M7 .J94o?D StCN N - as I tvXCNrvGVnIn.BI4R'OeW4U ~ I~/, C n ~f••.yl)L(-I~ '\D BF,WIEN RXCI~- ylPfflN ~~ yiu(Ft RR[N% O MBlR]yl a, ~o { IO 1 D 514N[16pvf t t INRI NCI C4Oy551Rll1 OR N1441yIMlF ROyr B rMRy ' w ACCIDENT •mR G W14 ~" SOO ,EI, of Q, 3 YLACt-EK IZD MI EAO[E COrtyOrv rvvOlvlD ytvE4 lr ~O141 NO 1'O.R(0 ~ NQ rN(Ue[0 ~ ^B41r4G1 ^$1r•t u aM~ vtn ClFS (® ~e4pRely D4m4GFOMV ^ ~~ ~vt,~i( OB ( le E i IN N y1R[f104404O aA k[iF4[NCt ~.'... IMERCIS CROSS iP[Ei OR 8040 Z7O as ~__ - 9 I C S «vIrv4M O CIB,[Ci SIRUCIt ANDOwNte SN4Mt1 Fyl DAmaGI ..~~" SRCI•I CODING USF `/ t0 s -UNIT NO. 1 UervlR~s rv4Mt w,i NR.sI MrDmt UNIT NO. Z VEHICLE PEDESTRIAN n yN ~ 4 O PEDALCYCUST 4MB. DI 19 a" ~ T! WILLIA L.• o-ARTElZ BARB(~0 Z.~ L4[U DD4O5 231 CZoBt~(ws Rig, Luft14Dp4E55 185 GiBas ~.~ RD• sl•n z~RCOpt ovt rvo No RD A D ~JA ~~~ 3~5-So7 O R c r. errom No C,HIh1ACUty~ uJA• gg3E~s ~3Z-414 12 2 pRrvl4s ueeNSt NO MART IVJ L.,$c{• 1(E, s14n WA w M•4t r.. M os o5 I~ 4 I D vt4 slurvst NO S~gO(D AftTEg 1 s14n WA sE. ~ D41tw nRln a. Rw .. ~o /~-Io OQ "~ n ~ «GVR•,IOr, •MEnRnGriINO Ens wECm wcnv RE,-rr BL.J i~ Sod E R r ~ «cuv4lroN Mrv,MEBR nDrvt NG vNirvl . --- (3L Iz`3 So$ "' CHECK (.•I G "s^` ^•r, nr 4N~1~ OD S ' ^ CHECK (/1 ~v nI r an°NOi~rti1A1 ~ cl r t 7 s ~ N E - e w .- v CODES ~ r a .. / sl / c(^' / N aR Z rv uRlrs N ; p L, . ~ 4,~~r.N., p ...,,.~I. ^ r ^ ;p.rre o ~ ~'I P: IDOUGFC~W r4 4 ~ r M M u~ ier o. ^ ~. ~.v ^ ~.~' ^ z,r.rt~ ^ ~~.°s' D ~ y „ ' ID ' v IgU4 r ~~ FoR.D ~Ir.~To y--pR~. E n4 MM I ntvr pEl Rl rvUVq , IaDR lg7o To o CoRoN. y-p ° n L r ~ oR rnrvv Ru t N s,4n •BI4 non NO s,411 r H cao4 N 4 ~ 4 t rvo 4n ~ ~ . 8zN 'fGS~•o7 wA. - - I C Taw g~ ~81~ Wa - - r, InICItrpINUNC•LONNO 9 L N DIrvUNC4u RAT .~, ~ I L Y. ~ I 5 ~ 3 S - - - - - - $ I ~ 5 lD 5 1-f• - - - - - - - • vtclsnvtpow,4ty u.v nvsl Mlpou f11AIZTlN WIL.t_!AM L~ N.o.n NO 365-So7$ W I IvwowNty t4s1 I41 MrDwl RCAQ7E,4 13AR s0 ,Vy n NI No 732-/}ISs u 2 •DDeuso owvle 5>,ME N E is rowN4 45arv~~. a•povusd ~NSCe4NClco oa •GU41 N I, ~ 4N "RTti1- ';Z S7A7~RM - PIT• - BALUtR113 R f~ON E~ ~a a N,. r rx. ~c ~ , ~ ° uM. etDl ve4 r -~o~.'.°.~y .o.., nl D•M.ct ~ w~'n, wIM4INrD a•ea U rN vIM4iNm ^:w R R' ~o ~.7f~i tsi D4M4ca , g ,D ' s ~ ~a _°-~' SI o0 Br O W n1 6p:°.:'9 tR 4 , O.°,:'9 e. sluDO ^ D eo_n. "'111""" - DIAGRAM OF COll15lON Est s4 a c•n NO4ur yNlu~ >ni 111r NICIyy4Rr~ I "y',~O 3"~ RO[iKINS RD• ~l)W ~ DFSCRIP110N OF COll1510N, Ivst wvRll MtN,•I SnrE,n Nlctss.v., ~'EI•IICLE ~I 1~1u` £i157(SC~.N'D bN fL-AUrLEK l~v ,s _ ~\ ) 54oL.~t-•D Tc r11AKE. A 121EN7 TUMi (+N I~GKIS WS ~~~- - - -'-- ~- -- t fZD ~ AND wn~ STK~GK (3y VE,NILL~'~"2. y \ ~ \ ~ I --- - A'F`fb.Mp7WC 7U /%AKC. A +-•E.F'( NAND full-~ 'U \ ( ~ orJTo fc.AGcfc /tD. VE,NICr.~ '~-2 wns NokrH- ~ _„ - ` IT ~ G~ TNT 0 # / IU - ~ ~ a ~ 'v )I I COfLN>:.2 Y(R V£NIGLE, I iJG l~. ~ ~ ~. ( ~CGE'S D s ~ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES l - 2 3 < 5 6 OCCUPANTSiWITNE55E5 "y„pn^,!°O^,`4yNi cru !; : sn •q r„s '" REaR lua, '"' o iJ ~ rU.. , MRIBS RI~t ,<Ir4„. ,. ~, o,1•r o r • ^» o :'c,,. A / .- . MVI55 e1M HI WIrvIU rRpv OI.MB ^~i '~ri • Qw ^i~ . Ctvr54 .,fir ,•r~f ` n.o: ^cv .r xre tlN „IDSr.rwr. n„ tC lM~nti a [T •MB [~n r[Iw r0vi I~i nrl R nD uma4,n X41 r p•u £ h. R, t .~ ~_ ,~ : ~ ~ ~ 1 i~'~' ~'. w Y'. ~~ ~. I~ s ~. i ~' iiA,J ,_ A r, t Bap ~~ nw'i ~"~•~"y ~ "' t+ 4{ , ~ _. t ' '.. f' ~ ,__ WSPI%I4tV. I.mI STATE OF WAS fNGTON ate. / Di ~ ® ~ ~ ~ No. ~ •, / TRAFF A POLICE TRAFFIC COLL NREPORT aK[ 4QNWAYA PRIVATE W V COUNTY ~ DA i IXli DAV U ~U ry lY CItt NO. ~ A / , IU Fj.DOHWR~ yp ~+,f. rv, L„ Rw NI, .ID ~ '• 1. SJ ~FFF~c or/ / / S / B. Vi / / ° RAl _ I r p rN °L pN C1v Oa tOWN 0O151a([r O4 MGNWAV ARlfS 05 ^W ^ai ON oe,k Jar ~ G5o-Ar 65 ROf1tF OR G19o ~, ,NiFREFR NG N'1iN: StatF104 ROAD ©1. /JI pUS V C NON iN1FRNClION BFiMFN S1RfFt 6 SivFFI R4t1L{ F MYE qx'i p ~ ~/ IANCF 6DiRt i RfiFa NCf. CR05551RFF104 NEARk51 MiIFW DTs ACCIDENT MA 1 Ml[5 N 5 f W E Or iE CP DE ~ COl40gN MVOI StvfRHV: 16 iorul NO No.. ufD_SZNO. NIU Ed Osoni.cE ^" 6VfH CIFS © aROfFRiv DAMAGE GNIV ~~/ ^ pI5UL1fD ^v(~iCl i'wDtya ~-~ ~ iNrtR ns° a maslcfcio4 rtoAD V '~~~' D ~~ OBxCis1RUC91N iOBlECl StRUCa ANDOWN[PS NAM[I Est DAMAG[ a SRCt4 WDNlfi lbf _ _ .. UNIT NO. 1 UNIT NO. Z C VEHICLE Q PEDE57RIAN ^ PEDALCYCLIST ~' _ 3~ Ovrvfv'S NAMf: U15r r N4sr Mi tF DarvFR'sNMAf U\sr Nv i t n ~S Wf1LARp C N71Ni ErhM Da+S Hr!?o ~~.. RA Mar/ s1Rffl ADDness on C FY?sA' 1~R. D 1 fr ADDmss ~~ , //t Jo rr/G A w4 Otv S1Alf ZIa CODE RNONf NO. PaQ'~ v/~t, w wA _365 -`/ 6 R Y SIAIF CODt F <r.c L FrT A G 9670 %93•SS 9/ DRrvf+SUCtNSf NO. ~ly.;fa3 S1AlF w4 t. F Da t0~.0 atN.+ `~ z'~. 's/ I `/ E vE sl CtNSf NO. Wo S 1 - OCC aANON aNONF NO stwtE C'b SE% OAIfMBIR N ~ to Xz LYES qNl HFgN ! B ~ OCCWA110N MNAMf6MONF NO [v[5 WFgNI NGHI E« /65 ~'~ R U MNAME6 . i B r'll C CHECK (.~ vita AUOINta A, ^ CHECK (.~ vtH Of AS AN fMafirtt aANOtH[o ` ` ~ v CODES ~ ~ ~ uii' "' Q 5 f e ,"',° •~ CODES - ~ D ~ ss 5 r. 6 "i° -Sr -7 ~ w4s o //c T/aNE~ ~ w".„aD,, p .RB.,.,Kf ^ M6lf ^ t8.... ^ ~ O a.6,. ro n O .NNAA"<[ ° RD u ° O ~b.R+ ^ ~ ^ os'N,. KD UR MA5[ IDODGf CNLV 1 n Dl, DAPYNOVAI t >D4 CONV 1 5Y1 laR 1 N v 1 NODFf IDAaI NOVPI I 1 Pq o 7$ Toya? ~ w C.c R E Tn• ~. S J? S Pv ~ 6 GR lu"sf afA t N ,A, AHaN An ND v.n s H vt~ caoa l A NT TSI'ov~J 6NF I9 'W4 ~ rFC~ k gG63 Cq NNKII iDEMiEKA1KWEq T o / o L vtHKU li I ~ , ~' T 1 K 6 S F o! ~ o 0 is [ WNl4: 1A51 EI+11 M t t O 'S MOISi1MDOW*x4 USl NR51 MiDDI! SAMC A S A V- RNON[NO yy S AMC S A I3GVy= 1i ~• ADwnssaoW.+tR N NER l . E NArfaAUO+essalNw+ANCe eo wAUw R 4R~Ri vT ~ ~- B4 •Z bWAGtD AREA ' ' ~ " D ~ ,~AVAGf M[A • v t 1 . b . iN CNAPDG N DAwAae tsr c + CHAFGi " 4tASU"m m,DAMACt ~a ^D w ~ Aw^ . tM.~NfD [] a 16ioiro A r .r ,oe lowm S~OoO 10 .•IDBY Y er Jc CVO 7t+s~%iv ~ o L ~ ~'_-. DIAGRAM OF COll151 N: "' ' av Aluaow'" (~L4L~ ~~ "Q-Y DESCRIPTION Of COLLISION: IVStBW%fMfNiM SNfFID N[eessA+Yl VEr~r //n. / 'N{.".r,ToPc.p r Sr6^'-4u~vr. a O T~RN~ AwaiJ'•rNG On<aMErNG ~'RAFFic .Et~ ? VENT !>/a .2 wnS gxSn , N• II ov/+O ~ 23 T , 7 D7~ ,~ ~, ~ F+,,a.cDTn 5Fc •('y/c vrGI+AS~-. u FNi ~o ~ STR~cr, No / FRor4~ TNc ~ ~ ` ~ skr R~4!' , , 3 '~ vE'Nr r,•o 2 ToT.r,L.. Sx;o 93r Y ~, ~ , Op' eti ', ~ ~ ~' ~ a• , ` ER ADDRES581NJURIES O O S NAME NVOLVEp~ :' `CODES 1 - Z 3 4 5 6 ss i~P N H , ' S ~ > ~ OCCUPANTS/WITNESSES ;DR,DOn,ou,;;N, ,,,f ll._~ i s Aa 1 : , n5n Excr ,. NM.f M•~ 6G..c SM/TN 4 r;D'" ~ 7 - 9y L Z F. ` u+Dnss(~s OL ASS IILYO• ~. ~•••OcDw , + S» .i 4rrT er AM e O~" O .ON ^ i:~y ~.. A[onss !, J - .r AO W ri.lwfM w .NMwto la pAMe ^'.°.' . 0.~. OI".: i0 w ~ NArIAI M N 1..~ A.MI<t•s NAw av.N. ~ uraw ,ENC. E a+ <.+D , i'~"i-~3~17 / X 4..<~.. -.. I '^y" n n yy/ D,e~ E DAn / ~~~ K'~'3'r1 O 9 ~~z e~"'~7,tia~Y N} I,~,w; ~ ~ .., .:'3~: J .eae °x c `. Y ' d ~ i ai , .i s 'r.: .~ b r 1~ ~ ~~ ~ , ~1 ';.r; , • ~, Ia " ~, ,:. ~~ f~. ^ ~eY ~~Yt ~~ o< a ~. ~~,ry ~~, a., .. ~gtaR., ', ~ r' .. .Y . ~~ POLICE TRAFFIC COLLISION REPORT iRAFF A ~ ~'\ I~ ^• \ __. ~ ,T WIKECOMKNNiN BFR ~ PRIVATE W V/ RI rtorcau A rmt coumr ys y~ ~C v„ .o. 9l «ro Iw I lusn.mfroual ^~~ o X l' ~ attNO. ^rNWA~ t F. W U F-IFFFERSO/J uyu ^N ^[ ^IN CrYORrOWN E6N0.0 SIaFEt09 WGHWAY ~o mIE3 ~3 ^W pGr D(ACK oN R INr[RYCt NG wIIH 1REf109 ROAp NCNINIFRffCi ON p3 (o gpI1EOR .sG/9o Sf n ARFDtI E .,_.(. MREpp3t ] MATS BFIW[[N SrNEFt 6 StRFft ~ 9G I DIStANCt D4l f4 I OM4atR(NCF CROSSSrvlF109 NfANf3i R I I M . M IE U ACCIDENT DNGRwM DA1A IO nt5 MIEEAGE far Cl n or R mDE OllgO'HNVO vr0 ~ _-~ NIURED ^ SgflwGF ^ IM[R wu IS H t6RUN /T~ / Cl3 fA06331Rat0R ROAO4RWp OFfRENO: I CIf S, 1~ I rlvlu ~- ~ ~ ]] m Ow9lr DAMAGE DNIY ^ R[SUttfD ^ VfNgF V ~,.ls~~~ I / %; OpxCt SIRUCx IN FE9ROSRCt SIauCa AND OWNER'S NAmfI IS. AGf SRCIN COOWGIAE M 1 E UNIT NO. 1 UNIT N0.2 {] VEHICLE ^ PEDESTRIAN ^ PEDALCVCLIST ~' 3 D9NlR'S NAmF: iIR51 miDDEf ORI fR'SNAMf: USr ~~T$T-- I t y~ ~ , SIRI^ AppuF3S Si RFFt wD0vE35 °2 GI r I ~?~-~ 5% o t3o 1 D t CUDf ONE NO Iv SiwtE E TO SEND A• 9a 38531! R Fpm WA. 48331 379.52D 12 2 DRIVER SUCf N3FN SIAI[ FF B IH ( ll NSF O "` « N iwtE OArf OfB RIH ~. CKSRC793~5 CJA M 2I ~ gAKERRlr752MT IaJA f11 0 30 ~ yy ° OCCURAtON HvMNAmF6Pox]NENO. fvFS WFGNIHFIGNI E OCCUaAIIOn NAMf6RIgNfNO. EYES WFIGHirEN]MFf. Q. ~,-~- 602 R TISl' fIRSEI~F ly0 b°- - ^ CHECK (/J D ^ CHECK (~ r r ll raAN m " A AI vE« ttt AS AN rmnortf a 'u ~ i 3 V~ NODES~+ gm c~ ID °w.°. NODES-' ~~AV 1 .° St x 1 aMk'nx` R, uv is o,M : ~ µ ^ f,. a .~ or„rR ^s ^,D,. ~~;of ^M«NA rou~r ^~a:4. ^» ^:.'H3. Cii V ~° ~ l] 1 It IDARI~NOVwI vtf IRDR~ONV.I EAR E 1 VI h'ODEl10 t-NOVA) M •ZO 1-I012~JET ~ 51 ~.-D E HS C.°A~ H R. r -D I}°'" z lu„st alAaN 9wnfa Rwtf NO stun H n o No. AE s BI.K~ YA1..855 Stwn A , Ry~~ I I LJR ~ . veNlCll IDfMINCAtroN NO L vEH CIE IDfNi rKwt f OE 55 G~At`5 CC RemsnRtoowveR usr fl sr I E RHO R NE NO O I n D tASt rlmt IDat M6 /}S DBAeE1Z W SATYIE /-~ 7~RlUER. u AolxnssvoWme9 z N wN tEwop9essamwRANeI CO ao welNt E A ~~ U•S.A. sa~~ta~to Tx• R co D u - ;', ::;,';;~; uau cruvGE ., m~,.o„„ DAWAgoAnu . - nor .• E e i /nvye~wet ~ Awnr ^REMNwD DRIVE RrmNNfD Esr. DAIAACe ~/(j~)~_~___' IORORO" D : ION AWAY ^ ly I " S /MQr t ..Y . s ^^W V IVDIw ~ n ~ fz H.w= ~~~~ f/~ ^AWyAE~ Y - DIAGRAM OF COLUSION~ lu u R vvl cAn ~IH DESCRIPTION OF COLLISION: Ius[suvnEMtNru sHta lr NtCESSARrI ~ srKNl Nicessss~~,, rov T N ~° OE ~ ` + S mnT3 OC RD ~1 - VEH I (• l.I.t.i.ED auER APPX 2 U(~TO TN6 $NI '~ ,^~ ~ w ~ ~ ~~ ~~ ~ Ir ;~) T . ..`I O Iq(.C.oW CARS TO oUEkTAKE xYJD 1155 E~ FIE ' ~ - CDUG.A LC1Rn1 O~JTO tnR'CMpT' EiCH•'RD. AS HG ~~ " ' , _ -_ / PUI.kED SgBJC OrUi C~ [FlE ~U,W,, t2pgDLJAy U~~ - - ~Il 'J - - - 2 GL~A3 ft~ LGE PRCJC65s BF !?f;SSIrJG bERIU6R ` E C!] oFUt;}1. t UID NOZ- SEE 6-{tlv) FRfURl~ SZ'A - I ~ '~ ' T Ca4h CiFlY RDT HGS UF I SRU Uu ' E P ~ \ ~ ~ - CK FJ{ 2 OIJ 1•Cl AsS ~R " ~ ~o ~ ~bRCln~ UEK 2, aT•~TD 7A~' U~TD ~ ~ ~ NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED 7 CODES - 2 3 4 5 6 D OCCUPANTS/WITNESSES 'rouv rs,'D"ai!aµir",f'rm.A„iii ~f .~ „,H,t slx IGe iArln '",„' " pES exa " _ i : roaf or + I IURI Or wS5 H Nonf ^AM! ^t. ^ v"i ^ti° W RY "" N vir. ~n « X ' IT"' ~~so '_~ usr.rcl«D t3~a RM HRS Iu R tO 1351 ]f0°„% DAna wroal 2.22ffi A D«n 2 2ar~5 ~t „t~ , ~` ~ ;'- ~' '"~ ~~~ ~,R ~ s ,;srf. ~ r f ~~~ ~ ,, -. K ~~ ~ x`W ,, ~. z ~ ~;n a ~ ~; ~"k.,.tx ~ ~~ 3 o- ~~ ~~~~ I ;, ,o ~~ Z w f i i ~,, ~,, r' j 1 1 t l i i j i i i ,.., h ...... ... _ ~' ': f •:: . ~ u „~1~,. ` MOTON VEHICLE COLLISION REPO Doug i ~ / /~ a r ' NO. ' ND /OaiOIXNWD6 E9 0"~ .TIS"P eB.1E~dSDYa LO, r N~ ~I ~ ~ &~ ~. S ^N ^, ^ W 1 TYD ,Dw» "a.ND IA ox,r O. ^w ^ ar GitlvYla [_LAWV. ON J1f/Sun DLAEJ~ a B/Qen[.Q ~. Ix Tr-o.: aET~ ~%GC.300De NINnP N ,N, TPIRDL.d. ~ E[DLQ, o0 ^ E^ PAPno"o aOSS NO MA[rosi Ox PfNNrwnO LANOWM 'xx p"E' WDATA OO .FO LJ O .,~ ^ HA[,YIADIq . f ,.LYID LRNIEYB„r10 AL ^ .... TEA ~ wB O aTP E ROAD OP EFEA E EO CR066 . .,. , ^ [ B B e r . ,, ' ^ TP[E .OR PO E3/SO ~ s ~ t ~ [ o ' OE4E51 BTfIUCK eN OWNEN OF OBJEGTB NAME ANO ADDRE38 1~PfT'NRGYIGT..4 . ecoOE VU S • • .. f uonE TwAN ..„ a!iYP-n~LAs-*rµ!s_.~_. eur~TnM!€. ._~.~:~.~r_Iss-~~ w~E ~ «~ED pnLY~n~>~Tr+AME IN Tm9 "-1"~T1RuLNG4T€_--_ ,.... ;::.:..:lALDA6E_-..._. ll d l V P ~ e. i e ~k-er t also.. EDLL[DHDP M. Iles s11AG/ ~ AIQA'. MoP E TITAN Two / ~ 3TPEET AODHE64„ _. O O N ....fl..l[TEflP,.AKDP. _M 2 rE Ox[wfnE ,~T~E7.AgpflF~¢g :~ NOUTE fjO AN490%JjO~ Se/36 sE' sa=' Sf NJ"R~w„~" ELA Po o ii3a~/ DITY,.. ~ 9TATE DP COOS PRIVEN6 OGOUPATIQN«,_ COLAS TN CITY _ ;,~ r,w 6L?Ea!' FIP CpDE DflIYFAS OCCUPATION; • /e(erzLr TSIF..d L/JG, ~;so~o Savda..~- i~;rb.-I "L. SCI. L..~ ~i8iro Msa ND.H._ rte;. ' Dfl1VER 6 LICENSE NO BTATE SEX ..DATE OF. DIflTry, .AGF~ DflIYER6.LICENS ND '-Yi:f:.. .STATE6EX 'DATE OF pIgTN..AOE, OELw1PN363CM IA)u Z ~ o BAT YP °"T ~' . . ~, WG, YLNICLE YR MA E . N ICHEV. DODDEI .MODEL (NO /I-DAflII.. BODY,6 L. ,I3„pfl, yEd11Gk6 ~'.P,• MA![E fDNEV,,pgppEl „M DEL lnp A.D.wTI ..,eooY6Trl,elx.DR,L is~s ~erw aooa a o~. etzLA, vGY. v~.r1 .LICENSE PLATE NO. STATE: .TRAILEN PLATENO ' ,,._:.FTATE .:.~.. IJCEN$E PLATE NO:: .. _i1T~aIE..._ ,.TPMLEfl PLATE,NO,",,... ,STATE".,..,. Z ~L 503 I,JG. EG W S.7Y bra. ..Y.EHIDLETpENTIFICATIDN NO._....~.:. r.,._.__.:...,,r ..:~..;;,_..,~.^..~~...::..: YEtl1G4614EMTl€JGATIQN,NG,:.~:.~: _„:_LC;: ,.a..........,. „_„_ ` 36'13'1 -.<.. HEOI~TEflED OWNELi,IIgST•iIN9T-LAIDDLF~NAME),;__„. Og1VER'S LICjyNSE NO_,,,;~_y,_,Q~g16LEgFiD O(VNEFI,(L(F§TfLfLgi•.L~J,DQL,P,f1AME,L •::_;.;;, DRIVEN'B LICEN~FE NO ' V /~-~ ~~e I~.kri NL'-LSD,. DELUhPN?63oM OWNER'SADDRESS,;..:.._I6TREET, CITY.AN0.8TATE1:.: '-..:_,:;. OATEDF.DIRTH_. AWNER:6JWq{ESS,,;,:.;,.19TAERT.,GIIYAtlR $74TF1,~..,:;:. .-" M gTg D y.Dlry pl.(:. . T . _ 5'93 ~ s' ^d O o T f ~ ~ 6 r , a Sf-I M. i. NJa y P RTS OF VENICE p_AMAGEO ~p ~~~!!o~ pAHTfi OF VEHICLE DAMAGED ,..; ~~: w rl ~`~r'OW ~` ..~._.....~:a. ... :. .._:.. .. _.... /T~oc1 t ~i~r~ R ron S Y6Y.73 r/O/u _~ ~ s - '_: ' LIABILITY INSURANCE INFORMATION-VEHICLE NO. i- 1 WA6 THERE AUTOMOBILE LIABILITY INSURANCE 1 : . ~ COVERAGE IN EFFCCT FOR THIS ACCIDENT ON YOUfl CAR ^ YES ~NO ~ ~ NAME AND ADDRESS OF LMBILITYINSURANGE PDLICY,NDLRER.;.r:;, oTT (-;llp:;~~1E QE.1IABIUTY.IN6UflANCE 40MPANY., _` / r ,,gyap~ G/T/ ~1C ~ f[a ~ :AN NA4E!II+D nop@E6;.pF FNp!4griN,64+.RAMSrEe!~HTrO / /yfH, G G.. S_O 61 [~...,,... .:LP - ~lrL. ,N.~P..L4T~I2MBE~y ' n a ~. a nre /~ i/` ~iit e I ~t~. .a~. •, t . !. T ,- 7S(IWUNYa ~,_ ......... ___.. ,.~. A,~O`E 2N INJU/, J '1 _ __ _ ~~~IOLE SEPNUTE P~Po T OP T Nn JV ~1 AOE I CSI ~:~~rXi AM ~ _- INAxiEO NAME .~..... : , ..... .... ~ ( ADDRESS M F~ ADDRE59 ;_6 •. NATURE ANO 11L~~• NATURE ANO ^ ^ E%TENT OF INJURIES ^ ^ ~ E%TENT OF INJURIES - ~ yT ~' OID INJURIE6 REQUIRE ~ ^ pDCTOfl S OID INJURIEB PEOUIRE DOCTORS ~ ~ E%AMINATION BY A DOCTORi NAME E%AMINATION BY A OOCTORi ~ ~ NAME ~ r ,~4 ' ~~ -;.s:.kTATN@9f.ANJURED .;.,,:. -WN!X f.VLSI ONESNAT APPLIES. ,57~T18S8F lNJUnEO_, ... tlJJRST ONE THAT MP!<IES. t '~ti", ^ ux 8LY 1 E "o W ^ A 1N:. 1 .,LC y' ' Z^HAfu„G NO KILLED Savfx[ INwp~ ,u N ^ M ND KILLED Iifvfnl IN xoPI 1 :'^Ot Hwnll[N ^ §^ s^ ~ CIT ^vLOLbTx ^ 5^ 6^ OE FA clT jTJ'~ 1 7 ^ ^ OTHEP wRNUn ~ r ~- MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED ~~ 5 O N O C lE I t~ 'DESCRIBE BEIMW~~~W~HIIA~T HAPP~NED, lgEFEfl 11-0 VEHLLO1~Ey BY NUMBE{Il ':: ,:: l~`N _.. ~rTtS T?,. .. _- r,YWTeMrrwN O ~ I (n 1 Z _ YC-YrJ~1~ u ¢CL 1_ail~_ vu~(a ~ ~ ` i \ 1 _V.rr.1?lLk_H a~~. . aww \ \ Rl -S{n [J~_a~..~'.~i,_.5{naP. ta[.~is~_ar+ fir. F~ ",a,~ /-~ . J L 4 ~~~. v~.=J~'~ `\\ L~x,c,W T n0 ~ '. J4Lt_I!H _._/_'L C_ OA~_ASOOL_C!S/ '1~, - O.L.' JGI/[ VS~'L_,.~L~T_~e•Fg •'A'J I r. - / ~I D__/'LC-~l4~tht~~l1C._1J-.t.?].4..._1!CR/G~_.:. - ~4, / '. ~ ` a~I ~ (. 1~G~.~ :GrFs~,_,/IG,~ ii[v~/pt~_ _~_.P..r '_ "i ; ~ -.f 0__J ~ ~~ P - i D - ---- - -- ;. VEHICLES POSITIONS BEFORE COLLISION L,x wv[snaAT[D Br4 ~ ~~ e A VEHICLE' N S E W ON STPEET OR HIGHWAY NAME OR NO. OMgNy ~ xARND I,ttl ofJ Flo F•' "o' Iralw ^ ^ ^ bl ccr xo no ^::ino. ^ia""r`ica ,' IO6RAl W ~ p~ O w-^~Y: Q....O~ O :Q,. OP«iu f~ oN ® 1 .. n TxMA ^ ^ ^ ^ AL .. [E ~. ;.. '~ YwBLLA,a, ;' .•. ....IRON .~ TO .'~ ', PEDESTRIAWPEDAL CYCLIST WAS USING: ,^a,pa , a^wN L^~ f^~ [^uo"I a^om ^ 1^ReA n~ PEDESTRIAWPEDAL CYCLIST CLOTHING COLOR: I^aw. •w"a^IlB AwA ' ` ,.r ^.,~. AT 'y RQ!IU BURFAC[ ..V1Ld1J~j..w.: "LIIMIT.Fi.~'1gIJIPl'L7 «~:v '. iL~.f1Q.40pT110F.:.:... ,TYPE ^F a0A ^ uiol at4 "x W ra.l :wE awl .. DAruagr ",n aaW .wa 9.,J1. w enu "A" uwiRnlY~!'.ENICSGcACTIONe ;~».. lq °~, ' ~ IT PO 1 bA l„ ,I I Wa wox InMI ~~ 1p[ ,~La [ ^DAwN ^al aaNINAL9 I] 1 ^ON[WAY QTI ^ GOIHDarflAIGHTNIEAD /^OILJO^Jwn [^NAWIIq [ ^W[IC ~J~aTOP aIDN L TWO WAY [ ^ aNOW1Aq 1 ^ L~iOnTI TOM LT ^ a ^ YI[l0 aIGN ~ [ ~ [NLRB BL[ ^ [ ^ OYERTANWO ANO IAEaINO ^ L ^ 6MOw [ ^ FOO L DARNJTN[[T ^ ^ ROAD I ^ i ^ MANINO RIGHT TURN ^ ~ ^IG OTn[q ^OARN~I,O F ^ N ^ /IAMIWO RLO ^ , ^ WTDF~PC'NAAN'I[ ^ a ^ MANINO ILFT TURN p ^ [ ^Vl`CN'/ L. ^ISPIWYI a ^~COTHLR INCITE ^ [ ^ /LAEHWO AYB[R ^ [ ^ AIILY ^ a ^ YAXIND U.NRN. ) Y CL „, / LJ IP[CrCY ^ L ^RR NIGNAL ^ L.^`TReU11N ^ E ^BLOWINO r ~ ..rlll~,~'LY YtlIFALE TY/4.,, ^ C ^ OIIKWF/AOMAN ^ 1 ^ DRIVLWAY ^ i ^ BTOPPED COq TgAFiIO r : _ y,~„ Rl'I+Ki6O1,,1 ~I,~ ^ L ^OTH[R. aPLUrr . AD,LD+Ey~ ... E EroroeD AralDNU .,~;j "`w QI^ .., _. ._ _... ^ L ^mvm[D ^ E ^ arDPP[DagDADGAV a ' ' ~'~ ~L~.,w,.:PL. ,••,••.. ^ L ^ cC°lir e:K -_ ___ ^ L ^ uNDnmm o arear ND N i q ` ^ I ^TRAIfIC LANE "" - ~ DID COIIIabN OCCURW ACONBTRUCTION Y[E ^ IT ^ ~.T[NIAIlD VOeniON Y ALY ~.... OR ROAD MMNT[NANCE ARfA1 I.ROIAq IIMLRINO wtTr[w,NAN[ Y NO ^ IL ^ IR.V IN:) T C4'µLw~ ~1. NE.T3'ta,r t~'Ga t, Ss.LI~C:.,.... ._ ^.[~o NaD Naxn h.; ti II ~ as ^ ^ WRONG WAY > ! ^ ^ LPlGIY A .i.. ^ CN[CN 1~11f YOU wCR( DMInµO A CDNYCRCIAI IPCW DlINITRW 01 A CdIMLRC1At VCIxCI[ Itl ANY VCIIICIL TN[ MINCIPAI. UEL 01 WHICH Itl INE iPANa• ,a,,~~,~ Yf111Ct[M AN f.MPIOY[L OF ANOMER IVATAfgN M fAUaIOd TII a. 41RC,IANDIR[, PROBUC[. YP[MHi. ANIMAIa OR PASRINOf R! fDR NIRLI ' .iW[},}TU11L REDN I'AMPLETINq R[ T .:_.....,_... r .... ..,.ADDREEE, ...~. wu.._::,«.......:, DATE OM,REPORT J - ....,:. INaigIRUTNNI bHl[T NO 1 WAEHINOION ETAT[ /AlgOl 7aL MAgiIN W AY, OLYMPIA, WA MMN EN[[i NO 7 TO LOCAL LAW [NFONCf Y[N7 AO[NCY WHORE O/ COPIlE 6N[ET NO. t 10 0[% Oi l IC[NBINO LNYIBIOµ OI /INANCIAL THE ACCIDLNT OCGURRLD v~ N[8POµ310H.1IY • OLYMPIA, WAa111NOTON lalOa EIIf ET NO A YOUR COPY 1 ` WBP•AR-ICI d[L ~ W, ~~ ~ i ~~v~Irv^+-yr.rKr!,rr~.:.v.:o-r;..[^. rt'a ^q°P, i~'"•q,ru"".°r 'It jn'?.r^,•• „~ r •,.py..-, _ }rl ut fT if ~ b"t:r ~ ~ ~ ~ - .._ L i~M1 17 ~.. ..,._ .. ..:. 3 ~ I '•~,~ ~ ~~a-,llf k - A~ 1Si4h 'n 1 IINIi `/ ~m . 3 k t ;,,5. {,~~ it I [ 11Y ~ IY+7'.~ Q ; ~ ,, .,~ ~~ r t 's'~.^. i r• JIHIC Vt WA F11NGT~N qc[ ~ of .I s 3 2 ' ' ~ POLICE TRAFFIC CO ~ ION REPORT ®TRAFFICWAY 4 `~ PRIVATE WAY -. ~ TI J~9 SA1y _~; IIMF COUN[Y ~ O]IMf 12 ~ 1 I ~ ' fu,. ~ IR wn. N s.. „ [usE s.DD Hose ~C~OS ~~ferso.~ _ _ _ _ .. - -..- - ~~ A. pwew . pN pF pry CI,Y 09 tOwN ft NO.Of StR[FI OR MIGHWq RWt ORSt f C yz M+[ES s pw of Ghi»+acum ON oD,[K (30,. rCf R f SfC[NG NtIH. S,Rfff 00 ROAD NON INlERS[C[ION ~ '' :./~/r1lO Y.C`e Li [ fl~~ ~ lJraver LhLL eEfwEFN S1RfE16 $teff F MRf P05f ~Q p0 6 ' 0151PNCfaOP t ry efFRfN .CeOS55tR[F, OR NfgRtSf Mllf roS, ACCIDENI Mit[5 E 5 f iFfi O[ MILEAGE w CODE DI RNA MtA ~ ~ CO[N51pNINVOIVED [vFe t.: MOH fOtgl NO ORIIIED~NO INAIR[D ^SVI~1gGF pH116 RU HIHRHR dV[HCI[5 ~ ry RO I B[R EIDRRWD RPERN~ - IMFR Cl5 QO555 ppgM O ~ Z pPROPF91Y0gM.G[ONIV ^e[SUII[D ^VfpClf OBI[Ci SteUCRINgMf OE pB1EC, StRUC[gND OWNFRSNAMlI fSi DNAAGf ~A J ,.. T~~~. SIECW COD NG IbF - . - f s UNIT NO. 1 - UNITNO. R De,v[ISwenf. Iqsr rlRS, p VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST R. ml of ~e ~ ~r .~ ~ rvle's NAME: IqS, I I IF °Z Stet!, gDDRF55 / ' + ~ SQ W~5 I N .n [FI ADDRESS F LI,rr ~~ 3 f LIP COIX InONF NO . D r ,q,[ IP ' 1`/cacl Cc ~ W V 9133 :,S j~ R ~ nfR'S UC[NS[NO q I I 4 U NSf NO, q,f Dgtlp BRt -e s 9 ig 4` ~ ` sxcwq,lul rlRy.~IAMFaPnoNE NO Ens wElwr nlcnr N V~ ^ '1J`[/'a .. T~ r i8v (oo ~ vr• E R occuPA,lory M NPMF a IHONf NO EYFS cNt LEIGH[ ' r q WN p CHECK (,~ I vrHKU. • oE.NSi**«f a: CODES ~' ] n • :i;, 5 In a "'O wc.c LrwN Hr ~ MM p CHECK I~ fASaorFFa..I"v"o,Hfcgl CODES ~ * ] ~ s ,. ~ ~ •'f :• , s..~w"' , ,~°'" n Z IN Ives L L.t~ Le ~ru ShD.IU e bN qr ~~'.,:roM p .M.,A.HR p ~ I p ~a:N. ^ r;:a ~ ^ ~~. sBlrov. p AM f ^ ~,RI ^ ~e:n ^ ~ ^ :°~,. ~ . LE ~ CnfV.) !f [DgRt.NOVgI S,rLL IR OR-COryvl 19'78 ~ F;QS~ 3R~v E r I H v.l MODEL IDAe,. VAI r I E _ . .. oe u uvu N l r s[qn N[ER ngrz rya. vqn H vH aoe Il LL~w AM RS `I W q ~ NnlClf ID[MINCq,N)N NO i~F T E86 4S efusnnoo eu -MIDDII f i InoNe NO ` V N U le N I I fR° . l)t'~ -~ 'r s W wryw. uss, NRU M~~r ' woefss a Ormlie N ER AM[ag Dy9fss ormwR.Na co. oR.sclry, R f E L fI~GY Nis Y'S OAMAGID MIq ~ ~ ti. R "I».<`o~.. cH.RU aAaw"I.".rno« gAM.cfD [h. s EsfrnwMgG~E ^ wwsr ^eErwN[° ~ ^~w~r ^R[MAwm esaoN.u ( loiono~ a1SWf ~w:°er ~ SD.N 1 ~ ^:wn ~er. S DIAGRAM OF COLLISION: lu NoKUl NOftn DESCRIPTION OF COLLISION: IDB[syneMENf.f sH[[fR rxnss.erl er.Reow ~ _ _ ERK eh:ct_Q. wcsr .., o°•K rc1- . _ r _~_ leaf - o ~ ~T •..fTrr ecTio.f/ - a -- - !x'-tj?>_f3Ha~ey_Ikt r_ .. r^cl - ~ ro v-e . -:_ '- '-' ~ - - _- _ -._._ ~..4LYbSS _L3_LeLV»r_Y~ICYs~ /'GI._-rF LsJ~G ' ,~... _. _ ~ _ ~_ i ~c.L,~='h~~_n+q d~K_.Bor!r ~-Irls(bM• .te ~eT rawL [ way r+ J~ ,y .y_ ^ __ ++.[.L - 9G~Y, _ l 1.-; .. _.~ .. ~ .~ ._... _... -. _.... - _.. _. .- fe NAME. ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES 1 - 2 7 4 5 6 CCCUPANT5/WITNESSES ~n wo~~o.Ii:"lr.~iu'u" si s[i ~e[ -uws 19m, tur . a r ii e -- lite '----°ecv- fHLr .. r. vl ~ no.rss - vt ry.tD. n ... `..-. . e e. p .M e ^ 15" ^ "' . ^ N "3wM _ .. .. __ ..... ~ . ... _. _ . Mla Now p _ ~MOS~tDl.rw p ^ ^ ^ p .Me _ . _ _..... No .._- . onus N ~ i of uu'~a e. p •Me ~ « , • pNJ p :° X '•'•' u. ~..• a Los c toI aD D•na Nroa n°n. D f, i L ~. L:~1~~RV '~~t f 1~ i1~AW17~ ' 1' 11 9'M~ .. ~, nN . `~ ~~ a ~ _ {/' } C , ~ ~ ~' r k' _ t a! i '~ry t'~ I ` '~~f7~ POLICE TRAFFIC COLC`!'t90N REPORT Eru. ~RAFFkWAQ Poucf INi OER PRIVATE WAV DAIf Oi <O l ~ lt N pull s N O` ,r rv W vOV wU i.ivs N s,i IUSf tCappNOVR) L~ COUNIY NO. CIrV NO. PV BAN J D /~ ~l• ~y~ U4Al DN 1a Dry CrYOR IOwN / NMAE6N0. Oi SIRFfIORNG"WAV Kt R I ROUIf OG Bt4F SF NON 3~ M s w Rfs O D of ON 3 594zp R F B F IN G wtr ~slRfEl04A ~ NON N]ERSFCrO ~ PRff% f0. MY P001 [~ eY A . y . t_A LE '.] BFIW[fN BrRFF16 -~• B1R[Ft ~ ~.3 D BiANCE 6D RECrI NiROMgFifRENCf. CRO50014fE1OR NEAVFOrM IE i Ml[0 s p ACCIDENT R P DIAGRAM DArA i[Fi W pp MILEAGE COEVBIONINVIXVFD: fvf RNY: CODE iOIAI NO NO vl1fO~N0 NIUq[D~ DSp IIaGE DHr6q N N ~RD IN SFC]IN BrREFIOR 40A0O4 RfiERENCF INIER Cls CROSBBrR[F]OR ROAD / OP U ~ '" O ~] •O , .. VFf11ClF0 pPOPFgir DAMAGFONEY [ BigfN ONfCr SrgUCR INAMf Or O01[Ci SIRDCS AND OwNfR'S NAMFI DRfSUtrED ^VFN CIF Y 5270 [51.DAMAGE SRCIAI CODING l6f I ` g 5 UNIT NO. 1 09 vFR0 NNAE: U5r FIRSt MIDIXF UNIT NO. ~ D VEHICLE D PEDESTRIAN D PEDALCYCl15T • D4 vtR0NAMf: U01 iIR M _ a2, sIRFFI AODRf50 ~2-O(oS P~A~. ~p. LIrY ECODE ryDM r:Os. D 514fEr AOD4E00 C r SrArF ~~ (OZ OR ~ O4 vfR'BICFNY NO. StAIF 1 J R IPC t RNDNF NG EIGS~I. L l_ OCCU4ANON t 41gNF NO V,LA Sf% D 6 1D,. ".4 ltt5 w41GN1 M GNr ( ~ E Ivf95 UCFN5E N0. OCLUPArION M NPME 6 PHONF NO SrniE Sf% DArEDOf B 4rrv "° _ HOED C R . EYFB WF GNr Er GN ] D CHECK (.~ sa ~ orFf cu ANOr"fv nl YEN of A A D CHECK(/) N vFN aE as: O O a nal "~ 5 I D so cr_ CODES-* 7 c,. % ~ c„D„ ss i,. N DMN VN E AN NF CODES - * ~ ~ ,ss ~o~oRrcN a ° . ~M"' 3 n u IN, 4rts 4y~.m, „ M,D ..,G~.NrI p s .., ,o, s rrN. re.RPo x lDOpee.atv.l MSDFIDiDAA~r+ovA~ "i.ir. l]D4.coN~1 5 NF N y s Ei .Nr Nl er , "<' D E °`F D i:5.N4 OK D1.° se Yt.R DAV. ~ ai v ~1 C! t I "evl rroaEIDARE.NOVAI . l .~ a uu uPUrtN sr.]t tR NArF NO. ArE H vtN <aoR ' l A N A m` I VfN CII ~Df N1 NCArgN NO C L vENICN IDENrI ICAV N N ~ G 1 ~AY l $ Z„ Reusrt4tpowNER usi nqv MmD¢ u~ ADDVfssaowN R ore NO Q~~O N wlsre4m wlvfR. Ar Ngsr mIDDU a wNt4 i s NNO. .~ I O~ ~ NAMEa ADDassalNSURANCE CO wACwr E I S s. ~.- paMAGI A4u N ~ R ~Z "T "'" cNaq~ ' CNAPGE uN°;" r{AMACfD AREA " ]] IGT1CifOii ] l51 pAMAGf ^AW^YN IM1UINID ~ ^~WiY ^REMnIN[D ISrD.,UAM W[ 5~3 DIAGRAM OF COLLISION: iNIEtu NEee:snill I"Oer~uR"o°°M r" DESCRIPTION OF COLLISION: lust supn[Mfryut sfrer lP NFCfssARrl VEH• $1 LErct Z1lE 1ZAP4Wr\Y 'esA "~lE ~.EpT - s ~ ~ b \ R - ~' - QAbJER I ~1lD ~AT R Q'~"t ~OC~E P (t~ ~~ ~ F - RNEtI fZ LAMERAro , ~NN6 G. q00 2L"~ I( ~. S,E. Av.9v. EJ WA. ~180D'2. MACE AC&l' F M_1 ~r,1 Ft~owSCOF ~LlLN.~vSWG ~1M'To~A1iE~E L+1 AcCC~ } Zo AV tiD #~ ~ „ pwsa..~ - 64btc~, w~ C :A ~4 N WNo ' ~ e M N F60 ~i R0.\VC RO SQ~Vg WG . . Toa 60 NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES I OCCUPANTS /WITNESSES IiVSE swnfaunu sM DR ADD~nDNA . n - Z 3 4 5 6 F I N ME ' NAM S, ' slY Aa uro °•' ~~ • RfsrR Nm " oNq tAa~ ~LJ... wDEFU tiG 8~t- ~53a uREa 3 ~ -_ ~ w srINiSIY DAM e DLyI^'D^ . D~ D~`lwr ]0 ADMIS] AtWid ~ pIMOVlDEx DaMO DKn"FDA .DN DiiD ,DMF , NO .., Dr . .,o.l...u aRKtesr .n;E E .rwr c• wr .. ~ ., D M~ , o s. D w D~: a . , X aa~r Dnp,lc"FE nA KI vfD I D ueN h 4 '' II . 8. ~..~: .~ ~.. N~ Jk ~ V Z ~. ,45 ~ `rte .~ ....~V E~ .Y,qr~ sa; w ~; ,~ z R+ tr ': '~ t ~.M ~ yV ~ ~1 M I'd~~ ~.`i Pk'~ f f ~''y,4 ~; ~~~ . , G ~~~}}. E ry, _ xb ¢i ~~, "I ~ N ~-; ?~°; ?vPi T` ., . , M wlz~ ~~ . L l~ ,_ I 2 ~~~ POLICE TRAFFIC COL~?fON REPORT IBIIRAiNCWAY fOli RAINi NIAMBER ~ PRIVATE WAY ._P..1 Q. SDtI pS/_ mD, ~ I O(7 • l Dmf 'lw ~ I I W (uSFRD~S wuNir O - B~ei COUNrr rq. CIrv ND. rrWA ^iU AN URAI / ^ ^t ~ N CUr O4 rOWN NpMF6NO.Of SIFFfrOR rvGHWAY M sts ^s ^w ^of ,g c/l C:N [ft~ S- iR C(5 RWif f L .J .SZ 7/O X 1 ~~ tfvuuiNC Vn,N: sr~ov aopD NoN,MtvseenoN IN Bf1VREN StREEI 6 siF[Fr f t mnf vosr O ~~ ' 3 DISr+NCI IDPfM u0 F fvFN t CROSS SIR(f10R NEARE51 MIlt POSr lE5 5 F fER w Of ACCIDENT MILEAGE CODE AMP rplA RAM DAIA Coll SqN NVOIVfD NfVf RDr' i6RU NO. ,NLUR[D~ ^SP IIAGF ^N O.lltD N m, pq ,UN ~. Jr0 IMFR Q5 i fR CM Rffr RROAD0R 0ifRfNCf CRO5551R[[TOO ROAD ~ i _ }OIAI NO. I~I O vfN CI[5 Ldl PROnRir pAMAGI ONLY ^pfSUIRD ^vFaCtf .J / Q ~_ A~ ODLtCr SrRUCRINAME0i OB1(Cr SIRUCRANDOWMe'SNAM[I fSr pAMpG[ P[CV3 CODING IRE s UNITNO. I UNIT NO.2 ^ VEHIQE ^ PEDESTRIAN ^ PEDALCYCIIST 3^ pR VIR'SNAME: IASt NR51 MI Ol OR VfR'SNANE: N51 FiG3T~ I l 7 ~,G 7- t U 6L /J l [ sr fu ADOR ss '{n~ Orr SIAIt~ :IPCDOIX PNDNf ND D vvm ADDRfss P / D BtA,t ~ 23S [ 1 A . cock R La A y'8'33~1 s-OSG6 Z DRrvINSI CENSfN ~ 5 rf Ulm F m N D ~~sR~6 I v E D v 'SICf NSE NO. IAIE x R oiPdljl-N rt F ocLUPpr,DN Af 6 P gNf NO D rE Of BIRtN o tai ., FYfS Wf GNi H GNl ~ l OC UPpr,ON TUO cA? m NAMf 6 PNONF ru0 EYFS GNr H GNr R C/~/,r7igCUir! fc o0I S R M NN 1 . i ^CHECK I/) ~vrRnr AS aN tmviov[f orAVOrNtaAl ^CHECK(/) ~vFNCIf AS+N rMftovff Of,NOrrvfept m ~ CODES ~ ~ 7 ~,: . s` n 5 r . w e ;;',°„ ~ CODES - * 9 ~ Ai`s i:inM 5 u N e ""D~r!ar T> , Z ,N1tK ES w ~ ' ,I;~ ^ ,me,R,NRr ^ Atifr ^ yam. ^ K~Ka ^ ~~,. 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CNARGt s,r~NC rw<r a.u ' Aeto ARu 5 rs:sr;s. lSf~pAMAG1 1pV~v ~RlMNN[D ~ DRI^YN ~R[AwN[p pw f5i DAIMGt t .D s ODO :a«[DBr r ^+°~;`.°er: s 00 DIAGRAM O F C Oll151 N: lu ND~CA,t ND Rm DESC RIPT ION OF COLLISION: IusF SWPILMt MAl SNFti Ii NtCtSSARrt I _ . _ _ _ ~ -- _ I .. ._ _._ _ _ _TQh _ ~ _J3oTn.__(/_e_NJGL. _fuC~c-~C??~?fl_t~?? lrfv~ 1~_lo_//~sinv.~oekf.~.4cc .r_.tl T.S!~ _ - -r ~ 1 ~ J t -} I_ _ - - j~ f ~ - ~- ~ _ I .- { -~ - - ~ _CE~~rR. O!~~7iS~E-.J~d_ --' -- _-- J$!_. UGY/C L6_ .t0»//rrl L- . D.FF ,.IQCO~ k/r.'6 ~O~T .IiS.L~.. R~/°APY_ S /JJW ? .~6 ~ ,e . _ ., .--~ ~-- _. .. ~ .I '- - -} --- . _ ._ .. . . ~ d 4 ~ ~ _ ' ~' ~ T-_ _ + ! ~ _ I _ idc~e or -, _ fsr,'u,__-S/ ~ _,c itrrcrm~... O ~ ~ - ~ w . ...._ 1 ~ . _ 1 °T? DG I i I I I a P I. ,A INJU CODES 1 ~ 3 4 5 6 OCCUPANTS/WITNESSES lu>f su.ntwaw s« roR amuoN,I N+Mr ur sI Aci~ urus su~ '",,~," un.. . N.. v .__.. ._. .. [sro uta rtcr .. wl ~ + ._. ........... _. _... __ N~mut of tNr B. ~ - ,Nv .,+I ~. +Dn.us - +me Nw O .EV•R .. __ .._ N nmr or .. S.rNi e, ^we ^ : `~ ^m . ^e_^ :::n. .1. .., ,. •DCra X _ .p ND ,u rr ,.. ,, nnc• ewn ao.~o R/A wuS vc a , D ~oi~'I TMA rvet n,nw Rt rovr _[9•x(0 -- ~'' D+n S ZD ~b ~ ~ . ~ ~.I S. r 1 T r~, N ~tii ~~ t''A ~N ~ r .~~ ~ i {'~ ~~ ~ r @:~T A (r S ~~ ~ ~~ t a „.~• ~`~ ~ , "n ~ ,. i S ~ ~/>J§~° '1 1: ~ ` ~ 1 - . e~. k.r+:t ~ ~ ~ a . aafk°~. R ' ` t;~. kk~ ~/ ~iVsd9 ~. ~ _ gM"'~ '_'Hf~ f~ P~ ~:'~~Yti ~ ~ ~ -''Q 1 ?fi' i -~L+.;'-. ,.. ~J'~f ~ ~A ~~. t'. [ _ ' ylT;1« F ~c L 41~ ~ 1 ~ 1 y ~twI R4 k;.. y ` ~' .~FP" ~ l i. 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R.t~ ~~ h '~^` FSr.OgMa F SRECIgL CODING USE $ ~ ~ ~' l`!:' "k ~ k ' ' ~ ~ yr " ~ Del eesNgmf: 2 P UNIT NO. 1 esr E MID«E UNIT NCO, Z Dx vfN E ~ VEHICLE Q PEDESTRIAN IASr ^ PEDALCVCLIST MI« ,7% '~ ~~ j-y ETE ~ SrRf DDRE'S q D V D • ` 1 p., a ~NY~ ~f}t1RE` ~ ' y ~ ~~ n ~~ -r` 7]~ ~~ o ~ (~ ~~~VVV 7 ~ T SrREEr gDDR 55 2~ of gl . 9 : ` ~ , rE EIR<GDE q NGNErvG m r D , u ; D4 fN3 LICENSE NO. L ~ G 7 R " ° R l_ ~ ~ }IRCOo l ~" q,~~'~ F~ f F -~ ,3 ~i .nom, PEr A o ccwarloN Eng AM NE NO. wA . rR ~ R•' 10 E ~ v DENSE ND Z N~~ Sf E W ~ SE% is f Of BIREn o~ 12 $~~ t =' I ~ 2 D f o Es wE wr NEC r E occw /~/E R q AMf 6 vnONf O 4J frES ,. Wf Gni HIGnr ~E f y F+~,> a,. ^ CHECK (.~ w %uorw[e°l EN Of as aN FM EE OGgf - ~ CHECK(/) G O2 Z „~ ' CODESP~ D a v" v2 I c 5 r q o '• R nEraN D yorDOC.cu N vFN iE gsaN Unv OrfF orN CODES - N 7 a ss q i+ n'.•." AS NE ER y °n .n nD~ '9P` }} k ~, - ~ rts ~w;~;o,. ~ qN ."Ef ° ~` ^ ro~° o zs: o ~~. ^ •'f , ` ' ~ R ri s e x ~ aU , qw IDO f Cnfvl vfn f/q4 l 19G5 ~ ,l. m FIID~g/4r~IygE Vq1 2 u~5. 5r l}D CONV.I ~ % ;; OM ^~~• ~ % fg4 V, NE (`' . V% ~El ~~b'irzq MODEL IDgRr NOVgI wKie ^lvi'NSr 1 D V, J ~ ' T'' ~ ~ n CEN R EKE/ u c SrAr E I , 982 d VU " y WD ~ ~ ) V }9 T3 19 F lF4 R wA q AEF NO. A s l l H vfn <« N ' E -.: R,.., ~' fn f u c iaN NO. ~' Z I 2 ~ I Ku~ ~ v cu «Nrf A Q tup ~ ~ ~; w~ m ~ aT { . ~ ~ qG f ASr ~ p O I ! i I I I i ~ , ~ ~2,'-Ji IClvl i y w {! . .) ~~ ~~ ~ I w A r^ i . I I MDIX[ RHONE NO ,-x GSrfq(DOwNtR~ Sr Sr nrx ~ I .. .,.. ^w ~I l ,>."fihRA ~~..t~Yfti~Ui?'vR ~Y - T~_.....rvu Cnq GF .. .. .. ` x w I o esr IMq.«gc~ weN IG iOtia:i S ^ Awgr ~ elMUNtD l rowf0 <NAgce p , t aUx ~i DgMACfD .wu a ' IS IRn GF 451oR ^ ~yl~vN ~4lMAIN! "'wA S C /$~"~"f/ Owtp 0 -'- ~ LoGF .wAy er wqr en E 2~d~ E I4 IAGRA OF O U ION: ^ ,SN[Si t 4Swyll--I l vRlmNAI IND UOpfoNrn SCRIP110N OF COLLISION: lusE SUgn[MwrAl sNefrR ecesv.Rrl } _. .. ... E_A1 /~ ~ ~ N . ~ - _ ... .. ---..... __. ~~~~ 2 I,- i 2 AS r ~ : e ! - . J t 7'aL~~ , .. I _ . _ jf~ppryl Q NAME, ADDRESS 8 INJURIES RSONS INVOLVED 'CODES I ;5~'s( 2 3 4 5 6 CKCUPANTS/WITNESSES';~~o^,!ot;f; , wr sFx Ace grus '" Rtv4 USCi ; 1., wNl ' ~ Yr 0 ~~. RE OE ~ W '". . O x° ~ .~ e- -T ~ T - OZ .IFS ,- ~ - L _ ~ 1 . ~ •.nr o. if l'a""'°M~ • ~^;'c'~H . . , . O :. ^ :' .p~ul ~ M1 ~ ..., S. v.f~r::. X ~ E, ~ WS Rtf, n 0 ^ lOt^^ ~O~ /// ,. :,,. .~. ~. //4~~ ,lD !r -•:, ,~ r r i ~~ t .. ~~, f ., t ~ ` t~~it a~`y~r ~' ?~ 7,t :~ ., l..i ~ u +~ ! ,.,.. ~ ... 1 .~" .. 2'~~. x .. r.. c~~b~}.p.,..3x... .. ~ . e n ~ ~ .. €, tL11A+tlYit.~'~. 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C905S 519ItIO9Jrv[wR[stM~LLft~/] n ~S' rlFi1 N 1 f W O• W10L. 6 F\ '\D • ACCIOENi MCODEE DiwGRAM WIA N COII'gNINVIXV[D' NO [4ill[0_]q INJUVfD ^YllwGf ^M16 RUrv OfM HO wrvpNpiM IN ~D M[9 Cl1 FFSF ri SnF OVROAp 09 nIf9tNCF C90515T9[R09 ROAO ]] avfeK¢s ~ pr9on9rrD.Mwafx+lr ^9istufnD O~i°ai `~/D06 ~ oeJlCr StvUC.INAMF Or OeJ[Cr s1RUL[y+ OWN[R'S rvwMFI [st.p.MAG[ a~~ ~~ (PoarLlna_u_a alfs~v- _ /~ SnC Aft OiNG TAE UNIT NO.1 ~ [ 1 u VEMICLE OPEDESTRIAN OPEDALCYCII=T ]' s p.WF. sN..At- usr NYSl M f s Do f9 s HAMt NLr cSGCXC 5 Ld"i 5` ~~ rvtfr ADDRt55 lISlo 3L~~ Pc. 51.,t. t9tR wDDRFSs t.rf ITV COIX MOrvt NO ' D r Stwrf Iv F s ~~ ~ . ~ ry u~. R ~ Dvrviv'1 LKtNYN SrAtt I i U [rv w f Arf GK a~ os RG E--A n1 tti p. Lo ~ r Z occupAtidv MrvAMFapMONt rvo. ~~n~s1 c~I KbNr RY ISv ~ E R occup.lioN N9 Nunf FpNOrvf NO. fns bHr {abH] O CHECK (.~ ~ vfMi IF A o wN r O CHECK(/( SAN UAViorrra.HDrw[aµ CODE=" ]~ l a/ es° - S A Mr • CODE=-t ~~ Su e,. /]] arts cA vN D ; br„r.D., ~.NRU,.M[I ^ ro,il o ~ pt,..o ^ rs~5. ~ v o,M9,,.Npl ^ ~:~' ^ zbm. ^ r;:K I ^,~~f. VIM vewa HA[t ID000e.eNtv.1 7 6 ~2fD Rlo ~ Sr le l]oY.eON I ~` ViC N.r Av I n v.l oAR1.rAVAI ~~ I .) ~ 1p Hsf pu s]An uF9 nut NO u.r H vfM CaoR ~ vIMKIFIp MUKAIgN HP ~,._..__ "' lsr 3 o z ~ a 3'{- !o L v i I NN . f vIGi1RV[DOWNt9- Wt iiv5t MiDOt[ vHDNt HO O ~ F WN!'. Wt f143r MI F mfs I; G• ADORlssa ow*Iw ~_ N A wNt9 ] / E .Mt [ Aowetsso IHSU[ANCf eo oR weFNl lthl lS ~ R IN u w p.M.GI 41. ' eMA9a wl I'WM G! • [MAYGF gJDWAGIpA.eA H ' I 1 A U O.WVMN QnMAIHfD Oev ~~ D91M.wtD AAU t1~ D Iror =e~0oo rfriJi9lr-!{'IC LLYi u • ~ tovn°er: _ DIAGRAM OF COlU510N: wur u~iJe<isi.iii Nev~:o~t" DESCRIPTION OF COll15lON: (VSesw.uMlNrAf sKnn Hluss.9r1 N VRIIMT'6 0/Llvlf .E{'~' VCS 4~ tu-[S' N(3 oA oA K 8A 4' R~ IrCSJ{~T' AQITW.L7 c.c]YtrJtS/Z '/'U RlGttv;.. Roalc ~ C/LOSSIf~ G-linlq"'(SRLI[+..(T fl~ ~ ~P~ liofl~ alfJY 7"O L[{f'`, VcltdFC.Ud' ST2 _ ~ /~O~IG Antes ELI pPIS/~ btiJT"o ~A'SSfsNbll~ ~ ~ ~'~ -.~ nq OsOt<. ~p /t. wRl~ ~ _.. . NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 - Z 3 ~ 5 6 OCCUPANTS /WITNESSES Ijpuj bD~1!W.f N4PMI SI sf. wcl ur ' nsn lecr .MI ~ e. ~ wl _1 ~ ADD.nS una ~ . MonDr.DM O.MF ~.o,[l O"' . O.rv. O :° \ \ . DNH1 ` N~.IIOi 5 f.. 1. o.Mf ^~.p{ oM:v. 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ED CnAi ^.w~r" ^IEAMIrvtU row[D r fa 'ui:D K 4 Irol rbionb'+ s ~ ~ °V,. fi Gl Aw Ar an s ~, DIAG AM OF COLLISION: mwN NDK.rt NOgIN ~nen NEwuKn er ARROW DESCRI IOfJ OF O11I510N: Ilne slr Nru SKtt rrecessARrl _._ ____ . ~ rs 4 T ~ ~ ! - o ~ . _ yG / ,a irs u- / G - ~ ' / . ~ ~ Gy.- c7 i..+Ta. ~ .l E.._C //ZcJ6. T./ c--- ' .C/~~srA."~_._G'.9du~y!%. a..L l'-.acs _ ' _ ~~ --- 4 _' I . ~ I : ! . I I , I ~ j ...i. oi-,~ Tic _ ~.2,rFiZ_ - ---._ -- __ .._ _ ..... _. ___-_ _.._ ____._. _.....' .__ ---._..~_ NAME, ADDRESS S INJURIES OF PERSONS I NVOLVED ~ CODES 1 - 4 J , S 6 '- N IuxslsRtMeausNE OCCUPANTS/WITNESSES lo°ADD'uo..a NAw .ME n sl ~~su ~ c~- aus ':,`s ;" nsi. i,ta :;cl Fc/ ~/iLG S No 37 yo . K Daw G i q, A N. ° °' No .M a pRl"' O ^ . O~ 144Lr. A I Np ~~ A DDV155 AMI NA)W d . MOVID KR p.Ma pluKl p ~. O N prrr0 p ~ • D(..1 I 5 N ti~110r S INI ~. ^.MI p N,,,fr ^[OI11. : ^r~i'Nv M f N rt1r~ 1 1 X _.7~~ . 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Pw 1 - ui lusl] Nou41 rcvn oboe rowN ^N pl ~N ON IaNO~sra o jw~r NG~ l,~"~'r _tts sell. 4aurtae rnf orG~'~%DiiJu/L µ r r uj ~ ` p ' "' eaN 04 ~ l4knlr "`/ •1D ic M,] j Sel[r 5 0200 NI Nora mn4kcraN 4nrix to Mnlros] ~aF~ ~ el~llN Sr4lH a s]erH O• a S e DiS1.WCr aD VI 4n14 1. 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R ~'i,'~~+~ EST? ~' ~ / r -- w / ^CHECK (.~ n«IalwswN rrw wNOrwvw' pCHECK (n ~ `~ CODFS-' ] ~"^' w•• NNClr wswN V•4ianr«wrnnee~ / I a ~ nn S ] crrcw p vo.wc.<~ CODES ~ * 7> o •rrc u nw"~' " a • < 9~" fi IN w ^ L <. . 5 u E ~ . 4s w GL.JG ~' n>« , ~ ,.D,, t . n °7 ~, o ~ - ~ p ...,w..Kl p f~rc' ^ i'b:.l. ^ ~ .,, .D. N rive I^~ Crv1V I IOwel wl srvlr nD4 C Yv ~ M~Dr p ~ I p A[ p ~• p rr.•o ~~~ a IN IN sun wne4 "M H n ~ L~~ w Vl Klllp Nlu KwiKIN IrJ ~ vlrvi nl 3 IGIS13;3,9:1/! t/161 IO,~ E II•I ncnn4loowvl. ' w ~ IN w I w 1 ~ I I ~ I I I I 1 ]D us] rnsl wDal w.o w 4 I sl NO O j I •DO4rsso ow..1. s ~ die:'!-. W n ~~~i L N 4 Nwwlawonssa wsu••NCr co o. •clm E Ir uT>~CCO~¢IR"'-. K.10 NI• 1,~wr. I ~^ ~ ~ . wcr4.~ <NMW ~ Crvwe n ~ 1 Dwww4r ANN vt ~~O 6 wx•r .rG e1OrU• ~'~ n ~ w• ~Ilw• ID ~De NN 51 I r Yion ii o n ~ 3 ov~D r o w: a OL<ii/cS,E'_ < DIAGRAM OP COLLISION: wur laswul ~c~~~IN DESCRIPf10N CN COll15lON~ INlsvn]ua t sret]rNassurl ._ •~E7f~-{aYilsc_ 1 I I i f/E1~'d`/ //9J . /..~Zi ef-n1 GA~Di.~JG/' ~ I _~ ! j ~ _~._f ~"_f~_ J I I ..air.-:;! ,~.,9a - , ~~ i ST - --.- - ~ ~ - " ._ ~_._ - ICI : I I I _(_I .+_~ I ~ 1 1 cr.e'a.+F./ a i.J..F.~-..G oo ~/«.~~.v./ ~~_//B.,S I ~~[[ ~ -~ - 1 ~ ; -- .... sT..x~ ~~ aw ~ r-E~ rni ~.I./~.4w ' a 1J I ..~~a >>/ ~ /s//~.c/ /6ff._fa_S..CD J~6b_T~~ OO .. _. E3T~l(`l~ ~ 1 ' . L`vY2~fii~ TL .s?/'b5 /~/, _ -- ... ~ .~iw~ - n~ I R~ ; . /-.s/.~ . ~~szTC / ~ . . . Nii __.o~~~:. Paz. ~ I• F i az` NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ~ CODES I 3 s N OCCUPANTS /WITNESSES ~ l:D'~ "' '" " 'f (; -. -__ _. - 7 _ _ 3 ~ 5 6 ,, l , r „ D - r.~,,~ ~s s~yo un _ ;/.~LIC-'r.l r7'..' 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T/~h~ ~G' t , .. __ _ _ ~2 ,Pr .. ~; d + ~ ' ' F„ _~: i'} ', Kli r~ ~{ }~ _ r "..~Y .~ 1' ~~ i`~~ / d' !fi tcM. ~ ~ ~ ~~ ~ h ~ ?:4 . ~~~ ~" ~ ~~ " 1 ~ , ~ r+,, '~ ~ ~ 91'.~~ e ~&fS~F ~ ~ .4~ ~~~~ ~ µ ,µ~~.~y ~gg t d" } ~Y qg +ul~ ~ ~{~SO~h ~xi.:71..1+~~~ ..g~~ r ~, L%Lfii. I~~ T~"'T` ~' ~ ! ~ `~" 4 \ ~ J t~ ) {~~~ 1~ ~. ~,~~ ~ ~ ~ ~.4, d~: ~ s_ i ..~ kY ~ ~ ~4 ~, f~'~1 j p a f,~,` ?'t r .. „ ~~. dim-.. _. ~. :- ,~.. ~. ... ~' ~~ ~~,,.a,.2 4,„~ .~,,.,n..,.u.. ~ w., ....sxSi~°ns;~...c. ~re.~,cu.,,.,~M ~.. :e.~r mc~.x ,waa, ~ au r~m_ (. j / l N-.-7,~-_. i~ f N r. o '~ ~ U '~ rJ i_ N N :~ ~ O H M O • O O O W O r-i Q1 V1 O N I j 1 O 2 No I 11~~ HO ' HWV~ `;t i _I. ~Yk_f4FZ •. .u~~ti ,e.dg '~1 hY~l,~ktl3 ih,~~'a~ 1 r ~ i 1 ~ ~ r ~ ~~ '~' 1 ~ i ~ L~ ~IA 0 ~~ ~iD~V r f {FI f~ ~ 1 ~~` - ~ Lr ~~ 1 ~~ vt„ ;1 ~ ti ~.. 1~ ~ ~" 1 e 4 ~ ~ ~ N 1 ,~ Yr . Jn ~ .~7 UR) ~, uvunlr~~ CITY NO. N.O. ~AY 79 -Yfk Z BUN 1 MD4 Y IDES D WEOA T ~ 5 FTiI D BAT (USE 240Q ll/J FNWA 2 [[f~ COUNTY 2 ^URBAN SRURAL ^bTATE ROUTE COUNTY ROAD ^CITY bTREET O AOM CLS Jeffers PilEF1X ROUTEOR STREET CODE bECT10N i on ^ODIERISPECIfYI N ~ /,O •y1 O N b E W ^IN CITY OII TOWN ~ PREFI% EO. MINE POST O MILES Q ^ ^ ^ ^ OF U LL NE6NO.OF bTgEETOR HIDHVIAY INTERSECTING WITH STREET /• C-/ J10 (pL'~ T O'V : ORROAD O RAMP OIAGMMDATA I Thorn a Road O NpN INTERSECTION S INTER NON %~fip TFRSECTING STFlEE R ROAD OH REF. ACCIDENT INTER Clb. ERENCE CROSS STREET OR ROAD N p[TYlEEN MILEAGE T X S REET ANO .STREET CODE ~.~'~6 t~ DIbiANCE ANDOIRECTK)NFROM flEFERENCE Ofl CROuSSIREE bPEGIAL COOING USE ^MILES N S E W .1~1 Hutiq+Elils l FEET OF vE COLLISION INVOLVED: ^~HICLE~VEHICIE ^VEMiCLE~RICYCLE ^OTHER IWRITE) ^HIiB HUN SEVERNY VEHICLEODJECi ^VEHICLE~RR TFlAIN NO. KILLED TOTAL NO. ^STOLENVEIfICLE OF VEHICLEb NO.INJURED ^yEHICLE~PEDESTRIAN ^NONCOLUSION ^HAZMDOUb MATERIAL ^ PROPERTY DAMAGE ONLY OGIECT STRUCK INAME OF OaIECTSIRUCKANDOWNER3 NAME) LO A C TION OF OaJECT bTgUCK EST. pAlAAGE ^ROADWAY~~~ ^ ^ ^ FEET DRIVERS NAMEAAST L7rJ RO. EDGE S FWSi MIDDLE pflIVER'S NAME~(AST FIRGT MIODLE IIF D1CVCL1510R PLDESiHiAN CHECKI ' O SNIDER JACK BOYDE D R SRJEET ADDPE53 I1 STREET AODNESS I V Route 1 Box 6 y flE CITY bTATE ZIP CODE PHONE NO. E CRY bTATE N ZIP CODE PHONE NO. Chimaaum Wn, 98325 437-249 N DIUVER9 LICENSE NO. STATE SE% GATE OF BIRTH N DRIVERS LICENSE NO. STATE ~ SEX DATE OF DIRTH ~ DoesnEt have WII. lio ~ M 07 11 28 O Mp. DAY Ya DRIVERS OGCUPATKAV FWM NAME PNONE NO. 'j DRNERS OCCUPATION FIRM NAME PH EN Retired U,SP Na , CODES ~ IJI CUSS 1 1~1 BEAT BELT 2 I+I EJECTON 1 CODES INJURY > IDI 141 ClA.SS BEAT DELT ISI EJECTION E9 F NATUR F IILU VED INJURIES SCENE KH. YEAH DYE MAKEIpODOECHEVJ T iNOM SE~NE MODElIOAHT~NOVA) StYLEIZ DRCONV.1 VEII.YEAn nY~ MAKEIDODGECHEV ) MOO V . ELIOART NOVA) BTYLE I2 DR.CONV.) 1 E Chevrolet Che anne Pio V YEH. COLOR LJC. PLATE NO. H STATE TRALER PLATE NO. bTA E VEH, COLOR UC. PIgTE N0 STATE TRAIL I Wh ed GH 1 ` H Wn. I . ER PLATE NO. STATE (~ VkHI LE 1 N AH N NUMU R OOOMEtEFl ` C vEMICIE IDENtiflCAif N NGMD R OD • ~ OMETER ~ E E REGISTER 0 ER -LAbi FIRbT MIOIXk REGIbiEHED OWNER-LA FWST M N IDDLE N O. ADDRESS OWNER D• ADDRESS OF OWNER ~ 2 NAME ANOAODN O W U .OR AOENi NAM EAND ADORE5.40f INSURANCECO. OR AGENT Stets Farm Por Towneend~ Wn D11h11 cIrAI No ENFORCEMENT crag e I A I N No Drivara 1loens //,~ AcTaN NAME, ADDRESS & INJURIES OF PERSONS INVOLVED cops _ ~ ~ s L[% AGE STATUS N EJECT L. NALIE~ 121 . (~. AppgFS.4~ U NA U ~OF rIF.MO EUFHOM 0 LYJUN[A A NAVE SDf NE nv N TO T Apd1ES3- 5 ~ ' F~_ sci pv DFI M ° H' To yy HAM[: ) A(wlES.4 ~ --- T . _--_ M11~rTiLL6Fi ,f ti-'~ - N m e. E bcr 11. Io S AMD ~ ___ __ _ _ __.~__. In __. 11 ny. 1.nn41K.. ylr~~~S ' Cl l I i IGIKJN IAKYII I 1 ffGE4t uA•! r' f IL C, NAY 1/,ll M!4I M.lCO N(1i1JfCI[0 ZU! n I.CI [ A J f Lll ! 1 ~ ~ Jf1 DM Z JI ILL IOI Il IJECTI I, IDNII NtY 1 6 ] 40~( I IIM1 Y'Jf.Cil.D 01. ~lfl lU •OJ. /M9v !11l111Y '111 /TI M1l14 D ) Y ~ ~ 1 ~ A~1~ DY ! I __ H11TrA 1. 111C 1 LI.II.DI ' . n. . ,+r.f.. •`~;-„~ .4..A. . ...s, :~~,.'ih I., C.',"~'::"SR'-'7A~1':?Tt'^?~r'-.:/megm ::.LT ~ ~• ~~ 1 ~ h N 4n Y ___ ... w - 'i ; I• ~m~~ - ,A t ~ ~ 3~ ~9 t '~z ~_~~ t'a' ~' ''k °Lrm~rc Fs, ,.',._,_ e"~~a%'ws«,~ ar'~; `~':~}.s~;:;a r,3t~r,'~a3~«ak: ~._... ~iw,>:," r7t~ ~.r' .s. ~~~~'` I.IN EACH BO%, CIRCIE THE NUMBEROF~'EACH DAMAGED AREA i EAAMP ,,, L~ ~': ti. - _ VEHICLE DAMAGE 2'iHADEAREAOFSEVERESTIMPACT. I• •{' ~ INSTR UCTIOMS: G.r MWARROWISI TO SHOW PRiNCIPALDIREOTION OF FORCE ©/. ,• 0 1 DAMAGED VEHICLE N0.7 P ILSSrwGE FOn GNETGwNG DAMAGE TOTRAaER6,MOrogcrc c.1 DAMAGED VEHICLE N0.2 ~ , IO.IbPB .. ~ raHOaa ~. 14. Pool ~ ~ 14 ga01 I6. TrunN L ,. ~ 16 Trunk ~ r rr l ~ Ie. UrdarcaMps ~ {C_': j (' p '.' s I T 10 UrtlwcarrW. 'I ~ 1T.WMUm I).DwMUm SEVERItt OF DAMAGE VEWCLE NO.1 BEVEgItt OF DAMAGE: (OiHERVEHiCIEI SEVEPoTYO DAMAGE: vEHiCU:N0.2 ~~ -~~ sr~ ~_Y+' 1QD19ABUNG DAMADE DQOT/IER M.V. DAMAGE II]DISABUNO DAMAGE SQOTHER M.V. DAMAGE IQDISABUNO DAMAGE 3QOTMER M.V. DIMAOE ' 2 FUNCTIONAL DAMAGE 4 NODAMAGE 2 FUNCTIONAL DAMADE A NODAMAGE 2 FUNCTIONAL DAMAGE A NO DAMAGE ~ _ TOWED UY 11A G C 11 1•,e EST. DAMAGE TOWED DY EST. DAMAGE TOWED OY EST. DAMAGE c. - TD ,.::.LL^.cu n s TOTAL ro a To s' T`[ , ~,~ DIAGRAM OF COLLISION I I I _ I U I D tt I I I ~ ^ OR ARROW SHOWING ~_~_ ~ '~"jTd r i9i'~e -a•_~..T. ~,.~ RTH IN CIRCLE ~: ,.~~;A .AawY.rFA,aRr~ _~ f_ r-r-r~1 !s I-~~ L I I-y 'i.-~}~~~ p{y .~.~ it ~ O61ff~ D~wOFFnWDNAY i ~ '. ~; • ryly- '~ - - -' ~~-T 1- ~1_! 1 i(( y~T O 1.~ - ~~'d.': r I L_.J ~I I I -f-I t-L I /'i~llr;Sjr`e//I MF.q Era1 I ~I I _I~}I r -~--~-~- ~-.i< 2L0(~rE WrO•A•LEPOWrG ~~ I ~ _ (--1 I ~~~ -~~ _ I-~ I _ ~~ .t ~ s ~:~~~~ 'oecer~ A±A.w~cT°A '-I,~~-E-~-I I I I I\•~~ ~ I r ,-~ ..s~wnaw•ABLevEH~nEDq X°~ AAnirT'wAA~~wBEroBe I _ _ _ 1. ~ -}~----j }-f - --~- L'+ pr. DESCRIPTION OF IINOM:AiE WHAT PROBABLY HAPPENED BEFORE DUPoNG ANDAFTERTHE CIUSH,INCWDE INFORMATIONNOT ON DVI(WNA,EQ DPoVER ~r. ~i~ _`.DOLLI$IO4 ~',,' ,,- DISABILITY-REWCEDVISIBIUtt,PEDE6TRIFNCtATHINO COLOR CONSIPUCIION OflflEPNq WOgI(ETCI pon thx R/0 arr>_vzng _at the accidDnt scene I couldn't find anyone around tTl' scene. A short E ~~~ _Eim, e lat_r th_~rt owner of the_ vehicle wife) showed up and informed me that -h~~iu'&~baiid P~ g; _ktnd been drivinc,=he PIIy_shortly_tfter this a passing rloto~•ict ;.ho:aed.un.and said that he.hac~ h"~ed the driver out of the vehicle_and the driver wai(dered c>oan the'roai~in'a`dtxze c°tkk-on3i~ o t *'ks",` .,,~ I :aas uni7ble to locate the driver and made contact t next dam Iie ityr~ed" _rr~th~~e had ''-r"',"is'', sltertced_t0 ~~ss t~+o dPe~ that w,l T in the roadway'b~didht t ramembex_a thing about the-~- ~~c~ ` Ocgzdent T'iere was__)60 feet of cuff rar4 fro~l the point of leavin the. roadway until '~"~ •~ --.. ~ k th impact *':on the vehicle xas thrown another 20 f et landing on ite: top: ~•`~`"' _~ '~ ' -~'~~,. _... -: ~ .. ..- ,.. .: i-l..w :~_nr.~'A:..L'N No. of UNES sPEE VEH. ~~ .HEADED MILE POSTpR 011 STREET OR HKiHWAY IUME ORNO. WONE gREOiION ,We lEOALLY WAS VEH. NO. WCREAGINO OECREA4N0 -'i S L' .L_A~~ Q p~um~ ~' I L D I!_JI 6i, I Nn S E W n ' ' y' ~{ I rl/!~t(~ Thorndik:e Road 1 '~ _ `.+! ..~/n. L~„~ _a _._ III ._.._ YE9 HD YEg ND ~~ 1" ~~' ~ a , ~'' '~'. , ~ ~ ~~. 2y_ ~L-1i ~_~L-J71 ~ ' ~ ::'D~ O a' o ::. f ~-_:v ---' n A PED ~ L ll~t 1 °A -_ - •r -oP -_ weca«en .ler`Iw.l ~I m4, I/BICYCUSi WA9 DS•10: BOEWNA r • DauU>FR I~7 F GLOMIIG r '-_-~•': li I I~wADOV n •L. IC~Sw I ID MSW °I IGICrCtERWTE Drlfll 1 •, IOAD SURFACE; ~a;,•,, EATHEfI_r.'+. ,,,w,r „y CONTAIB TING CIRCUMSTANCES ,y ~;,~,.,;_„ Vw~Pw9VM11PeADTprA. ~~~ ~tG NPIE,J{OWI ••_•• FWG~ADR MOgFI :a d..A.A I ~ oln,F,l ~ ee /~hiU A.. ono I I J °" ~ L~ :D.~N~; ~ ^ s.oe .f O wow.n •eaN~OiA ro ~•4^~ ruw to ,_'!!1Y1p°!^ _ ._~! s'-I~-, . wecrN+~ROe eaxr ~~~ ~ }.'' ~-- ~]n •~Gr1,SON4~\ ^I~' f 1010MVi0lIAll~dlrn iICLECONDITION ~ ~. SOBpIETY:: rcu ~ia"im ~o~l ,: vu.na"' IcHECAc oorlrnwllq I ND. r Ir; ~rF~ nln M, _. _...FnetA awet. .._ ...no T nr~ae _... r `~I ~ l i+owu ..._.~ .. .. -_..._.._ I Ho t"ICWGOnew wwc~ are wer ~ Ili ~ ~/ '-K M.uart _ f-1..._j_~ _.. _ - ..__- CY,lr r ~ roow.. ~_. . , ~".~ UJ 1NR ,l kowa I ~~ . ~ i ;:7 M aa.A•M. • , .µ r~ Alb + Fra AN.IA r OIW nI'l'tt,In • o AA" ~~ ~.. ur¢ I u. AMl10 I ..r ~--i trc.o ~ uHbY[(O J GwW ( ~ 1...1 HAa Mt~M 1 '; nM urt a•MA ~ CHEM. TEST ~~ Mom I i°•q rtAHrAo D°O ~• _ ^,^ DAAM le.r,,..1 . Or ~~ p ~.., OyCI [[-~tt f-~ mowEOlpl + rl • ~ al r•° o: owr°gNK ^•L7 ^I•J ~ wl. __- ~uL~ :AIFlO NBI~rION I Jlr~~ m•rA~K ttNruNo - C 1LLC~ MGM , 1 GIAOwn I NO r I. _I _~I .I ~,i.. ____ __, .. _. nriarrtN Dn,rAIN><urn ~J _ .___. _.~. I '.._~ _ .... _ ....__.__ i i rna rcn ! ~ TLrr Arruxo T ',oIW I°«n~~ % % TEST RESULTS 2 ,, .. _.. ,. k, r.,nuty ~ , ~,,... . ". ~:) ;~ '/ ~ 1+1 ;,]. L':°~ 11142 L•r ~ 0 i . :f/~, 0 I ~~". d 1 II ' I .~ ~ ~ ~ e ~ ~ ~ . Wf ~~~, ~ ~ ~ ~ ~> Y e ~~ ~~ R .,,~: I~ ~u._~~~; ~sy I ,_`1 M I', TI~ F ;, 'YEN _. I ~~77~.".` POLICE TRAFFIC COLLISION REPORT L;(I TRAFFICWAV PaKECOMPwnrnuMEER I ~ PRIVATE WAY A Oo~u d•O O v% Rw lyl} .ID IwN N 1C yl p~ gI NsETO I`J' R) 1 counrr-L (~/ ~~ JcTT'~RZOfI~ coullnNO. ~lo on NO. HWA OfuReAN RURAL CIII T G~a t Fip ONWAY o f IN I {I / O//W~INfI// NAfn~ME6N00.O I~R, f, 5 Q ° ' ~ ClS RW EO451 I . v ~ nn ~ { , ` W • Avl(S Iq Of C"1'![I~f.r/C,_L.. ON D/T K. I.+r• 1 r1~. N / ~ (/( ~ ] fINO :SIRff ROAD NON IN aSfRION ~ ,too. <~~ ~va~ ^ RfrY/fEN $1Rf d. Siaffr • • RNtN% FO. MILE POST G.9® - ~ WSI C aU~R CROSS SIR[fr RNEA4f ifAll (,q~ MttfS N R S E ~l 'A' 1~ iFEr W Df ~ IC7~.~TT-. ACCIDENT MILEAGE CODE R DIAGRAM MIA COIIgKJN INVOIVfD: SEVfRI(YI NO. INIURED ~ ^SRIIUOF ^HI6 J NO llCO NIFL N WNIMRIRf N .R IMER [l5 IN I [ R OR L L OIOSSSr4fSTOR ROAp ] ~ _ IOfAl NO. dFVENICIES ~ P40MRIY DAMAG[ONLY ^p(S lifD ^VFIIICIE ~' l~~~y~1~//Y~" Q -I ~ PU~CKpINpM.1f O/f~OB1KrSiRUCK AN00,fy~L,?~5 ) \ [SDDAMAGf L..1!^RF-E~~ l.~fi!-+~' - '-sfc. "'u, 5 ~ ~ DB SHLCWCOOING L[LF ~7 `~O ~/ - UNIT NO. I UNIT NO.2 ^ VEHICLE . ^ PEDESTRIAN . ° PEDALCYCLIST `' s Dalvtws NAMe: I. ci N s Av Daly R NAM . usr Nx MI I RYVI @ 1 LL ~c L. - 2 sr4ferADORe ~'r#z gl~ laEfr ADDNEss + ITY SATE LIPCOOE PONE NO. D I SRA E u 1 ~e~E -~,~~-. Paz- z - - NfRSU O. SIAIE p 1 Q(A , f% wl MD ~ ~,.I~~ ~ I N NO. D At ~ Ai INt ND. ~ D„ ~YK - q OCCVPAfION NAMEIRANE NO. [Y[S GHI KIOHI E URA ION f14M NM1E6 PNONt NO. ( LYFS K.IIR KIGHI - °CHECK (.7 ' vEN AE ASSN OYFaANOMf9u ^GHECK (~ 'vEr.KxEASAN (MH Y(E OFANOiKRK T CODES - T ~ ~ A i 5 r a ;p fg CODES -* 7 n % ;; 5 rA D ,A Z , `C INIlN45 NV isX°.'7:I.oM ~ A..AANKr ^ 'uLc' ^ F$m. ^ .•n°~KU ^ f"i L:, ^ AMNAANK ~':ct ^ PSrrz. ^ „~,E ^ ~ °•:.v ID VFN fA4 MARE IDODOE{HFVI ~~g ~~~- fl IDA9 .NWA) SIYLf I]OR~ ONV) ~~~~ zD EI R 1 l(DMr.NOVA) ( a R~ Y GP.-y . L N o~UOCS srAf -wA. eR Plnfe NO. iR -- surf H R RI rf _... NNKI D(NIIFK'AigN SCR r X50 1.680 ` V NICEf DfNi I I i . ~ ~. - 4eusrt4eoovmK: LAST DLSr DOLE -rcc~~~ SN PHONE NO. O R I LAST flRSr MlDae u Z ADOReu oAmR ~O B Z Z 5, N-/~b can c. w~i N E r ]I NAMe aADDRessn wwRANCE .o4 ACENr r 1..)l9Nt I R ' ~ '] •- DAMAOID MN MARI..D 04AAG ARG~ > ^""'°"%` cHA4~ /LA cHARCf n,`. ,IONN 1 K~ `~ t •rD. ' L nr. DAMACt Ive ~nMNneD ~DRInN ~REMNnm esr.D AWAY 10 ~OIf0~ OTTOM S 7nf OD s _ v 1pv.D ^IOWEO LIJJ eY: Aw I DIAGRAM OF COLLISION NA c quern DESCRIPTION OF COLLISION: (Ibl5lMP1[M!N(Al s1R[ruN asswrl IlYCLSSLRYI _.. ARx ~ _.VET+~ 1-_ .Qhssu~G-VEtlle.~-.~ T!{P.nt.. ~~ 5 u A - V +® P l ~ - I _ - :. o~Nt lf t:rTOl TE LSE t*H . ~t .= -; i .tk(_ ~ u A ` ~ ~7 ._ uE rNVO IrtD reD- tuP.r ~c I o eK ~ienr~s L p n~-k~r BI~pA~ek~ ~ -- . . . . __ _ - Y~tlei. (~ - ~ _ ~. -T ~,L~ee , . YeP s o(v ~k . _ Z ~ I5o P Q~i r Y X1 a.7 IR NAME, ADDRESS 81NJURIESOF PERSONS INVOLVED ~ CODES 1 - Z 3 4 5 6 "" CKCUPANTS/WITNESSES ~a; a")~y INI,~,,' ~ii ~uK ece~ rArus """" ° m : ~ msn, rncr N AML ,M eY L M nn N c{ ~ `~n A fMR(N J ti D.P(]r ~o~ . eY. AM I . o~ I ° •^ ^a " ^ra,,, `T$L ~! 5 r' NO J o A ~, -LUl1. ~.EU +iu4fa ~t)! C- A 'f N DrRO.M°AMe ^iZ°'Y° .Op r ^r': N,. i0 " ' ~}-A.JAkA GA-2US c.e. Ib ~~ ,ll u xxrs~'71~i nR nun 'LA cr ). ~ t H rfgeY ^AMe ^::"I "n ~ ^ o ~w 1 ~ If tK)AIRrOUNIKrRS NAMlaLAN[ eADr ~~ ~I XT~ -- ~ ALf NCY ~f DMAICN(D ~~ ND ~~ ~~ DArI I 0 ° 7r iAt1 ~ ~ ~;~R.~ Q~ b ~s . 8 Pa , ~ ~ . a :+Y ,a ~~~ ~~ ~ " - :~ .~aiW°"'~f ~~yy~~~~~ ,yL''"" ~.?:.A~ Kai ~~ l 6 M1R i$ r +4 x ~~ f< z I I t '~! { ,._ ^ y d ~A ~ ~ is Jr e .~I~ ~~ Y A9iA" .~t~~ Y • %~i .) h'~ji N . ` ~,d ~, . . ~~ ~. E~.. ,.~,.. ~:. ~~ ~~ '4; ~~ >, ~~~ °~ ~,,. ~ ,. ram-(t,,. +~"`~+ ~j~yY ~; , 6n..t' ~ '4~.-gy>'.l RTi5is,2 ~~•S ~N{.~;. I 7 .. Y -, ' i] J9~ k 4 ` ' ' ~:. _ - I ~D- E c\ u. ina 4 V ccu c w ~r L T ~Lrrr cuL .rrlo --~c / ~`° O -.. cD Tv cr TGWN ~n ML nY~rf, +~~Grv, rowHT ~ " ' \ \' ~L!lu AUM CLG IrHEFI% (rlyrw EICUUE SECTION T fVSN MEOFGTHEET.110AOORH GHWAY •'Y IN(Ei15FCi NC\rITN'. Sr{IEEi 041 NOAO ~ i~~ ~fr7 5 q~ IO~.Et,(IUN~LOCAIION OF gLLISIU ~'LAGG E.Q •.~0. 01AG•IPM pATA RAMF STREET PND '^. .v/`. 'R ©© GTnF.ET :IIL a••n .2 LYvD E• ^vTrnncrnu cr n YE cu.~rrsmucK ....,~,., ... L~~ E i-~ f / J'4 ml\". 1i': LACT EIAlAE Ii F L ~~! HUN/~l. ~~. . .EHE~~ 77 fE 7 O nF msr ~ r ~' M100LE _ 9 v. IUTE NO AND bO%NO. •. GiIYF.RG DCCURAiION 1 UAEE OE'W \TE AGE w l p. l H .. J 'l GATE OF DIRTH '' NO LIARII.ITY INSURANCE INFORMA710N•VEHICLE NO. 1 I.:UA-.vYrr D LI7 SU'HPHCEPp HOLDER +-..czs--.~.__ MIDAUOR S+Ur•I IApIUTYINSURAVCE AGENT MIDpLE I \-/RfJ [u 1 ~ ~- ........... _ ICCUHATION cRM~f E%AV _\N c,~wJ~cl RE ~~ -,"1.3:L ` r U b FY FOIICY MUMUER A.,: -' 1ST WJURY -- ~ A~ _c G ci~`f G'f~_._ , ACE I 2Nn INJURY: AAMEPEE(XU FOn Pr%xrprvu WURIfV AGE • (NAME _-_ luyE,E -,. .. r N E U ' ... OM F .... .. ME% (]- iAl SU wJUNED uE ~ f)r rmr ^0 Nn .. -. ARKFRST CY+E TAPP 5 SiATUG OFI VJUREO A I , O ' NVf IC2 \X~ _ M RKFIIbT ONE THAT PtJE9 [ll A~ r~ YJILfn •.:CYERH \wrxrl ^ lH NVEHICLE ~iri Hw6 ~lunnrv I'pi^WF ~%, ()ITUE , ^ NO NRlEO I+LVLpfI UCU/NtYrl~ 1[. cui ~i'r.r _ r)_ v~~v~ ^ e^ e^ o~Ofrp o N DEI•,,.r.,~ I slaw NDm R ARRpwwr cLF. O ~. ~`~N~-__ ^ 5^ 6^ 7^ r Y •. -_, ) .,W- O ', E I OESfRIflI fIELOW W AT MAVPF.NEO INEf EN TO VEHrCLF9 pY NUMHERI 7Ar ~ ' 1 ~, '-? ,~. 1' - 'rarer Cai.:ON UTAE xn tw ~ .-.. _ _.. yrn[Lt VR HAtrrw.r N "- . ...... _ Cr NaMAFAS °" ` llalJ/G LG ~ [lJ ~S ~ ,~. rA..r,Y» E.frr.H.c,f A.,D w ` ~__. _ Crc A..~, AC Prrrclo..E+rn.nEl.A,wn ` L(/i/£.u •c/J r/ /d_G,E r LLCM I ;•/-/JY_ ~+-L~_ -~~~ ~°_' ~, I«/pprwL. ... /C'c'CG// f' lyTCf' /f'T .Sicr.. Sj,ij~~,..~,,~ ,~ _ , ~ _ - . ~ i+T Fy (h' ._.ITLfCAT-iI~ (~A~yT!/L.G~/i....C(iJ.rY! .. _.. ) ly~rG,C ~ _ ._. { ;" - , r~ • ~~ V'' f -- . ' I flu ~r7 _.._ _ . . _ - 'E ~ r .~ .r,rrl,.,r....r ~ _ s _!~k n , r - v Ott VEIIICLES POSITIONS BEFORE COLLISION ~ _ ~.. ) ) Y ~N~^ E 1v GI CIIIFI.~~IIr.,,r~IINIE CII Nn t.. ul t Y[u?tF I~ A,~, ~ r~,'" ~ ^,r, CJ ^r,R Ocr;~,f110^A,~~D„°Vi .' t; ,o,.,} ~ a ~ 4KitiS411X'~ ~/ r -[ I - L~l ^ ^ ^ UIkL_~J:S'1fr1 /.z•:' - ~ rc ^ t '. ) v rt . ^ ^ ^ a ~~P.ccyJ.Ji.n:~a•: ~,L•~~ • __ ^_ ^ _^ r~ _^_^_ na.rlRr, '`~ ~ r'~t ~+ i -r~ ~ ~ .. --___. r L ;,T 1 x va ~ IV ~ r'r A: va^ ^ ^ ^ uoMl a°.u• nuTM RIIIECTION m t ~) er Y 1~. e _ 1 ^ •mrWUK__? r] wunw.r _ T r DIRECTION I ` ~ li ~, t ~ 'r l T ~,~~ IRIA IW eACE wr Alrren -'-- - -.-._._.-_'n.=~ I:N .ff~~ i, ,1. ~.e37'F ~41 1 r~ I ,,, U(:HTCGrIAlIGI`• tV1i ^frCUOV NIGL .r 1 FL)/'1 J\U +nUµ AlJ I V! %' EA(:T ON:nrr~urvlEt1r nn h«I [I,~jl x~ Y~FI~JViF.~ U ? r A I r ^y ~ I,Annrrt I '.rrr ` :. > I r i'{5~ ~ ~'^~~ t t ~ ~ n ^nRY r' ^ ~ ~ ~ ^n.:w' ^ J ^ i')'~"• rl •u ~ i [ ,M rxl m t TarEAn ~~~~~ ) 4 i ~: [•) i Lr r'r ' (~j: ) ~. ., (^,~ uu K r r D A:Ir+ND ~SA~'~ i~r,- ~~Y W ~~ Y .GW q ~,{ s n Rner n AK c, nurun;nrE 'I I tr ~ ~"°r~ v.! ~ ~ ^ ^ ~ ^ lat . ^ L I n I r'1 . nrn ~' - ^ A n • ^„ ~~„~ N; Li . (] r.A%NGUFr TDHN ~ F IhOp ^ , ~l, lAArnln ri ^ Ilv f I T n . Enr+l " ^ °v..acwE T L~ r. [1 u•"~'mn nuw r ) G W .t/ An VEER il'1„Nr; ^ ^ rJ iK fy •~ ~I ~'4i ~~~ ~ T ~ c~ , n rrlN,l r.M.N trNrG ' ~__.~ L7 T^ E.Irn I t rt` I. n I d Jl f ^ N ~r 11 IrE, ~_~ I r r ;,,rE EI A T I I ~~,, , T ~` ~ 11 "~ 1 r.~ ~~--~,~ ci n 1 M I W,Y f ; (Y'N 1C } J r ~ N / ~°~f Y A 1 I I1 i ,~ Y ) r + I .I ~f~ ~1 ..y ""~ ~l'. ^,'1'"~~. T i~.r .. , ~~ If ~ ^ppT+-~IITre~ { A r/l 1 y~ f q~.(~~«y~,c~+~~ ~1 •F It-u ~I~~ '_y '~~T pl,~ ~~~ rr.S' ti .. ~~.' ) 1' {~ 5 2, -~}~'. f ' V ' P k Y ~~ .~ ~ ~ ` r ~~ y ~` 1~4 v~. ~ t ~'~ .~. ~r ~~ _ ~. I 1 , , ' ~ ~ ttS e i "k ~ 1 . a~ W ~ F ~ ~ ~ z ? . i !y ~(~ 4 ~ i ~Z M, ~' d r. ~' .w ~. ~, s+ ~ ~ wa; fit: G ~ eY ~: .~ .r- 1 ~ 3 i ~~s~- ~R .~ ~~ v .~ k ~Nm~'a~ 1 ~ ~~ ~ } . ~.~ 1d ~ . 1. r, 1• .. 1 fit ~~~ ,'Yn"Ev ~ ~.~1 Id R .. ~ 1 ~~~' ,~ ., ~~ 8~ I~rr ;M ?~~ nC ' . dEI~ ~, ~ ,fie' r ~;~ I ~n r ~F {A{ 71A.. A ~, 11 ~ 6: v~, " ` rt ~'~a'~"~~~ ~_ c - l Q Pw I . fg1NTY.+w::r+..::.~GTY. TOWM ::.. SoE MM1E9..Q ~.. •.-'.. GTY. iOWN:~r: -. T F AOMC/~LSJ P11yEFrt 1 ~ t ~ t DufEWE KBE O~- GTMN1 S L 1T+v} .ex G/ ~Ir'S /O ® OF N/ I~•1/ c / .J Z.3~ ;~ .,,~,,.~. GVENAMEOF 9TREET.ROADORHIOHWAY ..... iFASECT WITH: STREE7OR ROAO'. i PR4iMV EO,:{L `W AVLEppyTt//K r~I~J ~'/f {[ ~ Y ocCw ' L /t/ . lU' L 1~~'[ U / Gu ~,-J ~ ,~',! ,~ NONINTFASECTN]N~LOWTIONOF CO .I ~ RAMP }~yp,•.r., ~• v ' ,~ pAGRNA ~DNAyTA - f' a, /~ ,~{~T~~j ' r fIETW[EN STREET AND STREET ~ :~ t f : ` r.by~ T. i NWSE MWefRPIWOf. rX)T MLHONDPOi'SW MnEa09f OPOfxlliNV6~%WwAP• ;E - N -%f10 WTEP RE11 CL3. wSECIWD fT q":3': mFSM[I gAp;py. En CA ~~ t WTF0.5fDIXW. i[FT OF ^.T ~ p A s ~f `L+ ~... SC~• colUypnrrvgvto ervcM.vEnGe ~ lCrtt¢ ^ orNERlwprEl / / SPECGDCE USE. ~i 1. ~ ~,t M3': - o ~v <° s . nOrEl•r,l owECl ~ cle R wN / ~n E QVEmLIE PFOESIWAN ^N]•K N ^Ini ' ;_llti, 4 ~., r' •~: 1 OBJECTmRUCN : IRAwl D/06KLTSTN:D .. v.-:: OWNEROFOBJECTSNANEANDADORES9 ". LOCA . :.-„WRDA TION ..::..... N n/ esTSr•r[olOXT '. OWAY,~ ^© POW IO PI/ARalC FEET !ON • DNVERSLASTHAME.. ... ,.. ...... .._..FlRm NAME .... ...... MIDDLE INO CUO wwlna wE DPoVER9 LASt NAME ...FWm NAME::..-.. __: .. .. AlDG.E ..: l ~• KS L/_ W ~ -~ ^ uM'eETADgE59 .. .. ~ ........ :.POLITE NO.ANOFIO% ~ NO. MDBE n mO PlBiD.,p WEPT Wlwl b PEETADM .; ,,,ROUIENO. fD%NO.-, o ~ - • sr ~ . tY ... ........ .. STATE~_ ~.....••,. .IIPCODE" DIBVERSOCCWAt10N ~~~ EIgfI91W GIY_ .SLATE ..:.~ .TY, :_ / gNEP90CG11PATM)N _: o S ~ V .rt- ,G. DIIIVERb LICENSE NUMBER, ,. STATE SEX DA EOF&XM AGE" - DI9VER9 LK:ENSE NUMBER STALE SEX OATEDF BWM - AGE VGIOLE YR. MAXEIGiEV.•WOGEI : MoDELINOVA•DAAT) OOOY 9TYLEI2 DRI VEHICIEYR. NAI(v:IGIEV.-0000iEI ~. LINOVA-0NR). BDDYSTYlE120R1,::- rd. L r LLENBE PLATEWO. ..,STATE".: ~ iRMLERPLATE NO . STATE ~ UCFNSEPIAfENO. STATE.. if1AAFAPUTE NO. STATE:':+:• ~ ~ ,. ... .119bBMODELSA NEWEAI VEHICLE IDENTIFIGTgNND. OOOMtTFA (MIIEAGEI '. RFTCAMIH TIO. ... 11988 MOOEl9s NEWETq... .l VEHIC $ 00 REOISTEPEDOWNER..... _IIAST-FFISTaAWIE NMEEI - .:.DRIV SUCENY ND. ~ RENSLE EOOYMER RA4Tfl ~NgGENANE)..:': .:.. '..... p9V61911CF76EN6. .. IG 5 L .~ 1. ~/ S 5 r OvvNERSADORES3,.~,.... ISIREET.CTIAND9TAlE7"~.... ..., . DATE OF&RTH ~. ~ OWNEASAOORE58 ..:' T '.. 191REEi,Ci[YPWOmATq' -.:-'. _.:.. _..ENTfioP',RRM :~ RD DAr a U / T ~ 9Rw n ~ _: :.. .. .., . ..:_. NRBOFVENICIEDASIAGED ..,. b~T .. ~'P nPUEAtEOCOSi P OF NIGLEDNAAGFD ~~.. / •-.... iolei n ieEs a a'e •. r •- IY•'l~.hrei~ s _ LIABILITY INSURANCEINFORMATION-VEHICLE NO. 1- WAS iHEPE AUTOMOSIE UA(VUTY WSIIHANCE CAVERACtw EFFECT FOarHLSACGDENr DN YOLIwcAR YES ^NO NAMEANDADgE590F UA&UTYmA1RtNCEPOl1CYNOLOER .. E.y n.wl -- . :.~-..'•~..sMi .~. tF.... NNAEOFllA9LITY HSWLVwECONPNiY-., ..... . .:.. ;. -:.... Orr ° ~,- ,E, 5 dr ox M ~ S o Z ~ R '. NNAE AHOADDRES90FIMBUTY WSURlwCE AGENT . .:. On ~. ,. ,: s iE, _.:...: .,. Sv ,.:.':UABeITY POl1GY NI:MBER ..:_.....:,.. ,,, ..."~ .,,..... . RY •9R WXAESI . !1L( Rt. n W E 'AGE ]ND WIURY WSE t ST PUU •w. _~~~~[/ NAME KR'/ ~ ~,/ V`Qi//'e~ __ ~ .l.. f...~~ a ~ ~ n ~~ T~OTU. NIME ~in/ C/Ki%! ~/ci//J__ __~ ~~ ' / ~~ Eo ~WDRE357J d C•U /s/ a T 3G/ YA~~(IHVL' •.c~ puM/:..r~.n!a~ tNr slr ADORES9 , /J G. SE% ~ D J3c~a„~!~ _o.~.lliiNd3~ ~~_ a /c/ o ~ H © oRS rT O ":: ro ~ ! a PeY.ooerq, DDCEgS ~ era MARK FIRST G1E MAT '~ A 4E9 STATII_OFINJUREO MAPK FI115T ONE iIUTAPPllE3 ..; •: STAIUSOFlUUREO .. W VEMCtE. IXS•Bq G Nw~•aU ~ WLLED IS[vf BR MW~I ~R NO vGSSgyE '~~Qfp~ W VEHICLE. dSbIM NDN roSYMi I~pDAN EicI O ~~A ~ KILLED ISE~VEnYO ISMDR B ~ RNnI q • TDI ~1!c.a ' s.wwNO MwARROwwcmaE '\ ~ Nac•tewrweo•Dfww~ I oESCmeE BELOwwIUr NPf+PE]+EO: tREFT3trotEwLiES BV NLIAEBFIq: - a ~ .__.. o4GCL1lts= s AACE Ta~f WRNS rMfPFIlECI3~ r' raN C LIxN uR.e. Y.RINa N ~\ . ~^^ ` ~W ~A~ \ SMMI[ilN9q rSGHWr NAVlS w • . ~ ~ OI' I •• - ~ ! wvllfR IN:N NHid! •rro ..HDW OlRCrgNpin•vtLerAwgw `. ~~ Qom, ~ I i ~~ ~~y~~ _~~~~~~~ -~` ~`~/.sF•.yL. _ I ., ~~E~ RDN --~J - - .Tifw /~~7` C _. . / o :"0 ( ' (~ 5r r ,q _r ._v _s a ,.y r~ r ,a ~I ; !~K ry iliy(~~._~3 ~ $ _.---- - ;, ~ I [/ : u. i. . + ~ _ . .. x I I Z __... _. W .w s rr o VEHICLES POSITIONS BEFORE COLLISION DIl '<u oiclW.v~'!D WVE9RMTEDm l il Ir Nwe ' l[ONIr SI~INIir•1 r rIS p ^ j~l l ^OTNfR np PpIG! ~ ~ VEHICLE N 8 E W ON TREET OR HIGHWAY NAME OII NO WRCIXN ^ ^ ^ibutt ^~~ln I.rX.n ^ ^ ~ ^ ,~ ~ / ~ ^ E ,P prMn~ ^ ^ f81 ^ ^ ~] ~~ wrrr ^ ^ W IrwN. ^ ^ ^ O ALGNO geylp rranM oIM ECTION To DIPECTION n1O'~ a gnER IYDI. SIRNI WAS UElNb I^SIOE WALX ]^WNNWAY ]^:.IgyIDER .^o ~"'ww! K•~ U1M/ER/VENX;IEACTIONS ,. ~ IgAOSWIAC! NEAIHEN LgHTCONGTIDNY TRAF/ICCONTROL ICrvfty wli TYPl OPROAO HSIe P;NCnbNq AWMI ~ v K vUC1 I~ iu.xl ND 'r 1 r I K!~ICA dA'I r a w 1 ^ DAYIrriHT T ] • ~ i 1 ^ OOING STRIIDIR NIFAO ^ 1llr: WAV ^r l ~^ Nf N9 ^I 1 GIr ]~RNNNOr ] ^ OAWN ^II ^ ~ ' ^ ] ~4TOP Gf1N ~] ~IW ~WA1 ^ 2 ^ OVERTANYq Nlp PA95N0 I•wlwt ^ ^ MA% ^ ] ~wFf 2/////"''''' ^^^^fy.ONrNR s ^ DuSN ^ S NO RXINT TURN Iv NI ^ ^ ] ^ YIftD :K/1 ^ D ^ s ^ W~ t f00 ! ^ l'GNT90N ft ^ F ' ^ ! ^ /IASHWD HEB ^ l C~IIiIV R~, 11•MMI ^ a ^ MAXINp LEPT TURN ^ 6 ^ MANWO U~TURN ^ • ^ ICI S ^ OTINR S ^ igHI80f/'T IJ'TGfYI O ^ s ^ IlA5NW6 •M9fR ^ n ~•) -Ill r A r IrAr WA/ ^ e ^SLOWYq lllN I a~•~ WXNO h PFY ^e^ y'%~9tn[ET IIW.f:. ^ e ^NI CVGNAI Ii~iTrl ^ `- ^ ] ^ST01MDPOR iRAFFIO NEASUN IOw M)TeFIAW D•Ni<R r ^OMIR J•[G/Y • ^ I ^Of/IDtR:fIAGU•N ....-- mGWED Ai IDONAL IAItD ^ e ... MrAACrvwv llCr ~<~p9r.• ..~ F STOP 81011 ^ e ^oMfR lvecvr ^ 1 (~I+ N ^ v 1. I IuN"11 ^ 9 ^ mafroeo W ROADWAr F O ~... 0 No ~n.ivle - E vXAr•NM ^ Ie ^ inur lcN L.ne F 9TION Wrt W.l1 MAMF AOdIFM MFRONI(1I(NT[RPq /1~~/~'~ss/~S ,10.: 'S ! _ 1,• a YP.111~EMR4'S'ID'T'..^ II ^ PNIIEOIV gIiCEP'^tlF31RR'f'u.T'SMIA! ~r ~ IA R•c%ING ~ , Cr-„• ~k ~r ~~ ~~ '... •: 4§ ~~• rr +5 fi (y~1 ~.~. Gi.~-~ '~~k i., - ~ n ~~T - ~ ~ Y ' ~~ k r 37 ~; T ~' u~ Y v "~ Ft a, ~~ . ~~, ' )~~ . ~ 7 - _aG s 1~ ~"'~ STATE;OF.WAStIINGTON` - ~ r~kG ~ ~~ ~'MOTOH VEHICLE COLLISION RE ORT L ~.. ~ - 1 J~• Rr _ OF COLUSIOH .: •... .GA sMI Y-•.- _ U&ON~. ..fIMEGF[.OWSNJr , M.NrLa a• __ r wUNT~~ 01 '. ~, ' ~"~ - 2~1 - 19~5~ rM 1' 2:15 .!,.. pArn[S- .~ ,.000NtY ..,.. .. CITY.TOWN - L Imo ET MILES - OQ CITY.iOWN. _ .. PONCES PREn% AOUrE,G Ff CPEE SECTNJN l~",u,30 ' „~ Jefferson,Port ` WAR pp DF [ - dVENM1EOf STflEET.nOAD O~HIGHWAY - 'yF~~ ~ •~F~~~ WTEflSECfWO W1T11~Sr11EEI 011IIOAp, ,. ~~ n PREFI%. - EO MILFPiST~~, - (!/% Count Road 1C7 ' «cv°fn"xEP Y ,rjc c~v~~K[. •.;~ quarry Road NON WTERSECTION~LOCATIONOF COWSI /~,~ Cl/ hA,7 - ~ FIAMP gA01UM Mrh , yy--~~/ ~ STREET AND .STREET EETWEEN , »v J.,V • ©© pAOw~~~psrwiEnstCrnparaFEi x W]E WNEEa. RVPDE. Os. nWEiO5r0"OEx[HYxn l4/Ww", NON %PO IN(E IN(ER CLA f ' FFA[K UO6f9 rt1~n11 N«Pb~-. i - ~ E ^ ^Orx[alwnrn - CoM v«v[P SPEGCOCE USE L.r Nr ! L~~O S7. - E ODIEDT gTRUCK •HE ni DarFCisiWDxl OWNER OFOSlECi9 NAME AND AGGRESS W~M In WF~Dw~E°T~ W~Y Q© "°`P F 0 Oe ! .. FEET s - • pPIVEPSLAST NAME (FIRST NAME NIGGLE [ IwV CAn' ~ E a DRIVERS UST NAME E FWSt NAME.•. MK10lE • :•iiles Loretta h1. ~ c Dloone J. D. STREET ADDRESS '... ROUTE NO.AND FX)%NO... PLD Nv q RONENO.ANOBO%N0.', STREET ADORE59Y , - 448 S1. Dell, P.O, Box 941 pnEOUSE~ 4258 Evergreen nVe. CITY SrATE DPCODE giIVERSOCCUPAiION EvARVrE CoulsnN CITY STATE .... ]]PCUOE DRIVERS.000L'f ATION. , Sequim, 'r7A 98382 Office Mngr EPDRrsoxM W. Vancouver, B. C, CAi7A A I DRIVE11g LCENSE NUMBER STATE SEX_ DATEOF&RTH AGE .. .... .. M F MO D•v vEM ~ DPoVERSUCENSENUMBER .. STATE SE]t DAlEOF BIRIN.. AGE u i wv vFM VEHICLE YR MANEIOHEY~DODGEI MOOELINpVA-0Afin OODY STYLE 120R,1 VEHICLE Y0. MAILE(CHEV.•000GE) MODELINOVA-0ARtf BODY STYLE LT DR.1 1980 n 4-d r - LK:ENSEPUTENO. STATE. TRNLERPUTE NO. 9TATE LM:ENSEPUTENO. 9TATE TRNLFAPUTENO. .STATE PDD 610 •a '/EHICLE IDENTIFICATgN NO. ' IIBBB MODELSa NEWER( ODOMETER IMILEaGEI VEHICLE IpENPFICATNJN NO. ((BBB MOOFISA NEWER( OOMETER (MILEAG REdgfERED OWNER ~'. IIAST~FXiST•M100.E NAME(, ~' giNERS LICENSE NO. REGLSTEREDOWNFA rtAST~FVIST~MIDOLENAMEI OiYVER9UCENSENO. Jimm Come Latel Gazzet e F Ril1 OATEf BiRTH , , CRYANDSTATE) , (STflEET OWNERSApORE59 '~ OI O,vNERBADUPEBS ,'.: ... ISTREET,CITYANDETATEI ,.- DATEO W °"' Y[•R w l~ , _ , . .... ,. W O Bax 1750 Seauim ;dA 98382 EsMATEO[mT PAAiS OF VEHICLE ONAPGFD EanM•iEPEOSr fender ri ht hdl t ri ht door s'°`Y"wCtS`ff PARTSOF VENICIE OAAIAGED front fender ri ht hdlt frole.rnvPwu WAS THERE AUT LIABILITY INSURANCEINFORMATION-VEHICLE NO. T- covERACew E OMOBILE MABIMTY NSURANCE FFEGT FDR iws ACgDENr DN wuflcArl ^YES ^NO .. .. ;.. NAMEOF LIABINTY WSURNKE COMPANY NNAE ANDADpRESSOF LMEIl1TY WSURANCE POIJ~HOLOER Grr Jl:orn Come Lately Gazette et. al P.O. 175~,ISeguim iiA ~ Oregon Auto Ins. Co. lIAMEIND 0.00RESSOF LMBAITY WSURANCE AGENT CHr siAIE '. lM&UTY fgLICYNUMBER .. •1,1•i, Fr er & Sons, Se uim, WA 98382 AC 45 7515 IST lAlI1RY NJE TNOINJGRY: ., NSFEFPNMTEnEPORTFM •OGTKw•LF•MSEA ;.... AGE ....... IOT•L NAME NAME wAME ...._......._....._._......__-__._._~__ ., ~..-. P- _... _ .-. .. _.... _.. SEX ADDRESS _ _._.____._ _._.-___ M ADDRESS SE% P _ _. _._ .. _ .. ....._ nt u wi ' ^ F E M . u ° ____ i__. __._ __._ __ _ fIf ^^- 1I uIENIPi wAAU[ _ .. .... .__.-. - ~" ®~ M".-..~ « ' x•uF i+ Mx IDx vArnnr«n IJ W°id" ® •r„ •uw"q'v BY •" AT APPllE9 .P. ,,, STATUSOFWNREO MNiX FIPST ONE THATAPPUES STANS OF WJURED .MARK FlRSr ONETH W VEIMAE "O"ti,unvVY° rOSVaLE ^ GWE W VEMIOIE r wA~iunw0 xwOwaN6 osvnlE ^P~f1Gfn ~ KILLED 13EVEREI I•~P~O Aof P C~" ~ KILLED IY""Enfl I4wPR1 n i ' [ r n o i w c l E ^P•511 i.1:(n iCl ^ DI.aiP~w F E ^ R•N P 4gWNORTH OY APROW WdRGIE ,.v ~- ~ I Nac•~Ewn-+o~.nrw•M ®'•\'~~C,TY ~ !I ~ I r,N°EeH[MRHErN,r1~REeP; ,"~ \\J~ .«A.~«IMaHacEHEwRR„nw ~ j "'H" °" MO""`T """" °" ~ .,,.,aEa, , DESCR BE BELO'NWNAT NAPPENED.IREFER TO l4NM%ES[IYMUMB[W , Driver of 't1, travelling at approx 45_. h saw ~2 arked with no blinker on, P P -_ , t intersection xzkifxs~gxmxiacats 1n an ry. Bw[cnoxaiwvT[er.,row '""""`"`•`""iuC1YiOS"°" ~ ~ y BraE r a.« ---~ ®F- ' ~'"'"" angle to move towards oncoming ri. Rig- and corner of 2 was on CR 10 roadway _ --_-_ ~~,' - - - - - - - Driver of 4~1,determin~d there, was room _ 2 without going over center li ss ; t - - . al ~ ~ ,i ~ o pa F ~ moved to-do so ';';-2 was-farttier`ou't- I '~ 'nto.road..way._than..it appeared._;~i_stru ' ~ i ' I~ P~z,_ right headlight to ..right._headlight,. - g us_hing.;p2. back,_ ravelling._ahead_.appro _ ., ~ I stopping aL,d,returning,.tR..ecen 50 feet, ~ . ,. VEHICLES POSITIONS BEFORE COLLISION M0 n '~" EnuD'v`:a. KNI+IP w•a wvesrKUreG Dr . ar.`.K+.D m vxcu «cu.er ^:r•e ^nm~A E AO Alx« P«if EE ' EY . v Ly M [B VCraOIE N g E W ON BIREEI OR WGIIWAY IIAME OR NO Pw CIiD a v,~Nn. ^ ©^ ^ Ta rkinE .lot mart Fd ® ^ ^ ® ^ ^ ®"A"'i ~ ^ O D D Ka%] `cwoMl~D mOM DIRECTION TD DIRECTION ' cwu+ B^ORIER rY1HSfPoN1WA9 U"tv0 1^SKXWKK T^WKKWAY ]^SIWULOEII 1^[r w~wM+ 6^~aix IIOAD':IMI/ACE WEANtfR IWIfCONgi1gIS fN,/ICCONTROL cN<+IN[I TYPE OF ROAp DRVEn VEHICLE ACTgNS , ' I F.N r. [r,l vN<rl Hv ll ICH[~bII AO I E Pw 1MO rt1 vN,LYI IGtCKOx[O M r M wt,r GI•Q I !gyp ~.~yl I ~ P•vLIGrN L J , ' ! ^ I ^ JGN•L9 ^ I ^ ONC WAY ® I ^ GgNO 6TRNdlf NIEAO ^ RN~p ] ^ OAWH MY ] ^ 1 ^ ^ T ^ gIG `.IGN j~ T ~ INV WAV ` ^ T ^ ovcnTAKwD ANn rA.551N11 C~ ] ~ wTl ] ^ 1NON010 ] ^ g15X DOLE ^ J ^ YHlO CAJJI ^ ] ^ mb ^ ] ^ MAKWO RIbIfi TUIIN ^ J ^SNOW , ^I00 A ^ q TOONEI ^ a ^ fU'IIVM. n(0 ^ , ^III~fW1~16E ^ 1 ^ MAKMOI(fI TURN ' ^ lbIr410ffEI 0 + W ' ^ ^ , ^ ^ a ^ II A',IMO AMAYR ^ B ^ E ^ B ^ MAKINIIU TURN 1 - A fC NI Ot HII ^ B ^ SP[CHY B ^ °mni°onrs WO WAV~ I ^ B ^ ro' 90NK ^ B ^ llf f TARN ^ 6 ^ Cf.OWNq as I~l •SO.N iOR1gf:'E(MDNRIaR OI FN ' ^v~(CUV Of IICER.ILAGMAN lINtO ^ ' ^ ^ T ^SIpK'(O fORTMf(IC , "vrw GyINICV•'ha,ICI ' '~V ~'OIIIER. IPidFY ^ 1 ^lf PANAI(0 ^ B ^p1AT01'CJ ~µ MtiHtG'-AGM ^ T ^nYKxD ^ o [~ s1ofKHDWraAnwAv ~ o ® x o IR nrlc ($ .T ®uNgvEr•D ^ [D ^ n[win "'e pp ~y ~Ji, .,,I n:Y~ 1 ; r H(~~.'.~~ .^n~ ~w~1~~~ (1t `]]y i~1r~r1 ~ 'I "Y '~ µyry H ~~ ~~Ay1~~~~~ '~'~ t 4 1 ~~ L f I11LI~[[ ! ror '~~~ (~i. I \, ~' .. ~~ ~~ ]EtL ~ .. ''~' ~h. r ~ E ~.k . ~I ~~~ '`~ 1 a~1 '. x ' +~'e ~ ~ w' r ''~; ~ ~ a - v~l e~ Y °1}i J ~~'dk E ~~.. ~ L , ~y$ .:.~~ ~~ r`Y~i ] (r _~) 4' 1~; P ,,1Y ~1 IL= I ~ 1 t. ~~ ~ ' l ~` _ ~ ~ II y a -s"g'• '~Mrmwrr~ ) ~. s l.R fir ''gg t ~, ~ ~l~{,t~- 1 r~ ~~, `~ ~]! ~~ , ~ ~~ •~ '~~~ ~i P 1 ~'. •~~ t x j.Y1Tr' ~~ ~ ilry~. f ~• ~JV ! 1~~SIf~S,iP~. n :J'D IEOF CJO~LL~ISION ,y/.~ YD C 1 Dl 1.'l. D^v,liN I`l>~U AYOF COL ~wED 45GH.. -~. TIMEOF COLLUIOH,,•~• rHl,x y, 3.r ~, • p~w11E! AM COUNTY NO/ CIfYM 4 ,~Cn="r "1 )'"S+ " p„~,,'{ I COUNTY GIY. TOWN ~x M0.E9 CITY. TOWN N ~ OMC[3 PREFIIF a fW! RFRr'M! SECTIDN kR -lrl=/~2°~/v w '.`,I ^ ® l Q® DF • ~,2T LI.iG~ra~~ ~ f 5..~ 9.a~. - hNCH r gVENAMEOF StREET, POA0~0~ MKWWAY s;(/ ~~~ D cz aNr~~ rv No lD dF ~ WTEnSECON6 WITH: STREET OR F10 -- r/1hY=r=}l r=oFo ~a~~~- ~ PHEFI% EO M0.EPOSr - . d GA ;. NONINIERSECTIgNLOCATgN OFCOLUBION ~ v/~ j MMP gAGRAM DATA. ~G PETWEEN 9iREEi AND ' SinEET ' ~ .. .. •~ ~© n:uoiacnoriww"Mnixasr n'sEr.nwrl asE rNMlER.lR~DCf. 9A OENi MVwaxxK NoH z.RO c.n Ee aA K P iiE [ O . xT,EGbrr: FFEr © INTEP INTER CI.S ^ P l Errt (MU! T nPWD~ 6991 _' ~- cOrLLSUrlwvpvfp --- v[nA:[[v[nKLE ^vEwuE DOrCLF ^om[nlwprU I SPEC. CODE USE ,_ ~ ^WrICLEDeIfCr ^VEniCLf IRAW OaV[nC°ES - 2~• L__J veHK[EV[D[srdw ^wNCausaN ^nrwn :.. ' . .,. --_ _. Op1ECi STRUCK - IN^MFCFaeKCrsrPOCKI OWNER OFOBJECTSNAMEMDAOpRE58 IN fl~OM W^r .; ,.. ^© wo e N roni wx°cavicr ~~ ~~ FEET D e s ~~• f iF MdrE MAN C • pPIV(RSLAST NAME ~ ,, FlPSTNAME ;. MIpOLE / . WExewWtvED DRIVERSLAST NAME FUiu NAME . MIDDLE . [ ~11.r'('!'vL,~! .~D?L:.fJ- L~ft'1./~(~ Wrws COLUS~Orr OR l~~lc<s~ L~,~~rr~', SrREET ADDRESS fWUTENO. MOBO%NO. MOPE mM1 Two STREET AppRES9 .. ... ROUTE NO.ANOBO%NO. ^ Ic JIMMJ (,c:a PA'S [~ GTY• STATE 2W CODE ~4rrj VA~LYIL'~rv E,G DRIVEP9000OPATN)N ?il~lrL~6~;/,ljti~ COLW~ nEPaRrFdw GTY .STATE .. .. .LPCUDE. OWVERSOLC[1PARON UFirvEPSLK:ENSE NUMBER 7j' F~lr/ ~- ~7 STATE 5E% M ~~%L' OATEOFdiRH AGE uo gAr .eAR / ORNERSUCENSE NUMBER STATE .. MI-L~R-$L-IY{ii'Li122 SE% M F WIEOFBIRM~ Lo D.r rf.w AOE VEHICLE YR. 1~7c% MAAEICHEV.-0ODGEI L!nlCtGN MCOEL(NOVA-0MT) T ~vN csv.~ BODr STY I]pR.) !. ccr~ VEHICLE YR. MAKEICHEV: pDOGEI MpCELINOVAOMn. BOGY STYLEI]DR) L K;[NBE PLATE~~qq: SZAFC. TRNLFA WATE NO . STATE, UCENSEPLATE NO. STATE 'iiWLER RATENQ. STATE., ,. VEH CLE IOENIIFICAigNIq. ItBBB MODEW^a NEWERI r•.~~ litrJ ~ ~ ~ 'G G%-, ODOMETER IMILEAGEI ., ,rca ~ - VENIClElOENTIFlCATION NO. (1888 MODELSS NEWER) pOMEfEI11M0.EAG J• S%~jo<l.c~ 47 nEgSTEREDOWNEfl ILASi~FWST•M100.ENAMEI. ONVEIISUCENSENO. U~~ titis /11~c ' gh flEGISTERE00WNEfl ILAST~FIPST:MIDDLE NAMEI OWVEfL9 LICENSE NO. , 7y Z~ u / OWNERSADDRESS ,..., ,. ... ..IST~iEET,CiTYMOSTATE)..,-., l?io V~r ~'i2ltitl.>:V/r VANC~IL~+G t%~, OATEO~gRfH OWNER9AOORES9 (STREEi.C1TYMDSTATE), _„ _, AL; . ~, [. c, c , F, L, .> e: r T: DATEOFBIRTH ~. MD wY LE OAM EO / ..: vEwOIE ~ ..•..:. FsnMArfOCO3r .F J ~ L.~ srD R~NR PMTSOF VEHf;LEOAMAGEO, .. .... .. ..',.: ..:.,.. fsrKrArtD mr .. SroRV^wvFl.cEf, WAR THERE AU LIABILITY INSURANCEINFORMATION VEHICLE N0.1• covERAGEWE TOMOBILE OABILITYINBUPMICE Llf"YES ^ NO ' FFECrroRTwO ACGDENr oN rouR Caw NAME MDAp ESSOFUA&UTY WlURANCE POl1C ^~IK1LflER .. NAME OF gABIU1Y WSURANCECOMPMY NAME SS drY SrAIE IP I .. NANEMDADORE990F11A&IRY WSURAHCE/UENT v sAiE _ LP UA&LIiY POUCV NUMBER .., _. .. ... :;., i ~ ~~ • 1ST WJURY - - . NAME ADDRESS .._. _ ME E% - AwIERFxORl FOR 2NpINNRY: ~ 1plE5 i0d _ rA)NKfu%EESI ~ NAME ADDRESS . - .. .-~_. __ -_ ~ NA .. _.__.__._-._^~ AGE _ 9F~t~ M yyCC..,, OW D' lrANK IOm © I~ xaME v N ~ Er OR+ ®~ x~uE STAIUS OF WIURED ^oxrv[n WVEHN:LE ^ ASSENOfR gLLED MMNFWST o I-'[v[IIEI CNE THAI APPUE auRD v 9 ROtsp lnR 1' 9TATUSOF WJUREp ^Dwv[R WVENK:LE ILLED MMKf413T d3xxwD IS`WEVEnFI ONE IMATAPPUE Na DI!^RLWO [w~O 9 ~p`E~ M ^ FSrPw ~ ^..~ .,,. r.•. ^ 5^ 8^ Oip I 7^E c ^REMSlmirr NO. ^„n,r:, A~rrz w ^ 5^ 1 R 8^ Pa otN[iCli 7^ SHOWNORTH BY MROWINGRCLE \\ ' I -ewe anww.N~.rwnlcr"e O ,• \\ ~ ~ rR.c rH suHF wr.rwaw ir°ii oq`'"nK ME! 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If d ~ ~~ rd r` f~ r ya~~ ~ ~ RCN r,~~x~ ~ 1~+'~p F`~ tPr e ~' 7~ ~ ~ ~ ~ u F ~l Sr ~a 7~ - " ~,"~~1~ -y~ 1 ~`" ~'" ~ i r ~.~ ~ i , ',~ ,~, ~1P y~ 9 k ~~.,y ,~, ~.w, i ~ 4 N~ f ~a':~r 9 ~n qty aa.,e,i "~S l " (INSTRUCTIONS; A.•, ARRrnvisl Tn-NOw RBUacmAE DlRlcnan of roar - ~_c ~~ Q ~'~ J r a sKEt.- Ic nApa-i t-q.tNS Ma*prTl.. tr- OAMAG EO VEHICLE IJ 0.1 n rx.. sr- OAMA GEO VEHICLE N0.2 t; l o. _ o:: SEVERUV Or OaNAGF~ vFNICLE nD. t pp INC p•macr. 5 ~ oTxER M.v. parnacE ~ ` __ Ata4[ I LFI IF^ n nlncErN ^^ M. .E p OF DAUwcI v CL "" ^^ eACFEI pp rA A •cF ~ c~ ~E x : ^ c> IDrvaL UANAGE . O N AacE z O F C] N u ^ . ^ xo onpacF row6oev ~~ I au E ST o wE sT.paxa wE - r, oaLtacF la L.,v: I, S I 1 To To :DIAGRAM OF COLLISION ~ ~ ~ ~' DRAW AflROW SHOWING E .tunes a ~ "^ 1 ~ " '~ _ ~ ~ ' I NORTH IN CIRCLE vE r. r J I _-., ~ O r -_.~ .__ .~ -- _.. . ._ ...... ~__~ _... ~ ... }. u« ~'PxpSne K[Pp NT pE ~ -_.. i. •r.____ _... I~~ _~____-.r_. _-._ _ ~ _ . _~ -~~ _ _ . '] sxpv vrN Cl[ IF VISt NrAV px pert Cl Ppsrt tirvE At NrA4x F WwwrxpsneE[vlx CEr ox Plo[Eta •v ol~ipryrunr ' ..• I. ..- _... .. _. _ .. _ I <. ~' 1 .._.._ ... .... ..~ __. _ 1 . . ___~ .__ .. . .. ' _ ___.. r. ~ _ ._ DESCRIPTION OF I I iPROeaely Na.PENEp DErpRE. Rlxc arvp AFTEn THE CRasN, INCL sele ui Wac im UDE INranrAanorvxoT pN macnaril EC..untvER COLLISION l . pucfowslblurr. PfDESTRInN C NlNy colon. rnxsrnucnDN Dx p nEPaIR wDRK. EIn ~ - ' - ~~... , ' ..... _._i. _.____ _..:- -_ ....._____. .._ . - r , . _ - _ _ . _ .. ra _. _ - __ ._. _ _ ._... _ y- _ _. _. _. ._ .._ ._ _ POSITION BEFORE COLLISION Np or L N[wpEU ON SinEEr OR xrGxwwv NArAE On ND~ - ~ Ix ONE DrR rvD. Irv l CREF5 N4 pT CREASr No N 5 E W ~. _. _... .___... r _ .._I ... ._ -_ "_ ,+., - . xEE Pfo. Ltots NC _. .. alp c.-__._ ____. __ _ _ _ J--- p ~:::. 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SLDwrND' -- I I cip iOR ~ TRAr C LIGMTCOIJDITIONS RAFFIC CONTRO v1 N0 tE. TYPE OF ROAD VEHICLE CONDITION SOBRIETY. ED Al SrcNAL rCxE(K UNfE ICL[ ICrIFCK UNF OR xIONE NoCL[ E Ox(C 3~ <.N[f.KU 1 ._I .J 5 pP SIGN S14N• I^ O [wwv ~^ P I IUPPEb IN _ ...._.. i........ _. ____.__. t pwvll4NT S~fN J Oww. ... t bH I LS V( I n ^ ... __. .... ._ ._.. _ ._ _ _ ,_ K . .. ._ h : = .~ WAV II L lv r ~ p....l 6 IxO IN IILp.. _.__. _._._. a-- - TRAFV'IL LANE . ' Nl vEr5Pl1 •J p[r l[iwl ~ J. . Uxp AplLlTV r_III- S1nHTINO FFnrA J' Uwwx ~ pr._: SG+n-. ~ NUAn _ N[4p Lr4NT5 .. _. .-. ....~ nUT SPAIFID_~-` _.. •- I.._. P•NKFD PUSITIDN `.._ ~~ ~~ } ~ - ~ r- NtlnCxwn41 ~5 +r VE ,1 NxUL WSR t . I.p. _. ..._ ._IOUP FatnP •. .... -ftC L .(lit .__. .. .; ... . UNn~ ~O t30N(Fl 6 Lnsr N4 ~ "" A(lCV lnil'. wOIIN E' xnn AVp[N 5 ~~. .... UM 5`A OO1N N(Fn D+ ~STx[ET -" rwpw•r_llrT ".,"'- .vct.~xlu i'ti~l~ .110 ....... 4., 54 A( 5 TVrlrllANlt + .- 1 ~Ur- .. bi R(1 O4 '... E ' 1 1 ) NU UE E 1 1 OMR [lv MSN NOICNIENIN4 I> -. _' TRA~FICI _. _... __ rvol ~ - ~ PACKING bIUNKx.f CHEM. TEST ". ' Dllllx LCIFVI L fN ~ O METE C " b[ r _ •r t.. T 1 TCST NESULTS 2~ -_ - c c I ..w ~- c E, lu wn l T A tEa.n~nuw n IIA.Ernn J_ >. KE - .-.._., ,IL, x ----- --rt-b.~.~ ~.;; _ ,fIR rPlt _IER.. .A N ~__PE PNE--1-` ~ nUPllCA1E COPY EOOAI LAW INI UllCl IAf NT AOFNL'v~SC(11`v~1111Pl ICATIsCOPVr IEIV F. ^.tIGh10NVt COPY ~~°. . ' .b' ~/ n x ~, r U .~ i ~~F ~' kE tl ~T~ ~ I ~ ~ ~ 1 :~ A~ly ~ , ; 4 ~ 'i ~ ~~ f I d~ ~ ++~j 1 . ",Rte 4 {t ' ' ~ n v I ~' I 4 M7 ; ( : I ~ ,}~ 1~ I ~ ^J {i I q x f ~ 5 _ F r ff PyE~ f ; Vut N~ c r ~ ~~• 41 -,~ ~ ~I R^ i C;~:,~•~~ J;`:IW."""tr r' ~~.7~, r . f Il § Q n L} ~ ~.tA~'.. ~~ n "-'v-^rDr -.•rc rn~" ~,.~... 1f(4 l 5 ..1 fr ~ " P G I I ' j ~ S / r _~1 i '` ~ .~ ~ 1 t r '~~44 •pltltt I u r, ! 9Y1 : Ec b ( 4 14 ~'b U T 1 I ~ `~+~r `~ r* _ > a _ I~ . ~ 1 H ~ ti . ~ ;+~ I 1' q j l }~ ~ ~ y;;j ~ ty I ~I L . ~y ~~ ~ n14 ~,t~~, T T L .`~l ~ •T, r;. 'Ri ~~i AD T E DALE OFCOlElS ON __ _ pAYOF COLISDI. -~-~ T E ~~-- M DAY SUN ED PM fRl y T ~Z IUly T Y.] V 4 S 6 IU O 1 ~ _~~R ~~11_.1L~~ ~ FOUR ~L . ~~ ~ )- J ---C OUNtY NO ~~ Ot NO p /~~/ ~e20 fnWA ^UPbAN VRAL C r _ _ ^51PIE POVTE I_YCOUNTV ROAD ^CITV biR E E i 0 OM Lb PPEFI% ROUTEOR biREET CODE CTION 1'{ ,(,~-~ rV J~'L'~ ^OINERINPEC FYI y{ N Jrr ~ Ct ORIOWN (~ ~Fv~J ff~~1 ~\\ /T ~~ r~11 N ^ ' ]1 '-1 ~1 ~ ~~ ^ ~ L REf EO IA Si C ( MILES . _ -nJ 17LOF._ .. _ l.~ LL T e bN FSTREET OR MIGMW INi ECTIN WIIH. SIPF.Ei OR POAO ON Lf; iNS ~•/ ~I~c.~" R LL AMP DIAGgAM DATA _.. ... .. ,' • . ~ O NONINTERSEL ACCIDENT IN j ANON %~PD INTEPSECi1HG bTREF.T pR pOAU OP PEE. ' N NET MLEAGE IMEP Cl5 EflENcCE C~flOD S STREET OR ROAD ' WEE _..__ ___ ... _.____. STREET ANO _.._. _._. _.. .__. _______.. SLHEET DISTANC R CODE ,. I . ~ - E UD ECTION FROM REFERENCE OR CROESSTPEEi N 5 E W ^ .nmUHfinS r 'ECML CODwG USE ~ '_~ LES ^FEEi ~ ^ ^ ^ OF _._..___ ... ._...-.. ._ .. ~.-.... VEHICLE VEHICLE VENCLF~NILYLLE Ol ERI VRITEI ^NIT dRVN COLLISIONINVOLVED: ^ ^ ^ SEVERITY TOTAL NO VFN CLE~OBIECT ^V[H CLEHR TRAIN _ ^biOLEN VEM CIE S NO MLIED ~ NO JUREO Of VEHICLE yEH CLE~PLOESIPIAN ^NON~COLLISION ^NAZARWUSA AIERIAI _- ~_-._ ^PROPERTY pAMAGE ONLY OWECT S TRUCKINAMF Of OBJECT SIRUCRANDOwNERS NAMEI _, IOCATIONOF ODJECT bTRUCN ~ . E ST. OMIA GE /l! ~ ~`~L" ^ , ~ ~ ^ fr,,~~(( nOAOWA~~ FEET ^1&1^ w FOEOG' JM1JUVI DRNEflSNAME~LAbI -FIRGi MIpOLE DRNEIi'S NAME~UDI FIRSTMDDLE IIF NICVCUy1.OR IAN CNELRI[]:= I D R 5 K°n~~ti~ L, D I bTR AD iEbb ~ .... IX R STREET ADDRESS .. '' ^^ u V E R CITY STALE .ZIP CODE. PHONE NO. E CITY STATE. ZIP CODE PHONE NO. {{~~ i R •• ~~ ~ ~ N O OHIV LILENSE NO STATE SE% ORIE OF BIRiN MO /Y YP N DNIVENS LICENSE NO GTAIE SE% DATE OF BIRIII . ? A /\/ O. MO OAY I YR. ~ , DRIVEPS OCLUPAtION FIRM NAME PHUNENO . y DRNEHS OCCUPATION FIRLI NAME '. N CODES > 131 CU55 _ Ia1 SEaT NELT__ . ISI EJECTION _-~' CODES > IJI CL455 _ MI SEAT bELT.__ ISI EJECTION ATURE OF ILUWES /~G Fn as 1, A.C. CVL ~YATSL I NAIU E F NJURES ' 0A1 SCENE / BY: F E TO ~07AL ~hU~~LJ , iaOMVED SLENF NY Tp , VEM YcAR ~ MANE IDODGELHEVI OOELIDARi~NpVAI STYL It V.t.CO1LyJ• I VEN YEAR MANE IDODGEGIEV.I MODELIDAgT~NOVAI STYLE IP DRCONV 66 1 ~ ~~ 2 ~.Z v . . I . E N VEM OR U C . PLATE f:0. STATE TRAILER PUiE NU, STATE E VEH COLOR VC. ELATE NO. S1ATE 1RAILER PLATE NO. STATE -• ' i ~lu~ ` ~ ~~ ~'HJZi3 Wig " O ' VEHp;IE IDENTIFICATION NUMBER ..,.... ODOMETER. C V EHICLE IOENRFICAT10Y NUMBER ~.. ... .. ..-. ODO EIEfl ..._J~. ~:_ E 3S ,y37C ~ 093 - .6 E ~ ~M Z6 /_. .5 3 o RECUSTEHED OWNER-UST .i.. .: fIRST. MIDDLE: . SK ~ G fl EGb1ERE00WNER-CAT .. ...... FAST . _I..:. .._ ...MIDDLE ~. . , J nv142 r4L o. A b OF OWNER .. ..'.... -..- ~ /~~ A DDRESS Of OWNER _ ..... ....- NMIL AND ADDR[SS OF wSURANCE LO.OR AGENT .. N AME AND ADDRESS OF MSURANCE CO. OP AGENT... .. _.......~.. .. ... ,;, CHAPGE .. GTAIroN NO. ENFOPLEMENT CMARG! ;. ~ .. GTAt10NN .~. ACTION ~ ~ NAME, ADDRESS & INJURIES OFLPERSONS INVOLVED Goofs i' ~ '''z` SE x AGE STATUS EJECT.' O O. ____ NAME: _,_ C _ ADWIESS ____ ~ U p NATURE Of R~MOVLUffi(IM nlwfs savf NV TO A N/.ME __~_.- N I T _ ADDRESS _ -_ '. S. r SCfD DfN~-~ TO MIUNtEb ~If N AME: ~~~__~ _____ T A GMF55 ~ - N N : ._.___ __-~.___ _. UFF~(5~ - -- R1:M~E~IIIOM N.IURVf SC.f NF NY Tp $ N AVE __ __ S A ~ - DIME55 E N 1 S• 'lu4 _-_.__......_.-_._._.~ . Y m<e~------- 1Rr1s~srNO.T . .- ,o I 1ISIAIUS I]ISLAI PpSRgN ;JNNJUNY CIA!:b ~u ~ I 1 I.I SLAT Nf II Iy ~f LCD ] :J 1EJECIgN I ~ L L L D A OIntR ~-« ~-~~ iAI l J p[AP ~ O P ~u 1N 0 wl 0 YI~LL~NI II INY I) D I V EDQy A [ T p UNHi ONN E b - b 05111pr WITNESS J O l p Sf Al llf LlrAIIIIRE f LL1ED 4 ~~ I ! '.; ~ ~ ~ i ~~ ~ Y Y r{11 r; t4E)'I~i 4 4lm°~~~tiIPl43~° ELF, 1' '1 x l ~ Jh ~ l ~~I ! )~T ~ E. 1 3 "lIT1~,J 'I N L s ' ~ A Y '! 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STREET OR ROAD ~ ~ PREFI% E O MLEPOSi ~. 5 2 PED s ~ 0•\ Zi NONINTERSECTION~LOCA1gN OF COLU510N (/' I RAMP gpGnAM DATA BETWEEN I / STREET AND SrREET Q© giLpObcLSn~YNa MLFEOPoSt onFMrvi~irwLLwouwp VEH epiWF' .M_1 `NON XRO ~C 6mEFn ro ~ rFFT ©® D I tE I INFER Cu^ ^ R FD6g55 O AO 0 vENCLF VExCLE ^vE ILaCrnE ^arHFB mwiEl y s%W NrOLrED . 7 KwCt[OeIECi ^vEHKLEIPUN ~/ • o E .COD E USE ~ ,~,~ E ^vfnKEErf D[SIaM ^NONCDU Sqx ^Hr-RUx sr OBJECT SiflUCK ECi Uc%) OVMER OF081ECTSNAME AND ADDRESS' LOCAi OF qD gN OO - - ~ ~ ~ ~ ~'INR 4D ~ WAY FEET Fn.w OlvE - [ DRVERS LASr NIME FIRST NAME ~ .. MID0.E IoE, PER IC IJE .r uOpE rKw rTN 4•RS . . DRIVERS LAST NAME FNST NAME _ MIDDLE l~Jlns ~ •za -t SiflEET ApDRE55 ROUTE NO ANp BOXNO. P o (ol No I,MDBFDp A ~ F BTREET ADDRESS ROUTE NO.gNDBO%NO .0. o X84 diY STATE ZW CAGE, 1..LZ1 ow WF1 9g3b MINERS OLLUPARON Studu).~'i cEDUisnr i "°" CITY, ,.:. •,. STATE. ZIPCOOE ock W 9833 duVERSOCCUPATgN sc OPIVERSLICENSE NUMBER '_. STATE SE% DATE OF&RTH AGE' MIVERSLICENSE NUMBE STATE SE% DATEOF &nTN AGE TO-a=P-PV-L34zKN WMi M x S DS ~Dl I'( WI-NS-I.E-N 3 I,JFa M F S Z.Y 3M yZ. VEHICLE YR. MAKEICHEV: DO[%iEl. MODEL INOVA~DART7 BDDY STYLE120R1 VENgLE YR. MAKE (CHEV.~D000EI MODEL INOVA~DNIT). BODY SIYLF~I]pli.l. S 19[73 Vol 181 T 1471 ~t~ LICENSE PLATE NO. ST TPIJLER PLATE NO. CIMK 5 I ~ (,~ ~ ST UCENSE PLATE NO. C~+1 3 STATE TRA P ENO._ yy STA VEHICLE IDENTIFggiqN NO. IIBCa MOOELSe NEWER( ODOMETEfl 1MILEAOEI VEHICLE IDENTIFICATION NO. 11968 MODElSA NEWEflI OOMETEfl (MILEAGE) I 30z~10'13 ~ 3oS N E SE~ nT EREDOVMER ILAST~FIRST MIODLENAME), 1ODRrV^RSl1C REGiB ~E~OK~IUST~FIRSi~MIpDyE NANIE~Q ) / ', Z. pRiVERS UCEN5EN0. _ I ~" M ` • OVMERS ESS 1 Ei. CI TM'O STATE) ~, ,-- P o ~ tL 1 > >ra DgTE OF &RiH z"a r i OWNERS AOD E59 ISTflEET.LRV ANO STATE( ., ~ DATE OF WgTM MD D.. .IM PMiSOF VEHgLE DAMAGED .. .. . ; .._.. 1O lu•rfD fASr "'9 PARiS OF~E7gl DAAIAG J *sDr~wprEDCCSr '/~ NR VEwaE " / ~ ~/~ T~ J r ~ ~ ~''!I O f .• ~ } [ y j a -. S WAS THERE AUTOMO&LE LIABILRT INSURANCE S LIABILRYIN URANCEINFORMATION~VEHICLE NO.1• covERgcew EFFECT FOnrnlS ACaD[NT pn rouR LAR YES ^NO NAME MDADMESSOF LIA&UTY WSURANCE POLICY HOLDEA ,NgMEOF UA&UTY INSURANCECAMPANY,; $IME - N,M~ D~a p rr ~ ~ S NMIE MIDADORESS OF UA&LRYN R LE AGENT LGV sr rF ZP UABIUTYP YNUMDER ,. S. ~ , o ~CIiD. O 3 0 O IBi NJWY NAME - .. - ._.._.._~._-___.__~...._____.__.__---_- AD011E55 E AGE SE% o rOrA4 NlUA[D 2NDINIURY: N s MERE rDB ADprpN4IHAY1iE51 NAME . ____-_.... _._.__.._....__._____. __.__-_..._..... .._.___~. OD ESS s ALE SE% ^ r-- ~ _. -- -.._ .__. _ ----._ . DIP © "Wf ~ o _. __. ..__ _ _._._. ".r~,"BrpDDL,Dq. DO ".ME r ~SIATUS Of NIUIiEO ^ NVFIIgIE ^.W ntx MILED MARK rIRST DIHJ~ sLWR[ I 1 CWE THAT APPLIE 1K14N~M~ wwOR S ~riMMrF Iav~ [ic 1 SIATUSOF WJUREO ^°iu NVEIIgLE ^PF_.q NO ~. KILLED MARK fIRB n.5lbq I~vfq EI i dIE THAT APPLIE 0"Dbnh ~~IWL S ro ~xE jD~f G µ ~ ^PL r ^,.. rtF.lx ^ 5^ 5Q Mr 1 ~^ N ~ds va er ^ 5 ^ 6^ r 7 ^ SHOW NORt Or ARROwINCIRLLE \ I DESC118[BELOW WHAT NMPENEptnEFER tO V[HgLES OY NUMBER) ~~ la w nn nMqul WwrH.rvLw.D O ~ '\ H[nmm nut wnJne i nwn oniSOVi.o. wi"rENU~eiIN \ ~~ I wAreFA: °R ((~~ ~~ ~ ~e ~~r,, ""~~ _'CX LV1~....~0~31v.%.ry.. 5 I L0__ ~[~ ~' '~Ut~-.._ 1\.S-'..._V.~ ~J_, OQ~j'S _ n\ c t l I ' > MK,IL. LfLN vfHDLF M.D Nbr, ~ ~ `~c ~ i . _wo.5- LA.... ~. ~MN~-+ 4e_•~ - D.FLIbHd,K.MI..MwD ._._.~ Q.- •• I An,l ,r ve~.A~Qr~..._Z._., .us•G.o- ``~~a~ . _ r __ __ _- .___ _ r _ _._ _ _ I __ _ . __ ._ . __.. VEHICLES POSITIONS BEFORE COLLISION Vf NCI[ M 5 [ dl SinFII DR HgNwpr NAMF On NO '~ ,.r.Ar t~^ ^ ^ a~s~.vtSlV.+-_ '°»~:.i"u •.clF v HnE rFA epY INVf SigpfED by i~. n..a+w ` e cDr o ^ is nu ^ r°u.e c 44 ur. Dlrr~rD wM E3 `DE n.TSI M,rlt... ^ ~ ^ p.~ ^ ^ , ^sr;;Kl ^aet~. ~~~ b ,Iwp, ^ ^ ~S ^ `7~Jt.i.u•e.~ i ^ ^^~ ^ ^ ^Ew1,I. n of r""" ^ ^ ^ ^ µoHn c pmL,D rROM DIRECTION TO DIRECTION nLlklIMAH WAS USwO 1^YDf WALK ]^wAl.%W AY ]^ LrOUI DER 1^riw ~iwH. e^ ~'iry;wu. !^OTHER ~np Ap SUV K[ NA.AIHEn lrwlCONdtldl3 .wr. owl .'.clr nl~ rrhsr~ pF I~i.l~ul I~DArIfR Mr 1 /// -- iRAFiq CONfnOI ...wc. FW[I . ~r ^l,s,~^;,NN4S ttm Or nOAp r.cL Ic" I r wIwAN ^1,^drE WAr MNCflrvUIrAC ACTgN7 .ELF Ic~.. •inwl rnr ~F'1 ^OdM Rin f{HT AHCAD L]1 K11 ^ DAWN Z ^ 0.N•M] ] ^ ^ J ~SIDP !X1H ~, 1 ~tWO WAY ^ ] ^ ON nTAKNO AIIp PA.SSIHO ^ ] ^ WYT ] ^.pgWSNO D (] wsK ^ s ^ Yn ID E,nr, ^ ] ^ novrl~nsnL[ ^ s ~uF%ND ngHT 1URN ^ ] ^ spgw . ^ roD % n °c~is a: [T ^ A ^ rlra.Wb mD ^ A ^ wirnr,HMlor noor,RAMPt ^ ~ ^ MA%NDIVT runes DMK xiRr[r a^LgHisw ^A^~[ °^D vi c ^ s ^ruvoFD wmn ^ e(]gl[r ^ s ^MA%NpumnN an . orH[n ^ s ^ sn crr 1 e ^ yrrniiE`~oHTa ^ e ^ nn "'E'O1 ^ e ^ iµ iwN ^ e (] [+oW+HD m Awes «]n.nlxe.rr.DMK.Ta r^v~ecir r .MF wAwm r r%w Ir41 ^ r ^orrq[q-nAr.MAH _rs ~ - ^ r ^BrMPrproR rnprrq , . .~_ r'1 ^ L..I a OtHIR !/`L fiIY ^~ ^r r - ,F MAID II ^ ^ORSYM 4GH Nu ^ ] ^ v rxD ^ D ^ stprrrD no Dwpr ~A~I / iY r l l I rr ~~. G'.J I ~ t ^ D r_) r~ Dlrrp r e _,, ti - a~~r ~.' r~ ~N, a ~ "~ k { ~ - ~ ~ ~~V1r]T '~~~ ~_.e`s~k_.r_.6,uJu~z~' T _,..u+9ru e.~',' -.(~y' ~' )4 } y.F ~ ~~~ ~ r ~' _ ~ ~. , ~~ _; • `~- N~ ,, 1 IN CAL 11 O% CII CLC fl E f f O CALI to CD IIkA VEHICLE DAMAGE' 2 EIAIEAREA0F5EVElESTIMYACT E%A ( 7- 1) - 1~(1 0~- I NS i'R LICTiONS: AW ARROWIEI TO EIIOW PRINCIPAL IHRECTION OF h011~~~~ DAMAGED VEHICLE NO. i I n vnrE FWI S%crcN Nc uwrAnGE To (nAlLUIS, MD(nncrcl~Ilc.i ~ /I (Jr t ,a I f ~. . UAMAGEU VEHICLE N0.2 I] rlom I lt- /~ Imal S~ `;' { ~,n;.~ 16 Tru L ~' a ~ e: I} 11 t E/~~ TuaL ,• T , E. Unne~eu T. O.nI un ,a I l(~ ~r LPT.1 , EvEnIiv OF OgMAf.F.~VENICLE NOI ~ [i WEnELING nAMAGE ] Ci ODIFIIMV OM.IAGF ~ s ITV OF UnMAGE~IpTNER VENICLEI NITYDF UnrAAGE VEInCLE NO.] ' IE iI OISApL NC. OHMAGE II{--=TI OTIIEX fA V. DnMFGE IE^pEAELING DAMAGE ] OTHEII M.v: pAEIAGE ~ ] IJ FUNCTIONAL OMMG[ A ONO DAMAGE ] O FUNCT ONAL OAnIAGE < `J NO nAMAGE ] C~ FuNCTInNAL UA NO Mnf.[ • GE iOW(D UY E I.DnMAGE S TO'NFp BY Sf. UAk.~nD OWED nY L EET. DAMAGE (O E S i S DIAGRAM OF COLLISION ~ ~ .. ~ DRAW.ARROW SHOWINQ NUR7/11N CIRCL ~. . es . 1 I aprrar ~ : - ~ - .. 1 I ~ NuH DN: ucnoN a. Lnc Nrw nIL VD Nror - _ _.\ ~.. _ I I ~ I ~. I I I DIN , . ; 31 ; ~ I __ __ + NnariTRLDLL,DN L : _ ;~D'' I ~ I I : ~ I f ~ i ~ ' _ . I ; I f ~! I .1 ~ . _ . _. i _ --I - I I I ~ i DESCFlIPTION OF unp¢wTE wNAT moswOLr NAPPENFD Oifon WANG ANOAFTfR THE CRASH, INCLUDE INFORMATION NOT ON DIAGNwM, E.G. p111VEn " i i COLLISION oTNlNC<aLON, eonsrnucnox pn REVgln woNK, EID.I . •. DlswmuTY, NEDUCfD VLSleanv, PEpcsTNlgr i GLJfIS 7~u.cPr~~+q ~2C-~ :_ w~~ 1~~ l o'~o _. (/Z ~ / Cam! ; co.c.~ _ ._., ... . _ 3~ - • F¢~wT G/ GY9rtE /q~ ...Lvl~us~c/FO,.T. vz.Z]ic/~ C/IasS~~ oLAr.C. - c - E -- -- _ - - -- - -- - -- . -- VOSITIO Ir OED N BEFORE COLLISION E O ' ' ~ ON STREET OR IGNSVAr nA3 E OT NO. - NDNE UIHECTiU s rW E S l ECwLL . ~~n I C( SIN D C k SING . ~ ~ ~~ ~' C'12/O _ 7 N P NEO ~ L I/I ~, ~ 4 i . _. r I U ~ I __ , i..,J I .i PN - - 1 E 11 ~: I G.... ._ C OSE .. - l ~~ FnOM T 'E DE I ] DI L I IC OSSE ° IC . I EO EnOU ~ IOTHER S ROAD SURFACE N. ICNECK ONEI WEATHER ICHCCK ONEI ~- CONTRIBU IC TING CIRCUMSTANCES rCCK ONF On MOREI .. E EIC E C Do O] Dq ryE Dnrv No ] °aoE] .. ~ DN rv " o (~~I co c m c T NERD - s /~~JI f, / . _ _ I ~ CLfwR, TiLCOY avrn+E~ASr I ~ I NUEn INFLU fE p -. nkcEl pL_. -I T I wEC ... _ 6tn. 1 ]~ I D G tpE A _~.. 5 5,.- o _ '~T L ]l' 1 ANO PASE~NG ' ' ; 1 E ] I ) 1 I 1 A NG i tl ~U D O J O F N( 1`_ E TL r T C ]I_ J RIG IT TUIIN , . . ' •I -- ] I E ~- IEp NG 1 ~ _. . . r [ <CEp DE} TE ']LJ NGT I i 'I Si OPEfIP nK G lON 0C I s ~ r lAt ~ MA ND 11 IC[ ._ I .- FOG.. _. - YfEO LIM.T xlia SAFE EPEFpn I E }, _.. iU NOP[I . II ) I 4 Ai . . . I T16( l_p ECTIVE ..._ .. _.~. _ LFFTTURN I.JEI _~ UTURN ... ..._ I l IE I ... 1 I ...._ _ . I p D T I Is~ O -. , . '~ I 6nNU ~I I E?23 GDFG r I! 1 1 SLOWING ~' ~-'J°~~ . .. %inRn liPEnfn _. orNF YrsPf< l.. • T r ,°i I _ _ I ~ _ f '~1]~ .I sfws cMAL roP -- '-~- i_ f I I Frl I'EL.1 No Eouif DN -- f sroro¢n FOn I~I]I_.~ mnFF¢ LIGHT CONDITIONS ICNLCK MIF'1 TRAFFIC CONTROL NO VFNIC ~ 4 E TVVE OF ROAD ~~] IC EDK ONE DN MOIIEI VEHICLE CONDITION VHrICLE ~,qF E{S~II~~pp~~{{ pp ~ ' b~ ` :::.,,'... SODRIETV ;NKLf ICNECK ONEI No ] ., ~ sio PED AT SIGNAL I~O~--lI On BTO SIGN I IG ( f o E I No : k fAiA tL ol UN ^°~_,I no°no °Tr"' IX (wVLIGHT ... J] ~IOP I ]~~ I~ ~~ T .. . I E TIV I... I..... Dlln%ES_ ~~ NUO ADILII I II~ ~_.IMPAIREO_-.__. . `. - _. ( ID ETA 61N~ 1 ~. TnAIFIt LwNE I L-I .. ]~ IDAWrF : .~] ~ SIUNp LE S ,DI ~ EE L. -noaD. i ]~ I LNV .. ..1 f U LIGI l9 r uT I 1 1 r ]' _. NOt IMPAII k4. I I I-Illr_I YARKfDNPOSIT ON . . .. l ~ DUK . 1 IlCO O I 1 LOO NGf ' I].. I IEAILLIGI T° I I -~ NK~SNItT t.Jl]I I l1~G NC6IENTEIi NO _ l D 1 F T E. I FuA Ci t .. X61 LL . ~ ... .l~ ~ 0 5 ODII Y ~ __.._.._._. /_~. ~ i NNDII NKING 'I I , JIS~. .1 SALKIN6 ' .~ D u K s t r ~ E. 1 nn - 4 i ,D~~ -~~ I, .vvL I ~ 1. NoEi CHEM. TES I T I 1 i _I - ,.• I 1 F ,' STIlr L4 L4NTE r Oif Lf AG N I -j IIt~Z7L IG[T vANAiTD . -... ~.... ._. I t LN 1 E ... ......~ _.. .... Ol I '. F 16vEL ~. FV .. I I > '.UT E l . ']~' 1 VIDFD ~ I ~ NO UEF LLTS j ~ j I f) nEf UEEn ~ ~ - '' (1n~R1WICIFVI_ .•~. rns rrc iE K ~. ~.~ .. ) uunwlo{p ' -O4~Ikf~ISVfWfvl ~ % % TEST RESULTS 2 ~ iwl ~.f IyG O+,'CfHEFFNw[Mi AIk rl1yK/~1 f1N~11f-`` I( IS v N ~ ~ 7 ~~E/ Mu v AIII/I/IV'Tf p Afr [•Ui~/tiYA1L'NI+U]C~ / ,Try) NIXI / ~~ / / OC~SU O7OV AIRn r nNIE I FY CrLDW yL(~~ M fDFn . ]IM N1E MIN. I ~~ . ~ _, r. ( 1'U fICf II 31A41~`]~ _. ~~-~GI ~In{~*~r. -SLI LU F 1IIVWlr nGI NCrGSO UNIT UII UI]l.A 41, nd ~`J III Av• UVIIS IIY l~nl[ ~~~~ f I~ ~: ~ xm~µr \ IIUn(ICAtF ICUPV. ILDCAL IALVI Nf OIICCAIf fIT Afif NCr'SI:OPV'TNIPLICAIE COPV~•INV kSTIGATGIIVS COPY 41~ir~'!.y!eyA~ ~~~i .. .I' 1 Zs {Fr ;~ J ~'~~~ r1 dy~ ~~' I.I ~If :.1~~ y ~T a T I by S P I E I t tT~ 1 )~'f, t iT J . J {.C i~ + ,ICI ~.' b51 "", "Pn'°y,y~C"°""~~`I ~°i ~-i ~.f F~,N ~>.. ,~F,...-»~r 4~nut~r~l~'~~"''/1' ~nh ~'-I fi - _. T~ h_p,k I ~ ~ `~~~ >~ ', I1 ~f t YS?Ir.. ..,~M1. • • ~4r " n DATE OF COWSION UAY OFF CL~LLSGN TIIAE IC OUYr/NO. CI[Y NO. f E 1.• ~},AY ~yJi ] l{ ] ~~/ Y INUN FI U S4i 1 SIIN I I.tUll 2 IUfN T vlk A IJ'yLi~~ E{OUHI ( ~ ' Z l~ 3Qj~p~ ~ ~UURAL "" ~ / ll '~ GOON I``Y<< L~ ^STATE ROUTC ry1fOUNTY ItOAU ^ Clr Y SIREF.T '` FF'~s~ ^Di11E11 (SPEC FYI T" / O W A D'LS. PREFI% ~ FO~~UZTfE/O~II SiREJEir~ppE~' S il0 f~(~~"~ C - OIJ n CiY 01 IOVN J'~ ~ ~/~IO N ~ V REFIA EU ~(' - IO.I/ /~ ~ _.&' ~~ ° ° Y.. Lam, _.. _.. .__. . .. MILFS ^ 1FU ^ ^ OF_ Y V 11 U GRAMn Y ~ ~~,rJI f T.. NA~ME6NO OF~STRE~E OHMIC WA O~ (~ YJi~ ,oNB.viO/SC ~ A Y"-' ~ I ~ INTE14tiECTINOWiII: STREET OIIRUAD y /! ~ -Ti.GK.HH,4Y.f' l.- LL ° R A ~' ~ .~.~ ~. . NONINIERSF.Ci O ~ ACCUE Ii y~ NO %'RD ' ISLCAN.. SIHEbT ON HUAU OR HEF• 1 ° ( MlY GC " ~ ~ ,~ 'U INTER .w L l5. EHENCE CHOi: STAEET ORROAO. / T- N OETVIEEN .... . \_ .STREET ANp. ..- _.... .. STRFEt CODE ' •' E J DlsraucE DUINECTION FNOM PE EIEIlCEO CHOSSSTREET / / I~ U S PECIALLOU 114 USE `~/~~ _ ~ ^FF. ET ^.~ OF .. ... _ _ -. ^VEIICLE `/EINCLE ^V[ CLbUIGYCLE ~OIMCRIWRREI ^IIiA RLIN SEVERITY _ NO. YJLLF.D COLLISION INVOLVGD:. / ^VEIICI[~ODJECT ^Vl IIL'l[~RnTRAP! l,O ~~~L7 (r' _- ^STO ENVEHICLE . ~ 110 INJUHEp, 101AL 1:0. ~ OF VF.IIICLCS ~/J ^V[IIILLE~PEOESTIIIAN ^NON~COLLIGION ^IIAZAl1000S MAICR AL ~'nOPEPTY DAMAGE ONLY OBJECT iiHUCK INAMF OF OIUECT DTRUCK ANDOWNERSNAME) ESt. DAMAGE LOCATION OF OWEGT SiRUCN S E a o ~D EDGE 5 ^iIOAU\YAY FEEL o r~ ' ~ -~~.~,MIDOLE ~ ~.~: fiRST ~ NAM1IE~L ASi ~ ~ CHIVER 9 DNIVEH'SNAME~LASt FIHSL MInULE IF ENGrf.LSl OH 1•k[[SIWAN CHECKIU'. ' // __ (7 / p ~ l A v StREEI P RESS : / .:. _ :' ~ ...~.. . .. / ~ ~l.a S Flli~~ ~l /'~AG '/J•'}~) i re~lc, ru, R ~ STREET ADDH Si .. , : . E GTY ~•~ ~.... STATE :....ZP LODE ~: ,. PHONE NO. ~ E CITY . ~. STATE,:.. 21P COUE, P1IUNE NO A p f G~dl~w w~ . v37-2z~z ft N A i E OF BH~TFF~ iAEE SE% O OR ERS LICENS ENO G ~~ rr11VERS LICENSE NO. - STATE- EE% DATE OF UIHTH .,. h~ ° ~ •~ LL ~G / ( iJ M / ~C7 ~ SSIpJ S6 2HpZ. °• TAO. DAY Y 'I ~ PIIONF. NO. OHIVF.fla OCCUPATION f NANE:. ~ ~.:... . 'j-. UHIVEHS OCLUPAi ON- _. FHM NAME ,... .: , ~, PHONENO. 17At ~T L~•Jio~ /-Id ~ _ , vuuHY /_T .,I CODES > I NI SEAT BELT.~._ EJECTIOnI .-I___.._.. ' CLASS. _ CODES > IJI I1IJUHV ... _._. I." SEAL UEIi_. I51 EJECTION.___._.._ CLASS --,-- _ ' NATUIIE OF '~.(•K/1 L~ INJURIES ~~/Yr]I •~V ~u•'1 (' AZURE OF INJURIES tM VEIL OM SCENE nY: TO E OVFD OA•.CENE RY TO VEH.YEAH IOOD(~.FLIIEV.1 - MA KE R[~1y0~ MO ~CONVI i 1E 13 U R VEEI YEAN MAKEIOODGECHEV.I MODELIDARI NOVAI STYLE(20A~CONV1 V / ~ V (J(// W~ ~ rr//JJ //77 r ~ ~ ~.L/i L~ ~ V E FI ,; VEH COLOfl. /~~ LTC. PIAfE h0 ;~~oby STATE o~c TRAILER PLATE NO SiAiE E " I VEN.COLOH UC. PLATE NO. : STALE TRAILER PLATE KO. STATE (~' VEhICLE IU TIFICATION NUMBER ::::. ~ _ '_ -.',.... Of%tM[1ER ~ C VEHICLE IDENIIFIGAEION NUNEER -. I.... ,...... ODOMEtER ,..:.':" ' ,. ~ F tL '~ E fIHSi. , ... . ~ .MIDDLE NER-UST REGISTENEU OW ' flEGIS1EIlED OWNER-LAST FIRST ~ MIUGI.E~: tt __~ II r F OWNER AOONes~ _. ..... ____ noonES Of ovaEn ~ r :•. ~,~~ 3 M ~ L 2 A ~o~ YU.~ NAME NIDADOP;55 DF YISUMNLt LO OR POA4 Ni... .. NAMY ANU,I0~RC550F INSUf1.~NCE CO. On AGENT , CryARG~ .~~.. ':, CI YAIIF!!NO -~- ENFO~CEMEN~ GIARGE _': ITAi1~NN '- Acnou • --:-- -- . ..:..._. :;. .. .. ~ ,:. . cones I -; , ,. NAMEE ADDRESS & INJURIES OF PERSONS INVOLVED' sr:% AGE srnnls ".°A'," ~ ,' ,' D e EJECT. L. NAME: __ , C AWRF59, -- - V p __ NATURE OF TIE IAOVIUfIIUM I¢wNlES r:crNF nY To A 1JAME' N T AOMI'JSS: ~_~ ~. _ $ _ np.MO em'nDM To vIJULIFFR F ..^•UFNF IIY NE IJAYE: I ADORES: T N o"uun~ s~ 5 NAME__ $ ARUNESS' E uhL'~C"' e~• .N4 .rIAIU 1 r' ,? Pr IN SIInwN 0 A.nlcrru,t E n'vilTVess N~•FAi rNJUn ICeI J VMUIIr ~In:.:. i /~ 1'N011EJlII1V rICAIILINO NINf1Y ~I 0 ~] _~_/ BOO'•~n0'~ ~IMIYOVnII i UIIOONOSMIAi I i f0'i! ~11lf. VIJUiiY ~L~ '/i I . 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MCI Ix r If 'OSi ~~/n/•L /.~•S G • H E NUr11L1EI1.,CG110N~LOCAi UNOfCOLUSI[gl '~~~~ ~ - HAAIP UTAGIiAM1I I OniA V ~i / oe~a6~ r~,ay Iv: nvEEn ( sin6er nrvn sineer ,~ rrrD Gr1owN Srnkkir ifvrW~Y. 1 ~~ I MUrO+o roll lu[NrYr NCtA U1. un lw[ 1 ^ I'iF ii Eli OLS ~~vro~~Q - - On IqA ^' (] U U ~ Z.. ;.1'I.O. .ODE USE .\.: - J i w tn arvurnc. rfnl IisI AI r, nn[cpN rrm! pv[ pro prr ~ UUJEGi S111UCN 1 nuE 01 O61FCTCNrVCw OWNEn OF ONELIGNAMC ANU ADDRESS LOCAIIUN - INI OnOVIAY ~~~ k•Nr,rArrpagsi Lll~l n rArr G VLCi _ -____ __- CJ __ FEET _ _-- ~~'~,I~~l~~~'r,~r3..3„%'yrW.1 ikrankpwl nS711°1w c'~~~1" 5~~ . ©~ S __ ~ ~ `~ -. _ k d . ~ " OIIIVCIISLNiT NM!E FIII~T LAME fAIODLE ia•'n<ua^. UR VEnS LAST NN.IE Fp INAI.IE ` ~` DLYLD . a a MpULE, 9 14 ' " „ 1. Cohr/Y7 ~•G,, r~IZYto A SinEEi AOUnEES _. nOUTE NO. AnID VU%NO. [:k l Q~x ~d7 FI Nl ivro ~~~o WEnE A STREET AUUflE55 f FI ~'(:X 7~~ TtOUTE NO ANp UO%NO. •~ -: .5 LIfY STATE LP OOUE DIIIVF.p.S OCCUPATION r~ aLidtaw (A.J0. g5.3GS v ec4 r- h ~' SLI MArk CML SqN nLPnlriiDriM CITY STATE 21P DUDE Cpl'/EnSOgpUPATION 1PrDLoaL yI~ J' ~ ° ~F , Y a »r 1. WA I --.- t ,~ , LNiIVCI1GLILCNSCNUlAUE11 ~., STATE SE% UATCOPUnTII AGE ro ~~ ~ , ~ ~, -~[3 3s OnIV[nS ULF.NSE IIAIOEH ~ STATE SE% CATL'OF UIIttH. .AGE ~I N ~ ~,~ „ i r D DAY YE.A ! 'I ;<: VEIIK:LE YII. MAKEIGIIEV: COIIGEI MODELINOVA~OARiI' IIOD'~STVLF.I]DR.1 7z Ub,-1LiP.hErr~ Syc!trlxEr.k L2 c1r - VEIIICLE YiI. MAKE ICHEV.~OODGEJ MOGELIt1pVAO MT) UODYSTYLE I2 UR.1 . ~rclr ~ ~• ,~ n I~ '~ ~ LILCrI..E rLAIE NO1 STATE ~InAILCHI'LATE NO. _ STnTE O~G ~l! / WR 1 i LICENSE *CL^VI[ND. JI`11 .SinTE - TflgltLn PLATCr:O. STATE'-.~ If/ r_ ~-.r 4 Vf IIILLC IOkN i:ilCnilON I:O. ', T196BI.IODCLSG NEWEN.,, DOOAIETEn IMIIEAGEI 3~2.2cr/ yzjy /~7L Yll~s IIEOISIinFUOV/NER. (LAST~FInSi~M10DLE IINAE) pNVEnSLICCNSE NO. ~ _ VCH OLE IOEIIIIFIDATIONNO - (1BGU MODELSB NEWERI ~ DpMETEn IM•LEAGCj t~IF'vt~L1~D~Gd6 i~,l1 $ty'~lr~ ~ IICGISTEHED OWNER ,ILASi~F11151~MIUIME NN.IEI. ~ DRIVERS LIGENS[NO. :,. ; ~~ cs ~• r1r,. rrn-wyn C~4,r=n >;rz•hLer~. wLl.~~v p . , UVrNEi1SADUHESS ,.ISIIIEET, OITYANUSTATE7 ~.:: DATEOFiLRTYfA; (i+ i ~~Y ~ a7 Po. ~ 4.LJdiclrwa ~ ~" ss OYINLHS ADORCFS .-ISTnEET,CITY M'DSTATEI . ,, ~• DATEOF BrRill ' E t • {'M TS OF VEHCLE Or+NAAGE~D`~ ~ ~ rMAUUfA ~~~ I- T•iS1~T ine)u,~~n~ fTOOt~•..... $ioF3.~`I`r- _ PARTS O~f] V~E~H~ICLE DAMAG[D T'll•r - rP 'r-~O-`~ ------ r u S~o3r~°-F~cco ~ ~ ~~~°~•~4"~J~ ~,,~ ,. 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I 1 •rrl,L(I.~ Y.r Alin.il IKrnGp.[Allfil:S TIIAiI K.CUNIIIDI Kltrr •.1 IYrL UI IlOAO gIIVCRr VLIIK;1.[AO11EN1n r 4G Y1 +rSY^( ~_ ,t 1 J £ C: { Tat ,fii [•••r ~ YI rcu a~w cvc Y rr louc.ali rrr.nnn { r~l ~ 1 d 4~ ~i ~.- Y ~ ~ A °( w .,a• ~ ^ I 1 TrArLV'dli K GLANS > [cKr[I 1 r.~ '1 { ;~r_.' ~v _ ,~rl ~J I ~ ^ ^r 1 '^ L ^` 1 ^(wC VIAY ~r'l l ^ 001110 SinA.O.IT NICAO 5 1 Y .'M^R'J•34 I- III ) ^ N ] ^ U ^ ) ^:il (Jr l.Krfl ~ ] IVNWAY ^ ] ^ OVrnl Arfnro ANO rA5s N0 , 11 + ~~ ti.~ Y } [J' O [I ' CJ"„Wrm D (] u O a ^ YIwGKiN D ~ ~rlpvrrnllvml ^ n ~ A•AKNnn%lllrnmN •f}cn1YII h i ~h,~ ~ ~r~tOFrIA/~ r ," [7Atj ,DrlElxrl CJ~A' oiLl ^' ^nASnNnrln ^'^nloiil;CnAAU~i D ~ (~LIAP,!IOlrfiTUIIN;j}TIY'1~111 1 "t v 1 1 ^ G ^IIA!'A(I AMIiII G A111.Y 6 MAN IIOU-iUllll 1~ r r. i J ( ) }t j~~~ t I l~ 11 `--'I. ( YI f~- ( 11At ,'US /~ O 6 ^lrl~l lUlill ^ A r^1 [i CllNrln 4 ~ ~ r .r,' .. .. .. tr al,i aJ..l i r n ` 1-_.=' lJ 1 ^ rU fILIN ^ll lfrMAN 1 fAµAnAlln a 1 ^•A ct Orl rn r(in inArrlC , V y ) tY. 1 r T C~~ ~~ LI [ ^ M G anon fI'1 E'FY (~ ^ LJ on is UNirmlu. ~~ 1 ~ ( ^ a L ja rN IiA 1 ~ n ~ ^ ^ 1n~l~ciuE r I 7 IJ4f A A IA 1 1 71 \ Ml r ~a~`~ i ,,~` '~' •it ... - f is v. I~tn~,.'~;'..~ ~: JeA" ~;II'l. ~~"~~La~l.r.l .-. r'l6q'j'] I,morvlnrD //nC. ^ In ilGl .llwcoNnltilDAnwAV n.r, I 1 t ,r 1 4JV yL, r J 4 y X ~Ta.f a~ IN ~. 4 t rnTl yr.. ~. f4 e; " r e I ~,r e + 1 ~ r `r i ~ri 1 I~f~ ~ r ' ~ +~r }3 ~ ~I , t~~~~ , , ~::{ ',. ,! f,; ;;i ,`~' ~' ;'. ~,~ ~~ ~~!'! h~ ~ '. _ W ~~ ~:' ~~ r+ - ~" ~h^~iu.:'. ~ . e. r0 -- OATEOFCOLLSION OAYOF CO I$IDN TIME COUNTY NO ~ - CtiY FAO FnwA p MO DAY YR Q SUN NCN IUfS '~E IIIUN FIU SAI I 3 5 IU$E 3a00 M0UR1 } /~ ^UflBAN E7 2 ~ 8 _ rNRURAL CWNTV ^STATE ROUTE ®LOU lry AU CWV STREET ~ ~ Z O ADM GLS PREFI% RWTE OR STREETCOOE.; SECTION ^OTHERI$PEOFYI ~ ~ W 3 '- 36990 FF - _ G IfY OfIiO N PREfI% EG ~ MILEPOST L' ~ N S EE I.-1V ~^p IN ~ inn , I W O , ... q tZI.Y ~' - L MILES ^ ^.riJ ^ CI OF _-_CIN!'A!/.LO G/S.-_ _. _---.._--_ _ V ,i C ,~ -,,NAME BN .OF~TREETOq HIGHWAY ~,-~-,. .. INTFRSECTINO WITH $TRE~TORHOAD ~ LL flAMP DI GHAM DATA U _ ORO ~ ~ NONWTERSECMW:1 GN ACCIDENT INTER NON MtEq %AD CLS I TERSE STR H HOAp CI+aEF'. ERENCECRO TF TO AD g ~~ ~ ~ MILEAGE S EE R O 7 37~y N BETWEEN . __..__. _..____.. STREET ANO .- _-_ STNEET CODE f ' 04STANCE AHDOWEC1gN FRD gEFERENCE ORCRO555TREE fl 5 E W' H TH.4 ' SPECIALGOOING USE , Y~..~ _ . ;. ~MIlE3 . ~-. .. .. .w ^VEHICLE~VEHICLE ^VEHICLE~DICYCLE ^OTHER IWRITEI ^RIi6RUN "COLLISIONINVOLVEp; SEVERITv __NO. %IUED TOTAL NO. (~ ®VEHICLE~OSIECL ^VEMICLE~PRTflRiN _--_ _. __ ^STOLENVEHILLE NO IIUURED OF VEHICLES ~/~J ^yEHILIE~PEDESTRIAN ^NON~COLUSION ^NA2AR000S MATERUL _ _-__-___ ~PgOPEgTY pAMAGE ONLY JSIECT SfgUC%INAMEOFOSJECT$IRUCKANOOWNE0.9NAME1 _:. .~!.- `- ~,~. . __ ..LOCATION OFOBJECT $TflNCK W:... ..: ~:~.:.,.., F$T~OAMAGE~;:;:i E S ^ROAOWAY FEET ^ ^ ^ ^ RD. EDGE S pF'UVERS NAMEiAST-,-•-• ~ - FIRST ~.- -,. ~~- MDDLE - ~r•~ DRIVER'S N~ME~UST FIRST MIDDLE; nF.DICYCMST OR PEOE5IRIAN CNECIUQ~ , ' _ STREET ADDRESS :' '... :..; ".. ., . ' ' .. STREET DDPE53 .. - .... :..,. ... V ~ i ; ~hj ~ 1'OX V . E CRY ,A. ., ~. , ;,,:...., n. STATE v .~ x ::, ; , ,ZIP CODE . s.: PHONE NO E ' CITY • ; , STATE. _. .. _.,....: ZIP CODE .PNCNE NO. ~., R . o2r ~.1.i0 W ~/05 7-z R- N OHNEIL4 LICENSE fq ............ ...:.......,... ,,;StAiE. SE%. OA EOF BIRTH- N OflNERS UCENSE -- -•~_.. :: . .SLATE- DATE OF.BIRTH_~... Q: MO. OAY YR. Q,- MO. OAY Yfl. - v78 w o s _z ~ pgNEg9000UPATION ~ FIRM AME. ~ ~...... _.. _ , .: ... .PHONE NO. 'j pflIVFP$OCCUPATION FIRM NAME .,_ , '.. ~ ,,. „ .,.. ,.. PHON N , R>iTSR6O ' CODES > wl IwugY EJECrION __ CUSS---- Iel $EAT DELT _ IGI COUES > IJI INJq RV CL SS I'U SE OELT~_ 151 EJECTION-- --- - ~. HANREOF WJURIES ATUREO INJURIES F MSC NE nV' TO FROM 6CENE NV~ TG VEn. VEM: MA%EIDODOECHEV.1 ~ MOpEL10AHT~NOVA1 , $ttLE I3Oq.CONV) ,, vEH. YEAq • MA%EIDODGE~CHEV,I DELIDAHi~NQVAI STYLEI3OH~CONV) ,.V ~V V .. E VE11. COL ,,.:, UG.RATE T.O.: : STATE..... iRAAEq PUTE NO.. STATE...... E VEn. COLOfl..... UC. PU NO. _ STATE TRAILER PULE NO. STATE . _._. N N • (.`. VEn ID IfICA NUU9! .: .... - ~. EtER .:: :...... (,`.. VEHICLE IDENTIFICA NNUMUER. .. .'.~..~.. OOOMEi R;: ~:,~:.i ..,:, 1, a e . CC 2 3F,~? 6'f e REG45tERED OVMER-LAST,.,....,.....: FUiST.,._~,: .,;,, ~.,... .......MIOpLE RE649TEREp nEH-U.T „~... .FIRST .; : r: , ,,,,: MIDDLE ~: jN N~ 0. ~ O O.. . :., ADORE OF OWnEH.r:. .,~:~:.:,...-. ..,. ~ :.... :...:......~.....~ - ADORE' OF OwrvER .. . .... : ....,,.: . :.:..:. I_.... ..:,..:....:-..n.. _. -~ r .. 2' NAM ANDAOOR WSU E AGENT-.... ':U.. .,-...: ~.-..-' ,;~...'.. .. NAME ANOADOHESSOFINSURAfICE CO OR AGENT -: ...: r . ........ .....;.:.....-.: v c.cls r~ CwN ~.....-.,,.. .:_ „A..-.~ ... ..:.... ... ... ,. CI ATTgNNO ~~..:.'.... ENFORCEMENT HARGE ... .. .. IAI Nb~.. ., i,~c.ZR.~ ~/ O ACtION ' Ytt4P~ ~(SS~L[~; „ , f.00ES _ 3 D 5 ADD RES Fyl~h RIES OF PERSONS INVOLVED' ` - ~'` NAME ,. sE% AGE sutus '^ ,~y; ~; T EJECT.: I L. / N E /i T~ ~ C~ ' C U ~ - ArgRESr A O ~ ) P II[ FDFRDM AIUNfO t. I NIUIXA:l V P Sff hF Uv 10 `. A NAME: ' N ADDRess ^- -g - of Mb~o~'17iu it ..rf of In to M19 ) '. ,~ N AMk. ~ __ ~. T A : tMl1E5D .- . ~_ . i.N N - uu ir` r•2S"+knri(IM to j ~ N 5 AMf_-_ -.-.-..~_-.~-_-~~~.-. rr u A fA1RET.S A S. P T ~~'~:cv'~__-._-'------ -- n~, ter; mrcM" -- --- °- - T p - US I}I•x.r >~ >wl I (' 1 E Inl ll I•AIJLLIgI '~C Q IUf 11 • nT CUSP I 1 ~^ )U t I'rl t % I ~ ~ 3ff f < E YD pU AL I 1 11 41..~IY I UINTI Y I ~ I~AI I(D TL n ~IOf k~YF~CLtfO ar t LIYI JLCICD E A LYttNl kS A U.~,I OLN U.Nn IUWf, _./ J j < GLUI IHO~d YI AI 1O1111i, IrURV T I W.AI l VLf TAI UIIk A fJl Cll.llfl I ~~~ ~) ~ A±'. 4 ~'k a 7 1, 4 ~~ ;' F ~~ 3 ~.. r~' .~ y~~~1.1,1 fifit f k 1 i~ ~ ~ w5 ~ ....~ } - ~. d'. ta~ S fi a ~ ~~ ~, 53_:_~~if "1 w~ `c7~ r ~A {{yy ~ "4. 4i` x ' ~'s i. r ~ ~~- ~~ ~~ A~'~"~~' ;pry ,~ I~ ,. ` ., s -... wsu '~ t :. ~~1{,. ~ ~.,. ,,i '..2•' t u s;r <- ,~~ ~ D ~ ~ ~ TE OFCOILS ON Opy R OAV OF COLLI310N E 011 NES WE IN11x FIII SAT B IA TIME E]<OD MOURI ~ r CAUNIY NO. CITY NO. 3 FHWA ~UflBAN ~ ~ M z 7( ] 1 ] D 4 5 Z p0M GL9. PREFI% ROUfE OR 9TREET 000E ECTRGN S COUNTY ^STATE ROUTE ~CWNtt ROAD ^CItt STREET W it/~.9~ Eo // /X ,~1-f"~"cJ ~l ^OIHERISPECIFYI N PREFIX O. . ~ MILEPOST ~I ` IN CITY ORTOWN W ~ ~. ~ 3 d 3 0 0~ o }~d~a~ k- MILES ~ OF T OR ROAD RAMP DIAGRAM DATA C AM 6NO.OFSTREET Ofl HIGHWAY INT~ SECTINOWITH: STREE O T p, O,Y /V ~ C CIDENT IN]E NON %~RD INTEflSECTIN6 RTR R OAO OR REF A a? ~ NON INTEg9 T6r`ION'_ ~f,~,C-/~~A~' INTER CLS. ERENCECROSSSiflEETORROAD 0 MILEAGE E r7~lO C.7 STREET AND / STREET MOD L SPECIAL COOW USE N BETWEEN e ~LTH9 ET B S ST R O OASTANCE AND DIREOTION FROM DEFERENCE ORCR ~J ~ t (L~ )r ~/ A~ ~' // / W/~ B N S E W ~`JO-~ .7o/r~rS ~ 20 OF } 0 ~FEET HITb RUN SEVERRY i~{VEHICLE~VEHICLE ^VEHICLE~BICYCLE ^OTHER IWRITEI ^ NO. KILLED LOLLISION INVOLVED: I I yEHICLE~O&IECT ^VEHICIE~flRiRAIN ^STOIEN VEHICLE NO.INIURED Y ~- ~ L TO]ALNO. PROPERttDAMAOE ONL J Of VEHICLES ~ ^VENICLE~PEDESTRIAN ^NONCOLLISION ^HAUROOUS MATERIAL EBT.OAMAGE LOCATION OF OBJECT tflUCK ~ASyy11 E OBJECT UCK(NAME OF OSIECT STRUCK pNOOWNERSNAME) EDGE S ^ ICJ ^ AO ~ ~ ^ . FEET ROpDVA G MIDDLE DflNER9 NAME~IAST FIRST MIDDLE IIF UILYCUST OR ~ CNEC I .~• DRNER NAMEiAST ~sT D ~ d i -1 ' ESS R ~~ V~ ~ ~~ R . _, STflEET AOOP ~ STREET AO EES , ... ^ ~,.~ ~ ODE PHONE NO k ~~Y' V it la . - c STATE 21P CODE PHONE NO. E CRY SLATE LP C E CITY R A R 6E% DATE OP B RTH STATE SE% DATE Of &RTH N OPNERS UCENBE NO. STATE MO. DAY YR N DRNER9 LICENSE NO. O o. Of~~ /n /D IDY SYD PHONE NO. 'j ORNER9000UPATION FIRM NAME P N O TION FIRM NAME OC INLNER ~ ~ (~/(/~ UN£ 4/J WU Y 151 CODES > LDI cL]G~ Isl BEAT BELT 151 EJECTION CODES > ul cuss IAI SEAT BELT EJECTION N NATURED T~~i E r'T~'~ N - ILIURIEB I W,IURI,S TO FR M ENE RV: T'NOVAI STVLEI D0.~CONV.1 MO EV L FEMOVEO ROM SCENERY TO VEH YEAR MAKE (DODGEGHEV.I M OELIDAflT•NOVA) 9ttLE 12 DR VEH YEAR ~ .) H MANEf Jtcl ~ ~~ 3j~,~ ~ V 7 p E COLOfl VEH llC. PUTE NO. STATE TRMIER PLATE N0. SEATE E ATE NO. R UC. R VEH C STATE iPAILER PUTE NO. STATE H . ? Pe ~. f` 8Z9 ~~ ~NI~ H J V""- ~~SMET R ~ . VEHICLE IDEN(IFICA I N NUMtl ._. ,: .,:. ;... OOMETER .':: i.::..1:,. C L .. .. .. V H P ICAT N NUMtlEfl ...... . . C E E FVLBT MIDIXE RECVSTERED O'NNEfl- FIRST, ,.. ....,..MIDDLE .. REGLSIERED OWNER-LAST N N y],,A~ it ~ O. NA ~ l - . . ~ . . : O ADDRESS OF OWNER . ... ' ...... : i.... •, .. ;:......~"~.... . . .. .. ADDRESS OF OWrvER .. 2 OH ENT /' ECO NAME ArvO AODPE590F WSURANCECO. OR AOENi ,_ ~-:... ~.i „ . f WSU IIA AND """ roT~d-l CE~,d~ c vc lldvfb ~ - 1 A CH I AIKN/ND. E NFORCEM ENT CHARD .. AOILON ' CO DES 1 - ] D ~ S NAMEI ADDRESS & INJURIES OF PERSONS INVOLVED BEx ADe BEAlU9 H EJECT.. `. NAME' D U A[ARESS' EDfROM TO 0 SCENE RV' I P HIU f5 A N NAME' T $ NDdLESR. n 9LENF nV. OM TO I , INJU Ifs ~. ~~ YI IIANE ~- T 1 ADaIE s D 1 ro Sf.ENF RV'. M 9 " IL 1~ ` S HA4. F S ADURESM1 TO I F ~ I~liiiA nv f.Zf ll JIIN+UIIY LIA'$ IFI bFAI IYLt 151l JEGIKMI 1 IAI UY 1Jl+l ni lv'wlKn 1 . 1101NJIIE~ 501BAlILIIJOINAI^,Y I.NOT IIISIAIICp ]NOI VIUBE ' I.NO7 EJECTCD ].IOIAILV F.JF.CICD ~ C }CI S`J. AV 1' ^ ,l 1't RI tiiNV': 11 1 ONIiRPOSItIpN ] JAIII IKi ]DI.ADAI SOCNf. 6NWIN RFAUORAnruVAL ICWDCNryI lUI1V DUiCD ,. PMIIRALLY EJCf.TCD NIF I a D .' ~ _ . ARK:vL11Yi '' Ir--5 ] I Lb ~l/~ I MOIDR<CGI A (IIe~N St f~ `~~~E/L.~1~1glyb~y~IVp1U OW .~. .s... ti:":-L~511]EL .1°13. i;l:l.. ... .... : fnf0v11q!.RIAL ]PUSSIHLE WNIIV y~FAr aIWiTUwne . ,. e1] _ T;.~ 'J .St O CJTL iCO 'iµ lc 1 n. ' Y"°i ~ '>V ~ . ~ ~i X ~rv A ,J; h ~ ~ { ~' '- F5 ~ ' ~ y " t ~,~ ~, "~; ~' ~~ ~. { r ~~ ~ ~ a.~~ ~ .u , ~, _. ~T ~~ ~. "Ymy ~ N s~ ~ ~,~ ±~yy~, ~~ ~- ..5 ... .. s ~:r x ~~. ' VEHICLE DAMAGE in;e.u~xox.clxcLE Tr~i r+uMBER OiL-ic~l oiin: Lc, onaew~ """1"~"' I ~ ~~ ~ ~^ V 4 INSTRUCTIONS: 3. ORAV/MRO ~ITOSNOW PP N CPAIgRECTION OF FORCE. I ®~ ~ I~` -e Y DAMAGED VEHICLE NO. 1 IVSE THIS SPACF FOR SKETCHING DAMAGE TO TRAILENS. MOIORCYLIES, ETC.I DAMAGED VVEHICLE N O. 2 ~~~~/~~y`°DL~ 1.. HDOD Rool _ 1 1 3. N000 t Rool F ]' 1y 111 RFC IS. TIInM ~ ~ ~ 1 fl 6. Trulk ~L~ 7/J`)'-~-)~1\f',T T 18.UMelcvru0e n. axnMx '. ljT I 1 D. UnOauvrupp T. axn~xn SEVERRY OF DAMAGE: VEHK;IF NO.1 I ^DISA&JNGUAMAOE GL$}OTHER M.V. DAMAGE 2 FUNCTONAL DAMAGE t NO DAMAGE SLVERITY OF DAMAGE: IOTNER VEHICLEI SEVEWiY OF DAMAGE:VE111C1E N0.2 10g5ABUNG DAIAAGE D~OTHERM.V. DAMAGE 10DISABUNO DAMAGE 300THER M.V. DAMAGE 2 FUNCTIONAL DAMAGE .t NO DAMAGE 2 + UNCTIONAL DAMAGE t NO DAMAGE TOWED BY I 1 )T? / EST. DAMAGE TOWED BY EST. DAMAGE TOWED BY ~ /? ) 1 EST. DAMAGE T6T .> s TO s TO s L'cf; DIAGRAM OF COLLISION 1 n xD A RDwY ' x ws AY -. f 1 ~'~I -'• I~ I ~ I ~ __ ~_ I' 1-_C ••I.I.I I I F- -`-' I i _I ~ ~ I I ~ I 1 -"- 11 I I I I I--- I I I I - l.' I L I I I I 'DRAW ARROW SHOWING NORTH IN CIRCL j~ I ~ ~ ~ ~ A P wucrKW ` I K E I -7 I-! ._I I i~ I I I I ~ y~ I i_ I 1 7 1 t __ i i I I I I ~ ~~ _ I -7 iu i Fw s : Ei%I SI - _, _ _ ~~ "'iii -~ - _ -r * I _~~, ~ -~ ~_ ~ i r 1 'aelEn ,A:'HO.n. ~ -- I I I ~ I T'_`_'~ _ I '_ 1 , I -1 . ~PxODAeLEVt~I£gl T __ I _ I ~ ~ ~ T~ - ~ - - - - -T ~}-i I 1-i I 1 I ~ 1~ i - I -1 I I I , f ' i~ DESCRIPTION OF (INDICATE WHAT PROBABLYMMPENED BEFORE, DUR NG NJD AFTERTHE CRASH.INCLUDEINFORMATION NOT ON DIAGRAM,EG.DRWER :COLLISION gSABIIRY REW CEDVIS BNTY PEDESTRIANC OTH NG COLOR CONSTRUCTION OR flEPAIR WORK ETC( t/G e1-,t~~s--c~75~ ~ ~I~'_ ~cl~ ~~ 1r,~a' ~ /~ s_~c~a ,~q_ y~~`e G ~iG/cl.~^--AUeo_t--~ ~s.sy~c~{' l~riJ/,-_ ~/~.~ ~,e-~~t~es_~~,J~v~.rj~_~ ` ' " ' ~ I Ed_! eT~ r ~ y_ j~ L F12~- G~~__ y!F~,GIE'_~r/ c ~:E1 -;T ~:_EcZSJ~~O ' ~G7~c ;/J~ ~r e~ ; ;~ 11~ s7_LK~.~ ~~~¢~.cui~~ ~ ~~ -- ~c c ~r sr{ ~ t/F ~i , _ . _ ~_ y . A r;G,.~.~ GGt!% ~e / Ft~ ~ ~e_G~ ~ Fl~j9_J ~'>_2~I ~ e~ C ~~~ ~ ~' ..: . ,,, y_;; -_;;:,P~SITIGN BEFORE C- OTSIG '' ..., "~~ •.,' ~, ,.';;, .: NO OF UNEB SPEE0.5 VEHK:LE IFPMKED VEN. HF.AOEO LE POST OR ON STREET OR HIGHWAY NAME OR HO. ~ IN ONE DIRECRON POSIEO E LEGALLY WA9 VEH. PARKED OCCUPIED NO. INCREASING DEGREASING ~ 1 ~ ^O I- N 5 /~'W I / A~ ~7 '~~/.l.% ~`/iV I ~~ u %NS EV 5 NO YES NO _ . PH . --- --~ o ~~ ~ ~,_ _ . ~ E -- - ~---1 I-~ Pso. ^I J! 'L_ RHgmv cdw MolE,4w1 -_-_____ cAOssxw_ ~ ___rrw_ To._ qa_- ;r~EGAacrcusr WAS USINa~ _ Ar wuA IcRDLSV YnE RauTE IrNDEY:Aq ~wA DrlsNOUinTn ~[-'.L"x""xs i_ ;~x~~c T~IoTHm ,ROAD SURFACE. ILHECK GNn .. ,_, ,.WEATHER .. cNEGKDN 1 FJ '~' ,:,.CONTRIBU ".- TING CIRCUMSTANpES„ DRD ~ u _; :,, --.-' --<LrgeVFA/vEHK:IE ACmNS.:. HKnE~ 'oGR 4oaE~E DRMR ~ ~ - ~ t ~ xrruN6icM AxEAD p1^' ~I.V ' 1_` ~oYlPCis °Y r-+ ll~ µ wE.rcE'a _ ~ f ! t oonosELr ~P ~ s°M ~ ^'.~! FN C! ^ WET ~ J ~ D ~,; D< DF ~-~ ,,, M~LENIM C ^ ~,E - E i~D~ D r . ~ vw _. U I ~ f-, ~--i' ~. µo T'o _ uluuo ~ `i M ~I. !~ !' U FOG .n-~ SAF _ ..:-.._ 1~-~_ A _.__ ~_L~, _o~E LmFEWm ..---- ~x'-- Pori _-__.._ - ._~__~_-_-_- _ . °~ __ _ ~ '..oA~~ ~"~-- DENT-- C-'-~--~-- ------- ^°4_I xDwwD' oThlRI3PEOVYI. ewEPEDm --- i..!e~, P _ L?12~ sG ~ ie~^ v~curn rT1_1 w°s"F~roR T IIOHT CONDITIONS Fx[CK OMI TAAFRC CONTROL . KxK~ vunca TYPE OF ROAD ~E Lw upAEl I VEHICLE CONDITION VFrYLtI ILxtLx WF OR -~-:... ~ SOBRIETY'':.; CUE ... ECK MOJ ~ •• OrvEO AT saNa ~xU onsmP SGK IJ L_ 1 ~~ OxE wA ~ 1 r' ~~ 1 Iq 7 N LONIIO M~i[q 1 NO. 3 ^ x r S OIPEO N LJ xOAOwAv `~ D..DD -- ^_! r ---_ 1 ~ I ~..'". ___ f ' ~' ""` _ - IJ Fk w ___ ~`~- 10'=-I w :NE wN T _.__. .' r In 1, ~-'^ LpN.--- RE.~T BtT ADAD r ~ i 7 . ----~ ~ I--1 s J_ _. r~l '„ >a i,.J " -...- - r-7 sTMxwTRw ~jll PMALO IrosnKM ~ .. n,Fx FlAVxrq - r . (- ~ooP ! LJ I ~ ~ wx L " ~RBORnETV - ~ i N61ENRwxO `12x1 TRA,.KI ~ l..~J ~ 1 A"`wr __ __ I~JeI _ ___ uL . 1 I 1 . _ I N `__• ~ ,; \~~I w ._. ._.___' t~ x ~le~ eACx.a _ =.._uo°ul"siarn ~-le.=:_~ ._ . _ ~,e _.J iu° _ _ _ a _ ___._ .-lef~^~. onnio°uwlxci mRF ;._ CHEM. TEST 1 rw x Lti L.I _. [ ., .rte-.. , - I ,/, K CA ONE( I l .y D _ .-._ .--_ - I r'I _ ~..__. ~ r' TLxTGMh r_~.-_ 1[91 HffVL[0 OM[R 12PlC VYT Olrn~ISOt~6FVl J = - ~.. ... ... L~ Y ~?riiK ~ '._._. .._____~ ; ~ ula. otn hEAI.A4C/VA .. ., % % TEST RESULTS 2 Hx<LArxxn[o w wA:[ uA~~oFLDw plCl x~t9EM AoE uNl Ux 02TLOET DMI WR[Ppll M+xUrFODY DATE G /cam= r .~J_~ /"' l 1 _,ZC. ~,C __ '.C~Jt~s?k " ~~' r'3 WPLICATE COPY LOCAIIAW EHFO/iCFMINT AO[NCY'S COPY-TIIIPUCAIE COPY:INVlSTN1A10R'E COPY I ~~Y ~' t J , V Y d~' ~ ~ T" _ f ~ ~p ~^ °M"~ t~ 2~'Ii I~ ~~$<'~~x/~I ~ 41 }4"~+` ~.,~i;l""'~q /1~ ~ a .. "#F."'~ li r7 ~ Z' J - ~, d ~A •1: ~ ".!~; {, ~E xat„ ~ r 1 sp ~~ / ~ KGY a~, _ Y IkJ I ~; ` ~ s~ , ~ . -:..~:~-si! O STATE OF WASHINGTON PAGE ~ DI r ~~ ~ UNIFORM POLICE TRAFFIC COLLISION REPORT ~' D _D .-_ -___..__. Ya~S_.._....u._...'~1~'y~,~y'< (~t~F"S~}41 ~an.h .~S.o No. PDLICE coMPUeuNUMBEp --- .fSd •r~~~~ p w k~r `; ~ ' -' f ~~._. F ' • ~' ~~ I ~ ~a ~xt ~, ~~ '11 e EOFC0.lIGION DAY OF COLlL51UN TIME C A~Yi ~ ~ ~ SUN 1 Mpu z tU[5 ] W[ A IHUN S FRI B 5+j I SE P<DO NOURI Cl O/•j• ~ ~- COUNTY NO./ CITYNO DURBAN COUNTY 'S ~O ^STATE ROUTE ifURAL DM CL P ®COUNTY ROAD ^LITY STREET ~~.rJ Dn ^OTHEgILPECIFYI O W ' S REFIX ROUTE OII STREET CODE 5 IION S ~ O LITY ON TOWN L S E ^IN N ~ GfiEFI% EO -~IAILE PpSi / C / MILES _.. . / / ___._____ A N E 6~OQOF STR ET OR HIGMWA~O IHTEgSECIING MITH: STpEEI OR gOAD T O N .9 E1_fyi / ~ LL O R AMP DIAGRAM DATA - ~ ~~ O NON INIE E ~ Q // /Jq~Q~.( N ~ " ' ~ ~ ACCIpErvI IN MLEAGE TER NON %~Rp IN}ERSECTING STREET DN ROAp Oq qEf• INTF• CLS. EgENCE CROSS STREETOR ROAD BETWEEN D!.- /L .-J . _. _ STREET ANpG-8~/{~ (I~~ TREET ~~~/ - Op -- DISTANCE ANUDIRELIION FNOM REFERENCE OHCROSLLTq N ^ C w 5 1 "LI%.t COOING USE MLES G IE~~ W /~ Q ~rEET ^ ^ L I ^ O //~~ J yiP/! /~f~oic~~ HS ^u I COLLISIONINVOLVED: ®VEHICLENEHICLE ^VENICLE~BICYCLE ^OTHERIwRITEI ^NR6RUN GEVERRY ^VENICIE~OBJECi ^YENN;LE•gR iRMN NO N:LLED TOTAL NO _ _ __ ^STOLEN VEHICLE ~ OF VEHICLES NO N . _ I JUREp ^yEMICLE~PEDESigIAN ^NON~COlLIL10N ^MAZARpOUS MATENAL ^PPOPERTY DAMAGEONLY _ ______ OSIECT STRUCK(hAME OF OBIECT STRUCK ANDOWNERSNMIEI LOCALION OF OBIECT STRUCK EST. DAMAGE DRIVERS NAME•LAST ~ ^ROApWAY FEET ^ ^ ^ ^ gp_EDGE S - FIRST MIDDLE ' ' ' ' " U • -/ .. .. ORNERL NFMF. LweT HNGT M POLE 1 F WCrGt SI OR PIOk SIRIgN-CN(LKI U.._ ... ..:. R srgE ADDRESS . ry ~_. ~N L R -~-~~ T ~ T : .. E ADDRESS . .' I BEE S ~ . • 1~~y v/ SJi - ~ >z y~'o x ~iG R STATE ZIP CODE -. PHONE NO. E CITY ~ STATE 21p CODE PHONE NO. R TT~ ~ y p ' N d. L d , _ ~/[J /ti G Q TUNERS LICENSE NO.. STATE SEX DATE OF BWTH N DR ERS ULEN~. •/ SGT TE SEk PATE OF BIgTH/ ~• MO DAY Y / ~ ~ . / c7 ~~UC . ~i D~v(~ p~~yp~T~p 5 iL9M NAME O O .2~ RM JG"~/'Y/[AJ~ . pRa~.rg PNOkIEND . ~GJJ rY- NyyAA~~~~~ Qc .. ~NEN. .U~°/•'tl'~jION NJ`Y"YSD/J ` ~ `` r 'tJ ~ d S'1 /'& /.5 G!i / ~~ ~ ~ J ~ ~ CODES 7 I]I CUGS ~- - IEI SEAT BELT. ' ISI EJECTION UR ~ NATURE OF - -~-I----- COOES~.~ IJI CiA55- tl TAI SEAT BELT_~ 151 EJECTION __~ - T ^ INJURIES / NA URE Of INJURIES EM vED ~ FR MSCFHEe N / ~'.ir i0 . J/!' P.•'J~ FROM SCENE BY' VEH.YEAA MAKEI DGE{NEV.J. MOpELIDART~NOVN STYLC I2 DR ~CONV.1 VEN YEAR MAXE (DODGE~CNEVU MODELIDART NOVAI.. STYLE I20RCONV.) E H ~ D ~s14z%9 yr JP. N. ~Jdi VEN. COL IJC. PLATE M]. 5}~E~ T~L"~pU}E NO. pTAIE ~ E VEH. CULOR LTC. PLATE NO. STATE TRMLEq PLATE NO.. STATE _ ~ ~ '-.C VEHICLE ID ~ ~.~ If ICATION NUM Ep ' ~ ~~ L . .-. .. ODOMETEq - :. (} VE F iION NUMBER .. ... ODOMETER . . . E L ,,.. .. ! ~ ~ % D O /~~' ~ E ~D / REGISTERED E - ,7,/_Q~ IAST rIRST - .MIDDLE - gEG15 E ED OWNEq-UI - ~ N O. ~.~//r ., :... . FWST_ MIDDLE r ~ 0. w~Bf3'D b/"J ODp7~ OvME lGE= ~ q J O// ' ' - '-' ~ FDORE55 Of O~YNER N AME AND ApDRf550F MSUNAN ELO.OR AGENT ~ ~ P ~~ ,r ~ NFME Ar1p ESS OF U:SUNAtIC ADD Ni ~ ~ C ,J HA~a . }~f~~~1.~r T/ 1 , -- ` ~ ~ t+ C y _ . A L IDN ND. .. 1 _L GG! NA ryJJar /~~ q ~ CNFONLEIAEHi ~ - CItAIION HV I}1Q~/~dsY/:r,~~i.'~e•ful~~0~33D „L AcraN. NAME, ADDRESS & INJURIES OF PERSONS INVOLVED coots _ } ] A s SE% AGE SiaiUS '•' EJECT C A C w DDREssr ~~/1_~_,~~ ~ ~~ !._.~[J..!~IG~ILE'~__ O - uwr - D °2 02 3 / a f A nLM VfOTRwn } s SCCNf Dr i0' N R MF: __..__ T A S M DOREss J F - ----~-_ - ~ • f RLM YE~U FHDM UR:re SCENE RY 10 W N AME' ( A DDRESS -~_. _.___ " ~~~-~~---_~______ N u i TCubv DFN'i oM nw~ E S A xrhE Dr TD ME. .._~ __ S AD A __--- -- M[SS x _---__- .-_-~_ - 5. IH III wfS SIAIUL I}I Sl AI POSIIIW f~6TA~6F.!- _- A __i0 ~tifiANT' I]I %uUNrCUSS L. + ' PASSL NGfR _ _ _ PI DI SI NIW rr 1 ) }DINER POSITION n l ~ ~~~ ILL AI MELT ISICJFCIKIN N AN I J UE DONSApRl iil D NCp1~DINi111N RIY I] U~[DN USE LCD O I i L Y C a E 5 DrDRL C EI w wi5s l _ e l%os'ggNUN%I~oiY,l ] PA gt % A I LY CJf C1 0 DICp IN NOSJUTAI ) IN)LLIRLE INJURY OWN ~ UN%NOWII I) ti[ I 5 A llCll rAIIURC EJ[Lllp f 1 M.,.... a..,.... _ JL~i ,~ ~f !T .- nniy ~I^py wtiY rt .t~ ~I ;. .~.za . .. a~ - ~~ ~ ~~~ „,~ : ; } ~ I: ,. ~, `" ' ~ R ~ • - °~` j 1 .. ~ ~~ i ~__ •~•°e+>wx:""•~eun'~'~.._ `~` 'Y14"' ~ SLV CIICSI-nl ' INSTRUCTIONS: L ] ORn1Y Al111U1Y(SI1O 511UW PII NCIPAL OIRLCTION OF FORCE _. 1r Q~W ^]- > r _ a DAMAGCU VLIIICLC NOI wSL IINSaIq[L run sKLtal NL UaNALt ID TnwILln5, lnoioncvCLLa.L1Ul DAM P AGED VCIIICLC IJU.2 ,m - rt ,,. , ~ f 'C I a[vl Y nF wuA4L V nLLL Np L ~~ ~ ~ • }.y I m1 .I I 11 ] puN/CiIINGnwuA4[ ]CI OI wMALE sLV FIIIIY OF UAnrn4t: IOiNLn VEInCLD ICl pagnl.ING Unrrg4L J~OiNfnsrV pgr.Iw4E IITY OF pA L ] rLI-I UISgtlL N40 4 ^ auA4E f ~h ., ~•, IONaL nu.Iw4E E ~ N 4[ Ur unGE A ^ Nn UnrAA4FDAMAG > CI IUNCl10nwl DAUwG[ l i n V«~ lowcb ~J1G1~SGi~%1• q : ni""~J pwrpf pr DI sr. Np punncE rowib er ~ NwcF ~ A - 1p~_¢GT /s+.%L.~Pnd %s~Fr `^ ip Ss uw ~ ~ ~r ,, a ,DIAGRAM OF COLLISION , ~ -TRAW ARROW SHOWING ,.~ ~~.. t+" $c I. rplxlnv' "I"-~. ~ O :. ~._.. .. •~ JORTH IN CIRCLE T~ I .` ~ Y 1i.,pxla i~ ~ ~ / I . I ....... 1 ,x,1frL[pxTA L, p NwY 1 i - -. ~ - _ _. • -I ~~ ~ is O a l • I a.rW.AKf p„p:pw,r1F,,. [D,pnrD.F ... ~::.. xLr..rLrILDNf,xpLIIDN , -> Antwf sic.l _~ __ 3 ~ ~ I f.J ~ a Lo[wls rnpfASS[ro xt Or ~ ~ ' n ~ Iurwci. -__ 1 1 .. I .. - ~._ ~/ .. ..... . ~ .. _ .. - _ vW u I I t . . • ~ ... i > slprv vl xrClf Ir plUxr~x Ux I I I I _ _~ t .. - nLirprrlr Ai rurr ,-_ __._ '' 'J • . ' 4 . oe pNS cT •~ _ I '. .. ,.~' - .xpwnLNLDEEI[pN. '. S. it'o/%~' DESCRIPTION OF 1 p a c F T L. E HFOn aTIOn NOT ON DIA4ngN,EG ORWfO .A .,~ COLLISION msgnbrt . ucm vlslennr.ablsin ewi um co n, eoxsTnucTSOr+ontn[Pa NwonK,Em.I . .. ' //r.S• .f/"i 6dds _.;n~,~/r On.. C4ao i°~•-/fin _i~ . d /F/-Y •e .i, ~ ,_r ~'i.d;__i:,e. .:,re.'s.ea~io., of..Gn•./•°J• ~/o--S•:iY u~ri.r- ~.~./, ~ i9. /O ~ Gai•.t~f_STi•vG/~_17 /!w ~f.Yi'r e. S/I r/~~/.vf i. i. off Gnus riiu.r d on .i'c//[~d oYNi'_ Loi ~/Try /~Cl_GUin E'.. :o_i'~°s'T on_i_Y'S ~?/S/IrJ.Ji.`/P~d./'i/~///y./O/ifi7iis,..'J. i~C - .~/>i F//G /.'_ . Un der._.af. f._i/F~Ai'c/e i ~O, .Y,L(i o! _.YJ. o~i:ils .,- _-- ----- - '6 POSITION BEFORE COLLISION NN Dr LaxES v[ECS NICLt N Pan ED ;~ F LF YUSOT pIn. Ov sTREET OR NILNwwr n'AUE On NO. O EDRLCTION . in suL LpG4lLOV w SVEn 5 x0.•_ w L rN ECREA51 IN _ OLCUPIEp d E rl 4 O InrN Sd o Es _ o >__l ~Lla~1 L_i (I _ _ rF0 G. _ _ -_<nU55InK x - -FROM _~- ps=tux-LxTOn 1=w=- • `~ ~ vCLI5T wg5U5 SID[wgLK ] > ~'SxOULOER' C OSSwwIK CRpLSV ALK CvCLE ROUTE I~ in(R ' I ~ 1'f AD ~i oM1 ACE H4 FYEATHER CON"TRIBUTI~L ory1Rf.VMn TANCES aN WLRFVENIttt ACllpNS T. '[I LNf Cx ONLI I. EON 1n0 fl ~ O.iv[x CLT •' :J NO> ~~/ DNIQ EI ~ I.. I SOI AO I[ - r _ _ V _ I GNT AHEAD '~' C NDIR flULV[[Of fOI LOwIN4 O SN S4nn OfD wqn I_II, DNY 1 X.~~rU 1 ~ ^vrnTq KING p ¢ ~ $ ..~~_ E .. AL pEROtir "L - O LO E f > >_. c __ • > D IASSIN4 .n >' > ~ O > Ux IuLN[L f C 1 - - 1. ... LJ_pnU4s ~ - L T TURN ~- ~, ~ _ F,~uj o3~]t (' > o s o I >. _~ sK iLLb xc srw L.e ~ . `~ OPER IKmc -- 1 ~;e - .L.__. _ 7 _._. ~/I rL DuralT J N N u I L •~ "° ~~ ~ ~ - 1 _I ¢e f p~ /~._.. s:i>H i~rioeE~ rl Sf ~ D f e___' E n r ,'s ~ _.- _ .... __ .. _ cnvf foul=.- - w~n 1 ~, ~~1 -. ( 6I~ ~ ! I ~ ~5j_ I ~C YL°TLl[ANT 11•- TOYA Ln°I 1 _ ._J SLDwIH4 ~~OTrI[N ISr(CU VI -- ~OTiNn ISrILn VI ( - uPnprlR - ~ ~ _ OLSn<SGANNLS tl_ - 0 fC YI -~-__ ~ ~ SfOP1[U 10n ~ P snG I> p FI ~ SlOP1 L IG/IT CONDITIONS RAF FIC CONiHO LLL TYPC OF ROAD VE HICLC CONOI TIOIJ SOBRIETY ~ CN(CK OVrI ) CL[ INO> ICN[CK OV[OR UONI C [ I n5T 5 p 1 1A ~~ _ 1MC [ ~buK , CN[GK ON[I InIJ O 54N ON ~. I VIrU r ~' r s ~IF1 oxewgY o> d YP S51`t of v~1:oi j i I I' v( ' ` x r ntl LI ,, o r c T > I Ic°rv /~ > v I p c kr ~-1 ~ sT ffIC LANf U~ P S .. ____ ..-_ Ennr;LS j N n iY .. ]In 111 O.-_ .. _ 1~ 1 >I O w .. _...> SLN `]l ~ 0 [ 1.. ~. DEI1C]IVl > , N gNrLIIY !~ 1~ Y n}I OIROU 1 i ~' I•~ ! I ]. D - nLAn tlLNli HO111aPAINLO_- I A H.ILN1LnIN0 I ~bANK-S1N(IT .~1.RLAlI L10111f > _UNK.... _ __ I...1 I T ._L Lmns oN ": euern ° ~. ISIt-. uY -. L~E-_.I sal sw~oi" ' ~°nNK tlc i-1 ~ tlgcKlNb ~. ~ 14~I1S OrirT L-~__! S14Ngl ~f i1 i~N lA~yirrl .. I n r~wN x 01~=~/f.'f ~'t1/TEST i I3. ~ . i ~/~ 3 R(L1vl4nlf F UE^[L^ slri 11 UND-- ~ 1 Tt51 LIVF fYl 1'. I' ). > ->-~ Oi Nln >i-' prWUrP X I NO DEF LLIS r I I Lsi nlf uLrn ~ _ ' /- O L Ilirt Cil Yl _ -. - .- , ` IUIII~IU'I t'II 11 I { Xf• Nv.I nr'[ns OE O X -Yvl TCST RCSULT> 2 v I31I SNwulfnANA x'J'I NO IILI Nr:r•AI IEI Alni vl 11 AN 1 AI IL rnV _~ ~1'>L]f~,~~ n~l~°~>_[=L~.Jy c~ i3.-!~~/.~S~~~n1~3 ;'nD: v[p LL ].ro l~~~[nlL ~M 1 i4 ~~~, • nI5 ~~. ~ NV wNNNwlrunSF•AUt II nnl NCY p- 1. uwu 0l mnml I RIU N _ IC~SP 8 8 ~J_79 qI~I~ l IY -3 ":~a ,j a ~z ' , ~j~y IIUI•LICAICICO•YOILUCAI I.nW 11110 ~CIA11 NI nIfNNCYO'SE.(N'Yr1fI1fI.If.EAICLCUYYI ~'INVI SiNCAl011{'Sf[~PV .•.~~ 1:.. i ~~ .1 ~ ~ y t v t1 .J +' ' ~ I ` !~ t, e ~5 ~v~r :~ w'A7T" ~~"i.^ ~~~~"BI@S~ `~'f~,~+ Rf~P"'r ffW^7ll, '.~ "'^.!° n'i'1*;'r' , l f ~~ Tk '`l,l, I ~r I I t .. r„ l;L' U ~ t• .~, ~ i ,~~(.{ 1 ~~,~ ~ w 11r ~ 1 7~ ~~ ~~~ _ ~, av4 n •>~1'' f s 4 * ,, {1 ~fA ? I t'1 • ~~~;~ ;. ;,rte _ ~ ~` " ~' ~''I. .,~ ~~k.,..>r...~.,, .-.~~ ~• ar.~ak~_.~L <k~'rr°'~d'.~7,_,a,~,.-'~ rs Ise-- .~rr d~~i, k_".y "~~ I.~~ ~ ~I i ,. S 1 !•S 1 V OI 1~Y I15~01 rncE ~ Df / IVY. " _, ~ ~(~,,v. I'UIgE CUM!'L.A NiI DEI UNIFORId POLICE TRAFFIC COLLISION REPORT /1 ~J,,/~ ~,4 GATEOFCOIUSIUN DAYOf COLT SION -V,t,:r•~jrL' COUNIYNO CITYNO. IMWA sjt TAT• O 1 SUN A+JU 1 lul lu SA1 ,./~ fr~rf~Rl } ^UI10AN E .3 / Y ~~ r I _1_I I X. I I I s` n Is/yYL J /Y/ . URAL J-Y v L AUMCLS. i'nEfl% nUUiE OR GInEEI COUE S 'LION COIINIY ^STATE POLITE ®LOUNTY nOAD ~'CIIY S1nEET O `.~. °>i ", ~~1~C/Soi9 ^DTHEn ISV[clfrl N ' 1~L ^IN ` LIIYONTOWN -----_--_ W PnCfl%EO. ~AxLC POST o Ur Q MILES ^ ~J 161 ^ ®Of/~~.lJ~ fI C: ~_ ...__ U 5, f3 ..3,, j 4 '+' ~.'7++1~ ~ D x NAME I NO. Di ipEEi Oli lual WAY Wi n E LING iH: S nE i nP D LL pAMP OIA MDATA ~ A G'cK B.aY .PO GF.GS~ O.~,r ~~~ ~o p ,'~Pr l { f I ~n NTEnSEC11NG SInEEi OR nOM OR nEF. I NOII INIERSECIgN ACC DENT , ~y' 0 MIEAI~w' ~ 1.1 I 5. ENL .ROS"Stp[~T U(R~HOAU p" N IIEYYJEEN STREET MD _ _ _ .._STREEI OE 1 • 7 O P' } DISIMCE MO(NNECII IFN r' nEFERENCE OR LnO5551PE i 5 ALC GUS ~ ~~ ~j..:t ^MILES I--I E W ^fEET L_I L7 ^ O Of _.__ _ __ ___ _.. _ __ - ti ~ tr 2 ^VEH CI[VEH CIE ^VEHICLE~p CYLtE ^Olnt I '' H 6RUN r J CEVERnY COLLISION INVOLVED:. .~ ~ N9 KIUEO m '/~ ~ TOTAL NO ~vEN CLE OUJECT~%~GC ^VEIi CLE~RR TRAN __- __- - _ STOLEN VEH CIE O.INJURED ~ y' Of VEHgLES~ ^VEHCLEPEOESTRIM ^NONCOLLIS ON ^HA2AH A+ATERL ____ ~_ ^PROPERTVOAMAGE ONLY ~ 1'.e ry'., ~ ODJECT SIRUCKIHAIA[Of 00.1ECT STRUCK MOO~YNCPS NAAIEI LOCATION OF UDJECI SIRN CKS E W ESL. DAMAGE AiAV . . __ ^nOADWAY FEET ^ ^ ^ ^ rOiD EDGE 5 ~ 01 L ~ '1 EHS IIAME~I.tST I^ FIIISi MIOUIE OnIVERt NAME lA51 fIpSTMDDLE III I+'C ~ll'41 CN YLUlS11JAN CHlLKI Y ~' ~y e l ~ Y _ p ~,~+ ~ D I STIU' T ADDHE ... .. ~ ~ I STREET AMM 55. .....:. ;._:..w-..... .. .. ~:. _... , ........ v ~~ E CITY STATE .. 2IP CODE .. P IE NO.. , \R Crt • An ... STATE .ZIP LOGE. , PHIXIE NO. ++ N OPIVEflG LICENSE NU STALE, SEX PMiC OF b (ii ,1, DRNERS LCENSE NO. SLATE LE% DATE OF b'RTH J D• ~ f _~ 0 OAY YR b M0. OAY VR yr/y ,• . , G ~ ~~ ~ f 1 ~. ~a ~ Df11VERb OCCUPAIIUN fIPM NMAE .. P IE NO. ~ DNrvEn5000UPAIION FIRM NAME .. PHONEN ~ •; ///'~, '~ CODES > ~>' cuss - 'I SEAT BELT .. . ~ tf'I FJEtllpl . _ . CODES J']' CiJ^55---- 'SEAT BEIT__ ISI EJECigY.. _.-- '~ •. NNIIIiUEOF ~ IN. H~' • ES L'~_.~.~~f_7/ ~nJr.JJ^1 •FS NAUA rs F ~ .,.,X ~~- FgMOVED FR0A15CENE DY ' [~-(t.~~ J I.AA ~~M ^ ~~` '.'~ F ON FCENF flr~ 10 VEH YEM MANE IDOOaEC EVJ ODEL IGMI~NOV 1 Sl YlE 1308 CONV.I' VEM VEM NAKE IDODGG~CHEV.1 MODEL IOART~IIOVAI~ GTYLE IZ DR.SONV] _ E VEH caoR UC. PUTE NO. STATE tflALER PLATE NO. STALE H VEH CULOR UC. PULE NO. SATE ipuLER PLATE NO. STATE ~~ ' N -, 7 1//S~fl 1 ~ I -- (~` VEM LE gEIiHFICA1gN NUMd[R DOMETER C VEHICLE IDENIUICAII N NUMDEfl OOOMEIEfl r~ e - /-S1L~~sd ' ~L' A L „~ ~x , V Jj' J:GISIERED Oml[p-LAST F T uDDIE REGISICRED OWNER-LAST FWSI ~ .MIDDLE - ' •. , ~ N N o. ~ B o. U + ~ I ' NAUC AND ADDI+[SS Of WSUILViCE CO. 011 AGENT ~ -~~ ,.i.... ~~ ~ ~ ~ 2 NAME AIIOOWRCLSOF'INSURMLE CO.OH AGENT •~- ~ ~ ~^ ~ ~ti t v/L `~ aluiaE ... cn^uoN ND. crlMCE ~ ..:. _. neuoN ~~ Anlal ~ ,. s i NANE, ADDRESS & INJURIES OF PERSONS INVOLVED LD GEX DE AGF i SlAlUS _ "' u ~ ] ~ s EJ[CT. . A, L, NAME C AUMESS~ r NIUN C S-~OVgy fUOM P E S TO a A NAME N T Annnrss m MDw n rnoM r I S u umL 0< IHrcA Rcn:r nr To W A E ~ N N 1 r I T AOTIn[44 wli~rd" 3`v~oTii M s N MnN1YA c TD ~ E NAUI - 1~; ':~F S AlNnrss - ~ E Ixy LJ vAi -'~--- 1 'I TA~lvir' M l TD ~ ~~ S+ x_AI, 1 ,,.,IAn•ovigrl I. Jlw~n.ruv. I•I•.I Aiuul rd l.nclNxl C 3 PAS51 NCrn ] ry1N:'1NNN 'TI A 1 ' NownnW 314 ANAL SCr NI I I ~IxcAlN WnxlJUnr N:W Ix'.ANI UK+ 1r n f 1 1NDI nISIAUto 3N01 u1 UuE ITglrncrto 31U1M IY IJI CIEU lI11AlLY1JEC11:0 I' Irt. ~~' D p .IICYCiISi s ouNn ~ I_~~~ r.ONIf 11P0 +It KIN nnl'IMOirlrlcul ]DI AIrONAIInIVK A pLD PUR)SN IAL l l lr IL VbN N 1 r ru ::+mE vualr ]U:.[n • IWNN,~wn A ] A uNVrDwNn tg 1 1? h1.,~ ~.p ' p r y. ~~ ' 'I fn r - ' ^Y- i'~ rUt ..~4 x ~. T: ~ '-, T !, i '~r ~ y • Iy L ` S F rr I 'Y L '1 / 4' II ~ ~ 1 }II I r ~r + ~ ~ ~. 7 'y 7 I y ~Wr1,~44{~~,1 J ~, ~' 4 ~ ' a r i 7L r. `t tx p ~ v ~~~y.~V'IYnt 1 Y r Nq ~r~i"`', 1 f i r a h ~' I ~ } . ; +~ ~ I ~# t ~ , ~ L~ K}~~ 'C E ~~ ~ 7 I 1 t ~ ~~~ ~ J 1~ us 4~ _ '~ a ~" f 1 ~ . ~ 1 ' I 'I~- ~ I ~ C1 ~p ~p~, ^~1!""Y7r^~~' .+"TUr' ,. t1hRt?*Eir-',1•^ ~~,'IK -r,11 t~. 'h~"E-` *T-w•r~. ,~ ~~ ~~F~ 1,,;' F ~tj 1 1; 'pry ' ~ h::. I f ' ~ ~ ~ I ' I . / , P I '. i'; '~'~ it S. ~ ` . .. . y# '>Wzu ,+~iso 1 ~~ ~ ~ '~ J y±, ' g1. ' . . - ~ SY '- ,fit ~'~ Lr r' .. i ~ sx ~~~ 'h~"~:T:sxm^1^'-_Q~ ~~'-~"~- +6 _ ~~ ' _E ~ .. !~ ~ .~~~r R~ tt'R!3'LN ~`~' '.; ; pSTInM1IMNMIMIALCLW'.',[NO TO WA:JNgI0N 9rAiE ^Aillp-OLYMHA VIApnNOTONUA'Aa ;~;~ '' DUNACAIP GJ^Y.IOCALUWCHFp1C[MENI AtiENGYSCMY-IHiP11CA1E C(N'Y'.VNESTIOAi01TG COVY .(.} j' FI ~.{~ jF ~' ~'"~, ze .~ I -~{rT~ ., "Ci;l, ri 1 r,tH~~~ r il.~ ~+~ry~(j~ 1 '~Y ` I~~r i~ ~P~~~' 1 [1~411I°~~ 1~~ ,L r ,y~y ~c r~ r r.'yL L+ ' C'J ,l ~1 ~f ~`~ U {{ } I r` y } i r 4 ~.4.~+M ~ r ~ , . T I ` P ~ F~~, '' '[ 1 '. ~ ~ I ~. ~.- - l 5 I -. , 1 1 ~ I I I ,II J R f .. S I 1 e .1 1 ,~ } • r f I'IIE P i I-~: 1 ~I t a 1 ~ t ~ 1 ~ ,~ ~'~~ ~il.-_. .. .. _ ~ JI E%AMP ~ - r.oxr -~ ,1 (~"`y!+ VEHICLE DAMAGE I.WEACHSOXCIRCLETHENUMHEROFEACNDAMAGEDAREA ~ ~f IHSTRUCTIONS% 3.°MWAHROWISITO SHOWYP~PALDINEGTION OFF°HI:E ~~.,,.I -0AMAGED VEHICLE NO.T (USETHISGPACE FORS^ETCHINOOAMAGETO TRMtERS, MOiORCYpES, ETCI DAMAGED VEHICLE N0.2 ID.INW IG.FboE ~ ^ STNn!.~~ ~((~ ,~.' ~/(I ~~~ I, 11 16 i µ IS. TIUnE - , r r.'^!Nr~---1'! s I] V°2\'f°~_'.'f`- t~JL_._._'rJ ID.IIrM^rcrNVa I V- , IU.UrWrc.nle°t I°. T t ! I ' n. alrl,AA ~ v.atHM° SEVERITY OFD AGE: VEHICIENO.I 6EVERIIY OF DAMAGE:IOTHER VEHKIEI I^DISABUNO DAMAGE D OMERM.V. DAMAGE 1QOISAUUNOOAMAGE GQO,HEfl AOE 4 NOOAMAGE ] FUNCTONAL DAMAGE 4 NOOA A M SEVERITYO DAMAGE: VEHICLE NO.]- M.V. DAMAGE IQDIGAEUNO DAMAGE D[%~OTHERM.V.DMIAGE MAGE 2 FUNCTIONAL DAMAGE A NO DAMAGE FUNCIIMALD , ~r TOWEODY aYr.~~. T' <~{'- EST.DMAAGE TOWED RY ~ _ EST. DAMAGE TOWED BY Y~ ~.a l]n ° P ESi.0AMA0E !~. O 6 d0 S TO S TO • TOOC/ R DI G DIAORAMOFCOWSIONN g ~j 1 ICrC;,.~ __l` -y y - - '~„ Aowr.t ~ , -I - ih[a II ~.r _ __~J -•{. {_. iDRAW ARROW SHOWING - NORTH IN CIRCLE _ I _ ~ l- o ~ ~ # - b ^ ~olm a a uP.canTK.a ~ - -'-- - -~'~ - '- nc~PS: ~jo9araocrw I I ~ ~ - --} . ~ - I ~- ~ 1 %-O-i--r- I -'1-Z ~~. ~ ~r~ ^, ,_~ `. ~ I z~ rs PROe.eLePOwr I -- _ . r _r I ~~ _ _. ~~._..; .. - r ~ ` . } r _ ~ ~ I r T f ~ 1 _ ~ ~ . _ ~ -- '~ 4. slowvROlrlLEreMnE { I :. ~ DESCRIPTION OFT" ,. ' '~j ~ ~ ONDICAT E WNAT PRODAELY HAPPENEDBEFOPE. D URINGANDAFTERTH E CRASH,INCWDE INFORMATION NOT ON DUONAM,E4OPoVER ...;~G•ULLI$~DN~~Su,. •7Y ~ ,~~: ., pSA&II TY, REW CED VISIBNIY,PE°ESTR4N CLOT HING COLOR.CONST RUCTION OR REPAIR WORK ETC,) __-V.ehicler~_z-~?as travelrryP_IB_oa CE 10 and was ctakis>g a left hand turn onto~~~~_ ^Vehicle~ I was elso travelin~tYB on_CR 10 was tlassin~_vehicle ~2+ Vehicle ~rl did note she that Vehacla~~2 was turning=left and struck vekucle 7r`2 in_the left side.forcir~q __ --- ~ _ . .___hhn~;nto the ditch '" _ •„•:j,; '?wi'~p:F, ,Q _ _ R „-_ .~ryY.J G yyr:-'~...R Y.^w.L!•?.' 1E.,:: i':'$.1 .s.~uA'S>`."WY:i~ ~VEH HEADED ~ ~ -MILE POST pR ON STREET 0i1HIGNWAYfUME ORNO IN ONE DIRELTON - rE°PEE0.9~! LEGKLY pppl(ED IWAD VEH OCCUPIED 'NO WCREASR160ECRF.ASING .. N 6 E W A ., /O .. 0 ^ ^ ^ ^ C ~ _ ti , iY1 ~ _^ _ .A r r'~~ f ~ .. PED ~~ ^ _f I On 4L ___ cra sswo- ewln Rn A w!. ,rlloM >le., wl ___ro._.___ __ PF D/DICYCIIGT WA9 USW _ r ~noawiW O: Il a~''~ I. J9xnwn / w r ((- °MA l,..liln °niiPms ~ ~7 (~ E °f 1~ r^rA°Ir! I' Loin ', Y •• _, R . ROADSURFACE„ IMECrt o^q . 't~j.WEATHER;.~g ICHEC^Oel1 ,.,7;;X~,yjT,y„r;,j,CONTRIOUT ~ ICII / INO CIRCUMSTANCES j fCA DNEbMDXEI '~y~S 4 "r ~ ~ {//LL``t+ i ~ ~ ~ ...':1 o~+r^^vacLe :;: ~ I NO i YLtLI! 1Oq Mpnlbj'! GMR - 1 . ,~~ ~~~. l.~M. 111{11 ^ ~D~~ / i HO ~. - ^ 1 (-1 L 1 1 _ L . r i ~ MCIWnY ~ F- ~.11 1'~ N~DFCORMWiNCEp J_ ,-f {~, J I Mn. ! ^ ^ ' 1 IOOG~ v_~ •! ` ~I]I ~ bW /90. ~' ~ __ Y VL].H-+• IOC A141q - l ~. _ rL ry! 1 ~ ] • RAN.q ~ } ^ ~ ~ Uwclb ~ r-~ V.~! ttR f-'I I'7 E Y ^a~ two ~' ^ saw 1 a ^ wa:.a f . ~~ ^ su u.tr°f ' . ^ ^ sa AA° ° I r16L1 EocA ^ a'° ~. - ~ ^' ~j •urtnn« _. _ I: ~~ ^ K. ~ ^ roo - ^~ ~ ^ EEn+ onews _- -~ °-^' , arn~ER 'f ' ~ °E _ °'w°EOU---- r ^ ° `'J1 U.IVM _t.,~~C,] __ ~~ ~~!_ Cl^C.L_""`=___ _ 1__a~DUN,, ~.,_~ _CLL..]_..____.--__. - ^°^ M°w.,° OMNII]P[CWI omWtinurn r-7t ('~ LJ '.-1 ~ ~* _ f'1ui l I_.1 1 iN1E°anu~OP ~'ul~~l DWERIe^rc~m I f ra.wuroH i T Aro^P!°roR . .~ ^ ,nuts LIOM7CONDITION3 r,TRAFRU fANTRU4^_~ L~TYPE OF ROAD( e l~ -` . r i ,; VEHICLE CONDITIONS ~;E.I;~-; ~'~;SOBRIETV ?I7y~.,:~,.:; ^!^ !p in ~n~ AL IUHlp MII _I_ra~]~Wr~pa I~l~ 1711 I~UrWi ~~ ~~ (~ l.J LI Knob brF UR MnAq ~ ~ 7 plwAY SruC1! KM~Ci /Hl OH ~ W ] WW wNUYt3~01 N~ Ib~ECR O^!I IMF ~N ^a^ 1 `x ~rrr t ~ ^ °~ I~°'~~ c~i ~ a ~;W. ^ ~ ~ ° ^1O^ ;; N;k L;;t ~ tr. ~ tMW ._~. I 1 ~^.. - ___ .__ I L. ~~~ ~ N ! ~...ll { °IX ~! ;_ . 1] t r.. .. ~~11{~ IMlD p041i°I • ] 1 . ) ~' NA9M F..1 L. _~ N ~~ 4 iKrur,•1! ~_~ ^ oD! ,w I I C t ~ -'l] rr .' { I __ ~. '~ IWrlNHO 1_. {I]l_~ ,wriKl . _ e;_l o+M-..Nn JJ 1 !~ I rte- J 4 ,L~ ~ ~ _. ___ ..f.l { ~ a °wwoo°°W . _ ~ ~~ ~ l~r nrrn..D 1 jlsL,l n,c^.a .. _ ! ~"T o.A+arArlt ; J Ia^rabr - -' -1 sr J 1._~ srilr _ _ _......._... '!( .w.rurt ~ ' ~ Lu.e] . _ _ . _ _. -Ic( 1 rwo NpaloNn ~ blown ~^ CHEM. TEST I No ] _ ^'1 ... L..j ` _ ._ m ° ~ ° i° .. ...`.~°r R.^«°.i- i ~'I M reo -^ -.---'--" ~ J ~ ~ --7 !' ~ rt um.N 1^ n,H ..ea ln~. rn wrta r E r -. i ,"~ olrw J __... C..;]{ I w+olo . . _ ___ ~i IX °!rlcn ..~ . ~__~ .I rLEI REroxo 1 .. -... orw^wYCrn .._. ~ y' ~ rc nr^.rwo.__. _ ...;o~q~WCm I % .C TEST RESULTS 2 N.E nl.lwrarce `~ , . ^ ~~,~.C~~~ r / L1._ a l'7~n.L3 h ' ~ vl ,E NO +. v i0 // ~ !, rwr.~.n iy`..c: ,n. o I 1: ti• /OOIO+ I c`~",c «ou-.e u.:vlo .nmio~ J ~4 ~ j `.m c~ A ar ~~ I.n nHh 1_ _ unvururx _«RI , v_ v_ ~,E ~~ .. ~~ CI DATEOFCOLUSION DAY OFCOLUBION TIME COUNTY NO CITY NO. fHW 8AN ~U r A T MO DAV ~~yy1 SUN M1lgl iUES WEO4IIIUP Ffll /~ 3 ~~' ) 1 Z J S S~ IUSF Z<00 HO RI `d ~ j- Z 9 UPAL E ADM~LLS. PREFI% IIOUTE OF STREET CODE SECTION I COUNtt ^ ^ STATE ROUTE LVZiCOUNtt ROAp CRY STREET O 0 3 -5~~t ^OTIIERISPECIFY) ~'L ~Es}~• ~ y 5G 99 - ~ CIIYORTO WN ^IN W PREFI% EO. MILEPOST ~ `-,, n I~ IrypY~ ~ MILEB ^ L'U ^ ^ ^ Of ~~TPf / 0 C ~ Lf~ M • / V Z~ C . NAMCdryO.OF 31flEET OR HIGHWAY INTERSECTING WITH: S TREETOR ROAD LL NAMP OIAGPAM DATA NONINTE(LSECTI A CCIDENT I NTER NON %~flD INTERSECTING 3 R E OR ROAD OR HEF. T POAD ° M ILEAGE WTEq C45. ERENCE CR0995TREE OR -~~ - - N BETWEEN STREET AND 6TREET CODE ~ s ~ r~ ~= CT10NF~OM EEF WENCE OR CROSSSIRE TANCE~00 pI3 HuH~EiRP ~f SPELIALCOGNG USE SS7'!~O E9 r~ A 2 FEET OF 0 ' VEIBtt VEHICUEVEHICLE ^VEHICLE~6ICYCLE ^OTHERIWRITEI ^HITd RUN NO. KILLED COLLISION INVOLVED: VEHICLE~OBJECT ^VEHICLE-RR TRAIN ^STOLEN VEHICLE NO.INJUPEO TOTAL NO. OFVEHIClES D ^VEHICLE~PEOESTPIAN ^NONCOWSION ^HAZARDOUS MATERIAL ~PROPErifY DAMAGEONLY OGIECTSTRUCKINAME OF OBJECTSTRUCNAVD OWNEfl3NAME) .W EST.OAMAGE. LOCATION OF O&IECT STRN CK R E ^ gOADWAY FEET ^ ^ ^ ^ HO. EDGE S ,,. FIPST ... .. MlpplE ,. ,. OflWER9 NAME~Wi IDOLE IIF SK:YLUSi Qfl PEDEbfRIAN GNECKI .,-.:.:..- DRIVERS NAME~IAST FlR3T M D _ , ~~ ~ I~ D G ~ k i Lt1 ~ ~~i 4 c, ~ R ,,///-~ e l ~ C O ~ . R 3 ~ ' STREET ADDPE99 'tR: f •P x /0 8 STREET ADDPE 9 _ v /sZb G48L~ e+,c E LI{Y STATE ZIP CODE PHONE NO. E Gtt - MATE ZIP LODE PHONE NO. R ~/Y ~./ ~wh6ah>al us-rj S $ H ~ ? seno'~ w 3$s-~.S N . / D rvEP9 LICENSE NO. bTAT SE% DATE OF BIPTH N ORNEA9 LK;ENBE NO. STATE 6E% DATE OF BWTH MO. OAY YR O. J M wQ '7. 3Y 9 °~ - -°~ -SV 7 ! c 7 L'-"~ Z 3 5- DRNEfl9000UPATKk1 FIRM NAME PHONE NO. 'J. DRIVERS OCLUPATION FIPM NAME P NEN . CODES > OI cuss lAl SEAT BELT lyl EJECTION / IDI CI AU59 ~ MI SEAT BELT IBI fJECTN)N / CODES > nATUPE OF / NATUR J'\~4II~ INJUPIES INJURIES p 8C N O DY: S8 J TO PEMOVEO FROM ENE BV' °A- TO Y EH. YEAR MAKE IDODOECHEV.) MODELIDARTNOVAI STYLEI2 ORCONVJ VEH. YEAR MAKEIDODGECHEV.1 MO~DELIOA T~NOVAI STYLE 120RCONV.1 v Doi e IQ ~/E><a, v ~&~~ /4 d E VEH. C UG TE NO. STATE TRMLER PUTS NO. STATE E V . COIA R UC. PUTE N0. STATE TRAILER PLATE NO. STATE " 1 Y.4NOG u7q " 1 e8~4 -7SS~I,~(i wA4 (~` V Hi 10 I I ICA ~ n NUMtlER OOMETER . ...._ O A I NNZ1M~fl ..,:-,•.: ~,•,. ,, E IOENTI VEHI CL 0 M T R ...:•s.:.l.'. , L C L E ' ' t-~lV E " REOLSTE OWN -LA9 FIR MIDDLE I'~a r04 ~ Y_ ~ o REGISTERED OWNER- /~ FIP9T ' ~. _ MIDDLE 1/`1/PI 1Ly-Y11y 1~.u1• ` L O. AOD E OP 0 ER . .- . ....: ..... ESS OF WN ... ~ n EANOA E OF W911 O.OR AGENT,._, ., ,....._ NAME ANDAODRESSOF MIBUPANCE OO. OR AGENT , T N NO A ~: . HAPGE CNAPOE C . ITA IO ENFOgCEMENT -, _„ ... . ACTION DO GES , _ a D s NAME, ADDRESS & INJURIES OF PERSONS INVOLVED SFJf AOE BTATU9 W EJECT. `. HAM!' C ADDRESS' U P NA UR OP INNRRS' REMDV DFR M SLFNF FlY. T O A NAME'. N r •DWIESS' DFR $ hL PI NibEB iNf RV 1 0 ~V NAME: 1 ADa1r.33 N y,F.~ .Y.fNi RY TO 5 4AUF- ^ •Dn esR F h u.~.M1~___.~.~.~...__.~ ~ r triY T D 1 •t AI KI4 .II CA .ISLAIIEII ISILJLCIION •1 r PS9I: AFII . I.NO LR BdBAlIl.IIIOFWRY INOTVIBTAILT.D I.IIOTEJCCTCO ZDE OAi SCE DNOH Dr1AlIlINf1 ZNOI VIUSE ]TOTALLY EJT.CTCD l 'G ICOdI^rl 1 y Z I UIHCI I ~~~ ~ UNKIiOWN PJCCTED Wr IUIHY ~ IIHM~DWN A 4 ~ ~ . D A „ I . F IAOTO.IC CIEI • PLO 4IgSHl•L 1 ) dEEAi VELI FIJIIIRF EJELTED 01 4 / A t .Ea3 1 AI.-IKlNt4rnA ~I~ - Y , L:, 1vi~ a-a~.a _ .. ,ut : s,+f ia':4a1 +a~ n+~1S:. .~ ~ ~TI i:~4 r '~ ~ a. at; 1 ~, nn 3 A . aVi {,; ~~, ~ ~ ~ ~, ~~ri ~~ ~l ~ ~~ . i , ..~~~~ c ~ ~ t ; - r ~ z~ ~i-; q~n i t ~ , r , `~~ ~~~y'~ °V{ ~ ~ . tt ~i ~ ~ n f ' y 1 5~ 1 Y ~1, ~;$+. ~--- -... ~. .. L...... ..L.ir....., ,, ;' ~ ~, i '~ 7 kS _ '. 5t~t z~a ~~ c~ { ~' r r i r 4 l '~ ~ Y ~ 11 i ~ - d h ti ,q„ y S s r ~_~,, k 9 _ ,fir r+K +~ ~, f ~ ~ • ~ - l ~ rt i ~~ 7 ~ ~ ~ ~; 4 ~ ~ { ~~~[ A5 i4I ~ 7 J' l~ ' ?~b i f : t r4 '~ ~ ~ ~~ ~z 3 R , ~a~ ~~ y !i L. '.d ~ ~ ~ ~ ~ I J "k J ~ ~'' ~' ~~~ ~ ,~ . I ~~ : ~ ~ ~ ~ ~ r ~ ~ ^~ _ 8 k 1 ~ x 1 Y ~, r., '~ ~ ~. ~ 1 t it' .< +~- f ~ i. w m j - y r r, .i ~ ti~ ~ , > _ ~ ~ O ' ~ 'f f, t J ~..,. 3 t - yi U ~ kr;' _ f~gg~r lJ f! d 7 '.l~ ~ p ~ { ~ O C t + _ f • 1 1 f'1 H O O `owo j 11. ,o i ~ ~o I i ~ o ~'~ ~ o ~~~ ~ C ~ ~. l~ \ 1~ ~. q t. j I j i ~'- z,, r i 1. ~ SS p ~ 7 ~ .y'~5," +~ Fa ~~~*'~~'~"~ ~ `~ ~ ~~ ~~ ~ r~u~ ~4~iib~f 4h~~ ~ ~~r hd'y~+ k~b ~ ~ 5+~; ~ x ~~ d ~~y ~' ~ `~r'~ ~ ~n y5{~ yact ~ ~ i ti ryP`~ ~~~ '~s'S ~' d' t t . ~ .. . ~ _. ,~1~ • q _ ~ ~ ~ yy~~ `4 "~, e~ . ~'N'}L`u""V~'._ -u.._,~ .u.._x iYA~' ~i r ':J .., ~ g ~'vrfibi 7Z3'S' '~u~r. S~+T.uJ'AM. 'w'~v'sYaGD..- .Y' ~~ . ' , A _ t v I Idyl MOTOR VEHICLE COLLISION REPORT . .. .. NO. '1 `; ~~e r DATE OF COLLICION D AY 0 CO LIST N TIME OF COL'ISION COUNTY N CITY NO P^ _, DAr 47 r. su von :r ~ r " w[D ,K[ ,Hun ~ i [p s. wR u nu [s AM ~ . SC PM x I] x n ~ I ~ . TOWN COUNTY CITY 'w ~ MIL CITY, TOWN E S AOMCLS PREF nE i IX C O y u I ~qn %E & , • O O // ~' `` -II ,O,t // LL 4 ~ SECTION .aF ~ .~[ % ~ ~ T `^ ~('. r c [-, wo n [• V I I ~ l~ S IVrI OF A C_ ! . _G~, ~ - Y '.yyp? . ~ 'C-A } 'r~ l y GIVE NAME OF STREET. ROAD OR NiGHWAY INTERSECTING N'ITH: GTREET OR ROAD PREFI% EO MILEPOST _ ~ ~ - ~ Q NON INTEflSEC110N~LOCATI NO LIEION RAMP DI GRAM DATA ~ ,(^ BETWEEN STREET ANO STREET ~ -- 1'~ rv T R En Dn, o "Oi ^N v xGr ~ O w" DGE. E EF C I ' D } ' ` CPOSS NG uE[POSi Ox Dfxi i NAnK. ..•- P•tno x l RStT,i On. IEET ^SQ OF I T INT ER ~ C $, f nF/^[i~On ROAD //yy G ~ (O~ V ,rt~ '~' 1 3lT. ~0.[x xw,N Ox LvO f0 ^v[ ^v[ SPL CODEU E 7 ~LY~J co N ~ OBJECT STRUCK I EOF VS~EC[sTROLKI OWNER OF OBJECTS NAME NO ADDRESS LOCA IN PO TION s.x WAY as AO OiREPAR VSI[ ~ ~[ ~S_~~dY ~ '~. " ~ ~f •'. • FEET S W EDGE $ ~ s N vd• "(: { E DRnnIVERS LAST NAME FIRST NAME .MIDDLE (l rv '~v r. 'r~P~ ~ ,p •x O[v(D coE"asaxon E DRIVERS LAST NAME ~„ b~~ FIRGT NAME MIDDLE 1GY7 P ~R ~3 ~ „i. ~ ~`~( ' J ~ ~ ROUTE N0. ANp BO%NO. STREET ADDRESS uOnE Tx•x En[ P GTFEET ADDRESS _ _ ROUTE NO. AND BOX NO. ~~+ { • 'Zt n ~. sfo~a sE A " ~. ~ Sy'~ ~ ~ ~' ~- ~ ~ TTY STATE 21P CODE DRIVERS OCCUPATI ON COE[is,~ CITY. STATE.. 21P CODE ~ DRIVERS OCCUP ATION ~ ( 9 y 4 '' ~ T ' ` n [Pon, ' , ~, +ro, , . ' ~:i? ~,~ c li ( .s ~cc C R C .-r 1_.., 1 i 36,, G-) Rc-i- LCe~ ~ DRIVERS LICENSE NUMBE STATE SE% M DATE OF BIHTM AOE DRIVERS LICENSE NUMBER STATE 5 DATE OF BIRTH pGE ~j (_' - - `- iC3 x W.;. 12 2s .i'3 ::Y -o._K - N- !M2 WA MX y Jo ([In qF.., c t' ' VEHICLE YR. MAKE ICNEV: DOWEL MO DEL (NOVA-DA RT( BODY STYLE (20RJ VEHICLE YR. MAKE (CNEV: DODGEI .MOD EL (NO VA~DA RT): BODY STYLE IP DRJ T . /4/,9 (~_..-,-: a C CI, s?. 5)lek. // i)LbY 1970 Foc ~ Fd"~c~ e 1. .,~.... tT ._'~ ~ , STATE an LICENSE PLATE N0. STATE .TRAILER PLATE REGISTERED OWNER (UST~FIRST~MIpOIE NAIAE) DRIVERS LICENSE NO. REGISTERED OwNAq RAST~FIRST•MIODLE NAME), _ DRIVERS LICENSE NO. •5a~w. rs 1noL'~ Sfl ' e A. ~ ~oEJP„ OWNERS ADDRESS : (STREET, GIN AND STATFJ OAT OF BIRTH OWNERS ADDRESS (STREET, CITY AND STATE) .. DAT OF B RTH MO vf•p PART=S OF VEHICLE DAMAGED E PARTS VEHICLE OAMAG ,. Es, Pi[Oc WAS THERE AUTOMOBILE LIABILITY INSURANCE ^ YES ~ NO LIABILITY INSURANCE INFORMATION~VEMICLE NO. T- COVERAGE IN EFFECT FOR THIL ACCIDENT ON YOUR CAfl NAME ANO ADDRESS OF LIABILITY INSURANCE POLICY HOLDER NAME OF LIABILITY INSURANCE COMPANY •yF •DORF55 DnT SIME SiP I ' NAME AND ADDRESS OF LIABILITY INSURANCE AGENT On _ st•,[ RP LIABIUtt POLICY NUMBER .- ~. .. .. 1ST INJURY AGE ~ [ND INJURY: ,vs[ R , _. _ AGE NAME TOU IL NAME RED -- ADORE53 ffSyy~~E%FF 11- ADDRESS SMMEXFF. toCNl4!~~.i4^![5__,"__~--- _---..Ll.u~ L~l[Nl pL3HLVP!FS ^.^, DDD,Dns , r^ F~ u "STATUS OF I 'nxR ~ f MARK FIRST ONE THAT APPLIES ••STATUS OF IN R ~ of MARK FIRST ONE THAT APPLIES IN VEHICLE " ~~'^~[ ••[I DRWER Oi~i~a ,gxo-s•eE ^DRWER IN VEHICLE iw~~ni ~iiiA vE PowiOlE T~PALLEMGIR ~~ KILLED Is v n iuiHOPI~ , ^PASSENG(q ~ KILLED sfv R iuiHORIPo npf fg4gACM O POED[CWR.AR,TC N ..J ^ FJ^(I 6'^ POP~•ixxEiGl ^OI H(E PRIVPIIEND..__ ^ IFJ^il G^ 7^E SHOW IfORTH DY ARROW IN CIRCLE ~ S DESCRIBE DELOW WHAT H``AP'-PENED: (REFEfl``TO VEHICL\ES BY NUM'ryBEEp - IxDIGIE ON ip ~3 DIAGRAM N t' 1 \ P ClL"~(1t 'l 2VCZ~17-Q_!~- WHATH`PfxED to on O ~ ~l~I-_~J., Y.~. ., .... x.. so M,r\,.. C~a_c.~. , ~.p ~_~ v_ti.~.~_ a :~'°^• wx,.D,x . 5_'rcJ.~'-5: ~1.:n_.cis-~--~..~1\_c_~v_\--- yE{~;~:.~~_ _ r.:~rc,Y.2-a~=_CfiLl~-.fJ1o_~[:_:_,rt[j_I~-o_ - TI Yn r 'f.'O__..`.E_T_o.\____-so t'ti 1_`IrS7,.-r .l-:C_1-- ' ----- - w _o..»_._TO _...5 6.a+J a.P._r__:f_~r_1__Gatt•4~.,~=r =L~? Ate- ~'rFf~ ) -- __~1'-.1_L i._5i 0_l'l.__._.. Q_S.<_da.'13~ 51.x"_._ ~Y r. u,~ n _-- _._.---- % _~ ~ ~~~ .1..T1.T.<. <'~=.~T~V.~g~.._t~. _O._ C~?CJ-'S "rr,ir _ .Ixll, Dx.,,G.p: ~~ ~ --A('~'~-`=K-A_VYMn <'.r.\y_.-"~._L~" 1nL.~?_N .~--- / O V[HICLES POSITIONS BEFORE COLLISION no oP E.nEa VCOHIC~Wq a ~ O Iu C 6iR[ET OR H16HWL,AY NAME OR NO. pp~ ~qH fm A1H(Iry ^ ~ ^ `~ r?7~z.~_'~~'-'"`r'ay - T4: CIA / nonlnuK ^ ^ ^ ^ AloxG " ~ cc«DssmD PIOESiPIAN WAS USING I l~ AIDTwaIA 1 1^ 5HWlD(R FDAD SIINFACE WGInlR UONI CONOIIONS WTRAI fIC CONTROL ic~icA ONN ,DxIOP Lx,[1 rl~•ar,(0 T r1 KAI f~~ "0 F f ca wiAx~:at^ [ rj~ OAYl10HT ^ 1 ^ SIONA/1 1 ~ ORY = ^ NA xINO ] ^ D1WN ^ T ^ L10P SIGN 1 ^ WLl 3 ^ Lr10WING 3 F^ DVSK F^'T 7 ^ of lD LIGN U 7 ^ LNOW A r 1 f00 a Il~ ~KINiS ON [T I-J f ^ FLASn IIG R[D ~~ [ ~~ If•[ all^JJ SP(CIFYE L `~ 1010"IS OfFT ^ L ^ Tl A3MiN0 AMDf.R ^ 3 ^ SP(G Y 6 I~ dl x((IDIIGniB ^/ / ^ RR dIONAI PCALON FOR NOI Lf TING DANGER T ~] O1HIR l~ rl AptCI,x10 V~5^'.v Nbrx tLl NrNf IICI SP(GIFY l 7 LJ Df fIC(R'iIAGYAN g v yti ,'. r! vaer I ,t I e p ~~ s ~1 q W4~ >~~ ~ ~~~~~ 3",~ Y - ~ ~! k ~°,+~t ~ ^ ioi a ~an,ox[En DIRECTION T`PE Of PDAD rlwYxO [rvluWl"I 1 DR VERYCNICLE ACTION'% - r x 1 L FMtA MfO O^EI c n 1 (, M1 r~~aN v' ~ w~0i ' ~ 1 ^ ONE WAY ^ ® I ^ GOING dTRAL611T AIIE 0 '~ ~i ~ E ~ T t ~r T 7~j 1W01YAY ~~ T ^ OVLRTAXIIIG ANO PA,aSIN6 .T ~; V ~ Y` '' t ~ 1 T ^ 1 ^ IOAO SIRLE ^ 7 ^ MAKING WGM TUDN yy y . -l ( ~~"~~'< 17;. f-l A I'11N1[ICNANOC I J U ^ E I rn '`I MAKING LCII TURN 1 1 ;i /.. - ~ . DpOPIRA41p I~ L ^ AILCY ^ 1 ^ I~'1 UNN ^ ^ 6 / IrJi MAMIND UTURN ^ RIOWINO ( ~ ~~~i ! ~' )5 I ~ lANC3 ^ T ^ 5101'PCD /Oq iMIC10 ('~- z /1'' - '[ 'I 1' ( ] 1 ^ d[PARAICO I~-- E I ( ~ O~OLIOP dIGM 6NAl -~A ''~I 1) ~, J t iI { / n~ 1• ~ J 7 "+ DWOLp IP 77 I.J 1 I ~ J L10PPfDIN CgAOWAY v tl j, . s r IrD 1 ~ ~~ "' 11 D n ii xi ~ica~nF 1!` ~ 1 ~`s~ ~" I n-7'l~ymG'~$,m~FAM''--•,^•~D ,-r',-;7R~,v-- -""Y+ .fiL-a.~.~l tt I- ~,x I +! I ?.r~ ` I . 1 [~~~ ~, ,' -! ( ~',: _ ,., iR._.~ _ , _ .. . _. ,.. , ... _ ....P .~. ~. f l (4 F e~ Gf ~~ . ~~ T~>~I t~r~ '~ I ~, ~r ~ .~I l~u 1. 1 ~~ t 11 ( ` u I '~ -L-~ ~ ~ ~ / 3 J!I M •!- ~ ~Kl fr-' YCT.7 <T S ... L~/ES <T .F N..:.w.:1 c ~ " r I/ ~~~~--- ~r ~ • ~~, E LLO, Sf 0;~1 t AJ!.;,.~ ~~_~ RS£<T .G 1 N~~ T EE qp D : " . L ~ 1 L 1..~ nl ~ ~ .~ P EF lT s' o sEC o ~~ N PNEFIX E a i o Z y LD,.,,TIpN DF <qL I, Ip y 7 R,LCTID ` BETW EEn l a,:qR ,~ I O~ ,^°r ..,tnP,o[no..n~.., d..,,naa,.o.,... `n ~_ b~ PO I HTEA TE C n ^ SG~~pr ..a .. a. P lw,.tl ~ ~` I~ / ti ar [ nl,n ^n,r,~N 1 ~P ~~ OU ECT U<N.3.^:.. I r .: .IA.I!~? ..:.•..wl,...~.. W E. ,Q~ OdlGCTS.HwME,A DORESE:rlyi....:IN RO ~ AOWAT, " `4-d~ ^^ crMN oa, n it ZJ ^ : no, F "/ DR RS LAST Nw rwo uns - ,jr .. P qn ;NAME ,~3,~,y,vy P LE„__-Z DRIVERS LAST er JR. T_N!• Erg. w..._~a~ wMlOpl~:i•~ nant,n.nrwa STR ETA RE96 ' ".~ ~rt,y~,vOUT@ ANp e X ',:. AEEi A00q_E-.. '. -~..s::l ~ ,' 'ey:.g0 T 'NO .) .__ .__...._ .. .. ._...:.... __,.N!DB N0. ~~~ .3 ..~s7 .an,raR r l Lx G,~i - na u GT ::.~...l:c.. TE:: ._IkL__.. E..p ER OGCU ....O_.i ..T. ...'.ii.~,..L. :..STATE: uw.,...T.~FIP.SOQE GRNERS O<CUP.ASLOR:;' I V CN ' 9 / i ~M/~G Y St4^ E LP D A~~ew r (,>~ K-VEn'1 /c ~' ' '~ ORIVEFS LICLNSCNU R -a' - . MBE `? r aihTE E :DATE OF TN E D _ A~x~...-.... E RIVERS LI<E N -c:l-1C-CGe3JB w~ N r _- ~..._..::i5:51. c`':^ 4 pE_ DAre„ a wcei dlaX•,wr MANE";ri~dt~V, ooeaAl. OEL ~^I ~-•u,nt BOOriSTyLEa~l -rR:l Nc~FY MANE. 1 -w [I MOD Y ST`TLE'~l. r,°., - LI O E SE. ZEN I i T ' ~ ~~, s~y..w ~ LER~LA E;NO'. ~~. ~gTE,j viy~M,. " . LICENSE PLAi~NO- ,a......} TE'' .. _.TR I... ..I4LATL ~SY AT6 ~ .= J ~ ) I ) ~ GG J n ~ . . VEN Cl14 _O[NFIFLGr10N.N0'~[ E .M[Vif 1000METERI __ VEHICLE IDENtIF CATIO Np,i,~••- IpEB_;11ou _.NCVwtlll pOMETERI,w~it[^f R EGISTC EpOW EH I a _.N _ ~ ,L,~ t T-PRIs~.R~EOLC.~n,-~yt~•r.L^r ::G~~~.S ~~E~.~;.~.w~'yTy/•~R G TERED~O~BR. w_ ~:DY?~RS~LIC ._-S.!Iff~iT' ~ ~ ~ ~ ~, Y tl`n . w S~i/ / S/7 ,. ~/? /O a - ~ Wr tE ~,y Rl ApOR ~~~u1rtRl[T.,A~~.wouAialrar 1.~.`pA(Q;P rF.IwT_1Fi'. RS O -Ve._..J~..... ~S.ia1.,.ri~~~ .~.,f I.E-OFB RTNj [., ,tAN %~i s tivo ~ T wNSsA/~ w . p. - ! P.:-~~OF.V[H1_CL ~- CIIr,t .~.Nrc -~.. r. ~ ~...- .rco cvc.r: ~ a..uv_w~s.: - P-~Sa'2E:d!~JL<!:fi.Pl~w1D!f J •• •sG-C.YV• WAn TN¢REEIAUTOMOBILELIABILITY INE EO . LIABILITY INSURANCE INFORMATION-VEHICLE NO.1- coveRAC NEPFECTiOR TN SACCIDE r u Agt~, `~,.,. ~' s ^ No wM AN AgonesPwft.ueluT,r sunAn e~fLru ~~-Ys :•.r-.,,~,+~m+~,`,~-~,,1.„. - uR ~ - Anw. :: arrr~a-. c.._..E. r0i1HO.wu~fl •t`.~^h+'+r• ~ -~ oil'-*~_s"°fv_: SS~L W 3 lC C C t 1 J~ ~ r C F~v.2t a ~ s 7 - //i A~.vC uM w 9 3 ~.°`,tr "~?y . 'OPU,pe?~+?i+4~^^-.Lr~ _*~1'."r~~;b y~..._ '~~,..,,o:~,^ ~ > ~-...~- ~'j'~ ~ t i 5 . -. , v-~ ~ =t /Y 81 ' ~Sl':11Y,WPY^°~~J ~ -;;n. .r.. ~ ~-N ..1 JURY'=TCuc4NYAI,Aie:~rM,IT } , .) ,^..L - ' 4't' .T~ AGE. .~ ~,,..,,,t~ wM..t.».r•..~.t:..1....n,..X.~...:..~u.1`~`~`~•*JI~ i'. ^'^,,,~y'".w'hi, .ACC, AMe - - NA e wns ~e~i tioge sn ~- '. ~s"eiE{ _ _ '}~ ~ ~ r , 'tu'g M _ _, r ,Doti `'~ © « u /UN,[t nfEU II[- ®©'6dH6 •~- ^ ^ al ~.. N SAT OTYJN UflFO ~L~r M yRtcfl~8 OMC7N T P SA tP BTA U C DI3UR D "./"' -J1.L ~ ovSttlc-[ N 1../u.. „~~.CL1Fi.w.' d P MM+rc^~ ~9Ne TMa APF51 I `. 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CONTq L- I •• S`-I E^ o-u a .~. on:l . ...- IRr...... .. ,oir!I nTC Ohio. l al BRNCni~yc«Tcts19 ~* r i'~r '~.. •, . nI _ l rnn.a I ^ caM anr. • , ~~ghrL16NT n 11 r, SIGN LS r] I ~,ONL Y+il ^ II ^ OOING .TRAIONT AN[AD 11 ~] qwY )^ RhINING ) ~ O1WH U ) ~ M1TOP S G r I N ^) ^ TWO WAY ~ r ^ OVrw TANIND ANO PA[SINO ) Cj WLT )n SNOwINO , L US U , ~ YIflO nION L'] r ~ w'a RMwL[ r7 1-1 ~ o , ° _ MANINO wIDNT TUwN rJ ) u SNOW 1C] fO0 A ^ L.O; r9ONfr ^ A ^ FLAn111NO qf0 ^) ~ 1 rrn<N.Na[ LL^JJ . LO, MANINO LIR TURN LCNIPIRAMPI A ~ IL[ t n •1 ~ o ~ ^ ^ 6PIE°I , r~ L PtT , rLASNINq AMa[q ^ S ~ ALLFY ~ S ~ M NINq U•TUgN Y I F ~ Cl S `~ r ~ rlin lGN T• ~~ ` ~ w S16nAL WOW SLOWINq ~~ N ~~ LANFf 11wN ~ --~0 NOT SE[NO N tR ^ GA G yntt Fi I ~ ~~ rlC l'w/IL.rIM aN r n STOPI•f0 fOR TRAf FIC ~..,. ,,.,<..,.....,.. I < t ArEla " LJ L~ :~65 • r :q AL , ^, ^ oq, _._.____,_ ~ ncnhwhren maN ,i. [~ I ~ _ [-] L [~ srorrcn IN gohnwhY c D 1 r n u q .D ^ ° ^ rlc i ~Ir~ # r~ r ~ T n ~ ~ '' ( ~ n rRgM '1'°&r5~. 51T' 'd,~+P~'^°p~^r'e• r ' r rmn I :' F, ~ . '-r ' ~ s 3~ .f~.radl a..4ir I ~..1, real +.1 ,nc.:,4r I , t . ~ ~ iJ.: ""~ I .'1 f!.: ~''^ G'~r-T t - _ ~~4 ~~ 11. 1 ~~ _... . .,. ~~ T, ~~ • ~ ,~ ~- ~ _ ,., L f f ~. otl u q (, m ._,._ , ~ .~ ~ .``- 'y~ • s'Jy ~ ~ jp 1O€~ t~~/ ~ i~`yp~'~"~ til `~"~'Sid4~++` .. ~~.., .:..,.~ -i~ -- i 1{i L lC4 J I 1 ~ V f~F1V `T gal IY P GE ~ OF ~ ~ J ~-F 1_I I ~I' .., COMPW T R ~ ~.. .IJ '911FJp ~'~ _ UNIFORM POLICE TRAFFIC COLLISION REPORT - .. '~. ., ~ --^ J:1 u3JAAtinJ _.ti ~s :'. f .DATE OF COLLISION " DAY OF LIX11510N t E CgUNTY NO.:: CITY NO H ~ ~ M ~ Fy' Y• T ~U t DY 2 111!5 G V/ED A iNUx y F a SAT IUSE TA `~ RI J f. 5 ,r ~ ~i i RAL L ! ~';~ ~ ~ ~ CWNTY ^6TATE ROVTE ~C(%INTY ROAD ^CITY STREET O ADMLU9 PREFI ROUTrE OR SIflfiiCA~DyE '~ /1n F C/ I i X54. ~ i L+' T4 ySD 5 ..E ..W (,OITHIERISPEL~f ,1 CT (TOR TOWN ~ W J. PREFOI E41 4 MILE PORT 'ivrt~.:.A ; )I'j v7. J ro ['"'' O ~ MILE6 ® ^ ^ E.J OF ~~ T /~ Y; UL (D t.S _ .--._ O } i. ~f 'Ki ~ ~ '1. T S C U' pIAGflAM D A T -t r' (.-'--.NUAE ENO. IRE HIGHWAY'-m ..INtERSELTING WITry, S ET OR ROAD LL ~ ee~~ ,A "L~t i ~T A ... .4K d~ ,9,~$ ~.acti .po O ~:.. ~r 9 a.^ .H Y~ fi ( ~~... .... i H _~ ^'. _O. Np11NTEPSEC110Nq ', .: .. .., - - Q ~ALLEAGE X N R L19.. RE ECROSS TREETOR ROADr PE~- ' X N BETWEEN ~_.____ _ -. -_. STREET ANO __ _ _.._ _ . -_ 1REEi CODE ~ NC~ ~ J CIS '~ p6tANCE M'O gREG1KJN FROM REFERENCE ORCNOSSbiPEE. iNiLS 6 EG ALCOWNG U$E 4 flL*O ,$ AY~F ~ e 1~:: ~ _ ~ ~M LEG N 5 E W ~ ( ~Ie~'~ i T~ ~. ~_ '{ >a2 L ~'JTJF4A ~w~S~ ~ Gre N e 'A• ','y FJfEET OF ,~T ~'N Tt ~~ANG~. Ow__._ 'J i i .~1 ~ x H \ ~ CSI: .^ ^ .. ..^ ` SEVERRY w ._. _ - ^VEHICLE VEHICLE ^VEHICLE~B CYCLE ^OFNERIWF iE) ^HITB RUN 1 OnLL FAT IOTAI NO _ _ NO NJURED, '~ • ~ 1 ~ .r I OFOV[H CO SINVOLVED: VEf11CLEPEDESTRIAN VEHICLE RR TRAIN HAZARDOUS MAI ERIAL _ B10LEN VEHICLE-~ PROPEflED-. ` - 1 ne D '^ - ~NON~COLLI6ION - ^ -_ '-' ~ TY DAAI GE CNIY ~~~~{{ OfLELI $tRUCKINA EOF O&IECT STRUCK AND OWNEfLSN E) "' -' a MONO OWECT SLFUON ', :, EST„OAM GE ':(~ u,l _ v:dti __... - - .. IN N 5 E W qF J.SG , ^ RO DWAY FEET ^ ^ ^ ^ D EDGE S ~ ~ A"q€ r ,. ( ' -- ~ DRIVERS NAME4A6T FWSi_•F- / DOLE- DRrvERBN ME WRT~f, R6T MDULE-IP,-BrC C DiLAR PH~E61W cnECnifl c, .' . '. ~ T. I R.. STREET /iOIXiE ~.... . ... .. . ~ 4.1-u.,,~ DSf. 6TREET ADD E93 :,__ _..__ , .. ~. ..~I.:-. S" ~. 1 I n' ! I _ V ., p-_ -. w ~ ~ '~ E~ CRY. ..- .:.+ .. , 6T lE_. ....,. ~,• '-ZIP CODE PHONE NO E CRY.. .. .. _.._,.. _ :. STATE .. .'.,: ZP CODE... PHONE HO. !4:{. ~ ~ V~ (~,, R ~ (PL.I l.U~l 98339 S-I76e R _ "~' y N~ DWVEHS ULEN6E FJO Y STATE. SE% DALE Ol fWiH _. N OPNER6 LICENSE NO. STATE SE%' OATEOF BIRTH - A L_ MO lO y0 MO. OAY Y' ANt O' e -86•'k'- -(~'7 00 D S ((( 1., `S' I Y" ~ ~ .. .. PHONE NO ~ _ . > : PHONENO. , .. ~ DRNER6 OCCUPATION FIRM NAME ~........~,. DRIVERS OCCUPATION .. FIRM NAM[,. .,`'.:,, II~ I CODES 7 IJI LlASS-1 TAI 6EAi BELT _.. I'vI. EJECTION CODES ~ IJI C1R55 1 I SLAT OELT ~ I51 EJECTION . 4 ~ ~ ._. i uUNIES ~ . JURRES F .. ,. ,~ Ali Y.. , y ~ . v D ~ L FROM SCFNE DV TO ~ FEOM SCE E ._..._-. TO ~. ~ •+ ~'. VLH YF.N MAKEIDOUGE{HEVJ ~ MOOELIDART~NO AI STYLEI DR CONV 1.. VEH YE fl AKE IDODGE~CHEVI. MODE IDART~NOVAI STYLEIZ DR tONVJ . TJ,>SZ~k F ~ ~ _ E ~ VEN COLOR ~-. ~C RATE W., SIATU4 ~ lER MTE NO SATE E EH COLOfl„-. _ _ LIC PWE NO.. ~ TE ,~- TRAILER PUTEN0.', STALE .:.J p'' ~ k R V LE OENIIFIC TION NUMBER. in i +. METER s C VEHICLE DEN161CAi1 N NUM ODOMEtE8..A13Y'• •+Ltii ~ - f a~~. ~, i L rl~ E<, C G G 35 8/SO 6 G 8 ~~S ~? 7•' E r.~ . i _y hEG161EHED OWNER LAST ~:::..~... +... .fIRST.'r - +a +1A:+.- l MIDpIE +.. REGISTERED OWNER- •. :..: i. .. FBIST a.. .. J e.tv: L AuODLEV ~ F '.. +y 1 7Yj~~ p~ .,.A 'A ~ ~.- I O, AUDHE~ Ffl~JMgy ,V ZOA~ ... ~ .: O ~ ADDRES6 OF OvNE •. ~ i e7{T'' ~.• i ~,~ ' ' - ~ __~a $ axle ~~_~_o_cti! Os-~~ `x.8.3 z ,. ~ ~ , ~, ~ I - 1 ' J ~r MAMC AND AIXIRE[S OF INSURANCEC OH AGENT .... NAME ANU AOUI _BS OFIN6UR YLE CO OR AGENT ..- ...uu.. J ~ Y , ' 1 +' CH FGE ,.. I .. -- C T t ON O C GE .::.... ~TAi-BN N~ J _...... ,. ~,-" "'a ,. I CODES Z ~':~ 1 i f ... , L ~~` `'I ~~° NAME,ADDRESS'& INJURIES OF PERSONS INVOLVED --- e f~ ' A __ '_ _ _'__ tC AGE St AtUS t EJECT.1 !~ . -~T ~~ _ ~ A N N.ME ApDRESS -.-.._.___~_._._.____.._._.-._-.___. --._ ~~ I I I. ~=1 ~ 1 T S ~_~~ ____~,~__.~~-.._______._ (p FN041 iiW L _.._ __ _ ~- TD . ~ . W Wf NAME' 11 S F ....... . T ti TuFiZ"DT'-'- Tf(u3ie57~ _~._-__ , N NI.RIF I6 SC[NF HY To E I S I 5 NAM[ _ ._~.~__ An. Ess ___.___.__-._.-.._____.___.__._.-_-_.. ._-__~~_~__ .._-__..___... __ .__. .. - ... - ... i $ , Is VS Z I O`JI%}J CU t IBC AT UT LT I5I LJLCigN C J .- 1 [ P 1- .A'. ' ~ - ~ ' 1 D~i i [ 111 i ~~ •i ~ 1 ~ O I ~ L L G V 0 1 [D NOI CJECJID ! G ) 0.11 E 1101ALLrf [CL[D Y Dtl 1'D T iJ[LIEp ' I ~ f ~ ~ l i , E ' . ; I i L .I• 1 7 ' b / ' O lN rlR . : CJFL O ILri IVRE L .1. ,1 ... ' A +: . 1 .1.~ 1 _ ... .. ... ... ~_ ... _...: . _ . ~~ .. ~~ ^ ~ ~.:] ~1~ ; DISiRIRUI Dun lu i r ~: ;~~. 4 HA C~ r . I ~~,,, ~r~ ~ ~~~ I `~ - ~? I~~„,'htn ;r ~~,( ~. ~ r "Rr~~ rh ~ li ~' ilYA'A~T9 l i -. 4 '.,o, ,~ A c i 1 1 el 1 tc~ r h I~ ,A 1-.ublK,(seT[ ,.,,~~..~ ~~u~ u5~ 1 ~ L~ 1 I `,:.~ t. A l ~.I,~~r •-;:~~ ..'-„lyyEy ~,r- l~~•y~i ~~ 7' ~~'frh M f , r I l'' 1 - 111 A' : I R ~. - - .~. -. ~ .Iles e- INSTRUCTIONS: u. LgcR UAmpOE6 AREA: ~' D. SIIADE AREA OF SEVEREST IMPgCT. ~ .. ~ ] DRAW ARROWITI TO SHOW PflINCIPpL DIREC ~ -TE ~N[ ~ •' ,•x[71 ,. _ O` DAMAGED VEHICLE N0.1 . TION OF FORCE. IDSE iNlssvwtF FDR SKfrCRINC DAMwcE TO TRwILExs MOion Q ~. • . crnET. ETeI _ DAMAGED VEHICLE N0.2 I ) ) ~ ) Hom _ 1 rl A SEVERITY OF DAMAGE VC CLE NOrr OF DAMAGEI ID O.) .rn Y FR ^^ YDf O 1 (] DITAbL1xG DAMAGE ~ ) ^ D IERM MAGF ? DO F LIxG DAMwGETH ]EOLOTHFR M.V. DAMAGE ~f•I~Ra LING DAMAGE HICL[NJ ^ N V OAMAGE~ )fl FuxcTlaNwL DwMACE .- . ^ o ce A uxerlDxAL DAMAGE I Q NDG F. Two iNERM. . xcn0 MAGF TowfD er Jy+ N ~ ~ c ~ O _ s.. oA cE ro s D MACE B tOWFO BY E D ro C~ 5 ~. E• MADE i) ° yi J ro ~ o .. T ~ 1 h.: OI AGRAM OF COLLISION - (. I I 1 +~ 1 ..1! I r }.:1 r I ~ ~ (.N. ~ DRAW ARgOW SHOWING ~. ~ ~ It CJ NUE7TH IN CIRCLE , 1 X J7 %cJ 11 L (~i~ Y E<r ~ +~ ~ ~ ! L _ _ - _ .._ 7 ~ , t l Y .~ -}-~ ~-I I I I I .~ 4 N I I~~Y E ~` T I ` l ~ ' ~ O - ~, ~ LI 1--,A-~-* ~ ,a .. _a ~ ` a 1 I I~iYI l.T ~ , i i,~ I T ,_( ,,._ ~,1 1 ~~~ i 1 J .xPA..txLDL LD :.., , . , >~- r-~--1~-j- : ~, t ~; r ~ - ~ L~ +' EI x ~ . , i r , , ~~ ,. .DESCRIPTION OP ". COLLISION - ~ I DcgTE (r NAPPExfD TEF wxo AFTER THE Cnw oNNOTO I M,E4 VER ' weu DucfD VlsbulrY,PEDESiq ecocoR eoNSTRUC O E Rw _ _ r- M ETCI :CE ) LF. - - - -- ' - -- _ ~ . r -, ~ _ - r -- - -I J ,~ ___ -- -< `~ ~ r 1`.-C~.1 -~ r r ,- .. , . POSITION BEFORE COLLISION -- - - ~ SPEEDS E G [ NAMED F E<iION y EHO 0 ~ L GO . N E - .1 .1 f ~ _ C LASING _ " ~ KE0 . O< _ - ~~ L _ - _ ; -----"~-~ ~. ^ ~ I 1 _ C 'I ~ C CL AT UTIHG. ~ S wA 1 L sNDU ( CNO ° -°L ~C T O b I C G Y Cl'E I O R~ ` R AD SUR ACE WE ~RHER \... GONTRIEIVTIN oNERCUMS~TANCES :, ,_ 'YryP~E CK ONEI D EI DA vER R D vE ~ ~ ~ ~ l ~ 7. ~,. O.) O.] ~ O EflI ~ T '~ L~ 501NG .N _ I '~ c R. c[o o .. _ rflgc T • 1 bPY1RCgTT ,__: .ICU-D cE OF ~~~.. S1P5 l I ~) r- Ntac oLD I_l);r 1 ovoRi ]-_- F ) I I xL ') i D G CE OF ~e•~ O E f - E L ,~ ~ NTTSING~ _ _ _ ~ _ f 1 I __ °' _ s o ) s Nc i_i°~.1 D T reo ~ ~(-'1 ~~ci . (' y?l ~ o .- ~ x ._ __ ~ IEAS. ~t~.i TEA 1 ~ a o JO4 _ _ Nu uR t I.. E . oc E o ~ - -J r x .. _ S f E ~J ~ 0 VF [a ' NIG N DTN[N IYCC FYI -O - - GAnO 1 I [A IT IC rYI -~`~' 0 L ~ (r-;^~+ .GOL I ~) j_BrJ TLOwING °; - i vnOP[R D O l ~I a0 1 Iv 1 ~ ~' I O FD rOH IGHLf CONDITIONS iRAFFIf CONTRO t gTVPE Of ROAD VEHICLE LONOITION rlc L SOBRIETY ' OH[I 0) ICL[ 0.) C OHE Ox O E ,f 5,p ttQQ '' 1 Pv OqI SIGNAL 1 NO. ]° jT~COH~SA bfU{IDI HICLE ICHFCK O EI L.1 ; OR STOP T PN •. GNA 3 r I r: C AY t x0.) ^ .. TIOPVLO IH ' 0A GHl STOV ~ ~ ~ ~I. tFICMV[ ~ LITY 1^~ OWAY .:-._ _ ° -. H. ' _' .. .. ,. - ..":' ..~ .tlR KkS ... ,. ',:.^I... AIPAIRED_, __ _ .. J ~ TT rrIC LANE ) DwwN no of v[nsmu ' s cx ) '. n°D A°ILnr ..- I] Na rxPM ) LG 5 N011MVAIfl ED _.. I I Afli 1 l'_WT ~ _ HG -' ~ [O POSITION - '~ MP,E ) 0 i ~ I ~ t E IxG I[NT[NING _ DgnK_T1glfY TH °._-. UOCY .. ~I EA L ._ .. - __ _ „T ICI ._LIC TT ON AMbfH .._; 011,5M(UiN ° nP fOi+OHIx KING I-1t TE tlgLKINL UAN iNf [T ~ Hn ~' `J t.l>FU..crur 0 IVfN 1 I ° ..:. Lla TorF _ ° . xlcxAL •°_'. ', ulbiN LANES .°. rwF+I.'- 1 No.) . - .CHEM. TEST I_J ~~~ -_.'DAHK-HD ..: I[ [tl~arifi ... _. .. ._ '. ° TiquT UCNTT nACM ' .. sE.AHAllO ~ 1 ' ~ int crvFH No DEFE cs sr o ~Ip Ix -- _ '~) s.f - -. ~ ~ TE iRETULTS 2 T O '- M1 -_ ° ~ c E c o )~ ~ o X , c ~.LF - ~ ~ -'T ~ D TnD IHnvfu Fr q~c ~L ~_- .II M O U I. 4 CL . L. O O N( i( t 11 [ 1 OLOL 1 A, AS 1 NGfON 911501 __. - I-+ `_ I Ix f.OPY INC EL r.l +I ~+tll {Nt /•LI YCY-,. COPY 1R1 CAIE CUI`r. fJVf ETIGAIOR's COPY J JII ~~~~ / , _, .~~ ~i~ ~ a ~, ~?: a ,I .,,`/ qJ~`' p~~ ,/` ~y. L`~/`,/~l°,y~a~/"~/~ ~~y ~q~~A:~T>i::_~._W_-..r.~ ~~.~'~ r _. ~" •~ S^ ~9Y1 ~C~~V1 VR /'~~77~1~1a7 VCi PAGE OF I~U. I -F2, , Q ~ . ~~~. - P$JLiGE COMFI>\WCNUMBER ! N5(, YF UNIFORM POLICE TRAF DECISION REPORT Yg®f _ ~f ~~ ~ D DATE OF COLLIGK)N DAV OFCOLLIS ON TIME LOUNIYNO. CRY NO FXWA ~ SANG - i ~. •T% T DAY i. T SUN 1 MGN E tUFS D PIED II UN S f G CAi (U "^aD HD~ RI } ^URBAN ~@' ~. ~' ~G s~~a RpRA '?v .~4 1 E COUNTY cc.nSTATE ROUTE aCOUNTY ROAp CITY STREET O AOM~CLG rREFI% ROUTE OR STREET CODE GTION " .~~r t I~' .~,. ~• ~~A]V OTHER (SPECIFY( N ~ ~~J~-~ L N S E W ~IN~. ~ qTY OR TOWN W PPEFI% EO MKE POST~7 0/~ w~~ FYI 3IF ~"°~~iwt .C MILES ^ ^ ^ ^OF ~~YT S1.01°~) LL •L . / V Q~,L . 1;~ ~I~J a A n; AhiEpp1 NO.OF STREiiETOl!R XIGXWAY INTERSECPNG WITH: STREETOR ROAD LL RAMP gAGRAM pATA ! x. 11 1' I O /~.O,eq.O~sE ~J)/.^QjJ `.~V/i(/C .h0~ ACCIDENT I E.fFA %PD i~1V5ELTING STR OR HOn00RREF- I ICNINTERSE MILEAGE INT R LLS. EPEIICE CROSS SfPEEi OR ROAD ~ f ',.~' ry~ Y N BETYEEN SiPEET AND STREET CODE X'° '~ -°~` ' Y,~, LISTA:.CE AND DIRECTION fROMPEFERENCEORCR055 SiREE ~E1H9v; PEgALCLUNGUEE 5'.'y ^ ^MLE9 N R E W J ~.S-SCd ^ Y vr,.~- ^FEET - OF ~.z ~ ~ VEHICLENEMICIE VEHICLE~BICYLLE OTMERIWRITEI HIid RLN SEVERITY ~ § Y F, - COLLISIONI.VVOLVED: 9 ~ ~ ~ NO. KILtEO ~,Y ~ VEHICLE~OBIECT ~VEHK:LE~RR TRAIN ~SiOI-c`I VEHICLE I .i~ ;/~ TOTAL YO iO.IWURFD Y P , CF VEXICIJ:G ~ VEHICLE~PEDESTRUN ~NON~COLUSION ~HALAPDOUS MATERIAL PROPERTY pAMAGE ONLY { ~:ry y r CBJFC/1T STRUCK{NAME OFj~OB~I~ECIT~S~TRUCK AND O(W~N~JF~R~SNMAE( ~ ^.y LOCATION OFOBJECT STRUCK EST, DAMAGE. '~ 1 lI.\CvLp /~ ~~ T 1\ ITL~' ~ 1 LAUC.~ \1J1~ 1lI~E.~ PC(.~"' N //e, 5 fF'ipp~~ OF II~~ yf~ 3;: ^ ROADWAY /L FEET ^ ~ 16 ^ RD EDGE S V h l /I ~~'-~ ICP •/SRS NAME~IAST ` FIRST AVODL pPIVER'S NAMELAST FIRSTMDOLE OF 6CYCLl.~i OR PEDES-RIAf: CNECRT ~~ ~ ~~~ q}' ~iM R EEC-T ADDRESS A STREET ADDHE53 _ E 'YI O E V $~. a 'r _rr, R qTY ., STATE LP CODE PRONE NO. RE CG-Y STATE LP CODE ^ . PHONE NO. ~.d~rtY,ala w,4 ~1~ 2. ~t - ;'~ . £ N DRIVERS uCENSE NO. STATE GE% DATE OF BIRTH ~ N DRIVERS pCENSE NO. STATE SE% DATE OF BIRTH T / d. ~~ ' 1yY ~ ~O ~13Y ~ p, MO. DAY VFL - ~ ~ :~ ~ CRfiERS OCCIIPATIDN FIR NAME ('•••/''7 OLPI,HONF. NO. '1 DflIVER5000UPATION FIRM NAME P N NO. ~"~~, gnaw,:'' CAS £IuTE~. Cz/ ~c~TnSL~Iv m 2fd .ls ~-~, ~ .~ '? Mx CO~E$ ~! 1311rLURY Ial SEAT BELT I51 JECTION CODE$ ~ 131 INJURY IAI -~ lJA `A' CLA53 E CU55 SEAT BELT 151 EJECTION ATURE OF `I ATUREO ~Yl ~4 WURIES `O \C Iti •, UT ~ ALOI itLURIES ~' '~ ~~ RR!`M~ENE BY: - TO FRON9CENEBY' TO ' - VEX.YEPA MAKEIDpDGEtXEVI MOOELIDART+IOVAI 9TY1E120R.LOVV1.. VEM.YEAR MAKELDODGEtXEV.I MODELIDART-NOVA(.. STYLEI20RCONVI ~ i ' r ~ ~ ` ~ t E VEH1. COLOR ~ ~ UG MiE NO. STATE TRAILER. PLATE NO. STATE -. ~ ~ E vEH COLOR UC. PIATE NO. ~ STATE ~~ TRAIER PLATE NO. STATE •• • - ' v; Y ~' `~ _. .v~. ". (~' VE+I LE IOENRFICA N NUMBER .._ . _.. _.::. ~:.:.. ODOMETER ._.. .... C VEXK:I,E IDEMIFICATI ff NUMB R .. ,... ,,.. ODOMELER -~~~~4.A : f ,:.. ' K '~' ~ } LI= A E PEGLSiEPED OWNER-LAST ....,,... _FWST .:.-_.'.. ~' MIDDLE E-' REGISTERED OWNEfl-(AST .::._. FBOT _ MIDDLE,.( ~~', tl.-, .r , ~. C~ nDORE53 U OwnER ... ...... ..:....... .. O ADGLF55 OF OWNER... .... .. ... ~..:.. ,. :... ..:. ~ ..(, t ' 2 _ _........ ~. ..,....... L '• HAMEANOAOORFSS FINSU ECO.OR nOENT ~ NAME nNOADDRESSOFINSUPANLEtO. OR AGEM ~ ~~~ ` , ,. ., g1ARDE ... giA110N NO. LHAROE .... „,. CI .:,: ' ` v ENFORCEMENT ~~ y Nd~ AcnoN cn - Y P g NAME, ADOAESS & INJURIES OF PERSONS INVOLVED coots 1 _ ~ A s ~• ' SE% AGE STATUS N EJEOT.! MI ~~ ~;1 ~ HAME, le,e L ~q Z l 3 ( 2 % ~J ~'~' S ,C ApOPESR: E ~. U rUIUHE OF IEMO ED FP.OM V IN:UR~ES' O SCF.AE BV TO ~ '( A NAMe'. 'y T ADDRESS. ~ ~~ 1u'~ " / U fP RCf hE OY' TO 1 gy nME' 1 N IXJUIN c ~ SCFNF PV- TO ( t H - E NAME. ~~ 9._ ~. • ~~ S ACDPf SM1. 1 ~.(1° s - LFNF'~.' M TG ~ ~ ~~ •IU `.t 1P05!ION J J L !.5 "E BF.LI S'f CTgH C 3 F'J f ~4N A 1 t O A,UI 5 GSAB I'OI (JURY OT 1;1tALLED .AOT EJECTED ~ ~I ~11~11 I~ ~ r \ T D A f tiC,rlE 4 Nor 0. B Ni S Ji IU'.E ] O LlV EJECTED rA}4 ~{ i E ( i '~ uSi I -_ ~~~~ I OIhE O IIO UE UON 1 II Al I EvC! fl UURV J SED t F RRALLV EJEGf[0 ~ ry~~~!! ~, ~~114 t ~x ~ JF.I I 0 ~ C,".t ..) I. M1 T B fOSt .O UI:rt~:OV.~I a Uf,pyI HD.~PiIaL i POi..llllE NJIrNV . FAT OMi fALUFIE A CJEL CDNIF k I I (~}~r-Yt+ •I IL' ;7)L ~ ~F~'A1M1tr ' rr al~a,wF E u' a. •,. I l 4'4 ~ ~ f t , 1~ ~ t Y Awr(AYdt _ 1 i _ _ r I , '~ 1 1 I> T I T~ r AI -0 t ~ )'r it 1 ~ 1 1 3 E i y ~ 1 ~ I Yt i ~-~ i ': iri Y. 1;. T ~ M1 L t ,~ ~- '~ ' ' ~ - 1 ~ ~ o-, ~ , r Cdr. ,1 Iti ,«~r i ~ ITP ~~ L _ ~ ~~ I I Y Y L !!~~ ~f,~" e '1i ~ - c Li ! ~ 1 d"~ ~ I, T f ~ i ~~~~ ~ >,~' ~~e,^~ +~.. t~1a,*^l ....^~gctivr ~;5^^~s~Df°-~- .~R'^ ~rc-^'~xfa~L^»• ~,cm+*^ .narrou+~ :,:a~mE~lr.~a,~h~"`-^rn~,~R'x.-,k~•>G~~Tr`N~jMF~~C ,i I t q ~ ~'~ / ~ '~ w~ i . S ,, ~~~ ~'i ~I ~. ~~ ~~~ 3 t ~5 VENICLEDA^hAGE I~IIFACHDOXCIRCLEiHENUMBEROFEACHOPI.IAGEDAREA ~ Mo{E I INSTRUCTIONS: ^. SIIAOE A;IEAGF SEVERESTIMPACT. !"°"' (if I to D. DHA W ARROWIS) TO SHOW PRINCIPAL gRECTON OF FORCE. ~ ~ DAMAGED VEHICLE N0.1 IUSE INIS SPACE FOq SKETCHING DAMAGE TOTRAEER9, MOTOPCYClES,ETCS DAMAGED VEHICLE N0.2 IaPa '.. w . : a ~ . 5 ~ t ~-...~.vi..:e e: IJ. HOOE t a. ROD! IA. ROaI Fupryi I~ I S3_I~U~p iS. Tlwrk .. y~ ' IM1' 15. TIUnF 3 I ~ ~,1 ' 'a-~ IS.V^MK;yr'+pa 1' i ~ i~T ^-a=~ v. o-,«vun ~ ' n.oramPD SE ERItt OF DAMAGE: VENCLE N0.1 SEVENTY CF DAMAGE OIMER VE I a013ABUNGOAMAGE GQOTHERM.V. DAMAGE FUNCIIO.YALOAMAGE ~ NO DAMAGE :I HICLE) 1QgSABU1Ki DAMAGE DQOTHERM.V. DAMAGE Z FDNCTbNALOAMAGE ~ NODAMAGE SEVERITY FOAMAGE: VEHGlE N0.2' IQDISABUNGDAMAGE OQOTHER M.V.DAMAGE TOWEDOY ~ I S L'7 WIF~cI v EST. DAMAGE TOWE08Y ~ •- EST.OANAGE FDNCTIONAL DAMAGE t NODAMApE EST DAMAGE TOW D TO ~ I/11M.'1L-V ['I C7~iA~ TO ~ I' S . E BY S DIAGRAM OFCOLLISION. TO j I I ~ ,__~_L_ (~~~^ _•S~1<~E~r! L,~i- I I I I I I I •DRAWARROWSHOWING _ .FUruA[a - ,~. r . i ~ `r </-.-"~v"~-~-"-~'T'-'a NORTH IN CIRCLE ~~~~~~RDAOwA .we" rc T~''~•w:v`°~"°Giwaui Aalre.l [w Ac aRCe.aEPaNTb -- ' - ! I t i~ l f t ~ i(( I? iT`I j 1 _ _j _ ~ I L'~ ._ -~- t--~ ' ~ 1 I--(- IK(" -I I I I t ~I - , ` I ~ I '; I^---(~ , ~ -~- ; ~ - - - L ~ O T,~l . ' - Yv[nic.EP[DESIwArlon [GTPDEI,tOnaATIMaAOT. ' t r i I -~ ~. I i t I Y _. . _ ,. ._ ._ .- --- - ~ I ._~ ~ f ~ Ua. U . --r- ' - r ; -{ ' ~ I I .. .+ID.YPPDEAB.EYEnktEDR I ; + r i I I . I j i ~ ~i ~ s~ r ~ .n i ~~ ANOisT~[R wwsip a+E ' - I I T i T ri~' 'T~~~Sr-1 l 1_Q_y7 tP ~ ~ T^I ' _I I ' I I I . .DESCRIPTION OF ~' COLLISION--~ PNOICATEWHATPROBABLY HAPPENED BEFORE.WNNOANDAFTER TIIE CPASH,INCLUOEINFORMATICN NOTON DMORAM, ED.DNVEq OISABILItt,gE000EDVI51BILfiY, PEDES[RIAN CLOTHINOCOLOR,CONSTNICTON OR REPAW WORK ETC.) - - h P~tt~ ? ~k~.-s- . c~ ynJ.Tf Sr c .^„c1~S,c vI - r oSiE c~ f~J w.T~_ o l~ ST, Lx e Cum- /~G. ~_. Lo~rr ;, ~ =- 1 c~C ~o:~'J 1-~_E c L ~ r ~ I - am ' ~ _ [ ~ .~ ~o=SSr~ arr , ICIn l , c.., _ .~~-y /~~.--Vfl~lc'~_- (r~C ~0 ~ni' c~'bY"oti"-.~i>iuF.? ,~ c- _ ,;, P03 NO r. ~Sn , HEADE 1T 0NB EC N}~.~'A:.v_,p;l,:Jt..,,~r.~,~ yy -.,N„. ~;,z~ y,{_ N0.OF lANE9 SPEE0.5 VEHK; ~ I P K D ON STFiEEf ORHgHWAYNAME0RN0 'W ONEOIRECTION LEONLY 9 G0 p S , 1 I~ 1~~ sAaE WASVEIL INLREA N ECi~A, WG ' ~ r _. . P,yiKED OCCUQIED ~ \O I 4 ~ .. ~ E `_~^ ->., _ . _ Man _ YES NO .YE9 :::S Hp • Cl ~ ... _ C r 'PED. ~ ~ (~ I 'lCM OR M t0 COrertRl IE O 1 CN0.S4M PED 91CYttlST WAS USN I~_^~my ~ AY L_s,cuucx O: .. ~ FV.AlK ~ 3~ ,l. icw~st~iv I _' a~ rs~ic IE "' TI IOrHEn ~ r' .. ., ~~- ;f;OADSURFACE Y. IOnE« owEl y ~ p h: ~'~:. WEATM~,s'u -~'- L ~k,S;;iS;d,[,•,!,CONTRIBUTIHOCIRCUMSTANCES r;,,,,[ IcnECA oND rcnE« onE GA MDAD _.. i:f.62"~+ a.r ~ tir~ a'Y['~ARV[uwaa; ~ K D'r~E" . _ ... L_ ~ VTMIE Dnv[n.. ' ` . ' ~ r } D ~~X Y ^ ~" ; ~ Y ! '~ R !c . ~. [ a IG°FY `f~• ^ HlN1F.1D 1~A~-.~~~~p~~,y~py 14.:.MPC4R .._ _____ ^' ^=CG!Ca FNLEO= (~i)~ iCOCV}S~EL i_J F D '~ x-72 LJ ^ L'1 ~ L { I I ' WEr .._ [ RMAw ~ wc[b ^~ ~ cEx*EA r Aw FHrtY _ '-; ~~ ~ , 3 ^ a.>Dr,ND _ _^, o_ ~EE~nAT[~- a ~ c ~ a ~aPN[~ ^, ^ , ~ 1G~ J -~ . [~ T00 -J__ -n! ^_ E AS t~ l.J [ _ Na~gpAEq J - f~-' ~~ cE:eame[ow. LL ~ 1. t ^:^' ru / I ~--~ arwRnnum °.^ oTHEnlvrc~Fii "- wcleurtvw ^ n ro '_ _. -- aRO lA ~ r ~ ~ _ ~ ~ 0 9 i ; C __ 1 \ d aovn.o LJ ^ p~ ~ L ~ sa 1 w°siaim°cc °P I n °a•ia"unb~i !-7 .. moPPeo aoR ~ - J T ^ mwRG LIDHTCONDRIONS IGM.CK Onfl iLTRAFRC CDNTRDL M YFnRIE vE!!gs!};-TYPEOFROAD; W. ICnlGA OPE OR MOKq ;,VEHICLE CONDITION. -VFHKtE Gt On OR ~~ '••- SOBRIETY~,:y?;~T}j;,, ~V[AUC~!{ C ^a^ ~aTa~DA~3K^,,,. alOn/A] _ I] ~ bE _ _ c M. ~At~R I MCK bKI I N0. P aiOAa[Ow YPI D^~ ~ Ft0 -~ _ - r7 nb _ ._. ~~ TWD P[ i~ I ~J ~ ,' ET"NE - ""e r~ t_ ~ ~ :~ "" _ - ~I ~•;pA~Lwl. ^ !< _ ~„ --- R, I - ,~ ~3 -- ? ,~~ ~ REO i `~I+[j ' MK ~I.IDN IAUK ._ ..~ mt"'n 1 I _'1 ioG? V':e ~ I^' a[er~ 'la~ wmsoelam -.^ ul[^~TU~o~IEHlml+n lion r l3 iu n'0 _ er AwY _ - ~I '~ c v:o ice" I ~', ~i w~DRTN.w ! jla~a.cKwo 3 o.n.3 `~ _ n[iiTUa.r '! ,,.[ b yµ .. ~`""'i~ ..' ae. rcneceonn Ano I ~J oA wM:TUxD r,,._. _.__ L j a ' Iq^~[ CHEM.TEST - rzaTa[rtn --I ^ .:, omulaae OmlRIY[O[Y or.eK ~ _ ..... ~ . .. _ ._. ... I ~ GTa ~ .__. i[STMTUYD .. ~ . ,. I .~ 1 .. P~MSmA[AAI baKlK IwnG 'con^'a anwl. P+~n UMMGl0 ~~ Pg •: GIIln1Y[GIP/j ~ % % TEST flESULT3 2 ~. 'ti ,.; ,It . i`~ ,' ; r\ ~h• ~ ~ ~• :w;, v ~~7 A;E P.wM<H!o MICl AAVNY.D ~ I r ~.: r ~-7 [~P ~ ~ ~-r r_, [aED ~Y[o ~ A;ri&o L°^I !~ ~~ E ~r'rtllM•gb.C!^, [an. . -. ,~. , Y. "M' N;iU nO Ip • P]T [OEi.- KN~ Aspq.fORY -_,3 nK5 !a W aIACATE C W Y. IOCAI UW ENVLPLEMENT AGENCY 5 COPY-iR:PUCAlE COPY: VIVES'WAfOR'9 CCPY ~~ IE.Y~: -~ ~~ :~ ~' ~ , Q~ ~ r { ~r ~ y ~ ~~ O 1- W A,1'41~ N la'~U iV P>M1 .. A. , 111`x`` ' k~ ' s. r~^' -__ - ~~ y~ W ~ LE COMPWNi NUMBER ~ W h r r ~ J I ~':~ ~• UNIFORM POLICE TRAFI:OLLISION REPORT - .~ ' a, A, i D DATE OFCOWSION OAY OF COWSION TIME LXIUNTY NO CDY tq. FNWP j r O D VR. SUN MCN tUES 'NEC iMIP FRI SAT IDBE VJp nWRI y .-,~ ~' f ~ E Z ) 1 2 J i 5 5 J / ! ~J ~O ^URBK ~ ~, ~y~ ADM{LS. PREFI% ~UTEO STflEEi CODE LRON L~" I}~. p ' COU_NiV1 .,p ~n ^STATE POUTS ~COUNtt ROAD ^CITYBTREET O ~ 1 v~~~L'/~~L:.U ^OTHERISPECIFY) N 3 ~ '?~~~E!yVa ' !. t~ j fly ~ L I N 5 E W ^IN CITY OP TOWN W PREFI% EO. AILS POST ~j~ •y' t1'. ..~ i ` C ~ ~~.nLES ^ ®^ ^ F ~T. ~.U Q LC~f~ LL Z.-'/v O • ~ -• y ~ ~~' A NAME 6NO.OF SIRE ORM NWAY yyyy~~gSECTING WITH: ST TOR RO O LL RAMP pIAGR:M DATA W, ~!; {;} r ON GC.D ~t+r ~~A fA' RA~~SA= F~A+-l~D.° 6E~? I NON INTERSECTION - '~ ACCIDENT INj ^ ON X flO NTEgSECT NG SiRE R OAD OR qEF '~ O MLE GE .' ,y IMEq CLS. ERENCE CROSG STRE OR ROAD •*"~ ~ N BETYIEEN ~~ STREET A40 ~~ STREET CODE 9/ _. ©~ .~~ ; 1 OIStANCEA p01gECilONfROMREFERENCEORCROSSSTR cT t PECIALCOOINGUSE ScLr~o ~~ 'I I~MIIES N 5 E W ~ ~ 1 U J. ~~E v.' y'. ~ .~. ~ ^FEEi OF TMS ~4R ,'•~ fn ^VEMICLEWEHICLE ^VEn CLE~BK:YGIE THEq IWRITEI HITBRUN SEVERITY Y} COWSION INVOLVED: Wplf^~ t1~' ^ NO. KILLEp L I C: NO rn ^VEHICLE OSIECT ^VEHICLE~RR TgAIN {~'~~~ y~C ^STOLEN VEHICLE NO.INJURED ~ ~ A, ~~'. .j ~ L _-VEHICLES ~-J ^yEHICLE~PE0E5TRIAN ^HON{OLLISKJN IL-Ji HPZAR0005 MATEYVVUwAL PROPERTYpM1AGE ONLY fi.~ V OBJECT STN~IL~/((NAME OF OBJECT flUCK ANOOWN PMcl LOCATION OF OBJECT BTPUCK EST.DAMAGE ` 1 ~ 1 ~'E- ~ Ec ~-.7~CJC11 ^gOADwAY ~OFEET ^ ^ E ^ qO. EDGE S ~ e~J ' DRIVERS NAME~IAST FIRS AIIDOLE DRIVER'S NAME~LAST FIRST MIDDLE IIf B{YCLISt OR PEOEStPI:N CNECKI" STREET ALIORESS R STREET ADDRESS ' V ~~'~~ ~~.Pc/11E17/~ v i ',!, ~ R CItY STATE LP LODE PHONE NO. RE Cltt STATE LP CODE PHONE NO. J ~T! N ORNEI~i$/ LICENSE O.1 /~-T~ S7A/t~E SE% DMA[~Tp~E OF &RTH N DRVERS LICENSE NO. ST E SEX OATS OF BIRTH ~t •. y',. rend^pY 1 O. I: ~i ~~l V 1 C..II~` ~ -L ~U R O. MO. DAY YR. '`dW I ~ ORIVER900~0+V ON FIgM NAME PHONE NO. 'j DRIVERS OCCUPATION FIRM NAM HON NO. ~ .P• ' ~UC-t ~, ~ CODES > :m uss Ia BEAT BELT '" EJECTION CODES > IJI cuss ' sEArefu I51 ~" ~~ ~~~ NATURE Of NATUR EJECTION ~` J: IWURIE9 IfMURIES ° ~~ R SHOVED - u ' ~ M VE ENE BY' T FROM ENE BYE TO ~ -- J ~~ I VE,,VEAfl MMME}BBBG6"IfiHE t NppyLpApiypygl BiYLEIVOR.{ONy,I VEH. YEAH MAKEIOOD CMEV MODELIOART~NOVA1 $ttIEIt DR{ONV.j ~ ;t ~ ~ .~ L .. L h i E ' VEn. COL LN« PuTE NO. STATE TRAIIEfi RATE NO. STATE E VEH.COLOfl TE NO. STgiE TRAILER PLATE NO. STATE ~±. C VEMI It 10 IFK:AiI N NUMBER O Efl ° ' y I ~ ~ ~ ~ L . VEHICLE IpENTIF 1 N NUMBEfl ODOMETER ~ s 5 E ~ 2 M~ E ~ ~ rs~ i flEGISTEq OwNEgc-L.AST fIRST IDOLS RECUSTERED NER-LAST FIRST MIDDLE ADDRESS Of OWNER O. ADDRESS F OWNER ' ~ Z f NAME ANDADDNESB AGENT NAMEANDAOORE590FINSURANCECO. OR AGM ,, i `-L4, s. A. A. - ~ ~>Jlo I GHMG ORATION NO. ENFORCEMENT CHMGE TA - i ACTION '• +. - ~ _ ,'~ NAME, ADDRESS & INJSJRIES OF PERSONS INVOLVED O00E9 ' ;,, 5 ~yq~,,`} ~ SF]t AOE STATUS Nw A EJECT. Y ( `"I ' I C NAME: I _~ Y . d C ADDRESS. ~ ~ I a I ~ I i9 P VUURRE9~F SCENE BY FgOM TO t ~' Ih~yI 'IH1. ~ I. H NAME ,6, r ADDRESS. {y 5 NuUUPIfS L NE RYf 70 ~!" 1 HI NAME: ~ T ADpRER9~ ~F', ' N INJ RIE SCENE RY' TO ~ 'Y~ S NAME. 7 S Af. T.RE95 E .uuY- . 5c Nc e. To ~ r ' 1y ;'+IUa JI aGAI I'OSIIK%1 I VJUNr LlA35 + SEAT BEIi IS~EJLCIKJN ' Y/ C I ; PEDE STnIAV A I ~ O fMURr S DIS+DL VO vJURY NOT INSTALLED NOi EJECTED ' 10EADAi SCENE SNON D~SAB: P.O INOI NUBS ]iOTALLYCJECiEO O S{rLUA1 I( 5 i I.OTnln p05 0 ' ] LFAOON ARRNAL IEVIDE VT NJURY ;USED D PMRµIV EJECTED F ~~. ~ ,' D D•+EA L---~~ BUSVf O YCLEI J OED IN NOSRTAL I i PCSS.BIC I'I:UIIY UNKNOw'. a UVKNRNNIA • C ~G ;: NIE35 B T pP0.5:TC.u•.+nONN SBEAIDELT FAIWRE EJECT[D _ m L ~„ ii(~i~~y'Pti'j~`~r~14~rlyi~~L11 x . ~ `i `~ r ' S a': rJ ~ ,: q ~~g ~ r ~ ,~ ~ I7iT fLx" - ~ ~..' ~ ~1 f ~~P I n l f K.~,~X+' ~' IFI ~ 7 n .' J I n d [T ~T N ~ I Y ,E,~ I I ly - I T I I ., I J ~ r4 / 3 . ~ T ;`. ,I~ ~~.I ~ "r~ ~,'t{~ '`~. " '•t .'I,:'9k".""' ""y"~~y''.,rr-~"ex-~r,r,---'~°.~~~~~~,FLvr~~l;'a3'T'";"~h'~'.",0"'"?~,ri'wafr-.ti~`-~ ~'''~, , 1'"L ~. 5 ! 1 I~ 'i L `° ~ ~, ~ J' L ~ J ,. - A } T ..._.. ~, _ ' _~ - , i I~ ' ~~~;" s~. a„ ,. ~~h 1.1 .. ,: _Yi4:~+~A~'~i -roses.. 'ievu .,^~. ~ ~_,:,,~ «.:....,..~°~'.u'-»:~..~rr.'I.°,~ VEHICLE DAMAGE 1.INEACRBON,COiCtETHENUMBEROFE.IGIIDNAM.EOMEA ~~ ~~" # Y~ INSTRUCTIONS: a ARROWISITOuM°OWPPof~OVAL ~ }' DYTEDfpN OF FORCE. ©/, '• `,i. t. ~a- OAMAOEO VEHICLE NO.1 Ns ~ LvaPADE POR S+cErcwwo DAMAGE TO rRULERS,MOroRCrc .'. c1 10 ° ,a NooC DAMAGED VEHICLEN0.2 9 r ~' ~ ° ,e Roof ° faNO°e ° r '~' q~ ; I(~, .. ~ I~}' ~ sEVERrnoF ODU~R n.a °e.Awe a ~'~ 1p. ; fe. °e.R,,,.a K NO.1 SEVE%TY OF OAMAGE:IOTMER VENKLE) ' ~• ° ° 1).Ownm ~.~%. IQDtSASlINO0AMA0E JQOTHERM.V. DAMAGE 1QgSABUNODAMAGE a SEVERNY OF DAMAGE: VEwp,EH0.2 N„ FA 2 FUNCTCAALOAMAGE A NOOAMAGE 2 FUNCTIONAL DPAIAGE ~ O E~M~VEpAMAGE 3QFUO NCnONA1. DAMAGE IQNOD.NIAGE AMAOE ¢ TOWEDBY 1"T t'..I Y.",:LC E9T.OAMA9E '~d rZ)~ ~ TOWED BY EST. DAMAGE .. TO a ((, 4, .GAM ' ~~'; DIAGRAM OF,CULLISION , TG a 1.ioERnrv..:: ~-;-.. ~ r I.._ ~_._- f' ~~.=7-OV1riCC`' ROW SHOWING4•~,~-1} "'~ DRAW AR ;y Mronrrs+RO.w.mwrvRea I _ TI _ C~ ~' 1 1 - '~ NOATHIN CIRCLE ~' W~' _ rs°~°i~s ~~ r~afsro.y,•r I ~ _ i ~ '~V ~" 1 I ~. A 1 '. .~ ~ SUAL/1pA f:OVdlq.a9 1 __{._ 1 T~ ~ +L 1 1 ~ 1 1 ~ ~ f ~_j IxAeAS.E?Gi ON°iPUG ~ 1 1 1 _L_ -_- '1___`~-7' ~ T _~p.,. ~ _. i~ 4"~, xfa~recweAeLewavra ~-~ i __ I I r - /~.. ?, 1 i~i I C f'/ ~ I _:.~~.). f I ; ' ~ aewwvEwcLZ °EOeam.RUB .~,p~ aaiEnwwriaNaArurACr -f-7 ~^ ~ ~ I r ~~ ~MZ i; ~~ ~ ~ n A ~+ ,~ _ 1 I ~ 1 1 - i I -i °' ~ ' I ~' kid ~ DESCRIPTION OF COLUSION,~- OISABIII~iI'.REWCO°as,BYI~PEDES°THIANRCtDTMNGCOI,ORC0N5TNUCTWN10Ri1EPNRWDRK ETO~TONOUDMM,E0.ORNEA ., p F , 1x _L~ /- C •. T~ `c r~~J Cif `:_>~ _~ l~r. f!' •: ~? = _[: t ~- ~~~ ~ ~ ___ ,,~Ex . _ --..CL_ f _a , ~'' tC ~- - rCEr c <. r_ I.~ C' '/7'< _ J C.fr r f.+ilJ~ G_Y,S fiT_-L~i ~`=" ~~ '~~•.: HEADED MILEPOST qR ONSTREETOR HgNWAY NAME OR YO ...•.•. - INOf1ONE DIRECnON ~~ V R WCRE0.5wO DECitEASINO i LEGALLY WASVEN. f. F N S E W PARKED OCCU%ED r ; E ~ J L ~ ~ ~ 7 L' _.. YE8 NO YES NO ~., DRe _ -~ ~ n~ PED. r 11, MDRD__ . , c - M c°ro ' b , __ _ __.. fERT wwwwre.T w, : f a cemsr.o-. ____ ~__ PEOiBfercuar wAS USfa: am.MK ~s.DUU~n Ar_cROss '""ieO ' ..._ -al c "NMA1b` m ° O°` L r u,c R ossw I aK „ CIERgrtE '„ROAD SURFACE WEATHER '~ ". CONTRIBUTIND CIRCUMSTANCES DK awa ITXL a `""`°' .,.. , .' ~ -:~ . >~ - Yr -' ti ~D 1. K °D ..~~.evwscuLACnrn ~-a :_. . IDNEa aRE OA MO°p ~_ _. J5^ Nn : rmrm x alum ow+en w Y k` a oaw ~°R uaa7 l uccR+.LwcEV rRO.'a ... 'L~' aiR.wnAKxo 1 n ~, ~.,,, ~,~, ~ x "~ ' ~ .DreTCVr C N .DL ~ u , 'ri, ; "' . .--- -- ~ .,,~, O ~__ _ ~ ~ . ,b„ ~ DwM.+ ~;, ~ a "iT V RAwPa ~2 ~~ OAI~ItV lRC+OI ~ _ e DRFA A AA NRY- - __ ' _. t~~ -_ A p _ ~ M, _ __ MA«ND ~D , n ° ~ IeDN1T1PM _'_ a ^ awxw a "'. BiDwwD I a u ~f:° ~ 0 . ^ A ~ Mut14 __._. .~ ~L.. _ !~'.ru. 6l~ °IOCA~iCN YMVNtI .. ~ ~ ^ ' A ~ Ike. ,,: 1 ~ ~ I ^~ oEAZCmelour. a ""'°'° e 1 ~ w oa*eauD = I ~ ~ - _ rn .. : ~ - _ . T~ mloNacwri - on~Kl ' - ar en kTw-ivc _ ~ mrcawara ~ e4' ~ __.'__ _'_ _ J ° "1 aara,D LIOHi CDNDRIONS TRAfAC CONTRGL ~ AA~oo L .12_ °G"'°q"`L ~ 1 TKwC°~° ~ Ti-~ ~~o eD~f y,q l MDaac,;:TYPE OF ROAD., -.VEHICLE CONDITION ' , • m ~ 8. . ~~ .; ,.SOBq~~ , i°r, norxo AT eiDx¢ 4"DT-~.~ rcKeeK oe an MDAef YweLA .ce oae aR Y9ettL .. 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LP,000C - R C ,• // _ ..~ ~ , ,P 3~_OCLU TION~1 LITY~,- - y~+."y STATE~.~yw~;n;,-t-,AP,000E .ORIV[jt9-JOLCU ATpyy b /n r ~C..JNSr,[. a5~i 9F'YS ~G6<-~ ..ORIVERB.LIO _,NYMBCR;~Ty SIA_E SE% xO EOF, RTH C' "~ IvER3l10EN9EnUw0¢fYlj STaS6 SEX D TE'O ~BIRTW AOp .. -.~,.r.... xI~'YR: ~rKSn:.S°'yo~N.j ,sroae~.u.L_.~..xYl a or sTrLg.u I ,.;. .'L wcu,J r_-.:~1... ..-_I .MO eL:y,u.o.~ I eoPr aTrLE: Ja.w: --- -_-.__ ~_._ s 9lr~i LICEx3P,:PLATE;~IO. • - ATE}~'~'~TRAI E.TN,)jTC ~:~9TATE ~~', `. ' L_{CEH fi LATLNO: .- E T-ZE;yr. ETA LLR;PEATG NO.. ~STAT -: , '+ VEHICLE')OHN7TGAi1PM^ryO;.A{y,L1.Y6p._NOOn.q~7.awg10QOMETLM '~~ YCNjLLE IOE)ITIFIGATIO.Jj10:~•a~(t9, -nool~jtA .S loan! ODOMLTERI.xwe ~{T~ RE ISTEA[D.OWNOt~ltvr.~..rlT•r, -. rw%1~'y['Y ~-,~O ERS L, CE MOf6.e~ .L;IIEGIffTE ED OWNER_IUaT;nq,FT-1[I o.A~xwIG .f~-DRIVERS LICEH3E~r10"'~^ owncna;HLDP~"S.swr._. „Aw..T/nom^:,,_,. LOws[ ROIRTR-x P.wNERS:irPOgfi35i'....r.s.:S~(..<Ti:.OTr.N'~.._)te~.Z.G,:~.: ..ORTLOi,;;,01RTM1 -f' ~ - i,Y r , PwRT ;-,}p;;yyEys-y~:r yty:a.. i':=•L~-: ~a Ap.T,9',Of'VEHICLE.OAMAOED~,,.~"' q.s. .v)a.'S::t1 iesSJ:J-L'c ~. . y ., ~< 'r., r 5 . .. . OC~ 4 5 LIA81 ITYINSURANCEINFORMATION•VEHICLENO. coveRJCeI evFCC°rFLOArilisL.liccioe°iioNCrouacAR ®rES ^ No -N^AM~GA~B~ILtiT~!IJUWrKGEPOLIGFN01•p6 ^'.~ ~/n ':::.•~..: ~ ~E~OF~LIAB LLTY'INSURANLC'.LOMP,WY:+.'-+v~-,.v. 'rrt irP ,. ^ !MAIU'+L2/.t?P_ISl33p-A/A01 .. _ RSF:1:3.e7s::.. :-:f,:e.;rr CAteE.c:«Cr,+.?4ifio~~it.:"~,.-..'j:.:;;~5!>::'..LUalui JroS!Sy:Ml~yeeR..:rzs~..;2s~iiC°.>:.F+'3+1gwa5> n '~~ X,+T+Intit.i ~.d$~rC4. ~'JwC tN01 RYTF-' ~. ~:~,. •. ~J lJ TaT N 8 ..aw N E FLU }/~~~.L~ J /' DD E99~j.3 [' SC%.. '}' ODRE33 - .SAY _ - - ,~~ sus - - --- ®~ - - ------ -----s- 00 w '-tT~L~IO~~fH)UR[D.d` Ys. + uARK IIRET CNt THAT wPILItS' ~ ". ~-,9 TUS OI JU [D -. ~ k: ~Gdt: oMKI1RSTON4THAT PKI(S ~yT IN V[NKLI NILICD IN LHICLi ,~wi~ N~ a;xVVrr lu lve ~.~T"~ ~ ILLED 1 c ~ein, .1 T I I T • ~.] II.v..cl Iw 1 6^ a 7 w ^ S^ Br0 P: x7 Oe:1 (.~ Hcal. xlrE ^ S^ P R I CLfi ~ ', O SCR 0[ 0[ OW WHwT qA /4 !Or IR[F[R TOy [NIG Bff,BYLNUY0LR1 .' I ~-o ~i-_ a •- arx.~,ax a ,x...... ,..a.Y. , ~ _ a r) `ry 6 F fr. ,vr d r. d / o _fl~c___cvvd._.._ -._._. _._.._ _..--_.__ -- ;I i. - .. ' ~ ~: r ._ _ _ _. - .. I la w[[ .- w VEHICLES i'OSIT IONS CIEFORE COLLISION INVE3ncA rcD oT [o «cu vc LADm o 1 sra LCr oR o Ar NAML on No. ~ ~ x Po. co qqy~~~/~y rr~~ ow '~]rro 'r ^4U RA:xlW ~ .. _. ~• ~ ,_ ^ ^. ^ ^ ~ ^ io. - wYreY n.nox In wol E ^^^ ^ ~77 _ ^ ^ ^ n ^ Lr.I (( ~YEpttT 4 I'~,~^^l.J ALOrM '.~. ,. .. C ~. ..IRO ... TO ^'L:/. ::,a .r L%l~i OSA O ^_ - . A a . l pblND I~ ~A )~~ ]^. nr ~< quo • ry ',./)O O!]M /!C[Hj -S4r`.r• f ~.L WNT CONptIONf Tq AIIIL CONTROL .. <x M<L ~ _ _,. TTPt OIRWD OglVtq/V[HlF.It AO C10NA-,., ei]M ;•~:b x r. I [ , I ~ O ll jwr[L<) •[I II I rJ ~~~T' 1 ~ DAYLIGHT [-, f~=41GNA10 nI1 ^iONC WAr ~ OOINO 6TRAIOHT ANP.Ap I [~ ORV ![~ RAI NINO ) I_~ DAWN ~ } CI 6r OP SICM ~) ~ iW0 WAT n ) [~, OVIIITAgINO ANO PASSING ^-I ] C-1 WeT ]^ IHOWIHO ] ^ pURN ~J l ^ YIIIp GIGN ~r1 ] [~' gO~VNHRLC ({I~~~Jf ] ^ MAKING nIONT TURN J [~ T.NOW An I06 A ~~ ~ Al PT ^ A ^ P l I J IGw rA ON NIH6 RF,D l.J A ^ 11.07 gCHAMP, l~l A ^ MANIHG LCPT TURN ~' ~ ( op~ c~ p• N arq<n ( [ ' If.[ !^ IT T , ~ 1.~ A ^ ] L_I <LAbH INR AMIIPn C7 f ~, ALLEr ^ ! C~ MANINO 11•rURN IG r!0« ( ^ 7 u ( ( ' r ~ HH 4IGNAL n . C, l H Cl q n II.O WING .~ A [ C] 3 l_..~ePI LI"• A 1.-1 b IfL 11LIC.n ri L L UR _ I~ _ lr vw V AOH •rR1 NO1!![Ig0 DIw6fq 1 [ , sPlL rrr [ ~ t I 1 OI<IC<I,/ILAU UAN lA ~.] 4rolrrrn IoN rnsrrn: [,_I > ^ - ~ l~ d . 1~ 11 r 1 .r. .w.... ,r.re.o~a., .: I : -- -_ r.l A Ll C Ir I ~ Cl I--ife ~_~ I ~ R.P OfO nlIONM. - I) r ~ [~ [ ~ . Te.q n 1 qe ADwwr y ( r ,-r,. ,'Ir•'ibt'h?xf"..'i'~ „~ ~-. ~W ~Y'".w +«.w.~...1 .Tyk~•YC• ~ ~RYhTfV"~XT.. ~ -R*~ 1 . ~ '__'e,~ , 'AViRfufriYt! ' "MRI~i "~ 1. - ~~ ~. ~{~~ ,R : ~.. SB{ Q - D FOF COLLISION - _- -DRr GF CO PION TIME _ y X U. - LUIS [D HJN IN ~SAf /5,~00aN0UR1 J~ p~ ~ ~ )J 2 ] 5~8 4 /J ~~- Z J __~-~ - COUM1'lr NO LIiY NO. iHYIA (//7 ~H9A11 /""' ~V ~~ NUPAL - f / .Y UOVNTY ^SIAIE PDUTE COUNTY POAp ^LITV G1HEEi Q C Cl5 MREFI% ROUIC OP/~b~1)N-E~~E(1 C~JODE+ LION ~ ~ ~~~r 5 e ,] ^OTHCP ISPFCIFYI _ ? ~ • A v L S VI ^ IN C TVOP 1/011VN / ~ W PNEFI% EO MILE MOST~2 2 ` G"J~"~ J•.I '~ C 1-I d/?/~ A/J /:'[Y.~L°-.. _._. _ A MILES Vim' I^ ®OF Cor~C LL NPMEA O iPEETOR NIGHr`rgY ~ INi[RSEC nG WITH'. STREET OR POAD LL PM DIFG DATA p _ O ~ ~ ~ + e ~ /~~1 ` ~ O ~ T O POAO OR PEE. ACCIDENT iE r~~fl LTD INTERSECTING STREEI R I flSE~ON EPENCE CRO55 STREET OR RO LEAGE VifER Clb N . / BET EEN STREE D ___ .. .. St EE CODE. •. DSi N E DOREG ON OM REFERS 'CE ORCPOSSb EET 2L %fH5 CMLCODrvG USE J ~ l r'.. ~i ~ C/ ^FFEi ^ L3~1 LJ OF 1~ SC JC y~91~. S R TY I E E CNICLE~VCH CLE ~ ~ ^VCH{LE~B CVCE ^Ul ERII'lP ltl ^NTh RUN _. O K LLED COLLISION INVOLVED: 1^~ ~I .ICY VFHirLE~OBIELT ^VLNICLE: PRTRAIN ., -„ _ ^STOLEN VEHICLE NO Ir11UPED ((~~T IOtALNO OF VC ~ . HICLES Imo?`^J ^VCM'tLE~PEDESTR AN ^NOrv{OLLI510N ^IA'ANDOUbIAA1ERIAL _-_._ -__, ~PPOPERTYOAMAGFONLY '~CRJECI ST UCKI /41AEOF 03JECib~RUC ADO'.NERSh EEI _ LOC4TIfiN Of OBJECT iNUCK ~ :,. .. ESiD ARGE /~J /J F C 5 G lt ~ ^ ^~^ OA ~ ~ ~ C! / ~~ ( ~ / P ! i FELT DEDGE OADI.AV(} _ ~~111Y /_G'~N% ~~ ~/- V~~ d1~~ ~ E -~~ , _ . _ pPrvEP$ NAME~LAST FIRST DDIE URNER 5 NAME U51 FIRST M ODLE f RICYCOSI OR MEDE biRIAN CHCCKIU--. -. R aiREET ADDRESS - _- ' StFIEET PpORt55 .. .. .......'.. .:.... '., I • ri ~„ x s c~ ~ .. ~ . - - - E R.. N O - --_ CITY ,, ,..., - ..,. bTAIE, ~. .'., .:.. ZIP CODE PHONE r10- R CrtY... ...,.. - -... btATE '.. •.,.,.. ZIP CODE .,. CC.. .PHONE NO. URtVEH4 L E SE NO - bl%lE SEK DATE Of b N ~ ORNERS ICCNSE NO . ~ STATE bE% . DATE OF D Rl •. OGAY ~ O, MO. D VR.. _ O c~7 ~~ 7 `~ A ~ ~. / . r> PN'~ 2 ORVERSOLLUPATION EIPMNAME .. . MOIENO - 'h - E ... ~. '.. - :. ': ORIYERb OC~UPATION ~ 11, ~, ' - ' ) +/ CODES > IJI CLA$b J ICI SEPT BELL _. CI'.. I~'I EJECl10N ._ _-_- CODES > 31 CL>SS ----IAI SEAT BELT-_ Ibl EJECTIO .______._ NAiI1RE0 NALUPE OF JUH ES L PIES i~ED E OvED A' i0 OM SC[NE flY TO SCEs E B ODELIDART NOVAI ST LE I2DR{ONVI E ~ODGE{NEV I .1 IU VOt YEAR KEIDOOGE{nEVI MODELIDART NOVAI Si EI2 DR{DNY.I EN YEA~ r/b TE R LER PLATE NO. STATE ~ E VEN CU OR LK: PLATE NO. SLATE. 1RAILER PLA E NO. STATE LIC PLATE O , COI R E H ' y . I . ~ !CJ ~ C ODOMETER IABER YE ~IJENTIFA:4TO BER. ODOMETER C VEHICLE DENiIFICAII ' ~ E . E 17/~ /~~ ~ ~ J.~o~/ 1~ L cs ~~ -L1 - C e.- /~ biERED OvrtIER-LAST FIRST MIDDLE PEG'biFHEU OYINER-LAST iIRST. .. . . MIODtE ,. HEG . N d ~ O. ~? D~so o .-EA - -- --~- pCRESS G o En > n , 2 err ,~~~ x ~yy/r._~~~;-~~~ 1,~~~, _ __ _ _ __ E DADCPF tiDFaURANCE CO O LL~N~i~ ~ J DLRti50F rvSURArvCE CO O~GEN Ai GN NO CnAPOE------ GTATI~- CnAH~E lL [N U CCe'ENi T _ `- COPES NAME ADDRESS & INJURIES OF PERSONS INVOLVED ' ' =r-'- AGE Si AtUS °'.;~ S EJt CT. ._ ~__ t _- _ _. .- L.~____._.-_ L -_ - l ~~ l ' c u f/, •.- _ _ .ij~~;~crT L_o .D. ~u !.'TJ__._4'cX_!/Y~/_l, /r'~--~ ~ r'- ____ - -- o T S _ I. J A T:. E _._. .... ._ _. . N .. _ _. . T S A: S .. .... _. _. __ -- --__-- _.. SOF -~ I 0 10 - rv -- - . F 71I ~~ ~I~~~ ~ At [ 5 ..... . E 1 ° __.__.,_ _...._ ..._. ____. __. _- __ .E 1 1-1. l ~ ~~i-~ i ~~I- S _. . -- __ _ . . t0 ! b ~ - C y Jr_-.~ ._.. .._ . ~ 1 ..i _ Rv ni :ll ll iLCiIJN I.If S I I i R tD +ilA,.I CiFD L < All tL ID _'~Y :~fo I .L. f.Lzrro ~ tN E . ._. (.. I r. I rA:nnlE r uto /{\/ e. .... ... .. I I I 1cjt a I'. , . ._ P ~. ;C."ij ~~. ~. t$ '` Rv: n ~ . r u q ,n ~p (~kAtlti' y ~,LOr~{ ~> r~ ~ ~~!~- "_""+F_.t~~~.;'-,'r ~ ,I~ .T'ES'",. ~ A ~~"~,~„'^I'°P""~"~ E ~~ '`1r it ~~i ~, ~ nl r I r 1J ~, ~ t ,~ `r- 1 I , I, ~ t ~ i jl f r 1L Ay ' L ~ I s ~l V" ~~~ I ~~ T•4 4 A I IIV51 tSUL.I IUIVS: m ~~py nnnow~sl ro sROw~ramcivnt DInECiroN oc roRCL (J ~:rur~:.~J , 1 1 DAMAGED VEHICLE N0.1 ~D+r~y','Y' [raFSat,<rvrnc owrnnGElD iFart[NS moioncrcL[ DAMAGEO VE ICLE N02 11 2V- H C ~ 1] r~n r]~ rr^ _ S[vLFrir Ur Dar.rnLE VEN CLE ND.1 a OI~vG DarraGE r ] ^ O x[F n,V O VALE ]~_VHCIIDrvAL Dara4GE . ^ HO Da•,rnGE n -L Or--CLEI -~ CLE N0.4 ~' ~r~Orsnxl NG OarnnG[ ] nD,rr J r33~iFERM V.Da..nLE ^ at Dar.r~._Fr I7 HD Da. cGEUarAav 1F ~F"~rC]iOnaU__aLt . ^ x u.nLE _- _ - _. DW-~c%~S -L~,r[l r~°ray"I'E . ]o s,. u~,Nac ,Dr,EDe~11'~`_'r~G 16 _ t T. un -4cE GV[ v __ S H' ~ iD~u'4 u!_S f. /_.~~~! C /~ s S ~ r 1 - - io `] -DIAGfl AM OF COLLISION ~ ~ Ln~~J ~)t~ ~ ~ '• DRAW ARROW SHOLYING F w. rr FLE NURTH IN CIRCLE .. Dr. m.xDaD a„ J'~C'i L+c%JN .-:°'I'~i',.'..~ _ ~ I ._~ - O - ;c µzv.FU[t I i ~ ___ __ 3 - - , Jf ~ ~ ~ cu,rJ' ~ (r/ r .fI L' NJ. ~ V rG~ f ~ 7 i N.aa..r.,.E.D.E _ , DESCRIPTION OF Tau Ec D 'cm ~aid~ it o O ie :rr~n *w~ t ` ! L ~ "u COLLISIONS Dr,aeari , LDO f is o ccuto FTeces*n Ne non:°o«K i oc ~o : oA :c - ~ /l,i _s K"/l. ~~ !C'r-S_ //"P: A of i/e'..%a/.-'~/. tee .t'~/ .f'o.. n% ~c~.e n c~i i.-9 d _ J~i si1 ~~ c _i3 . _ ;l s_- X~r../Ffr.._~N,J. ,r~-/.ra-,~rJis~,~lar.~..~<rF.~ ~~, ~~.- .~i./,~.L~~~FJ dr., _ t %°. •.. f ~/l~ /~/ S/~cs~ o/"f JfE'. ~e s ". s/%B, nf'_ i7ie~. r .-dol 'srroc'.<_ d /c„9J <d .rh.----- ~ p F/]. -f//'/!:%~. d Gd/'Gi's'.7-ti J'C~[S JFf .a ~d//!~°l ~!r/N l' /oIN-.._$'~GUy I[/l /'~`..%~E/' -f 1i~o~ L/T~i C~~.~/~I~ j/1iO /~..~ / FC]'/r C~.I'~/J' ~~. N/1.~..S~OK'lN/~.. `'~.{~F// //rY _ll ~l /Jj .__..__ ~ /HOC/'ls. /~~~• hAai/ I'Y.3 Gi ta~i`~ /JC//1 _•~. //]~NAi d /IEStc/pl.'G P- GJ~ r `~ .. _ _. . -_ /1/O_i/l Si ~d/ C~,rn?.~.3 f`_i0__l/5`IJ.~IB ~- ~----__ >OSITION BEFORE COLLISION '~~- O D GOT CFf nS xG Orv SrNFti OF FrDN ~ E On rv0. - UrvE D nECT,O ~~ ~r[ E IOCC EO x ~ I v ... S S E =E /1C ~"_. X . ~_d~<`ilb 114~~ ~C-JV J - - ED. wr _ -. .. G - .... TQ__.-.. [D a CvLLrs, W ns USrNG- S D[WnLK wnt[wav ] SrvOULDEP CFOSSwnIK y CxOSAVn Lt O C CEE FOUTF t • DTNE F .ROAD SURFACE ~ x KDx[r Ei WH AKOEfl r. +Er CON7RIBU F o[i TINF ON[uAEn onErANCES ~ DF nvtx ctt cTiDxS Ho.~.rL •,c LF - L. ~, O D D l' ctuour __ a.' utHLr , ...., __ FntD wnnn. r Onn~c. D NGEa ~ D~f NfnK oar ... __. SC ] wF, ~~ -- - r _.__. o t.casr ] X haiNiNG • '. r a o xcED t u _ .... D uG5 _ ~. ,-., aIFU ' I ir. ~+cirvvR N... _. ..... rail nG,O n wnv '~.f D.(. xL ] vaa vG ] xr4nr i:+FN '. - srvOw ] . rCt S .. J ivowiH4 . r00 S '. 't _ ir[[OL nai ... XE l.C[LOrHL ni.ai. Snr[:r rfD S DO\rf H[ Lrf4H1 N W ' y Sf..Nnl rD rrrrxOr In lunx 11 5 r~iGrri rs UCNTION 1L ~. CTIVL FDUF __ _.. r> rAgn rNG l LCf11UFN ~-- IIG ... t UiuHN 6' LDV.rHL n Sr[ _. -[IGHf f.ONCII fl0t 5 r .•rc. a.u O < r1 ___. _ -_ lRAE•Flf. CONTRO ~ ri' fR __ ~ v~i~~~F~ TYI E Oi HO O r, .. VEIiIC LC CON I iI OY U rtl r _ SORRIETV - ~ ~~ UEUn ]. _.. C G oa, s cHnL . . nt x,ES c tcr. DHL Dn raonE , G r p Q q rHD VE IFi.t~l{1aSxc~f`ini c lily I ~ f mrmcK Driri ~~o[> Fs,Dr srcn ~`irn,.m iH , D. ,~( Dnnwrrt . _. .. c o. cr.. s . .. ~(> a• ... _... .._ r nn r uu.n ~[ ur nEU ,. r ,.rs ~r ren anL ,v ~ rra FLU .,.F m .. _ r --jrD' s GrN u.uf cLa•rc .. :o Fi off '. Drn+ , ntl,l JN lt] l ~ io i n~i l' • ae,.•.rr D s .. Lr .. a.n r D r +•:~:r t ri aryl 5 ' n , ~ , mnu ~r r tl i . !, .. r a. ... . ~, ~' ,+n ,. Xl _ _ _ YC~ r rD 1 CHF M. It ST ,. r: o-nF ONr r.. ,Ci 'G 0a[Ki +L r n s F TS ~. sc-NnE rn ~ S'. .. v nr aHrs l ;, . j ,.I .I ';.I Itil 'alr IS n5 ._. 2 ~'..' : ~~i L •. 1 t .. r, L ~ ~ ~ - .x r - ... , ~ r . . n I _ , ur I _ Jr[ at ... ~ ... _.., ... ..rf.,.,:,ls~~~f'Y { ~ T 1 ~ ~ h r c ~'. 1 , `y rfttl ',.,,• ~~~~+T~.~~'-.~i„ :mi .'.rf',I;!~~'~1` ?"~~5 ?~T:. ~P'~;~d--~.m..`i lfl v., 1. ~~ rat ~: 7 f r.: ~~l ,;: v `Zfr ~^rl ,'4~4 ~ I. lr, rw'~' ~~ ~ =` r ~ ~~~ T ~ ~ ;yi !~!~~B rS'i ^ q e'Y~N 1 1~~~ j1 a ~ I yy ~r I ~ I ~- i T,N ?y~ W ~y All ~y yy YY1 5F {~4 ~, 1 ~~ ~~ ~ ~~11 b~'"r}p P .t 1 . ~ -. DALEOFCIXMSgN r •4., :-,f OAYOF COLlIS10N TME_ C Y fl.~- ~ UN MDI IUES WE IWIR fW 6AT IVSE 00 NDU 1 Q Y COU ]YNO -_ i ORjN -- ..~- F ~v rI 1 t Q ~ ~ R R I A ] E F ? (JC. ~j> ff It Rpµ t l y / ~ 1 - COUrv1Y ~1ATE nOUTE ®LW TY RO 0 nGT St EET O ~~ ` ' AOM ly P pM TF Dfl iREEi Iq 4~ t U IX~E.•A h - _ Jf'_~p _ y ^OTHERISP CIFYI ..._... ~. .-... ~ . _ r .. 1 L ®IN'.._ \ GTY ON IO N - ~:'N 5 E W. W ~~ .~ t ~ y ~. PPEF EO HOST t V 1 g O _ MLES ^ ^ ^ ^Of 530 Ln310Y - ._ O ~ , . FA i.. 1+ / L~ k ' 'a C' A ~ AME HO. AF SCREETOP HIGHWAY ~.• { G r •INTERSEGiING WITH 6THEET OA ROAD LL "'~ RAMP 0!AGgAM OAT ~. r. ' ., ; F W T I n (i•af [ y ~ J ®N ~$~ 04~' e Ti e F O 1'i ( ~ ~[ L rr ., "~7' - l } '~"~ e ~ ~ i , . tI' i ,/,~v. NON)M E ~ n oad ~. '..o J< _. r •r i t sar i/u.> . ND TERSELTINO WTER ON TR . O ~~4 '.~ - ~ ACCIDENT . S EE QA fpAO O~REP p M~TER. LlS ERENC ROB $T EETOq ROAD ~ 1.~N' BETWEEN _ STREET NO .. ~ - ~. iPEET CODE t ~i} .~ A~ %' ~ ~ " 4 pISTANCEANO DIRECTION fPOAtflEFEPENCEOfl Gg05S$THEEL i ^MILES N S E W "' ^-+ w ~E~~ am ~ C CODI GU9E yak F i ~ i-.,. .`~ .. .' FEET ^ OF ~ ~ :. S + L~_ . ' J M t ~~. {`i ~+ 1+ 7 t ilti'.T. RtaG~..l, ~ t ~ f J COLLISION INVOLVED LVEnICLE E ICLE ~ ~VEH CLE qIC CLE ,.y ^OTHERIWR iE) ^I T RUN 1 6EVENTY -NO NLLEO '-~•~ I E ' V ~ ~ ~ ~ V ODJECT V[ ^vHI ^ E CL LER TR N;.% -_ '~ SIOLENVE CLE H {L .^ ~.. OIWUflED ., ~ Of VEHIClFS -- ^yF111ClE~PEDEGTRIAN ^~ ^iIONOOWS10N '. OHAZARDOUSMATERIAL~'~ ~-" 1 •^PROPERTV OAMRGEb Y ~ MM OBJECT STRMCA INAMEOF OBJECj SIHVCKANOOWNERS EI f L' -_..~ LOCATION OFOBIECj STRNCN~ E,,,-~y.O ,EEt 1-xl GC -Y P F ^ ROADWAY FEET ^ ^ ^ ^ RD EDGE S v 1 DR EfL9 NAMEiASj~~---+~ F~6i MIpOLE ORN _l l -"rK. .Efl'SN ME lASi~RSt MIDOIEJI: nICTRT5I ON PEDE 3 ECAN L y[Cp[O 1 C T r ti R ~ $iiRRA^ILI Terrell L. H r oH1 ' Ja ca Dean ~ ^~ 1 J 1 Y " ut~l _ STREET ADDRESS ~ -E ~~ i'.+.. :~. l' STREET ADDNC55 -^ i •. ` - `A-'tf 2 ' E ~ ~ a K+ r. ; u r X, c f ^ci .. ~, o IL _r:>` V c 'ta i -1 .z.t ~, z, ~~~ n s 5 reel' ~'[1H + 39 ~ e a . C07 - S ~. iSJ+A .. cSTA1FJR ~,s. 2 CODE1 PHONE NO E CEiY,ZAL.[Z...~ 1. t .,~SCATEx +t,+~IC+:TZIPOODE -'.y~P{IOHC l14 ti_' Port To%nse d 4a: 98 8~ "'one ':,.~: o, ~: ,9~. Cfiisaclm'=4Fn o0~25 ~r~-:;C,32 ~..o'r'."c~ oec; ; ~ N DpvEn5l1CENSE,NO .:i4t L ',STATE SE%F D TM q N DRNERS LICENSE ~;~, ~ GTAIES, -.SE DMT E OF.WI{TN Y ~F O V O O Y0. MO DAY , ; SCSPi2SD~` 7 n•• 4 a. 19 43 17r i; ~ AE 9fLatW~ TD 3? D < da H 10 . ~ , . i_ 1 ' INUVE 6000UPAT ON FIRM NAME .. ,. _ _. PHONE NO Z DRIYFfRS COCU~ATION- } FMM NeME lA 93e' yAS..L Sawa[ ~ g -~~' (~ r " Landacap3ng Self en+1o ed y StnBent CiiicTacum S _ ^ ' CODES _> 1]I ~i 5;5_ SE TBELT_ 151 EJECTION. CODES ]I I^u R la IS) EI CLASS SEAT BELT EGIE]N ' { -, . ,.. NATURE Of - IWUWES ' - i~ pi T - - ATURE _ _ .. NJUR CS .} '.T ~. ` ~ . •.. :~ - " FROM SCEN€ EBY. I 1 I TO FROr0i 5GFNF BY -... I . •. TO 1 • . vE YEAR.. uAItE1D000ECHEVJ_ ODELIDARi~NOVN .. STYlE1R DR CONV.i.. ~ VEH.YEAR .f NE1D ODjE{HEV.I .. MO EL IDART~rvO'A1 6TYLEI LOr J ,,, , J ~ ' • ~ I ~ T ^ ~> C. PUTE M:M VEH COLOL{ ;- U ~' - STATE. ' TRFUIER FYAIE NO - ._ 6T TEn. ..-~.,. H YEN;COL {+_5,., UC u,J i NO.._,- F!JLPJtPUTE V 6TAIE iE f~ t , ~.;I: :; .... X k ._.- 1? -- .d.4--, 22ed ~- ~ V5 372 Yn ;'i~! 4 _ - ^ .C ; VEHpLEW NIIFICATION NUMDEM,IMr H'W~4A Y.. - ODCMAETEfl ~ ,[C .'. VEHICLE IDENIIFICATI nNUMVE fl ,~.~ yR_ D ~~ C,-. _ ,: ;-_ .,y. _--~ :.:rr -.~ ~ .:.: ; 4. _ .n: "-i'H ~s ~ ~ 2 it ~ab r ~E : -- - O~;LT?700 J- 5rr4F,$ ~ E•. ^ -7II. t J72 I.C,. fff~,p.1 {ASF. ~'RZ' FIi1iT'•~,.d\,.'C "uX:. MIDDLE. ~ REG44iERED OWNER-UGT U 1:.. fti6T~ 1 ~~i MIO ~ e p. a nrta' ea driver' ~.. ... O ;. ` 'Js es D''58sY ri' = ~ ,~ ~ '~ }t ~t ; ADDRESS OP OVINE0. i~•_..-I~ .,.>. „.,.: _..1.. .Y.. ~J.. . ,. ~ 40p1E55 OF.OWNEfl:._. _. .: /.t.. ti.:Y:.V.. ., - SiB 73 Ctiin~cvw ':7n i$ 7TH-~~F~2 ~ AME ANDADDRES50 LWSU~[CO OR AGENT. •,:. ..... ~. ,...t -. NN.IE ANO ADDRESSOF INSURANCECO. OR GENT ...~ '~,- ,. Stntnd !:nd rore IIo,:er itil enc not tLe o4 co -;zy ~ + C :t~'. iz. u.. .'e~+ ~ .... .. GIAfION NO -.3' Ce ONCEN[N~. . GHMGE i ,.i... r. .;. l~:. .. C Ail~N .61 - R.C.W, 45 20.342 ~L:72$ ActaN i': Plore st this t3.~e ;~!.~ .. . `~~~ ".'~~" yr YiR .3-m xf x 1 Hr J:'G:' 3C 1 `:.' u ~ AME ADDRESS & INJURIES OF PERSONS IN~JOLVED 5 ~ '~ .coons . - .._:' R ]' .I H~..; :. Yol : - •..? ! '-. .. -..... .. . ... ..., '~ 6[% AGE SiAiUS e. ven.r M T EJECT. ' C'" NAME ~ r',{71S17n^A __ _ \, `._, ~ - c ` V :DDRESS Route 1 riox fi531. Port La%1or ;:n~ tSo nJTlne F \21 2 ~' 3 1~ Z ~ wTxv - ~ [ o co xoM At at>1+gS A d n -~.:. sGNE nr~ To ~ ~~ N . ~~! TAw I~r~ ^~e-^F L.1D.r , T (J~ ry rF.~ ~~'q ADp ESR TC.rLSL~t-"'+a.-r"--a"+.~lr'~-'- ~ NA - Mo tofnp S . v A a ro Irw Es :;" .~^ Scr Nr nr 'TO ~.. .~. W' NAVE: " '.i{ - - 1'I' 4 ~ ~ ADDRESSI ~ ., _ I , T N : T ~ ~ Sit ubv'To €Fdrn-' INAmrs o .,.. T .".:... GCtNE nr , To I b'. NAME .. .. ~ _ .3 ° F ADDRESS •. I'1 V ' S rv t ~ ~ iRLT6rvp6TifbRi TD ar, J., Ij ' V ~ ' - 111!1 1U3 R lr{.CR IiI SE i VOSIIION ^ r ] C1A55 OWJURY 1 (NS n gV11URY Nl SLAT VELT ~' .,. ~ NOT fAl`CD 151 TRIM' { N01C CTI~ I ~ V O ' ] /0141 uy .. IIVC VCUST C ~~ ~ tll S i TO fn POSgrON IRUS OIORLVCt C1 RPCAD 15Ct NC ]Dl AUON nVAt t lLO hi IIOSRIAL I F (Mn AlVhq 11 VW[ 111WURY ! PO" l L t y RNOTMUS[ ~ - ]USMD ~ \ RlOIALRY RJt Ll1A ]P qI ALLYTJ[CICO '}41 E 0 wll N [53 .l A ] ! NJ qrl UMrJJOWN e w+ NJURY ' ~ NOWN S SCAT OF 1 /A IURE L NOWIIK UCCTtO ~ r~ .. v. - - _ _ - ..... ~. _.. _ -.... ~ 7___.YM - - .. _...... y _:........_~... . ~.»ti .. _ ~ I X f I,'nn~~AA~,~~ ~ ' ~~'Nu! TI: I {~~yj'y~yy~!"{yf~I.L 1 , Hf Li t'R~M'e - ~ SANIk r M1 . y ~ < L 4 _ ~~r t IVa4 I3, V ~ N7i ?>~.I -,.w."Ii~nnflClrv,.'~S~fl ~O"Frem~ rrly Nib ~ a* ri-- "'7;'~+` 1 l e 4,. 7 1 b~/. Y, ii ,,,1. u i 'a ,'n "~;~J }~s Ir"~"T "".,, ~ ~~ ~ ~~ ~ ~o t,~y,!r4s+~@.t"eu~'aj."~ gip r N ~ ~ rl f . 1 ~~ ,,.. r .. .. ~Y, 1 p ~. _ ~.~,~, , ~ ~, J L P.~ ~~ ~~ ,~~ )E~ ~ . x gy iE. _ YT'"'.BM1` ' wt~ ~k ' S T ~ a ; r~ _ 1 @. L 1 ~u / ~r~p '4~d4~ I' F I ~~ - k - T ~. N Pn» .~ ~ ~. ~: ~~ ,U I .t ~ .- u. n', DISTNIOUTION. OIIIGINAt.COPY. S[ND 10 wA51 NGTON STATE PATgOL-OLVMPIA,WASIIINGTON DR:Ak DUPLICATE COYY'. LOCAL IwwfNf ONC[MCNT Af [NCV'S COPY-TgIPLICATF COPY. INVESTIGATOR SCOPV ~ '; .. ~;.; r.. '.,,,. .1~t a M L', '!TL"` ' r' G ~- _, . , , _, ,t._ INSTRUCTIONS ] qW AggOW151 TOSHOW PR NCI ALD RECTIDN OF FORCE Q/ DAMAGED VEHICLE NO 1 I vac 1cnIN4 D TqA RcrD O.I DAMAGED VEHICLE NO 2 -4~F .. .. 'Ir 6 _. t8 U ~. ~ SEVFR Y 0 OE VT CLl: N4.'1 ITV Of DAMAGE ID1NER VfN CLEI SE YOi DAMAGE VEN CL O ':O"".1 7V.. 1.^ 5 GD G- ~ ]^ nMV.D AGE IE^015+DL xG DAMAGE )^O t LING DAMAGE 1 EN] OTIIEn AGE: 1 uNCTIONwI DAMAGE A ^ NO DAMAGE ) ^ fUNLt OxAL DAMAGE A ^ NO OAMAGE~ r E ) yr AGE A ~ NO OAMAGF F ~ FLNLTIONAL OAM "~ TOWED DY TOWED BY' EST 0 E TOwFO BY AGE Erickson To DAMAGE ~ To;' ->-y 5 5 •' - D_~Ort TONn60nd Vni ' S X00 y01f~GRAM Of COLLISION 1 .! ' 1 ..1 .~~ I !_ ~ ~ { ~ ~ ?f -r^-~.. f { ~ I ! _~ _.~-0I1AW ANROW SHOWING. ~. -E- ~~ 'i-~ t ~ ~ .-~ t T} I ~ I NORTH IN CIRCLE ~" . ~ ~ ~ ,1 _ $op~si~ 1 T ~~ a~ ~~ ~~ 1 x T _ -t-~ I~ i ~ '' ! 1 t; /~ r'~~I 11 lT,.f 1 I c ~1~l~p D.,I . ,DNA I. + I I - ,, _ _ i I 1 1 1 :'I=~i T--{-7-f ~`-i - ~ i I I~" ~' ; T ~ 1 _[. 7 [ i ~ ~~ I I 5 ar r._ _I ' I I .1 I I I l t I .I f I i l I 1 I ! I I -I ! 1 1 1 1 ~~DESCRIPI'ION OF~ :.:.COLLISION. .' IInO CA t U NG TEn TNEC0.ASN,IrvCiuOE ONNOT ONDIA4RAMYG E0. _ V O FDE COTN nGC On CONSTNUCTIOII On REPA `KETC [' [-- ,,, ,.7 ' Dls~ '~. q p cE,° _ ~ - _..9'T^~° c... atopped by the flagman a~~guat Sls~ ron~___ onto the Ol$ ShiaecRoad_and vsa turaed #~2 Lad Yeh _ _ _ . . as instruced to Lnrn around and go er of tleh $2 v :dri th led d d _ _ grave Q_ o p ..ea _yas.being_oile .another road_to_,get-to~Tia=degtinatiop and_in_doi.ng eo ha madeca II_tL~x ~a~d ~thep,etopp~a„ati ratfie vas eoo the atop sign for-his direction oLtravel~~Le thea_pulled up to ses if t ~ _~nY~®h ~"1 tp hi a hit and fie-~fiparentl~-pulled into F~14:=1_ntt'rsectioa cnus tt'e left front .. ` ~ - = sides--Moderate damage to both dehicles~ - ° ' ^. '. f q ~~-.lan-,L.-~_,_~a.,s....._- _._. g~ r ~ POSITION BEFORE COLLISIO Dt ... LT nli vE nf~0 Irv<NFw G REASING s "'i~ G M '_ ~ - ~ [ " ° L_i L O IL_11 ~':J~i rl ~ ~__ .o a'~ io _ .. ~ 1 - _So K,rN - D 51. a `; `5 _ _) C?r'~ 1 1'_sL L~ ~01~"Shini Road _. : ,._ S _5S1_MPN_~. ~ Lol ~ L. t~ Loe- ) ~ i r DIBCC~ YSxO. 51 I-~ I ' P~F e. ~urvMANKEO[ eo+ ) ~ _ cvA e+-~- I_I EALK SI. K~ ~ O ~OT ROAD Ci RFACE E Q4E1. - Ww ~KHER -._ W C CONTflIBU 1 \ 1• ' .1 TING CIRCUMSEANCES .: O :: On 2r Lt}1 D R[cl ~ D5~'; 6T tl ~~.f S ~I J ~ ) I~_ ~OY L v 0 0] U F ENL ~ _L';~~ i~ALGOLBDL .. O ~ I r' rvG 1~LT~OSSQ3.SAL t[ 0 1 _ n 0 E ED R . ,E ~ -( L D T GNT A ~a'Tp I[T K N6 t P'S 6'..' '~ 1 WET RAI fIVG ) r) INFLDENLE DE ~ R n I~ N - ~ 7 f]r p Y "."-~~ .-- 1 - _ pR1tOS --- " 1 IGNT UgN ]r- ] T • ! sNOwmc_ N ~3i J s. c I Irsiwi(li - i ~ o I IJ ~ ° oP[ Irvc ~ Klrv~ :.. T TI Cf. r, n 7 YfO~ ..7 ~ _~..".11~ f CFS Ef ~ C ~ 1~ J [~l l U ~J r TNG ~I - C v I I "' 14~ M G V u11 i~ ~EI..-' s...L.~. ..-. 10 ~ LF I ~ I qG0}SLL 1. .1 J L 50 6 _. Oi TR frl O nls ~ r ~ 0 Ep , '1 A O' J (^I C 0 TOP , J G 5 G ~.•~~ l ~ I YI ~I_1 D O 1. i~~ SOPED~O L' R1AR L 1 HT CEONDI TIONS c c4 DNfl RAFFIC CONTRO o. vE H . L -. TYPE OF qO QO ND^-c I-~ . . VEHICLE CONDITION v t o ~5~~~~~~~~m :M1 'SOBRIETY ": ,;. YtEH ~)~ ICNC EI s oP fDA c~A LJ°~~o o sc ~.. I ~ ! ~ ~ fl0 0 AY ` ~.~ ~ YF t s ~ ~ ~ v N I BqA [G.}[ [ 1 rf G~::l J. MCAIq ED_ r _t r PL iT Rf L LA E Y _.. ..~ ~.I. ' I I sG .~.] 1 05. ~_ ) ~. I+DLG iS ~.1) I- OT. BPA flfL. ~ iF} 'P q EDPO RTO v. ~ _ ] I . ~ -~~ - I._. R 0 D , ~. 00 pfl AMP GE ~~ J F kLT ... FAN L G TS I I]S J Ntf OK._ } S ~.y ), I.~MERGf GIB... R 6 D K-SInE[ A I , UC TS DN , r...1 AMBOi ._ f I ..`I fv ~ - - ~- 1rIC5W 1 ~ ~l_ON3NfiO1N~ .. ~ AO NOi IINK41P.1 ~.- 1. BFEN W ING . u(16a'B C .. . _~...~ • ~:. r[ 14 7f4 ~ . . nR ii4NAl _~ ! ..~ ~ TWD wAr l[rl I rvLA .... '~ [.v u 1 I uw _. __.. II V[n D CHEM. TEST t rv0..)_... _ . ._ '. __. _. ... ( ~ , _ - ~.~ (_]... _ ... :.... _ . .. .__ _.. .._ _ ~ DARK-NO I .i Or IIC[RI 6TRlEI IIGrITS M+N _~L ~FE7-. I 't rAi o _ r ~~ I TEST GIVEN - I/YI 4~ ~ 011~[ 1 B. _..w. ~. ~- I ) O CO _.... .... - ... / ~ND DE FELTS _ 7 .. ~ ~ t[sT n[r USFO ... I ` OiHlq UikCli Y'1 ~~ ~~~N ID[D aY n[R wlcl rl ~~ %~ % TEST RESULTS Z rNV15TWwtINGOrr1[[NSNn4l •NANK NGF NO IK.I U ISr+tCnt4 1 : o IL E Inllvt0 NIBiIVFD LI pna ~!L'.:^ )ADD " ' O iM [OCO~f OW O ' n I ~ Q C -Q . ~~a T4 zlt .r~.~ •~`~ x Gr~ rJ~ /4LL,1T-th Alr w[xcr D<.L 6 JCS 04 g ~ & ml O D Qu s [ T T os D o+Te or nvonr ileene 080478 I t o IRS .novE D o+Tn M ( ' r ~~9 r r.• ;~z}r~ ~.~; ,~; -~ ti ~ f P~ a ~ h1 t~i n uup t~ w~ ~ "g ~4 ~ ~ ~ i" i i 5 ~~, _ ~ ~ 8 ~R° ~^ ~ ~+ k s ~ r i .: fn. ,'. p i "'{ -r U N 0 3, M N O • 1~ O O ~ O ri H lfl, O N O I~CO O. P: Q1 O ~ ~ ~ ~:1 fi$gtP~~ 6 1, i t 3 T4J'7 ~~11~'*T1 k S~ ! ti - ii r..~ I t~~t; ~ ~. t ~r Ip ~ ~ ~ r iU ~ "~~y~y,~,~ y, L r A,r r ;~ ~ i n., l ~..r ~ r ~, t`~ 1~ S ~ A '~~ °rl I ;'.1 ~ , ~•i _~ ~r~ .. ` ,. ,., ' .' JAS •~.~ ~ ~f ~ _ _ *~ I ~r ~ F R3 •: : ' .k JJ : ~_ .Tab, .... ...~.-.:.........~W..-.._:_.,.dvo.. -.0 ~ • ~ ki F S ~~ 1~ ' .. ' r_ ~~ -. ~ :r IJIO'I UH Vh111CLE CULLISION REPORT Lllr rw sqn NO. ~~ sux yG [^w pn ugiq. n6M5 Ir E M ^~ Es COUNTY NO CITY NO ^Unµ W ^ ^E ^w cTY Oq row E w Fcr / ~ ~q~ Ea ^ a ^w ^ Dr 6M POAD ASECi[%J ON .a ip, i cLa. Pn[n. n~ srnEr~cop cr eJT p.,j/O I _ nlFM // J 7 © RAI wpApc En. DxlpcE. gosswp MlLE MAMA ©® cf r , rosrDn roErJnfYlxc unaJ,RK. roi~L pxwvOLVF ^YiUGE ^~ p Ali puOVauA1EN,La nEwp TPMEroRTFD x ~ ~ M OrvMIiO[[a ~ ^AESLtiEO Tatt ^ Maly ExgLOEIVEa ^CN[GiwE ~DJIIEn OLUECT STRMCK ^vEw E ^CORROSM ATE 4 BAMVOnIA ~q,aO ACT VEU 49 PIMECi O61EpT niqucKl OWNER W w T^ Eq pEiFP FNCEGCI1059[P EST C~ii FOAp ~, Jv A OBI CTS NAME MO DRESS €~ nEV p~~ EGCOpE 16E ~` I $ ~_ . ~ DRIVER'S LAST NAME ~ •INSTNMIt . ~TT~~~ MIDDLE F1vJ0 CMS B~E}1~1~ E I wEPE wvOLVEp DRIVER'S LAST NAME FINST NAM MIDDLE T ~ ~ On ~ STr1EET AD 9 OU E ~~ /~"r Ae n ~ ~~~~ NO. GT %NO. wERE STREET AOpRE59 ROUTE NO. MD DO%NO. 9 ATE LP DE DRIVER•9000 PATI COwaUx CffY STATE .'/ gEPOgrraw ~ LP CODE DRIVER'90WUPATI N .e. ~ ~I/ ~ G ~.,n t z,F ' ,ate . /~ DRIV R'S E IICF ENO. SA DATE OF SIRTM. ME DTUVER'3 LICENSE NO. STATE SE% OA ~.- cd- t W Yq, &R H AOE A P Mp~ ENICLE YR. MAKEICMEV.•WDGEI MODEL INOVA~OMTI C SO YfiTY 12 R. VEHICLE YR. MAKEICN EV: D(IWEI. MOD LI VA•O TI BODY STYL 120fl.1 LK;E~PLA / ,~C ~ TE NO. ATE TRNLER PLATENO ~~ . STATE LIC E PLATE NO. STATE -. TRN PLATE NO. STATE VEHICLE IDENTIFICATION NO. HEGI9TEPE0 NNFR ILAST~FIRSi~MID LE NAM 1 LK; 9e N0. VEHICLE IDENTIFICATION NO. PE019TERED WTJ ILAS .FIRS ~MI00 NAMEI .. ~ ORIVER'SM ENSE NO. n OWNEfl'S ADDRESS. ~ G• 't- ^~•'OGG4L ISTgEE GTY M03TATE DATE FSIgTM OW ' , ~ / jd 40 nG,~ w < C~ D NEq S MOgE55 ISrREET~CITY MDSTAT 1 .... A EOF BIRTH I.a A PMTS DF VEIIK:U:OAMAGEO r r0 -~~ s f- ~ w~~l~q€ s MT90F VEHICLE DAM ED wq I d ~ s LIABILITYINSURAN EINFORMATION~VEHICLE N0. 1 • wps THERE AUroEAOdLE UpelurvwsuR NLE N COVERAGE IN EFFECT FOq THIS ACCIDENT ON YOUR CAR ITO YE$ ^ NO NAME MDAODgE53 OF UA&LT'wSURMCE POLICY HOLDEq xME E59 ,NAME OF UADILRYINSUgANCE COMPANY Giv SipiE yP NAE MDpDORE550F lIMIMTY INSDRANCE ADENT /' ~ C n ,-, . ~ ADIUTY POLICY NUMDER 19i INJURY AGE 2ND INJURY; Iu5E9EP TE HEPoA,rOPAparxW4 ruVP ESI NN.IE Eu vu NAME AGE ADDRESS E%TENi OF NJUR E3 SE% pDORE59 SE% M F NpiURE MD M F ^ ^ dO INJUNES NEOUwE DOCTOR'S E%pMWATION DYA WCTORi ~ NME ^^ ~ E%iENT OF NJURIES p01NJURIES REQUIRE WCiOq'S ENAM I ® WATION DVA WCTOgi STATUS OF wJUREO NM1E MMKFIRSt ONE tMAT APPLIES STATUSOFINJURED MMKFIRST ONE THAT APPLIES IN VEHICLE G•.,elw P 6 O NGJ ;Eiunv []P ErK.[A ^PldarNM NO KILlJ:O ~vEPEI n 09V,[E (]DN En INVEMICLE Gp,0uN0 MOniDWIUIM POa3uIf IMwORI IIOfnOM Ftt1I ^PASSErvOER ND.. KILLED ISE Un IMINMI ECUMa VEgFI ^ (~ F PFDEarnI,N MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOi USED MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED SNDWNORtn DY MROVJ IN GRCLE ~J wpE,rF nl rrPnaAaIAM ` DESCg10E pELOW WHATHMPENED:IgEFER TO VEHK;LE80Y NUMDFRI __._._ ~ a„ „es'on n mnu, M fII[Apn ~rµo~5n6w ~~ ~ / ~ 0 /~/~ f //ee~./. v~ /C7 /t• 3• (CJ C)~ fiw ~° fi , --[- C~ wa•- , D... F cry/~ ff~. ~' 2 d.~/ ~ le. T~ v</w ~~~ ~~7-' ~~. f rq,[TDRwG,w,. - .1 y~ y~~ ~ ,L/~f Al.~~ ~r P~ ~. .~~Q.~~IE y ~ ,,e1/ . ( ~ ~ ~/ .. T ~ ~- ~ I ~ ~ . .7" n ~ y c ~vh' ~no c-z~//</y fc7 ~d / ~~ , . , S ' `~ - ~ aNY[rDx...wY,. ~ .. ~ ~~~TG~ ~`,2 ~~s•H•7` ~ave• AN VEHICLES POSITIONS BEFORE COLLISION v ra a LAn[9 INV[9TgAtED DY VENICIE N S E W DN 9TNE Or IP6rJWAY FOR HO wCx[ 6WVlET,, pq 1,64[ AnK[D v[rilC[l OGDIVKD ^'irr! ^Orn[q wMCrKW [[ ,9 a rts YPw Ea x6 ^ ^ ^ D ' LI J: PlaxlnAn Q ^ ^ ^ ^nlunrr ^ ^ ^ uaJa cnoaarJO FrJDM DIRECTION io DIRECTION PEOCSTMAN/PEDAL CYCLIST WA9 USWD. I^ud 4K ,^wµKw,+ ,^6rquuA [^~gwps~w4X [^ D [^ ^DE prrux r w <ro iw4 oiii s K e ^ m,ow,r uin Pf.DESTRIAH,PEDALCYCLIBT CLOTHV/O COLOR: J ^ o,pK , ^ MGn , ^ Ml.,p J ^ Re °' a ' Trn " x InN•AwrACe rfArnul LIGHT [:OHd'gN! [^ oucrm M.oiiiiuisiw TPMrIC CLw11IOL TYPE OF PDA A:-I [•[w,I I K I I OAYLIdIi I v U DIWEIIYVEnICLE AO1gN9 vMK[[ ICI.r CAa•rl wa IanE v[rn[LL G~ICK O I M [LVJY r 1~ ~1 ] DAWN I ~pJ,~ ] ~R4ivvv0 ] ^DUSK ~ d' I x, CJI,OnII r ^ pJE WAV uunil I M E r^ 1 ^ GKYJAl9 ^ I 1 WINO DTnNGni NIEAP ^ ] ^ grOP SIGN FY ' ^WEI Ll ,l ^SNO~NNO , ^ ~giJi90N Er 2 ~ TWO WAY ^ 2 ^ OVEnTAKINO ANOPMSINO 1 ^ l ^ YIGDWGN ~ l fA REVfR~OIC ^ ] ^ 5[Qw J ^ f08 1 DAnK 91nEET ^ ] ^ MAKINO IIIGIIT TURN ^ NOM CE 9 `~ OMK lgfh 9 ^ T ^ , ^ /LAlRhO RED ^ A ^ ILWp nAtMJOPE ^ A ^ MAKIIJD L[Fr TORN ti ~Orvl a ^ O NEE I lgIA9 ^ 9 ^ ti SCM• ^ 9 ^ rlA51MJO pMRCR ^ 9 ^ ALLEY ^ 6 ^ MAKINO U~fUnEJ R r ^ PECIIY I4)AOWAr CI[,RACiIP p ^ a ^ M!JfJ1AL ^ a ^ TWO WAY LErt TuIN ^ e ^ cLOVnNa RDA WAY NNh AC TYVE ~ ,(,~,, :.:CF:~ '.JS'.°::;,, 7 _I_ LMf9 ^ + ^Or11CF11/rLAGMAN E-~ [ ICI DrorrEn ron inAFrIC I ~:: i:: -~.:"~Y,t'r ,7!s.. ~ AYa~Yrn•• •~~lT.,1 _ '~aA••'~'TfS ~: SC~Ir ,~1 ~ i ~ J I ~~ ~ I ~+" ~ ~+ ~ ~;(ij r • 4 ~}~; ° ~ r~r~ ww~ - ~+n v ' _. I •,• „r,.l JiJ -li.; }' f r~ N'~' ~. ~ ~+ ~ ,.~M ~, i q to ~ a p„~a,..~ '(`~C~ {~t ~ n :: ~ in r *r^°~ ~ '.§ db ~, ,', t , !: y . ,: ,, R ~~ ak~~wr r,~ ~5;: ~F C Cu"~4' E ~ ~'Y ~a. 7Y YF. f p~ Y., ", ~~ . .. .N~f,. , ~ ~~ , ~ ~ ,~ ~ //gyppp ~ L w 'y,.Ni, . r \.~8~~ POLICE TRAFFIC COLLNREPOR7 UIHNrrll.wi,i PalcE dI~AINrNUmBER l ' ~ PRIVATE WAY ~a DA.EOECau ~r Der al oN E Sux up N p tw.f IH at. I~E1100110UR) couerv ..~ n 'VI V !V muenlw, // CO cur NO. `~O/3O iHW ^ wRu ~N ^[ ~N CItYOR tOWN NNAE 6N0 d3tREFtOR MGHWAY ' N]Cl5 ROUt OR 3I _ 3 ~~ C ANUS ^s pw ^or ~ ON 1 9 FRSECIING wiN•3' fE1Q AD NONINIfRSECVON PREPIA EO MIIE POST ~ 6 ~~ BErvrtfN STREET 6 StRLEt O ~• ~' ' ~SEANCEeUtR r A,II .CROSSSIN EEON NFANf51 Mll St MRES 5 f W (EFT Of ~ ACCIDENT MILEAGE CODE R OAGRAM OAEA AM .1iti COlOSK)N INVOIVfD: fRItY: H N t°fAINO. ~E NO. KIIIEO~NO.INIURFO~ ^ SPIKE dV[HrCIES ICf- PRORRIV DAMAGE ONIr ^ RI(SEUItED ^ VE~iCIE wvOHptH ~: ,4 , % INTER CIS CROSSStefEtOR ROAO~' RR F~ ~ OBiE[t SERUCKINAMf Oi OB1ECt StRUCK AND OWNER'S NAA1f) ESi.DNAAGF SRCW CODING USE / -~~~ UNIT NO. 1 UNITNO.P ^ VEHICLE ^ PEDESTRIAN ^ PEOAICYGIIST ~ c~il' d NER'S NAME: IASi EIRS MI Ul ~' D4r TfR'SNAMF US ~(~ r O~~~ ~ .K __ B SIR`EEl ADp953 ~ ` !01 iRfE1 PDD ~ ~.RE Ir r~ SiMf ~IIPCOCE ONENO ~ D StAtE LIP Nf P r LL~R CIg3 O ~ R uA~ Z fJ f "1 C EICINSEN E ~~~ ~ ~ SIAtf ~ ~ ~11~A EO,°R Hrv I 1 CENY NO. AtE ~ ~ ~ ' 3DAt IX B IH ' ~ ! e ~. di ~z EYfS GHI if GHi II4M NM1E8 ~~l.an~a T) C~otis; , !.u `60 ' E R fY[5 OCCUP ON IIRM N0.Nfb PHONE NO. Glt ~rt.alK=r~ s'o ^ CMECK (r~ . rEN CiE AS AN fMnorE A ANOtNEeA ^ CHECK (~) yEN CjE A54N (MPiOYFf OPANOI )/ N v CODES -~ ] ~, y5 ~ iriii 5 ee°a+ 6 y,°,',°°`Ff CODES - ~ 7 aii A i:snM"t 5 6 'n ' II ~1 /, wx,e es e. O ~f".E`7p..a. ^ .m ^ 'LA°6° ^ ~:rc ^ ,',E ^ ,a u~`d.°°' ^ A,.RIK.NLE p '~" ^ cS. O ' ^'1P° A~ ~ m Ku KN, Y(AR MAKE IDOOGF.CHfv.l i ~ ~ t , ANbfI IDPAt.NWA) 6~vu}]DR.CONV.I ~ ' rno~dAei E ~ MAK I E{HfV.I MODFI IDARi.NOVAI fAR /E /9 LT eGTe-/ - l 2d~'~ F P f ~fO ~ StAt! tvnilfR 0.AEE N0\•- St^t GL1~ ( 9 l4 I J%J I"I ~ LATER. vfH.Cd R TZFRSFi ~d S s- Gc1 I Af -~ O 0 ' • ICif rOENDrKAiION NO ~ ~ vEHICIE rD Ni CAt NN MIDIXf PNONFNO. RIGRRROOWNIR: {AST (RSt ~ /t1/}(~flN 7j OhAR~ O yV N IS fD OWNER lKt IIRSt MIDDSE -~OkIt15a - o!w ~ aAj 31 5 a ADDReadowNER L ~ E CM'N R !'~ ~a 3 X `1 NAAU •ADn dfPiwR co.wnuNt /~ N ~ , IXr i cv R I?gGSra~cJ ~~azsr-iJ ~o~>" zFS ulR ~" t ' a~PNw gAMAUOiitEAA D.MAGE AEU o-"s.w.w A' "'N a a R 5 A m'iLRwi CHARGE CHARGE orNi•om I lBr •tOP f5t. DAMAGE W NN 1 ••••~••• 5 AwAr ^RUWNfD ^AWAV' ^REM.VNED ESt.D f .... __.. 5 rOBOrt • tONYO IDBDrtOR ^ S S ^ ~wv°BV~ wer By i DIAGRAM OFCOILISION: ~° mNU w°rsAR NOREN DESCRIPTION OF COLLISION EsuPnfmwr sHRnr HfctzuRrl B I I . I . I '7zrAP.~. rA~r curb ~.I~.¢ sr,~E, E 2 fur ?~ ~ ~bo f~l,~sye A o!-s~°ir~. If . ; , r ~:~, z sr~~d ~r ~ ~ifx.~z~na~J. IB NAME, ADDRESS 81N1URIE5 OF PERSONS INVOLVED 'CODES 1 - Z J 4 S 6 OCCUPANTS/WITNESSES ~a sm°'wniw~i H,we ii sEa Ace torus ';,m," otsnr Dfa i NAME: G eE acka/nP M~C'[ Np rv `~Gti 37.30 , ~ . Aro.m rG E 0 YIMxr ^AMe ^EYL"'^"' .^~ 07:1:,M AMf Ii0 Aawss ;E.v; Hlo N w. ,~ ' AOEw115 NAiURRI 01 3(N•I llv. ^AMI1 ^~ixl ^[Ma ^`i" ^.i° HvI51rGA1Pw dIKiRSNAVER(ANK ~~~Y ~~liv RADdM °~, .LTIrKY "r cSO 1ear KE DIHAtOeD IrnHV1 POI Kl APRMD IAn 1Fs DAtId RIPUR! APPPpVID Ar DAZE X , ~ i , ~ ~h'~~, 9p~ln_ 0 ~ ° , ~ ~ ~a Y';~ a~l ~ ~ ~d '~ w ~' ~~ ~ i . y y Y. ~~ ~ ~ ~ l ~qg'„a ~ ~q -~ 'T'm0. _. Y ..~ u~ '~~ I 1 P ~4 " M 'I ~~..,. .S ' T ER A' ~ G I '< la Ebf '"l _' ' ~' R ~ '~' {1 1~ ii :'q,31 " ~Y "5;, _-,~i ~~ 1~~w j4 t ~ ~ ,(~ - !' lsi I M1 1 i I .', N! p}p>> M1].. `r i ~ , :, . . .'~~ - r ~ , . . 1 ~: Cr'9, I . ~~~~ °~ JJ r .J ~~ ~ r ,,~$ ,z_. w. ` ~~~ ~ ' . ~ . ~, ~ , r ti a e~ ~ ~ i w ~rt ~ ~ ' ~ ~ I ~ ~ „n ~ .~ 1 r i ~;~ ,. . 4 N t L{~ ~ OF ` r,~,~e _ ~ i 1 s yri~NS r7+~c ~ ~ ~ ~ ~a ' ' i - ~ a a .. ,~ 3 ~ # r ; - ,~ ~ Wit' ~. R o ~ ; -~ _ , ~ i:r s m v o Y~~ .~+r, . F O 7 i m O N O z ~ Q1 O _ .~. , ~ 7 { f ~ ° ~t ~ L ~ / r+~t ~ ~~ ~ ~ y ~ ~~ I I ~.i KT ~~ 1_ .. F t 3 m ,, t F i ~! k r rof~ c . ~. ~ ~" ~ ~^"" ~ i ~ , t f ~! i cn ~ I kt ~u~~~, fy ,~ IS ~ a ~i i - 4 ~~` F~ 1? s~, r ~ f~ ~7 1 ra ~, r ,~ ' i ,l ti ,t 1 I C ` 5 ' . ~~; ~ ! ~ ' ¢ , ' - ~~ ' ' ,~ r~i ~ i ~N , 4~T4j~v ~jl~ { d xF i F'l~^~P ~ f I y a~ til, I n l~ I ihV~~1~ ~t ~ ~~ Y ~~ .. ly ~` , ~ ;~~ ~la~ ~~ ~ ~'wp~ ~&Y ti~.~.r t ~ ... . -r ,. ~e%-. ~E._. .:~. ~ ~.: - ,- - itu. _ )i {~ .. ~f~'~1 STATF [1~ ~nrncu......~...... ,....._ _ _ ~ u: }, ~~; P~~' ; ~ ~ ~.= .* .~~ r.MP~, .~,~, ,u ~I ~~ ,Avg pp~ c J*~' i'! . ~ _ ~I ~ , p.Aaa i x: ~~ ~: ~ ~ +` ~' A` J " '.i 1 :_ ;; 0~'~ 1jy9~yih4 .~.i') 1 ii °!~ 2r~tr~7p~Y f ~ t ~~~ ,~~~' u t e{i 1 l ~, I ~ ~- 4 t '~~ rJvra yk "~f P'h`i !~W>F~u, w~4~' r~- ~ a h"~'~} y~{ .; ~~t,~ ~{'~1 y jf 'p _~ i )r . ~~~ ~.; ~. 1 f ~ ~~' i;- i ' ~ ~~~ vj w~!,F'WS AC..., ~:~ . .: _. , ~ _ . . ~ _ " ._ . _ .... . ~~"~~ , t {~ 1 ' ~~ ~ ~ ~Fa ~' ~ . ~. ~' ~: w _ ~ ~~> r ;,~ ~ ~~` ~ik"r ~i~'r•ri•-'hk~-kst_F7}r.-..9+iJP3S.lEU ^~y5 - r STATE ©F WASHINGT®N ~ _ :~~=--~----- ~`~ 4aG( ~ Dr^ , _ - ~~ POLICE TRAFFIC COE N REPORT ®fRAFFICWAY N~' 4IXrCF NNIN FR 4GGt rv ~ PRIVATE WAV I ..A, -~°+' ~ •- w* ~ - .I«~u.lw -i- I Ez:ooHOU4, cDUN,r couNrYra~ arvNO •.. ~ ~ ,+ *~ •j ,I rNWA • ^N ^! p H crvo4rowN Sertca' ~ .. ^ ~,,. ~~ F6NO Ot Sr4f[, O4 NrG«WAY 05 U4N M l[a ~a ~W ®O4 ~• ... //V. L ROUiF OR S`. '_ i mrF4un NC Wn«. sr4mo44o~ NoN rvm4sF«oN ON 1 'TH 1' 7lOtJ ~ ~ 7.#a" 1 _ 44ffU( F MRt PO}f I~ BfrWFfN ~~ ar4l[i a ~D !~/ v DrS,aN D4FCr`ONi OM 4Fft4f NCf, C405S a,P[R O4 hFa4far mrtF 405 ar4fFi O~~o. ~. d - ~S a F ACCIDENr 4aM4 OrA RAM MIA ~ 4F[ N W Or e p MttEAGE ~ -~ CO IagN NVOIVFD Evf9,r: IcODN t [~~w _ tY VE«C S ~ NO +ttfO NO Nry4fD~ ^ Sv tlaG[ ^««64Urv Dtw N IMF4 CLS @Oaaa14EROR~Pp•O4 OR HEE4fNC! •- ~i -a 4404! rDnMactoNty ^ vfsutrtD ^viO1at -~ -~ ~ q~~~ y~ 9 Dann sr4uc+tNaMF Or DeFfc, R4ucB aNDOwNF4s rvNMfl ~ ~fN S t 0 4acF5 S4FCIAt CODrNG DSE ~',y~~5~ ~~ ~ D4WF4'a NAME: F UNIT NO.I UNIT N0.2 ~ r` i~~r- ' ~ Dtt D4nw's NAME ^ VEHICLE p PEDESTRIAN p PEDA1CYCl15T usw~~ S~ ~ ., ~ ,- s,RlRaDD4Fa JC~AnT 'j"(jAU~ c _~. ,. ~, ~ ,4FR aoD4fss 2 .r, '~ a,arf sGDf G 34~ c ~. ~O-~P fNO D sort NO. r Z t%WEPaDCtNMN I w 98oI 4«` R cnT' w n - I p I ~v4 ctNS No. art sfn ~G'Sf~l 7~d;t`~.. ~, q occuvnrroN M ,M a4rwNl NO. F'1 ErZI ra V L ~ _ MD. i !~ 4, a f~'% ~ ~ .~ ~j ~_ N tec«r E a<u4nr~ ,3MI ~~ M 1 B _^ L yl N E l ONE NO. EYES IG«i NIGNr ~"~T~j '. IC ^ CHECK (~ ' mw ctlf_,t A Rv'n[ n auor« f R 1 t f1I I(as ~~~j a~ ~ 5 r E M K,r~. ^ CHECK .~S.~t~ _ ~ ~ COwrcs S * , " ~ :+i.i claN 1 CODES / + (~ w v[« of •~aN fAworRdnNOr«f4rnt '~ ,~ tJG ,fie ~, , , }~ry. Iw M• ~ n ~1p ^+sr ° asnM" S r4 roN y ~ rvxyC ~, . ~~ ~;~yo,.DM p .MOM.N! p AyR ^ ~X:rt. ^ ~ ~~{ 4~ .c, ,~, r 4r ve« u4 M,n[ID000EC«tv.l ID•a,.rgv r e:t ^+Mw„Nn p~yu ~E ) sirtF RD4 cGNV.I / y I ^ ~4n4 ^ n .~g 1 ~-- IJ:Cr ' 'a E lµ a00 ~~ « V I MDDtt IDA4,.NOVAt ritl v:l °°^' ~`^ ~- `.I N Ol~lN a4R a4f4RAR N0 s„rt H ` y. I 1 ~ 41G~aRPtDOwNf4 Wr frRS, ^ MIDIXf o •I I I ~ ~ W ~~ I ~ ~ ~, I rjY~' ; ~ ~DL I,A~C 4«ONE t=O- O r wtH IASi N45r MrDDI G ~ v~ -. ,DD4[ssa oarrve KAD1xtK v DDL ~ 1 a, a+ tE.i Taw ~P.knZ' T NtaA 87~-~a, ~~ a ~-r+. NwMla•Dwlssa wstn•NCl co. o4 acfN, E R1M•cE Al. 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V0V1"I~ISTcnTtO TM cTwn•~. 4.F Ve~H~~4~_ _ ~. .' i ' i I I CoaC~ oa t,tl t r I r • ` I ~ Aoo SooFpc,t -W k2 LvM~_ _ ~V !r ~~ R 31u . i I~ ; E. ~ ;~; i ... _ ¢, NAME ADDRESS 8 INJURIES OF PERSONS INVOWED _ Yn. r~ i OCCUPANTS /WITNESSES t ' GODE6 I 7 9 4 5 6 ~. 1 +vt r vs :oDR a N N•s"i s r I ~ 7 a:1J~I asp/ [ /1 " .~~„ sfB a l u,ua `~" .D.C fi ~ Nf<r :~ ~. 4~~ ~ m~.fm rFt .",.°r tcf t T M wt ~i4:luC ~d: p.Me p<ri<t ^.nn I I ~ I ~$~ ~" ~ ~ 's ~ a1~ $HCIti`~/ I,4i~ ~M p.Me p:L^ p^,.•r. ^ N ~ ~ E ~3p; ,..: ,,~ .. 41 «~~:~ 9.13156 r rit,` ~. I . "~, r ,', `I ~ I I ;~ ~r '~ s ,I~' r `! .., •. , ~ ~ ., } °~ ~ ~ ~ y ,g r„ _, •lpl i 4 , ,~ ~~ k J ,.t ~.Y ~+ r j~ S y ~ r .F ~ Y .' q ~~ q ~ - 6 I _~ T ~ ' I ~ ~ ~ , itr t y ~~ r ~ x .~ 1 .1 `? C .. F v t r ~4 [t R L s b. f ~ N `'°'` s 'y x ~'.t' ' i ~ i '~y~ e r ~ ~ ~ ,:, ( } 4 { i I . T f ~ v ~, I <n ~ Z ' p ~ ~ ,F w F-O ~ 0~` :; Z p 7 .r p ~F ~ p j ' ~' f i4. ~ ° i ~ w .,~ a ~ ' m 1 ,, <. { i .~ 1 "* ~ in o ' o • i% f fi:f .S. r ,~: ~. .h < ~ r ~~ R ~~ ~~ S .f ~` . f ~. I F P -N ~ l7 , ~~~ } e "~ • t F ~ Pa })~ w ~,. } . Y] 1 f ~~ 1 1~~~~~~` ~~ v r ~ c ~ '` .r~ y~ ~:~r ~ 4Y ~~ 4 ~ ~ ~ ~ ui~f~f~ ~ rrl! ~` F rp i, ~ , ; ~ ~y« . A 1 ~ ~a is~ " .y is Mn ~ ` In..4 Y ~ ~ ~.; h~. f ~ ~~ ' } - 7 ~ ~ ~, 5 .~ r j~~' ' ~ v ~ . ~ r f _yl ' ~ ~ ';~ tr ; ' ~ J ~ ~ r fMi ~~ 1 ' ~ ~~ ~ 1 , 7 ~ ~~ t . ~~r, ~jl 1RJ f;~ ' 5 _~ . f'.µ Vii; ti'~Y ,F',d „~ ~: 'x ;; . .~< U N Li N ;' C ', H O m O~ ~ ~ 'i i I~ I l I f ,._. - , O N M O •O O OW O .tiT v O r-~ I 1 O Q N O PG N0 FW'r~ ~t ~~~' 4 ] X F'p d1~ r t~ y ~ ~ ri ;v ~ p ~ w~ +4 ~ i i 's P ~tf9~ y1 i ., r r7f a~ x 4 C~ ~ t 1e etc ~ s a-y ~ r ~ DN a'~ 1nJRsr i _ ~` i i ti '' i.t+1 f ~ ~r t,t~Yr1R )~i] '~{~ ~i '~„~~l~r~{h -f ' , '-~ .,: ! iLu._. ., , ... ~. ,. , _ . ._ .... _ .. ,,. ~., _i __ ~., ... ~.. ... ~:.. ~... _: ~ , ..., . ~ ......~.,. .~< . 9 ~ ~ ~?x ~ _ . . - '~ I r ~ ~,, ry ~~+Th P '1 S „........: .Jre. ._st.• I a' ~ x•.., `- ' "x w "Am„~i 'R6~aa. _...'Y .. No STATE OFx"rJVASF~`GTOIV _ xz'A ~__~ ~ ~'. ~F PAEE GF ~ 1 POLICE COMPWNT NUMBkq T ' ~"• .A . ` , UNIFORM POLICE TRAFFIC COLLISION REPOR O OATEOf COWSION OAYOFCOfLSION TIME COUNTY Nf1/ CITY NO. PF~HWBA11 ~ i 7T7EEEp MO OAY Yfl. / SUN E 40N Z IDES ] B A IMUR 3 FNI B SAT IU$E 1JdIHWxI j ~ LO ~.ORURAL \ s~.: ) ~"• ~. 3^ COUNTY ^STATE ROUTE ^COUNtt ROAD J^•CItt STREET O ADM'CLS' PREFIX ROUT~O'H~ EEDT CODE SECTION r~ a ° .y '{` , %~~- ,~ ^OTHERISPEGttI My l/C .%G 3 •rt=11N CITY Ofl TOWN 7 PHEfI% EO. MILEPOST ~: L R s E w LLSS!! ~ O. 3~ p 'O MllEy^ ^ ^ ^ ^GF Urtfar~l t° f 1'~. A NAME tNO.OF 9TEiEETORHKiHWAY INTERSECTING WITH: STREETORROAO O MMP dAGMMpATA `G ~ {A £ ~ '. '3~ i oI NON NTENSECiION ' ~lf~:J~$O.(//G 7G~.-If GEC ACCWENT IN X~RD INTERS TH fl OAp OR REF. ~~~ „a YY ML~~ WTEN CIS. ERENCE C~JROSSGS-T.~RfEET~RROAD >R+ ~` I jr~ ~: N: SETNEEN BTREET AND ~~ ~ STREET CODE J~~JOQ „. I OISTINCE wNOOW CRON FROM REFS ENCEOR Cfl 9SSTRE _ ~ vNEIiH] PECIALCOdNO USE ~3 ~ ~ "S"~~i , pp!~~~~~ Y -. O MIlE9 N 3 E W L-~ O I •~O iE OF VEHICIFiVFHICLE - VEHICLE~BICYCLE OTHEfl IWPRE) HRARUN SEVCPITV ~~ COLEl510NINVOLVED. ~~' ® .- ^ ^ ^ NO.WLLEO 's i TOtAL NO ^VEHICLE-0DIECT '~ ^VEHICLE~PR TRNN ~ ^3TOLEN VEHICLE NO.INNRED ~ ~~' !~ OF VEHICLES ~'~~\^VEHICLE~PEOESTflIAN '^NONCOLLISION ^HAZARDpU4 MATERIAL ^PIIOPERtt OAMAOEONLY. „~ '~,yam _ O&IECT STRUC%INwME OFO3IECT STRUC%ANOOWNEHSNMIE) LOCATION OF OBIECT SfRNC%b E W EST.OMIAOE °,YA R"•'• ,i .. _. ~ ^IINApWAY FEET ^ ^ ^ ^ RO.EOGE S 1 1 '~' !'~~ f ORNER9 NAMELASi FWST MIpDLE DRNER'S NAME~IAST FIRST MI00LE IIF B~CTCUSI OR PEDESTRIAN CHEC%I ~'~ I-D LC A d A.I. -l L7" L= ~ H `!'I YLnR h?~r.K S"• R THEFT ADDRESS I STREET ADDRESS ]y ~ °~'A' '. ' I ~ .?: "e ' E Gtt ~uTATE ~ ~ ZP CODE ~,••,fHgNE NO E CRY STATE ZIP COpE' PMONENO. 7 y try i R rEJ7 •. R ~. - ~ ~ .~f(* ~.'Y ~~.. 't _ I Ca vrLCB..~ R ~I,f %"7G - 7- 7 JC-~L n ~ ' / "~b°~~• ~ ..~j ;~.,. y N D ER91JC ENO. - STATE SE% DATE OF xIHTH N DRNFAS LICENSE NO. ~ STATE SE% GATE OF &RT 'M.~,y y ¢.~1 _ ~ O• ~ ~ MO. OAY VP. O, MO. `Y Y0. E~ M,' ~ .JCC.7~'' ;c Wn - z ~~ •~• %f'Yc.dmsd3h f- ~' Ir l2 7 yA ~ OR VERBa PATION FWM NAME PHONE NO. Z DRNEflS OCCUPAT N'• FIRMNAM P N ~ i CODES ~ 1]I USS /' IAI SEAT BELT ..c 1'vl EJECTION / CODES > I]I ~~ IAI SEAT BELT ~ ISI fJECTgN '(~\ I. N NRE OF NA U . ~^rya~u ~~p. 11n,PoV9 xUUPIES `V~~ ~4z`""' ~ ~~ x 7 ~ Nf~~,~ ~ VEH vENTNE BL~E1pODGECHEV.1 MODELIOMTilOVA1 SlYLEI%D0.CONV.1' VEN vE RN MAKEIdHIOECHEV.1 MODELIDMiNOVN STYL 13 DRCONV.1 ~ n ~ ~~ J s•' I v ,,,, • s:>s~- .^ nr; v .L ,aas mhr~ ti•J S/cv f N ' I A Et ; E VEH. UC. PIAIE STATE TRNLEfl PUTE NO. STATE H VEN.COLOR UC. PUTE NO. STA E TRNLER ftALE NO. STATE `~,' I EttC[.I J~'tE w~ I -~+ Us.5~8 Gds! (~' YEn A NUM R C V H LE IDENPFIOA I MB A _ ~ } k + ' L ~~l`7J9~y~,25~ 3 E .~~~vs'E,ZI.^.oY7G ~/8•ifr`J~ ' ~ E FEGLST RE EA-lA3i xtSi MIDDLE PEOLRTEREO OWNER- FIRST MIOOIE ~~ o. art • o. ~ - s /' dvc ~ • ~ q 'A' 1 ADpRE R - ADOHESS OR OWNER l rk. ~~ ~-. T' - ~ 2 1 ~~' ~ NAME AND E EN IINA ANp A0011E58 FWSUIUNCECO. OH ENT .~. ~ ~ O ~• ern, rN r_'ac.. ~. GWJTEui' /R ANC it • C GOViAq u t _ j N~k • ~A ENFOIICEMEHT i I n/~ - ~~ ACTION U.v~ ~~ NAME, ADDRESS & INJURIES OF PERSONS INVOLVED eooes I _ ] ] a 1 ,1 - SE% AOE STATUB N EJECT. ~I j C NANt K ~" C .Daless~ u EorHOM I ~ P N Igf9f12 9CFHE RY TO 14 po {I C _'.N •~ l 7 t ~~ J ~~ I T ~oone:a 7D e~ #~' 'n ~A ~4 ~ I S PNANPP~F9 ~ Y NVNr TG "P '1., i'.; I NAMr ~~L1_0 ~ 1(~ '~ w JHL~M~,' I u " I ~!2 ! N ADT°cn~-,~F~ 1l~`'~ S scTNYBV. To J ' .~~& F E N y NAy I ~ J ( ~' ~, '. 1 S ' II ~N,I~~~~~'"S r 6 oonev 1,..~,~.. C Tf iA rxF Y t0 I ~ r 1~3 Y~"a~I''~{@, 5' I~•~iyb IrI SI Al PO'+IUH JHN+uHrGw.S IrI SFA1 Rf LT NISI tJkCIgN ~ ' f ]pr•.;trO[q I.NOWJURV 6d9 BLxq pUURr I.NOI NSTAII[D 11gTEJECTCD (~ ~ ; IDf g1T/N S ; /.OT ERPG4nd1 lbfA00N AO RNK 3IfNI[Ni NAIgI JUNSETD U9E ]P~NiIALLYf QC CD IIS4!' ~~. O Rf CEISI - D 50 ER ~ ] ^IDV ;MgON~ Y/IXfl AdfON W NTAL iPO551HLf NJUIir 66CATIUILT FNLl1RE AEJECTEbNI/ ~~ ~ r ~,} ' L I .r u ~ :}5.'' } '~. .+~ ~, .,k~~~1 ~C sl ~~~ ATS,~C~I~'~;,r{. f?7} , iz ~~;~ : ~'t I `/ 4 ,~y • °I {r ~ ~ 5. 'r N I ~ 4 ~ d" A.~ w~3+ SU ~ r~~ 1'i {1 I s r r 1' Y I '', 1 r~' ~` ~ : a s; y " R~&, r~ ~ r ' ~'-`, r / J T ` h r ~ J 1 { I•~~ ~gp r V ~1Px' ~~.I~ _ _ _ '+~ 't t ~. pQ v~ 4n+r~~ } Y~J~ ~~ , ~ ) ~° ~: k• r x7 y ~ RM ~ A ~~a ~.pi ~;, I ~ e~ - s.~ I~T~ ~a . ~~ i , . f ,~~" pp ~ ~E~k. LC UAMAIaC t. U1 EACII80X,CIRCLET/1E NUMOEROFEACN0PMA0ED AHE0. •~ INSTRUC710NS: 2. EMADE AREA Of SEVEPEST IMPACT .' IA a.OMWARROWISITO SHOW PflINCIPpL WRECRONOF FORCE. ®' I DAMAGED VEHICLE NO.1 (VSE THISSPACE FOR SNETCMINO DAMAGE TOTMILERS,MOTORCYCLES, ETD) pAMAOED VEHICLEN0.2 iD. AVwJ 5 r a a l 9 a l 5 19 Rool 1a. MooO r a : 5 1 FHU!! ,rj rr IS ~~ 15.TViA ~ I 5 If TroDl r '•::"', la I IB. UnSxterNeps " ra re 16. Trw4 e.1 I rD P e `f.~ j IB.UnEmcdMpe rT. Dr.wlNn " I Ir rT. aeRnwr SEVEWTYOF DAMADE: VEMICLENO.r SEVENTY F O OAMAGEIOTHER VEHICLE) iQUISABUNG DAMAGE DQOTHERM.V.OAMAGE IQgSABUNOOAMPGE GQOTHER M.V,OAMAGE 2 FUNCROrvAL DAMAGE 9 NO DAMAGE 2 FUNCRONALOAMAOE 9 NOOAMApE SEVERITY OF DAMAGE: VEHICLE NO.a 10019ASUNO DAMAGE D~OTMERM.V DAMAGE 2 FUNCTION U TOWED BV EST. DAMAGE TOWED BY EST.DAMAGE . . DAMAGE 9 NODAMAGE TOWED UY ES T D A MAOE TO a.L~svCl TO a DIAGRAM OF COLLISION - ~ ~ I ~ / ~. ~ nn TD ~ a AIL"y' _ ._ ~ _ _ ~ f~ r.REH I ~ ~~~I~ r i.- Tj~-- DRAW ARROW SHOWING "~ - NORTHIN CIRCLE ~ ~%~; fey I PE a o~nr .. 1 - rt - ~- _-~ dDOn ..' S~f Sr I"YI I ~ I i !'. A:x~ v~< rc ~ . fir. O L~ T I ~~ T- eNLOCAre PPOBAhEpOerrG T~ I ~ I -f~- '/ ~i ~'~~_ ~ I ~I ~ I I 2 ;-jam raI. 15~4~1ifnGlPeOeaRe ~-- r~ ~ I I d ~ rDaRatl ATU~vAC { i- 1 - ~=`~Ppr"~-•~~ ~ : , _ _ `r L.t I ~y~TS ,'~•~- ~ A ~ «2 -t-~-- -i-f I - - - - Cal14W I -~-~ - r 1 ~~ DESCRIPTIOCI OF aY7 j,~4 (INDICATE WHgT PRORABIYHAPPENEO(IEFORE OUNNO ANO AFTER THE CR '.COLLISION. 7°sJ ~ y,i,ri SA&uTY,REWCED WSI&IITY,pEDESTR ANCLOTHINOC0.0R,CONSTRUC ~ - I ASH,INCLUOEINFORMATH]N NOTON DIAGRAM, EO.DPoVER RON OR REPMR WORK ETC.), f/ 7 n UC/J., [/n ~nc~~Nevwb-.S~zn~Ar._~ LIJ~S_NIUGTDJ ~' ~'% ~~fli~~r.IilJ7~~^~~/lI C ./til N ' es 77tc-_~f~.(2KV /~up_ S4~o AFF,~~_15yd 4__STS'utK CICHa2~NO Cvr?s is - L~~rv [t'Emm-s . 7--(>Rnt-f-:l(>!f ~~c!~I) QN_'t7._(~JP3l/~A:GrcU'_=~_!~tf? ~c~rs?,_~ ~~_._ r _t= ~ U - - --- - ---------------. ------ _ ,..~.. ~.IS.:-uN 8 OR LI _ • -.:',:.-~.. .~. ~..-: - . NO.OFlANE9 SPEEDS V_N IFP N VEH. HF~DEO MILEP0.9i qR. ON STREETOR HgNWAY NAME OR ~"~- INGNE DIRECTION -i-...•... •.-.::.r NO ie0 5M! .LEGALLY WAS VEH NO. WCREASIND DECREASDq PMNED OCCUPIED ~ O L C~ e "'~`' W Q ~ - ' ~ ' Y _ ~~ , .__ ms) % ~ -_ _- A MR.' - =~ f I x~ C~~ ' " 1 CU4S NI..U6TC;*J ~ ~ ~ MpH'.K~J_ I f - r~ ~1 ---- - - ~ reD. o« SrPEEiDPlwnw . me cwn u ~ vle rows [ I r~ [~ r u ono_- _ I PEO/DICYCUST WA9 DSw0: r1 ~60ewAiA ~ I t 7ygUlncrl ,I. ;cno~iswwr I ~tnosf a 5I I DEVCrIAr o E TI ~ . Dm[ .ROAD SURFACE:,. ;ter.,WEATHER ,,;~CONTHISUTINO CIRCUMSTANCES P ICneCP Owr )cneePawr . .•n:..Lr -;;,...,sa .+.h:.orww)ne~.Te ACm ~.. ~., i c ane on I ... i nD b ~ N ~ e MR DRVen owrtP r uD : ra a DNHA s ~ ~~ r ~-, °~P ~,, A~ I ~ °~ ~ ~weJ~ D. ~'°i ~ x r;~n AaBe a=a ~ - - _ _ _ . DAY ~-~ _ Ix,-,` "~e~- 'l~__-___ _Jsn ~PwLUS«ce n r"~ ov a P C:~;n ~ „uv ~ ~-^a~ ~ ~ 4 J n.ru~------- X3-.1 _.~~~O -5M0'" a~ awlw.n ~ ~ ; a ~.'°f-l canAl~° C;a L~ ~,R, l I - , , - ~ . _ -- f_~' [~ ~E . L7 IDD n _~1 ° 5~ ~ ;rs l-j ~- -- _ - -r- -' ' ~°~ ,~w„D~ ~ ._._ (py ~D~~T f.., ~------ - or~.I;K~ --- 'C~AI,.e~.,; ~'u ° - 1.15 ~._~ runorE I. - i ' .~ r wEDA ~ o. _~ n°ulviollAMM'm rl' ~ w ~ rpl LIOHTCONDITIONS ~TRARE CDNTROI wrsaa ';-TYPEOFROAD ,VEHICLECONDITION q ~~.±;,$OBRIETY. :.,.,LSA: ]n~ eroHeD AT ionAA cneeN enR ~ One on MaRI oR R DN e O `~ ° Y' °N ~ Ve ~ ~ ~n N nleN ne) t- ° ~ ~ r I uo a ~ne i recn NLa r 1 CJ ene wA J w ,. . _.. _ , _ CCNmwnq _ il°.wcvAr -._. ~ ~ v I~~ .. ~ a.LAwr _._ /` ' ~ ~`."__ hn~ rwo r I ~ro ~ .1 r..r_~,_.. a~~ r r .._ 1 mvrria°ivie~ L -_ C )r^ ° _ _.__..-_ rr r 1 W ~~7 .. n6a r ~ w.w I ..~ I_ -...~ J. ....: . I .~~Ll ~~.. l 1 LJM~. vuu'UAt[o roY~ioN ~ .I ° - f ~ ~ . _ . YNwlTr-_._'__ _. ~_I ~ I i [.:.1 ~ _ (, I I ~,Rl,aw, f , ~ ;r~leNrew«s - _ - ~ra~ r r I A5^,o L a ~' ---------' °~ , •' V -ro .r so-e a. Ure~ eACN.,o ~BeenrN.nSwo l..~ -___._ L1-lJ?"~ ..._.. ~ 5 ° uw in ,_, I j eDNr i ~ ~ ~ a nncruwD ru~ ~ CHEM. TEST ^ 1- , I. __ ~ tJ aP LJ - or ¢Rlx:c~fn resTDmn ._5nR lava ._, _J a r•n ...~~..L.~ rc to"..~.*.I. L-:. L~ - ~~~ 1 : ' 1 - ' -" - - _ . ... . ~~ Y ~ OMN r ~ / . ..t l._J -._ („ lei„I DwrNO ~/\ /` M Ilfta I.., ~ I r[eTPf IUYD ~ ~~{. ~ orwn -. .... _- , ncw l o nouanc I ~„~ a.~(, UwrgD :. ,'r LID - 51yy0yyl ... % % TEST RESULTS 2 :j ,• . r.an,wsNww no . „~s_Qr3?c: w JArroprtfrr ....r n 1 S ~„14N- race DSr.rc•wo ~ r ~ Iouceu.lrnD u ANMr crrow NH~~~L ~LI - i ' 2. ~ L' • °N.; i.2 G ~~~; eNii~/? ra„^° Wf'DI.,, SbMw - w wronosrlnr, areornlenr MPm soer rn l I f ,4,, , ''_ ;, Ii~I l ~-}`~yyuj a "~ ~.S ~] Yn~ ~- .S i ~'~W Irb ~~ ~A~'~~ r 1CY'-~ Yc".".. t T~ f. :, ~.. P fi~ , ~p Y ' ~~ )~ ~~ ~ ~ ~ ; I f. J _ x, c ,fYt~ F~q ~~ ~ ~ ,. ~~^fF W 1 w21 P °~ ~ t ~ ~ ~ :c ~~~ f' F?~ ~~ ~ . . ~w A y Y . { ~ ~ ' ,~ ~•i~~ POLICETRAFFICCOLLISIONREPORT ~fINAINCWAY PIXICECOMPWNtNOMBE9 PRIVATE WAY L$ 1 DAZE icas on n 2 U~ Rl+~upv Nfl.wtD ~ {.! {A/~ nMf IUSEItlDHW9) O couNrv 1L~f ~E~C~/C.~ couNrr NO. I~ an NO. . iHWn pURMIV RAl ` pN ~• pIN Cr OR IN OLVN N FaN0.0V )IREEE09 wG A 1 /NIFi ps~ poi QUILesNE ON C.QCGIL~.~E: fCr Cl3 A ROUEF ORS ~j 7S0 ) EfNYCINGW ROAAD NONINEFRStCI ON Ix ~L4 IS_~~' BEM'FEN Y_ SEREEE 6 SERER PREII% E0. MItkPOSt //~~ ~ T~ Z I 1 CE 609 Rtif9 .CROS5319fI1 /OR~NfMF31 MIEE POS D . ~ `Et5 N s E w Oi ` `~jTS ~E"'(/TG~R ~• ACCIDENT MILEAGE CODE R P OIAG9AM DAEA AM COll13gNINVMVFO. SEVf91Y: 11 INIURFDy p3PIllAGE Hr RUN SIII[D NO NO D N .Ux nR D w 3 RU! NCE INtlR CC) CROSSSIRt[rORigAD . ~ . TOTAL NO d VEHKiES ® pIROPF9rY OAA1AGF ONIV pQ[SUItfD pVFHCIF GlO __ Oe:f~~tcSERUCK INAMEO 091ECT StRUC%PNDOWNfq'S NAMEI Fsf.DNAAUE yr-7Y~!E f~E,tB-JY/Cfi4-ND ~oBJr27 G/G. s lDD o0 SRCW CODINGUSf UNIT NO 1 UNITN0.2 p VEHICLE ^ PEDESTRIAN ^ PEDALCYCL45T 3 -' 09Wf9'3 NAMF: LS fI MI l C/1I Cz ~l._ ~ c_ .u,v r C.. DNNfR' NANF' IA31 I ~ il9D~_~~~~~ - - O NRtf ADDRfss R,-~ z s REfr.m ess oa8 !-~cvcc rot u l P„t~ u. ~ 1 Z U Y sIAEF ZIP CODE PNONE ND. QUIL.Cr ENE ~ • '? D R I AEF~i (}Q( ' LU LL ~. '1,t~ _ N _~ pRW{RS UCtN N 5o z D SIAE ~vA' N ~ D . 95 : ( ~ W N3g t S q ~ _ ~, BIRt ~ RAY ~2 t Z' O< WAEKRf - NRMNPME6PHONF NO. Yf3 -F~c. ~ H:Ht HEIGHT rt3 E R CUPAEION iNM NAMF6PHONE NO. YF IOfft 1lIGNi SSnc u c~ ~ It 5-) "' p CHECK (.~ 'vfHKl A : ri' AHOrHfR'u ^ CHECK(/) I CIF AS AN fNROrff dAwoiHfR.'u . AA CODES - ~ 7 n . s 3 t e s ° ~ CODES - * a "NN' S • ,'t, "' ( S fxc 6 sA.. - ~ _ `rr Z :N,uaKS NE .,v Qeaa . 3 ;~;;;of.D., p AMNAAf%f ^ ~ E ^ ~s.~. ^ ~ K~ a ,. ;; ~as..DN Ax.MA.Kf ^ us~l p <a:D. ^ W p ~:~.. 'MH x D V[H. Yf/Jf EIDODGEKHfv. ~-Zg ryy{ _ ARr~N AI SrvlE'ljD VI ~SOSE ~t'~ E I EV.1 ID .NDVAI I 'r~9 GaLte _ _ '~ I H uL. lKE D`rQ SIAI iRMlfR f1AEE NO. SrAIE ~h • - H ~ f QOR v ~L~. I b8 -cuA. A ~~ vlwttelaHnnenElo.Efq. 1 0 3 2 l.2 G o 6 5 ~ L f CLEIDFNI I ~J 5 l 1~ 2 .5; I I i 1 PtgW NO eIG15x9FDOWNfR: 1.551 iIRSt MIDDLE E"lu4EL IQ.K O W I f W FR. 1/Sr NRSt MIDDLE ~` 12 ADD9ESSa DwNfR ~JI JztE E N b ,, L? (2S )1,L(,QLcyE NWAEa ADdfssdlNwRANC[co. GR wGENr ~.K. _ R rs orAdlRl .~LYtI ErVD ~ AMAG~ MEA MAAGf) KNK CHARGE _ CHAgd • ' ~ •lD1 1 •10. a lSt. DAMAGE ^^W^V ^RtMNNlD ^AWAY ^RfAWNfD Eo0 fU~0lrOii S • rOWfO DO EOWED E~ S Q.INF-7 Ar er: S er Aw _ DtAGRAMOF COLLISION I D MN INDKA NORIN DESCRIPTION OF COLLISION: IDSESwneMFNEx zHEEr li rxaswlrs _ SHe3r rNECISSARrI erA w ._ _ _____. ~_~._ __ ... __~ .,.... ! ; _ 1/P1ftG+Le~.l E~1s7f3eu,LiD O~ ~. QutL3 _ ._ lm~ P ~ lt ,ufS I A ~ ..$IG,VAUIJCc.'Tb.7uRAJ LE'FT'c;~ SU.wIAJQ..--- _.... r ...... ., _, .._r I ._.. _ .. i c C1LcLLes.EJ~~r _.~ETI lee:~z_-:~PkoAeH-t,~6:~ ( :.:.. 2~5Y~.s~ _ - ~ N - ~ ' -' rl+ ~5 ~- ~as5w.c Ec t,vrEes~arro.E~._ _c. .... PPefl_ - ~ ~ iCS p I~' '~-~ of Utv~ 1 APORorC 3' N ~ ~e ^ _ ` , j ~ • . . . , .. o _ C~._ ~`~.y'Z P.It TT2EDr~`ZBE~~ our ~~. w~,- __. . r,0/~s! ~ -~ z zoacs~n . A egos„ _.. .. _. _ ~ ~oRdevAc~ , i,~m. ~-re H. I . 1° E, ADDRESS 81NJURIES OF PERSONS I NVOLVE ' CODES 1 - 2 3 4 5 6 "' _ CUPANTS/WITNESSES ~a'se"D,`oloMNtu l~tuw ii _ ~sd .ci uru _ 'H"" °•; "' nsre exf:r M~°r ,ME'1'll~r, ~ 3 - t~yMF>k2 Av If Alu.fa ~ ,t,1p P. ~.l e.. wM e Q9R. lK p I. '^ . U :4,. g ` SrMoWE ~:il ~ ~L "~ " . . DO.eu _ et NAEW d N _ f oM pAMe. p•aKt p..l.n. p N.Y ° 1 ~' A m..x NAZI yid SctW er. ^AMe pr'A% C7'N" p n A'~ , WIAiO W.K[+-SNwI. YAN. UWW ~ N:f.Kr OIKI DI)IAICWD a~. IV IG K l A ID O1IEd ifo. Mfl rr ,t, J. ~dAcr~,t'serf'~ ~'~`i x ~us0 ~,~~)`' y" / y 7 /)1aINCS~ EQ ., ~ S l ~ ti ~ y fv ~ R.(~ ~w 4 t~~ ..: ~N N , ~d a. ~ ~, ~ a~ A ~ ~ dpp ~L ,. _ I;;c; ..w a r /~ SFC, ION ~,/ V ~nxo~o MIDDLE ~. X NO. IOCUPATION. ~/ ~ /L THp- ~/ A--]TGE// ~Cp TYLE I ~, rr~ STATE :TER lu ~ a 6~GF NSE NO . ~ S/9Gy E O F BIR TH TT f~ ~~~ ^ NO YNi // nGE SEX __._.. M F i'7~iy'[`r~~ U S._ 7~ i EAUI 1331NO r. ..,~ ?~?1.::. 'dY'.Nf3` ~amy~~.' 31 n -' v 'R1 - Y I { "i .v, 7.. ~-`f J`r iii i :.7 _. } ;,, ,~i'i MOTOR VEHICLE COLLISION PORT NO. DATE OF COLLISION OA OLL _ Jrc e ISION tTIME OF COLLISION ^ wu ~ U, M.N~fS ` COUNTYI O CITY N0. /'(v .~0,~09 x COUNTY CITY. TGWN M ILES OO CITY, TOWN ADMCLS PRFFI% UTE OHS1REEi COOf SE ION .+,~-'„'~ JJL/'t_lln;~ "+ •" aoDF 3 X945-a GIVENAME Of 6TREETY OAD OR HIGHWAY I INTERBECTING WITH: STREET OR ROAD PREFI% EO MILEPOST p NON INTERSECTION~LOCATION OF COL I BETWEEN STREET AND STREET "AMP DIAGRAM DATA '~ N E annxpnp Fxp5Hx0 u[troR px lotNt tr~xc [nxpNnxa xaxoct, - NON %AO I E! ~WTER DLS. i a3 tn[~pa NOnp ^^ OF T / ^ O ~I ^vl xIx wxNtl I ~ ~EC~CODE USE n " °N ^ OBJECT STRUCK ~x ut arp J[c[sr VCF OWNER OF OBJECTS NAME ANO ADDRESS LOCwTI N E~ INRDADWAY "" .' ^N Q 1 n p fa rnervrt OeA[ / J~ M y % ~ r, AQ'1 /x % ~,/TI/~ 1 /•~~1 PEET 5 W n $ • • ~ .. DRIV ERS LAST NAME FIRST NAME MIDDLE 011,E r~ - A ill ~ a ,~ ~ + „xpx rxrxrxv `•"+^+"` : ;::~;' DRIVERS LAST NAME FIRST NAME.-. ,-:.. MIDDLE e •, (' , TREET ADDRESS ROUTE NO. AND 00%NO. .... "On1 •"•"^`O 5 EET.AODRESS ROUTE NO. AND BO%NO. . L3 Lf ' +x.ox, x.x x,~xtnml. y ~ ~ ~ 1 CITY. STATE 21P CODE ;~~11oc~J l... ~' F- 3 2 D I DRIVEflS OCCUPATION Sc c r J%!1^~ s+"•"•++ •' CITY ,~_ STATE _. ,ZIPCODE J r G' DRIVEfl5000UPAT10N U/!/e T - DRIVERS LICENSE NUMBER. STATE SE% DATE OF BIRTH AGE RIV RS LICENSE NUMBER E SE% DATE OF GIRT" ~ AGE I'77°~E -i/.- 1.~•' LG N ` M~ °~l oa I "1~ BV•~ -•a -o V _ Ma DAY YEAR vENICLE YR :., MAKE ppWU r'o•vp ODEL Ixpvn pnati Tn/2;1t1o a. BOGY STYLE '-: ~'n p vENICLE VR. ~ 1 MAKE Ixv M C ~P;appaH r .xoYnpnatrJ ODEL BODY STYLE Opa. ~- LICENSEPLATENO. STATE TRAILER PLATE NO. STATE LICENSE PLATE NO. STATE TRAI LERP TE NO.. STATE VEHICLE IDENTIFICATION NO. NFFeu + YN I ODOMETER ivI[tn [ [ VEHICLE IDENTIFICATION NO. Uxa uppESSAxtneal ODOMETER ~N L[n ,1 '3i f>; 3L1°,-i +150'`''-C1C3'+~ REGISTERED OWNER wnn rlxar Nlpp[t xnuL l DRIVERB LICENSE NO. REGISTERED OWNER lun.rlxsru pp[F xnuO DRIVERB LICENSE NO. p '~ (+_~'-/•~ I L"r LIT/~•'~ I~~ C7 OWNE ADDRESS ISTRFET,CItt ANO STATEI ~ DATE OF BIRTH S. MD OWNERS ADDRESS ISTRf ET. CITY ANOSTATEI DATE DF BIRIN MD PARTS OF VEHICLE DAMAGED AR V HICLE AMA LIABI LITy INSURANCE INFORMATION•V EHICLE N0.1- As THERE ADTDMDRILE UweartY INSURANCE ^yES ^N0~ COVERAGE IN EFFECT FOfl THIS ACCIDENT ON YOUR CAR NAME ANDAOORESSOF LIABILITY INSURANCE POLICY HOLOEtITr $tATE (NAME OF LIABILITY INSURANCE COMPANY. "`°` ; "° RFE. ~ ~ u.1 n 4~izJ?' ~R~ s 1J n>~ C_ o . +, , I NAME ANDADOflE~S OF LIABILIrTY~~INS RANG AGE C v STATE IIP LIABILITY POLICY NUMBEp 'per/~ tE_S +bC~~ taF~' ! ~i,'E!a G Wii e1~ !O1 IST INNRY - AGE ]ND INJURY: IVSE SEPARATE nEPORTfOfl AOOITIONAL INJURIE51 AGE . N Tptn[ N ANF. ANE _~. _.. _.__. .._ .. ______.._.__.___ SEK ~uunFp---_____.-___~.______.__.._~._____. _..... _..______-. _.__... _._._ BEX ADDn[a DRESS _ .- -_.. ...._ --_ M F -._ ___ ._.. __ __ .__.. _. ^ ^ o_n , ..x....x....~,p., •~ ...+ .....+ax...D~.ax x..l STATUS OF INJURED 1N VENICLE MARK FIRST p'uV n KILLED ua 1 ONE THAT APPLIES rm~t xMisnFOx xa iuixo~p STATUS OF INJUPEO F'1 ~ I IN VEHICLE `L,[I KILLED MARK FIRST ONE THAT AIPLIEE ons Oa Aofiw~ il u c" p ~ryi ~ ~,~:.. Nrl. ^ 5 0 r I 6 ^"t oT ^ta g c', x:•.RNTL ^ O l7 ~O SHOW NORTH BV ARROW IN CIRCLE \• Ixp~.t.pN,N„a,.Aa.N ~ L :C t. Ta.at.R. ap,[.x[.xM alr5lp,5 .aA+ WL[IFx. ,[IxI. NxINNp la pESCRIBE,BELOW WHAT HAPPENED: IREFEq TO VEHICLES UY NUMOEflI AJb•...2--_--Gq JC.._. t;;~"~ %e. ~G ~~`G_SE-[ v F,a[IT p, x,axN,. x.+.ts px [s [~~~Ca:";::'::.'.:",`,'~ ~.~_ I I.JJK~cTL~%._ _J.N__~~a~!T_~_~_F ~.1?l. s ----.. l,atltpax,axa T__._.___-___-- -----~ x ._._. _ V ENICLES POSITIONS BEFON eAp[D E COLLISION Ix [~ MAlctl ~aalo [ea +[[rr vr oc to NvunaATSD[T ' V EINCL[ ^ ^ b NWRI ~ ^ ON {TRL[T OR HIONWAY NAME OR NO, ~~v -rv , ^~1~,,~~ ~ 1 'rcJG /--CI ~ ^ ^ O O ^~~ ^ otii II ,~ t l px .7L~ fftia. ^ io ~K[L I[~~II IF '9 IOTNf RI ^ ^ fSl ^ ^ ^ ^ ^ F y J ~ 1 rr l .tr)11~Jd.~1 IRS I[OtliR1AN....Y.IO ~ O D ALONG J.::.u..k S.. -' ::: x.'yfi.:,.:' FR,O[{..g la '..». ~.ti.TO: ~~u:w~:':. .CROSSING' ••_~• ~~ PLO[STRIAH WAS USING St•'l cw• 6^ot 1^arot ]Q^A ] lJ [Y A R0~0 SUR!ACL R WLAT N E I G HT CONDITIONS L TRAIf'C COMROL autl TYIF Of ROAD pRIVERNLNICLE ACTIONS Sll I {S ~, ~[[ .~, ' ^3:T' lul" Ft L~t ''f I LJ DAYLIDIIT ~ " Kx~ " K S r x~t[I I[xlCF na[MUM1 F ~~I ^ORV A L^NAININ6 1^DAWN ^SIGNALS ^ I ^(INL WAY 1 ^ ^r 1^GOIN65TNAIGIITAII[AO ^ ] ^ Wf.T ]^SNOwING ] ^OUSR ^ ] STOP SIf.N ( 1 /"" 2 ®NEV 115 {L[ ^ P ^OVERTAKIN6 ANOIASSINO OANRSIR[[T ^ ] ^YI[LD 61GN ~~ ] ^ROAO ^ ] ^MAKIN6 RIONT TARN ^ ] ^ {NOW • ^f 00 A ^ I ~ ^ A ^ILASINNG R[O ^ A ^ OOI IIAMP [ ^ a ©MANIN6lL FT TURN ^A ^O[In 0 !Y ®vf X,^ Ar~ D I R SiRF[7 S^OAq ~NOFI ^N ^tLASNINGAMR[R IL I J ^S^ALLEY ^S^MAKINOU~TURN ^ y ^ VICIr• 1 J+ S ^ STII[/l LIGHTS ^ ! ^Ril [If.NAL ^ 6 ^iwp NaY 11TlInN LANs[ ^ B ^SLOWINO Rf ASON FOR NOT fE NNO DAI+O[R auuvatP.nxYY O.ata•<txr.s tte+ T^vl Ciir ^ t ^OII ICEIIlFIAGMAH ^ T ^STOPP[D IOR TRAIT IG ^ A ^vti clir I SIPARAT[D ^ A ^OR 6TOP SIGN GNAL ^ ] QnNID[D ^ o nS10PPTDIH IIOAftWwV g~~[ +~~LOE~tBp~L~ ~,•'~d'"`~,i`''~1A1~.1+•'N!!>:!:`"I747 ,. ~~... `lp, ~"::~~Iwd('."~ ,.... ':.'.(~~........~ ~~.I~t:15'~'.~i._~r J, ~~~, z r~ ~~ . ~` + ~; t . r • R , S ~*t , "~ ~ f y+~a; ~N ~ ~ - ~,wrpv.N . ~1 x ~ _ '. _ . ~ +Ra I _ G . . ~.k . Tn~ _ ~ ~~, 4~k ' ~r Y~ ~. srA °'~.. " p `~'~Av' I _ .. t~L.. ~ y~ ~~.~ ~~ ~ . ~~~ I I. ~. ~ I ., 4~ MOTOR-VEHICLE COLLISION r 'PORT I I DATE OF COLLISION pAY 0 COLLI ION ~~ ~ i 7' °~V 7~w .. TIME OF COLLISION - -r ~ e .. ~~ppTY~ CITY. TOWN ~.. RpLEBXL I~wi6r1 N rF~ (-IVY ~~~ T 10 G C_..a~'I~,gu ^ CITY.:.TOWN. _.-. ADAILLSE/4Ty^y'y-' f..., yy~~rr ~f~'sy~,, r~./. F~ 1 ~vv~ k4.,~" r q+9A ~L.LJYV( 15 ~1G OF .Sreglllm .~ ~ ~ F~ .:.. GIVENAME OF STREET. g0A00R NIGMYIAY :-~_INTERSECTING WITH: STREET.OR ROAD ,_,,, PgEFI%. Ep ~~ ° Gardiner Road I EPDST NUY INTERSECTION•LOCATION OF CULLIS' HwY 101 ~~O ~,~~~,5.} ~n BETI ESN -~ ~ flAMP pIAGRnM CATA H'+1~ I T 1D ~• N ^ P n SwREET .. ~~ .E , ~ ~~~r .,-.~se°, PI•rf..r,,~..,,~P.„. ., ND Cr )y -' L ° ..- pq ~ IuTEP i O CLS [ [/1 L -\ sve ..ss ~ 2e ~•1. .r.cT LI ` ^~*"eu.w„r.e' /~ SPEC. CODE USE -`FTIY^'• oOs /. . o c f J~i FI,•' ;r 4 OBJECT STq UCK v,.v sTF ^-•rvrv - -°YOWNER UFOBJECTSNAME AND ADOHES5 LOCATI S •JJ IN ROADWAY O O a °f.E ' P T S i~ ° S BECA x ~ ORIV cq3 LA$T.YAME. FIRST NAME • r..•r . . P.E rS MIpDLF .u DRIVERS LAST NAME ,T eders en Kirie ^r•„•".r FIRST NAME .:, AlI00LE '.,. ~ix~ / STREET ApORE55 (none) o... „„ Grimes Joyce (~) flOUTE NO. AND BOX NO. ~~ 851 Snee Oosh Road r„n,• „ STgEETApOgF55 ROUTE NO.ANOBO%NO. CItY STATE • „ Route 2, BOX 342 .. • ~ ZIP CODE DRIVERS OCCUPgiIDN ••^•• _ LITV STATE 21P CODE DRIVERS OCL'UPATION ~. ,r°^ aConner Wa 98257 Teacher „ Pt Townsend, SYA. DRIVERS LICENSE NUMBER STATE SE% pATE OF BIRTH AGE 98368 Unknown Pe de rk 496 DC WA M DRIVERS LICENSE NUMBER - STATE SE% OATEOFBIRTH AGF VEHICLE YA. MAKE I Ev Down ~ ~v ~~ 26 Unk-ma not have ~~ ,,Y YEAR 26 ~. ~; 4i MODEL ^ •ov. °.„n BOGY STYLE t ~ 67 VW ~ ,• - VEHICLE Vq. MAKE Iewev _ooueer MODEL r..wgsr BODY STYLEVw.I' I Squarebac 2 dr ~ Old.F Chev r • LICENSE PLATE NO. STATE 'TRAILER PLATE NU r, STATE / y Panel tru k 2 dr ~"' ~, ~In ~ CU 482 WA "' LICENSE PLATE NO. STATE TRAILER PLATE NO. "'STATE ,;~~J - VEHICLE IOENTFCATION NO ---0 TEp ~.>: A•X-5786 NA ~~. "'o.~ B, ~~ -, NA 17 262 VEHICLE,,IDENT ry ICATIO NO Ilgw .wEIII DD°METER • ~ e I '1 ~ - REGISTEREp OYMEfl ". lus :ORIVERSLICENSENO pEGISTEREDGOWN RrIF ~ than 68 U~ Y~ 8 in , Geor e Milo KI NG G ffi 0 W ' ~ OWNERS ADDRESS •~~_~ 1ST ET CITYA EI 5 ~ ~nElt Same gam' L $,~n LIC SE.N ~ ~! s ' '~ -~~- ,,,':'~ •=r. ,.DATE OF BIRTH .OWNERS AOpgESS ~~uu^" tOV/nfl3t OENmep :.; 3 `"~+ 51 Snee Oosh Rd ::..!n EE VANOS 7 (._.' DATE OFBIgTy _ _ ` PARTS Of VEHIC E.pgMgGEp LaC°nner,WA ~ D'1 YS'b U11FCnow ~~- ,,a= -M0 -p4v YFAq „' , ' e rout end, bumper, hood °`~x' - ._ a°F,.A,PreH.fL,. •~ _ ._...._ E,TIH,NR '. LIABILITY INSURANCE INFORMATION-VEHICLE NO. 1 WAS TNENE UTOMOB LE LIABILITY INSURANCE TOgwwv HKU;, ~~: NAAIEANOADORFSSOF LIABILITY INSURANCEP04CYHOLOER COVERAGE IN EFFECT FOR TH SACCIDErvT ON YOUR CAq [7~C YES ^ ' EGP M11O Kln 9 lESSC T' E '.r' '. NAME OF LIABILRY.INwRANCECOMPAN W,~a, N nee Oos~t IlaConner LVA 982,~~j ~ Farmers NAME gNDAOpgey OF LIAB LITY.INSURANCE AGEM•., .z,.C•Tr~' • ~. -••-••-•-.-.-~.:ki:S•a.ln. :~+A~.STAT ^ .... ~::'.4~ LIABILITY POLICYN MBER :F!.. r.~.,~y,.;},y;,:.- (~y' ~( Wend Berinato 6453 California Ave SW Seattle 981161 79 3815 50 16 ,N _ ITINJURY _ -.._sre:.'[ x : ;+, AGE ; 3N0INJURY: IU S PAgATE E DqT F[M AD • None ~ ~ .. _ ON L NAIRIE 1 ~~ ' None AGE• AD_ogess Li, STATUSOP INA/RED ;fir -.MApK FIRST pNl THAT APPLIES ~^ , ^ I T~~~. A.. '~2 .~~ ~ I ~ „~~ ^ WVIMICL[ U p~ ,WqN rie:c6 ; - 1.'-15'fATU30F INJURED ~ ~s .-AWRK FIRST ONC.TfWT AfFLIEBJ a~ )W i KILLED BfvenD _ os ..l.ssc.l ^.svro.. IN VEHICLE KILLED Iw,Nnio Pvlxe ras~f ps ~"r' +~^ ~,I~ E.IN S ^ B . e1 y 7g Oi R'J.'RIi •- ^ - , ^ ~nu n. ~ Rev)B wiwon w u ''„ . •.5r~ ~ E S OW NONTH BY ARROW IN CIRCLE r ^ 5^ 6^_. I 7^ ~~ r-, ~. ,A JI n ,,. r c. Pn•r+n °. e.......s.... \ ~Y~i 4571 E I ~~~~ ~- ~_ ea J ~ ll ~_~ ~~i p kl '' ~ ~1 NA ., 1 ~^A .,.., A X1:5 :f ~ ,, n~ Vehicle Number 2NEvrae A 1~ stp eeg~sl ~ gtt VehiO. was about oar--Ieri~ ~,nn~ •5 ~~' -the-owner-of the--t .' i _ __ Hwy --- 101 ~ i _,_~- VEFUCLES POSITIONS BEKORE COLLISION I r- VE Cl[ EAprp +•I yr ON STREET OR NIfiNWArN ME OR NO •el v nO1R' ~1 ^ ®^ Gardiner Road «" ;' IonNRI p~ ^ v~] ~~ Gardiner Road ~ .1 I ~~ ~ ^e vioem(uN ~^:^^ ^ Mora-., ~`fi•riX ir•1 N~ (',.(aLlri2Z•,.yU rnaul.~ t `"....lac PRplD Iw FACe u] Wegr R 1 ^ ..... : Q•..Lw.. ~ , a ~~//yy(E LIGNi CONO TIONS TRA ~PiC COHt ROL .. ] O P , ' Go• •^'^ I ~ruGNT °" Tree oP pogp (!'=~ , ~Rr 2 ^PAIN~Nfi pp.WN ~0~1 p~]IGN,L( O , ~a tin a•er l-1 E C~ WET J (, SVfM N0 ] ^ DUEK IYJ • YJ"OI fICN l~.~j ~O W. YG N, ~ I 0 ^ ShOW . ^f~ OAHK STREIi ~^ 0 ^YIELO SIGN D Rf VIRIIRL! ^[^IC( ] +^UFgvf Si llT ^A ^fLA3NIN4RF0 ^. ^INTlRCNANGf' ^iFrl~or ] (^ ^ L CNiS Of i HOOFrRA.Vry C ] C ui~:~'~r ^ ] ^f1A5111NG AD!(11 ~ 1 ^ALLLY B f~l 0 X K40 LJ T (Fi LIGHTS ^E ^qle Elf,NAL ~A ^rsM W.r NPASOM ipll hpT S!lINO pANGIR 1 ^ ° w..,.. ~M "W..rR.Ip.I ff ~~ - nNf M °MI LJ ~ ^CDINf. STRAIGHT AHEAD ... ^ E ODVERTA%ING AND IASSIMi ^ ] ^MAKIN4 PIONS TURN - ^ , ^MAKINO LlfT TURN ^ S a4AKIN0 U•TURN • ~~Np.~+~.~ 'T°M ~ I Fn;~FSPV++~..s•+.c+<.,1 Ir1. a/ec rr ~ ll l1 llrT eugV l..vt B oSLOW1110 f'1) ^OFF Cr Rif LAf MAN I`1!f'tyf f ^T^STOPFEp FOR THAF/IC •~. LJ U I ~, SEIANA I[U ST ^ R ^ f «MGMIGNAL - f' f I I - ~ ^ T OO Ulf ~ STMI[D IM RC CSV Y I~ } 1 ~.nl ~1 ~„ ~~„C~ J ^ .O T IF C CONfRUI k ~~-'~ V 2 n a r1UNU V U. U r11O ^SlAUfI le' IN I J !R F l f 1 ~i ~ ~ '1 ~ t r , 1 l m .~1:-, ~~~„ 4. 1. .. l r..• ~~ I 4, 11 - - 11 L'sl:w'sG2 ` ~ (a ' ~ n~ ~_ ~ I; t I n si: I ~ ~ Sv ~ ~rv'. ~ ~~!'~ /. d, ,lYl E ~ ~ 1 )I '~'~ .P17T~'d, Sit .;.1 •' t e j .. t~,b 1'~Mp A 1 ~~ ~~ f ~ xx r•~v; r kt. ~j ~`ta~ <~, '~° " 'S~ ,. Yee ~z~ ^~~.¢jS~ ~j~Ma F ~~~~~ ~k!, Z r L~ ~Irl~ 1 T k 1 r, r. b4. J 1'. 1J ,{ . ~ l • 1 1 r I J r~' ~ ~a P y 9'~~ ~. ~ '~„- ' 1er.19fAT5 ~ ~y YA ~ C ~.4 5• L~ ~ r x ~ ~ ~ 'l ~ ~ y~ ~@ 6 Y ~ ~ ~ . Fc ~ ~~ 1 . ~~ - . '' .., ~p r ~+.I M1 l t~Y+~yA4 r W ~I -• ~=~>a~e~tsx:YSxsracts~d?L~' . _ ~ ~' ~- ~~ WSP 1591RfV. 1.801 STATE OF WAS iiiiGTOiV PAGE ~ Di I No. ~•• • ^ I ~':, •` POLICE TRAFFIC COLLI NREPORT +~TRAFFICWAY •..J roucEC~'' INtNUMEER ~ ~ PRIVATE WAY l 1 toicau ~ N ~~ ~.r re 8 co G nmf 'x U Sxl (L15f ]rDOHOVRI ~ cou"rr ~ - ~~ muNrvno //. E:~ orvNO. ~0~3 ~9 wA ~ ~ 4U4A1 F ~tl ~ Ct OR ION'N F6N/O.Oi SiR[Ff O4NGHWAY - Ewlfs ^s w poE Ull~~iUE ON ~A.JU. _ /J~~. fCT Cl1 M A _ I kOUR U451RE~t i~~~.7U ]E IqN INif45FC~Z1ENG WPII0.: SiR t10 ROAD NONINIENSECIION ~ ~ PRtfIA EO. MITE POST ~~ r BETVFFN `EI_^~ SIR[fi6 SIR[EI ,/il'/I~.~ ~/^///'~f~ DISIANG <OIREMI kFEfRE .CRGSS$IREfiGR NEAREST MIIf YOS -_ R[SE N S F W ~ EFR '- Of gCCIDENI MILEAGE CODE R v DIAGRAM wiA ;/ ~~I~~`~f CI'~~J~G I/G'/ J,/ ~ / /'(r{ Sf% - h Cd1I310NIN'VRVEO. ~~fRIIY. iOIAI NO. RILFO~NO INIURED ^SP IIAGF HIT'(;LYt E ~/ E IN Y~NO iER3Ki 5 TOR bOR YEitRfNG e. ifR Cl5 CR0635IPEEI ROAD OR ]] ~I.. Cy VfN CUS PROVfRrv DAMAGE ONLY ^ g5 INRE llliFD VFHC . Y R..N // ~ OBJfCISiRUCY1NNAf Oi FR SiRUCy ANOOWNfR'S NAMFI ESI.pAMAGE SPfC]AICODING Vif 5 .. -.• - UNITNO.1 '. ~ „ UNITN0.2 ~ ^ VEHICLE O PEDESTRIAN PEDALCYCUSi 3' SZ p4NFR'SNNAE: LASt RSi RE ~fNkEZ-NIAN ~IeNA-kD 1 DRIVER'SNAME: USt EIR ~- 1 A~rN C.oc~ls - °Z SINEFIAOpRE55 nog ~Z ]iRFfi bORt55 Pog ~-~~- UIY StAIE ZIPCOOE v ONE NO. u.i ~¢c.~~ -cvA~ d3~6 65 39d' D R IfY SiAtf PNGNE u l ~e.~;vE -cuAp` 7 I - DRNtR'SUCWSEN SCAR R N 73 o JiV ~,YsJ_ rtt ~' )~ ~z~ I ~ N R U FNSE NO, - tF SEX DAit tll IN wL Io z b~. ~~ ~° RZ OCjy~~vAiION iCF9Cra,C ~<PMONF NO. /E ~ EIR !\ ~2S'T K~ !,7'ry RS IGHI IEIGHI - Y/!. .s-/ E R OC<UVgt ON iRfA NAMF6 PIgNf NO ETES GHi HEIGHT S'(ZtA~f Qt,~ L l@cAc~~' ~hl-. B,PT~ l~-0 -~ "- y ^CHECK (r) yFH<IFAS~N[MROV FOPANOlNf4M CODES - ~ ] n ~ a i 5 t 6 ;'A° ""r :]h,.Nl ,I«IDN „„ rLp - ^CHKK(E~ FM<IFASANFMPIOVEFOEANOiuFR~t :ss . iMN' rcn N A„„ .cu CODES - * 7 n < ° 5 u ~ 6 i'O .- ~+ 2 INJtY~S R ro ]°~tw °.. eOM ~ AmRUU"ee ^ °u°'RNI (] c$'rier ^ vn'F.Kii ^ iv°.xv EiO"e~or.o. ~ AyRU Nee ~ uRCi ^ ~S:nr Q vl ^ i. Nv A' Kl[ „ 1 vEN. YFA9 MAFt /j{00,[GE{NFV) E~3 l.cJ~C. MOGFlIDA4NNOVA) SfYlF 1`3P~ CDNV.I C.DJV'rr T~. E 4 AV.A I f nEy.l NOOfL(DANI.NOVA) Y 1 VI I30R. I~N pp~~.]e 5 N ` SCAR iRNlf9 MIf NO. SIAIF H vex. aoR N R N t A J ~ j~ePZSe -w~. I C ~,... '~ V[HICtEID[Ni1fIG1gN NO. 3. ~ 2 /~: AD'S 288 L f Cf DfNtIF C ~,% ~ I I R[GISR OOWNE4: MSI IIRSI MIDRE S4~^tE PHONE NO. O 1St pOwNt 1 i1R51 yi. MIDDR Y NO. IZ ADDRessor owNEa N A R EoWNER E ' NANe<Appaessa ww4ANee eo. o4 AUNr I u ~+LEZd'&f~C[FT-- - R LC5 T7i E {t?] T AMAGe .RU ' .UONB .' AUK' ~AMAeep ARU a . irlmCibNN CNARU CHARGE u3ic IbvN ] r I n Y EO AMAGE YIOP Y L31. DAMAGE ~ AW'wY ^4EMNNfD ~ ORNEN ~R[MNNID ISf.O 10 A ~'Z/J>C'f~ tOVIED tO AYD OY AWAY I 0 TIOii 3 DIAGRAM OF COlLI510N Iu M nN Ir siu1F~rN DESC IPTION OF COlU510N: lus[suvlRmENiAL SNtfI IE NEGSU4Yl _ .S RtI NFGSSMYI ' I ~a/iece~,~/_,E~oen/f,~ra.F~o o,~ LG,~Ge,C ~ y . . r ,_ I, GEC .14 _ + __..,. ' .. _ .. -' iG+YG~GE O~ii/E, 77~A~/ 7r10 ~~I.EJ /1 =] _-. i ' r \ B ` _,] L ._~ ~ ... VGr/~ec .B.PJ~A~c-~/ . /KC STR~IL~i~ ~ / . ' ,__ ._ I "'." p.J -- . _ l.u fir... aT. {~ r~Dc-.2. .__ _. ... s /o ~ ~S. ~/A V/.vG C~rCr~rrc ..,_, ~Q~c~Ya us r Evil s ~ ~ /~~nJ ... .SICIAW ,SroP ... ~•~cl.C'Et /T'~~/~Li9.f'S r.';O.UT' LUff~'E"L._ .. ~ ` ~ ~ i ,: f ~J.AYc^~/ ' CSO (~J'rJ~ U'~ /IS ~~!/ CX B.f/r'KE' C ~i D. 13 NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ~ CODES 1 - 2 a a 5 6 OCCUPANTS/WITNESSES ~~S.D"°pluot;uiiANe ii Se9 AG[ .TANS IgwO L Of SIR. UIG N AALL~ Yc .r.G'A rre Cb" , ~tss L!/! ~ ..tlE" r1Alu41a // urNi nr " O = 'Y [7 u'ti' D ": O ^ C N N E. _. .. ... .._._.. ~ a _~ 'T I I-~ H 2 LwFss NAru4fa ... .. ~ , IMw DrYCVA QAMe. ^", ^~r1:1. ~ A': ^o':~.r' r.:l ff . AN r to ~_j --• f - ~ - `C A Cb115 ~IAWNf~ ~~"x n1. ~I yin ^irL Vt XI ~ ~' C +`M 0 , nvlSlgwrrp (YEICIYS NAmi YYANR YADGW AW NCr R 1 ISrA1C1yp IlM <(j'1'~y.~ Oct10/1111nOY I t ~OYif X ~,e~z. J...~~rriPsei~c-~ '~'~ ru °¢'~P ~~,(,oC /jolt (1ui"L! =% cy}~~~ [ .v ~~:rns-Y - ,h y ' ~1 Ya ' r fi~~+ 4~' yJl.,i V Y ~~ ~ ~ t ~ I y N YIIy 1{ ~~ EN .M ~ ;. r- +! yl d' , El '. k SM1e11 . CL .6.11 ~, y '.d FU '.y . J 'iWAt ¢L .' rt fY L1 -n [ I 11 l'R L~, y I ~ ~ 1 r ~) 9. L I ~' J~ I t; t ~ ~ . -.1 I t i fr) ~t ~T - L ~ ~ i} J h 5 +~ 'M ~ C , [ 4 ... ef' ~ } y ' ~.i '_ 1 l7 ~ ~ t't f' ~~F t 1 ~ ~ ~ ~~ ~ ' +~ ' " ~ ~ ; + ~ ..~ H. a~...ai~~.i a t'+G"c',}.:.new.rrlk3.: mrrJ: +.fm,.wncrrr. , .: I- 3 /9•SD ~/ease iGb fe: Gir9~e Lcyi9e-s^.~d•~99sD~ e%es. _ . 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I G Sc _ :!Yl PM J 0 ~"_,?a~" l~P~+ ~~v. . En v 3.« ' i- LACE :. couNn.~::.. .:.. CRY.rUYM. -.:• OUTSDE MLES .~ ^N © .. .'~{ .CRY. TOVM ~. - .. . cnv UMl AOM{LS`•; PREFI%.:. wnl ON]TRlIT SEOTKVr, f0°.EZ . NeR~.. I".ow vl,n ©© nP « / r? ~L,~ ~'~ .~t %.7,;,~:J ~./c4~~i*~~ ..~'% wARE DA r tOH E ET;PjrAO R A'.v~ '~.. WTEPSEOTWO N'lilk STREET OR 110A0 ....~.. r PREE9L:A E L MEEP09T ' . ~ U -_ NONINTEPSE ION~LOCATN)NO 4.LUYON ~ afREET ANO STREET OETWEEN ~~• • _ ~ OIAGflAA1, WT "~' ~ ~P~E 4r~ f _ aM1 -1r^~ R R Er. Kw WMPEP.aR00E ~U y'4n0o aClnrsSwnuKEroaraa gU.ir iarLwvii A,. .` :NOR 'LORD. ItllCIM lTMl1OAR0 INTER WT RT .IDObLLifil!E8T POAO, ~ NSrDlgn IEE1 D D. p "/O!' ~:x ! ~y COLLISgNxvCWFO (~ yvEWGFVFHDIL ^VEK1E&CKLE ^OMERIwMIl1 "aMECr ~ v J SPEGCOOEI6E Y jy'4 (r ~~ • ~ ~r cr ve~c ES - L.-1., r~ ^HrRUx pvE AN p I«cLE PEcesrw causaN : "-- ~ - '" OBJECTSTPUCK ::._. ~... INM'lOOMlR]TIM0,1..: ....;, OWNEROFOBJECT9NAMEANOAODPE53 ... ~. LOCAT IN gOAO N)N ___;; -w._; N^® pM],D EYw Nsr WAY :+~I r0_n_V OsIFGf- , FEET tOr1 a • • OPWEPSIAgiNAME. ~. .:. FWSTNAME....._.. _•ML)pLE .; ' ` •" ' rrl N~ L L Ir MOPE LHNI MO C.wa E E WvpvEO ~,DR ~ ~ • • ~. •~.. - ORIVERSLAST NAME .... .. ... .... FIRb-T NAME _,. ":'MIpq,E ~'.~: 1 D / IC. STREETADOR ~;.~,,,.,,. ip)'~tENO.AN080%N0....:.. -~~'n ~ Rte- ~ , `" ;, m,N Tro °` D PEETAO gE59; .. .. ..... .:. .. ROUTE MO.AHO BO%.RO'- : . _,. 1 P.o o / ; GT .:.,:.'. ._.~_...:: STATE ,,.rM:;:udi_]IP000F OWVEASOLCUPATL)N _ ' ~ eaw!° EPDR rDPN CRr : I, .v ~ .::.,.ST tE ..:.:ei.:,:... LPCUOE- OfWERSOCCWATM) -.:..-..;; ~ ~ ~ 71 ~'~e i r ~~ c ~ 1 J . , /,Elt//O.r • / 3,?d OIWL1UMf:F7l5E_ aTATE Y7L .., pATEOF : AOE ~ ~ ,.- DIWEP9LICENSENU R .: : .:_. a. STATE SEX GATE OPaNEM;'::~ :AOEe '•. VEHICI.EYR. ICHEV.OOIX'.F]~. MODE!-WOVA~ONITI..,;: OOOf9FlLEI2IXL/:...+ LOOYSTYLEI]DR./Y.\'• VEIMCLEYR. MANEICNEV: OOOOEI. MOOELINOVA•OMiI. LICENSE PEAfEN4'.,. nW, TAT PUTEh'O,._. '.i -.STATE ..'-. .LICENSE PLATENO.~ ~. -STATE:..:. iRNLER PLATEN0.~ ~ .r-STATE~o4A: vErPLlEIDFNIIriCATCNIN4,:~~r,5+.11Y0a MO0EL9ANEWEPP;C~ OOOMETFA IME.EAOEI VEHICtEIOENTIFICATL)NNO...:....,.;. 119E8 MOOELSAN 1:.'.=. OONEEER,.I REGSTEREOOWNEq..,..~:W3T•Fi6iJYDOLE:N!'ME/v~::~. _iw,.:WWEPSIICFHSEE~O-:._:.. :.. RE044TEREDONNEf1',..;;;;ILAST.FIRST~MLro~ENAMEI.._,';'.. ::~DfWERaUCENSENO:^1..:n::J- e~ .r t L La-!F-L - c WN -~:.a~taJ.r, ~ ISTPF£~C[rY!rN,SiATEIL.:e:,:.+..~ DATEOF&RTH;:,~. i ~ ^ ~~.f" y ~(~' I ~i Flu % i OWNERSAOOREA4...r.,..,-::;:.~.ISTREET.CRYANOSTATEI : ~.;.::....::..: '...OAtEOPFPRTMu. ~ D;r YEM PARt O.vENneDAMAMEA<~f..,.rs1~1•.:~+ as.. v.r -:-~ .:tan r!a PARrsoFVENICLEDAMADEOr._.j~. ...~,..;I...:'. ,K ..:.:..: ..... _..:. b.~ ,~,-. WA9 THERE AU LIABILITY INSURANCEINFORMATION•VEHICLE NO. 1• wvERAC[WE TOMO&LE UA&LITY NSURANCE FFECr FOR THISACCmENrwmugcAR ^YES ^NO ' - .. .. ~.:'- NAMEOF UABAITY WSURANCECOMPANY ,:.~: ,;:-..._.,.:a~ NANEAHOAODRESSOFLMeILITYC4AAUHCEPOU Y I g OFN ~:;, -:.:-_... ... ... C L •• MiE r m P 1~1 ~l / 1 /~./•/ /IJC~11 -..L~S. - VrXO ~ ~~/ST~C ,JU. NMIENIDAODRE5.90PUAE4fEYH9URANCEIEiFNT :_~:.::.'A:ur. .':...a ..+,. .-.. ... ... .. .... IUA&UTY POUCYNUMBER... .,.. .rv .. .4.'... 1ST WJtaiY" .: .~ .. ~ ~~C+. nt.. ..-.::.."` r M.E 2EAIfUURY:.~ :. .: NSESE MIPUroRTroR,oarWl,LwwaES ': AOE.: NMAE ittt~~~ NAME Iw .___ _-- ',. ADDRESS -SE%i' AOOgESS ._ - _ -- - - - _ _ Q E9___ ~_ ^~ f1f 0 lMINla -_ _ _ NNWK YEA WCrOR' ® ~10R __ - ~ E •uir. Om ®~ n~uE' 3 µW STATIIa OP NAYIEO M.A..;, r ~ Or TMATAPPUES SiAN90F WJURED :' MARK FlgaT ONE THATAPPUL9~. -- .-~ IOS4 R W VEHICLE PSraWO BLM Pac aIE ^PIA1fN0lA W VEHICLE NILIEO. yvy~~l NP'OIA ^ NGE KILLED 15FHnE1 N IM'H~OArI I E 0 NO 1 I r I.p . 0f W W EICI S^ B^ o~OErcl O^u., v.•rr..w ^ 5^ 6^ 7^ n p ~1nLN wnRE.IH ^ Y+0 W NORTH fh AR110 W W GPCLE ,µy0E5CRIDE BELOW WHAT NAPPENED:IPEFERTO VEHw eP 8'INUM9ERI :,A,'iId•1nui+:Ic ._... . . ./L~ E ~twn try// ./rJrr"~ [, . /.E~JQ~~ L4-~ a ~ / Y~1-- A,CtC1i lP ~W. j ` I { • ' ~ i i V,_" w__- 0. G _ . _ . fJ. G LC Q ' n,etr II ,Awa ow ~,~ ~ \ r,AME ~ >P.a.. ~Lc~v(-' rA_~v...~_~.1,p~-~-_1~Ct-fl+=Lnt10/_~ : . wrcrpid /-' ~ ~ ~ ~ + ! ~' _. ~ - 'G - Lr.LITx,~.~.,. ~ _- _ -.... _ __. _. _ _. _.____ --- __- VEHICLESPOSITIONSBEFO VENICIC N S [ W RECOLUSION ON STREET OR IN.HWAV NAME OP NO. Haw L•Hn o+e aPIGTKN veHCle Em.EE. r.Nn+o a No vEHCU 1ln.aE•P.wEP r[E I:0 rPAN,ED wa v~.I.cu occweP !a ~ -WO INVearpArlD nr 01Htq ^ ^ rMiio. Ponce Raw -^ ^ ^ ^ . ' ~~:. ~ LSE Vu ^ ~ `.^. ..^' ~• ^AlP ict ~u:iKNlwm . w ro1I•KL . ^ ^ ^ ^ ! I ^ ^ ^ ^ ^ ^ ^sHLl,fr ..LVnKw-- ~'°_ ^ ^ ^ ^ ...,. ALOfa. ~ ~• '~ ... ....:.. .. '~~~~ cAOSwo .: ., ..,, ,., '.. :~. .-raoM'. CIRECTION to DIRECTION- - µ L O PEOEa1RANWAaVYNO 7^WMMWAY J^ 1^YOEWRK A a^OTHEq ENOUIOER ^ witiwu, 5^rIlo.A Ew LL NOAD YMfACL~-,.,. Ic.'talrel .. n. M~ATHEw h.. ~ ~ i. 1%Y1lCOMpTIONa iTW°1000HTROL. .. µf<, OHfI v1r'e1t TYP[OIIgAp .. ve'.Ge WI µK M! MrvERNCHICI[ACTNXIa '. „~;;, :,.;'r. ..~.~,. HcLt KHlaoNLawnei~ ' pp{{vTI,K}7UEE~rELr 1nN 1 R~~r ~ nUKri t ~RxNfq 1 ^ WrLN1Hr 7 ^ DAWN ^ 1 ^ SN:NALa ^ ] ^ StOP YON ^I I ^ oNE wAr ^ ] ^ TWO WAY 1 O OOIwT STRANiMT A11EA0 O ^ ] ^ OVERTAKING AHD PA.gYNO ^ } ^WfT NOW ^ ] ^ 0 ^ylDypq ] ^ WYl ET ^ ] ^ YRLO OIOrI ] ^ ItlM PIKE NlEPCMAHO! ' ~ ^ ] ^ MAN:NO PPLNT TURN . E ^f00 • ^ LIOHT70N ^ • ^ Ff ASHM", NEO • ^ ~ ILOOPrPAMry ^ • ^ MANWO LETi TUBA • IC[ ^ ~' a ^ISF[CIfYI OANK~9IPPFT GHTa OfI I a ^ ^ 3 ^ FU9n'Ml1 AMPEA - ^ 3 ^ALLLY ^ 6 ^ MAKWO U~TURN ^ E ^ SPICbr R[AAGN IpINVI AC- Al OArlOL,1'ar:.Y,f rK y U ! L(r9TRE[tlgNl! I OTNPR h' ^ ! ^ PR 30NAL ~ ^ / ^ OP/IC[RrRA04AN ^ a ^ L!R fIMIN LANla ^ a ^ SLOYAND ,:". ^ l ^ OfOPPEO POR l11AffIC ~ Kw,CTMOYKKx gtrA,CIUHlttt1 ![G ^ A ^ OTHER, R'FpfY ^ I ^ Y:PANATEG aTGPPED AT:}OHAL I~ ^ a ^ OR STOP YTW ._.._. __._._-_-._. ....._.__-_..._ ^ ] ^OVMlO ^ 9 ^ 9tOrMP.O IN fpAOWAY ~, 7 ^ ~ ~ 1=r1~ ^ ] ^UNTVNOFU ^ 1D ^~ItiAif fOU[ I ~.' a~'. af1°"7$~~~-'. ~.. `rll _ i .. ~4 °tit~ ~!(.y*`?n•, ¢a~Y~*^•n± --'~, an ,.... ~~r'Bi~':.- ~ ~~. ;~; ~'FH. ,. I .,. i 7 ;C ! ~ ~ ~ ~c 8 6 ~ A '~ ~ {~~ , G k °J p~ ~ 4 ~~ ~~u r ~ . y a~ ~, ii IVfita~:Y ;~ 1~ " ..~ }i rti E ~? ~~ ~ ~n~ r1.G .~. Cx' ~5 ~ ~ ~' 1 a. i Ai ' k Y ~ a r~ ~ ~ 2 ~ ti nvr~y Y $~ "~I Ir f `k ry l+ "~ M I.~,..~ ~~ ~ . ": A:i 'S ..vr^~ 'mow 5 .. f~/ RL ~ ^ ` P rt ~ _. _ t j ~. 9 ~I ~~ F ' r. ,.. ;.. ~ ~a,~< r.1i'~ t.^'. ; %d 1 ~ ,.`;.r; r `n' ~' r' F tr ~, ~ T~ ~ x. f - ~ , e~ ~ i „ r '... ~ \ ' P~ > ~ `~ e~` ~`° i ~ i ~ ~~ ~ ~ s ~~ ~ :~; i ~ ~ , k ,~ ~ i ~ ~. ~ I v N ~ ~ Sa- ~' i NO 1~ p H p i !. I ~. 'CO p.- 01 O ~.m, // q do y T. rc r 7ti S,1' ~'3n' p S i 7~ ~ ~ {~ lf~~ n'M}~9i~ `i'kf~ a ~~l~1.~1``~~~; .~r_ ~ ~,~ r,. .:a~ y,~' ~y."'~. _.~~~y 1, a'~~{ _ ,r ~ ~~u ~~ 2 I~ . .. pryRr~p9 • p .. wi+~' { ,{.6 z ~~r v~ ~ ~~ fi A.' '~' :. -ta. . ~ ~°+H r' ~ ~ '` ~ r 5 i ~ ~'~! ' [ . ~W ~ ~ ~ ~ ~ ' r ~ . ,~.. .~_w r~s r ~rrrc nna '" "~. .rRi V4 '' t w54l Sa lafv r BDI % ~. ~ .'ll ~ ~~ -;1~ O STATE OF WAINGTON ~ . G[ , Or N ,-,F~ ,~ G~ ~r- C$`~~ .-~ D~9_ e. r~~ i J ~~~q~ ..~,, +. ' ~£. 1 5 '*, _~' POLICE TRAFFIC COLL N REPORT ~TRi~vlc~av O 2 _.., ~ PRIVATE WAV Art Of <O115 N ~ va FC qAl uM r w D OuHir . w. .o ~,. ,; stn ,. {., u . n = v.m ~ouv + v COUHfYrq CITY NO. rHWA S , O F ~~ ^ 090M1 RUaAI ^'N C r04 rOx'H fM1V0 Or 51 rtr Oa HlGn'rvAr v ^f / ( Roure oo sre "I.Ipv,fa o5 ^w ~Or ~ oN w f4sfei~N x, srafrl o4 ao•D NON fasr-r~GN 6 3 ~-yo J D errwfFH scorn a vacn msuNa %D4 r room 4fnvu, c4oss sraurov wAao+m if vov ACUOUft m,l vRer,% r mrlEVOSi ~r~/ RAMV ~ . 5 [ MILEAGE rrEr [] Gr ~ COIX DucaAm wrA eou SroH Nvonfn e rv OlAlrq NO vall[D Na~ ^SV IInGL ^HrM1 ~~ p vfn C,[5 C© v404Fair DAMAGr ONI• .~/ SrpfNUN D ^ 4[SUIrrD ^ vfn <lF ~,v , %~RD IM9 !r0 90AUOR 4FHRFNCt ~, IMFR Cls CaOa'SrR[Er Oa pOAD L C rl ~ j OBrfCr Sr4UCVINM.iOv I[C+SraUt. NrDOwN[aS NAmEI AG[ f f , ~ / SafCW CODING USB .T a UNIT NO.I Dvlvfo-s NNnt usr s, m n4 I l UNI N0.7 v TNAM ^ VEMICIE ^ PEDESTRIAN ^ PEDAtCVCtIST r. ~ f wv N4 ~ u n2 s+9[ri ADD4($s rn srArt rlv coa vHONF HO D r9ffr nDD4F55 yr F I4 Df ~" ~ 8 09rvfa COfvS[NO SnrS [ • r R ~ ~ ~ i O 03 : t ~ 'Z V rv u kN0 Sinrf Sf% BIRin ~' _ B oeeu.•nar NAxf avHONf No 1q-1- 19e15 rrrs I Hr Hr leHr f E cuvnoN Nnr a vHONe No a 2. (O-~ R ryes wemHr r reHr CHECK (.~ tH <H• a fwgovr[or Aworwiv Al ^ CHECK (~) 's`5' N COOE5 -` T ~ 1 S r a s,° 1 ++Or AH CODES -* 7 ~, e i c~n l airs n,M o..D p .mM1«,.H~r ^ Ab`l ^ £6.... ^ ~ i ^ . vf m .r IDODGf Cnty 1 m9Dfl10ARl NOVAI rrtE Ia04. s i p..,,tw.H l ^ n r A4 1 ~<H V I v E. ^ FS.rf. ^ ~ ~ ^ "::5. r OVn _ ~ ~ l E . I Y f I D4. V.1 - m w ueFNSevu+ H n ,F l gArF HO. H N nH.<ao4 A A A ~ ~ 1 VFHICIr rprNlr CA KKV NO s I I ~, Hg 4eelsrt4fo w ~ C L v(Hr if rDENH A I I I.r N I I I I u r M,DpIF vHONf NO O I ww9: {ASr rlRSr MI ae " ADDVFSSp orvNFR W - 2 q'(5~3 N E' NAmrM1•DORUSpIN ANUC ao •c N+ _- w.s.mt •au I R ~ r ~. Dw D4N•GtD~N M1nu CHA DCA CHA4GF wii oD n v + ` V c . s Fsr. D•M ~ ^ n^r, n•~,Alrxo ^,°lwivN ^ ea oun• f r~ f~(~ iow oer. ~ ~{ iGwTO r wrD r u.: ^ f A •wAr er DIAGRAM OF COLEISION ISWi YNfC[SSAa! Bc.araow DESCRIPTION Of COll1510N: luseswne f A+s.un rwnssA4n % ' i 1 ; "' ~0 - ;_ L.-} i. _. !'.- _ ~_vfiH~ttE.. kk l._.WESt .onT..Stsow C.0.ESK..RD . . 1 } f_~ -_ Mweozo 1..EFZ 'to Avo.o 0~a.~~.T~ Snw _ ~ .. , .; , , _L. I 1 ! I -._AUZ-yP . ti'z .THE Cofa'ny~so aw~_6~Rw~swZTO '.------- - -t~uo~o C:cu L ~ c _. . .,. ~c,.z pcx~..6~Nt~ w~u ..._.. _: ' , , i __FilovT 6Lxr,PER. 1~~ Q.NSZI'!E.J SV hMT6 ~ . i I .. ~ ~._ 1T3to -O~RK . .. 1 _ NAME. ADDRESS 8 INJURIES OF PERSONS INVOLVED ~ 'CODES I - 2 3 4 OCCUPANTS /WITNESSES ~°o::°o"~oti:ia`AM~ i~ ; 6 • Dr 15t ~- :.o ' ua1M ^1 ~. ~ ~AN M1 ^^~I" ^ "~ . ^.i ^,i' ~. v%J~ r ^ ~: A rc ~ ~ Yl^4J " ~ ,v ..fl ~ ... .;I~.. . ` ~5 r_i-~~~'T.-.G"~'~-~^ S: ._ _ . .. r.. ~ I .. ._ .r. , i iw 14w , r nn S I ~ r °N , # y~ P7 ' z ( e. , y ~i 9 jf r ~ a btS` ,x Vii' ,'t' <d 1 ~~^SY ~ JSR O ~ ~ YYYYr+h+ l 1 ~ '1 y~ F~ n ~ '~ ~.- ~. si .r..ic a~~ ~~ , 4 _ U~ x R, 4 ~+ ~ i w ~~ ~ f A~. y F. pp 4 ~ 5. ~~' T~ + ~~ x Gy C t~L.~. ~} Y€~~A~A.W ~ 4.12 „ . - ~.. '.1 .. +. i ~'. '1.;. ~~ j j~-~i y _O {91 F- 1 U W N ~ i W O +, F - O Z O r-. ~ ' l~ O ~ O i M~., i ,. ~ ',' F._ ~. ji,_ ', is ~ j i i 1 i 1 t i 1 ,~ ~: i ~ r ~ ~ ti v N 1 h~ ~" 4T '~f q.Y ~_ h' } N J 7! '~rr i~ :!S( '1 ~~, N amxr~,. OA, ~ ~~'~ - BHP t ~~ ~ ~ ~. , ~ _ .,r.+~(. ,, q.. ~' I ~~J POLICETRAFFIC COI^'"','ON REPORT /U`TRAFFICWAV rolR'r wMN R. ,, ' ~ PRIVATE WAV , ~`- ~ Z- 0_ E ,. pill - rr AlP• Ipp~ r _ _.C_ IAf r. N x.1R -i tufl iI~3M RMF IUSf RRODNOVRI COVNET NIIEEEYNO. CITY NO. {NWA ^ r 7 o i47 I i L ~r~~Y/R/ V 4URAl ' pN ^[ ~rN CIEY 09 EOWN INlfS ^5 ^W pOF - NAM f6N0.0514tFIORNIGNWAY ON ,c co ~' /45 .~•~•" ROUTFIXf i J 0/30 Sf 9 rN1evSFCEING VAIN: SIRFLi Ox RDAD HON IN1fR5ECirON PREiI% E MRE POSI S D D rfA BETVf[N SiRfFi 6 STREfi . I IANC[60rvFCU ivOm REEERFN E, CROSSSrRfFf OR NFARFSi MrlF V05 mnt5 N 5 E rift OF q[[IDENi MILEAGE CODE RAMP RAM MIA CIXIrSpNINVC%VFO Sf Vf4rrr: HIE6RUN HO O[rllFD_NO. INJURED- ^SPIIIAGF ^ 10TA wvovER,. 5 D INFER CIS REfI ROAD OR HffRtNCE CROSSSIRfEEOR ROAO ~~ - l CEVFNICIes ~ ~PROMRIYDPMAGtONIV ^µyUlfFD ^V[14irCl[ O O _ ~~ A/T OB1fCi SIRUCF INNAI OV OBI[Ci 519UC[AND OWNER'S 114NF1 [Si.DM1AGf SRCIAL COOrNG ICt 7 s UNIT NO. 1 UNIT N0.2 ^ VEHICLE ^ VEDESTRIAN ^ F4DALCVCl15T ~' S OxrvFR'S NU%f. LAST NRS, Mr IXF xNER SHNAf: NSr EI Mr qF FEr ADD4t55 Fr AfARESS on IAit :I4 co nwNf NO. R r siAlE IPC .aNe D Z / DvrVF4'S lI<tNYN /~ YEA,F O I • • I V n lr FNSF NO. Alf DAEEp BIRIN MO i [M OCCUPArrON NAmf6 EHO. FYfS IGNr NEIGNi E OC<uPAIION MNAME6 PNONE NO. FYFS IGNI IEIGNF -~ Z R pCNECK (~ rAS aN UnriorN OrAr~o,NtaAl pCHECK I/) vFNraFASgN Vn4iart[orAr of NFeAI _ CODES - * 5 I e y °~o°c' ' CODES - * 7 ~I < is 5 IA e y 3 ~i ro •E ~,;;.p. p .Mx~I.H[I ^ u6° ^ ["b':nP ^ ~ ^ .:°L5. ^ W.HA.Nff p u ~I p ~bmx ^ K <~t ^ :°t.,. mN reAR AwtloooGt.cNFV1 7 PoP/i nIDA4FN0+q srv¢lFO4..coNV.1 ~ ! 2t~C E H r 4 I .Nn.l MoaIIDARr. vq r I .1 - ~ se r v~ I tNUVw N s,An ixAnfR nAR HO. uA,F I v N « R F RF I NT. A ^ ` . A vl N CItIIXMINCAigN NO i v INrCIE IDEHrIN A r I l 7 i ~ ~ I ~ RIGrSRVIDOWNiR LAfI irv31 mrDDll PNON[rq ADO4fssa oA++tR W vF rs P wNt4. l.ASr IIR51 MIDDIE A IR 't N COS S / E F SADDRI55 V rNSU ArKf CO. AGIHF R I U i IA °M ~ - «" ~ "` OAMAGFO ARu ' 4 rR µ cNA U CNARGI r D M M ~' no. 5 IG ioneii eu~ oAmACt O ^ A ^RIMAIHID w:: ~ ~I[M/JNID iw^r UeA~e u~D , ~. s IOWfD S AWAr By ^AW~DBY. s GRAMO II ISION~ ID i '+ (j5 er,An BEN 4 DESC RIR11 0N Of COll1510N; IUSl3lrv4lEN3MAl SNEi H MCeS5ARV1 ~~ _ __ -- - - .. ~y - ~ - - d -- ~ _~_ -~tvi' __ /_- ~ -LOST ._Ctr1~S.KOL__~ _ _ L _ CDt.R16 OF ~.iJC. NORi7/ S/l1E__ 1 ~ , .. 1 D/- . T/fit J?A90 _ 5Ti4iCiC'//YG' _T~Z/cT S_ - ~ ~ ~- ~ T -~ - t r Jencks ,__ __ _ - -- ~ ~ ~ ' . . _.. r i f ..} . '~ii~f. I,-ii~~I~ I-~~ . __ __ _. ._ .. _ .. ~---_ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ' CODES 1 Z 3 4 5 6 OCCUPANTS /WITNESSES Ir u sunEwmAl srR MADDii~OHAl wmi n sr _ SI[ AGI yn NUn RESrR IHCi M Aml rq I awns yA ~R a nn e, m e ^fYl" O "' . ^~ ^i4~.. ~ ~ .IR D~x;w r, A IxuM ^.mR p ::%I ^~I,s. O H ^Y°'N5, n .AYf ~ W • D .,' wlu. J.Sr' a.lo:r D ~ c1'" nAKI grto n a ,wx, 0708&7 oArl ''~ /i t,',;; ~.... ~ "% t I L ~ ~ ~n~ ~. t~ ~rj ~~~ 4 tit 1 ~ e rN ~. r ~i.y ~t f: :.r. t _ - "~~r t:, s. ` ~ ~' •1 L, R it a J ' r ,~ °i~3~1.. r / 4 > . ~AV ~ SV l A ,,~ R I J ,. 1 1 yAjs, ~'i Jm ~ r ~ ~ ' I ' I 1 f I I A~ I 1 ± I . <I r~P {~ TI •!,', I ~r I ~ ~ I 0 ~ ~ r ' `~ ` :, r ~- ~~ ~1. ~'~ ~.{ ~~ x ~~ oG ~ ~'s ~~ ~. ~~ k ~~~6L n ~[~~ ~ ~` q 2cd '~~ ~ r( I r ~ wfl ~: ~ y ~ .~ ~. G F~ ~ ~~w~,' aN S:'~ r ~!!~ PULICE TRAFFIC COLN REPORT ~{'fRAFFICWAY rout[ Nr ~y PRIVATE WAY ~I r ' pateor y /.,y ~t, (!~ / / .a. oN ilMt w. + lus[s.ooNO~ eourvir ! ~~~ eaurvrr ro. /( i <In NO. EtrvIA ^u9eAN u9u ~N ~t CIIYORIOwrv aME6rv0 gSIPffIOR I9GNWar Mftt° ^5 ow ^~E ~.tcr-~~ ortLia~~ [~,.~, fCECIS !. gOptf OR SIRE '!~ o/3d CI ~, f NG Vnm srettrCO~R Soap mr~}f:JilG•6/~J K NoN Nle9sfenorv Bf1W[[N slRffl6 519[Ei rIR to. MR[rose O.0 , '~ D,SIA NCF6pRIMi Orv 9 M9trf 9FNC[ tR033 SIRFFI OR rvtaRFSrM tF V051 FS 5 E ff[i W Or q[ 1 M IEAGE CODE DI RAN OAIA cou sorv rvvavlD r1O [Rll[D~NO INIUR[0~ ^ Sv~l1aGF ^« IOIatNU t6RU N +" %RD i~.lf9 Ct3 ~NI N lI RFFI 99M009 R[vE9E [2035 SIRt[IOR WM ~ .3 .. Ov!«,CIFS ~ OROV[Rir DAMAG[ONIY ^ MSUtilD ^vlaCiF I tStRUCV INANf Or OB,[Cl StepCV INDOwN[9'S rvAM(I EsI pAMAGF JG 6% ~o -~ ~o LCT ~%-3 E -_ SvFCW CODING VSF _ UNITNO.1 UNIT NO.P ^VEMICLE PEDESTRIAN ^ PEDALCYCLIST ~ .3• s 9 Delvf9s NU.t~ s, fws+ MIp E S ~ ~lE o .l ~~ 0 2' f F ~ AME /2 r9L7 G ~-iZ l st9lEIADD9tss s wE of>s - ?? /.]C I q G~ / ~O /~ • slAtf n9coa v«orvf NO D I Alt .EDNf r ~ ~'~ R U/~L6-~ '371v l'3- ~ / vw' suuNStN start [. pA « ° I I I fr+se rvo eRl« o ut lv .~ D I D. ~ ~~ ' ~ / s~ ~i t~ ° acwanoN oySTElL Ic«I raw«T E norv m NANf a R rvo. ns wf G«I ~. ^CHECK (/J vf«clfas:NfMno.ffaArvot«feat ^CHECK(/) vf«tt[as:NfunorfforarvolN[val ~ CODES - a ~ ~ . ~ °' "' S I t o« A .soma. - its nc cu CODES - * 7 i si . is 5 to y w oxrn` in:"' nrov r n ~4 Iwwrts E.,i i s ~N, u i , J ~~~o~b .M9c,..KI p vf« rtAR M st DOD' c«fv rI ^2b.~I. O ~I K9 O v»:. Moo a p,N . tr E t' O ~b6 ~N~~ O~ Nt er ' l I + i n ID 91 Novar r. tlROe eorvv I y as2 ~- : t~ H I I MGpeI IRD ~ .., L ~ ' ~ aa,Z~ ~ ~ « O9 r DCENSER a E ° It Ait p e A [ «COIGR ~ ~ -//L,..~ lll~ - - ~ tJL' GJ3 77 lr/rt~ - - ~9 'a vewut nNl NCAiKw NO. c s 7 /~/ o~0 9; 9. ; ----- ~ L ntlofrvlreAl BL It7~.l'~~ar3'7ior.s- I vfGiSRVIDOWNty Ie°1 DCt[ vHOM NO L u,a.~ t°N t Srf RID [9. A5I SI MIDDt[ s ~E .mac O Il ODRISS Or OVMtR a 1 NFR ;~ NAMEaAOpRfssalNSUeANCe o ov a[:frvr n~o~Gr R L'ATSS ;i,;CFfSI "e„JG 5~ DaM.G[DAAU uw ~c +cloNN + ' S ~ --' " ssa c w ~ DAMacto'aRu v e' c«a9 ,S c«AVCf ~ .c~, ,u ~ O' o~ - S [Sl MH~. yt ~wwi,vN ^RIMAIN<D ~09w ~9IMMN[D rN IS s +S f tOWID < Awav er ~.J DWED ~[ AWAr ev. GfY~. O~ a DIAGRAM OF COLLISION: to 9 alt NO9r« swfru Niussu I eraRUO'W ~ ~ . (, ~ , ~ ~ DESCRI ION OF COLLISION: vsESwnEMfNlu s.a[ fenOSSaRrI .~aSL.zs :. vr~/ ~a ~ Nis s•-tea - - s , I o A S3 7 r6/GS S%o/7 dic~J /JT / oDe~ ~~ S ~~ - ST Z I eA , 6 ir . . . . ' L.~GIrL Le /nJTC /7vt/f/L %7olG _ NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED 'CODES t - Z 3 4 5 D OCCUPANTS/WITNESSES ioo :npnlEfri:iN: e'i i~ u. AGf urps 'w"I" " .'., wslc t,ICi ~~; wns L /r wlo~-0t - .Me p~ti ^" .O.^t ^CL '° ~ ~ r A ~ 3.%~.l 7G3 ~ ~ . - DUrs ~ 3 ~ .~C ~ ~~ u9 " M orlc I9uM ~ AMe ^.'°"' O o . O .", '° ~.i 7~s=3y~y - - - - - 9 I°v o ~1 ..ad i u~5°isG' C '" f eY "" [7 ANe ~ ; ~' ~ ~: wN Y I ~ x .c~+.,. ~.« e•err e9 D ~ A;ort. '"' lDS9. e ~~C D J~4,S2~ p°n 9Iro r .9o.fpe An :~ Tl irw.. ? ~ yd. ~~ 55 .r ~ ~~~ ~ kyp ~" . ~. ~~T e '.y s. ~ `'~. `lf w ''¢~~j' ~ .V~ ~ - ' e ra - 't ~ Dj~ ~~..~ ~l ~'pR •~ t 1 ,r ,~ __ ..,, # { 1~ ~ ~ : , ~ }~ ~~ ~ t L + x ~~,' 1 3. S f • 'r y ? ' ~~~ ,l ~, ,} C. f } rt 3 '~ X14 7 r;. ~ ~, ~I i/ ` ~ ~w~l ~a , ~ [ . _ ~ ,~ _ ~ ~ , s~ ^{ ~'g ~ p;[F N`. ~ I -. - t"T55, rt dfJ~i ., ~ ~ ., ; :f ~~ C> ~. _; fr' ~ -~"~ l ~~t ' ~~ ~ ~ ~ ~ n ~,. r ~ ~.,~ r:a '~ S t ¢N~' '1' ~+,j a - ~ ~ I ~ ' .~, ,+p i j ~ M `~ ~~ U '. I ~i y N ~ ~, ~ ';~ ~ ~:.. .i C ., H ~ ~' ~lr -~ r ~~ r ~ .~~ r~ ~ r r .,~~pp q ~i ~,~ ;~ r f .ia r~~hl ~~ ~ ,:~ iY 1 } y 1 iii V ~ ~ 7~1t ~ ~~ ~ '.! ~ i ~ ~ 5 i rf~ i ~ J [ ~ •' ~ 1 ~~~ ~ Its ~ 1 ~ r ir~y :~ ? ~ ~ ,fir t~ ~{ f n i '~ 1 ~ ~ 6' r ~ ti~ ly t d' r S ff~ ~'~`~B ~ ~ .1 ~i'f~ r', Il ~t 4l I I f,,4 ':x 1 '~ T~ SS~~'~T u°,didn ` Y ~ ~ Y v i 5 ~. ~~ ~ I e, ~ ~' EZA ~. I O DATE OFCOLLISION A DAY Of OOLLISION TIME COUlIff NO. CITY NO FNWA MO OA ~/1n11 E I y 2 L U J • IUL': EU A IRU FRI SAT IU5 /2rIP~4DOUn1 i: N 1 I f.. 2 0 W y U ll l l~3 J /~ ^URBAN _~ {- LOUNIY f ll ~ ^SlATEHOUiE COUNTY ROAD ^CITY STREET Q ADM CL'' PllEif% ROUTE OR SfRCET CODE RURAL SECTION _'~ E _~N ^OTHEf115PEC FYI ~ N 3 22aSV ' ~- N D, E W ^IN p 1'1//C~ITY O~UWN 0 ~ B ~ PREf1X EO MILE IgSi hRLES ^ ~ ^ ^ OF ... Fiti7NO C V O . NAME BNO.OF STREETOR MK: AY INTEflLELTING WITH: SiiIEETORR0A0 ILLY RAMP DIAGRAM DATA T. 0~ YL14rANT1~-lrJ !'Pl 'r4lC, ~ 1!.tut!-RYA !U T L O NONWTERSECTION .. JI N OETW ACCIDENT MIEAGE INTER LION X~HD INTE SECTIOG SiREE OR flOAD ORREF. INTER LLS. ERFNCE CROSSSTPEETON ROAD ~ EEN .... _ SIHEET ANO .. ._.... .. .STREET CODE zLQBQ OhST A1NCEAND DIREORON FROMREFERENCE OHL OS SSTR E i ! /A G E W S HuNlp~tlir,4 S~ECIALCOOING USE ~~ . O y~~, rI /I/ ,AI /A / ( IIN ~ L ~I ~ ' O"C~ ~ ~ _ . FEET tl.r I... li/TN/ L /U 1 OF __ - I COLUSIONNVOLVED: I--I"""'~"`^""` UVUiwIC~nIUrcLe ^VEHICLE~OSlECT ^vEHICLE~RR TRAIN T 11.1 Y-" 0 HIWHITEI UlnienUN ~ SEVERITY ._.. NO. KILLED OT OF AL NO ~ VEHICLES ^yEHICIE~PEDESTRIAN ^NON~COILISION ^ a,L(J . 0(~ ^STOLEN VEN CLE lIAZAROOUS MATER AL ____ _ NO.INJURED PROPERTY DAMAGE ONLY ODJEC flUCKINAME OF ECISTR U C K OOW EflSNA ~~ - _-- LOCAT ONOFO BJECTSTRUCK ~~ EST DAMAGE . ~~ , FS UQE7' B'~ ch ~O`~ LZL. (L o ^ROADWAY O FEET ®^ ^ ^ R . .. ;~ • OWVER9 NAME~LAST~. _:".,, FIRST_ ~,;~; :_ _-~:;.,, MIDDLE DRIVER'S NAME~lAST FRSi MIDDLE IV DICYCL Sr O EDf.E OR PEDESLHIAN CNE 5 -^ ~; ;; CKI CI ;_; . , . . ; A. ' STREEF ADDRESS.: .... :... .. .. R STREET ADOHES9 ~.. . V ~I~ ~I~(/TiLA///J~N ~L /1/Ci ~~ V ... E R. N crtr_~.. .. GiATE nn ~. ZIP CODE P ONE NO. OPoVEH9 LIC NO. .. ~ 9TATE, SE% DATEOF SIRTN ~E IV CTV.... ., STATE -,.: IVSa_<I t:cucc url ~ ZPCOOE ,: ~:. PHONE NO. ~~... ~_ _ _____... o. 4L3q 9 -sus]. rH 'il ~~ ;7 0. _ ORNERS OCCUPATION FIRM NAMEL ~ _„ _. ~ .. PNONF NO. 2 . , ~:....... ~. . IOOOMkiEH :., ~. ... .,... .. CI-ArT-~,.-....-. -~, CODFS ~~ 1 ' - ' - C C M AI%fRESS 1~ hSSf~.t.YeRS I I I I I I~ V NAru-nt by ~r M V ornou VUIIIEES ~ N ~ r0 A NAMC N - T ADIIRESS s ~-~~1~z" ~ «<syr~r,aM - -~ TD - yy NAUr _ -_ ~ Annnrts --'--- N u E TYU11F.7A ------..--_-._ - ---_ Fre.5vL6lTli>R.-'.____._ INE nY _._. _ - _._ __ _ ro S r _AVt _--_~___ $ A OOIIT% ___.____'_.__- ~__._ ~__.____..__.~_ 5' .r w ro ~ ~rNrTr r ° ~ r . : SL I \ I llrD w io zrr e AL. c•uuru ~ Irrr ttvTrA rn ale nl rL Iror[Irrrt O nl c si cL I ~ 1 ~ ~ ~ r I l ii nu I 1 . IL Ln o l i r n u E I ror urr urn r rcn E A vitiiss `.. ..°. T / l I M~Ti', .,:i ~Lr nr ,..+ , x l ndw.L J r . al i.nr i ~vv,r Gruru.~r . ii'.~ruiill lin V (7'~ ')AOACO ~1^~LLCST~ GN~~. ~I E VEN R IIC. PLATE NO. - STATE TPAILER PLATE NO.. Sin TE E VER COLOR d (~` V N ID N ICA I~AIg~R .:....,,. ...~.: ...... ODOMETER _. (~` vEnICLE IOE-FII e 5 R 0 Z- - (2 L ~ 64'g3 000 E - N HEGLSIFREO. WNEH-LAST,, ~.-,..: iWSA .~.. .. .. MIDDLE ~ N nEGIST EO OWn ~. ,~j?~ O . ADDRESS OF OWNER ... ~. .. ,.. .. . , . ,. _ .. AUONk53 OF DWI ~' Z NAME ANDA 59 INSUR kCO. RAGEN-S I._ ,.:;,.. '.... .... .., NAME AND ApOREE ~Q~~ CIIAROE ... .. IIAfIpN NO •. ,rr~~~`\1~'~ 'I1 ~E [!lfO M1/L.~~i ~'~ I ~Li-r I^ A RCEME CTION MARGE Ni NAME; ADDRESS & INJURIES OF PERSONS INVOLVED A E Rrd f. : ~ ~~~-, ~. ~~ ~ .~..- _ 'SkiT~"r I ~.. ~ .. R .,`~~~,. ~ ! - I .. - ,.T rf. ,~ ... ,. Y.. _ _. ~_ ~" ~~ y,~ N' l ~ VEHICLE DAMAGE ~ I. IN EgC11 V0%, CIRCLE THE NUMBER OF EACHOAMAGEDARF~~- A - ~'r 4 r ~ ~ ~ INSTRUCTIONS' ]. SIIgUE AREA OF SEVEREST IMRACT. ~ ~~ -..a ..• .fig ]. DRAW ARROWI3I TO SHOW PRINCIPAL DIRECTION OF FORCE. '~Q/ g'r-.ry _ OAM1IACED VEHICLE N0.1 IusE rNlssrnc[FPNSKtrcH NG paMauE TD iNAREnE,MDiDRCrctfs, Eic.l "rr• ~1 ~V~. L DAMAGED VEHICLE N0.2 r Y'T nt (_~ ii ~`ftYv._=J~~ ,.,,r• I~ N 11. TrwM ~-; $ fly"'1~yj1 N t `L--.-~ _ , ~ ~ " E ~+.. '"'"l ~ e•ENnror ErgvneE voImLE NOI a. `~,°u• - Ir ez o.,.w," E (I rI UISgSLIHG OgtAgGE ]Ix-~ SE liv OF DAMAGE.. IOTHEII VENICLEI YOi OAMAGEVFHICLENO] ~ W '»~~ )CJ FU On4L OgMgOE 1 uNT E V MADE I nRDUNCT ING DAMgGE : iHEnMVO AGE IEI~]pUTSgBLING pq(AwGE ] ^OTNER M. V. DAMgGE 4 ] ^ ONAL pAMAGE LJ OD OgMAGE A ]~Q GUNCi OeIAL DAMAGE G MADE ~' r • - ~ NO Oq , I~~ '1 IfD'WEO BYO L MA4E TOWEOOY EST. DAFAgGE a " ~"~ +"• ~ 10 S _ TOWED SY EST. DgMgGE s `~ Ws,- ~' ~. DIAGRAM OF COLLISION ~ D rD s ' I. DcrR.r; L I n ' ~ I CDR ~~~ . .'E na.DW.ra nowr.rurunet c ~,' I~ I I ~ .. j- AW ARROW SHOWING f ~ ~ ii"aEt iT rl' l1 r lr< - ~ - E l ~_ . L I - NURTH IN CIflCLE ,. D„ra..r~„ar.np,pA,. -- -~ I - - ,~ ~ .n , t . LiwNEi pN - - i- _:-~-~ -~-` , r i = r ' ~-. ~_ ~ ~ ~ ! T ~, ~' ~' ' `~ «°" - i ~ 1 .. r. ri, , IM. - ~ ~.,~ " I I ' I _. ~ C I r ~ ~ I ,- I -~-+ ~ 1 ~'~ ~ ~ r. ~ _ INfD ItDY C , rI ~ ( 7{ I ' i T ~ ~ ~--(_.~ 1-,~ - , L t_ ~i ,'o:l".°.:: I I ,r i I f ``,;,~, ~L' 1".i~t-f ` - f 7 I-7~ ~ f - 1t3Y~` _ ~x DESCRIPTION OF IINOICATF WHAT PROBABLY HwPP[NEpOEFORECOURINO ANDAy ER EC AS HCLUOE INPORMgTIONNOT ON DIA~~ vM* ', COLLISION .~. DISgBILITY, gEOU<EDVSIBILITY, PEDESTRIAN IOTHINO COLD CO STRUCTION OR REPARWOgK, ETC.1 'M'y E.G.OgI E _i ~ ~, ' dY, ', R ll f4 i.t_ / / - ~ij ~ LL.. = G. i~IJ 1.- /.~Tr N ; ~/rlt L.i. ~ fli> 1 Llf_'t! =7 9./ J k ~ ~•~'. .5 J 7 t.. ~ LC I ~/J !Li /! Gam/ l~l~_'- J_....-!1= ~1-!J.-.%.',!:~e:t-~~_ ~~ N _ .,_ IJ=„], , ~ < ~ ~ ~ c .~ c:'~/ Li'k'es 2,,i/~.:~tr~ ,p <-a_~_/~cF{ ~ ~ .~...~-~a _ a~r'~ s .~ ~ ~~ ._ - _~~-!. E. f. ~L[~_~4i1___.__.-__ _..~_..~.._ ___.~-___~ Y Oyu ~' r ~. r ~- . ,~ . ~ ;. ,.' ;,.. -. ~;; POSITION BEFORE COLLISION '~ - - - - .- ---~ of LANES '^9 ? ' `.IEADlo MILE rosrDR ~ ': sYEEDS LE f R eD „g1ti~ E Ox Si ORII GHW gMEOR NO. ~ ~ '., ,^~ ' (NONE ORfCTION r0 N INCREKINC OEC E451NG si LEO LLY AS VEN. J3; N t [ IARKED OCCUPIED A S- _: r itt ~II~ .l I ~~~_._t ~iJ_.+_ '!~-ut;/i i,u 7:.iiriC ~i~T• f ~~. - ~ ^ Li C sa~ yy `• ~ _!~ 1 i~ ....I I_.~ I _ I __ YES NO, YFS _ NO Uw t M.N _ U C7 C1 rJ~. p L EO. ' I ~' " -IrNPH- neN i C ~ - v r , I :ALONG . __ ___-C1gi055 NO _ V I 1 FD IHCYCL ISIW SU31NG: I~, ~SIOFWALK ]1. I ] 1 r~7 MARKED Sr jUNMA E O ESG ATE )I'~1if ~ ~-'-'PTO"-^~ AY SIOULOER 1` ICNOSSWALK L A CRO]yW L~ ICYC pUTE 10 E n R AO SUR AC WE THER. ....., ,CONTRIBUTING IRCUMSTANCES - _ DnrvEpN(nlcL Acro !. ~ I i t ICIIECKONFI ICHECKONEI ~ ICHFCKONF OH MOHEI ~I} I k,' H0.]vIMCLi I~N ~.Ir~ i Y I Df IVOEJ D NVOEj DPIVFR DA VfR ' 0 qN0 ~' +~Y ^ 9 I-( 1 --t r_, pr] rIND.] I~ L_.JI~ sTIAIGNT AMIAD ~ ~~~ q r O Y 1 r CLEAR CLWOV (~-nll'- UNDER INFLUENCE Of 1..JH l- T LS QSEty _4>~-T~ ~ ~GRSOP FD w~ N E-'7]('~ i,- - ,f.\, aDVCnCA3i_ t._.~ALCOtlOL )` ] E_I u ~tvjD 16bIInG ' Y ]~, WE ] 4<JI RAINING I ] UNOFN INFLUENCE OF ,y I O E CENTER III APPApENTLY r RU45. E n]r~ MAKING t^ ]~fNOW ]~ OWING r( ]I~ [%C[[D GST TEO ~ G O - Ial-1~fSELEf RIONT TURN N I --~ ~~.L.YLfO II .L ~y yGN. ~ L 1~40CATitJ. fAN_~_~_ ~~,~~1~1 MAKING -1 (~ -"" ~ llYT TURN 5 f ,t/ i 1 ~_!. IC[ I..: p0 __ 1 \ r 1 [%Cff G FAy ~~I10 I ROPER r ~IEL.I pEfR T O t~~ I~I.•, MAKING SS . ~Lr _ E fFj. EFO I 7. TURN- EC V[!O L~IyIJ OTU11M 7f~"1 ~6 ~ y t ~ I Iyt~ DONO G q l DSNEGARO 1 " • .~ L.J 1 ~ -1 r 71 NEw ISY[CI/YI O1HfR IYECIf~vl - PVE C [ Ik.1,31DYA,4D lIftHT rI..rllr~-f ~6] SLOWIND ( 6. - t ° I~1} ~ DISNFf.ANO STOP 1~°I I O ER FCON I ~ T`~ ~TIIAM6C FOR " ;~ '~ ~ IGE CgND1 T10N5 igAFFI('CONTRO a TYPO OF ROAD .VEHICLE CONDITION. ' vE ncu SOBRDN[cIi'oiAei I.._1 ~ rtfl • I O E C E N0.] ICNECK ONE ON MORf ,,{{ xxpp LL,,ppyy ~ I STOPPED AT fIONAL ' ~ lcgrcKDnlr vE cLE b'~ °I~ oRatorman ~ ', '~i r i f o] 7 c~'Ihi~r7tdol r Hp.) fp v i 1 _~ S N LS- ` 1 ONE r- LLLL __,- ~_ f- 11fr 9l EIOH[p IN - I A rcnr ~ 3]~ ~,SroP nogpwgv '~, I ... LN .. ~) 1 MO _,.. J AI _ ~,. ~-1100 6TAPTIHG IN f 1`~ DRAKES E.. 'V r~ IMP REO TY D N_._ ]; Sr4N r ~ /10A 6 lF ~ I)I J-11tAP L1G1113_. I I]I ..NOT MP.EAIRLD_~ ~ I I ~ ~RKEp fp]HTION F 4r ~ I ] W]K 1' LASHING I NT[ f11AN4E 11'. I Dl IECTIVF I ]I ~11 II[D SOSp IFTY ~ 11I~ II SFRGINODI(NTk'111N0 1 - .. .. RLD ..,IOWI ...fICAn LO ii I j. I UNK._,._.._ L_JI)I _J illArilCl .. IINU ~ ... I .. ' .-'. p If ON EE ;°., E01 1 '. ALLE ..D SM OI1. OnTNKIND I _ IIEi ' AC%IN6 v is au Er .°. cN L s ~~ r I ~~ Irw.v •IU NOVL' ~ CHEM. TEST - I' I ! 7, '„~ I N'""- EI r P o r D rlcrn, ~'~FcZI'tiF'if'- .. I I~~. !'iC ~.. ~. /. 1 I ~ 1.-.I N • s l l t IlA4MAN AruRO ~ ' ernrn lsflnfw ,.~~ / ° IIINIH _ 1[ff4 IN ~ - > 1010 ~ NO UEf ECTS 1 ~ I i if ST l1UflU Y 'L r ~I r O ! f [~ I tnir. 1HIIN SrrC lrr ~ h ~. ° 1 rw MD M 9u T[ST RESULTS T rl t c[ S ~ •IwlK.t. NU I. nI U " I IrI1 F ~/ CIA IvIU II~LI IMilIIICILOw t /]y i f )Am /: / ) I )Am I DlD 4§Tp1 d11y~p1 tl `r I 1 't Alr (tI SNw [•NAhK U,L hI .l ltv I 'i~.. N 3 ~l I1 + 3 1~' ~~~__ I'f Ni. !v[UEY -. ] I A ~~ "r.~ I sv n I oq rr r, Nal c s. I ow r oN.T TE numL n[rMYIn, Y.ASrunrulN Dnsrl •• 1 l" a- / 3 f 7~~p~~++I~a ~~yy~~,, t AIt L'f L<:ALIAV/I l CI INIA tNl CO 11 IPI CArf OpY~ I~NVE ST OAI411'9 CU Y t 6 ._ ~ ~~~ } 1 1? I ~ [ ~1l~SF'~'S4~•~ X41 lr ~~~ {~ •... ~~1~ 7]11r'K!.tL ~lv~~fr'T I 1 Arr II 1'L~,~i~ i~. a ~~ ~, ug ~ c'95~1 L~+"~~1 d. l t . ;o Y~ a ~ I 1 t r ~ ~ ~~ ~'"~ ~ r 't ~ I ~ ~- ~~' 1 I / ~ w ?Is+ ' i~ ~ f~~Yy~rS~pti~~ If P~ c r~~~ gar t~~~. ~~,} r~ prn l I r I till Icy y'~> d'~ r . ~,1 ~ 11 ~ r~ 1 ` M ~Lt R~xl [ ~ 1 ~.F 4 f} t f ~ a ,,f' I ,I', 1 s . ~ ~ r 1 ' 'I ... - / ' ti ~' T l S T" ry l~ { + C I 'I I Y.~,L l Elf 1 I l I'1C Y '~1/ 1 - ~~~~ 11 Y ~i/(! I P':I r . ~ .... t e,•.. ,: . Y. j r f f I ~'~iy/ POLICE TRAffIC COLD JN REPORT ~TRAfFICWAY fOtlcE .AWrNUMEER , 3 ~ ~ PRIVATE WAY DAZE O{ P[ ll t 1 1 / 1 q 1MF COVNIY O Wv vRN MB n n.1~_Lr ~SE}bO N011RJ p /,~ . G ~ COUNry NO UryNO, IG ^fURA Uvµ C11YOR tOWN ^N ^F ^IN AMF6N0 Of S(RFf10R NgN'NAY 7 % MMES 5 pw ^or6 ~ n ON ~rrt M,<, WEPSf ING WI vflf OR ROAD NON INI SF 1 it CIS qWf 4 I E3 ~42G0 as PRffIX E MIU!POSt ~iV000Oe'i(i~.e!'A/ G/li BfNRFN SrRfEf 6 SrgfEt 0 OB DOrµ1CE6 IR F qU F CROSSSrPf OR NfAPf3 MIIE ACCIDENT DAMP DI•GRAM DATA MX N 5 F W MIEEAGE PEEr Of µ00E COLL15gNINVOlVEO: fvltY: W ~4D t O4 OR t ENOt Otµ NO. NO. gIILFD~NO.INJURfO~ ^ SPnUIDE NI wNDVevn INRR W CROSSS1MEt0Rr~ Ap dVFN1UE5 ~ ^rgORRrY DAMAOt ON1Y ^II SUITED ^vF~iCIF G¢ZYO - R as ~ OBJECT StRUCV INAMtCV OBJKt51RUCX ANDOwNE43 NAME) tSi DAMAGt SRCULL COD4xY VEE - ~ ' UNIT NO. i - UNIirRNO.2 ^ VEHICLE ^ PEDESTRIAN ~ p PEDALCYCUST ~ s DPwF4 NAME: usr 1 . DR1vf AMt: IASr }" - anes W }~Ro ~ n StRE AE RtE,MD9 f55 ~6 Bx (oo o l~.vn.4 U Y 5 AIE ZIP CODE PNONf NO D y Af X i C b 99.53 ~ {• .. / R ERS UCEN SrAfE X OA IMIN I O lv NO S AIf % f b b^AI/JCStu_ByY'7k/ Wb, ..5 I/z ~'S(c `/ MD. I wY I„E r OCCUPATION P1gNENO. EYES H.Nr NEX:Nt E UPAr10N FIRM NANf 6 PfxNRE NO. EYES Gf111EIGf11 Z ': G z ~~ R .^CHECK (/) vffaaf ASAfL rMriV1v N ^CHKKIP~ IMNIC EAS AN FMMOVFf OiArROt 4µ A ~ CODES - ~ D a• • isn s t Ecuav a *$;$ `CQ CODES -+ s niiY ~ iinr"' S fxclnN a ,'"0.' ' ss' I s Nry a 2 ~ ~q v 1NJI lf I ° '°° 3 ~«:: ~2:tKf o2s:,EP o~K„ ^rsr u;o..DN ^PNf1A.,Kf o~<E o~:a. ^:;4zFF ^:~»,. ^ ~ F E~ E VEN. YEAR IAA[ E NOVA) SIYIE E}DR..cDNV r I .NEV.) N4DEl l}l~ vn! ( 4. .) '° Y' c /~!• `7 (v ti e v ~•o ~~o ~ o)fe '% E Y ~Ae G ~+e fE'.j a S Z ( u uaNSE PEAT sole afR RASE NO. SIAI H vEN.ea R ` ~ m% L3t3G wAE ~ VENICI[10EMIPICAIVxR Np. L VFNrUE1DENilI I 11 3 I Y 3 P.,3 y'9'9 B 8' I I I i i I I PIOISRPFD 1 OWNER: WI I1RSt MIDDIF PHONE NO. 1 RD VM IASr f1R5r M1 D1 1E.7 ac lie a•.~ ~ I ~ ADD4fss or ovmu W A MR 2 !RO ~ ~ ~ ~ E F E.N4 NuAeeADDnssar wgANCECO DRAee . DAMAUD u " .P.D NAKrvwn ~ ' " 16 Aau I O1 CNARCx M,~ n ,N c g Af I f /~ 13T ~lC'tE r ~ ' ~wW YN pR1AWNF0 ros D f1 DRMN ~RfMNN[O LJ Awer t1r.DANAO! f STOP _ s 1Sio T'o1f S d ~ ~ eY •w ~ P ^ row[D A Ar er t t ~ DIAGRAMOF C:OllI510N: rD 1 cirtapvm 1 ~.-"~ .... sweru MasuRYl .._. e ~' ~`v= ~ ~ DESCRIPTION OF COLlIS10N: ID5[surn[AVMUSNeeruueussw 1 ~ I~elt.~ #~ ~ wa g C/ ~a a Q % s ' P'l~R1l - . a/aek : O . ._. oa. tf._ cn _._ u.eK 0.h_._ ' ~ ... ~. ~,,+ .,- IJ ' ~~ /09 F[P k.O tl~. f. 6 RE oih1J fl QR47~f C4~P_~4y_. 1 _ . .. ...: , `C~ ' Z e s o sI 1 ~eA. t frr~nE. I[a ~t fi / .. ~ • .0 _ .. e . ~. fe --. cn,Estaq- h,/ih.t .~o Ao/~_. OvCK re .. ('mfaE ~. /e~< .._ ~ 5e .. ~ 1 .: I _ ... . .' t r I ,.. _,_ RA ~KIC4 __ _ ..._ _..._. _.. ......... ..--- ----_ NAMF,ADDRE5581NJURIES PERSONS INVOLVED *CODES 1 ~ 3 4 5 6 OCCUPANTS/WITNESSES ~~: p^I1to~N,"u1 r~.AV"E lsi st>f~ Ace urus ~" v" ' - ~ - PESrR exec 1E: „ NAMe. 471~r OS o " N o AoD.f s o Ey ,~, lnq r +• • r ^ AM w ev e. ^ 231" ^ . ^ C1. ^ C4»o AX. •mnu N•ruEOr ... ...- 4wJVro EPOM oNAe ^Aac1 ^+u. NA,1I r .. Y . o a: ^ D fa • - N '~ a Ane4PSS x ~i .. ^AMS. ^ .: 1 ^ o w; ^ ,A W~n nuACa et. fNwa eEU Ot .efACY fur e s to RD vED D•~Ea Ero• Af.towoar DAR X ~~' se o D ~~'~~ ~~ti~ .~,,, $ I _. .y41• .S)ii.:: .i i ..r•27.. M _ ,. e . .: I:. .,. ! ~. ., .. J:'..•H ... l., ~~ J:.~ .f.`. c:.(.C:iJ ~~ ,.. nkn k ~ a ~ ~ _ ~?' ! - }: 17 ;~a° ++ - -1~' f ! ~~ .5 ,~ . ~ '" ~,ES~„A~ _i ,~ ~" ` ,,r~ ~ ~: f ~, )~ , {~j } ]' ~ ~rrA~..~~ .J+AZS7 - :~} .. ~~~£~~ ~ k~ L I ...7 '~ zMOTORVEHICLECOLLI510NRePOIzr ,~- r'x. --Y^' I~ ` - ~ [OLLAJON•.. 1y- .. DAY OFmEU OATE~ FC Oi u0n i - S •••. SON E RMEOFCOW - a Fn a+ Es AN CITY NO ~ 1 ~... v ^~igyr• Q w g . ~ [ V C ll ~" WTY'.~T+.. 'r:an roWTE :^,.:: ~•,.... :,: 'OU11W0E M N.ES:-O©•:v...-.~T.:.T,Gn. TOWN'. :~~.+r ~ AOMt9 PREFIX.. artORlrREET WB 9ECTgN• I .u:« xrw ~'. rSor u+LC eM~+ a µ ©© aF <,a ~? ,29050 ~, nOAOG .:..., avENAMEOP SIREET.IgAp ORHgMWAY,„:. :..; ._:.~_,NT.ERSECTWG WIM:9TREET OR ROAO,;,:;.':.u PHEFO( EO T MILEPOST }YO~~.I r t a ~'ED ~ur~e e Sf~ecrf- Fn, w1~J Ic ~:: ...~ ~>x NONINTENSECigN~LOCPTIONOF COWSION MMP 4j CIAORAM DATA j ' / BETWEEN ~ STREET AND STREET s _=~ '•~' ~+ eqr N^© PfiROa~ Er.n n n0 ufR.aNWE O exOSYiU MlEV09loAi0knliruKliAnO°Meµx ~ ~ aSfElWn' ©® iEE1 NON %RD I'ITE INTER CLS ^ SF s~pff 'EF 0 n0^0 S]S/Ldtb/DI , HOLE VEnCTE ^WwctE DCVGE ~OrnERIWPoIEI ~ C045gnNWlVFO 6PEGGODE USE '. Ofvf c~ES ~ ~ Z wNELE OEJEti ^vFnOLE rRAW ^vEnOLf NOESIH+N OMW OLUEOx ^nTNW , ~~ ~.• OIMECTSTRUCN ~, .. INwE00!%Cf! KI. ~._.. .. OWNER OF OFUECTSNAME 0 E49 ~ IN HOA UWAY ~'- ~ O© °P ~n90 `/ ~~ L C ~ ' li/ FEET Eon DWVERS LART NAME FF E P rvA CfR9 wERE Wµ LWO Ea«En pRIVERS LAST NAME f FWST NAME MODLE ~.. (3ct E cL•9- c 6TREETApaIE ~ ~., ROUTENG ANO BO%NO... ~ ' STREET RESS ~ ROUTE NO. ANOBO%N0. GtY S AT ~ LP CODE P E DPoVER9000UP TqH ~puSan CITY STATE ZIP CAGE pRIVERSOCCUPATION. ~ , ~ ~ (/! ,L ~~~ ,~~ TT:.t/cK U'B°. REPDRiFGRM ~ ~`•eo 3 +~/ 93jb l/NE/n/~~cy~d • TIVEPSIIGENSE NUMBER .. STATE SE% GATE OF F%RTN AGE Dfl1VER4 UOENSENUMBER STATE SF% DATEOF SIRtN AGE WR-tZD~-k-C-PISOY'• t~~ ,~~ f wY ~fAa 2 VEHKLE YR (v5' MAKEICNEV: OOOGEI .lie! t1Ac MODELINOVA-0ART) BeptG~ OODY STYLEIE OR] z.DR. -. VENICLE YR. q/ MA%EICNEV.•OODGEI CfJ6// MOOELINOVA~OMTE Pck-k~ BODY9nLE (20R) ZG'T LKEN6E PLATENO. 51 E. -: TPNLERPIATENO. ~, ,.:. SigiE CENSEPUTENO. STATE.'.. TRNIER PLATE NO.. .;;STATE.:.. XF PyD3 WN, ~if '73.3 WN. VCHICLE IDENTDKATIDN NO..., ~_, , IIBee MOOELSl NEWER( OOOMEtEq IMILEAa:) YENKIE IDENRHCATgNNO. (1086 MOpELS]NEWERI METER IMILEAGEt /egsyL~- REaSTEREDOWNER (LA.9T~FYISTAAIpOLENAME) ,' DRNERSUCENSE NO. ~-d L+~d Z•1F.£i~ :~R-RD-:kL-/SO9oN PEGWTEPED OWNER ILAST~FIRSTAIIOpLE NAMEI_':'. y~ckc,~ -- pRNER9 UCENSENO ... . OwNERlAGORElS,:::.: "...„ ISTREET•CGY AL~DSTATEI ~ .. ., DATEOF GIRTH OWNERS ORE6S .. ISTREET,CITY AND STATE( ....: •' GATE OF ®RTN ?E ~ d+u ~ i Y arLcENr- ,F/ q 37 YE YAHTBOFVEMKIE UAMI-0EO - - Dco'Y Es - ''-' SEOP E°`~ PARTSOF ENKL DAMAGED - ~ ,. rf°cOyj,~ l.. EN~e7 'r3cL.yyT. EY s.P '66 ~v( WAS THERE AUTOMO&LE UApIUTY WSURANCE SUABILITY INSURANCEINFORMATION•VEHICLE NO. 1• covfnAGE wEFFECT FOR THIS ACGDENr CN rpuR CU+ YII VES ^NO F VA&UTY WSURANCE COMPANY./n -.'~.. :.. .TAME ANDAppRE690FUA&UtY YEgRANCEPOLICYH0IGER - NAME(O ... N -+~ 5 ATE SP I ~ e F ~ ~ 7` ~//.l a . U (- /~ E L ^~ I NAME wIDA00HESSOFLMB%ln WlURN1CE AGENT,, ~,'. 6 F - W&UTY POUCV NUMBER f3 B•l..fler ,S'Ams /G •rf cu.E r..fcA+/d k/A/. ~ /6/3'•• 35,5'.-C;i;~- 3/713 1ST NJURY ...; .. NAME - ~ - ADORE59 _ _ -_ E.,~F °NWE bloNt -- _____--__.._.__ _ AOE E% -0--~ f ~ ]NOIN+URY. .. L 6 .wATEPERM IORAOD KK+4 W ~' AGE .. NAME . ... _- ..... _~_ __~ POD ESS _ . __--.._._.__- M A ° /VGNC - - -- °-~ pEx:rau .__._.___. a _ "EYAExraP ® 1 rocla+i n^M[ ~n _ ®^ N^NE E^^ lTATL190F WAURED (]pYVFA WVENKIE ^ JE Jn ~ pllED M,WNFa15 pl+Meq ~wvEnq T ONE TNAT APFLIE NW D9ANUxf MwOPI S. PoSYMe E COYC4Ewr STAfUSOFINJUREO ~pyWa IN VEMKLE. Q KILLED NO ~ MARK FIRST Ois. ^w0 IsEV[aFl ONE TIIAT APPL E NOn ON ~aLPq IVVVOPI 9 pE E h 0 E; ^N oN.An r ^ 5^ e^ ~^ D °~L_J1~-yB e^ s^ 7O WaRQE ~ S.IOW NORTN OY Y NUM -' OESCRIBESELOW WHATHAPPENEO (REFER TO VEHKIE 3 B B EpI '.,, :. i ~ rl.~ ` ~`• N.f i' ¢e e fuco 7 ~ I e ,~ ~ / 1 n( y_E{Tf¢L6_d!Z k1AS ~t,a.vEGin~ .(_V__T-HSf' > ' ' ~ ~ . ,mss ~N ~„a „~„ „„Ge AM fnDW \~ Da1GXP.EY RMKL.YAAN,N Ohi ~7G ONc~I <i.ON~ -#_Z _LOSf C- fo-r RoQOL,-C _Sc,-dd,~nr .__ D+.r,~cfG y._ iYVfo T.f~ _L?r~u~'r J_ d ~~ Q~" f '~'~~ ~,dE /-..- --- o . _.occr....(iEhrcGE ~ ~- _- s n o = ~~YE _G~(AS._SNO[/.. DIEL._YOCLd_L..If,tl __.-. Er/ r CoNd~'fioa/s v riu/N D ~7dEc N4 J ~ wAy ~ _ _ .. . i _ 1 _ _, .; - - -~! - -~~-• ~ Gp $I .. ___ .._.. _.. ._ _ _... .- - - i D . ; Ii MwfrEn».~.. ~ _ ~ • -~ - VEHIGLESPOSITIONS ©EFO vfHKft N s E w RE COLLISION oN Sinfcr on wGlwar rufae oR NO aL+n1. Nfwf. ! °NVan VparLa ro vrncLE uAm.ruNEn n0 .+a.ED w+f vi~.cLE OCawD .u fivfsgaicD pr ^r+tnEx ^va ci "°. I.~N ffS1 D D ^ MuA/ i X/fv 1Pfv:r / D D ^ D ^ D ^°«KE ^~°"~°' "" 'DID., ^ k- ^ O f /o Qr/ fu nn Il Nn i ^ ^ ^ ^ ^ ^ ~ fKfNEI nue^`"" ^ ^ ^ D ALOND c~aww rRDM DIRECTION TO DIRECTION PCDCStIeAN WAS USING 1 ^ f OEWKK ] D WIINW AY ] ^ SrgULOER A ^ ~wi%.:wNx E ^ ~ilniiw i~x a ^ O711fR IgADSIUIIACE fCINC•LYwI NKII 1 a YKAIHiR L 1 ^ L(f.~iK VV WNtDO'IDt10N! 1 ~ pArIKNI TIIATfK CONTROL IcMCx dII KII + ^' I ^ SK.NALS nPE OF NpAO N'.VReM1 ~;~Mf D' L D ONF WAY OnNFRIVEIIKLE ACtgNN v .ell f IC•KGa OYe MLKI11E1 ®I L ~ G(NNO 6TNMGNT NIF.AD D I ^a1Y f DIUPANf1 t ^DAWN ^ ] ^lIDI'6IGI1 ~ t ~iWG WAY ^ ] D GVEREAKWG AND PAlSING ^ WET ^ t ]~;MOWW ] D WSM D ] ^ YIEID iK:N D ] D ~M VIILL' D ] D MAKING ItgNf TURN p L I ~Y ] yy vqw E ^ fOp E ^ IWNSTCN EE ^ ^ ^ flA4luq RED ^ + D Ni[IgIMNGE IIAMP LEX)P D E ^ MAKING ICfT TURN E K[ D ^ OIHEa OTR{R ! ^ I'+PFCIFYI (-DARK SinffT ! ~• lC ITlOIF ^ ! D ILA,',n~NG AMNFR , I I ^ 5 ^ ALL[Y 6 ^ MAKIM U~TIIRN ^ ^ ] ^ DPFGIY a ^lt1IF~CAITO ^ ! ^ Rn UGIAL ^ 0 ^ li ~ IIUILN L L yy A ^ SI OVANG I'CASE1N fOR NOT 6lFYq DANGER r ^OfHEIE GFY ^ ! ^ OfI K[R•flA a4AN l/JIES ^ f ^ 9i01M•E:D TOR iRAiEK K+w'.IMOVNAtY L•fIAKrXwf TIE I IPE // 2 g ^ A ^ ON t PFC II ^ 1 ^ JPMAIED nvmEG t ^ al0 Tf0 AT D+WAL ^ ! ^ nn AIDP AInN ^ p ^ storofoWlroAOwer $u•d:~/, fMAP Pk/(%C~~ (//• .. ... _._.__ FCC m r a ~ 1 / • //,1 L A E D f ~I-tA"J + J lAI ~ o ~, ® ] ICI uNNV'D[D ^ 1° ^ to zinc LuIF A ..~,.-. ,-.,w-...,.-gar. ,,..ana>-..: f .f_1..+,L...Ci s..~•nr..,'~~..rnnM, .................. > 'TF+i~ iu v`F ~ ~ ~~ . ~, ~y ~: ~~} 1 t ~ r~ T ~~ ~~ ' ~ y: t., ~ ~~ ~ ~ L ..; ~.~~ ~~k kl ?' ~ b~ r~ ~ ~~ .~ I i 1 ~ y ,x ' ~~ 4~ {f! ~ ~~) / I ;,1 r 1 ' i1 f ie>! +;: _ f .~I L - _ t » ~ r z t ~ ~,~,'..~, rltJ,, r ~i } -, s.,. } • r 5 [ ~ : .; f ~~. ~ Z 4 ~ f f ~ t 3 ~ ~~ ~R ?. 7. ,ei~rr ~ , ~ ~ I 1 -! t z { ~ ~., _ . rq ~7r ~, ~ t~~t }j { ~ ;~.. Nat ~ < ti l t , ~ ,. f i'~ ~ .. ~~~ ~. j I~ t ~ 1 ~ r tl ~ ` f 3{ ' - ly Z ` ~ \ ~ i. r p,l ;t . F -.~ J . 1 C ' ~ ~ Fem. '~ r}~r j ` ~ 7 a t ~ 2 ' ~~, a~ 1 ' 3 yyp~~ S r l~ V "~ 1.r? f. ~ ' rytih~ ~V ~~ c .ti. ,. ~ E ~' c~:. ~ l ~ ~ ~~ } r r~ i f .2,~ i..l i- t F ~.. , s, If' b ~ F~ ~ A ~ { •~p ~~ ~~ L f ~Me"`"`~, ` ry _ !O ;` ;,~ '' i ~ O i .i ~( Y .. u 1 y i O lr f~l N O .J~O 1 1 OHM O~OI ~. mo a, rno ~i ri N Yk` ~.+w ~~~,A7.8f{f ~a w r~ L ~ ~ ~ ~ ~~ i i,1~i~1~''{"lf~ti '~i { s 4'AH~~ ~yyq~ r ~shC ~ i~ ~ )1 ~ 1 ~ 1 t ~ J S t r i t `~ kh1 ~~~ ~ t~ i r 4, ~ t ~ ' r ~ ~ >~ r~''~~.t~,~~'~~~" ~, naa=,'~ ~ ~~'~"7~F ~,,~ / ?~ J~Y l 1 IT ~ } ~ ~ ~.. RR N 4', J ~~~ ~1 }} h ~~ ~ ~' ` ~~ a ia•;t a Il _ ' . ~"~ ' ' ill _ ,5~.~. . M ,. D.>f ~TRAEPICWAr • ' t ND. __ . POLICE TRAFFIC COLLISION REPORT WIKE CUM%AININLM15f9 ~ PRIVATE WAY ,'d'j M , t au N i/'iv ~'~ _ T IME 311: rYl" IUSEICDHWRI W'~" I '3'i ° rpuNrv ~ 5 ? LnuNrrNO, /G crrNO.. ~ ~ ~ Y sHWA ^URaAN i ~ i s4i ~4 ">L>.<<. 1 9AE { /1 ~ ^N ^F ^IN p CITT Q4 TOWN NAMff NO pS1R[El09 WGHWAY jC, AVIIS 5 ^W ^O{/l E,; ,,,,.o oNC(,,I , v;4/ ET ( I I CES 90U1E0R IY /~ / ~ 3 zo7%!/ ~' SF ]] INIERYGIING V,riH lrREF109 WAD NpNIMFRYpION ~ F' ~ • ~. •r ~ .~i / ~ • eETVE[N SL¢Efl f SI9E[t p9Ef1X f M%E WST ~ ~ ~/' /~ 1 OISIAN aD M feE ,CWSS SIY[E109NW[SI^MI ACCIOEN7 M%ES N 5 [ W / / •%/G+ EtR '0{ ' r ~ )N,• • /:. 'S I L' A'CODE E ~ R IAG9AM O•Iw COlIISK)N NVIXVED: F911Y, fO1M NO. ^ NO RIIlD~NO.IHN9FD~ ^SPIIIAGF ^ UN ~ WNDND,N " D FR d3 E RUERFNp [9055519Efl0e R0Ap n - ' pvEHIClES ®PROMRiY pAMACEONIY ^ HSUtrED vin ~ .$~P(~ /L~/ ~ c Oa,[Cl SI9UCR INAMIp OBAC15r9UCR ANDOWN[R'S NANFt ESL DAMAG[ SnCD4CWING USE S ' UNIT NO. 1 UNIT N0.1 ^ VEHICLE ^ PEDESTRIAN . ^ PEDAECYCLIST ]' WE NuAE: I nfr NA,fM,.~~ wv E / SIe[f1ADD9[55 11 %. ~I Ll 17 ='/~ IJiL ..•i ri,~ REEL ADOgE53 .5~ i ~ .$ k,' .~C: ~~ ~ ~ UIY IAIE 21P CODE NC%rf NO. ~ry.: //in E L' ~: 'i:: a 'J~,~••N/?y L.+ D R IIY AlE IP f },: ~ :Ei ~: ~ G, ~ ~ljfi ~ lE~ • ^ /;2 `/ teSUCEN N rAi H I e l NSE NO AF % DAE a91H ./, • ir1 x01 D / 14 ~c,'s' ~ c%I "k t' G "3 A P uYi, rn a i ~"al:~ .~~ / a occurAlroN NRM N•MEamoNE NO. Ens 1cNr {LwM E uewnpr 119M NAMES PNGNE NO. . tns .cNr lLwHr ~ ^ CMECK (.~ vrN~ ws •H rMnv~vr •NOm[q~ -r CODES -' 7 ~ / ~ ° "' /A s {XC aN / e fw ^ CHECK (~ vfH LIE wsAH {MnovEEpwNO1N{ems W, / CODES - + ~ e ~ i s Ef e w ,?n ro 2 wes /V I I K7:r a wxwAgN[I ^ ~ o ~a:p ^ u ~ ,rOx ~;~:: o,M ~ ^ ~ ^ ~:~ ^ ~ rug KU ~ VIH YfAR MA%f IDDDGICN[V.) l IDMI",gyAl ' SITU 1]De" ONV.I lEIL"' rung FML 2s'~/. E n. Y 1 n L D VA ~ V. v.l I l yT /~Y G•L ~Ir Ffl. ( /ia pn _ ,' " a9 M 1 n ll hw Slwif IR.YUe RAIE NO. SrA H nN . ~ /~'eE:~ X/`7;7 ,,:,~ I ll,~l•/e TNT. 9e; L.E.a, ~>o VtN/,FIIXMIIICAIpN NO. i vtH ID[N 1 I N i ~(/ ' ?Ik•f l• ~)~oil,!al •I i l l~ i ~~I 1.31'ri~I~~Sl.:l7 'III I I I I I~ OEGISR9tDOWN19: IASI f1e51 MIDDLE MOVE Np. CL L O I R D WNE : 1/5i N9S1 MI M •, l ^' F 'Z$ u •pDxlua wmu N wN ~DI V NAMEaADDREll55//p INSV94K1 CO WAGINI R ~ I U TC(L•0~•Ct. ,~// ,./ ~] 4AIG~pNU (I L1 p1K °~''Gµ C"up ~ - ~ Y 6 f~AMwGIDMU pNy CNMGI ow~ ~ / .tDP ,O O f ISI.DMNGE ADWI~N D, icl DRInN Rw.uNeo 151.D flOr ' I f l r / S (.I I: ~ .'•~vpsY:" .S: /:/ /,/ . ,..K , ^ ~w~vp aY: S % LiaYl ~ L , 1 DI ~ l,9 IY/iLESfAfYI 5 = I DESCRIPTION Of COLLISION IEeuwnE/u ru fN[nuNEass•nq - `. ~ , lt ' II $ ~ I I ' ° ' " Vehicle ~2_;E ncii boun3 on Cenl Vie / t//, ' td . ~tr~ro 5ft >.ror ~e ~to~ •1 'n on ]f L• ' L_; ~ :._, ! ! '. :. . . ."; ..: ~ - 21J1. Vpl ~•ec soutal/ound_.on .],lUl _ ,ttela>tin o ~ci Cancl ht hl,D•i tur n on to 1,] i _ ; , ` i - I .,. _. ._ .. _ - ._.. _ _. Jim., Rri ,lo su t ,s tru ne lelin too I /\ ~ :~. ~ ; ! { ~ ,~ ~ ~ _. . . ." _, ._ U t to Ir,nle_.tn turn Dnd_.D~Jplied..ni rE,l:ae..,nd ^iidaea".into Y;F2 V,fl_snya .. ~ " . , . ., ~ ~eui ./as tra /elin.: /ery. clo~e._behind ._ . I ~., 7LE.~ N ~ ;- .' lilt on :iR-.101._.-,_....-.___ _ ___.._.. 1Y . r / NAME, ADDRESS 8 INJU 5 OF PERSONS I NVOLVED + CODES I - Z J 4 5 6 ' OCCUPANTS/WITNESSES IVSIfwnIMEMw{SM I(P •Dp110,Ll NANl II fI '°" '"'" "'- N% AGI IAIUS HNH Y•1` Ix "~~ • '°" " IlfI1. "' [Mp xl[i x Y N•Wf. - ~ ~ iq ... - . .. _ •ODrltl Nwlw p ~ AM Y a L21' ^ ^' r ^'RIX {L4NY p wMl. . . .. ._ ... ... _. .. __._......_. _. _ ~ V .."_~__. .. H•lwrp _-.._ . •~Iff N 1 ~ NO IOIY ^AMa. ^,qRl^ n r'^Qn' ^nD ~~ ruY r Y • m b }I,~ ADMiff , IM V rJ A/YJ. ^(•i'^C'MprNr ^'~+ ^iDwV wvlfl •IH6pIKE1 rlAMl afANL TSADLA OE NCY p NKJ 04r•ICNID P 61r 1p1 J SL / X I, , E 7, 1 '• •a .- . .. UKI /JNNO ',.AlEpilrOfITAMRORTDaY OAII //. /ll I ". 1 I I "P~7b1W/R a_ ~11~1~~4GR "UNy r` r ' '~,3~W~Li ~'~~ '~ ,r~'tx `~AI t~ ' ' t , r s I ~ ~i , ,, 4 lA ~ T j~S , I I I E t l . I VF ~ r . f l J f _ ~ _k. ~ ~ 1 h ' ;N~ I .1 i • [ r ~ w It It ~ 1 F ~ LY , ..r. ~ ~~ ' ~ - ~ .AT;I~a~, ". T ~ ~'~51i,1'~1Nyt 1 r~ ~' ~ ~ e ~. ~ ~ + ~S~w~J.. ` ~ °+'~vh~i~ l~~n ~h~+~hf i ~ ) , c (r'~ {~i V ~ I4~ ~ ~ 1 ~ t ~ 1 j I! ~, r I 4y ~~~ i ht~',~ i ~~ I ' u) 1 ~i ~~ :.5~f9~- ~ ~ I +7 ~~ it m NY: w3R SD IRfV. I~BYf Y v ~•. STATE OF WASOiINGTON RAG I E Oi QTRAFEIC ' ' ` N o WAV :9 y POLICETRAFFIC CO_..SION REPORT Rpl ARlulvrNUmeER - ~ ~ PRIVATE WAY OAIf OfCIXlI N _~ ~! oe^Y~ ,.'/: qY l wR ; wlR ...Rl. ilMf ID`s L h ~ COUNTY ^ J ~!~fl~F.~.~.~ ~~ Cg1N1Y N0. /~ CITY NO. ~ Cn 5Z~/O iNWw G eAN pRURAI ~~ pN pF ®N CI OR (OWN u NAME6N0 Of 31RFFE0~9'°G~y~Y 6~ K1 C13 : M R I ROUIEOR SIRfFt ~ SECiI N _ ~( + MIlE3 p3 pW pof S, hIE~171V o `~- ~.4A-H+fc. l L1P~K1)• ' ~'~/~"2~ ` n I ,IfRSECL~~~~FFI R NON INTERSECT ON SCf/bbC NOG/~c FJJJ, RRFfI% f0 MIlE RO3I ~.'_,, Ir L T`` C BFRVEEN S1RFFi 6 STREET O,ZZ -~ ~~ DISTANCE DRf tON R CR $3 S1REEtOR NFARESi M% 31 ACCIDENT Mlf3 3 F W iffi OF MILEAGE G O RAMR DAGRAM W]A COllI3gNINVOlVEO: SfYfRIIYI IOipI NO NO. KIllFO~NO.INJUREO_ ^ SRIl1AGF ® RU N m [ s u IunoR[Dl" T %~RD NIER Cl5 INI R N IRfEI RROAD OR RfEERfNCf CROSS SIREETOR RO ~] Ci VENICIfS ~ ®PRORERIY DAMAGE ONEY ^ EllFi~ll[D ^ VFHC f / _-' ~~ OBE[CI SIRUC%INAME~IF OBEICI STRUCK MID OWNERS NAME( ESI.ONAAGE ~~.~P;~?N :~). f~.~~.~), 1~rd_G_ S 61111•' SRFCW COD NG USE 4/~o'2lJ '~' UNITNO.I '. ~ -. UNITNO.Y ^VEHICLE • pPEDESTRIAN.: ^ PEDALCYCUST ?! 3 RIVER'S E: IA31 {IR31 MF DRrvFR'S NAME USI fIRSZ~ MI L ,• SIR( (ADDRESS StREEI aDORE33 CI I S1AIF ZIRCODF ~-R:H/~ONE NO l.V:~."LE1.Y0 J \ ..)C• ~~r~;"'?L.) /9!D'-~f;i,?/„ D R IY SIAIE IV E F / ORIVER'$IKENSfN ' SlwtF f% H . ( i ~~ I.. I DCENSF NO. AIE SE% OAlf pelRiH DAr Y.. RD. A?~T .TSr U/,~I r `~ t )F S t ~ oz ~ w ~ I _ B f OSCWAIION EIRMNAMf 61NONE Np. .Ir-P\F:;~SQ ,:F.I.F G6A'o;C{rr.P) EYES IGHI NfIGNI l /j ~~ E R OCCURAIION FIRM NAMF6 RHONE NO. EYES WEIGMt IEIGNI ,' p CHECK (~ vEHKiEA ~N lEUiovFF OE AE±DiHEC ^ CHECK (~ I vFHiCSF aS AN [MPIOYFE OFANOMfRAI ,RCor'{ CODES - * G ~ . y 5 l a iA° CODES - n' G a < ;; 5 EA 6 ~ `}~ 1 IN lmus IR ~ ° ~ :o DM ^ A,~,ANPI ^ ~ l ^ rsmR ^ H a ray,. K;~ ~o1RON ^ ADNIIANYE a ~[E ^ ro~OR ^ h~KU a ::taR R VLH.YGR AN%E (DODGE{HEV,I FI IDrrAAI~NOVA) S1YU.I]pR. CONV.1 H.YWf ( HEV.1 MOOfl1OM ~N VA) Y I ,) Roe•. ~ I lI N SIwIF (RAISER MIE NO. AwF H vn. SAT[ w -. L TI-I I 'n ~"I tJi C a9 V[ Cl[IDENl IICA1gN NO ' K;R 21(-+1 ,;LCI~i~ i~I Q1~71 ~ VEH CSE OENI I A I N , I I! I I I I I I I I I i I R[cnnayeowNU: wl (IRS! MIDDLE KETONE NO. O 131 DOWN[R: 1A31 IIRSI 'MIDDLE .>I-)(JIG. II.S ~\;'.CJ\I1=. W ' 13~ ADOReuaoWT+ER N NlR ]I E NMAE a ADURessv IHSwwNC[ eD, a AGENT 1'':I~1G R ]] r ~ - AMAGF MG ^:.q.nN:.yG- (: I:I~nor°u. f;AMAG[ ARN CHAR lo. o.R.DYDI I l eHARee o'„ ° i~V"4 % a _ R E S [SI. pAIMGf Q ^RFAWN[D E6ionoir RTO. EMUNEo ^AWAY ^R FSI.D [ I IDiOTtOM ] IOWID S I ~-sal Ar er: W 10VA0 ^ Awwr nr: f _ DIAGRAM Of C IN eIy AtRIQ ORIH OLLISION; I s W [I I{ NECESSARY(. OW DESCRIPTION OF COLLISION: Ilrsf slvn[Mw1M SHEENE NEEEssARY1 Z .~ 1/G H{ )" I UIF?;. f rl 61E;n.ln,l~ [7rJ 7k E. I Fb::- c{•F.r a, i c ) . 51 z.[ 1~~L. rrfG cE ~~,.:~n, ~ lll____ _______ L'»P FS E :'JTr ~ : h(:r rl ~1 ~wFJ /C1~C __ . ~, Y,l., .. G.' !~ 1 ~ .... .. ' ~ C . -Ae ID a J _ • NAME, ADDRE5581NJURIESOFPERSONSI NVOLVED +CODES 1 Z 3 4 5 6 OCCUPANTS/WITNESSES ;~,°,DD"'"11EG~NU p si ~ sf% ~ci wus '""" -° ~ R131R. IIICt NAME. is ADEV133 NA1DR1 Df y ,,, ~. wM e. o en I o ~~ . o alr' ^ rs:A. H AMI " ~ A ronss 1 a Dr pwua p.acF ~HII . O Qx • ^I"E°. o No A fURt aDRITe NAA,AI'S! N MeY. ^AMe ~~D,%IO[oHl[O~7 piw 1 E~d1 AT .F?' +.t'v'ti'~\ EC; r. aaJ" Cfh1A ~~, l ~ SIiES;tk: 1 s ~. 6~ t' Y. 1: . ~ ~ 4'i y ~ f• ) .: I }~' Y 9 ~ . r C ~ , n !~S „ ` ~ . :~. +' -,r `~'}ir'~ .r T aSrr~~yy ) .. ~~~ Ir;; ~. ~I~n I'E ', '~ ,t r ~ ~ e 1Ny t r r 3 ~ ~ ~ iff ^ ~ [ F r 1 ~ 2, r L r ~~ k~ ~ ~1V' :~ ~' ~~ ~~ r ~, i ~ r F~ r !tt !' ~ 1 i a. ~ ~ ~ ~ ~ ~1~ f t rTl '~~ r ~ r } ~{V6r 1 ~. ~ ~i r ~~Y i~"~V4 r i:.. ~ r, rrr ~lr ~ ~ ^ < ~ .r r+ r r ~' ~ g~ '. s c~'i e .', ~t ~c~~, d Htnr~9~~ 1;? e w rd° ,r~" y~~yr r ~'h~tr.-~ ,', µ~~~"' ..°rtfir~ SAN u~` , ~y ~ ti4' , . ~. 'y3~N'•, I a ~ ~[ I - yr wwaninNlVN TO '~MEHICLE COLLISION REPORT COLiL81C1{.- MVOF COLlL510N .~~ `.N.M v F A TWE OF COLU905 .. wFS wl0 rNUP F sA] AY V ^Y N ~ ~ PY ~ xK MILEg ActE~w Y „ GTY,TOWN OO 'CITY. TOWN °"" Ta L~]© of p DFFIGAL USE DNLY NO. COUNTYI/q. CITYNO ^u nAN Ilo [arlCij,tu AGA PREFI% rnslNEn caDF SECTKN[ ~ 20>yo NOM OI ~ OF i, npADOR HIGNWAY WIERSECTWO WITH SfNEEi OR gOAD PREFl% EO MILEPOS! " ~ DBIT ~ c'a.n.' .ST. :ni / O y~ y . NON WTEgsECraNaocAT slON RAMP DIAGRAM MIA l DETWEEN Sifl E E i T N // ~~,,(Y ..`rV' ®© M lxx Uw m f D xxU NON %-RD w .n GNx[roSr on oENiF YG L'x r lAVd ' YL ~ I ' B b ~ ~ . uln ~ t ,rpsy SN~ INTEg' INi ER CLS. NE F I O q t°py) wE<rxlN ©® ' ~ ~ ^ B GZ/Zo COwSAYINMIVlD 1^ ~~. .ul ~G ~v Efllwwl0 gPEC.CODE USE I ' ~~I ~A' E, .~~ ~ [v[ruClES ~ "~ ~ Q [wCIF ~[ ~s Ati ^Wx alusgN ^nt uu OBJECTBTRIICN w TSIp IIYM[v N OWNER OF . s OBIECTSNAME AND ADDRESS LOCATION F [ T // IN flOADWAY ^N © n T E / I Gv1 Q D AN ~ • ~ .~A . n~- _ L. /I' ~•. . FEEr tDIF L • ry::~.. • E ' Y.~ OWVERSLASIHAME ~ F . .... rvx. FlRSi NAA!E NWDLE vro CAgSB OPIVENgIAST NAM FYLRT NAME WDDIE I f L • r , ~ J ? : l Sf EfSB ',.,~y;, IgUTE .ANO BO%NO. vq STREET ADGIEE9 ,~ igUTE NO. ANOBO%NO. GIY ' E ~ ,). ;„,WATB'.G;. 21PCODE DWVE0.5000UPAiKW GTY STATE ZIPCUDE DIUVERSOCCUPATKIN [row saw ' ,~ ` j , ~ .DDEHSE -, ; j,(L,. STATE SE` SATE Of &RTN AGE DnIVERgIICENSE NUMBEq gTATE SE% MTE OF BIi1TN AGE ' DA. ~ _ , I br; ~s S~ Q(/C -~ v t{ t[/ M X x'° ~. a[.R 7~ VEHICLEMfL >•DOD[10~ MOOFIINOVAA TI BODY STYLEI20it1 VEHKIE YR. MAKE CHEV.~D000EI MOOELINOVA~UMTI 80DYSTYLE 120R.1 '~ ~ ' • /c! S^T c r L ~ c ~ C' r 7 ~ ~/I a ~ o lrT , : (' /I • . . .. L%EN9E PLATE ,~ eTgE.. TRNLERPLATENO. STATE UyC-ENSE PLATE NO. STATE inNLEq PLATE NO. STATE EMT _(] ~ ~L / + ~ ~"rl V ' ~ ~~~ . E/MLlELIFMfIG N0.;_, ~ ~ (I BSBMODELSL NEWEflI OOOMETEq IMILEAOE) VEHICLE IDENTIFlCATK)N Fq. (1888 MOOELSG NEWEgI DOMETER IMnEAGEI ms > 'S - . s _ „):,-, i~ Y r >r -~« ~~ oz RE ' -t+ . •JJ~D 044TE•IEO , AALRT•HISf~MIDIXFNAMEI INBVERSIK:ENSE NO. REGLRTEREOOWNER ILAST~FUiST~MIDDLE NAMEI OgIVERS LICENSE NO. 6 .Xy /, ' _ ~ aI D F %i ' tea. ,: , ~ r c i„•._ /' UC -L M• o y~ n ,;,y) ET, CI D iAT I DATE OFBIRTH OWNEI(IS ADDRE59 IgtREE[. CITY ANDSTATEI MTE OF BIRI T'HF•1 ~' .Y •.!.• .G DAr IAA ~ O a_ ~f/Ac /P I/~~t. /t~.o .,.,..... .l' -.. 7 I i! 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[w { yV I I!1 LOIrn1. 1~+K l ~MVY%I11 Q,'•[l ~^!RNNS ^r ~.IO CWE WGn ~.%+tl / ~1 K'1 ~ GpM Si[WCYIr Nlfe~rrryl •, t ( ~. ~Y•J r 1 1 ]^RNMI l^WWh ^ t ^SIOP N/1 ~ ] LL--l IN•;I WAr o ~j .. 1~ ~. ~~FF~~ ^ 7 aNtf 16, ^ ] ^ UW gtAKINn ANO PADMrKi ~ 1 4'l'( Yl 1^»]OYWAI J^fM4A ^ J ^YKa061GN ^ ~ ^r~~q`JBIk wnKNN IURN 4~ N T-a -A!}gj 1 :~ yl O T ^~W DuaGNaEr ^ , ^ MAxY { .L ! ual_ . ^roo ~ ^L%:nts oN rusHr,u ra0 T[NC ANra ~ ~'- r ^ [ ^ K:T ) ^ , ^ nA.uwr: AMBI N ^ , ^ w n ~ ~ [] MAxwn u n tunN ;'. 1 ' ` JL C y DrH[q rwu svNn n00PmAMnI r r 'B Gnxq ^teP[dn ^LCHts GF ^ ' ^ ^ [ ^AU2Y ^ f ^MAKw,u tunN I f.. ~ ^ ~ ^!I{CVY DM N0 ~ ~{ t t Y l ~ tl^Stn[fI LKWI9 ^ N ^Iw `16HM ^ tl ^fVVO wAV 'I 1 1.1 I~1 - I 1,'~{,'~`,'1 KASOM 10q NOrfLM[O DANOLLL, i.EVrtlyw ^ A ^ YFTVI.A I f 1 ! :r 4 M~ tA.., t' ~F ~ i~ ccY~ .~ 4 Iy"'^ A>•MOwrrr MllMGt 1(Irtl ] ^ SF'[GLY ^ ! ^ WFfl fl Il.(wAN ^ ! ^ gIGS•(n 1011 I1ULf1C I I -.: T '-. f / ( 1 "I 1 I ^ ! ^DIMA UYCBr ^ 1 ^![PMIAfEO ^ tl ^'IIGYNIIAI FI(JIAa _'f I jl{.~-dal f 1 ] ~ 01191G•M111[ } ~ i it Vll r t ~ ^ ] ^LYVKIEG ^ ^ gl<%Y10NIgAOWAY ~ 11 L L ~ ( ~I II, Y, ~ 1 ~~v r~' ~' l ~ ~ ,I" t:,,~ ~Tt . rm uru r Nlv ur Iu~IMm w I 111 1 1 f'., i~a~'A Ylb1r ^:rvYn„ ~~I 'a k' ,,a 7U 9 dk .,~" ~._~';~il.: .ti... '2.rFi ;"n.j"f1'81'^Df'~°~ ~I ~ ~ i~~ ~ET j c If l 1 c. uYJ i :{ 1~ 1 I 1 t a 1 I ~. ¢~ LIABILITY INSURANCE INFORMATION~VEHICLE NO. t I ~'~' ', ~ ~ ff~4,' ~ y l ~~ . ~ fw /,g ~ AE 4(:3 ~~ . ' x f ~ ~~ LS ..'I .~ 'JI drw/e , . ~ '' 'A ,~~r. ~ A. Y ~ pp .N ^ ulYSt ~ ocwxvro Nav ns. royyl ^ Lvu __ _. IN VEHK:LE ^""n • nay we rnnr Nmrc4 l K (]rASH ~ yJLI[0 IKKFIr n+~F lxr CWi fir. x KILLED I[i~~ir~l x~lw'nlx NU Pots [ ^~ ....w ^ S^il B^+ o~Oiiir pHUl.rru,.. NG uvr nr. w"wl [rc0*"'N~irc~ r O '~ ^ S^ B^ lrG7O .. gWN011TH BY An/gW wC111CLE N DESCgIDE BELOW WHAT MAPPEHED.IREFEq TO VEHICLEg DY HUMLIEry I.WDC.~; II((FCrFDAAY:~ I tAi[l Ir Dull.M crn O !/.•r_ /v.. ~ / IL¢ k....Y s; ~• ~'' 7c•,e A, h Mln mow:," on F.<:F.. G'K .[...! /srw ~-h. ~..•%'L pia LFL. •/W.[y. : w .i E A"'NIOL°" 1'A:. n.:Cl Al.t t i c ~ L, ; ,tr . ~. .< ~ ,. ~ Dlnl_J Q~ ..._an + fc, . ~ GPI ars7- o iv % /_'. [ / .c : n rJY l/C ~~.,-. :Y AGE ~tNOINJURY: r~~l Cl0 NAME SE% ADDnEBS o ~ ~_,.,~ ~ NxIDFN.,w[x NO AGE ... ,_ . ,; ~':• - ~. 1~1.~ <e QF W H~NG'TON ~ OFFIC AL USE ONLY -~--~ ~ _ NI TOR EHICLE~COLLISION REPORT NO. _ r__ N,~~'~ `DATE F„ An WYOF COLUSIONRn H _ . •:'~ wY TUIEOF CO~ULOy COUNTY NO. CITY NO. ~DFw ' ~ yK K Wx N sAl WH AM ' ~ >'~ ..CITY.IOYW UI MILE$ - ~ PM /~ ~~ }} ~,?~ 4 C CIt°Lwit ^N ^E CITY, TOWN AOM~CLS PREFIX AdllF aslruET CODE SECTION i ~~, .~'' - • «u..rLE ,fC F:rSCn +pDwA~ CI Ly w~i.CNM° GIVEEBWEOFSTHEET. ROAD Ofl HIGHWAY ©© °P ~ i1~ „ ~~; _, ~ ZZ/ZO ~'-.lv' ~,~~ W° ~ WTERSECTWO WITH. STREET OR ROAD PgEFI% EO MILEPOST +~ A - ODCLR~D L C! r-I,v' C ~/-Ctil~ O./`~ ~ ~5. ry~~,u ~ NON INTEfl CTION~LOCATgN OFCOWSION I ~~ VAMP pAGflAM DATA h BETWEEN BEREFT ANO ~,/ ~F` B.ac n Ln blEOCT 5~ .~' °x Mlr ns«rlan~ ©® n.LLHO:Di.~ltu'1ssrrrlc LLLerosronotF'.;i nr'wiwo°YM'u .""n- " E NoN xnD iFE INTER INTER CLS PLLrFWiI CIE~fn'a5551NEL°Wf OlligAO DDMISID.,HYOLY ^ 1'o7yb .. S Tw vEHKLE9 ~ I _Y~,~ ^vFR ^aRrruNiwwlFl SPEC.CODE IlSE A 4 ~1 i ° ~~f OBJECT S[IWCN y, IIMII[ ~ul ^NM ^rrl I~, q VY. I OWNEAOFOB1ECrS NAME ANO AOOflES$ LOCATION ^N © n W ~ ~~I .. ~ ~ rAA.. ' WN ~L{.tU'Ln ~' - U.I r.~ IN flOAOWAY--_ _ ~ t SO PM '11 , ~~ Yr ORIVEg8GA.9f NAME ..~: r.V+ ~. PFUL$T1LWE MIOaE N1 OnIVER3 UST NAMFpST NAME MOOLE~ m ~,. STREET AppiE53 ROUTE NO. ANO BO%NO. M,iA("P ;P,[_ '' -" 1 tvo SKEET ADaiESS OUfENO.AN000%ND. ~` -" ( ,. piY ,'...:., - ..STATE .,t. LP CODE OflIVEflS OCCUPATX)N ~GUL' rL~P OR ~(,~; -2 CIT BTATE ZIPCUOE aLIVER5000lIDATION .' a ~ I 71c L ~ ~ ~1C eL Fl~onri ~•.r, ['~4'~E. NN°A1 U O ~ L C4 PP A_. VERS.LIGENSE NUM STALE SE% OAIE OF BIIfH AGE nH~E h ,-ll ~ wER9 LICENSE NUMBER. r$TATE SE% l1ATE OF BIRM AOB _ M ~ ~ Y ~ ~ w r D.r ~"" .~s w ,' VEMXX.E YET:. MA%EI :WDOF]/: MOUEL INOVMDAgTI BODY STYLEI[ORI EHICLE Yq. MA%EICHEDV.•OODGEI MODEL INOVMDMT) BODY SIYLEI]ai.l p' ~ L' 1L e, ~ u ! ! w ' c I- D/c~s.+md C' G~ e ~ ('UTENO BTATfi TflNIEflPUTE fq. STATE LICENSE PLATE NO. STATE TRNLEfl PLATE NO. STATE ~~. V ' 7 Wusti . ~ cU~ A ~ F~ ~ FY `~ VEHIDLEIE[JFi1F CT ...:: .,..It~ MODEL56 NEWEflI OOOMLIERIMREAGEI VEHICLE IDENTIFICAipNNO. I1BB8 MOOELS6 NEWER( DOMEIER (MAEAGFI t IIEGLRTFE{ OWNEA, (FA.9Tfp~IwDOLE NAME( OWVEgSIJCENSE NO. REGISTERED OWNER 1 T~FInSTMIppLENM1E1 ORWEfl3 LICENSE NO. ~ ~'~ G ~G'71G ..L .. ..rz D T. clrr uw9r~TF,f.. DAT OFBWTH. OWNER$AODRE53 ti ° "' /iCi,'P1 rDP 73"3:-- ~^~, ~', ~ ~'~ (mREE .CRY ANDSiATEI DATEOF [BflTN ' # ^O ~ G r1Y10'F1 IC: ~° ~'~ UPMI • "1O _~r PAflT90P VEHICLE DAM~Ep„A:.; "'Q' NN •/ Ar t# is gvlitwPViHCLe PMiSOF VEHICLE DNA ED .#L44F3. 1' ~ ~ 4 L 'w:. J ~ ./ E nor ~ ~ sia lin:F~o~r "~'' LIABILITY INSURANCEINFORMATION~VEHICLE N0.1• WAS THERE ALIT MoaLEUA ILITY INSURANCE r COVERAGEW EFFECT FOR THIS ACCIDENiON YOUflCAfl YES ^NO A r'v! HAMEE ApORESSOf, N$IWIWCE POLICYMOLOEfl Ir , 9MI NAME OFUABIUTY INSURANCE COMPANY ~?r,y n, ;: - ~ . w NAENFOtaDRESSOE F~ ~ T~ Q-~YY'!L_ v a ' r'' EVSI[WlCE ADEN LIABILITY POLICY NUMBEfl 1ST NJUH~ ~~~, ..., .~, AGE [Np1NJUflY: IusFSU•MArf nEPOntr I vuuwt9l AGE NAME NAME J IAV~r AOaLESS .. _ _. ~ TwAnED I S. ,. ADDnL erq SEX ~~ ~ u 9iATVS OF WJUiED© MAH%FWSf OVE iIIAi APPLIES ^~ ~ uD µSIAEU90i1WURE0 ©O N In l111SI CWE IIIAf APPLIES ^ ~ „~ " '-1 ^ R D6NUM nal qS.M IveSXU Mr4 ^ gLlEp INIVn w r ^DW NVEHM:IE U'uu - ^ M~eXH ~ wvlR I IurNq'Ir D~inA I ^vA N~ KILLED [ [In M wqY R ~. j " ^ ^ 15^t 6^ 'ot~OElc" ^rv o~~~.N I r 1 d`.. STOW NORi B N1110W WCIRCLE DESLRIOE BELOW WMATNAPPENEO (REFER TO VEHICLES pY NUMpEHI ? .TOLD ~ .~~Dr.'Rrcrr O I~F3N/CL~ ~ o ~ c~ u~iL ~ '~~" ~ y-. 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Y4 AME AND ADOflE550 LIABILITY INSURANCE AGENT CIP LABILITY POLICY NUMBER rlt,~_1M1~ vE::;1Ctt c_~,LIy'ICk'I.l; 4' ~ ff v:~r' ~'(C!r+ 51~.~_l_ ~ ''33-(~-`-`~ `~(~cLG/- 1STINJURY AGE 1ND INJURY IUSE $EPAfl•i ORi rOA ADOHIOnAI IxJUNIE91 AGE IMNRED NAME 9E%. NAME SE%. AODPESS ADDRESS M F NATURE AND r NATURE AND ^ ^ E%TENT OF NJUR ES ^ ^ ~ E%TENT OF NJURIE9 U D INJUn I's nFOU nE ~ „OMFOn S E D NJUR ES nEOUIRE '^' ~ NAMEOR S %AM NATION UY A DOL TURD 0 ^ INAT ON BY A DOCTOR ,: STATUS OF INJURED NAflN FIRST ONE THAT APPL IES .. ..... STATU90F INJURED .MARK FIRST O NE THAT APPLI ES. ossiu+E , , ^ oA HI L fir" KILLED ~n,~':i° ,u"1nN .w un"E iu~HOnl Possix+ iouriA : 1E o ^ o" I NI L ^rA NO KLLED s xw siiu~ I I'M~r~nii ~ouil" P" or W aiE ^noss~•H NO. ~ ^ ^ ^ f wO : ^H°IS anH .. ^ . .. .. ^ 5^ 6^ 7 O p.~,... ,. 5 6 T .. . :.. .. MOTORCYCLE SAFETY: ^ HEwer ustD ^ HELMET NoT usED MOTORCYCLE SAFETY: ^ naMEr ustD ^ HELMET NOT USCG SHOW NOIISn Ur AnROw IN GIRLIE --.::" TKVPIME4 •':. 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'~ W°°~ ,..,,.,,.~ i..u~ ~...... i. ~O II.. ~ Yam -gTOR~YLLE SAiFT• ^ w VEHICLES POSITIptS BEiq ~Vl~d;n ~ t 3 ~ ~' ~~ n ~~~ ~ i `y~?~~e h~~ r,~ r t f ~i ~ i4Y~1~~fi~`¢n1! ~yy a ~~R , D GATE OF COLLISION OAY OF COLLISION A MO. pA `v T SUN) mql = lU[5 D E A MUP S FRI D BAi IUS L / J TIME 3000H RI } / COUNTY NO ~ CRY NO / FHWA URBAN J J EE COUNTY _ ^BTATE ROUTE ~CWNTY gOAD ^CRY STREET O \ /T ~~~ ~ @jITHERIBPE01FY1 ~/( I~ ~ ' ~n URAL OMLLS. PREFIx POLITE ORBIREET LODE SE LION ~ V Y G , N ~O ~~ L N fLBy E W ^IN CITY OR TOVIN ~/' O MILER L'S! ^ ^ ^ OF ~~' ~ /L ! ~ O PREFI% EO. MI I / 3 A E NO.OFBIREET OR HIGHWAY INTERSECTING YATM: BTREEI Oq ROAD ILLL / /l ~_„ ~l O T O ~ ^ I ^ ~^ / RAMP DIAGRAM DATA ' / ~ Q~ L O NONINIEa$ KNJ r G ` ~ TER NON A RD ACCIDENT MILEAGE ~ NIERSECIING SiRELT Oq ROAD OR REF. IN1ER C49. 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DAY YA. /1~~~~ ~~~ UPIVERS OCLU AION FIRM NAME PHO ' ` 1 ~ / f~ NE NO. j o , .'m°er ~ ~ e _ . er 3 -3:~. L A , PVERB OCCUPATION FIHIA NAME /n~ J M ENO. T c!f D ;v 'l ~ ? K~ `'~z0 has-~ NCOD ~$ > 131 CIA:d TAI SEAT BELT I'vl EJECTION ;s CODES > ul u ss TAI BEAT BELT ISI FUECTKk! ' // IHIUf-ES ~ / iL,t. J / nn iIIIURIES F t'F~ ~ / F SCENE VEX. YEAR r., BY: MANE IDOOGESHEVJ " TO MODEL IDART~NOVA) 12 DR.CONV.I FgMOVEO OM SOENE VEX. YEAR BV: MANE IGODGE~CHEV.1 TO MOOELID Ri•NOV S EIZ Ofl.LONV.I V nC T ~ ~ ei~~wc> / E y ' YEN. dA 'YfFu rf, . C GATE NO. ~ .7.308 STA ~" cv~ iP R PLATE N0. BTATE ~~ 9 .? ['V~v/ E H I EH COLOR i ~ ~~/• UC. PLATE NO. 2 ;n/ / BT // ~~ ' AVER PLATE NO. BTAT&~ I~f , // (, vEHI lE IDENTIFK: iION [tum8 q / ^ ODOMF.TEq pp C " J "` '~V EH ClE' DEI T F CATI N NUMBER W ODOMEIFA E ( /J p () O ''.SG i O E `~ ~C~ SC ~- J O N O. REGLSIER DO -IAST FRST MIDDLE . /~~ r,1J +C' O .- . REGISTE EO OWN_E.lR!'lASi FNiST MIDDLE T ~c~ C/'Q ~d~t1 P S A E:S O OWNER . ~ A DREBB OF OWIIER ~ (~ 1 ~J ~ NAM. DADDRES50 I B NANCE000P DEfI t i _,./ ~R~.Sea//Jr' NAHG ~E~l ~ `-f ) ,a Ui e 7/'i. LAME ANDA DRESS OGINSUgANCE O. Oq~AGENi .~ .(r , r= S;T~/te-~ f~`'~'~~a7T j ENFO A RCEME C110N M Cl1ARGE CIIATIC)N~N -~ NAME) ADDRESS & INJURIES OF PERSONS INVOLVED cones _ a ~ s b - BE% AGE 6TATU5 W EJECT, C J 7 '^ ., NAME. r,-r 7 ~ J C U ~ AOpRESG' ) C' / NAtURE Of S'.:,51 ~ _ A ' P vlR1aES ! ED SCENERY' {RUM Tp H NAME' _~ T $ AornESs N J __--_- i W N M fAD iHOM UIIIES. AME. 10 i I "~~1 F I #4 ~ „: ~. §'erSC _~. ~ '. r # n ' . PJ~,?T%Ar, .. 3 _. mL ' rtY.wr ' / d! '-~... 1~... s. *~ Lm ~~ 'N j ~mY ~ ~J . Lhun. . -.. itT ~.... . DL4TRIRUTION OHI GrYAL COPY' Sf.Np l0 WAS"INOTON SIAIE PATNOL-0LYMPIw WA5111NGT011 DBSpA WPUCAIF. COPY.lOOAL UW [HFDRCEMCNI AGENCY'S DOPY-TlUPIKAIE COPY.INVCSiK.AIOR'SCOPY R._,.x... _. 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DIAGRAM OF COLLISION ~ I I I I 1 P I I ~ .L DRAW ARROW SMOWIN6 -- -- - ~~- ~ -y-~ -(-NTORTTH IN CIRCLE mfg F.NIU Imo, ! I I~I ' I 1- I I? I I I ~ 1 i 1 I I O ,DW L; ~ I I I I~~ ;___ I I I I I I ~_1__;_,_ A~`°'"nd' V e ~ no"s j ' ~ ~'~ j l ~ I i I I i I ' i ~ 1-_ , _ _ - I _ - _ I - T I~I t Alrzs" LTC ICOnS 1 ~ I ~ I ~ I~ >E/RdveLE WLCY ~~ I ~ L f ~I-f ~ - _ I Po ..l ~L J_ _ 1 , - r '~ i I~~ -~ i I ~ I I I I~ ~ I ~ ~~ I )~_ s~,YLNDLEPEL>LSTRL.NpR 1-- ~- n GTPo.w,xns AnMPKT ~-, ~ ~' ~1~~ - --r_ I % i~ ~ I ~ -` __ I~ I I I I _~r I 1 A,~ARTLADDLL>~DN - -, - -~--~- }- - -~ - -1 = ^ -- - ~ - ~ ~ , ~ ~ ,.. ~ ~; ; ; , ' III r I I r i t I 1 .;[IESCRIPTION OF -1.:1; IINgCATE WHAT PROBABLY HAPPENEOBEFORE. DURING PNO AFTERTHE CRASH.INCLUDE INFORMATIONNOT ON DIAGR~;E G'DRNER i :,,COLLISI(JN,~4,.,j . gSAgUtt,REDUCEO NSIBIUTY.PEOESTRIANCLOTHING COLORCONSTRUCTION OR REPAIfl WORK ETCI I ;~ ~j r ,/ c~ r_t C.._ ~ ~J~7~ ~~';. 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R owvL ~~-> MYYEnn>:"'~~"d''9 ' IC~H~C• drE : vrwc~ and ~1 ~ ~ YLR r ND : wavLR ' ~ .HEAD - (~r~ om r-yDIF.YL~oY , ~ µor~LULNDL r ~l,r- r-i' l Y Fmn°"""°ncEL I ~"r' s"IGSanr~DLDW.ro..- --- IJa~ =G - _ _(~"~"~ _ ~_r ~DS~n~r»~E I~^O ~RDEMrA ~,.~_ ^~~ w ND ,~ --- - --- .. R>v~ F~• ^ cL . 1_I iaa y _ f i I _. r] °~I roRR r- e-~ rdR.. - y- a~ - - i^;_I N4~wY -- __~ 1 ... - _ - ,W I n No o - ~ r, NT .l ~_.1..., ,,, 4_.., L }- _~_. , MDN.,D L_~°~ Asvw I )r,r~ a RDSiro _ " a -1 r°1o no"uiwNFT' s~o ~o FOR _ LIONT CONDITIONS TXAFFN: CCXTRUL' VEwCLL. TYPE OF ROAD VEHICLE CONDITION _ SOBRIETY,i,`• ,., ' I oR,~a"~°N NNECA aND - J nlne i, Ho oNE OR .. I , Y oNr aR "ulf No a ~% ~LTE I oNEI ~ a+`LnN r-I n Nr - - -- ~ ~ oo _ - -- ~i _.. 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STAEETA D _-.._...._._ _ .. STREET GSTANC A DDIRECIKIN FROM REFERENCE OR CROSSSTREET / ^ I Ey~~N7 MILES B E p LFEET N w OF ~ O I._ / 7 v ELLj, ACC OENi f E DE COUE x~iau+eiH3 PHEfI% EO. NhE PO S T... ~. Z ._.. .-~ w'' HPMP DMGRAM OSTA HlTER NON A~RD TERSECDNO STR R OAU OR PE.~ INTER COS EPENCECROSSSTPEETOR ROAD ' SPECIAL COOWG USE _ - : ; (Epr~ lh'~a!tr. ~T *€tw3' . ' !jll s ,. . I ~ ~~.° ~' ' .L "~ -` rA V -~-- 1 • ~ ~ ,, 4 .~ V ~!y Z ~ J+~ _ ~~ ' 'ki -. .: VENICLE•VER CLE VEN CLE~BICYCLE 01 ERI RILE) id UN COLLISION I,NVOLYED: ~ ^ ^ ^ _ -NO.KLLEDEVENrv iC1AL NO VEH CLE~OSIECT ^ ENILLE~RR TRAIN ^STOLE VEH{LE I NO.INJURED IL~-J~ ... OF NEH CLES ~ ^VEN CLE~PEDESTRUN ^NON.COWSIO ZA OOUS MATER L ^ __ ... _ __-_ PROPERtt DAMAGE ONLY CBJECt StRUCKINAMEOFOBJECTSTRUCKANOOwNERSNAMEI -" ~.:.., LOCATION OF OBIECT STRIUCKS . E _ EST DAMAGE..-; q ORIVFpS NAMENASi ^POAOWAY FEET ^ ^ ^ ^ RD EDGE 9 ~. „_,+r ;- FRST._I;_-• :.~ „M POLE '-" OPIVFAS NAME~IASI FIgST MIDDLE •IE CR;YCUSI GH VEL ESIRIAN CnECKI[J :.~-;,,xa4 1 R STREET ADDRESS ., _..... ~•YNYY.\ _ _ \ O~ _,R STpEEi ADDRESS ... _... .. ,!ik.: RE CITY ~. ,; .. STATE ..,. ZNCOOE - ....PNO Elq. ARE CrtY STATE ~: ;:.LP CODE •PH ENO: 1~~-acs C¢~/-~- ~d~3 N PHI ERS LICENSE NO.. ,... ST iE , .SEX DATE OF BIRM N pRNERS LICENSE NO ::'. .:r. STATE'.. :.SE% , OATE.OF BIpTN,~..u. ~ O. ~-,7 ~ ~ MO DAI O. M0. OAY Y0.• ~ DRIVERS OCCUPATION FIRM NAME.: .. .!:: ,~ HG EN Q-~ pgryEA$OCCUPATION ;:: FIRM NAME ,: °. .. . ....._r.,.,. „y,,;~P NO. r t ~: T~ ~ ~' , » 3 ~ ~~•R. P ~ ~It ~ Eli k, ~ ~ 11VV: ~ y ~!~ ~¢ ~" ~~ti • • CODES > IJI CU55. lAl SEA BELT ~ I I EJECTION ~ _ CODES > WUHY U IAI TuREO -_ - 'I CUSS SEAT BELT__ I51 EJECTION A'i ~: .1 1 _. NIURIES Z V-D ~ S ' •. OM NE BY • Y : - RCN SCExEflv~ i0 4 4~~ - - YI ~' = .S I C C ~ VEN.YEAfl MAKEIDOOGE{MEV 1.. MOO LIOART~NOVAL:.:. STYLFI20R:CON RCOIOR:iii UC.PLATE NO...;: STATE.,. TRNLER PLATENO., SiATEri;~, cNICIE I ENTIFN:ATX:N N O/ER e.~..~7 v OOOAIEIEA •: - PFGLIiEAED OW R-LAS! ,A. J'IRS ly ._[. .~, DOLE ADDRESS OWNER-:^ •Y•}-..~51: 1!, r'_r. : y .. " :vE •~ (°' - t.... ,N ~. 2 VEIL YEAH. MAKEIDDDGE{NEV.)`_~; MOOELIDMT+gVAI<y STYLE I]DR{ONV1,y+EA.i VEELCOLOR.YJty. IK:.: PLATE NO: ~,.. STATE. a. TMLLERPLATEN6.i: STATEtiiii,'t4 vcNVV E: IDENT fp:At N.NUMBER - ( vL,e OppMFTEpyy].~t~~y-i..,l REGISTERED OWNEfl- T ,+T .._.,s srYfY6T ,i•y,yJj~; by y?„y+~Mipnc , __ DOf1ES5 OF OWNEIkwc.:. _.. K ' • ~ x (~ ' ' 4 :~ ,. 9@s~ ~ ^ ' NAME ANDADpRESS OF%14UFW+CEOQORAGENk.L..u~'.i:~.l..._.. ::..:~1.Eih •~ -` ~dL Y•S ~ -... CNARGE. . ., . Z. ~ : Gi T'AN NO-' - NAME ANDADORESSOF MISUR NCECO. ORAGEM .~rG.awW 1. v~..L 2%LLi1..L9Gy ~ CNAAG _ x '.: ~ ~~ ~ ~ . . . .. Er:FOgC EMENT ~ CT ON E .. _ .. _ _ ....4:. r. . .'. ~ a GTATION y' ~.,,,•~ ~ ~S~`Kr x 0 wu ~ }~ '.' ~ .' ; I J , L .. Y'... .. :. '•JIl - ..« ?., NAME, ADDRESS & INJURIES OF PERSONS INVOLVED •:^ .CODES ' 2~ ] S l• ~ ..... ... ., r. _... I.._.~.~i. c. _...\-•.+~_.... .:-.1 `.: ,::; :. SE% .AGE. STANS _... s[Ar Aa ~r; EJEpT9 : I ~ •: 1 '~ . -`. C P ME: DORf5.4:_ 'UU fBOP REMOVED FROM scENE n• TD ,., ~ .; _ ,L a uME n,f K~~ r ~'~ ' T AooRfss~ ~I* • S `IAURI 9 SCf xE HO FR M ~ ` ~/ 4AME. - T appRE55 N --T-R _ IATuvv~'E'ST'- I ~ v oFR M f ER 9 ~ E 5 ~-F I - __ L` ... K•1'N :I,E, U4 L O UI ]US gT I11 I IIY O I TL4 OtJ C R ) OM ' . fE CE E N IU I O CURDLING ~ I D °~ -5 I ) ; ~~ A T T, ( i C / IpISMD L I ] DE ON H L uEU NNGiPtAL - UENTINJURY T OU.BIE NIUHY . y c,. . E I 4. L L ._ AIOit10•IL .%•40Ay _ ' l,i ..... 1 •~~•. ,~. ... ., +..~ fl ~. NOfIN9tALLGO 1 NOT FJECIED ' T 40TIIIUSf TOf>ILV EJECTED ~ uBEO J PAH:MLLY EJECTED UNANOV.'I A L'NKNONNIF 5 5EAi tlEL!(A LURE f.JECTCD ~ - ~r ~i ~~[~ y~9p' 1 .v .... ~ I"~~. INYM . ~! It h t ~, I 1 r _, 1, . >~ ~ ' ,:: ' ~T R T3 9 ~ r VEHICLE DAMAGE I. I EAC 00%, CIRCLE THE NUM11tlER OF EACH DAAIAGED AREA ~~ %AM E T~ EAHEA OF SEVEREST IMPACT. ~ u ~rF c L INSTRUCTIONS' ' ]. WARHOWIGI TO SHO'H PRINCIPAL DIRECTION OF FORCE Q . DAMAGED VEHICLE N0.1 ~ ~ IVSE rrr ssvacc FON SKFrar nc uwAlagc to mAILFNS.ugrgxcvCLES trcl OAh1AGED VEHICLE N0.2• _ - ///~~v ~ F IE Nool ~' ] ~~ , v l"i F .. ~ ~ . i F IS 0.n I). O+.~IUrn Ir urn EEVERITY OGp a ENb.r I ~ pISABLING '- ] ^ OIHFNMV DAMAGE ]C] FUNCT A ^ x b eE ITV CF OaMACE uill RverI CLFI Ic^ OlsabLING DAMAGE E ] ^OTNEq M.V 4GE ] ^ F AGE 6 ^NO OAM STE C S I}-JI On OTIIEftMV.OaM GE ]ELJIFUN^ • C] NO OPMaGE'-• G Jr,,_ ~ 0 E 31T f .baMwcE T P AMp E T-DAMAGE iDweb UY DIAGRAM OF COLLISION 1 ~ rr AW ARROw SHOWIN _ 1 •~ OR G ~ ~~ - N R CIRCLE U TH IN a ~ I _ __ vNV3v. 3 -- I -~~-- ~_ 1•-• tr 1_><-is r ..t• ~r'.a t -: Ic! Fwr ucr ax a.E.3.L,c.1 .. I I - i I _ _ r w I \~ I I a.u YE. nEpR - - AAP Aw FR Cpuuc, _, _.. r..._.._.. _ i _ i ....1 :1 t ! 1 DESCRIPTION OF~ _ uxD Care wHaT Fgg3anLr HA.FENFb bE~ogE OVpiN4 wNO aGTEq THE Cgasn nCLVOE NFbRMgrION NOT ON OIAGRwM O COLLISION ' :: , ,E rDgw~R DlsanGlTY, glquceq vaeurr, FegesT ra LYD H:,c coLgq.egxsrquerloy oq gEFww wogK, Ercl ~ - 1 : •, I -1T1 ,-~ I °G'~'.r f "<li~.~ E- ~~~~f~ r t J { J.~ O,_~ ~F 1..~ ~1._., ~- ~ ;mss ~~~~-. ~~ r~,~_~~- S- _.. 11 . ~ • T f5~ ~ ~ j ~ f ~ . L :i L / 7~ y. L -, .'_ tiL S Jl O 3_~/ '_~.. ~l Lam: - , r_F;,^~ _ _ ~~ r __ ... 7 . ~ __A. _ ' - [.t,iL~ ~C r",_~II<J.~Lh~]- tslr~~ __ II;.F~T ..?.s -1 1 c .. E .~ ~ v POSITION BEFORE COLLISI .Z' ~ -:;:, - ~y 1K s.. owe o Frnon FD FFAN o NEAOEO MILE VOSTO ~ ° ST EE ORH CHWAV NAME ON NO E L EG L vEH. .~ O N , INCNEASING D y E w ...__ ._i.._.... ,. i '_ V AO ECREASING KEO. .OCCUPIED ~ ~ ... - ~. _ __ ~.. .._= •~ L~r p -'~ I ~ v M t., ~ MFH ~" ,res. no.rEe xo , __,:~ _.I ~_ _ _ _. .. r f E 033 G_-_ T _ 1 _ _ EO190vCL STw 3. . E ~ ] ~wiLKwav] 1' ULOER KEO a < R u L ~ C DOE IG E° ~ l ~. J CvC E F _I _ I "-~y : E f ROAD SURFACE IC qN .':WEATHER. E A .>++w~CONTRIBU C - TING CIflDgUMS ANCES F< 0 _ WEYtt '1 Y ~.T C ~ l pffV IjT.E1ECi0 .v,+yy fd OFT .. O OE] 1 N ° °Ej {~"vSlyh ~ OFA' ' . I '.~ ~ c G " T ~ 0 ~ ~ CLEaq, ClquOY .-_ 6SMEt1CA5T n , ~ D Rp OLLOw xc n ], ~ I O RH i ~ _ ]n A U LNG ' '~ h' WEt 1 ] YI RArxING _A\_.. ] UxOE N EM[E OF n n pflGG$ E~ Ov EER CENTER -i f~ F TLY J I_j SIyE ' KiNG ~ ^ PIG T Tu N 1 ] SNO ._~SNOwING ~] ,E Et gTFO ~ L TO ~ 1, 0 RK NG Of 3 ' OC ^`© T . ~_I 1 E OG 1~ nFE3vEE0 E S ° wN R ~ -- O R L . L 1 ~ 1 EEC O~ LEFT U x i~•el KnO ~ L~3 0 ]ER IS>EC - I N - I Is I _! c e ~ I I § 4J`GAS!fMr f ~'LJ~{,211.0 ~e Low Ha.h%I I I OT CIFY l~ ~ I p$ 0 . 1 ~ I r I 5 3 EGO Oi TOV J r~. OHEOI T I ~-^ ytpyF p .}, - T FfIL y~ ' LIGNT CONDITIONS ICEIECK ONEI TRAFFIC CONTRO 1 NO I f LE K~~s~TYPE OF ROAD T O ] ~ ICHEC O EO ORE VEHICLE CONDITION. 'e ppS y 9 } ay I E E ;.pc508RIETY+~'S~id'..M•1 IC ECK O E [~ I AT ON L 9 ~ 1 I ' SO I~1 r ONE ~ a C I~I NO. ] I JP(FNYE UUfEOI N I E OT -~ __ !~T OR naP 0 III , t . NAL S _ :. ~ ~g! -t SO OEV I ,r.,,~ J ~ I 0 GNT t I STOV G . ! --. ~I]I -nypwgv --• DEi I~ ECtIVE .._ ~ EftAKE3 ~ e IL v I IJA PA NE :~ -~j ~ t ....E ~ ~LJ y. ~ . ~ Flo ~]1 ~ S GN _. .. I nEVFPSIEI[ ~ HOAO_ .. . __~, ] -I OEF EGTIVF - ~~1_HEaO lIGd15 I ~ D 4EIlITV -~" I I ~ NpiJMPAIf1E0 TRAIF CUHf I~11~ yTAgTINO ~POM > u L ' KFD LO L ] 0 K ~__ K ~ 3 IxG -._._. RED.. r1. INTERCNANOE - ...-_L09PPAMP___ ~ 1] 1 p F CTIVL „~! REAHLIGHTS _~~ ,,LLrr """'~~ ~DNry~lRIETy J`I] _ _ S T Of • , L I[HTERIN6 ';` QI]~j'TERFF I DARK-S fE '_~. l10NT90 _ ~ SHING lE fR _. ~ '~' ALyyy .1J_.-. .____.~_. -_ _ __ IN ~ - i TRES wONN .~I___-A!LSMOOTH._ , I' T Hap NOT _gEFN DRINKING IC] ~-1 ~~ ~ "~ I-:'.s'._1..E C%IHp :I ! Y -. aqK-s E Lcnno ;! '. RN ~.. ac L ~ ' rvro way-LFGr a s y'1 r nwrruKlD ~u E IalR CHEM. TEST - . ,,. ~ ` ~ ' _~-I_i SIHEET LIf 3 ~_ ° GIAN v E I `~. L.Jf '1 TES O E ~ 3 ] rV O[O o FIOOEFEGT9 1 I TFSi NFFUSEp '~ • y~ A ~ ~T L~ 1rN ~. 10 YEC ,AN r.U - ' .En.N k J ]' I•rp EO , Ii Gr E ZCiirl ECNF° Y v TEST RESULTS `h.:; k 2 ~•• I 1 _ E° anfbiw EU LE TNAFFI[FLOW EOf - s y vun~al - .LJSx LNnnIK ., o AGING o u .r. nr _'~~ R ~~ • i i '`v ~, 1 ~ ~ [ ] - ~'., _. ~ T'. 1 ~' ~„" ~ tt? M V M1~... C .~ S ~C,~a ~.. .. _ S 1. .. 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Ot~J p ~. ©© u.~1 wiAwoAEOC~svria ui¢rrosianFO[xrlir4a NnEqulapcEE P IAanNA DAtA RA LwvMN1n I ©© i i t . %~ Colllla wvWVtO ^Pnf ^61~EUaE 0[vl~K[Ce ~ I ^PE ^ FwCE ^ ZAaWpp9MAiEwA9 BFUq iN.WSaplliEa: ~/nL~~ Y CI wo SO~ ~ w[~ CL9 II O n n[a PEF nE~~H~[O B ~ D B Eg YxTEa V CIMECI STRUC xAM ~ µ O // ~~ >> .N COga05NEM FJN AL AMMdxM ^R~OIO ALiIVE. ^ J M ] 7 s K I E OF~ ]IRUt%I e </ VJL Y OYMER OF OWECTS NAME AND ADDRESS Fr~[n[ail~awUIECT c.cOOE USE $ •'4 • Of11VEF'S LAST NAME 1 NAME ~ MIDDLE MoaE rnlw ~7~~y iiwn cws DflIVER'S LAST NAM® Flq NNA wEa wvolvEO MIDDLE o (JJ - E lL]ax as e STNEEi ADDHEgg ROUTE NO. ANO F>D%NO.. X ' / n Q P" EMw Twp _ P~[asON9 wEaE 9TREET ADORE59 ROUTE NO. AND BO%NO. y •4, piY STATE nEa USE A N ~' LP CODE 9 f ~ ~ aNN ~ DRIVEq'S OCCUPATION caw]ax CITY nEPpaT Fawn STATE LP CODE DRIVER'S OCCUPATI N DNVER~S U N AT gEX GATE O F BIq[H ~. t `/ ~]J~ /~ -~~ ' FW [ • AOE 4 M ONVEq'S UCENSE NO. STATE SE% DA E &qTH AOE M f M ~ VLMICLE R? MAKE ICMEV. DODGE` MODEL INOVMDM7) ~DppygTY~[1~2DRA SrQOG 8 Su6nR~.~ [. o oAr rn VEHICLE YR. MAKE gHEV: DODGE) MODELINOVA~D T) BODY STYE (20gJ . o,,, UCENSE PLATE NO. STATE T[WLEfl PLATE NO. TATE /t // ~ EN E PLATE NO. STATE TnP1LEq PLATE N0. STATE vEHICLE lOENTIFlCATKkI NO. ' gE.19TFAE0 ONNEfl (LAST~FIRST~MIDDLE NAME) s DNVEq'g LgENSE NO. VEHICLE IDENTIFICATgN NO. REGISTERED OYMEq ILAST~FI[IST~MgOLE NAME) ONVER'S UCENSE NO N [ OW ER'S ADDRESS (STflEET, pTY AND STAT )• MS' L DATE OF &qTH . ' _, OWNEq g ADDRESS (STREET, CIiY ANO STAT 1 _ DATE OF DI iN PMTS OF VEHICIE DAMAGED ~~AMiN ~kpn~~r i0 p AATg OF VEHICLE DAMAOEO ~ DA N I vAl a $ x~ LIABILITY INSURANCEINFORMATION•VEHICLE NO. 1- WAS THERE AUrorAOaLE UAawTY INSURANDE COVERAGE IN EFFECT FOR THIS ACCgENT ON YOUR CAq ~,VES ^ NO NAME AND ADDRESS DFl1AGILRYINgORANCE PO Y OLDEq ~ E x'A'E • NAME ANp ADDRESS OF UADIU YIN9URANOE ADEN .NAME OF UAWUTY INSURANCE OMPANY pn~ u ~ S Isr wJUgv: ' sTAre , »P UASIUTY PO CY NUMBER A ' NAM AGE 2NDINJURY: rvs[sEPAaA[EIIEPOarfoaAOdiaxul uNE91 AGE E vuun[D NAME ADpgESS ( SE% rvATpIE AND rT M F ADDRESS 9E% F.%TENT OFINJUIIIES ~ DID INJURIES gEOUIRE [LA~~ ppT q5 C..KAIAJIATION DY A DOCTOM ^b r ~i NATURE AND M F C ^ 1 ' I E%TENT OFINJURIES ^^ I • 1 pD IVJUgIEg )q NAME g TUg OFU11UNED ON REQUIRE OOCTOq'9 E%AMwAiION DY gpOCTOM ~ ® NAME _ ; ' N ~!1/'-+ u~cFIRST ~E lpy'~APpUES gTATUg Of INJURED MARK FIggT ONE 7HAi AP M VEHICIE I] ^ KILLEp Iv uar No / Ix~KnE 1 1 PIIEg IM wlv PC9u Rye ^aPJV~A IN VENICE[ d9ABtwa dl ois+ Po^siuu IM "w n uK1 coM"rwxr w r ^Pla1YN,wl ^ 5 ^ o f f,01 OP[DF]iN[w N0. KILLED Ia EVFI1Fl 1 rvWl IIOinWn~IC I[ B~Q 7^ ^,.I,,, ,. _... ^ 5^ 8^ 7^I MOTORCYCLE SAFETY: ^ nELMEr us[D ^ HEWET NOi V9ED MOTORCYCLE SAFETY: HELMET USe ^ SNOW NOIITN GY NIR01Y w CIRCLE D ^ HELMET NOT IISEO a,UCMl or ~aalAaUnAM O I NMLE, „l«9 .~ >WIL , ~ .-c OE9CRIDE BE`OW WHAT MAPPENED:IflEFEfl TO VEHICLES OYNUMOER) "' ca,es,~d h(~l oN ~S~~r eu~erzed ~fvrn[ ; . .,aw t"~S K w ~ ,Y~,~9t ~~yo,.~Pti, 1R ~~i- a~o~~asa rf ~ _, C~ e `-- * [,alll.anw „a ,r ~ h 5lo l~vdl~1 p(~ ~N,1~~ '+°hH-nrl~• ~-~ c It ~ , ~qq~~-.wGtrt! ~t-¢,tve~ ~erty:.ed w~h~el o - , cN ge inRa„ds s~l'(`~ s-eeo~(. G,~t,9. t. P~c~e~e~id t covle~¢ ~1 _ . ' O"' ~ y, -~]4~' it~.RolJ~c~ ~gee~onrly T~s _ .. ~ . _ 1- • ~N ffi _ ~~7"1 ~ f UlQ- / _.. _.. VEHICLES POSITIONS REFOR E COLLISION VtHgIE DII 9TREET CN I4WIWAY I w aasnro vrr.Fle wVE91gA1CD nY o4 wtw unV u a K Ir P / l[000 a INAL Oq NO ,p .[ ~{p d~[alaN • M1 v[] ^ NQ ^POUC[ IJxa IN ^ ^ ^ ^ ~ awVIRII~ 41n,WN ^ ^ ^ ^ ALdq ^ ^ ^ ^ ^ ^ ^ lnNnY cnu]Awo /~d IT,oM DIRECTION o rj DIRECTION PCUCSTNANiPLOAI CYCIISi WAS USWO: .LA i^wr:,Wlr I^uaAV• . ~y ~- i aorw ~ N~4o 7 PCOCSTRIMI,rP~ CURL CYCLIST CLOTNIN6 COLOR. µA ~ C J AW ]. • a^O,rKn [^m'E iii E^ra.lnv.Al I ^ pAn 2 ^ [aN[ J ^ .a,[ fWAp I W WCATNCq CC LAGNT GUNd I p +^ s ^ gN9 PETPa MII[C11K 'P.NIL h~0eiii~u~[A. FiC f C ~ + I ^ WYL%WI r K.l I fMifq COIIfROL TYPE Of ROAp DIIryLgrVEngLE ACtg119 vNKU ,C.n [v [wZl vNKLT 11rKL c1 4 [ r t J fiiVU3rM ^ pir I ~OKII'Ai, ] ^ DAWN 1 ~[ KC%dVL d, WnTl 1 i MI xOZ I ^ I ^ SI[ylAt9 ^ 1 ^ ONE WAYS iv]! I ^ p011q 6TgNM1T MEAD ^ 2 ^ K[i ] ^ 0 aA9Tq[f ^ ~JFF y T ^ ] ^ SIOn S%1[ 1(~] ] ^ TVA WAY ^ 7 ^ OYERfAKINO AND PASSING ] Wq ~ ^ ^ ^ LUHig ON ^ 7 ^ w[lD WON ] PEVCHWBLE ^ J ^•JQW ^ ^qp~ ^ ] ^ MAKIHO RgNf TURN + ^ [~ ] ^ 1W~19 OITC ^ A ^K[. A D1nEN OM %IA] ~A ~ ^ T ^ % ^ ILA911nq n[p A WT[RCNANGE `-' ^ILOOPrRAMPI ^ A ^ MAKIND IF.fi TURN ' y ,' 1 AMU[ll ] IWSCV YI ' F'] OT K'vIIGNi] ^ C ^ S ^ ^ ^ 6 ^ MAKPIO U~TUIIN ^ ^ 90W OrT M yp[µ TNq WAY. 9 VIII ^ E ^ RLOWINp IUAUWA Citll IgApWA 9UW ACE IrPE ^ ^ ^ E ^ lAV ~~ kl I!P' S ~Ar 1 h~' •~.~n T ^ [ ^OffglOl['LAGMAN T molY~[D FOn iRAfrIC n , ^ LYUYEWAY ^ ^ gppl y .. ~~~_ ,;°~Tf I f _ . ~ ~ ~~~ .~ ' C y A ~ ~, d ~ ~ ~ , p ~. ~' ~r:M1 ~Ill't~Ll"IE (7F VVASHING'1'OfV PAGF ( GF ( ~ Nn ' ~iSJ POLICE TRAFFIC COLLISION REPORT ILl'TRAFFICwAY Poucf cGMnAIm NUMBER r PRIVATE WAY OF C,%US N tlmE COUNIY ° E CITY NO. COUNfY NO f L ~4 "L SS w. N °~I; ..R Iw ; " I ,.I IlI5f 3.00 NOU¢ a a3 ~ T' F'- o,/ . /~ UR AN Q DGAF I ~N ~f ~IN CIIY OR TOWN f6NO.Of SIP(f10R HIGHwAT I r Av;fs Os ^w EdOi ~ uA/S' ~ ~ S:~N/GS +~ ON iCl ClS ADM P I RWEf OR SiGEF M 3 ~~/~~~ SfC110N n NI[u.tCNN =wItN. 51N[EI Oq RO ~ T (~ ~ N Z PRfFI% f°. MIlf P051 / GO v - 8 MrUaLEfbl~~s wFFNJ OHN ~f rKcZO/Si G / / . • UISIaNCf gpufMllON i4 REfNEN CROSSSiRFEt OR NFARE51MIlf Po51 IItS N~-.a.....f.-•~w gCCIOENi MILEAGE R P DIAG¢AM OAIA ' C J ~ ~t rffl _ of M I o/,.- ~ / coDE ZD COIL SqN NvOlv[0: SEVER IY: lOlAl NO. NO %Ill[p~NO.INIURfD~ ^SPIIIAGE XD 6IRUN U VOF CIfS ~ ~PROPFNIY OAMAGFONIY ^gESUItfD ^bEa~~ wrµiuaioln iN ~ D INiE CIS IN R CIIN IRE R AD OR R[i(RfEKf CROSSSfREF10R POAp _ (vG7.~d ~ W fCi B1NUCRINMAF Of OeItCt SIPUC%ANDOWNFRSNAMEI t51- AMAGf ,171 ZH{- SEE s SPFCIaI COOING Irit UNIT NO. i UNIT NO. Z ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYGLIST urv(N' NAMI: USI I I tJISE.I~S .r)r'1nJ/EL E GwfGSNAMF Usl I I L FN NF55 S PEEZ AOD RfS: ` ~o X .~ k 3 ~a 6~LG ~K SIAIE ZIP CODF PHONF NO D N N°. IIY SIAIE ZIPC DE -~' 41vf N'S IICENY NO. SIAIf SE% A O BIGIN I IV II fNSE NO. SIAIf Sf% DAlFO iBIPIH AT ( ~~ /~ O ~ ;4 NT V B OCCUPA110N NM NAMF6PNONf NO i EYES W E IGHI HfIGHI E OCCUPADON MNAMFa PHONE NO EYFS WFIGHI MFIGFII Z DEPu try r SoAr CU. SNCoq.NN~ b$ SlO R CHECK(/) n[asiN ri°APEOriF Or ANOfH[a'w vF ~ CHECK(/) FNC FASAN FmnovEEOPa"o1rER~k r~ y~ ~ < ~ s k I o" a ^'O~oNC.nl~ CODES ~ T 9 ~ A"' CODES ~ ~ ~ <Ti`s < 'sv 5 Enc N a ~~r •cu 1 L I„, ES 3 °N ^ •~ ^ Eb.il ^ ~ ^ ~. ~ I AY ^ AMggIANCI ^ E °~' ^ EbaE. O vi~Kle ~ ~. 'N:. Po e TtAC ~ MA%F IDO°Gf CNEVI MOUEl10AGt~NOVAI SITfE 1204 CONVI MA% F LHEV.I MODkL IDAGNNOVAI aR f E ( pq.~ V.1 1/ ~ o~.v Lrz~ ~I a•c E °:B ~ OR UCENSEPUIft Slalf IfR RACE NO. SIAI( F'I N lA A II vtN CIXOR ~ N IAIF f S VF"CIf JpFN11PICAtION L vtH CIf IDFNIIi AN NN c c(GISIINfp OWNlq' U51 NgSI MlpDll PNONF NO. ISIE DOwNFN: USI fIG51 MIDDIF Nf NO. il IJ Z D4f35p OwNlR ~ ~ ' C ! SE ' N 4 . wNEq L I d. uG.-fT /IacJC /r' oN FG~LS du,~ C~ E A 16 ADP4t13 (Y INSURANC[CO. p1 AGtNl ~ A I ~~ R IN.V AN ~ DAM.cTD AGU r F ~S[ID qo S'D~~+' s . DnnRiDrvN ks~I.. ~ pNAAG[ CHAPW ^A ~ Nlvlt!F RtAWNlD '~'~'~ ^ ~ CHARGE ~ ~aN ~V ~G[MAIJ[D , w ~ nCnOrvN ISI rUAMAGf [JAN FO APU I~~s `~- - S LIJCC7 IfiwkD IL f C.cSo.r TC t.NJ A% Y lowfp ^ Aw S ~ N Cxe NaF INIneAII NOVIN DIAGR .M OF COIUSION: I y swnu N¢tsuRr( er ARROw DESCRIPTION OF COLLISION: lusr wPrFEmfrvlAl sigFlli rvEC[ssANrl r C~3 OR IN a°N Cd• ,~J. RJn AY~GhaACNI,/!• ,4 \. r/L^ Cu.c:vE Tt T}r-,;' R16rs'i•..QL"C~A•IME~JEJ '- \ ~"f1Sn~6S SPEED ,~c-Y. ./1REVfiC Ll .Ai Su.cE n~ /Yr-rS S~i/Ee0 Co u rAi(, a r~ 2 Cu [ v't` A PifAKCA y rp /(C Go> /,. ~ nlc Cu a./C r/c gAl.arca> ' /C7 o~L~ ~cr -r Tr/c v~~htc tC f'aich, Tn Szc, r,~ -- ~ ~_,r,.x Cnraua./ 71/< vFrncf( w6^-T or?' nhc--. ^~ --`"'~-~.~ lLrnvC- l~-7T~ 77f4 l7Y !'GN NJ /T Cp...TnrGf~ I c E ri.r.. .'-f... <.'..r~ lylF Cl,c ti / E . / c'rYr C[ E / T ~'••.u c,e NAME, ADDRE 8 INJURIES OF PER NS INVOLVED N CODES 1 - 1 3 4 5 6 OCCUPANTS /WITNESSES Iiou4:npP,iioN:i nl:,.a ii u% apf ,uws '" gfslR. ufcr " I LI ,~ A L!'C.e W/. AI OG 6r ~ xlNk nr. M.. e ~FA1KI ( ] " . ~.Nir ^{'.°.'H mF qm m .r%wlss uR Or P RmovEDrRGM~ ~~raa ~c..~,rar ^IV° Ame AM1 Iq AMGIit INAN~~(a INF e• ^AMe ^~'ZI ~~~IY ~N11 ^li~ II t NN>IKAIq,GplKlgi W.MI{YANG OApGIW AGfIKr KI DISPAICMD Yq Kl AR41VED pAII OE GIFOgI OAIi I 1 I .. ~ ~„ E• ':1 ~ .:t. .:~ -: v.' _.. '~ .. .., .. ..~ _~.:. ... ... .. .._ 5.'Me ~~ Y1 , ' a 1 kn~ a S r ''`I..-+' ~ rim 1. ' ~`, ~ - 1~,1 ~ ~:%~~ MOTOR VEIi1CLE COLLISION REPORT NO. _ ~~ MO CINCY'IN Un uON UUtY wED~nuHD fN. aAT NEDFCCpLEgn CDUnrv/ CUUNTY NO CITY ND. ^ >i ~' f 7L ~/%_ a urr i 7" tTDCI/'t C // ~~ ©.. ^N ^E ^w ~ NAMEa NO. F ET ni wDNWAY ApA CIa, EW bTPFEi CODE + a:DD;~"D Ea ^ a ^ w ^ DF ., D .,, bN i= r r' %~ %,- /i.'-/. ~ R 9sz io ; FNS[CTw6 mTN aiNET pI wIEPSECigN NERx EO MlEgsl - ~' L~.s/ P/MP IILRAM DMA ~~~ ilFi ©.© SnD uIpDSEUJDRW DP npl EII~DG. nlsfa al: -'J r A r o /i wa MDr ' ^SVitAGE f ^ N9 MATFNAEa BE NxaPDli ~yg PwEiFpI FNCEODP0696i~REEI~lgAD .n o avO.D ADLE lquO EWLDSWE9T~^MLDnwE nEA D°`~"° ! ^~ ^YE 8~~"R~YIYEMNEN.L B.M ^R,DID M„gaK °p ,3-9?oc~ OBJECTk3T1iUCN 1 NAkCOFOWEGi atPUCKI OWN fl FOBJECTS NAME AND ADDRESS ME NEp~H t~01~ Fc.EDce ua[ "` fiJaSLfIiY/WW4 ~ f MJnE tnw 'LJ ~ i f 2 dIIVER'S LAST NAME FIH TNAME MIDDLE wEBE wvavsD ORIYEfl•S LAST NAME fFWST NAM MIOdE // ~ _ ~ Tnls e I' I ~ /Y- n /~I ~r: L-~ ~ caudal on t . ' . • •-• wnEi µTwo e. r : ~ :. STHEETADDRESS ROUTE NO. AND BOXNO. ERwx, wEne STREET ADDRESS ROUTENO. AN000%NO. VS ~.... ,,-: -_ CITY STATE LP CODE DRNER' OCCUPAOON aLSgx CITY STATE LP CODE OflIVER'9000UPATION ''~ EPDnT FDR N~i !' , OH VEfl•S LICENSE NO. S A SEX DATE OF BIPTp ~. AGE7 DRIVEN'3 LICENSE NO. STATE SE%. uDOATEA WRTM ~ AGE N I .Y _ VEHICLE YH. MN(E ICMEV.•DOIXLEI MODEL WO A~DART7 BOOM STYLE I.^DR.I VEHICLE Yfl. MAKE ICHEV: OODOEI MODELLNOVADARTI BODY STYLEI~ON] N - k LICENSE PLATE NO. STATE .TRAILER PLATE NO... STATE 'N SPLAYS NU. STATE TFWLEq PLATE NO. SLATE .p 8 /'ham . S % l ~.'~'>, 1 k j 'L ~ k ~ VEHICLE IDENTIFlCATION NO. VEHICLE IDENTIFICATgN NO. ~.. ' 'j P REGISTERED OWNER ILAST~FlRSi~MIODLE NAMEI DRIVER'S LICENSE NO. REOISTENEO OWNER IIAST~FIRSi•MIDDLE NPMEI OdVER'S LICENSE NO. ~ ,~ ~~~ Om1ERSADDRE33, ISTREET, OTY AND STATEI _ GATE OF BIRTH OWNER'S ADDRESS IS(REET, CITY AND STAY I OAT OF DIRTN PARTS OF VEHICLE DAMAGF/D I A ~ wp,~(~ol4Er D PARTS OF VEHICLE DAMAGED .~ .. ~H I LIABILITYINSURANCEINFORMATION-VEHICLE NO. T• WAR THERE AUroMOptE UeBILm NSUR,wcE ~ f ~ ~' •~;~ COVERAGEIN EFFECT FORTNIS ACCIDENTON YOURCAR ^YES ^NO P.~' NPME AND ADDRESS OF UABILRY INSURANCE PDL ~Y HOLDER -- ,NAME OF UA&L((Y INSUMNCE COMPANY 4 P ~' ~E I div /77 ~ k ~ NAME AND ADDRESS OFU ILRYINSUMNCE AGENTS _ ptt sTATE m ,UADIUTY POLICY NUMBER IST NJURY: AGE 1NOINJURY: IUSESEPAMIE xEP0RTf0R ADpigxN.wJUNEaI AGE •,-: NAME rxlun V ED NAME ADDNESS MEF ADORE59 MEF 9 1~{ NATURE aN0 r NATURE rW0 ^ ^ ERTENT OF UUUWE3 ^^ ~ E%TENT OFINJURIES E%AMIt1ATION UYDA OOCiOHf ^ ^w NAME RS EXAM NU TIE~RBEOAIPDOCTORT ~ 0 NOAMEORS t i ~, SiAt U3 OFINJURED MARK FIRST ONE THAT PPPLIE9 STATUS OFINJUREO MAR FIRST ETHAi APPVES ~'a 1~ ^ L I I VEHICLE u.WCw IATV~ugO PWauplF pSADt D xOn~ugpwD PDSUAM' ^D IN VEHICLE ~~ ^P[ IIVAN ~ NILLED aEVCRC uwpr D uP4Cwlt ^ N~ KILLED IaEVEPFI uw4n UOIP UftCI ^ mai ^ S^ 8^Y 7^E p., alw°I ^ S^ g^Y 7^ L '' lak f'. MOTORCYCLE SAFETY: ^ HELMET USED ^ HELMET NOT USED MOTORCYCLE SAFETY: ^ IIELMEf USED ^ HELMET NOT USED / Xj • '~~ ~; SHOW NDHTH UV NkIiOWIN CIRCLE _DESCRIBE BELOW WHAT IMFPENEO.IREFEN TO VEIIICLESBYNUMEIERI - r v.pCArf p. msp.MwAU O ___ ... ... _.. ... _ .___- mMHIAwNwD ...-_ I ~. [ aRwl lwrn Ewla - - ~' 7 '~Ml still wm~v'~f tu, 5 .. M1V n lAtrr vCwC AND 9.qw .... .... 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'.fir ~Y+ ~^ PEOL•STRIAN/PEDALCYCLISiWASU8W6 r^INwwr% F^...w.r ,QegL.oElr 1^no:..1N,^~"„~'..°K I^DrruA (^d~„pl;~ ,O AD f' 2 ,pi ti PEOESTRWI%Pf.DAI LYCUET Cl0711~N0 COLOR: aM+ I ..r [D Mru AVLlcirvF F v.ArL rgw.r ~ `.rl ~.. ~ ~ AO.PbIMIKE nCAin[Il LKWi CDNDItgN3 1RAIFIC CONIPOL IVPf OFIIOAD OIWEHYVF.HKLE ACTIONS ~I ' y ~ ~ ~A. 1 •. L L.! ,T ~.':~. I w.Y mrswr vIn KnrCF nal v K a <r.rC. MI Vln[M pYCN 4NL nr M'JIVI y _ k ^ OAYI%iHT ~ _ I , w f ~ ~ wi, ~~ > oNMOm t t I ('HD, 1 ^o~nA^P-kTAfr 1 ^ DANN ^ 1 ^ GdMLB ^' r ^ GNf WAY ^I I ^ OOINO SiRAdl1 NICAO I I S I ;1~ 11 +rr~Al (•~1 ^ i ^pH I ^RAPnq ] ^OUSK ^ ] ^ B10P `JGN ^ ] ^ IsYO WAY ^ 7 ^ OVERTANNO ANO PA331110 Apf ~ - ~" ~" ~: ~ ll, ^ i ^ WFT ] ^ yp,y~M, 4 ^ ~~ fSON Ei ^ ] ^ YLlO.40H ^ ] ^ ROTA SIOIE ^ ] ^ MAKINO RgHi TURN Y ^ ] ^SrK)w A ^ (~ S ^ ~Gr?S O(/Li ^ f ^ ILASHNO REO ^ / ^ LoowaANlAne ^ A ^ MANNO L[fi TURN L ~s lT '1,~ ^ 1 ^OiHLR S ^IDEYCCMYI S ^Sitlf Efp gNT3 0 flAd.NO AMD[q 6 AIIEY 6 MAKNOVTURN ~ ~ ~ , A } ^ a ^ SIFC.(Y O1N(11 ^ ^ ^ ^ TVA WAY. ^ ^ ~ r~u'' ;n Y ^ JYpIY ^ D ^ PoI XM4 ^ D ^ LAMISU N ^ b ^ & DWIND ,~~F V f U.: rYJApW C N1ACiLN NDADWAY aUWAC IY ^ I ^ OIfKCR'ILADM 1 (, ( ^ LVIIYE WAY ^ r ^ 6TOM'CD TOR 111Af(IC ~ 1 ~; 1'1 '~ I' ~w ~q + d~"l{ !I r . ~7w 5 la , ~~ ~ U~E~~ ~~~ ,4~' ~.,'rP'1 ,"~yF ~`+@5;44,.Me4y ~I 1 ~~~ , j~ ~ 1 J.VG I { d . x P ,.4, B '~ ra FMn, x I_~y _31N, Y'+. l I., ' '. .. ,, ~; ~. ~'' r, ~,; e t 1 `t, ~~u ~§ ~; J t .~i ~~ ~~, ~~ T , ~, r q ~ ~~~ r :;t~ F .. ....~ ' fa;s... `r .. .... - ... .. „_+. .. ..r .,........_ ... ~ ... ... ,. .. _....i~..~_.:. r»f~AV~.. xwralwz > ada _. _ . •r..Ak - 4~ .~: I F\~ POLICE TRAFFIC COLLISION REPORT ~ TRAFFICWAV nxKE mmxwmNUmbfR i V ~ PRIVATE WAV DArEOt colusl N auHON o DmE courvrY courvrv NO, cnrrJG. rnwA / ml end u H ~ pL ; l lusE ~ ~ _ // O N K I G _ D 4' ~anl p pE pl C1Y R10WN NAMfAND. Oi SIx[FIOR kbGNWAY P2. Mnfs s. pw ~gof,(10 GCG1L r/ ON R fCl ClS A RUUIf OVS REf ~ ~/.5"G 70 SFIUON > I IFNEFCHNG W ill iNF[1 OF NOAO NON INiFRS[CIION BFIN'FEN SIRFEIb BIPfEi ~ PNEH% FO. MLLE WSt ~G~ C I+" C'M1OUt ^I Ork 140E f[N NCf CRO5S51N(f10R NfANF51 MIlf P01 r / LLf5 N( 5 F LY ACCIDENT I E GE RAMP DIAGRAM DATA , E ' IEEI []\ [~ OP M L A CODE tlSOEI NVOIVfU~ SE•/fNliv ^SP IIAGF ^N~}'RUN NO %IILfD NO INIUR[D IOI E wrvpukOH INffR ~ Ct0 IN ER CIINGS4(EIONROADOR 9EEF4fNCE. CROSSSiRffIOR ROP9 r _ ~ AI NO. (Y VfHKIfS ~ p PRUYf RfY DAMAGE ONLY ^ PESEIIIfD ~ta<I!J^ ~ .,~ ~J~yOC ObltCl51RUCK INP.ME Oh OU1FCI STNUC%ANDOVMF4'O NAMEI ESI,DNAaG~I SPfCInI CODING USE .v ~ u, l ~c s o UNIT NO. 1 UNIT NU 2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST ~ ,HrvlN3 NAME' U51 IRSf I Dlt ~ M D4 v[v'SNNA[ N51 H4S MI Ul ~ ~ A - Ga ,v , F[InUVU ,Yy J SIVEEI ADONFSs .~T ~G c slAlE nr coce PH D r s1AlE zIPC DF PHONf NO. ~•'- p ~L /7' S.~"~/Q // /'^SIICFr.tN S1AIF F% DA1kU bIRLI m ( IV RSIKfNS~fNO: IAIE E% DAif Of BIRfH MD'D i b IXrVYAl10N lINMNAMf 6PHONEN trf5 W[ Glki KR:HI E occuPAlloN NRM NPME 6 PHONE NO EYES WEIGHt KIGHI ' z ,~ /,UTG~P.u9 r i,p so R p CHECK (/) WH rDR OV[El1PnEMioEH14N p CHECK (/) sA N A A D ~ CODES ~ v 7 a" s l e smAO ' CODES ~ ~ ] ~~ q ~ S f a 's"A° ' v w~IS S roM ' '~ 1 iu v ' ~; x' 'f " 1 YIAN VHr [{ UGF t'Hfv.) ~- mODH IDARi f SIYH I4ON.CONV) 1 ,e9- ,~ a dPe E r IYtAR ( ECHEV) Y MOOEl1DAR1.NOVA) l IR NV) ro` ' , 6 r k UN lCFNSEY IA EN 5141E IRMIER PtAIF NO. SIAIF F'I \M1H IXON l l Il lAl NO. ~E-~ p-' ` ~ ~~ VHIKIL OtNif CAtION I+. i VFHICIEIDENI1E CAl NN. RIGIS INI00W1LLN. NSI HRSI UUtf ~~Lr/ ~T ~n~5 ~ M t vIgNF NO. O W v[ ISLE LD WNfN: 1451 fIR51 MIDDtf N[NO. ~ ADD4usu fir, ~ OO _~/ST AQ SG ~J /],Nf/ N E A wNEN NASn AooNlssa ~risuNANCf co. l:+' ~ fsOA ~' (/A/J~ ° "• I I m e G~ R IN u rv A , Y zo II~^^ A ip ANIA lw I p '~d0 rvD .iu AMnct l51"U CHARGE t p;W^ly ha RIMPINIO YV C.IA4Gf L'~ ICI AR'AYN pRLNAINED w 1 oSAMirvG O~NPn.wx tS11UCNAAGE DNAAGfO A4FA ~s 1~ IlL/ oO S ~ AWAi°bY. ~7 AWn p M1Y~ $ ~ • 4 DIAGRAM OF COlU510N: I SuvnEMN AI N cAlk NORHi [tl 11 ll[CESURY) BY APVO STi1,1tJdLtkR/t I `/g x O ~ , ` ~ ` DESCRIP110N OE COLLISION: IUS[SUP%f M[NIAI BM[[I IE Nras5A4r1 _ ... UG•7//C [~ ~e~artl Gc~dlJtn Tf/G '~ Zz ,. ~uedc'+e> ~ M,~ /~a,rrf cdA~/ ov 7"!i~ GG~Fr ,s oer. _ -- _ t3 k Ct~~~SeNJ .STiZOtdB~KK~ Ca/ver~,y,7' ~i ~ y /,f Cz/GUCa!J' L1?Gs~ 7/yG~.2. ~1127~. sn , ~~~. ." X 'U~~' TrGKwG /3uy, ~ . Iv NAME, ADDRESS B INJURIES OF PERSONS INVOLVED ~ CODES I - 2 3 4 5 6 OCCUPANTS /WITNESSES Ilcw wD"~oEiu nASMiei AGL SfA1US u% - " "" P[SI4. f1LCl { '"'c" eMl YnAJI _ - Ml N .,s ~AllrR101 ls . MUVIU 140M p. p H.A:I p... • ^ ~ ^ ~: RU _ Anil .;aw _ T ~ r.. ..f HAAiw~a ,SI ". pAMe pH n ^t~»in pH ^ :_ ~ ' rono-: '- j ML Au n. AVI t nuo Lc rtAni vlo DAna Poxr Provme o n X T ~~'~~ ~1 ~r r "" Er,:A i a . . ..~r w r,!~d ~ .~ . ~ ~"' o-rrl 9P Vr ~ `~ f ~{K~~ .. ,~SYETI!'Vf~l IC t ~ l.~ ' "t'~f" iM I ": ~. ~9 Y ~ 7fr~y, i F _w' •~Y _... . t l `e. ' ,'~ ~4 ..~. '~:-_ r ~ `;r I ~~ ,~A~ ~', I'~rt I ~$ ,~H.~f St {1 ~y .. ~ k~ 1 f+. ~ ~ }~} ~.. r t J 4 - t ; } ! .( l .. w I F7j i~>Yrr , '~'. ' fl - , ,P.. K:.,. 4 ~.~ 2 ~ Wti Q~'.R ~ 7 _ @ __ - -~:~-. ~e~;;...au"1 .h1:,' 5"12..----'~. 'u „s'1p.a.,. tl....~..'~ _.-~ .. ~~ ~~Ll'°L_II IN.I F I X I ,u,~ ,, , ,•x~ nu ~~ t ..I L° ~ //I~F 5J ~ U (i ~ I , . , ~, , ,x L+i1s2w ~(~ srue~.. (7 ^ LJ` ^N uof sT ~©i II ~ ~ 1 ,. ~' + IN-.-~-,~L5-, G ON CCt/UT ~ ^W ^GF I/~ f- -3s A ~ a ~` Y 1 nNxs iun K ExLF, ~ O y~~~• ` ~ a. a x .+~ xMLIPANLxN::xtl.MlLrro,TDxDFNIFYx~L,x~MAln r ,M ~'f T `N LpM l~~x~Y fl p= i / ~ 3 ~- ~'~ ~2~ o ^.N N. IxAN:roSTfD. ~,u - """ .,`o~o' ~ ^ ^ BAD 6 DIYE ~ ~ o .o L Ffx otlL rsnwcK Murau NA rox xD, vE ~ OWNEH OF ODJECTS NAME ND AIJONE..S DTII~ Np ~tcT ~ooL [ zb :, ~~ r~~y~F~fs~~y'~~}~j!~~~~f'.~~I~~}}~~'~J~Ffp~l ~ ' ':' DIIIVEH'S LA57 NAME FIHSi NAM1IE ipl IF UOxF NI,x x.1.0. . F -~ f ~ . - ~ MDOLF iwD C,ns Ufl1yEH SLASi NAME FINSI NAIAE [ ' w vt xvosvFO ~ .. , MIDOIE _ STIIEET AODflFEE o C7t10/~4J ,(~/GG ~ ' t ~a r r xUU 0. ANO BO%NO,. vlNS ox J~~ 1.. ril/~~ nv~ ~/I / F SiNkEJA0UI1F55 IHUx[ <CJ J~ ~-~flOVTE Np AN000%NU /-/ F ., r , , 5[Y, ..STATE L yi ~~ . COtL ~- Z CODE OJII aSOf,[VrAil $~~-TI~ ~~ a M CI ~I~I ~M%?~.IL EroIN FOx TY.... GTATE _._ ,.. ZIP CODE ' - I l d L ~ ~/~~ - V~H :00011PAi1( f 4 ur lv(usuculsL NO, ~_/>~''s+-tom p. C'~/dl/~G'UIL~ ( S ~-c 6I~J i STgiE ~ ,[) 'A_' L e , , . J ~ CLX OgTE OF DIaiH AGE ~ I{:I.2.-L~/k • u F uo n,v UIIIVEfl'E LICCNSE NO. _ ~ - STATE LE% D ~if. L/sf/FAG HL;'c~ ATE F tlIIIT r ~ ~~~~ / ~ .°.`I 9 ° , _~~ F(// VEIIICLC Yq. MAKE ICIIEV.OODGEI, MODEL INOVAOANTI D ~ M f u Y YN. B n Z ~ ry .L- - •" " l 1 w .;Ay '. {7 J /~RL /O LI4lNSb tl0 S E IL on.f ~~ VFHICLEYfl. ~~ / MgKE ICHEV.DODGEI MO?DEL~INOVq~DAH7'1. DODYST LE.I Z DII.1 ... • -~ I r~ R _n Lgl[N0. STATE THAILLq PLATE [ L/ I0. • STATE •C.U J~J CI ~j }A(.l ~I ~ ~/~ , r GIJq VfIIICLE I D EN fI f IC . LI ENEE PLATE NU -STATE...... /~77J37 4 THAILEx PLATE NO.-., ,,... `uiATE. ..,. - F I n _ 'T ' ' n AiIUII NO. t,J. - f ~ .~ ~~T'{R ~U3 ~~XCOa 55DO VEHICLE IOCNi1FICATION N0. • ~ xLGISTEIJEU OWNCfl ILASTf IflST MIUDLE JIAAIEI ~ OgIVEfl'SLICENSE NO. flEG IEHE J q :L' OWNCN ~ LCS' - ~ DOWNEx ILASTFIflSTM DOLENAMEI,,: ~ Ofl1VEfl 5 LICENSE NOI.. . ..S f ~~ - s OII S, . 15jxEET,CITY AIIDSiATEI - -. -1__L_J-A~~L%• p7 [O/f~l DORTE O^BIHTrI OWNEII'S AUDflEF$ JSTNEET CIT NUG i ' Y, M~'v' PAIisSOf VEHICLE OAMgGEO , .x. CN/RlNCCru ~. ~~ DATED DIflTM YII. S ^ 4 ,~ -' Z/// T N{GAIT xcilT PAfsTS OF VEII CLE DAMAGED "_' I D 7 FJOAOYJ r LIABILITY INSURANCE INFORMATION~VEHICLE N0,1- wns nlENEAUroAIOO LE LIAU LIrv INSUxANCE COVENAGE S /~~ NyvI IN EFFCCT FOI 11115 gCCI0ENi ON VOUfl CAa u iES JaML'AIID AOONESS Of LIABILITY INSURANCE POLICY lIOLO fl ^ NO - ~~~l~n~l/FGrc,,,~ ,1 cN /I ~~ L p NNAE OF LIABILITY INSUHANGE COMPANY _. ,-, (nl fll E ~O LIg D1LITY IN5~1 -) /V~~ ~'~~~ ~C'Lr~'/ ~C ~ If I P 1 ' + .,/ ~_/ T ~~uco ~~ DE17 CITY ' ` 1 LIga LI T / Y ~ '1<Z N ,. . POLICY NU LJ .y MB E H . _ /[1r~G `~ A~ zIP `x/}'77C[T t 3 .. / S /S ~ ) ~ IST INIURY: / C. ~I'ZZO /2/~S L /T Z ~ j ~~ `~ ~~' qML AGE l ZIlD INJUIIY IusL ro A T uTgl ~ x nI R011L SS SE% IfU NAME NJ AGE ~ ,.tYfT ~~ '~ ~^~'.. ~ - - - ZI-"' A nJ11E No M F noonESS k%TfNi pf NAJxlFS ' s(z ^^ r 7 NATURE ANO SxEOU NE OOCTOfl'S I I ENFENT OF JUNIES Nx11111UN BYAOOCi0gF u NAME D 0 N UN ES xE0 M F. ^^ ~~~ • J ~ - SEATUS OF INNRED E%AM NAIIUN NY gIDOCTONi © 0 DOCTOgE !aM MANK f1H5T ONE lIIgT APPLIES STATUE Uf AMk ^ NVFII CIF ois,uL pgpy NJ EO MANK fI(1ET ONE THAT AP LIES Nj •'~~' ILLEO Is~rt~t I4,un vrviux ^ NDRVEN CLL O s xslxur N0. A^ 5^ N Huv ,UUV O ILLED ~Sf~x[I ~u~ o MY `~. ~ . '~ MOTORCYCLE SAFCTV: ^InLMEr us(o ^ 6^ lor7 Qiic ^ ^ry 1 K^ 5^Y 6^ ;A^x L:c ~{ IIEIMEr NOr usko MOTORCYCLE SAFETY: (]HELMET US(o •'~ ~ - 1( IUllill tlY AIINOW NflxClk '~ (~ x C LM }N TUSEO : ,. ux lxi4,•TxnM ~ D($CI1 LtlEIOW WIIAI PPE [0: IIIEfEq TO VLIIICLE^E DY NUMLERI IlFmxlD '~ ;~; xF ,ILI xrF,~DT. O `., I I !/=rFict.~ ~1.._ 5~exvEO aDCU.u ,( . -_ - Div.,, i /CTrs4-_ xr11Dx Df d /~, 7o fr~vur...2c~irA =-r~ cam-- i ,I,II,, IDIIw.Y ~zN/~~! ~., y '' I i _ ~. _ !f, r._/Tf~a _'2F.92 c',tJo of ___._. _- -a ~-+~ __ _---- Is R - b . -_.» _. ..__ - . _, ~_ / I ' lvgy - __ ,__ 1. - ,.. z _ .,. ..... _ - a ---.... .._._.._ ..___--'--r___.. i rl T, ___ _ - .. -_ i VEHICLES POSITIONS BEFORE CO I ~--~._..,__ ?P ; LIISION -41}} V,INLl1 N ( [ W OH (rN[lT~~ll-YAY NAM(Ufl NO, u~lcl Font ' Gnl .n. xlC urn IN'FSI OAiEO BY t ilia `Nr ~' [ ~' LD,xI ^ ^ 8 ^ ouelt x, ~~xD ll^LY xD rrL xD ^:, ^:U~ ,L,' y rL, ~ ~ ,l ,' `I'~~~'~, Ip 4~~L.x _^ ^ ^ ^ ~l Dll~ li__"-"-'~ D ^ ^ ^ ^ ^ ^ ^w,e ,f T1. t . ~ ;4' la~ L I LlDFST iIAN,P[OAI. CYCLIST WA^ U'I ---- '~~ Q -' c r _ FraM TD x~~,,((SV,I,a~V __ __.. ~ NG. ^ ux w..r .anx., ^ ..._.^ T Pf DI TIIIAN/F EGA_L_CYCLISi CI.OTIIJNO CO LOfI. I ^ uA f ^ L ~ L ^ DIInn r ^ x ' P ^ xo,rH,.r µ q~!pr,G ~~~~ ~~ ~ ~ Irvsl L wl AinlM - LIUIII COiIDI110HS c,l,.• ^VIrID 1, ^ ICNVL ^DIr,lY xll MlrlRVrlArfnnl• ~ yh r~, T~, l., !/' fNA%aCC~UNI.,U1 T un u,n-r-T'-w_r1 ,1r1__ 4 nu0nll :e~~i gY'~iii r s `r,J DAYLILIII r ll x L NL LLE ACTIONS a ~ i] ' J 1 '~F.:f1:" s^ngwN ~xIIYN,Kµ x KII'r Dxlo 't ~> - r [] Nq H HG s oils.. ^ 1 ^ oNE wnY I I ~ tc , ~'•A 3'i +Q ~' `~' ~ tiJ a I~ Wll ^ ^ ~ ^ sruY SlcN n ~ (~ Gomm sing air Al.+An y t i 1 s^tNOw1NG o s fLT r~ > l~,l Tw0 wnv ^ Z ^ OVfaTA%MO AHDfnSAN0 _ i F,~Ir (~ D ^sN:NV r l ^uun~so~l ^ T ^YUDf1cN I s xlvf xslsu .. T .' 4 -j~ ^ . rjILL L^ ~ f ^~wneuiilT ^ L ^ngvxr,c xrn ^ ^ nagR ^ s ^ uAK Nr.acm TUnN ~ ri V}Lp+:; (` f~l fl l 0 f^l'A'rt~1 Yl (^SixllrllGrlff ^ r ^ l ^ ( f „Gf ^ l ^ sAA[NG l[fi TUIIN rJ [ i "try-`,, LJ Ll ^ILALII Nf, AMxlx ~y{''-d5 l t Olllla ~ ^ f ^ ll ^ 6 ^ MAK NO UTU MN i f. /y U ~ C EA' r 'WIiFKr IYII I^ A^ µ~ H L'J f ^ fl.rlwlNO •' 1 I ~l yy y • S 1-; f~ Al ^ 1• I ^ ) ^ OIIICIN,1lALMAN ~ - f ~ 1~ ,47 r~ I Iv l ~ ^ I } ' 27 ~' "•~^ oT ^ r ^ D ^ F ^ s o rfl rml Tngrnc T YA lT, rj~I)r~~~q I xqn fl r N ^ a ^ srD rD TsrH ~~ ~ S d y 7 ru 'IrA r:~~ M, L".. •i>; ti ~ .~~.~~.F ~I~ s LnrJ ~~ -rl~ r ~'; f~ - ,_ J T, f ~1~I ~:~ l 1 7 Y • I' 1 A ~ ~1 ~~ ~ ',~1+•G'uY 'T ~ l TII E~, `+~ 1 ~j.i _ ~. _ i I ~i: I~ Y ?y ~ ' 1,w~ ~` -, ,,.~: t£ ~ ~~ ~~ ~ ~ ~ r '~ ay.. - ~ ~ ~~ a ~ ~{~ ~ °LEi 3. Ts N ' ~i ~ r~ ~ `~`~ ~~. i 1~~ ~F r ~r ~~ H« ~` ~~ ~~~, ~ I / «oi< s _.. .. _. _... ^PRIVATE'WAY ..A~~c c„M.wnrnuMeER D ' ,31 rv MD N iER~ud. A IHIRS nI~LE. /USf RRW NOUgI COVNIY COUNfYrq. CIfYNO. iHWA ~FF/c2.Sciv /G ^DReAN ^N ^f ^N CISY OR TOWN N E6N0. Of SrREEi09 HIGHWAY iC}CES Wif S uns SE O I N ARIE! ~3 ^W ®Of N, ON N ~ 9s/moo 3 aNit45lCrING WISH: SrRLET04Gf140 rpNIN1fR5FC r K )N pgEEl% EO. MIlF pOSr ( y 3 ' ISIANCf D19 I eETWEEN C~'c Q SS4EET 6 ,E T' /Z ~ TRfff ~~ ~J-PJ M0.L5 q CROSSSSRFES NfARE SMIEE ACCIDENT R P AN WSw D q IEEE Of e W ~ MCODE E COLLISpNINVO v l FO~ NO. KLLIFD~NO.INEURfD~ ^YIIUGE ^ I~91IKf RD I R 4ROADOR REEEgLNCE 9nD1«s tOTwINO. I~~ HIrMU'ss" In INTER Cl5 CRO455T9ffT091gIIp Oi VFHICEES ~ s ~RS ®pROpfgiYDAMAGF ONIY ^ ETUIRD VE rz S~ ZO R~ OBkGI SfRKKfiLiVAf (MOB1FCt5fgUC%ANDOWNFR'3 FI FSI.DMUGF SRC4l CODING USE - OIV A1C CZf4YG .(tJ. & L S CO ~~ ~. ~~ ~ ~ ~' llNITNO.I UNITNO.Z ^ VEHICLE ^PEDESTRIAN ^ PEDALCYCl157 DgrvfifSNNAf: USI IR MI Dlf RWfq'S NAME: 5! f~~ SID(EI ADDRESS ZC' y/ R .. REE Dgf55 -tax ~4 2 - S ~ , L rv :Ip CODE pHOnE NO. D VY / Srwrz I r W ~" a 8s- ~~ R MRS _ _ DK SrAff I D V U [NSE Af _ ~3t' % ~UAT B q OCOYAr10N fIRMNNAEt vaG Ltt5 GHi HFIGHr E URArION it NAMEf iNONf NO. FYFS NGa, o uS 0200 R IG11 IRIGH t -~ "= ^ CHECK (,7 AN Y wnor«Ea. ^ CHECK (i~ MS H A I A ' , vE E ASANSEAw~orle q. CODES -~ a aASS ~ vcrcu A qn°AW n« s E lerlw a "1p1p, CODES -' 7 n •eu ~' °r . w ° ~ " . u ~ llierwH a suer 5 2 IN Ltv S n D D,:... '°„ ^ .R.IAw.a ^ ~f" ^ gym. p nw,n ^ w:u ~"8`?Y.'°°„ ^ ,M Vim, ^ ~ ^ iiX:. YfIt TEM. MAKE ~ ~~ ~D ,f ( 2HtV.) IDAIIT.NOVw) SSYIE(R09. ONV.1 I .) LlDA4 +gvAf I . f sz r . Cu Ev _ E = ~ ~ S surz R,NUq NArE NO. s r urf H Hcao tR7FFf-' l is . w I Y[NKUF rOFNNIOAfKINNO C yEH CEF IDFN A N ~P~P: ~N~3~C:~i :2 !o o ;3 L l i ~~~~ II I_ ~. i ~ ~ i i ~ ~ OEG,SrzREDOWNI4 U31 fIRSi MIDD LE pMNL NO. O ISt OWNER: LASS {IRSr cc N N U O ~ ADDRLS}OIOWT,IR W OWNEq .~ N E w~Mea ALgxualrwxAN¢m. wAwNr N R DAMAGE AAA fa.u.n « u r DAMAGL IV«CrwM CHA9CR CHAe E ^'~ 5 f31. DAAV1Ge a D~M N '' O pfAWN[D' Nse 14 DgIVtN l51 • p C A Y ~ . TO'STO tOV.LD AWAY ^4fMNN[D Yi0R0 5 E 1 T . w DIAGRAM OP COLLISION: 4wA er: M In0 eNO rH wwr er: f le -~ -- -_ TuN[ S---I e ~ III DESCRIPTION OE COLLISION: IVSt SINSSEM[NrM S«EEiD NECLLSAYr) F ._:_.!1'~ - -i~(- -.- X VQki. EO FEhtI I o T N£G - r ` I I ' -__ .-- .-- . . _ _ o rs.gTE3H0_ ~ J- ~ I ' .~_~~L,~_ C/.~Cl~t3VE.. / 'C~RhES' NG OFf~.. OF__cS~ iZG { O!~?T_O._ ( ' - - .- - - - . , ~- W tAhrC~(__ -SF-IZ. - -^i/~H._!~ l_ L~.Nr~1-1E -.._. ~" ~T~ r _ ---+-~~-~-i F- -`-~ +-.`~T. ~ ;._. RoHDw0.Y.~. ST.RUC.k _A. TfcLEPHoNE._~TuacTS.oN _1 __.~ Box A~.LD. .Cl~nrL¢NaIE,D__ANOrNER_ APfPRoK i ~ 3 _ E_ I _:._.L 1 i ~ _ aE~ae L-I-~ I _f_ L\ 1 _I CoO f~T .,_. C'pMSNG 'm_ pE.ST~ ,q - ~ I ._ -..~ _ _~ t ,.._.~, ,_. . __ _._ I _- __ _ _-- ----- ----- ,~. NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED F ~D 3 5 6 ~ OCCUPANTS/WITNESSES li~i nRrro~N4Mi rMM NAwq wii nci rv u ~"vl« -uZi' « r -, r,- .s - ---- nsrR. Lxa ;Ki+ wLwnv ._. nAME NAiuv d _ ._.-_ - - er AM e. Q,R, 1" ^ "' . ^."i17 ^i:Jwle L .__ -"__._-_.__ _.. ._. _._.. ._.-.__..... -__.___ NO .._. Ananss n ........._.___... NMwra--- nMOwor M r ^uAe ^,o,Kl^M , O.TX ^~ _. _ -..... M •DCWSt .. .. .. .. NAMT~ _ e%vl qAI. IrROOM IRSNU.EeewN eA(K',fp AE')Kr ~ eY ^AMe ^f,R ^CKAIIV^M ^riU ~ X '~ ~ KI DIV4ICWV Iw Kl wRetNO Dwrl ar%pei Afl.eprLO er Wlt X ~"'k;i' o~ I '4} I ,i'~J 7~ ~': ,'.rl 4. 4 '~" ",: iP~ ^. fl 4 ~ r ~. ti1$p _ ' I ~4~ ~~ flR, .. 1 ~~ 'u gRep 'E " R=p ~ ` s ~ ~Xe .' .~,.,;., ~ ,y. .~. Y,w a. ~ . v- ..: R, ... • ,~" r HrF~ PR . i. I . a ~ ~/~ POLICE TItAhFIC COLLISION REPORT V-[` Iwd rlESV,Ir - - - ~ r~; ~ ~ OL ^ PRIVATE WAV RI F ~, a '•~ w'~ ~ ~ pAlEO Gol l l N. o'~ E9 ,£}~ . o co 'hilt M . ! ~ W ED$f]bDH RI COUNTY J^GFFEkso~v COUNTY NO. /~ CIfY NO. % ffIWA 0 ^DE',AN RAE ! ) ~ L7F~Fp SI.AS A' Ny r: ~5l .'~ ~!~ k -x~~~ r.9 CIY~O~RtTOWN L~ NPMF6NO Uf 5lRffiORHIGHWAY JLi/ ~N Qf QIN ( f~ S QW Of _ /V ,/~l.'- ~v co-.e o. /a iCi CIS P ROUT ON IP 3 9,s'i~o SfC11 . ~t rte, R, ~ t 1AV~,~'(~';± 7 .1' tcr.~c ~ . - INIFRSfCiING IH. SIREETOR 50 NON INIERS(CIION ~.q E.r}T7~L¢ p,~ /q' •`O , pREEI% f0. MIlf P051 ,, ~ ,f pp{~ F ~ ~ i I gyq' iyy~+p t L ~ {l}~ ' . I ~ ~ ~^~ BETWEEN Q SiRFfi 6~T'bi= DISTANCE 601RFMI EN C ES iROM Rf1 S1Rff104 NFARf51 MllF PO51 -SM[LT• ACCIDENT ~I ¢t/j RMM DIAGRAM OAIA "~I/ ~ 1 •C •.'~ ~ nl~' U ~ r Y rL' qy 5 l dU if ET ~ Of' ~~ ~~ MILEAGE D O ~- 9~ / .. ~ p .;F` '17RE' COllI50N NV VFO SEVf41Y. ~ SPILLAGE H 6vUN NO RLIfD fq IN1URE0 MI iS rN IuHO°Ign, N %.RD NIER IN 1RfEED4 ROADOR RfiERENCE~ l~ TS ~-~+.5. ~' r ~ F C ~ J~ , ~ ~~ , ~ IO1Al N0. Cf VEHICLES ~ pROpf4rv DAMAGE ONLY Q c ESUliEO ^ V lE ~- INiFR Cl5 CROSSSiREEi OR ROAD ~OB~V`O ~ ti ~ . ~ I ait w} ~ OBJF[i STRUCK INAMFOf OB1fCI5TRUC%AND OWN[R'S NaAEI ~~ ESI.pAMAGE SRCLLL COOING ILiE i _ _ f F~~iM f ^_ '. UNIT NO. I DRNER"5 N•MSE: UUi itRSl MIDDLE UNIT NO.: OR VFR SHAME ^ VEHICLE ^ PEDESTRIAN Q PEDALCYCl15T UST fIR R~ ,y YFL - ~- ~ r~ ~- -OCtRMONT N ~ s1REElnpoRF I l ST ti 86u G-RG EI pD4L S ~/ _l.' ,~1 A 31 4 A~ ~~~:':. y. •/ ~~- ,~ 4 o~Od sf CGC~H S; tl / n S ~D ~ p , , 1 •. .,r:~. C~• ' 11p GDDf ,/ ?AZ~/AGiC •v. `183,30/ pHDNENG. ^- D R IIY SIAIE C Df PiEON O/eG EgvS /Ed 6~9 G ~... 1 cpV ~ • ~S OXrv R'S UCFNS[ O. 5 AIf E% 0 IH A ( . ~r . UCf SE NO iAIE f% DAfEO BIRiN / p h ~' . .: t, .5~ O CCUPA~ION iRM NM1F 6PNONF NO. lu^i M 7 , , D,Y ., EYES Vh GNt iIE GNi V E . C E S / / 0 3 .vF~ M O ~03 I !~ OCCUPATION F R 6 17 GGG S '~ ; - ~ pp /1)gT8C1/G ^ CHECK (~ M IRLI L M.4~Kr~ALs QLN /,!O ,J/ vEHrtlE ns:N VApiov OP ArM o : ~' R RE~2eD Q CHECK (~ I M NAME PHONE NO. EYES WfIGHI KGHT -- tj/C /Sd 50 i l ~ R F . ~ l" ~ i FF lHfR A,• CODES -* ~ u q ^ 5 e ' " ° sier i rv FNIL F AS AN fMpIOrFE OCANO1HERa "1 Y[u CO * " "O °V '~ ' ~,. y_ f~ Z e t , r f NI fi •` DES ~ D n q i; 5 E% / 6 5 ~Si N awn siiM p >< ~ ' ,,, N ;a;„p,;,pD„ ^ AM.DInNRI ^ ~~l ^ zer,E• a~x~ ^ "M;,v r rn ;IRD ^,MRDIANU ALE ^ ~s:n ^ ~ K~ ^ rapt.. e ° ,_. _' ~ ~ ~ Y,wR ' r I KN. Y[M ~ S MA%F ILODGf~GHFY.) ~ C FLIDMI•N'OS'AI 51Y5E IRDR.GGNV) ~E~ Y AR ( ~ [V.) MODEL (DMI~N AI V ~ 1 ,, ,pV.1 1°/~ I ^ 1 ,~ ~ + us1~ dC ~1~ I V OR NSSM I FN S IRA4ER ftAlE NO. ~IAIF H vEH.caO w / R6 a ~~ ~ ~ Ea [rlrYl A'In 7y VFHICI IDEMIfIUTK)N NO (.e..v I C ~p /~n/ YvCl~ CU -_ _- ~ H ~'~ " , P ~,K}~NL; rF t ' 2 . .O . :F' 1 ;7 ~'o'S:`f '!~; RlG15RPf0OWNER; NST FIRST MIDDY IpH L VEH CIf IDFNI ICwll NN -7: 61 .c IS. i I I I I I I R ISt ED O I ^~ , ~ -!~ Wy 1,~ ~ . Y~D~A'&a IL ~ F DDRfssa owrf4 ONE NO. O Vl/ WNER: 1A31 iIRSi MIDDLE ~ M ~ ~ 31 ~ t .a5 YCS~~ 1 ~ ` NAf e D R f N E A s owNFR - • - , . ~. . : ,~.K•g +S~w AD IC, A O E550 INSUR CL CO pf AGlNI ti E " R IN tnz~ scRaFCE tstRrzcE NFr sJ~eiZy SNAFFE ENC ~ f.A...•- /L~RS. T/tY76 ~1rQ ~]~ ~ -I I ~,,, ~ wM.clD AREA + R D o owiou i '"-' 4 ~ .. ! S/ 7 O ~[ DAMAGFOARU , SD ~ ` ,~ ~ E ~ /n . •lOr S 1 IC ~OROU p f31. DMUGf D ~ CNMGf -~ ORNEH q[MUNlD O foWio ^ CHARGE L / ,. L DRIVEN • lOW[O ^AWAY ^RFMNNFD p," ~N o ESi DAIMG elpr I IC iOlioii 3 l., . .--. ~ ~ , wT+. ~ _ ~ O eY. AWA AWAY BY: EiCI L/CSON 7D W S /SOD • • ~ : ~? ~~ e-. DIAGRAM OF COllI510N lu a EmNA. INp cnR NOgrH ~ 5[[111 NfCE55MY1 YARROW 'U/C TL n-!.¢ v ~"~ DESCRIPTI r~ a0 T ON OF COlLI510N: IlnE SUpplfm[NIAI SH[fllf NeeessARYI _ . .. _ .._.._ N' S Cs ~ a ~ 3 ' ~ a" ; . V/«A6E ~ Y D GL. Ty-. O N uvT.. __ . >4 _. S e ~ ~x bi c 6 l /Q .xJ• RR~ .MEAL/z EDdM-E . Ct/A'S OAJ._ ~ . .:. ,. • ; IT _•, MLr r o,n 6 -sq CGt . n./.E GV i~0'J6 /Lo 9 .S~TiY A~TS~ .IrL,_. ~ 6 ,~'~ -: Ra A`~/~ .. ~ ~ ~ 7Lc /cam/ LbGf- /... /~.4-/~ /C rNG-_._._. i ; : ~ - . ,.. . ~ . , 4r! % OiCI /EP2 / (.f/iF5- .lA/.... /DiE=oCF.tI.... .. ,.~ Y ; . . D , i I ..r'~ O P i°/4-S S/.N/6 •F~` o'~ .~}'._ GO Li. C-.4 N_~T... ' ~; RT ( a --~ ---~ .. ' " ~ .. _ - •D2rvt:K ,z F.9-.L6.a _.ro Sis A. ~ .._.... , ~ 'aT " I t ~ d~ q . I I \ NAME,ADDRES581NJURIESOFPERSONSI NVOWED *CODES 1 - 2 3 4 5' 6 -~ r ' OC C UPANTS/WITNESSES ~°~:pp uoriu r~+:MHE ii ~sfx Act rAlus '"„°'" °"„ L„I Rf srR. um i'°;, I ~~ ; y,~ ( ~ ~; L (ZlG(C /cEA /L aEONr iq. •~ .3 ~'' - ~ R -• n pp ,[5f O C L NAT Off Of ~ Nf nr ^AMe. QR~LwI Q"IIN. QH,T ^ ClpuHy / ~ {yry~~,~y~1 }~~ ~Hp 'R" rY I y AH ltl I LPtwn S rA NS lJ u.c ~ - N ` EA ' TUBE Df " a MOVIp,RDM ° ~ ' ' . , ~ _ ADn•ESS fTr- 2 ,. • I Nr nr ^AMe, Q'c01,Rr O o:n• ^ Nx ^ "n:l„s. s "' keP~l a E l 1~ , _ " A"E F`La/tE.vCE STRVJ'lda.cy No - ~ I w v I ~ ~ 1 ~ A Dfw115 .,.. ~ /Ll' TJ= MAwY°I Di fHf eY. ^AMe. ^ui E Q[oin• ^GX Q n.rlu ~ • r I I 1 i 1 ..~,.I X +mvnAlwoafKErsNAwRUN~ a ~a A GUCY av"=~ ''' C' i fRD ~ ~o '3p ~ pA7 ~ • _ ~af D OBE~I~fa1 ~° I yn•I. , , ,~~ t ` y 'r4 µX,v. R`Pl'17!"'fit^~7NK{ ~"VE S ~l-,',1~a, a,tt~ ~rS";+Y4..tl ' ` I r~ ; ~~ I :; r y .I,~ ~ t _ ' r a '~ 11 t '1 ,/ t 1 ~, '1 -,. - r,)I~i 1 h: . S?;. LII 21 I I wk ~~sF~` S '' ~f S ~ ~ +~ ~ ~.I~N.;~YR.~.e~ ~ `e ............. . ,.F r DE r ~TRAFFICWAY `~' ~' POLICE TRAFFIC COLLISION REP N0. .~ ORT PRIVATE WAY E Of COEI ION I U 1 ME AY NLICF COMPUINI NUMBER '. %P COUNTY 9~ oft wln Ixue I (USE 1X00 HOUR) GI. ,C f,. / ,,; _ -~ ' . ;., .. ' ' COVNLY NO. CITY NO. pHWq OAN / G ^ uR . . i ~N ^f ^IN Ct OR TOWN NAME6 NO CiSIR[f10RNGNWAY e R iCi CLS M P I% ROUIf ONSIRFEf FCRON - AVEFS 5 W OF ,y.:. ~I.'. I , IN [RSfCYING VniH: SiREft OR ROAD NON INIEREFSIION E /.'•0'Y:i rv A /' : /• PRff1X EO. MITE POST . . '..7~ BF Y F[N r SiRfFi 6 ~~, ~ ~ ~ ' ~ 011 ~ ~D / ~ ^ •/ ~ U~Cf 601u[MILL51 MNf ~RWCE.CW 5551Rff10R NfAN~tMIIE PO]~~~//1..-/,.// ACCIDENT RAMP DIAGRAM OAIA ' /•' iffi Of//', Y~'e:.'./ 1 ~ MILEAGE CODE COLLISgNINVpVfD: NIIY: _~ ^ SPII~F Ii ?{1N IOIAI NO. O. fIILFD~~N0.IN/URED H wNOVIOM ^ CP VEHIRfS © I'I X~RD N TIN SIRfEIOR ROAD OR REFERENCE N~ INL~ Cl5 CROSSEiREE10R W AD x] ~> ^ PWPFRIV DAMAGE ONLY ^ pES~ll[D vfHlClf Otl,[Ci SIRIKXINNAF OP OBIFCI SIRUCR PNDOWNER'S NAMFI fS1. DPMAG[ p / p lp/~YPQ BPfCIAI CODING ISE / E UNITNO. 1 UNIT X0.7 ^ VEHICLE ^ PEDESTRIAN PEDALC xE > DRIVEq'S NMAE: IASI IR ^ YCLIST RIVER'S NAME: NSl II °.J RE ADDNE55 ~ ..l„'.",. ~ i''.-t: L /J'am' ~~- / SIPEEI ADDRESS L oN I,~I SiAlf EI'COOE ENO. D y S1AiE IP 0 II DR rvER'S IICFNSENO ~~ S,` ' / V PEgN NO. . SlAtf F% BIRTH ' J ~ J V=/ i° /._ ,'1 - ~ p ~yp^ I V WE' U FNSE NO. TAR SEX OAff Of BIRTH I,o. ~ DAY YR. OCCUPATION /~/\ MN E6PHONE NO._ FYFS IGHI Hf GNi E occuPgnoN NAME6 PHONE NO. EYES WfIGHt HEIGHI M ~ /. ' •5! .. )` R ^.CHECK (/1 W' vFn CIF AS qN FMNOYFE OF ANOIHERAI f I ^ CHECK (~) I V O O H Af ' "~ CODES-'H ] a . s : s s f aoN a i°{° ' I f vEN C F ASAN fMHO YAN Ff i ER le CODES -* 9 c: °° i ~ xp S ~ ' ° a y cro s ; 5 u a s r RDM ~^A..HA.Mf ^u :f"w° o ^c IP mo„ ^ ' fqx F DOOG e RI AY '" ^,MRIA,NRf p ^'vi ^r84~. u°6" ^c$Nfg Po ta S I ~ f {HEV) I MOOE 1 AR RIOVAI SIYIF IR DR ~CDNV.I ' A . 7 O ` ~ // / S , S FAR M.ix I HfV.I MODFI IDARI~NGVA1 v lx R vl RDw I xR , . 4 p yE IAIf N SIAI! MIER RAIf NO BIAIF H A VEH caoR I AIf N wtf ~ ~ ~ I Ili V(NICIF IOfN111IU110N NO. J 6 'i- %= . i 1. l ~ ;' ~~ , ~;. 4[GISRRfOOWNIR: IA51 NRSI IODIF C L E vFHICIE IDfNllfl A I N ~~ A ! ~ PHON[NO. O R f ISIFRFU WNFR: USI YIRSi MIODIF NO. IDE ADDgessaowNFR x W A E. NER y' N NATAL a ADD fss a INSURANCE co, a Ac[Nr I /) /l R ix - fUVNAGE ARIA E ) uilt iOn4 ' / '' C . , ~ •~~ • , u D A1AADE AA[A '~~O~y ' fO.OYT RT MDI FSI^IDARMGF E R :.: ; . _ CHARD ~ GfMAIN[D ~ . a ^ ^ CHARGE RrvFN gN iC iOI a r {SI UTAMAGF g RTOA N ..fix O -~~ ;~Yp f1 ^ ^ ^ ^W^YD BY• WAY R[MAtN[D . f f Io sonGii S 0 DIAGRAM Of COlL1510N: lu DI A INDIUIE NORIN SHfEIIp NfCESSARYII BY AggOW DESCRIPTION OF COLLISION: lose SUPPI[M(NYAI SNterIr NECESSARr) ~ s / ` ~ //~ / ` ... UO .ti f _ NAME, ADDRESS B INJURIES OF PERSONS I NVOLVED + CODES l 2 D 4 5 6 OCCUPANTS/WITNESSES lia ~oonfO~N~if~iMie AMI ii stX Acf taus '", ~'" ° ;, RfR1R. ^fCl jIC~' i o. A N pUR115 ,Mf NAIUR[OY R ffARY ^AM R ^[A~"f ^ "'I . ^N~ ^r sti ~ . DNf ss N AlugtoY G Mcrvln ,ROM . ^ H!7 ^i° ^AMB ^Ya[I^W/ ND . do ' DDRns "EAa~I~°p .y. pAM3. ^~°„ GIY~ ^~ ISIIGAIWG pYKIRSNAMI l9 H [ EA ~ AGINCY ID D nxlFE -pRIND OAI or 1POR1 D Jjl~E C Ll/ / 1 ( r / ,,,,,(.,,d., w :.,c" n * 41ir~'15 i ~" '~ ` ~~ ~ r ° 4 ~ , sP.~h ,. ,E Ck N,~~f F ca.- ...-. ~ .. ~. ~ . ~x~a ~: m '.. . _ .. "' , ` "gym....-~.::i,issA'~ta - J ,~ ~< ~3~ ~~. a. 1 ~ . ~~ ' ,~ ~~ „`fr,' ~zti ~g ~, ~~ ;d ~~ ~ ~r ~ ~ ~7}8'( +~~ .~ R, y C .~ ~` y {`' ~a,i=, ~ ~~7 ~{~. q !1 y ~ - ~~ ` 1 lTe~', d r ~~ ~' „ Nr ~ _ ~ ~~ { aup ~~ t r ~ , w ~ i 1 L ,: e ~ i f~~.: ~ a f' '~ ~,,~ , '}~~ ,K t ~ r l t ~ ~ `~ , ~ ~~ ~ ~ t'~ ti r a -'6 ~~ ~i 5 .' ,. ~~ I~ ~- -. - ~ , ( ~ . ~ ,. : ,~~. S E i n ~ xa~?x:- E , ~~ ~~ .~l r3~#K~F~. _-'.s13'1"fi, ""~~.~N` l~v~~'s:._~-a:2Y "31S_x NA,F ~:m_. ~tlr~.. 3 -°~~_. ._ °'~...~_d a1u pi. w,~ a r t~ f ~ ur vvHSHIiVGTOIV AGf ~ ! d No '~~- ~ • POLICE TRAFFIC COLLISION REPORT ® TRAFFICWAY o. '• ' PdlcECOMPIAIN1NUmeER PRIVATE WAY - DnlEO{cools n u oN ~' ~ ~ ~ rP .y . ...,EE ~ - V 'r s x'P ')'.~~ Wx ovU w v N NI ^ D IUSF TxgDHOURI COUNTY COON YNO. CIIYNO. fNWA .- . Y 4 _ ~ ,. wi' ^N ^E ^N CITORIOW J N PMF6 NO.O SI4EEIORHIGHWgY iC{Cl5 AM R I ROU}F OXSIXFEiC ~5E*C pry I INIE45fCt NGWIn'. SrREtipR ROD NONINIfRSECIION ON ~ 9 J /7O P Y ~ ~ Pgfll% / EO. MIIEPOSr T T ' •pl. ~ J I 'a. ( Ti DISINICF6D4FMI ON iR fFR`N ~~SS / l lf5 N f' BF1WFfN SLREFr6 SIRFf10R NtggfSr MllE S}PEEI - ACCIOEN7 4AMP OO r/~~x~7' DIAGRA W ~~ E , ' ~~ Y / n rtEl ~ Of ~1 ~ f M ip M E i ~ q ' - . COIII ION INVOFVED~ S ER IYI IOIgI NO O. KRIED~NO INJURFD~ ^ SPILLAGE ^ T6FUY~ dVO C [S ~ CODE xuHDl eigix I ~ ~RD IMF cl5 IN 11 R RREfFRfNCf CROSS SrRffi OR 1S ~ y~ r .•'EYd ' i ~ I I ^PROHgtYDM1AGE ONEY ^RESUIrFD ^vfdFN' CFF 9 OOJECI SIRIICK INAm[OF 001ECi STRUCK ANp OWNERS NAMEI F5I DAMAGE SPECIAL {~ CODING IJSE ROAD ~~/.SO ~ y X ~ e E - UNIT NO. I s DRIVER' NN.+f: LAS} R r UNI NO. Z ^s EHICLE ^ PEDESTRIAN ^ PEDALCYCLIST MI DlE D41VFR'S NAE: ~A ~ x~ . {n •t^$ ~~ -~ {I M ` SIR f1ApORr `~ N • i r ~' ~• ,~ _ E tADOR 55 ~/E D rY . ~ T 1 ^ SIAiE ZIP CODE PNONE NO. D I SATE IP Y ~ i ~^ H N ~ ~ ~ ~ , ~ R ` 5'Y i --D • ~. • DRIVER I NSE NO. ~ .~ s1AEE EX A B qin ( V lIC N F NO, MO ~ DAr YE. ~ IAIE 5 % 'IEDAYBIR{H YR ~ 7 ` L~ ..f i ~ - ~ L B OCCUPATION iIRM NAME LPHONE NO. EYES a WFIGNI FIE GH} E CUPAl10N I NRM NPME PHONE NO. FYfS WEIGHt MIGHT _ ~ ~ ~~I~ ~f Y Y .-~ } q^ ,~., ^ CHECK (.~ fH a 4 : " o o : ~ ~+ - ~ fn s N rPAa v ff fnnorMR ^ CHECK (/) ui, CODEE-~ ~ n" ~ s ~ • iir 5 F cr aN D NDIOPCraF CODES ~ Rwl JF u EH of qs AN aovff of ANOr "v r " '.~ ~f ,'~ ~ ~ "W^ G c N Fn N rCU Av a is n 5 v 6 vw'O.re°`c IE ~ • / ~ n ' -..3 6 r xn I Av vDw ® AxelnArK[ ~ R w cF ~ ~ VFH f DODG E C H I F 6 w vOrA ^ ~Svily ^ viwcl[ ^ iuusr nDr ^ ~~ ^ v[~CU ^ f:4„ ^ c ~ - { SA"T!. T' yob ~ I , V.) (Y ~~~, Il ^y ~ f D (~ HfJ 1'[C'l ~ A10pFl IDARI NOVA) SIYFE LTD <Onvl F MM . ~ NEV.) MODFI 1 NOVA E V I Y. Y ET R. V,I p FI earn ~ }. ~. ~f / . H.c ua Pu EN sure rR~R - ~ aAIE NO. Aif H vFH.cdaR 5 ^ 1 y ~' "~ ~ vF REIDfN1111GIpN C L f c DFrI N ~~ 7 N A 5-v ~•~ '~~, o - ~ REGISfERlpO FR; LISt {IRSt MIDp(f I ! I ~ IPNOM NO. RF Is FR D WNfR. ~ 1, 5} F I a • T ~ U ~ O _ $ IRS} MIDDLE nNEN _ ji. a Ik ~. . .. '~b'. R ~ ufssao ER '~ w WNR r a E ADDgfss d msuRANCf co. oR AGENr ~{ + RfMAwfD ~ Tf. C 1 er®ow I _ {X2zvq ~svE. .~~ ~D ESS 8 I iwlrr LQ Y XJ AwnY ar: ~ E I L~3 -_~1 PTION OF C041510N: lust SUPatM[NIAI safer Ir NEC[SSAgrI fDYCL~6P of l~~G wr~S ~YLTERtNG )'NE q P, /gz:->rgTE 82.cVE, qn.p CA ->/ TFCOL, L'f203'S6D T,V4. ~NT~12+E ~fa'•70- ANO LuF.YLT L~LE2 ,qn~ FTY E3PYvK, ~2.tTi~.2 o,G /~~c ~rgrF.t7 r~9r HG Tf?'k'E ~`~ p~F 7„i.C ~/ jH~J~T FC/Z /(,fiT eur.v~ ~fa[v ro /s-SOY rf/E: /1l~C. CODES 1 Z ~ 4 sf% I Acr t.N~. I ,,..._ _ 5 H6 1 '. AWfI. ' H pTUR10f H Y .. 1d i ~ I f 1 . 'yRHt , ~ 1 d SIEf K RADGI OR AGfIICY A1 N3 KlO SPAICMD fM ~Y. ^Y ^AME KE ^CAOTV ^ ~Y ~7M ^lii iN IJ ~' I l m ' x L d ME ~ `Y{D D IIpXIIOR~ ANgVIDSY DATE 1 i r ~} Ci fA~ r ~ S 4. cl'i ~::U;.M1iI I+T11.~1 iS Il+N F"1,,KJ t~ L k ~I jl { ~ L U 1 {1,r~ ' .X' n , ,{qbE "1 5 f ' > . 11G ~'~ ~~ Y ~ r J f'~ I~ o t J 1~ I t I 1 it 1 I l ~ i t 1 ' t " S .I. I ~(1 ~ 1 1, ll .. ~' ,`~ ~ ~ *' ~ ~' ,'i ~ f o- ' ~~~' I I` ~ ~ ' , ~ 17 ' '' ' ' ''1r" ,, _ 1 3 ,z: ' f ~: 4arra~ J 1 n?y{ !h "J ~~ ~~ -. .:A~, I tW ~~ _, . >-^'x~.-.~. ~irKU,xn __.~ ,zycss,~ _.__.,_ _ .. _,. _ __. _,_...~_ ~ 344~,~.- m~.E"JWUn+t '7z; _ _ RJa ~" S4 '~"~ ' , ,, STATE OF W ~ _,..,.,.;,~ .,., ,. ,:.~- _ ASHINGTON ~ ~ ~ WRP 1591REV.LW) ' _~I ., PAGE DE No lr ' ~ ~Y POLICE TRAFFIC COLLISION REPORT ~~< I i TRAFFICWAY NEICF COMRNNI NpNRER ~r '3i EOEC E s N PRIVATE WAY .. ~I ~ -fit LIME ', ~-~31~~ .I W,IUD,f~I S, M. IDI~ (URE 4f00X0UR) COUMY COVNEY /NO. <Itt NO . '„ r I ^N ^f ®IN atro4 rowN @.Ff-fE,R50FJ ~ ^u4D,w i~j NJlfS ^5 ^W N E6N0.0 SAR[EtOR NIGHWgY [CI CLS ~ ~ U4µ ^Of J4EZT•A Cu ON ~NTR/iN GQ Y~ RW IE Or SI f R N y INt[PSFCIING NtIH: $!R[Et OR ROpp Mw'I C.G 3 /J t~~'O ~ ~~E {{''~~ I NONINiFRSFCiION 7a/ l" PRff1X E MIF POei ~ ' 4 / 0151µI 6 IR ~i REiwFFN SiRfEI 6 n(F 1/V~ M SR E •CRiO553EREEt RNFARfSi Mll PO SIREfi ;70~ '• ~~ ~~:~ OO E[fi Of ACCIDENT RAMP DIAGRAM DAtq ~ _ COll15M)N INVIXVFO: ~ (~ MILEAGE ERIITI ~ ODE .. ',:.'' E IA~~ ~~'i5' V 6VfHI~~$ NO. AlllFO~NO,INlV9ED~L ^ ePIIIAGE ^H U IuH p[pty %~RD IN ~(~I Jyy~~ vrc m ^IgOPFAfYDAMAGE ONLY ^KRUIiFp ^ OE IMER Cle (FOSSeiN[Ei OR ROAp OR ROERENCF ~ .rZR j •„~. ,.,5'. .c ". _f FHI lF 7FV~~ ~ d R(~ OBIFCIStgLCK ENNAE Of OalfCi 5t9UC%INDOWNF4'S NNAf) SI~/IO l t9, EeE DAMAGE SPECW CODING USE ~ W Y, P ~.k UNITNO.1 f s pglvfws wvge uut 'UNITNO.4 ^VEHICEE '~' ~ NRSi I Dl ^ PEDESTRIAN ^ PEDALCYCLIST ~ o f ~ ~~~ DR fR'S NAME: uet II rr ~~ •Q ~ ~ I }yj ~~af 1;~ SiRFf IApp9fS5 s"Iy !+~ _ (,J x REFI AODRE55 ~ h ~.. ~~~1 ~ y` 2 CIIY CJO 1~ R„ • SigtE ZIP CODE PHONE NO D IE ~ pry,}:'.` t ~ ' ~. .__.. Q U ~ J )Ar '~ R V etµE IP P i ^hhlt,~ 5 N Rllt[NEE NO, etAEF $ 1?~~ .I .D.T-O qH I ~ l fNSF NO. i i ~ y~. 3 Ar I re. V µf pAl Oi BIREM ~ ,r '~s e. accurwrKxr iIPM NAME ~~NO. MD '~ Nn. I AA Ir4. i ~, kR~'~ ~ /EIJ [C EYES IGNt HENiNT E CUPAIION iIgM NAME6 PHONE NO. ~vw R fYE: WEIGHT HEIGHT ~ _ 'Si~P1 ^ CHECK (.~ v[H tt[ A:AN • CODES or E A ANOEHE c ~ - -~, ~+ 3 aipsr A iswA a [ aMO ~ ^CHECK I/) v[wttf ASAN rMAior[f aANOrHE4~ !~ Y IN~X[! rm w Y I IroN CODES - * ] nA"'a`sr - :i ~. ~~P slEw 9:. porn ~ ^ AwMANCE ~ ^d1" , Lf,pE X % : ' s ixcsroN a w •R x~_ I K~fRYR M(r\I~~f (pOpGf~CHEV.I Fl^jDMi.NOVgO SiYU ,Cr V.1 ~ s~ Mevq~ ^ AVeAANCE Q rGp44 ^ ~m ^ vt ~ryp4r ~ '~. S +' I V~^•I..A•^1vZ' J ~~ 1 XEV.I MGDFE IDA.4. ~A) vKUE ^lu `` v H. u sutE E~ //~~ tRAllf9 RATE NO. elAiF I'I y 6FFRTEq--~ p^Ze 7. ~a L r~• G.. • '~~ I H it A I,iR.rF N A N YEXICIf DEMI[KAlgNnlO 17!. cr [ Y C vfX Cl IDEn 7n ~ I~~I~,IC)101"ZIc3!S!Q!7i I I I I I L I I N I! I I efasn9mowN[R: uui I I I I I I I I I G- ~ )1 ' ~ ~ Rei /~ MDOIE PXONF NO. I p W [R ADOR(Sed OWM19 ~ ~• '•E O L 5t ilRRl MIORf ~ ' ~I eJ W A { .{ ~EA ..1Y1..::...FAu. 'q4 I_I .. r.Fe _ ,. ,. .. I j AMWf A4G p~n CiprpiA 410r D i0li0~ a Eat. IpMV1Gf f DIAGRAM OF COEEISION; ~~ .. ., \' ~C A :`F. (j" Ip LI °(nf » i 1 ^OwIO P er ALL A ~,,,,lD 4Hµ INDIGI[NORU r" uswpi..I er A4RDW a~ ~ '~ Sniilp/P.o..r. Custa~,,M Raak FFSTRgIJ ~. , ,i NAME, ADDRESS 8 INJURIES Op pER50 OCCUPANTS/WITNESSES ~~~^~µ I ~ I^ ^OWEp I'-I AWAV UAEMNN[D I [SL0 - lOr - I Euioii8~ s '• wgr en S RIPTION OF COlUS10N. IUR[.UP%fMFNIµ sNEn n rrEC[suRrE ~JL/PE~Jb A . f~/ GE1 ;SPE60 -~~Ge~1fN'k, _ IE I rLEE2 OF I/6N ~~ LuP,.$ ,9 F IkPY lC+-. -' D GkIEbPJ r/'J7'~I"LNCi- GNsp,LACU.I~( ~Rk, ~l~c# A `TREE STf.~MP, S~P~o~N6~. I . fV~Ci ~ , AN4 f ~WI~~t2~y~8oRr.l Foh, _'e 1 ~O Ft'r 8a1'N GAP~~ ^~ A u'ctroP. _ Ru .VED +CODES I _ y 3 4 5 6 ''~ r -~ 3f% Aff SIAIUS ,N ryH w ~~ gEAl1 1 IR ~ iir • i R ; ..; 1 i ... EN r. AMe. ^E`riKf ^C,.4,~,.. ^ it4Lo - ... .. c.l ~:..,. :;-.r. ~~ `. .~ J ~f u'.. M~~ ~„ . „: ' •,i ady,` POLICETRAFFIC COLLISION REPORT ^TRAFFICWAY IYU. ( Alt oicnunloN ~PRfVATf WqY POI¢f comnAlNINUWEfR ~} ~ IUrI µ' 3i d2 ,NR ~"' ~~' "~ " y IUSE }RDp HOURI COUNTY S~c.FFEeSav COUNTY NO. /G CITY NO, fNWA ^DRDAN ^N ^E ^ N CIY ON TOWN FB NO.Oi SIRffIOR HIGHWAY )O JMl[5 5 ^W OF `I V ~~ ON ~ ~ INI[95tC1 NG VAIEJ'sIN[tT ON ROpO NONINiFRS FC U O Y iCf ClB URAI ~ ROVIf 035/f~O SfCIION 9 1 ..N // ,l~I' ~~yy 1 ' ~ BEIwIFN (,~CSn' v}~LII 'IRFEt g 1,~~` ~ SIRFEE OISTA PRFfI% EO. MIEE P051 / (O 1 NC[80 vI m10N ik RFi[RtNCf CRO5551RfIIF10'^R~f[N•EnnARfSI M'lYlf 51 ACCIDENT f5 ~J S E n Oi WRA~~ A 0/ (~ ~ MILEAGE i[~r IV1N \C ~ti RAMP DIAGRAM MIA .. , CODE CDIl15ON NVOIV[D"' vfN IY. 1 lOIgI NO. ~I~ NO,%IIED~~NO.INJURED~ ^ CE j•^NIIB RUN rutwiDVFOiH bV[H Cl[S L1 PI OPfR ~RD ifR5EC11N 519fEtOR 90ADORRfiERENCE ' NI[y Ct5 CROi551REETOR WP- ~}} i `~ t IY OAMAGL ONLY ^ HSULIiO/ VFaCIf ODJ[CI SIRIJCK INAMf OF OeJ[Ci SIRDC%PNDOWNFR'S NAMF) ESI.OAMAGf Y/ `~~~~~ SPfC AI CODING USE S _ UNITNO. I sNAME: usl ilRSr " UNITNO.4 . DR VFR'SNAME ^ VEHICLE PEDESTRIAN ^ ^ PEDALCYCIIST • }. IJa~.NCA ~ U51 fIR SIREN ADDNfs l ~\ 2~1 ~ ~~~~ 1 IRFEI ADORf55 M1 SIA'If RIPGO~DF2~Q ONE NO. Ow '[~ ~ ~""'^' 3~~~3~ ' D R liY SIAIE IP COD PH NE NO. s ucwsf N '\l~\ / '~/ ((~((~ ~ SI\AIf (~ i ~/G ~LS N ( 71,11] EI~J~ T IXCUP i O (.JyQO,A C,J ~I wr ~ I V IV v ll FNSE NO. AIf FX DA fOFBIRiHv W. Y A I N MNAMF6RgNE NO. EYES GNI IfIGNI E OCCUPATION NRM NAME6P1gNf NO ~l) ~~ Ssl R . fYfs WEIGHT HEIGHT ^ CHECK (~ w i IliI AS AN imlrio:riaar~omlau v ^ CHECK(/) i v Al '" " P CODES - * ~ ~~u~ ~ . iv' S e ~ e im^a :xm" ,iaRY. 11 :x.ct r u ' EN CtE ASAN rMV o iF DP Aromie ssr ~M"1 .I~r .cl CODES - ~ y ~ pis 5 NtcI DH e y ° ' G -j ~ , xas~S~ f~-C NO ° X N ' I ID V[H Y,AN ~DWGI:~HfV i ~ ~ ~E° ~i:~P° ~S~YIE I}D° ONV ~ y ~ ~ DR•o m ^ AuWIAHD ^ I fv t U'CI ^ iNOVA ^ N Ku ^ ~ iHV. MODEL DARr. Y YI _ V1 ~Mbl. CFHSt P IAIIN CIftSSLe -IA2 E 7S FOR.d 2DR ?Ot2En ~}R IO I p r'F ~J ~1~1 ~c`,~ SiAlf [.~A IRAILfR0.A1FN0. SIAI[ F'I I H R ~.ai~ YAF~3~, t A N L`A ql wtxClF ID(Nix CATION NO C VfH CIf I(NNIIfI 1 N ~] _22 RIOIStI k100WN[9 U51 NvSt ~ L ` ~ _ MDDIF ol''E~r%r r ~ PHONF NO O Rf ISTlRfOOWNER: i iIRSI MIDDY ` I NE NO. N ADD~I>SE%D tR w l ~ A - ~ or H ~O E ~ wN C I}' aAOOR s • U9%r«I CO. uRnnACENr wM R~K. C T,-_.~~Iti4)IlS`c.~. R ~ u r~ -JT'l: L~•~ N~D~" ~f~~r•~cIFlLJ <~UA '} D.MAGIDAREA r i. .- 5 } S";:° ", cH.RDF ' cNAecE ~n"I'o",°iN gAMAL ~D'iwu C. I 5 E51 DAMALI UWAYN OR EY~~~~ClT ^R[ACW~.NID I~~~~ S~ WJ iw:vonY- ~~ W ' E~j~9[MAINED [SI.,DMUGf I 5 ^AWAY ILL Cry I1~ ^ ~ a E~ N Il l DIAGRAM OF COIIISION: u• Nu INDIUI IH DESCRIPTI ilnN linfcESSARYI nr Ad AWA nV: f~y ON Of COLLISION: IDSe surnEAVr:rAE SHEftP NlttssARr I K s . t(l''! ~ ~ '~' ~ ~ ~ d ' U'S.. 1•. ( G~. ~ ~ - Ctr~ ..t~ f.~~{~j. C'.(c'-12. L-T"~ . = - - - - - - - -, ~_ f _. ~~lZ...__...-__ -. ; - _ _ ____.- --._. - u 2 ~.1.,. ~ EC.C,. LA.JJ~ Ea.tlA,_ .~TEI.~L'd 01 ~'V-1 wt~~E. t J~~ _ . }J ~ 4~ IN ,Y NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED • CODES 1 OCCUPANTS/WITNESSES liq~,'o""', ;~ ~ °M~ ' ~ - Z ~ 4 5 6 N , , ,A Aw y n IN sE% AGf ,rerm '„;;" ° 9 ESIR. Nla s". It1 % No NATURE p XI OrA. ^ AM8 ^ ~KI ^"' r ^ H ^ iii{iN ~ A f M `{81 IJ.IIw OI N MOV DIROM ^AMn. ^nwAl^n.^N ^HO Al xwn, iut Ala s { RIB ~. N,I} ~, ~}'f I 'Y ' ' ~ ~ 4 tuxnr- ^AMe ^~.^'^~.. ^~ ^~~ ~ ' ~. rlx,,T ~ 1i J ' ~ . aii~i' •afig li Fl'.Y 1 .I i N~' y~K 1 ~x1^ ~!: . _ ~~,p,?'r: ~ A~ .~ '~ ~ r ,~ r` JJ ~'n r ~•~ t -d . f r :~ ~._ t M cf f4 ~ I I ~ /t it I. ~ ~ E tl ~ , ' I , I 1 _ , y (~~~r ! 1 r ~4 I ~ I ~~ Irv ;K ~ ~ rl1 ' ~ h 1 n ~ r , i I ~I t~ 1 ~ _. ~S R 11r ~.}r ~. . -. ~ ~ 1• T '-i ~ _ '~ 3 ~ ~ GI ~ ~ ,p, J ~". C2e A~ r ... ( ~ ~ ~ ' 2ca .,~ 1~' i y ~, rv . ~ ~ ~ ~~~ s' J -~a - - 'r # ~ G + e ' R a 7'. g ,..:_.~4.. F.$ 'SR SS '~xIRS;G;Yir><a A~ vN 'S; v _, •F' ,, SPA'f~ Ur ~iVASHING70N PAGE DE ~ I tl ..,_. ~~,~~ nI~, I No. . r I POLICE TRAFFIC COLLISION REPORT Iy TRAFFICWAY YoucF COMRAINr NUmeER ~ PRIVATE WAY ; y p DAZE Oi torus orv oar IoN nmE <ourvrr ~'L o ~ £i Z R,. «Bq ,qD ,. I.~ F o~~NS R, SE I muNroND. crtrmo. ^ ~aB:D . ~ ~ , ~ ,~ j _ ~~ / ~ ~ ~ CISYOR 100 N NAME6 N0.Oi BIRF E I ORNGHWAY AVIFS ^S w ~ H.~(15 ROM RF ? ROUIEORSIR EfC ~ , ~SfC11UN ~ ~ r ' ~ -L _ ^ Oi C ON rvIfRYCf NG YnIN SIRE OR ROAD NO e% ~/J~~7O _ ~~}q'[3. ~yy3 ,5~c . KSIV Y_~.. !rr n/~"iL" ~'•'IS N INIERSFCrION ~ /,~(~ /1 1(~ L~ r _.. TYF-~_ BEIWFFN l'1~~ ((1 KlPrsr. T').ft!5-TTI/.•~~n PRfil% FO. MIIE POST . ...i .•.. . ....X Z G .. . A r. V ~ •` qn E w Q fF DP =~ i8 CIXISNJN NVPIV fVfP IY: NO %tl[D ^ V ~ ~ unr,K,vn wrR ~ - MILEAGE CODE mtF3 H N %Pp NER I ~ rr r1! EC t;:, I ' iy , IOIAI NO. -ENO INJUREO~~, S IIAGE C7H R VINICEf3 ® ^ PRORRIY OMAAGF ONLY ^ F TE ^ 3 A I 6RN IN 51 04 ROAD OR RFEERENCF~ ~, INIE1( Ct5 CROSS Sip[Ft OR ROAD F / 3 fZ] @, lIFO F ODIICI5IRUC%INPME OF OBIfCE SENUCK AND OWNERSNPMEI ~L\ + H C O F51.pNAAGE SPF<IN COPING USf ~f G ` $ UNIT NO,7 \ s DRNfR'S NN.1 F: lA S E E I R SI mlDm UNIT NO.Z VEHICLE ^PEDE$TRIAN ^ PEDALCYCLIST vER~s a si N v ,<r"y ~ ~) //y~ ~ n ~ , /~•-~ > ~ y ) / L - - IVN liC~/`~~=/V `. \` J' ~(~ ~t~ i 1 Jl c~~ I V~/v.ITIKt L"~ ~ I ` - ~~. 514ffFAppRf y~3"~)~- .L c- / „3 A ~ Lac/./rV cJ s R p0 Ifff p433 • I \ 3 F~. D AZ ) /\I [- Cltx 5 1 [ 0~ ~~ '• ' V ~ / ~ IIP CUOf YHONF NO. .(JN. R U I ~ ~ ~ SIAiE /[/Z~Z~IP~~Y..C PH NE NO, ZS ~ f ~~%I Z NNERStCEN5fN0 sfAlF fX D IH I ,, "•-' R IICFNSfNO. RI 4 << a ,- 'LEAK wL ~ ~~ xR. ~ NOP ~35 N E -GC~4 SF% n DAIEpBRtY j ' " " ° ^ ~ B UCCIIPAiION NRM NAME6 PHONE O. EyFS WE OHI Hf IG E acuvAEION ^ EI .1E N 6 PHONF NO A i 0 6 5 t . Z ' .~ FI~^1 ~ R ChIECK I ~ `CJ.~~ /T //~1 ~~ FYES WFIGHE HEIGHI /T ,~~ ~%/V`f'f~UZ~ I S-i k , H ' z ^ (F7 vfH Clf A541~fm%UVfF OFANOIH[RAI CODE$-* ~ ~ ~ ~ •"I 5 NF<IK>r As; Pc ~ A53 Nf i° .- . ^ CHECK (f~ vFH CiE ASAN FMROrEE OPANDiHFn.At D CODE$ ~ * 7 n" si a s°°: iM"E 5 u n 6 "5'O -- '~ 3 a5 C ~ " E - ^ ^""^ ^ 4Rf ^ ~b.H ^ „r.N ~~Sr Vf WYEAR pV F{HFV.1 °mCpf O I.NOVA1 °" I10R.C0 /) r5 ~1 1 'µ€ 5 ONE x~koiRO NAAH~ FAR M ^rm I ^ C°nllC[ ^ CSirtR ^ ~NKi[ Y {HEV 1 ^'° p RI K °' I r 5??~4 . t5 ~ I° ~ -LL 'l rOn~T, Ep 'i'OR.nlll L/t E .N VAI t I V.1 gyl I~ ~O~o END Y G( P•p[!, B ON ll<EN f ItA I rv V " SIJAI[ 14AIt[R RAIf NO. SIAIf hl ~ L~LJn C E IXOR ~/ ~~/ f 'V ~~ t~~ ~~~ N ~ A • ~• IJ VE"ICIFI N IIPICAEION • v cff DENNP An 3 G c u' G, L Z .S 7 8 ~' ufcrsn4mowNER; EAST il4sr E ' 2 ~ ~ ~' 9 ~ ~ ~ ' I'~ -I ' ~ ~ r ~ IDDIf PHONf NO O IE4f00W fR; IASI EI45i IDIXE NE NO. ~, lo IS Z AOpPl13p DWNER W R f •- A WNfN N NAMF lAD04115dIN3U4ANCf CO OR A ' E 1 ~ ~O • 7 ye Ge"C~C C ~ ' - r ' R N t ~, f - . T E F.ct. rLw e7L.i~ NONE 'St EDAmAGfo ARU °w:~~;v AJRN~ 3 _ f~/~~~ ~ 3 ID IUD Ip~ V\\. 11 nr,R•B•ul FSE. DAmAGL .. .^J~~ .nV CHARD ^.....,. ^RIMAIN[D ,DEwnvN D [HARD[ DWi.IN ® npfMNNFD ~ HN rH Kwl fSOPAAIAG[ DAMAGED MfA _ fOP I~_ _~. ,L AL A J_ . DIAGRAM OF COLII$ION: I~SE~~c ANC swuuNeces%Rrl er ROl ~ A~luc ~ '~ t , ~ i - .~p ~ ° ~ -- .~f Y _. - _ - ~ ~ R NAMF AZ1f1DFCf D Iwl II lelee rye n. nn... I I IJ Aw~Y en ~ S'f'(,~° f ~,r~ CRIPTIDN Of COLLISION, IVSl SVIIIIMFN1Al SHlIi If NFC[SSA4Y1 1Er•flett+~l - No,eT-r+as,;L,~n o,L~. C!~~i2 U~{iQ~E*Z- ~~'oas-cn~A YG yUEev L6~r- WT[E Ql~IUdLJ~ As UcM•tCLt.~T ~~l WhS ~,tsSLtiY. ~ t-~~. ~ f Lo win ~12A LeES „qua Sr~, nn ~ ~T~ A I'al~r A'r 0~ N~~7r{c C~fi-•FoG l[,uc f~l1~E r,~le~~s ~a[.rcA~A. JLVED * CODES 1 - Z .8 4 5 6 a } 1'~, a~J, ~~. rE p 5`' ~ ~ ~Z'p V _ ~ Qt%. ;~ v 4~ ' >• 'R ~W K • c °~+ . .rev ' ~e ., Pd POLICE TRAFFIC COLLISION REPORT _ ._. _. _____ nJUCEmmHA m.. ~ ~ TE WAY 1RI DAIS OEGS% Yp ~ Y G. Pun I E. rHl W DR ED. LIME IVSE ]YDO HOVRI COUNTY P COUNTY NO CIEY NO. fHWA ^URDAN 182 x ~ I O ~= F .CS /!v RAl j ~ ^N ^F ^W CITYO4lOWN NAANf6NO.Of SiR(f10R NlGHWAY Z MILES ~5 ^W OF ,,.E ON ~.,P, ICES ROE/IEO4 tR ~ . ?/rll-~O SRI In NIFNSECIING WITH: ORROAD fjONINIFRSERION BEIWFFII ~ ~ /~ STR[fi 6 SIPFET PREf1X. LO. MiIE POST ,/ ~ %~ M DISTANCE ORf 11 Y F%E .CROSSSIRffIOR NEARf31 MITE POST ACCIDENF DIAGRAM DATA 6 MRES 5 F W MILEAGE ' fEfl Of AP CODE CIXUSION NVIXVE-~ SEVER IY. iOIAI NO. NO.K LLED~NO INJURED- ^SPIIIwGE RUN Cp V[NIClES ~ ^ pROPERTYOAMAGEONIY ^ pFDE 11f0 ^ VEMICEE runDEEDIH ~RD INIFR CLS ~ N I (IOU LV,.°OR RYEERff+CE CROSSSiRfROR RO/.0 ~'~"~~`~ 'ZS _ 4 OnJECi STRUCK (NAME Of OBIER STRUCK AND OWNER'S NAME) f5i.0M1AGF SPECIAL COOWGIIS ' '., UNI7 NO. L . - - - UNITNO, 2; ~ ^'VEHICLE ` ~"~ ^ PEDESTRIAN .'^ PEDALCYCLIST ~ ~' 3 ORIVE4'SNM1F: IASI fIR51 MI OlE mP~., pvrvfR'S NAME: ~ USi fl MI L - SIRfFTwODRf rP~ ~L. FfI ADDRfS OIT SlwtE ZIPCOOE PMONF NO. D IY STATE IP D J A/N/fL !/O - R DRIVER'S UCENSFN .R, ,en SIAIf .,,~ fX r BI H !MD ~ D Y ~. ( ~ V U ENSEN - AlE E% OAl O nRIH MD I .DAY lY~ OCCUPAI OfI RM NMIE {PHONE NO EYES WF GHI MIGHT E CUPAtION PRM NAME6 PHONE NO. ETES' W fG t MIGNi z "' c Jy -d3 R ^ CHECK (~ fH RFASnN EMROrfE OPANOIMR. ^CHECK (.~ A< NMnf wsAN lMaovfEaANOTHfa. CODES -~ J ~ X i J S e 6 "B'A° .m n n CODES -~ D n" ~ if. 5 Ex Et v a sIEM Hrr n DR uP 3l~:...D„ ^ ArBDIA+KI ue L ^ ~SkIY ^ K K~ ^ NM~v ^.M AHKE a usa ^ rbrR. ^ n~2 ^ ray,. 'l ~ N EN MAKE fpDDGf.GHEV.I FL IDARI.NDVAI SLYIE (RDR. GGNV.1 FV.) MODEL IDARI-NOVA .Y R I Y l •1 Haw ~ ~8 L'~ e m 7 Ok IICENSE PIAIEN . SIAIF tRAIUR MIE NO. StAIE H NM.COIOR L F- EA N . A EC.i./ O 7 GK.IA I C ~ VENiCI[IDfMIHU110N NO. VEHICIf IDENIIA SO IPIz131H!~iDI I IB!91611 ,zl I I I L ! 1 1 1 1 1 1 1 1 1 1 1 1 1 1 R[GISRRfDOWN[R: VSI HR51 MIDOI[ PHONE NO. F9P7~ ~ ~ w O W IS D WNfR. ULST PIR51 I plf NO. u ADDRluaormER F NER +31 AMtxAppReua WSURANCECO. oa wf:eNl Dai land Srainb a Island Ins. Co. . R + Sz FOAAUGID AR[A V3 CHARGE ~~^w • a L ' CjAMAGFD NEAP NARG[ D f/ " l TOp 1 -, S 131. MMAGF ^ AWAY RlAV11N[0 IG ~OITOEI C OYfpOMOE ~ ^AWAY ^ ESI!DAIM E I YIOp RLNPJNfD IO POITOU S p` ZONED f $~ Awwr ew fOWtO ^ Awwr nr~ f L 1 RAM OF COLLISION E I p[~Jo~oR•TH DIAG ..,sHlnuPJ[RSURYI e i - .. DESCRIPTION OF COLLISION IUSE SUPPI[AJ[NEAISM[i if NEaS.URrI __. _- _ .. _._ _.__ _ -- I :._ I. .. i. ,- ~ - iJeN/e~ .was S__e.Ca.,JE/n a.u_5.~4 /z _ 1 I I I _ _alJeKr oFr'- eaAa ._-tH4o,y6H r/zv<g _.-- ,. I i Ac,Kcors ~asr•*.cr.. YooY«cr.f_Nir ._ _ ~, I I I i. l _ , ^ - -- ^ .... _ I , ~ I I . _ _ _ ._ .._ _ i _ ~ ~fcu _. ,_ I I . __ __ . _... __ __ _ _.-.... - _. ._. __....._._._. ----- R D S 81NJURIES Of PERSONS I NVOLVED * CODES 1 - 4 3 4 5 6 S ~ WITNESSESIUSnE»PUMtwa3H CE000FAN TOR ApDNIONAL NAME ED S) --~-- ._..- SEX AGE 1AEVS n1VIH u H 'IHC- IA ._.._.. RISfR EJ[R 4.m..' .I n NAME: .... I . N AMYISS - IUR Of - I W i IM nn ^ AM B. ^ r~tiCl ^ ~N • r. ^ w ^ rtQHE/ NVA( ~ A ... ADDRIU NAwetor.. ......_ YMwlDrvoM AMe. ^ ^~fxf o~ . ^ a n :° Q HAME ~ A mrfsS NAttWf Df INJUxs ^AMB. p'KK""'^"p;x.^(A'x' ^I~::,.BP Y•MSIKiA1wG OYIKEY'S N4WS ANK n x O OW AGENCY Ki DISIAICMD zJ ~s 10FK1 ARYIND ?~2° DAZE OI IIICMf AI110VEDnY DAII I , z ~P , L ! ~ ~v~ 1 ~ ~ . , h *n5, ~x ~~, - .E [ ~y~~l ~ d 'til L. ~ . t ~'r1, s, P EC RI:1•~ . }. .'~~ ~; ~{ ! Y~ ..;,: ~~ ~` r . ~„ I ~~. r r ,>4Fz Y I iH ,~yy,L l I'JWmm.. ~ wiE .T. "5 ~ c ~ ';~ jIY:; POLICE TRAFFIC COLLISION REPORT Ia1 1'<.a,'ICwAY --- ~ . - _ __ ._.__.__. .: ~ '~'"" "'~; wuE2co u61 IV.,..,, 'C~ aux. 1 , •...- I ~ ~ PRIVATE WAY ~ ' 4-.- _'? r. ~ ~ DAIF Of,C0111 N_ } _.. IIMf COUNTY COUNTY NO. CITY NO. iHWA '~F +, '' r ~ ~~~:'s~ Yl I ,IDD:;,.IDIH~[,II[Ix 5g~o"' ~~'r-F o ~~ ^NRBAN '~~~y uRAE i~';+,~ ^N ^F ^IN ~IIYOR tOWN NAME NO OFSIRfF10R WGNWAY [l5 ROUt SFCII y ~~ MIEES s ^w OF CN/MAeefA ON Co t2/~ ~ .3 9.5'/70 ., Crn ~' 1 `I ~ INtE CIING WITH SlRffiO NONINtfP5EC1 ON PRff% f MIUE POST ~ ~ ;. ~' ~ 2 v .'~ rir BFTYIfN .EGG '~ SIREEI6CO R0 $ $LPffY [' 1 DI IANGE DRF~`OS I N 5 [ •CPWOSSSiREEI OR NfARESI MII[POSI ACCIDENT i DIAGRAM DATA ~, ~ , lEEi ^ ^ ^ OF E'G'G I• I Rd b MCODEE .; ,. I. '. COLLISONINVOIVED, fVERIIYI J!(l I %.RD INI R~ 9G0 OR k[f FRFrvCf ~ ] ~^ h >~~ ~ S OVfM Cl0E5 O.%llfD~N0 IN1UPF0~ ^SPRIFUGE ^SI FII ~"DYtDIH INTER CIS GQ05SSi4ffi04 ROAD ^ PROff4iY DAMAGE ONLY ^ PESUliFO VFH CIf AvUSW `~/~OO f .. 7 .,:. .. _, _, G [(~ OB1fCt STRUCK (NAME OF OBJECT STRUCK M'D OWNER'S NAME) FSi. DAMAGE SffCW COD NG USE ~ ` ~. RBA Z3AN a ~ RF E 'A ~,• UNITNO. I UNITN0.2 ^ VEHICLE ^ P.EDESTRIAN. ^ PEDALCYCLIST ~.' _- S ORIVfR'S NAME: IASI {IASt MIODI DRIVfR'SNAME: IASI - i1kS1~ I I I u ~b; ~.A 1. F1D' S.F' N - StR[[tADDRESS 9fft ADORfS$ • ~''• 'Id Y 5 A ZIP CODE PHONE NO D I Y A I r '. ~ A -Y( ~I Y NtYpLe ~)t w ass-3) 7 R ~ ORIVfR'S UCENSEN SIAi % q RI I V U fN5 NO AIE % OAi Of R N 0 ND I D,,, IY4 j s H wN !; ~, D,Y ~6Y~ ~ ' B OCCUPATION FIRM NAME PHONE NO. E 5 WEIGHT HEIGHT E CUPAIION FIRM NMIE6PHONF NO. ~ ~ EYES WEIGNf HfIGHI TR . T~nf'/Yp 6EC 3a SFC R ^CHECK (~ FHaEASnN DAnortFOFANO1HFa. ^GHECK (~ AL - ~' CODES-+ 7 ",Si• < °s M"`~ 5 uECnDH e;°,°r •C CODES-* 7 a VEH CEFA4A5 FMPIOYFF OFAS i~HFR. 6 w '°t~" E+ ~; v.~ Iw~ TES MO/Y :SSn D N eF ~, ifsnM t crwN Try .CIF N ~,+ >f ..I Y: '°'^ ^ AYWAANCI ^ Pa°6K' ^ F8NFR ^ ~~2,~ ~ Nv ~~reol.D ^ AM AHD ^ ~ ° ^ C"E'Pho ^ K~ cu ^ :°.HF.. s, YyN$Cfy fi. V[ TEAR MAKE (DODGELMfVi FIIDARi~NOVAI S1YlEfZDR CO V.1 NYfA ~ I ~HEVI t(DARI~NOVA) Y ( R Fp^•' ~ T~ 'PS / O V L/ E A ro x ndT ~ h ,. a R Ilcws vu o. sr~E4~ •IxnnER awre NO ~sRrc H vEH.eaoR f "`~4 I RFGI IER[DOiIWNER NJN IABIl+ I IIRSi MtDDI[ PHONENO ~ VEM fE IffDNllfIIAI I ~ I I I I I I I I ~ H~ .• ~~M ~ '~' `3 ~ OI 131 I f~l I I I I I ' CD (` ~`~ ~N WNE4: UASI {1451 MDDIf N ,I _. „-., ;._ o Q N l AD09E55OFOWNt9 OWNER " I ~ JIr ~ a a ?86 " ~ *~' nAMEa ADD9essar WSU Anee eo. oR AGENt E ~ ' k R D9 ~ , FDFMAG! AGG I Ne NLr • ~ DAMAGED A4G ;.r' ,~~., _ iw[I OrDi.i CH Dq CHARGE wtlOwt F ~ 1U~~5 t5110AMAGf ^A VEN ^p[MAIN[D ' ^ARIV[N ^P[MNNlO tSI'OIAMAGF I YiDP • • f ~~~ '~ ]~' T ~ ST ~ low[o AbGffaN 7bW/M2 ^~wAY°er: wAr S IoeurroV ' 1 DIAGRAM OF COLLISION E N I ult na9ln DESCRIPTION OF COLl1510N• IusesuvPUM[NIAI SHEEr IF Ee[SSMr s a1 ' ' ' le ...-,SM[FIRN[ClSSAPYI eY APROW -... ) _ __ l ::: , I .. t i_ 1 T ! ._I- ~ i_ I I ~" _. ~ FN f . /Ift 6~'TAida~- __4.!! R Y.S .. NF---IS C~SYd - ' I .._ .. L.. ; .. ;_ ~ i i iSoST_.CONTRo~, Wf/LN-°... _i. a-oki:v?--l.N----- ~r r ' ' ~ _: R+°a2.v;c,~! J~fl-Rnia2.,.~...ANO.__9-/E.T. T>f-ic"~_... ST ~" ., 3SOE'' ~ -. 1 r; ~ Re 4GZ3dNJQ. o/L.. N .-73e!v.HO_.S~'pcE_---._--- I --.; .. _,,:-._ .; ~ ~, ! of .KoJ1A. _ __. _ .._._._ . _.- - -..__ _.._ ..- ~ \ ' ° P ~ 4 ' .. ,.. ~ _ .. __.._._ u' _... .. __ -....._. ..._._._.... r ' ,. ~, .~ .. _ '~~ IUSt SWftIMI -... ..- _-. ~y ~ •' ' HAMf OCCUPANTS/SWBNESSESESOFPERSOANIIS`NVOLVED +si%~D~ct tAius ~" 21 n' oisrR llln ,.'6`,: f ' ,~ S49 +~ Y Y -. I 109 ADDHK)N Mr (~A~ p ~ ~_. _ Fa. ~ a , - Aoo9ns. .. NArI~RE ar _... eN er. ^AMe. ^Q7.1KI ^i41k. ^Ci~ ^it<4~o. '~h~ •~, ,' w9M t: AIwYIu `~ ~ .~, ~ HAMI ~ ~ >u tN'°A14,a Mov oFYOM ^AMe ^FaY I ^CO:rI. ^Gx' ^"n°.ws. nro ~ ~' ,III y,~~~FYy No "^'I .~ ADMISe NA~1 OF - ^AMS KE I 1 WvI5iWA19q OIIKIYS NAA4ttAN[ tApi1 OR AGIFKY q 1 SPAtDMD YOIKt AYYIND OA110191gY1 APMOVID tY DAtI I ".I I ~ ~• V`~ ~~ ~LS~ HYpt ~~~oi p~~ ^'~_ I d ~ 1 kaN0.1 i L7Z•t r\ j {~ y I .;' a: tl[k I l~t ':N q~p t, t ~'~R'14Ri'.«'~' +O it .•1~ 7 . 1•. JF. A=!.. tlf irNY'b' :'~ "~~ •1~4 TU / 'i .~ ~ ~~ ~ 1 1J I~~ ~ 1 ~, F I Y ~F rl, i ~ - r ~~~ ..may ~ ' ~ Nrv ~ '~' x ~~'1'C" ~~, H' a r 1, ~~~{{~~ I I 1 i i~(M yd ~ t ~' ~ f ~I s . t 1 ~ r .' i ~ v ,~4v t I •~ ~ ~ `~f i i PPf~* ` I ~ ` ~ ., I ~:1, I R,t Y qtr'" r ' ( Ik y P !I , ( - ~~f - 1 e 1, -S'~ , . ~ ' T ~ ~~ "~ , ., 1 I ~y C. ,. I ~( r .~ ... J 8 Y Y Y. v K W Y V : 1 ~ rT v ..., ~~: ~w E 9. ' ~ ~~ POLICE TRAFFIC COLLISION REPORT ,"¢~f TRnFNCwnv ~ ~ ~ PRIVATE WAY PoNC(comvulNlNUmnFR 1 !$ ~A¢ Lcou r N D r ' ~2 >u, I l ~ q(N i ~ umE IU$E Z+tq HOU 23(~ couNlr c'?=,~G~~ ~ coumv NO. ~C- arv NO. ~ fHWA p~y~'u A" / ^N ^f ^IN CITY ON TOWN NAM O. Gi SIPEFIOR HGHWgY 33 Nt[RSlCt:NGEVnIN: SSRL[a Mrr(y+0 r~ ~~O 4 1F ~C 10 ON ~~ ~ CR ClS D R I HOUIE UV 51 5(l'DON ~J ~7G'X Z~ Z/ N1 N P / / l L BFIWEFN rV~(/- ~ ~ a1RFf1 6 ~ l a1REEt UIa1A ICfeOGfC110NiN ANfi(PEN LPO l PRfN% EO MILE Y05t ~ ~ r~ /V. Sa51RFE OR NfAP[SIMRf P051 L, / MII[a w MIIEAGEr rEfl ^ of G'' { ~ coGE RAMP DIAGRAM DATA CO(I.gNIrlVOlvfO FPOr ~ ~ UN ,uxoPtUrr. IOIAI NO NO KILLfD~N0 INIURFD~ ^ SPRLAGE ^ ~Rp FRa C1N IREEIOR ROA00R NLFFRENCE I IFR Cla CROSSa1PEEl OR POAO qp ([[ss IXV[IIICEfS ~ PRORRIYDNAAGE ON(Y RU V~WP(f~ ^ RIFS [iFD 4b1[CI SIXUCKINAMf Of OB FCIS1P ' ~ ~ ~~L ~~ 9 I lM:N ANDOWN[R a NAMFI Ea1pM1AGE PiG9c.~ ' . s 00 ~ SPECIAL COOING USE a UNIT NO. I NNIN'S D NAME: al I al MI D UNIT NO.Z ^ VEHICLE ^ PEDESTRIAN ^ PEDAICYCLIST ' r / Q C//l~~ UVIVEN a NAMF: IA51 rl I l _ ~J e.L sIREU ADDR(as f CI atAlE ZIP CODF PHONF NO D SIREE ppbfss - Ilr I J~ . C ~~' ~ R SrAIF IP pE PNON NO. • rv(RSUCENSE N4. SIAIf fA F FbIRIH I pNIV N' LICENSE NU. AIf E PALE FbIRIH ~~ ~~liJ ~ P CAA M as i ~ "b ~ Aa ~ PAY ~,N. Y it OCCUPAH N E6PNONE NO. frf5 WFIGHt HEIGNI E OCCUPgt10N FIRM F6PHONE NO. FYEa WEIGIIi Mf IGIN z ~~~ S,~z cp~,~ f ~ ~ R ~. ^ CHECK jr7 ArMOnrtc"( ^ CHECK(/) ' N rmP(o"rEr of ANOrHiaA[ q / " CODES ~ F p ~ 5 I e s D " CODES -~ 9 ~, A .E 5 4 a 'SV.° ` °RY r z 4wIi5 ~ s ~i Nom p AMV:,gxa ^ ~ u Ye " O 2RSAN ^ ~9r~~ ~ ^ PNS'd,,. ^ AMN xa ^ l ' fO A Po4' ^ ~ ..(N ^ ~ ~K ^ w4;,sP. 'r I ARn ANNEIWCGC <HEV) MOOE(IOARI NOV I a1TIE IZO ~CONVI ! Y[AR H rrfV.l K 1 D [ MODE 0 INOVAI IY 120R. VI rN ~'' fUTL Srv u~ 'L (~ E vTl qON UCEN]t PlA tx SIAIE iRAllfR gAlf NO. $IAIf li of H. COLOR N A NO AIE ~~~ Ctr- 3B Cd,A - ~ . 3 VIN CIF IO(liC J(INO c5~~1~7~ I L VfNCIfONiN AI N N Sv , ~ E , I i i ! i i i i ~ ~p NEGr51EN(OU//w.r/(lN~'E(9~j~~~/f U51 f1R51 MIOU(E ~I L~ PHONE NO. W Nf 51[N[p OWNFR kg51 fIPSi MIDDY F AOpuF55 4wNE4 0 ( WN(N ~i~• IY/J1 U ~ ~ E RANCrco wAa(r EaAD,,D//( fir ~ N I u , R ,~,]]OAArA jIO ARFA ~<,'p ~N CH'wPG c 1 ~. ~ImE~liurDiN tM1AGFDNtFA 5] IS ~ Pr.n 1(f/ i i •+ Dg M EfN ~n 5 k51~ A/G}F ^DW~IY {yaylMMNfD - :un~ Y-` <N NGf nlrr(uuufr ^AWAYN ^NfMNN[0 ISI.DNAAGk on,'or ~~]a J / ) 77 `; ~1- S (l l/ ^e~v°nY. ^ w~fD9r : -LLLJJ A ' oInGRAM OFCODISION• ENU D<NN4 ARROViI" f LLEI { NICE55/.RYI DESCRIPTION OF COLl15lON: lus[suPPE[M(Nru sHEEiNNfcfssnavl 's ° i O ~r lldf/~Cl~ Cl~/r/v :9.P0(//ti0 /1- COQ-°aCf4 ~ . Cr,~i7 f</f ~tJ rte, 7-f/6- //r.2Gle` e ' ~hl~ikay ~ ~ F 7-/iE- ~s'a~,~f,~- a, T' _. _ aN K. R ~! 'L . NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ' CODES 1 - Z 9 n 5 6 OCCUPANTS/WITNESSES IE°,EauywlmrnlAtSrv ADDI:101uWAM( ^ 51 afA AGf alAfua '", 5 R61R, blCl M k iu ' _ N ADD+16Y N mR a NT - NtM~QI; rvNe ^ MB ^ror Kl ^:'~~rr N ^ n~i ^ ri NO - Dn..rs cyr or i~~. .^. w~nN ^vi ~7 ^;::'H.. 1 1 1 c vs E eYDCr F '. \ I s l ND rtA rrn r aPtror'T ~ e D.N .o u ' G /Oay f0y~ ~pirllr x ~~~ h ~~ ~fG~ ~ G' ~ y p ~ 1 ,iNG~ its ,Nn".N.L..1( ~7~ ~N17ffi. .. Y ~' -, C~ ~r„ ~I ~~Et b~ ~It~~~ ~~„n ~ ~~ ~~~' 0 G # Y ' _ „I ,r~ ~! ~,. Tr~ r } i .k ss ) ,~t°'• `Y "'. . ~_ `` ~; ~~ ~r~~~' '~~ ~~ ~ x ~~. N , ~ F $f r; ~~.f I ~a ~ ~N'i'1u ~ d 4 id. ~ ~°~S '" t1" "s~a~~y ~~ ` ~ FI Fj ~ ~ J -. - { ~ ICY' 1a , tU t ~ ~ ~' " ~ dd 1 ~1 ` ' ' n~ a,a._,«~,. _fE , : .~ _ ~ - ~I Ja .Zw. _... .d, ..._ _„,~',_•_ ..~,....S;I _ u ~t;~ .w. a.~ .u:~N._...ta:-s~~... ._.rrJe. . ..ua.„s.. ~..,Z: '~: [ k '4 vI..IL Vf 1 ~E Y ~ ~' rr `yJ MOTOR VEHICLE COLLISION REPORT "i~~ / DATE OF COLUYON OAY OF COL ' UYON TIME OF COWEION NU. COUNTY NO. CITY iiO. ^~~ ~ ' ~~• ~ o.rn ~. M EAR Un A,Ox NFS wE0 S ixuP ilU sA[ H R U1E9 A N M '~~ DAN Q,NIML ~~ 1 ' - k S ' ~ E Puc~ C UN CITY, TOWN a ,`/ occur~i,iu ' ~ ~i ~ wIOU[ixl No "T,w MILES. N l.5'• L~J' ®® CITY. TOWN ~~ 1 [~ of TcE1n P~L 6 ADM~CLS PREFIX `3 RWIf 0119[REET CODE ~ ~.5~/7P SECTION I E' F / ~ .. ~~J. , , rS . . ' ~,t aAO ql GIVE AMEO iflE .ROADOR HIGH WAY. WTERSECT810 WITEI: STFlEET OR ROAD ~ PREFI% EO - MILEPOST f ~r{-G4 O'KCLIK1iXE0 ~ LJ / ~~ . ~ I NON INTER CiION~LOCATIONO COL ETON RAMP DIAGflAM DATA i ..P ~ __ BETWEEN (O SiaRT MD ( .9itltt~ ' ®© SnO~wa~CES1 WlE E MR E. [rvUl R055NquL[aosi 0nm[Hi fvwaiulWn ,siw,~i R NON %~RO I E OP CFOLRO59siNEEtoR RO.tO I I ~"S ~ . rvIFUSFCIION FEET ©® Oi Q I . F INTER INTE CLS. ^ ~ ~ f}~ ~ COWSKIN WVOLV[D 1 ^ ENKIENENCLE ^vEn CtE&CYCLE ~OInfRIWWiFI ^ y OiALNO ^ EN U 06 EC1 ^ E E ~rtC~~=C~ EPEC.CODE USE ~ [ ~ o 1 V ClE 1 V n LL ~[R N vtnKLES ~ ^VEniLLE PFOfS,w,x ^MXi COwEKW ^N1RUx , ! 'Y ~ _. °~~ _ OWE iIiUCN IrvAMe OFOWFC16iRUC+1 OWNEROFOWECiENM1EMDADpRESS LOCA /' Q~u IN POA .C f~ TION 1 OWAY O© EocE ~o ni~AU~a~u[CF FEET S . ~ y*'~ ~E' ~' ~ E IF MORE fnNI f DNVEaEUET NAME [FIRST NAME MIDIXE FxO LU,s DRIVERS lA9T NAME • FIRST NAME MIDDLE ._~ .~ ~ ~ ~ ,(. wE wµavfD ~~l f ~~ I I us 7- A~ 1 r / . 1 cq ,oN ~ EL/flEET ADDRESS 7J~C flOUTE ND.AND DOX NO. A,ORE[ Arv[ SIRE P L ' / /7~ 1 rSU,yi[ usERA ~., ;. CITY S TE 21P000E DRIVERS ODCUPAIION CMUSgx CITY fION A a" n~ 1 W Uh ~/!+- REPORYigIM , ~.f/~u~Gic~ ~cl ~- ONV RELICENSE NUMBER ~ STATE EE% ~ATEOFjRr'~ ~E OBI) ~~N~CO, YCJ ,_ ,R AGE M F o J OETe-.E vEMICLE Yfl. MAKEICHEV: DOOGEI MODELINOVA~D TI BOGY ETYLEI20R.1 VEIL ~ TATS. ATE iflAILER PLATE NO. STATE E LICENSE PLATE NO C, i[ . //O ~ ~~ .~~ VEHICLE IDENTIFICATION NO II B9B MODELE6 NEWER( ODOMETER (MILEPOST VEI R (MILEAGE( NO N NO r . REGISi~RE OWNER (LAST-FIREInnMIpWE NAME( DRIVEflSUCE SE . REGISTERS[, L-. ~/ ~ T ~ (STREET, CITY AN09TATEI PATE OF BIRTH OWNERB AC OOFr BIRTH OvmERS AUIXVESE ~ ~ YEM . ~. l !. / lV '~ 5 ~ PMTS FVEHICLE AMAGEO PMTS OFV ,wil v[rOi<tE ~?~ ~aeEnJ Es,IMAIFDroET , FDREPAR {NKLE ?d ~ % ~' ~ ~~"~ ?j ,. J ! t J WAS TM RE AUTOMOBILE LIApILITY INSURMCE- "- ~ -'- "" """"""'pI LIABILITY INSURANCE INFORMATION-VEHICLE 0.1• CAVERACf WEFFECr FOR iws ACCIDENT ON YOUacM yyI YES-^NO 4...... NNAE OFUMILITY INSURMCE COMPMY NAME Nip ADDf1E5EOF UADIUIY MEURMCE IVLK:Y HOLDER rv,ME q[Y 9[Arf °° P RF ~ r1 ~/ ~ Q 1 .Z " Lc/It /& 1~ ~ .~/L - qtr s1AlE a UABIUTV POLICY NUMBER NAMEM ADDRESS OF LIABILITY INSURMCE AGENT - c ~ ;~ 9A' ~f. wn ' s 3G ~ ~d 3s1' ~ ~ N,x,q, ESEV.w A 1FP[PURi FORA iE91 PGE S IU 1ST WJUR AAE YNDINJUR Y Y ^ 4 :. / 1 / .{ . 10 J ~ // ~ HJ NAM[ 1'[[J A/J/U LD(e~~ ~/~~ O ~ i NAME / % /~ A~!•f/~~ % pDRESE L~~ =IIC! EE X ~ /Q~ 1 SE% CG~ ~ • d~~'~v V ~ ~ ~O DR ~V ,' ., ~ .. % /w . . X (/ / n.I ~ O D1wA,1m% /~Ja~C%C S NSiJ S ^ VO .. gEw~ ~ikr.5 •d~oPo//SP;i . -..... ^1~ ... ', __ ~. '' ry~ E 'uo,wm°.'inclgn © rv.MF°N9 rC ~1 ,rxKlom ®IYJ xmE ~ [u H T APPLIES A SiAiUEOF WJUREp MM%FRST ONE THAT MPUES STATUE OFINJUREO MMKFlflST ONE T ^ w IN VEHMIE O,s~%NO xWLM~,gwO P~59R ~,•/ IN VEHICLE RWAUtwO OrvIrD4A0t P<JSHnIf ~ NILlEO IYV[~EI N IMmOnIWO I MILLED ISFVER[I IMWOnI COMP i`ic 'o °a ti[ S F [ OM N N 7 Q F 1 I 1w,N NO ^ ~O ^ D ^ 5^ 8~ ^Mn ^ S^ 6(~ YIOW NOR( DY MROW NgNCIE ~ .. ~i~id pESORIBE BELOW WHAT HAPPENED,(REFER TO VEHICLES BY NUMOERI U uG Uehrc>/7. ~- I h~/~az.~ •rawAie~s !ili~n/cA[,.+ ~ pL,E ,~ ~„;~ q; „,D,„,,, ;,[N p, •~%'eJn Pv~t LriaJlv:~ A/~~**~~,. &~UtJa_ Uelley ,Puko! " ` ,KI( u,DFnOW T//F/ hr f deck lreU d /a/ - /:YD" t'uerv uu.,,. . (,Ln K '"° K ~, ~"bNq 1RA _.,.~ Q:-- l~RM1LR,.cnW,Y OUa~rvKpHnAbnci,L.~~C•Pf'a~l[n:~o 7e/o aFC/J G(.~7/1'~' down SQGCA!•A~.PjryE.~rtM.(.m6wZ CdC 4'~oG.'. . d,@;cY.:cuRF) pw TopE~j (A[s.P.' Q~ fhl gPp2mf• ,. ., i, x~ ~?, S __ _ , ys _._ - _. _ _.. ... , _. . , _ F~'~ ~ I • { A1wnDn,rmA1 ' I _~. p~~ ~T ~ ! ~ VEHICLES POSITIONS BEFORE COLLISION Now tM[E Y[NCt[ Yacu AR+[D w.E BNEBTIOATED DY q,t tlOAlly AfANONO IEONLV P,A+[O vfwCIF OLLWfO ^iijAPL ^10'O'tniG[ • VCNICIf ry 9 E W ON EIREET OR HgHWAYN FOR NO OR[clbi {p p iA Y{s [b ~~~; Ef~qy! E 1"W I)} iL (( qq tippYY q~I ~y M , WX ® ^ ^ ^ ~ ^ IO ^ A']J ^ Lni ^IOtvit[ {LY O,IW~611 ,~ v Y Aa , NNw ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^Y,[NII '~' n ; I ti' ~ I '~C 1 ! ~ ' MgA,w.N ^ ^ ^ ^ aara cnouiro moM DIRECTION To DIRECTION P(pf S1fuM WAS VS,iKI I ^ YDCWAL% ] ^ wuKWAY ] ^ YMULOCR A ^ ~,~vjii«w+ 6 ^ cw~ssw~~+ b ^ OlltEll ii t S (WAD SIKEFACE VrLALNCII LKSr1L CONgT1G[S TRAFFIC CON1a0L Iq,IC%OND TYPE OF ROAD giNCR/VEHICLE AGTIOHE L vlnttE L,w v +O q,[CAOx[On A,OIIf C yl, Y, f + , ~ ! , lI i ~ Krrv[r.( A1 I S N I Ai IIp~j[I r of rrOtl On I v ,il[ 1 NJ OKKNU~1 E ~ LAYIIWIT a , ~^ L,GHAL9 ^1 1 ^iONC WAY {E]II E ^ GOIN09TRNGIIi MEAD I J - i p~ } i I Y Ll t ^ I U ~Y ] ^ RNLYiq ] ^ DAWN ^ ] ^ 910P YGN ® ] ^ iA0 WAY ^ ] ^ OVERIAKINO ANO PAEYNO ( ,t 1 ~ i ~ ^ ] ^ Wfi T ^ypWriq ] ^ W9K ^ ] ^ YELO YON ^ ] ^ a0MR5101f ^ ] ^ MAKIHO RIOIIT TURN ' ('SJ:a ~ - 1 tl, kf j j V S Rl ~~ ~ +A ~" ^ ] ^~w A ^f00 A ^ ~gni3 DN ET ^ A ^ ILAEHW6 Pf0 ^ [ ^ WTERCHMGE ^ [ ^ MA%INO LEFT NNI CC OTnfR DMX~liREff fL00PrRAMP7 ~ A ^ DII,[R ~ ^ 19P[Crt YI ~ ^ IIONib OEF ^ ! ^ FLAENIryO AMBlR ^ ! ^ ALIEY ^ b ^ MANWO U~TURN b ^ EP(CIFV b ^ lIIIE[I~ION1! ^ 8 ^ WE 910NAL ^ 8 ^ LLR tURN ^ b ^ &0`MNO vq AryO[R 19 SF LANES gN l j ; : , I J ~ ~ i ~ ~ ^ 7 ^81(K'PEOfOR TRAIIIC !^pI[pIY ^ ] ^CNfIC[R/lLAOMW r A < ~I ~ } rF ~ 1 ? ~I I ~ f 1 ~ 8 ^OTIiER EPECVY ^ I ^6EPMAICO ^ 8 ^OR 810P YfW NAL ^ D ^ 9/OPPEOWIEOADWAV ~ 1 P F i-I ~ . ll' A l Y.,1, ~ ( ,..1 ~, _ [„9, pMOED "@~jTA ^t Tyr" . ~.i '~a ~rt.'` ,1, W`" k^1.-.T',. Iti I ii:.l.. ah~'.. t~. ^L-i' - ~~". i'. ~~ F, 1 ~r~ k ,~ ~ ,~. tl ~. , •~ ~ - ' ~~.. F 1 ~ t Y T' ~ f.i /y,II~ t 1,, A / Y L '~~ ,~ ~r ~ - { ~ i i \ ~..! LSE I.i 1.: t ~I. 3 ~ ~ ~ , ~ ~ ~ 1 i 2 ~~ F'F, ~ ; ~ ~a, ~ , r aew~; -a F. ~ j ~' ~ aI'~~'iv~t ~`~191r~~ ~ F i3X~+1 ,~ ~ rS11C~ ;pia 1 ~ t ~ ~~ y~i~~ 7 ~~~ ",i r ~ y~+~S;' '! yu A5a~Y1.~ ~:'', V i ,~ Y9~•. ., L~'~ ~. f~ ~Yy Y ~ N ~°' I t Y wJ• L '~~~~ POLICE TRAffIC COLLISION REPORT Iki TRAFFICWAY POUCF COMnAINI NUMBE9 2 PRIVATE WAY I DAZE ,CO1LI D r1AM COUNEY I x. rVO. v.. Vr_ (~~' O ~ UR) AJ COUNTY NO. CITY NO. ., iHWA QURB AN Q , I it F `,~rJ R R /~ ~ ~ ~ CITY OR TOWN F6NO.Of SIRfftOR WGHWAY ^N ^E al 3 nu1ES ®s 0 E2jo . - T nof^ Wr ON (' (YF s-F fCf CIS ROME 045]RE ~ ~ irG: c3CJ Sf1110N E INI[YSfCI NG VWEH: SfREf R M NONINIERSECIIOry L.~~~ ~ ~..~j PPffl% FO.. MRE POST ~ /O BETV[FN STREET 6 SfRFFi DISEANCf l01 I qE RE CPOSSSIREEEOR NEARFSt MITE POS ACCIDENT MILES W ~3 , M E RAMP DIAGRAM MTA ~i7 fEEt OF / OLINJ" ~'~1 ) CODE CoII SM)NINVIXVFD. VFRDYI 4 RUN IuHDV10rH IOIAt NO NO KIILFD~~NO.INJUR[D~ ^SPIIIAGF ^NU 0 I R I qE 4ROAOOR REf RENCE INIR Cl5 CROSSSjR[[TORROAD '. /]] L~~ ppL CY VfN CLFS ~ ,®PppPfgly DNAAGEONIY ^pESUIiFD ^V[wL1l~ -/ (~G ~C}~ C r OBJECT SIRLKKINAME Oi OBJECT STRUCKANOOWNfR'S NAME) FSi DAMAGE SPECIAL CODING TAE - 5 ' UNIT NO.1 UNIT NO.4 ~ VEHICLE ^ PEDESTRIAN (] PEDAICYCLIST ]' 3 ORIV[R'S NAME. 10.51 {I, .`7r Mi-n- e u~ ~~. krvfR $NAME: IASI I A V L7CJG`i (' .1Rr T5 (" ( ~" SIN[FI ADORE . . r R [EE ADDPFSS _ D1 ~~ J t~~r n UIY p ^ ~ t•^T' .=~ ~/Ck .^, I ~ ... `.. SrAIE ZIP<ODF PHONE NO. T',:~ To'udl,JB• '1 A. 43';31 S- os~ R IY rAIE IP E P Nf Ga ie t R YS R~~~t' ? ~ 2 _ D4IVfY'S UCtNSfN SIAIf , f% A f 91H I .ulJ}.IV . V U (NSE NO. lAlf SF% ?; -~? 1 D iE BgrH > »2=t'"i`, K D K 2102 33 ~ L) LTnii.c3Shl_Q leJ M oG~ IQ ~~; / B OCCUPAl10N iRM NM1Ef PHONE NO. fE5 WEIGHT wIGHI E CUPAiION IIRM NAME6 PHONE NO. EYES W [IGHi {EIGHT '~ nn:rE,s;t: Naz IssSr,~ R JTUC>fNi Poar In•~+P.D~EIm iGH 0 5-a~ ' ^CHECK (~ yfHKIf AS~NfMHOY[[OiANOrwR.u ^CHECK (i7 FNKLEAS AN FMPiOYEf OP wNO1H[R. ,x~u P CODES -+ D ~ A° 5 1 6 ^5',° CODES -* D q f °sv 5 u 6;° '~]> lumrts Mn:lp ^ AMRAAHKI ^ ue J ^ ~s: ^ :^~KI; ^ ra~SP M Iur~;: ^ AW t ^ ~Kt ^ ~a:tlN ^ „ ~ ^ r.~ r CU V. ~ vlH. YEAR IMKf IDODOf~CHtV.) t1tDMC,_NJVA1 SrYIF I]DR.~C V.1 G EI '( H Y ~ nv.l O[I IDAR NOVA H I L ,f - ~ / ' ~n Nl.DS E 7 FORT? F'Sr o '' D~' • ,e / t lA;1 f SIAEE rgAllfR RAEENO. SIAr I'I VIH. R N A '7 ~, E -Ci .0.2?r%1 oR I C F. RI1R ~S5 WA V[HICI[ID[t:,IItU1KYl NO. ICL IDEN I I A f '~ ~;A• r,;4~~NA~l~i~l'I I~,~~Il~ I ~ u~R~~) wlXilill~f~G;/i9! ~ ~ I ~ I ~~ REGAR9lDOWNtR: 10.51 NgSr MIDDLE r a ,- 'l PHON[NO. W I I f0 WNER: WI HRSI MIDD1 I,7)K!L T•n gF'/ .G- H N 33'5.009 0 G U ADDRISS OWNER f ~I 2 N Ki E .T. ~ f~:v' 21U ~~7F2T IOWAS rB NAMEawooqus or EH3uRANCe eo. oR weLNr I u A I~ I it. R ~r~Y ~-atn ~] ~ DAMAG[D Aq[A `- wtwxiHC '~ t q r fKw tNw.o .i fat. 0AMAGF ~ ~ r CH.VEG V!F!K i'0. KYE'/ ®~Wwi ^q[MNN[D .1 MA9GI ~~ VNfO ^P[M ' ~ OiwiioMGE [SI.DMMGE i fTOi• A 11 f ~ Ioww~EDgY A . AWAV ^ rowm Awwr ar: f ~;, ~/ loeorioil , - ,D DIAGRAM OF COLLISION: lu u NAI Irv ev ^otoo rH wE l{ DESCRIPTION OF COLLISION: (lOf SWR[MfNlAl menu N[efs3warF ® '/Q,/ ~2 Ui~.. W£StA¢ud~D. oN._CaPG ~£oFbF. ___._ I ._ -. _- - ' . f3',, HwPD ~GOwwT_ioG m N.Hkra. F1 h~t>-H'T ,AIP.N. , ' _ V=fc'! r F Rp. ,f; o„t _. Cf~F ;:r,rp R ('R~~n\T~- OP~V~.WFl'f. ~/E.H 761 uJ(~. _._.. _ _ ~ _ . 1)L:O WEST[30Uwd7 onJ CAPt.. Crt:C!Ri F ha'B,/ .._ _ (~ -.~. /~ ~ / S~ENL1.1;> IJF 5{. +r^i, filvli J71.:~Gi<. \tC-~}. 14 f. n J . T . I" ~ n _ _ .. IY T ~: fi _. NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED + CODES 1 - 2 3 4 5 6 wsE SlrnEMIND.L Sw CE000PANTS/WITNESSES rnAOprKYM1HAAU n SI sfK 0.a urus '«~" .°'{~ cesrq. wtt :~~ r NAMT "r•[[rq, ,:, lr:.C L,, io 7~ l~ ~" ~ C ~ 4'.J'riGTl..r `;I •l'TV 1J, ~ ~ 5 Tin.' j;~~-00 ~ •~. . wl3wu3l.'r. 11 ~ G7 T Pu'R, rwtor tDJN s ^,~K ^fr:.K1 ^,", ^ 11 O~° a Ho A OOPIt{ NATLII d AM~ 1~I qY ^AMf t.JC ^ lirfl ^ X ^HDwV n0. ~ U IG f I I i t IAN fADGF W "~ ,4RPKY PSi f u KID ArCMD K n tKF 1 IHD o~nl D II OI EIIOII AiPgOND11 DArt _. ,, ,c3 .. yi, „~s. .h•+ ~`; is 5::; .. w~ ~r>>tiYy i ~~,',~ ,.y s ~5A4""' C ~ ~ ~. '. ,~ }p- 3 (F. fa r~ , 1 ( ~ ~ 1~'. 'cr 1 = I h ~ ?+~ ~ I:I I -^~ 1 ,:V ~~ I ~ - ~ ~ _ ®TRAfFICWAV POLICE TRAFFIC COLLISION REPORT ~~ wucfcOMnAIfNNUMRER (xI ~ S~p~ ~ PRIVATE WAY J M1Yw pDM Df .IXII N ~Jl~l l UME COUNTY NN n I, MI (U3[aAID HOUAI J W, "" ' r/LSO/J C ~. ' p Y COUNTY NO. GR NO. //a ~URSAN Al { / r ~0 ~ ^N ~E ^IN GrY ifOWN f6N0.0 SieFEt/O~/Rf HIGHWAY `/ r~ ON N IN ^~/= /S 1 I RWIE 431 ION ICI C45 ~ ~~/~ ~ ~ KA A MM1ES S ^w ^Oi Tx. pefN% f MIIf IOST ' Rfft(/R wAO NONINIFRSECIION y~F INEERSEGING V%iH: Z. 9~r ... 7~ ~ . BfiWEEN IJ-/ S SYREEI6 LLIf ,~ ^Y SrR[Fi M DAFA GeA ] 6 OISIANCE6DI I MRE fef .[ROSS$iefEIOR NEMEESIMIIf wi ACCIDENT AUIFl ~N~-3- E w MILEAGE I~ FEFI of aw A/SrN~ µ°D~ . RAMP OIA C I R E RRO•D RENCE N (]] CIXDSgNINVOIVW: f9IYI D NO.INIURFD ~ ^[pOInGF HI. •N wvpvep., llfD~ NO. E S ~ NIF CIS GIOSSSFRffTOR ROAD I % Gj2s~V V - - v IOIALNO iJllfO ^VFaCtE tST OpVENKEt3 a ~ wIFRTY OAMAGF OERY ^p;AS DAMAGE DINO USE SpFCIAICO ~ - " q . OBJECT SERULRINANEOf OR1KI SYRUC%ANDCIWNfRl NNAF) s ao °% ~ ', ' Of.l `' E UNIT NO. 2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST ]" UNIT NO.1 WI IR~-- MID tR'S NMAE O I I Oi vER'S NAME: U51 - 3 : RIV ~/uz onE./o onA~A ieEff ADORf53 SrRFEf ADORE I B 2 r7 1/Y Sr• E NO D SA, IpG HDN Z s~~rAr))F zIYCOa .(~ pnoN ' 33 ~~~ ~~- R OwY/SLn/.o W{{• " BR IE I Af DAI YBIRIH Ivf IGNlF NO. n. w NO Mo • 0 NER'3lICW IA 1i,~9F Do S' ~l 9 t alA M J r~ oS r' EYES WEIGHT r.IGHI nME6p.aNf NO v E I I I C<CUYAiION FIRM NAME6 PHONE NO. EYES WFIGNI MfIGHi S y 7 . OCCDYAiION RMN p,c ~=[~i Aib T/c,z'rs `•A. ~ -o7 R YFtOF nNOIHEe CHECK ( ~ T ,r ~ CHECK (,~ H uuio.E os.NOrHEe. of A " ^ . . O VFHIGFASANfM CODES ®+ ] a S l% d y'"D•. n I i ~ Z 5 u / 6 y R S.,R CODES -+ ] a - S ~ Nnmles •f ,- N FSSP "D. NYAn .lp, ^ •MBI%ANG ^ wM ~a`I ^ [~':B, ^ K~KU ^ r..~,. OENM i~l~"OVIW ^ •+.e•uw ^ i°i ^ p0'E~IIE ^ vlvcu '%A"V ONV >SI l Sn v.l n TFAR y lID Af Yl 1 .pM I .I MAAF IDDOGESnfV.J IUNFNP/A) SiYlf l]D .C V[H.Y ~ E ~78 ro ' d 0 ~pLii N. iRAM1fR fIArE NO. SrArf Stni F'I vFH.COIOR l A A ' y n. v z G W A c p 50 • ~cA Upi NO. F CIf IDENrIEKA V L y HIGEIDEN If. r N N I ~ I I I ( IZ J r - (', si L~ I R''. N ~ 0 v ~l0 1 - ~~~ 9 ~ ~ ~ ~ RC013RRfOOWNfR: LAST NRSt MIDCIE pNONENO. O ' I I I I ~ RED wNfR: VST FIRST MIDDY SA//IE W A OVINlR ..22 SI ID ADaEU OfaW+x+ N ~ . E RTAi4~?R . n ]] nlvAtanoae33awsEJRANUeo. DR ALenr R L.I. S. A•A. siil+ AN YO pt AMAeeDARFA~ I " °] a on0" ',rw DAMAGlo.aNf _~ " DNARG CHMCf ESI.D ip f ~S DeIVFN. ^RfAWNFO OEORO" . • ^ R10 DRNFTi AWAV s ~ 0 Y ^ ' 5 l3T. DAMAGE ^ AWA REMAINED IOwtD oW+o W 6Y. OV s ^ SUMtM! SMflf l/ fa3uRY1 MNM I Are Noel DESCRIPTIONOF COLLISION IMF ru ---- ~ RROw __._ ._. ..... __, AMOFCOLUSIOM V nr ~ ] - . l nEU NfUS DIAGR r' i - _. __- ._ --__ --I ~ 1 _.~•. I I I 1 Pof.F. I I I O S r .... .__' n3 ~{kAOAN6 SOti Y(r _ Oi/ ../~lii'~'+: E .._i UQr~fw¢ w f ! -- _ _ -! -f- __ _._ .._.._ . I ANa __Oc«u•( _/..e.sr_._ ~NhtaLj Nf r..__pa~./ee'_- ~ ' I I O~ 6o1Y/~.._7u~w4A+._SAinE..IJ,r..r.r oN_..~.. ._ __._ .._. .. , I I ~ Alo N D.Aru+.. ~Fo.cp ...._ I . S /{oa.coeit A -~- -d ,,B ... PAST.. .._, i-. .-I '_.. }/F /w G /OLF../ S'O PT"_.. /~ OIT GN . _..- ~ 1 I _... . :.. ..:.. ;. ! .~ ~ r OFD 4. ._....... .. I , ._.:. .. I ...~ IR ._.. ,. :. NAME, ADDRE5581NJURIESOF PERSONSINVOLVED CODES 1 "-f" u2, 3 4 5, 6 _ w sorer ` `:' RESn [ en i l`l. e ; N ,, sf% Ace TAT , OCCUPANTS /WITNESSES Ilne swlaM roR AnarRBNU NAMZSf n NAME _... .. wiu3F OE .nNEAY' AMe. ^<1 ^"'r. ^Mx ^ NY:IM ~ ... NwArDEEOr ,}r NvEOr ~AMe ^,.A"E O,.` . ^Ci ^I:° , ,~fu ,r, . f ~ - Riu:i O1 YuiE.i eY QAMR ^::"0~.;:~.^'°. ^".:'.... y' oAIE •I`O.ill v .A.vE,:fn NAVIaR•D. A•DU UR AuE.c- „Nr KI O~3.ArvI:o nArcF ARnyIO Dare or nfgl A~-ROVEOer 1 omsr d LYS p/SopG/ ' pM ~ SO X u r +q~ 31 1 r ~~ ~1'4, ~H~~{Y 1 ~i 4f :IRYtAti~141 ~~ iax 1NA. ,~,A+,. r4~~ ~, ~. F 1 ~ Ir ~ .' ~ '~. .. 1 1 ° Ly 4~ f i s~ .Ili.l -i ~ a - r L z 1 1 r[ 1~ .I. V y ! ! i'7 ' I I .l ' l - 1 ~ 1 _.' ~1 1 I ~ ~ I. ~ . ' _ ' ~ j r I~ !I ~y rst~ i i 1 I I ti 1 l 1 I ~ t ~~ _ '~~ '. 1 I T~ I l UI ^ } ~ I ~ ) ~` d ~ ~~1 j1 1. ~ Ff x f... R~5 ~' ~~ ~~ ~., _ ry ~,~ 'E ~~'.~.`TS .. ~.r~ r~ aria.~~ ....R.,.. ~ x~,,.: ,^x'P, ,~r> ~6laP' . . -~._, Pi >~ ~:~~ ~ ~~ ~ '"`,~ ~~ cam:"' / ~: SiHYr OF VVASHINGY01~ AGE 1 GE I POLICE TRAFFIC COLLISION REPORT ®iRAFFlCWAY r EOIICE COMPIAINI NUMtlfR ~~ 'F r, At GE GL N . - , E ^ PRIVATE WAY ~ - I ,.ME 7 .~ ~r~" ` I.I. 1 SE xW NOUgI COUNTY'''E- n ~ l COUNTY NO. CI1Y N0.. a( (i l ` I ° wx lu4x v5., 1 ~ V ~WN .~O iHWA j ~. A} ~'" ~E°J ~~ I n+N ^E (]N ~~CI YOR }OWN ~ ^USAN // /'t' Nµ,E6 NO.OFStRFF}OR WGNWAY iCl U4 M RURAI I ~'FM ~t ti I~Jy , ~ I MIIf~ ^S ^W ^Op N` ON ~ E ROUE OR SIR SfC ION ~ f !p, ''~( INIE45fC1 NG IH S1RFF Y qp 3 NON fR5/[~/I~ON/~• .(/~~ ~/~ \/.1, 7JZ7O as NtF~ E k ~iV ~ a~ I BEF EfN (j.CIO' / RI/<K6. ~ t//I? pgfEl%-. E MILEPOST r~ f,~ DISIAN f DR NCf, CRO555I FFIOR NEARESIM LE PO 1 L-~ {TY 5 4 ' MLFS iR R E W ACCIDENT RgMP OUGRAN D.SiA v'J~ yF11 r E hu .+nkt 5. PE[T OF C ~ 8 MILEAGE b JQ ~„~,r ~`~` COIIISWNINVIXV[D: fRl}YI CODE E~ ry)~ ~t OF VEH COS ~ ^PRORRIYDMIAGE ONLYRFD~, agFSUIIEO ^NF6 UN HIUGHOM RD N IN RF} RROADOR pFEER NU al ''}S 5}~ L I~ US DOSS SiLLpEfi OR ROAp n `>•'t }P r":t OBIE<}SIRUCK(NAMf Of OB)FCt S}RE16%~WNfR'SNMIEI J 9~AO ~n ,~y ~" 'S~ ~~~ ~' - ' /GGff~'{{ ~ fSi. DAMAGES SPFCIAICOO NG USf r `^~4~ ~~ $ UNIT NO.I 5~-~-~ ,- yy' G' s DgNER~s NAN ~ usr IR M UNIT N0.2 ^ VEHICLE '>?;i , tt /^~ D41VER'SNAME: sl ^ PEDESTRIAN ^ PEDALCYCLIST a a NAJ y4 SiR[fi ADD ~' • - ~ ` r.p~ l f ~ ~ ~V V IgEFI ADOFESS ~ E rr 1 o(J } . SIAIF ZIP CODE PHONE NO. D }y t`~ '.: D4NER'S UC NSE NO. ~ `wA• q~3 5-.3/? tAiE~ IPC N , 1 S pH BG ~~~DKJ.5Z1lc $lAlf j B IN I IV UCENSE NO. Y. ~/U ~ ~ ~/ / V ~ Alf % ,DA} B1R1H k ~ uq;~}r 1 B OCC pA}ION f 4M LLK~ ~3 x I NNAE t PHONf Np, I!O~ 10.,V i YR. ~' '7 /~~{m YES WTIGN} HEIGHT E CUPA}ION ~ fIgMN PHONE NO. ~ Z ~ODK C~H~iYIA(s'ui ~~ // S EYES WEIGHT NfIGHI .-. ^ CMECK (/J yfNiClf ASSN (MPIOYFF OFANO}HF4.µ V rx CODES-+ 7 nA ~ ~ s f 6 MD' Rcrcl~ ^ CHEC+(~ CIf ASgN FMPIOY[E OFgNOIHFPnI [&~E'd w~,w s ! ur MwI nc CODES ~ D ~ ~ is s fn a ,, II xi . h-~- veH ~~ mM ~ q.wvUNC ^ u n ^ EBh~AIroN rrii ~^ ih°,Gs. f O cR4al ~ ~~ Q EoGDCFCHFV.I Moo DAgr. I IaOR: conv.l ~°ol °L ^ Ednw ^ vi ^ i:.;, )~ 2 "~ f n8®/T vs HNr uR~ ~F n v.l MooflfoARr.rmvAL w Ulf N SIAIE W ZD E KNI ° I_~ ,~ p tRA ER RAIf NO. StAIE H VfH R ~ I[F]S N ~(~,~ w.~ I _ '~(~ Uf IDENdIIfIU/t~ N0. /~ ~j ~ C ~ r ".'"'_ ~H / 1 ~ V 1 ',~ J ~ ~ ...J.~J I I L v nl EE lOE -.~ ~ I REGISR4fggqppp fR: IASI rIR51 I ~ I I I I I I I ^ @... ~. d I ~, ?' /Jl~~~ / /~~ ~DDIf~ ~pHONE NO' O 4 IStE O NER: 1 LA51 I 1145} MIOpE N ~ NeP~. ° SDr -. 1] ADOgtiS U•b.YN[R /K/ W 4 f 2 `](,/,~Y,~ N NFR I L',1Ge•~ V ,F`*'~ NAME °Ap04(SSdINSURANCE [0.~jy~~ E ~~~ ~.1 >R. '„'`JJ~~ . ~Y.eAil1GE - .~o.B~,~ ZU/LLS R u ~" ~;,E~,~: ~'.: Rlop s es}IwMAee eHgxeE ~~ CNARC[ "o HeuHa DgMACro AAfA FI ~~.. }(~~' orro~ K AA°w'nvN ^ RfMUNto ^ Dglvw DNCn~,v y F y #GL ~ I 100 S .. J A~,yDB /G(S_ Qu ^A~D AWAY ^R(MAIN[0 15t 101ANgGF I •lOp , {~ ~ i ` DIAGRAM OF COLl1510N; LPW1'1 u INDlure ORIn S :~~ ?,Wa, 10 (G1CE~yL2CK(}; ~,•j~l'v v~8Ygg90W DESCRIPTION OFCOLlI510N: Iu5E5uvrIEMENiuSn[eErNFCessARVE e I ~1; + ~" ~J ~'/G A~`^-~ ' .Scu~V~D ~T A ~ o/C/LIiY~D ..00 ....,' s :~L4 Nq ~ ~ Y'"'(, ?~ ,rs ~~ WAS .7yo CLGC)5'ETO call K ; ~~ ' ..:., ~ .. ...'7e/ 1it°.2tlC~~ YLCiE'.fd O ~ ~G11~Li °V~ %~~$TJCi K ~~ ~ ]B r k , " ~ NAME, ~.. Eie. ._. .. ...__.. .. I ( ` i H' 66 .,. I ; . ' ADDRESS 81NJURIES OF PE " I t ( ~ CiCCUP - _ _ - .. a ~ e d (wESwnRSOµS~INVOWED +CODES I r k ANTS /WITNESSES ra goarifuik Aeetii Act ums ' „~" ~ br. I ~. ~~ ~ ~ In .1 :';I 2kYl ~ i ~fu r»tN' or .. sEM Br AMe c afl • I) RE514. e)LCr . ~ ' ~ 1 ti ' 1 ) ..,,:..., ,. z ^ ^'4t ^ gym. ^D.T nna[~_ ~'° ., , i,•.,gi X ;, ~~ ~ =.J ~ ~, ~T , µ A - ,. ~~4, O° 11 5~ " ~ ~ y~ f ` - ~v b'S p~°' Y ~ , Y in . g:Y ~" ~ ~ ~ ..1Y 7 ' -..~.,46:'J~n3~+Ai 4th: .'2,!~;~ ~7.'TJnA~,~.B ~: ~re[EUU._ ~u~.R.- ~i.. _-. .3%s::vs~ zr. ~','~S_~.:'~'rosw ~ ~- ~' ' ., u 5-i ri i ~ cUr VVASHIIINGYOI~! PwGE GF Y'`"~ L~ 3a q ti I A >Y 1~ ~' S ,~ No. ' > ,~ I~ /l'' POLICE TRAFFIC COLLISION REPORT ®TRAfFICWAY JpIICF COM0.AWt NUMBER T ~ PRIVATE WAY ' - AfOECOIII AY 1 N .. TIME COUNtY CAUNIY NO. <ItY NO. FI1WA !~I . - ~uexRrt.I Ilu(. u. EUSE]pOHOVRI ., / ., ^U AN , 1` I °JZ f' I wR~ I I I I u4 [• S _SA ~.•< s:.e w veu~ff,^^ - ^N ~E ^ N CIfY OR TOWN NAMf6N0 Oi5Rff10R HIGHWAY PCl {'AS RWI ON iP SECtI N ~~'~uT r 'T ,~ 9sz ~o ,.1 Mnfs ^s ^w ^DF N~+K•lle~.ti ON C~:. A..( ]] ~°5^m INRRSfC1 NO wI1H: 51REFi OR ROAD NONINiER5EC110N PREfI% f MRE P051J I~ `L" • {' [ ~ ~ CI-, BETWEEN SRffi 6 STREET 3. ~ o ' STANCE AD9E~ f9 R E CROSS S1RfEt ON NFARFStM If PoSI ACCIDENT RAMP DIAGRAM DATA ~. x ~„ 1 ' ~ IlfS N 5 W 7t MILEAGE _ _ ~p fEEi ^ Of ~r fA: /~.' CODE CCRl15gNINVOlVEO: viR / ~HR4[Ra .RD IN N YREI RROAOON ROFRfNCF •f ]] T' lOIAI NO NO. KIIIED~NO.INJUREO~ ^ $PIIIAGF ^ Il UN INTER Cl3 CROSSSINEFTOR ROAp ' OVEN CIfS ~ ^ PROPERTY DAMAGE ONLY ^ pf5Ul1f0 Vf Grf KVIE ~N I ~~ 990 . 9 OBRCT SIRUCKINAMF Of 00J[CI SIRUC%AND OWNER'S NAME) f51. DAMAGES SRCRLL ttSD NG USE E ..-. .'~ :~ UNIT NO.1 UNITNO. ~ ^ VEHICLE' ^ PEDESTRIAN ^ PEDALCYCUST ]~ 5 091VfR'SNM'.D LISP N YI MI l DRIVER' NMAE: USI I l SIRLfIwDDRf53 P[EI ADDNE55 T ~! 1Y STAR ZPCODE PHONE NO D IIY AIf P DNrvER'SUCENY NO JET SIAif •% IRIH I IV V NSf NO. AlF F% OAlEp felRiH !~/~•/jp~ e.S--iiGf'/tN WA9 I° /:2 ~/.5.:~~ V MD.I AY iYR. a =. B OCCUPATION IRMNAMfb PHONE NO. EYES WF GHI FEIGNI E CUPAIION FIRM NAMFb PHONE NO. EYES Wf GNI IfIGHi '~' 1' , ^ CHECK (~ yfHKlfw Arv fAMOYFf OF wNO1HF9„l ^ CHECK (/) I VFNlClF 0.5 AN fMPLOYfE Of ANOtNEN'U "~ F CODES A' 7 0; % i in N1 ~ 5 f crroN ' a ;°,~Y°cY CODES - ~ 7 owv < sR:snM"' S ulc1DH 6 vr'i°,r~' u ] :: RiJURIOS~ ss. M.. /" .. /•iK.! ¢ 1. /°cu als Y Ig/ If^bN, e,. ^ ARaAA 1 ^ °u°Lcl ^ EBkI. ®~" ^ C .•v x;l~,f`7::'RO ^ AY.NA%Na ^ u6c` ^ cS+ne ^ ~:KU ^ is°A;.v " ~ . VEH YFM sNRf lD00fE{HEV.1 EI IDARI.NWAI 51 FI]D CONVI ,YEA 1 NV.1 110M1•NOVA) 1 1 vorn 09 1, PlA N SIAIE iRA UR 0.AIf N0 SIAIE I"I VfN IXOR A 1p' F {lF Cf IRIUI ON NO. L VFHI EIDfN 1 A I N 4f, ~, ~' 'j ],, ~, I p L7• I~ .5 I C: L~'.I I! I I I I i l j I I I I I i l I I J .M RIG SRRED OWNER IA51 F95T MIIDDEE~ PFgNF NO. f D WNE: UYI fIRSt MIDDLE N N N . n ~ !. W D I] ADDPISSOONN[R WN ~~ N ~ '~ E r nAWebw°D9ESSaINSURANU CO. oR//ACwI ~ ]] ~ ~ „ !t 4 i7/ .S: n f)n!'~nin 7v n, . ,Its: i'•'f; R wMACt JweA eu.,Nn eu. ND DAMAGE uEEA ~ ~~ IuNCRafu CH oIX CIJA9GF a'~ ic°Ni.~ci ! PYOP '•Y 4 - 1O'fO S ISI °N1N.G! ^ ^IN F+I REMAINED ^AWAY ^REN.VN[D ESI.DMIAGE 10>Ollaii V D1~" (.fAL Y KSI iGWID !~ '~v°RYI O AWAY eY' s w N u wocA I `; In DIAGRAM OF COLLISION;, ~nEEluT9EC[ssARrl awJl" DESCRIPTION OF COLLISION; (USlSWPIEMlNIAI SHEnur9eus5ARYl ~+ ~` I '. , ( VEHICAL #1-VAS VESTBOUND ON COUNTY RD. #4. -..... . ' y~ .. VHEN IT RIT-ICE ON THE ROAD-AND:SKIDD$D 138 FT, a ° AND CAl~ TO REST UPSIDE-DOWN ON THE-NORTR-SIDE- Zv COUNTY ROAD #4 ~1\. .. ~._ /~ I ~ , _ .- \. '` ,: , ~ o< 1.I "~, "ice. _ ~- ; Q _ ~ , Y j x ~;. i ~ ~ :I~ 1 ~.., I+k ~~ ~ NAME, I __ ° ' 1° ADDRESS 81NJURIESOF PERSONS INVOLVED f~ CODES 1 2 3 4 5 6 ~,, ~ OCCUPANTS/WITNESSES ~o:.FS,~~D,'„foN:iFMiFaA"riii sF% eeE urus '"'"" ;' Res1R. uFa ~' (, ;r J I'.E AMT: ~ _b~ N .DDRnY `E. 1 er ^ AMe. ^ Ei1"' ^ "' . ^ ~ CK4~v I 'L '' ~. ` 'f 'yy~gg~~ ~ - - NA1UR W' '" 9 MOVID I90M p ~ Hx 'yT' ~ Iw.f ^AMe p~"f Qal.. ^ px ^ :° '1 t .Fwns "A~JO1 br. [!AWb. Or::'^'c'°o:n9^Gx ^o::IV R VI314A1YNOp1[fYS N.MI 61 Y BADGE AGINCY KID31 ICMD POI K!/JI D DAtId RIIWI AIPb0VE01V DAn ~ ~. X A F ~ ,~ a ur iJ~ l i i[ 1 ~ I '1i } ~: 1 r~ 1+ ,.- 1 l~h n ti.~ s°i ~ ~ ,u4,'u ~8:rt .v } .J .A % ~ ~ s I ~fi ~S: J ~~' ~'avd"NF:m,rlq{0.~'~,,', :t~« ~.11~a Y((5x+_r1r6~i~ `~k" ~ 7~h '", i f +1 f - ~ a'y i:. 1~ I IY F ~Y4 I 11 V J[ 4~+ 1 I l ': ~ 11 r i 1 ~ ~ - r `. I f`! f ~ ~I,. - .r~. i~ - ~ M >~F~ I' Y' rJ~} R '9si-~ '> ~ ro' __ ~~~` vlglc•vr;.anonma wn ~ : - MOTOR-VEHICLE COLLISION REPORT I -. ---.. '",., NU " - ' DATEOFGxISION - .S DA / iy ~~ I GNINDR YO COL USgN 71ME UFCOLUSION PM W, ., .-- IEa • COUNTY NO/~ GTV NO. . ~~ - Et COUMYt` CIrY, TOWN . -0W MIES O~ CITY TOWN OMLLS PREF%' RCOaE SECTION GVENAME FS FEET, PIOAOORHIGN AY INTEnSECTING WIf11'JtnEET OR HOAU PRER% EO. MILEPOST N NON NTEIISEO iIONLOCAfIONOF COLU/YJON / !~ Ix:iWEEN !` ~ iSG. L f~l V~ STnEET AND /';'Pn~.~S'~T/uL J inEEi PUMP OUGPAM DATA ' ~' O TOT vlOw Iu1i/+ NN NcL RfR.PRiC4E. L=-t. ~,~/ N INTEP IN ON %RD TER .CLS I •I'~G'EO Ca0f9 atPft N ~ ' rvr[NSIGIro pF r 6 ~9~ ~ OI r..nusvJnw.a ---OvE"OLEvE"CLE ^vFrIIGLE rvpYCEE IRPIwHIFI SPED CODE USE - ' . a%vi~cus ® ~ r : ~."E'a`a.owFer Ovu~~cLF.rn.w KLE PeGEDtRN, OM%I ^H ca sro F" lYCBIECraPR1/CIII OWNE0.0FO ON/IECr STHUC% f_1 /F~~_~'J~~ i~. ~ ` • • WECT3 NAME`N NORE Mw D ADOFESa IN nQAOOAY ~~ D yr iO nFa.wOO°]GI cP FEET ~ 5 E ORIVERSLAST NAME FIRSTNAMIE AIIOG.E 'Ii=i k`C.~ll~•f'<1 ~/C°~}'~' R~ vOLWO GGU1~Ia;oR ORIVERSUST NAME FIRSTNAME MlpDLE T EET DORE4S ROUTE NO. OBO%NO.: UORF ui tv,0 BaFDpaFA STPEETappnESS pOUIE NO.AN000%NO.' GIY ,,,.,. STAT ..., .; LPCOOE DPoVEASOCCUPAMIH ,.. COUiSnIEi GTY STATE ~.. ZIPCUDE, ORIVER9000UPATgN,~...'., :' . ~~ ~ IJ /1 ' aFPORIPORM C C; Gc: ,;{i I.f rN DPwVERSLICENSE NUM~B]ER STATE BE% OAT GRIRTH pGE L~- A-S/--F AZrI$ A: y GD Jz OnIVERSUCENSE NUMBER STATE SE% M f GATE OF BIRM AOE. Mo rfAn vEMICLE YR. MA%EICHEV: OOOGEI. MODfLINOVA-0ARn'. BODY STYLE12 D0.1 VEHICLE YR. MANE ICHEV: DODGE) M ODELINOVA~DAnTI.- BOGY STYLE (200.1 .~ - 5' ~.~/ N . 2 . ~F - E TRMLERPIAlENO, T LICENSEPLATENO TA . S STATE - UCENSEPCATENO~ STATE' TPMLER PIATE NO. .STATE. - ` II ` ~T _ VErIICLEIDENtIFR:AigN NO. (IDEBMOOEL58NEWERI ETER IM LEAGEI VEHX:LEIOENTIFICATIONNO.-..: ItDEBMODELS3NEWERI DOMETEn IMM1FAGEI • s ~~• r-z~ ~-ss-.~ _ - rtEGSTEREDOWNER., ItAST~FwST~MNXILE NAME),,:,. ~,_~. DRIVEBSUGfNSEN0. -%~' flEOISTEREDOWNEf1 _.. ILAST~FlRSi~MWDtENAME) '. DRIVEFISt/CEN5E N0. -; S.JnEn oL]t --- .~_ .. OWNERS AOCRESS;,, ,. ISTREET,CRY.WDSTATE)~~~~^~- . . •.. . .OATEOf BIRTH- AO Wv vEAR. OWNERS ADORE33 ISTpEET, GTY ANOBTATE) ...... pATEOFBIRiN., I.U Y YEM PMISOFVENR:LE OAMAGEO , ~ ~cGl vi} . ~ oti P,D!!; Ii> _ s Ea PARTSOFVENICUE pAAIAOED; 7aOTMA a •~''~: W THERE AUTOMO&LEUABIUtt WSURANCE ~ ~. YES ^NO ' LIABILITY INSURANCE INFORMATION-VE CLE N0.1 COVERMIE INEFFECT FOR TNIa ACCIDENTON YOUR CAR ~EOFUA&UTYWSUR.WCECOMPANY..,.... ..-..;,';.. NAMEMiOADOf1ESSOF UA&L1ttWSWANCE POUDY HOLDEA"' ~ =-.•. •. m E.. ..... .. . •• a' I , P sil.i AnonESS 1Gf~/'!~ Sz2F_ w ~ b /f?tiC w~°•?St;i /fECONY`• Cd1i9f.1N5. CO. PoUO YNU ~R ~~, ':: ;:_ TAMnE U p ADORE590FUABILRYWSURANCE AGET CIE tt _ r r PY /CC)',~S TON EY /UA) !J ~ L..S~~.Z oIZ~ I, ... !! ~~ '.. .' 1 ,. . .. ~~-~ tttn111~~~~ ~ F .. - ApORESS _. _.. _ - ..__.- ADE SE% M ~ TOtµ. ~ ~ E usE S N E51 2 IWURY:.; : .._ .., NAME ADORE59 . __ . ___. __ __- AGE; SE%- M p i.NN,no a+. ooeloR• ~ ®' «NIF .. #'' . ~ I.Nlrover.nocrr%H ®© °N°.N°E STATUS OF wJUHED r.~ MMKFFiai CNE TMAT'APPU ~~ - STANS OF WJUREO MARKFlRST ONETHATMPUE a _,, - y Q IN VEHICLE "GFR ~ gLLEO O FAEI MIrI WAM 1I wM~"ORYI~ I ~pnvER IN VEHICLE PA55ENOFR ~ %ILLED WAOLF.6 II"V xfl GN MSARL H IW~EIOaI~ PO TIE W r a NO p~I .. ^. _ . .:.5^ OPPAN ErGI 6^ 7^ o DEStHIw NO ^o•I •a AI •ov: ^ 5^ 6^ OP PIw l1GI 7^ Sr10W NORTH FN ARROWIN CIpCLE \ I DESGRIBEBEIAW WHATHAPPENEp:IREFE11T0 VENIGES BYNUMBERI ,_ ' AG„PEA, ~ ~~ F !{/ G~ ~~ s w _ ~~0 rw er~c ] LVrRiR E E M,O 6tlw PAICIq^ RP IPROw lal~F -,~ ~.- , _. , .- .- or.FFr=~ ~/1N~- Ack. Tvc~Ar,O ` , _ .. SYu~~ - ~Y}N (G'y /_/fC Di7 ch _olt5_P_ ~ ~o% J '/ ~_ } ~ 6 ~i} aC ~n oi1~1., z f _ c _ c, ---~.~-.. T ,, ' "" ,-Go~'fvE~ o~ _~ty.~iY Tl~ ~-fJe redE.--- T ._~o - I ~ --.Co!1~yr~~' To i('E'ST--oN /T_s_..To~?. VEHICLES POSITIONS BEFOR E COLLISION ' A"I CfA a vn<u bMNNNO °~ nLUt t[D.LLr P.n+ro LP.n.FOw.a vRIICLe occu.vo wvea[aATED eY E l ° "E V[NK,IE N a F'Iy GI STIIE%fi pI MGNWAY NAMPI OII Iq R F Aq IS tl ^:;i pl ^ PtiuG [ Il~µ , q ^ a^ o a a o 0 0 ^;pyGE ^o b.,ar" . . '"""°^ Q ^ ^ ^ M dq ' : 'c ROSa.n RpM DIRECTION t0 DIRECTION . ~tol.slnlw WA.usvq 1^upewµ% ]^wM%wsr ]^ sl.uuwkn E^~H'"D+.;,"v.l. s^c:n"s ~:°. a DTHkn IgAV •vUHPAGC. H~ v 1 `+ ~ ] I ~ I Wf.ATnEH CU IA 1 ^ nrl~¢~M IgMTCONn110Ha I ^ pAYIIGIt tHAfiq CONIROL+ FNt<A WI In lirK t ^ 1 ^ fPdiµ3 ttPf OI HOAD D1 KU AO I AO> TOR LgHN E ^ 1 ^ ONE WAY 1NER/VEHICLE ACTION! .. vtISU ICW[%Or,t OI:uOn[~~. [ ^ I 1 ^ OpNO aTnMaHT An[AD ^ t ^~Y ~ ^1 WO ) UOANM ^ 7 ^etOP DGi ~ ] ^TNO WAY ^ 7 ^ OVCRIAMINO MID PA99N6 ^ 1 ^ W[f ] ^ 4gWM l ^ Ot13% ^ ] U YIFID aIG1 ^ ] ^ ~~ SMILE ^ ] ^ MANfq RAINi NRN ^ 'R ^ "ON A ~ Y00 E ^ ~%HIr30N ET ^ 1 ^ fLA:HIM nt0 ^ E ^ wfEnCHAHnE ~ ^ A ^ MA%INO LLFT NRN l~f ICE A `~ OtlHe a ^ D.w%SIPr[r ! ^Itin150tF ^ 6 ^ftASNIrq AMpiP M1OOP•n % ^ [ ^µICY ^ a ^ MA%N6 U~NRN ~'ttO fR ^ a L151tFIPY 1`w(COYI E DMAIq TnttlLgpf3 ^ e ^MLtfillµ ^ e ^LrlfuT UiN ^ E ^ aotwiD "nLA;:YIN iOx•gI SFf A N .OOANF IANEa G tiw I r C E MtGiY ^ ! ^ [N ftC111, rLA0MAN ^ I ^ BfOTED Ypn Tnaffq ... .. I „ ... ^ q. Q'p? FN, D+cGIr (( ~ - ~ ~hr AAAStn :: 1U ~~ Srnn~kDar aNA .IF QI ^IT.11~lrv~ni '. C ~~ E"J ~1 ftdr kM>FA' ini C 1~~~1~ t +v~>nvz~ ~r , ,~., . . ;,~ I r ~,, , ~ ~~~ a .~}.:; T •'{~.. y;, <I T I~ _ `I ~. v ~i i~i ' sr ~*,P ' 3 ~ ;~ ~ sq r r ~ ~ {) _~'~u +:dS. k! eI'. r '; ~ ~.~` e'1 -iN .. a ~~~ , ~J x ~}Pawoez is~~ya ~T~4P'SIp74C!1T~ [ .V ~ wFm ~ I YI.'1~~904T1,n~y'ly ~..r aY4~ ~ il~ .IC ir.lM -;i~~ J'~ Tam ~ A¢NTr, Y-. ,r., 1 .~I ~ ~~~~ tr is „ ~ ~ J r, 8P .w ~~. ~.}: ~~~ Q ~ _ ;;~R~ etf ~ ~ w AC. (. S ~- 1~ . ~ ~~. & { ~, b „ r T ~SL'rIXN lZ. .F~•tn~ I '~~J POLICE TRAFFIC COLLISION REPORT E5 TRAFFICWAY IOIIEECOrPIMNt NUrefR I ` ~ PRIVATE WAY E CwtiU CE.Y N 6/ S~ • ~ 4v ION Wx • -roll w10 r.u t nl 'f.r fIMF (USE ]IeD N011R) COUNTY EAllnlY NO. NO. iNWA UR6V1 / 3 ~N ~ ~N CHY OR rOWN E6fq Of SiRtFfOR rnGHWAY ~• wAES Qs UW 64r ONC y Cl5 ROUROY -3 %5" 7/S C INrE?SFCNNG WITH: SiMEt ~ NON INI(RSECiION BERV[fN ~ K 9refef6 ~. IQ siPFEi .REHA E MM1EPOST ~"~~p - DISiANC£LD Ni 9iR CFOSSSIeFE OR NFARfstrll MpF3 N "5'~~~F W I S ffff Of L '~ V RO nd ACCIDENT MILEAGE CDDE RAMr NGRA/A DAA COLL6ONINVOlV10: Felrv~ IOrAE NO. NO..eIFD~NO.INIUR[D ^ SrRUDF Mlt 4~1tl I V V[FRCEES '~.ROrfRtY 04MAGEONIV ^fR[°SFOIIED ~VENCIE rurmnam ,NR/9 CES !/ OR CYCFtS5Mff09/RO~My ~.. ~ G//CIO~~ >~~ 4 OsIECt SiRUCSINAMEOFOBIKtSigllClt MDOVMEN'SNAMFI FSe DAN/Lf SrtCNICOWrq IEf -" :.. l .ui.: + -UNETN0.I UNITN0.2'.: BIVEFIIQE. ^PEDF5TRUIN QPEDAECYCLST-. ~~ s^ 7 ORwf sNwrF: yyr fI MIOIX ~ ~Fl D A DRIVER .ME: USi I ~.m MN rsoN Da - ~- _ _ ' SIREE sr S~- RFEIAODR[51 ~ ' ~ Ro66:~- d, I SUt! ZIRCADE RHDNE NO. D 4 66 ! . . . WNEiSU FG[pRYIGg3yN SIAIE /y1 w BRH rD~r;/r. ~ M~-~o~w1sS~2c ~AtE ~ %2~o"3!zs ` e «cwwnoN NRr NAMEa RgNFrw. Ens wEgFEr of err ~t,~ 4~n S, M~/~ Qa1. ~y0 tJ E R oN NRr NwrearmoNe ra. ens Cav~.¢h{er -~ ( lurt relyen 6S 6 .- ~ CHECK (.~ EH -Ai s:N rorE ofA mfRU U~IECK I/1 vfH nE.sAN Uwar[ aANOrwv. o, ODES-~ J n ~ °s S E 6 yr~r.'~' CODES -+ ] ~~F,ss ~ a 5 F.a -6 (~.t. -Tr m X) C „~R.e I ° 6 . ~FM7,.a.. U Awww~<f ^ use' ^ ~a:~. ^ ~ Kr[ r~~,. ~„ ;; ^.....A»<, o ~~' ^ ~~ ^ w~Kn err:;nr YFH .rlAe ARE IDOOGfiHEV.I ~ IIDARr.NOVAI srrlf)]DR. cONV.I y E 1 E.1 N~WfllOy' w) .1 6 7 L ev' /c~ Z ,~, m 5 u .~ su eA TER nAre NO surf H v H GYr tH 189 ft -"- ~ ",~ Wf1 - Iti VfHICIEIIXNtI.H=A1gN NO. s:1/SF.~ xa:971G8: ~ ` Y IE IDEN II . Cls~/I ~/~~,3:ylo,3i ~ ~ ~ i 'S R[E:IsrtREDOwr.[a: usr NRSt rlDpf rHONe NO. % tr~~2~ /~ G~J r~ ,°, Is D wNER: usr NRSt I r'so,v o uJ ~ s~,G ;~ 1 MDeeu~a.Ne. ~i s~„F Ti v..d Yf' J E A N D I~/~r/~l ~~~i 1~~~./, NA ra M D.essalNwR.NCem aeAUNt ~rj., --8 h e~ R L -Sewn o+~ f4' C r__ ~h ' p~ .~F,~/~j ow „°,° eNAeee s t awa n star °10r s Est~aAr.u ~Aw~vN ^.[ewNED ~w'nrF ^RFMMNFO Fsr. sS:oirow s AY o:oi o+ r l f rowfD ^ rF>mDSr S w.r .w le DIAGRAM OF C00.1310N I NYA I cArE NOew DESCRIPTION OF COLLISION: Ilneswn[rENrAl sHeenf neeFSSAaq _ SWlf lr N[CfSLJIYI ~ e Row _ , ~ '... ~ ~` was soor~6oL~.J .ol.-_ o..faf y - / ~ ~ / as/E G.<ssa.) __Cewdu- A /h. Tfcrt'E SK,JS _ . a ~ E~ ~~ P ~ I, _ _a ,~ wck ., /eFT_ Rc..r-Cnrwn V __. _ . ' .. ... .. , ~. s•\va~ n.3' ."Sf~Fr ciCx tlY._ llllE~2 ~'dr W _. ,I i _. ___. 1° NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED ° CODES I 2 J 4 S 6 OCCUPANTS/WITNESSES ,o: eoutEHSr~Ratr~Flwu i "stx ice ur~ ' Resro, ex~ct wucY_ ANI 1q A mass ~ - N.r Rror - ,ter Ar a Ou'Yc' U "' . ^G: ^iS2wo N FwI M . rcnu NAr valor R~ra+~o,E°ar`pwMS. ~.DIRI ~"HD%n. 06~ ^rNO..:A. ..° . .Aw rio` - ,-.r„ ry't~ ,a ,. rAy Ir ^AAra ^ ~Rr ^ fir. ^ Nx ^ n •~ o.l E t .AM a e.D..fw r.E a cl Dj~,s`rD ra~ ~ D D.rF Ur nroer wrrROVEDSr D to X h~ n ~/ ,mr.o GSO, Nr ~d SU ].~ .y ~'07•d'I 1 ~ 4^i~ ' ".. ..1 { 1 :~.~~r`+1~5~ ,j~'~Ny}S^''. k. Ya-'.'Ytiii"~'Y J Ih ~~~ ~i tlt ~M ''' `.! r I I I I, i l .1 ' ~ - _ ~,. -J1, .. :i~N N ~ 1 } I~ ~i ~~ .. Si IBS- 4 ~ I ! J ... - .. ~.: i"d .~ ~ .: ,ia _sD;.~~ #f :tza~~, fit,:..:.. _. .s_a''a.v-, 's"...... r'„~ x SiAfE OF WASFiIN /''~ '~ ~ ~~ GT~/N I''~GE I DF I No. ~'L ~V~~~ '~'7•` POLICE TRAFFIC COLLISION REPORT LyTRAEFICWAY EoElceeomnurvrn'we_=Ea !i ( ~ ~ ~ PRIVATE WAY ~ _ ~ SII yLRI~M,E ppYy COUNT ~/~ ~ l COUI iYNO I 057 pA. I~81 wR. ~„oxlip 1 Ilu.jMf. 11]~a bR) ~~~RSa,J Ala ~ ^ 'fi n.`•~ 4~ [JN F Ik CItY OR IDWN URAE •~MIIES ^S ^W ^OI',~gp~e C)N NAMf6Np.Of]tgfFfOq HIGHWAY CIS ~ RWt9O`q F ~ S N ',~ INIFREFCTING VAIH~SI OR ROAD NON'I~N/IEER~SF~jR~IjON~Jq,, •~ c YS~~''~I• 9sz~o, ~ .2] T °° _ BETVEfgYI. `~"^'LA/~IQC~ R` EF~ ~ ~`'~ ~~iRFEi PRfil% f MIFPO]i E„ - D 8S• [L OIS AN f6 1 rv j CROSSSiRffr OR NFARESL MIIE Sr 1 MBE $ E W ,RE p ACCIDENT RgMP DAGRAm MIA = ~ F[Fi OP ~~'f+=10 MILEAGE ~ ~ .f COIIISIONINVpVfO. VERIEYI CODE , ' ~ ~` E ,~ ,~ I fORAI NO. NO.NiII[D~~NO INIURFD~ ^SPI(UGE ^ UN IN •RD:I I REO OPRffRNCE ]] ~°•S Ci VFHIOFS w pm IMER CIS UGSS S1REfi ROPD _ _ ~~ End ^ PROPfatt OAMAGE ONLY ^ PIR ULRO ^ VfaCIE ~~~a - 9 V 9 OBhCi S]RUC%INAME Of OBJECT SIRUCa AND OWNfr3 NgMFl ESi.D SAGES SPECWl C00 NG Uff ~' a~F~. ) IE lv`~,. } ~~ $ .~ UNIT NO. I UNITN0.2 ':. ^ VEHICLE .,~ ^ PEDESTRIAN ~. PED "~1 •"~ S ~ORNf 'S NAM(: UtSt~ IIR~i l DRIVfR'NNAE: IASt I ^ ALIX YCLIST.~.Z ~4.a3 ^. ~,. .. StREfi AD~~~ ~ I ~ 4 /n/~ ~/~~ ~/ ,. IREEi gp0Rf55 Z iY r SigrF ]IPC tl Nf NO. D I1Y Slgif DgNERsucfNSf NO. '~~• d R nE ~~~E.~'~u ~ ~GUFRSJ SigrE f% M0 pAr ,tHyR ~ IV U ENSf NO. AEF DAZE BRtH 1 - , Z~A p A Mp. I pAY I ~L t R,. OCCUPAFIIXJ FIRM NAME rPnONF NO. EYES wE GHi HEGHt E CUPAtION ~- ~r m ~ ~ FIRM NAMEBDNONf EYE]' WfIGHI IEIGMI _',~ z ^CHECK (~ EHttEAS AN eMPiovffol grvolHER:gf R ^CHECK (E~ E at~~ V CODES-+ D R R i VFH ClF gSgN FMPI(]YFf OEAPRDiM[R S I b~ ~ CODES ~'H G a 5 [A b u r Z IuUF3 _ INI R VP~F NTfAR ^ UuNtt ^ ~ t ^ CbsBA U VIrIKU lewil]P ~~off° ^ AM ^ ~tI ^ [SVBP ^ V1 ^ luN MA%FI~E{HEV.) ft IDARr NGVAI StYlE 1]D ~CONV.) EAR M ( EV.) MODfE IDAQi~rNJVq) n ~ SIyA~IE~ tRNIfR HAEE NO. I'1 VfN.Cq R VEH~~fIGfION NO. ~ VV A, C ~. ~ " ~ ro~ L vfn CU lDfnrlN .., ~. ,~ ~ 14-ITH'3'~i516! ;6' 1 I!; i I I 'I I i I I I I I I I' I ' R[GISRRfOOVMfR: LAST I145i MlDpl[~ PHONE NO. O ItRED ER. Ulfi IIRSL MIDDLE N N 4~&ry+~ 4 E ~~ II +t t. I. 4 k MM~ li ADORL]S gOANER ~ W A wNfR EI ~I Z N E ' NgYAeaADORESSaINSUR.wueo oR AGENr ,~~_ ~~~ " ~ x' ^ R II ^] r 1 ]DAMAGE ARG pf w O,U' ~ prH ~ 3 ~~~,~ PTBI • +bE CNMGE CHARD[ '~ii0v~°e gAMAGI ARU -]1 ? • ,.. ` 1 0 0 _.~ S [Sl. DA/A.SOt DR VtN pH AWAY ^ REMAINED DRIVEN ^ t31 DAMAGE f iDP A - ~ •• ~ - 5 gW1YDBY ^ AWAY°BY• ^ AWAY R[MNN[0 5 IO ~UTIOU ] _ 1 ,t ~ I 1510N I I M I D eA'suleeo°w ~ 1 BY Rr" DESCRIPTION OF COLLISION: lust su %EMfNiAI SNEnu tas]ARYI ~ ` MfRUNECESSARY D / ,1~q /~ • ~,j _.. _. _ ~__~ -. j d ~ 1 a G ,~ , . , I G.92 ,2ov~-Ugi.~E PZ(o y5 ' t Q~ _ /.. _~. __..._.___~_ ,.. -r - . ~ .~ -' .~ ~.9C~C~AC4/.UG 7D Yvir~6SS~ ] Y .. ~'sr.~ur/D olJ~ Cd2o ~ .4 . - _ r I ( I i I ! I i ~~ I ~~~INO J 7lt /~ ~/~ ~o ~~~7~~~ {~ _, , ~ ~ ~ ~ ~ i I ~ ~ \ / rD ~ssr.8 ,UDGE:~.955~'L( ps s (,~rst,{ Iv d-TJ r ~ " ~ NAME, ADDRESS8INJURIESOFPERSONSINVOLVED S 6 ~, 3; ~. S OCCUPANTS/WITNESSES IV]l SUPPIlMIMgE3HE[i ~/~/ ODES_ 1 - 2 ~~ roR ADwnowu NAAU)I N'viN 'LAr' .. 3f "4 ,M u NggF • I, •.. ~~.. P Sd AG[ rgms H r RESrR. utR ~ ~^N- ~ ~( + ; , Ik ~ DOrt1f S[/ A... LrClJge$ ..... H°i R „ ~ Y , 14) AAxr. P IEOr AMB, ^31 t ^""~. Opx' 1~. 76{M, A " ^ i19Go ' - Apprt33 ~' .. _ Nqr oR _, n5 - I t ~"i,` H.ME: ~ _ ... Rq~,IDI OM ^AMB. ^.acl^~I.., G'p ~I:°~. ° f •., Ts ... __ CuctE,. oSFA,y,Q,. NG _ - e 1 ~ ~~ .. Anwts. ~. ~ HAnw~a .'7. '~'~~ - we wE~ _~ ~~ l .. .. i&Fi r al[frs N+wtEr,. A° E tr, ^AxO. ^r..' OGx~ ^„ Hf. ~` 1 x ~ y "'v t;l tAODD a ENC. FA6PAICMD Ff% IIR nO Dqn OLENRr OVE D n ; I RYSi ~ + f~_ A J•kP H. iA '1 ~,, ~ :San ,v~ ~~'~" ~til~ ~ ~E dvidE t , ~'? E .. 1 I C56`TXt `ae ~~;J~ mmmm iii"` , ~ f , F 1 ILL', 7u 1 ? I ; '~:yySlyy1lyyyy,, ~JSS Y~ ~a': ~ a -. _ _. ' ~ „' ~~ .. a ~ ~, 4 "' ., y q ~~ _~~ .x:2_,.+~"~'_. ~ ,zLa-': ~. _:.~1 . ~ur_::ma KfI _._.Y.~_~~.-?,Ii.'a~r'r.. -a'~: k S~I P.7E OF WNSHING70N RAGE / DE x No. ~ ~ -~ ~= `E YYarw ~ - 'n{.IxS ~Srrv 1 :~~lSn ~ '~ ~. ~. ' . ~:~:-.- '/ POLICE TRAFFIC COLLISION REPORT TRAFFICWAY PoUCf coM%NNSNUmBER , PRIVATE WAY N, l IImE couNlr Y,°./ u0x.... iunl ;fu. Ir IUSE]IDDHOUR) fg fO~~l ' TT D I~ ' wurKn NO. arr NO {HWA / oAN p ' ' ~ ~+'~ l , - i I FE2SaN ~ O SE (a CIIYOR TOWN au Ep au ^N ~E ^IN AME6N0.0 SiRFF1ORHIGHWAY ~ Cl3 aW f O E CIN I•o AVl[3 ^3 Ow &7GF . /H C ~` H COUNT °~ / ~ f ~..s ~ 7J~/D ~~~~ an INiFV3FCIING VAIH: ~J OR ROAD NON INifa3FCZION ' ~a r•E N ~[ A ~H R '~J•o f PRE{I% f MIf POSt ~ ~~ ~ Bflv i di /N~K ~ BIwK6a I R sin OIStANC fD [~ IR I ,CROSS S1RfF1 OR NFANFSt MIIf pO A[[IDENi MIlE3 {R R 3 E W E G RAAV DIAGRAM DAi MIL A E pffi ^ Oi CODE K COIIISKIN INVgVFO VFRIEYI ~ ^spILIAGE I yOg wIN NO. xIIIFD~~NO.INIUREO !T iORAI NO wN vtBiH CK V[HICI[S ~ ^ pROFERN DAMAGE DNIY ^ 9ESUITFO V[aClf I %'RD S II to fi R40AOOR REfFRFNCE° IMEf CLS f:RAO3331REElOq ROAD ~ 94/ !~ ~ OBlECI SiRUCxINPME OI OBJfCi SFRUCK AND OWNER'S Nr.MEI fS1.0PMAGE Sp[CW CODING USF 1PF.OZStl 5 UNIT NO. I UNIT N0.2 Q VEHICLE PEDESTRIAN ^ PEDALCYCIIST aR 3 DRIV[R'S NPMf: Ul3I IIRSt MI DlE ORN[R'S NAME: UESI IR I -- ' Tw -LL ttw Stgfn AODRf LG'~D E'Nf N N ~~' _ P o I3 0 '1, ! 2 IY D R EI ADDRESS (! S1AiE ZIDCODE pN0 E O ` IIY StA E I H N N DRNfa'SILLNSfN SIAIE fA' BRIH I V 'S BC NSf NO. LASE x DAZE OiB 1 ~IW1=LH~53SQ~ wN P I!~/~y[ V NaN<'` R H. 61ST B ~, OCCUTARN%R ti..iftF FIRM NAME 6pHONE NO. EYES hDP,L' CHIT `\~~ WKSHI 5J E R CKCURAl10N { K4 y IRM NAMEf PHONE NO. EYES WEIGHT WIGW ^ CHECK (~ yfH aEASw[N FMxovN Op ArRO ~ ^ CHECK (~ I µ mFR CODES + ° VEHICLE aSAN FMPIOVfF O{ANOfWR. - a ~ A y ss :in Jfc1wN ~°i, s f 6 ","„° ' xWl t " CODES -+ a o < ; s u 6 s'n°" xO C ai 9. NJ w s ~ I Y , 3 , Hn ,J ~; 7[ ~^ ^ AMf,A,,.KE ^ ~ f ^ <bHfq ^ ~ K~ o a~Ex DM ~; °~npr ~ ^ <s:H, a cf ^ ray,. ~I ~~ VFH. YFAR f(DODGf{HEV.J [t EOAgI NOVA) SIYEF ISDR~LONV.) HTL[R 1 .1 MOG[LIDARi~NDVAI 1 _ ?y ~'~Y V ,~ eP E ~ x V OR I EN plA S°AIF RADER 0.AtE NO. 31µf H VEH. COLOR 1 Uf ry -~~ N. AT 79~ uN I zo VEHICLE IDfN11FICAIWN NO. V L 3, cl !~'3'7'3i9! ~~ i ~ L V HICIf IOfN11N I r , I l r l l l l l f l l l l l l afGISRREDOWN[a: IAS1 iIRSi MIDDLE %YLr F2FN ~ PHONE NO. O W I F WN WI {1451 MIDOI N N . a x ooalssaoW++fR 7A0 130 ~~~ }! ataC VN N A W.ry R 1 NAMEf ADORfssalNSURANCe eo. Dq AGENT R I ry as DAMAGED Axu '["c"0""' eHARGe w3.NIND gAMAGEOAqu ' q le'~ olwvDMU CHARGE axl iioDi OR S LSI. DAMAGt OI ~W~Y ~ REMAINIO ~ ARNFN ~RFMAINED kit. DAMA E I I~ O1 • f V Y a I ,'(w:vo ~ ^owFO wnr oeonoi: f ~.SO ^ er: f D BY. 10 DIAGRAM OF COLLISION: I IN e:i,u NOa1H DESCRIPTION OF COLLISION: IUSESURREM[MAI SH[EIn N[c[ssAarl SWE { 111 N[CfSSARYI ROW ` t .. ..,.... ._ ........... _. ..___. ......... ._. ON YFJ~I Kos / _..APRaA_c.yE77.TY./5'.___ ._._ - :. ~IdL~a el(. /yT~'R W.L"ST 1j_o_~!NO ON. _._...__ .. -I _. TNC BAST.3/ID~_Oh._7Llc_1.NT~,`RSEc7YaN v ~ - ~ S~'?~ck._,4. P,FO~'£'R%AN .dJ.ro_T?dvE~/r_a ' ~j-•. ~ v ~, ~ . - . wcST. oir _Qr.6HT. Say.ov/~.EY(_.. _.__...__._._ -- - ~ ae 3 . , _.... ' ____ k NZ•DS ~C'"~=mar. _._'- ___ 11 ' NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED + CODES 1 - Z 3 4 5 6 O IUSESb0.fANN1µ 3HI OCCUPANTS /WITNESSES {(p ADDIIKWµ NAM1 O 91 . slx AG[ IAIU INNM '-u - At w ~ ~ - uiyn Qf01 uon N Am,:ce'nn a'~'CR n~...cYM~ . ~ "D a . N ooqus V. v kC Pa r.AN AMI HAiu. o{ LP'C•.. ffEO iWer AM e. pf41c1 Q InI.1 ^wx. pCa:,, A N ' DO.IU Aw: NauR a.. ._ .______.. ° f MpvfDWOM N{ey, ^AAU. ^";K'^ a`n. ^Hx' ^P3 i0 _. ND . DOee~s Niu~°101 er ^AMe. ^[A'a 0~°o:n. O(;S. QNDI nn X vISIKAI VIOpIKERf NAAV SEAN[ IADGIM AGIpKY 1 KI DISYAICWD IQKAMeIND DAl/p el{MI nOV10 eY DAI( NO .r ~ *^"w"IIIK~" 3 ~ A 3 o ~ v~ - ,, ~{.; :. :a~.:r, I~S w+rr. = l " .,.~ ', M~ It y f- P1rlrJ'h .0 §45" ~I'Y.' , ~q° .f R " ~1 '~ '~k ~f ;i ~~ Y~~+~ , ~ yy ss ~ fiS pp~ E ~I~3 4~A~ , 8~ ~. . k . L~m .~ ~ / S ay Y1 wL_. F. ^e~tn H''; x n ) 1"" vtv . ~ [t [ ^ l~ ~ ~~ ;.f _ i , ; r•F ~ I ' ,1 r 1 ) iti' I I ~ I ~'~~~+ I.~~ 1 E ( 1 • ~ . f I ~I • M - (- S 1i ,`~~~+xM¢~'.Y J ,. ~' [i11K`. ~S ,Y~ . `'' yy 'S ,i~.. a rr~ ~ E ow' VVHSIi1Y~YG1'oll~ PAGE P GF / No C ~ ~ o , . x, ~1AM ~~` POLICE TRAFFIC COLLISION REPORT LITRAFFICWAY PouC[coMPwrmrlumeER ' ~ PRIVATE WAY ]I 3 DALE OfC l S N LIME COUNTY N ~ ' COUNTY NO. CITY NO, iHWq l 1 ~}• 1 IVLE ]RO]HOUR) 1`.0 I IY rl sux IY x / . t, .5u 1 Y J u .J , i•'F-/?/=.YL1A-' CIl OR TOWN NN IE6NO ' OE SIRE t O /~ ^URBAN RUgAI . ~ ]N ^E ^ N . R WGNWAY f MlE[S ^S ^W ('~p. Plor.]<n~n oN rte,+t~,-.~ %r INIFgSfaING N1IH: STREET OR ROAD NONINIERSFaION fa ClS M I pOUIf ON S1RfE1 SECTION -3 95-Z~o fl E0. MITE POST ]] BE[WFfN SiNF[i 8 $1Rff1 ' .- ~.~/] f ~- J ' • J DISEANCf6D1R CIICNiR RfiFPF O55 L1REFI gNEANfeiMlP 51 ACCIDENT MIlfO N L f W RAMP OIAGRMAMfA . / / _ > I F} ifEi pF /-, C. SI L'r: ] r! f: MCODEE i / !C~/~/'~'C~%i %. uCLf'~L !-~/, (~!/. CIXEISX]N WVOIVED: NO. KIII[D~NO.INIURFO~ ^SPILIAGE ^H16 N IurvpvtRlH f0[AL NO. J a ' %'RD N R C11N S1REftOR ROAD OR RfifR[NCF IN[FR CLS CROSS Sip[FiOR p0A0 (]] y y a VFNICI[S ^ppppER1VDAMAGFONIY ^pE5Ul1FD ^VF~itlf 1 OB1FC15iRUCKfNAMFOI OBIECI STRUCK ANOOWN[R'S NgMfI fSi. DAMAGE SPFCVLL CODING USF s UNIT NO. 1 UNIT .2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST ]' ! D IV R'S NAME: IA31 r L N~ I F ' TALI ~~ x7 e ~ SlRffi ADORf55 T C r S D STREET ADDRESS . I Y S1AtE ]IP CODE PHONE NO. s~.J'rn.1~ cJn 4,v/: ~' KJ+'L 4 ~TZ R I~~E I P N N DplvfR'S IIC[NSfN SIAIE F% I IH ~ IvR E U'.:vw./ ~/ 76'? ~(7 r../r1 m a! ! Z7 I /P?_ V ll N N A1E E% DALE Of BIRTH MD. RAY 'YR. 0 g OCCUPA[ION EIRM NAME 6PHONf NO. EYES WEIGHT HfIGNi E OCCUPATION FIRM NAME6 PHONE NO. EYES WfIGHI EfIGHi •~ - - e[~ ,l,~ L•~r R ^ CHECK (.7 vEwn A ~ vrvFfA Ar~orHEw ^ CHECK I~ IaE AS AN wPior o1ANOiHE?~l CODES-* ] n ~ ~ 0 1 0'y".° CODES -+ ] ci A s: 5 tl e 1 ,1 ]A UPrES Ir/ M ~.~I:.'^° ^ .MBDIANKF ^ ~yKt ^ ~s:RR ^ ~~KI6 ^ ~,~L. ;:' ^ AMBI%,WK, ^ upyrRF ^ ~s1;1R ^ ~~ ^ r: '~ ~ U V[H. YlA4 MA%FIOODGf~CHfV.I f[IDMt~NOVAI, s1YlE I]DR; CONV.) H YfAR D HfV.I NODFIIDMt~NOVA) T I v.) _ 'D '?J ~.a ~ GE/Ln ~ n : ' E r za ^ A .-. q LIONS S1AtF 1RAllfR0. lf Y 1'i ro EJ fi/6.J 1M//'/i'1 WA9 A NO. SIAIE I C VH.CIX q AI A N . N YIHICEE IDFNIIfICA110N NO, VFHICIf IOENIIEI A I N r !~!2 '~ E~ ' [j ti ~~ U - r~ . ') ~ 1 ' I L ' , , R[GISRREDUWNFR: 0151 EIRSi o E I I I ~ ! ! I N ~ MIpOIE NONE NO. n_ r.~KJ~r.: _ Toe:,.. rK/. W R ISIFRIDOWN[R: Uyl 1151 MIDDY ENO. R I] ADORISSaOWIrFR E %~C E - A R WNFR .R4Grl All/JiV,IH L r A. ~ ~ IA NAME agoDRfssalNSURANee eo. oq AC[wr R N AN N ]] f ARfA Cf AMAGf AAFA _ 10 X00 o~iowi 4 [BI,'DAMAGf CXARG[ ^ ^tAVI ^lYN ^AtMNNEO CHAAGC ~ ^AWAY ^RFMAINFD airNUeorncl ISL. DAAVIG[ ~ _ElO1 , L I ~ s..~Jr-A'e. _ :w°ivoe J~1. r11 r'-' ^ Aw~r°er: S I OBOiiOrA ' le AGRAM OF COLLISION: lu u l NM Ipw~ReW rH D~ ~ slY[ru N[c[ssAarl,. ~ DESCRIPTION OF COLLISION: lus[supplEMFNU[zne[n1 N[eESSApr) s .^© _ > HI[./, r../is _`o..E:.,.6oa,.a /JEr GAEa f..... \ Y S /N.A:'r L Lr,. r~ i /iF T Qi?/r. ,2...,.'-/r o e I ` _. m `~~`~__ W E rL"_ r. ~' f r. /EJ r OfJ..Ef ' IF A~ i! O I /~~ .~ ~ 1~. r ~~. ~/., I ~: _.. _ _, R NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 - Z 3 4 5 6 lust swneMENlu sHt OCCUPANTS/WITNESSES Epp ADDRIONAINAM1 el 51 SEK AGlSIAtUS '„~" HUi"~~ ~i K R1S10, tIICT AMr, TEE AAA, 1:.1; ~' Ar/!i ..a ~0 4fi_YS'1 _t,c m 7~• J / . DOrfss 7I 1~• I r.i I rv. r. A,7 Hqr QA a E AM e. ^~Nr ^ wl . ^(i!T ^ ~rH N A Aw ~N ~ - A DOpfss NAlwta •R~IAevaorRaA ^AMe. ^'r°.`,`E ^Fom. ^pX ^r:°.:r:. i0 N A«e Eio A DOp1f1 NAiI/r OF AMIIS W sV. ^ AMe. ^ IDIKr ^c lamt ^ ~«' ^ ri0 A Vxy111pA1 /+G aFrC1K'sl ~'~Ill N RIUGiq PGIHCY KI DISIAICIYD WIKf ARRMD OAIEa+t 1011 AMROVff10Y DAIS X 1 OIq 1 r JV~GU Ehiw f a kr I. rl rl 1 ~;~ I ~ I iSIL~~ 1 L t °~ ' n W v i f { J' 1 f r P^ i ~" ! r r :~Kl a i .i-e l i } r ~ r j;~ _ / , , I T r r .- i , r _ : ,_ , I t ~ Y. ~w ~ :'I 1 r, a ~[ ~ ~, ~~W, .~ {~ ~ 5 ~ h ~ A; ~ i '~1 n'r)' - 1 ~ ~ ~' ~ II ~ .~ . ~ - . (Ef~~ ~ »7 . - ~' N "}~ , I Q r IYU. ~32i '' ~~ ' .TRAFFICWAY ' POLICE TRAFFIC COLLISION REPORT . ~ ~ ~ PRIVATE WAY rgIICE COMRAINrNUMBER ~~ ~- - ~i~r ..~ ppiF Ofc Il rv J° .xY~ ~A. f :! DpT x epx tRN w rv 11 R Ip~ ,l I iMf IEDF }rM NOURr_ .ry 1_5 COUNTY 'S.r=i~f•.C:. ~ COUNEY NO. /lr GtY NO. iNWA ^URBAN I,RU 1 - E ~~ ^ (]N QF ^Nn CI110R TOWN NAMFBNO.Or 51RFEiOR WGHWAY J iCI CIS ROUIf ON iRft 3 9si~o SECTION "- ANNS• 5 ~[1D{T..; I ,~.. ;. ,.,~ oNc:, t;Y\_ •~. G -- , „ INIFeSECrNGVAUl.STRIO ROpD NON NIFRSECtION PREfI% EO. MILEPOST. BETWEEN -. S ~ iC .SIRFFii ~ E.f`STRfFr ~~ OG• , ]~ 05TANCF6URECt ROM R[r N ,CROSS SiRff OR NfA f5 IE POS 7 \ .HIES f w ACCIDENT E GE RAMP DIAGRAM MIA r~ _ ~ t -' ( IfFi - Or ~,I •'1Ir .'I- f, l'-ll'~ {r• MIL A ! CODE ,aa COllISgN NVpVEO fR IY: NO K4FD_NO7NlURFD_~-~^-ER UAGE '^~ME7. NUN lOlAl rvO N51" ru p R wpM N %~qD iE° Cl5 C IN SREi RROAD Oq PEfER NCE ROSSSiRE[IOR °OAD I ]] I . QTPOFFR7Y DAMAGE ONLY Ci VFN CIfS QPESUIIf FO~~-~VFN CIf ~ /By~D !P ~ _ OBIf<r STRUCK INAMI Of O°I[[i 51RUCK pND OWNER SNAM[I FSi.OPMAGE SPFCW CODING USE ~ ~ E UNIT NO. I UNIT N0.2 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCUST -~ ' ~ DRWF~'S NAME; VAST IR MI 1;l'i 1011 . c"•.i_l i•'r ~: c' ~ ' DRIVER' NAME: 0151 I I l '~ ~ 1 ' SIPFFL pDRE55~ STREET ADDRESS -. OIY STATE E PCODE PHONE NO D I Y SIAIE IP N I ~- ~ - _.. DRrvf R'Sl CENSFN /~ ~ I l7V( l'; 1'~~~1r-r.C~r SIAIE 61..',1, F H M / G7 ,~'O I ~ IV II fN5 N AF M DAE °IRIH AV,. ; pAY Y. ~ I^ ' __ ; ° OCCUPAEION {IPM NAME ePHONf N0. lYES WEIGHT HEIfiNi E CUPAiION {INM NAME 8 PnONf N0. EYES W EIGHT NE GNT •_ ~ ~ Z LY~n j%j ~i R ^ CHECK I/) I vFNgIF ASnN FMROYFF Of ANOiNfP AI ^ CHECK (~( ' yENICIE AS AN GM%OYEf O{pNOtrlfRAl ,pm y CODES - ~ 7 ~: R5' I + °5 ~: ' S D¢IKw a i`,°n°,°Q'°.. CODES - ~ 7 ni'SY + i+ irAA"' s lxngn a y: 'i°~ rcu D n ~7 w1uRlF S e S _ ~ ;t~rl, ,DM ^ A~RI.HRE ^ robKf ^ Es~f. ^ ~,~K,s ^ ~,~,. ;~y°r ^ w. r ^ u if ^ ~a;RP ^ „ ^ ra'"5.. AD 1f I V[H YEAR ANR[(DODGf~CNEV) C~ C ~ MGDFIIDAR1~ngVA7 ' ` SrYIF I]DR ~CDNVI n YFAR I NEVI MODEL (DART NOVA) T E 0 ~ V.) °D'w _]B ~~ '?I VN. OR IICENSF ffN StATF p lER RAtfNO. Sin H VFH. COLOR N ~~! I If NO. AT! - ~~ ~~ - Tc i~ v6rr. v -- -- I ~ VEngEDENIRICAY0NN0. i VEHICLE IDENiIN AIN ~C IJ RfG SR fDOWN[N: Vyl IIRSI MIDDEI PNONF NO. ~'r ; i ~ ~S'i i B'c%~ wpDRESS CI OKNIR O W R ISIEPfO OWNER: IASf fIRSi MIOOIE N NE NO. A wN(R ']' • N AMf anpDRfssamsueANa co. OR AGfNI lFl f,•iy7(~,_S ., • R 146E I uAN - _ ~.-E' 1\.~11.' ~ -l r\:: h'f /'• r ~7.1 Yl. "I C. . 1 AMAGf NEA ] unAN~i ' ' CNAP CI ~, CHARGE. V oiswu:NC (jM1AG[D~G + ' ~ N .._. / D DAMAGI ~ Rl ~tr, ^RIMNNFD a~S 131. f IUi io o ~ ^AWAV ^REMAIN[D f51 ,pAMAGf F ~ S 'LjUii ~~ vn LLLLLJJJJI =r~~ QAwpr er~~)•'1'. - rowEn ^Aw rer: S ` DIAGRAM OF COLLISION: iirtn liNECtsu°r11 Ise e'u°owl~ DESCRIPTION OF CClU510N: lust su°vE[AUrRru sN[Eru NFCfssARV) _ Ie _. _.... N .. - Qy _. , ...,. r n - - - . '' 1 .i5 ~• L, I ~ 1.~ .; I~Ei. t.,L.u~ c .A. C_.:I Do - , f ,, ~'• li• ~,yl~ ~{1-_ ~ 1~1.~: .kit ... ~~, i 117 .4• T'1~~.- L 1 •-~ l 'c-1.._ , ..4flr.t:_ .. • .A .. -: , .. , _ i,, - . 7' Y _ NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED i CODES 1 - 4 3 4 5 6 - 1 - ~ •~ OCCUPANTS/WITNESSES lia icD~orvu r~luu ii uY AcF urw '"„~" ° °l3r°. UfCi M.ICi' ~ ~ +_~:~ '1 ~.~; ' ' AEMer t ~Ai'Nl, r' ]'. L. --N Iw[or - ^AM Im r e ^ :IKI ~NI ^iKY'N5P t '- Aw f M. N .[gRE53 MUR q RL,yOV101°OM ^AVl. ~rgKf ^[" E ~ v~1~ ^iRi N Y P r7 ,nr a IA -_ - .f10flSS INNPR SP EM er: ^AME ^[N i':' ~C~u OG,T ^i:MV X RryEtIK,AIwG arcE.sN;Rf°.N. ~ up c~oR rcENC. Nu,.'u. r aArcf+D RxKE ~°I~D MnauroRl Arroavfoer D.n I - Sn ~; p 'ri Y ~ r 7 A.v .II ~1- .4 JSUl,{ r•~, ~, ~L+s 9 'M4 t(I~"R%,q<p 7k `~b IAY1S144"SlbVdlla' ~~~)iT ~ r A _ ,~ I!E T ~ '^^Pw. 'I % pt 1~ , ~I~ ¢~` ~ I I 1 h ~ 1 I r- ~ r A f~' --i ~ t Y( Y•t a 3 < s 7 "~ r s {I llr'S ~l ~, s~ lyyt! ~ ~ I r y7} rt ,r~ „Ir„~ ,' IT ~ r1 Fr ,h~~ l 4' ` •1 I YJQ~~ Y,}~ 5` 1 I I ~ ~t b 7 ~'~ t I ~!Y I ~5~ l i I I 'Y E : } E ,~~ E I ~~1"V r 4 I C I x ~9R`~ d~n~~ ~'~~ ~F t9 Yh~r iP ~ ^x Tl~r~ ~G ~P~ ~.~ r~Y ~~ •~_~ t I ~ ~ ~(~~ ~A ~~ a~l) 1 r 'y r ~ r+- Ir. ~ i} 4 y.~y r t ` ~ f ! l ~ r( t I 1 ,S {. r~, ~ ~~.' o ~~ ~ ~ , ~. ~ d f xxe~*gE~ alfrA•xrLRe~:;' I .' fV ;T 4 ' t E .~ ~ ,I , .. . ; k,~ • ~, ..~ - '~~ POLICE TRAFFIC COLLISION REPODTS4 UG TRAFFICWAY 66 vgICFCOMRAININIIMBER 6 3 3 ^ PRIVATE WAY I~ DA a au G' ~:G 8 r D . < u I uMt I IUSF OURI ", l "ER X IE F. J~IS coo .~'c~~c.E'SO~ couNrr NO. /lo rr NO. NWA ^UP&W ~RAt I CItV OR TOWN NAMf6n00.3•Rttr04 WGNWAY AVlf3 °: °ow..ooE~, a Sc~! oN r ~ , KClS f EI RWEFORS 3 9s'r7o f MI E PO51 ' ~ INIfXSFCtING WIEN. St4ff1 R NDN INr{a5FC1 ON~1 ~/f ~~ ~ BffWf[N I/]~.A1 EtIT ~/14'~C~ PRE I% l // O~ DI tANC a0 tC EEfPEr{ CROSSSrRtE OR NFARf IMI POS (~ [IEf '~!E W Of J~~.ZO ACCIpENi MILEAGE CODE RAMP DIAGRAM DAtA - 1 COIIISIONINVIXVEO: SEVERI TOfN NO. ~T NO KIIIfD~NO.INNRfD ^SPILLAGE ^M!6«J1 jj ' 1 t .- I iFa ~ %' Cl5 ~ CIIOSSSiPEETO p0 RRD•DO4R RtNfl ~D ~ ` ' cs v[NlclES IL1 ^ vROrtRIY DAMAGE ON{r ^ a~wllEO ^ v fO cl F ! J OIyS - ~ ObJKISIRUCK{NAMEOF OB1EGi StRUCR ANDOWNFR'S NAME) [Si.DAMAGF ~- 5 _~ SRCUI CODING USE •...~ ,.. ,~ UNIT NO. 1 ~ .... UNIT N0.2 VEHICLE ^ PEDESTRIAN ^ PEDALCYQIST , l ' s 1 oRlvEe~f~ CCLl~~~ C-!i~~~LE~S LADDEf cRVF4 NA~D~~ r ° SIRtF1AUDRfSS /002 `D'.Sr Sraffi 55 ~6 emu. //rx Z SIAIE ZIYCO NO. I>~ . ~w,us~D -tu~• ~~ P 3d5-00 D i E ZIP P ~rEDF/v.ev ~e~ 5 - Z rvFN'3 CtNSfN D n'7C/CGitQG6ZOdE SrArF % Ti./, j'( BIRTH Op Q•, •, v Iv R' IAIE % DA I4iH 1332~~ f3 ~C'~ ~ 03''°' S (. ° Z OCCWAtNXf 7t'7~ON f14M^~pE6 PHONE NO. tttv MIGNt ERIGHI f•~-rfuu%ccsEvD//S. Vi E R OCCLIPAIION f ry+-r~t+r,<,~.u- I4M NAMEb PHONE NO. FY[5 WFIGNt EfIGHi nv.9~.Eis CS4~ ~ ~7 5.r~ ^CMECK (.~ ,hN~F"'~AOE~ANti1NEaN vENCtE ASAN EMROrteoPANOrNEa.{ tq{~;^ CODES - t D a +~ s N a u~„~ °C rwN CODES S~ a a s°s' < i a "O s'N ro 'i 2 wwRlts • ~ ~ /UC7.C/YJ _ ;Fi~o,.D. ^ .Ed ^ 'G°.L { ^ "<bnly ^ ~ K~~ ^ ND ~ .nyyERw. PPE,NKE ^ ro&E' i•S:R. ^ K~K~F ^ uN:. V{N, YEAa FyIP~ f~CHFV,I MODEIIDARr~rAVAI SIYIf IRUR. VI iN YtAR Awcfl ;FI V.) MDMlIDA41~NOVwI Y Y .1 ~ '~•E' (' I 7z rvA~ /OD n I~~~~ E Eztoo7- So ct1 S ~ , I SIAtf r4Allf RAIF) StAtf li vF".CUtOR I FIZI LL AIL- '3 VE IpFMIPNiTigNrfO ~ I~: .~,m, 3i3~s~s! i i ! ~ ~ L of I IF ID NIIN I N S~D! ~a; ioi-~zii ib! i!oiS i I PHONf NO. R{WSRRtDOWN 4: Wf EIR51 MI[N%E ~l~~/f O W ~5 D WNER: ~` ~VSt~ ~ NR51 MlpgE J7YY/f C ]I ID 2 ADDP[530 DVMF4 N E • NER NAME aAO ssvmwa.wceeo wnpwr e~r~C~D -.~eX'~ 7zE R FESS - -- Sr~rs ,e.+~ -fT '~vvuSz~D v > NI.EC gAMAGED A4U• IUMAGDARN dYUmD ~ . ~ ~ '~-••• nwclaNU cNARGF _ a•au alor m1 E 5 ESIppAMAC.E Q AWI~VN ~RfMNNID ~ D4rvEN ~R[MNNEO [3i. I ... 1}OY 5 AWAY Ui0 I0~ E I ~~//~~~~ !OWED s ~L/I/ 1~D6 (.~. bV. E DIAGRAM OF COIIISION ,iFxeru NKtsSMrl I B RRO~W't DESCRIPTION OF COLLISION lose 3llPRfME tAl5HEE11E NFC[SSARYI _~ -!=j::i i ' i I ~e,~l~~ ~ T ~ J . ~ ~ _t~~tfiQCE?'~/.-5aeenN•Beelu/J eW C.~'~Z-i---._.. u ci6~! A/'~ lK~N6cus 2o -x~ ~ ?J t ~ --- _ . z...c AaH - 1 r_ ~f/~! E ~s ~L . 1 ~--- .--~Zi t ~ ~ ~ov uG ~ couF syd C6SoucGce Si - _. .__ ... _ - - . i . _ ,._ . :_ ~ _.....:.... 3'Ty,e~p- 7D- Oi!GZ'n/,~E tF~2 ! #.2 ~u.4De'--. _ . - ~, ~ I ,,.,, ~.- I .. - _ 1 ` ,. _:. ~ LEfr- 7lI.F.v ~B.e!/SS 77J~G f/1T11 O~If /,.._..... x „^ / ~ # i...~ ~~L~L"---f .... y~iUCE /.S ,P~~'~~.tcoe 7JClriCcE~Z ' %%~1 ~ ~-- . ~ iv Le~r-AQone 3Y gier-artc/ Dcy.,uo ._ ~ ~ ~ ~ . _ , .~ ter; ~~,~~, - 1° NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES L - 2 ~ < 5 6 OCCUPANTS/WITNESSES iD`~n fstl~wwtiai:iww' •eii ~s Ae[~ {elus '",,;"" y + RESr.. ixd ,".;;;, NAME: ATr1Lee~/ A/~~ C CiF ~°K ~ ~ i , ADDMSS ~ spt! AIUYI _ AV ^ +'Ma ^ [wti•'I ^.II ~ . ^ NM ^ rcilM ,E ~1 ~l ~.r NAMI. /E ~~4/e I~ ~ ~~/•`/~ ~~ ~ S HAl d •L~ a[I R ~ID IK/A ' D U ~ ,~,. ~RE5~,~/~YNF / lHl O B ^ir ^ ~i F ^ ilw ^ ti 'mieyA~vNZUic~ - ~ 5-I~S'~ - y +DOErss ~- REn31q..rwG OEr~el•s NAME SR+N+ Bo'I~w AeeEECE ~ F,,, A^AMB []~:°^^,: ,;: ^:;l„ wnxn .--- ifuuuE N~: 'a%In SrNCN10 rolrE :RR ViD D•rE airo~i'jA-rn D° toEESf ~ 'U .."."}'a Ew is c '`TF ., ~ ~P C K. C a~ ' ,h .; ,~ ~~ 119. "E;I A... ie. F 'i i •~f A ~) M ~''~".r ~ '° 'si ~',. 1 E ~,~. ~~ I~g ~ r ~~~~~~ . a x61a'Lil'S'Y' V~L 1f~tl. "YJdR4UllLvts':~ N~ ;'14'V~ ANs b ~ I ...~ .L rY i J L 1' ~ f•„ ,_ ~ ~ ~~ '~ POLICE TRAFFIC COLLISION REPORT ~` TRAFFICWAY roucf coMPwrRr NUMBER 1 I I ~ PRIVATE WAV gy~, pp~~ "~" ~ .DA o W"_-. r... i ~ ii.~, rmE couelr COUNTY NO. CIEV w. fHWA $ P~ l ) eEt nl. (USF R,Dp HOVRI URBAN 1 E TM.+s t0 SI ')C Ri zi• v •~ tF-c i13.0~/ .. ~l0 RAL ~~~~ I ~ ^N ^F ^ N CIrYOR rOWN NMIf6 NO.OfS(REftOR WGHWAT 45 ? I ROVfF OR SIRE SfCII N _~~` _~' '- HIES ~s of ~ , ~,,,,~~y'Frn ON C/r' / 1 E7 9/r/70 ~ ?'~ INIFREfCIING WIIN: Si fEOR AD NON INRRSfCIION I, //JJ PREFI% E MllE P051 / I B[iWFEN r.l.. ~ G SfRffi 6 K/L A /~R:/' NV- 9»Kt' I~ /a~ ~ S pISiANCF6 IRE 11 N{R MRtiERN E. CROSSSIREEi RNfARESi MllE roSt ACCIDENT RAND pIAGRAM MIA ~i '~ 6 ( MITES N 5 E W /, MIEAGf f. ,, ~ /Z PFn Of hHGIJ ~/Iw .l CODE ~ „-. COILSONINVOIVED: ERIITI wII3N N ~Rp N R IN SERFFI RROAp OR REFERENCE p3 pu w.KILIFD~w.INIURED_ ^SPILIAGE ^ b N INTFR CIS CROSSSTR[EiOR ROAD ,,~~((yy ~ Ci V[H C~S © ^PROfERtY pAMAGEONEY ^pfSUllfO i ( EGrvgnoiN r~OGD ~y ~',•~ t "t ~ Ia ~`Ji +~ ~ ~~ Otl1tCI SERUCR(NAME Of OBRCI StRUCK AND OWNER'SNMIFI FSi.pPMAGFE SPECW COPING USf 1, 5 UNITNO.I UNITNO.Z VEHICLE. ^PEDESTRIAN ^PEDALCYCUST ! ~ r"t' ovvfRSNAmE ~t la I l pawER•s NAme: usr I I ~~ ' S1Rff1AD0RE55 ~):E••>mn„/ hlf~R~S~:~'r T ,y,~s ,~€ IPfEt ADDRESS tr SIAIE 31P CODE PHONE NO. D RY SIAIE IP P ~N :~~~ Z 1 ~ z R hie L.s o w,, ~ ~ z c. i ~J DRrvERSUCENSEN SigtE eIRH I VR'UENSf NO. AR OAIf ORIH ' Xry C O~ r rv. NO. Irv ~ ~ NEwmA s .. •r :.r wQ m ov ~ ii le - ' +p~jg a OCCUPATION iIRMNAMEB PHONE w. EYES WEIGHT HEIGHT E occuagrloN FIRM NAMF6 PHONE NO. EYES WEIGHT HEIGHT IZ ~ S'~EtWW 2 R .-. .'•' as f u ~u„ ^CHECK (.~ ,"fHKlf AS AH fMROr fof ANOnlfa. ^CHECK (/) vfNnfgsANfMPiorEf oP.NOrHfa~ "O"• r ~' • ~ n CODES - * D " < ; 5 r 6 "s'„° CODES ~ + D n / 4 it ' I 5 f% e ; ° ,~ DR R I~ IN,UR E` -^Hisr Tie ,IC,wN iaxrCf ys I n,Awrv DIW ANr r~ ~~ ,,. IF w7e ~D ^ ArvNAAfKE ^ ~s~f ^ ~sN,. ^ H~K,e ^ r~~ .~Wp ^ AmN%,N~f ^ "~,<f ^ ~sNER ~KD ^ :~~,.. D_ ~~' Vf1f.TFAR m MARE EpDDGE{RENT FIIDAR1~wVA) StYU.IR04 {ONVI I~HNr FAi~ 1 HEV) NA)DFIIDARi~NOVA) of YUl ~ V.) ,1 ~~ {p ID7 6.v Fo.co ~y E G2 en Py ,,V10 • { 5 ~~ ^ H. R 11 PlA SIAIE IRAIIFR Mif NO. Sigff I'I VEH OR F}7 T'N q S ~" 'i H; P l.J /~(P' 3~o'/fJ / LEA; I E.. Hr 'F .. C rH ~a..i ~1 C 890 GE, /J DR ,yt; VF KIE IDfNi1fICAfION NO. CIEI EN A N u ,}~ 1 '~$~ ~ '3 r.I'Dlf,~!KIC'S~~iz,~7~s', i L 1='ziSIH'J2(=1310 IC~ZIIdI I I i I- i ,o u [GISRRtp OWNIR: IA51 PIR51 /~11 MIDDEF~ IPHONE NO. [t 4 I ff DOWNER. lASi fIR31 MIDpI w. SQ '~13,1j . r: N AooplnssaowNfR rn1 W owr:tx DI r~ • NAmfagpDRUSC.INSURANCICO.aRACENI R ~i pingci faEA p I' , I.n •}O1 M•wi P~iw:i CN oGf CHARGE owC O.ucf iM1AG!)O NU ~ ~~W1 IVEN f _ 1 ISi DAMAGI ~ ~R[MA NfD ' ~RrvFN •t51 pAMAGE I elD1 r• i ~1.;{. ' Ow WAY R[MAINED S E a 4" d [i IowfD - lovnD wer O oionoi: Ar er~ L•A.1 CJdN.s ^ Awgr Br: S fJG eonF COLLISION. ~ A wlulf o ..-. -.. .a i ~+~~',, • •"~ 41N DESCRIPTIONOFCOlL1510N: turf su"nemfmuS EnvN[e[ssARq D • `' '~ ,, ~ la I HEnu AJf.Y~ _Z was... 5___~a rn..-wfY'/V._.A __ I IA RAM~~-- NEtlisAnrl ~-~ .. L•AJ14t. Lprn//rr_ QN._.r/l(c _Q./CE<...7'Fle ~ ". ,_' ' C.Srilp~ ,r__ tJ-kJ-.. p IJNn•C E _. _ ... .... _. _. lNf'J. _D/reAl. A/vq. .TiSA,J ff.v.G n_-..._,. -... !.., ~. .~. ,; I _.,_ `_ •, :- ~~•~a ; I/30.~ /' w;E.J ~a.t~~in .- ~ti Sco/Er .a?~ . .. M , t -_ , ti e _.., _. _~ .. ~ RSONS INVOLVED * CODES I 2 7 4 5 6 ' ' `` I4 NAME,ADDRE5381NJURIESsOi~R ~ I~ ~~~ atsTe. F •~ OCCUPANTS/WITNESSES lMENTM Swn - °" --- N ~ uu msY ~ ~~~; ;' fa Anpuor+u NAmESI _ uK Aci uru5 rv nn s t•c: I. f NAw: I " v .y ,, I~ .. AIwIESS sr fn r OAme ^r134`I ^"°~!^^IY ^CIRi,,, i , 1 J.r r `~F,% f '' L ;. A .. NAI R a - ...., _.. R MOVID IROM I I , T" ' I~k~ A~ESS ~ N r ^AMe. ^~acf ^,.,~.. ^ R,Y ^iO1NE. %0 ' 1 rl ! ,'"' '- AtwNS .. NA~~a _.. I er: ^AMe ^cS%f ^~'D:n. ^tiW~ ^ I~°.~1. ~+ ~ :IL I M15tOA1WprKl e'1 ANMa alAHK eAfXA Oe AGNCY KIDISIAICHIp IGKE AeEIND UAllp elroRl AIIIOVIgeY DAt! C t V I :~ low I/BA - ry ~ ~ ~~~p ' x t' :~ ttf N r '~Tt d'~ ~ ~ ~ ,I h Lh dlF'~ 9 ..~alf'ht ' w,N °•r A r,ra tn6 N"••, & a ~ +Ytl ~ ~ J~ + c~, ~{ `' >~ t' x ~r 4 ~i ~} v r .. I ` S r i 11 f r, 1 f~J ~. ~S ~:-.~ Lq t ) E ~~'~1 { F ~~ ~~ I ~'.` pz II~~~ 1., t ~ ~ ~ 4 ry f~.• ~' '. ~. :,111 t + I 1,. I I~. ~~ , { .. . 1 Y f , t {` c~A~ ~;~` ~"~7 ` „ - ,~ f ~:~ ~ ~~ ~4 "a ~ ~~` ~ $ ~ a~ ..~t,~.,.,.. ^~~..~.:Ei>:ds"._.>~~ ? utati~~._ ~~..... _ .~.,.~'+ cw.ee ~~._ .:_~r.. d..ra ~ J 1 /~~ t ur VVHJY'1YIV(6 ~ CJIV P GE / GP / No. ~" TRAFFICWAY ' ~'~ ~~ i ; '~ POLICE TRAFFIC COLLISION REPORT ~ poucE COMn,MrvrrvumpLR. PRIVATE WAY ~ LS! ;~ ~ ~~ A E or of _ C ~ ~. I IR w(.. 'h.. EUSF ]9ro HDURI wuNtr courvrrra. clttrvo., PHwA ^ URBAN ^N ^E ^N CItYOR tOWN Ff NO.WSIREftOR HIGHWAY US I pOUtt ORS ~~. E_. ANlfs Ct4s ^ ®ur T lnr .r ~ ~ ON ~ ~ ~/5`/7D : ~ + -~.~ .~~ INI[P5fC11NG iH 51¢fEl OR ppAD NON NIfg5FC11~0/N - pRENx MIR pSi p ~ ` BEtN'FEN /t• SIRFfi t SIREFi /' ~/ ~`YI r DI~A CE6 D19 M4F5 MR SpE .CRW SS SIREEI Oq NFARE5i M1(f ACCIDENT, DI RAMGIA ~'f y rox , ' I Q iEEi OF I MCODEE ~ ~ ~ ' -,~lsT• ,. CO11131ONINVIXV(D: VFRIIYI ' rl tOIAI NO. NO. KIIIfD~~NO.INIURFD Z ^SPIIIAGE .^Hlt P~N/~ wNDH01H ~ IMER tll CROSSSipfDORREROADR FOM RR[ffRENCE Y]l }I, ~ - j O`VFHIC(LS ©. ^ pgOPERiY DAMAGE ONLY ^ RfSUlifO ^ t~'GlY M115 N `y-/~O P ~ ~! !J '~ OBIEG1 StRUCx (NAM[Oi ODJFCi SIRUCx ANDOWNfR'3 NAME) ESt.DAMAGf SKCDLL CODING U$E ~ -;~ 69 UNIT NO.1 UNIT N0.2 ^VEHICLE .OPEDESTRIAN OPEDALCYCLIST'. '] '~;~y ~~ DRIVER' NNAf L351 PIP t MI l DRIVER'S NAME: IASi r swE '~" yl ~ Y STAR ZIP CODE PHONE NO D I]Y StAIE 1 ~ D IH N N ' .~ 835 xgs` R 'ceuE ~J P~76 ,32 Y/9 ~ ~ y' 09NfP5 UCFNSF rvO~ StAIE f% MD ~ OArB R Yn V I lK[NSE NO. AE F% ~DIIf~Y091 Y9. '~ 8 6L ,D2 ~' y 'l 0 OC~~iION~ HvANNAf6 fNO. EYES wE GMI wIGHt E acupnrloN f MNM1E61HONE NO. EYfS WE GHI wIGHI ~ ;(yP . xY.~ d rY ~d rP T p /D .S r R "OP ~ J ~• f ^{HECK I~ VFHKlf ASMI(MRV Yf[Of ANOEHF4µ ^CMECK (~) I FH CIf ASAN FMPLOY[EOfANO1HFRµ PT'" ~~.p Y CODES -t D ani A ivin 5 ula DN a ",`,°,~°, CODES - * D a,;'u°YV a s°:sn tti1 5 Ex y ~NryK•cu _. n ~ , ,•Dw of L u Rdd rn m~ :~, '>Flw e..'o'^ O A.vulA.cr ^ FR1 ^ EBwe ^ ~F. ! ^ r"9.xv i.°~i9'R ^ AWwlwcr O '811 ^ Fb:n. N~ O CS6v t}Ti~ 9~~~"""y VfH. TfAR MARE IDODG(~GHEVI FI IDA (NOVA) StYIF (]DR ~C V.1 K R .) IIDA 1• VAJ fW.v. .e 1, E YA S d66.-r ~ - p ~ ~ v U N INtf StA.F/I IRAIIFR PMIf NO STAR ~ H VfN COIOpp N NO F IHKit IDLNDitG NNR NO., L VFHI E DfNlf Uil NN "'I~~en '~,~' ,6~6(~' ~ !/~ = 'f~13'2~71 ! I I61 I f I I 131 I I I a REGSRq[DOWN[R: N31 1195( IDDIE PWNE NO. O 9 13 ERED WNER~ 1A51 {193t IODI[ P NO. ' R td ,T W Q ~ `~~~ ` 4L ,u .~.: Ii a9ESSOCwmER N 9ES NER E p . -~'i" ~~c,+{F+.', N,vneaAOD9lssalNSU9ANCf eo. o9 ACFNt E u "L .. ~~~ 4'~,. ~( '~x~E r Td7'C' '•~i E T iiukrSc'itd D Nr' S' '>~ T. 11 :~ x 9 54~»`Y,Y ~ sDw.wi ARU ", r ~ R rlfJ C/s~ 4] , *` 1 ~.. ~, .ly ~... u.'E ~ to o w owu cHARCt I C y l/~~T.nr,+ cHARCE ny/ we eo",°~I..E iA'nwFDr.9u y ,~;. ev ~' ~ I e s ta. DAMACt Aw^N t mr ` ~ ~' ~ ""~ ® ~9lMNN[O DNIVEN ~RUWN[D ISDDMIAGE I a•f _ ~ ~,:L ,;, DIAGRAM OF COLLISIONe~ iDwwAEYDUr,I !+ wD Ute NO9(n ^w~Ar wAV f ~ d/ion'o' a 'R, R .`....~. ~ ~ ~~; I~i ~~ le ~ -'swnli NE 1ssA rl er AR9ow.. ~I/PT//d/i~G~e'J /~v!^EsuS utT~ aq+t1eC~/2.--/'~~;~2 ^] y 1~ ~ I :. ~Privyre S/orJdd sadc%i~/y o~id s.o ~.+ed Vii' fLi ~- ~ 1 r~S '~a ~ ~• d s. .~.. ~ N r _ . _ . _~_/ _ . D~ _ ,orr~ /.rah /~ s Y D r/er_ ~d ~ r~~~ti ~ - x ~` ~ ~ :r ~q ( r l~h~c/r .T/rfv.. sdds To~+irrf./~. #/ _ ] ~~E - ]0 .' ~ ~t I ~. ;, I] ,... _ _.. _ .. 1 .zrnFacr. - , „. uv U _ ~~ ` t ~ F7 1= NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES 1 - Z 9 4 1~,. ~{ 5 6 ~ ~ s3e•~' Y r a;.~ ~ OCCUPANTS/WITNESSES IiEiibDnEO~NUru+A.wii sex AG! rAruslwNH v.r ~ nsu. u(a :;°;' _ ~' ~ ~1I +~ If N,ME ~i^dG 'L C . HArdaoxQFE ~D. ,I... ~ ' ... Jp~ "~ Aoo9FSt - N r o o ENESV. AMe, O FRY" O " . ^ q7 ^ Cu~l1 Y ~ F '~ , ~' i >o Con.:i'8 ,G Sy~r9on S No. 38S d 57 r ~ ter '. f! ~ Aoo.fu ~i HAnm Or ~ Movlo (t ^AMt, OfaelO ' e:Opx' ^~: m ~'~ t 1i//idy /J!• IS!r9~YP ~ w a _.32..8 _ - Y :p CEP ~' ~ `Ttl `~a .. E // r v d INAwds ~ pr. OAMe O.to,Rf O~D:n Fix' ^n°.ul. ~Lt ~ ~~ 'k: ~';~ ; 0'~ X .msr A,p.o arx5r3w.wftANx fDAa MOt AcfNCr a ~y}u~cwo r~15Ly {(leo oAnanroxlJ ~ o,ER ~ ~^°~~I „'a ,., r N 3Y JS +il,. ].oDHn. ]RnD ws ~'~/ I,., ~l l.~ 1, ~,. _ .Y r~:,;.~ !rf .-s } . J.' }~. ,y~y .-1 ~r1: i% `"~'J,ti h {~ { h~i. l'• 1 tYi ' I I I~ ` ~ ' r 1 k r i I r ~i ., vl a 1 ' fi: ~ r~~ ~4 ,, ~ ~ ' I ;~: '~s. ~~~~ :~.:~ ~. ~ Y8 5 ~~' A~ iN I~F ^~r L ~ . ~ ~;. ~-'' b i _ ~' l~i ~'~' ~ ~` ( rt3 E ~. ~ E 1 ~~'~ r / `% -- •~••••`••~••• .-_... .. PRIVATE WAY DA ` FOI CECOMPWNfNUMBER ~ _ OECOI D IME COVNtV Wx IRA t M. i. (yt (u5F ]KBp HOUa I. ~ ~,r 8/ I i 1 iq /3 yo fiF/-'.rRSo N I COUNEYNO GIYAV.~ FHWA ^UP ~G , uRM ^N ^E ^IN CI[YORIOWN NAME6NO.OF S1REEl OR HIGH WAY ~j Cl5 A IE 5 / _ Avlfs (,as ^w ^oFOf, a AbLL ON<~ [ awl /Z I[RSEC(NG WITH. 51(fETOR ROAD NO > ~~JJ 3, '.'' 7,~/7Q ~ ]] N N(FRSECIION BfiwffN p ~~ ~ PREH% .. M FPoSi. yAq2 ~ STRfff 6 Q STREET / DISIANC DIRfM1 {fRF .CROSSSIRfEr RNFMESTMIIE 5 F V/ / yt ACCIDENT US FEFi MILEAGE RAMP pl RAN DATA ~. ~ -'~ ~ OP ~ODN COIISgN NVOIVFD SfVLRITY: l IOtAS NO O KIUE01[~NO INIURFD~ ^ SPIEIAGF N xuN4ne4rx •' XRp i N R ROAp OA (RfNCf ]] IFPf Cf V[HICIES © ^PROPfRIY OAMAGE DNIY ^RfSUIiFp ^VMCIf CS CR05551R~,i OR ROAD .7~/6O 9 OBIfCI S1RUCK(NANE Of OBIFR STRUCK ANOOWN[RS NAMEI fSr DAMAGE , sPECW CODWG <Ct ~- '.Ai'rJI E v ~: ,' ~.~ ~ , + UNITNO.1 o4rvfas PMME: usr FIRST ml ~ UNITN0.2 ~ D4NER~s NAME: ^VEHICIE C PEDESTRIAN ust ^ ^ PEDALGYCUST ~~' SRf a s ...u~ ,car iAV..1' ~.IS~En ~ -- /J.9 LJ ~ZU • Ftr AnD Eu 7 f zlPCODE PnoNE NO. PoR7'~ovNS ~N.o w/r 9336 DRrvF43 UCFNSEN . SUtf A D. R Irr A I ' r _ E F,A. n~. z s ~ JS .xAr r M ii I ~: '~.~ I ~ IV ll tN NO. Ai 0R N MD. (. IXCUPAIION FgMNANE6PNONENO EYES WEGMr{EIGHT E CUPAfION FIRMNAMf6pHONENO ( Rcb Bh l3%Sx y R . ETES IGNrNEIGNT +. ^ CHECK (~ vFH tF AS AN U+rtovFf aANOINFR l ^ CHECK (~ I u O O P a CODES P* 7 n % K 3 u 6 ^ix° ,s5 r]rt IC,KX+ r[n VfNiClEAS AN FMN VFF OF AN tHf . uwt n N CODES - H' J a , iv 3 e% Ass y in •W D ]> IIHF, si K n 6 u l ` I ys ,~ ^ AxN%ANDI ^ NN YWI MA E AXE ^ ~aa,l, ^ ~ Ka ^ ;a~,. ssr~`a~FroA, ^ M,AIAN.u ^ a~u ^ Ee . ^ N:a o rNs~ . m K IDODGI~CXEV,I IIDMi~NOVAI IYU1]DR~ONV.I ll 3 ~ V,I ll ~ VAJ _ ~ 1 4 FORD PIN S E MERC Z ]B U U SfAIE RAII[R MIF NO. SUrF H vm.caoR EP( .P A w PDD 8 WA ~ CZZ 8 8 WA v[HKUlarvrulunoN NO. v HI IEIDEN nl ~ >9 . 3 4R12n6 6 8 1 I I I I REGISR4f00WNlR: UST FIRST MIDpI[~ P ` „ . 8K 44 I! I I I i l l l l l I HONE NO. A O WN a: UN51 FINSr 10 AT~if' ~ F IJ _ ADp4t53 Ci OWNIR W ~ _ARCHIFxfJEAN A E FOWNfR, H 6 8 Hndlook WA N R HOX 2 NAmf(ADD4lss or wsuRANCf co, GR AGENT E I. OMAAG~O MtA dUNm6 1 R ' ]] _ ._r IvKtq~ CNARG[ 6 " CHARGE XnCn04u gM5/~GtO MN r U rP~OIIOU > [S1. pANAGE RJI AWAY ^RfM.UN(p ' D41wN fq ES~DMUGf I PTOP ..._... f I ld ^AWAV lp R(MAIN[D IowfD lo(onoM ^ Aw er f'~•b f s j E DIAGRAM OF COUISEON: D D]t rNOR(H DESCRIPTIONOF COLLISION: lln[slnweM[NrAI SH(D fuettssARq Mus~rE. 1ev aAOw _. _. _ _.__ _ ~~ t ~ .. Q M4I/,. N•' ~ S`!4 S B G !AIA J R ~a F . ._CR U, O_._/_9>_. ~ i SNt~ OJCN% Te ~~` Sxta<7~ p ._ ... o : .- .._; (~. :.. ,. ThgV[G.D. A<R~3: T~ i? ~ APPJ / '^ ~ 1U P .. . y .. ,e iNG. +IR nC O -~-- \. .o"T . ~Nr~ .1-1/T.v_,.NI_._1'.eRhx`2_AT A._R/ sZ__. . v ,. _ .._ , _. _ I _ __ -- _ .--- _ , . - -- ,.. _. _ ., I _.--- -.._... ...-- .._..x....,_._.ry.._..__„__. _..... NAME, ADDRESS & INJURIES OF PERSONS INVOLVED * CODES 1 H OCCUPANTS /WITNESSES IvSI swnfmatu sw FDO ADWIgHµ NAVE ARM. n 51 _......_.. _ ..__.. SEX AG( IAIUS - 7 . _ ~. `u:r l y 9 "'w/' R 4 _S_ "~-~ llI4. I11R 6 ']CV:' , DD,FS3 iq N,1 a Ol. - F AM O. ^K~•fKF ^ NN . ^C[w' ^{ L4:,J. A .. AKJ. H AMtIL NAIU4 d .. ...'_ p HbvIp FROM ^ ^ ^ I,ry AME. ~I"FI, ^ HN ^ riD RO , CWISS N1W ~~ I.(0 ^AMS ^n~Kf^ i. F, ^(AIY ^ n IS PFOOr Kt lFNM1( TIDY .DI K HV t NO V+. KIDS ICFEO 1K%IC! N4 D 1101 IgRi (UYYONDOY p I! X 4c a /A3ti v I I J ! k ~ - ,E~ . ~l d ... M( [ . _.: A .1. ~,A~Wn.W "_~e'1' T.:'..: ~.' ~.? ,YJh~ '~ll4~ V,' 1 . ~P ~ D . u 6 ~~aN' ~. I~... :. A~py4 ' .. STEL _ ~, ~ '~'~?,~e,r ~~~ ~ .. #~ {O~~c~cu i ,~ ~ tl ~ C{'- p _ _ .Jaw viym e~f ~ _EF 4 ~~ S~$ $ yx ~, • T,y L n nxB,,., Y'J .M1R. A...;,~a,~ ,{1,G' ' A S'-i "_ ..: r~-,; _..~ ~ ~ f +~~. R _ ~ , ~ siA-r~o~w~s~i~v~rorv ~~'~ , AGf pF No k d POLICE TRAFFIC COLLISION REPORT ~ . 0 TRAFFICWAY ppucfcomnuNrrgwaofR rgc • ~ .D FOF COII N IMF PRIVATE WAY ~ ,• I, ~ , { Y ~ MV I I IF ~lF~ " IU~}^OO HOB COUNtT - COUNIY NO. CITY NO. F A F ~ ~`, ' , ~ ny ~ LEI •.. Z ~~, 1 . /~ '.F I.G!~`..r~1~ 7 U ~ ^ AN Yt'T . i' ~~y~ y'} - t ~~ . ~l ^N ^E ^IN CItYO TOW NAMEb NOO SRFEtOR WGMWAY Cf [LS %y (~ MIIFS ®5 OW (fi~pp / r: ;I oL~ i ' ~r)- : R E 1 RWIEONSIRfF SfCll ~WTF ~ ~ Q' +il~ ~~~ - I ... .ItF c LL INIFRS[RING VAIN SIREEEOR NON NEFRSECIION ) , v r n. I w~ / pREfl% F0. 9~.~70 - xx MIIE POST 1rnl •~- , #-._ ~~~ IFl ~+~~ '~1 T DISINRCf 60R BftWF[N SIRFFi6 ~ RflfRf ,C SrRFEIOR NFARFSIM if POS 11 MRES ERN //~~ SIPFFT p.3O ACCIDENT RAMP DIAGRAM 04iA A, '~ ~~! ~ l~f~t~1 EEFT OF ~!` niT`I ~D. r, l~ COll15gNINVOIVFD / ~ , 1 MILEAGE C D D E 1 ; yrii `~ Xi ' ~4{S'~~ . fR IY. iOtAI NO. EI~~ NO gIIFD_~NO.INJU9FD~ ^SPIIIAGf CEVEHCIfe LIJ ©pRORR1YDlEMAGEONLY ^R[SULIFp ~} OBJECT SIRUCK{NAMf OP OBJFR SFRUCK ANDOWNER'S NAMfI / li RUN 5 FE En a FS r i HJNDne1H IN Fsi DAMAGES INTF ~ X-RO Cl5 IfR CII Stq Ei DR ROAOOR REFERENCE xx CYCGSS/IREf~i09 ROAD CW~o~ .. ,,AA yJ~ pp Y R 5 . SRGW CODING USF T 6 Iq ': ~at : 2 - UNITNOI ~,;' s o91YEq NAME lnsl qSt ~ ~. I Dlf I ;I:CG h. I~C.F.,F=tv m l~ h.IJ UNITN0.7 O VEHICLE 091vfR'S NAME: IPSr PEDESTRIAN ^ ^PEDALCYCl15T .y '~~-- FIR _ ~*~, . ', ' N , - ~. . '5 J S •+ , . sraEfl ADDaEs - Sr Ef1AODRE55 ~ ~' - ~~'~- ~ ~' ~`' `I •Y . STAR ' ZIPCODE PHONE NO. D LIT tAIF IP p tl~.I~'Tf_E. 1.1)r'. ?i~~ -r,..~l%[./ R P N. J 09IVER'S UCENSEN 51 f _F% oA 191H I rvfR' LICENSE NO. _ IAIf E ~DAtEpOf BIR'H ~ ~ `~ /I` I~15 V e «SSILOIIWL FlRMNM1Et PHONE NO. - ~ ( ~t / ~ C ~E{~. }~ EYES WEIGNt HEIGHT E OCCUPATION fIRM NANf 6 PHONE NO J . EYES WFIGHr ISIGH ~~ „~ °vr:r:> -r,.v~G:• riJ;r•.,~v~:~s•~:?mf 1Y~C~ R r _ ^ CHECK (~ I VFHICEEAS aN EM%OVFE OP ANOiH[RAl ^ CHECK(/) I ".c + VfHICIF ASAN fMROYEF OFANOEHFNµ CODES-+ D a ~ x s u¢IRXI bMOi° CODES '~ r - ~ a SHm INIU9IE5 % ii ! Ia 6 ~ <E'D "xx venoYFAR m ^ AwI%ANCF p uytl ^ ~SAEp ^ „~K~! ^ F:°GE. I~E'I"°E°;;• ^.mEDIA„cF ^ pg;;,, ^ MA EIDODGf{HEV ~M ^ ~[[ 1 MCgf l ^ C° D ID{ . v NF.. I I ARI.NWAI SIYIf IROR.CCNV.1 N. YEAR • ~7 E- 1 {HfV.I MODEIEDAgr-NOVA) YUI R.• ) Y = `' , r YCI;~f~ 'iti'.1_P.hlk". %•j;f`.E'. E ~ ~ LICENSE PUEfN SIAtE iRAIlFR 0.AIEN0. erAlE H VFN.COIOR ~ I AIF V[HICI( D I FNIINUr10N NO. VEHICLE IDENIIFI AI .< i:'. L .%, <; ; y:12.~ l 12!./l I~ ~ ` 4 I ~Ip E. lGISRRFD 0WN[R: lA5! FIRSt/ I I! I f! I I I! I I U ~MIDDI PHO I ' I ~ ~`r, NE NO. O ISIE9FDOWNf9: Z:: /. ~ I ~ IASr fIRSi MIDDFf NE NO. ~ '/•^'~• ~ ~~/• _ . I' ADDRESS OF OWNFq T r ~P7• 'G6 n N A OWrvER c. =:n`i i i I~^~JJ '~/ 5• ilfl;r~i ~7i ! ~i ~JT, ~ J. i NAME a ADDRESS a INSURANCE eo. a9 AeeNt E ~T T,(/F; R I I I N ~_• DAMAG[ ARU n ° Dx ... F x RtoP ~ wc ii i o1W. RNO CHARGE ,.___ CHARGE r ;D;c"~o~M gAMACfD ARU s .. I Ioiorioii s {sl.DAmACE ~y^ ~ ^ S ~ ~wwv ^ ~R{AWNED I]DRIVEN ~q{MAIN[0 AWAY s A~RD ' olHnomcF ESI.OAMAG U 5 0l 1 ' DIAGRAM OF COll ( I510N: RY: IYJJ.. ~ . •.: ~~ I(.,:I I]ASVA YeY: lu wgrcAn NO9rH f t OTtO sWFruNEassA rl e ao DESCRIPTION OR COLlI510N: IVSESUppt[MFNTAI SFUfIn NEees5Aar1 • .~ ~ EA ta... ) t ILiUu.1t.. OIL (,C _~_ - 1 I,I~u 1 f,c !tr-•r I~rrl1~ u~, l c_ _ ~ c ~ `/ 1 1 __. ~ ~ » J • I I '. ~ - - E -- . ... r C ~ ,., ` ., .. .._. ~ . J i//f }~ al~ - =' ~f P . s.El.l OI L, Pti EJ IIFII_. i~.Ufi.'GX r r~ ^I V.1 .. _.. f JI T T ~ . . ._- - .~_ I- .. ,. , r. 4, s F ,Ct Jf ~T C_hf r _, NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED + 'R OCCUPANTS/WITNESSES EUSteUPREM{NIAESHf {t CODES t _. .. ._ ....- - Z 3 4 S 6 roR ADauoNU NAMe AME~ a 3{% AG[ fAIU wWH u.r "IHJ" .. ~. RE519. IJICI MICr. , AOD1111 .. I HAMf F ~' ADDEI53 N N'OIU9 Op NO. AtUR I .. r er. ^AMe. ^E91'cI ^W;;, ^7, ^it4'HS. O AML' o RIND IROM ^AMb. ^ rotCl ^<nIi F ^ qw ^ I~ii,v V AD N ADDEfss A 1° O1 - .. - _.. s .Ir.Ga(cu' NAMEe RAH. eADa DR v JU t AGEHCr s EE%er~ []AMe ^'EO1G O~S:~I. ^Ux ^ o.lly F IsPA¢rrD Palo ARaIVED DbnoP eElWI Amo ED e r u.nl v r DAu En.l..~ I hYxt} .~ ~°~' ~ n '' i ~ s y ~~I ~~ "V ~ ~ ~ p x:~N+'iY'g, ~ I 1 £' 1 ~' ~ _~ fT ~Y z . R. .. I~~q~ r _,r r,l - I~A ¢ I r r IF 1 _~ ;j Ir• ~ _ E. I H~ 5 .' L "_ ~, ~~~. ,. _ ~~ ~ M.~ .-~~°'~- m ,:iii Tagr_, ar _~~~.'YiEe's`L,.--...,_. .T~,o..--:.sx x'l-~e..~~v::g `'~k'~,~~~ _ ~ `a'~ ~ 5~i ATE OF WA5HING70N IpAGf Di TR 4FFICWAY '~` No: . POLICE TRAFFIC COLLISION REPORT Ip( poucE COmrwNrNUmeER ~ PRIVATE WAY I - ~g DAI OE au N. _.. IIMF COUNRY ' R 1 ~ ' ) EG$F]bpHDEIR fADUNtY NO. CITY NO. ~ IHWA . ~ / )up IAER 1.1 S.I. I ~ / ^VRBAN ~ L ~ ~ _ u 6 ~ ~.R~AI CIY OR TOWN NAME6 NO.OF SiREEt ORHGHWAY CLS ROUfE OR I SfCENDN AVIES o= ow ~~ um oN c a ~ ~ ~b ~~o ~ ,] IMfRSfCtWG WIIH~ OR RDAD NON INiFR5FC110N PRSiI% EO. MITE PoSi /~ BETWEEN StRFEt 6 C/C s1Aff! ~J /~ .~J 8 .) L/./ DISIAN F61Rf I RFI F .CROSS SIAEEIOR NEA f51MILE Gp51 ^ ACCIDENT ES R f W ) iJ ~_)) MILEAGE RAMP DIAGRAM GIA N D~ fffi Of L•(~ (j~ CODE CO1U510NINVOlVfO: fRItY: NO.KIII[D~NO,INIUR[0~ ^SpILIA E ^NIIIpUN tOt.LL NO. HIN W %~pD N N SIR[EI AROPD RRfifpfNCF INt[R 'CLS CROSSSIREFIOR pOAO ~]] 9 6V[M{lf3 ~ PAOfFR}Y DAMAGE ONLY ^ g5 iFD VEH[lF OBIECISIRUCKINNAEOf OBI CI IRUCKANDOWNER'S NAME) ~ fSt.DAMAGF / Z.3'j~O SRCW COOING USL e s UNIT NO.1 UNITN0.2 ^ VEHICLE ^.PEDESTRIAN ^ PEDALCYCLIST ]' 3 DRIVER'S NM1f' UISi R t pRIVER'SNMAE: IASi IR l SlRfft ADDRESS O STREET ADDRESS SrAIF ZIP CODE PHONE NO. D ItY ~' IAIE Ip pM EN ~O/+.f WH- -- R DRIVER'S UGFNSEN SIAtf DA BIRTH ( IV U NENO. A}f DAIEOiBIR1H ' d L4 MO rR Y' v MD. ~ R I rR. I B OCCUAAiION FIRM NAME 6pH0NF NO. EYES WF GH~ HEIGHT E CUpgtION FIRM NAME 6 PHONE NO. EYES I WEIGHT HEIGHT iL J R ^ CHECK (F~ y[HI<If AS AN FMNOY[F Of ANOtH[v Al ^CHECK (F7 EHIClEASAN fMPIOY[FOp ANOtHFRI. " NODES -* 7n ai s l 6's""° CODES ~~ 3n Ks; So Bi° ~ 2 ~ ' ~°~: °~ ^ .MBA ^ ue° ^ ~nl ^ ~ ^ ~ A VfH.YfgIE m IW DGF{NFV 1 D A RI NOVA S ~ ~°~;F ^ .M E ^ ~eai ^ ~s:ll ^ „ ^ ray p E M V °d" l0 I . - ~ IYIF IZDR {CWV.I /I ) 7 ~ / G l_CJ~t~ ~ 1P E H. YFAR I fv.) MgpfI IDARt~NOVAI T I] R. V.1 r re l Kfn TAI SIAtE tRA IfR ftAIf NO. S1AIf H vEH.CIXOR q N q Gum C m D C.9 - ~ 1 vfHlnElof nHCAIION NO. L I sf loENnil AH N 3 ~ 8~2~~SI /. :8'~al~~' , ~ l i s t i I ~ 1 ~ I I ~ REGI R[p0 IASt fIRSi MIDIXE PHONE NO. I iF lD WNfR: USi fIRSI MIDDLE H N O _ W IS ADDRESS as OWNER A wH[A ~ N E NAMea AODRESSaINSwANeECO. oR ACwr I AN - re T, DAlnA4l KEA I I ' wt di R o / " l i M I CHMU CHARD[ a .uWD fVNCBOHN E DuAAGIp M[A 1 , }t 10 ~OTIOr DAA4GE > [SI, ^ RIMNNED ~^ ^ AWAY ^R[MNN[D fSi. DAMAGt p t Dp ~ p in ueo S ~() OWfD ^ Awgr nr: G iOW[D ^Awgr er' s H I r 10 DIAGRAM OF COIIISION: Eu n Hu volute NORTH .- '.. .S Uf1iN[C[SSA.RYI. BY ARROW DESCRIPTION OF COLLISION: IUS[SUPPI[M[NlAl suftlf NEC[ssARr 1 .__ _. I ' T gdd~G7 Nli/ T C 6 o ~iy _ . y _ Di I. _ ~ NAME, ADDRESS 81NJURIESOF PERSONS I NVOLVED 'CODES 1 - Z 9 4 5 6 OCCUPANTS/WITNESSES ~uo'rR:ooneieu nA'Ai ii atx eEE~ ums '"„"" ° ~ dsu. ena ~'°; AMU ia" wns 1. we of ~ R EwBY ^AMn ^fi1'^"' .^R ^rr°.:ISR l0 A DfNl1f NAIURf d. R RIMOVIp IROM ^AMn. ^raRl ^"II f ^n ^li~ b AMT. NO A tR+RI~s "ur"aRfa Iw ^AMe I]lol ^ '.^GX ^.°wsE A X ynl u.Fr as nAOGe oa AGfNC. arc Ds reHlo IKXKEA IWD D IanroRt Rweonr D n D 4 ' ~~.:.~'. r n~E r~.v +AEa,r~l 1. J. ~lT 1 ~, jl F • Mt a '~\~ !~.. ;i~~V ,i I ..:,it ' ~ - % 'I~ r>aM, `P .~'~ .9 '", I~ .~' A I ~.,auR ~ - 1 ?. Iii a.' r„n ar liTd ,'~_ 11 ~ d „~tt 1 l~yL,k rfr 1 .: ~: '. ~F. 1 C ±`, } ass'. i~; ( :;li 'l i r i r ;f f. .nl~ ~ «~i ~ ,E L ,,. a ~xFr Ar ,~~ ~. , •~+y~{. ~~~ Y~, jwa i ~ 5 ~{ „~ ~. C"~ ~ . L 3 u'~ b. ~C s < ~^ 7 ) , '•$~'.~ 7l• ~ ~' r Y,~Matx n wf t • •I . t ~~ D F Eta W$ '~ `~ /KA~ jl Try N{ ~is ~ r r F ~ ~~' ,~j~ , E Y .. } ~ •, u f e ~~ e c.%re r J~. ;: . .,, ~ `:. A •' ~3w IOi r° '~~" kuna~ "~d ~1 ~c~ sit ~' ~',' ~ ti :- ~' -~a f 1 '~ ; I I I.'.1 f I IVM1' ! 'n ~ I EE~vxry ^ 7 5 F _ Il'I i ~v~ ; 4' l I.; 11~~ ~ l ~ S Y l' J T I;r ~ 1' 1 ~ ~ t'~; I. ~.{~ 1. .- , TRAFFICWAY ' POLICE TRAFFI LLJ. •.,,_. C COLLISION REPORT PRIVATE WAY ropCFCOMMNiNUMBER DAIFO gw.IXLl D I (USE ]FW HOUR) COUNTY Wn lu w10 F. ljo yl~ fDUNiY NO CItY NO.. {NWA i l ~ ~ ~ ~'~ ~ 11 ^ URBAN R Y ^N OF ~IN C `OR TOWN NMAE6NO.OF y`iREEF+Op WGHWAY 5 W Of `~ W Cl5 FOUpIF ON SIR SFUI N Q MIIFS ^ ~ ~C!~CK ON C l . 1 INIfR5FC11NG WITH: STREET D NON INIERSFCIION ?1 /.S~~V , 7 BEIW,FN SiREEi 6 [ ,STREET pPE{I% EO. Mllf ro5i . G, G 9 OISIANCf6pRf MILES N N R 5 E .CNOSS SiREfI RNfANESIMllF ro51 ACCIpENT RAMP DIAGRAM DA,A MILEAGE {Efi Of CD ' E CODE - COllISgNINVOIVED. FRIIYI IAGE IY'e RUN HJNOCIDM S P II lOIAI NO F~ NO KIIFp~NO INJUgfD ~ O ~ M 15iN PDR ROADOR REEERfNCF INLF}. Cl3 CR05591REfIOR RO ~ y ~ ~ R [ ( O VfHIU[s Q O PROPEg1YOMSAGF ONLY L.1 q[SUIiED Q9[I~iClf OBJICISIRUCNINNAf Oi OBIICf STRUCK PNDOWNER'S NAMH ESt DAMAGE ~ E/ y~j ~ SaCIM CODING IAF - f S ' UNIT NO. 1 _ DRIVER'S N UNITNO.4 `~yEHICLE O PEDESTRIAN ^ PEDALCYCLIST -t" C~ MA[:~~IA51 ~ flRi ' ~IMeI ~[ ~ IVF^~q~ ~~~~ L ~~~~ IDl SiRfl1A Rk55 (A SINfEI ADDRESS ~ 2 ~' ~ ~ ,~ •_ ~ [7 • ~ ~ ~ ~ , O Uryry~~ ZIPCOI~ PHONE NO. Y'nC`1" LIA [•J RD ~ p SiAif rw (iI U S p ~5 X277 I DRN[R'S U[fN5f N0. SAIf YLEX'~~ 35M IM f% Yt1 A F IRiN p"°bi~s7 ( ~ fR' LICE Sf NO. IAIE F% CSiA13RCMNy~-o Z~ IF Of BINEH "'° ~~" '3~ "" -' 9 OCCUPATION r {IPM NM1E8pH ONE N O . EYES WEIGHT MF GHI E OCCUPATION f IRM NANf6PHONF NO. EYES WEIGHT HEIGHT '~ 7 rY.~C ~ ~ " ~ - ,,, ~ O '"tc u.r~ ' -3 Sor R. u~,~'. - QrcE 1Yi So3 EGK (.~ tb ,w~sd ~~ vfEUnEAiAN{MROrFFOFarvorHFR ^CHECK (~ IvFH GLf ASANfJAaorffagFJOiHER°A V~ _ CODES - * D t°,',u• x s,iiew I 5 e <Iwrv - / 6 u 1p°`~e`1- CODES - ~ 7 eiii' 4 sR. „",W' 9 [xnwrv 6 "'°E "e'W- INIU f NRI :F,~f.. RDM O AMeul..<L ^ ub° ^ PB:. 0 ~.21P pDi VD. Y[AR Uq fS M ~ r~ERD BArDA•„[t r«a O ~brR. ^ ri ^ P.' ri[u A ID MMtIDODGF CHFVI MOD IIDARI. I STYLE IZOR CON 1 7 ~ M ,a ~.k M ~q ~ E l D V N;7R7 I HfV.I MODfI IDARI~NDVA) I ~p 7 u ~ H U UNSF PIA IR 51 E A E9 RA1[NO SEA1[1 H VFH. OIOp 1F~ BYY. N- s _ Ivy}- 1,, ~ _ t~ OV v~vv 1 A w-4 ' VFHICIE IDF EfCAi ON NO ~ DNllf wl N D '~r 6 S y :& ' 17; ', I RfGISJfp[DOWNER: VSi iIRSi e INi I i5~ 3,kTl ill ~ ~ ~ ~ ~ i ~ MIOOIE PNpNF NO 5 F EDOWNFR, IA51 iIRSI MIDIXE N NO. 3 I` ADDRESSp OWNIR q OWNER 7 ~ ~ y $ Pe C'}' ~ ~ W Y`~ t N E NAMEewDRtsscA wsuR,wee m. DR AGFNi J u AN I"•~ Q I, `1- H Aw ens I.AJ R _ (~'~ •- ~c'1 1.E%.nse....~ of pNAAGE ARU I S p~clq,GiN ~ V L AMAGfO ARtA 1 CHARGE CHARGE o v>~ S '~ IGTIOilO~ I DAMAGt t fSf. L"'t11RIVAY ',O pFMNNlp ~ ONNDJ ~RFMAINfD A A Y EST. DAMAGE YDr • f r s u f /~~ rowFD . •w e~ iowm ^ Awgr er: r S ~ f~ U Io iorr5 AGRAM OF COIIISION. G 1 DIUIF NORTH rl }s+ N . I~ - ~ ' DESCRIPTION OF COLLISION. IDSE SUppL F sH[tl if rvFCf55ANp ~ ....... l)l VL Y ^ s P M / ' ~ _ . . ~ Kt . S . .L , t . N/ y `.. OI 0. U, E .!( Gn~l2 CU~~.I, 12.. n .lf~OI VCC.m. .. ttY. E.U 7rkc•k wc.S ~^ IR - F ,_ _. _ _ -,_. .. .. ~•~ wvti o.l- ISIuE.~C; FV ._.{1.15 ~V ). _Sif. {tL ~14-~41 Y~.~ ~ ~ •A l'U~Y In~J._'~W. I AN~G p.~ DJ R . 12 YcWtl F YC I w•.s W eTb ~.. ~'^ W {t,L L ~ J ~' O%IS C L~ _ _Hh ~., y CArI ' CM C w J:E ~e,IIl' ...C i.-.. G~ JbNCW:~,4E G.i l` J~YV_CK EI LIyw~'Y~ R r~ ~1 LA H,kNO WIt .C'.KM:jt~ ti k ' / % '~ . . a..c f6.., tnAc(c b (o.(' nr - vicu_ wn.r.__._.. ~ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED * CODES 1 - Z 3 4 5 6 OCCUPANTS/WITNESSES'iolui~ooli~o~NrrviiF~iuui i ~SiK ~AC~ urus'„"" " ";'~msie ina ~'R;, ' rI AKU: ~ ~p,1h,r,. 0. ~Vl AS A.N. C n D .31 7')3' _, /= 22 ~ { .~ • ,u npRlns P L N Sc.SO.. D~ QRf~lniL E N Upf or Air J+.Ir n' 3Sr-272>' AIIR ' INr er~ AMe. ^FPV" ^"" r Ow; ^itYuo rI • N DORfSS r 'r ~ AM R, ` J~DINOM~ a O(q l0 oI . OH~. Sfr Y AM Q :°.w ~ " p .,11E,t I~E,.,,t F,O ags. y~~3 - - - .. ~ O1 - • nant ~ 7 42D r eW ^AMe ^'K°A`%' ^Capp O:ix~ ^ n l l .NEt n, «aarKanF.aw uAN< e•acFa AuHCr Ic pnrAlcHLD la raD Duf ornron urpovED er Dqu 0 rtl X -~~.r I .5'S '/ 4 ~ ~ P. IC ~Jr . .,~, _q~ A ~ - ~~ ~k: ~><E ~ I ,~ +f~ r ai"A~- 4 2' ~~jxw ~~ .~ R,.~ i~ I - v; v~ ~ A .,... ~~ ~ ~ ~) r ,)•E I Jr q Y ~ n" (~{ IYU. POLICE TRAFFIC COLLISION REPORT IpITRAfFICWAY \• K E000f COMatAMIHLLMBFR ~~ -~ ~ PRIVATE WAY OAIEO dU N eA DA l ON y V ,rvN. wlD nKn H Yt IIMF (USE }Npp HOUR) COUNTY ..~. COUNTY NO // CITY NO. HWA ^UReAN I ~ Q CO qAl / ^ ^F ^IN CNYORIOWN NAMfbIb Oi SllEfl ORI LEEWAY iCICES ADM I RWIEOrN 51 yE ~/a 3 9 AVllS ^ S 01 ON z 1„7 ~f INNRSFCTING Vn IH: SIRft10R ROAp NpN NIF45FCIION / BETWEEN STREET 6 SiRFFI %EfF% EU. MRE POST ~'~/ w7 / ANCf6 i E R CROSSSIRFE OR NfMfSIMItE VO MN[S SR NE...w ACCIDENT MIEEAGE P DIAGRAM pAIA iFEi ~, OE ~ CODE D fOll15KIN VIXVfD: tR1lYi NO. KdIED_NO. INIVREO / ^ SP IUWE N dpUN T VFH~S ® ^ aROEFRIYD~EONIV ^ pfSUITFD ^ VENEICI~E WNwIRm ~RD 1 tFR Cl5 C ~ 1ER5(CII SIRE OR OR tR NCt ROSSSIq[E OR IIOA`D ~~/V O - - 9 O61ECl STRUCK INwAf OE OelERSfgUCK ANDOWNfR'S NAMFI ESI.ONAAOf SafCIAI CODING USF S UNIT NO. I. UNITNO.2 ^ VEHI0.E ^ PEDESTRIAN ^ PEDALCYCUST S ORNF SNAMf% U\SI iA51 MI - ° N ' OiNFR SNAMf: USI fIN /IT• z,L /n~s ~" ST ETAUDRf55 ~ ~ a 2 9 ~ INfE ADDRESS ox33 y~ 2~ '~ ~ . ~ sIAIF xlaw aHONENO. /O 0 S• ~A f3~ S•c7 .3 D R 1A-z T x~ c~yJ ,A I S S DNlR' UCENSF NO. 1 ~ 2 OG SIAIE A ~ D BRM MD1QAY 38 I ~ NR'Sl ENSfEq. Af~.TE L < pQ IAIE Sf% OA! IRIN A M ~ Dlo ~ 13, ~, OCCWAll011 NAME d IIgnE NO. EYES 'AE GII HUGNT E CURAI ON N f l aHONf NO. \ FYFS WEIGHT HEK:Hi M , 2 bA~ ~ d 6'A~1t~ c~orJ~S ,t3G A ~ R m S / O S / 6- ~y AI ^ CHECK (.~ KIE AS:N EMaYVEEa AHOrHFRU vFH ^ GHECK (,~ IEVEH CIF AS AN [MnOYFF OiANOINFN v , °.in S GKIroN 6 w'p1O CODES -* D n u, A M I ~ CODES ~ ~ D a"A"'sst' • ° 5 IArnoN 6 ~~•cu snM ~ 0 ~ f IAIE nA u ; °OM AMKWKt ^ <~ ^ (•'ntq ^ vexK~[ ^ Ia\NY t°~tw ~v fFewrl pv 1°~ ^ /MPUI MT ^ A °CI [~ ^ CoiRV ^ wMKU ^ li~~. : KH, YtA4 MAKE IDGDC ~CNfV.I i z o MODE I NOlAI SIYIE IRDR ~CDNV.1 Scv ~ s E tvl r,N VfAR ~ M~ o~T fl1U g1~NOVw) Fi3 Y (} 1 a42 !l.4r ~~° ~ YH. UCtN alA N STAIf IRA I[q Mif NO. SIAIE H vIN.CGOR t t A 3 ~o w - ~ Go~k~ E a~ _ A VtNKIE IDtNI fIGIgN NO, /~y 16:3~yi Ial 71.6./; I l i L tN f DfNI ON . 2Gf8171N.y'N 31~/`11o!S! i l 'I tASI IIRSI Mlp[KE 5 R WNFR ~ RIWSRREOOWNER. V31 IASI MIpDI! aNONE NO. O W ` . ~~ I ID~ AfIORlSSOOWENtR N MN R A E ~- NAMed AODRUSnINwRANCeco. aR AC R G~JJ~ R S IT} ~'f wMAw Aqu O gAA1AGf Axu~ IwCtgrOiu ~ d • ~ 01RIVDYCE w`r wi CIIARU MMG! Z 1101 RIOw t _~~.---~ E 151 DAMAG! ~ Wt0 ~RlMMN10 • IO'MO AWAY ^RFMNNlD l51 OAM t I tO ~OliOii S 10 e0fY01E S ~ 10 10 S Q eY. wAr er: DIAGRAMOFCOLLISION I t Nu Iwurt or DESCRIPTIONOf COEUSION IlneslAneMENru Swel rNfce55AgrE -T r - 3 EEE V MIC[SSARY) I GROW .. __- .~.- -T~-T I r I I~ ! _~ I _ ~O .... - (/E.%.#' / -..~/O.~°TiJY,BGYi.~/[~ __ f/67i~--__ I ` i t / mar To e' XI G '' T T I ~.--- . ii G F / .z>! NG ~ ~ _ >v //:S. C'O/ c°YJ_. o --- r I _ 1 .'~' _._~ :~ . ~-._ i ? SSG . U dK H (J % ~ -,. ~ vt/~- 2 _ dr"/~ __ ..~ . -; ~*' - ..;.: I -.. :, :! Fri Livcr ,e A n Ii~''F _..I ._. ADDRESS B INJURIES OF PERSONS NAME INVOLVED H CODES 1 - 2 3 A 5 6 , ,USE SUIgEMIMAI SER OCCUPANTS/WITNESSES Dd ADpIKNU NAAV FI 51 uK Act uTUS '""" °"~ H T, ."':e 4ESIR. lllCi iu`~r NAw No --._.. -. _ - Anrolds NAlwta w~_ ulNe a ^AMe ^ u1 ^iri:ilf ^ W J ^ i ."t. Y NAVE }D .. ArgRnd iwlwroE . 71AVNIp to ^AMe ^"OiKE ^"" e ^ y~H ^ :° 1 r . :n rt. NAVE AEVP155 Ii.AEllrv°~ w Efi:il e. ' ^AMe. ^ ~:,° ^ i"N1. ^'r7'~7 ^ ".':;.~ R,Yt)I Klvf I• AN•~ ~, ~ -_____-?~ MUG101 ID K.I E,CY .Sb rKy PaL ~ KI Un1.\ICWp I }uINRS QKI AEt~ND }EtlEE,.S UAII OE V1f0M1 AIIVONpeY ;Z~C- / OAII \~' I~ ~ a r r G ~i'I.~ ~; j JKjt' ~ ~' w ; ;~~ ~ y ~ ,:~ y~ 3f ~LYF ~ h l lJ N A• a'.'~"~ r . v„ ~ ~- __ h ~. y ~ ~ :~ I ' , ,,. ~ STATE ®F WASHINGTON .AG: ~ i '~` POLICE TRAFFIC COLLISION REPORT d I~1 No. yYy TRAFFICWAV y.T4$ ~( ~ I r R%ICECOMNAINr NUMbFR u,~vL y,'~i G41F 0{ pUS N IlS D ~ PRIVATE WAY / k3i~ I `, . ^ " r Wx "av. t W ~Y~ MII Mf (D$E ]KDIEODRI ~ COUNTY COUNTY NO. FE ON ~~ <IrY NO. IHWA a~RAL 'fiJ - A ! OrYON TOWN [ N ^N ^ [] NAME6NU.0 SIREFIOR HIGHWAY iR ClS AU ANLfS ®5 ~'w ~Oi Gu .~ I Nrf 4ffCIWG WITH SroFF UR 40AJ ON W ~ ' NON INIF45FCDON 40U1 C95 ~~~7`~ 77 ~ I~ ' •. ~ r ~~ ~~ h' BETWEEN SIREEr6 pREfIA M4F Sipffi p051 ~ 7~- ~ Sm k ~ D~ IANCF 6D~4 pNf RES .000SfSroEE 04 NFA4fsIMl 9 5 f ~N W ACCIDENT RAMR DIAGRAM DAfA + .l~f(~ ~`v#2, { ' `Y i[f! pi # CIXl1S9]N INVIXVFD: SEVE4rv. ~ MILEAGE ~~~ ' ~Itfi 1 rOtAllq N0.911£D~~NO.IN1URfD~ ^SpIIUGE '~flq Cf V[HIClES ~ ~ pRORRrv DAMAGEONLY ^ p[y ~S Wx4n4m IME 45 /p CA055510ftrOR ROW F r ~ xq ' ~ ~~';. - R Ul1fD OBIHT SIRUCS(NM1Ed OB1FCT 51RUCS INDOWNER'SNUAEI [MCIf ~ LSt.DA'NAG[ SKCW CDORVOIbF. '~~~, ~B~ 0 A. I ~!y5 ~~. = r S P. '~ i S H `~ -.' ~~ UNITNO. 1 UNITNO Z "' ~ yEH f' e ~I~~~ ~ ~ ~ ,~ ~ ~ ' ~ 1 } ~ x F~ ej- u.*5'J ~~. ~~ ~ ~~ an - 4 ~[ x"""71.. w. + ~ p # i F f ~~ ~srn. ..,. ~~~..... ~ R.. +'~ J I I ':r I I', ~C ,~t I ' ~r 1. ~~ ~1~ 1 1 : Py2'~I .~?E~' q . t ~ ,ti1~~',. > , , , '`s 3 D4rv x NAMr lwsr HR K1E' ^ PEDESTRIANL ' Q PEOAlCYQ6T ~ 4N R NAME: usr E~~ 3 S1Rff1ADpR A Ef oD9F55 ~ r o^' slwE ~ RHOaENa D srAl .j ~ `Z-`/~`~ R D4N rsuaNU ~ ~. , NO. slw E Y I V ENSf A Ay ' y4 D ATE D ~ C ON 119M NAME aplq lNO. T(I[, (~(~ /FO FTFS IGH! NfKaMr E CUpA ION MNAMEL pHONF pq - AZ T. ..S• R Y FJl:~Glt Ll( , EYES IGHI KlGll ISO R r ~. r ^ CHECK (/) ;,,aEA A fdANOrHEe'. CHECK (,~ Vf fAS wN ENROVEF INf4. V CODES-* D ~ > j S I NOroecy[u A '~" S + e ~ ' CODES - D n sr a ~; S u IR~ES ° '~"^ ter` ~:9,"° 'N,.I^„"'E ^ ~1 ` ^ Ebaf. ^ K ~ ^ ;. AMBMANa H %lne Er. ( V.1 YEAR N MAaf IDODGE{MEV.1 MOpEl IDA4 .NpyA) SIYlf 1]D Dx) Y O ^ ~.N O W ^~ inA '~' lIDA9r. u. 4A1 vA I ~ IvDN ID E ( rv _ m r 4 8 ICENS YLAI N SIAIf VEER RAZE NO. SIAM H vEH. aoR l . A AE r' ~- I ~ VEHCFfIDf661IK~A KRfNO, ~q+ C fNKIE IDEN ' ~ ~ L Y l,f ~ I ~ ~, 1~V IS I'~ ~ / Miff 9fG15 ~ ~ ~ I ~ I I [DpWNfR 1 3 4 41gNE N0. O I fDOWNER: fIRSr MI E t N ~ IS ADDaf55d OwNFR W A 9 fp I N wYtaADO4essdlNweANam. wAGeFfr POf oX E L AAEA Hr „D ' ~.~ R AM ~ . EuHC9a~ CN oU .~~ CRARG ~ ~ ] U A Sl roiorio': ° es~ wWAU ~ Awiv Q RtwuNm DRIVEN. fsr. ~D e y sro• ~RfAWN[D IOM10 AWAY I ° - s BY IOWEDBY t 10 i0i}Oil ~ Ie DIAGRAM OF COLLISION i frPNens,ARrl ~ ev e~1H DESCRIPTION OF COLLISION (USl SUPR[AeNtAI SHE[r lNeeesuRr] ~ I r _._.__ ..._. ._ __ ,_ . ..-.® V~~,{. _~.I.~ l!e~.REO_acF _oN7T0 TN~ .~ ~ _ /! ~ I !.. R~GNT._. r$NvuLpp~ER ~ Tl/6N 89Ck ONTO acEAi TI1C1E - . . I, _._. Ro/iAw19Y~ 4oszNF-,_CONrROG._AnFo__---_. ~ ..:.. D ~ HZ .,:. ..._..: TTLN(r. .HERO ..ON .ZNTO...AN...'~/'lBl9/VK•=. ' ~ `~ :.. _ ~, . /KENT CN .THE ti oRTH8000V0. ESLDE _C~ -_. fto.~ NAME, ADDRESS 81NJURIESOF PERSONS INVOLVED + CODES 1 '~ OCCUPANTS/WITNESSES ;aE~Af~ 'N~n " rr - Z 3 4 S 6 , e AMT' uR Act uru n" u ,rf RESro fact s . En vlu NO tu4ed p I BY A Me. ^~ l ^ "" R ORS i.2uy m r+o: AD VRI Sf A I HAtU9Ed w 4 MOVtO IVUM ^AMB ~rpc1 ^ttf. E [~ H ^ n °D Iq l lRld I .f.NE'S NA1 }d .Ea 4r5 NA BY ^AMB ~,ro, EE Ocn'h. 0;7: O~ .1 R B I OR AGEI / a lp , KY y N ~DS~r~rp ~y~~QD DAIip RIAdryr ARpROVIDBY DAZE x ~ GSff , ]mr,4s ]IW H45 ~ d6-fT k .,,sa ~~ :r a1 ~. ~ , ' ~ ~~i ~~ 9 -,wA E k,H.: k a ~ ~ ~ ~ ~ . { ~' ~'~ ~ .,, . m~x ,; ~A ~ rd ° f `'~ R AI ~~n. 1 t . . a 'a; fa', ~fi '. ~~ ~ I t~. { ~i :RR4i `.~i ~ k ... ~& ' E ~u+tE' . u ,ra ~~~ ~i a~. d ~-. {} ~ c ~ '~ a , , 1 .~fY a `. ? ~ ~ ~.^~ W ~ a`~Tvr ~~ rs ~ ~ t k' ~ , Y '%I { A ~~ pp. . L A 8u ~ i ~ L ' 7 , A ^~" 1,I ''I ~ ` ~ ~+~fj 4 y ~~~F~ ~ 11 I ~ . ~ ~t ~ ~ I I ~ 1 ~~~~ ~ x ~,: ,S~I,rY ~ 4,'.' .:~ F' ~., 1 i.-`' R .: 71 R'! ~ I ~~~. '~ ,~t Y _ E T S, , 1 ' ~ - ~ E7 ail I~~ ~ ^++ , 1j 1 ~~ I ~ T 1 G~f. r ~1, , ~ 11 ~ ~1 '~ POLICE TRAFFIC COL, ON REPORT ®iRAFFICWAY Poua UmNUMBER . ~x ' I PRIVATE WAY E 7 j DMf cour+tt Alf, oIXll N I (USEaWO XOURI w~ I ~ uD wlR couNn NO. att Ero. .. //-- HWA. piU 8AN . . . Y,x . Z. ~' ~I I I i U 7.f-t> T~ • %L ~1 U/a/ NAMEBNO OFStREEi OR NIGHWAY /E./~ ROU(FOR IR P.URAI 3( ' pN pE pIN OfYOA TOWN ~o ' '3 ~~ 9 '` AVLFS s pw poi C~i, mn ..+nE ON C. /G. / i l5 ~yY, INIFRSFCIING WIIN: SiRfF NON INn45ECIlON ~ PRfil%. EO. M LE PCLat ~~ BFiWEFN ~ Y SLRFFi 6 S. ~• / U `/ s1AEEi ~ V • DISTANCE (tIR ~I qMR FRrv CROSS SI4EF1 RNURfStMILE ACCIDENT RAMP .. DAGRAM MiA . • ~ ifEf ~ Di I •~C.f ti t:f/ I.J I MCODE E RD INI tGf tOR ROADOR RfifRFNCE N % b ~ CO1U510NINVOIVfD; VE411Y, RUN ^ SPIWGF INJUREO NO FO w+HS N wNBY[DM s N IMER . CIS CROSSS1pFFIOR ROAD . _. ~ . NO. %III ~ rA~1 Cf VEH14F5 © ~PADPf4ttDAMAGFONLY ^pFSUllFO 1.:1 VEMClNE ~• "~'' ~i~O l"'_ OB1ECt S1RUCK INAMEOi OBJECT S,RUC%AND OWNERSNAMn FSI. DAMAGE SnCVLL COOING TAE ~ UNIT NO. I UNITN0.1 ^ PEDESTRIAN . ^ PEDALCYCLIST p VEHICLE I l ~' ! D4rvlR'S NNAE: IASI fIR I MIDIX P_' .~ c r' DRIVER'S NNAf: ULSt , i i t ~ aR ~/ aEaeL_ - e SIREfI AODR 55 1 632 1 fIA Rf 4 ', u.t• ou 6~• v// ~ 2 SIAIE ZIP CODE PHONE NO. lr D IAIE ZI H pr: ~ J 3'~G~' 7lL-4Zsl R ~. Tal~sav w Y'3ay 35s-•v39o w D4NE4'l UCENSE '~ Voc•r = as 7x, P SIAIE f% A /h H Mo •~ L 3 1 ~ Iv R' LICENSE NO. AlE Gr,• ~+B s'o GP coq Sf% ~rl ~D ~ F BR H o• R.r IrK ~ e OCCUPAtION iIRM NAMfSPNDNf NO. FTES IGNI HGXI E OCCUPAI OV' f IRM NAMES PHONE NO. EYFS IGHI RIGHT ,. B ' 2 A+7 ~~c i%F ~ S'' Gl ~ %(Li ~ u? R 'E.h ~ . i A [CHECK (,~ vEwnE AS AN orfE Or Ar~Dmle~ ^ CHECK (~ YfwcIE AS wN waxorfE OlANOrXEIi. D ' n CODES - * ~ affil ~ °u~e ' / 5 uEC1 DX ~ e ,AiO,,,°. "" CODES - * ~ nis c °s`rin w'"' Sex no.J ewe L ' RE 4 ~ Iw„o log Hr%n °sflw`~. '°"' O AMADIAXa O ~,/ E ^ ~BRI. O A.YXKII 'b:.~sr. I ~. ,. vxAiK B."Dfriof.o p Ar e ^ 6°I'R ^ <8mR ^ Yi ".~ ' MKV I VFH. fM AM%FIOODGE{EIEV.1 fIIDMf.NOVA), SttIE I,OR.CONV.I. ' E V.) I DR. H. V.1 iAODEL lOM1.N A) Zot P - ~ - >e I H2• o. ~~ Pe mo..n/ H r-~/mo-,>~ s c N A ' IICE U SlAif iRAIIfR PU,E NO. SIAIE V[H.COIOR t/ h C 31 7'3 ~) /1 C ~1/aN 911 u/A o `~ ~ j b i VfHKI[ DENi1NCA1gN NO. p m 4 l! ,o'Oi( '4~615'I~I`fl i e A Yf ~E Z~!SIDi~lll~lzl 1! 1 1 1 1 1 •I MIDDIF RbN[NO Rf IE EDOWNER LA51 IIRSt MIDDI N Sv 13 . 4EGRRRfDOWNEA: UST NRSt 0 Il WIiER ADDR[SSd O OWNER 'Z / Y ~ T~~4fiA.~ ~-. txEP .ta CLIAE /t~'.fo.lY Cil Y [ W. E - . . , . 011 AGFHt U Rte ~ al I R NAMIYADDYLlSdINSVAANCE CO. ~ ~ AMAGfOMEA,- ~ ~ ~ ` S w<np~4 l ~ ~ OAMAGI MU R i Ntip'D"iv41 GNARd " iEs/frl.'d iJ. La CNARG! MXIY E I I N •TOI l DAMISGI r]. f AW'^Y ^ACMAINED ' AWAY ^RfAWN[D l51 DAMA [SI IO ~OtIOii s oT: ld o li loi loo ~ Iovrto f t/UO f :Z DO A Br. Ar er: A w ` U k IND N DIAGRAM OF COll1510N SiH[tuWUSSARr) B t" DESCRIP10NOF COLLISION (VSFSUPnEME IA{SNfft IN[CFSlARYI RRON ... ... .. ._. .._ ._. 10 I ,~ ( ~i/JtNai wA'(- I _ O JESNI<« '~/._ . o/fS .. Srntn.d~ /-u._'~7G,c _._ . . . I I I i ~ ut'.... WA'IN_. /'r/e.C__Lin. o!/c.~_/._y'tA6 r_..._ I .. ~ - - f.=d~ I.. { ~... 'n. SGL'•. _.. UcA//C ct u....2....._6o/.N. C__.Qdu"r.? .. 1± • ` ~ `v I / St2-.cr ..~ ._ .. ,_ Ni,n. qr0 /t: N.' _ i-7 _~------ _:.. , ~~ .~.-T- _ _.... _. ._...____ _ ---_ __.,_. ~_... ~ _. _--- t. ~_ . .. __. _.---- .. - I I _ ..._.. _ ..---_ .__. : .,., , ~ ix " « ES OF PERSONS ADDRESS 8 INJURI NAME INVOWED * CODES t - 2 J ~ < 5 6 , CUPANTS /WITNESSES ~°a i,D"IDilro~r'[ur~iASi."i ii _ ~ s~x~ ~~ce tetua . „Y'" u "') nsn uecr :;°,. NAME: I ' i R ° ...... ..... .. .. _..._.. _ .. ADDYEtS mR a __. _. N A I I . KI w.I. r y ^ AAEe, ^'c41 O . O w ^ {1i.~EA HAW - Eq A ADdltt .. .. .... ._.. _.. _.. .. NAIINEd _. __. .._....... ~ YNOVID IROM ^AMS. pIaKE ^,YI, Y•^Hir ^li~HV RD HAMI. Ij0 U'f ADMISt~ .. - N,tW h... __ B I Yr. ^AMS. ^ ^ ICY ^ax ^ n wx I I Yrvl w1Yp OIIKIYSNAWE H SAfKiI OR ADENCr W KI OISIAICMD Yp4l YYMD OAlld nldi A YDVID Yr M X m w o7~Y cYG3 I i 3 rv~~. N~'~, ~ANE ~!~ I~ ~.~ I~~ P ~'9 ~~ ~ f ~LJRL Y.Tz:,. ......~-... +« !k'vr-. .:Ywu.:bx•i~_-wi~_.id...: }`'e.~ _~.u'.; }~5~"'1'k55Dj+q.l4Pf53W .SIfA ~~{,x 9:'.. V PA' 4" I . L STATE OF 1IVASHINGTON PAGE ` Of ~ . ' tlD) O , . I~{ No. POLICE TRAFFIC COLLISION REPORT ILTTRAFFICWAY palcfcoMRUm NUmof ~} ~ q r yF,)~ -DAr f Glll PRIVATE WAY ^ ~w C ~ nmE couNrr IUSE D.pO HOVR) WUNIY NO GITNO. iNWA l wb DAy 1_•-I uw :IR6.w1 It v oz3s ~r.FF'~sGIV /G oE1R9A / ` v1 ~ - Z N e E , ) i n~ f ~f fYt L. i~'' - Y O ^N ^E ^IN ,y I RiY 04r WN ~~ (f~6 NO.Of 3iR[Et OR E4GNWAY Ct3, gWiE rR ~ MIlE3 3 ^W Oi GI.I J"La~~M ON C: (LLZ I ' ~~D,... INIF S[R NG ' F ~ F lyff„ . ~ . WIIN SIRE N 1..7 JAD NONINrfg3EC11 0N p4fr1% FO. MIIf POST ~ ~ L nn /~/ CC [` [EN C T~Ip SIRFfi6SlAi4l.~}iUVs ~IESIRFD / DI A - ~ R A N I D N R M4 EN CROSS SIRE I • MIlF3 E W ACCIDENE R DIAL 6i}A I dnE V ~nJ__-- ~ Ey 1 C~~~•.E rEfi Or Sf-~l~C/f V. ~~ ~7 MILEAGE CODE ~~ '~ CIXl13roNINVOIVFD EVE R f ~ ~ . : .. I YI 11 OOpp- D r 4 04 RD4 Qf V[HIClOE3 .Z NO KIllE0~N0.IN1Ua[Dy E_A SP4UGE ^ II R wlWioesorn INi[ CIS CROSSSiR[ OR ROAD ^ PROpERiYDM1AGE ONLY ^ q[SUlrEO ^ VlMiClf O 001[R SIRUC%INAME OF OBJfRStgUCK ANDOWNf45 NAMEI f 41 ~i ) ~ ~E 1 FST DM1AGE SRCELL COO NG US ' _ -_ r •. E'1 q ua. E~' UNIT NO. I UNITNO, e . ^ PEDESTRIAN : ,' ^ pEDALCYCLIST ~-J'1 DR VfR NAM;1 Lift '~ ~^VEHICLE .. AL I t - DRIVER' NAME: U55I I C) R S • ~~-~1 ~1.. F T;tt ' ' . Y (~(„) n T I A~ CYe-eL~s Wj ~~~ Si4fEt AD04E - IREEr ADDFF55 q ~'4-l (3qc (a33A .' ~ j >~ SiAIF EIP COCf ONE 0. D I Y rA E ~• Ludlow ~A 41J3b5 732113L11 R •~ s 'f ~ `7 ORN RS UCFNSEN StAIE E% DA f q ( IV U ENSf NO. AR E% DALE B141N / L ~ ~ ~~ ' , ou8HCC382oz. wa F q'zz i6z. ~ A,D. f DAy I ;,; ~ I + OCNPAEION {IRM NMIEBPHONE NO. FYfS GtwGHi EOCCUPAIION fIgM NNAF6 prIONf HO. EYES WEIGHI wroNi • ~~~ ,., ,~ ~ P a~' `" ^ CHECK (r7 I vfwttf,sAN fMrtv'v EOr ANOrHf?. ^ CHECK (I/) CODES ~+ D RNeY A ns,u VfH CEF A3 AN FMROyff OFANO1Hf4 5 e a ;u„,°y~y CODES w ~'' - ~ n a :: s exctwN ~ A Lx> p sAR wJEUlts k Sr .. LS4,G e ° " I . 5 v >feE~7f. A4 ^ Am«AANCE ^ ~ ~ ^ EBHI. eyA4 ^ 1"e°,r „or.om ^ m. W,[!s ^ uoyfE E O ES:4. ^ ~~KD ^ry~ 5. AVV(E EDDDGf{HfV.) IDARI~NOVAI nStYlEI O CONV.I ~ I NOVA) ( 7~ ' v f$(Zv y ~ Fond 1'I r1~0 S L>) E 1!`~' ~ EU. iJOU(-~ ~-I D~ ~ `lae ( . uc ~~~~~ SIAI I;A RAII{R RAtE NO SIAtf FI CIXOR {r sal MaQaxc,~ McL>`tsy (.E.a'q A EH nfIDENnr C p ' ~,.,.ar '~ ~ ~'' roArroN NO. v cu IDENr I 11 ~~~~ 21Z~ .y'8121t~'Z~ ~ ! I ~ L i(ol9 IDIbILII 131811 13121 I I i i EGISRR[DOYmfR: 1A51 Si MIDME~ P ~ r"~` ~ ~yA -- "A' ~,_,~ 'S HONE NO. O 1514D WNER~ Wt fIRSr MIODI T l4lz n rrN N, ~ II__l,,T ~ I AD04lSS OANIR W ~ 4'£' CIV VV\ ~ ~ ~ ~'~ " [ ,„~ * yY ~ ~ N IER C~LUCOd t-T> ~• -~f"t-ow,~~K.K! Lnan E ( 32~t D C~yA t-lac~E~t NAMlEApO4E33 t ]A , Y ~ R ~ c, ` • `~ • ' , , p NSUgA1RCtC0 OR AGENT ~~.A'c~-~- R aco l ES( bTFIT'C. Mv~t~~ 7aA)n~ Aau u ,~ ~ ~ ~, J l ~ 1 1 I :i ,.~ a wi o+N•ci v.H NO D E E DI 1 - ,C..H..,,AR~~AA/GWWE..,,~~ CHARGE 1 E~o.wcµ MSAG[ MU I3 S7omE IIY:D':U~... FO RL441Cn~1 IZO..C Y~IOWED AWAY MWNID tSf.lOAAVEE 1 IOieireie, y . ~~ ~ ..:~,. ....0 ;/•a .. ~ ~• w. le .. )~ y ~y, r) "^ OESCRIPTIONOFCOLLISION IUSESU>PllMENiAISwUIrH[cess,arl ~5 • 4[In NtCESSM e a ~n ~, ~ _, ~~~ l LA.T~s ?Qws.1~ _.. sIg U~1~- i~~,<J•, ut,LE~I~ I)s~+m ~ ~~ -• ~ ~ l LcrT T2.oq~wy~. ~ S~6 S/~o _ I " C.P_ I Z C u l E.trLT' Fo.c itr c ~ pct S/~ ~G ~ '~, ' ,. ~ ! :._ _ C~Uc. EI"AT~sp ~r~-[.~gg~ro4_ [s-Liv a _.~ LE4u~ Q~i~j._ „ ~) '~; ` ~ r ~ Cu I ErcEr ~ ~~}~ o ~qa(.. /115u ~~, 20 _ .. _ ~ d P~ Del ~ ~ ~C)S/tc ~L r I ~¢r ~sE.ay . 2 ~~L:. LE7>0.~ o LLB PMe.kc,LO%t;,l q ga~i.P;n,,,"!o Ie~~ P, ~' NAME, ADDRE5581NJURIES OF PERSONS INVOLVED + 1~;~.{~ -- ~' OCCUPANTS/WITNESSES Euuswn[MENrMSwn _CODES_ 1 - 2 J 4 5 6 ) ~, ( ~[ Iq A!lpiroNµ NAVIS, f[% AG! iAN IH Nn -IMY MSrR E11R ur<Y: ~! & H w~uR or a AVJVED r4 AMa'^ rolcr ^~I • ^R« P.2:,>r. 'I'~ c ~. tY. ;~ Anoerss _. __ y A.w. ~~I, ~~ r., ~_., L,,, _ ~ ,_ ,.. ... ,._,:.Y,.. NAME ^ o .. ^ ^ r;~ ^ ~.N,p '° . , , r ~ dl~j~~y~ d~ E y,. 1 •?i ~ F t , 4 1~ %wJ ~ OOaI[S N IUa OI NII ^AAI! ' ''l 7.~ sm t arurs al,HR uoua AcfNC Jwfs-, - ^~^ ^ ^G'« ^ .'„ os rcwD paKE nwo n [ 1 AIMONDa wn s. I -0d Y , E'"r j~~14. Ti~.1,` ,)E~ .r r . ~-:, r ~i:r~~~ L y a: ~ i ~ wir. LI +~. ~`- - 'Y.L_ p)E ~ xl C,r,~h "..4 `)_A 1~} R ~ I 7d 1 L` R~. s +S ~ 4rrlyn ~ J'P ~ [ 1 ~ - - ~ ~ I I '^a . I '.. q 1 l4 ( _~I ;,1 f :.~. Itr a u ~ I I F ~~~ Tx~ ~ 'd t I r o ' a , tl e ] 1 r~~.vr~ ~ r~M;' r ~ 7 Tr,;:r~ P-b~ ~ - L\~Y/ INU I UH V6111CLE CULLI5IUN REPORT F ' '~ I ,,,roArLOrcyaaFw xc oaa NU. u n^7 a MON UFSw oux xuriV"^Ay FWNrv - COUNTY!10. CTYND. , ~~.. ^CJ ^[ ^INeO nrYan rowN x aP Sr x 2 C' ~ ~P' i Dcc~w~o' I N. E ^sr ^w '^aF • ON ~sY-DU.a(!<t~h~T/~r f[TC0 .'~ t_ L, ~~ ~ , D W Lf n 9.5r~o "`~ x~P-..~ sr~~ro I'] urosT. ... I: ~4[x][~iIDN $ W E x0 A 3„F r1[r OW ~~ ^ I rfn C xfiEx[n -~ I `A" .A B y . ' ~ ~ OBJECT bTflUCK ^ ufcrs^sn B q aAa vE UA^ AEs P S ~ I DWNEfl OF OBJELTb NAME ANO pDPESS [~/,E~J slx[lr Ox AOAO Y `..... .. ...._..r.>.. _ NCT cO0[usF /7/SD ~Y} ~ %'LS r xF, _ . ' $ ; ~~ _.: `~ DPIYEfl3 LAST NAME:: ...._:..... ,,,._;[.,FIXbi NAME .,,., ~.... .,,'~: MIDDLE : ns OflIVEgbLAST. NAME, .~.............. FIP$T,NAME ',: .~.. ~ 'YK ~J t B I .: , ~. ~ ~ ~ ~ / (cv ~ 1 ~ .. ....,.......M DOLE I~ wen[ nn '"~~ - ~ J_~ .:,a,. fTHE T.ADDfl •. C. ,L'„gOVTEry0.µp80%NO~ uoxFTHANarwo {~A~r")5` .Ex~nfwExE c/CE P,CNL'.L_ p ~O 3 /~ . .. M,q,x[DE PEA Aoo E _.. ~ Au .AND .: IE D .. C < C ~a-~.. N BOX MO. ' LITY.. .... -... bTATE ... IP.LODE. ORIVEgb OCCUPATION. EA ~ , U J c L/ t ~i } J A 3 /J ;l rF'.~ LNs ~ I~ . - OflIVEX'b LIC N$E NO - : STATE .SE%. ,. DATEOF BIfliN., ;AGE, ~ I LM L ~T~F L' DPIV~C~ P+TIONw ..., ~TiJp, '~ ~ o v vn ~~ DPIVEflSLICEkbE NO __, -,;,~. E 6EXI<.~. aAFTIE•o^, BlflT p:''~sll_~IYY//AGE.. ~q';.•WM'~~ r ~' y ~ Z...Z /a ~ .w ~ 4-1 E C -5-- ~=, 3cc-Rt1^/~7YY-P'L/ (~,4 k Y /' ;~ _ ICLE YR. ,.MAKE ICNEV:pODGEI.. MODEL INDVP~DAflT .: ,,B OY STYLE 130X.1 VEHICLE Yq, MAKE CHEV.OODGEI. ..MODEL INDYA-0Afl .BODY rLE Il Ofl „ LI LA N .STATE :...` iflAILEfl PLATE NO... ~ K ~ 6S ~ nNr J /Z7~ - ~,[f~v. '~ ~ IF.A . ._: ETgTE.. - uCENBE PLAT NO.. ,bTATE.. ,: TRAILERPLATEND _:.:.bTATE~.~... ~/ '> 7'1..5 ~5 ~J i~jh h 1~ ~: ~G ~ VEHICLE IDENTIFICATIDN ND.. ., ~ TEo'Aa., C L/l ... ' ~ ~ ~ ~~ -~'~ ~~~~ ~~•"""'" -~" ~ VEHICLE IDENTIFICATION NO.. .. ~. ....:.. ,:..:.. i ~fr ~~ ~~ ~~ i~ ', flEGIBTEfl ED DANER ILAST~fIflBTAIIDDLE NAMfI .,: ,.'...... ~ ~ ~ ~_ '!~ I ;,. ~ ".~ ,~' _. ~ ~a ' :. DflIVEfl$LICEN ND, __ flEGI$TEREOOWNEfl ILABTFIq$TAIIDOLE NAMEI VEflSLIG , ' I. L ~. /~ ~ .. OR ENSE NO. OWNEfl3 ADDflE$$15TflE T.CITY Df ATEI :n ' ° ~ [ L ^' ' IMF ~ .. DATE pF BIgiN OWNEfl'b AOD ESS.,... ... ' ry/'1 s ~`~ rh I/J\ v (STflFET.CITY AN05TATE .: W ., pATEO B qTN ~, Yx. ~ rt . ' ~~.JJ: PAflib OF VEHICLE DAMAGED , ~ ~ ~~ i r ~- - '~rPPNN ~ '.' ,. ~' •_.; ~.', .... nn „ PA TS OF VEHICLE OAM GED ~ v +- ./I/U' .N ~ ... _ ._ ..... 5 - :: _. s I, nl a „I 1 t~ LIABILITY INSURANCE INFORMATIONNEHICLE NO t- wns rHEREAUrouoB¢E UABIUTY wsugpwcE ~ [(~~~111 ~jr ~JE~ COVEflAGE IN EFFECT FOq THIS ACCIDENT ON YOIIfl CAfl IgJ YES ^NO ~ 3'4 `_ '~,.. ~ NAM"EE NOADpPE55OF LIABILITY IN$UgANCEPOLICYHOLOEq _ ADOx[ .... 1 ~ -"ITV srxiE ~~~ t P - NAME OF LIABILITY IN$UPANCE COMPANY . , :. \. 17~, JYCI.Xa .T,I I,raN '~C ~I LJu.~ BILITY POLI .. ' ~. NAM AND AD X 0 LIABILITY IN UflANCE gGENT Ya ~'N a "r / .T~ // ~J ~~pf ]] ~ Ir~f. ' ,.L C V~ LJ.-v ' ~ ... P, T A ... lir LIP ~ CY NUMBEfl _.. .. ..... .... `-3,S ~j ' :i. .. ...... ... ~: .,. ,.:, AGE ]NOI UflV~ N AiE f I~'. _ An ADD:T, LINNx EII ..- .AGE ]°- ~ '¢. NAME .... F .. 1 TOTAL INJURED NAME p ry U', ~• ADDPE55 6EX. ~~ ~~ ATURE ANO M F AODREbb . ) .// ~ E% ~v~ 'aV ~' DID ENIURIE$ EWIgE ^ ^ / E%TENT OF HJUflIf$ -/i.Q@~v M IFm .~RE Eh, ~r .. J~, EXAMIN1TInN,vavN.~e. vl v~ rl DOCTDRS ~/ ~ _._... _._ _..(~(~l `s. E'J.i,CE. C_I l'tl kl _ ~ IN VfHICLE Oisivinu NtW,M an NDS owi ^ N~ KILLED 7 ^ , ^ 5^rO.~~I 6^Y I lol~Oiic" i',. _m LoTOacvcLE SAFETY: ^NELMErusfo ^NELMfTNDi VGED ~x ...:;:WrHA~~;o~~ ~ ~ ~ ^ on IN VEHICLE o SAE[ NO p I I roY Q;SO ND. _'-~ KILLED 11FVln[ IulxO,l ^"'~ ^ 5^ 6^ Dr~ MOTORCYCLE SAFETY: ^NELMfr u$EO ^NELMET NOT USED Rr.uro.n;rir:n. ~ III- ;__._ __..___...--~_.. _~~________ _ _ -__ VEHICLES POSITIONS BEFORE COLLISION - w00 VlNICI[ ~ 0~, OH STREET UR HIGHWAY NAME DR NO. P~fCrfpNS IxK it lr~xDiNG LSNIIr r F a1 A„f0 txltll OCCYI,ID INVESTIOATEO SY ^ nou,l ~, ^ ^ ^ rll NO rn ^,~ ^Dl Na ru xo eo roi ~i ` '~ pW[,I I o A o o ~ o ^ ir1`~'90vNIr1. ^ ^ ~^ ^~a[f PIPII1NAx ^ ^ ^ ^ ALOND f Ofl ^ ^ o ^WIMII o ^ ^ PEDESTRIAN/PEDAL CYCLIST WAS USING' F ^ Ho ] ^ .A ^ ~aoulND v l I^ IDr A A a w ~ Fqou ~ ~ TD E I^ Cn oHw ii F^ OMIR I^ is t ^,DA PEDCSTRIAN/PEDAL CYCLIST CLOTHING COLOR: 4^ D. E ^ [ IGr IFI""~'o ROAD WAl ACS ,:..Ifn MII Wf ANIlR LIGHS CONDITIDMS ] ^ N RAIf1C L "l l n ^ , I,O Af I[ Cr F ^ MiOii iil~Hl~ vi AwAnM, fC vlwAYl I ^DAYLIGI T ' l[, ~ K i Fx ' 11 1Yrl OP flOAO v • DRIVERN[HCLE ACTIDNS 1 DRY ^ ^I C I S~/ FyA! ~F ~J"p~~n i ^ DAwN I-1 )QRAINIMD ] ~~UfE ^ 1 ~^ LIGNALS ^ 1 ^3for flGN K r "D ~ FKF s O~"nili F ^ ^ ONt WRY ppII vi Kl KNl<, Dxf a, MDnll p,F Iq 1A]D~/ yal. 1 7}L GOIND fTRAIUIi RII[RO 1 WIT ^ 1 ^YIOW 1^tMOWINO 1 ^D A STRtIt ~ ~ ^ 1 ^YI[lO SIGN 1 F~}I W' kAl 1WO WAY ^ ] ^ 0i0RNlLI R ^ ] /^ bVfgTAKINO AND PALSINO ^L^ICl %f ffT ,^/0G 1 O ^LIOrNt OIr ^ E ^ILASNINO A[D 1 i IHTf RCHANOt ^ ] ^ MARINO RIGHT TUflN $^OTH[R t^DARXMO 1 ^ ^ ILOOPIRAMrI E MARINO LI/T TURN ^ ^ earl ..._r~~][„. '~:~ W "'t' 1 .%l I V %lQ ; u.at 3' ' -{ E 0! 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OOUNTY -.. ., CITY TOWN FqP t .MILES ::Oa : ,;,,J., GTY.70WW, p L ~ Pfi[F% ~ leflew,c SLCIIpN g "` n/ l -,., /-7 ©® % ' X5/70 .- WW OF '-r ~~ l ~~ ENAMEpF91flEET.flOAD Ofl MOHWAY:~:) _WTEPSECTWQ WITH: SiflEET Ofl.fl0A0 / PHEFI% [0 uLEP057 ' OcCwiiEO ~':. .~/~/.~.. •.: I/ /~-7 /sir / /li..r~/ ~% .S Il. ~_. _~ ~~'7 - NONwTER3ECTION LOCATN)NOF COL//USIpN L / /, // IWAp.., pA0f1AlA WiA I OETWEEN /K~S-.'.C J~ /C!!.-~~ C.•ir .~r rGY ~1JTr''7C CC C ' bTfl~ECt ANO / STREET ~- rOt P El NWNw/.v NCUSE NUNtlEP.aMODE ®© PALno.e CiWSSivo unevosronUDfr FrwO UNwJNIN If{iFJI u1rEP cLS '/ ~' ~~v NfEN3ECTX)N: FFET ©® OF ^ 1 ~/,T l~%_E COWEYkJ WVCLVED ^VENCIE VENC[E ^VEn <LE &CYCLE 7 „rj } O ^0 IwarEl SPEC CODE U9E T ^ f ,CIE t wl r i ~ ~ . ~ HiC E9 ~ ~ ^ MCLE961FCi - , ~ -: ' ^ NKAE EOETNAN ^NON<p 9 ^ t N 1 1' ~ , )1 .'_, ~: ~ Y - OBJECT biRUON __ { FpP,OaIECTSTHUCFI /1 OWNEROFRp1ECTSNAMEANOAODflE59 LOCATION ~ /.. ~'s'!J ) /~-.~ C. ~% - ~) ~ /f~... ~L~I~JNfiOADWAY J ^N© t0„EP fa: C ~, FEET EDGE p F~ DR/IVE}RS LAST NAM¢~:„..._, :,-,. ,fU19TNAME__~.' ...MIDOI.E. - rvuo 0 piWEflg LAST NNAE - ...FWST.NAME ...:.E:: vu.3.M10GE _ 14.' ~• `~jl * "~i17,' .#'li G~ay~' !7': /,: )..'Ji/ i L L!t'/r f'r:!C'!: /C`// ~r CausaN OP /7.~ri i~_'/ /I/ °i Ji: /~ ..l ..F~~ '/ r.r 8 C is Tfl k7 ADDflE({.9 - ..ROUT! NO.ANO BP9 N0.._. Aq E AN Two 97REETADORE99 ~ ~ .Y J +L ' ' :.-i.90.4IEL1Q NIDBO%qP ... .,F.'r ;~ .. lAa0N9 NF a ti ~ -~' „ CTY .. :.gLhiE ~ 21P GDPE, PRIVEPSO~G'C-VPAnON E '...iS hT n - RE'. PRIV oROUpnTION -. ~. ~ ~~ / /7r / v l~ a /3 ~~7 ~~l/ / r EPDPr 0//''%^'n7l L V . _ _ -EHS.. - _. _... ~ ~~ -_ ORIVER9 LIOENSE NRMBE...-.:. -... STATE. BE%, _, GATE OF&Rjlt;+, AOE ~~ F M0, Dfr tf~9 0(iIYERb UCENSENUMB R / „,,.,,,,.;. STATE:.[6E% ~~ TE,OF.BIfl?H ~ AOE,. : /f.F. ' / (:'`~'^-i~ / ~ %'t N /f' /'J D/~ J 1 ', l'J ~ ~ ~ . F ar rF.w ',"f - ~ ~ VEHICLE Yfl., MA%EICHEY.:D000FI - MODEL INOVNDARTI _.. BOpYSTYLEI2 CRI.. ~ VEHICLE YP. MN(E ICHEV;OODGEI. MO ~~ ~.DN1n-:_ DOOY STYLEI2 OR~•G .o, ,. ' - r r'/`- /e / C - $ } - _ N IICEN3E PLATE NO ;. MATE ,, ,. TfluIERPLATEN, ~ ;.STATE flNLER PATEN T e /~ ~/ -: LICENSEPUTE NO. '. gTATE .:_ .T O -;_-3 ATE ,:.. ~. T~! .~U ~~~~.~ - {rxa ~ '~ II96B MOOEL9I NEWEflI OOOME7ER (MILEAGE EHN)LEIOENNFICA7pNN0 .0868 MODELb9 NEWERI.. OPMETER IMILEAOEI ` '' VEHICLE IDENTIFICATION ND -• ,-__ IFY-.~C•L" C> / ' ; ~E... , ~ :.' A REO u ~ Y}T`A;'~ FIEGISTEREOOWHER.,.,,,,,u I~LAV9T'FN1S['MIppLEjlMlE1 PMVEP.SfjUPENSE NO..- _ IS EREDOWNEH. ILtST: IR3T Ml0[ILEN_AMEI- :. ~,..:::DNVFAg UCENSENO._x„:;... ~~ - ~}~ ~ ;- (9TFIEE`T OR. ANDS rE.w ". OWNEASAOPiiF:g3 ~ , ;.-, TATEI.'..:-.,.i, ~ OATEOFSIRTH..; OWNERS ADDREg9, ,..,;(91IIEE7, C1[Y-ANPiST(1TF1:,~~::.:..,:. ~WJTEOF &RTN; . '.,~ Py]T~SOF VEKIC~E DAMAGED.: .:..1 _. \ iiP.AA wT,~, PARTS OF VEHICLE PAMAOEO...,.,.1 .,., a„^,,, ,,~; :.. :.~ j..:. _ ~ T o E ~ _ 7~'' '/'J// rh::' °•• ._r/-.-rY i~ ~d'c/s ~ ~ Sro PFPUPyEI~ICLE_ Y ~_ A {h LIABIUTYINSURANCEINFORMATIONNEHICLE N0.1• was THERE AUroMDBLEUaelunwguRAWCE < ~ k p COVEPAGEINEFFECi FOR THIS ACGOENT ON WUR CAR ~) YE$ ^NO f er 3: ~, ,•~t a. NEE NIO ADGIE55OFUAWLRY WSUflANCEPO ~Y EEiO~pER '': ~.,,_. L ,.I NAMEOFUA8IUTYI V~ / ~ .,~. ~PT '.. ~"'_~ NN.EEANDADG1E990FUAWOTY WSURANCE AGENT .. ~ -, ... P?Y : 9rATE xP ..: A&UIYPOUCY NUMBER - -:'.._~- ~~ >t 9i NJURY ~ .T '/ ~/ ~' ./ ,~ ~~Y ... .:.. _.. .. -, .- ._...-. ~..:. AOE 2NDINJURY. NaE9EPAM EP[PDPTFOII ADp IDnIAI 9. TM . / ~ ... ... ... _. t¢ yq[``, ~~N NAME.+~i<:J-,~.-F/rl~Ff'r .('!~-/~.._ /"-Sp~wJUD P[0 NM1E .. .,-..,.... ... .. y7~+a~i'~._ : ',VT9 ~' ~ ~ ApDR`„S /L._~ ~ E _ r ~ ;-/-'_.1./ .~-1 ~ 1 Q A ACDRE99 _~ _ __ ___ SE% A'~~' Jv~~.:' ,if79 {yam Q M ~ E - -~ M . ~~``.. ~ !ION OrADDCtOPf ® 1. gPtlvAOGC ®© ~ `~~ ,{L' = a ' &i.ATU30F WJUTIED ~,. MAR%FWST ONE THATAPPLIEb, STATU90FINJUREO. MMNFlRSTONF TIIAT APPLIES 5511 _ ^ OmvE W VENICIE C r .. ~ . ~ ~ . - ~' QI NafA ~ IDILED IaEKPFI pv ~AwuA] ID E ~ wVEH CLE 0 095WE ~~~~ ^PEOESiWAN FIC IIT ^pE F9 NO WllEO ISFV[PEI IMwpll IIO P wE~Glt ~ L ~ I FPAw ^ ..,, .. n„.. ^ 5^ 8 7(':1 Iq,~ L Sr10WNORfN BY ARROW WCUiCLE \ O W pE3CPI0E BELOW WHATO PENED' REFER TO VENIClE90^Y NUMOERI. 7~^' t g . - '? ~ m.c[iNE anwE INATnnTnm~ ~ -..L - -- /.-J c [~r / G.-Si ~ ~.// "~] I ro°M ,5°"mlm. 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OIRECTIONO TO, OIREC'fION 1' F f PCD[9TRIAN WA91A1N0 1 ^ &OCWNR 2 ^ WKNWAY, .. ] ^ EJIOULDER A ~ ut I :-A-^yp ^ i e ^ ~IVUpy OA 6 O1HER _ I F fgApbUI1PACE, -}VEAINER UGHTCONDTIG19 TR.Yf)000HfRO[. KIaCr WU. TYPE Of ROADwµP GtlVER/VENICIfi (LC]gNB Plyll T .y~ „~~`f sD„!1 ~ v[r+ttt VUM:It 'ICrve~F M[ VUatlx ICI,[CMON[CPUDn[I ~' 11 't M I W [ REO,Mm FA.. 1 //~~I1 OAYINI} p I 'b [ ~ NO > la f J ~'~ ^) ^DRY [^C ACYI I.Ti ^ 1 ^~ 49 ^II ^DNE WAY I~11 PDINP STRNOHT AHEAD b t '~- ll'-, 1 •,+~ I ~'RAOMP 2 ^ DAWN ^ 2 ^ 610P SqN ^ 2 ~ iW0 WAY ^ 2 ~ OVERTA%Vq AND PA.491N0 I :L 1 1+ ^ t m Wti ] ^ g1ANtN0 ] ^ OU9% ^ ] ^ YIflO SIDE[ ^ ] ^ ~~ bOLF ^ ] ^ MANWO RgNT TURN a'I ~ ' rt': ~ ^ ; 'TAW E ^ F00 A ^ ~gN19 TON [T ^ E ^ M6nw0 RED ^ A ^ WT[RCHANOE ^ A ^ MAIEINO IEFi TURN 1 I I- ~,''T ^ ^ OTHER 6 ^ ~ICIRI e ^ CpHT/ OIf T ^ ! fLA9Htlq AMPCR a ILOOPARAMPI ,' I ^ ^ ^ ALLEY ^ e ^ MANWO U~TURN ''r ~ O e ^ 9[eeuY ! ^^ eDT"'ileef LaNrb ^ e ^ RR MONAI e ~ w.Y. P~ ~Y,~` '. (', REATONIORMOT9E(h00N10lA ^ ^llRTURN L1J e ^ 9LOW)ND ~ ~~rr F OTNCA LN1Ie 1 6E1~"a AYI%EttOVISRYI OV[TAUCNOVa IICI EPEGR ~~~"` I i ~ ^^ 7 ^ oFfKIRrILAOMAN 1 ^ Of E0. 9PCCM'Y ^ 1 ^ 6[PMAICD 1 bNOCO ^ / ^ Bi01'Plp fOR TRAIfq ^ e ^ OR tPI0P Nd1~~ ~ o ^ CEOPPEONFaAO t ,- ~ '{~/' ~+ '~ " ^Ji '•~ L t ~": " ~ I ~, WAY ~y-~p~u~ y " ; ;" ` ' o .~.. ,D 1 Po IJH~ %y.I FlJ /' a. ' _ V ' F"PP* .n III ~}I 1 -~ f " - •~ he' STN 1 ~ OF WASHIh1GTON ~ Gf ! aP ! ~ '•~! ` POLICE TRAFFIC COLLISION REPORT ©TRAfFICWAY No. ~~~ r o ^ PRIVATE WAY POVCE COMPWNI NUMREq ~ ~ !~ a'F . ~ .~ al. u ,I ~/. 07 oar ( nmf 'IN. lul (USFt(W NOURI I caunrr 3tl COUNfYNO. Derr Na. k ~ ^fl ~ ^F ^IN CiY OR TOWN FHWA .~ ~/ NgM[6 NO Oi5iRFfiOR HGHWAY MILES QS ®Or C Ey1 RURAL ROU[F OR 1 ,.,l •i1 FIC ~ .II ON C. ~. 41fR5ECi NG M11H. SEF O qp R NON INiFR5EC110N / ~ ~ /` F7~ 9a~ ~. _ I/ (t li'i : i S l /~~fl BfIWEFN tt PRfiq E Mllf POST _N C SIANCE{DR MIIF i NRffRE ,CROSS SfRfFi Oq NfARESiMIIE 51 SiRFfi{ SLRFfi ~.~I .S /~ ifft S f W _ )u151ON1 OE i7 ~'//<a ,(~J NVOIVFD 'a:A' A` ' ` [) ACCIDENT RAm MILEAGE - CODE DIAGRAM W q Y ~G S' . R IY: tOigl NO O. %IIIEO~NO.INIUR[D? ^Sp IUGE ^ OF VFII ClF1 O ^ PROPERLY DAMAGi ONLY q 64 NRHRIH O ~ W I I NI[4 '4D Cl1 I E SEgEE OR gOADOR EREN h CROSS S[N[Eln ry~ t , ~~ry f~ '~4' ^ [SVIiFa /E[tSIRUC%(NAMEOf OB1fRSIRUCK M'DOWNFR'S NAME) l fSi. DAMAGE SPfC4( / CODING USE o 40A0 ~//q/~~'^O ..._.. ,-- -/ J~-~ ~tus,~' ~t1 . " UNIT NO.1 S - - ~ I ~ Y VERSNA.ME usr IRS ,D UN¢ITN0:2 oR •S N. ^ VEHICLE ^ PEDESTRIAN ,~ ^ PEDALCYCLIST b a ~ I l- IZ L / TN _ mE: si - ,gip SIP (DOE PHONf NO. D IIY IP' Tic~.os[= i) alq `l.P3L,Y 3d5='7.)4'7 R RSYCFNSE NO. SlglE f% DDA BIRfN M I pA i y I N LICENSE NO. PAIION {IqM NNAf6PNONE NO. EYES ~~ IGHi HIGHL E OCCUPgtION rlq ./ E H I C. 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STATE OF WASFiORlGTON pAGE F ~ WSR j y91REV. ` O G 1~' No. POLICE TRAFFIC COLLISION REPORT TRAFFICWAY ® Follcf[omnuNr NUmsEa - DArf OFC 1 PRIVATE WAY l • 0 v ON IIMf CWNrv W4 ,IDr ul •IR Iw° ... (US(]b]HOU4) COUNTY NO. CNY NO. i . ~ 2 ~ .~ r pN - ®F pIN CITY O4 rOWN NAME `GN 6NO Of 5r9 El ~w MMA pu9suF ORAL "'r ` . F OR wGnv}AY 7X' ~2MUfs ps pw ®op D OC' ON INI(eXC11NG Vern; SrRCft OR ROAD Kr [E5 9W1f 04 f /~ l/F~ 270 SE 1 ' ~ NpNINtERXC110N n ] pFM'FfN /~ ~ SIRFF/ { ' UIS AN 6D14 'CYOSSSrvfEi RNfr5Rf5rMllF pOSr RYES ~~ SiRFEi EN K p E MILL pOSi . ~ZJ- ~ E M4f5 p ACCIOENi RAM oIAGRAM DAfA n~ FVIf Of , N ~' M E -. ~~ - COLLISION NvOI fD: SEVf9 rv: , ;E TOI.SINp NO KILLFD~~NO.INNRtD~~~ ^ SpIULE Oi VEN ClES ~ ~ pgpp(gry DAMAGFONLY EIR CODE p i4RON wMi.'ogorn ~WE IN I iF4 CIS I CA06551a[RORROAOR - OIE nCt =1 ^ SUIrFD u 1 eA OBIKiSrROCK (NAMEOF OS1ER SnuCK AND OWNERS NAMEI ~ [St.DAMAGE SFECUL / CODINGLRE SG ~ __ S ^yF y ` b .. .:' r I .. r ~ 1~ NAwE~ usr UNIT NO. (NRSr mr ti~ UNIT NO.7 p VEHICLE p PEDESTRIAN p ~AECYCLISt ,35 ~ , i .• Dv vE45NAMF• y yr I ~ ~~~. Slxtsl4pO4t55 9TE Dafss ( ~- .... ~`i:: s V. dd~ t ' n ~ ~ ^ O ~U ~ SfA E D. ~y YS OF pnONE NO IIY SrgrE Y / ' R I ~~ ~ t, .- 09NtR S 4CENXN ^ 2 ~~ SIAM Ex n ~ D I V v u Ns AlE Y I ~ t s 4F' R' acupwnoN nam NAmeaPR)NE NO. ~~ Erfs Icnr HEg Ni E occupnnoN f NAME 6 pFK)NE NO. EYfS i KR I I ~ ~ ,' ~, EAc ~ F KKMi N 1 $ ^ CHECK(/( fn CiEA Aw rM YY fOFANDMFe~ Y CODES -~ ~ ~ .I i s e ado ox.< ' ii' V vin ucla. u p CHECK (~ ~ CODES - AL `IF ASAN FMROVfE OFANO `wn _ y~~ ,.~"~ _ .~. P ` Z N p 7 a ui inw N ~ s 5 6 ~ I cY f swN J fib' i ~,~j ,. ~n':°r ~~ Wil: rpDm euANCe nvA.e DI ~ O paaG fl^ V(N vtA4 M OIDOOGf.Cn(V DA4r pA O 9 O IM~+'p Q ivn ~O [BSrtK p k ^ j~j ~ ~xl. . j VAJ tYLL I]D DNV I ID E. n vd MoDEI AR . A) T r{v a. .~ ~ ~ l~' '. F ~ , "" n.c ~ Yn p ~ uce u surf MLLI MrE NO. sArf H n. a a " -~ 1~ N VfnKIF IDFNIII ' P~,Y -12 W I C - ~ ~ ~ ' G/ AN NO. S, / ~~.: ! r r L vln CIE IUFNI FI AO N I . I .. ._., I ). YFGrSRYE~D-OWNfR LKSI RS DIXE p110Nt NO. IS pOWNtR lASI FIRS! . ~ /L1~ O~/~ u _ F r111333~,,, ~ v ~ ~f P i'~f I' ADD9e5s of N { NER ::~ G ° r ( ~ ~ umeaADDefsSalNweANCt co o9 AGEN1 E a R , ~ ~ . ~ R " ~ ~ ~ - , .,ly., AMKd AR[w : ~ ' ~ ,( I ,, '''{ v - vTDp S I>IIOTTO~ oi~Iie u CHARGE ~ E51. OSMAGF iW^Y ^ ~9fMNyFp .~.__ . . r , CHARGE ~ n0~ n09NLN I-lR[AWNFn ESL. pAMAGf ~ ..; S ARG ` fv , L aI . ... ~~ ~~1 ~o ,. -.. NfCESSAR 1 vYA RDW 1 ~ 1 ~ I ,~ I .. .'. ....!. f ~.. Co4vr,Y. RD, , ~ ~ - - - - ._ 4~J~: IR K ~ . _. NAME, AODRF.5581NJURIESOFPERSONS~ OCCUPANTS /WITNESSES EDX sup e!nEmAI sN Df~ " A; zm~ 'k .a ~~^d.. ~'. AtK, ,I/~kl....~ ~ .. CAST' ...CANTR'OL.. ON rG4.._ AND .WrclvT..OFF TN&..fdOf;(pWRY ..._ ..- 8rfai:.ks.NG- aN ,EMBANk~wN.r, =.1 ~ p~» ar~Ev _ G 1 - 2 w ~ S y TU~ 7 ErVS IN vt31R LEER Drc: r I Ame ^ f2L" p ""' ^ ~ p CuNI. ~ ~~ ~~ •~ v~EiGj(e ~'" E . . '. ''.~ •r '. L~ Ic pti<S . - ~ ~o, 5~ ,1~ ~~t _ ~ ~ :. I ". •] . ;r. .V,y~ ~( ',. A ~~. ~~~ POLICE TRAFFIC COLLISION REPORT ~TRAFFICWAY fOfICECOMRAIHr NUmazR ' PRIVATE WAY I D+r of au aN D [ c ,.- nmE couNlr `I (USF]9W NOU4) ~ Cti $¢ vR '" 7l jCv6~ACSuJ••~ cauNrr ro. cRr ta. NwA // OUR W U9AE - ON []vE ^IN OrY09iOwN 4nk6NO.Of 5I9fEE09NGnWAY ,3 AVEES •QS o Qo, rccK orv C:...d• iCIClS I 40UIt ORS 5ft1 -> r1~Z7G ZR IN F95ECIWG VA1M 5r r0 ROAD NONIMifRSFCiION BEIwRfN SiRffr 6 ~ staff! pNEflx FO. RE~PO]! / ./ ML'37 ~4P~Jr ~ ~~ ' C 6019 1 f .CROSS 5reEf RNfA9E5f MIlEW ACCIDENT Mttfz f N re SR F W 7 ~n~' ~({ -0 MILEAGE ~ R P DIAGR+M MIA _ ~ lFGi 01 P • R I ~ 6S ~~ CODE COEEISIONINVIXVfO: E N•~ RUN IN1URfD~ ^ SfRUGE NIl6 O Kll[D NO Mnlr N IUHDalDm IN INFE9 QS 090IE E R pg ~ R ~ . OlAI NO. [[ CF VEXKlfS ~ ^ p90RatY DAMAGEONIY ^ 9ESUlRO ^ VfaCIE EETOR OAD C6 ]S S939O _ C OBItCTZIgUCK INAMf Of OBffCl SIRUCR ANDOWNfR'S NNAf) f5t.0AMAGf SpKE4 CODING US! U .S S UNIT NO.1• ~' ' UNIT N0.2 ^ VEHICLE ~ PEDESTRIAN ~ ^ PEDAICVCUST ~~ S wV'NAE`: VESr flg5r IDDIE DCwFR ~ rvf9"zNNAE: U15i 1 M R~ Sfc7fE1 ADDRt ~~ ~L H O ~ • SrREEr AOD9t5S < Y SrAEE ZIPCOOE PHONE NO. D I StAIF Ip , R r ~ I-. R 091VfR5 UC N5E Si E EX I IV U N NO. 5 AEF DA BIR q OCCUPATION N9M NAMf6RN)Nf NO [YES IGNi ItgNT E occwwnoN iRM NINE6 PNONE NO ETEZ wElfir HEMiNi Z U 5 ) R ^ C ECK (.~ WH nFASANlMROrFEawrvorNfRUE (]CHECK (In rEHKiE ASAN UARO"rff ofAfrorHa CODES - T D tW] . s s E e ,"'0,,,r • CODES - ~ 2 ~ < ,', 5 en 6 "" ", 2 wnmlfz Lr . a s Nt,r R t}~w4f.D p +NNA+NC[ ^ GR VtN YEw4 N E(DODGf{NEV ) Y" ^ ~S.RR °i ^ C° :,s. w IDARr~r OVAE SiYkf CW V Z OR eg` ^ AmN]ANCk ^ u ' nVV f R~ m [ r OA9" ^ ~S.r[. ^ r°`f f D': NN ° y R~ ' I~ . 75 d~ N • a f E /u E AR N I NEV.1 N NgOEI (OARr~NOVA ,) ~]. q r R Ol KE SIAFE RUIRR RAif tq. Slwif I'i N A vEn.CIX R AE [ A OQ.~oe 599 y G/J9 • ' C - Lyi V[lI1REICfMIPICAigNNO. ~ 5~ Z Q, 'L. ~ L ofH GEf DFNtf r N ~ I i I i ~ I ; I ~ u x RtGISRRtOOYMfR: Lvzr NRS! MIOOIF PIgNENO. O 4 i a DOWN[R: LASr IIRSr MIDDtf N E~ ADDwSSaowne4 N fowneR ~rl `J E E]ADDR! plNwaAKtCO Ot AGtNr S- Yn •L rLtJ R N Nun N • r ~ A.e 1 pvKnW " CnA4u ~~ •. " CNARGE rpwC'icroiN 0 r I ~ANAUDI,ew ~ . ] e E]r. WMGI~ 6 ^AWwY ^RLMNNFD • ^AWAr ^RWAINFD k51 . D AM+Gf i RIOf 'S f rowEOgr~ KRS~.J ~~'QJ - ww ~ roweo eY: Aw+r S .. IA DIAGRAM OF COlLi510N ryl,gyrfwcEssur) I es rF NORrH _. __ ' DESCRIPTION OF COLl1510N• (ust ]uPRfMF r ESH[trRNtcfss ar) ._ -.. _ ... .. _.. _. _ ___ > _ _ o _. _ _._ ~.O/-f 7 v~ P C UEH•!~1_l~as.T/.nvEUU?G w.~><Cess ~Y?..50r]7P{.!__„ • b ... f .5 '~ Il // act+=a LGr=r nrt . RI6H r 5 /oE ov T7iE . ~Co~n . GAFYkF, Slit[. I, \~Orrc ; _ C"~ S~Ciol a~ . TN5 2ana SK/no~a ./,~pF~cX /?c~~• ~hRrtxcy_ » ~ ,_ ... , L . C/,assuu4 .: t16 _. _ ~n rc2 . G/n1E E. ~fiY_.7~rE_ k'cAO_._ _. :__.... 2prc~ .p.... Fa_ ~~ ON_rNE ~f$9r.~io~~.S7.10 _GLr-t_eN.rlie _._. ,„ ,. ~' ;S,(Cros . I ` . Orrcu ~,t RCLLlO Guar- 1C ~irFE_. ra. ~cr[ riu Q-J_-- S . \ . \ . ~ )DE, ,i~ID b~ Sr,1rc--, ib.i! prs .Gy,nr/~.ICrc~--.... LY! Tfv4 /ld. ~y R Di.'K,,,Cc.rU6i,'G Co • ~QJ, 4 ; ,.. , ~ _.. rrNG~t Snrr` r ~: r~ Ne Ev-s6~e.ocfJ „± .^~C , _._. _ ~ NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED 'CO DES t - 2 3 4 6 OCCUPANTS/WITNESSES ~~: ~r[gMitiui}Aa"i ii xx Ace urns'",~" " ., ' 4 euR rxcr °K!r IA~E7"/LG/1'4.U r caTr' _ ~ - .. N " ~~ • / !5 . cans / d 1 Ns ~4 rrne rlr pAMe pFaE O ~ " . ^Cr ^".". Hu q A NAw f rroela .. - - N :o au4ta ._ R A~ oI4oM ~AfnA. ^R:cl ~wH. r. ^ 7; ^ n wo .q Awl . . +o . I.p9lG5 N o.~Df Pk,.,ar DAR. ~~;Rlo~:~. ^~ nti x ,NVs•ro.rwo/ sN+,w •9 f e•Dr ~09 +uNC• rl fR ~tDlsP,slclao puKE~v~~w~O o I~,Efo.r .Pf4ovtonr J ^ 2 4C ' it DAR krts 1 I `; ~ t,~~ A A' ~r'i '~.I :'b bw.. ~r x L Y~ R~ Nsa~ U f~"g n~ P r •5 '+S$~lT~ a U' t~.,~, I~ ~ ~, 4k a' f I r S k - ~. ik v E i'! ~ L .~~j~'Z t~ ~I ~ 7R`I~ ~~, S~7 ~ ~' x~~feT • :' P 8" W ~ l i7~ M I '~,f p }x,4` ~ t.-~ ,V TJI I 1 .) L f ~+ II fr, 5U! lg 9 I '~ ~¢w ~1 .~i l~ 1 ~ '~"~ JH_i~5 ~ t ~ !4 '~1~y} ) 1 f 4, N y k ` ~ f ' )~ ( j I Ir I )•• , ~ t 1rl ~ - ( ,~I ; ~ ~ ~ I ~ ~fI ) e.~ ~<t h T. 1 "kf I ~ ' YYY ~ ~ . 15 ~ ~ 1 ~ ~- .. ~ - {n 1a X ~ E ~~ I . I ~ ~1 I ~` ~ r ~ I ( l y ~: ~I. ~~ :, ~ ti ~' $ ~ M1 v~ u%F }~ ~M1 _ t~ Y ~ ~~ ~~r F 1 ~ _.. i ~; ~ ,~ '. ~~ Q ~~ i ~R11 ~tJr r l 1 ~~ ~^ ~ ~t, ,Y FI I,.A Y - L 1tCr I Y^~I 1 ~ i { 1 „ -:~ r 1 ,. ~ I'~~ MOTOR VEHICLE COLLISION REPOFlT IIM1IEOF CCLUSIO!1 'Y`J CUU IY IlO LL r10 ~ R r ~c • ~: F ~ `UAfEOFCOI LISIiNJ ! YOFGOL .rn Axl ~ ~~ ' L YON AM r sM I rn^nLt D /V'J ^' , ' ~ ~ ~ / ~~ IM • OIP 1 SeGi WE ' COUHfY CITY, TOWN f,ItY TOWN LES ~ ~ I a l • . AOM LLS PROF Y U ~ ~I s~ ~' ~ Wr,1A;, ~~~ o l o . ~ ~ ROAI)ORMIUIIWpy kIfERSFCT OWiH'SinEtT UR NOAO H!li PREF% CO M CPU ~ n : -.~ , , LwVEf U~ ~,~rr (^ p '•~ ~E ~G~~ ^~/~ .-` ~ t 0r11•IIEHSECf tNI LM:Af ill Ot l:JLl1y ON\n •i V G NAMP U GR MOAA • ( // B IQq GTnFEr (,` IL1WlErIsLI~g~~g~~~"AI• S1nEC1 AND l'~,L ,KR .: T u. ~ll ~~ r,4,11D, DR NF NoN xnD II tER iER CLS GUS > ' - r~,.. b T11 a~IDF - ^ o s ' `~~ ~ '.I:M ~ ^v ODII. Iw ulU L_ SPEC LODE UGL- ' /~,~ ". r+' 1.4~ ~ nrl V~r%u ^P11u1N v 4 LUGAi ~±Y~ OIUlCT hTflUON IruvT 51 1 OWNER OFOflIECTSNAMEANDAD011-SS INf10A0/TAY ~~I~ t nFIA"CnJ X d ° ~, cF n FEET $ ~ §~ yJ `• w F n rvN D,r' DRNFIIS LAST NAM! FIiIST NAME AtIDME FIRSi NA1eE MIDDLE UHIVFIR LAST NAME -.f -2~uso~1 Rlc ~o~...M S~6pN~~ V ~«E,~~;o~ ~ ~~ rREET ADUNESS ROUTE NO.ANU DO NU b STREET ADDRESS HOUlE NO. rr:DUO%NO. ~eo?~3~C c~r~ac rJ Ec?~C5~2 Naor~oe '~ P U A c ~ .. ~ ._ . . CITY 6LAlE LIYUDUE Ilfi ERG LN:CIIPAiION l1iY STAtE 21PCODE DRIVERS OCCUPw1:tN ~ N Mr SD flD!.OC~W fJr 9833 S'TUnENT W,rTDNM STAEE SEX OAI..U DIf1iH AGE IHEfI ~ NUI .4* ,j,° y _~ ~ .. . LIIIYFn9lILENJE NI)MHEP TAIF. ..E OATEOF BIRiII~ AG! ORIVENSUCENSE S-VSO W A . I~M1R / r ~_ X10^Lrvl DR M1U ~ Y ..~ e ~ ~ ~ p DUDYSTYLE IR .7 DOUYSTYLE12 DH) VEHICLE TR. MAKEICHEV: COO.EI M1IOVELINOVA~DArlil ~'IEYN rA wEIGrIEV: DOOGEI EAOOLLINOVAUANTI , ~: ~? Vo ~ VAh) t9'zo cN u rc -t,~p STATE TRAILERYLATENU ,.SLATE-, IATE NO STATE L N+E TE NO ,"` ~ ~ ^ . IKCNSf PLw1EN0 STATE - TIIAILEH PLA X Ft ~OZS W ~ OQQ~• 7l/ 1 ~ ~. IE DENIIFICATION NO II9BUMOCELSA NEWERI OIX)M1IETEn IMILEADEI VEHICLE IDENTIFIC4110NN0. ',,: IIDDU MOUELE:6 NEVIEn1 nO AETF.R ,M LEACEI { Sl vr0 L F~ SE 110 REGISTERFOOYMkn ILASTFInSi~MIUDLE NAMEf OItIV1:R'. LICENSE F:O. :.•f FRED OWNER ILtii~FIRSTMIDI%E NAMEI DHI'/E ; ro~.r~~ o~a_N_~ too-~M - ~ N6az>° ~"E use ~1L~B.c{~2. CITV ANO VI 1. ~DAiE~OFDRM ISfHEF T , ISTREEI,CITY ANO STATEf OAtE OF WR OWNERS ADDIIEGS U c~~ ,R Rr t o 36 oNr /~1~ o fir I ` . ~nc -n ~5_~`_Ea t~„. -'- u 0 PMiSOF VF.NICLE OAMAfiED ~". ~ ~ P ~ 'OF VEHICLE D}MAO D rsvu, ° M ~ ~~ ~4 ~ ' `z ~ ' `~ ~ ~ ~T) ~~ ,..~ ~ ' - . .~ ,-rB-i.M - _ 5 oil r u~~~ta_o , ~ ~.- 5 s iotl'' ~~'c _EZ 1 ; l _.._ . WAS I rIERL AUiOMOR LC LIANILIfY LYSURANCE LIABILITY INSURANCEINFORMATION-VEHICLE NO. 1- eov[nnc.E nlrveci FOmrasaccmENr on vouecnR ~YL'S ^NO -- I POLICY NOLCER N0.1E Of UAUIUTV INSUf1ANCE COMYMI~ E550FtlAHIUTY INEVRM1Cf I . AM-AVD AUD I A[ TTY 1'000Y NUAIUlR A`.IEAlIDMOr1E550F LIARLLILY INSUNANC.F MiENT 51, R. ! U S~~1~Lat_i Z~a1N ~`_86TE1F1~. _I~ _g~?2EL- o0~=380 -~O Pot~ AO E . ISf I•:NI.W AOE FNUINJUIIY: Il SE.fnAR,t (% DMO I r14M1 NAM1E ... _.. J$~{ij' SE% AON! S SE% AOORL .. ___ ._. M f Ikl 1 L~ U ry ~ _ I.°µ ~~ rl.u- J RFD KFIRST WlU i11AT Ai YI ES F P ' i ~r, SIATUS O I .S A U OF WJUHFD M F TCHYI T PL I VE ICE ~ Inl n (]~ tI VEr DLE 1c NUN~L„11u R I 1 _ ~ ~ KLIER IuvrnMl M'~ T.R.n ~1M rA ~ KILLED I'vCIILI IMwCin 1 ~ ~ a t~ i + ~o 1 ~ ...,., ^ 5^ e^ ~a o ~ ^ J^ ~o - ~ ~ ~ _ ;'wgWTAlf LYMIK)WI CHCLi \ DCSCNRE UELOW WIIAI NAPPENEO.IIIEFFFI TO VErIICLES UY UMHERI L 4Lr,u1 ~ ,` ~ ! CAS. -~ba. SputJ ou, ohs lGE r ~ p~lJ6_uP cRo SCcJls~ tN~~~- -- al r.D i .K Ao. CAR-_~6 t CW rn.E ARowntD--, ~ Go Tv WAS ct-JAB~ ~ ~ \ ' u ".~ p 1~l~ ,YDA ~ _. _ _ . .. ~ R LrD„ C ~ VI :ApACII'`i0. Du.E..'z'O `C'b1 CG1~, tCE -•C7 Da- ~ / 3 , _ \ _ .. _. - _.Gf32 d~ 1 S'~1..0, !NZ'O eA2 b6.~. ,cv~(ccN_WAS .~~-o~GCIN~. RA~1Q _ D ' , ~.. __..V , _ _ ._. __ . __.pN. CAR..~tb`1 _.. S _510E .....__ E 1 ~ I; I ' : CAS ~`1 lvAs EOttil pP~t~ ~-uITN __ a ,, _ ~ ~~ CNgINs ~„ . ~ _ .._. ,~ ~ y _; cAR.+~a NAo -Jo cN1J~NS h.2~ =._ ~ e • pu.l2.En ASSCSTAlVGE FROM A ;' ~•'~I ~ , , 1 ....... ~lLl(s' K-T~? E~~~tT Q:F'._R~L~K2 ,. VEIiICLES POST TIONS FIEFORF COLLISION .I rY r^4.µrrN D.I 1a a wvrarwn¢n nr E, ~ Ir ucRL, A. vnuTl OCUwLU ^iAmr4 oui Sd 17 i~" IK. pl,rneL.r r%ullr, rnrruML UN rro ? ~'1 ~ / I vnIIGLr s r w O ~ ^ ^ ^ ^ ^~ Ila L;4to , ~. + 'r H,,.I p J~' ^ ^ ~RG~~._~0 ,~' ^ ^ o o. r~•.rl`.T J. :: / o .r R~/J ^ ^ kG~FF'~~ _ , ,nr, ~ __. ,. _ o _~`.„;.,,,R no DIIIECTION TD DIRECTION I ^ ^ ~ aorn r ~A,f%tt M.R .~[_n~~---- ^ II~H,IH.R ~l. I,YR Itr,A. DL_l 1 "ADFWAK 1'JIN(: IL , µl ~_ . J _ ILL vn nr ALL ncr rvs yu` nlui~wn AC! Wr Air`u- uxrtca-lDS uin v:rnra~roL ,In r.,-- rouanmo rY.r, u.. ;i L M a1,4 u Iy',DYi 1V4Y '•, ,~~OOIglI M1i11NNITA [M 1 ~" ^ : ~±T^ r ~RAVI."4Ir ~' I '~:,Lr145 I j/, ~'IIw( n7 ~/Jn ^ riLaT ,nl ]nD ^ / ^ D I ,•• N I ~ E ~,I f tl YYY ` J ~ I ~ ^ ~ ` L T _ (u. ~ rrl I D .RW r/i n o - - ~ ~ flum~ (, MAV gnL . ~ n , 4 , -J~ 1 ~ . nA'r,IirlD h1 A LL11 ,W ` P ile~ •~ I 1 G.~ L) [] ! ~~ L 1 ~~IA,Y1rIl,H LHIIN ~ r p ^/IILY LJ ` R II lWT vL ~ o r m r~ ^lrlrl,rl, ~ [~ T Iurr - ~ TI I ~~ ~ ~ / l nl Il.rf H'll ,IH ~-~(~ CI L~ L l rAl -- - -- ~ T ~ I , ' . ~ ` r p ~N I 4 T rl C1 r t11'~(""^,94rA T p",8Y7A~ r. r l "''~ f~i~P~RtPt25 r . ~L.>~Pt~/e ~; `^~ .-'.`am~rrn ' _ ~~~°~`'.. Ul,~ 1 ~, ~-_+ n~ " ''a. Jit VEtIICLE COLLISIUN FIEPOflT NO. IlP1E}DFf,U1lWON 0 _ ~ ~ r~ _L-L YOF GDL L L 51011 ~ fIME OG COLLI`AUN 7:. 11.:.1 It7 i3 D ~M LO 111IY f10. C if10. / G On ^^„~' f:~NTY CITY, }OYN .,; ~~/rF~'~~t ~'..~3' E~elun.eE F row FN1 MLES flff,~]l (L~I}f~Y,,i~O~WN// IJ, ELJJ f]F ~ 7~hKl/ AGM CIa PIILFI ~ GI. PllciroE /JY 7 ~•/ i SEC ION nowtw GIYENAMEIIFSIi1FE1 HOPf10DHDHwAY 111FNSECTIN0 WIi11'. Si11EET On flOAU ~ PfiCFI% EO ML[POS! ).Y IVTEn.'.EGI ONLOCAInJN OF CIn IIJON Iv1YrtrN sinEEr MD srnerr RAMP pIAOf1AM1l DATA " - *Il Hnvf. LANOMAAx. IF 1.4reM,E. ,../;/'l,'l1 F , ~ q e n ~ n ST,P/1 w`P, l~~P S'4;~,G ;'tr ~ INfE)1 ^ NDN 1D INT[fl ,CLS. ^~' _ ~,>on --f .. vNn~.lL Vw+CI[ QvNUCICrvcrC11. 1]D111t11 A\1n1f1 n SPEC. CODE U5E .. .~:., '.' '-~,^N1x.11:0 utC! ^vLnCtF 1n<N :)r vt nx.tF. `' ~ ^vF1x[IE 111H n11oAn 1]1%~HI'LDEI jDN ^141 wIN - ' ~. UIIJE(:r BTf1UGx InAN[Df ONfCl51HiA;.1 OWNFIIOFOIIdECiSNAME MOAODIIFSS LO(,gfllJN FI.~~ tanMAHD r,DSf IN NOAOWAY LID ~ I I•"xICwECr 1It -~-( ~/ CF .[ T ©~ I 3 . . _ . _ M~ /!~~~~L=__ _~.^__ • M r ~ ' ' y . I ~ Ul1VEfiS~itNME FIfIST NAME . ... MIUDLE EUNVpvED Df11VEflSUST NAME F41Sf NAM ~ /~Y~IDULE f 1 ~F. ,(!l•~/SO.I/ J~/G/{/r~p /¢ I ~ /-/0 L~ 2 S7~'d~ L:3 ~,5~- /G SIIII:Er AUURE:iS DOUfE NO.ANp 00%NO. MpnE IHw VA STREET AODNE55 ROUTE 110.ANU W%110. . CITY ATE I.IP CODE DRIVENS OCCUPATION N1A1N ~ ` CITY STATE. ZIP CUUE WIVERS OCCUPATION 1..,<//.'~/_~. rG r~ C!/,. o,~f. 2 % GL,a,,•~NAR~ ~ I;,.aN 4 ~ TATE EE% DATE OFB nDI AGE L E IUFH ~ L• uo>~ STATE SE PATE OFp RTM .AGE DRIVERS LiCFNBE NUMDER S ref nA. rtN1 i. Cl NEICIIEV: C,)U)EI MQOCL II:OVA-DAHiI POUT STYLE12 DF11 VEHICLE YR. MA%E (CMEV: OpIXiEI MODEL INOVAAlAN21 ~ POUT BTYIE (2 Dit) •70 c fur // P/Gr~~' Z .!-Iar,+,2 P A •0 STATF. iRNLEHPLATE NO. STATE LICENSE PLATENO. : SfA1E 1RNLEH PLAfE1:0. ,., SigTE ~~ Elf r.l. •IC.ATK]N NU. 11'v60 MODELSd NEWER( : ODOMETER IIAtLEAOEI VEH1ClE IOENTIFICAiION NO., .:.IIDBB FIODEL56 NE'WEnI. UOMIETER (MILEAGE) . CR.00'Mlr{I IL~STFWSi~MIDOI~ AAIEI , .., DRIVENBI:CEN5EN0 lu REGASTEItE00WNER ILASf~FIRSi~M1DDI.E NAME(. DRI'lERS LICENSE 110., ,.., rL`T CJS ~6 L/f// ~/ .. '. « r ISEHEET, GHYMUSTATEI OATF.OFNRTII OWNERS ADDHE59 ISIREET,CITY MDSTATEI DATEOFpIRTII , PPI CLE DAMAGED _ TEU r PMTS OF VEHICLE DAM1IAU'ED "1 ' ~~ OlnvAw /WCEE e• ~(YD._~.~7~~~~ a SIBS n~~ t YIAS f11ERE AUfOM110p1LE 11A01LITY WSUnulCE I.I T~IILITV INSUfiANCE INFOHMATION~VEHICLE N0.1• cov[nACEWtFrtcrfoRTwsacClpENT ON VOUncM LV VES ^NO ' .• 3.VUADCHESSOFLIABIUTY WSURANCEf tiL pY HOLOFn NN.AEOFLIABILITYRISURANCE COMPANY TiP +O AUUDF.SS OFLIAP.ILITYINSURMCE AGF.NiGrv slPrf. SIP UA[IIUTY POUCV NUMBER I SI IY A]f1Y AGE 2NDINJUNV: NSESEPAM,L nEpK1AN/fO~{nplr niC51 ~`` G N AGE NA, __,... _.... .. _ ....._ AOT FS - _ BF% IOr+E uN.•r. NAME „ .. _ r A _ _ /UDRES+ 1 ~U 198 M % __ __ _. -- _... pt 11,1 + I - FA fAtUB OF WHINED D [] IN VEIIICLE NLLED NNI%FWS IGnMw sivEnE 1 I T CNe TIIAf APPLIE xf+ps4u PAwOn 1 S Iry~ 1~ i0 C T SfATUSOFINJURED ~Un IN VEHICLE ~1 ~ NILLED MFJIN T]nSi rv~i~~ p ISLVFn EI ONE TIIAT API•LIE NWT "la IunHC111 S 1•+mE ~~ 1M 1 C~ ~ o ^ J^ s^ 7p I E I NO °" ^ 5^ s^ 7p, 1 pNlgNiIU DHOW NCRCLE ~~' .n`,.1 HA.„a vl O \ ~ +x,L ANn.+YAY ~~ ] ;~ le.. .Ire. I p I F~S1{'~~F( i T~Fr%;sN~~ j ~~ DESCn:nE OELOW WHATHAPPENFD-IHEFER TO VEIIICLE9pYMUAIBFRI ', 1. Gi~.~y _ Pu~c~~/ .?_/~t"iC', o//. F~'r6G~",L . _~D T . ~~r7 T!t'C u/~/.+is one. odf~_.7a. - - w~'~TH~Ie eN~. _~~/,/. s~/Pv~iJ ~ea~Nn ._ f + :~ Q+-. ~ IIOA Tl/ T/l~/~ c..fusuvG..vt~ 7D_ Sclp~ oF _., ._ . . __. ... ~ 4 _- ~-~uG(G_IB G,~-'~_.c/0+.2 _z ff_~A~.-- F r S 7 +1 ~ F ° t GE ! / ~ ~ C, y G c , J Fti S_o it ~ (~ r T_.~_.... _hl~ . ~? v~~ f~ !f~' J E Tu o :F E' ' v e~ ~ _. r ._ ....S _ . __. i l kfi ! 6 .~ +- /` 4t i'Y ~lKLr S G~usL/G .(fl.,~ To.._ 2 1 f/S . / 6 -/f? ~~ ..-.i /~ -~ Is // ~ ' p /'y ~ /1~e/ ,Y /E'I! IS/Lt1Tyf l /iv/. Cr . ~ . ' .._ ....- --- --- __ 1 ~. VEIiICLES POST (IONS OEPO Vf14C(f • ( W RE COLLISION d1 BInnT(N114GIIWAr NAME OIINO 1n w1A.H vu.cu rD.cu r.nnnwAa INVF.STIOATCD UY w(w~d IIGNIY elu+uaD M1N anx v1rt1(MCUIYP 1HG1 FP Ke ^I~IinY ^Pq F[ ...,.n a ri ^ ^ o 0 0 0 ^ o ^,~I;KL ^azw%~d,l. .^..n. ^ n ^ ^ ~ ^ ^ ^ ^ ^ ^ ^n1<Rfr 1, 1..~.,•. ^ ^ ^ ^ N.oNn oswD mou DIf1ECTION To DIOECTION wwr.rN~+v wAS U:A'.(: I^sr%wAl% a^wunwgr a^ r+wl:Lxn .[]~. n^In a^Onrcn W D11Mn of H:CII ACf WN9 '-IM~J:.U+Ia Af, L'-- 1H AI1N 11 LfA1f CEh D1l1(x~5 IIIA1iN:CUNiIiOI. Fr•IG. tA.ll TYPE Oi nOM n1 f n M1 ICI( I[1HCx GNY MAA]wl xtf r If r g N 1~ ra, l l11)HIO BInAIOIIi AII[AD v n 'f'• I l_l OV1~~'~ail 1 nDAVI%A 11 ^1 1 +t nft%IE WAY ^I C~:xWAI Tr ^ ' I• + ~ A lf ^ r ^ ON:nTA%INCI AIID i'AYhNO f+lr ] ^ IIA'NUn: 2 ^ DA'hN ^ 2 ^ M1ICA' WCdI f~ 9 ~ i'An 1'IAY ^ ] J ~~ 11n 11fK.r1 ^ ,T ^ IW~[R"a1DL ^ J ^ MANINO RIONT IUIIN ^ l_.l ~, v.fi p~FA/)IM•+f. .l ~~ DU'.+. I ~ ^ .I `K~'::Jw " ^ f!%i " ^ " ^ MANWO LI.fT TUnN ^ nC,H190•~f 1 LJ " ^ ILA'.NHM. Irf 11 ^ " ^ A ~' N I/Q>~ R 1 (( ~~ff M1 ^IIA^anN0 AM11111 ^ 'v ~~AIICY ^ e ^RIAIf INfl lllURN ? I H:C A~7 ~ ^ lvH11}(I+IFCI ~~ E F L'A A r 1 ~ f AM GNYI 1 T ~_\..1 ~•5~1U~ - - ^LJ ,p~ty~%y11S ^ II ^IHI b4NAl ^ ^ ^~IIf RNIN ^ e ^MOWIN(1 y nWT:.T<PA~ANAN ifl OgiTY ^ ) ^nn-NCENTlA11M Eq lPN1S ^ F ^eI01`I'IDfON iOAirq 1~rA IV r+ LJJ __._._.__-___ ~~ A (-]Dnnn•rIGRY r_~ I n:APN1AHN ^ ^ ^(HINHA'M(W zt. i ~ i A - .. tl ~ ~~ x; H~ ,1 "' rc~ .' ~C eer~ 8~~~~hw[C /Yn ~~ POLICE TRAFFIC COLLISION REPORT LpI TRAFFICWAV '~~' PoucF CO/APWNTNUMtlf4 z , ~ PRIVATE WAY ~) 71 Darf o,cau N r <au I N nmE couNn (USE teW HOUR) «p xv '- re u, ,gip».ruN _ ~E ~ 'tF~r C/C,SON couNrr NO. OrcNO. iHWq / ~UP~IArI / U° U j Z ClrroRrowN ~N QE ~IN O.Of StRFtION MGNWAY rCr ClS RE I pOUlE O45T f C j P SfGi _ 2•.S /NlES 5_[3Y( ~Gi NSE DON ,}s• ,~6s A/r ~ 9~v/~O n INIERXCrING SnrH: SlRLEr QIf ROAD NON INEFRSF<NON Y PRfrlx EO. MIIf POSE ] BEMIEFN SIPEEid SrRFEt .C CJ /~ ' ~ D41.WCE6 IR I REFERE .CROSSSrREfrOR NEARESIMIIE POSr ACCIDENT AVtEf 5 F W MILEAGE R P DIAGRAM DArq i[Fr OP GL ,! CODE • Y COLLITOU~ VfO: VERILY KA NO. KILLED-NO.INlUREO_ YIIIAGE ^HIIA RUN. nlrvpetpr« Mx Irv IM.fq Clt C40155rRIffT09 pOADR. 4MrfR[NCE _rT] e OE VfNIClE3 ~ ~PROFERIY pAMgGE ONLr ^iRESUlrfO ^VE~ICIF f/ Cpo-~J 3O /f OE:ER 51RUC51NN.IF CMOB/fR51RUC1(IND OWNER'S NgMEI fSt. DPMAGE SPECL4 CODINGUS __ Y S ' UNIT NO.1 .UNIT NO.Y ^ VEHICLE '^ PEDESTRIAN ~ PEDALCYCLIST ]~ 3 DRWFR'S NAME: WI NRSf MIWIE pRlvfR'S NAME: IASr rl4 I 4 W / C S _ 2 SrR[fi gppRESS r z /Soy( g82 rN[ET ADDRESS StArf - ZIP CODE PHONE NO. C. pp zs orlc D R NT SrAFE IP OD tNp. / NF93UCEN5E NO. DH C 3 K S SArE cJ A Ex F IRIN ~ j pp ' ~,~ I ~ IV UCENSF NO. wif DAI BI4M •Ip I p,r IrR ° OCCUPArbN FIRM NgME dP/pNENO. fYf IGHi HfIGHr E OCCUVgtION FIRM NAMf6 PEgNE NO. EVf3 WEIGNi E4K:Ht z o WO K/N (c0 41 R ^CHECK (~ IvEHlrit asnN fMaiorFEOPArmigr~ER_ ^CHECK (Er) IPyfHICIf ASAN LMPIOYFEOFaNOttilE9µ p ° CODES-~ ] ~ d °5 5 e 6's"A° ' . vio nrorv spa n ruE CODES -+ ~ ~< < iv S u 6 M .s~ N ° ~ J "']r ~ I m N reRr S~FV+E., .Dw ^ .A. ^ 'u°V'a ^~un ~. K ~ ~ ru "" ^ w F ^ u ^ cc"blr'n ~ vi ^ iR° Ar Po H E to V[H.YFMI ANRF (DODGE{HfV,I fI IDaH~ND°A) STYLE I]Da.dDNV.) if m T h d)" H~YEM MAx 1 {rIEV.) MOD[l1DARr.NOVA) I ( R. V.J m ~ V N pl UCFNSEPU N SrgrE r 4A il 90.AiE N0. SIAIF FI VfH.CIXOR N Iq ~ l i qr "IT. W A C Dv VFHYIE IDtN11iN:.rpN W. ~ D'7'T I :3: l 'S"i3 ~; l i f L E VEHICIk IpFNIIPI I N I 1 N ~ I l l i l f l l i 5'D REG:fRR[DOWNF4: 1/St HRSI MlpplF PHONE NO. ~ RE ISIER pOVMF4: lNr .FIRST MIDDLE F C W I] ~ AOORf53Of OWNtR N E A E WNFR ,;' Et uMtdApDReuorww RANCf eo. oP geFHr R m u A - ]] DAMACEO qRU I"~ AMAGFOApu ~ ~ CHARGE CHwRGf ( t t51. DMUGE ~ O4wMAV ~ RIMAINID i ' ~ AWVFN ~y~NNfO Ar f5f DAMAGE f lOr TOii 5 IO~O STD; Pt' owfoBr _ ~ AY ~ (OWED AY BY: AW 5 T ° INDIu ENOgIN OIIISION: f eriRRpW DIAGRAMOFC swEr 6NfCtSU Ys _. ... DESCRIPTION OF COLLISION: (USFSW ~M[NUIS eEtP Ett.sA4r1 ]s le i_ ~4,, ,~. E$ _ ... .. _. _~. __ _. _ vl1kF~.J__ 6o1•v6 . /a7-c. _'~y,tr~ JEIt l c4r___ _ s -. t f-. ~ _r 1 1. r SLID _ BkOAO S/ Of! .. DN ._'WETf~LCK.... I, ._ .. ,_;.. ~...; ROAD., wNE~ HF,T_.. DOPo$iTC BEIc!!4_ _. .. -. _._- ... ....... .... ......____._____. -- _ __ _...__ W 1° E, ADDRESS 81NJURIES OF PERSONS I NVOLVED * CODES 1 - Z 3 4 5 6 OCCUPANTS/WITNESSES liw rso~driav:i wiw ii stli Act {erus '",; ;" u _ ~~' R[fIR. IXR Rrtr. .. 5 H AMR ®2r~~ Rti rnp _ ~ ass-or3r ^~ ~.. ( . OOfESt I HAIU°! I Ok v {~AM S. p~L[r Q ~^, N(Y ^ K`1L,R N u ,Mt ODrrn Ert~IT.oN R ~r HOr ~. .. ~ A DOnu 3 ~. !il'IIM AGlg ny, ro ra ~/avlD rROM ~qMe. ^c O"r" r".J' ^i° '10 E ~ A rm+ru rw"li,i~sO1 if ..e e:.1Y ^AMe. ^•d':'^t[wN•OG7 ^;;s. H SroArR.e p•rx:lf3 NAMrf RANT f QV AGrH Cr KrDnrgronD refer AwmD pgna RfroRl Arvpouoer pqn lI w r ,~ ~. ~, -~~~ 1~ ~ , ~ ' (( ".M1r ,ryry f'~py{ IE.. ~1w ~ - yy ~G{ ~ q' µN~I 6 (G F Y~4/~'It ' yl f ~ ~ 1 ~~ ~L , . . •! J~' I~. If2 .. ELiAfP~Y~ NA ~ I.e~ I f ntiyn. ~ '~ r ~ ~ t ~ 1; o • if _ ~ ~ r 1,,.~, . f ~.. I)~ . - - _ ~ , ~Y ~ ~ ~ E ~ ~. 1~ ~\ ,. s {~'., o a u T ~. . uzla: ~ to F: y€,~.... - - ~ ~~, P rr-~sA .a "I L~ 14 C WYI L~ti "r'^ ~ f ~ ~'~~ ~ y , ~ 7~+L^~` T~ ~ J A~` ~ ~,~ ,,L~ ~ F~ I' ~ ~ "~~ "/ •.• ,,1~ I ~, I ~~ ;~rY S {I tt r 1 * l , '"i ~r ~ r~}~'~' N"~<'/w ' (Y" . .4w~•~,. ~.J ~'., .Y ~(.ti' ~ T', i I . 1 . ~~dLr r '.'~.Frll e ~ I I IJ I ~ ~ IL t ~~ r I . 1 , e ~x~~ MO7OR VEHICLEICOLLISION REPORT NO. O IE OF LCILUSION UA 4 ~ %9s'/~ .~YI YOf WL ~~ L UII IIMEOF CALUSION ~,:~~ ; MNNNa ~M COUN[Y NO. ,'~ LrVr U. ~_ ^ r LO NTY C TY TO /J ~` r G1U / Ptx~w/-rHJ.trtrl. A MW Mr E5 N CITY, TOWN Ql3 nFP,L~~T,. ~.Awr~.~ ADM LLS I'IiEFI% Pi ~~~_'~ SECTION 4' / GIVE NAMEOFSIREE i.IlOAU0N11rC11WAY ~ OI L.f%,J•J~ /i/'Cn.-~-,Ei/A,t..!.CL.L' ~ ~ YITERSELTaIUNtlII. Sr11kET OR HOAO PrlEF1X' EO . AL[I.OG( - J~C7 LII NLO(:A10 `I OF C IIIJION iS O E fMMP OIPGRAM DATA ~ j // ~ / /./ Civ ~IEL~A`.U ~ STR[Ei 1 tlWkrN (,U /fl• ,25~ Y'(.[.>:<+Y~t'/XR ~ Y © r r,luuprk. • N NON "HD ,tPCtcr r.r .v [ ros ctAA / ~ / Lr I LJ L'1 I 0 IrnUr0+uc 0 RtLe~f I~da ^ ~ rLa[/rCID 'row ItliEfl INTE CLS. -I ~~+ ^vU ^ONrUrI .aIN %"" SPEC CODE USE ' N . HOF ODIECTSrIAMEANDADOHESS LOCA DfU-CT .MUCK 1A t rPar.1 rI~ ~~'~~J fJ.~ VJ~~ Ir ROAD ,~..•.~ /3~. /I~i..; r;.V)l_'-^-~-0 Y~f J Jr~ Y.0 / ~~7~-~" (" - ~ f ON WAY ~© 0 co= _ 1 rfcr ~~ t+, D 3LLoo•aO r + µ r~ ..n-ss~k I DLE- e N111VEN:iLMTf1AME FIRS//i tIAME. MIDDLE GJOL~SC JU/7 J '¢ calisa~LOPr D FIRST NAME M l1RIVF.RSUST NAME tJ. /YO ( V M `/1 e ~ V.° I ..1 NEEr AUDHESS - ROUTE NO.ANDBO%NO. xo STflEEi ORESY I10UTE NO At~n BOX NO. ,.M.~i- 21P LOD'v I:HIVERS000UPARON IXUSON CITY SiaiE IIPCODE CHIVERSULCUPATION,, _~I / t.~?•~r l!:C/~JS'C/l/Lrr ,(.lN ~/ ~ /~e)A'i.ee~ fPGrr. ~. t•YC/N Pad. ~3l P• .... tiLX:F.NSE NUMBER , STATE GE% UAFE OF I4NM AGE pRIVERS LICENSE NUMBER STATE SEx DATE OF UInfH ME .6cd -s.l -5 ~S 1KC ~:.a ~IIA x ` ~` /•%.%~ L 7 A :~.1-VII AAF.lC11EV: WI%:EI rAODELINOVA~DARTI nODYSIYLF.l2ORT VENICLE YR. MAKEICHEV: DOIA:EI" MODEL(NUVq~DAHI) OODY STYLE (]ORI.';''. ..F l`LATENO. • STAE - TRNLFRHLATENO. '~' '/77 uIA STATE LICENSE PIATENO. STATE TRAIIf.RfUlENO STATE. ...r,:::1EN11iICAUON NO. IIDUN MOOEL58NEWERI `UWMETFJi1MILEAGE) 'rr. VEHK:LE IOLVIIPICATION NO.. WOOS MODEL56NEWERI DOMEIER (MILEAGE) c_L~ insD!:~:~~aL~ l;: env IILta:;IL0=Il0\VNER ... ILASi~FIHGrMIDOLE NAMEI DHI'JEII.q LICENSE NO. REGISTEPE00\VNF'R ..ILASi~FI•ILf~MrODLE NAMEI. ONIVEgS UCENSE NO."., _~ ^ ~- 0~:~•nni+':FrES:: ,. 15TflEEi, LIfV µ05TATEl S / ~ DAT - E OF HIfirH I ~ vGH L OWNERS g0ORE59 IS[HEET,CITY ANU STATEI ~ OATEUPnIRTH ~. rJ1 - .l ~~O V f )M1AGE/0 f L13 1 ~ iANTS OF VENICLE DAMAGED ' 5 -.'~kE - ~ ~TNf EAU ~ 11Y.~LI~i ~(\~EI.Vi _Fn l~L~P1~C E O 1• / COVERAGrIV F ® TG 1rfuLE L1Ad11.ITYINSUNANCE F E:,IFOR TtidACC f1ENTON YOUR CAR YES ^NO AYDADUIEnNUF LIAfPtITYNSUIIµCEI'OUCVIIULOER NAMEOF UAOIUTY INSURANCE COMPANY ,. •- Awvrl.Yi GrY argrF iw i irE AYOAOUNESSOF UAIUl1TVlrl.SUPANLE AGENT Grv $rAIF 2s UadILITYPoLILYNUMdEq ~ ., 151 rvJURV NAVE _.. ...... .... AUONC:S" - 1.11•., ....... ._ ..- ..tiE ^•E% U.~ • vD ]NDINJUNY:" IVSEi.EI'AHAIF. ntWr1I IW1ACGIKaIALMNVR'Fa NAME .. _...._...... .... _.....-... _ .._...._-. .._._ ............. ... _._. A'IUiIL S, 'J ....-_ .._.. ..-.... ..._ ..__. AGE 6E% ~..~ _ © DOfrOna ~ W ~Q x •' A,US DFINJl1Hen MAHKFrRS TONE THAT AI'PUE S STATUSOFIrUUNFD MAIiN FINSi ONE THAT AYPLIF .9 ' IN VF.HILIF PA:~,[NUH ~ KII.LCD De:+IUNO IuNIHI VArrPaµN IWUHUN PoiontF i~OUh AN1 IIU ~pq IN VEHICLE /W ~ KILLED I'Y F [I IumOFINR 11f U~MiiAnH a NO r O' OE~ NO ..Iv J^ d^ 7Pr^wilE) ivlOw NL HTI N H OWInL HCLL ~I I l:ESCgINE BELOW WHAT NAPPLNED.IIIEFER TO I'ENICLE9 UV tIIIMUEII . .'•:~ . 0•E v.Pru \ ~ ~ < I.nln, ®~ ~y( ~ ,. u. r .: N,rrtrL/i'w ~ r. r. s ' ! .. - ~~L~,~teJ ]~"/...~1-AtEe~ / C.a . /u-a.lQ esr.~ L-~L.•G.Ci ~P.a-t,.Y G_l.:a..L'+...r1 t"'"IJ-L/f.4~PeJ-l•~"sZ •W'rW._ A.~ rCr.wt~~w- V'. ~rJ I r~ W :'1T ~t I ~~- Dx r.w /MU7Lf ~r~. %~,~.~it~<J. F~"-l..~rLLr ~l:.A,rrt~-~G. f. ~~ l~ _. ..... ~ /. -. ~ !-_~: ~ L 4 ~w f::= ~~ ?111a -J- ~V L'7` ~~l~L%r<s(. y cN..f.!>.rt..t-as6,..t ,. ~Gfr..Cl -- -:ct-fl-+~-a~l-a-~t.•''j! JY.'/_.f v ~T..~'°/L.e-.s-"L' .O • . ~~ v LI ~ r ~ CJ ~ [ l 4 ~ L • - , / .. --~ ~ a.. -H +r .f L t .LC..O .. I ..RGf~.. .. L~, ..-,!„po I ;' ~ I .2 _. .61A['~(,(i ~-M-fW rC//,( .7.+J)w ~I AL1, b~tJ._._. i... - u : ~It, r I i ; _. _._ .-_ ._.._.... .._.. .. ~_.__. VEIIICLLS POSITIONS ^EFORE COLLISION O11%rA DuL r m.LW :°~„ raM•nowAa alvt5raatDm ~Nrnl~ :grr•n a Wr«Ge oe<unD N lr<iT II t lV WErfH~Cri pll00rlYlAV NAME. OIIIq wq< l 1 rf t[a rID ^iiiirOL ^IgreC( r r.•P ^ ^ ^ ~ O.rl. f/l0 /.{L/Ld.IG ~t,E.NQ/ r ( tl^YB ^ ^ ^ ^ ^ ^IM¢f ®O/D,Irdrarl ^ o n ^ n ^ ^I,rrl .,,M.r, c~ o ^ o~~,~ •f ~._ I•,r^•Y ^ ^ ^ ^ ALL:wr i.~ro•.NN moM DIRECTION ro DIRECTIt1N" irYUl'~N.AV K%:(r'nM5 I('.`u(x. vl%lx ]^\YAIx\yAY .l^..^VrnUl[A.II /^r~r 6^~ o^OlllCn r~ F Ati •.V If A-f.l:~ vA'ANltll Iail11 G[NlYT10rr!1 InArrrC CONTNOL M1rn E. rvxl Ivor OF ll0An 1r•r g11VVr1/Vr I11LLE AC710N5 k•+r rFLI Kr•1 E%OHI rvI L%NMI r • ~. ~I~fhf v ' J . 1 CT f~.ri"~'~,!~ , r~~UAtI L",{rT ^ , ^rjC •AID ^II ~rfv14 \VAV ~r 1 ^fAIr1O GT11AIf IT NIf AO K 1 I rr-- i 1 JrYrr ] ~ IINN••II J ^ DAWN ^ ] ^ SLOP !:r(:rl ~ ] ^ IYA YIAY ^ ] ^ OVTIITAKMO NID I'AS!NNO lJ r l l.J J CJ Wl.1 1 LJ •.M.NMI ] (~ IYItiK ^ ] ^ YN lp i.liN ^ 0 ^ ~µ1CNll f. ^ R ^ IAAKIIIn IIIQIIT ILITIII DAnP ~~Oer (~~ r~ ^ I hJ V~'0'v . nliHl % ^ lA'.rN': OV ^ % ^ Il A'lurNl litn ^ A ^~ r `-+ N L11 MANINOILfT IUItN l r 11AU 1 OOP IAAKnlnuqurul irvir~o~lr1 ^ ', ^rL-t :rru•n AMOrn ^ n ^AUrY ^ 6^ ~-J'~.'~+:r ^ •'ni ~ivrl ' ,n 1 1 f ~ ^ A ^ r:n fA:NAL ^ A CJ 11 T IINnI ^ n L~J C.[1AIN0 M1 (~ .~ f''r A ^ :iHrl I ItA•1M1 1--J ~~~_~ „ / r'. r 1 ur•.r rl r ('_J ;I I.I rIr~r {1 r n UIIGt N•I IA(luµ 1N114 ^ l ^ !~I d'I'TO in111RAF/IC .. 1 Y.e' { l' ~!`~r~~ _ f Ih Z rT", ( 1 - f+R; ' ~ ~, tl ti. .c :mAt' ~, s ,~ 1 _ i - ~,...+ 'ViA2e?~.,.u'vS~1~ "L`T655llL' Q >fi '~'' UFt VEHICLE COLLISION REPORT ILEOf cpw:ADN Eo rYO atr 'o ~ N ~'Y ~ ro.T. J,nr Li o co ,la ,wea - V xL ..L LI ~ I.fCLN I•(H FI% Ef ~ 7 ~ _V ~~ ; r~XA 1-L CJCV ~- ECTION 1 , C 1 ~- GII I owY 1.. ~ lEJ Alf 1 cllr. ipwn =. !uW a L / LJ .•~ 1 f/ / 7 ~. .N d~~r1.~, '^ . L~ /'i.: l~'A OF C3 f.J IU ~ t~NCl ~J y'} .~.d~~i ~j~~ I.`~L 1F YItENLEGt NG will SfREEt O(i IIOAO. PULFIX .O Mi f( f / ~i T"t"• ~ G 'f•">E-NAME~~,CE~~CbLriitU~v l~,Gi[ 9v. 4V { L /hi(>i%•i. _1 ~~ _( ~ I fiAMV p C1 O i 1 r F~ I IR CI YLOCAirONOf CO LS101 / /~ r '~ i' .fl'. it ~L~~l / ~~ S1nFETAD CL ELM uL`•J C ~C(iflFEI ~ XiU r u ic,M ~ rv~ 1 f~ ,q~ TN~~1/ uVxo ui r, ,cl • IntEFi t n LLS. 1 ~ yji l S 71 ~~ ~ Q ~ ..I, _. '!y~ ~ ) l-rIL LLJ 1~ Q,.~J i~~, UHNwrrll _• C.(OUE SE n ^ ~rr,rxNr, rP 71 ~I. n. ver .I. G G1 ^ fw VO OYMkflOFONECTSNAMEAN0AUIIFESS it TD ~^ 1,Dx.P+uu em Op LCf C111Uf.K (( •-~ !! iIOAONAY FLLT ti I ~~ T - MCJOIE Dn VF.RS IASf N0.~rE FI1 TJJ AF ALDOLE • DN VERSL/vSI NAMF. Flfl3f tlaME _ ~ r ~~ ~' ~( ~~ / [, ~'~! f'/LJ t o 1 ru Daax NU r K +S- vN sIREET AODNth.S ~F :silkEfafJUli43S ~fENO.=ND110%NO. ] ~ / ~ rlC~~l• '~ F L~ "~ a 1 rH tC A CITY SIAIE LP(C DE p fl'f1000PAt ON G ~. . p (ITY STATE / ].IP COOE URIV^~ENISOGLUVAt ON '~J ~-/~ ~ ~//~ /7 ~L L k .-' ".,r' [ 'f (:.J 'llJ. 3~i.-/-' /(•tYY ~AT 'A> (,>L '~. %'.9. J r~1 /L 4L f~•~~Ul~~ u^~ /rf' V UR VtNSLICENSE huFIr1EN STATE SF UAIEUF UIRItI^ PGE :~ IISLIC hSF. NI MHER STATE SE% UAlE OINTH. AGE . r +[A ,N 1 S.,' 1"~-l~~•fJ/' ~j~ /) 'f~ft u F LW Jv' ~'J -7 •y VEHICLE TIi. MAKEICHEV.~00M•EI iAODtLUvOVA~UARTI IHIr! CYLE 120R)' ~~ LE,11. MADE IGH~ W4, IAOOEL~NOVADAflt7 UODY Si /LE IT UR.1 <~~1/• p SLATE TflNL[R VLAfE NO SPATE L ~ CFN:F. VLAik M1O^ Si(~lE iRMILHVUIE NO. `utA1E U(:LNSE PI iF. O r 1 ~ ~y' ` ~~ ~ ~ ~~ ~"'^' • VEIIICLE IUEN114 CAlIONNO - (IVp3 MODEL36NE1'JEfll :UDMEIEfl IMILEAGEI I ,F «t L Y.L:IOENi1FIf.AHON NO. l1VHPMIXIELGA NEVIF.RI Ol)OF/E~ f•~1 •~I=-•~ I~C" ~- UR 4ERSUCENI'NU RF.GrSIeREDOKNER ILASTI li"AI pO1.E NAMEI DNNER`+LIC4NSE t10 ~ ~p el R IW fl"iF.UO EN (L SiF MIX] E LAM E/If ~ , 1 / `~ / 1G wN UIC.~f1 ~1fC '/ L' L'r~,/• j UjGG CIi L_I L„~tl' ~tEOFp ITH ^. {+ Jf ~ U /J,/YI AUf.fl-SS Y ISiUEET IiY AND STAfE1 DATE O/FURTH OWNENS ApORESS ISTRLEf CITT AND31AlE1 ~!~ ///~~ / ~:.1"/~•i. Ln w. .E!,r •l' 3 ~1 b" f4 /tf:'/ ~•.T JGCVi'S ~JCf% A *t4. ~A ' Y ~ CJO ~ ~ •ti• AI u PAPJS OF yyyEHJ.LE DAMAGED / IU IEP V•r icU' f ] - ~U~F/,~V(E~Hc ~C-L~.E rD~AMAGED '] io RuMi,v~wLE / /'~z„d~,, p~'r:IT ~~/,J~2=;/CJ (_'-Y S '~. ~ - L +- 1l--'=-'V ~~:.~^~•yt/f4~ --/,J•~tC/5 wrS nlFnenuioMNDRrtL_unm:n•nn3uRANCL ~ ~j YES ^NO ~, qT L ~jA I.IAFIILITV INSUr+ANCE INFORMATION•VEHICLE NO. 1~ covEr cE ITFFECT 'OFi FH SACG Dk Tp1Y0URCAR ;~~. ,p / NNAE OF UAR LITYINSUflANCE CO MANY r,- "~' ^t YtJAE NIDAWRkSS OFLIAnILIIYrNSUHANLF fOL ~V IOLUER ~~ Ulr ~l ~~ C/~iL]~/ ~• L I~~~1 CJ r ~, - [ C• ~rE A Dc; 7- CV<IIi.TC%Y 'ev. j u lU.d "~yr l .J /}• r r.t~~.u~~k ~ ~ , I ' Gt! f 2P U 1 L IY VOUCYIIVhrHfn 5 ~^ iAME NiO UPe55OFLI HUI~43UfiANCf ASENT ' C ~~'~/E / y ~ •/ .-L.YQrI'C.v 1 _ (/ r.n rrFrn c x.. 'PGE - ] - /ACk ]NDINJUiIY; IV6ESL r ( f ~, ' R ISL WJI iY ,_'. ~. ~ ~ N ME - .., 8 .. NNXE _ .. .... F _ ..... SE% SE% AD[HE ._ M uvnrKw Rn«~ctd C3 r .V~ S(AIUSOFVUUF.p ANiKf nST ONE111Al1 AYPLlt i ` I ; •. SIA 50 JWEp AI KF RSI CNt I'IAIIAI PLIES ro3•AxtE f IV1AU f QDx IN VEHICLE KILLED I,rV[xfl NOIU~MINn I[ ftt L rA QI Vf r1iCLE KILLLD ~KnE ~YAµN IIMii~~n ~~ ^PAf[ N~ 1 I 1 x , ^1 ~ Q 1 ^ 5^ G~ ~~ f ('^ ^% Q 5~ 6^ 70 ^_- LAP FF VE 1 Q DE X:nIbEO WI AllNFD, IR FHTO IICIF IY PFR J l C EQW PF // { t1U I t r,/ Cv10WllOHIIIM NI OW NC ClE '\!C / f4 ~O 1 O ~ ` / ,, f Ia 1~ ' ~ :i ~rCf rn7j~~rt (crrc~~~ cec.I(Ccr Stirs, cl uP d /~ r' ~ ',, .. ~~.".~9a'("rerr:.+i,.~sa ~\ (~ oc r~Jd~ Uay ~r ed r/+ .(:&rnftu+-t .. ` C. t( / ",""" ;APR YTrACLr..hp G,DN \ / c •• /<. cd [ > /5 __ a MRA%n nHWLnf u•ww ~`. (~c:I rG/c 7G r~ ~ / tU' 1 IuR.nrRr c+ 1 a,r.f 7 .. ~ R~ . --C~ ~~~ `,, _ ` 'c ri~e r~~ d(JtrV /Gnc!'l• .G~c7~f'?I' tiri ( r` l., k/, ,>7 4• ~sj'~ % .-' $ ~ /c! ~+ ~ ~1. ~ r~ccc.r J ! c2rtd ~ r._.. I ..J.r_=t, .. ~ I r .. -</^~~/~_/ ~.,,# /'CYLr-I<[ G~Cf /JO_~. S. .I/ c..~r .J - A„xruA., 1, f/ /4.^ I-+ .C~'r~'f c~YC L~rc /_ cG!(f..r ~J afJf/r>L~ T] /•~ e.~ ~ 1 _ d-L Cue `/"' I.J'^ I'i^[ IGAIFD Or I .~ ~ VEIIICLES POSITIONS EiEFORE COLLISION Rf~ (mHt+a] ° `W"'" ^I:A ^G aL j! N.FIIG•. t~ N R f. W ON STRTLI OIINOIIWA'I NAME OII NO 0 O ifal O rO UTO 1-1101 [ ^6 K1• y ^ I+n.N o a ^ o >~~~.~ ~ c r- IJ F~ 1 K~,~ ,~3 ~ „, xR O ^ O ^ C,.ttr.r~1 c'. Ga/(s~ f 0 0 D O O C) CJ"'" t ~ . ;r . I r s 'ray u ~ R' I,.., ~ ^ ~ ~ ALr%.n can.•.rn rT OM OIREC710N Io DIREC110 r t~AtJr:~r7S4~ t „~ F ...K . rl o ~rx°~w.,, a ^ Lr. fI n p,11E11 J 1'lr~~~~~~q{r ~ T r1 IKM,.'ll AY AY 411 I O'rlflwFLK T u IVAINWAY :1 ~ M~OIII O~11 ( ~ DI Vf 1 VCIIM;IF ACIK]N4 ~ ~T ~ yrS JJJ~~- * '1W VAAIHL II 110r11 L(111+11Ut19 1RACIIGCONIROL LYPE OiIIOAD If f If.NCMn4e fRUJu 1 ~ I% l l ACC V %. rr •+C,i V wtAA»fl r~ IL I~ ~ , r ~t 1 ~ CWC WAriE lJl I~ir~ CA f10 SiflAlGlli hllF.AD gk•J~~' .. k 1 A I1yy I .r t n.rtrait f~f'~1't1 l t~I[I-~]1 ~, M, ~-1 f^~I K r-1 R 1 {Yw ~ ) '1f J..1 U IJ r1 F k ~...Y' R 1 ~YWi J l LI L 4~r U J 4F.,~11 IINhvK3r [] pA14 Li U Q A l~J-'1 PJil nf.HANGr Or-~ A L~~(~J11T MAKIM1n ILir IDRNi;^JNC. ~. y,~L7yJT'~y 7 ,~~ t S J t. I :' I ~ ~7 + ~ Wn ] r' •wpAwo D [) aJ.' [r] ] ~ ur rC--11 J no 1 Y~Ji ~~ ~ ~" (' ~ ]~.~ VQW A f'l l(Ip . ~ O`I '1 fil fC'''1l J ~ IA. NflCI] lJ l.lf A 1 Nfl l..J lJ y yTY,IT A.{~1• {1 Eh ~1 .,,'•I /~. r^-~, ~~~n'f,l lfT T11~JJ OJ,iflif+l n~[)rul C :l. IuJ tt ~IVI'.nN.r1A4rN1.N O x OIliI 1111FV11 l.J ( JMAOY NR IUIIN ~ k S'~t L'~ 1 ~~ Er'~ i~ ~ r4 1 L,J EJ If ^LU 11 M',tNJ LfJ, (-~ Ni Rll .i if r 1 t~~~, r ~ OinrlOnf lfllJON \IF~ tJ> k (~ ~~~4 !~ ~~ 1(`~~~ 4~ J •' ~ ('~%'O _l.t`,NOUNK,fI~- )~U11CI+ ~~ ] G( 1 1 f 1 ~ ~~IIPAIIAII^ A tl + .~ s ,. ! i fl.' 1 j I n ~1 Anw A ~.,I} 'Wa 1'~r ,1 ' 'Y..[. -. '. ~ ::.. ~» ..,~ ^ -~-- ~': ~~.,Trl ~ . ~.,1~~r1r1A L L.I 1 1N1 n'i (1~A In T+ 1 ~I 4~JJr~~ k~ ti ,y1 !~ 1 J y, e r ~-~t ~ ~~ M" ^~t t -r ~!' y `~ .~'S~ Vi~ ~V1 t ~~4 ivy ...,-7 a ~ r, „yin +,.L ~ ~r ~ ( ~:~., r'.,7.,.. a ~ ~, I -, t T Y ° 1 ~~k"r'A~erf _ i~'r ~`~97"~' ~4Y „J'~~~ 1 ~ L I ~ '' t {~ ~r~.} ^-t L I _ 11 1~, M #t"~Ix ~~~~~ 1 ~ J~ ~Q 11 f~~~i ~' wt ttJktiY ~ { ;r 1 ~rL 1 ~ it ti' . ~ ~~ i I .pI tiYl~ t . ~. N7 ~,. W 5 :.?. 'K ~ ~ ~j ~"'" 1Ef r~ ,~ d $' . Gt:. . { s;~.; F •~w ~ ~ ' li b~4 ,~ 7 ~~ ~ ~I ~ : ~~', ~" ~'+ i ii ~ ~r ` 4 : r ~ I ~ k F3J ., a, ` a ~prF- . i ~c f ~ br T ~ _~ -~~'(~9 POLICE TRAFFIC COLD JN REPORT ~TRAFFICWAV pia - .NNLNUMazR PRIVATE WAV - ~ - ~ ~; a~ DALE C N _ _ Ar l _. _. rIMF COVNIY ' • run ,rn 'Lr. (VSE t.aDHOV9) ~T~ .... OILY 0410VM CWN ~~.. Ory Np iMyw 1 .fit U f6NO.OESLRlfr09 HIGHWAY pN p[ QIN ' if tW(ES Os ~lA' gd r ON ~i I [~ ~ INlE45fCDNG NLIH: SafEfO nONINttRStCfION RR(N ! fOSi , I BftVrtfN' 6 ~ SrRFfi D rANtf [ 07 ~ F`' IR MRFS N R S E SSSERfE NFA f5LM1( POS ACCIDENT ~.Z. i[n d E py~ MCODFE ' O.i .•T,.. T~.~~.t- "•y' ~ ••~I~ > • Cal15roNINVOIVFD VlRlryl u TOrALNO. NO. KIIIED~~NO.IN1fIRE0~ fUEDE Hli CiVFwnta ~ Q tAOR9rYDAMAGf dAY ^ oFHIlaO VffnCV: INHwro WEp• R R0153(II[i{W RC1M - ~ ~`~~'y ~-tJ~ , ^ OBaCf SrNKKINwMfd OBHRSrRUCK ANDOWnER'SNN,E) ESf.DAMAGE SRCW CADVG - r 5 -'' .=.:s;,;:UNIT NO L~'~r:•.-r Dxrvews Nawc .:UNITNQ2 '_': QVEHIQE. ^PEDCSTRIAN-. QP®ALCYQI$T.. Rx . ua R ST D.- _ DRNfR' NAME: IASt SIRf(i AO09 ~ ~1 3 N7 I st-f ADDxss 5 ArE 21I COa RHONE NO. D SLw W 6& SO $ ~ R -~ fx'S E iw R I I N H 2 OCCVRwipn - tIRMNaMf 6RWN[NO. EYES IfHlr HEIGHT Nit 6 o E e VRAfION L IRM NNAE6 RHONE NO. IVES r HEroID - Q CHECK I/) vfHK w • w wNOrHfv. ~ O1 ~ ^ CHECK (~ I H EASAN fMn rfEdwtarHfR. ~ [. CODES - D t ,,,s ) A y 5 e e ~ 'w•P1-• CODES ~ ~ 7 n . Trio«NI 5 exe(xv. 0 s.N L~ . p '~ uvlts 5°F..I 9"Ox' ^ AwwAAHU ^ u ^ ES:H. [S .'2":ea O . >, Kf p ww Aw p w ^ T$mv O h ^ {'4.:ai I~ vflr'r(Ap EfDDWe{H[V.I /Eyowvc _Ar sirlElxD~rv.l r C/7 l/? r I`Ei LKE surf awlDRnwre NO E H r H .r x I v.) LfD.wr wl .~ I .~V~ ~ . surf WA vEn. u nHlnflawtlurronNO. i vfHrof IaNrN A I S i~6~4 i ~l'~~ 3'S7~ ~~ I ~ i( i l i l i l i l I RLGISRR[D fR: IASi iIRST IODIF RHONf NO, ~I~1 (ZoE F~asov98 ,°N ISrFRF OWNER: fA5( fIRSf MIDDLE 2 ADDwuatowNev Q I S 1-e.~Sf' / ^~ ^ N E A OWNER .. NNAf [wD0Rf53dIN5V1AAC1 C0 CRAOENT I OiB leE•f rrwcTS T nse o.Afwee AerA '~ R H ~ w.,HO ~ UTARGf ~K t'~~i M~• CHwROE A r` S ^wvMwv Q4fMAIN(D ~ S v uior o"r s ~ O _ L r S}~Q roM•vDer 'c1•CS nr ^ewitrer: > DIA_GRAMOF COELISION f INwc ArRf~rH DESCRIPTION OF COLLISION: lustswtLeMtNru sEaerutaossAxrl -r r swn utafaswrl 1 _.. _ _- Pu~~ r!_1 t_.l ~' O _. _. _ .e.~LCCL..w.>`c_1ta-.)f __So,.~~Q~es ~ ~ ~,..~ I ~ , ~ I I ~ ~ ~ Ya6 al I~ 1 C k T ~ r ~ . _ , . ~ ._._ ~ ~ ~ e _ s ..~c -~ -I- - - jS- + . tI. Q _ ~ ZT ' { --- ,.. I _-I. ~ I .f I ~ _ ~ j ... d ~ '~t`t~_.- . ._V~_In.: G _ ¢_ ~_-O N-_ ~. I ' , ~ :_ ~ -. ~ I 7} 6 STd~2._._.~DOftZ',"i~ ~r'i'Sf_..EesT. . t -7 V ..... i 1 r (N1~f?/IJGP f ~._~ ~G~f refi.._ _lV 0.s _ e. pQa<cw~'(y ._ ~yeL' f~ ..~ I ' L-`1 .- ~ ..... .fp ! ~ I ( r E• I J _ Ks ._ .. ...... _I _.l . .__4 ~ _t._.. ..»v.r ...i(ac)Tc I /C~ '4 c. V~-G_._wcs [1n. tniT"`7- - r I I Il .l~ I G ~ -NAME, ADDRESS 81N1URIE5OF PERSONS I NVOLVED 'CODES 1 Z ~ 1 S 6 _ OCCUPANTS/WITNESSES ~o~v sAO~o^rio~NAHEri~iAMSN ii sLK~ Ace ur 'NxLH -o,r E Nt- . -- --~- esn fan ul~ n , awr r ..--._._. _.__._._.--------.- ___..._--_,__.. N awns w( vtd--'......_. O ___.~ f r AM e. ^KT1,'cI Q NU. ^FS C .2L55 N awf ~ N ~~ w .. __.... .. ..._.. ._.... ... .. .._.._.. _.. ... ._.... ...__... N WR115 Al td _.. _. _. _.._.___.. RLMOVfp 91 QAMB. p•alE prw MS' pq. awl' N .. _..._ . . - 6 .D . . . .__. _._._. N Orru Nv ro•rv.afrtK(n NNMfunK sADU O. r Aiuud NA,vn --.... ~.. _, fNfnr~ ^AMB p'f1:K'OmDV ^:ix ^"f°.~f. , .LNCr X _ % .s. K:EDlsrwrclaD tale AVVIVLD DAl(d xerovr AtrvovEDVr wn trfa o.a3~ co~vo /o-~sEt~ I I ~~~' ~I. [~. +•• ~: n: .~ ~• ~~ ~ s;,^^. -v w l y ,1 ` ; : ~,~, ~~ ~ ~I~ RR ' 3 ~~"~ ~gr ~ ~~ S~Y ~ 4 + i l ~~~ , ~ 1~ ~~:,~ i ~ ~' lB~~ • I 'fi f ~~ ~ f I ; ~ , ~, ~ ~ ~~ F ~ + ~ ~` S , yI ~~ M 'u aY q, 4 J <~"~ w;, I•. V~ ~ n' ~`<~ r ` ;7• `, ~ jy non rv REI WE h ~~i~W ` f O vCNx ~ US OBJEC / r. !~. DRIVER ,, ~~~ 9iREE - ~r ORIVEP ~~~ ~ ~~~ ~ VEHICL f LICE ~~ t vOIICI ~Y REGST ~ ~ OYW PAnrs - ~ LIABI NA~E yy ,, '1u ~. ~. NNAE ~dd 3. - _ *I''''MOTOR VEHICLE COLLISION REPORT ' ~ ~.. ~- - _ - -"_..."'•'-. " NTT:.""' `~"""'°'_~..", ....1; .,- __'.: _ _.. ~ ,.,.s . DATEOFCOLLI50N :. ...; .:. ,, DAYOFCOW50N .. 11MEOF COW5011: ~~ CO YNU IYNO ~. ., ( - Ir ~vEAP~ NFS wE° rnuH ila L IW~ • ,~Q MwuIES AI+. `//_ - / PM r~/',l! ^~u GAUNTY ~. CITY. TOWN - .., WOUISETk MILES. E ~ Llir. TOWN ADM~CI i~ PF EFI%.. np1ip10,nfET<A°E CIpCx - xr , e• c~ . n • ~ - ~ I . - v ~ :AR r~ p Yti aF ~r -U1(JYI ~'h ~ ", ~///, ~ x On dVENAMEOFSIPEEi. ROAD ORMIGHWAY WTERSEGTWO'MIN'bIREETOR ROAD, .. PREFI%. ,., EO :..,..' MILEPOST.,:. _... .. . _. _..~ ~ ;~ ~-ti ~' r.-` re. - ~ G9 rFHS/ECTION~LOCA ION FGOLLISION MMP dADRAM DATA. EN /~ 1 e ' .,. STREET ANO f11 ()L-(~( 1~1 ~~ ~l THEEi ~ - T~ i ~ ~ i~( NON %PD }~ °~j c3 InY, " ~'iE~iioillEEF i~llwiOW WSiwv xOEE. IFITER INTER CLB E ExCFD<ROX95rnR 0 W AAA +~ k', <r~l: 1 ~,n <<r Nub ° _ in ° °d .F~ I c ^i ~P_r~t~arx ^ ,..G>2530•. a~z <' j{~vErlglEvEncLE Qv[ncLEniCrCLE ^OR:E SPEC CODE USE ~ - ~ r O ~ W"gLE PFpESr QvFxKLErnAN ~ :.. ~ ~ ~'I~,' qvn u LC'~^VEnKL R,w ^MxCaIUEgR ^rllnVxwlArE ~. , TLGIPUC% R/. InwEp Ol°FC, srnuc%I OWNER OFOBJECTSNAME ANDAOORE53 LOCATO r G L Q© n <OSr i ~ ~° ', ~ .1y, (/ ! ~/ / O /~ [Ir L• / O/CI -$ ~!7 ~i )Yl , l~ •f~ ~ / INflOAOWAY i~Ff EOa6 S.(!()J//°2 I)' y li AgRE rnaN FA ~ ~. S IAST NAME SFIRSi NAME MIUOLE DRIVERS LAST NAME • FWST NAME MIDDLE, ~~ A ' P. ~ r..r^ ~ L, n c r 5 <«~-r.~ ° s ~ (1 L° /c L r ~, ' ~.~ ~N u- ~: H TAO ESS ~ ROUTE NO. AND BO%N0. WnE HrN ,wO STREET PDORE59 ROUTE NO.AND BO% O. - v~R~ swElrE ••~ ~Mfi E ~ ~e 3 0 ' aEr "E . ~. 'r ~. ~S er;c~~ 6. , n .- ~ ~ u E E, ~ ~ ZIPCODE DfiIVEP9000UPATION COLL Sqx A CITY STATE ZIP CODE, DRIVERSOCCUPATxIN ,.,, ,. rx~ 7` 1RSE 1 > 36K G(~-,. •• ss EADRrFDRN ~ rf atrJn er ~N'. %fl3L ~ccK/<ee re~^ SLICENSE NUMBER ,. -, STATE SE% DATE OF BIRTH AGE DRIVERS UGENSE NUMBER - STATE SE% pATE OFSRM ,AGE - - -LS Q~ ulN M ` i D,r ~R 3;2 Sna-lr--/(e-L sco s IUtiE. M K "° ,°', I"6 0 E YH. MAMEILHEV; WOGEI: AIODELINOVA.DAHTI, BODY STYLE12IXi1 ~ VEHICLE YR. MAI[EICHEV: OODGEI MOOELINOVA.DART) BODY STYtE(2 GLI. +~ ~' ~ ": 1'i ~l 0 dsttio 'e 9Y c~ccr Ser-. 6 Fa2~ c oneo wee ~ ; <~ NSE PLATENp'. ..,. STATE~~:~,~ -,TMILEFIPLATE NO..:... STATE M ExSE PLATE NO. GTATE TRNLER WATE NO. ,. ....STATE .- v ~ ~ .. ~,. ll- 06 nrr f~G l85 GtJnr. ~ ~ `r EIDENTIFX:ATN)NNO. ;;; (19F1BMOOEL96 NEWERI ODOMETER IMLLEAGEI ICLE IDENTIFICATION NO. (,968 MOOELSa NEWFJiI ,. pOMETER IMILEAGEI $ 3~cIY13 ,~Scc [Y179a0 I~!- - L ~'!. EREDOWNER „_, ILA3FFgi5f.MIDDLE NAME):,;, Oi11VERSLICENSE NO. ,.. .,, PEGSTEREOOYMER IUST~fIR3i.MIODLE NAMEI ... DRIVERS LICFNSENO._,~,_„, ~ J ~ ,- a ~ e]`'~acci le~/l~- -LS3 ~ LE ww . r- C-LSCbI a a SAOORESS ~_,.; (STREET.GTY ANDSTATE) „DATEOF dRTM OWNERSADORESS ,. ISTREE .CITY IND9TATE) :,. OATEOFBINTH„ ~r azeJrlse INE 1"° ?o.P~ou<253 ort`, n ~, ~' rEo ) OF VEHICLEDAMAOED " nMA,Ety<OSr~ PMi30F VEHICLE DAMAGED ~ F <DSr - _ ~~1- rear se ,` -:~ ,:: SES oAw_:~ . 1 . I e -r'- ravi~ 9„'RE ~ p ' WAS THERE AUTOMOOILE LIABILITY INSURANCE TpI LRYINSURANCEINFORMATION-VEHICLE NO. L covERaGEw EFFECT FDR THIS ACCrDENr aN roun cAR - Lry,YES ^ NO AYD ADdiE$SOF UAF%UTY WSURANCE WLICY HOLDER .. NAME OF LIABILITY INSURANCE COMPANY _ '. ",. ~ d E ~iP 7- .: ~ yl, ahh fl 3 x I ~eGlr 1 . ~6d~JC. ~r'v er ~su<~ ~L L~9.~ • I PNDADDHE590F WFFlITY WSWIANLEAGENT ~T .. E ,.:.. EP UABIUTYINJLH:VN BEfl - .... ...;.. .... ...: ,a " J G E ~I.INCs SOO ,,tro /~~i, r1 U SfPrV G .a 08 ~ l0 - O~ ~~~ ~. .3 / ~ r.29 9 s %EY ... AGE 2NDINJURV IUSE fPfIY,Rrf xAlR .. AGE p ~1~.~~ab61_1 I~TT~[~ /1 _. 37 NAVE MelJahb f(aerl of L _ _. 3.~- _. / _._ SpR'~sJ~~X /~/c_ OF ~ TC LLII ~C /lC'/ ~~,'/ M x ADDRESS. ~f'3. ~'iK I ~/k %~{ t T U:II ~t'{'LCII ..l,U./~~ _ M %F ) 12J O1 // c ~snfNEE Edr(afl~CS?` .~01.P r1eC(~aln ~~ ~ ° NeGK f ~iAl--- - - ^_~! AIUD OF WAWED •F" -MAPKFWST ONE iHATAPPUE3 '. STATUS OF INIUREO. I.iM%FlRST ONE THAT APPLIES •_- _ _ t ' rNF IN VEHgLE •.. .~ 0 nOx dSANaq E ^ IN VEHICLE p5iuilxD NOx 0.LNN0 E LS:fNG[R ~ gLlEO~ I FRET M/~ I r<OM I ^ [n NO .. NLLED IEEVERFI IM~ivOxl IE ,Cj ~~• •°fc ~~H'IVIN ^ 5^ 8^ 7~tC p x~.ui ~N ^ 5^ 8^ 7^` - sF+. EORTIf Dr ARROWWLRCLE '\ I - .. DESCR BE BELOW WHAT HAPPJENED:IREPER TO VEHICLES BY NUMBEPI P '.'.~ ....."".°".'A~,E.":° ~.... (~L) \ ~~ I I No l_ sr7~•fl~tc Ert CI! i.vECila.1/.r ~cok.NC/ f"4._ ,N<: 3, .A ~-- I~ ~~ . ~~~ '~ a ~E On IAfW W Ar NAME On NO hr h~•. a!_c? /ear.__- /ao[<~c~ fo 1~.~i'~ tr~E teol:For_tr'LLek .~bazct._l..op f-1- sway _- a.w,Y ~`°- ass ,-.-_[,co ker/_baok fi~_t^r~cc~~ h-t'._~f . . S- loo_~ec/ . ~-/ear Sc?.._No l .pcc~Pcc/._onto _.. ~ ffa~~}-;~'L~Q s_ at~~F. ~hc) /Jo..E~ _u~as _ _ __ t1a.. _.zrj-1~._'tTL._5. P_ E~~.._f'i_Y»~..---_-__ xn vLwl] µ rsrr H R.41.r°ws BrEarwercD Dr Y~ LE94Lr1 r.nnFr Vrrtlf OCCUKD ~icioN LT°fs ox Es xD xo ^r,iea ^r°ouii a/ o ^^ 0 0 0 0^^'°r~` tea"r.~[Drl. Axlmf cnossND p1pM DIRECTION to 8IRECTION Wa%wAr ]^SEIOULxn A^~I:".;,"„.,% a^ c»o"';r'8A a^Dnan .,A r 1 ~ DArtgHr aw ] ^ OASCI vMM ] ^ d15K , ~ ^ llr4lx~40N FF fR A ^ DAR%9tuFET GFVI lY 110i! OAN%NO a ^]TII[FI IxE:FT9 ~... E orrRR ^ Sricnr /~5rcn -mLES1h iMFFq CONTIIOL KMCACxFI TYPE Of ROM txRVER/VEHICLE ACigN9 vD.Klf NO I M > yr <r.i~AME A° I'K' VrrKlt KHICAb.f bl MDlnl M r ^ [ ^ SH'W49 . 1 ONE WAY [ ~ MRN091n•lOMT MEC'AD ^ ^ S ^D,pP CIGN ~ 7 IWO WAY ^ 2 ^OVF.IITANINO AI:DPASS:VO ^ ] ^ WFIO S%W ^ ] ^ rnirOVAD v~E j ^ MA%INO nN1NT TURN n ^ . ^TLA5rN0 REO ^ E ^ ~ '~OO /om~ / W A ^MANIIIn I[fi TUIIN ^ a ^FLASrnED AMNER P IIAMVI I ^ a ^ALIF.Y ^ 6 ^MAxfIOU~IURII ^ a ^ Ia14fW Al ^ a ^lE1 lUIN ^ A ^ BI.OWINO ^ T ^ DriKEn/f LAGMAH LANES ^ 1 ^ fli OlrFO fOn TIIAfFq irl~i ~~ t~:, ^ A ^01 fR.:i ECIFY ^ E ^afrAIIATED ^ fl ^ORR fl~OY dDF1 NAL I .[ ~ ?rt? Ri O QI ND IR~fIr •......._•. ^ ]' a UNMVIr10 ^ r0 ^ fl~ANI N[I NnOADWAY I I , i^. } ' _.r l.'" ~q , ~ ... - a ~G ~'m>^+;, ~3 J: W~ -. ' N-'L~'F'it ay'r5 ~ ss ~ ~ eme,~,~y;Y; r4 1 ~„ MSfiVt r iATE OF WASHINGTON ~i?A I ~ ''- ti~ ,dOTOR VEHICLE COLLISION REPUN( - ~ -= ., p _ DAfEOFCOLl1310N _.DAY OFGOL SW MON o,r ,R rE USION TIMEOF OOlIl310N r Pw r rd •~ uwutta AM GOINITY NO i CITYNO _ r/ ~ '.!^ ~~ a~ N O fOWN r C M ES i CITY,TOWN VM ADMCl3. PPEFI% OVif nEDtOOE SECTION . ~ r1~,o On CAVE N: EOF STPEET. RO0.00R HIGHW MIERSECTW6 W(TH:S EET OR NOAD - PPEFI%. EO - MILEPOST -' >~ ~G:9 t u .r .. a NON NTERSECi%JN~LOCAigN OF COLUYON f~Ei WEEN SfREEt ANO T T MM DIAGRAM DATA - 1 ~'. P ¢A W N^ © n,N10,n CIgaYRO MLEIVSiGi~q[xiiwi ru L,xoM,n+. ° INO NON %RO WTER- CL9. wtf MpaREET K rign4al [E ruwlgxww,vfo (~-^ vExKLf ~NE:4 ^+FI:CLE rcL[ ^OfNfR(wP11El . I o~~IEOR~E K` ^lulR°r1 " SPEC.CODE USE ::r ~ t'. ~ „ lr ' ~ 41~ , ~ MrYfRKna atw..l o r~ ODIECT STRUCK ^YIEMMEOF pufti ntwlCy OWNER OF OBIECTSNAM@AND ADDRESS LOCA W ROA Q© 0~ EOat TION DWAY i0 nvAwaalECi ' fEEi (~( S OPWERSLAST NAME °FIRST NAME MIDDLE 1F MORE wc~vW DRIVERS LhST N.VAE ° fFiSTNNA~ .... M1Dp,E ROUTE w ANOBO%NO.. R S ' MORE Tr.w lv.D STPEET ADDPESB POUtE NO.AND Fq%HO.,,. , . ~ . ,.. ... STPEET ADD ES ' n r~ ~ ci C~ SwEPE A vN°H1 Ry1. +•yv J~ • .~. ,. ..STATE ..... .'.:... LP GOOE ORNER9000UP ON cEau Clrv AR tE ..: aOx Ci STATE ZIPCUDE pEWEP94CCWA1gH.. - . _: ~, REPDIt TFpw ~ / / w s p11VERSlILEN3EMJMBEP .. .. . 9TAIE SE% DATE OF BIRM AGE R ~ OWVERSUCENSE NUMBEA STATE. SE% DATEOF&flM ApE M F r Y V¢n q, M X .~ DAr S, -ZT- .-LSD • _ _ ~ 3 . MOOELINOVA-0ARTI pODY STYLEI20R.1 VE IDLE YP. MAKEICHEV: DODOEI VEHN'.IE YR. MAKEICHEV.'D000EI MODELIwVA-0MTI BODY STYLE110f1.) STATE 'TRAILERPUTE NO iATE . TRIJLER PLATE NO. STATE A T E LICENSE PLATE iKI. ST ICENSEPUTEtq... /I , • • / T [ '~( ~ /T..7 // ~ c,~ '3 QP~ ' It'ABBMODEL56 NEWERI ODOMETER (MILEAGE) ~.rEHK1EIDEHRFICATN)N NO. VEHICLE IpENTIRCATK)N NO.. ITBeB MODELSA NEWERI. pOMETFA MREAGE) REfASTEREDOWNEA. (LAST~FFL5T4100LE N.V.tE1.. ._. DRNE SUCENSE NO._ PEGISTEPEDONNE _ILASTiIRST~MipDLENA111F.1 . t%RIVEPS UC NO L -1 ..y _ sr _ ` OWNERSAOpHE ~.ISTREET,CRY NJOSTATE) GATE OF &qiH OATEOf BIRTH OWNERSAODRf.59, (&TREET,CRY AE(OSTATE) ,r E -3 - P T Lw D,: rf F Rf. 3 Rmt A PANTS OF VEMICIE DAMAGED ~ ~... ,,_ PMTGOF VEHN:LE AGED ... ~6f-7 f.~l11YT Fes' s ,b - lL, s WAS TNFAEAUTOMORILEUA&UTY WSURINCE . LIABILITY INSURANCE INFORMATION•VEHICLE NO. 1- wvERAGEwePFECrfoRTHLS ACaoENr CNrouR CAn ES ^NO NAMEANOADORESSOG tIABRlrYw3URANCEPO ~Y OER ~ CECOMPINY... .. j urE A F 'Orr s z ' J''11 - NAMEINDADDRE590FW&IITY rtL3URAEtCE AGENT ,. D(Y V STATE iP'/ LIABILITY POl1CY NUMBER .. .... ~ [sEPwutetRFwTF AnOlrgxNrIAFAER 'KIE i ~3i'~j4!J - .. Na IOE TN0INJURY: ISi WJURY - NAME ~: T NM1E __ ..... .._ su _..._ _ SE% ADOPESS 8E% ._ __ -- M AIXME3 , M ~ _.E WK _ .. 0. O l .. _ _. ._.__. _ _ naM - -__ _. _._ -. - r,Mw.r%%.n.~noctan © I H.Mi°"° ' v' E..M«.rnxn.AmeroR+ ®~ °x°,M°i°A5 - ST0.tUSOFwJI%IED MMKiW3T CNE THAT APPLIES ~ SiATU90FINJURED MMKFlRSt QIE f1UTAPPlIE9 - .,,:_ ,A QnwvlR WVEHK:IE 06u pwo AOR NS,ot wnHlgE quy(R WVEHK:LE na~wp xd M9,RLNn POS4mE Q 1A'3ENOFn gLIED SfNINI N~I~ Ile E~Vp,PVM ~AY'AwGUt ~ 2 NILLED IBEYERFI INrKVR POPif~~wtClT I r wE to p.wi Hp . ~pt0Ea1PMN ^wolnlwAR o:,t. ,w1.,,f.,x ^ So B^ / o ,,t„.IRN-L, ^ 5^ e^ F.gWNORiHiIY ARROW WCIRCLE ~ ~ DE~~991<iE BELOW WHAT HAPPENED (REFER TO l4HICLER DY NUMBEfry ~ ue ST 'f d i wpDMEOn,NnrM1DA.M , wRMNw.(AKD t.tA,~EtxEOUrLw(tw EC~f ~ '• ~ °~t`~'~,~;,.:~xA,Ra ~, ` ° M,MKn fKN Nr.a E .,o abrr \ , ~ nwEnrDwa,R.YtL,.Awew ~ ~ r.nxr, . --~ CIF- ` ~ ' .. _iNGS aN.. HA i /G_~as Par /~/. /1Pa ~•~' 1~.2_e.7fE/'/i~c, ff~Sr/NGS~'~~-~~m ~/7e.Nol2ri-f.pur'oF._. .el~ew ..C~?~2.. /, u.'vu. e -{r~-- ea ~l. .t G___ ,a#~• ff7/// eaQ o~ u TH ~-he fE' '~ 22 s . , ~ ~~ . - _._.. _., ---. l - A t ~. . . - - ---- .t _ ..._ ._n W_ . ~~' ___ _.__ ~ A~'.3,ea.e.~hone Co._vG~n~,~vaS !G WC'ST QI lAtD1NG ' v /~/ Q . . O/n Qp0.~SSiNC~~- `~•CJ Cat ~ ~ C0.' ~$'Z ~t .~, . --- - dRIUPWAY..~ Q _. i ~ ~.. _ . ' Of Lw.ES voce voPCU~ owu wYESmAreo or w n.e Lro,LL. nuxora unutr Y, ( vEweu «eIF'E'o ^i,n ^omen VEHICLES POSITIONS BEFORE DECISION ItEET ORInNIWAY NAME 011 NO pRICIOV to rq H NO " Hs tlgl rglK( 011 D1 1 ~i. ~'('. ': j ~ , KIRCLC N S C W ~ O I D ^ D D O D. OFCDILE '~o:ilo»°" ^ O . , uy~; J( iT+OM DIRECTION I To DIRECTION ~ Nl . n NAw~.x ^ D ^ ^ ALDNR uoss.a ipAN LVAS U:VN6 1^.LpCWMK )^WALKWAY D^YgUI«R A^CnM'wHK S^~RnuµwE a omen MD(S IXnVER/VENOLE ACTIONS ....._ wApCW PALE MEATHFR IKBITCCNpTIONS TRAFFIC CONTRM Kxl'L+OYl1 FYPE Oi ROED v[wpL IEIIDNDIi D1,OAEl _ '~ ~~ ': ~~~~~~ Kr.tr, Wr rIP0,1 ( ,CIfM( pR~/AK1 vrr~S.: Iv _Gl.c.urwl t'~OAYIK;MI ^ t ^NCJI.LL4 ^rl ^OHE VIAY ~ I OOOVq BTIWd1i:WE.•:: AM n AA 0 AwNNn r A ~ . , IN 1 P l DDRV ° DIIMNiNO ~ ^DAWN ^ a ^S10P iAGN ~ t ~IYA WAY ^ e ^ OV[11T ^ .'. I i ~W(t a ^ WAwtAq O O DUSK ^ J O YR lO SIfW ^ a ^ IpV~ iPLC ^ D ^ MA%Wl1 RIWIT i1tnN T J W ~ ti G f -I O l ^C'A'OW (^f00 A ^ lG to ON FT ^ A ^ /t ASNmO RfD ^ A ^IlOOP11AA4 f D , O MApw (CFI TURN ! D OACW140FlET ^ e ^ fLASN1N0 AMnfll ^ ! ^ AILF.Y ^ e ^ MA%wnI1~TUPN ^ t ^ KL ! ^ ~ i M:CI YI ^ ! ^ ~~ftliv E ^ nnUFt IK:Nr4 ^ e ^ RN UGNAL ^ e ^ ~tfi TtX1YN ^ e ^ GIYMNp IfFwvJrt FOK if SE[wOpAHfiR (^ arHLry ^ I ^OIrICTn•IIAOMUI LN1F! D 1~.4iOPPFD f011 TRAFFIC w.wAVwvrn mrR,rtrA.a HCI CC ^ e ^DIIr{R.'PfCIFY ^ 1 ^LfPAPAtEp ^ e ^ORBTW'O A(Vt~°L r, ~ ._.....-...._. ^ % ^pNOED ^ e ^ 6TOPPEDwIIpAOWAY '• -" ~ ~._ ..___.... ~wT K: I'-1 a ur. o" 0 to [] arra ww ,` _ .>~t it il ~. ~, 1411- ~ .. t ... If '!t g?#MYEY / ~7 o7~ POLICE TRAFFIC COLLISION REPORT ~TRAFFICWAY Lolrcf comnwwrnuMBE I: PRIVATE WAY .. ~ 'ja - o r of al wr ul N - counrY couNrr NO. a a. fNWw lusE [.ao NOURI ~dAO ~O ~.. R,D ».4 BN,„, ,; •f:; f63d v,1~ /lo ., ^DRaNE ~~ ~. [IN ^EW~^~-%rIN E~//] CIIVOR fOWN /w. 6NO.Of5f4ffiOR HIGHWAY iCTC45 7 of/~j pry ~~ z MILES ^s IaI OfICJ ON N / /(/JO E '7 ~ N SfRINGwiH•E1Nf OR pNI NONINIER iION PRFN% f Mf f05T x I' BfM1Vff p Si4lfT SiaFFI ~ 4 G/ r f K / OI ANCE 601aK,1~ i x 5 [ .CROSSSIREf O NEw4flrmllf ~ ' ACCIDENT N DMG4wM Dw A } d [Ei Of O e ~ MCODE E J'~ ~.., , ~' rt"i,' - Dlu$KIn IN Vfo: VERIfYt wN4w4m3 n INiEN 0.S Q SN[FTORRWOR ~~.,• NCE - - ~'~ ..pR t°rAI NO. NO. KIIIED~NO.INRIRED~ ^n4IllAOE ^HIr64UN ~~~~ ~ pVFNIClf3 a 4RORRfY OwMAGEONIV ^ Yf5Ul1ED ^OIIXF~ - yi ~l ~, N ~ An OBIECI EiRLCKI FOf OB1ECTSiRUCS.WDOVMfaS fuME) fSf. DiINAGE SHCW COgNG IGE ~ / ~ ~ y(, ~ 7: r ,UNIT NQ.k~:~: UNITN0.2~:..^VEHICLE'.-s'-..^PEDESTRIAN.. ^PEDAIC,yCUST -. ~.,.~ p4NEN5 NAVF: U1Sf fl ml M• GrvEN'S NAMk: Iw31 - ~; I ml $ staeE OE ',: DRef DDaess ~- ~ _- ,~ on sue nveoDe fHOrNe NO. D srw E tx` u4n RS cfusEN . rwt a I Iv u N fa. t , /o M oQi a "i6/ ~ m~. ~ ~ - r'~ OCN4AIK)N i'Ry{. f6RrONF NO. EYFS GHi HFIGf1I E occDawo°N fINM FL %qNE Np. EYFS ElGflr Elfl°Hr ~ '~ 8 v( , ~~. ^ CHECK(/) iHln w A ^ CHECK(f~ ANEMq vEfSf.'""~HE9"" '~ y.~..~,, „~ ~ NODES- ~ D a u % i w 3 i e a CODES -* 3 ~ N 3 exe 6 wf n 7q '~ - rv.s O "" ,fKrDE. M°. :a"' sn: BDN n . D ;t -;~ .°.FilY.s9`°°"' ^ •..%wHa ^ T'°6. N[ ^ ~:R. ^ ::I cu ^ r:. v C'W E ^u ^~<~ ^„ ^I~ iI fH YFAN MwK[IDGDGf{HEV.1 InIDVw) SIYEElaO .{ Nv.l .Y I NMM.) DAN VA) 9: rv.f f~ ~~ .ES SrwiE f ~ IN•IEER MtE NO. fwrE H vtH. IXON w _ ~ ~~'S- 5'yy. 53.5 I • Eq n [DE slur Ho. ~ vw IEIBfNnn I •~3R ~~ _ ,/ .. F45 ftDOWNFR IASI IIRSI IDDIf~ FYpN[NO. IS O wrNER. Wt r fIRSt ~ MI ! ~ k0. k o ~~ ~a! I° essaowfNa r_ N n N a ~/~ ~ •.;~,' r~ z jf~ NwMEaAOOa or IN RANC[co. eo AGENr ~ E In H wP ~, ~. ~;~ ~ =: u R n 1kPTP .~~ Ep°"!~ ANU orr.w i eH.NCf eH•4u µ ~ °N•f~wro %aeA n '~~ r [ 'w~! F ~ o~• s fsi. oAwueE ^ ^RWrvw ^ aEwwrEeo ~ ^ °ewwv ^REMNHeD Es .owMwGf , • s ~'~ " s •~ ~" ~ ~ •r ^ rev, la rroL . ' ~ ~ DIAGRAM OF COLLi51 N; lu u IND Eno4rH DESCRIPTIONTOF COLLISION: IDEE SIwneMEMµ SHEFiIr NfCE34Nr ~ s :'~ ~. I> , (-... .._ SH UNEC[SUNYI. I n IE401V _ ._.-~. ~- _ f F, ~ ~~,p .- f Ty ~-~-- l~H~q bts_..AdiF~acr~~D°s - , ' ~~ - ~} _. ~ ..` f~ i- r.':~ ~ 1 .:..~.. ~.-, r /~ ~T ~ mG!/ /G ~G!/G/F/6%GH.B4.~ _ _. I'~ ,: , /T 5 .. _. ._ ... s{,,7 h I:~E~ ~ iY N.Mf / 4.PC~...UPA ~T~ WTN~SESESnsowwr`IRN~iM.s..i~~~ED...i~I «u OD~ci~ r~iw IN Wx -.EE?~ ..3f n~f a. -~e1ECr :ar ~ +ry ~~I. ~.~' rwe a ,, ,~ ~' ,, 1. ifs ~ s~~V MDO.Iss ` ,11 _ wMn ^[".t' ^ y ^ ^~:~N Ly~ h'' a •~ n~ ';5~ ~ •on.fss ...- S.E1D~ "E~uo o~... °T- _ N mweo rxoM ^AMn. ^'°%f ^.lH' . ^ .±+ ~ p ~~' ~~ '., ,,....-, ~' WNf ~vuwG OEEanNAMra<Ax< eAOOU a. ~. iNCr ~'""rnr N:ronf ~f+o fs%Ia .~u D oOaRefwrc~wrrROVroer ^~~ o^ ~ ~,;{ ~.~ ~ ~ ~ w.~ ~ X /E.5° /7d~ _ p E 4" Y f, aU_ '.w rH .Anti ~ Y .l.1 =L >r- V ~ Kdyv l,I~;{ ~~~ ~ t' t ' ~ . l It~ ~ ,YE I 1 "}'',9~', 1 1 ~ i ~~.tty~R I { f~G ~ 1 ~ ~ .~~' ~~ p R r ~'~ ~ fR~ 1 ~' ~. ~~~~ POLICE TRAFFIC COLLISION REPORT ~C TRAFFICWAY w31clcomiuwrriumeER I l ~ PRIVATE WAY .]I DA E i l A l ~y1 p`M0E -W\N(IY `~\(~ `~\ CWNEY NO. GtY NO. ~ {MMA l `v.D I\. ~.- - - IUE3..-.I i ' iL'~ ' lsEl \~RI v\`'. TrQ.[S.~i~ /~ ^DRGAiE 4Al 1~ I iL ^N ^E IN ~/ ECFf3OR tOW'N`` `!~ AME6N REEtO HIGHWAY iR CIS s RWIF OR SE Mllfi ^5 (]OF /tln'1 VJ~n ON ` \ 1, ~ 3- .9.~'~~o ~ _.]] ' lERSERING WSTM RF OR ROM NONI FRSFCII ~~~„~ ` - r `\ RREfI% f mM1E ROST ~~'/ _ P~i ~~ N •' e . \ ,S~V~etYt aW srwEl't~ v 7 ~St CE6Di .CRO535t EEO FARE IM t .i CCIDENI RPM AM DAfA iEEti N 5 E W Of U ~ 'E,`3 MCODE E A ~ h~, STONINVIXVID: vERIIY: '1f wl[sl» N 77 ~D}1 IOTM NO. NO. KIIIfD~NO.INAIRFD~ ^Y%IAG! ^116[ yr. 30»onom3 IMFR CLS CROSSS}p`f/~~O/4RW0 `-- T.iY~F '~{~ Cf VFN afi ^RWfERfYDAMAGF DNIY ^pEE liEO ^vfHl<IE %"/~s~ _ i tSTRUCKI Oe1LCT 5iROCR ANDO fR'S fs~.D SRECELL CODWG OSE •. , y ~ "' "' "~+ ~ ..,'~~::.UNITNQ I"~:' ., .. ~.. ~~ ~ UNITN0.2 ^VEHICIE - ^PEDESTRIAN ^PFDALCYCUST ~~ _ D41~fvs IASf I D rv R's NAME: usl I l - - 4I \v~ ~ \~' \O~ ~' E ADORE 5 ,~E E_. `L. E,. sut nvmn vHDNE no. O I r surf w S ~,, Y`1 Rr~.~o ~i11 2 -~3 R R ffii OCEn N $IAl % I W D H NO. AEE 91 N ~Aw110N , ` 6 NO., EYES GME ~wK:Nt E occuRAnoN fIRM NANF 6 RHONE NO. EYES IGNt w%iHt ".. ^ CHECK (~ vf» SE wsAN fmn n ofANOt»eR. ^ CHECK Ifs vfH Of ASAN fmvEEiYEEdwNOtwR. ~~" CODES - * D a °,yn» 3 e tKN 0 w CODES - ~ D a,",TS°' I i:iv° :'"t 3 excroN a sM.N°e ' ~ ~•ss bM ^ us ^ zs:~E ^ ;~~r~. ^ w.fI,A.KF ^ .~;TE ^ ~:N, ^ nxaE ^ :D:»3. vf~H7. YEAR µaFlpppGfLMfv.l EI IDMt.NWA) StYIE I]DR.CONV.) n^Y fARpM I IEV.) N9Dfl lDMt.NOVAI Y ( (j a I sl@SE tRPIIfR M]E NO. s]wl H vfn. aoR A R N . ~. ~,C l1 C' 1AfA I A IAy ~~ YFNKSE DfMIrIGt NO. C vfHlaflOfNi fl t N A R[US]ERFOOWN[R: VSi iIRiT MiDMf RHONE liO. I D WNFR: IA53 IIRSI mIDDIE I - \~cc ° wWWS3p OVIlff9 N w fR "~I '~~ o EO E J NAMEE ssdlNwePUU CO. wAUNr +u AN R I DAMAC~ A4ew ~ I%SwN w guAACef Aau ! MSM I •ewN /~~ S ~ ~ A p CNA4Gf CHARGE ~"IRC ~ .IDf ,.. ~t _ S f5 vfN FMA NFD D IVEN RfMAINlD S 1 DA.MK I _ 5 ' I ~ ^iOVAO fOWfy ^AWAY ^ IO~OTYON ~" z TTT DI GR FCOl 15lON F IND f E IPTION Of~llI510N Ilbfi A[M MAl3WO IiRC! 1 ~ ~ S f V Nfasun 1 e Y t ~ ~~+~~. ~ ~ i ; ! . ~ r_ _. 1C~~21Y0~.._. cwt ^, ~1.~~,e~-, ,~•l~~y. ~ .. 4 _ _ ,i .s k'l~£ -.-~ ~ r :.~._~ I 7 ;._.~ ; t ~ ~Qu ,. _.l- __ N U- ~- L' ~` ~~t ~ Q l.~ _. ~r ~7 ~t _ ` R\~~~V~~~~}~~~ ~~*~+ ,.,, s C ..:. I_ e ~ .`~~,~/~ ~ ~~~ws~aC l G3~..._!YR.S~SV .]e kv i E r... w..0. ~ .R3 p .r T ~ ~ ~, w R_ - t... NOCCUPAN~S/SWTNESSESESa~N;AmwNVOWED ............. ....+COD^Gf Ewru._~"~ 2 31`~ 4esr4. ~ a "6~~ _ ~ .i s~"~ uv I ~ ,r s ~.~ NAVE- _ io. vl» t IN rc„ ..-,.. ,,'~1 l C. t F ~_. ~ N~'ss .__. _..~_ .... .. ._.. --- _.__.._.... iN°AUntd-°-_--'---'-' ~MOVEDrRGM^AMe. ^.olKl~w31.R ^R'x ^~:,Rr o Id~~E'. y~ s NG " 3~1~, ~ AF 1.r NAEwed ' ~•.. ~:. .mau .. - ..~... .. _._. .._.._ wu.RS .. __. _. INee. ^AMS. ~crwcE ».. ^GHS ^~wv, ~ ~ ~::~naRp ~';. , 6 '11 E~ a~ ,5 X ~P.e r:Als.c rr 5 uoeed Her E vw3ewD pyllSF CtlIveD DAlfdnro. n D DAEe ~ ~v'ry ~ + , 1 t~+15 '° ~ '. R R~',b ~ .g..,/.:; rE . •~!i ~{;, ~`3 ,5,,'y;n H v.t'..Y.eE.. rY} $Y„~+~,I F r :..~ .r,.ra7~ 1 << h'}, ~ f,. ,I I ' f 1 1 1' r I. _ I h 11~ 71~ 1 C ~ _- ltl - ~ , E ~, l _`~~. .~ ~. 1~. ., I %i n~~ i r ~~. '"ygy~~ ~ti V ?3 ~ a 4'+f' ~ , tV. ' A rs~P~~ ,, ~ 1 ~~~~ s ~ K.v i f ~, ly. Y} ~`" aA ~ 7. ~Yi%+~ POLICE TRAFFIC COLLISION REPORT IL~ITRAEFlCWAY PouacoMRwlNrfluMRfR PRIVATE WAY 'R T I • D+rf of,cau5 N +r 8C D+rGi vls ntD AV,f ~,~ ~ umf IUSF ]/00 itOUgl couNn uNrr NO. ~ urr NO. itwA ^URlAH O ~ I ~ RURAI ~ ~N ~E ~IN CIEY OR tOWN NNAf6N0.0 SrgfEr 09 NtG WAT wus ~s ^w ®oP ,i~t Yr ON Y ~~.~ H:rCU ~ ROUrE 091 .-~ %~ /7G' S ON :] INrf95EU NG wsIH: SrREEr OR ROAD-.ANON INrtgSEC[ION/~ Eyy'~ (t [~ Rf]VIfEN ~~. U 519FFi 6 \J \\~ 5[RFFT putN% [O. MIlE FO51 /O/ 0 IANCE 6.' MRf3 N 5 F [ •CROSSSrREf OR NfARFSTM~I fVS Q FEEL W tK !/N ~ r / A[CIDENT MCOOE E R P DuG9AM DA[A CaIISIONINVOIVFD' SEVf9 rv. (~6~tUN ip ^SP ttAGF O^ NO N]URFD NO %RIED musty MIrvRRRrn IN X~RD INTER CO I F SRf 04 O4 lRtM:E CR06SSN[ETOR ROAD ']S _ ~ TOtAI NO ,5 ( 6 VfHlGIlS ~ ®PRORRTY DAMAGE ONIr ^ pESUIIFD /VFnCt% r~ R/1 y OSkCr SrRUC%INIMF OF OSIFCTSRUCR ANDOWNfR'SN4Af) ISt.OMAAGf SRCIAt CODMG USf { 5 _ ' UNIT NO.I UNITN0.2 ^ VEHIC[E ^ PEDESTnIAN ^ PEDA[CYC:15T ]+ 3 NtVS NAME: 10.,r i19 r MIDUEE l~ •~r G'1..1 v1 F.lr • gvfg3NAmF. N51 {IRT~~~. p ,f _ +~ SiR[EIAI~Cgfl+ C r ~O. i J~7 _ D 1 FEf JOgE55 '- / Ut SfwtE ZIP COIX PHONE NO. /a c.oG 933 n~on~,E R Crv 51AEF LIP E 1 '- MR'S DGfNSE Not, SIAIE Ow o ; trl "r.~ I ~ I'/ q' UC[NSE SfAEE % wrE DIRM D,r fir.. _ P OCCUDAEION NRM NAWf IDHONf NO. EYfS IGHr HIGHI E OCCUPAr10N FI AME 6 PHONE NO. ~ FTFS Vr[IGH[ 1lIGNI ^ R CHECK (.7 IvfHiCllASAN (MRVrt oPANOrHFa~ ^CHECK (/( Fws AN empio"vfEODANOm _°p" CODES -* 3 n s F a s; CODES ®* a d A sr s e s. ` ~ I IURIK ;FEM;o..D,. ^ AANM.NRt a ~ E ^ ~:D, ^ ~ Ka ^ ;wNf. o Amfu+NTE ue E ~rR. ^ ~:za ^ :~;.<. "tl ~ rFH 9 MAak IDDDG«HFV.I MDDEt IDADr.NOVAI sirltl]DR: cONV.I V 1 ECHEV.I 91.NOVAI nl R. v. v N`R D ~ rR LnTo c 2 E r v H. NSf RAr S[AIF RAItfR RwrF NO. l1AlE H vEH COIOR - N Il i N I YY _ ~ ~~, , I f 12 VtHKIE IDF ICAtN]N 4 58 i vfHKlf DENnE CA I NN ~ ~ ~, I~, I ~ ' ~ YQ RtGOrERfYOY~~OWN''lR``: IASr 11951 DDSE ~S..C t~ ~ ~ • DHONf NO. r NoI~E O I F9FD O'NNtR: lASr NRST MID t NO. r ` u woo euor ormr N w ooWNf9 ----' ~~ Z S DLC . awooRESSaP INwRANUm. oo wcfNr R ~+u ~- / ]] ~ w DAMAeeowv . ~,. ~ra"`HM CHARGE "~"a.`iM °]'""'yoE] ARU a..D»u CHARGE DrHr.nYDF ~ ~ / Y D, ~ y E51. DANAGF pit ADµ~: t NID DRNlN REMAINED tSt.DAMAGF RYD _ • y IU,D~TOii 101 ^ AWAr ^ fO~OTT rt WFD rdH S .r er: ,LCSOA+ O Awwr ar: S + DIAGRAM OF COLLISION I MfN l NDKwrf NOgrn DESCRIPTION OF COll1510# lusr suPRf tMrM SH[er NfeeuARrl ' I.. _.. ... _. 3Nf[iU NEQ35ARY1 . !RRO+/ r!' ... .___._ i"~- 1 I r N ` ._ '~`/2 e ~ . oh , r ~ crp O e z Tlf~ RoSOwflY~ Hxrrxp~(• _ .._ ^k.Q !9 tJ,crcH Ae..n F2ou..tn~G- ov~R, co~~Itn,G< To lPEsr an PASSEn~r ~t~r TNk ~R , ~] y . . rt .._ ._.. ._ - - - - ~ ~i 1~' - - :. .... ,~ , ,. :.. _. _ ._ ._ _.._.. .._.. 50 ~ ~ _. c~ I~ NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED + CODES 1 - Z 8 4 5 6 OCCUPANTS /WITNESSES roe sADwDiltomNt~i uAS'A"e ii sr% Ace uwrus ' „"„" " ; R t Sr9. U[CT ~'C. M AME -.. ~ i + DNI55 .. NAIVV p A ^ AM A. Q L)~Kf ^ ~Rt • ~ N ^ { P%IINS+ t Wls URIOI , a~ Y~sMinruDMOAIAM nKA91ORm,^N ^n' ,, Rr p Aqt ;U A nrwSA iiuviw ;r'"Enr"' ^wmR ^:::'^rr:n. ^t;~. ^":,,. , X ~. ew +.e ~ sN+ A, ( sAU Nw I wtr.cY "'°' Sr~I~~9n r ~je~~yt'n Y ~' uA N OFO io+.E~ f ~xrvtonr oAti- FYUr! r ~~ ,/t,~NS , ]MDHR _I ~ ~ ~ L<~E?-cL. L_. ' ti I• ~y •~'1~! ti ~w1M .,d~~ ~ix~..~^"i~ ~ ~ , / '3 W ¢<';IJ v ~ .on` ~,~ ao ~i •~ ~ ' ( 1 r. 1 I / >< 1 i ~~ (I I ~ (1. ~ / l 11 ~ / ~ ~ { ~ I~~ l ~ - 1 } J ~ ~~ ~ I f . -,. S , ~ ~ ' _: 'L1 .~, 1 y, 1' '~ 1 ', t 1 I 11 4r { ~t91 3 -~~ - , r • I I ~ tar( . ~;: N ~ wrK.a ~ I .ux '~ sln< .~ ~X..~r„ P~t.R I ~ ~,'. ~,~e v a •. f .,~ ~ ,. ' ~1 ~ ~tr ~ ~~_ . (~ ro 8•"Y4~Yi l .~ ~ i 11 Y~~;~ ~i~~ ~~ r r I ~ 1 „~~ ~~// ~~ r P A ~ ~ 6t'~`~ I r 5y E. tl' ~'"ru. ~~ i # r A 1 ~w. . '.~'J'r•3J POLICE TRAFFIC COLLISION REPORT L,XITRAFFICWAV fOIICFCOMftAINMUMRW I ~ PRIVATE WAY t oArt i us vo Q G( Der c u ~ " NM[ _ fun "/ly ruD w10 iw+5 Ni Yr I~L?EDD bU91 ! x 5 couN~' J~~ ` ~J couNlr NO / / (J cur NEE. iHWA QURBR.W Al ' `~ f CIEYOR TOWN FP6 NO OFSIRfftOR N:ONVIAV MRFS QS Qw QpF Ct ON "l..E~~ t8 rCTCLS 5 t ~ ~ <IUN INIERSiCrING Wn~: d9.tfl0 ~ NON I~Nef~RS/FC1t1Ep~N.~A.... P(~ I R GEM[~w'"''V,1 L~/• N ifI6 ~~ l O~ itRKt NrtiIK f Xl POSr ~O /AG SO I ' ols~ ~sD v Masi N 5 f 'c9oss~ Lf oRSARESxr~M1 ~0 ~ 4Lt1.VL~T" 7 r MILEAGE A coDE f 9AMR olADn V N7Y COll15H)N INVOLVED; NO. Kllll[D~NU.INNRED~ ^SRIIUOE 16R torAL NO " ~~ E9tNCE ~g 5 CV VFNIClES RROIEg1Y OAMAGl ONLV . ® ^iR~"suufo b[NIU - ~~ N- ,+.t/04 ~( 9 OSLEC15fRUCKfNAMl Oi OSEFCL SiRUCK,MDOWNE SNUnEI [Sr. D-=AOf N q s SRKW COO l6E UNIT NO. i UNITNO.Y ~ VEHICLE Q PEDESTRIAN ^ PEDALCYCUST 9 09NE9'S NANf: EAST ~ ~ fIR IDDE C-LEANT -~D~i lCK O. 09rvF ' f: NSI F 9 1 t UGKE/QSON ~p,B~T C. - ' srR[Er AOD9ss 2~6 -co S ~ (Zp R[fr ADOass ?~/ QLZ • S •^ `J . Equrw. gcr . svr 36 . r. G UlY SfelE I CODE ONF NO. S~=4urwL ~A. ~838z G83-3t D R SAIf C IY V~/1/eouv+t~ ~~v.14866 69 67 I NfP'S 4CEN 0 5og P? SIAIE X I N -wA. rit jpA'~7R'5o I v I IC N V G4/l~8 SIAIF A. X rta dRIH ~' ~ '. I . 2 Dkv~ FIRM S~ !5 iGS 58 a Ai~or ilRQrfiQN.4.e~a E 5 %Bo ~Nt - ~,CHECK (.~ I veN E : I;Vlrf AHOm v A i ^ CHECK (n I vENICEE AS AN rm9ioneoi ANOINfaA r CODES -~ D n e i "' O s r a ;,°N'Or r CODES -* a n A ,. 5 EXCroN a ,": 1 Z IN uRIES f t re:"°"-C7 .,.,K.,KE ^ uS° ^ ~b:~ff ^ „ ^ ,uGS. ;L ~w.~?rwsL_ ~ M+IKK.N[f ^ vS° p ES:v ~ r<~~D ^ r:A~E. ' vfN. YEAR rM[F IDODOE{NLV.1 '~ w fl1DARI~NOVA1 S1YlE IR09.{ONV.1 l.o~ `r~A ' E I NV.1 MOUFlfDA9~ 1 '73 0~~ '~/sNV I V.) E~ i~^ 1tR 2 V f.DK EI I +f~ 5i~tfE'~ t9 Rf9=ALE NO. IAIf W H C rfN. ~ `GJC9 W/F. ~ VLNKIE IDENNIICAIKXl NO. 0 638 ` VFHItI DtNII 11 IN. o L??HG'~4 962.4.'2-2 ' 9rGISRRfOOWNFV: EAST f195t MIDDI[ rNONf NO. O f 9 f l/et ~R51 11 S IZ AbD9ess orowMf9 _ N NR 05 Nw ?2 No Sx- VANc,.u~r~,2 tu-- , ~ NANt•i~a~'i"s"i~~i`~`~"ii["cs7-~~:A~uli ~ R w~p~ ~.~ei Po2rr.A-,~Q ' I DAMAOm weA E a o.".ri cNARU cNAau gAM,u Maf w ;'vi0n~,D', / •tor o o: e5t wMAU S~ D91vIN towlo ~ L m r er D9rveN roAto Awer ^RrAwNto Q4 AweY eY: l esr. DAMACt or no: s 6 • DIAGRAM OF COLLISION: I u n M N INO UnNO9r" ~ .... _ suttu wassA9rl Er AV9pw DESCRIPTION OF COLLISION: Ilaeswft[AUNtAE SF+[eru NECfSL rl ._... -n __ ~. _ . _ ge~1eN .--tea- ~ -Y~-}tr3~e~ I t~7As _SB o~i C-~.~k.t8 t-oLLSwsD _._ BV ~LcI•l.1kz. pp _ to .. r~ E e~if *~'t I{AD S~zoPPaD -to,CA WB f,E.71A~ toAO.~I~.. ~ _~ ~ t_ _~ _ TR/+-l~auDA~ZsLroPPFDB~tIND. _ = _:- - - -- . 'T?tE W1~ LOAD p_tka4RC-~ Rti10 ;~H~`1 STR21eD ~. -' . A-~An katnl r peer Wow ~Co nPD~ A~Alfu ~ a ~A~D tAES ADf - G`'f~/B -~- . - ~~z--SroVDe~AAGarEJ 6 u ~'l. Y~1.~1 Dr ~ ~~ - ~~ .. , .. ! n 4E ~ At~ ro ~Z, 6Ae~ uP tu I~ NAME, ADDRESS 81NJURIES OF PERSONS I N V ~ CODES 1 - 2 3 ~ S 6 OCCUPANTS/WITNESSES is imub u"i i ii siz Ac[ utvs '""" v';- ^,' Resn. Ena „°iY , A DMItt ((J NAIU9 p ONE w Y AM F ^c"ItiAE ^ 'R • ^6^i.T ^iu AM+ M + O A -. DD•ESS .. rutlY' fM0^Dr Q4ME. QrpKEQ o.n ppiT ^t:: p N ANI' ~ _. A DO•ISt ~ - I N.1iUU[•I Of NKP9S f VR SV ^AM! QC'O~KE Qr^~( Un.uV • N X w ISrr:A KoN {f9s NAMf•K.w. n 7~f.2..r ~~A l E.[ua D r+06 FcfNCr >,Sy~ ~ 0 O /fJSt7 0 ~ fA•nHO DAIf MIV r r :.G..., Y.DD°O 12~ ~a A `~ wn ~!- l L/- °'` ~~e{~; .T.i' ': Mn7 ~!~ "~ P `'~ _ 1F.; ~~ ~ ~I': L~~. r ' .~ ~>~~ .yam ' ~~' t...; L ~~` rI J'A L 0.50 ~ I) I ~~~J POLICE TRAFFIC COLLISION REPORT IaI TRAFFICWAY POLICE COMNUNrNUMBF9 31 ~ ~ PRIVATE WAY 1 pArl Dec l oar crxu I N W uME c ID$f pWI NOIIRI ouryrr couryn NO. atr NO, NWA 9Al 1 CIIY OR TOWN QN QE QIN f6NO.OF 519[fr OR wGNWAY Ey oP ON C~ N ~" F ICI CIS pM A ~ I 4W EEORSfpf ~S /7O SE mtERStcnfx: m ®rAEEOx NoNINrf9uefXVw , ypeNZ Mntyosr / 3 y Bf1VREN tpffr 6 Yl' SfREft ~7/ (o O~~C[a0: E~f1 M NC .CROSSSr9f 09 NfARESf MITE AGCIGENi lE3 f N p F W MILEAGE R P UAGRAM Mrq I[kt Of [~ ~ I CppE COlll$NJN INVOLVED: VERIIY~ /] QSPIIIAGf ^N)apUN tOtAl rx). NO %IllFp_NO.INAIRFp OG VFNICfF3 © Q Ip09F9IY pNAAGEONIY ^ tntwLlFD Q 4laKtl~ wNDMOm iN IN X~RO iF9 Cl3 IN SKp SRff p90ADOp RFifaf CROSSSt/p[fOtOR ROAD G~pOt%OQ }p3 ~ %~ 7 . OBRCi3rRUCK INMAf WDeI[C'r SrRUC%ANOOWNfkS N4AF1 [St.pN.1AGE SPECW COOING USf _ _ UNIT NO.1 UNIT N0.2 VEHICLE LJ Pp.DESERIAN ^PEDALCYCLISi Q /r' sC / ~ p9;vER~s NA"e~ usr rlRSr M;oaf ~ ZS ~- '` ~ _ parvfxsf.AMe ' ASt -~ F /~ O .LJs'~blAe +L'~':7 _ B SrREflgpp9f a3 r. 2 2 G 1rREFrAWR 2l I~ rf Sr ~ SFAIF 21P COIX PNONE NO. D SIAIE ~ yEgNEN , c ' z~ . n 37 -337/v R - D f TWN. 2 lwrvfRS UCEN3F NO. SIAEE BIRIN °' I U ENSf NO. AIE % N Oqr[ B1R . ~ ~ s w °~ ~ r ~ ~ ~.~ ln os: w 1 5 ,2 OCCUyAiION NRMNgMF6PrgNf NO. EYES - N±PI., R IGNr PfIGNr 170 S- E R OPy ~N A Z fIRM N0.Ml6 yHONf NO. EYES N21GNr NfIGNi F O l N, SP Q CHECK (.~ veNlat AS:N rsuM VIYE A AfMiorNfeAL ^ CHECK (,~ I'vf Eweif ASgN fMPiEivEf aE fw fwlM A ~ CODES -~ 7 n 3 f a A eeUON ^iO CODES -+ D u a ° ' nO r' "" 5 f ,'r 2 , , nn x a s , Ass . rtM " " ~ NELYfI ; ,~- O N IL„'2: U A" O p VtN rfAR~ MulIfDDDGf{Nfv "c ^ cS:n ^ K ^ ru DARt FL NOVA r f { ~ . ^'~" E ®'us O "cb`irt ^ „ ^ w:19 %~ ~~ " _ 1 . .) ~ I s YI IRDa. ONV.1 I ~) MODELIpA9l.NOVA) I ~ S1 ~t n ~~ N ` ro~ 1' 09 (EN$ yU SIArE IRUlf9 PIArf NO. SIAIE I"i .COIOR 11 l A A I I ~ 9y I~ ' C C //~~~~ W % '3 vt :CLF IpfNtlNUlgNrx). ~: : 17 g~9 ~( ` ~ e VfNKUIpfN IN '~ 6 ~ 9 ! ~ ~ F ~ ~ ' ~'L!3;l2!3! : ~ l i ~ I ! 9FGISRREDOVMfR: IASr N95i MIpUF PNONf NO. ' t- A N P O W R 6131 u(D OWNER: USf tIRSt MIIN%E r i ~_. N NO. S- x}35 lJ_ 2 ADDRfss GfowNfp N q AR p PNE it „ LE. E 2 . °Rr TwAK' ND r I~ NAMe aAOO9essalNw9uRCe eo. G9 AGENt ~ R ,.., A 1 AN & U R OW .CND 3: Z Aou I I _ v ptW ""'c'° " eNARee agau ---• n Rl A°u• __ __ , [Sr. DAMAGf ^ EWI^ N R[MUN[p Y ~ p91Y[N ~R[MAINfD AWAY far. O. jOiioY S ®IOwfDeY: LL,CS AW I CI (OWED PYr (. W AWAr S ! Ia "r DIAGRAM OFCOllIS10N• fw ne INplewrf NO9r ,. .sNftNErattssMrl _... Br Raow 1 I ( I t ~ J I .~ ,_... L.. ,.. ,. N DESCR}IP,F~I .. _..VE ON OF COLLISION: lus[swnFMt usNEet if NeeessAa ) K.. #, . V.fP.S _SOP.. IIoUNb ON_ CR~iZ_ ANb_. _ . .. 2 __ ~ CPVSSEu oVCR "ilia .C¢NtkRtsnf6J OF.r1'o _THE No• " IF "-' ~HodGaE ~ i , ; ScuA+D $FIOUtDER ~ FIIYTtNG!. F{EAD ON (U~1TH _. iRS p3o EH. ~ uND oN 2 WNsi H B tiz GR .__ .Z~ . I _, ~d 1 . , ~ o . _.. ^ _.__ VER ~/+ri{ DRs L S'i'Ri'£D HE DzD Np R ~~ ~ ~ ~ - 1 , , ~ RN'~(TNI1vCr OF T1iE ACCZOE7v'S'A j7RtVER l/EH• `~2 ~ - . - ~ . ^rRrEb r/Iqr TN F. R(r7: }f~nuG-1fT (t/qs ouron! .~ ~ ~ ~ i/EN. ~l f~ND /l6 71JOUbrIT sr WAS 9N /1~C oN $i/Gi/GD.Q;Ee ,, _ ,TILE SNOULd¢R/ GNTtL ~7/5T,8EFORB ZEt(°r7GT... Iv NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED ~ CODES I - 2 3 4 5 6 OCCUPANTS/WITNESSES Ilan bpirywiiir~ 'iii xx Acf ,uws '"„°f" ,~; ;1 9 - lSra. ~ lHR ";[j, , '^"'~ NA/SNb oNR rPp"f 3 s- y3sy A nnprm "~~ •Sr, l2r 7~~ !NA / yAn:°: °E xEwe..' OAM n pu'ticl Q •" . 7S CE Q C:IIw xf A Avl nCRt3A rq If IUV/d ; ;:' a "6.IU I9UM OM,N ^runl Q n' • Q ~i ^,i0 b A"[ , fq "- A :a+.r Nro.1a N uun'e.r ,rA QAMn ^nY..f Oiria. ~~. ^".` X SU RANI .... nAUGE OR Ip AGNCY ,I luf ry ~D/hu MU ~ O)//f"R /-// p DArIp RIW.r Pwrnnonr pqn T f ~.. .Q SAn NR >An N.s ;l-' "'~. t a, ~i~ "R'~' cX~-E .'an't U"v6"{ 7a ~,~', ~'~N . ~- 1~ a ~+v ~ ,,t ~ ~ It ~ S ~ 9~ ~ r 1 IR 1 l- "AEI _ 7 ~1 I I S ~~ ' r1~(I':, , I r ~ F V R G„i L J : 4 I ,. ~ ... ~"p ~~ r~T '+" ~ _- ;: ~E~ ~p' " ~ J v17 F~. . 35 ~ 'f_ b ~~ f - iy, f~j~ ~~y~ n~+3~ ~R "~~ '~ ~ A~pYy~y.j.. "M ~J T3C X555'' - / ~.. ~ ~ ~~ ~ ~ t~~.uJ ~{ q _ A ~ ~ ] ~A Y E ~~.~ POLICE TRAFFIC COLLISION REPORT VSJ IRAFFICWAY fIXKE COMRIANINUMBFR I I ~ PRIVATE WAY y D F CIXU U3U51 n TIME COUNir rIf (1 (~ CWNrv//N~~O. CI]Y NO. iMWA r O NU RID Swn1F Lr 1 E].DD C~91 ~~}{~I~~vd~ ~(Q ^URB•W I ^ ^[ ^IN -Or-IYl0,9' tO..WN~II NM1Fe N0 OiS`1r/RErElO414NWAY iCi US ADM I RWIEOR t9EyC f RN ss ' ~MRFS 5 ^~I" OP 1 PMJN ~~ N ~ ~~ lZ 1 ~ 95'i70 D] INtf45[C]INGWITH:SrRFtORRO NONINr9 Crg,~Nn ~(]^,]~~ PRffl% FO. MNfPp3t /'~I.R ] OISIANC/F 6019 C1 .C90535E9fEi EA/{~f51M `F PLO--t~}~ ACCIDENT R P DIAGRAM pA]A ^ _. t I R C [Fes N 5 f w OP V~'\Gl.~l ~r MCODEE I. ~. a COll15gNINVOlVEO. SfvFRIIY, ~~1 M1f3H N %.RD SR FIOR ROADOR R[F[RlNCf ] rq. KlllLO_NO INIUREO~ OSRRUWE ^ I6RUpv wDIDH INiFif. Cl5 CROSSSiRtR~jOR RO/A~D ~~le OPVEHIfCglFS ~ RROPFRtt DAMAGE ONIr ^p(SUIrED ^VHCIE ~^ ~/ BOLO _ R"f^I R~ 091Ki5iRUCK INNAf Oi OeJECi SIRUC%ANOOVrNER'S NAMEI FSt.DAMA4E3 SPFCW 0001NG VSE ~ ~.e ~~ I 5 ~.. '... ~ 'u . ~a UNIT NO.I UNIT N0.2 VEHICLE OPEOESTRIAN ^PEOALCYCLIST Y ut' DavfYS NN,SE: ULS 19t 09rvEN'SN f: lASt iIR ~ }e SQ Cz r~fi (/ES A ~ n-e- StxlfiAWRE33 /Y~~L ~N'~~ ~ IRfF1 AD~~f~~ ~Y~,`~~~ V~ 3? Urr '\r Srwlf /` ]IP C°pf PHONf nO. D Y / !J{ SrwifLl C P I ~ ' ~~ T_Tdri/NS~NA $r//~] ~ ~c~ R - `~dGUiUSOUD ZU/~~ ~~ T,~ Z DRNf9'SUCEN r St,riE [ BIRfH ( I ICFNEf rI }ALE IRH ~ ~ 'i 2 i!i'°`3i,wx ^ AM MLuOS °4 s ^ <<"8i3f. /% ./u ^ rw:.3. SF r: ^ AMfDIArKF ~ ^ cSril9 ^ ~r;KR IN8;.3. rDg ~.sl.a'u `(~ o!/ . -~'KGL. ~ E - 72 //~ No%'L~7- ~~FJ ~~j`IT7f-fin ((]]%]Tii~iD~~~],,, ~~yq~`'p 1 I f lKE SIAIf RAILER Mt[NO. SIA]E I"I vT .RUGR 5 A N roQ ~,v'~$',q`d}a( VfHKlE 10[NFVKArgN NO. L EH CIf IOfNli a 1~f•': .'• , S1 ~ 0 " ~ " "~ y ,v O -„~~ SiRFFi ' - v .~Y E eETVFF Ei 6 ~SZBK~D ~~, <- ~I D. ;r~ ~ 5~ ~E~17 v ~' %o!zr~~ I ~~? ° T IXCUPAIKJN fe PHONt NO s IGNt MIGHt E OCCUPAtION AMEn PM)NF NO. E s Wf14Ht 141GN1 OCHECK (.~ VEHCIf ASAN rt9 EOr EaANOrHFR. m + as' "'r ma rcle ^CHECK P/) HICIFASAN fMP30VFEOF ANOtMR. vfsr., N' °Cr°3 COD * 'Mf I~ x _ H s ufer D un CODES ~ ~ ~„ A n ES ~ S e%a oN 6 s D a u a wU.{HC VEN YEAR MA E StYlf l]D CarVl II DARt NOVA rFANPoM I E{NEVI MpOfL IDMI.IgVAI 1 1 ~.y Y'•~t#?vuri A f VI . I ) . . ,, k 2 aGGRRED OWNER. ti (1951 MIDDU: PM)Nf NO. I tfNEDOwNtR. lNt f145t MIOIXF 4-/t2E f ~ f ` od/CNLE W . i A UWNM ~~~ e~ n A ly/ ` ADpvess0l UA eR , ~ ~ ~ TE aR yt ~,~~~~ ,~ NAMeRAnp9Essy~ nsuvANCf eo. ao ACenr CaF./»lr~ R Inu N A f J lMMA0t0 ARG eNH3 ~°OHN I ^• .., ~~ bLHmp Hncnl%1 gArAAG[DA9FAA ~ . ' ~~i . ' ~ S ~j]~~ro'•~-~ I 33 ESL. rD4YA4t ~~ ~~,,~~33 CnA94E /1E3 WAY ^RfMAtNID {f1 towYD CHA9GE - I~AWAY ^9[MAINFD ^ro3vFD [SI.IONAAGp ~ 3 10IrOii ° r W Y. !L " ~` - '- ,' S eV fTGL~iJ DIAGRAM OF COLUSEON 1 uP Ira' rl NO9tH __ f. ._ slanuraaSSARr1 a ow 1 DESCRIPTI _.. nr ON OF COLLISION: (SnESWa[MINIALS Eervrrzc[ssA 1 .. _. .... ._._ ~__..J_._ ` a - , ;. • a_ „- t- , 1~~j2 ;--~-'~ - I 1 i _.. _ _..._ _ . _.__.. -..._ . _ ___ - ~E'f~ecE.'~~o2r,~~ ~1~.o,v C~Rfi~f2 _ -___ ik IJ ~7 kS ~l .E i ` Y r-- ~ -~ / o,v lzr-. AsS~A V~Thto.~~.ikz., .S. - ---- / ~' ~ i ' .. ~~ a- ~-K~.• -. ' ~ - . - i - nND{~ p ~ ~a , _ I ~ . _. ., .. r ~ ~-A_ .-., ^~ _ : . S~k c~ ~ N.f~~ P~ N TruR t - L~ ~ . . Dn A I ~' ~ ~ s oCr.-ts~0,v wi ra LcFro~ Iv~15 4 Gt.c~ _ ~ ~n~.~ y r if r I I I I I . I 1 . 1 1 I '...; .. r.. . I .. ' I , .... ......... _.......__... F r ~ i !1'Irvl ' r f ,, r P ~ ~ . -.- NAME, ADDRESS8INJURIESOFPERSONS r]vMDHUV ~ne INVOLVED rtn CODES 1 .. _.. - 2 3 4 5 6 -. ... - , ' ~ ~ ` k ~~. r sll CKCUPANTS /WITNESSES f la ADptIONAI NAA x51 „ AOf IAi 31% N.r H~H , IN 1 Mlcr: RE31R. I11CI S.r I ~ r k'~ 4f .., NAAV .. _ .. NAt ~ ~ e O1tiKl ^ M. ~~' i:2l O r v N '- n .~ ,., ' fro ADwfn ~, eY K v mf n t 1 1 r~l! > u NNxI ... ~ Aruaa -- N ° a rfox ru%I ivor ' K ' `', I. ~~ '.S '. ... i. I ~ ~ Amass N'. ^ : ~ y AMe ^ W R O O ^ ~:rl. N0 . - . a ' (4, J• PP q ~ , r 1Ax1 .. ... ~ - MIWS W NAtW fa w%w u A1An. ^I.nK.I ^c r _ GC Oiav LEI IM nv 0 A ~'~' 1 'r r ~ l {R~ 'S^ . 9 ~ ANK ~ r ° f o w ~u , 1NE Al 1CMp KI01H PUF~G AR~10 DArtp/ R A . p II Q '^ ..fi 1.~J' ~ c~'/~ x 7'.ZR/~iQ ~ ~ ~~ l r o ~ ~ ~ ~ / /r S.O°Ti~ i.f~a~ri ~ 99// ~ ~ t„ 7 f ~ t,} q f~F ~ 9~j ~'~„T'""...~ 1 x„i.. t . s , , ate.. .~^_Y""~`Y~-y'17 ~ 41+t'~'j.~~"']'' ~I-f 4 ~P c k,, h' ]h f t ' J ~ :r 1 ~ z} ~ ' ,p (. m ,, rl~ IE ' ~ r ~'~ l ~ 1 3 I - ~~ - ~ V ~ W ~ `~` $~`P iN ~I " f ~"~ 1 S IS r F ~ ~r iI ( I ~) ~ ~ r y 7 1 -'~ r ~, , { 1;F~ •Y u. r ~aE Lt(+~{1ie~. - ~ .~t:l y ~~~ ~ ' . ti' k p p f ~+ tS~ n: y~~v F N-. n x~~ B rhPi~ ~~itBS .~ I ~ ~y FFF . R ~ q _~r yyy , F iF°i' rty., o3y;nk~ ~~ 'fi"K57 G ~ b ` 3t} ~` ~ POLICE TRAFFIC COLLISION REPORT ~,TRAFFICWAY RoucE COmvEAwENUmeeR ' ' ~ PRIVATE WAY ~ V DAZE O! al o . . '. rv13 - s., {e..ur E (USE RfW NOUR) counEY ~ courvrr NO. /~ arc NO. iHwA ^UR Z Oi O ~'UO L`YKq 1•v R '~ ^N ^E ^IN CITY OR TOWN N E6N00 EIORHGNWAT 2'/aMlE3 5-ow ~Gi ow ss o orv C..e, / z it Cli A Mp5 P I RWIEOR I a 9bi~o N Sf II 3] INIERSFCIING iH: SIRf~09 ROAD NON INIFRSFCIION /Cnca p~,,.,r ,gq PRfil% EO. mIIE PO$3 9/'~ /~ BEIWFEN ~. 2/} SfRfFT6 L~.+1G'Qe~T S1RfEi ' DISTANCE{DI9EC MPi4 .CROSSS1RfElOX NfAXFSI St ACCIpENI MILES N 5 F W nn MILEAGE yvo REl or rq /D/NY Q[r l CODE R P DIAGRAM DATA ] COll3gN NvOIVED: ER IYI rUM.+oNR~H NO.INEURfO~ ^ SPILLAGE HIf~fEf"iUN NO. KIIIfD IN ~RD IMER CIS IfR D SIR R OR R[FfRWCE CROSSSIREEE Q9 / ~ IOIAI NO d VFHICSES ~ PROfER1YDAMAGEONIY ^ FFypli[e ^ V MICIf / -`"~ - ~O X` (IJ ODHCI519UCK INAMEOi 0e1KT 5ERUCK N:D OWNER'S NAME) ESI.DMAAGE S SPECIFE CODING IAf , UNIT NO. I ~ ~ UNITN0.2 ^ VEHICLE ^ PEDESTRIAN Q PEDALCYCLIST •' ]' IASt i191 MIDDLE D91Vf9'S NAMk o w ~nN a ' l~•rJ•r C . I DPrvfR'SNMAf: W51 ~I1T3i - SIRfEiAD0RFi5 .. 1 4 0$ m S L//L-Y SlRfff ADDRESS z uAIE zlPwx aNf NO D IP nr sIA1E o P P, oEdvsr-NO A//1 9J'~~ 38~=FZS~ R DRmf95 UCEN5EN SIAIf f DA bNIH I rv LICENSE NO. IAIE F% DAIEw B " RC• SJt-•AR• ~ v/ N wn F oo'zs Iii ~ R. ~. ~ ~ e OCCUPATION iIRM NAmf6PHOnf NO. EYES N21GH1 HEIGHT E OC<UPANON fIRM NAMf6PHONE NO. EYES pGN IGHI z CLnca - Bp/ ~o ••a R µ ^ CHECK (.7 yfH ;iE AS fW.N OWFOE ANOEHFR.•u I ^ CHECK (~ yFH CIf ASAN FMTOYEE OEAP OEHE4 S r CODES -~ p a 9 i S F oN / e ;; CODES -* D n 4 it 5 [x a 3. n z IE;fEN~E3 nl ~~7o..D,. ...HA.~<E ^ u ^ zs:D. ^ H~~t ^ M;+v . PD.v ErYeR ~ ^ ~^ ' ^ ry y ua ' ^ ss.rt, ^ ~~2 ^ :° A' ,l .°N' VFH.YFAR NMfIDOOGE.CHEV.) M EIIDARI.rgVAl SIYIEI]DR CONV.1 R H ( E,C .) A'ODEI IDARI.IJOVAI r V.1 l R. ID ~ (, (~i.Txnv.3ru F R N D2 E b - " O4 t SIAIf t9ARERMif NO. S:AIE H VfH.CQOR i+TFI A t i TAI wH OfIDEMIIIGixIN NO. ~I ~/~~!61A~z~yi9~l`15`! L VEHICLE IDfrv i II N ~~ i iN! i , ~ I~ ~ ~ i 5rJ >o 9lGIS1FRfDOWNER: IASR IIRSI MIDDLE PHONENO. O I ED OWNER: IASI iIR51 MIDIXF F NL N W ]I E] ~ ADDR[55p GWNER N A R OWNER rRwf aAOOnessalNwRANa co. oeAGwl R "u AN ~ TF'~ SE NONE DnwGEOwatA I I ,~..' ~uArGE~AREwA ° " ° ~ °"w,',°=',°. cHARCt CHARGE oi:l:o . r i I E~ .EDP S f51. EMXNG% ^ AW YN ^REAUVNFD AWAY ^REMMNfD FSI.UMNGf 3 noN f N A.uS O A s E K D royrtD ^ Aw{r e 5 1 DIAGRAM OF COLLISION vil ya °fN SHfIE V MCESN9Y1 I DESCRIPTION OF COtL1510N: FIaFSwttEMEMx sEEefr ENFCFSSARrI __ ._.. _... ... _._. _. _ 33 Es _ .. 7 .. ( f l I I I ~e 1 ~ I ._ _tl:/ Wa.S- f•In RN/NG . 1,.G/•T__OFf ____' vEN LL.G sE - ~ __• 1 y 1 .I _.. ~~. .. I ! I.I.,..:- ~ ~' . _ OF C.A. ./..Z r.Vb11/f:LL- ]~2. /:/VT!LGO _.C A/~...._ I ; .- I , I 1 ~ ! ~ ~ 7•hR eh A/L H/Y /iti~ .B,C.E /e~f__„/1YVQ __...---.. ~R I_..~~.... ~_.. _.: _ i,. . - - - - - - - SKE00~0.. OFF. ..ROnO /NTO D/Tell AND ._.._ l~lr TePESS . _ ..- - - ]~ .r _ ,. _ ,_. . I _: _ _ _.._..__. . _ _. _ PR.MAri: .. .._ _ _ _.... I.. ~ COLEJc ..r .. ' 1 .. .. .._ __ '° NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED t CODES 1 - 2 3 4 5 6 OCCUPANTS/WITNESSES liaai grtlllo~FEU NAMIe sI ut Ace rAlus '""" " ' Aeve. um Nwf rfC 5 N R in 731-UL4/ M -L S' / / / / ({ _ .. i»rT Gk .E%wlu r C Q . LOW fa N IEx nr ^AMe. ^ :1' ^~ I ^ NA°' pro R ~E37A 0 w: to .. x+ex wAlweor .... - •X. 9iMOVUnPOM ^AMn. ^ rolKi ^wl . ^ Q ^ :: n AMI NO ADMI3f N%~R'~ IN SCINI ev.X ^AMIE ^EUIKI ^(tNiTr ^~~S ^n Hvf3HCiA1NG OEEKIRfNW1 {{ANP eMG10R AGlNCY X '° ~' pw,wnl KI DIlPA1CEKD KRKf AXrINO bAIl C9 RETORT AAROVfOeY DAII SN HH R3 ] EDO NRS ~~gyy r' r`:;`-~~]Eii ,a , ^ ~''~''j'~ L ~~f1 EY'11,.'~S"IC.~~`"ILaC :=•iF'.:'1 .. 1~ _ _ f i ~' , i y I l i , l ~ 5 ` { a rtriE 1 , ~ r~ y r ~ ~' ,~ + "~ .I ~ ~ 'I ~; ~l ~ ~ ~E a J _ i.1 1 s ~ j ~. 1 r ~ h - 1 .. I_~ 1 I - ~ 0. ~ Y ({:~ Y ,~ 1 l r i I W~ I ' l _ ,. 1 .T r1 fl Y t l T~ ... ~. P' ~^3 ~ I ~~` ti~ F :. ra ~ ~~.:.a•, .S 1 A 1 r HJ"Fi ,~sDF;;Ei ~x~w4~,e ~r ~;a . ~R A ~^ ° ° °` No ~ ~` I ~ - _ . POLICE TRAFFIC COLLISION REPORT ® LL TRAFFICWAY • PF%,C[cnv.RA Nr NUM3fe ^ r ~'.I' DALE °i ccvu rv ° A •° aElsl D u ~ 1 PRIVATE WAY couNrr ~I _. o Y 2 s rves xm EF yl N LOSE tW0 pOR1 Wulvn NO. c,rr NO. iNw A ` i l rcFPf£R50fv /~i~ ^ ~ E ^ ^E ^I.4 CIEYOR TOWN NAME6NO.Oi SEgFFEOR IN G HWAY rCICIS M ~µ y S P I gWrEON SfPf . ,y M1U3 g13 ^W ~Of C u ON K ~ 3 /JCC SE II INIEgS[C1ING MAIH: STRfFLO FOA~ NCW IMf43KIlOV I %i/~7Q N ~.I. MMY[N ft' PFfN% EO. M4f 1037 CP ~~O 3q ' 3iR[fEa "J SIREfE ~v ~~ IuNCEADIF ~1~gpM EFN .CR0353E Efl09 NEARFSfM S-~_. pti G- _ MP E W .NI ACCIDENT DIAGRAM DATA EEFE Oi •Y x7O MIEEAGE R G 1 ^ EX~ ~ DDH COll3N)N INVOEVfD~ VERITY. IOfAlNO. NO FREED~N0,1N)Uq[D~L ^3PIlIAGE ^ b UN WN t4 N Oi VfwClf3 ~ ^ PRDR4TY DMnAGl ONLY ^ gj3~ t~EN~ • N RD I ER/ Cl3 N , 54 RNOAU09 gFEf4fNCf C40353RkftORIgAD 4 ~, 3 liE0 V El OBIECf 3IgUCS INNAEOi °9ttCi3IRUCC INDOWµER'S f1RMf) Vlf f3r.DNAAGE SPIC4l H v CODMGIb! a ., _, I~ f Y3~ - } ° ~ S UNIT NO. I ~ UN17NO.Y ~ ~ ~ ~ ~ DgnE sNAme IASr Nes , mE ^ VEHICLE ^ PEDESTRIAN ^ pEDALCYCL157 - TN I s ~.~,84 f sNAMe Sr IR m IE ~ l~~ j~OR y{~ S ~ ~ i,4 ° r 1'~ r ~ • ~ ra.Ernu wfss S _ ro ~ . *l - u ~ ~ , OtY . I~' iE I P CODE PHONE NO. D ~~ pp NY I,P OD 1 IUI'J ~LV ~ • 1G R SrAIE PHONEN wE45 DC(NSENO / ry 'Y ! ,(~ + STAY // ~ ~ ~ Y' OC tlIFIH ^q ~xr Yv ~ ,v DCFNSf NO, A E SE% D ! BIRTH w OAr IvF 44 ~ p ~ ~>r~ ' Y L,1 s ~ CUP i1DN 8 Pr4M NAV 6PrgM NO. FYFS GHl Hf GHi E OCCUPAT,ON iI4MN E6OiRDNE I ~ ~ ""- ^ CHECK (.~ NO. Ks111 Hfwnr -~. Z R s veHlnE. ui wvivr DE w~ - ,,,FS, ~ ~~ ANOrHr CODES + sIU ^ CHECK (i7 v~ IN - , D a irsrz S f crgw y ~'ryr_r[IE + xsil VIHICI[A3 NFMROYFf OE ANOMfe CODES - ~ ~ 3 v` I r R sn 1o nw r ° " ' rv FYI '/ ~ i YI, _ s z.clE . s H D f 6 wm 4 •sll'~.. •~ ^ wNelAx ^ ~oL,u .rx vIl ~` DI 41 v orPO ^ e • ~vt a 4t h°T ,f a +wV wvir w l ^AVeu Hf °. ;. H EAR MARtIWDGE{HEV.) °~ YE NWw) STYIf IRDq ~CONV) y q r ^u CbiRe ^ve ^tiDiNY r Y u to ~ I f. HEV H 1 °'oo Aar ~ "{I :, ~' 9 ! VµC Y l l . vAl oR ll YlA n ? _ ~~ ~ GRN iwlE M1'MIfRMTENp AEF H YEH caoN ~~ Q s s I No. AI pID PST 'T I' ~ VfHI[Ef IDEMIiIIiAT lJ pN NO. C VEHICLE IDENIIPIC f NN ~ F . L G.J ~. I i ~ I i 1 I 4fG31EgtDOWNt41 r ~6~ I I i 1 z Tt I ~ ~ ~ ~~ _ 1. 1143! M,Dpf R ' M~a I RgNE NO. O Rf ISEERfD f4: EA3l ll4it I „ ~ ~ ~ '~^ '> AoDR ~S _ ~ E n rte , _S ess oio-M,eR C yy G.vN 4 . - ' ~~, . .r ~W/~E/LD NAMfaADD4fssaA Nw4 a ~ ~ ' ~ 1- . - wiQ CD. G4 AGErvr u AN N b R • ~ ~ , ] g i - "r}~. ~ Y~ (( Y~~ ewAAGeDAR[A rvDOx«cic~MO.r _ "- ~ fSIipAMAGf Cµ SAY CHAS S fp~epf ~p~y ^ ^ 4[MAINfO f1 D4MN .-. DAMAGE 1 A /~~ ~ 'L ~ y.;EF'~ ~ 4~ A~3A7~~"T~.k:e6ti. .y e,n u .G,i ~ ~raU:y V' ~,y~ ~ ~. EG y }} t ~ %~~~ Ea .".~1- ;, ~ 4;i ~~RR "W5 ~ I ~ . r , !* f# x STATE OF WASHIi\IGTO~! RAG. DF ® ~` Na TRAFFICWAV POLICE TRAFFIC COLLISION REPORT " Ra¢tcoMFtwINr NUmatR PRIVATE WAY .y / 2 pA= cal N un O 8Ci oll fur uD 10 M`Cif OR IO umE lU5E tK0 HOURI N ~ couNlr ~/ F6N0 asRiR EIOON NGHWAY couNrr // arr NO. ~(0 FCf CIS ADM 6 I gWfFONS(RfE HWA ^RU95Aif SEC ON Y h 110.M ^N ^L ^IN _ /J ~1 ~~z m+tes ~5 ^w ®OF W J: OPJ T ~~.2. r ~j ./ 7J ~7~ n CI(NG (NLN: SrRttFORR~AD NOfffNr[PSECNOV r lfM1YffN SfNfFi 6 SIRfEi RREFI% FO MNF-OSi ~~ O~ NfARFSt MIU 8051 U~SIANCF DI it f MYfa .CROSS 51Rfff OR ACCIDENT PAMR DIAGRAM WIw C /I'7 Ff 15 N 5 [ W OF J• ~~ MCOOEE CONIS~ONINVCIVfD: SEVERRV, N NO.INlURfO~ ^ SRIIUWF ^ e U !NO %IIIFD wNlwfDlN x~RD IMER l5 EI 9 04 RIfYtKf CROSS SiN fEt04 ROAp I•N ~ OEAI NO S d=V[HICIES m ^ RRORERIY DAMAGE ONLY ^ glSUll[D ^ FI11Qt! n /~ V' /C~ ~iZ 09:FCTSIRUC%INAMf Oi OBJKi514UC%AND ONNa'S NAME) f51. DAMAGE SRfCW CODING USE S ~ G UNIT NO. 1 UNITNO. Y ^ VEHICEE ^ PEDESTRIAN ^ PEDAtCYCLIST ~7F DRWexs NAmE: IASr FIR IDa L 5-nt .- A vas NAME. ws1 ~ I - - SlRkfiADDRf55 t ~RA1f 28000E RNON NO D 1 fflA DRESS Y SIAE IR I . ~ff~~8 O R oR.vfR'S UCFNSfN P - - L G• 51Af CUA E% AE P{ oz' Dfr " I ~ IV R' LICENSE IA1f At BIR1N Ar ~r.. ~ ~- e rcr'' O~~ NRM NAMt6RHONE NO EYES AfIGN11kNiNf :A ~AS~- /OD G E accuRAlloN fl NMIE6 RNONE NO. FYFS IGNi E[IGHI Z /C K KLC RrLL rA 6Ru $ R ^ CHECK (.~ INH nE AS w>N FMR r1 or wlvolHa. ^ CHECK (~ vfH ws wN VAnovEE Of ~/pv , crwN CODES-~ 7 o x i 5 1 e;°,fOry r viv ` .is N Ion rcN CODES ®~ D a A a 5 fx a s,,,f ' n C ~ w w:fs s :F u`d: °°'" ^ ARSDIANEt ^ c" 0.1 ° ^ EB:IF. ^ ~ K~ ^ ,~~,. :oi ., ^ AMw,.KKE ^ c"~`:rfv ^ Po ~ H ^ 1:°NV Ku ` NH YEAR AIA fIDODGt{HEV,I fIIDAR1.NWw1 SfYU It DR ~Ca+V 1 fAR MA%(DO iHtv.l llOM1.NOVA) l 1 _ IICFNSL P1AfF NO. SIAE 1RMLFR RAZE NO. 51AIE I'I V EH.CIX R ~ -777 q WA I ~ RR VEHKIEIa fIC A EION NO. . V EHICLE ID[NIIRIUU NN . tt '' ~ RFG~5IEREDOWNtR: USi iIRSE MIDDLE Rlf0N4 NO. R Q tGISIFNF00wNFR: 1 fIRSi MID f Rq. V W I~ AopRLSS CE VxNa A N aowNER G. vEawpDRess orlNwRwNCeco. DR AGE R ~"~~- n - ,C r T ~ ~ _ pAMAGt uN oAReA _ -- CNARGf CNA E e1D1 t fSf. PWwGF ~^W^Y ^R[AWNfD ~ ^AWAVN ^RfAWNFO fSi.oMNC4 1 _ IGiOFIO~ lOWiO IOWFO ^ wr ev: wr er• f ww ww DIAGRAM OF COLLISION 1 R mfN A< 1 nNlafrH DESCRIPTION OF COLLISION: Iln[surRlLmENIU SHELrnNtcFSSwrI .r ,. _. _ _..._._ .__.__ ' suRnl " ...SWti iK~ ~ N a~ HE ~ r. _ i I I ~ r . RLV6R .._VE , . ,$TAY~d ukRyyEA_ •- _ ;. :..1. 7'b AVOIYO...9 D6bR oA~ 7f/E RQADLVR~~._G45?` ~.: w 4 ' x' Ii • i 12 CrrUTRoC. AND RAN OFF. TY/8_.Ra90Gvgy_-.-- .~ .: ._ ... _, ~ .I STR~kXNIr R _ TiPEE. _ __.__ ___-- _ ._ _ ~ ._. _... ss _ f,E~I,,,/S - ~" NAME, ADDRESS 81NJURIES OF PERSONS I NVOLVED * CODES 1 - 4 J 4 5 6 _ OCCUPANTS/WITNESSES IFG~,R,SeD~°`nE,o i`r~+ASN" e r ii ux Ace unn '"„'"" Resell. ucr " AVl jjp wDCasS NAIU. a rR eY. Ame. ^cRIN' ^"" . ^ H ^ N8{N. wvl NO n :nu NAIUR a RewovlurNtvn ^Amn ^1IX`l ^wl . ^.N ^~ .o wt N ra C'r155 A NATUfeM INAN~IS ~ ulrxer. ^AMe ^A?tl ^LW'ilrNr ^~n+ ^nrrly 5 rl IK.w S 1WW` 4 . y~ 4DIU 01 I14leKY I , tl. J SrwiCMp o~i Ra IARRINp 027 OAttp RErgf ArFROYID eY pAlt ~ X 1. 1 f1 J Y 75 -~ - INnw ~~~. F?+"S, 2154- ' l Lt; ~ ~"a~f4~1 - ~`,~ t 17 ~ 4 1 ~N f 1 t Ir-; }, L r ~ . is i _ .. - I ;i. }Ileum; ,.~ D GATE OF COLUSgN OAYOF LOLL SION TIME COUNTY NO. CITY ILO. FMWA T FIO. pAY YH I 3 C n 2: I AIJY Z IYkE J Yhp INIIN ~ FIL S SAi >C A IUSE 2JDU IIOUNI ~.. // Cl ^UflSAH E , r COUNTY C 210 -J Q C31fURAL ^STATE POUiE ©COUHTY ROAD ^CITY STREET AOM GLS PREFI% ROUTE OR S T R EET CODE SECTION ~~ ^OTHER ISPECIFYI OIJTJTL( RfIA() ~ N 3 A~ O / ~ {J ~~O +- N S E W ^ IN (~ CITY 1 COWN ~ PPEFfit E O. MILE POSE O C Mnfs ~ ^ ^ ©oF ,~O~.T_ ,i.QWNSF-Nib U ~fS'8 N EANO.OF STPEETOfl HIGHWAY A"1 - INTEPSECIING WITH: STflF.ETOR ROAp LL RAMP DIAGRAM DATA T ..~ .~ ~ N I O NONINTEPSECTION ~ r ACCIDENT INFER NON %~PD INTERSE TING StPEE ON ROAD Ofl REF. N DEN/EEN STREETAND '~% MILEAGE CODE INTE CL;. ERENCE CROSS SpTREET~Q~R ROPD S ~F ' .. _ .__....__ STREET DISTANCE ANO DIRECRON FROMREFERENOE Ofl CHOSSSiN Et V jT, -I ZQ PECIALCODING USE ^MILES N 5 E C ®FEEi ^ OFGP.I.ZWASRA'.~ SnrrE~A;ECrzoYv ~ ' ~ - ~ SEVERITY VEHICLE~VEHICLE VEMICLE~DICYCLE OTHER IWRITEI IIIi 6RUN COLLISIONINVOLVED: ^ ^ ^ ^ . NO.KaLED TOTAL NO ^VEIIICLE~OBJECT ^VEHICLE~RRiRAIN ^SIOLEIJ VEIIICLE N I D. WUREO OF VEHICLES O ^yENICLE~PEDESTPIAN ~NON~COLLISION ^HALAPDOUS MATERIAL ®PflOPER1Y DAMAGE ONLY ODJECT STRUCKINAME OF O&IECi STRUCK ANDOWNERS NAMEI ~ LDCATION OFOWECi STRUCK EST. DAMAGE V/ ^ROADWAY FEET ^ ^ ^ ^ RD EDGE ~ S DRIVERS NAME~IAST - ~ ~FUiST ~ ;MIDDLE - ORNER'S NAME~LAST FIRST MIOpLE Pi DICYGLISt.OH PEpESIPIAN CnELN1U. D p . ~Q~~R ~~ ~ R STREET ADPHESS _. - ~ ~ R 9TREET ADDRESS ~. _. v 9- G v _ E CITY. ,:.. ~STA1E •. LP CODE PHONE NO E CITY ~ STA lE LP CODE. .. .PHONE NO. _.... R R v N pflNERS UCENSE NO. SLATE SE% DATE OF BINtH N OflIVENS LICENSE NO. STATE SE% DATE OF BIfltN O M . O OAY YR O. MO. DAY Yfl. ~-2 Io- 2 pRIVERS OCCUPATION FIRM NAME PHONE NO. 'j pRIVEPS OCCUPATION FIIIMNAME PHONENO. rv r v y1 CODES > IJI I'u~ _~. _ INI SEAT BELT _.. "_L_ I~'I EJECTION _._I........ CODES > IJI INJURY CLASS.-.-_ I'll SEAT DELT.___._. IDS EJECTION INJURIES F ..____ INJURIES FnO~rA SCENE RY' TO EMOVE fPOM SCENF flv YEH.YEAR MANEIOODOECHEV.I MODELIpART~NOVAI STYLEIZOR.~CONVI VEH. YEAR . ip MANEIDODOE~CNEV.1 MODEL IDAHTNOVAI STYLEILOR.CONV.1 V ~ ~~ • V E H VEH. C Ofl UC. PLATE NO. STATE TRNLER PLATE NO. STATE E VEH. COLOR UC. PLATE NO. SIa IE TflAnER PLATE NO. STATE i L 8 , 1 C VEnN:LE IDENNRN:AD N NUMBER " ODOMETEfl C VEHICLE IDENIIFICAiI N NUMBER ODOME rEfl ~ E TS 2y6 Z. d/99 L. E T HEOLRTEi1ED OWNER-LAS fIRST ~ MIDDLE NEGLSTERED OWNER-LASE FIRST MIDDLE i N . O. EP a,v j, ~ o, ApOH 99 OF OWNER ..,.. ADDRESS OF OWNER ~ X (09 LltoLCn~AIS~p. 9P.'iA~ NAMEANp Ap(wE59 V.SU C fl z O A(IFNI ,.. ... NAME ANO ADDPESSOf INSUHANCECO. OH AGENt , ,. ,. ,. ,. CHARD .. ... ~ C ItAfN)N NO. ENFOHCEYENT CHAN4TE CI ATI .. N , ~. AcnoN .. NAME, ADDRESS Si INJURIES OF PERSONS INVOLVED ~' cones _ ' a • . SEX GE SiAlU9 'N~ .I P A~ I EJECT. , - `. Y%.~~ - _~ NAMEI ON CJf~I.I~ U ~ I 3 ~( Z NDUIFOi 80.699 CG'R~L(.~D.LCJ.U,.. 2~6'~6.~ p wJUafs e,CENE l1Y TO A NWE N T ADDRESS 5 NA UTI AWf : --_ Sff NF IDIIIOM _--IO W AYE' I ADpRl SS N NA u rR Dcir+ynv r~ to _-- S NAME .A A DOIIFSS r E N ~ AtuT~ - iIF"Mb"JC6ftfL'ir -- .. --- S' r JUH:fa ALrNF nr ro I C O Aloe vmr AU•omrY.w roPl aAOS Io HLA nILLT I JII D[%~w TA 1 ~IIND'NJOn 505n14 MOnWpY Ibol PlSreuCp II'r nFAOA SCTNF A11f/I M!IAl1Ur1. )N(II P11141 RN.YCLK1 ~ ~ ~~i I A ~~~ ~ slutunN yrror uEWfn IOr41LY [J/CIfD Jf CIiO 1 p '- 'U: S OIL` ~IL9 IYIAL r rr^O`YIILC VIJUII'1 ~ Ullr ~1DY/.1 ptL A 1t11IPYllw+l+J;w~i A IIN~ 110~\NIf •~J A SI Ai 11111 lAllUnl 1'JC CICO ~vlb 1w. AnN.n ~f_F'" FI'" : N'• til I.. F ~ I' o; ~a::' ~~~~ t r _.~ ~'i ~ , .y . yy ~. , mP~ ""/SJ IRA S' '.. ~~,L3. ~ A ":; ;, . ,: I INEACHUO%-gCLETNENUMOEgOfEACHDA MAGEDAHE -^ a CLEDAMAGE ] SHADE RHEA OF $EV EflEST IMPACT IE) ' 0C INSTRUCTIONS: . ] ORA64 ARNOWI51 TO SHOW PRINCIPAL DINFCTION DF FORCE ~ - 0 ~1 ~~ DAMAGED VEHICLE N O'. 1 lusE Tq ss ACE con sKETCHINC DAMAGE TD taw LEns, MOtoncvttfs, Erc I DAMA GED VEHICLE N0.2 {{11 r'MI} =i! SIx ((1 ]O..Rxn ~~ oRl rT 1i Io i-i'~ IS TrN.~c/ I0. 1>. OYE.lu~nr'~ TF. EHITY Of DAMAGE. VEHICLENO.r E ~ Y, o D OTNEn M.V, DAMAGE sEVtR1TV OF OHMAGE: IOTHFH VENICLEI ~ ~ aIAAGE g O H sEVERITYOF pAMAGE: vFNICLENO.t~~ ? ~ DIS I NG O AGE ] ^ O Fn M.V. DAMAGE ] ^ UNG! O.N DAMAGE LLLJJJ wG j ~UNCT ONAL Dw+aG6 K. DAMA NO GE CTI D o O p o GE WED BY'~: - EST. DAMAGE rOWED BY Si. DAMA E FS,T.OAMAGE TOW ED BY 10 ~ - _ t ,. t 3 C1IACRAMOFCOLLISION _ ., ,r~.' .:^. "•~-- ''„_ ~• '; DRAW ARROW SHOWING 1. DLAr~.x Au+awAr Aa]Mr, IfwivHFE I. ~ ~ ' .NORTH IN CIgCLE L 1 1 r aE.fG.,nNa..Na,aW T,.,.ElRtax.Ra F :;;~fN. GDNDIT Gx3 „°; _ _ I - I - N ,aEIA~;a,ax3R1aKT,ax AAE„ ~, , .; . _ .. ... - _-.. .. T 1 \n. 1 , .,. ._, i _ > lac,rtvnosaeLfroxr D. IN.,LI _ __ _ I I . I i _ I ] ixaWNfNGLE.LOF„PI,xaH , E ; '' i i ~ a.,faTlanNa,iATIN.Aar.. ~ -. ., ---------- . - ~ - T . .. sxow.NO.RR1EYw¢LE On .latsTAMx.Alxsee.oxE -i _ . ,.-. .._ ~ ~ .. r-_ __ i '. 1 I I .~ . -: t + I I ~~ I AxD Aerweoun ox __., .... ,......_ ._ .. I I _ .. ..; i. t. i _ ,~. I. _; I i { j I I DESCRIPTION OF (INDICATE WNATIHOOABLY NAroENEDBEfdE DUPING ANDAFTFRTNE[HwSN, INCLUDE INFORMATION NOTON DIAGRAM, E,G_DRIVER. COLLISION UISwBILITV,PEDUCEOVISIBILITV,vE0E5TR1aNCLOTNIN000LOH ,CONSTRUCTIONOflREIAIAWORK,ETC.I • -~ - OSITIO VEH. MEADFD N BE OR EIO I DECISION ST DIN. - -~ ~ - - ~ ~ --' ~ ~ ON StnEEi OR NIGHWAV NAME OR NO ~ ND. of LANES ONE OnECT ON s r IFE DS I vENICLF LEGALLY Iwpz VENp x0. N 5 E W ,__. INCREA SING ....~ DECREASING .-. AHKEO I ...., ~".. DCCUIIFp _._. I ~I. I _ J ... ._ ..... _,.. :_..... . .._ _ ...... _ : :~. ~I ,... 1 :.: _ rFS No YES ND : .. .,. .~ ] .. ..~1.,..' _, t._I I 1 ~ . . I I 1 1 _. __.. ... i.... L..1 L ' f ,il A D c _._ .. "_ _cpnpss NC.. _ _ ~ ~x~ asF CaxxsAla ., I . . ~ f oM _._____.~TO ._ IEDIRICYCLIST WA 31NG I SOEWA MARKED t ARNED L B CvCI[ROUT[ I , Di11 LK ] ) IfI10ULDEN KI ~CROSSwaI CHOSSwALN _ En ~ „ R AU UR AC ICIIfCK ONeI -WEATHER CHFCK ONE( .. ..,,. CONTRIBU IG TIN CIRC MSTANCES IECN ONE Un MURE .,. •~ tl,.: `` NweNICLq I~cnahs.,;._, " DIIO,]Y EN2lE' w~ Qxt T ORWFH 1 NO ] DRI En 1 NO ] • ON~fR ) Y DRIVER t O ] I , , I JI~~7 001N0 ~ . I pn y C[ CLOUDY ! I , i0 EIiCAST . U N CFO nlcoNOLfw i ~ ~ ~I IOILOW NG ~ I OSE TQOt . I -I ]I OITRlp ED WAI K ' _I (" ftRA1GNT ANFAD _J~AMMTAKINO LJ]L LJ L ._.." I)--- ' ) •~~I A NG ] ~ _.. ~_. _ . ]I_-~ U f UENCE Of N w1 as .._.L _ L LY_. ~^BT,. O! CE EH I H _ =!4.1L L_:_._.:_. r ~ AIIMENTLY I AU[S . . p PA.csINa T1 r.. ] MAKING I 1 ~ .. _ 1 L f-.- . - _ -. _.__._ ! [ Cf O OfTAT[0 YtF M [ ._ __ ~ y 'Na tU . { G _ [__. I311.1 YndFRI~NRIND IOCAIION 1 mmlT runty I yl~`~NAKINa r _ . k I K;f _. __ ~- _ _ __~ J i KCEEO nG RIAl. „~ . _ -, ~~ ~ ~ D ~ dEn . _-_ I 1 ~ OIEPAT NG B _ LF/T TURN 13~ ~ A -:.."_ ''~...j _.,. L ~ .SATE YE[D . _._. 1 1 I p0 [ Cl[ N R/w , U _ I ~ $ MEOGO L LHI ~ I ..:.: OF. EC lv,k[w1_. ~ ~ ...I" T U URN I TBI ~ FIOWIN6 UINFII IY[CIf TI OTnf11 I5P(CiAYI ~ ~ IfN 1 f PAtt Nfi ~... . _ ~ ~~ OSREG U Td 11 ).. SGN.S GNAL :. . _.. _ I~' r OlME IS F I y\r0 NO VIOLATION ~, ,{(OPTED fOH I, ,+C:I ~TRAIIIG GM CONDITIONS RAFFIC CONTRO ' vENlcu TYPE OF ROAD I NO ) ' ' .VEHICLE CONDITION .',_„+. SOBRIETY ~I~~~~ ' GNAL ' i B ~ K'IIICK ONE( U_] VLNIL L[ 111 . IL nfGK ONF OH HON[ f`N xQ j. SR VI NO ] N C~• ~ ~ VENICE! IGIIEDK ONFI ld9lfry OR . I __. ' I NGNALS ~I ON[WAY ~ ~}I A 7 Fp1 I NO ] 1 ; ~p~ ~ frOIPfDIN ' DAVLIG -~~) ( ... ..... __ _.. ] TWO Dl IICIIVI _ ', IIBDABILITV ~-•• M .. _ ?- nOADWAY . '`D~,:I'f,ARTINOIR I ' ] ', PAWN n ] [ Gh :] "1 Sn S1el! OAU •, 1 r tilJl' Of I IAU r •.I 1AIfltD ..~_ _ ] n B Tv ~ HD ' , ) A!/IC LANE ..I. ~11 , ATARTINa IIIaN ~ I > WfK _. _... ~ • ~ IIAN KlP nhO -_. INII IICIIANGf K lod nAlAl _ N IIGI S '.l D[I[C TIV( . , .NUT. MIA HtO., ._ NBD fOBHIf TY ~~.~) 1 , IAHK[D 10f11IUN ~ ~ ~ NInGING IENTtHINa I ]~ ' 1 K '.~ pARK •fINk EI I :. uegrt pR .. IIAN ..°, AMeL NNG R _.., All(v °, ., HLAII LICIT{ ~ llNif WdIN ;..;~... ~. oN TMaonl .. UMK~__.. .........._ ~ ~A, HAD NOT ~ RL[N DnINKwG . . 1NAifIC1 _ ~~ 16 {~CKINa .. - uwnK-SNHfT ° 'Nlt Orr ° iICNA L f Llir rvro w+r - ~s iw:~i»: n.lD iHO i DIIEM, TES '- - f •S Mltlhl GrrlS IIIC DIAG ] IIIi ah -~E£~[r- r ~ ~ I[{r GIV(N pill ISIEC IfYI ] ... M t OrI ) DI VIDIO NO DEiEUT$ ~ ~ ~ I[fT n[IUSfO I OIH1N IVl!'nrl ] ,r,nrvlDln oIxH11AIICIf Y. TFfT gEtUIT$ Z lfI1NANh4 Uf rrCFifti~- ~ ~ ~~ rI IKl U1 ., iu vULrCI A1N11v[U Uw ] iiiaen ct )Rro Mr mD _ T.~N X ~~'._•A. '._~~..rl~_~_.~ __~__.__ ~._~__ _~__~~._ _ nnlu lr l D r mOVIU uAT3 _._...__.. _... .... _. _ .... ...............................~-.,...,,.,,.. M.L.. ,.x,.I~Nr.ro•. ~rRmH IN]PI ICA TE E/WY lf]f.AI. LAYI[IIf UIICI AIf NI AEI( NCY SCOPYTIIIPLICATt DDIY' 1lIV N$11GAT011'S COZY ~„ ~~ -;~$ to ' n _ ~ ~dIMF Y {t S ~ a Fes( ~{7n1A ~~~ryf( '.Tr ~ r ~.: Sf M"t.V'~A]alfiW *TiAFW+ITTErY'~'-+P%+'41WwFY!1 l~l'T Y^~Ar^A~ - fv 4 L{ L. ~ ' , I ~ ''.~ ~ S 41, ~ y.~l' Ir~ tl i lpl I I r k A l i 1 7 ''1!'t , -'1 ~Ey r'I F {f _ 1 5 I ~ - ly 1I ~~~e ~ i t s I I ~ ~ + r~. 51~ lr '~(1 ~ ~ ~ r ~ 1 ~1 - 1 E T ~ ! ~ ~ ~~ 1. ' 1 1., d,l ~ - ,ra't ! . ~ ~~, i . ' i~ r ' ,.: ~,,, y ~, ' 4'. ,yy ~rr~~'• ~~^^r}}~~ ry ~~. 9"Y. •E ~:. t - e~~.• C ~~' 3JRjf~ . ~~_: .~*~ - 'A ,r,. lYmi '' >~ . ~~ pp %FL~ ~ (. I~ A N t ~"~ .. 5. A.. : r . wy,{v~ r G~ f4t r R r;: YOLICC IKAhFIG COLLISION KEPORT lAl'^^•^~••^' IgIICECOMMINl NUMBf9 PRIVATE WAY .. - .:... • '. / UAl O,<OLL! U51 IM U CWNTY COUNrvtq CrY np. INWA "` ( SEl HOU9 O O.S b'O b ;IYp . y ~'G~ oAJ ,. /~ ,. ~..... Q 4Al N b QN QE ~IN .CITY OR tOWN E NO.O rO4NGnW Y Mlus Os OW ODI ~o ON ~ EROS. ~ RWI ORS ,3 ,,: 9S~7d `~~ ~ INrf43FRING YAiN~5r4FRO440AD NON INIFRSERION p EEIWffN C L O Si9[Er 6 ~ i9fEt DIS ANCE6 9 WEfI% E MREPOSI ,..Q d/ T _ - ... ,C40555rRff RNf.WESt MIEE CgENT `%FS 5 [ W MILEAGE [Et OF CODE p G pAr YT 1 _ COlI15gNl vpVFD: Yf9M M.KIIOp~tq.INEUREO~ SI IEAGE ^NIi69UN i0 Al N0. 6 E LIES ® PRDHArv DAAUIGEONIY ^pESEU iEO ^VfKIE NuNDn D NF OS I F Y 09 R OIO3.5 S14ffT RROAO ~ 'C'^' y~0 Y OBIfR59uGfINMIfNCRlKtS YUCA ANDDWTVE9Y tl fSi.DAMAG( $EFCWCODING USE - ' ,. UNIT NO- ..:.:. ~ .. .::.. _ :._. ~ ..~' . UNITN0.2 ^ VEHIQE Q PEDESTRIAN -~ ^ PEDAICYCLISi ~. s D4Wfa NAM. LAS IR .. I ~T r s. ~'L.~K/A /,u Nr __ ~ D9wea NAME usr w I f Sr4FFr ADD~~ 'G ' l ,. EI AOD4E55 Gf S r! ZIPCOpf IgNE NO. -- 36 Pis .SAsy D R ~ - s1AlE I L D4Ma5 UCMSF -. tA2 5 ~ O DAVI I ~EO ~I . V. W U N NO. IME bW At0 ~r WY `I R OCCWANON MNAMf bPgNf f1D. TES GNr tEgNr E CUIwrgN FIRM NAME6 PHONE tq. EYf$ WE Wtr NfgNi w z. O.YGr ,d R .. CHECK (.~ A nv ofANOrNEa AS ` ^CHECK (r7 vfNltttwsAN rmPiorfeoPANOrNfaAf w~ f v CODES ~~ D a A i S D b itn Y .5, ~m Kiq.. ,~~ ~. In .~ CODES P t 7 n R it 5 me o / ^'si Z . N%~R, 3 ;.E ~~:: pm ^ ~' o ~ f o ~as;f. a K ,~ ^ uM. IY ;ot ^ A...Kr o ~ E ^ Fa.~1 0 Ni °~ ~ ~ ^ :: ,. Kn VtN.YFA9 F(OOpGE-0,EV.( EE(OANr.EVOVwI. S If I)p4.{pvV.l n fw4 Y nEV.I n100ELlpMr.NOVAI I l p4: VI 4pV , ' 3 Do o ~SGV E 1. v Pu srwrt rR.vfER aAm ra. sur H n. a 4 f A VfNgIE IDENOI1CAIgN NO lJ:LI '/iSl !25'61 1 1 ~ i V NKIf IDtNN I I Nn I I I I~ I I i l l l l l I I 4tG13 FDOWTR4: Wr I145r MIDD{F PrgMtq. O IS REDOWNf9: VSr ~ II93i MIODE N , is Apowssol OWNEY N 9 DWNf4 : ' - ,~ PST- E ,.: - ~ I. N.Mte bAOOlEaot ltouYANCe eo. AuNr _ R N .m .... G DA'w'Y't AAa ooA.Ab I A11 I e - CNAYG[ - - ... OIAROE ~ c wa ~ AGE AR[A ~ •. I IOiOtlaii Ut.pWAfiE Ip ORM ~OCMAINFO.. W ~ ^AWAY ^RNWNFD. fS .p/JAAG f f wwrtp+l DIAGRAM OF CO LLISION ( Nu ItN)ICAre NORr SlIOTY fRClSSMYS 0 AYgOW DESCR IPT ION OF COtLISION• Ilse suPnfAR iAI StYFr {MRSSA9Y 1 _ T- I I __I~_.~._.L_.._~~_,~ ~ i~' I i r~~~ __ 7 ___ _ _ _lIE//. ~~~aL~L~tl /O_ S {O~ _ S //Y°L/C ULN ~2 ~GS /n4 ! f I ~i- _ . V -- ./P~~w_~ U~~r ~x`3 _ ~ ~ i ~jT! i r i - - .. Y ^.. r .I... , rt-, ~ ,-- ; ~ -_V~ ,~i . ~.3.:was ~di,4e ive,..._ r %_. ~ ' - >e : '__ , __. I I - i .tai- _rt~?~Q , / _/~1•~s rf ~' .A _Lv ~T.. . u.C•v._._ _ . _._ .. .. __. ~ I i I r t ..._ ....._ _. _- _._ _ _._ _ _ , ._..._ ,_ _ .;_ 1 I ( __, .. ~_ i_ L .t-, r _ _ ... '1° NAME, ADDRESS 8 INJURIES OF PERSONS I NVOLVED 'CODES 1 - Z 3 4 5 6 OCCUPANTS/WITNESSES (USI SUIIIIMfMAl3n Id ApolgNAf NAMt 41 51 NR wGf IU 'N'n AIS Yl St EJtR ii[iv N AME ,qv~ ~crt'ETrs _.. ......_._. . ~ 9b's /SS.. i ~p.t5, I NAEVYf Of Yf INIYr owm %oTw Q NM.. oW. o ~w p AmE ... ... _.. ...__._... . w 1J fd NAIWfIY - .. mOVtOrIOM QAM4 Y QRV.1Qnlllnl Qv7':i ^ti~V .IO t M .. f-~ DM1\ NlN~G Q A ^cvir ^fw01^ Ian.' NvIS OfIKlaS E AOfAO AOINCY K DS U q O 1Q14 p4t AM4DVID YY Orr ~ ' ~,~L s s s ,~ ~,.j,111[rb', ~7l I^ } r,,. iii ., t'. '" ~JC~IN . SH.1 ' ..y r.,;. ,u. v I I I 1~ C. ~~ ^O.~ ~w ~~ '~ W I' ~y~f g .`r~ "4 C }'{~ W~'~ t Y 8F g; ~ ;?~: r ~ ~. ,k5~" ,~ .~ NgyR n*~~~7 ~. 7 .~k ~ ~" n ~. A u&~n i A `! u : 'u Nis ,;" " he fi} K • n ~~r ~ itl'tY~ ~ 1 ; (a/i E 1 f ~~~ ;~ ~~ v~N i M E _ I ; ` r; 1 ~ t f ~ - A r ~ ELu j . _ r r , ~ t. I ,.~.., .. I~ ~~ ~.' ,. ~ .... - ~~~ ' '' III...:-._--- '. ~. ~ ,1 ~~ e _ ..... , ~.~.... _ .... _ Iv i~ ~~~F~, ~~ :>~~w. ~~ ~' ,~ .a ~ 5p1++ ~(„ V E ~eE' yi a {s,~ ~ ~ ~ y ~f. Bs ;G ~ I ~- ~~ ~ - 1~ ~~ .'F""Fh ~ 1 r ~' ~ , V I~1 J'M.1. Yl I _ POLICE TRAFFIC COLLISION REPORT TRAPPICWAY t ~ ~ Rpp¢~pMgmNE IxrxR .' / PRIVATE WAY ,. :.'. 9A..+' ~ i.-.: r'+7 Z~ pnF IC u N ~. R.Y ' Ya IIMf .. 'IUSF ].DO HDUR ~ -Y! mn RN w ' COUNh COUNtY NO, fffY NO.. ~".' _ . iRWA QUEpAN ~ d I ., it r Q . •. RUSM / DDYORIOWN NrvnF6N0. 015(vlff 04 MGNWAY oN of ~FN OS~ ROUFE ''~ 9sz7n INFfS o5 a. oN INFFRSERING VAIN: S(v TOR nD NONINI[RSFC(IEOeN o f4(vvFM S]RfEt 6 RR( C Al ~ o (NEFIS MAFPOSI` f, '. 1 ~. y ~® J / Di51,wC lpl 1 ,CROSSStR R EARfS mi MRES N 5 F Eeer or ~ CIOENT ILEAGE cooE RNM Mfw ~l Y r 1 f' .. :. ' <• f:OllISgNINVOIV[O: ERlhl HIt iDtAI NO. NO.E4IFD~ND.INAIREp~ ^SRRUGE OVFH14F5 ® FRORRIYDAMAGEOWY ^ vF5ULR0 ^ VFaIECI! lu"RRED I NFER "r WC46S1R1ET09EFOwD'. '1':-:':~... ~O l~'~•. `~.t. f _/~ . OB]ECISIRUCR INAMEDIppxcr STRUCEANDOWM[YS NNAFI fSt. DAMAGE SV[CW mDRED t.F~ ~~gpE w% , . ._ _•:~•s~!''.sa.UNIT NO'J^~.:n .._t: ~•.:i. :.. .-~: .~.: -UNIT N0.2 .^ QYEFfIQF •Q.PEDE57RUW ;,:^PEDAICYCLIST :, -- / DeWE SNwmE. IASf I -' ATR DRWER' NAMf: USt IST 9 - ,e , ~ K~~ _s EA o SF fft ADOV[ , E ADORlSS ~ ~ E~ ~ h N ~~ U S AIE ZIRC(%FE FEgNE NO. ~ ~ ~j p~.S 035 0/f// s-a ~: ~: DvrvfXSU (NSFNO. 7 IYJ SfA A~ SRI Mp ~ i~' YE. E. ~ ~ 1 S fi° G/A M Ma ~ ELY R~<! ~., R Of WA(gN NRM HMIlARgNlN0. E GNt If~GHt E UVAt10N IRM NAME6 RNDNl N0. ~ EYES IfMt IlIGIft w 2 - CI I R ~~ U G ,c W ^ ELKI/! vfH~ w Er nNOlHEV~ n '^CNECK (~ vfNlcEf nsnN UlRfonfanEgr Y + i s E enbH a ,"W°! ODES -' 7 a."5, CODES - * ~ a s + .:sn ~! s E,lcna" 6 sn,E,Y ~ C p R 3 ` M M.s ~" o nmE.AM~ ^ u ^ ism ^ H o IR. • o ~ o ~ o ~bm o n ^ r ~:lm R I VFN. Y[AR MAnf IDDDGlCHlV.1 1 S(YIF I]DR, E. v.l EIIDART ~ ~ 1 EV.J ~ v YIDAR AI ~) ~ ~~ .4 b l. v OQ N.V p ~~ s/ MtFNO. StAt GdA- -- SIA( I'i ~ . o '3 VfHbfIDEM1I1CAlgN NO. COIL: .$I i .3~~f16 I i ~ i V H6E DfN ~~/2S/3!S131~a9=, i8'16' I I I I ~ IASt EKSt AVODIF RHOEw NO. RfWSRREp OWialR: ° W WNlR: l/St fIRS! MI o d scv u ~ '/ AOOR[}SOi D.VI,f. N n 2 / ~ p E y~~i1 rx~ Rrl 1 unniy FSADORessWI sW m.ExADFNF LL T r r' ,L -. ' R ~ I D C ' o_AfA.ae AEEu ~AmAUDnRU w°i..cri.w ~,IA.c~r Axw aARU H e.rA C 0• R -a ~Q 4 S at, ~E 4]3{ nWW Y ^RFMWNlO o AW Y ^REMNNfp ~ • 10'40TI IOiOR ~i o ( ' l er. ~ siZQOPJ w~r 3 :w voer~ E l; t DESCRIPTION OF COIUSION (En_ MEMAl51[[(rNEQ1M1Niv1 ~. DIAGRAM OF COLLISION iEafluNECESSAR{ I evnAifo " ~ E '_i_ I I I I I I I i-~ I Q_?- __ ~ I - TFA~L~z.... rp-_ ~ s ~ 6 1 I ~ ~ I ! ' T-Lr ~ I 1- ~ ~ vi vG N~ t~i~ T/~.r~t .. : _ /T_/!VTt7_.-ffGrJ/__~-`Y~ _.__ .~ ~ ';H. . ~,~ y _ _ _ _ =_: _:=_ NAME,ADDRES581NJURIESOFPERSONS INVOLVED *CODES 1 - 2 7 4 5 6 QCCUPANTS/WITNESSES laioWOli~urµ..wi si --six AGE (Aru '". n" y'r "' o e~i+ Fmi ".;~~ " ANOC~tcN ia f F n"' t~iD 385 /087 0 . _. __. ___ _ l w r mnu O . NA uue W ! AM L. o ~1 E ^ '"' iAlAi N Am No TS A . .. ., .. _, ... . _...__ DMISI N U IY._. ._ ....~ R D QAMS QEEaKf O.x~ Q NH ^ ~ v' M • n N AME'. ILO - -. _..... _. _ .. DnEu ~~a.. .. .... vIMV ^AM6 Q,aiU ^CWlEE oFN"~ ^n.H NvlsFr Er•<E sNJwE.1.". '/ Awu o+ AGENCr t Ear KE .HA HD FoE IW wnpRErwl AFREwfolr art ' ~;A{~ mY' ~. ~' {{~f ~' ri y 9 Y3 C ,, "~r x ~ ,~: ` C s° ~.' SN~~T ... ~. ~. ,t. , ~ ~ , '~' p + F~~~~ _ "~~ ~~yµ ...a r 4 Rk hi } r ~'.~ '~A ' ~ .~ 1P } R r 1 F~ i~ v -~~ I~W~~ a E 1 a ;. %~ ~' r~ , k~ I E, I~~~~ ~ y' g ~ } ~ . i ~ 1 3 ~ I t ~,} I r ;1 ~n~, ' ;~ 1 :~ ,,,~yy,~~ ~. ~J ! } v lLx 31„ ~~°- ~~ } f - ~ ~,1 ~_'. £ ~~ b s6 r .7 ~ ` ;~ ~.If 1 ~.~ ~ ~~ ~ .. 4 . ~; !~~ t t i Ta~~" + 4T~ ~tix~3,~'~s ~ __;` L, ~~~~ l ,1:, q? hYl {-,Y~ $ Y', - l J T+' ~. .. .., .. .. .. .. .. ... .. .. _ II. .YJ' ' t aa~ ,f .. R ... ~ ,.. `'+f '~'• ~ ~. TRAFF IVO. ,~ ft~f g. ~ ICWAY a POLICE TRAFFIC COLLISION REPORT PRIVATE W Y Iouctcomn.uNr uMnfn I A D foicolu " Ns N .rys[a+iuirouR couNms. ~~ 47 YI, ~ ,.I e ~SvN a " couNrrno. urc no •r"wA /ln OuRSMR 4 ~ ~ ~ n - ~~~ ~'Ky4~~~, pN ICTE Q CIE O4 rOWN NAME6 N0.015fRf[fOR WGNWAY ''IIW 5 ~Y - fCfCES RW 45 II . ~ ~ f4:. tib ~ O Gf f It , o Ntf YSECD GLM N SrNkft U4 gOAn . ` - .S°270 • as :. r 1 . NONINNRSfC110N BfTNEEN SI4ffT { ` SEREEr PREfI% f0. Mttl POST ~~~ O~/, ~~ / niSrANC LDI M if ,CR05551RfF O~ SI IE PO / COpGE Ei m LFS i N 5 f W 'A.\C/^J FEET Of R P DIFw.4AM MFA ~• ,+ ~1 -f•,'~ S, ~ COLLSONINVOIYED: ERIrYi tOTAI NO. IYO %IlIFn~NO.INEU4E0~ ^ 51%VGE ^ I ~UyIN p VtN CI[5 ~ pIROIE4rYDAMAG[ONLY ^iESUII[D OVfaCI[ AVIfSN IUNOY[Dr" •N ~ qp IMER_ CLS / R R 04 [R! Cg06551R[iTr~~ O ~ j .~. O{lECr SrRUC%INAMf Of OR1ECT SIRUCR ANOOWNfq'S NAMF) ESt.OAMAGE SIfCMI CODING ~ s . -mot r s t ~ p 1 UNITNO. s ~ UNITN0.2 O VEHIQE O PEDESTRIAN . O PEDALCYCl15T a , T;,~ ~'F. s DMI v R's NAMN IAST IR I ONWFR'SNAME: USr l ,~ ~ ~ ` . (r. ~ - SfNtEl ADO4f arN(Ei ADDRESS •5 " ~ ~ ~~ rAt 31PCODC PHONl NO. OKNtI EUd C// S Sz3 YID D R SA ~ ~!. ~° •< rvE4'3 CEN$f HO. rA IRH ( IV U N Iq. A % IRN fyg~,~ •. 7 A ~~ Da i RR. ~ N~ I D,Y ~.. ~~ { 2 CCCUP~IION II4M NAME{ NO. EY[5 IGNT tEIGNi E R UPAIION f INMNAME{PHONt NO. [YF5 NiNi N[MiNi ~ f ._. O CHECK (.~ vFNq:le AN tMOior EOf AN rNF4 O CHECK (~ vENlcu ASwN rMaorFt oiwNOr 4 r v i S NecrwN p ^`mr°RTU[ CDDES - ~ G niiR CODES -'f' 7 a ss ° : nMNr e° ~ ° '> ~I ~ !_ INnw Es GK/i 5 F%cmN 6 • v s T .n r r q~ 7 ~'i ;ff..l. O AwIAAMt 4~ O iS:D. ^ „;~;; ^ .;°[.5. f O N^' ^ ~6° ^ 28:R, ^ ~ O K:IN. E s~' vtN.Y MARFIOOOGE{HEV.1 fL(DAgf.NWw) SIYtE(aDR.CONV.I 1 .) wgntllDARi.NOV) f°~'^ ~y; 16 ~s L m i° ~ E . u ~,.: ~ ° ~ ~~ 4 UCEN Sr E rRAlU:4fHtF NO. SEAIf H V N. OLO4 A ~ ~ "y ~.. O~ ~ -` C ~ ~ VfNICIE IDfMIFNiRII /NO. n ~(D~ •~!Q.C1~~. 1~71rZ ! V Nrl I NI ~ ~ ~f I ~ I I ~ ~ ~ I I I I ~ - I ; f"y-~~.. In RfG15rfRtn VMf4: I.YSI /N5T DOIt PffONF NO. L LDJPAV/G (a/ S'S 3/dl1 ADDgf 1 O 3 O W 5 D NN[R: uvsr flgf} MI I ~ ' ~ WNIP 5 0 ~ f-G~GG~X o b " E ER , ~~ ~ ` ~ NAME DoNessn wwNANU CO. o4 AGfM LT - ~. ~ R ~ ' 4TOr 5 nr~o.4RAACe cNF OwAVN IO~ORO~ N[D 1 s O TwAYD '- gAMAOEF Aqu cNAtc[ oNIVTN Esr~~ .Tor ~ ^AWAY ^4[MAINm IO~OIIOU { 9 I ^ ~ ~}.1p~ •~ ~ I ~ '.. ~~•...YYY . • SY w 1, u Al NDKAre NOR1N DIAGRM_ 10F COLLI51 yNFltu N([ EYA tow Y ~ r h_ WAY 0Y• DESCRIPTION OF COLLISION: (w[surruMtMAL SEfEernwauAarl _ ~,' _I~ _ ,~El~ T ~ `Y K G _ ~ ~~ r ~r~ P p~T c ~ sPP~ Y '~ D , _ _. _.._L~ __._ ~---~ ~ ~ f ._ ~ __.l rf --- _ 6G9tE~ es?_ _Ccr7'7PVIG-__e_.V~ U~L_. i~ ~t3 ~/.r~aw ry ~ p . ,® _-L~ ~ I ___ T ( i~ I _ - _ 1 ~ i , LcrP_T-_,cSi~~°- o~~,.~aEss~/ _.. ' ,` ,3 _ ._ __ ) , . .. _ ~/ L. a.~ . En~-v ..~ . •- _ _.._.." _ ._.. _... - __... .. ._... I I • J • N NAME, ADDRESS B IN URIES OF PERSONS INVOLVED + CDDES 1 - 2 .9 4 5 6 ' ~~ I N OCCUPANTS/WITNESSES ioawar[iour'N+Aw. w ni ~ _ sr% Aa ~TArui '"'^" -LUG- ';' nin ~urcr "S`TY' f ~ If, : ._._._.......... ........_-____. _..___..~_..____., w. '"-._ ._. ~_ __._ Iv A aWlSt N `6, Nwr 4ror ,.. ~, p AMe, p v1 F O "' . O CT i 'u;.r _, , N n AMT ~. __ ._.... _______..._._....__...._. _._ ___~__ " ° '--' • AY.uY ,. . ru4ror Dt41U f Y In ttoM DAM{. O" '"f O'"' . O Hx. O ;°. N ~~ .f. a N A .Mr __ ...'D . .. ~~a. .._.__ oonu ... OHS On ~v i.:Y ~ Ou O ~ ~S,~I~ y ~ ~ i //~ S ISry o fu v ».Yn~r ^afR:rns NAM[. y$.~J~', .Anna ArEfR; fr K F' .,,1 v. E f~S1YF.ra.L":.. 4 oA lc Yfo w anro .F.t ano ir 'Y}I "~Y f~.h'iA ' ~~ , f AI' ,~ , ~ F ~ ~~y f'„ '~ ~ sLeN 'fir '" jy, o.~/ - ~,«'-~4,..? ~'+ ~ "`n ~'>. su ~t'CS°-wihT~ - ~~ * ~ ,~ ~ •.: - ~'t~, ., ,'•E: L ~~.. d ~u., ~ cd ,~nN ~~~ STATE OF WASHINGTON `'""'1`" '~ ~ ~ ~:: ~~' , r nut~ttm', .. MOTOR VEHICLE COLLISION REPORT '~ -' NO.~ ~' DATEOFLOLU9gN D E AYOF COW f SION . .MIMEOF LUWSIDi A COUNTY Nq. LITYNO ~ ~s: u aDY I o 31 1 ~ ~ AM r N ~S Mw~~ PM /~ uR ~E,.. L ~, ° ; COUNTY CITY. TOWN MLES 0191 GTY, TOWN 11 ~~ ADM~CL PREFI% AOU Ou9rNE1T000G~ SECIg N T If a .~e{'{-erv YL undloc WW 4 X © of ~-~u ~ 9,5 X70 GVE NAME OFSLflEEi.ROADOR HIDHWAY ul1ER$ECTWG WIM:SIREEi OH ROAD PREFIx EO MILEPOST ~ a ~.. _ _...._.. _ ................ ~ ~ ~.. 1:V+ ~':iWEEN n rL I. e.II..tClw.n' ~ v[k': I 51~ ! a I s dp i .. ` r (F e: I HJECT DIRUC% --- kn I .~ i:n EI15 USi N/ME / I may! {1 rn'. C~'4" ~:if RIETADOPE55 R+-. I VA ''' ILITY .., S ~-kcL{4ocK I ~ ~~' e a ens L CEN M R I SE DU DE •~ l ~c-Lt~ -z~-r~~ VErIICLE Vn MA%E I NEV:[ C / r I`16c1 ~DIh$L41 LILENSEPUTE NO. n~ r-IE ~ ~i 1 1~ I ~ GISTERED OWNER , 1 E4xi ~ ~- m:,~L,,Jw. ~,~ GWWErwnooRESS,. _ ' ~{- I r'~ox'i~8 MY-TSOF N,IC,ILE DA1MAI{~~GE--I [ ~. YY'JbL~W'_YtC~'LS ' yy I LIABILITY INSURANCE - ]I ~~.V~~MµEE V-7D-ADG1ES50F LU& _. . _. i r$r TI :ALAIM~IIf,f: r J~R~ n K Y+~cHll s+e r- 1133-10 ytY h'I F ~~ STREET AND A'•iUrs'w~NO UI cT'oxEOFrii~ErM :1~dAiDPaK ~ EE~~ SlonluHwm~N p;~;ti alal ^ ~n uuv OWNER OFODJECiS NAME AI M DDLE c"r'S Rri?_ cal sarvroR O. AND W%NO AVRE ENAN rwE ¢`ISfi gNSER: iIVERSOCCUPATION MBE EPOnT ra1M GATE OFBIRTH AGE 3 iq ~.4 !rn DODY STYLEI20R.1 JO. STATE ODOMETER IM~LEAGEI '7~F 000 DRVERS LICENSE N0. pEGISiI C..-1/M-IS- t SAf I N Fl DATE OFBRTH OWNERI IN_ "'~ YEaR nMArEOC wscU PARTSC - S iorePan o WAS TIIERE AUTOMODILI 1' - OrrLOVEPAGE NEFFEC'F' IVaO. l~wd:E NON %.PO r ' O ro t flr ~M~ _ INi ER INTER C49. rEFEPjJ AE II E-o'M9~9 T /D Y ^ ` O j fC sPEa.copElue " ~ ~ , i5 LOCAT ION [ © ~ y ~ aS IN ROAD R ~ IO PEVAW CW C! WAY ~~. sY FEET u V E § - ~ _. - F va .` s ~~ LADT NAME FIRST NAME MIDDLE Y 4pDRESS ROUTE NO. ANDBO%NO. STATE 21P000E aiNERSOCCUPAT10N z ~~ UCENSE NUMBEfl STATE SE% OATEOF DIRIH AGE YR. MA%E ICHEV: DOOGEI MODELINOVA~OMTI BODY STYLEI20RI .~ } SE PLATE NO. STATE TRAILER PIATENO. STATE w as IDENTIFICATION NO. IIO6B MODELSd NEWEnI DDMETER IMILEAGE I ER ILASi~FIRST~MIDOLE NAME) DRIVERS UCENSE NO. a fi - I IST(IEET, CRY ANDSTATE) PATE OF BIRTN : ~ z Mo 1 PAY I.E ", s.. ~..a~r« av rpupcM ~ YES ^ NO - ,~ NAMEOFUABIUTY INSURANCECOMPANY - iP p uABILITY I'OUCY NUMBER ' . .,_ .~_. ' AS Si WJURY AGE 2NDINJURY ' NsEa EPEPGIr rOH ION wJUR JJ 1~ !6 IWUP NAME r0 I_E ~YJf S I ALE... Ki]'L{V Q.ri,n.P ~ t-hY?+ C i-, AGE , ~ --v .. .. __ ... . R.,. t _ I DDRE 1 I T rJG J.?.~ 3 1"'4nd.I G K I ~A.: ~ H ~i 3 ~~._ M F nOGn[ss .. .._ -~. SEz ' rp.w :YEad,RL'- `.~" K. hto« o ;-It, ..._.._. ..__ - ^ Pr1 (' , "I a _ ft ... _ _... .. _---.. _ .Amcrom ® - fcK._r~, l I I ,;,"~;ardl. -®~ N --. ^ ~] ~1 ~~~'. <' AM,NSTAIUS OF WJUREO N.N[ r M' FIRST ONE TIIAT APPLIES ASIATUSOFINJUREO aNF MMNF RST QVE iIIAi APPLIES l ~~ WVEHICLE wNw.E ^ IN VEHICLE d9Aa.iNa Ov d,+nw0 1 ~~ O SafAOE% ~. I PILED I'~tl ~N~wOA0. CO+RA ^ t[ a[n NO NILLFD latvNtt•EI r ~ iCl ~ .• POT rAVF101 N I~~1 I[ '~`~ wr OPINE ,': ^ ~~ie.N ^ S^ 6^ 7® ^ OE :.. ^ S^ B^ ~^ .. r rrmNAd.rMAM c~. . ~ ~ B,ul. r >:" S%IW NOIITHBY MROW WG '• i BCn GE nELOW WHATIIMPENED:IE EFER TO VEHICLES BY NUMBERI ' NOa l AFPfH[O \~ Qt I NMaE tx[ N `', \ i ...~i~~-~...-Cc. ~ ~ ~.U['-O % l-~.~.~n..}-ieLC. ~ ~~(i _ wl~ ~ ,pMNr~MES oR --ht IO. [~ AEAC ~.^r.aE ANO Yaw \ 1 .C9RI.-(~ ~ /.'. A l°~'~+.a... ci+-o.. r.. .. ._. • w, cro..oY AY Mwow .. ' ~. ~ Q~ ~ ]cC~.l..i-..:L-c cC..i:<-..(.. cam.. /tc~~ arR DRLfsrw,Y _-.----...__. 1 ,. _--. a 1 _..._._ ___ __ .. ., a .... ' __._ _ ... . ^ _ ~!i `/ ~ --- 5 - --• . ~ I I.--~ Saul rEw r~r~.AA, .. _. L ~ ~ VEH'OLES POSITIONS ©EFORE COLLISION Yn.cIE r AOIO~LMa aui uEAV er.l I [ f W; C9TIDl rED DY ~ T' ~rMsC~ a. YrnClr N e E Iv pI BTH[Lf pll lniNIVAY NAME OII NO dAECrgN ~ ~M. ' MrgAa ^iAlnq ^I~OriKf 7~' ~7 Y ~ ~, ~+ ^ O G~ ^ LT Y 1 "^'"'''^r' I^L. O N Y ^ ^ ^P:i~ar ®~,"%~". In~Y~T~~a, ,~' 7 ~ ~: ,~,,.. ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ArNRrT Al ,r>ry~Y~x ~N~~ ~1 ~,. ' .~ 9°r°" ^ ^ ^ ^ tiaq °iowm nloM DIRECTION TD DIRECTION p ~i h bF ~ ~1 L E ~ ~ ~ ~ ~. frlRl .^,uaul WAS U.NEt I^mnE:wALZ a^wazWAY ]^alouLUER R^°aai~i«.,. s[] Rx D^OTNCII ~1 4~ ~F' y'i M. } r r d,y,r IanDEA»vnce r.[nnrtn I%:Nrecnanare rnArrceorllnoL r,.run,a Wrr OF no.D pnlv[n vF ICLE ACraNS ?, I' `, r 4 ~ 4 I ~ -Y1.Gr ,C. dAI r t rnrEH , iRi, ~IrwE rl r ICNI<A pNl to r.ORLI L ~ '~p x1. ~, ~ ,~ I ^ O ~i.~lr I I7 nAYL M%rl ^, rl ,~~ fX•rIAL9 ~' I ^ DNF WAY Ir ~ ~ Q IiOIMT SInMGIIi AIIEM ~ ~' 1 :~. rt^rt~~ , ^TaIV = ~ nybNO ] ^ DAWN ^ l ^ SIOn SN4N ~ ] ^ f,W WAV ^ P ^ OVFNTAI!INO MOPA9:,ING ~ t ~~ t ' '} ..' ly ? ^wTT ] ^fvgwlNO ] ^ W':% ^ ] ^ WILD S%1N ^ ] ^ Iq Af R'+a.[ ^ ^ LA ) I I .~~ i. ^ ] ^9FihY OM%ftlnELl ] MA%INO N%Illf iIlRN t F-'~ MA%INO IfFi TIInN I r ~r4 r!,1 I i ~ '. '.~I ^ A ^IU y ^O~iR t ^DUUE.TTEf IEr ^ L ^ fIANINn NED ^ T IJILIVr~r 11rLRA~I ^ R ^ &' f ~.~., ~-~ YIIIIfR ^I'3N'GFYI E ^IrPITftOr ^ 9 ^ilA•AINn AMHFn ^ A ^AIIEY ^ 9 ^MA%wOU TURN y, ~ r ~'l ~ ,. ,,. ~JM 1 1~ ^ 9 ^,EftVY 6 ®S NE ~%YIT9 ^ A ^ IpI CHWAI. ^ 6 ^Iii~ U~V 4 { 1 f 11 ~' N~Jfp'~~f7~y tI ft i ~, '.I 111 M4VIM IqT S[E Wn naNGfn plnFll IINhS ^ ft ^ fA OWING J 7 4A 8 91' ~ r l rClaian..In d.IrIrSIYM IrGI [^u•[Grr ^ ! ^UIrICLnrfLMMAN ^ / ^Bi NrEO FO111RAfFIC ~ 1~I/r'~"J! ,p~ Z ~ L F ~~ ^ ! ^ OIIRII. fPIGiY ~ I ^ :f PAIIATLD ^ n ^ p~ 9101' fry GNAT `~ }i 1J{i ~iq~~i`~ yY,[~~ A ~ r (^~ i E^~ f NO[O ^ R (^~ 1TO Y'10 IIWAl1WAY S~ ~ ~ '. ~ ~ ~~~ i~'r'+y y~ ~ k 1 ! ~ 4J1 a ^ M nAl11C I-.1 lJ ^ ll IRM! Nl N F ] T l I ..~ ~ ,l 1, n, Nr , uvawr n I 1 I .t.-A. ;'. ~~ ' ~ ~~ ~ 1 T ~~ 1 ,4 ~7k ' 4 ~ ,r, ~ al I a r ',`L~. ~'7,-r."-i'F I .. ..d o~T.-1 ~ll"'~ y r 1 I { ,,~ h IC.. '1 { ~'+ S~1 r a RI ~.4° t ~~" r a ~1 ~ ~ ,1~} ~ - ,- ~ U ,` ,J M~ ~ ~`~' ~:T~ ,~ E,. ~` •~` .',, I~; a ~' Ali ,~ ~y .~. ~i ' .$ ~ ~ r ~ .;., 4 i k l i / Y ~~L (T`V i•1~1. 1 s d V 1 V Y~ '[`[ ~' ,t I + R ~.' S' '~` ~~" N ~ a ' ,~f-~ ~ POLICE TRAFFIC COLLISION REPORT L.dI TRAFFICWAY' ,,,,Ol cuwRn Nl NUmotR ''R~.~ •~ "''• ` ~~'"' i ~ unit of Eaua ^W I r E Un, UI w f ~ 3oU ^ PRIVATE WAY CUUNII ( >I . ~~ D~~t tl~~~ )~ . [y ^ 11 1. Ull x Ynx Sul w r o wn 'y('•I III• +pURI ~~~~ DUNIV IW. Jeffers:on Cllr W, f11W n ~'~ ~' ~, /~` ' ^N Ot ~Inl CIIYUV IUWnI NAMl6 NU Oi 314!llOM ruGNwwY Illy HUM Mus ps W pDl Chi.maclm C,ount Y road il12 4t 5 ^t,RM, RUUN O4 yl4FlICU.:f SeCI OM x +~~ ~~ , C1N Imeeuuwe Wrur rRn DR EOno NornNn4sta oN `~ rvfrx to Mne R V Rd e[ Co ;fl ' (' Rd ifS lfs/70 osr rr ' ~ : ~~ ~ // . . 1 Lwfrf E gm o . g E SIRLR U51nN(164141~IIU tfvn<l C4U3451v ~ v , •. i . It1Ux AtAVISrM if vOSr N 5 L 1~ ACCIDENL NwMR MILEAGE Oa04M1pwlA 200 n[r K C Rd IL G ly, ~ o. . L 4 CIX{IyroNINVOtV[D Sf v14111 ~ wleiyDy tOIAI NO OEllllD~fJINNgfD ^SRIlIAO[ ~ ^NIE RUN r N' a p I f45tCiN yIRFFT04R [ o N V e ~ ~ x N T GS ~ rn n ) OL VFII CIFS ORRD ~( IN E Ct5 ( yy .•OE ONIV [ 510[[N X,C 4 ^ Qi O WUO4 RUf4FNCE C4p555rRffL0R 4prp r5 }:~ ~ ~ ~a, ~ smrm vLn nt Dena srx} 4wa•m of oanv sl4 f~ MI OK'N!4'S WVntI S ~Y ~90t~ SRCIwICOD NG IGL ~ Pure., Porrer Pole f°'P 1 23 7 , 33GL~7 2 ' i'1.+ a UNI7N0.1 UNIT D ' 'i V, n,W3x, ,~y :nws NAVE: ~sl NO.Z ^VEFIICL nvyr M,DOI( ^ PEDESTRIAN O PEDALCYCIIST # r4 i ~'°9' 1 vngsNMlf: Y.rUBRCr~ an1E '"- / f4 loolL ;Ia ~(~,, ~a O ~ `, ~;~y~( .y ' ~- A ~ ^~ 935 LoP,an RtErw ~ d;::~i y r L. n UI r SrwrE nvcoDF RnoNf NO. D nr ~ g„ TioT-t Totmsend T'!n. 9E13Ff3 UtIY., R ~ alt ° "°" N ' T _ ?q paNex S UCtNSt NO L X pwl RIN I D WfR UCLNSE N / h ~, S ~ ~ ` KT,tt?f;*1r• v(,c;la t.*n. 14 OCCURArION WNAME (RHONE NO. D p, 2 2h 41 v wiF ~DwrLwr I4rN Ya , ~ ~ 4 ~ Tom' ~`r•` Z P1:Y.• fYfy WLIGNr Mronl E OCCURnLIOn fI4M NNA[6 RIgNENQ RA 1! rr_ R Ens wNl f¢ronr- ~~~ . - t q~ O CHECK (n7 .L~ n[ns.NAi °.Rn I Iwl i•iuwn",ol.rtR. OCHECK (~~ nl CO * i v " • ~ '~ i DESD LnswNUn lov f[awruoafn. ~n +i 5 Nlcr,o-, ai+ . flac , u :i ; o~•c l CODES D' a i, vxv , i.in~ ea.ot 2. w N 5 IECr I ~i ,f~ w~ ' , pn p u; . wR; K ;fY ;5: b gi ..,RR.«<I O ~ ""' ^ ~~,n. O : ~<~i ^ ~ °: S r m ~ ~ vfn.rewR ,, p N4.n.N:t O ~° AMaEfCODOF.Cn[V,1 .NOOFIIDARI NUVwI LaDR OPS%R. O~~ ^6R„ eDNV •y ' n"" y L ~ • ~ " . .I .. n rwR I nr[ Moal[DnaINORA[ I 4• „~ 1O' ~ Hui.ck !•Ji.ldcat lt dr. E Vn. IXOR UCfnSERNft NU. SIAIE MlF4RAlf ND. SiwlE H VLn CIXOR a R ~ A~ '~ ' ~~' ~, Al IRw Rrn. NLnR73 >-In. none I ~tT ~. •' ~, Vic" @ ~' v[nICILIaNnRCwrroN o. C vflRUf iwNIN I a3 L I I N N . 6 9 C 1 0 ~ 90 ` ~:- ~. •.t S ~ R[G15R4FDOWN(4, Uyl q5f MiDpl[ S E ~ I I ( RHONE NO. 9f ISrL4ED OWNlq~ LMr ~ ~ Q , ~IIRSL ' Mi~ME ~ M ~ ame as driver 1 3 ST _.~,:y ... u x :a.. 7 wppRLss a oWNtx W n Du mow.. _ x:lxi- I .. .. .,~ _ .; }.': ~ Un!:roT.m `' wnnclDwRU o e -CE ~ c.wRU- ~ M4 t 4 15 0 ,D•wiv" `~ -._~9a 5120.~ C •. LoWlo ~ , ~> . r. Tolls Totrii DIAGRAM OF C041510N; lutn au,w nunrwl IND~unn Ie smero Nfe ss a n q GYwvq~ [ cEP /Jar.~p ~-/a '~ ~' 11 ,* ,, ~~_ lStq,.o ~ Vb r ~i.' bNy J [ Moues Pc•LC- 9GL/On Sklu ov Srfou..y Fn~._ NAME, ADDRESS 8INA1RIE5 OF PI Rt;O OCCUPANi$ i WIiNE55E5 ;` A•.[ -. •In4n){ wVl •'~ ~^.15y r- x M1Tr. nY,.4. I!olm~n I J it I `gip venLCle north on CEi, Rd. ;,{t{%/12 passing in a no• passing zone thru an intersect+.on, "Swerved to -' avoid a southbound car i.n the southbound left ' turn lane.. !•!ent otf the roa,i on the oast' side"ol dirt snoulder~ driver triad to turn'hard to "'"" hi.s loft cmisinP tho vehicle to po into a hrond- si~le said Into the power onloR Vehiclo had boon travoli.nr an an ertrr_mc1.y ~i.gh rata of spedv, Podv renovrd by Ow,yrn ilmoral home of Port T'Lrm.^n_^n~l. CODES L. ~..•I~HVLn I u?n ~~ 4 S __6 SIE I wrr to ~T~' 'rte li _ / ' f ~ J I ~ ' r~ t .u" ~~ ?~ sR F _ ~: 3~^j;^ ~~ t-C!~ 9 ~ ' ) ~ ~ S R ~~_ ' ~ ,rk' ~ v ~r ~~~ '• ~. . m~ ~ ` ~+x 'V tg ~•:/ POLICE TRAFFIC COLLISION REPORT 'L`l.IRnrrlc,wnr ~~i fOIICECOMNAININUMNR ~ PRIVATE WAY _ oArf of coluR n " r~"~ n Dnr a on , '"' ~ ,Rn r,IR ,„,., If ,. r1mE counrr (USE R+00 HOURI ~ ,.o .T -y; s ~f H counrr NO ~ /6 crtr ND. nlwA ^UPOAN RAl 2 WAY Q„ ^E g,„ CltY 09IOWN OO SIRFEr ONH4 4uifs ^s ^w poE ~ii~-itdi'•? ON /~ f~~~ CES ~ R rF 045/~o 95 SfCllOn INIFRSL INO YnrH. SIRElr OR ROAD NONINrf95ElCt ON ~~ BFiw'EF /I .//~t• 'JSrRFfi 6 ~ J ~ SrREF( RREfIx f0. AUlE POSt /•" O/ l/0_ 7 [p ~E b 1 p41ANCF 601 N ROm RfffR .CROSSSiREfI ~NEpRF ImIIE YOS 'DD FEIS 5 f w ORCG~F T !/ ~~ d f i A[[IGENL MCODEE R R IAGRAM DATA . CIXUSION INVCAVfO SfvERltrt RUN O flO KRLED~ND. INJURED ^SRIIUGL ^M14 I t l f INEER Cl5 1 I tt RROAD RRFtFRfNCE. CROSS ~ !(~ l [[ A f O OrVEII CI[5 ~ RRORERtY DAMAGE ONEY ^GfSUIrFD ^VfaClf `- v ~/~ ~ AQ OBJECt SrRUCR(NAME OFOnJ[R SrRUCK IND OWNER'S NMAE) ESt.ONAAGE SPFCW COD NO ` $ ' - UNIT NO. 1 - ~. ~ UNITNO. Z . Q VEHICLE ^ PEDESTREAN ^ PEDALCYCUST ~' 59 1A51 iIRSt 1DDlF OkrvER'S NAMf: ~..L. L 1_ f'oecJo."c/ ,~- DRIVER'S NAME: IASr IR I ilrDl~ .$' ~ ES~R-2 ~ ,-- •a SiR fiADDRE53 ~~Q ~G4 D 4 (ADDRESS ~Sr / 2 •/~ I No r s aJr rf zlRCOU PHONE NO :~i >1dG'[%i ~ i[~~? ~ JD oT•~ .:i r~'~'lc R . _ u 44 1'%~/l'z.%;'s~`+[F.) G3~ ' . 'S [+ C.S` 2 DRNER'3 UCFN Sfgrf n fl I DkV l EN NO. rE A wBIRIYR CK:CURAIIW MNAMf6NgNE NO. E FS IGNt NEIGH E OC A(`~N RNUN4AE6 RYONl O. ~~r`y EYES WEIG„t fE1G„r • Q CHECK (.~ wciEA nN EMWOrF of wNOmfliAl ECK(r7 vEH CIf AS AN VARiovEE Orp„orHFCAI ° ~r r., CODES - t a~ e i s f a;° CODES -~ 7 a x s. sex a 3„ ro L/ N,IiDUS O m ~k,"~.9'°D ^ ANR1„ANKE ^ u1° O "c~`:RE ^ K Kli ^ J4G,. KTordgEw.. p ANaK,.NKI ^'~" ^ ~S.NR ..O"W~ O i.AN . fD N YEAR AU[f IDODGFLNEV.I ~` /=vt; a~ mODflfDMiNOVAI SIYtE (TDR ~CONVI oc "-tJ E /% MAK! EV.1 mowIIDARt NivA) ~ ) rfG'C~ s-oJ°aE .,_~, s' r .c~ I~•Y' ~ vfN.C O c1 u'P'E lIClN fN -z.S:. 'SJ Slpr RwllfRfU1EN0. SrAFE !c~ H ~ VfN CQOR J ~ >`u) D.C? 3CD C r IRMr JRO. A A 3S 13 V[~OF GINiaKAi ON NO. o r 2y / Go L E if DEN( fICAiI NN s~ I I' ~.~s~: ~ ~ ; ~ I `y RECISnRFDOw„w: fws* NRSr mIDOIE vfaNE NO. i % G/~/'d iL~i+1,.L. O ,N NRSt IDDIf E 1~ FDOVmfR~ fASt fr -~`' ~; --~:.,~/ _•' Ss~~3 jS , la-., ADDREU Of oemR N A R NER ~ E//'n U. E ,~ t'~'~_ 7 ~S% cS~ - 4',.fSP!_C~ lyT G NAME 4A(WRFS30INwRANR CO aACFNr ~/ tJ SNP iz G,/!rCL:~ [~"', cYc~l/C~ R ~1 }/ " ' ~ ~ f ./.'/~ ,Oz I( AMpeE .RNI 1 A 1 .~SG• • A „ wcno.°lu gAMACepAxu S f31. DpmAG~ (~I iwAY ^REMAINfD TIUii / ~~WAV ^R[MNNfD t51.0MNGf f tO~OTfOi+ 3 e 'r,'r u-S OWfO C Awpr eY ^ rOWED f Awpr nr: le ..- DIAGRAM OF COlL1510N: Iu3 w N ~ ` - Hf[I rNEC[ Lt ESr {/~//Cr:i2a~ w wwure NOnm E er ARROw ~ O DESCRIPTIO OF COLLISION: Ilef3WMEMfNipl sNEfr If NERSURr) ..__ c~Iic ejf/.sJ.vt Rifra/'r:>:Y G'•'~r~~r./~9... .J 1 ' f,L / °dr/eIGE .ic /~~... Soi,Ai. /j~'aG /!/ ~ ~' r, • ~E E-F c'w/A/ ie~.'y'r /Ar5/ ~ 9" rote'«~/ia_.'7! , ~ ,.s`/F~-_ ~ a•~~ , ~'/ fir nJ i 1~/ In _ _ _ _. ._ _ _ ~~ ~ F , , . e ,~.K /: • r rP~,/r~ :r.y~' ••fivs srri.E:tC /n . i7r /e.~/ r' _.. ._ a ...~ ~ fh/r T,6~/ y !~,/ i~ is+a: ~/rSa:~f/ .~,US _/Jui _. J L'_ i , E. f /U[ii ° s'e•. •r/ ivlw v /a~i~N, die . _ iI a/i c TJr: cJ, i-~,tc%>t N5~%.1/vs R.~•i~F/' NAME, ADDRESS 8 INJURIES OF PERSONS INVOLVED * CODES 1 - 2 3 4 5 6 OCCUPAN TS/W ITNESSES Iic~R i,D""DUaFiu r~feM"E fi u: Ace urns '"„~„" °"; ,~ RLSIR. !MR ~ ~) ( aofrss F ~ uuftor fwnr~ QA Me. QfYI' ^"E' . ^W: ^Cuv Mf A ~Ax. ID ~ A1+M154 NprwEl>. _ Rmwfol OAmn pfaKrO o.R. ^r"i ^r'~" " r wA"" ,uo.Ex N nln or INJURN ~ - Kl ~ fir: ^ AM4 ^ rpKl ~ I :;iT ^ n~ C K ",• ,[) Ivafp '1~151`^f ANC IAOGf OR X ~NCY DAII E ~~1N0 IK]IICf R1D OAll Of EEIWI F ROVfO zfuD rms ~z~J ~- ~Ys ~l''~ \ IVIV ,~ n ..,,..., .. , .r. , .., ~ . try ' _ ~~ } J~t ~ . Y~ f. , ~ Y , $ h ~ r~ , ,ri.. ~~ , A t a n b oT ~i . . Yi .rlmx ;xl~.. J ~~ ~Y ~.1 I '~~`,~~ POLICE TRAFFIC COLLISION REPORT ~TRAFFICWAV HxIDEmmRwNi NUMBER PRIVATE WAY !Q 1ss OAf f 4 _ _ ll I N __ LIME COUNtt .O (UEf RtlONWR _ D~ ~ . CDUNEY NO. CITY NO. {MYA ^ URBAN RAl ^N E ^IN C YOR TOWN NAMF6nO.OF 51REf10 HGNwgY fCf CIS ADM ROVE OR f ~ Aulfy ^e~ Di H1,f} ON 2 .~ 9.9'/>p 9 INIE4 INO WIM: RER gOAD NON iNRRYtII / / BEfVYFEN SIRFfi Tt7L. ( Ffl RREN% O. MIlf P051 // ~~ff La•3T a 6 D'f CEa IR MMFS N e ['CROSSSfRfE O4 NFARF m A i I R R DI 9qM OAlA IIEAGE {Vfi DE ~ ~ CODE :ry ' COlll IONINVDI f6 E IM YOIN NO. 'Np.KRIfD~NO.INIUR[D~ ^ SReIAGf ^. Y6 NRgotN D 1 f R90AD 09 f9fnCf INi[9 CLS CR(Seen O490AD a - _ OV[NKlE3 9RDNRIY pANUV:f ONIY ^ pfSUItFD ^Vfa<lE ~~ ORl[Ci-igUCK INNAlp ClxCt ANOOWNfR E ESi. DPMAOE SRFCW COOIEO ~ cv . 5 f i'kl-i•;UNITN t - 09NF -•, UNIT N0.2 ~: ^ VEHICLE ~' ^ PEDESTRIAN ^ PEpgLCYQIST a~ V31 f ~~ I / Ti nfR'e WANE: N1i IR I l -- __ 519ffi ADOV ~ SiRFft 09ESS tY tAEE 21V COD[ RHONF NO. D IAIE IR N I %1.RC _ •i ~•S ~ s R D9NfR'S lICWS aiAtk W F% tl LPL I ~ AY IIS I v N 9' lI NSE NO. tgiE DAt B19 N NO f MY jYl OCCURAIION IIRMNAM[t ErgMNO. FYES NiNi Nf GN} E CV9At ON NRM F69HONf NO, fYEy WEIGNI HFIONi ,. 2 ~l9! R ^CHECK (/) ' AN N aANOrNfo 'LL ^CHECK ({~ IvfNI i O fO O ~l . CODES - ~ a a R i s u{cr,w e N C fA NFMH Vf f AN IH[R 0 SMo CODES - * a a . ' sex -` ~i 2 nuMlu •~ Nye{b ^ ANNAN~Rf ^ ~;Kl ^ ism ^ ~ ^ :A N ^ NA l a us ^ ~s:9 ^ ~ ^ 1;° ~v KLL N - VEN. YEAR M.%fl y IOMi~NOVA) Sfv R.C f v N Y R Mq[ I EV.) MOpfl lOMf~NOVAI ~ to ~~ ~ ~ IT/ E ' x /. v N. lKfn S 4 IRNU:R NAIF NO. SlgiE H VFH. IXOR /~'~ ~ / / ~. VlNx;l[IDfNIVKAI NO. ` vfN if D n IN AEI ,62:9 ~ ~SS ~ ~ I ~ I i ~ i I i l i i i l i i i' EW~OYYNl~IASi~ IRfET ~ MIDDIE ~ R{gNf NO. O I D WNfR; ~ lASi i19S! MI , Ia_ Aw9[ua e9 N A N wMetAOweuawweAnueD. o•ADENr oRAUNr AeE "O - R R I _ I ~ ~• u a aJ •I0A '.•R.vl CNAROf CNAIOf suN Onx•R A{ ~~ o.MAA,eDAxu a ,p y OiORDii U1. lVUM C,! p~MN y ^R[MNNED ~ ^RfMNNiO ^ f5. AM ~ y ^ AW y 10~0~%G~ S Q" AwA en 4, Y~ ^ w+v er: S DIAGRAM OF COLLISION: E N INa~Artuo DESCRIPTIONOF COIUSION IDSf SIAM1[MFNtAIeN[Eil1 NFCESSA9V1 -~ VNC[SURgJ a ARgOW _. _. ___~_ ip-r--- I _~ T I t i p '-~-1 _._l9c'~L...:_p.~iu~~ra-_.iu..Fdqcj-~ ~ a l A r T .~ ~_ L__~;._ J_~--~ I ~ __.(a . ~.l r- _ ~~~~`' ..Caw _ . iw ~4~'`2v/1f/._ I I , ~ i ~ E u ---- ---- -. _. _._ _ _.._. .. .__ ;_ ~ ` !_ Y .~ I .. 4 .- ._. _.. .. .. _. ... _.___ i _ NAME ADORE5581NJURIES OF PERS NS INVOLVED 4'CODES 1 - Z 3 4 5 6 OCCUPANTS/WITNESSES ~a.b^iroiafNNUAH eii u% e,~ rA~us '",,;;" ° r '; R esn. erta .n N AML: r .. _._.. _. _. A oonu w~u•E a ~ x{{x r. ^ AM R ^ i21,c1 ^ w:.Y. ^ ~: ^ i..°.hf{ N AM . ,.,N ° D A . _. __ ... - oany gru+ra..__ _.. ii Y {.9u ^~,D ^ x ^.MM1LL ~,N%wfo{9[vA ^AMe.^,{ D.n• W ... b ,M .. ..._. ...... . _.. ~,.. .. A [n.ny tnC:a°' S CNRY. ^qMR ^ ~Yl ^^Dm. ^:^ n ::~,. X A,YU ~~ Q f •ANK ~~ nAOU~DR . uN~C.V/~ ,...I O. T ~f3 ~qD / : ( f~is~ __ v~o ~. JJ D ~f a nron An•o.-o er wN ~ J~ c-. .L~J~ aDH E E F~ f~IIyy,, ..mt -:.'TEi. K .Yr4 _ ~. Ik ~Y~ ~~ ~1}' p.~ " ~ ` ~,L. 3 .n;Ul!'A~S ~° ~Y ~ M`y 1 1 I~('~Fk1 ~ i 4~ M ~~ ;4 ~~ ~ ~,e1 ` ~ .~ ~d I .. ,•1'~ ~.. ~~~ ~; e ~~"~ It ~. ' ~' ~~ ~~ .~'~+s ~ . vll ~~ ~" _ ~ ~ 4 N~~. ~ .t . ~ ~ (" e ~~ ~„ w _ ..n4 ~r(~riJ POLICE TRAFFIC COLLISION REPORT lal rRAFNCwAY PoD<F CDMxA~Nr Nwn3fR PRIVATE WAY 3RI DArrorcal brv r c o umt VSE a ODHCN R counrr counrr NO. urr NO. rHwA ~,r ~ ,,. N,. r4H ,la Xt FF N. , I I I 2zae ~TEFP&.RSctJ /~ U BAN °RURAI I E °N °E °IN CrY 04IOVIN NM,E6NO.Of S.aEEr OR NOHWAY 7 / mnfs $Is ^w ®or Cl~ii~sgc \/,p~, ON GEZ,~ '~ PCr Cl3 7 RW IE 045 .J 9S/70 fl N n 1 rtxsfer NCwIFH: srR rc~w.o rION INRRSfenoN IN / BEIWfEN SrRfFr 6 elRffi vveFln Eo mnE VOSr ~/O 6 wSIX~t6p,x ~ufSit(ROMRfrFRE EF.CR05531RfEr0 NEA4FSrMlIf YOSI ~ MILEAGEr P 04 RAM AM DArA rF[i or A1.TCR't / CODE COFlIS10YINVIXVID, SfvfRUY. RUY- NO.INlU4E0~ ^SPIUGf ^Ml6 OKIllFO wNgatorx N .4D I 1E R CLS R I Sr !r RROA004 ! NCE CR~S rREFIOR gOAD S 2p _ [[ OrAt NO OVFHtC:Ei ~ ° PgOPfgtY DAMAGE ONLY ° gSUliEO ^ VF~'ClF . / Iv / J % ~~~ __ 9 QYlfcr SERUCK(NAME Of OBIfCr STRUCK Arv00wNER'S POW E) f3E.OMIAGE SPECIAL COOING USE G~ s Usvk. UNIT NO.I UNITN0.1 UVEHICIE PEDESTRIAN ° PEDALIXYCLIS7 ° IN DavExs N.inl: ucsr NNS m f,1 v(RSNAmt. usr --' NR / ~ SIR1Etr AODNf51 ~ f rJ ~ Sr4fE1 AODRt , ~ E 4 UIY rE TIP COOP PHONE NO. D rY SIAfE I I RT of Iy .roD 3 38S-a3ZZ R rvFR'S UCENEfNO. SfAPE SE% I Iv LICENSE NO. AFE DA IRFH ~ occwnnoN HRM NAM[6PHONE NO. TFS WFIGHr MIGHT E OCCUPATION nom NAME PHONE NO. EYF3 W(i MEIGHi S7UDfl N . 't'&. tisV. 2 R U CHECK (.~ Ivf«ttEAS:NE.°xPlorR aPANOr«faAl ^CHECK (~ EVEH CIf ASnN OvfEOFANO I _ s CODES ~ ~ 7 n ss % i v.Nl 5 F e s,°:°r ' ' sn CODES - ~- a n a i; ncnoH p !°D.N ` n w~fs ZNSI.FfiIT• Nf' 'Sl.s t'ft ie.'r'° ®,MSR,,..cl U E;~KF U id:~t• ^ K cu U .o:vsP H a°F ^ .M Hce p ugrEc~b'+It U v~ U F::'«E. 'Y pv ~ Su vtH.YfA4 AMKE IDODOE DHFV.) lPK:UfI IDARI NOI'AI SrrIf IROR.CONVI « fAR MAK I Hfv.l I VAI l V.1 r er>M r RD E SJCy ~-DR • E ' ae HC r ENif lA N l s1AlE AIL[R MI[NO. rx SFAIF H~ v(H.caoR a TF;F9iATFRa- IiIZp N A Z 'Cel. O Wf3 I vtnClt lDtNru2ArION nO. F 3 Y 2 2 t P1 S i vEHKIF IU(Nrf CAn ~nN Q REGISR4FDOWN(R IASr Igit MIDDLE PHONE NO. O rERfU WN a: lA1F N4Sr MIDDI! N MA ADOgtssaownE4 • Y own1. Nn 8~po0 N A D s rDwnE4 ' ~ m AMfAAOD•lS1Or INSUOANC[CO. ON AGfNr OMT RT OWN ND I,l/P,. ~ R N (~~ Si CFFIT ~~ ~ DAMAGID ARIA . . .. OEAMAGfD IA[A CHARD CHAgG! ! • I 31 O AMAO! ^14vA+N ^REMAINFO ~ ^AWAY ^YfMNNEO f110AMAG ffOP •• PCfOrtOFr f ISf. rbioriov o wEO rowlo S r Awnr er: RA6'E ^ Aw.Ar av: DIAGRAM OF COlL1510N: lu suvl Nwl Inn¢AIFND4rH DESCRIPTIONOFCOlLI510N: (IbESUPRtM[Nru stllnRNfeessARrl er ARROw smug NeasuRr a If .. ._.. l: .. -- ..' .... ~. VEA• I FhS,:ED "SN6 WttNE55 C/gL{ _.AND IP~lEni .. ;.. , _ RE - _ . ~ .. „ _ :.. .... ~. ... En+r6RS+~'TN6.NoRTHAo!r.,p IANE.I RRN o~.`fNE. GR!+ I, '. ~ S11W1.D0Q fW0 LnsT GDMT.Pl-•. uLLD.APP.Mx.:. ~..ZOO.FT R(4!~fr.. ..~ . - - a ./ Q $koExA~.R/ T1iEnE RP4f<nX. !10 ,Ff_.Ikl20Qi. RoPOwaYa.?Flu' E[ _ ~I~ .~ T P.PPRox.. //S F7: ANGG,Tn.(,. OVER. RN_EMDRnrkMEM' TO, x If , %J ~ >< VEN•.a•I THE ClotTonti wN6Re Tf{E VEN• oVER'TLRyED~. E7fcGTTGUCY.. ~ .. © ~ EE .. TkE oarvER. 7NE•. V¢N. R!><.I-so BRCK oI,FTO ZTs...... y ~ lJi7NE'}$ VEK. WHEELS Rnsp .PrwGEEDFA RNOTSiER 90 ,~f. oa..AA,N,~y ., CftFz~,ER ESECTEfi ~or.P zTs WNEELS~ 'YO WkiER¢ LT CAME,TD Rk6T BG.f.LDfo-, 0 'T. ~ EED rJc P - 4.o p QARtJ 1° NAME, ADDRESS 81NJURIES OF PERSONS INVOLVED 'CODES 1 - Z J < 5 6 OCCUPANTS/WITNESSES ~a: a^rKV+uraF~Gni ii sri- Ac ur ~rv~H 'tor - ~ r nR nsR. [xa Mrcr ~ ' N'"" Mc~DOR:., BE,VE.RLy Cr. ~ ' uNSC • ' avlu T. AluaEnlD g ilAr(~• a ~j,' AM r e Uu" U "'".. UD'. ^C.X;o 'FMFW gGGoF./kR KE~ACN D. ~ .• uNk. o A ~ Eanss n ,, Trop a RMwID rROmU~e UruKF U"".«. UN~ ^»°.~s. '0 ~ rA Hus,rr PEED O. A r t r A y i lis a ufninr UAMe ^'!';: l CJ r~FinR• UG: ^ ~„F. f%MP.S !O K~ERG4 Q~ar /NAVC 4 s• N x FPV~snaArN.cc~.itsN~~r "lo~a°.° ~GF"cr O ufm uI`~sr41cmo s~r7rro oAnornrKPfr AnfovEOer DAR 3~ in 1~ L,. F''Tv" T ' ~"t r_ I J ~•Y ..Z ~t [~ _ f ~- ' '' r ; sT F wnsH,~iri oN ~ _ " r ~ \'~~~ MOTOR VEHICLE COLLISION FEPORT ~ " ~ N(. ;ry .:~~ ~ ,. ., OAYOF CAWSON 1 ._. .TIMEOF GXAISON .. ~, ~• G)UNTY NO CrrrrO 9 'L N ., GATE OFGOLUSIOH ~ } ~ -, MO r~M Suv EVON rvE4 wFe MUP rn 9.vr wCU NwVIE1 AM .:,:,/J- r .. .,. JI^N' ~Ar D : ~ PM wu ,' ~ O'2"ML y ~ n ~~, rf. .G) Y. -'-,.~ .LITY,iOWN._'.~.... fOUr9gE MK 9 ~ Om .. .:: .. GTY. TOWN ~ ADMKLS- PREFM nWr[ 9ialfT000[ SECTION , •~ ~P.~r' F rd i?c'JILi+' ©pF ou/I' 3 9Siid ~ pip GIVE NAMEOF 99TR?EET/R~OADOR HIG~JH AY~w wi R9EGTW6 TH: STREET Oq RGAD ~ PREFI% EO ~ MILEPOST •//~. j E 0.CGCFNra n • Vl / ~ /~/ ~~O/ 'A Q j!~p '~Sn ,K ONINTER CTION~LOC OFCO l1SION ~ MMP GAORAM DATA - z ht 6ETWEEN STnEET PNO SiP.ET ~~ ~ R O © NUMafP SwWE NON %RD w ER E31n INTER INTE ClS 3'T qN: aKT ©® Dr "`"°°[~aNN~~E~DSreNPEHr[rwpLAND, / ^ m~,,%OD " ~ I rw;LE VENCLE QVEIPCL[P{Y0. Dol"[RlwwrEl r SPEC.CODE USE 1 vgLV[ ~ OyEryGEOB1ECE ^vF CEEinuN [ ~`r~' ~~ „Y"~ Y ~ ~ I EvENgEE$ - ~_.. ~VENKLEKDESiPoAN ^MNGOluSgN ^wTNUN .. ~. 'U OOJECT SinUCK IN[MEOawECtsmu[q OWNER OFOBJECTSNAMEANO ADONE55 LOCATKJN ©~ O ro r[Anm~EC~ ',~' ifQ/~s~= o Ysci A,GC~/Y X3.2'70 /~o ~ /plyEF10ADWAY ,~ yE 5" FEET too! S ~~ _ ~ It • l' • • 1a MRE 1MAN • • '. L ro+" ~ UR VERSLASi NAME .. FIRST NAME.... .. MIDDLE lw0 cAa9 DfINERSlA57 NAME fIR9T NAME - WERE wv0.v[o ,._..'... .MXNM.E ~.w 7' d y ~'- ` ~~ ~~ ~ ~ ~I / zttf~' <~~r~.rGe A os' caislweR F ' ' StNEEi Apoi1E55 .~.. ... -. f1DUT NO.ANO tb%NO., MORE iNMl iwq STREET ApG1E99,- ~ ,,.. f10UtE AIO,AND BO%NO - -" "~" _ ~ `m ` RsoN9 WERE ~~ F ` 1 UREDUSEA '' " ~, 5[PARAIE a{ GTY SPATE :.:J:. 31PGTOE. DRMER9000UPATION c~~„ GTY 8TATE , _. ,WOE.., pPoVERSOCCUPATKNI„:r. v~q ~'. '~Tu;rAs~Nd, /~ EY~E~ etiErd nEPMTfDPM ~ " SF ~ ~ ~ ^- DRIVERSLKEN9E NUMBER : ,. STATE SEX PATE OOFMRTN~ AGE _' pRNER9UGEN9E NUMf1ER „.. SPATE. SEX -. MTE OF BRIM AGE ;+~ ff55 NO oAY Y[AR 'v1 `~ i IvEH CLE YR. MMfE ICHEV.apGaEl ... MODEL VADARTI (X)OY STYLE I2 MLI VEHKLEY0. MAKEIGHEV: DODGFj MODELINOVMDMT) 800Y STYLE IJ paI.. ;. „~ E ' ; //J /:Y4 ~C'l!1'-•YO Picket N ~~~f rLICEN9E P)IATENO... STATE RnI12i1RATE NO. STATE - LX;ENSEPLATE NO. STATE ~ TRAILER MTE NO. STATE:.... m ` ~' "fEHICLE1DFNpFlCAiION NO. _I18fiBMO0EL96NEWERI OOOMEfER (MILEAGE( VEMKLEIDENTIFICATgNNO. .:. IIBBBMOOEl9bNEWER) 1FA LMMJivGE ~ EL y ~ _ REG 9TEREDOwNER': [ ~F'dE -MIDDLE NAME)- DRNERSUCENSE NO. REGI9TEREOOWNFA nAST-FIRSi~MgOLE NAME( OPoVERSLICENSE NO ,_, -. 'p :.WNE.R/b ApO SS EET,CIIY ANOSTATE) ,~~ DATE OF &RTH OWNERS ADDRESS „19TREET•CRY AN09TAIE1 DAIEOFf%IIIH .- _~yT~~` 'r ~~~ 3~ ~ ~ ', 1,• A (\ ~~ 1. •' ,Y~~• ~ ~e„ YES MD p,Y r[AR . ~f k.~ y _ ld = i - - yRPU i•JaR9~VEHK AM EO ~ Em ocosr PMTSOF VEHKLE DAMAGED nip, ,1L/ER ) ./. ESIRMKOCO9r ':5S-,X~` s ~/Y ( {I V (A ' ~ , ... ' s ro; G~,v .... srow vwa, , • ~ ! ~}" WA9 TNERE AUTOMOfNLE LIADILITY WSURANCE '~ ~.-~ 1 *§ ,r°a~ _ # (LIABILITY INSURANCEINFORMATION•VEHICLE N0. 1• cpVERAGEWEFFEDrfDR iw9 AGGIpfNTav rpuR CAn YES ^NO ,' L y Y _..., .. .:, .' NAMEINDADDRE:w40FUAE11U1V IH9URANGE POl1C~Y M0UJFA ... -prv ~ ~-' ratE- NMIEOF UA&UIY N9URANCE COMPNEY .. ...,... _. . NA [~, 2r, - r 1• t n • "o t 19k ~~d dSl . '' ~ ~ ~ £ NAME ANDADORESSOFUABKffY WSURANCE AGENT -D SEME ZP UA[YIITY POLICY NUMBER a, •^5{: {') ~~ ° IST NJURY ~- AGE 3NDINJURY: nA,ESFPAMtEIWOIETfp1A0D1gNYHAXWb1 ,AOE.. 14 ~NMrE .. ..... ioTAL NAME } r - ..... d ,. I DOnE9S -. __ 9EXpp ADOFESS __._..~-._,_ BFJ[ 1 r ReNrnE HAw -.. - ~ q4. Ee ? _.__-_. __ __. .__~ T M F ~JA .II ' ~~ Lr { ,v~ wMNKSm E --~ 1 ~....9_.___ ___..__-_. aRR[ _ ~ooCiUli1 •i •.TU„ peCrORV ® ~ Ff Ar rA r ®~ NArp' Y ITj„ ' bTATUS OF WNREG N•u`. MARK iw9i WETHATAPWES ,. 6iATUS OFINJURED - ,- MMKFWST ONE TIMTAPPllE3 - r~lE tt ^pNKA WVFNKLE a~ilu~ AqN BIM KMSIBUE OMV WVEHICLE e9A0.H0 NON DbAHNO PO55 'E.. ?av I ^PAS%N4FR KILLED jVEPf) MvKXa 110 p~P4w1 SPA NO KILIED ISE~wP[I (wow 1« ^KMSrR.w [~ rGl ~KDE9rIVAN FfC IT I ~•I' SNOWIKIMMOY AAEK)W WCIRCLE ~ I OESCRRE BELOW WHAT HAPPENEp IREFERTO VEHI0.E98Y NUMffERI' R '., ,A. ' w.MtNN,E.aD ~ /•iP~ ti ~'CA~"y _ h r NG So u f_l~c.N_ ~ 1 w ~ ~~I[gEL :,~N,::/~;~ ~~ O \ ~ (,?. _. IZo-A ~ ! .T e Fa G I 1R ~~ I Q ,rAAMIR[rHww[E[ANDEHDw \ CR.US I N _bAM /~G[' 'tn ptUNt of v P • D.1EDrgNa,R.wE[..Rbw \~1II p/et<.UP TQ.I{E./NL2 1?.YACe,t/t ~~~ Qa{~ f 6r FoN Av. J _W~MeN-~v__h.e_G--p/l~--LN.-$_eh't~ll-1N ' - ----- -_. _~ ' 7_ dl,.v z re cvAx Gz _si~!G_LhC- •A ~, .. __. Q i /~ r ~ ( ft'en~r Ny ~teNed K,v t~.•etac._ / ~~ _ _ _ _ __ I r ; t'+y 1 f ~ }- 1 'lI~ .~I .. ~ s1"[Elcw ~.nry.. / I C rp pLANE3 ~_ hlcu._. _ Y[HKII ~ ~ PA1Neow - WyESTgATE00Y-- - + { 'I ( `, VEHICLES POSITIONS ©EFORE COLLISION wo"e rnuuslANIPKI lrnuu PARPm riHCUOCCwo rrt enNR I ~' ~ I `~ '~ ~ I VM1KLf N 9 f ON SifRET M ISGHWAY NAME OR HO pMCIgN t S q ^ ialADl ^ IGK[ ~ ;{~,~ n ~~,~ w I.D[A ^ ^ ^ 0 0 0 0 ~~ o ~ ^[1K DNewW[N r , ~ , faK[ nAlYw , n `• r r 1 a Ew,1.41. A ^ O^ O W I'C Iti I A S Is v ^^ ^ O ^^ D [1aREf ,~ ' r a ^ O D D uoNa <PDAwp rrwu OIPECTroN To DINECTION '~•~ i'" ~r~A 1 1eD[91mu+wASUSwE1 1QWDEwALX t^wALXwAY D^YWIAMn aD~«w;a°,Ma bD~Rnuw:°A a^OTHER ~ ~ n+F E I IL I~/,~ nOAp DWIfACE YAAIMN lrGHiCONMIIONS IllAffK COHTEgI KNICA ONE( fYPl OI ROAD GMVER/VfIRGIC ADTIpM9 ~. I ~ ~ ~1 ~ V L K1a Ca Mal vUKI[ wwGr rl~la dv VI„CI[ KrKCKbN OIMOI[I , ~ }) Y ^7K }4 4 ~ l~ ` ~} .[.•CH C I [A NO l r NO) `^ M I M i 1 r { t ~ yA fyl = ~ , ^.. S1f ! I ^ <E„ ~'V , ^ oArLr.HT O 1 ^ srONAas ^ 1 ^ MIE wAY ~ 1 ®.fi(MHO BiRAIONr MEAD I ` p I IC ~~1' Y' }y AXV V _: 1 ! 1 1ILI ! D MW T ^ RAINMI T ^ OAVm ^ t ^ SfOP •JGN ~ t fM'O WAY ^ T ^ f1VEniANIHO MIO PA95Pq * 4 /~ }(~V r, ~~~ ~~ ~d E - ,~ ^ T ^ wl'T S ^ yIO,NNO o ^A GJSK ^ l ^ Y [lD 6XW ^ D ~ ~MRYRL[ ^ D D MAKwO RKHf NRN I - Y J 1 `4 Y j,} 4 ~IV,11 1 rtr. ^]^:IA7w a~/OG E~~NITb ONfT ^ a DlLA'IMq RED ^ 1 DWTERCHMKIE ^ a ^MANPq LCFT NRN I ~' F,}~ ~ Y~ h,rh.~F r ILOOPAnAM% ? ~~~ ~~( ,,yE KE A OtIRR DNi1 StRI FT 11 ~ ~ b 1f ^ a ^ ! ^ LN TSD f ^ A ^ fLAS1rW0 AMNER ^ S ^ AI LEY ^ 6 ^ MAKwO U~TURN I - ~ l j f ti I r 4Tr^~, S MNfR ^1•JYCrf YI DAN b IWO WAY. J~ 1 ' fl ^ ^b[XCFY A ©bla[EI LgHiS ^ A ^RR TafJIAL ^ b ^llft IUIIN ^ b ^fAOVAAq F'. 2J~IE~ 2yyr ': • Z IIJ ATASON 10REgT SEEPA DANGER IANFS -~ I t ~{' ~- ) ^ ^ ) D Mi FRIFLAGMAN ^ / ^ lTCMTip FOR TRAFFIC FyyA~~ - L/.p X.' '' 7 G ~^ n,ElaNO curl MrArLrgv Ir[I J'LGry Q R ^ rvO TPAIFICC iY .._. O 7 DUNMNOf.O ^ 10 ^ a OPP~M IOADWAY ~+ '' `I ~I J~'Sl T IIT1 •~I~~I. 11~~ 11' qv... -~rt[~,, ~E*{El ,., -. 1.U t ^ i. . ^ I M! IANP !", y~~.' ` ~ ti , 7I~, '~,;"'."".~,~ .11; 9 ~i," 9' I~ "'r~'-" , ";~'"u~ a la` 113 ~I`~i~Y~~ i lY 4 r 'l f' - V L , 1' ~4 A ~ ! av 7 1- >, ~ (; t `f t a { '- t , i : ~ r 3 I~r Il' ti'i, p '' - Ec N ~ ,. , I ~~ ~' _ ~ - . _ ~aL:. .A f 3E I '~~7 a~3-~ POLIGB TRAFFIC COLLISION REPORT I~(I TRAFFICWAY ro11CE COM%AININUMbE9 ( ~ PRIVATE WAY ~~ OAI O_CQl N r O _ 3 3.1 Ru... w.. TIME IV$f pNA HOU91 COUN3T CODNfY NO. ~~ CIrv NO, FN WA ^URB AN l S O 2 , i O 0 S F k. S tV 4 L u ^N ^F ^IN CiY 0410WN NAME6N0 Ot SiPFEi Oq HIGHWAY ~~ AuLrs gIS'^W ~d CH 'JTd ~' rCf Cl3 UM CI gW/fORS ~ YJ~i7p ON SE z] INIf95EC31NG H:S~Et04 WAD NON INSF95ECfION PRffl% EO. eMIE POST '~- /~ bfIWfEN SigEfia Seq[ft ~~L~ 6 DISIANCFRDgfMll , LNCf. CROSSSf9EEIOR NfMESf MIIf WS nE5 N S F iFEI Of ACCIOENI MILEAGE CODE P OIAG4AM DAtA COlLISgNINVC%V[D~ SEVf41YI 4 N ^ SPIIUGE ^ I U NO INNRED NO KRLfD MIISV IOVpelptH 3 N _ .qp INYFR Cl5 t q ING Stiff R OR RLf(RfNCE DOSS SIRtOOR WAD ]] ' ~~ q ~ _ IOIAINO O VEN CLLS PWPEg1Y OAMAGF ONLY PIRE SIIXIN ^ IIFSULRD ^V[N Rf ~ ~' ~- /J _ R OBEECf SSRUCK NAM 09'e K DOWNE' f AGE L HyD~ W._1.lLFTL'1. t'. KT~'~~C^- SPECIAL CODING WE . 2 iMfiCltK ~ :Z~7 S ~ - UNITNO. 1 UNI7 NO.4 ^ VEHICLE ^ PEDESTRIAN ^ PEDALCYCLIST D91 FR'SNNAE tAS! NR51 MID lE W0.T 5 R DgIVfq SNAME. NSf fIR I , - SlgfflAW9E33 ~ IRfEt ADDRESS 2 tY StAIE ZIP CODE PHONE NO. D x TALE IPC I R.T ow £i~D 6 5- 41 R WER'S UCENSfN •CT-- to MN mE6PnONF NO FIR OCC P T SIAtf lil SF% i Fn n o9 z ~R. to I ~ E RIVER' V ENSE NO. P TIO OCC SIASE SF% DAt BI9tH ND + pAY ~ Y. _ a 2. U A ION ETzRE,D g . ! -~ EYES GHt SEIGHt R U A N f19M NPMF6 PNONF NO. EYES VIfIGHi IEIGHi ^ CHECK (.~ yfHKIF ASSN FMROVFE Of ANODSfe AL ^ CHECK (~ yFHKIf AS AN fMPIOVfE OFaNOiHFR~ 11 CODES-~ J n a °s S e 6 "iA° CODES -+ J n a is Sex 6 s• 1 ]) 2 wlnlES S iFi° evrwM ^ AvswH<e ^ c~i'KL ^ ~$.rtv ^ Vf ii ^ to v ^ Aytywxe ^ uR'KE ^ r:b:nR - ^ n ^ ii Nv `i ' VEH. YEAR hNKF IUODGE.CHFV.1 MOpEL IDARI.NOVAf SIYIE IRp ~pNVI .Y q I DGF NV.) MOOfL IDAgi•NGVAI vn Y l 1 R _ ~ E 'ab 5 v . EAO9 Cf PLA StAiE IRAnFR M1E N0. SIALE H w A vEN.CIXOR All LA AE 0 7 7/ /7 `l GuR C vfNKU3aFn flwwN NO - ' vfwaflDwnncAl N SQ 13 , w BoIY 4R Sa ~ ~v'7,2 , L . , ~ ~ ! i 1 i I _ REGIS1FRfDOWNFR~ I/SI rIRSt MIODI[ K.S tit BovE PMON[NO. O W RE SiFq OOwNFR: IASt rIR31 M100.F NE I] z ApD9t53p OWNER N A F WNER ]I NAMfEAppRL55aww4Ar.cf co. oq %cwl R LbD'9FaTfi. 'IFS'u u~IL~ZFC3. &7 n a] Trc ' ' wMAGeo Aau 3 __ o0uwv04 CHA9U .. . CHA9Gf sA>I~ p gAMACfDW3EA ~ a TOP 5 lo:oir::i fSt. DAIMGF O wPyvfN u ^ RLAwFIeD v AWIV[N ^ AT ^RtAwN[p FSIDAMAG aIOP lo:ori::i f N ~ ~a e ~ rawED Ar nr: = a I DIAGRAM OF COIIISION ~ AuNIA3 NDC EFIO HFtI NfCt15ARY1 BY 40W '-- '_' DESCRIPTION Of COIIISION Ilbf SUPPL[ [ lus e[rP tcesua) .. .._...._ ~ l f ' I _ ' _. I~ } I 1 ~ 1 1 4.1 I I ~ I ~ I I~ ~ _V+v~ 's'.l STf2U.LK A klORSE.. ~t,i _ 'RISC Ms-ODL.E,. CF THE. ROFpWR`i .. a i l i i _I ., . .. . ~ ,_., 1 ~._l f. I ,_. i_ ,_.~I __ -- -__ _----- „ I I i, ' - t ... t y ' ,. . -- ,_. _. , ~ l~ ~ _ ----... ._.... Sa NAME, ADDRE5581NJURIES OF PERSONS INVOLVED +CODES 1 - Z 3 4 5 6 CKCUPANTS /WITNESSES jO~a bq,11p~NAl NAM~ )1 NK~ AGf UIUS I W~H R [A9. OICI N AMe: . . .. . .. _ . ~ . .._....__._._._.. ..._ _ . . . _ .. _- a3Rev . NAnl9fd. .._ fNfilr- AM e. ^~1 3 ^ wIII. F ^R; ^iL.;,o N Aw p A __ ._.. __. _.. .._. .. .. .. l%NIN NAruvrd .._.. _ RfmwrD rapM m3cl IRrv MaV ^AMa. ^rA ^ Omf ^H ^~" .p , AML: e N .io A LSr«u i VR mA'RNf SCfHr xT ^Ams. ^rM11 ^7«~IR ^:7; ^~ v f1pAf~ . X FKI~ lAOFA W Io AGENCY SI.pL3 O( J n r3[D 3 •i, .~l!F(OR~Np oy DAIId RI WRI AIPWNDpY Wil I ~ t I~rypLL~ p~~Dp xy i t 'n "1P.'rlut'. -.~i F .li:f (i Sfi ~Y d 50 _ &64? P Lr ~P .. ~ I . ~{4 Z ~~~~ RS . fti • ~ '~ M i. " ~_ •Lv • $ ~''4 a ~ ~ ' E ,~ ~ , A F4~ J 5 ~ °L~ e44_ . - ~ ~ ~ ~ .~ . rm.~~S, ~ - ~ - '. a '~ k ~% YYWW R~„ ~ - Lk ~ ~ " ~ ~Iw~ _ YI 9 p . t k5 ~~ e -s~ _"~.~L'->a-'-- ~-:.d..........~":"._.1'u~sx _ 'arrtnrTat~ [Irin.~p '' ~e~.•a "S$ STATE OF WASHINGTON ' ~.: ~.~ Gf i Di ~ Nu '~ ~ 77~~ . POLICE TRAFFIC COLLISION REPORT LLSI , TRAFFICUJAY RTICE COMPIaNr NUMU4 A':"' ' a RRIVATE WAY '31 palf 0 c u+ a i s N ~' F ~ ! +r] Ar s ,;' Fes' 'I fun NM IRIS •IO Ott III ur (SE SbO HfJU41 ~ Q.J cou"rr COON YNO. CIrY iMYA /1 pD4 6 ~L' r! ..~: '.J ! J! ~ me,. {p. ~~ e 1 ~ - QN QL Q N CIEYO4 iOWN ~ AMFENO.Oi SF4ff104 HGHNAy Cr CLS V4AL z r ~,3 „ - ~~ AVIfSi~3 QW.~OE p,_ _~~~i.~ ON Ci. i~+/~ A1. (/ ~ INrf RSFCiING ' roN •"' F (1~ 1 SrNFEt OR VOAO NON INIE4IE[rION PNff X / I ` ~- O. I yr ~ E~p a J ~ y ~ t 1 + f BEIWFIN ~ 314ffT ~/ ~ 03161 6U K ONr T /'f EEr PfiE4r f ~ p {] ~ LU] (,f U 1980Q ~ 4 yR V.. RES S f'CW SS Sr4Ffi 9NfANE3rM tf vOSf ACCIDENT OIA04AM OAEA /V iVfl N Oi 8 / MILEAGE N eat saN wYa EO~ e4 rr. CDDE ~UNTY ;~ SJ' y,: ~i g ~~( ~i CFV HINCYOFS ~ FIGED__NO IN1URfD ~ ^ SvRIAOE H4 teVri rUw=:p~H ~ ^ PROPERIYDMAAO l IMF4 a O ]] ~ - ~"h'+ 2 f ONLY ^ qE SUlrfO ^ vffOiiClf 8 OREKISIRUCX (NAME Of OBE[R STRUCK ANp OWNER'S NAAV) V [Si.OANAGF SvfCW COpeK l6E _/~ L. - 1 t, tltltltltttt u~ UNITNO. 1 s~ pRIVERS NAMe. fASr 1R MI `, s UNIT NO.E1 Q VENICtE ^ PEDESTRIAN Q FEDAECYCUST - ] xvE4~ NuA IASr ' I~9~ J '~,~~,' _ 1tiu _/ sr4eEr,.fw4fss r ~' '~o ~.S ' e'//LLG J 19 /d a G __ , ~ ~, v T /' -^ 6 ~ UFY ~~ S' / f %/ t'/° t H ~ ZIP CODE ONENO S 4Efr ADDRESS O tl X ~).1 D r ~ml'.^B.-: m , ~~ I J ~ , y SIAIE I p suaNSfN s rf ~x ~ DAS ~. ~ R /',.' 1 R CE ~ f7 J ~•v.7 OCCWAt ON 114 _) N3E N0 rf / x ~ ' _ ~ ~ . MNAMf 6 PrgNf NO FYf3 tiE GM w GNr E OCCUP ION +Fd i.: R B Y ~ ~ `" ' f E RM NNAf 6 PHONE ND. L f / J Ens • ~n, wrFr SEaHr J2 4 _ , / . W ^ CHECK (,~ vfH OE. A V V'~ • I /~ ~~.~ ~'~ '~ ~ N fMR ANOrHE ^ CHECK (.~ CODES-* D n^y A onrn .,rO S Ieer ~+ pa VEHCFEASAN [MROYFFf%AlprwR. r u .;rt 1 R%1 J C MDrr°c.cu CODES `inw"` ~ rl[ A s 5 [xClro" 6 I r~ " ~ '. ': ; `~ " ' _ ~ N u4rcs r sue F~ e SI ~ /'E i [.!•it • '•- - e+ n ~ •SJ~.~ : ~f m`T° ro ~ A„NX.Ke ^ ;yu Q Es:R. ^ ~ ^ u: ., .o H4V 5. 5 ej. l " , jsµ E 1 ~ gVMIIANCI Q uRCI ^ cSI%rtV Q VFH riAY Y nwsE lUOpc,E.CHEVI MOOR IpA4i. S Q y NOVA) rY1E 1304 CONV.) r ( 1 MOpEI FDaR. ) ~] G ' C7 vInKV ^ig`i1v. rROy Si ,... ~~ Y T H ,I L /' ~/ ') i ° ,~dn A J" ' T>7 E /I L~R~/1 K C//'X IKZN PIgiE NU SFAFf R R H ~) h ]! ~. n(T! x~.,tl a' ~' - 4 nNlu[laElnE Ur ~ U RAfE NO SrgiE VfHC OR 1 t lw NO ~ /'~ C J /~/7~Cn %f !P „ - 5~ rYAln. '7 - ~ + ^ ~ ~ J ~ VENICSf IpfN1 I U REGISRRf i ]~ ~ f p OWNER IASr fIRSi MI00.E PNONf NO. O R I OWNf 5i ~ r iIRSr 100.E L` ~ ~'i^6.C FP (h,``']kd9 ] ADp4fssa aMN[R W svr'1 ~ ' A CJ L k ~y AY:~!-~F 4:: N NAM Ess of lnwe E '" ' ~l ~ ~ ~ G ~%~~,-x , ANCe co oRACwr f x5 R , ~ /! E. ~t a .,',7 .:{; rroP o»:o °rw cHAeu 7 J -1- r Ji,/!. ~ s cHAec[ + ,. ~c`rroNO.1K FSr /. i"~'[a Anu 1 ~ ,' ~ , ~ - eOiOrfOii .~JpAMA ~I O AW~vN Q eEMAINED ~ A4MN O1 ^4UWNED ESrD•P E rUWWAVDU // .t~ ~ SY 'M Aw'iv ~ Y f IoP se] J 'hN i .~ + -, = ~' 'I R DIAGRAM OF COlUSION 1 MNx INOI fNOem ~'C [ ..eE, S ~ I swn nruc[ssA4rl s~ ovv SCRIPTION Of COELISION: IUSESWR[ a iu sw[I N[assA4r ... y -S //FA"%°i1 G•i .r ~)/.~.~ v f/Ci~G' /~~ L: ~ +°~' ., 5 .. _ ~' ~E'/e d. c/ S /I C ! ~ ^ ^ 4 s . .. .+ ' S~Cy t! // /.E•e.I1d ~c• /. ' r rE .W, ~~ ..I4• OUl~IF cYO^</•. s~//.f.` ._.._ ~ ~ •~IiC .( :.~. z rte: ~ ~ <~~ - - - - - _ , I ._ __. '~ ~ _ ~; _ __ . , n, e Y. ~ NAME, ADDRES581NJURIF.S OF PERSONSINVOLVED +CODES 1 ~~ ~' OCCUPANTS/WITNESSES lusestsn[MwruswD ~ 3 4 5 6 19 =- ,~~F ~"': r NAMt YJ M~a•,s / IOe ApplgNAf NAW11 SI% AGF rAiU3 H .` 411M. IRR P ~,. ~ • _ .. ~_ ~ %:IC•«n/ En. i t.':l i~7ti•Y .til i '~,~vlnt~S~~ tX'; Y ~j' ~~ t '. ~5.f: ~ ~~ ~~` . ~' ~x~ 'D~ ~~. ~ ~" ,. ~ y ~ ~~yy((`` ~ ~ D~ r Mdl 1# n~~, ~y4 ~.uca A1~ .. > ~ ~r ~, l~ ~ ~` .,~,~ ~ is Y •. i^M1iT, ,kYr' ¢y~ 7~ I E+ ,, 1 ~~~ . , ~ . ., ,~a'.~~': I Nj f7~TRAFfICWAV POLICE TRAFFIC COLLISION REPORT rDIICE CUMw.INL NUMBER . ' ~ PRIVATE WAV DA kOf D 1, ' Av C iUn w ~ LI IIMF (USE ]fDOHW41 COUNty CWNIY NO. /~ CIfY NO. inWA pURBAN RAT 8 O 5C EFFk. N M RWIEOR rR D Yl N f pIN CIIY0410WN pN pE NMIE6NO.O SIRffiI~04 WONWAY IC15 3 9s~~o ..Il INNS ®S:OI ®Or ON ~ A Mllf ro5l ]] INI[45ECi NO Mtin: 51\4Efi OR ROAD NON INIf45EC110N "-•~-^"' BfIWFEN ~ SiREEi 6 ~ O S]RFEi wfil% E Dr 79 I DiS1An 8 ,4 i4JM E E F ,CROSSSIREf O4 NEARf51 MILFro ACCIOENi MIlfS N 5 F W / MIIFAGE CODE COII SgNINVOIVfD: VFRItY1 Oi /~ ,uNWEDIn LL p SDttVLf Hit »ti51N NO.IN1URfD RIllFO NO RAMD DUG4NAw A U wl I wwwNLE IM~ CLS Oi03551REETOR .n ~ ~ . OIAI NO. 114E SIIXEN Of VEHICiLS ~ p DRORR]Y OAAIAOl ONIV ^ RSUtRO ^VlH CIf ~/ -" OB1tC15(RUCRINAMfOi OB1fCI5iRUC%N:DOVMERS NAMF) tSi.DANAGE PA N 5 SRCW COpHG IH ., ]' - UNIT NO. 7 _ UNIT N0.2 DRI FR'S NAME ^ VEHICLE ^ PEDESTRIAN p PEDALCYCUST 5L3 1 5 DarvE4'S NAMf:, 1A31 IR 1 IDOL : Rffi AODRl55 S wfi w5 F D~ ( lY SIAIE 21D CODE DHONf NO. D UY SIAIE I rE ~ ~ R 04Nt44 UCWSfN ~ , SIAtE 1 N A I IV UCEN AlE 191N DAY n MD 3 1 V, » D v v i I OCCWAl10N- - RMNAMfa DNONE NO. FYfS CHII HE Gni f1 E OCCUPAtION rW NAME6 DMONf NO. EYES CHLi IENSHI 2 R p CHECK (.~ 'vEn le AS AN onE ANOt»fa ' ° ° °c' ^ CHECK (.~ I vfw fASAN wnavEEaA INL4~ nM I 5 f%cro» 6 swiOr.°c'OE CODES -+ S n ss % i f ro n , H Y CODES -' 9 uA' a s in D l IR%. A ; ASs s 2 w alfs LL pD1 ' p AMeR1A.,Ef uV° ^ Vim. ^ NnKD ^ ENE.. Y ;F~o,.d. p A„»%A.%f g ~ ^ ~bm, ^ ~:2~ ^ FV IIwR.NOVAI •) .DN VFn. Y[A4 AH4f fDDDGf{nEV.) MODfI IDAQI NOVA) SIYtE f]DR.CDNV.) ,1 Y ( ID 7 D -bR ~ E A" » U Pln([ SIAIE RAID4 RAIF NO. SIAtf H Wn.CIX l N . ~ •~ • E IDfNi1IICAIKW NO VW C ~• I N of n OE IDFN 1!1 I '2 , i I ~ :Q M 4Lzl ~ 1.2 I I I ` I I I I I I I 11 I tll5f r145t ODIE 151 D WNf4 REWSRw00WNfR: I/SI fIRSi MIDOIf L DNONE NO. ~- W . ' OWNER ADDxssaoE5Y+e4 33 N waADDeessorww4Ar4Q m. wACwi R " u 14 O Aww oMaE CHARGE ~ A , EOr 0 FN RfAWNfD t e 1S1a0AMA0! CH p4MN IUe ~iOM ! ~'A'-w r ^ AWAY ^efMNN10 ^AWAY ^ ~. '~ 1~0 EOaGTO 5 IOM10e ^ A AY eY '" DIAGRAM OF COlL1510N lu I er^[~rN DEXRIPIION OF COLLISION IuSESwneMtN USE+ErEr Nec[ssAlfvl SHU WAS ESouTNBO.uNO ON_GRi2~- ~.... USN ..._'a' ( ' ] 1 - I I I ' T ~ r a _ . I _ _ . _. l 1 R ' ~ - _ j rGH.Fo ._ VEERkD of rN6, fd~AD INTO THE DI~ ~ I I I i I l ' ' _ _ .. ?a F.T. ~ _T'HEN...S~ADSLZD _APPRdC _~00__4~.T_L_ --- 1. - AGROSS 7N2_ ROAOWPf~t-1.-HL'TTLN_Cr._AN _~.---- i__: , - 1 t. 1 ._t E ' I I' ftiKc?VF41E.~_. F1~BPrNKM¢FSC'. WS.'T`rl 'ENE .Fim~Y_OF. ~ ( _ ~ .. eWut'~ ( RQ ~'13. _ _ . OFG 'tiF1k. fcM$RNI:MF.~.!Y..At~Q'~RgV6l.ip I I BouNGG.p ! ; © ~ 1a _ ~-. . l .. .. , ..~ _., . ( .... APPttoXA (oo FT...8fcf~RE. _CpM3NCr_Yd__. (_ ANO'tNkR y _ ~------.~-~ ~:-~-. RYrsT'.'Ln) .'Sb4~ MsOO!-E..OP.'THE...Pa!~WA~ .._._-- ' I I._.__ .__ ...~-.I I .. ... _.. _. .. .. .. ... - . 1° NJURIES OF PERSONS ADDRESS 81 NAME INVOLVED 'CODES 1 ~~~ 2 ~ 3 " 1 5 6 ~~~~ , IUSE SI)rR[MIN1Al5 OCCUPANTS/WITNESSES !q ADD114JNAl NAA W11 4S1 -' x% AESI ui 1 YAL r . M wsl4. e~R "KY- u rr ~ NwIG ON 72NOT-HY R.w 2 N a S-.~ O ' . _ .. ARS lpe NEL. AY, 6pAMe. p11' p"".. pQx' pP:1 ADwfu ]0 Yl V.c.EI-Guth E GKaRI.E.S A(,L,~N And{55 n ~ NIU41 . ~ - " ' 41MOAD14(YA ~ANe. p':i ^N1 eptE,T pn~ NI Y 1. ° D X335- 1213 ~ » 'GLARx MLCUPs.L. KIc~LN NAtlo f C' u n5 INE ev pAMe. ^~4l p~o:;ER l9'C,T' ^ N ADC Iu .O, wtf. 4:f 5r cIRD IVh ~ •4w was wroYr ArvROVfoe wn R;ur~4(1a f 5 ra aIADDfa Wa»c . N. D,E .E.i p~02 O~D 5~' -24 ]400IE43 r ~ )dln t X c . 'Y ` ~ iy .. . ., 9 ~~ ~, ~. K:,. S. ~. ,~ i . :__~~! I JN REPORT ~iRAFFICWAV, '~°~~ POLICE TRAFFIC COL! falcE ,AINI NUfnnE4 I _ ~ PRIVATE WAV - 31 ,r O C<All qN a,Y Yo OwY E% ~,Y Ill, LI ,.1 TIME IU$f 3ND0 HOU91 3 00 COUNTY ~ FC-~? o COVNrv NO. // f0 rvNll. NWA ^URBAN R I ^N ^F ^ N C YON IOwN NNnELN0.0 St4FEIOR WGNWAY MIIFS ~5 ^w (kdCf~ /ACID ON (~U I~M /'.~ ECI CIS A RW IE OY SIi 3 95~ro SE I ~ „ INtf45ECtING~IN SIRfEt OR ROAD _~ NON INIf4SfC110N / // {~ BfiV/FFN f:/ Y ( Ft 6 C.. iC SIRfEf PNEf% f0. MITE POST ' DOD' 6 OISIwNCE 6ON I N NfiFRFNCE. CROSS StRfEIOR NEA4ESfMIEE PO51 TARES E N 5 f W EE[i ^ of ~(.='~/ / ACCIDENT MILEAGE CODE RgMP O GRAM UptA COll50Y NVOlVFD~ SfVER IY: NO. KIII[O~NO. NIUPED_ ^ SPINGE Ht NVI lOfAI NO EUxONe01H RD INtf4 Cl5 iE¢ CTING S1RfEt RROADO4 4fNCE CROSSSta[[i O R POAD N IZ . d VFNIClFS PNORERiY DAMwGE ONLY ^ vES~liEO ^ V[pCIE p L~ % ~~J O OBJEC St UCK (NAME OF OB1ECr SERUCK ANDOWNER'S NAMfI 1 fSf.DAMAGE L=a - Rico / s Sa. o0 SPECIAL CODING USE _ - : UNIT NO. 1 UNIT NO, 2 ^ VEHICLE ^ PEDESTRIAN ^ PEOALCYCLIST 3N 3 OarvfR'S NAMt UE51 45 MID ORIVFR'SN E: N51 FINS I E -- L EL v SIREEtAUONE S / ~ -~ tREEi ADDRESS SIAtE ZIPCOOE ONF O. ~(}} E OJC' OriM/ A ~~ H&~!<l D R r I StAIE ZIPCOD P L O41VtP5 UCEN5f NO. $1AIf F% ObxtN p I IV uCFNSF NO. qlE SE% OAIfdeIRN 7 0 ~ ~ W.~- M 2 ' %% ~ A ~ DAY CKC PA[ION EIRMNAME6PrgNf NO. 5 wflGHt REIGN! E CKCUPAIION MNAMF PHCNJF NO. EYES WFIGHt NfiGHt z ~ ,>P R ^ CHECK (.~ vfH CiE ASav rMNOr"EEOEpIVOmEa"l ^CHECK Ir7 fyFN [IE wS AN A OYEEOF wE O1HER~' A ~ v CODES P ~ 7 ~I, . ,~ ' 2, 5 e Kt ox a s"',°,~,° CODES ~ * 7 "ii i ix s ufe N a l"'O11rv"'Y°' J}> ~ art; R R,~~rsD 40f ^ ,NwAANte ^ C' V!N YYf AR MAKE HE DGDG Di.SEE ^ Conly ^ of ^ rapia~n MO Uwxt F O 'ei:' ^ ANeK,NCI ^ PDyce ^ iSenY ^ v~ ^ iv Y Ku ~ HY °~ ' 1 1 E~C V.1 I y /O .N U I ( VAI YLE I3 DR CE%NV.I X v~ E FA9 l] V.1 1 f~ NEVI MOOEII 41~NOVA1 y ' 3e 6 CNE N. uCtNSEPN(f n0. SIAIF 4wIlf4ltwif NO. SIAIE H VFN.CIXOR A A A N lQl~ !11 37 Gr/i9 I '3 vEmaEIDEN[INCpi NNO. 3 68 Om~/6~7 ~ E vfN CIE IDENNE Car N I I ~ I ~ RtW5tf4fOOWNfR: V.51 {I45t MIDDY ' o k' LionleZ <3tiS~1~ w f ISIfRO 'NNE4. lgSE fINSi MIDDLE nF NO. I~ ADDRfssdow++ER N p OWNER ~~ E NAMeawbDRessdlNwa~~~~Aefxr NN u ~ N R A I u V DAMAGE ,wu 3 N ,u+~'~^N ' trlAV d ,.... cHAacf u;,~ ,~ i~ew iAMACf3D ~4[A. ,, IS fiOR S IC~OTEOii E31. RtNA(:< C WAYN (J~[j~pEMNNEO ^ DRIWN ^AWAr ^RUINNED ,E E l3~rD fTOP o"sorio» 3 S ~Q~ lOWlO ^ wwpr er~ IOV/FD ^ Awpr nr: y A V SW DIAGRAM OF COLLISION ~ A' I aulEOO 4rN . 1._ F I ( I. rt[t IE NtCLSN 1 eY A4 ` N DESCRIPTION OF COLLISION: (us[supnEMfnru sNEfi NfC[SSANY) _.. ._. /~~ ..brier ~~ive~e 9~ r~ s T __ ,. .. , , _/NGu.,~rl. _ ~ ~ ~ _ K . . ~O9.D ,Br ~i.~srv~rK~ ~-r~z~Aor~~ P ~ /RT ROA/1 ~G ' ~"' .. O C~/f°/rG T . Sc AOG- S/d!!'fd/J~yy1 _--- '.'- < G' D 3 D ' ~ ' w _.._..__ . r ,. :_ ..-- . - ,.. I ~ GR(y- I >uJ c . /h/ To..... i7 ~ K( c z ~YJ f( o/¢ds _..____ _.._ .. If NAME, ADDRESS & INJURIES OF PERSONS INVOLVED 'CODES 1 - Z J 4 5 6 ' OCCUPANTS/WITNESSES 1f o;3 w"r~`E»i:ir~..SWr eii iiK AG[ :TALUS "q,~" ' ;' Y (sIR t1tR ... - ... A A DMUS ruN or N tier: ^ AM n ^ 11 ' ^ '" . ^ T. ^ N`KtN' r4 N paf j ~ ~ . A Drolss NAf oRfd - - ~ R ,wlvlD rNCrA AMA ^ ^ESKKI ^w . ^ n ^ :° N AwE .. .. _ ~~N - A MN" NA~ r~ rtNKI xW. K 1 r ^A e ^ ^Emn. ^p.~ ^ ~ X ++6drtlp3r,Aw{v f OG1U M' Y~l K~O 5~K1_D 'UlI(~~ y U [C NO t ~-- o E O RS ~3 ~~~ f aRoy AmwvlDer UAII Il'~t ~`(. Ham. i ~ ~~~~~p~' '~EE''~e}y ~;,.7 ; .r'1 ::'rh.'•.tL~ .: titl!ffD'r~,:~.::;[~ii rr .. l~'`~ 'Sac. 77~ 1'.u , / `' ' L 4F~ Ay S .t ~~ ., , .~~ ~~. rs k r :... ~-I,. ; :f s~ L"< u 'ie) _ . ~~ jj 1~t 4 W~1. .. ~; E E ~T p [ :, pF - - ~ / _' T 1 l f _ o f 1 ~ ~ ,Y 1 rl ~~, : ~ 4 ' l ~' .t~. I '.U ~Xr 1 ~~~~ E• f r s' Yy59dtt D';; :~ tFA i' S Y l ~` 1 i .,. ~• ~. A~ . 1' - y~:e. ~~~! b ' ^ ~ YYn ~ ~C Iljn~ .Ae N { >~t'S, " x tRk~ri a , ~~ fi a , .,y f •~. j -.. ~~ I ' Y~L i ~~ fe ~ '.: f4 xIN(1 ~.. ~~'. R III.,-'} ~. -.1 w , r. .\ ! a 'Ir ~ -. / ~~~ ~ ~t• r E I, i'; 4 -, .,1 ~~ ~ 1 ~ )t ~' yq ~ t L2 I r ' .lel {LL~~~~~'_ ~fWWI I '~~ POLICETRAFFIC COLS JN REPORT U(I TRAFFICWAY pOIK Mvfi HUMBER ~ ~ PRIVATE VlAY ' ~71 Dqrf Of CIXE :UN Dq+ .~ DAYU U1UN mr RD an w Iwn r. NI. IMf IVSF DVDOHOURI COUNIY COUNIYNO. / / CIiYNO. NNA ^fURBAN OS O O ~rFdL3 CO ~N pE ^IN ClrYpf rOWN gME6NOq SIRfEr OR HIGHWAY / M1VlE3 ^S pW pOF oto,,/ ON NC.~• /z CICfS vWlE 04 ~ 9570 >E 1 l NrtR3[CIING WITH: 51Rftr(/p:r ROJD NON INIfR5fC1iON IFJic 141.7 1 / BE1WFfN StvFR6 SERFEr vREflrt - f0. MXf pOSr ej.J/ D111ANCf dD14 1 ao, scut. CROSS SrREfI NNFA4ESrM1lE Sr m4[5 N 5 E W ACCIDENr MILEAGE NAMp D1gG1IAM DAfA F[Er OF ~ CODE ,~--{{ CIXUSKIN INVpVED ~ E4UED NO. NAIRfD~ ^ SpIIUOE LO HII `REIN ruNDnDIH INTER %Cf.S°. f FO3S514fR0R ROM4RW0 4W 4ENCF ~ll ~ role NO. ~ ^'I~19sinrED ^Vf~iCIE Of VEHKIES ~ pNOMRIYDAMAGEOVIY ti~ .s R1iiv re 9 OBJFCI SiRUCa INANE Of CMIlCCr SrRUCa gNDOwNFR'S NVA!) ESr.OMAAGE SpfCUMCODING USE I v' t.E/ y h 1eo1r> 5 UNIT NO. I UNITN0.2 ^ VEHICLE ^ PEDESTRIAN ^ PFDALCYCL15T l S 9NEN'S NAMl: Iq5 Iv M10q N k _ - _ R:vFR'S NgMf: Uv31 N 11 l -- -- °. sr4efrgooREss Rr / 1 ~ sr4ffr gDOxfu - ~ GIY AIE lIp CODE vHOHf NO. D Y a SIAfF ENO et !.J ~/ 9. 2/z R DRNf45 UCENEEN ND- a -F 2 m P SIAf r.J F IRIH /.R ( V N1V U EN NO, rgiC E% ~DAIE Of RI i '~ w l OCCUVg1.ON fIEw NNAf6RgNf NO. EYES 1GHi M:IGNr E OCCUVAI ON N4M NANF6pHONE NO. EYES IGHr HEIGHt ' 2 /JLI t.!/gS KI:,YOc.I)" dir / O SuY R _, ^ CHECK (/J yrHKIEA aN fMRiorl o. ANOrNfR~ ^ CHECK (.~ I yENK~F AS AN FMWOVEF OC ArvO1HfiAl ,-1 CODES ~ ~ 7 a;3^ • ;in"'N1 / s NICINa, / e N,N~.w M CODES - * 7 a ss5 a ,:iR» ' S urcro,. 6 win r°E I, y z (.A~ Ds G a..F C 5 sd 5 R I s ~ ~ ;~~,~+ ,M.1,. f ou E ^wmR ^:, t ^;°~,. ;ol ^qN f Quaff ^~s.DR ^ r ^.: ,. Ku ~ ev ~ vEH.vfAR MEIDODGE{HEV) fIIDARf~NUVAI rYlf 1404 ~CONVI M r fAN Mat 1 nEVI MODFIIDARI~NOVAI y l ; _ ~ mt~ u ~ Z E DB s N. xf c I srgrE IweER AgrFff o. srAlE H vfH. aoN A II A I ws vu7 WA I ~ vfHKIF IDFNIIfKAIIOH Np. l N O 4 f'S L L'EP '7 ! i vfnlOflUEN IN A 1 NH . ~ I I , i 4fGUIFVfDOVMER~ IAfi II4SI MIDDLE PHONE Np. O R ISRRD wNE4: fA5! 11451 MlDplf OKVS M/E,~ H 7.21 z9 W m Iz s ArD4essn owHee N A wr1ER . HANEagooRnsv wswANC[cq. MAUNr OMr.t S FTN ~ wNSq*r0 H I R ~TuYu1TCtSdR-AGFFT lE DAMgGfU MG - R O .~pyNgAj CHARGe ., ~. CHARGE 1NwycNroHU DAMAGED MFAd a 3J y IOIDrtO4 l5l. DgmAG! ^AVV1v1YN ^R:MNNfq ~ ^AWAEN ^4fA4VNED Y fSr.DAMAGE er°p aORON -E^ 7 /0774 ~Oivo r~ Gf[pGKSON O(JING n ^ ~w~rev: s d R DIAGRAM OF COLLISION I q IMK r w rH - sfREru NFCEssA.r Br NROw _ DESCRIPTION OF COLLISION: lose SUVnEmtNrAl sHEtr EReessw 1 . .. - ...__ _ _.. s la i , !... "O .. vRoPPao AN1T6m oN Fcoq.C (3aN _ _ T To I ,1, _, ., f,. ._ :_. W ~ PECK NP AMO.._RAN OFr RoAJ ..._ _. x I . ._I .. .. ~ _ - _......._ ~ ._..._ T .1 , r .. .. 1 ,... _.. ° ~ i .. '. _ - .. .. .. .......__. _. __.......-. ... _.. ..... .__ ...... ]0 ,. .. i.... .. .. ,., ~ . / , _ .. ..._.. ... 1° N E, ADDRE5581NJURIESOFPERSONSINVOIVED ~E~COD ES 1 - 2 3 4 S 6 IVSIyWAfwIHr4 OCCUPANTS/WITNESSES y"f'I fM Agdrl0rfAl HAMf31 NE ~ 1 qGl rAEU N MN Nrl Nfi .1r 1.1 - MIEY RESro, tAtr .I Ir N AMI ~q WMfV _.. ..... N.rwEea we n ^Ame ^c'Y.I41^ ~III ° ONCi ^ruiaV H gAV u ... NArwl or . R MwfOIRDM ..r N , Hq , . DMr33 ._ ... - IMroprof .. ul.,fs.. ^AMe p..q, f^ °Dk,. O(;: ^7.° N M tilgKY "1 DIbA1CHtp Nl K[g1'viNO UAD OE pIfOef AMEWfOBY ry1pAIMG q.f Kr.3fNMra RAMC BAW f Uqrf O - ~/ / YE=SO .1.1. X ai~r~fHa OL.'/vl/f:E OS'-OY~d'~ ; ~1 ; ,'~ ~r ~'~''n.t;', -, i y ~ ~r r .; "~~ r. ~ y ~a `«A, •.1~ . i '~ ~ h c~. '"9~ 1 ~~ II~ } Yu rf.,,ti y, _ ~ - i- ,.. q ~ 1 ` i ~ f ~ , 1 ~ ~ ~ , o ~ r ~ P ,y ~r~~. 5 __ i ~"`y es q Z ,~ > '~" ,+r ,2A ~ 1 . ~ ~2 ~ am '~ ~. Y p r .. 1 q. f ~ ~ P ~ ~ 1 ll 4 ~ ~ t '+N a. 4:S ~ ~.Pti ~S ~ 1 Y ~, ~. . k~ .v ~ ~r o~ ~ ~~, ~ J iFk S, ~`ri ~~ ~, ~ -• i J f , ~ } / " 5 Z ` ~. ~ ` ~, ~ ..z rk ti a . . a~ . . J r^ s .~ ... ~ { ., ~ T T~ ' ~`~ S ' - ~Y~ r ~ , ~ ~ ~~ ' ` ' ~ ~ ~ , ~ ' V A ~ s ,3 ~ ~ ~' v ' t __ t FJ'4~yr'~~ r a '~ ,~ . ~ ~ 1., / ~ ~ ~, i ~ y -Y' ~ ~ { ~ ~. ; ~ t'~~ ~ ~~ rcR "~ ~'.. w r~ L'S`' ~T` 'N. a 1, ~. ' } ;, I ~~~ ~~ r~ `' ~ ~ ~. ~ ~~+ r '~ ~ r,.~:~.,, r i ~ ~ .;~. ~t ~ i N ~ ~ ~ a. . ~ , ~ . ~' a ` p v ~ ~ § 6 a f;4 ~,= „- m ~ ~ °a o a~o~ { k ~o aio i L In ,. ram ~ . ~~. S 1 t ~~ F~ r y ~ i i I ~ - ~i.. ~' ~~ W q . 1 3n,$~ ~ ~ t'4 Y* Y t f ~E~,f j g~ ~ni QYy i ~rACw f,~`N'rt bJ ,`d; ~, d ~ 9 ,.i~ r r, ~ `Y ~ ~ ~ _ ~ " s~ _ ~. _ ~: - ,~ A~ I 1~ f#~L~ A~ ..;.., a< ~.w:zts,~.._ / ~ w 4w , ~ ' ',n~ _~.,.,.~ .,u1c% ,~~. ICP~ .• ~ ~ ; p ~ 1 `' ` 1 V 1~ ~-~E 1J 1 11~ ~.7 ` V ~ V aA7 ~ ~~ ~ L I1 rncE o + ~ , ~ue J~.' LISION REPORT AFFIC COL POLICE T R UNIFORM PoL iCE coMl ulln NurnuER ~„~Qj "~ D ~L DATE OF COLLISION OAV OI GOL ION InUN RI SAl M(y D ,Yj~ SUN MpN lU[5 E F IME COUNTY NO CITY NO. IHWA <0 ,[~QIa IUSF J / I } EL : A fi X U 3 ~ 1 / 7 l 1 1 ] 5 U .T ~1 UML AD M C LS PREFI% RO TE OR SiRE ICODE SECTION U E ~ L"f'J I J' ~y COUNTY ^STATE ROUTE ®COUNTY ROAD ^CIIY S INEEi O J ~r ~ ) . / J ~ ~ i v ~ I Jefferson ^OTHERISPECIFYI 12 CITY ORTOWN y V % ~/ Q Q PREFI% EO MILEPOST •'~ ' T ~~ J: m",IP 1 L IN N 5 F W ^ U /~ (. p rY r J I O 5 MILES ^ ^ ®OF POrt. TOwnsend. ._ ... -.. \ ~/O ` ((1[ 4 L ~ ) PME NO.OFSiflEETORHIGMWAY INTERSECTING WITH5IREETORROAO ILLL flAMP DIAGRAM DATA " '~~ ~ t d N12 R QN ° *^ ~ jy~ . oa unty ~ / ' ~ (wr~(.4"P~j, I NONINI ERSE ACCIDENT INTER %~RD MIERSEClIN6 GTR ET OR ROAD OR REF ~ • v ~ ~ E"~' Q MLEAGE IN E C15. ERENC CROSGSTREETOR ROAD ~- ,' ~ N BETWEEN _ .._.... .. _.. _. __ G1REEt AND _ - . GIREET CODE B4 D ~ ti v .I ~~ ' 6n, ~' ~ DLSIANCE AND DIRECTION FPOM REFERENCE OR CROGS STREET ^MLEG SOO FEET ^ G ^ W OF .SR . 2O unpxLiHG n GPEC L DING UGE 'f,~ 8F'; t ..JJ ^VFNICLFWEHICIE ^VEHICLE~OICYCLE ^O ^HIT6RUN THEPIWRITEI GEVERITY - : A %-. + ~ COLL ISIONINVOLVED: NO MILLED ; ~.- _.~ LL { '` c~ ~ TOTA EIIICLE~RRTRAIN ~V L NO ~ ^VENICLE~ODIECi ^ C?D _ ..-..._.,.___. - ^GTOIEN VEHICLE ___NO INJURED { M 'A '~ ' ~ . _ p ~ OF VEHK:IES ^VEHICLE~PEOEGTRIAN ~1"W{OLLISION ^HAZARDOUS MATER AL _ _ _ ®PROPEflTY DAMAGE ONLY _ ' ~+ A ODIECT GTRUCKINAME OF OUJECT STRUCK ANOOWNEfiS NAME( LOCATION OF OEUECT STRUCK EST. DAMAGE I~~ S E w RD ^POADWAY FEET ^^ D ^ ^ EDGE S ] ORIVERSNMIE~LAGT, .FIRGT ~ MIDDLE ORNER'G NAMEUSif RST MIDDLE Il piCVOl S1 OII PLDEStNIAN CNECKI[].. 2x' r ~ 4 s D .McMillen Jerr Lee D R '• ~ r 'u ~r R I GTREET ADDRESS _.. GTREET ADDRESS. I r v Rt 2 Bos 814 V k Y! E CRY GTATE 21PCODE PHONE NO E CITY STATE ZIP CODE P ONE NO. ~• ~ ~~~~ ! R. ~ 79 uilcene Washin ton 98376 4714 R ,}'~" Ew ~" r I - N DRIVERS lKENSE NO. STATE SE% DALE OF DIR1H MO OA Y YR N DRIVERS LICENSE NO. STATE SE% DATE OF BIRTH MO DAV YR q 1{I# i~ ~ :~ M • + O ME Wa G ~ O, . ~ ~ * . ~ DRNERS OCCUPA ION fIR1A NA PHONE NO. Z DRIVERS OCCUPATION FIRM NAME PH NEN ~y &I - , .'. T ~ •' A a ruuxr A CODES > 1]I CLA55._~ ._ 1al SEAT BELT._ __ ISI EJECTION .__ ___ I GEAT BELT_ 151 EJECTION_ _ CODES > I]I CLASS- T AEy ~ I~ULP EG F NJU ES V fi SCENERY: All-Cit Towin All-Cit Aut O gMOVED OM SCENE BP TO v vEH.YEAA 68 MAKE (DODGE{nEVI Olds MODELIOART~xOVN 442 STYLE I2 DR ~COxV.I 2-Dr v vEH. YEAR MAKEIDODGECNEV.1 MODEL IOART~NOVAt GTVLE IZ DR.{PNV.1 ~'~ E vEH. C0.0R LTC. PLATE NO. STATE TRNLER PUTE NO. STALE H VEHCULOR LIC PIATE NO. GihiE TRAILEfl PUEE NO. STATE ~5tt.. +• N I Blu KYA-788 Wa I - ;L (~` VEH LE %)ENIIFICATION NUMBEfl OOOMETEfl. O VEHICLE IDENi1FICAR N NUMD R .... ODOMETER ' ~ 3 ' L q'' ~ '` , 4 _ e ~ 878 yl$2' Unknown E A REGSTERED OWNER-LAST FIRGT DOLE REGISTERED OWNER-LAST FIRGT MIDDLE ~ 'I ~ N O Same as above N ° i " ' " ADDRESS aF OWNER ADDRESS OF OWNER i 2A( `~ ' 2 { ~ _ ~. ~~~ NAMEAND AODRE550FIN:AIRANLE CO OR AGENT LAME MIDADDRESS OF INSURANCECO. OR AGENT, - ~~ ' Homer Smith-Port Townsend ~. I K . ' CHAROE C IIAIgN NO ENFORCEMENT CHAPGE CILAiI NN ~ 1 ,T ~" None ACTION ti "7 J r: ` ~ ,; . I~ ' NAME, ADDRESS & INJURIES OF PERSONS INVOLVED CODES t - ? J S . NAME. _ N T ADDRESS'. ~ $ R~ YUURSS RfF NF BV FN TD / K/ NAME i ADDRESS' -.-_ ' ffIT1AI N N•aAlulur SC `ao TD S NAM[ ~__ S E ADMESS I ____ a~Y2rnara'__- S' ,",U ~G 4:l. ED IItS1ATU3 ITIGLAI YOSIIION IJIPIJUIIYCUES IAISf AI DfIT 151CJECipN N 1D~i.~~tRSL[NE ONION DISADIUN6IY ZAiOtilUSELCD ]I01 llYEJFLlEO O •R C4 Sµ I S j ! OTH[n POS111p! ~ ] D[AD ON ARRNAL If.NDI.NTInUURY ] USFO J PARTIALLY EJCDiED D 5 DinfP I ~ ~ BUG MOTORCYCIEI P A DI[OM1109PITAL / POSSOIEINJIIRY 1 UNKNOWN SuiREli FAILURE A UNKNDWtI If EJECTED E 6 AwTH453 - I _ OS11gN UNKNOWN 0 s ~t A ~,M~j l.i r .. ) 1 ~ yI ill ~ ' ! t ~! 1 k ,r..-e"^t" i 71* -~ -~ I I ~7A7"1*F'N""T~'"E""1"'~ 1 L Y i~ IL 1 ' ! L~ ~,y~: a , a:Y. _ ,i.+.~~ ,, ,.L._,~:_ .i. ..t .'~'C~'1i r+,c " ti i L~'i I•' YI ' 1 51;Y' ~~ ~ I ~ ~ J ri( 1 lu a~P, 1 l~ 7 1 t.~, „ ~' + Y # 7~ J~ ~~ ] ~~ EI ~ f ~i } 1- : ~ z ,- ~ 1 _J ~, s: c` ~' ~' - ~r a -~~. .t '!:`us`er `~ ~ ~ F.. f ~`~ '~ ~ ~~' I vare~~. `_,.x.c'~r_. __~._at~ m..al...,.:.: re~~ ~ v.s_... _ ., _..uASIrNK3. '. ] C L 1 ACT IL rr) __ _ Gr 1. . INSTRUCTIONS O/ ~ , D DRAW OWISI TOS OW NC AL OIH CTION OF fOfiCE ~, -•! DAMAGED VEHICLE NO.1 IG NssPACt FD s ETC Nc DAL GE TD rnaRFRS MOBOHCrttfs. ETCI DAMAGED VEHICLE N0.2 r- { IA H~ ( ~~_ _ Il new F~qr IS Tru lY 16. Trent ST. O.wrurn SEV[RITYOf DAMAGE: VEHICLE NO.1 AMAGE N S a SEVEnIiY Of DAMAGE: IUTN V LEI EH ]FIIICU ^ O o I AMAGE 5 N NG D O A n H ^ r}~{ OF DAMAGE: VEHHICIE NO.] E tlLING Dn aMAGE H DAMaGF ] ~ oU NCTIONAO pAMAGE ~ NO ? O u C TI ia LE OAK 4GE G l^ ^ J ] LJ fUN O MACE A ^ Np DAMAGE ^ LT OWED BT .. T. DAMAGE FS iOWFD Pr SI. DAMAGE i. MADE TOW ED BY S ' t. S TO S TO f DIAGRAM OF COLLISION ~ I t - / ~ I ! DRAW ARROW SHOWING r pwr flAT n xDADwwr An u es ~ T- j ~ L L I NORTH IN CIRCLE ; va¢LU r(Dtsrnrwxs DNE<r3 o«prf rDADw Tnwrf LcoxrA Ls fpDMAAKe DRIRx3 I .. - ..-, r i I • -. j I_ ~ M1 O - yxyfyADTIMrTON IiE.MLr,.LDH,TAyLTIDN Aa.3fTLI ~ : __ , ~ __ r i _ l _ ~ - Dw r,IHIiLf..tD(S,H wNOR xpN,w,IM..Lr D , I _, ~ I ~ I ~ i k ~- I - - -, .. .ILL Er . ow.HOPA.Lty[.KLLpR t f ..; . ~ i ' Dl3,RIwH.wTHL.LrOgE __ I - I_. . ~ i - ~ 1 ~ t ~ 1 , ~ . p..T.RODLLr.IOx - .. .. , r , . _ ` I . I , ;. DESCRIPTION OF IIxDKATE WNaT PROBABLY HAPPENED BEFORE. DURING AND AFTER THE CRASH, INCLUDE INFOPMATION NOT ON DIAGRAM, EG.OnIVEn COLLISION DISABILITY, nEDUCEO VISIBILITY. PEDESTRIAN CLOTHING COLOR,CONSTRUCTION OR PFPAIR WOIIK, ETC,1 - . . .. I .. ~ ' .. ! 7 ~ ~ ~• - i I ;.t r T. . T .. .: - - - - -- I - -- - - -- POSITIO HEADED E N EIEFORE COLLISION I T - ON STPEET Oq NIGNWAr NAME OR NO. IN ONE DIRECT ON T L NO. 3 f - _ IHCREA CR S NG O EwSING - RKEO DPI~_. 1~!~ ~r ----lrt .Il~~_G_~ __ i _ I -- - - ~- f n; IFO. O G A L .xt xLgr.. .pwl NG .wlMCrcusT wws uswG -- 'slDfwA ] _ - -- ~ ~--- ~. uxmwr«EO D -- o T_. o .._ _... to __.. ~ J wALK Ar :_.: sxouL ER _cnassw LK .... cnosswuK .. a rcLE nouTF ~ ~orwER flOAO SURFACE. CHECK ONEI WEATHER.. ICHECK ONEI CONTRIFIV TI`K OrCi[onVru,onTANCES. _ - 1 ER(vENICLE ACTI I~N0:2 •Ir Ito~ry[ r LN pgNV ER D I E ~ I E ER 1 ~1' ` ~ t O.] ~~., r r ORY _.~A~._. _.:. ~~ ~~ CLEAP CL O ~__r-s OVEPCASL i x O ] ~~ '~. ER INI LUFN EOF L_.~L.. . ALCONDL .-_ ... T x D ] ~ 1 ~ ING 1._.Ai~ 1 44USEFy ] ~-T r' LARDED WARN ~ G 5 c. : = ~ ~ STPAIGHT ANEAO ('~ ^ pvEHiwKING L I]~ AND PASSIND ~]. E _ ]LI G_ _IDR G r,B TF ~ _ _ _ I f __ - r I-~]t NT I I D " f- ° l s o a ow xc ~ 1 U ~-1 NGSiA ] s E LM I ~- ~ ~ G A __ _ L ~ Eil MqK NG ' ~ . y.. .-- - I ICE ~ ~ I 5 --" j oG ~ .., p. _._ 1 '" fornGRU ' ~SrF[D ~A y i.____ _ _;-, " '- HoPFH ~I~~ i TUPx : ocA iDy._____ ( ~ rte, TNC 1TS f TIV DU P LEFiiunN ...3;. N ., . . .... 7 ., ~ . IS - L • _... . ~ 3~ .... .._. _ IBi f T _ ~ ~ OG L _ __ . EE _. ' ! N :-_ L p NG TN[R ;SPfLirYl - ~ - pTNENIS ttaYl i r 6i l I P ... Q G ] S ., _ ~ IB 1 C 1 x r _: 1.J TTf(A EO FOR EPIC UGH7 CONOIF IONS RAFFIC CONTRO TYPE OF ROAD NO ]E VEHICLE CONDITION SOEIflIETY ~ OPPEO Ai SIGNAL ~ I B CHfCKO D]V[N LL[ f,lN r._ . ILNFCKOxt OR MORE (-- f yNICLE IS~~S,P'~CYj D1 ;ND. '"~ YA IItE v'NO }E CHECK ONfI N ~_. Og610PSIGN ~ 1~ ~ SIGNALS I _ _._~. pHF wAr ,~II _.... _.._._ ~ ; 3 `1 PTp.PED Ix Daowar r; DA L c r _..~: .. ~ I w ~ sTOP '.. SIGN ] wAV ..._i [fcuvE .. I -.D AKES . _ Imo we urY I 1 IMIA RtO__ _...IIa s~Annxc m T AFFIL LANE ]I DAwN - t YI[LO L. _... SIGN l E INSrf IL L... ... O D ]. I U[FFCTIVE HLwU LIGH25 -~_t - J I HRD ADILITY NOT M AIRED ._ 1 I._..II~ SIAniING rPOM Pwn KFO POSITION ii nU3K l N C N[DS. ~ _ A( HCHAxG[ .. OPRAMP L. ~ i F l~]' CRLLIGHTS _.. ~]. ImD SUtlIU(TY !UNK ~~~II]I l TfVI'fNO 1ENTFnINO J CI K-fln![t ,~_. lIG TS ON 5 ASH G AMSER - ~ . ._ ( LL[Y S A ~ -~_ OnN A ..J. 1 Sr.IOOTN ~ ~ __ .. _ _._ ( BEEN 011 NKING ~ 1 1151_, .I BACKING ' I DAR f ntfT ...; LIG SOff.,,,., NP - ..~ SIGNAL ~_.IP_ 1WOwAY-lfrl TURN LwN13 1 rrvlf ruNLrunED " I Orr Pl nrr ' . .. plNVfn - CHEM. TEST r x0 > ~ ~~ I r.-I .. ~. DARK-NO f _ fTnur uGNa T .. '. rr¢Ln ~ ucMwN .e_..- anon ., ~ -"~Z'"O- ... wllp ... ]._. OIV1pLD : - ._ ,.._ _ _ ~ NO DEFECTS _ ~ ..: ruT mv(n I LIST n[fOSED omE n Isr(c lfw O[Hl N~I3Pl Clivl - ~- ~ ND rNM rK 3' uNDIVIU[O --~ ~ ~ Oiwlll lSn[[N rl ~ ~ - % % TEST RESULTS .1 xvf3 G rNGUI[IC('3 [n0 LIC[USrATCIItU~ ](~ PGImL AINUV[U R ACE AIP f1 CILOw ] N AnNV4o irn9 II{(oE Nn3 MIN_ ri X Invf31G [i l f NK -_~ ~ pGl x] INCV AGti ~~ST f0 l l'ORI_ I DAff •.1 Av~-_- -~-~~•~--~•-~• -~.~~....... ..r.. ...nu iv r~narrinu~vn ar..r~r~nrrr~~-vLr mr~rn, rvnarNNtrlVrv VOSUA UufIICAIE COPY' LOCAL LAWENf UNCf M1I[NI AGLNLV'S COPY-Tf11PLILATE COPY: INVCSTIGAIOR'S COPY K?FS n +~r~n J ~ I , I +. i ~. ~g YT n , r ~~ t ~ ~L i ~ I ' ~ ~[I A 1 t ~3~ r 11: ' ,. ~.,~,I _ -. .............. ~: ~• - _. ~ .. ~ '~ ) "l, , ~ - . ,a e ~. ~i~ a ~ ]~ d Tx r A.sk ' ~Y3.x~:Y. ~ Y, ~~4falY.. ~~ ~ ~~ .. ti~Rx `~ ., ~. ". ~~ f~ px "~ _ ~~~ ~f ~~ rI !~! } 94-~' ~~J~MM PffeE.4}h.J~br i -. ~l/'1 ,F 1 1 Y F ~' -t;. f 1 P t~iQ, 1 f t ys ~ 1 4 a f){I t ;, 1 I ~ - / ~ ~ 1 L r ~1 .n„. Lv+"W{.A"IM`"r;~,y. ._... ... _._.. _...r .__.. _._. _.~_..u:.4nu. . _.m....,...,. __ A. Yrw;c..:._a, ...... ~...za :...~._.u ~~ MOTOR 'JEHICLE COLLISION REPORT NO. DALE OF COLLISION OA yp o•y rF•x Y OF COLU wED SIGI TIME OF COWSION nux I eAr uwurF3 AM 5J PM COLNTYN CITY NO ~Unn•h uRAL COUNTY CITY,TOWN f RON]DE MILES O Q GTIT\OWN ADM REFIX A OR S, R kfl CODE F CTx)N Occun ~ C 4l, row p} ~T, O'J© OF ~ c ~ / ~J ~/ O npAOON GIVE NAMEOF STREET, ROADOR NIyG./HWAY OciWnFO ii < NTERSECTN WITH. SiREE OR POAO % PREfI% EO ~ ~ MILEPOST ~~J''' ~~ l / a.~~ ~/ ONINIERSEC I LOCA qN0 COWEION lLETWEEN STREET AND STREET RAMP DAGRAM OATH 1' ©© Fxsf n fn. eR yy~~++ AEOCroivrvc NX[xo r] oR q[Bi~v RCLAwIX.Anx. aF - FEi A3J ® - ,~ QnA no O I / - O INTER I NON %~RD CLS.' EF - ~~^ RiE~O n 6rnin o•OR RO~+o D~KLE ^vFRKtfaKYCIE ^OtNFRIwPorfl COw orxrpvF v[n<U~v ° SPEC CODE E , IEOBIFCI QVENKLE inAw OF Y[nCtE3 ~~ ~IJ~~ L! [wCLEPE0f51aAN ^M]NLCEUSgN ^M11 nuN OBJECT STRUCK ,_, IN.wE OFOWFG 6rAUCXI OWNEROFOBIEOIS NAME ANO ADDRESS. IN ROA DWAY ~ ~~ ~© POAD IOxFVin p~nlECT FEET DRIVERS LAST NAME •FIR INANE ODLE frwOICM] CRIVERS LAST NA/ME E. FIRST NAME .•.. MIOd.E ~- Si AOpRE55 ~ ROUTE NO. ANO BO O. ~L n0 A S1REE AppRESS ROUTE NO.AND BOX NO./ /G. ~( GTY STATE P CODE L ~ DRIVERSOCCU PAT ON LITY STATE . -iP C00 ~ MNERS OCCURATgN ~ ~ 6: !fr.. Rc /'l r1 r r '-C /L rf /~ I.I.s. / ~l RIVERS LLENSE NUMBER STATE SE% DATE OF BIRTH AGE IXiIVEfl3 ULENSE NUMBER. STATE SE% iE OF BIRTH ADE / VEHrLE rR. A ICHEV ~DODGEI. MO LINOVA~OART) BODY STYLEI2 DR.1 VENICIE R. MAKE ICHEV: 00 EI Y ODELINS~Y ~.,DA~R'LT)... BOGY TYlE 12OR.I ` ^ ~ / IgENS^EPUTE Iq. SLATE T AILERP TE NO. STATE LICENSE PLATE ND. /STATE TRMLER PLATE NO. STATE HICLEIDENIIFgATgN NO._- NOBBMOOELSa NEWER( ODOMETER IMIlEAOEI VEHICLE IDENTIFICATgN NO IISSBMODEL36 NEWER( OOMETER (MILEAGE) / .. / /!- PEGSTEREDOWNER BAST~FIRST~MIDOLE AMEI pR1 ERSIKENSE NO. ` J REGSTEREOOWNER ILAST~F RST~MIODLE N.NIEI ~~ ORIVEPS ULENSE NO. OWN SAODRE53 (STPEEi,CITY AN05TATF1 GATE OF BIRTM WNEfiS ADDRE IBTREEi,CRY AND STATE( DATE OF dRTH . / PARTSO VENICE D A ! n ._ ... aiorcvi+a~wc~ PARTS OF VEHICLE DAMAGED .. .:~ SioT ai w°FW~sr WAS THEPE AUTOMOBILE LIABIUTY INSURANCE LIARILI WSURANCEINFORMATION~VEHICLE NO. 1- COVERAGE NEFf[m FORTHIS•cGO[NT ON rouacM+ YES ^NO AME AND ADDRESS OF WBILRY NSURANCE POLICY MOLDER NPMEOF LIABIUTY INSURANCE CgMPANY _ - TP UABIUIYP NUMBER. NAN AND ADdiE530f UA IITY'NSURANCE AGENT ` Pr eTMF ~c r l~ '~, ~/~ , r • 7 _ "' IST NJURY E AGE '~ i0i 2NOINJIIRY. IuSEE[RUVAiE RE iF wumf5l NNAE / _ ___ AGE DDRE55 _ ____ SEX ~ `~' DDRES$ _ __.__. SE~ ^ E TOR. e _.___ _ _ of wu . . ~ E ~0 N _.__.. _..____ ___. _... •uf • ai A}USOi NJURED ^M NVEMgLE QPA%f NO KILLED MAAN FIRST aBlw6 r[NxEI ONETNAT APPLIE N61 p]gRLXq IuaOnl S POSVW[ E`~aAHr ° STATUS Oi NJURED ~qy I VEHICLE OvAssfxOE n NO MILLED MM%F RST Nwa G 15EVfnE1 ONE THAT APPLIE p5•eL uwORl~ S P~eIF ECOu 1 ~ OR[OFS Ilrcn ^ 5^ 6^ O 7^ .. _... / OamEnNArL.n: ^ 5^ 8^ 7Q O NORTNB ARROW NC CL[ \ I ~\ SCR BE BF.LO WHAT HAPPENEOIR ERCTO VEHICLES BY N-UMypERI • ],':ir a NcNw.. ~"•.aiNON Awxrw °A Wl.nE M.o sNOw ~ ~ ; I ,., n E•cn ~ 1 7 T '~) / a,~( /~ .- -y} ~~..1F .__./~C - ~ d_.-Its ~4• _ ~,, v ''" m DR IaNa ,„L.rM.Iaw .'„~ Q't-- ~ ', w.Y ..___ / -_rL~~7~f' ~ t.t'~.(~ ~~-a~-~1 ~L?'cE0_~ U-z~T-~.--v ~ v__r~,~ -yr/-f~s._.. /. -rA ~ __ ~~ . ~~~/~ ~, -,tea ~..,~-~~ /, - -` ~' a . .~~.~~ ~ ._ ~ _- - I I '~ # L-~o . ~ ~E -... ..__ ...c C _ G / ~ NI+FI+w ~ I I ~ .- ~t ~-L~~-CLI~G/~ ~~ VEHICLESPOSITIONSBEFO RECOLLISION No a~•Ne] „«KLe nMeu P..A.eo wAE wvES1gAT[o nY VENICLC N S F W ON SInT.EI OR IEOHWAY NAME OR NO pntarXXl ucNL. Naha a uc.u.A.RAm „6 vN.cu occuno ^I°•1• a ^ FA IagltnKl " ,aTwA, o ~ ^ o ~ z o o ~ o ^ awN,[ °f]1°A" ^ ^ ^ ^ ALOrq ~eo][NO Fiqu DIRECTION TO DIRECTION RD[alhAn wlJ IISYlO 1^9DEWALK T^WNKWAr S^ SIIOULOER •^~.~;w+1X 6^ CwiKUii+wfii. a^oINER paO SIAfACE KN<.OVI „"•1l EO , ! 1 ^ ry1Y ^ NG1nER h1+A 1~0„KU, lK TCONdTICN1 1 ~ DAYLNII 11uffIC CONTROL KWCX OnEI rNCLf N01 ^ 1 ^ EK Al9 TYPE OF ROAD „NCU enema. or.e rq 1 M F p 1 ^ + ^ Cwf. WAY ' pRIVERNEHKAE ACrgN4 vEl.cLe K.a<. o-nwww,l NO 1 W T ^ 1 ^ 601NO a1RAlONT ulEAo ' } ^n4tYq T ^DAWN ^ T ^ aIOP ,LGN ~ } TWO WAY ~ T ^ OVEflTANINO AHD PAS5111p .~[[ ~~ L } I J- } JL wr'.l } ^ brOW1N0 l ^ (AJ]% ^ O ^ YI[lD SqN ^ } ^ ~~JBLC ^ O ^ MAMYIO PqI? 1URN ^ D ^"E•Ow X ^}Oa a ^ 1p4111l ONE ^ f ^ fl•]N~NG TIED ^ t ^IR [IICHaNOE P ^ •~MANMOIEFI TURN .r ^ [ ^ SE a OINIK ^ ' OaR%Sll; [( e ^ L%LIIS O ! ^ e ^ fUf~IN6 A40fR (LOOP/RAM ( ^ e ^ all[Y ^ e ^ MANWO U•TURN O11Hn ^ E ^ SPfCIfY f LlfYl Id a Oan+.NO ^SInE i 1 ^ e ^ M SKWµ ^ a ^ I1N [I l ^ 6 ^ O.OVANO RE •sbl lOR Ag13[[r KwACLAY Yu AD4l(1[R rrL Eitl T E lgN 3 I ^61'fGFY ^ I ^ OIIICfR /fIAOMUI l U LANCE ^ 1 ^ BfOPn(p TOR TRAIfIC ~~~ ~~+~/~ 3 Sre~y. f--rr C~'f.-~.Ci1%,/<A: (~/..:~Y,.Z ^ e ^ oln}R dNGIY ^ 1 ^ urw.r[o ^ } ^nvgfD ^ e ^ on TB°f"`on°UCL~oHu ^ o ^ aiorr[oNno•Dwer _ _.__._.._ __. 0 1p ~la;i>a~ _.. ~.5.___.~_.. N ] u olvmto ~:: _ ~lanINDN ^ LD ^' unCL ,Nf . ~.. . .., ~ _T 2 n r1 ',~- ~~~~ _ s ). hr. ~. ..~•. ~ T 4 SSry^ ~ ~ r ,,{ G ` ~ 1'r ~]~ YS ~}~: flY.~t ~ .-. ~ - Y:1 x~. R TR l.~.~ f::, l . y ,. i w ( wT . ~ ~ iyyi ~?x ~-...... ~~~.3 1~ ~T ~ 1 I ~ y ~ ~~ ~It(• L, ~ i ~ r t~ l Ixmrmern~"~?"r ul'~ :,+:'"~, ~~ 1,.~.: ~ , ~, "`_` . ~ ,. ~1.~ , + lE r+ c ~ rl)~ Ill '',- ~~'. S(~rl •, -'1; 11. 1 ~ n f r)~; ~ ~ ~~1'(,' n. , - , - ~ 1 ~ f - n •~ f ~' , ~f ~, ,~. .w .l Ql!_I OF i I- K NrKrEfC '~C)/'Y r/Jn// CFI WwILfJrN ~ L 1 f. ON GIVE NAMEOF STflEET,P0A00R HIGHWAY `. ~~ '.. WTFASECTWO WITH: STREET OR PUAO.. PREFX EO OSf !~ ~ - - F-~~, ff~0 © / / / 1979 R° D < , . N ' DAMP Di GR ~ A ~ ON OF GOWSIO :ONINi[nbECfK)N IOCAT. ( ~ l PEI WEEN \, _/ S1flEET MD STREET urEl[IrOSrankgEni~ruq NNOU.wx away iwWO[i or 5 'O Q© ~ ~ NON %AD PLiFPENCEOCnOSf ER CL9., WTEH IN E ~ r nA l . AUEn ECrgN rEEr © ® Oi l~l~a ,. I V ~ Ip v Y• vOLVEO pvFNGEF VUxC[F pvE E~OgrGEf porRFnlwwW / / N / ~ ~ii I . SPEGCOOE µSE y _ ..;' 1 V- y pvEwOEEONFC} pv L _ s D I _. pvErrKEE VEBfslww ^rKr! pRr E ~ . a g e ~© STRUCK INANE Oio01LOI5TAUOM OWNER OFONECTSNAMEMDAODRE55 IN ODIECT ROA I OT ~. na iO AEPA DWAY FEET EOa! DNVERSLAST NAME AFINST f4RME - MIDDLE wfnE WV0.5 DRIVERS LAST NAME A FIRST IIAME MIDDLE' ~ / ~ ' ~ ~ ~~, .~. i • t /, r i /. ~ . } / OWUSgN OA AODPE55• ROUTE NO.MOBOXNO. ROUTE NO.MDBOX }IO, Agni nr}N rwo STREET i11EET PUDHESS ~S KEn50N5 wEnE - . r LO F A f ... / '~ 1 OJ+ aU50R CTY STATE ZIPCOnE tliNER4000UPATION I nY STATE tPCOOE DNV~RS,000 AT r ' -.~ ~ /o . .. fPOnr TORN ~' - _• , r... I 1 .' 1:)HIVERS LICENSE NUMBER STATE SE% DATE OFIXRTH AGE ORtVERS UCErvSE NUMBER STATE SEX ~ TE OF &NiH AGE. N i wr vuR YEAn i +v r _ P . ' : . .; Ir .( \ ' . . - , . OODY STYLE II DR.1 VEHICLEYP. MAKEICMEV: pODGEI MOOELINOVA~DARiI BODY STYLE I]DR.I. vEHICLE YR.~•MAKEICHEV: DODGEI MDOEL INOVA~UMTI ~~ %.~.. -.~.. L - TRNLEfl PLATE NO. STATE l1CENSE PLAfENO. STATE TRwLERPLATE NO. STATE ; ~ - LICENSE PUTE NO. STALE EIIICLEIDFlliIFK:ATION NO! Y 11888 MODELSANEWERI OCOMETER IMILEAGEI VEHICLE IDENTIFICATION NO. - 11988 MOOELSA NEW ER) DOMETER IMCEAGEI /~E~v-Z"r-'- F~ /l / 4 Ch' nEGISTEPE00'NNER ILAST~FIR9T~MIpOIENAMFj _ ,: pflIVERSLICENSE NO., REGISTERED OWNER lLAST~FIPST~MIODLE NAMEI ORNERS MCEnSE NO. - -. .. /~Z /-j0~ ~ 00 TE F &RT O OW]lERSADOflEBS ISTREET,CItt ANOSTATE( ,. . DATE OFBIRTH OWNEP9 AOOPESS. : ISTflEET,CnY MOSTATEI ~ f.M , E: NI i...uuvn~w~. MP F M IPMiSOF VEHICLE DAMAGED ,. ... .., ... ,. rto:m vFwclE'. PMTSOF VEHICLE DAMAGED .. vWR VENCIE 7. Sio RE HJ~C'/AJ f !fir fJ G-~it/ $ O . W)S TIIEHE AUTOMOBILE IIABIUTY INSURANCE ^ yEnJ a NO DENr on munch LIABILITY INSURANCEINFORMATION•VEHICLE NO. 7- eoveaneEW EFFECT FOP THIS ACCI O AOpiE490FUA81UTY INSURMDE POLICY HOLDER -. - tP ~.I NAME OFUABIUttINGURMCE COMPMY , NAME A Y AooBFSS GW sr+rE / , ~FrO64 K H' rfA//C IC . 0.4E ANUADOHESSOG W&UttINSURMCE AGENT Grv .. 51ArF t :.., i VA&LItt POLICY NUMBER Ef R C~t~A+l/6c- :nr~i~•vtc- C'v_ s'c-~ /of/t~:,f"iuD uIu IST WJUflV :": AGE ~ }NDIWUflV: IUSESEPMIMER PM fOR ADGTq EWIUNESI: AGE ... 1~:.-, .. ,. . .. .. . ...._: . .. .. . ... .. .. loiAE NAME ._~___._._---. ~. _._ NAME ___ . SEX ADDRESS .SEX - ADDRESS __,._ - ' - - " --"-__ - M u _ p p ~ E ~- .. Caif 0 AMx 5 ~. aR oa 00.5 ..... ..--_-_-~- ~ i iF - ®© ° xM RAN w al r ® t EvA 4 ArgNnv ADOC v q" TONETIIAT APPLIES - : • IMK FlRS STATUSOF PUUPED MMKFIRST ONE TMATMPLIE3 - StATUSOFWJUREO -~ nlw0 S~ E Or O RON 4 gE r w 4a p OnNEP 4V VEHCIE AOpv NOr+nz• MSSq F pow W VEnOLE w Q AASFM.Fn KLLED SEVEnf IraMmOR ~ no nCMP[AMr pPAS. KILLED I vFPFI n++KMrI i PAw Fr01 ND YELCfi Ew arc I w ^MDt51wAN No. pifof ^ 5^ 6^ ~o 6^ 7(~ S p.n vr:n[Irl ^ p.)•+.n.Nr rca•; ^ ' ^rIOW NORr110Y MROW WCRCLE r \ ~:; DESCR BE BELOW WHAT HAPPENED (REFER TO VEHICLES BY NUMBER{ ~ .. ~ ._ ryoc a mu ... O ._ .._..._ __ _ f IR { W •\ ~ f F - _ _ IB M aq H _.. _-__-___ w RE \ ]WAM[N FALN V(rKl[NrO SrgW ~ Gn[C1gNb TAVFL RTMrgw ~, ~ ~ -._••• ~__ -•.~-.-. ..~..•.. _•~••_ ' __.~__~.__~.~~-.--~ ~--I ` SrnfFfOn N.rrWAr -~~ ~Jf_ . ~_ L --..______.__..~_._-.____.. - ---_ .-- _.~__-------•------- _ __.._ J Y ~ ~ .~ _ ... ..._.....-__..-•-_ _. ~ i ._ . r _ _-_ ~ • ,.Jv i ~$ ~ .. .__. _ ._ ~~ _ , I _ _. 1 iO 11 ._. 51W Lrplr Y % i ~ I ' _ ... VE~ICLES POSITIONSBEFORE COLLISION "°w IANES nrL `:I,ND YEHCIE rrAnxf9w.5 INVESfK1ATED 0'/ M4 IfONLYPNrxlO vFruG[F OOCOPYO OIArE rsrx lt ~„ ER NO r9 ^ r0. ^~MrCE I yM1M.1[ UE+SInEET OR InGNWAV NAME UR rq 0 a a o ~ ~ ^ o ^ o o a,r,Kr ^~ wySN ~"; nL.>e 2 x,1r.,Rr ^ ^ a PrJ ^ ^ ^ ^ ^ ^ RKCRri 'Yra„"~. ^ ^ ^ ^ uaNO c°n'w:AO rRDM OIWECTION To DIRECTION i Nwr:AS US)E.G ,rtrrsr 1avDewuK }^wuKWAr ]^ ' x a^onrtn fnoumrn +a ~.,o~hmx 9^;,~o° . Kq AO SIXN ACE nXr w Y.EAINI.H IGHfCU`IprIDNS T1IAPIH:C0111nOL Krrt[x fNH "l'rt TYPE OF HOAU T,Rlfxfwt I Kw1 p ' lE MNERIV(IIICLE ACrgN9rOrKfAOVF E+r lvlnEr r e. lC Giub 1 n'~fu IL ir I ~nAVIGHI ar 1 ^ 516•NI'{ A I } ^ ONE WAY O I ! ^I 1 r^ CAINO SfnNUIIT NIEAO ~~ 1 ~UIY • ] ^ nA1NWn ] ^ DAWN ^ ] ^ 5rOn'Af.N ^ } ~, IViO WAY ^ 1 ^ DVENrAKIHn MIOP 551N0 (~ } ^wfl ;) ^Dr:U,NMI W':i. ] ^ ] ^ WI.IU T~K.N a IKIAf R`.INIE ^ ] ^ ^ ;F ^ MAKING IIICrNT fI111N l~ 1 ^:'H0W f ^f!K• r- f Il~l! rH5f1•l.[r ( ''1 a + ^tIASnPM n(0 r ^ + IJ PHfnCll Af1GL cYGPaucl,l a + ~MANWOI[TT IURN ("•] + []aE mulB 5 ^ • wn+•;unrr XINIS Ofr r ^ ^ 5 ^ fLA.'AArrO A44FI1 B ^ `+ ^ All l Y Luxrvr. u.ruuv ^ ~ ^ 11 : ~J ~ ^SIt C~rlr I'A'l Gfvl I A ~ ^5~1~1[r LGm19 n Em E+rrNµ ^ `~' ^ ^lIf1IUYH D ^ •! ^ fAO1wNn lt[AZd)fOllrgT bl EIYD OAYDFR T ^ l~1NIR ^ I ^ 11r 11CL11. Il A0NAN IMlfi ^ / ^ GfUMKRrOn lnAfflC r.MxOwwW lrErwrOlMVItCr ILHV ^ A ^UHHN fJ•fGlfr ^ 1 ^CinNIArCD OR BIp !AGN UNAL ^ K ^ . ] ^rXNUfO ^ ~ }f ^ P Ey GTOImLDIH RnADWAY ^ Y I~iin Prt ~ ^•] Ll ] llNfniOFO ^ 1D ^TnMIICIANiv[ SEf AODnf 11 A00 ^ 11 ^ PMIAF.D Ig9NON j NI!Nr 19 MAMF , l IEN/ERiNO ^ 1} ^ I 1A l 1 IC I ^ IS ^ IIACMNn L ' ^ ^ WnnNO WAY I I ~..~aFi,-• { ~ ~ r 1 `r.,+~! r ~l.y _ ~~ Y, L, ~n y .~~ , ~ O N( CE ' y ~l~u~'f OI pf ~~~ S1 G OI t. ~~. VI VF ~ RI ~ O•. P, ~ _ % "~F~ v A p .' i ~5 W'' . ~'_ r` ' u~~ ~`N. $~:tU^ ktv~ LI ~ AI ~ y:-. ASwA95rASrj_~~ ~i +'~ .1 :: . a &~ rflL.Le L~'u ~ AF+`+' .. -,.- to -:.SSEt,"J,t cffi_45 ~ ~~ ,rFGDLUSION ...., DA wn AR Y OF G]L NE[ weD U90N NTIMEOF COMU~SIOa AM, InvP Fw s.r Houn GDUNTY NO CTY f10 I~ ^ , o. F sue. / : PM / - ~ - COLWTY . +. GT; TOVM ,.. I+EIC,(y5 x ^ Foui30[ MXES .I CITY.TOWN ..~...,... ®®'._. ...., . AOMCl4 PPEFW F CM Et OGL A :3:r 1J } S ]iU~~ 9 BECKON I . ~.`:A~ '..: f0 Z ^S ®oP N r .. .. -7 . .. . „ :.: - a GVE NAME OF~yfREET,RO ORMIGHWnY . ,... ~ ~ '_WTERSECTWO VATH: StflEET Oq 110M PREFI% y .}C.4 -E EO MLyEPrOSTf' 1~yE} SYM L. tT! I ~/' ~~P+ ' , T '.. HHfO 1 Z INTERSECTION~LOCAigN OF COLLISION r . . MMP. TyyI >~~ 7L ~ GIIGRAM DATA g~~~ y; 1w0 "+{~fyyv:', ~t F~Y3 Ar -i-~I ' +~ VEEN STREET MO STREET k 1n:" rSr'^':2` V G ,eY'!E`^",'. ?•'Cl^-K,w' yy~!""' ~..~rl ©© RAAAOAOCnossvw MAllrosr OR O[NrRrxOLiNa+~~Mw0.0mocE ~- NON INTER INTER Xfl0 GLS.~ s x[ ~.~ NIE"G ! PE ~ cr F[e r ©® O ^' f~.. •..::I'. Iiti~~g ~'(J'~ti'r.!vi.[~a'T - EnKEE ^v[nit[E eCrttE ^OMER Iwa rU wvoLYF 0 " .~ SPEC GD`E USE .;, ,~y g''T~ __: H' ~ r^ Co 1 ~ ^vE'N:LE OfoF61NAN ^vEnKLE rPAw nuN ~ L.._ .. ^v[ ^xaNCauvpx ^HT [ µf _ ~:fir7+ r .. V OF06[cflrRUGAt ; OWNEROF061ECiS NaMEANDApDAESS LOC :CT STRUCK IxAME ' IN RO ATION QQ OF - ADWAY OR A ONyfci FEET EON - ,~~' '2^ • ^: jE//RS//I~~A~~S~T (NA~M~ET .., •FI'Py7S~YT NAME .,. MfI'D~DLE I~aT ~(C~ FA`t~ lO / FMpxf MM txOOn'S cOWSgx OR ORIVERSlA5t~NA/M/E ~~~'f~ • FIRlS/~TTNAME ~ MN)O~L(E ' r~< •'• - :Ern00RESS FRDUTENO.PNOBOXNO =-t ; Z ~o ~' ~~'~ MoneT AN rvu P[AaRSnpFfO] ~nE ' STREET aDOPE59 gv ~ l ROUTE NO.ANOBO%fq, Roo ~ ' ~ • STATE. LPCOOE pRNERSCOCU AIgN.,:, A[PARArN COwsXI . CITY STATE ZIPCODE G(NEPSOCCUPARON ~ ~ ~ > Tb e Wt~ z3 EMR FORM C In4.4euM. ^A - ~ OF&RTH AGE AT ,, , ERSl1CENSE NUMBER ~ STATE SE%. - ,DATE OF GIRTH ,. AGE ,~ pnIVERSIIGENSE NUMBER , -.. ... STATE SE% M F , O E pAr r(AR ~ M F ~ -l L :~ pAY YfMi CLE Y0.. MAKE ICHEV~DODDEI MOOELINDVA~DMT1 :_. DODY STriEl2 p0.1 '... VENroIE YR.~ MAKEICHEV: DODGE) : MOD ELINOVAOMtI ~ G ODYSTVLEIa W(.1,.. ~ ` C P T E TRNLER PIATE NO " ' STATE.: ; : -~ ~ - .,1 ~' CENSE PLATEN0. '. ~~,STATE.'::'::vifWLFA pIATENp ;:. .::„: _ST!VT6;,,. .. .LICENSE PLATEND.. . . .: ; AT .. ... r..S . . :: T "~ S2 6 ~~c a F r ~~~ ttElOEMIfICATXN/NO. ;:-.:-IIBCGMOOEL9[NEWERI:; ~T,; OOOMEfEfl IMILEAGEI ; ~~:; VEHroLElOENTIFlCATX)N NO. .;.:.; I1BfiSMOpELGS NEWERI':,:~ OO MEfER.IMAEAOE 'P ' '~. ~ ~ ~ ~ ' V. iSfERE OWNER 41SF. N E ~v '_ lL:~AT: ~ c ~.OWVEflSIICENSENO^_,. .,, REGLRTE ILASi~FIRST~MroDLENAM61 RED OYMER:.,. ORNERSUCENSE NO..~s :,. 1 ` ' A l -` rrc 2 ~ C ~~1NE6 ~y` i x ~ ) I. I ERSAOORE ,A, ,~A,~,,,.ISfPEET,CrtYUfOSTATEI ., ~~ „pATEOFSWTH_~y "° OWNERSApORESR .,,,.,. ~ IE TREET, CfrYANOSfATEI. .. OATEOF&RTH ~. z aox 3~0 ~P,. o ~ iz r[o ~ PMTS OF VEHICLE pAMADEO .. ~.. - ~' P l ~ v` y n-MAGED . f.,., .. u. t., ,... " r^:.:.:r:. 1 :. ,.,:. ; 5 wun Ez 'SDO~P YEHICLEDV ia5 ~I~ _ . . ... _ C NK S OFEFU Vf E .. T.L1/ F WAS TNEREAUTOMO&LE UA&UTY WSURANCE BILRYINSUAANCEINFORMATION~VEHICLEN01 COVERAGEINEFFECi FOR THISACCroENT ON YOURCAR ^YES hO NO . ::.. NNAEOF UA&UTY MSUMNCE COMPANY : : ~ ~ t..~ '~ ~ '~ f~Y ,;Y:? tlP! Yi . ..: ... I E.NVDApORESSOFUMIUIYIfISURANGEPOU~Ha0aL0ER. .. ::: • Orv -. :. •sr~rE ~- :.'.:. xE A ~ i .. I .. .. E ANDA00fiESSOFUAGIUfYMSUfINiCE AGENT': ,.., ...: Grv, .,;,..:. .. ,, siaie: .,v.,.~,. P : ,.LIABILITY POLICY NUMBER ~ ,. ;.. ,., ..T, ... Qty LT'~ ~~ NAIt(Y ... :.,. .. •., ... ''. AGE. ~ aNDINJURY: ~.,. IUSE aEPA MrlaEroRTFORAlPiKAYNwAM SI . "::~.., '' AGE , E. NAVE •. ,~ rS E '~ ,: ~ LESS .SEX ADOPE55 __.._ SEX ~ -~ .~ '~ , rMD -^'-'---'..~ n IFi ~ _7 .._-_._..__ ._ ur[nroi°NAn,f] ,_-~ _ __-__ _ ~ M O.. 'Y,'~ ~° ' O y -MMKF•iST ONE MATAPPLIFS - - : STATU90PINJUP[D „ v.e ,nn, ,..r ~ r 11C1E. ARVIO fKA1 pLNPq ( ^. R IN VEHICLE NOxpDAMVq ~ W4ED IMHNeI Naonl I Fv~[rC ^ 'Yxn(n NO pLLEO~ Isfv[NEI IMwoRI AO cIT )s ^ 5^ 6^ p7^ ^' a Plr[~N ^ 5^ 8^ 7^ i CIRCLE ~ I I ,..„'.,",_DESCRICE BELOW WHATNMPENEOIREfERTO VEHV~tESRY NUMBERI„ 5 _ ~I.. ' SHOWNOflIH _'eG R~ ~~~ \ vN -r^-------•-------~"~^ 1 i -~ ~ti p^ .. .__ / / N._TT+~_.Sawut2E~_ ~_'G'E+~ ~-- - -- -- v^k M + ~, ~._ _ _ _ , [V~Anfs vN'A:U vOHtt[ PAnrrO wA• MVEpiIGATEp OY >~' x ELONIr SIANONO URN[Y FANA[P vIIK%L OCCW%O ^prAE ^'IN(R nrctpl L x0 U M ~-/ A tKK FWGL ^ ^ ^ ^ uoNO <ero{'.n rnoM DIRECTION rD DIRECTION ! ';,'~~ -'' `Lpl6IRtANWA1 U]W(i 1^bpEWALK a^WKMWAY l^Sf10lILGER f^~W~nw.lF 6^(IIn4{WµK A^OTIIER ~ ~~~~ ~ '; ~f 1X1Ap ]LE(YAF! wfATKI FI UONICCNU110NS IRAFFICCONiROI n /~ TYPC OF ROAD pIWFRNFH4:lC ACTIONS FA ~ ~"~' M~{!.'[Y I KFCEI [ KMnf~,frwL nK(! IGMCr DHI Cn IR1Rfl ~~ vflK.n LC. cwl L~~ ~ 4.rr~ ` a 1 ®•pAYlFSN1 •d 1 ^ •KNAL9 l ^I 1 ^ CME WAY ~ 1 ^ DGNOSIRMGIiAIIFAD ~ 'tl ^~1~ji~rnY i ^-~w,,,;,o a ^ p.wN ^ a ^ slpPar.~`~E, ^ a ~ Twow.Y ^ a ^ DvenTAKINpMpRASSWR IuRepfy ^ % ^wf/ ~ ^fAfovnNn ) ^ WSn ^ 1 ^ VflD SaN I. Iay \ ^ a ^ IIbM 'rWE ^ ~ ^ MAKWp nYlNr runty a~1, ~'. "A[A+T I '555 ^D^`'~W f^)00 f DMKS NfFf ^ A ^fUSHNO nFDW "E~) ^ A ^nITERC(IANr1F ^ A ~MANn101fFC EtIRN '~ ` ~~ ^ LGNIS ON p1 ILIXJR~~ AMI.1 ^{^CR 6^ptMfR ]^tOCO~t~OfF[T ^ 6 ^fIASM N(4 AUAE ^ ]^Al1.CY ^ S ^MAKING II.TUIIN _ I 1~..' 11 !rM(r ox lR>N~rAr r YLmCIE N 8 [ W ON "utrIEET On 1•f IWAV NAME OII NO. ^o^^ _ ,~~ ~ ~` ^s^M1MOi• I:A'EUfYi ! pTA'A~ ^ • ^NI GIfMAI ^ R ^LIM f14iN ^ A ^IKO~~ I r1 I}iN I ~ DTI of 1:qN FOR NOt XLIM DANfIfR ,. F DEMf ^ ) ^ OEFICLR/fl A(:MAN IANES f '~~1 I ~- ^„ry^ I l,~I, ~,. J'}yYRwvl+o-(rA.OrrIN{(fel ^M'fUFY Ll R ^SiO~EOAON~n~fIC yp 1 -. -`,`''~~7 TT l.~ ~A~AJ nAL~ ^ fl ^UII fR fE~)V _»._. .. .... ..-. -... ^ 1 ^''fPMA1fD ^ a ^L%VKWO ,--/URSfG'fT(W ^ V LYJ GtUM'fDIN RUAUwAV fTMINrI 11 I J,~. ,: ' { ~: ~(/~i{~ PtYT~t' k6Rcr=rw . ~Y,I/` DI MTR i K ^ + ^ ff t ^ D ^UNDIVrofO ^ 10 ^ rPAIFrD IANfl t N(IfRDM STA '; ,', i~-~ NAM'Iro ;I ADbE(SS .~ '.i 81'L ,.. ME , ... Li .,ey,l ~'w4:~4 ~ . _ - ~ '. ',',.: t,w..-. X ^ II ^ PA [p FYJNtroI Wn n'Lr,m.(.~{{tL~~1~,~J~ ~..Y ~ '.,~ ... r ' ,. ~'' -, {, +YlY~ Y~F_.-s ~~ ~!_: ~f ~ ~ ~.~,"• . +6u_._ x~ ~d.... -+r,uu.gAB ._ _ .z._ NO .... ,,, .,:: ~ct~ .~ ' ~aFa~l k -STATE ©~ 1n%ASf=11(ViGTOIV PAGE DF • - • ,,((~~ POLICECOMPLAI.VTNUMNER Y ~3 ~ L ~!~1` UNIFORM POLICE TRAFFIC COLLISION REPORT _ ~ ../ 'a rD DATE OF COLLISION DAY OF COlUSgN LIME COUNTY NO. CRY NO. FHWA ~F "~ ~~L MD pAV ~ i SUN L II.pN 2 IY(5 U WEp 1 IIWP ~ fql 0 ; IUSE ~IOOIIOUHI Y ~ HBAN - 1 tei ~ r 1 J RURAL , Y: ~ - COU.V lY ^ETATE ROUTE ~COUNtY ROAD ^CITV STREET O ~ ADMLLS. PREFI% POUTE OR STREET CODE sEOTICN -~~ 1~ ~ ~f _~.(rA~ ^OTNEfl ISPFCIFYI W ~ ~C/ O N L.J q a ! L N 5 E W ^ IN (/-~+1~ CITY OH fOn.V W PHEFI% EO. MILE WS! P r • ' ~' ~_ ~ .~ C .•3•~. ES ^ ^ ^ AF .Y I.'Y+T~ ~.GI.UAI. ~~FAi .). U /T rr hj~ - '~ A NAME dNO.OFSTRE OR iGHWAY INTERSECTING WITV. iTREEi OR ROAD O RA ~ pIAGRAM pATA ~ ,•• Q,, ~Po Ji µ~'A' ~lN,. Y'" ~y £ I NON WTEflSECT10N - ~• NTER NON %RO TERSEC iING STgEE OR IOAp OR REF ' M e ,a, ~ O ACapprvT ~ CLS. ERENCE OSSSTRE BROAD ~ i~ ' F', 1 N pETWEEN `C r /L. (T ~ Ly STREET ANp J I~ .`•~- ~-~J _ STRFEi GOOEE - " A r ~~ -' pISTANCE DDIREDTION FROM REFERENCE OR CROS95TREEi - ~• MLESw- BPEaAI TOOWOUSE H ~i'Q M A ~1~1~M1ES N 5 E 1Y ~ ~ L . LJ.EET OF ~ .... _ .. VENICLEWEHICLE• ~ VEHICLE.BICYCLE OTHERIIYRITE) ^HIT 6RUN SEVERNY ' .k,, ~ - •,'.,• COLLISIONINVOLVEO: ^ ^ - • 1 NO. KILLED -VENICLEOBJECT ^YEHICIE'Rfl TRAIN ~~7•y ~aC~T.~(!) ^STOLEN VEHICLE A'~NO INJURED t. OF VEHICOI.ES ^VEIIICLE.PEOESTRIAN ^NON~COLLISION -~AZARpDUS MATEnIAI' _-,. _,. __"__ ^PROPERTY DAMAGE ONLY ~~.'1Tf'.•, • ~ ~ ~ 061EOT SLRUCNINAME OF OBIFCTSfiUCK AND OWNERS rvAMEI / LOCATION OF OBIECTSTRUCK ESi.OAMAGE ~ ` ^ ROADWAY FEEt'^ ^ ^ ^ IDIO EOp6 5 _ , ~"v '~ ~IGV: ORIYEflS NAME•LAdi ~ FRST 'rM1UDLE DRIVERS NAME~IAST FIRST MIDDLE RI UICVCM5I, ON HEDESTNIAN CHECKI CJ • D l p I GTflEET A0piE59 ..... G_ T ..; . :.~..• _ R SiflEET A00RE95 [h ..~ ~~'y ~, ". ~ E- arr u~ ~ ~.,-:.:. siATE:: .,.... •.,.zlP.cooE ".. Pnorvervo E. arr. .-. - „srnrE ~ / . - , 5 ~ ,. fFe' R -. ~... .: - .. R .., ..... ._. _.r .. ..... 21P CODE 1 HIONE NQ ;~~ ..._ fir. [, 2•.r c„~r~ - ~; ~~ k ~ `~ N' ORNEfl3 LICENSE NO GTATE SE% GATE OF BIRTH N DHIVFRS MCENSE NO. - nB - O• _.. FATE pAT FBUi ,.: S LE% ![~Y $t ~ •~ "GL r / L N r /"I M~ ~Y ~JL O MO OOAVTH Yfl.~ G 1 ~~T ~ N 9000UPATION FIRM NAME ..... .... -...'.. ` PHONE NO Z ORNERG OCCUPATION FIRM NAME_ .fin ~ ~ 1 f !./ .. ,.. .... P NE F Jr, ~~j t r CODES > IJI Iwu Y ~ .. ' Wy F CUSS-- __ 11 SEAT BELT_•~ 1`'1 EJECTION .._ .__ CODES > IJI CLASS-- 1J1 SEAT BELT.__ I51 EIECTKk1 ~ - 3TSK .. ~: T' n IN)UAIES J~ /1lif: NATU E f j;~ . 2Y -. ~. INJURES _ fR MSCENE DV' • '. /J. AgMO FD {s, " - "l'w OM 9DENE RY• TO ' VE^H~YEAR. MAKEI ECHE.~, M OELIDART NO N'-. StttE12 Dfl: CONVIv. - VEH. YEAR MAKEIDOCGE{HEV.1:. MODELIOAAT~NOVAI STYLEI2 DRCONVJ .,., :,. ~Y~. ' '_ E VEH C O - LIG PLATE NO... TATE TRNLER PLATE NO.. STALE E VEH COLOR CIO. MTE NO ,. STATE .:. 1flNLER PLATE NO. •. STALE . • ~; ' O VEH r 10 MTIFI.ATK)N NUMBER ~ ." ~. ODOMETEq. ... O VEHICLE IOENTIFK;ATI N NUMBER .... , ~, •-,-_• - ;;~~,, ... ,. ..... ..:' ODOMETER ,- .. py ~ ~ -1~;: H^ RED OWN -•IAST.:,....... ,. FIRST.. ._ .:,..: ,.. ... MIDDLE ~ RFGLSTERED OWNER-LAST ,.... FUiST. ,.:. _.... ..... ,."MIDDLE.. ,.. rra~ O. ~ ~ /J ~G--LI- e T p,. if. ~. ADORE OG OWNER ~ ,. .:.. ....~.... .. ADDRESS OF OWNER ..•. ~ . TLC _ ~~,: ~ n/_S r 2 .. _.. . , _...,... . _.... «'L',i - di °~" r ~ - NAME ANDA c55 FWSUflMICE COLOR AGENT .- ": NAME qNO AOOREBSOF WSURANCE CO. Ofl AGFNi - , ~.. -. ••~; ~, ~~ ~. , + ~ HARGE .. CITATI NNO. CNAflGE ~ ~~ i 1 • _ ~ K,AYC ... .. .. ,, /^, ENFORCENENi. ... _ .. A . ~ _ ~1 • LG~ A/ .x L/d ~ /J V ~ ACTON .rl. ~ 5 ~~ I NAME, ADDRESS & INJURIES,OF PERSONS INVOLVED ¢c ODESe ..[..... mv[H 2 r ' ' .. ~. u 1 s 1. NO WNHY • ]pEAOAT SCENE F OTNER POSIIgN ] pEA00N MRIVAL IRUGMOTORCYCIEI A DIEDIN IIOGATAL S PO^JTION UNKNOWN #~~~5'd~,^~'a,t F1 ~ ',,, ~. ~'!f ~- -:,~~~ .:. _ ~~`F VEHICLE DAMAGE I NEAGH RO%CIRCLE THE NUMNEH OF EACH OAn+AGEOA.~ ~~ ~ AMP E~~-m "~L - ~ ~ INSTRUCTIONS: V. SHADE Al1EA OF SEVEHEGi IMPACT. ~) r ' ~ •~ ].SOHAW AIIHUW151 TO SHOW PRINCIPAL UIHECTION OF FURCF. ~ .. ~L ~"' DAMAGED VEHICLE NO.I rrNSSpncE rpN.KETUNNC UAMACE ru nIA L[IH, MOloncvcLFS, Lrcl ~ f .~ ~ s-' ~' DAMAGED VEHICLE NO. Y ~' - -Tvl '~+~ -_I~~ • Ifi Unar•w••i+W I6 TINnL "~ - k° ~~ee n. a.N~•n ..'.. - In :o .~a~- ~ f f Ie. u•In.,+. i. `}_ 4V [n1TY Oi UAMgGE' VEHICLE NO.I I I t ,~ ~ LIN'G OAMgGE ] Q UTIIEIIMV pANtAGE TY O[pwMAGE~ lOillEII VFII CLEIIEIIMV SE VEnIiY OF OAMAOF V }. OrwlV.n I ~` xp ur~crloNALOAMnGF ApN nIApF IEO+oHnoLwcpgn+ncE ;[]ar .. MncF ?~osnouNC OnMwce HICLENOx ' E ~CI^fuNCTIONAL On4gGE ^ NO UAMwGE A K ~ 00 UAMAGE !IMAGE I pyT - '~..:.: pwEU nY~~ll7 t`1 L I.E: a.• •. ....-. AAGF < '"r ? r 'YA - .34EG+.E ~5, ~. DIAGRAM OF COLLISION IPINn.r-. r ~ ~ ~ ~ ~ p,pw,.ANO DRAW gflROW SNOWING ' ' n. rewgnRs ~I<osN I ,r I NURTH IN CIRCLE ~., O - ~ ; Ia,IF.N IM.AEr • : ~ _. „ _.. _ R„ a I. Dns„ ,~ I . ., 5:•pWprcp.,x,LYEx:TLEpx _.__ : pEtlrrINI,NP,H SrIrDAE ' ANP.rHAKpLLI:~. ~, s' rr.c--~- R ~ ,.. .I I DESCRIPTION OF IINUL E a r r ~ T gBLYNAPPENE [ N N O Oi ONO AGRAM EG pgIV[rt COLLISION plsamuiY. n[oucfo msnnurv.FEU s Ru apm mcoLON, ~orvsilluc TSON ON ner +o K ETC 1 - v ,C;ou.•un -...r v„„ ~ _ , . t.+ lr'.... /~•~-?.• /k A CFUSSCS !7>C Y J72C-C'-- _ _- -- - .. . ..__ _-~-_ --_ _-_--- - . POSITION BEFORE COLLISION NEN ~ NFADE O NL IS GU q ON STIIEET OR GHIVAYNAME OHNO. IOiF UNECNON ~EEU r4]IE AL ENO' E SING E ~ _ L LEG LY SV An KEO OCCUpIFp PEO I - _ ., MPN J ES _ NO YF 110 -~ -I ... .. _ Pfp:RIC T AS US NG 151OEW _. ._ nps - ( r U }f WA AY]. ~SO En ! I OSS LK 51 I KG 7 U I M -' TO I ROAD SURFACE IC E O 1 WEATHER ICHECKO EI . . C CONTRIBUT ZING CIRCUMSTANCES c Ecrc n o E <EI~ E I TH -~ E E LE OR E [ A p} I orvE ~ O w:Ct E a S E ~.~ pqY -_- No N I~[CLE ,Blwbev I' E UE C O ~ 7 I" O LOW G bQyGLGaGi X i I CD i> O I p o f I EG npEp AN I ~T ~~ so G TAlIEAO ~~xL I WET ] ANNG ~ _ - ~ .. L`___- J- OPGLOS FY ~ WFLUE OF I I En CF Elt ~ O . ! 1 5 ~' -'--'- ~ L~} OVEPfi NC ANO I J -" i - t - UJ1 GS.... f .~ 1 [.- NTLY _ I S -[ I SI 1 .^.LJ [ O l S WNG J .._ I 1..1. 5Jf ~FEOM T AT I O 1 }O S I' ._ __ ~ S 1 OC ON . . RIGFIi TURN r I 1 I . IKI l C[ ~ A O .. ( ' ~ ~ ' ~ EO f . _._.._. L I LFfT TURN 4 ~SI 1 5 I U S F ^ E O OTC ANi ~ p REC4 I 1 t l O I ' f C EC(IVE EO ^__ ~ 1 ~ •U TORN ,,, OTIIEII I•PFC VI - OTHEN ISPFL FYI O F ._. ~ - -'~•^ - O L ~}• X I `j ~E~ J^ . /Y• lx ( I 9LOWINO ~ ` CM CONDITION S RAFFIf CONTRO i __ 11 I 'fi~ ASS NGII ~1] O CIGNp O 1 8~ 1 O 1 IYI. - o IoI.An N L v . E _ ~ ' I, STnpFEOfOn L 1 T InucK UNEt , TVFE OF ROAD yEHICLE CONDITION O xVEI11CLE NO } ICHCCK ONt N O ! 1 H{sxpj.Qp E I .. M ~ .SOBRIETY F E ICIILC EI ~~ _ nAFFIC [-" GN GNAL (.1 LI O 6TOP S I I SIG l O ONE WAV I f CUh'fIt Al7f[ I Q ] i I (( I'. . _ __ Y } . 1 T 7 '.`. ~ _ ~ Two Av I...-I ~ OnASCSV I- - " ~]~ %~~:. ~ tll L v AnEU i STARTIN61N I I UI N l~_,I..D ~~~ ]I ~ Y fI -SIGN ~ . S I [ 5 E ]I I U[ E " ILgUL GI 5 ' O . - ___...-. 1}}I ~ i v - + TIIAFFIC LANF I STARTING igOM SI J DUSK ~- fLA G _i .qEU r T FR ANGf - ~ j ` 100 nA4 ~~ L E ... OT IM Af1ED.-,___.~_ SO IFTY I]' I l l KEOPOSITION ~ I I PA fi [fT LG SO ._ iL, G fi 1 , _ .. P_ RF I L p T '• I I ~b I I A } I NK '. .1 - - -- _._ '_ I I} ENUINO IENTERINp __ TnAFfltl ~ .. i O nK FET .AIAtlE j_ .. ..r ~ O 001 ~ ~ NOOI NKINO 16E ~ OACKINO 6 t c Es _. . .. R I E DNA ni Tw'b ANFS FT I If a. moWN ° ° i~ot ~ CNCM, TEST .. ~ ~ pnnK-NO !-\.5 RfE IGNTE ` p cNL'L+3RT- ~ - _ I I [ I[O : E O ~-~ N x' ', Tf f fN `~~ OI ISaECIFYI OTiIEI l tCYI~~~ T F ~V ~~ ' ._ ~•'... p `. ~ NU DEFT LT t ~ I 1 TEST Rl ILSEU INVI I uUrr ~i~aa :r •, ~,_ NNHISI C • _ NOWIUIU I•j7u °ro TEST RESULTS T ION C COPY JAVlf3: .. L a.~ ~ N1v EA~ ~'l4 't il- 1 ~f'C*': .ra. fkY.~yl. I;- x~f`, . ~ .4TYE x~ I •r~rx'"f& b rl { )/ .I F If ~ I if~l .. ~.y ~ 7 5^: K ~ l{ I Ix ~} s T;1 I t ~. t•, ! cif - ~~ - - - ~': A ~{ °~ I ~ - - .. z ~ ~1~ ..{ ~r - k 'Irt~ ~y - R`.~ ~ i ;y~ ~' ~ Y 6m: ,1 ~ ~ ~ ~~ ~ ~k~ >s ' y;!• r' 1,:1 ~ ~ G 6 m ,~ ., ,, ~...,' T PAOL•• OF ~~ STATE OE WASHIPdGTON ~ ~ o. • ~ ..,. ~ 1`. s,. yisi r ~ a• r - I ° A ,~ _ -.~z,. iT. ~~ ~ UNIFORM POLICE TRAFFIC COLLISION REPORT POLICE GOMPLAWiNUMOER ""Xd~rt. } G t} ~~0, S•t< t' ' ( b ~ an y .[ . I ~'T~ .. a '.~ ~~ :4 _ L' ~ ,f "fR + x A D DATE OFCOLLIuIUN UAY OF LOLL SIGN -~~ TINE COUNTY NO CItt NO. FNV/A i A 7 M 2D~Y ~ T 5(l' I r,:Y•N Z IUeS T WE IMIx S FRf G SAt (ISFY].Iz rURI Y QURSAN E1. E y ` (fYJ J = DM CLS PHEF % P ~ URAL COUNTY ^SfATE HOUTF UNTY NOAD ^CITY STREET ° ~ , I OUTS OR STREET CODE. SECT ON ~}'~~G~/V~ ^OTNERISPECIFYI y ~ ~~~70 L /~[ C)I~TY OR iO':/N W ^IN /~ -N 5 E {` ~/ W P IIEFI% EO MILEPOST ~/ y1 ° ~ ~ . p G4..f~ ~. ~ MILES ^ ^ ^ IHJ ~OF /'J ""C. U .TJr~.7 ~ r .C RNO.OF STREET O°I rnGNWAY INTEPSECIING WRN: STREETOfl ROAD LL R AMP DIAGRAMDATA ;T ON 2 r Z I ON+ NONINTEPSE C 11 ACCIDENT 'N T R N1E CLS ~p OR REF. n g C ~ [' ~~f[, /1~ ~ C~ / ~ / E I O EflEN E CROSS STPFFf~.•I ~ I. N OETwEEN l . LY. STREET AND ..l~r`--- / ...;STREET COOE ~.33W DISTANCE AND DINECRON FROM REFERENCE ORCROSS SIRE N•^o Ky Vx G PEC ALLOD NU USE . :_ ^~~IICES N E W /i ~G~ ~. BOO L'IFFET _ ~~ OF VEH CLE~VEHICLE ^VEHICLE~SICYCLE ^OTHER IWPTEI ^IIIi6RUN . COLLISION INVOLVED: i SEVEPItt .... NO. KILLED . I TOTAL NO ~J~I VEtnCLE~OBJECT ^VENICIE~RR TRAIN _ ^STOLE VE CLE NO INJUFED OF VENICLES C~7 ^VENICLE~PEOESTRIAN ^NON~COLLISION ^MAZARpOUSAtATER AL . __. _... _. _ _ -..._._ _. ®Y!IbPERTY DAMAGE ONLV L j - OSJECTSTRUCKINAME OF OBJECT STRUCKAND OwNERSNAMEI .. LOCATION OF OBJECT STHN CK ,.E . ~ ... FST.OAMAGE , S ^ ROADWAY FEET ^ ^ ^ ^ RD EDGE 5 DRIVERS NAMELASi FWST MIDDLE DRIVEfl'S NAME•LASi FIRST MIDDLE of SICYLIISi UH PEUESIHMNC kC 1[I,='.-; f ° R ~t-F t'sn~.~:tK Q:9~+dAai1 o R W,1sD[a KA-4t.14c~ (Z~t. I ' ~ STREET ADDRESS -'- - ~ .. ~.. ~~` NLJ ~ ~~ '. ~ SL ET ADDRESS - ,.: ., ~yv ~+ 2 ~3 ~ t n t ~ E R CITY STATE ZIP LODE FMONE NO. S~A~~~~ (,.ir-1 ct ~ lD1 7S3-Z7g! E R Gtt ~ .STATE 21P CODE PMGNE NO. UL `C4.~E Wry .376 '732-yS6 N DWVEAS LICENSE NO. STATE SEN DATE OF BIRTK N DPrvE 5 UCENSE NO STATE SE%• DATE OF BIRTH o. ft l M b Y" q °' ~ 5 S S ~ (ate (= Y °~ 03 o w o ~ L : i DRIVERG CUPATION FIiiM NAME L. PHONENO. N~.hbf Nolccllc, S L9~Fllr L,n LLrG 'j DRIVERS OCCUPATON wz FIRMNAME .-. ..P NO , , L`°°ES ~ IJ1 CLA~._ 1rl SEAT BELT._ . I[rl FJECiWN _ __ CODES J IJI CiOS S-- - TAI SEAT DEIi_ _ 151 EJECEION_ NANRE OF ~ INJURIES AIUP ! IDN ~•.At~C~ IKIUR ES ,v ^l[ ~V SCENERY: TO FPOM 6ClNE nY' TO VEH. YEAH / ~ " M`E~~ NEV.1. MOOEL ID^N~O VAI STYLE I20 V.) c VEM. YEAH / MANE IDO~NEV.1 R MOO~~ OVA1 STYLE}2 ~ONV.1 . ( J d 1 ( -IJ l ' O ~ c `V V V (U ` ~~ T E E H C OR UC. PUIE I.O. 9TA TE . TNULFR PUTS NO. SIAIE E N VE . COLOR . UC. PUTS NO. STATE ~ TRULER PLATE NO . SEATS, _.:. ... C V H ~ ID NII ILATION NUMBER .... .. U METER .. ° V MICLE IUENTI ICA I NNUMD R :.. ..,,.r ~..... OD METER.: r.., .:x::i..'.,; ~ 2327/. 'E .. -' E , ST ,.. FIRST .. .MIDDLE R GISTEHED VMEH- LA flEGISTERED OWNER- ., - rWST a.:!r. IODLE., ~ Y ADORE OWNER ........ ....._:.. .... ..'... _._:._, ._.. ADDRESS OF OWNER .. ... .-~.. ;. ... _... ... '._... u.. ~ 2: , NAM ANDAOOHESS WSUR~EC RAOEN/ . ......... ....,. .. •.:.._. NAME ANOADOHE590F WSURANCEC0..ORAL N.... _.... I_:,v:..::.: ..... Atls-rA-cc.i.~sL„c, ,Uc~t ~ CH .... +. G~iP'°NO ENfORCEMENi KAR .....' .... .... N .: ~.. •Y:. ACTION .. (M1 ~~~y NAME, ADDRESS & INJUFlIES OF PERSONS INVOLVED '' r coDES - ' ' .~ SE% AOE STATUS wr r „ „ T EJECT. D NAMF M ~8 Z 1 3 ~ 3 1 C ADDr°ESS ~m6 _ tQJ - U p I DmoM r. runt kAlo wum[s scrrv nr TD A NAML' T ADDntss S _ uA uu_,v~__--- sciNS o nloM TD W NAME_ _. _~___ _. I _...___._ _ Dr.R[ss ~_.__.,._._____...~.. ___ ._ - • ~ ~~ N .__ _. rAr1 E~2SF~~._--__.~ [IL~f Of NOM ZSVZ 10 5 NAME .- . _ _ S ~.._-_~-__._~__._~._. ~~ _ __ ~~. A runt SY __._ . -_'-.__._ - _ E • S. _ _~._.__ :71 Tr~A~-______._._____._~ . Ti[fiTG9CDTJSGii ; I•. ANFNY A1 f T O , . °. r,;. b•: A S 4'+[AIHaT III tJLL[IDN ~ r •KTn ~ -. I G W 2D.A °,cr e n. n Nn • Jul r o NN[ DLD ° ND wsiuuD ° [a° utc[rD P m ust 2TOTAUr[JECTrn ° p L uanY .I art c [ J two D a IAL ~ ~ DI. ° [ rci °fuilP". Inr NUncr[a ~ s °O~ii ' ~ f . ~ / A rAlwnr ~i c°n [ • ~} ~ ~~~ I$~ ~-~ t „~r`. ° 9 { ~, n. T 1 s S I - ~ G ..b (4 451' r ~ ~ ~ '" ~L~JR ~ ~ " ~ Ik7 4~^a ~r~r aae~ :,~Pf,~y,. I t, ~ 'r '~,e; ~ 'j ~ l ~iti~ ~ rN, Y~ ~ r r ~ ~"r r I:;~a I I . . r~ 1 .~~ r i A.~ ~~ r ~A, t ~' t l~ ~ ~ l i l l ~~~~ ~ Y _ t _ ± I~ /~ I ~ - ' I I , , ~ - ~ ~ ~ ,' h 7L a~~ ~~ ~~ ~, ~~ - ,~ IMm4 VEHICLE DAMAGE INSTRUCTIONS 1. OF EACH NO%, CIRCLE THE NUM~OF EACII DAM1IAGED ANEA. II-E-KA-MPL~E - 2. SHADE AREA OF SFV EHEST MPACT. I ....: IE)f ~Y~CC : / 3. pRAWARf10W15110SHOWPHINCPgLOIFIECTIDNOFrOHCE. L -- DAh1AGED VEIIICLE N0.1 1 _ Iwr TINS:rACL FOn aKrlnl xc pAMAGE TO InnILDls MplOncvclES, ctC.l DAMAGED VEHICLE N0.2 _f .L, u. p-., ~.,,,,1. I _ ~e.,r„ow. ,.~ v fn.a~,N swcnrrvo LLE I U Fu C L NtAGE < MACE Na DA N ^Ilrv o. ogMACr oTnel ve LE ]FQ DSAXLING OALtAGE ] CI UTNUIMV.D FUNCT ONnI DAMAGE < ^ NO DAMAGE n E x err Da DnM ce E n] 1 ~UISABLINL G ES-~~ OrrIEn M.V. DAMAGE ] L iUNC MADE A L,J N r.IAGE TI 004 1UYIED tlY f- M GE ~ rpWEn BY k.i UnnIAG[ U MADE (OWED eV t0 S - 10 Sr ~1. DIAGRAM OF COLLISION ~ DRAW AflROW SHOWING I Infer .ones NORTH IN CIRCL ~ - . ; O . - f .. IIit PAlcN COw srNUCnnN AnkAt ElCr ___ _• .. - -' .: OxneLF raver On I - - '^' ~^. --. I I ). 3NVN V NI CLC P[OL.rR AN nn 1 I 3AlI rA UE [Rros11 Ov M i . DrNw.BDN,nLT VkN «LDn - -..I ' ' - '- . : : __ : ~ ~ ' I ~ ~ . _. , - .~ ~ :,._( r r i _.._.I I ANB,FTLR KOLI f„P.. ~ .---r -r - - r....,-.C ,-r . I I ~ ' .DESCRIPTION OF COLLISION' ~ IINOICATE wNAT VROXABLY HAVpENED DEfORF. DURING AND AFTER THE CRASH, INCLUDE INFOnMAT10N NDTON DIAGRAM, E.O. DRIVER I DISABILITY, REDUCED VISIBILITY, PEOfSTRIAx CLOTIIIxG COEOR;CDNSTNUCTIDN OR REPAIR WORK, ETC.1 s F r~ - `~ ~. - '' 1/ : I ) .. ~ ' \ r~ L :_- I l ~. ... ~ 1, 1 ~ -. l y t ja (t.~I~.:..r1 1~~ e ~ I ~~~-r it -: ~ ~~:] ~~-%J i , C7r _. ~- r I ~ tI\y _ -- r -P _ --- - _ _~T: .. __ ._.. _._ ._ EN. ~ ~ N[AOEp TIONB Ofl POSOT DIRSION O STREET OR IRO wAY NAME OR NO ~ ~ OIU]E OIRECIIOx U3t E snrk LEGALLY AS VEH mxy. F 4 ~ ' 40] I~~ UNY ~ JC AR l Vn ~ eOYfAGAST- D !O.] NOFn INFLUENCO -1 ~ ~~YLCONOL n EN NO.] I rOLLOWINO t.00 C ~ T' 9 Y ] I FT ] I l R NING ... _.-.._... IN LUf NCE O F ] I R ..- 4 354 ._ c[NTER R ' ,]^^ S O .....:...U_-_-.._ - _ ] ` [NOwINO ._.._.-. .. .._._-.. ^ `~-0 U09 I-i]I I C(EUINU Sinik'D ..LJ.9PE FU LIMIT _... _ „ L E - ~"~'' ILAGTO-- a I SIGN l -... -. , r._I IK' ICE . K r ~rpp _ _ I ~' FRCEf DING IIFAS SA [ ..._, E 4 OIII[R ISP[CIIYI 31 UTHFR DVkL IYE 1,.-_~_]M [UTGE N PnOPfN ~ I i 5 EG cN USIIFGAI n9T0 • _ ZT TCONDITIONS RAFFIr CONTRO 6 LE PATVPE OF ROAD v P«o 1] VEHICLE C O N D I TI ON IcHlu Onkl 1 0.] f ICLE I T IGNECK O4E ONM E 'f { ~ I~ p pp vE L h ' MONALS I ~- Ox! wAY NO S i7 iiNY i7 ~iiNYhi~5ffn1 • 9 j~ LIGNI U N - ) SIfM 4 1 t y!' VO WAV -; ! E ~ III UEI FC IIVt 1 LS. ]' nl 1 DI K .. AIGI ii UN FFt ilLr iM,~u O ~ i R 3 I II NO uN UL - R OU Mp i Aktlr R rmFWA. L nl f IS ) Cl t _ `I ~ueoi NILI ' f K j 1 n mIK r'11o,rt . ilnu I onnnl]fG IYI HcNAL r Or Mull m°i~:A N I.,IN,, ... 1 ~~-'PC-1i1- ] Blvmin D ) uxn n111 ' ..LIr,.., D Ur. n:c c: IIDUnIw II IN~ NO. INCREASING DECREASING N S E W f r_.. _.-.. .-~-. ,I r T ., i i ~ ~ .I ... ._.. V. ..__..r..1.... ,..J...., ... __. .-1.. a. __ . f..,~ r.. 1 1 - I I.,, 1 _., ._ on I .ALONG le¢rcusr wc: I s FwA p ~ LKwn ]I~~ uufnEi+El ci osSwLKa fn Olc~clfOONA .~. viEAK ONR EK - .... CONTRIBUTIN uEC.iu N~olSii I I~ NO YFS NO FS GNATFD CYCLE flnUtE I O ~" T11ER URI V FIt ~ ONO }IYIV FCXI3CLF ACTIONS ~„ L'pOING onP+rox(~P ilf I O ] EGf ROfU VI I I S ] -l - I SR GNTINNEAD T n I] , ,- GN . S ___ l A PARENTLY _ UPA591NG ~ P MAKING ~ ^ 'JE_ASLF[V_`-,_,_-__ SI ! IOCgTIONV~. D _ 1] NIGNT TURN ~. If ~I~ MAK14G P IURN I ~ CR TINE } F ECT VE [O I ,rM1_' /fL ~/ Sri VI ra ' MA ~''~6 N6 V i RN. !al 3 o I1 9P[CIFYI I p - wwo _ ~ IR r iO VEOL -. ON' SORRIET -; STOPPFn FOII _ T IIC -;a ~ sro rte Ar sIGNAL V1 M1ICLF CIIkCK ONEI O 6TOP SIGN ~~ O] p 9rDPPtI11N NO UYAY IxD ILIIY IMPA RtR...__ . .. I] I n „). TNAi/IC LANE 1 ST R IIIOM1I ' N IM 1 U50 r 1 f0 OSIT10Y I] N GN61kNTlNINI .... -UNIF_. t A C IN fNUnLInING INryvfR~- CIIEM, TL51'- I I, I. pA[KING rrsr mvrN rtsrnnDSfM I rrsrnfsuus 2 I .l I_. ~ F -rl -.. I IN fan,NnNn wIR.1.L. N wuL L R I a, 1 ]-~ ~'~ i~i ~iIH t7'dl~ifl].YJr'(t ~ ~JN ,•?Iw n ~~+T..~NWS kNSI ,o-l tia-.~•~ lRR•n•c ~kT c( fnn.~ M wrxnl Y ~y e ~q Ut, p'' a r~ yF,1~ wv~~` !,rte ~~y Ilp~~( ~,I~A !,r N~JifA,1sWL~FJ91p1~1"°'s`~IYy2~L N. Y ~~~ ~~ I f~ 99 ~ l` a 1 1~ ~ '+X n, ~ t , `' t } ~• `a 1 ~k I. ~. ;- Ij~,,,~v ( '~ _ Ifl t 11 1 tl 1 ~ 1 ,~ ; ~ ~ e ~ ( '. _.~~ ~. ~ 7.1%~ ~,~~:'' _ r ~ :TAP t ~ , '~ ~ F, ~ .r ,. a3 it pR 11 .cre1 +r516ur/~~m.+/6lumua~ ~g~~.:_~uYi"~,~.~!.~i~i.. ~_Y.^~. g/ifl~»'~x:d. F'1F 'SfIU( .. .i T ~~~~ F4 . , . k ~ ~ ~'~ ~ My i . ~. - ~~: .c• µt+ . r ~ 1 , p ' P ` A YY6 .N 'Fi ~ •~ ... ~ ~ .. _ .. .. ... _ WSP.1391HEV. 5/I6) .LU ~ r~~:,JJ .. STATI= OF WASI-IIiVGTOPd ,'ADE t DF ~ Na. .6pA PUUCE COMPLAINT rvVMBEP •~.,..:'` UNIFORM POLICE TRAFFIC COLLISION REPORT 4 ~~ ,,. ;~ ' T.,.. T _ Yy1 ~ T ~,,kkYY JtTi4. ' . ~ ' E ~ ~ Y ` ... A ,. D DATE OF COLUSION DAY OF COLUS ON TIME 1 •O COUNTY NO. CITY NO. FM'NA T . . D 1. T SIIN I NOJ ~ tet5 ~ Y/EU JN 5 fill d tiA IU`:E aA00 NOURI ~Z~ - A NI ). ~ // ^U BAN (O ~ E _ AA~A~ 1L~ ry COVN , . FVRAL ADM G PR - y\ ~~~p~ ,,. l ^STATEflOUTE 1/AICOUNIY IJOAD ^CITY biPEEi Jr'--~- E O ~ Ld. EFIK nO U TE On STREET COUE SECTION 't't~-(~UEi/~+ ^OTHER ISPECIFYI ^~+ N / J ~ /_570 C 1 N I II,A1 ~ALI/T~Y O~H~T,O~IrYN L MILES N ^ ^ ^. ^OF ... ~I-~-.ti/Ll'V L.GLJ'\- ~ LL PHEfI%EO. MILEPOST ,UU•~83. ~~' NO.OFi O RMG WAY I R5 WITM. bf EETOR OAO LL HMI DIAGRAM DATA I l~~ ~ / © ~ O NCN INTERSE N - J ~~'~' ACC DENT INI R NO I iE ~RD LLS rEPSECTINO Siff E ON NOaD ORREF. N LEAGE . EflENCECROSS STPEETOR ROAD RETWEEx _......_ ......_ _.... biREEi AND .... _...._ _...... _.._ . STPEET CODE ' ' ~ 300 DIbfANCE ANDOwECHON FROIA DEFERENCE OP CROSb dTRE T ~~ ~ rvlur[i bPECIAL COOING USE ~ ~.. ^MIlES N ~b7 ~E7 W . ~,I VEHICLE~VEHICLE VEIIICLE~D CYCLE OTHERIY/PHEr HIiSRUN COLLISIONINVOLVED: ~ ^ ^ ^ SEVERITY NO KILLED ^dTOLENVENICLE V O U ' L IN . OF FHICL.ES ^VEHIC E~PEOESiR1AN ^NON SION COL ^HAZAHDOUSIAATERIAL PROPERTY DAMAGE ONLY ~:~.OBJECTSTRUCKINAME OFO&IECTSIRUCNANOOWNEP9 NAMEI .....:... .. LOCATION OF OBIECr diRUCN „~,,, _, _, " EST. HAMAGE .; . ,, S E VJ ^ROAOwAY FEET ^ ^ ^ ^ PD EWE : 5 Fl OPNEfl3 NAME~IASt. ~„. ,, :-., FIRbT ~~~; MIDDLE ~S ~-C~l ~.IJ.tJ! S "f' _ R ORNERS NAME~IAbT RPbiM DOLE nF d~CrCL15t OH PEDEdIRIAN LHECAJ [7~ ~-I-t ~ E L'Y' l ~ L ,',v. SFREET ADDRESS :... .: .. .. ~ (o4-g S. ZooTFI ST, ~ STnEEi ^(~UHE55 ,:, .. :. .,.~... _ _,~, ._I Kr ~ ~C~33 E R CITY. ,:,ZIP CCOE PHONE NO bTATE ~~rr~.E, ~A - R g l ~$ E R CIFV _, 9iAFE :~ -... 21P.CODE ..~: PH011E rJ0. CEl-LrvtA Cccn~t •cvA. 32S N O OnNER3 LICE ENOG. .. :.. .. .~' ~ GTATE. .SEA DALE O uwm fA N OHIVENb LICENSE N O. ,.,: SiA TE LE% DATE OF BIRTH..,. " - ' ~ I ~~' A ~,,.,, Gg- ~ J~J O• / RU/O A A J~' ~ M DAY YI VFAS OCCUPATION : FIrIM E... .... ..... .. ....: P ONENO. '[ ORI Hb OCCUPAI ON FINM NAME ... ~ :; ,,... ,....:.P ENO. ~Dacc Cj.o ~ttC? o ~S ~ L,~ . . CODES >IDI Ley _ __ IJI npss. _- __ Ir SEAT dELT_..L_.I EJECTION.- _~ NATUPEO INJUMV b NJIIR ES f ~_ ' F ENE VEH. YEAR DY~ M EIDOWE{HEV.1 TO MODELIOANT~NOVAI .. ST IZ.OP~CONV.1 ~ iEOM SCEN VE YEAH E HY MANE G V I ' AtOOELI AHT NOVAI bTY p R SONV) ~ - ( Z CtFLY - ~ ~~ ~ ~ ~P . ~ ~~ . , ., , _ v ~ . ~ 55 _ , W E O.:.., VEy ~ C OR .., TIC: PLACE R STRFE TRAILER. PLATE Np. STATE E VEN.CULOR UC. RATE NO. STATE. i11AILEq PLATE NO. ESTATE , H- L ( G I~J~.LC- GTSZ Z A-. H YI'1F~f~. TzL~Z `Gt) .. .. ..,. C YEHI LE 10 NRFICA ION NUMBER ..., . :,. ,.. D-W' trT q C VEHICLE IDENTIfICAiI N NUMB R ODOMET'R ., :. ~..., ,,~ I„ e z~_15~-5 i(g73Z ~t-~210 e ID35N~z4~'S3tf 82311 -O REdSTF.REO YMEfl-IAbT ... ..-. ilflbT ~ .' .. .. . MIDDLE ZS `~ E ~ ~ N ' PFGISTERED OWNER-LASE. FINSr ~+ ~ ~ MIDDLE . tiY ~ e p. ..]YirLT'E ~ ADOHE990F 0WNfl ... _.. .: ... .~. .... .... .,... .... `~ ADDRESS UF.OWNER .'.,. .. ... .. ...:.. ....... :.. .. ..:..~.,..... ~.:~.:. .1„ S~N1E 2 , NAME AROADp1ES9 WSUR CO OA AGENT. ...~.. .,.,, v... ,.. ,.. , NAME ANO ADDHF.b'fINSURANLE CO.ORAGENi .. ... , ,,, ,~ , , ,; y[ ~t~~' 1 3UlCC`ILC/~L , , , ,,,, ,, L~S`I'~'~ CNAHG .... ... _....'.. ... ~ - ItptIOH NO ~~ ENFORCEMENT CnANOE ~~N ' ACTION ~' NAME, ADDRESS & INJURIES OF PERSONS INVOLVED cones L _ _ o ~ 5' _ SEK ACE biprUb 1 r EA_ r'~.T 3[~T GJECi. L. ~LL AA~~~ F~ n~ 1~ xAME- ~RR~ f ~~~ c . _ wt 6 2 2 3 1 Z. •WIJFes .S,bt<lF'~'Z P _ x runeP (~ -t±t~nY~ornou -- rD ~ A IJAV L N T _ DMESS -- n S ~ ________ !tlnt go€ - Ii7i;ILvt Drn~'-~ - --- m.u„ srf Ne nr ro W NAME..- ~~~._..._~__ __ T _ _ ~__~_~__..~_ ADDRESS r ~_~._~.__ __ ~_. ~. 7iluNi~"~ lYi.iSvF IT'i'i7~u"--"- N ~rJ rII. H to $ MF _._______~.. _.~._..__._____-____..___~._ $ • pN~tS E -iuuni,YiT"-~--'------__.._..__...___.~._.__..__.. _._ Ru3~'GrrC'ci _._.~_.__~.. -'_ _-_ -'-_TO __ __ _ ._ I e.n ~ lus ~rl Stu Paar.n ,, r:a •l utu lell:nanwl C O ~r/DC iil:a ( n I .r. Nnlm T v uul Nori HrrrD I. 1 r I 1 ~ i w! i i ri it i E L l ' 'E l I .r I r omc N r . ' 1 I .n rv L i innr i ~r Ll cD QOI AM O.IIIIJ,.AIA;, ir(. '.,.IJL 4JIIIIY /.- :J Allll . J~j~~ 1 nNl M1 ~M rr r .I S,r I ,L tl NUNUNFVI) Ua „ . u - v.~L Al lllll(AIUHL I,JI CII.O S.a i s ~ ~I ' rV' ,{r lf~ : ~y 3R ~ nti': . y„ t ~ ,~. ~ ' mom, i ,_ ..,f..~,;. ' 1 I,l' ~2L -'~ 1 f I .. ~' / fa .v _; . 1 Y r t.fl , +~' o rf' f{ y I ~ ~~~ ~ ~~ , ~ Ir s R ~~ ' ` 7* , , d. , . K ~/~ WET -i V ~:~~_ ] ININ6 -_{~.~RA-_____ ] ORINfLUENCCOi ~OnU05 E OvERCENTER INF I IIArI APPAnknTLV i ~ I A9lE P I~1~j N Q I It- 1 SNOW .-~•-~ ~.- 1 SNOW NO ~C~_-._~_ __~_ ~~] f%CfEOIN6 SfATEO ' ' r~. SIEEDLIMIL ~ , r ICING fO S GNAL~~ _. . f 7~I~ IpOASIDNrANKINO ~ 1~OI _~_y ~ I n T TURn I 11I'-~ [-AaL~ LF~E IUNN I I CE -r--•I ~ __.. E P06 _.:..` C. E C[FD G EA3. iE 6! t~ ~1 .L3 L V ]~ rNOFEn qN ~I `IO. t I--' OPFNATINa. I~~I ~' D CTIV6 E0Ulr i ('j NAKIHO C:J ~C'~ .-` Ifl I ~ ~~ f •~ [ 1 I - , . . I~ 1 , OY[ rc E NT RfW j~l I T V_- __ _.. .~I I ~OaRE0AX0 ~-J ~. flai S Gp C IDN2 . ( E _ ~ I~ .14TU RN rtE~ 6LOWINO 1 OTNfR INECIf YI OUIFR ISVFCIPYI ~ I' ~E I. 1 SO°FN 1 . , l ~-1 DIfN fOiONAI TOr 1 _1 I~IS ) NO VFOIS T C VI ~ ^ ] ICI 3TOPIFO ION L J N+~ C1 ONDI IONS ICNPCK ONkI RAFFIC CONTRO INO>VfN CLC L e TYPE OF flOAD vt O> 1 MFCK ONE ON MOPD VEHICLE CONDITION, ' C o [ C E ~ s_SOBRIETY ;;n~ ~ ~ ~ TNArr10 (( ff ~~II arwr[o Ar naxAL L f L J Iii f O LS ~~ r , O E AV V' OLL L' 4I q E x ( 9 E C4af NO > I.~Carr~rlrHl]TEOI E C E IC {CK ONEI VI O > a - ....I J OR flOrS ON Ems, P ~OW " ~ IYY~ D DfiNT { t _...I ETD. oN ._'C TWa;Y~--- YI° -i ~' ~' ELTIVE L n 1 oAf r _. ~ O AY _7 srAnnnam C-~10 ` ,,.. }I I DAWN -~ .. __... .. _.. _ _ ~ ]I _I 34 U . .._ r 1~'~i~ Rf V[nf flf I xaaD :.. en Kts_~_ ~ ~}r I O'EfCTlvf J I xfAO LlcIITS . - ~MrAlnt __ rl~~ I NO: ~MP ~1II 1NArnc LAnE 'r I~II ~ T J' DUSK .- A...-..I IOSHINfi .. _ •.~ I I. IOOr~11AMPOF.-.. _ - . .. ._ l . i^ J~: ~...1EAll LIO11T5. _ .. A nLO._. -~_~.. ~ I r NOO dOSNEIV UNK r-_-I MK[O Of ON `.,I>r_ ] TIIAf IIC11ENTlRINO DANK. E. ~_ 1. GNi301v ELi ~ i5' I AMrtM NO ~ ALLY I J[L~~. ..... I TIIE3 IIN 1_JE __x.011 SMDDIx .. _ . . _ ~____~ "~ IIAII NO! \ I BFfN OII NKINO f"' f_~~II6L _) B:LCKINO 0. DARK-6ruf[r uclTSOrr f ~ NH Menu ... '",f wpwar-un rwlx LANrs j -I r,xn...+ov,un .w nnAx I i muvul CHEM. TEST 1 ND > i 1 l E IIArIK-nD aneLr uenrf ] rnr¢r]° AG I arMlunl . ~....I I nar elvEN . oTN m uric lrp k f- ` > ~ pw10[U ~ '~~I l./I NO DEFECTS ~ I 1 TIST IIIiua[n r IN ISr(Cl~vl ~ > uNnrvlDlD _ :-OTNEN Iirlf. irl 9:. TEST RESULTf Z ~ Vvl [lIONIINUU / n0vk N K ,r~/T. .( ~ /yJ Y! r NI/ T 1 xAUGl xO/. L'~ G')~~ v011CI UrSPAtCNCO LI IIN lU 10 rLOW I ~7.. ~1.' ]EIw n ~J ~'v ,, iili] ~~p rvr/// ini iu:iorD s IN r,A.. yr A ,./ L DLI ;Ir 1.~ ArP1 x ---y~~l ~~,~' ~ 1~~1 ~~~•~ /'/ .~/71 +'JSyr ~~ VEHICLE DAMAGE I. INEACMBO%,CIRCLETIIErIUMHENOFEACIIOAMAGEOAHEA. E%AMPLE _ }. fIIADE AREA OF SEVEREST IIAPq(,IT. .'~QI~ F) L IN3TRUCTIDIV3; ] ~ l . RAWA ~~ IRO5Y131TOfNOWPRINCIPAL~IRECTIONOFFORLE. '~i~ r DAMAGED VEHICLE NO.1 wsf TlNSSrwcE FOgsKETCx NC 4rMACETO TRAILEns.MOrpNCVCLES,ETC.I DAh1AGED VEHICLE ND.2 N.aI 1}. n.wl .Vf FI. s TunIL " f z n~ , ~(QQs E uw IT run e ECVfn1TY OF DAMAGE. VEHICLE NO I ?~OISASLIrvG DAMAGE ] Q OTHERMV pAMAGE uNCTIOIIALOA•AAGE ^N SEVENITY OF DAMAGE IUTNEN VEN C.LEI SEVfNITY OF DAMAGE. VEHICLE NOI I ^OISAOLING DAMAGE iHER AL V. DAMAGE ~C.I DISatlLING DAMAGE : ~~pfNENM V.OAM G }^FUN<T ONAL DAMAGE xOOASIAGE ^FUN ONA OA CTI L MwGE xO DA.VAOE TOWED tlY kST. DaMaGE ~`'t• - 1 '! T . O WS EST. DaFAAGE ~lill l~L, CC: ESf.D E TOWED eY ] ~ TO .'-L( '. - TO ~. .. _ . ~ f TO S•~~f DIAGRAM OF COLLISION r_~ ~rrJ I ~ ' ~ ~ ~ I I ~ I ~ i 'DRAW ARROW SHOWING '~ +...,,,_~ f ~- „ I - I '.~' NORTH IN CIRCLE ~_ ' I ^__ i i,; r ', lf,~- r - ~-.- ,~, i ~ IV'~~~~I n I - ~ Iti L <~ +' , ~ I i ~j -- _ - I . ~ * I ,eL[.oN a >, oF.TI,IA IN.AK[ i ..I ..~ I t i "f I i I - I _I ~• `~~ I T I--1 I AxD. T[R LD I r!/ I I I ~ I I -~T- . I - I I -r- t I I 1 7 I i o tE. I~ au 'r~ l~ ~ _}~_i _ i ~ I~ i i f I DESCRIPTION OF - COLU SION . ~ I CA EW AT BL M E E O E D RN OA TE THE LRASH.INCL D MATION NOi ON DIAGfMM,CObRIVER saeluTV. REO CE ISIBILITY, PEDESTRIAN CLO NING COLOR;CONSTRUCTION OR IIEPAIN WOR K, ETC.I \/ ~ p p -- ~!~+'1..LLLE. ~_~~.>-,/..L~.IDL~~:<R~~-OT'-~-L7~='L.._.1iyr.At:`LAJ_[. •r~->=._iL~1t~:J ! 7Y~ te -._ r - C~ F~~ S ~sc_.~~r cy ~ - _ - _ _. ~. .r ~ r LL:~ c cJ~k ~.. ~ti ~t tiui.LJ-1...:tLS ~ir~l~[Zc?X1~L".!i-I:c(...' --~'~O(!r(,cA1 ( _r.;-~-..~.a-i t c.~ r;-~.r r <~ v~ ~ ,e i ~~ -mss tr.r n~,~ ~ ! c l~ . ~ ,>,~ ~~- C_:;~~.! -- r----- --- -- ~d l~ J ~ ._ ~~_.._- : -- - .. ^•- POSITIO ' xEADED O N BEFORE COLLISION MI FPOSTD R. S - ;' - ON STNEE O GHWAY NAME OR xO. ` o of LArvfs NONE DIRECTION SPEED . I ~ S jAlf vENICLV .EGALL IF fo WAS f . INCREA NG OECREAS NG ~ ` • TAFH _~ AN E VE9 n0 OGCU F YF NO _' _l~xf j; ~ -~ - I 7 ] (.I ~I'--~ t2_ 4~__ Ll u l L, PFD ~nl -;I LDND -... DR - . I ~ ~ / -.w{NUY a~ ~,a /1~ 3 ~ _ LF o. ~ ~- ~ ~u ~{ ~. *~ I~ ~ o. ,ll NE 'N~`s< _ -- I PFII/BICYCLIST wAS S II DEWALK ' - EAp551Ra__ ARSKSµDA Er q I t }C I OULOER ~ I O LK 1~ O Sw r,..... iRp __TD KE OES ON C ) ALK I I C C E I , l .. L U E OT E ROADSURFACE .'.'.WEATHER ._ CONTRI UTINC CIR gUMSTANLES-; D wvt lCL ADnoga ICNfCK ONEI IT.NECKO F1. ILNE KO EO OREr ~- ) ~~~ '. NO.]yCNKLf KbnN ~orPn OnIVOES D ER ~ p E IIIVER T ': r!• 5 ~ GOInO I,~ O } '< w r,T • ~ r F'.1 1( -11 II OqY --f_l .f__ r {CLEAR CLOUDY L~ _~yiOYE11CASL ] DFR INi LUFNGE OF I N I TOLLO I G I, I (y~~ ~LLD]NL L,OI ToDCLOSEAT_ u I ETRAI NT ANfAp ~O ] DISKED RDE6 A ` 1~-1I~,'(--~ ~ r~ ^NfigTAKIN6 J...~l~_F4N[~6 IJ}~ DrAS]IN6 f 5 ~"•1}' ~~ I . .,..-......__.. ............,....,.,....,r.,.,,....,,,.,~ ./i..,r,a.wa~rxNl.Il,rvpxp4r Dl1PlILA IC L'01•Y lI1CAL LAW[NIONCILIENT AO{NCY'ECOI'Y~~IIUPLICATE CI]PY. INVf STIGATOII'S CpPY ~. \I -.. ,~ -1 i ,.~ III L.. 4 C'. I Z ~ I ,. .,, rTr i 9 ~ "'aE MOTOR VEHICLE COLLISION REPORT D NO '~~ ~ ~ ~'N ! ' ~[ ATE OFCOLU90N WYOF CAlU90N TIME OF CgLU3105 AM DA. i[M~ 6ux ApxI NES w[D rNUp w p? MNVIE AUNTY 0 CITY NO ~~ . PM CDLNTY GTY, TOWN MlE3 O© CITY. TOWN ~ ADM~CLS PREFd SIpfETneDE CigN pw fVE NAMEOF STREET, ROMORNGNWAY WTERSECIWG WITH STREET Ofl ROAD PgEFI% EO. LEPOST 2 NON INTERSECT LOCw NOFC LU510 /'~! BETWEEN . / STREET ANO (.l~C>S T / T E T RAMP DAGRAM DATA , [^ ~ ~ E PTKDr 1 1 N Il®~(~E~AA ~ c.M,Einsl°on[oe~IV.mciM"as.`n:'" ' ©L':J 0/ ~ wxl xE~silrvl / f FEI y N q _ / INTEP `~N SRS W u ° Ao r CDMl6gx x C / ^ / p pm yy WLVEp LJ VEwCU VENCIE OvE^ [ lwWlEl / / ~ / - SP DE E OBJECT S1RlICK ^IxMN DFORIECiSpa~" ^DY `CJ MEA OF 08lECi5NM1EANOADORES3 NOCAT I ROAD gN O© ^ WAY OnEPAN LWEn FEET ° OflIKRS LAST NAME °FIRST NAME MDIXE uoxE IKAN ~C'•^5 DWVEfl3lA3J NAME ° ~FWSi fIAR1E MIDDLE R ' ~ -I- 51 EET ADDRESS ~6~N'WD ~ . .9mc /~/ac/a ROUTENO.ANDBOX NO. w0 STREET ADDRE59 ROUTE NO.ANDBOXNO .'~ Q 1 4 , .~ ~ '~~ A ~ GTY., STATE... LP CODE dUVEPSOCCUPwTgN pEP x Pn S ~ - , _ ~ TAE p rMp. Y STATE TIP CODE DRIVERS OCCUPATgN . .~ DflNERSLICENSE NUMBER STATE SE% DATE OF dRTN AOE I o ~ i . 3 STc%9c~17' VEHICLE YR M OWNERS LICENSE NUMBER STATE SE% ~ GATE OF dRgI AGE . AKE ICNEV~pO0GE1 ODEL IN VMOMTI BOGY STYLEI2 DW.1 T~ ~ T Co~ocL/~ ~ n ~ VEHICLE YR. MAKE ICNEV: OOOGEI MODEL OVwDMT) BODY STYLE I2 DR.1 , L y7/ <<, , ~ / ICENSE PUTE ISTAiE TRNLERPUTE NO. STATE VEHICLE IDEMIFICATM)N NO IIB6B MODElSE NEWER( ODOMETER (MILEAGE) UCENSC TE NO. STATE TRNLER TE NO. STATE /42G~S~S VEHICLE IDENTIFlCATX)NNO. 11868 MOOELSA NEWEflI DOI/.ETEP (MILEAGE) REGISIEBE .yNER, ~LASTFIPST~MIOPLE NAME( OrUVER3lICEN5E N0. _ 3 ~-ei3G~~rL/J/c ( C ' REGISTE _ R DOVMER IIAST~Flfl3 MIDDLE NAME) DRIKg3 LICENSE NO. ~ ~ ~ ~+~ riz-ctv- ~ e.. ~,/ Ovn1ER5 ADCWESS ISTflf.ET, CITY ANO STATE) OwlEO dgiN OWNERS wDOflE55 ISTPEET CRY Iwp3TATE) MTE OF 30o z 5r,. 20 A,°i~ ~~!- , dRgI a D r PMTSOF VEMM:IE DAMAGED MATEB °R p ~ ~ cF./ U F2C.U7' AL - ' s PAgIS OF KNIClE DM1AGED i v:I`n°vEHCQ9tcu 3 ~P". LIABILITY INSURANCEINFORMATION-VEHICLE NO. 1- wISTNERE AUtoAIOdLE Uweluir NSURµcE COVEflAGEW EFFECT FORTHIS ACLIOENTWYOURCM ^YES ^NO NAME MDw00RE550i UA&UTY INSUPANGE POUC~MyLDFA ~ NAMEOF UwdUTY WSUflANCE COMPANY roof NAME µDADdiE330FL1ABIL/ry WSDgµCE AGSM ~ iM v LIABILITY PDUCY NUMBER 1ST NJURY ' ~ - n,~~ !T. AGE 2N0 NJURV 1 SERE rOp A'JN NApuF NNAE CC/1/A//(~ G l/..[-i/II~.L•//~11G ~~ NAME ADE :.~~D !~cl3,C/~ L:YN.tL ~.~ r,~Tee r ---- ~5 ' ` ~ ' __-._ [ ADORE34 -~J ~ -T~j 1 JC ~Y~/[7 /.JG!Il~~!'/~ (JIL~~ SE% ADDRE55?II~ /IIA SE _ 9 fC!/e,.Z':e LCC ~ _.O. [ !'iAirs/n r~:D .~/ lff.ff/1/YQ._. O 01P I / J' Ddb ~ " . ~ /xAME E , 5 ~ l3 J [ „p,IbrrB..~«lop, ®1 ~~ . -. ~• W6TATUS Oi WJUgEO MMNTIRSi THA PLIES STATUS OiINJUREO MMKFgBi dIE THAT APP 5 p WKH%:lE Ns~rv ND^dSABI%q POS^AB[f [%SN w prl~ PoSYeL[ XILLEO ^MW[ NKHICIE ry T ~ p ^ 5[v[aE N 1 D nE Elc ~C[AAPU%q ~ PoE^ NO I KLLED I6EYLRE IMmd1 IIO ~f N` S~n" 1 I YI 7a 5^ rV T ^ rlll O'. " 7^ cl 6® 0. u n[-.. ^ 5 ^ 6$I S.gWNORTn BY MNOW NGRCLE • 1 ~ I I DESLR DE BELOW WHAT HAPPENED:IPLFER TO KHICI.ES BY NUMBER( I I Nc. u~ n%.:r~f /JG~~.-c5 6lzio~E Lt Lrv[~ ¢T InMt I ~ . ._ / « ~ K [C18 LIB K~Kw.Y K.Mis°o"1 \\ ,~ I /FPP.~OjY 5 _-/D /,~ r'f ,//OTL~O Q.f! _._ ,~d,~ n " C~c/t1dy~- _~-/..t/c'1C~u_T aF c°aNjeaL.__ L p. ---0 ~a- \ I Iplpi w.Y .~iuE~l///1/G'~-__iN.lO...f3•C'lL)GC_(rU.~[P/?._ ~ - ` .:,,e-A/L_Tf/fitl..~Efflt'/E.//D._.2-~F=~- --- "~'~~'~' -~- ~- L Ft/. S laF-~/G..ffit~0__C~k1S~ 6fE~b ~t -- ;. ~ __.. -- -- --- f / / f` .. _. .... -- _._ . g .. --- -- ,~ I ~ ,..~ _ __ .___ ____ __._ _.-- ~ ~ VEHICLES POSITIONS ©EFORE COLLISION pD aL.AL nrau YE KrME INVESTaAi[D Br LI KrpCIF % ONLY pNNn VI IEnN N 3 E W ~SIREFI OR NICJIW YNAME OR NO ylEtidr ~ p VE n~ Ofit~tn ^iiipG ^igKi ..« L o a o 1Jl ~ o o w o a~ ~ I o o ^ ^Eo / ^e. ~.TI o ^ ^ ^ o ^ M.MI Nw71w.A ^ ^ ^ ^ aorq cnoavp rtg~M1 DIRECTION ro DIRECTION not STRIAN WAS L11Aq 1^dDEWAt% 7^WNKWAY ]^9gUlOFR [^<rrsYwNA StJ Cpi wiip 8^OIMEn n pAp SIWFAC[ WEATHER UGHiCONdT10N5 TRAfrILCONIROL IGMCA[MI TYPE OF ROAD p11KRNU11ClE ACiM]N! H+CUE•lYfl v w¢L NNKYI IOn G i E vErCLE rn.[c+opYUrONI ` [ br KOE NO7 AO7 T U~ ~oW ^EAa~ AfiN9 ® 1 ®EXEY 1 1 ^ DAYLIGHT ^ 1 ^ !' ^' 1 ^ ON[ WAY ®' i ^ OqM 61PNGH1 AHEAD 7 ^ 11AfpA 7 ^ DAWN ^ 7 ^ lIOP Sgl1 ~ 2 ®TWO WAY ^ 7 ^ OK R1AKIrq AND PADdrq ^ NLT 7 7 ^ dAOwM ] ^ DUS% ^ 7 ^ YIfLD SON O gfV(N• B f D MAKNO RANT TURN ^ 7 ^ 6AOw D O `~ D CT A ° ^/~ A ^ I IGniS ON G A ^ IlAdrwo R[D A O, ii[ I CNANOC ^ A ^ MA%u10 LEFT TURN IPAMP D D ^ ^ ELlT6 GiEi ^ e ^ IIASHNB AMtl[R ^ B ^I~L~[v O1FI[II ° ^I 6MGYI ° ^I I ^ B ^ MAKND U.rUNN ° ^ ^ %ri CMY l 8 ~ SIP[C l~l %:N13 ^ ° ^ M 1iKf1Al ^ G ^ LTFn U N ~ 8 ^ ROMNO f ASOH 011 A9T6ETNO DArAD[Il ^ DIH[R ^ 7 ^ OIfKfR~/LAOMµ LNIC7 I 1<w MIAACIXwE CI ^ fA'EGFY ^ T ^ GIDPP[D/OR TRA//IC ^ E ^OIHFR 9'[CVY ^ 1 ^5[PMAI[0 ^ ! ^D11~d~dON (Illu • [] 7 ^avlaD ^ B ^ moPrfDnnw.DwpY _..... _....._. _.___. ....._____._. ..- ~ ° ly ~.i`"XK _ _.._...^`. T j?,f I .dvmlD ^ to ^ inu i¢Ki olr zr~nq.,lE«•,r~L-•,...,-~.,.p1,.,N.M..p.p~.......~._...___.-_~.-__._ ._. 1'-~:;-I~ .-. n n •„~....~I ,M I• . I ~~ '5yi4u ~~ i~9 i. S F 1 t, $1 S : Sg _3 ' ,y p ~~ ~YT AfiY~`+ f ~ Ib 7 b %pp~~ y j y! ~YS "- . ~:~ P . .x [ {{~pS t ~ ~' . il ..)) t'x 1 ,li, ~` ,~ ~ y `~ ~ ' Aa, ;~ 1 r ~`,I I i ~':~ f fS ' ~l / I?.I -L T~~. 1; . C:~. . ~ .. °: a ~ ".:R 'r.' ~ _ ,b ~~ $ ~- ~~1T , ~3~y4~ ~"~:y 3 ~V^` ~ , ~(e :z. $x . 'i /IA h , ~ ~E ~' ~' [ .• ._ „y YC~Py3} ' ~~ t''~ ,: ~~ 5 ~ I er ~, ~,. ; T 1k. t~ h S xIr F ~ ~ `~ ~~ ' ~ R ~ , `, ~, ~~ >x ` ~ rt~~ , . . ~: ,1 I ~~r X64 ~~ / q ~4 A ~ ..,. DATE OF C DAY OFCOLL 150N ~ •~ RME OF COLLISION C ~" , OLLISON MD DFV ~• wY. NED wFD pWp UrE9 AM ENUF EM rI CJ ~ Mw • ( PM • U ~ -. rF"CT COUNfY G ~ w fDUiSPF nW M//ILE9F E ~. ., GTY,TOWN ,.,.. ~ nEF x AOM CIS Fc~~rE/p~~D c-cT//~ WIEPEECTWOWIlH: 91REETOR ROAD "UG GVENAMEOGSfPEET,ROAD OR H%MIwAY --.r PREfI% ''r ~ LO '~~~, ',~i {~. L•~-C.~f'4-C~N V•~-~.i- NON NICfl SECTION~LOCAigNOf COLUPON I ( / ~ ~R~ ~ ~ ~ ~ ~ RAMP ~- pAGI1AM OA ~ 1 f ~ 1 ,E 1 SiREET OETWEEtM- ~ ~ IY 9~EET AN a C / ` l i? SIREFI.n vµ~SE~wNXFA nwuDE IF ~~O - /I III~IFVOStOn XI~Yw D fEFT TS L.i~DN NON %~ND INTEA INTER CLS, ^ wR SE vq BINtETO ):, ~•nCEDCproitcSm[t ON J 7 CJ / .ER IH I pJ ^vEw C E.uc~ E ^On SPEC. CODE U9E ` ~ p~ . - ~. .crnusXw Q n oAE I GTRUCK IxwEVDRIFCI SIPUC%I A OWNER OFOBJECT9NAMEAND ADDRE59 IN ~A~T OBJECi WAY Q© ~~~ ¢O EDTpST FEET § uIIWER9 LAST NAME FFIfl9T IU.ME ~~ tiAM+elE ~1 ~, ~ l~~ ~ fe ~pE w~asD CDR DRIVERS LAST NAME F FIRGT NAME MIOOLE (~ •- a GfR ~ OpEE59 ROUTE NO. Al10 BOXNO. nAn IYq STflEE DDR SS ROU TE NO.ANDBO%N LIT STATE ~, LPC DWVFA UPATOH, -~ GTY 9iAfE ~ 2W CUDE DRIVERSOCCIIPATgn : INNERS SE NU R STAT 5E% OATE OFBIRTH AGE DRVERS LICEN9E NUMBER ~ iATE ~E% OAIEOF&R M ~. AOE ~~ -N ~. ,,: M f Aq z Y 2 ~ ~^ ~,y-, l O S~/g Y E 7 v HIGLE YR. MAMEICHEV,-0Ol)GEI MOOELINOVA-0ARO ..:.. BODYSMEI2 DRI VEHCLE YR. NAME ICHEV.•p0OGE1 M ODELINOVADAHO - BODY STYIE(2 pl.l ':. _ LIC NBE PUTEtq. bTATE ;::.,~. TflWLER VtATE NO. ~- TATE -tf~~s7~ ~ UCEN9EFLATENO. STATE :.~ ..TRAILER PLAfE NO ~ ~ L~Jc ..,' ;,.9iATE, ,,;.;~ ____ VEHICLEIOENT6gATpH NQ -~. IIBBBMODEISA EWER). -. O170M EA (M%EAGEI yEHgtE IDENTIFICATN)NNO. _,. (1888 MOOEL9A NEWEPI METER IMAEAGE - O!o ` ~ d R G TE 00 (LAST~FWST~M%)OLENAMEI ..:, - :.D IVERS LIC ENO REG%;LERED ONNEP IIAST~FIP9T~MIDDLE NAME? ,-,. DRIVER9 UCENSENO. ,,. ~ OF O'wHEflSADDfiE93 _, ,: ., I9TREET,CITYAND9TAIE) : ,GATE OFB RTH MO v vEAX OWNEP9 AODRE93. ISTflEET.CITY',AND STATE) F a n~ :.;MTEOF DflTN., MO EM PART90FVENCLc DM1AGED ~ :.. 000Si ^H' U - § VE«wtE A p PMTSOFVENgLE DAMAGED f ,...,, .. ~ Esn DfAST L Oo (~ +- ..N _ .. ~ S _ i „ W0.RTIIEREAUTOMOBILE LIABILITY AN9UPANLE ^YES ^NO LIAd TTY INSURANCEINFORMATIONNEHICLE NO. 1- wvERAGE IN EFFECT FOflrw9 ACCmENr aN YOUflcAfl NAMEAND ADOPE590FU.ABIUTYWSURANCE IgUC~YNOLDER .. .-:.. sIME Td COma, .. NAMEOFUA&IATY INSURANCEfAMPN1Y...:.::, ,.-.. . Rucker Brothers Trucki"n Inc. 1820 Stewart St. ''.Dash 9821! United Pacific Ins. Co. NAME NIDADOHE390FUABrIfIY W9URNIGE AGENT PTY ~ SMIE iw LIABILITY POLICY NUMBER. _. ,~c Pfau & Carr Ins Brokers - Box 9203 -Tacoma, Wa 98409 ~ LP 6506525 EST WJUHY - ,,, - ..,-.., .~ • NAME _ __ ADORES AGE E% WN ED 2ND INJUflY: '. IUSE EREPoRifOn AMXnOn4IWUM L u- - AGE:' > NAME ADDRESS _ _ _ _ 8 ,E, X- ~ L~ ^ Enx A~LOCIDM COD 0%4 ® ^ ~ ®^ g A . ;., MAR%FWST GVE MATAPPLIES„ 91AIUSDF WUIWED QPweR DsAIXV.a wnavar rosvele QPA9ufNflR ~VEHgLE gLLED ISE~vErnFl M~MM~1~ IIOi ~wPIAwT , MMMFlRST ONE THATAPRlE9. STATUS OF WJURED ;... „ Irw VEN~gLE w•uNVO NaE nsAn+q Po, ^ ID[R ~ gLIED 13[vfn0 I'~OM I i ~ P ^PEDfslww GC ^rn•ua wnne.,N ^ 5^ 6^ 7^ N Cl O ~ swAN ,• ^ 5^ 8^ ~^ SHOW NORTH BI ARROW WGRCLE \ 1\ ~w~,9„. K: " ~ \ I ~~ t~a~ ,~„it,~Iw~~„ A . DESCRIBE BELOW WHAT HAPPENED:y~EFER TO VEHgLE9BY NUMBERI „~ (v ro~~o.w~n~ .. 1'i (eT_.~A2'~~ ~ 0.J ~.z s:r_•Qp ~~..~= ~--~P ~+~-r ao c!s _ ~L~~ Q~ \ i ~ , _t _ ~ N P 1, i_E S T4R7.' d o 51.1c(E.- T TpLrR 1~ ~~' S~~,~~(I.~~~C3~.~a~oJ- ti ~T_.~ ofd -- ----. - ---- -._ - -._ - j ~ I -'~ T ~ d___,L F-f_T.T. FZIV. -~l_STr~-~c-c %•-'~ f %` `~ .. ~Z- LrI/L1t~i~-~Fl~'~am~DEP.wCJ,(Et ._ _ -. /~ J 1' ~ Q (Ll-, L f1" _~ ~ o N~ oo iG v~ ~ ~=RoV17. r R , $ i - -_~ I W r ~ / F - _ __ --- ----------- 1 VEHICLES POSITIONS BEFO vCIIICLE N 8 E W RE COLIJSION ON 9tnEEI011 WDHWAY HAMS NAq wrr LANEn WOME DXNCIXYE viMCT IIDUIY FIMXYq vnrclL Ifn.tly nAA+[D R.eow•s YEN:L[DCGV50 i INVESTgATED BY A11F NI c ^ ^ ®^ ` ~ ~ ^ ~ ^ ^ ~ ^ ^ ia si ^ rDro~ige .~n:r p~' ~I ^ ^ 10 ^ 1 ro ^ ^ ^ ^ ^ ^ ^ MNIA.f DrarmAX ^ ^ ^ ^ M.Qq moM DIRECTION ro DIRECTION P[nE51RIM1 WA§USING L^PMWAI% 2^1VKKWAY J^ I--1 "WIOUIOF.R A^~ivr~viwM S^ LrnsA'w4M EIL-I OTNEfl IpAD:NNfACE vl"CFI«Wr I ' WEAinkH GPA EiN liµAp I ^ lgNf C[wpTIONY I +~A OAYtgrli Y` -` tILAFFq COHtnOI wrrt D. P.IE AX)YIr~MI ^ I ^ YGNN.9 TYPE OF IIOAD DI vu.ur o^riwcAar. Fq> nI ^I I ^ ONF WAY BVEn/VEHICLE ACt10NS vn•G.t ICMCx ONEPr Wrnl i ^E I ^ CA'q STRMGEIi MEAD ^ L ^ ~ ~ `rtt T e 2~RM.NYK1 OAVM t ^ t^--I 9 ^ Gt01'LrGrl ~ l fNq WAY ~ IGI~E ~ 2 ^ OVEI!/AXINO AND PA851NO E ^ 2 ) ^.V,OYAE,O O ^ a,sM L J D ^ YI[LD ti'GN ^ .] ,gM ^ O ^ MAXINO nM]NT TURN ^ ~ ^.cNOw • ^loD ' ^ °c YIG OH ET ^ • ^ nACwuxi NFD ^ A ^ WTEIrLrI AAX:E A ^ . E71 V.I MAXMO LEFT TURN ^ A ^ qE k ^ Ui4GiY1 I A ^ IrY.NI1 (ifFEt ^ E ^ f1A41W0 AMXEN IIODnrII MPI ^ 6 ^ AILEY ^ D ^ MAMWO U•TURN I ~ ^ > ^ ORJ Y E ^ SIPFEI lgN1!{ ^ D ^ ItlI tKNAI ^ b ^ l~/j IUHN ^ D ^ S10WIN0 RI A90N ION AgT9!lA '•cw f.eEA.t g0ANE1fR Ir+NA LrC i ^Y'IIGiY / Off ICIn~RAGMAN ^ ^ lMIF9 ^ T ^n101`PFOi011 TnAFFq r lL..nr I `" ^ tl ^OInN, !1 fCIFY (] ) ~~!3PANAfEO ^ n^ OR 6~Un JON~AL .._.. .. _ -._.-..... ... ^ ] ^f%Ygfp ,E y 5f0M1'fAWHD"DWAY ^ V I L B /1'1 M fnAF/IC ^ C IR!'M, ~ ] uNUNXIfO E g ^ IO ry iRAM'i RC L~NP. 1.11ANAM E_•,,.,{, YIn .•OOnt1 ~~~-i.Y- .NWIM.v~ SPIT ..~iY9 ~;M~~'I !T",,~Y1SE1 _ _ ~~•- Cf%' 'M!.', ~~'.. . .u~. ^ ^ ..ART N(1 FRCgN 11 v n''TM0._~f,~_.-~.~ma.~. ~ r/ S T^ ~r sr .-,.'> L~ ~'~ ,~~ fix.: ,~, Lt°~t~:. I '~ ,. ~ ~ ~- M~TnI ,f'^' ~ ~ v ~ . tAYt i ~; a» "°z Y / l JR P 1 (((N r ~ , ~1N A ~,N.. ~z e F ~ r„ y • T td ~~ gyp',+~ d~, A , ,,? ~+ -5 ~ Y ~! ~.ny Fq'11 P „ ~ 1...iI Y~1 ._•~ ^~T 1 j ~: ~1 r ~ ~ Yt ' / ~r s + I ~ ~'S I I;~° . ... ~ a H ~ ~ nsw•,96t Y.y ; . ~ a; fl ' t ~ - ' ~ - ' +',~ ~ ~~ .. }' ~! ,. S 1 ATI~ O{= V-~ASi-1iPdCU I ON 4AGE G, .gg ;`~ ~~~. UNIFORM POLICE TRAFFIC COLLISION REPORT - ~'°" ~°'. i•..iICE COM VpR NUMUER......-.._ ..-~~- v'n r g, [ ',,~. K .~~ 1P +6Y•S A [LATE O"cCO:~ISWN.___ _.__._._~_..oAY E1~CalISiON ---_-_ .- T E-_.. ._. ~- - IM M0~- DAr y }SUN 1 ppry' IIIIS ]WED YUx 5 iNl E Sni USE }a0 ~O HOUgI yl ~- -~.~ __ .- COUNTY NO / / CITY l10 CUgBAN J V / /~r - '~ C UNTr - ^STATF ROUTE ®COUNTY ROAD ^LITY SiIIEEi 0 ADIA'CLS 4gE F IX gpUTE OR GTREEt LADE 'CiION FG~u~OL ^DTNERISPECIFYI FF W L~'7 O L o CITY OH IOWN ~ ~ ^ ^ ® NOf2D 8 ~ PfIEFI% EO MILE POST _ ~ C MILES OF._ L N.R,_.I~JASHr___-._ NAM 6N0 OF STREET OR HIGHWAY INTERSELTWG WITH ETREETOR ROAD ~" - rg T w' O1Y . 0 RAMP DIAGRAM DATA I NON IMERSE O MCIDENi INTER OI ~ D iENSEC11NG 6TREET OR ROA-OR REF. N pETWEEN _ --... STREET PND • IEAGE Ir ~ ERENCE CROSS STREET OR ROAD . _ _. .__.._... ._ _ BEET DISTANCE A ND DIRECTION FROM REFERENCE ORCNOSSSTflEET CODE s ' I • I q '(y MILE$ N 5 E W 3 ~ uL[ n nVNWE1n5 SPELIALCO LNG USE ^FEET ^~~f or COUfJT_ _ ROAD. f0 . . (:ULLISIUNINTVOLVEU U"•••""`^"` UvenlLlt UCYCLE OF VENICOlES i u ^yEH CIE EDESTRIAN ~NON'COLLSON N U OTHERI LEI DNi6RUN SEVER iY _ ^STOLEN VEHICLE _~ NO~NJURED ^HAZARDOUS TERIgL _ ___ _ ___ ^pROPERTY DAMAGE ONLY LOCATIONOF OLUECi STRUC%_, FcTn d I ~ I ..•.•.crv nvnt•wl - MIDDLE ""'' "'- ~ ~' DRIVER'S NAME ~-~~ ~ V y u ..vcwt 5 USi FIRST. MIDDLE IIF lI CYCLIST OR PLDl SINMN CnEC%I^ i ' \T ~ ~ ~ ' R STREET ADDRESS .. ~~~~'"~~`~- .. R ,: ~ • I" I I A ... .-:... 3 I E I STREET ADDHE55__... .. ~ _ . CRY STAT ZIP CODE PNONENO. E - w GT CRY ATE ZIP CODE. PONE NO. ~ ~ ~* " N ~ (]Q? [ ., .. DRIVOERS LICENl~5~N0. '/~. -IYJ Y~.76 J- STATC SE y ..., ' c O. % DAtOE OFDATTN YR M M A3 2 6 20 N ~' DHMERS ULENSE NO. STATE. SE%. DATE OF BIRTH MD. DAY Yq. ~ ,~..~ : ~ DRIVERS OLCUPATIp! FWM NAME ,. ,, PHONE NO. Z DNIVERS OCCUPANON FIRM NAME ~ _- PHONEN . t.~, ~ ' _ LF L CODES > I]I ° _ , fY ~, t „ CU55 -- I I SEAT BELT_~ I51 EJECTION ._i... uURE Of CODES > IJ CipbS--- I°' SEAT RELT 51 EJECTION N T IRNJ RTES RO E OkF N_QIg_}.WHLL~$jj~_G~~y 'd(Z~,E A URE OF NJURIES J•.• T'U F M SC NE VExI YEAR RY MANEIDODGE{HEVJ 1~c~ MUDELIDARTV10VA ~ • 3 C RNMOVED NF RV 1 ST DF ONVJ I VEH YEAR AKEIDOWE{HEVJ MODEL10ARi OVAL STYLEI}CR CONV ) ,~ ' ~ v E 6 OLDS Sg H R, . . . R ~ > v ; ' H VEM COLOR LIC. PLATE ND. i lolfr STATE TFNLEq PLATE NO. STALE E N VEN.COLOq UC. PLATE NO. STATE . TgNLER PLATE NO., STATE r 1 j ~PG - H. ' I - ' • C VEHICLE IDENi1FICATION NUMBER " ODOMETER ~ O VEHICLE IpENTIFICAIION NUMBER. . ODOMETER E: , .' REGLRIEiLEO OWNER-LAST..-_ .. FIgSi _, ~„_..,,:.- MIDDY flEGISTEREO OWNER-LAST _. FWST ...:,~__ MIDDLE _ • o. ~M~ AS ~LROVE N ~ ~ ., .. ' ~ A DARE OF OWNER _. ..:_ .. ' ADDRESS OF OYmEfl ~ ~ ~ 2- ...,. _...... .._.,.,. ...... .-. '~ I'- NAME ANDADORFSG OF INSUNANCECO.OR AGEyT"~ FARMEP,S ~NSaP,ANeE LT+IV;JLP/Rp8 O'BRZEN NAME AND ADCR[S,ROF PIYJHANLE CO. ORAGEM... -.... Df~• o 074 PT. -roWN~EN ~II WA• 9~~ CHARGE CIIAigN NO CNFO LEMEN .. . CHANGE -- T C T 1 ~ I A gNN . • NAME, ADDRESS & INJURIES OF PERSONS I NVO LVED Lopes I ~ } ~ ° s C ryDDU ESS _ _ A ~--_ p A n nu%DViD rt7oTA"-"- - n:rum s~ SCEN[ Rr ro N AME N T S _.___ ADDnESs N~rur•~ or -_ nt v O - ~ s o E F o sceNr nr TG Hr AME: __ T ~ ` '-.. _~__ _.____ ADDRESS' _-_-_~^.. N _ NJUNIFS~ _. Ri M6vCOIaou._- sL r E F rt Rr To AMF S 5 A OORf sS ~ Sr -TA rvJU~~^-- .__..-__~.__n IscE 5i ~R3M'--- - . __ I N lINIAIUS I:I SEAT FYJ511gN C1A5 TD I I L. O } pASE[HG[n IAN PL I r 5 DINIDRY pASApLING nJJURr A O I°I SFAT Of LT NOr INSIAllCO Isl lJECIION NOI CJCLTCD E Il nrCYCDSr ~in[R I DUS MOIONLYCIEI 1RN ]DEADOHANNIVAI ~ A DICDINHOSPITAI I IF NDCNr~tNJURY }1'OSSI ]U~CpHUG[ ; }Up~AL~~,JELIED JP i11ALLY EJCCTED C „ F~ ` 8 } BpO: 1110N UN DWN ULE INJURY UN%IIOWN s 6CAi FI[LTfNIUr[E [JELLED CJ (2• 5 N ' ! ;. ^', .~ r~ ~` r_ ,s, , I ~ .' ' ,. ~vi 3LLUe]w ~.MI~ rs +XF ~ a r+t' ~• . ~iYiil~Ner' 1' _ ,fT.P./~xh ._ u.~g.~rVS"'~ _ tux ! '; VEHICLE DAMAGE 1 nF c R ~~ cu + 1 1 c rtM n nfA l SN OI NE O C [ f5 CT N F/„ `C[ r ~ r ~ - 4 INSTRUCTIO S: ] Dn w D" s Ta a v Nc AL D nfcnor a or cE _ _ f DAMAGED VEHICLE N 0. 11 wsE flNSf ACI D r.L CN LU NAnE to in. LtR. MDIDRCVC[[. []r.. _ OArviAGED VENICIC N OI x,N ?~ 0. rr i sfvERrtr of DAMAGE: vfNlclE o s(v[nrrr of DAMAGE mN [ cLFI 5 nnvor pAMACF of IlluErw> ',{: 1 n Dueunc DAM.cF ^ v. oAMACe ,[~{1 Inc nAM<c[ ~ I7 ornEnMV o MACE ~ Om3ARUnc onMncs. ~r~[ mNERM V. DA cE ` ,r OD ODAMAG 4 t ] ^ FUNGI ORAL DAMAGE . ^ N MADE ] Ll rUr. rInGE [n u ^ rvD DnMADE A ] ^ PuncrlOHAL ocMncE a LJ H [ I _ o Der. '- _. _ AMAC ._"o _ .. .. s Ac[ row(o er -f:. TM4 o v - '. T _ Tc ti ~, ~E m~ DIAGRAM Of COLLISION !! .nr n c / DRAW ARROW SHOWING ew i ` -_ t _ J- NORTH IN CIRCLE ~ ] ~= ~,, .._~ _ . ~ ,R.P. ,ROLE 3.IMr.RR3 DnR:v.Ln1... DDRD,NDn3 Ef.i,cR cpN _ _ --- . -- ..: ~' ~ ,: ~ " . ~ nm.[ RPOUr.MNON . y.A 3 I / .1__ ~ ~ _ ... .. nwM - 1 srvN . _~ `! / ~ 1 ,' ~ .v4. rw m[. ~- r` . _ _ .. _. .. ' ~o DESCRIPTION OF oICAT(wnAi PnoRAeLr NAP CHEO RFFORE or orvo tcnAM.F C. on vER _ f - ~ . COLUSION OH R F DRK F C I o Tr IS UIL CD N D EON GO D1 y I - r° r. .. ._'_. .__ ___..___ _. _._ .. ~ _' _ t /. . .,, . ,, - ,.. .- .. ' .. r _ __ _ 1. r" POSITIO N BEFORE COLLISION w ' o: RuoF° N 6 menurslu+c oecnusr HS1R[ETO en v NAMe .. o DIRFCnoN NF , Ly ° LEI « r ~ ` $ ] a ~~ ~~ \. ~ / ~ ~ / Ff D F • r ly I.~ u ~ - ~ ~ ,v Eo . _ __ _._ _.. ° G._ _ _ r.rr .. . M re [ Nr TD , .. E C l5T AS USING' ] I SNOULp D.Sw S CNO 55w 6 E c EROUiF x NLR _.tn, ~yG flOAD QUO FEACE K WEAT ONR R .CONTRIBV TINR OrCit on ufonilANCES I YDR D L [ •. - ~F~ pnwER N0.] ONivfR p.] o] N ] ~ x1 l GOR •NEAp _ ~ . , '~ ' ., ' ': "';Y ~1;' o _ _ '-• ttfAR.uoup .. ! ~ a ovulcAST._ - unow lrvauENCE OC ~ 'I . eLrsnaL__ - r ow c ] fo°oc3nsiEV__ .....L~ _. _ ._ rRFCA Ds no(o WARN smrvrsc ~ - _ AKINC ' ~ x Arvo PASSING - ' . ~' I I M_~ ~ __ ] . ~... x'__ 4 ... __ ] - uNOEn INFluEN4E •._ORUCS r E ~_.:. 1. F. ~ A F '[. . ~] N; ~ G unN x- ~ OWING ~ ( i C p ~: fP L Br I N l0 A ON y~. U RN LE amr~Jbe:~. ' - ' ~ " ~ r (~ A ICE - I..:._..__~. -. . _._ _. t t>C .~...e_ ... . .._ - - - ... _ ~/ E - S A S _ Al r. SP[f0 GNAN R v ~ . _...:._ -. R 0 uRrv PE [ - DS EG _ __ G OFf FCIIVE (OU_ .._ _ 16 N1G ' UiUR [ . • ~~ .- 1 ~~ ~ .. ~ 6 ~ ~ O T n S . .._ t_O C CLF _ ~ ..__.. S.. '. . _ .___ SLOWING 4 ~ ' OTrifP ISPECII VI aTiIFN ISPFCIFVI i3 PA.Rmcn - ° _ scN °cNAL ' R.J U1nER SPfclrvl Nov our oN [DfOR L_'xt~- rRAFnc ~ '' ~ IGHT CONDI ilONS I[NfDK ONf1 RAFFIC CONTRO N.]IiCLE - - IDLE TYPE OF ROAD cx 1CNFCKONF ORMORE _ VEHICLE CONDI TION VF^D(( ( o x ~~~dR~`S5~€ ,. I Nfi iE . SORRIETV ...' IDNEGK ONEI ~ ~ ie S o D TSIGNAI 1---- fUSGN - 1 ' „ . SIGNALS oN[ ~.1 wAr m ~. rfDIN je. `r ~ + o. G r o Fc V ES RD ARnn] 1PAINLO ~ hl; w^ar cc rv • ~ ~ -... ~ ` • ' pAVM ] _~ N . ,-- flp 5 s GH ~ H SPl[ RD v! [4DL 4N1S ~] ~ ~ ___. . NRD ~BILIiv N01 AflCO _ II fIHaE NV05 ~O N • ~ r . ~ ~ "~ ~I. " r ~ ~ . ... ] - OL3S ..... _ _ .._ - ...., ~ ASnrNG HfU.. .. .. I ANLI _'. LOO M . . ~]~ ~. PEPFUIIVE .~ I c 13. J / ...-- _ U I U Y.. .... '__II).,:_ G 4 [nTERIN4 r 1 , r 0 nK f lE 1L4ru,TfO N _1e eEn.~ ' ~ A C .... i ~..OI1C 00 D NLING Nc 116 1 .. 0 K 4 Ef nv 0 -~ ~ ~ ~ Noej CHEM. TEST JI ~ t ~ r ,. ~ '-. :i 3 L GRl p I .. ANK-MO ~ ~- 3 G t .. - n r NN LAr1fe icN~F[T- D serrrwr _ -~- '- IS1G VfN __ Orn L R rsree lrv l ri + t n ~ 6 Srllff T.lG L6 . .~ G AN ~ •1[O 1 5 ...... .. .._... _ / i - •~ 1, : .. .... . _ .,~. ~ - RSA ] , •0 ] D IUID NO DEFtUTS 1 5[NEruSFD '!} U^ )( e[ ~ ~ ] I D orlNn rsvfc I 76 E5T RESULTS _2 ~ r [ ~ i NvL311GAfINGDIPrCfRi N•MISNANK I r ..'. ~ veioe eD frcERS a ANK N UcI NO RA .' r0 I U A] •~1 4 D ;... ._ ]u null cE A LI 00 I r Row, nI [u Ilv Iv1f~ __ NOD AIIR u.PONr ~ PI ow D( Mi[DFDIL ~ ]u00 Nns M N moved er L E ~1'1 i y /~ ~~ .. ~ .. r,. .. - .. I I ~~. ~'~T~Oi i/ ~'} s r]r°"•`1N"~ +~r-st 'r~""~`r 1 P~ { i 1! - I _ ~1 ~~' _+ ~ ,i ~ ~ ~" ~t ~` ,e'£~,.~}S~Sb~ xi'~'t$L~~~F§~Y~..:r ~._ .3~c~s:._ ,~''id m~• ,_-• ^,,. e., 't~~l.rdl_~~'sfl8,~ ~~. . , S 1!•~'1'L U1- VtJ!~SfiE(J(a'1•UfV ,AGE ~~o. ------ I .. ~y~.~ .. .~{~ ro.IGF COmPLw Ni NUMBEA }5 „ ~~' UNIFORM POLICE TRAFFIC COLLISION REPORT '~,~~''' ~"°' B' ~ N;. ,Jq nj, D OATEOF COLLISION OAV OF LOLL SIGN IME COUNTY NO City NO fHWA ~ ~'' H i/ MO_ OAY YR T SUI/ 1 MpM1 2 IU15 D Wf0 A IHUx 5 FRI A SA1 IUS~2<DO C, RI J ~ L '~ COUNTY ~C, = ADM~CLS PREFI% ROUTE Ofl DiHEEi CODE LTION i , ~ A'. ^ETATE ROUTE ~LOUNTY POPD ^CNY E1REEt Q d A 50 = ~ J1~ fFCiAjY:J~ ^OTNERISPECIFYI y ~ ~ 2 / Q t~ 4 '-1 I ,~~.A L N S E W IN 1' CITY Ofl TOWN ~ W PREFI% EO MILEPOST/~~y~.n~~{I~ ^°y ~•i ~i2~.Ewy, ~n VM-~~. ~ MILES ^ ^ ~ ^ ^OF_..J~Z..C~`-.I'~ /t ..- ..._ LL .+i+-V / [, ~`.- ,~ +i~ i~.* L 4. A NAI NO.OF STREET ORHIGHWAY INTERSECTING WITH: STREEt ORROAD O RAMP DIAGRAM DATA ~ ~ C ^' ' I r: T O I \ C ~ ~ '~ ~ INTEN NON %~ ERSECTING Bi~I OR ROAD OR HEF~ 'I' _ *~ ~~ ~ I NON wW TERSE IIXi ACC GENT L 'V O ERENCECROSS STPEETORROAD 1 , MLEADE ~- N DRWEEN .. .STREET AND _. .._.-._ _ IREET COOE ~ - • DI i C AND DUiEC110N iROM REFERENCE OR CHOSS STREET VvtwEiHS SPELIA C DIND USE - Y ~.... ~~ MILES N B E W _ ~•. /i iEET OF /) ~V(T V~SI C//I~ %.S J. A_lv_I L.- . '~~ -, 7 x - ~ SEVERITY -,~ '' I ~d ,~~ - ^VEMKLE~VEHICLE ^VEH CLE~B CYCLE ^OIHER IWR iEI ^111TARUN __ NO. NILLEDO ~' v U COLLISION INVOLVED: ^vEHICLE~OBIECI ^VEHICIF RPTRAIN ^STOLEN VEHICLE O.INJURE ~ ~~ ~ ~~~ 8 - m._..... _. _. ~.., ~ ~ OF VEH ClES ~ ^VEHICLE~PE.OESiRIAN ~NON~COLLISION ^NAZARp0U5 MATERIAL ^PROPERTY DAMAGEONLY ..~5~~ ~i~ ~, . OBJECT STRUCKINAME Of OBJECT STRULR ANOOWNERS NAME) LOCATION OF OBJECT STRNCKS E W ESt.OAMAGE °°~•JJ ~yW ~ ^PDAOWAV FEET ^ ^ ^ ^ AD EDGE S r- yA~~~ ~ , •~ DRN[0.R NAMEAAST, FIRST MIDDLE. DRIVERS IIAMELAGi F RST MIDDLE IIF BKYLLISi OR PEDESIR AN CHECNIU I. ~ Y ' + a .V R ; R STPEEI AOORESG : ,: - .. ~ A . STREET.ADDA 53 .. •..' .. .. ,q, __ 7 ,~ RE. CRY .... I_ ... StATE~.: ... ..:. ZIP CODE.. PHONE NO. fl CRY.. .. STATE ..::.'._31P CODE. PHONE NO. '' _ '• >aY, I- - .L~3'' c .vc:P/v 'r^JJ !• 36. --' k' J' t ~ rti ~r ~ N OPoVERS LICENSE NO.. . - ..,. STALE SE% O,IOE OFDAVTH Y~ N DRIVERS UCENSE NO. . - STATE ~% DMO OFDAYTH YR .~ - ~. Q. Y% ~ pRNERS OCCUPATION FWM NAME PHOIJE NO. 'j ORIV[RS OCCUPATION FIRM NAME PN NE NO. + n CODES > ICI CI Au~-_ I.I SEAT BELT _. ___ 151 EJECTION-I CODES > IJI C AL 55---- lar SEAT BELT__ 151 EJECRON _ _____ ~ ~, ~• ~ J ATURE OF ~ NJUNRIES F ~~~ • " INJURIEB ' i bl F.V' fRpA SCENE DY: TO FROM SCENE BY TO f~ VEH.YEM MANEIOOOCELHEV.1 MODELIDAfli~NOVAI STYLEI2 DR ~CONV.1 VEH YEAR MANEII~DGE~CHEV~ MODELIDART-NDVAI STYLE I2 DR CONV.1 ~~yy •~~ V 7S I'c l~ P z J ' :'vL' R c A 5 V J~ZW, jC}~G N ~a ` - E '. VEH. COL lK PLATE M. STATE TRAILER PLATE NO. STATE - E VEN.COLOR UC. PLATE NO. STATE TRAILER PLATE NO. STATE .F ~ ~$ '' < " B+~N 8's:S21 ...-YU I Pi:p b '~' • ,. . C;. VEHCLE 2 NTIFICATION NUMDER ODOMETER C VEHICLE IDENTIFICATION NUMBER .. ODOMETER .. ~~ ,°S'``F e• Teti •KWLJ -5 c! E __~~ - REGIStERE00WNER-LAST FIRST MIDDLE REGISTERED OWNEfl -LASL FUiST MIOOLE . •_ o. SAMr /as BBL^A=` o. ; ADGHE59 OF OWNER ~ AOOHESS OF OWNER n 1 2 .':.:- . .. ,, ' ... ~ - ..................~ ..~~,e, o.u~c rn nn Ancui NAME ANO ADDREBSOFINSURANGECO. OR AGENT CHAROE ENFCRLEMENT -'"" I~ C lJL' ACTION i 2 D 5 NAME, ADDRESS & INJURIES OF PERSONS INVOLVED ¢ IYOOES f-~ _' ~I~ T-r.v~n I ?L~~I ~~: IEJECT.~ A N T S / w I T N E S S E S' S O~MRU µ II+I 1-~- ~ ~ e ~~f~ ~ K O~ ~ A ~ OONOSIniAI I t ~o ~IOLMt'oi~nRV 15 Cf T DE T fMtOURE ~; ~O ~IOEIOVN Ep[OTEO l1 ARt NESS __ll ~ 'ys~ppaq, s ~T! r, ~J~ 5 ~ U~~1, ~I ~ 1 I ~~T~'i gg w ~~~ ~~ ~~ w~f L r ~tl ~,i ~ .:1 !~ ~ b~~ .'L- ,•5~ ~ ~~~•~'~~~~'~~ ~. !~•1it~v.''!1~'-, i':7 -"~' "•'~*~/" .jl4h'•'~ 141•i'.~+11 ~~ 4 1 t..l fl wad il~ ~ I ~ ~ _ .../ '~Tx~~~ 4C/ fray' + a v I~' I;T ' VL-HICLE DAMAGE I. wu,w ua -IE na a i.:-~I LA u,mnG[u ralEA: -'°"__., ~~, .,~, ] $HAUE ARCA OF SEV EREST IMPACT (f>( ~ ~ . .. ~ , L , INSTRUCTIONS: ]. OflAW ARHOWISITO SIIOW PPINCIPAL DIRECT ON OF FOfICE. Oi/. ~T x DAMAGED VEHICLE NO.T usE tH SSIACf fpN SKETCH NC DAMAGE TO TNA LFns.MprONCVCLE5 Er01 DAMAGED VEHICLE N0.2 ~r.a~b-_==f- A ~~ ]. now PMYr~~AI • 'r ~~~, I IS. Tr I5. T.unIL IB. U 1 ]. OxHP 1 ,•Ix ^ Ix x SE Vf NITV OF DAMAGE VEHICLE NO.I 1 n O SABL NG OAMAOE S HER M V MADE ]OGMNCTIONAL DAMAGE F LJ NO DAMAGE A 5 gITY OF DAMA,.E~ IOTNEX V LEI I ~ 0 LING DAMAGE ifs};! THfq M V. D MADE ] OFUNCTIONAL pAMAGE . LJ<NO DAMAGE A IITY OF DAMAGE: V[IIICLf NO.] IE^ p15A0LING DAMAGE J O pTNER M.V. DAMAGE ]OFUNCTIONAL DAMAGE ^ TOW ED OY ST. pAIOAGE TOW ED BV ST. OAMA E GE 6 s TOWED BV i. pAMAGE To s o s To s DIAGRAM OF COLLISION AW ARRO ~ SHOW ._ ' ~ LNG - DR i. IO uiimA. An pwr.r[MUn[5 . . _ _ . F I ~ .... ;. :. -:.. '._. : RT I CIRCLE ~ I vFx cL[S vtpestn .xt pxncrf axmfP np.ow.. tnA.NL CaxrgoLS x ovwnKS uxusuALn[MP cpxDrG s _-. _ .. _. ,. ~... .. _.. I ~ ~ ~. . -- ~ . n I c[P.TCH cpnstnvcr ox Aq[Aeetc.l Loc.n.npsuL[rolHT Of IM.ACr -. _ ,,. .-. _ -' - - - ~. _ I ._~ ~ I ! I ~ __. { ~~ -- ' ,~,.. ' ~~.~ _.. _ _ .. ~~ ~~ ~ ExpNY[HKL[.[pkSTnAxpn P IT IM.A . .. . ._ . ~ : ~._a_ ,_ J~.~-j'1 ~ c o Rp ~ I I _ - - ~ ' . [xp.xxP.,..[YH,[L[Px I -.-~. ~ I I r ~---c.~.- .[p[f[x„x.AIxS.L.pAr xNO Unncoun,pK :.. .i , I, ~. I I I I I I -_~ ._ ___ _l_. ,_ I i DESCRIPTION OF IINOICAIE wNAT PROBABLY HAVPENFD BEFORE, OVRING AND AF TER THE CRASH INCLUDE INFORMATION NOT ON DIAGRAM E O ORrv COLLISION , , . . ER DISABILITY, REDUCED VISIBILITY,PEOFSTgIANCLOTH NGCOLOq. CONSTRUCT ON Oq gEPAIR WOgK, ETC.I ..V,~,N__./vo__psl~~-`__ 1..~~ys.._TR.AvEtiiy6..EAST_...aIY.. Gn {ZD.._.Np..r,~_. v-:N~.w. A~_~ ' ` J~,~=d __. PoR,yt3~lc _ 7/Z~vsL`u%+'G- wE s?~.PASS~D__~,_.v.~'Hi. _ ~v~<1~~-__A.__CAM.A T _7 R,n;.~,EfQ~._- .AXE-.F_DR-«.D..__.V,~H/_. 1>%0.l- -'1`o--1~A!!.~; TtLF _{QOAD.-To____' .._. ~ -.¢~' Pf'-~V~IV~ A N~G.4.. S P,~sEl~ ---. N~.AD_oX..Ca~-,(~~iaN« H~ /-'~~viy~vc_ V~H~ ~~lt I °~ ~ 7` ~? T o D ='~ _ .. . . A_ 1v _S ~ o vD ..WAS .NOT /.Ds.`~'i5i( ~O POSITIO HEADEp N BEFORE COLLISION MILEPOST I C ON Siq EET Oq HIGHwgY OR xO ~ ~ ND Do gANFs ONE I ECTION T IwPAq D x N S E - - - INCREASING DE REASING -- PagK ~ OCCUP ED !_ ^ ;, ~- ; ~ • r .. -~- MPH _ ] ( I .._ j ,:x ~~ F j - - -- _ 01 Pfp. I II '.1 ~' pq ux o , anN axc L g ~ ~ LEO/a CV< ST WASUSING ~ ~SIOFwALK ] TWA ~ -I SHO f (. 1}v 5 'CROSSWALK E~ EgOUTE IOTNf R-~- __-_ _ RO ~D ~K RFACE ONEI WEATHER ICHECK ONEI CONTRIBU i1N oNIRCUMSTANCES fOq MOgEI - O. [L[ n%x[ p ORNV Eq vE O. DgIVER 1 N pR y6 O. ] TRA NT ANEAO _Ixl_~ OqY _. I VCLEAq.tOp BOV ERC ST "~- _'~ p NFIU C L CO. OI ~] OLLOwIxG 1. ll SLQsES -,I EGAROEO WARN _ G .+ I~~ VOVFRTAKING ] II G '~] '' T I , NG I . t_ 1 D G U ~1 < E __ . ~ Ef Y t_7]I Itp R f I 1 N '] I 5 O 0 ( LNG _ f IJ ~ 1 P Ept MIT __ 1 191 NG TO AL . _, 6 -~ vfq PArIKING I I OC JON ~ 11 1 LE INU ~ ,. i E _ - ... : fa .~ S.F[SPEEO F MPROPEq r ~Ip I . __ U . ___ I ,16r E G -- 6 < T qN LNG 1 is pTll[R FC VI -~~ I H -FC 1 _5_'x. p cEnN ( 5 FA ~X vA55 nG II n - _p G 0 - -[ ~ I].. NfS GNA -~ .. v r _ VI /~ J Eql ION el ~ s owlvc }O f'U FOR I_ ~ C G T CONDITIONS cNfcK ONfI TRAFFII GONTRO o] CIRCLE F Tf PE OF gOAO ' Ic <KONED oqE o VEHICLC COsN/ D !II T I O 1N F 1S S E V SOBRIETY. ~. I 1 PEp AT SIGNAL I J L IG -' I ~ F DNE wAV A j ( C Q~ ~. ~k S~~ fiiic. ] 'i dN'f 51CDl ino iE InI CKONO _ oP SICN n E l3 1 _ __.. __ . J ~P STOPPED IN Av oADw L , v IDNT ._h-..~ ..-. .. _.. OAWM ... .... _.,. ] SlW :_.. SION S, VIF ..SIGN... /1 W+Y ~ D _ ^~ ._ -- _ ~._.] ROAD, atL I_.I D[rkCTNE ..BRAKCS.. ~ ..1) [CI VE ,I LAO LIGIIIS ,I.....I D BILITY _ A REO ._ I], Iv .. ~ NOT MI' H[O IIO _~ ~ _ NAFFIC LANE 1 '--11 ) STARTING PROM :1 I 1 N T E ' W '- I O f f _...LG SO I TNf FT 5 iIGH1S OPP ,. _. DANK-NO SIRE[, IGHTS ~ . rLA G rIFO E AM H 0 ~ SIGNAL Ofi< I ~ _ r ! Nt[xnlANC[ A IOOV NAMI A ALLIY _.. -- rwp wAr L[ t tuNN LAVTS 0' --- u, TR 6NE-' 1 SfvAIIAI[U .__ , _ '~'~] E .TINE ~ I F L i5 IE f ON. 0 ~" to 0 ~ Iw nI UwH .. _..._ . A . .... .... i ]~ pSOBi1 FiY ~ UNK pR NK NG [[N ''„a(? CHEM. TEST _.~ . ~ TEST GIVEN ... .. A K D POSITION 'I]f ~ MERG nG IFNTkgING ~ i FiICI 1 ACKINO 0 ~ ~ ~'I i ~ ~ OTx[q lSVECIfYI L . .: ] r ~f . .. u;;'ri N S~ ~. ... . _. ] OIVIp[O ~. X NO DLf EITS I ` -. L. __ ~ I TgEf USED .. ODIf IS FG YI xp lx.,! [ D N'3 . r V] _ Dl.p A._ 01H[I1IYll fvl io TES7 RESULTS 2 VEfYIGATING Of FI E 1nS.r T Inv s LTIGAT pOl <[ N/ [6NANK ~ [~~y,~.__' CL~N ANF w' 6,3Np p LICE nI .. ~ A.^<. uwrrM :pkN [HE M.,; ~L `~07 $ r PULI<[AIINwEO NCf ~ g.7- ;r~,~rD '„°: iA nfr pAlem nLPpnl. Ar iCfLOW M:EDED zf q; n IN. PgovfnsY NuAlf M X E '~ r^ 'o DUPLICATE COPY LOCAL EAIY ENf ONCEMCNT AGCNCV'sf.OPV-1HIPLICATExLOPY,INVESTIGAIORJSCOPY Ar `A I ~I~ B~~° ~+ "~' ' ,~ ~ ~~ ~ ~~ A . ;,' •A Y _ Nf L 1 I ~~~ +11 M r I _I i .1.. - ICJ a II I_ n r~.~7~_-.r~5-..r~.-ki`5'l; _.iY:~a>~ ~; _s -..~iL.-..-~......ed..,...~. -...0..._.. - _.......,,...._..§. __._, ~K MOTOR VEHICLE t:OLLISION REPORT f:Q, DALE OF G]LUSION O MD SMI AY OF COLLI SION TIME OF CAWSgN' AM OOUNTY NQ' CITY HO. ^uPgN U,[¢ J PM : 1 COWTY GfY.I WN ~~E ~.~:F'E(..SCi~ 1L soE qw MILE6 Q CITY,TOWII ~ ©©OF ADL . ApA3y4 PflEFI% ~-r~J[ nW y~~~ 5 CTgN ON GVE NAMEOFSTREET. ROADORHIGNWAY wNCw I i MTERSECTWG WITM:6TREET DR ROAp PflEFq E O~ MILFIN)6i ~ ~ A o ~ OiAn: ~ ..Ati OA4 j, NON WTERSECTKk1AOCATgN OF COWSI /~'~.[~22QLL:~,i G,J~ ~it+~7 fAHN ~ $~ RAMP gAGRAM DATA BETWEEN u+u n sNwn ~ ~T INI ®Q ~waN,ocnOiivrriEO.ukEros,OnLro[Hiv wa un ,H En.arvonE. rE ~ n nw INTER ~N ~~q wrEEp~++~w°~,s~rV+E9rp[iio~q R~D,D ~~ RSE<TgH. ~. ©® a „/.N OfgN -L/'t.Ad10 IOC 6 I ^ ~ .7 B / C~~ LS onnWlvED ^ OvE ^K ^D1nEnIwPorEI ° wc ^vEngLE.~..IgF l~ ~ L / bPEC O U5E . « vE E w°LE9 J III ^MH ^N, L OBJECT STRUCK IruME DFDDKDT ¢rnlCKl • OWNER OFOBJECTSNAMEANOADDRE55 ~. LOCAT ~ IN ROA gN ~~ ^N~ ~ IOrHFairi DMDIFR DWAY .~ -r ,. FEET E~ DRIVERS LAST NAME. EFIRbf NM1E MIDq.E rivq c/nsE DgIVER4 U6TNMIE a FINST NAME .. MIDDLE -~ OAJ/•! I f / IIE11E U causq°ION STREET ADDRE6S ROUTE NO. AND W%NO. ~ n x ~o~ -~ WnE IRAN w0 A STflEET ADgiE55 ROUTE NO.ANO BO%NO. GTV STATE - LPCAGE. . r'f I CU ~N . 32S giIVERSOCCUPATK)N ' i eACN ~~ CEauS,~Ox ¢EPDR, FDRM CITY STATE - ZIPGDDE giIVER50LCUPATgN DRIVEPSLICENSE NUMBER bTATE' SE% .DATE OF gRTN AGE giNERSl1CENSE NUMBER .... STATE SE% DATE OFgRTM AGE VEHICLE YR. MA%E ICNEV: DOODEI MOOELINOVADART) Ay II DOOM STYLEIT qi.l. VEHICLE YP. MANEICHEV.~DOODEI-. MODEL (NOVA-DARTI.,.' BODY 6TYLE 12 qi.i l G JGL BU6 /)~ LK:ENSE PLATEAq. STATE TRAILER PLATENO >' M 5"6 ~ UJA - . STATE - LgENSE PLATE NO. STATE,. TRWLFA PLATE NO,.,. STATE VENgLEIDENIIFgA1qNNO. 11088 MODELSd NEWEflI ODOMETER IMILEAGEI VEHICLE IDENTIFlCATION NO. IIB6B MODELSd NEWERI OOMETEfl (MILEAGE( REGISTEREOOWNEA IIJLST~FNST~MIDOLE NAME) DRIVER l1LEN4EN0. flEGISTERED OWNEfl ILAST~FIRSi~MIDOLE NAME) giIVERSIN:ENSE NO. ANGM! GSA yELLE /lJ3'2a /Q (~ OVMERSADMESS (STREET,GITY AND STATEI GATE OF gflTM OV.TIERS ADDRESS IsTREET. CffV ANOSTATEI DATE OF gflTH PARTSOF VEHICLE DAMAGED GJS~[ PMi4OF VEHICLE DAMAGED WAS THERE AUTOMOgLE UADILITY wSURANCE LIABILITY INSURANCEINFORMATION~VEHICLE NO.1~ COVERAGE wEFFECT FORTN15 ACCIDENral rouR CAR ^YES ^NO NAME ANDAp011E490f LM&UIY MSUTLWCE TVIgrNssLOFA NAME OF MAgIfTY WSURANCE COMPANY ,..,.. E ~ a,r srgE TP I r Ae.M~o 1,~/s Go: NAME ANDADORESSOF WgLRY WSURANCE AGENT. ... .. arr ¢,,,E iP UAgVTY POUOY NUMBER ,._ ,. 1ST MJWY ,., AGE ~ TNDIWURY: IVSESEPM,IE AEPOni/ORAEd,KWUIHNInES1... ADE NAME ~ 9 falELLL~___~..~NC.M_i _ J :~L~ ,O,AL wA,nEO NAME I _M_LEE ,(~I}~L.OU.) I~ n ADDRESS ^I. C f}L.y, ~G5__CJ~iM9CUh-t GJA._ M % ~ ' ooRESS FY-FL.AGLGrP. JYl~.7L. ~A~.I~ ~% 0 F ~j.eJiS ~_.i_EES ____.__~_ uaE __ O. ( nl __ - _. (32GGE ,LL7 P15Y ~B,E'L4ScD_L±~_ ~ _ O ~ II .cam. II _ ® I~P.Eiu/J1Jr-P IA STAlL13OF OMIIREO OI~ ~VEHgIE 0 WLLED MMKFWST ur uNin D I ONE iNAT APIRlE ~O~ngN6 IV~w°AiI B I Ou~~ " n~ STATUS OF IWURED ~VEH%:LE ~~ a • 9~ NILLEO MARK FlflST ONE THAT APPLIE a5,&HD Ovq¢AgNO ly" t'gEl lu iFDPI S `OSVeIE ILO 1n x t q;, °.E.,S~,~-.n«. ^ S^ 8 I 7^Elc Arl OnT~ln. ,.r~rr.nl ^ 5^ s. E, l ~^ SHOW NORTH BY ARROW MGRCLE \ DEECRIOE BELOW WHAT HAPPENED:IREFERTO VEHglE9 BYNUM8=R1 .c.n~auxw egriT ~a~Oa~ O \\ ~ I elwE a ngnw,r H Nwmre ] MAwEB E,CN .Tr.nE ,.q sMw I awEC,gNV rw..au•MFgw _..•~ Q•- \ „aI ,.~,,.~w.._ ~..I'f.I'i__._~G~-_,.__cs~./.~_~fV Z%_!7/_TC~ -__.. __ ...__________._.__..______...__.___ -- --_v l~_~oNr___E.~J-_~I~r_r_,~s~,_a~LC~~.h. t€ VEHICLES POSITIONS BEFORE COLLISION VCMICL! OrY 6i Rf E1 dI HgNwAY NAME OR Iq N b F W MDl u..n nwcu WI«cu KP,wnEOws INVCSrger[o ar awr ~ DNIr el,Hgq MnNAr FMI,FO VEHCLL OCGU'[D U !! M ¢ e M ^i~iA`Ol ^PpATC! ~v t Law ^ ^ ry ^ ^ ^ ^ ^ ^ ^ ^°rrmucE ^o°,°.iloNen q,n,~ ^ ^ o ^ rDIn/J 'ZSGa~LI~dA,'h 1 ^ o ^ o ^ ~" MI ^°'¢"""" ^ ^ ^ ^ uorq c Aglwo Irou DIRECTION ~TO DIRECTION TcoE Srn.N wAS IACOID T ^ sroEwALK T ^ wAL%wsr ] ^ SIIOLAOER , ^ ~,~;wMF e ^ Enos' wu°, e ^ oTNEn ROAD BL,nIK[ KMO WI WCATHLR LlblTCON0010N8 lwrq COMROL Iwdo..rl vIrKAE 1YPE OF ROAD vlr.Fi[ aE~ '! [%avEn/KNCLE AOTgN! v[rKll KNlCw ONE q1 AgBTl n1~E11 M r M E I• 1 ~cUiNa Y~ t OArtgIR ^ M] r 1 • ,AL! ^ ^ E M I q e ONF WAY ^ 1 ^ ] OGNO STnAIGNi NIEAD ~ I ^ y L-f 1 ^~Y ] ^RAIWrO ] ^ DAWN ^ ] ^ Sigr 6qN rECr YY I/~ T ^ TWV WAV ' ^ ] ^ OVEnTAKIN0IJ10 PAS61N0 ^ f ~wST ) ^6NOwAl10 ] ^ DUSK ^ ] ^ v[LD fqN ^ ] ^ ~~ yqE ^ T ^ MA%mO ngNT TARN ^ ] ^ Y1DW e ^ LOO % ^ Mb pI LT ^ e ^ IN6Nrq R[0 ^ A ^ wlf11CHANOE ^ % ^ MA%mO l[F1.TURN ~ IC[ O1MR [ ^ OIRK~bTR![T e ^ l6Hib pr ^ 0 ^ fIASHKq AMO[R ILOOP.RAMPI ^ 0 ^ ulCr ^ b ^ MANm0 U~1URN DTHfR ^ e ^ bFSCNr ISPl CUYI 0 ~y ~K NTE TL ^ e ^ M W+N4 ^ e ^ [~ TU1N ^ e ^ 6LOVANO KF A10N I4R Fqi 6[[r KtKAC/Ae Mq"perwK q OANDtn rYM IILI [ g I ^fPEG Fy ^ T ^OIIKLR!IIAGUAN l LANEB ^ ] ^BTdT[O FORTnAfrq ^ e ^ Oin[R. M[CIIY ^ I ^ Ex PARATlD ^ e ^ OR ib gDNON °Nµ ^ T ^gY,ao ^ 0 ^ II101'I'EDMROAOWAY _ ?. r h J HDryIDlD ID 1 ni ClgE ~ ;Y ~~ __ n I 1 f M 7 L ~,_~. k.? ~ ."~~~'°11V""" ~I ASy 'r~,~''!y~^'. {' rlj~ ICI V «I'ML ~i >r ( f I v.. ( I" ~i , i ;j 11 tf _ I I ~~~ i~iYr ~ ~ ¢rr~ r ~ _ .N ~.•~a1 . ~ ~, 1E _ ~~ ~ ' i ~ T ~ Y ~s.~.. ~.~ ~, .~ Gat~~,.A( °N.~tlr?a~sL.._:.___ ~ _ e,nB"u, ,::. Cf~ ', ~ '~~ ,:: ~ STJA"fE 0~ WASHING70N PAGE D NO LLD P.AII,i„ BER -- P()tiL ~p ' r ~ ~~~~~. UNIFORM POLICE TRAFFIC COLLISION REPORT DL D TE OF COILIS ON- --- ~ DAV OFfOLL50N - -~_~_ -TIME -~ _ COUNTY NU. / ~ CITTN~ A O. DAY $ T SuN 1 vpI 2 IUIE O WEO ° INUR a FR f ' i SE 2°00 HOURI j B ~ . ~ M L P UR ADM CLS PFIEFI% ROUTE ORGiREET CODE C0 {j! °~ I 4 ~ L' TY rr) Ln ~ `'/ STATE ROUTE AE~(000NIY ROAD CITY BTNEEI O M Y ~ _ J 4 r~-~r-a.S IVY ~OTHERISPELIFYI ` ^ N ~ G -/ O .rt L + ~O^ CITY ORIOWN ~ PREfI% EO. MILE POSt `/Yr r~ . '~- sY ~ `MIL N S ^ ^ IGl °F._~.CT1 -'. .N ~.•I~_ _-__. ____..__ V ~ I (~ L ~ e~ rt~~ A NAM ANO TPEE~ORNIGHWAY 1 iERSECTINGWITH:STREETORPOAD LL RAMP , DIAGRAM DATA I ~'; ~. T ON ~42,~1 16a~' l _ F W' INTER O %~RO INTERSECTING S1HEE1 OR ROAD OR HEF. . ~ I NON UTTER •" CC DErvi I T i CLS E I O. MLEAGE ~ Eq NCE CROSS rSTyPEEi OR ROAD ~ r°i~~' a.x ,~ ~. N BETWEEN __-.. ._..._.__STREETANO.._ ._._. _ _.._...- BEET LODE ~ 700 ~r ' DDET CE AN-ORELTIDN FROM REFERENCE OR LROSSSTREEL Pn[sw SPECIAL L'OOINO USE ~ ~ 1 ~'^ ~ ~v, rb f~ ~ TI!' /RRRNNN 1 f LwFiHS ~ ' jwybN. :n r ~ ~ LOMiLES N 5 E W _ .I ~~ C __. .. . :~ ..~~ /L FEET O~O OF . ~~t/Y71. L -. - _- L pp ~4, yffJ P)"., ~ ~EHIGLEWEHICLE ~ E CLE~BICYCLE ~OT ERIWRTEI ~NITARUN SE ER ~ `~ ~.•~: }..-.:``~ ~~AA1°' COLLISION INVOLVED _ N0. K L ED ( ~ ry~"'T.' TOTAL NO I~ VEHILLE~ODIECT OVEHICLE~RR LPAIN ^H STOLEN VEHICLE I JURED d iy., OF VEHICLES ~VEMICLE-PEDESTRIAN NON~COLLISIOry A2AH000S MATERIAL P OPERTY DAMAGE ONLV ____ ' q ` LOCAT ON OF OBJECT STRUCK :. _, EST.ONA GE ' `4 Try+~ _ ~~~q~KINA 0=0&12T UCKAN001VNERSNAMEI . '. ~~ ~ w S _~. ~.~.,.',-,.. FIRSCG~~~.. ...~Ie~~ D 0.91VER'G NOAMEAAGi FYHST ~DLE II^b~ L^IS10R RPE-06'.1NE LNEC ~D~Tx ~ ~"~{, DPIVEHS NAM ~ 1 Ri ' M I D ` R TREET PDDPE55 ~ ' ^' ~ - v Imo. U, l~2 ~ -J ~zC~i-~~~ ~ ~ _.. E CI - S E ZIP CODE PHONE NO. E CITT STATE . 21P CODE P ONE NO. :~ R ~t~l.~ ~ ~ C.~.'-t 1cS33~' R `'~ G,~ ~ ' ' s N ORrvERS UCENuSE NO / 'STMT ESL S/E.%./ DATE OF bIV1H N DRNEHS ULENSE NO.. STATE SE% DATE OF &RTH I ~:A t,. O. 5 1 ~ V C~~ lYG"l 1 C 1 O. . .M(I DAY YR ~~ pRIVERS OCCUPATION FIRM NAME ~ PHONf NO '1 DRIVERS OCCUPATION FIRMNAME .... .. rl NE NO ~ e _ CDDES > ICI cL:si-~-~ j°I sEATBELT _~ LEI E~ELnoN _'.__ CODES > I]I C A55 °I GEAi BELT 151 EJECTION __~_ ~ ' Y ~ ° LURE OF EOF ~+, ' NJMRIES 6u- . JU ES h R E00 E FNE RY TO " +,"T ~~ SCFNE BY: TO (r.~~ + ' 4,V'" ~ VEH. YE MAK[I E~LNEVJ M00[I~ID RT~N/Dy~~ BTYLEI OR: CONV_I VEH. YEAR MAKEIDODOE CHEV.) .MODEL IUART~NOVAI.. GTYLEIZ OR CONVI . ~ 7~ GAL) ~Z1 ~ ~rU` y !? ' ' E VEH. Ofl, LTC. RATE M1O. STATE... TR.ULEn PLATE NO. STATE......_ E VEH.CULOR UC. PLATE NO.: _ STATE ." TRAILER PLATE NO. STATE .. H- (+` VEHIC IDENTIFICATgN NUMB ~R .. .. ....._. ODOMETER C VEHICLE IOENIIFICATION NUMBER „..:.. ~ :'-. _ ~ ..-' ODOMEfER._I;.. • '~ - ~ ~~ .,:_ ' Ls. :: L r E,. E.. ~. .~.~; ~" ~'- ~ R-LAST FIRST. '- MDOLE' ~' PLGISTERED OWNER-LAST ~ ... FIRST .-..•.. ,~ MODEE ~. + r ' A • .. . O. i REGLSIEPEDyO~m_l~E ~. - -- nougess oF.owNER.. ~ ADDRESS OF Efl..' _ ... ... ..", . ...,. ... Z ! ' .~ ti , ' ~.' ', J "~ ~~ ~ NFM[AND ADDRESS OF INSURANCE CO. OR AGENT NAMEANO ADDRESS OF INSUMNLE LO.OF rGT~iT ~ "~J ~~ IJ III «c P'~'~`~ Jo~~~sc~L: ~~ - LN OE ~ ... '~~ IC~I,7/A_iION NO.. ENFOfICEMENT CHANGE...... ~. .... -.... .. C AT O! ...... ~ /_a I ACTION 7' LL__.. r 1~ I. ~ ~~._~ `j _ .~ NAME, ADDRESS & INJURIES OF PERSONS INVOLVED_ LO s[x DES AGE l ~ STATUS _ °' ] 'S T 5. EJECT. " .. ~.. ... ."711 - ~ p 'wriJnas - - 'v A NAME .___ _ T HD~p. F~- ------- i~rMOVtD rrTOM S ~ Uwrs ri sf[m'nY To ~ 'W J . i NAMC ~_~ ~.._.~~_ .~ . T SF- n" ~' ___ ._ ___- -._. _ I u6v~o`rn~M _. ~ . , N ZA urtLT iD ~ S N•MEr ___~. __ __ E ~1'11ii5~ _.____ '-_._..__~ ___ A[1~Ol..gbti- l - to , S• x' s ulsL•r rosDloN JINJUnrr.L.us I wlsLAr REU ulu[claN T u nl NOIrIJURY 5M^vRUNOINJL)RY I.NOI INSf•LL[p NOI EJF.ClEO (+` ;1`~OI51nW ?Uf AD AT E{LNF. 6NON DIE•DLING ]NOi IN USE 71DTALlY EJ[LTCD JLLICD D O~RLNrT / ~ ~~~ ~ ~d DA IIDN UNYNOVMI ~ J MLUOIN HU5PIlAL IT 1'OSSIDIC INJURY ~ UCAI•IO1CLi FAILUPF. , CJCLI~N1 E e. vA1NC55 I . 1 111 J1 AAA E OSI _ ._ ._.._ ~~ +,~r ~. ~~~~~; ~''~ ~~' ~ ' ~ ~~ 1 ~`fi~j;~a Y ~J~~ . '' TY , ~,I~1~,~'~ ~ °w k J~ F" it 1 ~ ~ ~LJ.`Y~~laj~ ~ ~ 3 ~ ~'. 'f~~ ~~ ~; ~~ a ' Z ~ `) ti E '3 1 Fr. ,~;~ ~ r ~ ~ ~r~ + t;r sl ~~ ~ --~~[ ',~ Ejrl~ ~ '~,,~, ~~ ~ J. LT'~'I F. _'~E~~l 'T'r ~p,~o°"""e'° r : gI I J ,+ ' ~ k f~ ,.a ci''~+Fi ~M '~ L, yyi..'Iti , i .._ ; t,A,%~~ . ),_ A i~'~:~,~ k f , f J 1 _,1 ~. , I L ~~ r y ,.I~ ,y$ ~~pp~~~~Y~,$r,»,.+~~ ~5i 11`~n~~AiH. q ~PFs~ , .aS it ~ . !' ~ ~ ~ ~~ 4 n l 1~~~ t .-' ^- N3 INSTRUCTIONS: ) s pE EAO sL E FsrlTlrnc]. _ ]. UNA4AE OV TU501YVH NCIVAL UIHLCiIUN OF PUgCE ~ ^-.~ ~., ~/ r _ DAMAL'ED VEHICLE N0.1 sE ] f svA t o sRF1cN N. pamacE to llur-MUiOi~ rcLe; Ptt I , GED VEHICLE N0.2 _- rp T .P."' r ~r '_^~ ty r ~~- r ~~ +• 16.Urwr GrrruP~ r rr ]. O. I rr.n SE AA f ~ +--. E F O V RITYOF OM G EN CLE xO.I 1 Q+ DISABLING OAM G ] ^ pTNFn M.v. OaAIaGE ]~(]'FUNCTIONALO ~ ^ MADE ~ Ffn iv Or UAMAGE:O IvEN CLEI ? CI Ous MAGETNE ] I~piNEn MV, pgMacF ^ x r ^ ,. GT F SEVfgliv Of UA EN CLE M1O) ] ^ A ^ I ~~u ] ^ DIME MAGE NO DAMAGE CL TO WED BV ~ r„r- ~ `ll'. ~ T. UAMA r OaEAAOE Ep ny TUwFO BV FST.OAMAGE T I p .lii ~ !^.t , ...o rp 3 3 DIAGRAM OF COLLISION 1 ! __ ~~~_^ ', -r. P.. 1. DgAW Aq ROW SHOWING ..rlannt3 owa. •nw. I I /~ ~ `--' ~ - "-' NURTH IN CIgCLE ,. p oFnc o~ox°,. E: ow ]nAr. SArI,w.R., MNxSxa.rnM. LO,o, ox3 - I ,! ._. _ ~ J~ r _.. _._ .. 1 - ~, 3{ _ - _ ' I .. O -- . IcF Palcx.co,nRO~,rox 3 Elc, , . .. .._. ~ .- ~ - - ..__ . -- anLA . .- _. ~]. N,ow rtNr[tt .LOt3.n.x oa. p.,rn.oSnmxSqu.r.gn ., _ i2 ^. ; ---'~ .._. .. -~ ..-,- ,_. ~ -- _ . __._ .__ .__ . __.:_ ...._.._ _ _. . _._: . ! - I. I ; -- -^ __ Dort ,rox. '.. _... .. '. .___. ~-._ __. .. r ~. i - - - I i - - DESCRIPTION OF COLLISION. NpcE OEABLV RAPPEnto nFFpnE punwc ANp arrEq rNE CngsN Nu E rpN x pIS Tr,gtouctpvslenlTr PlAtsTnlAxcwrxnlecpLan epnsTqucT O:~on n[PARwonK, FTC.I m ONOAOPAM, ORrvfq .. - - r, _ 1< 1 _ I., Iz ~ f E ...~ .~.~. c .._ I J!/~ ~ ~_~ .,..- - _. .. ----- - n r~~ _ __ _ _. _ _,.._r . -_._. .. ` POSITIO ~ N BEFORE COLLISION L IE P nEAO[D rv0. nEn V CREASI UN STn[Cr On HIGNwAY ra AME pq NO. SInG OT ONE OIRFCiIO . sarE Y RFEp S VEM~ OCCUPIED C _ ~_ . _._ YES ~ _ _ .- _I I _. - -MPN - -~ _. L_f _ ._ vE .EmR c c STWASp3 r NO- sr" cnp .._ rR ,. , I sNputp s -- .FO = OM SIp G W LnWAr ; _ ;,~. ` iRGY~LFnp TF pTNE o l0 w.r co ' ---rpt__ R .ROAD SURFACE NEG.OnEI WEATHER IcNE«ONEI CONTRIBU _ c TING CIRCUMSTANCES NFCN o E o N nMOnE OgrvtRrvFNICLE qcT Ons: 1N c.f nrtc. ~ of] onioER ] - - oiiofi N'p ~ - ~I I ~ cpgpcG oR.oa., NT AN EA ~; oar _...._ "~ :.C EVF~ oupY n ' unpEnl Nr LUENCE pr ~ ' 1 ALCpt10L - - ~ (-'7 raupw ~ ] I^=00 Cyy = nofo wAnN. T] s G "_ .tJ>_ vFRPASiiNp AN N wf] r AINInG IINpFnINrLpEnGEpP - r Ena __ Ir LEfP ' ~ _ G R G T URN 3 0 -- -- Ow G J .._ rNG 1 ia~ p ~_ ~nAP ° , ~ NOVEq Pqna xG .J ~ 1 M IcF . ...... __ G roc .~._.. _. , G /1A s 5 f9 -~ F _ 4 40C JON_ r_~6 c)IV[EOUm. ~ ~ [ u INGrIN MA 13 -~~OTNEn ISpfl'IF YI- ~ OlNf ft I i[clivr I - ~ -~ L _ ~~6GG _. v_ __. __ -~l]~ 6r SLOwIxG I . , r I 'n En - G I ] 0 .a rG _. le __ T VI C ~ ~ OP SIC FOR TNAF LICHT CONDITIONS I[ntc•ONEI RAFOFIf fONTRO 1Np) IcTYPE OF ROAD [A Ox On MOq[I E VEHICLE CONDITION E SOBRIETY _ ~ ~ I J srpvvfp AT LCnnI C ' sGNAL3 I I ONE wAY ~bCa€ QQSS CL[ ~~i~ U{FOI LF ICNFCIt vEN C ONEI J pP s]UP.IGn _v . , , _ __ _ ~ In ~ STUVPEO IN - I GNL ] SO ] O Av lCII[ - __ l pAaLly nto -_ _ _ ~ u n ..__ ] yF 34 f5 CI ~, L IL 5 ..: ~ O1 ICU ~ - ~ ~ N O i 3 - I c o E1 C ANGC oP RAM I G F n[ ]s ~ - nNl ] 0 n c iNTlnING E ] narF - T Icl RIET o _L..1 GN.aoN._.._ - r ._:.._. _.A E '_ js Lfr ___. .._._.__..__._ _ . -- wp a _~_ .~_Ol. sr.+OOFr ,_~.. .._ ,.A '. ~ EEN pnwrclNG 13-~ nlcKmc __.. J TnrET G O __ e nn _ _ sONAt n. owav_LLPt .._' r•rs. recl~.ly . rP,Own - nN~oEn CHEM. TEST t ~ ."., '-I ~ ~•'a3 N[IIIONTf _ '] 0 I C cIE2±SiET-- 'I aNAIIU ~ ~- ~' ~~ ~ f51 OIVIN _ I ` _J oT ISPEC FYI . _._ ]: IvlOl'U _ .. .. NO UEGLL'TS 51 N[rusfp OT f ~ ] F N ~ ~ % TEST HfSULTS Z - ' f1 In~ fy i ) 4ul X ' I T7 I M uN UO[ ~ I ~-_. L- pr~cE rf r Ow ]Rro iMlvilito PNnvronr alE ,- i i ---_ _ _ . ... _ ...............~.~..r~.ra rr..~rnN~lLrNxn3w OUPIICATt COVr LOCAL LAW RD OIICFMINI AOENCY'i COPY-tHIPLICAI[LOPV INV[SIIGAIOn'SCOPV ~ • t. _,~. s~ 9~ ~ ~ tJ, b rl~ i G _. L NmNlunr s Dlsun.INGINn,RY I Nm n+sr+ufo I Nol ufclfo I( ~{~"_ ]nE AnAt SCf Nf. 61181 n15A0lIRG ZNOi1NU5E ]IOTALLYEJCCIEO I-J~ 1ORU5R OTOIC ClE1 ]Uf A00N ARRNAI ICwUCN111NJURY ]U.`.[D ]PARTMLLY EJECTED L I M L Y ~ UKnIN HOSPITAL 11'055rPLE IIIIUIiY A UIINNDWN A UNIf110WNIf ~ ] PpO51TION UNANOVm 5fiLAl Rf.LT iuLURC LJECIED W NAME 1 AOp f 55 T NA'uA~ N $ NAMf S AonRESs E uH~- "' S ulsT+TUs C : vASxt LAGER ofM 9LRIUl O PCYCL151 O 5 OI~FR E a miNESs D DAIF Oi COLLUtON OAY VL CULLIGION TIME ~ C OLINTYN / CITY NO fHw'A A MU DAY yR MUN 2 lU(E ]YIE InUX 5 LRI E SA1 tiUlj USE V<UO HOURI ~ /!/ j '.]UNBUI IE r -- i 1 J` L :~ A = ' ORAL OVNTY ^STATE ROUTE ®COUNiv POAD ^CITY STREET O AOM~CIS PREFI% OUIE OR S1gEET C ODE 5 CTION ~~/-l V~.S ~:// ^OTNERISPECIfY) N 3 // ff _~~~/0 L ^IN CITY OR iOVIN N 5 W P REFIX EO MILE 1'OSI O E 4 ~ MILES ^ ^ ^ ^OF.._IYZ'V.SI.~^~{J/Y/J' _. _____.._._.__. V /- Co C NAME 6NO.OF STREET OR HIGHWAY iER$ECTING PATH' STREET Ofl ROAD LLLL R AMP D IAGFAM DATA A t ONc ,f5. ~" ~'o r/ /ra;.-;K f._i/~ p I _ NONINTERSEL I IOENT NTER NON %HD NTFREECTING GTREEI OR ROAD OR REF. O ML I EAGE IN Ct5 ERENCE L`ROSS STRE ET OR ROAD N ~Y ~ BETWEEN ~.. ^L1 C.^I"I Y<1J. STitffl AND ~~(Q/_-./=/JJC~L J RiRFH S REEl ^ - - GOOE 4 P CI U USE ~ y ~,J /O S1 ~ DISTANCE ANUDIRECIION FPOM HEFERENCEORCRO.. MILES I ~ 7T. ^FEET ~ ~^ ^ DF .p ~Y IUf'.L•'%1 h------ fi[i„s S ~In AL CO ING E '' gVEMICLL~vENICLE ^VEH LE~BICYCIE ^OInER IwRREI ^HITa RUN NO KILLED VERRr COLIJSION INVOLVED: ^STOLEN VEHICLE ^VEMICLEOBJECT ^VEHICLE~RRTRAIN NO INJURED __- _ T01AL N0 OF VEHICLES ~ ^VEHICLEPEOESTHI4N ^NOII.COLLISION ^HA2APDOUS MATERIAL ~_ ^PPOPERtt DAMAGE ONLY O&IECI STRUCKINAME OF OBIELT STPUCK ANP OWNEflS NAMEI LOCATION OF O[UECI GTRULK ESL. DAMAGE ^ROADWAY FEET ^ ^ ^ ^ RO EDGE S pRIVERS NAME~LAST FYLSi ,;.. .. MIDDLE-. pRNERS NAME~IAST. FIRST MIDpLE Pf, B{vLU510R PL UESIHIAN [nECKI R ~ STREET ADDRESS ... ... -' ~.. .. .. I STREET ADDRESS.. .. '. ,: ~.... , ...'. .' ... ... ., p E CRY ~ STATE 21P CODE ... PHONE N0. E CITY ~ SLATE ..: ,ZIP CODE ,. PHONE Ap. R R YJ N DRNEflS LK:ENSE Aq. ~ ~ ~ STATE SE% DATE OF &PTH N DRIVERS LICENSE NO. : .. STATE, .SEX DATE OF DIRTM .. O- 0 DAY R O- O. OAY YR DRVERS OCCUPATION FWM NAME PIK)NE NO. 2 DR N ERS OGGUPATI N FIRM NAME. .. .. .... ,.. .. :. P / ~ CODES > nl cuss-I/ °j SEAT OELTI ISL EJECTION _ _ T 151 ELECTION CODES J I]I C1n55--` TAI SEAT BEL 'LOUPE DF HIES - T NA.IU iE5 F Y '~.~ , C// Y. `%Y.LC fROM SCFNE BV: TO E OvEO FROM SCENE PY~ TO VCH.YEAR ANE ryOWE{NEV.1 M MODEL (DART"NOVAI. Sll'LE IZ DR{ONVJ VEH. YEAR ANEIpDLIGE{HEVI.._ MODELIDART.NOVAI~ STYlE 12 DRCONV.1 v 7 . ,.~, ~~' / C / \l~ v -73"" JS'wct~.~ 3' E:-c, t~ : C I E VEH. C .; LTC. PIAIE A:O. SLATE TRNLER PLATE NO... STATE E VEH. COLOR TIC. PLATE NO.. STATE TRAILER PLATE NO.: DTATE . :, . H C VEH -IDENTIFICATKJH HOWLER .. ,.. ." ODOMETER C VEHICLE IOENLIFICATION NUMBER' ..,_.. :.~..... . ODDMETER~_,,.,. r: _', L_. E L'~ E . REEJSTEREp MNEP-LAST ~ ... FIRST MtUpIE _. REGLSTERED OWNER-LAS'1 .. .... ,. FIRST..... :-: ..,; ~:;. MIOIXf . _ _. i. S.ry-J ~ ApORE65 OF OWNER .. .. F OWNER ~. .: .. .:.~: ... ........... /? r r '7 ~ ~<Y+E r' ?Z,•~•,,re/1~e-~ __ . NCf~v!/YL~ NAME AHDApLRE550FTN5URANLE CO.ORA ENT NAML ANU ADOPESSOF 415 DANCE CO. OR AGEM .. .. CHAR C NATION NO - EIIf ONCCA!ENT CHARGE _ .. ,. CIIATNMi ,. . ACIIOH DDRESS & INJURIES OF PERSONS INVOLVED cooES ' _ ° ' NAME, A SE% AGE STATUS , , -yyAc EJECT. __ _ NAME. O C _ AowaESS _-~. -.____ ._ _ _- {f p _ . ATONE Of RCMUVLOi ROM tD snLNf or w.KlRrts A -~- NAME - ~ N AoonESS - $ H[M lUfHOM AUUUrF 90 <CE NF RY TO 4 M xt ^ ~r;~e ~ xpim'..n>! ~ I J ~I~~~+ '~- ~:P ;r. r ~~f~ ~~ -7.. ITT N N••; 'T '~,~~~`",S~y ~'~ " '~'~ -)1 ~~ ~}, NN Y~ ;~ AT1 I ! ' 219 '~IJ.,, yj f ~ '' _ ~ I L L ~A' J i5 ~ ~ ~ .1~~ T~ ~m ~f • ~ ~ -. ,. r Vii.. ~~y~ t} t I ~'~ f` N F ~t ~ ' ' ~ ^P 't a a ~ e I~ ~ d'~1 ,i: ~ r'~I ~• ~' x.s DE F40F G!•k I[51 rA1ACT (" E.].' ' _ RUCTIONS: o. n 'AngowlslTOSnowPRNCPA DwecnD DrrorcE ~-.e~. r v~ 1 - - MDSE ,qAl, EE _ + ~:, y ~~ DAMAGED VEHICLE N0.1 -_ +'r 5sr wcl ro ETC DwuwcE ,D ERS MD, Dqc c f,cl DAMAGED V({~/EHICLE NO 2 ~ ,;F$4 w..~-~.°iT~r! yl ts. u ~l~ qr~`+~~-,.2_~ ~~ ~~ ~x ~i ~ ~ DF ° cocE oTNER vkH' LE H Tv or DAM c vEN ctE rvo x ~~ [ TEVFRMY OF OAMAGt VEH CtE NO.,~OINEnMV.D MA4E rE O^ o15wnElrv MAGF eRHO McF MADE IEO 3 MAG[ J ^ OTNEP M.v.O MnG[ ~ ,~ '" ~~. ~ t ~ DTPBLING DAMAGE A uNC, ONAL 4MAGE ^• M4 P MAGF t ^ ODAMAGlE$T oA "f r ' )[]ruNCTIDNAL OAMAGFI GE PGE iowEOBV O'7 AERI DAMAGE T MPCf v'~i ,. OwfDBY y~aT a c -x R _ '~. A O~ (+•/ MA [~~-aG 3.5 ~~/] T Si ~F~. - DRAW ARROW SNOWING 'tl ~ rfR TO 6 NUR IN - ' DIAGRAM OF COLLISION. -~ - - . r. :PeKr.. /y4 '-f-?a?e~ -~~nrcS\ btrJc ... - ~aK ~~. I RP.R•.... wDr,Y.rl„NHLS ~ - 1\Y/ _ _..-. „E.,c.u Pv*e ::k• ,. ... '"o;;.a;:„ROES ; .. ..-. . „ s -.. ~ ~.~ , . M,xrPA.,,3r..lDND:nPN3 `~-- S7 , -. PREAf 3,cT ~- - -~ f~ .. o. f,ow Yf. E.f.avrS,R ., DR ,Lk~~S- __. -._.. _ -... ... .~: .ND.r,IRCD..3M. -.--- f=fah'<c(j Ra~.:J _. ~) rroL3rn Rrvr.rR3PerR INr4grgAlloN NOT ONOACgwM fG.UPIVEH _ ~~ f~i P ~ DESCRIPTION OF Dawnlu, ,, wreENED REFaHE DDgINC wrvD 3~ COLLISION I NDmwrz E RAa<Y T ~rwtsTHl torN Nc c°toa eo ;NS;a~cis f :IR wonK ETC I ~+ r~ ~,., -N c a<p ,/ir•../-L5 ,cdTc Nr6NT..OcC~Pn1.~.[v_ OT : Pa~xF? 7~.=.t)t/cF? ,. :.' v<Ne l~o....(_ _. AS _ '._Tr-1~ or'c0••-c~.+~...Sn~oRr.i!F..a.L..~~-- ;~ .~; gricGL.7~Rr.wF_.A~'_°_s-LO~En-6 iN~-a-_,nrro on J o.~ ,; . , -. /Td-IZ'dVN~ /~~o ~R Gyctc ~ H • 1, I~/:NL N N/L /~ .50 TN.TI.O r/N.p ) A Sv YF ~___~ ?fin _ -/~ u ~ .J.YGNT -a ,_ Nt~.3- c >r ! Jc 7 ~~','. ~+ s76?. o~~.-rN.- ~~_ s`f,~la r vr~r1~J?r_"- rt- T. - '~ FJ~.IH/.P~Ta GFi OJT _OT C-t).C N.•_~'d /'/'._.!~(~K,C A/y~7N6 TF~ -J7S.L2~GT N_ ~1 ~~' ' sa F~'cR ST R_ fib/ ° ~ E, - YE ~ ED ~ POSITION BEFOR COLLISION A ED D~i olgtci~DN ,cD r vi.nwLL- Oc Eo 7 -? ~:~~ NEON. ADED INCgEAISE POTi PEAR NG ON 3iHEET OH NIGNw4 N NO '~ E _ L~ ..- ..- XI 1 ~I _..' __ __ .. ~ ~ NG ___. Cn0531 G _ - - TEO FD ._ . - ---~ x. --- x . - MA D C O I vCIE ROU OTHEH ~~en , E ICV[L ST ww3UTING. 'TIDEwA ISNOULOEn CPO - M C 4 x. WNATMEft LK CONTRIBUTING CIRGU OxE ANCES o MenEE F ROAD CK Ur~EICE , EcK GN LK Av ~ E " ER NO oEq n E D RM1 . RW ) 1 ~ ~~._ ' NO '~, UNDER InFLU ED G ~x G tl. ~ ~ ~ t~ OHr C E H,C D , J.T. SL43E4 = ° ~ r , 1 __ _.._„ -~6 DVEHCATT ~- A1COtlD LUFNCE OF XRI O - n x O .... ~- - wEl~_. -~.. IN NG _-x~- D GR.- ~_. AI ING,O lT RgOPOI YANKING ~^ 1 i ~R [~ _~, ~~ '"~~~' -~ ~~ j... _ TNOw ] iTNOwING l-.I l.~-- Y [D NGT O yl G RR, «. -___.-,__ _ MEET IURNN _ f ~r A' ay _ _..- _. _.. - E u,uRN IID E" ilenvt f.o_e XR -. , A IC[ rOG _ _ [ [. .-_ ._ __ . ~ ~ BLOWING f A: ~~ ~.- _. . __ _...._ .. .._. OT GHA ..II G ~.1 ~ R r' E s .. I ~ KLE 3 -_-__ DTgEN IRRr CIr rl ~ O [ 5 f rq Ge[R T E u T tR twl 0 I E PED OR G {f I• I I ewM VPE OF RPAD VEHICLE CONDI iION SOBRIETY.- , I s*o GrTi~cNAl LIGMi CONDITIONS RAFFIC CONTRO 'f LE' G cglGK Ox[I I ~ ~ IL'NECKOnEI No.xvIRIG 1 0) I[fcK ONFO ORLI v[NIC ~~~E " INICII ~ r - ~ - ^ I _ onf wwv I uD P r coN~~16r5~~m I No. x x' ~ TD°nowwv ~; sIC Ls _ tD I wruGNT - x ~ .. s oN J1 -. .~ -: is ~.. L T ~ '. vARlgcio:nsinox t I > uAwH sic .. D . 1 _ :. of nw._ -- I ._ ,L ~ rn:"u - lE I_°E 'AI°ft _.''L... EoN DgINKINC_._..___. ~e Erimn'ENnn nc .h '.- ° Rms'- Do. AcKma ~~~ _: L G ° tET. I ILnR _ .. ~. 0. 00 CHEM. TEST I ~ ~I }' -~ D ! " '6 ° ~-.16 IowA NO x - D1M[n ITPl CIf YI }~ 1{ a ',lc 7s 0.. L. FIG -IT-ti fig - T c ~.~," ~ ~~ ~ y~ AHAnD J ~ 'iAa`MAN I 3 .._ _ ' 1 Y: ` ~ ~~ f nuts °cqn r _. ... .. •~• 1. .T'\ E .. O1 ~ o DIVIwD ~, x ND ntr tLls _rs rusm _.r _, _ ~ _... _- -m dlli is In 9n T RU LTS 2 EST RE ~l '.~ O,gFx IViCU VI R. y [~. Fo, [ O D [ C LICI AHrnv[D AN,IGA, nGOrII )e A xA~IIA 'I ~ /-rihE •rA,~.r,s`.'~R B,3n ID.,3 S l6;~a3y3'I~~° off ~a .II"~ ArdA.~ T / z ~ ~ vn+wAl NG OnI<l Rs nww AHANK .. u . INCY , Dalr mnvlDR uwn. X IN ~ ~.e S, o, ~gle~`I c ~, < t I ~_~~~-~~=~Q~~. .l__:-_l_r D o 3, A Df C~ _I~ [ }' STIf OUTIO p ORIGINAL CGeY 5[ND 10 WASNINGTON STAI[I'AIROL-OLYMPIA WASHINGTON Otl'+M K.~6'.t~l _ DUPLICATE COV LOCAL LAW[NEORCEMrNT wc[NCV TCOPV-IR PL CATE COPY INVCS11GAlORS COPY ^^KK ~C j t ~{ • 1 ~ [ ~~ t {t [ L i ~ E~ ~ i G A.~~bi[u 5 .,, ,F A. 1 ~'. I.1 +,(1 ~'"tl.~ l iA I I~ ~ ~ 1 '' r ~1 ~ ~ t 1ti1~~ r s ~ E I "~. k I tl t N f r l ) iY~ '~~~~~ ~y~ 1 ~ i ' ~ I t~ r ~ r ?~~^I 71 i~ p ~~ + ~ 1~1 y.l ~ ~. ,, ~ .. _ . ,, n _ .. .I~~: i~~ of . ' ~" - ~~ ~ , P~,e cs'~*5' ~`~-~~ ~h`}'rt-~s., vG. FY. -~to.~~.~.__,~~k_~ ~ _. ,ua . ;Q<:;:....,..n~,~a.,,;: ~~ u - :;~K~ r v ....1 T a4 ~ STATE OF V~ASHINGTON PADS DF No. ~~ ~ ~k~ ~ I~1}I :UNIFORM POLICE_T_RAFFIC.COLLISIONREPORT _ ~_ECaAPLUNrxuMDEH .J . _. ~7:' ~.v e.'1R i.ON 3JOti13~~3DAg4D Y"' ',DATE OFCOLL1510N ~ DAY OF COLL19gN ,,,jJj''' ~I T _-~ DAY Y T SUN T Y011 T IUFS 3 WE , 11MR S FRI 6 SAT (USE 2100 xOUR1 Y ~~~~~,~ CITY II(1. ~~`Y--- __~~FNWA I _ CWNTY- •. ADMCLD. ,FREED(' ''ROUTE OR 6fREETr I ~ UFW. ' ~ - ^6TATE NOUTECOUNTY DOAD ^CRY STREET Q I '-I CTION ~ ' .. ~~'. ^OTHER ISPECiFr) W -- ' - I - x 6 E W ^ IN CITY OR tOWN :. ' ~ PaEFI% EO ~ AaIE PO .u 1 C. r. - IL MSES ^ ^ ^ ^ ^0F U rr'' ~•Lr0 I Ja JO 1 _ _ 34x1 I. l A .'NAME aNO OF STREETOfl IDCHWAY- aREHSECDIIG VATM SfRECT OfiflOAD LL OIAOFWA DAT T ~~ Ij ~~: .~ T~ ON' -,-; ,,T --- - - -- - __ .-- ---- Q~ ~~ a~. as ; NON%ITEASFGIICN.~ ~ ~VM +3 MAA A' ~ O ~ ACCIpEM PRE NON % WTEli3EC ST AD Ofl REF ~r 1LN.: BETWEEN MIIEAOE .. CL9 EfiENCE STREETOgigAD l:fr.. r l~ I ~ STRELT AND '.:^,~ TH CODE ~ ~ ~ ~ [~A-'"`' '. p3TANCE ANDOWECTION FFlOM REFERENCE OR CH Si ux s SPECMLCODWDLLSE -- . ..... ^MIlES N 9 E W NurvprE,Nq ''~' ~~jQ~ • N~', ~ ~, ~~ ~ ~ ' ; t ,. FEET Of -... 4'T~ ~.. T~_ t ~-~~ u".~~D . W TLFr•A9id1~ '~:. COLLSIONINVOLVED: ^VEIRCLE VEHICLE 1E~SICrCtEr ^OTHEfl RrNrtEI ^Hrt6RUN f ~' SEVEIVITY r; ~ V ~a 1. r- TOTALNO. ^VEHICLE-0BIECi -~-. IE.RRTMN~T~ STO.EN VEHICLE ,.,~Gk OF VEHICLES O .v .'L~ - ^ 1 _ NO ~ ~~ ~ ~ _ ~4',. ~;~0 {-r ~ ^VEHICLE PEDESTWAM lLLJ11 NONLIXL510N 7~. NATMDOUS MATEPoAL PIrOP AMKi -. :~,~ ' X~ ^^`` _.,..OBIECT STi1UC1(INMIE OF OBIECT STRUCK ANDOWNERS NAMEl ~i<';.q .ir y LOCATION OF OBIECT STRUCK y,,,,. +1ui~. : V ~ : - -- :-~ .. _. ____. N~ S^ O .~ `O~ q Few eFOf,F/,Or3 O ", ~ ..~ ~~ .. NAME T .. s '.• - ^ROADWAY FEET ^ ^ RD EDGEr• S„ JEA4A[>E r+ "Yi :, MaK%E ORNEIYS NAME FflST MIODIE IU'aIC'(CL13T, Op,PEOE$IBU~yfrF,FSi ~.R.. srREET,AmrESa,.,. tsRD ... ,ryvr v I ~.iiilZt.IJCJ' 'W I .. - .. :~:.. STREET ADOR ,... 5,.. < 1 V- t 1~ ~n ce u 3o L.Cr cor is 'H O~ 'v\ ~+ t< O~A a >rf b~ o Ti 7 ~t $ '. :Y' i I E' _ 6tATF~ +j, ~_ PC DF/ W r .: ESC Clry. 1..~ ~A ~ p E~ ~,+*~~ ~ a ~ R-, spar O..~f ~ hOl+ti 9 . d...O or ~ _c 3:'. 'tRo; 3 3~~ cd ~.fc rr .• j\F ... - n_r„ 7rtL. ~f O., DPoVE0.3 LICENSE Y fj 1.:.'1 ..MATE 6E1I OMO 00AY H:YR N,L pflIVEK$l1CF.N5E NO :.LbD XS :..TG s IATE:J JF04. DATE,OC SVfQr....: <n ' I ~ ORLVF.RS OCCIPATgN,,- FEIN NAPE v-.vs.:::. m;, -.,PlgN NO Z .' DRNFIi9000UPATgN; WMNAME: Y'. ~. Ys r. P IE ~. , ~ , ~, Rai' - - .. .. r ~ .. _ ~.. "F ~~~, I .. CODES > SI Pant Y..-_ ... .. Iwum N t '-!:., NATURE aF. CLti53 ~--. IAI SEAT BELT Isl FJECTgN - :... _. CODES>IDI C '- NI. SEAT BFIT"..:.. Isl EIE :,~ li `.Or.. 5,. .,r._,. m ' Ir~aITU vESV _ _ ` i ° ' ~YSCENE BY: TO ~ FROM SCENE RY '.. ..~ TU CrgN - .FAR. MAKE(DQ4DELMETA ~ lir LIDMLNLIVN :. STYLEI2 DRCDfN.1 _: .:. VELA. TE/J! ,.rA.K.~EI iDDO0EC1lEY.).: MODELIDARTNWN STYIE 2 S ~ I E )£H - ANTE, :' STATE i11AI1FA PNTE'HO:- STATE E N y .. N VFH,COLON-.- UC._ HATE ND- STALE THMLEII PLATE N0. STATE l~ r.'~ ua I 1 ' ~ _ a , 1 ~D ~Y. ` .. IER.'?•Y ` 1'EJLICLE IDENi1FK:Ai1 N IAL 1 yTZ _~_ DWE ~ r .14: +., flECGrFNEn ow11Ea- I Ml~ .. y~ ~~ ~ I N LAST ....» .~ A .:.~ ~ MIDDLE- E REDLSTEDE~oR- I :. ... F~ ...~ ~ MF ~ E ADOflES3 OF ~ ~RA `•• .°k EF. '`. ' ,.. ,, L .. '-2:: .. _-.._.L. ...CSI Lam.:: _._.-s.. .I yr1~..~~ ~: 3s' p ~ . . .. YF ' ,~ g" NAM ANp_ RA11CE 011 .,.._, ':: - - a. NAME ANDADDfiE590F P15UR.WCECO, OR ADENi y r , ,..: _ _ r ~ .. CITA NO .. ,ENFO{%:EMEMI H E - _ '_l.: r. C~iA ~~ p ~ ~ ,,,:. nv,. ..1 ' ~ r.. y-~s.sc ~.rn rL.o+JJ~¢1.q;uA r Ts: ' Y I~~r '~a ,) T, ~ ~ ','.,, ~ NAME, ADDRESS& INJURIES OF PERSONS INVOLVED ° COOP ' - T 3 ~~ ' B ~ ,~ k, .. ~~ 'J1S11 ~..t~ ~ I 9E% AOE STATUS FJECf.I .~~~ ~~ M `. NNAE ry C A0011Cm: -: U H .. ~a•. J .. P' NA~~OF ~ '• .. ~uOVEDFflOM I ' N EBY. NAME: ..... TD Y' r. :Yi ~ _ . ADdRSR: - .. - ~ 9A , T. , µ S " , S ,.. ... DFR ~~ ENE Y: .. TO ' '•' ~ I yy. . GAME: _.. _ . ~ .~ -.. :. r ~ 1 ' !~ I 8 '... ___ NIIaLC aCFNE Or O -:; - ! ~~ I I _ ~ 8 NAME- _.._ - 1 _: .. ~ -- ._._..... __ .. .-__. ._, :.' _. .___. _ _ __ ~.. T W I f I 8.. .E .. ... ... ADLYIF91' ~ . i v .,. ' ''i III STATUS ITISEAT PONTgN ~ 71 WwLRYCNm _ ~ ~ I C T.PwmTNOER ~If)tJ ' _ er.~Dly 1. NOINNLIIY 6dSAWlq HMIY I IIISEAi BELT I3I EIECTIpI D'. 4~aI CNTlaafµ-' L -' TOFwO AT BCEIC aNON~pSN%aMt L 1NOT HOTALlE9 TNOTTJECT[D f 1 T IIOTNU9E .. D.IOTALLY ELECTED .. .: R ' i a ] T.OTNERPOdrpN SDFADON ANWN 11 •. . alaalY. SVSFD 3. PAIRIALLY EKGTEO ' D ~ aoTlKa .s. D~~rD~ncrp~ aarowlLDePBAL. T,~ r.I~casIDLE~LLSwm~. L~ A.LMFNOWI/ KLINKNOwNS - awrLrim a ~ ~ . i I k xE a.aEAr SECT FA%UIE EJECTED I _. m y„ ` w24~.. '~~ ' ' ~,~ . - I ..:'?i~': r. ~'i ~~;~~ ' ~~, e~-1: ~~ '3 VEHICLE DAMAGE ~ - ._.,_~.Tw EACHDDCCIRCIE[ a I~ rc.cH DUAAC~D ANEA ~ ~~ ~ ~ °„ ~~ - ~~~~~ ' ,r Y.6NADE AREADF GEVEfU:6T IMPACT. l _1 INSTRUCTIONS. DOIUWAAROWISITOSHOW PPoNCIPAL pRECTwNOP FOfdCE. ©~ I ~~E#f ;a DAMAGED VEHICLE N0.7 N6E TH14 SPADE ROR eNErcnND DAUADE TOTTWLERS,MO[oRCYClFS, ETC.) DAMAGED VEHICLE NO.R L,„'1 & fir{ a I +.~ I a a Ia. HOOa ~ '_ So [ s 1 RAq ~ n I ^ 1~.nPa y~ a .rT. !~ !!bMl ;E TrIM ,[ 1E.TnriE .i + euAe.rPNNw. ~. ~ - ',I "y 1e.um.,amaDe , ^'4"~ a I n ID _~ ._' [ n.a.nMP ,-. :i. ;: s 1 y to o e n.oman ~, ~ i 6EVEWTY OFDAM :VEIUCLENO.1 6EVEMYOF OAMAOE:IOTNERVEHICLEI 6EVEPolYO OMIAGEVEHICIE NOY {}~~ 1~DL9AULNKi DAMAAE OOOTNEfl M.V. DAMNIE' 1Oa6ADUNp0AMA0E -' ~QOIHERM.V.OAMADE 10DI9ADLINO OAMApE 'DQOTHEfl M.V.0AMA0E N ~~. ~_W((! •'~' Z FUNCi10NN.0AMA0E A NODAMAGE Z FUNCTIONAL OAMADE NOOAMADE 2 NNC110NAl DAMAGE ~ NOOAMAOE _ -y{! A _ _ A°3~' EN_ TOWEOEY •~ E6T.OAMAAE TOWF E6T. DAMAGE TO - EST DAMAGE. 1 ~.,. DBY WEDDY ... TO _.... a F.... t 1 '.. a TO s:.:- TO i a[P,"!' '•1. ,. 2 -OIAgRAM OFC9~~0 ~ ~ ~ DRAW ARROW SHOWING , ~~, '+~ --~ ~- - - NORTH IN CIpCLE ~~ ~n vAROwr r[wTU ~ •,~ ~ r,. 'g '~~m~sa°r t^ I O I Caw I }I rR:srlc coii °fFrrouPO~ aT .I... ... ', 9 f 3. saner «a -l. _ r~ ~ ~ IDCAT[PRmAS[EPaWr II'~~I I'LI~Ij_ _(I- ' I : ~ ~ I I ~ 1 11I ~ ~ t. r" ' '~`' ~~ d ~ ~ a.xgwut:l~uEP¢nA eIwAN On _'1 -' "' ;L~' ,-'_~1~-~ t ~•E;+ ~ - I I '~ _ aM[crPDV)IDNa ~ I I I I- I I viz' . ~ ~, ~s, _ •.[~E~N,. na"`a[.~ I I j I ~ . ~" p c I ri fL~~l I I' I I I I I (~ ~~~~DESCRIPTION OFy ~ ONDICATE WHATPRDBADLY HAPPENED EEFOflE0UPoN0 ANDAFTERTHECRA6H,INCLUOEINFORMATIONNOTON DMORAM,EA.ONVE11'I' -'y~ ~~.'OOLLI$ION ;:':`: d6A61Un'.flEDUCE0VI61&IfIY, PEDESTIUAN CLOTHINDCOLOR, CON6TRUCTION OR REPAIRWOflK ETOI f A . , r., ~... .. ~, ri¢er_informed thia_R/_0_that~le r±aa N~~n.,'.CQR~-12 vhea all of a sudden he seen sereral ' ead_of~eattle_on=the_rosdwa~_and_waDStne~b_le~t®_aVoi.d them and ~truck.tiwo of the cattle--~ • ~',:,' killin6__them._This_R/_Q_wao._ablc_to_get ths~~et oY the cattle back inside the fence ~ ,C tliere_.vas.-si:-total.oi~ix~Lead_of_cattl'e~that vas_out~G~the=;tield_oa_the_roadwaU. '"' ' d .. ,. ~ . . • ,. I '~ ', -=- -- ~ ~ I- - y - - - .. __ ._ . _ ...~ _. _.. - - - -- --- - .,::IIS ,{,r' ~ ".~ ' NO OF LANES SPEEDS ' VEHIC P 'L4~ 6" ~ ~ ~ ~ VEH ~~-11FADED MNE PO6T q0. - ~-0N 6TREEi 0q 1110HNAYNMIE OR NO --- IN ONE DIRECTION eP s.ve LEGALLY" WA6VEH 4 NO. N 9 E W WCREAY O DECREA6W0 _. _ .. _ P/3111E0 OCGIID~I)„, . ':.. i -~ / _ ~_ " .('''~ - ~ C.R 12 - - .:. cl ... 0 ~ ~ rES~TNO YES ~~ t r~' >, ~y -_~ ^ ~ n _ -- -„IDHWA I MED~E,,,D~EDDRN[N I , . ~, ~.. PEG. ^~~~I Nnrlo eoex L~T ~I ;'~MNixm oR -iMU~ C~ y~ :n~ PED/BICYCU6T WA9 U6wD : ^ j7nsw L: crosm,-~wOmw~~ RartE n ,Nw i"h aw ' } p ROAD SURFACE.,,-,j,~,WEATHEII _>"._ -0ONTRIBUTINGp1RCUMSTANCES ";j~_, )' -~~ ';v[NgIE E ,~ f¢ ~!' IulErx alD w[u vm rc cu a..[ .law ^:. b"~`N ~ ~ _ '. 1 ,d; ~. _. _ .. .. _.~ - ::._ ,mow I_ ._ ~ ~~.:', .w. > I-~ f~ ~-L ,' g ..~ ~ ~~~ ~' owlcA+: !~' Ltl cuuAwuwwdcEOS ~ I-7_wcaa°wN°ineur _ -I-'•a^ slaa.ro[uwuva ~ ~_ ~.:i ~~'T.. ,+kt~ ,.. '.,u's ~~~ a ~ wsr a (~ n.A.n a~ ^ aNDW+o el~ ~-- do-. _. .exl ~ ~ ~^r a~ V )a ~ a ` { l .y _ - .a L .I J: 41 ~ ~a n a ~_ [1~10'N.. ,[ J r - I8lt&~ olK~l>.ECr.i _ D..~. r~e . .. y~I OW=,....:~~iM UNINUL, ~a enNAln mN°P _ oa~u [ewDA.[or ~' V cDrrDT f 1_ ~.pvmr 1„II .! L f l ~ ~ w~O10Nr I - nc[[DNCar f""io f-l ua[o J __ 4 -I i O e ~ = ~oAAlva - ^. f 1 ...~ [ . ;. t J • v°AisPi[DraAa ^ tO ~ ~,J"~~ "`~[_°"" M,PPU ~" ~° [~ ~ 1~ Whit O~IaM ____._.. II~~~~~~~~ N ONO ..[.~I_L..Lm OO LOM_ ~I . _4.~1 ~C~ ~____ i ~0~ BtowYd .- f , ' ' ~ I r1.af-~ aarunbruL a• •LP"O ~ [~i ~arrl ^,~ TRrASn N,R -' ~ ,TYPE OF GAD', roux a[oN UDA4~ ,,VEHICLECONDITION HTUON[Dn Naa ~ ,:.. :'. ` SOBH ETY i.cir` ~ roacNOw ~`':.~ I moPrm nor1AL ( . 'L-J°^ oA aroP ". .rl ,) o,cw.r ND. [ coNnevnDr, NO' _ mlaar>x~ .~R~ rAO ~'~ ~~ --tt u `^r : ~~ l ~'T .~10iJ °mrnc wrt _ . ~nt . __ __ ~~-PUeIxiHro _- y ( _~J?l~ ,_pf ~n ._._ IILJ P"^'ro L~] ~s "r" o40c o ~1'' K` ~ ~ 90DRE,T _ -~'~ [ ! w . „~ ; [ ; NOS PAA In ,_- 011f4 _ ~J Y _ IM L-,J ,, O, ~ ._ _ 4.J=.L~.J a ~ °~~ H M ~u~ NACNaq { ~- tu«w[c+~" OQ aamwi ~ L~ A TEST C E a _ _ ._.. -__ ?'~ (--~ . +,~ .iJ L..t __ __. ~ ' W Or~ ON[I ~ y 1. J' t`S '_ ~ ~ (1 I ~'. 1[m MEN - ~ Oi1tPI - ~ SRLfY1 X11 I lal nee ttran_ _ T. DNOON'M'rc ~Y ice.. .. __._._ Ji .:+ rienjericnl % art. - _G DArt~ 04 io1l 9 D>:yi' ~° r~ . ~ _ In. .o[.cr.. ... ...._ wlanom.Am ~%:~~:rn~ 6 JCSO uileene rta[A[Na[O. T 1 _! 1J % ~ - TEST RE8ULT8 ~ ^z ~ ~ T w ~ 1 au.En _ _.-. ~Dwwrs _. ~~Nn , r .' ~ r ' _ . Tecr A[ronT Aanown I ... 1 ~ , 040178 ' , ~ ASIRNOTON Oeew ~ s~z ,._ VEEigATOR'B COPT ,,~ . I. *S d ~ A'~ 1 S „ S S. r I~ Mi 'I ~ 1 9~~~,~ ..1 L~ fie':.' 1 ~.,- 1 ' ~ 1 ! ' 1 Y I ~ 1 Ju4 f 5 - d ~~ 1 ,~ ~ y;; I ~~A 'Id ~ 5? ~, ' _ . i ' +~ ~ ._ Nom- }},, ., _,: ..;. _.. ~ •. ," cr..ewa _ - g • ~'. +~• - ~ . b h. rrf ~` x.~i'n • •.:j~ ',. ,w:,wv If~T~. - fL ~,f LI CUV lA Y1~rJVM"itLll ._ ~~, - y ~ fs UNIFORM POLICE TRAFFIC COLLISION REPORT ~#, .;q; :'.. J r+' ; ~,wc}R/. UAiE Of CULIISION DAYO COL SON 1MC COUNTY NO LILY NO. IH1VA :~; •" (~ A ~ A ~ M( UA\' 111 - ~ '.I U•. S LU 11 T ~ur° r~f~i~-TAI IU:J'JUI~I OIWI ~ ~ y ~ UnUAN ~ NIIAL Y ' ~'„ ~( ~, ~ -;:r ~_~ COU IY ff ~E-'CCL~SOh7 . ^STMC nCU E COUNTY n0A0 ^cITY SIIILLI ^oulLPlsrtclfn ~. ~ O uwi ~ I~ MA S PREFI% ~ IIOUIC On SI R[F1 cofIE ,5"/.7.0 GIIO H ~' '~... ~k ~. ~' ~ ' b ~ $ L C C /Y n N 5 C W rL^~IN ~ t~ LIIYUIIIUWN /~ 2MnE5 ^ ^_ O yILOF T' ~`D~LI.~R~.~'~N_e Ll .. _ W P V LL III:I IA LO IAIIC OSi ~ ~ ~ FR~ ~ ,n..m k l ~ - ~~ N , pp~~ NAMCA~I N(nOIOF STflCEi 011 HIGHWAY IN1EIi5GOriING 1YIi11'SIIiCEl OPnOAD ~ ,#}- ~ ~ IZ d I O IAAIP DAGHAM UAT - ~ ~~ , T I h ZA IV - 11EfIGEC1rclN \ I NJCII ON %~PD ICIISELIING SIPEEI Offin AO On REF. ~ ~ ~ ~ ~ • O NpJ U 3 • ~ ACCIOCNL M LEAGC 11 L15. C [NCE CPO. ~ nEE].(bHPOAD LLLLLL~~~fff^^^^^^ ~ I y , • w .~ 1~ A N ~ OETWFEN - STflECI AND .. .. _.".___ .STREET DISIANLC UJUUWEO110NiROMnefCnk ROSSSICPCE /I~' ^MIlES N 5 E ~ CODE Hwisl[1He S ~."."~.... Z I'LLIALGOU NDUSE ~ ' 2 ~~ l k rvuN [ `,/~T _. v~l\~ L'O. ~ L.CN Lam.{ _... .._ ~Q TEFL I~_^^~ OF _ .~ ry } /'F COLLISIONINVOLVED: ^VCN CLE~VEIIILLE ^VEH CLE BLYCLE WOINEPIWPIIE)//RA I, ^IlienUN , ^VEInCLE•ODIECT ^VEHCLE~nRTPAIN QI-~~~ •I'rN~^SIOLCNVEHLLE TOTAL NO ( SEVEnnY Ie ,KILLED .I~NO INJURED y 9~ 'I ~.. ~ ~ ~ ~ - . ( Ol VEHILlES~ ^yENCLE PEOEGTPIAN ^NONSOtUS ON ~HAZAn000SMAlEI11AL _ -____ ^PROPERTYOAIAAGEONLY ~1 ~, ~uy" r ~ ' ' U I/.G[ NAMEO f BJECT"TR D OwNERSNAMCI "' .~,_, LOCAllONO UDJECi SinG(:K ESL. D OWLUI STRUC K O K A N U C I ~+, ~ . • I /^ ^~ 1I ( ~ I / ,~ / ~~ 1 ` N 1 ^nOADVJAV FEE N ^^^ HD.[UGE 5 ~`-~- IJi~I-`-l-I ~Rti~K ~ 21~ ~~.. ~• . j OnNERSNAME~IAST HR51 MIWL[ II Di V(RS NAME USI FIPSI AfIUOLE n4 bCC O11 vLI(SN rI CHELn,(J Ig7C.+ •~ SiNEET AUUIIESS .: Si Rttl ADDPESS ~ ... I- .' .. ._ _ S u ( rt~`a ~ ~ I v G CN. Q.~. I ~ [ E CITY n P iE ZIP CODE PHONE NO ( E CITY ~ STATE .ZIP CODE PMpJE NO. 4 V3 I A " ' y y' N C• DPIVENS ULcNSE NO. ~zF Z-7 cs 6 STATE _ 0 ~~. GE% DALE Of lflntll O OAY P Ytii '~ o ~- ~ N C• URIVCRS UCEIlBE NO. . _ SI,iE A SEX DAIC OF U .H H.O. U Y YP. R - i J t 1 DRIVERS OCCUPATION IWfA IJAME PHOYC NO p, ~, Z DRIVERS OLCUPAt10N PHONE HO. [InJA I.AIAE 1 ~ l~,r ,. •I ut sEAi RELT._ ' mloN .. I-.. CODES > ~J' c . ~n w ss . •~-.. i CODES > ." w U , ..r s c3ECn , ___ __ _ ~ .__ _-. _ ~ J 1 ~ ~ L f~ ~ ~ I ~ fROA~bLFIJE / L ~ iJ I l(/~ j OV /~ _lG, TO ~"I ~ ~ '{'">:a_LLL.I\: ~~al.L ~SCI(AE I~O P l riL' ~~ VE EM ~-~ MAKEIDOD`uC~GnEVI ~ AIODELIUAflt NOVAI Il 51 VLF I2 DR~CONV.1 Fr vEH \CAn `IUOOOE~ .V. M EL(DAHIN 'AI YIE1]DRLOfIVI ~ k Y ++~v. i Tf r.~ E VEH C OR LIC PLATE NO STATE (RULER PLATE NO. STALE E VEH.C 11C. iO \ STATE 111 ILEP PLATE 1:0. 61A1E cy„J,5 (~' VEwCIE IOENII F (CATION NUMBER 0[IOIAE TER C ILLS IUE MBER ...1.' OOOMEItN E n JAA 3~~ IZ.to p 5~[7 L~~Q E a' ) fi , ~ REGISTERED OYINER-LAST flPSi MIDDLE ~^ ... nEG. ED O1'/NF -LA \ !QST- " .. . _ ,. _ IAIDULE. 1 ' ~`,. *,V 'V AppFE55 OF OWnEfl AUDRCSS 0 01VA'EP • ! ~ 2 '"'~' ~' NN.:E UJp A[JMESS Cl WSUNANCE Opt AGENT ~ NM.i .rJOAOORCSS OF INSURANOEL On AGENT ,. .. .. , ~ .. CnAn~iE C rt AI ION NO fN[OnL[M[Ni LN4RGE '~ ... :. .....~. ~ CU AiI )NN I NAME( ADDRESS & INJURIES OF PERSONS INVOLVED cDDts se% AGr 1 sAlus _ VI ~+ D , `. s rJECI. ~' [ .. ti: -~ C ~ NAME L ~!i_YrNiN n.v_i2't~t,'rr311/ ~ll~~1P AJantss' '#'07 .C'/.' iJ~J A: .C v l /r/). /YA.*^/7/.~/ ~ ri ! f, ~ 2y z ~ ~ ~ ~ .2. _ - ~I A -f,.ME _-..... T Apnntss. --~ _ I_ I I 5 nin ilns ir nv rTmM ci J r r0 Hr AML ____ ~. T ApoR[ss N n~ MjW ^ _" trLT.loYnill ilDM _ To _ 6 riAME _ 5 ,OM[s3 E S• N,1~s rN Iml i A ---- r~aa7rrr+ia- RLI r.! III _ TO - IS1,IIO;J1Nn• ..n Nl nlll, Cl A•,S i,ISI AI nI II ISI(JLLIK]N C ] rASS1 fJGLR JU WJHJIY I • MKAIII PIR IrIJUPY , 1 N(IT WtIALtCO 1 rOI CJLLirn ' J p 1'1 OL'.IWAN RA:YCIGi \ ~ I0111!!1I'n^JI KrI JI AO AI ::fl rl[ ; IIIANONM1111'JAl ( i r:(NI nA:AlI1.ING 11 'JIUI NI IN 1Y U ]NO1111USE 1S p OtAllV f.ll f"11 ]1 O PAn1 V1 Jf C110 A p smmn i i- ~ Du•, H'n(J.'¢rraa : ' I +ml nuulmuNlAL J n I rro:x•mIt INJU u M0 Jowu e i 1 ] ll ,uNenuWNK E __ emuMU m,norl pJ•.raJw H e " s Aluw r%nunt 1 utcn.D wI A r y.f~ R I,~t ~~ '.v,~,~~~~~ I r -.-~ ~f ~1~V ! ~ t.,: 1 YA t 'r S ~ I„ ~~~'~G ~. 4 'h ~ ~ -. ~' /( '1J ~y41 L 1 II SIVN 1 ~ 41 ~ fy L,v ~r +~(~ I ~~N ~ ~ Ifs p IT 5. n1 h f T RN: :--"!^t19?'?~?fi'?,+ 7Rk' - ^1'~' S .j i ~ ,~'~~ ' ~ ( ,"'•!sLd ~• I rdMln~Rl 'ro~9T'''' ~^. ~4"'"~' f ''~.. ~r r, rltT'<9,T 1 Y ` ~.>ri _,~ •,; •',r'~,~ 'r . I. ~' ` ~ La . ~~aM~ ~; -. '~ .., rr, ~.~ 'r: ~ T ~ ~,~ .. , ~ ,~ ~.. :. .4 a~~ ~~ , cw~lN~rA-wrovrc'e"~-M, an .Ig~, ,e,,~ v ~ ~ w, r~RS~'~r '~ ' "'" DAMAGED VCIIIC LE NO 1 ~ ~ ~~1 I ~~' ~,-t n Eto CVCLIM1,L c Y`~,A~~ NN~~ F I '7 N{ b~ I `"' ,nltL ,. I! nnMnf cD vuucLE Nu. z i Y$Zrr ~ r J IL 6 w.. ~~.4.~f U ~;'. V N YOr DwugLE VIN CL[N0.1 V•DAUgGE I[vL-[IIIIIV DF UAMn,II.I r -~T~------~~jjj ~~ -0 A• ,,,,z a C~ 0i5nULING OnMnf.E I ] (] U AA U !n Vf I Cttl INr Uf OnMAD[: Vll LLl ND > ' 1) ~n "+i CilONnt DAMnf[ . ^ N ULI, ] C]OiNfNMV. UnugGE Ikn USnUL NG DAMAOE II ] QO V~.rl ''' ~' TOWLD RY G i Uq ~ ~ 4 I . ^NULnMn~ illEnuv. UnMnGE ' 4~ ~'~~ ~~ {~= s: SP JG. MgLL i ^ w qcF . O Ho ugMwcE ,_Sv lD nL HOES DwfD Rrc sl unMn o .A D Lal. unmwr Sv - DIAGRAM OF COLLISION ~l C~~{~4 `r E~r` , __ I \' ~\ I ~ ,DRAW ARRO'N SHON'IN LI ~ . ~' <v.nuv,. UgrunLa L_ILiIT 11^ A ~~- I .__ C I G (1 - -/L 1~1 \ ~ I _, _ ~y NUR TH IN CIRCLE ' -•~ u - u ,r ~~*I /,Z, Ti-"~'r~rl 1 ~- ~ ~: j I I ~I_ I ~,.,: I- ~-I '~G~_.~ ~ j •~ ~ L~ngFi"'7 ~~! ,~ ~~ qn , [Ir.MrII Ih~ i ~a+y , ; ~ I r , t /c~ ~ ~ ' v~h ~' De,q .. K.u gTO,..,or I !~ `1 '~r„r.~r'}~ _ j'-(~ I.. _i ~._~-~-i i-_ -i ~\~(il~~-~a I- - -- ~-~ srrD, ~ .n. ~h~ENaEDN I I C F r-! _ ~ ~_ I I I I ~~ I IC ~ ,- T rl DI51N ,N [,lnsn r "I '~Ij~''.~ r - I ~l -.I ~~~ g~ ...F q.D q.nNCDlus o,.a' i ~'_~l~s~ _~i E~i~ i T-~ 1 I I_i~ .1._. ~`. ~_~ yd ar <`_` 141NO agn>[r~: rrwnnDLr Na "~ DESCRIPTION OF I r uc , .m[s1nl<NC "E CnA "• nlNCn L COLLISION },6 sA Ll n[u DrISIR LII on. coxsmpc sur"cc F - r": eic 1"DI aNDn _~~ y. . ... .. ..: c o - ei a _ t^ / =ur/d_ : "/ Sk] L1_. 7~ .f.Jt-CaSIA:{ ---- ~ " A ---- -Ou,C'. vF 7v__Cc >•!T ~.-r (/.'i~'/'c.P -_ c?uTo ~.~:. J ~>,P r i ~ .S c~lJ ~.; _ ----TO-~'/-GHT. _./JC~.~G55- Gr/;~~.0/YJr~i!t'._ f/, /7GSi1J~~ ,r ~+ .,, L/1NF _.~.///J.S «J~",~---.(J~ . le/~%211,`._ ~I r f• ---~~~?.SSE.~tlcciC.yc>/!_5_E/C-'Q.c i:'=_-[-i~~~>LP:._~C,?Ll._c_!J._.G.YF'- r - ---.J~~SJ_zI/I.SiG~-..06u1r/_OnJ_~/.IS'S.G;JGc./'.._ _ _ 2 LA/yiE_rv-- ~ P --- --- _-- ------------- ---- . 4 '}~';~_~ .POSITION BEFORE COLLISION ~j C ~ NEwDEO [rOSTO n. S' O~ ~ IxCHFASINO UECNEA5 N0 ONSTnEET On rI GHwn nEUn NO.: Ix ON[G ECIION EE05 vErIICLE ' EO f / .. 'f ~ f OC D ~ < • ~_~~L.~-- ~ [A.,»I:= CI'A'-'^ 12 rl Ar~I.01'T ~tl/. ~ J, '-1 I' r' I 1,~ 3 l5 E ' L_ I. ALO _ Cn0551no o -5--1 uN" ~~ "rvnr .. z - -- '! ISIOULD[n Ef M,n [r 4i - CS GNwiFp - OL.I .. rER(..USUI[FACE W„ cK ONq,K CONTRIBUTING CIFlCUMS7ANCESISSww IcrCLE NOUTE al, IorNFn T-_ ~ 'I v[ U I EI ICNFCDK ONF ON AIOn EI _ EHr FIUCLE wCTlO O nIV[n v~nrKt[„ r x[~~ 4 ~' g p U. a L' l C fnH DLDUDr ' ND.> DC, rl ~ ~ D D -'r; S ,I Y nr y Aoscnu yy cE OF ~ .E o S -lam -!~_ 57_ JJ L LCONOL~_.__~!,,.^~ i00 [~y[Cr, ~ 16 I1FD Iv ~ _ ~""t'. ,"c. rl F >~nu _ _ (-,r 7=n Dnu [DNrL Nc[oF ~ I ~ cnnrNl r '-J>~ Mgovnsvxc ~' t ~,: "~ sm]w J shrnwNa 1.J°D T r ~ ' ~ F-t SE._. ~. ~'i _, nwHi iunn ; `. ,~ ~l Itt I r roc ~~ t r r I ~.N - ~.~ ` , A ~niio°i.nwn-K_NC ~j.%1~ i K,N~ ~ F,~ O n P. j n J ,D~nn,rT H„R ~ J 1w{f oi8n is[rclTri ~-I6~ t n a L )`. J .-. Ln W ~cx ~1'i L I IMrnorrn 5 I L_,SL:I ~~ IFn Nc 1 --- D I ~ rN Isn~nm (( s r - t IT LOND„IONS iRAFFIf.CONTRO r C T ~P oOF ROAD L ')(_~' iiuirlc FDn ~ ~ - ' ~~ D OrvI, CIE _ > IC K ton MOxcl VEIIICLE CONDITION SOIigIIETV I ( I[~~ -~t I smNwts t l o (cuE {~ y u aE amcK Dlrtl srMlus Pfo nr slcxu _ il,+ 1 wwr r d ~~ol ` ofs cN 1 1 rC. I oY D Y.`_ 7>_.1 slM 'V 1 .--___ r[ [ (~C i~.:IJI A-~7 I I ~ ~ STOn[oM ~, ! /1 onowar > ~. f ``n5 I] [ O -- R IAK 5 ' ~ f 14 ~, I t l• 6TwnTING IN a ~ . > > E4 L >. rr - ~ r n D . J mwnlc Lwxc . "'I-I v I ac i L. I n P HOOT rl~ wmwcrno ~t. k 5 W I ~. l 40M,IIi ~ L L 'I O rOR~iAi I[IIY--' I ~ ,~~ r K O[OSITION ~IV/ ln[[T f 11k n I ll[r -~ - -~' f nC1G _---- ( 1)r~ TFnFr~CI IENI[IIINO JJ~~ ~ IhG I I ~i KN~._. LJ LO 13 U-la A I SwDNN I nw ' ANRL .._ f- D [[ [ nH ~- lwn wnv-tl'rl I SMVOIII I nn Nx N,G I-j15! I R.SCKING ~(.,,1.. o s _ 3G L R I I CHCM. TTEST ' !:..! it rE °mlr5 '. otr c I ~^L FIT-- .. u ° ~..~ I_~ .._ _ _ :~ ~ J DNILn ISN Clfrl :. e, ~) `~ ) D ID . K I NO UEFFLTS ' I i 1151` fUSrU ~ ~ ~ i 0]i,iii lvrCli Yi - -- I ' rr~ ~~R ]' UrN ICII'YI~ I.J. 11 Nvlsuwnxc or nflu aN,MI RNwhN om NUlu uuu ~--1-fit- x 1FSr n[suku 2 ~? / ` II, r r ,; _ _ J LD DtnNEt 1 ~ II. LN:JI J 1iT• . i7t '~~ ~ INC. r~r ~+IJ~. (i ~~i~~ml I ~ ~Iti aaM n rl to >kM I nolL-- ~ „, "' .Ir I (~%.1f5 M~ uw ~ ~'~ ~~~ r~l II<NK <' I iI. naLl nu nl Dula 'Ir•. I ~ w I ~L 1 1 fn~_ 1j -!.+.J><:l•'~CYt/p nlF_~~,Ir~7. 75 J~~. { UISII nU711IH DIIICIFrnI I'/rY CI.Ni)in IVALIIINL.1Ur, KIA1LIAIIIr11 NI.YK11In WA1I1 NIilIlNnll!AM 1µ JC • -- '. •_ •-fM,NkICAIICUI'Y.LIICAL IAw INI UIII.IM[rJI AI.INf. z'UI.fIPV II I`L Il',AI[[.OI•Y IIIVI SIIGAIUII SCUYY ' .. ... - . ~f •. r _ ~ • ~ , i ~I ~. 9~"1 EL i 6~ ~ s r41~4' ~ t r i~dY ~1 I:: :i' t r ~r ,.,,: ,;: ---,-r- ~s, ....,f ~4>~,~z r'IJC~ 1~~ ~t ~ry~4 ,~ •4r" ,'H F r ' a .aUFaEI's.l . ~a~.E ys i'~~+ .~.,,~. ! ~. ir.. "'F' ~4~~.'~~"n~.1.,, ., ~<o I~1. Ed17,F,-,I,A~, y 'k I ~,,,, ,I rrryyl' 7 ~ t r t ~ t (" r ~~j rl ~r ~ ~ k "~( ~i y~lg 6t ~ ,~~w e ~ ai .e ~ u A ~ f ! ~y ~ s '•: I t ,.~.: DATE OF COLLIRION DAY OF COWSgN TIME CO NIYNO. GITY NO. in WA M DAY v Z SUN I MOI' 2 IuIR b wE , INUN b fnl D SA IUR ] W IOyRi 7- / ~ UgDAN rC -1 uqu C NTY ^SIATE flOUtECOUNTY flOAO ^GITY STREET O ADM CLS FREFM ROUIE OR STREET 000E SEC LION ~- OV ^OTHEfl I6PECIFYI N 3 ~ - ~/ ~~~- - - L' IN' CITY OA TOWN b E W ^ ~ P REFI% EO MILE VOST .~,. - A~F ~~~ ~~ S~X~ ~~ ^ ^ ^ ^OF ILZ ° . ... ~ ~ C MILES - - L-. - T LL ~ " 1 .; -, NAME dN0 OF 6TPEE O HWAY--~~~ -.• INTERSECTING WITH'. 6TREEl OR ROAD R P D GR MD TA '- - - T. J ON _ _.~ _ . _ _,.. ~ NpJ WtERREGiIDN, ACG DENT NTER NO %50 q TERSECNNG 6TREEl OR 110M OR REF. N O'. }~ yy ~ ~ " MLEAGE R E ENCE O REU'iii ROAD ~ miff N . .... _. STREET AND __~_/~ _3ll . . .GTREET BETWEEN _/~ . CODE ~ D DIgELT10N FROM REFENENCE ORGfl055 STREET DISTANCE AH S p~iHS PEC L ING USE R 1 ~T MILER 6 E W ,. _ ~ VEHICLE~VENItIE ^VEHR;LE~BICYCLE ^OTNER IWRITEI ^HITARUN ^ 6EVEflgY COLLISION INVOLVED: ^VEHICLE-OOJELT ^VEHICLE~Rq TRAIN ^6TOLEN VEHICLE _. NO.NILLED ~ ___- - _ _ TOTAL NO OF VEHICLER ~ ' PEDERTRIAN NON~COLIISION ^NPZARDOUS MATERIAL NO.INJURED ^yEHICLE~ ^PROPF.RTV DAMAGE ONLY OBJECT 6IRUCKINAME OF OBJECT STRUCK ANDOwNERSNAMEI ~ LOCATION OF OGIECT STRNCKS~ E.- ,_,-~„-• EST.DU%AGE W ^ ROADWAY FEET ^ ^ ^ ^ Rp EDGE b pRIVEflS NAMEiA6T~- .-:--- ':'FIRST'-_. ..._..__......__...MI~LE.. .- 0111YEq'S NAME~LARi. EIRST MIDDLE. III BrCrCUS1,OR PEHESIRIAN CHECKIO p ~ .D ~: R ', A ST T ADORERS':. ' -:: '-: -: ..'S: ,. _... _. _ ... _.. . STPEEi ADDfiESS-_ ._... . ...._ .. . V ~ JV V E Gi .. ~ STATE _ ._.. ZIP CODE PHONE NO. E CHY-. . .. STATE. . .. .. 21v CODE PHONE NO. w ~ - ~ 6 7 S- a N NERS IKENRE NO. ST TE R EA DAtE Of BIRIM N ORNERR LICENSE NO. SIATE 6E%. DATE OF OIgiN. O C ~ ~ ~ DAV YR p•. MO. OAY YR. pilV RIXLUPATNXJ fIHM NAME.. ~ PHONE NO. 2 DPNERR OCCUPA710N FIRM NAME ..,. P EN . CODES > IDI cuuss-6 HI BEAT BELT ul uELIwN __L. CODES > I]I Ci~5 5 JAI SEAT BELT IRI EJECTION NAUURR ~ T NAURIER iP SCENE BYIf .~ i///~~, TO• C^~ C~>I- • IRDMSCFNEBV TO VEH YEAR AK JDODGE~LHEVI ~ MOOELIDART~NOVAI 6TYLE 12 DR {ONV.) VEH YEAR MANEIDODGE~CHEV.I MOOELIDAgTNOVAI :.' STYlE 120q SONV.1,_._ 1 ~ E VEH. COLOR UC. PLATE NO. STATE 1gAILER PLATE NO. R E _ VEH.COLOR MC. PUTE.NO. STATE .. iRAILEq PLATE NO.. RTATE .._. (~` VEH LE IDENIiF Iq UMBER.., . ,...:.. ODOMETER. ..,;, p VEHICLE IDENTIFICATI N NU BER. -.~....~c. ODOMETEq ~ ~, .v r: _E_ ..6 .~oZZ ~~ ~ _E .:, flEGLRtERED OWNEq -LA6T FAST, '.. I:. - MODIE REGLSTEREDO NER-LA61 - 1 FuiRT ... .. AUODLE 1 o. uJ,d ~ TFa2 av~~A~U9 0 E5R OF OWNER- J' . ,........ .... .. ... . ADORERS OF OWNER. ~ .... .. .. ...~. 1 .. _ ....... .:... .. . ~ - a ! ~ NAME ANDADONE OF W6URANCECO.OR AGENT_.. . ~ _., NAME AHD ADDRCR6OF rcJRURUJLECO. OH AGENT, '~ LnARGE., ; -. .. C ~ RAIpN NO., ENFORCEMENT CMANOE :"~-...:.. ...~. .... CITA110NH ,.. ; : - ACTION I . ,1. ':.;.~: ,~,' i=Y' - ADDRESS & INJURIES OF PERSONS INVOLVED NAME CODES ' -. u2 ' ... b , SE% AGE- S1ATU5 EJEfT.! L. NAME. C ADDRESS V P NA/URE Of NE MMOVED inOM wJURIE9 RLENE RV i0 A NAME. T ADOalss S xEM vlom M ~JU Ew s L I.sclrlF nv To W NAM[' T ADDRESS' hL May[~ IIOM N AC[HF RV TO I 5 NAME' ~ ~_ _ i ~ S b' ADM[b6 NJU ~ ' MJr Rr _ Io ' IIIbIAIUb 121 b1 1 VSIIgH IJI RMUR LLARb I 1 LAI b[LT 1]I[JFCl10H 1 C 2FASSl MT[P U JUR A ]DRAB (INJURY INOT HRTALICD INOi CJECIEU ' JrIIHSIHMN L ~T ~ 201 p Ai LlIC A ]o[omi'osMi DNONU BMNG C 2H0 NUS[ G 210t AlLYlJECICD UPAnnuIY UlGIm p E ,1.. ROI IR eWI1HCS9 .... _ . ~ - 7 ._..~.. ~~b DOS tIGJ1U HOWIj~ ..~~..--..~-.._.. J, i ~~..r ._.._..__. INJURY )1'O!SRL 1 ~. .y ..l _a_.._ UHRNOWN ~ CA7 BELT fAllllllf _~._~.. .. • UN NOWNIF CJECIEO ~ ] tE 4 1 i~ i r~ ,' . , Lj l i 'r ~~ r~ + I r F IS',J y G ~ F,1, l,~Y I I J ;ra +.' a r 1 i. yy1 ~ f~ R ~ '~~. 1 f. ~~~ ~ ~~ E; [ N "i x yy~~VV~~' . k FYI- ~. ¢~t, ,a i ~ r r~ ; "f~~ ~..y..~,.r~ ' 1 ~ f. ~~~ ) ~~ ~ u; . I t t ~•. ~~~ f f' 5"~~~~y 88; 'E.. 1' 3 T ~ ~ ~,. a r .: ~I r~ ~ ~ ,~~•I _ I ~ ~~• ~,' . ~ _ ;Ew - ~ ~n -r ~, ~ . ~y x Y ' . BLS ~^ _ i i _ .. ., _. .~; f`IlrtoRY _. ynYT.lm ar ~.. ~. ~ UL .. INSTRUCTIONS: / D: [)R R110WI51 TO SNOW PRINCIPALO NECTION OF f01 CE. l~/~ , ~ P DAMAGED VEMILLE NO.T lusE rNls YaGF ioN SKf TCHING DAMAGE TO TxwuERS.MDIONGrtt[s ETC,( DAMAGED VEHICLE N0.2 a ~F'--~I " N LW 4l L. IS T~ 1] nuo V ~, . ' 16~ UnMlrin I 1~ro 1 1 ;.,• I O.nW.n Ir I F YOi DAMAGf~. VEN LLE NO.1 1 ^ 034BLING OwMAGE ] O OTNERMV DAMAGE TYOFDAMAOE~IOTHENV[n CLEI TNE)i q~v~OwMATf ICO D B I VENICCENOJ~~~1]~• SE ITr OF OAMAGE Iy~{DISABLIrvG DAMAGE ] 0 OTNERM V. DAMAGE ] ^ FUNCTIONAL DAMAGE ^ NO DAM ' AGE EST.OAMAGE u n0 M OE N 4 ] o T ti DA fat DAMAGE OW EO 9Y LT ] LJ sUNCT ONAL DwMwGE A ~ N Ems. nG ESy DAMAGE TOVIED 0Y OW ED 6Y ~, F ~ • '.. 3 .. O S ~ S DIAGRAM OF COLLISION P Na ~ 1 :.- 1--~-~~-~- 1 I ~'~ i ~ ~ i~.t NURTH NCIRCLEING ._. _~ I' ~ •~ ~ ! 1 _~ -_~~ T~ 1 ' S ~ 1 °'" - I ` - I_ .- 1 y., I 1 I I i EI ~.i ~ I O 3 w N ANE~Pi3. Lrc.i ° I ~ ~ ^~ ~ I • I 1 a LDC.rz r.ouiwDINT DF Lr.LT ] F.DwrL.IaE.PLDt31NAxDA D.,LLT.D,INDN]A,~NPALT. I~ ~ I ~ I __ ,~, ~ _ - i -I 1 - ~ I- i - ~ I '' -~_ I ' 1 i .. 1 I i . t,Dw.KO.,FtLYfNILLEDR PLDESTR..N.Al.3.EFDRf ANDAF, ALDLMMDN - _ I I _ I- ~ _ _ ~- _ L_ ~~ ! - ~- ~ ~ - -I - I ~ -- ' - 1 I I DESCRIPTION OF uxD CwrE WHAT rnababiY APPENED BEFORE DUR NG AND afTEO TNF CHASN Foxwwnox NDT DNDa M, HC.oND]AR _ GLtNSTRUCT ONO E `OR~yETCI ~ PFOfSTRUN tt4L1InF Op REDUCED VISE LITY DSABM1ITV COLLISION , , , , - ~ __ - __- t'l.T-, .~_~-L.»-s~ -_.._ __ tea ~~C- s _ POSITION ~iiFADEO BEFORE COLLISION P TO D I N - ~Ox STREET OH GNWAY NAME OR xO fDiE olain\DN L ppD K D - R IDLCIiPfEti j]O,' ~ E CR INCRFA S G EASING J, ~ ~ ^ 1 J~r~ ' ~ ~ ~ i ~ ~ , \. ~ Yfs I ~ I I ~r- ~ J _ 1 DN __ A ] I SINN L^I ED I ~ AD EO 6~Bf3 n L ]O D TS~ Sus O CYCLI fl0 DSUR ACE wG ( IYOEwAL WHATHNfl. ECKO EI I SHOULDlR IWA -`K.. ~~ CONTRIB ~ ._.CNOS CROSS I TI~N CIRCUMSTAN ES ONEO REI RMO OUTE LE -- -- - ~ ~ ~E_ PROTE~E ~ }~ ' `SL (CHECK ONE DR ' ER ~ VEN ER GO ~GxT AHEAD r~l I~ H O.] (~ 1~ 1 ~C EAN. CLOUDY O.] ~ 1 RINFLUEn[ F ALCOtlO IL I O I~~N]~OLLOWING. fi40SFL iJ Di TAI ~• EG EGW j-.lfl -~ 5 N150 •.- I~ n 0 fRp AKING L_.]~ ASSING L__. _] JI I WET i.OYFIiCA3L_ RAINING 1 ~ _ .. OFR INFLUENCE OF ~ r ~ UN ~] DP GS . _ ., oV EN CENTER C L xE _ nIK~ A PARfNTLY 1 J _ASSF{P ~3~ MAKING - R GHT TUPN - 3 NOW ~ N ] S Ow G (-1 E Cf G STATIU I Il ~ ,_SPFED L..1L ~ 0 3 _ ' 1 ~ OP N S __LOLA ION_ L~J' i~ f' i" G ' L-- EFT TURN -- ~1~~ ~ CC YYYY _ A I _ ~ ~yl ~F CE 3 ff0 E. S I^I L' r.. ~ _. 7~ I f arI OJ CI _ EO ~~a URN T . ~sl~ a ~ ' OT G E 5 n ~ r~ ~ EG 0 ' ...~.3 DJ,_LL_ ~ I ~ t ___ u ~ 6 a LOmNG D1NfN IYEC fvI _ D F 5 FC YI -MP 1 ROPER I.^ r -I1]` SGUaI D 11 r 1N[ of (FYI I ~ NO V10UTION iOPPEO FOR ~]O TRAFFIC (GHT COND ETIONS CNfCK O RAFFIf CONTRO O ] VLNICtE " E.. TYPE OF ROAD N0.1 (CHECK Oxf OR NORF .VEHICLE CONxD(1IT1I~OIN V' MU ~ ~b~~ ~ [S ~ 500RIETY.... ~_. 1 NO jE ILIIECK ONE(, ~Ja~.s]DrrfDAT SIGNAL OR STOr 61GN . 1 ~;. SIDNALS y~ ~ nln DNF WAY __, fYI }f Dl O f U ^ ~.^ giDPPED IN r DADwwr DAVLO T L ~ ~ or ]~ I r ]~ D L I i I L L a11AK[3 ~~ Nbo AbulTr I ~JMPAIRtn ~10' iPPifIC LANE u _ ]~ I DAWN N I 31 I L . -- i ~ E 3 D L J _ __. .. ',TI DL4oL GIIl3 ] OABNITr ~.~...NOT IMPAIRED I^1 STANTING inOM II II-~ PARi.E0PO3 TION 1-- _. WSK Sri' .- SGN~_ ~~ FLwSrIING -.. _ ... . r_ 1 If R 4C I-~ , .~ 1 ll 1~ J RWILIGIITS !y~ ~H SOBRIETY I _ LII]J THAOFNC IC]ITFRINO . ....._ I DARK STEET ~ J Lr.REO.._ - Ex 6 LISI [R . RAMI . L00 _~. r ISL IJ uE ~. ~ u ~ f ° OII SMOOTtL_ _ , .__ ~ r--' y~ yOn NKING i J LKIND. _LIGNTfO _. I DARK STREET UGNTIDEL ~ .A e •~~ . RR SGNAL l_ . ~~at•-,.. TW ~ E T NLANES - - ~ --1 1 {, 4..:.. _.'_. ER CHEM. TEST O. ] r'- I 1 ._ l j"., - DANK-NO _-~. . r-~E,-... Df rlt( dF.T( I ~ IC~Ei'it IED - . ~ ^ TG t :~ .. ._._._.._ DTNE R IYEC IFYI ~ _J,. STR[[I L 6NTS ' -._.. .. FLAGU OT xR .. ' . .. .~ NO OEi ECT6 _ -~ 11[SI Of FUSED. ' ~ ] 1 Or'w~nbfeTYi~ E ._ T' 3, cONinoL ~ I ]I .~ . _. _ I. ~,E'~~ NOwIOFO 1.~~.._~. D ER IYfcH.l ~~~~ I ~ YP TEST RESULTS 2 _ _ . - NvISl10ATIN60Ff ICLNb NAM( AHANK BAUGl MO~ POLICE OIYAILn[D P ULICE AxNivL4 AnNwLO CE 1MP[DED]lOw I .. - ]A00 O ]L00 )A f NNS ~ ILIIDAIING OIIICIH'3 NAM[ANANK LNO. ENCY IT nII ISI.A U[l, tPONI DwII OI PROVED by OAIE X - DUPLICATE COPY LOCAL LAw ENf OHCEMENT AGCIICV~S COP V-TRIPLICATC COPY: INVESTIGATOR'S COPY 1 ] ~ `' ~,~ .: ,. IE„A ,,; ::..: L . .. .~FM. 9T ~ i?",'I°_ l9 er~np~ew~~ ..t! ~ n~tl Y ~ ~~ .III ~ ~ ~ 1 ~~ .v. ti - _°~^7n_.+~" _ _; .. .U, -. ~'. .I .w.r~.. H '=a I L~ o-. ..~ I„'4 L ~ I ~° ~'' ~~ v ~ ~ 1 ~ ~ , I ' `~r ,. f ,To' ~"<: :4 ." e 2.1?,,. " ~~_ ~.. L- v PL; y n L ' ~. 't~ 0. V7 1 F1 1 ~ V1~~~ 1 I1~Y~ 1O1U PFGE Of ~~. ~ ,r 1 I ~~ OLICE COMPUINi NUMDER S " ~ .~ .~ ' UNIFORM POLICE TRAFFIC COLLISION REPORT .: ~ D GATE OF COLlIB10N DAY OF C04151ON TIME COUNTY NO. CITY NO. A MO ~ ~Y ~Y_. CJ T SUM i NDN 2 IUfS J WEpa IINXy B BAI IUS~zaO`lUgl // ~( // J VUgAL g COUNtt /n J ^STATEROUTE ~000NTV fl0A0 ^C IT Y SIRkET U ADM~GLS. PREFIX ROVTE OR y1R//E~~ET~~C((ODE 110N y ~'{-y-~SOI ^OTHERIBPEpFYI W -SI/V ~ ~L IN CITY Ofl TOWN ^ N B E W W FIX EO MILEPOST ' O f~ ( ~ ~ MMES ® ^ ^ IN OF ...T~"T..b-w~ JE~~L. RAJ - U O A N E NO.OF STREET ORHppGMWAY INTERSECTING WITH B1flEET OR ROAD LL R AMP DIAGRAM DATA L r _" T O~ t rr/'T;~~COAD#/? o I NON IMEflSE f`-~ _ `f-~ 1 B C~~~ 1 ~ ~ ACCIDENT I M E NTER NON NiF %~RD I CLR E NTERSECTING STREET Ofl ROAD OR RE RENL/EyR ST E q/p(),D ~ 'i"^ N ~!~C yTAfET AND DETWEEN !\ •`, B IEET LOOE ~/ (7 OISTPNCE ANOD RELiION iflOM REFERENCE OR CROSS BIREET f u~ttN S nuNpRE HS PECIALC LNG UBE ~ _~ `/ Ipg~ M LEB _ ~ ~'~V 3/ ' E.f FEET ^~S2__~ ~ ^ _. .,_~ ' I$ vFnICLE~vEn CLE vE CLE BCYCLE OinERI RiEI nHAPUN COLLISION INVOLVED: ^ ^ ^ ^ SEVERITY NO KLLLED ~ ~ '; ^ STOLE EHICIE TOTAL NO ~ O IN NO INJURED . ' - -~ OFVEHICLES LJ rY ATERIAL VEHICLE PEDESTR AN ~( NON COILIS ON ^NA2AR00 5 ~ PROPERTY DAMAGE ONLY }] ,F ODJELi BTRUCKINAME OFOBlECi BTPULK ANOOWNERBNMIEI LOCATION OF 00.1EC1 yTR CM ESi.OAMAGE ~ ^ROPO AY IFFY ^ ^ ^ ^ RO EDGE S *f T " OAIVEP ME~IASi (~ FIRST MIDDLE ORIVFRS NPME~IASi FIRST MIDDLE Ilr UICYLLIyI OR PCnEBTNIAN CNELKI^ '. v ~oufvAs {-7~'--J..'1JFS ~. u :~ R GTREET ADURESB A BIREET PODPESB ~ V E ~ ~ - `Z ~D E P CODE PHONE NO Z _ . ~ ~~ ` SY YYYY R CITY yTATE 21P CODE PHONE NO. R I CITY STATE ~ P, .-~.~~s~~ ~tA. ~~~ N ORNERB LICENSE NO. 5 ATE SF.% PATE OF BINTH N DRIVERS LICENSE NO. STATE SE% DATE OF BIflTH. °' ~1 ~ Z'I ~ J~ 2 °' MO. DAY Vfl ~ 1 • ltit I . DRIVERS OCCUPATION iINM NAME PHONE NO. Z ONIVERB OCCUPFTION FIRM NAME PHONE NO CODES FIJI CUSS. _....I .. I.I SEAT BELT ~ I~'I EJECTION .___ .___ CODES FIJI CLAB B-----IaI BEAT BELT_~.I51 EJECTION___ SAP` .~. n d IralUWES F 1~ ' NJURRiEBOF ~ f ~ ~ ~ i -~ FRMM SCENE BY' TO FROrOi SCENE BY TO I - VEN EAR MAKE IDOpGE~CHEV.I 0 ELIDARi~~OVAI BL YLE 120P~CONV1 VEn YEAn MAKEIDOWE~CHEV.1 AIODELIOARi~NOVAi STYLE I2 DR ~CONV.I .:.~ E. VEn COLOR L C PLATE ~ STATE TAAIIEn lE NO. BIATE E VEn COLOR UC. PLATE NO STATE 1RAILEfl PULE NO. STATE k Grw. N iz , ..~~, C VEHICLE IOENTIFICAIN)N NUMBER O OOMEIEIi C VErXCLE IDENIIFICAIION NUMBEn ODOMETER -3 I ~~~ E C@~13' Maa~~'z5 CS'1c,95 E ,~ ~' REGLBIEPEO OWNER-LAST FIRST MIpOLE REGISIERCD OWNER-LAST FIPSi -MIDDLE o ctmti C~~ ~u a~~-YC c.~ o - . ~ ADpRESS of o)~~JEq L~-~~ ~'I~1JlLJ~~ . 2 _ FDDRESS of o:mFn NAME ANO ADORCSBOrINBnURA1NJCECO.OR AGENt IJ1 ~ AME ANp POOHESSpF INSURANCE LO. OH PGENi LnARGE ORATION NO CHARGE LIIAlIOrvN ENLOXCENENT ~ ALNDN IJO[l~C ~ - __ NAMET ADDRESS & INJURIES OF PERSONS INVOLVED cones - LA w y SE% AGE STATUS EJECT L. NAME __ __ __.-_ C AADgfss ___ __-__._____._ .__ U p ~ nuro iuFnoM TvRE OF --`- u[,AIRIES scLNe n.' iO t A NAME. ~ .... - N T _._ _.--__ _. _ ADDRESS __-_ _. _..__.- - 1---------~-- - - ~ ~ ' ' S r0 EU FBZJM NAtURf OF unIES SffNl RY TO I , + ~ "~~' ' / Nr N AMF.~ ~. _~_._~-_._-_________.._,__.-..____.___ i , ~~ I N ApDRESB _ ~ U-~~FG~~~__..__ ~__...__--___. -.-__...~SCF aF IVII OM.____..___ _-..__ i0 S apDR[SB _ ~ I, I E S~ I C p _ naNH~-_____.________-____~__ I. FflY II•ul Al U9 tl -L POSII%%[ N UI C NAlllli , - TDLPD r CL C LD-[IS O fl nY i n c'is~:R D N un s l n p iRIVAL u I r. T '' nr ADO A `rsl y 2 [ onll n o°tii c a ~ s o~rt ~ I IJ U~LORU CICD ICI PO iI[IA~tIV [rJpI C1LD . u IKrmvrHlr /" ~ a~ ~~ ~~ ~~~~ ~ ~~~~ a~M1P a ~. '~ E J , l .1 /] I .nronnro^PUAL TIG.;w[INaugY n . [I , 4L 6 WI1NF 55 111 VVV~~J RPU~:II OYUr KNO11N ._ uYKNOwN Sh[AT NTLIIAIURC lJ1.CiCD . ~`!` R I+uP~"+111~`/ V`>M i 1~ A~ ~g- _ R~ iA ~ ~ I~~ ~Mlty ~ 1 I r L 11'Y ~, r ~ ;'l~A~~C 7" ova + , ~ ~.. 7~..-w~n~d'l'~ ri' 'L .;:., ~"i I~`,'I ~~$~ a ~>:a'~",. M 1-,. V ^~ T ~ AY' ~ I ti7 j , 1 T N F4 r I r, a ~ 4u Y ~1~ } j~ 1 I I~ ti~~` t! f I E1~I 1 _ M,:........ ,.~ ~. , Jn4 ]~ i .~. f' s ~~ a .r.-Ai __ y Tr_ s dI_C UFAIVIHII~"•15u'EltDid:A~_bvOw{ea, - r~E`plltWT~C IiCL' IL NU ...N Uf [nC. fA~IO AN CA. ~ ] SHADE AREAO SEVEREST IM pCT Y~~~~~~-1 y r A7 INSTRUCTIONS: . ] DRAW ARROWISI TO SNOW YR NCIPAL DIRECTION OF iORCE. Q~^'~"1~. MA D A GED V H I E C LE N O. 7 Iusf In s SPACE lon srcf TLn Nc DAMAGE TD TRaIL[n S.MDrGncrcus. [TOI DA MAGED VEHICLE NO . Z HoaO ung ~~~ 9!I r N ~ ~n 1 • . L ~ j ~ _ ~ !~ ~ y 16 V en it O.rnu rr •r3r ~n ;T~n++ ~ 5 T IB, SE Uf DAMAGE VEHICLE xO L pp ISADL NG DAMAGE ] O UIHE RMV OaMaGE ITY Oi DAMAGE: IOTHEHV CLEI 1[OHOISabL NG DAMAGE pOTNFnMV OHMAGE E 5[ EnITY OF OAMaDE~ VE ppOSAbLING DAMAGE Ii CLF NO] ] O V O uAGE ] ^ luxcT oNAL DAMAGE . ^ No D AMAGE : O ruxcTloNAL DAMAGE . ^ No oAMacE ] ^ ruxcT oNAL DAMAG E A O xo DaMacE TOwEO eY, 'TO .:, ESt. DAMAGE 3 fs IOwED BY T. DAMAGE 10 3 TOWED BY T EST. DAMAGE 3 DIAGRAM OF COLLISION ; ' ' DRAW ARROW SHOWING H n +uALI Y _ I I I I - L ~'_ . 1 NORTH IN CIRCLE l son Pw PP.Dw Ar ~ _. I I i _ T I I ~ ... ~ _ O aanr[IagcoN,RDU u`euw.Lnm. coxPlnpns , I I . ~ f : I -+ L-- ~ . ~ ~ ', . " - i . 3{.A+cn coxvRVC+,cN neu.{Tm ~ j ~ i 1 -~ _ I I ; - ~,rAp.,.LE.ON.Dr ~~ , r , - ___.. J , pe ~T~oN nT wrA NfT ros s C+. . sxorv rxos.eLL V[utt A r I I I ~ I I ,~ , i 1 I I I I f _ i _ ~ __ ~ l _ : ' - " ~ I I I i_ r{Dts+a .x rAtxs Y[rO ANP..nACOUnon. .:~' - ... . ~'- ~' I '. ~_ ... u.-l t ', ~ I -~~ '-~ - I DESCRIP710N OF' oxowATE WHAT PnobatlLY HAPPENEDtlerOR[ UHING ANDAltEn THE CnaSH,m[LUDE NFOnInATI0x x0TON pIAGRAM,EG OHNEn COLLISION ~ OISABILITY,nEOV[EO VISItlILITY, PEDESTRIAN ClO1NING COLOR, CONSTRUCTION OR REPAIR wORK, ETC .I - _ •. POSITIO N w. HEADED N BEFORE COLLISION E Post I ON STNEET On HIGrlwav NAME OR N0. xa. or LANES Irv ONC D nF[TION m • E[D s VwNKELY O CUYE o o -~ E'-1 1 I ._~ ~ ._ IvCREA5ING Df Cn ! ._._; fa51NG _^ - I •v_. I _ ES NOI C L._ YES NO .._. .~__._ ... I~..~....1.. I J •_~.i __ MPN I..-. _ r J _ ED. _. . G ..._ ._ _ _ O_ ~ p /elCYtl3 Sv1 NG. . LK K I.,CR 6' C ED I I ~ ISHOU t SSw ROAD SUR FACE CnE<K ONEI WEATHER CHECK ONEI CONTRIOU TIN oui ogUMSTANCES OREI D 3 ~ O.]venICLE On[7f pPe DR~F~ D NWER mV[R -..,L r-, Gpp~G I_ ~ NT AHEAD ORr I ~ I1! ' LCAn,c 1 ~ [ LO 60YINCAS -~ H INrEVE C ~ E .._A4COHOL ~ I~ LOw nG I . ~ [•40sE 4 ~1 )~ nEGAnOFD Wnnx. UIS SIGx15_ I OYERT K G I 1 ~-' a IN ]L: AND PASSING ]_ __ _. - ~ NU _ _ ___. r ]I_!DRUGS INFEUE O - . _ _ . . ~.. E _ , _.; J _ EE _ ~ I NT ~- T URN . ] Dw ) I G t-, StA ~ ! „ ~~ GTO ~~ RPARKNG r .. _.. ___._. _.~ ..-__._,_-- T ~J 4M ~ -- _ '_.: _--- ' ._ DN----.- -.~. L« l _~ LEfTiuRe - .. E ~ i I 5 C F I 1 I G C ~ 1 G _. I ry , 1 fir .. ` 3 I I .. ~ . E c HT _; n G _.. __ . . I - . ^. ~ NG MMeIV[tlf vl O nLn l~ [CIf YI I _ Pln _._ PA SNO ~IL~:' G _ D IGNIEIGNAL sl ~ S EL ~ -- I I N IOLaT10N -r~ >J OrOR Tn APFIC LI NT CONDITIONS CHECK pN[I RAFFIC CONTRO ] CLE E TYYE OF ROAD D] I[N[CK ONE On MOREI VEHICLE LO NDITION SOBRIETY... CKO EI L SDPTEDnT EwxnL LIS I P ~... ' ~ 1 ~- L I L ~b1I~E ~~r Caapp iPH,o i oN iu~iuitm HE ENOCLE I iN ] p SIGN ~ . Slcxnu 1 wnr DNE _ i _ .' .. I JB. I stoP.fDw _ HDaow.r -1 I DA cwt _ ~.. .. .. ._.. )t... PAWN '. ... ]. WSK .. _ slc°e ~ rItLD ...L._. EIGN • ... llASr L ~ ... .... _____ ] __ ] nF Vt NS tltE .._: IIDAD ~.-~ NHtxCNANGt ~A' _I' tnwf en KEE. ]' [ .,.. .._.~ N[Anl LHls T] LIVE I utlO aenlTV •...~.. IIAYAInED __ .. ] ~ xNV nR LITI' I ~ NOT IMPAIn[D_.__.. I]~~~~ NBOSORH CTY s Annxcw ... }Half IC LANE 11,, _.• jpI1KEO PO•.ITION •~- ~~Ij ~~~ MEIIG NG IENiERING . .. LA K~s1N1[T • ONTS ON `~ ..__. 11lD __ ..3 ASI InU l _... ... MRC _ LOOP VAMP ._L. f-~ Li(v _6 A :~~ _.,. !CARL GISlS OHN 16. ~ .MOOTn -.._vNK. ___ DNOi ~A HtrN URN KING _... --/ TRAFFICI 1-~ - '..~ .,I B~f.K NO s DAn f1Ht[T E LIG SOrr _. H 4 G Al mn wnr-L[l .__~E luHN IANlS '"I-~ uxc+uulD s rvN ..._... ~. i NuLli CHH EM. TEST ] 1' 1 1 .. .. f1P [1N~ONT3 ~;. , 3~ _ O' I<[n/ IIAGAIaN UNILII IGnl L'~Nlt •TLD 1 SEIAIi ]' DV DLO ,~ NO DEf ICTS SIOWtx ~ AI H[r US[0 DiNE n ISPFC IPYI OTHER NfCLIVI ~- ~~ 9 - ) Dtu l - - ~ UNN II ISPr CIr %1 A', TEST R[SULTS J Z VI{tlGAI iNOOrrI[[H-s NAMI snanA - - UC. H fl. Llcl 01- Ilv Lll n IVL[D ] II - 1~.~ ' cE r IC rLOW PEOFO ] ~ MIN NR X I v131 GOr IICY - UUI NO IDI1 I.1 Avl 1. EPU 1 Pxu UAI[ OUO~ICAIL COYVV I,OCAl ~LA1Y lNlOHC[M(NI AG[NCV'.".COPY~TRII'LICA tEVf,OPY',•INVI'SlIOAIUR~s~COPV ~~~v J L ~~~ _ ~~ ~~ b, k ,~ ~. , ' tfi ~~ &~ _ ~~ -'Y{ 1 "~ tT If Elf' ~' ~ }S I4 i rill T, 1 r .pr,h, ~J ~ ^r~?µ I },.c I~r,m 4 ~' x G.I „`....ux. ll ~ .I ,. ~ ~~' ~, A,q~i Sr E L e w Pqq ~" ~,{ ~~~'! ~ ~ f~ , A APMwtf~ Si~ ~ ~ .1 ¢ ~~ r i e ~~': + rr 9 }~ ,, ;I ~~i , rI ~fT~ ~, I ~cl ~~ 1 _ :l ,~ ~' t .. ,, 1,~ ~ ~ _ ,. ~ 1 i J ~~ C - a ~ k °~ r ~°. STATE 01=~i1V 4SHINGTOfd•.~ '`"KA Y _. -.0.~. .v r. r..'n Yh , -_ ~' ~ , , ~~ ~~ ~ G r }( PAGE ~ OF I •M UNIFOR NO. POLICE COMPWMNUMBER 3~~ ~~ ~ ~ • ~. M POLICE TRAFFIC COLLISION REPORT ~, o ~ ; $ ATEOFCOWSbN DAY OFCOWSgN TIME MO 0 gUN NES WE IHBN fW SAi IUS Z O R ] 1 2 3 / 6 B / ~ COUNTY ND. CITY NO. FMWA /~ URBAN ~J FG V~r~ ~. ~i l ~ CWN CC -- ^BTAlE ROUTE IVI COUNTY ROAD ^CRY BTREET p ~ Jw ORAL ~•?'CL3. PREFIx ROUTE OR STREET CODE 6 CTION ~ } -•• ~L. .t W ^OTHER ISPECIFYI W J1 9 / o ~~ ~ ~ • L N 6 E IN CITY,O~IR T~OW~N , •1 ~ C ~ MMES ^ ^ OF T•~ VCIL/D U PREFIX EO. MILE POET '% , ~ T'. 4'S N •~~,~~ ~^ a NAME 8N0. Lf L HIGNWAY INTERRECTVIGWITN: STREET ORROAD LL A _ ~ T o ~~ ~ RAMP: pIAGRAM DATA ~ ~ ~'~; f EpSECIgN ~V'IL 0 N D 1~ ~CY~.~ A ~/E 5~~ ~~ ' "` ACCIDEM E M IIRER INOI{ XAD IMEggECTING STREE OR ROAD OR REF GN @R Cld. ERENC CROSS 6TREET OIi ROAD ~" i1 ~ -{,?i~ `)I t - ^ BETWEEN STREET ANO i~ 991 /~ gTREET --- dSTANCE ANDOWECTION GROM REFERENCE OR CROSS STREET OE i / AY g ~Q SYE ~ w } M,LES N 8 E W .1L + ~F HIS , iHS A CMLCOpINOUBE ~ _. '.. _ 4 i ~ ~ I FEET OF ( N / C I Q COLLISION INVOLVED: ^VEHK;LE~VEMICLE ^VEHICLE~BICYCLE ^OTHER IWRITEI SEVERRY ^NITSRUN ~y~ ~~ 5 • I~ H•~ ~ ~ ^ VEHICLE-0SIECT ^ VEMICIE~PR TRAIN TOTAL NO OF VEwClE3 ^yEMICLE~PEDEBiRIAN NONLOLL1510N ^NAZARppU3 MATERIAL NO. KILLED ^giOLEN VENICIE NO.INJUiIED PROPERTY DAMAGEONLY _ ~' ,-~ ~• ~ J 4 - ~~ OBJECT 6TRUCK(NMIEOF OBJECT SiRUCKAN00WNERSNAMEI ~ LOCATION OF . OBJECT STRUCK ESi.DAMAGE ~ Y 1 A 'Sfi' F ~V P°~" » ^ ~ ~ ^ROAOWAY ORNERS NAM E L W OF N g E fEEi ^ ^ ^ ^ RD. EDGE 5 5' ~ J5 j$, ~~ {./..~~T' /~~,~~/ {~~J .~y~ MIDDLE DRIVER'S NAMEiAST FIR [ ~ rl/-//YOL-tJC~l~ Fw /Q / f ~ U ST MIDDLE IIF BKYCIISi OR PEDESTWAN CHECKI ~~ xA~ ~~. Pi .. .. l 1 7 .1.. C/y R STREET ADdiE95 R STREET h00RE55 ! •,. 4+ y ~~ r~ 11 IC- ~ ' RE CITY - gTATE LP CODE PHONE NO, E CNy Cult~t8E~G4N ~~7v7~ ~ 7YlA R STATE LP CODE PHONE NO ~ [ ~ 1 ~ ~ ' `i ~N T ~ ~[ ~ , ~N Z. / N DIiNENS LICENSE/J1O. STATE SE% DATE OF DIRTH N DRIVERS OCENSE NO. ^ /] O STATE. SE% DATE OF BIRTH ,~ ~ ].fl [ ~ ~ : -. 'L ~9~1 y~j / • ~~ Y • N / GO~6831 U /y' 0• MO. OAY YR ., 1 ~ ~ DRNERS OCCUPATION FR E PHONENO. •j DRIVERS OCCUPATION ~ S FIRM NAME p N ~T ~~ A~ SAC, 7uD O.P( S„v ~ --,~ CODES > 131 ~~ LURE OF MI BEAT BELT Igl EJECTKNJ CODES ~ IJI INJURY 1/I CLASS SEAT BELT Isl EJECTION ~ ~ ' ' IWURIES NATURED + I ~ `' FR SCENE VEH YEAR BV: AIAKEIDODOECHEV.1 / TO MOOELIOMTNOVN -STYLE I2ORLONV.1 REMOVED FROM SCENE VEM.VEM BY: MAKEIDOWECNEV.I MOOEI (OARTNOVN 9TYLEIYDR.CONVJ a*"1 M1v"'"•"1 ~, f+. - v 67 iV t ~ ~ _: ~ ` H VEX ~ LIC. PLATE AO. SLATE TRAILER PWTE NO. STATE H VEN.COLOfl tlc. PLATE NO. ' STATE iRAIIEfl PWTE NO. iSTAIE - ~ ',~ iu. Gi{R$o o I w '°' ~~, _ ~.G C L VENIC / x;AT NUMB(' I ` 7 O S ~DOIAEIER ~ K C (. VEHICLE IOEHTIFICATI N NUMB OIbMETER -. ' ;4i _~ .~ ~ E O d O . [ E ~ fi ~~ A~ { N PEGLRTEREU 'E/^R~-LAST /.FWST MIDDLE /^ - REGISTERED OWNER-LAST FIRST MIOdE k; `yl ~~ , ~ ~ ~ A~~~ ~ DWNER ~ AC~-,T~/ ~' ~/a/ ~i4lrCsC•' QC' p c z ADDRESS OF OWNER. ~ R .~ r ~6 'o- ' f ~ . ~ ., NAME.WD^~~55OFINSURANCE CO.OR AGENT 4/K NOD= C~irAno SSU~ ~ .f5 NAME ANO ADORE960FINSURANCE CO. OR~~EM ~VGER • UH f{AS a ' `~ .~ - c I Y G o fu ACC iS/A~D (/6t/~cD16 , ~:I,. N I A I N N .!~ ~~~~G ~~ n E A ~ ~D 908 ACTpN - ~& `~ NAME, ADDRESS & INJURIES OF PERSONS INVOLVED Copes - ~ ~ / B \ SFX AGE STATUE N T EJECT ~ T ;""~ ~ n ~ /`• µ `~ 3 ~~ ~ I I ~ , V U P H REMOVEDFNOM pLIUPoES' A S NAME: LENE BY. TO • E I' ( 1 $ AOMES4 H ~' P T p~, f., 1 ~' ~ MWPoF}: KI NAME: ~EN[PV i TD r t E k T AOMESI: A ~ E RLENE BY TD 1( f NAYF: 3: ~' ' ~ 8 8 Apauss E ~~ J , ` y5. 1 g. w%1 1. fiC NF. BY' TO ,S, Y~ i ' i IIISIAlU3 IlI SEA11pbIgN ~JIINNRY ClA ?PASSENGER NO MUURV C 3S I/I SERI UELT ISI EJECIKkI ~ l ~ L_ ~'y"' I • '. PFOT.g1wAi1 1 . 0 IKCYCUST ADEApAi SC }dgARONO ULNRY 1 NOT MSTALLEp 1.N0T EJ[C1Ep ENE 6Np1~p'UAtlUNP ]NOTWUSE Z TOiALLYEJECIED ~.~ - I , { ] f.O1HER POSRKIH D DF.AOON ARRNAL 11ENDENTIINJURY ].USED FJ[CTEp IPUBMOTORCYCLEI J. dEONH0.WTAL T.POSYOLE NJURY / UNKNOWN ~ { U KH V D 0 N11 M I ~ ~ 1. ' 1 I P ] . 1 4} E { P0611gN UNKNOWN . . N AV I O 6. SEAT BELT iNLURE EJECTED . , Y F .ry+ ~ - e U ~' ~ r „ • , w ~ ~ J ~ ~ ' r 1' I 1 ° r ~' ~ ~~'i i i ' ~«~ ~ IT I~ I ~I I^~ ~ f f I ~~~ ' [r I ~~ " k , r~~ ~1Mr,~~ ~ ., H ~i~l, „51 Ci 1 i ` 1 s 5~ i ..[ j''1,.'/ , .1~~"TJ4[S •''"M1i~, ~ ,~i~,. ~. r'.~.'""",~ ... , .1.-~..."-'°'~' d4`.rl.f :1~ "i: f' . : - , . ~ ~ h ,-Jl ~~ i ~~. ..~ ~. k ~. oaM.~cw~i:i7~(P„ ~' ^~ i~~crr_.., :~.,x::ex~~`x, ,mm-rece'~w .sta"~.°L«3`m^tl°bt~if~.t..:~a'~~S . _ IG. HOOD Ia.NOOa ;~! E7y'' t•.raol urea +` It r reDn D TQ~ Idumeruma. ~~i r le. u,ewurrw,+ ~ ~, ~ ~l 17.OrarNn IT•~^ ". SEVERITY OF DAAi E: VENICIE NO.1 SEVEfeEY CF DAMAGE: (OTHER VEHIgEI eEVERRY OF DAMADE. VEMIClE N0.2 j^.~~ 1QDL9ABt1NODAMAOE DQOTHEA Y.V. DAMAGE tQgSADl1NO0AMAOE DQOTNERM.V. DAMAGE IQDi9ABl1NG DAMAGE DOOTHERM.V.DAMAOE ~,j . 1' ~~~ 2 FIINCTIIXULDMIAOE • NO DAYIGE 2 FUNCDCNALDAMAOE • NOOAMAOE 2 FUNCTIONAL DAMAGE • NODAMAOE . "t,.. TOYlEO BY '~~IY •1~1f:' ESi.ON.lAOE TOWED BY EST.DAMAGE TOWED BY EST. DAMAGE wtt ro s ~ ~k~' TD s To s sx - - ;DIAOMMOF COLLISION' '. ~.yy I l_ ~ I I ^ I -'DRAW ARROW SHOWING - ~ I'oAnDR`wevuEwrr rTAmrE;e 'i ~ _ .I _ _ NORTH IN CIRCLE ~I ~IEH~.D,.M.EI~DE~TDF '° ~ - ~ i _ r ~~ A :~ 3ANDw WKlE PFDFenaANOA ~;: ~ ~ ~~ '~ r.~,~T. ~ ,~ i ~ ~~ , ~. . axpW.xOeAELeVD.CllOl1 ~ - - A,aA.,a ~, ~ , 5 + `DESC8IPTION OF =.~/'`" ~ ~, = _ ,r eNCICATE WHATPROGADLY HAPPENED DEFOi1E,WPoNOANDAFTER TNEC `,INCWDEM1FIXiMATKK1NOTON gAONAM, E.Q DPoVEfl ,.~ y:IrOL~$ION ., T-..e~ qSA&LITY REWCEOVISIBIUiY,PEDESTNAN DIDTNINGCOLORCONe1AUCi1fN10fl NEPA1RWORIt. ETG1 l ~7 L~F C~E~ •~ ~7 S~~/,C.Ft/./,[~ .'1/J__/7.;P/~~.e% .'r/..~1T7~T/~(if~3/li~: : ~y x'I r,l C r,,2E- /.~ [ c_u ` ./ ~ s7,U~ '/~',<~ ~i~ c S-,~~,z-.°_zl 7~. ` ~s~ :ti /C/~E 7J GE;CS_'..-~2,,::~~~/Jirc' ~ G'.T ~r .y///1' ~L.~! v/i /J,fIYJ ~ ~ /J ' y ,.µ i~ ~ 'i •"•.' NO OFLANES SPEEDS VEHa P D v ~"rx~'. l.,c. ... . _, ._v.. ~ ~:.-,.T^.x ~rv,`.:c '_1 ~.'.yi~c_'u^.t.F'i.:tivl.:c~' VIONE gRECTION , d ':':"~• VEN. HEADED M~IE POST pR ON STREET OR HgMWAY NAME OR NO. ~reo srFl ARMY OCCU IPIP ED +~t ~~i N0. PICREASLVO DECOFLA9W0 ~ ^ ^ ^ C ~y7 ' ~ [~ [~W M/,{I ~% ~ T ~ ~~ _ ,res No vES ND ~, ce.. , cy. r f ~ o a a .~D n DN „~D~H~,Ar ~ED~ o~ ~s~.,' - '7 r ,, ~~- - _... z ,_ ~ PFD,BiCYCLIGTWAeIISVa ~^eDew nw ^a.aDaER ~^~rA„< a^ n nDD~ Knp ~ .~ "9~+y ;;110AD SURFACE ri;;WEATHER,. -. ~.;,,,,~~y.:~~CONTHIEIUTINO CIRCUMSTANCES '.,;;~.: ,,.,,,,~,j .~p'L~or~~ 1~~,~ +' "'.~ t~ Ip2CN Oxq IMECA ONO ICNEOM~ MODeI ~ ODNFR ~~ ILJ ~^1 ~Np oN Ua~E~ 'j ~~,a ~ ~ ' '~ u _a I ^ wr I ~ .o rcue'T °Y ~^ "~-vKE OF ^ ^ :ooa~Lr ^'n a~DN.s,o°~ U' LJ ~ w~ ~, ~ .., I ^:^ wET a^ AA..w ~ ~ P.,DeaaeDP ^e~ ~-__~,.J"n~ "°F~ ^'^.^~'u^~ "?~ +~"' ~ ~ ;- ^i~ aeow ] a 9NO'Ma ~ ~. 6v~fEONU r ^e^ F~ T4 `- ~y^ ~PFA~v~6 ^~^ ~ _ p?4e?h'~~:: ~: a~~. ^eQ ~ .^ F~ ~.^ yFe ~~°- CI o , --~_D~,~Ea_ ce^ ~° f ;{ .. i. - ,.' ~ n _f"1 _` ~ Do NDw~rta.NTww . - nvcavo .. a aownD tc TNEAIY~~.r, ^ ^ •,~ND" ^,a^ ,~N,~ G~ ^ Ci , ^ ; D ,~ r«~ ~,,~ ~~ss - S ~ oA B 0 O E CLE 0 'SOBRIETY n~o•T ~N++ ~ ~~'+ ~T f~ yOHT~COu D~RION ~iR R CC 711 L,;. M) '?Noll 'L-1 I Q aaN.u ,c wEm,~,_TYPEOF ROA ND ICNECA ONEM IrOrll Q I DNE wAr ~ Y HI CON TTION . YENigl -FNEpt OR .OpHt~TEq .,~; , ;,,... ...:+...f',.. VENEYL F ONEI I ~ _ ^a^ aRera eGN r-~ 1 I • ^ ;gp~n.v r ~, -', l ~} ~w~,.,uart a _..... • z^ry_a S1~ ° °N ( ~ ~~`-t_nersn•ai -_ ' ' Q - . (~~I ~^-7 ~_c'___ "u° write -1 ' L..7 t ['^`~~I (^-~_~ I..: "°r""""'w~c° _.___ L..L ^IO^ muic vne ulI^ .°fwc""""°Enr`mn"°" _ ~., ._ , ^ ~, _ _ ~,~-r° o, . _ _-.--__ ~ . ^ ~~e . . _ . . _ - ^ ^ E°,~, . _ aa^ ~°oa.ETr_= c,r=^ r~~~DG~D ~ _I ~1_ •F...t.-_wHraOVA _ ~ n .,.oEe 4a.i.~i.-J-~w _f a _.-___.__-__. ~ n J..t..•~..L_µl_..___.__-_ _ -. OeulOO1H .-~_^.___e~.__- (('~~j`` 1/`•n K~Drpixeva ^Ie^ eACAM ~'~ am ° ^ Iw EarrR ^ ^ sau ~w.TErn ^°^ uraa wrcnae ~e^ T~ aaarnvx ~* ~ CHEM. TEST Ira. ~ ^ L..1 _ ~ra«oNEi "'~ T °~N orNUlaAecvn _C~ rt~ I1~ ~~_ 111 ~ ~---~ _L~ ~~ E^ ^E^?D'OI ^a^ m+oED ^ ^ wxscrn ~~ rtarAEpuxo ~ onunA~'e+n Norwrc ^E +,~~ _ -- -- ~a^ ueawrcn r`Y or~eAimeam -:, ~, 7~ % % TEST RESULTS 2 ~' I ... ,•. '~Ir. yprr/afartc+xaN..r[e /, eoa/eNa /il/ . \.:/ /.~!i';. i/ rV.~!/i~r ~ l: ~7 rol,ceavr/uo `~ wuc/eau/m<D Mvaveo .wnEO~ urz `t Y7 /' :.oa (7~J .f1//~ a.oo _ ~J u - X EwaalrAa HNEI,nA„rDD,rKD,..,~a r ,~ND -.~~s>c unoN Un.. oer. ~%,~ ~./!:n (1 ~ AnraNioer its- I ~/ i.~ L ~, _ .. ~~ f>, ~; .(. ?], ~J. D ) I ti: I w _ ^~ ~ l ~ I ~ 1$ fP ~ 3 _ . ~~, q ~ d db3 ~~•S Po S + ~ n .F+IA`J ti ..x+ _'~ ~ I ~. r, -~` ~'~r~~,`7 s~4E, _: ... ~' . .~ '~ ......>_. _-~"Ane4ra'si- ~.,., ~'+e:TF{`~.~ ~.p'v~+e~.+•;^_~k.,~".,~.4~_' '_ .,~~' tr10TOR VEIi1CLE COLLISION REPORT NO. r - OATE OF COLLISION Op -_ 7?s 7~R Iru S AY 0'FI "CO _1[n L LIS ON TIME OF COLLISION ..u.. rx •.., r,ouy-~ ue S ( AM ~ t PM /c ( COUNTY HD, l/O- CNY ILO. I-1 P . v.rv COON CITY, TOWN ~(~ J.2\~ Ul'+1~~.-.. P 'o.cv r'p MILES f CITY, TOV p^NII~ !-VlwwJ OF 1-~JI'~RJ[~[f ~I o ADIACLS PREFI% curF 00+5 H c ,~ xC J N/~v[ $ECTtON ,ow GIVE Nq[AE Of STRF~ErL EUA~I OP H GMWAY INTERSECTING WITH. STREET OR ROAD rv.arv FurZ6.xT/~LJ ,ac'([ f„c;-ti/ ,~ w°:r"io CF/ii~.OG/M Fi ,mil ~• /Z ~Q ___ PREFI% EO MILEPOST -~_ ON INTERSECTION LOCATION OF COLLIS19N RgIAP pIAGRAM DATA FrrOr ^N Q x,r[ROaO Nc.N[[xos, ox rODr,rrr rvc L,rvcM,RA Iw. u. mE INTER NON i %RO CLS x[i[xEhL" xca 05.5 x[L! cc. ~^ S W DF - rvNRS[c,lorv ^ . (J J4:~~L Q - Kil r[.. u[ ^.[ ko,rvln nva Nr [ rc,[ J7 ~ i~ "~ o ° ~D (7 II ' ` J SPEC. DE USE -' V[v . ~ Erv ES D °.., ~: J I : o ^. r,~, - I NCO OBJECT Si/iW'CK _ ~ Irk.-a'u~ b![<r Slxvcrv OV/HER OF OBJELiS NAIAE ANO ADDRESS (L{OiCAA Y~~~ ~~ ~1 TpIOWNyy QI'~r [Jl /~."`l FEET B Ivv D EOCE g ru o~gow[ • DRIVERS LAST NAME FIRST NAME MIDDLE rwo c,xs DRIVERS LAST NAIAE FIRST NAME MIDDLE STREET AOOP,ESS ROUTE N0. ANO BO N0, wo STREET ADDRESS R u N0. AND BO% NO. C--AJ. ST E ~~)J~IP CODE JISJ~ ORIVEAS pCCUPATIOH CiSa///~ [roxr rDa CITY. .STATE. .GOOF DRIVERS OCCUPATrON ORI VERS LICENSE NUMBER i~G~fi-.~T-OG%~/Z~ SLATE l.~r. SE% F DATE OF BIRTH AGE /2 S 3c3 39 DRIVERS 4CENSE NUMBER STATE S GATE OF BIRTH AGE VEHICLE YR. IAANE HES'DOOO E~ OD (NOVA-DART) M F} + / ROOM STYLE R DR.) VEHICLE YR. MANE ICH :DODGE! MODEL I VA~OgRTT, . BODY STYLE IR OR.) F~ ( / TRAIL R P TE N0. LICENSE PLATE NO. 57ATE yi-./c~e-7 ~ c.10. ~ LICENSE PLATE NO. STATE TR4ILER PLATE NO. ,STATE VEHICLE IDENTIFICATION NO. (1960 IAOOELS 8 NFWERI ODOMETER IMlt E1GEI VEHICLE IDENTIFICATION NO. N96B MODELS b NEWER) ODGI.IETEH IMKEAGEI D ~~ REGISTERED OV.NER (LAST~FIRST~MIDDLE NAME( DRIVERS LICENSE N0. REGISTERED OVINER (LAST~FIRST~MIODLE NAME) DRIVERS LICENSE NO. OWNERS ADDRESS (STREET, Cltt AND STATE) OAT OF D RTH OWNERB ADDRESS (STREET, CITY AND STATE) Dhl OF B RTN PAR150F V,EiII LE OAI.!AGED ~ S+ •rF00 CA'i ~/~ ~_'~ ~C?~ 1 /~YL ~N ` rx`~'1 PgR150F VEHICLE OAIAAGED [ So'v[e;`r°[ ~'c. LIABILITY INSURANCE INFORtdATION-VEHICLE NO. T- coETRncElrAU CF~e°ci'coalrrisl CCDENTON YOUR CAR ^YES ^NO NAME ANU ADDRESS OF LIABILITY INSURANCE POLICY MOLDER NAME OF LIhBIL1TY INSURANLE LDMPANY w[ ,O~xESS uT• s,At[ Slv I ' I NAME ANO ADDRESS OF LIABILITY INSURANCE AGENT u sr,N l.IABILItt POLICY NUTABER - I _ _._ ~ _ _ _ TST 1JUH AGE ST' '- 2 D INJURY ` ` 'Jn' AGE NAME O xED N E _ ~ _ _ DDRE 5 BE% hDOHE55 _ .. ._._.. _. N t ICJ k. _ ^~ C~ ° I ... .. .... 51X. _ ... ~L LL.1, STAT JS OF ": ZJWF.P rAARK FIHSi ONE TngT APPL ES ST TUS Of J Rf (ARK FIRST ONE THAI APPLIES ['c fc r.c . r. r. or 0r ] [ IN vEH CLE '`~~u ~~,;.v'P ~+ IJ [ E I VEHICLE 'r'r tior~ii x'-ti s F -_ [~. 4L CAR D KLLED tiE+rx ,v ~.oR t (] 6[ G[ ND KILLED uE` My [t.i , ,ro ft[ y '+ EDC+ '' '' I R rv `J~ s~ 7 7 ~ s aT _- ~ _ 5 T I 1 . ...r .r +t.i.~~_ ~Q ~ lJ 5 01Y NOHTN BY ANROW I L CLE '~ I DESCRIB/EJNELOW YlHAT HAP/P~ENEDn: IHEFER TOE-VE~HI~CLES 0Y NUMBE[R OL FO' S0 G ~ I i ~~LI"G... TVJ~I~1% FJ/ N/ '-' A C 'D O , __ ~ -_.... ~. ~ ~ I ! /~c?.~~7~~D Y/~S LYE __~._ _ ..,. ..._ ~ ,~ , _ - '. 1 1 V'I^ tI{L. HI~f l~1 ! L OI.LI IL Y - - r. ... ~ - ,.. i ED BV r. ,. ... 1U f7 ~;[ ur~l~~rl 1 ri r„.rr r~ r~ ii I] ~'~ ri I _ . ~~ ,A, I l l ~r. n ~_: _ ~ L.:I r ~ _ LJ I I I:~ .I_~._n ~ ~ I l r l l .J l 1 -•z ~ m aPnoN T o. cim~~ / ~ ,, a L i ~ ,' I ~~ ,! I 6~ L l __ t . '" . T At'E ~.ir 1 Ir.. 1 r . !.5 .~ ..i, , { [ ~ AI,I [ If , ~~... .r i- I,.l .. U ,r 11 ,[ ~ ] „ l I + ~ II l7 (,;r ,IF , I 1 I •, ~u:0 ~/ T , Y I ~ I 1 1 1 1 ~ DI 1 l 7 r ~l 11 11 11 I] D t ~ ~ N • r ' ! ~ ! / 11 `I . I ITI1 •Y + ~~/e x\ AM: I iI K I:IG l1.F 1 1URlI .~ 1 I~ r I.1 i I1 11 1 (rrr I141 ~ , . ,1,.'~II I) + I l I[LY I 11i [ I +I i [;~1 nTl +1 1 F I 1 + I I 1 + I l IA.NIR U,tN1N .. I I+ I 1 t. r E C l`-,°, ,.„N I J A I I+ A[ ~ 1 1 A I 1'; "['"~ L l b I] I JaNID : ;: + Y I I~ r e, ..r 11+ I I r „A"+ IDI nu r~ro ~ I . .. ,..... I / ° , 1 I i :'' II,II I ,.Y II[II IlAll ,.[ IID I' 11 J I' ~ AY - 1 I I I ~~r~ ~-+~~ ~~n'"'1~`^.:J a~t~..,T I. . ~ . .-,`T~)I,-. r i ~:~ ;~.~r:~3r,r.'^14"r+-i1:r.~r'.r, L',~: ~.:9~y ~1:2+i~ T ~~ +t ~' f .. _ '9 Y I l 'rL•V + ~ ~ ;(,r r'' sN ..~ -_ x % DATEMCOLUSION DAY Oi COLLI SION 11ME COUNTY NO CITY NO FHW ~ A2 ~ MO 0 ]SUN 1 MDN 2 LUIS ] WED d IIIVH 5 I S SAI IUSE S6p0 HOURI J dURDNI ~~ :' '~' - ' ~ { UP L _ '~ ' I F ~ ~ CWNlT/1VL'/\, ^SIAiE ROU[E~ ~COUHiY ROAD ^CITY STREET O AOM~CIS. PHEFI% ~[T CODE ROUTE Ofl Si•H1E qs ~CT ON u ~ ' JN\CEIC~pn• ^OIH[RISPECIFY) CITV Ofl TOWN N PRE I% EO / / 0 _ MILEPOST "' I& L N pp5~ E W ^IN 1 G ~ ~ T ~ U LL . . _,C C 7 _ Uh _...__ -._. V MILES ^!~l ^ ^ Oi /OR • ' I ~ r :. -~ NAME6NO OF STPEEV IGNWAY~- IHTEfiSECTWG WITHGTPEEiOq ROAD- LL ` - RAMP:. DIAGRAM DATA } I NON WIERSEGTION- -: ~ _ ACCIDENT w INTER NON %RD INlEHSECTInG STREET ~REF 1 TF LL9 2 EREHCE RO55%iPFE ~ TOR ROAp U~ N BETWEEN ._ _ _ ___ _ _._ -~. STREET AND. ._ .-._ _. .. _... TPEET CODE 1 8 Y •• ', • •. . ~ DIBIANCE AHD GRECiIONiROM DEFERENCE ORCROSSSl11EEi' - " " ' f ~H Nu 3 n ,PECML LODN USE • .. , .. ~ $JMLES Q S E^ w OF `` ~/ ] A ~ 0 _ FEET J(l.: .. _ ~ ~ _~VEHCLENEHCLE ^VEHICLEtlCYCLE ^OTNEPIWflTEI '~ _^NIidRU COLLISIONINVOLVED: ^VEN CLE OBJECT ^VEN CLE~RR TRAIN _ ^S10LEN VEH CLE SE EHTY ~ ,h HO NLLED ~}y~~`^ I URE ~q~ ~ ' TOTALNO ~ OF VEHICLES 'Z ~ DESTPIAN NON COLl1510N A ARDOUS MATERIAL P J O. O 1{ ~„ 'M' . p ^ ^ ^N VEHICLE E 2 ~ , ROPEPIY DAMAGE ONLY G ~ ~ ~ ----OWECI STRUCRINAMEOF OOIECT STRUC%AND OWNERS NAME7-'- "'- "" ":" ~ LOCAT ONOF OBJECT SIHNCK E-,~ _,.~_, .:. EST.DAMAGE - - ' r. S a ^ROADwAV FEET ^ ^ ^ ^ RO EDGE 3 1 ~ ~ ~~~ - -' .~~ pPNEHS NAME~LAST-. .. -.. .-.., f IflST: . -~.,..._.. __ .. -.... MIpOLE ". ' - 1 • ORIVEP S NPME~LAST FIRST MIDDLE Ili UICYCOSI OR PEnF.SINAN CHEC%IU -""'. '- L31,4 is /A /11, R HJa m i on o W, >~ ~ R STREET ADDRESS -' - _ ~' - 5 EET ADDRESS ~ -- W ' ° ~ • ' v .. , :, . rJ /o /C s7 : v - _ SJ IBo ArJ4 ' ~ f / 6 S- 8 ~ ~' ~ E ..'PHONE NO: STATE. -. \... KIPCODE~_ CITY _..:. i :.. ; E.. CITY '~, ~'.• Y,~~.1 L' . SLATE y\lt-., ~ 21P CODE \ PHONE NO. ^ R 1 / /~ Ppt/ u~AS~iId. K~fl. 9iFJv 60 R J Y~rAS ~naf ~W 9''s 3(O 8~ • ~~ N O^ DMVEflS LICENSE NO... STATE SE% DATE OF BIRTH O D Y YR N O• DRIVERS UCFNSE NO. STATE SE% DATE OF BIRTH r r / ~ ! c ~~~ ~~ M~ pAV YR pRIVERS OCCUPATION FIfIM NAME... ~ PHONE NO. '1 pPIVERS OL AVON. I MNAME Pn NE O f'{~~ /,~.,~st i3 CODES > w cusR~_ TAI SEAT DELT_ 151 EJELTION.I- - ~ CODES .> I]I CLJU.SR- Ill SEAL BELT_._ I51 EJECTWN._I-. LIa _ ! ' TORE OF N1URIE5 ~ NATURE F //~~ L NJURIES NO I74 YF, iHOM 6CENE BY' TO FnOU SLFNf RYA TO 5 ~ + VEH YEAR MANEIpOOGE~CHEV.I A!OOELIDAni~IJOVAI STYLEI2 DR ~CONVI VEq. TEAR MA%ELDOQGE~LNEV.1 y MODCLIDARi~NOVAI. STYlE 120RCONVJ r 't: v 97/ ~stcr Ga T y ~ v GB Fo.4er ~/ SP,(Cr 2 E YEH COLOR Lk. PIAIE NO: STATE iPAILEN PLATE NO. STATE ._ _. E. yCH COLOR. UC. PLATE N0.• SLATE. 1RNLER PIATF NO.. STATE _, .M.. iI/PJ¢ v~u8.z7 'uA :~" ~ .coon oGZob w.4 ~.'.':, ~ (~• VENKLE IDENTIFICATION NUMBER - ,-..... OOOIAEIEfl:~ '. _ 'C VEHICLE IDENIIFICATI H NUMBER ~ ~... . . ODOMETER L _ e I PS Hi~o~ b E'' 3SBKO~,S~/o3 ~ HEGISTEPED OWNER-LAST .. .... FIRSt -.'..- I MIDDLE .''~r~ REG151ERED.OWHER-LAT-'~.. FIRST _. .. MIDDLE, 2^ ' 1 o". Sao] a s AJC3oee o. _, P.oe /~_ f/f~es~` .. l // Te/:`C]a. AWRESS OF OWNER .• .. .. ........ _.. ... :. ... _..___.:....,.'. ADDRESS OF.OWHER.... :- I ~. .I ~ ; • ~ 2 ~ ~ ~ ~~LP (o ~ y`f S, ~en11L wA 96'03 '"< ,': NAME ANpADDP[55OFINSURANCECO.OR AGENT.:..~......~ :•~•'- .. NAME ANDApDRESS OTMSURANCE CO OR AGENT. .....~ Cn . I CIl AT1ON NO. --'- LL [HFOHCEMENI C AHGE -.:: _.:-: .I ~ GIATI ' ES OF PERSONS INVOLVED ~ ' ~ ADDRESS~& INJURI NAME copes , _ u ~ a , SEk AGE STATUS w EJECT. C c HAMS _ ApOPT55 ~• ~~ '4 U p __ HArunE Or' Rt MD rDT1oM ;r; IHluwfs st[HnY to s+ A NAME ~ N T Auoncss - - 1+',i~ LMD tpinoM Ar ~ scrHi n. To ' U'a'~E I"IL 1 ~ I S , ' N ;, , T ron[ss : ~ urn ~ G3-A^ '- n H , N To nm~ I .~ S NAM[ _ I. -,.. IM• ,_~ G J J J 5 ApDN133 .--~ 7 ~ S• vuuw s-= ~ \ ccrHrm ` to ~~' s ~ ~ , III STATUS III SI Al RO511 K1n IJI MJURYC455 ~ • ... I116LAT 11[Ll ISI[JICTION A y_ ' 1 r S C O I 95[M[R S f01911•tAN 11Y: tU51 [ 1 I T5 ] T Ofll(R POSlllgl ~~~ 1 NOIN.IURY , 2p[ADAT SC[II:"~ • ] pI AD ONFMNAL 4 [ASAIII HO IWURY N09AnlING I[ DCHTIINJURY 1 Ui IAII[J) ~. •101 WIJ..E ; USfD 1 HOT [J[CIfD ^101 Al LY I'JFCIFD' ]lARI ALLY CJCCTf.D ~~ } 4 ~' ~' 1 ~1 1 ~'-. ~ D SOlfl I s i nU= OIORC CUI 11 y SI•QYIIION U4MNOW11 "OI.OMnOSA1AL TM4'INf MJUnY 551A10[ Ir VRE d[JICOWNIr ~ ~ ,~ V L. E.. N e s ._. ___.i _ .,41.4' .. _....-~'-.. , . - y--• r ~ , i 9 ,r,~ J , ,,~ 1 - 1 L t r \ y it ~ I ~f 4 1 g~ 1 I t .y" ~i` ~ I 4': 1 4 T aT I~ J i` 1 . .. rl I ' r ,, .. dt I )„ . ~ !~Y ~1~ ' 11 t ~j'' r`~ It a~,; : ,.+rJ.J.~r ,IaY~4~`4,'~,~'~"°....W,~Ier^.•...TT.~~`T~ `(~^' P~+. ~~~ "'..r ?u~rT~~ ;r 11...~. S T 'f ~i Y 1' r °4~ ,. ., ,. .•.. I .. .n- B ~~ 1 Y8'.E b I. ~~~„ -~ ail, - ~,~r ~~~NL -NS' DAMAGED VEHICLE N O, 1 • IuSE TNIa (PACE FDR SKErcn ND DAMAGE t0 TRw LFRa rogcr CLEa, ETC.1 DAMAGED VEHICLE N U.2 > I . I ELP! 1... ]. noW E Pwl TrunL ' ''- I 1 I (wAr!!r! 1 n- I I 1 Is. u 11. O.~NUrn,r+Fr ... _. .. _ ~ Y` 11 II [ ~ IP u II Or.nu n sR a AMAGkVFHICLE NO.I Eye ENG OAMAf.E 1~-+I OTnER M.V.OAMApE 2 F f SEVENITV OF DAMAGE. IOTNER VEN CLEI I ^ DISABLING DAMAGE 1 ^OTNEHMV DAMAGE SEVEIIITY OF DAMAGE VEN CLE NOt I ^DISABLING DAMAGE ] OTIIln MV pAMAGf. ll wMAGE : L~I ND LI CT G t O FUNCT GNAL DwMAGF ~, ~ ND DAMAGE t CI EIINCTIGNAL DwrAAGE .. LJ ND DAMANE '~ F AM~OE TOWED BY 10 f So iOwED Oy Ea .D IAOF TO f _ TOWED OV ~` E9. MAGE ~{Ptl TO f ` DIAGRAM OF COLLISION ~ ~ ~ -' - ,. _ ~ I DRAY/ARROL:SHOWING -C ~ / [ C oR ewes ' -' ' TH IN nrr. Dwowwranpnr rF+TUnu ~ CIRCLE . E~;io orrIlD.DwAY ._ ..,_. 1 ~~;~.TADI] ED.LNFMP[DNDwIDNa 3 I 1---~- ~ ,~-- {-. 1 r 1 L 1'~ i: ~ ' .tLKLDN A aTwu<T ~, A[Ifl ~ ~ . A I L. f `~ J ( ti. ~I ~ I I I~ I ~~ Ro M r I , _... 1 AD. PAD.A.a.q NTDr 111 I _ 176 f I ~y I _ ~ I ~r , i _ f I M~DWYDIaE..[DLaTNI,NDP Tro>rtwgs At lMrwcr. ]/, _ ~~ r ' } , r f_ ~. - ~----~~` -~- --`•~----Y/'.Z~I-;-"- '1 AnU wrxR o [ ~ I t I I ' - ! 1. ~ - _-1 ~ I... t..1._, - i ~ DESCRIPTION OF D TEW T p0 YnM E E EFORE D RNG OAFTER C f NC E FORMATION NOT ONO G MINER ' COLLISION - ~ 10(S f ITVI~E9V0(0 I~IBILIT+~ EOESTRIwNC PIG COLOR, CONSTflLICT1ON OR gFPA RwOF ETC.I ~- ?-~~, 1 _ ,. ,. . _ ~prcl.veec:. /~/of ~ ~_ur~es;.~1_rra.~C.n --q ~4 f 7/~c•4n D .~c~ ~ ,i/,~ _ LI~ Np:~71/ ~odSSi,,[[r]g ARi.YB.v No,~ --~L.~ Sl~.[rrC!~._ a~KttieK No.~ ~~ I.P. 1`.'IL ~y41!CL.C/~'.._ pC~.I,ZGI~. `-••-3~--- - 1\ _ •( - -" r~----ra •j .. . x P I ~ ~' ~ .--4 ,Fly 1' s~ _ %~-k C . ~--1`-'~~'-~ ~,~'~ ~- ~ ~•' a~ A"f, ~` "3`; `~ ~ ¢ „ .-.,,nrr.~~- y .: ~ .~ „' - _ - T.. :. ~.~'XE ~' t '. ~ ; ~ _,;, _: ,-~--.005 IqN BEFORE COLL SIGN -' ,,,- ~ of ~ sAEEOS ~ c E IF L -' - Y' ~ E ~ NEAOED MILE FOfiO R. (IN STREET OR NIGNWA NAME UaNU IN ONEW EC ON resx suE L LL S E , r 3 O C f NG OE EATING ~• ~ ~ F R [ID '' OCCU EO • ~"~ :'...,N f E vW ~ ,.. - -. O O 'l:J L Sri _ rEs . I .. MPN __ _ - K ER ~~~ E Icrcusr As usmc ~ -s } ~ KWA } ~s utOER ''^ocgossw L EI. Ic osswwii f !ei~Fa ouTe }i I , -.E~ A SURFACE. WEATHER ., ~.,CONTRIBU7'ING CIRCUMSTANCES ql rvE 1~y:ACtD I FCK ONFI ILNECK ONEI. `, ~ ( ;~ ~ ICNECK ONE OR MOREI I N,1 ~NO.a Cf ogfU o~[ y Oll OF} OP OET D OFl p OE= []II ~ BRA] TA EAD ~~,~ I ~ ~. I `~L nwr_ ~ E ctocD ~~, u DER INFwfxcfo ~I ,-'I roLLOwrxc I~ f ~~p 'b"+. ~ _ : ~ : I f.G4GNGAf2- L ~ACCOMOL I I TOQ{,L43SL rL ]. f5 Fc. (.`,;.~]I_. aN~N~N3.9IN6 ~ . '] ~ Y ~,, 1 1] I ET ~I I 0 }I IU iLUFN<EO 1 fl-~ OVEPCENTER 1 TEO 4 yE]~ R R -A. _ .N ~ I +.1.Y J._ ~ .-may ..:.DRUGS r,_ E - ~I - ~ nS EE C TOPN ~~yf y~ ~. ~aL~i OW ] i~J.f OW N6_ ]~ YEEOD NdS Tfp 91 L L ~ LJ 1 ~ LOCA ENV R ING -. r~A'X MFPT]RN ~ ~-. ~f yp: /4 f _ Or Ott T 0 I ~1 K b: - _ r lrr~~~_ CE_E'`-_O0 ,__ ~fA~E SDEEO ~~ _J_ V N, __ J~ _pL ECT VE EOUP LIP I TURN l I'~ 1 1 I^' - r7 DD o c r Iw D D I ~Jfl„--7 _ ~_ d_I~ _. Jf1~0 F E.__ I._l S 0 fGOG I _:~_- _ uBu fLOFf10~., I , {~ OTIiEq LYECIFYI O1nfR ISPEC FYI P, MSSO En } ~ D] G f L. I OTNER ISPECIFYI C]^ STOMp~FOR ~ { I 0 'S 'O VIOLAT OrI u TNAf qI } Iult~ oNETIONS RAFFIC CONTRO yi xo ]yF F TYPE OF ROAD VEHICLE~CI~O€IN$,DIjTIQOfN SOBRIETY _ P sTOPPPIAr aICNALI ~~ .~~_ LIGGN_._. ~\ -A1i-ZONE wAYNF OR MO [ ~ _~;If CON~f~ILSTEDI I C~ N BL TTK ONEI ~0~ ~ ~ ' Y~ , I-, ^ ' - - 5' -, ~1 1 J[1 OAYLG T I] SLOP ] iw0 v 1 I DfFFCTIVE _ r~sA{Rt0 ~ jp1 f L S ~~L ~ r ~ {~ }I I 0 WII L}i I .[IGN ]~ J nF [ SIBIF i i]i I OFi[CTIVE ~I]~ NLO we LITY-- ~JIIrJ T ~`;JY 1 ~.., , r, I 1 --__ RO O. __ ~ ... NE U L GlEif_ i _ NOT FMPAIREO_~_..~ L. [ R y; Op I ] WfK I 1 LA NG I I: NT PC G -' T J ' 7 F I ~] '~ .. I RIO... J L., L00-q -.._ ~ J. OIiF/JIL G[Tf .. ]~. J yW SOORIETV" f 'I~J [ Orl 9111A ~': II 11 _ IJ TRAFF~f. I i ~ .. . .. . • ? a ~w NnxDro [[T ~ +I ~ f aL CI NG I lfI ~~ i ..EnAI ra Pte- u ~_DII YSAUOIn.. O N fL'' s} o CHEM. TEST' L !N~ PonnrnE F t~ E, I ', .: ITPLfi LIGRT3. ..-. FLAGMAN .. .,. fl fU ~ ~ -,~ l3 GVEN - ~ - VI ''N @~ ;, F" 1 p} } , D 0[O ~ ODEFELTS E '~~ TFS R[FUSfp a v _._ _ ?( .x.. X X" I. o [ Ivw r Y ~ ~ f ]I u D Dt0 cn[o OfNlR lVftl rl OTEST RESULTS Z x w AL . , 1 NvtfllOAIIN OFIrLL fN IlfnANK nAUUt NO n0•r I... F]IM PUIr~%N~E }ImAIEIV[0 CE }1- QED}~ ~ ~}, IIt ~~~ `^ . • I ~ n 3'• 961. ~__ ,;: ~ ,,:, I~~ •~ ;' ~ ~, r , - f ?' , > 4 ~, ' t~ _ I;r L ~'l. '". ~ t FI 'r~ F~ ~, T -' ~ ~ ~~ '~ II T li ~~~ ~::{{ ~ i n u xy f t y r (L f. / L ~~ Ir , `~~'?h~1'~J[ I°t~:::~' ~,.~'. ~"~;. ~ II,I ~+' ~~~,,' ,~a ~~~':M', ;; ~~~~.~" ~* 1I+~TY, r 11. ~t j :I ~ 't ~ ~ 4 yl; Y , ; . I . ' I ~~~ ~~ c~ a ~ >rx jai ~ n 'T' ~~ff~~`3 [ s w'~`~i,.J~, [' I~~ f firSA~kl ~V~;~.;,t~~', ~ ifs,. +~s>ao~°a ~• ¢ 1 ' I/ i V l hh I L O~ /lt a~~ {~tV ~•l OIV rAGE OF , I~t ~,,~~' 1•OLICC COMIMINI NUMUi 11 - 7, ~;q i_ UNIFORM POLICETRAFFIC COLLISION REPORT ~ ~ n I '~'" DATC OF COLlIS10N DAV 01 Coll SION IIMC LUUNIYNO. CITY NO. INW , ' N R MOO ; nY 70 1 i :dIN I ulw T I`..; D wLU d I uR y III H 9A1 Ius2335oun1 j / . uURUI . il. COUNTY Vv ^STAIEROUTEA ~COUNIY NOAp ^CI1Y 511iECT O AUM~~CLS. VIIFFI% ROUTE ORSiREE1 CODC EEi10 ~~ JEFFERSON ^on ER lsrrarrl uwT %..J ~~~~® ~.. , C L N 5 E W ^ IN CITY OII IOLYN W VRC(I% EO. MILE V 5T ' s '.. O 4 wLES ^•®^ ^ ®oF PORT TOWNSEfiD ........ LL u - Z . +J•,'Y"^ A EM1t(IO.OFS1NEEl OIIHIGHWAY IERSECIIi.IG WITH: SIRECT OR POAD O RAMP DIAGRAM pATA ~~ 4 . a ,I~ I NON WIEHS CIION ACLIDENI INICN ISO O INtERSEC NNG SIREE OH Ii0A00R REF 'r O MLEAGE CLS E /~$J5 RFEI OR ROAD „„'~ 9edN " N RETWECN • RD• STRCET MID C•R• 38 ... STR T CODE ~- V YS ~~yY OSI.wCE®MDES C110N Fa0MEEF `PENCE OR CROLS EIHEET VN~11115 SPCC ALL DINGUSE °""' I EEr ^ L3 of KALA FOINT ROAD _ TJ ^VCMICLE~VEHICIE ^vENICLF. ~BIDYCLE OTH i11YRlTE1 ^IiI18 RUN SEVERITY 1 n ~ K. COLLISION INVOLVED: ~ I ~NO KILLED ~ ,~ ',~ 41 ^ ®VEHICLE~ODIECT ^VENICLE~Rq (RAIN - - - - ^STOLEN vENICLF TOTAL NO ~I - I NO.INNRED OF VEHICLES L~J ^VEHICLE~rEpESTRIAN ^NONCOLLISIGN ^IIAZARWUS MATERIAL _- _ _ ^PROPERTY DAMAGE ONLY ~LLr+ ~iA - v _ R OBlEC15TRUCK (NAA•,E OF OBJECT SIPUCK AND 1ER5 NAME) 'LOCATION OF Op![Li SIRN CKS E EST.OAMAGE P ^ROAOWAY FEET ^ ^ ^ ^ RD EDGE 3 M'~ -- - ~' L ORrvERS NAMELAGi RRST MIDDLE IF bL,CtliI ON PLMSIRInN CHCCnI[J g~}¢„ ~ ~ R CADIPB CAAEL B. R .. t"' " Y~i I 1REE1 ADDIi I Si BEET ADDflE55 .... ... ._. .. ... ... ... ..._ _ •~ ;, ~ ;r3 , ~ IO ' S D' n ., ~I ~ H crtr ~ TAT zW cooE _ PHOriE No. R crtr ~ I _ ~/ ., ...... ... _. STATE ._.. .. ,.... LP CODE P IXiE O atrTkw* y~ ~~ PoRr TowNSExD~ 98368 Dx Yt t NO, GWVEA3 LICENSE NO. STALE SE% DAiOE OFD^RTH R ND- DRIVEgS LICENGE NO. STATE SE% DATE OF BIRTH MO. OAY vR 44KN WA 14 M ~88~ ~~ ~," ~ DI}rvCRS OCCUPATION FWM NAME _... -„ .PHONE NO. '1 GRIVEHS OCLUPAiION RNMNAME . ... ., P ENO '• r !- ~ ri LABORER i_NE .. -_. ... ~,~~.a .~,_.._ _ .. r•.nnFS > °un~ -~ I .SF.T qF1, 't I I FIFOTIDN 1 CODES > ~=, :~uR. -~ «., .,,. s~ ...~,,..", _ .. t .d.~. ... . x~t S T AM vcn -i.... '3 F dA SLENE BY BA TO PO T TO,,'TII`AS 1 HgMUVt:o i OM SCENC qY TO ~,.. ~ VEH.YEM MAKE IDODGE~CH'cV.l MUDELIOART•NOVAI STYLE I3 DR~CONV.1 vEH.YEAfl MFKEIIXIOG ELHEV.1 IADDEL IDART~NDV AI STYLE 130RCONV.1 ,~ ' ~ ~ Y 63 CREV CHEV7 II 4 DR V '~./ y+a R ~1 ~ E VEH. CMOfi IJC. PLATE M1O.' SLATE 1gMLER PUTE NO. SLATE E VEN CULOR 11L. PULE NO. STATE ~ TRAILEq PLATE NO. STATE ~ .. ~ d~ a "' " H WNITP. AP7 0$9 WA H `'a ' - ~ (~` VE k E IDE NFC TION xUMDER - _ ~ OWMETER C VEHILLE IDENTIFICAII N NUMOER ......., ~. ,. ODDMEIEfl _::.._ ~ ~ x ;, •: ~;• " e 304690136 47 3 307 e . flEGL3TEliED OWNED-LAST FIRST ., ~ MIDDLE ~~ REGSTERED OWNEfl-LA i ... .. iLiLST ..... .:........ .. .. MWDIE '_ - . ~ ti<r ~ MOSS. PH7IIIS ~, g '' ~ `I` 1} ~ a " earl - ~ ' ... _._ • ..... .... .... ... . .... ADDRESS OF OWNER ADDRESS OF O'NNER ..... _.. _ . __.•..._. ' - : :_.~ .. " >. ~ SAFE AS ABOVE p `I'N , ~~ -~' - Lam" ~ V ~ NAMC MIDADDRCSS CF INSIIRAN:E CO.OR AGEM ~. ....__. ~. ~,... ,, NMIE ANU ADDRESS OFINSUIIANCE CO. Ofl AGC11T ~ '~ '~ DK ~ N CriN1G~--. .. _.. .. CIlA1gN N0. [NFORCEMCNT CHARGE .. ... .. ... _ I Al NN~~ ACINJN ADDRESS & INJURIES OF PERSOIJS INVOLVED NAfdE Lours 1 ? ~ y a ,r I S[% AGE STATVS _~ A s ~ ~ EJECT w AA Y'. 1. `, NAND • !. C Aoonr:s. l=' ~ _ U NAl iI1C0~~ iLMOVny IIIOM INnirvrs srrNi T o ~ ~ ' -~ s• p _ ` wT A NAM[ ~ ,, q ~~ T Aopra:s I I I I I S w~mu OF criiii+nv uloM YV 10 W - NAME: __ T ~ ; r. '(. i a { T 7 Tufr~v rnule zr' ' rra-RE"CETV E D ; _ L , N I L ,n 11 TD t ~ ~ , ., s -1-OCi-+1-1978 fur-MVq~-- 4 ~ r S Ar11vIrRR ~ AiT D' libG'- ,~ F R L $" + viiN ILK Y ^ I Y to DST. Vttt-tiDQ ~./, dni.u '!. '431 AI NI LI I'•II JILpUII P ~ ~- .~ 4 O f r J IGrn -_ _ 1 inm I r 3 nsMiuwn nu~nlY r ~ , um uiv Al lco LNnly Jrmrn ( i . ,1 ~ O ~..~. ~ nn .RIMI '_~ rove ul i~e;~c i i~a iiiiiiirlniii l ~eilniini niiv auQiriuLE aieiliiei vi ~cuu 4 .. ll. _ N u F. • , i l u i ur u bN'lI1R GS _._ nl'O AII(MINNANOWN A a«Nnvnl SrAI UIL1 fALLVlIC A uNxunWNn CJIf.11N .{ ~ _ g/i:, ° t ~, 3d "I°h .T"'" -~ .yrL n A~ .n - +~1 ro L• ~ u I• L ~! L , ~M6 I ~ +I '4 y I ~ ~f ~~ ~ ~ ~ ~ I'iiq I ~ ( 1'I•- L pp 1 I _ . ~ s",},~l}. 1 '. I _ t ZTAJ~r, , I I " 1 ~ - ~'77~ • u o-Nm;. s . :, ,~„~ _. ~~~ ,;.~ { 1 ~ r ~ ,Ica ~ ,. .., ,.. , P ~ ~1 ~+ t E,. -.~ sa ,:~ ;,~ .xy.,,4 ?A i VEI ICLE~OAMAGE-Y[1'c• °.~"''-as'-~"Tf7YfAL s -Yr[Lrtr '`6r~Te~Y '-7k15fi'.U -. ~.. Lam`' r;...,....,,..N .~...deT~ ] s pE Fn D'sE E Lsr ncT I /I INSTRUCTIONS: ] on [ Isno ow Nr c nLnnfcnoNO RDI CC ~ (~~ a~lF~{.~~~~~' 913:;: 7~. ~: , E ~~ ~~„~' k DAMAGED VCIIICLL N O.I _ lu+t lNSVnftlall aALl II pANA4L lD INA1l UIS, up1011Crcl[S. LIC.I DAMAGCD VFIIICLE N O.Tr 11 IJ U. 1 ~~}}~~ NA4E vtNIOLE x0.1 17J p FApI N4 puAAGE ] O O V.OAVAOF - 1 SEVEN1iv OF pwASAO[ IOInfNV SEVNI iv Or Dwun4E VFINCLE xD.] .. f NAUF ]EC]coINFR AS V O NA 1 ^ p SABIINa pAAIAGE ] OTNfR N V DAUA4 ~ ] ^ ru Cl w pAUAO[ . ~ N Aa . ; ~uN . ^ ND ] 1] EuNCT1UNAL UANAGE . ^ NO OAUAOE CI rY,ILLE S OARAGS 'j+,-~'+.,L~E towEOBY LS i.UnAIA f TOWrDeY .. i.DA+lA4f s roClllr'L1CUH T600.00 To T F -UI oGNAM OF COL `ISuON _ ~ /ry ~('iZ~Q ET~..C .DRAWARROW SHOLYING !/' ~ u•y Ar ~r NURTH IN CIRCLE .. .. np.pw.Y /d r/ N . ,NDLT ( 1 [ j.. ' [f.pNT . lrF,pN i _ ._ - t~, . ~ ~~ DESCRIPTION OF - pxolcAlE wNAi PnpnAafnlA..E FT TNL CRwsN. NnvOF wfoNmAno Acn .c n[pucfp Ylve olswmLliY lY . ~ COLLISION , , nl , siRlAn cLOT CO OR, CONTTFVCLION ON RFPMR wOnK, ETCI q1 _ v] ~ju" T ~rv^~. _•YEHICLE'c`l hlAS 7103T/I 1;/Dt>D ON C.P.. 12E RAIL Or^F TIDi HEST SID& OF T1Lr IpAD'dAY - j ~: „ - r;: -' '.T.RAVEIST,D DOnT7 '~. DI'ir.E3 STRIKIl{>^] A TREE HEESADN. . _.j - ..:'•_:. L :u# -_- '--- .-' -- OSITION bEFURE COLLISION ' ' ~ ~ I• cci o ~ v E Lv 1 UAV ~ ~~~ VF NFApfD MI fPO N[n[ FT p1R C SM4 ON SINEETO 1cNwAY fOR NO. ONF pln l N mll A FO W ~ OOCU E i F - - '' I 1 S ~' . x.inl~~) 1 ~r110 C.R. 12 1-. YES o _ ~ 4 .. ___ D '1 ~1f- I _. ALONG_ ______ _~ CNO S x Rn wr.Ar _ ry se p F dA TO ' O nlfiwwsuslN4 •E 1 v0[wA LK N ] ._. ]_-I SN •; ARK~O S - UNN 01nprR craps LK SF _ nKED 6 FY4xE nO~TE i ,. w ~T, Yi- ( u E U . ~ r' flOAD SURFACE IC F O EI WE ~TEOHR Il K CONTRIBU IC TING CIRCUidSTANCES Nt< O ORFI N p :'~ NO) 1 ~l, - ' . D 1 I ' CLOUD (~~g D .. - ENCE OF On E 1 w1xG _ I ER ) [ Z - 1 FTnA1GNT ANEAO j 1 D Y x .. . g -OLFRCAST_ T -. OI,~_ U Ff4 ~ ] 0 I ORT FIND I ]r P "f+ 1 ~~] WET ] I I NING A L' I D. 421NiLUFNCE OF [ _"3 F NTER ' x ~ S EE~NTLY (. 1]- , y ~ A T " yq5} t^J I KNOW r IA K! ] S Ow_ DG (' J- f~ fO LIANTSTAI[0- ~ CEEp 4N -4 - 9. FON L N . __~~ _~I I~ L p p G RN I -.I LFiiT G '.T F, ~1 1 P .. I._ ~ . 1 I n ISNLC1iv ~- •O F~T~ _ N r 3(~ wl ._ T c E ,+.. pF G O ...T, cos c ~ -___.-..__ l r CJ'I :I f [KY c J l ' I IFLGIEYI f, INrnOPEn . lj l0E ~ Urin iNFR Iy[<UYI O V101 A11pN , [~ 1310 ED O ] ~ - wT IGHTICONDITIONS {CK LI RAFFIf. CONTRO 1N0.]V CL Y[n1 TYPE OF flOAD 1N0 ]F IONFLK ONE On Al011[ VEHICLE CONDITION E p p V 4 ~ SOBRIETY NCLE ICNICKON[I Y _ t~ ~: TRwfilt _ STOrr[p AIfIG ~ ~ 4' a ~ ~ •J aR SrorslcN ' :: . ; . sc f I 'I_ wAY _..~._ IN ] D ~: c'oF Yh~~Stlpl AND] F r.. ,pPPrp 1N nowownr ' y^, , ~ ., :-: ~ ' , I I -~ DA e T ~ _ Is I ioP ..__. ,X ~ owAY ~ .~_. f - p[nenve .. nnA Ls. J nio Y• ' - .: Jrp_~ rneii cierv . ' ` ~ • .•- ]j D WN ; I] " [LO L.. ~ d ON e AFN a ' i _ Oho S E ~~_ I ~I 1 1 ] 1 rr rc [ LAn aNlf ._ .: ~] I .•_-_ NOT M MntO. ~. X - ~ F Il~r.. iTAnl xa snOH' I AR/.LO PUTITION . ... C ~ ~ L IN _. ._.. ncp ' ~ A' LOO~ne n4 . _. ..._.. ; [ f<L GUT I S. ~ F~ RNRTY ' ~ ~ --- L~1,_ ~; I[NT[NI ~ r T I . f O -ilnt[T A' 11011iE ON ... . iLASN1Na F uptN .. A ' i ALL[Y .S .__ __.. - UFwnNN 1 O UpONI 1 F " A N[INUI~INKINA ~ _ ~1 r I EACKSN6 _, ~ iX pAIIK •Sl lrf FT ` a z ' c • lwp ww [iT NT1NCr-' 1rs n~vclpnlV 1 ~~ 41N0 ] C11CM. TEST v DLOOD ^~J]ST A ~ ~ ` ~ v Li a TF )I I ]... ° [. L sr 1, >. O l0 X 1110 OCFELTS , n /~ , ~ I lLfI RfIUiEn ~ ~ ~ _ T nL.rr Tn "r;~ '`.15! I ' ~~ ry ~ I K ~ A ~ OI IHLC 1 T/ X ]~ O S 11{YLLIIYI x TCST RLSULTS 2 a ' ?~ h ,'. + ^~ ~.~ ~ t^~^, i' ,- ~ ~ )~ ISI IY.A11N1: vNwus A11ANA NV1:.L. Jflll n~_xa00Pr~t I Lvl u, U1W IUT NAUI AI Nul. Nn. R 1+36 u•.1N1 - lul A Lu SNI npSIV1U rxul n1e 1. uw . , to . 3~ 2400 ; 0025 ];~1 "'Im%" „~„ IN1,`DII 1.„ IN nJnl 1 UI,11 m NNUFVInuY IN IU1l a . _ Af13r ~IS-Blw + S a" i rf 'Ej '~.,,A, +- 4 Il1S111111111111N NNIf.INnl. 1:1x•\' .:I NIl lrI SYA INIi111N !:I All I•A 11101. ,f11 YI,11.1A. WAN111NI:I IIN IIII!~1 J I _ IIUPI ICAII I.III'Y: LIN:AI IAIVI NI 11111:1 A11 111 AI:I.IIL'1"41;UI•Y TIIII'I.II:AIL CIII'Y: INVf S11GA11111'S CDPY ~i ~ 1rar~lT~a Y i ~W !~7 r ~ ~ q{ ~L~1pI~I~ ~T.Fry{ I I ~ ~ v!'~ ~ 4 i.. 1 1{ b s. ) ~ ll 1 ..r~~µ ~c /~ +a, w I t uE i,~~. 11 31 b{ W 71 11 P l sr 1' '~~~rr~~1 ~ `ti' ~" 5~~ r~ t ~`~ ~.ti I r I•,k~ ~ ~j~~~lu~,p1~ 1 ~;'1~1~L~t l i,l r `, {~ a r F! c+ ~ ~ 11 ' l i , e ~ gg~ - r _ n '~ t t r~ ~ s P :~~ .L, .. . .1 ] ..~..:;: _~ a f ~1w ~~ ~ d ~- xF ......ti..~..z. '...Lf~ai : Y ~ yy••••••)1. ~ 1 ay i c, i.lr p/y yy a71 111!1 i;1 1 LJIV PncF ~~i- ~ ~Y ~-~~i1" UNIFORM POLICE TRAFFIC COLLISION REPORT POUCECUMiLA1NRIUUBER .y~~~"'"~I~~~ ~~ D GATE OF LOWS ON UAY OF COF OLUS UN ~ ~' h10 OAY YR. SUrv hIN; (UaS '.IEp IPUB FNI SAt TIIAE COUNiIN%~ LIfv NU. FNWA ~ x'• y T !' E •"1[ ) I '! x ] J cu c TUBE ZAUUMOURI j. ~'.. 1~M Jyd',~'., COJN rY''^ ~ =•_Y ~ ry UUdRAN R ~, ~ ~ ` T'C ~ r .'J. DSTATE FOUTE ~i COUNTY RpAp DCITY STRELT O gDMCLS. PHEFM ROUif. OR STREET CODE S TIDN ^OTNER (SPEC FYI W ~' Y. L Ci/Y OR iUWN ~ VflEF1X EO. IAILE POST VY. '6. C Cr IAllE3 ~ ^ ^ ^ O OF ~L :•. .~ 1 6 :.. \~_ V 1 `} (/ 'q.~ NAME+6 NO.OF SiREETOR HIGHWAY INTERSECTING VlITH: STREET OH NOAU ~ L L `~ C- I ~ >, _'.. T ©•~ ` I~ :Ic:'~ O RAMP DIAGNAM DATA ~' : L NON INTERSECTION ~Lv^- - t• ' $° ~ ~ ACCIDcrvi INTEP UN %RD TERSECTIM1G STREET Ufl ROAp OR qEF. ~~ ,~ ,, ' N BET1•lEEN C : C ~~ M LEaGE VT' CLS. EHENC R TP~.~SOP gpgO y( - STREETANO C YTr ~ J STREET CODE ` Q ({• ~N ~y '. y~ 5 UISIANCE ANO DIRECT O4 FROM gEFEgENCE OR CROSS STREET rJ 'S `.0.• ~ ©MIIES N ~ E w ;. IuM1~IH SPEC+L LOD NGUSE YY ' I. ~ ~ .+%. ^FEET ~ OF ~ iC. ~ ~' i p'~.}, A' COLLISION INVOLVED: ©VENICLEHEHICLE ^ vEH CLE BICYCLE ' ^VEHICLE~O&lECT /D OTHER (YJRIIEJ N DHITd AUN SEVFRIFY 6. ;~ ^VEHICIE~HR TRAIN ^SiGLEN VEHICL NO. KILLED ~~ • ~ ~ OF VE CLEB ~ D yEHICLE~PEDESiiiIAN NO.INJUPED : ,C ~ ' - ~'~" D I;ON~COWSION DHAZAgDOUS AIAIEFIaL d,' OWEGi STRUCNINAME OF OBJECT GTNUCK ANp OWNERS tIAMEJ PROPERTY DAMAGE ONLY .A ~~ LOCAL ON OFOBJECi SiR1UCKS E W EST. DAMAGE "} URIVERS NAFIE~LADT _ ^ RO-:':LAY F--i ^ ^ D D RO EDGE 5 -7- FIRST I.IIDpLE RIVEfI'S Elrii FIRSTIA DDIE LF Ii.LYCL:P10H PCDCSIR 1Y CHt'Ckl ~; D /r~•~ ^ STREET DDRESS / 'i •II(^~P TI °/rJ~ ~ V ~ A SFREET ADDReSq /lr c•/+~ R CITY STATE ' ZPDODE PHONE NU E CITY p - "~YTYle. r /~ Jr ~ !.J/,• •''~~i'` it J'U:•e_ R /.. STATE ZPCODE PHONE NO. (~ N DNVERS CENSE NO. STATE SE% DATE OF Bgill ~^` ~ _ Ii ) O rL r'` N DNIVERS CEN E1:0. ~ //~ ~ ~1! ~- ~'{ _ M, ~ . OAY fR p• STATE SE,//X DATE OF BIRTH a ~ DH VERB UCCUPATIUN FIgM NAME ~ PHONE NO. ~V..u L-Ti'L y 1 ~ ~ ~ ~~ r'l /i V J ! / / ~ • f ,~, ^'- '1 URIVERS OCCUPai ON FRM NAM ,~ R .fL.+r•r~:s:.~v, !' PHONE NO. ¢~ y CODES > IDI cuss / lil SEAT BELT L/ 'sl EJECT104 / V J: ATURE OF CODES > >~ C1A59 / 1AI SEAT BELT L Isl r,~v _ INJUR EB In ,J /. .. NATURE / EJECTION { ~ .4ZrA ` R MMVEp NJURIES G• U ,• C ~Y V y4 ^ FR SCENE BY: TO FEIADVED r ys VEN. YEAR MP1fE1DODGE~CMEV.1 MODEL IDARi~N0VA1 STYLE IZ OR;CONV.I VEH YEAgNE MANEI00DGEGHcV.l MDDELIpAgi NOVA) STYLEIZ D0.~CONV.J i•~ . ~A /+ E VEH. DOLOR MC. PLATE NO. STALE TRAILER PLATE NO. STALE E //yd ^ G •:~/ ~~ • H H VEH.COLOq UC. PLATE NO. STATE IgMLEFl PLATE NO. STATE F Y L VEHICLE IDENRFICgTION NUMBEfl I v/%E ~/'~ L S T~ CA~JC F ODOMETEfl (•' VEHICLE IpENTIFICaiI N NUMBEfl ODOMETEq ~~ Ix ~ E l'/1 ~ i!= 7S/~~ ~// L "J,5 Fy N REGISTERED OWNER-LAST FIFST E ~ ~ V J ~ ^I U -h ~I I ~~ ~~ L / ) MIDDLE REGISTERED OWNEfl-LAST FWSi ~ O. ,7 / I S ^. Ir c ~ lJi /~ o r N _ y . .MIDDLE - . ADpHE55 OF OWNER ~7 ' O. ~D IJ ~•(-.^ C J d GCr,tiel/tee ,C, ~; •;`.~ ; r ^ ~.. - ADDRESS OF OW4Efl b NAME AND ADUHESSOFINSUNANCECO OR AGENT `~.~f..•A. L J ~V , NAIAE ANO ADOPESSOFINGUflAYCE CO. ON AGErJT t.' • CHARGE Cligi~Orv NO. I/ ENFORCEMENT CHARGE ITATIOIJN . {~'+J~Jr Fn Y ~I/~'„~+IJ/.U, .1 rc G(:JI~ ACTION NAME, ADDRESS & INJURIES OF PERSONS INVOLVED cpDES _ s p A s NAME' 1 SEX AGE STATUS MA P" A EJECT, ,- C ~• C. .. I F-Y ~ w ne c ADDNESS. r ,,,...yyy ~'~ D N TUBE OF LYI Ir r_ - ~r TLI sa ~ / app ' P NJUR ES JI ~; fItMOVEp FRUM ^'~1 A IlAME: LCEYE OY TO N /,;. T ADDRESS'. ' S I`uU~IfS F I.. :' l~I l< • I / ~ x IEIAU'IFD FN M KI iIAME: SCFNC qv. TO T ADOAE.S9 N IvJUA:ES' ~ C ~ E I M~ DF UT ~ SCENF HV' NAME' 5 TO 3 ACf.RE:S j Yi ~L~t'- -- -_ u li(u~i fiAlM -- i ~ o u L I gsrgi BFU s1L Lc n 1 ~ t aE . J r n \~~\7 ~~ l f .~ 5 B I:onN,uurD S I oY 1 NoT USCreD I E ! ~'li ft SS H , ) /~/ E DOU ` O~CN~ ~ I i i DED ~HO P /AlL I ) O," 0 e . ~IYY U .l UO ~ JFGT[D ]PAR TIµ LY EJECTED Z O N ~ . O :SCAT UEIT FAILURE UVIC401YN A[JCCrT.D If` L i ~ r L ., ~ s I :', II h $ y~ l ~ aG Il x`` ` } r '7' ., ,,I<:, 'yi~ / I N 19.. ~ I Y 7 t ~;1 rr +~}t, x ~' S ';~'°m~-~dpA"F"", _y~y,~, ,I:•~~.p~~.. YyN,,.A.~„~,'TA lq ~i~,. .'. ~?lVl Av ...5 ,,., .. ~'~' t) II ~ ~`w y , , ,t r u ~°il` ! ~4~ YO6 ? - 1" t .. _ 1 ~L [~ °~ Y F P ~~ e. ~ ' ~ ~ i ~~, 1 1 ~ ~~ I IL.1_+y '.,y _ '~ ~. ~'~ ,r _ '~' I' _ - 4e / ~11 ~~~ Y~ -t, ~'_ a ~ ~ _iaar ;.. >~~Sa`'n _~_a .t._3,".: ~t ~- -uE~:._. ~. +s~t1u~"a •,nPi .... ...y..~.:L ,.~iL `.s~.,_ L~ ~ a~ y ~ ~I^ ~~ ~ .VEHICLE DAMAGE I.IN EACH BO%CIRCLE THENU BEfl OF EpUI AMAGEO AREA EAAAI ~ r l~ It `~tl 7 1.SHAOEPREAOFSEVENESfIMPACT. ( YYY ' i!ICi ~ INSTHUCTIONS' ]. DRAWAHROWf91iO5HUWPAINCIPAL DRECTION OF FOflCE. ©j , r f EW Mr~ '~ ~ DAMAGED VEHICLE NO.T N$ETHIB$PgDEfDR SKETCHINUDAMAGE iO TgA:LEgS.MOfORCYLIES, EIG.I / {{I[', +~- ~ ~, jt ,, „` ~~r}, IG HOaE DAMAGED VEHICLE N0.2 A 14 Rwl 17. Ybo0 A IpI- ~ _ ~~ sm _ ~ IL~~ )A 1B TML `t`~Y^1~U ~~ ho 19 Raul 1 U arcAnlaye ~~~B'w IS Tnnk f T.OvfOUm ~--~~~JJJIII 18 UMercrrupn ~y- SEYERINOF pAMAOE VE LLE NO.1 SEVERITY OF pgMAGE.IOTHEq a-H~CLE) SEVERITYUFDAMAOE VEHKlEN0.3 IT ~~`u~ 1ODISABtJHG0A4AGE ][IOR1Eq M.V DAMAGE IQWSABLING DAMAGE ]QOTHEfl M.Y.DAMAGE 1 2 FUNCTIONAL pMAAGE 9 ^DISPBUNG DgMAGE OQOTNERM V. DAMAGE + r~ )~'w []NOOAMAGE 2 FUNCTIONAL DAMAGE a NO pAMAGE 2 FUNCTIONAL DAMAGE 6 NO DAMAGE ~ 5', ~,~ TOWEDBV' I'~! ..Fd: EST.OAMAGE/ TOWEp BY EST. DAMgGE '.E ro s t~.$J~i roweppr U~r/rv, F(•P Esr.DAMAGE ~9'~ r. '-.OIAGAAM OF COLLISION TD ~' ~--I .--~ i.._l__~ ~ ~ _~ _ _.-_ J ~ I DRAW AAAOW SMOWIN6 rFANgE3 ~ I f ~ r ,- -.._ _1-f_~ ~ i I I L. _.~ f" ` ._ i ~_T- -T I I I 1 NORTH IN CIACLE ~: r+~ ~,l RC wn10Pi.5R0ADWAY , _T~~ I_~~f~_~ \~~,~ f I I I ~ I , rTT '~~'._' 1 O ~'. _ V 1 f ~ I .. - 1 ; ~HB;~D~~e I. ~ ~ s; I i. . ~I _ ~ _ ~ _ _.. :i ' ~ zwPACr.ProaASLEraNraF . _ I ~ I f- =~ 7Il __ I I _ f- ~. _ I -~/'~''l~ tt'~~.I + 1 y ', . : s ] WgWVERKLEPEOE4 MAx OR 1 _ 1 I 1 i._~ ~ ~~- _. 1 - ~._.f-' ~ I t ~ ~1 ~Y; p 'R 5 y OWECrMCBAazEUEX MPACr. _-T_ ~ ~ I _ ~ ~ _ ~ I I ~ . i ~-. i C-I_ I '.. ^1 - I ~~ e e' ~ 1. ' rl ' • .SHOW A ~ ~ I '~' --,c'1 ~ ~ a°.$o reR CausKN oRE ~ < ~ z/ c / ?' r 7- i ~/ l / I i I _j_._. ~~ _~T_ I i ~~~--~ 1 ~4 ~` ~"9 g~r DESCRIPTION OF pNDICATE I4HAT PROBpSLY HAPPENEDDEFORE CUR NG NDAFTER THE CggGH INCUIOcINFORMAT10N NOTON DIAGRAM, E.G.ORNER ' ~~ tlis ,~ COLLISION ;~~ _„ ~ DISABIUTY,REDUCEO VISIBILITY,pEOESTRIAN LLOTHWOCOLOR,CONSTRUCRON Oq flEPAIq WOgK, ETC.) ~, gy r ~ P1: ~ A __ lj /-tea -~, -:----=-'-'-- - .. ___ A w ~ ---' 9a' . ... --- -- ° C n L.o2__w 11 e ~ U e r '~/ P /!r ~-o uT i. r ~ :r i ~, ~• ~~ O`-'. __Unlt r=a ... _-tom K..'.Jn~._.__1.- _ 7 ~ a ' . d ._._ ._.,- 1 .1L ~. -~ ._..~ .y__ J,__AL_._ ~n 1 ._ d"y ____ _.__-_ -. ~~ ._ ~ __ -__ .~__. r___.__.._.__.. _._ ...___ h aT. 1i ...._ ____~~_. _____. _... __ - - POSITIO eEFOAE COLLI510 ~ ~ 0,~,,~ , ~. .. -_ ___ NO OF LANES POBTEOPEEDS VEHKIE IF PARK U VEN HEADED MILE POSTD R. .. ON STREETOR HIONWAYNgME Ofl NO. ~ WONE DIRECTION ~rt''/^ NO WCREASWG DECREASING E LEGALLY WAS VEH N S E W PARKED OCCUPIED +,.FY ~`~ Any .l -' `~~_L~( __(~~_ _~(I__ /' YA r2. r .. = Vi [~ i t C '.r __Z Y ? ~ C I 1 ~ MPN YES NO YES NO ~ 1 PED ~ .~., ; 1' Atdq_ .. OOA s - IH~M 9PCGW RI EiOwl ~ ~ ~/ ,' 1q r 1 ' EO EE ('1 F r0 ] ~; PED/D CYCLIST WA9 U5 N0 ~ ls0f f i~gHpAOEq 9~ D ;-' I ~ 0 ~ '--~ __ •- ' Y ROAD SURFACE WEATHER CONTRIBUTING CIACUAISTANCES c ~~ 1 oTM~ k' ';~;, { .i'^~~e 0 NfA ~[~ ) ;~7 ~~ ` -^ ~ ~ ~OHECK f ~Cwsc J A Fc9~0 .uW ~ ~VE)xC ~~ q E • µl . `-' / ' 1 }i ~ L _.r.__ _u ~ .... ~ ] ~ onu NF uuK[Oa ~ C•.ERCfHrER I-~~r_ nw _ __ 1._+ I erD '~ki+ ~1 .,' 1 SNOW 0 &row/q nr1~ EMM3rAiE0 (~ ~ L ISLE -~ +- L~]r~ q~TTUAN 'x ~ C ___ .. fE rt LJe aE ..TO ~~~ ~ ~A~'. ' ~~~ ~ _ i r. C~ F00 ,. r 1 u0 PG4i - L J W.nu j1S(~ Lac _ Alutw-O --- L~ ~ I._7 tMfs~r n~iM A .. __. _._... sAr [D ~_-I .,PSaofn ~ m a,. r, s --~ M I e~ B ~ ~ f1Aa~ ~ ~ - A. ~ c oum-_ _ l~ cJ urvN`"I°Rn __ ~ n J BLDA,.,D O E IBPECG -lRjSifGSll 1 µ - -~ t IK I~VI` ~`' • _ IBl I A~A SKF L ~ _fYe MVAIA~OONm C. J ~ ~~ ~O FOM ,~ LIGHT CONDITIONS TRAFl4C CONTROL - IurtcK OHa No s Bewaf ~°. TYPE OF ROAD: ;VEHICLE COND1710N [ , _. 7 w rc c onf oA MOgfI vE K~ r coo eoR ".~)~ SOBRIETY ,~ --I ` ~ ~ LJ I 1 ~~ I J 1 ~p OYE r HO PNSPC I p I K OM1EI r l_ e ~^J7 OR 6 0 bqN ~µ '~~ .` l :~ wrLnNr^ r ~ L I s~ aka L"1 lwo -.._ _ (~ ~ crve 1 71l (L"_'1 ..J ~"°A°°°°Ew H r t Ii( M ~] BE LJ I ~ ~ -_ I ~ SAC L/VE 7 ^~ EU>K ._._. I I f lAWeq '~~ 0 _A~OF `_I BOO OrR9 Of MPa AF _ rY r~l ~ARAr^in Pw I i i P ICI 60tliaETY 1 I ua°NOtHria~Nrt iB ...+u~ ~~...'eA Ji ~.._.._._ _...... ..n° cw`~.Ire t._ K _:..~~._ ~._Ila~ ~ IDRBAw. 7 i ' !, AMBB EB'WORN MTlurr 1 '-~ .. a ., i " [MOruarts I JT G_. o~ e., ~ u w [of_~ r j [ '"'°°. ~ ff [ CHEM. TEST ~ IrB`~ eACxv,p • F y~ '.~~F! _ _ omulssfcrn $~ a"~ 1. sor~wixcrrl ..... %lcMOaiwiK ~~4 ~~k1 uwwoEa l_i. ~ fA [snclr»' I 'x ~r~sfo T 1 lti '~", 1 yi ~ 1 vNe~BVr, orrK[Ke +w[.nw /„ wweHO ewo HxKL 9 TEST RESULTO 2 ~'~ ~~~~ ~ ,I l 1'_ /1 ~~/ •4J wf lnw Llf.-:!/~!.. / j..'1'E ::.LS ~i.W L_.- .r ..7i >.a0 AMnTO B./.) ~P[~O ~W ~ '. _ ~. rM p prKEA B~(KIINO q] /L%i% M9pp KM ~~ 1 r.'. ~ /.. ~/+/L<,. -I / /.: ~ r^ rWl Pli 9p[r. InLPORr APPRgYOBr pAre h~~ ~ ~ ~i ~ ; ~~ G . ~ J : P~ I ~ IN~ ~R ' / L ` -~'. . ~, e"~ ~-., .. 3Ni._. .. ,.. - - ~,r fi 'ro~ ~~ 77 C ~~,~ '.~xY .c 'i:X w1~Pa.'t' r. 7 . ~r~~ n ~EL~ _. a .. ~ _~ ------ ~ Iy I L V!'1JI ITV 1\ PAGE f OF / -- -- - - - - - ---- _-_ [ , O. ~• y~•• P UNIFORM POLICE TRAFFIC COLLISION REPORT OIJLE COMPWNT NUMEIEfl ,, ~ OATEOF COWSION OAYOF COL lIS1pN TIME C OUNTY NO CIIV NO. FHNA ~~ ~ MO D R T SUN L MUY 2 IULS D WED A iMUP 5 FRI B SAT IVf A N RI Z / ^URDAN ORAL ~~ ~ qrN LOU fr TrtA1 ^STATE ROUTE IIIICOUNTY ROAD ^CITY STREET O OMCLS. PREFIX TEORS1flEET f.ODE ROU CTION ~, 'jZ , _ ~ ~~/ J J ^OinERISPECIFYI TT N ~ L J Q •y . C CITY ORTOWN P l1EF1% EO M ~ ILE POST "Y L ^IN N 5 E W W / /~ ~1 /~ ~~ //~/ / /CHIEFS ^ ^ OF._._.. c?N~m/./C:(/L/I (. .. _._~ _... _.-_ U LL ~•O~ , ~ C• A Ed O.OF GTREET OR HIGHWAY INTERSELTINO WITH: STPEETORROAD LL C MMP D IAGRAM DATA • ~ ~ ? ~. ~.,.. ~ ~ ®~ ~ ~ ~ RSECI ACCIDENT W ISP N %~ O MERSECTI STPEE OR ROAD OTL REF /^1 Q O ~ ? ~ ~(~ E M M CLS. E RENCE CROSS STR ETOfl ROAp ~ • N /'T~ STREET AND /E~' TREE] BETWEEN ~ COOE ~ '2/y"Y DISTANCE ANDDIRFCTION FROM REFCRENCE OR CROSSSLREET S N 5 E W 0~ ~ W S ^- PEGAL COOING USE , 1:`~ % . /C N Of . r /.~O/7 L) _. C / FEET gVC11KLE~VEMICIE ^VEHICLE~BICVCIE ^OTNERIWRITEI ^NIT6RUN COlL1510NINVOLVEO: ^BTOLEN VENKLE VFHKIE~OCVECT ^VEMKLE~RR ]RAIN SEVERITY NO. NILLEO ~ U ~ •~'~wr,-, __ __. OTAL NO T OF VEHICLES ~J VEH LLE~PEDESTRIAN ^NON COLLISION ^NAEARDOUS MATER AI _ O.INJURED ^PROPERTY DAMAGE ONLY ;,~' 1ECi 5TRN CKS F W EGI.OAMAGE RB HAMEI IOCAT ON OF 00 OBJECT CK NNAME OFO CT STRUCK AN00 8 ~ L , I ' '- GIGET ~' ^ROAOWAY /SPELT ^ ^ ^ RO.EOGE 3 C Y ? dAST iWST MIDpIF ORIVER9N DRIVER'S NAME~LAST F10.5T MIODLE.RE DCYCUSi On Pt DESTRIAN CMECKI^ D ~ /~sE O.eYi~c - ~• D R R STREET ~°°~w4 STREET ADDRESS ~ i ~ E City STATE LIP CODE PHONE NO. R CRY ~ STATE 21P CODE PHONE NO ~ d' ' P;i N OPNEIiS LKENSE NO. STATE SE a % DATE OF BIRTH AY YR. MO N p DRIVERS LICENSE N0. STATE SE% DATE Of BIRTH MO. OAY YR °• ~ , '~• ~ LI/ ~ ~ , r pRryE FIPMN ~ PHONEN 'j OnIVER5000UPAIION FIRM NAME EN y ,~ ~%~~ ~~~ ` _~ / v/ .aG' E.Y~ t CODES > IDI LLASS~-- TAI SEAT BELT.I . IEi1 EJECTION .i CODES.> IJI Ci~55- IAI SEATS _ I51 EJECTION. , i. N NPAMTUU SOF , - - NJIIR ES tl'T FROM 6LENE 8Y1 TO EMOVED GPOM SCENE DV TO VEH. YYF M oocceECHEW MAKEIO oqq MODEL(OMT~NOVAI STYLE I2 DR•C -I VEH. YEAR MAKEIGODGECHEV.I M EL IOAflT~NOVN~. GTYLE I2 DGL.CONVJ FFF y p YGK'J ~^ + 'Y'Z'~V 'YY1Cl5T ~1JC /~7' V TTT .:,~ , ` E ' VEH l1C PLATE f:0. STATE iFWIEfl PLATE NO. STATE E VEH. COLOfl lC. PLATE NO StATE TRMLER PUTE NO. STATE : " 1 .~er ~lAc 30 ~rv --- ~' r ;a (•` VEH I//D~~ IiIfKATION NUMOEfl DOMETEfl (•• VEMKLE IOENTIFKATI N G n0'R ODOMETEA ~ f( E M ~ FWST MIDDLE T REGISTEflED WNEFi-LAS nEGISTERE00WNE -LAST f%iST ... MIDDLE ` ~ I +~ ~ ADDRESS OF OWNER .. ADDRESS O OWNER ... ~ 1 2 8 EGS OF WSURNICECO.OR AGENT H NAM AND ADD NAM DADORESS OF WSURANCE CO. Ofl AGENT // II f d LJ. ~• CHARGE CIT ATION NO. ENFOGiCEMJ:NT CHARGE ~ RATION ~/TT~~ ~~jj~t rj//Lu'f.'E iTi L.CSF /~JLFE (..'Ii~C~ C CC , IOL7 ACTION ~ NAME, ADDRESS & INJURIES OF PERSONS INVOLVED COD ES ' ' ~="': SE% AGE STATUS NY ~ ,„ , LT EJECT J //11 NAVE' /NL - (CBE , '~ ` ~E I ~ 1 / '':T. C ApDRF55 ~f YIE •` p uuu Ew s°F [' YJ9 - O ~'C(/ _ Mov I r _ - _ To - A NAME T ADDRESS' 5 iunt R EomoM WJURIFS SCENF RY TO ' NI NAME. i; 1 ADDRESS' N WNRIE4 SCENERY TO E S NAMF S ApLMESS , S• hAJ~S SCf.NFRY TO ' .l C IIISt AlU3 JPASS[NG[R µ 1215tA 11'O SUg H IDI WJUNYClA55 NOINJURV 2 DEAD At SCEHE 505ABLING UUURY D NON pSAOIING IAI SEAl11ELT 1NOi WSTAILCD 2 NOTWUSC +ItJEL1K-1 I I,NOT EJECTED 2 TOTALLY EJECTCD ~ I O i BG CLISi R ~ 2 OIBU 1 C LLEI ADEODIN IIK)51'ITAL I (I'FOSSlnlilllr~wnv T UNRNOWII O UNKNOWN F[GIEO A I yyK } D E dO1NE E 1WTN[ES F D P~T~ 10N d VM . . 6 SEAT pEIi FNLURE . EJECTED • I A `NT ~ 1I 'RT}{ y ,N 1 ~ 1: { ~~~h«' I Y l' N` ~ Y ~ 4 Y ` ~).( ~ M ~t. f'V'~ 1 ~~ ~•~ 1 ~ f ~ , % ~ AL , 1 1~ 7N~ ,'1 ,i~„ f _ 'I . X1 ~ L . ,, . 1 }~~~,yyyF I fµ + J I 1 .'R~f ~ i l ~ 1, r 4 t 1~ I I :~ I I Y r~ YI ~1k~ ~f 1 !, l tii f I i I -I 1 _ r ~ ~ 4 + '' t a >r 1~ ~ t ` 4 t • ` ., ~ }~~ J , YIUF - ~ ~ I m 'r . ~,: . ... ' -~~ ~7~ r M1 „F P i • ~ ~ r " ' ~~ ,. N - r fl ~ ~ - fi •~~~~ ~ F . s s„ _ • ' ~ ...-!T p;~MFr'.: T.P-' d' ~ ~ VEHICLE DAMAGE .Ib PN a`c'Y"ti~1;".a ... ,y ~ ~ I.+. •_,~t, d' 4 EeEaLl.1...~ - 1. IN EACN 00%, CIRCLE THEN OER Oi EACH OAIAAGED AflEA '~ - ~~u~y'¢{r ~ ~-" . ~ "~ ~~~~k~ ~ } ,~ ~!° F INSTRUCTIONS: 2 BHADE AREA OF SEV EREST MPACT O. DRAW ARROWI5I TO SNOW PRINCIPAL DIRECTION OF FORCE O~ . _~L~ ff - .k a ~ DAMAGED VEHICLE N O. 1 lusf lxls svwa Fan sKElcNlnc DAMAGE Tp TnAILEns DrDRCrcL[s, E c DAMAGED VEHICLE N O. 2 i d _ -: ;,;A AY ' IT 'u,^ Il k Y~ E FRITY OF OAMAGE'vFHICLE NO.I 1 O DISAELIN60AMAGE ) O OTHER M.V.OAMwGE o ^ NO DAMAGE SEVER TY OC OAMAOE' IOTNER VfNI<LEI V I O DSABLING DAMAGE ) ~oTH[N M. DAMAGE ] O FuNCT10NAL DAMAGE .ONO Dw"wGE SE AMAGE VFNIf,LF NO.] I ^RDUS DI NG DAMAGE ] ^ NiHFR M.V DAMAGE ] ^ AMwOE ^ - ~ y _ 4 ] fUxCT ON E fi OWED BY EST. owMAGE TOwEO DY Si. DAMAGE TOWfO BY EBT. DAMAGE ~~ , t TO ., , f fF TO B I RBI- . T;I DIAGRAM OF COLLISION _ I ~ DRAW ARROW SHOWING ~ fr I losxlvr: ~' ~ ~ I' r reA+unes I N H IN RCLE A, ~~ ~ ~ rfDFSlnuxs I ~ ' - ~ ~. D..EC.LOA,DFr AD.DwAr ...:.~ , Y t-~ ~, iii O ~ ,A.FII«DATRDLf FE.wANAI _ _ i w.. uxufuALrt[ur. [DNPIiIONI i ~ ~ i 666"' ~ KE /AICH [Ox>lautilDx I 1 - - -. ARFAf Ettl .. ~_ .. .. ~_. i +T 1 1 • ~ q ~ r~ ]. LDLATF /AOFAEEF /D Ni OS _I IurA - ' ' - . _ . _. _. ~_ ~... i .I I •). sxowvLxKlE rtPL)rn AN Dn oUecT rosll ONS.I urALT. .• I ~ '. _.. _' _...... _ .... ., - x `Tj- "_ ~j ~ ,_- ~ ,. . ' ~ ' r U ALNawrroFAFLE VLUCi[on L .EDLFTALx..,,..L.P. AND.FTEwLDLLMwH - .. .-_ . j I .. __ _TI_-r-.._. r -j ...• I. I ~~"" ~. • -• --- --- - - i I i ' , ., • DESCRIPTION OF COLLISION IND¢ E D c Ec s cL ~ o roN NOT ONDACawM, E.c D R _ OKABR T , OUCW v S B 4TY, PEDESTR Arv ttOTH NG OLO ,LONSTflDCT Orv OR RfPw R WORK,ETC I N ; *~" • _.. y • rv~ . _ ._ . ., a .-,. e .. ~ __ ~ -Y "-- ------ ---- --- - - - ---- _~ .. ---~------- _._ ... .__ ' POSITION BEFO ECOLLISION ~ niiii O O i IF PSR EH. • • ~ ` ~ EH E 0 D OP L Orv STREET OR HIGHWAY NAME OR NO. IN rvE l D Y vapnK FD . , . . + OC '- M p, f ~ I ' . N EC EwBING C E _ _ ~ ~ : L_ EG_ NO ^ p -. t B NO _- I z __ .~~ IJ I' ~ A __ Ec ~~ ~.~, ~ • ED I[_ oxc-- -- _- EOIBIC 0 ST iBIOE ~SHDULDFR E CONTfl IBU LK D CR - ass c __ _- _ oM TD '_.iC F K SI I ALR f , CLF nOUTE ]~ ~OTNE S~ MSTANCFS TINC CIR U L + ,~1 _ - - _ ,.,,,. - Ww A~eNR ROAD SURFACE _ q r 1ND ]Y~„¢LL ¢ ~ NECK ONFO OREI uORU -.. pPiVER 1 O.] ~.~I(^~ --- C EA LOIlOY _.:...SDVEflLAST.__ ONIVER I O.] .~ ~ I UNDER INFLUFxCE Oi _l_?ia..ALLONOL ^,I] FT _ ._ t~ ..~ "" __ '' __I ND R LUENCE Of .Ll~.. onucs IN ._ ~],~.s"°Lr... _s~.~sNOw NC ~~i~r~. s:iioo rNC T_rfo -. , ~ ___, . ~~_..._ I _.~._iOG... J E F45/ [D E ]. ~_I E_. .. ~l'B~ 1 ~~01N[R ISPfCIfY'1-" 5~ ~ ~ _ OTiIEH IYF IfYI - ~~6j ~ My ~T~L€ T."~ -( -, I ROV[R - I K:NecK Uxel i ' I,NO vFIEIGNAIT ~ .... I IF r' ONE WAY^' V^-V•" ~ _._ __ ` 1 ~. DAYLIGHT ~_. . .. - 1 ]]~ I SOP ..3G ',,] OwAY _. __ ~__ _ . ] ~~ 1 DAWN Y 0 ~~~, fIGN _ L~.~L._ ROAD BIBLE - - ] '! DVFK .. ~~._ .... -. I. I w IINO ~ ~ _. ALOB , r I INTFPCNANLF __~L.. LOOr IIAMP _. ~~ w ,', ~ll~ OwRK-f1RFFT __~.LIGNTt ON....... ~~y E' -. ILABx NO .I .._., ALIBFR ( ~6~ ALL(V ~.~.. __... _.. -. _. ~ ~ 'DARK-rtnur uDHTT prr °' ~ ".t. nR acNAL _~. L' -Ert Twn1 iB :Nis 1 ' _ . . .. ._. ~.:.. ~T~L[TNLGIITf ]' ' oirlFr lviciiYi ` . . .. _ )_.. IL L! M E its aoNr.DL n. N 1 PA lF ... .. .p ovm[o ,);`- uxmvmrD I NIOf] NDE] GARDEDW OS E 1 ~-~-i i I SiRw GNT wNEAD " ?~_Dp,C1pSE iel + OGEE Cfrv1FR S _T] - v IE RENT AND PASSING ^)~ ING a uH 91 ~S LFLi~~ ~.. IS LOCITION. _ ~.. . ~ l T TURN . I I MAKING EF UnN ~ L ~I O NPE - T NG 6 C VE EOU_ p L N E UT ~--p0 00} - _ ;E 1 I r URN 6' I SLOWING .,~.i Ilj i D fG DS 0 GNIS LNAL E 0 F IB/EL iYI B NO VIOLAT ON r ~ STOPPED FOR TRAFFIC OI ION, /EHICLE CO N T SOBR~wF V ~ lcNA IBI f on iio c Ss ~44 /vAA ~LL ~ I E ~ ~~ ~ C K OwO V F ~ F l _! v sl NO. ] ~D1 I~ ~(~11.1 BU I NO. ] I. ~B•_.1 R05vPWAY" D OEf E[TW[ -.;~BIIAKt9 ~ I NBD ABIIITr '. MPAIRtO.__._._. _._ ~~ ~ D I 1Rw{{IL LANE ~' ~~]~__.~ OEf E01 I.HEAD LIGIIT$_. DABlllly '~ NOi IMPAIflCO ______.. ? ',1 YARKLOPOSRITION , fECTIVE a(JUI LIGHTS I ~ .l IBD SOBRIIIV UNA ~ .I> MERGIN61[NTfRIi I TRAPFI<I - _ . IR SWOItN I..Dl1_SMOOTN - ...__.. _ . _ NAD MOT PEEN On NEIN6 , IS ~ lACNIN6 I.. ~Si~ ~ N „L En CHEM. TEST D xo. ] ~ i :i ' TFBT GIV FN TH Fa IS/EC IPV'. OEf ECTS ,~ ~ NO ' TFET n[IUfEO ~ - , OTiliii~lSrFCif rl % % TEST flESULT3 2 `•° ixl I I I I ~~y~nr~ ; ~~ OISTRISUTION: ORIGINALCWY: S[NO TO WASxINGTON STATE PATROL-OLYMPIA, WASNINOTON 0850E I ~ l~If ,d tAC~ DUPLICATE COIV; LOCAL LAW ENFORCEMENT AGENCY'S COPY-TRIPLICATE f.OPV~ INVESTIGATO"'SCOPV ~~~~,Wy~(~fiia~' Y ~ 4 ~, li ti t7 ~,1y~ ~`M 1v' Y 1S tit i` r[ 1 M I I I i 11 ~ ~k ~i r i ~ ~ f. dap EL ~ .: 4P^ r I ~ ~ L I ~~~ ,Irk - ^ ,~rr,,,,..~,,,~y t~ . ~~~~+ E ~ ~n Ir~~R ~kd~ ~ "~ Y L1 . ~~ ' 1~p~4~ I i .f ~ p't1~I~ F ~t r~+h ~ , w~ ~ In v 'J~L'n~/~a ~~E ~y~ i~ 411 '~~"1 I,~ ~e L'f 1W ~'~I it 5~.~ I, f;9N I I d~ ~ ~ ' r1 ;l "~ }'Y,4~1t~ ~~ .a~1 r t I q~"~~4 k 1 i 311j I~, ~' S ~+ ~ L ~: x_cr,~ iT'- ~,~ r mxlr,~-r .~,.,.,..,.Y,D, 1: i ! ~e r~ t~.~ A .S".1.1 .n. ~',j f :.a z , ~ 1,TI ~r~`~I' I VI "" ~,i ,~~:~' L rl ~ e r yPI ;,LEI ~ ~ { I 1 ~ ~ .~, ,~ I, ' .~ ~ . _,.. -. - . M.. ~~ _. f _ - ,' ,> ~, >_ ~ „•. - ~ ' ~. ~, ~a ' ~ i ~ u n i~- ~~ ~: " _ F~-~~ ~ '~ . . _ ~ .. 51 N7L UY- ~I P1V! 7i77G i.V~V PAGE UNIFOpMPOLICETRAFFICCOLLISIONREPORT _ ; :tea DP .m ~a ~~VO l t raucEClJAwuwrNUUeEffy ;21r• F ~ ~-~ .' fr 6 1. ~ ',` Ala a I t ~. - v D A ei DATE OFCOLL1510N MOn DAY ~YR OAY OF COWSION ~ r 4UN I MCN 2 iUES J WED A iFL'P y fHl d SAT TUAE'.: :: MUSE 2~WO HOUHI v Y i ~ ~. , , COUNtt NO. `' CRYI p i `/J - ~' C p ~. CWNtt ^STATE ROUTE J^c'COUNTY ROAD ^CIrv STREET O U R AOMCL'i. PPEFI% POLITE Ofl STHeEf fAOEn CnON. / J, .H ~/~S~JN ^OTNEfl I4PECIFYI N 3 95~~-0 ~ 'Y O ^IN CITY Ofl TOWN N 3 E ~ ^r l~ PREFIX EG. 111=Fp3T ~ ] `, 't/(~ F MILES ^ L;] I_I OF ~~i /~/f E] • ,/ ~ GL~•I ~JYe•~• z F.~r A NAME 6N0. STR Ofl HgNWAY -. INTEHSECTNKI WITN: STflEETOft RDAD O A ~ / LJ f RAMP DMGRAM OAi T pL~ Qltl ' :' . ,^ ~ NON TERSECi -.: ~. f Q N ~ BETWE ACCIDENT MILEAGE N Ep NON X~qD i-~iSECi1NO SiHE Il QAD OftR I CIS. cAE~(~. gO5S 3T REET ON nOAD l EN SipEET ANO STREET T CODE O J /(o O ..,' DIS ANCE ANO DWECigNFPOM REFERENCE ORCROSS STR ET: ^MILES 4 E uxpHET PECIALCOCVK3 USE ^FEET DF r7 . t ~ F ~ i n u K ~$ 3 ~~E ~' is i 4.l 4 I. +F ~ Y~~ ~ Nm,„ . ~ CALC($fONINVOLVF.O: ^VEHICIENEHICLE ^VEMICfE~81CYLYE ^OTHEfl TNRITE) ^HITd RUN SEVEflIrv • ~ ~ TCTALNO. ^VEMICLE-0BIECi ^VEHICLE~Pq TPAIN ^SiOLEN VEHg E ^NOi NJLLI1PED~.O~ V4 1~ ~j 1 ~r •;J CFV EHGLES ~ ^VEHICLE.PEOESiRIAN NON-0OWSION HAZAPOOUS MATERIAL p', ^ PPOPEfttt DAMAGE ONLY OUJECT 5T5UCRINAME OFOSIECTSTRUCKlw00wNFRSNAME) _ IOCATIOn OF OBIECT STquCN , •~~ ~ ^ ROADWAY FEET ^ ^ ^ ^ RO EDO~ 4 ' ~y~„rF0 9 t. ~ DRIVERS NMIEI.AST .,~.• FIflST ;,,,,:~ .~_, _. DLE NERS NAMEIAST FgSTMDOLE II 1 MIp - oR $~ T 7 ~- ~ HS D DisTn~ fit. ~.F }~ ,' R StpEEF ADDRESS ~. ....., .. .. r' R STREET DDREES . $ .. ... .: w-.. r. 1 D .... A.... ~...... ..._....... .» ,,..._~, ' ~ ~~ _ S ~, R GTY ... ,.SAT ,,........... LP,000E, .,.:.: PHONE NO. E CRY ',~,'. .~:~: ,,.er-.: r'STAIE .:-. ~w11we. LP CODE t~-;l_:;. VIIONE NO. F~fi ~'~ d L~ > -'. ~, R J" c Lug-~SC)/D / fJ ~ R yx ': N OArv'ERS LICENSE NO. '.._... . STwi 'SE%~ OA O &RTH N:IXiNEPS UCEN]E NO. .. ~...:.. .STATE..: ,BEX .. DATE OR BWTH. .~ ~~ Y ~y,~~'0.: ~> F ., ..~... '` O• ~ ~ MO OAY YR. Q•, MO. DAY YR L ~ ) 1 DRNEAS OCCUPATION ~~ '- I ,U )v I ~ ~ ~ `^ • "~ FiRM NAM :.:. ....... _ ;•nr-PMCNE NO. .. _ _ . Z DRNEPS OCCUPATION..::: FIRMNAME ....... >s~~ ~ • ~~ ~Iq1~ aY'~^" ~ CODES > WI cu°sqs 1'1 sEArssa < Isl FjErnoN '. CODES > I]I Lui4 (q sEAr BELT _ (sl ~ ~'` P`'?e ~'""''~y 4Af ppE OF .. EIECTION.._ R !` ,~ ' [ -: ~' It4U ES WURIE9 ~~~UN y ~ MOVED FgMOV(O (~~ t~ '.qOM 4CENEBY: TO OM SCENE eY: TO ±~'~j~ , VEH. YEAR MAI(EIDDDDECHEV.):, MOpEIIOMiilOVA1.::; STYLE120R-00NV1 ._ VEK YEM-, MN(E(OOODECHEV.1 ~. MOOELIOART+Y0VA7:~: 4TYLE120Ei, 1~ SLY Dk'~1[{1. H .... ^~' UC. PLATE NO ~; Sf~TE TWVLER, HATF„lq_ STATE J E vEKCOtAN '. µ• tJC: PUTS NO ATE;, TANLEF[PtATE,NO. STILiE:d._ L..~„ „~ I ~: O: v wFN F iwn.nuueEq;.a,..•:,,. .;,e:lz.,.G ETErc ~C YEHICT.E wENLIF1Dnn H.NUrAe ;; - ~ ~ n ,~~~ ~ C ; ' REfiS[EREO.OWNEA-IASi .y:.r.'...?-r•FWSL.~v:M.w..i.....~' MIODIf: ,;~.~~ REGISTEPED.OWNEA_~ . S! v.: FYiSL~ ~~ N .. , .~ _.~. ..aE4L.L41P=C.G.7'2+m~lree&Itw DLL. ~ ara ~'I . >" . A ss.oF-owNER..: ~,,. •......,y.~w.- sr >r, :. ~ •xr ' ~, ~: ~ AomESS,of.owNErt.,~5a ': .. ' _, + 2 ',sFm L.1 ~as..:,•~,xoaey.<r.~, +d~a. ~r rx. ~I r i i ~. /'i ~i 2 ~ e Rs ~ ' 'e' - V{a NAME ANDAOIXiE990F C4UaWaCECQ AGENT r!-'. d~w:.~..._.. i~ N•WEMIDADOHE490F WSUliANCECP ORAEiFJ1I Y}'..r,~>`]liss1'-'lYa~ ~i~ a 5 _ .} , 5 . CMY.t VAH G, CHAFAE 1 fJ G.: .. 14 ORATION ENFOgCpM ~...~.~' :'l..jweLv A ~Ty+y Vy.<GV h~~ ~tn PYY666=..~ ,• EIR E"^..u./.: a-.._...._...r _ ` ; k, d ~ ACTION "~ ~:'. x,~a~x 1.. w ;. , ~ '~ . "' • ~Y ~, _._ NAME ADDRESS & INJURIES OF PERSONS INVOLVED +•~kT,''F,`~ sExD ADE srenLS ~ D ' 1 , A ` 'f ., ::.... S.; E: AME ifli /)~ L >'PA NA • 1EIECI Rj ~~~ L NHE OF .REMOVED FROM P., IWUmEg: SCENE dY' TO • '~H A . NAMe ~ N T ADCPE49: ' ~ { 6 WUpIE4: 3T.fNEVdr fflOM ~ & jj~~j •~ I ACDPE99: I ~!` ~ N IryI:R,E ~ M & ~' ~~M' E scfNF dr To ~ gY$ ~ ~ '..;a S NAME: .: T' ~~ I e~' ~ ADOPE39 ~ ~~~ g. Ii+JUH F ~~ 'Zly eeqq}}~. TO JI '~ 1 C+ It: vtA NS Itl>EAt POy:ILN ,J HYCU5.9 ~Y 1~1 A .l tJ {, { C J P ySFNOER I. NO WUPY Y S DISAUMNOINIVRY 1 NOTINSTALLED t.NOT PJEGTFO _ ~ FFDlitRIAV 1 1 2 CEAG Ar SCENE 6 NDN-014ANL N0 2 NOT NOSE Z.TOTAILY EJECTED y )~I ~ y ) / rOIHF.RPpgTON ]DEADONAHANIL IEVDENTIINIURY JUSEO J.PARRALLY PJECTEO ~ J•k _ IdU9~MOTOPCYCLEI 10EDIN HOSPRAI ). POSSIPI.E IWURY UNKNOWN A. UNKNOWNIF Y~ I~ ~,,~'~~ ~ E Aw~ FWT ~ ] O. PO41nOV UNX.VCwY I SSEAT PELT P.µUPF. ELECTED mL, .').~i ~.T r~y %^'3 ~ ~~1 . ~~ r ~~ n ~ ~~ ~r ~ ~ / I~. s^aF~ f Y~ d :. ,y x ~~~ '~ ~~~ a rt ~~~~ i ~; ~..- ~. ~ . ~ ~ ~. ,- =~~1 ~~D I VENICIEDAM1AAC=E INSTRUCTIONS ~ I.INEACXEO%.CIRCLEiHEHUMBEROFEACHDAMAGEDAPEA. EXIMP ~ I E.SHADE AREA OF GEVEPEGTIMVACT. J ~ I ~ • ~O' F.~ ~ •~ D.DRAW PHPDw151 t0 SHOW PR NGPALDRECDON OF FORCE. Q~ DAMAGED VeHICLE NO.1 u HoaU IGSE TH6 EPACEFOR EREICMINO DAMAGE TO TAAIlER4. MOTORCYCIES,ETC) DAMAGED VEHICL~N0.2 •=~ a IA. raPr r .==-• Ia HPPC E- // ~}. u,ROO1 1 FAR 15 Trunk D ~I ~ ISTVJI I ~ ~ ` -~IlS~,t.T IB UMx - I I w' u \ v a v = I -T~_ ~ wriape __ I IB.UMxrarmpr N ~ T .r n v~ axrwn r 'r'FITY OF DAMAGE. VEN CLE NO.1 SEVEFITV OF DAMAGE:IOTHEfl VEHICLEI SEVER iY OF DPMAGE.VENICIE N0.2 QCSABUNGDAMAG E GQOTHEfl M.V.DAMAGE IQDISABUNG DAMAGE G~OTNER M.V. DAMAGE t(]DSABU[A DAMAGE GQOMEfl M.V DAMAGE Il 1. CnONAI DAMAGE HODAMAGE 2 FUNCTIONAL DAMAGE NODAMAGE 2 FUNCTIONAL DAMAGE 0 NOOAMAGE l_ tOh DBY,_+" ..~L.{~/~~/' EST.DAMADE TOWED BY - EST.DNAAGE TOWED BV = EST.DAMAGE To - ~ . s`7/iA~j To s To i DIAGRAM OF COLLISION r.RPwY F[A [a 1 ~j l_ 1~-I ~ I I ~ -1-ri ~ ~ 1 I L DRAW ARROW SHOWING I l ~ l l i I -f-I I I I` I I- NORTHIN CIRCLE "9i~, ~.PD.DwAY I I { , r T '- ~ ; I - ~ - I - - ; --..~ T ~I ~ I ~ rcMCO[°Arnw°cna~.n0"' ICEPA I I --? 1 I I! f' 7 ~1 I! -~-(- i !~-~ =.IMna~T PR«AeLErowTOF TswwwRCla srRIAPaR '. ~ ~--~._1~ I I I I ~ I I~~ I~ I~~ ~I _~ ~ (~- I I ~ r Li I-'- i I- -~I L~ I -rr--- I ~ celLCrPCymwAnr.RACr. - . YfCwPRDBAELEVEHtLEDP RT«RrRMN ATH~~EEDRF M,DAFIFR CDMA4DN ,. ) I l i [ *--- ++ I ~ '- i ~fii- I ~ r' f ~ t TI ~'~ ~~- I ~ I I ~ _ ~ } ~ .; ; L._l~ ---~ 1 ~-- --i ~ ~~ T-i-f -I ITf- -,- I T1 DESCRIPTION OF~~ COLLISION G ~~~ A,~ j[S'„' (INDICATE WHATPROBABLY HAPPENEDBEFDgE dIRINO ANDAFTERTHECPASH,INCIUDEMFOflMATONNOTON DIADNAM E40PIVEII DIBA&UTY,RE000ED VISIBILITY, PEDESTNIAN CLOMING COLDR CONSIRUCTIDN ORf1EPAIR WOgK RC) _ -~ ' ~ ~i_J_:`---~~~._..-- _!: -.,~1 C^ i~ , r' _.r T i.: rte/ r -'S~ ' ) i- ~. +..:-V+ D ITI_ 6N.B~E;D~~~ FJi HEADED MILE PAST DIR rv0 INCREASING DECREA&ND ~.1[' 1<[3{ m{'~' yl.~j{4 ~:+A _.^_~'~[" NO.OFlN1E9 .. S ONSmEEr Ofl HIGHWAY NAMC OR H0. ~ D/ONEDWECTION PEEp9 VENIC ~.IF D LEGALLY WAG VEIL PARPFD OCCLW E D ~ - ~N S ~ E W ...:.. .. ( ( ^^ ^ ^ ^ L.J , 1 - /l ~ -. ~ - ~- . ~.. .Y'~:/T .. ~~ _ .. _.. YES [p .YEe , lA5 caa ~ ~ ' ~ ~ - ~ - - :~:~ . - E PE0. ~^a^ «~ ~ ~r~R -x~ .T~,~c~HE.II , .; .;.- ,~ FED/'vICYCUSi WA9 USR~I ~ 7 ~~ •5. G: ~ µ` jsotw ?~w,wtw :=^Srqulnp[-:. ^tR~ ~•u ^cws ^~~ttElaurk 4=~ 4 .,;'.A.F., :}.~. ' ROAD SURFq CE nH•,WHEAT~ER,~ ~ C01{~i{BU71NG fIR MS~ANCES~~gyj~, :, •: - CU ~pxhntl~[a6ACnva,~E Et' ~£~~ ' 7 ~~ _' ' ^ Dm ~ r " I , ~ ~ . w;{z~7vulceE ,~MORa ... - ~~r o~ .,; .: rte ~.LJ, amaa.wEu ww[.rccn.. x ~ ° s" w J . 0 Rc I .1' ors M ^ 4 "LCOrw ~ rooc[nanr . , ~~.~ A: °"x'aC a i~sg, `~ I ~ ~ y~wNwD _^ - .. ^_^ ;~ ~ ^>^~~ro - ^~d^;~ P a~^ T~~ I -~ I II Rz _ _ ~ [aa ~ _ , ~ ~_eEOU.oRw : ~. ^ o~ ~~.nRw 'e~ ~[ me[aw. ~~ ~~° ^ 4' t ~_ ' ~I . j ~ 1_C~~KwCn ^ ^. WDDM" ~~ ^;a{~SLY,.104 1 . . . j I ' r "" ~T ((' LIOHi CONDRIONS -TAAR3C CDNTflU4-~ TYPEOppOAD, VEHICLECONDITION ~$SOBRIETY'~%1 .+°"~+- c cR p.D x K ae ~ No ICHE Morel ^ Q aR ero. wl .nRClc . o o L . .. ~ ~ ii .. ,. . ro ecNw I,.~.I P, on ,~ r,al,[ .~_^ ~ ~, ~ "N~ -` ^ ^ ~ ^ fah °~ D ~^~ MV:r ~` + ~I D ArI T I. ~ ~I yon . _ t -~ .. ~ L..: na °wa ;--ov[- cme' ~' _ - D ~ ~-Y mH __ - ~ - ~ .... .. J, ~~ n ~ ^_^ u"'°°°NCn .- ~n~ M[~~rwrt[Rmn ._ _, .LOOT n =-1 K""In"'° o m ! ,o•r „>~_^^~^ _ .. .. ~_ A;uY _ ~ ~ D~~,H r1AI~ n"e FNwHI[.o '- -~I;p .~DRxD: - Lm a E I J r yaAML _ ' _ ~ ~ Tuw. [* ( [! 1 DRNa.'~r"RD ~ CHEM. TEST ~' r~,- 5 l7 . F ~ nLATH r I _°x ° .- _. - - _. ..___ w AeMI ~~ r. ._ leeecen x..,l I ~I . _ , , DMEq _.-_. _.-- -. _ .__ _ ~,~j = J pN0[D ~ i I ~ _., T[Sr R[ql«D ~ ! 1 .' i,3 .1}'[•[ R o so•'c wr~~u„rc . •-..1 c a MMeAR vx Br,O, -- ~"Ong yecan wR % TEST RESULTS 2 ~ t ~L ~ ~ ~ ~ ~~.. ~ . . n.cwO wcLOn ,a.ce ArxNeO µrmeo 'c we o 1ON~ L "•O C[ ~ r _ r uvroR On [«r r ReroR •PRroiO [r an , ~,7 pUPIA:AtE COPY. LOCAL UW ENFpRCEMF.Ni ADENCY9 CCT'-TRIPLICATE COPY:INVESTH3ATOq'9 COPY P:' - 4 ~an ri; f ~~ r ~5 „~F ii x ` £~ I ~A ~ rk I;•~ ~~ ~ .r.= ,p r ~. y VM11:~~ i ~. a ~;, S L 4 R: ~ n .M~w., ~ M ~ ~ , ce ~ , r ~~i~%r r ' . "( I w ~~ ~fF1Y' ~ y t 5 ~ ~ I ,~ ~ ~ ~ 1i t y :. j 1 l~~i t ~ j' 1 4 1 l , } L A~ J f { LA y l t Y y~ aG11 / ~ ! ~( `'Mss ~ ~ ~ p ~ ~ t .. ~ ` 1 ~ r A "P.,+ ' '' f ~ ~t~i~~'"" I 1 ~ It {3 1/ ! '. p~L[~Iy~rr +~T~_ ~F~" p+~ nN^ +t Y.. 1' U.^ -v '~ ~.'Wl~ I ~~,~ ,...~R~ I ttLr'" f ~ Y;nll T t ~~ ~ . j~pplllY ,~ r . I l , I 1 . r~HAv ~~~'7 1 _. r~ I I f I.,T I I ~ r F, ` I 1 ~, , ~~ . Y _~ • fns ti;t~^ fi d ~' 0 OF LOLLISKk1 OAY OF COLLISION TIME P YH ~ )SUN 1 MW 2 LUIS A W A IMBN 3 Ffl 9 SAI IUSEZ 0 I 1' COUNTY NO / CITY fK). FHWA GI fff CW tY J /Y/ ^URBAN Y rr ~~~ OSTALE ROUE IV (COUNTY ROAD ^CITY STREET V/ OTHER SP F W'I Q AOMCIG PRFFI% POLITE Oq GTREET CODE S CTION G¢, In L ( ECI Y( w ~ S / ® _~ O CITY OR TOWN / N ^ ~ w PREFIM EO. MIL POST ~ MILES ^ ^ ^ OF._ N O.O.F~S[TREEFOq HIGHWAY INTERSECTING WITH: 5IHEET OR ROAD LL RAMP D ATA ~ T O ON ~# /Z NON WIEgSE N Q /j ~ . a a)t~ INTER % N ,, II~~++ A BETWEEN.._. ~ _ ~[( GTHEETA C S ~~ ~ PCC DENT M E D NTEHSECT NG STREET OR NDAp DR qEi~ I T CL3. ERENC~CROSS STH ET gOAO . ND__N =.J . DIST A UCE ANO DIRECTION FROM REFERENCE OR CROSS STHEEi CODE ..i 3 O I ~ / / MILES 5 E W O ~ ^ JFFET ^ r I S SPECIµ CODWO USE V D( - OF / , F r ~ , yr ,~ ' nw ~ ~ , +~r.~yry ~'Ei: ~~ A -~ . ~5 ~y ti Y ''~ ' iL, k CO 0 LLISIONINVOLVEO: HI VENICIE~VEHICLE ^VEIIICLE~gICYCLE •!L-J`f VENICLE~ODJECT ^ VENICIE~RRTgAIN E~LLES© ^VEHICIE~PEDESTRIAN COLLISION ^N~' OBJECT STRUCK A ^ --~ ^ OTIIEq (WRITE) ^NgdRUN SEYFAAY NO KILLED ^STOLEN VEHICLE -~~~- ~~ _~ (((''' HAIAROOUS MATERIAL ~1 NO INJUPED PROP A ENIYD MACE ONLY },1,~~ J~ k'il£ 5~~~~~ ~~ ~- J ;y '~~' °~R~N 1" ,-4~ • - (N ME Oi OBJECT STRUCKANDOWNEHS NAME( - ~_~. LOCATION OF DEUECISTRULK ,. ESi.OAMAGE • ... .•". '..: . ~ " ~Y a ' OgIVEH3 NAME LAST _ . N B E: W ^ROADWAY FEET ^ ^ ^ ^ q ~ }. '~ I , rv ~ ~ ' D A .. FPISt '~ "'"" -' ~. MI KU 5 ~ nl~R, f3U 2K i CZ.•C. ~~. D D EDGE 3 NA ORNERS ME~UST FFIGT MIpOLE, qF BICYCLIST Ofl PEDESTNIAN CHECKIQ_~:~.- Yr~ Izk ~1+ ' STREET AODPEG9 .: .. <~.. .. `Y R • a F L=J I~/lF~LM S SigEET A "ES4 ' S~M ~yt V 1 R I O i ...1 ' ..._ .:. .:.. is (~ ... .... ~ E CIT ~ ~ .STATE ~ 21P CODE PHONE N0. E CITY N PT.~i'7-GV.V~E~D ~Gc:A• °$''_ N ..-STATE,: : LIP CODE.:. , PHONE NO. Cat-~rvln~ t ~~~ RS' ~ ~ '~ ORNERS LICENSE NO.. BT TE. SE% DATE OF BIRTH N v . ~zs M1 O• U ~~ 1 MI I O Lq TION iwM O IXiIVERS LICENSE NO ^7 STATEE GATE OF•~BW1N y /.R~ ~ 3~ .~ P l /{ IO 1 ~ ~ `EJ 41<'~. tl y '! p NAME VV\NC~N ' ^ ONE NO. .' _ 'V~ (\711 ~ •j 4~ . iii IVERS OCCUPATION A FII AME .... 1O 1 D PM EN ~ D ~~ •~`N~•~ S ` ~i ~ ~ c s ~3" ~ CODES ~ ICI CLA9n,RY- - I° TBELT _•,~ L 1 N~~ OF G.- ELECTION ~A_~ I ~ ~ N ODE$ ~ IJI C1A55 1°I SEAT BELT- I31 EJECTION ~ ~~ 1• F . . _~- 1°JUR ~ : R I FR SCENE BV: TO IES _ R MOVED _ ..+ } _ VEH. YEM MAKE IDODGELHEV.1 MODELIDART~NOVAI BTYLE (YD .CONV.1, g F OM SCENE RV TO VEH, YEAR MAKEIDOOCE~CNEVJ MOOELIDAgi~NOVAI STYLE13 pR.CONV.1 ~~'~'°~ ~ LIG PLATE AO STATE TFW ~~ H . LEq PLATE NO. STATE E VEN. COLOR UC. PUTE NO. . STATE TgNI I +~. R '{ ~ (,` T VEHICLE OENIIFK;A1gN NUMBER ,.• ~1 ODOMETER '" -' H I C . Efl PLATE NO. STATE ~~~ A~Yo "'• VEHICLE IOENIIFK:An N d15i i _ ~! ~ ~~ 6u~ ~~t ~ X ' E j (] ~z '. F .~J2 ~-13a(p. PEGISlE~ I~q S e NUMBER ,. ODOMETER g 133133Sz_$ '..~ ( 93,7 ~ ~. ~, A~ ~ ^ ,Y~N N' T wST - MIDDLE p REGISTERED OWNER- i" FWST ' •Y' ~ O. ~../~~ • i°' ~E N MIDDLE R ~'~ ~~ ' J •o S ADDRESS OF OWNER ' O• 2 ta I C~ JA.q~s AOIXiE55 OF OWN ~ g. t ~T ~ ~~~ I , NAME AND AOpPESSOFINSIIRANCE CO.Oft AGENT .- SY4z1.~~~ F ~ ~ J~~ ~ L - ~ L K Q NAME ANO AODRESSOF~URANCECO. DR AGENT ~+ ,~ • . C CIi ATIDN NO I K. N ~ (:} r ' ENFORLEN.ENT ACTION DNA G I ATIONN ~ ~ ~Y, s •• _. v , ! .. NAME, ADDRESS & INJURIES OF PERSONS INVOLVED COOFG I - ~ _ D 3 ~} I „ I ' 6 P p INJUnIFS n Mav(DFRDM _ scENE nr .'~ A •,~ k -<r .'~. A N NAME TG ; . ~F ' T ADDRESS. ~ $ ' NA uR DE PUURIFB II hFAOM M ? ~ _ I ?:1 IL4 (ry µl N AME CF NE R t0 J ~1~~ ~ ~. A D DR[55' Y T H N P A n . ~ E N OU K3 AME M EDfROM SCFNF nY TO `% 5 • a ~.1 $ A Dd{Li[33 ~ P S, IAJW R SftNf HY i ~>~ II ISIAlU3 I)IS(1i VOSIIMYI NNJUNY ClA55 J TO • Z I D ] O PASS[NGER PCD(Sl11IAN 1 1 NO NJURY S DISADUND NJURY 11 SEAL nEtT OT INSIAlLCO I SIEJECTgN IC Rk J ~ D S DK:YCIRi OIM[R ! ) 1.OTHCRP051}pry (BUS MOTMLYCLF I t D[AD AI SCCNC GDEAD OH ANRVµ O NUN UISAq'Illp IENDENi) UURY ) NOi W USE SUSFO .NOT EJCCTCD ) T01µlY EJ[Ci[n P Y ~ ~ j' E a W11 H1:33 C 7 I ! POSInON UNKNOWN IOCDWHOSIryIAL ).POSYDIE INJURY IUMKNOW:1 B AnnµLY EJEDTEO .. UNKIIOWNIi F• So ~~ _ S. SEAT BELT FMLUnE EJEOTEO . ~ r • ~ ~` F v ~ ~ i Y~ t~ I .,~ N~ I d J I Wx 1 •. , r ~ 1 . ~.,~ w J ~ ,64 f J .~ ~ Y ' , I ~ 9' ~' ,, 1 6 ~ ':ri I. ~.- ~yz'.1.•.;...>'Sim.Eaa•r•-eF(e~-•LR.w.RF,.,......,..._..•...._______. ~~5~ 1 ~ . ~ '~. .~} ~~'.` Yfi _.......-...e.. - .... _ E~~Uu>~ao~.a,A~Pf~NM..~B%~, ~ cul .,,;;;,=~rvrert*wwrem~lr^rt~rret.•e°urernnT~~cE~1~E°r.. ,~--L 'x~~--'. , ~ • a~• ]. BIIAOE AREA OF SEVENESI IMVALT. ~ -- INSTRUCTIONS: ]. pPAWARROWIfITO SHDWPPINCIPAL DIRECTION Of FOnCE. Q/ - P DAMAGEDVEHICLEN O.T NsE 1NISSPwct roN SKEICNING pwMwcE lO Tnwll[n3MOioncrCLFS, ETC.I DAMAGED VENICLE N0 .2 I ~ IW!'. 4! r N•~F'~ IS 14. 'ne.~r.•~ I \ rr l~T F N SEVfNIIY OF OwMAGE VENICLE NO.t f O D6wBlING DANwGE ] OTNER M.V.OAMAGE 8 ITV OF DAMAGE: IOTNEN VE CLEI IE OPD SwpLIND DAMAGE ] OTHER M.V DAMAGE g 3 EPITY OF DAMADE: VENICLE NO ]' f v p15AeLINO DAMAGE O E V LADE ~ ND DAMAGE ] o fDNDTIDNAL DAMAGE . ] o FDN[llaxAL DAMADE . xD pAMwLE ] NDTIaNAI aAMAGE : xa DAMADE . TOWED by ~ E fOWEO BY EST, DAMAGE A MAGE TOWEDBY 1 ESt. D t0 f ( " TD f / ~ TO.-. f .~ ] . DIAGRAM OF COLLISION ' ~ I 1 1 •; - _~L, li L I DRAW ARROW SHOWING _'r •+tl ~ CJ NORTH ----~ -~- N CIRCLE -~' AT l ~ ~.I i I ~ 11 "~- I ~ '` SO"ti-~Y t~ ~t L>,r' ~t-_T"_._ i.. ll~ (b ~Y-=-f-'~ ~~~ I I' ~ ~I ~ _ I iII I ~ _ - ~ I ~ ~---i ~ AR fc xl r 7 I I I i I ~ I ~ ~ I n _ i. ~i' - ,?tom` ~.~. ~ i . ~ -I"- - 1FR COLt son. F _ _ - I _ _.I I_ I t-'-~~- I ~ I i DESCRIPTION OF ~ IrNDICATE WHAT Yno3ABLY NArPENEO BEFOnEC N D TN[cRn3N, Nc I c DIi1vEP --COLLISION - ITY, REDUCED VISIB Ir:v, rEDESTRIAN [O NrvG COLOR,[OxSTPUDiION On E PwOPKrE C1. OISAB L ~ L ` `~ 1 LLf=~-~U!L ~l % _' ' - J ti~ ., ;..L-L _=f` .~~...f: 1 1 .~l..lS~i r .~ /~'^~' l L ri 1 "'...L ~. __.._ 1 r _..-_ _ _.__ (` .... _~_ _ vl ^ ;: 1 f r" ' ~ .L '! i_ L . __.'.ul r _ ~..~~ L+-c::-- C!-I.-~:-~~-~_... - Y ~- ._ - ' y ~_(._ 1I L.s.-i ~ .~~ LE :// ,J ~.L ;:. h~ 2 I1n A_~ _ .1:rtiY S5 f • FOSITIO N BEFOR COLLISION R - - ~ - N ST ET OR N GNwAY NAME On ND x s ONE o nECTION esf P aE LEGALLY f YS VEHO LADED ~- NO. . N . NS . E W u lE POST D I. INCREASING DECRE NG . O ~ - v1APKE~ (OCCUPIEE~D~ C L! I'1 t r l ~- rI r_.. L -.. __ - , I J l vEy NO YES NO D. ~ _ FPOM_ t KTOn. IONG~ - OSS nG _ CP I _ ' ~. ~ %I IM n nKED 6~DE5 GxATED .BILVCtIST WAS USING: SD ]'.~SNOULDE -IC~OSSwA BCVCLFR~OTN 55W ( EP ROAD SURFACE 1[NfCK On EI WEATHER ~ CNF[K ONE( _.-. CONTRIDU TI~K OtCi[on mMSTANCES OR€I ~._ ~ 3 n EAfYENILLE ncnoNS L ~~L, d ] NO[) o Di NIOE] ] IxOF] I r ©II__..1 5 RAID A EAD llr OPY _ ~ / CLOUDY ~ .=.ALYFIICAST x R Nr UENCEO _~ALCOr104`__ ~ F ..~_1..J~.4.S145EGV (~]r SILx/SGCPDED wwn ~]~ ~ SIND ns x R ] wFi -' ] ~_ xING _ , p R UN uENtE O I ~ 1_ORUGS '. O EP CExTEn V INE. __ ~3 ^I A ENily rPAR ._7 sL~_._-~_- ^ r1 M KI xO 3L_ ~ nICNT uPN !1 I ] rl OWING ~_, _ r rl E%Cff G 1wIED ~_ YE[p 4.... i~' ' O I 8 SIGt[inl T ! ...J -_ ` I5~ En PARKING _I,OCADOS'..,~_ ~If, ••f1 M KxG 1 LEFT TUPN C[ _ L ~____.-. -~ i..._._. ___ F%<EE GnEw1. AFES EF __ I.L__ rl I rM PfP J_ _ T OPf _.. Ef t [W P.. _ ~ ~y' ~ MAKING ~ V U.fUNN 'I I~SI ..I - - 5 L i - 1 D T T ILA ~_.! ?._9 C.E"_` l O6 F .._ S fD UQNT _...I .]- ~ I ~,.. B SLOWING L L~ MNEX IY[Clivl DTI( ISPECIWI '' - r - t] 3 (-. TxfR ISrfOfYl IOUOV aLAIION ^ E~ Tq~FPEC FDN Y YI _ IGHT CONDITIONS CNf CK ONE( RAFFIC CONTRO O,]V[NICLF v[NI TVPE OF ~OoD D.] ICNFCK OnEO RFI r__ CONDITION. VENICLE y'NICLF vxt~tkp~`NJCCQ[t } r ~ t r O T ~k~~ SO[SRIETV. V1 NICLE ICNECK ONE( O] ''77 r ~ LJB^ onaiioislcN GNAL t-1 SiDNnlf __ _~ Il ONE WAY __ _.__-_ 1 1 U k 01 ' •" ~y1 ' TOPYEa IN v nowpwnr LIGt ~ >~.- OP __ f ] ~ Tvrowwr . ~ OFr[CTIV[ 1 __BItAKLS. .__ _ _'~ NBD nBIIITV ~ JMPAIfltp_..__.__ ~Ip''~_, STARTING IN TRAFf IC LANE ' DnwN ]• " ''.!' In D sen. '. ntv I lE f e _ _.. ND _ I Drrm vF __ _.. eAD UCxu .. _ ~] ! Nnn ABI Rv - L .._.. nm/MrnntEn.__._ ~IFI~ i ARTING FRDM en%EDrpsmDN _ ] ~ DUfK _. . __ 'K~ lASN NG -_._ _ n[D.. ~ INII IANGf. __ ._.. uwPT AMY.. _ I 1 ' ..._.. :' nEen[ilcliTS ] NIIp SORB ETr ~....,_uNK___.~, .. - - ~'~F]r..l MFNGINU IFNTfnING L ~-- TRArrlcl '', DARK-sl EE __„LIGHTS ON. _ .. y a xc ~...._.._. En... .._. Auw __ ~'_ .. .._.._..__.. _ -~ __ T acs wonN _.Ox SMOOTH _. ~. ~ ruD Nai n[fN DnINKINC ~' ISr~ eicKlNc .- PK-s P[ET ! IONTiO f ._. ~ nN fILNwL . 6 _~~~ •~ Twa wwr.l rrr B. IUNN LwNFS _ y ~ 1 1wRD w _.. ~ only- CHEM. TEST I NO. ] !'"""~ I_J LJ . OANK_ND .. . OPI [(Pr Y -~- -1 i TfSTG IN DTN EN ISPEC IFVI 3 f1R[f1LG Tf ~,..t GMAN f ~ In ) - DIWD[D NO OE FEOTS i . '~ 1[ST FUS[O ~ ~~ J .. ._ _ _ D1NfR ISYECIfYI -~..._.. ... '~, f \~ S ..~_ uvDlvlpfp . J .... _._ OININ ISVFCnvI 1: % TEST RESULTS 2 vlfllGw IINO Or rICIX'f NKME •n.FNK IN ... i ~ .:. ~ l bwtwl NO ._. Irt1. 013 YO D -:-• r "-~ App ANCE PFIC FIOw IIV[O AMnUL uw v[D Dm . ~ ~ l; ~! ~ND '` / ~ >1M ..,.._~.. xP3 MIN. X INVffIIGAI U N3N aI NU GI NGV ~ OFT _REYOIIi~ - AYInOVlD br -OAT! , - " L-. ~y r'r , ~., / i is 7.•: I" pUPLICATECOPYV LOCAL LnW ENr ONCI MEN( AFi[NLY'SCOrv~TRIPLICATC•COVV •~INVESTIGATORuS COPY ~' CIS S Y T ~~ - P ~. ~ s , F~ . N .I IDS ~.: ~ _. ~ .... aG . ' rv . a b 4 J J I ! i 1 { ~f1nn ~ ~F 1'~.~; N 'G-~1N~4 ~ ~i~-.k. ~~ I' y, r s~~~'~i ~t r. ..[. 'S". , r 'B ~e S ~:~~u, "~J~,nrrtr ~wlf~1 1'cSY. ~'~ ~~~ ;/ ~ I ~ I' :~' ~ r~ +'~'` i4 - ( ~~ {i, ` ,.~ 1 ` ~, Ib ', .:~~... . .. _ ~.,; ~~ ,` r ~ ~ r , a., ~-.,1i.1~ :~ .:---' _ ~`U "4'~~ti°"' '""` ~ J ~ ~ 1 NSHItJG10~) uF ~~INTE ~~~~~ ~:IJ MOTOR VEHICLE COLLISION REPORT . NO.a \ -~ ~~ h DATE OF COLLISION ..,.. p A sU Y 0 CO Llugl n in T n0uq TIME OF COLU SIGN AM OS X CO~II~ ~~ ' ' ~INTF)lO~~~~~ W ~ F'f " ~3Pq I JULY 1 1978 PM 9 • r te .. ~•11 v~ a r. + gaA"l~ ~, COUNTY .. CITY. TOWN n u[ .-. CITY, TOWN MILEB ~^E ADM L8T PflEFi% r~5oyy EET CGOE ~ ~~! ~ ~ 6E R)[1, ~ ~l h Yr 'P JEFFERSON POR ROAD Ofl HIGH ~ DIVE NAME OF STflEET xY',.e of INTEflSEGTING WITH: BTREET OR ROAD r ~, ~ i. fj : PREFI% EO MI~ POST +T'[P 1`y) , ,,~A`.y'- ~ _ _mf ro , •P Ox [ a 4~V4 ~ .. f~ P '$i 3>ty ~ ~„ a °:kP COUNTY HWY 12 Y . .. _+rr ~ c ( N ON INTEflSECTION~LOCATION OF COLLISION MyMP3Jyk~T+ 't DINGRAM DATAr^ } ~~ ~ '~ ` A'\ ~' ~' ~'~ UT F TREET AND PARK STREET TWEEN ^"+ [ B ~ E F.q we s,qE w[ROAO Cgossxc.ul[wsT Oq ofxT Fr qcl x E" uP INTE(i i T CLS. ^N ~ I ~~ ^ A ~.. ~ Y L J ^ ~A gTEASfcilo FEET s^^W OF ~'. % f c oLLSO Eo ^ xru ^r[xiu [ ~o,.[q PVw,u SPEC:CO USE ° °Nf~, ^rlq~ DEER ~'-~ ~~~ CO y1~Ty ~ ~ I i ,, . a •. . O [P[arw.x ^xoxml pw[.wx r.- .E z t ,- or vixc~ ~ ' OBJECT 6TRUCK'.:~-_,. ".:_'I of °F OeI[n s[gw.l. ::.........OWNER OF OSIECTG NAME AND ADDRESS __. INORDG,TIOAY;ys"`x-"1"' OQ RoAO. LS sEO C°a[~:, FEET S W FDGE -; Ir TN.x Iwo c.qs x ;+r~ t MIDDLE - DRIVERS LAST NAME FIfl57 NAME:. eG `S , DRIVERS LAST NAME.. ~. ~-;~ . ~ - FIRST NAME _, ::.~.. MIDDLE wFRE lxvolvEO .. _... u.a+. . . CARMELLA A PR I OR x,N~s GDII . °" °" ' , ~' ~ STREET ADDRESS ....... ROUTE N0, AND SOK NO. . 7TH S HAINES , Moq[ ix.N two rEns°x5 WERE Ix,°q[DasEA STREET ADDRESS- ,.,. _ ~... _._._.:;,,.;..:AOUTE NO,,PNO BO%NO -, ~ r v u-v ~ 3 ~ 3 CRY,:: ~,-,-v.,,: ~.: STAIE .r' " :'. LP CODE DRIVERG OCCUPATION :::, RECPT-CZ X n<~p sFOn E ~ CITY„ ..::...: ... STATE: ' _ ~:.:, 21P.000E DRIVERS OCCUPATION .; " PORT TOWNSEND WA 983 68 - PB OF BIfiTH AGE DRIVERS LICENEE NUMBEfl :: '- STATE G OATE OF BIRRI ;;. -AGE. ~(~, ~ '; DRIVERS LICENSE NUMBER ,::_-: STATE A SE% R X DATE °~r ~~ ~~ .. 50 - ._. M , MD °.. R - ~ ~ PR-IO-RC-A736N7 W 2 ~ ' E fl " -r ~ V EHICLE Yfl. MAKE (CNEV: DODGq. MO DEL (NO VA-DAflT) -BODY STYLER Dfl I, VEHICLE YR MAKE {CHEV: OODGq ,MODEL {NOV A DA RT) .BODY SIYL J. RD V 1976 FORD LTD 2DR HP.TP ~ _I rn~ > i STATE TMILER PLATE : NO. . ::. GTATE . ~. _ LICENSE PL ATE ND.. .._. STATE ~..:; , .TiUILEfl PUTE N O ;„ .-:.STATE'.. ~ ;,~ . . . LICENSE PUTE NO. ( ~" YAJ 922 WA VEHICLE IDENTIFICATION NO ..:_(18GB MODELS A NEWEiA _. O DOMETER IMILEAOq ~. : VEHICLE IDENTIFICATIO {` N NO.:.. (1858 MODELS n.NEWEf3..,.. ODOMETER (MILEAGE; ~ "'~" 6J6 $118 C4VBG74 2DR LTD 16,268 O REGIST FIRSTMI DLE NAMq; ,~ ,, RAST EREDCWNF P 'DRIVERS LICENSE NO.y.;_. ~ ; ' ' ,,. ) REGISTERED OWNER ILAST-FIPST-MIDDLE NAMq ... DRIVERS LICENSEN .: , ,, ~ , _ , . „~ "~ -` PRIOR GLENN EDWARD PR-IO-RG-E816L8 r I v ~. ~ r OWNERS ADDRESS ,:, (STREET. CITY AND ST ATq ... DAT OFBRTH ~9 Y~' OWNERS AODflE33„_~r..; (STREET,. piY AND STAT q OAT OF BflTtlq .,1F ' ~ {' 37TH 6 HAINES -PORT TOWNSEND WA U ~ !t ' ' ~ ~ ~ [sr uAi[o wsT :: .... .... . . DAMAGED [ F ' pgRTS OF VEHICLE DAMAGED,-„...:;;:::'..a«,....'.va_...;snlxw'is... LO nV VEnICL!' ~ - • ~ . . .. ... . To gf,AIPY PARTS OF VEHICLE f~ A END LL LLUUIIII UUUU $ .' ' Zn WH FRONT WAS THERE AUTOMOBILE LIABILITY INSURANCE ®YES ^ NO LIABILITY INSURANCE INFORMATION•VEHICLE NO. 1- covERAGE IN EFFECT FDR THIS ACpDENT ON YOUR CAR ,. -~ NAME.OF,LIABI E POMCY MOLDER...... ::. _ ~F:'- -~. - LI'[Y,INSURANCE COMPANY,.,,; ' ia,: 'J E AND ADDRESS OF LIABILITY INSUMNC T _ ^ N .y TOWNSEND WA 98f390CI ALLSTATE INSURANCE COMPANY OR 37TH R HAINES PORT [ r .E+ '"" _ GLENN E. PRI NUMBEP .Yii,;{. L LIABILITY PoLICY TE ~ ,.. Ct/ri ~ ~ , ~ _ I _..,..,. NAMEANOADORE530FLIABILITYINSURANCEAGENT . -• ~ ~~OAKPBA 4 6 ~ W ~ r " 8 016 007 FRANK ERB 983~ ~ .~~ A . . st Ly'~~.I.-` ._ NDINJURY A AGE A OE_ •: . , . ,. .. ,. ., .... .. .. ...... IST,INJURY NAME R Y~ . ~ ¢VFJ. ~p ' ~ 1 G. NAME ADDRESS INJU ED ADDRESS SE% SIX ~II>r~ ~ p ~`_`,y - "`y~~""' L F .~ ES___ y1> S Lg19E 1 I- f ~. ~ E L'lLG 1Y1 ~ I~? Y~ n: T~-t. n.HIH s ( p ~ p• ' r p ' ~$ ~ 6TATUS OF ^ IN VEHICLE R KILLE MARK FIRST ONE THAT APPL D xOMroiJUns q IES , ' '. r STATUS OFI UR ^GnrvEq IN VEHICLE ^ PASSfNGER KILLED .MARK FIRST s[ q ONE TMAB,APP,llES 1',;I,f NNN quxc rvs P[ I ul r ~ A A"I'F. " ""A' ~ ~' .35EHGER ^ V/ ^PFOFSIR AH NO D1HER \'JRIi E~If.NDNE ^ Is v w u,HO 6^ S^ POF r. x F tI 7 NO _ ^PEOfSTq AN ^OTHER \YNIIF IN ^ S^ F cl s^ 7^[' yL g ~ " S ` ~ ~~G ~ ~1 V SHOW NORTH BY ARROW IN CIRCLE ' MGIGIEOHTNAD a I .. .... DESCflIBE BELOW WHAT NAPPENEtr IREFER.TO. VEHICLES BV NIIMBE[D •,,, ,, _ VEHICLE 1 AND DEER ~ E ~ ~" ' 7~~ ~ ~ x" - u ~ .u , r r. WHAT HAPr[ fD o .r ...[. o O ~ I I ON JULY 1 1 78 AT APPROXIMATELY 9:05 AM Cp~y Dnen !I-wvl ( ~.' ~, i;~ 1 _ st~w~i.aze ] I .°a° n;.~ rn "~T'w ~; " "" _~~'!AS_DRLYING_ON_JEEEER59d ' •""" 1~T0_CHIMACU[`LON MY WAY TO SEALLI, -~1•L•~"°"• 1~:•Q''- 'G"~" ~_NQIICEPII~EER LRQ~~ING THE RDA--D _ ,~ ~,.r TO LET IT CROSS.WHEN IT WAS ON 0TH JEFF RSON COUNTY HWY 12 TOWARD CHI ~ 1 INCREASE SPEED TO GET OUT OF THE _ ~ ANOTHER CAR WAS COMING, AND WHEN T / / .~ P ;. SAW IT. IT TURNED AROUhm AND CAME [. 1 11CL/1V1_V[_I•r- - ' ""' 'VN]LV_o1vU1.-.usvv.~v_r ~u [I^ ~ ~kv p ~ , Rr"t fl 5 ` Sj~.l,(„j{IT IT. TURNING LEFT I WOULD HAVE HIT I~ ~ + ar ~ h E ONCOMING CAR. z I ~ 1" lG1 ~~( E ~' l;P N (; I - F J ( - Now ;1 - ,,:~~1,. VEHICLES POSITIONS BEFORE COLLISION 1.+[[ vIHKII nxluL rrur[Dwu INVEBTIOATED BY I " Dq1 IMLLr EI.HbHG llr r MAID NNDI OCfW D ATM[ iH[A iP~~ ~I VENK:LC N 3 E W ON 3TREE1 OR HIGHWAY NAME OR HO qH Y[n O [s O a 1 ( ~ No [YOIKe ^ ®^ ®ht+i1' 12 ... .,.. ,.,, ^ `,:^ ^..^ •-^'.'^ : ^rwn[ ®G.m. ~~ N; K11H[R ~ IurF I, lT<J ~ nDtnlwN ~ ^ ^ ^ ^ uG[ID - ' - cpe3v[n FR011 DIRECTION -'TO:' DIRECTION '~~~ ~~S YDI WALT ]~ wAlAw.r I SxOUfO[ ...~• f rvm wi° !^OTHER Pf D[STPIAN WAS II31Na 1 ~ 1 ROA,p 3L'~ ACE WUTHiA IKiNT CONDITIONS iMIPIC CONIiIOL KArtfA ORlI .TYPE OP ROAD DRVFpNE/11C1E ACTIOND } - y[ _ pp77 M 1[x,GG iro [ +Kl~ F If [I WHU~i FHIGI ONI pI NO 1 ~ ?[~ T Y~~ ~ ~ [ I ^ ~ 1 rJ DAYLIGHT ^ 1 ^ 6KiNAl6 ^1 I ^ ONE WAY ~ I ^ OOINO 31RAIOHT AHEAD `H~ Y wb I ~ '.'' { W t ^ DRY ] ^ RAMING 7 ^ DAW N ^ 7 ^ 310P 810N ^ 7 ^ TN'0 WAY ^ ] ^ OVERTAKING AND PADBIND {~S I )~ ~., I lR76 ^ 7 ^ ~T ] ^ BNOWINO ] ^ DUSK ^ 7 ^ YIt ID S10N EIiJ~'UT ] ~ SAD 310LE ^ ] ^ MAKING RIONT TURN T~ ' ' ^ DAPK.51R[ET f'1 s ^ lJ ^ p00P 11~Ml~E ^ ^ ~µ T j ,r'~~ ~ ~ L 'j ~ ^ ] ^ SNOW . ^ !00 A CION130N I_l IIASNINO R[D ! E MAKING CEFT TURN }5,. r IOE 5 O1NCR 5^~gr[II OfiT 5 PlA5NM0 AMn[R 6 ALIET 6 MAKING LLTURN r '~I ?? ^ ^ OTN[P ^ ISPCGlYI pANY,NO ^ ^ ^ ^ TWO WAY. [^[~[ ^ ~. ^ 3 ^ IPfCI!`I 1 ^ SlNffl IIGNT3 ^ 6 ^ RR 3gNAl ^ / ^ LCFT TURN RJ 1 ^ SLOWING 'd~ I ~- 1 - ~ pCA30N PM NOT BEGNO DANDER ! ^ 4PEGlY ^ 1 ^ or/ICf PJitAOMAN lANEB ^ ] ^ 3TOrPED lOR TRAFFIC ' J J '`~ pPKUPIO wS.OH J,lTA.cIroN! ITC( ^ 1 ^Ol t0.3PCtn ^ 1 ^ SLPARATED ^ E ^ ONOtITOP SIGN DNAL i~ I~ I I $AW THE DEER BUT ~] 3 ^ DTOrPCD IN ROADWAY ' IT C1iMIGED iT5 MIND AND ANOTh1ER CAR _._ _ _.._ ^ ] ^ DWIDE° nunnNalN ~I+~1 ` 1N rl Ar- T (• ~I ~Nf1r~,pp iiG n , n vR[D I 1 IR ^ iR fi I. i ~I $ ~I A ~~~ Y({y~~ v- „~I1 ~hl rt 1 ti 1" 1>A 1 ': ~"h4 IR" .Llc. T ~.' J~T' ~,-, i pI ~. }~. [I _ ~ r ~: >~ a '~ ; ~ ~ ~ s, `~ • Lr; a 'bpi ~ '' . i~ ~ "~ ' P i x ;~tl. ,~ ~, Fp 4 x ,~ I~d w~ r DATE OF COLLISION _ DAY OF CALL rl D °"r SON TIML Of LOLU9IDN AM " r s.r `"'VI[s COUNTYNO / C ILY NO. ^ r 1 Dec. 8 PM 12 0 X (/p su MACE COUNTY LTY TOWN aE MLES Qo CITY TOWN AOM~CLE PREFIX R(MrE OPS1PlR COpf LTM)N UCUxRWp Jefferson ChimacuTrl W L°•~ T" ^D ©of ~AnW GIVE NAME OF 5IREET. ROADORMgMWAY WTERSELTWG WIiI S~T/+EgqT''Oq ROAD ' ~ PPEFI% EO MILEPOST ac~`in Chimacum School.Drivew C o .cf./VO, /2 Port Townsend-Chimacvm H'rlY NONINIER9ECTIOrE~LOCATKN Of LOLL 10 RAMP OIAGRAIA DATA BETWEEN ~~.• S,REET AND i T fR pNW p[ «uNR AAROAn[RpSVrlpu [FPpsr OROENirrr Np luKxAUr" `' NON o RErfn f f 0 5 EoNM . NrfRMC11W. ©® rFFr INTER CL9 ^ p A 5 .~ . S/4 i o Qvl ^Orn[RlwwrEl / Ov WVOW[p '( V E / SPEC COD U9Ey. _ '~ ~~ pr [NClE9 Y ~=~jO [NK F~oFDFS,RAN ^ WN Cp[u5K)N ~nr~nuN l°_'~7 - - OBJECT STRULN InAM[Or ONIFCl9TRUCAI OWNER OF 091ECTS NAME ANO ADDRESS IN O O WAV QN © OF Fonts N ' FEET foot ' CAIVERSIART NUAE ,. +FIRST NAME MtODLE ARµ ~° DRIVER9lA9T NAME + FIRST NAME ~ MIOGLE , Hvnt Lester D. "'~i Bland Luther Jr. 91REET ADpgE55 ROUTE NO.AND BOXNO. An tvA STREET ADDRESS ROUTE NO,AND BO%NO. 615 E. Beach Rd. P`",~N'NSER; HiYXd€Z Rt. #1 Box 780 CRY 9TA(E 21POpOE ONVER90LCUPATION CITY SLATE LIP CODE MIVER9000UPATION Nordland WA 98358 LO"'r Port Townsend) WA 98368 Student DgIVERSLKEN9E NUA10ER _ STATE 9E% DATE OF &RTH AGE DgIVERgLKEN9E NUMBER .... 9TATE. 9E% DATEOF BWTN. AGE HU-NT-L-D732J6 WA ~ r tr° °~~1y" 51 M r Mp pAY YEAR VEHKLE Yfl. MAKE ICHEV; OODGEI MODELINOVA~DARR... BOGY STYLEIL OILI VEHKLE YR.. MAKEICNEV ~o0oGE1.. M ODEL INOVA~DAgTI .. BOGY STYLE I)Dal,....: 77 Chev Pickup lKEN9E PlATENO. 9TATE ,_. _TRMLERPUTE NO. _ 9TATE tKEH9E PLATE NO. 'STATE TRA%ER PLATE NO. _,.STATE., Ps 7961 wA VEMICLEIDENTIFICATKNNO.. 119GBMODELSA NEWERI OpDMETFJEIMKEAGE) VEHKLE IOENTIFICATKN NO. 1[968 MODEL9A NEWERI. pOMETER IMREAGEI ccL24247J165326 z5,ooo PEGI9TEREDOWNER IL/u^i'FIR9i~MIDDLE NAMEI DRrvER9LKENSE NO. REGISTERED OWNER ILAST~fIRST~MIDOLE NAMEI OPIVERSUCENSE NO. Hunt[ Lester D. same as above OWNERSADDgE59 ISTREET.CITY ANO STATEI DATE OF BIRTH OWNERS ADDRESS I9IREET, CffY AND9TATE1 GATE OF BIRTH:. 615 E. Beach Rd. ~° °12`6 ~7 `"[ PAgT90F VEHKLE DAMAGED .. 1O PMT90F VEHKLE DAMAGED ~~ *o g ~ g ..... WA9 THERE AUTOMO&LE LIAB UTV W9URANCE LIABILITY INSURANCEINFORMATION-VEHICLE NO. 1- covERACew EFFECT FOR rH9ACCIDFNT GN rougcu+ x^YES ^NO NAMEYNO ADDfiE590F LIABILITY WSVRANCE POUCYFgLOEA. NAMEOF UABIUTY W9URANCE COMPANY,. _._~. ,-,. ;. PEMCO A~Rfss Seattle[ ]BHA yaio9l PEtdCO NNAE ANDAODRE590FUABIUIY W9U([/WCE AGENT, -.. ~:. rrr s,A,E _ _ TIP ~ LIABILITY POLKV NUMBER „-. ;.. ~, -, ...~„-,:-,,;-, .;.;J„ CA173902 1ST WJUI[Y .. - .. AGE LNOINJURY: IUSESE ARATE RCPl1R[Fd+Appilnnu AUURiE I '. ApE.. NAME ..-_____ _______-..___ _ ,O,AL wuREp NAME ~ _ - ApDRE59 __._-_ ___~___.__ 9E% -__-__ ___-__. .. ADDRESS _ - . - .. SE% -- ---- ----- M F oo U _.. __ - F M ^ o. M[ rb~p:. ~, ANr ate ~° 'STATUS OF WJURED ARK fIR9T p1E THAI APPLIE S 9i ATUS OFINJURED MARK FIRS T ONE THAT APPLIE S Q plunA EHKLE ~ KLLEO °m.rtm uv[Re 1 { "On:EUn N•rpRl w~un CC.uru ^ ENKLE ~ NLLED owi"Pi lm IsEVFAE I w.pa.x iuwOnlWp P E [ O ^'. Ax r ^ 5^ 6^ l or7 QFrc 0 N O ^ 5^ 8^ r c ~On SHO NOg1H BY MROW WC CLE • rA I \L DE9C BE BELOW WHAT HAPPENEOIREFER TO VEHKLES DY NUMDER~ - ' ` '~ WH. O ~ i =T ; ° a J #1 vehicle leaving echoolt_preparing_to stop _ for highway to see if Port Townsend-Chimac ~s~o nr:.rr, n.M, M E D ~I : -- -- -}ighway was clear.--- -- aRaEw•v I ~ \ ...- ' - - ------- #2 vehicle turned into school driveway an3 hid "'"'~~ ~~' J \~""' - -' vehicle'il on left'Te'ar. .. ..--~_ CJ:-. . _.......___...-. __ F--- ~ --._ - - __ ----- k West Valley A oad ... _ _- - ------- • ~~ _._., - ~ _ it J - -. _.-__-- ----- --- - ~ ~ ~ 16 1 Chimacum School ~..J- C . -' --~ - -- ' A ____ _ __ Driveway ~i ! :~ _- --- -' - - - -- -- VEHICLES POSITIONS BEFO RE COLLISION ra EK [.Hn [ E rrnKlq F.N•~n N.K gNE9TI0ATE0 BY VEHKLE N g [ ON SiREEt DrI HIGHWAY HAML Dq NO N{prXn Y A N~ s'rq "HSLr E vl ns` W n ^ni~gp ^ ppK[ ^~ rrlAw ^ ^ © ^ l ^ ^ ^ ^ ^ ^ ('~~ ( ^Lri'W[[ I[dl G~IgN [fi """`"` ^ ^ ^ ^ ALGND e ROesND rnou DIRECTION to .DIRECTION P(DE G,wAN wA.S II•,.rNO [^91D[WALN }^Wµl[wAY ]^ 9HOULDLR E^cinuwuA 9^ cMO•.swu°rl 9^OiHER NOAD SVRFKE Kf Ain[R lKirTCWnilp[9 K.N E•[Y{Ir iRIJrK LOMROL Cn[cA O.tl rlrK[t TYPE Of gOAD DR vl.vCl[ ~ IVER/vENKLE ACiKN9 vfwCl[ ICN(CA VI[[/r WAll r "n) [ NJ nv [ ~ OAnKNt r [ ^ [ ^ GGHAL9 ^[ [ ^ ONC wAV ^, 1 ^ DdN061RU0NT AHEAD ' ^ ' ~ ~' [ ^ NuNPVG ) ^ DAYm ^ } ^ StOP SKN ® ) ^x tNV WAY ^ L ^ OV[PtAKIIq AND PA991N0 ^) ^N(T ] ^S+AN+•q ] ^ WSK ^ ] ^ rl[l0 [+GN ^ ] ^ ~~ 4gLE ^ ] ®MAKPr6 RX)FR TURN ^ ] ^SNOW A ^i•J . ^ OC.ni]OH ET ^ F ^ rLAEu•MO REO ^ A ^ C ^ A ^ MAKWOIEFT tURN ^ 1I iET 9 ^ OK`r t6 " ^K` E ~~ ' rl F!r,rNG AMDLR ^ A^ RAMPI IIOJP ^ 5 ^ All[Y ^ p ^ MAMHO U~TURH I 0 F~ Y 1 CMYI i LJ [ ^ 5%Clir A ^ STlrt[~ i 1 ^ E ~J "R !K•:AL ^ E ^ j j~ t[MN ^ 9 ^ SLOwiN(i IGN 9 '[(A•ON IJA rAl3E [nA DArF.[R i r-[O[NLR .[aN.rNp.r+MN per,•iT.nLlrCl IJ ,A'LCIrY i Oif KCRirLAGMAH ^ ^ l 141E9 [ L ~ ^J I ^6TOM, EDfOR iRAiiK -~ -- ^ e [] DinfR. ;vLLMV [~ , !] sfrw%r[D ^ 9 ^ oi[st°oP° .+.uil"D"~ ^ [ ^ nrpLO ^ , r ^ stormrp W ao.DweY ^ ~ n ['" ~~ ~ ] QurrnmOrD ^ ID ^inunL'" Ww[ __._-._._.._.._~....__. ___.__..~.._._.___-_..__. .r.,N .. ,.M[ - .,,,n,.9 .S.L_L _ .___.._ - --- - 9Lr -AG[ ^ L, II o ~:,,^~~~ a°~N r' T ~~ 4 .. E ~Y ' [ ~ ~ i u ~ ~ 1 }' ~~ , w ,m '_ ~. ~. ~~ ~ ,, y n _ ~~ ~1 ' 3 t~-, r '. ~.- ~,~ [. a ~i~ ~~. ~~ 0. ' .. fp W , ~~ 1`s~1,~ JVn 0' b ~'~£ • s .'= r ~. .K' P. .fJr~IUT Dwr •~IVE•HAM BTREyT (+Oa OR HIGHWAY'. INTENSECTING WITH: STREET ORR ~D YREFIK ED •.11LEPUST ~NONrINTERSECTION~LOCATION OF COLLISIO1N L `/ /R ~ Y lJ0 a-1 / ~ - 'l / RAMP OI:.,GAAM DATA ~ 4 -- THEET S BETNE"N / I STREET D x t N E . ., n. Lxu.oc ,r L .,~_.. •' ^ ly OF I ^ ••OF C % ~~ /(/ lDl Lli cr tirDL u w b ~ r.x nx~rU ~ -~ S EL'. l: OE USE ^ ^ L ^ DF OBJECTS NAME AND ADDRESS LOCATION .';1 Q e YxIN ~E OWNER xue er o` fs rxuc - 04 .tcT ~OBJ.CT STRU~K x IN HOAOWAY ~ :J <• ~ `' C f ~ / ,/ C N FFET 5 ~W - `•x r . AST NAME FIRST NAME MIDDLE DRIVERS L FIRST NA E ........ _ :.MIDDLE DRIV ERS LAST NAME ~ti e i:te ` ADONESS L,r'' - R UTE NO. ANO 00%NO. STR EE T ~ ETREET ADDRESS ROUTE NO. AND DO%NO:. --~~ ~~ // ptl l ~~/iH NCG/A ,~ CITY STATE 21P CODE DRIVERS OCCUPATION " n.,roxr ro,, , CITY _ STATE ZIY CODE -DRIV ERS OCCUPATION _ Ly f: SLI , rl l.cr . DRIVERS LICENSE NUMtlER STATE SE% DATE OF BIRTH aGE .. DRIVERS LICENSE NUMBER STATE SE% DATE OF BIRTN. ,~ YEAH a AGE ~ G~ - ~ • PiG/b.ar - Dnr rEa 9. D sv ooocV wxxr, Oax., VEHICLEYR. MAKE I MO EL Ixov BODY STV LE vENlclf vP. Kx,v. woeel MAKE vaD.x,l, MODEL' 000Y STYLE. 0 LICENSEYLATENO. STATE„ TRAILER PLATE NO. ...STATE LICENSE PI.ATENO. STATE TRAILER PLATE NO. ,,.STATE :-: vR L C- ~/ I GL'N 5'/t VEHIDLE IDENTIFICATION NO. Otim MOef LtA V[NEA - ODOMETER wnenON _ VEHICLE IDENTIFICATION NO.,, oxb,, Mee Nf„fxl.,y ODOMETER IMRfAOU ` A. zs / REGISTEREDOWNER;,,,, rlxjT o0L -. ,. DRIVERS LICENSE NO. Ilwci. [xAN[I REGISTEREOOWNER ~.., a _ DRIVERS LIGENSENO._•:• ..lusT rw o wwN .,. r~/Y/YC 4I C/X C OWNERSAOOR 55 ~, ~, ISTREET,GTY AHO SiwTEI '.; ~.- .~ DATEOF BIRTN OWNERSAOORESS ISTREE ITY ANO STA EI -~'~~, DATEOF, BIRTH' o YEAa Ic'T ! a ~ 3 ~ ~ z ~"5 YARTS OF VEHICLE OAMAG- - ;+. ...,... ., s.....+•..,_ ox v. ~ - ~ ICL A A .:_ _:. .-]'... _.._ .. .a;' -IOxfexnM i- ~ G>t ( 5 W S E E UTO OBILE L B ITY NSURANCE LIABILIT INSURANCE INFORMATION•VENICLE NO7 covER CE EFFECT FOR TH SACC OENTO YOUR CAR ^YES.^NO ' -y''T~„ fI.,ME ANO AODRESSOF LIABILITY INSURANCE POLICY NOLOE~Itt "~-,,~~.•, r~'•siwif V~ 21i -~'i'NAME OF.LIABILITY INBURANCECOMPANIr*.u_+yy~k', NAME ~ ...-PDOPf55 ... ._ ..._. NAMEANOAOORESR.OFLIA8ILITY INSURANCE AGENT..~~.•C.:~G.c•~..,;::yp,•I.W.~~/._^-ST.AiE;_.A.,~~;~~y2,T~~rL1ABILITY POLICYNU ,BE~~,~=_...~lf~'1~`-~ yy I ADd IDrYLINJURIE9 F ~' ~' 'AGE - it -7.':. .AGE ~.7NDINJURYj!:,1. _.SEPA wiERfFORT COR _ ..._~-_...L +~~. FD'IC' 1ST INJURY.'. ' .. ...~iJc-.+. j.c ~_._ ._...._li'^.._ - .uw. ~ L xAME .. sfx A - D Ess AO - M F DNfss / _ ___ M F r ~1 STATVS OP INJURED -'. .%, {~ ,MARKPIRST ONETHAT APPLIES,;' ,, -y. STATUS OF INJURED .,: -MARK FtRSTONETHAT APPLIE6T I'.~,:ll'I., IN VEMICLS ei " w ^ IH VEHICLE 'r"O ~ C KILLED ^ N ~ KILLEO N No. ,rc.l ^ -SrOf1 6~ ~o 7. N ^ '^ ^ ' L 1- :~ ^ ' 7 RIT:..IN ^ 5 ^ 6 ^ SNOVI NORTH OY ARRO NCIRCLE \\ I J h ESCRIBE, BELOW WNATNAPPENEV (REFER TO VEHICLES By NUMOE(11,~'~j~i'Ek,?yy ;',~• D G GI r"~ ' O \ \ vl pa ~ T .•1 , ~ G i-1 „~:-1 _ __ ___. ._._ L G ~ .f , ` { , ~ ~ _ ~ ~ I q ~ - aC~ -~ ' ~~ rF _ _ __ ~ ~ , I ~r ~ . - V £~~ r __ ~ ~- VEHICL[S POSITIONS OEFORE COLLISION AOID Y NO -~^eer~o vs 1e Nrsx n.s vesnewreD Dr ^.n ^•eL~G L NAMF.ON . VCNICLG E-1 ON STREET OR NIGNWA ••' tv0UN1 ^ ^ ^ J _ _ ^ ^ ^ ^.::.. ^wl«vesnD. no4 ^ psrtF JF OTSTRIAH ,. ^ ^ ^ ^ ALONG ~. 1. ~-~iRfOSSIH6. -. i it",..5 KnV i:: '..FROM,YG...iM2~~{uu0c'.:,TO. Z't~. i.P~ ' , 1NG 1'T 0(STIIIAN IYAS U 5 ^ ~ 5 n : 4 ^ o ] ~I.r ] n:~ A 1 ^ i ' - r 1}AD SU a~E 1 " LICNT CONDITIONS E THFfI jf TR FFIC CONTNOL TYPE OP ROAD KN ORIVIRNENICL6 ACTIONS`^. y:y..~;i'~~rll: EI e I I j'~• I 11 UAYLIGNT r ~^"I, f.NAIS J I ' ^ ^UNE WA ^GOINfi STRAIGHT AIIP.AD ^ l ' (~' )~ I,., 1~INAWN ~'••! ^'I S,Ox SIf.N L J ^2 ~HYO Wnv ^2^OVERTAKINf. aNO FA311N0 _ .._~ ••.1 ~ J ~ ~ 51 .,IYf. > ~ i OU!;N ' I 4 J Y. ^ .l ~ 'ELU SIGN ^ J ^ noYan El ule ^ ] ^MAKNIG RIONT TURN _. r-' ,. . ', .,..I .,~,n .tl t ~~~ l1A tIK !:i NF r• 1J/I!G ..J SI~N,SON (.~~.I L~T~•ASRI•.G O10 ^'I ^ILODe gIAMI'IF ^A^MAKINGLEFT TURN '~~1 v. il:I .; r~ ~. 1. Or t -'•S ~x, ASN NI, AMxfR ^!^ALLEY ^^MAKI`JG U•TURN ! f•rf1/-l1 ~~:iNf EI L~.'. ~':. NH .i G'rA,. n ^ ^ 4 ^ jil eLNY I.AN11 ^ 4 ^SLOWING I i '~^uG S ~ t OA~cI .._, ti •r I' 'T } HFLAr,N AN II Je.Y Cr 1_ T TOFPBU fOR TRAFFIC ^ ^' •. ...•.,•••~1. •.„ --.... . ~or~ r. 1 SLYANAiEO ^A^O~fTOP 316M GNAL '1 _ .... _.,, ^ 7 ^OIV tDlD ^ O ^S70PIlD IN ROADWAY ' ~~a OT 1cIC CD4TROL ^ ] ~UNOIVIOEO ^10 ^TAAf FICA ANF %- ` rr.~r-remAamaEa~~sm,M-xiPfewi^~~...T,1-mammr-~...x.,.... r, x,..,.., T#~R'~' ?^`Y r -1~ '"^±*~L~. r'-~•~,-i~'~~£"1 ~~ 7 i "~Y. ~: ~afst _~~f~ .~ } ~,: f4a . c'.wa„, Ok VEHICLE COLLISION ktk'UFt 1 I F CULLIS O TI Of COLLIS ON COU Ty - CITY NO fir" ' ~ E OF COLLISI ,. ON OA ,,, a Y O ~E..b.e .,..~, N R .,„ ES 'o M ,~-~ / 3y ' O T CITY TOWN AIILCS ~a , CITY. TOWN / AOM~CLS PNEF % TE O R Sf tC O U ~L'T O` .a;~ ~ J/ ~ ' ' ~7 o C ... .. t ~} JLI .I },L? RR~~~~' ~ av'•$ r ~~, ari.,.:.: ~7'. .~ :c . s~..: z' 1rry.--z~v{L d;~j''~ ~a~~2L~a~(~ ~y ` f~~+Lrr/rr_'{a }L ~ 9Y _ m~ _ ..~~"r.a'r, ~~..~~) ',~,t •hy'~ 7 .. ..5 ~'.. ~~I M~~~I./~ Y11 f'1~1~1rlIYI L7 I,UIY~PAGE~P'~V DF + PIXICE COMPIAINi NUMBER - "y~'L' ~, a "aj ~!~ ~ UNIFORM POLICE TRAFFIC COLLISION REPORT R "I'4 nD DATE OF COLLI IDN PAY Of COLLISION TIME COUMYNO. CITY NO fNWA Y ' Yt ~ ~ /Ay /~Y ~fl T SUN I MINI 2 I~ ] WEO d INIIN S FRI B SAi IU5~2d1]~H~URI ~ ~ DURBAN i,; rC G J URAL yy COUNTY /L/~.~C~,~] ^STATEROUTE ~LOUNTY ROAD ^CITYSTREET O OMCLS. PREFI% ROUTEOR STREET CODE SELTIUN ~. IkY Y '~fd'3 ~~L'I'/ `/\WN ^OTHER IBP[LIFYI y A~ 5 O ~)1'£. A E '' ~~ ~ O N S E W N /~ JJ y~/~CI/TJ OR 10W W PPEFIX EO. MILE POBi *~ ~ ' - _ MILER ^ ^ gOF__._l,!f/./LfA/O.uJVI ____ U ~.y~ A NAMEB O TREET Ofl HIGHWAY INTERSECTING WITH. SiREETORROAD LL RAMP DIAGRAM DATA T ~N P .rz o A I NON INTEiiBELTION ~ ' D [/ ACC DENT W E NO %Rp INTERSECTING BYREET OR ROAD ON REF. ,) //•J~~~( n R MLEAGE Ni L4A, ERENCE A 55 TR RT BROAD ' • ~~ ~ N DETWFEN __ =-`.~.~~._..._......_BiREET AND __ ~#22 STREET LOGE ~~ V. .~ Pa( ' DISTANCE ANpO RECTION FROM REFERENCE Ofl CROSS STREET MUSH SPE ALCOpINO USE Y, MILES N S E W - / H i o ~ FEET ^ OF . C. ~/\_~ /C.l _ ._.. ..._ / Fa. _..-__ .C'FY'Y I ~, J ^VENICLE•VEHICLE ^VE CLE pICYCLE 1=101 ER IwAITF)A-_ ^HITa RUN SEVERITY ~. 2 F ~ COLLISlON1NVOLYED: w ~/,[1d _NO. KILLED 1 ~~',~, TOTAL NO ^VEHICLE.OBIECT ^VEHICLE~AR TRAIN C4'/IN/•~•IIL.._.__.. ^BLOLEN VEHICLE NO.It JURED OF VENICIEb D ^yEHICLEPE0E5TRIAN ^NONCOLLISION ^MAZARDOUB MATERIAL _ ^PROPERTY DAMACF.ONLY -( OBIE/.C/.T,STRUCK(NAJM~E~OF/O~BJE/CT STRUCK AND OWNERS NAMEI ,.- ., LOCAi ON OF OBJECT STRUCK EST DA AGE ' r ~rU/J,!'/JJ'V7IG ' YS ' , ~. • >~~ ~ ^ROAOWAY V FEET ^ S ^ ^ 10ip. EDGE S ~ _ ~~N pRWERS NAME~LART - FIRST IDDLE DRIVER'S NAME•lAST FIRST MIODIE Ur BICYCLIST OR PCOESIRIAN CHECNI ^ D, /~/Y TP~oJ~'7c1 /~A r?/~ L. u ~ ~~d w ~~ ~ .~ R . I BTREET AD/q,AESS .. R .. E uq - I e~ ~ / `T ~ / ~/L ~ d / V V STREET ADORE59 , .,~ i~ 4 ° ~ CrrY,..... BTAIE 21P LODE PHOrvE N0. E CITY STATE 21P CODE P O E O Y R I ~r ~-ccu.vs~-~1~, ~..~JA . 9rY~8 ' N DRIVERS DCENB,E/NO. J~ J~ BTATE~t SJE/_%~ DATE OF BIRTH N DHNERS LICENSE NO. STATE - BE%. DATE OF B RTH ~ -.~~ D. L7O Z/J rT L.UT . T M~ ~ r ~p O.. MO. DAY VR pRNERS OCCUPATION FWM NAME ,., PHONE NO. •1 DRIVERS OCCUPATION FIRM NAME PMONEN tihAA./~ Q CODES > IJI CU55 ~- Idl BEAT RELT._. _ I'vl EJECnoN _/ CODES > 131 Irv.lq Rr +. .~.~ f * a •b NATURE OF LL BB--~.IaI BEAT OELT~ I51 EJECTION ___._ R3 L y w INJURIE B Yl~OAJc: INJURES F [ SCENE BV' TO FROM SCE VEM.YEM MAKEIOODGE~CHEVI MODEL(pART~NOVAI STYLE (2 OR ~CONVJ NE RV~ YEN. YEAR MAKEID ` - f: E H VEH f9LOR UO. PLATE NO. STATE.., TRNLER PUTE ND. STATE E VEH.CULOR., UC "~ y/~ !i 9'7 ZNA f H L VENICIE IDENTIFICATION NUMBER pOMETEfl (•` VEHICLE IDENTIFICATIf E' 5? 4 633 9 - / ~z~~~f E ~, ~ REGISTER'1E//D OWNER-CART FIRST ODLE GA~L i ~ ~ IZ / /~ R N EGISTERED OWNER- p, ~ O Ci - , T ~ Y N O -:~ i ADDRE OF OWNER ' A OgiE55 OF OWNER ~ AME AND ApDRE590f INSURANCE GO OA AGENT. AME AND AppRES50F ~ A. QF KF CHARGE ' ... CITATIONND ENF U ~ 4 ORCEMEN CHARGE T ..t. -- A 1G 9~~~~ CTION 4.' NAME, ADDRESS & INJURIES OF PERSONS INVOLVED L. NAME'. ~~ /~ A9 ~U~ c „ooRE55 ~~ T ~~r ocuv5c~n O 5 F ViDf ROM W1UWC BCE A NAME N T. S ADDRESS' F IE MJURi ` ~ MOV DFROM E4 ScrNF nv W AME' ( T ApDRF..R$ ~ N i I~M YCC ffi~~~ 'Niunlfl~ scrNE nr . T-. ,.~. ~ i S N AMC _ I ~' S A E p(IRCBB s~- S• I Nx1mrB xcFNio 'j~M;, • 1 1191AIUS I)I SI A I INJ SIigN IJIINNRYCU55 ~ Q O ; 1'(Of ~IRICAN 1 OWNRY Z DCAO AT BCENE 5015ARUNG WJUIIY SNON pISABLING D PCYCWT BOTHER / 6 ] ] ~ T.OTIICR PO'1gN IIIUSMOIORLYCIEI ] OEAp ON ARI µ dDICDINNQSry}AL I CNUE NIIINJURY 1 ~SStBLE INJURY E B NTTNE39 A POS1IKW UNKNOWN . .... .._.. FIRST .Ivw. .. M[ :O. ON AGENT „ 6 I. NOT INSTAllCO 1 NOT EJECTCD 7 NOtINUSE ?TOIAILY FJECIFD i lU1NnNOWN ] PARIIALLV EJ[CTEp S SCAT PELT FAILURE dfJ[CIGUNR m a. k ~~ r ~~ ~¢ VM' Fe A ~.. 4M'{} .- I _ nwaMww ;,n ,~1 .-a .A:gIMN ., ~ .YfvSWI. W ' .~i -~,!'..' SY^Af,.=It1 )A .°IJ/.f:YI J3. 1K .. '~1~L 4~ ~ 1 f b +~~1 i 11~ 7' ~"ti 4.ia - y !: I ' ,~,~!~*J 1~ ~ ~ ` i I ~ I,~, % I _ .. r..l. 8 ''~ :. ,. I ,.F rw D A MA GED V E H I C LE N O.1 IusE TNls sngcE FDa SKElC111NG DAMAGE rD TRgILEHS, MOlancrcLE; LICI GED VEHICLE N0 A A D M .1 -- ~ r - - - ~ / ) l ~ ~ ~ ~-- /t~ y ~ I=P"] I «~~ Lr~ , - • ` I55 Tr I )0`•IV^ ~ ~ ,~7 ~ 7 V ~ e~~l IB U ITV OFOAMPITy GE'VEIIICLEG E V EIIICLE NOt 1 ~ IE~OISABLINa OPMwGE ] LJ OIHEaM V.OPMAGE TYOF UAMq:.F'IOTxFaVEN LEI if Oa0lSPBl NG OaMAGE pp wMAGE D D D Sfv[RiYOF DAMAGE VEHI [~ NG D4I+PGE CLE NO.] ] p xEaM V. A AGE D ]^ FuxcnaNAL DaMACE + ^ ND D4MacF ] O FuxcTloNwL DaMacF + L7 +D DAMgGE r ] ^.uNCe IONAL PgMACF +o oAMgcE + ^ r TOwEO BY ( ~ - EST. DAMAGE lOWEO BY ESi. 04MPGf TOWEDBY ST. 04MgGE TO 5 - E TO 5 DIAGRAM nF COLLISION rr ' -TI-.I~ ;~.. _ ~ ~'_ * mo. I" -• '' --- ( DRAW ARROW SHOWING NURTN IN CIRCLE I ~ -- -_ - - ~ - ~ ~~;~; I . ~ ~ I I . . tPNPIlIPNS nt[PML~LDNS,HMLIIDN AR[M LT~I ~ I ~ .~ ~ r 1 1 - - ~ _.. ' -t'- i_ I ) lHL„I.aPP..LI.PNTDP IMr4cr I r i .. ; ._ '- I. - _ r --t„ _~'_ -- I . L t" '' ' oB.L l.HS~nBN A «P. [ I - 1 - ! r - ~ ~ t 1„=~ I I r._ I _ _-+ 1 T_L - ~ ~ ~ [Bta,la~aN - yC L_ .I~. . L ~-Ii-Ir~ '-- -j `` - i` I~ _' ~ } ~ I I t DESCRIPTION OF NOICwTE wxaT PPOBgBLY navPENEO BEFORE.OURING aNO artEn THE CRASn,INCLUD[INFORMATION N OT Ox plgGnwMrE.G. DNIVEa COLLISION DISABILITY, REDUCED VISIbILITV, PEOESTPIAN CLOTxINO COLOF, CONSTRUCTION OR REPAIR WORK, ETC.1 _ ..:. - ' POSITIO E .~ HEPDEO N BEFORE COLLISION ' - - _ - ~- OxS nEET OR NGNWwr NAMED NO. xP OF LANES INOxf DaCCT10N s ref os vEN CLF FaHR Y IF Vwa KED CC PF N 0. -M f REAS REaSING c oic ,- E - ~ iJ O U E~ I _ I ' I ~ I 1 I r ~ ~ - ~ Es %L...NO rE3 ~r ,r-~ PFD. I~~If JI_:I q[oxG _ ~n osslxc_- sr~ ~~~4MW~ FRO M rvN s...c TD ,oa _ _ _ _ r D Tw uslxc: ) I I JSNOULDFR of ~cPiossweLK s` ,Icn"osiw ~ ~°cvc F F I Io L K F flOAD SURFACE IC C ONE -. Ww ~~HER ONEI CONTRIBU ING CIRCUMSTANCES -- T ONE OR MOnEI x EaryEnknEgcT NO ]v[N U[ [ I ] 1 HOE] t~Nla E] I HOE] ~ t ~ I SiRPIGNT A EAO rj o uwv 1 n aauor .49YEHC I-'I x n N ENCFOO J._/~:_1..ALC9NO FL r ~ F I ~- SLF.SESY_ ~~sf ~ Ds Ecgnofowgn . _li t_ I _ u]~ ~ p°oiwuixG c )r' wFT _~LJJ.__- ] t aw_IC_ N [~]~ F cF OF 4RUGL_ LU _ i bf-~!. D 4 _ ~~ I_ Y SLEEPN a ^] J~ M Hli iuaN ~~~]]~ SNOW _.1.... _ _ ] ~ I SxpvlxG _ (,l EKLFEDI~G STnTFD ,.~~ YEFD. L~ li ~,~ri F II nG TO 1~°~.~_;IGNw[. _ _ I-IIIS(-i avFn PwRKING L. [_J__l.Ot1LlON_ ~I+j~ MwKING L-~ If FT TURN ~.. ~ __. _ Ir _- - I z FFDING PEAS ..:.I +~ . ~.3gFEN(L P.__.__ _ ~ ~.III f TVnu vER 1~16'_I D_EST_EEOUIV._ _ S~ V ~_.~ I I ~[,F ~ _ • v -" y ._y,~y - ' (~ 1 NT W L~6.~1 To C __ ~ ~ 9 ~ Q 4JQN ~ UB ~ sLOw Nc u I FfiiF~ En IS•ECIFn I noPFa r-:B~ . SINa ~ osnfcano noP I~_-' S f f"I FcIFW 1-_. nBLJ roi I~ J]~ ;DiFri oFUR L I ONo ITIONS ~ ICNfCK EI RAFFIC CONTRO N ]V[xICIE vFx CLE TYPE OF ROAD I ND . ] ICn[CKONEOa MOaE .VEHICLE CONDITION . ,.,SOBRIETY..:. -, N I- r IJ f~1 STOPPED wT SIGNAL t aLl . -7 - t ( -1 f I ~~s PjQS SN~I i~Ut D VINO. )F ~ EI WILE I<nFCKO IND ] OR STOPSIGN GN4L5 ILL I._J_'__. 11: I O _ _ ____ I E I <[ . B- 5 ED IN '_~ ~ nowowgr . _ \i AYL16xT 1 I]. I S10P GN__. ) iNO I _ .1NF ~ LeIA ES ' I ~ ~IHOq IT Y MPAIRLO k.IIOI_, TRwfFIC LANE _ ]. I 0 WN . .. ..l..__~ .._ ii ELD '...._. `.,SIGN~.~ __ ~__.~ ) PE BLF .~.~. NO ___. ... . I .... _...~ IkAO LI0HT5_... . ~ NBO ABItIiY .... _-...I..NOI.IMPAINC4~_.__. rlll~l STwRTInc [NOM 1... 1_.~ PARKE4POSITIDN .,.DUSK '._l:+ RASn N6 'Arj wiFNCIIANGE ... } ~_, OfFfCTly[ .. _I , NBOSOemfrr ~......`UN ('~_I]F M,RarNG 1[xIIRING ' ~i DRNK-5 FET ~_IWNTAON '~' In NG ' ~5'. 1. [rl _. 1 ~I 4l F ~ !.. ._.. ._.. . iN1[S wOnN I _ 1..011 SMOOtn _ .. -~ ~- +I BE MUn xK NG ' ~.~16 I P%.CKINO " IiAnKS E[r 5 - la N° ° ~ -' T ^, ' "u.HNOIw1O unlvUw CHEM. TEST '-'~ 7 ~ .-... Icnno..: .._ .--._...~. SGN4L iunN uNFi on Plo.x ,. _.. I ND ] I ~ ~.i OgWR-NO ..n. 51A[FT LIGNIS ~ UrPICEPI __[ I ( 4N -. N i StP ATED ... ..... _.... v~TO' lESt GIVfN ..--__-_- /_n_~.~._. .. ... PY I ~..; N R E ', ] OIWU[D 1 . NO OEikUTS ~ I ~ TC51 RFrUSFU I OiwkP ISPIC rri~ n+IrK E L (~ urlDlvlOEO ] •. i.. _ISVECIIVI ,~ ~ TESTRESULTS Z V SIHjPIINU UrF IClN5N4MEAn4NK u4IIG[x0 LI[L OISrgiCxlp rDLICl 41NIWFD Nfl NW[ IrIG FIUw lDD v13TrGA G EFI INS N4M[AAPxK ' OF nNCY Ill AOI T. ON I 'LI'E ~ DATE ' DUPLICAIECOPY~LOCAL LAW FNf ONCLMENT AGENCY'SCDPY~TRIPLICATE~COPV~~INVESTIGATORIS COPY ~~~ ~ '~ fl [IS 5 F ,~~~ ~; ~ .f. ~` , _.GM N %:" '• ~i'~A~~ (UF'YilA~fiil~tal CAN _.~,,.:]~.~R-- >,- N~_ ~ N . ~~ v~ I PAGE Of , o POLICE COMPU UNIFORM PO '"V ~~'° r INi NUMUEN LICE TRAFFIC COLLISION REPORT ' , r ~ DATE OF COWSION •. ~ ~ ._ A } l y ~ D OAY OFW OLLISION A MO. T fl T SuN } MOn ] IuLS ] ED A Illux S Fry S Sai C TIME COUNTY NO j / C TY NU. IUSE ]A00 HOURI ]• ~S ~ FHWA ^ RDAN ~} q y ` ay f ~+ ` I J COUNTY . QSTATE'ROUTE ~('~ COUIITY ROAD Z ADM CLS. PREFIN ROUTE Dfl STREET LADE •. ,7,:J OCITY SiflEET O 4E TION T V 9 Y e OOTHERISPELIFYI ~ ~ S O . w ~ . '• ~ '~.~~ O N S rr''E~~ W ^ N CITY OR TOWN ~ PflEFM .. ' K MLES ^ O ^ 2 ~ EO „ M lE P ST ~ - ~ 5 ~ C . .1`.®OF C ~. -~~ .L~ U ~., ... ,--... N NO OF STPEETO HIGHW Y ,. '~ 'n' -... ~ ~ / D Q ~ ~ , 11 , T •f] Er't'O' n '~ ~"-~- -INTERSECTING WITH: STREET OPROAO-~ LL RAM1tP _ _ ' ON ` DAGRAM DATA .~ 1 A y , . . ..4 o JO 11,t?j n: ~ 2 n :_s y - - ~I ~ a'~ ,.O'. NONINTERSE ' ~ ~ ACC DENT WTER NON ,• S' ~ N ~• r. %•RD - Y _., ~ INTERSECTING STREET Ofl FAAD Ofl fi r $~S lk }~° . . BETWEEN _ - MLEAGE - - STREET ANO ~ CL9; ~ EgENCE CROSS STREET POAD ~• ~' __ _ STREET CODE O DISTANCE ANDDIRECiION FROM REFEflENCE OR CROSS Si, EET, ' :1. 7, ~' MLES N S E W ~. w GRf S ECVAL COD GUSE - Ir C, '~ COLLISIONINVOLVED. fQ VEHILLE•VEHICLE ., VCHICLE BICYCLE OOTHEq(Wg1iEI O TGRJJN SEE RY'~' ~~ OVEN CLE OSIELT ~ ~ TOTAL NO r1 NO. KILLED • '~'- OVER CIE RR T d{F•NL~ ~.-~ IkL T ~M1A {N, ~FVT' ~i - ~ •% -~ D N }} OLE VEHICLE NO OF VEHICLES L~ OVEHICIE PEDE INJUR TR D ~ ~ f ~ S IAN OH COL4514J ^ .h:~ OHAZ RWU OSJEGi STRWKINAAIE OFOBIkCT SiRUCKAN00WNER7 N M ~ ~• . E SMATERIAL- " OPROPERTYDAMAGEONLY - t ~ ~~~ A. ~ ~ I I, A E) • w ' ~ ~ z - -.LOCAT ON OFOOIEC7 STRN CK' -•-, .-.; ,~, ETD AG AM E ) S 1 ^ s, IXiWEflS NAME~LAST~' - - Y ;- FWST ,. --„ M WLE __. - ~ ~ ~ ~ ~ ^"' DIVERS ^RO DW Y FEET ^ ^ ^ ^ RD EWE S AME IwST FR ~~ 1 ~ . ~ STMODLE fBICVCUSI Ofl PEOESiRMry LHEC 1[J ~' "R STREET ADDRESS R-:IA..Ru R -.. u ~ .. ... ... ~ S EET ADDRESS t ~- . , ~ ,i ~ ^ i 7\ . 5 R ti , 3 T • r.t 2 0'~ t• oy1 '•" A 3 CRT .I • .. STAT ~ TIP ODEI P E Y' ~. . . ~ SA' _ JION NO y. C¢ OJ.DSI:'1\ i _ .. ^JTATE J ~O T If 21. C0~ . PrIQJI /A0 oFi u4ocU°S' ;~+p 3n ~ ~ - ~ ~ ~ . ~ n o i~ ~N ppVERS'L1CE 5 O J '1 '• 9 23 $O ' ' a~An~F,+~ 3}Jr ~ O :ov sr 3 ~ i o„ O7•' ^. 3+c r .~, , 0 2 O x{ } C ~ _ ~ + STATE'. SE DALE FBIfl H •N r x RS LILEM O, MO. DAY Yfl O ~E "^'• ~ .} y ''STATE + SEX.,. DATE OF B flTR )$ ~ -•, ry , r • q ' Yb..I. ._.q 2f. • Tl. '}F 75 CS '. :O L fT ~r 16 MO DAY YR A y . .N G G ;.1 WMEi19000 PATION iIRM AM .:~ P ~•~: PnO ENO T2 • ORI ERS OCCVP TO •0 - - RS 0 fl MN M : 'fpna : R }I:1'J f'1 ' j ;.T 'i 2 '1 ' P J '^'~~ Petired 7 ...: OrIEN r ,. , ,~ ~ ~tr. CODES ~ ID) l Uu~_ TAI SEAT DELT ISI EJECTION_~_ ' CODES J ] C ~55 V _R ~^~~3 .. ) ~ ~~ ' ~~ v~~ ~ w € ~ ' X . AT RE OF L ~ I SEAT BELT~_ I51 EJECTION ~ WU ES ~ NATURE F J~ , ~ „ . TT ' INJURES C ~- ~ ~ I ~ ,C SCENE VEN.YFIA.. BY' MANEIDODCECNEV,) h TO RgMOVED ° MODELIDART~NWAI : STYLE I]OR•CONVI f OM SCENE 9Y ~ n E OT Q ° VEN YEAq KEI OGE~CMEV.1 MODELIDAgT~NOVAT: STYIE ] • ~ -. DR I ~~ •• , LTC. TE AO. E :H ., STATE ~ TflMLER PLATE N0. STATE - E v H. OLOR N. ~ - ~ • .~~ C ~ 1... UC. PUTE NO. . STATE... TiWIER PLATENO.ti G TE,;..._. ~ I ~ ~' , n C EH LEI Ntl ICATWN J PO T Q I~ . _ NUMB fl.'...,Y .,_. ::... ;•.-.'.. '.L " OWMETEfl... .... O VEHI ~.IOENTIFIC ATI NNL M ER k ..~ .. L. ~ , OOOMETE fl -tjtA ~ L`U •~ ~ L "E DEkI;•2562lr63 - L "., ~ - . A , . - , ' gEGISTEnED OWNER-tI ST :.:FIRST- ` ~ •• - .:. . E~' 2OOp6S MIDD :- - •St .~... ~. ~-.~^'1r, (~ ±. . N .. _ .- LE .. ~ REGISTERED.OW ER l T. .::: , t _. I.y .J{ :MIDDIE:y FIRST .... ..... • O Sn~^ os driver N ;aefe as Eixzver .;: ApDRES$.oF OWNER .,..... . ~ O. .. " `" • ~ .~ 4.... " ~. ~•••------~ AOpflESS.OF.DWNEfl a;l `PR .: ,. NAMEANDApDRESS OF mSUflANCE CO.OR AGENT.,....-.. ....r: NAME AND ADDRESSOFINSURANCE CO. Oq AGENT.': Port Townsend 47n. °h ' ~~ O w ( " EN ORCEMENT - --+>-'~~ 4.: ...:,;, _ ~ ' ITATI ~n~p ~ a.,+,y- cnorl _ Pen i nveativatlon ' CT p " r .J. A,. ~ ' .NAME, ADDRES§'$ INJURIES OF PERSONS INVOLVED I- ` • coDES _ ] .] .. .:~-,, t ` '' .-..' .. NAME IU„lt';IY Gn+ ilIInettO C 0 SEX AOE: STATUS %' ,. .EJECT l ADDRESS' 1 02 S tb Port Anrles 4!n. 17: 45 ~io7n U TURF OF •~ ~ 2 ,~~f , - ~ RF.MOVkDFROM ' P-' VUIIRIES' ~ Irn.V A•wr•r • { ri• S N ~: NAME. ~ CENT PV .7 •--.•K A_A•• n 10 OP rl fl T AppRE.t4: . S NA U Of / VUUNES SCF iV~Y FxOM 4N NAMf. TO 1 : Apogfas. . N .iwunrt E : $ MwE' EM nM scrNi Dv ro 6 AppRf 59 ' ST INAIH ~7 ~- • ~ y ~y' M IIISIATUS I]ISCAI POSITVYI SC[Ni nY I J V4UR 3T 10^ .C;'~' ••+I~ n ]PASS[rAGfR C' •'! ~~rt I YCU55 l NO NJUA TAI SCAT RfLT ISIEJ[SigN SrCW91 H~AH O NCYCIISi A } . V ]DCADAI SCENE 5p9A01IN01NJURY SNCW DISAOU O 1.NOT IN9TALLCD 1. NOT EJECTED • D SOIHCq ' OwRN S ] • ] TOT CRPOSRHYI m SMOIORL CIEI OpfADON AIINVAL OICD NI105P I ~ N IENDENTIINIURY ]NOTIN USE ~ ~ ,.USED ]'iOlµLYEJCCTED J PARTIAILV CJCCT k . TSS lPO.SITIONUHKNOVM I}AL 1 PpSS10lE INJURY UNKNOWN . ED, UN NOWNIF ' _ SSCAT DELT F.VIURE -_-:~- EJECTED _ 1T r~ 1 -.:~ ~I ~~ 1'- ~ to§) ~ }. 4 _ Y YI` iJ. i~. } ,ITV ~q. r, 4 1 'M I: E J'_k 'f'l )A r J 1 '~ ~1 d ;3~'L ' }I I t I ' ~ I I ~ r1~4~ I 1--- A ~k~" ~~ I1~ ~' ~ ° ' r • ? } ~ r t r ~}-, ~ I , ~r*TJMI~ I , -,.,UI.~~.,, ., ~, ~...I ~~ia 7 l ~; ' ,..~ 'd '.:•' ~..'~.~~ ~~.7: ~ ~ ~ I ~.. ~ t ~ . i ,~ Yjh f r ~ , T~.. I ~,~ , y 7 ~ } ~ ~1 ~ I r ~~ 1 ((( I 4 V •. 11~7~ r i :,1 t I 6g ,y ~~ ~n I.„,. n', iiL-'~1F3LY_'. ...... .u'L .auw..4-x.i.~.~. y._,1 _'LS'S..y.:4Y..,.n% '""` VEHICLE DAMAGE ,a4w, tmE-N...," ~ ~ ," t 1. ~IN EAC OX C C E TNf NU ER OF EACH DAMAGED AREA. E ~ r tl ~ ' ~; ~~I INSTRUCTIONS: z. sHAOE RE DF SEVEREST MPgCT. ~~~(T~JJ~7,,--~~~._ (III' ~_ ~'. ~. ,Fr:~ ]. DRAW ARgOW151 TO SNOW PRINCIPAL DIRECTION OF FORCE. O~ A DAMAGED VEHICLE NO. i lusf THIS SPacE fox sKfTCH nG DwMACE A LEns, MOlol+crcLES, ETC I DAMAGED VEHICLE N0.2 i :,r ~ u. H~a to Tn t I f I]. x f rtE~ 1 '. 1 •~ 1 t5 ur~lY f..orr.+ q.E y 1199.• .i~~ 16. n .rcur. b Kfl +TY tl r SE 0 pAMAGE: VEHICLE NO.I - E En TY Of pAMAGE' (OTHER VE CLEI v x CL r^ A~ ^ 5 B NG DAMAGI : O NTNEn M.V. DAMAGE 1 ^ DISABLING DAMAGE ] ^°TNEnMV D Ma +E C]n BLING DwMAGEE I p OTHER M.V. pAMAGE „~'- ~' i ] ^ r oNAL pAMAGE ^ MAGE : ^ Pux AL DAMwGE . ^ ND AM : ^ FuNCr1oNAL pAMACE E xi [] x E "7 I0 I ,~ '_ >"y ` TowfD er $illfs Gara a Esr. owmact Towfp Br LT .. Dev $illfa Gara a Ac EST. DAMAGE f „a ' ~"'~, ? o Chimacum WnDgFS : °51700. * DN I L 5 :EpIaM m D NORTH IN CIRCEr~ ~ E 3 4 -' .,'~~~ DIAGRAM OF COLLISION ~ G_ I W h . , I i8 Wn. RAW ARROW SHOWING y,a _ _ I I - ~ I LarpN,a,f,DPPnpAn,:A. ~~, I 1~I I i ~ I I~ Df CII ~~ ~ ~ ~ = r r ' DNUSUAtnrxP cpnp npvs hS : '.- Ira rwrcrr cpxsrnu[r ux ~~' ~ - F' ~ r~: /~ ~ -'~ ^d'i ;~ -~~ - ~ ... Aaw Erc, ~.. I C I ~ I I I I T-1 I J s}~ • ~ :.pLA,t.PpE,aE.DINTpE ~~ I -T~ I I__ - ~,-I ~ ~ i --- -I ,+~ ~` "~ .„ ,. f.pNrfNrt p. Lr DS a ~ I ---r- ; ~ I i I fi DESCRIPTION OF urvDICATEwHATPno6ABLr gwnPENFOeEPDnE OURIrvc ArvOAFTEn nrE CnasH, rvcw ElrvroRMArloN xoTON DwGRAM,FC pnrvEn ~" »~ eI +~COLLISION Dsge u]Y, REDUCED Vlvfialrr, PEOE5Tn1aN ELOTN NC COfon.[oxsrnunroN OR R¢PAw woRK, ETCI M!~ t ~~~ ~ Driver of Veh ~1 informed this R 0 that E on C,R° 4 and had _ ~i'~ 'r ,: - -_--.- _.. / _ __~$ _ just rounded the alight ctu-ve } ~ when-.all_mf a euddet_there was a vehicle coming._at him in his lane of traffic he att--em~d to r,l _ - tl~~, ''~' wenve__to miss-the_.veh_bltt_~oo_.}.atf: tm uroid the accident. I then talked with driver of. Vih >~ ~ .2~nd_he-said._that~e-.had reached_ovE~to_brttsh_sot2e_t~Jing__off of the face--~-'of his vassenger-and ~ ~ ~a ~ ~:~. ,.p~ I ':_ x r ~1 -when-he:-lmoked _back_he_was~n_..the~rroag._lanD_of trafSic~nd ha..,a~so swerved to -attem t'~to ~ ~.. ';-ytiP~~~ "A~;~.~- - .avoid_the_accident._but._too ],ates_The_ assen er of_ veh #2 also informed this R 0 the same '~~ ~`_r~' ~' as_theslriver of_Veh fE2 P -B -~- ~~ POSITION BEFORE COLLISION ~. r , ~~ E -xE D TaEE OR q AME OR NO. ~ ~`--- ~ ONE DIn[LTIOrv LARKELY IF PS VfN ~: ING E LG OECREA NO ' - P p OLCU If0 ~ b !I --..J.rli?!J!-' '-' c.R 4 F BSI ~ E ~ r _ 4 -MPH- ^ rJ G 1 ~ . PfD. ALaxr. _'T c s c O 1 ~ '~ I PED/BICYCIDT WA 5 +~. ~SIpEWALK ]~ I ]rI5N0ULDER A~ .1< OSSwALK SI-iCa05 6.. B XW EO TE OE _ Sw E ~r nDD n ~ . ''~ ~ ~ ..ROAD SURFACE. WEATHEq._.. .. CONTRIBUTIN CIRCUMSTANCES..a <K ONE( CHECK ONE( ~ ICH CK ONEROn MUREI O.]r E Of rf~ ER - .. e ] O ORC ] OE] V 1 ~GT ° ~ E ° ~yAQ I ~ r ORY - rXCLEAR CLOUDY ~ ~ E LEO ~ ~ ~~ -1I q CST,Lj ~ ~,3,{' _ ~_ ALYERCAS -L~ ~ aTLSOHO - 1J_LZ°4GL93€ 1~ Sr xl E AR ' r~E~ O E G Gn ',~ r _ ~, _ I WE ] ~-~ nnlx_ _ ~-~ n E WENCE OF I-I.l a' rvE- ~ '~ L^ P TL L~JS^ p DINT ING y~.r DRUGS I I °I L_ r ]~ SNDN ]~_ OW rvG ~~_ EFUL Gs gTED ~~y~Il-l' TOE (~ (~'~ wPK NG N ~ C r 1 - T I~-~J_c~.ILS:O. JS I OCn71GNV ^A^. G"n ~~ .t: ~~ I _ I ~ CE . 1 FOG _~ , 1 l x'EE G 5_ l I J ~ Tx RN - y'Jbr' '' '~ ~. -~..~ A E.S.FE I n ~^ 5:~T ,~ E E EpU v. LI .._J ' ~ DNOT CnAxr Rlw n+ I m._G Y Erfc r~ swwlxc r I6 ~-_1.1_ l I ! Uvf LLE ~STG GU LIGI+T T.I/I IB~ D n I6>FC PYI OTHER SPFCIF VI ~ j -- L- CI6 , SNGn ]J SI°xr5°GrquAL TOP ~ LJ xO VEO I ~S~ TFPFFIC FOq ~' I ~ IG ~ EONDITIONS gAFFIC CONTRO cE. TF PE OF gOAD .VEHICLE CONDI{T{IOBBN.. ~. SOBRIETY ~7 <KONEI Nt] E CE HOE] IC CKONE On MORf F CLE 1GtjI~Di§t~~L'UI INO ]E ICNfCK ONEI~^" ' B OR°STOPS ONIGNL R - 1_1_SIf.N_ A_~~-:J~~. oNE~ NO] 1~ rffl ~BI~ SR OVIWAIN ' ... TwO WAV { EC f. nD ITV IB STA a ]~ ° ~ L.. SGN ' n[vfPS BLF I ] ~pl^ fTS_ :~]~ PAINEp___, - TRAPiIt LANE C I] ~_~ AB ITY (''7 T RTING rROM - -" _ - I~ npAO.----- ILFO L GHLS~ .~~ OT.IMPNREO 1 ~IIU v A T' _ 1 I_ ] Wf ~[ REDS NG O!. L.LLOO~ IIANGE I '. ~ pf EE [ r I] I rBO SOpn IETY J ^ MgAi PIG ENT( NO I . I I DANK-STR[[ I6 i 6 r RAMP_ .._IIEAR GNTS ~ . .._LNK.~__~ 1]l_I i [I i_LlGnii ON sx n0 TIq[ wOnN ~ '- ~ ~ ~ ~ ~~• y _~. McLli ~ ~ LI.. ALLFV I I ~_ OILSMOOf I I AEN °nTINKING ~I6~ BACKING k r '•..+ Rn ~6 nw i~Ni¢rT ~ 15-~ +rnr mrD~ pn En CHEM. TEST I'7 ('I ' ~ . ~. .LG fO.IE ~1 6 AL _ _~ w• H° 1 1 i_1 f :' -.. N. __ r_ !.~ i .B ~,S P[Fl LG i _. _ C[ I fPAriA+[p x - I T[sT f.IV FN MEn ISPECIFYI ~ ~ ~ ~ 1 . G '_~ . ^~ i T e... 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EL AL LUD N6 USE Q^MIIES N ^ ^ ^ ____ _. _..__ F[ET OF ~ Sf VL COLUS:ONINVOLYED: ^YEInCt[ ENICIC ^vFN,CLf I,i^.rflC ^OrHt n, J,Itri Lt LrrnaFU•J GRILLED ~:JEIIICLC~ORIECI ^VErf.CLL~F`~IF..'.!: ^SiOLCN VCHILLE ~ NO I!:JUFCD OFYEHICLEG L!-J VEMILLC~PEDESTPI<N OrI LOILI i~CN hUZA!<TI. P.Ar. ^FROI'CPTYGtI/<GEO._Y OBJEC~.T,,//SI FUCKINANE OF OBIECT~SiPUCN AV00:•NCP9 NAA!EI ~-[(K 010E 061ECr SIH'JCIfs [ E51 LMrnf.(,r~ '~~arJ_"~Ye ~~_/~J:~ ~~~N J[~L'~'~J~>C{rt=..~A`.i.rt i F• LJ '!" L~ rEET ^ ^ ^ ~ F~ ED::F S.C.• .~- LR~VERSNAME~uGT GI r1pCLE DNI'JEFS A S Psi rJ DOLE If Lx;r ULrS10H FC[ESI!r :.'. GHL Lrt!(J D R i.~J':"'ii9 ~/~~•"J -' R s1NEEr <noRESS I S1FEEr AODHESG I V ~5 ~1-1~'`~-J_P~ 1~~1_4 /y-`-'--- E crtr-- srwiE zIP CODE =np'IE NC. E crtr sfAfc- zlPCwL Prgaf. NO R • R ~~ / L'-'--~S~S ~~- 1 ~A sLC[r.scl.D si<iE seA o<rtu!EPrn N •DWVCNS IDLEUCE S~ SAIL Stx D<IC O~ "' / N LP!'.Ln ~ tP DPrvErtS OLLUPASION F AME L •1 DPIJERS UCOUP<igtl FIRM NA!AE I Gn3~lEr:O CODE) > ~~' S`At BE~J~ fJ[C ~_'~ CODES > - cross J SE4i PEL: EJr.C'•:1'• ~ ° ~~-_-~- - pF tuPE OF /~ .Z'.JUP ES /JG/~=!A _/yJ S ~ LNC•~ E•.E PY 0 ~[iiMU 5E0 1 Q _ GEr.E BY CC / 10 1~~.1 ~:y VEH YEAR EIDODvE~LMEV11'JOLEl10<Ri NOVAI BTYlE 1]D C..NVI CH ,CAR EEIDOUGC~CNEVI A!00 I ~ JVAI STYLE t: DP ~LONY! E Il!I YE LOLOR UO v.ATE O. ISrArE 1P<,ER PLAlF r.O Si...E H \EH LULON LC VLAIE l.O STATE rF~.•n PL<TE NO~=i<ii H 1~~~%1 =L- ' I li ~.Sa/ `" '/•' 'BEE UDJ!<irEF C .. LE J NI 'CR ODO, EiCP. C I L E J I L E (car yo: /-5 ;.-.. ~9c_ y' {~•~ ~ y E <sr iPEGIGiEPED UYIAcR-UST FPSI _ IJU..,r IiP!'U9 SPEDU''Cft L rIP51 -~ Apo EGS Oi GA'I.ER PDD'nr:S ..f C'..:.P ~ _ 2 ~sJm N __.___.__ N44EAHOFpO EGS Or lNSUHN+Ck CO On A[:E4i 4r.!C <•,p P.'.~RE.•iBOr '. ~ ~~CC CO OP <OENi /~.S %.+•/'~J. _ __..__ __I '___ _ ___cv _______. 141i0tili0 __- LrV -GE - Llr<T10N •.:i F.r.: C1'.i:l:E•F Nr CNApGE ~~GFi. • P ACIIOV i - ~ __ _ _ ~__-- _.__l____1-.- CODES _~~? I D I ~ - ..r ., ,~., . r.. - NAME, ADDRESS & INJURIES OF PERS~~S INVOLVED_ _ sEr _ s,ATU` i ~~ [=ECr C NOME: _ ~__ ~_ ____.._. __._-.____ __.___~ ~~ C ADDPE SS __.__-__._. ._.... ..___ ._ _.__ ._ _ p uvJJP FS TD T e. AME _ __. .. _. J L. _~.__-CJ~.1~ ADdtE53 ______.____-_..___-.-.-.__.._..___. $ N• uPf Of ~ I r L <• _ TO JU ES ~~- W E __ ._-__. __ _...._ T ~rl [j Jj _.._._. _._ ~__., _._.1___ _..J -'IIII r S 1•:•f _~ .. __ S ~!D: Rr 5 ~_ .. ._. _ _.~... J._. J_. -1~ _L__1--r--.I_.. g ___ r E. -n ~H ..-rnnl I c q of•TUS z la" I [ c •a rulro [tr r' C s`:.Nlifn i~ 1 i[ r r. r., ' P ~•. usf I [.:,c.c:[~ I I O in~.~LCrE(I1I c•..FP; ~n o•I [. ~• O rq Ury[H Ir I. ~, LT. 1~ ••=!C r., rC., •[ ~: Q~Lr AL ,;:r L! ._ t .:~iI rArl.~nr [1l.il:+ ~.~ { ~" ~E. Y Sl. Y tt~ M~1!~ ~ L Il s i y I 1 ~ , ~ 1 , ~, tJ I Y r I ~ ~~ °~ I w j~ ..TP. R _;'. Y ~'~ r J~ ~ MM~1 nt E11 VE Hlf LE N01 r,•• 1rrr: ••r•.r rr.., .r. ,.,,<. rv ..a. rr ,......r- .. _ ... UAf A( CU VCIIICLC f U l • J r-. - ~ . , -~ . -- ' ... _ ''VV I 5 ,rue, ,;_ ~/ - ;~ +~~ U _ II i - rs . ,r i.-rte i. •r U 11. _.J Ir~ U_r_n re • - f rro o rnrN r --- - -- nciv cti rro> _ , ffS o5u ca ,T Cl ourlN rnv o r.,nct rr oru, r rc o •. ~ ur ar ., n ~ ncf ° (`7 n v<cf 10 ruc L o<unct O N + C7 r~ p <c_i i_ a _ 0 - - = '' 1 rmvro ev . //S T-. ' -.T .u - - i u...-,< T lm,~fo e. - T - . ~, ~ ~•. s~>, = o to T DIAGRAM OF COLLISION DRAW ARROW SHOl57 NG r rr4.rr rr.r4Nrs NORTH IN CIRCLE srNSUCNUN --G ~' s.`.',~.FS~ Sr' ! ./.• TY/,+, ra/ .?y/': !/J F~ O OSr~irn rrr `fwiviarar ... TW/ '~ ~ ~ ~~~ - _ _ r _ ~~c ~ ~L DESCRIPTION OF ~ orc<rt corn ~r': 1rNm•ne:. .,<..rstu ulru•a unni•:c<• =<r . n n rrmrrx<,mN COLLISION or,nrr~,rl..muuero.o.e.~r.rur.yrr.~..nmN~....o.ar•eo•s«c za oN`FE :.nvrwra.nelNO r<, „!ee ~~ y~/ ec%-'•~ ec~<S,-, ,,, ~a~•,.:y ; '.~ sss; _-;.•s:;:.? r:;~~ -<- r ~r,- - J ~~ ~ ~i/n ~ ~° /d~1 c! c+~-~ p,r.r„ e : ~' ~ T : n ;'n r .. ^ ..../' ?-r' v n ! ~ ~ .~ .. '.~. i r T +G~e~ PJ . ' POSITIONN yEFURE COLLISION -4u L - rNO Nf.oto r a u•LTroN oa srn¢l oN ,r, a_. .\<,t La .o I rn u•rt 1ci~o.. ~~cni ~r.>~' _ usrac o cvusmc .Kf oc:u=rto s f _ , ~ t t5 .. - -_ ~ ,.,. olrr vCLr5T w45 vSrNG. ;l0•r TI()i1'rn T+yvt~ t0 •:_ [•. G\ NOS pr ~•• vtF:OAU `Uary ACE NrcrL<[ Auur[ r or.r U 1YEAKMER LN r.nty CONTRI U1tN6 CIfLCU STAt CES •4 L m c<crro..s !rr o• tr D~ . ., . , __. ~s`o~irice`owr c~oicwl..-1 r •,o:.~~:: a ..<r.u xr1 r"ooU r<:r sc f,. O I ~ T-iv0 uvoln nrnufa; n tr n 1 ? _ ~ ,. . c N s c ° tr io°raos<.r re c n `nv X ~ rLF yr fOG X < .r r -+ r. 4 .r.\4 f v ' Ir[G O[~1Grrvl tUVrr S \ o v I X 4 5 _ L`r[a\, r ,r .• 'rl ,r 6 .S, O.HV.. ._ •lTN[n rSr~ttifvl -OIN[n rSrtCrf vl '.. y.. O 5 TO•NUV[H 1J ~'Lr.(^;. r.:•:,: v.f rB ~ rt4 fON f ~ rr r y nr ~ ~ r LIGII'f CONDITIONS TRAFFIC CONTROL ,.,, Cn1i•tr o 5V[NrCtt 'oTk , TYPF OF ROAD N l rCNf CK Or.l on rrUNli nL< G. Un "~ ~ •~~ VEHICLE CONDITION SOGHIETY •~- ~ r l rr rC rrfu tt s.c\n: n FO , uar•tLS , mn: w.r .'I N:L,r n .: ir. i:.t iCNIL[O.vtl rNO: .'t~rr•h -Ll• I ,. rr cc. u:~latu., .o: (r 51UP SrON aor.rlo.r. ' 1 x o<vumn -._ ._ ~ t wN .° s n ,n . x.. : vn wa• ~ c,f eo~ofT. i r xn - - ~: ~~uutu,v rrro.m^r:r ..l~~,.':.., i ~ orto nonnrr<r ,o i,ia , LrN ru r e yin •'ouime. s n a . nitivr ' oanisunntlT 5 rr n iour•rwn~.~,:1 5 nu,r I rr:••..r I Lrn rv Y,' °~...wc ~ ~ ,J ie~~N~:ua ulnm rs n<u~Nr: y o<n.. s,nf!• rOr.lS Olf _ r S ilu<.NO ! IN [I G S lrw w.,v trrr 4 t<i<T• i1~.\-- ~------CIIEM1I. TEST ~ O I •r' •.r•r[revr • r , N I ~ .rr .,r _. 1 > .. X 1 510 O' ln rYl _ ~ I N ( '~~ ~ rr I ntsuus ---- ` 1 1 2 t b /~ /~ ~ •. / i . c ~.%r~ J .L.i ~../A . f1 e l ~- / ! S - // '~ '~'f l ~ _- I __ I. -- + 'a_~ JP[ ' __._...,. ._, .. ._ . i T r r I/ i ___ -"lu <,l - .. ,r r ~ .. i r: ,,.:rn :.~•. .o.. ,r. r. .:t:~ .~. r~, •. .... .. c~„ ~.., i.... .•. i~ci~u;.~. r,nr s~cw~r .. r.u .............. w~.,< ~~1~j~~~~.~. - ~~, ~:. ~~ ar ...... +:r~: ~ + ,., 9 _ 'N0. 'ViR1G!CAIV,'• U ~'i QQ E -. Dn Eo re eu - -. `linva a r. { c. `~/f' T.nl ~ I2 ('~I~ ~ I ,~1c'/~ ~C ~ 1 ~ ~_ ~Z .. ..._ couv`r.u _-_____ aiv rio.'____. __FNwA /W ~mmnL _ ._ _ ~ . COUNiY ^SiAT[ROUC 6CC • ^f 1•EC1 U _ _ CIA CIS. PfcFl% I+U'JIE ON6igEl rCDDE SGI+ON - _ ^oTH„n 1. PEC rr, . ~ / W N 2 95zr7Q lL L L D L i. !•+., - E •I ^VJ - N b ~ W ~~- - . PNEI I% EU. fA!LC OSr n //r, J ~ C p~ NAME A NO.OF SiAEE10q NIG IW%•Y J (+L'C inC -r f f J ,/ LL~ ~ _- R AMP- p AGn AMr ~ T ' ~ ICI _ NON INTEN ECIIWJ ~ ~ ~ ' . ' D ' J C ~ t 1 O CL It iEC (INTi SI E OH CiOnp Uh HGF. Ei[ CECROSS ST EEi OH ROAp , N R[TWEEN SlgCETANp ___ F.i ~ A E C DISTANCE MJD DIHECTIUN FNOM f1EI ENLE UiI ChOSS SINEEI ~~ E-H N S +EG G pINO USE F ~ ^FEET ^ ^ ^ OF ___ _ _ L __ ^VENICLE~vENICIE ^vEN+CLf ltl^.i C11: ^OIhEP.:.NIILI ^HIfa HUV COLUSIONINVOLVE~: Sf vF.q~r, NO KuLeD TOTA: NO ~EIIICLC~ORJFCL ^VChICLL~Hf: *hAI!: ^STCLLN VCHICLE OF VENICLES ~ ~ NO INJUR[D ^yEHICLE~PEOEGTRIRN ^NON LOILI :ION ^NA_APOOUq MAiFmAL ^PgOPCRTY GAlnAGC O'JLv d OBJECT STRUCKIIJAME OF OBIECi3SRUCKAYDOLVNEg9NA51E) / ~j [J~gN :fl~~1J.% `/ ~N >~}~A".>Gf ~'__ C •~ '_ - - ~ Y- _ ~ I-IIOCAiION OF OBIECr SLRUCK CSrrAMAGI: LJ H~I:.D.rAr CJ rEEt ^ ^_^ ~ P^. ED'~F S •_J~~ (~ - [ E ONIVERS NAME~VST FgST CI~IVF riS Nhhl_LAStf Nbi 1.<UULE CGM, nC. S1 UH PEUESIh M1f. CNLDK ~_ ~ ~ I STREET ADpgCDS "' R JiHEEI POUgE55 E - - R N crtr .... .. sr~ tIP cape wio.+t lla ~ L E arY su1E aP eooE vNDNe N:, o. DWVE IS LICENSE r.. / ~ ' STnI~St% p'iC Of t j YI I N I o. .ER;iLCE`:L NO °H yf AlE SE% OAIE OF URfn ,,D I DAY rR ~ , • ~ ~ - _ .J L~ ~iL-IL ~ ~ P OflIV SOCCUPATION FIRM NAME Of+E t.O. 'j UH+YEHS OCCUPATION FIRM NA!nE PNONf. NO. CODES > r. eus _ a, sear BELT +~ EJec` a_, % CODES ~' ~I y`^,5 I' SEAT qEL' FJCC'.O': ' TU EOF' /~ NJURiEb A!} _ RE OF caOMV GENE eV lMJJ. TO F /C~.:•. c' ~- IJF'+E'q i0 VEH.YEAR MAKEIDODOE.CNEV.1. N.OOELIOART~NDVAI STYtE 12 DR Ca,IVI VEN YEAH AKEIDOUGE~CNEVI M1'OOeI IDARi:JOVAI Di YLE 12 DH ~CONV I H VE11.C Ofl -~VC.PUiE M1O. STALE 1RAl[R PLATE NO IST:.',E H VEH COLOR L•C PLtiE :O StACE inA Liq FLA1EN~5TAiE C vAla it DeNiwcAHON NUMB[R DD T ' C: -- E _ C/ /0% /-5~ ~yC h ,.nH D ,mss` ~ , i ' `J~ O E ~ ncu ID Tncal N Nuh+EEq ' opoME1C;+ _ REGISTERED UVR+Eq-LAST fl{iti iUE:lr O' 1 t(',IUit.1~tD O'::':CIV::':CIV LAST hNSi -~M:DULE ADDnESS DF owIJER nnDR~3s DT orr•.u+ sum N '~--"--"-""--- 2 ---- NAME AHDepDREGS Or wsulwJC[cu Dneccvr ~, F n ANU ADUr+ESar wnun•NCE CO off AGErrt /J~Oi'' P r I- L ~ - _ ~ NAME, ADDRESS & INJURIES OF PERSONS INVOLVCD Gc e ' S[r F t fuv ~_ ,._ ~ ' r n... __ EJCCI L. NAME. C ADDRESS _._. .. ' -_ __.___- _ AT R : - P N U E OF „1v:iZi;7~tR- . wJUmgs ~_n n w To ~ A T .vAuE Anoncss -- .-._. ..___._._____...----- A ~~ S -~.. uu nlr's F u •.. : o W Nwe i T ADLwess ~ l ... I 'i. i G ~ _ NAME ~l -1 -~_L S prnE SS 1 1 E L,.~_,_~___.__.__~._ _. , t ._._ .. -_. .. ._ __ A , I [ t C'Ct Or TD ,Ir V,~IFD `'~~FIi E. q I ~__ ', ~. + I \~ ~° ~J f r` I D f ,.. l ( '.'. t .,+. J', + J~ L , - ; n 0 w+H. .:4 L . l I .. r ( r,. F aL.U r ., . ,:~;~ ~.' Y~ ~ • t 5 `~ _f~ .. ~~:;; `~F h11CLE N 0.7 u,t rl ., I•~•v.l rl. I.._Ir .nll. . IS.I r.. DAM1IAGEU VE HICL[N 0.2 ~ r ~I P1 ~L~ - '.I-~U ~ r ( o v ~I t J.I. rf ~~ SEVLRIIY Of onrnnC.E v CILNn l ~ ~° o~ I:L~II T n R L~~L ~ ° _ Cl u L r,~ n R ^ .L .oN .,n ..~' ct ~ <,~ - u lowm er ~ i/S T%/ sr.u un:m xr - ~- Lowco nr t r unNn e o OIACRAM OF COLLISION ~ DRALY AHROYJ SHOWING ' II ow • rx l .ef NORTH IN CIRCLE +y . p '!~~ •:~iP",b! ~T.1 f/..J,• T'f~ .'</ ,~/~: !/.~C~ O =L.p'NI^ ; •. M T - - - - - - ' l.,>,I.I , n/ ~ ` ~ cif _i ~ ~ / ~ -1~ / /~ ~ C / 'DESCRIPTION OF !, -, c o , .. ..>~•t . •,(. now :f .,~.: n.,LN .:, IN_•U - u,.,.n ,v o n.Hn n.. •,u. L C OL LISION .. , oiaoxitn:.nmuau,,.~n~.m ,un.+r•I~~~.aol~•~n,. coaa• o:.•sll."c*~o•: o~lrc+n~o r:olrn.Ltt.~ - O~ / ~ 1~i^!'d'Jt:,i yr/+~ Jf% .S/,~ ^/•T.~ T~:~ r=, .•r/, G/. /~c. /:~ '/ rf•,~ij. .t~a..r~,>' i n ii1 ~` /dC fc nn! Coc/I„ E . , , .: r /„ /+ ~ , nr ~Ti; c a-.+ .,/ ~/ . - VOSITIO . wL n N BEFORE COLLISION NCn ~ c pia. ~ I.•+ cl tn. o, srllt Lr ~Il~~c.•+rvar Na•.t u.+vl ~ - m - l -- n [a u [n o n N 5 [ w ~ t~ - ~ -- 1 LU'IR fll C Pf LIST Wn5 U5 ING < , 6 .IOi,Yn SrrnUL~t•I , r to ROAD SUti PACE ,LEATHER COfJiRIUl 1TLN ; CiF'CUt STANCES ' nlNVUI .a.. u ~~ i ..I. x'I nm Lr I ~evviiicnii u a RnININI. . .. nica HOif 11f '" z r ... n ' .,.. ~ I. lo.°.wlm ,I.. , ~ vc ~ $NLM _ x SNOW fOG NC L f O x I ~•, I ~ y rlltrN~ ' n[I![r vl. EOUII N a 11 ~/ X _ )11f~lYLC LYI S Ollrfn lSVlClfvl ~~ t• • r I i ~ Ir ~~ p lpl l • 1 u N SLOI.INfi ~I ~ t fo IIfIC NOIiIONS . ~cn CRAFFIC CONTRO IctL T~NE OF HO`D NRT ~IIICLE COfJDIT10N ~~ s I SOURIETV• ~~ I f ~ l •it SlGVnL O l r o s ' INU 1vClnttL SIGN1l5 I Q iL ,j Link wny ' ( n.vtl IN.I, ClltLa H S p I S C.I. mI~LC iN . Y _1 /• OnvLlRrll i~ LInHN } S1DV ~ viYl~ 5~[.v ~/ Ilrtl lrn /l i xlF I ,•' 1 I • i RU• j . . ~ • ~ to I 'I NRI R•vO5~1rRV UJSa ~. L io Ll rn ll<t~ I Ifl rlr..w•. lOlir 11 n,N.'' ~ I•Nil iv ' .,. .. ~ Y ".. c. _ I! tll llr. N ~iINYEIIING Ic n:cKrNr. e C 1 EIl I -v I.t•r ~ CIICM TCSi ~ 111 ~ t 1 j iLSr ( .vtN 'vf Clf vl 5 1 Cwlf Lf InG~Vlnv 1/11111/ • T ~ 1i~. IIL •, ' X fl(I:.LI •. t i I '..lilll :ril __ -_ ~ . _ _ Urll[R ILVLf IV '~ ~~ 'I'v'1'I t, ----- ------ ~ ~ iCST RESULTS Z _ . -- ~~~T~ ,~ ~~.1~ .L,_..1r',tS ~ /r'+e! nll.:,. .r,,...1 rN1 5' J S I~_ ... .._ _ - - In trll i ~ rl // /'/f 5l c~ ~y ~ ./o _ I':IJoio ~ N _.._ I. I...I ~ y S~~ ~, r ~ ~% F II P f~ ~~. ~ t 9 4jhJ • T r ~~. 1 ~_ - VDLILE LOMPUINi NUMBER A, 1i; ~.~~ ~ UNIFORM POLICE TRAFFIC COLLISION REPORT _ # D GATE OF COLlI510N DAV OF COLL SIGN TIME COUMYNO CITY NO. fMnA ~ ~'. ^UPBAN ~~pp aW V ~ A M OAY T SUN I u0i 2 1 !i ] WED A INIIN 5 FRI G 6AT IUSE [aGOHWRI J /~ RAL ~~~ E/' - - E! COUNTY ~ Y B O Z AOM~CL6. PREFI% ROUTE OP STREET CODE 6 TION 4 ^STATE ROUTE ®COUNTY ROPD ^CITY SiPEEI W Sz7~ '1 i~ ',' JI' ~,!~ ^OTNERISPELIFYI y '1 i ~, . l% ~~/( << CIlY OR 10WN ~ PREFI% EO. MILE O6T /~ () ppry~yE '~+ - A ~~ O MILES ^ ^ ® ^ ^OF!/~C~~~GLI___.____~ U r ~ P--~ /~,Z 7 r C A.. NAME 6NO.OFSTREEI M{)[G./'WAY INIER6ECTING WITN: 6IREET Ofl POAO. O RAMP DIAGRAM DATA 4}~.~ i~.y: 5V ~}~ NV' ~T - ON / ~• ~// ~ r~dn~ ~ IN1E'R X~RD I iERSECTING SIRE ~ORROAO Ofl REF A XP I NONWTE ECIION /CCIOENT „/ CLS FNENCE CAD565 E ORAOAD tay T Q ~ MIEAGE N/p~L A~ ':~ N BETWEEN __ _ _ .STREET MO _ __ __. __...STREET LOGE ~' L d ! l0~ ~ T ,~ - ,rya. OISTMLE MODIRECTIO iROM REFERENCE OR CROSS 6TREET ` P ~ SPECIAL COOING USE - ~ ^MILES N 6 E W ;[4i1 -RI ^FEET~ OF __._ ___ __ _ __. - ~ 6EVEPITY ~~t '~ C 6 e 1 ^ EHICLE~VEHICLE ^VEH CLE BC CLE ^OTHERIWR EI ^Hlil RUN _NO %ILLED .C COLLISIONINVOLVED: v - ~ ~ -. TOTALNO. ~EHILLE~OGIECT ^VEHICLE RPTRAN ^STOLEN VEHICLE _~-NO.INJURED __ _ OF VEHICLES L~ ^VEHICLE~PEOESTRIM ^NONCO l510N ^MAZARDOVS MATER AL ^PROPERiY OAMAGEONLY 1 ,' ,~ H. I, OBJECT STRUCK INAME OF OBJECT~S)PUCN MOOWNERSNAMEI -. ...' LOCATIONO OBJECT STPNCNS E W .' ... EST.OAMAGE _ ~~,,±• , _.._ ~jYJ Y. ' ~' I L¢T~/~-IPSO AJifTY ^PO DVA O FEET ^ ^ ^ ^ OD.EOGE f S~ ~~ . r '~ od a ,c' pp~~~f}}gg s ; • ~ '.. ~- IXi1VERS NAME~USi FIRST: ~ --. -. MIpOIE,,, OPIVER'S NAME~LASI FIRST MIDDLE IIF.BICYCLISI.OR PEDESIRIM LHECXI^ -''. ': A'91S - r/,yx .. A ~; STREE AOpRE95 -. - , 1 _ ,.; ... .. • ' I STREET AOOPESfi ... ~ ... ....:... '. ... ~. P E CITY STA E 21P CODE , PHOM1E NO. E CRY.. , STATE ... ZIP CO E •! PHDNE NO. R R .. .:.. ,~ r' ~N DfUVERS LICENSE- STATE $E% OPIE OF BPTH N Dfl vEPS UCCNSE NO STATE SE% OMTOE CFpBAIYTN-YR / g~ I 0•. / - MO. I OA_Y I YR O. 9.. "„9 ' DRNE S OCCUPATION FIPM NAME :. '~ /G PMOIN4JE~N0. 2 DRIVEP6 CCf.UPATION FIPM NPME ~ . - PH NE NO. ~ +A'. ~ i3 S I / TG°/Y - ~ e2' JURY ~-' ~ - .~'. \ -A .CODES > IJI INJ CODES > IJI INCA AI SEAT BELT~.~ 161 EJECTION - CU55 AI SEAT BELT I61 EJELTION~ C 65 a.'~Ae ~~ ~ IURE OF INJl gREO tAr IFLNR E6 I E/ U E6 RgMOVED t -' FR MSLEMC BV' L ~ TO N O~~/.GP F OM SCENE RV~ TO Y ~ ~ • VEM.YEM NANEIDODCECMEV.1. MODELIDARi~NOVAI 61YLE 12 DP.-CONVI VEH. YEAR: MANE IDOCGE~CHEV) MODELIOMT~NOVfJ. STYLE I2 DR.CONV.1 ° ~ v o ~ e/ y -,E/ ~ ~~' E VEH. TIC. PUTE NO. STATE /`TRAILER PIAIE NO. STATE H VEH.COLOII LTC. PLATE NO.. STAfE TRAILER PLATE NO... STATE ,. ~. vX~ ~ t ._ '_ ~ H 7 v }} I ~ r -~ (,' VEHI IOEHTIFIGATION NUMBER ODOMEIEN :. : C VEHICLE IDENiIFICAII N NUMBER - ~" ~ ...: ODOMETER.. .._.s i '}YyJ,1 I ' .' r p p - 9 ~" ,:~}~r „_ ~^ E: L OZ IS 7~D 7 ~~~ ~ E ~ -v... MIDDLE F '~ - ~. REGISTERED OWNED-LAST FIRST .. MIOCLE : REGI61ERE0 OWNER-LAST ....„. ..... FIfIST ...~ ~.. I -./ 1 /1 /J ~~ ~• ADDRESS OF OWNER.. ... .. ,. ...:. ....: ~ N r '~ 0. ADOFE OF OWNEfl .. ... .. . - ......... .~ m ~ p `. _ NAMC ANDPODRCSS OF W6UNMCE CO.OR ACi_M '. _ NAME ANO AGGRESS OF INSURANCE CO, OR AGENT - ~ - ' .` ': ` '~. ~ ) :..: C ~IS% ~/ Q .. .. ~ CITATIONN • r . -,. .. ... rtATIONN ENFORCEMENT HAHGE. ,.. " ~ ~ ~ . _ /OKi a AcIroN /// CODES Z ] 6 ;• NAME, ADDRESS & INJURIES OF PERSONS INVOLVED' sE% AGE STATUS T EJECT. O NAME 5 U HAFT RURE OY _ __- nEMO EUFHDM ~- TO ~~~ ~' F WJUmE3 SCENE Pv ~,~ A NAME iP N ADDRESS ~t T FlEMOV ~Of ROM $ wJUmES SCFNF nY TO V/ HA4F' 1 I AponESs T lf-ETASEUT 1 I N ~Anu -~---~ sr.I NF nr To S NANF ! ~ (1 $ ADnRESS C~Dv-FbY r ~. ~ S• INNJU~uiti -_ . ~ 1O ~I 5 11161AIG6 I21 SLAT POSIIgN IJI WJURI CLASSNF'nV IM 6LAT BELT ISI[JEC1gN ~ F,. 1 . 2PAS.SlhLL11 OWJURV SnSApLIH61NJURY N0I MSTAILCD 1N01 FJFCifO ~.. C :PIlN 61Rw 2DFADAI GCEHE Ip IIOF/gSA0L N6 2HOIMUSE 210TALlY CJECI[0 ~ T YOIHFRPOS tIOFI .l 0l Ap ON AIIP VAL IF WpENT1111JUnY ]USED ]PARl1A1LV FJCCICD rIY p lFBO1Y; ~~T S 2 IDU$4010n~C1E1 ADEO NH05PIAL lPOS$TILL INJURY SfilAl DEti FAILURL AEJECT ONIF E gjil~• E C : s- ] ~ A Povllnf uH owH _ i[~~~ q ~ h! 1 ` rx 1 Ad q t ,p ~ Y; ~~ ~, ~i ~ I t f ~\ a r Y A I" 1 t ~ / --~ ~~ 41 r 1. Mv~ 't, ,, , r p ; _; c < '.; ~ 1 A v ! I~ I ll t L~~~ '~: ~mh .~ L - PF ~ylll t r IV Eli I ~~ ~ ~ ~ s ~ e 1~ 1 }rr ~, r Flljl' t .1 ~ '" i t+ r r ~J ~~..pp 'Yt' ~I E f } "7' I l1 t~~~~~~~p!~~L M t~'~I I~ <P" tL 4 ~ ;r ~, I•'; t +"+~T4~ h1Fr S~r ~Y. 1`~d ~;~ ~ ~, Y v r i ~fll ~ l~ (y . l ~ ~ rr 1 ri ~I Y i ii l~~ 4 ~1 ~ r~~ ~~h•~/ ~ fu 8v t~ c ~ `tk r e d f t '` ~ .. ,~ _ I I ~~ ~ L ~. yy ' .a"' ht DC17"U" q ! .1 . OAH A ."~: "'~~:wlClttL°C-' r ~, •, INSTRUCTIONS ] S1gDEAf1EAOF3EVEN[STIMP4CT. ~(~ 0L [!~~aa__ ]. DRAW ARROWI3I TO SHOW PI NCIPgL DIRECTION OF FORCE. I. VJ` Y ~ ~s~~r DAMAGED VEHICLE NO.t IusF Tn ss>act Fp ry sKETCrnNC pwr"wc[ Tp tHglLt s O/ ~• `N '; „, puW Mprpncrc LES ftc DAMAGED VEHICLE NO 2 ~ C ~~,. .-. {' _-: IE G; 1] Orrnurn "w 'rrj_ . r' I/ I -[1r ICI.. Ifi. U ~ ~'t _ E E of v Or DaMpGE' VEHICLE NO. E SfvEnlTV Or ppMAGE. IOTnEn VFN OLEI I tlp'-_r'I'~~~~-'- - ~-r~_rVll` f~ r~ ry ' R. (R SaBLING DaMgGE ; ^ p]ryEH M V. ppMpGE E ^ DIEgBL NG OnMAGE : ~ OTNEn M E H Tv pi DgMAGE' VEHICLE x'. ] ] 0.. r. ~ n . _ ] (] FuxCTIONwL pgMaGE ^ NO Ogrnapf ] (] FuNCTIOngL pprnnGE V ppMAGE ; O OuSaBLING p oaMnG K g H y paMwGE 'f~ [OB ~~ FSi.O E GF ^ <iIONpE iryEH M.GEE ylJa OWEDB Gf _ f D o By . O ~ ~~ Ka7 T. DAMP D s ,.Q ~~ ': DIAGRAEA OF COLLISION j~ ~~~ I y - '„ - B. ..'rfwru"n ..`'. i I + ...-.,..._ '.__.. . _ _ I DRAW ARROW SHOWINGLE fib vfryKUl --.-_ I ~ - Tpl I -'- NUflTH 1N CIACLE :. .LDfvrglwNS --r __ .. _ :.. :a.:ElpNpErHpwpw.r 1 _ _ __;-- ~ ; - - - ~-- IEEpN,nDU . ~_ __ ~~ --- . ~ s.Im.nKt ~-. ..- .-.- ~ ~ I ' i A 1 ,_. Nyfy,.,,[M. EpNp T BYf _!- , n - - dsy ... ~eEr„KnKDHTIHy(Ip„ -z' ~' l.f/~~d i~iiu3N 1 I .; I I - - -. r Irrw T. _ _ -- _ i ~__ ... ~~ _ i Hyw ~ - 1 . - p. ~ o '" , I' . ~ r, ~ I I ' ' 1 +rT I 1 ~` .6r o~ N I ~ ~ EF -DESCRIPTIONOF plspBlurv.n[pucfp WSle urv .EpfETHI LDT G L TnF Cnp3H. NCwpf wronMa T /X ~~~" - - " -~~COLLISION Geld tel uxplcpT T ,, ~ ' - O E n N CO G TnyGT w YroIM _ D k -YB~l3't/- S ~S~ on rnpeaeL ' ' -_ _~ _ _ Co/n.y_~K/ ~y G%?SJ ii1,;Q T~N.-e~vdio[i '..L S~dn cdn ~.. •` ~ --~r~ i7?~_. /_dd ~ dHu! Go^r..~±E :~_.L`_~.f r _~l<1~_d/url~d-_-- - -- ~ µ u ,C, nr ~~, r - POSITION BEFORE COLLISION , O' N[n[aI5 NG DT [wBING i On HiG a O ND - - O RfCTION r •}~ •^ L w - F OC. p ~ .~KA I E _l~L.~- ~ u~y CJ ~O [L D EE as ED I~L Ir 0 a s" n"I ."wr -~ ~ I ~~ P ~r'• rED/BICYpt15 ] '-nDMpRKF n uLDEn 1 CHOSSw r ~ flOAD SURFACE G WEATHER K w I N~H i 1'-lo c i D f?i" JD W^~ 'r ~ DR V[HK Nu p EOK OxE1 -q' CONTRIBUTING CIRCUMSTANCES ;,, c En ~' ~, [ o Eon MOHEI pN0 O t --III^ p.] j p~loEn ryf ~. 15YMS _ -. ' q~. ~* t pnr s ~yDYE9CnsT~ _pNp0110 .+_.- OSLO G OE *p D • ~ 1 ,_- WfT ([, 1 , p9UG5 L-Cr B(r' _~ a ICI O G r dv M _ • >( .,~ ~ , 1l ~. ] I_ G 1 1 u NF LUFNCf ~ 1 ~ , p_ p FE~_J ~ a^•- ]~' ~ AutryG Eq ~ -- _ r -_ - E E 1]'~ ~pw ] L.' NG - ~ I,~ EKE[EDING STaTF I r ; -~,D n ---SLF~ T_r_ TI N f , _ _ K _ _. pnKING 'n a ~::. v I I~ t ~-7 ~~. - X ~ c[ . ~ DG X : ffL __ _ Dcp~oN .-_ r~'L-~ i Tic li L ° , K p c - r nrw -. ~ .. pD c om_ > X rrn._~ I TD p E -- -' DnH N piry[IE INEGIrYI DT [H IS/EGlfvl (• - --_ 0. G.1 ~ I L BU SLOWIND C: ~.. ~ I ipsiacn ~ ] - _ -. LIGH xcONDITIONS TRAFFIC CONTRD TYPE OF ROAD scxrslGxwL 7 I y -p rl i ']C TDPPED FOH cKO E ] cLC - ND]' VEHICLE CONDITION iFgrTlc a IeryeeK Oxe On MO . .SOBR~NTV - _ ~~ ~~ H EnIDtIE ~~r{= j~ [CQ f E o F ECK ONFI L.JB~ IDSI[D qT 61GNgL 4 - I GH4L5 ~ 1 ~ DNE wwv " ] ~~~i15U+EOI x ] . I•^ DP4GN - ly D r c r _ - X _. --_- r gTDPPLD IN t ~_~ r~ I I] ~ To. ~, Two wp. pu fcE VE "~ _ ID pownr I I p S _ ' ,... pOpp K[3_ ... 1 rI w Irv ^I ~-1 T Hu GI _ 0 ~ D E r pf1V( MPAI ILO ~- I ) O FFIC Iq F P' - S N fwp LlLni3 ._ ] r 0 E1n ' I cFHOM ] ptK NO C G[ n ND CD.-_~ I 1 q EKED POS f ON ~' r Eq RT l~EIT •_-,i ..."SENpn N6 I ~ w0 n IS ~._. OLI[iMOU~lS I pN O [ II)LJ (/q.Ffltl lF iERING ~ ~§~r. 6 / Y . iTNI ETNLDEGHIS .-. ] UEn1I1 wH Br. ~_ I ' ~~~-~- ... _ Yr~N ~ O >i Ef e M NM TEST f'I ~ ~.. [IlN[H ISr[Clrrl „ ~ ~ r ~~'4~ ee~ • ~ ~ E ....e .._~'..._.,prvlD[p N l0 p ... ' I . Mrv^ ~- IYICIrvI .. ,. /I ODEFELI3 IFS 1 9E0~ ~° wri or~K X], .. -_'- to lw[r.rn rS Y t_ NvElirl:wTlN<,wrc •SHpVl lnwN. % TFSi RESULTS 2 jy I ucE NO Lrcc cn[p r 'r - k I pL L.w nuvl° N uw r. I ,c ~,, y v f_, ~, r~ ! , ~.r vrsTlw~Ir~NL~I~~ n~` F,o..!'~ A~r~// %Y~8 ~J?`/.~',],~°' /a.0 ]rI» " ~Lf~_u ]rro IM En[pE` ,. v Ip IM tv4;` ~~ ~ ~~~~ u. II un p, rIIH pyfu M" .. 1 _ _II~w :r + ' t. X nlrs Mn nni I. ulwff ~~~~y,LL'~ pIOLICAT[CWV~lOC4l Lqw INfOHCfMI inlfiFNfr`tCOnv~TH PI~~AT~LCOPVAINVf3TNGAfOI15C0PV ~~ ~• s~i5vrp~i •. `WID' .~;Q,{I t`. [Iti ?ti ''}1 wtil~ ~.. w_.. r #~ t r + ' ~ ~ ` '4~~t*+1~ ; mom. ,~ " t ` }~.. xt~ ; r:. ~~ t _> ~~.,:~aF!,~' `ET+S"'" ~~-~?mFmPy+~ -n~~y~I~ I 1 I 7 1 p~Yr,t ~rt t4 ~. F'~ R "H'm : ~. [t i~~ 4~~ ~° i r Lrx ,'. Y _ )''; ~Y j r rr,~9r ~ t;: ~~ r tl I i' 4 1 ~ J 'k E 1~ F ~' - 1 ~ ::~'j p i gy r2 1I` m~ . 99 ~r . .. ~° Jf ~ { p ~YdyW6'Hs4+: ~ ~ - k. ~:~ ~~ e^ .. '..~~ ~ ~ ,. ~~: ! 3 ':. i+• . , _ . ' iYy d 6iiS~~1Lhp..~.... ..... u * I ~ ~ 1 N. ~,4 ~ PAGE OF Q ~~ UNIFOR~d POLICE TRAFFIC COLLISION REPO RT ~~ POUCE COMPUINi NUMBER ~ ,~ 1.. v {~ " . ~ GATE OFfAl1150N OAYO LOl11S ON THE ~ M ~ r AY ! SUN f NDI P IUES D W}'D i11UP !RI SAT (USE Zl HOURI ~ ~- COUNTYI O. CRY NO lNWA ~ • ` l S D Li• L.` 2 / URBAN - ~. ~ SIURA ~ .,. ' • ' COUNTY ; _ ^STATE ROUTE ^COUNtt ROAD ^CITY SIPEET O L ApALLS. PREFI% NOUTE Ofl GTREFT CODE kGT10N 1 C .,- 1 + ~ t U~•',: ^OTM RISPECIFYI N 3 ~~ E - l L CItt OR TOWN - N 5 E W ^ IN ~ W PRE O % E ICE OST 6 N A -NAME.I NO.OF ST TOPNGNWAY IMEFiGELTiN I LL R, G W TH: ~ ~ i + O LTREET ORROAD ~ RAMP DIAGRAM DATA , f i qt ~ I . 1~ t10N IMERSECIION ~ ~ ~'., ~ ~ ~ 1 r • •~ AL CDEIET TEfl N X~qD EASECiING 51REET q C OH REF ~ R . ~ ' ! N. ' . _ '- BETWEEN. - .. ' STREET MID STREET MILEAG CODE ~ .CIE C CE CROSSSTREET OR RCAp P y A WSTAALE ND GRECIO FHO PEFEFENLE ON CROSSSTREET Nurlglfl Ng SPECUL COOING USE , I _ II~-1 ^ EET ^ IJ ^ ^ OF '. .. r - _~ ~ ~ ~ I Xh COL USIONINVOLVED: ^VEHICLE~VEHICIE ^VEI11LlE~BICYCIE SEVEHIfY ^OTIIER D'lRITEI ^NITd FUN I x TOTAL NO. ^VEIIICLE-0GIECT ^VEHK:LE~flR TRNN OF VEHICLES ~ N0. NILLEO ^STOLEN VEHICLE NO.INIURED ~ y .1V y jj ^yEHICIE~PED[GTRIAII ^NON~COLLISION H ^ A:AHOpUS MATERIAL ^PROPERTY pAMAGE ONLY ~+%ti~- F i• 1 ' - OSIECT STRULKINAN.E OF O!UECI STRUCK AND OVMEHS NAMEI LOCAiIOV OF OBJECT STRUCK EGT D G y y vt' ( _ ~:. .. . AMA E ^NOADWAV FEET ^ ^ ^ ^ O Y f ~~.' . ~ ~~? DRIVERS AAMEdA:iT FIRST MID DLE . : R . EDGE S DRIVERS NMIE LA..T F q5T M DD E RF BrCYCMSf OR f EOES Rt E KI i PH CH f ., ~~ w ~ D / ~ r 1'. _ - ~~ t } I . ~ D Y 1 F 'tl ~ „ R STREET ADDRESS ,: .. •..... . ~ .. .. R SIAEEI nODRE55 .... ... .. .. .. . ~ ...... .. .._ . . ~' .; R. CITY. ~. ,~.,~ ~. 'STATE, ~ ,. „,,,. LP CODE „' PHONE NO. I. ER. CRY: STATE ... LP CODE,._ ~ P ONE NO. - ... .. . . . N _ 1 . L -` ~ ~ O OfuvEgS LICENSE NO. ,, _ STATE SEX DATE OF WHIN MO O R N DRNERS LICENSE,NO. GTATE SEX DATE OF BIRTH .. .-.. I . ~ Y . I .,• ~~ . Q~ MO. OAY YP. ~ ' f 1 DWYERS OCLUPATKNI FWM NAME, PHONE NO. ~2 DRIVERS OCCUPATION FIRM NAME .P N . ~~ ~~- ~ Q ~ ~ ~~ +" ~ r '~ '~ CODES > IDI Iwugv _ CLASS Ill GE TBELT ~:~ 151 EJECRON ( . RES R'• .. . IWU • CODES >IDI CUSS Ill SEAT BELT 151 EU ECTION f1ATUR , t .: RI . ~- . • • ' . . -. ... : : :. '• ~~ E : - , E NIURIES EMOVEO ' . . . ESY : TO EN.YEM EIDOD^E{Hlr l MOI EL (DART~NOVAI STYLE P ORLONV .. OM SCENE RY: TO ~ . .1 I VEH. YEAR MAKE IOODGECHEVI MOOEL(DMT~NOVAI SttLE I~DRLONV.) ' t r ~ _Iryyn~ . V ~ ..: ~ y ~ 'A2 . f E R EH. COLOR LK:. RATE Ap Sin E tgAILEP PUTE HO. STATE E VEH. COLOR IJC PLATE NO. STATE TRAILER PUTE N0. STATE `~7 ' ' - - ': 1 "' - '~ R t •Y~~~,, wAth '..:_ '. ' (+` VEMI LE MIFX;A BER - .. ODOMETER C VEHICLE IDENTIFICATION NUMBER .. ODOMETER . .~' ~ . - L ` .,. ... ~ ' L .......... .. _ , .. ._. ._ ` E ~ : . ' .: ; E ~ EOt6TERED OWI ER-LAST FIRST MIDDLE gEGISTEREO OWNER-LAST FIRST MIDDLE ' ' I ,, l O ~~ : ;- E DDRESG OF O ER 2 ADDRESS OF OW!:ER ~ .~ • t ' 11 ~~ Kl~l NAME MDADOHE!;SOFIN URANCE CA. ORAGENi NANEAND ADUREESOf IHSUNUILECO. UR AGENT ~-' 1 . ' E __ CHARC CH ATION NO. __ ____ _ __._ '- RGE •. t ~ ~ EHF OR^E E _ _ ~ T CIInIION NO. I ' j - _...__~____~________ A^- CTION __ 1 { ` ~. NIA NAME, ADDRESS & INJURIES OF PERSONS I INVOLVED I` __ .. I 1 SERI G_ Tnius ~ ~ l ~ 5 ,cre , p .F6 _ .~ JSCFYF RY: }p A N E ...-__. - ____.__ .. . __._... .._. . _ .. .. ~_ __ S A 1 :hE OF W ulf 6. _~_ .-._ _ - .... gEMO fD iNOM- tiCF!:f R ____ __ ._. TO _ HI, HAVE .~___~_~ _.______ I T N i. ~ __.. ___ _ _._~ ~ 55 e _.~. _ 1 t 0 L rr 5 I __ ___ __. _ 6 ~ - _~ ._. _. .... .. _. _ TO - -~ $ E _ _ _ _ - 5 r ~$ - l ( T 1 1 ~1 E I I Iw fi' _.._._ _.__~. ___ __. .... 1 M - , - _ __ __ S C O h ff u 5. 5 I;,e; rlyl +iLR If \'1W 1 ~1 CM>t 1 ~ 81] I ~ L- I ! T ! IT I ~, r I ll II' ~ '-' ~ 10 i~ iLtLT Si 1(D 1 [ I II Jf Ci 011 O/f FGTCD ].1 J1 l f lCIFO D ,,,/// t'2R / d ] L . I.1 E.C Ir ~. t'AL , l~ . !IV ., ITY ' ..I 1 :-D Y I. tJLG]FD E . OV .C"S `~~`~~~JJJ II . o r..~.. .t,. v... , .iAt i, 4l rfrllJN E iJ1CliD lli 7 I t„t~~ :l " I% {t~ }~ ,~ 7S~s r~ ~,'.J{x51 ,w.~~ti, ~'~i. ~, .`q4.. m,.. ., "T9!';1:::-~ll~' ~!.'Y~Nw„" ri r~ An~~ I•L di'~F 7 E E r- 1 N~ '...~~~~p.,-•~,1,,,~ :!`''~1A IFn~ 1. ,.; 5~ r rd~.' 1 I '} .;7r. -~ A, ~, ~ .1`~r ~ I ':~~ --- _ .., __. 1, .,..... ,.. .. s.....~_... 1~.....,. .. . ~~ -a.I~f, T fi ns'~,~Jtt~ ..~A~ ~` r~ ~~ ~ Y `''t,~,3"~x..'~~'7'Iy¢?i'~,Fx '~^Jr~. ~av.ts'eni1'a~_-~"~ri3r» ~~;~_~re~sa".'~~lNw~t'.~>~~`~- ., "' ~L, IL. L. .,. G.. ~ , + U t .~ V, IAI.H DA aLD ARCA. ~ ' ~ ~~lY ~~ 3 SH E qEA OF E ERESI M ALT ~ ~' _ INSTRUCTIONS: - DORA O ISITOSHOW PH C AI OIREOl10N OF FOPLE. '©~ .~ DAMAGED VEHICLE N0.1_. NSE TH SSPALE iOR SAETLHINGDAMAGE TDTHA LERS. MOroncvcLES ErcI DAMAGED VEHICLE NO.2 , ~~'~ ~. F1 . \ l e '~' 1 `1 ~ p' A. Ibol/ _y ]=- lA Jlool C Y ilw ~~..:. M' tS. Trunk ~J(~ ._ . ,'~ . C'2' ~ 1 ! 2~ b ~ 15 TrvN .. ~ ~a ,ol/ tS.UMarumboa o~c-Tr~i 16.Unau.[wne.Je k ~f SEVEwiY OF OArAAGE: VEHICLE NO.) EEVERItt OF DAMAGE.IOir1EH VEN,[lEj SEVEPAIY OF DAMAUE VEH CIE ND.2 1QDISABUNG DAMAGE' - SQOMERMVDAJAAGE 1QOISABUNGDAMAfiE GQOTHEHMV.DRMAGE TQ019ABUNG DAMAGE 3QOTMERMV DAA!AGE 2 FUNCTIONAL DAMAGE A'I`~~NO-DFNAGE 2 FUNL110NA10/JAAGE_OHODAMAGE 2QiUHCT10N 10 AAGE A(7NODNAAGE' TOWEDBY 1„}~! `~'~ 'y'!/~~- EST. DAMAGE TOWED BY ESi.ONAAGE TOWED BY EST.OAMAGEL ~',~;' To_~ 1. 'I`-h~<)\ To 5 To -' - - s ' tr,..,a , i DIAGRAM OF COLLISION. DEx E nD I I. ~ ~ ~:I i t 4 DRAW ARROW SHOWING ( ~" ~' ~ ~-1- 7 ~{'~ -~,/ ~ ~ ~~'1 NORTH IN CIRCLE ____....,~.~ 1 :~ z~ ~, tYh NryDN ~,E -- , ~ - - _ _ - ,-, - J ^DESCPIPTiGNOF' ~r i TC D M FE:EGd ORE DURI'G D fTERi iE CRA Ml CLUD FORNRTIONNOTO JDA UM,EG Ddl: R . ! ., COI,.i SION 1 DI 9..I.r.fi_.+~,:EUI.d UTY,P[D_~THIANCLOiH,.3COlOR CCN.. :+UCHON ORREP..RVIORK ETC) - ;~ . L~;<;~.. ~ c- 3,,,, _,t _~;~t~ ±~ _ _ .~.~:~~ vti.1...: ~ l~ r>~ ~, „.,~~ :c~ d 6~-,cam, -- _ . - >. { S~ C3tLLE i D ~ Ii0 ..-SLED IDI L. L/,:.I L LLI~IJNj =:C1 ~ ...~. St O '^ O_U..E..T~ _ ~ iI.'/ O 4 LU ~D j 1 N TS' E W I „ 1 'J .. ; /L I~ `t ` I Y . l~{I `~ J.~ ` ~~I~`~ TES n ~ ND g 'F .. I . .• .. ca ._ [_ .n. .. ..- _.. _. '-__ l .~G . l TT C .1_ L ~. S L.. = E 9~ T: _ , ~ ~ i ~ ' j ~ jA ~ _. y ,. ,,, ~ ... ..,. I ~ ,L,..~ I ~ ,, _ _., _ .:. - ~ ,- I , 1 ~ 1 ~ _ ~ ~- r I ,, I .. '-r r~sr - --- -- ' I A , ,_ ~ = ~ i _ I _ ' j ~ ~ ~ - ~=- ~~ ' I ., - ,4 R MI5-~ ,1 ; i . , .,, J _. . , .. ~L _ ~ --- - _ ___~. J--. --_ v~ ^' ~`j i ~~ 1. d , ~ ~ :~ Y ~~~ ~i A - 41n. ~3 dM ! I~ }~ %a ~~a L { _2if r S, ,. S¢ 4':- Y ~~ f ~~ 'r',- k ~.~ I' . ''. v~ DATE OF COLLISION DAY OF COLLISION TIME ~ CITY NO COUNTY NO FHWA U~µ AY T SUN 1 ~(1 2111L5 ] WE A IHIIN 6 iHt 0 SAI ,l IUSE 2%OOHWRI O Y J / AURAL CWNTY ~ ^STATE POUTE ~LOUNIY ROAD ^CIIY STREET Z O ADMtL4. PREf1X ROUTE OR 6TRE/E~TJLODE O S 5 LTION '~ CS Y ^OTHERISPECIFYI ~ N ~ 9 Z' -/, L~ F E Oi IN ~,%~,jl,/~~~CI~IYjOR TOWN N E W ~ORQIl ` `"~L_. _ _ ^ OF ______. W U PRE I% EO. ~ ~ -. MLE POST} ~'~,~,. .... ~T~=/: `c,1~.1 C . MILE6 NAME .OF ST~IEET HGHWAY ::-' INTERSECTING WITH BIPEET OfIROAD LL O RAMP DIAGRAM DATA --- ~ ~ _ .: ~. T_ ~- ON CYL ~ OFI REF. NTER % I NON WTERSECTpII. - / `,, (,(_(/ ~ ~ ACC DENT MLEAGE ~ CIS EREy{'S CNOSR§THEETOOfl ROAD ~J SC~~, - N 1 6TREET MIDf~ v"--u ...._-- .. REST SM _JIl__- OETWEEN CODE / Op OUSE - ._ pSTANCE ANDDUIECTION FROM flEFEREHCE Ofl CROSS6THEE ~ urionEIHS SPECIAL C ' ... MILES N E E W GAS ~l~b.._._. FEET OF . /_ -. . .. ..,. ,~'. : SEVERITY ^VEHCLE•VFHICLE ^VENICLE~BICYCLE INVOLVED ^OT H T flUN HEn IWRITEI ^ OxII.ED VE KLE T COLL16 : 1ON VEN CLE-OBJECT ^VEHICLE PR(RAIN _ _- ^6TOLE NO IWUPED OF VEIO T CLE6 ~ ~VEN CLE~PEOESTPIAN ^NON{OLLI610N ^HK ARDOUS MAZER AL ^PflDPER1Y DAMAGE ONLY O GHINNAE OF OBJECT STf1UC%AND OWNERSNAMEI - U BJECT STR LOCATION Of OBJECT STRN~S E ~ W ..... EST.D AGE ~ a• ~. ti ^ ROADWAY O FEET ^ ^ ^ D E f - l - MIDOLE'~' .. . __ _ _- FMST:;- -._.. - -'--'" ORIVER6HAMLLA51 fIR5T MIDDLE'IIF BK,CLI610R PE HIAN CHECNI ~~'"'~" O D RS NAMERNT - RI L' !-tom ~ ~ ' R V-F~ - ... ..: ._ ~_ ., "' H . STREET AOOPESS.... _.... .-.. - - - S , R ESS TREET ADD ` ` ' O ~ ~~ 113 V E 1 ' STATE ZIP CODE PHONE NO. . : E CITY STATE ZIP CODE PHONE NO. R ~ . -- . w 9 ~t2S 32y-I~ l n N E ~r LENSE HO STATE SE% DATE OF &HTH N DPNERS LICENSE NO. 6TATE 6E% DATE OF BIRTH. . OAY Yfl MO ~• . DWVFAS U ~ 5z7 ~ ~Z ~Y ~ IJp `~ YR (/~~/iVl Q . DP ER5 CUPATION iWM NAME -PIKKJE NO. a~ ~: ~ z ~~ Z ORIVEfl6000UPAT10N FIRM NAME N N . , ~ o INJURY MI,6EAT BELT I51 FJECTONJ_~ CODES ~ I]I C1A55 CODES > IJI CuA55 1%16EAT BELT I5I EJECTION RE F TUBE OF ANU N RTES a pLURlVS ~~ EMOVEO iPOM SCENE PY' - TD F ENE BY: '~ V! MODEL IOMT~NOVAI STYLE 120R~CONV.1 H E K VEN YEAR IDOOGE ~ VEH YEAR MANE IDODGE~CHEV.I. MODEL (DART-NOYN STYLE 120RCONV.1 1 ~ ' ~ C f ~{L` . V_. .._. .. V E .. AA.~ O VEH. COL UC. PLATE IW. BTATE TR4LER PLATE NO. 6TATE. ~ _E : H ' VEH. COLOR. ~. TIC. PUTE.NO..: ~ STATE ~ TRAttEfl PIATE NO.. STATE..-....__.: H t , . ` ~ 1 N IFKATgN NUMBEfl. ~ -" ~~':: .- O METEfl .. :.,..... C VEHICLE ~IDENLIFKAII N.NUMBEP :~. . ~.. ~,. ODOMETEfl:....:._:. ,. (~ VE 'E' .. ~.. f MIDOIE~.- flEGLSTEIIED OWNER-LAST _.. ~~ _ F1RST:".. .. E~ REGt91ERED OWNER~LAT '.. 1... FIRST ,.. DOLE.1 .. ... - p ~ O. AWRE OF OWNER .. ... ._.. _..... .:. ...,._ .. _.. ..... :..:.t ADDRESS OF.OVMER... ..,-, :. :-, .: .. ~ , ' 2 . NAME ANDAOWiE55OFW RJNLE CO Ofl AGEM. .. ~.~'•: NAME ANO AODflE65 Df WSURANCE CO ONA EM ... :.: _. _,._ ..... .: ... . .. Mail ; '~~1 IA '' ~ :: '.. ~ CMM LIiAI N ENFORCEMENT . . ~ ~ ^ -• I {VOht, ^ ACTION E D NAME, ADDRESS & INJURIES OF PERSONS INVOLV sex .ACE STATUS EJEC*•: NAME: C C D ADDRESS' RLMO kU1nOM H Tula of scENinr To p ' PLnJRES A Nave ~ AOp1E3.5'. S T HiriuJwES ~ .. sc~nYF To W M.W[: T... . ADOnF91' ~ . N sc ENe PY 8 NAM ~ . S ADDR[ss , 4 5 fNf. RY S I A1 ^ P 111 IU5 12151a MVIW IJI EAAINY ClAS] C 2 Pa65[ApCR t 1 NO RLNII 2D[ADAT6C[NE 5 DIRAnlINOINNRY SNpJ ORAPIIIq ~. O PI Df 51RW PCYCl131 1.O1N[R rOSnM]N Y I M I I O ; DE AD ON AnnNAI 1110nAlAl 1 DIED M1VIDCNl11WUPY. F P0951fILE PAIIJnY p 5 OINFII -a 7 ~J x N IM ~ S P09511 D r ~NOi FJ[CTED 7 TOIALIY EJ[CICO ] PARTIALLY CJCCTCD X UNXNONN If EJGCTCD yp~ ~` 1 t ~~ y ,t ,p~u S, r< '~w ' ~ i~< 1 ~ , ~-1'','~. I I JI~~ '' I~t ' ,~ . } 11~ I~ ~tl Jam~t- :_°~._T",~r J.'~+°.,.- , ,~,1.. 'r'~"`.-A, L} I •:,~. r E B ~' f, 1 ri';` n ~, ~ r !~- ,~ ~ t~dk _ y II Y t~ ~. ~ .°I a ~ V tH C E D~A~'IV'~A~•~~„t _N,~'c,_ : ,.i~5",~..oe4r::... 4 rz~ rfaNT We : ~,a.g:i.._. :w'::. '.,~.5~~ "°',° x~a°. _ ~ d 9 - ;~' ~V ~` 2. SIIAOE AREA OF SE E E T I ACT. ' INSTRUCTIONS: 0. DRAW ARRDWIaI TO SItOW PRINCIPALD RECTION OF FORCE. ~ O/' i~~ JI f'. } I IUSf THIS SPACE FOR SKETCHING DAMAGE TO TnA1LEfl5.MOTORtY<LfS, EIC.I DAMAGED VEHICLE N0,2 r DAMAGED VEHICLE NO.1 H 1 F 1 noel R ~~ x fu !"P' LF• 15. TruAL ._ ~Iew'T I 1 1 5 T _ ri>I ter. 18. OrrUU nr •~ ' b. U urn w!: ~\'~ H.7 It. r' \ O or `MCI ~- SEVERITY Dr DAMAGE IOTNER VEIL CLEI ItY OF pAMAGEvEHICLENO. T" ~ I r.. SE ERITY OF DAMAGE VFHICEE NO I SPL ui w u DISABLING OAM GE J ~y1 OTNEP M.V.OAMAGE 1 ~ DISABLING OAMAOE -t L"I OTNERM V. DAMAGE ~E nRF~BL NG OAM GE OTHEfl MCE OE 1 DAM a t~ fuNCTIONAL""DAMAG~'~ A LJ xO DAMAGE ) O FUNCTIONAL °wMAGE l ~ NO DAMaOE r r ^^ O M i '~h TOWED BY EST.OAMA4E iOWE00r T.OAMAG TOWEDBYT J\I, NO A EST. OAMAOE .r . 5 TD , ,~ . , 3 TO I O [ _ P '. ~'Y(' ( DIAGRAM OF COLLISION ` _ L _ i _ _ ~__ I 1 - I ~ -~ NO R ,. .r :ow E ~. _ ~ \ I ~`T ~y_~~ -j....j(~Ij r ~I ` ~OR, TH IN CII OWING tm B,r Y i A s,RIxnDN ~ ~ i _ _ ~ - i . i ':I _.~ I ~-~-, ~~i _~ ^ ~ .. ~i .}, I ''!{" 1 ~ d I ~ , ~ i i i ( k4° 1 i ,. II ,r,F:n ~ -,-i( t I I 1 _ r, I i_I ~ ^~ I ~? ~ ~ .Kl N DxoaL--.. __~__I-.r~~~~~~. ~ - -1 --' - - - I I 1.. , 1 s"' _ °; i~ . :r~5;.~.;o;,~s.[;. ,.: ~ i AFT DNMA D ! DESCRIPTION OF uxmcwrE wHAr PxoeaStY NAP Ex ED BEFORE. DUNWG AND RTNE CRASH, wc[wE N NNOT ON OIAGRAM,E G~g1I E 1 COLLISION. OSABILITV, REDUCED VISBLITV,PEDESTRIAN CLOTDINGCOLOR.EONSTNDCTIDN On REPAIn WODK,ETC.1 I ,i; . _ d EII -POSITION OEFORE LO LISION. Nsr ~ ~"- D En ID V D E ~~ - yy ~ : MEwOED NI EPOS EET GP IGNwwY N ME ON ND O r KED 1 . -1 NO.~ EASING DEC G _ ~ '. ~ ~ . S I - 1 _ q - - DR NlH _ ^~,n.J ~ _ GRDSSxG__ i EO. ° c ~i-MAR W~T__Tp . LKw LK , i~ ~ ~ ( EDlelcrcusrwasGSlHC. EwA ~ IwA tl ISNOULOFR Llcwos`iw°LLK aL Icx"OS ~° al i 'ROUTE TL ° E D ' ra14- I ~ ROAD SURFACE ..WEATHER _. __,... . CONTRIBICITiECKOrL+eoaOFFOniIANCES ... .- '' `"'1 oa iwttfL K K [ '- "^'~~ - ~ IGHECK ONFI I< < ONEI D TR oR ~~D ( DIIIVEn pNlvE9 RI ER WEn ~1~ G O. t O t 0) H T H T3 O.] rIAL YERCAE°OVL~ALCDl11NFLUENCE OF I~T~ T000 C~OISECV ~Il~ O E D aR QrI.AE A~ G Y ~--1 ! ~Y CE ^i LJJ .r~~ R ~ Imo)' WET t ntn o En INFLUENCE OF I~T..~ NTER I !N~ 54ER~NTLV ~)~. G TT ~" _ 1 A~._- RUGS I I• L t rb. - A{y"" _ ~ I)I~ SxOW ]7~ SN _ ) EzCEE0INO5TATE0 ~ -i TO bn I OPFR PAIIKING ~ u G a Wy _ .: LNG 'R4Gte b TEE L - L IJ.OC1T14H. FTIN N ~ i ~'4Ri ''~ .~ ~ _I ~ll l ICE l I IFOG ^.. li F,~y. O E ~... O=J n ~u"11ryI5~ EC FEOUIP. I~a~ UtURN 1.... '~~_~-17 ~~~)I -l5 OT L 1 i, '~ I s- ' ~ ~ C~6I~ SLDw NG b4 s~p~- '. hp:,:' orxYTl""is.EElFri "-o*uFli i-ECl n I oIC _ ~r1 o c4QD Imo' 7 oHE IsP[clFn C ~.~ OPPCp FOR ~ ^an Rq ~~ITLI SGNISIGNwI I 18CJ M VIULaTIDN RAFFID ICH CONDITIONS RAFFIC LONTRO V111ICtE~. TYP oOF ROAD VEHICL1E[~~CI,,((O INI~~D9ITfj~~I,QQO@N ... SOBRIETY." _._..~Ie~ o~srED P ~~ A ~ ~ ICH[CK ONEI INO.t VEHICLE ~ NO'] I EC FOR E NENO.t ~f~~`I!IIA17{EDI 1 OLE ICNFCK ONEI OPS N i ~1 N ~) nTOroEO _ _ nen .' -, ~ 1 r! GNALS I I EWAV - - DAOWA ~L ~~ p~ - °. T_ ~ II ~!~- II nEF ECnvE n I ~ Im° AD urv . _ r I~ L~. sTANnxc ~ L ~!' ~~1 ^t i SG i~.4J O 4~l~BflA E5~ _IMPANEO -- iNAiilt NE ~, x tf -1 DA I ~ I O _ L~^,. C D F )~~ ~- OLGN(a ~~_ NOT MPAIIIYn A (~II~ P~NNEO GOEIITION .L+.....- -sox - L '' •"-~- 5~_OUSK -. L.L 1 REDS n. _I~~.^ LOOP RAMPGf_ .~~~. °REAR. ICNTS S I~S.. IJIN CSOBRIFTV-.. ~IIt~ TEn4~IDG IENTERIN° '. p ?1 EET ~. 1-~ ~!!~ I~,p( ~. _ t ,u~~ Of aMDO1H ~vL ! NfENN°RIxKING I ~JI ~ B CKIN ~> I1.LIGNTa~ __ ^ 1 L~ u. r ; T ! ` "' e'"? DAnK-srnE[T rte ..( ~e r' Two EFr `,s ~""._ .. CHEM. TES a ,~L..1 uGHi[Cf2_ _ a GnA [ N°° No. i AMAZED ' I[ST GIVEN ^ OTxEn ISPFtIi Y, r ~ I<,. _." DanK-NO rr ' orFl E I ~.-. " .M. r r5 ~ .. 1 0 ., ' !. fTR[[T IIGHTa. ~. -. FLAG ~_ ) S - .,.L ~. .-._ -.~ -. -..._- ' .._.. ~ i En 1 I ' )~"-' E ' _ ~ DIV D[D ~ I NO DEFCCTS ~ (-I TEST REFUSED ' _ i~ l I ~...~.1 ... -_-' _--~ - ~`~ OINF.II IS/f bFYl 'Z -. ... .. ~ , Dili[n l[Penirl pI' TH I,)I'--. ""' % TEST RESUL7a WD~n - I PO fhr:i.,_ NVt[lI4AtIND UiIIO[n 6HAUFARANKL nGE NU, L,C[OISrAT[IIFD OLItt ANH VfD 1BiIVFD CE Iu1[0[p FLOW , .- .HBO .. ~ . i. I .I 1 .:. ... O • .~, F I ! ~ t100 ~ .. tlM - HP)...... rTi ~! V15T41 G0I PICT S 4[ARANK r 4f NO AV[l D IOFRS[PORT PROVtO1Y ~•• DALE i ~ r i N Y D 4. TIC .~.)S.' - + r ~ IN A t, .. r U - T,. . . T { I~r' ~ , r OIa TRIElUT10N: ORIG NAL LGPY raEND TO WASHINGTON STATE PATROL OLYMPIA WASHINGTON DRSM DUPLICATE COPY. LOCAL LAW ENFOIICEM[ IAf.ENCV COPY-TRI LICATE COPY: INVESTIGATOR SCOPY ,1, F~ ,,~~!! MII YR'13r~1~1 .•` :~ ~ , I - a~ •. ~ ~' !i 1, _ %'A 7 ~ '~ R# `~ ~ S I ti• ~ ~ ( a ~. t ~~ - ti ~~ "9:1 $ ry' r~ ~ .i y} Y ~ ~S w ~.~ • S - L.44'Ji ~' • Z:..~l„ tYa 5. •. FF•'n. . - ..:u.. o . ~.o _ _. ~ _ ~r~t.-- _ ,.- ~'i Si 1 F-1`~ ~F= WASHINGTON PAGE DF No. _ POLICE COMPWNi NUMBEq UNIFORM POLICE TRAFFIC COLLISION REPORT -S .- ~ „„.; GATE OFCOLLISWN DAYOF COL11510N THE COUNTY NO / RY NO ~FNWA AY Y T bUN T MOI 2 IUES ] WE , nNfl FW SAT IDSEP DD IIOURI r ~•, ~ ~-~ fi B A,1 ._._ J ~:. ,RURAL .. C NTY `1, ^bTATE RDUTE QCOUNTY ROAD ^qTV bTREET O ApAt & PHEFD( 110UTE OR STflEET CODE SECTION ::~ ' •, `-\\~ i~ + ^OTME0.ISPECIFYI N "- ~ ~~,. ^ CRYOfl TOWN ~ PREFIX EO MLE POST G ~ "'" W /JnLEB o ~ o o e~ t Gl.nla„ 1-'c t .,r ~ - r~' ~ ~~ A : " N O.OFSTREETOR NKiHWAY INIEFIBECIWO YATN. STNEET OR flOAO LL ' RAMP `~ ATA S,_ F ~ ~4-•`~(!I. O ,' ' s .I NON WT ... ._ .~ r ~N.,. .+~FOMlE9 ~Ni80MREFEIiENCE ORCR0595TRE D . ... •.. ; REET M~a WYGCIA~GOR OUSE E E~ECR0.4SbiRi~~~ A~ ..`'~~ ~ ~ ~f ~, . J.. Ylv> ~':.~~.: ~t T. FEET OF. f~l ~ . r 1.?." 1 :: `. I i ~.~ ~ 1 I. L: •. ~ .. ~. I ~+.n:A ~ F : . 1 -~ •:Y ~COWSION INVOLVED: ^VEHICUE~VEHICIE ^VENICLE~BICYQE ^OTHER(WNTEI ^NREflUN NO. KIILED VEARY - - ~ -14 TOTAL NO. I ~"~ QVEM'LtF-0BJECi ^VEHICtE~RR iRNN -..-__. .._...__..._..__. .. ^bTOtEN VEHiCIE NO.IWURED ~~ ~~~.~ ,. OF VEHICLES (=~t„^J ^yENK'IE.PEDEBTRINI ^NONLOWSgN ^MA2AR000b MATERUI ^PPOPERiY DAMAGE ONLY ' .__ ... _..__ .~udM• w ' '..,,,•,OBIELT SiRUCKINAMEOF OBIECTSTRUCKANDOWNE0.4NAME).,. _......'..~~ i. ~::.;:._::_., _LOCADON OF O~SIECT.ST0.UCK eA-, K~~.:+L6'.:_ E$T;DAMAGE, aa_2 ~ -:: 1 ~ w1 ~ ~~ 1 ~^ ^ROADWAY I'.J FEET ^ ^ Q ^ RD EDGE ~ ~'* s h 1 ,~.' DfIVE95 NNAE~ _.'r.: _..,...~~FWST ,;,;,:_• ;.~, AIWDLE OflNEq'b NAME~IAbi FBLST,MIDOLE IIF BICYCUS[,Oq PEDEST[IIAN_CNECyJ -..•: Z,i 'F D ~~ ~~ ~ I ~ 2" 1'~ r~ i,T~ n -~ D~:~ u~r 'ii r I '..tF.. .`J.~. BTREET ADDR _ ~ R. bTREET A~Df_iEb9 A ~.• -_..> > ..L . ~- b 1~.•<• c.vFC Rtf.Fr-w'. ,T '.R. CT•'.._c'..'.~_, a.: :,, _.STATEJI~:± LP CODE .: PNONFNO E CRY.k.... .:..: ..STATE .ava.r. _.: .LP_CODE n,,_R1p1E NO 5f8 r~ra ~~ T• T _ ~,< STAT N . DFYVEiib LICENSE NO ~ - E SEX GATE OF &flTN -, , N ' DR VEHS LICENSE NO ~ ~ STATE EE% DATE OF BWTN ~. •O. (~' t ~~~« ~ M0 ~ DAY VR Q... •••• MO DAY -Y0. }~ ~ R•~.: I: r, >,G rat :-•hT. 7 l: a r~ ~i ;_ ;7 n ONNERb,00`0UPA71QV feint NAME -. ~. :PHONEN 2 ~ DgIVEgb OCCUPATIDN~ _. FRM NAME ~.'~'o pll `_~ c iii f1l \~< ' i I ._ _~_,__<._,..~_.ss.A~.:_P . _. ~ - CODES > 31 W~SS.__ Hl BEAT BELT Ifil EJECTION CODES >IGI Iwunr NI ~' ~ LLASS BEAT BELT Ibl EIECTgN FUTURE OF .. NATURE Y i ": W1UPoE5 - !~ •. NIURIyEEb - .. :-' V ENE OYI'.i. ~1. rT n>~~i• TO ~~•~" .`tr ~.. FROM SCENERY: TO 14. 7 ' YEN. YEAR, MAKEI CMEVI MOOEI.ryMi OVN_; STYLE IT D0.i.ONV.I ~' VEK YENi._ MAKEIMIOGECMEV.)._ MODELID_.WT.NOVN: BTYIE I]DR~CONV~-d-. !- ~ . -~ , - -E;y VEM,~~_ -_'L'UG;PUTE Nn-BTATE~~`1j~WLE}LPWTE HO._BTATE- E-YEN.COLOR;-r-UC PLATE,NO:- STATE-~. TRNIERPWTE NO STATE~~,;,~ I~ ~ t cs~ VEN!CtE IDENFIFICATK)NIA!MBEfl,y.~....;,,~: •,:,:.. , DDDMETFA _~ .. .. _ ~ ;,. .:.. / ~• ..~,,.> C VEHICLE IDENTIFICATI _ NUMB _._ .may.,.... ~ DpOIAETEq ;~E,"' ~S'vl Cj ~ {~ -73(r {~~f.' ~~~lF l %'~ E' .. .. , .._ .C~, '~ :, PEGLRTE0.ED.OWNER-LAST.;;," ''d ~.Fpi4i _. :. w::_. ......:: ~. MIDL%E ;N;'-, REGLttE}1E0 OWNER_ ,,,::,_ ;,_F!nST.,l -'MIDDLE~1 ~~"!' .L'~ni:: O:' ~tl~I-,r n f~CP 1~ O, K~, OF O ER.:r.t.: \( . ~.~.y.. a•~ +11~ .:si~:.~.. L fa. _: .•' ADDf1Ebb OF OWNERI_.~.. :.'~•..,j...~f....: Wrv:i c..2.Y_.::~.TtR A.l.'.~.c'a:1i.~1 ~a:, i,\ ~ I J ~A lJ~ IJ C I I I j~}• 2 NAME AND _,. OF MSU _ ECO OR AGEM ;,, NAME ANDADDRESSOFINGURANCECO ORAGENT-'_ ~ •i • •,- CNARDE..•'.i•"...~.L'.a..^5.+:.c L ..~_n«._ .:'-_._. LRATKNi NO _.., CNNiOE,•. «.•. ATI .~ •~ ,~~ ~'. ENFORCEMEM •-•~:• - .• .__ a.. ~ _ v I dil n I }y~ 'NAME, ADDRESS & INJURIES OF PERSONS INVOLVED SF%~AOE srATUS W T EJECTI `. ~~' NNAE I ~ ~. C ADDRESS: ..P .. HAIPoES bCEMOVDED FROM n - .. > ce. .:i'. A NAME: N. T ADrnESB $; NA + MovcO R r,,. B :LENE BY: . \1f NAME: ' I ~~ ` ADDRESS: N ~ wLME Y _ V Of rcFHE Dr: l :: $" NM1C.. .. $. AoonEey. $. null SC NF RV: _ . .: I II SIATIq ITI SEA T PO SI1gN 1]I YLAIRY CUS9 D', ia°~ocn~ ~ T +.NO BUUm B asAeuNDlwuRr O D A.BCYCLRT R ° D ~ e ) ].OTHERPaiR1011 I ]. DEADA}eCEHf. ]. DEADON ARRNAL B.NW pSAfWNO EVIDCNT7INNRY ~ e . T ra B! e a a Po~?i~T~~ a pED W NaSwTAt T. r o.sIDLE auum E... . ..- . . ____-__ ._. TO I.NOTINSTALLEO I1. NOT EJECTED Y ]. NOT W USE ]. TOTALLY EJECTED ]USED SPAnRNLY EJECTED .UNKNOWN /.UNKNOWNIF B.6EAT BELT FNWRE EJECTED sl _ ' ' _ ''. S t °~ _ .. _. .. . I~i~51ST~ct`,'~,t:~Xa.~..,._:~ . L' ~;'."^'..__..rr'~a... :. .,'. ~ ._Je4L: ,_. l~mw".11 .i '. -.,.S~~d... rza VEHICLE DAMAGEI 11 EACMDD%CHCIE THE NUMBER OF EACH DAMAGED AREA ~ ~~ INSTRUCTIONS: 46H DE MEA OF SEVEREST IMPACT. rwn F"'y ' G.DMW MHOWISI TO SHOW PWNCIP,LL gREC110N pF FORCE. 11 ~P^`pYf~ DAMAGED VEHICLE NO.1 IMSE TMIBbpACEfOq SKE[CIUNO DAMAGE TO TRAILERS, MOTORCYCIfS,ETC. ®/ t 1O ° ~ • Ia.Ha,a 1 DAMAGED VEHICLE N0.2 ~~ Np'H) LI Lys a 'J. pool , ~ e tD.lbw e F tf 1J- 'H 6. Tlunkl (~ fA.HOOI to > 1B. Un0awlMpv - - _) - ;~tJ'e 1', 6e rT.ow%IMIt -_' U la,rrw ts.,~ np~fiT~,s `.LEVLW[Y QF /.M~GE'~I IC{~N ,l 6EVERRY pFONAAGE.IOTMER VEHICLE) $ t' ' tl ~ t° a e IT~„~ 1 qSA DAMAGE G~OTHERM.V. pAM~(JE ~ r EVERITY OF DAMAGE~VEHICLE N0.2-, - ' I " 2 FUNCTION pAM ^gBABNNG DAMAGE 300THERM.V. DAMAGE 1~OLHABUNGDAMAGE 300MERM V. DAMAGE ~ NO DAMAGE 2 FUNCTIONAL DAMAGE NO DAMAGE An 2 ~ TOWEDB ~ ESi.DAMAGE ~ ~ FUNCTIONAL DAMAGE ~ NOpAMAOEA p TOWED BY ~'s~'A ~ ~ _,F,BT.OM1pGE TOWECBY __: EST OAMAG I'r TG Sl 1 Y1C' s 0 ~-^ To c~,-c_ s - ~'~,~/. ;... sl. ~ err ''V psi; ~ y„~„glaG ~FCOUlslor~ ~,~. ~ To , A t 1pEH""' '^ ll_ I DRAW ARROW SHOWIN~ *~ ~` ~'~~ ~ ~ ~~ ~~' - X., W H I -n' NORTN IN CIRCLE ` aal[enwsorFHOAOM ~ I~ k if y calnnals 7t ~ wD`IU~sAinFMpcwolnN,y I`. ~ ~ ,!E , coliwAUCrpN V . I ~I f z rw ~•cr»,axFrowr ~ ~ t t ~t ~ .1 I I ~ ~ - o.D°J°"LCrpaV°'mTlge~E °" ~ _~ 1 ~ " ~- ~ I s~ A.rnaeeeLtl ~ ,w ~ .: M~ A,>uDFFaRE ,~~ - caunw - .. - ~ 1 i .~ ~ ".DESCRIPTION OF IINgCATE WNAT PROBABiY HAPPENEOBEFORE DURING ANDAFTERTNECMSH INCLUDEINFGRMAiION NOTON gAGRAM E.G~ ~~,:~; ~~~F gpp ~,L,~.:, /COLLISION~at gSAR LliY,REWCED VISBIIIY,PE0E5TRIANCLOTHINGCMOq,CONSTRUCTION Oq gEPAIfj WORK ETC.)I~. I~iS ~;",{' •y -,[~,~ ~~ ~~ ~ &~ I ~"7 . Q U h tt _ . _ . ~~~Ub _ I '- { x ~e.U» -. fs? I, / ITi . I ~ JJ',,~~ RR}}ww , VEII. HEADED IIE POSE qR I ~°ONSTREET ORHKiNWA AME OR NO ~ ~~''Y IN ONED flEC11pN SPEED9 VEH LE PM%D ~'{;° „'hr'~ ~ ~•.. ...~ MCREASING DECREASING .. ".__ _- - _ W LEGALLY ^AB VEH -}n' N ~-9-'E W PARED' OGCUPIEO ~~ .. PEG. ~ O ^ ~I~''77 ~. < .. _ IA /: ~ -aril it ~ .. a n~~ ~ PED/gCYCIIST WA9 USING' IJSmEWAD( L.~ w 'fem. ~ , ~W CPWOO IE - - c I' . ~~ ~ '. .; ROAD SURFACE,; WEATHER L'q"" ~CA°~"' ' 1". ~' _ RARE ,HL„`" YT`_^~D"~ ~+ ~'. laic oND c%onD ._L. .,:;~;;;~,., .CONTRIBUTING CIRCUMyST}11s~CE^3, - : LI e 'tDnvDll OrYV[q ..... Iar,ECn~HOR MgI[IL' : ) aYVEn ~f-, ~,'~ ~ WEt~~~„ ~ ~~.. a t ^ aRT hEAn aID„D, „, , ~ ° ~ n`q~ ~,; ~` ~~°' n -o=^-~ -o~ o a ~ D[~E°` o:G ~,'= FL~~I,'~ °AH~E°. ~,--,,}I©y'~'~o-,I ~~.DK..~!{.~• _..^i^._°wW %wwr.o `^a~ pDwnsAT[a FuD.o,D ~ j ^-. ,t¢rEr~Y- .~ V L-J "A~~4 ~~ '~~, ! ~, ~ ~E ^D C7A rJ ~E ~, _ ~eG ~,ML . =~1pu ,~^,P;~• I = ~~ ~' ~_.A;~' I .i r t i `°° L °"e'" ^,o'-l rD`r:°°°' _ (~e~wFC'm~° ^ ^ ~ h'~ ~ ' '. ~I,,, 3'r ~' 4 .. ~ a ~. , _~ .., a ° f-~ ~ ~- 'r-~I11'!F''->~I+ ~ - ~(L`_~~, ~yF~am. a } _ THLn ISrLCfYI IM'ECtfYj O° L^I P ~!+-.~+! {~„\'' I N Y~1 K L1t ~~„( O ~ DM'NO~~' :( J1.' IIFL''--"J"""71717 an°'"°rv,La.or ~ n ~ I ~aFn ^ ~ m~ ~ ~ UGHTCONDI710H$;JpAFRC KONipOL KJ4iE, TYPE OF ROAD, VEHICLE CONDITION . IaHLa%anD IAIXE . « oHe on en%,A) ._ .~ SOBRIETY~._ ^ ~ ow[a DIoNAL :l ~:: I~'~ ~ rcRC« oHE an _^ U o°""IS o.E No. cr`~a.nnrou r' °A~ on srro eDN A1~ ~o+.Lrurt - ~ ~ ___ ~I r rFm roAwO°~oi w ~,. ''~+ ~ ~ ~ ~-` ~ ~ aiaO° t _ ^ MwN f '~-- _~ _ _ ____ i_~. _. _ ~~. " ~.-t._.___.__.1.~1 ~-o ro ~ -- -~°~~o[iLCrrL~ ~a ~ rlmeoewLTY .~.__ a °~ D~ ~ I~ Vn ~~ I ~[,' ~ ~,~~ _ '?~ ,, , DLn,a,srtET ((''~~, ~ aTSt aR MwD !-? e"E°LN wN%.sa wcntn 1 -; .. LuRr` lJ ~ e%m.L n°L~ ~wca ^°^ oA>avnncH TUrco I r~ CHEM. TEST f't~ 1-I ....}. '~G ~...., ..._~ ._.. ._.a _'. s... '. • i I °n'°AL'n DHts ~~ rtnu'w'.wi tt rc.eu oAFl - .. __ ,a.. .. .... ' _- .l.J (~ ~~{ ~ ~ --- I rEeraN[„ oiHniiwvriy----11 _ M0 , ; r[s ncruso °T ' ~\~°i_J ~rnoi° !~Ia~MO,mDt~ r,{,,,,r~omLH~s~•cii _- ~ ren F LAA.K yar t 96 96 TEST RESULTS ~2- rArirW vws tA]uCLau~AICreD tODCF MFwTp AMxuIAHGE _ . ... DrI~..S.4"=R/Qt I t A~ ~ 0.h $# _ f~ O SCr:,~ I}?- b X oL+reaat NN.L ,MrrL wri ~ ._ N ~~_ 1` ~ G ran oer .on. "o+rz or rutonr - .. Arrrrnv ~ SD PtTOu11~ ' ~~~ p, . \ DBITWgIIgNpHpINALC0PY:9EHDT0 WASHINGTON STATE PATRa-GLYMPIA, wASHINnTON YU6W . .. w DUri1CAlE COPY.IOCALLAW ENFONC[MEHf AOENCYB COPY-1gIpLJOATE CCPY:INVESTgAfOR'9 pOPY; . 1=r .. ._ ,.~ 1 .•., sE' „~ Nryry .??*,~~'JPJYl~. ~Y-~.~";. 'NIWG•: ~ ~,~ ~~ 'i f •5 ~~~ ~ ~ ; ~ ~ ~ , ~ ~~"l+y ' " .. .. .fly ~~ 7 ~ ~ ~ - ,~ ... ~•~ 'i' - t ... '~; psi: ~'.+ ~ S2i3Y.., d.;xr, ~',,yrnxu I ^'"$+~f~~.'Y"1 _,w['.. IAu3.. _ . ,~-. . TATE OF WASHINGT(~f~ PAGE DF .. r.~...',."~ ,.~ .u Y ~v2 ..~ :iv._+. CVO. _---_--_~-~ ~ - _ ~ ~ri! :. ~a ;~. •SV~.'t S UNIFORM POLICETRAFFIC COLLISION REPORT ~-: ~ POLICE COMPLA NT IIUMBER ~ w` '~' i11 ~~1 ` :~ , ~Yl. 1i u.4 ~ ,,. ~ ~~a d ~ I A r J. ~~ i d•~"'., I It' x : 0 Al PATE OF COWSION OAY OF COLLISION TIME COUNTY NO. C11Y NO. UP AN IHDfl S Ffll E 6Ai USE 2/ NOURI J URAL WED lUES N SUN D Y •'~, - / ] ~ T ,,, A 2 7' ADM~CL6. PPEFl% ROUTE Ofl 6TREET CODE S PION O Ntt ^STATE ROUTE COUNTY ROAD ^CIIV 6TREET O , L ~ " ~ Z - FF C'~..l~N ^OTHER ISPECIFYI j ED. MI ' CITY OR TOWN W I y ;' L N 6 E ^IN V RAMP DMGIUM DATA S ^ OF- ~~~~~--__ LL 4 - MILE OF 1RE OR HIGHWAY INTEfLSECTWG WITH: bTREET OR ROAD LLO C AME •NO . F . ACCIDENT INTER NON %/iD INTERSELIING SIRE OR AD OR RE CLS. ERENCE CROSS STPEETOEIROAD , I NONINTEE45EG1%%1, MILEAGE . O - .6TREET AND_-------- ~--- 6TREET CODE - _.... - ~ n 6PEL L qN6 USE ' BETWEEN. - -- ~ [+ i ~ 1 ~ - ^ - . [ H] np u6TREE . , ' DLSIANCE ANDDWECTION FPOM REFERENCEORCR05 .... - /^~~' "' ~MILE6 N 6 E W //~~~ L 1t_l- 41L_.. ~ - - "'--- 6EVEPoTY FG-17`! ~ Q ' i. ~ - iEET OF VEHICLE VEHICLE ^VEMICLE~BH:YCLE OTHER IWP TEI ^HITE RUN __NO. KILLED VEHICLE / ^ '. Ysa '~ ~ ke NO.INJURED COLU610NINVOLVED: VfwLLE~OBJECT ^VEHICLE~RRTRAIN _ __ ^STOLEN ^PPOPERTY DAMAGEONLY ^MAZAflD0U6 MATER AI' NO ~ ~ a~ . , I . TOTAL VEHICLE~PEOESTPIAN ^NON COLLI610N __ E6T DAMAGE OF VEHICLES L.~-~ .-,. L OF OBJECT SIRHLK (k~ S P WANE OF OBIELT SIPUCKANOOWNER6 NAME1 .; , -. 4TC~ F~/Iy 14Pr OBJECT 6TRUCK P -~ -. 't; OE S A FEET ^ / I POLL f F~G~V L. l7/'LI /V OL IF BICYCL151 OH RIAN CHECKI^ FIRST MIDDLE 6 F ~ ~~ T I .- pgNEA9 NAME'tAST .. FIRST :.'. ODLE ORNER6 NAME~LA O ~ ~~ .,F.b~K ~~ ~f p .. R - 6TREET ADDnE56 - .. .... •~: ... Ya R 6TR ET ADO SS ~.• ~ I ' ~ V ~t . YI .. 6TATE .....:... 21P LODE... - .PHONE U J ~/ S ~~ ~ 1 E LRY ~. PHONE NO C DE i ,~, . . O E LRY STATE - ;. ZIP R 1 . R SI33 OF 61RTN AT ~~ r E Si/IlE SE% DALE OF BIR1N N . ORNEP6 LICENSE NO... ... STATE SE%. P MO.' DAV VR. 'y>,~d ~ . N E 6 NO. O DAV YR. O, o a Z ~ ~~ ~ . PHONE NO. ~ pRNEfl6000UPAIgN FIRMNAME EN ~~~ #'j #' ' D ORNERS OLL PA ION FWM NAME s / 161 EJECTION la l SEAT BELi~~_ WU Y IDI ELECTION ~~~ CODES 71]I CL~55- J I~1 6EAT BELT- ' CODES > 1]L C USS- NATURE F NATURE OF , `. ~ IwURIE6 - URIES F~l. D iR MVED Tp E RV' O $` - Y I ~ S SCEN T STYLE I2 DNCONV.1 VEH YEAR MAKE (DODGE{HEVI MODEL IDART~NpVN STYLEI2 DR{ONVJ IRON 6LFNE BV: _ f ~ VA Y ' , I VEH. vEA11 MANE IppppE{HEVI MOOELIO RT~N I yD2 ~ S~c ,' ., ,L v 71 M~2c.,.~t TE E VEN.COLOR 11L. PLATE NO. 6TATE liWlEfl PLATE NO. STATE S . R ,. - E VEH. .PLATE NO. STATE 1RMLER PUTE NO. 6TA ~ ~ ti N i Q N W~ I ODOMETER .. C - VEHICLE IDENTIFICAIJ N NUMtl ..... ... . .. ..... ' ..:... ~. DOMEIER ~~-~ • ~ •. -1, ~ • `~ _ . (~`'., V LE NIF ATION NUMBER... .....' .. ... .. MIDDLE 1Z 1~1~~~~7C1~ E . TERED OWNER-LAST FIRST E + ~ y . . REG STEflED VAVEA-LA51 FIRST MIDDLE REGIS I } IowE~s ~n N .. - . t .v . . ADME56 OF OWNER .. . : O., . • ~ r .{N ~ AODRE59 OF.OWNER ,.~.. ~ 2 g f1 1 1 ~" N :c ~ NAME AVD ADDRESS Of WSURANLECO Ofl AGEw ~ " ~ 62b ~~ . _ NAME AND ADdlE65 FWSU ECO.OR AGENT Lr1 knOWN I ATI ., ` CHARGE. CITATION NO ENFORLEN.EM ~ ' , CH ACTION ~" '. NAME, ADDRESS & INJURIES OF PERSONSINVOLVED COOE6 sE% AGE , STAIDS R 2 w /,. T .S EJECT ~"NNN 1 C NAME: ~ C ' AOORESS. REMOVEUf HOM TO 1 P N~u~ OF SCENE BY I". A NAME: - N ADDRESS. $ .uGwES {tyt ADp11E]6 ~ R TO E A T SLFN Y N I. t4i S NAME: 8 AOOFlE64 TO i E $' Y , ~ scEN PuN IL INJUnVCU53 MI SEAT DCLT I5I EJECTION ~ I1161A1U3 I216fAl ppylgN HO NNRY 5015ADLIND IIUI%f/ 1NDT WDTALLCO d NON'019AOLW 2 NOf III USE INOTGIELIED j ~ J I ~ C t PASNNO[R 1 2 Df D 16LEHE OOICR PO6RION ~. S DEAD 011 RNVAL I[NO[Nl71NJUM ] U5[0 UNVNOWII ) 1A1Y I µ RIIKLV [J[CTLD P UNKNVN A ~ L'I ~ ~ • O D -~ . - 1`POSGIilyEW E ] i RILYCIIti '-•e lUU,~I~ip~CYCI.EI /DIEDWH061'ffAL...- xNOO''MM// ?6EA10[L1 iARURE 601H[R -" E ] J ,~_-- = EJECTED ~~ Y ~._I . ~Y E _Y . eLMlNE56 _ _.._ -. ~• - M~ -71c. ~. ~ 1 ~r'°R'°T .1;: ., :~}I"'~~~ ~ .~" ~1~`::I~iS ~ ' .", .d°~'~~«.,; t.' A l J r7 h 1 i , ;I y;, j'~, :i~ ->l r.. '«ua ~ ~ ~ ~ _ ,~ ~~ - ~.~. ti ~~ I '. sf y C n~~~V~"`Ofej"~"~~V''"'-"°iizl"~'h~M17T'iiCTi'N]k~G'~i~ ~ HE"7dASYtE r"i`Oi CfYLTAT:t~i"li`2D'NIf~.1:i ~ .•.•~•_ IY==1 0C = x SHADE AREA OF GEVEREST IMPACT ,: p. t ~' I P 'F ~/i UCTIONS: ] DRAW AflflOW151 TO SHOW PR NCIPAL DIRECTION OF FORCE Q/ ` ` 3 ~' DAMAGED VEHICLE N 07 ] Nem IUS[TNI56PACEfOP SKfT<MINGOwMAOE TO TRAILERS.MOTOR<YCLFS.ETC.I DAMAGED VEHICLE N O. Y ] 1 L~ ~ _ 4Au I I 9 . 4.[ •3•• 15 UIMnn. I w, ~ f_~'" a `.'~r~ 5 T~~ ~ T 1; ~ OITY OF OAMAGE'VEM CEE NO.1 ISABLING DAMAGE ] O OTHER M V.OwM AGF ~ E ERITV OF DAMAGE. IOTXFR MV I ~ OISABL NG DAMAGE pp LEI GF N [FpDNO MAC ~ c D 10 MAGE E SEVERITY OF Ow4A0F VEN CLE NOa pp O SABL NG DAMAGE I p OTHER M V. °AMAGE x ^ FuncTIONA}DwMACE ~ ^ ° f Ary T ~' r I ~'~"j ~ xo DAMAGE uxcn NwLDw4wcE A GE a u A EST O MAGI A E M T D GE AG ( . ' ~ .. ,I D TOW~O BY ~ MA 1 G ES ti' ^ p 1 10`i 1IV{•1L LILV~ 1700 T [ O S T ES . OWED BY O : ; [~ ~, ~ . , ~ .~ - -r ., _ ,« u " ~ ~ DEACRAM OF COLLISION.. I mex[n :' xe~Dw n .r[AFUaFf i I I DRAW ARROW SHOWING I ~ I .-.-I_-_ _- _I _ _r _ _~~_~_I .. .- ._ . _; _- .. i _.'_`_Il~ . { NURTH IN CIRCLE ~ I ~I ~I ` ~ W~ ~.; - a ~ ~ , q , K , ~ :,D[na;.NF T DN,ar. aD .. DDN,RDL[ ~ I C r`y I ti~ tc,z.`~ --~ - ~ ~ :_ I ~ {~_ I E'~ { I ~ I-~ I .. I t A ~, ~ ~~ . ~ ~ e. „~o; 73 ia~cno ~ - ~ ~ I _ ~ .. T i ~..-, -r _....r I I ~_. I T I I ~ r ' 6.[«~ ~_ °~- [~ . s aI I ~ f , . I_ I I .i I I __ I ' . I _I_ ~ 1 7 . f { ..-.-~ .-. ! q I I ~u~ •_'"" e, [[.D NTD .] SNDWYFNKL[(FD[„N.NDx .,. NSA, M. T. --~ _ y. ._ _.,- _ _ I _ ~ 1 r.. I 1 =""` _ ~ I 1 • I I S I - I ~ - I . _ ~-1 ~~ ' ~~I;.d"ca"b.;Da4R . _ _ ~ i r 23et.(.F.:i_ l i'--G~~~-; I~! I _ l(e'3+l IT { I L_ P K. Lcf r--t! L i Lr-c .~~ I ''< 1 R~ f 1 mil- .L ~~ ~* ~ a ~ '+. 1 N OF IP I I MATE wM B n ED F o E DURING AND AFTE THE [RASN I C INFORMAT ON OIAG EG ORIVER ~ ... I ~' ! ' ~^T~.}.A ^ . DESCR T O COLLISION , . DISABILITY,RF000EUV 50 LITY [STR LOTNINGCOLOR,CONSTRUCTIONOP gEPAIR WORK,E CI - ~ ANC / 10„p`,~, ~' s'; y A ~i ' G uLl," 'ltd l E,.~~S TT2A ~lln IJ g _ FIF~{Ic~ Kd•. t..,l/.Ckn v :~_~ _~C 1.t 3-~ ~o ~ci~xl 1 _ k, ^'r ' ' ~ ~ ' ~ T ~ ~ ~ J.- a , ' Y~ , L f ~2civ_cli.[ r}~.- T t l.ct..>t.c _ C-~~' nc_ti.~ -- .._ -' (~(~wc~C._5=-fi ~. _ ~? , M •, S _ A . ------ - -- - _~2~~~t' L ~ __ S'trCC~.7-~ ~ 1T- L,i _ SwC Lr ~ To ~`~,I SS -r~---U L~ ri~'g ~ l[+-E (_ h ... `~ -. . .___ _._. __ ~ 4 L n - _.- __.___.. __-___- - -~- -.-_ _ _ ___ of 5 P N EEFOR CO LISION - ~ ~y ~ r ,, ~iV t ~ ~ OSITIO ~H.e HEADED W E INCNEn15 NG DECREASING .- HD_ ON Si EET ORM 6Mw vNAMEO DNE DwF CT ON rosT, I ggKED ~ ^ OC ID 1 } ~. T-if . ~ ~~ ]>.~ I ED 1 ~ . ~ N ALD c -- - - ]"-7 A 1 I On°MS~na _ .. « f o _ Td IL W I cn j 5 E ATEO 1 I C `~ ~.:. , - 1 D CCL STWASUSING I SIOFWA ' LK C. IWA ... SMOULDER CONTRIBU 6 OSSwA K o LJCR l ICR JBC TING CIRCUMSTANCESSSW TE IO RWEP/YEN CLF Att x3 9 ~{ I ROAD SURFACE CHICK ONEI WXATHER ECK ON C 1 HECK DNE OR MOREI . ~; _. f, , . 1 .x veMKt[~_IuusDnn[ ~ • y C ' ~, 1 nIVER ~ x0.3 r~l LOBBY ~ }SST °NOF] ~ j U 'R IN LUFNCE OF III i w~{pNOLF DRIOVEj n i -I FOLLOW NG I Ixl^f NY[} ~ - 1 I ~ Or 5 EG R°ED wAR I°NISIG -II C I C0 ° ST A G T AHEAD I ix ~I A EPT KING L~J lJ ND PwS51NG V ~ « ql+ •. , 3 '~ „.. ~ T. r ,l ~! _ E ~]~ 0 , ] 1 ' _ING ]~ OwING -- a ~~ORUGS_FLUENCEO ~~]~ E%CEEO GS TED _u_ YE[ E G _ g ~_I~ TO _I 1'I ~y_ - - wRENTLY ~ C7 n,gkEFF PAR I l ICI KxG I_J L~1 }OCryJ14N UV I~7 '-!! fI-I]C_I MIGHIT TURN I 'A~ I G ~ ! " LEFT TUgI. . i. , ;~ r ~ ~~ ICI A 1 ~ FOG _ ~ ~ Sq, S.EE° r I ~ P L n r -f-" UTURN ~~ r _ rJ f . N SL ' I DID NT RAV G .1l=LTa _ O 05 EG II_'I SLOWING Y , ~"; ,,~~jj,, W ~.,~~ ~ ~ . .__ 'ISPFCIFYI OTMF OT F IS CF 1 r ~ IM 0 F C S I.. Pg53INC. ~( 05 EG D I~ I SGNIS GNAL I- OT F ECf I C- I-! 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PPEFD( I AEiLLOD,E i SECTION I I `:. ..C:•. ~, ^DTHER ISPELIFYI CRY Ofl TOWN N PNEFIX EO J~J ~ ~V'rr 'K ~ L ' N n E W ^~ ( ~ W ~ .. h fit, 'a. 1 T ~ ~. ~Y 1' C L ... ?MMES ^ ^ ^ ^ OF 1 J -a ..'1 LL ' i Y ~ ~ .yp V [' Y A ~ :. NAME.B NO.OFS?fl IGHWAY .+., ~ o .. INIERSECTWG WITH: STREE70ii ROAD iJ ~ LL o T~.: nAMP _ DIADRMI DATA 1 f' r.+',~,`'~z~`~"'°T~t` ~is >~i , :T : ®N - ~ Is~i71r7 ~-.~ ~ - i.. ~ ~ - ~ `7 ~ r I - _ 3.. ~<'Y -rt,'!Y'f:~i.;~ r'J,~ fist<i~KV.*7 ` I ~ O - NDNINTERSEGTpN_ - ACCIDENT I MLEAGE NTER %fiD CIS_ - IMERSECTWO 6TR f10AD Ofi NFF. EPE~ Cfl/'!18i Dfl.Df1M ' I N BETWEEN .. STREET ANp ..... . ... STREET NDE . ' 1 r { pl$LNLCEOM ~CTpNFJ. L; eOM EnEFEL1E11CEUR CfVOSS RE : Mxm~THS, SPELULCOf%NG USE >fyf ~ rte. rsf t ~' ` ~' "~ FEET a " y ~ ~ I,. ~ 1^~D i ` ... .f,S~ fS ^VEHICIE•VEHICLE ^VEHICLE~WCYLLE ^DTHEfl IWwTEI ^HR6flUN SEVEAIry - COLLISION INVOLVED: _ NO NAI.ED TOTALNO. ^VEMICLE-0RIECT ^VEHILLEAfl TiWN .. ^STGIENYEHICLE NO DIIUlIED ..:, ~ . 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OTWEIiS OCCUPATION.~~ FWANAME.,,L:~- ' .~ . ~ 7 Ibl EJECTION ~ CODES > IBI ~~ (Q SEATpELT Ibl EJECTION ' CODES > ISI CUSJ HI SEAT enT `.~ J NATUREOf~.. iT '_4 f' !Ir/~~ %UUPoE9 ~~ iWUWRES .~~ . - . SCENE Ffr: TO - RFMOyED FROM SCENE Dr: TO VEN,TEN) MANE IDDDGEtiI!EYA. MODELNNR:NOVN...., STYlE 12 DRCp1V.1 .: :.. ~. VEILYEAR_„ MAI(E(DDDGECHEVJ,~~ MODELIDART;NOV(0,,.~, E'[YlE(301YCDNV~..~'.. , - r E VEH.. _ lF. MTE NO: .. BTATE_ .+ TTIIJlE11 PLATE NO.- ST TE . ,.~~._._ E ' VEH _COLOfl, ;~ LIC :PLATE NO.. :. STATE -.. TM%EII IM1E N0~. 8TATE ' Ir :: C . I AIETEN ~ 1 RIFILA N NJMBER : ~ ' C VEIIICLE IpENTITICATI !1 NUMB ODOMELEfl ~L?. nx ia W. i ....t>r. :~.c. L , _ y y ~ .Y.f:;y E` .. E . .: RE66TERED CM1ER' LAST .:. FTfiST: ,::,, -1 WOOIE .. ', PEOU`TEflED OWNEIT-. ,: FE15T .,...e.',' .... WDDIE. N' °` AD(%IES9 WNER r ./~.~, ... ,,' ADDRESS OF,OWNETT,.. ._. ...n.. ._~. ,<. a. .bra.... ,..._. ,( AND OFINSURANCE_CxO., AOEM~..~. ..:,. ..... .~ NAMEANDADDRE590F WSURANCECO:OR AGENT . ' -..,~...:. ;a.._.....:.,. ......,..'. ".:..... . Al10N ND. .._. ENFORCEMEM~ ACTION ~ . ~~. :..~ •. a::t-..':.. .. ...,.',. ~1'. , . GA. ~... __.... T . •'. ADDRESS & INJURIES OF PERSONS INVOLVED ME N COOE9 1 = D 1 Q , •, A aEx naE STATUS "„~,,, ~,,, ,° T EJECT. L. NAME ' C ' Apg1E.53: ____ ~ I1 .. p I REMOVED FPOM HAIU Of .uunES~ I scENE Dv: TO • N NAME: .____,_ :T:' ADpIf.11'. ' S ILLI S' SLFHE NY' R TO M/' NAME:' lad: AppZSS: T.. H'' xPNE nr: TO E : g ~ ;1 . .8 ' rnalESt C '~ E '. 8' .aM r FNEpr: To .. .. ' ' (1L6TATW ITIbFAT WSR%%L IA~LALRr CI/ V I f O aPEaaiwia 1 r ~ . o ~ V a:a AAp T°iP1AYBUNE i ~ K o o°N e'.HON O~AM10cA7 xN°U1M' I i.roi rouse ED s:?mAUrF~.lecrED P YF ~D ~ E be:~ OtOFICYW ~ ~ ~ l& 1S 109fIlOF! . Hw9P ir ~ T.VOS4RE HMIY LUNNNOYIII 6 SEAT DELT FNWIE NNOWN L W ELECTED .. . O ~ 4 I .. o. - ~ ~ J ~ ,Di. - ~ t. _ y ` ~ ;. ;. ,. r, fg ~ nr ~~` .. ~ `z (I i, t+' U y 1,' L rl v a ~~ . , A ~ ~ J" (} ~ ' L ~tS r ~ J ~ ~,t I'~ .I. f 1 `. 06' 1~ ;1 ~~ f A i ~ t ;7 t w ~ ;NN yy~~ dT~}' ~ , 1 ~~ 1 ~F-~YDMD r.l.~r ~. ~~.~ , . ri 1 ~:s .. e9~5 ~~ , ~# r ~, ~~ ra.,^~ 7 J l ~ ~. ~ ~~ C 4La, ~ ,. A i ,.'.~3+r~ 4 2.511ADE ANEA OF SEVEflEST IMPACT. ~r ® 1 /' INSTRUCTIONS: ~ - 10MW MROWISI TOSNOW PNNCPK pNECTONOFfCNGE MOTOF4YCLEA ETCI DAMAGED VEHICLE N0.2 R 51(ETCIeNG DAMAOETO TFiArtEri9 , DAMAGED VEHICLE NO.1 NSETWSSPACEFO ISMroC G.IboE _ ~ ,-•I f I aI . s 1~POd e ( If ~ 6~ ~ Ii TVIM .. Imo- ~ 10 N I] l :. .. .... ~{'.. ~ 1:9U! 16. k\ t 10.UMwrartbOn ' ~ / ~/ ~-~+~~`~ ~ - 1f , 10. UMaunlnee A./I.V~J ~'OlIN7r If I 11 1e . • I1.OMUn I 1T ~ 1 D 1T OVSnm t L - . SEVEwtt OF AGE VEHA;lEN4. SEVEwtt OF OAMAOE.IOTHEn VEWCIEI SEVFNtt OF DAMAGE:VEIIICIENO.I 1 pE9ABUNG DAMAGE OTHEn M.V.OAM~ IOpSAWNO DAMAGE SQOTHEH M.V. DAMAGE tODlsAeuNa DAAAAOE '- SOOTNERM.V. DAMAGE 1 NNCTgDALDNAAtiE :. t NO DAMAGE 2 NNCr10NALDAMAOE • NODAMAGE -- 2 NNCTIONALDAMAGE • NG DAMAGE ~ EST. DAMADEL TOWED BY EST.DAMAOE TOWED BY A". F],UAI.IAGE TowEDer /a< ~. ~ _ _QR11 L_4:!St.3N,:; '++f . T .. DRANORTH ION CIRCLE NO C .. Y.IOWY rUTDIRe •. M1]MA'A - - _ yy PFO~FSDWC 11`.~.a ~ Y~I C r ~ I ~ .: ~ ~c°N w1N oln ~~ '• ~ ~ ` _ ` WIAlAV1EAIP.CCMrIClA ~ ~ ~ ~~~ .. _ '.. ~ _ •. ' r - ~_ __ F.b. e rCl ' • IA lMIGrePnOeMAlIVwr OF n"4.~ / I : ' MPACT. ' erONVFIFILPQF-smWM mfLfPDffref6 ACT. ' ~ .: ~ J. '. _ ~ _ ~ A~ P1IVBABIE OEPpE i~ y ~ - ~ AM)ARD - I I ~ -~rDESCHIPTIONOF'~'F ~~,.'% '~ ~ Y ~ IWDIGTEY/ n ABM1^Y IUT EDU PNOBABL NE CEDV~sIDlurr PEne ODE mn FOfl uN EW Cw NGANDAFTERTHEC rriNa caLOrtcaNSmu MSIIINCW mION ON nE DEWFOi1 PAU+wa MAT uc ION Erc. NOTONWAOPAM,E6OM'ER 1 ...1~: ;', ~: „4. COLLISION ~~ ,.~ ~'I C«: . 01S . °~,~ ~ - '~' ti~d~l ti, 6 f~os-n~~s ,~4 ~ ,. 6,,~ts,~ ~,c 1 ~o~~~.: t l I-A7 mss? -o. A.-r,~. a c r. , ,.~ .. ~~ . 1 IVIN5_-fu ~1)iT moo/ C.~AC UL .~1o 5i'E.o_LSS~~ ,--. - ~ ~ _. ._ .,_ 1 - .... «vlr. ~. ,.,,'P ITT D R =t4Y .....M.«....y" Gy:•„t:'43+ „z-..•°•,.-~w~• ~~ Owl cE¶ON Peer SPEEDS VElECJ1 ~Y WASVEH E sv D Y - - , PAHIfED OCCUPIE NAME OR NO. ONSTREETOIiMpI1WA VFN. HEADED MttE POSTd0. Hp. WCPEASINO DECPEASIt10 _ .. ... _ ._ - - ' _ - • E II~~''... ~ n .j~`. !5 .5 YES NO YE9' !q ~ 1 _ t ~ 1 n I ~ . . ^ ~ ~ __ ~ ~ on Pxuiwe ~ a ~WEIirDe ~ I rrf inOtA D .. PE0. cnosaw ~ ^ f MAN~m ~~,A~GD ~D ~N„ : f PEDADICYCUST WAS USPq sLUULn TnwfwAax -OWN re ~ ^ a ^ DPo,FAM1fl,CtE AD,IDN] ';.ROAD SUPFACEy- •,;~~~WFATMER ,~. _,,,, .,.:_:.;,:y:. ;CONTRIBUTING CIRCUMSTANCES,: _:- ' nxcAwO Id1ECK wD N%IlEar wEw MOPq ~'.. Wla~ DN UOnEI :. rnrTn aa.Tn amrA .._ ~~ aTr°O°"waIrtANFAn DAA~Dr,MW ~~ ~. LEDF oTQ ~ ~ Y ^ a ~ = :^_^ .t~P ,=, ~. , ~~ moo - - ~O.~N1LY `-- ~ ~I ^T^ 3~ ^_^ ~WiWEACE OF ^en ,~ DrtU- ro: 4 F rm f-l P'e'Og -~ • ' ~ , ^ ^1!Q_IU noN L ~.Y r~ ^ a^ eNOw a (~~~ saww f ^ ..n~EPnwEpNO•rsTA . .a ~p~m~c Eaum. ^^~. u~~ ! F -_ ~ ^ eEfAFT'Ee sPED^'eE O; I^-ILoI~ _~ ^ ^ ~- A L ~ d .. _ ~ -+ omwE°a° L ~-y f ow~r aE rww ' a L_^ ~ Q e ^ - nonmo a _- o e A ~ N ~ L oiKA ~ , amulsvee+n ~ Amw IJ"l_j °' LJ' ^ ra I um ^ r ~ °DPP~D F - ~war01`FDa D'TD„S10N'A LIDFRCONDITIONS =~Tfl~FAC. CONTRDI;;; w~ xTYPE OF ROAD 'YEHICLECONDITION,. i~,ti,,,SOBRIETY ,ce% ~e^ ~ a«~"" , vDaaE , AXO[ aNn na f wl.ar. KHEtn w=on MDDG vu«u D~ an t ^ BIDt1A1f ~ pEwAr wrt[q ^ _ ^ ~'= N I ~ ^11^ ~,Iw ~~ ~ ~i^ ~ ~ ~ ~ - _ ~ __. PAVAI ~-~ `-- -~ -I 4EDD.IDIF ,Fn•.. ° ------ - era.n ' _ . J....l=^ ~'' . !__ ~_L-J--°r~8°M°°TM uwrfaoN~' . 6 J = L. l~ I . • .. ^ ~e _... _~ .,- I . . _ CHEM. TEST Q ^ Ia°MtnaarE~ I_,1°^ eTIDxeA ^°^ iu WAiAifsER ^e^ ~ aa~NerueFD I ra f ... .... _ _ -~ OTME1119PECDi1 ~ ' 1FIfrOAEN ~ OPrCEA.• F~Gt MI ~ . LI_YP4NifL___ ~._ -' 1 ~' ~ • erKRUDHIe _ r i ~t~ / / +~ 1 1 ~. ~~ I ~[N ( "1 ~I Uf ~, pND[D ^ O tO rf n r[T R[IWED f^r ) ^ '. - ~ __,___ --- T ` :• I _ _ D(A ePE[Irvl 1 I~ . D ~li^T _._._ ... ne~~-~~ ,a^uMfwf _.__ -., ...__ % %-NEST RESULT tAAt Z L ._ . fMM~t - OrOef r . l7, l~n H f ~ ~' ~J ~ ~ ... . .. P0.Lt CK ., TOILE wvrt .._ ule an ~l ~! ~d ' ~ 7~ ~ ! 7. ?- ~ =PIe AI.WE - ,~ „d =: ;,,, wn e; X ~ N~ ~~.~~~~T ~- 7 ~ - G So.~ u.ronDDr o= wreawPwr , AmmTner. .._. ... .. , paTwnuraN~ oreaPULCw.: a.w I.,..~P.W..,.P.o~.~ ~..,.....- ..............._...._. ___._ DI1PU(.AIE COPY:tDCAL UWENFONCENEHT A0E11CYD CC/P1'-TwPUCATE COPY:INVESiIGATOR'SCOPY ~~~1 ~ ` ~:v4 r ~ <: a~da' ~ 6 h! ry y 1 I \ t s "1 t w ~ "r i if ly I ~ is f r `I ~ ~ 1 w '{ • EF }I i, t T) i.~ r 1~. ~~ .; ~r- } Y , .1 w. f . x '~. 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MIDOL ~ , T '- 'ROUTE NO. N 80% NO. /N ~= ~ ~ /'L /r3'L r5S' LL G G1,g ~1~J9~'/' /~-~ IT TATE / ~ = C E E D ft loxi+nx xa~ TNExT ADOHEBS UTE NO ND BOX NO - _ ! J ~iV (yE=Zc$ C-r9 ! ~/Gc 7 R V 5000UPAT UN ~/,'c'1/ 2-Z"s~' ITV 5 T - E ~ >: OOE O VEHS OCCUPATION'S UH v E Hp E N--yH „ ET A T SE aTF OF OIR ~ ~ > ~+ 1 /~ U /ICI /r~~ ~ /IL c - N . IH la~GG .~' u r~ ~ x 3 DPIVEH> LICENSE OIUMBF.'H .. .. !E Ex D E- pjH 'H E; I ae rx: M .-nV -. 7 FT hSC/iZ CNS A M DEL' nil / ~ pODY STYLE 12 x.l .-~ ~~/ rx ' %E . OO 1 I E OV. TYLE 2 U STATE LATE NO- STATE ~" G - - ~ e ~K ~ C/r-[.- -- -- ICENSE P ATE NO, qTE TH L ~6TA E VEHICLE IDENTIFICATION O ' 119A9, xoe[aa a xewtxl ODOMETER u ae,eU ~; ~~~Il- 2.3 you ~ ~ ~/ RG 'I r : yEHICLE (DENT ICATIOII NO.; , ,~ 11988 a ets & x[wa ODOMf'TERI [L ER .D O i E ^Il.,anirnaT-H~no,[ x,u+l ;~ OHIV EHS LICENSE NO. R~GISTE DOWNER luxT nx]r-x RnLC "x,H[ ~.. ORIV EHS LICENSE ' U R O „~, :, ,x .:,. TE O p R N A L~II ~~~~ E G ~Lr~~ /~l'il-y/C , - J y ^ ~~ ~ .. ODRES rL B T N ,v~/LF~O+jM E ''.. ~ T I "- PAR UF,VEHICLE DANAGEO , n LIABILITY INSURANCE IPJFORMAcION I V O~o LE NO. 1 - Au a a LI Y ANCE - _ GO EF.N FOiTV CCO O YOU C YE$ ~ NO A OD S P T E D I I il L (. S ~Ys f u C ~, ~'~ JAJvTz /~ E~ LI LITy URANCE p NY - r`" ~c~t;)r 7jzss' M . J,+~ p ~ ~p /~ J ~ C-/Zt-~,. J. .K, Y CjC C E J ~rrlie> >'~' Sl.=7r77.Lc= aiA B T PO MU E .,. ~ rP- 9s7tr ST NJURYr.F k 'AGE //r1 I~ // ~~ vL+n G y~ ,.i NAME ~7~ L_C-. f~~/C-4L~ Y T+~` ? DR 95 /'/~L L L/JLL 1/(~IL7 La 5X /V~1 . 2ND1 JU 1 n N ..... .4 A... -._ ~ - G ~ ~J A HE % ~ R ;gin ~~ P~.n[. - ~t ~~.~~.1.~;/ [!] f + o+ xu [ o~q Ix ex.[ xaen eainx. - - - ~~ ~^ TAT p F.N REO NiIRaT ONE THA AP 1 ...1 4 ~ '[-* - xo 1 LHIGL LL Nr+ Y ~ / Ix e. ~ ~((~ST U- I xr RK.F 5 ONET PLE l I /Ly e ~ nC LL Fo( lu Son -. .~ NO / 1 5 ^ ~ 7^ ~ lJ ' 5 1 TI U l C R LL l J ^ Q ..... ^ tttt ~~~~ 6 ~ l \I „e 1 \` ~\ ~ V x ,.OE CR BE. pEL W WHA! MAPPC ED IREFE R TO VFH CLES U DERI v~lev;i/C ..-f~-~~!'ifrf -~f~ 3?J,.rlr/~~ _: xtx [.[x [x [.a ,Hn 9Ix[[. nx e. ,x..aa n. ,n.Pw . -,.~ Q.- ~, 7 la.xla,nn w,. r iT .S~o. _ _ ?- -- ~L~Cj~~ ~ st?• ?- ---_- ------------- ~ - ---- -_ 4.-_ - ' -- _ _ ~ .~~" . 't4{~- /Le ~j1lj / -_C,9~~ _. ~,C Jli/1E*2j_ I -.--- ~ _ . v __ VCi11CLE5 f'U5I TIONSDi3C1'UltE COLLISION - --- --- inyrsr cgrco Br Vl [ 1 PAF Npl C[ IIIIGII\VAY NAVF. OR NO Ix nra ,a +u vN IAN !'~ I''~ IYO ~.~ [ O I-J I 1-J rn HCv ~e.;'~~ `~'c~.:,ci n ^ - ~ : al+ a „n Ixa,l e Na ~~,Jlk~n c,~:; ~'~,,_ ~ . 1 ,,, I,~ 1 l I I [J 1 1 ~ ^ ~ ~ _ , a~"'-~"```nJ-C! .x,n.+ U II [l f~ a P,D..r,RI N -ClOl~f_lf~O _ - _ ! --tr ,, rD - .,': ,.. rini r aue ap ~ P[J o sn. _ - '[-~=--r r arl GI:~_:~,rP a[ It ~Cle• Ii.. FF WE' j~•i~' , ~ Q - HI GONDI iIOIIb T CO L ) ^,I > I [,"J IIAV LICNT I 11! r 7 ~ I 1 0 L r ~ n i01 D BTHA G li AI rA0 Y .I 1 III O ) 1 UAWN I 1 ) i -1 I GII [..1 ) [ 1 w -T >I 1 NO\V t D I. 1 [ 1 -~'S,I~Y :4f .. IC I~l) ~l D W rCI > [ .1 DVI.11 lA KING AND !•AG^.ING I , r I , 4 I I ] I~ I MAKING IIIGN, T11IIN I f I a DW f 1 G [ 1 I" i 1 L I 1 G i; l (-1 E f I " t I ( - _ n I l• f 1 - (I [.1 AIA KI nlr LFrT TNRN " _ i [: I I L7 ;~C[ .a.,. ~~ l I I~ ,rl. f I f ] I I 4 ~d:"o .1 [IA%IND N.rBRN [:~ •• f 1 A 4 [ J Ir I [ ; ! ~.I I+, ;,I,.,I [a A ~~~, D G TaL o , y! L..U.. ~.. ,.,, i..l I ~~ I..I to ~ -r ~~'Ll t rGD ,A!'IG y% C~ ^~ ~C E:1L1 f i l Ll - J./ / ! . , [ ~ I ! I lIE l _- ~ hr ~~~,.v err-_'*~i:,":~,~-ry.,£~^B~i'~t . , ,","°! , r ~i4~'[" ~. ~I `. - ~a r ' c ~ r - - - r.: ~m~' . ~' .. ~ I -...a a-.. _,....,._. .. ~. , ,~,. w .,. _._~___.~....:...~» .. - t _ t, S T61~• ~ fl ~ ~/ ~ S ~3 ! I11 G T t! N .GE i -1 ~l t3 ueFeDMILAINr u FEw ° >x a TY~~1 UNIFORM POLICE TRAFFIC COLLISION REPORT ~ 4 Yan ., a S a' yY f rir~ '~ sir 1 ~ 3. E~ ~~ . .:y y y N S • ~ , ~ ~~ ~~re~ E~ ~ -F.~i '! ~ ~.~ • a `~ ~~~ ~, ~. t t ~~ r T ~ i . . ~!'ceFbMl9d<. 3 o • I s ~s,s .~ E ATE OF LOLL 51 P ~JP. {)PY ~ LL SIGN I 5 F)I fl ' /` Af i IU~E i~ ~uAI J DN iYNP Tv NO }(/vn ~ a UMIfAFY • '~ N[Y ~' ^ ^SrAfe HOUiE uHfY RUAp ~CITV STwEEi CO W AOMC PNFP LS O E RST .ET C°°! SFR' G ~~ ~~ G +t-'°~•1~ ~OTMFfl 1YPECIFYI y B J /'7 ~ W c E N r~;~s~o_- SM __ ~ ILES o ~ n a °~ W ~ EO. Ilf 103'f p, o~zJ " 7 ~A~ HAMEa NO.O EE b~ IO?d lz /~12p~ r C a IHTERSlCTINO WITN.SiREETORwOw LL o DIAGA M -, O HON InTEPSECTION ~~~ R ~ NO X~RO iEfaFCTING T FE w OAD OR fEAf HCE 5 EET OR RO+ N SETVJF.En rvo' '• REEL sTP EfTA - .--. - -- ST LOPE 5 ND DIRtCiIOn FROM REFERENCE OA CROSS STREET ~ = E -.C~ `O ~ ~•7 ~_ QMILES Q 5 uNOnM SPECIAL COOING USE ffyyl a COLLISION INVOLVfDT I/tJ VEHICLE-VENFCLE ~VENILLE-BICYCLE ~DTHER IWRITEI ~HIT6 RUH ~ HO. KILLED Irv AIN ~ST°LEN VEHICLE TOTAL NO. ff~L ~111 O I C ~H°. IHJURfO * Oi VEHICLES ^ VENICLE -PEDESTRIAN ~rvON COLLI510N ~ HAZ Ou5 MAT IAL ° ~ PROPERTY OwMAGE ONLY wJE<T DTRUCK IHAME OF OeJER STPUCK AHO OWNERS HAMEI LOCgTION OF ONE<T 9TRUC K EST.pAMAOE R I '~ 1~I ^ROaOWAY Ef i]` 1QL' aO. EDGE S q' DRIVE NA -LAST C~2S~?F~ _ . FIflST M ODLt lCN- - ~_, .. R ~CVCLK: OH PEUE5TNIwx CHFC%I ~] : , ~-nA-'~LLrM E~I`/=-~1 ~. - ~ 1 v STREET 1 a " :.. ...... .. .. ... . T~ Z~ _ I v E . A w RESS .. . .:.... .. ~z-~ I ' b`~ c E- R CIT~ ~, ,_ „STATE .., 11 CODE .., PNONE NO. .`l~~rrla~~R%Q ~':.)/t. 7lo E R STATE "ZIP CO°E ~., ONE p I~~ LCC -i..t~l{. ~0~7~ PN fl• J,O. D IVl~~E51Z ~- TA E =Ua. SE% EOfAeIRTN n~ ~° ~ Y ~ o. IV lAS LICENSE NO. A ~ r~ vt P STAi SEX -~L'A. n'L EOF SIgTfI~ M-'t z, DRIVERS OCCUTATIOn FIRM NAME ~ ,, IHONE NO. TK ~Q. . ~G-7-c~,~ ;, Sn~~ 2. DRIVERS OCCUPgTION . ~~ FIRM NAME !h0- 11111 L~c7&~E ~E ~, P CODES 10J c IaI SEAT OELr mIEJE<TIDN ~~ CODES ILL ~ _ aI SEAT BELT E F Of k~~ ` • iE ~J '' J REMOVED NE wv: ••'' SCENE B Y : Y N e EAR MAKEI DOE-CHEV. 1~'' l'1-fEV. 1 MOOkL/~I~~°ART-nOVAI STV IE I>°R-[Onv.l LSD +~TT,t7(L V v lE„. ,~ YEAR 0°GE-C Ev. ~~ ~~~ MOOILID RT-NOVA ST F1 .-COHV.1 y I - E ~ ~~{. ~iG PLATE rvO. I..J~ STATE AILeRPLATEHO `C~f.~/1 ATE.. .. E H v p.COL A tIC./PL DLLG ltJ , lr jN 1L_j TATS 4 Z T EflILA i TF. U~•y : (~` L N EHICLE IOfNTIFIC#TION ._ t~143-Z ~R-7135y~ ODOMETE7 -7(v 1t7~3 C L Y EHICLE IDENTIf IL O ~ ,mss ~r ~ ODOMETER. ~• ,~ _ -' 4~ z E - flEGISTE9[D Own ER-L~i ,,, ,..:., IflST: IDOLE E R NER f GISTERED Ow -LAST FIaST OpLE " . ,- .N N31 L 6 ~ - ~~ O. " A ORES9 OP OWNER .. ..... .... -. ~" ~ O• MOwESS OF OwN _., ~ . i Z ME AnO ADDRESS Of InSU ! CO.OR w ~ _, - ' aME A OGRESS OF INSU r ~H<E CO.~~ T CHAflpf CITATIOn NO. ' ~ - •ENFOR<EMENT ACTION CHAAGE - TATIOH HO. NAME ADDRESS & INJURIES OF PERSONS INVOLVED CO°~ - , " SfX AOE 5 TUS P T EJECT. " L3~" - " z ~ C _ DREss: R J3 . 3 ~ U P uaE DI NEMOVEO IRON PIIf er ro sc A t 1 N .>rS.~) ~ ~v1 ZI lG 5. eo1 nCerovfp FwoM ~ w , 1 m - - i Sy. E N I iEO FnoM E S 5. of sor F N f° I C n Srgrus >. Iwn fN0[R ! ESTRIAN I>I Ee wT ro t srt 1 roN n11nJUAr cL AU ] HO INIUNr . OEw D wT SCENE NISN fp NO INJUNr O - SABLINO ul rsoAr et Lr f h tINSTALLEO NOT IN USE IsIH JFrnoN Ut lJE<iC0 ]. YOTALLY Uf CTED O D : o CYCLIST y > T.OMER POSITION I D S.O ON Afl RIVAL OElOINNOSPITw 'l VIOENTI INJURY I' ; U„E!N . O. N TI WLY EJf CTED E " 6WITNf3] - 6 7 L~OSSTION UNKNOWN I O SSISLE INJURY ySfAI Pf.LTFwaURF U K O A[Jf.LTfpnlf ~ ~ , i ^~` t rt I'm 7 t- ~ ;~ a' `'- x ; 'r ~ F r '.f L.: I A,i ~ • • ~,; i. r 1; , . d ~~- T <a 1 ~.~WY.~ I / t ~i ~V + i IIt ~+wr ~ _ ~ 1 3 S , 1 r -r fi't'. ~I I llf ~ t 1 r ~~?r ~ ~ ^~ I,~ ,fi,~f• `!~7' Ih::1f ~~l ~ .,.'i'pE~7p '~~- ...li '~~3 ' ~ tI• NSi~R It 1 l y1 1 ;: 'YIi i ~, ! 1` al, ~ I - - e-' ~ 4 ~' L t~~F - - ~ l} ,II `~1 r J , °~ ~ 1 :k ~~ ~ I I~ ~ h"A.R ::~a ~ i hT . r.> ~ f I; -. ~~. m ai .. b. '3+fi ty Z ' "~ •~ ~ g' - ~R' ~.e+ A ttzzv,{y"Tlv' r ti ~ .. t,.r .~_. _ - t ` (VEHICLE DAMAGE NEACH ao CRCLE' EYUMBE•'N OG A NUAAIgGEO ARE - "" OrSJb,b. ./L~.Y, tiB."-1°'iLJLt •t~'V AY!ON ~ry f INSTRUCTIONS: ] $NADEA EAO ~EVEI ST p CT I LE .2_ d _ ] mE.:,v ,.Reowlsl TO.;ga L Lo .I ~ ~ ,.'k~ •~~ ~ I __ ^ ~Ah1a~E0 VEFIIC ov Op FDq E L RI' I LE NO 1 I_--~E ~pu .A~nN t, unu.c,t ro r _ .t Is elproNCru s f c -- r? / • '~• • • ~~ ~ - r--y DA"AJ+ UVEti1CLE N02 "~ ~~ t ~npr- 3 ~ ~ ]. ~v,J ~ sev t YfHDtENpI ~ ,l I1~I~~-r-L~~~.. J 14 ) A I Ro- AA F. sE rrDFOCAOaMOTHfp rf..,ctEl I ~~_==1 sOD no... ,~ ru~ Jn :? yr = ^ A o eE ^ N v Dae aeE I O"olsaaLr .eF 3 OornfnMV oaMgeE~ :~p pvNa o Maef vf. _•.o. N~,'hx' F~ '<4 ' nAMA f A D ° c x ^ Fu"crn"u Oa a ^•.o nau s.~ .7 LVF r,pav',E_ s ~ ornf D GE I ~. rD. L - IL)K \ Jti e N -. OE ToWEn by AS ^ E_.~ n }~ - 4'Y.4~rJU_;C;tJU s l/Y4o~.p '°A"'' pwfperc ~~I a„1.~ sN~-nAMAC ' ~ -, DIAGRANIOF COLLISION /1 . I .. ~ s J'vv i ` ~ ...FUrun.a ,._ .._,` .. .... _.. _ ~ I ! i ~'RAl'/ ARROri SMOi'l ~ T Y ;; _ , .i NURTfI IN CIRL> - _._ ~, -_- 2 ~~ I . , oe~ECTrWIr pw At INrACr •_~• d •. sl.aE.«D...elvr«~etfop ji --"-----~- . ~ ~ '7 EEpfsrKlu r.rw eEFO«f I '.. \ th .: - ~IpAE,Ep~Dttlfl~N - - _ _-~~.~,-F-~~rr?J -__ F Ay i{ DESCRIPTION OF. a ~ ~ ~ ~ --- - "' , .`~~!}~"' COLLISION .. '.,. ovu nITY. REDUCED PPVeoisin ui'w«YC N ~.IQ . _..-_ .~ w AM _ ~~ ,'~ .v~~ra't ...... ~t ~YC[t ~~- ~~Tdc..?;IND O.CJY 7y c OTHIN Drop [ONSTH P„q K, frc.b D"o .E.e.p«rvE«. _ ,e, r . ~ ~ >. _ Fr - Z1.vf uuvc ~ ~ , . Gciv„-- ~: a E p c.:r ~~E k ~ ~ ~ 1/~D-" ~E'3f.--L 7L^ ' /-7 ~~' B ~! _..7 -i?y D% i ~_ ~iG~/.~ - ~ '',. ,r .r --- LTA Y-5/~~S- C-v~s//t~ ~/1% ~ ~r ~_..~/I!1!liG.). /t`c~_"'1/L.c'~_@~UADA mf U ~ ~'~ _~' ---~li~~V~Q- i,CG/.PAJ/f..7j. ~i.r[! V C~c _/ ~y.[x ~'y r- ~ -' /J.c St/tis1 Ti/c' C':, c_. •,~ :L:-~ C'~ h '. ' --- /~,.-~16GI//,G ~l~c ~uEf~ .r"f. ,~s Er Goa ~+'~' •q f f~Y ~ ~~... I ° .2i~U>-77 T -S ctJ~i'~5 ~ a °~ ~f ~ E&~'~ - -.~~/1/E,~.Q7~. ~ ~f~~K~Q c'~ /t T%/E-i2E--(.rJ/7a~ .G.CJ~//i !J/.. Ti~i,?~ - ~,~p ~. ~~ yy~'~~, y,rltl - ,cl s'. _,., ~ ^ G/~ ~ rl5r~...; ~. [~.LE- fl.L~l/s1y. ~ ~ S~~c'G s+Y[ +~ ~ ER NE PODITION BEFORE COLL SIGN ~ - Y NO.' C ASNG C al 0 TpEET OH W YNA NO. ONE OIHFCTIO r _ E LE Np fl c y NG eP ECx ¢ LSE j Fex a E G E Y kl YF FN I '/ .-1 I -1 ^ ~ CCCU EO ~r ;= , 1 o " f E !BICVC T WAS USING SIDEw > 5N0 CN O .. ~ .. ~ ~ E 1 '1 ~:' ~,q ROAD SURFACE WH gTHER K LK DSSwatK a CYCLE NOVrE or•Ep [, _ ~ CNECK ONEJ ECKONE 'WaL CONiRIB~TING NE On uNIS7ANCES ' .~, ~ OpIVE« • ~ ~ _ HECKO OpEI ~ OtE ACT ONS _ ~ ~ ~ NO > ~ OrNIOE] yE '~/ E '~ r>e _ ~ 1 ~ OpY I A .. O RC tOT" OE D O Ow G NOE> ~ X ~ I~ Sr NGEII r s -... ,` q33 A EO C ~} .. CO 0 x ANE ] ET > NO CE OF OOC f I] G O O O EOge >fG M'U ry~. HN, 3l - > U E C Nr ~rl E NG 'il+bif'SI - . DN D a IIVE -~ ~ ...' T @F. - r svpw 3 f riiriuHn ff~~ ,". ] OWING 'J yC Mr iEO 4'TO faILIY 0 D aH 3 ICE - ~ SIGNaE la KING ' ~ -~ a OG •' f EE OnEAt. ~ ~ ~ NO - ~ ._.... - ~ ~ SAFE 3PEEU 10 Iva«WEH - . ~ _f _ r ~ a _.. .. IVRN 0 E _ E TU .. IG Ifi T N ' 0 O O ANT nqY -, I•W ' '~ pTMEP 15PECIEYI - ?' .5.. T E II DISHEOAHp 'x~: D F TvE ED -._.... a TUH« ~ I 3 OT«Ep ISPECI[YI ~ SirF OI C.«r F I ~. .a IMrHOVLN ~ NG y 6 OmxG pp"" LIGHT CONDITIONS RgFFif CONTRO I E r> scFgi ~slcrNV,pi t'TpA Xe /\ tIc r q 1 ~ ~~~p( 1' CR[CK ONE( PTVPE OF ROgO O " I TtIQ°~D OR r o.x FRICLE Er"+o.i ICMECK pNE Oq Mppu VEHICLE CONDITION SUBRIETV I '~ x9 SIONA t vIENO ]E W~€`S ~i EC9~O1 vIFNO. >E ICnfCK OYEr O«STDu SIGN ONAL "~ ' ' .. .I~ ~ O WAY IE COH U _ f /\~ 0 _ µy> I~. 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SEND TO waarRNGTOr. aT..TE PAiJiOL- ~~r~ ~ ' J DUPLICATE COPY LOCAL LAW ENFORCEMENT AGENCY SCOPY_rII PLICgTDFLCOpV'It iNyFSi~GA DR'S COPY et 1 `I r _ ]8509 , E 1 -r,F % I' a ,•, :..fn,.:l:.:~ 4,J MOTOR VEHICLE COLLISION REPORT - - N(:• ~ - - T C. 1 -1 -GAY L T E L: A'. % JO ITY l?~c- ~ /s~~7 / ~ ~ ~//yxf~ ~ ~ CL PREFI% / ~~,fpllH~ 5~_Y~_ TYy; ~ M LES T~~. C ]PW a r CJVr./i AD ~ ~ Z > ^ L' Y31Z 1' ~ ~/NS lV ~ ~~~~0 cr oN ' ~. ..-•-r Gl!LSTI.Nr~S4_`Fx >:8-T.aA_Qr: ORH _.MWAY,vu ~. .rii. E. . ~.~TREET`R,F. ..;: PHlFI% O M POST CtivncvlZD ` I L ~~N~~ .yr/ C~IrJ, .ON In TERAEGTION-COLA f10WOF GO ISION MP AOHAM +1 ~~VL/ /~Y( DETWEEN 3OC! /'LI/V 'L , S• S.aEEt O ^N 0 a...oxa cxo+. xa x,~r.o.r ox Iv[xn.,rxa L.xa..x.. •x °ar°`L INQa cis: Fep<m~ O s^ ~ '" ..~ DPfi11AE ~: wy ,~ x.x .xrrel ~~ ~~- xa: o~ ~ fiG. _. r :., LX.x. ax.ea~~larox r.x~x - SOB.1 _T,"STRUGK' w•P4.,iaN~sT [I~~u. •;,_,:;,:;OWy ;..FOOJEGTS NAME,AHO. AOOflEE .;,,,:,~,; ..,:.. ~~ Xsr [."_ - 1 noa wwT a. $ x.......w.. ORNER9-l~A:.Ggll_Ny~yw~:FIR9,T_NAME.;~~,,,A.•w.~.-_MIDO E r.RIVERA LAST. NA Ei.i. _ ~.. .:FIRST ;NAME.:.. ...- MtDPLE.~:-: '~ ;~ ,J ~n~~• n osLle ox uv LLI l~l\. r ~r/~/~7Y ~! w{~'~ xe.x.n iwo ' -- ft,OI1TErN0,~- „BOX N vsex•w[aa 9TR,EET,ADOREAS, TRECT A.- RESE , T '--` ~ Ixiuweousex ~,,; ~~,yt RO TE NO: ANO;90X O '} :•~ a.P.x.v OTT~~u~:.l:"x( s.. :.. F•'T jE•-syypy : ZiP,'GODE PN R ~„OGCU A 1 N rox.rav -_ •-'-v µW,`STATE~~:,,'~ ~._' IVEgS.v9(wCUPATIO ' [ ITY q ~f)>/~u~4cc~ C.) jso! Z StGr ='''17r-.: 9A lr r :3 r F „~ RNER,9 ,L~PFNSE:NU~•M _9ER~~ ST TE SE%'. DATC„~~B RTH A E, °RIV R ~ CENSE~iUM j. ~RTW 'AO_E~ V h7D 360 ~3~ 7 c v F v ao i x s - rLv t`.r. vtac•G•~w.~ ^-Oaew! MOOEIj;~~-Ixwr.run.l BOOT;`SME,y i :1 ~ V[MIS~rrYM; MAKC'ty-IC.[v^: MO _ E~ owY /s•t s~ iL,zD VH-N r s/rr7Z vA,V - ~ o. ~ Clr `~' _ _ _,r c!ITC,EyN9~R~)CNOr' ^ ". -TRAIL60.-PLA GMT ~jw~„ST T ~ LICE SE;PLAJEN -.'_;J ,~ A,1 ___,. ~I~; ?Y(v~ _T.E - '' J (G "~.pS'~ Cpl "'__. ._....._ '. ~ ~.. /wrv, ~'.t sr- ° YE28:~-Ef474R17J1R:2v"~dd84 _Y.aal[4a:x[v!{?I OPOM~TER1 1 Vaa VEH CLE.IOENTIFICAJIOj1~N ~ 1960`_. EjU~[~Aa[ a - ~ `e „. - . ' 11EW5~4rLEl3it~!Y~[P.a11a+:N4^. S:.MP!L +ia: vs' RIV[RSL N_~~~ ,~;;~REOjSI;fiREO~OYJ,NER~IWT-!R!r_ 4lS, .iu:9R~ v ¢ ... 5FaN.Q c~RRi Cff~ ~w~ /I'/ 3G 23i- ? a,~ ;iyst ~ omY __' - -wfL*Sh F:l >_.~oi 41rtr1!?~ ~wyaRS,p?n gssmx~:.m.e I~PI.~;.~I*y,/.•oe[._cT34^;~.' }'?c?E@Y!__ Yuw ao rwr /198 fiA/~F/T ~ 577~u/rt(.Z t .[J ' 1. -.+a ,<. •. •---•..aj rr....4.AKT6i FYElIIC1E PAMAOEO~.tiJ1"^irsu.+;5•_•••~• .•- ,_.-.[ [ai.:n S AVww.TW g' LIABILITY INSURANCE INFORMATION-VEHICLE NO.1- Covin"AGEIN6FFECTFORTWSLAGCIOENTONVOUacAR ~ ~ YE5 ^ No NNAE• )IV9ryU+RAN<WPOUCT:MOLUERY',4+ •..'~..N'?:Yw+•~K ~•^ "-'~~"++' •.+q~~'NAME~OALIABILFSI"UISUM~CE~CONPANTv' j ~:•[ n s P?~v T[ r IL .A/ (SiT~La SSE./N s ~"' ~i3 ~ s~ I S r'~E"co ~.~ ~ ~,NAlQC.ltl WtAiff.F'~iS .'. J rw. .~. c~T-« Slb:'i.'..~L'~:sn~~W61~'~ s~.~S.Rc ~' •~~ YY crra~~ e. c~?~~ gqy~trX~i~~~~ L~ ~c.~ ci/ . y'ser L ~,..r (~ - ,I n R' „Jxir.. -' 1NO[a~°MSurRA.Sx 5ilu+Ee 2NDVYJURY ..J.C~ac~~~-r..'u..~ rNN..w..MK:r.A.rMxAfi~Le'Axt6laJu 'ii4 9r. Doacss ~....~lSJw M~ 5 e s //L/f /~~Hl `ef~~c.ar_~_LA MO'c. e a~w.Nw..,. ~ N,,_~/ . o ~ a B,,N s.,z .I ~rxa~ C~h~~:: UNK I :" i .> uNK ~ M ow r ,rT r f oNl[LrPe LO. CTNA=~Pk SB'IU..1rL. ..I' ~SLATVSOI NJU C `R Vx S~.FlC ~~NI:.)S~`ZNPMIF$(/w•b t; ®N A. N x.oN • rvew IN YFJIICL[ __ LLCO Iwo.. Ix,vw. ••ex KaLeo' V T I ~- 1•evew[I IP . ae•. ~ [ er . 1 e.+,T r TNCNwI•IrX IN ^ 5^ D^Ie lo.7 O[rc ~orNCN E.,, ^ 9^ 6^ 0 7~ .,AwROwIN CIRCLE ~ ;~L1,•'DJ ~EyS~Crt 9c pcLOw.wHA~I~CHeu ~a~rE-,R.TavE,xctiev-orNDAr9e T`•••• ~~,,~~ Y ~ _ O V ~C._._ ~ L_IJ,~I/r='~_jj!/ SMuc~-' c C .I~}. - ~~x \~ _ ,~OVND CJ`Z/=OV% O~ GON7XIL-~TYIJJ~ y x.,_A...x.. _g, ~~T~' , p ~ Di rcd ~11?2E _ Tl/t_<.r~0 ~/ _ ., . ,, - al..eaa+.. .w...A .. A,.or.. ~ L. .¢11D__.GS //!~Y~7L i~9 ;--!'11r0 M-r i LE'F r ~ w ~- r;~a.. r f" ~. 7//M= wAS._ s7L Y9~ o^! fZl~_ r '~' ~~ 'I ~ ~- -- ----------- - ,` 4 - •.a•r. o•,.c. r:, . r VEHICLES POSITIONS OEFORE COLLISION ~ ~~ vex ~ INVCSr PA r[D sr -. ~ [ u N [ D~.oW stauro ~c r o o .e ::.:or m ~ ro:': Ra,D•.-~on>~o~~»~~.~r,- p.~-~Y --r c n o .d~~'o nNRlw[..Irl..la. I~ ~ <. _ _ . To n~wr~Q~f Q ~ ~ 7 . .. c.JAe1.n li inha7. "t'~IcROS : . F ~7 ..+ PR^o 7 3,J;.;;; rT,°, llllll~1~~1{{{{{,,,,, ~, l ' s n l_I vh.~ OPP'•VR/.KR;~ TN[R'~: A..NOMr,coMaTN![es. TR I Ic C' TROL yl __[i.°wel TTr[O[w,oAO•yl ~vu. `+, ORIVC `II,~SNIPtE ACTIQ ii . rk•" 4 n1y~ : ~ ~K. I I ~ •.c..r I ^ DAYLIGHT ^ II [Cl lIDNRL4 ~, LJ l [ WA ^ II I^ OOINO ETRAIONT AN[AO -„ ^N { r~ 1 ~[/"'TIlUNT )C, RAI NrNO t n [LAWN C, l ^ 4tOF SI°M C~~TNWO ^ i ^ OV[RTAKIN6 ANO MOfINO C_1 S l l WFr T^ 6NOwaINO l ~ DUAX n ) ^ ,1[LD AION C7 1 ^ RD.Owire L[ f l ~ ^ MAKING RIONT TURN '. A OAw [.wra[[T ~'7 LA8NINO R[p ILr~wCNANO[ LJ .'y~-~,`IN6 L[PT TURN ~' ~y~ !~ CJ T ^ AMOW KC7 F04 • I_7 ION rA Oa L. 1 ^ ^ A ^ I RAMFI ^ A [. YI """ 01wK ATR ,fT LAANINO AMNIw ! ALL[r MAKING U-TURN +~ [ _] ~ l I ~I:. ~ CJ ; " :°[ ^ n w AIDNAL C7 ~ C] `W" W"T ^ R ^ YLDWIyO f L(.NT• .N[; ORN ' ': [A.~..FWa.w;R IMCO ~ [ T ^ ;,r,~;, L1 T C'~11 FI~[a/.,.GMAN L ^ T (f~]~ 4T Orrc° FOR TRA[. ~4 ,. .,~. „ ~ _w ru •nv •xvv, nnov, r• . [ r ^ l 1 'f G:, -- ^ 0 LJ O °SfOn E16XIGNAL f~r~ (''I 9 8TOr1•ED IN RDADW ~ , [~ LJ DNID[O I ~1O^ OTARTINO III l~-- ~~ ~ [IG ~~ ~~ D D D T KLANR I 1 rl n rwo ~{ ,~~~ nor °m~l Tum,e rs~ . ..,r' - ~F ~ a~rTre ~+ ,~*t p°..r T / ~ Ah ~.. , . F ~ V~~~.. .~, ,.rl+{r' 1Y .r..l L / 1 I.t.v'n ~ ,k (,~ (.~ I I ~ },1. ~ ~ I~~ 11 ~~ ~~1 _. 1 ~~ 1 - ~ ~ ~ t .. ~~ _. ; / ,. ~ ~ ~ ~ '` '~' I Y ~ ~ ~a ..: Nr~A „~",;: `s..'F-; ~~Ttg.,,. ~`'A4 ~'w ~ `~` ` ~ ~ ;-'u _..". ~ ~iIW.~YS~'c~"f "y'~ ~ ~ t y ` . _ ~ . STATE OE YVr~,SHINGT0i~7-PAGE . ' / OF . No. ~ ' ' ; 5~ ~ ~ ~;= ~ POUCE COMPLAINT NUMBER r - ~" UNIFORM POLICE TRAFFIC COLLISION REPORT ~ k T !' DATE CF COWBAN DAY OF COLl1510N F SAI MUH D W iME 2TJO nGUR1 5 1 COUNT~O./ CRY 110. _ J ( _ FHWA ^URBAN AL ; ~eif IYS ~~ l"f3„ ~ I T ly~ ~Ay YR. B ~ A T SUN f NUM Z IUES G E 1 ' 1 j = ! EFI% PLATE OR STREEt CODE P Ufl S CTON J ~r : h ,.f,~yy P " E i COUNTy ^STATE ROUTE ~CWNTY ROAD ^CITy STREET O W R ADM~CLS. ~ / Q p `' N¢ D y ~ ~~ ' ' I `~~I..r l a-'J ^OTHER ISPECIFYI ^111 OITYGR TOWN N W PREFIX ` EO. MILE POS~ , v ~ ~ ^ ~"7 II " ~ , -;~ .l i i 1 ~ V ~ L I O L N S E W 1 11 1~"' -- MILES ^ ^ ^ 'r~®OF 1 ~ ( 1.~~~~ S, /1,~ U LL „/ / DIAGRAM DATA , ~ i " Z 1 9 I C ~ A 1 'AME 6NO.OF BTR EFO IGHWAY INiERBECTN6 WITH: STREETCR ROAD LL O RAMP ~ ~ " ~ e ~y~7q T I 0~ ~, ~! " AG OIOEf? NiER NON i %~RD CLS `ITERBECTING STREE OR OAD OR REF. ERENCE CPOSSSTREETOR ROAD y; ~}y • _u k Y 'P(~s. ~ O NON INTERSECTION _ ``//~~ STREET ANO LIZ "•-~ F~. ~ ~ U ' STREET MLEAGE COOS . X~ ~ O S; Y h ~ ~ N J 9ETN cEN ` DISTANCE ANO DWECTION FROM REFERENCE CR CROSSBTPEE „ EB N S E W ^ HvYCFE r5 SPECIALLODWG USE ~ } ; °1 ~ 7 ` ,~ ~ ~~ MIL ~^FI T~cEET DF !~' `J TLRUN ^M1 SEVERITY w`}y~' ~ ~~,~~ ' h~ k P~ L ~ ~ VEHICLE~VEH CLE ^VEHICLE~BC/CLE ^0' COLLISION INVOLVED: VEMICIE~RR TRAIN ~ nERIWRITEI ^ STOLEN VEHICLE NO.XILLED NO.INIURED ~: ~ ~i~ Y h I VEMICIE~OBJECT ^ ~ ^ ~'! TOTALNO © ICLE~PEOEBTRIAN NON~COLUSION ^HAUfl0005 MATERIAL ~PPOPERtt DAMAGE ONLY s ^ {, OF VEHICLES VEH T ~, OB:ELT STRUCXINAME OF OBJEGT STRUCK AN001vrvER5 NAMEI LOC+TION CF OBJECT SIRUGK EBT.DAMAGE N S E W OF ^AOFON>Y FEET ^ ^ ^ ^ RO EDGE 5 +~ ~ '.;,~ I +} ` ~ FIRST MiDOLE CFI'/ERS NAME~UBT DR VERG NAME~LABT F RST MIDDLE IIF WCYCUBT OR PEDESTRIAN LHECXI l l~'/ "- ° " G ~ ` 1 `~ 0 ~ I Cr11~ L- `" L I'~ r~-~ bf~_ i 7C ii ~" R . tv ( v iZ ~ i ~ 1 1. C~ t~ R ~ ~ R . STPEET PODRESB STREET AOORE6S ~ ZW CODE PNONE NO. ~ 1 • E R CITY STATE LP CODE PHONE NO. I " ~ ! J '~ ! ~ ` L E R OrtY STATE }~{, T~~_115c•,~a c~a 9~3ETti F BWTR R ~ ~ ~ ~: ~(a I N o l , 'C l .l A ORnEPS LICE SE NO. c c STATE l ~1~ SE% OATOE OFO&yTH Y t~1 ~ ` ~ N o. DRNERS UCErvSE NO- ` ~~ L~l~i.,<+ STATE L --/~ SE% r`'t DATE O OAV YR y r~ 2C ?, ,~ v '~1"!"~ .I } >. . , Ly. t 3c f„ I I 2 ~ CDUPAi10 FIRM NAME N P N ~ ~ f f LM'~" .~. t ~ PHONE NO. ORrvERS OCCUPATION FWM NAME z DRIVERS O h - l.. 5 / ' sy ric ~ - ' ~ _ CODES > 121 aASS TAI SEAt'BELT ISI EJECTION c~ EJECTION CODES > 1]r cuGSS 1X1 BEAT BELT ) 151 ' X ~ - . ~ ~ ~...$T IWURRiES~ 1 ~If.U '~LC)1\L 1 •' vATUR xIURIE9 14.. /\LA-'.'{ ~EMOVEO I TO I~' " ~ t " _ FE V ENE BV• ELMEV 1 YO MODEL IDARTNOVAI STYLE 120R.LONV.1 OM SCENE IEH.YEAR BV' M XEIDODGECHEV.1 LE 120RLONV.1 tt S MODEL IDMT~NOVA ~y "f -~ .~~ ~ VEn. YEAR bt . MAKEIDODG 5~~ ~ 1~t1s;i 2D~ v 73 ~-n-F, ` y ~ 4zcu s~ ~ ~~ ~ v u c~ 1 STATE E UC. PLATE NO. VEH.COLOR STATE TRNIER PLATEN STA ~~~ b5 ~.~ ' E YEn. G LOR UC. PLA ND. STATE TRAtLFA PLATE NO. H / ' l-ly 07C LJr'1 ~ex~ i FF I H ~L~~•T vC1~3 t..)1~ ' ~C ~ E:ih, IDENTIFIC ATi N NUMBER ODOMETE . fl y ` ;; ]¢, (~` VEH LE ID NTIFICATION HUMS R ODOMETER L L VEHIC ~ A E MIDDLE q ' u - A - ... E A. FWBT MIDDLE REGISTERED YMER -IA:iT CC .J ~I~ G1 N ~~ REGISTERED ONNER- fWSf h~tlr ~yE~2~ c.~.ar r AODRE59 OF OvMER n .:.~:,~ t, '' ~wrr1 :"~ ~ .y~y-~n~L,r, n~'°;xN~Fd'""M'.r„ .I VEHICLE DAMAGE ~-A,`IN EACH BO%.CUiCLE TNEHJMBEROF EACH DN.IAGEO AREA. --/f- r•.;n _ 1~~7e. " r1D E POWISITO SNOW PRiNCiPALDWECPON OF FORCE ©~. Rg w INSTRUCTIONS: ao DAMAGED VEHICLE N0.1 IUSEiHLS SPACE FOR SNETCHiNDDAMAGE TO TRAIIEgS. MOTORCYCIES,EIC.I DAMAOEO VEHICLE N0.2 mHn°E . a la ROOT IA. ROOI 1a a . Fx_nv `"°I+' rs. m.ur ls. rr„a .L~ 7 ~/ hr~, ra ' '• \ T m.uw«u~n.D. \ T ls.uro.rnw. '-~r ~iO T o ~ ~ a rr ro s a.rsfP \ u L~ 1 1. ,.'le~t,• l la . n.o..N.R BEVEg1TY OF DAMAGE.VENICLENO.1 IQDISABLDWDAMAGE SQOTHEPM.V. DAMgGE 2 FUNCTIONAL DAMAGE A NO DAMAGE SEVENTY OF OAMAGE:IOTNEq VEH1ClEl i '~ ~• 1~g9gEUlA DAMApE GOOTHERM.V.OAMAGE Z FLNCi10.VALDAMAGE A NO DAMAGE SEVE OF DAMAGE: VEMAENO.S - 10DISASIING aAMAGE 3a6T1ERM.V. DAMAGE E RJNCRDNALDAMAGE 4 NOOAMAGE TOWEDBY BIZ 1Cti:~1 ~j',"j, DAMAGE E/ST TOWED BY EBT.OgMgGE TDWED BY -. EST.OAMME ro 1~7 1.'LUr^>-..~5 , ^ 'C7-~~•l. ro s ro s~SQ~ DIAGRAM OF COWSION'„ ~~ i i j I r i. y_- I ~,_ ~ 1 I _ I _~ I ' ,DRAW ARROW SHOWING '~ NORTH IN CIflCLE ~ ~ Df1 `~• •~~ (' ~I T~ l ~ I I I i 1tlH° wADWAr • ~ w~ailROra . i DCDOH FraeAauPOwrai I ~.-' I - i ~-I '_f-i - 1 i"! I~ ~~~T- »~_ ~~ I 111 ! f I i - 1 f i~ L ~. I I ___,_ i I I I, I~-t ~ I I I I 1 avawrvENarcfEcearwARa oLEtTE051RON9Ar MAM;r ~_~ ~ i l _ { r ~ l i I I T7 --~ '~ I I C I , 1/~'~~ 11 t i I a! 1 I I I~ 1 I ~ ( 1 . _ '~DESCRIPT70P10F `%' ,..COI.U$IONj SY.'`, _ ~IN.ICATE WHAT PPOBABI.YHAPPENEDBEFORE.WPoHG ANDAFTER THE CRASH.INCWDE INFORMATbN110TON pL1GRAM, EG. DRNER 1,CCNSTi1UCTIOH OR REPAW,VIOi11LET0.) dSFNLfrY.REWCEO VbIPiRY,PEDESNUPN OLOTHltq GOlOf ` _JiL... lc ~ Z._c,JV' ,__ -•• ~rkv"I. N-• 5 U ~~' ~' 1 ~. L,.~1-~1-/l _Sy r1 1 yr . !fir"J ~Jf 5- JL S ~ - , P,~1 ~ ~1~~~.~_~~l~:~i~.\ 4JCR`e ~. __~I^, - >l,~l` :J ~ 'nr t ~ 1_, '^_1.11 ~~ , .:l ` ` ~L ~_ 1 V ~'_v1 S ~ /lA_~ i 4J~G f'1'f V+ ~ n ..',cU~'. I-~,~~) Lcl_ rl VO~ _.V QC1r~,...V~ ~Y . 1 ~_-_~_ \ ~ l ` S ' H •~ i% ' ~ ~ ~_ ' /~J . c l l~r r~ . L Sal 1~ C`O { J~n I. ~~_~j Y.. t : 1 Z ~7~v:.c. S ? -~ - ~ ------ - ./' 7 ~f .ti ~-c.. •. . " .. l ,.~ ~ •..... NO. DF LANES r~pEcna EEHDgLLY WASVEH :,: R.•I...n... PO i VEH. HEADED- ~ MiLE POST Drti dI STREET OR MgMW1YHAMEOR ND..~.,a..w.....e..:.-:-o-. WONEDIHECIION _ srFg- PARy(ED OCOUNED : - ' -- NO - NCRFAS:ND DECREASING ^ ~~ L ^ . N S E W I JL~ 5 • -' 4 ~ ~ ~_ ~` ~ I,~ YES 110 YEB N0. -- - - - ~ ~ - PE0. n n p2COPNBl r0 a000M1f1°TMCT WI SIR OR •Y yr ~ ----._ ~caesnD --- PED/BICYCl19T WA8 U51N ('~ G. ~ r1 I>IpeaAlN ~ °nW AY °; ~aipnDFA~ •nLR~u% a1 )C~PO~ ~. I P~OIRE rn Dilrt ~ ll - .. . 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R L ~ ~ . . ~Y~ i~ ~ ~~ .i . .}~,z ~ ~ ~~, _ _ . ~~ : ~.. ~~ ~d .: Di~~ ~?k" ~. ~"~ ~~~ 1 ` 4~l Ilyl ~ VI ~/V ""1VElfltlv E va~.,..,~ J/ UNIFORIN POLIC° TRAFFIC COLLISION REPORT ~ t •-• NILt LUwYLnINI nUwDEn r: ~ ~ J E ~ uslD= D.Y - ~ OI ,N,f r~r~~~~~-~ ,,~,~~~~ la~E „ ,~.. ~LLJ Li ~L1 ?L ~ ~ J Y z __ DNTY / l e LDD Y \ ` ` D 1X . ~SIAIE NO E ~JLO f]nFY STNEET o FI LES . oulE , i _ l~Lc~~C'r.~) 1 ~' II LL~~ tel. t~ D,N R I'.vFLIGYI E ~ 7 v E'I FO IF YU'. ` h o cl DR TDw r~4F 1,'~-~-E-E,,~;TS~o ^r.~a I.~ wNE I>. wY . aDNnw D ~w `~&JS'J f ~. C _N . //~'~ O SI NIIFF..€€~~,~, I~ RSE<TInG wNN:STNf ETON NOw LL Jly ~h P i O' nON IN O pp !^ T Ny ~ ! !J IxmA 71~C ~1~'PUE=T 4~i`e,T ~~~ yy~ C lly I fE~ ' E " N N 1 SETwfs ~ _-NCE AF400.5 O G OE nFFE 1FnCE O'•ENOS~SIREET ~~` I , „N., , unuFlln A ELI nlnc we , ~ DG S rz.U • ~1 rIGEET ^ GI O ^ / ,r ~, ~ - ! ^VENICEE-VGNICLE nVENICLE-BICV CEE - OT 1'wR iEl 1~NITANUN (/E~ COEUSIfY1 INVOLVED: C VENICEE-OnJ[CT ~~ofj NICLE-NR iRnIN `l`~~'~. ,-. ,-. USTOEEN VENIL TD,aE nO, a~ ~ ^ - - r Yek r V CLk3 ~VENICLE-REOEST PIwN ~NOn-COLLISION ~~' ''+~+~ F O' TSTRULS INAInE OT OSJECT STRUCK ANO OwnER4 nawEl ~~ VE ANE-LAST T wl0 ~,.:D ~. R ~-~NICz D[:1.; YVl t CFN/~EL ~ . ~. ' i _ TREET ADDnfss - - (R ~ J ICE „ 1135 i~csC:R/'~-,~=s Sr• J ~ v r~ E Y E I oDE ;RO E ;.v ~+x~'~ ~ r"w, d.o R T ~T Tl..-1.c%f~ ~cti%p -C.c:A. q f=,7(ePJ ~ R 'II ~ ~ y ~ ORIV ERS LICENSE NO.- STATE SEK DATf Of BINiR I N ~' , o, C ~tl-Z ()~~ ~ -[L'A. 111 3 I ~ E~~. o. E O. r ~, ~ ' RIyER3 gcc~il IPyel r,tA ~ ~_~.Ir1I Ll/ N 2 ~. .E$,'~ /l.ll(R~_/ /l_'./M1Jl, .E'er, ~. _ oC0(JEosf '= < : sY ~ - E.r RELT "'uE Tlon ttnrC'.! LL }111-+ +l,: <tl - 1 /.:-1. T. ,:0- .~ NOw4 A~EI00 GE•CMEVI wOOELIOANf-n0 IS Y E.I}OR.-COMV.1 ,tl E E~ p E n0 STA E aTE E ~&,~ ,'~ H ~~~~, L,~.3~i ~W i AI FR.LATENO. ST R I C VENICEE IOf NTIFICATI Nn • ODONETfP C SA' ...; ~a~~ L ~ (311A~SXo93 $Z~T. ~~~GI O L u ~r, E E REGISTEgE00vrnFR-LwST fInST MIDDLE E • ~ N - ELt E ra wUUnl53 Oh OwrfkR 2 00 ATION OF ORJECT STRUCK ~~i aA ADwAY-~ FEOr ao~ r LR E.L GIRY wlu E +E. E T ,ak' I rnk«" Nt 73/f7~E ~~ ~.. >,~ ; DI-]~ ~a N, EET O'NO O.~ ~c~s~}Q oN ~~ 7 ~ J FVLNITY 4pr JNO. K LLCO O. INJU NEO ^!r ER.Y DAw.GE NE ~ EST. DAw C EDGE 3 ~~ _ .... __...,..~ -- .~z CE NSE NO. •- -~~ TATE SE TE OAY ~ dC o. LLDFATIDN w F D E ~~~ _ G.c>c ~~ rCc.~-N I+ `'SEAT BEL EJFCTIDv G / / T C a .,7d E xY: ~EIOOOGE-CnfV w D l^ E. AST VIE I]OR.-C ~ ~. q LIGFLATEN ATEIO LE TEND. SiaiE ~ ]ENTIf ICATI NUNNER ., GOOEFE IER EO Ow R-LASE FINST w100LE ~I,. OwNkN i ~; '~~ .A ROE~1 !~~ • CITATION MO. ENF4NClwE~ CNANOE L NAA1E, ADDRESS & INJURIES OF PERSONS INVOLVED ,~ cE TA, n j N ALN,Q~dr l_ . i n,? ti F ~~, _I~LLE-..r. s E Nom` _,: ti. ; _-;._n~.~E L ' iv : f_-~C:11D_'!-r-1~=1.x.)_47 c I~;.~n E, ; i, ~1>J-,~ ~ -- ~: -- 5 `:! ~~ =~. •. 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T .r ~;1 :.,• J~K Dwfuar ~ r ., iovrEO nr :o 'lGL 7FJS:.fJll 5,2 ~(O_ T to s q ,r':F, 1 D'FGHAM OF COLLISION .e]1J1/~i; 'r'%O/OQ=/h DRAW AH ROY/Sh10:'IING ~~ ' n .I~.lz --~~ NOFlTH IN CIRCLE L .. ........ .• ~ I.,xr _~ ~--,.,., ~~ ~ s [ K -~ . 5.~...n. r4n :. ._ q _ _ _ _ .I, .. .nD.(ilw ... ., ~ . .__ . ... . ___ - .. - :- _ ~ ~ A DESCRIP710N OF unpruTLr.wAT Ewoe.aly NUrENEpafroaE OUnrr,e ar,p.ETEfi rwE CNCS~rNCLVDE Ir.(oN oT Or+4 aena5r,caD vJ .f ER COLLISION psAanrtr,RmuclD Vrs vu:r, EEDfnwAw Lolwum cplaR,co.uTnucnovpR?ERA awo ,El d / ~~f C•L E. ~/_-://Oi.°Ti>/~~+r!N/J O,t/-C~~'~~•2. </f~~~iG'~P: GG/TJ/~i~L/ -SGQ.Qlr -- l! / _..._ .. ~Er: S/.Ll c'~-d~-~G/.lv.:/l/,'w- ~ ~i.CaGf"L r~ Y'/i?._T~~rE. --- - - -- . I. --'- - - - -- - - ~ POSITIOt EAptp ) 0 J BEFORE COLLISION NKED arILE VO Ov SiNEET OR nrGwLrar vaL.f ON VO OnFUD nt[l~OV r pEGAi~v wAi vEn N - " . .. f[O vfp eKVCI'ST VAS USING. __ IvC l ASIVG D NE ASING ~ - . . NKED OCCUVNO ( / r~ VCS ES (HO'I wne La TO! alOVO .. 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